key: cord-325296-zrvykzof authors: zuhorn, frédéric; omaimen, hassan; ruprecht, bertram; stellbrink, christoph; rauch, michael; rogalewski, andreas; klingebiel, randolf; schäbitz, wolf-rüdiger title: parainfectious encephalitis in covid-19: “the claustrum sign” date: 2020-09-03 journal: j neurol doi: 10.1007/s00415-020-10185-y sha: doc_id: 325296 cord_uid: zrvykzof nan included positive serum antibody indices for sars-cov-2. on day 4, respiratory deterioration required endotracheal intubation and treatment of bacterial superinfection was started according to antibiogram. eight days later, the patient could be extubated and pcr tests were negative for sars-cov-2. yet, the patient continued to show concentration difficulties and delirious behavior. subsequent mri (fig. 1a c) revealed signal alterations within the claustrum/external capsule region, showing reduced diffusion. cerebrospinal fluid (csf) analysis disclosed a mild lymphocytic pleocytosis with negative test results for common neurotropic viruses. tests in serum and csf were also negative for various antineuronal antibodies. the patient recovered and was discharged with only mild cognitive impairment. follow-up has been carried out four months later showing a normalization in cell count of csf and improvement of mri findings, although the claustrum lesions persisted. clinically, his neurological and cognitive status was normal. our case is characterized by evidence of parainfectious autoimmune encephalitis in the context of severe covid-19 pneumonia. clinically, the patient presented with various neuropsychiatric symptoms, which were reported before in other covid-19 patients with encephalopathy [1] . neither sars-cov-2 itself nor antibodies against the virus were found positive in the csf, precluding direct viral cns infection. comprehensive laboratory tests ruled out antineuronal antibodies as well as common infectious causes of encephalitis, altogether supporting the diagnosis of parainfectious autoimmune encephalitis. in addition, the diagnostic criteria for possible autoimmune encephalitis as proposed by gaus et al. were met [2] . while immunological markers remained unspecific and imaging findings of acute necrotizing encephalitis were absent in our patient, brain mri disclosed a unique pattern, a.k.a. the claustrum sign. previously, this sign has been coined in mri studies of autoimmune epilepsy, where an immune-inflammatory-mediated encephalopathy is suspected [3] . the claustrum is known to play a crucial role in regulating consciousness [6] correlating well to the randolf klingebiel and wolf-rüdiger schäbitz both authors contributed equally to this work. clinical findings of impaired levels of consciousness in the presented case. in autoimmune epilepsy, the claustrum signals normalized in the majority but not in all patients [4] , suggesting a varying severity of claustrum damage. this is confirmed by reduced diffusion in the first mri scan of our patient, heralding irreversible tissue damage (as proven by the 4-month mri follow-up). at no point in time, there was evidence for other causes of diffusion reduction, i.e., hypoxemia or status epilepticus. comparable claustrum lesions have also been reported in the context of autoimmune encephalitis without epileptic or anoxic episodes, supporting inflammation as a decisive factor [5] . a particular vulnerability of claustral neurons to hypoxic stress has been shown [7] , without relating to the inflammatory pathogenesis of our mri findings. yet, astrocyte proliferations and microglia/macrophage infiltrations of the claustrum have been observed in non-herpetic encephalitis [8] . to which extent other pathomechanisms, such as encephalitic hypermetabolism as known from the striatum [9] . additionally, compromise the claustrum remains speculative. common mri findings in a recent study of covid-19 encephalopathy were cortical signal abnormalities on flair images (37%), accompanied by diffusion reduction, leptomeningeal enhancement and cortical blooming artifacts in some cases. these imaging findings, termed by the authors themselves as "rather unspecific", did not allow [10] . mri findings in covid-19 encephalitis, especially when suggesting autoimmune encephalopathy may imply therapeutic interventions, such as immunosuppressive therapy. recently, progressive clinical improvement along with a reduction of inflammatory csf parameters has been observed in covid-19 encephalitis, following high-dose steroid treatment [11] . in summary, a previously undescribed imaging pattern in parainfectious covid-19 encephalitis is presented that bears a strong resemblance to mri findings in autoimmune encephalitic syndromes, such as known from epileptic or encephalitis caused by antineuronal antibodies. this claustrum sign should be added to the still limited knowledge of encephalitic imaging patterns in covid-19, as it most probably represents an autoimmune phenomenon that might progress from reversible signal changes to permanent tissue damage and thus may trigger appropriate as well as timely therapy. author contributions fz is lead author, analyzed and interpreted the collected data and literature, designed and wrote the manuscript. ho&ar participated in the design and coordination of the manuscript. br&cs helped in drafting the manuscript. mr&rk provided figures and data and revised the manuscript for important intellectual content. imaging (d-e), the flair-hyperintensities persist (d) whereas tissue diffusion has normalized (e). csf-cytology (f) showed a slightly elevated cell count (9/µl) with a lymphocytic predominance (88% lymphocytes, 12% monocytes). a meaningful plasmacytic transformation was not observed, the monocytes being only slightly activated neurologic features in severe sars-cov-2 infection a clinical approach to diagnosis of autoimmune encephalitis new-onset refractory status epilepticus and febrile infection-related epilepsy syndrome what is the function of the claustrum? voltage-gated potassium channel antibody-associated encephalitis with claustrum lesions claustral neurons are vulnerable to ischemic insults in cardiac arrest encephalopathy neuropathological studies of patients with possible non-herpetic acute limbic encephalitis and so-called acute juvenile female non-herpetic encephalitis striatal hypermetabolism in limbic encephalitis brain mri findings in patients in the intensive care unit with covid-19 infection steroidresponsive encephalitis in covid-19 disease key: cord-302015-z2k6wuhm authors: bonardel, claire; bonnerot, mathieu; ludwig, marie; vadot, wilfried; beaune, gaspard; chanzy, bruno; cornut, lucie; baysson, hélène; farines, magali; combes, isabelle; macheda, gabriel; bing, fabrice title: bilateral posterior infarction in a sars-cov-2 infected patient: discussion about an unusual case date: 2020-06-28 journal: j stroke cerebrovasc dis doi: 10.1016/j.jstrokecerebrovasdis.2020.105095 sha: doc_id: 302015 cord_uid: z2k6wuhm in time of sars-cov2 pandemic, neurologists need to be vigilant for cerebrovascular complications of covid-19. we present a case of bilateral occipito-temporal infarction revealed by a sudden cortical blindness with haemorrhagic transformation after intravenous thrombolysis in a diabetic patient infected by covid-19. differential diagnoses are discussed in front of this unusual presentation and evolution. bilateral posterior infarction in a sars-cov-2 infected patient: discussion about an unusual case abstract in time of sars-cov2 pandemic, neurologists need to be vigilant for cerebrovascular complications of covid-19. we present a case of bilateral occipito-temporal infarction revealed by a sudden cortical blindness with haemorrhagic transformation after intravenous thrombolysis in a diabetic patient infected by . differential diagnoses are discussed in front of this unusual presentation and evolution. a 51-year-old-man presented with one-week history of cough, dysgeusia and diarrhea. the patient complained of moderate headache without fever. the patient had a history of diabetes mellitus, hypertension and obesity. blood investigation showed a lymphocytopenia (1.08 giga/l), an increased fibrinogen (5.1 g/l), ferritin (1190 µg/l), creatin-kinase (749 ui/l), c-reactive protein (71 g/l), asat (54 ui/l) and glycated hemoglobin (9.1%) concentrations. prothrombin ratio was low (66%). antiphospholipid, platelets and partial thromboplastin time were normal. the rt-pcr for sars-cov-2 using a nasopharyngeal swab was positive. a chest scan showed bilateral ground glass opacities concerning more than 50% of the parenchymal lung ( figure 1 ). six days after arrival and 30 minutes after the fourth injection of remdesivir (loading dose: 200mg iv, 100mg iv per day thereafter), he presented an abrupt cortical blindness and disorientation (nihss score: 4). an atrial fibrillation (af) was recorded. a first brain mri performed one hour after clinical onset showed bilateral and asymmetric acute occipito-temporal infarction without visibility of the p3 segments of the posterior cerebral arteries (pca) (figure 2a to c). fluid-attenuated inversion recovery (flair), t2*, mr venography and mr angiography of the supra-aortic trunks were normal. no pathological enhancement in leptomeningeal spaces was observed. alteplase was injected 128 min after symptom onset. the following morning, blindness was unchanged and anterograde memory disorders with anosognosia were noticed. the 24-hour control multimodality mri showed a haemorrhagic transformation of the previous lesions ( figure 2e -f). dynamic susceptibilityweighted contrast-enhanced magnetic resonance perfusion imaging (dsc-mri perfusion) showed an increase of cerebral blood volume (cbv) and flow (cbf) in the right thalamus and an increase of the mean transit time (mtt) and cbv in the right hemisphere ( figure 1h ). distal segments of the pca were permeable ( figure 2d ). nine hours later, the patient died due to a rapid respiratory breakdown, without neurological worsening. this bilateral cerebral posterior stroke may be secondary to an embolic event (af). stroke could also be explained by the state of hypercoagulability induced by sars-cov-2 infection 1 . severe patients are more likely to have neurologic symptoms 2 and bilateral frontotemporal hypoperfusion 3 has been reported. in our case, mtt and cbv were increased in the right hemisphere which may reflect reduced cerebral perfusion pressure. the increase value of the cbf in the right thalamus may correspond to a post-recanalization hyperperfusion 4 . other stroke mechanisms can be suggested. infection may have induced cerebral vasculitis, explaining the stroke and the perfusion's anomalies. severe reversible cerebral vasoconstriction syndrome (rcvs) cases with cerebral infarction and intracranial haemorrhage have been reported but the absence of thunderclap headache is unusual in rcvs 5 . the absence of rapid increase in blood pressure and the presence of an initial cytotoxic oedema instead of vasogenic is less in favour of posterior reversible encephalopathy syndrome (pres) 6 . an adverse effect of remdesivir is also to be discussed, but no neurological adverse effect potentially related to remdesivir have been reported 7 . finally, the absence of thalamus involvement makes the diagnosis of acute necrotizing encephalitis unlikely 8 . in conclusion, the origin of the stroke is probably multifactorial: the cytokine storm syndrome and hypercoagulability may have induced blood flow dysregulation, associated with an embolic event that may finally induce arterial thrombosis. a cerebral artery vasculitis or a rvcs are not excluded. this unusual case confirms the increased risk of thrombotic events in sars-cov2 infected patients. figures legend figure 1 . axial ct scanner shows focal subpleural ground-glass opacities in the left and right lobes. the right lower lobe lesion is accompanied by air bronchogram (arrow). second mri (d to f). tof shows better visualisation of distal segments of bilateral pca (arrows) (d). fluid--attenuated inversion recovery (flair) shows a hypersignal in the initial ischemic lesions (initial flair was normal) (e). susceptibility-weighted imaging (swi) shows hypointensity (haemorrhage) concerning the totality of the ischemic lesion (f). mri perfusion shows an increase cerebral blood volume (cbv) in the right thalamus (arrow) (g) and an increase of mtt in the right hemisphere (h). annecy hospital annecy hospital * corresponding author: fabrice bing imaging unit, annecy hospital, 74374 metz-tessy, france email : fabricebing@yahoo.fr phone number author contact information: claire bonardel: cbonardel@chu-grenoble.fr mathieu bonnerot: mbonnerot@ch-annecygenevois.fr wilfried vadot: wvadot@ch-annecygenevois.fr gaspard beaune: gbeaune@ch-annecygenevois.fr lucie cornut : lcornut@ch-annecygenevois.fr hélène baysson : hbaysson@ch-annecygenevois.fr magali farines : mfarines@ch-annecygenevois.fr isabelle combes : icombes@ch-annecygenevois.fr gabriel macheda : gmacheda@ch-annecygenevois.fr keywords: infarction; mr perfusion; covid-19; visual loss; sars-cov2 running title: stroke in a sars-cov-2 infected patient conflict of interest: the authors report no disclosures difference of coagulation features between severe pneumonia induced by sars-cov2 and non-sars-cov2 neurologic manifestations of hospitalized patients with coronavirus disease neurologic features in severe sars-cov-2 infection diffusion-perfusion mri characterization of postrecanalization hyperperfusion in humans severe reversible cerebral vasoconstriction syndrome with large posterior cerebral infarction posterior reversible encephalopathy syndrome and reversible cerebral vasoconstriction syndrome: clinical and radiological considerations controlled trial of ebola virus disease therapeutics covid-19-associated acute hemorrhagic necrotizing encephalopathy: ct and mri features key: cord-288158-6gicgsj8 authors: mahammedi, abdelkader; saba, luca; vagal, achala; leali, michela; rossi, andrea; gaskill, mary; sengupta, soma; zhang, bin; carriero, alessandro; bachir, suha; crivelli, paola; paschè, alessio; premi, enrico; padovani, alessandro; gasparotti, roberto title: imaging of neurologic disease in hospitalized patients with covid-19: an italian multicenter retrospective observational study date: 2020-05-21 journal: radiology doi: 10.1148/radiol.2020201933 sha: doc_id: 288158 cord_uid: 6gicgsj8 of 725 consecutive hospitalized patients with coronavirus disease 2019, 108 (15%) had acute neurologic symptoms necessitating neurologic imaging. all images were obtained as per standard of care protocols. mri scans of brain and spine were obtained with 1.5-t scanners with standardized protocols. gadopen-tetate dimeglumine (0.1 mmol/kg gadobutrol [gadovist; bayer, berlin, germany]) was used for contrast materialenhanced studies. the neurologic imaging characteristics that were evaluated are listed in table 1 . all scans were initially analyzed by the institution's own neuroradiologists. subsequently, all images were reviewed by three neuroradiologists in consensus (r.g., l.s., and a.c., with 30, 14, and 32 years of neuroradiology experience, respectively). continuous variables are presented as means 6 standard deviations and were compared between patients with altered mental status by using the student t test; categoric variables are presented as frequencies with percentages. all statistical analyses were performed by using software (stata, version 15; statacorp, college station, tex). p , .05 was indicative of a statistically significant difference. a total of 725 consecutive hospitalized patients with covid-19 were reviewed. of these 725 patients, 108 (15%) met the eligibility criteria (fig 1) . of the 108 patients, 107 (99%) were examined with unenhanced brain ct, 17 (16%) with head and neck ct angiography, and 20 (18%) with brain mri. of the 20 patients who underwent brain mri, 10 (50%) underwent mri with and without intravenous contrast material, 10 (50%) underwent head and neck mr angiography, and three underwent additional mri of the whole spine for evaluation of lower extremity weakness. table 2 summarizes the demographic characteristics, medical history, and neurologic characteristics. the most common neurologic symptoms were altered mental status in 64 of the 108 patients (59%) and ischemic stroke in 34 imaging of neurologic disease in hospitalized patients with covid-19: an italian multicenter retrospective observational study e271 10 had acute ischemic infarcts and two had intracranial hemorrhage. seventy-one of the 108 patients (66%) had no acute findings on brain ct scans; seven of the 20 patients who underwent mri (35%) had acute abnormalities on brain mri scans. there was a statistically significant association between the prevalence of altered mental status and patient age (mean age, 72 years 6 11 vs 64 years 6 18; p = .007). the main neurologic imaging hallmark was acute ischemic infarcts, which were present in 34 of the 108 patients (31%) (30 [28%] on ct scans and four [20%] on mri scans). of these infarcts, 19 (18%) were large (15 in the middle cerebral artery territory, two in the posterior cerebral artery territory, two in the anterior cerebral artery territory), 11 (10%) were small, three (3%) were cardioembolic, and one (1%) had an hypoxic-ischemic encephalopathy pattern. six of the 108 patients (6%) had intracranial hemorrhages, with subarachnoid hemorrhage being the most common (n = 3, 3%). additional neurologic imaging findings are shown in table 1 . (12) note.-numbers are numbers of patients (numerator/ denominator), with percentages in parentheses. flair = fluid-attenuated inversion recovery, iv = intravenous, ms = multiple sclerosis, pres = posterior reversible encephalopathy syndrome. * one patient with miller-fisher syndrome, a regional variant of guillain-barré syndrome, had both cranial nerve and cauda equina enhancement. a 62-year-old man presented with bilateral facial nerve palsy, ophthalmoplegia, areflexia, and polyradiculopathy. results of real-time reverse-transcriptase polymerase chain reaction assay of the cerebrospinal fluid were negative for severe acute respiratory syndrome coronavirus 2. † a 60-year-old man without history of seizures presented with first time convulsion (fig 2) . real-time reverse transcriptase polymerase chain reaction assay of the cerebrospinal fluid was negative for severe acute respiratory syndrome coronavirus 2. ‡ one patient, a 53-year-old woman, presented with seizures and altered mental status. (31%). of the 108 patients, 31 (29%) had no known past medical history and 77 (71%) had at least one of the following chronic disorders: coronary artery disease (n = 25, 23%), cerebrovascular disease (n = 15, 14%), hypertension (n = 55, 51%), and diabetes (n = 30, 28%). of the 31 patients without known past medical history (age range, 16-62 years) (29%), our study demonstrated that the neurologic imaging features of hospitalized patients with covid-19 were variable, without a specific pattern but dominated by acute ischemic infarcts and intracranial hemorrhages. we also showed that the neurologic mri spectrum may include posterior reversible encephalopathy syndrome, hypoxicischemic encephalopathy, exacerbation of demyelinating disease, and nonspecific cortical pattern of t2 fluid-attenuated inversion-recovery hyperintense signal with associated restriction diffusion that may be caused by systemic toxemia, viremia, and/or hypoxic effects (9) . currently, we have a poor mechanistic understanding of the neurologic symptoms in patients with covid-19, whether these are arising from critical illness or from direct central nervous system invasion of severe acute respiratory syndrome coronavirus 2 (10). accumulating evidence suggests that a subgroup of patients with severe covid-19 might have a cytokine storm syndrome that could be a trigger for ischemic strokes, probably related to the prothrombotic effect of the inflammatory response (3, 11) . our results showed a lower prevalence of central nervous system symptoms than the wuhan experience (8) (15% vs 25%, respectively); however, the prevalence of ischemic strokes was higher in our study (31% vs 11%). furthermore, our findings also support the suggested potential for co-vid-19-associated guillain-barré syndrome and variants (12) . none of our patients showed abnormal parenchymal or leptomeningeal enhancement. in conclusion, neurologists and neuroradiologists should be familiar with the broad spectrum of neurologic imaging patterns associated with covid-19. coronavirus disease 2019 (covid-19) situation report -115 ct imaging features of 2019 novel coronavirus (2019-ncov) acute cerebrovascular disease following co-vid-19: a single center covid-19-associated acute hemorrhagic necrotizing encephalopathy: ct and mri features neurological complications of coronavirus disease (covid-19): encephalopathy neurologic features in severe sars-cov-2 infection a first case of meningitis/encephalitis associated with sars-coronavirus-2 neurologic manifestations of hospitalized patients with coronavirus disease nervous system involvement after infection with cov-id-19 and other coronaviruses covid-19: consider cytokine storm syndromes and immunosuppression guillain-barré syndrome associated with sars-cov-2 infection: causality or coincidence? we thank all patients and their families involved in the study.author contributions: guarantors of integrity of entire study, a.m., r.g.; study concepts/study design or data acquisition or data analysis/interpretation, all authors; key: cord-012651-7bllqwh1 authors: kalidindi, kalyan kumar varma; gupta, mayank; chhabra, harvinder singh title: a rare cause of neurological deterioration to complete paraplegia after surgery for thoracic myelopathy: a case report date: 2019-06-05 journal: spinal cord ser cases doi: 10.1038/s41394-019-0202-z sha: doc_id: 12651 cord_uid: 7bllqwh1 introduction: progressive deterioration of neurological status post-thoracic myelopathy surgery after a clinically stable period is rare and can pose a diagnostic dilemma. we present our experience with such a case where all known etiologies were ruled out and the cause of deterioration could not be conclusively identified. the course was found to be similar to sub-acute post-traumatic ascending myelopathy (spam). however, the condition has only been described for traumatic injuries so far. case presentation: our patient presented a history of back pain and associated gait instability for one and a half months. there was no history of trauma. investigations suggested an anderson-like lesion at t11–t12 with cord edema at the same level suggestive of instability. she underwent posterior stabilization t9 to l2 and laminectomy of t11 as well as t12 under neuromonitoring. the postoperative sequence of events included an episode of pyrexia on the fifth day of surgery, neurological deterioration from the seventh day of surgery proceeding to complete paraplegia by the fourteenth day, no response to steroid treatment and no signs of recovery till two years post surgery. mri findings were suggestive of spam, and there was no evidence of infection. discussion: ascending myelopathy is a potential but rare cause of delayed deterioration in neurological status after surgical intervention. mri findings of cord edema extending more than four levels above the involved segments is a characteristic finding of the condition. ascending myelopathy may lead to complete cord injury. the precise cause of the condition is unknown and prognosis remains poor. outcomes of surgical management of thoracic myelopathy have not been very promising. one of the main contributing factors to the poor outcome is the vulnerable spinal cord at the site of the lesion due to relative avascularity and reduced available space [1] . the deterioration of neurological status is a known complication of surgical decompression of thoracic myelopathy detected, either intraoperatively through neuromonitoring or in the immediate postoperative period on assessment of neurological status [2] . progressive deterioration of neurological status postoperatively is rare and can pose a diagnostic dilemma. we present our experience with one such case where all known etiologies were ruled out and the cause of progressive postoperative neurological deficit could not be conclusively identified. on thorough search of the available literature, the clinical course was found to most closely resemble an entity known as spam, which has so far been reported to occur only after significant trauma. the rarity of occurrence and lack of any published article till date warrants this case to be reported in the literature. a 43-year-old female was presented to our center with severe pain of 6 weeks' duration in the mid-back. the pain was insidious in onset, continuous, of progressively increasing intensity and with a postural variation. she was unable to lie supine due to severe intercostal pain and had to sleep in a sitting posture causing severe disability. there were associated non-dermatomal paresthesias in both lower limbs. she had been bedridden for the past 4 weeks before the presentation due to severe gait instability, resulting in an inability to walk. there were no bowel or bladder symptoms. there was no history of associated fever, significant trauma, constitutional symptoms or history suggestive of an inflammatory etiology. she had a past history suggestive of compressive cervical myelopathy two years ago when she was presented to us with difficulty in walking and weakness in both upper limbs. her neurologic status at that time of presentation was attached in fig. 1a according to the asia/ iscos-isncsci (american spinal injury association/ international spinal cord society-international standards for neurological classification of spinal cord injury). posterior stabilization from c1 to t1 and decompression by cervical laminectomy c1 to c7 and foramen magnum decompression was done at our center. she had a good outcome with an improvement of symptoms and regained the ability to walk without support (fig. 1b) . on examination, there was tenderness in the mid-back over t11-t12 region. movements of the spine could not be tested due to severe pain. higher mental functions, cranial nerve functions and neurological status in the upper limbs were within normal limits. in both lower limbs, there was increased tone and weakness. the neurologic status was as attached in fig. 1c . deep tendon reflexes in knee and ankle were exaggerated and plantar reflexes were extensor bilaterally. on the basis of clinical findings, a provisional diagnosis of thoracic myelopathy was made. radiological examination revealed multiple syndesmophytes with suspected instability between t11 and t12 vertebrae on standing anteroposterior and lateral radiographs with features suggestive of diffuse idiopathic skeletal hyperostosis (dish). the patient could not lie supine in mri due to severe back as well as girdle pain and hence, an mri was done under sedation. it revealed a three-column anderson-like lesion at t11-t12 level with cord edema behind t11 vertebra suggestive of dynamic cord compression (fig. 2) . based on these clinical and radiological findings, the patient was advised stabilization and decompression under general anesthesia to reduce pain and prevent further deterioration in neurological status. after a thorough preoperative workup, preanesthetic checkup and written there was an incidental durotomy, which was covered with fat graft and fibrin sealant. there was no loss in the motor evoked potentials intraoperatively. there was no deterioration of neurological status on immediate postoperative assessment. postoperative antibiotics and analgesics were given according to the institute's protocol. rehabilitation was initiated. on the first postoperative day, there was a significant reduction in back pain but she still complained of severe intercostal pain around t10 to t12 region predominantly on the left side which temporarily responded to intercostal blocks, tens (transcutaneous electrical nerve stimulation) and pregabalin. the intercostal blocks had to be repeated several times postoperatively. she had hyperesthesia in both lower limbs since day two for which the dose of pregabalin was increased gradually. postoperative mri revealed an adequately decompressed cord (fig. 3a, b) . radiographs and ct scan demonstrated a stable fixation (fig. 3c, d) . the screws were well positioned. she had one spike of fever (101 degrees fahrenheit) on day five of surgery for which no infective cause could be identified. the fever subsided with supportive treatment and antipyretic medication. at seven days post surgery, she started developing weakness and loss of sensations in both the lower limbs. repeat mri revealed hyper-intense signal changes extending five levels above the index level (up to t7 vertebra) but no static compression or instability at the index level (fig. 4) . she was provisionally diagnosed as a case of subacute ascending myelopathy, a type of noncompressive myelopathy. the prognosis was discussed with the patient and attendants in detail. she was put on a high dose of intravenous methylprednisolone (1000 mg) for 3 days followed by a course of oral steroids (tapering dose from 16 to 4 mg). there was a temporary halt in the progression of weakness. csf tap suggested no signs of infection, virological and serological workup was negative, and mri of the brain was normal. the wound was dry. there were no other signs of infection. her total and differential white blood cell counts were normal and creactive protein was normal. the weakness gradually progressed from ninth postoperative day resulting in complete paraplegia (neurological level t8) with completely absent perianal sensation and voluntary anal contraction by fourteenth postoperative day (fig. 1d) . mri was repeated at 6 weeks and 3 months post surgery, which suggested persistent edema till t7 vertebral level (fig. 5 ). she underwent a comprehensive rehabilitation program and was independent in the activities of daily living at the time of discharge on the 90th postoperative day. there was no further recovery in her neurological status even after two years of follow up. spam has been described in the literature as an unusual cause of delayed neurological deterioration after traumatic spinal cord injury in cases where the deterioration could not be explained by mechanical instability, syrinx formation or therapeutic mis-intervention. it was originally described by frankel in 1969 [3] . very few such cases have been reported in the literature suggesting that it is a rare entity and the condition is poorly understood [4] [5] [6] [7] [8] [9] . this entity has been described only in post-traumatic cases. common reported features of spam include neurological deterioration after few days to weeks of surgical spinal stabilization, an often preceding episode of pyrexia and an area of hyperintense signal extending at least four levels above the initial injury level on t2 mri imaging [10] . proposed hypotheses include impairment of spinal venous drainage, arterial thrombosis, inflammatory processes or secondary injury processes. inadvertent cord handling rarely causes extension of edema more than two levels above the injured segment and should be evident in the immediate postoperative period [3] . after an exhaustive literature search, we could not identify any case with such findings reported after atraumatic thoracic myelopathy. the case described here had clinical and radiological features closely resembling spam. the fact that there was no significant trauma and no extension of edema from the index level even 6 weeks after onset of symptoms suggests that secondary injury processes are unlikely to be the cause for the condition. the gradual onset of symptoms, no sparing of the posterior column and no evidence of abnormal vascular markings on early and late mri suggest that arterial cause is less likely [7] . venous congestion may involve the central gray matter more than the peripheral white matter, an axial mri finding seen in our case. however, the mri images did not demonstrate venous stasis or engorgement of surface venous structures, findings that are frequently seen in this condition when caused by a dural arteriovenous malformation [7] . the inflammatory pathology of the disco-vertebral anderson-like lesion, radiological findings of enthesitis, the temporal progression of myelopathy and mild pyrexia suggest that inflammatory pathology may be a likely contributing factor for ascending myelopathy [7] . cordectomy has been described as an effective treatment by meagher et al. in his case [4] . laminectomy and pial incision as a treatment option has been proposed by okada [9] . various other treatments proposed are anticoagulation, steroids, and mannitol. none of the treatment options proposed have been established as a standard treatment till date and the prognosis of the condition remains poor. this case report provides us with an insight into a potential cause akin to spam, which needs to be considered in a patient with progressive neurological deterioration after surgical decompression and stabilization for myelopathy. to the authors' knowledge, this is the first case report of such a condition after surgical decompression and stabilization of thoracic myelopathy. in conclusion, ascending myelopathy is a potential cause of delayed deterioration in neurological status after surgical intervention. an mri finding of cord edema extending more than four levels above the involved segments is a characteristic finding of the condition. ascending myelopathy may lead to complete paraplegia or even tetraplegia. the precise cause of the condition remains unknown and prognosis remains poor. staged spinal cord decompression through posterior approach for thoracic myelopathy caused by ossification of posterior longitudinal ligament the incidence and risk factors of postoperative neurological deterioration after posterior decompression with or without instrumented fusion for thoracic myelopathy ascending cord lesion in the early stages following spinal injury resolution of spam following cordectomy: implications for understanding pathophysiology subacute delayed ascending myelopathy after low spine injury: case report and evidence of a vascular mechanism pathological features including apoptosis in subacute posttraumatic ascending myelopathy subacute posttraumatic ascending myelopathy after spinal cord injury ascending myelopathy in the early stage of spinal cord injury sequential changes of ascending myelopathy after spinal cord injury on magnetic resonance imaging: a case report of neurologic deterioration from paraplegia to tetraplegia acute ascending myelopathy of the spine acknowledgements the authors would like to thank the concerned patient for allowing the details to be shared. conflict of interest the authors declare that they have no conflict of interest.publisher's note: springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. key: cord-308270-343r91km authors: sawlani, v.; scotton, s.; jacob, s.; nader, k.; jen, j. p.; patel, m.; gokani, k.; denno, p.; thaller, m.; englezou, c.; janjua, u.; bowen, m.; hoskote, c.; veenith, t.; hassan-smith, g. title: covid-19-related intracranial imaging findings: a large single-centre experience date: 2020-09-15 journal: clin radiol doi: 10.1016/j.crad.2020.09.002 sha: doc_id: 308270 cord_uid: 343r91km aim to describe the neuroradiological changes in patients with coronavirus disease 2019 (covid-19). materials and methods a retrospective review was undertaken of 3,403 patients who were confirmed positive for severe acute respiratory syndrome coronavirus 2 (sars-cov-2) infection, and admitted to our institution between 1 march 2020 and 31 may 2020, and who underwent neuroimaging. abnormal brain imaging was evaluated in detail and various imaging patterns on magnetic resonance imaging mri were identified. results of the 3,403 patients with covid-19, 167 (4.9%) had neurological signs or symptoms warranting neuroimaging. the most common indications were delirium (44/167, 26%), focal neurology (37/167, 22%), and altered consciousness (34/167, 20%). neuroimaging showed abnormalities in 23% of patients, with mri being abnormal in 20 patients and computed tomography (ct) in 18 patients. the most consistent neuroradiological finding was microhaemorrhage with a predilection for the splenium of the corpus callosum (12/20, 60%) followed by acute or subacute infarct (5/20, 25%), watershed white matter hyperintensities (4/20, 20%), and susceptibility changes on susceptibility-weighted imaging (swi) in the superficial veins (3/20, 15%), acute haemorrhagic necrotising encephalopathy (2/20, 10%), large parenchymal haemorrhage (2/20, 10%), subarachnoid haemorrhage (1/20, 5%), hypoxic–ischaemic changes (1/20, 5%), and acute disseminated encephalomyelitis (adem)-like changes (1/20, 5%). conclusion various imaging patterns on mri were observed including acute haemorrhagic necrotising encephalopathy, white matter hyperintensities, hypoxic-ischaemic changes, adem-like changes, and stroke. microhaemorrhages were the most common findings. prolonged hypoxaemia, consumption coagulopathy, and endothelial disruption are the likely pathological drivers and reflect disease severity in this patient cohort. ☒ performed the analysis ☒ wrote the paper infection with the novel pathogen, severe acute respiratory syndrome coronavirus 2 (sars-cov-2) has resulted in a global pandemic, which has claimed the lives of over 630,000 globally (as of 23 july 2020). severe infection culminating in acute respiratory distress syndrome (ards) along with relatively high transmission rates, has led to the greatest global public health crisis in 100 years. there is predominant respiratory involvement; however, multi-organ complications have been reported. cerebrovascular events and altered mental status have been described as the most common neurological presentations in covid-19 [1] . recent studies have described abnormal brain imaging findings of microhaemorrhages, multifocal white matter hyperintense lesions with variable enhancement, infarcts, haemorrhagic lesions, acute haemorrhagic necrotising encephalopathy, inflammatory cns syndromes including acute disseminated encephalomyelitis (adem), and medial temporal lobe abnormalities [2] [3] [4] . as one of the largest uk centres, the present study describes the intracranial imaging findings and likely pathogenesis of patients with covid-19. this retrospective observational study was approved by the institution's review board and the need for ethical approval was waived. consecutive patients with covid-19 and neurological manifestations who underwent brain imaging between 1 march 2020 to 31 may 2020 were assessed for inclusion. all patients had a confirmed diagnosis of covid-19 based on detection of sars-cov-2 by reverse transcription polymerase chain reaction (rt-pcr) from sputum or nasopharyngeal swabs. they required hospitalisation with neurological signs or symptoms during inpatient admission, warranting brain imaging. patients with abnormal brain imaging studies j o u r n a l p r e -p r o o f were included (fig. 1) . informed consent was obtained from patients or where appropriate, consent was provided by the next of kin. clinical, laboratory, and imaging data ct brain imaging was performed using a 64-section multidetector ct system (siemens, erlangen, germany). mri was performed using a 1.5 t system (siemens, erlangen, germany) with a 32-channel phased-array head coil. the following sequences of the whole-brain were obtained: t1-weighted sagittal, axial t2(table 1 ). the most common indications were delirium (n=44), focal neurology (n=37), and altered consciousness (n=34). brain mri was abnormal in 20 patients and ct was abnormal in 18 patients. results of abnormal ct studies are summarised in table 2 . findings included subacute infarct, acute infarct, basal ganglia haemorrhage, and subarachnoid haemorrhage, with most patients presenting with focal neurology. the majority of patients presenting with altered consciousness and delirium were investigated by brain mri. for patients who had an abnormal mri brain study, the mean age was 59.7 (range 32-91) years, and the male-to-female ratio was approximately 2:1. sixty percent were of white ethnicity and 25% were from an asian background. eighteen outcome was variable with seven patients discharged home, six undergoing rehabilitation, four patients died, and the remaining three patients continued to remain as inpatients for at least 1 month. patient demographic and clinical information is summarised in table 3 . a number of neuroradiological findings were identified in patients with abnormal mri brain studies (n=20). mri patterns and likely pathogenesis are described in detail in electronic supplementary material table s1 . findings included microhaemorrhages j o u r n a l p r e -p r o o f (n=12), watershed white matter hyperintensities (n=4), susceptibility changes on swi in superficial veins (n=3), acute infarct (n=3), subacute infarct (n=2), acute haemorrhagic necrotising encephalopathy (n=2), large parenchymal haemorrhage (n=2), subarachnoid haemorrhage (n=1), hypoxic-ischaemic changes (n=1), and adem-like changes (n=1). results for mri findings are summarised in table 4 (fig. 2) . similar lesions were also seen in the corpus callosum and cerebellar white matter. in addition, microhaemorrhages were noticed in the splenium of the corpus callosum and brainstem. the other watershed pattern was of scattered dwi high signal lesions in centrum semiovale with micro-and macro-haemorrhages (fig. 3) . susceptibility changes on swi were seen in superficial veins in 15% of patients, in conjunction with microhaemorrhages, likely representing microthrombi (fig. 4f) . all of these patients had diabetes and two of these three patients also had hypertension as a predisposing risk factor. haemorrhage. there is emerging evidence that the underlying pathogenesis for these presentations is closely linked to a combination of prolonged hypoxaemia, consumption coagulopathy, and endothelial dysfunction [5, 6] . the spike protein of sars-cov-2 has a strong affinity for angiotensin-converting enzyme 2 (ace2) receptor, which allows it to enter host cells. this protein is expressed on alveolar epithelial cells, intestinal enterocytes, and arterial and venous endothelial cells [7] . using electron microscopy, sars-cov-2 viral elements have been demonstrated within endothelial cells themselves, associated with profound inflammation and tissue oedema in covid-19 patients at autopsy [6] . a recent j o u r n a l p r e -p r o o f neuropathological series of 18 patients has shown that although the virus was detected at low levels in five patients, there was no evidence of encephalitis and the explanation for this could have been due to in situ virions or viral rna from blood [8] . all the patients in this neuropathological series demonstrated acute hypoxicischaemic damage. hypoxic-ischaemic damage has been shown to cause leukoencephalopathy and white matter cytotoxic oedema in critically ill patients. leukoencephalopathic changes with or without cytotoxic oedema are seen in many other condition including posterior reversible encephalopathy syndrome (pres), sepsis, adem, hypotension, hypoxia, prolonged ventilator support, drug therapy, and toxic metabolic diseases [9, 10] . sars-cov-2 infection initiates a pro-inflammatory cytokine storm led by tumour necrosis factor α (tnf-α), interleukin 6 (il-6), and interleukin 1β (il-1β) [11] . this results in a downstream increase in vascular permeability, blood-brain and blood-csf barrier dysfunction, neuroinflammation and subsequent leukoencephalopathy, thought to be due to oligodendroglial cell death and consequent demyelination predominantly in the deep watershed regions [12] . one patient, who had sustained a cardiac arrest, showed restricted diffusion in the basal ganglia bilaterally, in keeping with hypoxic-ischaemic changes. in this patient, the imaging appearances were likely secondary to hypoxia from cardiac arrest, which could have been a complication of covid-19 infection involving the myocardium. a neuropathological study has also demonstrated similar appearances in the brain after cardiac arrest in one covid-19 patient, thought to be secondary to hypoxia [13] . microvascular disruption of the endothelium in brain tissue may be responsible for extravasation of red blood cells and extensive microhaemorrhages [6, 14] . microhaemorrhages have been reported previously in a number of locations j o u r n a l p r e -p r o o f including lobar, subcortical, deep, corpus callosum, pontine, and cerebellar [2, 3] . a few studies have reported the splenium of corpus callosum as a predominant location for microhaemorrhages, with or without oedema [4, 15] . microhaemorrhages in the splenium of the corpus callosum have been reported previously in severe ards and high-altitude cerebral oedema, thought to be due to hypoxaemia [16] . it is increasingly recognised that respiratory failure may be due to micro-emboli, and these may also affect the cerebral microcirculation resulting in microthrombosis and microvascular ischaemia. linear structures resembling vessels were observed with susceptibility artefacts on swi, which are probably microthrombi. this increases the risk of stroke or ischaemia amplifying the cytokine-induced injury to the brain [17] . ischaemic stroke was a common pattern seen on both mri and ct. fifteen patients presented with large vessel stroke on ct and five patients on mri; most were severe, including bilateral mca infarct, as noted previously [2] . acute stroke seems to be the most common neuroradiological presentation in a large cohort of covid-19 patients [18] . similar findings with ischaemic changes and microhaemorrhages have also been published in isolated case reports [19] . elevated d-dimer levels were observed in most of the present patients, probably due to a hypercoagulable environment. four patients presented with intracerebral bleeds on ct and mri; causes could be due to predisposing vascular risk factors (in 76% of the patient cohort) such as hypertension, anticoagulation treatment as prophylaxis from thromboembolism, and ecmo. adem-like presentation was seen in one patient, with evidence of haemorrhage, also reported in a previous study [2] . although scattered white matter demyelinating lesions and perivenular tracking raises the possibility of a parainfectious adem-like process, the authors' impression of the overall phenotype suggested a primarily vascular insult, with secondary white matter injury. a detailed neuropathological examination of one patient has been reported recently [14] , which concluded that vascular insult was the primary driver of the neurological sequelae. at the peak of the pandemic, although delirium and neuro-cognitive symptoms were neurological and neuropsychiatric complications of covid-19 in 153 patients: a uk-wide surveillance study the emerging spectrum of covid-19 neurology: clinical, radiological and laboratory findings brain mri findings in severe covid-19: a retrospective observational study covid-19-associated diffuse leukoencephalopathy and microhemorrhages covid-19 related coagulopathy: a distinct entity? endothelial cell infection and endotheliitis in covid-19 tissue distribution of ace2 protein, the functional receptor for sars coronavirus. a first step in understanding sars pathogenesis neuropathological features of covid-19 differences of clinical manifestations according to the patterns of brain lesions in acute encephalopathy with reduced diffusion in the bilateral hemispheres pattern of brain injury in the acute setting of human septic shock covid-19: consider cytokine storm syndromes and immunosuppression hypoxic-ischemic leukoencephalopathy in man microvascular injury and j o u r n a l p r e -p r o o f hypoxic damage: emerging neuropathological signatures in covid-19 neuropathology of covid-19: a spectrum of vascular and acute disseminated encephalomyelitis (adem)-like pathology unusual microbleeds in brain mri of covid-19 patients the pattern of brain microhemorrhages after severe lung failure resembles the one seen in high-altitude cerebral edema covid-19 related neuroimaging findings: a signal of thromboembolic complications and a strong prognostic marker of poor patient outcome evolving neuroimaging findings during covid-19 covid-19-associated acute hemorrhagic necrotizing encephalopathy: imaging features transient cortical blindness in covid-19 pneumonia; a pres-like syndrome: case report key: cord-265293-l9omunq4 authors: schönegger, carmen maria; gietl, sarah; heinzle, bernhard; freudenschuss, kurt; walder, gernot title: smell and taste disorders in covid-19 patients: objective testing and magnetic resonance imaging in five cases date: 2020-10-24 journal: sn compr clin med doi: 10.1007/s42399-020-00606-4 sha: doc_id: 265293 cord_uid: l9omunq4 smell and taste disorders are acknowledged as characteristic symptoms for sars-cov-2 infection by now. these symptoms have been linked to a neuroinvasive course of disease. in this study, we investigated five consecutive covid-19 patients with a prolonged course of dysosmia and dysgeusia. those with objectifiable alteration in taste or smell were subjected to mri with contrast agent to investigate possible involvement of the central nervous system. we found dysosmia and dysgeusia to be mostly objectifiable, but no evidence for neuroinvasiveness could be detected by mri in the late stage of the disease. alterations in taste and smell could be objectified in most patients. nevertheless, no evidence for a neuroinvasive potential could be identified by mri, at least in the late stage of disease. we encourage medical professionals to conduct specialized examinations and mris in the acute stage of disease, which guarantees an optimum patient care. although a lot of effort has been made in order to investigate this novel coronavirus, our knowledge about many pathogenic aspects of covid-19 is still limited. clinical and experimental studies proved that several coronaviruses have neuroinvasive capacities, since they show the ability to spread from the respiratory tract to the central nervous system [1] . hypothesis of neurotropism of sars-cov-2 is based on covid-19 patients with neurological manifestations. furthermore, neurological complications up to actual damage hint neurovirulence [2] . actual case reports substantiate this assumption. covid-19 can cause meningitis with a fatal outcome, which was evidenced by the case of a 24-year-old man in japan, who succumbed to the disease [3] . brain mri demonstrated hemorrhagic lesions that were consistent with acute necrotizing hemorrhagic encephalopathy [4] . another manifestation of nervous system involvement is the appearance of alterations of taste and smell [5] . anosmia and dysgeusia are by now acknowledged as significant symptoms in association with covid-19 by the american academy of otolaryngology-head and neck surgery (aao-hns) and other researches [6, 7] . case series show a high frequency of chemosensitive disorders in patients, ranging between 19.4 and 88% [8, 9] . according to vaira et al., the presence of olfactory and gustatory dysfunction may predict a milder course of disease. on the other hand, the neglect of such symptoms suggests a more severe course of disease [10] . some patients reported isolated olfactory or taste disorders, but more complained about a combined dysfunction. even though a complete recovery could be noted in regard to most patients, evidence has been found about persisting alterations in chemosensory function for a prolonged period [11] . at the shahid beheshti university of medical sciences in tehran/iran, possible olfactory bulb alterations were investigated by olfactory bulb magnetic resonance imaging. in spite of isolated sudden onset anosmia and positive sars-cov-2polymerase chain reaction during the acute phase of the carmen maria schönegger and sarah gietl contributed equally to this work. this article is part of the topical collection on covid-19 disease, the mri demonstrated normal volume and signal intensity of olfactory bulb with no sign of nasal congestion [12] . the study was conducted on five patients reporting impairment of taste and smell with confirmed sars-cov-2 infection in east tyrol. written informed consent was obtained from all participants. age ranged between 41 and 57 years, and all the participants were female. clinical data and history of symptoms were assessed anamnestically. olfactory and gustatory testing was conducted between 11 and 30 days after disease onset, which was defined as the commencement of symptoms. in case objective testing revealed alterations in taste or smell, patients were subjected to mri in a timely manner. a follow-up examination was conducted in three of the patients whose mri raised suspicion of alterations in the first run. olfactory and gustatory function assessment was carried out by means of burghart screening 12 test with taste strips in accordance with the manufacturer's instructions [13, 14] . in order to evaluate olfactory function, an identification test, called sniffin' sticks, was performed [13] . twelve common odorants were consecutively presented to the patient close to both nostrils. out of four options the participant was requested to identify the presented smell. results were interpreted according to a scoring system considering patients age. a score above ten was determined as normal, between six and ten a hyposmia was diagnosed and a score below six was reported as anosmia. gustatory testing was performed by taste strips covering the four basic gustatory qualities sweet, salty, sour, and bitter [14] . taste strips were applied on patient's tongue. for each stripe, the test person had to choose the corresponding odor from four answers. according to the count of correct answers, four categories of classification were established: normal (score 4), mild hypogeusia (score 3), moderate hypogeusia (score 2), severe hypogeusia (score 1), and ageusia (score 0). a standard brain mri protocol was used involving axial t2 tse, axial flair, axial dwi (b0 and b1000), dadc, axial t2w ffe, and isotropic t1w 3d ir tfe with a 1-mm slice thickness without contrast media and cet1w 2d mprage, on a 1.5t prodiva philips mri machine. the 3d t1 sequences with and without contrast were reconstructed in coronal, axial, and sagittal projection for the radiologic evaluation. a short-term follow-up examination 10 days later was performed with the same axial flair and dwi/dadc. sequences were used as well as isotropic 3d t2 and 3d flair sequences (appendix). olfactory and gustatory testing was conducted between 11 and 30 days after onset of disease, which was defined as the commencement of symptoms. out of the five patients three showed a manifest anosmia, one result was rated as a hyposmia and one as normosmia. gustatory testing revealed two normal scores (4/4), one moderate hypogeusia (2/4), one severe hypogeusia (1/4), and one ageusia (0/4). detailed results are summarized in table 1 . three weeks after the first olfactory and gustatory examination, a follow-up testing was conducted with the three patients who also had a second mri. this investigation revealed one persistent anosmia (5/12), one persistent hyposmia (7/12), and one patient's condition improved from anosmia to hyposmia (10/12). gustatory testing showed an enhancement in two patients (3/4; 4/4); one patient had the same score (4/4). detailed results are summarized in table 2 . none of the patients showed any changes in the paranasal sinuses, not even small fluid collections or mucosal swelling. the cribriform plate was normal in all cases, and the olfactory nerve was normal in size and signal, without any side differences and there was no neuronal or perineural enhancement. the meninges showed no enhancement or thickening. the gyrus rectus was normal in size and signal intensity in all patients and showed no swelling. no signal changes in the medial temporal lobes or the thalami could be found and no hemorrhagic microbleeding in t2* sequences were observed. even though ischemic events and leptomeningeal enhancement have already been reported, there were no signs for an acute or chronic ischemic event [15] . in the first examination, one patient showed a symmetric, slightly hyperintense signal in the head of the caudate nucleus, parahippocampal gyrus, and the uncus, predominantly on the left side. in t2, the area appeared thicker and swollen with a higher si, but all the other sequences including dwi were normal. also, si measurements were slightly elevated with values of 1021 compared to 865 on average in primarily healthy individuals. in the follow-up examination, there was a slight drop to 970, but the additional high-resolution 3d flair and t2 images showed no anomalies, so probably this finding lies within the normal range. all the other patients had a normal brain mri (images 1, 2, and 3). in contrast to galougahi et al., we evaluated symptom status in the late stage of covid-19 [11] . the smell and taste disorders could mostly be objectified, although not in regard to all patients, which underlines the necessity of objective testing. compared to dell'era et al., who reported a median recovery time of 10 days, our findings show that olfactory impairment is a long-lasting sequela of covid-19 [16] . even after 30 to 50 days, patients still suffered from objectifiable smell and taste disorders. in order to rule out permanent damage, further surveillance is necessary. however, it should be notified that a loss of smell and taste is not pathognomonic for covid-19, as it appears as well in the course of other respiratory infections. nevertheless, controlled studies indicate that anosmia is more common in covid-19 patients than in patients suffering from other viral infections or controls [17] . in contrast to other infectious smell impairments, a loss of smell and taste in covid-19 seems to be rarely accompanied by a severely blocked nose [18] . the first mri images showed slight alterations in one patient, which could be associated with a sars-cov-2 infection. however, the follow-up examination contradicted this assumption. image 2 mri cor t1 the mri investigation in our patients taught us two things: first, at least in chronic stages of the illness, we did not gain any evidence of prolonged neuroinvasive association. up to now, mri investigations have focused on the acute stage of illness and are very rare. in our case, the organization was hindered by the concern that such investigations might be an incalculable risk for the staff involved. according to politi et al., conducting an mri examination in a patient suffering from persistent severe anosmia and dysgeusia, cortical hyperintensity in the right gyrus rectus could be detected 4 days after symptom onset. consistent with our results, a complete resolution of the previously seen signal alterations could be observed in a follow-up imaging 28 days after symptom onset [19] . contrary to assumptions of other researchers, no evidence of a general neuroinvasiveness could be given, at least in the chronic stage of disease [20] . more extensive studies in the acute stage of illness followed by long-term follow-ups are desirable. contrary to other evaluations, our study population is rather small which is a limiting factor to the informative value. as hygiene measures proved to be sufficient avoiding contagion, we encourage medical professionals to conduct specialized examinations and mris in the acute stage of disease, which guarantees an optimum patient care. authorship contribution sg and cms wrote the manuscript and were responsible for the organization. bh was responsible for magnetic resonance imaging, kf for the objective olfactory and gustatory testing. gw supervised and reviewed the manuscript. conflict of interest the authors declare that they have no conflict of interest. consent for publication written informed consent was obtained from all participants. ethics approval ethical approval was not necessary as the evaluation was performed in the course of patient care and clinical monitoring. human coronaviruses and other respiratory viruses: underestimated opportunistic pathogens of the central nervous system? viruses neurological complications of coronavirus and covid-19 a first case of meningitis/ encephalitis associated with sars-coronavirus-2 covid-19-associated acute hemorrhagic necrotizing encephalopathy: ct and mri features evidence of the covid-19 virus targeting the cns: tissue distribution, host-virus interaction, and proposed neurotropic mechanisms covid-19 anosmia reporting tool, american academy of otolaryngology-head and neck surgery self-reported loss of smell and taste in sars-cov-2 patients: primary care data to guide future early detection strategies isolated sudden onset anosmia in covid-19 infection. a 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sudden olfactory loss in the diagnosis of covid-19 magnetic resonance imaging alteration of the brain in a patient with coronavirus disease 2019 (covid-19) and anosmia sars-cov-2: olfaction, brain infection, and the urgent need for clinical samples allowing earlier virus detection publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations key: cord-003095-m9hmv8c8 authors: zhang, ya-zhou; cao, xu-yang; li, xi-cheng; chen, jia; zhao, yue-yuan; tian, zhi; zheng, wang title: accuracy of mri diagnosis of early osteonecrosis of the femoral head: a meta-analysis and systematic review date: 2018-07-04 journal: j orthop surg res doi: 10.1186/s13018-018-0836-8 sha: doc_id: 3095 cord_uid: m9hmv8c8 objective: to evaluate the overall diagnostic value related to magnetic resonance imaging (mri) in patients with early osteonecrosis of the femoral head. methods: by searching multiple databases and sources, including pubmed, cochrane, and embase database, by the index words updated in december 2017, qualified studies were identified and relevant literature sources were also searched. the qualified studies included prospective cohort studies and cross-sectional studies. heterogeneity of the included studies were reviewed to select proper effect model for pooled weighted sensitivity, specificity, and diagnostic odds ratio (dor). summary receiver operating characteristic (sroc) analyses were performed for meniscal tears. results: forty-three studies related to diagnostic accuracy of mri to detect early osteonecrosis of the femoral head were involved in the meta-analysis. the global sensitivity and specificity of mri in early osteonecrosis of the femoral head were 93.0% (95% ci 92.0–94.0%) and 91.0% (95% ci 89.0%–93.0%), respectively. the global positive likelihood ratio and global negative likelihood ratio of mri in early osteonecrosis of the femoral head were 2.74 (95% ci 1.98–3.79) and 0.18 (95% ci 0.14–0.23), respectively. the global dor was 27.27 (95% ci 17.02–43.67), and the area under the sroc was 93.38% (95% ci 90.87%–95.89%). conclusions: this review provides a systematic review and meta-analysis to evaluate the diagnostic accuracy of mri in early osteonecrosis of the femoral head. moderate to strong evidence indicated that mri appears to be significantly associated with higher diagnostic accuracy for early osteonecrosis of the femoral head. avascular necrosis of femur head (anfh), or osteonecrosis of the femoral head, is a pathologic process, which was first seen in the weight-bearing area of the femur. the stress can lead to bone trabecular structure injury (microfracture) and influence the repair process of the femur, and if not managed timely, it leads to the collapse and deformation of the femur. with many etiological factors, anfh results from interruption of blood supply to the bone and then leads to ischemic necrosis. anfh can be divided in traumatic anfh and non-traumatic anfh with the non-traumatic anfh further dividing into steroid-induced and alcoholic non-traumatic anfh and so on. the timely treatment of early anfh could promote the recovery the disease. however, in the late stage, it results in femur collapse, loss of hip function, and a very poor outcome that affects the quality of life. therefore, the early diagnosis of anfh is of great significance [1] [2] [3] . several methods for early diagnosis of anfh have been proposed, including mri, spect, ct, x-ray, dsa, and laser doppler with different characteristics. mri has been characterized as being non-invasive, rapid and high sensitive, and commonly used by many clinicians [4] [5] [6] . furthermore, mri has been used in many studies in the diagnosis of early anfh. therefore, in this paper, a systematic review and meta-analysis of all qualified studies were performed to explore the diagnosis accuracy of mri in early anfh. the following electronic databases were searched from their inception to december 2017: the cochrane, pubmed, embase database, for all the qualified trails that analyze the diagnostic accuracy of mri of early osteonecrosis of the femoral head. other related articles and reference materials were also identified for additional available studies. the literatures were searched independently by two investigators, and a third investigator was involved to reach an agreement. the studies that met the following criteria were included in our review: (1) prospective cohort study or cross-sectional study; (2) the research objects are patients suspected with early osteonecrosis of the femoral head without other serious diseases; (3) the studies provided the data of true positive (tp), false positive (fp), false negative (fn), and true negative (tn); and (4) the publications were only available in english and chinese. the studies that met the following criteria were excluded in our review: (1) repeat publications, or shared content and results; (2) case report, theoretical research, conference report, systematic review, meta-analysis, expert comment, and economic analysis; (3) the outcomes were not relevant; and (4) two or more results of the tp, fp, fn, and tn were zero. two independent investigators extracted the following data based on predefined criteria. differences were settled by discussion with a third reviewer. the analyses data were extracted from all the included studies and consisted of two parts: basic information and main outcomes. the first part was about the basic information: the author name, the sample size, the percentage of male, and the age. the second part was the clinical outcomes. a 2 × 2 contingency table was constructed for each selected study; the results corresponding to the gold standard and mri were selected as positive or negative. the data included true positive (tp), false positive (fp), false negative (fn), and true negative (tn). in studies in which one single cell in the 2 × 2 contingency table had a value of 0, 0.5 were added to all of the cells for calculation. sensitivity, specificity, and likelihood ratio were calculated respectively, and the diagnostic odds ratio (dor) was used as the measure of diagnostic accuracy. a dor value of 1 indicates a test without discriminatory power, and the higher the dor value is, the greater the degree of relevance of the assessed diagnostic test. the studies were performed by two reviewers independently. any arising difference was resolved by discussion. all statistical analyses were performed in the stata 10.0 (tx, usa). chi-squared and i 2 tests were used to assess the heterogeneity of clinical trial results and determine the analysis model (fixed-effects model or random-effects model). when the chi-squared test p value was ≤ 0.05 and i 2 test value was > 50%, it was defined as high heterogeneity and assessed by random-effects model. when the chi-squared test p value was > 0.05 and i 2 tests value was ≤ 50%, it was defined as acceptable heterogeneity data and assessed by fixed-effects model. for further assessment of heterogeneity, diagnostic threshold analysis was performed based on the correlation (spearman's) between the logit of sensitivity and the logit of [1-specificity] . when a threshold effect occurs, the sensitivity and specificity of the investigated study exhibits negative correlation (or a positive correlation between sensitivity and [1-specificity]). therefore, a strong positive correlation between sensitivity and [1-specificity] suggests the presence of a threshold effect. when heterogeneity caused by threshold effect was observed, a summary receiver operating characteristic (sroc) curve was plotted. this method was appropriate given that the global sensitivity and specificity values were overestimated. in such cases, analysis of the roc panel points, as well as analysis of the sroc curve, was recommended. deeks' funnel asymmetry plot was used to identify the publication bias. a total of 2092 articles were searched by the indexes. after screening the titles and abstracts, 1986 articles were excluded, leaving 106 articles for further selection. during full-text screening, 63 articles were excluded due to the following criteria: unqualified outcomes [7] , theoretical research or review [8] , and has non clinical outcome [9] . at last, 43 studies with 3133 hips were involved in the final meta-analysis. the selection process was presented in fig. 1 . the main characteristics of the included studies were summarized in table 1 . the basic information included number of hips, age, and gender. all the included studies reported the results of the accuracy of mri of early osteonecrosis of the femoral head. based on the correlation (spearman's r = − 0.209, p = 0.589) between the logit of sensitivity and the logit of [1-specificity], there was no threshold effect. based on the chi-squared test (q = 166.45, p = 0.000) and i 2 tests (i 2 = 74.6%), heterogeneity was high, so we chose the random-effects model to analyze the sensitivity. the global sensitivity was 93.0% (95% ci 92.0-94.0%, fig. 2 ). based on the chi-squared test (q = 144.43, p = 0.000) and i 2 tests (i 2 = 70.9%), heterogeneity was high. therefore, we chose the random-effects model to analyze the specificity, and the global specificity was 91.0% (95%ci 89.0-93.0%, fig. 3) . based on the chi-squared test (q = 125.33, p = 0.000) and i 2 tests (i 2 = 66.5%), heterogeneity was high, so we chose random-effects model to analyze the positive likelihood ratio, and the global positive likelihood ratio was 2.74 (95% ci 1.98-3.79, fig. 4 ). therefore, a positive mri result was increased by 2.74-fold in the odds of an accurate diagnosis of patients who actually had early osteonecrosis of the femoral head. based on the chi-squared test (q = 69.58, p = 0.005) and i 2 tests (i 2 = 39.6%), with low heterogeneity, we chose the fixed-effects model to analyze the negative likelihood ration. the global negative likelihood ratio was 0.18 (95% ci 0.14-0.23, fig. 5 ), indicating the use of mri, which was close to zero. specifically, the odds of a false-positive result were increased by only a factor of 0.18. based on the chi-squared test (q = 59.71, p = 0.037) and i 2 tests (i 2 = 29.7%), heterogeneity was low, so we chose the fixed-effects model to analyze the dor, with the global dor being 27.27 (95% ci 17.02-43.67, fig. 6 ). and the odds of a positive mri result were 27.27-fold higher among individuals with early osteonecrosis of the femoral head compared to those without the disease. the area under the sroc was 93.38% (auc = 93.38%; 95% ci 90.87%-95.89%, fig. 7) , indicating high accuracy. several systematic reviews and meta-analysis have been published concerning the diagnostic accuracy of mri of early osteonecrosis of the femoral head. li et al. [51] found that the sensitivity and specificity of mri were 95%(95% ci 94-96%) and 77%(95% ci 70-83%), respectively. moreover, the dor was 31.89%(95% ci 17.32-58.70%), and the auc under the sroc was 0.9166. mri was associated with high diagnostic accuracy in the patients with suspected early anfh. song et al. [52] , who included 21 articles, reported that mri was more effective than ct in diagnosing anfh. significant statistical difference was identified between them (or, 0.13; 95% ci 0.03-0.51). su et al. [53] , who included 8 studies of 515 patients, found the anfh positive rate between ct and mri was statistically significant (or, 0.12; 95% ci 0.04-0.33), so as the early stage positive rate (or, 0.45; 95% ci 0.26-0.78). therefore, mri appears to be a promising diagnostic tool for avascular necrosis of the femoral head. however, there were several limitations in this analysis: (1) differences in the inclusion and exclusion criteria for fig. 6 forest plot showing the diagnostic odds ratio of mri of early osteonecrosis of the femoral head patients, (2) different patients with previous disease and treatments were unavailable, (3) all the included studies were from english and chinese articles, which may be the source of bias, (4) the fluency of technicians between different studies varied, and (5) pooled data were used for analysis, and individual patients' data were unavailable, which limited a more comprehensive analysis. in summary, in this systematic review and meta-analysis, mri as a diagnostic method is associated with higher accuracy for detecting anfh. more studies and randomized controlled trails with high-quality and large samples are warranted for further evaluation. ethics approval and consent to participate not applicable. nontraumatic necrosis of bone (osteonecrosis) core decompression and conservative treatment for avascular necrosis of the femoral head: a meta-analysis comparison of core decompression and conservative treatment for avascular necrosis of femoral head at early stage: a meta-analysis early magnetic resonance imaging and histologic findings in a model of femoral head necrosis idiopathic bone necrosis of the femoral head. early diagnosis and treatment in brief: ficat classification: avascular necrosis of the femoral head comparative analysis of ct and mri in diagnosis of femoral head necrosis comparative study of ct and mri in diagnosis of 100 cases of femoral head necrosis the value of contrast mri and ct in the early diagnosis of femoral head necrosis the application value of ct and mri in early diagnosis of osteonecrosis of the femoral head the application value of ct and mri in early diagnosis of osteonecrosis of the femoral head the value of ct and mri in the diagnosis of early femoral head necrosis the value of ct and mri in the diagnosis of femoral head necrosis application value of ct and mri in the diagnosis of early femoral head necrosis ct and magnetic resonance imaging (mri) in the diagnosis of femoral head necrosis in comparison mri and ct diagnosis of avascular necrosis of the femoral head comparative analysis of ct and mri in the diagnosis of early necrosis of femoral head comparative analysis of ct and mri in the diagnosis of early necrosis of femoral head summary roc plots for diagnostic accuracy of mri of early osteonecrosis of the femoral head clinical value of mri in the diagnosis of early necrosis of femoral head comparative analysis of diagnostic value of x -ray, ct and mri in early diagnosis of avascular necrosis of femoral head analysis on diagnosis value of mri in early femoral head necrosis comparison of x-ray, ct and mri in the diagnosis of early avascular necrosis of femoral head application of spiral ct and high field mri in the early diagnosis of adult femoral head necrosis clinical value of ct and mri in diagnosis of early osteonecrosis of femoral head in adults clinical value of ct and mri in diagnosis of early osteonecrosis of femoral head in adults clinical value of ct and mri in diagnosis of early osteonecrosis of femoral head in adults patients with avascular necrosis of the femoral head using mri, spiral ct examination contrast. china reflexolocy comparison of multislice spiral ct and mri in the clinical diagnosis of femoral head necrosis comparative study of ct and mri in patients with femoral head necrosis femoral head necrosis in patients with a comparative study of ct and mri diagnosis comparative analysis of ct and mri radiological diagnosis of femoral head necrosis comparative analysis of ct and mri in diagnosis of avascular necrosis of femoral head comparison of ct and magnetic resonance imaging in diagnosis and treatment of femoral head necrosis effect of ct and mri in diagnosing femoral head necrosis diagnostic value of two methods of mri and ct in avascular necrosis of femoral head mri combined with ct in the diagnosis of avascular necrosis of the femoral head observation on the mri diagnosis on ischemic bone necrosis and surgical treatment the value of ct and mri examination in the early diagnosis of adult femoral head necrosis low field strength mri diagnosis of avascular necrosis of femoral head diagnostic value of multislice spiral ct and mill on femoral head necrosis evaluation of the value of multislice spiral ct and mri in the diagnosis of femoral head necrosis early diagnosis of avascular necrosis of femoral head in adults early osteonecrosis of the femoral head: detection in high-risk patients with mr imaging evaluation of magnetic resonance imaging in the diagnosis of osteonecrosis of the femoral head. accuracy compared with radiographs, core biopsy, and intraosseous pressure measurements the diagnostic value of magnetic resonance imaging in non-traumatic osteonecrosis of the femoral head the value of magnetic resonance imaging in the early diagnosis of noninvasive avascular necrosis of femoral head bone spect is more sensitive than mri in the detection of early osteonecrosis of the femoral head after renal transplantation comparative study of radionuclide scanning and mri in diagnosis of avascular necrosis of femoral head in early adults avascular necrosis in severe acute respiratory syndrome: mr imaging with radionuclide correlation diagnostic value of ct and mri in the early stage of adult femoral head necrosis meta-analysis of mri diagnosis of early avascular necrosis of femoral head meta-analysis of ct and mri diagnosis of avascular necrosis of femoral head meta-analysis of ct and mri diagnosis of avascular necrosis of femoral head the authors declare that they have no competing interests. key: cord-306611-8s4scr7r authors: fattore, julia; goh, daniel soon lee; al-hindawi, ahmad; andresen, david title: revisiting the important role of magnetic resonance imaging (mri) in long bone acute osteomyelitis: a case report of methicillin resistant staphylococcus aureus acute tibial osteomyelitis with conventional radiography, computed tomography, and mri date: 2020-08-22 journal: radiol case rep doi: 10.1016/j.radcr.2020.07.079 sha: doc_id: 306611 cord_uid: 8s4scr7r the tibia is an atypical site of osteomyelitis (om) in adults, and patients with this infection experience a significant degree of morbidity as well as the need for prolonged aggressive antibiotic therapy. the early diagnosis of om remains challenging, and often relies on imaging modalities which are of variable sensitivity. we present a case of a 49-year-old male with a methicillin resistant staphylococcus aureus (mrsa) left tibial om, contiguous left knee septic arthritis, and concurrent bacteraemia. eight days after the onset of pain in the left knee and lower limb, conventional radiography and computed tomography (ct) imaging had only subtleties of a soft tissue collection and a knee effusion. a mri demonstrated significant involvement of his tibial bone with a collection, from which surgical specimens confirmed mrsa. this case demonstrates the difficulty of diagnosing early acute om with conventional radiography and ct imaging, even after a week of symptoms in the affected limb. given the poor sensitivity of conventional radiography and ct in the diagnosis of early acute om, this case report illustrates how mri is the imaging modality of choice in this setting. mrsa. this case demonstrates the difficulty of diagnosing early acute om with conventional radiography and ct imaging, even after a week of symptoms in the affected limb. given the ✩ informed consent was gained from the patient for the manuscript. ✩✩ acute osteomyelitis (om), a bacterial infection of the bone, is a serious condition which has the potential to result in significant morbidity and high economic impacts on both the individual and the health care systems. it can develop as a complication of contiguous spread from an overlying soft tissue or joint infection, direct inoculation via an open fracture, following surgical or other procedures, or via haematogenous seeding [1] . om has a bimodal age distribution, with acute and subacute haematogenous om more common in children and the metaphysis of long bones being the primary site of pediatric infection [2] . in adults, direct inoculation of bone is the more common mechanism of bone infection, typically associated with open trauma in young adults, with contiguous soft tissue infection in diabetics, and with implant surgery such as hip and knee replacements in older adults. typical sites of nonimplant-associated adult om are the tarsal, metatarsal, toe and vertebral bones. adults at increased risk for hematogenous om include intravenous drug users, patients with indwelling catheters, the immunosuppressed, and those with compromised vascular supply [3 ,4] . the majority of acute om cases are monomicrobial and usually caused by staphylococcus aureus, both methicillin sensitive and methicillin resistant. polymicrobial infections are more likely to be seen on om complicating a contiguous focus of sepsis or open trauma. in this setting, common microorganisms including coagulase negative staphylococci, streptococci, enterococci, pseudomonas aeruginosa, the enterobacterales (enteric gram-negative rods), anaerobes, and in some epidemiological contexts mycobacterium tuberculosis [1 ,5-7] . goals of om therapy includes eradication of infection, minimization of complications, and the restoration of functionality. for this to occur, many patients require a combination of both medical treatment and surgical intervention to ensure adequate drainage of all infected tissue and removal of any hardware present. however, the diagnosis of acute om remains a challenge in clinical practice. along with the assessment of history, clinical examination, microbiological and biochemical laboratory results, the use of imaging is central to the diagnosis of om. plain x-rays are the initial imaging modality of choice and are useful in detecting noninfectious bony disease and more advanced sequelae of om, such as destructive changes of the bone. however, plain films are of variable sensitivity and early infection may not be evident on the initial images [8] . computed tomography (ct) also has utility in the setting of om, where it is particularly useful in detection of sequestrum in the setting of chronic om [9] . as with plain x-rays, though, ct is limited in its ability to demonstrate bone marrow oedema which is a key feature of acute om [10] . hence ct scans are often not diagnostically useful in the acute setting. magnetic resonance imaging (mri) on the other hand, appears to be the most sensitive imaging modality in acute om and can demonstrate early features of infection such as bone marrow oedema just days after infection onset [11 ,12] . in a meta-analysis of the accuracy of diagnostic tests for om in diabetic patients with foot ulcers, dinh et al. showed that plain radiography had a sensitivity of 0.54 and a specificity of 0.68 whereas mri had a sensitivity of 0.90 and a specificity of 0.79 [8] . furthermore mri has the ability to detect associated soft tissue changes and micro-abscesses whether intraosseous or extraosseous which can assist in surgical drainage targets and source control [13] . in this case report, we describe a patient with acute tibial om secondary to haematogenous dissemination who did not have diagnostic features of om on conventional radiographs or ct. he had vivid features of om on mri, supporting the notion that acute om may often require mri for diagnosis when initial conventional imaging is unremarkable. a 49-year-old caucasian male who presented with a 7-day history of fevers, progressive knee pain, and limited range of motion in his left lower limb. presentation for medical review was delayed due to concerns regarding coronavirus disease 2019 infection (covid-19). he had a background history of intravenous injecting drug use 10 years prior, current oral opioid maintenance, and a recent prolonged hospital admission for a left sacroiliac om and a right wrist septic arthritis caused by bacteroides fragilis and streptococcus agalactiae . this had required removal of metal hardware and multiple washouts. the patient further reported a right dorsal foot injury 3 months prior to admission where he sustained a cut from an oyster which had developed into a chronic wound which was described to have had purulent discharge in the weeks prior to admission. other relevant history included a long history of motocross sporting injuries with multiple long bone fractures in his upper limbs and previous skin grafts to these sites. the patient's vital signs were all within normal limits and he was afebrile. physical examination revealed warmth over the left lower limb at the tibial plateau and the left knee. the knee had no clinically evident effusion and preserved passive range of motion. the patient had mild peripheral oedema of the left leg in comparison to the right. there was no erythema, overlying skin lesion or indication of recent trauma in the left leg. he had an ulcerated ovoid wound (8 × 5 cm) over his right foot (see fig. 1 ) with minor purulent discharge. there was no erythema, pain, warmth or tenderness over his left sacroiliac area or right wrist, the sites of his previous infection. his cardiorespiratory and gastrointestinal tract examination were unremarkable. admission investigations revealed that he had a raised white cell count of 16 × 10 9 /l with a neutrophilia of 13.8 × 10 9 /l. his hemoglobin was 105 with a microcytosis, his platelet count was 413 and his c-reactive protein was 212. he had normal renal function and only trivial derangement of liver function tests. blood cultures taken on admission grew a nonmultiresistant methicillin resistant s. aureus with a vancomycin minimal inhibitory concentration of 1 μg/ml. a swab of the right foot wound grew mrsa sensitive to rifampicin, fusidic acid, trimethoprim/sulfamethoxazole, doxycycline and clindamycin. surgical specimens from the left knee and tibial washout grew an identical mrsa. x-ray imaging of the patient's left knee demonstrated a small joint effusion (see fig. 2 ). there were no erosive or destructive changes. x-ray of the right foot was noncontributory. on ct of the left leg there was no bony erosion, periostitis, acute fracture, or left knee effusion identified (see fig. 3 ). there was a small volume of complex fluid between the medial head of the gastrocnemius and soleus muscles, which was suggested to be an acute rupture of the plantaris tendon, although clinically this was unlikely in the absence of acute onset pain. with the patient's ongoing pain, raised inflammatory markers and the identification of mrsa bacteraemia, there was a suspicion of tibial om. mri performed on day 12 after symptom onset demonstrated heterogeneous marrow signal with areas of t2 weighted hyperintense confluent change and patchy enhancement following gadolinium administration in the proximal tibia, as well as a multilobulated collection extending along the posterior cortex (see fig. 4 ). there was a small infected suprapatellar joint effusion and increased oedema in hoffa's fat pad. on subsequent mri imaging a week later, a focal defect in the posterior cortex of the tibia at the proximal metaphysis was visualized, highlighting the anatomical path of contiguous spread from the tibia into the left knee joint. following diagnostic confirmation of the patient's acute om by the mri scan, he underwent an operative washout of the areas of bony infection. intravenous vancomycin and oral clindamycin 450mg 4 times daily were administered. the infected right foot wound, which presumably represented the original portal of entry of his bloodstream infection, was treated with bedside debridement, microdacyn spray and compression bandaging. following these interventions, the patient improved significantly, and further blood cultures were negative for mrsa. a minimum of 6 weeks aggressive antimicrobial therapy was planned. this case illustrates the diagnostic challenges often encountered in a patient clinically suspected to have acute haematogenous om. despite clinical features, microbiological and other laboratory findings that supported a diagnosis of fig. 4 -selected sagittal and axial slices, t1 spectral presaturation with inversion recovery following the administration of gadolinium (a and b), and t2 fat saturation (c and d) sequences demonstrate marked marrow oedema in the proximal tibia with patchy gadolinium enhancement. there is a focal area (x) of cortical thinning with possible breach. no intraosseous abscess is visible. there is an adjacent fluid collection (short arrows) with peripheral enhancement consistent with abscess formation (arrowheads). oedema and enhancement extend to the soft tissues, involving hoffa's fatpad, the adjacent musculature, and subcutaneous tissues. there is also a small enhancing suprapatellar effusion (long arrow) suggesting articular involvement. om, the patient's initial tibial imaging results by conventional radiography and ct were unconvincing. further assessment by mri was required before a definitive diagnosis could be made and hence appropriate medical and surgical treatment initiated. this underscores the importance of pursuing bone imaging in the form of mri in the setting of suspected early acute om, particularly when the clinical concern for bone infection presentation is unsupported by the conventional radiography and ct findings. despite its demonstrable utility, the limited availability of mri and contraindications to using this modality make the appropriate imaging pathway for acute om an ongoing challenge. while mri confers several advantages in the diagnosis of om, there are several instances and settings where mri may not be practicable or possible, placing significant limitations on its utility [10] . some contraindications include devices, such as permanent pacemakers not compatible with mris, or metallic foreign objects in certain locations, such as in the eye, and even aneurysm coils that have been inserted previously. in addition, imaging artifacts from metallic hardware or prostheses may obscure findings despite the use of modern artifact suppression techniques. similarly, hardware artifacts may also complicate ct interpretation in suspected prosthesis-associated infections. mri is still not widely available in certain practice settings, particularly in remote and rural healthcare environments. in certain patient populations assessment with mri may also be difficult, such as patients with claustrophobia or those who may require general anesthesia, such as those with movement disorders or young children. alternative imaging methods for acute om may also be considered in settings where mri may not be practicable, such as the use of nuclear imaging modalities and dual energy-ct. several nuclear imaging techniques may be considered, including positron emission tomography (pet) scans, 3-phase bone scans, and tagged white blood cell scans. in these scans, areas of increased uptake of injected radionuclide can be detected by a gamma camera, and correspond with areas of abnormal bone metabolism suggesting the presence of om [9] . a recent meta-analysis by treglia et al. suggested that fluorine-18-labeled fluorodeoxyglucose pet imaging and pet/ct imaging were useful in the suspected om related to diabetic foot with high specificity [14] . however, several other pathological processes can also result in abnormal bone metabolism, such as degenerative bone disease or tumors. there may also be poor anatomical localization of disease, even when ct co-registered images are produced, usually inferior to that achieved with mri [15] . there has also been interest in the applications of dual energy-ct (dect), where it has several uses, such as in the detection of monosodium urate deposition in gout, and in the detection of bone marrow oedema, particularly in the setting of fractures [16] . a systematic review by suh et al., which included 12 studies, that assessed the sensitivity and specificity of dect in detecting bone marrow oedema found that dect had excellent sensitivity and specificity for bone marrow oedema detection, with a pooled specificity of 0.97 and a pooled sensitivity of 0.85 [17] . more recently, muller et al. investigated the utility of dect, in comparison to mri, in assessing bone marrow oedema and fracture in those with wrist trauma and suspected wrist fracture who had negative radiographs, and found that in terms of detection of bone marrow oedema, dect had a high specificity and moderate sensitivity [18] . however, despite increasing evidence in the use dect in bone marrow oedema detection, whether this translates to better diagnostic utility in acute om compared to other more established imaging modalities remains uncertain and hence should be the subject of further future research directions. acute haematogenous long bone om with contiguous spread into an adjacent joint is a rare occurrence in adults in modern times, although it was well described in the preantibiotic era. at the onset of om, imaging studies including conventional radiography and ct may appear unremarkable, lacking features suggestive of acute active infection. this case report highlights the significant disease severity that can be demonstrated on a mri in the setting of a normal conventional radiography and computed tomography imaging. whilst there are several practical limitations to the use of mri that may preclude its universal use, this case underscores its potential utility in the early diagnosis of acute om in order that timely and appropriate management and treatment can be initiated in such patients. the host and the skeletal infection: classification and pathogenesis of acute bacterial bone and joint sepsis mandell, douglas, and bennett's principles and practice of infectious diseases osteomyelitis-a historical and basic sciences review bacterial osteomyelitis: microbiological, clinical, therapeutic, and evolutive characteristics of 344 episodes microbiology and management of joint and bone infections due to anaerobic bacteria trends in the epidemiology of osteomyelitis: a population-based study diagnostic accuracy of the physical examination and imaging tests for osteomyelitis underlying diabetic foot ulcers: meta-analysis radiographic imaging in osteomyelitis: the role of plain radiography, computed tomography, ultrasonography, magnetic resonance imaging, and scintigraphy. seminars in plastic surgery. © thieme medical publishers the imaging of osteomyelitis radiologic approach to musculoskeletal infections infection: musculoskeletal soft-tissue infections and their imaging mimics: from cellulitis to necrotizing fasciitis diagnostic performance of fluorine-18-fluorodeoxyglucose positron emission tomography for the diagnosis of osteomyelitis related to diabetic foot: a systematic review and a meta-analysis current concepts in posttraumatic osteomyelitis: a diagnostic challenge with new imaging options dual-energy ct: a promising new technique for assessment of the musculoskeletal system diagnostic performance of dual-energy ct for the detection of bone marrow oedema: a systematic review and meta-analysis dual-energy ct for suspected radiographically negative wrist fractures: a prospective diagnostic test accuracy study key: cord-272623-j5gpww9q authors: sun, wei; shi, zhencai; gao, fuqiang; wang, bailiang; li, zirong title: the pathogenesis of multifocal osteonecrosis date: 2016-07-11 journal: sci rep doi: 10.1038/srep29576 sha: doc_id: 272623 cord_uid: j5gpww9q our objective was to study the incidence, etiology, and diagnosis of multifocal osteonecrosis (mfon) and its treatment options to facilitate an earlier diagnosis and to optimize treatment. a radiological investigation was performed in osteonecrosis patients with a high risk of mfon for a more accurate diagnosis between january 2010 and june 2015. for patients with osteonecrosis of both the hip and knee joints or for patients with a history of corticosteroid use or alcohol abuse who had osteonecrosis of one or more joints in the shoulder, ankle, wrist or elbow, magnetic resonance imaging (mri) was also performed on other joints, regardless of whether these joints were symptomatic. furthermore, we performed a radiological screening of 102 patients who had a negative diagnosis of mfon but were at a high risk; among them, another 31 mfon cases were successfully identified (30.4%). thus, the incidence of mfon during the study period increased from 3.1% to 5.2%. patients diagnosed with osteonecrosis and who are at a high risk of mfon should have their other joints radiologically examined when necessary. this will reduce missed diagnosis of mfon and facilitate an earlier diagnosis and treatment to achieve an optimal outcome. between january 2010 and june 2015, only 48 of the 1507 osteonecrosis patients under our care were diagnosed with mfon (3.1%) upon admission. after the comprehensive evaluation of the joints of 102 patients who had a negative diagnosis of mfon but who were at a high risk, another 31 cases of mfon were successfully identified (30.4%). consequently, the incidence of mfon during the study period increased to 5.2%. the mfon patients admitted to our center had a mean number of 5.7 osteonecrotic lesions, similar to the mean number of lesions (5.8) found in post-sars mfon patients. the associated factors, diseases, and comorbidities are listed in table 1 . of the 48 patients diagnosed with mfon on admission between 2010 and 2015, 31 were male and 17 were female. forty-seven of the 48 mfon patients had a history of corticosteroid use, and the remaining one patient had a history of alcohol use. of the patients with a history of corticosteroid use, 18 had sle, nine had chronic nephropathy, five had hematological diseases (four had acute lymphoblastic leukemia and one had non-hodgkin's lymphoma), five had an organ transplantation (four had a renal transplantation and one had a cardiac transplantation), three had sjogren's syndrome, two had dermatomyositis, two had multiple sclerosis and three received steroid therapy for trauma emergency. of the 31 newly diagnosed mfon patients, 19 were male and 12 were female. all of them had a history of corticosteroid use. fifteen patients had sle, eight had acute lymphoblastic leukemia, five had chronic nephropathy, and three had an organ transplantation (two had a renal transplantation and one had a hepatic transplantation). the mfon patients most commonly had osteonecrosis of the femoral head, followed by the knee, shoulder and ankle bones. the majority of patients had bilateral lesions (hips, knees and shoulders) (fig. 1, table 2 ). there was a significant difference in the number of mfon patients identified after the radiological screening based on risk factors compared with that before the screening (p < 0.05). incidence of mfon. there have not been any journal articles in china concerning mfon, and such reports were also limited in other countries. mont et al. 1 studied 101 mfon cases diagnosed between 1980 and 1996 from 21 centers in the united states. according to the available data from 12 centers concerning their total number of patients with osteonecrosis, 81 patients had mfon of the 2484 patients (3.3%) diagnosed with osteonecrosis. in 2003, we screened post-sars medical workers with corticosteroid use and found 37 patients had mfon of the 176 patients (21%) with a diagnosis of osteonecrosis. by contrast, between 2005 and 2009, we found only 17 patients with mfon of the 657 patients (2.6%) diagnosed with osteonecrosis who were admitted to our center. the incidence of mfon in post-sars osteonecrosis patients was obviously higher than that in daily clinical practice. this is because the lesions found in joints, such as the knees, shoulders and ankles, in the early stages of mfon cases may not have any signs or symptoms. in our screening of post-sars patients, all of them had a comprehensive mri evaluation of their bilateral hips, knees, shoulders and wrists or ankles, which revealed the asymptomatic osteonecrosis. however, in daily clinical practice, we often focus on the osteonecrosis diagnosis of the femoral head without performing an mri on the other joints. this implies that there are possible missed diagnoses of asymptomatic mfon patients. a recent study also showed a higher incidence of mfon than that typically reported in literature 4 . dose of corticosteroids is the main risk factor for mfon. in france, hernigou 4 reported on 140 mfon cases diagnosed between 1985 and 1995, all of which were associated with corticosteroid use. in the cases reported by mont et al. 1 , 91% had a history of corticosteroid use, and the rest had a coagulation disorder. our study showed that 94 of the 96 (98%) mfon patients admitted to our center had a treatment history of high-dose corticosteroids, and the two remaining patients had a history of alcohol use. moreover, the dosage and route of administration of the corticosteroids were obviously related to the incidence of mfon. a study by hernigou 4 demonstrated that the total dose and the daily dose of venous injection were closely related to the occurrence of mfon. this was also found in our study of post-sars osteonecrosis patients caused by the use of corticosteroids 3 . there have been a limited number of mfon case reports and a high occurrence of mfon in asymptomatic patients. therefore, the exact incidence of mfon in patients with various diseases remains unclear. the incidence of mfon in 200 patients with sickle cell disease was reported to be 44% (87 of 200) 4 as a complication in the maintenance treatment of acute lymphocytic leukemia and non-hodgkin's disease, and its incidence in these diseases is also higher than that reported in the literature. solarino et al. 9 performed mri screening in patients with acute lymphoblastic leukemia after chemotherapy and found that 82% of them had mfon 9 . in the mfon cases presented in this study, most were sle, followed by hematological diseases, nephropathy, organ transplantation, dermatomyositis and multiple sclerosis. mfon was especially prevalent in leukemia patients; 17 of the 20 osteonecrosis patients with leukemia under our care were found to have mfon. three of the four patients who received pulse steroid therapy for trauma emergency had a spinal cord injury, for which steroid therapy was considered appropriate. however, one patient received pulse steroid therapy for only an eye injury and was found to have osteonecrosis in eight joints, including the hips, knees, shoulders and ankles. caution should be taken for such cases in the future. mfon patients most commonly had osteonecrosis of the femoral head, followed by the knee, shoulder and ankle bones. osteonecrosis of the shoulder, ankle and wrist never occurred aloneand was always accompanied by osteonecrosis of the hip and knee. among the three populations of mfon patients presented in this study, 98-100% had femoral head involvement, 78-88% had knee involvement, and 29-67% had humeral head involvement. the average number of osteonecrotic lesions was 5.7 per patient. to date, mri is the most sensitive and specific tool to diagnose mfon. initial studies found that low field mri was as sensitive as a radionuclide scan in diagnosing osteonecrosis. nevertheless, recent studies have demonstrated that high field (1.5-3 t) mri has a higher sensitivity, specificity and accuracy in diagnosing osteonecrosis. mont et al. 17 compared the sensitivity of radionuclide scans with mri, and found that mri has a sensitivity of 100%. by contrast, the sensitivity of radionuclide scans is only 45%. radionuclide scans have a higher sensitivity in detecting advanced stage osteonecrosis of the hip and knee than of the shoulder and ankle. although the diagnosis of osteonecrosis by mri has its advantages, the screening for mfon with mri is faced with a long scanning time and high cost. there have been debates regarding the optimal method to screen symptomatic and asymptomatic mfon 18, 19 . plain film x-ray is not sensitive enough to diagnose asymptomatic mfon, but there is still an advantage to carrying out an x-ray examination. even if the x-ray result of a joint with pain is negative for osteonecrosis, it provides a preliminary examination of the local bone structure, which serves as a reference for further investigation by mri. other methods include a short time inversion recovery (stir) mri test followed by mri or a radionuclide scan of specific joints. nevertheless, further studies are required to determine the optimal method for early detection of osteonecrosis. moreover, as the majority (70-100%) of osteonecrosis cases reported in the literature are bilateral, patients diagnosed with osteonecrosis of a joint on one side should be radiologically examined on the other side. missed diagnoses of mfon have frequently occurred in clinical practice. to reduce this, we recommend the following measures. 1) patients with associated diseases and long-term use of high-dose corticosteroids should have their hips and knees evaluated by mri within six to twelve months after the medication. 2) patients diagnosed with osteonecrosis of the hip and knee should have their bilateral shoulders evaluated by mri. 3) patients with corticosteroid use or alcohol abuse and who are diagnosed with osteonecrosis of one or more joints in the shoulder, ankle, wrist and elbow should have their hips and knees evaluated by mri. mfon patients usually start with silent lesions. as the disorder gradually progresses, patients will experience joint pain. at first, the pain is mild and patients may only experience increased pain during movement or weight bearing on the affected bone or joint. as significant damage develops in the joints, patients will experience severe pain. the period of time between the first symptoms and the loss of joint function varies for each patient and ranges from several months to several years. in the late stages of mfon, patients often have symptoms at rest and reduced joint activity, resulting in severe joint dysfunction. the treatment of mfon remains controversial. the general principle is to estimate the prognosis of each lesion. in addition, predicting the presence of collapse of the joint surfaces is the basis for determining the order of treatment. the progress of osteonecrosis is often different for each joint. osteonecrosis of the femoral head progresses the fastest and attention should be paid to the early appearance of symptoms. this is followed by the progression of osteonecrosis to the knees and shoulders. patients who have osteonecrosis of multiple weight-bearing joints and a large necrotic lesion area may develop joint destruction, and early intervention should be used. the progression of osteonecrosis to the elbow and wrist is relatively slow; however, we still lack experience regarding the appropriate treatment method for this area. bone infarction often leads to calcification and self-repair. hence, osteonecrotic elbows and wrists should mainly be managed by monitoring, and over treatment should be avoided if there are no clinical symptoms. in addition, an appropriate treatment strategy should be selected according to the stage of osteonecrosis in each joint involved 20 . for symptomatic patients at an early stage (i.e., arco stages i, ii or china stages i-iii), joint-preservation treatment options are commonly used, such as extracorporeal shock wave, core decompression, and vascularized and nonvascularized bone grafting. when > 2 mm of the articular surface has collapsed or the necrotic lesion area is > 50%, joint-preservation treatments may not provide good efficacy. in the advanced stages of the disease (i.e., arco stages iiic and iv, or china stages v-vi), arthroplasty is required when joint preservation is not possible. there are some limitations of this study. this study is limited by virtue of the retrospective analysis at only one center. and there was no randomized and blinded control group with conservative treatment in this study. the incidence of mfon was high when clinical risk factors were present, such has high-dose steroid use, alcohol abuse, sle, chronic nephropathy and leukemia. for a highly suspected case of mfon, a radiological screening of multiple joints is necessary, and mri is still the gold standard for diagnosing mfon. such screening can help to effectively reduce missed diagnoses. the goals of the treatment should be to take measures to delay the progress of the disease, to preserve the joint function and to avoid joint surface collapse and destruction by diagnosing the disease early. in addition, an appropriate treatment strategy should be selected according to the stage of mfon. conservative treatment and joint-preservation treatment options should be adopted during the early stages, while arthroplasty should be performed during the advanced stages. this study was performed in accordance with the principles expressed in the declaration of helsinki and approved by the ethics committee of the china-japan friendship hospital. informed consent was obtained from all patients. a standardized mri was taken of patients, including their bilateral joints. the apparatus was a ge sigma profile/gold, and t1 weighted, coronal stir, and transverse t1wi sequences were used. the parameters of the scan included a layer thickness of 5 mm and a distance between layers of 5 mm. the t1wi were obtained with a tr from 416~440 ms and a te of 15 ms, and the stir images were obtained with a tr of 1512 ms and a te of 80 ms. if an abnormal signal was found, then a t2 weighted scan was added, and for some of the patients, we also performed fat suppression and water-fat separation sequences. we only used t1 and t2 sequences for the other joints of the patients. osteonecrosis was defined as either a subchondral or an intramedullary area demarcated by a distinct marginal rim with low signal intensity that encompassed the medullary fat on the mri images. in addition to the mri, all patients were subjected to an x-ray that included the affected joints. our general survey on the bones and joints of post-sars medical workers who used corticosteroids revealed that the corticosteroid dose was approximately 2000 mg in unifocal osteonecrosis patients. by contrast, the dose was > 5000 mg in all mfon patients except for one patient who received 2000 mg, with the highest dose at 31,000 mg. the mfon patients also had prolonged corticosteroid treatment (≥ 30 days) 3 . of the 17 mfon patients diagnosed between january 2005 and december 2009, one had a 30-year history of alcohol abuse (average daily alcohol consumption of 500 g). the remaining 16 patients had a history of intensive steroid use for the following diseases: sle (7 patients), acute lymphoblastic leukemia (4 patients), chronic nephropathy (3 patients), anaphylactoid purpura (1 patient) and pulse steroid therapy for traumatic shock (1 patient). therefore, we summarized the high risk factors for mfon to include: a medical history of sle, chronic nephropathy, hematological diseases or coagulation abnormalities (especially leukemia); total corticosteroid (methylprednisolone) dose > 5000 mg, especially for patients with a history of intravenous pulse therapy; and a total corticosteroid administration time of > 30 days. between january 2010 and june 2015, a total of 1507 osteonecrosis patients were admitted to our center, and only 48 of them were diagnosed with mfon (3.1%) upon admission. a radiological investigation was performed in patients with a negative diagnosis of mfon but who had a high risk of mfon and complaints of pain in other joints. for patients found to have osteonecrosis of both the hip and knee, mri was performed on their bilateral shoulders and ankles, and also their bilateral wrists and elbows when necessary, regardless of whether other joints were symptomatic. for patients with a history of corticosteroid use or alcohol abuse and who were found to have osteonecrosis of one or more joints in the shoulder, ankle, wrist and elbow, mri was performed on their hips and knees and their other joints when necessary. the results were analyzed by a chi-square test the using spss 17 software. a p value < 0.05 was considered statistically significant. symptomatic multifocal osteonecrosis. a multicenter study. collaborative osteonecrosis group clinical research of correlation between osteonecrosis and steroid multifocal joint osteonecrosis in sickle cell disease thrombophilia, hypofibrinolysis, the enos t-786 c polymorphism,and multifocalosteonecrosis multifocal osteonecrosis in systemic lupus erythematosus: case report and review of the literature multiple site osteonecrosis in hiv infection osteonecrosis as a complication of treating acute lymphoblastic leukemia in children: a report from the children's cancer group on a case of multifocal osteonecrosis in a patient suffering from acute lymphoblastic leukemia multifocal avascular necrosis after liver transplantation: an unusual presentation of the antiphospholipid syndrome multifocal osteonecrosis associated with human immunodefi ciency virus infection symptomatic steroid-induced multifocal diaphyseal osteonecrosis in a patient with multiple sclerosis widespread osteonecrosis in children with leukemia revealed by whole-body mri vibration-induced multifocal carpal osteonecrosis in a 31-year-old man a rare cause of peripheral arthralgia in inflammatory bowel disease: multifocal osteonecrosis non-traumatic osteonecrosis of the femoral head: ten years later bone scanning of limited value for diagnosis of symptomatic oligofocal and multifocal osteonecrosis detection of multifocal osteonecrosis in an adolescent with dermatomyositis using whole-body mri fast sequences mr imaging at the investigation of painful skeletal sites in patients with hip osteonecrosis chinese specialist consensus on diagnosis and treatment of osteonecrosis of the femoral head this study was supported by the national natural science foundation of china (81372013) and the china-japan friendship hospital youth science and technology excellence project (2014-qnyc-a-06). the funders had no role in the study design, data collection and analysis, decision to publish, or preparation of the paper. w.s., z.c.s. and z.r.l. conceived the experiments. w.s., z.c.s., f.q.g. and w.b.l. performed the experiments. w.s., z.c.s., f.q.g. and w.b.l. analyzed the data. w.s., z.c.s. and z.r.l. wrote the manuscript. all authors reviewed the manuscript. competing financial interests: the authors declare no competing financial interests. this work is licensed under a creative commons attribution 4.0 international license. the images or other third party material in this article are included in the article's creative commons license, unless indicated otherwise in the credit line; if the material is not included under the creative commons license, users will need to obtain permission from the license holder to reproduce the material. to view a copy of this license, visit http://creativecommons.org/licenses/by/4.0/ key: cord-025535-dmcfy7ht authors: chelghoum, rayene; ikhlef, ameur; hameurlaine, amina; jacquir, sabir title: transfer learning using convolutional neural network architectures for brain tumor classification from mri images date: 2020-05-06 journal: artificial intelligence applications and innovations doi: 10.1007/978-3-030-49161-1_17 sha: doc_id: 25535 cord_uid: dmcfy7ht brain tumor classification is very important in medical applications to develop an effective treatment. in this paper, we use brain contrast-enhanced magnetic resonance images (ce-mri) benchmark dataset to classify three types of brain tumor (glioma, meningioma and pituitary). due to the small number of training dataset, our classification systems evaluate deep transfer learning for feature extraction using nine deep pre-trained convolutional neural networks (cnns) architectures. the objective of this study is to increase the classification accuracy, speed the training time and avoid the overfitting. in this work, we trained our architectures involved minimal pre-processing for three different epoch number in order to study its impact on classification performance and consuming time. in addition, the paper benefits acceptable results with small number of epoch in limited time. our interpretations confirm that transfer learning provides reliable results in the case of small dataset. the proposed system outperforms the state-of-the-art methods and achieve 98.71% classification accuracy. brain tumor diagnosis is very important in order to develop an effective plan of treatment. there are more than 120 types of brain and central nervous system (cns) tumors. neurologists classify manually the brain mr images using the world health organization (who) classification [1] . the automation of the classification procedure, in particular brain mr images classification help radiologist in their diagnosis and reduce enormously their interventions. the first automatic classification methods are the machine learning ones. these methods take a long time because they need pre-processing and handcrafted features by experts. the classification accuracy depends on the extracted features which depend on the expert competences. despite the limitation of machine learning methods, some works [2] achieved between 79% and 85% classification accuracy with their proposed method used tumor extracted features such as shape, rotation invariant texture, intensity characteristics and mr images for brain tumor classification. to avoid handcrafted features extraction, deep learning (dl) methods involving deep neural networks to classify images in self-learning without the need of handcrafted features extraction are used by benjio [3] and litjens et al. [4] . among several dl methods, cnns are one of the most useful that have been used to solve complex problems in various applications such as detection [5] , localization [6] , segmentation [7] and classification [8] . they have also yielded good results in medical image application [9] [10] [11] . the first real-word application of cnns was realized by yann lecun in 1998 to recognize hand written digits [12] . since 2010, imagenet launched an important visual database project called imagenet large scale visual recognition challenge (ilsvrc) [13] . this challenge runs an annual software contest where research teams evaluate their algorithms on the given dataset and achieved higher accuracy. moreover, cnns become more useful when krizhevsky et al. (2012) proposed their cnn architecture called alexnet [14] . the later competition allowed creating and improving real deep cnns architectures that have achieved higher accuracy on several visual recognition tasks. in recent years, cnns have achieved good results in medical image applications due to the growth of available labelled training data, the increase of powerful graphics processing gpu, the rise of accuracy to solve complicated applications over time and the appearance of numerous techniques to learn features. according to the statistics that we made from google scholar, the number of publications using cnns in the field of medical image applications in general and brain tumor in particular is increase since 2014. this trend can be observed in fig. 1 . and fig. 2 . today, several public brain mr images datasets for classification are available for researchers. this help medical scientists to develop more automated classification methods [15] . however, the cnns training become more complicated and can lead to overfitting because of the samples size of medical datasets. also, applying deep pre-trained cnns based on transfer learning in medical imaging needs to adjust the hyper-parameters and learning parameters of the models in order to achieve a good result. training the networks with transfer learning is usually much faster and easier than training the networks with randomly initialized weights [16] [17] [18] . in [19] , authors used a small cnn architecture and achieved 84.19% classification accuracy. a block-wise fine-tuning has been proposed, this one, based on transfer learning, reached a classification accuracy of 94.82% [20] . other approach proposed by [21] used pre-trained googlenet and transfer learning to classify brain mr images and achieved 97.1% of classification accuracy. in this paper, we present an automatic classification system designed for three types of brain tumor. we use the brain ce-mri dataset from figshare [22] which consists of three kind of brain tumors (glioma, meningioma and pituitary tumor) in order to classify only abnormal brain mr images. based on this dataset, we adopted deep transfer learning for feature extraction from from brain mr images using nine deep cnns architectures: alexnet [14] , googlenet [23] , vgg16 [24] , vgg19 [24] , residual networks (resnet18, resnet50, resnet101) [25] , residual networks and inception-v2 (resnet-inception-v2) [26] , squeeze and excitation network (senet) [27] . this system makes easier the interventions of radiologist, helps them to solve brain tumor classification problem and develop an effective treatment. we report the overall classification accuracy of the nine pre-trained architectures based on training time and epoch number. we explore the impact of epochs number to minimize the consuming time. we classify the extracted features for three different epochs. we achieve good results compared to related works. also, with smaller number of epochs, we achieve acceptable results in short time. the paper is structured as follows. the proposed method and different pre-trained cnns architectures are given in sect. 2. the experimental setting, the networks preparation and dataset are shown in sect. 3. the experimental results with a brief discussion are provided in sect. 3, the conclusion and an outlook for future work are given in sect. 4. in this work, we applied nine pre-trained deep networks including alexnet, googlenet, vgg16, vgg19, resnet18, resnet50, resnet101, resnet-inception-v2 and senet for brain tumor classification problem using transfer learning. cnns architectures have been designed to learn spatial hierarchies of features by building multiple blocks: convolution layers with a set of filters, pooling layers, and fully connected layers (fcls). the real deep architectures created until 2012 through ilsvrc challenge. the classification error of ilsvrc challenge winners is decreased from 15.3% in alexnet (2012) [14] to 2.251% in senet (2017) [27] . also, the number of layers is increased from 8 layers to 152 layers. table 1 summarizes the differences between those architectures regarding the classification error, the number of layers, the tasks, the execution environment and the training datasets. alexnet. alexnet [14] architecture is deeper and much greater than lenet architecture [28] . it consists of eight layers, five convolutional layers most of them are followed by max pooling and three fully connected layers. the output is the 1000-way softmax that represents the classes. it is trained on two parallel gtx 580 gpu 3 gb which communicate only in certain layers. this scheme reduces the top-5 error rates. alexnet is improved with zfnet architecture [29] which visualizes the alexnet activities within the layers to debug problems and obtain better results. it allows observing the evolution googlenet. googlenet architecture codenamed inception-v1 is the improved utilization of computing resources inside the network [23] . the network with the inception architecture is faster than the network with non-inception architecture. the googlenet architecture including the inception module uses rectified linear activation function, average pooling layer and not fully connected layer and dropout after removing fully connected layer. inception-v1 is improved to inception-v2 by ioffe and szegedy [30] who tried to solve the internal covariate shift. they achieved a top-5 error rate of 4.82%. this result is outperformed to 3.5% by szegedy et al. [31] with their new inception architecture called inception-v3. table 2 shows a comparison between the three inceptions. vggnet. karen simonyan and andrew zisserman [24] investigated the effect of the neural convolutional network depth on its accuracy in image recognition. they pushing depth to 11-19 weight layers of the developed vggnet using very small (3 × 3) convolution filters. the configurations that use 16 and 19 weight layers, called vgg16 and vgg19 perform the best. the classification error decreases with the increased depth and saturated when the depth reached 19 layers. authors confirm the importance of depth in visual representations. resnet/ inception-v4. resnet [25] used residual learning to ease the training of the deeper networks and reduce the errors from increasing depth. this architecture proposed many structures including: 18-layers, 34-layers, 50-layers, 101-layers and 152layers structure, where the 152-layers structure is better than the other ones. it is less complex and deeper than vgg, and has similar performances to the inception-v3 network, this is why szegedy et al. [26] combined the inception architecture with residual connections. they evaluated the three resnet-inception and the inception-v4 architectures: the inception-resnet-v1 has similar performances to inception-v3 while the resnet-inception-v2 performs more than resnet-inception-v1. the inception-v4 is simpler and has more inception modules than inception-v3 but has similar performances to resnet-inception-v2. senet. senet [27] used squeeze and excitation (se) block which improved the representational power of a network by enabling it to perform dynamic channel-wise feature recalibration. it was applied directly in the residual network architecture such as se-inception-resnet-v2, se-resnet-101, se-resnet-50, se-resnet-152 and can be applied to the other existing architectures. it has been performed on imagenet, coco, cifar-10 and cifar-100 datasets across multiple tasks. transfer learning use the gained knowledge that solve one problem and applied them to solve different related problems by using trained model to learn different set of data. the setting for transfer learning used in this work is explained in the following statements. the pre-trained cnns architectures: alexnet, googlenet, vgg16, vgg19, resnet-18, resnet-50, resnet-101, resnet-inception-v2 and senet consist of 1000 classes, 1.28 million training images, tested on 100 k test images and evaluated on 50 k validation images. they are challenging the accuracy of human with the best given results. the networks take an image as an input and produce the object label in the image as an output as well as the probabilities of the object categories. in this research, we focus on slice by slice classification of brain tumor using ce-mri dataset into three types of tumors. first, we modified the last three layers of pre-trained networks in order to adapt them to our classification task. next, we replaced the fully connected layer in the original pre-trained networks by another fully connected layers, in which the output size represents the three kind of tumor. the transfer learning setting and modification are shown in fig. 3 . finally, we used transfer learned and fine-tuned deep pre-trained cnns for experiments using mri data. the proposed classification model is implemented in matlab 2019b on a computer with the specifications of 16 gb ram and intel i9 4.50 ghz cpu. in this section, we describe the dataset used in the experiments, the training parameters and classification accuracy prediction. figure 4 represents the pre-processing of training dataset and the use of transfer learning networks for brain tumor classification. dataset and pre-processing. the public database used to train and test the networks is available in [22] . it has already used in previous works like in [32, 33] . the dataset is collected from nanfang hospital, guangzhou and general hospital, tianjin medical university, in china during 2005-2010. it contains 3064 abnormal brain ce-mri from 233 patients with three kinds of brain tumor: meningioma (708 slices), glioma (1426 slices), and pituitary tumor (930 slices). it is based on two dimensional gray images (2d slices). those data are organized in matlab data format (. mat file). the size of images is 512 × 512 pixels and the pixel size is 49 mm x 49 mm. in our work, we normalize the gray mri images in the dataset in intensity values and we convert them into rgb images by corresponding color map to rgb format using matlab function. we specify the slices as an array of data type where the value 1 corresponds to the first color in the color map. rgb images are returned as an m × n × 3 numeric array with values in the range of [0, 1]. the value 3 corresponds to red, green and blue colors. then, we resize them according to the used network: (227 × 227) in alexnet and senet, (224 × 224) in googlenet, vggnet and resnet, (299 × 299) in resnet-inception-v2 rgb images. the dataset pre-processing is shown on fig. 4 . we divide the data into training and test datasets, where 60% (1836 slices) of the images are used for training and 40% (1228 slices) used for test. the splitting of data into train and test set is performed on a slice basis. training parameters. for transfer learning, we train the networks by stochastic gradient descent (sgd) with 0.9 momentum. we use a minibatch size of 128 images and a learning rate of 10 −4 . to speed up the learning in the new layers, we rise the weight learn rate factor and the bias learn rate factor to 10. even though, the transferred layers are still slower than the new layers. in order to perform the transfer learning, we train for 25, 50 and 90 epochs where an epoch is a full pass during the dataset training. the networks are validated every 50 iterations during training. in this part we use the trained networks to classify the test images and calculate the overall classification accuracy. the classification accuracy is the ability to predict correctly and guess the value of predicted attribute for new data. it is defined as the ratio of sum of true positives (tp) and true negatives (tn) to the total number of trials: where tp and tn are outcomes produced when the model correctly classifies the positive class and the negative class, respectively. while fp and fn are outcomes produced when the model incorrectly classifies the positive class and the negative class, respectively. we evaluate the classification performance using the nine pre-trained architectures and summarize our results in the form of tables. in fact, the purpose of this study is to increase the classification accuracy, speed the training time and avoid the overfitting. this can be assessed through the classification accuracy and the training time of our pre-trained networks. the classification accuracy and the training time using different transfer learning architectures trained for different epochs are respectively shown in table 3 and table 4 . all our pre-trained networks excepting senet are reached up to 90% classification accuracy for three different epochs. despite the use of transfer learning, senet has an overfitting with epoch equal to 25 and 50, but achieves an acceptable result with epoch equal to 90. another characteristic observed during experiments is the impact of epoch number on the classification accuracy. this effect can be seen in table 3 and table 4 . the training time is increasing gradually with incremental epochs number, which means that we can consume less time using less epoch. however, the classification accuracy is neither influenced by the epochs number, nor the deep architectures. as shown in table 3 the table 5 shows a classification of three sample instances. we find that all of the prerained architectures pertain to the class glioma and meningioma. all of them, excepting resnet-inception-v2 pertain to the class pituitary. this confirms that the deeper architectures do not result good with small datasets. table 6 provides a broad comparison based on classification accuracy with the existing methods on the same ce-mri dataset. abiwinanda et al. [19] achieved 84.19% accuracy with their proposed cnn. swati et al. [20] propose a block-wise fine-tuning method based on transfer learning and achieved 94.82% accuracy. deepak and ameer [21] used a pre-trained googlenet to extract features from brain mri images and achieved 97.1% classification accuracy. our proposed method using the pre-trained vgg16 achieved 98.71% classification accuracy. this paper presents a fully automatic system for three kind of brain tumor classification using ce-mri dataset from figshare. the proposed system applied the concept of deep transfer learning using nine pre-trained architectures for brain mri images classification trained for three epochs. our system outperforms the classification accuracy compared to related works. it shows a good performance with a small number of training samples and small epochs number, which allows to reduce consuming time. the architectures which have fewer layers perform more than the deeper architectures. in the future work, we will apply our system to classify medical images from different modalities such as x-rays, positron emission tomography (pet) and computed tomography (ct) for other body organ. also, we will address the effect of epochs number to the classification performances. optimal symmetric multimodal templates and concatenated random forests for supervised brain tumor segmentation (simplified) with antsr classification of brain tumor type and grade using mri texture and shape in a machine learning scheme learning deep architectures for ai. found a survey on deep learning in medical image analysis autonomous concrete crack detection using deep fully convolutional neural network a coarse-to-fine deep convolutional neural network framework for frame duplication detection and localization in forged videos testing a deep convolutional neural network for automated hippocampus segmentation in a longitudinal sample of healthy participants image-based text classification using 2d convolutional neural networks automatic detection of cerebral microbleeds from mr images via 3d convolutional neural networks state-space model with deep learning for functional dynamics estimation in resting-state fmri deep convolutional neural networks for multi-modality isointense infant brain image segmentation gradient-based learning applied to document recognition imagenet large scale visual recognition challenge imagenet classification with deep convolutional neural networks brain mri tumor segmentation with 3d intracranial structure deformation features brainmrnet: brain tumor detection using magnetic resonance images with a novel convolutional neural network model active deep neural network features selection for segmentation and recognition of brain tumors using mri images deep convolutional neural networks for brain image analysis on magnetic resonance imaging: a review brain tumor classification using convolutional neural network brain tumor classification for mr images using transfer learning and fine-tuning brain tumor classification using deep cnn features via transfer learning going deeper with convolutions very deep convolutional networks for large-scale image recognition deep residual learning for image recognition inception-v4, inception-resnet and the impact of residual connections on learning squeeze-and-excitation networks handwritten digit recognition with a back-propagation network | advances in neural information processing systems 2 visualizing and understanding convolutional networks batch normalization: accelerating deep network training by reducing internal covariate shift rethinking the inception architecture for computer vision enhanced performance of brain tumor classification via tumor region augmentation and partition retrieval of brain tumors by adaptive spatial pooling and fisher vector representation key: cord-323470-lpeeugdf authors: ates, omer faruk; taydas, onur; dheir, hamad title: thorax magnetic resonance imaging findings in patients with coronavirus disease (covid-19) date: 2020-08-15 journal: acad radiol doi: 10.1016/j.acra.2020.08.009 sha: doc_id: 323470 cord_uid: lpeeugdf rationale and objectives: the aim of this study was to compare the findings found in thorax computed tomography (ct), which is increasingly used in the diagnosis of the important public health problem of coronavirus disease (covid-19), and the findings of magnetic resonance imaging (mri) as an important diagnostic alternative. materials and methods: thirty-two patients diagnosed with covid-19 who underwent thorax ct for covid pneumonia and mri for any reason within 24 hours after ct were included in the study. the number of lobes affected, number of lobes containing ground-glass opacities and consolidation, number of nodules, distribution of lesions (central, peripheral or diffuse), lobes with centrilobular nodular pattern, and the presence of pleural effusion were recorded separately for both imaging methods. results: seventeen of the patients were female (53%) and 15 were male (47%). the mean age of the patients was 60.5 (range, 20-85) years. a total of 31 patients (96%) had signs of pneumonia on ct. the most common finding in ct was ground-glass opacities in 29 patients (90.6%), followed by consolidation in 14 patients (43.75%). both consolidation and ground-glass opacities were also observed in mri in all of these patients. on ct, nodules were detected in 12 patients (37.5%) on ct and 11 patients (34.4%) on mri. the sensitivity and specificity of mri in nodule detection were calculated as 91.67% and 100%, respectively. conclusion: although thorax ct is widely used in the imaging of covid-19 infection, due to its advantages, mri can also be used as an alternative diagnostic tool. in 2019, a new corona virus disease caused by the severe acute respiratory syndrome coronavirus (sars-cov-2) was reported in the wuhan province of china (1) . the disease spread first in china and then over all the world and was declared as a pandemic by the world health organization (who) (2) . the sars-cov-2 virus has been shown to enter the cell through angiotensin converting enzyme 2 (ace-2) receptors in humans. therefore, the virus first causes interstitial damage in the lungs followed by parenchymal damage (3) . although the most important clinical symptoms are fever and cough, other indications, such as fatigue, headache and shortness of breath can also be seen. however, diagnostic tests are needed because these symptoms are not disease-specific, and the disease can progress rapidly to severe pneumonia (4) . although the real-time reverse transcription polymerase chain reaction (rt-pcr) test for viral nucleic acids in the diagnosis of covid-19 is the gold standard, computed tomography (ct) has become increasingly more important in the diagnosis (5) . however, considering that it contains ionizing radiation, ct should be used as a problem-solving method rather than for screening purposes in patients who are found negative for rt-pcr but present with clinical symptoms (6) . also, the recent consensus statement from the fleischner society lists the risk of radiation exposure to the patient as one of the costs that diminish the value of imaging tests (7) . due to concerns about the effects of ionizing radiation, magnetic resonance imaging (mri) is emerging ct as the primary cross-sectional imaging method in evaluating many organs. today, low dose ct scanning protocols are being developed, however, considering covid-19 pneumonia and similar pandemics that affect a large number of human populations, dose-dependent and dose-independent effects of ct that may occur due to radiation exposure, poses a serious risk in terms of malignancy that may develop after years (8) . although the low proton content and movement artifacts of the lung parenchyma make it difficult to evaluate the lung with mri, with recent advances in mri scanner technology such as t2-weighted spin-echo propeller mri sequence (9) , it is now possible to overcome many of these challenges. in addition, the low proton content of the lung is, in fact, an advantage in imaging pneumonia because pulmonary consolidation and ground-glass opacities occurring in pneumonia cause an increase in proton and signal intensity, which becomes more pronounced with the background of the adjacent normal signal (10) . in addition, cranial mri is very useful for the evaluation of anosmia which is frequently seen in these patients (11) . the purpose of this study is to describe the thoracic mri findings of covid-19 pneumonia with those of ct and to suggest mri as an attractive alternative imaging modality is specific cases for this retrospective study, approval was obtained from the ethical committee of our institution. of the 1,311 patients diagnosed with covid-19 pneumonia (rt-pcr at least once + clinically confirmed) in our institution between march 27, 2020 and april 13, 32 who underwent thorax ct for covid pneumonia and mri for any reason within 24 hours after ct were included in the study. since one patient did not complete the mri examination; thus, his images could not be evaluated, but they were added to the image quality evaluation. a total of 32 patients were included in the study, with 17 being female (53%) and 15 being male (47%). the mean age of the patients was 60.5 (range, 20-85) years. all patients had complaints of dry cough and shortness of breath. the patient population has a wide range from patients with mild disease to those in need of intensive care units. however, none of the patients were intubated. both ct and mri scans were for clinical purposes. t2 propeller images were generally obtained during mri scans for the following reasons: pulmonary mra obtained for suspicion of pulmonary thromboembolism in some patients with increased d-dimer without renal failure but with limited renal function and patients with suspected cardiac involvement and therefore imaged with cardiac mri. mri was performed with a 1.5-t system (signa voyager; ge healthcare, milwaukee, wi, usa) using a phased array body coil. t2-weighted fast spin echo propeller axial images were obtained with respiratory triggering (triggered by the expiration phase of the respiratory cycle) at an echo train length of 13, matrix of 224x256, fov of 38 cm, band width of 125 hz, tr of 1000-1500 ms, effective echo time of ∼90 ms, and four excitations. slice thickness was 5 mm, and interslice gap was 1 mm. the imaging time was approximately 3 minutes, but it was extended to 5 minutes in patients with breathing problems. ct images were obtained with a 64-row multidetector ct scanner (5 mm slice thickness, matrix of 512x512, 120 kv automatically modulated ma; aquilion64, toshiba medical systems, japan) for 21 patients and with a 16-row multidetector ct scanner (5 mm slice thickness, matrix of 512x512, 120 kv automatically modulated ma, alexion, toshiba medical systems, japan) for 11 patients. all scans were performed during inspiration and with the patients placed in the supine position. the mri and ct images of all patients were evaluated for opacity and unilateral or bilateral involvement. the number of lobes affected (n = 1-5), number of lobes containing ground-glass and consolidation, number of nodules, distribution of lesions (central, peripheral or diffuse), lobes with centrilobular nodular pattern, and the presence of pleural effusion were also recorded separately for both imaging methods. on ct and mri, a density/intensity increase in which vascular boundaries could be distinguished was accepted as ground-glass, and a density/intensity increase in vascular structures that could not be differentiated was considered as consolidation. the affected lung volume ratio was evaluated observationally. by definition, a lung nodule is a rounded or irregular opacity, which may be well or poorly defined, measuring ≤3 cm in diameter. the ct and mri images were assessed for quality: 5, excellent no artifacts; 4, good (few artifacts); 3, moderate (of diagnostic value but impaired by artifacts); 2, poor (of no diagnostic value); and 1, not tolerated (examination could not be completed). the causes of impaired quality were attributed to ghosting, motion or patient movement artifacts, or a combination thereof. the evaluation of the images was independently undertaken by two radiologists (both are board-certified and have 8 years of experience) with the pre-diagnosis of covid-19-related pneumonia. two weeks were waited for evaluation of mri images after evaluation of ct images to prevent memory bias. if their initial opinions differed, a consensus was reached. medcalc (ver. 12, ostend, belgium) was used for statistical analysis. the descriptive statistics were given as median (minimummaximum) and mean ± standard deviation. categorical variables were stated as frequencies and percentages. the chi-square test was used for the comparison of categorical variables. the independent samples t-test was used for the comparison of continuous variables with normal distribution and the mann-whitney u and kruskal wallis tests for the data that did not conform to normal distribution in the kolmogorov-smirnov test. coherence between two observers with respect to pulmonary findings was assessed by cohen's kappa coefficient. a value of p < 0.05 was accepted as statistically significant. a total of 31 patients (96%) had signs of pneumonia on ct. pneumonia findings were observed in the mri of these patients. the most common involvement pattern was bilateral and peripheral (table 1) (figure 1 ). almost perfect agreement was found between the two observers in terms of pulmonary findings (κ = 0.934). the most common finding in ct was ground-glass opacities in 29 patients (90.6%). ground-glass opacities were also observed in the mri of all of these patients. lesions were observed in one or two lobes most frequently in both ct and mri (37.5%) (figures 2 and 3) . while a total of 90 lesions were detected on ct, 85 were detected on mri, but there was no statistically significant difference (p = 0.710) ( table 2 ). the second most frequently observed finding in ct was consolidation in 14 patients (43.75%), which was also observed in the same patients on mri. lesions were detected in one or two lobes most frequently in both ct and mri (25%) ( table 3 ). nodules were detected in 12 patients (37.5%) by ct and 11 patients (34.4%) by mri. taking ct as reference, the sensitivity of mri in nodule detection was calculated as 91.7%, specificity 100%, positive predictive value 100%, and negative predictive value 95.2%. while 53 nodules were observed in ct, 52 were observed in mri, and no significant difference was found between the two modalities (p = 0.967) (figures 4 and 5 ). in addition, on both ct and mri, three patients (9.4%) had a centrilobular nodular pattern ( figure 6 ) and eight (25%) had pleural effusion. the median image quality score was 5 for the ct images and 4 for the mri images (table 4 ). however, there was no significant difference between the two imaging methods (p = 0.147). the most important result of our study is the nearly complete overlap of ct and mri findings. minor differences between ct and mri may have been influenced by the fact that ct scanning is obtained during the inspiratory phase of respiration and thoracic mri with respiratory navigator during expiratory phase. in this context, mri was shown to be a useful modality in terms of showing both parenchymal and extraparenchymal (pleural effusion and lymphadenopathy) findings. in a recent study involving 23 patients by yang et al., ultrashort echo time mri was evaluated and compared to ct. in this study, similar to our study, a perfect match was found between mri findings and ct findings. however, the most important difference of this study from our study is that no patient with a nodule was included in the study (12) . there are also two case reports in the literature regarding the mri findings of covid-19. the first belonged to a 47-year-old male patient and both parenchymal consolidation and pleural effusion was demonstrated using mri (13). the other case report described a 33-year-old male patient, who was shown to have parenchymal ground-glass densities and consolidations successfully revealed by mri (14) . various findings can be seen in the lung parenchyma in covid-19 infection (15) . the most common of these is the ground-glass appearance, defined as an increase in fogshaped density in which the walls of the vessels and bronchi are not wiped (16, 17) . it develops due to mild interstitial thickening or air loss within the airways (18) . in a meta-analysis performed by salehi et al. involving 919 patients, ground-glass density was determined in 88% of patients and reported as the most common imaging finding (19) . in a study conducted in italy, all patients were found to have ground-glass density (20) . similarly, in our study, all patients had ground-glass opacities. it is also known that ground-glass density is the earliest radiological finding of the disease (21) . this appearance is considered to be due to edema and hyaline membranes in the lung (22) . ground-glass opacities can be seen alone or together with different findings, such as interlobular septal thickening and consolidation (23) . consolidation is defined as the air in the alveoli being completely replaced with pathological fluid, cells or tissues, resulting in an increase in density, and it is usually multifocal, segmental, patchy and subpleural or peribroncovascular in patients with covid-19 infection (24) . in our study, there was consolidation in 43.75% of patients. pathophysiologically, these cases are thought to be associated with fibromixoid exudate in the alveoli (25) . in addition, the presence of consolidation has been associated with the prognosis of the ailment and may be an indicator of a progressive disease (23) . crazy paving, which is defined as thickened interlobular and intralobular septa and the background with ground-glass density, is important because it is a sign of a progressive disease, although it is not as common as consolidation and ground-glass in covid-19 infection (26) . apart from these major findings, a reticular pattern, air bronchogram, and nodules can also be seen (18) . lymphadenopathy and pleural effusion are rarely observed in covid-19 infection and tends to suggest a bacterial infection in rt-pcr positive patients (18) . the use of thorax mri has been increasing in recent years. since there is no radiation risk, mri allows multiple examinations to be performed on the same patient, and it can provide additional information to ct during patient follow-up. in a study by leutner et al., in which 16 immunocompromised patients with pneumonia were included, all ground-glass opacities and consolidations could be diagnosed with mri. moreover, the presence of early-stage necrotic pneumonia, which could not be shown by contrastenhanced ct in 25% of patients, was demonstrated by mri (27) . in subsequent studies with a similar patient group, mri was found to be very useful diagnostic tool, especially in its use during follow-up (28, 29) ; furthermore, mri was reported to be promising in detecting nodules in these patients (30) . in our study, the sensitivity of mri in nodule detection was 91.67%, and its specificity was 100%. in a recent study by syrjala et al. including 77 patients with immunocompetent pneumonia, the effectiveness of mri in diagnosis was investigated, and it was reported that mri was superior to direct radiography in diagnosis and showed almost identical accuracy with ct (31). one of the disadvantages of mri in pneumonia patients is imaging time and artifacts. in addition to longer scan times, mr is less readily available and more expensive than ct. in our routine practice, we use the propeller technique, which has been shown to obtain better quality and less artifact images, while taking the thorax image (9) . the t2 fse propeller sequence used in our study lasted an average of 3 minutes. shortness of breath, which can be seen in patients with covid-19-related pneumonia, can cause an increase in both ct and mri in motion-related artifacts. at the same time, since this sequence is obtained with a respiratory navigator, the scanning time is prolonged in patients with irregular breathing. although it is more sensitive to motion artifacts due to the long scanning time, respiratory navigation may be an advantage, especially in the imaging of some lesions adjacent to the diaphragm. in breath-hold ct, since inferior slices are taken toward the end of the patient's breath, more intense motion artifacts occur, especially in the inferior slices in patients with shortness of breath. in the technique we use, even the lesions adjacent to the diaphragm can be easily viewed in patients who regularly breathe quickly, as it is not necessary for them to hold their breath. although ct was better in terms of overall image quality in our study, there was no significant difference between the ct and mri examinations. in addition, no artifact formation at the level of no diagnosis was observed in the mri of any patient. in addition, no artifact formation at level 2 (poor image quality, of no diagnostic value) was observed in any patient on mri. there were some limitations of our study. the first was the small number of patients included in the study, and second was the retrospective nature of the research. more comprehensive and prospective studies can be planned for this subject. finally, since the mri examinations were performed without contrast, the effect of the contrast agent could not be evaluated. in conclusion, although thorax ct is widely used in the imaging of covid-19 infection, we consider that mri can be used as an alternative due to its various advantages. especially, mri is important to assess lung pathology over time as more is learned about covid and the long-term impact on lung health. t2-weighted spin-echo propeller sequence, variations of which are readily-available sequence on most mri scanners, is a good option for clinical translation to other platforms, sites. a novel coronavirus from patients with pneumonia in china severe outcomes among patients with coronavirus disease 2019 (covid-19)-united states evolution of the novel coronavirus from the ongoing wuhan outbreak and modeling of its spike protein for risk of human transmission radiological approaches to covid-19 pneumonia clinical features of patients infected with 2019 novel coronavirus in wuhan ct of coronavirus disease (covid-19) pneumonia: a reference standard is needed the role of chest imaging in patient management during the covid-19 pandemic: a multinational consensus statement from the fleischner society cancer risk in 680,000 people exposed to computed tomography scans in childhood or adolescence: data linkage study of 11 million australians mri of the lung using the propeller technique: artifact 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distress syndrome novel coronavirus (2019-ncov) pneumonia chest ct findings in patients with coronavirus disease 2019 and its relationship with clinical features radiological findings from 81 patients with covid-19 pneumonia in wuhan, china: a descriptive study thin-section ct of severe acute respiratory syndrome: evaluation of 73 patients exposed to or with the disease mr imaging of pneumonia in immunocompromised patients: comparison with helical ct mri of pneumonia in immunocompromised patients: comparison with ct diagnostic accuracy of magnetic resonance imaging in the evaluation of pulmonary infections in immunocompromised patients magnetic resonance imaging of pulmonary infection in immunocompromised children: comparison with multidetector computed tomography chest magnetic resonance imaging for pneumonia diagnosis in outpatients with lower respiratory tract infection key: cord-255240-ltatgq3e authors: kesserwani, hassan title: cerebral microbleeds to treat or not to treat, that is the question: a case report with a note on its radiologic deconstruction and therapeutic nuances date: 2020-09-20 journal: cureus doi: 10.7759/cureus.10548 sha: doc_id: 255240 cord_uid: ltatgq3e with the ubiquity of susceptibility weighted imaging (swi), cerebral microbleeds (cmbs) are fast becoming a prevalent phenomenon. they are tightly associated with age, neurodegeneration and diverse vascular etiologies. cmbs have a unique radiological signature. their morphology, number and topology are quite informative. they also pose a therapeutic conundrum, as they are associated with the risk of cerebral hemorrhage. we present the case of an 86-year-old woman who has a vascular dementia, binswanger's syndrome, and coronary artery disease, who presented with more than five cmbs. we present this case in order to highlight the dilemma of anti-platelet therapy in this group of patients and we demonstrate the cardinal radiologic features of cmbs. we then segue into the pathologic correlates of cmbs and associated risk factors. we finally analyze the risk of anti-platelet therapy in the presence of cmbs, and we unfold the latest data on cmb number and anti-platelet therapy. cerebral microbleeds (cmbs) are an increasingly recognized diagnostic entity. they represent microhemorrhages in brain parenchyma. pathologically, these microbleeds are hemosiderin-laden macrophages. deep seated microbleeds, in the corona radiata and basal ganglia, are more commonly seen in hypertension. cortical lesions are commonly seen with amyloid angiography. parasagittal linear streaks are more typical of brain trauma and diffuse axonal injury [1] . in the rotterdam study of close to 4000 patients, cmb prevalence increases with age, from 6.5% in people aged 45 to 50 years to 35.7% in people older than 80 years. 15 .3% of all patients had at least one cmb [2] . systolic blood pressure, hypertension, smoking, lacunar infarcts and white matter lesions were associated with cmbs in a deep or infra-tentorial region, whereas apo-lipoprotein e4 (apo e4) and diastolic blood pressure were related to cmbs in a lobar location [2] . there is an elevated risk of both hemorrhagic, odds ratio 8.52 (4.23-17) , and ischemic strokes, odds ratio of 1.55 (1.12-2.13) , in patients with recent ischemic stroke or transient ischemic attacks (tia) and cmbs [3] . radiologically, cmbs appear magnified on susceptibility weighted images (swi) due to their paramagnetic properties and this is known as a blooming artifact. cmbs appear dark, hypo-intense, on all swi images. however, this finding can be due to either iron or calcium deposits. in order to differentiate, phase mapping is obtained [4] . these are rapid acquisition images at no extra cost. if the magnetic resonance imaging (mri) scanner software is endowed with a left-handed reference frame such as siemens, the cmbs appear hyperintense on the phase map. if the mri scanner software is endowed with a right-handed reference frame, the cmbs will appear hypo-intense on phase maps. to orient oneself, we can look at the superior sagittal sinus or a venous tributary, and establish the "color" of the mri acquisition sequence on the phase map. in the left-handed reference frame, the sinus will appear bright. in the right-handed system such as a general electric scanner, the cmbs appear dark by noting the dark sagittal sinus or a venous tributary. the reverse situation is seen in the left-handed siemens scanner; here the cmbs and sagittal sinus appear bright. swi images and phase mapping are advanced imaging techniques that are sensitive to cerebral microbleeds. they utilize long echo sequences and gradient echo sequences (gre). these image acquisitions rely on the magnetic susceptibility of tissues, whether paramagnetic or diamagnetic. paramagnetism occurs when atoms have an odd number of electrons. hence, they have a net magnetic dipole moment, which aligns and reinforces an applied magnetic field. if the number of electrons is even, that is paired, then there are no dipoles to align. however, the applied magnetic field distorts the motion of electrons via the lorentz force. the induced magnetic dipoles anti-align with the applied magnetic field, and reduce the applied magnetic field. such a material is diamagnetic. the filtered phase images or phase map exploit the magnetic properties of tissues; paramagnetic (such as iron) and diamagnetic (such as calcium), which have opposite 1 signal intensities in phase mapping [5] . we present the case of an 86-year-old woman with binswanger's disease characterized by a vascular dementia, lower half parkinsonism and more than five cmbs. binswanger's disease is a subcortical vascular dementia characterized by loss of executive function: planning, insight and foresight, with relative preservation of memory. it is frequently accompanied by a gait disorder. she has the typical risk factors of binswanger's disease including chronic hypertension, coronary artery disease, hyperlipidemia and is a lifelong smoker. the question at hand states: is anti-platelet therapy safe in this patient with more than five micro-hemorrhages (cmbs) in the brain? the data to answer this question is evolving [6] . in this article, we lay out the pathologic correlates of cmbs, gently outline the radiological nuances involved in analyzing cmbs and finally we display the latest data addressing the role of anti-platelet therapy. as cmbs are incidentally discovered on routine mri studies, whether to continue or discontinue anti-platelet or anticoagulant therapy, is an open question. the clinician has to individualize therapy, weigh the benefits of therapy and consider the pros and cons, until more definitive data becomes available. we report the case of a previously active and independent 86-year-old divorced female patient who over the course of two years, especially last year, has become increasingly forgetful and confused. she left the stove on at least twice and once boiled eggs without water, forgets relevant family conversations and repeats questions frequently. she was no longer able to balance her checkbook and has become increasingly distracted, "spacey" and "not together", as per her daughter's testimony. her daughter also noted that she cannot keep up with conversations when there are more than two people conversing. sometimes she cannot finish a sentence, has become increasingly argumentative and quit driving five years ago due to anxiety from a car accident. her hygiene has declined, sometimes forgets to bathe or fix her hair, forgets to do laundry, but when remembers may wash clean clothes. in the past, she worked at convenience stores and focused on inventory. the patient now presents emotional lability with excessive crying, with abandonment of social activities, such as reading the newspaper and watching sitcoms. her medications include atorvastatin 20 mg, lisinopril 10 mg, escitalopram 10 mg, baby aspirin 81 mg and mirtazapine 30 mg daily. her past medical history is significant for at least a 20-year-history of hypertension, coronary artery disease and hyperlipidemia. there is no family history of dementia. she has smoked cigarettes, at least one pack a day, for 50 years. on examination, her blood pressure (bp) is 145/63 and a pulse of 67 beats per minute. her height is five foot and three inches with a weight of 120 pounds and a body mass index (bmi) of 21.3. precordial examination revealed no murmurs and carotid auscultation revealed no bruits. her gait was stooped and shuffling, with adequate arm swing. no retropulsion was noted. at most, she had a mild symmetric bradykinesia but without a rest, postural or kinetic tremor. no sequence motion of the hands was noted with rapid finger apposition. cognitively she appeared distracted and a little paranoid despite a mini-mental state score (mmse) of 27/30, which usually indicates a mild dementia when the score goes below 27. visuo-motor skills were impaired with pantomime mimic. she has ideomotor apraxia with tool use, using the hand as the tool object. deftness with a coin, limb-kinetic praxis, was preserved. despite the presence of a grasp reflex and a snout reflex, a palmo-mental reflex was absent. but gegenhalten (paratonia) was noted in the arms, with compensatory increasing resistance with increasing velocity of flexion at the elbow. her cranial nerve examination was significant for a lively gag reflex. power was preserved in the arms and legs, with symmetry. her deep tendon reflexes were lively in the arms and legs, with a negative plantar extensor response bilaterally. of note, stereognosis and graphesthesia were preserved in the hands. due to her dementia presentation and clinical findings of lower half parkinsonism, an mri scan of the brain was obtained revealing severe subcortical white matter disease ( figure 1 ). susceptibility weighted images (swi) and phase map images reveal cerebral micro-bleeds (mcbs), more than five lesions; note hypo-intensity of bleeds on both sequences implying a right-handed reference frame ( figure 2 ). cmbs and betraying the right-handed reference frame of the mri system (red arrows). these images look similar but are different acquisition sequences; note difference in peri-ventricular white matter intensity between both sequences (yellow arrow). mri: magnetic resonance imaging; cmb: cerebral micro-bleeds; swi: susceptibility weighted images. a carotid duplex scan and a transcranial doppler ultrasound did not reveal any significant cervical carotid or intra-cranial artery stenosis respectively. she has stable coronary artery disease and more than five cmbs on susceptibility mri of the brain. hence one faces a therapeutic dilemma; with such extensive cerebral white matter disease and stable coronary artery disease, is anti-platelet therapy warranted in the presence of more than five cmbs? our solution was to continue the statin, atorvastatin 20 mg and aspirin 81 mg daily for the following reasons. we considered substituting cilostazol, an anti-platelet phosphodiesterase inhibitor for aspirin, as we do know that when cilostazol is compared with aspirin, the risk of cerebral and gastrointestinal hemorrhage is lower, with a 25.7% relative risk reduction of ischemic strokes, but only in patients with prior ischemic strokes [7] . however, there is no data for the effectiveness of cilostazol in stable coronary artery disease. we decided to continue low dose aspirin therapy in order to protect her coronary arteries. we continued statin therapy, atorvastatin 20 mg daily, as this too has anti-thrombotic effects on both the coronary and cerebral circulation. she was encouraged to quit smoking. for her cognitive impairment, the patient was started on an acetylcholine-esterase inhibitor, donepezil 5 mg daily. the risk of an ischemic or hemorrhagic stroke in patients with less than five or more than five cmbs, treated with antiplatelets, will be outlined in the discussion section. as outlined earlier, cmbs are radiologically small round or ovoid regions of signal loss seen on paramagnetic mri sequences. cmbs are due to hemosiderin-laden macrophages. cmbs are a direct result of extravasation of erythrocytes from diseased arterioles and capillaries damaged by hypertension, such as the small perforating arteries of the deep gray and white matter, in the basal ganglia and the lobar regions. in caucasians with intracerebral hemorrhage, cmbs in a lobar distribution are associated with cerebral amyloid angiopathy (caa). caa leads to progressive deposition of β-amyloid in small cortical and leptomeningeal arterial walls, increasing their fragility [1, 3] . lipohyalinosis, also known as fibrinoid necrosis, occurs in small vessels in hypertensives, affecting deep perforating arteries, which branch off from large arteries in the basal ganglia, white matter, brain stem and cerebellum. the fibrinoid deposition in the tunica media of the blood vessel wall is due to blood-brain barrier disruption leading to destruction of smooth muscles and the extracellular matrix. this leads to the formation of micro-aneurysms and micro-hemorrhages. hyaline arteriolosclerosis is characterized by thickening of the arteriolar wall by collagen deposits around the basement membrane, leading to fragility and cmbs [8, 9] . the pathologic and radiologic findings of cmbs are summarized below ( table 1) . size of lesion < 10 millimeters; round or ovoid microbleed -extravasation of erythrocytes hyperintensity on gre/swi in patients with cerebral amyloid angiopathy (caa), the prevalence of cmbs is 100%. the distribution of cmbs in caa is lobar, mirroring the histopathology of amyloid angiopathy in cortical vessels. this lobar pattern is also seen in alzheimer's disease. involvement of the leptomeningeal vessels explains the occurrence of superficial siderosis that is observed in both caa and alzheimer's disease [10] . cmbs also occur more frequently in patients with vascular dementia displaying a more central distribution pattern, and may involve the thalamus, brainstem and cerebellum [11] . in diffuse axonal injury, cmbs are typically located in the corpus callosum and at the gray-white matter junction, and tend to have a more radial configuration following the perivascular spaces compared with the more spherical cmbs occurring with neurodegeneration or hypertension [12] . radiation vascular injury begins above a dose of 25 grays (gy). it can acutely involve the small vessels, through fibrinoid necrosis and telangiectasis with vessel permeability and vasogenic edema. chronically, the larger vessels are affected with vessel wall thickening, thrombosis and fibrinoid necrosis. cmbs occur in at least 50% of patients who have undergone radiation treatment, in pediatric and adult patients. the rate of cmb formation increases significantly two years after radiation treatment and is associated with cognitive impairment [13] [14] [15] . cavernous angiomas have a popcorn-like high signal intensity on t1-weighted images and a hypo-intense hemosiderin ring on t2-weighted images. small type iv cavernous angiomas may be indistinguishable from cmbs. cavernous angiomas can be classified into four types: type i -extra-lesional blood beyond cavernous angioma; type ii -mixture of subacute and chronic blood; type iii -area of hemosiderin with a small central core; and type iv -area of hemosiderin deposition without a central core. because of a lack of a central core, type iv lesions are only visible on swi images as hypo-intense spots, identical with cmbs [16] , type iv lesions being the most similar to cmbs. swi hypo-intensity and t1 hyper-intensity have been deployed to detect micro-metastases. these signal characteristics are five times more common in melanoma metastases than in lung cancer metastases. three quarters of melanoma metastases have one or the other signal characteristic and a quarter have both findings. this combination of findings was sixteen times more common with melanoma metastases than with lung cancer metastases. melanin leads to t1 shortening and the propensity of melanomas bleeding, with methemoglobin accumulation, can lead to t1 shortening. the susceptibility effects on swi are due to the presence of metal ions: iron, copper, manganese, and zinc. of note, 7% of melanomas had no t1 shortening and were only detected with swi [17] . there are strong associations of cmbs with age and hypertension, more likely deep in the brain. carrying the apo-lipoprotein e4 (apo e4) gene increases the risk of lobar cmbs most frequently in the parietal lobes [2] . cmbs are strongly correlated with volume of white matter disease [18] . the presence and number of cmbs also correlates with the congestive heart failure/left ventricular systolic dysfunction, hypertension, age ≥75 years, diabetes mellitus, stroke or tia or thromboembolism, vascular disease (chads2-vasc) scores, which is used to estimate ischemic stroke risk in patients with atrial fibrillation. in a study of 131 japanese patients with atrial fibrillation and 112 controls without atrial fibrillation, patients with atrial fibrillation had a significantly higher prevalence of cmbs. there is also evidence that lobar cmbs may be more common than deep cmbs in patients with atrial fibrillation [19] . the various causes of cmbs with their topography and mechanisms are listed below ( table 2) . knudsen et al. [ in the study by lau et al., in 1811 patients who were prescribed anti-platelet therapy, the five-year risk of recurrent ischemic stroke and hemorrhagic stroke both increased with the number of cmbs [6] . high cmb burden, greater than or equal to five, was an independent risk factor for recurrent ischemic stroke, hemorrhage stroke, all cause mortality, and nonvascular death. patients with greater than or equal to five cmbs experienced a three-fold higher risk of recurrent ischemic stroke and a 13-fold increased risk of hemorrhagic stroke than those without cmbs. for the patients with less than five cmbs, the five-year absolute risk of ischemic stroke was much higher than the incidence of intracranial hemorrhage. for those with greater than or equal to five cmbs, the risk of fatal and disabling ischemic and hemorrhagic strokes was similar in the first year, but this calculus changed from the second to fifth year, where the risk of a hemorrhagic stroke was much higher, almost 13 times higher [6] . in summary, cmbs are associated with a higher risk of ischemic strokes than hemorrhagic strokes during the first year, regardless of the number of cmbs and treatment with anti-platelets is recommended, if indicated. for more than or equal to five cmbs, this issue is still contentious, as a head to head study is not available. however, withdrawal of anti-platelet therapy may be considered depending on the risk profile. these findings are summarized below ( table 3) . findings suggest that anti-platelet use is safe when cmb number is below five, but questionable when cmb number exceeds five from year two to year five [6] . our case highlights the dilemma the clinician faces in patients who carry more than five cmbs on an mri of the brain and who have co-existent co-morbid diseases, such as coronary artery disease. as we highlight in the discussion section, anti-platelet therapy in patients who harbor more than five cmbs can be associated with as high as a 13-fold increased risk of an intracranial bleed, especially in those patients who are receiving anti-platelet therapy for more than one year. we tackle this therapeutic conundrum by considering an alternative therapy with cilostazol, a phosphodiesterase inhibitor, which is less likely to lead to an intracranial bleed. however, this approach was deemed insoluble, as there is no evidence for the effectiveness of cilostazol for coronary artery disease. the literature of cmbs is extensive. in this article, we streamline a lot of the data and address the key points. in particular, we unravel the radiological signature of cmbs, its pathophysiologic correlates, outline the risk factors and common diseases associated with cmbs and at the end of the discussion we address the risk of ischemic and hemorrhagic strokes in patients with cmbs who are receiving anti-platelet therapy. human subjects: consent was obtained by all participants in this study. conflicts of interest: in compliance with the icmje uniform disclosure form, all authors declare the following: payment/services info: all authors have declared that no financial support was received from any organization for the submitted work. financial relationships: all authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. other relationships: all authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work. cerebral microbleeds: histopathological correlation of neuroimaging prevalence and risk factors of cerebral microbleeds: an update of the rotterdam scan study cerebral microbleeds and recurrent stroke risk: systematic review and meta-analysis of prospective ischemic stroke and transient ischemic attack cohorts cerebral microbleeds: imaging and clinical significance cerebral microbleeds: a guide to detection and interpretation antiplatelet treatment after transient ischemic attack and ischemic stroke in patients with cerebral microbleeds in 2 large cohorts and an updated systematic review benefit of cilostazol in patients with high risk of bleeding: subanalysis of cilostazol stroke prevention study 2 fibrinoid necrosis of small brain arteries and arterioles and miliary aneurysms as causes of hypertensive hemorrhage: a critical reappraisal stroke patients with cerebral microbleeds on mri scans have arteriolosclerosis as well as systemic atherosclerosis clinical diagnosis of cerebral amyloid angiopathy: validation of the boston criteria use of antithrombotic drugs and the presence of cerebral microbleeds: the rotterdam scan study the difference in location between traumatic cerebral microbleeds and microangiopathic microbleeds associated with stroke 7-tesla susceptibility-weighted imaging to assess the effects of radiotherapy on normal-appearing brain in patients with glioma radiation-induced microbleeds after cranial irradiation: evaluation by phase-sensitive magnetic resonance imaging with 3.0 tesla presence of cerebral microbleeds is associated with worse executive function in pediatric brain tumor survivors the natural history of familial cavernous malformations: results of an ongoing study improved detection of metastatic melanoma by t2*-weighted imaging white matter lesion progression in ladis: frequency, clinical effects, and sample size calculations cerebral microbleeds and asymptomatic cerebral infarctions in patients with atrial fibrillation covid-19 is associated with an unusual pattern of brain microbleeds in critically ill patients (preprint) key: cord-027730-xn12s005 authors: jlassi, amal; elbedoui, khaoula; barhoumi, walid; maktouf, chokri title: unsupervised method based on superpixel segmentation for corpus callosum parcellation in mri scans date: 2020-05-31 journal: the impact of digital technologies on public health in developed and developing countries doi: 10.1007/978-3-030-51517-1_10 sha: doc_id: 27730 cord_uid: xn12s005 in this paper, we introduce an unsupervised method for the parcellation of the corpus callosum (cc) from mri images. since there are no visible landmarks within the structure that explicit its parcels, non-geometric cc parcellation is a challenging task especially that almost of proposed methods are geometric or data-based. in fact, in order to subdivide the cc from brain sagittal mri scans, we adopt the probabilistic neural network as a clustering technique. then, we use a cluster validity measure based on the maximum entropy (vmep) to obtain the optimal number of classes. after that, we obtain the isolated cc that we parcel automatically using slic (simple linear iterative clustering) as superpixel segmentation technique. the obtained results on two challenging public datasets prove the performance of the proposed method against geometric methods from the state of the art. indeed, as best as we know, it is the first work that investigates the validation of a cc parcellation method on ground-truth datasets using many objective metrics. thanks to advances in magnetic resonance imaging, neuroscientists and clinicians can study in depth the corpus callosum (cc) and mainly the correlation between the cc's dimensions and some neurological diseases. the cc, which is the largest white matter structure and the biggest fiber tract connecting corresponding regions of the cerebral cortex in the two cerebral hemispheres, integrates motor, sensory, and cognitive functions of the brain [1] . anatomically, more than half of the axons composing the cc are surrounded by myelin, which gives this structure its remarkable appearance in midsagittal t1-weighted mri images. however, in many sagittal brain mri slices, the fornix appears in the neighborhood of the cc with a similar intensity ( fig. 1 ) [2] . the cc is usually divided into smaller regions such as rostrum, genu, body, and splenium. this subdivision of the cc is called parcellation and it is proving to be very useful for an effective analysis of the cc [2, 3] . in fact, the cc shape may be the cause of many neurodegenerative diseases such as epilepsy, alzheimer, autism, depression and other types of psychosis [4] . the cc analysis is also important for studying aging, gender differences and laterality [5] . hence, various studies have evaluated shape or volume variation of the cc parcels. they revealed a correlation between cc's abnormalities and many diseases. for instance, [6] shows that the rate of change in cc or one of its sub-regions is more closely associated with the progression of alzheimer's disease. moreover, the cc parceling can be an appropriate group biomarker for an objective evaluation of treatments aimed at slowing the progression of alzheimer [7] . furthermore, several works have identified volume alterations of the cc and its sub-regions in subjects with autism spectrum disorders (asd). in this context, a study of the cc volume of 40 pre-schoolers, with different sex and age, suffering from asd was made by applying the "freesurfer" automated parcellation software. this study demonstrated that the total volume of the cc and its sub-regions is correlated with autism severity [8] . another study conducted on 75 participants with parkinson disease (pd) and 24 healthy control (hc) confirms that cc sub-regions abnormalities might be the cause of parkinson disease. indeed, participants with pd showed an increase in the 3 anterior callosal segments compared to hc [9] . generally, the cc parcellation into callosal regions allows for a precise differentiation of motor connectivity and the structural integrity of these tracts in the cc [10] . thus, the cc parcellation should be so helpful to better understand inter-hemispherical callosal connectivity in patients or healthy subjects [11] . in particular, mri takes advantage of the macroscopic geometrical arrangement of white matter bundles that it makes capable of generating good cc visualization from the sagittal plane. in any way, the parcellation of the cc stills an important task for radiologic assessment despite there are no real or visible borders to allow this subdivision. nevertheless, the visual inspection of cc structures in mri scans suffers from both inter-and intra-specialist variability. on the one hand, the manual cc segmentation methods require strongly visual effort, specialized training skill, and are time-consuming processes. on the other hand, several geometrical methods for the cc parcellation have been proposed such as witelson and hofer methods [12] . however, these methods cannot be satisfactorily validated due to the lack of qualitative parameters and reference standards. although all these difficulties, the development of an automatic cc parcellation method is an inescapable need to ensure a reliable diagnosis. such parcellation is so independent from the operator skills and may be extended to other brain structures parcellation. thus, since there are no visible landmarks indicating where the cc should be subdivided, the development of a fully automatic cc parcellation method is highly challenging, even for specialists. to deal with this issue, we propose to automatically parcel the cc within mri images. by validating it, for the first time, on large and public datasets, the proposed method records promising results. in fact, the contribution of this work is twofold: -as best as we know, we adopt for the first time the superpixel segmentation algorithm called simple linear iterative clustering (slic) for the cc parcellation [13] . despite its simplicity, slic has been demonstrated to be effective in various computer vision applications [14] . -the subdivision process of the proposed method is fully automatic and it is the second study that proposed a non-geometric analysis for the cc parcels, to the best of our knowledge [15] . although it is based only on the mri data of each analyzed subject, with no parameter adjusting, the proposed method proved quantitatively its superiority over state-of-the-art methods. the rest of this paper is organized as follows. in sect. 2, we briefly review existing methods for the cc parcellation. section 3 presents the proposed method based on slic. experimental results are discussed in sect. 4. the last section concludes the paper and points some directions for future work. few cc parcellation methods were proposed. however, most of these methods have not surmounted all the challenges encountered. in fact, the cc parcellation is a challenging task given that a normal shape of the cc might not clearly highlight all parcels, what can increase the diagnosis complexity. in addition, many internal abnormalities might include bumps which are hard to detect. existing cc parcellation methods can be divided into two main classes: geometric methods and non-geometric ones. on the one hand, since there are no real or visible boundaries allowing the cc parcellation, several geometrical methods were presented to perform this task. among these methods, two particular ones are widely adopted. the first was proposed by witelson and it is based on postmortem connectivity analysis in primates and humans [16] . this method divides the cc into five regions ranging from anterior dimension to the posterior dimension. the cc subdivision is done into an anterior third, the middle of the anterior and posterior midbody, a posterior third and the posterior one-fifth. the rostrum, genu, and rostral body presenting the regions of the anterior third illustrate the prefrontal, premotor, and supplementary motor cortical areas. however, the posterior midbody is crossed by the somaesthesic and posterior parietal fiber bundles. the sub-regions of the posterior third, containing the isthmus and splenium, are allocated to temporal, parietal, and occipital cortical regions. thus, this parcellation method, and as any geometric methods, neither reflects the real texture nor the internal organization of the cc. in addition, the cc parcellation is strongly dependent on the brain conservation process, since it is based on post-mortem data. differently, hofer proposed the only work based on tractography of dti (diffusion tensor imaging) by subdividing the cc into five regions from an average behavior observed via tractography in a specific population of 8 subjects [1] . as already proposed by witelson, the geometric baseline in the midsagittal section of the cc is defining the anterior and posterior points of the structure. the first region, which represents the first sixth, contains fibers projected in the prefrontal region. the remainder of the anterior half cc illustrates the second region containing the fibers that form the motor and motor areas of the cerebral cortex. in fact, these fibers form together the largest cc region and are placed in the back section of the structure. the third region presents the posterior half minus the posterior third. it contains fibers responsible for the primary motor cortex. however, this part of the parcellation scheme is in conflict with witelson's method. the fourth region forms third minus the posterior quarter, presenting the primary sensory fibers. the last and the fifth region represents the cc posterior quarter crossed by the parietal, temporal and visual fibers. figure 2 shows a comparison between the geometric schemes proposed by witelson and hofer. we notice that geometric methods allow only to divide the cc into the same regions among all subjects without considering the human and individual brain features between different subjects. on the second hand, differently to geometric parcellation methods, rittner proposed a data-driven method based on the watershed technique [15] . this method is composed of four steps. the first step consists in the weighting of the fractional anisotropy. the second step performs the selection of the brain midsagittal plane, followed by the third and the last step which are the cc segmentation using the watershed technique, and its parcellation with fixed markers. nevertheless, this method suffers from sensitivity to parameters selection. in order to overcome its limitations, cover extended the rittner method with some important changes [12] . practically, the author replaced all steps except the first step in order to lead to a more robust data-driven method. indeed, the parcellation is improved by applying the kmeans algorithm after defining the cc centerline. when comparing this method to that of rittner, and although both are based on watershed, it is confirmed that this method had a better generalization ability using no fixed markers to execute the watershed transform. however, due to the lack of quantitative metrics and reference standards, these methods cannot be correctly validated. differently to existing methods, we propose a subdivision scheme that considers only the mri data [14] . using the slic superpixel segmentation technique, the method is composed of two main steps: cc segmentation and cc parcellation. this comes from that the slic presents one of the most popular images over segmentations that is commonly used as supporting regions for primitives to reduce computations in various computer vision tasks. we adopt herein our previous method [17] for the automatic cc segmentation of mri sagittal section. it includes three main steps: image preprocessing using the anisotropic diffusion filtering (adf), classification based on the unsupervised probabilistic neural network (pnn) classifier, and cc isolation using a spatial filtering (fig. 3) . in fact, the first step aims to enhance the signal-to-noise ratio by eliminating unwanted parts in the background and smoothing the internal part of the region while preserving its borders. in fact, adf allows to unblock high-frequency noise while preserving the main edges of structures [18] . then, the classification step permits to define the target classes using k-means, before classifying them by the pnn [17] . thereafter, the vmep index, which is based on the maximum entropy principle as an evaluation method that is called the cluster validity, is applied in order to determine the optimal number of clusters. the optimal number of classes is obtained when the vmep validity index reaches its maximum value. this number is adopted for the pnn classification process to obtain the final cluster map. once the cc class is identified, the cc region will be isolated by a spatial-based filtering. finally, we defined the cc contour by applying a follow-up algorithm on the border pixels of the cc region that are characterized by a maximum of the spatial gradient [19] . we propose a cc parcellation method based on slic, which is non-geometric and fully automatic superpixel segmentation technique. it works with no parameter adjusting and with no instantaneous training, leading to a more robust technique. thus, in order to segment the cc into a set of superpixels, which refer to groups of pixels that represent perceptually significant small defined regions, we adopt the slic technique. it is an arrangement of k-means for superpixel generation in order to be faster than existing methods, more memory efficient while improving significantly the segmentation accuracy. it allows two important directions [14] . firstly, it reduces greatly the number of distance calculations by restricting the search space to a region corresponding to the superpixel size. therefore, a reduction in the complexity of being linear is achieved in the pixels' number n and superpixels' number k that is independent and user-defined. in our case, n and k are equal to 256 and 200, respectively. secondly, a combination of color and spatial proximity is reached by a weighted distance measure that allows both controls over the size and compactness of the superpixels. thus, each slice of the input mri image is partitioned into different size regions. in fact, the initial grid size is defined as s (1). from the geometric center, the center superpixel of each region is computed. this geometrical center of each region is recursively updated in each iteration. in order to regroup the pixel, both spatial and intensity distances are used. the spatial distance between the pixels i and j is defined as follows (2): where the coordinate values of pixel i and j are represented by p and q. the eq. 3 calculates the intensity distance. where n j and n i represent the normalized intensity of pixel j and i, respectively. equation 4 defines the combined distance measure c d of spatial and intensity. where e denotes the compactness coefficient. in fact, larger value of e illustrates more compact segments, whereas lower value of e represents flexible boundaries. the compactness coefficient is fixed in the range of [0, 1]. the superpixel computation of the proposed method is shown in fig. 4 . for the evaluation of the proposed parcellation method, we are the only study that used brain mri scans from two public datasets. on the one hand, we used the open access series of imaging studies (oasis) dataset, which is freely available on www.oasis-brains.org. it is created by washington university alzheimer's disease research centre. this mri dataset included a longitudinal collection of 416 subjects aged between 18 and 96 years, men and women, including 100 individuals with very mild to moderate alzheimer's disease (ad). all images were acquired on the same scanner using the same sequences. each subject was scanned on two or more visits, separated by at least one year for a total of 373 imaging sessions. each mr image within this dataset is composed of 128 slices with a resolution of 256 × 256 (1 × 1mm). in this work, we selected 1806 sagittal images that are qualified by a quality control according to severe artifacts. on the other hand, autism brain imaging data exchange (abide) is also investigated. in order to accelerate understanding of the neural bases of autism, the abide dataset has supplied functional and structural brain imaging data collected from laboratories around the world. this dataset is composed of two large-scale collections called abide-i and abide-ii. each collection was collected independently across more than 24 international brain imaging laboratories. thus, we generate a total of 2200 sagittal images with a resolution of 256 × 256. it is worthy noting that we have a challenging heterogeneous set of images of normal subjects and individuals with autism and alzheimer. for each subject, the proposed parcellation method gives an apparent variation in the positioning of the cc parcels. this is because this method is purely automatic and does not follow any atlas or any prior knowledge (fig. 5) . the geometric methods of hofer and witelson do not present the variation of their proportion of cc parcels and consequently, the same behavior can be observed on the results of all the subjects. figure 5 shows that the proposed cc parcellation method is more similar to the hofer parcellation than the rittne one. this can be explained by the fact that hofer subdivisions are based on the connections of the cortical fibers to find the cc parcels. the largest differences between the proposed parcellation and that of witelson are observed in the parcels 1 and 4. in fact, according to our collaborator clinician expert, the cc shape and parcellation are well defined and the delineated cc area shows closely the five anatomical subdivisions of the cc, especially the critical ones: the rostrum and the splenium. the fornix is correctly removed from the cc area and the obtained cc parcellation shows a precise subdivision of cc into five regions within brain mri scans, without penetrating the irrelevant neighboring structures. note that, within the selected sample of mri brain scans, the cc is extracted and parcelled both on female (column 1 and 3) and male (column 2 and 4) subjects. in fact, we applied the proposed method on subjects from the abide dataset (column 1 and 2) as well as from the oasis dataset (column 3 and 4). in order to evaluate the performance of the proposed method, we used the following commonly used metrics: dice, accuracy, sensitivity, specificity and precision. -the dice coefficient (5) is a statistical measure that is used for comparing the similarity of two sample sets. -the accuracy (6) is defined as the rate of correctly classified items. -the sensitivity (7) is the proportion of positive items correctly classified. -the specificity (8) is the rate of negative items rightly identified. -the precision (9) is the ratio of correctly predicted positive samples to the total predicted positive samples. tp refers to the true positive (region correctly parcelled as the concerned parcel), tn refers to the true negative (region correctly classified as background), fp refers to the false positive (region which is parcelled as the concerned parcel) and fn refers to the false negative (region which is incorrectly classified as background). we notice that we produce five parcels, and for each parcel we measure the five metrics. it is worthy noting that for the first time, a very useful ground-truth for cc segmentation and parcellation within the challenging widely used oasis and abide datasets is used. therefore, we are the only work that is compared to a such ground-truth. however, the rittner method is evaluated only on the agreement between the results achieved by different cc parcellation methods. in fact, a professional neurologist from pasteur institute of tunis and a junior doctor have been charged with manually preparing the cc regions and parcels from all images belonging to the oasis and the abide datasets. besides, we applied post-processing in order to exclusively extract the cc area and parcels. table 1 shows the recorded results comparatively to the ground-truth. it is clear that the proposed method (pm) records the higher dice coefficient score (> 0.84) in the parcels 1, 2, and 5, and a sufficient dice coefficient score (> 0.75) in parcels 3 and 4 comparatively to the ground-truth. evenly, it reaches a higher accuracy, specificity and sensitivity scores with values > 0.90. the decline of the proposed method performance according to the precision metric can be explained by the cause of the ground-truth which is manually drawing and the processing applied to do the evaluation in each parcel. furthermore, for the two datasets and for each cc parcel, the dice coefficient was computed pairwise for the methods of the state of the art ( table 2) as it is used in the rittner work. therefore, the previous analyzes allow only verifying the similarity between the resulting cc parcels, or which present statistical differences between methods of the literature since this is a problem without a gold standard (table 2) . hence, it is now possible to know the correct cc parcellation by producing ground-truth for both witelson and hofer methods. since the hofer and witelson cc parcellation methods are based on geometric cc parcellation, their results did not vary among different subjects throughout the experimented dataset. this explains this overlap measurement obtained which would have maximum value if any of the methods was the same. the most pertinent difference between these cc parcellation methods was related to the automatic and non-geometric behavior defined by our proposed parcellation. table 2 presents different results between methods while recording interesting similarities in some cases. the proposed cc parcellation method demonstrates to be nearby to the hofer method, mainly on parcels 1, 2 and 3, while the witelson method presents significant statistical difference on the parcels 4 and 5. cc is the biggest fiber tract within the human brain that allows the communication between the two cerebral hemispheres. the cc form and sub-regions might cause some diseases. the cc parcellation from mri images can predict future cases of diseases or progress neurological patterns in the development of different diseases. this paper presented a fully automatic non-geometric cc parcellation based on the slic superpixel algorithm, with no parameter adjusting and instantaneous training. since there is no gold standard used to evaluate the existing methods, we produced for the first time a ground-truth led to evaluate quantitatively cc parcellation methods. extensive experiments and quantitative comparisons with relevant cc parcellation methods, proved the accuracy of the proposed method on two challenging standard datasets. indeed, the proposed method achieves higher performance values for each parcel. as future work, we aim to propose a super voxel method based on the slic algorithm, from not only mri scans but also from functional magnetic resonance imaging. topography of the human corpus callosum revisitedcomprehensive fiber tractography using diffusion tensor magnetic resonance imaging anatomical mri study of corpus callosum in unipolar depression the relationship of hand preference to anatomy of the corpus callosum in men accurate automated detection of autism related corpus callosum abnormalities corpus callosum surface area across the human adult life span: effect of age and gender callosal circularity as an early marker for alzheimer's disease corpus callosum shape and size changes in early alzheimer's disease: a longitudinal mri study using the oasis brain database the effect of age, sex and clinical features on the volume of corpus callosum in pre-schoolers with autism spectrum disorder: a case-control study white matter abnormalities in the corpus callosum with cognitive impairment in parkinson disease parcellation of motor cortex-associated regions in the human corpus callosum on the basis of human connectome project data white-matter microstructural properties of the corpus callosum: test-retest and repositioning effects in two parcellation schemes data-driven corpus callosum parcellation method through diffusion tensor imaging computational methods for corpus callosum segmentation on mri: a systematic literature review slic superpixels compared to state-of-the-art superpixel methods automatic dti-based parcellation of the corpus callosum through the watershed transform hand and sex differences in the isthmus and genu of the human corpus callosum: a postmortem morphological study unsupervised method based on probabilistic neural network for the segmentation of corpus callosum in mri scans multimodal registration of pet/mr brain images based on adaptive mutual information boundaries detection based on polygonal approximation by genetic algorithms key: cord-011669-hkkpw2bl authors: rodríguez-sánchez, diego noé; pinto, giovana boff araujo; thomé, edval fernando; machado, vânia maria de vasconcelos; amorim, rogério martins title: lissencephaly in shih tzu dogs date: 2020-06-20 journal: acta vet scand doi: 10.1186/s13028-020-00528-0 sha: doc_id: 11669 cord_uid: hkkpw2bl background: lissencephaly is a brain malformation characterized by smooth and thickened cerebral surface, which may result in structural epilepsy. lissencephaly is not common in veterinary medicine. here, we characterize the first cases of lissencephaly in four shih tzu dogs, including clinical presentations and findings of magnetic resonance imaging of lissencephaly and several concomitant brain malformations. case presentation: early-onset acute signs of forebrain abnormalities were observed in all dogs, which were mainly cluster seizures and behavioral alterations. based on neurological examination, the findings were consistent with symmetrical and bilateral forebrain lesions. metabolic disorders and inflammatory diseases were excluded. magnetic resonance imaging for three dogs showed diffuse neocortical agyria and thickened gray matter while one dog had mixed agyria and pachygyria. other features, such as internal hydrocephalus, supracollicular fluid accumulation, and corpus callosum hypoplasia, were detected concomitantly. antiepileptic drugs effectively controlled cluster seizures, however, sporadic isolated seizures and signs of forebrain abnormalities, such as behavioral alterations, central blindness, and strabismus persisted. conclusions: lissencephaly should be considered an important differential diagnosis in shih tzu dogs presenting with early-onset signs of forebrain abnormalities, including cluster seizures and behavioral alterations. magnetic resonance imaging was appropriate for ante-mortem diagnosis of lissencephaly and associated cerebral anomalies. lissencephaly in mammals occurs due to the failure of neuroblasts to migrate to the cerebral cortex, during development [1, 2] . it is characterized by smooth cortical appearance and by the absence of surface folds (agyria) or abnormally broad folds (pachygyria). histopathology demonstrates thickening of the cerebral cortex, altered gray-to-white matter ratio and replacement of a normal 6-layered cortex with a 4-layered disorganized cortex [2, 3] . two types of lissencephaly can be distinguished in humans: classical lissencephaly (or type i), characterized by thickened brain surface with agyria or pachygyria that results from neuronal migration arrest [4, 5] and cobblestone lissencephaly (or type ii), characterized by thin and nodular brain surface, resulting from glial and neuronal overmigration [4, 5] . muscular dystrophy, ocular alterations, obstructive hydrocephalus, and malformation of the brainstem and cerebellum are often associated with cobblestone lissencephaly [4] [5] [6] . lissencephaly has been described in lhasa apso [7, 8] , pekingese [9] , australian kelpie [10] , wire-haired fox terrier [11] , irish setter [11] , and mixed-breed dogs [12] . in humans, lissencephaly is associated with gene mutations related to brain development or cerebral metabolism [1, 5, 13] . in addition, nongenetic causes, such as intrauterine viral infections, vascular events (hypoxia or hypoperfusion), and maternal metabolic disorders that interrupt cortical formation, have been described [2, 3, 13] . the neurological signs in dogs commonly begin with an early-onset of seizures and behavioral alterations, leading to disability [7, 8, 10] . clinical findings and magnetic resonance imaging (mri) features of lissencephaly in shih tzu dogs have not been reported previously, and reports of concomitant brain malformations are scarce. four apparently unrelated shih tzu dogs were presented with lissencephaly between 2011 and 2018 at the veterinary neurology service of são paulo state university (unesp), brazil. details regarding clinical features, neurolocalization, ancillary diagnostics and antiepileptic treatment are shown in table 1 . mri was performed using a 0.25 tesla scanner (vet-mr grande, esaote, italy) in all dogs to obtain t1-weighted, t2-weighted, fluid-attenuated inversion recovery (flair) and postcontrast t1 sequences. in addition, gradient echo (gre) sequences were obtained in three dogs, and hybrid contrast enhancement (3d hyce) sequences were obtained in two dogs. all mris were evaluated and interpreted by two researchers (ra and vm). a summary of the mri findings, equipment, positioning, sequences, imaging parameters, and the contrast medium are detailed in additional file 1. the first case was an 8-month-old spayed female referred in 2011 due to seizures of suspected idiopathic origin that were poorly controlled with phenobarbital (gardenal ® , 2.5 mg/kg, orally q12h; safoni, brazil). the dog was evaluated by the referring veterinarian 2 months after the onset of tonic-clonic seizures, which had progressed over the last 2 weeks to 2-3 seizures per week. in our service, the owner reported that the dog experienced cluster seizures that occurred over 48 h and were treated with diazepam and thiopental. on presentation, neurological examination was performed 1 week after cluster seizures and was unremarkable. based on a history of seizures, the lesion was localized to the forebrain. physical examination findings, biochemical profile, and complete blood count (cbc) were normal; polymerase chain reaction (pcr) for canine distemper virus in urine and indirect immunofluorescent antibody tests (ifat) for antibodies against toxoplasma gondii and neospora caninum were negative. mri showed mixed parieto-occipital agyria and pachygyria of the frontal and parietal lobes (fig. 1 ). temporal and occipital regions lacked gyri and sulci. mri diagnosis indicated lissencephaly and supracollicular fluid accumulation (sfa) (fig. 1) . treatment with phenobarbital (gardenal ® , 3 mg/kg, orally q12h; safoni, brazil) and levetiracetam as an adjunct (keppra ® , 20 mg/kg, orally q8h; ucb biopharma, brazil) effectively controlled cluster seizures after presentation. levetiracetam was discontinued after 4 weeks. the neurological signs were nonprogressive and this dog experienced only isolated episodes (interictal period of 2-3 months) over a period of 24 months after diagnosis of lissencephaly (> 50% reduction in the frequency of seizures). it was not possible to obtain information regarding survival for this dog. the second case involved a 43-month-old castrated male which was referred in 2014 due to the occurrence of cluster seizures. the dog was diagnosed by the referring veterinarian with presumed idiopathic epilepsy at 24 months of age and treatment with phenobarbital was then initiated (gardenal ® , 2.5 mg/kg, orally q12h; safoni, brazil). during the first 16 months after diagnosis of presumed idiopathic epilepsy and the onset of treatment, the dog experienced both isolated seizures and cluster seizures, with an interictal period less than 30 days. relatively low levels of phenobarbital (< 25 µg/ ml: therapeutic window 25-35 µg/ml) were detected in serum; therefore, the dose of phenobarbital was gradually increased (gardenal ® , 4 mg/kg, orally q12h; safoni, brazil). however, despite the increase in serum phenobarbital concentration (35 µg/ml), the dog continued to have repeated tonic-clonic seizures. therefore, potassium bromide (kbr) (30 mg/kg orally, q24h) was also prescribed 1 month before referral to unesp. on presentation in our service, in addition to cluster seizures the owner reported behavioral changes between seizures, such as difficulties in learning basic commands, changes in sleep cycle and compulsive pacing. aggression was noted in our service during manipulation for physical examination. during anamnesis, the owner reported polyuria, polydipsia and polyphagia. biochemical profile showed increased levels of alkaline phosphatase (216: reference interval 20-156 u/l). these alterations were presumed to be associated with phenobarbital treatment. neurological examination revealed no abnormalities except for the presence of bilateral central blindness and bilateral ventromedial strabismus during cranial nerve examination. physical and ophthalmological examinations were normal. the anatomical neurolocalization was compatible with a forebrain lesion. pcr in urine for canine distemper virus and ifat in the serum for t. gondii and n. caninum were negative. mri showed absence of sulci and gyri with superficial undulations in the frontal and temporal lobes. the main gyri, including the marginal, ectomarginal, suprasylvian, and ectosylvian gyri, were absent. a rudimentary lateral rhinal sulcus was present, while the cingulate gyrus was not apparent. the internal capsule was abnormally small (fig. 1) . a diagnosis of lissencephaly, internal this dog remained stable and neurological signs were nonprogressive for 36 months after diagnosis of lissencephaly (interictal interval of 3-4 months with > 50% reduction in the frequency of seizures) using combined polytherapy involving both phenobarbital (gardenal ® , 4 mg/kg, orally q12h; safoni, brazil) and kbr (30 mg/ kg, orally, q24h). levetiracetam (keppra ® , 20 mg/kg, orally q8h for 4-6 weeks, ucb biopharma, brazil) was initially included as an adjunct treatment modality. no more cluster seizures were reported after presentation. a carbonic anhydrase inhibitor (acetazolamide, diamox ® , 10 mg/kg, orally q8h, genom, brazil) and a proton-pump inhibitor (omeprazole, gaviz ® , 10 mg/dog, orally q24h, agener, brazil) were used for supportive treatment of hydrocephalus. however, the difficulties in learning basic commands, changes in sleep cycle, compulsive pacing, strabismus and aggression were persistent despite treatment. phone conversation with the owner revealed that the dog was alive 6 years after diagnosis. the third case involved an 18-month-old intact male which was referred in 2014 due to the occurrence of cluster seizures starting 12 days prior to referral. the dog was previously treated with phenobarbital (gardenal ® , 6 mg/kg, orally q12h; safoni, brazil); however, due to poor response to treatment, adjunctive therapy with kbr (40 mg/kg, orally, q24h) was initiated. on presentation, anamnesis revealed that 6 months prior to referral, the dog had experienced over 14 isolated seizures within 45 days and subsequent episodes monthly. at evaluation, the dog experienced two tonic-clonic seizures, and emergency treatment was provided using diazepam (1 mg/kg, per rectum and repeated iv bolus 3x). during the 48-h postictal re-evaluation, neurological examination revealed central blindness, and the owner reported that the dog demonstrated abnormal vocalizations. in addition, aggressiveness during the interictal period was noted, mainly during dog handling. anatomical neurolocalization was consistent with a forebrain lesion. physical and ophthalmological examination was unremarkable. laboratory data, including pcr in urine for canine distemper virus and ifat in the serum for t. gondii and n. caninum were negative. mri of the third dog showed presence of some sulci in the temporal lobe, including the caudal sylvian gyri and lateral rhinal sulci. however, the main gyri, including the marginal, ectomarginal, suprasylvian gyri, and suprasylvian sulcus (division between the parietal and temporal lobe), were absent (fig. 2) . the internal capsule was abnormally small. diagnosis was consistent with lissencephaly, asymmetrical internal hydrocephalus, and corpus callosum hypoplasia. this dog showed progressive reduction in isolated seizures throughout the year following diagnosis (> 50% reduction in seizure frequency) with an interictal interval of 2 months, maintaining combined polytherapy involving phenobarbital (gardenal ® , 6 mg/kg, orally q12h; safoni, brazil) and kbr (30 mg/kg, orally, q24h). serum concentration of phenobarbital was not tested due to financial constraints. no more cluster seizures were observed with combined polytherapy. a carbonic anhydrase inhibitor (acetazolamide, diamox ® , 10 mg/kg, orally q8h, genom, brazil) and a proton-pump inhibitor (omeprazole, gaviz ® , 10 mg/dog, orally q24h, agener, brazil) were used for supportive treatment of hydrocephalus. behavioral changes and central blindness persisted despite treatment. overall survival was 6 years after diagnosis, confirmed by the owners after our phone call. the fourth case was an 18-month-old spayed female which was referred with seizures in 2018. the referring veterinarian suspected meningoencephalitis of unknown etiology and reported poor control of seizures with phenobarbital (gardenal ® , 2 mg/kg, orally q12h; safoni, brazil). prednisolone treatment (predsim ® , 0.5 mg/kg, orally q12h; medley, brazil) was added empirically 1 week prior to referral by the referring veterinarian. in our service, the owner reported the first isolated tonic-clonic seizure when the dog was 9 months old. after the interictal period of 9 months, the owner reported that these seizures began again 3 weeks prior to examination. over the 3-week period before examination, during the interictal periods, subtle behavioral changes such as aggressiveness (mainly after handling), compulsive pacing, abnormal vocalizations, and licking at things were observed. the dog presented with cluster seizures in our service and was treated with diazepam. after stabilization, the postictal state in the following 24 h was characterized by ataxia, paresis, and behavioral signs. upon neurological examination after postictal stage, consciousness, posture, gait, and postural reactions were normal. cranial nerve examination showed bilateral central blindness and bilateral ventromedial strabismus. the findings were consistent with a forebrain lesion. physical and ophthalmological examination findings, biochemical serum profile and cbc test results were unremarkable. thorax radiography and abdominal ultrasound did not show alterations. pcr in urine for canine distemper virus and , h) in the third and fourth cases. mri of the third dog showed a few sulci in the temporal lobe, including the caudal sylvian gyri and lateral rhinal sulci (arrow). the main gyri (including the marginal, ectomarginal and suprasylvian) and the suprasylvian sulcus were absent. the internal capsule was abnormally small, and internal hydrocephalus was visualized (a-d). mri of the fourth dog showed generalized agyria with an absence of sulci and thickened gray matter with smooth appearance (arrow) (e, f). rhinal sulci in the temporal lobe were not apparent and cingulate gyrus was absent (arrowhead). internal hydrocephalus and supracollicular fluid accumulation associated with dorsocaudal outpocketing of the third ventricle (type sfa-iii) were observed (g, h) ifat in the serum for t. gondii and n. caninum were negative. mri showed generalized absence of sulci and gyri and thickened gray matter. the main sulci and gyri, including the marginal, ectomarginal, suprasylvian, ectosylvian, and lateral rhinal sulci, were absent. the cingulate gyrus was not recognizable, and the subcortical internal capsule was abnormally small (fig. 2) . the diagnosis was consistent with lissencephaly with sfa, internal hydrocephalus and corpus callosum hypoplasia. prednisolone was then discontinued due to lack of indication. clinical presentation and mri did not support a diagnosis of meningoencephalitis. after dose readjustment with phenobarbital (gardenal ® , 2.7 mg/kg, orally q12h; safoni, brazil) and levetiracetam as an adjunct (keppra ® , 20 mg/ kg, orally q8h for 4 weeks; ucb biopharma, brazil), seizure frequency was reduced for the first 3 months (> 50% frequency reduction of seizures). adjunct treatment with levetiracetam was discontinued after approximately 4 weeks. at the 12-month follow-up examination, seizure reduction with an interictal interval over 2-3 months was noted and no more cluster seizures were observed. however, the behavioral changes, blindness and strabismus observed were persistent despite treatment. a phone conversation with the owners revealed that the dog was alive at the time of writing this report 2 years after diagnosis. malformations of cortical development have rarely been reported in dogs, but epileptic seizures seem to be a frequent clinical sign in affected dogs [7, 9, 10] . lissencephaly represents an uncommon disorder of the cortical gyration in dogs [7, 9, 10] . lissencephaly without concurrent intracranial malformations was described in lhasa apso dogs, in an australian kelpie dog and in a small mixed-breed dog [7, 10, 12] . this report is the first on lissencephaly in shih tzu dogs with other concurrent intracranial malformations and the first report providing a detailed neuroanatomical description of lissencephaly identified on mri. in humans, malformations of cortical development can lead to lissencephaly type i, characterized by pachygyria or agyria with thickened and smooth brain surface [4, 5] . apart from lissencephaly, cortical development disorders that may cause epilepsy as subcortical band heterotopia, polymicrogyria, and cobblestone malformations have been described [1, 2] . such disorders are rarely reported in dogs [14] . four shih tzu dogs without any known close relationship, were referred because of epileptic seizures. the dogs were not selected among breeds. the onset of seizures was at the age of 6, 9, 12 and 24 months. previous studies have reported the onset of seizures in dogs between the age of approximately 12 months and 5 years in two lhasa apso [7, 8] , one pekingese [9] , one australian kelpie [10] , and one mixed-breed dog [12] . in humans with lissencephaly, approximately 83% of patients experience earlyonset seizures earlier than 7-months-old [15] . neuro-ophthalmological abnormalities have been poorly characterized in dogs with lissencephaly. central blindness was previously reported [7, 9] . we detected central blindness in three out of four dogs. bilateral vision deficits were thought to derive from occipital lobe lesions. bilateral ventromedial strabismus (esotropia) was detected in two out of four dogs. only one other report has described ventromedial strabismus in a dog with lissencephaly, which was associated with an orbital anatomical abnormality or short medial rectum muscle [7] . we assumed that maldevelopment of the primary visual cortex and visual motor control mechanism may lead to esotropia [16] . humans with lissencephaly have visual abnormalities, including no ocular fixation or tracking, poor visual tracking, nystagmus, variable esotropia, oculomotor apraxia, optic nerve and macular hypoplasia/ atrophy, delayed visual maturation, and cortical visual impairment [17] . approximately 67% of human patients with lissencephaly type i have neuro-ophthalmological abnormalities [17] . severe mental retardation may be observed in humans with lissencephaly and is associated with neuronal migration defects in spatial learning areas [3, 5, 18] . motor disability as early hypotonia, spastic tetraplegia and opisthotonos is observed in human cases of lissencephaly due to defects in motor areas [3, 5] . humans with lissencephaly often die before adulthood [1, 6, 17] . in our study, early onset of several behavioral changes was detected in three dogs between 6 and 24 months old. alterations in locomotor behavior (pacing and changes in sleep pattern), aggressiveness (irritability to manipulation) and vocalization in addition to seizures were observed. previous studies observed late-onset behavioral changes in dogs with lissencephaly over 12-months-old [7] [8] [9] [10] 12] , aggressiveness being frequently reported [7, 9, 10] . the different clinical pictures between human and canine lissencephaly could be explained by the fact that the cerebral cortex is less essential in dogs than in humans for motor function [11] . in dogs, motor function may be maintained despite frontoparietal lobe (motor area) and pyramidal system lesions. however, cognitive and learning abilities may be affected [11] . magnetic resonance imaging in dogs with lissencephaly showed thickened cortical gray matter with smooth appearance, an abnormally small internal capsule, and absence of the major gyri and sulci when compared with healthy shih tzu dogs (additional file 2). previous studies did not report detailed neuroanatomical examinations of cortical gyri and sulci in dogs with lissencephaly [7, 9, 10] . in addition, mri was informative for correct ante-mortem diagnosis of multiple congenital anomalies, determination of cerebral morphology, and the degree of lissencephaly in shih tzu dogs. lissencephaly is graded in humans using a 6-point grading system based on the severity and anterior-posterior brain gradient of the abnormalities. grade 1 represents severe lissencephaly with complete agyria, while grade 6 represents mild subcortical band heterotopia [3, 5] . grades 1a to 6a are more severe posteriorly and 1b to 6b anteriorly [3, 5] . using these criteria, the second (fig. 1e) , third (fig. 2a) and fourth (fig. 2e) cases presented here were classified as grade 2a with diffuse agyria and few shallow undulations in the frontal and temporal lobes. the first dog was classified as grade 3a due to mixed parieto-occipital agyria and frontal pachygyria (fig. 1a) . previous studies have reported lissencephaly grade 2a [9] and 2b [10] in dogs. in our study, behavioral alterations and central blindness were noted in dogs with more severe lissencephaly grade, indicating a possible correlation between mri severity and clinical signs. the grade of lissencephaly was not related to the severity of the clinical signs in previous studies [9, 10] . two forms of lissencephaly have been described in humans: classic lissencephaly (or type i), characterized by abnormal thick cortical layers (four layered, with a cell-sparse zone), agyria or pachygyria without malformation of the brainstem and cerebellum [2] . mutations in cytoskeletal genes, such as the platelet activating factor acetylhydrolase 1b regulatory subunit 1, doublecortin, and tubulin a1a genes [1, 2, 5] , can lead to lissencephaly in humans and mice [1, 5] . cobblestone lissencephaly (type ii) is characterized by multiple shallow furrows, a thin cerebral mantle and malformation of the brainstem and the cerebellum [2, 5] . in dogs, genetic mutations for lissencephaly have not yet been described [7, 11] . in our study, muscular and ocular disorders were not observed and mri did not showed nodular brain surface and brainstem or cerebellum malformations associated to cobblestone lissencephaly [4] [5] [6] . therefore, our dogs likely have lissencephaly analogous to type i human lissencephaly [2, 5, 19] . lissencephaly is overrepresented in the lhasa apso dogs and was also reported in the genetically related pekingese breed [7, 9] . considering the genetic relation among lhasa apso, pekingese and shih tzu breeds [20] , it is possible that lissencephaly may be a genetic disease in dogs. hydrocephalus and sfa are intracranial malformations most often reported in young and toy breed dogs [21] [22] [23] . enlarged ventricles (a condition known as ventriculomegaly) comprise a common finding in adult brachycephalic dogs [21, 23] . dogs with only ventriculomegaly do not have increased intraventricular pressure and are considered to be asymptomatic [21, 23] in our study, internal hydrocephalus was confirmed based on specific mri features that indicated increased intraventricular pressure in three dogs [21] . hydrocephalus with concomitant lissencephaly has not been reported in dogs. in dogs, lissencephaly has been diagnosed together with ventriculomegaly rather that with hydrocephalus [7, 10, 12] . in a human study, ventriculomegaly has been observed in 73.7% of patients with lissencephaly type i [15] . supracollicular fluid accumulation without concomitant lissencephaly has been reported in male brachycephalic dogs, and the shih tzu dog breed was most often reported [22] . in dogs, most sfas are associated with dorsocaudal outpocketing of the third ventricle (sfa-iii) [24] . an expansion of both the third ventricle and the quadrigeminal cistern is another type of sfa (sfa iii-qc) [24] . a few cases present with enlargement of the sole quadrigeminal cistern (sfa-qc) [24] . previously, it was hypothesized that type sfa-iii in predisposed breeds can be part of hydrocephalus rather than an anomaly itself [24] . in our study, the first dog presented with sfa-qc and type sfa-iii was detected in the second and fourth dogs. although sfa can be related to the presence of neurological signs in dogs with lissencephaly, the clinical significance of sfa is variable and sfa may be incidental in dogs with other intracranial diseases [22] . there is no reported genetic relationship between sfa and lissencephaly in neither dogs nor humans. in humans, supracollicular fluid accumulation is associated with a defect in leptomeninges development [19] . corpus callosum abnormalities have been sporadically reported and are still poorly understood in dogs, typically being an isolated abnormality or associated with holoprosencephaly and inborn errors of metabolism. the most frequent clinical signs described are hypodipsia/ adipsia, tremors, and seizures [25] . we observed concurrent corpus callosum hypoplasia in the second, third, and fourth dogs, which is not commonly reported in dogs with lissencephaly [11] . epileptic seizures may be related to corpus callosum hypoplasia. in humans, corpus callosum abnormalities are associated with classic lissencephaly (type i), cobblestone lissencephaly (type ii) and polymicrogyria [2, 15] . the antiepileptic drugs used resulted in good control of cluster seizures with mild adverse effects in the long-term follow-up (12-36 months). seizures were persistent, although, compared to pretreatment, a reduction in the frequency (> 50% or more) and severity of seizures as well as cessation of cluster seizures was observed. other signs of forebrain abnormalities, such as behavioral alterations, central blindness, and bilateral strabismus were persistent. several medications, including carbonic anhydrase inhibitor acetazolamide and proton-pump inhibitor omeprazole, with the goal of decreasing cerebrospinal fluid production, have been proposed as medical management in dogs with hydrocephalus [23, 26, 27] . experimental studies in healthy dogs and rabbits reported that cerebrospinal fluid production was reduced after acetazolamide and omeprazole treatment, respectively [26, 28] . due to hydrocephalus, the second and third dogs were medically treated with acetazolamide and omeprazole. nevertheless, aggressiveness, changes in sleep cycle, compulsive pacing, central blindness, and strabismus were persistent during the follow-up period despite treatment with acetazolamide and omeprazole. one previous report has described no significant effects on recovery of the neurological signs or ventricular volume reduction after treatment with acetazolamide in dogs with hydrocephalus [29] . furthermore, chronic oral omeprazole therapy in healthy dogs did not affect cerebrospinal fluid production [30] . the major limitation of this study was the lack of histopathological evaluation, which was not possible because dogs were not euthanized during the follow-up period. although transcranial ultrasonography or computed tomography may aid in diagnosis, these methods are not precise [9, 10] . in our study, the use of low-field mri provided a good resolution for ante-mortem diagnosis of lissencephaly in all dogs. variations in signal intensity, identification of abnormal cortical layers and depth of cortical sulci were observed. all anatomical structures of the cerebral cortex were identified (additional file 2). in agreement, previous studies performed diagnosis in dogs using mri fields between 0.4-and 1.5-tesla [7, 9, 10] . mri is the modality of choice for lissencephaly diagnosis and for the differentiation of other neuronal migration disorders, showing a correlation with histopathological features in dogs and humans [1, 2, 7] . lissencephaly should be considered an important differential diagnosis in shih tzu dogs presenting predominantly with early-onset signs of forebrain abnormalities, including tonic-clonic seizures, behavioral alterations, central blindness, and bilateral ventromedial strabismus. low-field mri may be a useful diagnostic tool to detect cases of lissencephaly. hydrocephalus, sfa, and corpus callosum hypoplasia comorbidities could also be associated with lissencephaly in shih tzu dogs. genetic malformations of cortical development a developmental and genetic classification for malformations of cortical development: update 2012 lissencephaly and other malformations of cortical development: 1995 update genetic basis of brain malformations the genetics of lissencephaly neuropathology of lissencephalies. child's nerv syst magnetic resonance imaging features of lissencephaly in 2 lhasa apsos lissencephaly in two lhasa apso dogs lissencephaly in a pekingese lissencephaly in an adult australian kelpie veterinary neuroanatomy and clinical neurology clinical and mri findings of lissencephaly in a mixed breed dog inborn errors of metabolism leading to neuronal migration defects polymicrogyria in standard poodles lis1-related isolated lissencephaly brain abnormalities in infantile esotropia as predictor for consecutive exotropia ocular findings in lissencephaly wynshaw-boris a. impaired learning and motor behavior in heterozygous pafah1b1 (lis1) mutant mice a developmental and genetic classification for midbrain-hindbrain malformations genetic structure of the purebred domestic dog magnetic resonance imaging signs of high intraventricular pressure-comparison of findings in dogs with clinically relevant internal hydrocephalus and asymptomatic dogs with ventriculomegaly clinical and magnetic resonance imaging characteristics of quadrigeminal cysts in dogs congenital hydrocephalus multidetector computed tomographic and low-field magnetic resonance imaging anatomy of the quadrigeminal cistern and characterization of supracollicular fluid accumulations in dogs corpus callosal abnormalities in dogs inhibition of cerebrospinal fluid formation by omeprazole different effects of omeprazole and sch 28080 on canine cerebrospinal fluid production effect of certain drugs on cerebrospinal fluid production in the dog effect of acetazolamide and subsequent ventriculo-peritoneal shunting on clinical signs and ventricular volumes in dogs with internal hydrocephalus evaluation of the effect of oral omeprazole on canine cerebrospinal fluid production: a pilot study publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations the authors are grateful to heraldo andré catalan rosa for technical support with mri. data have not been published previously. supplementary information accompanies this paper at https ://doi. org/10.1186/s1302 8-020-00528 -0.additional file 1: table s1 . doc. summary of magnetic resonance imaging (mri) findings of lissencephaly and concomitant congenital malformations in shih tzu dogs. details regarding malformation type, mri scan, positioning of the patient, sequence types, imaging parameters and contrast medium are described.additional file 2: figure s1 . doc. brain magnetic resonance imaging (mri) in a healthy shih tzu dog. transverse t1-weighted (a and b) and transverse and sagittal t2-weighted (c and d) imaging. the following structures were identified at the level of the interthalamic adhesion: marginal gyri (a); marginal sulci (b); middle ectomarginal gyri (c); ectomarginal sulci (d); middle suprasylvian gyri (e); middle suprasylvian sulci (f ); middle ectosylvian gyri (g); caudal ectosylvian sulci (h); caudal sylvian gyri (i); pseudosylvian fissure (j); lateral rhinal sulci (k); splenial sulci (l); cingulate gyri (m) and corpus callosum (o) (a). the following structures were identified at the level of the mesencephalic aqueduct: marginal gyri (a); marginal sulci (b); middle ectomarginal gyri (c); ectomarginal sulci (d); caudal suprasylvian gyri (e); caudal suprasylvian sulci (f ); ectosylvian gyri (g); lateral rhinal sulci (h); parahippocampal gyri (i) and caudal composite gyri (j) (b). in transverse and sagittal t2-weighted images, all anatomical structures were normal, including the lateral ventricles, quadrigeminal cistern and corpus callosum (c and d). authors' contributions dnrs and rma conceived and designed the study. dnrs, gbap, eft and vmm performed the diagnostic work-up, clinical assessment, and provided professional discussion regarding the cases. rma and vmm evaluated and interpreted magnetic resonance imaging. dnrs and gbap wrote the manuscript. rma critically revised the manuscript. all authors read and approved the final manuscript. not applicable. mri equipment was acquired through funding (procedure number 2009/54028-8) provided by the são paulo research foundation (fapesp). the datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request. this study was not submitted for ethics committee review because it is a retrospective analysis of medical records of the veterinary neurology service, school of veterinary medicine and animal science form sao paulo state university-unesp -brazil. not applicable. the authors declare that they have no competing interests. key: cord-302862-znnlyz3y authors: lim, peter a.c. title: transverse myelitis date: 2019-04-17 journal: essentials of physical medicine and rehabilitation doi: 10.1016/b978-0-323-54947-9.00162-0 sha: doc_id: 302862 cord_uid: znnlyz3y transverse myelitis (tm) is an inflammatory condition across the spinal cord, along one or more levels and in the absence of compression. idiopathic acute tm is rare and with improvements in diagnostic tools and longer follow-up, the etiology which may include post-infectious, multiple sclerosis, or neuromyelitis optica often becomes clearer. the patient may present acutely with weakness, sensory impairments, or bowel and bladder changes. a careful history, physical examination, and appropriate diagnostic studies including blood tests and an mri scan may help determine the diagnosis and etiology. following the acute management, which may include use of steroids, immunosuppressive drugs, and plasma exchange, a comprehensive medical rehabilitation program is important to optimize recovery from the resultant impairments and disabilities and manage associated complications. complications such as paralysis, autonomic dysfunction, neuropathic and musculoskeletal pain, spasticity, contractures, neurogenic bladder and bowels, skin breakdown, and psychological issues will benefit from the expertise of the physiatrist. rehabilitation will include functional restoration with therapy as well as compensation of residual impairment with mobility and various other assistive devices. to maximum weakness in idiopathic tm has been reported to range from 10 hours to 28 days, with a mean of 5 days. 13 subacute presentations, progressing over days to weeks and ascending, are associated with a good to fair prognosis. acute and catastrophic presentations with back pain have a poorer outcome. 14 recovery is often related to the clinical presentation and may or may not be complete. in general, one third of patients with acute tm make a good recovery, another third have fair recovery, and the rest either fail to improve or die. 3, 5, 13 in idiopathic tm treated with methylprednisolone using the medical research council (mrc) scale for muscle strength, 37.5% were reported to have complete recovery or minimal residual deficit (mrc 5-4), 43% had partial recovery (mrc 3), and 19.4% had severe disability or absent recovery (mrc 0-2). factors associated with poor outcomes include severe initial symptoms with spinal shock, delayed presentation to the hospital after maximum deficits have already occurred, development of syringomyelia, and extensive mri lesions. 6, 13 if no recovery has occurred by 1 to 3 months, complete recovery is less likely. 4, 14 patients with tm may present in the ambulatory clinic, urgent care center, or hospital setting with complaints of weakness of the limbs, sensory impairments, pain, and difficulties with the bowel and bladder. weakness may affect only the lower limbs or all four limbs with varying severity. it may be complete, incomplete, or may present as one of the spinal cord syndromes. the clinical spinal level usually corresponds to the lesion, but lower limb findings do not preclude a lesion at the cervical level. sensory complaints may include hypersensitivity, numbness, tingling, coldness, burning, or as a circumferential constriction. pain is a common symptom in one third to one half of patients and may be central or localized, aching or radicular in character. bowel frequency or constipation may occur, and bladder symptoms include increased frequency, retention, and incontinence. 2, 3, 13 the history, including past medical, family, and detailed social, may reveal symptoms of recent infection, immunocompromised or autoimmune condition, space-occupying lesion, demyelinating disease, travel, vaccination, trauma, sexual exposure, animal, insect or tick bites. whether vaccination triggers tm has been debated. there were only seven cases of tm and eight of acute disseminated encephalomyelitis (adem) in the primary vaccination exposure window of 5 to 18 days prior to onset, after 64 million doses within a healthcare network. the incidences were both nonstatistically significant except adem with tdap (tetanus, diphtheria, and pertussis) vaccine at p = .04 (translating into 1.16 cases per million doses). 15 a careful review may yield systemic symptoms, including the upper respiratory tract with cough and difficulty in breathing, chest pain, rashes, joint aches, muscle pain, vision changes, nausea, diarrhea, constipation, and problems with urinary function. particular attention should be paid to details pointing toward potentially treatable or reversible conditions responsive to antimicrobials or surgical decompression. there may be a history of invasive spinal intervention for pain management, and tm relating to the infected catheter tip of an intrathecal morphine pump for chronic pain has been reported. 16 the physical examination should be broadly systemic as well as focused on neurological findings such as motor weakness, changes in sensation (pinprick, light touch, vibration, position sense, or temperature), tone, muscle stretch reflexes, coordination, and bowel and bladder functioning. changes affecting the brain, such as cognitive dysfunction and cranial nerve and visual abnormalities, are generally not seen with idiopathic tm. fever, tachycardia, and tachypnea may indicate an infectious etiology. infections, autoimmune, and other conditions that cause acute inflammation of the spinal cord may also manifest in the other body systems. respiratory, cardiovascular, gastrointestinal, and genitourinary tracts as well as the musculoskeletal and integumentary systems should be assessed accordingly. the findings will assist in determining the level of spinal involvement, guide diagnostic testing, and help rule out other diagnoses. the physiatrist is likely to encounter the patient as a consultation for rehabilitation assessment and management, or referral for a specific problem, such as spasticity or pain intervention. the functional limitations in a patient with tm usually depend on the level of spinal cord involvement and corresponding muscles affected. debilitation and deconditioning from associated illnesses and prolonged recumbency will also affect function secondarily. the functional capability review according to spinal level may be influenced by whether the cord injury is unilateral or bilateral and the degree of completeness. high cervical lesions result in tetraplegia with sensory impairment and also affect the phrenic nerve (c3-c5) with diaphragmatic paralysis requiring mechanical ventilation. a patient with c4 innervation preserved may or may not have respiratory difficulties but will be dependent for most self-care activities. using appropriate technology and devices, whether customized or commercially available, the patient may be able to control the home environment, summon assistance, direct their care, and mobilize in an electric wheelchair with a chin control or a sip-and-puff interface. a patient with c5 level may be able to self-feed and perform personal grooming with equipment such as a universal cuff for the hand allowing attachment of tools (e.g., fork, spoon, or comb). the patient can independently use a powered wheelchair and propel a lightweight manual wheelchair with hand rim projections ("quad knobs") for limited distances over level ground. c6 innervation allows independence with upper extremity dressing, bathing with equipment, and functional propulsion of a manual wheelchair indoors. the patient with superior balance and motor control could theoretically perform independent or supervised transfers with a sliding board, and self-catheterize with appropriate assistive devices. driving a specially adapted automatic transmission vehicle with powered steering, hand-controlled accelerator and brake can be achieved with c7-c8 preservation. a c7 level allows independence in all self-care activities with equipment, independent transfers with ability to push off using intact elbow extensor muscles, and the patient may be able to live alone. a patient with c8 and t1 innervation will have improved manual strength and dexterity for self-care, is independent with a manual wheelchair, and should be able to self-catheterize. preservation of upper thoracic innervation allows a greater degree of trunk control, increasing stability during use and propulsion of a manual wheelchair. it also adds to ease and independence with bladder and bowel self-management. with bracing of the hips, knees, and ankles (kafo or knee-ankle-foot orthoses), minimal ambulation can be attempted, although mainly for training and exercise purposes than truly functional. independent ambulation, even with bracing and bilateral axillary or forearm crutches, is usually not realistic unless the patient has preservation of some upper lumbar innervation. further preservation of lumbar and sacral innervation will increase ease of ambulation with better trunk and pelvic control. the patient with incomplete spinal injury is less predictable, and functional abilities will largely depend on the degree and nature of neurologic preservation. with increasingly greater resolutions and techniques such as t2-weighted fast spin-echo and short-tau inversion recovery (stir) to enhance or suppress the appearance of fat and tissues of different densities, the best tool when tm is suspected is mri. mri not only allows visualization of the lesion but also rules out treatable causes, such as tumor, abscess, and other lesions causing compressive myelopathy. contrast material can be given to highlight lesions, 17 and myelography may rarely be considered if mri is not available. mri scans show features that help differentiate tm from disorders such as multiple sclerosis (figs. 162.1 and 162.2). the lesion in tm tends to affect the central region of the cord and involve more than two thirds of the cord diameter, whereas in multiple sclerosis it is usually more peripheral and involves less than half of the cord diameter. 17 tm is more often associated with high signal intensity on t2-weighted images extending longitudinally over more segments. 17, 18 the number of segments involved may be from 1 or 2 up to 11, and the entire cord or sometimes only the medulla may be affected. 17, 18, 20, 21 the lesion in tm at times resembles a spinal cord tumor and biopsy may even be attempted during investigation. 17, 18, 19 mri of the brain with contrast enhancement is often performed to help determine whether the mri findings point toward multiple sclerosis rather than "idiopathic" tm. in idiopathic partial tm, a study that does not show brain lesions translates to the likelihood of evolving multiple sclerosis at 15% to 44%. when brain lesions such as white matter plaques (especially periventricular) are seen, the chance for development of multiple sclerosis increases to 44% to 93%. 22 asymmetric motor or sensory symptoms and absence of peripheral nervous system involvement at presentation suggest acute myelopathic multiple sclerosis, whereas symmetric symptoms and peripheral nervous system involvement suggest acute tm. 23, 24 immunoglobulin g antibodies may be useful for determining neuromyelitis optica (devic's disease) as the etiology in patients with acute complete tm. longitudinally extensive tm spanning three or more vertebral segments is an important feature and detection of anti-aquaporin 4-specific antibodies (anti-aqp4, aq4p-ab, or nmo-igg) is useful to determine both increased risk for recurrence and conversion to neuromyelitis optica. 13, 25 other tests include the usual blood counts and chemistry, tests for autoimmune conditions, such as antinuclear antibodies, anti-double-stranded dna antibodies, anti-sm antibodies, erythrocyte sedimentation rate, ss-a antibody for sjögren disease, immunoglobulin levels, and vdrl. vitamin b 12 enteric cytopathic human orphan virus may be elevated. the polymerase chain reaction (pcr) technique is useful for amplifying minute quantities of dna or rna. it was used in a recent case report on acute myelitis caused by zika virus infection, which responded well to high-dose prednisolone. 26 a lumbar puncture allows assessment of cerebrospinal fluid pressure, and samples for cell count, determination of protein and glucose concentrations, measurement of immunoglobulins, and protein electrophoresis. oligoclonal bands detected in cerebrospinal fluid are useful in making a diagnosis. in one report, they were present in three of five patients with multiple sclerosis-associated tm, but in none of four patients with parainfectious tm. 4 nerve conduction studies (ncs), electromyography (emg), as well as somatosensory and motor evoked potentials may be useful for establishing diagnosis and monitoring progress. 2,27 urinary system evaluation including cystourethrography, cystoscopy, a baseline renal ultrasound, and urodynamic studies with or without video, have been recommended because of the very high rates of persistent long-term bladder dysfunction. 28, 29 bowel evaluation may require radiography, computed tomography (ct), and mri scans with or without contrast, or colonoscopy to rule out obstruction. in 2002, the tm consortium working group proposed the criteria in table 162 .1 for the diagnosis of idiopathic acute tm. 1 a comparison by de seze 8 of the clinical findings, mri results, laboratory profiles, and outcomes of patients with acute myelopathy according to etiology is presented in although the physiatrist may manage stable long-standing tm on an outpatient basis, hospitalization may be necessary during the initial presentation to monitor vital signs, manage respiratory difficulties, bowel or bladder complications, and carry out diagnostic investigations. 13,28 abnormalities of vital signs such as tachypnea or tachycardia may suggest impaired oxygenation or blood flow to be managed urgently. the ability to provide antiviral or antibacterial agents and surgical intervention may also be critical when a specific cause has been identified. several anti-inflammatory drugs have been tried for tm without clear success. although there is insufficient evidence for corticosteroid efficacy, intravenous methylprednisolone is often used to prevent further damage to the spinal cord as a result of swelling. 12, 20, 21 during the acute phase, it may lead to faster recovery and less disability, and is well tolerated. 22 cyclophosphamide exerts an immunosuppressive and immunomodulatory effect through suppression of cell-mediated and humoral immunity (on the t cells and b cells). 22 cyclophosphamide together with methylprednisolone may help in lupus-related tm. 21, 30 however, there appears to be an absence of any beneficial effect of immunosuppressive drugs (cyclophosphamide, azathioprine, intravenous immune globulin) in patients with idiopathic acute tm. 6, 12 plasma exchange to remove autoreactive antibodies and other toxic molecules from plasma may be effective with a good clinical response, especially within 20 days of onset and when nonresponsive to highdose corticosteroids. 12, 21 the monoclonal antibody rituximab can be effective in decreasing relapses in tm due to nmo. 12 the management of any spinal cord injury will include rehabilitation, and the more severely affected cases of tm will require a comprehensive multidisciplinary rehabilitation program led by a physiatrist. physical and occupational therapists on the team can work with strengthening, endurance, balance, coordination, joint range of motion, reconditioning, mobility, and independence with activities of daily living. the goal is one of optimal functioning and independence in the activities of daily living and mobility for the patient. functional independence measure and the modified barthel index are among the more widely used outcome measures during the rehabilitation process. assessment for appropriate equipment, such as a wellfitting wheelchair and other assistive and walking devices, is needed. gait efficiency, stability, and overall mobility can be improved with bracing devices such as an ankle-foot orthosis or kafo. education of the patient and family about the disease, resultant impairments, potential complications, rehabilitation plans and prognosis is important. the psychological state of the patient should not be neglected, and there should be monitoring for depression and medications initiated if necessary. sexual functioning is often affected, and education and counseling, with or without intervention, may be appropriate early. discharge planning needs and issues potentially affecting the patient's community reintegration, including vocational and recreational, should be assessed. recovery to some extent is expected in tm, but it is important to minimize the effects of even temporary impairments and immobility. all muscles and joints should be kept as active as possible, and daily exercises to preserve range of motion of the joints will help prevent contractures and keep joints flexible. progressive resistive exercises and possibly functional electrical stimulation (fes), also known as neuromuscular electrical stimulation, help maintain strength and decrease muscle atrophy. 31 exercises for inspiratory muscles should be included and use of an incentive spirometer as needed. rarely, glossopharyngeal breathing may need to be taught and electrical stimulation of the phrenic nerve diaphragm considered in the high cervical cord patient not showing recovery. 32 spasticity (see chapter 154) is a possible complication and regular stretching with use of antispasticity medications such as baclofen, diazepam, gabapentin, and tizanidine, can minimize and decrease development of joint contractures. if pain is present, appropriate medications, thermal (heat, cold), and electrical modalities including transcutaneous electrical stimulation may be helpful. antiepileptic drugs such as gabapentin, pregabalin, and carbamazepine, may be prescribed as they have good efficacy for neuropathic pain. amitriptyline may also be useful, although caution is advised with its strong anticholinergic effects. thorough checks of the skin on a daily basis can help avoid pressure sores and associated infections. insensate areas, particularly over bony prominences, should be relieved with special cushions and mattresses such as eggcrate foam and alternating pressure overlays, and pressurerelieving ankle-foot orthoses (prafo) may be helpful. the many varieties of hydrophilic and antimicrobial wound dressings currently available promote faster healing of skin breakdown. bladder (see chapter 138) and bowel (see chapter 139) functioning should be assessed, and a bedside ultrasound for post-void residual urine volume is a simple informative procedure, as is a rectal examination. a program may be needed to avert a neglected neurogenic bowel or bladder leading to stool impaction and hydroureter or hydronephrosis. an indwelling catheter can initially be used for bladder drainage but intermittent catheterization, independently or otherwise, should be instituted whenever possible. longterm follow-up of 2 to 10 years in pediatric patients with tm has shown that residual bladder dysfunction is common even with improvement of paraparesis and lack of urologic symptoms. in one study, 86% had persistent bladder dysfunction and 77% had persistent bowel dysfunction. 28, 29 a bowel program includes adequate fluids, proper diet, activity, and scheduled bowel movements. upper motor neuron bowels may need a stool softener (e.g., docusate), osmotic laxative (lactulose), or stimulant laxative (senna or bisacodyl) for evacuation. digital stimulation of the rectum is often effective and needs to be taught. with areflexic lower motor neuron bowels, use of bulk laxatives like psyllium or methylcellulose to produce formed stools may help during digital manual evacuation. bowel evacuation is often done on a daily basis in the hospital, but frequency can be extended to every 2 or 3 days once an individual returns home. the patient requiring a wheelchair, walker, crutches, or cane will need training, including maneuvering over steps and curbs. if transfers and ambulation require assistance, the training should also include family members or assistants. for patients with tm at the cervical level especially, various types of equipment and orthoses can be provided to help with self-care activities. proper bathroom equipment and modifications, such as a tub bench, commode, handheld shower, raised toilet seat, and grab bars, may make the difference between dependence and independence. selection of appropriate assistive devices helps maximize function. some of this equipment can be fairly expensive; hence, timing of purchases must be carefully considered, as they may not be required soon after. despite a reasonable prognosis for eventual recovery, complacency is to be avoided as it may result in unnecessary secondary complications. renal ultrasound and urodynamic evaluations are relatively routine procedures to assess and monitor bladder dysfunction. electrodiagnosis including ncs and emg are useful for diagnosis and for monitoring recovery. intramuscular botulinum toxin injections are very effective in the management of spasticity and commonly performed by the physiatrist, as are the alternatives of alcohol or phenol nerve and motor point blocks for spastic limb muscles. an intrathecal baclofen pump may be effective in intractable cases and allows much smaller doses and concomitantly fewer side effects. many physiatrists are able to manage the settings and refilling of these pumps. intractable neuropathic pain may respond to an intrathecal morphine pump, which will also require management. 33 the field of rehabilitation uses a plethora of devices and technology during the process of restoring or compensating for the impairments and disabilities resulting from conditions such as tm. some individuals receive fes systems to help maintain fitness and muscle bulk or improve and restore function. fes for the forearm and arm muscles is a routinely employed technique with many devices commercially available. exercise bicycles for the lower as well as upper limbs (e.g., ergys3 [therapeutic alliances, inc.], rt300-s [restorative therapies, inc.]) have also long been used, although are not cheap and have a risk for osteoporotic fractures. from simple body weight-support suspension devices, stationary and mobile, allowing for safer ambulation training, to motorized treadmills allowing flexibility in intensity, velocity, and effort, multiple devices from various manufacturers are available. robotic wheelchairs are ubiquitous equipment, available as either manual, powered, or hybrid, with an almost infinite offering of choices for size, weight, purpose, and even color. control of the wheelchair can be achieved by hand, chin, or other head part, and by voice activation. other than locomotion, there are also wheelchairs available for standing purposes, whether for activities at an erect level, or for weight-bearing exercise. braces or orthotics have also undergone much development and come with different materials, rigidity or flexibility, weight, and functional goals including for support, pressure relief, positioning, or protection. powered exoskeleton systems are currently of interest with systems to assist standing and ambulation such as the rewalk 6.0 (rewalk robotics inc.), hybrid assistive limb or hal (cyberdyne inc.), rex (rex bionics), ekso gt (ekso bionics), and indego (parker hannifin corp). at this time, they are mainly for training and exercise, and limited by the individual's abilities, terrain, device battery, and need for safety supervision including skin breakdown, falls, and equipment failure. 36 the next wave for independent mobility in patients with handicaps could well be that of self-driving or autonomous cars undergoing trials by the major automobile companies and various research laboratories. environmental control units or multiple devices within a smart home controlled using simple touch-pad, infrared or motion-sensitive, and voice-activated mechanisms including automatic doors, curtains, and various electronics such as the television and personal computer, are now commercially available, easy to control, and importantly becoming increasingly affordable. apps (applications) that allow easy communication, videophone interactions, and ready access to the internet are already built-in for many smart phones. intelligent voicecontrolled personal assistants include the apple siri, google assistant, amazon alexa, microsoft cortana, and samsung bixby. there is no specific curative surgical procedure for tm. however, lesions such as abscesses, herniated disks, spinal stenosis, and tumors may need surgery as soon as possible to relieve pressure and prevent further damage to the cord. timely management of compressive lesions may reverse or at least halt further neurologic injury to the cord. pressure sores may require sharp débridement on the unit to remove dead or infected tissue and other debris to accelerate healing. tendon transfers may be considered at a later stage to increase an individual's functioning. nerve transfer in patients with permanent upper limb deficits may be considered to restore or to improve ability to voluntarily activate a muscle. in one case report, a child with tm who underwent multiple fascicle transfers from median and ulnar nerves to the musculocutaneous nerve, spinal accessory to suprascapular nerve, and medial cord to axillary nerve, had excellent recovery of elbow flexion. 37 potential complications from the spinal cord dysfunction of tm are numerous and may require medical or surgical intervention. they include orthostatic hypotension, impaired thermoregulation, autonomic dysreflexia, lung and urinary tract infections, ileus and constipation, electrolyte imbalances, skin breakdown, spasticity and contractures, musculoskeletal and neuropathic pain, injury (including fractures) to bones, muscles and joints due to sensory impairments, heterotopic ossification, osteoporosis, kidney stones, depression, and anxiety. there may be respiratory muscle weakness depending on the level of spinal cord involved, and when severe, mechanical ventilation assistance may be required. the risk of bronchopneumonia and sleep apnea is compounded by any sedating medications or respirationdepressing medications. spasticity and joint contractures are common complications with spinal cord injury and management may be straightforward or extremely difficult, requiring several interventions simultaneously. heterotopic ossification (see chapter 131) may develop around a joint, especially the elbow, knee, and hip. gastrointestinal complications include gaseous distension, regurgitation, indigestion, and chronic constipation. urinary tract infections and urosepsis are also common with a neurogenic bladder, as both retained urine and bladder instrumentation increase infection risk. autonomic dysreflexia/hyperreflexia may occur, especially for lesions above t6. pain is a very frequent complaint and may arise from musculoskeletal sources or be neuropathic in nature. pain management may include medications such as analgesics, nonsteroidal anti-inflammatory drugs, short courses of cyclooxygenase-2 inhibitors, various anticonvulsants, and tricyclic antidepressants. overuse syndromes often occur because muscles and joints are overstressed during functional compensation for weakness or even during the process of rehabilitation training. shoulder pain is a common phenomenon with causes including tendinitis, rotator cuff injury, impingement syndromes, contractures, and inflammatory or degenerative arthritis. steroid and local anesthetic injections in the joint may sometimes be needed, but topical anti-inflammatory drugs, heat, cold, and other modalities, with proper transfer techniques or specific adaptive equipment such as sliding board, are often helpful. a common complication is ischemic breakdown of the skin if pressure relief is not regularly performed. awareness and monitoring for deep venous thrombosis and pulmonary embolism should be routine. prolonged pressure on a peripheral nerve can also cause dysesthesias, pain, or weakness. there may be sexuality, reproduction, and fertility concerns, particularly in younger as well as sexually active patients. the concerns and possible solutions should be discussed, addressed, or referred to a specialist as appropriate. depression and anxiety are not uncommon and usually respond to supportive counseling, but may need antidepressants such as the selective serotonin reuptake inhibitor or the serotonin-norepinephrine reuptake inhibitor drugs. treatment complications may occur because of the medications and equipment required to manage the disease and its complications. strictures or tracheal irritation can result from tracheostomy tubes, lung infections are common in this population, and the ventilators may break down, resulting in an emergency situation. high-dose corticosteroids frequently used for treatment of inflammation in the spinal cord may result in peptic ulcer disease or gastrointestinal bleeding. thromboembolism prophylaxis and anticoagulant treatment in the event of this happening may result in serious bleeding complications. skin breakdown may result at contact and pressure areas with devices or dressings used. frequent catheterization results in increased risk for urinary tract infections and accidental creation of false passages in the urethra with development of strictures. if bowel programs are not well managed or carried out gently, there may be discomfort, pain, and anorectal injuries. transverse myelitis consortium working group. proposed diagnostic criteria and nosology of acute transverse myelitis transverse myelitis fact sheet transverse myelitis: retrospective analysis of 33 cases, with differentiation of cases associated with multiple sclerosis and parainfectious events acute transverse myelitis: incidence and etiological considerations idiopathic acute transverse myelitis: application of the recent diagnostic criteria long-term follow-up of acute partial transverse myelitis acute myelopathies: clinical, laboratory and outcome profiles in 79 cases analysis of prognostic factors associated with longitudinally extensive transverse myelitis the clinical course of idiopathic acute transverse myelitis in patients from rio de janeiro a retrospective cohort study of 8 years follow-up evidence-based guideline: clinical evaluation and treatment of transverse myelitis: report of the therapeutics and technology assessment subcommittee of the american academy of neurology idiopathic transverse myelitis: an experience in a tertiary care setup the prognosis of acute and subacute transverse myelopathy based on early signs and symptoms acute demyelinating events following vaccines: a case-centered analysis transverse myelitis associated with acinetobacter baumanii intrathecal pump catheter-related infection acute transverse myelitis: mr characteristics magnetic resonance imaging findings in 22 cases of myelitis: comparison between patients with and without multiple sclerosis idiopathic transverse myelitis mimicking an intramedullary spinal cord tumor sjögren's syndrome with acute transverse myelopathy as the initial manifestation transverse myelopathy in systemic lupus erythematosus: an analysis of 14 cases and review of the literature idiopathic transverse myelitis and neuromyelitis optica: clinical profiles, pathophysiology and therapeutic choices transverse myelitis. comparison of spinal cord presentations of multiple sclerosis discriminatory features of acute transverse myelitis: a retrospective analysis of 45 patients distinct features between longitudinally extensive transverse myelitis presenting with and without anti-aquaporin 4 antibodies acute myelitis due to zika virus infection clinical and evoked potential changes in acute transverse myelitis following methyl prednisolone residual bladder dysfunction 2 to 10 years after acute transverse myelitis transverse myelitis in children: long-term urological outcomes involvement of the entire spinal cord and medulla oblongata in acute catastrophic-onset transverse myelitis in sle neuromuscular electrical stimulation for muscle weakness in adults with advanced disease point: should phrenic nerve stimulation be the treatment of choice for spinal cord injury? effective management of intractable neuropathic pain using an intrathecal morphine pump in a patient with acute transverse myelitis effects of locomotor training after incomplete spinal cord injury: a systematic review robot-assisted gait training (lokomat) improves walking function and activity in people with spinal cord injury: a systematic review powered exoskeletons for walking assistance in persons with central nervous system injuries: a narrative review nerve transfers for restoration of upper extremity motor function in a child with upper extremity deficits due to transverse myelitis: case report key: cord-267110-2g6owogs authors: sharma, suvasini; dale, russell c. title: acute disseminated encephalomyelitis date: 2017-11-17 journal: acute encephalopathy and encephalitis in infancy and its related disorders doi: 10.1016/b978-0-323-53088-0.00018-x sha: doc_id: 267110 cord_uid: 2g6owogs acute disseminated encephalomyelitis (adem) is an inflammatory demyelinating syndrome with encephalopathy. adem typically affects young children, is often postinfectious, and is typically monophasic. mri neuroimaging, which shows new lesions with poorly demarcated borders, but not old and established lesions, is essential to diagnosis. autoantibodies against myelin oligodendrocyte glycoprotein (mog) are found in ∼40% of adem patients, and these patients have different clinical and neuroimaging features to seronegative patients. treatment in the acute phase is typically with high-dose corticosteroids and intravenous immunoglobulin or plasma exchange for refractory patients. outcome is usually good, but residual cognitive, inattentive, and executive issues are likely underestimated. in patients who have a relapse, biomarkers and imaging should help differentiate multiphasic adem, neuromyelitis optica spectrum disorder, anti-mog antibody–associated relapsing demyelination, and multiple sclerosis. acute disseminated encephalomyelitis (adem) is an acute immune-mediated inflammatory demyelinating condition involving the brain and spinal cord, which presents clinically with new-onset polyfocal neurologic features, which by definition include encephalopathy. 1 the mri shows characteristic multifocal demyelinating abnormalities. there is often a history of infection or immunization, and adem is considered a postinfectious/parainfectious condition. this condition is a common cause of encephalitis in children and must be considered in the differential diagnosis of a child presenting with acute febrile encephalopathy and altered sensorium with or without fever. children with adem respond well to immunosuppressive treatment (steroids) with the majority having a single event, i.e., a monophasic course. a small proportion of children with adem may have relapses, and in this subset, multiple sclerosis (ms) is a diagnostic consideration. in this chapter we discuss the epidemiology, pathophysiology, clinical features, investigations, treatment, and outcome of adem in children. adem is a clinicoradiological diagnosis because there are currently no diagnostic blood or csf abnormalities or biomarkers (apart from anti-myelin oligodendrocyte protein [anti-mog] antibodies, discussed later). therefore in earlier studies there was a marked heterogeneity regarding the criteria for diagnosis. in 2007, the international pediatric multiple sclerosis study group (ipmssg) proposed consensus definitions for pediatric acquired demyelinating disorders of the central nervous system (cns) to improve consistency in terminology. 2 these criteria were revised in 2013. 3 for the diagnosis of adem, all of the following criteria are required 3 : 1. a first polyfocal, clinical cns event with presumed inflammatory demyelinating cause. 2. encephalopathy that cannot be explained by fever. encephalopathy refers to an alteration in consciousness (e.g., stupor, lethargy) or behavioral change unexplained by fever, systemic illness, or postictal symptoms. or more after the onset. this implies that the confirmation of the monophasic course requires followup and can only be done retrospectively. 4. brain mri is abnormal during the acute (3 months) phase. 5. typically on brain mri, there are diffuse poorly demarcated, large (>1-2 cm) lesions involving predominantly the cerebral white matter. t1 hypointense lesions in the white matter are rare. deep gray matter lesions (e.g., thalamus or basal ganglia lesions) can be present. if a child has a first monofocal or polyfocal clinical cns event with presumed inflammatory demyelinating cause in the absence of encephalopathy and the mri criteria for ms are not met, this is known as clinically isolated syndrome (cis). 3 examples of cis include optic neuritis, transverse myelitis, hemiparesis, monoparesis, and brainstem syndromes. cis has a higher likelihood of progression to ms as compared with adem. 4 the clinical symptoms and radiologic findings of adem can fluctuate in severity and evolve in the first 3 months after onset. accordingly, a second event is defined as the development of new symptoms more than 3 months after the start of the incident illness. there is no strong biological rationale of the use of 3 months as a cutoff, although it is hypothesized that monophasic immune dysregulation is usually resolved within a 3-month period. a small proportion of children with adem (10%) will have a relapse of an inflammatory demyelinating event with encephalopathy. 2 in the 2007 criteria, two terms were used for relapses of adem: recurrent and multiphasic adem. recurrent adem was defined as acute disseminated encephalomyelitis suvasini sharma, md, dm • russell c. dale, mbchb, msc, mrcphch, phd a new event of adem with a recurrence of the same symptoms and signs, 3 or more months after the first adem event. 2 multiphasic adem was defined as a new event of adem involving new anatomic areas of the cns and occurring at least 3 months after the onset of the initial adem event and at least 1 month after completing steroid therapy. in the 2013 revision, the term recurrent adem has been dropped. 3 multiphasic adem now encompasses both new as well as reemergence of previous clinical and mri findings. also, the timing criterion in relation to steroids for recurrent/ multiphasic adem has been removed. a third adem-like event is not consistent with a diagnosis of multiphasic adem but indicates a chronic relapsing demyelinating disorder, such as relapsing optic neuritis, neuromyelitis optica spectrum disorder associated with antiaquaporin-4 antibodies, relapsing anti-mog antibody-associated demyelination, or ms depending the clinical phenotype, biomarker, and neuroimaging findings. 1 epidemiology population-based studies have shown varying incidence rates of adem: 0.07 per 100,000 children per year (germany), 5 0.3 per 100,000 children per year (china), 6 0.4 per 100,000 children per year (san diego), 7 and 0.64 per 100,000 person years (japan). 8 the varying incidence may be influenced by factors such as genetic predisposition, latitude, environmental and socioeconomic factors, and study methodology. 9, 10 the median age at presentation of adem is 5-8 years, with male predominance. 1 a recent study from a single center showed that adem was the most common cause of encephalitis (21% of all encephalitis). 11 adem is preceded by infection or vaccination in 50%-85% of cases. 9 common antecedent infections include flu-like illnesses (56%-61%), followed by nonspecific upper respiratory tract infections (12%-17%) and gastroenteritis (7%). 9, 12, 13 in children, exanthematous diseases are also reported as an infectious antecedent. adem has been reported more commonly in winter and spring. this seasonal distribution is likely due to seasonal viral illnesses and epidemics. viruses (coronavirus, coxsackie b, dengue, hepatitis a virus, hepatitis c virus, herpes simplex virus, varicella zoster virus, epstein-barr virus, human herpesvirus-6, human immunodeficiency virus, measles, mumps, rubella, and parainfluenza) are the infectious agents most frequently associated with adem. 9 bacteria (streptococcus, mycoplasma, legionella, chlamydia, borrelia, rickettsia, campylobacter) and parasites (plasmodium vivax, toxoplasma gondii) may be rarely involved. 14 the mean latency between the infectious prodrome and the onset of neurologic symptoms varies, often being between 4 and 12 days (range: 1-42 days). 9 postimmunization adem accounts for only 5% of cases of adem. 14 postvaccination adem has been associated with several vaccines such as rabies, diphtheria-tetanus-polio, smallpox, measles, mumps, rubella, japanese b encephalitis, pertussis, influenza, hepatitis b vaccine, and human papillomavirus vaccine. in a recent retrospective review of vaccine adverse event reporting system (vaers) database and the eudravigilance postauthorisation module (evpm) from 2005 to 2012, a total of 404 cases of postvaccination adem were reported, 15 and half of the patients were less than 18 years of age and with a slight male predominance. the time interval from vaccination to adem onset was 2-30 days in 61% of the cases. vaccine against seasonal flu and human papillomavirus vaccine were those most frequently associated with adem, accounting for almost 30% of the total cases. the risk of developing adem following vaccination is relatively low, compared with the risk of adem following infections against which the vaccines are aimed to protect. 1 the benefits of vaccinations are considered to far surpass the potential risk of postvaccine adem. the exact pathogenesis of adem is unclear. postinfectious immune-mediated mechanisms are implicated. molecular mimicry with t cell-mediated cross-activation and response against myelin proteins, such as myelin basic protein, proteolipid protein, and mog plus b cell activation and autoantibody production, may play a role. 14 this hypothesis is supported by studies showing the presence of anti-mog antibodies in the serum and cerebrospinal fluid (csf) during the acute phase and their progressive decline along with disease resolution. 16 in a single study comparing the profile of myelin peptide autoantibodies in children with adem versus ms, adem was characterized by igg autoantibodies targeting epitopes derived from myelin basic protein, proteolipid protein, myelin-associated oligodendrocyte basic glycoprotein, and α-b-crystallin. 17 in contrast, ms was characterized by igm autoantibodies targeting myelin basic protein, proteolipid protein, myelin-associated oligodendrocyte basic glycoprotein, and oligodendrocyte specific protein. there may also be a nonspecific self-sensitization of reactive t cells (bystander activation) against myelin proteins secondary to infections. 18 in a recent study comparing the csf cytokine profiles in children with adem, enterovirus encephalitis, and anti-nmda receptor encephalitis, patients with adem showed predominant elevation of th1 (ifn-γ, tnf-α, cxcl9, cxcl10), th2 (il-4, eotaxin, ccl17, il-13), th17 (il-23, g-csf, il-6, il-8, and il-17a), b cell (cxcl13, baff, ccl19), and other cytokine (cxcl1, ifn-α 2, il-1ra) molecules, which supports the hypothesis that both cell-mediated and humoral effector mechanisms may play a role. 19 in a recent study comparing the cytokine profile of anti-mog positive versus anti-mog negative demyelinating disorders it was found that the csf in anti-mog antibody positive patients showed predominant elevation of b cell-related cytokines/chemokines (cxcl13, april, baff, and ccl19) as well as some of th17-related cytokines (il-6 and g-csf) compared with anti-mog antibody seronegative patients. 20 these findings suggest that patients with anti-mog antibodies have a more pronounced cns inflammatory response with elevation of predominant humoral-associated cytokines/chemokines, as well as some th 17-and neutrophil-related cytokines/chemokines, suggesting a differential inflammatory pathogenesis associated with mog antibody seropositivity. 20 these findings also suggest that there is a considerable pathophysiologic heterogeneity in patients with adem, suggesting a spectrum of inflammatory demyelination rather than a single disease entity. histopathologically, the hallmarks of adem include perivenular sleeves of demyelination, perivenous inflammation with infiltrates of myelin-laden macrophages, t and b lymphocytes, plasma cells and granulocytes, axonal injury, and edema. 1, 14 the axonal damage is demonstrated by the increased level of a phosphorylated microtubule-associated protein, primarily located in neuronal axons, known as tau protein, in the csf, indicative of the clinical severity of adem. 21 moreover, the csf tau protein concentration in patients with partial lesion resolution in follow-up brain mri has been shown to be significantly higher than in patients with complete lesion resolution. 21 in addition, there are diffuse cortical microglial alterations (multifocal microglial aggregates), which may be partly responsible for the encephalopathy seen in children with adem. 22 adem clinically presents as an acute onset encephalopathy along with polyfocal neurologic deficits. the neurologic symptoms are preceded by prodromal symptoms such a fever, malaise, irritability, somnolence, headache, nausea, and vomiting. 1 encephalopathy presents as a change in behavior and/or consciousness, varying in severity from lethargy to coma. commonly headache/ vomiting (58%-32%), seizures (13%-47%), and meningismus (5%-43%) may be associated. 9 the patient may also have focal or multifocal neurologic deficits such as hemiparesis, ataxia, aphasia, diplopia, and rarely dystonia and choreiform movements. 14 multiple cranial nerve involvement may occur. spinal cord involvement may be present in up to 24% of cases, with clinical features of flaccid paralysis, constipation, or urinary retention. 23, 24 myelitis is significantly more common in anti-mog antibody-associated adem and is associated with longitudinally extensive lesions on the mri. 25 the clinical course of adem is rapidly progressive, with the development of maximal deficits within 2-5 days. 23 rarely, respiratory failure occurs because of brainstem involvement. fever and seizures are described more frequently in adem compared with other acute demyelinating syndromes. 1 combined central and peripheral demyelination has been reported but is very rare in children. clinical manifestations of peripheral neuropathy may occur simultaneously along with the cns manifestations or after them. 9 the diagnosis of adem is clinicoradiological. the characteristic mri lesions are t2-weighted and fluidattenuated inversion recovery hyperintense multifocal, irregular, poorly marginated areas with diameters between 5 mm and 5 cm. 14 adem lesions typically involve the subcortical and central white matter and cortical gray-white matter junction, thalami, basal ganglia, cerebellum, and brainstem (figs. 18.1-18.4) . 1 the reported frequency of gadolinium-enhancing lesions is highly variable between studies (10%-95%), perhaps depending on the timing of obtaining mri in the course of the illness. 9 spinal cord involvement is seen in 10%-28% of patients. 9 five radiologic patterns have been described in adem 26 : (1) adem with small lesions (<5 mm), (2) adem with large confluent white matter asymmetric lesions, (3) adem with symmetric bithalamic involvement, (4) adem with a leukodystrophic pattern with diffuse bilateral and usually nonenhanced white matter-sited lesions, and (5) adem with acute hemorrhagic encephalomyelitis. the latter two phenotypes are uncommon. mri abnormalities may appear later than the clinical symptoms, and progression of mri lesions has been reported during the course of illness despite clinical improvement. 9 mri at presentation can even be normal, 27 and delays of between 5 days and 8 weeks between symptom onset and the appearance of mri alterations have been reported. 28 in a recent study on the evolution of mri during adem episodes, it was noted that new lesions and enlargement of existing mri lesions occurred in the first 3 months in about 50% of the performed mris, despite clinical recovery. 29 however, this was not noted 3 months after first onset of adem. therefore it should be recommended that convalescent mri scans performed during the first 3 months after adem that show new lesions should not necessarily infer the patient has ms. to differentiate from ms, lesions of ms tend be smaller, discrete and ovoid, and periventricular, especially perpendicular to corpus callosum (dawson fingers), in contrast to the fluffy poorly marginated subcortical lesions in adem. 1 the main differentiating features of adem compared with ms are periventricular sparing and the absence of periventricular dawson finger lesions and black holes on t1 sequences, which are typical of ms (fig. 18.5) . follow-up imaging is important to demonstrate resolution of lesions and confirming that no new lesions have developed. in asymptomatic children, repeat imaging is recommended 9-12 months after the episode of adem. 1 an earlier repeat imaging at 3 months would be optimal. 1 in children with new symptoms, imaging should be considered earlier. advanced neuroimaging techniques such as diffusion-weighted imaging (dwi) and magnetic resonance spectroscopy appear useful to exclude other diseases, such as strokes and neoplasms, to discriminate between acute and chronic lesions, and to add information about the extent of the affected areas. 14 in a recent study of dwi in 16 children with adem, vasogenic edema was demonstrated on dwi and corresponding apparent diffusion coefficient (adc) maps in 12 of 16 patients; cytotoxic edema was identified in 2 patients while the other 2 patients displayed no changes on dwi/adc. 30 because the presentation of adem frequently mimics acute encephalitis, csf studies are often done, and although they may confirm an inflammatory process, they are nondiagnostic in adem. csf examination is, however, important, especially to exclude an infectious pathology, which is a common differential diagnosis. csf examination in adem reveals inflammatory findings in most patients, consisting of elevated protein levels, up to 1.1 g/l (seen in 15%-60% of patients) and lymphocytic pleocytosis, which is typically mild (seen in 25%-65% of patients). 1, 9 the csf may be normal in 25%-33% of patients. 9, 13, 31 intrathecal oligoclonal bands are rare, and if present should raise consideration of ms. 1 in three recent series, of 53 patients, oligoclonal bands were reported in only 1 patient (1.9%). [32] [33] [34] recently, it has been shown that serum igg antibodies to mog are present in up to 40% of children with adem. high-titer anti-mog antibodies have also been found in children with bilateral often relapsing optic neuritis and aquaporin-4 seronegative neuromyelitis optica. 35 although some relapsing patients with positive anti-mog antibodies can fulfill 2013 consensus criteria for ms, anti-mog antibodies generally do not associate with ms and, instead, suggest anti-mogassociated autoimmune demyelination. 36, 37 these antibodies are seen almost exclusively in demyelinating illnesses and may help to differentiate from viral encephalitis. 38 in patients with adem, the majority of children with anti-mog antibodies have a monophasic course with a rapid decline of anti-mog antibodies. 16 the presence of anti-mog antibodies is likely to be a negative predictor for a future diagnosis of ms. 36 in a study comparing children with adem with and without positivity for anti-mog antibodies, children with adem who were seropositive for anti-mog antibodies had mri characterized by large, bilateral, and widespread lesions with an increased frequency of longitudinal extensive transverse myelitis and a favorable clinical outcome in contrast to children lacking mog antibodies. 25 corpus callosal lesions have been found to be uncommon in children with anti-mog antibodies. 39 csf pleocytosis is more common in children with anti-mog antibodies, suggesting more inflammatory burden in the acute phase as compared with seronegative patients. some children with adem and seropositivity for anti-mog antibodies may have a relapsing course with future development of optic neuritis or myelitis, 40 or multiphasic adem, 41 but development of ms is rare. 42 the diagnosis of adem is based on the clinical features and suggestive mri findings. the clinical picture mimics acute meningoencephalitis, and excluding infectious causes is the first priority. this is done by csf examination for gram stain, bacterial culture, and viral studies. peripheral smear should be obtained for malarial parasites in endemic areas. the mri obtained should be a gadolinium-enhanced image to look for any leptomeningeal enhancement or any other feature of infection (e.g., basal exudates, brain abscess). in a child with unexplained altered sensorium and neurologic deficits, other possibilities include autoimmune encephalitis (especially anti-nmda receptor encephalitis), viral-associated encephalopathies such as acute necrotizing encephalopathy, hashimoto encephalopathy, cns vasculitis, primary and secondary (systemic lupus erythematosus, anti-phospholipid antibody syndrome), metabolic (both inherited and acquired) disorders, and rarely toxins and nutritional deficiencies. anti-nmda receptor encephalitis must be suspected if the patient has behavior problems, psychosis, sleep disturbances, and movement disorders (especially orofacial dyskinesias) along with encephalopathy. other inflammatory demyelinating conditions must also be considered in the differential diagnosis. if the patient has monofocal or polyfocal symptoms in the absence of encephalopathy, then clinically isolated syndrome is diagnosed. if the predominant presentation is optic neuritis and myelitis, then neuromyelitis optica must be considered, and testing for aquaporin antibodies must be done if possible. neuromyelitis optica with anti-aquaporin-4 antibodies is an uncommon form of cns demyelination in children; therefore autoantibody testing for aquaporin 4 antibodies should probably be done only with optic neuritis, myelitis, and brainstem symptoms with typical aqp4 antibody-associated features. 43 the diagnosis of ms is not made during the first event but may be considered if the mri findings are suggestive, such as the presence of old and new lesions, and fulfillment of mcdonald or other criteria. 44, 45 treatment the treatment of adem is based on observational studies and expert guidelines, because there are no randomized controlled trials. high-dose intravenous corticosteroids are generally considered the first-line treatment. the treatment regimen consists of iv methylprednisolone at a dose of 30 mg/kg/day (maximally 1000 mg/d) for 3-5 days, sometimes followed by an oral taper over 4-6 weeks with a starting dose of prednisone of 1-2 mg/kg/day. 1 the risk of relapse is increased if the steroid tapering period is less than 3 weeks, although not all experts use tapered prednisolone. 24 the aim of steroid treatment is primarily to reduce the cns inflammatory reaction and accelerate clinical recovery. recovery rates with steroid treatment are generally good, with full recovery reported in 60%-85% of the patients. 23, 24 a repeat pulse of intravenous steroids may be considered in the case of unsatisfactory clinical improvement or early relapse. 46 iv immunoglobulin (ivig) treatment has been described in case reports and small case series, mostly in combination with corticosteroids or as a second-line treatment in steroid unresponsive adem. 47 the usual total dose is 2 g/kg, administered over 2-5 days. treatment with ivig has proven effective in about 40%-50% of steroid-resistant patients. 12, 48 ivig presumably acts by binding and neutralizing autoantibodies, inhibiting cytokine release, and modulating lymphocyte activation. 14 plasmapheresis may be considered in therapyrefractory patients with fulminant disease, with an estimated efficacy of 40%. 49 the usual regimen is five to seven exchanges but there are not infrequent complications in the form of anemia, hypotension, hypocalcemia, thrombosis, and line infections. 14 moreover, plasmapheresis is technically difficult to perform in young children. rarely, patients with fulminant adem and cerebral edema have been treated with hypothermia in which the body temperature is reduced to 34°c and intracranial pressure and cerebral perfusion pressure levels are maintained low using mannitol and dopamine. 50, 51 decompressive craniectomy may be considered in cases of refractory intracranial hypertension. 52 in pediatric series, adem has a favorable prognosis, with a good functional recovery reported in 60%-85% of patients. neurologic improvement is usually seen within days following initiation of treatment, and recovery to baseline usually occurs within weeks. 1 mortality has been reported in 1%-3% of affected patients in recent series. 53, 54 residual severe disability is rare, reported in 7% of children in recent studies. 55 about 10%-40% of children are reported to experience residual cognitive impairment or changes in mood and behavior, and the neurocognitive burden of adem is probably underappreciated. 24, 31, 33 few studies have analyzed the neuropsychological profile of monophasic adem patients. although, overall, these patients showed a satisfactory global performance, a number of children demonstrated isolated deficits in one or more cognitive domains, most frequently the attentive and executive domains. 9 greater vulnerability to cognitive dysfunction and behavioral problems has been noted in adem patients diagnosed before the age of 5 years. 56 optic nerve involvement at presentation 23 and antecedent viral infection 24 have also been suggested as indicative of a poor outcome. in a recent study of the long-term neurocognitive outcome of children with adem, the most common residual symptoms were concentration difficulties (30%), behavior problems (28%), and learning difficulties (26%). 55 on the kaufman intelligence test, a full-scale iq of more than 85 was found in only 60% of patients, and 44% of patients fulfilled the criteria for adhd. male gender was a predictor for a worse neurocognitive outcome in this study. 55 the attention and behavioral impairment in adem may be attributed to the cerebral white matter damage that may interfere with information processing and attention skills, which are critical for emotional functioning and behavioral regulation. 56 when persisting symptoms continue after adem, persisting chronic immune activation should be considered, and a retrial of immune therapy can be used to determine if there is a reversible cause for ongoing symptoms. although in most cases adem has a monophasic course, a variable number of patients (10%-30% in previous studies) experience relapses. 9 because of the high interstudy variability and inconsistency of definitions in the past studies, it is difficult to have conclusive findings on relapsing patients from the current literature. latency from first episode to relapse is variable, ranging from 2 months to 8 years, 23 and even after 33 years in one case. 41 relapses have been reported to be more common in the first 6 months after the first episode, mostly occurring in children who underwent oral steroid tapering for 3 weeks or less. 57 most children experience a single relapse, but as many as three relapses are reported in some studies. 23, 57 an increased risk of relapse after adem has been associated with coexistent optic neuritis, familial history of cns inflammatory demyelination, the presence of ms findings criteria on mri, and the absence of sequelae after the first attack in one study. 58 multiphasic adem is uncommon. in literature, multiphasic adem was diagnosed in only 2 of 117 (1.7%) children in one series, 59 and in 5 of 132 (3.8%) children in another series. 58 after the initial episode of adem, a subsequent diagnosis of ms is not common. a long-term follow-up study using the 2007 international pediatrics multiple sclerosis study group criteria evaluated the parameters at initial diagnosis and eventual conversion to ms in a cohort of 123 children with a first episode of acute cns demyelination. 4 of the 47 patients initially diagnosed with adem, only 4 (8.5%) were eventually diagnosed with ms at follow-up versus 38.8% of those initially diagnosed with clinically isolated syndrome had ms. on multivariate analysis, the following predictors for developing ms were identified: female gender, clinical presentation with monofocal brainstem or hemispheric dysfunction, and fulfillment of the mri criteria for ms. in a patient with first episode of adem, criteria for ms are met, if after the initial adem, a second clinical event (1) is non-encephalopathic, (2) occurs 3 or more months after the incident neurologic illness, and (3) is associated with new mri findings consistent with revised radiologic criteria for dissemination in space. 3 patients with anti-mog antibodies who relapse typically have further episodes of adem 60 or optic neuritis, 61 and typically do not have new lesions on mri during asymptomatic periods. adem is a polyfocal immune-mediated inflammatory demyelinating disease of the cns that involves multiple areas of the white matter, which mostly affects children under 10 years of age. common antecedents include a recent viral or bacterial infection or more rarely immunization. the diagnosis is made in the clinical setting of acute onset of encephalopathy with other neurologic deficits and mri findings of multifocal demyelination after excluding cns infections. commonly, adem has a monophasic course in 70%-80% of cases, with most children having a good recovery with high-dose intravenous steroid pulse treatment. ivig and plasmapheresis may be considered as second-and third-line therapies. adem overall has a good prognosis, but 10%-40% of children may have neurocognitive dysfunction on follow-up. relapses may occur in 10%-30% of patients in the form of multiphasic adem, optic neuritis, myelitis, or ms. there is need for further evaluation of biomarkers such as anti-mog antibodies for prediction of relapses and prognosis. acute disseminated encephalomyelitis: updates on an inflammatory cns syndrome consensus definitions proposed for pediatric multiple sclerosis and related disorders international pediatric multiple sclerosis study group criteria for pediatric multiple sclerosis and 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meta-analysis acute disseminated encephalomyelitis in children and adolescents: a single center experience multiple sclerosis and acute disseminated encephalomyelitis diagnosed in children after long-term follow-up: comparison of presenting features anti-mog antibody: the history, clinical phenotype, and pathogenicity of a serum biomarker for demyelination anti-mog antibodies plead against ms diagnosis in an acquired demyelinating syndromes cohort myelin oligodendrocyte glycoprotein antibodies are associated with a non-ms course in children highly reactive anti-myelin oligodendrocyte glycoprotein antibodies differentiate demyelinating diseases from viral encephalitis in children clinical and mri phenotype of children with mog antibodies persistent presence of the anti-myelin oligodendrocyte glycoprotein autoantibody in a pediatric case of acute disseminated encephalomyelitis followed by optic neuritis. neuropediatrics an adult case of anti-myelin oligodendrocyte glycoprotein (mog) antibody-associated multiphasic acute disseminated encephalomyelitis at 33-year intervals antibodies to mog have a demyelination phenotype and affect oligodendrocyte cytoskeleton neuromyelitis optica and neuromyelitis optica spectrum disorders mcdonald criteria for diagnosing pediatric multiple sclerosis risk of multiple sclerosis after a first demyelinating syndrome in an australian paediatric cohort: clinical, radiological features and application of the mcdonald 2010 mri criteria a case of relapsing acute disseminated encephalomyelitis with high dose corticosteroid treatment treatment of acute disseminated encephalomyelitis with intravenous immunoglobulin severe steroidresistant post-infectious encephalomyelitis: general features and effects of ivig plasma exchange for severe attacks of cns demyelination: predictors of response fulminant form of acute disseminated encephalomyelitis in a child treated with mild hypothermia therapeutic hypothermia with the use of intracranial pressure monitoring for acute disseminated encephalomyelitis with brainstem lesion: a case report life-saving decompressive craniectomy for acute disseminated encephalomyelitis in a child: a case report severe acute disseminated encephalomyelitis: a paediatric intensive care population-based study disease course and outcome of acute disseminated encephalomyelitis is more severe in adults than in children long-term motor, cognitive and behavioral outcome of acute disseminated encephalomyelitis neuropsychological outcome after acute disseminated encephalomyelitis: impact of age at illness onset acute disseminated encephalomyelitis in children: outcome and prognosis acute disseminated encephalomyelitis cohort study: prognostic factors for relapse prognostic factors after a first attack of inflammatory cns demyelination in children children with multiphasic disseminated encephalomyelitis and antibodies to the myelin oligodendrocyte glycoprotein (mog): extending the spectrum of mog antibody positive diseases acute disseminated encephalomyelitis followed by recurrent or monophasic optic neuritis in pediatric patients key: cord-011165-slu5531z authors: rabbitt, angela l.; kelly, teresa g.; yan, ke; zhang, jian; bretl, deborah a.; quijano, carla v. title: characteristics associated with spine injury on magnetic resonance imaging in children evaluated for abusive head trauma date: 2020-01-04 journal: pediatr radiol doi: 10.1007/s00247-019-04517-y sha: doc_id: 11165 cord_uid: slu5531z background: spine injuries are increasingly common in the evaluation for abusive head trauma (aht), but additional information is needed to explore the utility of spine mri in aht evaluations and to ensure an accurate understanding of injury mechanism. objective: to assess the incidence of spine injury on mri in children evaluated for aht, and to correlate spine mri findings with clinical characteristics. materials and methods: we identified children younger than 5 years who were evaluated for aht with spine mri. abuse likelihood was determined a priori by expert consensus. we blindly reviewed spine mris and compared spinal injury, abuse likelihood, patient demographics, severity of brain injury, presence of retinal hemorrhages, and pattern of head injury between children with and without spine injury. results: forty-five of 76 (59.2%) children had spine injury. spine injury was associated with more severe injury (longer intensive care stays [p<0.001], lower initial mental status [p=0.01] and longer ventilation times [p=0.001]). overall abuse likelihood and spine injury were not associated. spinal subdural hemorrhage was the only finding associated with a combination of retinal hemorrhages (p=0.01), noncontact head injuries (p=0.008) and a diagnosis of aht (p<0.05). spinal subdural hemorrhage was associated with other spine injury (p=0.004) but not with intracranial hemorrhage (p=0.28). conclusion: spinal injury is seen in most children evaluated for aht and might be clinically and forensically valuable. spinal subdural hemorrhage might support a mechanism of severe acceleration/deceleration head injury and a diagnosis of aht. compared to accidental head injury, brain injuries in abusive head trauma (aht) are more severe, more often diffuse, and commonly involve hypoxic-ischemic injury [1, 2] . retinal hemorrhages and noncontact injury patterns resulting in multifocal subdural hemorrhages located over the cerebral convexities or within the interhemispheric fissure are also highly associated with aht [2, 3] . occult spine injuries are increasingly common in aht, likely related to increased awareness and screening for injury using improved imaging and autopsy techniques [4] . although few spine injuries require surgical intervention [5] , identification of occult injuries can strengthen maltreatment investigations by highlighting the severity of injury and risk of harm, and by clarifying the mechanism of abusive injuries. given the potential for detection of clinically significant injury and improved child safety, the american college of radiology (acr) recommends mri of the cervical spine in the evaluation for aht, and that whole-spine mri be considered [6] . despite acr guidelines, the use of spine mri for aht evaluations varies among institutions [7] , suggesting that additional research on the utility of spine mri in children evaluated for aht is needed to promote its inclusion in institutional protocols. additionally, the mechanism of some spine injuries is unclear [4] . an accurate understanding of injury mechanism is important in the medical assessment of child maltreatment to ensure evidence-based abuse diagnoses. the purpose of this study was to assess the incidence of spine injury on mri in children evaluated for aht, and to correlate these mri findings with the clinical characteristics of this population. we hypothesized that the clinical characteristics of rotational acceleration/deceleration typical in aht (noncontact intracranial injury pattern, retinal hemorrhages, and severe diffuse brain injury) would correlate with spine injury. all procedures performed in this study were in accordance with the ethics standards of the institutional and national research committees and with the 1964 helsinki declaration and its later amendments or comparable ethics standards. our institutional review board granted a waiver of informed consent, and the study complied with the health insurance portability and accountability act of 1996. in this retrospective case series review we identified all children younger than 5 years who received an mri of the brain for an abuse evaluation between january 2010 and december 2013. during this timeframe, the hospital's child protection team (cpt) used standard guidelines for abuse evaluation, including head ct in any child for whom there were concerns for aht, and in infants younger than 6 months for whom there were concerns of physical abuse. if concerns for aht remained based on the head ct or clinical findings, the cpt recommended a noncontrast mri of the brain and spine. if a brain mri was the first-line study rather than the head ct, we included the case for analysis if the mri was part of an aht evaluation. the spine mri non-accidental trauma protocol included t1 sagittal, t2 sagittal and axial, 3-d t1 sagittal with axial and coronal reformations, axial gradient echo/susceptibility-weighted imaging, and sagittal short tau inversion recovery (stir) sequences. the upper thoracic spine was included in cervical spine mr imaging through the 5th thoracic vertebral body. all children who received a brain mri for an abuse evaluation were included in the study, regardless of whether an mri spine was obtained or revealed any evidence of intracranial injury. we excluded children with a medical condition that might impact the appearance of spine injuries (skeletal dysplasia, connective tissue disorder, prior spinal surgery, a history of spine injury, or bleeding disorders). two members of the hospital's cpt abstracted clinical data from the medical record. they reviewed 10% of charts together to establish a uniform and accurate data collection process, and the lead researcher (a.l.r.; 12 years of experience) reviewed another 10% of data collection that occurred separately to ensure ongoing integrity and consistency. two board-certified radiologists (a pediatric neuroradiologist, t.g.k., with 27 years' experience in pediatric radiology, 11 years in pediatric neuroradiology, and subspecialty certification in pediatric radiology and neuroradiology; and a pediatric radiologist, c.v.q., with 10 years' experience in pediatric radiology and subspecialty certification in pediatric radiology and nuclear medicine) reviewed the anonymized spine mris and recorded findings by consensus. variables included patient demographics (age, gender, race, ethnicity, insurance status); likelihood of abuse (accidental, indeterminate, abuse); whether the child received an mri of the spine and whether the imaging was of the whole spine or cervical spine only; injury severity (length of intensive care stay, ventilation time, initial mental status described by providers, initial glasgow coma scale [gcs], neurosurgical intervention, and mortality); criminal convictions; confessions; mechanism of head injury (combined, contact, undetermined, noncontact); the presence of retinal hemorrhages; and presenting symptoms of spine injury. initial mental status was recorded from the first available physical exam pertaining to the abuse concern. a presenting symptom of spine injury was any symptom documented prior to the spine mri that the treating provider or cpt consultant thought raised concern for a spine injury. the mechanism of head injury was determined using a previously described classification system based on the pattern and characteristics of the head injury [8] . this method classified injuries as: (1) contact: injuries from cranial impact without significant cranial acceleration or deceleration (skull fractures, craniofacial soft-tissue injuries, epidural hemorrhages); (2) noncontact: injuries from cranial acceleration or deceleration without evidence of cranial impact (concussion, abnormal subdural collection extending from the interhemispheric region, diffuse axonal injury); (3) combined: both contact and noncontact injuries; or (4) undetermined: injuries from contact or noncontact mechanisms (subarachnoid hemorrhages, brain contusions or lacerations, a subdural hemorrhage not extending from the interhemispheric region). we classified children with hypoxic-ischemic injury but no intracranial hemorrhage as "undetermined" and those without intracranial injury confirmed on mri as "no head injury." abuse likelihood was determined a priori at the time of the initial cpt consultation. as standard practice, the cpt consultant assigns a physical abuse likelihood score to all cases using a previously described 1-7 scale (table 1 ) [9] . a diagnosis of aht is made by consensus after peer review by the cpt when a child presents with diffuse primary brain injury and extraaxial hemorrhage that cannot be reasonably explained by an accidental mechanism or a medical condition. the diagnosis is made after careful consideration of all historical and clinical data in collaboration with a multidisciplinary investigation. although information about confessions and criminal convictions was collected, this information is unreliable for an accurate medical diagnosis and was not required to classify children as abused. children <5 years of age were included to align with the narrow definition of aht developed by the centers for disease control and prevention [10] . for this study, the cases were grouped into accidental (1-2), indeterminate (3) (4) (5) , and abuse (6-7). cases classified as abuse were further divided into "aht" or "abuse, not aht." children with abusive extracranial injuries with no intracranial injuries, or intracranial injuries that were indeterminate for abuse were classified as "abuse, not aht." to assess the effects of selection bias, we compared variables between children evaluated for aht who did and did not receive a spine mri. outcome variables included intramedullary injury (spinal cord hemorrhage or edema); extramedullary hemorrhage (subarachnoid, subdural and extradural); spinal fracture or bone marrow edema (bony injury); ligamentous edema or disruption (ligament injury); posterior paraspinous muscle edema; prevertebral soft-tissue swelling; and vertebral and carotid artery injury. ligamentous injury was defined as ligamentous disruption or the presence of hyperintensity on stir sequences surrounding the ligaments or membranes (figs. 1 and 2). spinal hemorrhages were classified as subdural if there was epidural fatty tissue without dural displacement and epidural if the hemorrhage caused dural displacement toward the spinal cord (fig. 3) . we compared clinical characteristics with the presence of spine injury seen on mri. to explore the mechanism of spinal subdural hemorrhage (sdh), we performed a post hoc analysis to compare the association between spinal sdh and the presence of other spine injuries and the presence of intracranial hemorrhage. we used the chi-square or fisher exact test to compare categorical variables. we used the kruskal-wallis or mann-whitney test to compare continuous variables. p-values <0.05 were considered significant. we used statistical software sas 9.4 (sas institute, cary, nc) for all the analyses. the study population is described in fig. 4 . of the 137 children who received brain mri as part of a physical abuse evaluation, 76 (55%) received spine mri (age range 2.0 to 9.3 months; 44 definitely not inflicted injury accidental 2 no concern for inflicted injury while no evaluation can completely exclude abuse, the evaluation has not raised a reasonable suspicion of abuse. the injuries or findings could be reasonably explained by accidental or benign events. 3 mildly concerning for inflicted injury indeterminate 4 intermediately concerning for inflicted injury the injuries or findings raise suspicion for abuse, but an accidental or benign event or preexisting medical condition cannot be excluded. 5 very concerning for inflicted injury 6 substantial evidence of inflicted injury abuse 7 definite inflicted injury to a reasonable degree of medical certainty, the injuries/findings cannot plausibly be explained by accidental injury, preexisting medical illness, reasonable discipline, or benign events. of the 47 children diagnosed with aht who had a spine mri, 29 (62%) were abnormal. in 29 children who had a spine mri as part of an evaluation for aht, the cpt could not ultimately confirm aht. sixteen (55%) of these children had a spinal injury (table 3) . injuries in these children would have been missed if mri spine had been assessed only in children diagnosed with aht. mri spine findings often provided additional evidence of trauma when intracranial findings were otherwise nonspecific for trauma, evidence of injuries that were inconsistent with the history provided, or clinical information that influenced medical care (figs. 6, 7 and 8). clinical characteristics associated with spine injury among children with spine mri spine injury was suspected prior to mri in 2 (4%) of those with spine injury, but the assessment was limited by altered mental status at initial presentation in 25 (56%). table 4 describes the demographics and clinical characteristics of children with and without spine injury. there was a confession of shaking in 7 (9%) and of impact in 18 (24%). ultimately 31 (41%) perpetrators were convicted criminally. spinal injury was not significantly associated with an initial history of trauma (p=0.09), confession of shaking (p=0.69) or impact (p=0.20), or criminal convictions (p=0.13). when considered individually, many types of spinal injuries were associated with increased measures of injury severity; however, spinal sdh was the only injury also associated with the combination of non-contact head injury mechanism, retinal hemorrhages and an aht diagnosis (table 5) . fifty-nine children (78%) who received an mri spine had an intracranial hemorrhage on mri brain. of these, 11 (19%) had co-occurring spinal sdh. intracranial hemorrhage was not associated with spinal sdh (p=0.28). none of the three children with accidental intracranial subdural hemorrhage had spinal sdh. the presence of other spinal injuries was significantly associated with spinal sdh compared to those without other spinal injuries (30% vs. 5%; p=0.004). all but one child with spinal sdh had co-occurring subdural hemorrhage, with subdural hemorrhage in the posterior fossa. hypoxic-ischemic injury was the only intracranial finding in the one child with spinal sdh without co-occurring intracranial hemorrhage (case 1 in table 3 , fig. 8 ). she did not receive a lumbar puncture for a sepsis evaluation until after completion of the spine mri. fig. 3 abusive head trauma in a 5-month-old boy with multiple bruises, diffuse severe brain injury and subdural intracranial hemorrhage, liver laceration and multiple fractures. a axial t2-w spine mr image shows a small epidural collection posteriorly (arrow) on the left at the base of the odontoid process with displacement of the dura; low gradient recalled echo (gre) signal was seen as well (not shown). b sagittal t2-w spine mr image shows the epidural collection (thin arrow) as well as a subdural t2 hypointensity extending from c6 to t4 (thick arrow). c axial gre mr spine image shows corresponding low signal layering in the subdural space without epidural displacement (arrow) five of six children with epidural spinal hemorrhage were victims of aht (fig. 3) ; none of the five had a lumbar puncture prior to spine mri. the one child with an epidural spinal hemorrhage not classified as having aht was a 2-month-old who presented with sepsis and an incidental skull fracture with a history of a short fall, and this infant did have a lumbar puncture prior to spine mri. epidural hemorrhages were not associated with bony injury. multiple extremity bruises, metaphyseal fractures, diffuse intracranial subdural hemorrhage, and severe retinal hemorrhages were also present. prolonged unilateral extremity weakness was noted after he regained consciousness. father confessed to shaking him and throwing him onto a bed and was convicted of physical abuse we found a high incidence of spinal injury (59%) in children evaluated for aht and in those ultimately diagnosed with aht (62%). the reported incidence of spinal injury in aht varies considerably (13% to 78%) [11, 12] because of variations in the extent of imaging performed and study designs. in publications with methods like ours, which assessed for a wide range of spinal injuries regardless of whether aht was ultimately diagnosed, the incidence of spinal injury ranges from 30% to 69% [5, 13, 14] . among these studies, jacob et al. [14] described a similar rate of spinal subdural hemorrhage (18%) and spinal epidural hemorrhage (10%) compared to our population, but higher rates of ligament and bony injury (67% and 9%, respectively). in contrast, kadom et al. [13] and oh et al. [5] found no bony injury and spinal subdural hemorrhage in only 1% of cases. the addition of sagittal stir sequences improves the detection of soft-tissue injury and is useful to confirm the presence of spinal hemorrhage [12, 14] , and this might have contributed to the higher percentage of injury detected in our subjects. whole-spine imaging can also result in increased injury detection compared to cervical spine imaging alone [12] . if we had excluded thoracic and lumbar spine mri, we would have missed three children with spinal extramedullary hemorrhages and two with thoracic vertebral body fractures. additionally, 3-d t1-w sequences used in our mri protocol might have facilitated detection of spine fractures (fig. 9 ). research by baerg et al. [15] , the only prospective study assessing spine injury in aht, found the lowest rate of injury (15%). the authors used strict inclusion criteria requiring loss of consciousness, and imaging findings of intracranial hemorrhage, diffuse axonal injury, hypoxic injury or cerebral edema. abuse cases without a confession or witnessed abuse were table 3 , a 35-month-old girl presenting with altered mental status, lethargy and vomiting after a reported fall from standing height in a bathtub. a axial gradient recalled-echo spine mr image shows abnormal left vertebral artery flow void compatible with dissection (arrow). b t2-w axial mr image of the brain shows evidence of completed infarcts in the distribution of bilateral medial branches of the posterior inferior cerebellar arteries (arrows) table 3 , an 18-month-old boy found by mother unresponsive and not breathing in the crib. sagittal short tau inversion recovery spine mr image shows prevertebral soft-tissue swelling (long arrow), posterior paraspinous muscle edema (short arrow) and subtle interspinous ligament injury (arrowheads) excluded. mri stir sequences were included, but authors did not describe how ligament injury was defined or whether paraspinous muscle edema or prevertebral soft-tissue injury was recorded as injury. if we had used similar inclusion criteria, our incidence of spine findings would have remained high at 67%. if we had also used a more restrictive definition of injury by excluding paraspinous muscle edema, prevertebral soft-tissue injury, and ligamentous edema without disruption, the incidence of spine injury in our study would have remained comparatively higher (33%) than in baerg et al.'s (15%). useful interpretation of spine pathology in child abuse evaluations depends on clinicians' ability to interpret findings as traumatic injury and to differentiate abusive from accidental mechanisms. mri findings might overestimate the extent of disruptive ligamentous injury, limiting the utility of spine mri when the goal is to detect potentially unstable injuries requiring surgical intervention [16, 17] . however, in child abuse evaluations the goal is to detect both apparent and occult injuries to outline the severity of injury to the child and support opinions regarding injury mechanism. soft-tissue pathology on spine mri does correlate with clinical impairment in adults with whiplash injuries as compared to controls [18] . in children, choudhary et al. [12] compared spine mri findings among aht, accidental trauma and non-traumatic cohorts. after excluding medical causes, the only spinal finding in the non-traumatic cohort was a nuchal ligament injury in a child with sepsis who sustained a 20-min tonic-clonic seizure. the authors concluded that bony or ligamentous spinal abnormalities in the accidental and abusive cohorts were from injury and not normal variants [12] . although spine mri rarely resulted in additional medical treatment, it did often provide clinically and forensically valuable information including additional evidence of trauma when intracranial findings were otherwise nonspecific for trauma, and identification of injuries that were inconsistent with the history provided. consistent with other studies [15, 19] , spine injuries in our subjects were often occult. none of the fractures noted on mri were identified on preceding plain radiographs. symptoms are difficult to assess in very young children and the symptoms can be masked by severe brain injury. evidence of unexplained trauma might prompt additional investigation for maltreatment and in this way affects medical decision-making. interestingly, in several children with altered mental status, respiratory distress and hypoxicischemic injury, the spine findings were the only clear table 3 , a 2month-old girl with diffuse cerebral hypoxic-ischemic injury and no history of trauma and no intracranial hemorrhage. a sagittal t1-w spine mr image shows linear posterior hyperintensity (arrow). b axial gradient recalled-echo spine mr image shows a corresponding hypointensity layering in the subdural space (arrow) representing hemorrhage without a posterior epidural concave displacement of the dura. c axial gradient recalled-echo spine mr image shows distal extension of subdural hemorrhage without dural displacement (arrow). prevertebral swelling, posterior paraspinous muscle edema, nuchal ligament edema, and interspinous edema were also present on short tau inversion recovery sequences (not shown) evidence of trauma (table 3) . these cases suggest a need for research assessing the prevalence of spinal injury in infants who present with severe unexplained respiratory compromise. in contrast to other spinal injuries, posterior paraspinous muscle edema was interpreted with caution by the cpt because it was often thought to be the result of fluid shifts during resuscitation rather than primary injury. mri spine has only poor to moderate specificity for paraspinous muscle injury when intraoperative findings are used as a gold standard [17] . however, in adults with whiplash injuries from motor vehicle collisions, cervical muscle strain (defined as altered structure, size and signal intensity) and muscle tears/ hematomas on cervical spine mri are significantly more common compared to non-injured controls, as are spinal fractures and bony contusions (defined as altered bone marrow signal intensity without fracture line) [20] . similar comparative studies in children and in more severely injured patients are needed to guide the interpretation of spinal findings in children with isolated paraspinous muscle edema. although no children in the accidental trauma group had bony, hemorrhagic or ligamentous injuries, overall spinal injury and aht were not associated. spinal sdh was the only injury associated with a diagnosis of aht. the low number of accidentally injured children who received a spine mri (n=5) aht abusive head trauma, gcs glasgow coma score, icu intensive care unit data presented are median (interquartile range) for continuous variables and count (%) for categorical variables. percentages from some subgroups do not add up to be 1 because of the rounding of numbers. bolded p-values are statistically significant a race information is missing in 6 patients b initial gcs was not assessed in 40 patients table 5 clinical characteristics associated with spine injury type (n=76) .001 compared to those without the specific type of spine injury compared to the abuse (n=55) and indeterminate groups (n=16) might have caused a lack of power to detect differences; higherpowered comparative studies do suggest cohorts with a higher incidence of spinal injury in abused infants [12, 19, 21] . choudhary et al. [12] found a higher rate of both cervical ligamentous injury (78% vs. 46%) and spinal sdh (48% vs. 2%) in children with aht compared to accidental injury. when henry et al. [19] compared spinal injury in children with aht and with accidental injury associated with non-motor vehicle crash, the authors found a higher incidence of spine injury overall in children with aht (31.3% vs. 7.1%), but the rate of ligamentous injury was similar (8.7% for aht and 5.8% for accidental head injury) [19] . in contrast, other studies did not find a higher incidence of spinal injury in abused infants [11, 13] . the lower number of children with spinal extramedullary hemorrhage in these studies might contribute to the lack of significant findings between their abusive and accidental cohorts. additionally, baerg et al. [11] included children with severe accidental rotational acceleration/deceleration head injuries who can have spinal injury similar to that found in aht. although spinal injury and aht were not associated in baerg et al.'s study, spinal injuries were associated with other clinical findings of severe rotational acceleration/deceleration head injury typical of both aht and severe accidental head injury involving similar mechanisms [11] . we found higher severity of brain injury in children with spinal injury and an association between spinal sdh and other injuries typical of aht. although the association between injury severity and spinal injury should be interpreted with caution because of the low number of less severely injured children who received a spine mri, it is consistent with previous literature [11, 19] . like aht, spinal injury is associated with global parenchymal injury [16] , hypoxic-ischemic injury [12] [13] [14] [15] and a rotational acceleration/deceleration mechanism of head injury in both accidental and abusive trauma [15] . using autopsy techniques that preserve the entire spine for microscopic analysis, matshes et al. [22] found that 100% of subjects with injuries involving hyperflexion/extension forces to the head had injury to the spinal nerve roots. in living children, spinal nerve root injuries are infrequently reported but might be below the current level of detection on mri [12, 23] . although we did not analyze the association between hypoxic-ischemic injury and spinal injury, other research suggests that hypoxic-ischemic injury is more common in children with ligamentous spinal injury [12, 13, 15] , and spinal sdh is rarely identified in accidentally head-injured children [12, 21] . our study supports and adds to this literature by highlighting an association between spinal sdh and a combination of higher injury severity, noncontact head injury pattern, retinal hemorrhages, and an aht diagnosis. despite the association between spinal sdh and aht, the source of the bleeding in spinal sdh is debated. spinal sdh is most commonly attributed either to direct injury to spinal vasculature or tracking of intracranial blood [4] . sequential migration of intracranial blood into the spinal subdural space has been reported in adults [24] . case studies of children with aht report spontaneous resolution of subdural hemorrhages at the clivus, which seemed to have migrated into the spinal subdural space [25, 26] . spinal subdural hemorrhage is also reported as a complication of ventriculoperitoneal shunting, where low intracranial pressure from the shunt is suspected to cause dissection between the dura and arachnoid layer of the spine, allowing migration of the intracranial subdural hemorrhage [24] . however, in the only prospective study assessing the incidence of spinal sdh in people with intracranial subdural hemorrhage, only 2 (1.2%) of 168 adults with intracranial hemorrhage had spinal hemorrhage; both of those people had experienced concurrent injury to the head and the back [27] . direct vascular injury to radicular veins traveling through the spinal nerve root is also a known cause of spinal sdh in victims of aht, likely caused by traction on spinal nerve roots during hyperflexion/extension from shaking [28] . if migration of an intracranial hemorrhage were the sole mechanism for spinal sdh, we would expect to see an association between intracranial and spinal hemorrhage, regardless of the presence of other spinal injuries. although all but one child with spinal sdh also had intracranial hemorrhage in our study, intracranial subdural hemorrhage was not predictive of spinal sdh. spinal sdh was associated with other spine injuries. the lack of association between intracranial and spinal sdh suggests that caudal migration of an intracranial hemorrhage is not the sole mechanism for spinal sdh. our findings suggest that either the spinal sdh is caused by direct spinal injury at least in some cases, or that a similar injury mechanism caused the other spinal injuries and the caudal extension of the intracranial hemorrhage into the spine. choudhary et al. [12] also found a higher incidence of spinal sdh in children with aht compared to their accidentally injured cohort and a correlation between ligamentous spinal injury and spinal sdh. the authors proposed that traction on myodural bridges and the intradural nerve roots and dentate ligaments during flexion/extension of the spinal cord in aht could cause disruption of the dura-arachnoid interface, facilitating the migration of blood from the intracranial compartment into the spine [12] . the association among spinal sdh, other injuries typical of rotational acceleration/deceleration of the head, and a diagnosis of aht in our subjects supports this theory. however, it is important to consider that spine mri extended past t5 in a minority of our subjects, so the incidence of spinal sdh might be underrepresented. additional studies using whole-spine mri are needed. there are several limitations to this study. first, there is a risk of circular reasoning if the presence of spinal sdh heightened providers' concern for aht. however, upon review of consultation reports for children with spinal injury, no children were classified as abused because of a spinal injury. to further assess for circular reasoning, aht likelihood was compared to a second classification method developed by duhaime et al. [29] and then modified by kadom et. al [13] that does not use spinal injury as a diagnostic consideration. because this classification system was meant for people with head injuries, people without concern for head injury were excluded. using the weighted kappa statistic, abuse classifications determined by the modified duhaime criteria and lindberg scale were significantly correlated (îº=0.67, 95% confidence interval [ci] 0.57-0.77). second, the potential for sampling bias exists. because the majority (93%) of spine mris included cervical spine only, our study might underestimate the incidence of spinal injury. the number of children with isolated lumbar and lower thoracic injuries is unknown. abused children and children with higher severity of injury were more likely to receive a spine mri, potentially causing under-detection of spinal injury in accidental, lower-severity injuries and resulting in a lack of power to detect differences between abused and non-abused children. if we assume that all children who were not imaged had a normal spine mri, the incidence of spine injury would remain relatively high at 33%. finally, because we did not assess inter-and intraobserver variability in radiologists' readings of the spine mris, our ability to comment on the validity of the interpretations is limited. our rates of spinal hemorrhage and ligamentous and bony spinal injury overall and within our aht population were similar or lower than reported by other studies that used methods and mri sequences comparable to those in our study [12, 14] . this suggests that our interpretation of the spine mri was similar to or more conservative than those of researchers at other institutions. there is a high incidence of spinal injury in children evaluated for aht (59%) and those ultimately diagnosed with aht (62%). higher measures of injury severity were the only variables associated with spinal injury overall. however when considered separately, spinal sdh was associated with aht and with other head injuries typical of a rotational acceleration/deceleration injury mechanism. spinal sdh might support a mechanism of severe acceleration/ deceleration head injury and a diagnosis of aht when interpreted in conjunction with other intracranial and ocular findings. mri of the whole spine should be included in future studies to further examine the predictive value of spinal sdh for an aht diagnosis. while bone, ligamentous and other soft-tissue spine injuries likely result from a wider range of injury mechanisms, detection of occult injury could be clinically and forensically valuable. additional research assessing spine findings in accidentally and less severely injured children and investigating potential nontraumatic causes of posterior paraspinous muscle edema in children could further our ability to interpret spinal pathology on mri. finally, studies assessing the incidence of spinal injury in children presenting with unexplained hypoxic-ischemic injury and respiratory distress would be useful to examine the emerging link between hypoxic-ischemic injury and spinal injury in abuse evaluations. conflicts of interest none prevalence, patterns, and clinical relevance of hypoxic-ischemic injuries in children exposed to abusive head trauma clinical and radiographic characteristics associated with abusive and nonabusive head trauma: a systematic review abusive head trauma: recognition and the essential investigation spinal injuries in abusive head trauma: patterns and recommendations changes in use of cervical spine magnetic resonance imaging for pediatric patients with nonaccidental trauma acr appropriateness criteria: suspected physical abuse -child hospital variation in cervical spine imaging of young children with traumatic brain injury mechanisms, clinical presentations, injuries, and outcomes from inflicted versus noninflicted head trauma during infancy: results of a prospective, multicentered, comparative study variability in expert assessments of child physical abuse likelihood pediatric abusive head trauma: recommended definitions for public health surveillance and research cervical spine injuries in young children: pattern and outcomes in accidental versus inflicted trauma imaging of spinal injury in abusive head trauma: a retrospective study usefulness of mri detection of cervical spine and brain injuries in the evaluation of abusive head trauma mr imaging of the cervical spine in nonaccidental trauma: a tertiary institution experience cervical spine imaging for young children with inflicted trauma: expanding the injury pattern correlation of mr imaging findings with intraoperative findings after cervical spine trauma efficacy of mri for assessment of spinal trauma: correlation with intraoperative findings magnetic resonance imaging assessment of craniovertebral ligaments and membranes after whiplash trauma cervical spine imaging and injuries in young children with non-motor vehicle crashassociated traumatic brain injury are there cervical spine findings at mr imaging that are specific to acute symptomatic whiplash injury? a prospective controlled study with four experienced blinded readers spinal subdural hemorrhage in abusive head trauma: a retrospective study shaken infants die of neck trauma, not of brain trauma spinal cord injury without radiographic abnormality in children, 2 decades later concomitant intracranial chronic subdural hematoma and spinal subdural hematoma: a case report and literature review retroclival collections associated with abusive head trauma in children acute clinical and spinal subdural hematoma with spontaneous resolution: clinical and radiographic correlation in support of a proposed pathophysiological mechanism prospective assessment of concomitant lumbar and chronic subdural hematoma: is migration from the intracranial space involved in their manifestation? thoracolumbar spine subdural hematoma as a result of nonaccidental trauma in a 4-month-old infant head injury in very young children: mechanisms, injury types, and ophthalmologic findings in 100 hospitalized patients younger than 2 years of age publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. key: cord-289605-gvc673ij authors: klaunberg, brenda a.; lizak, martin j. title: considerations for setting up a small-animal imaging facility date: 2004 journal: lab anim (ny) doi: 10.1038/laban0304-28 sha: doc_id: 289605 cord_uid: gvc673ij imaging techniques allow for the conduct of noninvasive, in vivo longitudinal small-animal studies, but also require access to expensive and complex equipment, and personnel who are properly trained in their use. the authors describe their planning and staffing of the nih mouse imaging facility, and highlight important issues to consider when designing a similar facility. state-of-the-art biomedical research often uses rodents and other small animals for disease modeling. a recurring issue for many investigators is the desire to obtain anatomical and physiological information from valuable research animals without sacrificing them. in vivo imaging is a noninvasive way to gain insight into the animal's anatomy and physiology 1 ; however, the unit cost and complexity of many such methods may preclude an investigator's ability to gain access to such devices. location of the imaging equipment in a shared facility can overcome these obstacles. the vision of the nih mouse imaging facility (mif) is to offer various state-of-theart, in vivo small-animal imaging techniques in one facility. the mif is a shared resource for the nih intramural community, and currently has more than 70 active animal protocols. at this time, the mif has three magnetic resonance imaging (mri) scanners, a micro x-ray computed tomography (ct) scanner, two ultrasound scanners, a combined luciferase/gfp imager, and a laser doppler imager. in addition to administrative personnel, the staff consists of a veterinarian, three imaging scientists, an electrical engineer, and three animal technicians. setting up this facility took planning and intellectual contributions from experts in many fields. we provide resources for a wide variety of investigators from many of the various institutes within the nih. this is not a 'how-to' manual, but we will discuss some of the issues that the principal players considered when designing and staffing the mif. a small-animal imaging facility can represent an enormous investment of capital and personnel. to obtain the maximum usefulness and ensure success, a certain amount of planning must take place before an instrument is ordered or facility construction begins. planners should recruit the advice of experts in various imaging fields and involve as many people as necessary to share in the decision-making processes, so that everyone has a voice. knowledge of the needs of the research community is one of the most important priorities in setting up any facility. a consultation with your research community will help to determine which imaging modalities are most needed. it is pointless to include an instrument that no one will use. consultation with experienced operators for each of the imaging modes chosen will elicit useful advice on special needs for each instrument. veterinarians and animal care staff should also have input because they will have a considerable impact on traffic patterns, animal care requirements, and other features. if possible, one should visit other small-animal imaging facilities. what imaging modalities do they have? what problems have they encountered, and how did they solve them? one must consider what types of animals and models could come to the facility for imaging, because these considerations will impact staffing choices, housing availability, and imaging modalities. one should also consider the health status of the animals; a facility that can accommodate immunecompromised animals has more stringent requirements. the biosafety level that the facility will maintain is also a consideration; animals carrying pathogens or treated with radiolabeled agents will require additional restrictions. the mif operates as a clean conventional facility that excludes the following specific pathogens: coronaviruses, pneumovirus of mice (pvm), sendai virus, endoparasites, and ectoparasites. to prevent cross-contamination between rodents, disposable, absorbent material covers all surfaces. all surgical instruments are steam-sterilized for survival procedures, and devices such as nose cones are either placed in cold sterilization or cleaned with a bleach-based disinfectant. planners should decide whether to design and staff the facility so that researchers can be human and animal safety should be the primary consideration when planning an imaging facility design. in addition to excluding specific rodent pathogens, the mif operates at animal biosafety level-1 (absl-1) [author: edit okay?]. some imaging animals may receive agents (chemotherapeutics, infectious organisms) in higher biosafety levels in other facilities. those animals cannot be imaged until they satisfy absl-1 requirements. planners should determine the need for a preparation room. it is possible to perform simple procedures such as anesthesia induction and tail vein catheter placement adjacent to the imaging instrument. more complicated preparations that require sterile or aseptic procedures will require a dedicated room. in the mif, there is a small preparation area adjacent to each instrument. in addition, we have a preparation room set aside for rodent procedures more complex than anesthesia induction and tail vein intravenous catheter placement. each preparation area is set up with anesthesia and physiological monitoring equipment, as well as a surgical microscope for microsurgery. we use inhalant anesthesia (isofluorane) as much as possible, and each imaging device preparation area is set up identically. all preparation areas have central gas supplies for oxygen, medical air, and nitrogen, as well as a vacuum system for scavenging anesthetic gases. anesthesia and monitoring equipment must comply with magnet safety. anything that enters the scanner room must be nonmagnetic, and any equipment within the fringe field must operate correctly. once there is an understanding of the goals of the research community, the needs of the investigators can determine the imaging techniques to be made available. some techniques, such as optical imaging, are relatively inexpensive in terms of equipment, personnel, and space. individual laboratories may have the financial capability to purchase these types of devices, but more elaborate techniques, such as mri or ct scanning, require a more substantial investment of resources. individual laboratories rarely have the funds to purchase such equipment or the means to maintain them; therefore, mri and ct are usually the core of an imaging facility. please refer to table 1 for a summary of imaging modalities, their applications, and their estimated costs. mri is one of the most powerful noninvasive imaging methods currently available to research. this technology uses radio waves and powerful magnets to generate radiograph-like images of tissue. a strong magnetic field partially aligns the hydrogen atoms on water molecules in the tissue. a radio wave then disturbs the built-up magnetization, and radio waves are in turn emitted as the magnetization returns to its starting place. these radio waves can be detected and used to construct an image (fig. 1a) . unlike radiographs, the mri patient is not exposed to x-ray radiation, so repeated imaging is not a risky procedure 2 . mri is excellent for imaging different types of soft tissue with high contrast 3-6 . researchers can use it for anatomical and functional studies. some applications include tumor growth and treatment, brain function and stroke, and cardiovascular disease. contrast agents, which are drugs that function like histological stains, increase the usefulness of this imaging method. for 2 resource volume 33, no. 3 lab trained to run the instruments independently, or whether to offer complete service, in which researchers can deliver animals to the facility and then return for images. this choice will have a profound effect on staffing requirements. the mif is designed to be a resource, not a service, so that investigators are encouraged to participate fully. even if the investigator has no desire to learn to run the equipment, it is our requirement that someone on the protocol be present and responsible for the animal during scanning. an important initial decision is whether or not the animals will be housed in the facility. the number of animals housed and the duration of housing will have an impact on space usage. animal welfare guidelines dictate space requirements that must be carefully considered. moreover, one must also consider space for traffic between housing, preparation rooms, and instruments. at the mif, we provide temporary housing (monday-friday) for mice only. we have one 60-ft 2 animal room with one ventilated rack that can hold 45 shoebox-sized cages. additionally, we have 400 ft 2 of animal husbandry support area for storage and cage washing. animals involved in long-term studies that must come to the mif periodically for imaging are usually returned to a quarantine facility. because of the surrounding magnetic field, an mri system requires a large area (≥700 ft 2 ). the magnet itself requires ∼200 ft 2 of surrounding clear area. the fringe field is the distance that the surrounding magnetic field extends before it drops to the level of 5 gauss. the fringe field can occupy an area up to 250 ft 2 . the mri suite must have a design that prevents casual visitors from entering the fringe field. a magnetic field >15 gauss can adversely affect persons with pacemakers or other metallic implants. the distance to the 15 gauss line varies widely with field strength and magnet type. there are magnets available that have a fringe field limited to a foot or less, but these cost more. mr scanners use extremely heavy magnets; therefore, most facilities locate the mr imager on the ground floor. additionally, because the magnets are cooled by cryogens, good ventilation must be present. rapid boil-off of the cryogens could lead to asphyxiation. the instrument manufacturer can provide a detailed description of space requirements and suggested architectural layouts. a facility will need to plan for additional space for the electronics and console for the scanner as well as a preparation area outside the magnetic field. this can amount to another 250 ft 2 . researchers currently consider a 7-tesla mri system an optimal field for imaging rodents. at the mif we have several bruker avance mri scanners (bruker-biospin, billerica, ma). some other manufacturers of mri consoles are varian (varian medical systems, inc., palo alto, ca), tecmag (tecmag, houston, tx), and mrrs (mr research systems, guildford, uk). a basic setup for the mri includes the superconducting magnet, the imaging console, and several probes for approximately $800,000-$2,000,000, depending on the options. it is ideal to enclose the magnet in a room shielded from radiofrequency, but this construction would generate additional costs. the magnet itself comes with end caps that adequately shield it; however, passing anesthesia and monitoring lines becomes awkward. because of its complexity, the mri requires a scientist with not only the necessary academic qualifications, but also a technical background for operation. there are many mri measurement methods, each with many control variables, designed for specific purposes. the mr operator must be familiar with the basic physics of the mr measurement and the effect of the controls on the image outcome. if new methods are going to be developed or implemented, a postdoctoral-level scientist will be necessary. new methods require sophisticated knowledge of the hardware and computer programming. this individual will be responsible for running the scanner and maintaining the system. mri maintenance requirements include both hardware and software. hardware maintenance includes the associated magnetic field. the magnet requires liquid nitrogen and liquid helium to maintain the superconducting magnetic field. allowing for a safety margin, most magnets need liquid nitrogen once per week and liquid helium approximately twice per year. if the cryogen level is allowed to become too low, the magnetic field can spontaneously quench (i.e., lose its magnetic force). quality assurance includes regular test images of a standard sample. a small loss in performance can result in unusable images. the operating computer and software also require regular maintenance. system software requires periodic updates to install security patches, repair bugs, and add features. these updates are particularly important if the computers are on a network with outside access. despite hardware and software designed to limit external access, new security holes appear on a regular basis. a malicious attack could destroy valuable work and render the instrument useless until the base software can be reinstalled. archiving and removing old data are important parts of computer maintenance. if the number and size of the stored image files grow too large, system performance can slow or even become blocked. a policy for data management can help prevent major problems, but periodic enforcement is still necessary. this policy can range from a simple principle of moving the oldest data first to a more complicated formula based on size and age. at the mif, we encourage everyone to transfer data from the instrument as soon as possible. when data space becomes an issue, the users with the largest amount of data must export or delete files before they can resume scanning. x-ray ct is an imaging method that uses multiple radiographic views of a subject to construct an image (fig. 1b) . in our system, an x-ray source and detector rotate around the subject 360 degrees while generating a number of projections or views. the mif has a microcat ii ct scanner built by imtek, inc. (knoxville, tn). other manufacturers of the manufacturer can provide exact measurements of the machine footprint. there are several micro-ct manufacturers, and the price ranges from $250,000 to $400,000. the instrument will require one technician for operation and maintenance. this individual should have a sophisticated education in biology or a related field and be comfortable with computers. the ct scanner relies on several computers on a small network. the ct operator will be responsible for maintaining the computer system software, managing the accumulated data, and quality assurance. a good knowledge of anatomy is vital for data interpretation, and the person should be able to interpret radiographs. reporter gene technology has revolutionized the ability to track cell populations in vivo 11 . optical imaging devices, which allow the user to monitor gene expression [author: edit okay?], are easy to operate and have no special environmental requirements. there are several different types of optical imaging. bioluminescence is an enzymatic biochemical process that produces light. the luciferase gene is first inserted into the targeted cell population. image acquisition requires live cells to process the substrate and produce light. advantages of bioluminescence include high sensitivity, and virtually no background noise; disadvantages include the need for cofactors (i.e., oxygen, magnesium, and atp) and expensive substrates (luciferin). fluorescence imaging also requires genetic manipulation; however, the technology does not require a living system to produce an image. fluorescence imaging differs from bioluminescence in that light must be applied to the tissue to generate a signal. one advantage of fluorescence imaging is the commercial availability of numerous markers (gfp, dsred, icg, and cy5.5) with no need for substrate or cofactors; a disadvantage is the low signal/noise ratio due to autofluorescence. basic equipment for bioluminescence or fluorescence imaging consists of a light-tight chamber, a sensitive camera (charge-coupled device), and a computer. it is possible for the ambitious investigator to manufacture his or her own imaging device; however, commercial products are available for about $200,000. the mif owns a xenogen ivis 100 (xenogen corp., alameda, ca); other manufacturers include eastman kodak (eastman kodak co., scientific imaging systems, rochester, ny), roper scientific (trenton, nj), and advanced research technologies, inc. (saint-laurent, quebec, canada). our imaging device occupies a space measuring 16 ft 2 ; additional benchtop space is necessary for preparing the animal. image acquisition is simple, and it is not necessary to have a dedicated system operator. investigators can easily learn to perform their own imaging study. our system's operating software first acquires a black-and-white photographic image of the subject, then acquires the luminescent image, and finally overlays the image onto the photograph for anatomical signal mapping (fig. 2) . both bioluminescence and fluorescence imaging are useful to detect tumor cells, monitor tumor growth, or track cell movement (e.g., metastasis). optical imaging can be highly specific, but it has low spatial resolution. optical data are typically two-dimensional (2d), but 3d methods are in development. a high throughput of animals is possible because imaging time is 4 resource volume 33, no. 3 lab micro-ct equipment include ge medical systems (london, ontario, canada), scanco medical (scanco usa, inc., southeastern, pa), and skyscan (aartselaar, belgium). each projection is the equivalent of a radiographic image. a method called 'filtered back projection' permits these projections to be reconstructed into a three-dimensional (3d) data set. a micro-ct scanner for rodents typically uses less x-ray power than a conventional clinical ct scanner, so the effective radiation exposure per scan is reduced. the highest radiation dose we have measured was 35 rad for skin, but typical scans are much less (9 rad). the radiation dose is ultimately dependent on the scan parameters (i.e., number of projections, exposure time, x-ray beam strength). ct is excellent for studying the skeletal system, certain internal organs, and fat distribution [7] [8] [9] [10] . ct can also be used for tumor studies, depending on the location of the tumor. a typical 3d image with 100-µm resolution takes about 10 minutes to acquire; higher resolution images may take up to 25 minutes. image reconstruction can take as little as 5 extra minutes or up to 24 hours depending on hardware and software options. as with mri, a contrast agent can be used to enhance the appearance of some organs. in rodents, the half-life of most clinical ct contrast agents is short, so some experimentation is required to find the optimum dose and administration regimen. a micro-ct scanner requires ∼200 ft 2 of short, usually from 1 second to 10 minutes. laser doppler is another type of optical imaging that uses a laser light source and the doppler effect to measure capillary blood flow (fig. 3) . the equipment consists of a laser source and computer, and costs less than $50,000. the footprint of the laser device is small (4 ft 2 plus computer), but its sensitivity to movement warrants placement on an antivibration table. this machine is simple to use and is highly sensitive, but it is limited to small vessels within a 1-mm depth. the mif owns a laser doppler imager from moor instruments, inc. (wilmington, de). another manufacturer is perimed, inc. (north royalton, oh). ultrasound imaging is a rapid, real-time in vivo technique. an ultrasound transducer broadcasts sound waves beyond the audible range into tissue. as the sound waves encounter the interfaces between various types of tissue, they are reflected. the transducer detects the reflected sound waves and uses them to construct an image (fig. 4) . the depth of penetration depends on the frequency of the sound wave. the image-processing software produces an image in real time, and the various tissues within the image display different 'echogenic' properties. ultrasound machines used for rodent imaging are similar to those used clinically; however, the larger field of view offered by a clinical scanner is not optimal for imaging smaller subjects. resolution increases (and field of view decreases) as the ultrasound frequency increases; therefore, high-frequency ultrasound is ideal for rodents. ultrasound is excellent for cardiac studies and evaluation of embryonic development 12, 13 . it may also be used for various organ evaluations, tumors, and guided injections. advantages of ultrasound include rapid image acquisition and ease of use; however, time is required for the operator to develop proficiency in the acquisition techniques and image interpretation. knowledge of anatomy is useful for positioning the transducers, as well as evaluating the resulting images. a well-trained operator should be able to distinguish normal and abnormal anatomy. scattering of the sound waves in the tissue often cause ultrasound images to appear 'noisy' . also, most ultrasound images are 2d, although some 3d-capable instruments are available. most ultrasound machines are built on portable carts for easy relocation. the image display is most clearly visible in low ambient light, so this should be a consideration when determining the location for ultrasound imaging. the mif owns two ultrasound machines: a siemens acuson sequoia (siemens medical solutions, malvern, pa) and a visualsonics vevo 660 (visualsonics, inc., toronto, ontario, canada). there are many other ultrasound manufacturers, including philips (philips medical systems, andover, ma) and general electric (ge medical systems, london, ontario, canada). a commercial ultrasound imager can cost about $150,000. although one can perform data analysis on the scanner, this does take time away from available scan time. an additional data-processing workstation could cost as much as $60,000. the mif does not have a dedicated ultrasonographer at this time. the investigators that use our acuson ultrasound most frequently have experience in its operation and often collaborate with other investigators in need of their expertise. the mif staff is developing proficiency in ultrasonography. positron emission tomography (pet) is an excellent method to perform functional imaging in vivo [14] [15] [16] . uptake of radioactive compounds can demonstrate the presence of tumor, abnormal cell function, or metabolic changes. this imaging technique can generate 3d data. pet imaging is highly sensitive but suffers from low spatial specificity and needs to be superimposed on an anatomical image for signal location (fig. 5) . the footprint of a micro-pet system may only be 16 ft 2 , but it is ideal to locate the micro-pet adjacent to a micro-ct or mri because an anatomical image will be required for co-registration. this allows convenient transport of an anesthetized animal from one machine to another. micro-pet imaging presents its own set of unique considerations. the use of radioactivity dictates its own specifications. the imaging area should be in a location that allows the environment to be properly controlled and appropriate precautions taken.your institution should be able to provide you with a detailed description of the rules and regulations that govern the use of radionuclides. the imaging animals will remain radioactive for some time after imaging, so housing for these 'hot' animals must be considered. the half-lives of radionuclides in the radioactive compounds are typically short (e.g., 18 hours), so housing vice to new users. at the mif, we train investigators to perform simple data analysis. for more complex data analysis, mif staff collaborates with the investigators. this system works well because, having trained an investigator, the technician is freed up for other duties; the investigator can often then pass that training on to new individuals in his or her group as well as other collaborators. once the user base is established, equipment needs are defined, and the facility floor plan is designed, one must consider the staffing needs. a variety of personnel are needed for a successful imaging facility. diversity of experience will enhance the resources as well as expand the knowledge base of the entire personnel staff. certain base criteria must be met for each unique position, but it is our experience that personnel experienced in imaging laboratory animals are difficult to find. many of the necessary technical procedures may be learned on site. we believe that a strong desire to learn may be more important than experience and formal education. it is important to have at least one person on the staff that is skilled in the routine technical procedures and can provide training for new staff members. as with any animal facility, husbandry staff is necessary. ideally, housing for imaging animals should be on site and accessible. the size of the animal housing facility will determine the number of necessary personnel. routine husbandry duties include daily health checks, cage changing, cage washing, room sanitation, sentinel maintenance, quality control, etc. husbandry staff is the foundation of all successful animal research programs. the qualifications of the animal care staff are dependent on how many people will be required to run the facility and in what capacity the people are expected to function. if you can have dedicated husbandry staff, their qualifications will be less stringent, and a person with aalas alat or lat experience would be sufficient. staff members who will be assisting with imaging experiments are expected to work independently, so it is ideal to have personnel with aalas latg certification or equivalent experience. if the technical staff is required to assist with (or perform) husbandry duties, they should understand that it is part of their job description so that no misunderstandings occur later. laboratory animals must be immobilized for imaging procedures. it is important for the laboratory animal technical staff to maintain a working knowledge of anesthesia and physiological monitoring for a variety of species. additionally, basic procedure skills such as venipuncture are required for the administration of imaging contrast agents and other pharmaceuticals. familiarity with aseptic techniques and rodent colony health management techniques will aid in maintaining the level of health standards for the facility. additional useful procedures include intubation of rodents, placement of rodent femoral, jugular, and carotid catheters. the computers acquiring the images and the networks they are connected to can be complicated. many of the personnel operating the imaging devices have sufficient knowledge of computer operation and software programming to repair problems as they occur; however, given the number of computers needed for imaging and personnel support, it is a good idea to have someone dedicated to their maintenance. it is important that these networks are secure and protected from any outside abuse. the mif has shared information technology personnel that maintain computer software security and upgrades. the imaging instruments require regular hardware maintenance as well as periodic repair. the best solution is to have an engineer on the staff to address these issues. it is possible to maintain a service contract with an outside company, but an internal person can aid in quicker diagnosis and repair. the mif has maintenance contract on all equipment, but the level of each maintenance plan varies from a 'parts only' plan to a full-service plan that includes yearly preventative maintenance. the mif is fortunate to have mri scientists who are knowledgable in mri mainte-6 resource volume 33, no. 3 march 2004 animals can be a temporary situation. the availability of radioactive compounds will have the greatest impact on the success of a micro-pet program. radiolabeled glucose, oxygen, and ammonia are commercially available; however, many studies may need custom-made radioactive compounds. the ideal arrangement is an imaging suite located adjacent to the radiopharmacy that will produce the radionuclides. production of these reagents can represent the largest expense because of the need for highly specific equipment and personnel. manufacturers of micro-pet imagers include general electric and philips medical systems. micro-pet operation will also require a postdoctorate-level scientist to assemble, operate, and maintain the equipment. it is easy to generate an enormous amount of image data in a relatively short amount of time. a single image data set can range from a few kilobytes to over two gigabytes for highresolution three-dimensional data. the amount of image data generated over time can be a problem. mass storage devices must be available for data storage during analysis. if backup and archiving are required, the amount of equipment needed can be considerable. a room will need to be dedicated to computer storage and workstations for post processing images. a minimal room will have space for a rack containing data servers and network equipment. qualified information technology personnel should be able to provide additional advice. in addition to data storage, extra workstations for data processing are almost a necessity. the alternative is allowing data to be analyzed on the acquisition instruments. this reduces the need for extra computers but takes time away from the instruments. the time required for data analysis can be considerable. some consideration must be given to who will analyze data. often, users of the instrument will not have the experience or skill needed to gain the most information from the images. one solution is for image analysis to be part of the imaging service. another approach is to train the investigators to analyze their own data; this reduces the facility burden, but reduces the usefulness of the ser-nance and repair, as well as an electrical engineer who assists with mri and ct maintenance and repair. the imaging facility also needs personnel to attend to nonscientific tasks. administrators must handle daily paperwork such as budget management and supplies, as well as provide other organizational services. these people are critical, because if the facility is successful, none of the scientific personnel will have time to attend to administrative duties. the mif has shared personnel for these tasks. any facility that conducts laboratory animal research should be accessible by authorized personnel only. we cannot overemphasize this because of magnet safety, radiation safety, and animal health. traffic patterns for animals entering the facility may be necessary if the animal health level varies in different areas. the amount of personal protective equipment (ppe) needed will be defined by the types of animals in the facility, as well as the health standard. the minimum ppe for handling animals in the mif includes a disposable lab coat and gloves. because animal studies are ongoing, and we temporarily house mice, personnel must don a lab coat upon entering our facility, regardless of their animal contact. studies with nonhuman primates require a higher level of ppe that includes mucous membrane protection. standard ppe worn around the mri scanners must be nonmagnetic. an institutional animal care and use committee (iacuc) should approve every study conducted within the facility. new investigators may seek the assistance of facility personnel in writing their protocols. this gives the imaging facility personnel a chance to suggest feasible imaging modalities, preparation methods, and anesthesia regimes. the mif has a committee of experienced researchers that review experiments for feasibility, safety, and time requirement. imaging time may be scheduled on a firstcome first-served basis, or otherwise. instruments with short imaging times allow for a larger number of studies in any given period of time. when demands exceed the available scan time, one solution is to assign blocks of time for specific groups. then individuals within the group can work out their own priority for imaging. in our experience, it is easiest to have the equipment operators schedule the investigators. the operators will be most experienced with the requests of the prospective study and can schedule time accordingly. in the mif, magnet scan time during regular working hours is assigned to institutes in blocks; the remaining scan time is assigned on a first-come first-served basis. the other imaging devices require less time per scan, so it has not been necessary to assign blocks of time yet; each investigator is assigned time on a first-come first-served basis. scan time is charged back to the institute by the hour, and the dollar amount is calculated with a budget-driven formula. noninvasive imaging of rodents and other small animals is a powerful tool for biomedical research. setting up an imaging facility is a complex process that involves many decisions affecting everything from available instruments to staff composition. careful planning should help prevent operational snags. the advice of experienced people will be the most valuable asset. it is our opinion that the facility should be designed around a primary mri scanner because mr offers versatility for many applications. acquisition of other devices will be determined by the needs of the research community. growth of the facility is limited only by usage and executive decisions. staff must include a few experienced personnel, but inexperienced eager personnel can be trained to be experts. we have tried to provide an outline of some of the important considerations that went into the creation of the mif. challenges in small animal noninvasive imaging reproductive and teratologic effects of electromagnetic fields mr microscopy and high resolution small animal mri: applications in neuroscience research imaging transgenic animals in vivo imaging of gene and cell therapies electron paramagnetic resonance for small animal imaging applications molecular imaging in small animals-roles for micro-ct the use of microcomputed tomography to study microvasculature in small rodents a review of high-resolution x-ray computed tomography and other imaging modalities for small animal research high resolution x-ray computed tomography: an emerging tool for small animal cancer research advances in in vivo bioluminescence imaging of gene expression advances in ultrasound biomicroscopy noninvasive cardiovascular phenotyping in mice molecular imaging of small animals with dedicated pet tomographs high resolution spect in small animal research radio-imaging in small animals the authors would like to thank stasia anderson of laboratory of diagnostic radiology research, nih, for providing an mr image, dan schimel of the nih mouse imaging facility for providing a ct image, cecilia lo of the laboratory of developmental biology, nhlbi, nih, for providing an ultrasound image, takashimurakami and sam hwang of the dermatology branch, nci, nih, for providing a luciferase image, michael green and the imaging physics laboratory, nih, for providing a pet image, and afonso silva of the laboratory for functional and molecular imaging, ninds, nih, for providing images for this paper. we would also like to thank alan koretsky of the laboratory for functional and molecular imaging for helpful discussions. key: cord-267605-efb10j3u authors: zheng, li-zhen; liu, zhong; lei, ming; peng, jiang; he, yi-xin; xie, xin-hui; man, chi-wai; huang, le; wang, xin-luan; fong, daniel tik-pui; xiao, de-ming; wang, da-ping; chen, yang; feng, jian q.; liu, ying; zhang, ge; qin, ling title: steroid-associated hip joint collapse in bipedal emus date: 2013-10-21 journal: plos one doi: 10.1371/journal.pone.0076797 sha: doc_id: 267605 cord_uid: efb10j3u in this study we established a bipedal animal model of steroid-associated hip joint collapse in emus for testing potential treatment protocols to be developed for prevention of steroid-associated joint collapse in preclinical settings. five adult male emus were treated with a steroid-associated osteonecrosis (saon) induction protocol using combination of pulsed lipopolysaccharide (lps) and methylprednisolone (mps). additional three emus were used as normal control. post-induction, emu gait was observed, magnetic resonance imaging (mri) was performed, and blood was collected for routine examination, including testing blood coagulation and lipid metabolism. emus were sacrificed at week 24 post-induction, bilateral femora were collected for micro-computed tomography (micro-ct) and histological analysis. asymmetric limping gait and abnormal mri signals were found in steroid-treated emus. saon was found in all emus with a joint collapse incidence of 70%. the percentage of neutrophils (neut %) and parameters on lipid metabolism significantly increased after induction. micro-ct revealed structure deterioration of subchondral trabecular bone. histomorphometry showed larger fat cell fraction and size, thinning of subchondral plate and cartilage layer, smaller osteoblast perimeter percentage and less blood vessels distributed at collapsed region in saon group as compared with the normal controls. scanning electron microscope (sem) showed poor mineral matrix and more osteo-lacunae outline in the collapsed region in saon group. the combination of pulsed lps and mps developed in the current study was safe and effective to induce saon and deterioration of subchondral bone in bipedal emus with subsequent femoral head collapse, a typical clinical feature observed in patients under pulsed steroid treatment. in conclusion, bipedal emus could be used as an effective preclinical experimental model to evaluate potential treatment protocols to be developed for prevention of on-induced hip joint collapse in patients. steroid-associated osteonecrosis (saon) is a common orthopaedic problem although steroids are initially prescribed for many non-orthopedic medical conditions, such as systemic lupus erythematosus (sle), organ transplantation, asthma, rheumatologic arthritis (ra), and severe acute respiratory syndrome (sars) [1] [2] [3] [4] [5] . part of saon patients even evolved to hip joint collapse with subsequent total joint replacement [6, 7] , and its long-term durability however still remained a big challenge [8] . how to prevent accumulation of saon lesions is the first-line strategy for avoiding joint collapse. therefore, establishment of appropriated saon animal models that mimic clinical etiology and even evolves to joint collapse is desirable prior to translating prevention and treatment experimental protocols into clinical validation and applications. up to now there is lack of ideal animal models to exam the treatment efficiency or therapeutic strategy for saon-associated joint collapse. the limitation of the existing animal models, such as rabbit [9] [10] [11] [12] [13] , rat [14] [15] [16] [17] , mouse [18, 19] , pig [20, 21] and chicken [22] is that they fail to progress to the end-stage of saon, i.e. structural collapse of the weight-bearing joints. with bipedality, high activity level and large enough bodyweight similar to that of human beings, on model to be developed in emu femoral head could provide a unique opportunity to progress to human-like femoral head collapse [23, 24] . focal cryogenic (liquid nitrogen) insults [23, 25] and alternative cooling and heating insults [26] have also been tested to induce on in emus with femoral head collapse. however, these models are not etiology-and or pathophysiology-orientated for saon research. accordingly, the aim of the current study was to establish a saon model in bipedal emus, with potentials to bone structural deterioration with subsequent femoral head collapse, a condition seen in saon patients attributed to similar biomechanics or loading ratio imposed onto the hip joint [23, 24] . such a model would be essential for testing strategies to be developed for potential clinical applications for prevention and treatment of steroid-associated joint collapse. of all available animal models, rabbits were intensively used for establishing on model where either lipopolysaccharide (lps) [27] or methylprednisolone (mps) [12, 28, 29] or their combination (lps+mps) [11, 13] were tested. all of them showed effectiveness in on induction, yet with varying degrees of on lesions and mortality of animals. based on our established saon rabbit model with a high incidence of on and low or no mortality that was induced by a combination of lps and mps [11, 30] , we hypothesized that such a combination of pulsed lps and mps injections might also be able to induce saon in bipedal emus with subsequent hip joint collapse. the research ethics committee of shenzhen second peoples' hospital reviewed and approved the experimental protocols [licence no. 2009-001] (appendix s1). both the guide for the care and use of laboratory animal (1996) [31] and the arrive (animals in research: reporting in vivo experiments) guidelines [32] were followed. eight 24 months old young adult male emus were used for this study. they were kept in shenzhen emu institute and received food and water ad libitum. five emus assigned to the saon group were treated with a combination of lps and mps. three emus were used as controls without receiving either lps or mps. the emus were euthanized by intravenous injection of overdose of pentobarbital via jugular vein at 24 weeks post injection. the details of this combined protocol were described as follows: each emu was intravenously injected with lipopolysaccharide (escherichia coli o111:b4; sigma-aldrich, st. louis, mo, usa) twice via jugular vein with 8 mg/kg body weight at an interval of 4 days from day 0. thereafter, three injections of methylprednisolone (pharmacia & upjohn, peapack, nj, usa) with 10 mg/kg body weight were given intramuscularly at gluteus muscle at an interval of 2 days. in addition, each emu was intramuscularly injected at gluteus muscle with 40 mg omeprazole sodium and orally with 250 mg amoxicillin dispersible per day for 7 days immediately after induction to prevent potential stomach ulcers and systemic infection ( figure s1 ). mri was performed with a 1.0 t mr unit (magnetom harmony; siemens, erlangen, germany) at baseline, week 2 and then at monthly basis on saon induced emus for in vivo examination on bilateral proximal femora until 12 weeks post induction. for facilitating in vivo bioimaging examination, a specific posture fixture was designed to obtain a highly reproducible image during mri scanning ( figure s2) . a phased-array body coil was used for mri scanning. coronal turbo spin-echo fatsaturated t2-weighted images (4000 ms repetition time, 96 ms echo time) were obtained with a slice thickness of 3 mm and interslice gap of 0.3 mm from a field of view of 300 mm 6 300 mm with a matrix of 3206320 pixels. blood was sampled at baseline, week 2, 4 and 8 post induction for routine blood examination and serum was prepared for examination of both coagulation and lipid metabolism. the serum parameters related to lipid metabolism, including total cholesterol (tc), total glycerin (tg), low-density lipoprotein (ldl) and high-density lipoprotein (hdl), and the serum parameters related to coagulation, including prothrombin time (pt), prothrombin time and international normalized ratio (pt/ inr), fibrinogen (fbg) and thrombin time (tt), were tested using standard clinical laboratory protocols for blood chemistry in shenzhen second peoples' hospital. gait of emus with saon was observed regularly after induction by recording abnormal gait pattern using a video camera. normal gait of the control emus was also recorded for comparison (video s1 and s2). emus walked or ran on a 20-meter walkway, and the sagittal plane motion was videotaped at 300 hz by a highspeed video camera (casio ex-f1, japan). the videos were analyzed by a motion analysis system (kwon3d xp, korea) to obtain the included ankle joint angle during a gait stride cycle with respect to the time presented in term of percentage stride. gait pattern was defined abnormal when there was a deviation of the included ankle joint kinematics (more than 20 degrees at any time) or the proportion of the stance and swing time (more than 10% deviation from control case). bilateral proximal femora from both control group and saon group were sampled and fixed in 10% buffered neutral formalin solution for 10 days, and then soaked in 70% ethyl alcohol for measurement of trabecular morphology within and around on lesions. in brief, the proximal femur was scanned using a highresolution peripheral ct (hr-pqct) (xtreme ct, scanco medical, brüttisellen, switzerland) at a voltage of 70 kv and a current of 114 ua, with entire scan length of 40 mm in a spatial resolution of 40 mm used for animal experimental studies [33, 34] . after the initial scanning, 2-dimentiaonal (2-d) images were realigned in the z-axis along the direction of femoral neck for further evaluation. for separating the signals of the mineralized tissue from the background signal, noise was removed using a lowpass gaussian filter (sigma = 2.5, support = 2) and mineralized tissue was then defined at a threshold of 85. 3-d structures of entire femoral heads were then reconstructed. the collapse was identified when fracture and/or clear deformation appeared in femoral head. a 10 mm 610 mm 68 mm region in the centre of femoral head was defined as the region of interest (roi) for analysis and comparison. roi was defined within subchondral region centered in the collapsed region or the corresponding region of the non-collapsed femoral heads, where the largest thickness of this roi was 1/3 diameter of the femoral head. bone mineral density (bmd), bone tissue volume fraction (bv/tv), trabecular number (tb. n), trabecular thickness (tb. th) and trabecular separation (tb. sp) in the roi were measured separately by the workstation with the built-in hr-pqct software. after micro-ct scanning, femoral heads were sawed in half longitudinally along the coronal plane. halves were decalcified and embedded in paraffin; and halves were embedded in methyl methacrylate (mma) without decalcification. 1. decalcified sections. for paraffin embedded samples, sections were sliced along the coronal plane for hematoxylin-eosin (h&e) and fast green and safranin o staining, respectively. a microscope imaging system (leica q500mc; leica microsystems, wetzlar, germany) was used to digitalize the histological sections for histomorphometric evaluation. 1) examination of on: the entire area of each h&e stained section was examined for the presence of on with the established criteria, i.e. diffuse presence of empty lacunae or pyknotic nuclei of osteocytes in the trabeculae, accompanied by surrounding necrotic bone marrow [13, 28] . the femoral head with at least one on lesion was considered as on+, while that with no on lesion was considered as on[11, 35] . 2) quantification of fat cells in bone marrow: fat cells were quantified for both average of fat cell size and fat cell area fraction. the total bone marrow in subchondral bone was 200 fold magnified and captured. the fat cells were manually traced and then quantified. the fat cell size was interpreted by fetet's diameter, i.e. the longest distance between any two points along a region of interest (roi) boundary [11] . the fat cell area fraction was defined as total marrow fat cell area normalized by total marrow tissue area [35] . 3) histomorphometry of the subchondral plate: the thickness of subchondral bone plate of the femoral head was measured on the 506 images. at least 10 views per section were randomly selected for measuring. the thickness was examined by measuring point-to-point distance from the top of the calcified cartilage to the deep surface of the subchondral bone plate [36] . 4) examination of articular cartilage: the average thickness of cartilage were examined by the total area of cartilage divided by the length of cartilage band measured from the manually traced region on the entire frontal sections for evaluation under 2006 magnification. the thickness of cartilage at the collapsed region or the corresponding region of the non-collapsed femoral head was also examined. the proteoglycans content was quantified by measuring the thickness of safranin o stained articular cartilage. 5) calculation of osteoblasts: the osteoblast perimeter percentage (%ob.pm) was calculated as the ratio of the total perimeter of the trabecular surface covered by osteoblasts to the whole perimeter of the trabecular surface [37] . 6) blood vessel quantification: the number of blood vessels within the collapsed region or the corresponding region of the non-collapsed femoral head was quantified on h&e sections [38] . 2. undecalcified sections. the mma embedded femoral heads were sectioned along the sawed plane using a diamond saw (isomet, buehler). the cut surface was polished on a soft cloth rotating wheel [39] . the surfaces were acid-etched with 37% phosphoric acid for 2-10 seconds, followed by 5% sodium hypochlorite for 20 minutes. the samples were then sputtercoated with gold and palladium, as described previously [40, 41] and examined for bone matrix and features of osteocytes in the scanning electron microscope (sem) (jsm-6300, jeol, japan). statistical power was set .0.8 and the type i error probability was set ,0.05 for calculating sample size (n = 5) using ps (power and sample size calculations version 3.0) for establishing saon model based on our previous rabbit model with a saon incidence of 93% [11] . the incidence of collapse was defined as the number of collapsed hips divided by total number of hips in each group. the incidence of saon was defined as the number of saon emus divided by total number of emus in each group, and analyzed with fisher's exact test. the serum parameters were expressed as mean 6 sd, and analyzed by one way analysis of variance (anova) with a post hoc bonferroni's multiple comparison test to compare the differences between every time point and baseline. micro-ct and histomorphometry data were expressed as mean 6 sd, and analyzed with mann whitney test to compare the differences between the control group and saon group. spss 10.0 was used. the significance for comparison was set at p,0.05. in t2 weighed mri images, intense signals of edema in the proximal femur were found at week 2 post-induction when compared to the baseline. the edema signals in proximal femur decreased in t2 weighed mri image at week 12 post induction ( figure 1 ). no collapse was found from mri images in the first 12 weeks after induction. the results of routine blood examination showed abnormal increase in percentage of neutrophils (neut %) at 2 weeks post induction (figure 2a ). for the time course changes in serum parameters related to lipid metabolism, tc was significantly increased at each time point post-induction, and ratio between ldl and hdl as well as ldl was also significantly increased at each time point post-injection (p,0.05 for all) while tg did not show significant increase post-induction ( figure 2b ). however, as compared with baseline, no significant difference was found for the time course changes in serum parameters related to coagulation post-induction ( figure 2c ). all emus were observed to be less active but with normal gait in the next day after the first lps injection; while an asymmetric limping gait pattern was firstly observed at week 12 post induction during loading and unloading gait cycle ( figure 3 ). in the early post-induction phase the asymmetric limping gait was only observable when the emus were running. with time the asymmetric limping gait was observed when emus were walking; closing to week 24 post induction some of the emus were observed no more active and kept sitting most of the time. no emus died during the experiment period over 24 weeks. all five emus in saon group developed edema, an early stage sign of on at bilateral hip based on mri observations as described above, in part also shown by gross morphology after sample harvesting ( figure 4a and b) , and confirmed histologically as described below. the incidence of hip joint collapse was 70% (7 out of 10 hips from 5 emus) found in the saon group, including 3 emus with bilateral collapse, 1 emu with unilateral collapse, and 1 without hip joint collapse ( figure 4a-f) . there was no collapse of the hip found in control group. micro-ct analysis was performed for the trabecular bone microarchitecture in the subchondral region ( figure 4e and f) and in the center of the femoral head ( figure 4g and h) , respectively. within the subchondral region, the bmd, bv/tv, tb. n and tb. th in the saon group were found significantly lower than those in the control group (p,0.05 for all), while the tb. sp in the saon group was significantly higher than that in the control group (p,0.05) ( table 1) . however, no statistically significant difference was found for all micro-ct indices of trabecular bone in the centre of the femoral head between the control and saon group (table 1) . gross coronal view of h&e stained femoral head in the control group showed well-arranged trabecular bone supporting the subchondral plate and the articular cartilage ( figure 5a1 ); while the collapsed femoral head in saon group was lack of vertical arranged trabecular bone to support the subchondral plate and the articular cartilage, and bone fracture shown at collapsed site ( figure 5a2 ). though 70% of 10 hips from 5 emus in the saon group developed hip collapse, 100% of hips from all emus in the saon group developed on at bilateral hips as confirmed histologically while as expected no on lesion was found in the control emus (p,0.05) ( figure 5b , c, d, e). osteonecrosis was distributed in whole femoral head, including subchondral bone ( figure 5b2, e) , middle of the femoral head ( figure 5c2 ) and femoral neck ( figure 5d ), with numerous empty lacunae in the trabeculae and marrow tissue degenerated. compared with the control group, the marrow fat cell size (fetet's diameter of fat cell) and fat cell area fraction in the saon group were increased significantly with decreased number of mononuclear cells (p,0.05 for both, figure 5b and figure 6a , b). the thickness of subchondral plate of femoral head of saon emus was decreased significantly (p,0.05, figure 6c ). the articular cartilage of saon emus also showed pathological alteration with significantly thinner thickness (p,0.05, figure 5f , g and figure 6d ). the proteoglycans content as interpreted by maximum thickness of safranin o staining was decreased significantly in saon group (p,0.05, figure 6e ), with osteonecrosis located at the collapsed region ( figure 5e ). the osteoblasts perimeter percentage (% ob. pm) of the saon group was significantly lower than those in the control group (p,0.05, figure 6f ). the blood vessels at subchondral region of saon group were surrounded with enlarged and compacted arranged fat cells, with some blood cells effused out of the vessel (figure 5b ). at the collapsed region or the corresponding region of the non-collapsed femoral head, the number of blood vessels of saon group was significantly less than that of the normal group (p,0.05, figure 6g ). sem images showed that in the collapsed region there was no osteo-like structure; instead, there were more osteo-lacunae outline, with more removal of bone mineral or less matrix; and that in the normal control, there was osteon-like structure and there were few osteo-lacunae outline with much solid bone matrix (figure 7 ). using a combined pulsed lps and mps induction protocol previously established for saon quadrupedal rabbits [11, 13] , the present study established a saon model in bipedal emus characterized with subchondral bone deterioration and hip joint collapse, an experimental model mimicking human on often developed at hip joint with femoral head collapse. as bioimaging evidence, we used mri to evaluate in vivo alteration of mri signals in the first 12 weeks post induction as mri could diagnose early-stage on, even presymptomatically [42] . abnormal signals were firstly detected at week 2 postinduction, showing large scales of edema at the proximal femora. this phenomena is similar to clinical on where the bone marrow edema was found from mri earlier than either formation of the necrotic lesion or the collapse of the necrotic fragment [43] . however, mri of emu hips merely shows bone marrow edema without typical band pattern shown in initial mri signaling of on patients [44, 45] . this could be explained by the differences in anatomy and physiology of human (mammals) and emu (aves), such as that the bone marrow of emu hip mainly presented in subchondral bone in a shell-shaped region and there was hollow structure in emu's bone marrow cavity at both femoral neck and head. irrespective such differences, there were common structural features, i.e. on lesion and hip joint collapse found in saon emus and this would provide a platform, i.e. a large bipedal animal model for testing biomaterials developed for bone defect repair, including for that after surgical core-decompression in hip joints, a condition indicated for patients with early stage of on. for functional evidence, asymmetric limping gait was observed at week 12 post-induction, suggesting that emus might suffer from joint pain caused by the on lesion formation and structural damage confirm histologically after harvesting the samples for detailed analysis. this symptom was also common in patients at early stage of on [46] . the asymmetric limping gait shown in bipedal emus was similar to the low limb dysfunction in saon patients with subchondral lesions [47] . for biochemical evidence, the current study suggested hyperlipidemia occurred after saon induction, which was evidenced by a significant increase in tc at all examined time point postinduction. in addition, abnormal higher lipid transportation to the peripheral tissues also occurred after induction, as evidenced by a significant increase in ldl/hdl, which was consistent with the results found in both saon rabbit model [9, 11] and on patients [48] . however, there was no significant difference in coagulationrelated parameters after induction as compared with baseline, while hypercoagulable and hypofibrinolysis state were reported in saon rabbit model [9, 11] and sars on patients [49] . this inconsistency suggested that the pathogenesis of saon in emu might be explained by the dominant disorder in lipid metabolism. histological and histomorphometric analysis was performed in three rois of the femoral head, including the articular cartilage, subchondral bone region and the central part of the femoral head. under higher magnification of the subchondral bone region where edema was shown in mri images, remarkable necrotic changes were observed in emu after induction, including 1) avascular zone at load bearing region, referring to the blood vessels quantification within the collapsed region; 2) extravascular adipogenesis (fat cell enlargement); 3) apoptosis of osteocytes in regions next to the marrow region packed with fat cells; and 4) thinning of subchondral bone, poor quality of bone matrix and more osteolacunae that weakens the mechanical integrity of the femoral head, which could also be weakened by the necrosis and thinning of articular cartilage. these were essential indices of later joint collapse, typically seen in saon patients [50, 51] that were substantiated in our histomorphometric analysis. on the contrary, our micro-ct evaluation for the central region of the femoral head, where no bone structural collapse was demonstrated, implied that the pulsed lps-mps induction protocol did not result in general osteoporosis as no difference in boney structural and bmd was found between saon emus and normal controls in regions away from the subchondral bone. this finding was also similar to a bone densitometry study in sars patients who underwent pulsed steroid treatment in hong kong [52] . no obvious osteoporosis found in saon patients with joint collapse or animals were mainly explained by short-term effects of pulsed corticosteroid administration that resulted in local damage of vasculature in the subchondral bone region and impairment of bone marrow mononuclear cells, which triggered up-regulation of osteoclastic activities and inadequate bone formation known as destructive repair [1, 6, 10, 34, 53, 54 ]. yet, long-term steroid administration was known to be able to induce secondary osteoporosis in patients [55] or animals [14] . in spite of the presence of difference in hip anatomy, the similarity in biomechanics of the hip joint with regard to proportion of joint loading between human and bipedal emu was well characterized by iowa biomechanics research group [56, 57] . the contact stress of femoral head was reported with a maximum hip contact force of approximately 5.5 times of body weight in emus, directed axially along its femoral neck, which was moderately larger than that of humans [56] and the contact stress magnitude and the sites of habitual loading on the femoral head was also comparable between emu hip and the human hip [57] . that the joint biomechanics plays a crucial role for no-induced hip joint collapse was also well supported by findings obtained from bipedal and quadrupedal animals. in fact, the on-induction protocol with a combination of lps and mps successfully induced saon in quadruped animals, yet without resulting in subchondral collapse [11] , although inadequate repair was also demonstrated in quadruped saon animals [35] . besides emu study, another report showed that the chicken was also bipedal animal suitable for building up saon animal model [22] , yet their induction protocol did not result in hip joint collapse. in order to mimic on and hip joint collapse, we tested large bipedal emus not because of its similarity in hip joint biomechanics to that of human but mainly that emu hip was sizeable to perform core decompression and testing porous scaffold biomaterials developed for potential clinical applications [58] [59] [60] . the saon induction protocol tested in the present study successfully induced hip joint collapse in large bipedal emus. the occurrence of hip joint collapse in emus was apparent more (7 out of 10 hips from 5 emus) than clinical data, such as 32.7% saon incidence reported by li zr and co-workers in their welldocumented clinical study in sars patients who were treated with a high dose of corticosteroid for life-saving [61] . as saon incidence is often dose-dependent and the purpose of the current preclinical study is to establish a saon bipedal large animal model with high incidence of on and hip joint collapse, we tested much higher dose of mps as compared with clinical recommended dose for sars patients [61] . differ to human situation where only mps was used, we used both lps and mps pulsed treatment, where lps served the purpose to mimic clinical conditions, i.e. disease-related tissue inflammation [11, 27] , in addition to higher mechanical loading imposed to the hip joint in emus where emu hip joint share 65-70% of the body weight as compared with around 60% of body weight in human [56] . in present emu study, we selected two lps injections with 4 days interval that showed safe and effective to induce saon. neut % increased 2 weeks post induction and decreased gradually to baseline level from 2 weeks to 8 weeks post induction which indicated inflammation reaction induced by lps. no typical clinical shwartzman reaction was observed in emus as we did not systemically study the non-skeletal tissue thrombosis or reticuloendothelial blockage for comparison with that in saon patients. it would be of interest to study in details the differences in physical or immune responses between human and birds in saon in future. in our previous study, we established saon in rabbit with 16lps (10 mg/kg) +36mps (20mg/kg) [11] . as emu was estimated with similar body surface area to that of human, we calculated the current experimental dose based on the conventional human-rabbit dose conversion. however, the dose for the initial experiment for emu was 6.67 mg/kg. as we found that emus could tolerate larger dosage from our pilot study, we increased mps dose to 10 mg/kg for the current study at a time interval of 2 days for avoiding potential side-effect of mps injection. specific design for studying dosing effects (amount and frequency of lps and mps treatment) would also be of interests for further studies. the limitation of the current experimental study is that we are not able to delineate if the cause of joint collapse is attributed to saon and/or cartilage and subchondral bone thinning as we did not observe typical destructive repair by uncoupling of osteoclasts and osteoblasts as well as extensive local fibrosis found within necrotic regions reported in both quadrupedal rabbit model [35] or patients [62, 63] . future studies shall be designed to monitor such pathological changes at various time points after oninduction. larger sample size would also be appreciated although our findings did reach statistical significance where we estimated sample size using ps (power and sample size calculations version 3.0) for establishing our current emu saon model based on our previous rabbit model with a saon incidence of 93% [11] . in conclusion, this was the first experimental study to confirm that a combined injection protocol of pulsed lps and mps was able to induce on and deterioration of subchondral bone microarchitecture in bipedal emus, with subsequent femoral head collapse. the establishment of this bipedal emu model with hip joint collapse provided a platform for evaluation of potential treatment protocols to be developed for prevention of steroidassociated hip joint collapse. pathogenesis and natural history of osteonecrosis steroid-induced osteonecrosis in severe acute respiratory syndrome: a retrospective analysis of biochemical markers of bone metabolism and corticosteroid therapy the functional capacity of healthcare workers with history of severe acute respiratory 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osteonecrosis in a chinese population osteonecrosis of hip and knee in patients with severe acute respiratory syndrome treated with steroids investigation of proximal femoral marrow with magnetic resonance imaging in recovered patients with severe acute respiratory syndrome reduced bone mineral density in male severe acute respiratory syndrome (sars) patients in hong kong relationship between bone marrow edema and development of symptoms in patients with osteonecrosis of the femoral head decrease in the mesenchymal stem-cell pool in the proximal femur in corticosteroid-induced osteonecrosis osteoporosis management in patients with rheumatoid arthritis: evidence for improvement hip joint contact force in the emu (dromaius novaehollandiae) during normal level walking contact stress distributions on the femoral head of the emu (dromaius novaehollandiae) comparative study of osteogenic potential of a composite scaffold incorporating either endogenous bone morphogenetic protein-2 or exogenous phytomolecule icaritin: an in vitro efficacy study exogenous phytoestrogenic molecule icaritin incorporated into a porous scaffold for enhancing bone defect repair plga/tcp composite scaffold incorporating bioactive phytomolecule icaritin for enhancement of bone defect repair in rabbits magnetic resonance imaging and histology of repair in femoral head osteonecrosis osteonecrosis of the jaws in patients treated with bisphosphonates -histomorphologic analysis in comparison with infected osteoradionecrosis the authors would like to thank medical staff from shenzhen second people's hospital, including dr. j xia for mri scanning and dr. jy xiong for providing anesthesia materials for animal experiments and dr. xh pan from the first peoples' hospital (shenzhen, china) for providing technical support. key: cord-351440-vtf3o5ml authors: zhang, tianshu; hirsh, ellen; zandieh, shadi; rodricks, michael b. title: covid-19-associated acute multi-infarct encephalopathy in an asymptomatic cadasil patient date: 2020-10-06 journal: neurocrit care doi: 10.1007/s12028-020-01119-7 sha: doc_id: 351440 cord_uid: vtf3o5ml nan and myalgias which were mild, lasted 4 days, and were self-limited. her sister did not seek any medical care. the patient fell ill 4 days after her sister's return with similar symptoms of a headache and myalgias. after developing lethargy, dysphagia, and speech difficulties, she was brought to the emergency department. the physical examination revealed a patient in moderate acute distress. she was febrile with a temperature of 102.2°f. her blood pressure was 140/80 with a heart rate of 106 and a respiratory rate of 27. the room air oxygen saturation was 92%. neurologically, she was awake and alert and followed commands although sluggishly. she had difficulty with her speech with components of both dysarthria and expressive aphasia, difficulty handling her secretions, and dysphagia. there was no meningismus which could be elicited. her pupils were equal round and reactive, but she showed a right gaze preference and a mild left facial droop. she had mildly decreased but equal bilateral strength. the deep tendon reflexes were preserved. the remainder of the examination was only notable for diffuse rhonchi on auscultation of her lungs. initial laboratory studies showed a mild leukocytosis with lymphopenia. the chest x-ray demonstrated patchy consolidation in the right lower lung. a non-contrast computed tomography (ct) of the head showed no evidence of intracranial hemorrhage, but there were multifocal patchy areas of white matter hypoattenuation (fig. 1) . a lumbar puncture was performed to clarify the diagnosis and to exclude central nervous system infection. cerebrospinal fluid (csf) analysis revealed normal cell counts, protein, and glucose. a polymerase chain reaction (pcr) panel for meningitis and encephalitis, including herpes simplex 1 and 2, human herpes 6, cryptococcus, and varicella zoster virus, was entirely negative as were bacterial cultures. a lyme titer was negative. an electroencephalogram (eeg) did not show electrical evidence of seizures. the covid-19 pcr test of a nasal swab became available 2 days after admission and detected the novel coronavirus (sars-cov-2) target nucleic acid. the covid-19 pcr test of csf was negative (cepheid genexpert system). to assess the white matter lesions found on head ct, a magnetic resonance imaging (mri) of the brain with and without contrast was obtained. the mri showed extensive patchy areas of abnormal signal involving bilateral frontoparietal white matter, anterior temporal lobes, basal ganglia, external capsules, and thalami. additionally, some of these foci demonstrated diffusion-weighted imaging (dwi) changes and corresponding apparent diffusion coefficient (adc) changes, with questionable minimal enhancement (fig. 2 ). magnetic resonance angiography (mra) of the brain and neck was essentially normal. the patient was treated with hydroxychloroquine, ceftriaxone, and a 5-day course of intravenous immunoglobulins (ivig). steroids were not used as it was felt to be contraindicated given the acute covid-19 diagnosis and in keeping with the then current guidelines. the patient was also given aspirin for stroke prophylaxis. after 5 days of ivig, the patient showed signs of improvement-she was better able to handle secretions, less dysarthric, afebrile and had no respiratory symptoms. because of her acute covid-19 diagnosis, it was difficult to get her placed in a rehabilitation facility. the patient's speech, strength, and ability to swallow continued to improve, and she was able to be discharged to home by hospital day 23. at an outpatient follow-up 1 week after discharge, the patient was found to be almost at baseline-tolerating a regular diet, normal speech, symmetric face, normal motor and sensory examination, and able to ambulate independently albeit at a slow pace, with some easy fatigability. a follow-up brain mri (fig. 3 ) was performed 7 weeks after the initial mri study. it showed that the initial dwi and adc changes had largely disappeared. there was a hypodense area on t1 flair images without enhancement and with persistent t2 flair changes in a similar distribution as previous mri. the chronological changes from the initial dwi and adc images to the disappearance of these signals in the follow-up mri support that the patient had acute subcortical ischemic changes or necrotic changes. the patient continued to recover from her acute illness, and 8 weeks post-discharge she resumed driving and returned to her previous work. an additional workup became available a month after the second mri including a negative myelin antibody and notch 3 genetic testing. it revealed the presence of a pathogenic variant in the notch3 gene-a heterozygous missense mutation (sequencing test by athena diagnostics) which was consistent with a diagnosis of cadasil. it is important to consider other infectious etiologies with or without a diagnosis of covid-19 in a patient with fever, neurological deficits, and encephalopathy. an electroencephalogram (eeg) is indicated to exclude subclinical seizures and non-convulsive status epilepticus. the ct findings prompted a further workup for cerebral abscesses and septic emboli. it is difficult to perform an mri on a covid-19-positive patient or a person under investigation (pui) due to the concern for contamination of equipment, the requisite patient transportation, and the risk of exposure to healthcare providers. given the clinical picture and the ct findings, it seemed rational to take the necessary steps to obtain such imaging. the brain mri showed multiple dwi lesions and corresponding adc sequence changes which were consistent with multiple acute infarcts possibly related to hypoxic-ischemic injury from systemic perturbations and resultant tissue hypoxia. the predominance of the extensive t2 flair signal changes in the cerebral white matter lesions is more suggestive of a demyelinating process. these lesions are extensive, bilateral, and predominantly subcortical, with additional involvement of the deep nuclei. these features are compatible with an acute inflammatory encephalopathy in the setting of a recent or ongoing systemic viral infection with acute neurological deficits. this case potentially represents atypical acute disseminated encephalomyelitis (adem) as the csf did not show any pleocytosis or increased protein levels [1] , though absence of csf changes could be related to the timing of lumbar puncture. the initial presentation of multiple sclerosis is within the differential diagnosis, but given the lack of any prior neurological symptoms and the clinical picture described as well as the acute diagnosis of covid-19 it seems unlikely. myelin oligodendrocyte glycoprotein (mog) antibody-associated encephalitis is also a consideration; however, the patient had negative myelin antibody. in a patient with multiple infarcts, the differential diagnosis also includes a cardioembolic cause. in this case, it was initially suspected that these multiple infarcts could be from a combination of hypoxia and a hypercoagulable state from the acute covid-19 infection [2] . the subcortical multiple infarcts this patient experienced along with the relatively symmetric white matter lesions seen on brain mri suggest a case of cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (cadasil). the acute infection combined with a complete lack of family history of stroke, dementia or migraine, and the patient lacking of prior migraine with aura, stroke, cognitive impairment, or psychiatric illness is unusual but does not exclude a diagnosis of cadasil as de novo cases have been described. the clinical course of complete recovery in a few weeks is also atypical for a diagnosis of cadasil. our patient did undergo genetic testing which revealed the presence of a pathogenic variant in the notch3 gene consistent with cadasil. it is still not clear if the multiple subcortical infarctions seen on mris are from cadasil itself, or some combination of direct viral invasion, an immunological reaction, or a cytokine storm syndrome despite the findings of normal csf and a negative covid-19 pcr of the csf. the distribution of the ct and mri changes in our case is similar to a recent case report of acute hemorrhagic necrotizing encephalopathy in a covid-19 patient [3] , which case, to our knowledge, was not tested for a pathological notch3 mutation. we present a unique case of acute multi-infarct encephalopathy in a covid-19 patient. the clinical features and ct and mri changes are consistent with acute subcortical multiple infarctions which could be related to or provoked by a viral infection. further genetic testing revealed this previously asymptomatic patient to have a pathogenic variant of the notch3 gene consistent with cadasil. even though it is known that there are vascular wall smooth muscle abnormalities related to cadasil gene mutations, it is not clear what triggers the multiple infarcts in these patients. the acute infection likely induced a milieu of inflammation, hypoxia, and coagulopathy in this covid-19 patient which triggered multiple infarcts. further investigation as to the precipitants of the hypoxic-ischemic process in cadasil patients is of interest. our described case is an atypical presentation of an acute covid-19 infection in a previously asymptomatic cadasil patient who presented with multiple infarcts and encephalopathy. it is illustrative of the difficulty in searching for a definite diagnosis and the requisite workup to explore the different treatable etiologies of this clinical picture. acute disseminated encephalomyelitis in 228 patients: a retrospective, multicenter us study arterial and venous strokes in the setting of covid-19 covid-19-associated acute hemorrhagic necrotizing encephalopathy: ct and mri features the submission of the manuscript was approved by the rwjuh somerset institutional review board. all authors participated in the clinical work. t. zhang and m.b. rodricks wrote the draft. none. the authors declare that they have no conflict of interest.ethical approval/informed consent irb approval was obtained for this study. springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. key: cord-308869-tuyac4oq authors: kido, hidenori; kano, osamu; hamai, asami; masuda, hiroyuki; fuchinoue, yutaka; nemoto, masaaki; arai, chiaki; takeda, teppei; yamabe, fumihito; tai, toshihiro; kasahara, mizuki; suzuki, kenichi; shiraga, nobuyuki; sadamoto, sota; wakayama, megumi; takahashi, yukitoshi; iwasaki, yasuo; shibuya, kazutoshi; urita, yoshihisa title: kikuchi-fujimoto disease (histiocytic necrotizing lymphadenitis) with atypical encephalitis and painful testitis: a case report date: 2017-02-01 journal: bmc neurol doi: 10.1186/s12883-017-0807-4 sha: doc_id: 308869 cord_uid: tuyac4oq background: kikuchi-fujimoto disease is a self-limited clinicopathologic entity that is increasingly recognized worldwide. kikuchi-fujimoto disease is characterized by cervical lymphadenopathy occurring in young adults. neurologic involvement is rare, and testitis directly caused by kikuchi-fujimoto disease has not yet been reported. case presentation: a 19-year-old man was brought to our clinic with complaints of fever, headache, fatigue, and left lower quadrant pain that had persisted for 3 weeks. on physical examination, painful cervical lymphadenopathies were observed. meningitis was suspected based on a cerebrospinal fluid examination, and left-sided orchitis was diagnosed based on findings from magnetic resonance imaging and ultrasonography. however, neither antibiotics nor antiviral drugs were effective in treating the patient’s symptoms. on the 20(th) day of hospitalization, the patient experienced a loss of consciousness, and brain t2-weighted magnetic resonance imaging showed asymmetrical, high-signal intensities in both basal nuclei and the left temporal lobe. encephalitis was suspected, and the patient was treated with intravenous prednisolone pulse therapy (1 g/day) for 3 days and intravenous immunoglobulin therapy for 5 days. a left cervical lymph node biopsy showed apoptotic necrosis in paracortical and cortical areas with an abundance of macrophages and large lymphoid cells, which had irregular nuclei suggestive of kikuchi-fujimoto disease; the pathological findings from a brain biopsy were the same as those of the cervical lymph node biopsy. the encephalitis and cervical lymphadenopathies followed a benign course, as did the testitis. conclusions: this is the first report of kikuchi-fujimoto disease involving painful testitis and pathologically proven asymmetrical brain regions. kikuchi-fujimoto disease should be included in the differential diagnosis when a patient presents with encephalitis, testitis, and fever of unknown origin. kikuchi-fujimoto disease (kfd), or histiocytic necrotizing lymphadenitis, is known to be a benign disease that usually resolves spontaneously. it is a rare disease and was first reported in japan in 1972 [1, 2] . kfd usually affects female patients under the age of 30 years and is characterized by regional lymphadenopathy with tenderness, predominantly in the cervical region, and is usually accompanied by mild fever and night sweats. it is of clinical importance because it is often misdiagnosed as tuberculosis, lymphoma, or systemic lupus erythematosus (sle); therefore, the diagnosis should be confirmed by biopsy study. diseases that generally accompany kfd are sle, arthritis, mixed connective tissue disease, and similar conditions; however, comorbid testitis has not yet been reported. neurological complications occur in about 11% of cases, as revealed by a review of 244 cases in which a minority of cases evolved to developing encephalitis [3] . brain magnetic resonance imaging (mri) includes symmetrical hyperintense t2-weighted and flair (fluidattenuated inversion recovery) signals in the temporal lobes, pons, and periaqueductal gray matter [4] [5] [6] [7] . this is the first report of kfd occurring with testitis and pathologically proven asymmetrical brain regions. a 19-year-old man presented to our hospital with complaints of fever (39.5°c), headache, fatigue, night sweats, and lower abdominal pain, which had been present for about 1 month. for 20 days, he had used anti-flatulent medications before presenting to our hospital. he had no history of close contact with pets, he did not travel often, and similar complaints were not present in his social circle. according to the patient's physical examination on admission, his general health status was good; body temperature, pulse, and blood pressure were 37.2°c, 102 beats/min, and 106/70 mmhg, respectively. he was alert, oriented, and cooperative. mobile, painful lymphadenopathies were observed on both sides of the cervical region, of which the largest was 2 × 1.6 cm in size. bilateral cervical lymphadenopathy was present and involved a posterior group of cervical lymph nodes. cardiac, respiratory, and neurological examination revealed no abnormality; vegetation was not detected by transthoracic echocardiography. laboratory investigations showed leukopenia (total leucocyte count: 3200 cells/mm 3 ). cerebrospinal fluid (csf) analyses were normal. no positive results that could explain the high body temperature were found during serological testing for epstein barr virus (ebv); cytomegalovirus (cmv); hepatitis a, b, and c; parvovirus; human herpesvirus; chlamydia trachomatis; mumps; human immunodeficiency virus; echo virus; coxsackie virus enterovirus; and measles spp. results of tests for rheumatologic markers (ferritin, anti-nuclear antibody, anti-neutrophil cytoplasmic antibody, anti-cyclic citrullinated peptide antibodies, extractable nuclear antigen antibody panel, anti-double stranded dna, and rheumatoid factor) were also negative. results of tuberculosis polymerase chain reaction (pcr) and herpes simplex pcr were also negative in the csf. blood and csf cultures showed no growth after incubation for 6 to 8 weeks. brain t2-weighted and flair mri sequences showed a slightly hyperintense signal of about 4 mm in the left temporal lobe (fig. 1) , and antibiotics and acyclovir treatment were begun because we could not rule out encephalitis. however, the patient's body temperature could not be reduced by routine anti-inflammatory drugs and intravenous paracetamol. thoracic and abdominal computed tomography (ct) and mri scans revealed a testicular lesion having no contrast effect (fig. 2) ; lymph nodes were predominantly located on the right side of the cervical region, with the largest measuring 2 cm in diameter. thus, one of the lymph nodes located in the right cervical region was removed and sent to pathology for analysis. on the 4th fig. 1 axial t1-weighted mri with gadolinium contrast (a) and flair-weighted mri (b) show mild enhancement and a highintensity area, respectively, in the left temporal lobe at onset (arrow heads). following periods of acute exacerbation on the 20th day, axial t1-weighted mri with gadolinium contrast (c) showed slightly larger enhancement, and flair-weighted mri (d) revealed an asymmetrical hyperintense signal in the left temporal lobe and both basal nuclei. after 2 months of hospitalization, the abnormal lesions became smaller (e, f) day of hospitalization, an excision biopsy of the cervical lymph node was performed. microscopic examination showed that the lymph nodes were expressed in paracortical and cortical areas of conspicuous apoptotic necrosis with an abundance of enlarged lymphocytes, which had prominent nucleoli in the absence of neutrophils and a proliferation of macrophages (fig. 3) . results of tests using in situ hybridization to detect ebv with marked paracortical expansion due to a proliferation of immunoblasts were negative. on the 20th day of hospitalization, the patient's general status suddenly and temporarily worsened. the signal intensity on brain mri had changed and showed an asymmetrical hyperintense signal in the wider larger left temporal lobe and both basal nuclei ( fig. 1) with slight gd-enhancement. csf protein levels and pleocytosis were increased (protein: 50 mg/dl; pleocytosis: 24 cells/μl), but csf cultures were negative, and cytology showed no malignant findings. anti-nmda, co, tr, gad65, zic4, titin, sox1, rec, hu, yo, ri, ma-2/ta, cv2, and amp antibodies associated with auto-immune-mediated encephalomyelitis were all absent. oligoclonal bands were also not detected in the csf sample. since acute disseminated encephalomyelitis (adem) was suspected, the patient was managed with intravenous prednisolone pulse treatment (1 g/day) for 3 days and intravenous immunoglobulin treatment for 5 days, and these therapies were repeated 3 times every 3 weeks. electroencephalography showed no waves characteristic of epilepsy, but levetiracetam 1000 mg/day was begun. on the 34 th day of hospitalization, mri investigation of the brain revealed that the previous abnormalities were present and had not changed. since the cervical lymph node biopsy before steroid therapy did not reveal lymphoma, a brain biopsy of the temporal lobe was performed. steroids can obscure diffuse large b-cell lymphoma or intravascular lymphomatosis; however, no recurrence was experienced. the pathological results revealed many cd68+ macrophages and histiocytes, as in the cervical lymph node, suggestive of kfd (fig. 4) . the cervical lymphadenopathies disappeared after 2 months of hospitalization, and the previous abnormalities on mri became smaller during follow-up. the testicular mass that showed a contrast effect on mri and ct similarly was smaller (fig. 1) ; therefore, we suspected that the testitis had been caused by kfd. his complaints of fever, headache, and fatigue gradually improved; he was discharged on the 90th day of hospitalization. he was followed for more than 3 months in our clinic and did not show any recurrence. kfd was first described in japan in 1972 and has increasingly been recognized worldwide since 1982 fig. 2 a axial t1-weighted magnetic resonance image shows that the lesion has an isointense signal. b after administration of gadolinium contrast, material internal enhancement is not observed. c coronal t2-weighted magnetic resonance image shows that the lesion has low signal intensity (arrow) fig. 3 left cervical lymph node biopsy shows conspicuous apoptotic necrosis in paracortical and cortical areas with an abundance of macrophages and large lymphoid cells, which have irregular nuclei [hematoxylin-eosin staining × 4 (left), ×40 (right)] [8] . according to a review [3] that summarized 244 kfd cases, the mean age was 25 (1-64) years, and 70% were younger than 30 years; 33% were men, and 77% were women. most of the cases were reported from east asia and the far east (50%), and the others were from europe (27%) and america (7%). as in the present case, the most common symptoms were fever (35%), fatigue (7%), and cervical lymphadenomegaly (100%) [3] . our case did not show any evidence of sle, lymphoma, tuberculosis, arthritis, or viral disease based on laboratory findings and cervical lymph node biopsy. testitis has not been reported as a co-morbid disease in kfd. after diagnosing kfd based on results of the cervical lymph node biopsy, we could not explain the central nervous system (cns) involvement in this case. neurological involvement, including aseptic meningitis and encephalitis, is rare, and abnormal mri findings in kfd usually show symmetrical, hyperintense t2 and flair signals in the temporal lobes, pons, and periaqueductal gray matter [4] [5] [6] [7] . therefore, we considered the possibility of co-morbid adem. avkan-oguz et al. [6] reported the co-existence of kfd and adem based on brain mri findings without a brain biopsy. our case did not show symmetrical lesions, which were reported in the previous kfd reports with cns involvement; hence, we evaluated brain pathology, and the results were consistent with those for kfd and showed a benign course. although the etiology of the disease remains unknown, infectious or autoimmune pathogenesis is thought to be responsible. the factors that likely result in the infection include herpes simplex virus, ebv, cmv, human herpes virus 6, varicella zoster virus, hiv, rubella, measles, coronavirus, coxsackie virus, hepatitis a and b, yersinia enterocolitica, toxoplasma, influenza viruses, mumps, streptococci, leptospira, and chlamydia. it has also been reported that the disease may occur after rabies, diphtheria-tetanus, poliomyelitis, hepatitis b, and influenza vaccines are injected [9] . kfd may initially be mistaken for various benign and malignant diseases, such as tuberculosis, lymphoma, sle, limbic encephalitis, and sarcoidosis. on the other hand, with regards to clinical and laboratory presentations, kfd frequently mimics sle, arthritis, mixed connective tissue disease, aseptic meningitis, encephalitis, tuberculous lymphadenitis, malignant lymphoma, and some other benign and/ or malignant diseases [3, 10, 11] . in addition to painful cervical lymphadenopathies and aseptic meningitis, our case showed testitis and encephalitis, which are not typical mri findings compared with those reported in a previous case report. previous papers reported that most cases of kfd had a benign course; therefore, it was difficult to evaluate the effect of our therapies, such as prednisolone and intravenous immunoglobulin treatment. the definitive method for confirming the diagnosis of kfd is with a lymph node biopsy, and therefore, physicians should not hesitate to perform one in order to diagnose the condition. in addition, if progressive cns involvement is observed, either steroid therapy or brain biopsy should be considered. thus, kfd may exist on a wide spectrum of diseases, and we suggest that kfd should be included in the differential diagnosis of lymphadenopathy, encephalitis, testis, and fevers of unknown origin. in conclusion, this is the first report of kfd involving testitis and pathologically proven asymmetrical brain regions. lymphadenitis showing focal reticulum cells hyperplasia with nuclear debris and phagocytosis: a clinicopathological study cervical sub-acute necrotising lymphadenitis. a new clinicopathological entity kikuchi-fujimoto disease: analysis of 244 cases histiocytic necrotizing lymphadenitis (kikuchi-fujimoto disease) with cns involvement in a child brainstem encephalitis with kikuchi-fujimoto disease a case of fever of unknown origin: co-existence of kikuchi-fujimoto disease and acute disseminated encephalomyelitis (adem) encephalitis and csf increased level of interferon-alpha in kikuchi-fujimoto disease histiocytic necrotizing lymphadenitis without granulocytic infiltration post-infectious encephalitis in adults: diagnosis and management histiocytic necrotizing lymphadenitis (kikuchi's disease) with aseptic meningitis encephalitis associated to kikuchi-fujimoto's disease in a young woman: a case report none. not applicable in order to protect patient privacy.authors' contributions study concept and design: hk, ok. acquisition of data: hk, ok, ah. hk, ok, ah, hm, yf, mn, ca, t. takeda, fy, t. tai, mk, k. suzuki, ns, ss, mw, k. shibuya, yi and yu examined and evaluated the patient. yt contributed to the csf analysis. all authors read and approved the final manuscript. the authors declare that they have no competing interests. we obtained written informed consent from the patient for publication of this report and any accompanying images. a copy of the written consent is available for review by the editor-in-chief of this journal. submit your next manuscript to biomed central and we will help you at every step: key: cord-346172-7ah22li0 authors: yang, shuyi; zhang, yunfei; shen, jie; dai, yongming; ling, yun; lu, hongzhou; zhang, rengyin; ding, xueting; qi, huali; shi, yuxin; zhang, zhiyong; shan, fei title: clinical potential of ute‐mri for assessing covid‐19: patient‐ and lesion‐based comparative analysis date: 2020-06-03 journal: j magn reson imaging doi: 10.1002/jmri.27208 sha: doc_id: 346172 cord_uid: 7ah22li0 background: chest computed tomography (ct) has shown tremendous clinical potential for screening, diagnosis, and surveillance of covid‐19. however, safety concerns are warranted due to repeated exposure of x‐rays over a short period of time. recent advances in mri suggested that ultrashort echo time mri (ute‐mri) was valuable for pulmonary applications. purpose: to evaluate the effectiveness of ute‐mri for assessing covid‐19. study type: prospective. population: in all, 23 patients with covid‐19 and with an average interval of 2.81 days between hospital admission and image examination. field strength/sequence: 3t; respiratory‐gated three‐dimensional radial ute pulse sequence. assessment: image quality score. patient‐ and lesion‐based interobserver and intermethod agreement for identifying the representative image findings of covid‐19. statistical tests: wilcoxon‐rank sum test, kendall's coefficient of concordance (kendall's w), intraclass coefficients (iccs), and weighted kappa statistics. results: there was no significant difference between the image quality of ct and ute‐mri (ct vs. ute‐mri: 4.3 ± 0.4 vs. 4.0 ± 0.5, p = 0.09). moreover, both patient‐ and lesion‐based interobserver agreement of ct and ute‐mri for evaluating the image signs of covid‐19 were determined as excellent (icc: 0.939–1.000, p < 0.05; kendall's w: 0.894–1.000, p < 0.05.). in addition, the intermethod agreement of two image modalities for assessing the representative findings of covid‐19 including affected lobes, total severity score, ground glass opacities (ggo), consolidation, ggo with consolidation, the number of crazy paving pattern, and linear opacities, as well as pseudocavity were all determined as substantial or excellent (kappa: 0.649–1.000, p < 0.05; icc: 0.913–1.000, p < 0.05). data conclusion: pulmonary mri with ute is valuable for assessing the representative image findings of covid‐19 with a high concordance to ct. evidence level: 2 technical efficacy stage: 3 demand with limited manufacturing capacity of rt-pcr kits, especially in less-developed countries. 2) false-negative rt-pcr results have been broadly reported. 3, 4 given the aforementioned challenges, chest computed tomography (ct) has been strongly recommended and encouraged for screening for covid-19. 5, 6 ai et al suggested that chest ct has ultra-high sensitivity (97%) for diagnosing covid-19. 3 besides, excellent performance of chest ct has been reported for diagnosing cases with negative rt-pcr results. 7 previous studies have reported the clinical and ct imaging features of covid-19. 8, 9 typical ct findings include ground glass opacities (ggo), ggo with consolidation, crazy paving pattern, or consolidation in a peripheral, posterior, and diffuse or lower lung zone. [10] [11] [12] ct is helpful to guide clinical management and surveil the progression of covid-19. because of the rapid progression of covid-19, the interval between the initial confirmation and the transfer to an intensive care unit (icu) can be as short as a day. 11 patients often receive more than one chest ct during their disease episode. 3, 13 hence, there is a theoretical radiation risk to these often young patients. an image modality without ionizing radiation would be of great clinical significance for evaluating covid-19. 14 as an image modality without ionizing radiation, magnetic resonance imaging (mri) may be a potential alternative to ct for pulmonary application. being less susceptible to fast t 2 * decay as well as respiratory motions, respiratorygated ultrashort echo time mri (ute-mri) has shown utility in pulmonary applications. [15] [16] [17] ohno et al concluded that ute-mri could be applied for visualizing the ggo, consolidation, and so on, in high concordance with ct. 18 we therefore hypothesized that ute-mri may serve as a valuable technique for noninvasively assessing covid-19. based on the aforementioned points, this study aimed to evaluate the clinical potential of ute-mri for assessing covid-19 with ct as the reference according to both a lesion-based and patient-based comparative analysis. this prospective study was approved by the ethical committee of shanghai public health clinical center. written informed consent of each patient was obtained. from february 2020 to april 2020, a total of 36 patients were enrolled in this prospective study. the inclusion and exclusion criteria were as the follows: inclusion criteria: 1. patients confirmed as covid-19 according to the results of rt-pcr. exclusion criteria: 1. the absence of ute-mri examinations. 2. the time interval between ct and mri examinations was greater than 2 days. the average time interval between the hospital admission and ct examination as well as hospital admission and mri examination was 2.74 days (median: 3 days) and 2.87 days (median: 3 days), respectively. ten patients were excluded because the intervals between the ct examination and ute-mri examination were larger than 2 days. three patients were excluded because of the absence of ute-mri examination. ultimately, this prospective study included 23 patients. ct acquisition: ct examinations were performed with a 64-section scanner (scenaria 64 ct; hitachi medical, kashiwa, chiba prefecture, japan). the scanning parameters were listed as: tube voltage, 120 kv; tube current 150-400 ma; pitch: 1.5; slice thickness: the entire thoracic cavity was excited with a nonselective hard pulse, followed by acquisition of a free induction decay (fid) signal instead of an echo (as in the case of most conventional clinical sequences), resulting in a center-out radial encoding trajectory. signal acquisition was initiated during the ramp-up stage of encoding gradient to further reduce the effective echo time as well as potential susceptibility artifact as a result of the air-tissue boundaries in the lung. the direction of the encoding gradient was incremented from one acquisition to another to cover the whole k-space in a "koosh ball" pattern. a total of 40,000 encoding directions was prescribed. in order to alleviate respiratory motion artifacts, the ute sequence was interleaved with a navigator sequence to track the diaphragm displacement in the superior-inferior direction. the acquisition module was enabled only within a certain predetermined displacement range, during which 2000 fids were collected each time. during reconstruction, the radial k-space data were first regridded onto cartesian the coordinate using a kaiser-bessel convolution kernel. all the qualitative and quantitative assessment of ct and ute-mri were carried out by three experienced radiologists (s.y.y., with more than 6 years' experience of chest ct diagnosis and 3 years' experience of pulmonary mri; f.s., with more than 19 years' experience of chest ct diagnosis and 8 years' experience of pulmonary mri; z.y.z., with more than 36 years' experience of chest ct diagnosis and 20 years' experience of pulmonary mri). all the ct and ute-mri images were randomized and independently analyzed by the above three radiologists without any information about the patients' clinical characteristics and results of other image techniques. image quality analysis. all ct and ute-mri images were independently scored by three radiologists with a 5-point scoring system. detailed scoring standards were: 1: unacceptable nondiagnostic image quality, 2: poor image quality, 3: acceptable image quality, 4: good image quality, and 5: excellent image quality. patient-based evaluation. patient-based quantitative imaging indexes including the number of affected lobes, the number of ggos, the number of consolidations, the number of ggos with consolidation, the number of crazy paving patterns, the number of linear opacities, total lung severity score (the sum of the severity score of each lobe; severity score of each lung lobe was based on the involvement) (score 1: none involvement [0%], score 2: minimal involvement [1-25%], score 3: mild involvement [26-50%], score 4: moderate involvement [51-75%], or score 5: severe involvement [76-100%]) were independently evaluated by three radiologists. lesion-based evaluation. three radiologists independently evaluated the presence of representative image signs and the shapiro-wilk test was performed to evaluate the data normality of the image quality score. the image quality of ute-mri and ct was compared with a wilcoxon-rank sum test, because both the image quality score of ct and ute-mri were not in normal distribution (p < 0.05). kendall's coefficient of concordance (kendall's w), intraclass coefficients (icc), and weighted kappa statistics were calculated for determining the interobserver and intermethod agreement. the interobserver and intermethod agreement were determined as excellent for kendall's w = 0. it should be noted that: 1) all the statistical results concerning the interobserver agreement evaluation were calculated by the independent evaluation of three radiologists. 2) intermethod comparison of image quality and patient-and lesion-based evaluation of intermethod agreement were based on the evaluation of the z.y.z., who is a nationwide recognized radiologist (with more than 36 years' experience of chest ct diagnosis and 20 years' experience of pulmonary mri). intermethod statistical analysis was according to the previously reported method. 19 two-sided p values of less than 0.05 were regarded as statistically significant. all the statistical analyses in this study were conducted with spss 26.0 (chicago, il). a total of 23 patients (men: 12, women: 11; median age: 32, age range: 17-62) were finally included in this study for subsequent analysis. table 1 summarizes the clinical characteristics of the included patients. as shown in table 2 , chest ct examination showed that seven (30.4%) patients had one affected lobe, five (21.8%) patients had two affected lobes, four (17.4%) patients had three affected lobes, five (21.7%) patients had four affected lobes, and two (8.7%) patients had five affected lobes. in terms of lesion distribution, bilateral involvement was present in 10 (43.5%) patients and multifocal involvement was presented in 20 (87.0%) patients. ggo with consolidation was identified in 22 (95.7%) patients, pure ggo and pure consolidation were respectively identified in eight (34.5%) and six (26.1%) patients. air bronchograms (14, 60.9%) and crazy paving patterns (two, 8.7%) were also observed within the lesion. other secondary image findings included linear opacities (10, 43.5%), adjacent pleura thickening (12, 52.2%), vessel expansion (16, 69.6%), and pleural effusion (one, 4.3%) also occurred. figures 1-3 demonstrate that representative radiological signs of covid-19 including ggo, consolidation, ggo with consolidation, air bronchogram, and pseudocavity could be visualized with ute-mri. table 3 shows the interobserver iccs of the evaluation of the image quality score of ct and ute-mri, which were 0.924 (p < 0.05) and 0.862 (p < 0.05). as fig. 4 shows, there was no significant difference between the image quality of two image modalities (ct: mean score: 4.3 median score: 4.0; ute-mri: mean score: 4.0 median score: 4.0; z statistics: 1.72, p = 0.09). the results of interobserver agreement evaluation in table 4 suggest that the interobserver iccs of the patientbased evaluation of covid-19 ranged between 0.939-1.000 (p < 0.05). as demonstrated in table 5 , the overall detection rate of affected lobes, ggo, consolidation, ggo with consolidation, crazy pattern, as well as linear opacities were 98.3%, 66.7%, 100%, 89.8%, 100%, and 84.6%, respectively. moreover, intermethod iccs of two image modalities ranged from 0.913-1.000 (p < 0.05). the total severity score quantified by ct and ute-mri were 2.65 and 2.65, respectively (icc = 0.980, p < 0.05). kendall's w statistic was utilized for quantifying the interobserver agreement of the lesion-based evaluation of image signs, which is listed in table 6 . table 6 demonstrates that kendall's w was between 0.894-1.000 (p < 0.05). lesion-based intermethod agreement of ute-mri and ct for assessing representative pulmonary findings of covid-19 are shown in table 7 and fig. 5 . a total of 100 lesions were included for the comparative analysis. the intermethod agreements for assessing the ggo, consolidation, ggo with consolidation, crazy paving pattern, pseudocavity, air bronchogram, axial location, and anteroposterior location were all statistically significant, with kappa values ranging from 0.332-1.000 (p < 0.05). notably, the intermethod agreement for evaluating the ggo, consolidation, ggo with consolidation, axial location, and anteroposterior location was determined as substantial or excellent (kappa: 0.649-1.000, p < 0.05). as shown in fig. 5 , the visual score differences between ute-mri and ct for assessing the different representative signs of covid-19 were small for most lesions. in detail, for assessing ggo, ggo with consolidation, consolidation, pseudocavity, crazy paving pattern, and air bronchogram, the proportion of lesions with a difference in visual score less than 1 were 95.0%, 77.0%, 98.0%, 94.0%, 98.0%, and 58.0%, respectively, which indicated there was a high intermethod concordance. the results of this study suggest that there was not only high concordance between ute-mri and ct in assessing the representative image findings of covid-19 but also similar image quality for two image modalities, which implies that ute-mri could have potential in aiding the diagnosis and surveillance of covid-19. the imaging findings of covid-19 by ct have been reported recently. 7, 8, 20 typical image manifestations have been described as multifocal ggo, patchy consolidation, crazy-paving pattern, air bronchogram, and multiple lesions with bilateral involvement. 21 our study suggests that the ggo with consolidation, ggo, and bilateral and multifocal involvement with periphery distribution were the most frequently occurring ct imaging signs. pathologically, the alveolar damage with alveolar and interstitial edema results in the appearance of ggo and crazy paving pattern. 12 as the alveoli are progressively filled with alveolar fibrinous exudate with hyaline membranes and reactive pneumocytes, ggo evolves into the appearance of consolidation. 12 chung et al indicated that 86% of patients had the image manifestations of ggo or consolidation. 10 similarly, li and xia indicated that the two principal signs of covid-19 were ggo and consolidation. 13 however, similar to some previous studies that reported that 5-8% of confirmed covid-19 patients were with pleural effusion 5, 8, 22 ; pleural effusion was less frequently observed in this study. it is known that the pulmonary application of mri has been severely limited by respiratory motion artifact, low proton density, and fast signal decay caused by short tissue t 2 *. 23 in this study, there was no significant difference in image quality for the two methods. the results presented above indicate that ute-mri was capable of providing image quality similar to ct when it was utilized for evaluating covid-19, which was concordant with several previous studies. 18, 24, 25 a pilot study carried out by delacoste et al showed that ute-mri had image quality similar to ct for quantifying lung nodule volumes. 24 moreover, another study revealed that submillimeter resolution could be achieved with ute-mri for assessing cystic fibrosis, which suggested that ute-mri holds promise in serving as an alternative to unenhanced ct. 25 the excellent performance of ute-mri for providing an image quality similar to ct was due to the following aspects. 1) respiratory-gated mri is effective at greatly reducing respiratory artifacts. 2) with the assistance of ultrashort echo time, ute-mri is capable of compromising the fast t 2 * signal decay, which improved the signal-to-noise ratio of images. 26 both the lesion-and patient-based comparative analysis showed that ute-mri has high concordance with ct for detecting typical pulmonary lesions, including ggo, consolidation, ggo with consolidation, axial location, anteroposterior location, the number of affected lobes, the number of crazy paving pattern, and the number of linear opacities. however, the lesion-based intermethod agreement for evaluating secondary signs such as air bronchogram, pseudocavity, and crazy paving pattern were between fair and moderate. the potential cause for this may be the lower image resolution of ute-mri as compared with ct. the above results are consistent with one previously reported study. 18 ohno et al suggested that the intermethod agreement of ute-mri and ct for assessing the representative pulmonary findings such as ggo, consolidation, nodule, fibrosis, and so on, were all between substantial and excellent (kappa value: 0.67-0.98). ute-mri also displayed an image quality similar to low-dose ct. due to the high concordance with ct for visualizing the representative pulmonary findings and an image quality similar to ct, ute-mri is considered valuable for evaluating the radiological findings of patients with various pulmonary parenchyma diseases. 18 given the short supply of rt-pcr kits, which was caused by the surge in confirmed covid-19 cases, especially in less-developed countries, and the high diagnostic sensitivity of image techniques, chest ct has been strongly encouraged for aiding prevention and control of covid-19. 13 however, biosafety concerns are warranted due to repeated exposure of x-rays over a short period of time in the hospital. one previous cohort study demonstrated that each patient with covid-19 underwent an average of four ct examinations within 16 days. 11 therefore, ute-mri may be a valuable technique for noninvasively evaluating covid-19. first, because of the strict inclusion criteria and the singleinstitution study, the sample size of this study was relatively small, which may have potential risk for leading to bias. second, the ct image acquisition and ute-mri image acquisition were respectively performed at end-inspiration and end-expiration. moreover, there was a time interval between ct and mri (no more than 2 days), which was established due to consideration of the clinical process. the above issues may affect the quantification of the intermethod agreement. with the continuous and rapid global spread of covid-19, imaging examination has been widely accepted as a useful tool for aiding the control of covid-19 patients. this study suggests that ute-mri may act as a potential alternative to ct for noninvasively evaluating covid-19. this study was funded by the novel coronavirus special research foundation of the shanghai municipal science and technology commission (no. 20441900600). coronavirus disease (covid-2019) situation report -104 nowcasting and forecasting the potential domestic and international spread of the 2019-ncov outbreak originating in wuhan, china: a modelling study correlation of chest ct and rt-pcr testing in coronavirus disease 2019 (covid-19) in china: a report of 1014 cases sensitivity of chest ct for covid-19: comparison to rt-pcr clinical features of patients infected with 2019 novel coronavirus in wuhan china epidemiological and clinical characteristics of 99 cases of 2019 novel coronavirus pneumonia in wuhan, china: a descriptive study chest ct manifestations of new coronavirus disease 2019 (covid-19): a pictorial review radiological findings from 81 patients with covid-19 pneumonia in wuhan, china: a descriptive study performance of radiologists in differentiating covid-19 from viral pneumonia on chest ct ct imaging features of 2019 novel coronavirus (2019-ncov) time course of lung changes on chest ct during recovery from 2019 novel coronavirus (covid-19) pneumonia pathological findings of covid-19 associated with acute respiratory distress syndrome coronavirus disease 2019 (covid-19): role of chest ct in diagnosis and management assessment of the radiation effects of cardiac ct angiography using protein and genetic biomarkers ultrashort echo time imaging of the lungs under high-frequency noninvasive ventilation: a new approach to lung imaging can texture analysis in ultrashort echo-time mri distinguish primary graft dysfunction from acute rejection in lung transplants? a multidimensional assessment in a mouse model iterative motioncompensation reconstruction ultra-short te (imoco ute) for highresolution free-breathing pulmonary mri pulmonary high-resolution ultrashort te mr imaging: comparison with thin-section standard-and low-dose computed tomography for the assessment of pulmonary parenchyma diseases differentiation between malignant and benign solitary pulmonary nodules: use of volume first-pass perfusion and combined with routine computed tomography chest ct findings in patients with corona virus disease 2019 and its relationship with clinical features coronavirus disease 2019 (covid-19): a perspective from china clinical and ct features of early-stage patients with covid-19: a retrospective analysis of imported cases in shanghai high-resolution lung mri with ultrashort-te: 1.5 or 3 tesla? mr volumetry of lung nodules: a pilot study lung morphology assessment of cystic fibrosis using mri with ultra-short echo time at submillimeter spatial resolution k-space water-fat decomposition with t2* estimation and multifrequency fat spectrum modeling for ultrashort echo time imaging key: cord-289861-i6bfuvq1 authors: macdonald-laurs, emma; koirala, archana; britton, philip n.; rawlinson, william; hiew, chee chung; mcrae, jocelynne; dale, russell c.; jones, cheryl; macartney, kristine; mcmullan, brendan; pillai, sekhar title: csf neopterin, a useful biomarker in children presenting with influenza associated encephalopathy? date: 2018-09-28 journal: eur j paediatr neurol doi: 10.1016/j.ejpn.2018.09.009 sha: doc_id: 289861 cord_uid: i6bfuvq1 purpose: neurological complications of influenza cause significant disease in children. central nervous system inflammation, the presumed mechanism of influenza-associated encephalopathy, is difficult to detect. characteristics of children presenting with severe neurological complications of influenza, and potential biomarkers of influenza-associated encephalopathy are described. methods: a multi-center, retrospective case-series of children with influenza and neurological complications during 2017 was performed. enrolled cases met criteria for influenza-associated encephalopathy or had status epilepticus. functional outcome at discharge was compared between groups using the modified rankin scale (mrs). results: there were 22 children with influenza studied of whom 11/22 had encephalopathy and 11/22 had status epilepticus. only one child had a documented influenza immunization. the biomarker csf neopterin was tested in 10/11 children with encephalopathy and was elevated in 8/10. mri was performed in all children with encephalopathy and was abnormal in 8 (73%). treatment of children with encephalopathy was with corticosteroids or intravenous immunoglobulin in 9/11 (82%). in all cases oseltamivir use was low (59%) while admission to the intensive care unit was frequent (14/22, 66%). clinical outcome at discharge was moderate to severe disability (mrs score > 2) in the majority of children with encephalopathy (7/11, 64%), including one child who died. children with status epilepticus recovered to near-baseline function in all cases. conclusion: raised csf neopterin was present in most cases of encephalopathy, and along with diffusion restriction on mri, is a useful diagnostic biomarker. lack of seasonal influenza vaccination represents a missed opportunity to prevent illness in children, including severe neurological disease. severe neurological complications from seasonal influenza, including influenza-associated encephalopathy/encephalitis (iae), cause considerable morbidity and mortality in healthy children, and those with pre-existing neurological disease. 1e3 recent estimates indicate the annual incidence of iae in australia is 2.8 per 1,000,000 in children under 14 years, with around 1% of hospitalized influenza cases associated with iae. 4 other populations show similar or higher incidence, with japan's annual incidence of iae recorded as 6e11/ 1,000,000. 2, 5 neurological complications attributed to influenza range from a mildly altered mental state, vertigo and brief febrile seizures to life threatening complications such as status epilepticus, meningitis, stroke, and demyelinating disease. 1 antiviral agents, predominantly neuraminidase inhibitors, and immunomodulatory treatments (corticosteroids, intravenous immunoglobulin), are used to treat patients with influenza-associated neurological disease but there is limited evidence on their efficacy. 6 while it is thought that more extensive changes on mri correlate with disease severity 7 there are no other available biomarkers that predict outcome. the australian influenza season typically occurs between july and october. the 2017 season saw the highest levels of influenza reported since the 2009 pandemic year. 8 the authors of this report noted an apparent increase in iae and other severe neurological complications during 2017. here, we describe the clinical presentation, laboratory testing, neuroimaging, treatment and short-term outcome of these cases. in addition, we observed elevated cerebrospinal fluid (csf) neopterin e a marker of central nervous system (cns) inflammation e amongst children with iae that has not previously described. we compared the frequency of iae during the 2017 influenza season with previously published incidence estimates. materials and methods we identified children aged 0e14 years, with evidence of influenza and associated severe neurological disease including status epilepticus or moderate to severe encephalopathy, admitted to two paediatric hospitals which comprise the sydney children's hospital network, the largest paediatric network in australia. cases were ascertained between april 1st and october 31st, 2017. at the children's hospital at westmead, cases were identified from those recruited under pre-existing surveillance studies: the australian childhood encephalitis study (ace), and the influenza complications network (flucan) surveillance study. 4, 9 at sydney children's hospital, children were identified from neurology consultation databases. children were included if they required hospital admission and consultation from a paediatric neurologist for a neurological complication or worsening of a pre-existing neurological condition due to proven influenza. all children included either presented with status epilepticus (for 30 min or longer) or reached level 2 diagnostic certainty on the brighton encephalopathy score. 10 children were excluded if: influenza was not confirmed, neurological symptoms were mild, hospital admission was not required, and when an alternative diagnosis could better explain the presentation. data were retrospectively collected from electronic medical records. we collected demographic data, presenting clinical characteristics, intensive care unit (icu) admission, and length of stay, laboratory results including csf testing, and influenza testing. csf analysis included cell count, protein, glucose, microscopy, lactate, oligoclonal bands, neopterin and influenza pcr. an elevated csf neopterin result was defined as >30 nmol/l. 11 electroencephalogram reports and brain magnetic resonance imaging (mri) (t2 weighted, flair and diffusion weighted imaging) were assessed by a neurologist (s.p.) and neuroradiologist (c.c.h.). the neuroradiologist was blinded to diagnosis during review of the mri. influenza was most commonly acutely diagnosed through the detection of influenza rna in respiratory samples. both hospitals used multiplex pcr assays (seegene, south korea) which detected up to 16 respiratory viruses. the assay has targets for both influenza a and b and was performed daily with a turnaround time of 1e2 days. at sydney children's hospital, the assay also had targets for subtypes of influenza a: h3 strains and the pandemic strain h1n1/09. when influenza serology was requested to diagnose a recent influenza illness, this was performed using a complement fixation assay (virion, germany). treatment given including oseltamivir, empiric aciclovir, or 3rd generation cephalosporins, ivig, corticosteroids, and e u r o p e a n j o u r n a l o f p a e d i a t r i c n e u r o l o g y 2 3 ( 2 0 1 9 ) 2 0 4 e2 1 3 plasmapheresis were recorded. time from admission to commencement of oseltamivir was recorded. each case was assigned a modified rankin scale (mrs) based on the examination at presentation and discharge from hospital. 12 the mrs ranges from 0 (no symptoms) to 6 (death). a poor outcome was an mrs score of >2 which indicates at least moderate disability requiring assistance. the relation between categorical variables was investigated using the two tailed fisher exact test. the mannewhitney u test was used to determine the relation between continuous variables. ethics approval was granted by the sydney children's hospitals network ethics committee (lnr/17/schn/497). twenty two children were included in this case series; 59% (13/22) were female. the median age at presentation was five years (range: 1.25e14 years). eight children (36%) had preexisting epilepsy and/or developmental delay. one child had an immunodeficiency (hypogammaglobulinemia) and receives monthly ivig. this child, who presented with status epilepticus, was the only child recorded as having received the seasonal influenza vaccination. eleven children (50%) met level 2 brighton criteria for encephalitis and were designated as influenza associated encephalopathy/encephalitis (iae). 10 two children with iae had previous episodes of acute disseminated encephalomyelitis (adem) with complete clinical and radiological recovery ( table 3 cases 1&2). one child had mosaic tetrasomy x, while another had epilepsy and developmental delay. the remaining 11 children in our series had status epilepticus. in contrast to the children with iae, over half of this group (n ¼ 6) had preexisting neurological disease including two children with refractory genetic epilepsies (dravet syndrome and cdkl5). the majority of children had a fever (82%) and two-thirds had respiratory symptoms. half presented with neurological symptoms within two days of onset of their influenza illness. sixteen children (73%) presented with an altered level of consciousness. seizures occurred in 19 children (86%) at any stage of illness and status epilepticus was frequent (n ¼ 17, 77%). other neurological findings at presentation were weakness (n ¼ 9, 41%), pyramidal signs (n ¼ 8, 36%), movement disorder (n ¼ 7, 32%) and ataxia (n ¼ 6, 27%). hallucinations, meningism, cranial neuropathy and pupillary changes were infrequent (<20%). the majority of children (n ¼ 18, 82%) had influenza a. of those sub-typed (n ¼ 8) half were h1 (2009) and half were h3. four children had other respiratory pathogens co-identified on npa (rhinovirus, coronavirus, mycoplasma pneumoniae). enterovirus was detected in the npa of one child but was absent in csf. one blood culture was positive for staphylococcus epidermidis, and this was assessed to be a contaminant. lumbar puncture was performed in 14 children where it was considered clinically indicated ( table 2) . of those who did not have a lumbar puncture performed most were children who presented with status epilepticus alone, usually with known pre-existing epilepsy. one case, with acute necrotising encephalopathy (ane), who was deemed to be too unwell to undergo a second lumbar puncture for measurement of neopterin. where sampled, csf showed pleocytosis and elevated protein in only a third (each n ¼ 5). influenza pcr on csf was positive in 1 of 5 children tested, in an immunocompetent previously well 10 year old. the csf neopterin was elevated in 9 of 11 children tested; in seven children it was considerably elevated ranging from 74 to 669 nmol/l (normal < 30 nmol/l), one had a borderline result (34 nmol/l). csf neopterin was measured in one child presenting with status epilepticus and was 31.75 nmol/l (borderline result). while most children with iae had a raised csf neopterin (8/10, 80%), only three had csf pleocytosis (10, 18, 19 cells/mm 3 ) and two had an elevated csf protein (0.7 g/l and 7.0 g/l). oligoclonal bands were measured on serum and/or csf in 10/11 children with iae and were not present in any. some children with iae had anti-neuronal antibodies testing performed on serum and/or csf, usually nmda and vgkc (table 3 ). these were negative apart from two cases with mildly elevated anti-thyroid antibodies. other routine laboratory data were normal or only mildly abnormal in most children (table 1) . mri brain was performed in 15 children and showed new abnormalities in eight (53%), all with iae. the common acute mri abnormalities were the presence of t2-flair hyperintensities, diffusion restriction (each, n ¼ 8), and gadolinium enhancement (n ¼ 4). the spectrum of radiological features are shown in fig. 1aei . diverse clinico-radiological syndromes were diagnosed including: ane (n ¼ 1), acute encephalopathy with biphasic seizures (aesd) (n ¼ 2), posterior reversible encephalopathy (pres) (n ¼ 1), hemiconvulsion hemiplegia syndrome (hhs) (n ¼ 1), and cerebellitis. genetic testing of ran-binding protein 2 (ranbp2) was performed in the child with ane (table 3 case 2) and the child who died from an ane-like illness ( table 3 , case 1). both were negative. one child who met criteria for iae was subsequently found to have a mutation in the polymerase gamma (polg) gene (table 3 , case 11). fourteen (66%) children were admitted to the icu and nine (41%) required mechanical ventilation. thirteen (59%) children received oseltamivir. median time to commencement of oseltamivir from presentation was 1 day (mean 5.6 days, iqr 0e9 days), but >3 days in five cases. two icu ventilated children were commenced on oseltamivir nine days after admission. in contrast, nineteen (86%) children were treated with a 3rd generation cephalosporin, while 14 (64%) received aciclovir. nineteen (86%) received anticonvulsants and 16 (73%) continued these on discharge. first-line e u r o p e a n j o u r n a l o f p a e d i a t r i c n e u r o l o g y 2 3 ( 2 0 1 9 ) 2 0 4 e2 1 3 immunomodulatory treatment (corticosteroids and/or ivig, plasmapheresis) was given to nine children with iae (corticosteroids (n ¼ 9), ivig (n ¼ 7) and plasmapheresis (n ¼ 1)) but none of those with status epilepticus alone. the median length of icu and hospital stay was four days (range 1e37) and 8 days (range 2e108 days) respectively. children with iae were more likely to have both longer hospital (mean 33.5 days vs 4.8 days; p ¼ 0.001) and picu admissions (mean 7.7 days vs 2 days; p ¼ 0.03) compared to children with status epilepticus. one child with iae died following an ane-like illness, although mri findings were atypical (table 3 , case 1). her post-mortem was inconclusive: showing generalised cerebral oedema and some features of acute hemorrhagic leucoencephalitis. ten out of 11 children with iae had an mrs score of 0 (normal) at baseline. at discharge from hospital 7/11 (64%) of children with iae had a higher in mrs score (mrs > 2; moderate disability) compared to those with status epilepticus. the change in mean mrs was significant between the two groups: children with iae had a change in mrs of 3.1 points while those in the status epilepticus group had a mean increase of mrs of 0.4 points (p-value: 0.001). nearly all children (7/8, 88%) with mri diffusion restriction had a poor outcome. the child with mri diffusion restriction and a good outcome had posterior reversible encephalopathy syndrome (pres). among the 7 children with iae and a considerably elevated neopterin, four had an mrs > 2 while three had mild deficits (mrs 1, 2 and 2). there was a mean increase in the mrs of 2.8 points the seven children with highly elevated csf neopterin (74e669 nmol/l). in this case series we observed two groups of children who presented with severe influenza related neurological disease. one group of children fulfilled criteria for iae, while the other group, most often with pre-existing neurological disease, presented with status epilepticus but otherwise did not fulfill criteria for iae. amongst cases of iae, elevated csf neopterin appeared to correlate with the presence of diffusion restriction on mri brain and adverse outcome. use of oseltamivir was infrequent among all cases, although use of antibiotics occurred in the majority. only one child had documented influenza vaccine, even amongst those with pre-existing neurological co-morbidity, despite the fact that this is recommended in australia. 13 influenza associated neurological complications are thought to occur due to an inflammatory or immunemediated response to influenza infection rather than direct viral invasion. 14,15 among those with iae we observed, similar to previous authors 2,6,16 that csf pleocytosis and detection of influenza in the csf occurred in a minority (n ¼ 5; 35%, and n ¼ 1/4; 25%). 3, 7, 17, 18 however csf neopterin, a biomarker of inflammation, was elevated in most children with iae (n ¼ 9, 81%). neopterin, a catabolic product of guanosine triphosphate (gtp), is synthesized by human macrophages upon stimulation from interferon gamma and can be measured in urine, serum and csf. 19 while serum neopterin levels are useful in the diagnosis and monitoring of systemic infectious or inflammatory diseases, such as hiv, 20 csf neopterin, reflecting intrathecal production by microglial cells, more accurately detects cns inflammatory diseases (infectious or immune mediated). 11, 19 a recent review assessing biomarkers of csf inflammation found, among clinically available tests, that csf neopterin performed better than the presence of oligoclonal bands or csf pleocytosis in detection of cns inflammation. 21 there is limited data regarding prognostically significant biomarkers in iae. pro-inflammatory cytokines may impair the blood brain barrier and induce apoptosis of neurons. 14 elevated cytokines such as interleukin-6 (il-6) and tumour necrosis factor alpha have been demonstrated in children with iae and correlates with poorer outcome. 14, 22, 23 testing csf il-6 outside the research setting is currently unavailable. clasmatodendrosis, abnormal morphological changes in astrocytes, occurring presumably due to the effect of proinflammatory cytokines, has recently been suggested to be a pathological feature of iae on autopsy. 24 clasmatodendrosis was found in the cerebral white matter, thalamus, corpus callosum, cerebellum, thalamus and hippocampus of children with iae and may correlate mri changes commonly seen. 24 previous authors have associated abnormalities on mri brain with poorer outcome. 7 in our cohort mri brain abnormalities were diverse and common, particularly diffusion restriction in the subcortical white matter. diffusion restriction correlated with a poor outcome, apart from in the child who had pres, and was associated with an elevated csf neopterin in most cases. further studies of iae are required to evaluate whether significant elevations of csf neopterin, particularly in combination with diffusion restriction and other mri changes, could predict short and long-term outcome. oseltamivir, a neuramidase inhibitor which prevents release of influenza virus from infected cells 25 has been shown to reduce influenza symptoms in otherwise healthy children by 29 h (95% ci 12e47 h,p ¼ 0.001). 26 only 59% (13 children) were treated with oseltamivir and there was a significant delay in commencement in 5 cases (>3 days in hospital). in contrast, empirical 3rd generation cephalosporin (86%) and aciclovir use (64%) was more frequent. this may be related to the perception among practitioners that antiinfluenza therapy has little benefit. we suggest in accordance with local guidelines, 8 that children with encephalitis should be empirically treated with oseltamivir during the influenza season (may to october). the evidence for use of immunotherapy (ivig, corticosteroids) in iae, is limited 27, 28 however, in our case series, most children with iae were treated with first-line immunotherapy with uncertain benefit. no serious side effects were reported. in 2017, the burden of influenza in australia (particularly the eastern states) was the highest seen since the 2009 pandemic. 8 based on iae incidence estimates published by britton et al. 2 from the 2013e15 influenza seasons in australia and the population coverage of our hospitals, we calculated that we would expect 5.2 (1.3e14.5) cases of iae in children (<14 years) per year. the iae case frequency observed in our cohort was twice the expected point estimate based on these previous incidence estimates but within the 95% confidence interval, 2 and so contribute to validating the estimates from britton et al. 2 the short-term outcome of our cohort, particularly those with iae, was alarming with 64% having a poor outcome. while there was a significant rate of icu admission among the group of children with status epilepticus (45%) this was not as high as children with iae (82%) and, most often, non-iae children did not experience a significant change in their mrs. this supports previous observations that survivors of iae during the 2009 h1n1 pandemic, and in more recent nonpandemic influenza seasons in australia, experienced significant ongoing disability. 29, 30 we have previously shown in a large retrospective encephalitis cohort study that icu admission, mri diffusion restriction and status epilepticus and were risk factors for a long-term abnormal outcome. 31 these risk factors were common (82%, 73%, 45%) in children with iae from our cohort. the medium and long-term outcome in our cohort should be assessed including formal neuropsychological testing. further research is required to understand and modulate the cns inflammatory cascade present in iae in order to modulate long term neurodisability. the overall influenza immunisation rate during 2017 in australia was low at 33%, 32 however a recently observed rate of vaccine receipt among children was even lower at 17.1%. 33 four age-specific quadrivalent influenza vaccines containing two strains of influenza a (h1n1 [michigan] and h3n2 [hong kong]) and two strains of influenza b (brisbane and phuket) were available in 2017. children older than six months were eligible to be vaccinated and the vaccine was provided free to children with neurological disease. 34 in our cohort just one child had a documented influenza vaccination, although a third of children were eligible for free immunisation and the remainder could have received an immunisation at the cost of around $20e50 aud. we emphasise that the severe syndromes and adverse outcomes observed here should be considered preventable. following high rates of influenza related morbidity in 2017(including these cases), new south wales and other australian states have introduced universal funded seasonal influenza immunisation to all children aged 6 months to 5 years. 35 our series has limitations. we describe children with severe influenza-associated neurological complications but did not include children with mild neurological complications. children with pre-existing epilepsy may not have always been tested for influenza and may be under-represented. the collection of clinical data was retrospective, and some electronic data were incomplete. seasonal influenza immunisation status was not always clearly recorded, although we reviewed the australian immunisation register to verify vaccination status where possible. influenza sub-typing from npa samples and csf influenza pcr testing was not routinely performed. in the se group, csf studies, including csf neopterin were performed infrequently and mri brain infrequently requested. due to this we were unable to use this group as a direct control for the finding of elevated csf neopterin the iae group. serial csf neopterin to assess treatment and clinical progress were not performed. this is the first series to demonstrate that elevation of csf neopterin, a marker of cns inflammation, occurs commonly in children with iae. csf neopterin may be a useful diagnostic marker for iae while its role as a prognostic marker e u r o p e a n j o u r n a l o f p a e d i a t r i c n e u r o l o g y 2 3 ( 2 0 1 9 ) 2 0 4 e2 1 3 requires further evaluation. mri diffusion restriction was associated with a poor outcome in iae. short-term outcomes of children with neurological complications of influenza, especially within the iae group, were alarming, with nearly two-thirds of children having a poor outcome despite receipt of icu support, anticonvulsants, first-line immunotherapy and, in some, anti-viral treatment. given the severity of influenza associated neurological complications, we recommend a "treat and test" approach to the use of oseltamivir in children presenting with acute encephalopathy/encephalitis during the influenza season. finally, seasonal influenza vaccination should be universally provided to children and those at risk of severe influenza, with better education and awareness to increase uptake in the paediatric population. this research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit 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paediatric active enhanced disease surveillance: a new surveillance system for australia encephalitis, myelitis, and acute disseminated encephalomyelitis (adem): case definitions and guidelines for collection, analysis, and presentation of immunization safety data cerebrospinal fluid neopterin in paediatric neurology: a marker of active central nervous system inflammation recovery of motor function after stroke atagi) atagoi. the australian immunisation handbook australian government department of health acute encephalopathy and encephalitis caused by influenza virus infection evidence for influenza virus cns invasion along the olfactory route in an immunocompromised infant neurological and muscular manifestations associated with influenza b infection in children influenza virus and cns manifestations central nervous system manifestations in pediatric patients with influenza a h1n1 infection during the 2009 pandemic neopterin in the diagnosis and monitoring of infectious diseases csf fluid neopterin: an informative biomarker of cns immune activity in hiv-1 infection utility of csf cytokine/chemokines as markers of active intrathecal inflammation: comparison of demyelinating, anti-nmdar and enteroviral encephalitis h1n1 encephalitis with malignant edema and review of neurologic complications from influenza influenza-associated neurological complications clasmatodendrosis is associated with dendritic spines and does not represent autophagic astrocyte death in influenzaassociated encephalopathy prevention and treatment of influenza oseltamivir for influenza in adults and children: systematic review of clinical study reports and summary of regulatory comments immunomodulatory therapies in neurologic critical care intravenous immunoglobulin for the treatment of childhood encephalitis national survey of pandemic influenza a (h1n1) 2009-associated encephalopathy in japanese children influenza-associated encephalitis/encephalopathy identified by the australian childhood encephalitis study 2013e2015 infectious and autoantibody-associated encephalitis: clinical features and long-term outcome influenza season in australia. a summary from the national influenza surveillance committee influenza epidemiology, vaccine coverage and vaccine effectiveness in children admitted to sentinel australian hospitals in 2017: results from the paeds-flucan collaboration influenza vaccine effectiveness against pediatric deaths seasonal influenza vaccination the authors have stated that they had no interests, which might be perceived as posing a conflict or bias. this manuscript has been contributed to, seen, and approved by all the authors. all the authors fulfill the authorship credit requirements. no honorarium grant or other form of payment was received for the preparation of this manuscript. supplementary data to this article can be found online at https://doi.org/10.1016/j.ejpn.2018.09.009. r e f e r e n c e s key: cord-011990-feqqx32n authors: carminati, marco; fiorini, carlo title: challenges for microelectronics in non-invasive medical diagnostics date: 2020-06-29 journal: sensors (basel) doi: 10.3390/s20133636 sha: doc_id: 11990 cord_uid: feqqx32n microelectronics is emerging, sometimes with changing fortunes, as a key enabling technology in diagnostics. this paper reviews some recent results and technical challenges which still need to be addressed in terms of the design of cmos analog application specific integrated circuits (asics) and their integration in the surrounding systems, in order to consolidate this technological paradigm. open issues are discussed from two, apparently distant but complementary, points of view: micro-analytical devices, combining microfluidics with affinity bio-sensing, and gamma cameras for simultaneous multi-modal imaging, namely scintigraphy and magnetic resonance imaging (mri). the role of integrated circuits is central in both application domains. in portable analytical platforms, asics offer miniaturization and tackle the noise/power dissipation trade-off. the integration of cmos chips with microfluidics poses multiple open technological issues. in multi-modal imaging, now that the compatibility of the acquisition chains (thousands of silicon photo-multipliers channels) of gamma detectors with tesla-level magnetic fields has been demonstrated, other development directions, enabled by microelectronics, can be envisioned in particular for single-photon emission tomography (spect): a faster and simplified operation, for instance, to allow transportable applications (bed-side) and hardware pre-processing that reduces the number of output signals and the image reconstruction time. the impact of application specific integrated circuits (asics), in particular, of cmos analog front-end interfaces for solid-state sensors and detectors, differs significantly among various application areas. for example, the field of high-energy and particle physics has been heavily reliant on integrated circuits for the readout of the detectors and parallel processing of signals for decades [1] . instead, different from experimental physics, whose advancements are often constrained by the performance of electronics and instrumentation, in the field of bio-medicine, the role of microelectronics appears less consolidated nor univocal. in fact, despite a large penetration of micro-fabrication techniques in this field, and a considerable volume of publications, asics are rarely pivotal in the success of micro-analytical devices, especially from a commercial point of view. in this brief tutorial review, we focus on non-invasive medical diagnostics and discuss some challenges for the future development of integrated electronics, with reference to diagnostics in particular. non-invasive medical diagnostics comprise two complementary approaches: (i) imaging internal organs by means of energy penetrating through the skin and tissues, and (ii) taking out of the body a liquid sample for bio-chemical analysis ( figure 1 ). non-invasive imaging can be performed by the main advantage offered by the deployment of cmos asics in micro-analytical devices is miniaturization. massively parallel readout systems (with thousands of channels, such as 1024 [3] or 2048 [4] ) can be squeezed into a chip footprint of a few millimeters inside. the miniaturization of electronics matches the concurrent miniaturization of fluidics (locs handle volumes of samples in the microliter range) and of micro-machined transducers and electrodes. the main challenges which still need to be addressed in this area can be grouped into two classes: (i) at the circuit level (ii) at the level of packaging and interfaces. at the circuit level, one consolidating trend is the reduction in power dissipation, both for thermal issues, critical in high-density chips, as well as the increase in the battery lifetime in the case of portable (and implantable) applications. in order to reduce the power dissipation in analog front-ends, different approaches can be adopted. amplifiers can be shared among different circuit blocks [5] or stacked to re-use the same bias current [6] . individual ac-coupled transistors can be stacked [7] and self-biased [8] . analog processing (signal shaping, feature extraction) can be tailored to the type of signal and the first approach is mostly based on sophisticated and expensive scanners, which require special facilities, the handling of radioactive material and skilled personnel, thus, are almost exclusively located in hospitals. the second approach, instead, is nowadays mostly pursued within the lab-on-a-chip (loc) paradigm, aiming at the realization of portable and automatic micro-analytical platforms. the main advantage offered by the deployment of cmos asics in micro-analytical devices is miniaturization. massively parallel readout systems (with thousands of channels, such as 1024 [3] or 2048 [4] ) can be squeezed into a chip footprint of a few millimeters inside. the miniaturization of electronics matches the concurrent miniaturization of fluidics (locs handle volumes of samples in the microliter range) and of micro-machined transducers and electrodes. the main challenges which still need to be addressed in this area can be grouped into two classes: (i) at the circuit level (ii) at the level of packaging and interfaces. at the circuit level, one consolidating trend is the reduction in power dissipation, both for thermal issues, critical in high-density chips, as well as the increase in the battery lifetime in the case of portable (and implantable) applications. in order to reduce the power dissipation in analog front-ends, different approaches can be adopted. amplifiers can be shared among different circuit sensors 2020, 20, 3636 3 of 14 blocks [5] or stacked to re-use the same bias current [6] . individual ac-coupled transistors can be stacked [7] and self-biased [8] . analog processing (signal shaping, feature extraction) can be tailored to the type of signal and communication channel [9] and it is generally preferred to fpga-based digital elaboration [10] . in order to reduce the energy consumption in data transmission, analog compression [11] and pulse-coded communication can be adopted [12] . a low-power design is typically opposite to a low-noise design, for instance, in terms of the flicker noise of mosfets, but is clearly fundamental in pushing down the limit of detection (lod) of target molecules. in order to analyze the strategies and compromises in noise minimization, we consider the case of current amplifiers. their application in bio-sensing is ubiquitous, spanning from electrochemical detection (where the charge is exchanged between the electrodes and redox molecules in the solution, figure 2a ) to optical detection (where the current is photo-generated in the photo-detector). as shown in figure 2e , the input-referred current noise of a classical transimpedance amplifier (tia) is given by the sum of three contributions: the thermal noise of the feedback resistor (r f ), the input-equivalent current noise of the amplifier (i n ) and its voltage noise (v n ). the latter becomes the dominant term in the total noise spectral density at high frequencies [13] . the voltage noise produces an input noise current proportional to the value of the total capacitance (c tot ) connected at the input. c tot includes the feedback capacitance, the amplifier input capacitance, the sensor capacitance and the parasitic capacitance of the connection between the sensor/detector and the amplifier input. evolutions of the basic tia scheme, such as integrator-differentiator configurations, enable the combination of low-noise with extended detection bandwidth [13] . additionally, for integrators (i.e., charge amplifiers) the minimization of the c tot is crucial. sensors 2020, 20, 3636 3 of 15 communication channel [9] and it is generally preferred to fpga-based digital elaboration [10] . in order to reduce the energy consumption in data transmission, analog compression [11] and pulsecoded communication can be adopted [12] . a low-power design is typically opposite to a low-noise design, for instance, in terms of the flicker noise of mosfets, but is clearly fundamental in pushing down the limit of detection (lod) of target molecules. in order to analyze the strategies and compromises in noise minimization, we consider the case of current amplifiers. their application in bio-sensing is ubiquitous, spanning from electrochemical detection (where the charge is exchanged between the electrodes and redox molecules in the solution, figure 2a ) to optical detection (where the current is photo-generated in the photo-detector). as shown in figure 2e , the input-referred current noise of a classical transimpedance amplifier (tia) is given by the sum of three contributions: the thermal noise of the feedback resistor (rf), the input-equivalent current noise of the amplifier (in) and its voltage noise (vn). the latter becomes the dominant term in the total noise spectral density at high frequencies [13] . the voltage noise produces an input noise current proportional to the value of the total capacitance (ctot) connected at the input. ctot includes the feedback capacitance, the amplifier input capacitance, the sensor capacitance and the parasitic capacitance of the connection between the sensor/detector and the amplifier input. evolutions of the basic tia scheme, such as integrator-differentiator configurations, enable the combination of lownoise with extended detection bandwidth [13] . additionally, for integrators (i.e., charge amplifiers) the minimization of the ctot is crucial. in order to minimize this noise contribution, three strategies can be adopted: (i) canceling the ctot with an inductor, (ii) reducing the sensor capacitance, and (iii) reducing the parasitic capacitance. it has been shown that by placing an inductor parallel to the ctot it is possible to improve the noise performance (of about one order of magnitude) thanks to the resonance [14] . this approach has two main limitations: (i) the enhancements are limited by the quality factor of the inductor, and (ii) the noise reduction takes place only in a narrow bandwidth around the resonance frequency (tens of mhz), thus being suitable only for impedance sensing at a fixed frequency. a very relevant design guideline is the reduction in the capacitance associated with the sensor geometry, typically an electrode collecting the signal charge, whose area should be minimized. of course, very often, the amount of collected charge is also proportional to the sensor areas, thus, in order to maximize the signal-to-noise ratio (snr), noise should be minimized while preserving the signal amplitude. in the case of electrochemical sensors, despite a decrease in the working electrode area, the capture of molecules by means of this electrode should be simultaneously enhanced, with respect to passive diffusion, by means of active solutions, such as magnetic, electrophoretic, dielectrophoretic, thermal and fluid-dynamic ones. this approach proved to be very successful in the in order to minimize this noise contribution, three strategies can be adopted: (i) canceling the c tot with an inductor, (ii) reducing the sensor capacitance, and (iii) reducing the parasitic capacitance. it has been shown that by placing an inductor parallel to the c tot it is possible to improve the noise performance (of about one order of magnitude) thanks to the resonance [14] . this approach has two main limitations: (i) the enhancements are limited by the quality factor of the inductor, and (ii) the noise reduction takes place only in a narrow bandwidth around the resonance frequency (tens of mhz), thus being suitable only for impedance sensing at a fixed frequency. a very relevant design guideline is the reduction in the capacitance associated with the sensor geometry, typically an electrode collecting the signal charge, whose area should be minimized. of course, very often, the amount of collected charge is also proportional to the sensor areas, thus, in order to maximize the signal-to-noise ratio (snr), noise should be minimized while preserving the signal amplitude. in the case of electrochemical sensors, despite a decrease in the working electrode area, the capture of molecules by means of this electrode should be simultaneously enhanced, with respect to passive diffusion, by means of active solutions, such as magnetic, electrophoretic, dielectrophoretic, thermal and fluid-dynamic ones. this approach proved to be very successful in the field of radiation detection, where the silicon drift detector (sdd) outperformed other solid-state detectors in terms of noise thanks to properly-shaped electric fields, which force the collection of the generated charge (across a wide depleted detection area) to drift towards a miniaturized anode [15] . another drawback of shrinking the electrode area is the increase in the access impedance in the case of ac-coupled sensing, both in solid-state [16] and biological applications, such as impedance flow cytometry [17] . another approach to reduce the sensor capacitance is the repartition of a large sensor area into n smaller ones, each one connected to an independent readout chain. in this way, the individual capacitance of each sensor is reduced by a factor of n. if the output signals of all n parallel chains are then summed, the signal will increase by a factor of n (i.e., it will recover a value equivalent to the case of a large area), while the noise (summed in power, since it is uncorrelated among chains) will only increase by √ n, thus leading to an improvement of the snr of √ n. for example, this has been used in the readout of silicon photo-multiplers (sipm) [18] . this interesting solution implies a growth in power and area occupation due to the multiplication of the readout chains. furthermore, it is important to control the layout of connection between the sensor and the front-end: while the sensors capacitance decreases by a factor of n, the parasitic capacitance of the interconnection typically does not scale down and can become the dominant term. finally, in order to fully profit from miniaturization and to preserve the detection performance by minimizing the length (and parasitics) of the interconnection, the transducers and the readout chip should be closely coupled and, when possible, monolithically integrated. from the noise point of view, the micro-sized sensor-on-chip solution is optimal [19] . figure 3 shows a broad range of bio-sensing technologies that have been integrated on cmos platforms: electrical and electrochemical, photonic, magnetic, micromechanical and nano-fabricated. their position along the bottom horizontal axis qualitatively highlights the increasing technological complexity of integration on a cmos substrate. rf electronics and on-chip coils even enable single-chip nmr and electron spin resonance detectors [20] , targeting, in particular, point-of-care diagnostics [21] . several efforts have been undertaken to improve the compatibility of bio-sensing with cmos platforms: one example is the reduction in the temperature of fabrication of silicon nano wires (down to 200 • c), thus making them compatible with the standard cmos process [22] . field of radiation detection, where the silicon drift detector (sdd) outperformed other solid-state detectors in terms of noise thanks to properly-shaped electric fields, which force the collection of the generated charge (across a wide depleted detection area) to drift towards a miniaturized anode [15] . another drawback of shrinking the electrode area is the increase in the access impedance in the case of ac-coupled sensing, both in solid-state [16] and biological applications, such as impedance flow cytometry [17] . another approach to reduce the sensor capacitance is the repartition of a large sensor area into n smaller ones, each one connected to an independent readout chain. in this way, the individual capacitance of each sensor is reduced by a factor of n. if the output signals of all n parallel chains are then summed, the signal will increase by a factor of n (i.e., it will recover a value equivalent to the case of a large area), while the noise (summed in power, since it is uncorrelated among chains) will only increase by √n, thus leading to an improvement of the snr of √n. for example, this has been used in the readout of silicon photo-multiplers (sipm) [18] . this interesting solution implies a growth in power and area occupation due to the multiplication of the readout chains. furthermore, it is important to control the layout of connection between the sensor and the front-end: while the sensors capacitance decreases by a factor of n, the parasitic capacitance of the interconnection typically does not scale down and can become the dominant term. finally, in order to fully profit from miniaturization and to preserve the detection performance by minimizing the length (and parasitics) of the interconnection, the transducers and the readout chip should be closely coupled and, when possible, monolithically integrated. from the noise point of view, the micro-sized sensor-on-chip solution is optimal [19] . figure 3 shows a broad range of biosensing technologies that have been integrated on cmos platforms: electrical and electrochemical, photonic, magnetic, micromechanical and nano-fabricated. their position along the bottom horizontal axis qualitatively highlights the increasing technological complexity of integration on a cmos substrate. rf electronics and on-chip coils even enable single-chip nmr and electron spin resonance detectors [20] , targeting, in particular, point-of-care diagnostics [21] . several efforts have been undertaken to improve the compatibility of bio-sensing with cmos platforms: one example is the reduction in the temperature of fabrication of silicon nano wires (down to 200 °c), thus making them compatible with the standard cmos process [22] . in the case of electrochemical sensing, the "electrode-on-chip" solution is apparently straightforward. the highest metal layer, commonly exposed to realize the bonding pads, can be used for patterning sensing electrodes. while this is simple in dry applications [23] , it is more complicated in the case of bio-chemical sensing in liquid for two reasons: (i) materials and (ii) morphology. in fact, the metals commonly adopted to realize this metallization (aluminum and copper) are not suitable for electrochemical sensing, where noble metals (such as gold, silver and platinum) are preferred in the case of electrochemical sensing, the "electrode-on-chip" solution is apparently straightforward. the highest metal layer, commonly exposed to realize the bonding pads, can be used for patterning sensing electrodes. while this is simple in dry applications [23] , it is more complicated in the case of bio-chemical sensing in liquid for two reasons: (i) materials and (ii) morphology. in fact, the metals commonly adopted to realize this metallization (aluminum and copper) are not suitable for electrochemical sensing, where noble metals (such as gold, silver and platinum) are preferred thanks to a stable (i.e., minimally reactive) behavior. consequently, post-cmos metallization is performed to electrochemically grow the proper metal on top of the working electrode. the morphology of the pad presents two additional issues: the roughness of the inner surface (even when avoiding the diamond of vias, visible in figure 4a , typically realized to strengthen the stack of metal layer for wire bonding) is not negligible (~100 nm) and this inner area is surrounded by a 2 µm-tall shoulder due to the lifting of the top passivation layer (sin) on the metal. both issues can be solved, for instance, by evaporating a sensing area that extends on the side of the pad (on the flat nitride capping) as recently proposed [3] . sensors 2020, 20, 3636 5 of 15 thanks to a stable (i.e., minimally reactive) behavior. consequently, post-cmos metallization is performed to electrochemically grow the proper metal on top of the working electrode. the morphology of the pad presents two additional issues: the roughness of the inner surface (even when avoiding the diamond of vias, visible in figure 4a , typically realized to strengthen the stack of metal layer for wire bonding) is not negligible (~100 nm) and this inner area is surrounded by a 2 µm-tall shoulder due to the lifting of the top passivation layer (sin) on the metal. both issues can be solved, for instance, by evaporating a sensing area that extends on the side of the pad (on the flat nitride capping) as recently proposed [3] . to quantify the improvement in noise performance enabled by on-chip sensing, different figures of merit (fom) can be adopted. for instance, in capacitive resolution, a δc-fom can be defined at the input-referred noise spectral density in zf/√hz, normalized on the amplitude of the forcing ac voltage signal. for dry sensing (detection of micro-particles in the air), the δc-fom improved from 1100 zf·v/√hz of a discrete-component implementation to 34 zf·v/√hz of a monolithic integration [23] . other figures of merit can include the power dissipation (tens to hundreds of mw for this application), area occupation, maximum operating frequency and detection bandwidth [19] . for measurements in liquid, we can consider the current resolution: in nano-pore current sensing, the current resolution (for a 100 khz bandwidth) improves from 21.8 parms of the state-of-the-art discrete amplifier (with a miniaturized and cooled head-stage and integrator front-end with periodic reset) down to 12.9 parms with an integrated amplifier and on-chip electrode [24] . taking as an example cmos capacitive sensors, a steady improvement of the δc-fom down to 1 zf·v/√hz has been observed in the last decade [19, 25] , where the capacitance resolution has moved from the attofarad to the zeptofarad domains, achieved by miniaturization (parasitics reductions) and differential sensing [26] in the mhz range and leveraging resonance in the ghz range [27] . beyond the circuital and morphological challenges illustrated above, a pervasive diffusion of asics for biochemical detection is still hampered by additional technological challenges which include packaging, patternable passivation and the fluidic interface with the off-chip world. different from all other application areas of microelectronics, here packaging has to protect the chip and its electrical interconnection (such as bonding wires) from environmental agents such as dust and humidity, while allowing the liquid sample to contact only specific areas of the chip with a spatial accuracy down to fractions of the pad size, i.e., to tens of micrometers ( figure 5 ). packaging has to be reliable (to avoid leakage and aging during the device lifetime), bio-compatible (to avoid contamination of the biological sample) and cost-effective (since a very sophisticated packaging easily becomes the most expensive step of fabrication, as witnessed, for instance, in mems [28] and silicon photonics [29] ). coupling a cmos asic to a microfluidic device is often complicated by the difference of materials (silicon vs. plastics, different metals) and disparity of sizes (mm-sized cmos to quantify the improvement in noise performance enabled by on-chip sensing, different figures of merit (fom) can be adopted. for instance, in capacitive resolution, a ∆c-fom can be defined at the input-referred noise spectral density in zf/ hz, normalized on the amplitude of the forcing ac voltage signal. for dry sensing (detection of micro-particles in the air), the ∆c-fom improved from 1100 zf·v/ hz of a discrete-component implementation to 34 zf·v/ √ hz of a monolithic integration [23] . other figures of merit can include the power dissipation (tens to hundreds of mw for this application), area occupation, maximum operating frequency and detection bandwidth [19] . for measurements in liquid, we can consider the current resolution: in nano-pore current sensing, the current resolution (for a 100 khz bandwidth) improves from 21.8 pa rms of the state-of-the-art discrete amplifier (with a miniaturized and cooled head-stage and integrator front-end with periodic reset) down to 12.9 pa rms with an integrated amplifier and on-chip electrode [24] . taking as an example cmos capacitive sensors, a steady improvement of the ∆c-fom down to 1 zf·v/ hz has been observed in the last decade [19, 25] , where the capacitance resolution has moved from the attofarad to the zeptofarad domains, achieved by miniaturization (parasitics reductions) and differential sensing [26] in the mhz range and leveraging resonance in the ghz range [27] . beyond the circuital and morphological challenges illustrated above, a pervasive diffusion of asics for biochemical detection is still hampered by additional technological challenges which include packaging, patternable passivation and the fluidic interface with the off-chip world. different from all other application areas of microelectronics, here packaging has to protect the chip and its electrical interconnection (such as bonding wires) from environmental agents such as dust and humidity, while allowing the liquid sample to contact only specific areas of the chip with a spatial accuracy down to fractions of the pad size, i.e., to tens of micrometers ( figure 5 ). packaging has to be reliable (to avoid leakage and aging during the device lifetime), bio-compatible (to avoid contamination of the biological sample) and cost-effective (since a very sophisticated packaging easily becomes the most expensive step of fabrication, as witnessed, for instance, in mems [28] and silicon photonics [29] ). coupling a cmos asic to a microfluidic device is often complicated by the difference of materials (silicon vs. plastics, different metals) and disparity of sizes (mm-sized cmos chips vs. cm-sized fluidics) [30] . a high-density placement of electrical and fluidic interconnect is typically achieved with a photo-patternable material deposited from the liquid phase, conformally covering bonding wires, which is cured and selectively removed to expose only the sensing electrode. the main challenge of this powerful approach lies in the preservation of the electrode surface cleanness (at the atomic level since the electrical double layer interfacial capacitance depends on the first ionic layer) after dry or wet etching of the passivation. a systematic review of the possible coupling strategies is reported here [31] . sophisticated examples include both clean-room based post-cmos approaches, achieving, for instance, planarization, gap filling of the cmos chip embedded in a die carrier and coupled to taper joints [30] , as well as lab-based solutions such as direct writing of a sacrificial channel [25] . sensors 2020, 20, 3636 6 of 15 chips vs. cm-sized fluidics) [30] . a high-density placement of electrical and fluidic interconnect is typically achieved with a photo-patternable material deposited from the liquid phase, conformally covering bonding wires, which is cured and selectively removed to expose only the sensing electrode. the main challenge of this powerful approach lies in the preservation of the electrode surface cleanness (at the atomic level since the electrical double layer interfacial capacitance depends on the first ionic layer) after dry or wet etching of the passivation. a systematic review of the possible coupling strategies is reported here [31] . sophisticated examples include both clean-room based post-cmos approaches, achieving, for instance, planarization, gap filling of the cmos chip embedded in a die carrier and coupled to taper joints [30] , as well as lab-based solutions such as direct writing of a sacrificial channel [25] . in order to achieve cost-effectiveness, all these challenges should be addressed in a way compatible (in terms of production time and scalability) with large-volume industrial manufacturing. for this reason, polydimethylsiloxane (pdms), which is the workhorse elastomer solution for laboratory-grade microfluidics, fabricated by means of replica molding and which offers excellent bio-compatibility, can hardly become a well-established industrial solution due to the cost and delicate steps in the fabrication process such as degassing and peel-off. other polymers offering similar rapid prototyping versatility but a better resistance to chemicals and operation at high pressures have been identified [32] . additive manufacturing (3d printing of plastic filaments or resins) [33] , the micro-milling of rigid plastics (such as polycarbonate and pmma) and laser ablation are all promising techniques for the fabrication of microchannels that, unfortunately, are all characterized by the sequential operation of a single machining head, not easily scalable to mass production. an emerging solution that can better suit the industrial manufacturability of biochips is represented by photo-patternable dry resists, such as sinr [34] . finally, the standardization of the design flow and of fluidic components and interconnects (similar to that of an electronic design) is still a chimera in this field and should be pursued in order to achieve market success in genomics and real-time, as well as point-of-care diagnostics, with the same effort that was devoted to the integration of the sample preparation on-chip. in order to achieve cost-effectiveness, all these challenges should be addressed in a way compatible (in terms of production time and scalability) with large-volume industrial manufacturing. for this reason, polydimethylsiloxane (pdms), which is the workhorse elastomer solution for laboratory-grade microfluidics, fabricated by means of replica molding and which offers excellent bio-compatibility, can hardly become a well-established industrial solution due to the cost and delicate steps in the fabrication process such as degassing and peel-off. other polymers offering similar rapid prototyping versatility but a better resistance to chemicals and operation at high pressures have been identified [32] . additive manufacturing (3d printing of plastic filaments or resins) [33] , the micro-milling of rigid plastics (such as polycarbonate and pmma) and laser ablation are all promising techniques for the fabrication of microchannels that, unfortunately, are all characterized by the sequential operation of a single machining head, not easily scalable to mass production. an emerging solution that can better suit the industrial manufacturability of biochips is represented by photo-patternable dry resists, such as sinr [34] . finally, the standardization of the design flow and of fluidic components and interconnects (similar to that of an electronic design) is still a chimera in this field and should be pursued in order to achieve market success in genomics and real-time, as well as point-of-care diagnostics, with the same effort that was devoted to the integration of the sample preparation on-chip. when the target molecule in the patient is not accessible from a fluid sample, nuclear imaging techniques with molecular selectivity are needed. the combination of different imaging techniques, offering complementary information, is becoming a consolidated trend in radiography. typically, molecule-specific techniques (pet and spect) are combined with those providing anatomic information (such as ct and mri) in order to register (i.e., align/overlay) both images (simultaneously acquired) and correctly locate the pathology in the body, as illustrated in figure 6. when the target molecule in the patient is not accessible from a fluid sample, nuclear imaging techniques with molecular selectivity are needed. the combination of different imaging techniques, offering complementary information, is becoming a consolidated trend in radiography. typically, molecule-specific techniques (pet and spect) are combined with those providing anatomic information (such as ct and mri) in order to register (i.e., align/overlay) both images (simultaneously acquired) and correctly locate the pathology in the body, as illustrated in figure 6 . the main challenge posed by simultaneous imaging is clearly the mutual compatibility between the two scanning systems. secondary challenges are the complexity and cost, to be compared with the clinical advantages (i.e., benefits for patients and clinicians, especially in terms of improved diagnostics and insight). today, the adoption of integrated circuits is limited to the front-end of the acquisition chain in the gamma cameras pixels. we foresee that future breakthroughs in this field can be enabled by augmenting the range of functions implemented in silicon. pet is a nuclear imaging technique that relies on the emission of a pair of counter-propagating gamma photons (at an energy of 511 kev), generated by the annihilation of a positron with an electron [35] . the positron is produced by the decay of a radiotracer and this recombination takes places in the body within a short distance (~1 mm) from the radioligand. the major trade-off governing the performance of pet is between measurement time, sensitivity and injected activity [36] . there are two main development avenues. one is the extension of the axial field of view in order to improve the solid angle capturing gamma photons. recently, the first results of a total-body pet have been reported [37] . the explorer systems feature an axial field of view of 194 cm, extending along the whole body, and it is fully covered by 53,760 detection channels producing ~1 tb of data per scan. thanks to a 40-fold increase in the signal with respect to traditional clinical scanners (capturing only a few percent of the emitted photons), the same snr can be achieved by reducing the activity injected into the patient or by reducing the measurement time down to seconds. the latter result would lead to an unprecedented capability of tracking fast dynamics. clearly, asics are pivotal in handling tens of thousands of channels and reducing the burden of data processing by implementing data preprocessing on-chip. the main challenge posed by simultaneous imaging is clearly the mutual compatibility between the two scanning systems. secondary challenges are the complexity and cost, to be compared with the clinical advantages (i.e., benefits for patients and clinicians, especially in terms of improved diagnostics and insight). today, the adoption of integrated circuits is limited to the front-end of the acquisition chain in the gamma cameras pixels. we foresee that future breakthroughs in this field can be enabled by augmenting the range of functions implemented in silicon. pet is a nuclear imaging technique that relies on the emission of a pair of counter-propagating gamma photons (at an energy of 511 kev), generated by the annihilation of a positron with an electron [35] . the positron is produced by the decay of a radiotracer and this recombination takes places in the body within a short distance (~1 mm) from the radioligand. the major trade-off governing the performance of pet is between measurement time, sensitivity and injected activity [36] . there are two main development avenues. one is the extension of the axial field of view in order to improve the solid angle capturing gamma photons. recently, the first results of a total-body pet have been reported [37] . the explorer systems feature an axial field of view of 194 cm, extending along the whole body, and it is fully covered by 53,760 detection channels producing~1 tb of data per scan. thanks to a 40-fold increase in the signal with respect to traditional clinical scanners (capturing only a few percent of the emitted photons), the same snr can be achieved by reducing the activity injected into the patient or by reducing the measurement time down to seconds. the latter result would lead to an unprecedented capability of tracking fast dynamics. clearly, asics are pivotal in handling tens of thousands of channels and reducing the burden of data processing by implementing data pre-processing on-chip. the second development direction is the use of the time-of-flight (tof) information to improve the spatial resolution, sustained by the push to improve the timing resolution of photodetectors and readout electronics. a "10ps challenge" has been launched [38] in order to stimulate step-changes in scintillator materials and detection approaches (looking, for instance, to prompt emissions), as well as in electronics [39] . both perspectives clearly impact on the design of asics for pet: the first in terms of the number of channels and scalability and the second in terms of the intrinsic timing performance (currently in the~100 ps range). if we take the coincidence time resolution (ctr fwhm ) of a full detection system as a figure of merit to compare asics in terms of the timing performance (to be compared with similar scintillator and photodetector conditions), we can observe a continuous improvement trend. considering lyso crystals and 3 × 3 mm 2 pixels, the triroc asic (2016 [40] ) achieved 423 ps, tofpet (2016) 294 ps and stic (2018 [41] ) 214 ps. for smaller pixels (2 × 2 mm 2 ) flextot v2 reached 123 ps and nino (2017) 93 ps [42] . spect differs from pet in that it does not rely on proton annihilation: the radiotracer decays, directly emitting gamma-rays. in this case, a collimator is needed to select the trajectories of the photons impinging of the gamma camera. tomographic images are then reconstructed from the planar projections imaged by the gamma cameras surrounding the patient. different radiotracers can be employed, even simultaneously to map different molecules, if the energy resolution of the detector allows the discrimination of the photopeaks. the most commonly adopted is a metastable isotope of technetium ( 99m tc) which has a line at 140 kev. photons at such an energy are not absorbed within the thin silicon wafers and, thus, direct detection cannot take place. instead, an indirect detection approach is adopted. figure 7 illustrates the typical architecture of a solid-state gamma camera. in particular, this scheme refers to the insert system which will be considered as a reference design. each individual gamma photon is absorbed in the scintillator (here a csi:tl crystal of 8 mm thickness) producing a handful of visible photons, collected by the photodetectors placed at the bottom of the crystal. given the limited number of photons, photodetectors with internal multiplication are commonly used. previously, photo-multiplier tubes (pmt) were employed, but they are being systematically replaced by their solid-state equivalent: silicon photo-multiplers (sipm). they offer a much higher compactness and, of utmost importance for mri compatibility, much better compliance with magnetic fields. sipms are typically organized into tiles (here 6 × 6 pixels of 4 mm side in rgb-hd technology by fondazione bruno kessler, italy). the second development direction is the use of the time-of-flight (tof) information to improve the spatial resolution, sustained by the push to improve the timing resolution of photodetectors and readout electronics. a "10ps challenge" has been launched [38] in order to stimulate step-changes in scintillator materials and detection approaches (looking, for instance, to prompt emissions), as well as in electronics [39] . both perspectives clearly impact on the design of asics for pet: the first in terms of the number of channels and scalability and the second in terms of the intrinsic timing performance (currently in the ~100 ps range). if we take the coincidence time resolution (ctrfwhm) of a full detection system as a figure of merit to compare asics in terms of the timing performance (to be compared with similar scintillator and photodetector conditions), we can observe a continuous improvement trend. considering lyso crystals and 3 × 3 mm 2 pixels, the triroc asic (2016 [40] ) achieved 423 ps, tofpet (2016) 294 ps and stic (2018 [41] ) 214 ps. for smaller pixels (2 × 2 mm 2 ) flextot v2 reached 123 ps and nino (2017) 93 ps [42] . spect differs from pet in that it does not rely on proton annihilation: the radiotracer decays, directly emitting gamma-rays. in this case, a collimator is needed to select the trajectories of the photons impinging of the gamma camera. tomographic images are then reconstructed from the planar projections imaged by the gamma cameras surrounding the patient. different radiotracers can be employed, even simultaneously to map different molecules, if the energy resolution of the detector allows the discrimination of the photopeaks. the most commonly adopted is a metastable isotope of technetium ( 99m tc) which has a line at 140 kev. photons at such an energy are not absorbed within the thin silicon wafers and, thus, direct detection cannot take place. instead, an indirect detection approach is adopted. figure 7 illustrates the typical architecture of a solid-state gamma camera. in particular, this scheme refers to the insert system which will be considered as a reference design. each individual gamma photon is absorbed in the scintillator (here a csi:tl crystal of 8 mm thickness) producing a handful of visible photons, collected by the photodetectors placed at the bottom of the crystal. given the limited number of photons, photodetectors with internal multiplication are commonly used. previously, photo-multiplier tubes (pmt) were employed, but they are being systematically replaced by their solid-state equivalent: silicon photo-multiplers (sipm). they offer a much higher compactness and, of utmost importance for mri compatibility, much better compliance with magnetic fields. sipms are typically organized into tiles (here 6 × 6 pixels of 4 mm side in rgb-hd technology by fondazione bruno kessler, italy). figure 7 . architecture of the gamma camera of the insert spect system: the current signals of 72 silicon photo-multiplier (sipm) pixels are read by two asics [43] , featuring a low-impedance input stage, programmable shaper, peak stretcher and fast comparator to trigger the acquisition of events by the fpga-based daq unit [44] . the current signal produced from a single sipm can span from the µa to the ma range, with a typical duration in the tens of ns range. given the large capacitance of the photodetector (~1 nf), differing from biosensors (typically in the pf range) and sdds (in the sub-pf range), the additional [43] , featuring a low-impedance input stage, programmable shaper, peak stretcher and fast comparator to trigger the acquisition of events by the fpga-based daq unit [44] . the current signal produced from a single sipm can span from the µa to the ma range, with a typical duration in the tens of ns range. given the large capacitance of the photodetector (~1 nf), differing from biosensors (typically in the pf range) and sdds (in the sub-pf range), the additional parasitic capacitance of the interconnection (in the pf range) is not too critical, and the readout asic can be placed at a reasonable distance on the pcb. in order to grant a low input impedance, bandwidth and stability in these conditions, different topologies can be adopted. in the angus asic [43] , the weak positive feedback of a themes current conveyor is successfully implemented. sipms are biased at 35 v. the possibility to individually adjust the input potential with a dac allows for the correction of gain mismatch across the channels (typically~15%) and, more importantly, to selectively kill hot pixels affected by fault or large noise (dark counts). the tiles of sipms are typically cooled (here between 0 • c and −10 • c by refrigerant fluid) to reduce such a noise. the attenuated current pulses are then shaped by a programmable rc filter (~µs time constant), setting also the baseline. a fast discriminator triggers the acquisition of all channels and a peak stretcher allows the external 14-bit adc to sequentially sample all outputs through a multiplexer. an fpga acquires all the signals (at a rate of~11 k frames per second) and transmits them to a laptop through an optical digital bus [44] . the operation of the insert system is shown in figure 8a . the spect scanner is placed inside a standard mri scanner, connected to a custom-designed and shielded transceiver coil placed inside the bore of the spect static ring, which contains gamma cameras and the collimator. figure 8b shows the preclinical version of the scanner [45] , while figure 8c shows the clinical prototype [46] , the only existing mri-compatible sipm-based spect insert for human brain imaging. the main features of the two instruments are summarized in table 1 . sensors 2020, 20, 3636 9 of 15 parasitic capacitance of the interconnection (in the pf range) is not too critical, and the readout asic can be placed at a reasonable distance on the pcb. in order to grant a low input impedance, bandwidth and stability in these conditions, different topologies can be adopted. in the angus asic [43] , the weak positive feedback of a themes current conveyor is successfully implemented. sipms are biased at ~35 v. the possibility to individually adjust the input potential with a dac allows for the correction of gain mismatch across the channels (typically ~15%) and, more importantly, to selectively kill hot pixels affected by fault or large noise (dark counts). the tiles of sipms are typically cooled (here between 0 °c and −10 °c by refrigerant fluid) to reduce such a noise. the attenuated current pulses are then shaped by a programmable rc filter (~µs time constant), setting also the baseline. a fast discriminator triggers the acquisition of all channels and a peak stretcher allows the external 14-bit adc to sequentially sample all outputs through a multiplexer. an fpga acquires all the signals (at a rate of ~11 k frames per second) and transmits them to a laptop through an optical digital bus [44] . the operation of the insert system is shown in figure 8a . the spect scanner is placed inside a standard mri scanner, connected to a custom-designed and shielded transceiver coil placed inside the bore of the spect static ring, which contains gamma cameras and the collimator. figure 8b shows the preclinical version of the scanner [45] , while figure 8c shows the clinical prototype [46] , the only existing mri-compatible sipm-based spect insert for human brain imaging. the main features of the two instruments are summarized in table 1 . mutual compatibility between spect and mri electronics entails several critical aspects. in order to reduce the distortion of the magnetic field due to the spect insert, electronic components (free of ferromagnetic metals such as nickel, present in connectors, plating pins and iron cores of inductors) and materials should be carefully selected. in particular, the introduction of metals in the mr bore should be minimized. for instance, collimators are fabricated by laminated layers or powder-epoxy mixtures to avoid solid regions and, thus, reduce the paths for eddy currents. at an electronic level, it is crucial to reduce the irradiation of disturbances from the spect in the regions of the rf spectrum (~130 mhz). to minimize the impact of mri on spect electronics, it is important to design special circuit geometries and layouts (avoiding loops and solid ground planes), add filtering on tracks that could pick-up rf interference and apply mri-compatible shielding. the fundamental design guidelines and the results of compatibility tests are reported here [47] . another direction of development at the system-level is to lighten and simplify the instrument and make it movable, in particular to make it a bed-side scanner. this would avoid the need to bring the patient to the room and might be relevant either during surgery (where intra-operative gamma probes are already used) or to promptly study sudden events such as epileptic seizures and strokes. since the first movable mri has been recently cleared by the fda in the usa (model lucy by hyperfine, targeting stroke), a transportable spect/mri system for the bed-side is foreseeable. the key to make a movable mri system is in the use of low-field (and thus lighter) magnets [48] . the key to realizing a movable clinical spect is the reduction in the weight/size of the collimator, the detector refrigeration system (in the case of multiplication devices) and the electronics (again an opportunity for microelectronics to reduce the bulkiness and power dissipation in data processing). additionally, the increase in speed by reducing the image-reconstruction time (currently in the hour time-frame, compared to acquisition times of about 15 min) is clearly related to new paradigms in the operation of spect, aiming to achieve quasi "real-time" imaging. one of the major challenges hindering the scaling up of static preclinical spect systems to larger ones (i.e., with a larger field of view) is related to the growth in complexity in terms of the number of channels and signals travelling in the system (especially from a reliability point of view), and in terms of the processing time. one promising way to address both aspects is to shift the processing from the digital domain back to the analog domain, i.e., closer to the front-end. the reduction in the number of output channels can be achieved by using smart algorithms for machine learning (particularly for the estimation of the spatial coordinates of absorption of each gamma-ray photon) based on a partial readout of the crystal and by, for instance, principal component analysis and multiplexing strategies [49] . so far, they have been demonstrated in software post-processing and in discrete-hardware implementations (such as the decision-tree classification of gamma events embedded in a microcontroller [50] ), but it is evident that an integrated implementation of such strategies in asics would offer significant benefits in terms of: (i) compactness, (ii) the robustness of signals and reliability, and (iii) processing time, as demonstrated by several emerging examples of hardware acceleration in image processing and machine learning based on neural networks on-chip [51] [52] [53] . in order to increase the robustness of the signals through the long connection from the scanner to the base station placed in the control room, outside of the mri room, and decouple them from electrical interferences, optical fibers are typically employed. in the case of the insert system, a 15 m digital optical daisy chain composed of two rings with 10 nodes each has been implemented. since the operation of powerful digital processing platforms, such as fpgas, inside the bore there can be severe issues of heat dissipation and mutual compatibility, it is possible to envision a tighter combination of readout asics with silicon-photonics transceivers, potentially on the same monolithic silicon platform as the robust analog transmission and direct modulation of thousands of optical signals injected in optical fibers, as recently proposed for high-energy physics [54] . we have summarized some recent results, development strategies and directions for integrated circuits and electronics for biomedical applications. two apparently distant, but complementary, application areas in non-invasive diagnostics can both significantly profit from the advancements of cmos technology. targeted, yet cross-disciplinary, development of microelectronic designs and integration solutions can consolidate the pivotal role of integrated circuits in bio-sensing. clearly, each application domain poses specific challenges and offers a very different performance of molecular detection: for example, the dynamic range of a micro-impedance sensing chip is 100-120 db, while mri can reach 150 db at the expense of size, cost and measurement times that are several orders of magnitude larger. some of the most relevant challenges have been discussed: packaging and the noise/power compromise in micro-analytical devices; scaling to a large number of channels; migration of processing from digital to analog, at least for the reconstruction of the position of the scintillation event; and transition towards transportable systems for medical imaging scanners. the impact of the fabrication cost significantly changes between the two application domains: when considering disposable diagnostic kits (with a production cost in the order of~1$), the fabrication of silicon chips in cmos foundries is economically sustainable only for mass production. instead, when considering medical imaging scanners (with prices in the~m$ range), small-volume and, thus more expensive, asic productions are still acceptable. in conclusion, the current covid-19 pandemic has raised urgent concerns about diagnostic tools. the possible combination of ct scans of the chest with antibody-based assays for early, accessible and systematic diagnostics of the sars-cov-2 [55] is a vivid example of a possible effective combination of complementary diagnostic tools. integrated circuits for particle physics experiments liquid biopsy: a perspective for probing blood for cancer single-cell recording of vesicle release from human neuroblastoma cells using 1024-ch monolithic cmos bioelectronics impedance spectroscopy and electrophysiological imaging of cells with a high-density cmos microelectrode array system low-power and low-noise capacitive sensing ic using opamp sharing technique a low-power current-reuse analog front-end for high-density neural recording implants a 13.9-na ecg amplifier achieving 0.86/0.99 nef/pef using ac-coupled ota-stacking comparative analysis of information rates of simple amplifier topologies an aquatic wireless biosensor for electric organ discharge with an integrated analog front end assessment of analog pulse processor performance for ultra high-rate x-ray spectroscopy toward wireless health monitoring via an analog signal compression-based biosensing platform a low-power high-speed ultra-wideband pulse radio transmission system noise limits of cmos current interfaces for biosensors: a review resonant noise-canceling current front-end for high-resolution impedance sensing design and test at room temperature of the first silicon drift detector with on-chip electronics design guidelines for contactless integrated photonic probes in dense photonic circuits miniaturized impedance flow cytometer: design rules and integrated readout music: an 8 channel readout asic for sipm arrays advances in high-resolution microscale impedance sensors towards low-cost, high-sensitivity point-of-care diagnostics using vco-based esr-on-a-chip detectors integrated circuit technology for next generation point-of-care spectroscopy applications biocompatibility of silicon nanowires: a step towards ic detectors multichannel 65 zf rms resolution cmos monolithic capacitive sensor for counting single micrometer-sized airborne particles on chip integrated nanopore sensing platform with sub-microsecond temporal resolution cmos based capacitive sensors for life science applications: a review note: differential configurations for the mitigation of slow fluctuations limiting the resolution of digital lock-in amplifiers oscillator-based reactance sensors with injection locking for high-throughput flow cytometry using microwave dielectric spectroscopy wafer-level fan-out for high-performance, low-cost packaging of monolithic rf mems/cmos roadmap on silicon photonics lab-on-cmos integration of microfluidics and electrochemical sensors system-on-chip considerations for heterogeneous integration of cmos and fluidic bio-interfaces rapid prototyping polymers for microfluidic devices and high pressure injections 3d printed microfluidic devices: enablers and barriers microfluidic structures for large-scale manufacture combining photo-patternable materials sensors for positron emission tomography applications total-body pet: maximizing sensitivity to create new opportunities for clinical research and patient care first human imaging studies with the explorer total-body pet scanner* the 10-ps challenge high-frequency sipm readout advances measured coincidence time resolution limits in tof-pet triroc, a versatile 64-channel sipm readout asic for time-of-flight pet a silicon photomultiplier readout asic for time-of-flight applications using a new time-of-recovery method a comparative study of the time performance between nino and flextot asics characterization of the detection module of the insert spect/mri clinical system validation and performance assessment of a preclinical sipm-based spect/mri insert clinical sipm-based mri-compatible spect: preliminary characterization spect/mri insert compatibility: assessment, solutions, and design guidelines low-field mri: an mr physics perspective characterization of highly multiplexed monolithic pet / gamma camera detector modules a sipm-based directional gamma-ray spectrometer with embedded machine learning machine learning on-a-chip: a high-performance low-power reusable neuron architecture for artificial neural networks in ecg classifications on-chip sparse learning acceleration with cmos and resistive synaptic devices adaptive neuromorphic systems: recent progress and future directions use of silicon photonics wavelength multiplexing techniques for fast parallel readout in high energy physics covid-19 diagnostics, tools, and prevention. diagnostics 2020 acknowledgments: all the students and technical partners of the insert project (mediso, fondazione bruno kessler, nuclear fields, san raffaele hospital and university college london in particular) are warmly acknowledged for contributing to this 6-year-long effort. the authors declare no conflict of interest. key: cord-319930-ymqnb54a authors: kremer, stéphane; lersy, françois; de sèze, jérome; ferré, jean-christophe; maamar, adel; carsin-nicol, béatrice; collange, olivier; bonneville, fabrice; adam, gilles; martin-blondel, guillaume; rafiq, marie; geeraerts, thomas; delamarre, louis; grand, sylvie; krainik, alexandre; caillard, sophie; marc constans, jean; metanbou, serge; heintz, adrien; helms, julie; schenck, maleka; lefèbvre, nicolas; boutet, claire; fabre, xavier; forestier, géraud; de beaurepaire, isaure; bornet, grégoire; lacalm, audrey; oesterlé, hélène; bolognini, federico; messie, julien; hmeydia, ghazi; benzakoun, joseph; oppenheim, catherine; bapst, blanche; megdiche, imen; henri-feugeas, marie-cécile; khalil, antoine; gaudemer, augustin; jager, lavinia; nesser, patrick; talla mba, yannick; hemmert, céline; feuerstein, philippe; sebag, nathan; carré, sophie; alleg, manel; lecocq, claire; schmitt, emmanuelle; anxionnat, rené; zhu, françois; comby, pierre-olivier; ricolfi, frédéric; thouant, pierre; desal, hubert; boulouis, grégoire; berge, jérome; kazémi, apolline; pyatigorskaya, nadya; lecler, augustin; saleme, suzana; edjlali-goujon, myriam; kerleroux, basile; zorn, pierre-emmanuel; mathieu, muriel; baloglu, seyyid; ardellier, françois-daniel; willaume, thibault; brisset, jean christophe; boulay, clotilde; mutschler, véronique; hansmann, yves; mertes, paul-michel; schneider, francis; fafi-kremer, samira; ohana, mickael; meziani, ferhat; david, jean-stéphane; meyer, nicolas; anheim, mathieu; cotton, pr françois title: brain mri findings in severe covid-19: a retrospective observational study date: 2020-06-16 journal: radiology doi: 10.1148/radiol.2020202222 sha: doc_id: 319930 cord_uid: ymqnb54a background: brain mri parenchymal signal abnormalities have been in association with sars-cov-2. purpose: describe the neuroimaging findings (excluding ischemic infarcts) in patients with severe covid-19 infection. methods: this was a retrospective study of patients evaluated from march 23th, 2020 to april 27th, 2020 at 16 hospitals. inclusion criteria were: (i) positive nasopharyngeal or lower respiratory tract reverse transcriptase-polymerase chain reaction assays; (ii) severe covid infection defined as requirement for hospitalization and oxygen therapy; (iii) neurologic manifestations; (iv) abnormal brain mri. exclusion criteria were patients with missing or non-contributory data regarding brain mri or a brain mri showing ischemic infarcts, cerebral venous thrombosis, or chronic lesions unrelated to the current event. categorical data were compared using fisher exact test. quantitative data were compared using student’s t-test or wilcoxon test. a p-value lower than 0.05 was considered significant. results: thirty men (81%) and 7 women (19%) met inclusion criteria, with a mean age of 61+/12 years (range: 8-78). the most common neurologic manifestations were alteration of consciousness (27/37, 73%), pathological wakefulness when the sedation was stopped (15/37, 41%), confusion (12/37, 32%), and agitation (7/37, 19%). the most frequent mri findings were: signal abnormalities located in the medial temporal lobe in 16/37 (43%, 95% ci 27-59%) patients, non-confluent multifocal white matter hyperintense lesions on flair and diffusion sequences, with variable enhancement, with associated hemorrhagic lesions in 11/37 patients (30%, 95% ci 15-45%), and extensive and isolated white matter microhemorrhages in 9/37 patients (24%, 95% ci 10-38%). a majority of patients (20/37, 54%) had intracerebral hemorrhagic lesions with a more severe clinical presentation: higher admission rate in intensive care units, 20/20 patients, 100% versus 12/17 patients, 71%, p=0.01; development of the acute respiratory distress syndrome in 20/20 patients, 100% versus 11/17 patients, 65%, p=0.005. only one patient was positive for sars-cov-2 rna in the cerebrospinal fluid. conclusion: patients with severe covid-19 and without ischemic infarcts had a wide range of neurologic manifestations that were be associated with abnormal brain mris. eight distinctive neuroradiological patterns were described. eight distinctive neuroradiologic patterns (excluding ischemic infarcts) were identified in patients with severe covid-19 infection with abnormal brain mris. in patients with covid-19, the most frequent neuroimaging features were: involvement of the medial temporal lobe, non-confluent multifocal white matter hyperintense lesions on flair with variable enhancement and hemorrhagic lesions, and extensive and isolated white matter microhemorrhages. a majority of our patients presented intracerebral hemorrhagic lesions, which were associated with worse clinical status. 3. of 37 patients, only one was positive for sars-cov-2 rna in the cerebrospinal fluid. describe the neuroimaging findings (excluding ischemic infarcts) in patients with severe covid-19 infection. this was a retrospective study of patients evaluated from march 23 th , 2020 to april 27 th , 2020 at 16 hospitals. inclusion criteria were: (i) positive nasopharyngeal or lower respiratory tract reverse transcriptase-polymerase chain reaction assays; (ii) severe covid infection defined as requirement for hospitalization and oxygen therapy; (iii) neurologic manifestations; (iv) abnormal brain mri. exclusion criteria were patients with missing or non-contributory data regarding brain mri or a brain mri showing ischemic infarcts, cerebral venous thrombosis, or chronic lesions unrelated to the current event. categorical data were compared using fisher exact test. quantitative data were compared using student's t-test or wilcoxon test. a p-value lower than 0.05 was considered significant. thirty men (81%) and 7 women (19%) met inclusion criteria, with a mean age of 61+/-12 years (range: 8-78). the most common neurologic manifestations were alteration of consciousness (27/37, 73%), pathological wakefulness when the sedation was stopped (15/37, 41%), confusion (12/37, 32%), and agitation (7/ patients with severe covid-19 and without ischemic infarcts had a wide range of neurologic manifestations that were be associated with abnormal brain mris. eight distinctive neuroradiological patterns were described. i n p r e s s sars-cov-2 is the seventh member of the family of coronaviruses (covs) that infect humans (1) and induces covid-19 disease. human covs (hcovs) have neuroinvasive capacities and may be neurovirulent by two main mechanisms (2) (3) (4) : viral replication into glial or neuronal cells of the brain, or autoimmune reaction with a misdirected host immune response (5) . thus, a few cases of acute encephalitis-like syndromes with hcovs were reported in the past two decades (5) (6) (7) (8) . concerning covid-19, current data on central nervous system (cns) involvement is uncommon but growing (9) (10) (11) (12) (13) (14) (15) (16) (17) , demonstrating the high frequency of neurological symptoms. however, the delineation of a large cohort of confirmed brain mri parenchymal signal abnormalities (excluding ischemic infarcts) related to covid-19 has never been performed, and the underlying pathophysiological mechanisms remain unknown. the purpose of this current study was to describe the neuroimaging findings (excluding ischemic infarcts) in patients with severe covid-19 and report the clinico-biological profile of these patients. this retrospective observational national multicenter study was initiated by the french society of neuroradiology (sfnr) in collaboration with neurologists, intensivists, and infectious disease specialists, and brought together 16 hospitals. the study was approved by the ethical committee of strasbourg university hospital (ce-2020-37) and was in accordance with the 1964 helsinki declaration and its later amendments. due to the emergency in the context of covid-19 pandemic responsible for acute respiratory and neurological manifestations pandemic, the requirement for patients' written informed consent was waived. consecutive patients with covid-19 infection and neurologic manifestations who underwent brain mri were included from march 23 th, 2020, to april 27 th, 2020, in 16 french centers, including 11 university hospitals and 5 general hospitals. inclusion criteria were: (i) diagnosis of covid-19 based on possible exposure history or symptoms clinically compatible, validated with a detection of sars-cov-2 by reverse transcriptase-polymerase chain reaction (rt-pcr) assays on the nasopharyngeal, throat or lower respiratory tract swabs; (ii) severe covid-19 infection defined as requirement for hospitalization and oxygen therapy; (iii) neurologic manifestations; (iv) abnormal brain mri with acute/subacute abnormalities. exclusion criteria were: (i) patients with missing or non-contributory data (lack of sequences, numerous artifacts) regarding brain mri; (ii) a brain mri showing ischemic infarcts, cerebral venous thrombosis, or chronic lesions unrelated to the current event. clinical and laboratory data were extracted from the patients' electronic medical records in the hospital information system. only laboratory analysis within three days before the brain mri were considered. in the case of redundancy of the tests, the worst value has been kept. clinical and biological data were reviewed by two neurologists (j.d.s., and m.a. with 25 and 15 years of clinical expertise on neurology, respectively), and by one virologist (s.f-k). they participated to the elaboration of the study design, the interpretation of the data, and to manuscript editing. when available, all electroencephalogram (eeg) were reviewed by one expert neurologist (c.b.) and classified into five groups (normal, under sedation, nonspecific, encephalopathy or seizures). quantitative real-time rt-pcr tests for sars-cov-2 nucleic acid were performed on nasopharyngeal or lower respiratory tract swabs, and cerebrospinal fluid (csf). primer and probe sequences target two regions on the rdrp gene and are specific to sars-cov-2. assay sensitivity is around 10 copies/reaction (in house-method, institut pasteur, paris, france) (18). imaging studies were conducted either on 1.5-or 3-tesla mri. the multicenter nature of the study and the various clinical setups did not allow standardization of sequences. the most frequently sequences performed were 3d t1weighted spin-echo mri with and without contrast enhancement, diffusion-weighted imaging (dwi), gradient-echo t2 or susceptibility-weighted imaging, and 2d or 3d flair after administration of gadolinium-based contrast agent. after anonymization, images were presented to readers with our ge picture archiving and communication system (general electric, milwaukee, wi, usa). after review of mri studies by three neuroradiologists (s.k., f.c., and f.l. with 20, 25, and 9 years of experience in neuroradiology, respectively) who were blinded to all patient data, brain mri findings were divided by consensus into eight groups: (a) unilateral flair and/or diffusion hyperintensities located in medial temporal lobe; (b) flair and diffusion ovoid hyperintense lesion located in the central part of the splenium of the corpus callosum; (c) non-confluent multifocal white matter (wm) hyperintense lesions on flair and diffusion, with variable enhancement; (d) non-confluent multifocal wm hyperintense lesions on flair and diffusion, with variable enhancement, associated with hemorrhagic lesions; (e) acute necrotizing encephalopathy (ane) (9) when symmetric thalamic lesions (edema, petechial hemorrhage, and necrosis), with variable involvement of the brainstem, internal capsule, putamen, cerebral and cerebellar wm; (f) extensive and isolated wm microhemorrhages; (g) extensive and confluent supratentorial wm flair hyperintensities; (h) flair hyperintense lesions involving both middle cerebellar peduncles. patients could have had more than one pattern. data were described using frequency and proportion (n, %) for categorical variables, using mean, median, interquartile range, and range for quantitative data. in a second step, patients with hemorrhagic lesions were gathered into a single group called « patients with hemorrhagic complications », to look for clinico-biological differences between the two populations. categorical data were compared using fisher exact test. quantitative data were compared using student's t-test or wilcoxon test. a p-value lower than 0.05 was considered significant. between march 23 th, 2020, and april 27 th, 2020, 190 consecutive patients with covid-19 infection and neurologic manifestations, performed a brain mri in 16 hospitals. among them, were excluded all patients with normal brain mri, ischemic infarcts, cerebral venous thrombosis or chronic lesions unrelated to the current event. a total of 37 patients with covid-19 infection were finally included in this study (figure 1). the average age of the patients was 61 +/-12 years with 30 men and 7 women included (table 1). the majority of our patients (32/37, 87%) were admitted to intensive care units (icus) because of acute respiratory failure. the most frequent neurologic manifestations were alteration of consciousness (27/37, 73%), pathological wakefulness after sedation (15/37, 41%), confusion (12/37, 32%), and agitation (7/37, 19%). among the 26 eeg performed, 2 (8%) were considered as normal, 6 (23%) were realized under sedation, 10 (39%) showed nonspecific findings, 7 (27%) were classified as encephalopathy, and 1 (4%) case of seizures was also described. at the end of the study, the mortality rate was 14%. the blood counts of patients showed leukocytosis, lymphopenia, and anemia. patients had elevated serum levels of c-reactive protein, ferritin, alanine aminotransferase, aspartate aminotransferase, urea, creatinine, fibrinogen, and d-dimers (table 2) . fifteen out of the 19 patients (79%) studied for the presence of a lupus anticoagulant were positive. thirty-one patients underwent a lumbar puncture, and among them, 21/31(68%) had increased markers of inflammation (high white blood cell count, and/or high proteinorachia, and/or elevated immunoglobulin g). one patient demonstrated the presence of sars-cov-2 on rt-pcr. high levels of interleukin-6 were found in 2 out of 6 patients (table 3) . the results of mri findings are summarized in figure 1 . among the 37 patients included, 28/37 (76%) were associated with one neuroimaging pattern, 7/37 (19%) with two patterns, and 2/37 (5%) showed three patterns (figures 1-6). the most frequent neuroimaging findings were: signal abnormalities located in the medial temporal lobe in 16/37 (43%, 95%ic 27-59%) patients (figure 2), non-confluent multifocal wm hyperintense lesions on flair and diffusion, with variable enhancement, associated with hemorrhagic lesions in 11/37 (30%, 95%ic 15-45%) patients (figure 3), and in 9/37 (24%, 95%ic 10-38%) patients extensive and isolated wm microhemorrhages were detected (figure 4). the comparison between patients with and without intracerebral hemorrhagic lesions shows that the hemorrhagic complications were more frequently associated with icu admission (20/20, 100% versus 12/17, 71%, p=0.01), with acute respiratory distress syndrome (ards) (20/20, 100% versus 11/17, 65%, p=0.005) and with pathological wakefulness when sedative therapies were stopped (13/20, 65% versus 2/17, 12%, p=0.002). the time between the onset of symptoms (most often respiratory) to brain mri was longer for patients with intracerebral hemorrhagic lesions (mean duration of 33 days versus 19 days, p<0.001). leukocytosis (median of 13.4 x 10 9 /l versus 10.4 x 10 9 /l, p=0.03), anemia (median of 87 g/l versus 110 g/l, p<0.001), and renal dysfunction (urea's median of 18mmol/l versus 7mmol/l, p=0.026) were more pronounced in the case of hemorrhagic lesions. among the eight groups of brain mri features classification, three main neuroradiological patterns appeared more frequently in patient with severe covid-19: signal abnormalities located in the medial temporal lobe, non-confluent multifocal wm hyperintense lesions on flair and diffusion with variable enhancement, associated with hemorrhagic lesions, and extensive and isolated wm microhemorrhages. the presence of hemorrhage was frequent, and the detection is of clinical importance as it was associated with worse respiratory, neurological, and biological status. nevertheless, the underlying mechanism of brain abnormalities remains unsolved, and the direct implication of sars-cov-2 is not clear as only one patient was positive for sars-cov-2 rna in the csf. unilateral flair and/or diffusion hyperintensities located in medial temporal lobe were frequent and have been previously reported in one patient with covid-19 (10) . the latter is frequently observed in case of infectious encephalitis (especially with some viruses like herpes simplex virus, human herpesvirus 6, or epstein-barr virus) or in association with autoimmune limbic encephalitis (19) . non-confluent multifocal wm hyperintense lesions on flair and diffusion, with variable enhancement, which could be associated with hemorrhagic lesions, have rarely been reported in patients with covid-19 (20) . the latter presentation is close to what can be observed on brain mris in case of an inflammatory demyelinating disease such as acute disseminated encephalomyelitis (adem) or acute hemorrhagic leukoencephalitis. however, these two latter diagnoses cannot only be retained on the radiological presentation without the typical csf analysis or clinical presentation (21, 22) . several putative mechanisms underlying neurological consequences of covid-19 are evoked and among them immunological parainfectious processes (23) . the immunologic assumption is also reinforced by a recent neuropathological study which described adem-like lesions in the subcortical wm in a patient with severe covid-19 (24) . extensive and isolated wm microhemorrhages pattern was recently described in 7 critically ill patients with covid-19 (12) and in the neuropathology study above mentioned (24) . a similar pattern was recently described in one case (25) with disseminated intravascular coagulation. however, according to the criteria endorsed by the international society on thrombosis and haemostasis (27) , when they were available, no case of disseminated intravascular coagulation was present in our cohort. its precise pathophysiology remains uncertain and will require further studies. radmanesh et al. (12) evoking the assumptions of hypoxia or small vessel vasculitis. a small number of patients presented extensive and confluent supratentorial wm flair hyperintensities (figure 2), as previously described by kandemirli et al. (11) and radmanesh et al. (12) . its precise pathophysiology remains unclear: viral encephalitis (not supported by csf analysis) or post-infectious demyelinating diseases, as previously mentioned, may be evoked. since most of our patients were admitted to icus for an ards, more general assumptions may be considered, such as delayed post-hypoxic leukoencephalopathy (27) , metabolic or toxic encephalopathy, and posterior reversible encephalopathy syndrome (pres). this last hypothesis is in accordance with recently published nonhemorrhagic and hemorrhagic pres in patients with covid-19 (28) . even if this national neuroimaging cohort remains unique, our study has several limitations, mainly due to his retrospective design. the main limitation is that certain laboratory data were missing for some patients, notably the immunological tests. moreover, patients' outcomes were not always known at the time of this communication. thus, the mortality rate is probably underestimated in our cohort. in conclusion, in this multi-institutional study, we report 37 patients with covid-19 and abnormal brain mris (excluding ischemic infarcts). three main neuroradiological patterns could be distinguished, and the presence of hemorrhage was associated with worse clinical status. sars-cov-2 rna was detected in the csf only in one patient, and the underlying mechanisms of brain involvement remain unclear. imaging and neurological follow up has to be undertaken in order to evaluate the prognosis of these patients. n is the total number of patients with available data, and n the number of positive patients. i n p r e s s a novel coronavirus from patients with pneumonia in china neurologic alterations due to respiratory virus infections human coronaviruses: viral and cellular factors involved in neuroinvasiveness and neuropathogenesis human coronaviruses and other respiratory viruses: underestimated opportunistic pathogens of the central nervous system? viruses coronavirus infections in the central nervous system and respiratory tract show distinct features in hospitalized children severe neurologic syndrome associated with middle east respiratory syndrome corona virus (mers-cov) neurological complications during treatment of middle east respiratory syndrome detection of coronavirus in the central nervous system of a child with acute disseminated encephalomyelitis covid-19-associated acute hemorrhagic necrotizing encephalopathy: ct and mri features a first case of meningitis/encephalitis associated with sars-coronavirus-2 brain mri findings in patients in the intensive care unit with covid-19 infection covid-19 -associated diffuse leukoencephalopathy and microhemorrhages hemorrhagic posterior reversible encephalopathy syndrome as a manifestation of covid-19 infection neurologic manifestations of hospitalized patients with coronavirus disease imaging in neurological disease of hospitalized covid-19 patients: an italian multicenter retrospective observational study neurologic features in severe sars-cov-2 infection neurologic manifestations in hospitalized patients with covid-19: the albacovid registry protocol: real-time rt-pcr assays for the detection of sars-cov-2 institut pasteur diagnosing autoimmune limbic encephalitis covid-19-associated acute disseminated encephalomyelitis (adem) acute disseminated encephalomyelitis: updates on an inflammatory cns syndrome weston-hurst syndrome: a rare fulminant form of acute disseminated encephalomyelitis (adem) neurological implications of covid-19 infections neuropathology of covid-19: a spectrum of vascular and acute disseminated encephalomyelitis (adem)-like pathology severe cerebral involvement in adultonset hemophagocytic lymphohistiocytosis towards definition, clinical and laboratory criteria, and a scoring system for disseminated intravascular coagulation posterior reversible encephalopathy syndrome (pres) as a neurological association in severe covid-19 i n p r e s s key: cord-329750-purunxce authors: waldman, amy; o'connor, erin; tennekoon, gihan title: childhood multiple sclerosis: a review date: 2006-06-28 journal: ment retard dev disabil res rev doi: 10.1002/mrdd.20105 sha: doc_id: 329750 cord_uid: purunxce multiple sclerosis (ms) is an autoimmune demyelinating disorder of the central nervous system (cns) that is increasingly recognized as a disease that affects children. similar to adult‐onset ms, children present with visual and sensory complaints, as well as weakness, spasticity, and ataxia. a lumbar puncture can be helpful in diagnosing ms when csf immunoglobulins and oligoclonal bands are present. white matter demyelinating lesions on mri are required for the diagnosis; however, children typically have fewer lesions than adults. many criteria have been proposed to diagnose ms that have been applied to children, mostly above 10 years of age. the recent revisions to the mcdonald criteria allow for earlier diagnosis, such as after a clinically isolated event. however, children are more likely than adults to have monosymptomatic illnesses. none of the approved disease‐modifying therapies used in adult‐onset ms have been approved for pediatrics; however, a few studies have verified their safety and tolerability in children. although children and adults with ms have similar neurological symptoms, laboratory (cerebrospinal fluid) data, and neuroimaging findings, the clinical course, pathogenesis, and treatment of childhood onset ms require further investigation. mrdd research reviews 2006;12:147–156. © 2006 wiley‐liss, inc. m ultiple sclerosis (ms) was first described more than 170 years ago in adults. although rare, ms was recognized in children as early as 1922 [wechsler, 1922] . nevertheless, ms is still thought to be a disease of young adulthood, typically presenting between the ages of 20 and 40 years, and the diagnosis is rarely considered in children. physicians have questioned whether or not childhood ms is the same entity as seen in adults. in 1958, gall et al. published one of the earliest retrospective studies on pediatric-onset ms [gall et al., 1958] . between 1920 and 1952 , 40 children met inclusion criteria for the study. the patients demonstrated neurological signs and symptoms due to scattered lesions within the cns separated by time and space and supported by objective evidence. the study concluded that children and adults with ms have similar clinical profiles, including mode of onset, symptoms, and physical and laboratory (cerebral spinal fluid [csf]) findings. nevertheless, diagnosing ms in children is often difficult and controversial. the estimated prevalence of ms worldwide is 50 per 100,000 with 2.7-5.6% of patients presenting before the age of 15-16 years [ sindern et al., 1992; gadoth, 2003 ]. the calculated frequency of childhood-onset ms is 1.35-2.5 per 100,000 [gadoth, 2003] . ms has been diagnosed during infancy and early childhood (younger than 10 years of age) accounting for 0.2-0.7% of all cases [ruggieri et al., 1999] . there are reports of children presenting before the age of 2 years, even as early as 13 months [cole et al., 1995] . as seen in the adult population, there is a female predominance in childhood ms ranging from 2.1-3:1 [gall et al., 1958; duquette et al., 1987] . the presenting symptoms of ms in children are similar to those reported by adults. in 1987, duquette et al. reviewed 125 pediatric patients with ms who presented most commonly with either pure sensory symptoms or optic neuritis [duquette et al., 1987] . diplopia, pure motor symptoms, abnormal gait including ataxia (cerebellar or vestibular), mixed sensory and motor symptoms, and sphincter disturbances were also reported. in 1992, sindern et al. identified 31 patients with ms using poser's criteria (see diagnosis section) who presented before the age of 16 years and compared them to 72 sex-matched control patients diagnosed with ms between the ages of 20 and 40 years [sindern et al., 1992] . the most common finding at the onset of disease for both children and adults was optic neuritis, accounting for 52% and 40%, respectively. the second most common presenting symptom in children was sensory disturbance, seen in 16% of children and 15% of adults. transverse myelitis was more common in children, whereas motor symptoms were more common in adults (18%) than in children (6%). furthermore, in 71% of children, the initial presentation was rapid, resulting in admission to the hospital within a few hours to days. a longitudinal study by boiko et al. confirmed duquette's and sindern' s findings that sensory symptoms and optic neuritis were the most common initial manifestations in patients with the clinical onset of ms before the age of 16 years [boiko et al., 2002] . in 1995, poser et al. characterized the presentation of ms in adults (table 1) [poser, 1995] , and the diagnosis of ms should be considered in children presenting with similar symptoms. the clinical course of ms is divided into four subtypes: relapsing-remitting (rrms), primary progressive (ppms), secondary progressive (spms), and progressive-relapsing (prms). rrms is the most common subtype in both adults and children. there are no diagnostic tests for ms. however, a lumbar puncture is routinely performed to obtain supportive evidence of cns inflammation. in approximately 60% of patients with childhoodonset ms, the routine analysis (cell count, protein, and glucose) of csf is normal [duquette et al., 1987; dale et al., 2000] . the remainder of patients has a lymphocytic pleocytosis (typically ͻ50 cells/mm 3 ) and/or elevated protein (typically ͻ75 mg/dl) [dale et al., 2000] . intrathecal synthesis of immunoglobulin (ig), predominantly igg, is also seen in patients with ms. approximately 80% of children with ms have increased csf igg synthesis [jones, 2003] . furthermore, oligoclonal bands (ocb), markers of antibody synthesis in the cns, are present in about 85-95% of adult patients with ms [olek and dawson, 2004] . in children, ocb were present in 40 -87% of patients and may appear later during disease convalescence or relapse [sindern et al., 1992; selcen et al., 1996; dale et al., 2000; jones, 2003 ]. ocb are not specific to ms [poser, 1983; olek and dawson, 2004] . they can be found in chronic cns infections, such as subacute sclerosing panencephalitis, viral infections of the cns, autoimmune neuropathies, cervical myelopathies, and cns tumors [ cohen et al., 2000] . magnetic resonance imaging (mri) reveals asymmetric, multifocal white matter lesions on t2-weighted sequences and fluid-attenuated inversion recovery (flair) images [miller et al., 1990] . the lesions are most commonly located in the periventricular and subcortical white matter where they appear ovoid with extensions called dawson fingers [barkhof et al., 1997] . additional lesions can be seen in the cerebellum, spinal cord, basal ganglia, and thalami [dale et al., 2000] . new lesions may enhance with gadolinium administration. there are no longitudinal mri studies in childhood ms to establish whether there is progressive atrophy of the brain or the appearance of "black holes" (chronic inactive lesions). furthermore, unlike in adults, diffusion tensor imaging (dti) and magnetization transfer ratios (mtr) have not been systematically performed. finally, magnetic resonance spectroscopy (mrs) shows similar changes to those reported in adult ms patients with decreases in nacetyl aspartate (naa) reflecting neuronal loss, increases in choline reflecting remyelination, and increases in myoinositol reflecting gliosis [wolinsky and narayana, 2002] . ms remains a clinical diagnosis. in 1983, poser et al. published guidelines incorporating laboratory, neuroimaging, and neurophysiologic data into the diagnostic criteria with four proposed subtypes: clinically definite ms, laboratory-supported definite ms, clinically probable ms, and laboratory-supported probable ms (see table 2 ) . in 2001, the mcdonald criteria were introduced to facilitate and simplify the diagnosis of ms for patients between 10 and 59 years [mcdonald et al., 2001] . the authors further defined mri criteria and included both monosymptomatic disease and ppms in the clinical presentations. caution was suggested in applying these guidelines to children younger than 10 years. in fact, the sensitivity in diagnosing pediatric cases was questioned by a second panel that revised the mc-donald criteria in 2005 (see table 3 ) [polman et al., 2005] . furthermore, hahn et al. reported that many pediatric patients did not meet the mcdonald mri criteria for dissemination in space (see table 4 ) [hahn et al., 2004] . demonstrating dissemination in time (see table 4 ) is also challenging in pediatrics due to the possibility of relapses in a monophasic disease (see differential diagnosis section). nevertheless, a repeat mri performed three months after the initial study is recommended to show dissemination in time. acute disseminated encephalomyelitis (adem), multiphasic disseminated encephalomyelitis (mdem), and ms share similar clinical presentations, laboratory data, and neuroimaging abnormalities. subtle differences between the [dale et al., 2000; hynson et al., 2001; stonehouse et al., 2003 ]. in addition, hepatitis b; measles, mumps, rubella (mmr); bacille calmette-guérin (bcg); meningitis a and c; rabies; influenza; smallpox; and japanese b encephalitis vaccines, given within the six weeks prior to the onset of adem, have been suspected in triggering an autoimmune response [dale et al., 2000] . clinically, adem is more likely to present with ataxia, encephalopathy, bilateral optic neuritis, and seizures [hynson et al., 2001] . children typically have a polysymptomatic presentation with sensory, pyramidal, cerebellar, and bulbar symptoms [dale et al., 2000] . headache, fever, meningismus, and vomiting are more often associated with adem [brass et al., 2003] . unilateral optic neuritis and internuclear ophthalmoplegia are more common in ms [dale et al., 2000] . in adem and ms, the csf can be normal, although many patients have a lymphocytic pleocytosis or elevated protein. in adem, the csf white blood cell (wbc) count can be as high as 270 cells/mm 3 , with a mean around 51 cells/ mm 3 . in ms, the cell count is lower (range, 0 -130 cells/mm 3 ; mean, 18 cells/ mm 3 ) [dale et al., 2000] . the csf protein varies from 0.1 to 3.3 g/dl (mean, 0.69 g/dl) and 0.2 to 0.99 g/dl (mean, 0.38 g/dl) in adem and ms, respectively [dale et al., 2000] . ocb are seen in the csf in more than half of patients with childhood ms but can be seen in adem [dale et al., 2000; brass et al., 2003] . with considerable overlap between clinical and laboratory findings, mri is an important tool in determining the difference between adem and ms. both can affect the periventricular, sub-cortical, and deep white matter; deep gray matter; brainstem; cerebellum; and spinal cord. cortical white matter lesions are typically bilateral but asymmetric. in adem, lesions are less likely to be periventricular. also, adem more com1 yr of disease progression (retrospectively or prospectively determined) and two of the following: a) positive brain mri (9 t2 lesions or 4 or more t2 lesions with positive vep) f b) positive spinal cord mri (two focal t2 lesions) c) positive csf d note: if criteria indicated are fulfilled and there is no better explanation for the clinical presentation, the diagnosis is ms; if suspicious, but the criteria are not completely met, the diagnosis is "possible ms," if another diagnosis arises during the evaluation that better explains the entire clinical presentation, then the diagnosis is "not ms." a an attack is defined as an episode of neurological disturbance for which causative lesions are likely to be inflammatory and demyelinating in nature. there should be subjective report (backed up by objective findings) or objective observation that the event lasts for at least 24 hr. b no additional tests are required; however, if tests (mri, csf) are undertaken and are negative, extreme caution needs to be taken before making a diagnosis of ms. alternative diagnoses must be considered. there must be no better explanation for the clinical picture and some objective evidence to support a diagnosis of ms. c mri demonstration of space dissemination must fulfill the criteria derived from barkhof et al. [1997] and tintoré et al. [2000] as presented in table 4 . d positive csf determined using ocb detected using established methods (isoelectric focusing) different from any such bands in serum, or using an increased igg index. e mri demonstration of time dissemination must fulfill the criteria in table 4 . f abnormal vep of the type seen in ms. abbreviation: vep, visual-evoked potential. three of the following are required for demonstrating dissemination in space 1. at least one gadolinium-enhancing lesion or nine t2 hyperintense lesions if there is no gadolinium-enhancing lesion 2. at least one infratentorial lesion 3. at least one juxtacortical lesion 4. at least three periventricular lesions there are two ways to show dissemination in time: 1. detection of gadolinium enhancement at least three months after the onset of the initial clinical event, if not at the site corresponding to the initial event 2. detection of a new t2 lesion if it appears at any time compared with a reference scan done at least 30 days after the onset of the initial clinical event note: a spinal cord lesion can be considered equivalent to a brain infratentorial lesion, an enhancing spinal cord lesion is considered to be equivalent to an enhancing brain lesion, and individual spinal cord lesions can contribute together with individual brain lesions to reach the required number of t2 lesions. based on data from barkhof et al. [1997] and tintoré et al. [2000] . monly affects the thalami and basal ganglia, with a greater tendency for symmetry in the latter [dale et al., 2000] . in adem, a repeat mri scan performed more than two months after the onset of symptoms often shows partial or complete resolution of lesions with no new lesions. enhancement after the administration of gadolinium can be seen on the initial scan; however, no lesions enhance on the follow-up mri in adem. in ms, both new and enhancing lesions may be present when the scan is repeated, although the time to develop new lesions is unpredictable. in the absence of clinical symptoms, new findings on mri are useful in differentiating ms from adem. mdem presents a challenging dilemma in diagnosing childhood-onset ms. the clinical presentation, laboratory data, and neuroimaging features of mdem resemble adem, both of which are monophasic illnesses. however, patients with mdem have a clinical relapse after their initial illness or develop new lesions on mri, suggestive of a chronic demyelinating disease or ms. despite the presence of new lesions on mri, suggesting dissemination in time, some investigators believe that mdem and ms are separate entities. a diagnosis of mdem should be reserved for patients whose relapses are caused by the same trigger responsible for the inciting event and occur shortly after presentation or within two months of discontinuing steroids [dale et al., 2000] . ms is a neurodegenerative disease that affects young adults and children, often women. linkage and twin studies demonstrate that individuals carry a genetic susceptibility to this disease [rice, 2004] . a susceptibility locus for ms has been identified on chromosome 6, specifically the major histocompatability complex (mhc) class ii alleles human leukocyte antigens (hla) dr15 and dq6. this association is seen in all populations. in sardinians, there is an additional association with dr4, and, in turks, there is an association with dr2 and dr4. in finns, there is an association of ms with myelin basic protein (chromosome 18); however, neither this association nor an association with any other myelin genes has been noted in non-finnish populations [kenealy et al., 2003] . aside from the mhc locus, other regions of interest identified from the united kingdom study for ms susceptibility are located on chromosomes 1, 5, 6p, 7p, 14q, 17q, 19q, and xp [chataway et al., 1998] . some of the genes in these regions include tumor necrosis factor [tnf]␣, interleukin [il]-1ra, il-4, and cytotoxic t-lymphocyte-associated protein 4 (ctla-4). aside from the genetic predisposition for ms, epidemiological data indicates that an environmental factor also plays a role [compston, 2003] . for some time, an infectious agent has been suspected in triggering an autoimmune response. this theory was supported by apparent epidemics that occurred in the faroe islands and iceland following world war ii [rice, 2004] . additional support for an infectious etiology was provided by further studies that showed elevated antiviral titers (measles, rubella, mumps, varicella/zoster, ebv, influenza/parainfluenza,coronavirus, htlv-1, borna, etc) in the csf of ms patients during an acute exacerbation [ sibley et al., 1985; panitch, 1994] . presumably, the elevated titers represent nonspecific activation of b cells in the nervous system. in addition, the ms literature is replete with the isolation of viruses from the brains of patients with ms including measles, coronavirus, retroviruses, htlv-1, hhv-6, and scrapie agent. current focus on infectious agents includes ebv, hhv-6, endogenous retroviruses such as herv-w, and chlamydia pneumoniae [johnson and major, 2003] . oldstone postulated that an environmental trigger activates the immune system by "molecular mimicry" in which an infectious agent has sequence homology to a myelin protein. following the infection, tolerance is broken and an immune response ensues with the appearance of autoreactive t cells (cd4 and cd8) [oldstone, 1998] . alternatively, the pathogen activates toll receptors that then initiate the cellular immune response with the production of il-12 and il-23 [vasselon and detmers, 2002; frohman et al., 2006] . the earliest pathological change seen in an ms lesion is oligodendrocyte apoptosis with microglial activation but lacking infiltrating lymphocytes [barnett and prineas, 2004; matute and pérez-cerdá, 2005] . older lesions have perivascular infiltration by lymphocytes, plasma cells, and macrophages; loss of myelin and oligodendrocytes; axonal damage; and reactive astrocytes. chronic lesions are sharply demarcated with a hypocellular center and axonal loss, perivascular infiltration by lymphocytes, and increased number of oligodendrocytes. in chronic silent lesions, there is a loss of axons and oligodendrocytes. lucchinetti et al. have grouped the neuropathological lesions into four types, each containing t cells [lucchinetti et al., 1996 [lucchinetti et al., , 1999 [lucchinetti et al., , 2000 . type 1 is characterized by a predominance of macrophages, type ii by the deposition of immune complexes, type iii by oligodendrocyte malfunction, and type iv by oligodendrocyte death. there is insufficient data to describe the pathology of ms in children. ms is an organ-specific autoimmune disease mediated by type 1 helper t cells (t h 1) that recognize components of myelin and induce an inflammatory process by recruiting other inflammatory cells such as macrophages. in patients with ms, myelin-reactive t cells found in the blood stream produce a cytokine profile consistent with t h 1 cells. in demyelinating lesions, t h 1 cytokines, such as interferon ␥, tnf-␣, and il-2, are expressed by these leukocytes. the chemokine profile also suggests a t h 1-mediated inflammatory process. nevertheless, ms is likely to be more than a purely t h 1-mediated disease because it is likely that cd4 cells, macrophages, b cells, and a paucity of regulatory t cells also play a role [merrill, 1992; sorensen et al., 1999; frohman et al., 2006] . therapy in ms targets four different aspects of a child's illness. first, disease-modifying drugs, or immunomodulators (id), are used to alter the biological activity of the disease, thereby preventing neurological disability. second, additional medications help alleviate symptoms such as fatigue, spasticity, bladder dysfunction, and depression. third, neuroprotective agents are being studied to prevent and repair nerve injury. finally, rehabilitation is needed to overcome physical handicaps. disease modifying, symptomatic, and neuroprotective therapies will be described in this review. in evaluating effectiveness of therapies that modify the biological activity of the disease in children, a major challenge is the inability to predict the outcome of the disease and the lack of good outcome measures. the goal of any disease-altering therapy is to prevent longterm disability which evolves over many years [goodin et al., 2002] . the efficacy of the newer therapies has predominantly been studied over a short time period. moreover, the expanded disability status scale (edss) that is used as an outcome measure in adult studies has not been validated for use in children. children with ms may have cognitive dysfunction, which has not been evaluated as an outcome measure, although the ms functional composite (msfc) places some weight on mental functioning. once again, the utility of this scale has not been established in children. currently, most studies use the short-term attack rate as an outcome measure as well as mri data to assess t2 disease burden, cerebral atrophy, and the appearance of t1 black holes. although there are very few trials that have included children, in this article we review therapies that are recommended for adults and, where data is available, highlight the pediatric studies. glucocorticoids, such as intravenous (iv) methylprednisolone, are the mainstay of treatment for acute attacks or relapses in ms [goodin et al., 2002] . they suppress the immune system in many ways, such as altering cytokine profiles, inhibiting the synthesis of matrix metalloproteinases, and reducing csf antibodies to mbp and ocb [kupersmith et al., 1994] . in 1970, a multicenter trial compared adrenocorticotropic hormone (acth) (80 u/day given intramuscularly [im] for four days with a 7-day taper) against placebo in 197 patients with acute ms [rose et al., 1970] . after four weeks, the authors found that acth accelerated clinical improvement, although there was no significant difference in the outcome. in another study, acth (80 u/day for one week followed by a taper) was compared with 1 g of iv methylprednisolone for three days. in this study, there was no significant difference between the two treatment arms [thompson et al., 1989] . subsequently, a number of studies have been published using glucocorticoids for optic neuritis, most notably the optic neuritis treatment trial. this multicenter study compared iv methylprednisolone for three days followed by oral prednisone for 11 days against a 14-day course of oral prednisone and a placebo group. for both primary (visual fields and contrast sensitivity) and secondary (visual acuity and color vision) endpoints, the group that received iv methylprednisolone had an accelerated recovery of visual function compared to the placebo group. the rate of recovery for the group receiving oral prednisone was in between the iv and placebo groups. at six months, there was no difference between the treated and the placebo groups [beck, 1988] . furthermore, the group receiving oral steroids had an increased number of recurrences of optic neuritis. in addition to their use in optic neuritis, high-dose ste-roids are also known to enhance the resolution of gadolinium-positive mri lesions [barkhof et al., 1991; burnham et al., 1991] . finally, abrupt discontinuation of steroids can lead to severe clinical, radiographic, and histopathologic relapses; therefore, an oral taper is recommended. although these studies were performed in young adults with rrms and cis, iv steroids (15-30 mg/kg/day given daily for 3-5 days followed by an oral taper over 14 days) are used in children with acute attacks that impair function. interferons (ifn␤-1a and ifn␤-1b) are recombinant proteins, which inhibit the adhesion and the migration of wbc across the blood-brain barrier, thereby blocking antigen presentation and the synthesis and transport of matrix metalloproteinases [harris and halper, 2004] . in addition, they may cause a shift from a t h 1 to a t h 2 response. in adultonset ms, ifn-␤ has a beneficial effect on the clinical and radiological outcome measures. because the drug is not marketed for the pediatric population, there are no recommendations available for dosing children. for older children and adolescents, adult doses are most often used. interferon ␤-1a (inf␤-1a) is available in a weekly im injection (avonex, 30 g) or a subcutaneous (sc) injection given three times a week (rebif, 22 g or 44 g). interferon ␤-1b (inf␤-1b, betaseron, 8 million international units (miu) or 250 g) is given sc every other day. for smaller teens or children younger than 10 years, the doses are often adjusted to minimize adverse events and increase tolerability, such as starting with a half-dose of avonex or betaseron or using the lower dose for rebif. in 2006, banwell et al. retrospectively studied dosing, safety, and tolerability of ifn␤-1b in 43 children diagnosed with ms who had been treated for an average of 29.2 months [banwell et al., 2006] . treatment was initiated at full dose (8 miu or 250 g) in 15 children, all of whom were older than 10 years of age. younger children were started at 25-50% of the full dose and slowly increased; two children, both under the age of 10 years, were unable to tolerate the dose escalation. none of the children had any serious adverse events. therapy was discontinued in 25 of 43 patients after being treated for a mean duration of 111 weeks for various reasons, such as perceived lack of efficacy, cost of medication, lack of adherence, injection pain, and change in diagnosis. nevertheless, of the 38 patients with confirmed ms, the annualized relapse rate was reduced by a mean of 50%. the side effects of inf␤ in children are similar to those reported by adults. fever is the most common side effect, reported in 50% of the patients [ghezzi et al., 2005] . additional side effects include headache, myalgia, flu-like symptoms, injection site reactions, fatigue, nausea, and asthenia [waubant et al., 2001; banwell et al., 2006] . the majority of these symptoms are transient. to alleviate side effects, children may be pretreated with acetaminophen, ibuprofen, or naproxen. laboratory abnormalities, such as elevations of liver function tests, can also occur. when present, a temporary discontinuation of the medication is recommended. often, the inf␤ can be restarted without a recurrence of the elevated transaminases [banwell et al., 2006] . ga is a random polypeptide composed of four amino acids (l-glutamic acid, l-lysine, l-alanine, and l-tyrosine) resembling myelin basic protein (mbp). this drug has a number of effects on the immune system including inhibition of antigen presentation, competition and displacement of bound mbp, conversion of cd4 t cells from t h 1 to t h 2 type cells, and induction of brain-derived neurotrophic factor (bdnf) expression [teitelbaum et al., 1992; neuhaus et al., 2001; aharoni et al., 2003; azoulay et al., 2005] . it also induces antigen-specific suppressor t cells which release anti-inflammatory cytokines thereby generating tolerance to self-antigens [harris and halper, 2004] . there are no trials similar to those conducted in adults that have primarily focused on the efficacy of this drug in children with ms. there are, however, reports of using this drug in children who were given 20 mg sc daily, the standard dose for an adult. in one child treated with ga, chest pain was reported; however, no other clinical or laboratory abnormalities were identified [ghezzi et al., 2005] . although inf␤ and ga have been used in practice, the long-term tolerability, side effects, and overall efficacy in the pediatric population is not yet known. in a multicenter italian study published in 2005, ghezzi et al. focused on effectiveness and tolerability of interferons and glatiramer acetate in patients treated before the age of 16 [ghezzi et al., 2005] . sixty-five cases were reviewed. the majority was treated with avonex (38), followed by rebif (18), betaseron (16), and copaxone (9). relapses were defined as the occurrence of new symptoms lasting more than 24 hr with objective findings of cns involvement in a previously unaffected patient or the acute worsening of preexisting symptoms lasting more than 24 hr and causing an increase of at least 1 on the edss. all four of the drugs substantially reduced the relapse rate with combined data showing a decrease from 2.8 to 0.5 relapses per year and similar results for the individual medications. the change in edss was not significantly different when comparing the first and last visit in the inf␤ subgroups; however, a statistically significant difference was seen in the ga subgroup (baseline: 1.1 ϯ 0.5, posttreatment: 0.6 ϯ 0.5, p ϭ 0.007). it should be noted that the patients on ga had overall lower disease duration when compared to the other groups and edss at entry was lower than that in the avonex and rebif/betaseron groups. natalizumab is a recombinant monoclonal antibody directed against ␣4-integrin. in experimental autoimmune encephalitis (eae), the animal model for ms, the expression of t-cell surface receptors (integrins) promotes adhesion and transport of these cells through capillary endothelial cells. this antibody against ␣4-integrin blocks the adhesion of activated t lymphocytes to endothelial cells thereby preventing these cells from entering the nervous system. this is the only selective immunomodulating drug for the treatment of ms. the results from the natalizumab safety and efficacy in relapsing remitting multiple sclerosis (affirm) and safety and efficacy of natalizumab in combination with interferon ␤-1a in patients with relapsing remitting multiple sclerosis (sentinel) studies in adult patients indicate that the annualized rate of clinical relapses was reduced by 68%, the number of new and enhancing mri lesions was reduced by 83%, and a decrease occurred in progression and prolongation of the interval before neurological deterioration, demonstrating the usefulness of the drug [polman et al., 2006; rudicket al., 2006] . although natalizumab had significant short-term beneficial effects, unfortunately, three patients who received this drug developed progressive multifocal leukoencephalopathy (pml). the relative risk of developing pml in ms patients on natalizumab is 1 in 1,000 [ropper, 2006 ]. moreover, the use of this drug may have other long-term effects, such as unmasking latent viral infections as well as other diseases that are dampened by immune surveillance. in children who have a malignant course of ms, the use of this drug on a short-term basis may be warranted. campath-1h binds cd52 antigen, which is present on the surface of all b and t lymphocytes, as well as some monocytes. it is a lympholytic antibody that has been shown to prevent relapses and the formation of new mri lesions in ms; however, it does not seem to have any effect on disease progression [paolillo et al., 1999] . furthermore, when campath-1h was initially used in patients with ms, a transient worsening of symptoms occurred due to the release of cytokines and nitric oxide (no) [moreau et al., 1996] . in vitro studies demonstrated that no can cause conduction blocks that could account for the transient worsening of symptoms with treatment initiation. pretreating with steroids can avert the cytokine release. rituximab is a humanized monoclonal antibody directed against cd20 and antigens found on b lymphocytes [valentine et al., 1989 ]. b-cell proliferation, as well as an increase in the mutations of their receptors, has been shown in the csf of ms patients. the b-cell response reflects the presence of a specific antigen in the cns. thus, the b cells have become another therapeutic target in ms. rituximab, a drug that depletes b cells, is currently being investigated in the treatment of ms [reff et al., 1994; frohman et al., 2006] . mitoxanthrone is an anticancer drug that acts by intercalating into dna thereby producing dna strand breaks and interstrand crosslinking. in the immune system, it causes the elimination of lymphocytes and reduction of t h 1 cytokines. the major side effects include cardiac toxicity, presenting as a cardiomyopathy with irreversible congestive heart failure, and increased risk of developing malignant tumors. nevertheless, this drug reduced the attack rate of patients with rrms by 66%, reduced the number of gadolinium-enhancing and new lesions on the mri, and reduced the clinical rate of progression of the disease [millefiorini et al., 1997] . given the toxicity profile, this is not a first-line drug for the treatment of ms in children. cyclophosphamide is a powerful immunosuppressive agent that has been used to treat relapsing-remitting and progressive forms of ms. side effects include alopecia, nausea and vomiting, hemorrhagic cystitis, sterility, and long-term risk of malignancy. the use of iv cytoxan (400 -500 mg/day with wbc counts about 4,000 per microliter) did not show any benefit for patients with progressive ms at 1-and 2-year follow-up after the initiation of therapy [hauser et al., 1983; likosky et al., 1991] . in a canadian study using 1,000 mg of cytoxan with a 3-year follow-up of patients with progressive ms, there was no significant benefit from use of this drug [canadian cooperative ms study group, 1991] . nevertheless, in a study of 256 patients with progressive ms, younger patients derived some benefit from the use of cytoxan [weiner et al., 1993] . methotrexate acts as a folate antagonist, thereby affecting dna synthesis in immune cells. it decreases proinflammatory cytokines and enhances suppressor t-cell function. the major side effects are nausea, headache, diarrhea, liver damage, and the risk of developing non-hodgkin's lymphoma. a small, doubleblinded study of low-dose methotrexate revealed a benefit for patients with rrms but not for patients with the progressive forms of the disease [currier et al., 1993] . however, in another study of 60 patients with chronic progressive ms, low-dose methotrexate was found to be beneficial and showed a reduction in the t2 diseased burden [goodkin et al., 1995] . azathioprine is an analog of 6-mercaptopurine that inhibits purine synthesis, thereby impairing dna and rna synthesis in b cells, t cells, and macrophages. its side effects are anemia, lymphopenia, alopecia, liver dysfunction, pancreatitis, reactivation of latent infections, and the risk of developing malignancies. in a retrospective analysis of seven studies that had enrolled 793 patients, use of imuran reduced the number of relapses; however, the drug did not seem to affect the course of patients with progressive ms or their disability [yudkin et al., 1991] . cyclosporine is a potent immunosuppressive agent that selectively inhibits helper t cells. side effects include hirsutism, headaches, nausea, hypertension, edema, paresthesias, nephrotoxicity, and abdominal pain and discomfort. studies conducted in london and amsterdam showed no benefit on the relapse rate but did show some effect on slowing the progression of the disease [rudge et al., 1989] . given the side effects of this drug, its use in ms is very limited [goodin et al., 2002] . cladribine, an adenosine deaminase-resistant purine nucleoside, is a potent immunosuppressive drug that is selective for lymphocytes. side effects include nausea, diarrhea, fever, fatigue, and leukopenia. although cladribine does not have a significant effect in reducing the relapse rate, it may slow the degree of disability. in addition, it reduces the appearance of gadolinium-enhancing lesions on mri [beutler et al., 1996; rice et al., 2000] . 3-hydroxy-3-methylglutaryl coenzyme a (hmg-coa) reductase inhibitors, also called statins, have been recently studied in a variety of cns disorders, including ms. statins disrupt the activation of proinflammatory t-cells by inhibiting signals from mhc class ii molecules [neuhaus et al., 2002] . they also decrease migration of leukocytes into the cns, expression of inflammatory mediators by t-lymphocytes and in the cns [stüve et al., 2003] . statins, such as simvastatin (zocor) and atorvastatin (lipitor) have been shown to inhibit and reverse chronic and relapsing eae [stüve et al., 2003] . atorvastatin induces stat6 phosphorylation and enhances the secretion of t h 2 cytokines (il-4, -5, and -10 and transforming growth factor [tgf] ␤) while inhibiting stat4 phosphorylation and secretion of t h 1 cytokines (il-2, -12, ifn-␥, and tnf␣) [youssef et al., 2002] . in small, shortterm studies, zocor decreased the number and size of gadolinium-positive lesions on mri scans without effect on progression and disability [vollmer et al., 2004] . the immunomodulatory effects of the statins offer promise in the treatment of ms, and their usefulness is being further investigated [neuhaus et al., 2004] . vaccination therapies are currently being developed that would alter the treatment of ms. vaccinations that promote the development of tolerance have been effective in eae [robinson et al., 2003 ]. in addition, t cell and t cell receptor peptide vaccinations have been studied in humans with ms [correale et al., 2000; bourdette et al., 2005] . none of the vaccines have been studied in children. iv immune globulin (ivig) blocks fc receptors on macrophages, alters the cytokine profile, and has antiidiotypic effects. ivig is typically used as an adjunct for acute relapses; however, its recurrent use has been studied in rrms. in a multicenter, double-blind, placebo-controlled study of 148 rrms patients given ivig (0.125-0.2 g/kg) monthly for two years, a reduction in the clinical attack rate (ϫ49%) with a possible reduction in the degree of disability (not significant) was observed [fazekas et al., 1997] . in a separate study, the number of total and enhancing lesions seen on mri was decreased by more than 60% in patients treated with ivig compared with placebo [sorenson et al., 1998 ]. thus, it appears that ivig may reduce the attack rate in rrms but probably has little effect in slowing the progression of the disease. although it does not alter the long-term course in ms, plasma exchange has been used to treat acute relapses, presumably by removing harmful antibodies. several groups have investigated this particular therapeutic modality for treatment of patients with progressive ms [hauser et al., 1983] . for some patients who had not responded to iv steroids, plasma exchange performed every other day for a total of 14 days provided a greater degree of improvement when compared with a sham-treated group [weinshenker et al., 1999] . some patients receiving plasma exchange improve very rapidly, which is unlikely due to the repair of the injured tissue. instead, the rate of recovery may be due to the rapid shifts in electrolytes that result in improved axonal conduction or the possible removal of an antibody that affects transmission of electrical impulses. although fatigue is a common and debilitating symptom is adults, children rarely complain of this symptom. the mechanism for fatigue is multifactorial and includes depression, excessive effort due to muscle weakness or spasticity, re-lease of cytokines, and sleep disturbance. therapies for fatigue in ms include the use of amantadine, modafanil, and pemoline. all have been shown to have modest beneficial effect in adults. when patients have involvement of the corticospinal tracts, whether it be due to lesions in the spinal cord or higher, treatment should include physical therapy, splints to prevent contractures, and stretching exercises combined with pharmacological treatments, such as diazepam (valium), tizanidine (zanaflex), baclofen (lioreseal), and dantroline (dantrium). less well established is the use of tetrahydocannabinol. for contractures that do not respond to stretching, alternatives include serial casting, botox injections, and tenotomy. in more severe cases, a baclofen pump, or rhizotomy or myelotomy, may be considered. hemiplegia in children is disabling, particularly because of the loss of dexterity. sensory impairment further aggravates movements of the hand. such children do not use the affected hand, which results in learned nonuse of that hand. recent studies indicate that such children benefit from intensive practice and forced use; restraint of the noninvolved arm appears to improve function of the affected hand, probably due to functional reorganization of the nervous system. patients with ms have a variety of paroxysmal symptoms that last seconds to minutes and are not associated with alterations in consciousness or any electroencephalogram correlate for seizure. paroxysmal sensory symptoms and motor symptoms, such as ataxia and lhermitte's sign, respond to low doses of carbamezapine, phenytoin, and acetazolamide. heat-sensitive symptoms can respond to potassium channel blockers with the caveat that these drugs can induce seizures. this is not an uncommon symptom in some children. nonsteroidal antiinflammatory agents are recommended. if they are not sufficient, gabapentin (neurontin), carbamezapine (tegretol), or amitriptyline (elavil) can be beneficial. in ms, axonal injury occurs early in the course of the disease with eventual transection of axons. factors that have been associated with axonal injury are cytokines, no, superoxide radicals, proteases, cd8 t cells, cholesterol breakdown products, abnormal expression of sodium channels and function of the sodium-calcium exchanger, and glutamine excitotoxicity [waxman et al., 2004] . when an axon is demyelinated, there is abnormal expression of voltagegated sodium channels with increased influx of sodium in an attempt to restore conduction. to compensate for this, there is a reversal of the sodium/calcium exchanger with efflux of sodium and an influx of calcium. this could result in calcium-mediated neuronal degeneration. this hypothesis has received some support from work on eae models where sodium channel blockers, such as flecainide and phenytoin, help preserve axons [lo et al., 2003; bechtold et al., 2004] . in patients with ms, mrs has demonstrated increased glutamate concentration, providing the underpinning for considering glutamate excitotoxicity. the increased glutamate could result from a decrease in glutamate transporters in glial cells and elevation of glutaminase, a glutamate-synthesizing enzyme, in microglia [werner et al., 2001] . however, increased glutamate acting through the ␣-amino-3-hydroxy-5-methyl-isoxazole-4-propionic acid (ampa) and/or nmethyl-d-aspartate (nmda) receptors, which are present on neurons and oligodendrocytes, can result in calcium-mediated cell death. riluzole, a glutamate antagonist that has been used in infants with spinal muscular atrophy, blocks nmda and sodium channels and reduces the number of t1-weighted hypointense lesions on the mri scans of patients with ms [frohman et al., 2006] . because axonal damage is a feature of ms, promoting neurite outgrowth could be beneficial. however, axonal sprouting is inhibited by activation of the nogo receptor by agonists such as nogo, oligodendrocyte-myelin glycoprotein (omgp), and myelin-associated glycoprotein (mag). thus, blocking the nogo receptor could represent a therapy that would be of value in promoting axonal sprouting [wang et al., 2002] . in acute ms plaques, there is clearcut evidence for remyelination; however, this is minimal in chronic lesions. the recruitment of oligodendrocyte precursor cells to areas of demyelination is mediated via chemokine and cytokine receptors, a pathway that appears to be intact. once attracted to areas of damage, these precursor cells recapitulate the differentiation process; however, full differentiation of these cells may be dampened by macromolecules that are negative regulators of this process, such as activation of the notch pathway due to reexpression of the ligand jagged or the nogo receptor interacting protein. in the future, both of these targets may be sites for therapeutic intervention that will aid the process of remyelination. in addition, transplantation of stem cells or oligodendroglial progenitor cells may be a consideration [john et al., 2002; mi et al., 2005; frohman et al., 2006 ]. ms is best recognized for its relapsing and remitting clinical course. in fact, in both children and adults, rrms is the most common form, followed by the secondary and primary progressive forms. however, the prognosis for pediatric ms remains controversial. the edss has been used to quantify the disability associated with ms by assigning a functional score for multiple systems (pyramidal, cerebellar, brainstem, sensory, bowel and bladder, visual, and cerebral) [kurtzke, 1983] . patients with a score of 0 have a normal neurological exam. scores between 1.0 and 3.5 are fully ambulatory, whereas 4.0 -5.5 are ambulatory for short distances without aid or rest. patients with scores greater than 6 require assistance with ambulation as well as other activities of daily living. in 2002, boiko et al. compared the time to edss of 3.0 (mild disability in at least three domains or moderate disability in one area) and 6.0 (requiring intermittent or constant unilateral assistance to walk 100 meters with or without resting) in adult-and pediatric-onset ms [boiko et al., 2002] . on average, adults had a 50% risk of reaching edss scores of 3.0 and 6.0 in 10 and 18 years, respectively, after onset whereas disability in children was much slower, taking 23 and 28 years, respectively. in addition, 53.1% of children with rrms progressed to spms after an average of 17.7 years (sd 1.17 years). the 50% risk for conversion from rrms to spms was 23 years in children, whereas it was 10 years in adults. although this data suggests a slower disease course in children, the overall morbidity is typically greater when children reach adulthood. children have higher edss scores when compared to adults with ms of the same age [ghezzi et al., 2005] . ms is under-recognized in the pediatric population and presents new challenges in diagnosis and treatment. despite significant advances in neuroimaging, ms remains a clinical diagnosis. new guidelines allow earlier diagnosis, but they have not been reliably established in children, especially those younger than 10 years of age. in addition, these guidelines may not be sufficient to prevent the inclusion of monosymptomatic demyelinating disorders, which do not require long-term treatment. early diagnosis and treatment with immunomodulatory agents are critical to reducing the morbidity and mortality associated with this disease. although these drugs have been used in practice, more data is needed on long-term tolerability, side effects, and overall efficacy in the pediatric population. f glatiramer acetate-specific t cells in the brain express t helper 2/3 cytokines and brainderived neurotrophic factor in situ lower brain-derived neurotrophic factor in serum of relapsing remitting ms: reversal by glatiramer acetate safety and tolerability of interferon ␤-1b in pediatric multiple sclerosis comparison of mri criteria at first presentation to predict conversion to clinically definite multiple sclerosis quantitative mri changes in gadolinium-dtpa enhancement after high-dose intravenous methylprednisolone in multiple 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the northeast cooperative multiple sclerosis treatment group a randomized trial of plasma exchange in acute cns inflammatory demyelinating disease multiple sclerosis: altered glutamate homeostasis in lesions correlates with oligodendrocyte and axonal damage magnetic resonance spectroscopy in multiple sclerosis: window into the diseased brain the hmg-coa reductase inhibitor, atorvastatin, promotes a th2 bias and reverses paralysis in cns autoimmune disease overview of azathioprine treatment in multiple sclerosis key: cord-282342-5158g9kb authors: takao, masaki; abe, hirohito; sakai, takashi; hamada, hidetoshi; takahara, shiro; sugano, nobuhiko title: transitional changes in the incidence of hip osteonecrosis among renal transplant recipients date: 2019-07-04 journal: j orthop sci doi: 10.1016/j.jos.2019.06.009 sha: doc_id: 282342 cord_uid: 5158g9kb abstract background immunosuppressive therapy for renal allograft recipients has changed substantially since the introduction of the anti-cd25 monoclonal antibody, basiliximab. we hypothesized that recent improvements in immunosuppressive treatment may reduce the incidence of osteonecrosis of the femoral head (onfh). this study aimed to investigate transitional changes in the incidence of ofnh among renal transplant recipients by mri. methods participants comprised 110 patients who had undergone renal transplantation from 2003 to 2012, during which time basiliximab was in regular use at our institute (recent group), and 232 patients who had undergone rt between 1986 and 2003 (past group). we compared onfh incidence between the two groups and evaluated risk factors for onfh, including immunosuppressants (calcineurin inhibitors, basiliximab, and/or steroids) and postoperative renal function. results incidence of onfh was lower in the recent group (0%) than in the past group (3.4%; p = 0.043). in the recent group, age was greater, abo/human leukocyte antigen incompatibility was worse, while steroid dose was decreased and post-transplant renal function was improved. cumulative methylprednisolone dose at postoperative week 2 and delayed graft function were identified as risk factors for onfh. conclusion risk of onfh after renal transplantation has fallen with the advent of regular use of basiliximab, although this agent does not appear to be a factor directly associated with the incidence of onfh. study design clinical prognostic study (level iii case control study). osteonecrosis of the femoral head (onfh) is well recognized as a musculoskeletal complication after renal transplantation (rt). with advances in immunosuppressive therapy, improved posttransplant renal function and reduced corticosteroid dose are reported to have led to a decrease in the incidence of onfh [1e4]. however, according to recent screening studies using magnetic resonance imaging (mri), this incidence ranged from 3.8% to 25.5% [3,5e11] , inferring that onfh remains a significant complication among renal allograft recipients. immunosuppressive therapy for renal allograft recipients has changed substantially since the introduction of the anti-cd25 monoclonal antibody, basiliximab (simulect; novartis, east hanover, nj). when administered as induction therapy during the early postoperative period, improvements in postoperative renal function have been reported [12e15] . decreases in the doses of steroids and calcineurin inhibitors have also been reported [15] and indications for rt have therefore been expanded to include higherrisk patients with older age and increased human leukocyte antigen (hla) mismatch. however, the impact of basiliximab administration on the incidence of post-transplant onfh has not yet been determined, and few mri screening studies have been conducted since its introduction [3] . we hypothesized that recent improvements in immunosuppressive treatment may reduce the incidence of onfh even with wider indications for rt. the purpose of the present study was twofold: 1) to investigate transitional changes in the incidence of ofnh among renal transplant recipients by mri; and 2) to investigate factors related to onfh for the entire cohort. the ethical review board of our institution approved the design of this study (registration number: 13271). the recent group included 110 patients (61 men, 49 women; mean (±standard deviation) age, 43 ± 13 years, range, 16e70 years); mean body mass index (bmi), (21.9 ± 3.3 kg/m 2 ) who underwent mri of both hips after rt between april 2003 and june 2012 (i.e., during the period in which basiliximab was regularly used). during the period, 155 patients underwent rt. the past group included 232 patients (143 men, 89 women; mean age, 34 ± 13 years; mean bmi, 21.9 ± 3.4 kg/ m 2 ) who had undergone rt between january 1986 and march 2003 (i.e., prior to the regular use of basiliximab). during the period, 332 patients underwent rt. there was no significant difference in the rates of mri screening between the groups. (69.8% (232/332) vs 70.9% (110/155), p ¼ 0.80, chi-square test). all patients were notified about the reported incidences of onfh after rt, benefits and risks of mri, and possible treatment options, and given the opportunity to object. mri was performed 3 months after rt using either a 1.0-t superconducting magnet system (signa horizon lx 1.0t; general electric medical systems, milwaukee, wi), or one of two 1.5-t superconducting magnet systems (smt150x; shimadzu, kyoto, japan or achieva 1.5t a-series; philips healthcare, amsterdam, the netherlands). osteonecrosis was defined as an area of normal intensity demarcated by a low-intensity band on t1-weighted imaging [16] . t1-weighted spin-echo images were obtained using a 1.5-t system in the coronal and sagittal planes, with the following settings: repetition time (tr), 500e800 ms; echo time (te), 12e43 ms; and slice thickness, 2e10 mm. spoiled gradient-recalled echo pulse sequences were obtained using the 1.0-t system in the coronal plane with the following settings: tr, 4.5e14 ms; te, 1.84e3.08 ms; flip angle, 30 ; and slice thickness, 1.0e1.5 mm with no interslice gap. the following items were evaluated: onfh incidence; patient demographic and background factors, including gender, age, bmi, and abo and hla incompatibility; duration of preoperative dialysis; type of renal graft (living/cadaveric donor); preoperative immunosuppressant use, including calcium inhibitors (cyclosporine a/tacrolimus) administered initially or at the time of hospital discharge; concomitant basiliximab administration; steroid administration at 2, 4, 6, and 8 weeks after rt, as prednisolone (psl), methylprednisolone (mpsl), and total steroid doses (converted to psl-equivalent doses); postoperative renal function, including delayed graft function (dgf), blood urea nitrogen (bun) and creatinine (cr) levels at 8 weeks after rt, and acute transplant rejection; and duration of hospitalization. psl-equivalent doses were calculated by adjusting the mpsl dose on the basis of antiinflammatory potency, using a conversion factor of 1.25. acute transplant rejection was diagnosed as follows: a 40% increase in bun or a 20% increase in cr level compared with those at a previous sampling, daily urinary output 750 ml, and diagnosis by biopsy. dgf was defined as a patient requiring hemodialysis in the first week after rt. we compared these items between the recent and past groups using the mannewhitney u-test, chi-square test, and fisher's exact probability test for statistical analyses. in addition, we investigated factors influencing the incidence of onfh for the entire cohort. uniand multivariate logistic regression models were used to identify significant risk factors for onfh for the entire cohort. the adjusted odds ratio (or) for predicting onfh was determined for each factor identified by univariate logistic regression analysis. spss for windows version 20.0j statistical software (spss, chicago, il) was used for all statistical analyses. a 5% significance level was applied to all tests. no cases of onfh were recorded in the recent group (0%; 95% confidence interval (ci), 0%e3.3%), although eight cases of onfh were recorded in the past group (3.4%; 95% ci, 1.5e6.7%; one-sided fisher's exact probability test, p ¼ 0.043). intergroup comparisons of background and demographic factors revealed significant increases in age, bmi, number of patients with abo and hla incompatibilities, and living kidney donors in the recent group ( table 1) . comparison of postoperative immunosuppressant use showed increased frequency of tacrolimus use, increased number of patients with concomitant use of basiliximab, and decreases in mpsl, psl, and total steroid dose at postoperative weeks 2, 4, 6, and 8 in the recent group ( table 1) . regardless of the increase in risk factors for rt such as older age and increased number of abo/hlaincompatible transplants among patients, decreases in steroid administration and improvements in postoperative renal function have been observed in the recent group. in addition, significant decreases were seen in the number of cases with dgf, concentrations of bun and cr at 8 weeks after transplantation, incidence of acute transplant rejection, and duration of hospitalization over time ( table 1) . the overall results were surveyed for risk factors for onfh. according to the analysis of individual factors, total mpsl dose at postoperative weeks 2, 4, 6, and 8, total steroid dose at postoperative weeks 2, 4, 6, and 8 and dgf were identified as significant risk factors (table 2) . psl administration at postoperative weeks 2, 4, 6, and 8 was not a risk factor. we performed multivariate analysis (logistic regression analysis) for age, gender, and total mpsl dose at postoperative week 2, and dgf. significant risk factors for onfh were total mpsl dose at postoperative week 2 (or, 2.90; 95% ci, 1.04e8.07; p ¼ 0.04) and dgf (or, 5.97; 95% ci, 1.36e26.26; p ¼ 0.02) ( table 3) . when the mpsl doses at postoperative weeks 4, 6, and 8 were selected as a risk factor rather than that at week 2, the following were the adjusted values: for week 4, or was 2.29 (95% ci, 1.03e5.13; p ¼ 0.04); for week 6, or was 1.83 (95% ci, 1.02e3.28; p ¼ 0.04); and for week 8, or was 1.71 (95% ci, 1.03e2.83; p ¼ 0.04). mpsl administration at week 2 showed the highest adjusted or. the types of onfh according to japanese investigation committee classification, their natural course and surgical treatment were summarized in table 4 . improvements in post-transplant renal function and reductions in corticosteroid dose may have led to a decrease in the incidence of onfh [1e4]. renal graft function after rt has been improving with advances in immunosuppressive agents such as cyclosporine a [2, 17] and tacrolimus [12e14] . several other immunosuppressive agents including sirolimus, everolimus, mycophenolate mofetil, and basiliximab have been introduced in combination with cyclosporine a or tacrolimus and have also improved postoperative renal function [18] . in contrast, few reports have been published about the influence of these new immunosuppressive agents on the incidence of onfh after rt. basiliximab, an anti-cd25 monoclonal antibody, is a very strong immunosuppressive agent that exerts its effects through competitive interleukin-2 antagonism [19] . when administered as an induction therapy during the early postoperative period, in conjunction with one or more conventional immunosuppressive drugs, decreases in the incidences of acute transplant rejection and dgf and improvements in survival of the transplanted kidney have been reported [12e15] . decreases in steroid and calcineurin inhibitor doses have also been reported [15, 20, 21] . these marked changes in immunosuppressive treatments and postoperative renal function may have reduced the incidence of onfh. the proportion of onfh patients receiving steroid treatment for renal transplantation has reportedly decreased recently according to the multicenter hospital-based sentinel monitoring system for onfh in japan [22] , although the reasons for these decreases in the proportion of onfh patients receiving renal transplantation remain unclear. in addition, only a small number of reports since 2001 have described mri screening for onfh after rt, and the impact of the introduction of basiliximab on the post-transplant incidence of onfh has yet to be determined. we therefore investigated the incidence of onfh since the advent of regular basiliximab use and found that postoperative renal graft function had improved, and the mpsl dose and incidence of dgf as risk factors for onfh had decreased. in addition, the incidence of onfh had decreased. basiliximab seems likely to indirectly reduce the incidence of onfh by reducing the incidence of dgf and allowing reductions in mpsl administration. three main limitations need to be considered when interpreting the results from the present study. first, the number of renal transplant recipients with use of basiliximab might be too small to evaluate its effect on the incidence of onfh. the number of patients included in previous mri screening studies ranged from 26 to 150 [3,5e10] , so the number of patients in the present study is comparable with the numbers in those studies. second, mri screening was not performed before rt, so we could not be sure that onfh had not been present prior to transplantation. nevertheless, because the incidence of onfh in our study was lower than that in any previous study evaluated using mri, the incidence was presumed to have also been low even before transplantation. third, the timing of mri screening was earlier compared to other mri screening studies. this might be one reason the incidence of onfh at our institute was lower than described in other reports performed during a similar period. we did not encounter any symptomatic cases with onfh in which mri had been negative at 3 months after rt, so we considered that the incidence of onfh occurring after 3 months after rt was unlikely to have been particularly high. onfh did not occur in any of the 110 patients who underwent rt between april 2003 and june 2012 at our institution, despite the wider indications for rt in high-risk patients, such as older age and more severe abo and hla incompatibilities. in previous mri screening studies of onfh after rt performed between 1986 and 2001 without the use of basiliximab, incidences of onfh after rt were within the range of 3.4e25.4% [3,5e10] . although a downward trend was observed in those studies, no mri screening studies for onfh have been reported since 2002, and the present study showed the lowest incidence of onfh after rt among all relevant studies (table 5) . to elucidate the risk factors for onfh, all rt recipients who underwent mri screening at our institute were analyzed. the results showed that dgf and cumulative mpsl administration up to 2 weeks after rt were significant risk factors. other risk factors for onfh reported after rt include daily oral steroid dose, bun level 2 months after rt, accumulated steroid dose at 2 months, accumulated steroid dose at 2 weeks, ethnicity (african-american), history of peritoneal dialysis, rejection, delayed graft function, and cyclosporine a administration [1,10,11,23e25] . to date, cumulative steroid dose as of 2 weeks postoperatively has been reported as the shortest-term risk factor for onfh [24] . the risk factors for onfh after rt in the present study were in accordance with past findings. this result suggests that onfh occurs mostly within the first 2 weeks after rt, suggesting the importance of controlling postoperative graft function and reducing cumulative mpsl administration in the first 2 weeks after rt using immunosuppressive agents that are appropriate for the prevention of onfh. a recent meta-analysis of onfh occurrences among patients taking corticosteroids reported positive associations between mean daily corticosteroid doses and onfh across all diagnoses, including severe acute respiratory syndrome, systemic lupus erythematosus, bone marrow transplantation and renal transplantation, although the correlation between mean daily corticosteroid dose and onfh incidence was not significant among renal transplant recipients [26] . no evidence of a significant correlation between cumulative corticosteroid dose and incidence of onfh has yet been provided [26, 27] . in renal transplant recipients, daily steroid dose is gradually tapered according to the immunosuppressive regimen, so reflecting an overall picture of steroid treatment using a mean value for daily steroid dose is difficult. in addition, duration of steroid treatment and overall cumulative steroid dose vary widely among renal recipients, and steroid administration after onset of onfh might be included in the regression analysis. we therefore focused on the correlation between steroid administration including oral steroid administration and pulsed steroid therapy in the 8 weeks after renal transplantation and onset of onfh at 3 months. the risk of onfh after rt has fallen since the advent of regular basiliximab use, although this agent does not appear to be a factor directly associated with the incidence of onfh. factors related to onfh incidence were found to be renal graft function and mpsl administration for up to 2 weeks. since the introduction of basiliximab, immunosuppressive therapy has changed markedly and renal graft control has also been enhanced, which may have led to decreases in the incidence of onfh. this research is supported by the practical research project for rare/intractable diseases from japan agency for medical research and development, amed. in accordance with icmje criteria, ns and st designed the study and mt wrote the initial draft of the manuscript. ha contributed to the collection and interpretation of data and the assistance of the preparation of the manuscript. the literature data were searched and analyzed by mt and ha. all other authors contributed to the data collection and interpretation. all authors approved the final version to be submitted for publication and agree to be accountable for all aspects of the work. none. all procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional research committee and with the 1964 declaration of helsinki and its later amendments or comparable ethical standards." informed consent was obtained in the form of opt-out on the web-site. those who rejected were excluded. maintenance immunosuppression use and the associated risk of avascular necrosis after kidney transplantation in the united states cyclosporin a and osteonecrosis of the femoral head incidence of hip osteonecrosis among renal transplantation recipients: a prospective study tacrolimus may be associated with lower osteonecrosis rates after renal transplantation early detection of avascular necrosis of the femoral 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femoral head from 1997 to 2011: a hospital-based sentinel monitoring system in japan hospitalized avascular necrosis after renal transplantation in the united states corticosteroid administration within 2 weeks after renal transplantation affects the incidence of femoral head osteonecrosis cyclosporine use and male gender are independent determinants of avascular necrosis after kidney transplantation: a cohort study high-dose corticosteroid use and risk of hip osteonecrosis: meta-analysis and systematic literature review etiologic classification criteria of arco on femoral head osteonecrosis part 1: glucocorticoidassociated osteonecrosis authors thank dr. hideki yoshikawa, dr. koji yazawa, and dr. naotsugu ichimaru for helpful advice. key: cord-257075-9x0530cb authors: claudi, carolin; ganser, joachim; andreisek, gustav; vrugt, bart title: a juxta-articular myxoma of the thumb a case report date: 2020-04-20 journal: j hand surg glob online doi: 10.1016/j.jhsg.2020.04.002 sha: doc_id: 257075 cord_uid: 9x0530cb abstract juxta-articular myxomata are benign tumors which are mostly encountered in the vicinity of larger joints. few cases in the hand have been reported. we present a case of a juxta-articular myxoma at the metacarpophalangeal joint of the thumb in a 40 year-old man. the preoperative diagnostic work-up included 4d mr-angiography and ultrasound. the histochemical examination of the resected tumor established the diagnosis definitively. a follow-up mri, scheduled without any clinical suspicion of tumor-recurrence, 9 months postoperatively, did not reveal any obvious recurrence. at 14 months, the patient has full motion without pain and declined any further imaging. juxta-articular myxomata (jam) are benign soft tissue neoplasms of mesenchymal origin. 18 these cystic tumors resemble a ganglion, and tend to recur after resection 1 thumb. initially, this tumor was hardly noticeable, but it grew slowly over the past year. as it 27 was situated in the commissure between thumb and index finger, the pressure when 28 grasping larger objects provoked mild pain. 29 the clinical examination revealed a solid, circumscribed round mass of 25 mm which was 30 adherent to the ulnar-palmar aspect of the metacarpal joint of the thumb. it was scarcely 31 visible as the texture and color of the skin were normal. the tumor did not adhere to the 32 skin or tendons (figure 1). the stability and mobility of the thumb joints were not 33 compromised. 34 the clinical impression of close contact to the joint was verified by ultrasound. it was by mri 35 (figure 2-4) and 4d mr-angiography that the final diagnosis of a jam was suspected. as a 36 well circumscribed, septated, scarcely vascularized (supported by duplex sonography) mass 37 without any pathological tumor-feeding vessels, it could be distinguished from a 38 myosarcoma. we forewent plain films as they seemed sufficiently replaced by mri and 39 would only be useful to rule out any arthritic changes and bone infiltration. 40 without suspicion of malignancy, we elected to proceed with marginal resection rather than 41 a biopsy to avoid a second operative procedure in a delicate region. 42 at surgery, the tumor could be completely resected without destruction of the joint 43 ligaments, tendons, vessels or nerves (figures 5, 6). 44 the histological examination revealed non-malignant spindle cells, embedded in a myxoid 45 matrix (figure 7). the diagnosis was confirmed immuno-histochemically with the affirmation 46 of cd34 and the exclusion of s100 and actin. 47 the postoperative healing process was uneventful. the thumb regained full motion and 48 became completely pain free. 49 the regular follow-ups including ultrasound and mri examination were initially scheduled on 50 a yearly basis. a first control-mri, conducted without any clinical suspicion of tumor-51 recurrence postoperatively 9 months postoperatively, did not reveal any obvious recurrence. 52 at 14 months postoperatively, the patient is still pain and symptom free. compared with the 53 contralateral side, he has full range of motion, equal power and normal sensibility in the 54 thumb. the patient elected to defer additional imaging during the covid-19 pandemic. 55 compliance with ethical standards 57 58 conflict of interest: the authors declare that they have no conflict of interest. although classified as benign lesions, myxomata can be locally destructive and thus cause 99 symptoms like pain or nerve palsy 15,17 . in the setting of local tissue destruction, one must 100 consider malignancy in the differential diagnosis 2 . 101 macroscopically myxomata present as cystic formations 5 of soft or friable consistency, white 102 to yellow color, ranging from 2 to 6 cm in size 2 . microscopically these tumors can appear 103 like fetal wharton's jelly 18 . few spindle-shaped fibroblast-type or stellate and fusiform cells 104 are found within reticulin fibers and a myxoid matrix. the mucin consists of hyaluronic acid 105 and mucopolysaccharides. vasculature is usually poorly developed 1,3,19 . one report of an 106 unusually large myxoma in the hand even showed hormone receptors 20 . 107 a few differential diagnoses should be considered when seeing a patient with a swelling on 108 the hand or wrist like in our case. the most probable diagnosis would be a ganglion cyst 109 however these are smaller than jam 5 , show no septation on mri and have a less developed 110 myxoid component 8 . a hibernoma of the hand should also be considered, even as a rare 111 cause for carpal tunnel syndrome. this tumor of brown fat tissue shows spindle cells and 112 myxoid structures like a myxoma but would be positive for ps100 and cd 34 21 . 113 in cases of a rapidly growing mass, a sarcoma must always be considered 12,13 . unfortunately 114 the diagnosis is often only confirmed by histologic examination after excision, so reoperation 115 may be needed 7 . careful preoperative planning including mri and even core biopsy should 116 be considered in these cases. nodular fasciitis (nf) is a benign reactive myofibroblastic lesion 117 that may occur after trauma. it also presents as a rapidly growing subcutaneous mass and is 118 sometimes said to be a benign version of a sarcoma. microscopically spindle-shaped cells in 119 myxoid matrix with collagen are found. nf is positive for alpha-smooth muscle actin, and 120 negative for many other markers (beta-catenin, s-100, cd 34, hmga2, cytokeratin, ema, 121 caldesmon, desmin) 22 . lastly, an intramuscular myxoma should be considered in differential 122 diagnosis. it is more common in women around 50 and often affects large muscles in the 123 thigh or shoulder. in contrast to jam it shows only minimal cystic changes and has a low 124 recurrence rate even with incomplete resection 1,2,8 . on ct, mri and ultrasound, they 125 present with an intrinsic high water content and a surrounding rim of fat 8 . activating 126 missense mutations at the arg201 codon of the gs alpha gene leading to increased levels of 127 cyclic adenosine monophosphate are detected in intramuscular myxomata (and also found 128 in mccune-albright syndrome and sporadic fibrous dysplasia of bone), but not in jam 16 . 129 in our case, the diagnosis of a jam was confirmed after immuno-histochemical staining that 130 was positive for cd34 but negative for s100 and actin. juxta-articular myxoma of the wrist: a 136 case report juxta-articular myxoma of the 138 palm recurrent myxoma of the hand myxoma and myxosarcoma of the soft 142 tissues of the extremities juxta-articular myxoma: a clinical and pathologic study of 65 144 cases musculoskeletal sarcomas in the forearm and hand: standard treatment and microsurgical 147 reconstruction for limb salvage soft tissue sarcoma of the hand and wrist: 149 epidemiology and management challenges imaging of soft-tissue myxoma with emphasis on ct and mr and comparison of 152 radiologic and pathologic findings myxoma of the palm an intramuscular myxoma of the hand periosteal myxoma of the femur. a case report juxta-articular myxoma of the shoulder 160 presenting as a cyst of the acromioclavicular joint: a case report juxta-articular myxoma of the 163 tolhurst de. myxoma of the palm myxoma causing paralysis of the posterior 166 interosseous nerve activating gs alpha 169 mutation at arg 201 codon does not occur in juxta-articular myxoma posterior interosseous nerve palsy caused by a 172 myxoma. the british society for surgery of the hand editorial: myxoma of soft tissues myxoma of the dorsal 176 hand carpal tunnel syndrome due to hibernoma of the 178 wrist: case report intra-articular nodular fasciitis of the proximal 180 interphalangeal joint of a finger: a case report the authors do not have any conflicting interests concerning this article. key: cord-330284-r3l6hdrk authors: gao, min; huang, siying; pan, xuequn; liao, xuan; yang, ru; liu, jun title: machine learning-based radiomics predicting tumor grades and expression of multiple pathologic biomarkers in gliomas date: 2020-09-11 journal: front oncol doi: 10.3389/fonc.2020.01676 sha: doc_id: 330284 cord_uid: r3l6hdrk background: the grading and pathologic biomarkers of glioma has important guiding significance for the individual treatment. in clinical, it is often necessary to obtain tumor samples through invasive operation for pathological diagnosis. the present study aimed to use conventional machine learning algorithms to predict the tumor grades and pathologic biomarkers on magnetic resonance imaging (mri) data. methods: the present study retrospectively collected a dataset of 367 glioma patients, who had pathological reports and underwent mri scans between october 2013 and march 2019. the radiomic features were extracted from enhanced mri images, and three frequently-used machine-learning models of lc, support vector machine (svm), and random forests (rf) were built for four predictive tasks: (1) glioma grades, (2) ki67 expression level, (3) gfap expression level, and (4) s100 expression level in gliomas. each sub dataset was split into training and testing sets at a ratio of 4:1. the training sets were used for training and tuning models. the testing sets were used for evaluating models. according to the area under curve (auc) and accuracy, the best classifier was chosen for each task. results: the rf algorithm was found to be stable and consistently performed better than logistic regression and svm for all the tasks. the rf classifier on glioma grades achieved a predictive performance (auc: 0.79, accuracy: 0.81). the rf classifier also achieved a predictive performance on the ki67 expression (auc: 0.85, accuracy: 0.80). the auc and accuracy score for the gfap classifier were 0.72 and 0.81. the auc and accuracy score for s100 expression levels are 0.60 and 0.91. conclusion: the machine-learning based radiomics approach can provide a non-invasive method for the prediction of glioma grades and expression levels of multiple pathologic biomarkers, preoperatively, with favorable predictive accuracy and stability. gliomas are the most common brain tumors and are often classified as world health organization (who) grades i-iv, depending on the different tumor cells, and the degree of abnormality (1, 2) . as a tumor's grade increases, gliomas process more aggressively (3) . treatment options and responses differ from glioma grades (4) . pathological findings are the premise of rational treatment. usually, glioma grades are confirmed by pathological examination during surgery or biopsy (5) . then, a following immunohistochemistry (ihc) test determines the molecular biomarkers of tumor tissues at the microscopic level. these pathologic biomarkers, typical proteins, are useful indicators for diagnosis, prognosis, or treatment response (6) . however, obtaining such information for gliomas requires invasive approaches. the surgical decision making could be difficult and time-consuming for many patients. those patients who are not eligible for a surgery or seek nonsurgical treatment may have limited treatment options without pathological guidance. therefore, presurgical glioma grades and the expression of biomarkers are valued and preferred with non-invasive approaches. at present, the medical imaging can differentiate the tumor phenotype and intra-tumor heterogeneity (7) . conventional magnetic resonance imaging (mri) is routinely used in the diagnosis and management of glioma patients. t1-weighted contrast-enhanced mri (t1c) is the current standard for initial brain tumor imaging (8) . radiomics can generate image features with high dimensional data from the intensity histogram, geometry and texture analyses on the entire tumor volume (9) . with the emergence of artificial intelligence (ai) technologies, advanced informatics tools have become accessible to facilitate machine learning (ml) based radiomics applications using image features as the data source (10) . radiomics is gaining ground in oncology and have the potential to accurately classify or predict tumor characteristics. radiomics approaches have been applied for the predictions of glioma grades or differential diagnoses (11, 12) . several studies have reached a prediction accuracy of above 80% using popular ml models. the commonly and frequently used ml algorithms in radiomics include logistic regression (lr), random forests (rf), support vector machine (svm), and etc. each ml method has their own advantages in the classification. for example, lr fits the variables coefficients and predicts a logit transformation of the probability of being one class or the other. svm separates the classes by finding an optimal hyperplane. rf uses bootstrap aggregating to decision trees and improves classification performance. when compared to tumor grading, to make predictions at a molecular level is more challenging. kickingereder et al. reported the association between established mri features and cancer gene variations (egfr amplification and cdkn2a loss), but failed to build a sufficient ml model to predict the molecular characteristics (13) . in clinic, pathologic biomarkers are more frequently tested for than genetic testing. idh1 is one important glioma biomarker and idh1 mutation along with 1p/19q is a part of the molecular diagnosis in the updated 2016 who classification (14) . ki67, s100, and gfap are also the common protein targets for gliomas. idh1, ki67, and gfap were once considered as the golden triad of glioma ihc (15) ki67 is highly correlated to proliferation that may indicate the tumor grades and prognosis (16) (17) (18) . s100 has been implicated in the regulation of cellular activities, such as metabolism, motility, and proliferation. under the pathological conditions of tumor and inflammation, the concentration of the s100 protein increases to the micromole level, which stimulates microglia and astrocytes, and increases the expression of pro-inflammatory cytokines (19) (20) (21) (22) (23) . gfap is the most widely used markers of astrocytes (24) . under the condition of injury (trauma or disease), the expression of gfap in astrocytes rapidly increases (25) . gfap is often used to reveal the astrocytic lineage of glial cells and glial tumor cells, and plays a more significant role in tumor pathology, when compared to the differential diagnosis of astrocytoma. ki67, s100, or gfap may not be a reliable diagnostic biomarker for gliomas, because their roles in gliomas are still under investigations, while controversies have been observed in experiments (26) . however, there is no doubt that these proteins can provide some insights into the tumor intramicroenvironment. so far, it is not surprising to know that most radiomics studies favor the prediction of the idh expression for molecular diagnosis (11, 27) , with a few reports on ki67 (28) . in order to expand predictive effects of radiomics, the investigators aimed to assess the prediction feasibility of glioma grades and the pathologic biomarkers of ki67, s100, and gfap in gliomas. the investigators believed that the combination of multiple biomarkers can increase the predictive power, and the information obtained can help in understanding the underlying pathologic process in gliomas. the investigators designed the present retrospective study and extracted hundreds of radiomic features from the t1c images of 367 glioma patients. three machine-learning-based models (lr, svm, and rf) were built to perform the tasks: (1) classify the glioma grades, and (2) predict the expression levels of ki67, s100, and gfap. this study demonstrated that multiple pathologic biomarkers in gliomas can be estimated to the certainty levels of clinical using common ml models on conventional mri data and pathological records. the investigators retrospectively collected a data set of 420 glioma patients, who had pathological reports and mri scans performed between october 2013 and march 2019, from the second xiangya hospital of central south university. the patients who met the following criteria were included: (i) a histopathological diagnosis of primary glioma based on the who classification, (ii) the availability of ihc profiles of biomarkers (s100, gfap, and ki67), (iii) preoperative mri data of post-contrast axial t1-weighted (t1c), and (iv) age > 18 years old. patients were excluded due to the following: (i) secondary gliomas or postoperative recurrence of gliomas, (ii) obvious artifacts in mri. ethics approval was obtained for the present study from the ethics committee of the second xiangya hospital, central south university. patient demographics (age and gender), and histopathologic diagnosis and ihc results were obtained from a surgical pathology report. on these reports, the diagnosis included a specific glioma type by cells (e.g., astrocytoma and oligodendrogliomas) and a given who grade (i-iv). the ihc results were presented in the list of glioma biomarkers (e.g., s100, gfap, or ki67) and their own expression profile in tumor cells. it is noteworthy that the list was not standard and varied upon the request or availability of the biomarkers at that time. for example, few patients received an idh1 test before 2017, but after 2016, the who classification standard was published, and idh1 tests became common. so, a patient might have a different set of tested biomarkers, and the number of cases can differ for each biomarker. their ihc results depended on the scoring system used. the expression levels were usually evaluated by the staining intensity of positive cells, and points were assigned to describe these positive cells by count (e.g., 0 points as negative (−), 1 point as positive (+), 2 points as medium positive, and 3 points as high positive), percentage (e.g., 0 points as none, 1 point less than 5%, 2 points approximately 5-25%, and 3 points above 25%), or the appearance of a clear brown color (e.g., 1 point for light yellow). in the study, the glioma grades were classified as low-grade (who i-ii, benign) and high-grade (who iii-iv, malignant), and expression levels of biomarkers were divided into two categories: a low expression scored less than 2 points and a high expression scored 2 points or above. magnetic resonance imaging scans were acquired from different scanners over time. the picture archiving and communication system (pacs) exported the selected dicom images to a local computer using the radiant dicom viewer (medixant, pl). in order to reduce the influence of different scanning parameters, post-processing and image registration were applied using the advanced normalization tools (ants 2.1, pa). then, the dicom images were loaded into itk-snap for segmentation and standardization (29) . two neuroradiologists (5 years of experience) drew the region of interest (roi) around the tumor boundary on the t1c images. the neuroradiologists were blinded to the patient identification and diagnosis. after a joint effort, disagreements with the boundary were solved. the roi segmentations were resampled to match the dimensions of the original images, and both images were saved in.narrd as the input for feature extraction. the pyradiomics extractor was customized to calculate and extract the features (10). all built-in filters [wavelet, laplacian of gaussian (log), square, square root, logarithm, and exponential] were enabled on five image feature classes [first order statistics, shape descriptors, and texture features on the gray-level co-occurrence matrix (glcm), gray-level run length matrix (glrlm), and gray-level size zone matrix (glszm)]. feature definitions and calculation algorithms were available in the pyradiomics documentation 1 . the feature importance and the following predictive ml methods were implemented using python (version 3.7.0) with machinelearning library scikit-learn (version 23.0) (30) . all features were standardized through min-max scaling. features with all zero scores were removed. clinical data (age and gender) were added in constructing the final prediction models. the feature importance helped in understanding the importance of the features, since a large number radiomics features with high-dimensional data are difficult to interpret. three technique approaches were used to identify the important features. first, chi-squared (chi 2 ) tests were applied in the scikit-learn selectkbest class to obtain a list of the top 15 best features. second, the heatmap of correlated features was plotted to identify features highly correlated to predicting targets (glioma grade and biomarker expression) using the seaborn library. third, a rf classifier was initiated and the in-build feature importance was used to extract the top features. three frequently-used machine-learning based models of lr, svm, and rf were built for four predictive tasks: (1) glioma grades, (2) ki67 expression level, (3) gfap expression level, and (4) s100 expression level in gliomas. each sub dataset was divided into training and testing sets at a ratio of 4:1 (train_size = 0.8, test_size = 0.2). principal component analysis (pca) was applied for high-dimension reduction that maps n-dimensional features to k-dimensional features (n > k), resulting in brand new orthogonal features. for the unbalanced data in different classes, the synthetic minority over-sampling technique (smote) algorithm was used to oversample the minority class (31) . on training set, the grid search with crossvalidation was applied for hyper parameters tuning (rf and svm), and k fold validation was used for lr. the accuracy score was compared with the result from their base models (default settings in scikit-learn) for model selection. the testing set was used for final model evaluation. the performance of the models was evaluated according to accuracy, the area under curve (auc) of the receiver operating characteristic (roc), sensitivity, specificity, the positive prediction value (ppv), and the negative predictive value (npv). according to the auc and accuracy, the best classifier was chosen for each task. one way-anova or simple t-test was applied to test the differences among gender, age, glioma grade, and the expression levels of the biomarkers. descriptive statistics was used to summarize the important features through filters and feature classes. all significant levels were tested at 0.05. a data set of preoperative mri and surgical pathologic reports of 420 glioma patients were collected. a total of 51 patients were excluded for not meeting the inclusion criteria. among these patients, 40 patients were under 18 years old, seven patients had quality issues on their mri data, and four patients did not have an assigned who classification level in their records. the age of the enrolled 369 patients ranged within 18-75 years old (mean age: 45.63 ± 13.22 years old), and consisted of 210 males (age: 46.99 ± 13.24 years old), and 159 females (age: 43.84 ± 13.03 years old). the clinical characteristics of patients and the distribution of the selected biomarkers across glioma grades are presented in table 1 . the expression of gfap, ki67, and s100 was reported as follows: 367 patients had gfap results with four negatives (0 point), 323 positives (1 point), and 35 medium (2 points), or 5 high positives (3 points); 348 patients underwent ki67 tests, including 96 negatives or low positives (≤5% in tumor cells), and 252 strong positives (>5%); 338 patients underwent s100 tests, which included eight negatives (0 points), 315 positives (1 point), and 15 medium positives (2 points). there was a significant age difference among male and female patients, as determined by one-way anova [f (1, 367) = 5.17, p < 0.05]. furthermore, there were significant differences in age, gender and tumor volume among glioma grades (who i-iv). moreover, there were significant differences in glioma grade, tumor size, age and gender for the ki67 expression. however, there were no significant differences in age, gender and glioma grade for s100 and gfap expression. the t-test and one-way anova results are shown in table 2 . the investigators obtained the list of the top 15 important features based on the scores obtained from the chi-squared stats between each non-negative feature and the glioma grade, and s100, gfap, and ki 67 expression levels. the features and their scores are shown in table 3 . the scores ranged within 3.67-44.04. the mean score of the top important features was 9.30, with a standard deviation of 5.83. the frequent top features within the image type were exponential (23), wavelet (22) , square (6), square root (3), original (3), gradian (2), and ihp-2d (1). for the feature classes, the frequent top features were divided as follows: glszm (27) , glcm (9), glrlm (8), gldm (7), first order (7), and ngtdm (2) . the heatmaps of the correlated features for glioma grade and the biomarkers of ki67, gfap, and s100 are presented in figure 1 . the rf model built-in feature importance is presented in figure 2 . the performance of the 12 predictive models is presented in table 4 . the rf models performed slightly better, when compared to the other models. the comparisons with accuracy and the results are presented below. figure 3 shows the auc_roc for the rf classifier in sub test sets. the sub data set was randomly split into the training set of 276 cases and the test set of 93 cases. with a pca retention of 0.95, the pca process reduced the dimensions frontiers in oncology | www.frontiersin.org a total of 338 patients had s100 test results, which included 323 low expression levels (<2 points) and 15 high expression levels (≥2 points). the class distribution was 323:15. the training set and test set were split into 270 and 68, respectively. after the smote oversampling, the resampled number increased to 518. with a pca retention of 0.95, the pca process reduced the dimensions to 38 components, and these were used for the final prediction model for the s100 expression. after grid search with cross validation (cv = 5) or k fold validation (n_splits = 5), the selected classifier included: (1) lr (penalty = "l2, " c = 1.0), (2) svm (c = 1, kernel = "rbf, " and gamma = "auto"), and (3) rf (min_samples_leaf = 1,min_samples_split = 2, and n_estimators = 100). among these classifiers, the rf classifier achieved the best prediction performance on the s100 expression, based on the measurements (auc: 0.60, accuracy: 0.91, averageweighted sensitivity: 0.88 specificity: 0.91, and f1 score: 0.90). it is noteworthy that the average-weight computes f1 for each class, and returns the average while considering the proportion for each class in the dataset. for s100 low expression levels: accuracy (0.95), sensitivity (0.94), specificity (0.97), and f1 (0.95). for high expression levels: none of the four high expression cases was correctly predicted. a total of 367 patients had a gfap test. among these patients, there were 327 low expression levels and 40 high expression levels. the class distribution ratio was 327:40. the training set and test set were split into 293 and 74, respectively. after the smote oversampling, the number of samples increased to 532. with a pca retention of 0.95, the pca process reduced the dimensions to 38 components, and those that remained were used for the final prediction model for the gfap expression. after grid search with cross validation (cv = 5) or k fold validation (n_splits = 5), the selected classifier included: (1) lr (penalty = "l2, " c = 1.0), (2) svm (c = 1, kernel = "rbf, " and gamma = "auto"), and (3) rf (min_samples_leaf = 1,min_samples_split = 2, and n_estimators = 100). among these three classifiers, the rf classifier achieved the best predictive performance on the gfap expression measured, as follows: auc (0.72), accuracy (0.81), average-weighted sensitivity (0.74), specificity (0.81), and f1 score (0.76). the machine-learning based radiomics approach was applied to predict glioma grades and the expression levels of pathologic biomarkers ki67, gfap, and s100 in low or high. the overall performance of the ml models was satisfactory. the rf algorithm was found to be stable and consistently performed better than lr and svm. feature importance varies on predictive tasks, glioma grade or specific protein expression. the most frequent important feature classes were textual and first order statistics. we selected lr, svm, and rf as classifiers mainly for their popularity. lr, svm, and rf classifiers can work on non-text data set less than 100k. whether the data is linearly divisible or not, the linearly separable models (lr, svm), and the non-linear separable model (rf) are helpful to view the effect and avoid the impact due to poor data. lr shows a higher auc, in gfap's prediction model, but performs worst in s100's prediction. comparing the overall results from three biomarker prediction models, the combination of pca reduction and rf classification consistently performed best. it suggests a common ml pipeline that may be helpful in standardizing the prediction process of multiple protein expressions. also more recently, researchers have demonstrated achievements of deep learning (dl) in the image segmentation and glioma grades prediction (32) (33) (34) (35) (36) (37) . convolutional neural networks (cnns) started outperforming other methods on several high-profile image analysis projects. dl has advantages in computation, as high-performance graphics processing unit (gpu) supports fast computing and less time on modeling. like a kind of end-to-end learning, dl can automatically extract relevant functions from images, and tasks such as raw data processing and classification can be completed automatically. however, dl is complex and requires thousands of images to start with, otherwise due to a relatively small collection of images like ours, overfitting is more likely. the classic ml methods met our needs and suited the data. rf models performed well for predicting glioma grades and pathologic biomarkers s100, ki67, and gfap. as it is known, the roles of these biomarkers can be complicated and controversial in laboratory experiments (26) . in addition to the abilities of predicting tumor phenotypes, radiomics might offer a new approach to evaluate biomarkers, since their differentiation can be identified through the analysis of imaging features. the expression level of ki67 was significantly correlated with the tumor grade and tumor volume, as well as the patient age and gender. a study once reported that the high level of ki-67 expression was correlated to poor overall survival (os) and progression free survival (pfs) (16) . the accurate prediction of high level ki67 is more meaningful than its low level expression to indicate poor prognosis for glioma patients. the gfap has been widely expressed in gliomas. merely four patients presented as gfap negative. the majority of the patients (323 of 367, 88%) had gfap positive (+), and 327 patients with low expression gfap (90%), combined with four that scored (−), were distributed all over the gliomas grades, including low grade (132, 40%), and high grade (195, 60%). the minority of the patients (40 of 367, 12%) had gfap medium positive (++) or high positive (+++) distributed in low grade (15, 37 .5%) and high grade (25, 62 .5%). in the literature, a high gfap expression is likely to be found in low grade gliomas. the present result was confusing, that is, the high and low expression levels of gfap were more correlated to high grade gliomas. this result may echo that gfap is not a direct predictor of low grade gliomas (15, 26) . on the classification report of the rf_gfap model, the accuracy score of predicting a gfap low expression was up to, while that of predicting high expression levels of gfap was much lower. the overall prediction performance might not be meaningful, since gfap was lowly expressed in 90% of patients, and the model could always answer 90% correctly. the same problem was found in the predictive model of s100. it required the rethinking of these two models. there was a need to determine which expression class is more valued. and then, as one solution, the roc thresholds can tuned, increasing the sensitivity of the favored class. the interpretation of the predicted results is complex, but may be helpful to understand the molecular mechanisms it underlies. in addition, the investigators selected ce mri from several typical cases for demonstration, in which the different expression levels of biomarkers exhibited different imaging characteristics (figure 4) . for the high expression of s100 case (figure 4a) , the tumor exhibited an obvious rosette enhancement, no enhancement of internal necrotic components, and a few edema zones around it, and was diagnosed as glioblastoma (who iv grade). in the image of the tumor with a low expression of s100 (figure 4b) , the tumor mass effect was obvious, but there was no obvious enhancement, and the surrounding edema was not obvious, which was diagnosed as astrocytoma (who ii grade). in this case, the positive correlation appeared as both the s100 and glioma grade moved in the same direction that was contrary to many observations. the study conducted by wang et al. has proven that s100 is expressed in most gliomas, and that this is an important inducer of ccl2 (19) . ccl2 participates in the transport of tumor-associated macrophages (tam) in gliomas, which affects angiogenesis, invasion, local tumor recurrence and immunosuppression. this may explain the relationship between the degree of tumor enhancement and the expression of s100 in the present cases. there are some limitations in our study. first, we only used conventional mri sequences with a default set of tumor features extracted by pyradiomics. advanced mri sequences (e.g., dwi, dki, mrs, asl, et al.) can reflect the microstructure and metabolic information of tumors. in future study, we will further investigate the molecular phenotype of gliomas using a multimode magnetic resonance scheme. second, we only selected 3 common pathologic biomarkers for gliomas from a wide range of biomarkers either current available or under investigation. we have to develop an evaluation plan for other glioma biomarkers and find candidates that can be benefit from radiomics applications. third, imbalance classes did not reflect the incidences of glioma in real world, where glioblastoma is the most common subtype, and grade i glioma is relatively rare in adults. we used the smote algorithm to balance data, oversampling the minority class, but the differences in data distribution cannot be ignored. in our experiments, before and after the use of smote, auc was only changed slightly. a larger dataset from multiple sites is expected to complement predictive effects, and the resulting classifiers can be more accurate and stable. fourth, after pca reducing feature dimensions, a new set of features was less remained but difficult to interpret. a combination of hierarchical clustering on pca may help us to select feature more efficiently. at the current stage, a real-world application is out of our scope, but further prospective assessment is warranted. based on the results we obtained as a reference, we will extend the study to identify the best classifier algorithm and the best set of features to simplify the classification tasks. the standardized computation methods would greatly enhance the reproducibility of radiomics studies, and it may also lead to standardized software solutions available in clinical practice. in conclusion, the machine-learning based radiomics application provided a non-invasive approach for the prediction of glioma grades and expression levels of multiple pathologic biomarkers, with favorable predictive accuracy and stability. the study also demonstrated the potential of radiomics for pathological assessment and individualized cancer treatment. the raw data supporting the conclusions of this article will be made available by the authors, without undue reservation. the studies involving human participants were reviewed and approved by ethics committee of the second xiangya hospital of central south university. written informed consent for participation was not required for this study in accordance with the national legislation and the institutional requirements. the 2007 who classification of tumours of the central nervous system glioblastoma and other malignant gliomas: a clinical review cbtrus statistical report: primary brain and central nervous system tumors diagnosed in the united states in 2006-2010 malignant gliomas: current perspectives in diagnosis, treatment, and early response assessment using advanced quantitative imaging methods limitations of stereotactic biopsy in the initial management of gliomas molecular pathology of tumors of the central nervous system how clinical imaging can assess cancer biology current clinical brain tumor imaging radiomics in glioblastoma: current status and challenges facing clinical implementation computational radiomics system to decode the radiographic phenotype multimodal mri features predict isocitrate dehydrogenase genotype in highgrade gliomas machine learningbased radiomics for molecular subtyping of gliomas radiogenomics of glioblastoma: machine learning-based classification of molecular characteristics by using multiparametric and multiregional mr imaging features the 2016 world health organization classification of tumors of the central nervous system: a summary ki67 and idh1: perhaps the golden triad of glioma immunohistochemistry ki-67 is a valuable prognostic factor in gliomas: evidence from a systematic review and meta-analysis the use of the monoclonal antibody ki-67 in the identification of proliferating cells: application to surgical neuropathology diagnostic and prognostic role of ki67 immunostaining in human astrocytomas using four different antibodies s100b promotes glioma growth through chemoattraction of myeloid-derived macrophages the heterodimeric complex of mrp-8 (s100a8) and mrp-14 (s100a9) biochemical characterization and subcellular localization in different cell lines anti-infective protective properties of s100 calgranulins biology of the s100 proteins-introduction glial fibrillary acidic protein is a body fluid biomarker for glial pathology in human disease effects of traumatic brain injury on reactive astrogliosis and seizures in mouse models of alexander disease importance of gfap isoform−specific analyses in astrocytoma a radiomics nomogram may improve the prediction of idh genotype for astrocytoma before surgery radiomic features predict ki-67 expression level and survival in lower grade gliomas userguided 3d active contour segmentation of anatomical structures: significantly improved efficiency and reliability scikit-learn: machine learning in python smote for high-dimensional class-imbalanced data deep multi-scale 3d convolutional neural network (cnn) for mri gliomas brain tumor classification automated glioma grading on conventional mri images using deep convolutional neural networks prediction of lower-grade glioma molecular subtypes using deep learning deep transfer learning and radiomics feature prediction of survival of patients with highgrade gliomas a novel fully automated mri-based deep-learning method for classification of idh mutation status in brain gliomas idhresidual convolutional neural network for the determination of status in low-and high-grade gliomas from mr imaging jl, mg, and sh: conception and design, and provision of study materials or patients. jl and ry: administrative support. mg, sh, xp, xl, and jl: collection and assembly of data. mg, sh, xp, and jl: data analysis and interpretation. all authors: writing and final approval of the manuscript. the authors express their appreciation to ying zeng for the acquisition, analysis, and interpretation of data for the work. key: cord-327543-kibjwfad authors: ong, s. j.; renfrew, i.; gopinathan, a.; tan, a. p.; sia, s. y.; low, c. k.; hoon, h. x.; ang, b.w.l.; quek, s. t. title: sir helmet (safety in radiology healthcare localised metrological enviroment): a low-cost negative-pressure isolation barrier for shielding mri frontline workers from covid-19 exposure date: 2020-07-01 journal: clin radiol doi: 10.1016/j.crad.2020.06.015 sha: doc_id: 327543 cord_uid: kibjwfad • low cost reusable acrylic and silicone rubber barrier shield design. • localised negative pressure environment simulating isolation rooms. • does not affect mri image quality even on the most sensitive sequences. • additional personal protective equipment for frontline healthcare professionals. covid-19 is a highly infective infectious disease caused by a novel coronavirus first identified in wuhan, china, in december 2019. it has now evolved into a pandemic affecting at least 216 countries. the precise incidence of stroke in covid-19 patients is unknown but is thought to affect up to 5.7% of severely affected individuals [1] . it is also being recognised as the first clinical presentation of covid-19, especially in young patients [2, 3] . although computed tomography (ct) is the first-line technique to assess patients presenting with acute stroke symptoms, many centres prefer to evaluate further with magnetic resonance imaging (mri) [4] . hence, more patients with covid-19 are attending for mri examinations. in well-resourced hospitals, infective covid-19 patients are nursed within negativepressure rooms. even within these negative-pressure rooms, research has shown extensive environmental contamination when occupied by infected patients [5] . although patients can be provided with filtering face piece (ffp) masks to reduce their infectivity, studies have demonstrated high rates (up to 87%) of poor fit of the face masks among untrained non-healthcare professionals [6]. most mri rooms are not built with negative-pressure ventilation systems. in addition, there are limitations to the use of personal protective equipment (ppe) by both patients and staff within the magnetic field of the mri room. therefore, each time a patient with covid-19 undergoes mri, there is a real risk of mri room contamination and exposure of both staff and subsequent patients to the virus. to address the above problem, a low-cost physical barrier was designed and developed for use within the mri machine that could produce a localised negativepressure containment area around the patient's head. the barrier has been named "sir helmet" from safety in radiology healthcare localised metrological enviroment. the "helmet" can potentially reduce the spread of pathogens via the patient's breath. in addition to assessing its functionality, the present study also evaluates the impact of the shield on mri image quality. the sir helmet is a dome shaped, re-useable barrier that fits into mri machines with a bore size of ≥65 mm. it is made of 3 mm clear acrylic with chloroform used as the primary adhesive. the access port on the front of the "helmet" is covered with a 1.5 mm silicone rubber membrane with slits for access and clamped to the main structure with another layer of 3 mm acrylic, held together by plastic screws (fig. 1) . the calculated raw volume of the helmet is 139 l with an effective net gas volume of approximately 130 l or less depending on patient position within the barrier shield. negative pressure within the "helmet" is generated by connecting a standard medical gas wall vacuum using extension tubing via a port in the barrier shield. continuous for this study, two healthy volunteers were scanned in a 3 t magnetom skyra mri unit (siemens, munich, germany) and a 1.5 t optima mri unit (ge healthcare, chicago, il, usa) using standard head and neck sequences (eight sets of examinations in total; four of the head and four of the cervical spine). each participant was scanned using each machine by the same senior mri radiographer with and without the "helmet". images were loaded onto a standalone staging picture archiving and retrieval system, centricity universal viewer (ge healthcare). the eight anonymised sets of images were reviewed on diagnostic-quality monitors by two consultant musculoskeletal radiologists, two consultant neuroradiologists, and two consultant clinical diagnostic radiologists, blinded to the acquisition history of the images. overall, eight examination sets were read independently by six different readers to provide 48 total sets for scoring. images were scored on a scale of 1 to 4 regarding diagnostic quality, structural delineation, and severity of artefacts for each set of images as per ryu et al. [7] with area for free-text comment. negative pressure airflow rates of >20 l/min was obtained with the underwater seal filter system and at 40 l/min without. this allowed at least 9.2 full gas exchanges per hour for the underwater seal filtered system and at least 18.5 for the other one. there was consensus regarding scoring of all eight sets of images among all the readers with full points for diagnostic quality, delineation of structural margins, and complete lack of mri-related artefacts (fig. 2) . post-scoring, the readers were informed that half of the image sets were performed with the "helmet", but they were not able to identify these sets from those scanned without the helmet. although transmission of covid-19 is predominantly via direct contact or aerosol inhalation, it may also occur via indirect delayed contact, for example, through the use of the same physical seat [8] . droplet transmission enhanced by air-conditioning airflow creating super spreaders is also documented [9] . hence, isolation of the most infective patients is essential [10] . nevertheless, when an infected patient is brought outside their isolation ward to other clinical areas, such as radiology departments, this "isolation" is interrupted, creating potential opportunities for virus dissemination. as the covid-19 pandemic continues, there is high likelihood that more coronavirus-infected patients would present with stroke or stroke-like symptoms, thereby increasing the need to perform mri examinations in these patients. as a limited resource, it may not possible to reserve an mri machine exclusively to image covid-19 patients. hence, it is essential to explore alternative ways to control the spread of infection from transit of an infected patient through an mri room. the effort of thoroughly cleaning the shield between patients is much less than that of cleaning the bore of the mri machine. using the ubiquitous medical gas wall vacuum apparatus, the "helmet" can provide at least 9.2 full gas exchange per hour with the afore-described filtration system or 18.5 full gas exchanges per hour without filtration. this gas exchange rate is similar to or above that of the requirements of a negative-pressure isolation facility, which is usually 10 to 15 exchanges per hour. hence, use of this helmet would effectively provide frontline healthcare staff and patients with an added layer of protection against airborne pathogens. this can also avoid the cost and time required in installing negative-pressure ventilation systems within an mri room. use of the helmet without suction is not recommended due to concerns regarding carbon dioxide retention during long examinations. in an unvented system, there are also concerns of a high concentration of aerosolised pathogen that the mri technician would be exposed to, while removing the "helmet" from the patient. the decision to vent the suction via an underwater seal sterilisation scrub or directly to the wall vacuum port would depend on the local hospital infection-control policy and the underlying infrastructure of the vacuum system. to improve patient comfort and to reduce claustrophobia, the helmet was intentionally fabricated using flame-polished translucent acrylic, using the biggest arc possible to maximise the sense of space. given the multitude of different scanner and coil configurations, the length of the "helmet" was increased intentionally to fit across all the mri machines within our institution. if required, it is possible to customise this shield for individual scanners with shorter lengths to increase the air exchange rates. acrylic is cheap and can be fabricated quickly, and in addition, is suitable for cleaning with most of the usual disinfectants. the image quality of mri examinations was not affected by scanning with the helmet on. the adoption of this or similar barriers would provide frontline healthcare staff and patients with an additional level of protection without prohibitive financial costs to the institution. highlights: 1 • low cost reusable acrylic and silicone rubber barrier shield design 2 • localised negative pressure environment simulating isolation rooms 3 • does not affect mri image quality even on the most sensitive sequences 4 • additional personal protective equipment for frontline healthcare professionals covid-19-related stroke large-vessel stroke as a presenting feature of covid-19 in the young covid-19 presenting as stroke imaging of acute stroke prior to treatment: current clinical feasibility of 1-min ultrafast brain mri compared with routine brain mri using synthetic mri: a single center pilot study investigation of three clusters of covid-19 in singapore: implications for surveillance and response measures covid-19 outbreak associated with air conditioning in restaurant rapid expansion of temporary, reliable airborne-infection isolation rooms with negative air machines for critical covid-19 patients key: cord-338751-2eo7ityc authors: anzalone, nicoletta; castellano, antonella; scotti, roberta; scandroglio, anna mara; filippi, massimo; ciceri, fabio; tresoldi, moreno; falini, andrea title: multifocal laminar cortical brain lesions: a consistent mri finding in neuro-covid-19 patients date: 2020-06-06 journal: j neurol doi: 10.1007/s00415-020-09966-2 sha: doc_id: 338751 cord_uid: 2eo7ityc nan neurologic manifestations of severe acute respiratory syndrome coronavirus 2 (sars-cov-2) have been recently reported [1, 2] , with relevance to vascular aetiology [2, 3] . the neuroinvasive potential of sars-cov-2 has also been advocated, by infecting the cns through hematogenous or neuronal retrograde route [4] . here we report four cases of subacute encephalopathy occurring in patients with sars-cov-2 infection. they are part of a series of 21 patients presenting with neurological symptoms studied with brain mri with otherwise no significant imaging findings. a multifocal involvement of the cortex was evident in all cases (figs. 1, 2) . the multiple areas, from punctiform to some millimeters in extension, appeared hyperintense on t2-weighted and flair images and were located in the parietal, occipital and frontal regions. on diffusion mri, all but two of the lesions were characterized by the absence of apparent diffusion coefficient (adc) changes (figs. 1c, 2c). a minimum involvement of the adjacent subcortical white matter was evident in only a few lesions. susceptibility-weighted imaging (swi) sequences were acquired in all patients and did not show any alteration. very subtle contrast enhancement was detected only in a cortical lesion. in one patient a follow-up mri scan was obtained after one month, demonstrating a complete resolution of all the lesions (fig. 2f-l) . all patients (2 men, 2 women; age range 46-63 years) have been intubated in the first week from onset of ards and presented neurological signs of agitation and spatial disorientation after weaning from mechanical ventilation. one patient had a generalized seizure. the time interval from onset of neurological symptoms to mri was 2-6 days. diagnosis of covid-19 was made by detection of sars-cov-2 viral nucleic acid in a nasopharyngeal swab specimen. all patients received the same treatment for sars-cov-2 infection. none of the patients had a relevant clinical history or previous treatment or hypertension. laboratory findings revealed in all cases a second smaller c-reactive protein peak from the initial one and raise of serum level of aspartate and alanine transaminase before the onset of neurological symptoms. d-dimer elevation was present and stable during the disease course. mri lesions' characteristics are unusual but demonstrate a highly consistent pattern through all the four patients with similar neurological symptoms. they do not fulfill any typical criteria for a definite neuroradiological entity. we speculate that this pattern may be related to a possible transient dysregulation of vasomotor reactivity. in particular, the cortical involvement may suggest a possible vascular mechanism more shifted toward transient vasoconstriction. although the predominantly parieto-occipital distribution of the lesions recalls posterior reversible encephalopathy syndrome (pres) [5] , the prevalent cortical involvement and diffusion mri pattern are not typical of pres. at the same time, an alternative hypothesis of embolic cortical infarctions is unlikely due to the absence of diffusion restriction. it is currently known that sars-cov-2 might dysregulate the renin-angiotensin system (ras) system by acting on ace2 receptors, causing microcirculation impairment possibly impacting on blood flow regulation. more recently, evidence of direct viral infection of the endothelial cell and diffuse endothelial inflammation has been reported, resulting fig. 1 forty-seven-year-old man diagnosed with covid-19 and presenting neurological signs of agitation and spatial disorientation after weaning from mechanical ventilation. before the onset of neurological symptoms, laboratory findings revealed a c-reactive protein peak (262.5 mg/l, normal range 0-6 mg/l). a axial flair, b diffusion-weighted image (dwi), c apparent diffusion coefficient (adc) map and (d, e) sagittal flair mr images. multiple, cortical areas of punctiform and gyriform flair and dwi hyperintensity (arrows) in both parietal lobes, with no adc changes fig. 2 fifty-four-year-old woman diagnosed with covid-19 and presenting neurological signs of agitation and spatial disorientation after weaning from mechanical ventilation. before the onset of neurological symptoms, laboratory findings revealed a small c-reactive protein peak (27.5 mg/l, normal range 0-6 mg/l) and raise of total white blood cell count (12.9 × 10 9 /l, normal range 4.0-10.0 × 10 9 /l). cerebrospinal fluid (csf) analysis performed on the same day was negative for the presence of sars-cov-2 viral nucleic acid. a-e initial mri scan. f-l follow-up mri after one month. a, d, f, i axial flair, b, g diffusionweighted image (dwi), c, h apparent diffusion coefficient (adc) map and e, l sagittal flair mr images. multifocal linear and punctiform cortical flair and dwi hyperintensities in the left parietal lobe, bilateral precentral gyri and left middle frontal gyrus (a-c), with no adc changes. bilateral occipital involvement is shown in d, e, with a cortical/subcortical flair hyperintense lesion at the level of the left occipital pole. f-l follow-up mri demonstrates a complete resolution of all the lesions in endothelial dysfunction and impaired microcirculatory function [6] . along with inflammation, there is a tendency to thrombosis in more severe cases [7] . nonetheless, other vasculo-mediated mechanisms including altered vasomotor reactivity may play a role and cause neurological symptoms in covid-19 patients [6] . in this regard, normalization of mri findings in one patient (fig. 2f-l) may corroborate the hypothesis of a transient functional nature of the impaired cerebral microcirculatory function. we believe that, due to the peculiarity and subtle appearance of the mri findings, our report may alert neurologists and radiologists to the existence of this subacute neuroimaging picture in sars-cov-2 patients, clearly different from cortical ischemia, and also to inform clinicians about the possible spontaneous reversibility of the picture. neurologic manifestations of hospitalized patients with coronavirus disease 2019 in wuhan, china neurologic features in severe sars-cov-2 infection large-vessel stroke as a presenting feature of covid-19 in the young neuroradiologists, be mindful of the neuroinvasive potential of covid-19 posterior reversible encephalopathy syndrome: clinical and radiological manifestations, pathophysiology, and outstanding questions endothelial cell infection and endotheliitis in covid-19 microvascular covid-19 lung vessels obstructive thromboinflammatory syndrome (microclots): an atypical acute respiratory distress syndrome working hypothesis informed consent all patients provided signed informed consent prior to mr imaging. informed consent was collected from the patients for the inclusion of deidentified clinical data in a scientific publication, in accordance with the declaration of helsinki. key: cord-339759-us1spoxu authors: cornelis, i.; volk, h. a.; van ham, l.; de decker, s. title: clinical presentation, diagnostic findings and outcome in dogs diagnosed withpresumptive spinal‐only meningoen‐cephalomyelitis of unknown origin date: 2017-03-07 journal: j small anim pract doi: 10.1111/jsap.12622 sha: doc_id: 339759 cord_uid: us1spoxu objectives: to summarise clinical presentation, diagnostic findings and long‐term outcome for dogs clinically diagnosed with meningoencephalomyelitis of unknown origin affecting the spinal cord alone. methods: medical records were reviewed for dogs diagnosed with presumptive spinal‐only meningoencephalomyelitis of unknown origin between 2006 and 2015. results: 21 dogs were included; the majority presented with an acute (43%) or chronic (52%) onset of neurological signs. ambulatory paresis was the most common neurological presentation (67%). neurological examination most commonly revealed a t3‐l3 myelopathy, and spinal hyperaesthesia was a common finding (71%). a spinal cord lesion was visible in 90% of cases on magnetic resonance imaging. eighteen lesions (86%) showed parenchymal contrast enhancement and 17 lesions (81%) showed contrast enhancement of overlying meninges. all dogs were treated with immunosuppressive doses of glucocorticosteroids, sometimes combined with cytosine arabinoside. at time of data capture, 10/21 dogs (48%) had died or been euthanased because of the condition. overall median survival time was 669 days. clinical significance: meningoencephalomyelitis of unknown origin should be considered in the differential diagnosis of dogs presenting with a progressive myelopathy. magnetic resonance imaging features can possibly help to distinguish presumptive meningoencephalomyelitis of unknown origin from other more common spinal diseases. overall, long‐term survival is guarded, approximately 50% of dogs will die or be euthanased despite appropriate therapy. pure myelitis (inflammation of spinal cord parenchyma) or meningomyelitis (inflammation of spinal cord parenchyma and surrounding meninges) are rare diseases in small animals but occur most often in combination with inflammatory brain disease (tipold & stein 2010 ) . viruses [canine distemper virus (cdv), feline coronavirus], bacteria ( staphylococcus species, et al . 2009 , csebi et al . 2010 , dewey et al . 2016 . apart from infectious causes, non-infectious meningoencephalomyelitis including granulomatous meningoencephalomyelitis, pyogranulomatous meningoencephalomyelitis and steroid-responsive meningitis-arteritis (srma) are described (meric 1988 , griffin et al . 2008 , parry et al . 2009 , dewey et al . 2016 . current terminology implies that dogs clinically diagnosed with non-infectious inflammatory myelitis without positive infectious disease testing, not classified as srma or eosinophilic meningomyelitis, and not histopathologically confirmed with alternative diagnoses are categorised as having meningoencephalomyelitis of unknown origin (muo), equivalent to dogs diagnosed with meningoencephalitis of unknown origin. a clinical diagnosis of muo is typically made by a combination of clinical presentation, mr imaging of involved part of the central nervous system (brain/spinal cord), and results of cerebrospinal fluid (csf) analysis (griffin et al . 2008 ) . currently, only one study has focused specifically on the clinical presentation, diagnostic findings and outcome in dogs with meningomyelitis caused by a variety of underlying aetiologies (griffin et al . 2008 ). of 28 cases included, 15 dogs were diagnosed with muo. clinical signs were reflected by the affected spinal cord segments, and younger dogs, toy breeds, and hound breeds were suggested to be predisposed for meningomyelitis. although results of myelography, ct, and ct-myelography have been reported, little is reported about magnetic resonance imaging (mri) findings in dogs with muo of the spinal cord. the aims of this study were therefore to describe the signalment, clinical presentation, diagnostic findings, including results of mri and long-term survival in dogs diagnosed with presumptive muo of the spinal cord without concurrent clinical signs of intracranial involvement. the electronic medical database was searched between march 2006 and february 2015 for dogs diagnosed with "mua," "muo," "gme," "myelitis," "inflammatory spinal cord disease." dogs were included based on the criteria used by granger et al . ( 2010 ) , if they had (1) complete medical records available, (2) a complete neurological examination performed leading to a spinal cord localisation, (3) inflammatory csf analysis, (4) mri of the spinal cord and if (5) long-term follow-up information were available through revision of medical records or through contacting the referring veterinarian by telephone. dogs were excluded if (1) the clinical records or imaging studies were incomplete or not available for review, (2) dogs showed clinical or neurological signs of intracranial involvement at time of presentation, (3) they had a peracute onset of clinical signs that were not progressive after 12 to 24 hours, (4) they had signs of extradural or extradural/intramedullary spinal cord compression on mri and if (5) they had positive infectious disease titres or if clinical presentation, csf analysis or necropsy findings were suggestive of srma or eosinophilic meningoencephalomyelitis (>10% eosinophils in csf) (dewey et al . 2016 ) . typical clinical presentation for srma was considered to be a dog less than 2 years of age of a typical breed (boxer, beagle, bernese mountain dog, nova scotia duck tolling retriever, golden retriever, german shorthaired pointer) presenting with pyrexia and cervical hyperesthesia. csf analysis in srma typically reveals a predominantly neutrophilic pleocytosis (dewey et al . 2016 ) . dogs with histopathological confirmation of the disease [granulomatous meningo(encephalo)myelitis (gme) or necrotising meningo(encephalo)myelitis (nme) only needed to fulfil inclusion criteria (1) and (5). information retrieved from the medical records included breed, gender, age at diagnosis, body weight, results of neurological examination including neuroanatomical localisation, duration of clinical signs prior to diagnosis, results of complete blood count (cbc) and biochemistry profile, results of csf analysis including total nucleated cell count (tncc), white blood cell differentiation and total protein (tp) concentration, treatment received and outcome. duration of clinical signs prior to diagnosis (days) was classified as peracute (<2 days), acute (2 to 7 days) or chronic (>7 days). for dogs that had csf analysis performed, site of collection (cisternal or lumbar), tncc, tp and cytological differentiation were recorded. tncc was considered normal if there were <5 cells/mm 3 . protein concentration was considered normal for a cisternal collection if <0·25 g/l and for a lumbar collection if <0·4 g/l. the neurological status was classified from 0 to 5 according to the clinical examination (adapted from scott 1997 ): grade 0=neurologically normal; grade 1=spinal hyperaesthesia without neurological deficits; grade 2=ataxia, ambulatory para-or tetraparesis; grade 3=non-ambulatory para-or tetraparesis; grade 4=para-or tetraplegia with or with-out bladder control, and intact deep pain sensation; grade 5=para-or tetraplegia, urine retention or overflow, and deep pain sensation loss. possible neuroanatomical localisations included c1 to c5, c6 to t2, t3 to l3 or l4 to s3 spinal cord segments. dogs were diagnosed with a focal lesion if only one spinal cord segment was affected, and with a multifocal lesion if more than one spinal cord segment appeared to be affected on the neurological examination. magnetic resonance imaging mri was performed under general anaesthesia with a permanent 1.5-t magnet (intera, philips medical systems, eindhoven, the netherlands) and all images were reviewed by the corresponding author using osirix dicom viewer (osirix foundation, v.5.5.2 geneva, switzerland). sequences varied, but included a minimum of t2-weighted (t2w) [repetition time (ms) (tr)/ echo time (ms) (te), 3000/120] and t1-weighted (t1w) (tr/ te, 400/8) images of the affected spinal cord region in a sagittal and transverse plane. the t1w images were acquired before and after intravenous (iv) administration of paramagnetic contrast medium with a dose of 0·1 mg/kg gadoterate meglumine (dotarem, guerbet). if mr images of the brain were available, they were reviewed concurrently. variables recorded were lesion intensity on t2w and t1w images, lesion localisation and distribution, lesion length and parenchymal and/or meningeal contrast enhancement. lesion length was measured using osirix dicom viewer, and performed on sagittal t2w images for dogs that had focal lesions. lesion length was measured twice, and the mean value reported. to compensate for differences in body size, values were corrected with respect to the length of vertebral body of c6 (for cervical lesions) or l2 (for thoracolumbar lesions). vertebral body length was measured on t1w sagittal images. for all dogs, the specific treatment protocol was recorded. during hospitalisation, all dogs underwent daily at least one general physical and complete neurological examination by a board-certified neurologist or neurology resident. the results of the neurological examination as well as response to treatment (improvement, deterioration or static) were systematically recorded on the kennel sheets. follow-up information during hospitalisation was collected from the medical records, and later through medical records of re-examination visits or telephone contact with the referring veterinarian. a successful outcome was defined as the dog being ambulatory, with faecal and urinary continence and, according to the owners, without overt spinal hyperaesthesia. an unsuccessful outcome was defined as (1) deterioration in neurological status by one or more grades after diagnosis and treatment or (2) if the dog was not independently ambulatory, possibly with previously non-existing or worsening faecal and/or urinary incontinence, or was experiencing spinal hyperaesthesia as defined by the owner. data analysis was performed with the aid of a standard statistical software package (prism, graphpad software inc). numeric variables were expressed as median and interquartile ranges (iqr). values of p<0·05 were considered significant. survival analysis was performed using both a log-rank (mantel-cox) and gehan-breslow-wilcoxin test, resulting in median survival time (mst) calculation and a kaplan-meier survival curve. survival was defined as time from diagnosis to death or euthanasia, including whether this happened because of disease progression or due to unrelated causes, or time from diagnosis to last follow-up for dogs that were alive at time of data capture. dogs that died because of unrelated causes and dogs that were still alive at time of data capture were censored for survival analysis. twenty-one dogs were included in the study. represented breeds included french bulldog (n=2), jack russell terrier (n=2), lhasa apso (n=2) and one each of akita, bearded collie, boxer, bull mastiff, chihuahua, cross breed, english springer spaniel, giant schnauzer, labrador retriever, maltese terrier, rhodesian ridgeback, rottweiler, shih-tzu, west highland white terrier and yorkshire terrier. overall, median age at presentation was 56 months (10 to 128 months). thirteen dogs (62%) were male and eight (38%) were female. compared to the general hospital population between march 2006 and february 2015, there was no difference in sex distribution in the group of dogs with muo (fisher ' s exact test; p=0·075). median duration of clinical signs prior to diagnosis was eight days (ranging from 1 to 90 days). one dog (5%) presented with peracute, nine dogs (43%) with acute and eleven dogs (52%) with a chronic onset of neurological signs. thirteen (62%) and eight (38%) dogs were diagnosed with a focal and multifocal spinal lesion on neurological examination, respectively. for dogs with focal spinal lesions (n=13), three were diagnosed with a lesion affecting the c1 to c5 spinal cord segments, two with a lesion affecting the c6 to t2 spinal cord segments, six with a lesion affecting the t3 to l3 spinal cord segments and two with a lesion affecting the l4 to s3 spinal cord segments. at time of diagnosis, no dogs presented as grade 0; 2 dogs (10%) were grade 1; 14 (67%) grade 2 and 5 (24%) grade 3. no dogs were paraplegic or tetraplegic at presentation. pain on direct spinal palpation was present in 15 (71%) dogs. urinary retention was observed in two dogs (10%), and a combination of urinary and faecal incontinence was noticed in two dogs (10%). one dog (5%) developed seizures 669 days after diagnosis of muo. clinical findings of the 21 included dogs are summarised in table 1 . as required by the inclusion criteria, csf collection revealed pleocytosis in all cases. overall, median tncc was 209 cells/ mm 3 (ranging from 6 to 6000). tp measurement was performed in all but three csf samples, and was above reference values in 17/18 dogs (94%). the median tp concentration was 1·67 g/l (ranging from 0·21 to 16·3 g/l). cbc and serum biochemistry results were available in 16 dogs (76%). leucocytosis was only present in two dogs (10%) and lymphopenia was present in six dogs (29%). infectious disease testing based on serology and/or polymerase chain reaction on csf for cdv, t . gondii , and n . caninum was not performed in two (10%) dogs and was negative in the remaining 19 (90%) dogs. in the two dogs lacking infectious disease testing, full necropsy was performed, revealing gme. magnetic resonance imaging mri of the spinal cord was available in all cases, revealing a focal lesion in 15 dogs (71%), a multifocal lesion in four (19%) and no lesion was visible on sagittal t2w or t1w images in two (10%). lesion length was measured in the focal cases only. median lesion/vertebral body ratio was 4·8 (ranging from 0·6 to 10·9). all visible lesions were ill-defined, intramedullary, hyperintense on t2w images and isointense on t1w images (figs 1 and 2 ). lesions showed parenchymal contrast enhancement in 18 dogs (86%), and contrast enhancement of overlying meninges in 17 (81%). in the two cases in which no lesion was visible on sagittal t2w and t1w images, there was also no observable parenchymal contrast, but one dog only showed meningeal contrast enhancement. in two dogs (10%) intracranial images were contained within the field of view of the cervical spinal cord images (t2w transverse and sagittal images), revealing multiple t2w hyperintensities in the forebrain and/or brainstem. neither of those dogs had clinical or neurological signs of intracranial involvement at time of diagnosis. the first dog, a 56-month-old jack russell terrier, did not recover from general anaesthesia after diagnostic procedures, and full necropsy revealed gme. the second dog, a 123-month-old rhodesian ridgeback, developed seizures 669 days after diagnosis and was euthanased without further investigations. as required by the inclusion criteria, outcome was available in all dogs. as described above, one dog did not recover from general anaesthesia for mri of the spinal cord, and was censored for survival analysis. mean duration of hospitalisation was five days (ranging from 1 to 19 days), with 17 dogs (81%) showing improvement in neurological status within that period. one dog (5%) remained neurologically stable (no improvement nor deterioration), and three dogs (14%) showed deterioration of their neurological status. all dogs were treated with immunosuppressive doses of glucocorticosteroids immediately after diagnosis. this consisted doses of 0·3 to 0·5 mg/kg/day dexamethasone in nine dogs (43%) iv and 2 to 4 mg/kg/day oral prednisolone in 12 dogs (57%). fourteen dogs (67%) received additional treatment with cytosine arabinoside as a constant rate infusion (cri) of 200 mg/m 2 over eight hours in one dog (7%) and as four subcutaneous (sc) injections of 50 mg/m 2 every 12 hours for two consecutive days in 13 dogs (93%). twenty dogs (95%) survived to discharge. of these dogs, nine dogs (45%) were still alive at time of data capture. of these nine dogs, eight were neurologically normal according to the followup information and one dog still showed ataxia and ambulatory paraparesis. of the eight normal dogs, two were still receiving a dose of 5 mg/kg cyclosporine every 24 hours, one was receiving a dose of 50 mg/m 2 cytosine arabinoside every 12 hours for two consecutive days every nine weeks, one was receiving a dose of 0·2 mg/kg prednisolone every 24 hours, one was receiving doses of 1 mg/kg prednisolone every 24 hours and 50 mg/m 2 cytosine arabinoside every 12 hours for two consecutive days every four weeks, and three dogs were not receiving any treatment at time of data capture. the dog that was still showing neurological abnormalities was receiving doses of 0·5 mg/kg prednisolone every other day and 50 mg/m 2 cytosine arabinoside every 12 hours for two consecutive days every 5 weeks. for the 11/20 dogs (55%) that were dead at the time of data capture, three had died or were euthanased because of disease progression, six were euthanased because of acute neurological deterioration after initial neurological improvement and two were euthanased because of unrelated causes (complications after stifle surgery and development of aggression). dogs that showed acute neurological deterioration after initial improvement did so within a median of 171 days after diagnosis (ranging from 30 to 669 days). of those six dogs, one showed acute deterioration after discontinuation of prednisolone treatment and five were still receiving treatment doses of 1 mg/kg prednisolone every 24 hours, 0·5 mg/kg prednisolone every 24 hours, 2 mg/kg prednisolone every 24 hours and 2 mg/kg azathioprine every 24 hours or 50 mg/m 2 cytosine arabinoside every 12 hours for two consecutive days every seven weeks. overall, we can conclude that 10/21 dogs (48%) died or were euthanased because of muo. overall, the mst was 669 days (ranging from 1 to 2250 days) (fig 3 ) . confirmation from post-mortem examination was available in three dogs, revealing gme in two and necrotising meningomyelitis in one dog. all clinical data are shown in tables 1 and 2 . this study evaluated the clinical presentation, diagnostic findings and long-term survival in 21 dogs diagnosed with presumptive spinal muo. dogs had a median age of five years at time of pain on direct spinal palpation was present in 71% of dogs. spinal pain may reflect the involvement of the meninges, and/ or vertebrae (vertebral periosteum), and/or nerve roots or spinal nerves (da costa 2012 ). in the present study, the lesions showed meningeal contrast enhancement in 18/21 dogs, but there was no apparent association between spinal hyperaesthesia and meningeal enhancement on mri. mri of the spinal cord revealed no lesion on sagittal t2w and t1w images in 10% of dogs (n=2), which appears similar to the 7% described for the brain in dogs with muo (granger et al . 2010 ). in the retrospective study of griffin et al . ( 2008 ) , only one dog with meningomyelitis had mri performed, revealing no abnormalities. based on these findings, muo cannot be ruled out based on unremarkable mri findings. the first dog was a 42-month-old bullmastiff with a 1-month history of slowly progressive t3 to l3 spinal cord lesion. after diagnostic procedures, the dog was treated with oral prednisolone but continued to deteriorate and was euthanased after 6 days. no post-mortem examination was performed. the second dog was a 136-monthold bearded collie with a 1-week history of a progressive multifocal spinal cord neuroanatomical localisation (t3 to s3 spinal cord lesion). the dog showed improvement on treatment with prednisolone and cytosine arabinoside (see table 1 ) after diagnostic investigations, and was still alive without current treatment 1100 days after diagnosis. both dogs had inflammatory csf analysis (increased tncc and tp concentration). for both dogs, vascular, degenerative or neoplastic spinal cord lesions cannot be excluded. as both dogs had a progressive disease course, a vascular (ischaemic) lesion seemed less likely. a neoplastic lesion cannot be excluded, although this seems rather unlikely in the bullmastiff considering his very young age. the second dog had a lymphocytic pleocytosis on cfs analysis, but no signs of lymphoma on microscopical examination, although no specific test for clonality was performed. all mri-observed lesions were extensive, ill-defined, intramedullary, hyperintense on t2w images and isointense on t1w images. other spinal conditions, including acute non-compressive nucleus pulposus extrusions (annpe) and ischaemic myelopathy (im), are also associated with intraparenchymal hyperintensities on mri. however, these conditions are associated with other clinical and additional mri characteristics, which could potentially aid in differentiating between these conditions (cardy et al . 2015 , fenn et al . 2016 ). according to cardy et al . ( 2015 ) , in dogs presenting with spinal cord dysfunction, im [most commonly fibrocartilagenous embolic myelopathy (fcem)] and annpe are typically characterised by a peracute onset of non-progressive clinical signs and affected dogs do not commonly demonstrate overt spinal hyperaesthesia at time of admission. this is in contrast with the clinical presentation of dogs with spinal muo, which was characterised by an acute onset of progressive and mainly symmetrical neurological deficits, with pain on spinal palpation or manipulation in 86% of dogs (cardy et al . 2015 ) , which is comparable with the 71% of dogs presenting with spinal hyperaesthesia in the current study. although csf analysis in dogs with im is most often within normal limits, affected dogs can demonstrate an increased tp concentration and mild neutrophilic or mixed cell pleocytosis with a median tncc of 12 cells/ µ l (de risio et al . 2007 ) . a marked pleocytosis with a median tncc of 209 cells/mm 3 was seen in the current study, although this conclusion should be treated with caution because csf pleocytosis was one of the inclusion criteria. to conclude, the presentation of a dog with an acute or chronic onset of a progressive and painful t3 to l3 myelopathy in combination with an extensive, ill-defined, intramedullary lesion plus parenchymal and/or meningeal contrast enhancement on mri, and marked pleocytosis on csf analysis, can be presumptively diagnosed with spinal muo. the importance of differentiating between these conditions is highlighted by the differences in treatment and prognosis between dogs with presumptive muo and dogs with annpe or im. a previous study demonstrated that short tau inversion recovery (stir) hyperintensities in the cervical epaxial musculature of dogs with meningoencephalomyelitis had a sensitivity of 78% and a specificity of 92% in predicting inflammatory csf results (eminaga et al . 2013 ). in the current study, stir images were unfortunately only available in 3/21 cases. adding this sequence to the protocol in dogs with presence of a focal or multifocal, illdefined t2w intramedullary hyperintensity might be considered in the future. several studies have evaluated survival times of dogs diagnosed with muo (granger et al . 2010 , coates & jeffery 2014 . overall, dogs with muo appear to have a guarded prognosis. a large meta-analysis of dogs with muo revealed an overall reported mst of 240 to 590 days in 96 dogs treated with corticosteroids plus any other immunosuppressive protocol, compared to a mst of 28 to 357 days for 43 dogs receiving corticosteroids alone (granger et al . 2010 ). in the current study, dogs with presumptive spinal muo had a mst of 669 days (2 years), but ultimately, 48% of dogs died or were euthanased because of the disease, indicating a more guarded long-term prognosis. limitations of this study are the small sample size and retrospective character, which limited standardisation of patient assessment and treatment. although all dogs were treated with glucocorticosteroids, it cannot be excluded that specific differences in treatment may have influenced outcomes. despite including cases over a relative large period and from a busy referral hospital, only 21 dogs were found through our record search. this could indicate that spinal muo should be considered a rare disorder, which is in agreement with previous reports (cardy et al . 2015 ) , suggesting that muo represents approximately 6% of all spinal disorders in dogs. presumptive spinal muo can be diagnosed in any type of dog of any age that is presented with signs of acute or chronic, possibly painful, myelopathy. although clinical signs can vary, affected animals most typically present with ambulatory paraparesis and ataxia, localising to t3 to l3 spinal cord segments. mri typically reveals an extensive, ill-defined and intramedullary lesion that appears hyperintense on t2w images and isointense on t1w images. most lesions showed parenchymal contrast enhancement and/or enhancement of the overlying meninges on post-contrast t1w images which can possibly differentiate dogs with muo from other more common spinal diseases. in 10% of cases, no lesion was visible on sagittal t2w and t1w images. almost 50% of dogs died or were euthanased because of muo, with a mst of 669 days. none of the authors of this article has a financial or personal relationship with other people or organisations that could inappropriately influence or bias the content of this paper. clinical reasoning in canine spinal disease: what combination of clinical information is useful? perspectives on meningoencephalomyelitis of unknown origin vertebral osteomyelitis and meningomyelitis caused by pasteurella canis in a dog -clinicopathological case report spinal pain magnetic resonance imaging findings and clinical associations in 52 dogs with suspected ischemic myelopathy neurodiagnostics . in: practical guide to canine and feline neurology stir muscle hyperintensity in the cervical muscles associated with inflammatory spinal cord disease of unknown origin inter -and intraobserver agreement for diagnosing presumptive ischemic myelopathy and acute noncompressive nucleus pulposus extrusion in dogs using magnetic resonance imaging . veterinary clinical findings and treatment of non-infectious meningoencephalomyelitis in dogs: a systematic review of 457 published cases from meningomyelitis in dogs: a retrospective review of 28 cases canine meningitis -a changing emphasis imaging diagnosis -necrotizing meningomyelitis and polyarthritis hemilaminectomy for the treatment of thoracolumbar disc disease in the dog: a follow-up study of 40 cases inflammatory diseases of the spine in small animals key: cord-102474-fmq98aa8 authors: gooding, k. m.; lienczewski, c.; papale, m.; koivuviita, n.; maziarz, m.; dutius andersson, a.-m.; sharma, k.; pontrelli, p.; garcia hernandez, a.; bailey, j.; tobin, k.; saunavaara, v.; zetterqvist, a.; shelley, d.; teh, i.; ball, c.; puppala, s.; ibberson, m.; karihaloo, a.; metsaì�rinne, k.; banks, r.; gilmour, p. s.; mansfield, m.; gilchrist, m.; de zeeuw, d.; heerspink, h. j.; nuutila, p.; kretzler, m.; wellberry-smith, m.; gesualdo, l.; andress, d.; grenier, n.; shore, a. c.; gomez, m. f.; sourbron, s.; investigators, ibeat title: prognostic imaging biomarkers for diabetic kidney disease (ibeat): study protocol date: 2020-01-16 journal: nan doi: 10.1101/2020.01.13.20017228 sha: doc_id: 102474 cord_uid: fmq98aa8 diabetic kidney disease (dkd) is traditionally classified based on albuminuria and reduced kidney function (estimated glomerular filtration rate (egfr)), but these have limitations as prognostic biomarkers due to the heterogeneity of dkd. novel prognostic markers are needed to improve stratification of patients based on risk of disease progression. the ibeat study, part of the beat-dkd consortium, aims to determine whether renal imaging biomarkers (magnetic resonance imaging (mri) and ultrasound (us)) provide insight into the pathogenesis and heterogeneity of dkd (primary aim), and whether they have potential as prognostic biomarkers in dkd progression (secondary aim). ibeat is a prospective multi-centre observational cohort study recruiting 500 patients with type 2 diabetes (t2d) and egfr > 30ml/min/1.73m2. at baseline each participant will undergo quantitative renal mri and us imaging with central processing for mri images. blood sampling, urine collection and clinical examinations will be performed and medical history obtained at baseline, and these assessments will be repeated annually for 3 years. biological samples will be stored in a central laboratory for later biomarker and validation studies. all data will be stored in a central data depository. data analysis will explore the potential associations between imaging biomarkers and renal function, and whether the imaging biomarkers may improve the prediction of dkd progression rates. embedded within ibeat are ancillary substudies that will (1) validate imaging biomarkers against renal histopathology; (2) validate mri based renal blood flow against water-labelled positron-emission tomography (pet); (3) develop machine-learning methods for automated processing of renal mri images; (4) examine longitudinal changes in imaging biomarkers; (5) examine whether the glycocalyx, microvascular function and structure are associated with imaging biomarkers and egfr decline; (6) a pilot study to examine whether the findings in t2d can be extrapolated to type 1 diabetes. the ibeat study, the largest dkd imaging study to date, will provide invaluable insights into the progression and heterogeneity of dkd, and aims to contribute to a more personalized approach to the management of dkd in patients with type 2 diabetes. diabetic kidney disease (dkd) is the leading cause of end stage renal disease (1, 2) . it is currently estimated that approximately 20-40% of people with diabetes will develop dkd (3) , and this is expected to rise in the future. with the global increase in the prevalence of diabetes (4), particularly type 2 diabetes, dkd is reaching epidemic proportions, with health and quality of life implications (e.g. increased risk of cardiovascular mortality) for the individual (5) . even with current approaches to management of diabetes and renin-angiotensin-aldosterone system blockade, there is still large residual risk in dkd (6) . dkd is routinely classified clinically based on albuminuria and reduced kidney function (estimated glomerular filtration rate (egfr)). albuminuria is traditionally viewed as a hallmark of diabetes related kidney damage. however, there are limitations of using albuminuria to classify dkd, which include the need for multiple measurements to mitigate spurious results due to factors such as infection and physical activity. additionally, the heterogeneity of dkd is increasingly recognised, as reflected, for example, by the disparity in dkd progression (fast versus slow dkd progression) and by patients with declining kidney function but normoalbuminuria. for example, 51% of participants in the uk prospective diabetes study whose egfr declined below 60 ml/min/1.73 m 2 had normoalbuminuria (7) . this heterogeneity in dkd highlights the need for novel biomarkers and a more personalized medicine-based approach to managing dkd. the fundamental aim of the biomarker enterprise to attack dkd (beat-dkd) consortium is to increase our understanding of the pathogenesis and heterogeneity of dkd, enabling the identification of novel biomarkers and treatment targets, to facilitate a more personalized medicinebased approach to managing dkd and increase the efficiency of clinical trials (8) . cross-sectional imaging, in particular mri and us, is increasingly proposed as an alternative source of biomarkers to inform chronic kidney disease (ckd) management (9, 10) . an important example is the qualification by the food and drug administration (fda) and the european medicines agency (ema) of total kidney volume (tkv) as a prognostic enrichment biomarker for autosomal dominant polycystic kidney disease (adpkd) -one of only a handful of clinical biomarkers approved by the fda so far (11, 12) . in recent years the interest is increasingly moving towards advanced mri and us techniques that are sensitive to structural and functional tissue characteristics such as perfusion, oxygenation, blood flow, glomerular filtration, tubular flow, fibrosis, inflammation, metabolism and tissue composition. additional utility derives from the fact that these characteristics can be measured separately for left and right kidney, for cortex and medulla, or to map functional and structural heterogeneity within those areas. a number of preclinical and single-centre clinical studies have indicated a potential utility of mri and us biomarkers in dkd specifically. for instance, us-based measurements of kidney volume have suggested that kidney enlargement is associated with poorer outcomes in early and advanced dkd, despite the often better gfr of larger kidneys (13) (14) (15) . a possible explanation is that hypertrophy indicates a sustained state of primary or secondary hyperfiltration and associated damage due to intraglomerular pressures. a mechanistic study suggested that the mri method bold (blood oxygenation level dependent mri) can highlight areas at risk of ischemic damage due to oxygen depletion after sustained hyperfiltration (16) , and a recent clinical study has confirmed that the bold signal is predictive of ckd progression (17) . some mri biomarkers derived from diffusionweighted mri are sensitive to renal fibrosis (18, 19) and can identify microstructural changes after sustained hyperfiltration (20) , though the clinical potential of mri measures of fibrosis and microstructure remains to be confirmed (21) . kidney perfusion and glomerular filtration can be measured with mri. renal blood flow has been shown to correlate with egfr in dkd (22) . other non-renal imaging biomarkers characterising general risk factors for diabetes and its associated complications may be relevant in this context as well and can easily be measured in the same mri scan session, such as liver and pancreatic fat fraction (23) . the aim of ibeat is to evaluate the evidence for the utility of imaging biomarkers in dkd in a large cohort of heterogeneous type 2 diabetes patients, in the early stages of dkd where there is high potential for effective interventions to slow the rate of dkd progression. the key hypotheses are that (1) imaging-based biomarkers of dkd provide additional information on the pathogenesis and histological and clinical heterogeneity of dkd compared to biomarkers sourced from samples or physical exams, and (2) that changes in imaging biomarkers precede increases in albuminuria and decline in kidney function as measured by egfr. as a result, we expect imaging biomarkers to improve the identification of dkd patients at risk of rapid decline in kidney function, either when used alone or combined with clinical data / biological fluid biomarkers. an additional aim of the ibeat study is to establish a biobank of biological samples (blood-and urine-based) from well-characterised patients for use within the beat-dkd programme and future dkd studies. this will facilitate biomarker discovery studies using novel blood-and urine-based biomarkers and may serve as the foundation for a comprehensive multi-scale phenotyping strategy linking data from blood, urine, tissue, microvascular assessments, imaging, physical measurements and medical histories. the specific study objectives are:  primary objective: to examine whether renal imaging biomarkers are associated with severity of dkd as defined using classical biomarkers of dkd, albuminuria and egfr, in individuals with type 2 diabetes and egfr > 30 ml/min/1.73m 2 .  secondary objective: to examine whether renal imaging biomarkers are associated with changes in renal function over time as measured by egfr over a 3-year period. ibeat (registered at clinicaltrials.gov under nct03716401) is a prospective observational study that will enrol 500 participants, stratified into six subgroups based on three albumin-to-creatinine ratio (acr) and two egfr categories, with type 2 diabetes (t2d) and egfr greater than 30 ml/min/1.73m 2 across five european centers. a schematic overview of the study assessments is presented in table 1 . at baseline, each participant will undergo comprehensive renal imaging (mri and us), biological sample collection (blood and urine), physical measurements and their medical history will be collected. they will then be invited back annually for 3 years, where all measurements except the imaging will be repeated. participants can then be followed remotely, through medical notes and/or questionnaires, for a further 15 years. the organisation of ibeat is shown in figure 1 . the study is led by the coordinating centre in leeds with a co-lead in exeter and a study manager in michigan, currently there are 5 recruiting centers (university of leeds, university of exeter medical school, university of bari, university of bordeaux and university of turku), a central laboratory (lund university) and a central data repository (swiss institute of bioinformatics (sib)). all ethical and relevant local approvals are in place at each recruiting site. as a beat-dkd work package the study is supported by the beat-dkd consortium steering committee and an external scientific advisor. . cc-by 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not peer-reviewed) the copyright holder for this preprint . https://doi.org/10.1101/2020.01.13.20017228 doi: medrxiv preprint . cc-by 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint . https://doi.org/10.1101/2020.01.13.20017228 doi: medrxiv preprint the ibeat study will recruit participants with a diagnosis of type 2 diabetes, egfr greater than 30 ml/min/1.73m 2 , aged between 18-80 years, who are able to give informed consent, and do not satisfy any of the exclusion criteria. the exclusion criteria are listed in table 2 (see also supplement 3.0). ibeat will recruit across six strata defined by the a1-a3 albuminuria range (normo-, micro-and macroalbuminuria) and the (g1+g2)-g3 egfr range. in line with the national kidney foundation guidelines (24), albuminuria will be classified using two (or three) independent values of acrs measured within a 3-month period: one at the screening visit, one at the baseline study visit, and a third if the classification differs between the first two samples. we define normo-, micro-and macro-albuminuria as an acr of <2.5, 2.5-25, >25 mg/mmol for men, respectively, and as acr <3.5, 3.5-35, >35 mg/mmol for women, respectively. following the provision of written informed consent at the start of the screening visit, potential participants undergo a number of health assessments including, for example, medical history, random spot urine collection for assessment of acr and a blood sample for the assessment of egfr (unless these have been performed in the last 3 months) to assess eligibility for the study. . cc-by 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint . https://doi.org/10.1101/2020.01. 13.20017228 doi: medrxiv preprint baseline study assessments participant preparation: fasting blood samples are taken in the morning following an overnight fast. medications may be withheld or altered on the day of study visit to ensure participant wellbeing (e.g. omitting morning insulin injection to maintain blood glucose levels) and integrity of the study. a point of care glucose measurement will be performed upon participant arrival and the visit will be cancelled if glucose levels are below 3.5mmol/l or if the participant reports a symptomatic hypoglycaemic event on the morning of the visit. all other assessments are performed following a standardised meal. participants are required to be on stable diabetes and hypertension related treatment (though dose changes to current medications are allowed) for the 3 months prior to study assessments. the study visit will include a checklist to record the adherence to instructions (supplement 3.1). mri biomarkers: 59 primary mri biomarkers will be recorded (see supplement 1.0 for a full list), characterising general body composition (e.g. visceral fat volume, pancreatic and liver fat fraction), renal morphology (e.g. parenchymal volume, cortical thickness), renal tissue structure (e.g. mr relaxation times, apparent water diffusion coefficient), renal hemodynamics (e.g. cortical perfusion, renal artery blood flow), filtration (e.g. single-kidney gfr, filtration fraction). all mr scanning is performed at 3t on siemens, philips and general electric scanners. mri data are uploaded on a central xnat database hosted by sib and quality controlled within 48hrs by the central processing site in leeds. the mri protocol takes approximately 1hr and 10mins and involves the injection of a quarter dose of clinical macrocyclic mri contrast agent. the protocol was first developed on the reference siemens scanner in leeds using an iterative optimisation guided by the nist (national institute of standards and technology) phantom and healthy volunteers. the resulting final protocol was then characterised on each mri vendor using a repeatability study in healthy volunteers to determine within-site variability (5 volunteers with 4 scans each). the nist phantom is scanned at regular intervals in all sites to check for between-site calibration. full details of the mri acquisition protocol on the 3t siemens reference scanner in leeds can be found in supplement 1.1. renal ultrasound: kidney size will be non-invasively determined from longitudinal and transversal images of each kidney. resistive index (ri), indicator of the resistance to flow within the kidney, will be determined from three measurements in each kidney (upper, mid and lower poles). the mean of the three measurements will represent ri for each respective kidney. a list of us biomarkers are provided in the supplement 3.7 and the standard operating procedures (sops) for us scanning are in supplement 1.2. blood and urine sampling: fasting blood samples (~70mls designated for ibeat central requirement) will be collected from each participant for participant characterisation and biomarker analysis. glycated haemoglobin (hba1c), full blood count and fasting glucose assessments will be performed locally (supplement 3.4). the remaining plasma and serum samples will be processed and stored following a standardised protocol (see supplemental 2.1-2.3). a first morning urine void and one additional morning void (same day) are collected by all participants. a small proportion of the first morning void is sent to the local laboratories for acr assessment. the remainder of the first morning and second void are then processed and stored following a standardised protocol (see supplemental 2.1-2.3). the standardised sample collection and processing protocol, informed by provalid and neptune trials (25, 26) , was developed to maximise the utility of stored samples for future biomarker analysis (e.g. lipidomics, rna analysis, urinary vesicles and urinary sediment) within beat-dkd and to form a biobank for future dkd related studies. a separate check is performed to confirm that all samples are collected and processed according to protocol (supplement 3.8). . cc-by 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint . https://doi.org/10.1101/2020.01. 13.20017228 doi: medrxiv preprint the central biochemical laboratory is located at the clinical research centre (crc) facility in malmö (university of lund). the central lab will prepare and distribute kits with sample collection and processing materials for each patient labelled and barcoded with the study id. each kit comprises of 66 storage tubes per patient. the samples will be temporarily stored at each recruiting site, with regular shipments returning them to the biobank in malmö. samples will be stored under secure conditions and monitored with a dedicated electronic sample tracking system (laboratory information management systems). a small volume of blood and urine will be analysed in malmö for known clinical biomarkers (e.g. renal function (serum creatinine, cystatin c, potassium and albumin), lipid profile (total cholesterol and sub-fractions, triglycerides) and c-reactive protein) at the central laboratory, according to standardised methods, and the remainder will be stored for future analyses by beat-dkd investigators. the samples will also remain available for secondary research provided approval is granted by the ibeat steering committee. physical examination: the core physical examination assessments include blood pressures (sitting and standing blood pressures) and anthropometrics (height, weight, waist and hip circumference) assessments. see supplement 3.2 for details. medical history. a detailed medical history (including, for example, current medications, smoking history and presence of co-morbidities) is also collected. see supplements 3.3 and 3.6 for data fields that are captured. routine lab data: routine local laboratory data will be captured to aid in the interpretation of the results by tracking temporal changes at a finer time scale than the yearly follow-ups. only laboratory values available for clinical indication will be captured at this time. supplement 3.4 lists the data fields to be captured but missing data from the local chart is not deemed a protocol violation. the biological sampling protocol, medical history and physical examination will be repeated at 1, 2 and 3 years (± 3months) following study enrolment. for participants who are unable to attend the local research centre for an annual follow-up visit but are still willing to participate in the study an update on their medical history will be collected via direct communication with the participant and / or by accessing their available medical records. clinical images, associated data and metadata will be stored using the xnat platform (www.xnat.org) hosted on the dedicated beat-dkd server at sib. clinical study data will be managed using redcap (www.project-redcap.org), also installed on the dedicated beat-dkd server. all variables will be recorded on ibeat central clinical record folders (crf's -see supplements 3.0-3.8) and uploaded onto the central redcap instance. it is envisaged that the ibeat clinical study will be set up as a federated node enabling remote analysis of the data generated in the future, and integration of the ibeat data with other datasets collected in beat-dkd. sample size: the sample size calculation for a study such as this one would be complex and unlikely to be accurate. thus, we opted for a more pragmatic approach, and arrived at the sample size by considering the scientific and feasibility aspects of the study. specifically, in considering the sampling design, we were mainly concerned with whether it would allow us to answer the scientific questions we have and whether it would be feasible to carry out. we opted for a stratified sampling design, as we were interested in evaluating the association between imaging renal biomarkers and dkd in type 2 diabetes patients in various stages of dkd, as measured by acr and egfr, widely used biomarkers of dkd. this ensures that we will have a reasonable sample size for all combinations of acr (a1, a2, a3) and egfr (g1+g2, g3), even those that are typically rare, specifically a1 and g3, as well as a3 and g1+g2. in terms of feasibility, we considered the number of imaging facilities available to us and the estimated rate of recruitment in each for each strata of our sample. based on these considerations we arrived at a stratified sample of 500 patients, 4 groups of 92 and two groups of 66. see table 2 in supplement 5.0 for details. we will begin by describing our data, comparing the descriptive statistics of all covariates across the study centers, assessing the bivariate relationships between sets of related covariates. we will then perform a cross-sectional analysis using data collected at baseline, as well as a longitudinal analysis using the imaging data collected at baseline and blood and urine markers collected over the three years. given the large number of covariates in our study, we will use variable selection and regularization methods such as lasso (27) and the elastic net regularization (28) . the modelling will be done appropriately for a given setting, with linear models for the crosssectional analyses, and linear mixed effects models for the longitudinal analysis. the analyses will be performed separately in each strata and, whenever possible, accounting for the stratification in the modelling, as we expect there to be effect modification in the potential associations we will be estimating across the strata. we will adjust for multiple comparisons as needed. if we identify any renal imaging biomarkers as having promise as early markers of dkd progression, we will use them in risk prediction and evaluate their predictive accuracy, as measured by prediction error, receiver operating characteristics curve (roc) and the area under the roc (area under the curve, auc), using cross-validation. we plan to take a conservative approach in all of our analyses, meaning that we will be careful with the number of models we fit and statistical tests we perform, and will treat our analyses as exploratory and hypotheses generating, rather than hypothesis testing. building on the strengths and interests across the ibeat participating centres, six ancillary studies have been incorporated within the central ibeat study. participants taking part in the ancillary studies will be recruited from the central ibeat study at the relevant sites. ancillary study 1: to examine whether mri and us based imaging biomarkers correlate with histopathological markers of dkd and discriminate different renal lesions in this t2d cohort. for this ancillary study, led by bari university, ibeat participants will undergo a renal tissue core biopsy (n=100). all biopsies will be digitalized and characterized by light microscopy (hematoxylin-eosin, periodic acid-schiff, silver methenamine, and masson's trichrome), immunofluorescence microscopy (with the use of antisera against igg, igm, iga, c3, c4, c1q and fibrinogen) and electron microscopy. glomerular and vascular lesions, interstitial cell infiltrate, fibrosis and tubular atrophy will be quantified (29) . samples will also be processed and stored for later biomarker discovery. the procedures for processing, storing and capturing meta-data regarding the renal biopsy tissue are described in more detail in supplement 4.0. ancillary study 2: to examine whether mri-based measurements of renal blood flow correlate with h2o-positron emission tomography (pet) renal perfusion measurements, validating the mri based measurements against the standard pet perfusion measurements. for this ancillary study, led by turku university, a direct comparison of mri and pet-based measurements of renal blood flow will be performed in a cohort of ibeat participants. renal perfusion will be assessed during hyperaemia with both systems. ancillary study 3: to develop machine-learning methods for automated or semi-automated processing of multiparametric renal mri. in its current form the generation of biomarkers from complex functional mri scans involves significant manual intervention as well as automated but slow iterative optimisation methods. in this study, led by leeds university, a subset of the ibeat data will be used as training data to develop an ideally automated approach for image processing, which will then be validated on the remaining test data against the manual results. . cc-by 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint . https://doi.org/10.1101/2020.01. 13.20017228 doi: medrxiv preprint ancillary study 4: to investigate the longitudinal changes in mri and us based biomarkers, compare them against changes in egfr and other known markers, and determine whether changes in imaging biomarkers precede dkd progression as assessed by egfr decline. for this study a cohort of 100 patients will receive repeat mri and us after 2 years, and changes in imaging biomarkers over that period will be correlated against changes in egfr and other assessments. ancillary study 5: to examine whether the glycocalyx, microvascular function and structure (retinal and skin) are (1) altered in microalbuminuria; (2) associated with dkd progression as assessed by egfr decline and (3) are associated with novel mri and us imaging dkd biomarkers. for this study, led by university of exeter, ibeat participants will also undergo comprehensive microvascular assessments (including non-invasive estimation of sublingual endothelial glycocalyx integrity, retinal vascular oxygenation and skin maximum hyperaemia) at baseline and at 2 years follow-up. ancillary study 6: a pilot study to examine whether the findings in t2d can be extrapolated to type 1 diabetes. in this ancillary study a cohort of 50 patients with type 1 diabetes will be assessed using the same procedures as the type 2 cohort and observed findings / trends will be compared across the two populations. patient and public involvement and engagement is a significant component of the ibeat study. potential participants have played an important role in ibeat, reviewing the protocol to ensure the feasibility of the study design (core and ancillary studies) as well as contributing to the development of patient facing documents (e.g. patient information sheets), ensuring that they are clear and informative. participants within the ibeat study will play an integral role in the dissemination of the study results to the wider, non-expert population. within the beat-dkd consortium discussions with patient representatives, ranging from experienced patient advocates to ibeat participants, will help inform how research from the beat-dkd consortium is taken forward to implement a more precision medicine based approach in dkd into clinical practice; for example, validation and qualification of new biomarkers by regulatory agencies, optimising clinical study design and integration in the regulatory process of drug registration. indeed, this has already commenced with an ibeat participant, along with other patient representatives, attending the 2nd beat-dkd stakeholders' symposiums in april 2019 (30) . quantitative and functional imaging of the kidney has been an active topic of research in the mri physics and radiology community for over two decades (31) , but the last few years have seen an explosive growth in clinical interest. the first international meeting on functional renal mri was held in 2015 and attendance has been increasing steadily ever since (32) (33) (34) . in 2017, a pan-european network of researchers in renal mri (www.renalmri.org) was funded for 4 years by the european cooperation in science and technology (www.cost.eu). in 2018, nephrology dialysis transplantation published a special issue on renal mri with a clinical position statement supported by over 30 authors including leading european nephrologists (9) . in the same year, in the us, the national institute of diabetes and digestive and kidney diseases (niddk) at the national institutes of health (nih) conducted a workshop on renal imaging to review the state-of-the-art and plan potential future endeavours [7] . also in 2018, the uk renal imaging network (ukrin) received a 3-year partnership grant to create a national infrastructure for quantitative renal mri, and has advanced plans for a 10 year cohort study in 450 ckd patients (afirm study; principal investigator: nick selby, university of nottingham). ibeat builds on these developments and is the first study to respond to the clinical need for systematically collected evidence at a larger scale and across institutions, with well-validated methods linking up the imaging findings with other sources of data so the added value can be identified. in that sense, ibeat is inspired by the landmark study crisp (consortium for radiologic imaging studies of polycystic kidney disease) (35) -the first multi-centre cohort study exploring a quantitative mri biomarker (tkv) in ckd and a foundation for the aforementioned fda qualification of tkv. like crisp, ibeat has built in a technical validation phase of the imaging biomarkers by including a repeatability study on all scanner types deployed in ibeat, and by calibrating betweenscanner differences through a travelling test object developed for this purpose by the national institute of standards and technology (36) . also following the example of crisp, ibeat is committed to sharing the technical details of its imaging protocols and expertise in image processing and quality assurance -not only to facilitate the cost and setup of future studies but also to maximise alignment and future opportunities for pooling the data. an example is an ongoing collaboration with the dynamo consortium (https://www.duke-nus.edu.sg/about/achievements/awards/collaborativegrants) in setting up an imaging biomarker study aligned with ibeat. collectively, the integration of the ancillary studies into ibeat will provide valuable information on the pathogenesis of dkd and the clinical utility of these imaging biomarkers. crucially, they will explore the association of renal based imaging biomarkers against histopathological markers and different histological lesions of dkd, validating the imaging biomarkers and substantiating their clinical utility. mri renal based perfusion measurements will also be validated against h2o-pet renal perfusion measurements. the potential automation of the mri image processing will streamline a labour intensive process, thereby increasing the clinical applicability of the assessments. the microvascular assessments, including the examination of glycocalyx integrity and endothelial function, will provide invaluable information on the pathogenesis and heterogeneity of dkd, and may well aid the identification of individuals with fast progressing dkd, for example, we hypothesise that individuals with type 2 diabetes with early signs of perturbations to the glycocalyx will be at an increased risk of dkd progression. ibeat has greatly benefitted in its setup from study documents and standard operating procedures (sops) provided by other investigators, in particular the provalid (26) and neptune (25) studies. in turn, ibeat is committed to a "pay-it-forward" philosophy and will aim to share its study documentation and procedures widely for use by other investigators. ibeat collaborators are also committed to maximise the opportunities for data sharing in order to increase the lifetime value of their research data as assets for human health and to do so timely, responsibly, with as few restrictions as possible, in a way consistent with the law, regulation and recognised good practice. beyond data, ibeat will aim to form a powerful resource for future biomarker discovery sources by . cc-by 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not peer-reviewed) the copyright holder for this preprint . https://doi.org/10.1101/2020.01.13.20017228 doi: medrxiv preprint collecting a rich collection of blood and urine samples in its central biobank. these will be made available for external investigators subject to formal application and approval by the ibeat steering committee. after a 2-year setup period the first study participant was recruited into ibeat in october 2018. first results on technical validation of mri methods on the reference scanner are expected at the end of 2019. the projected deadline for recruitment is 1 september 2020 and first results on the primary objective (cross-sectional analysis of baseline data) are expected to be made public in 2021. completion of follow-up data is expected in 1 sept 2023 with results on the longitudinal analysis expected to be submitted for publication in 2024. this project has received funding from the innovative medicines initiative 2 joint undertaking under grant agreement no 115974. this joint undertaking receives support from the european union's horizon 2020 research and innovation programme and efpia with jdrf. . cc-by 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not peer-reviewed) the copyright holder for this preprint . https://doi.org/10.1101/2020.01. 13.20017228 doi: medrxiv preprint chronic kidney disease: global dimension and perspectives. the lancet diabetes and ckd in the united states population diabetic kidney disease: challenges, progress, and possibilities global prevalence of diabetes: estimates for the year 2000 and projections for 2030 albuminuria and renal function as predictors of cardiovascular events and mortality in a general population of patients with type 2 diabetes: a nationwide observational study from the swedish national diabetes register the effect of raas blockade on the progression of diabetic nephropathy microvascular disease: what does the ukpds tell us about diabetic nephropathy biomarker enterprise to attack diabetic kidney disease magnetic resonance imaging biomarkers for chronic kidney disease: a position paper from the european cooperation in science and technology action parenchima functional magnetic resonance imaging of the kidneys: where do we stand? the perspective of the european cost action parenchima clinical review of pkd outcomes consortium biomarker qualification submissionle renal duplex sonographic evaluation of type 2 diabetic patients persistent renal hypertrophy and faster decline of glomerular filtration rate precede the development of microalbuminuria in type 1 diabetes large kidneys predict poor renal outcome in subjects with diabetes and chronic kidney disease renal diffusion and bold mri in experimental diabetic nephropathy reduced cortical oxygenation predicts a progressive decline of renal function in patients with chronic kidney disease new magnetic resonance imaging index for renal fibrosis assessment: a comparison between diffusion-weighted imaging and t1 mapping with histological validation magnetic resonance diffusion tensor imaging for evaluation of histopathological changes in a rat model of diabetic nephropathy use of diffusion tensor mri to identify early changes in diabetic nephropathy could mri be used to image kidney fibrosis? a review of recent advances and remaining barriers arterial spin labeling mri is able to detect early hemodynamic changes in diabetic nephropathy remission of human type 2 diabetes requires decrease in liver and pancreas fat content but is dependent upon capacity for β cell recovery national kidney foundation. k/doqi clinical practice guidelines for chronic kidney disease: evaluation, classification, and stratification design of the nephrotic syndrome study network (neptune) to evaluate primary glomerular nephropathy by a multidisciplinary approach a prospective cohort study in patients with type 2 diabetes mellitus for validation of biomarkers (provalid) -study design and baseline characteristics regression shrinkage and selection via the lasso regularization and variable selection via the elastic net pathologic classification of diabetic nephropathy highlights from the beat-dkd symposium on precision medicine in diabetic kidney disease radiologic imaging of the renal parenchyma structure and function 1st international meeting on renal mri 3d international meeting on renal mri volume progression in polycystic kidney disease quantitative magnetic resonance imaging phantoms: a review and the need for a system phantom key: cord-008085-3ihuqvei authors: thomas, william b. title: nonneoplastic disorders of the brain date: 2005-07-06 journal: clin tech small anim pract doi: 10.1016/s1096-2867(99)80030-9 sha: doc_id: 8085 cord_uid: 3ihuqvei computed tomography (ct) and magnetic resonance imaging (mri) are helpful in the diagnosis of many nonneoplastic brain disorders in the dog and cat. the ability of ct and mri to depict normal and abnormal anatomy facilitates the identification of developmental anomalies, including hydrocephalus, chiari malformations, arachnoid cysts, and cerebellar hypoplasia. these imaging modalities also allow the detection of hemorrhage and infarction and are therefore useful in the evaluation of spontaneous cerebrovascular disorders and head trauma. finally, many inflammatory diseases, such as encephalitis, brain abscess, and parasite migration, cause abnormalities detectable by ct and mri. although more research on the imaging features of specific nonneoplastic brain disorders is needed, current information indicates that ct and mri are useful in the management of these disorders. imaging strategies for ct and mri are similar to those described for intracranial neoplasia. (refer to the article entitled "intracranial neoplasia" by kraft and gavin in the may 1999 issue.) throughout this chapter, the mri features of the various disorders are those depicted with spin echo imaging. readers should refer to the article entitled "advanced imaging concepts: a pictorial glossary of ct and mri technology" by tidwell and jones in the may 1999 issue for a description of other pertinent mri techniques such as gradient echo and inversion recovery pulse sequences, magnetic resonance angiography, and diffusion/perfusion imaging. disorders of brain development ecent advances in imaging techniques have greatly improved the ability to detect pathologic processes in the brain, localize lesions precisely, and predict the type of disease more accurately than ever before. 1 although most reports of computed tomography (ct) and magnetic resonance imaging (mri) of brain disease in veterinary medicine have focused on the diagnosis of brain tumors, these imaging methods are also valuable in the evaluation of various nonneoplastic brain diseases. the purpose of this article is to provide an overview for imaging some of the more frequently encountered nonneoplastic diseases of the brain. clinical features of each disease are included because imaging can supplement but never replace a careful history and thorough physical and neurological examination. typical pathological changes are also mentioned, because ct and mri reflect gross and microscopic pathology and an understanding of the expected pathological changes can be very helpful in predicting imaging findings. ideally, a review article such as this would be based on systematic research and clinical data. unfortunately, the current literature on imaging of nonneoplastic brain disease in veterinary patients is fairly sparse. therefore, the information presented in this article is based on the limited data regarding veterinary patients supplemented by the much more complete information on comparable diseases in human patients, as well as my own experience. as more information becomes available, the conclusions in this article may have to be modified. hydrocephalus is a pathological condition in which there is accumulation of cerebrospinal fluid (csf) within the cranium. 23 this usually occurs within the ventricular system (internal hydrocephalus) but can involve the subarachnoid space (external hydrocephalus)) hydrocephalus is not a specific disease, but rather a multifactorial disorder with a variety of pathophysiological mechanisms. csf is produced at a constant rate by the choroid plexuses of the lateral, third, and fourth ventricles; the ependymal lining of the ventricular system; and blood vessels in the subarachnoid space. the csf circulates through the ventricular system into the subarachnoid space, where it is absorbed by arachnoid villi. 3 hydrocephalus can be caused by a blockage of the flow of cse called obstructive hydrocephalus, or secondary to decreased volume of brain parenchyma, termed hydrocephalus ex vacuo. (increased formation of csf is virtually never a cause of hydrocephalus.) a number of conditions, such as infarction and necrosis, can result in decreased volume of brain parenchyma and hydrocephalus ex vacuo. obstruction to csf flow can occur anywhere along the pathway from its formation to the site of absorption in the cranial and spinal arachnoid villi. obstruction within the ventricular system or at its outflow through the lateral apertures is called noncommunicating hydrocephalus because the ventricular system does not communicate with the subarachnoid space. obstruction within the subarachnoid space or at the level of absorption in the arachnoid villi is called communicating hydrocephalus. ~ hydrocephalus can be classified further as congenital or acquired. congenital hydrocephalus is most common in toybreed dogs. the causes are diverse and include genetic factors, developmental anomalies, and intrauterine or perinatal infection or bleeding in the brain. congenital hydrocephalus may be associated with a wide range of other nervous system anomalies, including meningomyelocele, chiari malformation, dandy-walker syndrome, and cerebellar hypoplasia. clinical signs of congenital hydrocephalus include an enlarged, domeshaped head with persistent fontanelles and open cranial sutures. neurological deficits include abnormal behavior, disturbed consciousness, ataxia, circhng, blindness, seizures, and vestibular dysfunction. in mature dogs, diseases such as tumors and inflammatory diseases can cause acquired hydrocephalus. neurological deficits are similar to those m puppms, but if hydrocephalus develops after the cranial sutures have closed, malformation of the skull does not develop. 2, 3 ct and mri allow accurate assessment of ventricular size, extent of cortical atrophy, and the presence of any focal lesions that may account for the hydrocephalus. imaging is also useful in monitoring patients after surgical placement of ventriculoperitoneal shunts used for treatment. changes in ventricular size can be monitored, and the presence of complications such as subdural hematoma or hygroma can be evaluated. 4 ventricular size is usually assessed subjectively, noting the progressively greater proportion of the intracranial volume occupied by the lateral, third, and/or fourth ventricles 4,5 ( fig 1) . several investigators have provided quantitative measurements. when measured at the level of or caudal to the lnterthalamlc adhesion, hudson et al 6 state that lateral ventricles are considered enlarged ff lateral ventncular height exceeds 0.35 cm or the ratio between the height of the lateral ventricle and the width of the cerebral hemisphere (ventriclehemisphere ratio) exceeds 0.19. spaulding and sharp 7 consider the lateral ventricles enlarged if the ratio between lateral ventricular height and the dorsoventral height of the cerebral hemisphere exceeds 0.14. however, there is a poor correlation between clinical signs and ventricular size, and symmetric or asymmetric enlargement of the lateral ventricles is relatively common in normal adult dogs and puppies. 6q° therefore, diagnosis of hydrocephalus must be based on clinical features, not just ventricular size. hydrocephalus ex vacuo can be distinguished from obstructive hydrocephalus based on enlarged cortical sulci and subarachnoid space secondary to atrophy of brain parenchyma (fig 2) . in obstructive hydrocephalus, the site of obstruction may be identified by dilatation of csf spaces proximal to the obstruction, and normal or collapsed spaces distally. for example, obstruction at the level of the third venmcle would be expected to result in enlarged lateral ventricles but no enlargement of the mesencephalic aqueduct and fourth ventricle (fig 3) . dilatation of all the ventricles and the subarachnmd space implies an obstruction at or near the arachnoid vilh. unfortunately, this simplisuc approach has limited accuracy. for example, 25% to 35% of human patients with communicating hydrocephalus have little or no &latation of the fourth ventricle. 4 obstructing masses, such as tumors, granulomas, and cysts, may be identified, especially on postcontrast images (fig 3) . mri is more sensitive than ct in showing small focal lesions, especially those in the caudal fossa) periventricular edema may be identified in some patients with hydrocephalus. experimentally, acute obstructive hydrocephalus in dogs causes edema starting at the dorsolateral angles of the lateral ventricles and spreading into the adjacent white matter, n on ct, this is evident as blurring or loss of the normally sharp ventricular margins. 4 the edema is best appreciated on t2-welghted mri as increased intensity compared with normal white matter. 1~ periventrlcular edema is most frequently associated with acute hydrocephalus and increased intraventricular pressure, rather than chronic, relatively compensated hydrocephalus with normal intraventricular pressure. 4 imaging techniques make it possible to readily identify ventriculomegaly but may give little clue as to its clinical significance. it is therefore necessary to interpret the finding of ventriculomegaly in context with clinical features. chiarl described four unrelated types of malformations of the brainstem and cerebellum in human patients. the most common is chiari i malformation, which consists of caudal displacement of a portion of the cerebellum through the foramen magnum into the cervical portion of the vertebral canal. the cause is an underdeveloped occipital bone that induces overcrowding of the caudal fossa, which is accommodated by caudal displacement of the cerebellum. 12 many human patients with this malformation develop hydromyelia (a dilatation of the central canal of the spinal cord that is lined by ependyma) and/or syringomyelia (an accumulation of fluid within the spinal cord that is not lined by ependyma). the term syringohydromyefia is often used because it can be &fficult or impossible to tell whether the cavity is lined with ependyma except at necropsy. syringohydromyelia in chiarl i malformation is caused by obstruction of csf flow at the foramen magnum. the brain expands as it fills with blood during systole, inducing a pressure wave in the csf that is accommodated in normal subjects by rapid movement of csf from within the skull to the vertebral canal. with obstruction to rapid movement of csf through the foramen magnum, the caudal portion of the cerebellum moves downward with each systolic pulse, acting as a piston on the surface of the spinal cord. this relentless compression of the spinal cord propels csf into and within the syrinx. 13 some pauents also have hydrocephalus attributed to obstruction of csf flow in the crowded caudal fossa. clinical signs of chiari i malformation in human beings can develop in childhood or adulthood and include head and neck pain, myelopathy, or encephalopathy. 12, 13 a similar malformation has been reported m adult dogs with neck pain and tetraparesls. 1~a5 diagnosis is best made on sagittal mri of the craniocervmal junction (fig 4) . the caudal portion of the cerebellum is displaced into the vertebral canal to a variable degree3 4, 16 the cerebellomedullary cistern is small or absent and the caudal fossa may appear subjectively overcrowded. hydrocephalus and syringohydromyelia may be evident. 14-16 syringohydromyelia often involves the caudal cervical or cranial thoracic segments, so this entire region should be imaged. all patients with syrmgohydromyelia should have imaging of the craniocervical region to rule out a chiari i malformation or other obstruction of csf flow. 16 chiarl ii malformation, also known as arnold-chiari or cleland-chari malformation, involves caudal displacement of the brainstem and cerebellum through an enlarged foramen magnum. the fourth ventricle is elongated and extends caudal to the foramen magnum, and the brainstem may be kinked. 16 chiari iii malformation is displacement of the cerebellum through a cervical spina bifida resulting m a cervmal encephalocele. chiari ii and iii malformations are not well described in small animals. chiari iv malformation is severe cerebellar hypoplasia and is discussed separately.17 in human patients, the dandy-walker complex is a group of malformations consisting of an enlarged caudal fossa, hypoplasia of the cerebellar vermis, and cystic dilatation of the fourth ventricle that nearly fills the caudal fossa. the cerebellar hemispheres are usually hypoplastic as well. other anomalies are also common, including hydrocephalus, hypoplasia of the corpus callosum, and syringohydromyelia. dandy-walker malformation is caused by outflow obstruction of the fourth ventricle in the developing embryo. this causes dilatation of the fourth ventricle, which enlarges upward between the developing cerebellar hemispheres, preventing their fusion. when the cerebellar hemispheres do not fuse, the vermis does not form. 16 analogous malformations have been described in the dog and cat. ~<18-21 in contrast to human patients, most dogs and cats with this syndrome do not have obvious enlargement of the caudal fossa, ls-21 neurological deficits typically occur at a young age and primarily reflect cerebellar dysfunction, including ataxia, hypermetria, intention tremor, and vestibular dysfunction, ls-21 on ct and mri, dandy-walker malformation is characterized by an enlarged caudal fossa filled by an enormous fourth ventricle and a small cerebellum. 14,16,2°,21 the cerebellar vermis may be absent, producing a cleft in the middle of the cerebellum. hydrocephalus may also be evident.20.21 a variety of in utero msults and heritable defects may cause failure of normal development of the cerebellum, resulting in a hypoplastic or absent cerebellum. the most common cause in cats is in utero or permatal infection with the feline panleukopenia virus. cerebellar hypoplasia has also been reported in dogs, in which a heritable basis has been suspected in some cases, but in utero infections cannot be excludedy ,23 single or multiple animals within a litter may be affected. there is nonprogressive ataxia, hypermetria, and intention tremor, first apparent at about the time the animal begins to walk. ct or mri shows a small or absent cerebellum. the remainder of the caudal fossa is filled with cse other anomahes, such as hydrocephalus, may also be apparent. = arachnoid cysts (also called intra-arachnold cysts) are accumulations of fluid surrounded by a membrane resembhng the arachnmd mater. they carl develop in the subarachnold space anywhere along the neuraxis. congenital arachnoid cysts are developmental anomalies originating from a splitting or duplication of the arachnoid mater. the cyst wall is formed by several layers of arachnoid cells. acquired arachnoid cysts may result from postinflammatory loculauon of csf caused by trauma, infection, or hemorrhage. 24 in human beings, congenital intracranial arachnoid cysts may be asymptomatic or cause neurological deficits as the cyst progressively enlarges and compresses adjacent neural structures or interferes with csf circulation. enlargement of arachnoid cysts occurs because of fired production by the cyst wall or an anatomical communication functioning as a oneway valve between the cyst and the subarachnoid space. 2~ intracranial arachnoid cysts have been reported in the dog and cat. z5, 26 the most common locatmn is the subarachnoid space between the cerebellum and the tentorium cerebelli. clinical signs may occur in immature or mature animals and include smzures, paresis, abnormal behavior, and cranial nerve deficits. in some patients, the cyst is an incidental finding on imaging. 26 on ct, the cyst has well-defined margins and contains fired that is isodense wath csf (fig 5) . there is mal, or intraventricular. epidural, subdural, and subarachnoid hemorrhages are often associated with trauma and are discussed later. intraparenchymal hemorrhage can be primary or secondary and can extend into the ventricular system. the cause of primary intraparenchymal hemorrhage is incompletely understood. people with this disorder often have systemic hypertension and fibrinoid degeneration of arteries in the b r a i n y although intracranial hemorrhage caused by hypertension is poorly documented in dogs and cats, primary hypertension and hypertension secondary to other disorders, such as renal disease, hyperadrenocorticism, and hyperthyroidism, are well recognized. 28 these animals may be predisposed to cerebrovascular disease and intracranial hemorrhage. 28 secondary causes of intracranial hemorrhage include trauma, infarction, congenital vascular malformations, intracranial tumor, vasculitis, and coagulopathies. [29] [30] [31] [32] [33] [34] [35] [36] [37] [38] the clinical signs of intraparenchymal hemorrhage consist of a sudden onset of neurological deficits referable to a focal brain lesion. signs may progressively worsen as the hematoma expands, compressing adjacent neural structures and increasing intracranial pressure. 30-33 36-39 computed tomography ct is exqmsitely sensitive to acute hemorrhage. because the attenuation of x-rays is primarily attributable to the globin portion of blood, there is a linear relationship between ct attenuation and hematocrit. 4° the attenuation of whole blood with a hematocrit of 46% is approximately 56 hounsfield units (hu). in comparison, normal gray matter has an attenuation of 37 to 41 hu, and normal white matter, 20 to 34 hu. 4° acute hemorrhage in a patient with a normal hematocrit is therefore immediately evident as increased attenuation on ct ( fig 6) .31,36 hemorrhage in patients with severe anemia may be less obvious. an acute hematoma may he surrounded by a hypodense region corresponding to edema, and there is often an associated m a s s effect. 31'36 41 the attenuation of extravasated blood increases for the first 72 hours with clot formation and extrusion of low-density serum and subsequent increase in hemoglobin concentration. 4° after that, the attenuation gradually decreases as the result of lysis and phagocytosls of erythrocytes, which starts at the periphery and progresses centrally. 4°~1 the hematoma eventually becomes isodense at about 1 month after onset. 4°-41 use of contrast agent is unnecessary in most acute hematomas and may obscure the inherent hyperdensity, confusing the diagnosis. however, use of contrast agent may be helpful if there is a small hemorrhage with mass effect out of proportion to the size of the hematoma. in this instance, the differential diagnosis includes bleeding into a tumor, and contrast may be necessary to visualize the tumor. 4° in hematomas not associated with underlying neoplasia, enhancement first appears at the periphery of the hematoma at approximately 4 to 6 days because of neovascularization.36.40-42 a ring pattern of enhancement may persist for 2 to 6 weeks. 4° although variations can occur, the mri features of most intracranial hematomas follow a predictable course over time. factors intrinsic to the lesion that affect images include the age of the hemorrhage, whether the bleeding is arterial or venous, the location of the bleeding, and the presence of any underlying lesions. operator-dependent factors that affect the images include the mare magnetic field strength, the exact pulse sequence parameters used, and the method of echo formation. 43 hemorrhage can be thought of as an iron salvage pathway, in which iron from the extravasated erythrocytes is mobilized from hemoglobin and converted to short-term iron-containing proteins for transfer to the reticuloendothelial system, or to long-term storage proteins for local deposition. 44 during this process, oxyhemoglobin is converted in a stepwise fashion to deoxyhemoglobin, methemoglobin, and finally ferritin and hemosiderin. these various forms of hemoglobin affect the appearance of hemorrhage in three ways: (1) protein effects that are present with all forms of hemoglobin; (2) paramagnetm relaxation caused by paramagnetic molecules, which is significant only with methemoglobin; and (3) inhomogeneous susceptibility effects induced by paramagnetlc forms of hemoglobin (deoxyhemoglobin and methemoglobm) within erythrocytes. 45, 46 protein effects. relaxation times are shortened in the presence of proteins in water solutions. 45 this is caused by the changing magnetic fields of nearby nuclei as the molecules undergo brownian motion. 45 protein effects are generally proportional to protein concentrations and result in shortening of t1 and t2; that is, increased intensity on tl-weighted images and decreased intensity on t2-weighted images, compared with pure water. 45 paramagnetic effects. biological substances containing unpaired electrons have magnetic properties dominated by the magnetic effects of these unpaired electrons. the magnetic fields of the unpaired electrons are normally oriented randomly such that there is no net magnetization. however, when an external magnetic field is applied, the unpaired electrons tend to align parallel to that field, resulting in enhancement (increased magmtude) of that applied field. substances that have no intrinsic magnetic field m the absence of an applied magnetic field, but align with and thus enhance that applied field, are termed paramagnetic. 46 some forms of hemoglobin contain iron with paramagnetic properties, which greatly affects the mri appearance. if water molecules approach a paramagnetic center, there is an interaction between the nuclear magnetic dipoles of the water (protons) and the magnetic dipoles of the paramagnetic center (unpaired electrons). this proton-electron dipoledipole interaction shortens relaxation ume of the water protons. for proton relaxation enhancement to occur, however, the water proton must come within about 0.3 nm of the paramagnetic ions' unpaired electrons, because the magnitude of this interaction is inversely proportional to the sixth power of the distance between the dipoles. 46 these paramagnetic effects are more prominent on tl-weighted images than on t2-weighted images. 43 they will therefore result in an increased signal on tl-weighted images, similar to the effects of gadolinium-based contrast agents. (paramagnetism of mri contrast medium is also discussed in the tidwell & jones article in the may 1999 issue.) inhomogeneous susceptibility effects. when paramagnetlsm is confined to a small region (such as within erythrocytes), there is an inhomogeneous distribution of paramagnetic susceptibility that creates microscopic field gradients. 45 water molecules diffusing across the erythrocyte membrane experience a fluctuating magnetic field that results in dephasing and shortened t2 relaxation, a process called inhomogeneous susceptiblhty effect. in spin-echo sequences, inhomogeneous susceptibihty effects result in signal loss because of shortened t2 relaxation. this leads to decreased intensity on t2-weighted images. 46 hematoma evolution. these three relaxation mechanisms along with proton density contribute to image contrast during the various stages of hematoma formation (table 1) . because numerous factors can effect the appearance of intracranial hemorrhage on mri, the following summary is necessarily oversimplified but generally applicable to spin-echo sequences at 0.5 to 2.0 t. (refer to the tidwell &jones article in the may 1999 issue for a discussion on gradient echo imaging of hemorrhage.) furthermore, the timing of various stages may vary significantly, and different stages often overlap. 43, 45 the precise dating of specific hematomas is notoriously inaccurate, so the nomenclature of the temporal stages of hematomas is somewhat arbitrary. 43 oxyhemoglobm. freshly extravasated blood from arterial bleeding is composed of intact erythrocytes containing primarily oxyhemoglobin. 43 the iron in oxyhemoglobin is in the ferrous form (fe+2). because there are no unpaired electrons in the iron (or other atoms), oxygenated blood is not paramagnetic. 43 in the absence of paramagnetism, peracute hematomas appear as a high-proton-density region, with slightly shortened relaxation times, compared with water, mainly because of the protein content of blood. 43 this peracute stage of a hematoma usually persists for fewer than 24 hours. because of their transient nature, peracute hematomas are rarely seen in clinical practice. they are isointense to slightly hypointense on t1weighted images and hyperintense on t2-weighted images, and therefore appear similar to many other brain lesions. 43,.7 thus, ct is the preferred imaging modality if peracute hemorrhage is suspected. deoxyhemoglobin. after a few hours, the oxygen tension within the hematoma is reduced, resulting in the formation of deoxyhemoglobin (acute hematoma). deoxygenation is usually complete by 24 hours. 45 removal of molecular oxygen changes the distribution of electrons in the ferrous ion, leaving four unpaired electrons in the outer shell. these unpaired electrons confer deoxyhemoglobin with paramagnetic properties. the paramagnetic iron of deoxyhemoglobm is contained within a hydrophobic crevice in the hemoglobin mdlecule. this prevents water from coming close enough to the paramagnetic ion to induce paramagnetic (dipole-dipole) interaction, thus, the hematoma is still isointense to slightly hypointense on t 1-weighted images. 43 as long as the erythrocyte membrane is intact, the paramagneuc deoxyhemoglobln is localized within the cell. this results in inhomogeneous suscepub]lity effects# 3 acute hematomas that contain intracellular deoxyhemoglobin consequently appear very hypointense on t2-we]ghted images. 43 at this stage, any surrounding edema appears as a hyperintense perimeter on t2-weighted images) 3 intracellular methemoglobin. as oxygen tension within the hematoma falls further, deoxyhemoglobin is oxidized to methemoglobin (subacute hematoma). in whole blood, methemoglobin begins to accumulate at the rate of about 10% per day, after the first 2 days. 4s conversion to methemoglobin is maximal when the p02 is approximately 20 mm hg. if the oxygen tension is higher or lower, conversion to methemoglobin is slowed, affecting mri contrast. 46 the iron in methemoglobin is in the ferric (fe +3) state, which has five unpaired electrons in its outer shell and is highly paramagnetic. also, one of the coordination sites of the methemoglobln molecule is occupied by a water molecule that is rapidly exchanged with other water molecules in solution. as a result, water is positioned within 0.3 nm of the paramagnetic iron. this allows paramagnetic (dipole-dipole) interaction to shorten t1 relaxation, causing methemoglobin to be hyperintense on tl-weighted images. this hyperintensity begins at the periphery of an intraparenchyreal hematoma and progresses inward, probably because the outer rim of the hematoma has the optimal oxygen tension for the oxidation of hemoglobin. 43,45 at this stage the hematoma is still hypointense on t2-welghted images23 other causes of t1 hyperintensity or t2 hypointenslty include fat, calcification, mucinous material, intratumoral melanin, flow effects, and enhancement with paramagnetic contrast agents23 extracellular methemoglobin. soon after methemoglobin formation begins, glucose reserves in the erythrocytes are depleted and hemolysis ensues. this eliminates the inhomogeneous susceptibility effect as the methemoglobin becomes uniformly distributed. this prolongs t2, and the hematoma is once again hyperintense on t2-weighted images (rebound hyperintensity). 45 on the other hand, tl-weighted images are not affected and therefore continue to show hyperintensity. 45 this paradoxical state of t1 and t2 hyperintensity may persist for 1 month or more (fig 7) . 45 ferritin and hemosiderin. after 2 to 6 weeks, modified macrophages (gitter cells) infiltrate from surrounding brain and remove iron from the hematoma (chronic hematoma). this eventually eliminates the remaining protein and inhomogeneous susceptibility effects. the center of the hematoma eventually either collapses or is replaced by cse 45 the iron is deposited at the periphery of the hematoma as hemosiderin and ferritin, which behave paramagnetically. 43 the iron in these storage forms is not accessible to water, so paramagnetic (dipole-dipole) interaction does not occur, but the inhomogeneous susceptibility effect shortens t2. a chronic hematoma has a rim that is hypointense on tl-weighted images and very hypointense on t2-weighted images. the rim becomes thicker as the hematoma resolves. 45 whenever intracramal hemorrhage is identified, it is important to determine if it is associated with an underlying tumor or is caused by a nonneoplastic lesion. the use of a contrast agent often allows identification of an underlying tumor. 4° an important finding in a hemorrhagic tumor is persistent surrounding edema (decreased attenuanon on ct, hyperintensity on t2-weighted images), whereas edema has usually resolved by the chronic stage of a nonneoplastic hematoma. 43 in neoplastic hemorrhage, mri signal intensity patterns are more heterogeneous and the temporal evolution of intensity patterns is often delayed compared with nonneoplastic hematomas, probably because hypoxia within the tumor delays methemoglobin formation. 4°,43 neoplastic hemorrhage often lacks the well-defined hypointense rim characteristic of nonneoplastic hematomas in their subacute and chronic stage. 4°,~3 this is because the persistently altered blood-brain barrier of tumors may allow more efficient removal of ferritm and hemosiderin. 43 in situations in which the diagnosis is still uncertain, repeat scanning is often useful because this allows evaluation of the expected temporal changes. 4° the most common is the arteriovenous malformation (avm). clinical signs are caused by spontaneous hemorrhage and are usually suggestive of a focal cerebral lesion. the onset of signs is usually acute and occurs in middle-aged to older animals. 3>33 the relatively late onset of signs associated with a congenital lesion can be explained by contmued hemodynamic stress and consequent attenuation of the abnormal vessels, which eventually leads to hemorrhage, z° when a cerebrovascular malformation has bled, early ct or mri usually shows intraparenchymal hemorrhage (fig 6) . 30 ct of capillary malformations is often normal, but may show an isodense to slightly hyperdense mass. contrast enhancement is usually minimal. 51 mri is more sensitive, and shows a lace-like region of stippled contrast enhancement with no or subtle abnormality on unenhanced images. 5a a cavernous malformation appears on ct as a focal hyperdense region with variable calcification with mild contrast enhancement. 5152 on mri, a cavernous malformation is seen as a central region of mixed intensity, corresponding to methemoglobin, surrounded by circumferential rings of hypomtense hemosiderin and ferritin)2 53 whenever a spontaneous intraparenchymal hematoma is identified, it is important to look for any associated large vessels to suggest a vascular malformation. however, the failure to identify large vessels does not entirely exclude a vascular malformation, because compression or obliteration of vessels by adjacent hematoma, extremely slow flow, and thrombosis may obscure the abnormal vessels. 51,52 although ct and mri are useful in detecting hemorrhage associated with vascular malformations and depicting the vascular anatomy of some of these lesions, catheter angiography or magnetic resonance angiography (mra) is often necessary for complete assessment of cerebrovascular malformations m human patients. 51,52,~4 (refer to the tidwell & jones article in the may 1999 issue for a discussion of mra.) obstruction of flow in the vessels of the brain can result in a sudden onset of neurological signs caused by infarction. arterial obstruction can be caused by thrombosis or embolism. a thrombus is a blood clot developing within a vessel that causes obstruction at the site of formation. embolism is occlusion of a vessel by a fragment of blood clot or other substance that has flowed to the site of obstruction from a distant location. because of abundant venous anastomoses, venous infarction is less common than arterial thromboembolism. 55 in human patients, cerebrovascular thrombosis or embolism is often secondary to atherosclerosis. 56 atherosclerosis also occurs in dogs, especially older dogs, dogs with hypothyroidism, and miniature schnauzers with idiopathic hyperlipoproteinemia. 29,57,5s atherosclerosis associated with these conditions can lead to cerebral thromboembohsm and neurological dysfunction. 33 57-59 other diseases associated with cerebral thromboembolism in dogs include sepsis, coagulopathy, neoplasia, and heartworm infection. 3>6° the hallmark of brain infarction is an acute onset of focal bram dysfunction. neurological deficits depend on the site of the lesion and are typically asymmetric. involvement of the forebrain, such as with thromboembolism of the middle cerebral artery, usually results in contralateral hemiparesis with decreased postural reactions. seizures are very common in dogs and cats with infarction affecting the forebrain. there may be contralateral bhndness with normal pupillary light reflexes, and the patient may circle or turn toward the side of the lesion. lesions in the cerebellum may cause ataxia, hypermetria, vestibular dysfunction, or opisthotonos. brainstem involvement is characterized by gait deficits ranging from ipsilateral hemlparesis to tetraplegia, cranial nerve deficits, and abnormal levels of consciousness, including coma. 30, 31, 33, 36, 38, 55, 61 nonhemorrhagic infarction computed tomography. changes may be detected on ct as early as 3 to 6 hours after onset of signs and consist of a slight decrease in attenuation and subtle mass effect. 62 63 these changes are related to edema and reach a maximum at 3 to 5 days (fig 8) and resolve by 2 to 3 weeks after infarction. 62 the location and shape of the lesion correspond with the distribunon of the involved vessel(s), most commonly the middle cerebral artery. 62 abnormal contrast enhancement may be seen as early as 24 hours but often does not become evident until about 1 week after infarction. 62,63 enhancement is most apparent at the periphery of the lesion and reflects growth of new capillaries without a normal blood-brain barrier. 62 enhancement of hypodense infarcts can result in isodense lesions, thereby masking their presence. 62 for this reason, unenhanced as well as enhanced ct should be performed. in the chronic phase (3 to 4 weeks), the hypodense region becomes more sharply marginated as necrotic tissue is resorbed. 62 ultimately there is a loss of parenchymal volume with attendant dilatation of adjacent sulci and ventricles. 62 contrast enhancement does not usually occur in the chronic stage because the integrity of the blood-brain barrier is restored. 62 magnetic resonance imaging. early changes on mri consist of a subtle increase in intensity on t2-weighted and proton density-weighted images. these changes reflect edema and can be detected as early as 1 hour after vascular occlusion. 64 mri is thus more sensitive than ct in early infarction. also, mri is more sensitive in detecting small infarcts and those involving the brainstem. 65 in acute infarction, tl-weighted mri is less sensitive than t2-weighed and proton density-weighted images and may be normal. ~6 parenchymal enhancement with gadolinium is uncommon within the first 24 hours. 66,67 the use of functional mri techniques such as diffusion and perfusion studies for the detection of acute infarction is currently being investigated and is discussed in the arucle by tidwell &jones in the may 1999 issue. after the first 24 hours, the hyperintensity on t2-welghted and proton density-weighted images becomes more obvious (fig 9) .64'66'68 during this time, tl-weighted images may show decreased signal. 64,66 68 gyral swelling and mass effect are more prominent, becoming maximal 2 to 4 days after onset of occlusion. 6466 parenchymal enhancement becomes evident within 4 to 7 days and may persist for 3 to 4 weeks. 66 after several weeks, the signal changes seen on earlier scans become smaller and better defined. there is focal atrophy with dilatanon of nearby sulci and ventricles. there may be a collection of fluid with the s~gnal characteristics of cerebrospinal fluid. 69 contrast enhancement does not usually occur. 66 the above description applies to nonhemorrhagic or "bland" infarcts. however, many infarcts will have attendant bleeding caused by reperfusion of damaged blood vessels. 66 this results in a hemorrhagic infarct. petechial hemorrhage into an infarct may result in an isodense lesion on unenhanced ct because of the combined effects of the brain edema, which decreases attenuation, and acute hemorrhage, which increases attenuation. mass effect caused by the edema usually provides a clue to the presence of a lesion. if hemorrhage is a large component of an acute infarct, unenhanced ct shows a hyperdense hematoma surrounded by hypodense edema. these changes are often confined to a vascular territory, a feature that is helpful in differentiating hemorrhagic infarctions from other causes of hemorrhage. 4° in the subacute phase, the region around the infarct may enhance, increasing the possibility of hemorrhage within a tumor. mass effect from a hemorrhagic infarct is usually minimal or decreasing at the time of maximal contrast enhancement (2 to 4 weeks), which is useful in differentiating between hemorrhagic infarct and tumor. 5~ the mri features of hemorrhagic infarction are similar to those of lntraparenchymal hemorrhage. 4° compared with other causes of lntraparenchymal hemorrhage, hemorrhagic infarcts tend to have a higher p02 because of earlier revascularization and collateral perfusion. the higher p02 decreases the amount of deoxyhemoglobin, and therefore minimizes the acute t2 relaxation effect. 51 uncontrolled seizures or status epileptmus may result in neuronal degeneration progressing to necrosis. the distribution of lesions varies somewhat among individual patients, but the hippocampus, basal nuclei, and frontal and pyriform lobes of the cerebrum are most severely affected. f° lesions are usually bilateral, but may affect one side more severely. f° these changes are thought to be the consequence of ischemia secondary to accumulation of cytotoxic agents and a mismatch between brain metabolism and blood flow during prolonged seizures. 71 persistent or reversible mr lesions have been described in human patients after seizures, and similar abnormalities have there is also a smaller wedge-shaped region of hyperintensity in the vascular territory of the right middle cerebral artery. se, 1500/105, 0.064 t. been described in dogs, [72] [73] [74] the most consistent finding is unilateral or bilateral lesions of the hippocampus, pyriform lobe, and frontal lobe. the lesions are hypointense on t1weighted images and hyperintense on proton densityweighted and t2-weighted images. there is minimal mass effect and no or moderate contrast enhancement tm (fig 10) . these lesions may persist or disappear on subsequent scans. head trauma results from a variety of causes, including motor vehicle accidents, bites, kicks, and gunshot wounds. previously, imaging of head trauma was limited to skull radiography for the detection of fractures. plain radiography, however, cannot identify many traumatic brain lesions, such as hemorrhage, and therefore provides only limited diagnostic information. the development of ct provided a sensitive means for detecting and localizing intracranial hemorrhage, permitting expeditious surgical treatment, and improving outcome. 75 mri has been shown to be similar in sensitivity for detection of hemorrhagic lesions, but is much more sensitive than ct for detecting nonhemorrhagic lesions, such as shearing injuries of white matter. 75 neuroimaging should be considered early in the management of animals with head injury and marked impairment of consciousness or neurological deficits that progressively worsen despite initial medmal therapy. the most critical issue is to detect potential hematomas that may be treatable with sur-gery. 76 in general, ct is the diagnostic study of choice for initial evaluation, because it can be completed quickly and is sensitive to acute hemorrhage, r6 ct also provides fine anatomic detail of bone when viewed at a wide window width allowing accurate characterization of any skull fractures 77 (fig 1 1) . although mri is slightly more sensitive than ct for detection of hematomas, those that are not seen on ct are usually small and typically managed conservatively. 75 a disadvantage of mri is the longer examination ume and the difficulty in monitoring unstable patients in the mri environment. therefore, if ct is available, mr examination is usually delayed until the patient is stabilized. in patients with severe head trauma, mri should be considered in the first 2 weeks after injury, because most parenchymal lesions are more easily detectable during this period. 75 epidural hematomas accumulate in the potential space between the inner surface of the skull and the dura mater. they are usually found in the temporoparleteal region, and have been caused by laceration or tearing of the middle meningeal artery by skull fracture. the arterial force of the bleeding dissects the dura away from the bone, often resulting in a rapidly expanding mass. clinical signs may consist of rapidly progressing focal neurological deficits and deterioration in consciousness. however, patients with associated parenchymal brain injury may have severely impaired consciousness at the time of trauma. 75 on ct, an acute epidural hematoma is typically a well-defined, biconvex lesion between the inner table of the skull and the underlying depressed dura and brain. tm the attenuation of the hematoma is initially greater than brain parenchyma and increases further during the first few hours with coagulation and clot retraction. with time, the attenuation decreases with clot retraction, erythrocyte lysis, and hemoglobin degradation. the hematoma becomes smaller and fades to isodense and then hypodense within 1 or 2 weeks. the inner surface of an epidural hematoma is dura mater, which normally enhances with intravenous contrast material, but this enhancing margin becomes even more prominent as a neovascular membrane develops over time. 78 on mri, the intensity varies depending on the age of the hematoma, as described in the section on intracranlal hemorrhage and summarized in table 1 . occasionally, an epidural hematoma may not have the classic lenticular shape or associated skull fracture, making it difficult to differentiate it from a subdural hematoma. mri can be helpful in this regard, because the medially &splaced dura mater is usually directly visualized as a thin line of low signal separating the hematoma from the underlying compressed brain parenchyma. 75 mri is also superior in the detection of subacute and chronic hematomas, which may be isodense on ct77 78 subdural hematomas accumulate within the potential space between the pia-arachnmd and dura mater. they are usually caused by tearing of veins that traverse the subdural space. subdural hematomas appear to be less common m dogs and cats with head injury, compared with human patients. clinical signs may consist of progressive asymmetrical neurological deficits and decreased levels of consciousness. an acute subdural hematoma appears on ct as a hyperdense, crescentshaped collection conforming to the inner surface of the skull. tm mass effect is evident and may be compounded by contusion and edema of the underlying brain parenchyma. acute hyperdense hematomas may not be vislble on a narrow window width (soft tissue window), appearing only as an apparent thickening of the skull, since the bone and hematoma may have the same pixel brightness, r5 78 mass effect is usually present, however, providing a clue in their detectlon. widening the window width may be necessary to distinguish an acute subdural hematoma from the dense skull, rs as with other intracranial hematomas, the density of a subdural hematoma decreases over time, becoming isodense to gray matter by 1 to 2 weeks. accordingly, subacute subdural hematomas may be difficult to detect on ct but are readily detectable on mri. 75 a chronic subdural hematoma (2 to 3 weeks old or older) is hypodense compared with normal brain on ct and is surrounded by a well-defined capsule (fig 12) . this results in a more focal collection of blood with a straighter medial edge compared with crescent-shaped acute subdural hematomas. 78 the capsule of a chronic subdural hematoma enhances with intravenous contrast material and may calcify. tm subarachnoid hemorrhage is bleeding into the csf-filled subarachnoid space. posttraumatic subarachnoid hemorrhage is relatively common and often associated with cortical contusions. acute subarachnoid hemorrhage is evident on ct as increased attenuation of the sulcl, fissures, or basal cisterns, with the degree of increased attenuation being related to the amount of blood in the subarachnoid space. 78 with time the attenuation decreases and subarachnoid hemorrhage may not be detectable after the first week, unless rebleeding has occurred. 51 acute subarachnoid hemorrhage is usually not detectable on mri, probably because the po2 of the subarachnoid csf is too high for the conversion of oxyhemoglobin to deoxyhemoglobin and methemoglobin. 51 however, mri is excellent at detecting subarachnoid hemorrhage in the subacute or chronic stage. 5i brain contusions are common after head trauma and consist of heterogeneous regions of hemorrhage, edema, and necrosis, often located in the superficial gray matter. in human patients contusions tend to be multiple and bilateral and are much less likely to be associated with severe initial impairment of consciousness compared with diffuse axonal injur~ 75 initial ct findings are often limited to faint, ill-defined hypodense areas mixed with tiny regions of hyperdense hemorrhage. 75 contusions in which edema and necrosis predominate may not be visible imtially on ct but often become apparent several days later as regions of decreased attenuation and mass effect caused by edema. 7s mri, because of its greater sensitivity in detecting edema, is better at detecting early contusions, which appear hypointense on tl-weighted images and hyperintense on t2-weighted images. 75 head trauma that involves rapid angular acceleration may result in diffuse axonal injury. these shearing injuries result from differences in elastic and inertial properties between different but adjacent brain tissues/s,79 in human patients, these injuries are characterized pathologically by disruption of axons, especially at the junction of gray and white matter of the cerebrum, and at the corpus callosum, basal nuclei, and cranial aspect of the brainstem. there is subsequent axonal swelling and infiltration with macrophages. these patients present with severe impairment of consciousness starting from the moment of injury. 76"77,s0 mri is much more sensitive than ct in detecting diffuse axonal injury in human patients, although even mri findings usually underestimate the true extent of these injuries. 75 ct is often normal, but may show scattered hemorrhages. the mri appearance reflects the prolonged t1 and t2 values of increased tissue fluid (edema). there are multiple, small elliptical lesions in the white matter. these lesions are hypomtense on tl-weighted images and hyperintense on t2-welghted images. 75, 78 infectious and inflammatory diseases inflammatory diseases are important diagnostic considerations for patients with brain disease. infectious agents, such as viruses, protozoa, and fungi, cause many inflammatory diseases, but for others the etiology is unknown. despite the numerous causes of mflammatory brain disease, the affected tissue can respond only in a limited number of ways. thus, many of these diseases appear similar on imaging studies and differentiating the potential etiologies based on imaging features alone may be impossible. furthermore, it may be difficult to &scriminate between inflammatory diseases and other categories of disease, such as neoplasia and vascular disorders. accordingly, results of imaging studies must be interpreted in context with clinical features and results of other laboratory tests, especially analysis of cse 8i all inflammatory brain diseases share a common pathological feature--an influx of leukocytes into the brain (cerebritis or encephalitis) or meninges (meningitis). because of the close anatomical association of these structures, more than one area of the nervous system can be involved in the inflammatory process. for example, inflammation of the meninges and brain is called meningoencephalitis, s2 the most common cause of meningitis in dogs is steroidresponsive meningitis-arteritis, a nonseptic suppurative meningitis of unknown etiology that responds to immunosuppressive dosages of corticosteroids, s3 infectious causes of memngitis are less common in small animals and include bacteria, viruses, fungi, and protozoa s4 pathologically. acute leptomeningitls results in congestion and hyperemia of the pia-arachnoid and distension of the subarachnoid space by an exudate containing leukocytes. clinically, affected patients show fever, spinal pain, cervmal rigidity, and stiff gait. several complications can occur m the ensuing days to weeks. there may be extension of the infection to the neural parenchyma, resulting in focal or diffuse encephalitis, myelitis, or abscess. inflammatory exudate may obstruct csf pathways, producing hydrocephalus. endogenous host inflammatory mediators can result in disruption of the blood-brain barrier, cerebral edema, and increased intracranial pressure. 85 definitive &agnosis of meningitis is based on analysis of cse neuroimaging is useful in detectmg some of the complications associated with meningitis and when the differential diagnosis includes other diseases. neuroimaging features of experimental bacterial menmgitls in dogs is comparable with naturally occurring bacterial meningitis in human patients. 868r in human patients with uncomplicated early bacterial or viral meningitis, unenhanced ct and mri are often unremarkable or show mild dilatation of the ventricles or subarachnoid space (fig 13) . 88 with more severe involvement, there may be diffuse or patchy brain edema. 88 postcontrast ct or mri may show abnormal enhancement of the leptomeninges. 89 in experimental studies in dogs, tl-weighted mr images with gadolinium showed abnormal leptomeningeal enhancement better than ct. 8r mri also identifies complications such as encephahtis more effectively than ct. 87 encephalitis generally refers to nonpurulent inflammation of the brain and is distinguished pathologically from suppurauve inflammation of the brain (cerebritis) assooated with bacterial infection. 88 viral encephalitides of small animals include canine distemper and feline infectious peritonitis. other causes of encephalitis include rocky mountain fever, canine ehrlichiosis, toxoplasmosis, and neosporosls. finally, there are encephahtides of unknown etiology, such as pug dog encephalitis and granulomatous meningoencephalitis. distemper encephalitis. the two most common clinical forms of distemper encephalitis are acute encephalitis in young dogs and chronic encephalitis in mature dogs. immature dogs with distemper encephalitis typmafly suffer a rapid onset of systemic illness characterized by conjunctivitis, nasal discharge, cough, vomiting, and diarrhea. neurological dysfunction can occur during or after the systemic illness and includes seizures, abnormal behavior, blindness, and paresis. mature dogs are more likely to develop chromc, multifocal encephalitis with a predilection for the white matter of the brainstem. many of these dogs have an adequate vaccination history, and signs of systemm illness are often absent or transient. 9°-92 these patients often have slowly progressive gait deficits or vestibular dysfunction. 9°, 91 ct of dogs with chromc distemper encephalitis may be normal or show focal or multifocal hypoattenuating lesions with a predilection for the white matter. 93 these lesions may have uniform or ring-like enhancement 93 (fig 14) . some lesions may be associated wlth hypoattenuating edema and mass effect. 93 lesions are typically hypointense or poorly defined on tl-weighted mri, hyperintense on t2-weighted images, and enhance with contrast agent. 94 feline infectious peritonitis. feline infectious peritonitis (fip) is a systemic disease of cats caused by an immune response to a corona virus. neurological signs are generally associated with the parenchymatous (dry) form of fie neurological deficits referable to brainstem involvement predominate and include ataxia, paresis, and vestibular dysfunction. [95] [96] [97] imaging features of fip reflect the pathological changes, which consist of pyogranulomatous inflammation of the leptomeninges, choroid plexus, ependyma, and brain parenchyma. hydrocephalus is common and is probably secondary to obstruction by ependymltis. 95-98 the brainstem and fourth ventricle are consistently involved, but other regions of the central nervous system can be affected. 95 96 the inflammatory process primarily affects the inner and outer surfaces of the brain with only secondary extension into the parenchyma. recognition of this surface-related pattern can be helpful in differentiating fip from other bram diseases in the cat. 98 ct may be normal or show hydrocephalus. 95 mri may show ependymitis, choroiditis, and memngitis. this is evident as hyperintensity of the ventricular lining, choroid plexus, and meninges, respectively, on t2-weighted mri and abnormal enhancement with gadolinium-based contrast agent 97,99 (fig 15) . fungal infections. many fungal agents can sporadically infect the nervous system, causing meningitis or granulomas. cryptococcus neoformans is the most common fungal infectmn to involve the nervous system of dogs and cats. in cats, this organism generally induces a mild, nonsuppurative meningitis or encephalitis, whereas affected dogs typically develop a granulomatous reaction in the brain and meninges. 98 neurological deficits can be acute or chronic and include seizures, lethargy, ataxia, and vestibular dysfunction. 1°° 101 on ct, mass lesions (cryptococcomas) appear as single or multiple isodense or hypodense masses with ring or solid enhancement and surrounding edema. 81,89,93i°2 leptomeningeal enhancement may also be apparent if the meninges are involved. 81,i°2 hydrocephalus may occur secondary to meningitis or obstruction of csf pathways by the mass. 81,89 in human patients, mri is more sensitive than ct and may show clustered foci of signal abnormahties that are lsointense to csf on all sequences. these lesions represent small granulomas or dilated virchow-robin spaces filled with fungal organisms and mucoid. these are often bilaterally symmetrical, and are located in the basal nuclei and midbraln. these lesions do not enhance with gadolinium and are not associated with mass effect or edema. 89 similar changes have been reported on mri of canine cryptococcosis.i°3 cryptococcomas appear as masses that are hypointense on tl-weighted images, hyperintense on t2-welghted images, and enhance with gadolinium. 8<1°3 other fungal organisms sporadically infect the central nervous system, including blastomyces dermatldis, histoplasmosis capsulatum, aspergfllus spp, coccidiodes immitis, and phaeohyphomycosis (fig 16) . l°4qn necrotizing encephalitis (pug dog encephalitis). a necrotizing form of encephalitis has been recognized in pug dogs, maltese terriers, and yorkshire terriers between 6 months and 10 years of age. n2-n6 signs include progressive seizures, abnormal behavior, blindness, ataxia, and walking in circles. pathological changes consist of multifocal necrosis and nonsuppuratlve inflammation, with a striking predilection for the white matter of the cerebrum. lesions are often bilateral but asymmetrical, n2-114,n6 enlargement of the lateral ventricles secondary to shrinkage and cavitation of the cerebral hemispheres (hydrocephalus ex vacuo) is common n2,i14 n6 (fig 2) . in yorkshire terriers, the brainstem may be preferentially revolved. 113 the etiology is unknown. in acute forms of the disease, ct may show one or more focal hypodense lesions, most commonly affecting the cerebral hemisphere. the lesions may or may not enhance with contrast agent. mri shows the early edematous changes as increased signal intensity on proton density-weighted and t2-weighted images and decreased signal intensity on tl-weighted images. in acute cases, there is often substantial mass effect and minimal if any abnormal enhancement with contrast medium (fig 17) . differentials include neoplasia, other inflammatory lesions, and acute infarction. in more chronic cases, necrosis and cystic changes usually predominate. the centers of the lesions appears similar to csf; that is, hypodense on ct, very hypointense on tl-weighted images, and very hyperintense on proton density-weighted and t2-weighted images 114-116 (fig 18) . lesions are usually located in the white matter of the cerebral hemisphere, often in the area lateral to the ventricles. ii3 typically there is no mass effect or even a reverse mass effect (shift of surrounding tissue toward the lesion). lesions usually do not enhance, but may have a ring pattern of enhancement. 93 114, 115 asymmetric enlargement of the lateral ventricles is common. 93 the primary differential is chronic infarction. however, in necrotizing encephalitis the lesions are not confined to a specific vascular territory as is typical of infarction caused by thromboembolism. the onset of signs (sudden in infarction versus slow onset in chronic necrotizing encephalitis) ts also helpful. granulomatous meningoencephalomyelitis. granulomatous meningoencephalomyelitis (gme) is an inflammatory disease of the canine central nervous system characterized pathologically by an accumulation of mononuclear cells in the parenchyma and meninges of the brain and spinal cord. 117 lesions may be disseminated or focal. in the disseminated form, lesions are distributed throughout the central nervous system, with a predilection for the white matter of the cerebrum, cerebellum, caudal aspect of the brainstem, and cervical spinal segments. the focal form is manifested as a single granulomatous mass, most commonly located in the cerebrum, with smaller disseminated lesions, ns-ln the cause is not known. adult dogs of any breed can be affected, although females and toy and terrier breeds are at increased risk. 118122 dogs with disseminated gme usually have rapidly progressive signs including neck pain, vestibular dysfunction, paralysis, and seizures. the focal form is manifested as chronic, gradually progressive signs, with seizures being the most common. iis-123 the clinical presentation of focal gme often mimics that of a tumor. on ct, disseminated gme is seen as multiple foci of ill-defined contrast enhancement involving the parenchyma and meninges. some lesions may be associated with hypoattenuating edema and mass effect. 124 other inflammatory diseases are the primary differentials. focal gme appears on noncontrast ct as an isodense or hyperdense mass, most commonly located within the cerebrum or at the cerebellomedullary junction (fig 19) . 93 '125 on mri, focal gme is usually isointense or slightly hypointense on tl-weighted images and hyperintense on proton density-weighted and t2-weighted images (fig 20) . 126 enhancement is variable, including no enhancement, ring-pattern enhancement, or moderate homogenous enhancement. 93,t24,i25 there may be edema in the white matter surrounding the mass. 93, 125, 126 asymmetric enlargement of the lateral ventricles has also been reported. 93 the primary differentials are neoplasia and other inflammatory lesions. biopsy is often necessary for definitive diagnosis. 125 focal infection of the brain with pyogenic organisms is uncommon in small animals. bacteria may gain access to the brain through penetrating wounds; secondary to direct extension from infections in the eye, ear, nasal passages, or meninges; or via hematogenous spread from extracranial sources, i27128 with hematogenous spread, lesions often arise at the graywhite matter junction of the cerebrum, s8 clinical signs reflect a progressively worsening focal brain lesion. 127 i28 several reports detail the pathological and ct features of experimental cerebritis/abscess in dogs. 129,13° these imaging features are similar to those reported in human patients with spontaneous brain abscess. tm pathologically, serial changes occur over 2 to 3 weeks, starting as cerebritis and culminating in abscess. focal but poorly localized areas of scattered necrosis, edema, vascular congestion, and perivascular inflammatory infiltrates characterize cerebritis. at this stage, unenhanced ct shows only an irregular, poorly circumscribed region of low attenuation, t29-132 scans obtained immediately after contrast administration show ring-like enhancement. on delayed scans, contrast diffuses into the center of the lesion, starting peripherally, until the center of the lesion may be completely filled with contrast by 30 minutes after admmistra-tlonj 29-13t the inherent sensitivity of proton density-weighted and t2-welghted mri to aheradons in tissue water enables earlier detection of cerebritis compared with ct. 89,132 these images show increased signal intensity indistinguishable from or slightly hypointense to surrounding edema, sg,j32 on t1weighted images, cerebritis is isointense to slightly hypomtense to adjacent brain parenchyma, with associated mass effect.89,132 over a period of 1 to 2 weeks, untreated cerebritis may progress to abscess formation when the central zone of necrosis becomes liquefied, better defined, and encircled by a collagen capsule, which is formed by fibroblast migration from the surrounding vessels. because of relatively poor vascularization of white matter, the medial aspect of the capsule may be somewhat thinner. this predisposes to expansion of the abscess into white matter, the formation of daughter abscesses medially, or rupture into the lateral ventricles, lz9,13°,132 the capsule is visible on unenhanced ct as an isodense rim that is visible because it is bordered medially by a hypodense liquid center and surrounded by hypodense edema (fig 21) . 131 the edema may be greater in volume than the abscess itself, causing much of the mass effect. 131 on contrast-enhanced ct, the rim is usually smooth and brightly enhancing. there is no diffusion of contrast into the necrotic center on delayed scans as there is with cerebritis, n9-131 on tl-weighted mri there is mild peripheral hypointensity representing edema and a more markedly hypointense liquid center. the capsule is a discrete rim that is isointense to slightly hyperintense. on t2-weighted images the abscess center is isointense to mildly hyperintense to gray matter. the capsule is seen as a dramatic hypointense rim, possibly caused by paramagnetic free radicals within phagocytic macrophages. 89 the ring pattern of enhancement parallels the enhancement seen on contrast-enhanced ct. the differential diagnosis for a ring-enhancing lesion includes primary brain tumor, metastasis, infarction, granuloma, and resolving hematoma. 42.89 helpful clues that may identify abscesses include the time course, location, temporal pattern of enhancement, and predisposition for the abscess rim to be thinner medially, s9 cuterebra. dogs and more commonly cats can suffer brain disease caused by aberrant migration of cuterebra larvae. [133] [134] [135] fly larvae attach to the host and burrow into the subcutaneous tissue. the developing larva (1 to 10 mm long) may migrate under the skin and enter the brain, most likely through the nasal passages and cribiform plate. 134,135 pathological changes in the brain consist of multifocal meningoencephalitis with malacia and hemorrhage •133-135 affected animals typically have access to outdoors and develop signs from june to october, coinciding with the larval migration portion of the cuterebra life cycle. a recent history of upper respiratory disease is common, likely reflecting migration of the larvae through nasal passages. 135 there is an acute onset of neurological dysfunction, most commonly referable to a focal forebrain lesion. seizures, abnormal mentation, circhng, hemlparesis, and unilateral blindness are common. 134,135 clinical and pathological features in cats are similar to what has been previously reported as feline ischemic encephalopathy.i35 a mottled appearance to the brain has been reported on ct of an affected cat} 35 based on my observations, ct may show focal or muhifocal regions of decreased attenuation with minimal mass effect. the may be one or more tract-like regions of contrast enhancement (fig 22) . lesions may be hypointense on tl-weighted mri and hypermtense on t2-weighted mri. edema is fairly minimal, and there may be small regions of hemorrhage. contrast enhancement is s~milar to that described for ct. an enhancing tract (arrows) extends from the cribiform plate through the right cerebral hemisphere. this cat, which lived outside, presented in october, 5 days after suffering a sudden onset of sneezing followed by seizures, left hemiparesis, depression, and circling to the right. clinical signs gradually resolved over the next 2 weeks, so the diagnosis was not confirmed by necropsy, but the clinical features are consistent with intracranial migration of a cuterebra larva. and does not enhance. i36 the intraparenchymal location is helpful in differentiating these lesions from arachnoid cysts, which are associated with the subarachnoid space. 25,~-6 ct and mri are helpful in identifying and characterizing many nonneoplastic brain disorders in dogs and cats. the imaging features of some of these disorders are unique, permitting definitive diagnosis based on imaging results and clinical features. however, the imaging findings for other brain disorders are nonspecific. in these instances, ct and mri often allow detection and localization of abnormalities, but definitive diagnosis may require other laboratory tests or surgical biopsy. as the use of ct and mr] becomes more widespread in veterinary medicine, further research in the imaging findings associated with various nonneoplastic disorders will improve our ability to diagnose and manage these conditions. imaging the brain (first of two parts) canine hydrocephalus. comp contln ed pract vet computed tomography in evaluation of hydrocephalus diagnosis and management of an atypical case of hydrocephalus, using computed tomography, ventrlculoperitoneal shunting, and nuclear sclntigraphy ultrasonographic diagnosis of canine hydrocephalus. vet radio131 ultrasonographlc imaging of the lateral cerebral ventricles in the dog diagnosis of cerebral ventrlculomegaly in normal adult beagles using quantitative mri normal variation in size of the lateral ventricles of the labrador retriever dog as assessed by magnetic resonance imaging developmental change of lateral ventricle volume and ratio in beagle-type dogs up to 7 months of age magnetic resonance imaging of silastlc-lnduced canine hydrocephalus pathogenesis of chlari malformation: a morphometric study of the posterior cranial fossa pathophysiology of synngomyelia associated with chiarl i malformation of the cerebellar tonsils hydromyelia in the dog occipital dysplasia and associated cranial spinal cord abnormalitles in two dogs magnetic resonance imaging of the brain and spine common congenital brain abnormalities cerebellar malformation in two dogs and a sheep cerebellar vermian hypoplasia in dogs dandy-walker--like syndrome in four dogs: cisternography as a diagnostic aid dandy-walker syndrome in a kitten ataxla of the head and hmbs: cerebeliar disease in dogs and cats comparative cerebellar disease in domestic animals arachnoid cysts arachnold cyst in the cerebellar pontlne area of a cat--diagnosis by magnetic resonance imaging magnetic resonance imaging and computed tomography characteristics of intracranial intraarachnoid cysts in 6 dogs spontaneous intracerebral and infratentorial hemorrhage hypertension: a review of the mechanisms, manifestations, and management cerebrovascular disease in various animal species chnlcal characteristics of cerebrovascular disease in small animals surgical excision of a cerebral arteriovenous malformation in a dog cerebral artenovenous malformation in a dog canine cerebrovascular disease: climcal and pathological findings in 17 cases cerebellar infarction caused by artenal thrombosis in a dog cerebral infarction ~n a dog. prog vet neurol computed tomography of an acute hemorrhagic cerebral infarct ~n a dog vet rad~ol ultrasound 35 magnetic resonance ~maging appearance of intracranfal hemorrhage secondary to cerebral vascular malformation ~n a dog magnetjc resonance imaging of brain infarction in seven dogs cerebral hemorrhage in an old dog intracranlal hemorrhage natural history of experimental intracerebral hemorrhage, sonography, computed tomography and neuropathology intracranlal ring enhancing lesions jn dogs: a correlatwe ct scanning and neuropathologlc study vet radlol ultrasound 36 magnetic resonance imaging of the brain and spree biochemical bas~s of the mr appearance of cerebral hemorrhage mr imaging of cerebral hematomas at different field strengths: theory and applications magnetic resonance imaging of intracranial hemorrhage deo-narjne '4. et al. mr imaging of acute intracran~al hemorrhage: findings on sequential spin-echo and gradient-echo images in a dog model pathology of vascular malformations of the brain embryological bas~s of some aspects of cerebral vascular fistulas and malformations artenovenous malformations of the brain nontraumatic intracran~al hemorrhage intracranial vascular malformations and aneurysms, in atlas sw the mri appearance of cavernous malformations (angiomas) intracranial vascular malformations: mr and ct imaging cerebral infarction with associated venous thrombosis ~n a dog vet patho125 pathophysiology and chnical evaluation of ~schem~c vascular d~sease chnical and pathologic findings in dogs with atherosolerosis 21 cases (1970-1983) hypothyroidism and atherosclerosls rn dogs. comp contm educ pract vet neurologlc manifestations of cerebrovascular atherosclerosis associated with primary hypothyroid-~sm in a dog jam cerebral infarction associated with thromboemboli cerebral infarction caused by heartworms (dirofilaria immitls) in a dog latchaw re cerebral ischemia and infarction sequential computed tomography scans in acute cerebral infarction mr imaging of acute expenmental ischemta in cats the impact of magnetic resonance imaging on the management of acute ischemlc stroke cerebral ischemla and infarction, in atlas sw magnetic resonance imaging of human cerebral infarction: enhancement with gd-dtpa gd-dtpa-enhanced magnetic resonance imaging for study of blood-braln-barner permeabdity in naturally occurnng and experimentally reduced brain infarction magnetic resonance imaging brain damage in the epileptic beagle dog vet patho120 the biochemical basis and pathophysiology of status eplleptlcus magnetic resonance imaging evidence of hlppocampal ~njury after prolonged focal febnle convulsions reversible mri lesions after seizures reversible magnetic resonance imaging abnormalities in dogs following seizures imaging of closed head injury magnetic resonance imaging of the brain and spine blinded companson of cranial ct and mr ~n closed head injury evaluation head trauma mechanisms of brain injury prevalence of mr evidence of diffuse axonal injury jn patients with mild head injury and normal head ct findings fntracranial infectious and rnflammatory diseases, in latchaw re inflammatory diseases of the central nervous system in dogs steroid responswe mening~tis-arteritis m dogs: long term study of 32 cases meric sm canine meningitis: a changing emphasis bacterial meningitis" pathogenesls, pathophysiology, and progress apreliminary study of magnetic resonance imaging (mri) in experimental canine meningitis gd-dtpa-enhanced mr imaging of experimental bacterial meningitis; evaluation and comparison with ct burrows pe imaging of pediatric central nervous system infections magnetic resonance imaging of the brain and spine a retrospective evaluation of 38 cases of canine distemper encephalomyelitis neurological manifestations of canine distemper infection diagnosis of inflammatory and jnfectlous diseases of the central nervous system in dogs: a retrospective study computed tomography of primary inflammatory brain disorders in dogs and cats magnetic resonance imaging--a general overview of principles and examples in veterinary neurodiagnosls feline infectious peritonitis with neurologlc involvement: clinical and pathological findings in 24 cats a review of the clinical diagnosis of feline infectious peritonitis viral meningoencephalomyehtls diagnostic features of clinical neurologic feline infectious peritonitis inflammatory diseases of the central nervous system, in veterinary neuropathology what is your diagnosls'~ (feline infectious virus encephahtis) cryptococcosls of the nervous system in dogs, part 1: epidemlologlc, clinical, and neuropathologic features feline cryptococcosis: a retrospective evaluation acryptococcal granuloma jn the brain of a cat causing focal signs prog vet neurol 7 a case of canine central nervous system cryptococcosis: management with fluconazole blastomycosls in dogs 115 cases (1980-1995) blastomycosis in cats: five cases (1979-1986) central nervous system d~sease due to histoplasmos~s ~n a dog: a case report systemic aspergillosls in a cat vet radio131 coccidioides immitls encephalitis in two dogs granulomatous meningitis caused by coccidioides immitts m a dog bayles wb cerebral phaeohyphomycosis phaeohyphomycotic encephalitis in two dogs a necrotlzlng menlngoencephahtis of pug dogs. vet necrotlzlng encephalitis in yorkshire terriers necrotizing meningoencephalitis of maltese dogs necrotizing encephalitis in a yorkshire terrier clinical and pathological findings of a yorkshire terrier affected with necrotizing encephalitis granulomatous menlngoencephalomyelitls in six dogs clinical and histopathologlcal features of granulomatous meningoencephalomyehtis in dogs cordy dr canine granulomatous meningoencephalomyehtis granulomatous men~ngoen-cephalomyehtls of dogs in new zealand granulomatous meningoencephalomyehtis in 21 dogs differential diagnosis of granulomatous menlngoencephalitls, dlstemper~ and suppurative meningoencephalitis in the dog prognostic factors for dogs with granutomatous meningoencephalomyelitls: 42 cases (1982-1996) imaging dlagnosls--granulomatous meningoencephalitis in a dog computed tomography in the diagnosis of focal granulomatous menlngoencephalitls: retrospective evaluation of three cases magnetic resonance imaging in the dlagnos]s of focal granulomatous meningoencephalitls in two dogs brain abscess associated with a penetrating foreign body brain abscess in a dog neuropathological and computerized tomographic findings in experimental brain abscess experimental brain abscess; computed tomographic and neuropathologic correlation staging of human brain abscess by computed tomography the magnetic resonance imaging of infections and inflammatory diseases cerebral cuterebrosis in a dog aberrant intracranlal myiasis caused by larval cuterebra infection clinical and clinicopathologic features in 11 cats with cuterebra larvae myiasis of the central nervous system cerebral coenurosls in a cat labuc ret al: cerebral coenunasis in a domestic cat magnetic resonance imaging cerebrovascular disease key: cord-346815-4t4gr0jz authors: moshayedi, pouria; ryan, timothy e.; mejia, lucido luciano ponce; nour, may; liebeskind, david s. title: triage of acute ischemic stroke in confirmed covid-19: large vessel occlusion associated with coronavirus infection date: 2020-04-21 journal: front neurol doi: 10.3389/fneur.2020.00353 sha: doc_id: 346815 cord_uid: 4t4gr0jz the outbreak of covid-19 has posed a significant challenge to global healthcare. acute stroke care requires rapid bedside attendance, imaging, and intervention. however, for acute stroke patients who have a diagnosis of or are under investigation for covid-19, the concern for nosocomial transmission moderates operational procedures for acute stroke care. we present our experience with an in-hospital stroke code called on a covid-19-positive patient with a left middle cerebral artery syndrome and the challenges faced for timely examination, imaging, and decision to intervene. the outlook for the ongoing covid-19 pandemic necessitates the development of protocols to sustain timely and effective acute stroke care while mitigating healthcare-associated transmission. rapid attendance at the patient bedside, clinical exam, and timely imaging studies have been emphasized in the care of acute ischemic stroke patients, but the global pandemic outbreak of covid-19 (1) has created novel and significant challenges to acute stroke care. protocols to sustain acute stroke care for covid-19 patients while mitigating nosocomial transmission are needed. in this report, we share unique challenges in treating a covid-19-positive patient with acute ischemic stroke due to occlusion of the left middle cerebral artery. we also discuss the current evidence and recommendations to decrease healthcare-associated transmission in acute clinical examination, imaging, and interventional procedures in acute stroke patients with a diagnosis of covid-19. a patient in his 8th decade of life was admitted to our facility with acute chest pain, diaphoresis, and hypotension with st-elevation myocardial infarction (stemi). he underwent coronary angioplasty followed by stent deployment and was admitted to the coronary care unit (ccu). transthoracic echocardiogram revealed left ventricle (lv) ejection fraction of 10-15% and lv thrombosis measuring 2.8 cm × 1.1 cm, prompting initiation of iv heparin. he also had bilateral lower limb paresthesia and loss of temperature and arterial pulses, raising concern of ischemic limbs, with lower extremity arterial doppler confirming occlusion in multiple arterial segments. due to his presentation with shortness of breath, he was designated as a patient under investigation (pui) for covid-19, and, the day following admission, his pcr testing of respiratory secretions showed evidence of 2019-ncov rna. he was intubated due to hypoxemic respiratory failure. standard facility protocols for droplet isolation in a negative pressure room were implemented. the patient was extubated on day 4. on day 5, an in-hospital stroke code was called after the bedside nurse found him to have an inability to speak, rightsided weakness, and right-sided facial droop, with last known well time the night before. the stroke team arrived, and one team member wore personal protection equipment including an n95 respirator mask, goggle, gown, and gloves and entered the patient's room to perform an examination, which revealed an inability to speak or comprehend, a conjugate gaze preference toward the left side, no blink to threat on the right side, and no movement in the right arm and leg. since the patient presented with a large vessel occlusion stroke syndrome within an extended time window, advanced multimodal imaging was indicated to measure infarct volume as well as salvageable tissue. according to the institutional policy for acute stroke codes, as well as the patient's renal failure prohibiting the use of iodine contrast for ct perfusion studies, he was transported to mri. the institutional protocol for transferring patients in aerosol isolation was applied by having the patient wear a surgical face mask. laboratory results were notable for renal failure, normal platelet count, and activated partial thromboplastin time (ptt) >85.5 while on heparin. brain mri, obtained without contrast administration (due to severe renal failure) and reviewed during image acquisition, revealed a 60-cc acute infarct in the left insular, temporal, parietal, and frontal lobes, as well as smaller acute infarcts in the right caudate and left cerebellar hemisphere. mri also showed evidence of hemorrhagic conversion in the left fronto-temporal territory. mr angiogram showed occlusion of the left middle cerebral artery proximal m1 segment. the patient was not a candidate for thrombolysis as he had elevated activated ptt on heparin, in addition to an unknown time of stroke onset and evidence of large and established infarction with a small region of hemorrhagic transformation. endovascular thrombectomy was considered but not pursued given the large infarct size and evidence of hemorrhagic transformation since reperfusion could have led to a much larger intracranial hemorrhage with no meaningful clinical benefit. following this ischemic stroke, and given other comorbidities including heart failure, cardiovascular shock, and ischemic bilateral lower limbs, discussions on goals of care were held with the family, and his care was focused on comfort according to the patient's wishes. following the completion of his mri, the mri suite was out of commission for about 3 h to complete disinfection. early reports from the covid-19 pandemic have noted a 41% nosocomial infection rate (2) , which highlights the importance of developing protocols for transfer, imaging, intubation, and surgical or endovascular procedures on covid-19 patients presenting with acute stroke. the novelty of the covid-19 pandemic outbreak means that there are few evidence-based and informed protocols. the current recommendations have centered on the airborne and direct contact methods of transmission (3) . to perform mri or other imaging modalities, it is recommended to switch a patient's bed and accessories to mri-compatible equipment in the patient room with enhanced airborne precautions rather than in the mri suite. designation of a single entry point to imaging facilities and limiting other traffic through the healthcare facility is preferred (4). installment of physical barriers and the donning of n95 masks, face protection, and gloves for physicians or ancillary staff en-route are recommended. discussions on safe pre-operative procedures are underway (5) . studies published before the covid-19 outbreak noted that a high-flow nasal cannula, non-invasive ventilation by masks with optimized vent holes, or a helmet connected to a doublelimb circuit may lower airborne transmission (6), but closedcircuit ventilation with use of filters is regarded as a safer option. given the relatively low risk of operative site infection, endovascular suites capable of conversion to negative pressure facilities appear to be ideal solutions. the covid-19 pandemic outbreak has exhausted and overburdened healthcare systems. in a situation of extreme facility shortages, triaging covid-19-positive patients with acute stroke based on severity and extent of their premorbidities is a grim but unavoidable necessity. in acute stroke patients presenting with symptoms of large vessel occlusion in an extended time window, and therefore requiring advanced imaging, ct perfusion has been shown to be equally capable of selecting patients for endovascular thrombectomy when compared with mri (7). the time required for disinfection protocols to be conducted may require judicious use of mri for acute stroke patients. in the face of the current pandemic, our institutional policy for acute stroke care has changed and now prioritizes ct perfusion over mri. all datasets presented in this study are included in the article/supplementary material. the studies involving human participants were reviewed and approved by ucla irb. written informed consent for participation was not required for this study in accordance with the national legislation and the institutional requirements. and dl: conception and design and administrative/technical/material support. pm: acquisition of data and drafting the article. all authors: analysis and interpretation of data, critically revising the article, and reviewed submitted version of manuscript. dl: approved the final version of the manuscript on behalf of all authors and study supervision. responding to covid-19 -a once-in-a-century pandemic? clinical characteristics of 138 hospitalized patients with 2019 novel coronavirus-infected pneumonia in wuhan more awareness is needed for severe acute respiratory syndrome coronavirus 2019 transmission through exhaled air during non-invasive respiratory support: experience from china microbiology for radiologists: how to minimize infection transmission in the radiology department intubation and ventilation amid the covid-19 outbreak: wuhan's experience exhaled air dispersion during noninvasive ventilation via helmets and a total facemask thrombectomy for stroke at 6 to 16 hours with selection by perfusion imaging dl is consultant to cerenovus, genentech, stryker and medtronic as imaging core lab.the remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.copyright © 2020 moshayedi, ryan, mejia, nour and liebeskind. this is an openaccess article distributed under the terms of the creative commons attribution license (cc by). the use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. no use, distribution or reproduction is permitted which does not comply with these terms. key: cord-322890-w78tftva authors: suran, jantra ngosuwan; wyre, nicole rene title: imaging findings in 14 domestic ferrets (mustela putorius furo) with lymphoma date: 2013-06-06 journal: vet radiol ultrasound doi: 10.1111/vru.12068 sha: doc_id: 322890 cord_uid: w78tftva lymphoma is the most common malignant neoplasia in domestic ferrets, mustela putorius furo. however, imaging findings in ferrets with lymphoma have primarily been described in single case reports. the purpose of this retrospective study was to describe imaging findings in a group of ferrets with confirmed lymphoma. medical records were searched between 2002 and 2012. a total of 14 ferrets were included. radiographs (n = 12), ultrasound (n = 14), computed tomography (ct; n = 1), and magnetic resonance imaging (mri; n = 1) images were available for review. median age at the time of diagnosis was 5.2 years (range 3.25–7.6 years). clinical signs were predominantly nonspecific (8/14). the time between the first imaging study and lymphoma diagnosis was 1 day or less in most ferrets (12). imaging lesions were predominantly detected in the abdomen, and most frequently included intra‐abdominal lymphadenopathy (12/14), splenomegaly (8/14), and peritoneal effusion (11/14). lymphadenopathy and mass lesions were typically hypoechoic on ultrasound. mild peritoneal effusion was the only detected abnormality in two ferrets. mild pleural effusion was the most common thoracic abnormality (3/12). expansile lytic lesions were present in the vertebrae of two ferrets with t3‐l3 myelopathy and the femur in a ferret with lameness. hyperattenuating, enhancing masses with secondary spinal cord compression were associated with vertebral lysis in ct images of one ferret. the mri study in one ferret with myelopathy was inconclusive. findings indicated that imaging characteristics of lymphoma in ferrets are similar to those previously reported in dogs, cats, and humans. l ymphoma is the most common malignant neoplasia in domestic ferrets, mustela putorius furo. following insulinoma and adrenocortical neoplasia, it is the third most common neoplasia of domestic ferrets overall. [1] [2] [3] [4] in ferrets, lymphoma can be classified based on tissue involvement, including multicentric, mediastinal, gastrointestinal, cutaneous, and extranodal. [1] [2] [3] the presentation and organ distribution of lymphoma has been associated with the age of onset. 5, 6 mediastinal lymphoma is more prevalent in young ferrets, particularly less than 1 year of age. these ferrets tend to have an acute presentation and may present with dyspnea. ferrets with mediastinal lymphoma may also have multicentric involvement. 2, 5, 6 ferrets 3 years of age and greater have a variable presentation with multicentric disease being more prevalent. clinical signs in older ferrets may be chronic and nonspecific depending on organ involvement. some ferrets may have intermittent signs over several months, while others may be asymptomatic with lymphoma being diagnosed incidentally, detected either during routine physical examination or during evaluation of comorbidities. [1] [2] [3] despite lymphoma being common in domestic ferrets and the use of radiography and ultrasonography being touted as part of the minimum database in the diagnosis of lymphoma, 1, 7 imaging findings in ferrets with lymphoma have been limited to a few case reports. 1, 2, 5, 6, [8] [9] [10] [11] the goal of this retrospective study was to describe radiography, ultrasonography, computed tomography (ct), and magnetic resonance imaging (mri) findings in a series of ferrets with a confirmed diagnosis of lymphoma. medical records at the matthew j ryan veterinary hospital of the university of pennsylvania were searched for domestic ferrets with a diagnosis of lymphoma confirmed with cytology or histopathology that had radiography, ultrasonography, ct, or mri performed between january 2002 and april 2012. signalment, clinical signs, laboratory findings, and any prior or concurrent disease processes were recorded. vet radiol ultrasound, vol. 54, no. 5, 2013, pp 522-531. radiographs, ct, mri, static ultrasound images, and when available, ultrasound cine loops were retrospectively evaluated, and abnormal findings were recorded by j.n.s. the imaging reports generated by a board-certified veterinary radiologist at the time the study was performed were also reviewed. ferrets were excluded if the imaging studies were unavailable for review. any imaging studies obtained after the reported start of clinical signs until a diagnosis was achieved were included. in addition to the reported ultrasonographic findings, the maximal splenic and lymph node thicknesses were measured from the available images if they were not reported. as splenomegaly is common in ferrets, most frequently due to extramedullary hematopoiesis, 2 splenomegaly was subjectively graded as within incidental variation ("incidental splenomegaly") and larger than expected for "incidental splenomegaly." those with subjectively normal spleens or "incidental splenomegaly" were referred to as normal for the purposes of this paper, unless otherwise specified. retrieved ct images were reconstructed with a high-frequency high-resolution algorithm (bone algorithm with edge enhancement) in 1.25 mm slice thickness. the maximal lymph node thickness was measured on precontrast images. fourteen ferrets met the inclusion criteria. lymphoma was diagnosed from ultrasound-guided aspirates, surgical biopsies, and/or necropsy; three ferrets had two diagnostic procedures performed. ultrasound-guided aspirate cytology was performed in nine ferrets, surgical biopsy in three, and necropsy in five. both aspirates and biopsy were performed in two ferrets, and both aspirates and necropsy in one ferret. one ferret in this study was previously described. 8 the median age at the time of lymphoma diagnosis was 5.2 years (range 3.25-7.6 years). eight of the ferrets were neutered males, and six were spayed females. prior disease histories included adrenal disease (n = 5), cardiovascular disease (5), cutaneous mast cell tumors (4), diarrhea (3), insulinoma (2), cataracts (2) , and one each of granulomatous lymphadenitis secondary to mycobacteriosis, renal insufficiency, and a chronic pelvic limb abscess. cardiovascular disease included second degree atrioventricular block (3), systemic hypertension (1), hypertrophic obstructive cardiomyopathy (1) , and in one individual both aortic insufficiency and arteriosclerosis. for most ferrets, the time between the first imaging study and a diagnosis of lymphoma was 1 day or less (12/14) . in one ferret each, the time between the initial imaging study and final diagnosis of lymphoma was 7 days and 6.9 months. the duration of clinical signs prior to reaching the diagnosis of lymphoma ranged from less than 1 day to 8 months with a mode of less than 1 day and a median of 6 days. clinical signs include lethargy (n = 9), diarrhea (8) , inappetence (7), weight loss (6), ataxia (4), lameness (1), and vomiting (1) . diarrhea was chronic in three ferrets and consistent with melena in two. two ferrets did not have overt clinical signs. physical exam findings included palpable abdominal masses (8) , generalized splenomegaly (5), palpable splenic nodules or splenic masses (3), dehydration (5), paraparesis and ataxia (4), abdominal pain (4), hypotension (3), lumbar pain (2), abdominal effusion (1), inguinal and popliteal lymphadenopathy (1), pyrexia (1), urinary and fecal incontinence (1), and a right femoral mass (1). paraparesis and ataxia were attributed to t3-l3 myelopathy in three ferrets and hypoglycemia in one. one ferret also presented with ptyalism and tremors, which resolved with dextrose administration. blood analyses, including a complete blood count and chemistry profile, were performed in 12 of the 14 ferrets. blood glucose evaluation alone was performed in one ferret. abnormalities included azotemia (5), elevated liver enzymes (5), nonregenerative anemia (4), hypoglycemia (4), hypoalbuminemia (3), lymphocytosis (2), hyperglobulinemia (2), hypercalcemia (1), and elevated total bilirubin (1). two of the four ferrets with hypoglycemia had a previous diagnosis of insulinoma. radiographs were performed in 12/14 ferrets. each of these 12 studies included the thorax and abdomen-six studies included a right or left lateral projection and a ventrodorsal projection and six included a left lateral, right lateral, and ventrodorsal projections. one ferret's radiographs were in an analog format (screen-film), and the remaining 11 were digital (rapidstudy, eklin medical systems inc., santa clara, ca). ultrasound was performed in 14/14 ferrets using a 13-15 mhz linear transducer (ge medical logiq 9 ultrasound imaging system, general electric medical systems, milwaukee, wi). abdominal ultrasonography was performed in 13/14 ferrets. ultrasonography of a rib mass and a femoral mass was performed in one ferret each. abdominal ultrasonography was performed twice in one ferret after the start of the reported clinical signs, but prior to the diagnosis of lymphoma. ultrasounds were performed by a board-certified radiologist or a radiology resident under direct supervision from a board-certified radiologist. in the one ferret with two ultrasounds performed prior to diagnosis of lymphoma, the later scan was used for measurements. computed tomography of the thorax and abdomen was performed in one ferret. the ferret was scanned under general anesthesia in dorsal recumbency using a 16-slice multidetector ct unit (ge brightspeed, general electric company, milwaukee, wi) in medium-frequency soft tissue algorithms (2.5 mm slice thickness, 1.375 pitch) before and immediately after iv administration of nonionic iodinated contrast (iohexol, 350 mgi/ml, dosage 770 mgi/kg, [omnipaque, ge healthcare, inc., princeton, nj]). contrast was manually injected through an iv catheter preplaced in a cephalic vein. one ferret underwent mri evaluation of the lumbar and sacral spine. magnetic resonance imaging was performed using a 1.5 t mri unit (ge medical system, milwaukee, wi) with the patient in dorsal recumbency under general anesthesia. image sequences included t2 weighted (t2w) image series in a sagittal and transverse plane, t2w fat-saturated images in a sagittal and transverse plane, and a sagittal single-shot fast spine echo. additional sequences including t1 weighted (t1w) images and administration of gadolinium were not performed due to anesthetic concerns for the patient. radiographic and ultrasonographic findings are summarized in table 1 . radiographic abnormalities were predominantly noted in the abdomen. decreased abdominal serosal detail was present in 10 of the 12 ferrets with radiographs. this was interpreted to be potentially due to a poor body condition in two ferrets. abdominal serosal detail was additionally mottled in seven ferrets. sonographically, peritoneal effusion was detected in 11/13 ferrets, and was considered mild in 7, moderate in 4, anechoic in 8, and echogenic in 3. the spleen was considered enlarged in 7 out of 12 ferrets radiographically and in 8 out of 13 ferrets in which abdominal ultrasonography was performed. the remaining five ferrets were considered to have "incidental splenomegaly" on ultrasound and were radiographically considered normal (n = 4) and enlarged (1) . of the eight spleens sonographically considered abnormal, multifocal hypoechoic splenic nodules were present in six ferrets (fig. 1) ; one of these six ferrets was considered to have a radiographically normal spleen. an isoechoic to hypoechoic mass with central hypoechoic nodules was present in one ferret. the spleen had a mottled echotexture in one ferret. three ferrets were sedated with butorphanol (torbugesic, fort dodge animal health, fort dodge, ia) and midazolam (hospira inc., lake forrest, il) prior to abdominal ultrasonography; sedation was not performed in any ferret prior to radiographs. all three sedated ferrets had enlarged spleens with one spleen having a mottled echotexture and the other two spleens having multifocal hypoechoic nodules. splenic cytology or histopathology was not performed in any of the ferrets that received sedation for ultrasound. cytology or histopathology was available in seven ferrets-aspirates were performed in 2/7, necropsy in 4/7, and both aspirates and necropsy in 1/7. lymphoma was confirmed in three out of six ferrets with splenic nodules, the one ferret with a splenic mass, and one out of five ferrets with "incidental splenomegaly." in three of the five ferrets with "incidental splenomegaly," marked splenic extramedullary hematopoiesis with splenic congestion (1) and without concurrent splenic congestion (1) was diagnosed. the other seven ferrets did not have cytologic evaluation of the spleen. splenic thickness in ferrets where the spleen was considered within incidental variation ranged from 8.0 to 16.2 mm (median, 15.0 mm, mean 13.4 mm, standard deviation ±3.5 mm; n = 5), while in ferrets with splenomegaly splenic thickness ranged from 14.2 to 33.1 mm (median 19.9 mm, mean 20.9 mm, standard deviation ±6.4 mm; n = 8). single or multiple, round to oblong, soft-tissue opaque, abdominal masses consistent with enlarged lymph nodes were visible radiographically in 7/12 ferrets (fig. 2) . one of these ferrets had a large cranial abdominal mass, which was subsequently confirmed to be a markedly enlarged pancreatic lymph node. one ferret had splenic lymphadenopathy detected on the radiographs retrospectively after evaluation of the sonographic findings. lymphadenopathy was reported in 11 of the 13 ferrets with abdominal ultrasonography and the one ferret in which whole body ct was performed. sonographically, abnormal lymph nodes were hypoechoic, rounded, variably enlarged, and surrounded by a fig. 3 . ultrasound image of an enlarged hepatic lymph node in the same ferret as fig. 2 . the hepatic lymph node is markedly enlarged and lobular. although the node is predominantly hypoechoic, there are patchy hyperechoic regions and smaller, round, hypoechoic, nodule-like regions within (arrow). the surrounding fat is hyperechoic, producing a halo around the lymph node (arrow heads). scale at the top of the image is 10 mm between the major ticks. hyperechoic rim (fig. 3 ). some lymph nodes had patchy hyperechoic regions within or a reticular, nodular appearance. abdominal lymph nodes involved included the mesenteric (n = 10), hepatic (7), sublumbar (5), splenic (4), gastric (3), gastroduodenal (3), colonic (3), pancreatic (2), ileocolic (1), renal (1), and inguinal (1) lymph nodes. in one ferret other lymph nodes were reported to be involved in addition to the mesenteric and sublumbar nodes, but were not specifically identified. nine of the 11 ferrets with abdominal ultrasound and the one ferret with ct had involvement of 2 or more lymph nodes reported; 2/11 ferrets had only one reportedly abnormal lymph node (1 splenic lymph node, 1 mesenteric lymph node). lymph nodes measured from 4.8 to 29.5 mm thick (median 8.5, mean 11.6 mm, standard deviation ±8.1 mm). the lymph node thickness in ferrets with radiographically evident lymphadenopathy ranged from 6.2 mm to 29.5 mm with a median of 9.7, and mean of 14.5, and standard deviation of ±9.7 mm (n = 7). in ferrets in which lymphadenopathy was detected sonographically but not radiographically, lymph nodes measured 4.8 mm, 5.2 mm, and 11.7 mm thick (n = 3). lymph node cytology or histopathology was available in seven ferrets-aspirates were performed in 3/7 ferrets, both aspirates and surgical biopsy in 1/7, and necropsy in 3/7. it was not clear if lymph nodes were histopathologically assessed in 2/5 ferrets in which a necropsy was performed. lymphoma was confirmed in 6/11 ferrets with sonographically abnormal lymph nodes (range 5.2-29.5 mm thick, median 14.8 mm, mean ± standard deviation 17.2 ± 9.3 mm). in 1/11 ferrets, lymphoid hyperplasia was identified postmortem (6.2 mm thick). cytologic evaluation of lymph nodes was not performed in the remaining ferrets. in ferrets with lymphadenopathy, eight had concurrent splenomegaly with fig. 4 . ultrasound image of the gastric antrum. the wall of the gastric antrum, especially the muscularis layer, is circumferentially thickened (arrows). a small amount of fluid and gas (*) is present in the lumen. splenic nodules (6), a splenic mass (1), or a mottled splenic echotexture (1) . lymphoma was identified in the liver of 2/14 ferrets by surgical biopsy (1) and at necropsy (1) . mild hepatomegaly with a normal echotexture was noted on ultrasound in the ferret with lymphoma diagnosed by biopsy. additional findings in this ferret included mild peritoneal effusion and lymphadenopathy. the ferret with hepatic lymphoma identified at necropsy had no radiographic or reported sonographic liver abnormalities. this ferret also had hepatic lipidosis. imaging findings in this ferret included an aggressive vertebral lesion, splenomegaly with splenic nodules, and lymphadenopathy. lymphoma was confirmed in each of these organs, as well as in the pancreas, which was reportedly normal on ultrasound. in addition to these two ferrets, hepatic histopathology from necropsy was available in four other ferrets. hepatic lipidosis was identified each of these four ferrets; one ferret also had extramedullary hematopoiesis. none of these four ferrets had radiographic or reported sonographic abnormalities. cytology or histopathology was not available in the remaining 8/14 ferrets. of these, 1/8 had no radiographic or sonographic abnormalities noted. mild hepatomegaly was noted radiographically in 5/8 ferrets; however, sonographic hepatic changes were not noted in these ferrets and cytologic evaluation was not performed. on ultrasound, one ferret had moderate hepatomegaly with a hypoechoic, mottled echotexture (radiography was not performed in this ferret). additionally one ferret had two hypoechoic cystic masses, one mass of which had central mineralization, detected with ultrasound (radiography was not performed in this ferret). gastrointestinal lymphoma was confirmed at necropsy in two ferrets. in one ferret, thickening of the gastric antrum up to 4.5 mm and blurring of wall layering was identified sonographically (fig. 4) . (to the authors' knowledge, the normal gross or sonographic wall thickness of the gastrointestinal tract in ferrets has not been previously reported.) fig. 5 . ultrasound image of the right kidney. there is a round, hypoechoic nodule in the parenchyma, which bulges from the renal contour. the calipers (+) denote the renal length (1) and margins of the nodule (2, 3). no abnormalities were noted in the small or large intestines. at necropsy, lymphoma was identified in the stomach and small intestines, in addition to a chronic ulcerative gastroenteritis. in the second ferret, aside from poor abdominal serosal detail attributable to poor body condition and mild anechoic peritoneal effusion, there were no other radiographic or sonographic abnormalities. in this ferret, lymphoma was identified postmortem in the descending colon. the colon was discolored, but there was no reported gross colonic wall thickening. renal masses were present in two ferrets. in each ferret, a single renal mass was detected with ultrasound and was well defined, hypoechoic, centered on the cortex, and protruded from the kidney. the mass was right-sided, rounded, and measured 8.6 mm in diameter in one of these two ferrets. in the second ferret, the mass was left-sided, lobular, and measured up to 17.9 mm in diameter. cytology of the right renal mass in the first ferret was not performed; however, the patient received chemotherapy for the treatment of lymphoma, confirmed from aspiration and biopsy of an enlarged lymph node, and the mass was seen to decrease in size during follow-up studies (fig. 5) . although the masses in both ferrets had similar ultrasound characteristics, the renal mass in the second ferret was diagnosed as a spindle cell sarcoma. additionally that mass had been identified sonographically 1 year prior to the diagnosis of lymphoma, was progressively increasing in size, and did not decrease in size following administration of chemotherapy for the treatment of lymphoma. concurrent sonographic changes in both ferrets included lymphadenopathy and peritoneal effusion. a large lobular retroperitoneal mass was present in one ferret. the mass was on midline, extending into the right and left sides of the retroperitoneal space, laterally displacing the right kidney. the left kidney was not visualized radiographically. in the right cranial retroperitoneal space, cranial to the right kidney, there was a cluster of heterogeneous mineral opacities in an adjacent second, smaller mass. sonographically the large retroperitoneal mass was heterogeneous, hypoechoic with patchy hyperechoic regions, and laterally displaced both kidneys. the smaller mineralized mass was confirmed to be an enlarged right adrenal gland sonographically. at necropsy, the retroperitoneal mass was confirmed to be lymphoma; however, a specific tissue of origin was not determined. as a normal left adrenal gland could not be identified sonographically or at postmortem, an adrenal origin for this mass was considered most likely, although adrenal tissue was not identified histopathologically within the mass. alternatively the mass may have arisen from a retroperitoneal lymph node or retroperitoneal adnexa. concurrent abdominal imaging findings considered incidental to the diagnosed lymphoma included renal cysts (8) , cystic lymph nodes (7), adrenomegaly in ferrets with diagnosed adrenal disease (5), and pancreatic nodules in ferrets diagnosed with insulinoma (2). on thoracic radiographs pleural fissure lines, consistent with a small volume of pleural effusion, were present in 3/12 ferrets. pericardial and pleural effusions were noticed during abdominal ultrasonography in one ferret. possible sternal (2) and tracheobronchial lymphadenopathy (1) were seen radiographically. in one ferret, sternal and cranial mediastinal lymphadenopathy were detected with ct. an interstitial pulmonary pattern was present in two ferrets, but was potentially attributable to the radiographic projections being relatively expiratory. aggressive osseous lesions were detected radiographically in three ferrets. the one ferret with a history of lameness had a soft-tissue mass involving the entire right femur with marked, multifocal areas of geographic to motheaten, expansile lysis throughout. smooth to mildly irregular periosteal reaction was present along the femoral diaphysis and greater trochanter. the adjacent acetabulum and ileum were questionably involved based on the radiographs. sonographically the soft-tissue components of the mass were homogeneously hypoechoic. cortical irregularities and disruption, consistent with lysis, were also present. histopathology of the mass following limb amputation was consistent with plasmablastic lymphoma. this ferret was previously described. 8 vertebral lysis was apparent radiographically in two of the three ferrets with t3-l3 myelopathy. in one of these two ferrets, there was geographic lysis of l1 involving the majority of the vertebral body and a pathologic fracture of the cranial end plate (fig. 6) . other radiographic changes present in this ferret included splenomegaly and decreased abdominal serosal detail likely due to poor body condition. on ultrasound, peritoneal effusion, splenomegaly with splenic nodules, and lymphadenopathy were detected. at necropsy, intramedullary lymphoma was found in the l1 vertebra with epidural extension of the tumor. lymphoma was also found affecting the spleen, liver, pancreas, and fig. 6. right lateral radiograph cropped and centered on l1. at l1 there is geographic lysis, including cortical thinning or loss, of the cranial two-thirds of the vertebral body and the cranial aspect of the pedicles (arrows). the cranial end plate of l1 has a concave indentation, presumptively secondary to a pathologic fracture (arrow head). mesenteric lymph nodes. in the second ferret with vertebral lysis, there was geographic lysis of the cranial two-thirds of the body and pedicles of t14. there was also possible lysis of the cranial body and pedicles of l4. the dorsal half of the left 9th rib was lytic and no longer visible. associated with this rib, there was a large, ill-defined, soft-tissue mass, which extended into the thoracic cavity. the adjacent ribs and vertebra were not appreciably involved. additional radiographic findings in this ferret included splenomegaly, hepatomegaly, and abdominal masses consistent with enlarged lymph nodes. with ct, expansile lysis of the left t14 vertebral body and pedicle was seen associated with a hyperattenuating (to muscle), strongly enhancing mass (fig. 7) . the mass occupied the ventral two-thirds of the spinal canal and resulted in severe spinal cord compression. a possible pathologic fracture was present in the cranial endplate. at l4, there was lysis of the left pedicle and body associated with a mildly compressive, hyperattenuating, contrast-enhancing mass. an additional, similar mass lesion was seen at t4, with lysis of the midvertebral body and mild spinal cord compression. the rib mass was isoattenuating (to muscle), heterogeneous, mildly enhancing, and resulted in severe, expansile lysis. cytology of the rib mass obtained by ultrasound-guided fine-needle aspiration was diagnostic for lymphoma; cytological assessment of the other lesions was not performed in this ferret. one ferret with t3-l2 myelopathy did not have gross skeletal pathology. radiographic changes included splenomegaly and poor, mottled serosal detail. sonographically, a mild peritoneal effusion was present, and the spleen was considered within incidental variation. an mri of the lumbar spine revealed an ill-defined area of suspect intramedullary t2w hyperintensity within the spinal cord at the level of l3. differential diagnoses for this lesion considered at the time included an artifact, prior infarct, gliosis, edema, myelitis, neoplasia, and hydromyelia. at the postmortem examination performed 5 months after the mri, lymphoma was detected in the brain, meninges, choroid plexus, spinal cord, and extracapsular accessory adrenal tissue. additionally there was multifocal spinal cord malacia and hemorrhage. the lesions in the spinal cord were identified in histopathologic samples obtained at intervals from the cervical spine at c1 through to the lumbar spine at l5, including at the level of l3. specific correlation between the suspect mri lesion and histopathologic findings was not performed. splenic changes were consistent with congestion and extramedullary hematopoiesis. multicentric lymphoma was the most common presentation in this study. this is consistent with prior reports in which multicentric lymphoma is the most common presentation in ferrets older than 3 years of age. 1, 5, 6, 12 the most common imaging findings in this study were intraabdominal lymphadenopathy and splenomegaly with mildto-moderate peritoneal effusion. lymphadenopathy consisted of multiple enlarged, predominantly intra-abdominal lymph nodes, particularly including the mesenteric lymph node. only one ferret had peripheral lymphadenopathy, consisting of enlargement of the inguinal and popliteal lymph nodes, in addition to abdominal lymphadenopathy. lymph nodes greater than 6.2 mm thick sonographically were generally appreciable radiographically as round to oblong, soft-tissue nodules or masses in their respective locations. of the three ferrets in which sonographically detected lymphadenopathy was not appreciable radiographically, only one had a lymph node thickness greater than 6.2 mm. that ferret also had a large, retroperitoneal mass that likely accounted for a lack of visualization of the enlarged mesenteric lymph node due to silhouetting and displacement. previous studies in normal ferrets using ultrasound have reported the normal thickness of mesenteric lymph nodes as 5.3 ± 1.39 mm and 7.6 ± 2.0 mm. 13, 14 given that some radiographically visible lymph nodes measured as small as 6.2 mm (which is within the reported normal ranges for mesenteric lymph nodes) it is possible that normal lymph nodes may be radiographically appreciable. in the authors' experiences, however, visualization of normal, small abdominal lymph nodes on radiographs of ferrets is uncommon. normal abdominal lymph nodes are not radiographically distinguishable in dogs and cats. 15, 16 although some lymph nodes in this study that were considered abnormal measured within the reported normal ranges, there were other changes to those nodes to suggest pathology, such as hypoechogenicity. in dogs and cats, sonographic changes that have been associated with malignancy include an increase in maximal short and long axis diameter (enlarged), an increase in short-to-long axis length ratio (more rounded appearance), hypoechogenicity, hyperechoic perinodal fat with an irregular nodal contour, and heterogeneity. [17] [18] [19] similar to previous reports, the spleen was the most common extranodal site of neoplastic infiltration with lymphoma in the current study. 5 in a prior study splenomegaly was attributable to neoplastic infiltration in 67% of ferrets with lymphoma and extramedullary hematopoiesis in 33%. 5 in general, splenomegaly secondary to extramedullary hematopoiesis is common in ferrets. 2 to the authors' knowledge, there is no reference for normal splenic size in ferrets using ultrasound. grossly the normal spleen has been reported to measure 5.1 cm in length, 1.8 cm in width, and 0.8 cm thick. 20 given that these are gross measurements, however, they were likely obtained postmortem. splenic size is variable and decreases postmortem, so these measurements may not be translatable to antemortem studies with sonographic measurements. 21 the smallest splenic thickness in this study was 0.8 cm; using the gross measurement guidelines all spleens in this study would be considered enlarged. the degree of splenomegaly was therefore subjectively characterized as within incidental variation and larger than expected for "incidental splenomegaly" based on the authors' experiences. of the seven ferrets in which splenic cytology was available, lymphoma was confirmed in the four ferrets in which the spleen was considered abnormal and cytology was performed. of the three ferrets spleens in which cytology was performed and the spleen was considered within incidental variation, lymphoma was identified in one, and extramedullary hematopoiesis was confirmed in the other two. potential differential diagnoses for multicentric lymphadenopathy with splenomegaly in ferrets include reactive lymphadenopathy secondary to gastrointestinal disease with splenic extramedullary hematopoiesis, systemic mycobacteriosis, granulomatous inflammatory syndrome, and aleutian disease. 1, [22] [23] [24] [25] with systemic mycobacteriosis, ferrets can have other lymph nodes affected in addition to the abdominal lymph nodes, with the retropharyngeal lymph nodes being affected as commonly as the mesenteric lymph nodes. 25 as with lymphoma, clinical signs of mycobacteriosis in the ferret depend on the organs that are affected and can include lethargy, anorexia, vomiting, and diarrhea; but as with other infectious diseases, changes in white blood cell counts can be seen. mycobacteriosis can be diagnosed on cytology and biopsy of the affected lymph node or organ. 25 granulomatous inflammatory syndrome is a newly recognized systemic disease associated with coronavirus that causes inflammation in the spleen and lymph nodes. 23 this syndrome results in a severe granulomatous disease that can affect the gastrointestinal tract, mesenteric lymph nodes, liver, and spleen. unlike lymphoma, it is usually seen in younger ferrets, but like lymphoma, clinical signs are nonspecific and depend on the organ that is affected. patients with this syndrome usually have polyclonal gammopathy that can also be seen with aleutian's disease virus and lymphoma. definitive diagnosis requires cytology or biopsy of the affected organs. 23 aleutian's disease is a parvovirus that can cause lymphadenopathy and splenomegaly. as with lymphoma and granulomatous inflammatory syndrome, aleutian's disease can cause a polyclonal gammopathy. ferrets with this virus usually present with generalized signs of illness (lethargy, weight loss) as well as neurologic signs such as paresis or tremors. 24 aspirates and biopsy samples of lymph nodes and the spleen can be difficult to interpret as the disease causes lymphoplasmacytic inflammation that can be easily confused with other diseases such as small cell lymphoma and epizootic catarrhal enteritis. 24 in the one ferret with colonic lymphoma, there were minimal imaging findings including poor abdominal serosal detail and mild peritoneal effusion. at postmortem, lymphoma with mucosal erosions was detected in the colon. segmental lymphoplasmatic enteritis was identified in the small intestines. this ferret presented cachexic, hypotensive, anemic, had melena, and died within 24 h of presentation. given that melena is referable to upper gastrointestinal bleeding, the clinical findings in this ferret could have been attributable to both helicobacter mustelidae gastritis and lymphoma. it is also possible that lymphoma was present in other portions of the gastrointestinal tract, but was not detected postmortem. after the spleen, the next most common extranodal sites of neoplastic involvement with lymphoma in ferrets have been reported to be the liver, kidneys, and lungs. 5 in this study, two ferrets had confirmed hepatic infiltration-one of which had mild hepatomegaly on ultrasound (subjectively normal on radiographs) and the other of which had no reported hepatic abnormalities. hepatic lipidosis, identified in four ferrets, was not associated with radiographic or sonographic changes and may have been due to inappetence. 26 given these findings, ultrasound does not appear to be sensitive for the detection of hepatic lymphoma in ferrets. sensitivity of ultrasound for hepatic lymphoma has also been reported to be low in dogs, cats, and humans. 27, 28 one of two ferrets with renal masses had probable renal lymphoma based on the response to treatment. the second renal mass, a confirmed renal sarcoma, was not sonographically differentiable from the presumptive renal lymphoma. pulmonary involvement was not identified in this study. the small number of individuals in this study precludes extensive comparisons of the affected organ distribution to prior studies. the most common thoracic finding in this study was mild pleural effusion, which was present in four ferrets. there were no ferrets with a mediastinal mass in this study. mediastinal involvement, in general, is more prevalent in ferrets less than 3 years of age, and has been reported to be the more common presentation of lymphoma in that age group with or without concurrent multicentric involvement. [1] [2] [3] ferrets with mediastinal lymphoma may present for tachypnea or dyspnea secondary to the space-occupying effect of a large mediastinal mass, as well as concurrent pleural effusion. no ferrets in this study were less than 3 years old, which may have accounted for the lack of mediastinal involvement in this cohort. additionally, although this institution also provides primary care to nontraditional small mammal species, it is also a tertiary care facility and the population of ferret patients may not have been representative of the general domestic ferret population. there may have been a selection bias for ferrets with more insidious signs, which tend to occur in ferrets greater than 3 years of age, as opposed to younger ferrets, which may have a more acute and more rapidly progressive presentation. aggressive osseous lesions were present in three ferrets with skeletal lymphoma involvement. to the authors' knowledge, only three other ferrets with osseous involvement have been described previously. 2, 9 in those ferrets, lytic lesions were present in the tibia, in the lumbar spine, and in the lumbosacral spine. 2, 9 based on those ferrets and the ferrets in this study, it is possible that the lumbar spine is a predilection site for vertebral lymphoma; however, this remains speculative. an alternate possibility is that lysis may be relatively easier to detect in the lumbar spine where there is less superimposition of structures over the vertebrae, compared to the thoracic vertebrae where the ribs proximally are superimposed on the vertebrae. in humans with primary bone lymphoma, three radiographs patterns are described: the lytic-destructive pattern, which is predominantly lytic with or without a lamellated or interrupted periosteal reaction or cortical lysis; the blastic-sclerotic pattern in which there are mixed lytic and sclerotic regions; and "near-normal" findings in which there are only subtle radiographic changes and additional imaging (scintigraphic bone scans or mri) is required. 29 osseous lesions seen in the ferrets of this study and the prior reports are similar to the lytic-destructive pattern, and had cortical disruption. this is also the pattern most typically seen in canines and felines with osseous involvement from lymphoma or other round cell neoplasms. diffuse central nervous system infiltration with lymphoma was present in one ferret. as lymphoma outside of the central nervous system was only detected in accessory adrenal tissues, this ferret presumably had a primary central nervous system lymphoma. primary central nervous system lymphoma in dogs and cats has not been reported to have an extraparenchymal vs. an intraparenchymal predilection. 30 in humans, lesions with primary central nervous system lymphoma are most frequently intraparenchymal, and metastatic central nervous system lymphoma is more frequently extraparenchymal. 30, 31 in this ferret, the meninges and choroid plexus were involved in addition to the brain and spinal cord. protracted clinical signs in that ferret consisted of variable paraparesis and lumbar pain over 8 months from the start of clinical signs to the final diagnosis of lymphoma at necropsy. gradual progression of signs and the protracted clinical signs suggests a relatively slow-growing process. prednisone, administered for palliative treatment, was started approximately 3 months after the initial clinical signs. radiographs and ultrasound, performed prior to starting prednisone, had minimal, nonspecific findings. magnetic resonance imaging, performed 1 month after initiation of the prednisone regimen and 5 months prior to the diagnosis of lymphoma, was inconclusive. administration of prednisone prior to the mri may have resulted in partial regression of lymphoma, therefore making it more difficult to identify; however, the ferret did not demonstrate improvement of the clinical signs so whether prednisone affected detection of neoplastic infiltration or not is speculative. additionally the mri was limited in that only t2w images were obtained. perhaps if additional sequences were performed, particularly t1w postcontrast images, or if a follow-up mri was performed at a later date, meningeal or parenchymal abnormalities may have been detected. also because the necropsy was performed 5 months following mri, it is likely that the extent of the lesions seen postmortem had progressed com-pared to at the time of imaging. magnetic resonance imaging lesions in dogs and cats with primary central nervous system lymphoma (compared to white matter) have been reported to be predominantly t2w hyperintense with indistinct margins, t1w hypointense, contrast enhancing, had perilesional hyperintensity on flair consistent with perilesional edema, and had a mass effect. 30 in humans, lesions have similar signal characteristics (compared to white matter) being t2w hyperintense, t1w iso-to hypointense, and contrast enhancing. 30, 31 these findings are considered nonspecific in dogs, cats, and humans, and lesions may not be detected with mri at the onset of clinical signs. 30, 31 two ferrets had no clinical signs referable to lymphoma. in one ferret, the owner palpated a markedly enlarged abdominal lymph node. radiographic and sonographic findings consisted of multicentric lymphadenopathy, peritoneal effusion, a renal mass, a hyperechoic liver, and "incidental splenomegaly." in the other ferret, progressive lymphocytosis was detected during routine treatment and monitoring of adrenocortical disease. lymphoma was identified in the peritoneal effusion of that ferret. additional sonographic findings included a multicentric lymphadenopathy, splenomegaly with splenic nodules, a cystic hepatic mass, and a renal mass (sarcoma). adrenal disease was a common comorbidity seen with lymphoma, as found in other studies. 32 this is likely because adrenal disease is common in older ferrets in general. 1, 4, 33 other relatively common comorbidities found in this study were cardiovascular disease and cutaneous mast cell tumors, both of which also commonly occur in older ferrets. 1, 33 one ferret had a history of granulomatous lymphadenitis suspected to be secondary to mycobacteriosis. although this study describes the imaging findings in a small number of ferrets with lymphoma, it provides an important source of information for practicing clinicians. the small number of ferrets able to be included during the time frame of the study likely reflects that imaging is not performed in every ferret with suspected or confirmed lymphoma, and that a definitive diagnosis was not always attained prior to treatment in individuals with suggestive clinical and imaging findings. ultrasound-guided aspirates of lymph nodes, spleens, and aggressive osseous lesions performed in ferrets of this study were each diagnostic for or strongly suggestive of lymphoma. although aspirates are often the initial tissue sampling procedure, previous reports have cautioned the use of lymph node aspirates in the diagnosis of lymphoma as inflammatory and reactive changes may be misinterpreted as lymphoma. 1, 3 this is particularly true of the gastric lymph node in ferrets with gastrointestinal signs. a false positive diagnosis of lymphoma is considered not likely to have occurred in the ferrets included for in this study. lack of a definitive diagnosis (i.e., false negative results) from aspirate samples likely resulted in exclusion of some individuals from this study. analysis of the frequency of misdiagnosis and nonconfirmatory aspirate samples in patients with lymphoma was not performed. this study was also limited in that histopathology was not performed on all organs in each individual, and therefore, whether or not the changes seen were each attributable to lymphoma cannot be confirmed. additionally, because ultrasound findings were based on the reports and images obtained; some structures were unable to be reassessed. this is particularly the case in which multiple lymph nodes were affected. images of each lymph node may not have been attained, the imaging report may not have been complete in describing which nodes were affected, and measurement performed retrospectively on the available static images may not have reflected the actual maximal nodal thickness in that individual. in conclusion, findings from the current study indicated that imaging characteristics of lymphoma in ferrets are similar to those previously reported for dogs, cats, and humans. lymphoma may most commonly be multicentric in ferrets. imaging findings frequently included intra-abdominal lymphadenopathy, splenomegaly, and peritoneal effusion. lymphadenopathy and mass lesions were typically hypoechoic on ultrasound. osseous lesions, when present, were predominantly lytic. lack of imaging abnormalities did not preclude the diagnosis of lymphoma. ferrets, rabbits, and rodents. saint louis: w.b. saunders hematopoietic diseases ferret lymphoma: the old and the new neoplastic diseases in ferrets: 574 cases (1968-1997) clinical and pathologic findings in ferrets with lymphoma: 60 cases malignant lymphoma in ferrets: clinical and pathological findings in 19 cases ferrets: examination and standards of care diagnosis and treatment of myelo-osteolytic plasmablastic lymphoma of the femur in a domestic ferret t cell lymphoma in the lumbar spine of a domestic ferret (mustela putorius furo) t-cell lymphoma in a ferret (mustela putorius furo) malignant b-cell lymphoma with mott cell differentiation in a ferret (mustela putorius furo) cytomorphological and immunohistochemical features of lymphoma in ferrets anatomia ultrassonográfica dos linfonodos abdominais de furões europeus hígidos ultrasonography and fine needle aspirate cytology of the mesenteric lymph node in normal domestic ferrets (mustela putorius furo) bsava manual of canine and feline abdominal imaging. gloucester: british small animal veterinary association the peritoneal space characterization of normal and abnormal canine superficial lymph nodes using gray-scale b-mode, color flow mapping, power, and spectral doppler ultrasonography: a multivariate study observations upon the size of the spleen splenomegaly in the ferret. gainesville: eastern states veterinary association ferret coronavirus-associated diseases aleutian disease in the ferret mycobacterial infection in the ferret gastrointestinal diseases diagnostic accuracy of gray-scale ultrasonography for the detection of hepatic and splenic lymphoma in dogs ultrasongraphic findings in hepatic and splenic lymphosarcoma in dogs and cats primary bone lymphoma: radiographic-mr imaging correlation mri features of cns lymphoma in dogs and cats primary cns lymphoma in the spinal cord: clinical manifestations may precede mri delectability bienzle d. laboratory findings, histopathology, and immunophenotype of lymphoma in domestic ferrets the senior ferret (mustela putorius furo) key: cord-345445-9t1vebey authors: radmanesh, alireza; derman, anna; lui, yvonne w.; raz, eytan; loh, john p.; hagiwara, mari; borja, maria j.; zan, elcin; fatterpekar, girish m. title: covid-19–associated diffuse leukoencephalopathy and microhemorrhages date: 2020-05-21 journal: radiology doi: 10.1148/radiol.2020202040 sha: doc_id: 345445 cord_uid: 9t1vebey diffuse leukoencephalopathy and juxtacortical and/or callosal microhemorrhages were brain imaging features in critically ill patients with coronavirus disease 2019. coronavirus disease 2019 (covid-19) has been reported in association with a variety of brain imaging findings such as ischemic infarct, hemorrhage, and acute hemorrhagic necrotizing encephalopathy. herein, the authors report brain imaging features in 11 critically ill patients with covid-19 with persistently diminished mental status who underwent mri between april 5 and april 25, 2020. these imaging features include (a) confluent t2 hyperintensity and mild restricted diffusion in bilateral supratentorial deep and subcortical white matter (in 10 of 11 patients) and (b) multiple punctate microhemorrhages in juxtacortical and callosal white matter (in seven of 11 patients). the authors also discuss potential pathogeneses. © rsna, 2020 online supplemental material is available for this article. this retrospective study was compliant with the health insurance portability and accountability act and approved by the institutional review board. the requirement for informed consent was waived. critically ill patients with confirmed diagnoses of covid-19 by means of reverse-transcriptase polymerase chain reaction assay (cobas 6800; roche diagnostics, rotkreuz, switzerland) of a nasopharyngeal swab specimen, who underwent brain mri between april 5 and april 25, 2020, at new york university langone medical center campuses (manhattan and brooklyn) were included. mri examinations were performed according to a routine brain protocol (detailed protocol is available in appendix e1 [online]). two academic neuroradiologists (a.r. and a.d., with 6 and 9 years of experience, respectively) reviewed brain mri scans independently, with no disagreements. patients with abnormal white matter t2 hyperintensities (more than expected for agerelated microangiopathy on the basis of visual qualitative assessment) and/or microhemorrhages (4 mm in size) were included in the series. microhemorrhages confined to any areas of acute and/or subacute infarcts were excluded. diffusion characteristics of white matter were investigated and qualitatively graded as mild or severe on the basis of apparent diffusion coefficient maps. electronic health records were reviewed for all included patients. twenty-seven critically ill patients with covid-19 underwent brain mri between april 5 and april 25, 2020. of those 27 patients, 11 (mean age, 53 years; age range, 38-64 years; nine men, two women) were included in our series. four patients had only diffuse leukoencephalopathy, one patient had only microhemorrhages, and six patients had a combination of both. among the 16 excluded patients, mri findings were as follows: acute or subacute infarcts in 11 patients (including three with microhemorrhagic transformation), parenchymal hemorrhages larger than 4 mm in four patients (all .1 cm), and thalamic expansile t2 hyperintensity in one patient (presumed acute hemorrhagic necrotizing encephalopathy). all 11 patients in our series were on mechanical ventilation at the time of imaging (mean duration, 26.5 days), and the lowest blood oxygen saturation levels were 60%-85% (mean 6 standard deviation, 73% 6 8). the indication for brain imaging in all patients was persistently diminished mental status. the neurologic examinations showed preserved brainstem reflexes and diminished-toabsent grimace or response to noxious stimuli in extremities. no patient required extracorporeal membrane oxygenation. none of the patients had overt disseminated intravascular coagulation based on the international society on thrombosis and hemostasis diagnostic scoring system (4) . additional individual clinical and laboratory data can be found in appendix e1 (online). cerebrospinal fluid workup was available in only one patient (with both leukoencephalopathy and microhemorrhages) and was negative for infectious or inflammatory meningitis covid-19-associated diffuse leukoencephalopathy and microhemorrhages equally or more conspicuous compared with t2 hyperintensity (fig 2) . abnormalities extended from the precentral gyrus down to the centrum semiovale and corona radiata. at the level of the temporal and occipital horns, the posterior cerebral white matter in all patients was involved more than the anterior (fig 2, g-i) . the deep gray nuclei were spared. the juxtacortical white matter was also relatively spared ( fig 1, a) , with the exception of the precentral gyrus in all 10 patients (fig 2, a-c) and occipital lobes (fig 2, g-i) in seven patients. one patient received intravenous contrast material for mri, and there was no abnormal intracranial enhancement. the infratentorial parenchyma tended to be less affected; only four patients had mild involvement of middle cerebellar peduncles and medial cerebellar hemispheres (fig 3) . microhemorrhages were seen in seven of the 11 patients and varied in number from a few (five or six) to innumerable. microhemorrhages were predominantly punctate, and in all cases smaller than 3 mm. there was no concomitant larger intracranial hemorrhage. punctate microhemorrhages predominantly abbreviations covid-19 = coronavirus disease 2019, dphl = delayed posthypoxic leukoencephalopathy summary diffuse leukoencephalopathy and juxtacortical and/or callosal microhemorrhages were brain imaging features in critically ill patients with coronavirus disease 2019. or encephalitis and negative for coronavirus polymerase chain reaction assay. three patients were diagnosed with bacteremia and treated with antibiotics before mri (appendix e1 [online]). during the 3-5 weeks after brain mri, six of the 11 patients died (three had leukoencephalopathy, one had microhemorrhages, and two had both). the other five patients continue to receive critical care. the 10 patients with leukoencephalopathy had t2 hyperintensities that were symmetric and confluent, demonstrated mild restricted diffusion, and involved bilateral deep and subcortical white matter (fig 1) . the restricted diffusion in all cases was figure 1 : axial brain mri scans in two critically ill patients with coronavirus disease 2019 with persistently diminished mental status. a-c, images in a 56-year-old man. d-f, images in a 64-year-old man. a, d, diffusion-weighted images, b, e, apparent diffusion coefficient maps, and, c, f, fluid-attenuated inversion recovery images at the level of centrum semiovale demonstrate symmetric diffuse t2 hyperintensity (arrowheads) and mild restricted diffusion (thick arrows) involving the deep and subcortical white matter with relative sparing of juxtacortical white matter (thin arrows) in both patients. the restricted diffusion is more conspicuous than the t2 hyperintensity. workup for headache) and revealed that all microhemorrhages present on the current study were new (fig 5) . four of seven patients had undergone brain ct 3-7 days before mri. ct, even upon retrospective review, did not reveal punctate microhemorrhages. all seven patients with microhemorrhages were, at least temporarily, on closely monitored anticoagulation therapy involved the juxtacortical white matter (in five of seven patients) (fig 4, a) and/or corpus callosum, particularly the splenium (in four of seven patients) (fig 4, b) . only one patient with microhemorrhages had previous brain mri scans available for comparison. the scans had been obtained 7 days before the current hospital encounter (during with no supratherapeutic coagulation indexes, and no patient had concomitant intracranial hemorrhage larger than 4 mm or known bleeding in other organs. we report on two neuroimaging features observed in critically ill patients with covid-19: (a) diffuse leukoencephalopathy, with symmetric confluent white matter t2 hyperintensity and restricted diffusion with relative sparing of juxtacortical and infratentorial white matter, and (b) punctate microhemorrhages with predominant involvement of juxtacortical and callosal white matter. in a series of 11 critically ill patients with covid-19 who underwent brain mri for a persistently depressed mental status, four patients had only diffuse leukoencephalopathy, one patient had only punctate microhemorrhages, and six patients had a combination of both. physicians who manage patients with covid-19 should consider these findings during work-up for persistently diminished mental status. although initial reports of brain imaging findings in patients with covid-19 showed ischemic and hemorrhagic complications (2, 5) , there are now increasing reports of other findings such as patchy demyelinating lesions (6) and acute hemorrhagic necrotizing encephalopathy involving the thalami and medial temporal lobes (3). our report comprises 11 patients in a single 3-week period in april 2020, with all patients having been critically ill and on mechanical ventilation for a mean duration of 26.5 days. we believe the diffuse leukoencephalopathy and microhemorrhages described herein are late complications of critically ill patients with covid-19 and likely related to hypoxemia. previously, we reported brain imaging findings in 242 consecutive patients with covid-19 seen at week before the current hospital encounter, during work-up for headaches. b, image obtained after 23 days of mechanical ventilation in the hospital intensive care unit due to coronavirus disease 2019 show multiple juxtacortical punctate microhemorrhages in bilateral temporal and right occipital lobes (arrows) that were not on the previous mri scan. our institution in march 2020 (2) . none of those patients demonstrated these diffuse patterns of white matter involvement that we describe here. this suggests that these findings are not typical of earlier stages of covid-19. the diffuse white matter t2 hyperintensity and restricted diffusion reported herein may relate to delayed posthypoxic leukoencephalopathy (dphl), for which a similar pattern of involvement has been described in patients approximately 10-14 days after a hypoxic insult (7) . dphl was previously described in victims of carbon monoxide poisoning, drug overdose, and cardiopulmonary arrest (8, 9) and is believed to relate to oligodendroglial cell death and subsequent demyelination occurring preferentially in the deep interarterial boundary zones (10) . observed mild restricted diffusion can be related to acute demyelination. the predominant involvement of the deep white matter, sparing of juxtacortical white matter (except in precentral and occipital regions), and sparing of deep gray nuclei are typical of dphl and in contrast to acute hypoxic ischemic injury (11) . the leukoencephalopathy observed in our critically ill patients is, however, nonspecific and the exact cause is not clear. other potential causes of diffuse leukoencephalopathy in critically ill patients include direct cerebral infection (although this was not supported by negative viral cerebrospinal fluid assay in one patient), sepsis-associated encephalopathy (12, 13) , postinfectious demyelinating or hemorrhagic encephalitis, toxic and metabolic causes, and posterior reversible encephalopathy syndrome. white matter microhemorrhages with predominant distribution in juxtacortical white matter and corpus callosum are also nonspecific and similar to dphl, are thought to be related to hypoxia (7) . similar microhemorrhages have been reported in high-altitude exposure, possibly relating to hypoxemia and disruption of the blood-brain barrier (14) . multiple hemorrhages can alternatively be related to a small vessel vasculitis. although the imaging distribution is reminiscent of traumatic axonal injury, none of our patients presented with severe head trauma. of note, none of our patients fulfilled diagnostic criteria for disseminated intravascular coagulation (4) . limitations of the current report include small sample size, retrospective nature, lack of quantification of mri findings, and lack of histopathologic determination of underlying cause. clinical follow-up to determine longer-term outcome in these patients should be further investigated. in conclusion, herein we describe two neuroimaging findings, leukoencephalopathy and microhemorrhages, in critically ill patients with covid-19 that affect white matter diffusely in characteristic patterns. we believe that both findings are related to hypoxia but have different pathogeneses: demyelination versus disruption of blood-brain barrier. it is important to recognize these findings as potential late central nervous system complications of covid-19, particularly in patients with persistently diminished mental status. a.r. activities related to the present article: disclosed no relevant relationships. activities not related to the present article: has stock/stock options managed by a third party and unrelated to the content of this manuscript; received travel/accommodations/meeting expenses unrelated to activities listed from the american society of neuroradiology. other relationships: disclosed no relevant relationships. a.d. disclosed no relevant relationships. y.w.l. activities related to the present article: institution received a grant from the national institutes of health. activities not related to the present article: disclosed no relevant relationships. other relationships: disclosed no relevant relationships. e.r. activities related to the present article: disclosed no relevant relationships. activities not related to the present article: received payment for expert testimony from various law firms; receives royalties from springer; received travel/accommodations/meeting expenses unrelated to activities listed from microvention, stryker, and rapid medical. other relationships: disclosed no relevant relationships. j.p.l. disclosed no relevant relationships. m.h. activities related to the present article: disclosed no relevant relationships. activities not related to the present article: received payment for legal consultation without testimony by uc regents. other relationships: disclosed no relevant relationships. m.j.b. activities related to the present article: disclosed no relevant relationships. activities not related to the present article: is employed by nyu langone; received travel/accommodations/meeting expenses unrelated to activities listed from nyu langone. other relationships: disclosed no relevant relationships. e.z. disclosed no relevant relationships. g.m.f. disclosed no relevant relationships. neurologic manifestations of hospitalized patients with coronavirus disease brain imaging utilization and findings in covid-19: a single academic center experience 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severe lung failure resembles the one seen in high-altitude cerebral edema key: cord-258556-hglp1vpm authors: peña-solórzano, carlos a.; albrecht, david w.; bassed, richard b.; burke, michael d.; dimmock, matthew r. title: findings from machine learning in clinical medical imaging applications – lessons for translation to the forensic setting date: 2020-10-18 journal: forensic sci int doi: 10.1016/j.forsciint.2020.110538 sha: doc_id: 258556 cord_uid: hglp1vpm machine learning (ml) techniques are increasingly being used in clinical medical imaging to automate distinct processing tasks. in post-mortem forensic radiology, the use of these algorithms presents significant challenges due to variability in organ position, structural changes from decomposition, inconsistent body placement in the scanner, and the presence of foreign bodies. existing ml approaches in clinical imaging can likely be transferred to the forensic setting with careful consideration to account for the increased variability and temporal factors that affect the data used to train these algorithms. additional steps are required to deal with these issues, by incorporating the possible variability into the training data through data augmentation, or by using atlases as a pre-processing step to account for death-related factors. a key application of ml would be then to highlight anatomical and gross pathological features of interest, or present information to help optimally determine the cause of death. in this review, we highlight results and limitations of applications in clinical medical imaging that use ml to determine key implications for their application in the forensic setting. forensic radiology is not clinical radiology applied to a deceased person. in the forensic setting, findings that a clinical radiologist may not typically have encountered are commonplace [1] , e.g. post-mortem gas formation [2] . post-mortem computed tomography (pmct) is widely used in forensic investigations, where acquisition protocols used during clinical ct are not applicable due to rigor mortis and aversion to repositioning the decedent to avoid tampering with evidence. however, ct scans can be acquired with higher doses and there is no patient motion, therefore improving image quality. additionally, recent developments such as pmct angiography (pmcta) with specialized pumps allows the diagnosis of vascular lesions whilst maintaining the integrity of anatomic structures, thus preserving evidence integrity [3, 4] . in order to overcome the limitations of soft tissue contrast and a lack of vascular visualization provided by pmct [5] , postmortem magnetic resonance imaging (pmmri) is increasing in impact, albeit in a small way thus far. whilst pmmri offers improved soft tissue contrast, for vascular diagnoses it presents similar performance to pmcta, with higher associated cost. however, applications to cardiac imaging are an exception, due to improved visualization of the coronary arteries and myocardium [5] . image processing typically involves segmentation, feature extraction, and classification. image segmentation refers to the partitioning of a digital image into multiple segments that are sets of pixels (or voxels) which usually represent discrete structures. approaches to image segmentation prior to ml included probabilistic atlases [12, 13] , statistical shape models (ssms) [14, 15] , graph-cut (gc) algorithms [16, 17] , and multi-atlas segmentation (mas) [18] . feature extraction is a dimensionality reduction technique used to efficiently represent parts of an image as a compact feature vector. feature extraction was traditionally performed through determining properties such as first order textures (e.g. mean or entropy) or correlations [19, 20] . image classification is the process of taking an image or volume and predicting whether it belongs to a list of predefined classes. traditional approaches to classification included linear-and normal-discriminant analysis [21, 22] . a variety of ml alternatives to each of these image processing tasks have now been proposed and pipelines that can automate many diagnostic and prognostic tasks have been introduced to reduce the burden on radiologists [23, 24] . ml techniques can be categorized as supervised learning, unsupervised learning, and reinforcement learning. in supervised environments, data is composed of input-output patterns, and the task is to find a deterministic function that can predict the output from an observed input. unsupervised techniques are a type of self-organized learning that extracts structures from the training samples directly, without pre-existing labels [25] . more recently, self-supervised techniques, a type of unsupervised learning where the training data is automatically labelled by exploiting the relations between different input signals, are being studied for better utilizing unlabeled data [26] . reinforcement learning on the other hand is based on trial-and-error, where the algorithm evaluates a current situation, takes an action, and receives feedback from the environment; this feedback can be positive or negative [27] . the most common ml techniques used in medical applications are summarized below. rfs operate by creating a multitude of decision trees (fig. 1 ) that can be trained for classification and regression tasks [28, 29] , where the output is obtained by majority vote. majority vote is a technique utilized to combine the outputs from multiple classifiers, with the voting rule following one of three forms: (i) unanimous voting, where all the individual votes must agree in one output class, (ii) simple majority, where the class with one more than 50% of votes is selected, and (iii) plurality or majority voting, where the class with the highest number of votes is chosen [30] . in k-nn, the training samples are divided into classes, and the prediction of a new sample or test point is classified by a majority vote of its neighbors (fig. 2) . the algorithm uses a distance measurement function to search the (defined by the user) closest training samples in the feature space, and assigns the case of the class that is the most common in the subset. artificial neural networks (anns) anns are inspired by the biological nervous system. anns contain a large number of highly interconnected nodes (called neurons) separated into layers (fig. 4) , enabling the network to process different pieces of information while considering constraints to coordinate internal processing, and to optimize its final output [25, 33] . cnns were inspired by the connectivity pattern of the animal visual cortex. neurons respond to stimuli only in a restricted region (receptive field) of the previous layer, where receptive fields of different neurons partially overlap until they cover the entire visual field (fig. 5 ). unlike other ml techniques, the network learns the filters that are usually "hand crafted". also, cnns exploit the strong spatially local correlation found on images, allowing the features to be detected regardless of their position. in recent years, deep neural networks (dnns), which differ from anns by their depth (the number of neuron layers), have proven to be successful in solving diverse problems, mainly for their capacity to learn features from large datasets [34] . it should be noted that in the following discussion, algorithmic performance is assessed in terms of dice's coefficient (dc), the modified hausdorff distance (mhd) and the area under the receiver operating characteristic curve (auc or auroc), where possible. the quantification usually starts with calculation of true positives (tps), true negatives (tns), false positives (fps), and false negatives (fns). tp refers to cases correctly classified as pertaining to the class, opposite to fp, when the case is wrongly classified. inversely, tn and fn refer to a case correctly and incorrectly classified as not belonging to the class, respectively. the dc quantifies overlap between the processed image from the technique with a defined ground truth, ranging from zero (no overlap) to unity (identical segmentation). mhd is a measure of similarity between two objects based on their shape attributes. auc combines information of the true positive rate or sensitivity, and false positive rate or fall-out. sensitivity measures the proportion of actual positives that are correctly identified, while fall-out indicates the proportion of cases wrongly classified as positives. inversely, the specificity measures the proportion of negatives that are correctly identified. recall is the ratio of tps to the sum of tps and fns, indicating the proportion of actual positives that are correctly identified. precision is defined as the ratio of tps to the sum of tps and fps, indicating the proportion of identified positives that are correct [35] . in terms of the currently reported use of ml in forensic post-mortem imaging, it is in its infancy. ml has only been trialed in a few specific forensic applications including automatic forensic dental identification [36] ; sex determination [37, 38, 39] ; the automation of bone age assessment [40, 41] ; prediction of bone fractures [42] ; and the automatic detection of hemorrhagic pericardial effusion [43] . as far as we are aware, none of these studies has translated into daily forensic practice, despite the potential to streamline case-work. the legally robust identification of a decedent is the first objective when their body is triaged for a postmortem. dental analysis and comparison of ante-mortem and post-mortem information is one of the recognized tools for determining a decedent's identity. this traditionally requires an odontologist to find the best match to an ante-mortem database, using features such as dental restorations, pathologies, and tooth and bone morphologies. zhang et al. [36] proposed a new descriptor that encodes the local shape of a person's dental features. they subsequently used an rf classifier to match the features of the unknown person to those in the database (n=200). the result yielded 100% accuracy for complete (n=20) and incomplete (n=20) feature datasets. incomplete datasets were derived from cases involving trauma. the method presented was shown to be rotationally and translationally invariant, and was orders of magnitude faster than conventional 2d methods. it is important to note that the database was constructed using a surface laser scanner on plaster samples in contrast to pmct scans. accurate determination of the sex of a decedent also aides in the identification process. several different approaches have been used for sex estimation. arigbabu et al. [37] utilized 100 head pmct scans. they combined and evaluated six local feature representations, two feature learning, and three classification algorithms. this technique of combining multiple features and classifiers is often used in ml pipelines as it has been shown to improve accuracy and reliability. the best prediction rate was 86%, which was within the reported sex prediction range for applications that use cranial features. the small number of cases obtained only from south east asia limited the generalizability of the results. anderson et al. [38] utilized morphological gray matter differences on mris to differentiate between male and female incarcerated offenders, with implications to cognitive neuroscience research. preprocessing steps were described, including realignment and image registration, to obtain the volume and density of the gray matter on each case utilizing statistical parametric mapping software (spm12; http://www.fil.ion.ucl.ac.uk/spm). source-based morphometry (sbm) was utilized to extract features from the gray matter spatial information, with sbm being able to identify distinct regions with common covariation between subjects. a number of ml classification approaches were trialed, however, only an svm and logistic regression were described due to present the highest classification accuracy of 94%. limitations included the use of volumetric brain data only, without accounting for other moderating variables and quantitative methods, such as age, functional activity, and structural and functional connectivity. ortiz et al. [39] compared five different ml techniques in the assessment of panoramic radiographs. the ann outperformed the rest of the models, including k-nns and logistic regression, with an accuracy of 89%. only 100 panoramic radiographs were used, limiting the statistical significance of the results. as with the identification of a decedent's sex, their estimated age is also an important parameter for streamlining the identification process. štern, payer and urschler [40] compared two ml approaches, rfs and dcnns to determine age (through regression) and distinguish minors from adults (classification) using bone ossification from mri scans of the hand/wrist. as a general note, dcnns are often compared with rfs as the dcnn can determine the most important features itself whereas the rf must be supplied with those deemed important by the user. to better study the impact of different input information on the decision process, three strategies were tested: the use of the whole hand, a cropped image with age relevant bones, or the hand-crafted filter-based enhanced epiphyseal gap. the best mean absolute error and standard deviation results with respect to the biological age (as estimated by radiologists) were 0.20±0.42 and 0.23±0.45 years for the dcnn using cropped structures and the rfs using enhanced images, respectively. the results were reported to achieve the new state-of-the-art accuracy compared with previous mri-based methods and their earlier work. furthermore, when the technique was adapted for 2d mri, the method was in line with state-of-the-art methods using x-ray data. limitations of this work included the requirement for age-relevant anatomical information, which implies a labor-intensive pre-processing step, and decreased accuracy for cases with biological ages greater than 18 years. in an alternative approach, li et al. [41] utilized pelvic x-ray images and a dcnn to create a bone age assessment pipeline which yielded a mean error of 0.94 years, 0.36 years better than the existing reference standard. this work used transfer learning from a cnn pre-trained on the imagenet database [44] , achieving an appropriate accuracy for this type of input data. transfer learning is widely used in ml applications and is particularly useful when small or unbalanced datasets are available. limitations acknowledged by the authors included the lack of diversity in ethnicity of patients, and the exclusion of images with artefacts and diseases. many forensic institutions utilize pmct to guide the pathologist in their approach to the autopsy. pmct is particularly useful for identifying fractures due to the high attenuation of bone. heimer et al. [42] used an undisclosed dcnn from a dedicated software (vidi, cognex, natick, ma, usa) to predict the presence of skull fractures using 150 head pmct scans (75 scans for each case: with and without fractures). the skulls were preprocessed through the generation of curved maximum intensity projections, so that the skull's surface could be unfolded onto a single image. deep learning was applied and the best-performing selected network yielded an auroc of 0.965, a sensitivity of 91.4% and a specificity of 87.5%. an auroc of 0.5 defines a model that classifies at random, while 1.0 is a completely accurate model. pmct is also useful for assessing many aspects of cardiac condition prior to autopsy, e.g. the appearance of discontinuities of the aortic wall can be a direct sign of injury in the aorta, whereas the appearance of a blood collection within the chest cavity (hemothorax or hemopericardium) can be an indirect sign [45, 46] . these signs, observed on plain film x-ray or pmct must be interpreted by radiologists and forensic pathologists. ebert et al. [43] used two separated and undisclosed dcnns from a dedicated software (vidi) for the classification of images with or without hemopericardium and also the corresponding segmentation of the blood content in pmct. the average dc, recall, and precision for the classification task were 77%, 77%, and 85% respectively. for segmentation, the values obtained were 78%, 78%, and 79%, respectively. limitations of this study include the small number of training cases (n=14 cases with hemopericardium), while the use of a dedicated software restricted the training data to individual slices, losing sometimes crucial volumetric information. due to the dearth of information relating to the application of ml to forensic imaging, it is important to review the state-of-the-art and establish lessons learned from the significant body of literature describing its application to clinical image analysis. current clinical applications ml techniques have been used in the diagnosis and prognosis of diseases, as well as for segmentation, classification, and measurement of anatomical structures [24, 47] . in this review, the ml applications have been grouped according to the tissue or organ studied, where brain, lungs, and skeleton were chosen to highlight results and limitations. each anatomical section concludes with a summary evaluating the key implications determined from the clinical literature and their application in the forensic setting. traditional atlas-based segmentations require registration to align the atlas images to the unseen image. whereas, ml approaches can learn the variability between patients, making them especially useful in forensics, where variance is greater than for clinical imaging. ml can also be used in combination with atlas-based approaches or in its own right. as an example of the former, srhoj-egekher et al. [48] used atlas-based segmentation for pre-processing t2-weighted mri neonatal brain images to obtain initial probabilities, subsequently refined using a k-nn approach. whilst this approach achieved dcs and mhds ranging from 77% to 93%, and 0.35 to 2.86 respectively, the assignment of a tissue classification to each voxel independently, post atlas registration, meant some voxels were attributed to more than one class, while background voxels were unclassified. conversely, zhang et al. [49] opted for purely ml approaches that analyzed image patches for segmentation into white matter (wm), gray matter (gm), and cerebrospinal fluid (csf) of infant brains (n=10). four network architectures were tested and, in most cases, the cnn method significantly outperformed svms and rfs with overall dc scores and mhds of 85% and 0.32, respectively. the cnn method also outperformed two other common image segmentation methods: coupled level sets (cls) and majority voting (mv). three further publications were found where the authors segmented similar structures within adult brains. van opbroek et al. [50] applied an svm for pixel-wise classification to registered volumes from a variety of mri sequences for patients with diabetes and controls. the resulting segmentation of eight different tissue types demonstrated limited success ( table 1) . the svm showed poor performance in low contrast areas, while atlas misregistration caused voxels to be improperly classified. moeskops et al. [51] used cnns to process t1-weighted scans to segment the same eight tissue types. with cnns, the use of different sized patches during training allowed for a smooth segmentation and analysis of local texture. in general, cnns delivered better segmentation (table 1) , although this was a different patient cohort. a more recent application of 3d dcnns [52] was used to identify 25 brain structures in t1-weighted mri scans (n=30). again, image patches were utilized as input to the network. however, spectral and cartesian coordinate information relating to the patches was added after the convolutional layers (e.g. see arrow in fig. 6 ) in order to introduce spatial information, which substantially increased the segmentation accuracy. ml can also be used for the assisted diagnosis of neurodegenerative diseases. salvatore et al. [53] used a combination of principal component analysis (pca) with an svm to classify morphological mri sequences as patients with parkinson's disease (n=28), progressive supranuclear palsy (psp) (n=28), or controls (n=28). the large cohort sizes, inter-class cohort balance, and separation between psp patients and other parkinsonian variants were identified as particular strengths, compared to other papers. the performance (accuracy, specificity and sensitivity were all > 80%) of the model was shown to be limited by the number of principal components (16 to 26) utilized for classification. this dependence is an important consideration when using dimensionality reduction techniques and was also demonstrated for approaches that classified alzheimer's disease [54] . finally, ml techniques have also been used to segment and classify brain tumors. zacharaki et al. [55] used conventional and perfusion mri from patients with a diagnosis of intra-cranial neoplasm to classify them by type and grade of tumor (n=98). their approach consisted of region of interest (roi) definition, feature extraction, feature selection, and classification by svms. for comparison, linear discrimination analysis (lda) and k-nn were also implemented. the mean classification accuracy was 91% for the svm approach, compared with 81% for lda and 90% for k-nn. some of the limitations were related to the lack of features selected that described deformation of healthy structures due to the tumor, and the utilization of rois which yielded inter-observer variability. once the presence of tumors is verified, one possible subsequent step would be segmentation of the pathology, which is challenging even for experienced neuroradiologists [56] . to address this segmentation problem, a variant of cnns named u-net is often employed [57] . beers et al. [58] utilized two 3d u-nets connected sequentially to perform whole tumor, enhancing tumor, and tumor core segmentation, achieving mean dcs for the test set (n=95) of 84%, 70%, and 71%, respectively. when the methodology was implemented on patients from ongoing clinical trials, the mean dcs decreased to 66%, 54%, and 45%, respectively. the lower performances on the clinical trial patients were attributed to scans being post-operative, highlighting the importance of case selection for training. studies on brain tissues used mostly mri data due to the multi-modality information and a good softtissue contrast. whilst the specific pathologies discussed are not all relevant to the forensic setting, the general conclusions deduced from the segmentation and localization of anatomical abnormalities are. models that utilized dimensionality reduction techniques prior to classification were shown to yield performances dependent on the number of selected components. in addition, the identification of abnormalities in biological tissues required features capable of describing complicated deformations of the healthy structures. for cnns, the performance of the pipeline depended significantly on the training set adequately representing expected cases. in general, cnns outperformed algorithms such as svms, rfs, clss, and mv in segmentation and classification tasks. note that some studies used small datasets, which limited statistical power. in addition, as will be demonstrated throughout this review, a combination of the variability in reporting of metrics, the lack of reporting of a diagnostic odds ratio [59] , the unavailability of datasets and reference implementations, and the effect of imbalanced data in the classification accuracy, common in medical datasets [60, 61] , made it difficult to compare papers quantitatively. in forensics, pmct does not provide good resolution of internal cranial structures or brain metastases, and in general, the resolution is not sufficient to identify neurodegenerative issues, but degeneration can sometimes be observed in defined structures, e.g. in the caudate nucleus in huntington's disease. on the other hand, pmct is adequate in showing evolving brain infarcts and in displaying collections of blood, e.g. subdural hemorrhages (which are reasonably common). pmct can also show intraparenchymal hemorrhages and parenchymal hemorrhagic contusions. intra-parenchymal hemorrhages, e.g. hypertensive hemorrhage, classically involve distinct areas in the brain: basal ganglia, thalamus, pons, and cerebellar hemispheres. parenchymal hemorrhagic contusions are classically seen with contra-coup basal frontal lobe contusions (bleed within brain tissue occurring on the opposite side of the head to the primary injury site) when someone falls onto the back of their head (often associated with a skull fractureoccipital). in ml, feature learning refers to the automatic discovery of meaningful representations from raw data, in contrast to manual feature engineering, where the features have to be chosen by a domain expert. feature learning allows for end-to-end learning, where a complex system can be represented by a single model, bypassing the intermediate layers present in traditional workflow designs. learning a representation of any tissue is a useful process if subsequent classification is required, or if the goal is to find differences between samples in the training data. the representation quality is highly dependent on the learned features. a restricted boltzmann machine (rbm) is a generative neural network that can be used to perform automatic feature learning. li et al. [62] used a gaussian rbm with a training dataset consisting of different sized patches obtained from high-resolution lung ct images (n=92), with the purpose of classifying five tissue types using svms. the best accuracy obtained was 84%, with a high rate of fps caused by the similarity between tissues. van tulder and de bruijne [63] utilized convolutional rbms, adding learning objectives that helped the algorithm to extract features for description and training data classification. the training data consisted of ct scans (n=73) with five types of tissues classified. resulting accuracies were <75% and 85-90% for the classification of lung patches and airway centerlines, respectively. the low accuracies were attributed to small training sets and number of extracted filters due to computational restrictions. netto et al. [64] utilized examinations (n=50) with 198 identified nodules and an svm to classify the structure as nodule or non-nodule. the resulting accuracy was 91%, with a sensitivity of 86%. the largest errors were reported when the feature was very large or very small, where it could be mistaken for other structures or for being the continuation of one. hua et al. [65] used images containing nodules from the lung image database consortium (lidc) ct dataset to train both a cnn and a deep belief network (dbn) constructed by stacking rbms. the performance of the two networks was then compared with two feature-based methods ( table 2 ). the major limitation reported was resizing of the input images, which discarded size cues that were important indicators of malignancy. kumar et al. [66] also classified the lung nodules in the lidc images (table 2) using an autoencoder (ae) and a binary decision tree classifier (bdt). an ae is an unsupervised deep learning technique utilized for feature extraction, while a binary decision tree is a specialized implementation for classification where every node has only two branches. the false positive rate of 39% was attributed to the visual similarity between benign and malignant cases, which can be compared to a 27% rate obtained on the national lung screening trial (nlst) using low-dose ct (ldct) [67] . a more recent study compared massive-training artificial neural networks (mtanns) against cnns [68] using a database of ldct scans (n=38), consisting of 1057 slices. mtanns are an extension of anns, where a large number of overlapping sub-regions are created for each voxel of the original image and used as inputs to the network. the reported auroc was 0.88 for the mtann, and 0.78 for the best of the four cnn architectures. the mtann required a smaller number of training samples than the cnns for a better classification performance. this was attributed to the hierarchies of the learned features, where the mtann learned to detect lesions utilizing low-level features, while the cnns extracted low-, mid-and high-level features, increasing their reliance on irrelevant characteristics. a recent focus of attention was related to the use of ml for early diagnosis, assessment of severity, and differentiation between the novel coronavirus (covid-19) and community acquired pneumonia (cap) from ct scans. barstugan et al. [69] utilized n=150 ct abdominal images from 53 infected patients, five feature extraction methods, and an svm for the final classification, achieving a maximum accuracy of 99.7%. the main limitation of their work was the manual selection of the patches obtained from the original images and used for the training, which restricts the usability and reproducibility of this approach. tang et al. [70] assessed the severity (severe, non-severe) of the disease from chest ct images from 176 patients, utilizing quantitative measures, e.g. the ratio between the volume of the whole lung and the volume of ground-glass opaque regions, with several rf models. the best performing rf yielded results of 93%, 75%, 88%, and 91% for the sensitivity, specificity, accuracy, and auc, respectively. to differentiate between covid-19, cap, or non-pneumonia, li et al. [71] collected 4356 chest ct exams from 3322 patients. a dcnn was utilized, with an architecture denoted covnet, able to classify the volumetric data with a sensitivity, specificity, and auc of 90%, 96%, and 96% for covid-19 cases, 87%, 92%, and 95% for cap cases, and 94%, 96%, and 98% for non-pneumonia cases, respectively. a limitation of this work included the lack of laboratory confirmation for each case, where covid-19 could have similar imaging characteristics as other viral pneumonias. studies on lungs generally used ct scans for the segmentation of tissues and tumors, and classification of nodules for early cancer diagnosis. due to the low contrast between different tissues in the lungs, the approaches reported were reliant on shape, texture, and feature size. the segmentation performance was poor for nodules at the size extremes. major findings included lower performances due to image resizing, and the importance of reporting fp rates, which can yield high values in applications that intend to determine nodule malignancy. potential applications to the forensic setting include detection of emphysema, consolidation of lung parenchyma (pneumonia), and if appropriate windows are used, interstitial changes. of crucial forensic interest is the presence of blood and fluid in the chest. furthermore, establishing the presence of a lung lesion (and especially more than one) independently of the cause of death may indicate the presence of occult malignancy. in such cases, the deceased's next of kin can be alerted, and the family contact nurses can organize appropriate follow up for family members if a cancer is found. it is important to note that the appearance of the lungs in pmcts can be affected by aspiration of gastric content that may occur in the process of dying, e.g. from a 'heart attack'. skeleton skeletal segmentation usually occurs before measurement and/or diagnosis of bone or articular diseases. koch et al. [72] segmented mris (n=110) of the wrist using marginal space learning (msl) and rfs, where msl incrementally learned classifiers in marginal spaces of lower dimensions [73] . the segmented images were used to compute the 3d model of every carpal bone, with aucs of 0.88 for both scan modalities. the approach was an order of magnitude faster than previous work using a semiautomatic method. similar literature did not report segmentation errors and could not be used for comparison. bone age assessment from plain x-rays is used in pediatrics by comparing the results to chronological age for the evaluation of endocrine and metabolic disorders. a fully automated pipeline was presented by lee et al. [74] using a pre-trained cnn (transfer learning). both male and female test x-rays were assigned a bone age within 1 year of the correct value over 90% of the time, and over 98% within 2 years. x-rays have also been widely used for fracture detection, e.g. of the tibia [75] , where texture and shape features were fed into three different ml algorithms: an ann, k-nn, and svm, and the outputs fused using a majority vote scheme. the combination of the classifiers using both types of features presented a significant improvement over using just one classifier, or only one feature type. reported accuracies, precisions, and sensitivities were above 97%. instead of fusing the results from the classifiers, multistage classifiers have also been used. wels et al. [76] reported a fully automatic system using several rf stages, capable of detecting osteolytic spinal bone lesions from ct volumes, with an average sensitivity of 75%. the performance was affected by differences in contrast and noise characteristics in the data used for training and testing, however, values for accuracy were not presented for further interrogation. sharma et al. [77] measured trabecular bone microarchitecture and used the information to discriminate between healthy cases (n=10) and patients with type 1 gaucher disease (n=20). svms were used to classify different genotypes of the disease, achieving an average 70% classification accuracy, 74% sensitivity, and 85% precision. the structure of the trabecular bone obtained from mri have also been used classify knees with osteoarthritis [78] . the characteristics found to relate to the disease were useful in classifying healthy from affected patients (n=159) with an auc of 0.92, as well as predicting the risk of cartilage loss. in a similar study, the fractal analysis of x-ray images with svms enabled the automatic classification of osteoporotic patients (n=39) versus controls (n=38) with accuracies of up to 95% [79] . reported limitations from the papers in this section include the small number of cases and the high percentages of patients at early stages of the disease. orthopedic ml applications include disease diagnosis, age assessment, and risk prediction e.g. osteoporosis, osteoarthritis. plain film x-ray and ct were most common; however, mri studies of joints are being increasingly reported. the performance of ml applications was shown to be affected by the number and selected features, which is significantly influenced by differences in contrast and noise characteristics in the datasets. comparison or ranking of the results was limited by reported performance metrics and the use of databases that were not representative of the disease stages studied. other limitations included small patient cohorts and the processing times. the most common skeletal disorders that could be picked up on pmct scans are osteoporosis and paget's disease, while fracture diagnosis, and then pattern of fracture diagnosis, e.g. a "hangman's fracture", extension/tear-drop fractures of the cervical spine, and spiral fracture of a long bone in an infant are of significant forensic interest. j o u r n a l p r e -p r o o f discussion typical goals of ml techniques in medical imaging include the differentiation of healthy from diseased patients or tissues and the localization of pathologies in anatomic structures. algorithmic performance can be significantly affected when trying to process a new sample that differs significantly from the training dataset. this characteristic is especially important when it comes to applications in forensic medicine, where there is a high variability in the structures and image acquisition protocols, and unclear definition of what normal implies, due to changes occurring because of circumstances of death, tissue decomposition, trauma, or incineration. however, some applications e.g. organ localization, can be immediately translated to the forensic setting by using the appropriate training data, or by using the clinical medical images for the initial training of cnns and then fine-tuning using forensic information. this is usually referred to as transfer learning. on the other hand, due to the size and availability of forensic databases, the opposite is also possible, with applications being trained in forensic data and then fine-tuned to the clinical setting. to improve the capabilities of ml techniques, the training data can be modified, or more informative features can be used as inputs to the algorithms. the selection of features can be optimized using learning objectives [63] or by utilizing an unsupervised technique as a preprocessing step to the classification task [66, 80] . the features selected can also be used to alleviate human labelling, by selecting more representative training data for the medical expert [81, 82] . another approach to the improvement of ml performance is the combination of several techniques using a majority vote scheme [75] , or the use of multi-stage classifiers [58] for segmentation of different spatially related tissues. a wide range of implemented algorithms were found during the review process, where svms outperformed techniques such as lda and k-nn [55] , however the trend in recent works has been the high performance of cnns [49, 51] . the main disadvantage of classic ml approaches compared to cnns is the performance variability due to the quality of the features [53] that must be hand-crafted by an expert according to the goal and dataset. the selected feature pool is commonly processed to lower its dimensionality before training the classifier by using techniques such as pca. it is important to note that the number of principal components or features selected at the end of this step plays a key role in the classification performance [53] . the performance of the algorithms can also be significantly affected if the labelling process (diagnosis) is prone to error [54] . furthermore, for medical and forensic applications, the common practice of resizing input images can yield to a loss of information that could be essential for diagnostic purposes [65] . an additional consideration is that some authors use for example a radiologist to classify cases, then benchmark the performance of the algorithm against radiologists. rajpurkar et al. [83] , for instance, presented a cnn that achieved radiologist-level pneumonia detection on a database [84] for which no gold-standard label existed, and listed as limitation the lack of information in the database that affects the radiologists' accuracy. it is also important to note that the lack of reporting of a diagnostic odds ratio [59] and the variability in reporting of metrics makes it difficult to compare papers. for the task of segmentation, both multi-atlas algorithms and dcnns with multiple patch sizes showed comparable results [48, 49] , demonstrating cnns were most successful. patch-based techniques could be a good approach in forensic cases were organs or structures are not localized in the usual anatomic positions [63] . furthermore, the use of different sized patches in segmentation tasks allows for both a smoother separation and the detailed analysis of local texture [51] . three important results for the use of ml in clinically-related applications were found that can also be applied in the forensic setting: firstly, temporal efficiency through the use of transfer learning; secondly, improved accuracy through the combination of ml classifiers using majority voting techniques or multi-stage approaches; and finally, the addition of an active learning phase, where the human labor can be alleviated during labeling. one of the main issues that affects both the clinical and forensic settings is the lack of interpretability of predictions by black-box approaches such as neural networks. this is active area of current research and a current approach to addressing this concern is the use of visual explanations for the class label under consideration, obtained from the convolutional layer feature maps [85, 86] , and attention mechanisms [87] , able to determine the parts of the input images more relevant for a particular classification. furthermore, depending on the application, it is not required and could be counterproductive to completely automate a task, for which a human-in-the-loop can be beneficial by reducing the complexity through human input and assistance [82] . some applications of ml already found in clinical medicine, that could be repurposed for forensic medicine, include segmentation and classification of organs and structures, including arteries, tiny blood vessels, the liver, spleen, stomach, gallbladder, and pancreas [88, 89] ; computation of organ 3d models [72] for virtual autopsies; detection of lesions and calcification on vascular cross-sections [90]; identification of bone and joint atrophies or disorders [81, 77, 78, 79] ; fluid volume and composition on body cavities (blood, pus, ascites) [91] ; and organ volume estimation, e.g. heart size with respect to body size [92] . tasks in forensic radiology that to our knowledge have not been tackled using ml include: segmentation and classification of foreign bodies, differentiation between ante-mortem and postmortem gases, calculation of body mass index, and determination of skeletal completeness after accidents. for the segmentation and classification of foreign bodies, e.g. bullets, metallic dental fillings, the main challenge becomes finding the object that does not belong inside the body. furthermore, metallic components can create artefacts such as beam-hardening on ct scans or field distortions in mri [93] , which can also be addressed using deep learning [94] . differentiation between ante-mortem and post-mortem gases can be difficult using the voxel values of ct scans or mri, so emphasis should be placed on understanding the expected location and evolution of these gases at different points in time [95] ; also, differentiation between acute and remote infarction on the brain, which on a ct scan can be characterized by voxel values and tissue volume changes, can be tackled utilizing existing tissue classification techniques [50, 51, 54] , with the addition of new classes to differentiate the types of infarction. in forensic anthropology, tasks that could be addressed using ml include: determination of skeletal completeness after accidents [96] , e.g. plane crashes; 3d reconstruction of incomplete bones, that could be extrapolated from the work by hermoza and sipiran [97] on incomplete archaeological objects; and 3d reconstruction of fractured skulls [98, 99, 100] , used to infer a cause of death, or to perform facial reconstruction. in addition to the aforementioned applications traditionally related to medical imaging, there is the potential for the use of ct scans for facial identification [101, 102] . as a final note, the release this year of the new mexico decedent image database (nmdid, https://nmdid.unm.edu/) [103] should be acknowledged as a significant step forward for the development of tools that can be used to enhance the post-mortem workflow. j o u r n a l p r e -p r o o f conclusions ml techniques have been applied to a large number of tasks that can be used in clinical medicine, where the algorithms most widely utilized in applications with medical images include rfs, svms, and cnns. cnns have shown better performance in the literature. techniques to improve the ml performance in radiology include data augmentation, improved feature selection and algorithmic combination, e.g. majority voting. performance was shown to be affected by resizing of the input images and the accuracy of the labels provided with the training data. in addition, benchmarking was found to be difficult due to the lack of gold-standard labels, as well as the variability in reporting of metrics, and lack of reporting of a diagnostic odds ratio. ml applications investigated for clinical medicine could be repurposed to the forensic domain with careful consideration to account for the increased variability and temporal factors, e.g. decomposition, that affect the data used to train the ml techniques. due to the complexity of the autopsy process, a key application of ml to forensic radiology would be to streamline decedent identification and highlight and annotate areas of forensic interest. ml pipelines could be used to present information to optimally determine the cause of death, including differentiation between body cavity fluid accumulations (blood, pus, ascites) and their corresponding volumes, calculation of organ volumes and weights, percentage of coronary artery calcification, identification of subtle fractures especially in critical areas such as the cervical spine, and determination of skeletal completeness and skeletal commingling after mass fatality incidents. the artefacts of death: ct post-mortem findings imaging and virtual autopsy: looking back and forward postmortem ct angiography: capabilities and limitations in traumatic and natural causes of death post-mortem computed tomography angiography: past, present and future future prospects of forensic imaging niftynet: a deep-learning platform for medical imaging advanced machine learning in action: identification of 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modeling using heat kernels virtual reconstruction of paranasal sinuses from ct data: a feasibility study for forensic application case study: 3d application of the anatomical method of forensic facial reconstruction development of three-dimensional facial approximation system using head ct scans of japanese living individuals standardizing data from the dead this research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. j o u r n a l p r e -p r o o f key: cord-328513-81yvcgul authors: bellastella, giuseppe; maiorino, maria ida; bizzarro, antonio; giugliano, dario; esposito, katherine; bellastella, antonio; de bellis, annamaria title: revisitation of autoimmune hypophysitis: knowledge and uncertainties on pathophysiological and clinical aspects date: 2016-08-08 journal: pituitary doi: 10.1007/s11102-016-0736-z sha: doc_id: 328513 cord_uid: 81yvcgul purpose: this publication reviews the accepted knowledges and the findings still discussed on several features of autoimmune hypophysitis, including the most recently described forms, such as igg4 and cancer immunotherapyrelated hypophysitis. methods: the most characteristic findings and the pending controversies were derived from a literature review and previous personal experiences. a single paragraph focused on some atypical examples of the disease presenting under confounding pretences. results: headache, visual field alterations and impaired pituitary secretion are the most frequent clinical findings of the disease. pituitary biopsy, still considered the gold diagnostic standard, does not always receive consent from the patients. the role of magnetic resonance imaging is limited, as this disease may generate images similar to those of other diseases. the role of antipituitary and antihypothalamus antibodies is still discussed owing to methodological difficulties and also because the findings on the true pituitary antigen(s) are still debated. however, the low sensitivity and specificity of immunofluorescence, one of the more widely employed methods to detect these antibodies, may be improved, considering a predetermined cut-off titre and a particular kind of immunostaining. conclusion: autoimmune hypophysitis is a multifaceted disease, which may certainly be diagnosed by pituitary biopsy. however, the possible different clinical, laboratory and imaging features must be considered by the physician to avoid a misdiagnosis when examining a possibly affected patient. therapeutic choice has to be made taking into account the clinical conditions and the degree of hypothalamic-pituitary involvement, but also considering that spontaneous remissions can occur. hypophysitis are inflammatory processes of the pituitary gland often involving contiguous structures that are classified as primary and secondary forms [1] [2] [3] [4] [5] . the primary forms are characterized by an inflammatory process confined to pituitary gland without a well identifiable etiological agent, while the secondary forms are pituitary inflammatory processes triggered by definite etiologic infective or pharmacological agents or by pituitary involvement of more generalized known systemic diseases (table 1) . on the basis of histopathological findings, primary hypophysitis is divided into five types: lymphocytic hypophysitis (lyh), granulomatous hypophysitis, xanthomatous hypophysitis, necrotizing hypophysitis, and igg4 plasmacytic hypophysitis, which are still considered truly distinct entities by some authors or only different expressions of the same disease by others because of the possible occurrence of mixed forms [6] [7] [8] [9] [10] . lyh, which is the most frequent form of primary hypophysitis, is characterized by an extensive infiltration of the pituitary by lymphocytes and plasma cells [11] . because of the involved structures it is classified as lymphocytic adenohypophysitis when the process involves only the anterior pituitary, lymphocytic infundibulo-neurohypophysitis when involves the posterior lobe and the infundibulum and lymphocytic panhypophysitis when it involves globally the anterior and the posterior lobe and the infundibulum [12] . a new form of primary hypophysitis has recently been described: igg4 plasmacytic hypophysitis. this is characterized by the massive infiltration of pituitary gland and/or stalk with numerous igg4-secreting plasma cells [13] . this disease also called igg4-related hypophysitis is included, together with several other diseases, in the spectrum of igg4-related disease [14] (table 1) . autoimmune hypophysitis is still considered rare, but cases with pituitary autoimmunity are increasingly being recognized. an autoimmune pathogenesis for lyh was proposed by goudie and pinkerton in 1962. they described the occurrence of lyh in a young woman showing postpartum amenorrhea and hypothyroidism who died 14 months after delivery for acute hypoadrenalism following surgery for appendicectomy. autoptic findings showed massive lymphoplasmacytic infiltration of both pituitary and thyroid glands and adrenal atrophy [15] . actually, a first description had been made by simmonds [16] in 1917 at pituitary autopsy. subsequently, a case of panhypopituitarism due to pituitary atrophy with diffuse fibrosis and a moderate lymphocytic infiltration with the lymphocytes collected in small foci, was described by rupp and paschkis [17] . however, these authors could not classify this disorder as autoimmune because the concept of endocrine autoimmunity was introduced several years later for hashimoto's thyroiditis [18, 19] . from the first description, the frequency of case reports of lyh in the literature is increasing with time. the 1 per 9 million per year incidence estimate, derived from the data by buxton and robertson [20] may well be an underestimate of the present incidence of the disease. caturegli et al. [3] reviewed 379 cases until 2005 and 750 cases until 2008 [21] , diagnosed on the basis of clinical and histopathological findings, magnetic resonance imaging (mri) and detection of pituitary antibodies but the number of new cases described are increasing considerably from these years onwards. this has been favoured by the growing general awareness in the medical community of the condition. moreover, the recent increase in the use of noninvasive pituitary imaging and of methods to investigate the presence of pituitary antibodies in suspected patients, as well as the pathological findings of pituitary specimens from patients undergoing transsphenoidal surgery, have greatly contributed to the increasing diagnosis of lyh. however, even if several (but not many) cases have appeared in the literature over the years [22] [23] [24] , at present the true prevalence and incidence of lyh are likely to be underestimated. the prevalence of all primary hypophysits is approximately 0.2-0.88 % and the annual incidence is about 1 in 9 million but this is probably underestimated [1] [2] [3] [4] [5] . in fact, in the database of the population only cases of biopsyproven or suspected lyh are included but that the disease is often misdiagnosed has to be considered [3] , especially in patients in the subclinical phase. lyh is the most common form of primary hypophysitis, considering that about 71.8 % of these forms are lyh [2, 3] . lyh is more frequent in women, especially in the last semester of pregnancy and in the post-partum period, with a female/male ratio of about 5:1 [21] . however, cases occurring outside pregnancy have been on the increase in the recent years [3] [4] [5] 21] . the mean age at diagnosis is usually 35 ± 13 years for women and 45 ± 14 years for men [1] [2] [3] , but some cases have been described in children [25] and in the elderly [26] . among the ethnic factors, in the first series of patients the caucasian to japanese ratio was about 3:1 [2] but a recent reevaluation by caturegli et al. [21] lowered this ratio considerably with increased cases of japaneses affected, even if still inferior to caucasians in percentage. the most frequently described hla alleles were in the first series hla-dr4 e dr5 [2, 21] , but recently hla-dq8 and dr53 have been found to be commonly present in patients with lyh [27] . an autoimmune pathogenesis is suggested by several clinical, laboratory and histopathological findings, even if this is still argument of debate [2-5, 21, 28, 29] . other endocrine diseases, such as hashimotos' thyroiditis, addison's disease, type 1 diabetes mellitus and graves' disease fulfil the criteria to be considered autoimmune organ-specific diseases. in particular, their respective target autoantigens are well-known tissue-specific or cell-specific enzymes or hormones or receptors capable of evoking their respective autoimmune response [30] [31] [32] . autoimmune hypophysitis is classified as an organ-specific disease because it is caused by selective destruction of pituitary hormone-secreting cells by immune cells. in fact, even if the true pituitary antigen(s) responsible for the immune reaction is (are) still debated, circulating pituitary autoantibodies can be detected in affected patients. moreover, autoimmune hypophysitis fulfills indirect and circumstantial evidence of autoimmunity according to the established criteria to define a disease as autoimmune, especially regards the histopathological findings [18, 19] . histopathological findings are suggestive of an autoimmune process overlapping those described for other endocrine glands. specimens are usually derived at autopsy, pituitary surgery or pituitary biopsy, which is still considered the gold diagnostic standard. they show massive pituitary infiltration by lymphocytes (t more than b lymphocytes, mainly of the cd4 class), plasma cells and macrophages, grouped in aggregates surrounding atrophic acini of pituitary cells [33] [34] [35] . lymphocytes are sometimes arranged in lymphoid follicles with a germinal center, whereas areas of reactive fibrosis can be shown in the remaining pituitary tissue [11] (fig. 1) . these germinal centres frequently consist of cd20 positive b cells located centrally with peripheral cd3? t cells. it has been recently suggested that two distinct entities of lyh can be distinguished on the basis of the prevalence of t-regulatory cells or th17 cells, which are cd4? t helper cell effectors in many human autoimmune diseases [35] . one of these entities demonstrates an autoimmune process with th17 dominance and lack of t-regulatory cells; another form appears as a process in which t-regulatory cells control the immune response which may not be ''self-targeted'' but rather ''foreign targeted'' (infective agents?). immunochemistry also shows numerous mast cells localized in proximity to capillaries, thus favouring their permeability and angiogenesis, which contribute to perpetuating the inflammatory autoimmune process [36] . other reasons for considering lyh as an autoimmune disease the natural history of lyh is similar to that of other autoimmune diseases, progressing through several stages with cycles of remission and relapse and with good response to immunosuppressive therapy [37, 38] . possible spontaneous remission or the progression to the established chronic stage is most likely related to the severity of damage of hypothalamic-pituitary cells and the relationship between the cytokines produced at the sites of the inflammatory autoimmune process and the hypothalamic-pituitary-adrenal (hpa) axis. in fact, these cytokines usually stimulate the hpa axis leading to its hyperactivation with hyperproduction of crh and avp, both stimulating directly or indirectly adrenal cortisol secretion, which contributes to the limitation or the extinction of the autoimmune process [2] . when the immune aggression causes severe damage to pituitary cells, mostly acthsecreting cells in the early stage of lyh, the consequent impaired secretion of cortisol may not be able to interrupt the immune process. this contributes at perpetuating the aggression to pituitary cells with progression to stable pituitary dysfunction. this condition is even more severe when the autoimmune process involves the hypothalamus, damaging crh-and avp-secreting cells, and thus preventing the stimulatory effect of cytokines on the hpa with perpetuation of the inflammatory process. in contrast, when pituitary cell damage is transient, because mostly related to pituitary edema, hyperactivation by the local cytokines of the hpa axis with the consequent cortisol hyperproduction, may interrupt the immune process with recovery of pituitary function [2] (fig. 2) . patients with lyh often have a family history of autoimmunity and in some of them lyh shows close association with other autoimmune disease or with autoantibodies to other endocrine glands, configuring in some cases an autoimmune polyendocrine syndrome (aps). association has been described with several endocrine or non-endocrine diseases [1] [2] [3] but the most commonly observed association is with autoimmune thyroid diseases [39] among the aps type 3 or with the diseases falling into the aps type 1 (fig. 3) . several autoimmune diseases are correlated with particular human leukocyte antigen (hla) alleles [40] . hla has been typed in a small number of patients with lyh but with results so far inconclusive. in previous studies on 17 patients the predominant allele found was the hla dr4 and less frequently hla dr5 [21] but the pituitary cells of none of these patients showed hla class ii molecules, which are often expressed in tissues attacked by autoimmune processes [41, 42] . however, as previously specified, a recent study by heaney et al. [27] investigated the relationship between specific hla markers and lyh in 15 patients with sporadic lyh and in 4 patients who had developed hypohysitis after treatment with ctla 4 antibodies for melanoma, comparing the results with those obtained in patients with other pituitary mass and in normal controls [27] . in patients with sporadic lyh they found hla-dq8 expressed in 13 (87 %) and dr53 expressed in 12 (80 %) of 15 patients. in contrast none of the four patients with acquired ctl 4 ab hypophysitis exhibited the hla-dq8 and only 1 of 4 (25 %) exhibited the hla-dr53 marker. comparing the results with patients with another pituitary mass, odds ratio of a patient with lyh expressing the hla-dq8 marker was 23.1-fold higher than a patient with another sellar mass. these results, on the hand support the autoimmune pathogenesis of lyh, but on the other suggest that hla-dq8 testing may assist in the diagnosis of patients with atypical lyh [27] . the diagnosis of autoimmune hypophysitis is very problematic, as this autoimmune disease can present not only with many different faces, but also because its natural history is very variable [1] [2] [3] [4] [5] . during the natural history of the disease an endless series of reversible changes in clinical, morphological and functional findings of the disease can be observed. we describe these diseases including the igg4-related hypophysitis, and the ctl4 hypophysitis (a new drug-related secondary form of hypophysitis) as forms of autoimmune hypophysitis, because their characteristics tend to overlap with those of lyh. clinical and hormonal findings lyh may present as an acute, subacute or chronic condition with a correspondence between clinical aspects and pituitary involvement in the autoimmune process. figure 4 summarizes the correlations between the stages of pituitary involvement and clinical and hormonal findings in lyh. in the acute/subacute phase lyh is characterized by pituitary mass-related symptoms and signs frequently accompanied by symptoms of pituitary failure, which are similar to those of a non-functioning pituitary adenoma [34, 43] . in particular, as regards symptoms of mass effect, headache develops frequently and can occur in a dramatic fashion and then other symptoms, such as visual impairment, nausea and vomiting can be also present [2] [3] [4] [5] . usually the symptoms in this phase are evoked by pituitary edema with extrasellar expansion and pituitary infiltration of lymphocytes and plasma cells. even if the pituitary biopsy is still considered the gold diagnostic standard for lyh when symptoms of mass effect are present, this is an invasive procedure not always consented to by the patients. thus, in some patients in the acute/subacute phase, a presumptive diagnosis of lyh could be made on the basis of clinical features and of imaging and laboratory findings [44] . moreover, as regards isolated or multiple pituitary hormone deficiencies, in these stages they can be sometimes misdiagnosed because the patients are clinically asymptomatic. however, in this phase acth is the most frequent and earliest pituitary hormone deficiency, usually associated with hyperprolactinemia. in some rare cases, the rapidity and severity of disease progression may cause a severe secondary adrenal insufficiency with consequent sudden death [1] [2] [3] [4] [5] . a multi-factorial etiology has been suggested for the hyperprolactinemia, which affects approximately one-third of patients, causing amenorrhea/galattorrhea in women and sexual dysfunction in men [2, 3] . in some cases it can be due to a decrease in the dopamine delivery to the anterior pituitary related to stalk compression by a pituitary supra-sellar inflammatory mass or to an alteration of dopamine receptors. hyperprolactinemia can be also present in patients without involvement of extrasellar structures. in these cases, the diffuse lymphocyte infiltration of the pituitary gland could determine an escape of prl into the circulation secondary to the massive cellular destruction. however, prl could be directly released by the immune cells infiltrating the gland, considering the relationship between the immune system and prl [45, 46] . whatever the cause, the high levels of prl could contribute to perpetuate the immune process in lyh, through the well-known proinflammatory immunogenic effect of this hormone [45, 46] . in the established chronic phase, pituitary fibrosis and atrophy are accompanied by mono or pluritropinic deficiencies with secondary impairment of the respective target gland function. acth deficiency may thus be temporally followed by lh, fsh, gh, tsh and more rarely prl deficiency [47] , until a possible panhypopituitarism develops [2] [3] [4] [5] 27] . the symptoms and signs are usually not correlated with the severity of pituitary enlargement, suggesting that pituitary hormone deficiencies could be due to the early direct attack of the autoimmune process on the pituitary-secreting cells rather than to later pituitary histopathological alterations [5, 48] . in patients with infundibulo-neurohypopysitis central diabetes insipidus (cdi) is usually present but in some patients with lyh, cdi can be sometimes present, even in the absence of radiological findings of lymphocytic-infundibulo-neurohypophysitis, [2] [3] [4] 48] . retrospective cross-sectional cohort study on the clinical and endocrinological features of primary hypophysitis in 66 german patients with results partially in contrast with those in the literature [49] . headache (50 %) and weight gain (18 %) were the most frequent nonendocrine symptoms. the association of hypophysitis with pregnancy was observed only in 11 % of the female patients. diabetes insipidus was found in 54 % of the patients at presentation. hypogonadotropic hypogonadism was the most frequent endocrine failure (62 %), whereas gh deficiency was the less frequent (37 %). granulomatous hypophysitis was associated with more severe symptoms than lyh [49] . even if this german study comprises data from several forms of primary hypophysytis and not from only lyh, the discrepancy between the results from a german population and the data in the literature seems to indicate that environmental factors may influence the clinical features of hypophysytis in affected patients. magnetic resonance imaging and its role in differential diagnosis as previously specified, pituitary biopsy is the gold diagnostic standard for lyh. however, this invasive procedure is not always consented to by the patients. magnetic resonance imaging (mri) may help in the diagnosis of lyh and to differentiate this disease from other cases of pituitary mass, in particular pituitary tumor [50, 51] , even if imaging findings sometimes tend to overlap, limiting a correct differential diagnosis. in patients with lyh, mri usually reveals a homogeneous pituitary enlargement, symmetrical supra-sellar extension, compression and displacement of the chiasma, and a thickened, but not deviated, stalk. in german patients thickening of the pituitary stalk is the prevailing neuroradiological sign, being found in 86 % of affected patients [49] . after gadolinium, mri shows a prompt, intense and homogeneous enhancement of the mass with a strip of enhanced tissue along the dura madre, the so-called: dural tail [50] [51] [52] [53] [54] [55] . in patients in whom the process involves the neurohypophysis, the 'bright spot' is usually lost and subclinical or clinical cdi is usually present. in some cases, an empty sella can represent an unusual feature of lyh at mri, particularly during the later stages of the disease [56, 57] . a possible final outcome in empty sella on mri has been described both for lyh and shehan's syndrome (ss) [58] . this syndrome, due to pituitary ischemia after a severe postpartum hemorrage, may be characterized by empty sella on pituitary mri. the finding of prl deficiency with postpartum lactational failure has lead to considering a possible diagnosis of ss. however, it is not always possible to differentiate this disease from lyh, because the pituitary ischemia occurring in ss with the consequent cellular damage may trigger an autoimmune process at the pituitary level, which contributes to perpetuate the hypopituitarism in the affected women [59] . in patients with pituitary adenoma, mri commonly reveals an endosellar mass with unilateral sellar floor depression, asymmetrical supra-sellar extension and controlateral deviation of the stalk. after gadolinium, the enhancement of the pituitary mass is slight, delayed and inhomogeneous. usually, the dural tail is absent and the bright spot is preserved [50] [51] [52] [53] [54] [55] ( table 2) . the above very scholarly criteria do not always provide a correct differential diagnosis. in a further contribution to this argument, gutemberg et al. [54] some years ago proposed a new radiological score to distinguish autoimmune hypophysitis from not-secreting pituitary adenoma before deciding on a more appropriate therapeutic choice. in particular, the authors analyzed, by multiple logistic regression, eight features that contributed significantly to classifying pituitary masses as pituitary adenoma or hypophysitis: relation to age, pregnancy, pituitary mass volume and symmetry, signal intensity, signal intensity homogeneity after gadolinium, posterior pituitary bright spot presence, stalk size and mucosal swelling. the score c1 suggests a diagnosis of adenoma, whereas the score b 0 suggests a diagnosis of autoimmune hypophysitis. use of this score resulted in a significant improvement in the differential diagnosis of adenoma and autoimmune hypophysitis compared with the results obtained from the assessment of the single parameters [54] . however, despite the use of the score suggested by gutenberg et al. [54] the diffferential diagnosis by mri between lyh and other pituitary mass is still problematical. this was also confirmed by an important paper published in 2011, reporting the results of a 10-year experience on a population of 2598 patients who had been submitted to mri because of the presence of sellar and parasellar masses [60] . famini et al. showed that only five patients of 2598 had an lyh, all presenting with panhypopituitarism, but three of these five had been initially diagnosed as having a macroadenoma. these results confirm, on the one hand, the rarity of lyh with respect to the other sellar and parasellar masses of other origin, when investigated by mri, but on the other hand,also the possibility of misdiagnosis also following the criteria suggested by gutemberg et al. [54] . searching for antipituitary antibodies (apa) may help to diagnose or at least suspect an lyh, especially in patients who did not consent a pituitary biopsy and in whom pituitary mri was inconclusive. however, while other organspecific antibodies are considered good markers of their respective autoimmune endocrine diseases [61] [62] [63] , the role of apa in autoimmune hypophysitis is still debated because of several methodological problems and uncertainties in the clinical interpretation [64] [65] [66] [67] . moreover, it has to be considered that the true pituitary antigens reacting with these antibodies are still unknown, even if several antigens have been proposed as responsible for the lyh and as target of apa [67] [68] [69] [70] [71] [72] [73] [74] [75] [76] [77] [78] [79] . but their pathogenic role is still argued. recently, a new target autoantigen, the rabphillin-3a, has been identified as responsible for the autoimmune response in several patients with lymphocytic infundibulo-neurohypophysitis, but also in some patients with lyh [79] . finally, pituitary-specific transcriptor factor 1(pit-1) has been shown as a pituitary target of cytotoxic t lymphocytes in a novel clinical entity, the anti-pit-1 antibody syndrome, that presents an acquired combined pituitary dysfunction characterized by a specific defect in gh, prolactin and tsh. circulating anti-pit-1 antibodies along with other various autoantibodies have been detected in some patients with multiple endocrine organopathy, meeting the definition of autoimmune polyglandular syndrome [80] . the first method used to detect apa was the complement consumption test [81] but after the first report this method was never employed by other laboratories. the most used methods are immunoblotting assay, radioligand binding and indirect immunofluorescence. the immunoblotting method [76] [77] [78] utilizes a homogenate of human autopsy pituitary tissue as a substrate to identify the antigen target of apa. by this method, crock [73] showed that serum antibodies against a 49 kda pituitary cytosolic protein were present in 70 % of patients with biopsy-proven lyh and in 55 % of patients with suspected lyh, including patients with isolated acth deficiency, patients with hypopituitarism associated with other autoimmune diseases or females with sheehan's syndrome [73] . subsequently, crock et al. identified the 49 kda pituitary cytoplasmatic protein as an a-enolase, which is a ubiquitously expressed enzyme and considered the antibodies to this antigen to be a marker of lyh [77, 78] . interestingly, a-enolase is expressed in both the pituitary and the placenta, thus providing a theoretic basis for the strong association between pituitary autoimmunity and pregnancy [78] . subsequent studies have suggested that antibodies to a -enolase cannot be considered specific for lyh because they are frequently present not only in patients with lyh but also in some patients with hypopituitarism secondary to pituitary adenomas or to other pituitary diseases [75] . the technique of radioligand binding assays has led to several studies in organ-specific autoimmune diseases. this method was able to detect autoantibodies against pituitary gland specific factor 1a 306 (pgsf1a) in 33 % patients with biopsy-proven lyh and in 20 % patients with isolated acth deficiency [72] . pgsf2 autoantibodies were detected in 14 % patients with suspected lyh or linh. anti-gh antibodies were present in 25 % patients with lyh and in 6 % patients with other autoimmune diseases. no patients with pituitary adenoma showed reactivity to either pgsf1a or pgsf2, but pgsf1a autoantibodies were found in 77 % patients with rheumatoid arthritis [73, 74] . however, no information is available on pituitary hormone function in these latter patients and it is not possible to know at present whether these results are due to a lack of specificity of this autoantibody marker or to a high diagnostic sensitivity for a subtle pituitary dysfunction. immunofluoresce method is one of the more widely employed methods to detect apa. however, the clinical applicability in the routine diagnosis is still debated for several methodological problems. the main problem of this method is the use of pituitary sections obtained from a variety of species and under a variety of conditions as substrate. in particular, apa were detected in cryostat section of the pituitary gland obtained from humans, primates and rodents and processed with fluorescein isothiocyanate conjugated goat anti-human ig sera. the influence of human or animal pituitary substrate on the sensitivity and specificity of the immunofluorescence method is still discussed. in fact, immunofluorescence has detected apa not only in some patients with suspected or biopsy-proven lyh, but also in patients with non-autoimmune pituitary diseases such as pituitary adenomas or empty sella syndrome [82] [83] [84] [85] [86] [87] . some authors, by comparing the results obtained from the use of either human pituitary gland or animal pituitary substrates affirmed that the results with animal substrates were inconclusive or had a lower sensitivity and specificity than that with human substrates [65, 82, 83, 88] . conversely, other authors obtained the same or quite more reliable results using animal than human section [89] [90] [91] . finally, reliable results were obtained by using adrenal and hypothalamic tissues from animals as substrates to search with immunofluorescence for antibodies against key adrenal enzymes or avp-secreting cells in patients with clinical or subclinical addison's disease or cdi, respectively. thus, these antibodies have been considered good specific, sensible and sometimes predictive markers of addison's disease and cdi, respectively [61] [62] [63] . taking into account the previous arguments and aiming to improve the specificity and the sensitivity of the immunoflurescence method, we have established that some characteristics have to be satisfied when processing the immunofluorescence results. in particular, we consider reliable results from immunofluorescence apa detection, by using as substrate cryostat sections of pituitary from young baboon, only when the titre was higher than a cut-off value and when it was associated with a particular kind of immunostaining pattern. following these criteria, we searched for apa by immunofluorescence in a large cohort of adults and of children with idiopathic ghd and in patients with idiopathic hypogonadotropic hypogonadism [92] [93] [94] [95] . the results of these studies suggested that apa, when present at high titres and with an immunostaining pattern involving selectively some but not all pituitary cells, could be considered good markers of autoimmune isolated hypopitutarism. these antibodies have been further characterized by a four-layer double fluorochrome immunofluorescence test in which, in a second step, the same pituitary section is tested consecutively with the patient's serum, found positive for apa in the first step, and with the animal's pituitary hormone antiserum. the different color of the anti-ig conjugate against the human and the animal serum, respectively green(fitc) and red((rhodamine), allows direct visual assessment of whether the patient'serum and the animal antihormone serum stain the same or different pituitary cells. this allows the identification of the kind of pituitary hormone-secreting cells targeted by apa in patients previously found positive for these antibodies [82, 83] . by this method, we could verify that the pituitary-secreting cells targeted by apa-were somatotrophs in patients with gh deficiency [93, 95] and gonadotrophs in patients with hypogonadotropic hypogonadism [94] . it has been shown that patients with aps or with isolated autoimmune endocrine diseases are at risk of more complex autoimmune diseases, which can be unveiled by searching for the respective autoantibodies [96] [97] [98] [99] . concerning this, in recent studies we have evaluated the predictive value of apa and antihypothalamus antibodies (aha) detected by simple indirect immunofluorescence, for the occurrence of subsequent hypopituitarism. to this purpose we planned to investigate their time-related variations during a longitudinal study in patients with autoimmune polyendocrine syndromes (aps) positive for these antibodies but with normal pituitary function at diagnosis [95] [96] [97] [98] . our results showed that in some cases, the presence of aha but not apa was associated with selective or combined hypopituitarism, suggesting that an autoimmune process involving the hypothalamus but not the pituitary, could be responsible for secondary pituitary dysfunction in these patients [98] . on the other hand, the finding of apa at high titre and with immunostaining involving some but not all pituitary cells, were able to predict the occurrence of subsequent hypopituitarism in a follow-up of 5 years in patients with aps without pituitary dysfunction at the diagnosis (97). moreover, the characterization of pituitary cells targeted by apa in patients with isolated autoimmune diseases, positive for these antibodies at the start but without pituitary dysfunction, may help to foresee the kind of subsequent hypopituitarism [99] . in fact, the detection of apa by double immunofluorescence, selectively directed against gonadotrophs, corticotrophs, thyrotrophs or somatotrophs at the start, was followed during the follow-up by a corresponding pituitary hormone deficiency [99] . recently, to ascertain the responsibility of hypothalamus or pituitary or both on the pituitary hormone deficiencies in patients with autoimmune hypophysitis positive for apa, the italian autoimmune hypophysitis network group performed a study on 95 of these patients, searching for antihypothalamus antibodies [98] . sera positive for aha, detected by immunofluorescence, were retested by double immunofluorescence to identify the hypothalamic cells targeted by these antibodies. the results showed that these antibodies were directed not only towards argininevasopressin-secreting cell (avpc) but also towards releasing hormone-secreting cells. in particular, the detection of aha targeting crh-secreting cells in patients with gh/acth deficiency but with apa specifically directed only to gh-secreting cells, suggested that some pluritropinic deficiencies in some patients with lyh may be due to combined autoimmune aggression both at the pituitary and hypothalamic level [98] . as regards the relationship between pituitary autoimmunity and pregnancy, we recently described a 34 year old woman, who presented with lactational failure after delivery, growth hormone and prolactin deficiencies and subsequently severe primary autoimmune hypothyroidism [100] . immunological study revealed the presence of apa, identified as targeting gh-and prolactin-secreting cells by double immunofluorescence and elevated levels of antithyroglobulin and antiperoxidase antibodies at the subsequent appearance of thyroid dysfunction. this was the first observation of autoimmune hypopituitarism involving growth hormone and prolactin secretions in a patient with lactational failure after delivery, subsequently followed by severe primary autoimmune hypothyroidism, thus falling into an unusual autoimmune polyendocrine syndrome type 3. a second similar case has been recently published by iwama et al. [101] . pregnancy may also favour the transition from a potential/subclinical to a clinical stage of an autoimmune hypothalamic-pituitary disease. recently, we studied two women, positive for avpcabs before pregnancy but without clinical cdi and who became pregnant 5 and 7 months after our first observation. the behavior of post-pituitary function and avpcabs (by immunofluorescence) was evaluated at baseline, during pregnancy and 2 years after delivery [102] . avpcabs, present at low/middle titres at baseline in both patients, showed a titre increase during pregnancy in one patient and after delivery in the other one, with development of clinically overt cdi. therapy with 1-deamino-8-d-avp (ddavp) caused a prompt clinical remission. therapy was definitely stopped at the 6 th and 7th month post partum period, respectively, when avpcabs disappeared, accompanied by stable post-pituitary function recovery, which persisted until the end of the follow-up. these results indicate that the determination of avpcab is advisable in patients with autoimmune diseases planning their pregnancy, because it could be considered a good predictive marker of gestational or post-partum autoimmune cdi. the monitoring of avpcab titres and postpituitary function during pregnancy in these patients may allow an early diagnosis of cdi and an early replacement therapy, which could induce the disappearance of these antibodies with consequent complete remission of autoimmune cdi [102] . an interesting question is whether antipituitary antibodies can change their pituitary target during a life span with consequent change of the kind of pituitary hormone deficiency. concerning this, we conducted a longitudinal study of pituitary function and apa (by immunoflurescence) on 24 children with apparently idiopathic isolated gh deficiency (ghd), treated with replacement rgh therapy from childhood to the transition age [103] . pituitary function and apa detection were investigated before starting rgh therapy and after stopping of therapy at transition age. sera of patients positive for apa were processed by double immunofluorescence to identify their pituitary target. at diagnosis, 16 out of 24 patients were apa positive targeting only somatotrophs (group 1), while eight were apa negative (group 2). when retested off therapy 12 of 16 patients in group 1 persisted being apa positive, while the remaining four became apa negative with recovery of pituitary function. all patients in group 2 persisted apa negative but still showing ghd. of the 12 patients persistently apa positive, eight with confirmed ghd showed apa still targeting somatotrophs, whereas four showed apa targeting gonadotrophs associated with hypogonadotropic hypogonadism (hh). these results suggest that a possible remission of autoimmune ghd, diagnosed in childhood, may occur in patients positive at middle but not at higher titres at diagnosis, after gh replacement therapy. apa may shift their target in transition period, especially from somatotrophs to gonadotrophs. thus, an early characterization of apa by double immunofluorescence is advisable in apa positive ghd patients showing delayed puberty to allow an early diagnosis and an appropriate therapy, thus preventing the progression toward a clinically overt hh [103] . finally, searching for apa in patients with idiopathic hyperprolactinemia may help to disclose the possible occurrence of autoimmune hypophysitis. in these cases, the finding of apa at high titres associated with acth or gh deficiency, suggests the diagnosis of lyh in some of them [104] [105] [106] . in conclusion, in spite of the diffuse use of the immunofluorescence method, the results appeared in the literature so far, are often conflicting, particularly due to the use of different human or animal substrates. however, we think that improvement of specificity and sensitivity of the method may be obtained, excluding the low titres and the confounding immunostaining patterns. this procedure may allow reliable results for diagnosing or at least suspecting pituitary autoimmunity, by also using animal substrates, especially when the results are validated by a second step with the four-layer double immunofluorescence. we think that searching for apa in some particular conditions, may help to avoid an underestimation of autoimmune hypophysitis; thus, we suggest that the possible presence of apa should be investigated [2, 5] : • in patients with apparently idiopathic hypopituitarism especially if associated with other autoimmune diseases • in patients with hyperprolactinemia without pituitary adenoma at mri, without hypothyroidism or associated to iatrogenic causes • in patients with hypoprolactinemia and post-partum lactation failure • in patients with empty sella • in patients with previous traumatic brain injury and in those with infectious meningitis • in patients treated with monoclonal antibodies for several types of tumor • in patients with igg4-related syndrome • when apa are detected at high titre and with a particular immunofluorescence pattern in these patients, a pituitary mri (if not yet performed) and a complete evaluation of pituitary function should be performed to discover those with pituitary impairment even at subclinical stage • in some cases, searching for antihypothalamus antibodies may help to ascertain the occurrence of an autoimmune process involving selectively the hypothalamic cells or associated with pituitary autoimmunity a new form of primary hypophysitis strictly correlated to lyh has been recently described: igg4 plasmacytic hypophysitis. this disease, also called igg4-related hypophysitis, is included, with several other diseases, in the spectrum of igg4-related disease (igg4-rd). this is an increasingly recognized syndrome of unknown etiology, which comprises a collection of disorders that share specific pathologic, serologic, and clinical features [13, 14, 107] . the commonly shared features include tumor-like swelling of the involved organs, a lymphoplasmacytic infiltrate enriched in igg4-positive plasma cells and a variable degree of fibrosis. moreover, elevated serum concentrations of igg4 are usually found. several organs may be affected by this disorder. the most frequent presentations are igg4-related pancreatitis and sclerosing sialoadenitis, but other associated entities have been described, such as sclerosing cholangitis, orbital inflammatory pseudotumor, igg4-related dacryoadenitis, aortitis and periaortitis, igg4-related lung disease and mesenteritis, riedel's thyroiditis, igg4-related kidney disease and igg4related hypophysitis [14, 107, 108] . in particular, igg4related hypophysitis initially was diagnosed in a clinical setting in a 66-year-old woman with inflammatory pseudotumor affecting salivary glands, pancreas and retroperitoneum [13] , and also by pathological examination of a 77-year-old man with a history of sclerosing pancreatitis and cholangitis [109] . subsequently, until 2011 a total of 26 cases of biopsy proven or clinically suspected igg4related hypophysitis has been reported [110] [111] [112] , but further cases have been recently described [113] . this form of hypophysitis is characterized by massive infiltration of the pituitary gland and/or stalk with numerous igg4-secreting plasma cells [13] . this inflammatory pituitary process can be misdiagnosed as it mimics clinical and imaging features of sellar or parasellar tumor. following the criteria proposed by leporati et al. [111] , igg4-related hypophysitis is characterized by the following features: igg4 serum concentration [135 mg/dl; involvement of other organs; infiltration of igg4? plasma cells in the involved tissues, favourable response to glucocorticoid treatment. igg4-related hypophysitis is more commonly present in men of older age. the more frequent findings are: anterior pituitary enlargement with acute acth deficiency when the process involves particularly the pituitary gland; and pituitary stalk thickening with loss of bright spot when the process involves extrasellar structures. in this case cdi may be observed in the majority of the affected patients [18] . a particular case of igg4-related hypophysitis has been recently described by hattori et al. [112] . the affected patient presented with loss of bright spot and pituitary stalk thickening on brain mri but without cdi or anterior pituitary dysfunction. moreover, he showed a high serum igg4 level but without other coexisting igg4-related diseases. an infiltration of lymphocytes and plasma-cells of the posterior lobe, frequently showing igg4 on their surface but no alterations of the anterior lobe observed on biopsy of either anterior or posterior pituitary lobes [112, 114] . the authors suggested that igg4-related hypophysitis can be often unrecognized especially in the asymptomatic phase. with regards to cdi, frequently observed in this form of hypophysytis, we found in previous studies that some patients with lyh associated with cdi, were positive for avpcab without typical signs on mri of infundibulo-neurohypophysitis, suggesting that a direct autoimmune attack to avp-secreting cells could be responsible for their cdi [29, 63] . following these findings and considering that avpcab may belong to igg4, we think that searching for these antibodies in patients with igg4-related hypophysitis, could be advisable to clarify the role of these antibodies in their cdi. a secondary form of autoimmune drug-related hypophysitis has been recently described and related to the treatment with cytotoxic t-lymphocyte-associated antigen-4 (ctla4) blocking antibodies [115] [116] [117] [118] [119] [120] [121] [122] [123] . a recent review by faje summarized the clinical presentation, treatment and biological insight of hypophysitis secondary to immunotherapy [124] . this therapy is frequently employed in the treatment of melanoma and other malignancies. several autoimmune side effects from these agents have been described, termed immune-related adverse events (iraes) and can include multiple endocrinopathies. among these, immune-targeted cancer therapyrelated hypophysitis has been recently recognized as an endocrine irae [124, 125] . in fact, recent reports observed that patients developed lyh and other autoimmune diseases during the treatment with the ctla-4-blocking agent ipulimumab, suggesting a possible correlation between ctla4 and lyh [115] [116] [117] [118] [119] [120] [121] [122] [123] [124] . it has been suggested that these blocking antibodies may act by depleting t-regulatory cells [120] . in another study the antitumor and autoimmune effect of these agents resulted from direct activation of cd4? cd8? effector cells [123] . in this context, future studies should be planned to investigate whether a microsatellite polymorphism on the ctla4 gene, as shown for other autoimmune diseases, could be associated with the development of lyh. clinical features, including pituitary dysfunction, and mri of this form are similar to those of lyh. in some cases an electrolytic alteration with hyponatremia has also been described [121] . usually, following cessation of therapy, a normalization of pituitary morphology at follow-up mri and return to clinical baseline conditions can be observed spontaneously or after early treatment with high-dose of corticosteroids [122] . predictive factors for onset of hypophysitis in patients treated with this immunotherapy remain at present unknown. it often presents insidiously with subtle symptoms and can have life-threatening complications, especially related to possible acute hypocortisolism [121] [122] [123] [124] . thus, it is imperative that this form is distinguished from pituitary metastases of melanoma or other malignancies and that a close clinical observation of patient's progress must be made by physicians. in particular, they have to be cognizant of the overall clinical and radiological picture of this form of hypophysitis, when treating patients receiving ipolimumab or similar drugs with the same effects on the pituitary, to avoid possible severe complications [122, 124] . unusual presentation of lyh or presentation of other diseases mimicking the features of lyh, may delay the diagnosis with possible damage for the affected patients due to untimely or inappropriate therapy. here we report some particular presentations appearing in the literature, that may be considered as examples to help avoiding misdiagnosis. • several years ago lidove et al. described a 36-year-old woman with a prominent lymphoid infiltration of lachrymal and salivary glands, associated with pituitary dysfunction: laboratory and imaging findings allowed the diagnosis of lyh, which showed a dramatic response to steroids with apparent complete recovery. instead, 4 years later, graves' disease developed, which required an appropriate prolonged therapy. in this case the autoimmune process followed a regional tissue distribution, including pituitary, thyroid, lachrymal and salivary glands [126] . • usually the mri in lyh shows pituitary enlargement with symmetrical extrasellar expansion, with homogeneous and hyperintense signals after gadolinium extending sometimes to the basal hypothalamus in a tongue-like fashion, with stalk thickened but not deviated [50] [51] [52] [53] [54] . instead, perez-nunez et al. [127] described in 2005 an interesting case of a patient with lyh presenting with mri of a cystic lesion with ring contrast enhancement. since this appearance in imaging studies is not unusual, it should be considered among the possible features suggesting this disease in an appropriate clinical context. • huang et al. [128] [130] . before this paper only five cases of hypophysitis spreading over the cavernous sinus had been published. cases of lyh presenting as temperature dysregulation have been recently published [131, 132] . • the first case, by jain and dhanwa [131] , presented with documented body temperature oscillations, hoarseness of voice, sexual dysfunction, pan-hypopituitarism, elevated titre of anti-tpo, postural hypotension and typical findings of lyh on mri. prednisone therapy along with hormone replacement therapy induced recovery of a normal rhythm of temperature and of all previous alterations within 30 days. • the second case described a complex association of post-partum hypothermia, hypoglicemia, hypoadrenalism and hypothyroidism, accompanied by characteristic findings on mri. following these results, the authors suggested that practitioners should keep in mind the possibility of lyh in any pregnant women with symptoms of hypoglicemia and hypothermia after delivery [132] . • the rupture of rathke' cleft cyst may cause lymphocytic-infundibulo-neurohypophysitis. two cases were published in 2016 by hayashi et al. [133] presenting with visual disturbances, headaches and endocrine insufficiencies, followed by diabetes insipidus. these are two rare cases of lymphocytic-infundibulo-neurohypophysitis confirmed by post-surgery pathological examination, showing a massive lymphocytic infiltration of the cyst wall and the posterior lobe [133] . • specific characteristics of possible autoimmune hypophysitis may also be observed in patients in late phase of complete or selective hypopituitarism, as in patients with sheehan's syndrome [59, 60, 134] , with hypopituitarism occurring some years after a brain injury [125, 135] or after meningo-encephalitis [136] or in children with celiac disease and short stature, who do not show significant increase in stature on gluten-free diet [96] . in these diseases to search for apa by immunofluorescence may help to disclose a pituitary autoimmunity. the different expressions of this autoimmune disease require different therapeutic strategies, even because a possible spontaneous remission during the natural history of lyh can occur. for this reason, first, a careful follow-up is advisable in patients without symptomatic extrasellar expansion or important hypoadrenalism [2, 3] . then, therapeutic options must be different in the acute and chronic phase [4] . in the acute phase, glucocorticoid replacement with stress doses is mandatory in patients with acute adrenal insufficiency. in this phase a surgical option by trans-sphenoidal surgery may be necessary in patients with symptoms and/or signs of severe compression, even if a possible reduction of pituitary mass volume by high doses of methylprednisolone (1 g/day for 3 days), followed by a tapering dose, may be observed [2] [3] [4] 129] . other immunosuppressive drugs, including azathiopirine, methotrexate, cyclosporine a, have also been used successfully, particularly in corticosteroid-resistant cases, but their long-term efficacy still needs to be confirmed [2] [3] [4] 21] . therapeutic strategy in the chronic phase has to be aimed at restoring adequate hormone levels in affected patients with appropriate replacement therapy, recovering secondary hypoadrenalism, hypogonadism, hypothyroidism and gh deficiency, if present, due to lyh per se or as results of neurosurgical therapy [4] . dopamine agonists (bromocriptine, cabergoline) can lower hyperprolactinemia and improve visual field alterations in some cases but their impact on the course of the disease is still discussed [105] . however, it is well known that high levels of prl can contribute to perpetuation of the immune process in lyh, through the proinflammatory immunogenic effect of this hormone [45, 46] . this has also recently been demonstrated for hyperprolactinemia related to prolacinoma, which may increase the prevalence of autoimmune diseases, mainly thyroid diseases [137] . thus, to normalize prolactin levels by dopamine agonists in hypeprolactinemic patients with lyh it should be advisable to prevent possible autoimmune involvement of thyroid or other endocrine glands. a recent study on the outcome of the main treatment options for lyh has been conducted on 66 german patients, comparing the outcome of the different options. the results showed that glucocorticoid pulse therapy was associated with a high recurrence rate. moreover, evidence suggested that surgery was not able to prevent recurrence. the authors concluded that, considering the favourable results of observation, conservative management is recommended in lyh unless symptoms are severe or progressive [138] . recently, rituximab (rtx), a monoclonal antibody that lyzes b cells expressing cd20, usually employed for treatment of several autoimmune diseases, has been employed to treat single cases of steroid-refractory lyh [139, 140] . it was able to induce a remission both in case of isolated lyh [139] and in case of lyh associated with immune thrombocytemia within a polyendocrine syndrome type 4 [140] . thus, rtx could be considered 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infliximab and rituximab acknowledgments the authors wish to thank dr trevor g cooper, hong kong sar, pr china, for his precious suggestions and advices in editing the paper. conflict of interest the authors declare that they have no conflict of interest. key: cord-331268-kzy33hdb authors: lynch, sharon g.; rose, john w. title: multiple sclerosis date: 1996-01-31 journal: disease-a-month doi: 10.1016/s0011-5029(96)90012-7 sha: doc_id: 331268 cord_uid: kzy33hdb abstract multiple sclerosis is a chronic disease that begins in late adolescence or adulthood. it is highly variable in its expression and severity. it is believed to be autoimmune in nature. the cause is unknown; both genetic and environmental factors have been implicated in the pathogenesis. ms generally presents with the acute or subacute onset of neurologic abnormalities that may wax and wane over many years. diagnosis is generally made by means of observation of the clinical course in conjunction with a neurologic examination and laboratory tests. these tests may include magnetic resonance imaging of the head and spine, lumbar puncture, and evoked potentials. treatment is based on general supportive care, the use of corticosteroids for relapses, and symptomatic management of ongoing problems. the frequency of relapses can be reduced with interferon-β (betaseron). copolymer 1 and interferon-β la are being evaluated by the u.s. food and drug administration for approval for use for reduction in the frequency of relapses in relapsing-remitting ms. treatment of chronic progression is often attempted with immunosuppressive agents such as corticosteroids, azathioprine, and cyclophosphamide. use of other agents is being investigated. multiple sclerosis (ms) is a chronic disease of the central nervous system that typically begins in late adolescence or early adulthood. the cause is unknown, although the disease is believed to be autoimmune in nature. both genetic and environmental factors have been implicated in the pathogenesis of ms. a viral cause has been postulated, but no single virus has been confirmed to be associated with ms. the pathologic features of ms include the presence of demyelinating areas in the white matter of the brain with perivascular in-flammation and relative sparing of the axons. plaques are commonly found in the periventricular areas of the cerebral hemispheres, in the optic nerves, the brainstem, the cerebellum, and the spinal cord. the presence of inflammation in ms plaques and the presence of oligoclonal immunoglobulin bands suggest an autoimmune basis of the disease. characterization of the inflammatory cells in the plaques and in the cerebrospinal fluid has revealed a predominance of t cells. this finding has focused a great deal of attention on the trimolecular complex, which consists of the major histocompatibility complex, the t-cell receptor, and the antigen. consistent associations with dr2, drbl501, dqb602, and the dw2 haplotypes have been identified in white persons. studies of restricted use of specific t-cell receptor regions in the immune process have not revealed a specific receptor in this disease. the antigen remains unknown, although many investigators are working with myelin basic protein and other proteins associated with myelin. two animal models, experimental allergic encephalomyelitis and theiler murine encephalomyelitis, are valuable in testing experimental immunotherapies and other aspects of autoimmune mediated demyelination. ms generally appears with the acute or subacute onset of neurologic abnormalities that may wax and wane over many years. common early symptoms include numbness, double vision, paraparesis, monoparesis, bladder control problems, optic neuritis, ataxia, or tremor. common ongoing symptoms include those just mentioned, vertigo, increasing spasticity, depression, emotional lability, gait abnormalities, fatigue, dysarthria, quadriparesis, constipation, incoordination, fatigue, and pain. diagnosis is made by means of observation of the clinical course in conjunction with the neurologic examination and laboratory tests. magnetic resonance imaging of the head and spine can be valuable in the evaluation of suspected ms. the presence of an elevated immunoglobulin g (igg) index or oligoclonal bands in the spinal fluid also can be helpful. evoked potentials can help confirm subclinical involvement of the eyes, vestibular function, or sensory tracts. the differential diagnosis of ms includes other demyelinating syndromes, particularly the monophasic syndromes, such as postinfectious encephalomyelitis, postinfectious transverse myelitis, and isolated optic neuritis. some infectious diseases, such as lyme disease, syphilis, and htlv-1 myelopathy, can be confused with ms. other autoimmune conditions, such as systemic lupus erythematosus, behcet's syndrome, sarcoidosis, and sjogren's syndrome, can cause symptoms similar to those of ms. some leukodystrophies and hereditary degenerative syndromes can be confused with ms. ms is often classified by its clinical course. benign ms is charac-dm, january terized by mild intermittent relapses with nearly complete resolution. relapsing-remitting ms is the most common form of the disease. it is characterized by episodes of acute or subacute neurologic dysfunction followed by periods of improvement and stabilization. secondary progressive ms begins with a relapsing-remitting course, but the disease gradually worsens, causing slow accumulation of neurologic signs and symptoms. ms that never has a relapsing-remitting course but begins with a slow progression of signs and symptoms is classified as primary progressive ms. treatment of ms is based on the progression of an individual case. general health measures include exercise, physical and occupational therapy, a balanced diet, and aggressive treatment of fever and overheating. treatment of relapses is recommended for moderate to severe relapses. corticosteroids are choice of treatment of relapses. steroids should be used with caution because of the large number of side effects associated with long-term use. the frequency of relapses can be reduced with interferon-i3lb (betaseron). copolymer 1 and interferon43la are being evaluated by the u.s. food and drug administration for approval for use in reduction of the frequency of relapses in relapsing-remitting ms. these drugs soon may be available for clinical use. treatment of chronic progression is often attempted with immunosuppressive agents such as corticosteroids, azathioprine, methotrexate, and cyclophosphamide (cytoxan). other agents under investigation are cladribine and intravenous immunoglobulin. symptomatic treatment of the chronic symptoms of ms is important. treatment of symptoms can help patients remain functional and comfortable even with relatively severe chronic problems. fatigue can be treated with rest breaks during the day, exercise, and energy-conservation techniques. medications that may help are amantadine hydrochloride and pemoline. spasticity is a severe problem that causes contractures, pain, insomnia, and increased fatigue. it can be treated conservatively with physical therapy, particularly stretching exercises. baclofen and diazepam can also be useful and are often used alone or in combination. in patients with severe spasticity, baclofen can be administered with an intrathecal pump. urinary dysfunction is a common problem. a urologist usually is needed to define the type of dysfunction present. a hypertonic, spastic bladder can be treated with anticholinergic agents. a hypotonic bladder may require intermittent or long-term catheterization. detrusor-sphincter dyssynergia may require a combination of anticholinergic agents and intermittent catheterization. urinary retention, which causes frequent bladder infections, may require acidification of the urine or long-term administration of antibiotics. patients with severe retention may require urinary diversion. sexual dysfunction often requires a multidisciplinary approach, including counseling, modification of sexual techniques, medication, or prosthetic devices for men. tremor can be a severe, intractable problem. medications include clonazepam, propranolol, acetazolamide, or diazepam. emotional problems are common in patients with ms. emotional lability may respond to tricyclic antidepressant medications. depression is treated with antidepressant agents and counseling. pain is a prominent concern in many patients with ms. dysesthetic pain can often be managed with tricyclic antidepressants, carbamazepine, phenytoin (dilantin), or valproic acid. musculoskeletal pain is treated with antiinflammatory medications and physical therapy. cognitive dysfunction can be a disabling and distressing component of ms. documentation with neuropsychiatric testing may be helpful in managing these problems. current investigations of ms center on the concept of autoimmunity, possibly mediated by a viral illness. studies designed to define the role of the immune system in ms may be useful. medications designed to reduce a specific autoimmune response and medications that assist in stimulation of remyelination or improvements in quality of life are being developed. over the past few years, great strides have been made in understanding the role of the immune system, in improving diagnostic capabilities, and in managing the problems associated with ms. as this trend continues, we may have more diverse and effective therapies for the management of ms. table 1 . jean martin charcot's description of the clinical and pathologic features of ms is the foundation of our knowledge of the disease.l the historical aspects of ms are reviewed in previous publications. 2s3 we are now entering a new phase of understanding brought about by careful clinical trials and the capability of monitoring the disorder with longitudinal magnetic resonance imaging (mri). in an individual patient, ms can be described by means of clinical observation. current concepts of the clinical courses, their relative frequencies, and mri characteristics of ms are portrayed in table 2 . investigations with mri have changed the concept of ms by demonstrating more evidence of disease activity than is expected from clinical examination. disease activity, as measured with mri, is particularly high among patients with chronic progressive disease. 4 the acute lesions of ms can now be demonstrated with gadolinium-enhanced mri. the initial event is associated with local disruption of the blood-brain barrier (fig. 1) . as the abnormality evolves, increased signal intensity becomes evident on t2-weighted images (figs. 2 and 3). the lesion may grow larger over a few days and then the areas of high signal intensity may begin to recede. over time, the lesions may completely resolve on tzweighted images. with each relapse, which is defined by new or newly enhancing lesions on mr images, the older areas of involvement may be reactivated. reactivation is associated with the development of permanent lesions on mr images. 5 clinical correlation is frequently observed with areas of contrast enhancement or abnormal signal intensity in the cerebellum, brainstem, or spinal cord. abnormalities in the cerebral hemispheres are frequently periventricular in distribution and only occasionally correlate with specific symptoms or signs.6,7 the accumulation of lesions in the frontal lobes is associated with a decline in memory.8 in addition, a change in the number of lesions on cranial mr images correlates with a change in overall clinical status as measured with standard scales.g observations made with mri are having a marked impact on both our basic knowledge of ms and on therapeutic trialsjo mri studies will provide considerable insight into the natural history of the disease and will be an excellent independent variable in future clinical trials. traditionally ms is thought to have a relatively high incidence in the northernmost latitudes of the northern hemisphere.l* this theory is based on the incidence of the disease in scandinavia and the northern united states. a similar association is documented in the southern hemisphere in australia and new zealand. these observations are supplemented by data from m igration studies, which demonstrate a relation between age at m igration and assumption of disease risk for the location. risk is conferred by exposure to an environcertain populations are susceptible to ms, and certain populations are resistant to ms. for example, lapps in scandinavia have a very low incidence of ms, even though they reside predominantly in the far northern latitudes. in north america the disease is infrequent among hutterites and native americans. ms is uncommon in japan. 13 the incidence of the disease in first-degree relatives of patients with ms is 20 times that of the general population,14 suggesting that genetic factors influence disease expression. the results of populatidn-based studies of twins offer evidence that environmental and genetic factors contribute to the development of ms. these investigations show that the concordance in monozygotic twins is greater than 30%. it is less than 5% in dizygotic twinp suggesting that although genetic factors are important, environmental exposure also is important for disease expression. it is now commonly accepted that multiple genes influence autoimmune diseases in both animals and human beings.16 therefore polygenic inheritance is postulated for ms. like other autoimmune diseases, ms is more frequent in women, with a ratio of 2:l. the pathologic features of multiple sclerosis were first described by charcot,l who recognized plaques in.the white matter (scleroses en plaque) during pathologic examination of brain sections. these plaques were demonstrated to lack myelin and to contain perivascular inflammation. these features were established as the pathologic hallmarks of ms. the following discussion centers on the typical findings in ms. comparisons are made between ms and other forms of inflammatory demyelinating disease. the distribution of plaques within the white matter is restricted to the central nervous system (cns). plaques are found frequently in a periventricular distribution in the cerebral hemispheres. some of these plaques may be associated with the distribution of terminal veins.17j8 plaques may occur anywhere within the white matter. when plaques are near the cortex, sparing of the subcortical myelinated fibers is often observed. plaques adjacent to gray matter may at times spread into the gray matter, including the cortex and deeper nuclei. plaques are frequently found in the white matter of the optic nerves, the brainstem, the cerebellum, and the spinal cord. plaques in these locations more frequently correlate with symptoms. within a plaque, axons are frequently preserved. 18 the evolution of a plaque is not known. mri investigations show that the blood-brain barrier is locally disrupted at the onset of symptoms. pathologists disagree as to whether demyelination precedes inflammation or is secondary to inflammation. at present the latter view predominates. in acute plaques, the inflammatory response of lymphocytes, plasma cells, and macrophages is capable of producing or augmenting demyelination by direct and indirect mechanisms. the inflammatory response is predominantly perivenular, with a lesser response at the edges of or within plaques. the macrophages associated with acute plaques characteristically contain myelin fragments or myelin breakdown products.lg lymphocytes may contribute to the pathologic process by means of direct or indirect pathways. direct mechanisms include antibodyand cell-mediated immunity. t-cell-mediated reactivity is favored because most inflammatory cells are t cells. indirect mechanisms include the secretion of lymphokines and cytokines. the ability of molecules such as tumor necrosis factor to damage myelin or oligodendrocytes is the focus of ongoing research.20 cytokines may influence macrophage activation, stimulating the phagocytosis of myelin. in addition, the release of heat shock proteins may result in stimulation of ty6 cells, resulting in increased cytotoxicity. the cns lesions of ms can be classified as early active, active, inactive, early remyelinating, and late remyelinating, according to histologic criteria. the features of these lesions are detailed in table 3 . studies of oligodendrocytes early in the course of ms have demonstrated relative preservation of these cells in some patients,z1,22 and remyelination is possible in these patients. other patients have a striking loss of oligodendrocytes, making remyelination unlikely. these differences may reflect the severity of the injury at a specific site of demyelination, or they may indicate that the pathogenesis of demyelination varies among patients with ms. this may imply that an autoimmune basis for ms has long been suspected because of the inflammation in the cns and the presence of oligoclonal bands in the cerebrospinal fluid (csf). the inflammatory response is primarily lymphocytic and mononuclear.2~3 the predominance of t cells among the lymphocytes has led investigators to evaluate the role of the t-cell receptor and its recognition of antigen combined with major histocompatibility antigens (mhc). this has been named the trimolecular complex.23 the t-cell receptor recognizes antigen in the context of the mhc molecule. in the case of mhc class ii molecules such as drz, the antigen fragments are bound in a cleft, which is presented to the tcell receptor for recognition. with regard to the components of the 18 in the context of the trimolecular complex, it is important to note that ms has been associated with certain mhc or human leukocyte antigen (hla) markers. a consistent observation is the association of dr2, drbl501, dqb602, and the du2 haplotype with ms.31 different hla associations are reported within ethnic groups. the mhc molecules may contribute to genetic susceptibility to the disorder, but they are only one of a number of factors that confer risk for the disease.32j3 the presence of oligoclonal bands in the csf of patients with ms is frequently observed (fig. 4) . these abnormal immunoglobulins are identified in a high percentage of patients with clinically definite ms, and they are present in approximately 60% of patients at the clinical onset of the disease. 34 the oligoclonal bands in ms are of unknown specificity. small percentages may bind to known viral antigens in some patients. consistent binding of these antibodies to specific viral polypeptides or viral oligopeptides with homology to myelin components has yet to be demonstrated. the oligoclonal bands are not specific to ms and can be observed in patients with cns infections such as syphilis, subacute sclerosing panencephalitis, viral encephalitis, or meningitis. 35, 36 if the infection is self-limited, the oligoclonal bands may be a transitory abnormality. in comparison, chronic infections of the cns are associated with persistence of the oligoclonal bands. in these settings, the antibodies that compose the oligoclonal bands have pathogen specificity. oligoclonal bands can be observed in patients with autoimmune diseases such as systemic lupus erythematosus. the probability that an environmental factor is involved in the pathogenesis of ms has stimulated interest in a viral cause. although viral isolates are reported from the cns of patients with ms,37-3g there are no consistent observations. attempts to detect viral nucleic acids by means of in situ hybridization and polymerase chain reaction (pcr) are in progress. these techniques are extremely sensitive and require rigorous controls. careful confirmation of any future viral isolates or viral nucleic acids by multiple laboratories is required. [40] [41] [42] [43] [44] [45] [46] recent studies of tropical spastic paraparesis demonstrate that the retrovirus human t-cell lymphotropic virus type i (htlv-i) is involved in the pathogenesis of this disorder, which shares some clinical features with ms.3ga it is clear, however, that htlv-i is not a pathogen in ms. 40 there remains the possibility that a retrovirus or endogenous retrovirus could contribute to the pathogenesis of ms. there is considerable interest in the possibility that exposure to a virus may lead to an immunopathologic condition that results in ms. of particular note are investigations that demonstrate the potential of molecular mimicry to produce autoimmunity. the term molecular mimicry arises from the demonstration of shared homology between normal human myelin proteins and viral polypeptides. if an immune response is mounted to such a viral epitope, then it may be perpetuated by exposure of the shared region on the normal human protein. in ms, homology between myelin antigens and viral peptides is established. thus this mechanism could result in cns demyelination after viral infection. autoimmunity could also result from superantigenic stimulation of t cells by viral or bacterial proteins. superantigens are capable of binding to specific t-cell receptor proteins, producing nonspecific stimulation of relatively large numbers of t cells, which might cause clonal expansion of t cells reactive to myelin or oligodendrocyte antigens.47s48 animal mqdels of demyelinating disease cns demyelination associated with inflammation is present in animal models of experimental allergic encephalomyelitis (eae) and theiler murine encephalomyelitis (tme). these models provide an opportunity for the investigation of autoimmune and virus-associated disease, respectively. eae is an autoimmune disease of the cns and a model for immunotherapy. a cd4+ t-cell population specific for a myelin antigen, either mbp or proteolipid protein, is required for initiation eae. eae and ms share characteristics that include cns demyelination, perivascular t cells, association with mhc class ii antigens, and possibly restricted tcr v-gene utilization.4g the murine adoptive transfer model has another important feature of ms: the chronic relapsing clinical course.4g this clinical course is useful for investigations of the immune response and immunotherapy not only during onset of the disease but also during relapse. the pathologic features of this murine transfer model are inflammation and prominent demyelination.4g-51 eae is not associated with an environmental factor. the tme model of immune-mediated demyelination is of particular interest because it has important parallels with postinfectious encephalomyelitis and ms. in this model, antecedent mild or even subclinical viral encephalitis is followed by a period of quiescence and the eventual onset of demyelination. 50 the virus is persistent during the demyelinating phase of the disease. this implies that either low-level expression of viral polypeptides or immunologic cross-reactivity between virus and myelin antigens is crucial for initiating demyelination. the demyelination in the tme virus model is mediated by t lymphocytes. these t cells may have viral specificity but produce demyelination. this mechanism would be relevant to ms if the suspected environmental factor were one or several viruses. as in ms and eae, t cells appear to initiate immunemediated demyelination in tme.!~~z~~ experimental immunotherapies are evaluated in these animal models and provide a basis for clinical trials in human beings. examples of these investigational treatments include cytokine transforming growth factor-i3, (tgf131,53 lymphokine-toxin,54 anti-t-cell receptor vb-specific monoclonal antibody,55,56 t-cell vaccination,57 blocking peptides, anti-adhesion molecule specific monoclonal antibodies,5g and nitric oxide synthetase inhibition. 60 these experimental models provide an invaluable resource for the study of immunotherapy. although these experimental models are not likely to mirror the pathogenesis of ms, they are extremely useful in the study of cns inflammation and demyelination. ms is primarily a disease of young adults. most patients report their first symptoms between the ages of 20 and 45 years. the disorder rarely appears before the age of 15 years or after the age of 50 years, although it has been reported to occur in both children and the elderly. the symptoms of ms in children are essentially the same as those in adults; ataxia, numbness, and visual disturbance are the most common presenting symptoms. in elderly persons, a progressive onset is more common. ms is characterized by episodes of neurologic dysfunction, followed by periods of stabilization or remission. symptoms, once they appear, may partially or completely resolve or may be permanent. these episodes tend to develop over hours or days. sometimes the symptoms occur with almost strokelike suddenness, or they may develop slowly over a few weeks. once the symptoms have developed, resolution generally occurs over weeks or months. certain signs and symptoms are more common in the early stages of ms. these include numbness, double vision, monoparesis, paraparesis, bladder control problems, optic neuritis, ataxia, or tremor (table 1) . 22 dm, january 1996 numbness can be difficult to evaluate. numbness that suggests early ms includes an ascending numbness beginning at the feet. this may be a sign of transverse myelitis. hemiparesthesia, bilateral hand numbness, and dysesthesia in both hands, both feet, or on one side of the body, also are early symptoms of ms. the numbness is usually present for days, weeks, or months. many patients describe numbness or paresthesia with no objective abnormalities. if objective sensory abnormalities occur, they are more commonly reduction of vibration, proprioception, or stereognosis rather than pain or fever. the diplopia that occurs with ms is frequently partial or complete internuclear ophthalmoplegia, which is often bilateral. a small percentage of patients have sixth nerve palsy" or, more rarely, third or fourth nerve palsy. ww sometimes monocular diplopia is a symptom of optic neuritis. optic neuritis is usually characterized by monocular blurred vision, sometimes with scotomata and often with alteration of color vision. retroorbital pain or headache is common in patients with active optic neuritis. 63 the pain may intensify with eye movement. motor weakness is usually accompanied by upper motor neuron signs, such as hyperreflexia or the babinski sign. paraparesis is the most common early symptom, but the weakness also can occur as hemiparesis or monoparesis. spas.ticity can be a later manifestation. signs and symptoms that commonly occur as ms progresses include vertigo, tremor, incoordination, increasing spasticity, depression, mood swings, cognitive abnormalities, impotence or other sexual dysfunction, weakness, lhermitte's sign, gait abnormalities, constipation, urinary incontinence, optic nerve pallor, fatigue, quadriparesis, dysarthria, loss of upper extremity coordination, and dysesthetic pain (table 1) . uncommon but important problems include seizures, atypical facial pain or tic douloureux (trigeminal neuralgia), bowel incontinence, swallowing problems, hearing loss, and dystonia. bell's palsy is sometimes seen in patients with ms (table 1) . the classic course of ms is one of intermittent neurologic signs and symptoms over many years. as time progresses, chronic problems accumulate. the amount of total disability varies from patient to patient. after a number of years, a patient's condition may stabilize permanently, but this does not always occur. d&f, january 1996 23 subtypes of disease ms can be divided into subtypes according to the course of the disease. there is a continuum among the various subtypes, and the disease in some patients does not fit into a pattern. benign ms accounts for 10% to 20% of cases and occurs more often in young women. in this type of ms, symptoms are mild and often sensory. resolution of neurologic problems is nearly complete. over the years, these patients rarely experience considerable disability. relapsing-remitting ms is the most common form of the disease. it is characterized by episodes of neurologic dysfunction [variably called exacerbations, relapses, or attacks) followed by periods of improvement and stabilization (called remissions). during a remission, not all symptoms resolve completely. the patient may be left with permanent disabilities, which may vary in severity. the condition of 30% to 50% of patients with an initial relapsingremitting course begins to worsen gradually over time, and neurologic signs and symptoms accumulate. this form of the disease is classified as secondary chronic progressive ms or relapsing-progressive ms. the latter term is also used to describe disease in patients who have sudden deteriorations in a stepwise manner without clinically significant recovery. primaryprogressive ms occurs in 10% to 20% of patients. disease in these patients begins with a slow progression of neurologic deficits with no history of relapse and may also have periods of stabilization or subacute worsening. common problems that appear and gradually worsen with time include spastic paraparesis, cerebellar ataxia, and urinary incontinence. clinical findings although no neurologic findings are pathognomonic for ms, certain abnormalities found during a physical examination can be helpful in providing a clue to the diagnosis of ms. these include internuclear ophthalmoplegia, which is rarely seen in other diseases and is especially rare in young adults. hyperreflexia and the babinski sign are common in early ms. optic nerve pallor can provide a clue to subclinical or resolved optic neuritis. altered color vision in one eye and a marcus-gunn pupil also are signs of optic neuritis. nystagmus is a common finding in patients with ms. many types of nystagmus are identified, including pendular nystagmus, small-amplitude nystagmus, or gaze-evoke nystagmus.63a65a66 absent abdominal reflexes in a slender patient who has not undergone an abdominal operation may be a helpful sign. a mild intention tremor with or without past-pointing is also an early sign, as is a positive romberg sign or difficulty with balance with 24 divz,january 1996 tandem gait. subtle motor weakness or spasticity may also be found. loss of vibratory or proprioceptive sensation in the lower extremities is common early in the course of the disease. ms should be strongly suspected in young or middle-aged adults who describe symptoms consistent with the lhermitte sign in the absence of obvious cervical cord abnormalities. the lhermitte sign consists of paresthesia or an electric shock-like sensation that radiates up the head or down the spine on neck flexion or extension. other important abnormalities are gait disturbances, persistent binocular double vision when looking in a particular direction, or a history of optic neuritis or transverse myelitis. fatigue and depression are not criteria for the diagnosis of ms. no laboratory test is universally diagnostic for ms. certain studies can be helpful in confirming the presence of separation of lesions in space and time. examination of the csf can be valuable for two reasons. first, the pattern of csf findings can help confirm the presence of demyelinating disease. the protein level is often slightly elevated but is rarely greater than 0.1 g/l unless the patient is experiencing a severe exacerbation, particularly optic neuritis or transverse myelitis. a modest elevation in cell count, generally less than 50/mm3, is seen in some patients. the cell pattern usually consists mostly of mononuclear cells. if more sophisticated testing is conducted, most cells can be identified as t lymphocytes. qualitative analysis of proteins can be helpful in suggesting the diagnosis of ms. at electrophoresis oligoclonal immunoglobulin bands can be identified in the csf but not in the serum of many patients with ms 34,67 (fig. 4) . the igg index, a comparison between igg levels in the csf and igg levels in the serum, is elevated in many patients with ms. 68,6g although these findings suggest ms, they also are found in other diseases, most commonly other inflammatory diseases of the cns. these diseases include lyme disease, systemic lupus erythematosus, progressive multifocal leukoencephalopathy, encephalitis, and subacute sclerosing panencephalitis. 35 the ver is abnormal in approximately 70% of patients with ms, regardless of whether there is a history of optic neuritis.70 a slowed ploo in a patient without a history of optic neuritis can be paraclinical evidence of a second lesion and can be used to confirm a diagnosis of ms (fig. 5) .6g the baer is more difficult to interpret than the ver and is abnormal in approximately 30% of patients with ms. in the baer, five 26 d&z, january 1996 consecutive waves are identified; these are numbered i-v the wave interval i-iii is considered the peripheral system. abnormalities in this wave suggest a lesion in the peripheral auditory nerve. the wave interval iii-v is generated from the central hearing areas in the brainstem. slowing in this area suggests a brainstem lesion. abnormalities in waves iii-v are seen in approximately 30% of patients with ms. 70 the sser is a technically more difficult study than the other responses, but it is useful for identification of slowed central conduction in the sensory pathway in the spinal cord and brain. the sser is abnormal in approximately 80% of patients with definite ms. 70 the sser also is useful in the identification of peripheral lesions, suggesting that peripheral neuropathy rather than a central lesion is the cause of numbness. the development of mri has been extremely important in both making the diagnosis of ms and helping researchers understand the dynamics of ms in patients with the disease. mri findings should be interpreted with caution, however. abnormal mri findings alone are not sufficient to confirm a diagnosis of ms without clinical evidence. 71, 72 in patients with ms, patchy areas of abnormal white matter are seen on t%weighted and spin-echo images. these are most commonly found in the cerebral hemispheres in the periventricular areas. in some patients, however, lesions also are identified in the brainstem and cerebellum. mri also helps identify lesions in the cervical and thoracic spinal cord. gadolinium enhancement can be seen around some lesions, particularly if a patient is having an exacerbation or fairly rapid chronic progression. gadolinium enhancement is considered a sign of an active lesion. (table 4 ).76-7g mr images should be interpreted with caution, particularly in patients with chronic illness of any kind or in patients older than 50 years. fazekas et a1.75 attempted to differentiate the mr images of healthy persons older than 50 years from those of patients with ms. they identified the following three criteria for the diagnosis of ms: lesions abutting the lateral ventricles, lesion diameter greater than 0.6 cm, and lesions present in the posterior fossa. if two of the three criteria were met, the specificity for ms was 88% and the sensitivity was 100%. a follow-up study in which 1500 consecutive mris were examined yielded a sensitivity of 81% and a specificity of 96%" these criteria may be useful in the interpretation of mri findings in some patients, but they should be used with caution for patients with other diseases that can affect mri, such as hypertension and diabetes mellitus. patients with those diseases were excluded from the study by fazekas et al. the size and area of the lesions present on mr images correlate poorly with the patient's disability. 4,81 many patients with large lesions on mr images have minor clinical findings, whereas some patients with small lesions have severe disability. one area in which mri may indicate the severity of the problem is in the cognitive status of the patient. an increase in the area of the lesions in the cerebral hemispheres or thinning of the corpus callosum may correlate with poor cognitive function. the presence of lesions in the spinal cord does not correlate with disease severity. a recent study in which body coil imaging was used showed that 74% of patients with ms had lesions in the spinal cord that were identified by this technique. 82 although the presence of lesions and the area and number of lesions did not correlate with a patient's level of disability, the presence of spinal cord atrophy did correlate with greater disability. 82 patients with partial or complete transverse myelitis who subsequently are found to have ms often have lesions on mr images that correspond to the level indicated by symptoms and the level of neurologic findings (simnad v, rose jw, manuscript in preparation). the use of mri for the follow-up evaluation of ms has become an integral part of research into the course of the disease. however, because mri findings do not correlate with a patient's clinical condition, new abnormalities on mr images in the absence of clinical worsening should not be treated as an exacerbation of the disease. new abnormalities can, however, indicate that the disease remains active. mri should be repeated in patients in whom the diagnosis has not been confirmed or in patients who have new symptoms that suggest a second disease. as the choice of treatments of ms increases, monitoring of disease activity may become useful in determining the course of treatment. optic neuritis is often seen as a first demyelinating episode in patients with ms. the diagnosis of ms should be considered in patients with optic neuritis, and a careful history and examination should be performed to exclude other neurologic abnormalities. however, many patients who have a single episode of optic neuritis never have other demyelinating episodes. one study of 60 patientsgo found that ms developed in 74% of women and 34% of men within 15 years of an attack of optic neuritis. transverse myelitis, inflammation of an area of the spinal cord causing ascending weakness and numbness up to the level of the lesion, can also be seen as the initial demyelinating event in ms. 88 other causes include infectious, postinfectious, and postvaccinal demyelination. 81 sometimes the cause is never determined. when transverse myelitis occurs, an imflammatory lesion can be identified on mri images of the cervical or thoracic spinal cord. estimates of the risk of ms after an isolated episode of transverse myelitis range from 50% to 80%.g1-g3 im'z, january 1996 29 the use of the cranial mr images in patients with optic neuritis or transverse myelitis may be helpful in predicting which patients are more likely to have additional problems. one prospective study identified patients with a single demyelinating episode such as optic neuritis or transverse myelitis. patients with abnormal mri findings at the time of the first episode had a 65% risk of a second episode within 5 years. patients with normal mri findings at the time of the first episode had a 5% risk of development of a second lesion in 5 years.g4 a syndrome in which optic neuritis and transverse myelitis develop with no other demyelinating events is called devic's neuromyelitis optica. in this disorder, cranial mri findings remain normal. this is considered a monophasic illness-both abnormalities occur within a year of each other, and patients may never have another demyelinating event. this is a rare syndrome.g5 the following characteristics are associated with a favorable prognosis: (1) female sex, (2) early age at onset, (3) onset of symptoms referable to a single neurologic system, (4) substantial recovery from relapses, (5) early symptoms of numbness rather than corticospinal or cerebellar symptoms. unfavorable prognosis is associated with chronic progressive disease (either primary or secondary), older age at onset, and male sex.g6-g8 dlagnostic criteria because of the difficulties involved in the diagnosis of ms, several criteria have been published to standardize the terms used to describe the certainty of the diagnosis. the two primary sets of criteria are those of poser et a1.6g and shumacher et a1. 83 the poser criteria are more recent and are summarized in table 5 . it is important to remember that no abnormality should be used as a criterion if it can be explained by another medical problem. other conditions may commonly be confused with ms and should be considered in the differential diagnosis. the differential diagnosis depends in part on the clinical and laboratory findings in an individual patient. postinfectious encephalomyelitis is a subacute syndrome, possibly caused by an autoimmune response to a viral infection. patients with this illness experience the acute or subacute onset of confusion, disorientation, gait abnormalities, loss of bowel or bladder control, weakness, or other symptoms. abnormalities in the white matter can be seen with mri, and evidence of inflammation frequently is seen in the cse the patient's condition may or may not return to normal; recovery may take months or even years. 84 lyme disease is a prominent concern and appears to be a cause of intermittent neurologic events, 85 the most common of which is bell's palsy. encephalomyelitis may develop, with vague symptoms of numbness, fatigue, and memory deficit. abnormalities in the white matter may be seen with mri, and csf findings may resemble those in ms, including mild leukocytosis and oligoclonal bands. patients may have a history of a tick bite, a rash, or recent arthralgia. lyme titers or a lyme pcr in the blood or csf may be helpful to these patients. 85 systemic lupus erythematosus is a well-known syndrome that may cause transverse myelitis, strokes, encephalopathy, and optic abnormalities. clues to the differential diagnosis are systemic abnormalities such as hematuria or leukopenia, arthritis, or an elevated antinuclear antibody titer, erythrocyte sedimentation rate, or other blood measurement. sometimes both systemic lupus erythematosus and ms occur in the same patient. primary cns vasculitis can cause a syndrome similar to ms. differentiating features include prominent headaches, confusion, and sudden strokelike episodes. an elevated erythrocyte sedimentation rate may be present in some patients, as may an elevated csf protein level. patients may have an abnormal cerebral angiogram. bi-opsy of the temporal lobe or meninges may be helpful in the diagnosis of this syndrome. 77 the htlv-i, a retrovirus, causes a syndrome known as tropical spastic paraparesis or htlv-i-associated myelopathy. it may cause progressive spastic paraparesis or generalized white matter disease. htlv-i is relatively rare in the united states but is present in some patients who have resided around the caribbean sea. 86 behqet's syndrome can cause mri findings identical to those in ms. cardinal features of behqet's syndrome include oral ulcers, genital ulcers, and uveitis. variable features include involvement of the skin, eyes, joints, lungs, intestines, and heart and venous thrombosis. neuropsychiatric symptoms, including quadriparesis, pseudobulbar palsy, cranial neuropathy, cerebellar ataxia, peripheral neuropathic lesions, or cerebral venous thrombosis may be present.7g,87 sarcoidosis and sjggren's syndrome are autoimmune diseases that may show lesions on mr images that resemble those of ms. meningeal enhancement is a clue to cns sarcoidosis. a chest radiograph may show granulomatous lesions suggestive of systemic sarcoidosis. although igg levels are raised in the csf of patients with cns sarcoidosis, oligoclonal bands are found in some patients. csf angiotensin-converting enzyme determination may be used to further differentiate cns sarcoidosis from ms.78 vitamin b deficiency and syphilis can cause posterior column abnormali& and dementia. tests for these problems should be performed when a patient with these symptoms is seen. certain leukodystrophies may appear in adulthood. these include adrenal leukodystrophy, krabbe's disease, and metachromatic leukodystrophy. mri findings in these diseases show large areas in which no normal white matter is present. female carriers of the adrenal leukodystrophy gene may have an ms-like syndrome.88~8g hereditary degenerative syndromes, such as familial spastic paraparesis, olivopontocerebellar degeneration, and spinocerebellar degeneration, may be confused with ms, particularly with primary progressive ms. in these diseases, mr images may be normal or may show atrophy of the brainstem, spinal cord, or cerebellum. the csf is normal in these patients. studies support the concept that exercise is beneficial for the patients with ms.ggjoo simple measures such as walking, using an exercise bicycle, and swimming may be of considerable value. exercise should be performed in a cool environment whenever possible to prevent heat-associated transient declines in neurologic function. swimming and water aerobics in pools that are not overly heated are particularly valuable, because the patient is cooled while exercising. physical and occupational therapy are often invaluable for maintenance or improvement of neurologic function. bracing disabled portions of limbs, particularly the ankle, provides considerable benefit. exercise regimens tailored to the patient may help to maintain or improve strength, range of motion, and mobility. devices that provide assistance with walking can be important in reducing the risk of falls, allowing for greater independence and increased activity. other assistive devices can be helpful in reducing fatigue and increasing independent activity. careful consultation with a specialist in rehabilitative medicine can assist the patient with management of work and daily activities.l"o it is advisable for persons with ms to maintain a balanced diet. weight control is a prominent concern. overweight patients with motor, sensory, or coordination deficits that impair ambulation are at particular risk of falls, which may result in serious injuries, including fractures. patients who are overweight and whose strength is decreased lose any reserve strength they may have because of their weight. some patients with ms lose weight and require dietary supplementation. patients with dysphagia may require feeding tubes to help prevent aspiration pneumonia. although various diets have been advocated for ms, there are no substantial data from controlled trials to support the assertions. as a general health measure, it is commonly suggested that patients with ms restrict cholesterol and fat in the diet. diets that meet the requirements of the american heart association are likely to be useful, because most patients with ms live into middle age and beyond. pregnancy is a concern among young women with ms. many studies of the effect of pregnancy on ms have been undertaken. an increased risk of exacerbations in the first 3 months postpartum has been reported.lol-la4 however, the risk of exacerbations during pregnancy appears to be unchanged or slightly reduced.lo5 overall longterm disability does not appear to be altered by pregnancy.lo4j05 the increased relapse rate seen during the postpartum period has been postulated to be caused by an increase in immune tolerance during pregnancy, followed by a return to normal in the postpartum dm, january 1996 33 period. it has also been postulated that the relapses are secondary to the decrease in the level of female hormones after parturition.lo*-lo3 in addition to the physical effects of pregnancy, another major concern is the care of an infant or child by a person with physical problems. persons with ms need to consider carefully whether they can handle the additional work of caring for a child. persons with chronic physical problems may need special provisions, such as extra assistance in the home or special equipment. the physician should discuss pregnancy, delivery, and child care with women of childbearing age. increased core temperature, whether due to heat exposure or to a febrile response, may lead to a transient increase in neurologic symptoms.lo6 if the event is due to heat exposure, the patient simply needs to rest in a cool environment and await recovery. if an infection is responsible, the source of the infection should be determined and treated. an antipyretic medication such as acetaminophen can then be administered. many patients with ms are susceptible to urinary tract infections and may not have clinical manifestations of the infection. in some patients this is due to impaired sensory capabilities, and some patients have chronic urinary symptoms that may not change substantially with an infection. one study of ms exacerbations pointed to an association with antecedent infection.lo7 if a patient has persistent worsening after an infection that has been appropriately treated and resolved, steroid therapy should be considered in the event the infection recurs. a relapse is considered to be the onset of new neurologic symptoms or marked worsening of old symptoms lasting longer than 24 hours. certain conditions may mimic an exacerbation and should be ruled out or treated before steroid therapy is considered. these include fever, infection (commonly urinary tract infection or viral illness), overheating, fatigue, severe emotional stress, or the effects of medications such as baclofen, which can increase weakness. if these problems are appropriately treated, the patient's condition usually improves. mild relapses may be best treated without steroid therapy. the symptoms include a mild numbness, mild changes in bladder function, mild optic neuritis (visual acuity better than 20/40), slight increase in spasticity, or a dysesthetic pain syndrome. any new abnormality that does not change a person's ability to perform his or her usual daily activities may not require steroid therapy. in these patients, rest is sometimes helpful. patients with more severe worsen-ing may benefit from steroid therapy. the symptoms include gait disturbances, severe numbness or paresthesia, moderate to severe paresis, moderate or severe optic neuritis, severe vertigo, or marked impairment of eye movement. it is often appropriate for the physician to observe the patient for a few days before making a decision about the use of steroids. standard therapy for many years, immunosuppression with corticotropin (acth) or steroids has been used in the treatment of the exacerbations of ms. the primary effect of these agents is to shorten the duration of an attack, and no benefit has been proven in the overall outcome from an attack. steroids should not be given until an abnormality resolves because this may never occur. acth was the first immunosuppressant to be widely used in ms.lo8 although it is still given to some patients who respond well to the medication, acth has been largely supplanted by other steroids, most commonly prednisone and methylprednisolone. many different regimens have been used. a typical regimen is 80 units by intravenous or intramuscular injection once a day for 10 days. prednisone is commonly used for mild or moderate exacerbations of ms. although low doses do not appear to have any effect on an exacerbation, larger doses do appear to shorten the duration of an ms attack.log there is no standard treatment regimen; a dose of at least 1 mg/kg per day is commonly recommended and should be continued for 7 to 10 days. our regimen is 80 mg once a day by mouth for 10 days, then tapered by 20 mg every 3 days. other regimens range from 10 days to 6 weeks or longer. methylprednisolone with sodium succinate (solu-medrol) is often used in the treatment of severe relapses, or when the patient's condition continues to worsen after several days of high-dose prednisone.'lo typical dosages range from 500 to 1000 mg/day and last from 3 to 14 days. a typical dose is 250 mg in 250 ml of 5% dextrose in water over 45 minutes every 6 hours to a total of 16 doses. another is 500 mg in 250 ml of 5% dextrose in water over 45 minutes every 12 hours for 10 doses. an oral prednisone taper over about 10 days to 2 weeks may be used afterward. one study of optic neuritis suggested that high-dose methylprednisolone produces more favorable results than oral prednisone for patients with poor visual acuity. this study showed only a faster recovery time; follow-up examinations at 1 year did not show any difference in final outcome."l the study involved patients who did not necessarily have a diagnosis of ms. however, a follow-up evaluation with patients in whom ms subsequently developed did suggest that the methylprednisolone-treated group had a longer time interval to the development of a second demyelinating event than dm,january 1996 3.5 those who received prednisone or placebo.l12 for this reason, some neurologists believe that all attacks of ms should be treated with intravenous methylprednisolone. the side effects of steroids are well known. these include nonspecific immunosuppression leading to opportunistic infections, induction of hyperglycemia, fluid retention, hypertension, emotional abnormalities, hypokalemia, peptic ulcers, occasional aseptic necrosis of the femoral head or other bones, and demineralization of bone. chronic use may lead to cataracts, osteoporosis, muscle wasting, hypertension, diabetes, increased susceptibility to infections, and a cushingoid appearance. steroids should be used with caution. we have found the,following precautions helpful: administration of calcium and possibly vitamin d during the administration of steroids and restriction of foods with a high sugar or sodium content. we encourage our patients to eat foods rich in potassium, such as bananas, orange juice, and tomatoes. patients who experience indigestion may benefit from the use of histamine blockers such as ranitidine. some patients may need sedation with diazepam or other agents because of severe mood swings, anxiety, or sleeplessness. patients who receive high doses of methylprednisolone should be observed for hypertension, electrolyte imbalance, and hyperglycemia. these problems should be treated appropriately. occasional psychiatric symptoms, including depression, psychosis, and severe anxiety, may necessitate cessation of steroid therapy. betaseron, a recombinant interferon-& has been approved by the u.s. food and drug administration (fda) for use in ambulatory patients with relapsing-remitting ms. this approval followed a 2year, controlled, double-blind study that showed in patients treated with 8 million units of betaseron administered subcutaneously every other day the relapse rate was reduced to 0.84 relapse per year compared with 1.27 relapses per year in patients given placebo.l13 an mri study performed with the same population revealed fewer new lesions in the treatment group than in the control group.lo the drug did not improve ongoing symptoms. the study was limited to patients with relapsing-remitting disease, and the findings should not be extrapolated to patients with chronic progressive disease. a study of the use of betaseron by patients with chronic progressive ms is planned. patients whose condition is stable would not benefit from the use of betaseron. there are problems with the use of betaseron. although the drug may be helpful in patients with frequent relapses, it does have seri-ous side effects. almost all patients experience local reactions at the site of injection, and some patients have had tissue necrosis at injection sites. the injection site must be changed regularly to reduce the likelihood of ulceration. many patients have a flulike reaction, which may include fever, chills, malaise, and myalgia. this reaction resolves with time and commonly lasts only a few months; however, it may last as long as a year. these symptoms can be partially controlled with acetaminophen or ibuprofen. liver function studies may show abnormalities, and leukopenia may be present. fatigue and emotional disturbances have been reported. our patients have experienced episodes of acute depression and anxiety, and one patient had an episode of uncontrollable rage. depression may necessitate temporary or permanent cessation of betaseron treatment. however, antidepressants, such as fluoxetine, sertraline, and paroxetine hydrochloride, may help counteract the depression. in a few cases, ms appears to worsen when the patient is taking betaseron. acute weakness develops in some patients with the first few injections. this is not always associated with fever and may resolve with time. menstrual irregularities have been reported, and betaseron cannot be used during pregnancy. some patients tolerate the medication better if the full dose is titrated up over approximately 1 month. periodic blood tests to check for leukopenia and abnormal liver function are suggested. clinical trials of other preparations of interferon-a and interferon-13 are nearing completion. one clinical trial involved administration of a weekly intramuscular injection of interferon4la. the results suggested that this drug reduces the likelihood of progression in patients with early disease. 114 a phase iii clinical trial of another investigational agent, copolymer 1, has been completed. this drug appears promising in reducing relapses and has a good safety profile.115j16 these agents will likely be available in the near future, pending fda approval. although most treatment aimed at chronic progression remains experimental, the use of intermittent intravenous methylprednisolone has become a common practice. most commonly, patients who experience subacute worsening may respond to a course of highdose solu-medrol similar to that given for a severe relapse. the condition of some patients appears to stabilize, at least temporarily, with this course of therapy. some patients with progressive disease may respond to a single dose of 1000 mg of solu-medrol in 250 ml of 5% dextrose in water given over 1 hour once a month for 6 to 12 months. subsequent treatments may be given every 6 to 8 weeks. azathioprine has been used for the treatment of chronic progres-sion with some success. studies have shown a modest benefit of azathioprine, primarily in stabilizing the condition of some patients.l17j18 patients who take this drug should be examined for leukopenia or hepatotoxicity. about 15% of patients are unable to tolerate azathioprine because of fever, rash, or nausea. patients with continued progression during therapy with azathioprine or solu-medrol may benefit from combined therapy. cyclosporine was evaluated in a multicenter clinical trial and was found to have modest clinical benefit.llg the prolonged use of cyclosporine in patients with chronic progressive ms was complicated by side effects, principally nephrotoxicity and hypertension. the use of cyclophosphamide in the treatment of chronic progressive ms is controversia1.120-122 the results of clinical trials of this agent in chronic progressive ms are contradictory. the drug may have use in rapidly progressive ms that does not respond to steroid therapy. further investigation with mri and neuropsychological testing and careful clinical assessment should resolve the controversy. a number of promising phase iii clinical trials of therapeutic agents for relapsing-remitting ms are being conducted. for two of these agents, the 2-year placebo-controlled phase has been completed. these are an interferon-& given once a week by intramuscular injection, and copolymer 1. both drugs reduce the frequency of relapses and favorably influence disability. the interferon-l3 is identical to human interferon-8 and differs from betaseron in that it has the sequence of amino acids and glycosylation of human interferon.l14 the results of a review of the safety profile of this drug compared with that of betaseron will be of considerable interest. copolymer 1 appears to have activity similar to that of betaseron with regard to reduction of relapses in ms.l15,116 the side-effect profile appears to be favorable compared with that of betaseron. laboratory investigations demonstrate additive effects of copolymer 1 and interferon-l3 in vitro. because the drugs theoretically act through different mechanisms, combined therapy might be possible. because of the results of a pilot study, oral myelin is being tested in a phase iii clinical trial. lz3 in the pilot trial, the efficacy of the drug was observed in only a subgroup of patients (dr2-negative men). two pilot studies of the use of methotrexate for ms have been performed.124j25 methotrexate in low doses is used for the treatment of rheumatoid arthritis, psoriasis, and crohn's disease. similar therapy may be of benefit to patients with advanced ms.lz5 a phase iii controlled trial and dose response testing will be of considerable interest. methotrexate should be used in clinical settings that allow careful neurologic and laboratory follow-up evaluation. 38 dm, january 1996 cladribine by intravenous administration appears to alter the progression of ms. lz6 the drug has relatively selective toxicity for lymphocytes; however, the side effects can be substantial. additional studies to evaluate dose and route of administration are being initiated. the clinical effects of repeated dosage with this medication also require study. immunoglobulin therapy may be useful in ms; however, controlled trials of intravenous immunoglobulin (ivig) must be completed.lz7 this therapy may be useful in relapsing disease and can be considered for patients with both ms and diabetes. ivig therapy is not necessarily benign and can be responsible for the transmission of viral hepatitis. several clinical trials of monoclonal antibodies are in progress. a number of monoclonal antibodies with specificities for either lymphocytes or adhesion molecules are being subjected to initial trials in human beings. a monoclonal antibody that appears to lower lymphocytes and have an appreciable effect on the lesions of patients with ms as seen on mr images is being studied.lz8 ,%klptomtic therapy one of the most important aspects of the treatment of ms is helping patients manage their ongoing symptoms. because of the chronic nature of the problems associated with ms, medication and adjustments in lifestyle are used to help patients cope with their disabilities. table 6 gives a summary of possible symptomatic treatments. fatigue can be disabling in patients with ms. it is described in different ways by different patients. the classic description of fatigue is increased weakness with exercise or as the day progresses. the patient may walk fairly well in the morning but need a cane or walker by afternoon. other descriptions include sudden attacks of sleepiness or excessive chronic sleepiness, even though the patient has had enough sleep at night.lzg patients who describe fatigue should be questioned closely about their sleep habits and other symptoms of depression. many patients with fatigue may have poor sleep habits or insomnia, which lead to daytime fatigue. depression is a common problem in patients with ms.130 if the fatigue is a product of depression, treatment of the depression should be helpful. fatigue is sometimes managed without medication. patients may respond to one or two brief (15 to 30 minutes) naps during the day. if this is not helpful or not possible, amantadine may be given to help control the problem. the mechanism of action of amantadine is not known, but it is helpful in approximately 40% of patients.lzg side effects, such as dizziness, headaches, nervousness, or edema, may limit the usefulness of the drug. pemoline is a cns stimulant that may be helpful in some patients.131 it should be used in low doses and should generally be given early in the day because it may cause insomnia. anxiety and anorexia are other problems that may occur with this drug. liver function studies should be performed periodically to monitor for hepatotoxicity. fluoxetine (prozac) may be helpful both to increase energy and to treat depression.*32 40 d&z, january 1996 vertigo vertigo can be an intractable and disabling problem. vertigo can occur in sudden spells that last a few minutes, or it can be chronic and last for hours. some physical therapy techniques involve habituation exercises to help with vertigo. medications that may be helpful include meclizine, promethazine hydrochloride, and low-dose diazepam. oscillopsia may occasionally respond to clonazepam or baclofen. vertigo with nausea and vomiting may respond to metoclopramide. spasticity can appear in many different ways. it may be seen at direct examination as a "catch" in the muscles with passive rapid movement of the limbs, or it may cause severe stiffness or rigidity. some patients may have severe spasms of the affected limb, which may be precipitated by movement or occur at night. these are most common in the lower limbs and may be either flexor or extensor spasms. the spasms can be quite painful. primary treatment of spasticity includes physical therapy with stretching exercises, combined with medication. baclofen is the most commonly used drug for spasticity, although its mechanism of action is not known. the dose of baclofen should be low when treatment begins and should be titrated slowly and carefully. patients who take an overdose of baclofen experience weakness. the dose of baclofen is extremely variable-some patients with only moderate spasticity tolerate high doses, whereas others with severe spasticity tolerate only low doses. other limiting side effects include drowsiness, confusion, and nausea. use of baclofen should not be discontinued abruptly but should be tapered over a few weeks.132 *133 diazepam in combination with baclofen may be helpful for patients with severe spasticity or those who cannot tolerate high doses of baclofen but need to control spasticity. diazepam can be used alone for spasticity, but it is not as effective as baclofen.133 diazepam can be particularly helpful for flexor or extensor spasms at night. dantrolene has limited value because of its hepatotoxicity and the weakness that accompanies the muscle-relaxant effect. it may be helpful in intractable cases of spasticity. the baclofen pump was developed for use in patients with intractable spasticity. 134 this device is an intrathecal pump with a subcutaneous reservoir of baclofen that administers continuous doses of baclofen directly into the spinal canal. this method of administration can be effective. with the lower dose delivered directly to the spinal cord, patients seem to have fewer side effects than with other routes of administration. dose levels can be programmed to change throughout the day, so patients with problems that are worse during the night or another part of the day can take increased doses of the drug during those times. tizanidine is an agent used outside the united states for spasticity. 135 it is being studied in the united states and may become available in the near future. other agents that may be useful in the treatment of spasticity include carbamazepine, phenytoin sodium, methocarbamol, and cyclobenzaprine hydrochloride. clonidine patches may be used for adjunctive therapy in patients with persisting spasms who are taking other drugs. spastic dysarthria is an uncommon symptom in ms. speech is hesitant and stuttering, and breath control is difficult. baclofen sometimes is helpful in this condition. bladder dysfunction is an extremely common problem in ms. examination of postvoid residual urine volume and urodynamic testing are extremely important in delineating the causes of bladder dysfunction. other urologic examinations, such as cystoscopy, may help eliminate mechanical problems as the cause of urinary dysfunction. consultation with a urologist skilled in the evaluation of neurologic dysfunction of the bladder is essential to the best therapeutic outcome. the most common problem is a spastic bladder. this is a small, hyperactive bladder. symptoms of this type of bladder dysfunction are urgency, increased frequency, and incontinence in which the bladder empties completely with brief warning. this condition can be treated with anticholinergic agents such as oxybutynin or propantheline .136j37 sometimes baclofen or amitriptyline can be of use in the control of this problem (table 7) . detrusor-external sphincter dyssynergia is a common problem. in this syndrome, the bladder attempts to empty, but the urethra remains closed. symptoms may be urgency and hesitancy, double voiding, and increased frequency with a feeling of incomplete emptying. anticholinergic or tricyclic agents alone may be of help with this syndrome, but more commonly a combination of anticholinergic drugs and intermittent catheterization is needed to control the problem. 137 the patient performs self-catheterization two to four times a day. a flaccid bladder is less common than the other types of bladder dysfunction. this is an enlarged bladder that empties poorly. symptoms include hesitancy, double voiding, a feeling of incomplete emptying, and dribbling incontinence. untreated urinary retention can result in hydronephrosis. urecholine can be of use in a few patients. frequently, however, a schedule of intermittent selfcatheterization may be needed (table 7) . patients with flaccid bladder or sphincter dyssynergia may have frequent urinary tract infections. acidifying agents such as hippuric acid or vitamin c may be useful in the prevention of infections.136 longterm administration of antibiotics should be avoided to reduce the risk z patients with severe bladder problems that are unresponsive to noninvasive therapy may require a chronic indwelling catheter or urinary diversion. these techniques may be required by patients who cannot perform intermittent self-catheterization. sexual dysfunction is common in both men and women with ms. women often report decreased sensation, lack of vaginal lubrication, difficulty achieving orgasm, or painful muscle spasms in the legs or pelvis during intercourse. men report diminished sensation and difficulty in achieving or maintaining an erection or experiencing orgasm. there is no simple answer to the sexual problems that occur with ms. a multidisciplinary approach is needed in which the physical and psychological aspects of sexual problems are considered. for women, treatment of muscle spasms with medications for spasticity may allow intercourse with less pain. techniques to increase vaginal and clitoral stimulation may help women experience orgasm. other methods of increasing arousal may be helpful. men are interviewed to determine whether there are other causes of erectile dysfunction. medications that may affect erectile function should be eliminated if possible. yohimbine, an a-2-adrenergic receptor antagonist, can sometimes help restore function in a patient with borderline function .138 other methods, including papaverine or phentolamine injections, a vacuum erectile device, or a penile prosthesis, may be considered.137 inappropriate affect can be a problem in patients with ms. many patients have severe mood swings that can affect both their work and their social relationships. low-dose amitriptyline or another tricyclic antidepressant is frequently helpful in controlling mood swings.13g depression is a common problem in ms.130j32,140 the suicide rate among persons with ms is estimated to be 7.5 times that of the healthy population. 130 whether the depression is a primary symptom of ms or a situational problem is not known. physicians should be alert to the possibility of depression in their patients. full-dose antidepressant medications and psychological counseling may be beneficial. tremor can be a limiting factor in many patients with ms. treatment with medications is frequently unsuccessful. agents that may be useful include clonazepam, acetazolamide, propranolol, primidone, and diazepam. 132 isoniazid has been reported to be helpful in some patients. 141 we have found clonazepam to be the most helpful of these agents in our patients, but treatment may be limited by drowsiness. a common misconception is that pain is not a symptom in patients with ms. the truth is that pain is often a problem and may be a prominent concern for patients with ms.142 this can be a primary factor in the disease, or it can be a consequence of disability associated with the disease. much of the pain reported with ms is musculoskeletal and is related to abnormal use of muscles and joints. for example, patients who use a wheelchair may experience wrist, shoulder, or elbow pain from manipulating the wheelchair. patients with paraparesis or ataxia may experience back or leg pain from poor posture and balance when walking. these problems should be treated with antiinflammatory medications and physical therapy. primary ms pain is often dysesthetic.14z the patient describes a burning sensation or perhaps even electric shock-like pain. this pain can be in any location, but it is most commonly in the lower extremities. some patients experience tic douloureux or atypical facial pain. this primary pain may be controlled with tricyclic antidepressants, phenytoin, or carbamazepine.142 in patients with refractory pain, valproic acid can be tried. 13z headaches can become a problem in patients with ms. it is not known whether these headaches are caused by ms or are a separate problem. both tension and migraine headaches are common, and treatment is similar to the treatment of headaches in patients who do not have ms. retro-orbital pain is frequently observed in patients with optic neuritis. these patients may require steroid therapy. spasticity and muscle spasms can cause severe pain. treatment of the spasticity helps the pain. many patients with ms experience cognitive abnormalities. unlike the dementia of alzheimer's disease, the cognitive deficits seem to be more scattered and tend to be retrieval deficits rather than memory loss. 143 patients can have substantial cognitive difficulties but still have normal mini-mental state examination findings. neuropsychological studies have shown that as many as 40% of patients may have some cognitive difficulties.143 these difficulties can be important in terms of disability and ability to cope with illness. only a minority of patients have severe cognitive abnormalities. mr images in patients with cognitive problems tend to show a larger number and size of lesions in the white matter of the cerebral hemispheres. frontal lesions are more common in patients with cognitive difficulties.* the corpus callosum may be thinner than normal, as seen on sagittal images.8 patients with cognitive problems should undergo careful neuropsychiatric testing. sometimes depression or anxiety can be contributing factors in these symptoms. the minnesota multiphasic personality index or the beck depression scale in conjunction with cognitive testing may be helpful in differentiating emotional problems from structural cognitive deficits. proper treatment of the anxiety or depression may lead to improved cognitive function. recognition of the areas and degree of cognitive difficulty in patients with ms may be helpful in the care of the patients. patients may be able to learn ways of working around a problem. problems with a job may be related to cognitive problems, and ways of altering the job may be found. patients may become disabled from working because of these problems. this testing also may help the family understand the need for helping the patient deal with problems that have become too difficult to handle alone. cognitive rehabilitation techniques are being tested for patients with ms in some centers. further investigation is needed to evaluate the efficacy of these techniques. careful assessment of the patient's abilities and disabilities is crucial for proper management. in many patients, chronic symptoms cannot be prevented. symptomatic therapies are often effective for alleviating the afflictions produced by ms and for allowing the patients to live a productive and comfortable life. the cause of ms is unknown. theories revolve around the idea that the disease is either autoimmune or virus-mediated. it is still reasonable to question which pathologic feature is the inciting event. much research is focused on the t cell and potential mechanisms by which these cells could initiate ms. hla associations are found in many populations; however, hla markers are neither necessary nor sufficient to confer disease susceptibility, and other factors that confer disease susceptibility are being sought. at this time there is no confirmed evidence of a viral cause of ms. investigations with in situ hybridization and pcr technology are being conducted in an attempt to identify viral nucleic acids in the cns. perhaps these techniques will assist in unraveling the pathogenesis of ms. an intriguing possibility is that molecular mimicry may be re-sponsible for the initial generation of autoreactive lymphocytes. this mechanism involves exposure to viral or bacterial antigens, which generates an immunologic response that consists of reactive t-cell populations. because t cells cross-react with myelin peptides, a potential for demyelination exists. this theoretic mechanism is known to cause demyelination in rabbits. 144 an interesting investigation of human mbp-reactive t cells demonstrates that mbp-specific t-cell clones can recognize multiple viral polypeptides presented by dr2 or dql mhc antigens. 145 this would imply that ms could be generated by exposure to any one of a number of antigenic stimuli, such as influenza viruses or herpesviruses or even bacterial antigens. selected activated t-cell populations that enter the cns could then recognize a myelin epitope and initiate the autoimmune response, which would persist long after the inciting infection was cleared. recent investigation with mr spectroscopy demonstrates that white matter outside ms plaques may be abnorma1.14" these findings may signify that there is a fundamental abnormality in the white matter. whether these findings are secondary to genetic, biochemical, autoimmune, or viral factors remains to be determined. despite the deficiencies in our understanding of disease pathogenesis, therapy for ms has advanced. phase iii clinical trials with interferon-8 and copolymer 1 have demonstrated modest but definite benefit. the mechanisms by which these drugs favorably influence the clinical course of ms remain to be elucidated. recent studies of chemotherapeutic agents suggest that control of chronic progressive disease may be a real possibility. future clinical trials will attempt to define the efficacy of and parameters for these therapies. another question that remains unanswered is whether the use of multiple-drug therapy might be beneficial in the treatment of ms. for example, combined therapy with interferon-i3lb and copolymer 1 may produce more benefit than either drug alone. in chronic progressive disease, the use of solu-medrol in combination with another immunosuppressant such as azathioprine or methotrexate also should be explored. remyelination is another topic of interest for future research. research is being conducted into the use of ivig as a remyelinating agent. in addition, oligodendrocyte transplant experiments are being conducted in canine modes and may eventually be used for human patients. research involving medications to improve the symptoms that limit the lives of many patients with ms is ongoing and should continue. 4-amino-pyridine and 2,3-diamino-pyridine are being studied as agents that may improve conduction through poorly myelinated areas. these agents may reduce double vision, improve strength, and possibly reduce tremor. more research is needed to evaluate these dm,january 1996 47 and other compounds that may improve the quality of life of many patients with ms. although the cause of ms remains a mystery, important advances have been made in the understanding and treatment of ms in the past few years. as this trend continues, we may have more diverse and effective therapies to offer patients with ms in the years to come. lectures on the diseases of the nervous system multiple sclerosis multiple sclerosis benign versus chronic progressive multiple sclerosis: magnetic resonance imaging features neuroimaging in multiple sclerosis acute vith cranial nerve dysfunction in multiple sclerosis genetic epidemiology of multiple sclerosis: a survey genetics of multiple sclerosis a population-based study of multiple sclerosis in twins: update genetic analysis of autoimmune type i diabetes mellitus in mice demyelinating diseases oligodendrocytes in the early course of multiple sclerosis allen iv pathology of multiple sclerosis tumor necrosis factor identified in multiple sclerosis brain histopathology and the bloodcerebrospinal fluid barrier in multiple sclerosis multiple sclerosis: oligodendroglia survival and proliferation in an active established lesion isolation of myelin basic proteinreactive t-cell lines from normal human blood assessment of antigenic determinants for the human t cell response against myelin basic protein using overlapping synthetic peptides heterogeneity of the t-cell receptor beta gene rearrangements generated in myelin basic proteinspecific t-cell clones isolated from a patient with multiple sclerosis a myelin basic protein peptide is recognized by cytotoxic t cells in the context of four hla-dr types associated with multiple sclerosis t and b cell responses to myelin-oligodendrocyte glycoprotein in multiple sclerosis antibodies to myelin-oligodendrocyte glycoprotein in cerebrospinal fluid from patients with multiple sclerosis and controls multiple sclerosis: cells secreting antibodies against myelin-associated glycoprotein are present in cerebrospinal fluid multiple sclerosis is associated with genes within or close to the hla-dr-dq subregion on a normal dr15, dq6, du2 haplotype the molecular and genetic basis of neurological disease linkage strategies for genetically complex traits. part 1. multilocus models multiple sclerosis: diagnostic usefulness of cerebrospinal fluid immunoglobulin abnormalities in the guillain-barre syndrome relationship between measles virus-specific antibody activities and oligoclonal igg in the central nervous system of patients with subacute sclerosing panencephalitis and multiple sclerosis multiple sclerosis: relationship to a retrovirus? multiple sclerosis and human tcell lymphotrophic retroviruses amplification and molecular cloning of htlv-i sequences from dna of multiple sclerosis patients htlv1 and tropical spastic paraparesis the g and brahic m analysis of human tlymphotrophic virus sequences in multiple sclerosis tissue serologic studies of ms patients, controls, and patients with other neurologic diseases: antibodies to htlv i human t lymphotrophic virus type i may not be associated with multiple sclerosis in japan detection of human t-cell lymphoma virus type i dna and antigen in spinal fluid and blood of patients with chronic progressive myelopathy detection of coronavirus rna and antigen in multiple sclerosis brain bacterial toxin superantigens activate human t lymphocytes reactive with myelin autoantigens v-beta specific stimulation of human t cells by staphylococcal toxins the t lymphocyte in experimental allergic encephalomyelitis adoptive transfer of myelin basic proteinsensitized t cells produces chronic relapsing demyelination disease in mice adoptive transfer of experimental allergic encephalomyelitis in sjl/j mice after in vitro activation of lymph node cells by myelin basic protein: requirement for lyt-1+2-t lymphocytes pathogenesis of theiler's murine encephalomyelitis virus cellular immunity in chronic theiler's virus central nervous system infection characterization of theiler's murine encephalomyelitis virus (tmev)-specific delayed hypersensitivity response in tmev-induced demyelinating disease, correlation with clinical signs prevention and treatment of chronic relapsing experimental allergic encephalomyelitis by transforming growth factor-beta 1 chimeric cytotoxin il2-pe40 inhibits relapsing experimental allergic encephalomyelitis limited heterogeneity of tcell receptors from lymphocytes mediating autoimmune encephalomyelitis allows specific immune intervention experimental allergic encephalomyelitis by t cell receptor v-beta-specific antibodies immunization with a synthetic t-cell receptor v-region peptide protects against experimental autoimmune encephalomyelitis prevention of experimental encephalomyelitis with peptides that block interaction of t cells with mhc proteins prevention of experimental autoimmune encephalomyelitis by antibodies against alpha, beta, integrin aminoguanidine, an inhibitor of inducible nitric oxide synthase, ameliorates experimental autoimmune encephalomyelitis in sjl mice isolated pupil-sparing third nerve palsy as the presenting sign of multiple sclerosis the ocular manifestations of multiple sclerosis. part 2. abnormalities of eye movements optic neuritis and ischemic optic neuropathy: overlapping clinical profiles mcalpine's multiple sclerosis nystagmus in multiple sclerosis acquired pendular nystagmus in multiple sclerosis: clinical observations and the role of optic neuropathy cerebrospinal fluid in the diagnosis of multiple sclerosis: a consensus report formulas for the quantitation of intrathecal igg production: their validity in the presence of blood-brain barrier damage and their utility in multiple sclerosis new diagnostic criteria for multiple sclerosis: guidelines for research protocols trimodal evoked potentials compared with magnetic resonance imaging in the diagnosis of multiple sclerosis contribution of mri to the diagnosis of multiple sclerosis national multiple sclerosis society working group on neuroimaging for the medical advisory board the role of i\tmr imaging in the assessment of ms and isolated neurological lesions fazekas e magnetic resonance signal abnormalities in asymptomatic individuals: their incidence and functional correlates criteria for an increased specificity of mri interpretation in elderly subjects with suspected multiple sclerosis nuclear magnetic resonance image white matter lesions and risk factors for stroke in normal individuals mri brain scanning in patients with vasculitis: differentiation from multiple sclerosis magnetic resonance imaging in central nervous system sarcoidosis mri findings in neuro-behcet's disease assessment of mri criteria for a diagnosis of ms patterns of disease activity in multiple sclerosis: a clinical and magnetic resonance imaging study spinal cord mri using multi-array coils and fast spin-echo. part 2. findings in multiple sclerosis problems of experimental trials of therapy in multiple sclerosis: report by the panel on evaluation of experimental trials of therapy in multiple sclerosis influenza1 encephalopathy and post-influenza1 encephalitis lyme disease: recommendations for diagnosis and treatment human t-lymphocyte virus type i antibodies in the serum of patients with tropical spastic paraparesis in the seychelles the diagnosis of childhood neurodegenerative disorders presenting as dementia in adults textbook of child neurology risk of developing multiple sclerosis after uncomplicated optic neuritis: a long-term prospective study transverse myelitis: retrospective analysis of 33 cases, with differentiation of cases associated with multiple sclerosis and parainfectious events long-term follow-up of acute partial transverse myelopathy early risk of multiple sclerosis following isolated acute syndromes of the brainstem and spinal cord prognostic significance of brain mri at presentation with a clinically isolated syndrome suggestive of ms: a five-year follow-up study neuromyelitis optica and schilder's myelinoclastic diffuse sclerosis prognostic factors in a multiple sclerosis incidence cohort with twenty-five years of follow-up multiple sclerosis: early prognostic guidelines studies on the natural history of multiple sclerosis: eight early prognostic features of the later course of the illness cardiovascular testing and exercise prescription in multiple sclerosis patients multiple sclerosis. part 1. common physical disabilities and rehabilitation multiple sclerosis andgestation pregnancy and multiple sclerosis: a longitudinal study of 125 remittent patients pregnancy and multiple sclerosis: a prospective study pregnancy and multiple sclerosis the effect of pregnancy in multiple sclerosis the effects of induced hyperthermia on patients with multiple sclerosis clinical viral infections and multiple sclerosis multiple sclerosis: treatment of acute exacerbations with corticotropin (acth) use of oral corticosteroids in the treatment of multiple sclerosis: a double-blind study a double-blind controlled trial of high dose methylprednisolone in patients with multiple sclerosis: part 1. clinical effects a randomized, controlled trial of corticosteroids in the treatment of acute optic neuritis the effect of corticosteroids for acute optic neuritis on the subsequent development of multiple sclerosis ifnb multiple sclerosis study group. interferon beta-lb is effective in relapsing-remitting multiple sclerosis results of a phase iii trial of intramuscular recombinant beta interferon as treatment for multiple sclerosis experimental therapy of relapsing-remitting multiple sclerosis with copolymer-l clinical experience with cop-l in multiple sclerosis clinical experience with azathioprine: the pros azathioprine in multiple sclerosis: the cons efficacy and toxicity of cyclosporine in chronic progressive multiple sclerosis: a randomized, double-blind, placebo-controlled clinical trial intensive immunosuppression in progressive multiple sclerosis: a randomized, three-arm study of highdose intravenous cyclophosphamide, plasma exchange, and acth experience with cyclophosphamide in multiple sclerosis: the cons intermittent cyclophosphamide pulse therapy in progressive multiple sclerosis: final report of the northeast cooperative multiple sclerosis treatment group double-blind pilot trial of oral tolerization with myelin antigens in multiple sclerosis meydrech ee low dose oral methotrexate treatment of multiple sclerosis: a pilot study low-dose (7.5 mg) oral methotrexate reduces the rate of progression in chronic progressive multiple sclerosis cladribine in treatment of chronic progressive multiple sclerosis open controlled therapeutic trial of intravenous immune globulin in relapsing-remitting multiple sclerosis preliminary evidence from magnetic resonance imaging for reduction in disease activity after lymphocyte depletion in multiple sclerosis amantadine therapy for fatigue in multiple sclerosis depression and multiple sclerosis a double-blind, randomized crossover trial of pemoline in fatigue associated with multiple sclerosis new advances in symptom management in multiple sclerosis antispasticity drugs: mechanisms of action intrathecal baclofen for spasticity of spinal origin: seven years of experience safety and efficacy of tizanidine in therapy of spasticity secondary to multiple sclerosis management of bladder dysfunction in multiple sclerosis urological and sexual problems in multiple sclerosis the role of yohimbine for the treatment of erectile impotence treatment of pathologic laughing and weeping with amitriptyline suicide in the medical patient a controlled trial of isoniazid therapy for action tremor in multiple sclerosis pain syndromes in multiple sclerosis fujinami rs, oldstone mba. amino acid homology between the encephalitogenic site of myelin basic protein and virus: a mechanism for autoimmunity molecular mimicry in t cell-mediated autoimmunity: viral peptides activate human t cell clones specific for myelin basic protein fdg-pet, mri and nmr spectroscopy of normal appearing white matter (nawm) in multiple sclerosis key: cord-022594-fx044gcd authors: pirko, istvan; noseworthy, john h. title: demyelinating disorders of the central nervous system date: 2009-05-18 journal: textbook of clinical neurology doi: 10.1016/b978-141603618-0.10048-7 sha: doc_id: 22594 cord_uid: fx044gcd nan demyelinating disorders of the central nervous system istvan pirko and john h. noseworthy multiple sclerosis (ms) is now known to be a common malady even though it was first recognized as a distinct clinicopathological entity less than 150 years ago. 1 the lack of clear medical reports before the early 1800s is sometimes interpreted as evidence that ms is a relatively new disease. however, it is more likely that the evolution of medicine into science led to more precise observation and description of human diseases, including ms. saint lidwina of schiedam (1380-1433) developed a relapsing neurological disorder at the age of 18 and may be the first case of clinically described ms. 2 ollivier was the first to report a clinical case in the medical literature in 1824. 1 shortly thereafter, carswell illustrated a case of what is now clearly recognizable as ms in his atlas of anatomical pathology. cruveilhier published gross pathological and clinical descriptions of ms. vulpian first suggested the rubric of "sclerose en plaque" in 1866. charcot was primarily responsible for establishing ms as a unique and recognizable syndrome. 3 he also described the clinical spectrum and the histological appearance. pierre marie was the first to suggest an infectious cause of ms in 1884, a hypothesis that is still debated. toxins were also considered to be responsible in the early 1900s. a major advance toward the understanding of demyelinating diseases was the discovery of experimental allergic encephalomyelitis (eae) by rivers in 1935. 4 a variety of different demyelinating diseases have subsequently been described (table 48 -1). myelin provides insulation for axons and is necessary for saltatory conduction. it is composed of tightly wrapped lipid bilayers with specialized protein constituents. peripheral nervous system (pns) myelin is formed by the extension of schwann cells, and central nervous system (cns) myelin is produced by oligodendrocytes. the myelin coating is interrupted at regular intervals (nodes of ranvier) where the axon membrane with its concentration of voltagegated sodium channels is exposed to the extracellular environment ( fig. 48-1) . 5 the presence of myelin is essential to maintain conduction velocity; its loss or damage can lead to significantly slower conduction or conduction block. other factors affect conduction velocity including certain antibodies and chemicals like nitric oxide. in certain cases, blockade may be the initial event in the cascade of events leading to demyelination. cns and pns myelin differ in a number of important ways. schwann cells myelinate only one internodal segment from a single pns axon, whereas oligodendrocytes myelinate multiple cns axons. the proteins also differ. proteolipid protein (plp) accounts for approximately 50% of the cns myelin proteins. mutations in this highly conserved protein cause pelizaeus-merzbacher disease. protein zero is the major pns myelin protein and performs a function similar to plp in compacting the intraperiod line. myelin basic protein (mbp) makes up 30% of cns and 10% of pns myelin proteins. mbp is not an integral protein but binds to the cytoplasmic surface and is responsible for compaction at the major dense line. myelin associate glycoprotein accounts for about 1% of both peripheral and central myelin. myelin oligodendrocyte glycoprotein and cyclic nucleotide phosphodiesterase are minor constituents of cns myelin and are not found in the pns. peripheral myelin protein 22 is a minor component of pns myelin. ms is an inflammatory relapsing or progressive disorder of cns white matter and is a major cause of disability in young adults. pathologically, it is characterized by multifocal areas of demyelination, loss of oligodendrocytes, and astrogliosis but with relative preservation of axons. while demyelination is the classic hallmark of ms, axonal and neuronal injury are important aspects of the disease and are gaining more recognition. although certain clinical features are characteristic of ms, investigative studies are often needed to confirm the clinical suspicion and exclude other possibilities. recently, there have been advances in understanding the etiology, mechanisms of myelin injury, and potential for repair, and several partially effective agents are now approved for use in relapsing-remitting and secondary progressive ms. the pathogenesis and pathophysiology of ms remains incompletely understood. several mechanisms may be important to ms plaque formation: autoimmunity, infection, bystander demyelination, and heredity. although convincing proof is lacking, dietary factors and toxin exposure have been hypothesized to contribute as well. these mechanisms are not mutually exclusive, and the true pathophysiology is likely to depend on more than one of them. autoimmunity. during ontogenesis, autoreactive lymphocytes normally undergo clonal depletion, but some escape and are merely suppressed, becoming tolerant to their antigens. low levels of autoreactive t and b cells persist even in normal individuals. autoimmune disorders occur when the tolerance of these cells toward their antigen is broken. the decreased suppressor activity of circulating lymphocytes from patients with ms and other presumed autoimmune diseases may reflect loss of tolerance. 6 one potential mechanism that may break tolerance is molecular mimicry between self and foreign antigens. autoreactive t4 lymphocytes may become activated on exposure to structurally similar foreign antigens. some evidence suggests that molecular mimicry is relevant in ms. not only do several viral and bacterial peptides share structural similarities with mbp, but it has also been demonstrated that these antigens may activate mbp-specific t-cell clones derived from ms patients. 7 blood-brain barrier leakage alone may break tolerance because it gives cnsreactive lymphocytes easy access to otherwise inaccessible antigens. alternatively, a primary event such as an infection or injury may release cns antigens into the periphery, where they may activate corresponding autoreactive cells. 8 the major support for autoimmunity in the pathogenesis and pathophysiology of ms is by analogy to eae, the major animal model for ms. eae is, however, an artificial situation and there is no spontaneous autoimmune animal model of ms. while eae is the most commonly studied model of ms, several features of human ms can not be adequately captured by this model. 9, 10 over a hundred different effective treatments have been described for eae; however, almost all of them are ineffective and some are harmful in human ms. a recent editorial discusses the merits and important limitations of eae as a model for ms. 10 in eae, just like in classic human autoimmune diseases such as systemic lupus erythematosus (sle) or rheumatoid arthritis, the main target antigens are known. however, despite the discovery of several "weak" antigens in human ms, no dominant antigens have been identified to date. the only human demyelinating disease with an identified specific antigen is devic's disease (neuromyelitis optica), which appears to be a novel autoimmune chanellopathy with an antigen that is neither neuronal nor myelin related (see later discussion of devic's syndrome under neuromyelitis optica). 11 infection. the role of viral infections in the initiation and maintenance of ms has been debated for some time. several viral infections are known to cause demyelination in animals, including visna virus of goats and sheep, canine distemper virus, and theiler's murine encephalomyelitis virus. viral infections in humans can also cause demyelination (progressive multifocal leukoencephalopathy [jc papillomavirus], subacute sclerosing panencephalitis [measles virus], and human t-cell lymphotropic or leukemia virus type 1 [htlv-1]-associated myelopathy). the epidemiology of ms suggests that environmental factors may promote the disease state, possibly due to one or more viruses. a virus may be involved in the pathogenesis of ms in several ways: 1. transient or persistent infection outside the cns may activate autoreactive t cells by means of molecular mimicry or by other nonspecific means (as superantigens do). 2. transient cns infection may initiate a cascade of events that fosters autoimmunity (breach the blood-brain barrier, release cns antigens). 3. recurrent cns infections may precipitate repeated inflammation and demyelination. 4. persistent cns viral infection could either incite inflammatory reactions detrimental to oligodendrocytes or directly injure them. beyond speculation and epidemiological observations, there is insufficient evidence for a viral infection playing a causative role in ms. early serological studies are difficult to interpret because of nonspecific immune activation and resulting elevation of titers to many different viruses. many ms patients have elevated cerebrospinal fluid (csf) titers to measles and herpes simplex (hsv) viruses, but this finding appears nonspecific. virus has rarely been cultured from csf of ms patients, but a new strain of hsv (the ms strain) and a new virus (inoue-melnick virus) were first isolated from the csf of ms patients. 12, 13 newer molecular techniques to search for a viral genome in csf and brain have rejected the claim that htlv-1 is associated with ms. the finding that human herpesvirus 6 (hhv6), although present in 70% of brains from both control subjects and ms patients, is localized to the oligodendrocyte nuclei near plaques of ms patients and to oligodendrocyte cytoplasm in control subjects indicates that persistent cns viral infection is common. 14 this raises the possibility that ms may depend on an aberrant host response to this normal condition or that a defective virus that lacks the ability to evade immune detection may be to blame. more recently, measles and canine distemper virus antibodies were found elevated in blood and csf samples of ms patients, although their relationship is not clear to the disease process. in a study from denmark, patients with serological markers for late-stage epstein-barr virus (ebv) infection had a threefold increase in the likelihood of developing ms. a follow-up study from sweden failed to reach this conclusion. in general, serum samples of ms patients may contain higher titers of antibodies to the following infectious organisms: adenovirus, canine distemper virus, hsv, hhv6, and influenza, measles, mumps, parainfluenza, rubella, vaccinia, and varicella zoster virus (vzv). similarly, csf samples from ms patients may show higher titers of adenovirus; chlamydia pneumoniae; cytomegalovirus (cmv); ebv; hhv6; coronavirus; influenza viruses a and b; measles or mumps virus; mycoplasma pneumoniae; parainfluenza viruses 1, 2, and 3; respiratory syncytial virus; rubella virus; vaccinia; and vzv. there has been an interest recently in a potential link between c. pneumoniae infection and the development of ms. no direct cause-and-effect relationship has been observed between any of these infections and ms. "bystander" demyelination. immune actions may mediate myelin injury in a nonspecific manner. many soluble products of the immune response other than immunoglobulins are known or suspected to be toxic to myelin and oligodendrocytes. activated complement is capable of lysing oligodendrocytes in an antibody-independent fashion. 15 the proinflammatory cytokine tumor necrosis factor-a causes myelin disruption and oligodendrocyte apoptosis in vitro. 16 arachidonic acid metabolites may also participate in myelinolysis, and reactive oxygen species released by macrophages cause lipid peroxidation that can damage myelin. other soluble substances that are potentially toxic to myelin include nitric oxide and vasoactive amines. histological subtypes of ms lesion development. through the groundbreaking work of lucchinetti and associates in the ms lesion project, it is postulated that the formation of ms lesions follows one of four patterns. 17 patterns i and ii are related to immune-mediated damage to myelin sheaths. in pattern i, cellular mechanisms of injury seem to prevail (macrophages and t-lymphocytes) whereas in pattern ii humoral mechanisms of injury predominate (e.g., antibody and complement-mediated mechanisms). patterns iii and iv are related to oligondendrocye pathology: in pattern iii, a distal oligdendrogliopathy and apoptosis have been reported, whereas in pattern iv, primary oligodendrogliopathy and degeneration of oligodendrocytes have been described. currently these subtypes can be diagnosed only by biopsy; serum and magnetic resonance imaging (mri) markers are not yet known, although lesional t2 hypointense rims and response to plasma exchange may correlate well with pattern ii pathology. it is important to note that the patterns do not correlate with clinical subtypes of ms, with the exception of pattern iv, which has been identified only in primary progressive (ppms) patients. evidence to date suggests that the pattern of lesion formation remains the same within an individual patient; patients do not "switch" from one pattern to the other. also, the patterns do not seem to represent different chronological stages of lesion formation. gray matter involvement. it has been known since the late 19th century that ms affects both gray and white matter structures. the importance of gray matter involvement has received little attention until recently, largely due to the development of advanced mri techniques (see later) that indicate neuronal and axonal involvement even in the earliest stages of this disease. a classification system of gray matter plaques was proposed by peterson and associates 18 they described three patterns of cortical demyelination: type i lesions are contiguous with subcortical white matter lesions; type ii lesions are confined to the cortex, and are often perivascular; type iii lesions extend from the pial surface to cortical layer 3 or 4. besides cortical gray matter involvement, there is also evidence for prominent basal ganglia involvement, which can be seen in the early stages of ms, and may correlate better with motor outcome and cognitive measures than measures of white matter involvement. lucchinetti and associates demonstrated that biopsy samples from newly diagnosed demyelinating cases contain numerous infiltrating immune cells, and can be destructive. the pathological classification of cortical lesions as described by petersen can also be found in these early ms biopsy samples. approximately 20% of biopsy cases in which gray matter was also sampled had evidence of clear cortical demyelination. in 2005, an extensive histological study by kutzelnigg and associates investigated the role of cortical demyelination in all clinical subtypes of ms. 19 in this study, 52 brains of ms patients (relapsing-remitting [rr], secondary progressive [sp], and ppms) and 30 control subjects were studied using advanced quantitative morphological techniques. cortical demyelination and diffuse axonal injury in the normal appearing white matter (nawm) were reported as hallmarks of progressive forms of ms. cortical demyelination was mainly seen in the subpial layer of cortex, and was associated with significant inflammatory infiltrates in the surrounding meninges. diffuse inflammation was also found throughout the white matter of the progressive cases, associated with activation of microglia. no significant correlation was shown between focal white matter lesion load and cortical demyelination. this study defines three crucially important pathological hallmarks of ms-focal demyelinated white matter lesions, diffuse injury in the white matter, and cortical plaque formation-and concludes that white matter lesion formation predominates in active forms of ms, while cortical pathology and diffuse white matter injury characterizes the progressive forms. the authors of this landmark paper also established that these three processes are potentially independent of each other. heredity. epidemiological findings support a polygenic hereditary predisposition to ms. a number of candidate genes have been investigated, often with conflicting results. the only definitive genetic association in ms is with the serologically defined human leukocyte antigen (hla) dr15, dq6. this is one of the dr2 haplotypes, also known as dw2 in cellular terminology and drb1*1501, dqa1*0102, dqb1*0602 in molecular nomenclature. though its link to ms is well established, the risk conferred by this haplotype is small (relative risk of 3 to 4), and it is neither necessary nor sufficient for the development of ms. linkage to this locus has not been proved, indicating that it plays only a minor role in familial susceptibility. other susceptibility genes likely contribute, possibly the t-cell receptor variable b region and the igg heavy-chain variable region (especially the vh2-5 gene). but their specific roles have not been established. other genes under study have been the mbp coding gene, the ctla-4 gene on chromosome 2q33, and the interleukin-1ra associated gene, in concurrence with the hla-dr15 haplotype. mitochondrial mutations are also under investigation, and an lhon-associated mtdna mutation may be an important cofactor in developing ms in some patients. the apoe4 gene, as in alzheimer's disease, has been associated with a higher incidence of ms. on the other hand, apoe3 is considered to have neurotropic, immunomodulatory, and antioxidant properties. these findings are yet to be confirmed by larger studies. twenty percent of ms patients have at least one affected relative. only about 4% of first-degree relatives of patients develop ms, but this represents a 20-to 40-fold increase in risk compared with the general population. unaffected family members sometimes have abnormal findings on cranial mri, implying that this risk is even higher. one study of ms rates in adopted relatives of ms patients verified that the familial distribution is due to genetic factors rather than shared environment. 20 twin studies lend support to both genetic and environmental influences on ms development. genetically identical monozygotic twins are more often concordant for ms than dizygotic twins (26% and 2.4%, respectively), indicating a genetic component; 21 however, even after following monozygotic twins past age 50 or using mri data, less than 50% are concordant, suggesting a role for environmental factors. epidemiology and risk factors. ms is not a rare disease. it affects millions worldwide and approximately 400,000 in the united states alone. symptoms usually begin during young adulthood, with the peak onset at age 24. approximately 0.3% of ms cases are diagnosed before age 15. women are affected nearly twice as often as men. ms has a predilection for whites, especially those of northern european heritage. other races and ethnic populations are resistant to a variable extent. ms is virtually unknown among black africans but occurs in african-americans at half the rate of whites, possibly due to racial admixture or environmental factors. ms is rare in tropical areas, and the prevalence increases proportionally to the distance from the equator, excluding polar regions. the prevalence is less than 5 cases per 100,000 in tropical areas; in high prevalence areas it can be higher than 30 per 100,000, 22 reaching up to 100 per 100,000 in selected areas. although usually interpreted as the effect of environmental factors, the prevalence gradient is at least partially due to racial susceptibility. 23 perhaps the most incriminating evidence for the role of environmental factors in the development of ms is the changing risk with migration and the occurrence of ms clusters and epidemics. immigrant populations tend to acquire the ms risk inherent to their new place of residence. migration from high to low prevalence before the age of 15 lowers the ms risk, whereas migration after this age does not affect risk. 18 migration from low to high prevalence areas increases the risk of ms, but the effect of age is less clear. many clusters of ms have been reported. 24, 25 the occurrences of ms epidemics in iceland and the faroe islands have been proposed to be the result of exposure to a pathogen brought by british troops during their occupation in world war ii. other environmental factors associated with the development of ms include cigarette smoking (odds ratio of 1.81, ci: 1.1-2.9), animal fat intake, and deficiency of vitamin d. 26, 27 epidemiological data support the view that ms is caused or triggered by an environmental factor in persons who are genetically susceptible. the familial frequency and distribution implies that several genes contribute to susceptibility, and this is consistent with the low relative risk conferred by the genetic loci studied so far. data from clusters, migration studies, and family studies reveal that there is a latent period of some 20 years between exposure to the environmental factor and the development of clinical symptoms and that the age at exposure is around 15, the putative age at acquisition. the precise environmental events that lead to cns demyelination are uncertain. viral infection is the most plausible, but because of the nonspecific elevation of viral titers and long latent period, there is little direct evidence. minor respiratory infections precede 27% of relapses in patients with established ms. measles infection was found to have occurred at a later age in ms patients than control subjects, although the incidence of ms has not been reduced by immunization against measles. head injury and trauma have received attention as putative triggering events, but cohort studies have not verified any link. pregnancy does not alter the risk of developing ms, but it does seem to influence disease activity. the annualized relapse rate drops from approximately 0.56 to 0.12 by the third trimester, but this is offset by an increase to 1.2 in the first 3 postpartum months. most studies have found no longterm effects of pregnancy on the prognosis for progression or disability, although one did report a favorable effect. 28 a multitude of other environmental factors have been suspected to alter the risk for ms (cold climate, precipitation, amount of peat in the soil, exposure to dogs, and consumption of meat, processed meat, and dairy products), but none has been verified to be an independent risk factor. ms can cause a wide variety of clinical features. many signs and symptoms are characteristic, and a few are virtually pathognomonic for the disorder. conversely, some symptoms are atypical and some are so rare as to suggest a different diagnosis (table 48 -2). the course of the illness is also variable, but it remains a critical consideration in the diagnosis of ms. sensory symptoms are the most common presenting manifestation in ms (21% to 55%) and ultimately develop in nearly all patients. 29 loss of sensation (numbness), paresthesias (tingling), dysesthesias (burning), and hyperesthesias are common. these symptoms may occur in practically any distribution: one or more limbs, part of a limb, trunk, face, or combinations. the more distinctive sensory relapses of ms consist of the sensory cord syndrome and the sensory useless hand syndrome. a common scenario is that of numbness or tingling beginning in one foot, ascending first ipsilaterally and then contralaterally. the sensory symptoms may ascend to the trunk, producing a sensory level, or may involve the upper extremities. associated symptoms commonly include poor balance, weakness, urinary urgency, constipation, and lhermitte's sign (see later). brown-sã©quard syndrome may occur with sensory disassociation and hemiparesis. the sensory cord syndrome reflects an evolving demyelinating lesion that begins in the medial posterior column ipsilateral to the first symptoms. sensory cord syndromes are common in ms and suggest the diagnosis when they occur in young persons and remit spontaneously or in response to corticosteroids. patients with the sensory useless hand may note subjective numbness and lose discriminatory and proprioceptive function, resulting in difficulty writing, typing, buttoning clothes, and holding onto objects, especially when not looking at the hand. this problem can occur bilaterally even without lower extremity symptoms. the responsible lesion is in the lemniscal pathways either in the cervical spinal cord or in the brain stem. this syndrome usually remits over several months. the useless hand syndrome is a very specific symptom and is only rarely caused by other disorders. a large portion of ms patients have persistent sensory loss, usually consisting of diminished vibratory and position sensation in distal extremities (video 5, sensory ataxia). itching may occur in a dermatomal distribution with relapse or in paroxysms. pain is not a major manifestation of ms, but distressing lower extremity dysesthetic pain associated with spinal cord involvement, radicular pain from lesions at the root entry zone, paroxysms, and an uncomfortable sensation of pressure or tightness surrounding a leg or the trunk may be present. pyramidal tract dysfunction is common in ms and causes weakness, spasticity, loss of dexterity, and hyperreflexia (video 80, hyper-reflexia). motor deficits can occur acutely or in a chronic progression with weakness of one or more limbs and facial weakness, leg stiffness that impairs gait and balance, or extensor and flexor spasms (video 3, spastic gait). exercise or heat frequently worsens subtle deficits. muscle atrophy is usually due to disuse, but lesions of lower motor neuron fibers or of the anterior horn itself can cause a pseudoradiculopathy with segmental weakness, atrophy, and diminished reflexes. motor symptoms are presenting manifestations of ms in 32% to 41% of all cases; their prevalence is higher than 60% in long-standing ms. the initial symptom of ms is optic neuritis (on) in 14% to 23% of patients, and more than 50% experience a clinical episode of on during their lifetime. the most common manifestation is visual loss in one eye that evolves over a few days. periocular pain, especially with eye movement, usually accompanies and may precede the visual symptoms. bilateral simultaneous on is uncommon in adults, but formal visual field testing reveals unexpected defects in the clinically normal eye in a substantial number of patients. children and asian patients are more likely to have bilateral simultaneous on; it may also be seen in neuromyelitis optica (nmo) patients. examination shows an afferent pupillary defect, diminished visual acuity, subdued color perception, and often a central scotoma (video 200, afferent pupillary defect). funduscopic examination is usually normal but occasionally will reveal papillitis (more common in children) or venous sheathing. most patients begin to recover within 2 weeks, and significant visual patients with frequent and severe on events in the first 2 years were more likely to convert to nmo; they also had a higher likelihood for significant persistent vision loss. 30 cerebellar pathways are frequently involved during the course of ms, but a predominately cerebellar syndrome is uncommon at onset. the manifestations include dysmetria, dysdiadochokinesia (video 12, dysdiadochokinesis), action tremor with terminal accentuation, dysrhythmia, breakdown of complex motor movements, and loss of balance (video 14, tremor with ataxia). patients with long-standing ms may develop a "jiggling" gait and an ataxic dysarthria with imprecise articulation, scanning speech, or varying inflection, giving it an explosive character. urinary urgency, frequency, and urge incontinence (due to detrusor hyper-reflexia or detrusor-sphincter dyssynergia) result from spinal cord lesions and are frequently encountered in ms patients. the combined incidence of bowel and bladder dysfunction in ms is thought to be higher than 70%. symptoms of bladder dysfunction may be transient and occur with an exacerbation but are commonly persistent. impaired vesicular sensation causes a high capacity bladder and may lead to bladder atonia with thinning and disruption of the detrusor muscle. incontinence results in constant dribbling of urine in this irreversible condition. interruption of brain stem micturition center input sometimes leads to cocontracture of the urinary sphincter and detrusor muscles (detrusor-sphincter dyssynergia). the resulting high pressure may lead to hydronephrosis and chronic renal failure if untreated. constipation is a common problem, occurring in 39% to 53% of ms patients, especially with limited activity and spinal cord involvement. fecal incontinence is a socially devastating symptom that is often associated with perineal sensory loss in ms patients. sexual dysfunction is seldom mentioned, even though it is a frequent problem in ms. nearly two thirds of patients report diminished libido. one third of men have some degree of erectile dysfunction, and a similar percentage of women have deficient vaginal lubrication. besides direct neurological impairment, sensory loss, physical limitations, depression, and fatigue additionally contribute to sexual difficulties in ms patients. in addition, the partner's attitude and psychological factors dealing with self-image, self-esteem, and fear of rejection may also lead to impotence or loss of libido. intense vertigo associated with nausea and emesis is an occasional manifestation of ms relapse. in the absence of a clear diagnosis of ms, these symptoms are often attributed to vestibular neuronitis. patients may also develop a persistent but mild vertigo that is precipitated by movement, or this may be a residual finding after an acute relapse. internuclear ophthalmoplegia, caused by a lesion in the medial longitudinal fasciculus, is the most common cause of diplopia in ms patients (video 200, afferent pupillary defect). when symptomatic, it produces horizontal diplopia on lateral gaze that usually remits. examination discloses incomplete or slow adduction of the eye ipsilateral to the lesion and nystagmus of the contralateral eye during abduction (see chapter 9) . dissociated nystagmus may be the only finding of an old or subtle internuclear ophthalmoplegia (video 19, internuclear ophthalmoplegia). bilateral internuclear ophthalmoplegia is strongly suggestive of ms, although this rarely may occur with tumor, infarct, mitochondrial cytopathy, wernicke's encephalitis, and chiari malformation (video 229, wernicke's encephalopathy). vertical and diagonal diplopia usually results from skew deviation. nystagmus, slow saccadic movements, broken ocular pursuits, and ocular dysmetria are other eye findings produced by lesions of cerebellar and vestibular pathways (see chapters 9 and 12; video 228, saccadic dysmetria). abducens paresis occurs on occasion, but oculomotor and trochlear nerve impairment is rare. corticospinal, spinothalamic, lemniscal, vestibular, and cerebellar pathways can all be affected. cranial nerve impairment may be seen with lesions that affect brain stem nuclei or exiting and entering fibers. usually this occurs in association with other symptoms. because of the long spinal tract and nucleus, the trigeminal nerve is frequently involved (video 106, trigeminal neuralgia). facial nerve paresis does occasionally occur, but ms is an extremely rare cause of bell's palsy in patients without previous symptoms. acute unilateral hearing loss is an uncommon manifestation. dysphagia is often due to impairment of cranial nerves ix, x, and xii and generally appears late in the course of some patients. once thought uncommon, cognitive disorders are now known to be present in 40% to 70% of ms patients. 31 age, duration of ms, and physical disability do not completely predict the presence of cognitive dysfunction, but classic mri measures like the total t2-weighted lesion load does not seem to correlate well with the degree of cognitive decline. measures of cortical atrophy, venticular enlargement, and neuronal integrity seem to correlate better with the cognitive aspects of ms. the problems are often subtle and may not be detected on standard mental status evaluation. the pattern of cognitive decline is typified by decrease of episodic memory, processing speed, verbal fluency, and difficulty with abstract concepts and complex reasoning. to a lesser extent, executive functioning and visual perception, semantic memory, and attention span may also be also decreased. general intelligence is not typically affected. as expected, cortical symptoms such as aphasia, apraxia, and agnosia are unusual. homonymous hemianopia, which can be caused by cortical or subcortical lesions, is also uncommon. despite prominent cerebral white matter involvement, many of the disconnection syndromes such as alexia without agraphia, conduction aphasia, and pure word deafness have not been reported in ms patients. affective disorders are more frequent in ms patients than in the general population. these include both anxiety and depression. in long-term studies, the incidence of depression in ms patients is close to 75%. neither depression nor anxiety is related to physical or cognitive disability or mri lesion load. patients sometimes experience uncontrollable weeping or less commonly laughter incongruent with their mood. interruption of inhibitory corticobulbar fibers is responsible for these symptoms (pseudobulbar affect). fatigue is a pervasive symptom among ms patients that is not related to disability or depression. over 75% of ms patients experience fatigue during their disease course. a diurnal pattern is characteristic and follows the normal circadian pattern of body temperature fluctuations, with the worse symptoms occurring in afternoon hours (peak core body temperature) often giving way to improvement in the late evening. ms symptoms may fluctuate in a predictable fashion. transient worsening of symptoms frequently follows exercise or elevation of body temperature. one example is uhtoff's phenomenon, in which visual blurring occurs during strenuous activity or with passive exposure to heat. these episodes resolve when the body temperature cools to normal or after a period of rest. an intercurrent infection with fever can induce worsening of symptoms and may be confused with a relapse. heat sensitivity is presumably related to conduction block, as demyelinated axons are more prone to failed conduction than normal, myelinated fibers. 32 paroxysmal symptoms are characteristic of ms and are believed to be due to the lateral spread of excitation (ephaptic transmission) between denuded axons in areas of demyelination. symptoms are typically brief (seconds to 2 minutes) and recur frequently, occasionally dozens of times per day. they may be precipitated by hyperventilation, certain sensory input, or particular postures. tonic spasms (paroxysmal dystonia) most often affect the arm and leg on one side, but the face, one limb, or bilateral limbs are sometimes involved (video 20, tonic spasms). these spasms may result from lesions anywhere along the corticospinal tract. they often begin during the recovery phase after an acute relapse and remit after a few months. intense pain and ipsilateral or crossed sensory symptoms may accompany them. paroxysmal weakness occurs, but it is uncommon. a wide variety of paroxysmal sensory symptoms may occur with ms, including tingling, prickling, burning, or itching, and sharp neuralgic pain is common. trigeminal neuralgia may appear in patients with ms (video 106, trigeminal neuralgia). the occurrence of trigeminal neuralgia in a person younger than age 40 is suggestive of ms. lhermitte's sign (transient sensory symptoms usually precipitated by neck flexion) is usually described as an electrical or tingling sensation that travels down the spine or into the extremities. although quite common in ms, lhermitte's sign can also occur with a wide variety of other disorders, such as vitamin b 12 deficiency, spondylosis, chiari malformation, and tumors, and after cisplatin chemotherapy. several other paroxysmal symptoms are occasionally encountered, including paroxysmal dysarthria and ataxia, paroxysmal diplopia, and combinations of these symptoms. facial myokymia and hemifacial spasm are additional transient (lasting months) phenomena sometimes due to brain stem demyelination (video 110, facial myokymia; video 224, hemifacial spasm). trismus, kinesigenic dystonia, paroxysmal kinesigenic choreoathetosis, and segmental myoclonus have also been described in case reports of ms patients as rare and unusual examination findings. seizures occur in a larger proportion of ms cases compared to normal control subjects. a recently published review of 29 case series of ms patients with epileptic seizures yielded a prevalence of 2.3%. 33 this represents an approximately three-to sixfold increase compared to the general adult population. cortical and juxtacortical lesions may be responsible for the increased incidence of seizures in ms patients. however, such plaques are common and seizures in ms are not, which suggests that other factors may also contribute to the relationship between epilepsy and ms. focal motor seizures, possibly with secondary generalization, are the most frequent. the occurrence of seizures usually follows one of two patterns. on occasion, focal onset seizures begin early in the course of ms and later remit. the start of seizures late in the course of ms more often poses a chronic problem and may be difficult to control. the eye is the only organ outside the nervous system that is sometimes involved in ms. uveitis and retinal periphlebitis each occur in at least 10% of ms patients. in a recent study, most patients with ms-associated uveitis were white females between 20 and 50 years of age. 34 the diagnosis of ms preceded the onset of uveitis in 56%, followed it in 25%. in over 90% of the cases, the uveitis was bilateral. pars planitis was found to be the most frequent form of uveitis (over 80%), and concomitant anterior chamber inflammation was also common. usually ms-associated uveitis is benign from the standpoint of visual acuity. uveitis can involve the posterior, intermediate (pars planitis), or rarely anterior portion and resembles that seen in other inflammatory (e.g., sarcoid, reiter's syndrome, behã§et's syndrome, inflammatory bowel disease, systemic lupus erythematosus) and infectious (e.g., syphilis, tuberculosis, lyme disease) conditions. periphlebitis is seen as venous sheathing on funduscopic examination and is histologically identical to the perivascular inflammation present in brain white matter. it is interesting that inflammation commonly occurs in the retina, which has a peripheral type of myelin produced by schwann cells. there are occasional reports of peripheral nerve or nerve root demyelination in ms patients as well as central demyelination in acute inflammatory demyelinating polyradiculoneuropathy and chronic inflammatory demyelinating polyradiculoneuropathy (see chapter 49) . some of these cases may be due to the incidental occurrence of two unrelated disease processes. however, because the pns and cns share many antigens, including mbp, it is possible that an autoimmune reaction or a viral infection could involve both the cns and pns. persons with one autoimmune disorder generally have an increased risk of others. even though there are several reports of systemic and organ-specific autoimmune diseases in ms patients, population-based studies have not confirmed any increase in prevalence of these disorders among ms patients. 35 in fact, there appears to be a negative association between ms and rheumatoid arthritis. multifocal cns involvement and acute relapses, remissions, and slow progression of neurological deficits typify ms. a single episode of neurological dysfunction can be suggestive of ms if it follows the typical time course of a relapse: progression over less than 2 weeks (usually days), with or without a period of stabilization, and improvement or resolution (often over months). insidious progression of deficits localized to a single site in the cns can also be due to ms, but other causes must be excluded. the temporal course of ms can be described by one of four categories: relapsing-remitting (rr), secondary progressive (sp), primary progressive (pp), and progressive relapsing (pr). 32 many physicians use the term relapsing progressive, which encompassed patients with spms, prms, and even those with rrms who have stepwise relapse-related worsening disability. this term has recently been abandoned. other terms that relate to the course of ms but have no consensus regarding their definition are sometimes encountered. benign ms generally refers to patients who have had ms for a long time but have little or no disability. malignant ms is sometimes used to describe patients with frequent relapses and incomplete recovery but is also used in reference to patients with acute fulminant demyelinating syndromes (see later). the term clinically isolated syndrome (cis) refers to patients presenting with their first episode of region-restricted episodes of cns inflammatory demyelination. this may remain an isolated syndrome (no recurrence), it may remain a forme fruste of acute disseminated encephalomyelitis (adem), or it may be the harbinger for one of the relapsing forms of ms. the probability of recurrent demyelinating episodes (e.g., clinically definite ms) has been the subject of several important investigations, and several clinical features and test results are of predictive value. optic nerve, spinal cord, and brain stem are the most common sites of these recurrent monosymptomatic events, and the time profile follows that of ms relapses. the pathogenesis, pathophysiology, epidemiology, clinical features, associated disorders, differential diagnosis, evaluation, and management are the same as in ms. the prognosis for visual recovery after each episode of on is good, and most patients regain normal visual acuity. profound visual loss, recurrent on, and age older than 35 are associated with a higher risk for poor recovery. investigators have concluded that recurrent multifocal demyelinating episodes, fulfilling the diagnostic requirements of clinically definite ms, develop in 50% or more of patients after isolated on when follow-up is extended beyond 20 years. 36 most of this risk is incurred within the first few years, although significant risk may continue into the fourth decade after the event. children much more often develop simultaneous bilateral on and have a lower risk for subsequent ms than adults. factors that are associated with an increased risk of developing ms as a disseminated illness are the presence of venous sheathing, recurrent on, family history of ms, white race, previous vague or nonspecific neurological symptoms, and the presence of oligoclonal bands (ocbs), elevated igg index, or igg synthesis rate in csf. the severity of acute transverse myelitis is inversely related to the risk of acquiring further symptomatic demyelinating lesions. complete transverse myelitis with profound loss of motor, sensory, and sphincter function imparts a relatively low risk of 3 to 14 for the later diagnosis of ms. partial transverse myelitis with preservation of significant motor function at peak is associated with a much higher incidence of ms. although monosymptomatic brain stem demyelination is not as common as either on or acute transverse myelitis, similar conclusions have been reached. in the only study available, two thirds of these patients with cerebral white matter lesions detected on mri developed ms within 5 years, compared with none of 5 patients with normal head mri. 37, 38 a recently published 10-year follow-up of the original queen square series continues to demonstrate the value of the baseline cranial mri study in determining risk of recurrence (ms risk). in this cohort study of 81 cis patients, approximately two thirds had at least one asymptomatic lesion (54 of 81, 67%) at baseline. after 5 years of follow-up, slightly more than half with one to three asymptomatic baseline cerebral lesions had developed ms (13 of 24) compared with the majority of cases presenting with at least four baseline lesions (28 of 33, 85%). after 10 years of follow-up, the majority of patients with any asymptomatic cerebral lesions had developed definite ms (45 of 54, 83%). 39 the recently published 14-year follow-up data on this group of patients reveals that 88% of the initially mri positive patients developed ms versus 19% of the mri negative subgroup. 40 this information is helpful for treating patients in the setting of cis. differential diagnosis. only a few diseases cause neurological deficits that regress spontaneously and relapse in different areas of the cns over the course of many years. however, because of the remarkable heterogeneity of ms, many disorders may resemble ms (table 48-3) , especially in the first years of active disease. other primary idiopathic inflammatory demyelinating cns disorders may be mistaken for ms. adem usually causes monophasic cns demyelination. although it frequently involves multifocal areas of white matter simultaneously, adem cannot be reliably differentiated from the initial clinical episode of ms. fulminant brain demyelination in persons without previous symptoms of ms is more likely due to adem or other conditions (schilder's myelinoclastic diffuse sclerosis, balo's concentric sclerosis, marburg's variant of ms). neuromyelitis optica differs from ms primarily in the topography and intensity of the lesions. several systemic or organ-specific inflammatory conditions can involve the cns white matter. on, myelitis, and other syndromes sometimes occur with systemic lupus erythematosus. whether this autoimmune disease increases the risk of developing ms or causes similar syndromes by a different pathological process is unknown. sarcoidosis can affect the nervous system in several ways, including multifocal, corticosteroid-responsive white matter lesions. sjã¶gren's syndrome sometimes occurs with ms, but this may only represent a chance association. neuro-behã§et's disease has a predilection for the brain stem. occasionally, isolated demyelinating syndromes are associated with inflammatory bowel disease. a wide variety of vasculitic syndromes (e.g., primary angiitis of the cns, periarteritis nodosa, wegener's granulomatous angiitis, vasculitis associated with rheumatoid arthritis, susac's syndrome, eales'disease) may mimic ms. however, these syndromes can usually be distinguished by involvement of the cortex, seizures, early dementia, personality changes, psychosis, infarcts involving large vessel territories on mri, and lack of improvement. findings characteristic to the particular vasculitis (uveitis and vitreal hemorrhage in eales' disease, retinal and cochlear involvement in susac's syndrome, upper and lower respiratory tract involvement in wegener's granulomatosis) also aid in the correct diagnosis. a few infections must also be considered in the differential diagnosis of ms. both lyme disease and syphilis may cause multifocal white matter lesions. htlv-1 causes a chronic progressive myelopathy (htlv-1-associated myelopathy/tropical spastic paraparesis). acute or recurrent myelitis can be caused by vzv. progressive multifocal leukoencephalopathy and toxoplasma abscesses should be considered in immunocompromised patients with progressive neurological decline. bacterial endocarditis with brain abscess formation, subacute sclerosing panencephalitis, or chronic rubella encephalomyelitis may need to be considered in the appropriate circumstances. cerebrovascular disease is only rarely mistaken for ms. occasionally, an ms relapse has an abrupt onset that may mimic an infarct, especially in those not previously diagnosed with ms. the usual circumstance is that of a hemisensory or hemimotor deficit imitating a lacunar infarct. disorders with multiple cerebral infarcts (emboli, hypercoagulable states, sneddon's syndrome, cadasil, vasculitis) may produce an mri appearance and course resembling ms. vascular malformations may also produce symptoms similar to ms. additional neurological illnesses capable of producing multifocal lesions rarely mimic ms. metastatic tumors and multifocal gliomas are often cited examples, but rarely is this distinction difficult for an experienced clinician. lymphoma more commonly masquerades as ms because the lesions may involve the white matter, may be multifocal, and are corticosteroid responsive. in addition, demyelination sometimes presents as one (or a few) mass lesion(s). in this situation, biopsy may be needed for diagnosis. neoplasms can cause paraneoplastic syndromes that may be confused with ms. a high index of suspicion must be kept for older age at presentation, subacute ataxia, early dementia, and personality changes. a few metabolic disorders may resemble ms, such as vitamin b 12 deficiency, vitamin e deficiency (seen in bassen-kornzweig syndrome, hypobetalipoproteinemia, and refsum's disease), and central pontine or extrapontine myelinolysis (video 113, pontine myelinolysis). leukodystrophies are usually not difficult to distinguish from ms. krabbe's disease (galactocerebroside-b-galactosidase deficiency), metachromatic leukodystrophy (mld; arylsulfatase a deficiency), and the usual adult form of adrenoleukodystrophy (ald) and adrenomyeloneuropathy (amn) exhibit both central and peripheral dysmyelination. blood leukocyte or fibroblast culture enzyme activity levels will confirm the diagnosis of krabbe's disease and mld, and elevated levels of very long chain fatty acids occur in ald/amn. mitochondrial disorders should also be given consideration because symptoms and mri appearance may be similar to ms. a relapsing remitting disorder identical to ms is sometimes seen in patients with the mutations responsible for leber's hereditary optic neuritis (lhon). 41 this usually occurs in female patients, and there may not be a family history of visual loss. a number of rare biochemically defined illnesses and other genetic disorders may occasionally merit consideration (including cobalamin and folate dysmetabolism, adult polyglucosan body disease, hereditary spastic paraparesis, spinocerebellar degeneration, and hereditary cerebroretinal vasculopathy). 42 several additional disorders must be excluded before diagnosing primary progressive ms (ppms). spinal cord compression from spondylosis or tumor may produce chronic progressive myelopathy. chiari malformations, syringomyelia, syringobulbia, other foramen magnum lesions, spinal arteriovenous malformations, and dural fistulas may also need consideration. careful imaging readily identifies these structural abnormalities. degenerative diseases such as olivopontocerebellar atrophy may mimic ppms. mri and csf examination will help distinguish between the two. conversion reactions and somatization disorders are commonly encountered in a busy referral practice and must be accurately diagnosed to afford optimal patient management. evaluation. the diagnosis of ms is based on the demonstration of white matter lesions disseminated in time and space in the absence of another identifiable explanation. ms remains a clinical diagnosis, although mri, evoked potentials, and csf examination can help clarify less certain cases. for research purposes, various categories of ms have been defined based on the certainty of the diagnosis. 43 at least two attacks and evidence of two separate cns lesions (clinical or paraclinical) are required for the designation of clinically definite ms (cdms). two attacks and evidence of one cns lesion or one attack and evidence of two cns lesions (clinical or paraclinical) is considered clinically probable ms. cases that fulfill the criteria for clinically probable ms and have supportive csf findings are labeled as laboratory-supported definite ms. patients with a clear history of at least two attacks and supportive csf but a normal neurological examination and no paraclinical evidence of cns lesions are categorized as having laboratory-supported probable ms. suspected cases that do not fit any of these criteria may be regarded as possible ms. paraclinical evidence generally refers to abnormalities on evoked potential studies or imaging procedures. as a result of increasing availability of refined paraclinical diagnostic modalities (especially mri) and an overall better understanding of the disease process, new diagnostic criteria for ms were proposed by an international expert panel in 2001. 44 three out of four of the following findings should be present on mri: (1) one gadolinium enhancing lesion, or nine t2 hyperintense lesions; (2) at least one infratentorial lesion; (3) at least one juxtacortical lesion; and (4) at least three periventricular lesions. according to the clinical diagnostic criteria, if a patient had two or more attacks with objective evidence on examination of two or more anatomical areas involved, no additional data is required to make the definite diagnosis. however, if such diagnostic studies were done and are not supportive of a diagnosis of ms, then the diagnosis should be reconsidered. if a patient presents with a history of two or more attacks, but objective clinical evidence only suggests one lesion, the following additional data is needed to confirm the diagnosis: the disease process has to be disseminated in space as demonstrated by mri; alternatively, two or more mri-detected lesions consistent with ms plus positive csf would suffice to meet the newly defined criteria. the clinician also may elect to await a further attack implicating a different anatomical site. in case a patient had one attack, with objective clinical evidence of two or more lesions, dissemination in time as demonstrated by serial mris separated by at least 3 months or a second clinical attack would clarify the diagnosis. if a patient has a clinically isolated syndrome, or "monosymptomatic" presentation, the following criteria should be met: dissemination in space as demonstrated by mri (again separated by at least 3 months), or two or more mridetected lesions consistent with ms plus positive csf and dissemination in time on serial mri scans, or a second clinical attack. in case the patient presents with a progressive course, the presence of positive csf is required, and dissemination in space should be present, as suggested by nine or more t2-weighted brain lesions, or two or more cord lesions, or four to eight brain lesions plus one cord lesion on mri. alternatively, abnormal visual evoked potentials (veps) with four to eight brain lesions, or fewer than four brain lesions plus one cord lesion, and dissemination in time on serial mri scans, or continued progression for a year would meet the diagnostic criteria. "positive csf" according to this set of criteria is defined by either the presence of oligoclonal bands detected by established methods (preferably isoelectric focusing on agarose gel followed by immunoblotting) different from any such bands in serum, or by a raised igg index. the presence of both enhancing and nonenhancing white matter lesions on a single mr image must not be used as evidence of dissemination in time as well as space, because these can also be seen in adem. oligoclonal bands (ocbs) and an elevated igg index provide supportive csf findings. ancillary tests are frequently required to confirm the diagnosis of ms and to exclude other possibilities in uncertain cases. laboratory tests on peripheral blood can help to exclude many of the infectious and other inflammatory disorders. a chest x-ray is generally needed to assess for sarcoid or paraneoplastic disorders if these are under consideration. an ophthalmological examination may be needed to search for alternative causes of visual loss. imaging studies, csf examination, and evoked potentials are often helpful because characteristic abnormalities are frequently present. mri of the head is the most sensitive imaging study for ms ( fig. 48-3 ). focal areas of increased t2-weighted and decreased t1-weighted signal reflect the increased water content associated with demyelinated plaques. the mri appearance of ms lesions, however, is not specific and similar abnormalities may be seen in normal aging, small penetrating vessel infarcts, lyme disease, tropical spastic paraparesis/htlv-1-associated myelopathy, sarcoid, systemic lupus erythematosus, sjã¶gren's syndrome, mitochondrial cytopathies, vasculitis, and adem. the specificity for ms can be increased by consideration of lesion number, size, location, and shape. 45 this is especially important in persons older than age 50. mri characteristics, other than the ones suggested by the international criteria outlined previously, are size larger than 6 mm, oval shape (often with the long axis directed perpendicular to lateral ventricles), and locations in the periventricular area, corpus callosum, and posterior fossa. longitudinal mri studies have shown the evolution of ms lesions. 46 gadolinium enhancement, indicating blood-brain barrier disruption, sometimes precedes the development of t2-weighted lesions and typically lasts for 4 weeks in the brain (occasionally longer, especially in larger hemispheric lesions), and perhaps somewhat longer in the spinal cord. flair imaging is especially helpful for evaluating periventricular lesions that may go unnoticed on regular t2-weighted scans. the disadvantage of the technique is its relative insensitivity to posterior fossa lesions. proton density weighted images are also part of the usual sets of images used in the mr diagnostics of ms. these images can be evaluated similarly to t2-weighted images. technically, they are usually acquired together with the t2-weighted datasets, as a first echo in conventional fast spin echo sequences, where the subsequent echoes can be used for generating the t2-weighted images. new t2weighted lesions have a fuzzy border and enlarge over a few weeks. after a period of stabilization, the t2-weighted lesion regresses and becomes more sharply delineated from the surrounding white matter as edema resolves. most of the time, a residual abnormality with increased t2 weighting and decreased t1-weighted signal remains, reflecting demyelination and gliosis. the low attenuation t1 signal, or "t1 black hole," is more often seen in secondary progressive ms and is thought to represent actual tissue loss. in several well-documented cases, hypointense lesions on t2-weighted scans were described in subcortical gray matter structures in ms patients. on a molecular level these areas are thought to represent iron deposition; their significance in ms is not fully understood. the mri activity of disease, defined as either the number of new, recurrent, and enlarging lesions or the number of gadolinium-enhancing lesions, is usually higher than the clinical activity. this may be either because of the involvement of asymptomatic areas of the cns or because of a pathophysiological difference between symptomatic and nonsymptomatic lesions based on the presence or absence of axonal dysfunction. there is only poor correlation between disability and lesion load (volume of white matter abnormalities) determined by head mri. sometimes individuals have severe impairment and few mri abnormalities, and the converse may occur. this disparity is partially explained by variable spinal cord involvement, but a pathophysiological difference may account for some of the discrepancy. several mri markers of gray matter involvement correlate better than measures of white matter pathology with clinical functional outcome measures in ms. in a recent study 47 edss showed the strongest correlation with gray matter volume loss and with t1 black hole volume increase (p < 0.01); both are considered to reflect neuronal and axonal pathology. ambulatory function, assessed as the 25-feet timed walk, also correlated well with gray matter volume loss and t1 black hole volume. on normal appearing gray matter magnetization transfer ratio (mtr) histograms, normalized peak heights inversely correlated with edss in 18 rrms patients (r â¼ ã�0.65, p â¼.01). 48 in a study evaluating a number of mri parameters (including brain t1-hypointense and flair-hyperintense lesion volume, third ventricle width, brain parenchymal fraction and t2 hypointensities in the dentate nucleus), the best correlation with edss (and the only correlating parameter with 25-feet timed walk) was t2 hypointensity in the dentate nucleus. 49 in 41 ms patients, an mri study concluded that gray matter atrophy correlated with clinical status (edss, 25-feet timed walking and disease duration). 47 a study of patients with ppms and rrms showed that neocortical volume as determined by mri correlated with edss scores across all the patients, but the strength of the correlation was stronger (p < 0.05) in the ppms (r â¼ ã�0.64, p < 0.0001) than in the rrms group (r â¼ ã�0.27, p â¼ 0.04). 50 mr spectroscopy is increasingly becoming an accepted diagnostic modality, where information can be obtained about the biochemical constituents of selected voxels of interest. with this technique, a cubic volume of interest is defined based on a regular mr image set. simultaneous acquisition of multiple volume units is possible. with long echo time (te) studies, naa (n-acetylaspartate), choline, creatinine, and lactate peaks can be identified on the mr spectrum. with short te studies, myoinositol, lipids, and some neurotransmitters may be identified. the resolution of the mr spectrum (the "number of lines" in the spectrum) is proportionate to the magnetic field strength used. naa is the second most abundant amino acid constituent in the brain after glutamate. it is localized almost exclusively in neurons and axons. creatinine is used as the "constant" peak in a mr spectrum, since it is the least likely to be altered by cns-specific processes. therefore, numeric mrs data are usually presented as ratios related to creatinine. the naa/creatinine ratio is decreased in areas of axonal or neuronal loss. it correlates well with disability. it can be decreased in normal appearing white matter, also in early stages of lesion formation, thus representing a challenge to the usual dogma of axonal loss being secondary to myelin damage. the decrease of the naa/creatinine ratio may return to normal following the resolution of the acute phase. this process may be related either to reversibility of neuronal injury or to disappearance of edema in the involved areas. in general, more reduced naa peaks are seen in progressive forms of ms with more profound tissue loss. if a relatively large hemispheric lesion shows decreased naa content, similar findings may be seen in the other hemisphere in a "mirror" location. the lactate peak can be elevated in a variety of acute processes, and as such, carries relatively low specificity. the short te spectrum is used less frequently; the "mobile lipid" peak (which is thought to represent macromolecular protein fragments) is increased in areas of acute demyelination. another newer mri technique used in ms research is magnetization transfer imaging. the principle behind this imaging modality is relatively simple. in complex macromolecular systems, there is a baseline magnetization exchange in equilibrium between macromolecular protons and mobile protons. if the macromolecular protons are saturated before each excitation (and subsequent data acquisition) with a prolonged off-resonance broadband pulse, then the signal intensity of the image will be reduced owing to magnetization transfer exchange between the saturated ("bound") and free ("mobile") protons. by obtaining duplicate sets of images (with and without magnetization transfer pulse), a magnetization transfer ratio can be calculated. the ratio reflects the integrity of the macromolecular environment. it is reduced by approximately 3% to 5% in areas of edema, but it is more significantly reduced in areas of demyelination or axonal loss. if the ratio "normalizes" in a lesion, no subsequent tissue loss is usually seen on other imaging modalities. despite these advantages, the magnetization transfer imaging is technically difficult because it produces variable findings depending on the technical environment and is not universally available. it has not become an accepted and standard technique for evaluation of ms patients. it may be very useful as a marker for remyelination and tissue repair in future neuroprotective or tissue restorative trials. diffusion-weighted imaging is well known from its widespread use in the diagnosis of ischemic stroke. this technique can show early stages of ms plaque formation. the increase in apparent diffusion coefficient correlates with acute plaques, and seems to best correspond with t1-enhancing lesions; this technique may show the lesions at an even earlier stage. mri has become an important component of clinical trials in ms. because of the high sensitivity of mri for disease activity, it is reasoned that periodic mri may determine treatment efficacy more quickly than monitoring relapse rate or disability level. many studies have used mri as a secondary outcome, but clinical outcomes are still used as the primary outcome for definitive trials. additional mri techniques have also proved useful in the diagnosis of ms. mri of the spinal cord shows discrete lesions in about 80% of cdms patients. several semiautomatic methods exist to determine lesion volume, ventricle volume, or hemispheric volume. these are generally applied for research purposes only, and are not part of the usual workup or diagnostic follow-up of ms. csf evaluation remains a valuable diagnostic tool for ms. a lymphocytic pleocytosis occurs during acute exacerbations in about one third of patients, but this seldom exceeds 50 cells. eighty percent of the lymphocytes are cd3 positive. the ratio of cd4 to cd8 cells is 2:1. less than 20% of the cells are b cells. csf protein is normal in up to 60%; levels above 100 mg/dl are unusual and may suggest a different disorder. the proportion of g globulin is high owing to the synthesis of immunoglobulins within the blood-brain barrier. the majority of csf immunoglobulin is igg, although igm and iga may also be elevated. measures of intrathecal igg production have been devised that are more useful than simple g-globulin levels. the igg index and synthesis rate are elevated in 70% to 90% of cdms patients and occasionally in other disorders. agarose gel electrophoresis, or the more sensitive isoelectric focusing of csf proteins, often reveals discrete bands of immunoglobulin, each a monoclonal antibody. it is pertinent to compare serum and csf banding patterns because peripheral monoclonal gammopathies may produce csf bands. to reduce false-positive results, only unique csf ocbs should be reported. between 85% and 95% of clinically definite ms patients have ocbs; however, early in the course they are not as prevalent. once present, ocbs persist and the pattern does not vary, although new bands occasionally appear. unlike subacute sclerosing panencephalitis, in which the majority of ocbs are antibodies specific for measles virus, the antigenic specificity of ocbs in ms is unknown; they are unlikely to be pathogen specific or autoantigen directed; there is some evidence that they may be genetically determined germline antibodies. five percent to 10% of noninflammatory cns samples and 30% of inflammatory samples are also positive for ocbs. 51 more detailed recommendations about the inclusion of csf parameters to the diagnosis of ms were recently published 52 suggesting that the cell count and differential should be completed within 2 hours. the new and recommended method for the detection of ocbs includes immunoelectophorsesis on agarose gel followed by immunoblotting. the reported sensitivity of this technique is above 95%, with a specificity of 86% to 87%. in other inflammatory or infectious illnesses, ocbs are often transient features. their persistence is more suggestive of ms. the presence of myelin components, antimyelin antibodies, and kappa light chains in csf has also been used in the diagnosis of ms. however, the sensitivity and specificity of these products is less than that of ocbs. in late 2005, a new set of recommendations were published based on the first 5 years of using mcdonald's criteria in diagnosing ms. 53 the original mcdonald criteria have been incorrectly interpreted by some as mainly relying on mri for making a diagnosis of ms. in reality, the mcdonald criteria cannot even be applied without careful clinical evaluation of the patient. neurological deficits must be evident to the examiner, and must be suggestive of ms. scans that "look like" ms (and meet the criteria of barkhof and tintore) but have never been accompanied by an obvious and documented neurological examination finding do not fulfill the mcdonald criteria. there was some sympathy among the international panel members revising the mcdonald criteria to allow selected symptoms that are clearly and specifically enunciated by the patient (e.g., lhermitte's symptom, trigeminal neuralgia, numbness ascending to the waist or higher) coupled with objective paraclinical (such as imaging and csf) findings to be sufficient as an indicator of a prior or current attack needed for an ms diagnosis. however, the panel was reluctant to endorse the diagnosis of ms in the absence of any objective clinical findings, even if objective paraclinical findings are in place, at least until such a scheme is tested in prospective settings. patients with imaging and csf findings suggestive of ms but not showing any objective evidence for neurological deficits commonly seen in ms require careful clinical and radiological monitoring. until objective evidence for neurological deficits are found, ms can not be diagnosed. ms may be the correct diagnosis with less stringent imaging criteria than originally proposed; however, the panel was uncomfortable making changes that would allow mri confirmation of dissemination in space based on lower stringency imaging criteria without appropriate prospective data. most studies performed to date have been inadequately designed to address this issue. advanced imaging technologies are constantly evolving and will likely one day be shown to aid in making the diagnosis of ms. visualization of intracortical lesions, use of higher field strength magnets, and analysis of "normal appearing brain tissue," may be conrnerstones of a future mri criteria for ms. preliminary evidence suggests that "occult" damage in normalappearing white and gray matter seen with magnetization transfer, diffusion tensor imaging, or spectroscopy is an early feature of ms, whereas it likely does not occur in other demyelinating conditions such as acute disseminated encephalomyelitis and nmo. important changes have been made to the original definition of "dissemination in time" by mri. in keeping with the definition that clinical relapses must be separated by at least 1 month, it was agreed that new t2 lesions on mri should occur at least 30 days after disease onset. this means that any new t2 lesion occurring at any time point after a so-called reference scan performed at least 30 days after the onset of the initial clinical event is useful in meeting imaging diagnostic criteria for dissemination in time. it should be noted though that a new t2 lesion must be of sufficient size and location to exclude lesions that could have been missed previously for technical reasons of slice orientation, thickness or spacing, tissue contrast, patient motion, or other artifacts. this requires standardized scanning procedures with emphasis on careful repositioning, as well as input from qualified evaluators experienced in ms imaging. with the new revision, there are two ways to show dissemination in time using imaging: (1) detection of gadolinium enhancement at least 3 months after the onset of initial clinical event, if not at the site corresponding to the initial event; or (2) detection of a new t2 lesion if this appears at any time compared with a reference scan done at least 30 days after onset of the initial clinical event. spinal cord lesions can be important in differentiating ms from other white matter diseases; however, the original mcdonald criteria did not provide sufficient guidelines for the use of cord imaging in ms. spinal cord imaging that detects typical ms cord lesions (minimal or no swelling of the cord; clearly hyperintense on t2-weighted imaging; at least 3 mm in size, but less than two vertebral segments long; and occupying only part of the cord cross section) is particularly helpful if brain imaging does not detect dissemination in space in a patient suspected to have ms. for dissemination in space, a spinal cord lesion is equivalent to, and can substitute for, a brain infratentorial lesion, but not for a periventricular or juxtacortical lesion. an enhancing spinal cord lesion is equivalent to an enhancing brain lesion, and an enhancing spinal cord lesion can "count" doubly in fulfilling the criteria (e.g., a single enhancing spinal cord lesion can "count" for an enhancing lesion and an infratentorial lesion). individual cord lesions can contribute together with individual brain lesions to reach the required nine t2 lesions to satisfy the barkhof-tintore criteria (the mri criteria incorporated in the original mcdonald's criteria). the panel recognized that diffuse cord changes may occur in ms, especially in the progressive forms; however, these changes are not sufficiently reliable to allow for their incorporation into the diagnostic criteria at this time. repeat spinal cord imaging in patients without new symptoms of myelitis has a low yield in efforts to demonstrate dissemination of lesions in time. in other words, while it is common to see asymptomatic new brain lesions on repeated scans, new cord lesions generally do result in new neurological symptoms. therefore, repeat cord imaging is recommended only to support an ms diagnosis when there is a clinical reason to suspect a new cord lesion. important changes have been proposed in diagnosing primary progressive ms. these revised criteria stress clinical and imaging (brain or spinal cord) evidence for diagnosis and place less emphasis on csf findings. the new criteria for ppms is as follows: (1) at least 1 year of disease progression (retrospectively or prospectively determined) (2) plus two of the following: (a) positive brain mri (nine t2 lesions or four or more t2 lesions with positive vep), (b) positive spinal cord mri (two focal t2 lesions), (c) positive csf (isoelectric focusing evidence of oligoclonal igg bands or increased igg index, or both). evoked potentials are summed cortical electrical responses to peripheral sensory stimulation that can be used to localize sites of disease and measure conduction velocity along sensory pathways. vep and somatosensory evoked potentials (sseps) may detect subclinical sites of demyelination, thus providing evidence of multifocality. brain stem auditory evoked potentials (baeps) are occasionally informative. more than 90% of persons with a history of on have an abnormal vep, and 85% of cdms patients have abnormalities on veps even when the history of on is absent. slowed conduction is present on ssep in nearly three fourths of patients with cdms. baes are the least sensitive, with abnormalities in less than 50%. mri has largely supplanted the use of evoked potentials in ms because of the greater sensitivity in the diagnosis and the detailed anatomical information it provides. in 2001, the american academy of neurology released practice parameters regarding the usefulness of evoked potential studies in ms. according to these recommendations, veps are considered probably useful (class ii evidence) to identify patients at increased risk for developing clinically definite ms. sseps are possibly useful, whereas the evidence for baeps supporting the diagnosis of cdms is insufficient. management. there is no available prevention or cure for ms. treatments focus on three areas: treating acute exacerbations and hastening their recovery; altering the natural history of ms; and providing symptomatic relief of current symptoms by enhancing physical abilities and preventing or treating complications. a fourth management topic concerns special treatment issues related to pregnancy. acute exacerbations. corticosteroids are the most commonly used treatment for ms, although there have been few studies to address their efficacy. adrenocorticotropic hormone (acth) was shown to speed recovery from an exacerbation but had no effect on the ultimate degree of recovery. because of the unpredictable cortisone response to acth, oral prednisone and later intravenous methylprednisolone became the preferred treatments. the optic neuritis treatment trial verified that intravenous methylprednisolone but not prednisone increased the recovery rate and unexpectedly increased the time to the next relapse, thus delaying the diagnosis of cdms. 54 moreover, the prednisone-treated group had twice as many recurrences. the finding was not replicated in a second study, but it has affected the practice of treating acute ms exacerbations. the current recommendation is to treat disabling attacks with 500 to 1000 mg of intravenous methylprednisolone per day for 3 to 5 days with or without a short tapering dose of oral corticosteroids. according to the practice parameters for steroid treatment of acute on attacks released by the american academy of neurology in 2001, oral prednisone in doses of 1 mg/kg/day has no proven value. higher dose of oral or parenteral methylprednisolone may result in quicker and more thorough recovery of visual function. there is no evidence of long-term benefit for visual function. a study suggested that intravenous steroids may also have long-term effects on disease progression when given regularly. 55 in this study, rrms patients randomized to receive regularly scheduled pulses of iv methylprednisolone (every 4 months for 3 years, then every 6 months for 2 years) demonstrated stability or improvement in disability measures, fewer "t1 black holes," and less brain atrophy than did control patients randomized to receive steroids only with relapses. these findings suggest a possible long-term benefit of pulsed iv methylprednisolone therapy on brain atrophy and disability. this as yet unconfirmed approach to long-term therapy might be considered a reasonable "control arm" in future phase iii trials of experimental therapies. up to one third of patients do not have an adequate recovery after a relapse despite the use of corticosteroids. plasma exchange (plex) alone was found beneficial in a substantial proportion of patients with severe inflammatory demyelinating episodes who had failed to improve following treatment with high-dose iv methylprednisolone. 56, 57 a randomized, sham-controlled, double-blind trial in 22 patients (seven exchanges over 14 days) without concomitant use of immunosuppressants in acute demyelinating events confirmed these findings. 58 moderate or greater clinical improvement was observed in over 42% of participants. a trial of seven plex treatments (alternate days) is a reasonable option for patients who fail to respond to conventional iv methylprednisolone therapy in acute, severe episodes of demyelinating diseases. the response to plex is stongly associated with the histological ms subtype. 59 antibody and complement plays a crucial role in pattern ii lesion formation. in a study of 19 biopsy-proven ms cases by keegan and associates, 10 pattern ii cases showed good response to plex, whereas 9 cases of pattern i or iii did not respond at all to plex. neuromyelitis optica, which is now considered an antibody-mediated condition with a known serological marker, also shows good response to plex: in a study by the mayo group, 60% of nmo patients showed moderate or marked improvement to plex, and an additional 10% showed mild improvement. 60 alteration of the natural course. the primary goal of drug treatment is to alter the natural course of the disease (e.g., reducing the frequency and severity of relapses, preventing the chronic progressive phase, and slowing the progression of disability). the disease activity seen on mri is often used as a secondary outcome, although mri measures currently correlate imperfectly with clinical outcome. knowledge on altering the course of ms is largely restricted to three patient groups, those with clinically isolated syndromes, those with rrms, and those with secondary progressive ms. before we discuss the known data in each of these demyelinating disease categories, it may be worth while to review the use of the most important evidence-based medicine (ebm) statistics that are applied to measure the magnitude of treatment effect. relative risk reduction (rrr) is the metric most commonly cited in publications and promotional materials about clinical trials. the rrr is the degree that the treatment reduced the frequency of the outcome measure (experimental event rate, e.g., relapse, progression) compared with the control treatment (control event rate). the rrr is a ratio, not an absolute number, and is calculated as follows: rrr â¼ ã°control event rate ã� experimental event rateã�= control event rate if the control event rate is low (making the denominator smaller), it will obviously inflate the rrr. an "impressive" 50% rrr may have a low biological significance if the outcome occurs infrequently. therefore, the absolute risk reduction (arr) should be calculated as this corrects for the frequency of the outcome. for most of the approved ms agents, the calculated arr is considerably less than rrr. this metric is usually not cited in reports of clinical trials of disease-modifying agents. to calculate risk reduction, one must have access to the data citing comparisons of proportions (ratios), and this is not always immediately available in publications. another useful measure of treatment effect is the "number needed to treat" (nnt). it is calculated as the inverse of the arr: overall, the nnts for the disease-modifying agents in ms are in the 7 to 14 range for treatment periods of 2 to 3 years. however, these nnts are for outcomes that have limited predictive value for long-term outcomes (e.g., relapse behavior does not precisely predict long-term disability) and the agents are expensive, inconvenient to use, and not without risk. we must also remember that clinical trials typically enroll patients with very restricted eligibility criteria (often a history of considerable recent disease activity or progression), and considerable efforts are in place in trials to optimize compliance with the treatment plan. as such, the nnt experienced in a practice setting (effectiveness) may considerably exceed what was reported in the trial setting. altering the course of a clinically isolated syndrome. when should treatment be initiated in patients with very early demyelinating disease? two recently published multicenter studies have addressed this issue in persons at high risk of developing ms. in the champs study, 61 383 patients with their first episode of presumed demyelinating disease ("clinically isolated syndrome") in the setting of an abnormal, asymptomatic baseline cranial mri scan, were randomized to receive either weekly interferon-b 1a 30 mg im or placebo after an initial course of steroid therapy. this study was terminated early when the primary outcome measure of conversion to "clinically definite ms" (cdms) status was reached in a greater number of placebo-treated patients. these findings were not unexpected given the known effect of interferons on reducing relapse rate but do provide some support for early treatment. the duration of follow-up in this study (71% 1 year, 34% 2 years, 16% 3 years) is insufficient to determine long-term benefit from early intervention, however. it is also clear that the treatment is only partially effective, as 50% of interferon (ifn)-treated patients in the champs trial had clinical or mri evidence of recurrent disease within 18 months of starting treatment. 62 the analysis of treatment effect related to the champs trial reveal a rrr of 38%, an arr of 14.6%, and an nnt of 7 patients over 2 years to prevent one conversion to "clinically definite ms." in a second placebo-controlled study of 309 patients with either monosymptomatic (61%) or multifocal onset (39%) early demyelinating disease, early treatment with interferon-b 1a in an unusually low dose (22 mg subcutaneously once weekly), reduced conversion to cdms (34% versus 45%) at 2 years. 63 again, there is no data on whether these treatments offer long-term benefit. the ebm calculations regarding this trial show an rrr of 24%, and arr of 11%, and an nnt of 9 patients over 2 years in order to prevent one conversion to "clinically definite ms." these two studies provide support for considering early treatment in patients presenting with first attack, in the presence of multiple asymptomatic mri lesions, but further studies are needed to determine whether this approach will provide a prolonged benefit on disease course. it is important to note that these studies do not provide guidance about clinically isolated syndromes that present with a brain mri that is not suggestive of ms (i.e., only one optic nerve lesion, or one brain stem or cord lesion explaining the cis symptoms). we do not recommend that cis patients with fewer than two asymptomatic mri lesions receive treatment with interferons. please see the discussions under "summary of recommendations for the treatment of rrms patients" for further advice on patient counseling and decision making about the use of the disease-modifying medications. altering the course of relapsing-remitting multiple sclerosis b-interferons. interferons are a class of peptides that have antiviral and immunoregulatory functions. both interferon-a and interferon-b are part of the anti-inflammatory t h 2 response. interferon-b 1b (betaseron) was the first drug approved by the u.s. food and drug administration (fda) specifically for the treatment of ms. a large clinical study in rrms patients demonstrated a reduction in the frequency of relapses by about one third with subcutaneous injection every other day. 64 the severity of relapses was also lessened. interferon-b 1b had a striking effect on mri measures of disease activity. the placebo-control group continued to accumulate white matter lesions, whereas patients in the high-dose arm (8 million iu) had stabilization of their mri lesion load. no difference was found in the disability levels, however. side effects include injection site reactions, flu-like symptoms (low-grade fever, myalgias, headache; these lessen in frequency after treatment for a few months), mild liver enzyme elevation, and lymphopenia. depression and attempted suicide were more common in the treated groups. to illustrate the magnitude of treatment effect of the pivotal interferon-b 1b trial, the rrr was 18%, the arr was 15%, and the nnt analysis showed that 7 patients are needed to be treated over 3 years to increase the number of those who were relapse free by one. one particularly disturbing result was the production of neutralizing autoantibodies (nabs) in 38% of patients after 3 years of treatment. not only do patients with these antibodies thereafter fail to respond to this drug, but there is also a concern that nabs may cross-react with natural interferon-b and interfere with its function. all positive sera for nabs seem to cross-react with both interferon-b 1a and 1b. switching from one preparation to the other does not change the pattern of antibody response. 65 the long-term effects of nabs are unknown. recent studies seem to support that nab formation reduces clinical and mri effects although often nab formation subsides with time. there are no firm guidelines for monitoring nab formation. most physicians do not measure nabs but rather change therapies empirically when patients appear to be failing treatment. low titer nabs may be just transient phenomenon related to ifn treatment; persistent high titer nabs on two consecutive tests at least 6 months apart is likely associated with poor treatment response to inf. interferon-b 1a (avonex) has the same amino acid sequence as natural interferon-b and differs from interferon-b 1b by one amino acid as well as by the presence of carbohydrate moieties. once-weekly intramuscular interferon-b 1a has been found to have effects similar to that of interferon-b 1b in reducing the frequency of ms relapses. in addition, a favorable effect on disability was also demonstrated and side effects were less common. in the original interferon-b 1-a intramuscular trial, the primary outcome measure was time to edss progression. the rrr was 37%, the arr was 13%, and the nnt was 8 for 2 years to prevent one patient from developing edss progression. the calculations for "proportion relapse free" show an rrr of 16%, and arr of 12%, and an nnt of 8 over 2 years (8 patients need to be treated for 2 years to increase the number of patients who were relapse free by one). nabs occurred half as often as with interferon-b 1b. interferon-b 1a has been approved by the fda for treatment of "relapsing ms." 66 the "correct" dose of interferon continues to be debated. in a recent placebo-controlled trial, patients randomized to a high dose of interferon-b 1a (44 mg three times per week) did better than those receiving half this weekly dose. both groups outperformed placebo and the high dose seemed to have more effect on relapse severity, hospitalizations, mri activity, and lesion volume accumulation, and possibly on delaying disability in the most severely disabled patients. at the end of the 2 years of follow-up, placebo-treated patients were randomized to 22 or 44 mg subcutaneously three times weekly; patients on active treatment were continued on their original dose. 67 the authors reported a benefit for the higher dose and for those treated for the full 4 years, again suggesting that early treatment and perhaps higher doses of interferons may be beneficial. the primary outcome, however, was relapse count per patient per 4 years and, as such, patients treated early had a significant advantage using this outcome measure. there were trends favoring the higher dose (relapse rate, mri volumes; not for time to first confirmed progression, however). the authors did not make statistical adjustments for multiple comparisons and there were many dropouts in the high-dose groups, making it difficult to draw firm conclusions. again, the answer to the question about the benefit of early treatment can best come from long-term (perhaps 8 to 10 years) studies using "hard outcomes" (e.g., time to progression, major milestones in disability). the ebm calculations based on the "proportion relapse free" data for the original interferon-b 1a (rebif) study show an rrr of 19%, and arr of 16%, and an nnt of 6 over 2 years to increase the number of relapse free by one. relative treatment advantages of interferon-b 1a and 1b have not been clearly established but are under study. 68, 69 a pilot study in rrms patients suggests that interferon-a may also have a therapeutic effect. 70 a study of interferon responders showed that younger patients with frequent relapses, and higher edss scores upon entry may be associated better response. 71 laboratory monitoring of interferon products. it is important to note that even though the interferon products are generally safe to use, they can be associated with potentially harmful adverse reactions. we recommend that every newly starting patient should have a baseline complete blood count, liver function tests, and thyroid-stimulating hormone (tsh) test. the liver function tests and blood count studies should be repeated in 1 week, 1 month, and every 3 months thereafter; the tsh should be repeated every 6 to 12 months. glatiramer acetate. glatiramer acetate (ga) is a synthetic mixture of polypeptides produced by the random combinations of four amino acids that are frequent in mbp. after a preliminary study suggested efficacy, 72 a phase iii randomized, double-blind, placebo-controlled, multicenter trial showed a 29% reduction in relapse rate. 73 the fda has approved this medication for use in rrms. even though this disease-modifying therapy requires daily subcutaneous administration, the side effects are relatively minor compared to the interferons, and patients do not need regular laboratory monitoring (table 48lesions, lesion volumes, and the percentage of new lesions that will evolve into t1 "black holes," although the mri effect may be less pronounced compared to the interferon products, and is not apparent until the agent has been used for at least 6 months. [74] [75] [76] the ebm calculations for ga using the "proportion relapse free" data show an rrr of 10%, arr of 7%, and an nnt of 14 over 2 years to increase the number of relapse free by one. combined azathioprine and interferon-b 1b. a small trial at nih showed significant reduction in the number of contrast-enhancing lesions when azathioprine in an average maintenance dose of 2 mg/kg/day was added to interferon-b 1b in a study of six rrms patients followed for a median period of 15 months. the addition of azathioprine may be considered in "treatment failure" cases, but this study was hampered by the small number of patients, no control subjects, and no blinding. 77 intravenous immunoglobulin. monthly treatment with low-dose (0.15 to 0.2 g/kg) intravenous immunoglobulin (ivig) in rrms patients resulted in fewer and less severe relapses in addition to slowing the accumulation of disability in a single randomized trial. the outcome was similar to that of injectable interferons. 78 this therapy is less accepted in the united states. more studies with larger number of patients and extended follow-up are needed to confirm these limited observations. recent studies have failed to demonstrate that ivig administration reverses long-standing deficits from ms and on. [79] [80] [81] ivig was also recently studied in acute on and failed to demonstrate benefit on any of the outcome measures. 82 natalizumab. in late 2004, natalizumab was approved for the treatment of rrms. 83 natalizumab is a humanized a-4 integrin antibody that inhibits the migration of all leukocytes (except for neutrophils) to target organs. a phase 2 study established 84 that a 300-mg monthly dose reduced the number of gadolinium-enhancing lesions by 90% and the clinical relapse rate by over 50% compared to placebo. this study was followed by the affirm and sentinel phase iii studies. the affirm study enrolled over 900 patients with rrms; none of them had been on other approved immunomodulators for longer than 6 months. the annualized relapse rate at 1 year was reduced from 0.74 in the placebo group to 0.25 in the treated group (66% relative reduction, p < 0.0001). the proportion of relapse-free patients was 76% in the treated group, 53% in the placebo group. the number of enhancing lesions was reduced by 92%, and the number of new or newly enlarging t2 lesions was reduced by 80%. the proportion of patients without clinical and mri activity was 46% in the natalizumab group, and 14% in the placebo group. in the sentinel trial, the combination of intramuscular interferon-b 1a and natalizumab was studied against im interferon-b 1a and placebo in patients who had demonstrated an incomplete response (relapse suppression) to interferon therapy. the ebm calculations of the affirm data based on proportion with relapses suggests an rrr of 49%, an arr of 23%, and an nnt of 4 over 1 year to increase the proportion of relapse free by one. the senti-nel data shows an rrr of 31%, an arr of 17%, and an nnt of 6 over 1 year to increase the proportion relapse free. the original pilot trial data shows a rrr of 50% and an arr of 19%, with an nnt of 5 over 6 months to increase the proportion relapse free. based on these data, the fda granted expedited approval of natalizumab on november 23, 2004. on february 28, 2005 , the medication was voluntarily withdrawn from the market by the sponsor (biogen-elan) after two cases of progressive multifocal leukoencephalopathy (pml) were reported in the sentinel study cohort. 85 both patients were in the combined interferon and natalizumab arm. a third pml case was later identified from one of the phase iii inflammatory bowel trials of this agent. at the time of writing this manuscript, natalizumab is still off the market. the natalizumab story has received significant media attention. several consequences can be drawn from this failure. first, highly potent immunomodulators like natalizumab are best used by specialists in selected cases. a large number of prescriptions were written for natalizumab during its short 3 months on the market, including prescriptions by general practitioners. widespread use of such medication in relatively stable cases of ms is not indicated. second, the combination of potent immunomodulators may result in unpredictable adverse outcomes. many ms experts anticipate that in the future ms therapies will need to be administered in combination to optimize therapeutic benefit. however, the exact effect of such combinations on the highly complex immune system is difficult if not impossible to predict. furthermore, our inability to treat ms more effectively does not stem from the fact that we can not provide powerful immunosuppression, as evidenced by the autologous bone marrow transplantation studies. ms is a complex disease with a prominent inflammatory component; however, increasing evidence suggests that the neurodegenerative component of this illness may be independent of the inflammatory component, and is just as important, if not more important, from the standpoint of long-term disability. third, in chronic diseases such as ms, a short 1-year trial, no matter how convincing the outcome may be, should not be considered sufficient to approve a medication, which will then be used in tens of thousands of patients on a "lifelong" basis. there clearly is a need for new and more effective medications for treating ms; however, clinical trials in chronic conditions are very difficult to sustain. to overcome this, many ms trials use primary mri outcome measures, since inflammation and new lesion formation-related mri markers respond more immediately to treatment; however, these markers do not correlate well with long term disability, as discussed earlier. summary of recommendations for the treatment of rrms patients. when making decisions about starting an ms patients on immunomodulators, several factors must be considered. one must realize that even though there are medications available for relapsing forms of ms, all the currently available therapies are only partially effective, the most reliable data is about short-term relapse rate reduction, and a relapse rate reduction does not necessarily translate into reduction of future disabilities. natural history data clearly suggest that a subset of ms patients will do very well without treatment (see discussion about the olmsted county cohort later); this information can be very useful when deciding about treatment in patients with a 5-or 10-year disease history and minimal disability (edss 2.0). in this patient group, a careful wait and see approach with appropriate monitoring is acceptable. counseling of newly diagnosed ms patients is of crucial importance, and it should usually include family members. most patients have easy access to an abundance of frequently misleading information on the internet, or from relatives and friends with ms. it is important to realize that every case is different; however, through the rational use of natural history data, clinical and mri features of the specific case, and the clear understanding of the available clinical trial data, the clinician should be able to provide customized and relevant advice to patients and families. considering that the treatments are only partially effective, the wishes of an educated patient constitute an important part in the decision-making process. ultimately, the treatment decisions should remain individualized between the patients and their treating physicians, and the physician's role as an information clearinghouse and educator cannot be overemphasized in this process. the three interferon products and ga represent the most commonly used ms immunomodulators in the united states; therefore, it is important to draw some practical conclusions about these agents. by now, several class i studies demonstrate that these agents are effective in reducing the relapse rate in rrms over a 2-to 3-year period; the reduction is roughly 30% with the high-dose interferons and ga. the above-mentioned nnt data are also very useful for the clinician and the well-informed patient when making treatment decisions. there is evidence for a dose-response relationship among the interferon products, mostly from the evidence and incomin studies. the double dose im interferon-b 1a study did not show a dose-response relationship; this may be related to the fact that the increased dose was given with the same frequency as the standard dose. the injectable immunomodulators have incomplete evidence for efficacy in disability-based outcome measures. many of the long-term extension studies suffer from several drawbacks, including open label unblinded design, significant dropout rate, and lack of control subjects; this is especially true for the ga extension data. the currently available few head-to-head comparison studies are also hampered with methodological issues; new comparative studies are under way. overall, these agents remain partially effective in relapsing forms of ms; their long-term effects on reducing the clinically most important feature of ms-disability-still remains unclear. altering the course of secondary progressive ms. within 15 years of onset, almost 60% of rrms patients will enter the secondary progressive phase of the disease. treatment approaches aimed to affect the natural course of disease are available for these patients. interferons. interferon-b 1b may have a beneficial effect on the overall outcome of spms and may also alter mr lesions, 86, 87 but this question remains incompletely answered. in the placebo-controlled european study 88 of inteferon-b 1b in spms, the time to worsening was extended for treated patients. treated patients were less likely to be wheelchair-bound and had fewer hospitalizations. another analysis 89 of this study confirmed the benefits, though the dropout rate in this study was relatively high. the patients who responded best to interferon therapy were those who experienced relapses during their disease course. mri monitoring suggested that the benefit on t2 lesion activity was seen early and persisted into the second half of the second year of treatment. t2 lesion load increased in placebo-but not interferon-treated patients in the first 2 years of treatment. 90 contrasting with these results, in another trial involving patients with spms, 91 both high dose (44 mg) and lower dose (22 mg) interferon-b 1a failed to change the primary outcome of time to disability worsening. positive effects were seen on relapse rate and reduction of mri activity, but the effect on disability did not replicate the european interferon-b 1b report. a combined analysis of the american and european trials concluded that continued relapse activity and more rapid progression over the preceding year (by >1 on the edss scale) are the best predictors of response. 92 ivig in secondary progressive ms. a recent european trial reported that ivig did not have a significant impact on clinical and disability related outcome measures. ivig did reduce the accumulation of brain atrophy in spms, but did not reduce the incidence of blood-brain barrier abnormalities. there was no statistically significant change on magnetization transfer mri measurements; however, a trend for conservation of normal-appearing brain tissue was found. 93 overall recommendations for spms. in general, as the evidence that interferons alter long-term disability is limited and controversial, we generally do not newly start spms patients on interferon products. in a subset of patients still having disabling relapses, interferon therapy may be offered to specifically reduce relapse rate. the data by confavreux and associates, however, suggest that the edss in populations of spms patients continues to progress independent of relapses 94 once a "fixed" baseline level of moderate disability has been reached. therefore, while interferons may reduce the relapse rate in spms, the rate of progression of disability may not be reduced by these treatments. more usually, spms patients are already on an injectable immunomodulator, and the question of whether it is worth continuing the therapy may come up, especially in patients who have a hard time tolerating these medications and feel that the side effects of the medications have a clear negative impact on their overall health. in these cases, we usually allow the patients to stop their medications. just like in the rrms cases, however, patient education about spms trials and realistic expectations about the treatment is a crucial element in the decision-making process. understanding the patient's needs and fears and clarifying potential misconceptions constitute a very important role of the treating neurologist. in those patients who continue their interferon therapy, we must continue to follow them for toxicity and disease activity. please also see the following discussion under mitoxantrone for recommendations on the potential use of that specific agent in spms. mitoxantrone. mitoxantrone (novantrone) is an anthracenedione chemotherapeutic agent licensed . . .for reducing neurologic disability and/or the frequency of clinical relapses in patients with secondary (chronic) progressive, progressive relapsing, or worsening relapsing-remitting multiple sclerosis (i.e. patients whose neurologic status is significantly abnormal between relapses). mitoxantrone is not indicated in treatment of patients with primary progressive multiple sclerosis. significant benefits were observed in a group of spms patients as in a european phase iii study of mitoxantrone. 95 it has also been used in combination with methylprednisolone. 96 several clinical and functional outcome measures were reported to stabilize or improve with every 3-month administration of this intravenous medication. secondary mri outcome measures, including enhancing lesion formation and overall t2 lesion load, were also better in the treated patients. the greatest concern regarding this medication is its cardiac toxicity: the cumulative lifetime maximum dose was established at 140 mg/m 2 . mitoxantrone can induce a seemingly dose-dependent cardiomyopathy, leading to potentially fatal congestive heart failure. we generally avoid exceeding a total lifetime dose of 96 mg/m 2 (8 doses of 12 mg/m 2 ). patients receiving mitoxantrone should also be monitored every 3 months with echocardiograms or muga (multiple gated acquisition) scans to determine the ejection fraction. reduction in the ejection fraction should prompt discontinuation of this therapy. besides the cardiac side effects, mitoxantrone may cause menstrual irregularities or overall ablation of the menstrual cycle, which may be permanent. in a review of the literature, ghalie 97 estimated the risk of mitoxantrone therapyrelated acute leukemia in ms patients at 0.05% to 0.1%; in an international registry of ms patients taking mitoxantrone, the risk of leukemia seems somewhat higher. this therapy has been approved by the fda for treatment of spms, but no peer-reviewed full report of the mims study had been published until 4 years after the initial report in an abstracts form. the study 98 showed a treatment effect in rrms and spms patients with "recent rapid worsening." the study had a high dropout rate and a small sample size. most patients (74%) had relapses in the preceding 2 years, suggesting this cohort mostly includes worsening rrms or prms patients, in whom a positive treatment effect is expected; however, it does not mean that for classic spms patients who no longer have relapses the study outcome is applicable, and it is especially not applicable to ppms cases. the primary outcome measure was a composite score comprised of five clinical measures: change in edss at 2 years; change in ambulation index at 2 years; change in the baseline standardized neurological status at 2 years; number of relapses requiring corticosteroid treatment; and time to first relapse. seventy-seven percent completed 24 months of follow-up. at 24 months, benefit was reported in all five components of the composite measure for both active treatment arms, with the overall greatest benefit noted between placebo and the group receiving mitoxantrone at a dose of 12 mg/m 2 . the magnitude of the effect on edss was rather modest (mean edss change for high-dose mitoxantrone, -0.13 [sd 0.90] versus ã¾0.23 [sd 1.01] in the placebo group). the mri results of the mims trial were published in 2005 and are frankly disappointing. 99 in a subset of 110 patients (out of 194 in the trial overall), the 12 mg/m 2 dose failed to reach a significant difference from placebo as measured by the primary mri outcome (total number of scans with gadoliniumenhancing lesions). the 12 mg/m 2 dose reduced the number of t2-weighted lesions at month 24 (p â¼ 0.027) and showed a trend at month 12 (p â¼ 0.069). the number of active mr lesions showed a trend toward reduction in the 12 mg/m 2 group only at month 24 (p â¼ 0.054). overall, the limited evidence to date supports the conclusion that mitoxantrone reduces relapse frequency and mri evidence for blood-brain barrier disruption in patients with very active ms. the benefit for patients with relapse-independent progression is uncertain at best. from the mims results, one would need to treat 11 patients with secondary progressive multiple sclerosis for 2 years to prevent one person from worsening by 1.0 edss point. this modest benefit must be carefully examined in light of the significant risk for toxicity. therapy of ppms. unfortunately, for classical ppms cases that present with insidious progression of usually myelopathy symptoms, none of the currently available treatments offer any clear benefit. the promise trial, in which over 900 ppms patients were treated with ga, was terminated early owing to lack of effectiveness. the results of this trial have not yet been published. a small study with intramuscular interferon-b 1a was also negative. 100 currently a large trial is under way with rituximab in csf ocb-positive ppms patients. until we clearly understand the pathophysiology of slow progression in ms, it is unlikely that we will find a treatment that has an important impact on this form of ms. symptomatic treatment modalities, including physical and occupational therapy, are very important, yet frequently overlooked in this patient population. other immunomodulator therapies. cyclophosphamide is an alkylating agent that has indiscriminate cytotoxic effects on rapidly dividing cells, including lymphocytes, making it a potent immunosuppressant. several studies have claimed a beneficial effect in both relapsing and progressive patients. because one of the major studies included acth, iv methylprednisolone is sometimes given with the cyclophosphamide. other trials have not found a favorable effect. because of the inconsistent results, high potential for serious side effects, and adverse reactions, including hemorrhagic cystitis and malignancy, cyclophosphamide is not widely used. some centers, however, use cyclophosphamide in patients with aggressive disease in whom more conventional treatments have failed. azathioprine, a purine analog antimetabolite, has marginal efficacy in the treatment of ms. a meta-analysis of all blinded, placebo-controlled studies confirmed a slight benefit of slowed progression and less frequent relapses. 101 the toxicity of azathioprine and its slow onset of action have prevented its widespread use. besides the liver toxicity and hematological effects, the induction of malignancies has been a concern. one retrospective study did not find an increased incidence of cancer in ms patients treated with azathioprine, but this remains a potential risk. methotrexate is a folate antagonist that is effective in rheumatoid arthritis. weekly low-dose oral methotrexate was found to delay upper extremity dysfunction in spms patients, although it had no effect on the more traditional measures of disability, including the expanded disability status scale (edss). 102 the use of cyclosporine in the treatment of ms has been evaluated in three clinical trials, none of which have demonstrated a convincing benefit. in addition, side effects such as hypertension and elevation of creatinine were common. numerous additional therapies have been tested, and many others are undergoing evaluation. the antiherpesvirus drug acyclovir has been shown to reduce relapse frequency in a small prospective trial. total lymphoid irradiation was found to slow the chronic progression of ms, but because this approach precludes the later initiation of immunosuppressant drugs and may be associated with a higher mortality rate, it is not widely used. cladribine is a nucleoside derivative that was found to decrease relapse rate and slow the progression in patients with spms in an initial investigation. 103 the drug is better tolerated than other parenteral immunosuppressants, although bone marrow suppression is a risk. in a more extensive clinical trial, 104 cladribine therapy did not change disability scores, but significant reduction in enhancing lesions and overall t2 lesion burden was observed with higher dose treatment. a study of a small number of patients treated with autologous stem cell transplantation 105 suggested possible clinical stabilization or minor improvement over a 15-month period of follow-up in both secondary and primary progressive ms. the induction chemotherapy (beam regimen) resulted in one fatality in this trial; similar incidences are known in patients undergoing this procedure. the small number of patients and the different methods used (some patients received cd34 ã¾ selected graft) makes the interpretation of this data very difficult. trials with higher number of patients under standardized circumstances are needed to verify the validity of these observations. symptomatic treatment of existing disabilities spasticity. spasticity is common even in patients with only minimal weakness (video 3, spastic gait). it is usually prudent to begin treatment of mild spasticity with a stretching program. a randomized controlled crossover trial 106 of physical therapy (8-week blocks of therapy twice a week, for 45 minutes per session) showed significant benefit on several outcome measures related to improved mobility. no apparent differences were observed between home-based or hospital-based therapy. the addition of an evening dose of benzodiazepine may help relieve extensor spasms and clonus that may interfere with sleep. as spasticity worsens, it becomes necessary to use baclofen. doses should be escalated slowly to prevent the occurrence of overt side effects, and up to 120 mg/day may be required. although baclofen is well tolerated in most patients, limiting side effects such as sedation and increased muscle weakness may occur, and rarely a paradoxical increase in spasticity is noted. liver enzyme elevation and nonconvulsive status epilepticus presenting as encephalopathy have also been reported in association with baclofen. abrupt withdrawal of baclofen may result in hallucinations or seizures, making it necessary to taper doses. despite symptomatic improvement, antispasticity measures may not increase function or independence. in paraplegic patients with severe spasticity and intolerance to the required oral dose, intrathecal baclofen delivered by a subcutaneously implanted pump allows a much smaller dose and is often effective in alleviating intractable spasticity and may lessen urinary urgency. tizanidine seems to be as effective as baclofen, although it may be associated with more fatigue. dantrolene has been used for spasticity, although the therapeutic window is small. fatigue. for treating fatigue, medications are only partially effective. amantadine at 100 mg twice a day is the standard initial treatment, although pemoline 37.5 mg daily is also superior to placebo. a recent, small pilot study by the mayo group suggested that high-dose aspirin (1300 mg/day) may sometimes be effective in the treatment of ms-related fatigue. 107 this finding needs to be confirmed by a second, larger trial, however. the stimulating effects of the selective serotonin reuptake inhibitors may also be somewhat effective in combating ms-related fatigue. modafinil, a medication approved for the treatment of narcolepsy, has also been used with good success. often, however, patients need to limit activities and schedule rest periods. paroxysmal symptoms of ms. paroxysmal symptoms are highly responsive to medical treatment. a small dose of carbamazepine is often very effective. if not tolerated, several alternative medications may be tried, including phenytoin, acetazolamide, baclofen, and gabapentin. in addition, misoprostol has been claimed to be effective in ms-related trigeminal neuralgia. after about 1 month of treatment, a periodic attempt at tapering off these medications is a reasonable approach because these symptoms usually remit. seizures in ms are treated no differently than in non-ms conditions. heat sensitivity. heat sensitivity may require avoidance of precipitating activities, but this depends on the nature of symptoms and the situation in which they occur. if the precipitating activity cannot be avoided, a cooling jacket may be an option. a potassium channel blocker, 4-aminopyridine, improves temperature sensitivity in some patients but occasionally causes seizures or disturbing paresthesias. action tremor. action tremor is a common disabling symptom (video 14, tremor with ataxia). unfortunately, it is often only marginally amenable to medical therapy. clonazepam may offer some relief, but tolerance frequently develops, necessitating increasing doses. isoniazid and carbamazepine have also been found marginally beneficial. one clinical trial showed ondansetron to reduce tremor-related disability. anecdotal reports suggest that gabapentin may be partially effective. improvements in stereotactic neurosurgery have made thalamotomy a legitimate option in those whose disability is mainly due to tremor and not ataxia. cognitive and memory problems. cognitive problems can also be seen in ms patients. these symptoms are generally not very severe; however, in some patients these may be one of their subjectively most bothersome complaints. it is important to make sure that such complaints are not depression related, as mood disorders are otherwise rather common in ms, and may explain the subjective cognitive impairment. while it is not fda approved for the treatment of ms related cognitive dysfunction, in a placebo controlled, randomized, 24-week long study of donepezil in 69 patients, significant improvement was found on the selective reminding test (srt). 108 this improvement was independent of ms subtype, gender, age, reading ability, and baseline srt results. the patients did not improve on other cognitive scales, but they were twice as likely to report cognitive improvement. dysesthetic pain. dysesthetic pains are difficult to control but sometimes respond to tricyclic antidepressants, carbamazepine, or baclofen. gabapentin, tramadol, and duloxetine may also be effective. standard analgesics are not often useful in ms-associated pain, and narcotics should be avoided in the treatment of chronic pain. emotional incontinence may be amenable to a low dose of a tricyclic antidepressant (video 10, dysarthria). symptoms of bladder dysfunction. symptoms of a hyper-reflexic bladder (urgency, frequency, and urge incontinence) are often manageable with anticholinergics such as oxybutynin, propantheline, or imipramine. a flaccid bladder can sometimes be aided by bethanechol, although intermittent self-catheterization is more often needed. symptoms that suggest urinary retention (a feeling of incomplete emptying, frequency, hesitancy, or a need to apply pressure to the lower abdomen to urinate) should prompt evaluation with urinalysis and a post-void residual urine measurement. residuals in excess of 15 ml are abnormal; and if they are above 50 ml, consideration should be given to urological consultation for more thorough investigation and to blood chemistries to determine urea and creatinine levels. detrusor-sphincter dyssynergia, diagnosed by cystometrography, is treated with anticholinergics, sometimes with the addition of an a-1 blocking agent (terazosin) or intermittent catheterization. it is important to reassess bladder function periodically, and residual urine volumes should be monitored if there are any persistent changes in function or symptoms. intermittent catheterization should be considered when post-void residuals reach 100 ml. a chronic indwelling urinary catheter should be avoided if reasonably possible. it is usually not necessary to use antibiotics prophylactically in the prevention of urinary tract infections. urinary calculi may be prevented by acidification of the urine with cranberry juice. bowel dysfunction in ms. constipation can usually be managed with bulk laxatives and stool softeners. more severe cases may require osmotic agents, bowel stimulants, anal stimulation, suppositories, or enemas. bedridden patients may develop fecal impaction unresponsive to these measures and require manual disimpaction. fecal incontinence can be minimized by adherence to a schedule for bowel movements. fiber supplementation may be of some benefit even in these cases. sexual dysfunction in ms. the clinician should determine the precise nature of any sexual dysfunction in patients with ms. physical difficulty from spasticity may be alleviated by premedication with baclofen, and a fast-acting anticholinergic such as oxybutynin may calm urinary urgency. sexual dysfunction should not be automatically attributed to ms. it may be necessary to investigate hormonal levels and to obtain urological or gynecological consultation. manual lubrication with gel is a ready solution to vaginal dryness. erectile dysfunction responds very well to sildenafil. less frequently, vacuum devices, intracavernous injections of papaverine (or combinations of papaverine, prostaglandins, and epinephrine; triple agent), or penile implant are also used in the treatment of erectile dysfunction. thalamotomy or thalamic stimulation may provide some short-term clinical benefit to patients disabled by appendicular cerebellar tremor and ataxia. the benefits on disability and quality of life are much less clear, however, and the early benefits may wain within 1 to 3 years. 109, 110 further studies are needed to clarify how best to select patients for these ablative and stimulation treatment interventions. general recommendations for ms patients. it is advisable for ms patients to attain good health habits, including proper diet and fitness. smoking, excess alcohol intake, and obesity should be avoided. exercise can help maximize function by increasing and maintaining joint mobility, strength, and stamina; may promote improved sleep hygiene; and may reduce the severity of fatigue. physical and occupational therapy can play an important role in regaining independence. canes, walkers, and wheelchairs or scooters may be needed to maintain safe mobility. hand controls can be installed in automobiles for patients with lower extremity dysfunction. in debilitated, immobilized patients, periodic shifts in posture to change weight-bearing regions and air or water mattresses prevent bedsores. passive range of motion exercises prevent contractures. when ventilatory dysfunction occurs, it should be evaluated and activity schedules should be appropriately modified. 111 special considerations during pregnancy. before initiation of any drug in a woman of reproductive age, the potential for teratogenicity must be discussed. in general, immunomodulator therapy should be avoided if one is planning a pregnancy. the treatment of acute exacerbations is unchanged during pregnancy, although one might have a higher threshold for treatment. both corticosteroids and plasma exchange are relatively safe during pregnancy. none of the drugs used to alter the disease course, however, should be used during pregnancy. interferon-b drugs should be stopped 2 to 3 months before planning pregnancy. interferons are associated with an approximately 39% likelihood of abortions. this is close to eight times higher than the usually quoted approximately 5% spontaneous abortion rate in women. interferon-b use is also associated with lower birth weight. 112 the cytotoxic immunosuppressants have teratogenic effects. the effects of many of the other drugs are unknown. it is best if these drugs are stopped several months before a planned pregnancy. prognosis and future perspectives. because most information on the prognosis of ms is reported in terms of the edss, it is important to have some understanding of this scale. the edss is a 10-point scale, with each increase representing worsening symptoms of function. the score is derived from severity scores in each of six systems as well as ambulation and work ability. a score of 0 means no signs or symptoms; 1 to 3 represent mild disability with no or minimal impairment of ambulation; 3.5 to 5.5 refer to moderate disability and impairment of gait; the need for a cane to walk one-half block (100 m) receives a score of 6; an edss of 8 refers to the need for a wheelchair and effective upper extremity function; an edss of 10 refers to death related to ms. ms has a highly variable outcome, ranging from asymptomatic to fulminant with death ensuing in a matter of months. autopsy series have estimated that unsuspected ms may occur in as many as 0.2% of the population. even when symptomatic, ms may cause only nuisance symptoms. benign ms, when defined as unrestricted ambulation or edss of 3 or less 10 years after onset, accounts for about one third of cases. however, many of these patients acquire more disability later. when considering all patients with ms, weinshenker found that 15 years after onset, 80% had edss worse than 3, 50% had reached edss of 6 or more, 10% were at edss 8, and 2% had died. the percentage of patients with initially rrms who develop spms increases steadily with disease duration. 113 at 10 years, 40% to 50% have continual deterioration; after 25 years, approximately 80% have slow progression. in the most recent study published about the olmsted county ms prevalence cohort consisting of 161 patients, the mean change in edss over 10 years was 1 point, and only 20% of patients had a change larger than 2.0 points. 114 eighty-three percent of the patients with mild symptoms (edss < 3.0) were still ambulatory without cane 10 years later. among the patients with an edss of 3 to 5, 51% were using a cane; in the 6 to 7 edds range, 51% were wheelchair bound. strong predictors for the outcome were not identified in this study. population-based studies with complete ascertainment can effectively remove the bias of a referral practice, which is inherently biased towards the more active and more serious cases. these studies also provide some much needed balance to the "heavily skewed for recent disease activity" clinical trial experience. from the most recent extensions to the olmsted county ms cohort studies conducted by the mayo group, several conclusions can be drawn. the number of relapses in the first year of the disease do not predict long term outcome. the time to disability is not influenced by ongoing relapses once patients achieve an apparently permanent degree of moderate disability (edss 3.5). overall, 80% patients who are still classified as rrms into their second decade of disease continue to do well for 15 to 20 years with limited permanent disability. patients doing extremely well (edss 2.0) after 10 years of ms generally do well in the next decade. however, very rarely patients doing well even for 2 to 3 decades may develop severe late disability. we advise that neurologists share these findings with patients who are in periods of prolonged remission during the discussions about the merits of beginning disease-modifying agents. natural history studies have identified several prognostic indicators that predict outcome to a limited extent. factors associated with a better prognosis (slower accumulation of disability, longer time before chronic progression) include young age at onset, female gender, rr course (as opposed to ppms), initial symptoms of sensory impairment or on, first manifestations affecting only one cns region, high degree of recovery from initial bout, longer interval between first and second relapses, low number of relapses in the first 2 years, and less disability at 5 years after onset (both edss and number of systems affected-sensory, motor, sphincter, brain stem, vision, cerebral). despite the indolent nature, a pp course is the worst prognostic factor, with the median time to reach edss 6 of only 6 years, compared with approximately 20 years in rr patients. men and patients with an older age at onset are more likely to have ppms. the survival of ms patients is only slightly below expected. seventy-six percent of patients are alive 25 years after onset, which is 85% of that seen in age-and sexmatched control subjects. 35 ms is rarely the direct cause of death. complications of ms such as pneumonia, pulmonary emboli, aspiration, urosepsis, and decubiti are responsible for 50% of deaths. most of the other deaths are from heart disease, cancer, cerebrovascular disease, and trauma. suicide is the only cause of death that is overrepresented among these cases. the suicide rate among ms patients may be as high as two to seven times that of non-ms persons. neuromyelitis optica (nmo) is an uncommon neurological illness characterized by the occurrence of optic neuritis and myelitis. the names devic's syndrome, devic's disease, and nmo are often used interchangeably, although the first name encompasses all patients who fit the preceding definition and the second and third should only be used to refer to those patients presumed to have a distinct disorder. the term opticospinal ms is often used in the far east to denote patients with exclusive or predominant involvement of optic nerves and spinal cord, encompassing most patients with devic's syndrome. devic's disease (nmo) may be a monophasic illness, or may show a relapsingremitting course. 115 it is the first inflammatory demyelinating disease with a known serum marker, the nmo-igg antibody. pathogenesis and pathophysiology. devic's syndrome may occur with adem, autoimmune disorders (e.g., systemic lupus erythematosus), ms, and possibly viral infections. also, patients with devic's disease may have other coexisting autoimmune conditions. classically, acute spinal cord lesions demonstrate diffuse swelling that extend over several levels or involve nearly the entire cross section of the cord. acutely, there is destruction with dense macrophage infiltration involving white and gray matter, loss of myelin and axons, and lymphocytic cuffing of vessels. in chronic lesions, the cord is atrophic and necrotic, occasionally with cystic degeneration and gliosis. in the absence of perivascular cuffing, these extensive lesions resemble infarctions. the prominent spinal cord swelling in the confines of the restrictive pia presumably may raise intramedullary pressure, leading to the collapse of small parenchymal vessels, further propagating tissue injury. proliferation of vessels with thickened and hyalinized walls similar to that seen after infarction or other extensive injury may occur. 116 less fulminant lesions may coexist and are much more typical of inflammatory demyelination. the optic nerve lesions often involve the chiasm. even though nmo is usually restricted to the optic nerves and spinal cord, one may see classic ms like lesions in up to 10% of cases, and hypothalamic lesions have also been described in approximately 10%. the newly discovered serum marker, nmo-igg has a sensitivity of 73% and specificity of 91%. 117 the discovery of this novel immune marker also clarified that most if not all cases of "opticospinal ms" reported in the japanese literature are also cases of nmo. to the surprise of the ms research community, the antigen is neither myelin nor neuron related: it is the aquaporin-4 water channel, a component of the dystroglycan protein complex located in astrocytic foot processes at the bloodbrain barrier. 11 nmo thus may represent the first example of a novel class of autoimmune channelopathies. epidemiology and risk factors. devic's syndrome occurs in patients of varied ages (range, 1 to 73 years). the mean age at onset of monophasic devic's syndrome is 27, whereas relapsing nmo (see later) tends to occur in an older age group (mean age at onset of 43). monophasic devic's syndrome affects males and females equally, whereas relapsing nmo affects females predominantly (f:m, 3.8:1). one third of patients have a preceding infection within a few weeks of neurological symptom onset. most commonly this is a nonspecific upper respiratory tract infection, flu, or gastroenteritis. the most common specific infections preceding the development of devic's syndrome are chickenpox and pulmonary tuberculosis. devic's syndrome has also followed vaccination for swine flu and mumps. only a few instances of a possible familial occurrence of devic's syndrome have been reported, and in one of these families, a unique mitochondrial mutation was found. devic's syndrome is said to be more common in japan and east asia, although even there it is uncommon (less than 5 per 100,000). three cases have been described in the literature with familial occurrence of devic's disease in the far east. in a genetic study, hla-dpb1*0501 was more frequently associated with "opticospinal ms," whereas hla-dpb1*0301 is the most strongly associated allele with conventional ms in the japanese. symptoms of on and myelitis develop over hours to days and are often preceded or accompanied by headache, nausea, somnolence, fever, or myalgias. continued progression of symptoms over weeks or months occasionally occurs. most patients (greater than 80%) develop bilateral optic neuritis. bitemporal or junctional field deficits, indicating chiasm involvement, are sometimes present early in the course of the on. visual loss is often accompanied by periocular pain, and myelitis onset is sometimes heralded by localized back or radicular pain. lhermitte's sign is common. severe degrees of neurological deficits are usual, and the degree of recovery is variable. approximately 35% of nmo patients have a monophasic illness, 55% develop relapses usually limited to the optic nerves and spinal cord (relapsing nmo or opticospinal ms), and rarely patients have a fulminantly progressive course without relapses or a course typical of ms. 115 according to a study conducted at the mayo clinic, 115 patients with a monophasic course usually presented with rapidly sequential events (median, 5 days) with only moderate recovery. patients showing characteristics of the relapsing form of devic's had a median interval of 166 days between index events, followed within 3 years by clusters of severe relapses isolated to the optic nerves and spinal cord. most relapsing patients developed severe disability in a stepwise manner. approximately one third died from respiratory failure. predictors of a relapsing course in nmo 118 include longer inter-attack intervals (relative risk [rr]: 2.16 per month increase), older age at onset (rr â¼ 1.08 per year increase), female sex (rr â¼ 10.0), and less severe motor impairment with sentinel myelitis event (rr â¼ 0.48 per severity scale point increase). autoimmune disease history (rr â¼ 4.15), higher attack frequency in first 2 years (rr â¼ 1.21 per attack), and better recovery following index myelitis (rr â¼ 1.84 per point) are associated with increased mortality rate. features of nmo distinct from "typical" ms included normal initial brain mri, more than 50 cells/ml in csf with polymorphonuclear predominance, and lesions extending over three or more vertebral segments on spinal cord mri. relapsing nmo is often associated with autoimmune disorders, most commonly systemic lupus erythematosus. these patients also frequently have an elevated erythrocyte sedimentation rate and nonspecific elevation of autoantibodies, including antinuclear antibodies, anti-ds-dna, and antiphospholipid antibodies. tonic spasms and neuropathic lower extremity pain are common sequelae to the spinal cord damage. symptoms referable to brain stem lesions (nystagmus, ophthalmoparesis, and vertigo) can occur in these patients as well. differential diagnosis. the differential diagnoses for devic's syndrome includes ms, adem, pulmonary tuberculosis, and viral infection (especially in the immunocompromised patient). in patients with an apparent affected family member, consideration should be given to mitochondrial disease. relapsing nmo should raise the suspicion for associated autoimmune disorders. because devic's syndrome can occur in persons older than age 60, when an unrelated ischemic optic neuropathy could occur, and because isolated or recurrent myelopathy may precede the on, additional consideration must be given to spinal cord compression, spinal cord tumor, and spinal arteriovenous malformation (avm) or dural fistula. evaluation. imaging is needed to exclude structural lesions and provide information on the pathological process. optic nerve or chiasm enlargement, t2-weighted signal changes, and enhancement may be seen on head mri during the acute phase. increased t2-weighted signal in the medulla is not uncommon and usually represents extension of high cervical lesions. spine mri characteristically shows cord swelling, signal changes, and enhancement extending over at least three levels ( fig. 48-4) . this appearance may resemble a spinal cord tumor, prompting consideration for biopsy. on magnetization transfer (mt) mri, no significant difference was found on normal-appearing white matter of devic's patients and control subjects, whereas ms patients had a significantly lower mt ratio peak and histogram average. 119 t1 hypointense lesions in the cord and linear lesions that cross over more than two segments are more suggestive of devic's disease. an occasional patient may need prone and supine myelography to exclude a spinal dural-based avm. laboratory investigations reveal an elevated erythrocyte sedimentation rate in one third, positive antinuclear antibodies in nearly one half, and occasionally other autoantibodies (e.g., thyroperoxidase antibodies). 39 it is reasonable to exclude syphilis, lyme disease, and human immunodeficiency virus by laboratory testing. in a few patients with the far east variety of devic's disease, hyperprolactinemia was described predominantly with optic nerve involvement. a chest x-ray helps to exclude pulmonary tuberculosis and sarcoidosis. csf examination is an essential part of the evaluation for devic's syndrome, and repeated studies are sometimes necessary to ensure that there is no infection in that the csf findings are sometimes atypical for inflammatory demyelination. a marked pleocytosis is often present, sometimes exceeding 100 cells. moreover, neutrophils are commonly seen in csf and may predominate, a situation virtually unknown in ms. 120 the protein concentration is often very high and in 41% exceeds 100 mg/dl. anti-mog antibodies are the predominant autoantibody detected in csf; anti-mbp or anti-s100b antibodies are less frequently seen. despite the intense inflammatory response, ocbs are conspicuously absent in the majority, being present in fewer than 20% of patients. csf serology for the herpesvirus family (hsv types 1 and 2, vzv, ebv, and cmv) is important, and polymerase chain reaction testing should be done in cases suggestive of viral infection (immunocompromised patients). management. patients with acute or subacute devic's syndrome may respond to corticosteroids (e.g., intravenous methylprednisolone). they may respond to plasma exchange even when intravenous methylprednisolone does not produce significant improvement. attempts at preventing relapses and the subsequent disability are often disappointing even with the use of immunosuppressive agents. the classic injectable immunomodulators used in ms are insufficient to reduce the relapse rate in relapsing nmo. most commonly, a combination of azathioprine and prednisone is used for secondary prevention. other agents including mycophenolate mofetil, ivig, and mitoxantrone have been described to be effective in some cases. a small study of rituximab, a humanized anti-cd20 antibody showed a siginifcant reduction in the relapse rate of 8 patients, making 6 of 8 relapse free. 121 a large multicenter study of rituximab in nmo is in the planning stages. supportive care is important in the management of nmo. these patients are prone to many complications and require measures to prevent deep venous thrombosis and pulmonary embolism, urinary tract infection, decubiti, and contractures. mechanical ventilation may be needed either temporarily or permanently. patients with monophasic devic's syndrome generally have simultaneous or rapid onset of the on and myelitis (interval usually less than 1 month). although some have significant residual disability, many recover remarkably and have little or no permanent deficits. a history of previous vague neurological symptoms or definite demyelinating events is predictive of future relapses, either typical of ms or relapsing nmo. those patients destined for recurrent myelitis and on have a longer interval between the onsets of myelitis and on. the vast majority of patients with relapsing nmo have very aggressive disease with frequent and severe exacerbations and a poor prognosis. adem is a monophasic inflammatory demyelinating disorder that characteristically begins within 6 weeks of an antigenic challenge such as infection or immunization. it occurs more often in the young and causes the rapid development of multifocal or focal neurological deficits. perivenous inflammation, edema, and demyelination are the pathological hallmarks of adem, although these lesions commonly enlarge and coalesce, forming lesions pathologically indistinguishable from ms. moreover, perivascular changes typical of adem are common in patients with ms. there is considerable overlap in the epidemiological, clinical, csf, imaging, and pathological features between adem and ms, often making it difficult to distinguish between the two with reasonable confidence when encountering patients with a single demyelinating event. pathogenesis and pathophysiology. adem closely resembles the experimental allergic encephalomyelitis animal model of ms (eae) both clinically and pathologically, and is most likely due to a transient autoimmune response toward myelin. the occurrence of adem after vaccination with the rabbit spinal cord preparation of rabies virus led to the discovery of eae. infections and non-cnscontaining vaccinations may induce adem by molecular mimicry or by activating autoreactive t-cell clones in a nonspecific manner. lymphocyte reactivity toward mbp has been identified in blood and csf from patients with adem, but its absence in others indicates a role for other antigens. increased peripheral blood g interferon-producing t cells have been described in adem. epidemiology and risk factors. adem can occur at any age but perhaps because of the higher frequency of immunization and exposure to new antigens; it is most common during childhood. unlike ms, both sexes are affected with equal frequency. no association has been noted with pregnancy. adem has been reported to follow a number of different immunizations, usually within 6 weeks, including those for pertussis, diphtheria, measles, mumps, rubella, influenza (postvaccination adem), tetanus, and yellow fever. in addition, there are case reports of adem following hepatitis b vaccination. however, the only epidemiologically and pathologically proved association is with rabies vaccination, which also causes demyelinating peripheral neuropathies. the original pasteur rabies vaccine, prepared in rabbit spinal cord, was associated with an incidence of adem of approximately 1 per 3000 to 1 per 35,000 vaccinations and is no longer in use. a later vaccine, made in duck embryo, which contains little neural tissue, carries a risk for adem of 1 per 25,000 vaccines. the use of human diploid cell lines, which contain no nervous system tissue, for the production of rabies vaccine has virtually eliminated the risk of adem. the association of bee stings with adem has also been reported. parainfectious adem usually follows onset of the infectious illness, often during the recovery phase, but because of the latency between pathogen exposure and illness it may precede clinical symptoms of infection or the two may occur simultaneously. the most commonly reported associated illness is a nonspecific upper respiratory tract infection. there have been a vast number of specific infections associated with adem, such as virus infections (including rubella, mumps, vzv, ebv, cmv, influenza, coxsackievirus, and hepatitis c) and infection with mycoplasma, borrelia burgdorferi, and leptospira. measles carries the highest risk for adem of any infection, occurring in 1 per 400 to 1 per 1000 cases. although adem has been reported in association with measles immunization, the risk is far lower than the risk of acquiring measles and its neurological complications. clinical features and associated disor-ders. a prodrome of headache, low-grade fever, myalgias, and malaise often precedes the onset of adem by a few days. in a german study of 40 cases, 122 the most frequent clinical signs were motor deficit (80%), followed by sensory deficits, brain stem signs, and cerebellar signs. csf findings were variable; normal results were present in up to 20% of patients. oligoclonal bands were positive in over 60%. almost all patients improved during the acute phase of the disease. of the 26 patients with the final diagnosis of adem, 21 had minor or no symptoms, 2 died, the rest had moderate symptoms. compared to ms patients, the adem patients were older, and more often had a preceding infection, clinical signs of brain stem involvement, a higher csf albumin fraction, and infratentorial lesions. neurological symptoms develop rapidly in the acute phase and are commonly associated with encephalopathy, stupor, coma, meningismus, and seizures. peak severity occurs within several days, and recovery may begin soon afterward. occasionally, adem may evolve over a few months and there may be a second clinical deterioration or subacute progression for a time. in these unusual cases, the distinction from ms is difficult. three recent large retrospective series and an accompanying editorial have highlighted that there remain no clinical or laboratory features that accurately allow one to predict which adult or pediatric adem patients will develop. [122] [123] [124] [125] differential diagnosis. one of the primary concerns after a single demyelinating episode is whether other bouts can be expected (e.g., ms). several features may tip the balance toward one or the other, but the proper diagnosis becomes apparent only with time. classically, adem is characterized by the multifocal involvement at onset whereas ms often presents with monosymptomatic deficits such as on. however, adem may cause unifocal symptoms and ms may present with multifocal cns involvement, especially in children. the monosymptomatic deficits caused by adem are more commonly severe, such as bilateral on and complete transverse myelitis. although ocbs occur transiently in about one third of adem cases, their persistence implies a diagnosis of ms. the subsequent disappearance of ocbs, when performed by consistent techniques, is evidence against ms. the mri appearance of these two disorders is often identical, 125 but the presence of basal ganglia or cortical lesions, or large globular white matter lesions, is more frequent in adem. the fulminant development of adem is distinctive but not pathognomonic, because a rare form of ms known as marburg's ms is also rapid in onset and often deadly. the appearance of brain stem, periventricular, and multiple, large cerebral white matter lesions and the presence of ocbs may distinguish marburg's variant from adem. on rare occasions, inflammatory demyelinating lesions may reach a large size and resemble tumors (especially lymphoma) on mri, necessitating biopsy for clarification. there is usually one dominant lesion, but smaller separate lesions may be identifiable. these have been referred to as both adem and ms in the literature. the prognosis for recovery is often quite good, although approximately one third suffer subsequent attacks. some develop typical ms, whereas others have recurring tumor-like lesions. the term multiphasic adem has been used when patients have large recurrences in the same location, and relapsing adem refers to recurrences at different sites. the relationship of these entities with ms is unclear. balo's concentric sclerosis refers to the pathological finding of alternating bands of demyelination and remyelination. these patients typically have large lesions and subacute deficits similar to those described earlier. typical demyelinating lesions commonly coexist, and rarely cdms patients are noted to have similar-appearing lesions. the reason for this peculiar alternating pattern is unknown. schilder's myelinoclastic diffuse sclerosis is another rare condition that may be confused with adem or other demyelinating conditions. this progressive demyelinating disorder usually begins in childhood. the features are often atypical and include dementia, aphasia, homonymous hemianopia, seizures, psychosis, elevated intracranial pressure, and the absence of ocbs. the most characteristic finding is the presence of two large, roughly symmetrical lesions on mri, one in each hemisphere. the diagnosis is made by excluding the known inherited leukodystrophies, especially adrenoleukodystrophy. management. treatment with intravenous methylprednisolone seems to halt progression and allow recovery to begin sooner, just as with ms. plasma exchange can be tried in those with severe deficits and little response to corticosteroids. ivig has also been used successfully according to case reports in the literature. one fulminant case responded to hypothermia only. genetics of multiple sclerosis utility of mri in suspected ms the use of mitoxantrone (novantrone) for the treatment of multiple sclerosis disease modifying therapies in multiple sclerosis natural history of multiple sclerosis a randomized study of two interferon-beta treatments in relapsing-remitting multiple sclerosis cortical lesions and brain atrophy in ms the pathology of multiple sclerosis management of multiple sclerosis: current trials and future options competing interests in multiple sclerosis 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multiple sclerosis study group further study on the specificity and incidence of neutralizing antibodies to interferon (ifn) in relapsing remitting multiple sclerosis patients treated with ifn beta-1a or ifn beta-1b intramuscular interferon beta-1a for disease progression in relapsing multiple sclerosis. the multiple sclerosis collaborative research group (mscrg) the long-term safety and tolerability of high-dose interferon beta-1a in relapsing-remitting multiple sclerosis: 4-year data from the prisms study randomised double-blind placebo-controlled study of interferon beta-1a in relapsing/remitting multiple sclerosis. prisms (prevention of relapses and disability by interferon beta-1a subcutaneously in multiple sclerosis) study group magnetic resonance imaging results of the prisms trial: a randomized, double-blind, placebo-controlled study of interferon-beta1a in relapsing-remitting multiple sclerosis. prevention of relapses and disability by interferon-beta1a subcutaneously in multiple sclerosis ingested ifn-alpha: results of a pilot study in relapsing-remitting ms clinical characteristics of responders to interferon therapy for relapsing ms a pilot trial of cop 1 in exacerbating-remitting multiple sclerosis copolymer 1 reduces relapse rate and improves disability in relapsing-remitting multiple sclerosis: results of a phase iii multicenter, double-blind placebocontrolled trial. the copolymer 1 multiple sclerosis study group glatiramer acetate reduces the proportion of new ms lesions evolving into "black holes european/canadian multicenter, double-blind, randomized, placebo-controlled study of the effects of glatiramer acetate on magnetic resonance imaging-measured disease activity and burden in patients with relapsing multiple sclerosis. european/canadian glatiramer acetate study group united states open-label glatiramer acetate extension trial for relapsing multiple sclerosis: mri and clinical correlates. multiple sclerosis study group and the mri analysis 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patients a serum autoantibody marker of neuromyelitis optica: distinction from multiple sclerosis neuromyelitis optica: clinical predictors of a relapsing course and survival mri and magnetization transfer imaging changes in the brain and cervical cord of patients with devic's neuromyelitis optica clinical, csf, and mri findings in devic's neuromyelitis optica neuromyelitis optica acute disseminated encephalomyelitis: a follow-up study of 40 adult patients adem: distinct disease or part of the ms spectrum clinical and neuroradiologic features of acute disseminated encephalomyelitis in children acute disseminated encephalomyelitis. mri findings and the distinction from multiple sclerosis interactive study questions and referenced videos for this chapter are available on the dvd-rom key: cord-006828-i88on326 authors: nan title: abstracts dgrh-kongress 2013 date: 2013-09-15 journal: z rheumatol doi: 10.1007/s00393-013-1255-1 sha: doc_id: 6828 cord_uid: i88on326 nan im namen der dgrh, der dgorh und der gkjr begrüßen wir sie ganz herzlich zu unserem diesjährigen kongress visualisierung therapeutischer effekte von vasodilatantien beim sekundären raynaud-syndrom mittels fluoreszenzoptischer bildgebung di.14 stellenwert der gelenksonographie bezüglich diagnose, behandlung und therapiekontrolle der bursitis intermetatarsalis -einer häufig übersehenen differenzialdiagnose. fünf fallbeispiele wegen der deutlich eingeschränkten nierenfunktion konnten therapeutisch keine nsar angewandt werden. wir haben mit 2×0,5 mg colchicin täglich behandelt. die anfänglich schwerkranke bettlägerige patientin konnte innerhalb von 48h mobilisiert werden. um eine abschließende sicherung der diagnose einer uratinduzierten sakroiliitis erreichen zu können ist die patientin mit einem dual-energy-ct (dect) untersucht worden. ergebnisse. mit dieser methode konnten gichttophi in beiden sakroiliakalgelenken dargestellt werden, ebenso an beiden mtp1-gelenken. schlussfolgerung. aktuell liegen bisher noch keine weiteren berichte vor, dass diese methode auch für die diagnostik einer gicht im bereich der sakroiliakalregion zuverlässige ergebnisse liefern kann. zudem zeigt dieser krankheitsverlauf, dass sich die gicht durchaus primär im bereich des achsenskeletts manifestieren kann und nicht in erster linie an den peripheren gelenken zu entsprechenden beschwerden führen muss. a. glimm 1 , s. werner 1 , s. ohrndorf 1 , c. schwenke 2 , g. schmittat 1 , g. burmester 1 einleitung. typische pathologische veränderung bei der rheumatoiden arthritis (ra) ist die synovialitis. auch bei der osteoarthrose (oa) lassen sich entzündliche veränderungen der gelenke finden. diese können mittels fluoreszenzoptischer bildgebung (foi) und dem gelenkultraschall (us) sichtbar gemacht werden. ziel der studie: vergleich der foi mit dem us bei patienten mit ra und oa. methoden. es wurde bei 90 patienten (67 ra, 23 oa) die foi beider hände sowie die us des handgelenks (hg) und der fingergelenke (mcp, pip, dip) der klinisch beschwerdeführenden hand von dorsal und palmar sowohl im b-bild (b-us) als auch mit power-doppler (pd-us) durchgeführt. synovialitis und tenosynovitis im us sowie die intensität des fluoreszenzsignals im bereich der gelenke in der foi wurden qualitativ als auch semiquantitativ nach standardisierten verfahren für den primavistamode (pvm) und drei verschiedene phasen (p1-3; [1] ) bewertet. in der statistischen analyse wurden anschließend sensitivitäten und spezifitäten für die foi bei der ra und oa getrennt für synovialitis und tenosynovitis, dorsal und palmar jeweils für b-us und pd-us als referenzmethode berechnet. ergebnisse. in abhängigkeit von der betrachteten phase zeigen sich für die ra und oa moderate sensitivitäten und spezifitäten. für die ra wurden in der phase 2 des foi die höchsten sensitivitäten mit 68% für b-us und 77% für pd-us berechnet. auch bei der oa ergaben sich die höchsten sensitivitäten in der phase 2 des foi mit 77% für b-us und 89% für pd-us als referenzmethode. die höchsten spezifitäten für beide diagnosen wurden in der foi in phase 3 erreicht. hierbei lag die spezifität bei der ra für b-us bei 96% und für pd-us bei 90%. der höchste spezifitätswert bei der oa sowohl für b-us als pd-us war 88% (. tab. 3 background. pet is a nuclear imaging technique that depicts functional processes within the body with high sensitivity by detecting annihilation radiation from radioactive decay of a positron-emitting radionuclide that was labeled to a biologically active molecule (tracer) and introduced into the body. 18f-fluoride (18f) can be used for pet as a bone-seeking agent reflecting bone perfusion and remodeling. we inaugurated a pilot study with simultaneous pet/mr to examine whether addition of pet provides different and additional information in comparison to mri in axspa patients. methods. eleven axspa patients, median age 39 y, disease duration range 0.5-10 y, mean basdai 5.3, were examined by pet/3-tesla mri 40 minutes after injection of a mean dose of 157 mbq of 18f using a integrated whole-body pet/mr scanner (siemens biograph mmr®). 3t-mris were scored blinded to patient's clinical characteristics by two readers (1 rheumatologist and 1 radiologist/nuclear medicine specialist) using the berlin mri score and also by recording inflammatory lesions on a vertebral edge (ve) level. in a second step pet/mris were read blindly by the same readers also based on the ve involvement of individual vertebral bodies. results. the procedure was successful in all patients. the resulting mean effective radiation dose per patient was 3.76 msv. co-registration of pet/mri fusion images was highly accurate, allowing a precise comparison of mri and pet. in the direct comparison of the mri and pet signal the two readers saw consistent signals in almost 90% of the sites studied. however, there were areas where signals differed, e.g. within existing syndesmophytes where pet signal was increased but conventional mris showed no signal, or the sternum area and lateral or posterior spinal elements such as facets and spinous processes. conclusion. the new technique of integrated pet/mri provides similar imaging signals as conventional mri. however, we observed differences between the two modalities in areas with less inflammatory activity but where bone metabolism seemed to be active or in areas with blurred resolution on conventional mri. the possibility that pet detects osteoblastic activity in areas where no inflammatory signal is detected with mri seems to be of interest. einleitung. sensitiven bildgebenden verfahren wie der hochauflösenden arthrosonographie kommen bei der detektion initial entzündlicher veränderungen im rahmen der frühdiagnostik der psoriasisarthritis (psa) eine große bedeutung zu. die vorliegende prospektive studie untersucht die diagnostische und prognostische wertigkeit der sonographischen befunde im vergleich zur klinischen untersuchung auf ebene einzelner gelenke bei früher psoriasis-arthritis (psa). methoden. rekrutierung von 50 patienten mit therapienaiver früher psa. sonographie von 56 gelenken mit semiquantitativer graduierung (grad 0-3) von b-bild (gsus) und power-doppler-aktivität (pdus; baseline, 12 monate). klinische parameter: anzahl druckschmerzhafter und geschwollener gelenke (tjc68, sjc66), visuelle analogskala, das28-crp, health assessment questionnaire haq. für jede followup-visite erfolgte eine kategorisierung des klinischen ansprechens nach eular-response-kriterien und der für die psa validierten minimal-disease-activity(mda)-kriterien (coates et al.). ergebnisse. baseline 50 patienten, nach 12 monate 19 patienten, erkrankungsdauer (12±17,6 monate). patienten ohne therapie (1), mit nsar (1), steroid i.a. (1) , dmards (10), biologicals (6). bei diagnosestellung zeigte sich eine signifikante korrelation zwischen dem us synovitis score und folgenden klinischen parametern: tjc68 (r=0,52), scj66 (r=0,63), das28-crp (r=0,34). nach 12 monaten zeigte sich eine gute korrelation zwischen der relativen veränderung des us synovitis scores und der relativen veränderung folgender klinischer parameter: tjc68 (r=0,72), haq (r=0,41), pasi (r=0,42), das28-crp (r=0,33). zu baseline waren 407 von 2730 gelenken sonographisch auffällig, davon zeigten 239 kein klinisches korrelat (subklinisch). nach 12 monaten zeigten 29% der initial subklinischen gelenke einen unveränderten befund, 61% waren sonographisch nicht mehr auffällig und 10% wurden klinisch manifest. bei den klinischen respondern war der rückgang deutlicher ausgeprägt. schlussfolgerung. der ultraschall-synovitis-score korreliert mit klinischen aktivitätsparametern sowohl zum zeitpunkt der diagnosestellung als auch im krankheitsverlauf unter immunsuppressiver therapie. die subklinischen veränderungen bilden sich unter immunsuppressiver therapie zu einem großen teil zurück, deutlicher bei klinischen respondern. ein geringer anteil der initial subklinischen gelenke wird im verlauf klinisch manifest, in höherem maße bei klinischen non-respondern. t. diekhoff 1 , k. hermann 1 1 charité -universitätsmedizin berlin, radiologie, berlin einleitung. die gicht ist mit einer prävalenz von 0,4-0,6% insbesondere in den industrieländern eine häufige erkrankungen, die mit gelenkschmerzen einhergeht. bei typischer symptomatik und laborkonstellation ist die diagnose der arthritis urica oft einfach zu stellen, ein atypisches beschwerdebild kann jedoch gelegentlich die abgrenzung zu anderen erkrankungen erschweren. besonders die kalziumpyrophosphat-kristallarthropathie (cppd oder pseudogicht), die selbst mit sehr variabler symptomatik auftreten kann, ist eine relevante differenzialdiagnose, besonders bei älteren patienten. methoden. mit der dual-energy-computertomographie (de-ct) steht ein modernes, innovatives verfahren zur verfügung, das eine detektion von harnsäurehaltigen weichteilverkalkungen ermöglicht und darüber hinaus eine sichere abgrenzung zu kalziumhaltigen verkalkungen gewährleisten kann. das prinzip der de-ct ist relativ simpel und seit längerem bekannt: die messung des untersuchungsvolumens mit zwei unterschiedlichen röhrenspannungen macht es möglich, einen schwächungskoeffizienten zu errechnen, der spezifisch für das untersuchte material ist. allerdings ermöglichten erst moderne cts mit zwei röntgenröhren die klinische anwendung. in jüngster zeit werden jedoch anstrengungen unternommen, die de-ct auch für ein-röhren-systeme verfügbar zu machen. ergebnisse. mit der de-ct können gichttophi sicher vom knochen aber auch von anderen verkalkungen getrennt und zum beispiel farblich kodiert dargestellt werden. im gegensatz zum konventionellen röntgenbild verspricht die de-ct jedoch nicht nur eine höhere sensitivität für tophöse veränderungen, sondern als schnittbildverfahren auch eine bessere abgrenzung und einordnung von anderen morphologischen veränderungen wie zum beispiel von erosionen. schlussfolgerung. dieser vortrag fasst die vor-und nachteile der de-ct in der detektion und abgrenzung von weichteilverkalkungen bei kristallarthropathien zusammen und gibt darüber hinaus einen ausblick auf zukünftige entwicklungen in diesem gebiet. background. anionic glycosaminoglycans interact with a variety of soluble and membrane bound molecules. chondroitin sulfate was shown to have anti-inflammatory properties but its role in arthritis is controversial. methods. we have analyzed the effect of chondroitin sulfate on collagen induced arthritis starting treatment before and after induction of arthritis and in mice with established arthritis. results. in all of these settings chondroitin sulfate significantly reduced the severity of arthritis. it prevented joint destruction, diminished the inflammatory infiltrate and reduced proinflammatory cytokines in joints and plasma. splenocytes restimulated with collagen produced less il-2 and more il-10 and il-13. the beneficial effects of chondroitin sulfate were transient and closely correlated to the suppression of the collagen-specific humoral immune response. chondroitin sulfate, but not other glycosaminoglycans induced a direct btk and syk-dependent proliferation of b cells and markedly expanded the number of plasma cells in the spleen. in immunized mice chondroitin sulfate reduced the number of antigen specific plasma cells in the bone marrow and was able to suppress established humoral immune responses. conclusion. displacement of disease inducing plasma cells from the bone marrow might contribute to the beneficial effects of chondroitin sulfate and could be an attractive strategy to suppress antibody mediated autoimmunity. background. in rheumatoid arthritis a functional deterioration of the hpa-axis in form of inadequately low secretion of glucocorticoids in relation to severity of inflammation can be detected. the reasons for this phenomenon are not known. the purpose of this study was to find possible reasons responsible for adrenal insufficiency during arthritis. methods. da rats were immunized with type ii collagen in incomplete freund adjuvant to induce arthritis. plasma corticosterone was evaluated by ria and plasma acth by elisa. adrenal cholesterol was quan-titatively studied by sudan-iii staining and scavenger receptor class bi (sr-bi, the hdl receptor) by immunohistochemistry. fluorescent nbd-cholesterol uptake kinetics were analysed by flow cytometry. ultrastructural morphology of adrenocortical mitochondria and lipid droplets was studied by electron microscopy. results. initially increased corticosterone and acth levels were reduced to baseline levels in the later phase of the disease. serum levels of corticosterone relative to il-1β were markedly lower in arthritic than control animals (inadequacy). cholesterol storage in adrenocortical cells and expression of sr-bi did not differ between immunized and control rats. however, number of impaired mitochondria largely increased during the course of arthritis (maximum on day 55), and this was paralleled by reduced numbers of activated cholesterol droplets (inhomogenous droplets relevant for generation of glucocorticoids). in addition, number of normal mitochondria positively correlated with serum corticosterone levels. conclusion. this first study on adrenal reasons for inadequate glucocorticoid secretion in arthritis demonstrated impaired mitochondria and altered cholesterol breakdown paralleled by low corticosterone levels in relation to ongoing inflammation. justus-liebig universität gießen, kerckhoff-klinik gmbh, rheumatologie u. klinische immunologie, osteologie, physikalische therapie, bad nauheim, 2 agaplesion markus krankenhaus, akademisches lehrkrankenhaus der johann wolfgang goethe-universität, klinik für orthopädie und unfallchirurgie, frankfurt/main, 3 universitätsklinikum gießen und marburg, orthopädische klinik, labor für experimentelle orthopädie, gießen, 4 universitätsklinikum gießen und marburg, orthopädie und orthopädische chirurgie, gießen, 5 universitätsklinikum erlangen, medizinische klinik 3 , rheumatologie und immunologie, erlangen background. obesity is a risk factor in osteoarthritis (oa), but there is limited information about the interaction between bone formation and adipose tissue-derived factors, the so-called adipokines. adipokines such as adiponectin, resistin or visfatin are associated with the pathogenesis of rheumatoid arthritis (ra) and oa. adipokines are produced also by other cell types than adipocytes in ra and oa joints, for example osteoblasts, osteoclasts or chondrocytes. however, in contrast to their joint-destructive role in ra, their role in oa joint remodeling is unclear. therefore, adipokine expression in osteophyte development and bone forming cells as well as their effect on these cells was analyzed. methods. osteophytes and bone were obtained from oa patients during joint replacement surgery. serial sections of bone tissue were stained (masson trichrome, trap) and scored from grade one (no ossification, mainly connective tissue and cartilage) to five (ossified, mineralized osteophyte, <10% connective tissue, ossified remodeling zones). immunohistochemistry against alkaline phosphatase, collagen-type ii, adiponectin, resistin, and visfatin was performed. oa osteoblasts were stimulated with adiponectin and measurements of il-6, il-8 and mcp-1 were performed in cell culture supernatants. results. adiponectin, resistin and visfatin were detectable in osteoblasts and all osteophyte grades. in non-ossified osteophytes (grade 1), especially adiponectin and to a lower extend resistin and visfatin were localized in connective tissue fibroblasts. in ossified osteophytes (grade 2-5), resistin, visfatin and to a lower extend adiponectin protein expression was co-localized with osteoblasts. resistin and visfatin were expressed by osteoclasts. visfatin was found in chondrocytes of all osteophyte grades (50% of chondrocytes) and adiponectin was detectable in blood vessels. osteoblast stimulation with adiponectin increased the release of the inflammatory mediators il-6 (2.6-fold), il-8 (4.9-fold), and mcp-1 (2.1-fold). zeitschrift für rheumatologie suppl 2 · 2013 | conclusion. the expression of adiponectin and visfatin expression in osteophyte connective tissue and cartilage suggests their involvement in early osteophyte formation. resistin and visfatin expression by osteoblasts and osteoclasts in ossified osteophytes indicates a role in bone remodeling of osteophytes at later stages. osteoblasts respond to adiponectin stimulation with the release of inflammatory mediators. therefore, adipokines are most likely involved in osteophyte formation at different stages affecting different cell types of bone remodeling. free fatty acids contribute to promotion of arthritis k. frommer 1 , a. schäffler 2 , s. rehart 3 , a. sachs 3 , u. müller-ladner 1 , e. neumann 1 1 justus-liebig universität gießen, kerckhoff-klinik gmbh, rheumatologie u. klinische immunologie, osteologie, physikalische therapie, bad nauheim, 2 universitätsklinikum regensburg, klinik und poliklinik für innere medizin i, regensburg, 3 agaplesion markus krankenhaus, akademisches lehrkrankenhaus der johann wolfgang goethe-universität, klinik für orthopädie und unfallchirurgie, frankfurt/main background. obesity is a known risk factor for several arthritic diseases and mechanical stress has been shown not to be the only factor. due to increased levels of free fatty acids (ffa) in obese compared to nonobese individuals and due to the involvement of ffa in inflammatory cardiovascular and metabolic diseases, we hypothesized that ffa play a role in the promotion of arthritic diseases. therefore, we therefore investigated the effect of ffa on various effector cells of arthritis. methods. rheumatoid (ra) synovial fibroblasts (sf), osteoarthritis (oa) sf, psoriatic arthritis (psa) sf, human primary chondrocytes (hch), human osteoblasts (ob), human macrovascular (huvec) and microvascular (hbdmec) endothelial cells were stimulated in vitro with different ffa within their physiological range of concentrations. immunoassays were used to quantify ffa-induced protein secretion. sulfosuccinimidyl oleate sodium (sso) was used to inhibit fatty acid translocase (fat). results. ffa dose-dependently increased the secretion of the proinflammatory factors (il-6, il 8 and mcp-1) as well as matrix-degrading enzymes (mmp-1 and mmp-3) in rasf (e.g. for lauric acid [100 µm] with rasf/il-6: 9.1-fold increase; il 8: 14.9 fold increase; mcp-1: 2.4fold increase; pro-mmp1: 5.1-fold increase; mmp-3: 83.6 fold increase). saturated and unsaturated ffa had similar effects on rasf. however, saturated ffa induced strong secretion of il-6 in chondrocytes, while unsaturated ffa only had a weaker effect on this cell type. at 100 µm, both saturated and unsaturated ffa significantly increased il-6 secretion by osteoblasts to a similar degree as for sf. a high concentration of ffa (100 µm) significantly induced il-6 secretion in huvec and hbdmec, whereas a low concentration of ffa (10 µm) did not have a significant effect (p>0.05) on human endothelial cells. blocking ffa transport into rasf by using sso almost completely abolished the effect of palmitic acid on il-8 secretion. conclusion. ffa are not only metabolic substrates but can also directly contribute to articular inflammation and degradation mediated by various effector cells of arthritis. our data also show that ffa transport into the cell is required for ffa-induced effects in sf. background. chronically inflamed tissues in ra are characterized by local hypoxia and enhanced angiogenesis. the hypoxia inducible factor (hif)-1 and (hif)-2 serve as key regulators of adaptation to hypoxia thereby promoting both angiogenesis and metabolic adaptation of endothelial cells. to investigate the impact of hif-1/hif-2 on the angiogenic and metabolic transcriptome under hypoxia (1% o2) versus normoxia (18% o2) we performed a knockdown of either hif-1α or hif-2α in human microvascular endothelial cells (hmec). methods. specific knockdown of either hif-1α or hif-2α was achieved using shrna-technology. angiogenic and metabolic transcriptome of hmecs was studied by performing an agilent human whole genome microarray under normoxia vs hypoxia. significantly regulated genes were allocated to angiogenic and metabolic processes using panther database. results. in comparison to normoxia the incubation of untransduced hmecs under hypoxia resulted in 73 regulated angiogenesis related genes and 17 regulated cellular metabolism related genes. in both hif-1α and hif-2α knockdown cells, hypoxia was still capable of inducing a differential gene expression pattern, but with a much less pronounced effect compared to control cells. analysis of angiogenesis related processes (vegf-pathway, hif-activation, egfr-pathway) showed that 74% of the differentially expressed genes are controlled by both hif-1 and hif-2. another 14% of the regulated genes are controlled by hif-1. the remaining 12% of regulated genes are under control of hif-2. the differentially regulated genes involved in the cellular metabolism (atpsynthesis, glycolysis, tca-cycle) were found to be to 80% controlled by both hif-1 and hif-2. the remaining 20% are dependent on the presence of hif-1. conclusion. hif-1 and hif-2 are both key regulators of the adaptation of endothelial cells towards hypoxia with overlapping functions. however, they do differ in their capacity to regulate cellular energy metabolism and angiogenesis. this leads us to conclude that hif-1 affects angiogenesis via indirect effects on cellular energy metabolism as indicated by the regulation of metabolic transcriptome to one fifth. hif-2 does more influence angiogenesis directly via regulating the synthesis of proangiogenic factors (as has been previously shown).these findings provide new insights into the divergent regulation of angiogenesis in inflamed (hypoxic) tissues by hif-1 and hif-2 and are, therefore, considered to be of clinical relevance in ra. background. membrane bound glucocorticoid receptors (mgr) play a pivotal role in pathogenesis of chronic inflammatory diseases as indicated by clinical observations. patients with sle show high frequencies of mgr positive monocytes, sometimes even higher than found in patients with active ra. with increasing glucocorticoid dosages expression of mgr on monocytes of sle-patients is downregulated, suggesting a negative feedback loop to control glucocorticoid action. these receptors represent an effective target for diagnosis and monitoring of different inflammatory diseases, but a feasible detection method is still necessary. objectives. we compare two methods of high-sensitive immunofluorescence staining -the well established liposome procedure with the commercialized faser-technique. methods. hek293t cells were cultured for 24 h with/without 5 µg/ml brefeldin a in a humidified incubator at 37°c. human cd4 positive t cells and cd14 positive monocytes were isolated via magnetic-activated cell sorting and subsequently cultured in rpmi 1640. monocytes were incubated for 24 h with/without 2 µg/ml lps. for liposome based highsensitivity immunofluorescence staining cells were incubated with the monoclonal (digoxigenin conjugated) anti-gr antibody, followed by incubation with anti-digoxigenin/anti-biotin matrix. subsequently biotinylated cy5 liposomes were added. faser technique was performed as described by the manufacturer (miltenyi biotec). dead cells were excluded by adding pi before cell acquisition, using a bd facs calibur flow cytometer. the acquired data were analyzed using flowjo 7.6.1 software. results. the human mgr, which cannot be reliably detected with conventional staining methods, is detectable with the liposome procedure as well as with the commercialized faser-apc technique. furthermore, the faser-apc-procedure is more sensitive (94.51% vs 73.2%) and more specific (99.57% vs. 98.93%) compared to the liposome technique. additionally, minor changes of mgr expression can also be demonstrated with the faser technique. the faser procedure shows technical advantages: the commercially available faser-apc-kit is performed according to a standarized protocol and is less time consuming compared to the liposome procedure. conclusion. the human mgr is easily detectable with the commercialized faser kits, which represent an alternative due to a consistent quality and a standardized production. this method facilitates the analysis of the role that mgr play in the pathogenesis of chronic inflammatory diseases and perhaps provoke new insights in glucocorticoid therapy. background. in previous studies we detected th-positive, catecholamine-producing cells in inflamed hypoxic synovial tissue. therefore, the aim of our study was to investigate the influence of hypoxia induced catecholamines on inflammatory responses in arthritis. methods. synovial cells of rheumatoid arthritis (ra) and osteoarthritis (oa) patients were isolated and cultivated under normoxia or hypoxia with/without stimulating enzyme cofactors of th and inhibitors of th. expression of th and release of cytokines and catecholamines was analyzed. the effect of th+ cells was tested by adoptive transfer into dba/1 mice with collagen type ii-induced arthritis (cia). th+ cells were generated from mesenchymal stem cells by defined dopaminergic factors. results. hypoxia increased th protein expression and catecholamine synthesis and decreased release of tnf in oa/ra synovial cells compared to normoxic conditions. this inhibitory effect on tnf was reversed by th inhibition with alpha-methyl-para-tyrosine (αmpt). incubation with specific th cofactors (tetrahydrobiopterin and fe2+) increased hypoxia-induced inhibition of tnf, which was also reversed by αmpt. adoptive transfer of th+ cells reduced cia in mice, and 6 hydroxydopamine, which depletes th+ cells, reversed this effect. conclusion. in summary, this study presents that th-dependent catecholamine synthesis exhibits anti-inflammatory effects in human ra synovial cells in vitro, which can be augmented under hypoxic condi-tions. in addition, the anti-inflammatory effect of th+ cells has been presented the first time in experimental arthritis in mice. background. previously, we demonstrated that long-lived plasma cells contribute to the pathogenesis of antibody-mediated diseases and should therefore be considered as a promising therapeutic target in systemic lupus erythematous (sle). in bone marrow stromal cells expressing the chemokine cxcl12 organize these niches that provide for the plasma cell survival. cxcl12 is the ligand of cxcr4 expressed on plasma cells. in this study we investigated the contribution of cxcl12-cxcr4 interaction to the longevity of plasma cells in the murine model of lupus. methods. plasma cells purified from spleens of nzb/w mice were incubated with the cxcr4 blocker amd3100 and then adoptively transferred to immunodeficient rag1−/− mice. after 14 days we analyzed the number of plasma cells in bone marrow. furthermore, ova immunized nzb/w mice were treated intraperitoneally with amd3100 after boost; anti-ova secreting plasma cells in bone marrow were checked on day 3 and 15 after boost. the effect of plasma cell depletion was investigated in nzb/w mice using amd3100 alone or combined with bortebomib for two weeks. results. two weeks after adoptive transfer the number of plasma cells treated with amd3100 was lowered by 60% in bone. after secondary immunization with ova the amd3100 treatment resulted in a significant reduction of anti-ova secreting plasma cells in bone marrow by 33% on day 3 and by 23% on day 15. after 15 days the number of mhc class ii negative anti-ova secreting plasma cells significantly decreased by 42% in bone marrow of treated mice. amd3100 efficiently depleted plasma cells including long-lived. after two weeks treatment, total plasma cell number was decreased by 69% in spleen and 61% in bone marrow; long-lived plasma cells were reduced by 67% in spleen and 64% in bone marrow. the combination of bortezomib with amd3100 in nzb/w significantly enhanced the depletion of long-lived plasma cells compared to monotherapy. conclusion. cxcr4 blockade with amd3100 can reduce the homing of plasma cells to the bone marrow and the survival of long-lived plasma cells. the combination of bortezomib with amd3100 shows synergistic effects on plasma cell depletion. the findings highlight the importance of the cxcr4-cxcl12 axis for the plasma cell niche. zeitschrift für rheumatologie suppl 2 · 2013 | er.09 tnfr1 expression defines synovial tissue infiltrating cd4+ t cells in patients with rheumatoid arthritis k background. one hallmark of rheumatoid arthritis (ra) is the infiltration of the synovial membrane by cd4+ t cells. it has previously been shown that infiltrating cd4+ t cells differ from non-infiltrating ones in their increased expression of tnfr1. furthermore, tnfr1 is expressed on a fraction of circulating cd4+ t cells from ra patients, but not from healthy controls. aim of the study was the characterization of tnfr1+ cd4+ t cells in patients with rheumatoid arthritis. methods. peripheral tnfr1+ cd4+ t cells from ra patients were analyzed by flow cytometry. the expression of naive and memory t cell markers (cd45ra and cd45ro), markers for t cell activation (cd25, cd71 and cd154) and of icam-1 as well as the frequencies of the positive cells were determined. to identify the t helper cell signature of tnfr1+ cd4+ t cells, intracellular staining of the th1, th2 and th17 master transcription factors t-bet, gata-3 and ror-γt, respectively, was performed. results. peripheral tnfr1+ cd4+ t cells have neither a preferential naive nor a memory phenotype, but showed higher expression of the activation markers cd25, cd71 and cd154 than tnfr1-cd4+ t cells. tnfr1+ cd4+ t cells express higher frequencies of the t-bet and rorγt than tnfr1-cd4+ t cells. there is no difference in gata-3 expression between tnfr1 positive and negative cd4+ t cells. functionally, it has been shown that the cytokine tnf acts as chemokine to attract cd4+ t cells to the rheumatoid joints. beside this direct effect of tnf, there are known indirect effects of tnf including the upregulation of cell adhesion molecules like icam-1. therefore, icam-1 expression of migrating tnfr1+ t cells was investigated. the results show, that migrating tnfr1+ t cells recovered from synovial tissue are more frequently icam-1 positive than non-migrating ones. conclusion. tnfr1+ expression characterizes cd4+ t cells functionally capable of infiltrating the rheumatoid synovium in an icam-1 dependent manner. the results show, that tnfr1 expression defines a pathogenic subset of activated cd4+ t cells with th1 and/or th17 signature in patients with rheumatoid arthritis. hypoxia increased the production of interleukin-1β in lps-primed human monocytes n background. monocytes are major players in the innate immune system and are recruited to sites of inflammation, where the environmental conditions vary extremely compared to the interstitium under physiological conditions. for example, in rheumatoid arthritis the inflamed joints are severely hypoxic. this decreased oxygen level could be a triggering factor for the activation and survival of monocytes. aim of the study was to analyze the influence of hypoxia on lipopolysaccharide (lps)-induced cytokine production in primary human monocytes methods. immunomagnetically separated monocytes from the blood of healthy donors were cultured for 16h under hypoxic conditions (1% oxygen). results. cytokine measurement in the supernatant with elisa showed increased concentrations of interleukin-1β (0.9 ng/ml vs. 4 .35 ng/ ml, p=0.0019) and interleukin-6 (63.8 ng/ml vs. 125.9 ng/ml, p=0.019), but not of tnf, after hypoxia and lps-stimulation. cleavage of the il-1β proform to its active form is dependent on the assembly of the inflammasome and the recruitment of caspase-1 followed by their activation. when inflammasome assembly was blocked with high extracellular k+-buffer or by inhibiting intracellular ca-signalling with the ca-chelator bapta-am, hypoxia induced il-1β release was abrogated. similarly, il-1β release after culture under hypoxia was also abolished in monocytic thp1-cells, which are genetically made deficient for the inflammasome components nlrp3 and asc. one activating signal for the inflammasome was shown to be the release of reactive oxygen species (ros), since mitochondrial ros staining with mitosox revealed an increased mitochondrial ros release under hypoxic conditions. accordingly, the induction of mitochondrial ros through decoupling of the electron transport chain with rotenone also triggered an increase of il-1β release under normoxic conditions. analysis of blood monocyts from ra patients showed no difference in lps and hypoxia induced il-1β release compared to healthy controls (1.84 ng/ml vs. 1.88 ng/ml). conclusion. this study shows, that hypoxia leads to the activation of the inflammasome, the recruitment of caspase-1 and the subsequent cleavage and release of interleukin-1β in human primary monocytes. intracellular calcium mobilization and mitochondrial ros production were shown to be essential mechanisms triggering inflammasome assembly. background. cell-derived membrane-coated microparticles have been identified as important mediators in intercellular communication. during the process of apoptosis, dying cells start to dynamically release microparticles. polymorphonuclear neutrophils are the most abundant type of leukocytes, representing 50-70% of all white blood cells. due to their very short lifespan, they are the source of massive amounts of apoptotic cell-derived microparticles (admps). while the interaction between neutrophils and t lymphocytes has been focus of extensive research, the influence of neutrophil-derived microparticles on t cells has not been analysed yet. in this study, we investigated the effect of membrane-coated microparticles released by apoptotic neutrophils on different t helper cell subsets. methods. different cd4+ t cell subtypes were sorted according to the expression of cd25, cd127, cd45ra and cd45ro and co-cultured with admps or apoptotic cell remnants purified from uv-irradiated neutrophils isolated from the peripheral blood of healthy donors. t cells were stimulated by okt3 and anti-cd28 antibodies and cell proliferation was measured by 3h-thymidine incorporation or pkh26-staining. secretion of cytokines was quantified by elisa. results. admps released by neutrophils selectively suppressed the proliferation of cd4+cd25-cd127+ tc in a dose-dependant manner and prevented the upregulation of cd25 on the t cell surface, while maintaining the expression of cd127. the secretion of tumor necrosis factoralpha (tnfα) by t cells stimulated in the presence of admps was significantly reduced. interestingly, in contrast to admps, the apoptotic cell remnants of neutrophils exerted no effect on t cells. the suppressive effect of admps could be completely abrogated by the addition of interleukin(il)-2 or il-7 or by the presence of cd4+cd25+cd127+ t cells. conclusion. neutrophil admps suppress the proliferation of cd4+cd25-cd127+ t cells under conditions of limiting il-2 and il-7 concentrations. this could represent an important mechanism to prevent inappropriate activation and expansion of resting t helper cells in the absence of sufficient stimulation and cytokine production. t. alexander 1 background. recent reports have shown dysregulated micrornas in murine lupus models, among them increased expression of mirna-182, which has been demonstrated to target the transcription factor foxo1 in activated cd4+ t cells. the loss of foxo1 activity in t cells is associated with spontaneous t cell activation, clonal expansion and autoantibody production, all of which are present in systemic lupus erythematosus (sle). methods. expression levels of microrna-182 and foxo1 were analyzed with rt-pcr in magnetic purified peripheral blood cd4+ t cells from 9 patients with sle and healthy controls (hc). multicolor flow cytometry was performed to analyze cd4+ t cell expression for ccr7, cd45ra, ki-67, foxp3, the interleukin-7 receptor-α and phosphorylated stat-5a (pstat5). analysis of serum il-7 levels was performed with elisa in 27 sle patients and hc (r&d systems). results. mirna-182 was significantly upregulated in cd4+ t cells from sle patients compared to hc (median expression 8.89×10e-7 vs. 3.96×10e-7, p=0.008) while foxo1 mrna levels were decreased, yet without reaching statistical significance. analysis of ki-67 expression revealed an increased percentage of proliferating cd4+ t cells in sle (5.23% vs 2.21%, p=0.006). overall, cd4+ t cellular proliferation in sle was associated with increased frequencies of cd45ra-ccr7-effector memory t cells and enhanced basal pstat5 levels (median mfi 503.5 vs 399.0, p=0.010), suggesting a recent stimulation with common gamma chain(γc)-signaling cytokines. in this regard, tcons from sle samples displayed decreased expression levels for the foxo1 target gene cd127 (mfi 2021 vs. 2553, p=0.049) and serum il-7 levels were significantly higher in sle compared to hc (17.0 pg/ml vs. 10.2 pg/ml, p=0.001). conclusion. mir-182 expression has been shown to be dependent on stat5 activation and to promote clonal expansion of activated cd4+ t cells. our data suggest that enhanced il 7r/stat5 signaling mediates induction of mir 182 expression, which in turn promotes the proliferation of tcons in sle. the relative contribution of il 7r/mir-182/foxo1 axis on the enhanced proliferative capacity of sle tcons remains elusive and merit further investigation. collectively, our data provide new insights in the pathophysiology of t cell hyperactivity in sle and identifies mir-182 as a candidate target for future therapeutic approaches. background. cell activation and apoptotic cell death leads to the formation of membrane-coated vesicles (mcvs). mcvs have previously been identified as mediators of cell-to-cell communication and carriers of microrna. an impaired clearance of apoptotic debris caused by an increased rate of apoptosis or a defect in phagocytic-cell clearance has been observed in sle patients. in this study, we analyzed the microrna content of activated and apoptotic lymphocytes and their corresponding mcvs from both normal healthy donors (nhds) and sle patients. further we investigated the immunomodulatory effect of mcv uptake by monocytes. methods. microrna content of activated and apoptotic lymphocytes and corresponding mcvs of nhds and sle patients were compared in an agilent microrna array and validated by qpcr. apoptosis was induced by uvb-irradiation. mir-155 expression in monocytes after uv-mcvs engulfment was determined by qpcr. expression of mir-155 target protein tab-2 was analyzed by western blot. results. mir-155* levels were decreased after apoptosis induction in lymphocytes and apoptotic mcvs compared to their viable correlates. mir-155, mir-99a and mir-34b were decreased in apoptotic lymphocytes compared to viable ones but increased or not significantly changed in apoptotic mcvs compared to viable mcvs, indicating a directional transport of microrna into mcvs. mir-34a was expressed at higher levels in viable sle lymphocytes and mcvs compared to nhds. mir-34b expression was decreased in uv-lymphocytes and uv-mcvs of sle patients. functional assays confirmed higher mir-155 levels and consecutively decreased target protein levels in monocytes after engulfment of uv-mcvs. conclusion. within this study we could show an unequal distribution of distinct microrna into mcvs released by activated or apoptotic lymphocytes. further the microrna content was regulated in whole apoptotic cells after uvb-irradiation. this suggests a directional transport rather than a random distribution. thus, cells regulate their microrna as well as the microrna content within released mcvs. we could show a microrna and protein expression change in phagocytes after mcv engulfment. hence, our results suggest mcvs could serve as a transport vehicle for microrna to mediate cell-to-cell communication and influence intracellular processes in phagocytes. disturbances of this system might contribute to the pathogenesis of sle. results. we found in the spleens of nzb mice 10-times higher numbers of long-lived plasma cells and megakaryocytes compared to wildtype, in nzw mice equal numbers and in nzb/w mice numbers between those for nzb and nzw or wildtype. moreover, in the spleen a fraction of plasma cells clustered around megakaryocytes. we also detected a missense mutation in the c-mpl gene of nzb mice leading to an amino acid replacement within the essential tpo-binding site. upon tpo stimulation of splenocyte and bone marrow cultures nzb cultures responded significantly stronger resulting in the double amount of megakaryocytes compared to nzw cultures. conclusion. in summary, our data indicate that augmented megakaryopoiesis enables the accumulation of a greater number of autoreactive plasma cells in lupus prone nzb/w mice. thus, we assume that enhanced megakaryopoiesis and higher megakaryocyte numbers are contributing to the development and/or pathogenesis of sle. background. baff is a cytokine important for the stimulation and survival of autoreactive b cells and therefore might play a role in several autoimmune diseases, e.g. autoimmune arthritis. in psoriasis arthritis, baff correlates with disease activity and testosterone, but only in male patients, suggesting a role for sex hormones in the regulation of baff. therefore, we wanted to determine if baff production in rheumatoid arthritis and osteoarthritis fibroblasts was regulated by neuroendocrine mediators. methods. fibroblasts were isolated from synovial tissue of ra (n=10) and oa (n=10) patients and cultured in vitro under different conditions. baff was determined by elisa. results. isolated fibroblasts were cultured in the presence or absence of interferon-gamma (ifn-γ), il-1, lipopolysaccharide (lps), tumor necrosis factor (tnf), cpg, poly i:c, and cortisol in different combinations for 48 and 72 hours to determine the optimal stimulation strategy for induction of baff production (measured by elisa in supernatants) in fibroblasts. ifn-γ best induced baff in ra and oa fibroblasts. ifn-γ-induced baff production in fibroblasts was decreased by dihydrotestosterone in a concentration dependent manner. the effect was specifically inhibited by nilutamid, a testosterone receptor antagonist. furthermore, stimulation of beta-adrenoceptor increased, whereas stimulation of alpha-adrenoceptors did not change inf-γ-induced baff in synovial fibroblasts. in general the effects were more pronounced in ra as compared to oa fibroblasts. conclusion. taken together, inf-γ-induced baff production in synovial fibroblasts is decreased by testosterone and increased by betaadrenergic stimuli. therefore, neuroendocrine regulation of inflammation in the inflamed joint might be in part mediated by regulating baff production in synovial fibroblasts. a. grützkau 1 , c. kyogoku 1 , b. smiljanovic 2 , j. grün 1 , r. biesen 2 , t. alexander 2 , f. hiepe 2 , a. radbruch 1 , t. häupl 2 1 deutsches rheuma-forschungszentrum (drfz), berlin, 2 charité -universitätsmedizin berlin, medizinische klinik mit schwerpunkt rheumatologie und klinische immunologie, berlin background. gene expression profiling experiments using peripheral blood mononuclear cells (pbmcs) revealed a crucial role of type i interferon (ifn) in the pathogenesis of systemic lupus erythematosus (sle). however, it is almost unknown how particular leukocyte subsets contribute to the overall type i ifn signature described for pbmcs. furthermore, a detailed analysis of how ifn signatures differ in autoimmune disease from that observed after viral infection is missing so far. therefore, we compared expression levels of 2442 ifn signature genes in peripheral cd4+ t helper cells and monocyte (mo) subsets isolated from patients with sle, healthy donors (nd) and nd vaccinated against yellow fever by global gene expression profiling. methods. peripheral blood from 8 patients with sle and 4 nd were recruited. same nd were examined before and after immunization by yellow fever vaccine. after sorting cells, isolated rna were applied to affymetrix human genome u133 plus 2.0 array. data analysis was done using bioretis database, genesis software and ingenuity pathway analysis (ipa). results. comparing gene expression profiles of yellow fever immunized individuals and active sle patients it was possible to identify a "common" and an "autoimmune-specific" ifn signature. although major ifn signature genes were commonly expressed in cd4+ t cells and mo of patients with sle and immunized nd, expression magnitudes of them were higher in patients with sle compared to immunized nd. in sle, in addition to the typical "viral-induced" ifn signature, genes that are involved in apoptosis signaling, antiviral pkr signaling, fcγ receptor-mediated phagocytosis and il-10-/il-9-/il-15-mediated jak/ stat signaling pathways were identified by ipa. conclusion. this study demonstrated that ifn signature in autoimmunity and that in viral infection are quite different in the number of ifn-related genes activated and their expression magnitudes. autoimmunity is characterized by a much stronger expression of ifn signature genes and is obviously modulated by a separate set of co-regulated genes defining the "autoimmune-specific" ifn signature. in summary, "common" and "autoimmune-specific" ifn signature genes are of potential interest as clinical biomarkers in sle diagnostics to differentiate between a disease flare and a viral infection. of peripheral blood lymphocytes (pbl). there is currently no data available about nk cells in gpa. the aim of this study was to evaluate the presence of nk cells in gpa granulomas and their proportions in pbl as a basis for a potential role in gpa. methods. paraffin sections of granulomas of 20 gpa, 5 sarcoidosis and 5 tuberculosis patients were stained with a cd56 monoclonal antibody. nk cell (cd3-cd56+) proportions of pbl in 30 gpa patients and 27 healthy controls (hc) were analysed by facs analysis. clinical data was extracted from medical records. results. contrary to granulomas from tuberculosis and sarcoidosis which showed a considerable infiltration by cd56 positive cells, there was not a single cd56 positive cell in granulomas from 20 gpa patients. therefore, the tissue destructive character of gpa granulomas is associated with a lack of nk cells. gpa patients with inactive disease [birmingham vasculitis activity score (bvas) = 0, n=19] possessed a significantly higher nk cell proportion in pbl (mean ± standard deviation: 24.4±13.5%) than both gpa patients with active disease (bvas>0, n=11, mean=10.7±5.6%) (p=0.0026) and hc (n=27, mean=14.4-7.7%, p=0.004). thus, clinical remission is accompanied by an increase in the nk cell proportion in pbl. interestingly, patients with inactive disease that had "normal" nk cell proportions of less than 20% of pbl (n=7) showed a more severe disease course than those with more than 20% of pbl. conclusion. nk cells might, therefore, be helpful to limit granulomatous inflammation. whether nk cell proportion in pbl might be a useful biomarker in gpa, e.g. as predictor for relapses, will be further evaluated in our future studies. v. gerl 1 background. plasmacytoid dendritic cells (pdcs) are considered a crucial element in sle pathogenesis due to their potency to produce high levels of ifn-α. this innate immunological function of pdcs is lost by terminal differentiation into a professional antigen-presenting cell (pdc-derived dc), thereby upregulating costimulatory molecules and downregulating innate characteristics, e.g. bdca-2 and ifn-α expression. pdc-derived dcs have not been described in vivo yet, probably due to the fact that they lose their specific markers during differentiation. furthermore, pdcs can differentiate into myeloid dcs by various stimuli. in sle, where low expression of bdca-2 is commonly seen, this differentiation could be relevant and point to such a lineage switch as well as to an activated state of pdcs. aim. to characterize pdc subsets of differentiation/activation in human peripheral blood and to study their impact on autoimmune inflammation in sle. methods. 8-color-flowcytometric analyses were performed on whole blood of healthy donors and sle patients. pdcs were identified by cd3-/cd19-/cd14-/cd123high//bdca-2+/hla-dr+ expression and characterized for cd11c, bdca-1 and the macrophage-associated siglec-1, expressed on monocytes of active sle patients in an ifn-α dependent manner. cd86 and cd83 expression were measured in parallel. results. we found a small subpopulation of siglec-1 expressing pdcs in human peripheral blood. compared to siglec-1 negative pdcs, siglec-1 positive pdcs express significantly lower bdca-2 and cd123, higher hladr background. agonistic autoantibodies against the angiotensin ii receptor type 1 (at1r) and the endothelin receptor type a (etar) have been identified in patients suffering from systemic sclerosis (ssc). here we examined the expression of at1r and etar in human immune cells and pathological effects mediated through these receptors by corresponding autoantibodies (aabs). methods. at1r and etar protein expression on peripheral blood mononuclear cells (pbmcs) from healthy individuals and ssc patients was analyzed using flow cytometry, mrna expression was examined by real-time pcr in pbmcs from healthy donors. in addition, pbmcs from healthy donors were stimulated in vitro with affinity-purified immunoglobulin g (igg) fractions from ssc patients positive for at1rand etar-aabs, and with igg from healthy donors serving as control. alterations in cell surface marker expression, cytokine secretion and chemotactic motility were analyzed using flow cytometry, elisa, and chemotaxis assays, respectively. results were correlated with characteristics/clinical findings of the igg donors. results. both at1r and etar were expressed on human peripheral lymphocytes and monocytes. protein expression of both receptors was decreased in ssc patients when compared to healthy donors and correlated negatively with disease duration. in addition, igg fractions of ssc patients induced t cell migration in an anti-at1r and anti-etar aab level-dependent manner. moreover, igg of ssc patients was capable of stimulating pbmcs to produce more il-8 and ccl18 than igg of healthy donors. all effects could be significantly abrogated by the application of selective at1r and etar antagonists. statistical analysis revealed a negative correlation between ssc igg-induced il-8 concentrations and disease duration, between ssc igg-induced ccl18 concentrations and time since onset of lung fibrosis as well as an association of ccl18 concentrations with vascular complications of the corresponding ssc igg donors. conclusion. we demonstrated the expression of both, at1r and etar, on human peripheral t cells, b cells and monocytes and found signs for a chronic receptor activation in ssc patients. the inflammatory and profibrotic effects upon aab stimulation in vitro, and their associations with clinical findings suggest a role for autoantibody-mediated activation of immune cells mediated through the at1r and etar in the pathogenesis or even the onset of the disease. the bioenergetic role of hif-1 and hif-2 during angiogenesis of human microvascular endothelial cells background. hypoxia and angiogenesis are features of inflamed and injured tissues. the transcription factors hypoxia inducible factor (hif)-1 and (hif)-2 regulate the cellular and metabolic responses to reduced oxygen tensions thereby promoting angiogenesis with implications on the pathogenesis of ra. we investigated the effects of a knockdown of either hif-1α or hif-2α in human microvascular endothelial cells (hmec) on angiogenesis and bioenergetics under hypoxia (1% o2) versus normoxia (18% o2). methods. specific knockdown of either hif-1α or hif-2α was conducted by shrna-technology. to assess angiogenesis of hmecs both tubuli and node formation under hypoxia versus normoxia were investigated. expression of hypoxia driven genes involved in the metabolic response to hypoxia (gapdh/pgk/glut1/ldha) was quantified by realtime rt-pcr. the bioenergetic status of the cells was quantified via atp/adp measurements. results. knockdown of hif-1α/hif-2α resulted in a loss of hypoxia induced angiogenesis. focusing on bioenergetic aspects, we found hypoxia to significantly induce pgk, ldha and gapdh in control cells. knockdown of hif-1α and hif-2α, respectively, did not affect the hypoxic induction of pgk and ldha. in hif-1α and hif-2α knockdown-cells, hypoxia was still capable of inducing gapdh, with a less pronounced effect in hif-1α knockdown-cells. hypoxia did not significantly up-regulate glut1, neither in control nor in hif-1α or hif-2α knockdown-cells. the knockdown of hif-2α resulted in significantly decreased expression of glut1 under hypoxia. we also found the atp/ adp ratio to be similar in control, hif-1α and hif-2α knockdown-cells under normoxia. under hypoxic conditions hif-1α knockdown-cells showed significantly reduced atp/adp ratios -indicating that less atp is available -compared to hif-2α knockdown-cells. conclusion. hif-1α and hif-2α are both key regulators of angiogenesis. however, they do differ in their potency to regulate cellular energy metabolism. this leads us to conclude that hif-2α does directly influence angiogenesis via regulating the synthesis of proangiogenic factors (as previously shown), whereas hif-1α affects angiogenesis via effects on cellular energy metabolism as indicated by the reduced expression of gapdh and the diminished atp/adp ratio. these findings provide new insights into regulation of angiogenesis in inflamed (hypoxic) tissues and are, therefore, considered to be of clinical relevance in ra. low baseline complement levels, autoantibody persistence and delayed thymic reactivation are risk factors for development of relapses after hematopoietic stem cell transplantation for refractory sle background. our previous research has provided the evidence that an autoreactive immune system can be "reset" into a healthy, tolerant state by immunoablative treatment to eradicate pathogenic effector cells, followed by transplantation of hematopoietic progenitor cells (hsct). nevertheless, disease flares may occur in a subset of these patients posttransplantation. here, we longitudinally analyzed the immune reconstitution of these patients to identify markers for favorable long-term responses. methods. since 1998, 10 patients with refractory sle received a cd34+selected autologous stem cell transplantation after immunoablation with antithymocyte-globulin (atg) and cyclophosphamide as part of a monocentric phase i/ii clinical trial. autoantibody titers were evaluated with elisa, peripheral t-and b lymphocyte subsets immunophenotyped using multicolor flow cytometry. results. clinical remission (sledai ≤3) could be achieved in all patients, despite immunosuppressive drug withdrawal, associated with disappearance of anti-dsdna antibodies and marked reduction of protective antibodies in serum. unfortunately, two patients died due to transplant-related infections. from the remaining eight patients, five patients are in long-term clinical remission for up to 14 years after hsct, while three patients suffered a relapse of sle at 18, 36 and 80 months post-transplantation, respectively. patients with early relapses (≤36 months) had decreased baseline complement levels, showed persistence of antinuclear antibodies (ana), less significant reduction in protective antibody levels and had slower repopulation of cd31+ cd45ra+ thymic-derived cd4+ t cells after hsct (<100/µl at 18 months) when compared to long-term responders. in addition, flow cytometric analyses revealed an expansion of circulating plasmablasts and increased coexpression of siglec-1 on monocytes (as surrogate marker for type-i interferon signature), preceding the clinical flares by ~6 months. conclusion. low baseline complement levels, persistence of ana and delayed thymic reactivity post-transplantation could be identified as risk factors for development of lupus flares after hsct. since atg-mediated cell lysis is complement-dependent, we conclude that low serum complement is directly associated with incomplete depletion of immunologic memory cells in these patients, which provides a rationale for complement substitution before immunoablation. moreover, lupus flares may be predicted individually by flow cytometry with plasmablast expansion and recurrence of type-i interferon signature. background. systemic lupus erythematosus (sle) is a chronic autoimmune disease characterized by the generation of pathogenic antibodies directed against a variety of autoantigens. we have previously shown that long-lived autoreactive plasma cells can contribute to chronicity and refractoriness of sle. our study is aimed to develop new methods for depletion of long-lived plasma cells in nzb/w mice, a model of sle. methods. we studied different treatment protocols on plasma cell survival: irradiation-based and more selective depletive treatments. 10-12 week-old nzb/w f1 mice were exposed to three different irradiation doses (10, 14, and 15 gy in two splitted doses with a 3-h interval). the following protocols were also investigated: 1) two bortezomib (bz) injections (0,75 mg/kg, i.v.) combined with anti-mouse cd20 (10 mg/kg, i.v.), 2) three bortezomib injections combined with anti-mouse cd20, 3) three bortezomib injections combined with anti-lfa-1 and anti-vla-4 antibodies (affecting directly the plasma cell niche; 200 µg, i.p.) in a 2-d interval, plus anti-mouse cd20 and anti-b220 (250 µg, i.v.). the plasma cells were analyzed in spleen and bone marrow by facs and elispot. results. the frequency of remaining plasma cells in bone marrow after 10, 14 and 15 gy irradiation were 52, 14 and 0,7% respectively, and in spleen were almost 50, 10 and 0,2%. short-term treatments with agents that affect plasma cells (bortezomib, anti-lfa1 plus anti-vla4) effectively deplete plasma cells including long-lived plasma cells in spleen and bone marrow of nzb/w mice. because of the b cell hyperactivity in nzb/w mice, we observe a rapid regeneration of autoreactive plasma cells in spleen and bone marrow. therefore, plasma cell depletion protocols were combined with b cell depletion. especially, the combination of plasma cell targeting with bortezomib, anti-lfa1 and anti-vla4 with b cell targeting (anti-cd20 plus anti-b220) interrupted the repopulation of autoreactive plasma cells in spleen and bone marrow. conclusion. very high doses of irradiation result in effective depletion of long-lived plasma cells but lower doses not. depletion of long-lived plasma cells can be achieved by the proteasome inhibitor bortezomib and by targeting both adhesion molecules lfa1 and vla4. the combination with b cell depletion is needed to prevent regeneration of autoreactive plasma cells. varicella-zoster-virus(vzv)-specific lymphocytes and igg antibody avidity in patients with juvenile idiopathic arthritis or rheumatoid arthritis background. varicella zoster virus (vzv) is a herpes virus that establishes a life-long latent infection with risk of reactivation (shingles) particularly in immunosuppressed patients with autoimmune disorders. patients with rheumatoid (ra) or juvenile idiopathic arthritis (jia) have a high risk for disseminating varicella zoster virus (vzv) infection or herpes zoster. this study was aimed to investigate the humoral and cellular immune response to vzv including assessment of igg-anti-vzv avidity and vzv-specific reactivity of lymphocytes in ra (n=56) or jia patients (n=75) on different treatments, including biologic agents, such as anti-tumor-necrosis-factor(tnf)-alpha or anti-interleukin-6 (il-6) receptor inhibition (tocilizumab), compared to 37 healthy adults (ha) and 41 children (hc). methods. igg-anti-vzv concentrations and avidities were quantified by an adapted elisa. vzv-specific interferon-gamma-producing lymphocytes (spot forming units, sfu/1,000,000 cells) were analyzed by elispot. results. no significant differences in the vzv-igg concentrations or avidities were found between the groups. however, lower igg-anti-vzv concentrations were found in tocilizumab-treated ra compared to ha and ra without biologic agents. ra showed lower median sfu (15/1,000,000 cells) than ha (57/1,000,000 cells), with lowest sfu in adalimumab-treated ra (10/1,000,000 cells). sfu were not altered in tocilizumab-treated ra and after incubation with anti-il-6 in vitro. no differences regarding igg-anti-vzv concentrations, rai and cellular reactivity were found between jia and hc. conclusion. our study demonstrated that ra and jia patients are still able to maintain humoral and cellular immune responses to vzv despite immunosuppressive therapy or biologic agents. in ra, the role of lower cellular reactivity for risk of herpes zoster has to be considered for recommendations on vaccination. cmv-specific cd8+ t cells from ra patients contribute to autoimmune disease 41 zeitschrift für rheumatologie suppl 2 · 2013 | 1. increased frequency of lir-1 (also called cd85j or ilt2) on cd8+ t cells has been associated with autoimmune disease. furthermore, it has been shown that latent cytomegalovirus (cmv) infection contributes to the expansion of cd28− t cells. hence we were interested in the influence of cmv infection on the lir1 expression on t cells in ra patients. methods. we were interested in the role of lir1+ t cells in ra patients, which potentially contribute to the autoreactive t cell pool, especially in cmv+ patients. therefore, we investigated the expression and function of lir-1 on cd8+ t cells in peripheral blood mononuclear cells (pbmc) from patients with rheumatoid arthritis by flow cytometry and cytotoxicity assay. results. flow cytometry analysis revealed higher frequencies of lir-1+ cd8+ t cells in cmv seropositive ra (n=49, mean%: 10.4) compared to cmv+ hd (n=51, mean%: 7.5, p=0.043). using hla-a*0201/cmvpp65 dextramers we analyzed cmv-specific cd8+ t cells. patients with ra had higher frequencies of cvm specific cd8+ t cells (n=8; mean%: 3.28) compared to healthy individuals (n=12; mean%: 1.35, p=0.04). phenotypically, cmv-specific cd8+ t cells are mainly cd28 negative and express lir-1. analysis of the cytolytic potential by cd107a expression revealed higher numbers of cd107a+cd8+ t cells in ra patients (n=3, mean%: 0,57) compared to healthy donors (n=3, mean%: 0,17). importantly, we found a significant correlation (p=0.034) of high numbers of cd8+lir-1+ t cells with high disease activity score (das28) in ra patients without immunosuppressive treatment (n=14, r=0,568) . tab.5 . conclusion. this is the first demonstration of significantly increased frequencies of lir-1+cd8+ t cells and of cmv-specific cd8+ t cells in patients with rheumatoid arthritis. these cells are characterized by a terminally differentiated phenotype. the higher cytolytic potential of cmv-specific t cells likely can be attributed to their function in containing latent cmv infection and to prevent cmv disease, but might potentially contribute to disease severity in ra patients. background. systemic lupus erythematosus (sle) is an autoimmune disease characterized by an acquired il-2 deficiency, which leads to a homeostatic imbalance between regulatory t cells (treg) and effector t cells (tcon; humrich et al. 2010). we recently demonstrated that treg homeostasis in lymphoid organs of diseased (nzbxnzw) f1 mice can be restored by treatment with recombinant il-2 (il-2) resulting in an amelioration of kidney disease. the aim of this study was to investigate the impact of il-2 therapy on intrarenal foxp3+ treg and kidney infiltrating conventional cd4+ t cells (tcon) in the (nzbxnzw) f1 mouse model of lupus nephritis. methods. (nzbxnzw) f1 mice with active nephritis were treated with recombinant il-2 either for a short period of 5 days or for a longer period of 30 days in total. absolute numbers, phenotype and proliferation of kidney infiltrating cd4+ t cell subsets were determined by flow cytometry at different time points. results. short-term il-2 treatment resulted in an enhanced proliferation and increased numbers and frequencies of intrarenal cd4+foxp3+ treg compared to untreated control mice. on the other hand, long term il-2 treatment did not result in a persistent expansion of the intrarenal foxp3+ treg population. however, total numbers of kidney infiltrating cd4+ tcon with a memory/effector phenotpye were diminished and cd4+ tcon showed markedly reduced signs of cellular activation. conclusion. our data indicate that short term il-2 treatment is able to expand the size of the intrarenal treg pool. in contrast, long term il-2 treatment decreases the numbers of kidney infiltrating memory/ effector t cells and reduces cellular hyperactivity suggesting that treg suppress the activation and expansion of infiltrating tcon. these results may in part explain the amelioration of disease induced by treatment with il-2 and underline the important role of intrarenal treg for the suppression of kidney disease in lupus mice. these results also provide additional important rationales for an il-2 based immunotherapy of human disease. from transcriptome to protein biomarkers in ra: joint compartment and monocytes outperform serum and whole blood background. a main challenge in disease-management of ra is to establish objective criteria relevant for diagnosis and therapeutic stratification of patients. this study focused on global approaches in dissecting inflammation in ra including transcriptome analyses of synovial tissue and blood monocytes and proteome analyses of synovial fluid and serum. methods. gene-expression profiles from synovial tissues and blood monocytes of ra and osteoarthritis (oa) patients were generated by affymtetrix arrays. elisa and multiplex immunoassays were used for validation of 30 candidate markers at the protein level in synovial fluid (sf) from ra and oa patients and in serum from the same group of patients and healthy donors. results. transcriptome analyses of synovial tissues from ra and oa revealed more than 1000 differentially expressed genes. to avoid difficulties in sampling synovial tissue and to avoid fluctuation in cellular composition of various cell types in blood, the transcriptome analyses from peripheral blood was focused on a specific cell population. monocytes were selected as the favourable cell type involved in the production of cytokines, which are often considered as therapeutic targets in ra. comparisons between ra and oa monocytes disclosed differential expression of more than 100 genes. in total, 30 genes that were up-regulated in synovial tissues and/or monocytes were used for validation at the protein level as potential biomarkers for ra. among these 30 biomarkers, chemokines (cxcl13, ccl18, ip10), adhesion molecules (vcam1, icam1, e-and p-selectins), proteolytic enzymes (mmp1, a1at), and the shedding form of cell surface molecules (cd14, cd163) background. idiopathic membranous nephropathy (imn) is a common cause of nephrotic syndrome in adults and has recently been identified as an autoimmune-mediated disease [1] . autoantibodies directed towards the m-type phospholipase a2 receptor (pla2r) are fairly specific for idiopathic mn and only found to a small percentage in sera from patients with secondary mn [2] . the outcome of patients with imn is quite diverse: about one third of patients have spontaneous remission, another third progress to require dialysis and the last third continue to have proteinuria without progression to renal failure. we performed serological profiles of 162 imn patients in order to compare antibody profiles to antibody frequencies found in the normal healthy population and to hopefully identify factors that help to predict disease course in imn. methods. serum samples of 162 patients with imn were assayed for a variety of autoantibodies by elisa, addressable laser bead immunoassay (albia) and to dsdna by crithidia luciliae assay. results. the prevalence of autoantibodies found in our imn cohort is summarized in tab. 1. anti-pla2r antibodies were found in about 54% of imn patients whereas the frequency of other antibodies was mostly below 2%. the one exception is anti-dfs70 that was found in 16.05% of imn patients. conclusion. the prevalence of anti-pla2r positive patients in our imn cohort matches what has been previously described [3] . the frequency of the other antibodies that we determined is comparable to what has been reported in the normal healthy population. it is important to note that anti-dfs70 antibodies are more prevalent in healthy individuals compared to patients with systemic autoimmune rheumatic diseases (sard; [4] ) whereas anti-ro52 reactivity is often regarded as a marker for sard. the absence of anti-ro52 and the high prevalence of anti-dfs70 confirms that imn is a rather organ specific autoimmune disease. background. activity and the quality of movement belong to the most fundamental diagnostic parameters for neurobehavioural analysis but in the past it has been difficult to include this information into pre-clinical murine disease models. here we tested the applicability of a radiofrequency identification (rfid) based automated tracking system in the experimental murine model of ovalbumin induced arthritis. methods. c57bl/6 mice were immunized twice with cationized ovalbumin in freund's complete adjuvant and onset of arthritis was induced two weeks after the last immunization by direct injection of cationized ovalbumin into the knee joint of the right hind leg. severity of arthritis was assessed through measurement of joint swelling and evaluation of histological changes. additionally mice were implanted with a rfid transponder and throughout the experiment their activity level was monitored by an id-grid sensor plate placed underneath the homecage. results. the joint inflammation in the ovalbumin induced arthritis model showed a quantifiable impact on the activity levels of the mice. our experiments could also show that movement activity correlates with disease severity as evaluated by clinical and immunological parameters. in the past employing behavioral methods was often limiting by group size, observation time and reproducibility and the stress of handling and new surroundings made results difficult to interpret. in our experiments a rfid-based automated tracking system allowed us to monitor individual activity long-term without removal of the mice from their homecage environment. this allowed for the correlation of clinical parameters to behavioral factors and adds another level of analysis to an established murine model. progranulin antibodies in a wide spectrum of autoimmune diseases results. autoantibodies against progranulin, a secreted and direct inhibitor of tnf-α receptors 1&2 were frequently identified in primary vasculitides. in detail, progranulin-antibodies were found during the course of disease in giant cell arteritis/polymyalgia rheumatica (14/65), takayasu's arteritis (4/13), classical panarteritis nodosa (4/10), behcet's disease (2/8), in granulomatosis with polyangiitis (31/81), churg-strauss syndrome (7/31) and in microscopic polyangiitis (6/17). in extended screenings progranulin-antibodies were also frequently detected in autoimmune connective tissue disorders, in rheumatoid and psoriatic arthritis and in inflammatory bowel disorders. in contrast progranulin-antibodies were only detected rarely in healthy controls (1/97), patients with obesity (0/40), residents of nursing homes (1/48), not in patients with cutaneously limited psoriasis (0/100), not in patients undergone sepsis (0/22), and not in patients with melanoma (0/98). a significant association of progranulin-antibodies with active disease states in granulomatosis with polyangiitis suggested a pro-inflammatory activity of progranulin-antibodies. this was supported by an observed neutralizing effect of progranulin-antibodies on the levels of circulating progranulin in elisa and western-blot. moreover, functional assays revealed, that progranulin-antibody containing sera render wehi-s cells far more sensitive to effects of administrated tnf-α, providing evidence for the suspected pro-inflammatory effect of progranulin-antibodies. conclusion. progranulin-antibodies occur in a widespread spectrum of autoimmune diseases and have a pro-inflammatory effect by neutralizing the physiologic tnf-blocker progranulin. background. flow cytometry (fcm) is widely used in research for molecular characterization at single cell level. conventional analysis is a semiautomated process of user defined gating and investigation in 2-d projections. for multiple parameter analysis with hundreds of marker combinations, this manual process is most limiting and impedes high throughput analysis. therefore, we developed a new algorithm for automated and standardized analysis of multiplex fcm data. methods. automation included asinh-transformation of data, cell grouping, population detection and population feature extraction. for grouping of cells, an unbiased unsupervised model based t-mixture approach with expectation maximization (em)-iteration was applied. populations were identified by meta-clustering of several experiments according to position and extension of cell-clusters in multi-dimensional space and by including a general procrustes analysis (gpa) step. for validation, peripheral leukocytes from healthy donors and patients with rheumatoid arthritis (ra) were prepared by hypoosmotic erythrocyte lysis and stained with different sets of lineage-specific antibodies. in parallel, different leukocyte samples were depleted of one of these populations by magnetic beads. qualitative and quantitative characteristics of major populations were compared with conventional manual analysis. results. whole blood leukocytes stained simultaneously with up to 7 markers were correctly distinguished in all major populations including granulocytes, t cells and their subpopulations, monocytes, b cells, and nk-cells. the result was comparable to the "gold standard" of manual evaluation by an expert. the new technology is able to detect subclusters and to characterize so far neglected smaller populations based on the new parameters generated. automated clustering did not require fluorescence compensation of data. cell-grouping is applicable even for large fcm datasets of at least 10 parameters and more than 1 million events. comparing the cell-clusters between ra and healthy controls, differences were detectable in several cell (sub-)populations, stable enough to perform correct classification into controls and disease. conclusion. this new approach reveals promising results for automated and time-saving analysis of large datasets from multiplex fcm. the algorithm avoids operator-induced bias, is able to detect unexpected sub-clusters and to characterize so far neglected populations. this may reveal not only new markers for disease activity but also for therapeutic stratification. background. lasp-1 localizes at focal adhesions, along stress fibres and leading edges of migrating cells regulating metastatic dissemination of different tumors. since rasf have been implicated in the spreading of disease by leaving cartilage destruction sites, migrating via the bloodstream and re-initiating the destructive process at distant articular cartilage surfaces, the underlying mechanisms are of special interest. therefore, we investigated the role of lasp-1 in sf migration and its effects on ra. methods. to identify lasp-1 expression and its sub-cellular distribution in human sf as well as in hind paws of wt and htnftg mice, we performed western blots and immunofluorescence. the migration of sfs derived from wt, lasp-1-/-, htnftg and lasp1-/-/htnftg mice was studied in a modified scratch assay as well as in live cell imaging studies. furthermore, a transmigration assay using sf from all four genotypes and murine endothelioma cells (bend.5) as an endothelial barrier was carried out. sf transmigration under inflammatory conditions was also evaluated by tnf-alpha stimulation of the endothelial cells in vitro. results. lasp-1 expression was up regulated in rasf and in sf from htnftg mice compared to healthy controls and was found at structures of cell adhesion and invasion. the scratch assay as well as the live cell imaging studies showed a significantly reduced migration of lasp(1 ng/ml) was applied. in parallel, il-2 stimulation significantly amplified the expression of anti-apoptotic bcl-2 in sle treg but not tcon. conclusion. in analogy to our previous findings in lupus-prone mice, treg from sle patients show the classical hallmarks of il-2 deficiency with loss of cd25 expression and a homeostatic imbalance between treg and tcon. these findings could be associated with a reduced il-2 expression by cd4+ t cells in sle patients. on the other hand, low-dose il-2 stimulation in vitro could restore these defects, underlying the potential of il-2 as a novel therapeutic option in sle. the glucocorticoid-dependent modulation of immune-mediated inflammatory arthritis by osteoblasts in mice is t cell independent background. at present, the role of adiponectin in rheumatoid arthritis is still controversial. there is some evidence indicating anti-inflammatory effects, for example adiponectin reduces the tnf release by macrophages. in contrast to its anti-inflammatory role, adiponectin also exerts pro-inflammatory effects locally in joints, inducing for example pro-inflammatory factors and matrix-degrading enzymes in ra synovial fibroblasts. moreover, our immunohistochemical analysis of ra bone tissue showed a co-localization of adiponectin with key cells of bone remodelling (osteoblasts, osteoclasts). however, the role of adiponectin in bone remodelling of ra still needs to be defined. in this study, we therefore focussed on adiponectin and its immunomodulatory properties on ra osteoblasts and osteoclasts. methods. human osteoblasts and osteoclasts were isolated from bone tissue and blood samples of ra patients. immunocytochemistry and rt-pcr were used to analyze the expression of adiponectin and its receptors in osteoblasts and osteoclasts. osteoblasts and osteoclasts were treated with adiponectin (10 µg/ml). adiponectin-mediated effects on the cytokine expression in osteoblasts and osteoclasts were analyzed using elisa. results. the expression of adiponectin and its receptors (adipor1, adipor2, and paqr3) by cultured ra osteoblasts and osteoclasts could be confirmed on translational and transcriptional level. stimulation of primary ra osteoblasts and osteoclasts with adiponectin resulted in an alteration of cytokine release. osteoblasts showed a time-and dose-dependent increase in il-6 production. furthermore, adiponectin induced the secretion of il-8 and gro-alpha and significantly increased the il-6 and mcp-1 production (il-6: 5-fold, p=0.004; mcp-1: 6-fold, p=0.004). stimulation with adiponectin resulted in an increase in il-6 production in pre-osteoclasts (5-fold) but not in osteoclasts. the secretion of il-8 was increased in pre-osteoclasts (18-fold) and osteoclasts (2-fold). the results of the present study confirm the pro-inflammatory potential of adiponectin in ra. the cytokines released after adiponectin treatment by osteoblasts and osteoclasts promote osteoclastogenesis or the migratory potential of osteoclasts and monocytes. together with the finding that adiponectin is present in the bone compartment of ra suggest an involvement of adiponectin in articular destruction. acknowledgement: funded by the german research society (spp1468, immu-nobone, ne1174/6-1). novel mechanisms of glucocorticoid therapy in arthritis anti-inflammatory acting glucocorticoids (gcs) are an important component of rheumatoid arthritis (ra) therapy. but their beneficial usefulness, especially in ra therapy, is hampered by severe side effects like glucocorticoid-induced osteoporosis (gio). until now the molecular mechanisms underlying the beneficial and side effects of gc therapy are poorly understood. gcs exert their actions via the glucocorticoid receptor (gr) that alters gene expression by either binding as a dimer to gc response elements in the promoter region of target genes or by interacting with and thus interfering with other transcription factors. for a long time gr dimerization was considered as the molecular base of side effects. interference of pro-inflammatory transcription factors, such as ap-1 and nf-κb by the gr monomer was believed to contribute to the therapeutic effects of gcs. in a model of gio we previously showed that unexpectedly interaction of the gr monomer with ap-1, but not nf-kb in osteoblasts is decisive for bone loss (cell metabolism 2010 11:517). in contrast, in antigen-induced arthritis (aia), we could demonstrate that gcs act in the acute inflammation of ra via the dimerized gr. particularly, gc therapy suppressed th1 and th17 cell derived pro-inflammatory cytokines in a dimerization dependent manner. furthermore th17, rather than th1 cells seem to be the most crucial targets for an efficient gc therapy since il-17-/-mice were resistant to gc therapy whereas ifnγ-/-mice responded as efficient as wild type mice to steroid treatment (pnas 2011 108:19317). in a more chronic arthritis model, the k/bxn serum transfer induced arthritis, we demonstrate now that, unexpectedly, dimerization of the gr in non-hematopoietic cells also contributes to the anti-inflammatory effect of gcs. thus, for immunosuppression of arthritis the gr is required in distinct cell types. taken together, for anti-inflammatory actions the gr dimerization dependent gene regulation is decisive in ra, whereas gio depends on the suppression of ap-1 dependent gene expression. intriguingly for anti-inflammatory activities of gcs immune and non-immune cells are involved. our approaches give new insights into gc action on arthritis and bone that can be translated into new concepts for anti-inflammatory therapies preventing gio. background. new bone formation and ankylosis are a hallmark of ankylosing spondylitis (as). the impact of cytokines and different mechanisms of new bone formation (endochondral vs. membranous) to syndesmophyte formation and joint ankylosis in as are still poorly understood. in order to analyze cartilage hypertrophy -as a potentially important element of endochondral bone formation -and to assess the possible influence of cytokines, we performed an immunohistochemi-cal study of the hyaline articular cartilage of facet joints of as patients in comparison to autopsy controls and patients with osteoarthritis (oa). methods. the cytokines interleukin(il)-6, il-10 and il-22, as well as the marker of cartilage hypertrophy runt-related transcription factor 2 (runx2), matrix metalloproteinase 13 (mmp13) and collagen type 10 (col10) were determined in facet joints from 13 patients with as (undergone correction surgery of rigid hyperkyphosis), 11 oa patients (undergone surgery of the lumbar spine, because of neurological deficits) and 12 controls (autopsies without spinal diseases). immunohistochemistry was performed and the entire cartilage area was analyzed for the frequency of positively stained chondrocytes. background. immunization with glucose-6-phosphate isomerase (g6pi) induces arthritis in susceptible strains of mice. depletion of regulatory t cells (tregs) prior to immunization switches the usually acute, self-limiting course to a non-remitting, destructive arthritis. this provides a possibility to study molecular switches for the transition from acute, self-limiting to chronic, destructive arthritis within one mouse model. to examine the role of fibroblast-like synoviocytes (fls), which are known to modulate immune responses via the production of pro-and anti-inflammatory mediators, the phenotype and function of fls from mice with either acute, self-limiting or non-remitting, destructive arthritis was studied. methods. fls from dba/1 mice that developed either the acute or the chronic form of arthritis were isolated from joints over a time course of 56 days. to investigate the phenotype of fls elisa studies as well as zymography have been performed. for the functional clarification of those cells the matrix-associated transepithelial resistance invasion (matrin) assay and a cartilage attachment assay have been used. furthermore, fls have been transferred in vivo into the knee joints of immunodeficient mice and the joints have been scored histologically. results. fls from treg-depleted mice produced significantly more cytokines (e.g. interleukin 6 (il-6)) upon stimulation with other cytokines, growth factors and tlr ligands. this increased susceptibility to cytokine stimulation in chronic animals compared to acute ones is observable throughout the disease course (56 days). furthermore, the secretion and activity of matrix metalloproteases (mmps) was enhanced in the fls from chronic mice compared to samples from acute ones. additional functional differences include the collagen-destructive potential and the potential to attach and eventually invade wild type cartilage. here, fls from treg-depleted chronic arthritic mice showed a higher invasive and destructive potential. ultimately, fls from treg-depleted mice were able to destroy cartilage in immunodeficient mice. conclusion. our results are compatible with the hypothesis that uninhibited inflammation in the early phase of treg-depleted mice causes the acquisition of an autonomously aggressive phenotype of synoviocytes which contribute to the switch from acute to chronic arthritis even in the absence of late support from t and b lymphocytes. collagen-induced arthritis modulates reactivity to sympathetic neurotransmitter stimuli during osteoclastogenesis of bone marrow-derived macrophages from da rats background. osteoclast(oc)-mediated bone destruction contributes to increased disease burden in rheumatoid arthritis. simultaneously, changes in synovial tissue innervation occur, leading to a reduction in catecholaminergic nerve fibres. studies on sweat gland innervation revealed that catecholaminergic fibres are capable of phenotypic transition to cholinergic nerves. the sympathetic neurotransmitters norepinephrine (ne) and acetylcholine (ach) affect osteoclastogenesis oppositely prompting us to study osteoclastogenesis at different phases of collagen-induced arthritis (cia) in an altered neurotransmitter microenvironment. methods. for induction of experimental arthritis, da rats were immunized with bovine collagen type ii while controls received isotonic nacl solution. to generate oc, bone marrow-derived macrophages (bmm) were isolated and differentiated with recombinant m-csf and rank ligand. the influence of ne and ach stimulation on osteoclast differentiation and activity was compared between arthritic and control animals at the acute (20 days post immunization, pi) and the chronic (40 days pi) disease state. as the nicotinic α7 ach receptor subunit is involved in the cholinergic anti-inflammatory reflex, we also applied a specific agonist, arr-17779. additionally, the gene expression profile for ne and ach neurotransmitter receptors was analyzed. results. ach stimulation generated significantly more osteoclasts in controls (40 days pi). arr-17779 mediated effects were similar to ach. ne decreased osteoclastogenesis via β-adrenoceptors and enhanced via α-adrenoceptor stimulation. cells from arthritic animals were less affected by ne and ach stimulation.oc from arthritic animals showed tendentially decreased activity in an enzymatic cathepsin k activity assay. ach and arr-17779 stimulation decreased cathepsin k activity 20 days pi, but the effect disappeared 40 days pi, representing the chronic arthritis state. ne stimulation significantly inhibited enzyme activity 20 days pi, but has little effect under chronic conditions. the receptor gene expression profile changed in the time course of arthritis. 20 days past immunization muscarinic ach receptors m3 and m5 were significantly upregulated whereas after 40 days adrenoceptors α1d and α2b were significantly downregulated. conclusion. we conclude that cia differentially modulates neurotransmitter influence during oc differentiation and activation but the underlying processes remain still unknown. the observed time pointdependent changes in neurotransmitter receptor gene expression may constitute a regulatory mechanism to counteract alterations in the local neurotransmitter composition. background. the generation of memory t lymphocytes allows effective and fast immune responses during antigen re-challenge and represents a hallmark of adaptive immunity. previous work from our group has demonstrated that murine memory cd4+ t cells reside in specific bone marrow niches and are characterized by the high expression of cd69 and ly-6c. these cells were designated as resting in the context of gene expression and proliferation. here, we aimed to phenotypically and functionally characterize human memory t lymphocytes in peripheral blood and bone marrow of healthy individuals. methods. mononuclear cells were isolated from paired blood and bm samples from individuals undergoing hip replacement surgery. phenotypic analysis and cytokine profile of distinct memory t cell subsets were assessed by flow cytometry. proliferation and cell cycle status were analyzed using ki-67 and propidium iodide (pi) staining, respectively. results. distinct populations of cd69-expressing cd8+cd45ra-and cd4+cd45ra-t cells were detected in bone marrow but not in the periphery. ccr7 and cd62l expression was reduced on bone marrow cd69+cd4+cd45ra-and cd69+cd8+cd45ra-t cells compared to their cd69-counterparts in bone marrow and peripheral blood. cell cycle analysis and ki-67 expression levels demonstrated the nonproliferative state of bone marrow memory t cells. furthermore, bone marrow resident memory t cells showed reactivity against various pathogenic agents, such as tetanus, measles and cmv. conclusion. we have identified a population of cd69-expressing cd8+cd45ra-and cd4+cd45ra-t cells in the bone marrow. despite cd69 expression, which is generally regarded as early activation marker, the cells were resting in terms of proliferation. bone marrow cd69+ memory t cells have downregulated ccr7 and cd62l indicating reduced homing capacity to secondary lymphoid organs. our data underline the role of the bone marrow as a major reservoir for resting memory t lymphocytes. therapeutic methods exerted an influence on satisfaction and future expectations in patients with rheumatoid arthritis (ra). methods. when visiting their rheumatologist, patients with ra were asked to complete a questionnaire at home after the consultation and then return it to an independent opinion research centre, where the data was collected and analysed. the form comprised various areas, namely demography, aspects of the diagnosis, medical care, therapeutic measures, and the illness in a personal context. results. 127 patients (122 females/25 males) from the whole of austria with a particular emphasis on lower austria, upper austria and tyrol completed the questionnaire (of 150 distributed), resulting in a response rate of 85%. 63% of the patients lived in settlements of under 5,000 inhabitants; a further 18% in settlements of under 50,000 inhabitants.. the rheumatologist attended could be reached within one hour for 90% of the patients and within 30 minutes for 41%. in slightly fewer than 30% of the respondents the diagnosis was made within three months, in 44% within six months. in 75%, the diagnosis was made by a rheumatologist. after experiencing the first symptoms, 80% contacted their general practitioner. a high degree of satisfaction appears to originate from the information supplied by the rheumatologist attended. most patients felt they were involved in decisions regarding their therapy. 77% of the respondents were employed prior to their illness; as a consequence of the disease 27% had to leave their jobs. conclusion. the majority of the respondents came from rural areas. the correct diagnosis was made within six months for almost half of the patients questioned. most patients felt well informed by their rheumatologists and involved in therapeutic decision-making. , combinational therapy of synthetic dmards (9.6; 5.1-14.1), and biological-monotherapy (6.07; 0-13). all of these differed significantly on later observation periods. comparing the prescriptions separately by sequential treatments there were no differences in retention rates for the individual dmard classes. regarding retention, in the first treatment synthetic dmards showed the longest retention, but from the second on this was the case for tnfi-combinational treatment and non-tnfi-biologicals (. abb.12) conclusion. traditional dmards are the starting point of therapy and mtx is the anchor drug for the first and all subsequent courses. already at the second sequential course, the combination therapies of mtx+tnfi become numerically more relevant, and their retention is better than mtx. therapie der rheumatoiden arthritis im letzten jahrzehnt -was hat sich verändert? abb.13 | ev.198 anzahl eingeschlossener patienten nach einschlussjahren und therapie sowie zeitlichen entwicklungen im das28 und der eular-response cal features of ra (erosive arthritis with classical radiological features) plus specific laboratory markers (ccp-antibodies). the third patient, a 48-year-old female presented initially with features of ra and sle simultaneously (alopecia, subcutaneous nodules, leucopenia, positive ccp-antibodies, high titres of ana and dna-antibodies). the fourth patient, a 40-year-old patient presented with severe polyarthritis in the upper and lower limbs, subcutaneous nodules, fever and cervical lymphadenopathy, she had high titres of ccp-antibodies (170 u/ml by a normal range of less than 5 iu/ml), ana of 5120 (normal less than 80), and dna of 290 iu/ml (normal less than 100 iu/ml). conclusion. the take home massage of this presentation is to be aware of rhupus if the sle patient develops erosive arthritis or subcutaneous nodules, or if the ra patient develops features of sle like leucopenia, active urine sediment, or clinically significant serositis. rhupus seems to be a distinctive entity and should be kept in mind while dealing with patients having ra or sle as it can affect the treatment and outcome. vorgeschichte. bei der abklärung eines akuten thoraxschmerzes sind auch seltene ursachen, so zum beispiel der einbezug thorakaler organe in eine entzündliche systemerkrankung, zu bedenken. anhand eines besonderen falles möchten wir den weg zur diagnose bei einem schwer kranken notfallpatienten zeigen. leitsymptome bei krankheitsmanifestation. ein 57-jähriger mann wird bereits zum dritten mal mit akuten thoraxschmerzen in die notaufnahme aufgenommen, jeweils war eine kardiale ischämie ausgeschlossen und ambulante diagnostik empfohlen worden. nach der schmerzcharakteristik, der vorgeschichte von rezidivierenden thoraxschmerzen und entsprechenden risikofaktoren wird bei massiver symptomatik jetzt von einem akuten koronarsyndrom ausgegangen und die invasive diagnostik durchgeführt. eine akute koronare ischämie kann jedoch ausgeschlossen werden. fieber, hohe entzündungszeichen, hinfälligkeit und gewichtsverlust von mehr als 10 kg in den letzten wochen lassen dann eine infektbedingte oder tumorbedingte ursache vermuten, abdomensonographie und röntgen-thorax sowie ausführliches labor samt immunologie führen nicht weiter. wegweisende weitere organbefunde finden sich nicht. die behandlung mit antibiotika hat keinerlei effekt auf klinik oder entzündungsparameter. nach 3 tagen wird der krankheitsverlauf kritisch evaluiert, eine nichtinfektiöse ursache der beschwerden wird in betracht gezogen, eine transösophageale echokardiographie wird zum ausschluss einer endokarditis und zur beurteilung der aorta (leitsymptome thoraxschmerzen und fieber!) durchgeführt. dabei zeigen sich die klappen sämtlich unverdächtig, die aorta ascendens weist eine massive echoarme wandverdickung auf. zum sicheren ausschluss eines intramuralen hämatoms wird sofort eine ct der thorakalen aorta durchgeführt, die eine ausgeprägte zirkuläre wandverbreiterung ohne hinweise auf dissektion zeigt. diagnose. riesenzellarteriitis mit aortitis. therapie. steroide, einleitung einer remissionsinduzierenden therapie mit cyclophosphamid boli. weiterer verlauf. innerhalb von 2 tagen ist der patient beschwerdefrei, die entzündungsparameter sind halbiert, der bettlägerige patient lässt sich mobilisieren und verlässt nach 10 tagen die klinik. bei der diffe-renzialdiagnose des akuten thoraxschmerzes sollten eine unklare entzündungsserologie und eine b-symptomatik frühzeitig an eine aortitis denken lassen. in diesem fall fand sich bereits in tee und ct ein ausgeprägter befund, der sich am ehesten durch den langen verlauf vor diagnosestellung erklären lässt. einleitung. die progressive familiär intrahepatische cholestase (pfic) gehört zu einer heterogenen gruppe seltener, autosomal rezessiv vererbter erkrankungen der gallensäurenexkretion mit intrahepatischer cholestase, hohem risiko der leberzirrhose bereits im kindesalter und hepatozellulärem karzinom. das auftreten eines sle bei pfic ist bisher in der literatur nicht beschrieben. methoden. wir berichten über eine jetzt 23-jährige patientin mit genetisch gesicherter pfic-2 (defekt der atp abhängigen gallensalz-exportpumpe bsep), biliostomaanlage im kindesalter, therapie mit udca und kontinuierlicher hepatologischer betreuung. 12/2011 manifestierte sich ein sle mit az-minderung, florider polyarthritis, polyserositis, splenomegalie, anämie und leukozytopenie. die ana waren mit >1:5120 homogen erhöht, die dns-ak im elisa mit 6738 u/ml, ena und antiphospholipid antikörper waren negativ. eine steroidtherapie wurde mit prednisolon 30 mg/tag begonnen. bei guter verträglichkeit und stabilen cholestaseparametern wurde die therapie um chloroquin mit 250 mg an 3 tagen der woche ergänzt. die betreuung wurde interdisziplinär fortgesetzt. ergebnisse. unter der steroidtherapie waren gelenkbeschwerden und serositis gebessert, das crp, die leukozytopenie und anämie normalisiert. die dns-antikörper fielen auf 1977 u/ml, c3 und c4 stiegen um 20%. es persistierten lediglich physiotherapeutisch behandelte muskuläre schmerzen und schonatmung nach pleuritis. bei steroidreduktion unter 10 mg traten die gelenkbeschwerden wieder auf, die dns-antikörper stiegen auf 4549 u/ml und c3/c4 fielen um 10%, das crp blieb normal. die steroiddosis wurde auf 15 mg/tag und die chloroquindosis auf 5×250 mg/woche erhöht. neue organkomplikationen im rahmen des sle sind nicht aufgetreten. die gallensäuren waren mit 47 µmol/l (norm <8) im jahr 2009 (letzte messung vor manifestation des sle) deutlich erhöht, bei manifestation des sle mit 12 µmol/l bereits deutlich gebessert und unter hoch dosierter steroidtherapie mit 4,7 µmol/l nach 1 woche sowie 5,4 µmol/l nach 1 monat normalisiert. unter prednisolon 15 mg/tag stiegen sie bei inaktiviertem sle auf 15 µmol/l nach 4 monaten an, bei steroidreduktion unter 10 mg auf 69 µmol/l. nach erneuter steroiddosiserhöhung auf 15 mg prednisolon/tag fielen sie auf 12 µmol/l ab. schlussfolgerung. die pfic-2 schützt nicht vor der manifestation eines sle. eine behandlung mit steroiden und chloroquin ist auch bei pfic sicher und wirksam. der floride sle und die höher dosierte steroidtherapie senken trotz bestehenden genetischen defekts unabhängig voneinander und synergistisch die gallensäurenspiegel im serum bei genetischer störung der atp-abhängigen sekretionspumpe bsep. augenentzündungen. eine ausgeprägte b-symptomatik mit fieber, nachtschweiß und abgeschlagenheit seit ca. zwei jahren hatte sich jeweils unter der therapie der hörstürze verflüchtigt. die mr-angiographie der aortenwand zeigte den typischen befund eines ausgeprägten wandenhancements der thorakalen aortenwand sowie der supraaortalen gefäße, duplexsonographisch fand sich eine zirkuläre wandverdickung der proximalen und mittleren acc beidseits ohne relevante stenosen. bei fehlendem nachweis zerebraler vaskulitischer oder embolischer veränderungen im kraniellen mrt und bei normalem eeg wurde der cerebrale krampfanfall als gelegenheitsanfall dd im rahmen der hochaktiven grunderkrankung interpretiert. diagnose. takayasu-arteriitis mit assoziiertem cogan-syndrom und rezidivierender polychondritis. therapie. steroidstoß, darunter rasche reduktion der entzündungszeichen und promptes ansprechen der b-symptomatik, beginn einer steroidsparenden therapie mit mtx. bei anhaltender krankheitsaktivität und hohem steroidbedarf wird der patient aktuell mit tocilizumab behandelt. schlussfolgerung. der präsentierte fall zeigt, dass mittels neuer bildgebender verfahren gelegentlich eine großgefäßvaskulitis detektiert werden kann, obwohl das klinische bild (hier: kopfklinik) eine kleingefäßvaskulitis vermuten lässt. das cogan-syndrom ist häufig mit einer großgefäßvaskulitis assoziiert, in diesem fall auch mit einer polychondritis. umgekehrt erweitert sich unser wissen um das befallsmuster der großgefäßvaskulitiden, die zwar überwiegend große, aber auch mittelgroße und kleine gefäße einbeziehen können. in unserem zentrum ist dies der zweite fall einer takayasu-arteriitis mit assoziiertem cogan-syndrom in einem kollektiv von 8 fällen. diagnostik. im rahmen einer vorstellung in unserer rheumatologischen ambulanz zur abklärung eines möglichen sjögren-syndroms, konnte in der lungenfunktionsdiagnostik eine leichte restriktion und überblähung festgestellt werden. in einem auswärtig durchgeführten mrt der halsweichteile zeigten sich die glandula parotis und submandibularis beidseits inhomogen und kräftig kontrastiert, ebenfalls mehrere grenzwertig große lymphknoten. aufgrund der erneut pathologischen lungenfunktion und dem verdacht auf eine lungenbeteiligung bei sjögren-syndrom erfolgte ein ct-thorax. hier zeigte sich eine zysti-sche rarefizierung vor allem der zentralen lungenanteile, differentialdiagnostisch mit einer langerhans-zell-histiozytose vereinbar. auch erschien der diabetes insipidus passend zur histiozytose. die immunologischen untersuchungen waren unauffällig, insbesondere konnten keine ssa-/ssb-antikörper oder eine hypergammaglobulinämie nachgewiesen werden. somit erschien ein sjögren-syndrom unwahrscheinlich. zur weiteren abklärung erfolgte eine bronchoskopie, in den biopsaten konnte immunhistochemisch eine langerhans-zell-histiozytose nachgewiesen werden. in einer pathologischen nachuntersuchung auswärtiger parotis-biopsate bestätigte sich diese, zudem konnte eine mutation des braf-proto-onkogens nachgewiesen werden. im abschließend durchgeführten pet-ct konnte eine vermehrte kontrastmittelaufnahme des hypophysenstiels, eine vermehrte stoffwechselaktivität der parotis beidseits sowie kutan axillär links diagnostiziert werden. abschließend lag somit eine langerhans-zell-histiozytose mit befall von hypophyse, lunge, parotis, haut, lymphknoten sowie einem fraglichen befall des darms vor. therapie. in absprache mit der adulten langerhans-zell-histiozytose studiengruppe erfolgt nun eine therapie mit cytarabin. weiterer verlauf. der weitere verlauf nach geplantem therapiebeginn bleibt abzuwarten. einleitung. die anti-gbm-erkrankung (goodpasture-syndrom) ist eine prototypische autoimmunerkrankung mit ernster prognose, wenn sie als "pulmorenales syndrom" mit der trias rapid-progressive glomerulonephritis, alveoläre hämorrhagie und nachweis von autoantikörpern gegen glomeruläre basalmembranen (anti-gbm-ak) auftritt. über weniger aggressive verläufe ist wenig bekannt. in der literatur wird die bedeutung der frühen diagnosestellung für die prognose der patienten betont. wir berichten über eine 36-jährige patientin, die sich mit abgeschlagenheit, müdigkeit und blutbeimengungen im sputum vorstellt. sie betreibt einen nikotinabusus. methoden. wir sehen eine blasse patientin (hb 4,0 mmol/l, normochrom, normozytär), die keine weiteren auffälligen befunde in der körperlichen untersuchung zeigt. die apparative diagnostik mittels endoskopie und sonographie ergibt keine befunde, die die anämie erklären können; in der bronchoskpie zeigt sich das bild einer alveolären hämorrhagie ohne aktive blutungszeichen. neben der ausgeprägten anämie bestehen eine milde proteinurie mit 300 mg/d sowie eine geringe erythrozyturie. die immunologische diagnostik ergibt gering erhöhte anti-gbm-ak, negative ana und anca. die nierenbiopsie zeigt eine rapid-progressive glomerulonephritis mit halbmondbildung in einem glomerulum, zusätzlich können lineare igg-ablagerungen in der immunfluorenz dargestellt werden. es ist ein glomerulum in der biopsie betroffen, die anderen glomeruli sind unauffällig. es bestehen einzelnen erythrozytenzylinder, diffuse entzündungszeichen lassen sich nicht nachweisen. die nachträglich durchgeführte immunfluoreszenz in der lungenbiopsie bestätigt den befund linearer igg-ablagerungen. ergebnisse. in unserem fall sehen wir eine junge patientin in einem relativ guten allgemeinzustand mit gering erhöhten anti-gbm-antikörpern und einer gering ausgeprägten nierenschädigung mit einem befallenen glomerulum in der biopsie. es wird angesichts des jungen alters der patientin und der geringen ausprägung der erkrankung eine therapie mit cyclophosphamid nach dem "euro-lupus-protokoll" von f. hossiau eingeleitet. im verlauf steigt der hb auf 5,6 mmol/l, die alveoläre hämorrhagie sistiert und die proteinurie ist rückläufig. schlussfolgerung. das goodpasture-syndrom mit einer inzidenz von 0,5-1,0/1 mio. einwohner und jahr ist eine sehr seltene autoimmunerkrankung mit ernster prognose. möglicherweise spielen umweltfaktoren (hier: nikotinabusus) eine rolle für die manifestation der erkrankung. interessant ist, dass die erstbeschreibung im rahmen einer influenza-epidemie -wie auch in diesem jahr bei unserer patientinerfolgte. über die therapie gibt es wenige informationen. die meisten empfehlungen gibt es zum pulmorenalen-syndrom, über weniger aggressiv verlaufende manifestationen gibt es nur wenige informationen. einleitung. wir berichten über einen 46-jährigen raucher mit akut aufgetretener polyarthritis und neu aufgetretenem raynaud-phänomen. auffallend war die diskrepanz zwischen nur geringer systemischer entzündungskonstellation und einer hochaktiven polyarthritis mit schwerem raynaud-phänomen. im verlauf kam es zu einer spontanen thrombophlebitis der v. cephalica. methoden. pathologische werte: crp maximal 1,4 mg/dl (norm <0,6), zellzahl im gelenkpunktat 20.000 leukozyten/µl. im normbereich lagen: bsg 12 mm/1 h, ana, ena, ds-dns-ak, rheumafaktoren, anca, kälteagglutinine, kryoglobuline, tumorsuche initial ohne befund (ct-thorax, bronchoskopie, ct abdomen und becken, coloskopie, gastroskopie, skelettszintigraphie), fdg pet-ct: zwei suspekte lymphknoten rechts cervical sowie suspekte rechte tonsille. ergebnisse. selbst unter 60 mg prednisolon weiterhin hochaktive polyarthritis. nach unauffälliger initialer tumorsuche veranlassten wir ein fdg-pet ct mit nachweis zweier suspekter lymphknoten rechts cervical sowie einer suspekten rechten tonsille. die biopsie der klinisch sich nur in der palpation diskret induriert darstellenden region ergab ein gering differenziertes, gering verhornendes plattenepithel mit 98%iger sequenzhomologie mit hpv typ 16. nach resektion des tumors und radiatio sistierten sowohl die polyarthritis als auch das raynaud-phänomen ohne weiteres rezidiv auch nach absetzen der glukokortikoide. schlussfolgerung. eine akut auftretende hochaktive polyarthritis mit hohem glukokortikoidbedarf in kombination mit einem raynaud-syndrom, auffallend niedriger systemischer entzündungsaktivität und fehlendem autoantikörpernachweis sollte insbesondere bei einem langjährigen raucher anlass zu einer intensiven tumorsuche geben. ein fdg-pet-ct kann bei okkulten tumoren zielführend sein. bemerkenswert ist hier der nachweis von hpv-16 im tumor als weiterer risikofaktor neben dem zigarettenrauch. methoden. bei der klinischen untersuchung fielen ein beidseits positives menell-zeichen und deutlicher klopfschmerz über dem lumbosakralen übergang auf. labordiagnostisch konnte ein erhöhtes c-reaktives protein und ein positiver hla-b27 nachgewiesen werden. der bath ankylosing disease activity (basdai) index betrug 6,875. die beckenübersichtsaufnahme zeigte eine definitive bilaterale sakroiliitis grad 3 gemäß den modifizierten new-york-kriterien. der befund der kontrastmittelunterstützten mrt der iliosakralgelenke bewies das vorliegen einer bilateralen floriden sakroiliitis. bei gesicherter hla-b27 positiver ankylosierender spondylitis wurde die indikation zur einleitung einer biologikatherapie mit einem tnfα-inhibitor gestellt. während der abklärung von kontraindikationen wurde in der konventionellen röntgen-thorax-aufnahme eine rundliche, glatt begrenzte zystische läsion mit flüssigkeitsspiegeln im rechten mittellappen entdeckt. die weitere abklärung mittels nativer thorax-ct, bronchoskopie und biopsieentnahme bestätigte den verdacht auf eine bronchogene zyste. die erregerdiagnostik in der bronchoalveolären lavage zeigte lediglich eine kontamination mit der residenten standortflora. ergebnisse. in anbetracht der geplanten immunsuppressiven therapie, die mit einem erhöhten infektionsrisiko einhergeht, wurde die bronchogene zyste im september 2012 operativ entfernt. zur linderung der beschwerden erhielt die patientin eine schmerztherapie mit nsar. als sich die patientin sechs monate später erneut zur einleitung der biologikatherapie vorstellte, berichtete sie, dass die schmerzen etwa einen monat nach der operativen resektion praktisch verschwunden seien. die klinische untersuchung war unauffällig, der basdai-index lag bei 1,2. auch das zur verlaufskontrolle angefertigte mrt der isg zeigte im vergleich zur voruntersuchung einen deutlichen rückgang der floridität. schlussfolgerung. es handelt sich um den ersten fall einer kompletten klinischen und radiologischen remission einer hla-b27-positiven ankylosierenden spondylitis nach operativer entfernung einer bronchogenen zyste als potenziellen entzündlichen fokus. bei der systemischen verlaufsform der erkrankung treten neben kutanen erscheinungen zusätzlich muskuloskeletale, hämatopoetische (20-60%), renale (ca. 50%), kardiale, cerebrale und pulmonale (4-9%) manifestationen auf. eine polyserositis (11-60%) ist häufig. mit 8-40% werden im sle-schub abdominelle schmerzen beschrieben. nur in seltenen fällen (amerika 0,9%, asien 2,2-9,7% aller sle-patienten) kommt es zum bild einer lupusassoziierten mesenterialen vaskulitis (lmv). die ätiologie der lmv ist weitestgehend unklar, eine genetische präsidsposition sowie auslösende faktoren (bakterielle darminfektionen, medikamente wie nsar, phosphodiesterasehemmer) werden diskutiert. pathogenetisch wird eine mesenteriale ischämie durch eine mikroangiopathie (arteriolen, venolen) bei inflammatorischer immunkomplexpräzipitation sowie thrombembolischen ereignissen angenommen. radiologisch/sonographisch zeigt sich ein segmentales darmwandödem mit darmdilatation. endoskopisch dominieren oberflächliche ulzerationen, perifokale hämorrhagien bis hin zur gangrän. eine erhöhte perforationsneigung wird beschrieben. mikroskopische befunde zeigen eine fibrinoide nekrose subseröser gefäße mit leukozytoklasie der gefäßwand bzw. ein submuköses ödem mit nur diskreter invasion mononukleärer zellen. die prognose der lmv scheint abhängig von genetischer prädisposition, raschem beginn einer immunsuppression sowie restriktivem einsatz operativer interventionen und wird je nach literaturquelle mit einer letalität bis zu 50% angegeben. background. we report a patient with tma in the context of sle treated successfully with the c5 inhibitor eculizumab. the patient had sle with lupus nephritis (ln). before she developed tma with renal failure and neurologic manifestations, she was treated with various immunosuppressive regimens for mucocutaneous and musculoskeletal manifestations and later for ln. the diagnosis of atypical hemolytic uremic syndrome (ahus) was made based on the presence of coombs-negative hemolytic anemia, thrombocytopenia, renal failure, seizures due to cerebral ischemia and signs of tma in the renal biopsy. plasma exchange and hemodialysis were started immediately and could stabilize her condition. six weeks after the beginning of plasmapheresis but still severely compromised renal function and thrombocytopenia, complement inhibition with eculizumab became a therapeutic option. after the first infusions, renal function, anemia and thrombocyte counts markedly improved. dialysis could be stopped. extensive genetic testing of mutations associated with the overactivation of the alternative complement pathway was negative. after 7 months, when the patient was still in remission, eculizumab infusion intervals were widened and it was finally stopped after 12 months of treatment. since then, renal function remained stable with nearly normal glomerular filtration rates. background. il-6 signaling plays an important role in inflammation but is restricted by different regulatory mechanisms. these mechanisms include the decreased availability of gp130, the signal transducing chain of the il 6 receptor, on the cell surface. the aim of this study was to determine whether the inflammatory environment in the arthritic joint has an impact on monocytic gp130 surface expression and the extent to which regulatory processes in the synovial fluid (sf) can be transferred to an in vitro model. flow cytometry and live cell imaging were used to measure the cell surface expression and internalization of gp130. stat3 phosphorylation was monitored by flow cytometry and western blotting. results. the level of cell surface gp130 expression on sf monocytes was reduced compared to peripheral blood (pb) monocytes from patients with juvenile idiopathic arthritis (jia). this reduction could be reproduced by stimulating pb monocytes from healthy donors with sf and was dependent on p38 mapk. the induction of p38 by il-1β in pb monocytes interfered with il-6 signaling due to the reduced cell surface expression of gp130. the results suggest that p38-mediated pro-inflammatory stimuli induce the downregulation of gp130 on monocytes and thus restrict gp130 mediated signal transduction. this regulatory mechanism could be relevant in the inflamed joints of patients with jia. kr.08 sjia patient characteristics of those who successfully discontinued corticosteroids during canakinumab treatment: secondary analysis from a pivotal phase 3 trial background. interleukin-1β (il-1β) is a key driver in the pathogenesis of systemic juvenile idiopathic arthritis (sjia). canakinumab (can), a selective fully human anti-il-1β monoclonal antibody, has been shown to be efficacious in the treatment of sjia [1] . corticosteroids (cs) are a mainstay of therapy for sjia, however due to the well-known long-term side effects, reduction of cs dosage is desirable. objectives. to assess patient features associated with cs discontinuation during can therapy. methods. patients (2-19 years of age) with active sjia received s.c. can (4 mg/kg to 300 mg max) every four weeks during the maximum 20week cs-tapering phase [1] . cs tapering was to be initiated when at least an adapted acr50 was achieved and no fever. a 12-year-old boy presented with nocturnal tingling paresthesia affecting his feet and his calves. no excessive leg movements were noted at night. within a few months, his symptoms worsened. the paresthesia occurred both during the day and at night. moreover, the paresthesia came to be triggered by merely standing up. affecting a sharply demarcated area not corresponding to dermatomes, symptoms resolved promptly with movement. the paresthesia was associated with local skin erubescence in spots that slowly began spreading all over the affected area. symptoms did not occur while the patient was seated. mild painless swelling around both of the ankles was noticed in the evenings. approximately one and a half years after the initial manifestation, painful triphasic color changes of all fingers and toes triggered by cold or stress occurred. the family history was positive only for psoriasis. extensive laboratory studies excluded inflammatory and hematological conditions as well as occlusive arterial diseases known to be associated with secondary raynaud's phenomenon. polyneuropathy and other neurological disorders were excluded as well. inflammatory joint disease suspected from the initial imaging with magnetic resonance of the feet and ankles was not confirmed by repeated investigations and scintigraphy. the only consistent abnormality was a reduced pulse amplitude corresponding to vasospasm, which was revealed by photoplethysmography of toe vessels. additionally, paradoxical amplitude reduction after application of nitroglycerine was seen in finger vessels. placing his hands or feet in cold water did not trigger raynaud's phenomenon. initial treatment with non-steroid anti-inflammatory drugs, topical isosorbiddinitrate and local steroid instillation (suspicion of inflammation of tibialis posterior tendon) was ineffective. systemic therapy with the calcium channel blocker amlodipine was initiated. the initial dosing of 5 mg (0.09 mg/kg/day) was slowly increased to 15 mg (0.27 mg/kg/day) which lead to complete resolution of the patient's ailments. after three years of pharmacotherapy and 1.5 years in remission, a weaning off the treatment is planned. based on the patient's positive response to calcium channel blocker, we conclude that the lower-leg paresthesia was of vascular origin and can be considered an atypical presentation of raynaud's phenomenon. background. the initial treatments of choice for jdm are high-dose corticosteroids and methotrexate. however, no consensus exists about second line therapeutic options in refractory or recurrent cases. results. we present a 9-year-old boy who was diagnosed with jdm due to severe proximal muscle weakness, dysphagia, a heliotrope rash, gottron's sign, nail teleangiectasia and a characteristic muscle biopsy. creatine kinase levels were within normal range and no antinuclear antibodies were present. over a period of seven years, the patient was treated with high-dose corticosteroids, methotrexate, intravenous immunoglobulins, oral steroids, mycophenolate mofetil, rituximab and infliximab. despite all treatment efforts, skin and muscle inflammation persisted and the boy developed severe subcutaneous calcifications, rendering him wheelchair-bound. as il-6 production correlates with disease activity in adult and juvenile dm, treatment with tocilizumab (8 mg/kg every 4 weeks) was initiated, leading to a complete resolution of skin inflammation within 6 months. within 12 months of treatment, the disease activity score (das) decreased from 16 to 9 (out of 20), the childhood myositis assessment scale (cmas) increased from 17 to 27 (out of 52) and the kendall manual muscle test (mmt) increased from 60 to 75 (out of 80). in daily life the wheelchair was no longer necessary. treatment was well tolerated but accompanied by a moderate increase in liver transaminase activities. interestingly, therapy with rituximab was associated with a decline in igm levels only, whereas igg and iga stayed markedly elevated. in contrast, following initiation of tocilizumab treatment, igg levels rapidly declined to normal range, emphasizing the role of the humoral immune system in the pathogenesis of dm. conclusion. taken together, treatment of a severely affected jdm patient with tocilizumab was safe, well tolerated and led to a significant improvement in disease activity. further investigations of il-6-blocking agents as a treatment option in otherwise therapy-resistant jdm patients are warranted. functional capacity of jia patients with an initial adjustment to an anti-tnf-alpha therapy background. thirty three percent of patients with polyarticular jia are treated with biologics [2] . despite substantial improvement achieved by anti-tnf-α treatment according to disease activity [1] patients have joint-specific impairments. this factor should be considered when analyzing the functional effects on joint limitations while performing daily activities. methods. in a prospective study on polyarticular jia patients treated with anti-tnf-α therapies plus functional therapies we study the longitudinal effects on joint function. the measurements include 3-d gait analysis (eight vicon f40 cameras, omg, london, balance control (s3-check, tst, großhoeflein), pedobarography (emed plate (4sensors/ cm², novel, munich), daily activity assessment (step watch, orthocare innovations, ok usa), acr pedi and joint mobility testing. we here present the cross-sectional data of the first 17 patients (15.0±3.1 yrs, 162.7±14.6 cm, 60.0±17.2 kg, pain-level: 4.8±1.7/10 vas, active joints: 6.2±5.9, chaq: 0.4±0.4). results. preliminary results demonstrate that the ability to walk is slightly limited. patients have a reduced push off power generation within the ankle joint (patients: 3.4±1.4 w/kg; healthy controls: 4.5±0.9 w/ kg). further on they show limited sensory motor control and stability in comparison to patients with an inactive disease status while performing balance tests (patients: sensory index: 2.9±1.0, stability-index: 3.7±1.1, patients with inactive status: sensory-index: 2.1±0.8, stability index: 3.0±1.0 (p<0.05). note: lower indices values are better results. conclusion. it is one of the first studies which show functional joint-specific deficits during every day activities in patients who receive an initial anti-tnfα-therapy. the limited stability and motor control might be due to limited joint integrity in the ankle joint. this is supported by the impaired push off function while walking. the next study step will show possible effects of the anti-tnfα-therapy. background. the role of sport as a therapeutic tool in treating patients with jia is becoming more important recently [2] . effects of exercise therapy are reviewed beneath others by takken et al. [3] . they state that short-term effects look promising but the effects of long-term studies remain unknown. methods. the preventive mobility workout (pmw) is a whole body home-exercise-therapy (10 min each day) for patients with an inactive diseases status. it counteracts the deficits which were observed during functional studies in the past [1] . it consists of exercises for muscular strengthening (squads: hamstring to quadriceps ratio), hamstring flexibility (lift and raise), core stability (prone bridge -time-to-failure), shoulder griddle mobility (horizontal extension) and ankle joint integrity (mechanical power while walking . for statistical analysis an anova was calculated and the level of statistical significance was set to p<0.05. results. preliminary results show a group effect of the pmw for the hamstring to quadriceps ratio (h-q-r) for the right side (p<0.05) and a tendency for the left side (p=0.065). the h-q-r for the right side has changed in the tg and cg from 1.6±0.3 to 2.0±0.6 and from 2.1±0.6 to 1.6±0.3, respectively. it has changed for the left side in the tg and the cg from 1.9±0.5 to 1.6±0.3 and from 1.5±0.2 to 1.7±0.3, respectively. all other parameters regarding flexibility or joint integrity show low or no effects. we have re-tested n=18 out of 75 so far and the pmw training show little training-effects. the preliminary results might be a reasonable proof for long-term effects. a possible reason for the little effects might be that patients are supposed to train every day but the training diaries show that they exercise approximately three times a week. the authors would like to thank the "deutsche kinder-rheumastiftung" for supporting the study. conclusion. we will validate these proposed definitions prospectively in a jia associated uveitis cohort. based on the results, we will weight these measures to develop an overall scoring system. background. 6 minute walk is a primary outcome measure in studies in pulmonary hypertension. currently we have a two of sets of data [1, 2] regarding test results in the 6 minute walk test (6mwt) in healthy children with a large span in the norm values in the different age groups. aim of the study was to establish norm values for healthy german children for the 6 minute walk test. methods. the team of an occupational therapist and a study nurse were visiting schools. permission from the parents was give before the test. always just probands from one class were invited to participate. the test were performed according the international guidelines [3] . the demographic data of the probands were collected and the parents filled out a short survey regarding the physical activity and the health condition. children with chronic diseases, which decrease the stamina were excluded. up till now 611probands participated from the age 5 to 14 years. 343 of them were female. the mean 6 minute walk continuously increased with age (. tab background. juvenile idiopathic arthritis (jia) is the most common chronic disease in pediatric rheumatology which often results in foot impairments [1] . patients with jia are reported to have smaller pressure loads underneath the foot while walking [2] . the aim of the study was to analyze the peak plantar pressure distribution of a well described cohort of jia patients with an active symmetrical ankle joint arthritis and no history of foot involvement. [1] ) wurden in bezug auf therapie und outcome anhand der wallace-kriterien beurteilt: "active disease" (ad), "inactive disease" (id), "clinical remission under medication" (crm), "clinical remission off medication" (crom; [2] background. familial mediterranean fever (fmf) is one of the most common autoinflammatory diseases (aid). pathogenomic relevant mutations in the mefv gene show autosomal recessive inheritance, but co-dominant mutations have been described. we aimed to evaluate correlations between ethnic origin, phenotype and genotype for fmf patients in the german aid-net-registry. methods. we used two common scoring systems modified for children (mor et al., pras et al.) to assess disease severity in 243 fmf patients of the aid-net-registry. for the five most frequent mutations, we tested for a correlation of the genotype with the phenotype, mean crp and ethnic origin, respectively. furthermore, we evaluated the applicability of the two severity scores for children. results. among the 243 patients, we detected a total of 433 pyrin mutations and 22 different sequence variants, including one new mutation (p.gly488asp). the five most frequent alterations were p.met694val (55%, n=238), p.met680lle (12%, n=52), p.val726ala (10%, n=44), p.glu148gln (8%, n=34) and p.met694ile (2.3%, n=10). ethnic origin could be determined in 224 cases; the prevailing ancestry was turkish (83%, n=185), 8% (n=18) were lebanese. p.met694val in homozygous form (30%, n=73) was correlated with a more severe disease activity, based on the score by mor, as well as with a higher mean crp (74 mg/l, n=60, 31 mg/l, n=59) compared to patients without this mutation (p=0.01 and p<0.01, respectively). the score suggested by pras did not yield a significant genotype-phenotype correlation; indeed, the two scoring systems were inconsistent with each other (κ<0.07). although a typical distribution of mutations in different ethnic populations was obvious, this trend was not statistically significant, probably due to the divergent number of cases. conclusion. the homozygous p.met694val substitution was associated with a more severe disease activity. there was no origin-genotype correlation in this fmf population. the well-known severity scores for children (mor, pras) are inconsistent. the aid-net is working on a new scoring system. 3. all patients with rp should be investigated by capillaroscopy. capillaroscopy will be classified into "normal", "aspecific changes" or "scleroderma pattern". 4. all patients who have additional symptoms pointing to a definite connective tissue disease should be evaluated according to disease specific guidelines. 5. ana-negative and capillaroscopy-negative patients should be followed-up at least every 6 months. 6. ana positive patients without disease-specific antibodies and with negative capillaroscopy findings should be followed-up at least every 6 months. 7. ana and disease-specific antibody positive patients should have organ specific evaluation according to symptoms, examination and relevant to that particular disease e.g. patients who are ana and scl-70 positive may need organ specific evaluation for jssc as per the juvenile systemic sclerosis inception cohort protocol (www.juvenilescleroderma.com). 8. ana-positive patients, who have no disease specific antibody but have positive capillaroscopy results, should be followed-up at least every 3 months. 9. ana-negative patients with positive capillaroscopy result should be followed-up at least every 6 months. 10. the group could not reach an agreement regarding treatment, due to a lack of data for the paediatric age group. the group agreed that implementation of adult recommendations conclusion. the group made a suggestion for a standard of good clinical practice for rp in children. our aim is that this will facilitate a large multicentre prospective follow-up study of children with rp. background. chronic non-bacterial osteomyelitis (cno) is an inflammatory disorder of the skeletal system of unknown etiology. long-term follow-up and response to treatment data have rarely been reported. the aim of the study was to characterize the clinical, radiological, histological and laboratory data at juvenile cno onset, and to analyze the long term treatment response. methods. the course of disease of 95 juvenile patients with non-bacterial inflammatory bone lesions was evaluated retrospectively. clinical, radiological, histological and laboratory data were assessed at disease onset and for a median time of disease of 40 months. results. the mean age at disease onset was 11.7 years, the mean time between the first symptoms and the diagnosis of cno was 9 months. 84% of the patients had multifocal bone lesions. biopsy was performed in 80 patients. only when bone biopsy was taken within 12 months of symptom onset, cellular infiltrates could be observed. at later time points, fibrosis, hyperostosis and bone edema predominated. the initial treatment consisted of non-steroidal anti-inflammatory drugs (nsaids). 39% of the patients required second line therapy consisting of sulfasalazine and short term oral corticosteroids, 8% of the patients required bisphosphonates or tnf-blocking agents. the number of clinical lesions decreased to 50% within 3.1 months and reached 18.8% after 24 months of treatment. the number of radiological lesions, however, declined to only 66.5% after 24 months of treatment. in detail analysis of the tre-atment response revealed that initiation of sulfasalazine treatment in nsaid non-responders led to a significant and sustained decline of the clinical, as well as the radiological number of lesions. conclusion. the rapid clinical improvement in cno, following initiation of therapy with nsaids, is not accompanied by a likewise decrease of the number of radiological lesions. treatment with sulfasalazine is effective in childhood cno. background. exercise has a wide variety of beneficial health effects. it stimulates bone formation and maintains bone strength as well as decreases the risk of falls. moreover, exercise at regular intervals is also assumed to positively affect immune functions. conversely, in more than 50% of the astronauts during/after space flight and under simulated weightlessness immune functions are suppressed. to assess the effects of simulated weightlessness during the 2nd berlin bedrest study (bbr-2) on immunological parameters. furthermore, to compare the effects of two different exercise performances (resistive vibration exercise and resistance exercise without vibration). methods. 24 physically and mentally healthy male volunteers (20-45 y) experienced 60 days of six degree head down tilt bed rest. they were randomized to 3 groups: resistive vibration exercise (n=7), resistance exercise without vibration (n=8), inactive controls (n=9). blood samples were taken 2 days before bed rest, on day 19 and 60 after beginning of bed rest. composition of immune cells was analyzed by flow cytometry. cytokines and neuroendocrinologic parameters were analyzed by a multiplex suspension array/ elisa in plasma. general changes over time were identified by paired t-test, exercise-dependent effects by 2-group repeated measurements anova. results. for all cases pooled, the number of granulocytes (p<0.05), nkt cells (p<0.01) and hematopoietic stem cells (p<0.01) increased during the study; the concentrations of dhea (p<0.01) and eotaxin (p<0.05) decreased. different impacts of the specific types of exercise on the change over time were shown for lymphocytes, nk cells, nkt cells, tcell subpopulations and the concentrations of ip-10 and rantes. conclusion. we found immobilization/simulated weightlessness to significantly impact immune cell populations, and cytokine and neuroendocrine factor concentrations. exercise was able to specifically influence immunologic parameters. interestingly, these changes resemble those found during the aging process. background. novel therapies have made remission and low disease activity (lda) achievable goals in ra. we assessed the impact of treatment with subcutaneous abatacept or adalimumab on these goals and on functional and radiographic outcomes in ample (abatacept versus adalimumab comparison in biologic-naïve ra subjects with background methotrexate), the first head-to-head trial of biologics in ra patients with inadequate response to mtx (mtx-ir). methods. ample is a 2-year, phase iiib, randomized, investigator-blinded study. biologic-naïve ra patients with mtx-ir were randomized to receive 125 mg abatacept weekly or 40 mg adalimumab biweekly, combined with a stable dose of mtx [1] and radiographic non-progression (defined as change in modified total sharp score ≤2.8) were analysed in patients achieving or not achieving remission or lda at days 85 or 169. results. baseline clinical characteristics of abatacept and adalimumab treatment groups were balanced, as was clinical, functional and radiographic efficacy and safety at day 365 [1] . the proportions of patients meeting each of the remission criteria or lda at day 365 were similar for both groups, but significantly more patients achieved das28 (crp) remission compared to cdai, sdai or rapid3 remission, and the smallest proportion achieved boolean remission. compared to remission, a higher proportion of patients achieved lda. across all definitions of remission or lda, >60% of the patients achieving remission at days 85 and 169 were haq responders at day 365. more than 80% of patients achieving remission or lda at days 85 and 169 were radiographic nonprogressors at day 365. improvement in physical function and radiographic outcomes were consistent between the two treatment groups in both remission and lda populations (. tab.11). conclusion. through 1 year, patients treated with subcutaneous abatacept or adalimumab in ample achieved comparable rates of remission and lda. similar improvements in physical function and radiographic outcomes were observed. these data help to illustrate the relationship between remission, lda and functional and radiographic outcomes independent of treatment with subcutaneous abatacept or adalimumab. background. previous small studies suggest that responses to some immunizations may be attenuated by intravenous abatacept but remain clinically meaningful [1, 2] . we investigated the magnitude of response to pneumococcal and influenza vaccination in a larger number of patients receiving subcutaneous (sc) abatacept therapy. the objective of the study was to evaluate the antibody response to the standard 23-valent pneumococcal polysaccharide vaccine and the 2011-2012 seasonal influenza trivalent vaccine in adult patients with ra on sc abatacept and background dmards. these multicentre, open-label sub-studies of the 23-valent pneumococcal polysaccharide vaccine and seasonal influenza vaccine enrolled patients in the acquire (pneumococcal and influenza) or attune (pneumococcal) studies. patients were enrolled at any point during their sc abatacept treatment cycle after completion of ≥3 months' abatacept treatment. all patients received fixed-dose sc abatacept 125 mg/week with background dmards. a pre-vaccination blood sample was collected and vaccines administered, while continuing background sc abatacept and dmards. after 28±3 days, a post-vaccibackground. in real life, dosage increases are common with biologic agents [1] . intravenous abatacept is administered by patient body weight (10 mg/kg) 2 and 4 weeks after the first infusion and every 4 weeks the-reafter [2] totalling 8 infusions over the first 6 months. no adjustments to this schedule are recommended. abatacept retention rates, efficacy and safety over 12 months in action (abatacept in routine clinical practice) have been reported previously [3, 4] this study was designed to assess adherence to recommended dosing of abatacept over the first 6 months in action. methods. action is an ongoing, 2-year, international, non-interventional, prospective cohort of ra patients treated with intravenous abatacept. all patients on abatacept treatment for ≥6 months, and with infusion data available at initiation and at 6 months, were considered in this analysis. good adherence was defined as correct dose by patient body weight and number of actual-to-recommended infusions within the range 80-120% (i.e. 7-9 infusions). results. in total, 783/1120 (69.9%) patients received abatacept ≥6 months and had the infusion data available. most had established ra and failed ≥1 anti-tnf agent (87.5%). of 774 patients with body weight data available at initiation, 87.6% received the recommended initial dose, 6.5% a lower dose and 5.9% a higher dose than recommended. good adherence to the abatacept treatment schedule was found in 670/783 (85.6%) patients. over 6 months, 34.0% of patients received 7 infusions, 50.1% received 8 infusions and 1.5% had 9 infusions. change in dosage over time was assessed in 680/774 patients with data available at both time points. the majority of patients (86.6%) maintained the recommended dosage. 500/680 (73.5%) patients received abatacept at the recommended dose for body weight and at the recommended treatment schedule over 6 months. conclusion. in the real-world action study, adherence to the recommended abatacept treatment regimen over 6 months was good. few patients received changes in dose and/or frequency of administration over this time period. background. in rheumatoid arthritis (ra), synovial fibroblasts (sf) secrete large amounts of il-6, il-8 and matrix metalloproteinases (mmps) which are crucial for cartilage destruction. rasfs are sensitive to the action of cannabinoids and they express cannabinoid receptors type i and ii (cb1 and cb2), the vanilloid receptor (trpv1) as well as endocannabinoid degrading enzymes. cannabinoids are regarded as antiinflammatory and since anandamide (aea) is found in ra synovial fluid we investigated how this endocannabinoid affects adhesion, proliferation, and production of inflammatory mediators of rasf. methods. adhesion was assessed by the xcelligence system. proliferation was quantified by the amount of incorporated fluorescent dye into cellular dna. mmp-3 and cytokines were detected by elisa. in oasf, aea dose-dependently decreased the il-1β induced production of mmp-3 (by 23%) in a trpv1-mediated manner. il-6 and il-8 levels were only weakly modulated. in rasf however, aea decreased il-1β induced production of il-6 (23%), il-8 (18%) and mmp-3 (20%). the effects of aea were not inhibited by cb1, cb2 or gpr55 antagonists but were blocked by the trpv1 antagonist capsazepine. the inhibitory capacity of aea was enhanced by cyclooxygenase-2 inhibition in rasfs and oasfs, but was unaltered or even slightly reduced by faah inhibition. aea was even more potent in reducing above mentioned mediators when rasfs but not oasfs were incubated under hypoxic conditions and treated with tnf. furthermore aea increased adhesion of oasfs and rasfs to fibronectin. adhesion was modulated by cb1, gpr55, and trpv1 antagonists. combined faah and cyclooxygenase-2 blocked the stimulatory effect of aea on adhesion. proliferation was decreased by aea in rasfs and oasfs via a cyclooxygenase-2 but not via cb1, cb2 or trpv1 dependent mechanism. conclusion. in conclusion, aea promotes an antiinflammatory phenotype of rasfs and oasfs by activating trpv1. cb1, trpv1, and gpr55 act in concert to modulate adhesion of sfs and this is highly dependent on the intracellular concentration of aea. additionally, cyclooxygenase-2 metabolites of aea exert their anti-proliferative effects independent of cb1 and cb2. fc. it has been reported that lower levels of czp, compared to ada or ifx, are transferred from treated mothers to the neonate [1] . this discrepancy may be due to active transport of antibodies across the placenta thought to be mediated by the neonatal fc receptor (fcrn). however, anti-tnf binding to fcrn, and fcrn-mediated transcytosis have not been studied. the objective of this study is to quantify binding of czp, ifx, ada and eta to fcrn and to measure fcrn-mediated transcytosis. a biacore™ assay was used to determine binding of czp, ada and ifx to human fcrn. anti-tnfs were passed over an fcrn-coated chip .mdck-ii cells transfected with human fcrn were used to measure fcrn mediated transcytosis. the anti-tnfs and the control antibody (p146), which possessed a fc modified to prevent binding to fcrn, were biotinylated to allow visualization. the amount of each anti-tnf transcytosed across the cell layer over 4 hours was measured by msd assay. results. ifx (132 nm) and ada (225 nm) had high binding affinity to fcrn while the binding affinity of eta to fcrn was 5-10-fold lower (1500 nm). in contrast, czp did not bind to the fcrn with any measurable affinity. the levels of transcytosis seen with ifx and ada were 249.6 ng/ml and 159.5 ng/ml, respectively (mean of 3 experiments). transcytosis of eta (81.3 ng/ml) was lower than that of ada and ifx. in contrast, the level of czp transcytosis was significantly lower, at 3.2 ng/ml, than that observed with the other anti-tnfs and comparable to the control p146 (5.9 ng/ml). conclusion. czp didn't bind to fcrn and thus no fcrn-mediated czp transcytosis was detected. in contrast, ada and ifx had a relatively high binding affinity to fcrn and were actively transcytosed. eta showed lower binding affinity and transcytosis, but fcrn-mediated transport could still be measured. these results explain the previously observed active transport of anti-tnfs across the placenta seen in patients treated with ifx and ada, whereas only low levels were observed with czp [1]. background. anti-cyclic citrullinated peptide (ccp) status was reported previously as predictive of abatacept response [1] . predictors of retention with abatacept have not been published previously. this study was designed to identify predictors of abatacept retention after failing ≥1 biologic agent. in routine clinical practice) is an ongoing, 2-year, international, non-interventional, prospective cohort including patients with ra treated with intravenous abatacept [2, 3] . patients from canada, germany, greece and italy, where patient numbers were sufficient to explore between-country effects, were included. at data cut-off (february 2012), all patients had 1-year follow-up (interim analysis). abatacept discontinuations were reported by the investigator at any time point during follow-up. socio-demographics, disease characteristics and medical history at abatacept initiation, and previous and concomitant treatments were deemed potential predictive variables. clinically relevant variables and those with p≤0.2 (univariate analysis) were entered into a multivariate cox proportional-hazards regression model, adjusted for clustered data from one investigator. using backwards selection, variables with p≤0.1 were retained in the final model. . there were no interactions or effects of c-reactive protein level, rheumatoid factor status, type of previous anti-tnf failure, infection at initiation and abatacept monotherapy. sensitivity analysis, including all variables significant in univariate analysis, was consistent. conclusion. in this first report of real-world predictors of abatacept patient retention, anti-ccp positivity and failing <2 prior anti-tnf agents were associated with higher retention. differences in retention between some countries may reflect specificities in healthcare systems and populations. abatacept, a biologic agent with no contraindications or special warnings for cardiac comorbidity, seems to be a good option for these patients. weekly subcutaneous abatacept confers comparable onset of treatment response and magnitude of efficacy improvement over 6 months when administered with or without an intravenous abatacept loading dose 109 zeitschrift für rheumatologie suppl 2 · 2013 | methods. patients from the intent-to-treat populations of the acqui-re [2] and ample [3] studies randomized to subcutaneous abatacept plus mtx were included. all patients received fixed-dose subcutaneous abatacept 125 mg/week; in acquire but not ample, patients also received an intravenous loading dose (~10 mg/kg based on weight range) on day 1. for this post-hoc analysis, assessments included acr20 and haq-di response (improvement ≥0.3) over 6 months, with patients who discontinued considered non-responders. mean changes from baseline over 6 months in das28 (crp) were assessed in patients with das28 >5.1 at baseline (last observation carried forward) to account for differences in baseline disease activity between the two studies. results. all patients were biologic naïve at baseline, with mean disease duration of 7.6 and 1.8 years, das28 (crp) 6.2 and 5.5, and haq-di 1.72 and 1.5 in acquire and ample, respectively. efficacy was compared throughout the study. for patients treated with subcutaneous abatacept with and without an intravenous loading dose, acr20 response rates were similar (. tab.18). haq-di response rates were also similar with and without the intravenous loading dose (. tab.18). for the overall populations, mean (standard deviation [sd]) changes from baseline to day 169 in das28 were −2.57 (1.30) and −2.09 (1.38) in acquire and ample, respectively. for patients with baseline das28 >5.1, mean (sd) changes in das28 from baseline to day 169 were −2.65 (1.29) and −2.49 (1.35) in acquire and ample, respectively. conclusion. time to onset and magnitude of acr20 and haq-di responses and das28 improvements were generally similar with subcutaneous abatacept with or without intravenous loading in patients with ra and an inadequate response to mtx. the findings from this posthoc analysis suggest that subcutaneous abatacept can be given effectively without an intravenous abatacept loading dose. background. ra is associated with pain and impairment of physical function, significantly impacting a patient's health-related quality of life (hrqol) and ability to perform daily activities. patient-reported outcomes (pros) related to hrqol and daily activity have become an essential part of assessment in ra. we continue to report here comparative findings from pros assessed with subcutaneous abatacept or adalimumab on background mtx in the first head-to-head study, ample. we compared changes in pros at 1 year in patients with ra treated with abatacept or adalimumab, both on background mtx. methods. ample is a phase iiib, randomized, investigator-blinded study of 24 months' duration. biologic-naïve patients with active ra and inadequate response to mtx were randomized to either 125 mg abatacept weekly or 40 mg adalimumab biweekly in combination with mtx. pros evaluated through day 365 included: hrqol, assessed using short form-36 (sf-36; including physical and mental component summary subscores [pcs and mcs]); activity limitation over the previous 30 days, using the activity limitation questionnaire (alq; [1] ); productivity, using the work productivity and activity impairment questionnaire for ra [2] ; physical and psychosocial independence, captured using items from haq, sf-36 score; and alq [3] . other pros previously reported from ample include: patient pain, patient global assessment, fatigue, and physical function [4] . all efficacy analyses were done using the intent-to-treat population, which included all patients who were randomized and received at least one dose of study drug. baseline characteristics were analysed descriptively and changes in pros from baseline were assessed using ancova. results. baseline demographic and clinical characteristics of the abatacept and adalimumab treatment arms were similar. improvements in all domains of the sf-36, including pcs and mcs observed at day parameter baseline woche16 woche32 itt-gesamt das28, mw ± sd 5,7±1,0 (n=507) 2,6±1,3 (n=423) 2,7±1,4 (n=150) vas da pat., mw ± sd 63,3±20,6 (n=509) 26,3±22,5 (n=429) 28,9±25,3 (n=155) sjc28, mw ± sd 8,3±4,9 (n=509) 3,2±3,6 (n=425) 3,0±3,9 (n=152) vas schmerz, mw ± sd zielsetzung der ole-studie beinhaltete die beurteilung der verträglichkeit und der wirksamkeit von czp. die retentionsraten sowie die wirksamkeit wurden bis woche 280 und die verträglichkeitsdaten bis woche 364 beobachtet. in die verträglichkeitsanalyse wurden alle pat einbezogen, die in die ole-studie eintraten und czp erhielten (n=402; n=276 kombitherapie; n=126 monotherapie), einschließlich der plazebo/czp-patienten, die die ausgangsstudien erfolgreich abgeschlossen/abgebrochen haben. bezüglich der wirksamkeit wurden folgende analysen vorgenommen: 1) czp pat, die die ausgangsstudien erfolgreich beendet haben und zu irgendeinem zeitpunkt während der ausgangsstudien oder ole-studie andere dmards eingenommen haben (n=123; kombitherapie completer); 2) czp pat, die die fast4ward studie erfolgreich beendet haben und zu keinem zeitpunkt andere dmards eingenommen haben (n=48; monotherapie completer). ergebnisse. verteilung und häufigkeit der unerwünschten ereignisse (ue), einschließlich der reaktionen an der injektionsstelle (ereignisse/100 patientenjahre: monotherapie 1,4, kombitherapie 0,9) und der schwerwiegenden unerwünschten ereignisse (sue) waren mit dem vergleichbar, was bisher für czp berichtet wurde (. tab.21) . das auftreten von schwerwiegenden infektionen (si) und malignitätsraten war niedrig. es wurden 11 todesfälle berichtet: 7 kardiovaskuläre ereignis-se, 2 infektionen, 1 unfall und 1 tumorerkrankung. die retentionsraten der pat, die die ausgangsstudien erfolgreich beendet haben, waren zur w280 in der czp monotherapie-(24/48, 50%) und der czp kombitherapie-gruppe (67/123; 55%) vergleichbar. der durchschnittliche das28-3(crp)-wert und dessen abweichung vom baseline-wert der ausgangsstudien zum zeitpunkt des eintrittes in die ole-studie und nach 280 w der monotherapie-completer und der kombitherapie-completer, sowie die zugehörigen haq-werte sind in . tab.22 dargestellt. schlussfolgerung. vorliegende ole-studie konnte das günstige risiko-nutzen-profil der czp-monotherapie bestätigen. die langzeitwirksamkeitsdaten zeigten keine unterschiede zwischen pat, die czp als monotherapie erhielten und pat, die czp in kombination mit anderen dmards erhielten. background. rheumatoid arthritis (ra) is the most common disease of joints that non-or deficiently treated leads to functional loss and premature cardiovascular death within years. but nearly 50% of the ra patients fail to treatment with tnfα-inhibitor (tnfi) indicating a switch to rituximab (rtx). the urgency of personalized promising treatment in time presupposes predictive parameter. rheumatoid factor (rf) and anti-citrullinated protein antibodies (acpas; especially accp) are shown to be better diagnostic than less theranostic biomarkers. in that context we investigated the role of antibody subtypes against mutated citrullinated vimentin (amcv) that determine response outcome in rtx-treatment. methods. a cohort of 50 only amcv igg positive ra patients was tested for amcv subtype igm and iga (additionally for rf igg, igm, iga and accp igg) by elisa at baseline (after failure to first approach with tnfi) and at week 24 (after first rtx cycle). responders were characterized by a difference in their das28 of ≥1.2 (eular good-response) between baseline and week 24. the cohort comprises 37 responders (rr) and 13 non-responders to rtx (nrr). results. amcv igg, igm and iga showed higher treatment related decreases compared to rf and accp ig subtypes and additionally even diverged in both groups depending on response outcome: especially amcv iga exhibited a higher mean titer decline of rr by 67% at lower baseline titers (90.14 to 29.84 u/ml) and a mean titer increase of nrr by nearly 20% at higher baseline titers (182.51 to 218.57 u/ml). at baseline rr displayed relatively more negative iga titers (68%; n=25/37) than nrr, who in return showed more iga positive titers (69%; n=9/13). amcv iga positive patients were more likely to show positively for rf iga (80%) and igm (70%), what could be inversely detected for iga negative patients with seronegativity of rf iga (68%) and igm (60%). conclusion. amcv immunoglobulin subtypes showed treatment dependent changes contrary to already known antibodies (accp). especially amcv iga reflects response outcome: amcv iga negativity at baseline and decreasing titers during treatment are predictive for good eular-response to rtx. einleitung. im rahmen der abklärung eines unter tocilizumab-therapie aufgetretenen arzneimittelexanthems erfolgte die bestimmung von c3c und c4 -beide parameter waren erniedrigt. bei recht geringer und nur kurz andauernder ausprägung des exanthems wurde die therapie komplikationslos fortgeführt. die komplementfaktoren wurden im verlauf bestimmt und blieben erniedrigt. im weiteren verlauf erfolgte die konsekutive messung bei weiteren patienten. methoden. nephelometrische bestimmung von c3c und c4 im serum vor und während der therapie mit tocilizumab (jeweils vor der nach 4 wochen anstehenden infusion) bei patienten mit gesicherter rheumatoider arthritis (rf+, ccp+). ergebnisse. c3c-und c4-komplement wurden bei 13 konsekutiven patienten mit rheumatoider arthritis vor und unter tocilizumab-therapie bestimmt. bei allen patienten fielen sowohl c3c, als auch c4 unter der therapie mit tocilizumab (8 mg/kg kg) ab. 8/13 patienten hatten eine c3c-erniedrigung (bestimmter wert unterhalb des laborinternen normbereichs). 4/13 patienten hatten eine c4-erniedrigung (bestimmter wert unterhalb des laborinternen normbereichs). drei patientinnen entwickelten unter der therapie ein exanthem, davon hatten 2 eine komplementerniedrigung. keine "offensichtlich" erhöhte infektneigung in abhängigkeit von komplementspiegeln. bei verlängerten infusionsintervallen aufgrund von infekten zeigte sich, dass der effekt von tocilizumab auf die komplementspiegel reversibel ist. durch blockade des il-6-rezeptors tocilizumab kann ein erworbener komplementmangel induziert werden. ähnliche daten wurden im rahmen einer pilotstudie an sle-patienten erhoben, die mit tocilizumab behandelt wurden. der effekt ist bei der rheumatoiden arthritis nicht vorbeschrieben. der genaue umfang des komplementmangels ist bisher nicht untersucht (andere bestandteile der kaskade?) wurde in der sle-studie ausführlicher untersucht. da die verschiedenen komplementbestandteile erniedrigt waren wurde auf eine synthesestörung und nicht auf einen gesteigerten verbrauch geschlossen, was auch in dieser kohorte der fall zu sein scheint. der erworbene komplementmangel könnte einen teil der infektiösen komplikationen unter der therapie erklären. eine korrelation ist aber aufgrund der geringen fallzahl nicht möglich. schlussfolgerung. anhand dieser studie konnte eine exzellente korrelation zwischen den parametern der dxr und des bx verifiziert werden. mittels der neu entwickelten voll digitalisierten bx-technik ist somit eine quantifizierung der periartikulären demineralisation möglich und als surrogatparameter der radiologischen progression bei einer ra eingesetzt werden. 3 jahre, die ra bestand im median seit 7,8 jahren. 74,7% der patienten waren mit tnf-alpha-blockern vortherapiert, 23,7% ausschließlich mit dmards. der mittlere das28 lag zur baseline bei 5,3. zur woche 76 zeigten 34,0% der patienten eine das28 remission (<2,6) und 29,1% bzw. 56,9% der patienten ein gutes bzw. moderates ansprechen gemäß eular-kriterien. über den beobachtungszeitraum stieg der anteil der tcz-monotherapiepatienten von 40,1% auf 58,4%. die mtx-komedikation sank im gleichen zeitraum um 13,3%. 21,9% der patienten, die tcz zunächst zusammen mit einem dmard erhalten haben, konnten dieses absetzen. tcz zeigte in der mono-und kombinationstherapie eine vergleichbare wirksamkeit: 18,3% bzw. 20,3% der patienten erreichten eine cdai remission (≤2,8). der anteil von patienten ohne glucocorticoid(gc)-begleittherapie stieg über den beobachtungszeitraum um 8,2% auf 25,6% an, der anteil mit einer tagesdosis ≤5 mg auf 76,2%. bei 49,4% war eine reduktion der gc-dosis möglich, nur bei 10,1% war eine erhöhung notwendig. bei 14,5% der patienten, die zur bl mit gc behandelt wurden, konnten diese komplett abgesetzt werden. die mittlere gc-tagesdosis verringerte sich kontinuierlich von 9,2 (bl) auf 5,9 mg/d (w76). schlussfolgerung. diese interimsanalyse der nichtinterventionellen studie ichiban zeigt bei den ersten 490 patienten mit mittelschwerer bis schwerer ra über die bisherige beobachtungsdauer von 76 wochen deutliche verbesserungen der aktivitätsparameter, sowie eine reduktionen der begleitenden dmard-therapien und des bedarfs von glucocorticoiden unter behandlung mit tcz. vergleichbar mit den kontrollierten studien ist die tcz-monotherapie auch unter praxisbedingungen der kombination mit dmards ebenbürtig. diese anhaltende wirksamkeit wird erstmals in rheumatologischen praxisdaten für den langzeitverlauf von 1,5 jahren gezeigt. zeitschrift für rheumatologie suppl 2 · 2013 | einleitung. die arteriosklerose (as) steht als häufigste todesursache im besonderen fokus der medizinischen forschung. neuere erkenntnisse weisen auf einen starken zusammenhang zwischen parametern der systemischen entzündung und der pathogenese der as hin. patienten mit rheumatoider arthritis (ra) haben daher ein stark erhöhtes kardiovaskuläres risiko. ziel: untersuchung des zusammenhangs zwischen verschiedenen ra-krankheitsspezifischen risikofaktoren und dem auftreten einer arteriosklerose bei ra-patienten. methoden. 139 ra-patienten, davon 77% weiblich, 64±11,6 jahre alt, wurden hinsichtlich der krankheitsaktivität (krankheitsdauer 13,8±0,9; das28 3,5±0,1; serum-crp 8,1±0,9 mg/dl,; anti-ccp-antikörper 80,4±8,8 u/ml, radiologisches stadium 1,8±0,1; davon 50,5% mit erosionen), sowie klassischer kardiovaskulärer risikofaktoren der as erfasst, welche durch den score-wert (systematic coronary risk evaluation) zusammengefasst wurden. zur as darstellung wurde eine carotis-duplexsonographie mittels eines 7 mhz-schallkopfes (ge vivid 7 pro) durchgeführt. die mittlere intima-media-dicke (imd) der a. carotis communis wurde durch ein softwaregestütztes messverfahren ermittelt. ergebnisse. plaques waren bei 54 patienten (39%) nachweisbar. diese korrelierten mit einer erosiven form der ra (p=0,05), einer längeren krankheitsdauer (p=0,03) und höheren anti-ccp-antikörpern (p=0,02). die mittlere imd betrug 0,67±0,11 mm. je ausgeprägter die radiologischen veränderungen sind, umso höher war die wahrscheinlichkeit der plagues (p=0,02). mittels altersadjustierter partieller korrelationsanalyse wurde der das28 als altersunabhängiger einflussfaktor auf die imd ermittelt (p=0,02). mittel-und hochgradige stenosen zeigten sich bei fünf ra-patienten (3,4%), welche ausnahmslos eine erosive verlaufsform aufwiesen. normalbefunde stehen in zusammenhang mit einem crp-wert unter 5 mg/dl (p=0,04). auch die traditionellen kardiovaskulären risikofaktoren haben signifikanten einfluss auf as. der score-wert erwies sich als äußerst verlässlicher prädiktor für plaques (p<0,01), imd-verdickung (p=0,01) und stenosen (p<0,01). durch elimination der traditionellen risikofaktoren mittels partieller score-adjustierter korrelationsanalyse bestätigte sich erneut die assoziation von pathologischen ultraschallbefunden mit dem das28 (p=0,03). schlussfolgerung. die erhebung klassischer risikofaktoren bei ra-patienten ist unerlässlich. die nutzung des score-werts als screening-parameter ist besonders effektiv. zusätzlich sollten parameter der krankheitsaktivität von ra zum management von arteriosklerose herangezogen werden. besonders aussagekräftig hierfür sind der das28, ein erosiver krankheitsverlauf, die crp-werte und die erkrankungsdauer background. apremilast, an oral small molecule specific inhibitor of phosphodiesterase-4, works intracellularly to modulate inflammatory mediators. the palace 1-3 trials compared the efficacy and safety of apremilast vs placebo in patients with active psa despite prior dmards and/or biologics. the overall safety and tolerability of apremilast was assessed in a pooled analysis of the palace 1, 2 and 3 placebo-controlled phases. methods. safety data was pooled from 3 phase 3, randomized, placebo-controlled studies; patients with active psa despite prior dmards and/or biologics were randomized 1:1:1 to placebo, apremilast 20 mg bid (apr20), or apremilast 30 mg bid (apr30) stratified by baseline dmard use. at week 16, patients with <20% reduction in swollen and tender joint counts were required to be re-randomized (early escape) to apr20 or apr30 (placebo group) or remained on initial apremilast dose through week 24. stable concurrent dmard therapy was allowed (mtx, sulfasalazine, leflunomide, or combination). the analysis comprises data from the placebo-controlled periods (weeks 0-24). results. 1493 patients were randomized to placebo (n=495), apr20 (n=501), or apr30 (n=497) and included in the safety population. baseline demographic and disease characteristics and prior/concurrent therapy were comparable across treatment groups; 22.4% had prior biologic exposure. adverse events (aes) occurred in 47.5% (placebo), 61.5% (apr20), and 60.8% (apr30) of patients. aes occurring in ≥5% of any treatment group were diarrhea, nausea, headache, and urti (. tab.27); most occurred within the first 2 weeks of treatment and nearly half resolved within 2 weeks. of patients with these aes, most (93-96%) were mild or moderate. rates of discontinuation due to aes were low: 4.2% (placebo), 5.6% (apr20), and 7.2% (apr30). serious aes occurred in 3.8% (placebo), 3.4% (apr20), and 3.8% (apr30) of patients. one death occurred (apr20) due to multiorgan failure not suspected to be treatment-related. no cases of serious systemic opportunistic infections, lymphoma, vasculitis, or reactivation/de novo tb were reported. there were no clinically meaningful differences between apremilast and placebo in terms of major cardiovascular aes, changes in blood pressure, malignancies, or effects on laboratory measurements. conclusion. apremilast was generally well-tolerated with no new safety concerns identified compared with the known profile. the aim of the current study was to investigate the relationship between worsening of functional status, clinical disease parameters and radiographic spinal progression over two years in patients with early axial spondyloarthritis (axspa). methods. in total, 160 patients with early axspa (91 with as and symptom duration ≤10 years, and 69 with non-radiographic axspa (nr-ax-spa) and symptom duration ≤5 years) from the german spondyloarthritis inception cohort (gespic) were included in the current analysis based on the availability of radiographic data and data on the functional status at baseline and after 2 years of follow-up. spinal radiographs were scored according to the modified stoke ankylosing spondylitis spinal score (msasss). functional status was assessed by the bath ankylosing spondylitis functional index (basfi), and clinical disease activity by the bath ankylosing spondylitis disease activity index (basdai). results. basfi worsening in ≥1 point after 2 years (n=44, 27.5%) was significantly associated only with higher basdai worsening over 2 years in comparison to those without functional worsening: 1.2±1.4 vs -0.6±1.6, p<0.001. basfi worsening by ≥2 points (n=20, 12%) was, however, associated not only with basdai change (1.5±1.6 vs -0.3±1.6, p<0.001), but also with a higher rate of radiographic spinal progression measured by the proportion of patients with msasss worsening by ≥2 units (35.0% vs. 13.6% in patients without basfi worsening, p=0.024), or with new syndesmophyte formation (25.0% vs. 6.4%, p=0.018). importantly, in the multivariate analysis both basdai increase and progression of structural damage in the spine remained statistically significantly associated with basfi worsening. no other disease-related parameters (e.g. sex, hla-b27 positivity, symptom duration etc) were found to be significantly associated with basfi worsening over two years. conclusion. in this prospective study we could demonstrate that only 2 factors were significantly associated with worse functional outcome over two years in patients with early axspa: 1) increase of disease activity and 2) progression of structural damage. elevated serum vascular endothelial growth factor is highly predictive for radiographic spinal progression in patients with axial spondyloarthritis who are at high risk for progression background. vascular endothelial growth factor (vegf) is an essential mediator of the endochondral ossification and, therefore, might play a pathogenetic role in the process of syndesmophyte formation in axial spondyloarthritis (axspa). the aim of the study was to investigate the role of serum vegf as a predictor of radiographic spinal progression in patients with axspa. methods. altogether 172 patients with definite axspa [95 with ankylosing spondylitis (as) and 77 with non-radiographic axspa] from the german spondyloarthritis inception cohort (gespic) were included in the current study. radiographic spinal progression was defined as 1) worsening of the modified stoke ankylosing spondylitis spine score (msasss) by ≥2 units after 2 years, and 2) development of a new syndesmophyte or progression of existing syndesmophytes after 2 years. serum vegf levels were detected at baseline. results. mean baseline vegf values were significantly higher in patients with msasss worsening by ≥2 units after 2 years (n=22) as compared to those without progression (562±357 vs. 402±309 pg/ml, respectively, p=0.027) and in patients with syndesmophyte formation/ progression (n=18) as compared again to those without progression (579±386 vs. 404±307 pg/ml, respectively, p=0.041). area under the curve (auc) was 0.646, p=0.027 for the msasss worsening ≥2 units and 0.648, p=0.041 for syndesmophyte formation/progression. importantly, the performance of vegf as a predictor of radiographic spinal progression was clearly in patients who were already at high risk for such a progression due to the presence of syndesmophytes at baseline (n=48): auc was 0.812, p=0.001, and 0.772, p=0.003, respectively. vegf serum level of >600 pg/ml in high-risk patients had a sensitivity of 53%, a specificity of 97%, and an odds ratio (or)=36.6 (95%ci 3.9-341.5) as a predictor of msasss worsening by ≥2 units over 2 years. the same serum level of results. immediately after the second session of plasmapheresis, therapy with infliximab 5 mg/kg resumed. after 2 weeks of hospitalization with repeated administration of infliximab had good dynamics (bas-dai 5.6, asdas (crp) = 3.8, basfi 7.8), significantly reduced pain in the joints and spine, stiffness, increased mobility in the joints and spine. the treatment continued: holding plasmapheresis followed by infliximab. after 6 infusions patient experienced a good effect -basdai 3.6, asdas (crp)=2.2, basfi 6.2. conclusion. plasmapheresis in some patients could be effective by reducing activity and dealing with secondary tnf inhibitors failure, since this procedure deletes the macromolecular blood proteins, including tnf-, igg antibodies, and circulating immune complexes results. there were still signs of osteitis in sacroiliac joints in 5 patients at week 24, in 1 patient the mri-determined sacroiliitis has resolved completely. the patient has improved clinically and fulfilled asas40 improvement criteria. there was a minor decrease in sparcc sacroiliitis score (from 16 to 10) in 5 patients at week 24, indicating reduction of inflammation in sacroiliac joints. sparcc sacroiliitis score stayed the same in the remained patient. conclusion. rituximab may be of some benefit in decreasing mri-evident sacroiliitis in patients with highly active as, even in patients in whom tnf-α inhibitors have failed. background. despite the differences in the pathogenesis of ra and as, neck pain is a frequent clinical symptom in both diseases. we evaluated the correlation between subjective reports of neck pain and objective signs of inflammation as assessed by f bone marrow edema (bme) on mri in ra and as patients. methods. stir-mri of the cervical spine of 40 patients (34 ra, 6 as) were included. mris were scored by two blinded readers using a recently published mri scoring system, with quantification of the extension of bme in the atlantoaxial region, corpus, facet joints and processus spinosus of all cervical vertebrae, ranging from 0-57 points. the presence or absence of degenerative changes was also recorded. conclusion. the majority of patients with ra and as had objective signs of bme but also degenerative changes on mri at different cervical locations. assessment of bme in the atlantoaxial region is important in clinical practice, in addition to degenerative changes, since its presence seems to influence the intensity of neck pain reported by these patients. x. baraliakos , 13 having mri data at w94. of these 13, ten were treated with secukinumab and 3 with placebo in the core study. mris were rescored for this study. asspimri-a scores and the occurrence of vertebral edges (ve) inflammatory and fatty lesions were evaluated by an independent blinded reader. results. all 13 pts completed this exploratory mri substudy. in pts receiving 2×10 mg/kg secukinumab followed by 14×3 mg/kg (n=10) secukinumab, spinal inflammation was reduced compared to bl at w28 -similar to the results of the core study -and this reduction was sustained up to w94 (abb. 1). also in 3 pts who had initially received placebo switching to secukinumab at w28, mri inflammation at w94 was reduced. of the 920 ves evaluated, the proportion of ves with inflammatory lesions was reduced from 9.9% (n=91) at bl to 3.7% (n=34) at w28 and 3.6% (n=33) at w94. in contrast, the proportion of fatty lesions at bl (13.5%, n=124) remained largely unchanged at w28 (14.3%, n=132) and w94 (13.7%, n=126). secukinumab reduced mri inflammation at w28 and w94. conclusion. mri analysis suggests that the il-17a inhibitor secukinumab can reduce spinal inflammation and this effect may be sustained for up to 2 years. unlike reports with tnf blockers, secukinumab appeared to leave the proportion of fatty lesions unchanged. the potential impact of these preliminary findings on radiographic progression under secukinumab therapy will be studied in larger trials. schlussfolgerung. es zeigen sich keine signifikanten unterschiede in der krankheitsaktivität der beiden gruppen (vor einleitung der ada-therapie nach dmard-und nach anti-tnf-versagen). auch bei der patientengruppe mit mehreren vortherapien mit tnf-inhibitoren können keine signifikanten unterschiede in der ausprägung der erkrankung nachgewiesen werden. im trend wurde ein früheres einsetzen der haut-und gelenkmanifestation sowie eine stärkere systemische entzündungsreaktion in den patienten mit vorheriger tnf-therapie festgestellt werden, während die dauer der erkrankung und der bmi mit den charakteristika der patienten mit ausschließlicher dmard-vortherapie vergleichbar sind. long-term (52-week) results of a phase 3, randomized, controlled trial of apremilast, an oral phosphodiesterase 4 inhibitor, in patients with psoriatic arthritis (palace 1) background. apremilast, an oral phosphodiesterase 4 inhibitor, works intracellulary to modulate a network of pro-and anti-inflammatory mediators. the palace 1 study assessed the efficacy and safety of apremilast in patients with active psoriatic arthritis (psa) despite prior dmards and/or biologics. methods. patients were randomized 1:1:1 to placebo, apremilast 20 mg bid (apr20), or apremilast 30 mg bid (apr30). at week 16, patients with <20% reduction from baseline in swollen/tender joint counts were required to be re-randomized (early escape) to apr20 or apr30 (placebo group), or remained on their initial apremilast dose. at week 24, all remaining placebo patients were re-randomized to apr20 or apr30 through week 52. results. 504 patients were randomized. at week 16, significantly more apr20 (31.3%; p=0.0140) and apr30 patients (40.0%; p<0.0001) achieved an acr20 vs placebo (19.4%). at week 52, all patients had a minimum 28 weeks of apremilast exposure. response to apremilast was generally maintained over the treatment period. at week 52, acr20 was achieved by 63.0% (apr20) and 54.6% (apr30) of patients (table) . exposure-adjusted incidence rates for adverse events (aes), severe aes, and serious aes were comparable between 0-24 and 0-52 weeks. the proportion of patients remaining on apremilast to week 52 who first reported the most common gi disturbances (e.g., diarrhea, nausea, and vomiting) after week 24 was low (ranging from 0.6-3% for apr20 and 0-1.8% for apr30). there were no clinically meaningful laboratory findings with exposure up to 52 weeks. no deaths beyond the 1 previously reported in the 0-24 week period were observed in the 24-52 week period. no safety signals with respect to major cardiac events, malignancies, and opportunistic infections were observed, consistent with the 0-24 week period. no cases of lymphoma, tuberculosis, or tuberculosis reactivations were reported for the 52-week period (. tab.30). conclusion. apremilast administered to patients with psa beyond 24 weeks continued to demonstrate meaningful clinical response. for patients who completed 52 weeks of the study, acr20 response rates up to 65% were observed. apremilast continued to be well tolerated with an acceptable longer-term safety profile. methods. to identify how conventional cd4+ and cd8+ t cells and regulatory t cells are recruited into the inflamed kidneys in ln, serum and urine samples of 98 sle patients were analyzed for 18 chemokines using multiplex assays. based on the assay's results a group of 8 corresponding chemokine receptors (ccr1-6, cxcr3 and cxcr6) was chosen, whose frequencies on urinary t cells were subsequently determined in 9 patients with acute ln by flowcytometry. results. 12 chemokines (ccl2, ccl3, ccl4, ccl5, ccl7, ccl8, ccl11, ccl20, cxcl9, cxcl10, cxcl16 and cx3cl1) were significantly elevated in the urine of patients with active ln when compared to the control group. the other 6 chemokines (ccl1, ccl17, ccl22, cxcl1, cxcl5) and cxcl11 showed no significant differences between the groups. ccr5 and cxcr3 were the most prominent receptors on both urinary cd4+ and cd8+ t cells, although cd4+ t cells also expressed high amounts of ccr4 and ccr6. however, when compared to t cells in the blood, urinary cd4+ t cells showed significantly higher expression of all examined chemokine receptors but ccr2 while urinary cd8+ t cells only had higher expression of ccr1 and ccr5. the chemokine receptor expression on cd4+foxp3+cd127-regulatory t cells (treg) differed from conventional cd4+ t cells as well. treg expressed significantly more ccr4 and significantly less cxcr6. conclusion. ccr5 and cxcr3 are the primary receptors in the mechanism of recruiting t cells into the inflamed kidney. key chemokines are ccl3, ccl4, ccl5 and ccl8 as well as cxcl9 and cxcl10. however, at least for cd4+ t cells, there are secondary pathways of recruitment involving ccr4/ccl2 and ccr6/ccl20. also, treg recruitment seems to rely more on ccr4 than that of conventional cd4+ t cells. methods. observe is a multicenter, retrospective medical chart review study. rheumatologists from german academic and non academic centers who treat >10 sle patients annually and have >5 years of practice experience were randomly recruited. physicians identified consecutively all their adult sle patients who had received belimumab as part of usual-care. index date was the first belimumab infusion date. the primary outcome was the change in overall sle disease manifestations 6 months after index date based on physician judgment. the overall response rates as well as reasons for early treatment discontinuation within 6 months were assessed. changes in formal disease area indices, e.g. selena-sledai if available and changes in oral steroid dose are also reported. results. previous analyses from us patients treated with belimumab have described significant clinical improvement across relevant organ systems based on clinical judgment and formal disease activity indices and marked reductions in corticosteroid use in patients that received at least 8 infusions of belimumab. the current study is the first description of patient characteristics and outcomes after 6 months of therapy with belimumab outside of the us. it is also the first time overall responder rates and reasons for discontinuation with belimumab have been described in a real world setting. the study provides insights into the effectiveness and safety of belimumab in an ex-us clinical setting. larger, prospective observational studies are needed to confirm the results. commercial support grant disclosure: research funded glaxosmithkline. background. toll-like receptor 9 (tlr-9) signaling is considered to play an important role in b cell hyperreactivity in sle. b cells from slepatients express significantly more tlr-9 than those from healthy donors (hd), especially if patients have positive dsdna-antibodies and high disease activity. tlr-9 stimulation of b cells is tightly linked to their differentiation into plasma blasts and memory cells. the objective of this study was to analyze in a comprehensive manner the effect of tlr-9 signaling on cytokine production by b cells from sle-patients, in comparison to b cells from hd, and in relation with disease activity. methods. b cells from 19 sle-patients and 13 hd were stimulated in vitro using cpg for 48 hours, and culture supernatants were then tested for 28 cytokines and chemokines (bio-plex). the cytokine responses were compared between both groups. in addition, within sle patients, the patterns of cytokines produced by b cells were compared with indices of disease activity. results. cpg-stimulation significantly increased cytokine production (24 out of 28 parameters; p<0.05) compared to baseline. striking increases were found for il-1ra (94±40 pg/ml), il-6 (431±225 pg/ml), il10 (72±37 pg/ml) and ip-10 (361±289 pg/ml; p<0.001). there was no significant difference between both groups. remarkably, production of il-2, il-4, il-7, il-12p70, il13, il-15, il-17a, eotaxin, basic fgf, g-csf, gm-csf, ifn-γ, ip-10, mip-1α, and vegf correlated inversely with the sledai (p<0.05) and even more (additionally il-1β, il-1ra, mip-1β and tnf-α) with anti-dsdna antibody titers. the frequency of cd27+ memory b cells showed a positive correlation between the production of ip-10 and tnf-α in sle, whereas the levels of il-1β, il-7, mip-1α, and mip-1β showed a positive correlation with cd27+ b cells in hd. conclusion. the current data indicate hitherto unknown perturbations of cytokine/chemokine production by b cells in active sle. the inverse correlation of cytokines/chemokines produced by b cells from sle patients with sledai and anti-dsdna titer suggests that the known enhanced b cell proliferation and differentiation upon tlr9-stimulation possibly diminishes cytokine production. background. several cytokines, including ifn-γ, il-18, il-12, and il-23 have been implicated in the pathophysiology of autoimmune disease. il-18, a potent inducer of ifn-γ, enhances th1 responses that are thought to be synergistic and dependent on il-12. we tested the hypothesis that intra-renal il-18 mediates kidney and systemic disease in mrl-faslpr mice. methods. by constructing il-12p40/il-23-/-mrl-faslpr mice and using an ex-vivo gene transfer to deliver il-18 intra-renally, we determined that il-18, independent of il-12 and/or il-23, incites kidney disease in mrl-faslpr mice. moreover, we provide the novel finding that local intra-renal il-18 mediates systemic disease (lung pathology, systemic auto-abs). results. thus, our data indicate that il-18 is a potential therapeutic target for immune mediated kidney and systemic disease in mrl-faslpr mice. using a caspase-1 inhibitor, that inhibits the release of active il-18 and il-1β, we successfully treated kidney (improved renal function, pathology) and systemic disease (skin lesions, lymphadenopathy, and splenomegaly) in mrl-fas lpr mice, while administration of an il-1 receptor antagonist did not influence disease progression. probing further we found that inhibition of il-18 activation results in an amelioration of lupusnephritis by a reduction of intra-renal infiltrating leukocytes (macrophages and t cells) and reduced activation of these leukocyte populations. moreover, caspase-1 inhibition resulted in decreased inf-y and il-17 production, indicating an altered balance of th17 and th1 cell responses in this model. conclusion. taken together, our findings indicate that il-18, independent of il-1β, il-12 and/or il-23, is the major mediator of kidney and systemic disease mrl-faslpr mice. therefore, caspase-1 inhibition is a potential therapeutic target for autoimmune disease in the mrl-faslpr mice. background. in the treatment of giant cell arteritis (gca) glucocorticoid-related adverse effects occur frequently, particularly in patients with relapsing disease. a 50-year-old woman presented with a 2 month history of fever, chills, arthralgias and cephalgias and markedly elevated serum inflammatory markers. whereas further evaluation including ultrasound of the temporal arteries was unremarkable, a positron emission tomography-computed tomography (pet-ct) demonstrated an intense fluorodeoxyglucose uptake of the aorta, the subclavian, carotid and femoral arteries. gca was diagnosed and treatment with high dose prednisone was begun. results. because of disease flares at prednisone dosages below 20 mg/ day and the occurrence of vertebral fractures, cyclophosphamide and methotrexate (mtx) were added as glucocorticoid-sparing agents. as these treatments had to be stopped because of intolerance and mtxpneumonitis, respectively, we started tcz infusions (8 mg/kg body weight). the clinical status rapidly improved. after 2 infusions of tcz follow-up pet scan showed resolution of the previously seen uptake and we were able to taper the daily dose of prednisone to 5 mg. treatment was well tolerated. however, the patient developed mild hyperthyroidism with a rapid rise of the initially normal levels of anti-thyroid peroxidase and anti-thyroid antibodies, anti-tsh receptor antibodies remained normal. thyroid function normalized and the antibody-levels fell without further treatment in the following months. in conclusion, this case demonstrates the successful treatment of a patient with relapsing giant cell arteritis with tcz. for the first time, we report the occurrence of a transient autoimmune thyreoiditis possibly induced by tcz. klinik für pädiatrie mit schwerpunkt pneumologie und immunologie, sektion rheumatologie, berlin, 4 vestische kinder-und jugendklinik der universität witten/herdecke 13 deutsches zentrum für kinder-und jugendrheumatologie organización médica de investigación arthr care res ar&t in press sp division of rheumatology diagnosesicherung: a + b) mr-morphologisch myositistypische veränderungen (os) histologie + c) generalisierte myalgien und laborchemisch dtl. elevierter ck, sowie positivem nachweis von ana und jo-1-ak, pulmonales ct mit diffusen milchglasinfiltraten, in bronchoalveolärer lavage neutrophile alveolitis. ergebnisse. vormedikationen: a) glukocorticoidmonotherapie, mtx-monotherapie, mtx in kombination mit etanercept, cyclophosphamidboli, und zuletzt intravenöse immunglobuline (ivig) in kombination mit mycophenolatmofetil . b) mtx-monotherapie, mtx in kombination mit glukokortikoiden, cyclophosphamidboli, intermittierend intravenöse immunglobuline, cyclophosphamid per os (fau-ci). c) cyclophosphamidboli jeweils gutes ansprechen des ck-wertes auf jeweilige rituximabgaben mit ebenfalls ansprechen des klinischen bildes mit guter regredienz des aus myalgien resultierenden schmerzniveaus. im fall a keine beatmung mehr notwendig. im fall von c) auch gute regredienz subjektiver dyspnoesymptomatik und besserung wichtiger lungenfunktionsparameter, regredienz ctmorphologischer milchglasinfiltrate, im verlauf fehlender nachweis neutrophilie in bal. weitere rituximabgaben bei a, b und c im verlauf zum remissionserhalt nach jeweiligem klinischem befund production of cytokines by b cells in response to tlr9 stimulation inversely correlates with disease activity in sle-patients berlin zeitschrift für rheumatologie suppl 2 · 2013 | das muskuloskeletale system, eines der am häufigsten betroffenen organsysteme bei sle (bei 53-95% der sle-patienten). das ziel dieser analyse war es um diejenigen parameter zu identifizieren, die zu diesem effekt beigetragen hatten, wurde jeder der 9 einzel-parameter zur untersuchung und symptom-erfassung innerhalb des muskuloskeletalen bilag-organsystems analysiert. die post-hoc-analyse umfasste nur patienten, bei denen ein parameter zu studienbeginn als vorhanden gewertet wurde, und jeder parameter erforderte ≥20 patienten-beobachtungen pro kohorte um einen vergleich zu erstellen dadurch wurde die zahl der patienten mit einer initialen beteiligung des muskuloskeletalen systems aufgedeckt, die eine in woche 52 auflösung der manifestation aufwiesen auch im selena-sledai-score war die rate der verbesserung bei dem arthritis-parameter in der belimumab-gruppe mit 1 mg/ kg (58,3%; n=362) und 10 mg/kg (56,6%; n=364) signifikant höher als die daten weisen darauf hin, dass 10 mg/kg belimumab effektiv auf muskuloskeletale organmanifestationen sind akzeptiert als posterbeitrag auf dem eular klinische forschergruppe für rheumatologie (kfr), freiburg i. br., 10 universitätsklinikum ulm, klinik für dermatologie und allergologie die physikalische therapie (pt) ist ein wesentlicher bestandteil der medizinischen versorgung von ssc-patienten patientenregister des dnss erfasst prospektiv, jährlich klinische verlaufsdaten zur organbeteiligung und therapie von patienten mit systemischer sklerodermie. die mittels freitext erfassten angaben zur verordneten pt wurden ausgewertet hivamat n=50 (3,7%) und hylase n=54 (3,9%) anwendung. die anzahl der verfahren, die die patienten zeitgleich erhielten, variierte zwischen mind. 1 und max. 8. über 50% der patienten erhielten 2 anwendungen gleichzeitig. insgesamt wurden 39 therapiearten genannt. 12,5% der patienten mit gelenkkontrakturen zeigten nach einem jahr physikalischer therapie eine signifikante verbesserung der symptomatik (p=0,027) gegenüber den patienten die keine physikalische therapie erhielten. nach drei jahren waren es 15,7% der patienten (p=0,023). bei den patienten mit muskelschwäche zeigten 11% der patienten eine signifikante symptomverbesserung (p=0,048) dieser studie kann erstmals gezeigt werden, dass pt-symptome wie gelenkkontrakturen und muskelschwäche bei ssc-patienten signifikant verbessern kann. dennoch erhält weniger als die hälfte der ssc-patienten eine physikalische therapie punkten zur kontrolle einer mmf-therapie in der klinischen praxis zu untersuchen bei 15 patienten (12-mal sle, je 1-mal systemische sklerose, sharp-syndrom und primäres sjögren-syndrom) die mmf erhielten, wurde 40, 120 und 180 min nach einnahme von mmf die mpa-konzentrationen im serum per hplc bestimmt. die mpa-auc wurde durch die mathematische methode der bayes 20%) und in der standarddosis von 2 g/tag bei 6 von 9 patienten (66%) eine mpa-auc von >35 µg.h/ml. bei zwei patienten wurde nach der messung die dosis adjustiert: eine patientin mit einem sle mit diffus-proliferativer lupusnephritis hatte trotz einer mmf-dosis von 2 g/tag nur eine mpa-auc von 32,9 µg.h/ ml. die dosis wurde daraufhin auf 3 g/tag erhöht. der mpa-auc stieg danach auf max. 54,9 µg.h/ml und die krankheitsaktivität nahm ab (sledai von 8 auf 0, proteinurie von 550 auf 150 mg/24 h und prednisondosis von 6 auf 4 mg/tag) pharmakokinetic study of mycophenolate mofetil in patients with systemic lupus erythematosus and design of bayesian estimator using limited sympling strategies mycophenolic acid area under the curve correlates with disease activity in pupus patients treated with mycophenolate mofetil colony stimulating factor-1 (csf-1) -neuer aktivitätsmarker der lupusnephritis? brigham and wome's hospital, boston, renal division the authors would like to thank pfizer for supporting the study. furthermore the authors would like to thank the "deutsche kinder-rheumastiftung". einleitung. bei patienten mit früher axialer spondyloarthritis (spa) mit einer krankheitsdauer von<5 jahren und nachweis von akut-entzündlichen veränderungen in der ganzkörper-magnetresonanztomographie (mrt) in der wirbelsäule und/oder den sakroiliakalgelenken (sig) zu baseline [1] untersuchten wir die langzeit-effektivität über vier jahre. methoden. in der esther-studie wurden patienten mit etanercept (eta, n=40) vs. sulfasalazin (n=36) behandelt [1] . ab dem zweiten studienjahr wurden alle patienten mit eta behandelt (einige patienten unterbrachen zwischenzeitlich die therapie (n=12) zur untersuchung der biologika-freien remission und wurden dann (erneut) mit eta behandelt) [2] . klinische, laborchemische und mrt-daten der patienten, die zu den jeweiligen studienzeitpunkten vorhanden waren, wurden im vierten studienjahr analysiert (as-observed-analyse). ergebnisse. von 76 patienten, die zu baseline eingeschlossen wurden, erreichten 52,6% das ende von jahr 4 (n=40). in der gesamtgruppe zeigte sich ein gutes bis sehr gutes ansprechen, wobei etwa 50% eine asas partielle remission und etwa 60-70% eine asdas inaktive erkrankung erreichten (. tab.29). der anteil der patienten mit normalem crp ("crp-remission") stieg von 43,7% zu screening auf 90,2% zu woche 216, während der anteil der patienten mit negativem mrt ("mrt-remission" definiert als fehlen akut-entzündlicher veränderungen in den sig und der wirbelsäule gemäß beider scorer) auf von 0% auf 18,4% anstieg. 10,5% der patienten zu woche 216 waren sowohl in asas-remission, im status einer asdas inaktiven erkrankung als auch in mrt-remission. das ansprechen nach vier jahren war sehr ähnlich in den gruppen unabhängig davon, ob im ersten jahr sulfasalazin gegen wurde oder die therapie im jahr 2 unterbrochen worden war (ergebnisse werden nicht gezeigt).schlussfolgerung. es zeigte sich ein konstantes und anhaltendes ansprechen bei patienten mit früher axialer spa, die mit etanercept behandelt wurden. das ansprechen scheint besser zu als bei patienten mit etablierter ankylosierender spondylitsi mit einer langen krankheitsdauer (>10 jahren; [3] ). einleitung. in einer 12-wöchigen placebokontrollierten studie mit 40-wöchiger offener verlängerung bei 46 patienten mit aktiver nichtröntgenologischer axialer spondyloarthritis (nr-axspa) wies adalimumab eine gute effektivität auf [1] . bei patienten, bei denen es zum wiederauftreten der krankheitsaktivität nach absetzen des medikaments in woche 52 kam, wurde die therapie wiederbegonnen ziel der studie war es, die langzeiteffektivität nach wiederaufnahme der therapie von adalimumab nach stopp über 5 jahre zu evaluieren. methoden. bei 46 ursprünglich in die studie eingeschlossenen patienten wurde die therapie nach 52 wochen beendet und 23 patienten (52% männlich, mittleres alter 32 jahre, range 24-45, mittlere krankheitsdauer vor therapiebeginn 4 jahre, range 1-10, 74% positiv für hla-b27) hatten, definiert durch erreichen eines 40% ansprechens gemäß der assessments in spondyloarthritis society-kriterien (asas40), gut auf die therapie angesprochen. bei wiederauftreten von krankheitsaktivität (definiert durch nicht mehr erreichen von asas40) wurde adalimumab 40 mg alle 2 wochen über 5 jahre (woche r264) weitergeführt. die asas kriterien und der bath ankylosing spondylitis disease activity index (basdai) wurden in form einer completer-analyse berechnet. ergebnisse. 19 der 23 patienten mussten wiederbehandelt werden: 17/19 (90%) erreichten jahr 3, 16/19 (84%) erreichten jahr 4 und 11/19 (58%) der patienten erreichten jahr 5 der wiederbehandlung. nach 3 jahren wiederbehandlung mit adalimumab erreichten 13/17 (77%) wieder asas 40 und 11/17 (65%) erreichten partielle remission gemäß der asas-kriterien. nach 4 jahren erreichten 11/16 (81%) und nach 5 jahren 9/11 (91%) asas 40. asas partielle remission wurde nach 4 jahren von 9/16 (56%) und nach 5 jahren von 7/11 (64%) patienten erreicht. in der completer analyse fiel der mittlere basdai von 5,1±1,8 zum zeitpunkt der wiederbehandlung auf 1,6±1,6 im jahr 3 (p<0,001), 2,2±2,1 (p=0,001) im jahr 4 und auf 1,5±1,8 (p=0,001) im jahr 5 der wiederbehandlung ab. schlussfolgerung. in dieser gruppe von 19 patienten mit aktiver nr-axspa, die ein gutes therapieansprechen über 52 wochen mit adalimumab erreicht hatten und die bei wiederauftreten von krankheitsaktivität nach stopp der therapie in woche 52 weiterbehandelt werden mussten, sprach die mehrheit der patienten, die in der studie verblieben, gut und anhaltend auf das fortsetzen der therapie an. tab. 29 | sp-17 langzeit-effektivität über 4 jahre etanercept-therapie bei patienten mit früher axialer spondyloarthritis. daten zu baseline (bl), jahr 1 (w48), jahr 2 (w108), jahr 3 (w156) und jahr 4 (w216). daten background. secukinumab (ain457) is a new fully human monoclonal antibody (mab) targeting il-17a for the treatment of inflammatory diseases. administration of mabs can be associated with immunogenicity via the induction of anti-drug antibodies (adas). adas can lead to unwanted clinical consequences, such as loss of exposure, loss of efficacy due to altered pharmacokinetics and/or functional neutralization and, in the worst case, anaphylactic reaction and immune complex diseases. the assessment of ada formation is therefore a critical component in the assessment of biotherapeutic safety. methods. the immunogenicity assessment strategy for secukinumab follows a three-tiered approach. first, samples are analyzed for presence of ada in a screening assay which takes a 5% false-positive rate into account. in a second step, screening assay positive samples are tested in a confirmatory assay that identifies true positive responses. finally, true immunogenicity-positive samples are quasi-quantified via titration. a biacore-based assay was used during the early stages of the secukinumab program, and an msd-based bridging assay was applied during the later stages of the program. in addition, pharmacokinetics and clinical efficacy as well as safety data are also evaluated. samples to assess immunogenicity were obtained from 1582 individual subjects encompassing 18 clinical studies in different indications during treatment and during follow-up. dosing regimens included single doses such as 25 mg subcutaneously in psoriasis patients as well as multiple 7×10 mg/kg doses intravenously in ms patients over a six-month period.results. none of the subjects tested for immunogenicity developed sustained adas. in total, 4 subjects met the definition of treatment-related, transient positive immunogenicity showing low ada titers. none of these subjects had evidence of loss of efficacy, deviating pk behavior or reported anaphylactic reaction or immune complex disease.conclusion. based on the available data, secukinumab appears to carry a low risk of immunogenicity. in the very few transient immunogenicitypositive patients identified so far, there has been no indication of altered pharmacokinetics or loss of efficacy, and no adverse event that could be linked to immunogenicity has been detected. more data from the ongoing phase 3 studies are required to strengthen this encouraging finding in a larger patient population. risikofaktoren für eine aa-amyloidose bei entzündlich-rheumatischen erkrankungen und bei der idiopathischen aa-amyloidose methods. we report a case of an 84-year-old woman suffering from ulceration and signs of infection of the ulnar aspect of the right forearm due to subcutaneous calcification in association with crest syndrome.results. this case presents an unusual case of extensive subcutaneous calcification in crest syndrome requiring surgical excision due to secondary ulceration, inflammation and infection. while a surgical approach has already been described for calcification in different connective tissue diseases, only scant data of massive subcutaneous calcification related to a forearm in crest syndrome followed by surgical excision exist. conclusion. in crest syndrome, extensive subcutaneous calcification related to the forearm can occur. surgical excision followed by primary wound closure can lead to an excellent postoperative result. background. the whole blood interferon signature (wbifns) is measured in several clinical trials studying inhibitors of interferon alpha (ifn-α) in sle, but failed repeatedly -in contrast to the less sensitive ifnα -to reflect longitudinal changes in lupus activity and to guide dosage finding of rontalizumab. therefore, better ifn biomarkers reflecting disease activity over time and individual response to the inhibition of ifnα are needed to optimize the risk-benefit ratio of ifn-inhibitors. here, we show that the highly sensitive monocyte restricted ifnα response protein siglec-1, also known as sialoadhesin or cd169, is a useful biomarker to monitor longitudinal changes in disease activity of sle patients. methods. ifn-α and siglec-1 were measured by delfia and flow cytometry, respectively, in 24 accurately characterized lupus patients over a period of up to 12 months (overall 112 visits). changes of biomarker and changes of disease activity (bilag2004) were correlated using spearman rank test (srt). disease courses of selected sle patients were plotted to demonstrate in detail the relations of ifn-biomarkers with disease activity, sle medication and clinical manifestations. background. a 74-year-old woman was admitted because of sudden attack of convulsion and somnolence situation with positive canca and myeloperoxidase antibodies. cerebral magnetic resonance imaging (mri) showed thickening and marked progression of the dura-meningeal enhancement and edematous changes at pre and post central gyrus left side. based on these findings, it was diagnosed as hypertrophic cranial pachymeningitis related to anca-associated vascultis as unusual presentation. there was only temporarily und partial responce to a 7-month therapy with cyclophosphamide 1000 mg i.v and oral glucocorticosteroids . taking into consideration the severe, life-threatening course of the disease in the case of our patient, the decision was made to use rituximab, a chimeric, monoclonal igg1 antibody directed against cd20, leads to destruction of b cells via complement mediated lysis and antibody dependent cellular cytotoxicity. the first administration of the medication was performed according to the pattern for rheumatoid arthritis patients treated with rituximab, i.e. 2 infusions for 1000 mg in 14-day intervals in combined therapy with glucocorticosteroids. a follow-up mri at 6 months after start with rituximab showed significant regression of the meningeal pathology at temporo-occipatel aspects (pachymeningitis) and completely resolution of edematous changes at pre and post central gyres. the complete clinical remission was achieved by introducing rituximab. conclusion. rituximab seems to be successful therapie for the induction and maintenance of remission in patients with anca-associated vasculitis (aav) with cns involvement (hypertrophic cranial pachymeningitis ) , who had previously failed to respond to standard treatment with cyclophosphamide and steroids and a range of alternative treatments [1, 2] . antikörperdiagnostik. mit prednisolon-therapie (1 mg/kgkg, 40 mg/ tag) und zusätzlich methotrexat 15 mg wöchentlich war keine anhaltende normalisierung der entzündungsserologie zu erzielen. infliximab (5 mg/kg) 6-wöchentlich i.v. erbrachte nur kurzzeitig eine normalisierung der entzündungswerte, dann trotz weiterer infusionen einen erneuten anstieg der bsg bis auf 91 mm, crp 58 mg/l. nach umstieg auf tocilizumab (400 mg /8 mg/kgkg) alle 4 wochen konnte nach 6 wochen eine bislang anhaltende normalisierung der entzündungsserologie erzielt werden (crp 1,1 mg/l, bsg 9 mm 1. std.). der allgemeinzustand der patientin besserte sich deutlich, der hb-wert normalisierte sich auf 7,9 mmol/l. in der kontrastverstärkten sonographie fand sich ein abfall in der kontrastmittelaufnahme der a. carotis communis. die maximale intima-media-dicke reduzierte sich bislang auf 1,7 mm. schlussfolgerung. die bisherige standardtherapie der takayasu-arteriitis mit prednisolon und mtx führte auch im vorliegenden fall nicht zur remission. für infliximab fanden wir ein frühzeitiges therapieversagen des sonst erfolgreich beschriebenen ansatzes einer tnf-α-blockade bei riesenzellarteriitis. dennoch gelang mit tocilizumab eine bislang über 12 monate andauernde klinische, sonomorphologische und serologische remissionsinduktion bei monatlicher fortführung der il-6-blockierenden therapie. 4 background. cd56 is the prototypic nk receptor that is also expressed on a unique population of effector cd4+ cells. these cd56-expressing t cells are expanded in rheumatoid arthritis patients and had features of senescent cells. nkg2d is another nk receptor over expressed on effector cd4+ cells in aav patients. cd 56+ as well as nkg2d + t cells seem to be involved in tissue injury as they are capable of mediating tcr-independent immune activation. it is hypothesized that il-15 is able to up regulate the expression of nk cell receptors. interleukin-15 (il-15) is a proinflammatory cytokine that is over expressed in aav and is linked to the expansion of cd4+ effector memory t cells (tem). in aav in remission a persistent expansion of these cd4+ effector memory t cells has been observed. in the present study we assessed the expression cd56 on cd4+ t cells of aav and if expression of these molecules was influenced by il-15. methods. the distribution of cd4+ tem and the proportion of cd56+cd4+ t cells and nkg2d+ cd4+ t cells were analysed in 52 aav-patients and 30 hcs by facs. in vitro effects of il-15 on the expansion of cd4+ tem and up regulation of cytotoxic markers were assessed in the same way. in addition il-15 serum levels were measured in patients and hc by elisa. results. we observed an increased proportion of circulating cd4+cd56+ t cells in aav as well as nkg2d+ cd4+ t cells in patients in remission compared to hc (13.6 vs 0.6 p<0.0001 and 14 vs 0.7 p<0.0001). 80% to 90% of these cells were cd4+ effector memory t cells. the percentages of the cd56+cd4+ t cells and nkg2d+ cd4+ t cells were constant over time. we also observed elevated il-15 serum levels in patients in remission compared to hc (p=0.001). in vitro stimulation of pbmcs with il-15 increased not only the proportion of cd4+ memory cells (cd45ro+) but also the expression of cd56 and nkg2d on these cells. conclusion. the driving force behind the persistent expansion of a cytotoxic subset of cd4+ effector memory t cells expressing cd56 and nkg2d+ and being tcr -independent is likely the increased il-15 expression in aav patients . ergebnisse. unabhängig von regime der remissionsinduktion und der primären erhaltungstherapie lag am ende der nachbeobachtungsperiode bei 69% der patienten eine renale remission vor (45%; 24% pr). 16% hatten eine persistierende proteinurie von >0,5 g/tag bei stabiler nierenfunktion, 3% eine persistierende niereninsuffizienz mit erhöhtem kreatinin bei inaktivem sle, bei 12% wurden eine persistierende aktive ln und/oder renale rezidive beobachtet. vier patienten verstarben. patienten mit langzeit-cr waren gekennzeichnet durch einen niedrigeren tubulointerstitiellen chronizitätsindex in der initialen nierenbiopsie (0,37±0,40 vs. 1,47±1,13; p=0,001), eine hochsignifikant geringere proteinurie nach 6 cyc-pulsen (0,36±0,36 vs. 1,97±1,57 g/tag; p=0,000) und niedrigere dsdna-ak (61±72 vs. 110±89 u/ml; p<0,05) zum zeitpunkt des beginns der erhaltungstherapie. eine proteinurie von <0,35 g/tag nach 6 pulsen cyc zeigte eine sensitivität von 71% und eine spezifität von 94% für eine langzeit-cr. schlussfolgerung. eine proteinurie von <0.35 g/tag nach remissionsinduktion mit 6 pulsen cyc sowie ein geringer tubulointerstitieller chronizitätsindex in der nierenbiopsie sind prädiktoren einer anhaltenden kompletten renalen remission bei ln. background. to evaluate and compare clinical efficacy of three biomarkers for interferon activity (measured directly and indirectly) and six traditional biomarkers to indicate current disease activity in sle. methods. ifn-α (delfia), ip-10 (elisa) and siglec-1 (flow cytometry) was measured in 79 accurately characterized lupus patients and compared to serum titres of anti-dsdna (elisa and ria), anti-dsdna-ncx elisa, anti-nuc elisa, c3 and c4. disease activity was evaluated using bilag-2004 and a modified sledai-2000 (msle-dai-2k). additionally, 31 clinically quiescent patients were monitored for flares over the course of 180 days. results. increased levels of ifn-α, ip-10 and siglec-1 were found in 32%, 50% and 86% of 66 active sle patients. ifnα (r=0.45; p<0.0001) and siglec-1 (r=0.54; p<0.0001) correlated better with bilag-2004 than ip-10 (r=0.38; p=0.0002), farr assay (r=0.40; p=0.0001), anti-dsdna-ncx elisa (r=0.28; p=0.0061), anti-dsdna elisa (r=0.31; p=0.0025), anti-nuc elisa (r=0.25; p=0.0121), c3 (r=-0.43; p<0.0001) and c4 (r=−0.33; p=0.0013). predictors of sle flares were disease duration ≤92 months, mild clinical activity (in contrast to no activity), complement c3≤89 mg/dl and ifn-α ≥20 pg/ml, while only lymphocyte count and age were independent predictors in multivariate analysis. conclusion. ifn-α, ip-10 and siglec-1 emerged as beneficial biomarkers for disease activity in lupus patients. therefore, implementation of ifn biomarkers in standard lupus diagnostics should be reappraised, especially in view of emerging anti-ifn-directed therapies. .0001) and carried significantly more often other antibodies (71.1%; p<0.0001), which were separated into u1rnp-(22.7%), ro-(16.8%), pmscl-(11.5%) antibodies, followed by 10.8% with rheumatoid factors, 7.5% with la-, 5.8% with dsdna-and 2.8% with jo-1-and 2.6% with ku-antibodies. the kaplan-meier analysis of the onset of organ involvement revealed a clear inclined position of overlap patients between patients suffering from lcssc and dcssc, especially regarding lung fibrosis and heart involvement. patients suffering from pah, oesophagus involvement and kidney involvement, overlap and lcssc patients showed nearly similar curve progression (log rank <0.0001). furthermore musculoskeletal involvement was significantly more frequent and more progressive in patients with overlap disease, followed by patients with dcssc and lcssc (log rank <0.0001). conclusion. these data support the current concept, that ssc-overlap syndromes should be regarded as a separate ssc subset, distinct from lcssc and dcssc, due to a different course of the disease, different proportional distribution of specific autoantibodies and skin/organ involvement. methoden. 18 patienten mit gpa (11 mit aktiver und 7 mit in remission befindlicher gpa) wurden durchflusszytometrisch analysiert und mit 17 gesunden verglichen. eine färbung für cd27, cd20, cd19, igd, iga, cd95, mhcii, wurde mittels flowjo-software analysiert. die statistische auswertung erfolgte mit "graph pad prism" und p-werte<0,05 wurden als signifikant angesehen. die studie wurde von der ethik-kommission der charité genehmigt. ergebnisse. deutliche unterschiede (p=0,0018) wurden sowohl für die absolute zahl als auch die frequenz der plasmazellen im peripheren blut der patienten mit gpa mit krankheitsaktivität (6,4±5,06/µl) im vergleich zu denen mit einem bvas von 0 (2,52±1,6/µl) oder gesunden (2,27±1,15/µl) gefunden, ähnlich wie bei sle. bei patienten mit gpa ist außerdem eine signifikante erhöhte anzahl der plasmazellen igapositiv (p=0,0028). die anzahl der plasmazellen sowie die frequenz der plasmazellen an den b-zellen im blut korrelieren mit dem bvas (r=0,9135; p<0,0001). interessanterweise zeigte sich keine expansion der doppelt negativen memory-zellen, die zum beispiel beim sle beschrieben ist. für die naiven b-zellen fand sich ebenfalls ein signifikanter unterschied zwischen patienten mit aktiver erkrankung im vergleich zu gesunden. bei den t-zellen fanden sich nur diskrete veränderungen. schlussfolgerung. die anzahl der plasmazellen ist bei patienten mit aktiver gpa deutlich erhöht, was eine rolle von plasmazell-vermittelten mechanismen in der pathogenese nahelegt. ein großteil dieser plasmazellen ist iga-positiv, diese könnten eine rolle bei der hno-beteiligung spielen. key: cord-323581-qtasvgtd authors: zhang, yu-dong; dong, zhengchao; wang, shui-hua; yu, xiang; yao, xujing; zhou, qinghua; hu, hua; li, min; jiménez-mesa, carmen; ramirez, javier; martinez, francisco j.; gorriz, juan manuel title: advances in multimodal data fusion in neuroimaging: overview, challenges, and novel orientation date: 2020-07-17 journal: inf fusion doi: 10.1016/j.inffus.2020.07.006 sha: doc_id: 323581 cord_uid: qtasvgtd multimodal fusion in neuroimaging combines data from multiple imaging modalities to overcome the fundamental limitations of individual modalities. neuroimaging fusion can achieve higher temporal and spatial resolution, enhance contrast, correct imaging distortions, and bridge physiological and cognitive information. in this study, we analyzed over 450 references from pubmed, google scholar, ieee, sciencedirect, web of science, and various sources published from 1978 to 2020. we provide a review that encompasses (1) an overview of current challenges in multimodal fusion (2) the current medical applications of fusion for specific neurological diseases, (3) strengths and limitations of available imaging modalities, (4) fundamental fusion rules, (5) fusion quality assessment methods, and (6) the applications of fusion for atlas-based segmentation and quantification. overall, multimodal fusion shows significant benefits in clinical diagnosis and neuroscience research. widespread education and further research amongst engineers, researchers and clinicians will benefit the field of multimodal neuroimaging. neuroimaging has been playing pivotal roles in clinical diagnosis and basic biomedical research in the past decades. as described in the following section, the most widely used imaging modalities are magnetic resonance imaging (mri), computerized tomography (ct), positron emission tomography (pet), and single-photon emission computed tomography (spect). among them, mri itself is a non-radioactive, non-invasive, and versatile technique that has derived many unique imaging modalities, such as diffusion-weighted imaging, diffusion tensor imaging, susceptibility-weighted imaging, and spectroscopic imaging. pet is also versatile, as it may use different radiotracers to target different molecules or to trace different biologic pathways of the receptors in the body. therefore, these individual imaging modalities (the use of one imaging modality), with their characteristics in signal sources, energy levels, spatial resolutions, and temporal resolutions, provide complementary information on anatomical structure, pathophysiology, metabolism, structural connectivity, functional connectivity, etc. over the past decades, everlasting efforts have been made in developing individual modalities and improving their technical performance. directions of improvements include data acquisition and data processing aspects to increase spatial and/or temporal resolutions, improve signal-to-noise ratio and contrast to noise ratio, and reduce scan time. on application aspects, individual modalities have been widely used to meet clinical and scientific challenges. at the same time, technical developments and biomedical applications of the concert, integrated use of multiple neuroimaging modalities are trending up in both research and clinical institutions. the driving force of this trend is twofold. first, all individual modalities have their limitations. for example, some lesions in ms can appear normal in t1-weighted or t2-weighted mr images but show pathological changes in dwi or swi images [1] . second, a disease, disorder, or lesion may manifest itself in different forms, symptoms, or etiology; or on the other hand, different diseases may share some common symptoms or appearances [2, 3] . therefore, an individual image modality may not be able to reveal a complete picture of the disease; and multimodal imaging modality (the use of multiple imaging modalities) may lead to a more comprehensive understanding, identify factors, and develop biomarkers of the disease. in the narrow sense, a multimodal imaging study would mean the use of multiple imaging devices such as pet and mri scanners, different imaging modes such as structural mri, diffusion-weighted imaging, and magnetic resonance spectroscopy, or even different contract mechanism such as with or without contract agents in a single examination or experiment of a subject. this practice has been widely used in clinical diagnosis and medical research. for example, a routine protocol of mri examination of a stroke patient may include t1-weighted, t1-weighted high-resolution structural mri scans, diffusion-weighted imaging, swi, etc [4, 5] . a protocol of an mri study of a psychiatric disorder may contain a combination of structural mri, functional mri, mr spectroscopic imaging, etc [6, 7] . in the broad sense, a multimodal imaging study may mean the use of multimodal imaging data obtained separately, from different subjects, and/or from different clinical or research sites. this practice offers the advantages of large and diverse datasets. however, it also comes with challenges of sophisticated models, complicated data normalization (that includes correction of errors and variations imbedded in data from different institutions), data fusion, and data integration [8, 9] . in recent years, the quantity of peer-reviewed journal articles on neuroimaging has been increasing steadily. a database (pubmed) query using the keywords in titles of "neuroimaging" or "brain imaging" returned more than 39 ,000 articles from 2010 to the present time when this paper was drafted in feb 2020 ( figure 1 ). these publications include not only applications of multimodal neuroimaging in clinical examinations and biomedical research but also methodological studies in imaging processing and fusion of multimodal neuroimaging. therefore, this present paper will focus on the following two main aspects: (1) we will review some of the recent, typical papers that exhibit the strength and limitations of the neuroimaging modalities and the corresponding analysis methods, and in particular, the needs for improved image fusion methods and (2) we will review recent methodological development in data preprocessing and data fusion in multimodal neuroimaging. we note that although we tried to cover all neuroimaging modalities, we inevitably paid more attention to mri modalities. this is not only due to the most practical application and versatility of the mri but also due to the limitations of our expertise. figure 2 shows the taxonomy of this review. the main contents of the paper are organized as follows. chapter 2 will give a brief introduction to neuroimaging, and challenges of multimodal imaging; chapter 3 introduces the commonly used neuroimaging modalities, which include computerized tomography, positron emission tomography, single-proton emission computed tomography, and magnetic resonance imaging, which has many modalities in its own right. for each modality, we will concisely describe its signal source, energy level, spatial resolution, temporal resolution, and major applications; chapter 4 describe applications of neuroimaging in three major areas: the developing brains, the degenerative brains, and mental disorders. in each part, we will first briefly describe what the clinical and/or biomedical problems are, we then review recent papers on how neuroimaging has been used to address these problems, and we point out what the unmet needs and challenges; chapters 5 to 9 are devoted to the multimodal neuroimaging fusion, covering some important procedures in data fusion. the topics are not necessarily complete and their order of presentation is not necessarily coherent with the pipeline of fusion processing. chapter 5 reviews the fundamental methods, which covers types, rules, atlas-based segmentation, decomposition, reconstruction, and quantification; chapter 6 reviews subjective and objective assessment of data fusion in multimodal neuroimaging; chapter 7 reviews the advantages of data fusion in improving the spatial/temporal resolution, distortion correction, and contrast; it also reviews the benefits of these advantages in fusing structural and functional images; chapter 8 reviews atlas-based segmentations in multimodal imaging fusion; chapter 9 reviews the quantification in multimodal neuroimaging fusion. while the focus of this part is given to pet and spect, some of the approaches and principles discussed here, such as partial volume correction and attenuation (relaxation), can be applied to quantitative mri modalities, such as dti, asl, quantitative susceptibility mapping (qsm), etc. chapter 10 concludes the paper. figure 1 numbers of peer-reviewed papers with the keywords of "neuroimaging" or "brain imaging" in titles (the numbers and the bar graph were generated by pubmed in feb 2020). in this part, we will review the current challenges of neuroimaging, including limited spatial/temporal resolution, lack of quantification, and imaging distortions. these challenges often create fundamental limitations on individual modalities of neuroimaging, while some challenges also exist in current multi-modal neuroimaging. this part will mainly cover the challenges of individual neuroimaging modalities that led to the development and ongoing research of multimodal neuroimaging methods. neuroimaging can be divided into structural imaging and functional imaging according to the imaging mode. structural imaging is used to show the structure of the brain to aid the diagnosis of some brain diseases, such as brain tumors or brain trauma. functional imaging is used to show how the brain metabolizes while carrying out certain tasks, including sensory, motor, and cognitive functions. functional imaging is mainly used in neuroscience and psychological research, but it is gradually becoming a new way of clinical-neurological diagnosis [10] . the amount of information obtainable through single-mode imaging is limited and often cannot reflect the complex specificity of organisms. for instance, although ct imaging is effective in identifying normal structures and abnormal diseased tissues according to their density and thus can provide clear anatomical structure information, it cannot image soft tissue well. generally speaking, mri imaging has good soft-tissue contrast resolution for most sequences, but its display of bone structure is relatively poor. pet imaging and spect imaging are not limited by the detection depth, with high imaging sensitivity, and are easy to quantify, but their spatial resolutions are low [11] . optical imaging refers to the detection of fluorescence or bioluminescent dyes using the principle of light emission. this technique has high sensitivity, no radioactivity, good specificity, and low cost. optical imaging allows dynamical monitoring of the replication process of virus bacteria in organisms. however, it has low spatial resolution and limited imaging depth [12, 13] . therefore, it can be observed that various imaging technologies all have both benefits and drawbacks, as shown in figure 3 , and it is difficult to provide comprehensive and accurate information through utilizing individual modality imaging. the nowadays most commonly used noninvasive functional imaging methods and their spatial and temporal range are illustrated in figure 4 . it can be distinctly observed that among these most advanced methods, functional mri (fmri) reaches the highest range of spatial resolution. fmri can assess the whole brain and image the microscopic level hemodynamic processes at the layered and columnar levels of the human cortex, under the condition of a high-intensity magnetic field (i.e., submillimeter level) [14] . however, it has a relatively lower temporal resolution in terms of imaging the neuronal population dynamics. electroencephalogram (eeg) and magnetoencephalography (meg) can both measure electromagnetic changes in the scale of milliseconds. however, their spatial resolution/uncertainty is more than several millimeters [15, 16] . the microscopic level of neuroscience is often beyond the reach of noninvasive imaging techniques due to the requirement of high spatial or temporal resolution. the majority of imaging modalities are non-quantitative and have to gain complement information from other data. this additional information allows the normalization of signals, acquirement of absolute units, and inter-subject comparison. as an example, the fmri signal is a measure of neuronal activity incited hemodynamic changes caused by a combination of complex physical and physiological processes. in different subjects or brain areas, the same level of neuronal activity can evoke different corresponding fmri signals. as a consequence, fmri signals can only be considered as roughly proportional to the activity of neurons. four years later, in 2008, the studies from ances have found that the cerebral blood flow (cbf) is relevant to fmri signal variations in individual's brain regions, patients' age groups, and health conditions. this broad relevance brings fmri signal high sensitivity [17] . various approaches have been proposed to explain the ensuing sensitivity differences. amongst these approaches, the so-called calibrated bold approach proposed and improved by blockley, chiarelli and hoge over the years has been the most widely used [18] [19] [20] . however, the more reliable absolute quantitative results of cbf with improved spatial and temporal resolutions are provided by the arterial spin labeling (asl) technique by the umich fmri lab. [21] some neuroimaging modalities are prone to geometric distortions. echo-planar imaging (epi) is a fast imaging approach that could obtain the completespace data set just in a single acquisition. due to its unmatched acquisition speed, it has revolutionized the field of neuroimaging and has served as the standard readout module for most fmri and dmri acquisition. nevertheless, epi suffers from distortion and intensity loss mainly caused by field inhomogeneities, leading to relatively poor image quality [22] . in general, the imperfection of equipment may result in information loss, noise amplification and artifacts, resulting in the distortion of images. to conclude, in practical application, utilizing individual modality imaging often has limitations, such as low sensitivity and specificity, low spatial/temporal/contrast resolution, distortion and so on. because of these deficiencies, we need to introduce the usage of multimodal neuroimaging to eliminate those shortcomings in some degree. positron emission tomography, shortened as pet, is a combination of nuclear medicine and biochemical analysis that is mostly used for the diagnosis of brain or heart conditions and cancer. instead of detecting the amount of a radioactive substance existing in body tissues of a specific location to check the tissue's function, pet detects the biochemical changes within body tissues. the biochemical changes can reveal the onset of a disease process before other imaging processes can visualize the anatomical changes related to the disease. during pet studies, only a tiny amount of radioactive substance is needed for the examination of targeted tissues. pet scans not only can be used to detect the presence of disease or other conditions of organs or tissues but can also be used to evaluate the function of organs, like the heart or the brain. the most common application of pet scan is cancer detection and treatment. figure 6 (a) shows a pet image of the brain, and figure 6 (b) shows a pet scan of the kidney [27] . (a) brain scan via pet scan (b) kidney scan via pet scan (c) brain scan via spect (d) brain scan via mri figure 6 common scan modalities single-photon emission computed tomography, commonly known as spect, uses gamma rays as the tracer to detect blood flow in organs or tissue. therefore, a gamma-emitting radioisotope, such as isotope gallium, should be injected into the bloodstream of the patient for spect. the computer collects the gamma rays from the tracer and shows it on the ct cross-section. it bears similarity with the traditional nuclear medicine planar imaging but provides 3d information as multiple images of cross-sectional slices through the patient. the information can be manipulated or reformatted freely according to diagnostic or research requirements. besides detecting blood flow, spect scanning is also applied for the presurgical evaluation of medically controlled seizures. figure 6 (c) [27] shows a spect scan of the brain magnetic resonance imaging (mri) utilizes strong magnetic field, magnetic field gradients, and radio waves to generate pictures of the anatomy and the physiological processes of the body [28] . different from pet or ct, mri does not need the injection of ionizing radioisotopes or involve x-rays. as all radiation instances can cause ionization that leads to cancer, mri, without exposing the body to radiation, becomes a better choice than ct and one of the safest medical procedures. mri is widely used in hospitals and clinics for the medical diagnosis of different body regions, including the brain, spinal cord, bones and joints, breasts, heart and blood vessels, and other internal organs, such as the liver, womb or prostate gland [29] [30] [31] . besides, mri can also be used for non-living objects [32] . figure 6 (d) shows an mri brain image [33] . t1, t2 and proton density (pd) are three basic types of mri imaging. t1, t2 and pd, which all vary with sequence parameters, can simultaneously determine the contrast of the mr images [34] . via selecting different pulse sequences with different timings, we can decide the contrast in the region being imaged. there are also other types of sequences, such as fluid attenuates inversion recovery (flair) and short tau inversion recovery (stir). in this section, we will only mention the three main types. figure 7 shows the relationship between and , of which refers to plane [35] . different from t1 and t2, which mainly focuses on the magnetic characteristics of the hydrogen nuclei, pd is more related to the number of nuclei in the region being imaged. pd weighted images are obtained by a short echo time and a long repetition time, which can provide a more apparent distinction between the gray matter and white matter. pd weighted imaging is specifically useful for detecting joint disease and injury. figure 8 (a) and (b) show a t1 weighted brain image and t2 weighted brain image, respectively [27] . (a) t1 weighted brain image (b) t2 weighted brain image figure 8 two types of weighted images of the same brain functional magnetic resonance imaging or functional mri (fmri) measures brain activity by detecting changes associated with blood flow. as it has been proved that when an area of the brain is in use, the blood flow to that area increases, which means that the neuronal activation and cerebral blood flow are matched. fmri is a particular type of imaging technology used to map the neuron activities in the spinal cord and brain of humans or animals by visualizing the change in blood flow, which is related to the energy use by brain cells. fmri also includes resting-state fmri [36] or task-less fmri, which can provide subjects' baseline bold service [37] . diffusion weighted/tensor imaging (dwi) generates image contrast from the differences in the magnitude of diffusion of water molecules within the brain. diffusion in biology is defined as the passive movement of molecules from a higher concentration region to a lower concentration region, which is also known as brownian motion [38] . diffusion within the brain is affected by many factors, such as temperature, type of molecule under investigation, and the microenvironmental architecture in which the diffusion takes place. based on the mri sequences of which diffusion is sensitive to, the image contrast can be generated according to the difference in diffusion rates. dwi is highly effective for the early diagnosis of ischemic tissue injury, even before the pathology can be shown by the traditional mr sequence. therefore, dwi provides the time window for tissue salvaging interventions. perfusion weight imaging (pwi) is defined as a variety of mri techniques that are able to provide insights into the perfusion of tissues by blood [39] . pwi can be used for the evaluation of ischaemic conditions, neoplasms, and neurodegenerative diseases. perfusion mri mainly has three main techniques: dynamic susceptibility contrast (dsc), dynamic contrast-enhanced (dce), and arterial spin labeling (asl). susceptibility weighted imaging (swi), previously known as bold venographic imaging, is a type of mri sequence that is extremely sensitive to venous blood, hemorrhage, and iron storage. as an fmri technique, swi can explore the susceptibility differences between tissues and detect differences based on the phase image. an enhanced contrast magnitude image can be obtained by combing the magnitude and phase data. swi is commonly used in traumatic brain injuries (tbi) and high-resolution brain venographies as it is sensitive to venous blood. magnetic resonance fingerprinting (mrf) [40] is new mri technique that integrates mr physics theory and computer pattern recognition technology and realizes fast and multi-parameter parallel quantization imaging. the technique consists of three modules. first, the fingerprinting signals are excited and acquired from the subject in the mr scanner by the pseudorandom temporal varied pulse sequence to reflect the physiological property of tissue. second, the evolution of fingerprinting signals with different physiological parameter combinations are predicted by the computer simulation using the bloch equation; and a fingerprint dictionary indexed by the quantized parameters is constructed. finally, the pattern recognition technology is applied to find the matched fingerprinting entries for the measured fingerprinting signals, so as to obtain the corresponding quantization parameters and realize quantization mr imaging. different from most of the conventional mri modalities, which provide qualitative contrast-based images that are determined not only by the tissue properties but also by experimental conditions, mrf provides quantitative images of tissue properties that reflects pathological conditions of the subject. figure 9 shows currently, the applications of mrf have been limited to biomedical research and the fusion of mrf with other neuroimaging modalities has not been reported. given its parametric and quantitative features, the mrf technique will play an important role not only in neuroimaging but also in fusion of multimodal neuroimaging. figure 9 digital phantom experiments of conventional t1 weighted and t2 weighted mris, and mrf table 1 lists the main advantages, disadvantages and applications of each neuroimaging technology. in this section, we listed some public databases, as shown in in this part, we will review recent advancements in the application of multimodal neuroimaging in some clinical and research areas such as early brain development, neurodegenerative diseases, psychiatric disorders, and neurological diseases. it is not our intention to cover all aspects or provide a complete review of these areas. instead, we focus on the aspects related to the development and applications of the multimodal neuroimaging techniques that meet the expectations and challenges of biomedicine. as such, each of the areas will begin with a brief description of background information such as clinical features, pathology, diagnosis, treatment of the diseases; then a general introduction of the roles, applications, and current status of the medical imaging techniques to the disease; the major part will be a review of recent papers that used one or more imaging modalities and used image fusion in multiple imaging modalities. recent studies show that the human brain experiences a rapid development in the first eight years and continues to develop and change into adulthood. during this long period, the brain develops in size, neuroanatomy, and functions. this period is significant for a person's physical and mental health, intellectual and emotional development, and learning, working, and life success [41] [42] [43] . many factors have influences on the brain development of young children, which will have an impact on cognitive abilities and mental health in later life. these influencing factors include genes, maternal stress, and drug abuse, exposure to toxic environments, infectious diseases, socioeconomic status of the family, etc. approximately one-third of genes in the human genome are expressed primarily in the brain and will affect brain development. many psychiatric and mental disorders, such as autism, adhd, bipolar, and schizophrenia, are highly heritable or have genetic risk factors. maternal stress and drug abuse are associated with preterm birth and low birth weight and increased risk of neurodevelopmental disorders and mental disorders in children [44] . the nutritional status of a child, which is affected by the socioeconomic status of the family, has a significant impact on neurocognitive development [45] . neuroimaging techniques have been used to study normal and/or abnormal development of the brain, enhancing our understanding of neuroanatomy, connectivity, and functionality of the brain. these techniques also reveal the etiological associations of abnormal brain development with risk factors and contribute to the development of intervention procedures for diseased children [42] . young children are more sensitive to radiation than adults are, so the use of pet and ct is limited. thanks to the in vivo nature and versatility of mri, not only young children but also newborn babies can be imaged, offering the opportunity to study white matter development and cognition in babies [46] [47] [48] . mri has become the most important pediatric neuroimaging modality and has been widely used to study normal and abnormal brain development, allowing repeated longitudinal observation of the changes of brains of the same individuals before and after birth [49] . in the following, our review will focus on the major mri modalities in pediatric imaging, which include structural, functional, and diffusion tensor imaging. early pediatric brain mri studies focused on the anatomical aspects using t1-weighted and t2-weighted images. qualitative studies provided information about changing patterns of gray matter and white matter differentiation and myelination in the first months of birth [50] and early childhood [51] . quantitative studies also revealed the changes in water contents, t1, and t2 relaxation times in both gray matter and white matter; age-related changes in gray matter, white matter, and csf volumes. all these reflect ongoing maturation and remodeling of the central nervous system [52, 53] . compared with adult cohorts, brain mr imaging of young children is challenging because of several factors. young children are less cooperative than adults with scanning procedures, which can be long, noisy, and uncomfortable when lying still for long; the images are often plagued with motion artifacts. the brain changes rapidly with age in early life after birth; the brain is not well myelinated; the contrast between gray matter and white matter is low. these pose difficulties to the optimized parameters for data acquisition protocol and also the standard parameters or criteria for the postprocessing procedures, such as the segmentation of the brain to determine cortical thickness [54] . as a result, the physical properties, such as relaxation times, water content, diffusion coefficients, of the developing brain are not very well characterized. other technical challenges exist to scan young children [55] . knowledge of the variations of biophysical properties, such as t1 and t2 relaxation times, water contents in gm and wm during the early life of children, is of critical importance to the understanding of neurodevelopment of young children and also to the development of diagnostic protocols of abnormal brain development. the measurement of these biophysical properties is challenging due to the prolonged scan time. recent technical development of magnetic resonance fingerprinting (mrf) allows rapid and quantitative analysis of multiple tissue properties [40] . for example, mrf can provide t1, t2, and proton density maps of the brain in contrast to the conventional t1-weighted, t2-weighted, or proton density-weighted images. a recent paper reported an application of the mrf to study the t1, t2, and mwf of children aged from 0 to 5 years old [56] . this study was able to record different patterns of variations of tissue biophysical parameters over different age stages. mrf techniques were also used to parametrically characterize brain tumors in children and young adults [57] . in a broad sense, the parametric information in mrf opened doors to studies of the correlations between brain tissue properties and brain development, impairment, and physiopathology. techniques of image fusion can play an essential role in the processing, interpretation, and application of mrf data. degenerative brain diseases are caused by the decline of neuronal function and the reduction of numbers of neurons in the central nervous system (cns). known degenerative brain diseases include mild cognition impairment, alzheimer's disease (ad), parkinson's disease, etc. the patients of these diseases suffer from losses of functions in memory, speech, movement, etc. most of these diseases (except for some mild cognitive impairment subtypes) are progressive, i.e. the symptoms deteriorate as the brains age. as the population is rapidly aging, degenerative brain diseases post enormous impacts on individuals, families, and society. the etiology of these diseases is still unknown, and there is currently no cure. in the following sessions, we will review advances of neuroimaging on mci, ads, and pds. mild cognitive impairment (mci) is a clinical transition between normal aging and dementia or alzheimer's disease (ad), in which individuals have memory or other cognitive impairments beyond their age, but not to the extent of dementia. patients with mci often only have minor difficulties in functional ability. in studies based on people older than 65 years of age, the incidence of mci is estimated to be at 10-20% [58] , and the mayo clinical study on aging shows an 11.1% incidence of amnestic mci (amci) and 4.9% incidence of non-amnestic mci (namci) in undiagnosed patients aged 70-89 years [59] . several longitudinal studies have shown that most mci patients have a significantly higher risk of developing to dementia compared to the general u.s. population (1-2%/ year) [60] , the community population (5-15%/ year), and the clinical patients (10-15%/ year) [61] [62] [63] . the latter data suggest that cognitive impairment tends to develop more rapidly for the patients that display serious symptoms. although some studies have shown that the incidence of mci reversals to normal cognitive function is as high as 25-30%, recent studies suggest that the incidence may be lower. in addition, cognitive reversals over a short period of follow-up study showed that they did not prevent subsequent disease progression. magnetic resonance imaging magnetic resonance imaging (mri) techniques have been used in the clinical identification of mci and various types of dementia to predict the progression of mci to dementia. for mri measurements of brain structure, linear, area, or volume measurements can be used. the results showed that the area of mci brain atrophy was consistent with ad, but to a lesser extent, between the normal elderly (control group) and ad patients [64] [65] [66] [67] . similar results were found using voxel-based measurement and analysis, with abnormal changes in not only gray matter but also white matter [68, 69] . the previous diagnosis of ad by structural mri was mainly based on the degree of brain atrophy, especially in the medial temporal lobe. the structural mri studies showed the atrophy along the hippocampal pathway (entorhinal cortex, hippocampus and posterior cingulate cortex), which was consistent with the loss of early memory. as the disease progresses, the temporal, frontal, and apical lobes shrink with neuronal loss, causing abnormalities in language, practice, vision, and behavior [70, 71] . however, no definitive biomarkers have been identified by structural mri alone to distinguish mci and ad, to stage mci, and to predict mci conversion to ad or not [72, 73] . mri-based functional imaging has been applied to the understanding of and to the discrimination between ad and mci. these techniques include perfusion-weighted imaging (pwi), diffusion-weighted imaging (dwi), diffusion tensor imaging (dti), and blood oxygen-dependent fmri (including task execution and resting state) [72] . functional mri allows the delineation of microstructural brain changes, which is complementary to structural mri that can depict the global changes of the brain in mci. an mri-based functional imaging study that employed pwi, dti and proton mrs showed significant abnormalities in parameters derived from the three imaging modalities for ad patients. pwi and dti parameters showed a significant, but a lower degree of abnormalities in some areas for mci patients. fmri has also been used to distinguish ad and mci and to predict the transition from cognitive normal to mci and from mci to ad. recent studies show that bold-fmri can detect changes in brain function before mci progresses to ad, making it an important technique to study the neural mechanism of mci [74, 75] . proton magnetic resonance spectroscopy ( 1 hmrs) is a noninvasive imaging method that can detect biochemical and metabolic changes in brain tissue in vivo and conduct quantitative analysis. early mrs studies show abnormal concentrations of n-acetylaspartate (naa), creatine, and choline are associated with the status of memory and cognition impairment and have a promise for assessing cognitive status, evaluating response to medicine, and monitoring progression during treatment [76] [77] [78] . in recent years, with advances in the technical development of mr hardware and pulse sequences, the roles of glutamate, the excitatory neurotransmitter, and gaba, the inhibitory neurotransmitter, in mci patients became the main focus [79] [80] [81] . for example, with ultra-high field 7 tesla mr scanner, abnormal concentrations of gaba, glutamate, naa, glutathione, and myo-inositol (mi) in different brain regions were detected [82] . the manifestations of 1 hmrs in mci patients were mainly shown in decreased naa/cr ratio and increased mi/cr ratio. the pathological results showed neuronal deletion and glial proliferation, and the changes in metabolite concentration were consistent with the pathological results [82, 83] . multimodal imaging pet and spect provide insight into blood perfusion and metabolism in tissues and organs, as well as explore changes in function. the nuclear medical images of amci patients showed decreased perfusion and metabolism in the hippocampus, temporoparietal lobe, and posterior cingulate gyrus. studies using pet, spect, and mri have shown that glucose metabolism in the hippocampus, glucose metabolism rate in the bilateral temporal-parietal lobe, and blood perfusion in patients with amci are lower than those in normal elderly. these studies have also shown that low glucose metabolism in the temporal-parietal lobe is a reliable indicator of conversion to ad [84] [85] [86] . excessive deposition of β-amyloid peptide in the brain and the cascade reaction caused by it are the early onset of ad. therefore, early detection of β-amyloid peptide in the brain can help identify patients with amci, and monitor the progression of the disease and treatment effect. it was found that the 11 c-pib-pet could attach to aβ in the brain. pet imaging showed the amount and location of aβ deposition in the brain, which was expected to be an early diagnostic method for ad [87] [88] [89] . multimodal imaging techniques involving mri-based imaging and pet-based imaging have been frequently used for prediction, characterization, and classification of mci [90, 91] . in facilitating these complex tasks, imaging fusion methods based on artificial intelligence, neural network, deep learning and graph theory have been used [92] [93] [94] . brain network studies based on multimodal mri and graph theory analysis have found that the topological properties of ad and amci affected brain networks have undergone abnormal changes, which mainly manifested as the imbalance between functional differentiation and integration. this approach provided a new way to reveal topological mechanisms and pathophysiological mechanisms of brain networks [93, 95] . in addition, the combination of graph theory analysis and classification analysis suggests that the brain network topology attribute can be used as an imaging marker of ad and has a good clinical application prospect. alzheimer's disease (ad) is a neurodegenerative disorder and the most common cause of dementia. ad is characterized by progressive memory loss, aphasia, loss of use, loss of recognition, impairment of visual-spatial skills, executive dysfunction, and personality and behavior changes [96, 97] . it has become one of the major diseases that seriously threaten the health and quality of life of the elderly [98] . the onset of ad is slow or insidious, with patients and their families often unable to tell when it starts. it is more common in the elderly over the age of 70 (the average male is 73, and the average female is 75 years old), with more females than males (female to male ratio of 3:1) [99] . there is currently no cure for ad, but large numbers of novel compounds are currently under development that have the potential to modify the course of the disease and to assess the efficacy of these proposed treatments. there is a pressing need for imaging biomarkers to improve understanding of the disease and to assess the efficacy of these proposed treatments. magnetic resonance imaging structural mri (smri) is the most widely used imaging modality for the study of ad. the techniques for analyzing smri are classified into volume-based and surface-based methods [100] . previous studies have shown that hippocampal volume atrophy and whole-brain atrophy independently predicted the progression of ad [101] . hippocampal damage or atrophy occurs in the early stage of ad, which is an important structural basis for the clinical manifestations of ad. although global hippocampal atrophy in ad was well accepted, the differences were often detected large sample-size studies [102] . de winter et al. studied 48 elderly ad patients with depression and 52 healthy control elderly people and examined all the subjects with smri and neuropsychology [103] . they found that there was no significant difference in the positive rate of aβ between the depression group and the healthy control group. however, the hippocampal volume in the depression group was significantly smaller than that in the healthy control group. there is significant hippocampal atrophy in elderly depression patients, and hippocampal atrophy has nothing to do with aβ, which challenges the reliability of hippocampal atrophy in the clinical diagnosis of ad. it is suggested that hippocampal atrophy not only occurs in ad but also in senile depression. the study of smri indicates that the brain atrophy shown by brain morphology and structure has reference value for the diagnosis of ad. however, the diagnosis of ad still needs to be confirmed by combining clinical manifestations, neuropsychological assessments, and other examination methods. it also indicates that follow-up is needed for suspected depression in patients with ad. the above studies showed the limitations of structural mri and the necessity of the multimodal approach in the study of ad [104] . other mri modalities, including functional mri, dwi, pwi, have also been widely used in the study of neurodegenerative diseases. we will review recent advances of the resting-state functional magnetic resonance imaging (rs-fmri) as an example. as opposed to the conventional task-based fmri, rs-fmri does not require the subject to perform any task or be subjected to any external excitation. the rs-fmri captures the low-frequency oscillations signals that are related to the spontaneous neural activity of the brain by analyzing the brain blood oxygen level dependent (bold) signal. sophisticated methods of analysis of the rs-fmri data depict the functional connectivity of the brain. the rs-fmri has been used to reveal how the networks of the functional connectivity are correlated to the brain functions of individuals with cognitive impairment. zamboni et al. found that the recognition task of ad patients was related to the increased activation of the lateral prefrontal area, which also overlapped with the functional connection enhancement area indicated by the rs-fmri [105] . zhou et al. predicted the pathological changes of ad by using the calculation model of resting brain function network and studied five different brain regions vulnerable to neurodegenerative diseases through the use of task state fmri [106] . they found that the brain network of ad patients may have the phenomenon of weak functional connectivity and their ability to transmit information of functional brain network decline. wang et al. found that the functional brain network of mci patients had different degrees of functional connectivity disorder. the evaluation of overall functional brain connectivity of patients plays an important role in the early diagnosis and treatment of ad [107] . abnormal brain connectivity can be a biomarker of the disease. many neuropsychiatric diseases and dementia can change the default mode network (dmn) of the brain. identification of the change in the connectivity of dmn is constructive for the early recognition of ad. jin et al. collected 8 patients with amci and 8 healthy people to analyze rs-fmri data by independent component analysis (ica) [108] . they found that the functional activities of the lateral prefrontal cortex, left medial temporal lobe, left middle temporal gyrus and right angular gyrus in amci patients decreased, while the activity of the middle and medial prefrontal cortex and the left parietal cortex increased. further studies found that the functional activities of the left lateral prefrontal cortex, left middle temporal gyrus and right angular gyrus were positively correlated with memory, especially delayed memory [109] . although there was no significant difference between the two groups in the degree of medial temporal lobe atrophy, the functional activities of the left medial temporal lobe decreased. this decrease suggests that the functional changes of dmn may occur in the early stage of ad, i.e. amci, and the functional changes may occur before the obvious change of brain structure. multimodal imaging due to severe overlap in symptoms and findings of individual imaging modalities of the neurodegenerative diseases, it is difficult to identify the biomarkers that could be used to differentiate the types of these diseases and/or to stage the progress of a disease. therefore, multimodal neuroimaging techniques are used to overcome the challenges [110] . as pointed out in [111] , individual modalities of mri and eeg lack precision in ad diagnosis and staging. by employing both imaging modalities, with the mri measuring the cortical thickness and the eeg measuring the rhythmic activities, the authors found joint markers that identified the subjects of alzheimer's disease with an accuracy of 84.7%, a significant increase from those of individual modalities. while some studies of multimodal imaging confirmed correlations of findings among individual modalities as in a study of smri and fmri [112] , multimodal imaging studies can also be used to dissociate the tau deposition and brain atrophy in early ads using pet and mri. the study found that the tau load had little effect on the gray matter atrophy, and this might imply that tau protein deposit precedes and predicts brain atrophy. the multimodal imaging studies require statistical and analytical models, advanced computing algorithms, and especially, novel data fusion methods [113] [114] [115] [116] , which will be reviewed in detail in the following sections. parkinson's disease (pd) is a chronic progressive degenerative disease of the central nervous system, which is commonly seen in elderly patients. typical clinical manifestations of pd include static tremor, myotonia, bradykinesia, and abnormal posture and pace [117] . with the continuous increase of the aging population, the incidence and disability rates of the population are also increasing year by year. the results of epidemiological surveys indicate that the prevalence of pd in people over 65 is about 1.7%, and the prevalence of pd in people over 80 is as high as 4% [118] [119] [120] . pd is more and more harmful to the health of the middle-aged and elderly, especially involving the central nervous system. due to the lack of objective basis and diagnostic criteria for the diagnosis of pd, the previous clinical diagnosis of pd was mainly based on the clinical symptoms, resulting in a low coincidence rate between the clinical diagnosis and pathology of pd and in a significant lag behind the pathological changes of brain microstructure. with the increasingly standardized diagnosis and treatment of pd, neuroimaging examination has become an indispensable part of the diagnosis. this differential diagnosis of pd can help identify different movement disorders, locate anatomical dysfunction sites, and determine the causes of the lesion, which will improve clinical evaluation and prognosis [121, 122] . magnetic resonance imaging structural cranial mri can distinguish white matter from gray matter by setting different imaging parameters while avoiding radiation. it is better than cranial ct in revealing white matter lesions, small infarcts, subacute intracerebral hemorrhage, and lesions in the brain stem, subcortical regions, and posterior fossa. on structural mri such as t1, t2-weighted, and fluid-attenuated inversion recovery (flair) images, pd patients usually exhibit broadening of the ventricles (caused by extrapyramidal atrophy) and widened sulci (diffuse brain cortical atrophy) [123] . the quantitative measurements of cortical atrophy can be measured based on voxel morphometric assessment. when the compact belt of the substantia nigra shrinks and the short t2 signal of the substantia nigra disappears, the width of the dense belt of the substantia nigra, the ratio of the width of the dense belt of the substantia nigra to the diameter of the midbrain, the caudex nucleus, the putamen nucleus, the thalamus and other areas of interest are measured. in evaluating the extent of atrophy, physiological changes such as age increase and relevant clinical supporting evidence should be taken into account [124] . neuromelanin-sensitive mri is used to detect neuromelanin, a surrogate biomarker for the pd. neuromelanin is a dark pigment found in neurons in the substantia nigra pars compacta. the concentration of neuromelanin increases with age but is found to be around 50% higher in pd patients compared with age-matched non-pd subjects, due to the death of cells in the substantia nigra. neuromelanin-sensitive mri allows the visualization of the neuromelanin-containing neurons in the substantia nigra, pars compacta. with the use of morphological analysis and signal intensity (contrast to noise ratio), the width and cnr of the lateral and central substantia nigra were found to be significantly lower in the pd subjects than in the control group and untreated essential tremor (et) group [125, 126] . therefore, this imaging technique can be potentially used as a biomarker to differentiate et from the de novo tremor-dominant pd subtype. the neuromelanin levels were quantitatively assessed using neuromelanin-sensitive mri and quantitative susceptibility mapping (qsm) [127] , an mri modality for measuring the absolute concentrations of iron, calcium, and other substances in tissues based on changes of local susceptibility [128] . while the neuromelanin imaging found significantly lower neuromelanin levels in the pd group than the health controls (hc), which is in agreement with the neuromelanin mri only study, the qsm values were significantly higher in the ps group than in the hc group. this result suggested the usefulness of qsm in detecting pd [127] . resting functional magnetic resonance imaging (fmri) is a technique that collects the blood oxygen level dependent signal changes of patients in the awake and resting states to obtain the functional activity level of the brain in the baseline state. in recent years, fmri has been widely used in clinical studies of all motor disorders or neurodegenerative diseases, including pd [129] [130] [131] . resting-state functional mri (rs-fmri) can calculate a variety of brain activity attributes, such as local consistency, range of low-frequency fluctuation, and amplitude of low-frequency fluctuation etc. by observing the correlation between time-dependent signals of blood oxygen levels in different voxels or areas of interest, we can further evaluate the synchronization of functional activity in different brain areas, i.e. functional connectivity [129, 132, 133] . in recent years, calculation methods based on independent component analysis, granger causality analysis and graph theory can help to find complex pattern changes in the brain network of pd patients. other imaging modalities and multimodal imaging other imaging modalities, including pet, spect, eeg, ct, have been applied to study the functional and structural abnormalities and changes of pd patients, and they provide much complementary information to mr-based imaging modalities mentioned earlier. pet studies investigated cerebral glucose metabolism with or without medications, with or without brain stimulations [134] [135] [136] . metabolic and brain chemical changes related to dopamine neurons in pd patients were also studied using spect, which cannot be assessed by other mri modalities including proton magnetic resonance spectroscopy (mrs) [137] . by jointly applying spect and dti, this study identified regions and connections of the brain that differentiate pd patients and healthy controls. different from the imaging modalities in that study, a recent study employed pet scans with two different tracers and rs-fmri to investigate variations of metabolism and functional connectivity of the pd patients [138] . it identified correlations between motor impairments with hypometabolism and hypoconnectivity in multiple brain regions. with the use of different modalities under similar aims, results from these studies can provide complementary information for the impaired regions. the data from them can be integrated and analyzed using data fusion like the work in [139] , in which data of anatomical mri, rs-fmri, and dti were analyzed for more accurate and reliable biomarkers of pd. mental disorders are conditions that affect a person's thinking, mode, behavior, relationship with others, and depression is a common mood disorder, which can be caused by a variety of reasons. the main clinical feature is marked with persistent depression of mood, which is incompatible with the situation. in severe cases, suicidal thoughts and behaviors may occur. most cases tend to show recurrence; and most can be relieved each time, while some may have residual symptoms or progress to chronic depression. at least 10% of clinical depression patients also show manic episodes and should be diagnosed as bipolar disorder [150, 151] . what we commonly call depression is clinical or major depression, which affects 16% of the population at some point in their lives [152] . in addition to the severe emotional and social costs of depression, the economic costs are also enormous. according to the world health organization, depression has become the fourth most serious disease in the world and is expected to become the second most serious disease after coronary heart disease by 2020 [153] . so far, the etiology and pathogenesis of depression are not clear, and there are no obvious signs or laboratory indicators of abnormality. although there have been many basic and clinical studies on depression, no critical breakthrough has been made in the three most important clinical problems: pathogenesis, objective diagnosis, and efficient treatment. a key breakthrough in these issues is to find and establish a stable biological marker from gene to clinical phenotype and then further study its pathogenesis, establish objective diagnostic methods and develop efficient clinical therapy. magnetic resonance imaging up to now, in the clinical research field of mental illness, especially depression, the most sought after biological markers may potentially be provided by the study of neuroimaging, especially brain mri. brain mri examination have characteristics of good clinical applicability, non-invasive, simple operation, universal, relatively stable results and easy to repeat, but its sensitivity and specificity need to be improved. brain mri research has become an intermediate mechanism from molecular research to clinical phenotype. through this mechanism research, we can not only explore how genes, molecules, and proteins affect the brain structure and function of patients with depression but also use mri as an objective diagnostic tool for the most urgent clinical needs. over the past 20 years, the application of multi-mode mri technology to study the brain structural and functional characteristics of depression, especially to establish clear biological marker targets around the characteristics of emotional circuits, has become one of the major scientific frontiers in the basic and clinical research of neuroscience. many studies have found that patients with depression have abnormalities in brain structure and function of emotional circuits, as well as in neurotransmitters associated with these circuits [149, 154] . mri studies in recent years found that the depressive mood is associated with three brain regions, namely in the amygdala and the ventral striatum as the primary mood areas, the orbital gyrus, medial prefrontal cortex and cingulate gyrus as the emotional auto-regulation areas, and the dorsolateral and ventrolateral prefrontal cortex as the center of the active emotional regulation area [154] [155] [156] . multimodal mri techniques used in mental disorders seek to find correlated, complementary, and/or converging image features from multiple image modalities and applied sophisticated analytical methods to identify robust biomarkers for the types of depression. a study employed dti, magnetic resonance spectroscopy (mrs), rs-fmri, and magnetoencephalography (meg) and revealed patterns of abnormalities of patients with major depressive disorders. these patterns included factors in the neurotransmitters (glutamate concentration), white matter fibers (fractional anisotropy), and functional excitations (fmri) [157] . a multimodal mri study involves structural mri and asl to assess grey matter volume and regional cerebral blood flow in mdd patients. this multimodal study revealed negative correlations between the extent of depressive symptoms and cbf in the bilateral para-hippocampus and between depressive symptoms and cbf in the right middle frontal cortex [158] . in addition to confirming the correlations among findings of individual modalities, some multimodal mri studies, however, found disrelations among individual findings in the mdd group [159] . further multimodal data analysis involving mri imaging data and clinical, neurobiological metrics of the patients may resolve the disparities. among the methods of the multimodal mri image fusion in depressive disorders, support vector machine (svm) [160] and linked independent component analysis [161] was recently used, respectively, to identify biomarkers for the classification and prediction of symptom loads of heterogeneous mdd cohorts. imaging data and neurobiological data were included in the data fusion. in both studies, the results did not show strong support for the hypothesis and did not provide sufficient evidence for the sought biomarkers [160, 161] . obsessive-compulsive disorder (ocd) is a group of neuropsychiatric disorders with obsessive thinking and compulsive behavior as the main clinical manifestations. it is characterized by the co-existence of conscious compulsion and anti-compulsion, and the repeated intrusion of thoughts or impulses into the daily life of patients that are often meaningless and involuntary. although patient perceives that these thoughts or impulses are their own and resist them to the utmost degree, he or she is still unable to control them. the intense conflict between the two causes the patient great anxiety and pain, which affects his other study, work, interpersonal communication, and even daily life. magnetic resonance imaging voxel-based morphometry was widely used in the smri studies of ocd. these studies measure the structures and volumes of regions of interest in various ocd groups and healthy control groups. ocd patients were found to have lower grey matter volumes in specific regions of the brain. for children with ocd, these regions include the bilateral frontal lobe, cingulate cortex, and temporal-parietal junction [162] . for adults with ocd, these regions are the left and right orbitofrontal cortex [67] . lower volumes were also seen in white matter in the cingulate and occipital cortex, right frontal and parietal and left temporal regions [162] and in a small area of the parietal cortex for patients with ocd [163] . fmri studies can provide information about the pathophysiology of ocd [164, 165] . however, whether this information from single fmri modality alone could be of clinical value in the diagnosis of individual patients is not clear [166] . the pathophysiological feature of ocd, as revealed by fmri studies, suggest that abnormal brain metabolites may be implied in ocds. abnormalities in brain metabolite concentrations in patients with ocd were investigated using proton mrs [167] [168] [169] [170] . among about ten detectable metabolites, glutamate, glutamine, and gaba are of particular interest, as they are involved in neurotransmission. recent studies show that ocd patients had an elevated gaba level and a higher gaba/glutamate ratio in the anterior cingulate cortex [171] , and they had lower gaba concentration in the prefrontal lobe, as compared to healthy control groups [172] . the roles of glutamate and glutamine in ocd are in the focus of research interest, but the findings lacked reasonable consistency [173] [174] [175] . the heterogeneity of structural neuroimaging findings of ocd may reflect the heterogeneity of the disease itself. multimodal mri multimodal mri studies in ocd provide complementary, correlated and/or integrated information of findings from individual modalities [176, 177] . early structural mri study suggested that the volume reduction of superior temporal gyrus (stg) is associated with the pathophysiology of ocd [178] . a functional mri study found increased low-frequency fluctuations in neural activities in stg [179] . a correlation between these findings was found in a combined structural mri and fmri study, which shows that the volume of the superior temporal sulcus is strongly correlated with functional connectivity between several brain regions that may form a neuro-network [177, 180] . the simultaneous 1h-mrs and dti study, to investigate metabolic and white matter integrity alterations in ocd, found that the level of glx to cr ratio in the anterior cingulate cortex was higher in the ocd group than the healthy control group [181] . the study also found from dti analysis that the fa values in the left cingulate bundle of the ocd group were significantly higher than the healthy controls. a limitation of this study is that the glx level, which is a combination of glutamate and glutamine, was measured instead of measuring glutamate and glutamine individually. it has been recognized that it is difficult to distinguish these two structurally similar metabolites using 3 tesla scanners and ultra-high magnetic field (e.g. 7t) scanners are required. schizophrenia is a group of serious psychosis with unknown etiology, which usually starts slowly or sub-acute in the young and middle-aged individuals [182] . clinically, it often manifests as a syndrome with different symptoms, including abnormalities in sensory perception, thinking, emotion, and behavior, as well as uncoordinated mental activities [183] . schizophrenia is a multifactor disease [184] . deterioration. some patients eventually show recession and mental disability, but some patients can maintain recovery or basic recovery after treatment [185] . magnetic resonance imaging structural mri was widely used to study the morphology and volumetry of the brains of schizophrenia patients. studies found that the average brain volume of schizophrenia patients was smaller than that of healthy people [186, 187] . the abnormal volume and structure of white matter usually appear before the onset of the disease, and these abnormalities tend to be stable during the development of the disease [188] ; the change of gray matter volume is more evident after the onset of the disease and decreases progressively over time [189] . according to a longitudinal study, gray matter deficiency in schizophrenia mainly occurs in the first five years [190] . quiet complement to the structural mri, dti reveals the abnormalities of white matter microstructure of schizophrenia patients [191] . decreased fractional anisotropy in white matter tracts, different cortical regions, and subcortical regions was found in schizophrenia patients in some studies. however, controversial findings were also reported [192, 193] . these inconsistencies might be attributed, in part, to small sample sizes. a large-scale dti study involving more 4,000 subjects found widespread white matter microstructural differences between schizophrenia patients and healthy controls [194] . significantly reduced fractional anisotropy values were found in 20 of the 25 investigated regions within the white matter. furthermore, significantly higher mean diffusivity and radial diffusivity were also observed in schizophrenia patients than in healthy controls. functional mri techniques are used to detect the deficits in neural networks of patients with schizophrenia [195] . brain network studies show that the functional connectivity of the default mode network (dmn) in schizophrenic patients has changed. although the research structures are inconsistent, most studies show that dmn functional connectivity is enhanced in schizophrenia, and functional connectivity in the prefrontal cortex is weakened (especially in the prefrontal cortex) [196] . in addition, the functional connections of auditory/linguistic networks and basal nuclei are related to auditory hallucinations and delusional symptoms. the study of brain structure networks found that the number of frontal and temporal core nodes decreased and the average shortest path increased, indicating decrease in global efficiency. wang et al constructed a network of dti images of 79 schizophrenia patients and 96 age-matched normal subjects [197] . they found that: compared with the normal subjects, the global efficiency of the schizophrenic group decreased; the local efficiency of the core nodes distributed in the frontal cortex, the paralimbic system, the limbic system and the left putamen decreased; and the global efficiency of the network was negatively correlated with the panss score. research shows that the change in brain structure network started at the beginning of the disease. more severe symptoms indicate lower the global or local efficiency of the network, and the slower the speed of information integration. magnetic resonance spectroscopy studies found that the brain metabolism of schizophrenia patients was abnormal [198] [199] [200] . the levels of n-acetyl-aspartic acid (naa) in the hippocampus, frontal lobe, temporal lobe, and thalamus of schizophrenic patients decreased; the levels of naa in the thalamus of high-risk groups also decreased, while the level of naa in temporal lobe decreased. it was also found that the increase of glutamate level in the hippocampus and medial temporal lobe was related to the decrease of executive function. multimodal imaging the heterogeneities of findings of individual imaging modalities have been driving the multimodal neuroimaging approach to the search of the more consistent and precise biomarkers for the deficits, abnormalities in functions of schizophrenia patients. a concerted use of three mri modalities, namely, resting-state of fmri, structural mri, and diffusion mri, was able to simultaneously reveal abnormalities from these three kinds of mri images and, thereby, identify the cortico-striato-thalamic circuits that might be related the cognitive impairments in schizophrenia [201] . in addition to the multimodal imaging investigation of structural and functional brain abnormalities in schizophrenia, proton mrs has also been used in combination with fmri to investigate cognitive impairment in schizophrenia at both neurometabolic and functional levels [202] . the combined proton mrs and fmri study are particularly useful for short-term longitudinal studies on the effects of medication, which is invariant to brain structural change. in this study [202] , the relationship between glx/cr levels and bold response significantly changed after six weeks of medication for schizophrenia patients, although factors that confound interpretations of the results remain. more examples of multimodal imaging studies on schizophrenia are given in recent review articles [203, 204] . multimodal fusion has gradually entered the center of research interest as an approach to tackle the challenges of neuroimaging. the first main reason is that there exists a great complementarity between different imaging modes. for instance, the images obtained by positron emission tomography imaging (pet) or single-photon emission tomography imaging (spect) do not contain high resolution, three-dimensional anatomical information. on the other hand, high-resolution structural images can be obtained via the use of ct and/or mri. these images complement each other to provide a complete picture of the targeted organs' anatomy, physiology, and pathology. the fusion of these images is of great significance for the relevant clinical and pre-clinical studies. another outstanding merit of utilizing multimodal fusion is that it efficiently enhances the spatial and temporal resolution in the characterization of brain processes. in other words, multimodal imaging may allow the combination of the hyper-temporal resolution of one imaging mode with the hyper-spatial resolution of another, taking advantage of the spatial-temporal complementarity. take a study in 2014 as an example, ke zhang et al have successfully measured the cerebral blood flow with a combination of arterial spin labeling (asl), mri and pet [205] . apart from this, utilizing eeg together with fmri to improve spatial and temporal resolution has also been studied by many scientists in neuroscience [206] [207] [208] [209] it is worth mentioning that, in both narrow and wide senses, multimodal data fusion has a high capacity of generalization. a typical instance is the alignment of functional mri, eeg, and fnirs images to an anatomical coordinate system. the coordinate system can act as a template to standardize reported results. the alignment of the images to a single coordinate system not only allows comparison with other studies but also allows the combination of functional and structural information [210] . pet/ct combination is a multimodal absolute quantification approach where ct provides structural data information on bones, which also serves as the main absorber for the γ-rays in pet. this combination allows decay correction, in which the accumulation of radioactive isotopes in human tissues becomes apparent, and the amount of radioactive decay can be absolutely quantified [211, 212] . multimodal imaging also has the benefit of utilizing data from one modality to improve the data quality of another modality, such as correcting the geometric distortions of epi images by acquiring a b0 field map or obtaining epi with different parameters [213, 214] . another classic case is in a combined mr-pet study, where the motion information provided by high-temporal resolution mri data was used to help the reconstruction of the pet data [10] . the long history of neuroimaging has led to the development of an assortment of imaging technologies and modalities, as seen in section 3. the existing research and apparatus provided a solid foundation for multimodal fusion, leading to the rapid development of many fusion techniques. in this part, we classify reviewed methodologies into four primary forms: multimodal, multi-focus, multi-temporal, and multi-view. modern medical imaging methods aim at revealing possible dysfunctions in patients. for example, neuroimaging methods are often used to image the structure of nervous system on a macroscopic level, which in turn helps explore the neuroglial basis of behavior and cognition of patients. however, how to combine different medical imaging methods to provide images with better quality or clearer structures remains to be the heated research interest in the field. therefore, multimodal image fusion is proposed to minimize the gap. in a narrow sense, multimodal image fusion, a technique to improve the interpretation of the structure and functions of target organ or region, generally combines two or even more images collected from different imaging instruments. in order to achieve the goal of simultaneous acquisition, researchers have developed particular instrumentations to allow data of one modality to be acquired with low or neglectable inference from another modality. for instance, the eeg-fmri combination fuses data acquired from eeg instruments like amplifiers and mri scanners. also, the novel instrumentations range from simple arrangements to relatively complex technological innovations. however, in some combinations, simultaneous acquisition of data was impossible due to the physical interactions of the imaging devices. multimodal image fusion, in a broader sense, also combines data but collected with the same instrument. in this case, mri is widely used due to its versatility in the generation of different tissue contrasts with the well-studied phenomenon of magnetic resonance. there is also research that combines two and more contrasts in the same acquisition, which has been routinely used for many years. multiple contrasts can also be acquired by pet (positron emission tomography) when radioactive compounds injected are different. a region-based method, which incorporated segmentation into the fusion process, was proposed by s. li in and local focus measure comparison. it was pointed out that local features such as dense sift can also be used to match pixels that were misregistered between multiple source images. in methods based on frequency, images are transformed into the frequency-domain for fusion. wavelet-based methods, including discrete wavelet transform (dwt) [221] , haar wavelet [222] and pyramid-based methods such as the laplacian pyramid [223] , fall under the category of frequency-domain methods. a dwt based method was proposed in [224] . principal component analysis (pca) was used for approximating coefficients of input images. the principal components were evaluated to obtain multiscale coefficients. the weights for the fusion rule were then acquired by averaging those components. besides the promising performance, the proposed method was widely applied in medical image fusion for ct and mri images. in [225] , the authors proposed the daubechies complex wavelet transform (dcxwt) to fuse multimodal medical image. by using the maximum selection rule, the complex wavelet coefficients of source images are fused. source images at different levels are decomposed by dcxwt, followed by inverse dcxwt to form the fused image. compared to the other five methods, including dual tree complex wavelet transform (dtcwt) based fusion and pca based fusion, the proposed method achieved the best performance in terms of five measurements, including standard deviation, entropy, edge strength, fusion symmetry, and fusion factor. it was proved that the proposed method was robust to noises, including speckle, salt and pepper, while maintaining the property of shift-invariance. multi-temporal fusion is to fuse images taken at different times but of the same modality. multi-temporal fusion enables easy detection of changes in images by subtracting one or multiple images from another. data acquisition consists of separate recording and simultaneous recording. the choice between separate or simultaneous acquisition should be cautiously considered. compared to separate recordings, where an image from each modality is acquired individually, simultaneous acquisitions have relatively lower data quality and more artifacts. for example, eeg-fmri simultaneously acquires cardio-ballistic artifacts and mri gradients. data acquisition consists of separate recording and simultaneous recording [226] . in the mr-pet scenario, components of the mri scanner would trigger degradation in pet scanning results. therefore, the costs of simultaneous acquisition are higher than separate acquisition due to subject discomfort and long set-up time. however, there are also many cases in which costs are of less concern, given the benefits of simultaneous acquisitions. in multi-view fusion, images of the same modality are taken under different conditions at the same time. this fusion technique is applied to increase the amount of information for the fused images, while source images are taken under different conditions. the choice between asymmetric and symmetric data fusion makes a significant difference in the integration and joint analysis of multimodal data. for integration methods falling under the asymmetric category, information from different modalities is assigned with different weights so that information from one modality could be treated as a constraint on the other modality. for instance, fmri contrast maps limit the source localization of eeg/meg. modalities in symmetric data fusion, however, are treated equally in terms of spatial and temporal resolution as well as the uncertainty in the possible indirect relation to neural activity. hypothesis-driven approaches and data-driven approaches are the two main categories of symmetric fusion approaches. hypothesis-driven approaches, also called model-driven approaches, are usually in model-based setting, while data-driven approaches belong to blind source separation methods [227] . examples of different fusion methods are shown in table 3 . image fusion rules are applied to highlight the features of interest in images while suppressing the unimportant features. generally, fusion rules are mainly comprised of four components: activity-level measurement, coefficient grouping, coefficient combination, and consistency verification [230] . the activity-level measurement rule, as can be subdivided into window-based activity (wba), coefficient-based activity (cba) and region-based activity (rba), characterizes coefficients at different scales. in the coefficient grouping component, there are mainly three typical groupings, including single-scale grouping (sg), multi-scale grouping (mg), and no-grouping (ng). sg indicates that the same strategy is applied to fuse different coefficients between sub-images on the same scale. the coefficient combination component mainly comprises of maximum rules (mr), weighted rules (war), and average rules (ar). mr can be given as: where c f indicates the combined coefficient, 1 and 2 are the coefficients of two input images at the level of . for war, 1 and 2 are combined by multiplying different weights 1 and 2 , that is ar, which has the coefficient of input images averaged, is a special case of war. the consistency verification component ensures that the same rules are applied to fuse the coefficients in the neighborhood. there are three different levels of image fusion: pixel level, feature level, and decision level. this categorization can be seen in table 4 and figure 10 . pixel level rules directly deal with the information acquired from each pixel of source images and then generates pixel values for the fused image correspondingly. feature level rules focus on regional information and features such as texture and salient features. the fused image in the decision level is acquired through rules of fuzzy logic and statistics. before rules in feature level and decision level apply to the source images, segmentation of the source images is needed. compared to the pixel level fusion, feature and decision level fusion shows more advantages are less affected by noises and misregistration. feature and decision level fusion also shows better contrast and lower complexity [231] . in the following sections, we will introduce fusion rules for multi-model image fusion, followed by validation metrics. figure 10 pixel-based and window-based fusion fuzzy logic-based rules belong to decision level fusion. these rules are usually used to solve challenges in blurry fused images. mamdani and t-s models are two fuzzy logic models. the difference between them lies in the consequence parts. t-s models linearly mapped input variables into functions to form the consequence parts, while mamdani models used fuzzy sets. the t-s model is more advantageous than the mamdani model in regard to number of rules and accuracy. in general, feature extraction through fuzzy logic algorithms is performed prior to fusion, which generates pixel-wise features 1 and 2 from two input images. the fusion procedure can be divided into three steps. in the first step, the fuzzy logic, which is usually comprised of four conditional rules, is used to label the individual pixels as following. = { , both of 1 and 2 are high (rule1) , 1 is low but 2 is high (rule2) or 1 is high but 2 is low (rule3) , both of 1 and 2 are low (rule4) then the new pixel-wise feature values can be calculated through: where 1, 2, 3 corresponds to low, medium and high components, respectively. and are the mean and variance of each component. by incorporating the center average defuzzifier to process fuzzy outputs, the weight of fuzzy logic can be obtained. the essence in statistics-based methods lies in the data-driven technique and high order statistics that can reveal the underlying pattern across multiple modes of data. principal component analysis (pca) [232] [233] [234] [235] together with hidden markow tree (hmt) [236] [237] [238] are two typical examples of statistic methods in the field of multi-modal medical image fusion. pca is an orthogonal linear transformation that reveals the most valuable components of the input images. let 1 and 2 be the two coefficients of the input images that can be denoted as: where 1 and 2 (1 ≤ ≤ ) are column vectors of two coefficients 1 and 2 . the importance of components is related to the eigenvalues in the covariance matrix between 1 and 2 . the covariance matrix can be computed through: where is the expectation of vectors, 1 ̅̅̅ and 2 ̅̅̅ corresponds to the average of 1 and 2 respectively, that is given the eigenvalues obtained from the covariance matrix as , the normalized weights 1 and 2 for 1 and 2 can be denoted as: therefore, the fused coefficient can be the combination of two input images: the two-state hmt method, unlike pca methods, can be deployed to model the coefficients. two mixed gaussian random distributions, as well as the hidden states, depict intra-coefficients. the hidden states here refer to the one parent and four children coefficients. given each coefficient denoted as , the coefficient is obtained by probability density function: when the coefficient in the state n (n=0, 1), ( | = ) is the probability density function correspondingly. the fused coefficient is then given by: methods based on the human visual system (hvs) aim at solving the fusion problem in the way of image recognition and comprehension. the system includes components such as visibility, smallest univalve segment assimilating nucleus (susan) [239] , and retina-inspired model (rim) [240, 241] . the sharpness of an image can be quantified by visibility. therefore, the images with higher visibility show lower blurriness. given an image of size × , then the visibility of the can be mathematically expressed as : where µ is acquired by calculating the mean grey value of the image and , the visual constant varying from 0.6 to 0.7. susan, proposed in [242] , is a feature extraction algorithm inspired by hvs. susan computes the feature of a pixel by considering a circular mask around the pixel. in the mask, the area consisting of pixels that have similar brightness to the nucleus, or the central pixel, is selected and is called univalue segment assimilating nucleus (usan). let the input image to be and the circular mask with the radius , then simplest usan can be given as : where 0 is the central pixel, is a nominal depicting surrounding pixels. ( )is the pixel value at and is the brightness difference threshold. the value of , which specifies the range of pixel values to be considered, must be carefully chosen because extracted features are sensitive to it. in order to lower the sensitiveness, the distance between pixels is also taken into consideration, and the extended usan function is: where is the distance scaling factor. for components in intensity-hue saturation (ihs) decomposition methods, the rim model can be used as the fusion rules. there are five layers in rim. the first cone layer outputs an array of high-resolution cone photoreceptors with high resolution. the second layer is the extractor for spatial feature, while the third layers are horizontal cells. the fourth and fifth layers, which combine features, are bipolar and ganglion cells the rim based image fusion rule can be demonstrated as: where 1 and 2 stand for intensity components of two source images. 1 and 2 are the filters of feature extractors. the filter 1 , a high-scale spatial feature extractor, calculates the spatial difference between high-resolution and low-resolution. filter 2 combines the output of horizontal cells. objective evaluation metrics are used to evaluate the efficacy of image fusion rules on improving the quality of the fused image. widely used metrics includes spatial frequency (sf) [243] , the ratio of spatial frequency error (rsfe) [244] , wavelet entropy (we) [245] , signal noise ratio (snr) [246] , mutual information (mi) [247] and directive contrast (dc) [248] . sf metric, which measures images' activity, is generally used for pca integrated his methods in multimodal image fusion. sf can be defined as where and stand for column frequency and row frequency, respectively. based on sf, rsfe compares the sf f ′ of the fused image with 1 ′ and 2 ′ of the input images where sf' can be extended as: where and are the main diagonal sf and the secondary diagonal sf. rsfe can then be formulated as: calculated by multi-scale entropy, we can be given by: where i is the resolution level, is the density distribution derived from the energy of the detail signal and the total energy = in [246] , the authors proposed snr-based image fusion rules. the proposed fusion method can be formulated in the following form. for a specific region . ( ) is the activity level of that, while is the total number of pixels. the probability of pixel activity can be calculated through: where is the weight of snr from the image, is the number of decomposition levels and ( 1 , 2 ) is the detailed wavelet coefficient. mi is deployed as the fusion rule for wt-based multi-modal medical image fusion. mi between the input images , and the fused image , is maximized to give , which is acquired by: dc measures the difference between the pixel and its neighbors. the ratio between the high-frequency intensity and the low-frequency intensity is the intensity contrast dc. for the multi-modal image fusion of neuroimaging, the selection of various decomposition and reconstruction methods influence the fusion procedure and outcomes. in this survey, we shall discuss seven popular methods: (i) rgb-ihs; (ii) pyramid representation; (iii) wavelet-based approach and its variants; (iv) multi-resolution analysis; (v) sparse representation; and (vi) salient features. the intensity-hue-saturation (ihs) model [249] helps transform the original image in rgb color space to hue, saturation, and intensity channels. this rgb to ihs procedure is calculated by simple equations. besides, the reconstruction is carried out by inversed transformation (ihs to rgb). for the rgb->ihs procedure, the intensity of each input image was estimated by the following equations: then, we consider three conditions: c 1 : b<r,g; c 2 : r<b,g; c 3 : g<r,b. the hue value is obtained by the saturation value was yielded from the equation on the other hand, after the revision was performed on the i, h, and s components, we can convert from ihs color space to original rgb space based on three various conditions: for c 1 , we have for c 2 , we have for c 3 , we have pyramid representation (pr) is commonly employed in image fusion. pr is a typical multi-scale signal representation approach that can be used for 1d signals, 2d images, etc. figure 11 shows a toy example using the cameraman picture. there are two pyramids commonly seen in practice: lowpass pyramid and bandpass pyramid. the former smooths the image and then under-samples the smoothed image. the latter generates the difference between images at adjacent levels and carry out image interpolation between neighboring levels of resolution. suppose f k is the filter and down-sampling, pr can be obtained by where r k is the residual image of i at i-th level, and k is in the range of ∈ ,1, … , where k is the maximum iteration number. after modification on the pr of input images, the fused image i f is obtained by inverse pyramid transformation (ipt) as the process of pr based fusion is shown in figure 12 . figure 12 diagram of two-level pyramid representation based fusion wavelet transform (wt) based fusion is one of the multi-scale analysis methods. the idea is simple, as shown in figure 13 . wt will decompose the input images into low-frequency (lf) and high-frequency (hf) subbands. the corresponding image fusion rules will be applied to fuse lf and hf subbands. finally, the fused image is yielded by the wt reconstruction technique [250] . where here, the wavelet φ , ( ) is calculated from the mother wavelet φ( ) by translation and dilation. the dilation factor c and translation factor b are all positive numbers. on the other hand, the discrete wavelet transform (dwt) captures both spatial information along x and y axes, by discretizing above two equations then, suppose a low-pass filter (lpf) and a high-pass filter (hpf) are created, we have where n is the discrete version of time t, e represents the coefficients, a and d correspond to approximation and detail, respectively. the symbol ↓ represents the downsampling operation. the above decomposition process can be iterated with successive approximations being decomposed in turn, so that one signal is broken down into various levels of resolution. when i(n) is extended to be a 2d brain image i(m, n), the 1d-dwt is applied to row and column directions separately. the approximation (a) and detail (d) subbands now expand to four subbands: approximation subband (a), horizontal subband (h), vertical subband (v), and diagonal subband (d), as shown in figure 14 . figure 14 diagram of 2d-dwt 2d-dwt can even be generalized to 3d-dwt. a straightforward implementation is to apply 1d-dwt to row, column, and slice directions, respectively. figure 15 shows an example of carrying out 3d-dwt to a cubic image. the dwt can provide better performances than traditional signal processing techniques, but it lacks translation-invariance and directional selectivity. hence, new variants of wavelet-based techniques have been applied to multi-modality image fusion. the stationary wavelet transform (swt) can solve the shift-variance problem by getting rid of the downsampling operation from ordinary dwt. swt can provide more details and texture information than dwt. (2019) [253] used swt and convolutional sparse representation for multi-modal image fusion. the dwt calculates each decomposition level by passing only the previous approximation coefficients to quadrature mirror filters (qmf). nevertheless, the discrete wavelet packet transform (dwpt) [254, 255] passes all coefficients (both approximation and detail) through qmf to create a full binary tree. sreekala and kuncheria (2016) [256] used wpt to implement misaligned image fusion. shah, merchant (2010) [257] combined curvelet wavelet and the wpt method to carry out image fusion. to increase directional selectivity, the dual-tree complex wavelet transform (dtcwt) used two separate two-channel filter banks. the scaling and wavelet filters in the dual-tree cannot be selected arbitrarily. in one tree, the wavelet and scaling filters produce a wavelet and scaling function, which are approximate hilbert transforms of those generated by another tree. at each level of 2d dtcwt, it produces a total of six directionally selective subbands (±15°, ±45°, ±75°). figure 16 lift scheme (ls) is a solution to reduce computation time and accelerate the design and application of dwt [258] . the idea of ls is to factorize dwt with finite filters, into a sequence of ordinary convolution operators, which are called "lifting steps" [259] . this procedure can reduce the arithmetic operations by almost two. mathematically, the analysis filters ( , ) can be formulated in the form of polyphase matrix this polyphase matrix p(z) is a 2 × 2 matrix, which contains the analysis lpf and hpf, each split up into their even and odd polynomial coefficients and normalized. [261] used the level-set method and ls-based cdf wavelet to compress magnetic resonance images. apart wavelets also fail to capture the geometric regularity along the singularities of surfaces, because of their isotropic support. shearlet transform (st) is one of the best sparse directional image representation methods. figure 18 showed the st coefficients, where the input image is figure 16 different from standard multi-scale analytic methods, the sparse representation (sr) assumes that both high-frequency and low-frequency components share the same set of sparse coefficients [269] . sr based fusion method root from compressed sensing. nowadays, there are some famous variants of sr, such as group sparse representation and joint sparse representation (jsp) [270] , the diagram of which is shown in figure 19 . from figure 19 we can observe the detailed steps of jsp [271] . first, both input images i 1 and i 2 are transformed into vectors via sliding window where sw represents the sliding window method. an over-complete dictionary sparsely represents the vectors of both images where c represents the intersection of vectors of images i 1 and i 2 , and u represents their differences. the two variances c and u can be obtained by where e stands for the over-complete dictionary, and t c and t u denote the sparse coefficients (sc) of c and u . afterward, scs from both input images are combined using fusion rules as where t f stands for the fused sc. the over-complete dictionary can generate the fused vectors where f stands for the fused vector. finally, we can transform f to image space and get the fused image i f . salient feature based fusion approaches are a type of novel methods, with the benefits of shift-invariance, low-cost computation, and saliency-feature preservation. the edge-preserving filter (epf) is an important research method among all salient feature fusion approaches. scholars have proposed many epf approaches, such as local extrema scheme [272] , multi-scale edge-preserving decomposition [273] , edge-preserving smoothing pyramid [274] . the bl of each input image at different scales is obtained by assessment is an essential component of multimodal data fusion that provides perspective into the quality of fusion results. there are two main forms of qualitative assessment: subjective quality assessment and objective quality assessment. in this part, we will review the conventional techniques and metrics applied in both forms. subjective assessments are established as a reliable form of quality evaluation in image fusion [275] . professional subjective assessments based on medical and radiology expertise are widely applied in neuroimaging studies. conventional subjective quality assessments are in the form of surveys with a set predesignated of questions and solutions, which represents a non-linear mapping to quantitative quality metrics [276] . typical questions in neuroimaging fusion are the number of artifacts or distortion, while typical solutions can be in the form of basic descriptors (e.g. none, minimal, some, substantial) associated with continuous scores. subjects are required to answer questions with respect to a set of images. it is ideal for image sets between subjects to overlap in order to ensure multiple surveys for the same image. with a set of high-quality fused images as references, the survey scores are then converted to difference scores with respect to scores of reference images. the difference scores are then converted to z-scores and rescaled to the required range for analysis [276] . the double stimulus method is commonly applied to account for the potential misalignment in quality scales between different image sets or different assessment sessions. in the double stimulus method, both surveys and references are randomly included in the test set [277] . conventional quality metrics obtained using these methods are the mean opinion score (mos) and difference mean opinion score (dmos). data noise elimination and outlier removal for images & subjects are then performed after obtaining the scores. subjective quality assessments are vulnerable to both intra-expert and inter-expert variability, while the requirement for expertise significantly increases the cost of assessments. for extensive studies, considerable efforts are required to standardize and maintain assessment protocols for optimal consistency [278] . in contrast to subjective quality assessment (qa), which involves a complex organization of observers and strict tests, objective qa only requires the computation of a single numerical score. objective qa should be consistent with subjective qa, and often relies on statistical properties of the images, or even stochastic modeling of the human visual system (hvs) [279] . objective qa can be classified according to the reference (distortion-free) image used in the score computation. the best-case scenario is the full-reference qa [280] , in which , with the same resolution as the fused image , is known. this approach is, by far, the most widely extended. however, this full-reference is rarely available in practical applications. for example, in multi-spectral satellite imaging or medical imaging, some image modalities are acquired at a lower resolution and then fused with higher-resolution gray-level images. this is known as the reduced-reference case, where is sometimes available at a coarser resolution and sometimes just a set of extracted features, and the qa is performed in this feature space. finally, a third case is when no reference is available at all [281] . in this case, is considered by itself, and measures like entropy and contrast are computed using only the information contained within. depending on the type of quantification used, the metrics can be classified into "signal distortion" and "salient feature" categories. the former uses strict mathematical theory to assess quality, e.g. with entropy, standard deviation, etc. the later is grounded on a modeling of the hvs to assess salient feature transferred from to . the first signal distortion metric is a commonly used statistic, the standard deviation (std) between the input image and . let us consider the images as a function ( , ) and ( , ) defined in the range ∈ ,0, …and ∈ ,0, … -, with the number of rows and the number of columns in the image. the std is computed as: being the mean intensity of the fused image. similar is the root mean squared error (rmse), also widely used in many applications, included objective qa: an additional measure based only on pixel intensities is the sharpness (sp), that reflects the level of detail transferred to : and finally, the peak signal-to-noise ratio (psnr), which is perhaps the most widely used objective quality assessment: where is the number of intensity levels, typically 256 for 8-bit images. now there are many other measures based on information theory and entropy [282] . to perform this computation, let us note ( ∨ ) as the ratio of pixels with gray value equal to over the total number of pixels × of image . we define the entropy (en) as: the difference of entropy (den) [282] quantifies the differences between and . the smaller, the better: another possibility when a reference image is available is to compute the cross-entropy (ce) between the reference and the fused image : from ce we can derive the overall cross-entropy (oce), which measures the entropy between several input images and the fused image. the formula below refers to images, but the most common case is the one that uses just two images, 1 and 2 : in sheikh and bovik (2006) [276] , 51 the mutual information (mi) is then obtained in [284] as: with = 1 , 2 to obtain them with no reference images. however, the ( , 1 ) and ( , 2 ) are not guaranteed to be on the same scale. the solution is the normalized mutual information, devised in [284] and re-formulated in [283] for the fusion of two source images 1 , 2 as: ( 1 , 2 , ) = 2 0 ( 1 , ) the spatial frequency (sf) [285] is often used to measure the overall clarity of the fused images. it is obtained from the row frequency ( ) and column frequency ( ) of the image as follows: 77) and the sp is obtained by the harmonic mean of these two measures. ( ) = √ ( ) 2 + ( ) 2 (78) salient feature metrics assess whether the salient features of the source images have passed to the fused image, following the hypothesis that the hvs is highly adapted for the perception of structural information. the most widely used measure in this category is the structural similarity (ssim) index [281] , which is based on the degradation of structural information. the ssim compares local patterns of pixel intensities, based on luminance , contrast and structure : ( , ) = , ( , )-, ( , )-, ( , )weighted by some exponential variables that were set to = = = 1 in the original paper [281] . several expressions are provided for ( , ), ( , ) and ( , ), with certain constraints, and after substituting on the previous equation, it becomes: ( , ) = where 1 and 2 are two constraints of the model, expressed by 1 = ( 1 ) 2 , 2 = ( 2 ) 2 and 1 ≪ 1, 2 ≪ 1. the notation and corresponds to the mean intensity and unbiased standard deviation of the intensities of , as in previous equations, and is the covariance matrix of the intensities of and . with and the mean vector and covariance matrix of the mgm of . multimodal neuroimaging and the fusion of multimodal data tackle the challenges of neuroimaging and the fundamental limitations of individual modalities, and therefore provide significant benefits to the overarching aim to achieve higher image quality and reveal brain physiology. this part will review some of the main benefits with specific fusion examples. mr-pet refers to a functional metabolic and molecular multimodal imaging method integrated through a combination of mri and pet. it has the potential to achieve the maximum complementary advantages with the examination function of both pet and mri [287] . mri can not only display structural details through multi-parameter sequences but also perform a variety of functional imaging. in other words, it can be seen as a means of anatomical imaging. however, compared with pet, mri still has certain limitations in metabolite imaging. pet imaging can show trace amounts of radiolabeled molecules, but its image resolution is poor and the anatomical structure is not clear. it is the complementary characteristics of mri and pet that led to the birth of mr-pet imaging, which not only has high soft-tissue contrast and resolution but also can provide valuable functional information [288] . at the radiological society of north america meeting in november 2006, siemens presented the first mr-pet images of the brain from their diagnostic machine. during the imaging process of mr-pet, pet and mr imaging can be performed simultaneously with minimal interference; the pet scan detects the accumulation of fluorodeoxyglucose, while multiple sequences of mr images were obtained [289] . in neuroimaging studies of mri, the common approach tends to acquire t1-and t2-weighted anatomical, t2*-weighted functional data within the same session and then make a combination of these different contrasts for further exploration and research. here, t1 refers to the recovery time of longitudinal magnetization, and t2 refers to the decay time of transverse magnetization. both of them are special values associated with the spin of the nucleus in the tissues. in humans, t1 and t2 values of diseased tissue and normal tissue are different, so diseases can be diagnosed by nuclear magnetic resonance imaging [290] . magnetic resonance images are presented in different shades of gray, reflecting differences in the intensity of magnetic resonance signals, or in the length of relaxation times t1 and t2. pure t2 dephasing is intrinsic to the sample. while t2* dephasing is relevant with true t2, field inhomogeneity (t2m) and tissue susceptibility (t2ms) as shown in equation (82). according to the common neuroimaging protocols, t1-weighted scans have good resolution and gray-white matter contrast, so it is better for observation of anatomical structure. t2-weighted scans perform well in showing histologic lesions, so it is often used for checking permanent brain injury. t2* is mostly used in scanning brain activity. an increase in t2* weighted signal between baseline and an active condition is associated with brain activation in studies using blood oxygenation-level dependent (bold) fmri. for instance, as displayed in figure 21 , brain regions become oxygen-rich after activity, which leads to a decrease of the hbr/hbro2 ratio and the increase of fmri signal. consequently, for t1, t2 and t2*, each method provides a physiologically and physically filtered view on one or more brain processes of interest [291] . figure 21 comparison of hbr/hbro2 ratio in brain capillaries before and after activity thus, combining different contrasts has the general merit of getting a more comprehensive physiological view on brain processes than utilizing just one imaging method alone. in figure 4 , the spatial and temporal ranges for the most widely used non-invasive functional imaging methods are presented. functional mri, as the non-invasive functional imaging method, has the highest spatial resolution though the temporal resolution is relatively low compared to neuronal population dynamics. meg and eeg can measure magnetic and electrical changes on millisecond time scales while the spatial resolution is beyond seven millimeters [15] . ultra high-field mri has been widely used for the mesoscopic level of neuroscience in humans [292] [293] [294] . as a consequence, the spatio-temporal resolution can be improved by combining different imaging methods, especially through the combination of one modality that has a higher temporal resolution with another modality of superior spatial resolution. the fused images are called validation when spatio-temporal resolutions are similar. when considering improving spatio-temporal resolution, the resolution of each modality is not of the biggest concern. each modality's effective resolution and the additional effect after the combination of data from different modalities should be considered instead. while the nominal resolution is generated according to fixed physical parameters of instruments, the effective resolution depends on the information of the data instead. in fmri, field-of-view and the k-space acquisition matrix determine the nominal spatial resolution, while the effective resolution is largely affected by fmri sequences and spread of the hemodynamic response [295] . because of the slow development of hemodynamic response, the effective resolution is lower than nominal temporal resolution in fmri, while the latter resolution is determined by the repetition timetr. the nominal temporal resolution of electrophysiological methods is usually in the millisecond range. the effective resolution, however, can vary from tens of milliseconds to hundreds of milliseconds due to the slow evolution of neuronal field potentials and statistical detectability. also, many repetitions have to be implemented before a detectable signal comes up for the evoked potentials in eeg, while a detectable hemodynamic response can be acquired through a single stimulus in fmri. eeg-fmri, as the combination of eeg and fmri, turns out to be the typical example of improving spatio-temporal resolution through multimodal neuroimaging. epilepsy research facilitated the development of simultaneous eeg-fmri recording [296] . in the case of localizing epileptic foci, simultaneously recorded fmri help by connecting epileptic foci with interictal epileptiform discharges (ied) acquired by eeg. simultaneous eeg-fmri can also be utilized as neuronal oscillations in neuroscience [209, 297] . in these studies, the process of analyzing the recorded fmri data takes power in the frequency domain of the eeg signal as a variable. an mri machine uses a static, homogenous, external magnetic field b0, a radio-frequency magnetic field b1, and three orthogonal gradient fields. however, magnetic field variation may result from imperfections of the main magnetic field coil, the exciting gradient coils, and susceptibility of the tissues [298] . field inhomogeneity is one of the causes of blurring or spatial shifts in mri images. a typical region of distortion is the borderline between tissue and air, where a difference in magnetic susceptibilities exists. a standard process in neuroimage processing and fusion is the registration of multimodal images to standardized templates. hellier and barillot (2000) [299] introduced 3d non-rigid registration of multimodal images by mapping the deformation through cost optimization. the registration process provides the foundation for higher quality fusion with less distortion. the fusion of the main imaging sequence with supplementary sequences is also widely employed for distortion correction. as mentioned previously, a well-studied example is epi, a high temporal resolution mri technique that can collect multiple images per second. the high imaging frequency of epi acquisition results in geometric distortions to its images. acquisition of the static bo fieldmap before or after epi can provide additional information on local static field inhomogeneity and magnetic susceptibility. holland, kuperman (2010) [300] developed an efficient non-linear registration method by acquiring epi of opposite phase encoding polarities, while oh, chung (2012) [213] applied psf modeling to map the distortion field. another example is the fusion of mri and pet images in mr-pet systems. in these systems, apart from the combination of structural and metabolic information, the fusion of mri and pet also allows enhanced distortion correction. in simultaneous mp-pet systems, motion distortions of pet can be corrected with the volumetric information provided by continuous epi acquisitions or navigator sequences [301, 302] . joint reconstruction of mri and pet utilizes dependence between the two modalities for image reconstruction of one mode based on the other. reconstructed images show sharper edges and less distortion [303] . this entire process can also be formulated as a single optimization problem [301] . segmentation has been one of the main challenges faced by neuroimaging experts during the last decades. it refers to the process of tagging image pixels or voxels with biologically meaningful labels, such as anatomical structures and tissue types [304] . the segmentation task and data analysis are very often guided in most of the neuroimaging experiments by atlases that provide standardized, or stereotaxic, 3d coordinate systems for statistical data analysis and report of findings [305] . one of the earliest works in anatomical brain standardization was by talairach, tournoux (1957) [306] , who developed a 3d coordinate space for the brain to assist surgical techniques. this work was later updated by a full printed three-dimensional atlas of the human brain, which was especially beneficial for clinical studies, electroencephalographic investigations, and statistical computations [307] . tzourio-mazoyer, landeau (2002) [308] developed an anatomical parcellation approach with the spatially normalized single-subject high-resolution t1 volume provided by the montreal neurological institute (mni) [309] . these developments have contributed to better define the relationships between brain structures and their functions in modern human neuroscience research, as well as to reduce the variability found between different subjects. the traditional approach for brain image segmentation is the manual annotation or delimitation of the regions of interest (rois) by a trained expert [304] . this process is subjective and strongly influenced by expert performance. it is then of limited applicability since it is time-consuming, prone to error and difficult to reproduce. automated segmentation methods have been developed during the past decades. these methods can be classified into basic tissue classification and anatomical segmentation procedures [310] . tissue classification methods segment a 3d image of the brain into different tissue types (grey matter, white matter, csf, etc.), while also correcting for spatial intensity variations (also known as bias field or rf inhomogeneities). these methods normally incorporate probabilistic tissue atlases to improve their performance and have been successfully automated for fmri studies as well as integrated into several neuroimaging toolkits such as fsl fmrib's automated segmentation tool (fast) [311] and statistical parametric mapping (spm) [312] . however, anatomical segmentation procedures are much more difficult to automate, since different anatomical structures that consist of different tissue types may exhibit similar signal properties. this observation is the reason why automated anatomical segmentation of the brain into non-homogeneous regions needs to be guided by atlases. for atlas-based segmentation, an atlas is defined as the combination of a brain volume (atlas template) and its corresponding coregistered segmented volume (atlas labels). the atlas-based segmentation method registers the atlas template to the target image, and then the atlas labels are propagated to the target image using an effective image warping method [313] . let ( ) be the volume to be segmented, with ∈ ℝ 3 representing a 3d voxel coordinate vector. for the purpose of single-subject atlas-based segmentation, a grey level atlas volume ( ), a labeled volume ( ) ∈ = ,1,2, . . . , where is the number of anatomical regions or labels defined in the atlas and, optionally, a probabilistic atlas p(x), all within the same spatial coordinates (the atlas space), are required. the segmentation process consists of a registration step and a label propagation step. in the registration step, the atlas volume ( ) is registered to the input image ( ) by means of a spatial transformation ( ), which optimizes a given cost function. in the label propagation step, labels defined in the tagged volume ( ) are assigned to each of the voxels of the input image ( ) by applying the normalization transformation ( ) to ( ), thus spatially aligning the atlas to the input image ( ). the atlas probability maps ( ) are normally used for mri since they enable to improve the segmentation accuracy of t1-weighted mri into grey matter, white matter and cerebrospinal fluid tissues with higher accuracy when the regional tissue densities need to be quantified and compared for between different groups of subjects [314] . medical image registration is routinely used in neuroimaging. it aims at determining the spatial alignment between images of the same or different subjects by means of optimizing a cost function, which measures the similarity between the transformed input image and the reference image (template) [315] . the registration process involves a spatial transformation being global rigid and affine transformations usually enough for intra-subject image registration [313] . however, the atlas-based segmentation task requires intersubject matching or registration of an input image to an atlas image and, as a consequence of the variability of the anatomical structure across different subjects, non-rigid registration algorithms are widely used. single-subject atlas-based segmentation approaches suffer from a reduced ability to capture the variability of the spatial distribution of anatomical structures across different subjects. multi-atlas segmentation was introduced in some pioneering works [310, 316, 317] to address this problem and to offer superior segmentation accuracy. for the purposes of reviewing the existing methods for atlas propagation and atlas fusion in multi-atlas based segmentation, a similar notation to the adopted ones in [318, 319] will be used. these works have addressed the atlas-based segmentation problem as a classification task where the atlas is the training set, and the training is associated with the process of computing the registration between the image and the atlas. let ( ) be a 3d image to be segmented into different classes belonging to the atlas label set = ,1,2, . . . , -. multi-atlas segmentation methods use 3d atlas images ( ) and their corresponding atlas labels the coordinate transformation ∶ ℝ 3 → ℝ 3 defines a mapping from the coordinates of the atlas a k (x) to the target image i(x). once the registration transformation is obtained, the input image ( ) is automatically segmented for each one of the atlases available by applying a label propagation technique, thus obtaining k different segmentations (x) ∈ λ, = 1,2, . . . , these candidate segmentations must be combined later into a final estimated segmentation (x) ∈ λ by applying a label fusion technique, as shown in figure 22 . once each of the k atlas images has been coregistered to the input image, the labels are then propagated to the space of the input image in a process called label propagation. label propagation applies the registration transformations to map each of the available atlas volumes ( ) to the input image, and an image warping technique preserves the discrete nature of the labels. note that the transformations t k : applied to the atlas label volumes l k (x) are 3d continuous transformations that do not match grid points in the atlas space to grid points in the target input image. the purpose of label propagation is to perform the interpolation of the transformed atlas label volume for grid points in the target image space [320] . among the different label propagation techniques, the most widely used are nearest-neighbor interpolation [310] and linear interpolation [316, 320] . nearest-neighbor provides the unique label of the nearest atlas grid point. partial volume interpolation, a technique that was first introduced in [321] for image registration, is a more sophisticated method for label propagation that takes into account the contribution of adjacent grip points to the final propagated label. during the last decade, several improvements have been proposed and reviewed for label propagation in multi-atlas segmentation [304] . most of them incorporate additional information to improve the performance by augmenting the information with a tissue consistency map in nearest-neighbor interpolation [322] or introducing signed distance maps of the original atlas labels [323, 324] . the final step in atlas-based segmentation is atlas fusion. after registration and label propagation for each of the k available atlases, a final unique segmentation (x) ∈ λ is obtained by merging the information provided by each of the individual atlas-based segmentations into a single segmented image. this approach has been shown to be more accurate than an individual atlas segmentation [316] in the same manner as a combination of classifiers is generally more accurate than a single classifier in many pattern recognition scenarios [325] [326] [327] [328] [329] [330] . the conventional method for combining individual segmentations is an equally weighted majority voting framework [319] . a more sophisticated approach estimates the performances of the individual atlas segmentations and combines them by weighting them according to their estimated performance. both approaches are described and discussed in this subsection. majority voting atlas fusion. the combined multi-atlas segmentation output (x) ∈ λ for a voxel sample given the set of k single atlas segmentations (x) ∈ λ, with = 1,2, . . . , , is obtained through the vote rule decision function where the function is defined to be atlas label fusion based on majority voting considers all the segmentations equally accurate, and no prior knowledge of segmentation performance is required. performance weighting atlas fusion. majority voting equally weighs the individual atlas segmentation without using a segmentation performance model. in order to improve the performance of the multi-atlas segmentation, the combined segmentation output (x) ∈ λ should be the class maximizing the probability, given all the individual segmentations (x) ∈ λ, with = 1,2, . . . , and some available segmentation performance model [319] : using the bayes rule, and assuming independence of the individual classifiers, simplifies the problem and enables us to find an optimal segmentation based on a model of segmentation performance. rohlfing, russakoff (2004) [319] proposed different classifier performance models and used an expectation-maximization (em) algorithm that simultaneously estimated the performance parameters of the segmentations and provided an estimation of the unknown ground truth. this novel strategy enabled us to learn classifier performance parameters and to adopt weighted atlas combination for atlas label fusion in multi-atlas segmentation following a novel supervised training stage [331, 332] . the application and improvement of the quantification in medical image allows to increase characteristics such as sensitivity and specificity, among others, obtaining more accurate patient's diagnoses. to perform this analysis, the emission computed tomography (ect) is used, since it is the most important medical imaging modality in nuclear medicine. more specifically, the two image modalities analyzed are positron emission tomography (pet) and single-photon emission computed tomography (spect), which differ in the radiotracer used and the nature of the emission measurement. it should be noted that the factors associated with quantification that affect pet and spect are also extrapolated to multimodal images. furthermore, multimodal images can be of great interest to improve quantification. both, pet and spect, have proven to be effective imaging techniques for the diagnosis and monitoring of treatments in different medical applications, offering information about biological processes, which is very important for the study of brain activity [333] . the level of intensity in these types of images is bound to physical parameters, such as cerebral blood flow, glucose or receptor binding among others [334, 335] . since these modalities were conceived in the 50's and 60's jones and townsend (2017) [336] , several improvements have been developed in terms of quantification. one of the most relevant improvements in this field is due to the development of dual-modality imaging in the 90's [337] . this type of imaging allows the combination of complementing functional information (pet and spect) with structural information (computed tomography (ct) and magnetic resonance imaging (mri)), leading to increases in sensitivity and specificity. the combination of different characteristics that can be observed from each type of image allows us to obtain a better understanding of the structure and function of the human body. for example, pet/mri combination offers remarkable advantages compared to the use of pet/ct since ct radiation dose is avoided and soft tissue images from mr could be acquired at the same time as the pet ones [338] . pet offers higher resolution and better quality than spect, particularly in pet/ct. furthermore, it allows for easier quantitative measurements [335] . for example, sensitivity could be up to two orders of magnitude greater with comparable axial fields of view [339] . nevertheless, the spatial resolution that can be obtained in both techniques tends to be low, due to its dependence on the radiation dose administrated to the patients. also, ect images are usually degraded by several factors, such as photon attenuation, partial volume effect or scatter radiation [337] . moreover, spatial resolutions associated with structural images continue to be higher (≈ 1 mm) than in functional images (≈ 4-6 mm) [340] . regarding quantification, an increasing number of relevant research aims to propose new quantification techniques or improve previously existing ones is observed in recent years. the possibility of quantification in nuclear medicine imaging is one of its successes. due to the increasing use of nuclear images in therapies, the way of measuring functional images is changing. while historically, the use of relative and semiquantitative measures was typical, the recent application of absolute quantification is gaining support. one of the first steps was considered activity concentration and normalized uptake using the standard uptake value (suv) [341] . nevertheless, to reach quantitative imaging as a useful and potential tool, several factors must be addressed. as zaidi and hasegawa (2006) [339] mentioned among these factors are the system sensitivity and spatial resolution, dead-time and pulse pile-up effects, the linear and angular sampling intervals of the projections, the size of the object, photon attenuation, scatter, partial volume effects, patient motion, kinetic effects, and filling of excretory routes (e.g., the bladder) by the radiopharmaceutical. in neuroimaging, pet and spect are a popular option to detect biomarkers associated with degenerative diseases. for alzheimer's disease (ad), the accumulation of amyloid-β plaques and tau aggregates can be detected [342, 343] , while an increased diffusivity in the striatum and thalamus can be observed in parkinson's disease (pd) patients. a well-defined quantification of these biomarkers would allow more precise and reliable diagnoses. this section is organized as follows. firstly, quantification both in pet and spect is analyzed considering the associated effects and their correction, especially those related to photon attenuation, scatter, and partial volume effects. then, novel developments focused on cerebral medical imaging are highlighted. even though pet scans could be evaluated qualitatively through the visual examination of the tracer uptake in cortical regions by a trained radiologist [344] , the best way to analyze these images is quantitative. for that, automated or semi-automated localization methods can be used to evaluate regional levels of tracer uptake [345, 346] . within automated studies, an essential step is to use spatial normalization to register subjects' brain to a standardized template space, so that all subjects in the study can be compared [347] . another procedure of great importance is intensity normalization, which is the object of study in this analysis. as foster, bagci (2014) [348] mentioned, several semi-quantitative and quantitative parameters that can be considered for intensity normalization exist, such as standardized uptake value (suv), fractional uptake rate (fur), tumor-to-background ratio (tbr), nonlinear regression techniques, total lesion evaluation (tle) or the patlak-derived methods. nevertheless, the most widely used is suv, which can also be used in spect [348] . the use of body weight (bw) in suv has been discussed in the literature, and the general advice is to use more reliable measures such as body surface area (bsa) or lean body mass (lbm) [349, 350] . moreover, a decay factor that depends on the particular radiotracer used may also be considered [351] . several physiological and physical factors can influence the standardized uptake value obtained [348, 352] . regarding physiological factors, some of them are weight and fat of the subject or blood glucose concentration, etc. physical factors include partial volume effect (pve), image manipulation (reconstruction, smoothing), and artifacts related to involuntary movements of the patient. the relevance of these factors lies in the variability of suv. studies carried out in the literature suggest that these factors may alter suv in the range of 10%-30% [353, 354] . nevertheless, the importance of correcting these effects depends on the clinical trial performed, since it can be a complex task and is not always worthwhile [355] . moreover, these factors affect not only semi-quantitative measurements but also affect absolute quantification. there are several methods to consider within the absolute quantification, such as image reconstruction, effects correction or calibration to obtain the measured activity distribution [356, 357] . among the mentioned factors associated with imaging quantification, we analyzed three effects and their respective corrections, since they are popular bias sources for pet and spect quantification. these effects are pve, scatter, and photon attenuation effects. regarding the quantitative accuracy of pet image, partial volume effect (pve) is the most relevant effect [358] . pve is related to the finite spatial resolution of pet scanners and its discrete nature. that discrete nature causes a voxel to could be composed of more than one tissue, which leads to a final signal that is an averaged mix of signals, which is also called tissue fraction effect. moreover, the larger the voxel size, the more tissues can coexist in it. this effect, along with the point-spread effect (or spillover), is the cause of image blur [354, 359] . also, it is an effect that often causes confusion among clinicians and researchers when analyzing the image, since it is necessary to distinguish between loss of radioactivity due to pve and the true loss of tissue. strategies to address this effect are called partial volume correction (pvc) methods. distribution of both signal and noise are the main factors to consider for the selection of algorithms for pvc to apply [359] . several pvc techniques have been proposed in the literature for improving image quality and quantitative accuracy in pet [360] [361] [362] [363] . historically, these techniques have been classified in several forms. in this work, these methods are grouped as region-based (rb) and voxel-based (vb) techniques, based the most commonly used classifications [340, 355] . the most relevant differences between them are that vb methods produce pve-recovered images while rb methods do not, and rb methods are associated with regions of interest (rois) while vb methods are applied at a voxel level considering the recovery of the spatial resolution of the system. usually, rb techniques tend to be used more frequently than vb ones since they include regional homogeneity assumptions, simplifying the problem [359] . [364] in 2d and later extended to 3d by meltzer, leal (1990) [365] was a segmentation in anatomy into two classes: brain and non-brain. mullergartner, links (1992) [366] proposed an improved version of this technique (known as gm algorithm) to use three instead of two classes: grey matter (gm), white matter (wm) and cerebrospinal fluid (csf). meltzer, zubieta (1996) [367] added a fourth class to the previous algorithms in order to compensate for the real heterogeneity in gm tissue. the importance of this method is that pve can be corrected between high and low intensity brain structures. regarding the iterative reconstruction algorithms associated to vb methods, as v. bettinardi, castiglioni (2014) [340] noted, some of the best known and used is the van cittert (vc) algorithm, the re-blurred van cittert (r-vc) and the richardson-lucy (rl) algorithm. for broader coverage, readers are referred to reviews related to pve [340] and iterative reconstruction methods [368] . four classes: [367] finally, data extracted from the alzheimer's disease neuroimaging initiative (adni) database (adni.loni.usc.edu) is used in order to show some pve correction methods. this data consists of a patient diagnosed with alzheimer's disease from which fdg-pet and t1 weighted mr images were taken, as shown in figure 23 . both modalities are registered to respective templates of t1 and pet, and pet image was not normalized in intensity due to use only one subject in this manuscript. pvc techniques are applied by using pvelab [384, 385] , a platform developed by the eu sponsored pveout project. pvelab can facilitate pve correction through a graphical interface with several steps, including registration, segmentation, reslicing, optional application of an atlas (none in our case), and pve correction. three methods discussed above are those analyzed: 3d meltzer technique [365] and gm algorithm [366] regarding vb methods, and the rb method proposed by rousset, ma (1998) [374] . the large difference between methods is shown in figure 24a . another relevant effect to analyze is photon attenuation. this phenomenon occurs due to the interaction between the photon associated to the radiotracer and elements in the body such as tissue. normally, this interaction leads to a scatter in the photon radiation. the probability that a photon experiences an interaction is represented by the linear attenuation coefficient [386] . the situation of this phenomenon differs between pet and spect imaging. in pet, two antiparallel photons are detected in the collimator, so the total tissue thickness crossed by them is the same body thickness that intersected the straight line between the two detections (line of response). nevertheless, in spect imaging, the attenuation depends on the total tissue thickness crossed and its type (e.g., soft tissue, bone), which varies depending on where the points of emission and detection are [386] . traditionally, this correction was much more commonly performed in pet imaging than in spect. nowadays, it is done in both to be able to achieve much more accurate quantitative results, although it is more difficult to apply in spect. attenuation correction is necessary in order to obtain accurate quantitative results and is widely implemented. for this, an attenuation map is needed, which zaidi and hasegawa (2006) [386] defined as a representation of the spatial distribution of linear attenuation coefficients and delineates the body structures located in the image. once the attenuation map is done, the reconstruction algorithm can be implemented with more information. attenuation correction techniques can be classified into two major groups: transmission-less approaches and the ones based on transmission scanning. while the first group considers the measured emission data to develop the attenuation map or assumes a uniform distribution for the coefficients, the second one uses transmission data of external sources such as ct and mri, i.e., the use of anatomical data. the second group offers a more accurate solution. nevertheless, there are situations in which the correction made by the first group is sufficient, without the need to complicate the applied technique. a brief introduction to the various existing methods for performing the attenuation map is shown in table 6 . for a more extensive reading of this topic, readers are referred to reviews about attenuation correction [386] [387] [388] . transmission-less based methods are easily applied in brain imaging because the brain is considered a practically homogeneous region composed mainly of soft-tissue. moreover, these methods allow results regarding the skull [390] and optical tracking systems to be used to obtain head contours [391] . despite being a typology that has not been used frequently, research on these methods has increased over the last years due to shift away from anatomical information. one of the first methods was proposed by nuyts, dupont (1999) [392] , which consists of a maximum likelihood approach known as mlaa (maximum likelihood reconstruction of attenuation and activity). it is commonly used in non-time-of-flight (tof) pet images, and several studies have tried to improve or test it [393, 395, 396] . another popular algorithm is mlacf (maximum likelihood attenuation correction factors) [394] , mostly used in tof pet, which jointly estimates the attenuation sinogram and the activity image. less popular than the previous one, this method has also been tested in other studies [410] . moreover, machine learning techniques for attenuation correction are emerging, such as deep convolutional encoder-decoders [334] or deep convolutional neural networks [411] have also been applied in attenuation correction. for this last type of technique, there is considerable interest in this field of research, and new algorithms are constantly presented. regarding transmission-based techniques, the added difficulty for mri systems to obtain attenuation maps compared to ct systems should be highlighted. the reason for this is the connection between the attenuation coefficients and the electron density of the tissue. in ct, the data is associated with electron density and photon attenuation properties of the tissues. in contrast, mri data is correlated to proton density and magnetic relaxation properties of the tissues [387] . as a challenge related to pet/mri (or spect/mri) systems, several methods have been proposed in literature regarding attenuation estimation. the mri-based methods can be classified into two groups: segmentation-based and atlas-based methods. of the two groups, the segmentation-based one tends to be used more on the literature. technique, which depends on the density and composition of five tissues: air, skull, brain tissue, and nasal sinuses. similar to the latter case, wagenknecht, kops (2009) [408] presented a method where tissue classification is done with neural networks. first, a voxel classification with five tissues (gm, wm, cfs, adipose tissue (at) and background (bg)) is made, then a second classification is done depending on the previous classes to detect extracerebral tissue and finally, segmentation is obtained. the main drawback of this method is the possibility of mis-segmentation or over-segmentation of bones, especially in the presence of abnormal anatomy or pathology. in order to improve bone detection, ultrashort echo time (ute) mri began to be investigated. firstly, dual-echo ultra-short echo time and three tissue classification (bone, soft tissue and air) were used [370, 413] . in parallel, methods related to the dixon technique were raised. dixon-water-fat-segmentation (dwfs) allows the separation of soft and adipose tissues. the method was applied dwfs for the whole body in [414] . considering both techniques (ute and dwfs), berker, franke (2012) [415] proposed a method trying to reduce the drawbacks of these two techniques: time-consuming and complex image registration. this new technique applies ute sampling for bone detection and uses gradient echoes for water-fat separation, obtaining a four-class pet attenuation map. an example of dwfs application in neuroimaging is the study conducted by andersen, ladefoged (2014) [416] , where this technique is used to generate the attenuation maps. taking into account the time-consuming problem with ute, short echo-time (ste) has been tested as a method to obtain attenuation maps of three (cortical bone, air and soft tissue) [417] and four (cortical bone, air , soft tissue and fat tissue) tissues [418] , both in combination with fuzzy c-means (fcm) clustering method. besides, the second study also used two-point dixon sequences in image acquisition. the latest research in this field has been the use of zero echo time (zte), initially proposed by wiesinger, sacolick (2016) [419] as part of a segmentation method for cranial bone structures. all studies found in the literature, specially the ones related to zte, indicate an improvement in results compared to the use of atlas-based methods [420] [421] [422] [423] . the basis of atlas-based approaches is the use of an mr template instead of multistep segmentation procedures, so atlas-based methods use a general map while segmentation-based methods generate a map for each individual. this template can be obtained from two sources: an image labeled as if it were a segmentation of the different tissues or a coregistered attenuation map from a pet or ct scan with continuous attenuation values [354] . as usual, it is obtained from an average of co-registered normal patients, and it has to be warped to the target patient image volume. in any case, most of the studies related to this approach combine atlas-based and segmentation-based methods since the use of an atlas can be an important source of information and can reduce computational cost [424] [425] [426] . despite this, other studies have proposed methods purely based on atlas images [405, 409] , such as the one developed by johanson, garpebring (2013) [427] where linear attenuation coefficients are predicted from a gaussian mixture regression algorithm. once the attenuation map is generated, attenuation correction is applied in the process. for that, two techniques are mainly used [386] . the first one multiplies the attenuation coefficients obtained by pet image data in the sinogram (or projection) space [428] . the other procedure is performed when pet image reconstruction is performed with an iterative algorithm, using attenuation coefficients as data weighting. while pet images can apply both methods, only iterative methods are used for spect [429] [430] [431] . scatter in pet and spect is another relevant effect for absolute quantification, especially in spect, and which is usually associated with compton scattering. it consists of an energy loss and a change of direction of a photon after an interaction with surrounding atoms. nevertheless, this effect is not highly relevant in the clinical environment, according to the literature. the reason for this is that the techniques implemented have little impact on the final result, and since the photon change of direction is practically zero, the energy loss is minimal. however, several researchers are convinced that in order to obtain a high accuracy quantitative image, this artifact should be removed [432, 433] . several methods have been proposed for scatter correction, but most of them were developed many years ago and are inefficient. however, a few recent methods are getting remarkable results. regarding the categorization of these techniques, a similar classification could be made for both pet and spect, considering that pet techniques began to be developed much earlier. following the review of zaidi and montandon (2007) [432] , the classification would consist of five groups: hardware approaches using coarse septa or beam stoppers, multiple-energy-window approaches, convolution/deconvolution-based approaches, approaches based on direct estimation of scatter distribution and approaches based on statistical reconstruction. due to the low clinical implementation and the diversity of existing methods, this work will only highlight the most innovative and relevant methods. therefore, readers interested in this effect are advised to read the following reviews [389, 433, 434] . table 7 summarizes the different existing categories indicating some examples. the first method proposed to narrow the photopeak energy window to avoid the acceptance of scattered photons. however, this technique has significant drawbacks, such as the elimination of unscattered photons in the process, and therefore, a loss of intensity appears in the image [434, 435] . thus, multiple-energy-window became much more popular, and it is one of the simplest and most used approaches. the techniques have been developed from two [436, 437] three [438, 439] or even multiple energy windows [440, 441] . decades have passed since it is known that monte carlo techniques are ideal for scatter correction [433] [434] [435] . nevertheless, it has recently become a viable solution in the clinical environment, as the computational cost is reducing and techniques are faster. moreover, the monte carlo technique can be applied to several methods, either iterative reconstruction based or direct calculation methods. finally, another factor to consider in the quantification of functional images is the voluntary and involuntary movement of the patient (e.g. breathing). however, since it does not have high relevance in neuroimaging, its analysis has been dismissed in this study. functional imaging is very useful for the diagnosis of neurodegenerative diseases, such as alzheimer's disease or parkinson's disease due to differences in brain activity which can be observed in temporal and parietal lobes (ad) or the striatum (pd) with respect to healthy subjects. therefore, the systems must allow a correct quantification in order to offer an accurate diagnosis of the patient's condition. as already mentioned, the correction of the aforementioned effects improves the quantification of the images. for example, some studies associated with attenuation correction demonstrate this improvement. delso, kemp tissue segmentation, and these results are also very similar to those that would be obtained with a pet/ct system. in the study developed by sousa, appel (2018) [422] , a comparison between using an attenuation correction method based on zte and atlas-based correction shows that the former produces less variability than the latter. however, bias correction is similar in analyzed brain regions. for example, the correlation coefficient associated with anterior cortical regions is 0.99 for zte-based correction and 0.92 for atlas-based correction. similar results are obtained in the study by sgard, khalife (2020) [423] . other interesting results are produced by those that apply machine learning methods. for example, the deep convolutional neural network used by yang, park (2019) [411] for both attenuation and scatter correction designed for situations where it is difficult to use a combined ct or transmission source. the results were similar to the ones obtain with an ct-based scatter and attenuation correction. pvc methods are also used in brain images. for example, regarding pd studies, du, tsui (2005) [376] proved than using a modified gtm method in brain spect images, the underestimation of striatal activities could be reduced to 1.2% from an initial value of 30%. finally, a correct normalization of the images can also highly increase the accuracy of the study. salas-gonzalez, gorriz (2013) [456] proposed a method for intensity normalization of fp-cit spect brain image based on α-stable distribution. this method was tested by castillo-barnes, arenas (2017) [457] , showing significant differences between the images before and after normalizing. for more information on intensity normalization, especially associated with pd, we recommend reading [458] . in conclusion, the possibility of improving the techniques exposed in this manuscript to reduce unwanted effects on images is highlighted. despite being applied in clinical systems, they are not considered of high relevance due to the limited improvement they provide or, sometimes, the increase in noise they produce. therefore, the area of absolute quantification must continue to be investigated for more accurate and faster solutions. this review presents an overview of multimodal data fusion in the field of neuroimaging, including current developments and challenges. we first outlined the fundamental limitations of individual modalities, which can include distortion, non-quantitative nature, and limited temporal/spatial resolutions. these limitations are the general motivators for the development of multimodal neuroimaging and fusion. multimodal neuroimaging provides more comprehensive information on pathology. we have summarised the individual benefits and limitations of the current imaging technologies and modalities, including ct, pet, spect, mri, fmri, dwi, pwi, and mrf. building upon the available individual techniques, we summarised current development and application of multimodal neuroimaging and fusion in terms of neurological disorders and brain diseases, with a focus in three areas: developing brains, degenerative brains, and psychiatric disorders. the utilization of multiple modalities helps in clinical diagnosis, prevention of misdiagnosis, progression analysis, and research-oriented studies that allow us to gain a more in-depth understanding of human brain pathologies. nowadays the effects of covid in the human body are not well-known and maybe we could find in the future some people affected in the brain structure (micro ictus or ischemia). nevertheless, the fusion techniques and strategies discussed in this survey may be transferred to covid-19 multimodality image analysis [459] . the forms of multimodality fusion include multi-modal, multi-focus, multi-temporal, and multi-view. these forms combine images from different instruments/acquisitions, acquisition focal lengths, time of acquisitions and conditions, respectively. fusion rules were specified with respect to its components and three levels of fusion and theoretical foundation, i.e. rules derived from fuzzy logic, statistic models, and the human vision system. then we summarised conventional and novel image decomposition and reconstruction methods for the fusion process, including methods based on rgb-ihs, pyramid representations, multi-resolution analysis, sparse representation, and salient features. in addition, we summarised both subjective and objective methods for fusion quality assessment. the major benefits of multimodal data fusion in neuroimaging include distortion correction, higher temporal/spatial resolution, the combination of structural and functional information. we summarised these benefits with the current applications of multimodal fusion, e.g. mr-pet, eeg-fmri, and epi correction. this review also adds a particular focus on the application of multimodal image fusion in standardization, via atlas-based anatomical brain segmentation and the use of multi-atlas fusion. in addition, we summarised the effect of multimodal data fusion on the shift of neuroimaging diagnosis from qualitative analysis to quantitative evaluation, with an example of the effect of multimodal data in photon attenuation, scatter, and partial volume effects of pet and spect quantification. modern neuroimaging has seen significant improvements in acquisition quality and a constant increase in the abundance of imaging modalities. the fusion of modalities combines complementary information, expands resolution limits, provides standardization, and improves data quality. it is expected that the effect of multimodal imaging fusion could 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tomography images standardized uptake values of normal tissues at pet with 2-[fluorine-18]-fluoro-2-deoxy-d-glucose: variations with body weight and a method for correction standardized uptake values of fdg: body surface area correction is preferable to body weight correction quantitative techniques in pet-ct imaging variability in pet quantitation within a multicenter consortium improved correction for the tissue fraction effect in lung pet/ct imaging resolution modeling in pet imaging: theory, practice, benefits, and pitfalls quantitative spect/ct: spect joins pet as a quantitative imaging modality absolute quantification in spect partial volume correction for pet quantification and its impact on brain network in alzheimer's disease. scientific reports positron emission tomography partial volume correction: estimation and algorithms partial-volume effect in pet tumor imaging correction for partial volume effects in emission tomography partial volume correction strategies in pet a review of partial volume correction techniques for emission tomography and their applications in neurology, cardiology and oncology regional correction of positron emission tomography data for the effects of cerebral atrophy correction of pet data for partial volume effects in human cerebral-cortex by mr imaging measurement of radiotracer concentration in brain gray-matter using positron emission tomography -mri-based correction for partial volume effects mr-based correction of brain pet measurements for heterogeneous gray matter radioactivity distribution iterative reconstruction methods, in quantitative analysis in nuclear medicine imaging a recovery coefficient method for partial volume correction of pet images pet/mri for neurologic applications a new fast algorithm for the evaluation of regions of interest and statistical uncertainty in computed-tomography a method to correct for scatter, spillover, and partial volume effects in region of interest analysis in pet a maximum likelihood method for region-of-interest evaluation in emission tomography correction for partial volume effects in pet: principle and validation correction of partial-volume effect for pet striatal imaging: fast implementation and study of robustness partial volume effect compensation for quantitative brain spect imaging symmetric geometric transfer matrix partial volume correction for pet imaging: principle, validation and robustness impact of image-space resolution modeling for studies with the high-resolution research tomograph improvement in pet/ct image quality with a combination of point-spread function and time-of-flight in relation to reconstruction parameters clinical evaluation of pet image reconstruction using a spatial resolution model influence of the partial volume correction method on f-18-fluorodeoxyglucose brain kinetic modelling from dynamic pet images reconstructed with resolution model based osem deconvolution microscopy, in microscopy techniques a multiresolution image based approach for correction of partial volume effects in emission tomography integrated software for the analysis of brain pet/spect studies with partial-volume-effect correction mr-based automatic delineation of volumes of interest in human brain pet images using probability maps attenuation correction strategies in emission tomography vision 20/20: magnetic resonance imaging-guided attenuation correction in pet/mri: challenges, solutions, and opportunities towards quantitative pet/mri: a review of mr-based attenuation correction techniques attenuation compensation in cerebral 3d pet: effect of the attenuation map on absolute and relative quantitation automated pet attenuation correction model for functional brain imaging acquisition of attenuation map for brain pet study using optical tracking system simultaneous maximum a posteriori reconstruction of attenuation and activity distributions from emission sinograms completion of a truncated attenuation image from the attenuated pet emission data ml-reconstruction for tof-pet with simultaneous estimation of the attenuation factors optimized mlaa for quantitative non-tof pet/mr of the brain a multi-centre evaluation of eleven clinically feasible brain pet/mri attenuation correction techniques using a large cohort of patients transmission scanning in emission tomography evaluation of spet quantification of simultaneous emission and transmission imaging of the brain using a multidetector spet system with the tew scatter compensation method and fan-beam collimation nonuniform transmission in brain spect using 201tl, 153gd, and 99mtc static line sources: anthropomorphic dosimetry studies and influence on brain quantification investigation of the relationship between linear attenuation coefficients and ct hounsfield units using radionuclides for spect. applied radiation and isotopes image fusion using an integrated, dual-head coincidence camera with x-ray tube-based attenuation maps impact of metallic dental implants on ct-based attenuation correction in a combined pet/ct scanner x-ray-based attenuation correction for positron emission tomography/computed tomography scanners method for transforming ct images for attenuation correction in pet/ct imaging evaluation of an atlas-based pet head attenuation correction using pet/ct & mr patient data scatter and attenuation correction for brain spect using attenuation distributions inferred from a head atlas magnetic resonance imaging-guided attenuation and scatter corrections in three-dimensional brain positron emission tomography knowledge-based segmentation of attenuation-relevant regions of the head in t1-weighted mr images for attenuation correction in mr/pet systems quantitative evaluation of atlas-based attenuation correction for brain pet in an integrated time-of-flight pet/mr imaging system evaluation of mlacf based calculated attenuation brain pet imaging for fdg patient studies joint correction of attenuation and scatter in image space using deep convolutional neural networks for dedicated brain (18)f-fdg pet segmented mr images for brain attenuation correction in pet mri-based attenuation correction for pet/mri using ultrashort echo time sequences tissue classification as a potential approach for attenuation correction in whole-body pet/mri: evaluation with pet/ct data mri-based attenuation correction for hybrid pet/mri systems: a 4-class tissue segmentation technique using a combined ultrashort-echo-time/dixon mri sequence combined pet/mr imaging in neurology: mr-based attenuation correction implies a strong spatial bias when ignoring bone generation of mr-based attenuation correction map of pet images in the brain employing joint segmentation of skull and soft-tissue from single short-te mr imaging modality generation of a four-class attenuation map for mri-based attenuation correction of pet data in the head area using a novel combination of ste/dixon-mri and fcm clustering zero te mr bone imaging in the head evaluation of sinus/edge-corrected zero-echo-time-based attenuation correction in brain pet/mri improving pet/mr brain quantitation with template-enhanced zte evaluation of zero-echo-time attenuation correction for integrated pet/mr brain imaging-comparison to head atlas and (68)ge-transmission-based attenuation correction zte mr-based attenuation correction in brain fdg-pet/mr: performance in patients with cognitive impairment pet attenuation correction using synthetic ct from ultrashort echo-time mr imaging probabilistic atlas-based segmentation of combined t1-weighted and dute mri for calculation of head attenuation maps in integrated pet/mri scanners cluster-based segmentation of dual-echo ultra-short echo time images for pet/mr bone localization improved quality of computed tomography substitute derived from magnetic resonance (mr) data by incorporation of spatial information -potential application for mr-only radiotherapy and attenuation correction in positron emission tomography a method for attenuation correction in radionuclide computed tomography maximum likelihood reconstruction for emission tomography em reconstruction algorithms for emission and transmission tomography an attenuated projector-backprojector for iterative spect reconstruction scatter compensation techniques in pet review and current status of spect scatter correction scatter correction strategies in emission tomography absolute quantification in spect -a phantom study improved spect quantification using compensation for scattered photons correction for scatter in 3d brain pet using a dual energy window method compton scatter compensation using the triple-energy window method for single-and dual-isotope spect triple energy window scatter correction technique in pet spect compton-scattering correction by analysis of energy spectra energy dependence of scatter components in multispectral pet imaging a monte carlo simulation study on coarse septa for scatter correction in 3-d pet novel scatter correction for three-dimensional positron emission tomography by use of a beam stopper device a fast, energy-dependent scatter reduction method for 3d pet imaging pet energy-based scatter estimation and image reconstruction with energy-dependent corrections a convolution-subtraction scatter correction method for 3d pet a transmission-dependent method for scatter correction in spect non-stationary convolution subtraction scatter correction with a dual-exponential scatter kernel for the hamamatsu shr-7700 animal pet scanner a technique for the correction of scattered radiation in a pet system using time-of-flight information a monte-carlo correction for the effect of compton-scattering in 3-d pet brain imaging new, faster, image-based scatter correction for 3d pet optimization of a fully 3d single scatter simulation algorithm for 3d pet efficient fully 3-d iterative spect reconstruction with monte carlo-based scatter compensation absolute quantification in dopaminergic neurotransmission spect using a monte carlo-based scatter correction and fully 3-dimensional reconstruction fully 3d monte carlo reconstruction in spect: a feasibility study linear intensity normalization of fp-cit spect brain images using the alpha-stable distribution on a heavy-tailed intensity normalization of the parkinson's progression markers initiative brain database comparison between different intensity normalization methods in 123i-ioflupane imaging for the automatic detection of parkinsonism the role of multimodality imaging in covid-19 patients: from diagnosis to clinical monitoring and prognosis this study was partly supported by royal society international exchanges cost share award, uk guangxi key laboratory of trusted software (kx201901). yz and jmg conceptualized the survey paper. all authors organized the references. sw and jmg planned the methodology. yz and jmg administrated the review project. yz and jmg provided resources. yz, zc, and jmg supervised the paper writing work. all authors validated the whole work. all authors wrote the draft. qz revised english. all authors gave critical comments and helped improved the quality. the authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper. key: cord-023353-2yoz1t6a authors: nan title: abstracts from the 2010 evdi annual meeting date: 2010-12-28 journal: vet radiol ultrasound doi: 10.1111/j.1740-8261.2010.01774.x sha: doc_id: 23353 cord_uid: 2yoz1t6a nan oral malignant melanoma is the most common canine oral tumour being characterized by local invasion and a high rate of regional and distant metastases. the overall prognosis is guarded, mainly because of the poor response to adjuvant systemic treatment like chemotherapy. melanoma is sensitive to radiation, which may reduce/eliminate tumour volume in macroscopic tumours or prolong local control in microscopic settings. neither surgery nor rt can control the high risk of distant metastases though. interesting approaches for immunogenic tumours such as melanoma are the use of tumour vaccines. the objective of this study was to evaluate toxicity associated with concurrent administration of an intradermally administered tumour vaccine and radiation. materials and methods: nine dogs with histologically confirmed oral malignant melanoma were treated with rt in combination with a human recombinant tyrosinase dna vaccine. patients were staged according to the who tnm-staging-scheme for oral tumours1. in 5 dogs a ct scan was performed to assess local disease, 4 dogs were evaluated clinically for local disease extension. for assessment of metastatic disease, regional lymph node aspiration, thoracic radiographs and abdominal ultrasound were performed. all dogs received 4 fractions of 8 gray each at 7-day intervals to a total dose of 32 gray (6mv linear accelerator) to the primary tumour and the regional lymph nodes (mandibular and medial retropharyngeal). the vaccine was given 4 times at 14-day intervals with the first vaccine being administered at the first fraction of rt. the acute radiation toxicity was evaluated according to the vrtog scoring scheme2 at the last rt and 2 to 4 weeks after the last rt. the anatomic tumour locations were as follows: mandible (n ¼ 4), maxilla (n ¼ 3) and buccal mucosa (n ¼ 2). metastases were initially identified in 8 of 9 dogs: ipsilateral mandibular lymph node (n ¼ 5), ipsi-and contralateral mandibular lymph node (n ¼ 1), ipsilateral mandibular lymph node and lungs (n ¼ 1), liver (n ¼ 1). local acute rt toxicity (mucositis, alopecia/dermatitis, conjunctivitis) never exceeded grade 2 toxicity and did not have an appreciable negative impact on quality of life. the melanoma vaccine was well tolerated by all dogs, minimal side effects were observed in few dogs: fever (n ¼ 2), lethargy (n ¼ 2) and local swelling (n ¼ 2). locally and loco-regionally all tumours could be controlled with a mean follow-up of 195 days. three dogs developed lung metastases after 41 to 68 days. three dogs died of tumour unrelated reasons. three dogs are still alive (for 109 to 351 days). discussion/conclusion: we could not observe an increase in severity of acute local radiation toxicity administering rt and vaccine concurrently, as it has been suspected initially. this is an important fact, since early timing of the vaccination might be essential for its activity. more patients will be collected to evaluate these preliminary results. owen ln: tnm classification of tumors in domestic animals, world health organisation geneva, 1980 ladue t, klein mk: toxicity criteria of the veterinary radiation therapy oncology group. vrus 42(5) [475] [476] 2001 introduction/purpose: pulmonary angiography with multi-detector computed tomography (mdct) is the standard of care in humans for non-invasive diagnosis of acute and chronic pulmonary embolism, pulmonary hypertension and other diseases or anatomical variants of the pulmonary arteries. however, there is paucity of data in the animal literature despite the expected diagnostic performance of mdct for pulmonary angiography. therefore, aim of this feasibility study was to evaluate the anatomy and visualization of the normal canine pulmonary vasculature as the basis for further application of mdct in diagnosing canine pulmonary arterial disease. materials and methods: experiments were previously approved by the responsible animal care and use committee (v1430). in four one-year old beagles, pulmonary mdct angiography (mdcta) was timed based on an individualized timing bolus and calculated delay after bolus injection, scanning the entire thorax in caudal to cranial direction using helical scan mode at 0.625 mm collimation, 0.625 helical reconstruction interval utilizing all 64 detectors. images were retrospectively reconstructed at 1.25 mm and 2.5 mm collimation for each dog. the pulmonary arteries were evaluated for anatomy (relationship to major vessels, cardiac and bronchial structures visible), visibility and visible generations of branching using all three reconstruction thicknesses. results: all lobar pulmonary arteries and adjacent anatomical structures were visualized at all reconstruction thicknesses. subjective blurring of small sublobar arteries occurs using 1.5 mm and 2.5 mm reconstruction thickness, particular with multiplanar reconstructions. fewer generations of sublobar arterial branches were detected on 1.5 mm and 2.5 mm as compared to 0.625 mm reconstructions. computed tomography of the brain in small animals can be limited by contrast resolution. the ability of the observer to differentiate grey and white matter is an important measure of image quality, but this can be reduced on images with low contrast. various factors affect the contrast resolution, including exposure, slice thickness and patient size. while slice thickness can be adjusted on retro-reconstruction, the exposure settings are fixed for the study. the purpose of this study was to determine the effect of kvp and ma on objective and subjective measures of image quality, and to identify the technique that results in the best image quality. materials and methods: six fresh canine cadavers of medium size were imaged using a 16-slice ct set in axial mode with 2.5 mm slice thickness and soft tissue algorithm. twelve different protocols were used to image the brain in each dog: kvp was set at 140, 120 or 100 and for each kvp the ma was set at 360, 280, 200 and 120. all other parameters were kept constant. a slice at the level of the internal capsule was selected for analysis. using image analysis software identical regions of interest were placed in the white matter and grey matter, and the mean hounsfield units and standard deviation calculated for each slice. image quality was evaluated objectively by measuring a contrast to noise ratio (cnr), calculated as cnr ¼ (mean gm roiàmean wm roi)/ f(sd gm roi) 2 þ (sd wm roi) 2 g 1/2 . images were evaluated subjectively by a radiologist blinded to the technique who graded the image quality on a 5-point scale (subjective score; ss). a two-factor anova with repeated measures was used to determine the effect of ma and kvp on cnr and ss. the spearman test was used to correlate cnr and ss. significance was set at po0.05. the exposure factors had a significant effect on objective and subjective measures of image quality. increasing ma significantly increased cnr (po0.001) and ss (po0.001). increasing kvp also significantly increased cnr (p ¼ 0.0176) and ss (p ¼ 0.0055). a technique of 360 ma 140 kvp resulted in the greatest cnr, whereas 360 ma 120 kvp resulted in the highest subjective score. a technique of 360 ma 140 kvp resulted in a higher cnr, but a lower ss than 280 ma 140 kvp. ss was positively correlated with cnr (r ¼ 0.61; po0.0001). discussion/conclusion: ct acquisition with a high ma and kvp technique is recommended for canine brain imaging. it results in improved contrast resolution, primarily due to a reduction in image noise. while this was expected for ma, the reduction in noise with increasing kvp also offset the corresponding reduction in contrast. when tube heating limits the use of a 360 ma technique, acquisition at 280 ma provides subjectively good contrast resolution. introduction/purpose: classroom performance systems (cps) [audience response systems (ars); ''clickers''] provide a means of encouraging student interaction in a traditional didactic lecture setting. cps tm is the leading response system in education, being used by over 5 million students worldwide. cps tm response pads (''clickers'') are handheld devices that allow students to respond to questions asked during a lecture enabling students and instructors to instantly assess their comprehension of lecture material. materials and methods: student performance in and student evaluations of the 3rd year (5th semester) didactic radiology course were evaluated from [2005] [2006] [2007] [2008] [2009] . additionally, student interactions were evaluated subjectively by instructors who used cpstm. results: from 2005 -2008 , all lectures and laboratory sessions were held in conventional fashion. in 2009, cpstm was utilized by 3/5 instructors. there was no significant difference in overall student performance and student performance on individual instructor's exam questions. on a scale from 1 (worst) to 5 (best) the radiology course was evaluated higher by students when cpstm was used than not, however, this difference was not significant (p ¼ 0.075). subjectively, students appeared more interested and involved when cpstm was used. discussion/conclusion: cps may be beneficial in radiology education. benefits include interactive involvement of students in a lecture setting and immediate feedback for students and instructors. disadvantages include time constraints, technical problems and dependence on willing student participation. introduction/purpose: non-invasive imaging techniques have been developed for phenotyping genetically engineered mice created to model human cardiovascular diseases like atherosclerosis. b-mode and doppler ultrasound may be useful because it is a fast and real-time imaging technique which gives structural, functional and hemodynamic information and it makes possible to perform temporal longitudinal studies. atherosclerotic lesions do not occur at random sites. the spatial heterogeneity of their distribution is in part dependent on hemodynamic factors. in murine models of atherogenesis lesions tend to develop at the ascending aorta, near the ostia of the three major branches, and on the lesser curvature of the aortic arch. the purpose of this study is to describe normal hemodynamics in mouse aorta and its major branches in the thorax by ultrasonography. materials and methods: 27 inbred c57bl/6 adult mice were studied (10 males and 17 females; 17-25 g body weight). anesthetized mice were scanned in supine position with an ultrasound biomicroscope (vevo 770, visualsonics, toronto, on, canada) provided with a 30 mhz transducer. aorta was studied at five different regions (ascending aorta, near the ostia of the three major branches in the arch, and in the proximal portion of the descending aorta). brachiocephalic trunk (bt), left common carotid artery (lcca), and left subclavian artery (lsca) were imaged near its junction with the aortic arch. systolic area was measured in b-mode, and peak systolic velocity (psv), minimum diastolic velocity (mdv), and time average maximum velocity (tamx) were measured with pulsed doppler ultrasound. pulsatility (pi) and resistive indices (ri), and mean blood flow (fv) were calculated. mean values and standard deviations were determined averaging a total of three doppler waveforms in every mouse. flow velocity profile and flow pattern were recorded in each region. the statistical analysis was performed with the statistical analysis system (sas institute, cary, usa) by applying the glm and ls means procedures. a p-value less than 0,05 was considered statistically significant. all anatomical terms are in accordance with the nomina anatomica veterinaria. results: aorta in the thorax has a plug flow profile and a typical high resistance flow pattern. bt, lcca and lsca have an intermediate flow velocity profile and a high resistance flow pattern. there were not differences between doppler data obtained in males and females. the ostium of the brachiocephalic trunk, because of its topographical disposition and flow direction changing, was the region were doppler has been most difficult to record. statistical differences were found between systolic area, psv, mdv, tamx, and fv of the aorta at the five different regions described above. no significant differences were found between systolic area, psv, and fv of the aorta major branches, although differences were observed between the mdv and tamx in these branches. values of pi and ri don't differ along aorta and its major branches in the thorax. this study provides normal doppler wave pattern and vascular values of the aorta and its major branches in the thorax of adult c57bl/6 mice by ultrasonography. these values may be used as normal reference to compare with mutant mice with cardiovascular alterations. pascaline pey 1 , massimo vignoli 2 , hendrik haers 1 , luc duchateau 3 , federica rossi 2 , jimmy saunders 1 . 1 department of medical imaging of domestic animals and orthopedy of small animals, ghent university, belgium. 2 clinica veterinaria dell'orologio, via gramsci 1/4, 40037 sasso marconi (bo), italy. 3 department of physiology and biometry, ghent university, belgium introduction/purpose: the microbubble-based contrast agents for ultrasonography have become more used in recent years in dogs1, and have been reported to be useful in differentiating adenomas from nonadenomatous lesions in human patients with adrenal masses2. the purposes of this study were to evaluate the feasibility and to define the perfusion parameters of contrast-enhanced ultrasonography of the adrenal gland in the normal beagle dog. materials and methods: six healthy female beagles were injected with an intravenous bolus of sonovue s (0.3 ml/10 kg, mechanical index ¼ 0.10). subjective and objective analyses were evaluated. objective measurements were performed using an off-line image analysis system (imagejr). results: subjective evaluation: the aorta was first rapidly opacified after injection of the contrast medium, followed by the renal artery and the medulla. subsequently, a homogeneous centrifugal enhancement from the adrenal medulla to the adrenal cortex was observed. at this point, a homogeneous decrease in opacification of both cortex and medulla started, associated with an enhancement of the phrenicoabdominal vessels. then a persistent enhancement in the splenic parenchyma, in the renal vein, the caudal vena cava and phrenicoabdominal veins was noticed. at the end of the parenchymal phase a second contrast enhancement was observed, corresponding to the refilling time. discussion/conclusion: the shape of the time-intensity curve reflecting the adrenal perfusion was similar in all dogs. however, the absolute values of the measurements and of the parameters of perfusion displayed considerable variations. ratios of the peak values of the cortex and the medulla to the peak values of the renal artery showed significant difference allowing differentiation between the cortex and the medulla for both adrenal glands. contrast-enhanced ultrasonography of the adrenal glands is feasible in dogs and the optimal time for adrenal imaging is between 5 to 90 seconds after injection. introduction/purpose: testicular anomalies are common in dogs. the aim of this study was to describe contrastenhanced ultrasonographic features of focal and diffuse testicular lesions, compared with normal tissue. materials and methods: seventeen dogs with scrotal anomalies were considered. all dogs underwent b-mode ultrasound, anesthesia, contrast-enhanced ultrasound (ceus), bilateral orchiectomy and histological examination. ceus was performed with cnti mode (esaote s , italy) and a secondgeneration contrast medium (sonovue s -bracco, italy) injected at a dosage of 0.03 ml/kg, iv. parenchymal perfusion was recorded for 2 minutes. time-intensity curves were reconstructed by a commercial software (qontrast s -bracco, italy), using the gamma-variate bolus-corrected model. the peak intensity (p), time to peak (ttp), regional blood flow (rbf) and mean transit time (mtt) were calculated. data relative to neoplasms were compared to those of normal/non neoplastic tissue by fisher's exact test. a po0.05 was considered significant. results: nine normal testes, 18 tumors (11 interstitiomas, 3 sertoliomas and 4 seminomas), 9 degenerated testes and a chronic orchitis were histologically diagnosed. eight dogs had bilateral involvement, while 9 monolateral. two seminomas (intratubular type) were not visualized. perfusion parameters of each group are summarized in the following table. peak intensity time to introduction/purpose: studies with contrast enhanced ultrasonography (ceus) on focal splenic lesions have shown discrepancies in accuracy for differentiating benign from malignant lesions.1-3 a speculative explanation for false positives may be the absence of a dual blood supply to the spleen compared to the liver. we therefore hypothesized that the early wash in/early wash out (ewew), and the hypoechogenicity during all phases are unreliable in differentiating malignant from benign splenic lesions. materials and methods: a retrospective study reviewing ceus studies of 17 splenic lesions (7 malignant, 10 benign), with concurrent cytology, core biopsy and/or excision biopsy was conducted. sonovue& at a dose of 0.03 ml/kg was used in all dogs. tortuosity of feeding vessels, presence of ewew, and hypoechogenicity during all phases were assessed visually and used to characterize the lesions. there were 4/10 benign, and 4/7 malignant lesions with ewew. therefore, sensitivity, specificity, and accuracy for ewew in differentiating malignant from benign lesions are 57%, 60%, and 59% respectively. there were 3/10 benign, and 3/7 malignant lesions with persistent hypoechogenicity throughout all phases. therefore, sensitivity, specificity, and accuracy are 43%, 70%, and 59%. there were 0/10 benign, and 5/7 malignant lesions with tortuous and persistently visible feeding vessels. sensitivity, specificity, and accuracy are 71%, 100%, and 88%. finally, there were 7/10 benign and 7/7 malignant lesions with a combination of at least one of the above parameters. sensitivity, specificity, and accuracy are 100%, 30%, and 59%. discussion/conclusion: these preliminary results support our hypothesis that the interpretation of splenic lesions cannot be performed accurately on the basis of ewew, or persistent hypoechogenicity throughout all phases. instead, we recommend assessing the presence of tortuous vessels in the periphery of the lesion during the early phase, and the persistence of these hyperechoic tortuous vessels in the late phase. further studies with larger numbers are necessary to better assess these findings. introduction/purpose: ceus has been used to detect focal perfusional changes in the spleen in humans and dogs. no earlier studies exist of contrast ultrasound of the spleen in cats. the purpose of this study was to evaluate perfusion of the cat spleen, and to compare the perfusion patterns in awake and anesthetized cats. the spleen of 18 healthy cats was imaged with ceus (acuson sequoia 512, siemens or esaote mylab70, biosound esaote inc.). two groups of cats were imaged: group i comprised of ten young, anesthetized cats and group ii of eight young to middle aged cats that were initially imaged awake (iia) and later anesthetized (iib). mechanical index (mi) was set at 0.32 (group i) or 0.04 (group ii) in the focal zone area. parameters were standardized including depth gain, power, number, and location of focal zones in relation to the spleen. all cats received multiple bolus injections (0.1 ml) of contrast medium (definity s o) per imaging. a 1-to 2-min digital clip was recorded for each contrast injection and analyzed off-line. the timing and grade of heterogeneity of the spleen were estimated in a standardized manner, blinded and in a randomized order. the grade of heterogeneity (1) (2) (3) (4) was estimated when the spleen was the most heterogeneous. the grade of homogeneity (i-iii) was estimated when the spleen was the most homogeneous. student's t-test was used to compare the time to first appearance of contrast in the spleen (at), and the time to the spleen becoming heterogeneous or homogeneous. frequencies of each heterogeneity and homogeneity grade within separate groups were calculated with statistical software (statistix version 9, analytical software). statistical significance for analysis was set at po0.05. results: enhancement of the spleen was bi-phasic in all cat groups. at was significantly faster in awake than anesthetized cats. a marked heterogeneous perfusion pattern (grade 4) was significantly more prevalent in anesthetized (50%) than awake (12.5%) cats. these results indicate focal perfusion defects, more pronounced with general anesthesia, of the spleen with ceus should be evaluated with caution and only after disappearance of the initial heterogeneity. introduction/purpose: diabetic nephropathy in small animals is a controversial issue. it is known that some spontaneously diabetic dogs develop significant proteinuria and hypertension. in cats ''diabetic nephropathy'' is a term describing fatal, chronic renal insufficiency with low urine specific gravity and proteinuria often occurring in feline diabetes. measurement of intrarenal resistivity index (ri) values is described in human medicine as an useful method in early diabetic nephropathy diagnostics. up to the present time the results of such tests in dogs (novellas and others)three diabetic ones and four suffering from diabetes caused by hyperadrenocorticism-did not reveal any ri value deviations in animals suffering from diabetes not caused by hyperadrenocorticism. the aim of this study was to compare the ri values in diabetic dogs and cats with the healthy ones and evaluate the possible relationship between ri, age and duration of diabetes. one of the study groups consisted of 10 dogs of both sexes and different breeds. the mean age was 10,9 ae 0,3, the duration of diabetes was from 1 month to 6 years. another study group were cats -five european shorthairs of both sexes (mean age 7,8 ae 3,56, the duration of diabetes from 1month to 2,5 years). the data confirming diabetes, using blood and urine analysis were strongly documented. patients with indication for ultrasound examination, but without any signs of serious or systemic diseases (eg. the animals with diseases of musculoskeletal system, routinely monitored geriatric patients) were assigned to control groups. control groups consisted of 15 dogs and 15 cats of both sexes and different breeds and ages (mean age in canine group 6, 9 ae 4, 5, 1 ae 3, 07 years) . animals with the suspicion of urinary tract infection or with history of previous kidney conditions were excluded from this study. renal ri values were higher in diabetic dogs and cats than in healthy animals. in the group of diabetic dogs in four animals ri exceed the accepted limit 0,71. mean ri for the group of the dogs with diabetes was 0,66 ae 0,07, in control group 0,62 ae 0,05 (p ¼ 0,08). as many as four diabetic cats had significantly elevated ri and in two of them the diabetic nephropathy was suspected. mean ri for the group of diabetic cats was 0,71 ae 0,07 and for the healthy cats 0,59 ae 0,04 (po0,001). in all animals the positive correlation between the ri and age was observed (healthy dogs r ¼ 0,38, healthy cats r ¼ 0,51, diabetic dogs r ¼ 0,39, diabetic cats r ¼ 0,71). correlation between ri and duration of diabetes was more relevant in cats (r ¼ 0,56) than in dogs (r ¼ 0,06). discussion/conclusion: our study proves that renal vascular resistance value is elevated in some of small animals with diabetes. it is not possible to conclude much about usefulness of doppler ultrasound in monitoring the kidney condition in animals with diabetes, from study performed on such a small group of patients. our results may serve as an introduction to the research on bigger group of animals, which would be enriched in detailed laboratory and histopathological data providing new information about diabetic nephropathy in dogs and cats. brkljacic b., renal vascular resistance in diabetic nephropathy: duplex doppler us evaluation. radiology 1994; 192: 549-554 introduction/purpose: ultrasound (us)-guided percutaneous renal biopsy has become invaluable as diagnostic method in kidney diseases that is associated with minor or major complications, reportedly being more extensive using large-bore 14-gauge needles. 1 contrast harmonic us (chus) increases the intensity of the blood pool echo signals in parenchymal organs and enhances existing lesions. this study investigated the value of chus as a screening method of post-biopsy renal complications, and evaluated the traumatic importance of 14-gauge biopsy needles. renal biopsy was performed in 11 healthy beagle dogs at 3 occasions (0, 4 and 6 months) for a total of 33 biopsies using 14-gauge needles (vet-core tm , surgivet, usa). a chus examination was performed 30 minutes after biopsy using a mylab30vet us machine (esaote, genoa, italy) with a multifrequency linear transducer of 5-7.5 mhz. approximately 0.3 ml/10 kg of contrast medium (sonovue, bracco), was injected twice iv. the chus study was repeated each week, until complete dissolving of the lesions. the images were recorded and reviewed using subjective and semi-quantitative methods for description of the lesions including their number, shape, size, sharpness, echogenicity, and evolution over time. results: chus performed 30 minutes after biopsy revealed hypoechoic lesions in all kidneys, visible as 2 tracts (n ¼ 17), 1 tract (n ¼ 13), triangular or nodular area (n ¼ 2), or area þ tract (n ¼ 1). one beagle had perirenal bleeding. ten lesions were small to mild and 23 lesions were moderate to large. ten tracts had a thickened nodular base, subcapsular at the renal cortex. at week 2, all lesions were still present but slightly (n ¼ 8) or significantly (n ¼ 25) decreased in size and sharpness, with increased echogenicity. the perirenal bleeding disappeared. one beagle showed ureter and renal pelvic dilation and anechoic round lesions were present compatible with hematoma. at week 3, 27 kidneys were normal, 5 showed vague lesions and one was still abnormal showing the same features as at week 2. at week 4, all kidneys were normal. discussion/conclusion: chus enables assessment of the evolution of post-biopsy renal lesions and can be an adequate screening method. moreover, 14-gauge needles were not found to be quite as traumatic as generally believed. introduction/purpose: variable ultrasonographic measurements of normal and abnormal canine adrenal glands have been reported.1-3 moderate correlation was present between ultrasonographic and gross measurements of thickness (dorsoventral measure) for both glands, but no correlation was found for width (mediolateral measure) or length.1 however, the repeatability of such measurements has not been determined. the purpose of the study was to assess the intra-and interobserver variability of sonographic measurements of adrenal glands. materials and methods: six healthy beagle dogs were used. three observers, two ecvdi diplomates (j.h.s. and v.b.) and one ecvdi resident (p.p.) scanned both adrenal glands of each dog three separate times. the observers were asked to measure the maximal length (craniocaudal direction), height (dorsoventral direction) and width (mediolateral direction) of each gland. length and height of both cranial and caudal poles were measured in longitudinal plane. height and width of both cranial and caudal poles were measured on transverse images. a random effects model was fit to the data with dog, observer and measurement within observer as random effects. measurements of the length of both glands had the highest intra-and interobserver variability. height of the caudal pole measured on longitudinal images had the lowest intra-and interobserver variability. measurements that also presented low intra-and interobserver variability were: height and width of the caudal pole on transverse images and height of the cranial pole but on longitudinal images only. discussion/conclusion: length measurements appeared unreliable due to difficulties in obtaining the complete length of the gland on one image and in defining clearly the cranial border of the right gland. measurements of height and width of the cranial pole of both glands on transverse images were unsatisfactory due to its inconsistent shape and position. hence, height of the caudal pole measured on longitudinal images should be preferentially used, as it is the less variable and the most accurate sonographic estimation of gross adrenal size. grooters am, biller ds, merryman j. ultrasonographic parameters of normal canine adrenal glands: comparison to necropsy findings. vet radiol ultrasound 1995; 36 (2) introduction/purpose: dogs and cats presented with signs of upper airway obstruction frequently have to undergo bronchoscopic examinations for a final diagnosis. although usually followed by surgery to relieve the obstruction the procedure carries a high risk due to the need for general anesthesia. the goal of this study was to assess computed tomography and virtual bronchoscopy in awake dogs and cats with signs of upper airway obstruction. materials and methods: five dogs and 2 cats presented with signs of upper airway obstruction were included. final diagnosis was made by bronchoscopy, physical examination of upper airway under general anesthesia, fluoroscopy or histopathology. the patients underwent head and neck ct examination with a 16 detector-row helical ct unit without sedation or general anesthesia. all patients received oxygen during the entire ct examination. five patients presented with respiratory distress (dogs 1, 2 and 4 and all cats) and one with chronic cough (dogs 3 and 5). other clinical signs included cough (dog 2) and stertor (cat 1). the imaging findings and final diagnosis were: dog 1: diagnosed on ct as focal severe tracheal collapse and final diagnosis of tracheal collapse on bronchoscopy. dog 2: diagnosed on ct as tracheal stenosis; final diagnosis on necropsy of severe submucosal granulation tissue and stricture due to scar tissue. dog 3: diagnosed on ct as everted sacules and elongated soft-palate; final diagnosis on bronchoscopy of everted sacules, elongated softpalate and grade 2-3 laryngeal collapse. dog 4: diagnosed on ct as laryngeal paralysis and final diagnosis of laryngeal paralysis on physical examination. dog 5: diagnosed on ct as tracheal collapse and final diagnosis of tracheal collapse on fluoroscopy. cat 1: diagnosed on ct as mass, probable neoplasia; final diagnosis on histopathology of pyogranulomatous laryngitis. cat 2: diagnosed on ct as regional wall thckening (inflammation or neoplasia); final diagnosis of severe suppurative laryngitis. discussion/conclusion: ct of awake patients using the vetmousetrap was successful in accurately demonstrating upper airway disease. ct vetmousetrap imaging was a fast and non-invasive procedure that allowed simultaneous oxygen administration with minimal stress to respiratory compromised patients. introduction/purpose: the purpose of the study was to design, construct and test a device for clinical computed tomographic imaging of awake dyspneic cats. this abstract reports on device design and clinical testing on normal eupneic cats. materials and methods: ten normal cats were placed inside the device for measurement of carbon dioxide (co2), fraction of inspired oxygen (fio2), temperature at rest. twenty two awake normal cats were imaged with two different kvps (80 and 120) and 2 different pitches (0.562 and 1.75). the signal intensity of the pulmonary parenchyma (si-lung), signal intensity of background (si-backgr.), contrast, noise, signal-to-noise ratio (snr) and contrast-to-noise ratio (cnr) were calculated. images were evaluated for sharpness of liver margins, motion artifact, aliasing and windmill artifacts. significance was set at p ¼ 0.001. the final device design was a transparent acrylic tube with a wall thickness of 5 mm, outer diameter of 21 cm, 40 cm in length, with oxygen and catheter line access, and no metallic components. no artifacts related to the device were detected and the cats could be visually monitored throughout the imaging and quickly removed. oxygen and catheter line access was uncomplicated and effective. carbon dioxide levels were mildly elevated by 5 minutes. the mean fio2 at 25 minutes was 68%. temperature levels inside the device increased over time with the highest mean of 26.81c at 30 minutes. overall, 75 out of 80 (94%) examinations were judged to have absent or minimal motion artifact. higher kvp protocols had higher snr and cnr. higher pitch protocols had lower noise, higher snr and cnr, and less motion artifact. low pitch protocols were deemed clinically better because of significantly lower windmill and aliasing helical artifacts. discussion/conclusion: the vetmousetrap was an effective device for imaging awake cats with minimal elevation in carbon dioxide and significant elevation in ambient oxygen. the only clinically relevant artifacts noted were windmill and aliasing in the large pitch (1.75) protocols. motion was not a clinically significant issue. section of diagnostic imaging, department of companion animal clinical studies, 3 section of epidemiology, department of production animal studies, faculty of veterinary science, university of pretoria, onderstepoort 0110, south africa introduction/purpose: canine chylothorax is a problematic condition to manage due to poor response rates with both medical and surgical management. surgical ligation of the thoracic duct (td) has been the most frequently reported treatment; however success rates with td ligation alone have been reported to be between 53% and 59%. failure to ligate all of the td branches has been described as the most common cause of surgical failure. lymphography has conventionally been conducted by catheterization of a mesenteric lymphatic, but has recently been described using the less invasive technique of percutaneous injection into a popliteal lymph node. computed tomography (ct) has been shown to be superior to radiographs in detecting td branches and providing td topographical information. this study assessed the ct comparability of the two lymphography techniques and determined the equivalency of helical and sequential ct modalities for td lymphography. materials and methods: seven beagles underwent both mesenteric lymphography (ml) and ultrasound guided percutaneous popliteal lymphography (ppl). iohexol 300 mg/ml was administered at 1 ml/kg for both techniques. for the ppl, contrast medium was administered at 100 ml/hr where as for ml it was given as a bolus over a one minute period. helical ct was initiated immediately after completion of contrast medium injection, followed by sequential ct of the same area. for both administration techniques and ct modalities, images were taken at the mid-vertebral bodies of t9-l1. images were assessed for the total number of td branches and their position relative to the aorta, as well as the cross-sectional area and mean hounsfield units (hu) for the largest td branch. the effects of administration technique, ct modality, vertebral site and animal on the observed td number were assessed using zero-truncated poisson regression, while their effects on cross-sectional area and mean hu, were analyzed using multiple linear regression. the number of td branches detected did not differ significantly between the two contrast administration techniques (p ¼ 0.256) or ct modalities (p ¼ 0.417), although the count ratio (cr) indicated a trend for the ppl administration technique (cr ¼ 0.830) and the helical ct modality (cr ¼ 0.876) to detect slightly fewer td branches. ml and helical ct both resulted in significantly greater largest td branch cross-sectional area and mean hu (po0.001). this study suggests that ppl is an acceptable alternative to ml for identifying td branches when using either helical or sequential ct. introduction/purpose: thoracic computed tomography (ct) is superior to conventional radiography by eliminating superimposition and enhancing resolution, thus improving detection of pathology. acquisition timing during computed tomography angiography (cta) is critical to optimize contrast medium enhancement. due to the large differences in veterinary patients optimal timing of contrast enhancement cannot be standardized. this study serves to determine if there is any statistically significant difference in the two cta techniques, namely bolus tracking (bt) and time delay (td) utilizing a test bolus in terms of enhancement, scan time and ct dose index (ctdi). materials and methods: 6 healthy beagles (36-48 months), underwent dual slice thoracic cta using the bt and td techniques. the time interval between studies was 6 weeks and the order was randomized. images were interpreted at the level of the cranial aspect of the 8th thoracic vertebra (t8), mid and caudal t8, where the aorta (ao), pulmonary artery (pa) and caudal vena cava (cvc) were visualized simultaneously. images were viewed in a mediastinal window. in this within-subject study design the bt and td techniques were compared with respect to the hounsfield units in the ao, pa and cvc during the arterial and venous phases, respectively. findings were compared using the students paired t-test and in each case the result was confirmed by the non-parametric wilcoxon's method pairs signal-ranks test. the shapiro-wilkes test for normality was done. additionally, the 95% confidence interval for the difference of the means between the bt and td techniques was rewritten to a 95% confidence interval for the bt as a ratio of the td studies, where the latter was considered the gold standard for an individual. (gsd) . although various studies dealing with radiographic appearance of the lumbosacral region in gsd exist, radiographic anomaly of the lumbosacral transition has not been confirmed by an adequate population size so far. the aim of this study was to analyse the anatomical variance and frequency of early onset pathologies of the lumbosacral transition between gsd and other large breed dogs. furthermore, a genetic analysis of radiographic signs related to lumbosacral stenosis was performed for the gsd. a total number of 1.267 lateral lumbosacral radiographs of clinically sound large breed dogs -733 of which gsd (mean age 15 months) and 534 dogs of other breeds (mean age 31 months) -were studied using established methods (1, 2) . nine specific findings and 17 anatomic dimensions were assessed with emphasis on malalignment and vertebral canal height at the lumbosacral level as well as lumbosacral osteochondrosis and transitional vertebrae. the results of radiographic examinations of 572 gsd (95% born in [2000] [2001] [2002] [2003] [2004] [2005] [2006] [2007] with complete pedigree data were included into heritability estimation. there were significant differences between the gsd and the other breeds in most of the assessed morphologic parameters. the prevalence of lumbosacral osteochondrosis and 4 other specific findings was significantly higher in the group of the gsd. the ratio of ventrodorsal lumbosacral subluxation was 2:1 between gsd and other breeds and was significantly higher for the gsd. dorsoventral dimension of the lumbosacral vertebral canal was significantly lower for the gsd in any location, whereas the ratio of caudal lumbar vertebral canal height to cranial sacral vertebral canal height was significantly higher in this group. genetic analysis of the collected parameters in the group of the gsd resulted in moderate to high heritability estimates for specific findings (h 2 0,22-0,64) and predominantly high heritability estimates (h 2 0,31-0,73) for anatomic dimensions. discussion/conclusion: compared with other breeds there is a primary aberrant anatomic conformation of the lumbosacral transition and a higher frequency of promoting factors such as sacral osteochondrosis, malalignment and inherently narrow vertebral canal, that predispose gsd's to lumbosacral stenosis. genetic determination of these predisposing factors suggests that a selective breeding scheme based on radiographic parameters could be promising. introduction/purpose: previous studies reported the german shepherd dog (gsd) being overrepresented in the occurrence of cauda equina compression syndrome (ces) as a consequence of degenerative lumbosacral stenosis (dlss). a congenital predisposition for the early degeneration of the lumbosacral intervertebral disc has been suspected. male dogs show a higher incidence of ces and multiple anatomic variations such as lumbosacral transitional vertebra or osteochondrosis of the sacrum are reported as predisposing factors. the purpose of the present prospective study was to evaluate degeneration of the lumbosacral intervertebral disc in the gsd compared to other breeds. the lumbosacral spines of 126 gsds and 54 other large breed dogs were examined using magnetic resonance imaging (mri). the signal intensities of the entire disc and the nucleus pulposus were determined. the dimensions of the disc and the lumbosacral angle were measured, and step formation as well as conformation of the lumbosacral junction was recorded. in addition the degree of degeneration of each intervertebral disc was graded using three different classification systems. results of gsds without clinical signs of ces were compared to healthy dogs of other breeds and to dogs showing signs of ces. statistical regression analysis was performed to identify possible associations between the morphology of the intervertebral disc and the training level of the dogs. results: a significant difference in the severity of degeneration of the lumbosacral intervertebral disc in gsds in comparison to other breeds was found. degeneration of the lumbosacral intervertebral disc was not associated with the degree of degeneration of other lumbar discs. morphologic differences concerning gender and breed could be deminstrated. discussion/conclusion: we concluded that male dogs and gsd dogs have a higher risk to develop degenerative changes of the lumbosacral intervertebral disc. introduction/purpose: when interpreting mr images in veterinary diagnostic imaging a thorough understanding of brain anatomy and species characteristics are of particular importance. although feline and canine brains have been examined for decades most other mammals are only occasionally scanned. materials and methods: scans of anatomical of various mammalian species specimen were analyzed and retrospectively compared. results: metatheria (marsupials): the corpus callosum (and septum pellucidum) is only present in eutherian mammals, kangaroos and other marsupial brains are remarkable for their lack of this and have a well developed rostral commissure that connect the hemispheres. in the opossum the cortical surface only shows two major furrows, one is the lateral rhinal fissure, separating a large ventrolateral rhinencephalon from the neocortical part and the other is the orbital fissure at the rostrodorsal end of the hemisphere. in higher marsupials, as the kangaroo a gyrencephalic brain is present. the olfactory bulbs are huge and solid, without an olfactory recess. lagomorphs: in hares the surface of the pear shaped brain is smooth with only the lateral rhinal fissure and a dorsal longitudinal fissure, the marginal sulcus. neocortical and older cortex divisions almost equal in size and the large ammons horn parallels the neocortical surface over a large extent. in contrast to higher mammals, the paleocortex is less developed, thinning rather in its dimension when running caudad. in the cerebellum, the vermis is straight and the most pronounced structure is the ventral flocculonodular lobe that extends far laterally. ungulates: the scans nicely reflect the important characteristics of artiodactyl brain, e.g. the dominant position of the visual and olfactory systems. this is seen in the large diameter and size of the eye, optic nerve/chiasm, and rostral colliculus respectively, as well as in the impressive dimension of the olfactory bulb and tracts as well as of the piriform lobe. the cortex of ungulates telencephalic hemisphere is densely folded and the major sulci show a high variability in ramification. most pronounced in the horse. the corpus callosum is well developed in artiodactyls. in the diencephalons a large pituitary gland and pineal gland are striking. discussion/conclusion: for the identification of structural deviations from normal anatomy in species other than cats and dogs a thorough understanding of brain anatomy is necessary. introduction/purpose: gliomatosis cerebri is a neoplastic condition of the central nervous system characterized by widespread diffuse infiltration of the brain and spinal cord by neoplastic glial cells with preservation of the brain architecture. the condition is rare in all species and has been confirmed histologically in dogs. a case report of a single dog described mri findings as hyperintense and ill-defined in t2-w and flair sequences within one hemisphere of the forebrain and extension to the brainstem and cerebellum. the purpose of the present case series is the description of the mr features in five dogs and their correlation to histopathology. the present case series includes 5 dogs, one yorkshire terrier and four bearded collies, presented because of neurological disorders including circling (3/5), central blindness (2/5) or decreased menace response. the disease was localized to the forebrain. mri was performed at two different institutions: 3 dogs were examined using a 0,3t mri unit and two dogs using a 1,5 t unit. minimal sequences consisted of t2-w sequences, t1 sequences pre-and postcontrast in different planes and flair (3/5). results: mri findings included diffuse hyperintense areas in t2 w sequences in all dogs. the ill defined lesions were hypointese (4/5) or isointense (1/5) in t1 w images. no contrast uptake was present in any case. the lesions were bilateral with one side always more severely affected and continued along the white matter extending partially into the gray matter with contact to the brain surface. in all cases the thalamus and cerebellum were affected. mild to moderate mass effect and midline shift was present (5/5) and there were signs of increased intracranial pressure with flattening of the sulci, transtentorial herniation (3/5), herniation through the foramen magnum in two of these dogs, and periventricular edema on flair images (3/5). other signs included syringohydromyelia (4/5) in the cervical spine. additional hyperintense areas interpreted as infiltration within the spinal cord were visible in two cases. histopathologically all cases revealed a glial cell population with homogenous morphology infiltrating diffusely the white and gray matter of both hemispheres, the thalamus, brainstem and cerebellum. in two out of three cases an infiltration of neoplastic cells in the spinal cord was found. discussion/conclusion: mri features of all five dogs were very similar in distribution; signal behavior, lack of contrast uptake, had signs of mass effect and increased intracranial pressure. descriptions in men are similar except mass effect, which might be explained by the later presentation of dogs and progression of disease. distribution and extent of the lesion corresponded well to histopathological findings. on mri interstitial edema could not be differentiated from cellular infiltration, however, hypointense signal in t1-w sequences in more severely affected areas could be a sign for brain edema (high water lesion), which was confirmed by histology. because four of the five presented dogs were bearded collies we hypothesize that gliomatosis cerebri in this breed may have a hereditary background. c. haarstrick, c. niesterok, g. oechtering, m. alef, i. kiefer. department for small animal medicine, university of leipzig introduction/purpose: in small animals the soft palate can only be examined by oral inspection, such as pharyngoscopy enabling only examination of the organ surface. investigation of the internal pattern is possible by ct or mri, but the expensive equipment and required anaesthesia form limitations of performing these examinations. the examination of the palate gains importance due to the increasing popularity of brachycephalic dog breeds. because of their anatomical conditions and problems during recovery from anesthesia, less risky procedures, such as ultrasonography, are needed. the aim of this study is to characterize the normal sonographic anatomy of the soft palate and to define predetermined landmarks for ultrasonographic measurements of the soft palate diameters in dogs. the study was performed on seven canine heads. the dogs were euthanized because of various diseases not related to the head. ultrasonography was performed via a submental approach. depending on the shape of the ultrasonic probe also intraoral ultrasonography was performed. the studies were performed in three or four probe positions in sagittal and transversal direction. thickness of the soft palate was measured at two defined locations. subsequently the detected anatomic structures were reexamined by submental approach in a water bath. afterwards the single anatomic layers were dissected starting with the submental layers working up towards the soft palate. after every single preparation a sonographic examination was carried out. finally the isolated soft palate was analyzed in the water bath by ultrasound. the produced images were assessed regarding recognizable structures and analyzed for image quality by a subjective score system. the transition between the hard palate and the soft palate as well as the middle section of the soft palate was distinguished from the surrounding tissue by submental approach in all cases. evaluation of the echogenicity of the soft palate parenchyma was difficult. also visualization of the caudal part of the velum depended strongly on testing conditions. the differentiation between cutaneous and subcutaneous tissue, sublingual musculature and tongue is easily achievable. measurement of the thickness of the palate was done at two defined locations. the first was defined one centimeter caudal to the transition between the hard and the soft palate. the second more difficult location was determined at the caudal soft palate adjacent to the presumed palatopharyngeal arch which is identified as hyperechogenic line caudodorsal to the soft palate. discussion/conclusion: in this study the sonographic appearance of the canine soft palate using cadavers was described. the submental approach enables the differentiation between intraoral structures. evaluation of the echogenicity and length or thickness of the soft palate is limited, due to influence of surface pressure by the investigator for instance. the normal echographic anatomy of the esophago-gastric junction and the gastro-duodenal junction has not been studied in the normal cat. the aim of the present prospective study is to describe the normal aspect of the pylorus, proximal duodenum and the cardia of the stomach. a prospective study was performed in 15 fasted adult cats (11 purebred, 2 crossbreed and 2 domestic shorthair cats) free of gastro-intestinal disease and deworming. cats were scanned in dorsal recumbency, without sedation. a linear probe (12 or 18 mhz) was used for better resolution during the study. measurements were obtained for caudal esophageal wall thickness just cranial to the cardia (from inner mucosa to external serosa in longitudinal section: ew), cardia wall thickness (cw, in longitudinal section), pyloric wall thickness (pw, in longitudinal section), muscularis of the pyloric thickness (mp, in longitudinal section), length of the thicker part of the cranial duodenum submucosa (dl), gastric lymph node thickness (glnt). freezed images and videoclips were recorded for retrospective review. several cats free of digestive symptoms were excluded of the study because of: incomplete emptying of the stomach, abnormal gastric thickening, abnormal digestive lymphadenopathy, incomplete alignment of the gastroduodenal junction, agitated cats. images obtained during the prospective study were reviewed by two ecvdi diplomates (lc and dr). the most caudal part of the esophagus and the gastro-esophageal junction were identified in 10/15 cats (66.7%). submucosa of the most cranial part of the duodenum was thicker in 13/15 cats (86.7%). in all cats, the muscularis part of the cardia and the pylorus was thicker. the former was strip shaped and the latter had a short triangular shape. on the 15 cats studied, only 3 measurements could be systematically performed: pw, mp, glnt. measurements (1st number correspond to mean, minimal and maximal values are in brackets, confidence intervals of 95%) were as follows: ew: 3.1 mm (2.3-3.8 mm); cw: 4.7 mm (3.6-5.1 mm); pw: 4.2 mm (3.1-5.2 mm); mp: 2,5 mm (2-3.6 mm); dl: 7.4 mm (3-13.7 mm); glnt: 4.1 mm (3.4-5.1 mm). discussion/conclusion: linear probe seems to be an efficient tool to identify the pylorus in cats but limited for the cardia and abdominal esophagus especially in fatty cats. the description of the normal echographic anatomy of the ß borders ý of the stomach could help further identification of cardia and pyloric disease in cats. olivier taeymans, dvm, phd, dipl ecvdi, dominique penninck, dvm, phd, dacvr, dipl ecvdi. from the department of clinical sciences, foster small animal hospital, cummings school of veterinary medicine, tufts university, north grafton, 01536 ma, usa introduction/purpose: few reports exists on normal 1,2 and pathological ultrasonographic appearances of the structures at the ileocecocolic junction (icj) in the cat. during routine abdominal ultrasound of feline patients, we observed that it is not uncommon to find changes in this area particularly in cecal wall thickness, cecal contents, mesenteric root fat, and regional lymph nodes. we hypothesize that these changes are not incidental, and may be representative of gastrointestinal (gi) disease in cats. materials and methods: the hospital information system of tcsvm was searched for ultrasound records of feline patients containing a description of abnormalities at the level of the cecum, ileocecocolic area, ileocolic junction, ileocecal (cecal) lymph nodes, or colic lymph nodes between january 2002 and june 2008. patients having gastrointestinal neoplasia were removed based on available patient outcome. this resulted in 29 cats, 14 males and 15 females. mean age was 87 months. results: there were 18/29 cats with enlarged cecal lymph nodes. focal hyperechoic mesenteric fat was noted in 18/29 cats. mild fluid accumulation at the ileocecocolic junction was seen in 7/29 cats. fluid content was noted in 7/29, and foreign cecal material in one cat. six cats showed a rounded shape of the cecum. the cecal wall was thickened in 19/29 cats, 6/19 showing wall alterations. the ileal wall was mildly thickened in 6 cats, and 4 of these had altered wall layers. 18/29 cats had no ultrasonographic evidence of gi changes in other portions of the gi tract, and 17 of these 18 cats were symptomatic for gi disease. 8 cats had fine needle aspirate or biopsies. histopathology confirmed mild colitis/enteritis in one case, and mild reactive lymph nodes in another case. cytology showed reactive lymph nodes in two cases. our results show that icj changes was the only gi finding in 62% of our population, and that all except one of these cats were symptomatic for gastrointestinal disease. these results support that ultrasonographic changes noted at the level of the icj may have clinical relevance, and may represent typhlitis. introduction/purpose: comparison of the kidney long axis dimension to the second lumbar vertebra (l2) on ventrodorsal projections has proved to be an accurate method for assessment of kidney size on radiographs. in the adult dog, the kidney length has been reported to be 2.5-3.5 times the length of l2. 1 the aim of the study was to test the hypothesis that the suggested maximum normal kidney size obtained from radiographs is too high and also to evaluate whether breed type (brachycephalic, doliocephalic, mesocephalic), age, gender, weight and body condition of the dog have an impact on kidney size. abdominal radiographs of 100 dogs with no evidence of concurrent disease that might have an effect on renal size and that had no clinical or ultrasonographic evidence of renal disease were included in the study. all animals had normal renal blood profile and electrolytes. the animals were radiographed in right, left lateral and ventrodorsal recumbency although not all animals had all projections performed. the number and type of projections depended on necessity, and the reason for the clinical investigation. radiographic length of the kidneys was measured on digital images and compared to the length of the second lumbar vertebra. the ratios of kidney length to length of l2 (kidney/l2) of each dog in all available views were calculated from measurements obtained from radiographs. the length of kidneys of 3.5 times the length of l2 was above the 97.5th percentile of the distribution for all the ratios except the left kidney/l2 measurements on vd views. significant differences (p ¼ 0.008) in kidney/l2 ration between the groups were present, especially between the brachy-and dolicocephalic groups. the brachycephalic group appeared to have the highest kidney/l2 ratio. the dolicocephalic group never reached a kidney/l2 ratio of 3.5. there was no significant difference between genders. higher kidney/l2 ratios were observed in intact animals compared to neutered animals. the weight did not have a significant impact on kidney/ l2 ratios although there was very close to a significant difference between weight categories (o10, 10-30, 430 kg) with the largest difference between the categoryo10 and the other two weight groups. discussion/conclusion: mild renomegaly should be suspected if the kidney/l2 ratio is equal to or larger than 3.5 in dogs other than brachycephalic breeds. the kidney/l2 ratio of 3.5 in our study was found only within the brachycephalic dog group. all other groups had slightly lower ratios. it is suspected that this may be due to shorter vertebrae rather than longer kidney length in brachycephalic dogs but further studies are needed. introduction/purpose: granulomatous meningoencephalitis (gme) is an acute progressive and often fatal inflammatory disease of the central nervous system (cns) mainly affecting small and toy breed dogs, often young and middle-aged. a definitive diagnosis of gme can only be achieved after postmortem and histological examinations. the purpose of this study was to describe the ultrasonographic findings, using color doppler mapping and spectral analysis in dogs with postmortem histologically confirmed gme. retrospective study of transcranial doppler sonography (tcds) examinations performed between august 2005 and september 2006. during this period, 116 dogs with clinical signs of cns disease were submitted to tcds. but only 11 dogs were selected with gme diagnosis confirmed at postmortem examinations. b-mode images were taken to evaluate brain parenchyma anatomy and echotexture. color doppler mapping was performed to identify the circle of willis on both hemispheres. after identifying the vessels, pulsed doppler was accomplished on each one, obtaining resistive index (ri). seven female (64%) and 4 male dogs (36%) presented gme diagnosis confirmed at postmortem and histological examinations. the mean age was 6 years (range: 3-15 years). decreased parenchymal echogenicity was observed in 9 dogs (82%); 8 dogs presented ventriculomegaly. focal lesions were detected in 6 dogs (54.5%). color doppler study revealed conspicuous vessels in the circle of willis of 10 dogs (91%). pulsed doppler detected the six major cerebral arteries in 7 dogs. in 2 dogs only one artery was not depicted and in one dog, two cerebral arteries were not outlined. pulsed doppler showed normal and high ri values in the outlined arteries. discussion/conclusion: tcds findings were correlated with pathologic examination diagnosis. there was a positive correlation between ultrasound and pathology findings concerning the focal lesions. color doppler study showed conspicuous intracranial vessels using minimum color gain, possibly due to the increased diameter. vascular occlusion and stenosis caused by space-occupying masses or inflammatory infiltrates may be the possible cause of undetectable vessels. csf pressure is normal or high in gme patients. the dogs showed normal or high ri values. focal granulomas and vascular changes in different locations and various degrees of presentation can modify microvascular impedance. sonographic findings in this study corroborate previous gme pathology reports. although it is known that an in vivo diagnosis is difficult, tcds can be a useful instrument to evaluate cns when gme is considered. introduction/purpose: in recent years, with the new development of high resolution, electronic broad band transducers, ultrasound (us) is being considered as an optimal image technique to evaluate normal anatomy and abnormalities of the peripheral nerves. to the author's knowledge, information regarding the appearance and ultrasonographic approaches of peripheral nerves in the cat has not been documented. the aim of the present study was to determine the ultrasonographic appearance and the approaches to assess the sciatic nerve (scn) in cats. materials and methods: anatomical nerve study: eight limbs from four feline cadavers were used for anatomical dissections. another two fresh feline cadavers were frozen and cut in cross sections to determine the anatomic landmarks. ultrasound nerve study ''in vitro'': eight pelvic limbs from four fresh feline cadavers were employed. all limbs were scanned using a 4-13 mhz linear transducer (mylab 70, esaote s ). the examinations were performed in three regions: glutea, femoris and poplitea. the accuracy of the ultrasound localization was demonstrated by injecting ink around the targeted nerves which were, then, immediately dissected. the obtained ultrasonographic images were compared with the anatomical cross sections to facilitate their interpretation. ultrasound nerve study ''in vivo'': five healthy adult experimental cats were sedated to perform the ultrasonographic examination of the scn using the technique described for the ''in vitro'' study. the ultrasonographic images of the scn showed a good correlation with the anatomical nerve study. the scn was easily identified on glutea, femoris and poplitea regions. on the longitudinal view, the ultrasonographic appearance of the scn was a tubular hypoechoic structure with internal echoes, outlined by hyperechoic lines. on the transversal view, it was observed as an ovoid hypoechoic structure surrounded by a hyperechoic rim. there were no differences between the ultrasonographic appearance of the scn in fresh cadavers or healthy cats. discussion/conclusion: this study shows the usefulness of ultrasound to evaluate the scn in cats, from its origin until its division into the peroneus communis and tibialis nerves. the ultrasonographic appearance of the scn was as a hypoechoic structure with internal echoes, outlined by hyperecogenic lines. benigni, l., corr s. a., lamb c. r. ultrasonographic assessment of the canine sciatic nerve. vet. rad. ultrasound. 2007. 48 (5) : 428-433. echeverry d., gil f., laredo f., ayala m. d., belda e., soler m., agut a. ultrasound-guided block of the sciatic and femoral nerves in dogs: a descriptive study. vet j. 2009 (in press). introduction/purpose: ultrasound examination performed by and experience sonographer is becoming the elective exam when suspecting of a gastrointestinal obstruction, replacing contrast radiographic studies for confirmation of these. to the author knowledge only hyperechoic interface foreign bodies with acoustic shadowing have been described in the literature. this report describes the appearance of hypoechoic foreign bodies, specifically rubber pacifiers. three dogs with gastro-intestinal clinical signs where referred for an ultrasound. in all of them, a throughout exam of the gastro-intestinal tract as of the remaining abdominal cavity was made (sonosite titan with microconvex transducer from 5-8 mhz). a gelatin model (collagen based) was made containing 3 rubber pacifiers (1 latex and 2 silicone). an ultrasound scan was performed to access the ultrasonographic appearance of the pacifiers without the interference of gas or ingesta from the gastrointestinal tract. results: three foreign bodies were detected ultrasonographically. one foreign body was detected in the stomach, 2 were detected in the small bowel (jejunal loops). only two animals had ultrasonographic signs of mechanic ileus, the ones that were detected in the small bowel, the one visualized in the stomach was only partially obstructive. all of the foreign bodies shared the following ultrasonographic appearance: hypo to anechoic band with a hyperechoic capsular interface. their shape varies according to the plane sectioned as well as the part of the pacifier scanned. the teats had an oval shape, were composed of and hypo to anechoic band with strong hyperechoic contours, they were open on one side, allowing for the content of gastrointestinal tract to enter it. all of the foreign bodies detected were surgically removed. the pacifiers visualized in the gelatin model had low or null acoustic impedance, and therefore were anechoic with a hyperechoic contour. discussion/conclusion: rubber pacifiers, latex and silicone based, are present in many households with children and seem to be a commonly ingested foreign body by our pets. their specific ultrasound appearance makes their diagnosis easy by ultrasound, since its ultrasonographic features are patognomonic. rubber pacifiers size and position as well as the size of the animal, will determine if they are completely or partially obstructive. nonetheless even in partially obstructive cases, their surgical removal is advised. introduction/purpose: recently, a fatal syndrome characterized by mesenteric lymphadenopathy and hypergammaglobulinaemia has been recognized in domestic ferrets. histological lesions are similar to those of the non effusive form of feline infectious peritonitis (fip), and with immunohistochemical techniques coronavirus antigen in several affected organs have been detected. a recent mutation or shift in the ferret enteric coronavirus (fecv) is thought to be the cause of this syndrome (known as ferret systemic coronavirus infection). this report describes radiographic and ultrasonographic findings observed in the abdomen of seven ferrets with confirmed diagnosis of systemic coronavirus infection. materials and methods: 7 domestic ferrets (2 female and 5 male; 8-18 months) were presented at the veterinary teaching hospital with a history of lethargy, hyporexia or anorexia, and weight loss. diarrhea was recorded in 3 and vomiting in 1 of the ferrets. abdominal masses were palpated in 4 animals. pale mucous membranes, abdominal enlargement, and abdominal pain were observed in 2 of the ferrets. faecal examination, complete blood count (cbc), serum biochemical profile, abdominal radiographs (right lateral and ventrodorsal views) and abdominal ultrasound (linear high frequency, 11-13 mhz, transducer) studies were performed in all the ferrets. hyperglobulinaemia with monoclonal gammopathy (7/7), anaemia (5/7) and severe neutrophilic leucocytosis (4/7) were detected. ferret systemic coronavirus infection was diagnosed based on histological findings (pyogranulomatous inflammation of the viscera and peritoneum) and on immunohistochemical confirmation of coronavirus antigen presence in affected tissues. radiographically, signs of emaciation (loss of lumbar musculature) and decreased serosal detail were recorded in 5 animals. presence of mid abdominal soft tissue mass was observed in 4 ferrets. other radiographic findings include moderate splenomegaly and mild to moderate dilation of the intestinal tract with gas (2/7), pendulous ventral abdominal wall and left kidney enlargement (1/7). sonographically, a mild amount of echogenic effusion and thickening of the peritoneum, omentum, and mesentery with a hyperechoic and hyperatenuated aspect was the most common finding (6 ferrets). heterogeneous, ill-defined soft tissue masses, surrounded by hyperechoic fat and mesenteric lymphadenopathy were imaged in 5 animals. mild to moderate splenomegaly was observed in 3 patients and inguinal inflammation accompanied by signs of vascular thrombosis was recorded in 1 ferret. although definitive diagnosis of systemic coronavirus infection is based on histological and immunohistochemical results, a tentative diagnosis can be made on the basis of the animal's history, clinical signs, and clinicopathological, radiographic, and ultrasonographic findings. imaging signs of peritonitis and the presence of soft tissue masses are highly suspicious of systemic coronavirus infection. aleutian disease, lymphoma, and chronic inflammatory bowel disease should be included in the differential diagnosis. susanne stieger-vanegas, christopher cebra, jason wiest. department of clinical sciences, college of veterinary medicine, oregon state university, corvallis, oregon, usa introduction/purpose: in llamas and alpaca colic symptoms can be obscure. additionally, the cause of colic symptoms can be difficult to localize due to the limited availability of diagnostic techniques evaluating the abdomen. colic symptoms caused by bacterial enteritis or enteritis caused by eimeria macusaniensis can be very difficult to differentiate from colic symptoms caused by intestinal strangulation, entrapments, or intraluminal obstruction. the lack of the ability to differentiate between medical and surgical causes of colic symptoms affects treatment and therefore the survival rate and outcome of new world camelids with colic symptoms. computed tomography has been performed in llamas 18 hours after barium was given with an orogastric tube.1 however, 18 hours can be a long delay time for medical or surgical treatment in a patient with colic symptoms. the purpose of our study was to evaluate a new gastrointestinal imaging protocol using iodinated contrast media diluted in water. the objective of this study was to evaluate the feasibility of this new ct protocol to evaluate the gastro-intestinal tract in clinically normal new world camelids. three hours prior to the computed tomography study, three alpacas and two llamas without clinical signs indicating gastro-intestinal disease received iodinated contrast media diluted in water via an orogastric tube. following sedation, the animals were positioned in sternal recumbency on the ct table and axial, sagittal and coronal images were obtained. to enhance the definition of the organs and gastrointestinal wall intravenous iodinated contrast was applied and images were obtained with a 60 sec delay. in all animals the first, second and third compartment of the stomach (c1, c2, c3), small intestine, spiral colon and ascending colon were identified. in all animals the cranial and caudal glandular saccules of the stomach were observed. the ampulla of the duodenum was well seen and could be separated from the remainder of the duodenum. the walls of the intestine could be identified. in all patients the contrast reached at least the cranial aspect of the spiral colon. introduction/purpose: although radiographs are essential in the evaluation of thoracic diseases, the findings may not be specific or limited. in dogs and cats, the use of ultrasonography in the diagnosis of thoracic extracardiac diseases demonstrates an important role, providing images in real time and providing additional information regarding the location, size, extension and nature of the injuries. this study aims to compare the radiographic and b-mode and doppler ultrasonographic findings of the thorax, excluding the heart. materials and methods: twelve dogs and one cat suspected of thoracic disease undergoing thoracic radiography with formation of potential acustic window (caused by fluid, lung consolidation, mass lesions and/or pulmonary nodules) where submitted to ultrasonography of the thorax between march 2009 and march 2010 in the veterinary department at the federal university of viçosa, minas gerais, brazil. four cases had the post mortem examination. in 12 cases the radiographs showed effective acoustic window. in 10 cases the thoracic ultrasonography added important information such as: location of the lesion in the pulmonary parenchyma because of the sliding sign (9), best estimative of the amount of free pleural fluid (3), visualization of structure not detected during radiographic exam [cranial mediastinal lymph nodes(1) and atelectatic lung (2)]. in 10 cases the lesion was suitable to doppler evaluation: mass lesions and/or pulmonary nodules showed peripheral vascularization (9) and it was possible to separate pulmonary vessels from fluid filled bronchi. in 3 cases ultrasound did not add to the diagnosis. discussion/conclusion: in this study the b-mode and doppler ultrasonography played an important role in better characterizing of pulmonary, pleural and mediastinal conditions. besides it is an easy, fast, inexpensive, safe method. when available it should be considered to be done to help to reduce the list of differential diagnoses. christian niesterok, eberhardt ludewig, gerhard oechtering, michaele alef, ingmar kiefer. departement of small animal clinic university of leipzig introduction/purpose: both ct and radiography are commonly used for detection of metastases or primary lung tumors as well as for staging of neoplastic disease. on the other hand, they play a minor role in detection of benign round-shaped nodes, being differential diagnoses. the aim of this study was to estimate the value (sensitivity/specificity) of plane radiographs as a first line diagnosticum compared with computed tomography (msct philips brilliance mx 8000) as gold standard. in our study, we were looking for animals which were diagnosed in ct with a nodular lung pattern. in a second step, we then compared those results with those findings from the radiographs. altogether there were 55 dogs and 24 cats that met our inclusion criteria, undergoing both thoracic radiography and ct between june 2005 and dec. 2009. ct diagnostic was performed with a 6 line-spiral-ct ( philips brilliance), with a slice thickness of 2 mm, collimation of 1.5, pitch of 0.9 and a reconstructing matrix of 512 â 512. finally, statistic analysis was performed on order to determine the radiographic sensitivity. overall in 56 of 79 animals (71%), nodular changes already were detected during the radiographs and confirmed later on by the results of the computed tomography. in detail 39 of 55 dogs (71%) and 17 of 24 (71%) cats showed nodular round herds undergoing plane radiographs. the remaining percentage, which we missed in the radiographs mostly consisted of either very small changes or -even more often -were the result of highly changed lung lobes (like pneumothorax etc.), that lead to an overall lung opacity, providing only poor contrast. therefore, in these cases, soft tissue interpretation was difficult or even impossible. discussion/conclusion: radiography still plays an important role as a first line diagnosticum in detecting and differentiating nodular lung lesions. however, one needs to be aware that quite a high percentage of nodular lung changes can be missed with radiographs showing an overall sensitivity of 71% with no differences between dogs and cats. furthermore our study showed, that plane radiographs are of poor diagnostic values wherever concurrent problems (e.g. pneumothorax, pleural effusion etc) exist, that lead to an increased lung opacity. introduction/purpose: oesophageal pathology is not always easy to detect on survey thoracic radiographs and the exact nature of the pathology may be difficult to determine. endoscopy and ct are reliable diagnostic methods to address these deficiencies but are not always available in general practice. it is hypothesized that pneumo-oesophagraphy may be a cost-effective/affordable and readily performed technique to provide additional information on oesophageal pathology. thirty dogs with endoscopically confirmed spirocerca lupi nodules were selected from a larger prospective spirocercosis trial. each dog had rlr and dv survey thoracic views. dogs then had endoscopy under general anaesthesia immediately followed by rlr, llr, dv and vd pneumo-oesophagraphy thoracic views (pneumo-views) made whilst still anaesthetised. endoscopic nodule number, location and characteristics were recorded and were used as the gold standard. the oesophagus was inflated with a ambu bag s through a cuffed endotracheal tube placed in the oesophagus. radiographs were evaluated for degree of oesophageal distension (graded 0-4), nodule/mass visibility (yes/no), nodule surface characteristics and their mural attachment location. data were analysed in excell using paired t-test and chi-square tests and significance was set at po0.05. results: dogs had a mean age of 52 months (range 9-125) and weight of 19.6 kg (range 3.6-41.4 kg) and a variety of breeds were represented. lateral pneumo-views had more oesophageal distension than the dv/vd pneumo-views. dv survey and rlr pneumo-views detected significantly more nodules than the rlr survey and pneumo-dv views respectively. if all four pneumo-views were used 90% of nodules found on endoscopy, could be detected and if this was combined with the 2 survey views this became 93%. there was no significant difference in apparent length of oesophagus affected between the views or the modalities used. in six of nine malignant nodules an irregular mucosal surface, (indicative of neoplasia) could be seen on at least one of the pneumo-views. the mural attachment location could readily be seen on pneumo-views. the associated gas filled stomach gave the best visualization of the cardia on the rlr view. discussion/conclusion: this study indicates that pneumo-oesophagraphy is a useful and simple technique to use in a clinical environment to detect oesophageal pathology and its characteristics. introduction/purpose: pulmonary edema is the most common complication of congestive heart failure in dogs. interstitial pulmonary edema, which usually precedes more severe alveolar edema, may not be radiographically detectable. in human medicine, transthoracic ultrasonography is used to detect narrow repetition artifacts, or comet-tail artifacts, that indicate the presence of edema in the lung. the hypothesis of this study is that comet-tail artifacts can be identified using ultrasono-graphy in dogs with cardiogenic pulmonary edema, and that these artifacts occur in greater numbers and are more widely distributed in dogs with congestive heart failure than in normal dogs. transthoracic ultrasonography was performed in a normal group of clinically healthy dogs and dogs with heart failure with radiographic and echocardiographic signs of congestive heart failure. physical examination, two-view thoracic radiographs, two-dimensional and doppler transthoracic echocardiogram and heartworm antigen test were performed on all dogs. during ultrasonography, dogs were gently restrained in a standing or seated position. the thorax was divided into 4 quadrants on each side, and video clips and still images of each quadrant were recorded. distribution, characteristics and number of comet-tails were determined using qlab software (philips healthcare, bothell, wa). statistical analysis was performed using sas software version 9.1.3 (sas institute, cary, nc). results: 31 dogs were recruited in the normal group and 6 dogs were included in the heart failure group. transthoracic ultrasonography was easily and quickly performed on all dogs, with an average examination time of ten minutes or less. comet-tails were detected in 32% of the normal dogs, with a mean of 2 per dog. no statistical association was found between the variables age, sex, side and distribution using a phi correlation coefficient. subjectivley, in dogs with cardiogenic pulmonary edema, comet-tails occurred in greater numbers and were more widely distributed. in severe cases, comet-tail artifacts were so numerous that they became confluent and obscured the borders of the pleura. the presence of artifacts was consistent with the distribution of edema on radiographs. discussion/conclusion: artifacts are rare and isolated in normal dogs, but numerous and widely distributed in dogs with congestive heart failure, as has been described in human patients. further studies are needed to determine if the number and distribution of comet-tail artifacts in dogs with pulmonary edema correlates with the severity of clinical and radiographic signs. thoracic ultrasonography is a fast, easy, and effective method to characterize pulmonary edema in dogs with mitral valve disease. it may provide additional information in combination with traditional diagnostic tests for the assessment of dogs with heart failure, the most important being the detection of early signs of heart failure and monitoring of the response to treatment. introduction/purpose: to evaluate multiobserver diagnostic performance and reader agreement for meniscal tear detection using low-field mri (lfmri) in dogs with suspected cranial cruciate ligament (crcl) disease, with arthroscopy as the reference standard. materials and methods: fifty consecutive stifles with clinical and radiographic signs suspicious for crcl insufficiency underwent mri using a 0.5 tesla philips gyroscan t5 nt magnet with a human quadrature knee coil. the protocol contained sagittal und dorsal pd-and t2-, sagittal and transversal t1and sagittal fat suppressed t2-weighted sequences with images of 3 mm slice thickness and a total scan time of 32.5 min. after mri, diagnostic arthroscopy was performed by 1 surgeon (p.b.) unaware of the mri findings. mri images were read independently by 15 observers, unaware of historical and clinical data, asked to identify presence of a meniscal tear, which would necessitate invasive verification of meniscal integrity probably requiring meniscal surgery. diagnostic performance of each individual observer was analyzed. the impact of the individual observer's experience in stifle mri on the observer's diagnostic performance was estimated by correlating the level of experience (5 self reported levels) with all parameters of test performance. the overall diagnostic performance for the lateral and medial menisci expressed as median and associated interquartile range (iqr) was: sensitivity 69.2 (61.5-73.1), specificity 91.9 (85.6-94.6), ppv 72.7 (62.4-81.8), npv 87.7 (86.0-90.3), accuracy 85. 6 (80.8-87.6 ) and diagnostic odds ratio 24.5 (14.7-45.0). the level of experience in stifle mri did not influence the diagnostic performance of the individual observer (p40.05). discussion/conclusion: in a previous study with a single observer, using 42 data sets out of the 50 data sets from the present study, sensitivity and specificity of lfmri for detection of meniscal tears were 0.56 and 0.97, respectively, with a ppv and npv of 0.88 and 0.84, which might have been related to the low oberserver experience. these results with 15 observers of various levels of self reported experience in stifle mri show that the level of experience did not impact on the performance of the individual observer, with a median diagnostic performance similar to the first study. introduction/purpose: the temporomandibular joint (tmj) is formed from the temporal fossa of the temporal bone and the condylar process of the mandible. investigation of tmj diseases such as osteoarthritis and dysplasia requires a clear diagnostic image. while advanced imaging such as computed tomography allows clear imaging of the tmj, superimposition of the tmjs on conventional lateral radiographs creates difficulties in visualization and interpretation. oblique projections are generally used to separate the tmjs on a radiograph, but these are technically challenging to achieve. the aim of this study was to compare 5 different oblique radiographic views with the head in lateral recumbency, assessing the clarity of visualization of the normal tmj anatomy. the views under investigation were the laterorostral-laterocaudal oblique at a 101 and 201 rotation of the head (''nose-up'' view), lateral view with a rostro-caudal x-ray beam angulation of 101 and 201, and a parallax view with the beam centered over c2 and collimated to include the tmj region, using the divergence of the x-ray beam to project the tmjs separately on the radiograph. the views were performed on both tmjs of thirty canine cadavers with no breed specification although brachycephalic dogs were excluded. the radiographs were graded independently by experienced (board certified radiologist) and inexperienced (undergraduate veterinary student) observers. grading was performed on the temporal fossa, condylar process, joint space, retroarticular process and the overall tmj, and was based on a four point scale, with 0 indicating the structure could not be visualised and 3 indicating clear visibility and definition of the structure in question. mean grades for each component and for the overall joint were compared for each observer and each projection. mean grades were significantly (po0.005) higher for the ''nose-up'' projections than the angled beam or parallax projections, and both observers showed significantly higher (po0.05) mean grades for the 20o ''nose-up'' angulation than the 10o ''nose-up'' angulation. cohen's kappa was used to assess interobserver agreement, and was also highest for the ''nose-up'' projections. discussion/conclusion: these results suggest that a latero 20o rostral-laterocaudal oblique gives the best representation of the anatomy of the tmj of the dog of the projections assessed, and should be considered when investigating clinical cases of tmj disease. introduction/purpose: foot pain is a common cause of lameness in horses. when horses with foot pain have no radiographic abnormalities, soft tissue assessment remains a diagnostic challenge without magnetic resonance imaging (mri). the purpose of this study was to retrospectively review ultrasonographic (us) findings in the front feet in a series of clinical cases with lameness abolished by palmar digital nerves block but without radiographic bone abnormalities. medical records of horses that underwent a complete us examination of the digit were collected. history, clinical findings, radiographic and us results were retrospectively reviewed. the records of 39 horses satisfied the inclusion criteria. thirty of the 39 horses had lesions affecting the deep digital flexor tendon (ddft), 27 horses had abnormalities in the distal interphalangeal joint of which 6 had a visible abnormality in one collateral ligament. distension of the podotrochlear bursa was seen in 22 horses and abnormalities in the ligaments of the navicular bone were detected in 2 horses. irregularity of the navicular bone flexor surface was found in 8 horses. in only 3 of the 39 horses the ddft was the only structure affected. the other 36 horses had us abnormalities in more than one anatomical structure. discussion/conclusion: us diagnosis of soft tissue damage in the foot was possible in cases where radiographic diagnosis was unsuccessful. us offers an easily available diagnostic tool for an evaluation of the digital soft tissues and may decrease the need for mri when this modality is difficult to apply. introduction/purpose: trochanteric bursitis is said to be common cause of lameness in horses and is usually diagnosed based on clinical signs and findings during physical examination. the purpose of this study was to describe the anatomical features of the trochanteric bursa and to develop a technique for centesis of the bursa. the trochanteric bursae of 2 cadavers were injected with latex to demonstrate their boundaries. four techniques for centesis of the trochanteric bursa were evaluated by attempting to inject dye into the bursae of 20 horses which were scheduled to be euthanized for unrelated reasons. following euthanasia, the region of the bursa was dissected to determine the location of the dye. injection was successful in 8/10 bursae when the foot was situated in a hickman block without using ultrasonographic guidance, in 6/10 bursae when the foot was situated in a hickman block using ultrasonographic guidance and a needle guide, in 3/10 bursae when the needle was inserted without ultrasonographic guidance and without placing the foot in the hickman block, and in 9/10 bursae when the foot was situated in a hickman block and the needle inserted using ultrasonographic guidance without using the guide. discussion/conclusion: placing the foot in a hickman block facilitates centesis of the trochanteric bursa. warren-smith cmr, s. danika, n. saunders, l. sambrook, t. bouts, j. hutchinson, r. weller. royal veterinary college university of london, zoological society, london (sambrook l. and bouts t.) introduction/purpose: foot problems are considered the most important ailment seen in captive elephants and can involve the integument and/or the musculoskeletal system, their aetiology can be infectious, traumatic or degenerative. radiography is currently the most commonly used modality in the clinical investigation of musculoskeletal problems in elephants. in this study we described the radiographic and computed tomographic (ct) changes observed in a range of musculoskeletal pathology in captive elephant feet. we also established the intra and inter observer agreement regarding the topographic location and type of these disorders on both radiography and ct. radiographs and ct scans of fifteen cadaver foot specimens from one african and fourteen asian elephants (euthanased for various reasons unrelated to this study) were acquired. in addition 24 radiographic sets were obtained from six live asian elephants from a single zoological collection. a total of 22 front feet and 17 hind feet were evaluated. radiographic and ct assessment was performed by two observers according to an evaluation grading scheme developed based on the reported radiographic and computed tomographic findings in elephant foot disorders. each observer performed the reading of all images twice. pathological changes were observed in 50% (observer 1) and 90% (observer 2) of cases with pathology equally divided between front and hind feet (contrary to reported studies where forefeet have been more commonly involved).changes were seen in all five digits but most commonly in digits iii and iv. pathological changes included osteitis (39.2%), enthesiopathies (17.5%), infectious arthritis (14%), osteoarthritis (7%) and soft tissue infections and defects (21%). intraobserver agreement ranged from ''good'' to ''moderate'' for topographic location, from good to substantial for radiographic diagnosis and was good for severity of radiographic lesions (k: 0.656 to 0.029). however interobserver agreement was only ''moderate'' for diagnosis (k ¼ 0.595). both intra and interobserver agreement for ct agreement was ''poor'' at all levels including topography and diagnosis (k ¼ 0.000 to 0.198. discussion/conclusion: radiography offers an effective way of identifying and differentiating pathological changes both in vivo and post mortem in the elephant's foot, allowing diagnosis and treatment plans to be generated. however ct appears not to offer any advantage over radiography at this time. significant differences in inter observer agreement were seen likely reflecting different levels of expertise in reading radiographs of elephant feet. further large scale studies are warranted to evaluate the different pathologies seen and their respective causes. introduction/purpose: foot related problems are the most common cause of euthanasia in captive elephants and at the moment radiography is the only imaging modality that is available for their assessment. the aim of this study was to (1) develop standard protocols for front and hind legs that are practical to use and allow the thorough examination of all digits and (2) to describe the radiographic anatomy of the elephant feet on those projections. materials and methods: fifteen elephant cadaver feet of different ages and sizes were radiographed using a portable, digital radiography system in a variety of projections for which a custom-made block was designed. in addition computed tomographic (ct) scans were acquired before the cadavers were finally dissected. anatomical features and the pathological changes which were observed on ct scans and gross inspection were identified on the different radiographic projections. the projections that allowed the best visualisation of the most common changes were subsequently trialed on eight live animals using a custom-made block. 3d reconstructions were created from the ct images and registered onto the radiographs to demonstrate the radiographic anatomy of the various skeletal elements of the elephant foot. the dorsoproximal-palmarodistal and the plantarodistal-dorsoproximal projections were found to be best for the examination of the most common sites of pathology. a custom made block allowed the accurate positioning of the foot without endangering the personnel involved. ideally each digit should be radiographed individually and the angle adjusted accordingly, however it was found that the time needed to do this exceeded the patience of any live elephant (and their keepers). hence the number of radiographs was reduced to two per foot, resulting in a total acquisition time of less than 30 minutes for all four feet, which was deemed to be acceptable, but may still be too long in less well-handled individuals. the radiographic anatomy of the elephant foot itself is not overly complex however pathological changes are very common and often result in severe changes in the shape of whole bones. discussion/conclusion: the combination of a dr system and our custom-designed block facilitates radiographing elephant feet considerably. the proposed standardised protocol will not only aid in monitoring the development of foot pathology in individual elephants but will also allow the comparison between elephants in different collections. the detailed description of the normal radiographic anatomy provides a reference against which suspected pathological changes can be compared. introduction/purpose: infiltration anaesthesia of the alveolar branch of the mandibular division of the v th cranial nerve at the mandibular foramen offers superior pain relieve for invasive dental procedures of the mandibular cheek teeth (1) . precision of infiltration is enhanced, if needle placement is guided by computed tomography (2) . this pilot study explores the feasibility of the technique in horse cadavers as well as the possibility of a catheter placement. materials and methods: isolated heads of nine euthanized warmblood horses were scanned using a single slice 3rd generation ct scanner as well as a multislice scanner. all heads were placed in dorsal recumbency within the ct (according the positioning during a head ''real'' scan). the mandibular foramen was located on transverse images and marked with a radiopaque marker or a hypodermic needle using the laser light. the nerve block-simulation was performed with a spinal needle (quinke type point, 18 g, 152 mm). the needle was introduced through the skin medially to the mandibular notch and advanced between 13-15 cm perpendicular to the table surface in the direction of the mandibular foramen. subsequent needle adjustment was guided by ct scans until correct position of the needle's tip at the mandibular foramen was confirmed. diluted contrast medium lopamidol (scanlux r 370 mg j/ml) was injected in eight horses and imaged using a control ct scan. methylene blue was injected in one cadaver and verified by anatomic dissection. the assumed complete coverage of the mandibular nerve could be demonstrated by injected methylene blue during dissection. final positioning of the needle required only a few additional minutes following the first scout ct-scan of the head. one to three corrections in needle placement with subsequent ct scans were necessary to reach the final location. the placement of a catheter (perifix r epidural catheder, 1000 mm, 20 g) through the needle is possible and stays in place after the removal of the needle. a proper fixation on a living horse has to be evaluated. discussion/conclusion: ct guided infiltration anaesthesia of the mandibular nerve in horses is feasible and can be performed immediately after diagnostic ct scans. precision of local anaesthetic deposition at a location that is not readily accessible can be enhanced using this technique. further pain management could be improved by the positioning of a catheter next to the mandibular foramen. metal is a known source of image artefacts in mri by creating image distortion and large areas of signal void. radiography has not been validated for metallic screening, nor has the relationship between particle size and resulting mri artefact size been established. purpose of this study was to gather sensitivity and specificity data for radiographic screening procedures and to create a scoring system for metal particles for their resulting artefact size. materials and methods: 14 cadaver horse feet were radiographed (dprpadio, lm views) and a standard foot protocol mri (t1w gre, t2 ã w gre, stir fse) was performed. stainless steel ball bearings with known diameter (1, 2 and 3 mm) were placed into the most dorsomedial and palmarolateral nail hole of the foot, and dprpadio and lm radiographs were again obtained. the mri foot protocol was repeated with the metal particles in situ. radiographic and mri studies were evaluated by one board certified radiologist. radiographs were scored for presence, diameter and location of metal particles. on mri studies the maximum signal void size was measured in all sequences. radiographic identification and accurate measurement of all metal particles was possible using both projections. on mri metal artefacts were seen as an area of signal void, often with a high intensity rim and distortion in adjacent tissues. sequences in transverse and sagittal planes that contained the entire particle volume within the slice thickness showed the biggest signal void. the size of the mri artefact was approximately 10 â larger than the original metal particle in fse and 15 â larger in ge sequences. t1w gradient echo sequences showed void signal areas 5-10 mm larger than fse sequences. discussion/conclusion: radiography is a sensitive and specific screening tool for mri-artefact-inducing metal particles of diagnostically relevant size. two orthogonal radiographic views are necessary to correctly localize metallic debris. if a metal particle cannot be removed, the diagnostic quality of a foot mri exam can be predicted by plotting the predicted artefact size on the anatomical area of clinical interest. ge sequences should be avoided due to their higher artefact sensitivity. the magic angle effect is a magnetic resonance phenomenon responsible for increased signal intensity in tendons imaged at 551 relative to the magnetic field using short echo time pulse sequences. the magic angle effect has previously been considered as a deleterious artifact responsible for false positive diagnosis of tendinopathy. recently it has been suggested that intentionally imaging tendons at 551 relative to the magnetic field may enhance the detection of some lesions. the purpose of our study was to assess the benefits of magic angle imaging for the characterization of lesions in a diode laser-induced tendinopathy model. materials and methods: 6 isolated equine limbs were imaged in the study. a total of 16 lesions were created using a surgical laser. in 2 limbs, 2 lesions per tendon were induced post-mortem both in the deep digital flexor tendon (ddft) and in the superficial flexor tendon (sdft). in the other 4 limbs, 2 sdft lesions per limb were induced in vivo 3 weeks prior to euthanasia. the limbs were imaged immediately after euthanasia with a 1.5t mr scanner using a surface general-purpose flexed coil. the limbs were imaged parallel to the magnetic field (01) using sagittal t1-w and transverse t1-w, t2-w and stir sequences. imaging with t1-w sagittal and transverse sequences was then repeated with the limbs positioned at 551 relative to the magnetic field. the conventional (01) and magic angle (551) images were reviewed independently for presence and pattern of lesions. all lesions were examined histologically. all lesions could be identified on the magic angle images. the post-mortem induced lesions were not apparent on any of the sequences with the limbs positioned at 01. on magic angle images, the post-mortem induced lesions appeared as a hyperintense core surrounded by a hypointense rim, whereas the ante-mortem induced lesions appeared as mildly hypointense relative to the normal tendon. on 01 images, the ante-mortem induced lesions were hyperintense relative to normal tendon on all sequences. discussion/conclusion: magic angle imaging allows detection of lesions that are not detected using conventional imaging. the differences observed between ante-mortem and post-mortem induced lesions may be explained by the presence or absence of an inflammatory process. with the postmortem induced lesions, in the absence of an inflammatory response, changes in the tendon result from a modification in the organization of the collagen fibers, which can be detected with magic angle imaging. these results suggest that magic angle imaging could be clinically relevant to detect reorganization of collagen fibers in chronic tendinopathy in the absence of an inflammatory response. introduction/purpose: experimentally induced tendinopathies represent an accurate means of evaluating the efficacy of new treatments using blinded studies. in these investigations, imaging modalities are frequently used to assess tendon healing. the purpose of this study was to compare ultrasonographic (us) and magnetic resonance imaging (mri) evaluations to assess the healing of induced superficial digital flexor tendon (sdft) lesions. materials and methods: bilateral metacarpal sdft lesions were induced surgically in 10 standardbred adult horses (week 0). us evaluations were performed before induction and at week (w): 3, 7, 11, 15. at each time, the maximal tendon cross section area was measured and the echogenicity and architecture were graded on a 0-4 scale (0 ¼ sound tendon). low field (0.2 t) mri was conducted under general anesthesia at w11. ultra-high field (7t) mri was acquired post-mortem at w15. for both examinations, the lesion was graded subjectively using the same 0-4 scale. quantitative data were also measured using a homemade matlab image analysis software for the 0.2t data and imagej routines for the 7t ones. these included: tendon and lesion volumes, t1-weighted signal values, t1 and t2 (only for 7t) relaxation times of the lesions. correlations were calculated using pearson coefficients and statistical differences were evaluated using paired student t-test. in both cases, statistical significance was set at po0.05. results: us parameters changed significantly over time: the mean tendon grade decreasing from 2.8 ae 0.2 at w3 to 0.9 ae 0.2 at w15. no significant differences were found in the mri grades of the lesion between the 0.2t (2.6 ae 0.5, w11) and 7t (2.7 ae 0.7, w15) examinations. these grades were significantly higher compared to us ones. significant correlations were found between 0.2 and 7t values for the tendon volume (r ¼ 0.92), lesion volume (r ¼ 0.78), t1-w lesion signal (r ¼ 0.55). in contrast, the lesion volume, expressed in percentage of the tendon volume, was significantly greater in 7t (62 ae 15%) compared to 0.2 t (47 ae 11%). a positive non significant correlation (r ¼ 0.31) was found between the t1 lesion relaxation times at 0.2 t (362 ae 16 ms) and 7t (1749 ae 86 ms). compared to 0.2t, 7t mri allowed to calculate the t2 lesion relaxation time (17 ae 1 ms) and to assess, based on high resolution images, the fascicular architecture of the injured tendons through the visualisation of the connective septa dividing the collagen fiber bundles. this study provides reference data that can be used for future assessment of new treatment efficacy. it confirms the interest of us for evaluating the healing process, particularly in the first stages. despite a significant us improvement, lesions remained severe on mri which may indicate the interest of mri to evaluate the late healing stages. high correlations found between 0.2 and 7t data validate the interest of low field mri, even if 7t mri permits a more accurate evaluation, particularly through the assessment of the tendon fascicular architecture. introduction/purpose: lung diseases occur commonly in captive snakes, especially when snakes are housed under inadequate conditions and/or when errors of management are made. the assessment of the snake's lungs by computed tomography (ct) has already been reported but not compared with radiographic examination. the purpose of this study is to describe and compare the radiographic and ct findings of normal snake lungs and lungs with bacterial pneumonia. materials and methods: six healthy snakes (4 common boa constrictor (boa constrictor), a brown water python (liasis fuscus) and an african rock python (python sebae)), and four snakes (a carpet python (morelia spilota) and three indian python (python molurus)) suspected of respiratory diseases based on clinical examination, transtracheal wash and culture, were used for this study. radiographic examination including a lateral view of the pulmonary area was performed without sedation. ct was performed using a high resolution ct (somatom 16, siemens, germany, erlangen) and obtaining transverse reformatted images of 1 mm thickness. also for the ct examination, the snakes were not sedated and held with plastic drainpipe and straps. results: radiographically, the normal lung appeared as a radiolucent, cylindrical shadow with a ''honeycomb'' weft. on ct images, the healthy respiratory alveolar parenchyma was a circular, hypoattenuating, homogeneous area with a ''honeycomb'' weft around a central lumen. the plexus of blood vessels is seen as a circular hyper attenuating line. in boidae (boas) the left lung appeared to have less volume then the right lung. this difference was less evident in pythonidae (pythons). radiographic findings of the diseased lungs included one nodule of soft tissue opacity in 1 patient, several small nodules in 2 patients, and 2 thick lines of soft tissue opacity perpendicular to the lung's axis in 1 patient. on ct images the following findings were made: the respiratory parenchyma was in all patients more heterogeneous with several focal hyper attenuated areas in 2 patients, or with more extended hyper attenuating areas in 2 patients. these lesions were more obvious in the cranial part of the right lung. the inner margin of the parenchyma appeared focally hyper attenuated in 3 cases. when comparing the lateral radiographs to the ct images the extent of the pulmonary lesions could be assessed in detail more on the ct images. discussion/conclusion: even though the radiographic findings of bacterial pneumonia in snakes were less obvious than on ct images. pulmonary changes could be diagnosed in most cases in this series. ct images could show early changes and may be useful for monitoring the disease process during treatment. introduction/purpose: the production efficiency in hatching senegal sole (solea senegalensis) is highly influenced by the development of bone deformities during the rearing process. the presence of vertebral deformities may be caused by a variety of factors such us genetic, nutritional, environmental conditions in the tank, or possible infections. the present study is a radiological description of the meristic characters of solea senegalensis and the skeletal bone malformations present in juvenile specimens coming from farms in northern spain. for this study, 30 specimens of senegal sole (solea senegalensis) with 481 days after hatching (140-220 mm long) having macroscopic signs of spinal malformation were selected. after a morphometric study, the specimens were radiographed (dorsoventral projection) using mammography films. from the images obtained, the number of vertebrae and their associated spines in the different body regions were observed. metric measurements of vertebrae of each region were taken and the vertebral anomalies and of their associated elements were counted and described. finally, the severity of the injuries was assessed. results: skeletal conformation: the number of vertebrae ranged from 42 to 45, including 6-8 abdominal, 31-34 caudal and 3 in the caudal complex. 60% of specimens showed variations in the number of rays present on the caudal fin. variations in other regions were less frequent. skeletal abnormalities: 96.7% of individuals had skeletal abnormalities, and they were severe in 30% of them. the most frequent abnormalities detected were abnormal vertebral bodies, either isolated or as a part of more serious lesions including deviations from the axis (60%) or spinal fusions (23,3%). 70% of specimens showed abnormalities in their neural or hemal elements. the most commonly affected region was the caudal complex with 90% of the animals affected mainly involving the rays of the caudal fin (86.7%). the discrimination of juvenile specimens based on their appearance is an effective method of selection. it is suspected that slight initial bone changes might be accentuated in the adult stage and its presence may be an early indicator of suboptimal rearing conditions. therefore, new studies are necessary to determine possible causes, and thus to obtain better performance in captive breeding. introduction/purpose: diagnostic imaging techniques are being utilised more frequently for the diagnosis of disease in wild animals. however, there is a lack of literature describing the normal appearance of the gross and imaging anatomy the purpose of this study was to describe the normal anatomy of the grey seal using radiography, ultrasound, ct and mri. a 26 days old male grey seal was admitted for treatment of a humeral fracture. radiographs of the humerus and the chest where taken with the patient under general anesthesia. given the difficulty in obtaining standard views of the humerus and to completely characterize the fracture ct of the humerus was performed and the chest was also scanned. surgery was attempted to reduce the fracture, but it was found that the fracture site was infected and the seal was euthanized. postmortem ct scans of the whole body, with bone, lung and abdominal windows depending on the area was performed to obtain images of normal anatomy. abdominal ultrasound with a 5-8 mhz probe and mri of the brain including t2 weighted sagittal, dorsal and transverse sequences and t1 transverse sequences using a 1.5 tesla scanner were also performed. ct images provided images of the skeletal structures and thoracic cavity. abdominal contrast however was poor and the different organs were difficult to individualize-this was likely caused by the young age of the patient. ultrasound of the abdomen allowed the identification of the different organs. these had similar appearance to those in the dog or cat with the exception of the kidneys which showed a heterogeneous echostructure with a hyperechoic parenchyma and multiple small irregular shaped-anechoic areas. this structure is thought to represent the kidney composition of many closely adherent renculi surrounded by pericapsular plexus and interlobular veins in the seal. mri of the brain allowed identification of the brain and other head structures and organs. the seal underwent post mortem examination and the gross anatomy was compared with imaging findings. discussion/conclusion: having normal references for anatomy is important especially when imaging species unfamiliar to the radiologist. ct provided good quality images for the skeleton and the thorax of the seal. ultrasound and mri allowed identification of abdominal organs and brain, respectively. description of normal imaging anatomy of more individuals and different ages would be useful to aid in recognizing disease. introduction/purpose: the most commonly presented problem in reptiles are abscesses. subcutaneous abscesses, superficial, or abscesses localized near the oral cavity are well noticeable and readily palpable on clinical examination, thus easy to diagnose. internal abscesses remain a diagnostic challenge owing to their different locations, which in turn, determine clinical manifestations observed. a male 5-year-old boa constrictor, 800 g bodyweight was presented with deep cutaneous inflammatory lesions due to burning, caused by a heating cable 5 months ago. since the burning event, the snake refused any food. the clinical evaluation showed emaciation with concomitant severe dehydration and decreased responsiveness to external stimuli. the boa was assigned to strict quarantine in a terrarium for observation and diagnostic procedure. the microbiological study of the skin lesions revealed the presence of pseudomonas aeruginosa. the blood examinations indicated elevated count of total white blood cells twbc (18 10 3 /ml) and heterophils (78%). due to poor body condition, the snake underwent ultrasonographic evaluation. the study was performed with 7.5 mhz linear transducer. a nodular lesion of 2 â 2,5 cm dimensions, localized caudally from the thinned-wall, anechogenic gallbladder was visualized. the tumor-like lesion showed heterogeneous echogenicity. centrally located an irregular anechogenic area of 1,3 â 0,9 cm was visible. the ultrasonographic appearance suggested abscess or neoplasia with the presence of large focus of tumor lysis. the other abdominal organs did not show any changes in the ultrasound image. other diagnostic procedures and surgical intervention were not possible to perform due to poor animal condition. despite therapy the snake died after 6 days. the necropsy confirmed the presence of a well formed encapsulated abscess located in the duodenal wall. the lesion caused marked narrowing of the intestinal lumen. the microbiological study of the abscess contents showed the presence of the same bacteria that were detected on the skin at the earlier bacterial culture. discussion/conclusion: infectious factors producing internal abscesses may be identical with those developing epidermal lesions. most probably they spread via the hematogenic route 1 introduction/purpose: in order to establish the venous pattern of the body cavity in the common buzzard (buteo buteo), a venographic study is carried out by means of a postmorten technique. materials and methods: six common buzzards (buteo buteo), coming lifeless from a wild animal recovery center, are kept freeze at à201c until the moment of the venographic study. for the contrast medium application, the right and left jugular veins are located. a lead oxide jelly solution with a 150% concentration of pb3o4 is injected at 501c. the filling process is controlled under radioscopy. after the radiographic study, the anatomical dissection of the body cavity is performed. pictures of the anatomical dissection, radiological projections and the tomographic images with their corresponding schemes are shown. this postmortem technique is a simple technique, and provides fairly good vascular images, allowing appropriate study of the vessels in the body cavity. the venographic studies and the anatomical dissection permit the accurate identification of the main veins and its branches and allows to establish the venous pattern for this species. introduction/purpose: ectromelias are congenital deformities characterized by total or partial absence of one or more limbs. total absence is named amelia while partial absence is anamed transversal or longitudinal hemimelia (''congenital amputation''). these malformations are reported sporadically in children and in several mammalian species. herein we describe the radiographical and ct pattern of hemimelia and amelia in a group of mediterranean italian buffaloes. materials and methods: 14 mediterranean italian buffaloes, 8 males and 6 females, from one day to six months old, affected by limb malformations of the thoracic or pelvic limbs or both, from different farms in campania, were studied. radiographs were performed on the euthanized animals or on the isolated limbs, using the two orthogonal views. in two buffaloes affected by amelia of the pelvic limbs, ct study of the pelvis was also made. results: 7 buffaloes had unilateral transversal hemimelia of the left pelvic limb; 3 buffaloes had bilateral transversal hemimelia of the pelvic limbs; 1 buffalo had bilateral amelia of pelvic limbs; 1 buffalo had transversal hemimelia of both the pelvic limbs and of the left thoracic limb; 1 buffalo had bilateral pelvic amelia and longitudinal hemimelia of the right thoracic limb; 1 buffalo was affected by transversal hemimelia of all the limbs. in all the buffaloes the malformed limbs presented more or less developed outlines of claws. in 2 animals affected by transversal hemimelia of both the pelvic limbs the bones amputated were exposed. the transversal hemimelia showed different degree of amputation. in the case of longitudinal hemimelia the third digit was absent. the two buffaloes affected by amelia of pelvic limbs showed small calcified oval-shaped nuclei near the left acetabular rim. the ct study demonstrated a cartilaginous bud of the proximal femur. discussion/conclusion: radiographs were valuable to characterize all the bones malformations distal to the carpus or the knee. ct demonstrated to be more accurate in cases of amelia since it demonstrated that clinical lack of a limb does not always imply the complete absence of the underlying bones. the more frequent radiographical pattern of the transversal hemimelia was represented by a ''wedge-shape'' of the bone affected. our findings show that in italian buffalos pelvic limbs are more frequently affected than the thoracic ones and this is in contrast with the reports in human medicine. since the true prevalence of these malformations may be underestimated and since a possible toxic teratogenic toxic etiology (e.g. dioxins) is possible, our report could also have an epidemiological significance. introduction/purpose: the equine tarsal joint is an anatomically complex region and has already been thoroughly described with radiography and ultrasonography.1-3 however in clinical conditions these techniques are sometimes inconclusive and computed tomography (ct) is recommended. this study was established to describe a detailed ct reference of the normal equine tarsal joint. materials and methods: ct was performed on 3 normal equine limbs from patients euthanized for reasons unrelated to this study. in all limbs ct was also achieved after intra-articular injection of the tarsocrural, centrodistal and tarsometatarsal joints with 60 ml, 3 ml and 3 ml contrast (30 mg iodine/ml) respectively. 1,3 mm and 0.6 mm slices were made (120 kv and 352 mas), dorsal and sagittal planes were reformatted. the ct images were compared with corresponding anatomical slices. the tibia, talus, calcaneus, central, fused first and second, third and fourth tarsal bones could be clearly visualized. the long digital extensor (with tarsal extensor retinaculum), superficial digital flexor, deep digital flexor (with tarsal flexor retinaculum), gastrocnemius, peroneus tertius and tibialis cranialis tendons and long plantar ligament could be clearly identified. the lateral digital extensor, medial digital flexor, splitted peroneus tertius and tibialis cranialis tendons and collateral ligaments could be localized but not always clearly identified. some of the numerous small tarsal ligaments could be identified: the plantar, lateral and interosseus talocalcaneal ligaments, interosseus talocentral-centrodistal-and tarsometatarsal ligaments, proximal and distal plantar ligaments and talometatarsal ligament. the articular cartilage at the non weightbearing surfaces of the distal tibia and proximal talus could be clearly assesed on the postcontrast images, the articular cartilage at the weight-bearing surfaces of the distal tibia and proximal talus was more difficult to examine and the articular cartilage at the small tarsal joints was not visible. discussion/conclusion: ct of the tarsal joint can be of great value when radiography and ultrasound are inconclusive and in pre-operative planning of complex fractures. with ct having a superior anatomic resolution and detailed bone and soft tissue visualization this technique can increase our knowledge of the pathology in the equine tarsus. introduction/purpose: the aim of this study was to provide a detailed anatomical description and reference values of the structures of the thorax in clinically normal goats by means of ct for use by radiologists, clinicians, researchers and veterinary students. twenty-six clinically healthy, anesthetized saanen goats (median age 4.0 years; sd 1.1 years) were positioned in sternal recumbency. transverse images were obtained with a 40-slice ct scanner (120 kv, 350 ma, 1 s tube rotation and a slice collimation of 5 mm reconstructed to 1.5 mm). subsequently, 12 animals were euthanized, frozen and sliced into 10-15 mm transverse sections, of which the caudal aspect was photographed. the study was approved by the animal ethics council of the canton of zurich. corresponding ct and anatomic images were compared. absolute and relative measurements of thoracic structures were obtained. corresponding thoracic structures on ct and anatomic sections were well identified. speciesspecific features, like the synostosed sternum, bronchus trachealis and large caudal mediastinal lymph node were consistently identified. contrary to the dog, in all goats the lung lobes could be differentiated, except the right middle lung lobe. the thymus was inconsistently seen (12/26). minimal to moderate interstitial pneumonia or bronchopneumonia (24/26) and pleural thickening (5/26) were diagnosed in the caudal and dorsal lung fields. mean values of thoracic structures included: angle between trachea and spine (16.51); ratio of tracheal to thoracic height (0.13); vertebral heart score (8.0); ratio of thoracic aorta to caudal vena cava (1.0); ratio of maximal height of cranial vena cava to the length of the thoracic vertebrae at the level of the tracheal bifurcation (0.8); mean cross-sectional area of the tracheal lumen just cranial to the thoracic bifurcation (2.1 cm 2 ). further, the square area of the principal bronchi, the caudal lobar bronchi and the concomitant pulmonary arteries and veins was measured. discussion/conclusion: with the exception of small vessels, nerves and certain small lymph nodes, all the structures of the thorax that were identified on the anatomic sections could be identified on the corresponding ct scans. subclinical lung disease in the majority of goats, most likely attributable to parasitic infection (protostrongyloides), was documented in ct and confirmed with fecal examination and macroscopic pathology. introduction/purpose: contrast enhancement in computed tomography (ct) plays an important role in the detection of several diseases. in human medicine, use of a saline solution injected intravenously immediately after the contrast material bolus, also known saline chaser, has been reported to allow a significant reduction of the contrast material volume in helical ct. however, there was no study about the reduction of the amount of contrast material using a saline chaser in veterinary medicine. the purpose of this study was to assess the degree of dose reduction of the intravenously injected contrast material without decreasing vascular enhancement using a saline chaser in multidetector-row ct of cattle. dynamic ct was performed in the head of six normal holstein. in a crossover study design, group a was administered only contrast material (600 mgi/kg) whereas group b and group c were given contrast material at a reduction of 30% and 40%, respectively, followed by 50 ml of saline solution. in all groups, a power injector was used with an injection rate of 4 ml/s and a pressure of 4.7-5.7 kg/cm 2 . attenuation values were obtained from the right and left maxillary arteries and dorsal sagittal sinus. there was no significant difference in the maximum enhancement value (mev) of the maxillary arteries and dorsal sagittal sinus between groups a and b. mev of the maxillary arteries and dorsal sagittal sinus in groups a and b was significantly greater than that in group c (po0.05). discussion/conclusion: results indicate that use of a saline chaser allowed 30% reduction in the dose of contrast material of without decreasing vascular enhancement. introduction/purpose: subchondral bone damage has been diagnosed using magnetic resonance (mr) in the equine distal limb as areas of reduced signal intensity in t1 weighted sequences and increased signal intensity in stir sequences 1 . a recent study showed no correlation between degree of lameness and radiographic changes in the tarsus 2 . the purpose of the present study is to describe mr findings in horses with acute onset of severe lameness localized in the tarsal region. horses were selected for inclusion that had acute onset of severe lameness localized to the hock by local analgesia and the results of radiographic and ultrasonographic examination did not conclusively explain the degree of lameness. mr images were acquired by use of a 0.2t imaging system, with the horse under general anesthesia; 3d t1 gradient echo, t2 fast spin echo and stir sequences were acquired on sagittal, dorsal and transverse planes. we included 3 horses (used for show jumping, age range 6-12 years) showing 3/5 unilateral pelvic limb lameness localized to the hock. radiographic examination showed enthesiophyte formation on the dorsal aspect of the central and third tarsal bones and dorso-proximal aspect of the third metatarsal bone in case 1; case 2 showed mild degenerative joint disease of the distal intertarsal joint and no radiographic changes were observed in case 3. mr images showed marked irregular thickening of the subchondral bone plate and abnormalities of the adjacent spongiosa of the third and central tarsal bones in all cases. increased signal on stir sequences involved the dorso-medial aspect (case 2 and 3) or axial portion (case 1) of the third and central tarsal bones. in addition, case 3 showed a linear area of hyperintense signal in each sequence on the dorso-medial aspect of the central tarsal bone, interpreted as an incomplete slab fracture. therapeutic plan included distal intertarsal joint medication (case 1) and extracorporeal shockwaves (case 2). case 1 and 2 were rested for 1 and 8 months respectively before return to the previous competition level. case 3 is still in the rehabilitation process. discussion/conclusion: increase signal intensity in stir sequence could be related to different pathologic situation such as hemorrhage, edema, bone necrosis or fibrosis 1 . in the present report, horses showed acute onset of lameness suggestive of bone trauma, microfracture of the subchondral bone and fluid accumulation within the bone as the more likely cause of the abnormal signal observed. subchondral bone trauma can involve the small tarsal bones and mr is crucial for lesion identification and therapeutic plan when radiographic and/or ultrasonographic findings are equivocal. introduction/purpose: the purpose of study was to register the reason for extracting the incisors in upper and/or under jaw and to examine the consequences of extraction of all incisor teeth by taking radiographs regularly for 1-2 years post operatively. materials and methods: four horses, 14 to 32 years old, were presented at the university clinic for large animals. the horses had problems with eating including weight loss, related to dental disease. in all four cases treatment included extraction of all incisors in the mandible and/or maxilla. the horses were monitored using radiography prior to tooth extraction, and at regular intervals over a period of one to two years post-operatively. images vd and dv for the mandible and maxilla respectively were taken using intraoral position of the cassettes and developed in a digital method (cr-system). the underlying pathology detected in these horses included both infectious and non-infectious diagnoses. specific clinical diagnoses included tooth resorption, periodontitis, dental-fractures and malocclusion. all horses showed signs of oral cavity related pain and gingival inflammation. all horses commenced eating within 24 hours post surgery. after eight to 10 weeks the alveolar sac was filled with regular trabecular bone. areas of sclerotic bone on the preoperative images remained slightly visible for some months after surgery. in cases where there was severe bone resorption associated with the initial dental disease, there was no significant re-growth of bone, so that the outer bone margins in these cases remained irregular in outline. all horses improved after surgery, gained weight and returned to normal use as pleasure riding horses. discussion/conclusion: no problems were evident with grazing; eating apples and carrots however presented problems unless these items were broken into small pieces. in general these horses became slower at mastication post surgery and this should be kept in mind if they are kept in groups with normal horses where feeding is from a common source. all horses showed a dramatic improvement after removal of the incisors. there were no side effect or long term special requirements for these horses other than ensuring that they are fed individually if housed in large groups. the tongue was occasionally visible in some of the horses. the experience reported in the abstract suggests that removal of all incisors is a viable option in cases where these teeth have significant irreversible and major disease. l. evrard ã , s. rabba ã , g. bolen ã , d. verwilghen ãã , v. busoni ã . university of liège -university veterinary clinic. ã diagnostic imaging section. ãã surgery section introduction/purpose: when horses with foot pain have no radiographic abnormalities, the soft tissues have to be assessed. however, some radiographic changes in the foot (e.g. enlarged synovial fossae, distal sesamoid bone fragments) are commonly seen in horses without lameness and their significance may be difficult to correlate to the clinical presentation in some clinical cases. the aim of this study was to review us findings in horses with lameness abolished by palmar digital nerve block but with inconclusive radiographic examination. medical records of horses that underwent a complete radiographic and us examination of the digit were collected and reviewed. horses with a clinical history of infection or direct trauma and horses without radiographic abnormalities were excluded. results: twenty-three horses fulfilled the selection criteria. on radiographs, 16/23 horses had enlarged synovial fossae, 8/23 had distal sesamoid bone fragments, 1 had a suspected irregularity of the flexor surface. at us distal interphalangeal joint (dipj) synovitis was seen in 16 horses, of which 6 had a visible abnormality in one of the dipj collateral ligaments. lesions of the deep digital flexor tendon (ddft) were seen in 9 horses and distension of the podotrochlear bursa in 14. the ligaments of the navicular bone were abnormal at us in 3 horses. at us the flexor surface of the navicular bone was irregular in 11 horses. us abnormalities in more than one anatomical structure were seen in 20/23 horses. discussion/conclusion: in horses with foot pain but inconclusive radiographic examination, us may reveal useful complementary information about soft tissue involvement and integrity of the navicular bone flexor surface. k peremans, s vermeire, a dobbeleir, i gielen, e vandermeulen, j saunders, k dik, h van bree. medical imaging department, faculty of veterinary medicine, university ghent, belgium introduction/purpose: canine orthopedic problems in the forelimb frequently originate from the elbow. the origin of pain can be caused by developmental, traumatic or degenerative processes requiring different treatment strategies. bone scintigraphy is included in the diagnostic frame work when clinical/ radiographic examination is inconclusive or non-localizing. determination of the exact localization of pathology within the elbow is hampered by resolution limits of conventional gamma camera systems. the use of conventional micro-spect systems is precluded by limited gantry opening. the aim of the study was to investigate the value of hispect (multi-pinholes mounted on a conventional gamma camera) in the evaluation of elbow pathology in the dog. materials and methods: 5 dogs with elbow disease were included (7 elbows). radiographic examination was negative (n ¼ 1), inconclusive (n ¼ 3) and not performed in 1 case. two dogs had undergone arthroscopic interventions for an elbow problem, but lameness had switched to the other leg. all animals underwent planar bone scintigraphy. micro-spect was performed using a conventional triple head gamma camera (triad, trionix), adapted with 3 multi-pinhole collimators (6 holes, 3 mm diameter, resolution 2.5 mm) (bioscan). data were acquired in step-and-shoot mode (10 steps, 361 angular step, 120 sec per step). images were reconstructed using a dedicated ordered subset-expectation maximisation (osem) algorithm (scivis). structural imaging and/or arthroscopy were performed to confirm pathology. the lame leg was correctly identified based on intensity of uptake on planar scintigraphy but no localization within the elbow could be determined. on the hispect images, pathology could be confined to anatomical regions. four elbows showed high uptake in focal regions. pathology was confirmed with structural imaging or arthroscopy and included: insertion desmitis of the flexor carpi ulnaris (n ¼ 1), detachment of the medial coronoid process (n ¼ 2) and a cystic lesion in the anconeal process (n ¼ 1). in one elbow, several areas of increased uptake were noted in the humerus and radius representing severe subchondral erosion on arthroscopy. in the previously operated elbows residual mild increased uptake in one elbow was focally at the level of a removed fragment of the coronoid process (scar tissue on arthroscopy) and more generalized in the other (erosion of the joint cartilage on arthroscopy). discussion/conclusion: with the hispect system increased uptake was discernible in localized elbow areas correlating with pathology found on structural imaging modalities and/or arthroscopy. hispect improves anatomical localization of pathology and may allow a more accurate choice of subsequent structural imaging modalities and therapy. introduction/purpose: idiopathic pulmonary fibrosis (ipf) is a chronic, progressive parenchymal lung disease described mainly in west highland white terriers (whwts). high resolution computed tomography (hrct) is used for visualizing pulmonary parenchyma and diagnosing ipf in man. the study objective was to investigate hrct findings in whwts with ipf and in healthy control whwts. materials and methods: hrct was performed under general anesthesia to 7 whwts with ipf (mean age 11.6 years) and 11 control whwts (mean age 8.5 years). a ct-scanner with axial high-resolution algorithm, 1.0 mm slice thickness and 7.5 mm table movement was used. the findings were evaluated and classified according to previously published criteria 1. quantitative ct-values were measured from the nondependent parts of the lung. the radiologist was blinded to the dog's disease status. the radiologist was able to distinguish all sick whwts from healthy controls. the hrct findings of ipf dogs were ground glass opacity (n ¼ 7), traction bronchiectasis (n ¼ 5), parenchymal bands (n ¼ 5), consolidation (n ¼ 5), peribronchovascular interstitial thickening (n ¼ 3), honeycombing (n ¼ 2), subpleural lines (n ¼ 2), and subpleural interstitial thickening (n ¼ 1). control dogs had only 1-2 focal lesions in the dependent part of the lung. the ct-values were significantly higher in ipf (mean à731 ae sd 51 hu) compared with controls (à821 ae 36 hu), po0.001. no correlation with pao2 was detected. discussion/conclusion: hrct was accurate in differentiating dogs with ipf from healthy controls. ipf causes a diffuse increase in radiodensity and lesions which are not visible in healthy lungs. unlike in man, ground glass opacity is common but honeycombing only rarely seen in canine ipf. introduction/purpose: feline injection-site sarcoma (fiss) is a locally invasive and rapidly growing tumor. computed tomography (ct) is widely used in the preoperative evaluation for clinical staging. however, ct can also demonstrate the volume of the mass. the aim of the present study was to retrospectively analyze the ct features of 200 cases of fiss and to assess whether there is a statistical relation between tumor volume and local invasiveness of fiss. materials and methods: ct images and medical records of 200 cases of histologically confirmed fiss were reviewed. diameter and volume of the mass were measured on ct (tomographic diameter, td, and tomographic volume, tv) and compared to the diameter and volume recorded during previous clinical examination (clinical diameter, cd, and clinical volume, cv). statistical analyses were performed on sas 9.1 software to evaluate the influence of tumor variables (site, first presentation or recurrence, aspect of the mass, number of involved muscles, involvement of underlying bones, presence of skip metastasis, of lymphadenomegaly, of radiographic or histological evidence of lung metastasis), and animal variables (breed, gender, age and body weight of the cat) on cd, cv, td and tv. values of po0.05 were considered significant. results: no significant difference was observed between clinical and tomographic tumor measurements. a statistical association between the mean diameter (mean of the cd and td) and each tumor variable was observed. a statistical association was also observed for mean volume (mean of the cv and tv) and each tumor variable. a greater diameter and volume was associated with an interscapular localization, first presentation, heterogeneous aspect, greater number of involved muscles, involvement of underlying bones, and lymphadenomegaly. smaller diameter and volume were associated with radiographic or histologic evidence of pulmonary metastasis. no statistical association was observed between any animal variable and mean diameter/mean volume. discussion/conclusion: the volume of fiss is related to the local invasiveness. larger tumor mass is more invasive locally, involving a greater number of muscles and underlying bone structures. a larger volume is also associated with an increase of lymph node volume, suggesting further diagnostic steps, but not necessarily proving metastatic disease. in this study smaller tumor volume was associated with a higher occurrence of pulmonary metastatic disease. however, 35% of the animals with lung metastasis were patients with recurrent tumor growth. furthermore, histological confirmation was not always available. introduction/purpose: elbow dysplasia(ed) is common in labrador retrievers and is frequently found in radiographic screening. grade 1 (mild osteoarthritis) is the most common screening result of affected individuals in finland. regardless of extensive screening based mainly on secondary radiographic signs of the disease, progress in decreasing morbidity has been modest. the aim of this prospective study was to compare ct findings and radiographic findings of mildly affected dogs to find out if finnish protocol using one mediolateral flexed radiograph with emphasis on osteoarthritis is sufficient to reach a diagnosis of ed in this breed, or if signs of the primary lesion should carry more weight. thirteen clinically healthy labrador retrievers with screening results 0/1 or 1/0 were studied. their age ranged from 16 to 28 months (mean 21 months). age range at the time of the original screening was 12-19 months (mean 14 months). mediolateral 451 flexed and oblique craniocaudal radiographs were made and a ct study was conducted on both elbow joints. mediolateral radiographs were first graded according to finnish kennel club's regulations, where main emphasis is on osteophyte formation at the dorsal border of the anconeal process. secondly, the mediolateral and craniocaudal radiographs and also the original mediolateral radiographs were evaluated by taking into account also blurring of cranial edge of medial coronoid process (mcp) and ulnar trochlear notch sclerosis. ct was used as golden standard for diagnosing ed. on ct nine dogs had fmcp, three dogs were affected bilaterally. one dog had bilateral osteochondrosis of the trochlea humeri. ununited medial epicondyle was diagnosed in one joint, which was excluded from the study. on radiographs 12 of 14 joints with ed and two of 11 joints free of ed had blurring of the cranial edge of the mcp. sclerosis of ulnar trochlear notch was seen in seven joints with ed and in three joints free of ed. in the radiographs taken for the original screening five joints with ed had blurring of the cranial edge of the mcp and seven joints had subtrochlear sclerosis. in the joints free of ed one joint had both signs. the most reliable radiographic sign in the present study was osteophytes distal to the medial epicondyle seen in the craniocaudal view. they were visible in all dysplastic joints but in none of the healthy joints. in the present study, evaluation based on secondary radiographic signs was correct in 21/25 joints (sensitivity 79% and specificity 91%), and in 16 of 25 joints in the original screening (sensitivity 64% and specificity 64%). discussion/conclusion: accuracy of screening for ed in labrador retrievers using a single flexed mediolateral projection based either on secondary radiographic signs or radiographic signs of the primary lesion was only moderate in the original screening. however, accuracy based on either of these signs was noticeably higher in the present study. screening for ed at the age of 24 months instead of 12 months and including the craniocaudal view in the radiographic protocol could be considered in this breed. skrzypczak p., atamaniuk w., kiezbowicz z., biez ' yński j., nicpoń j. department and clinic of veterinary surgery, faculty of veterinary medicine, wroczaw university of environmental and life sciences, poland introduction/purpose: vascular ring anomalies in 95% of affected dogs are represented with persistence of the fourth right aortic arch. double aortic arch is a very rare anomaly of the vascular ring that results in esophagal compression [1] . the use of computed tomography angiography (cta) has not been described in a dog with such an anomaly. in humans, double aortic arch is the least common but most symptomatic form of vascular ring anomalies. a ten-week-old czechoslovakian wolfdog (ceskoslovensky vlcak), male, 18 kg, was admitted to the department and clinic of surgery with a suspected vascular ring anomaly. the dog regurgitated regularly shortly after feeding. there were no changes upon clinical examination. the dog was smaller than the littermates. during laboratory examination, there was mild hypoalbuminemia and neutropenia. rx, esophagoscopy and subsequent cta were carried out. for this purpose, contrast material (omnipaque s 240 mg/ml) was injected into the saphenous vein at a rate of 2.5 ml/s for 30 s. transverse images were obtained using helical ct (ge s , light speed vct) scanner (5 mm thick slides, kvp 120, mas 4200 matrix 512 â 512, pitch1.2). images were acquired 8 seconds after the start of injection. following data acquisition, 3d image reconstruction was performed using vascular software. radiography and esophagography examination revealed dilatation of the esophagus with no signs of displacement at the level of the aortic arch. this was confirmed with the contrast study. the initial diagnosis was the presence of a persistent right fourth aortic arch, although leftward displacement of the trachea was not observed. computed tomography angiography was performed to further classify the anomaly. 3d ct reconstructions of the patient depicted the presence of second hypoplastic aortic arch. after surgery, the ct angiography procedure was repeated. the initial diagnosis of the presence of a vascular ring was confirmed for this case. ct angiography was used to better characterize a suspected vascular ring anomaly [2] . it fills the gap between standard diagnostic modalities, such as conventional radiography or echocardiography, and angiography, which is more complicated and hazardous. non-selective ct angiography is a reasonable choice in the diagnostic process for vascular ring anomalies. moreover, 3d reconstruction provides an excellent illustration of the problem for the owner or for students who are not involved in diagnostic imaging. introduction/purpose: ultra high field mri (uhf mri) has recently become available in a few research units. beside the experimental use of spectroscopic and functional mri applications, it is also used to obtain high spatial resolution images of the cerebral system of humans. the aim of this poster is to present the mri cerebral images of a clinical case with neurologic disease obtained post-mortem at 7 tesla mri and to compare them to macroscopical and histopathological examination. a 9 year old yorkshire terrier was administered to the critical care unit of the veterinary school of liège. the dog was in shock and had difficulties to maintain his head in equilibrium after he had fallen from stairs. the shock animal was finally euthanized in comatose state. a ct-and mri-scan were performed post-mortem. ct revealed fracture of the skull with cerebellar and cerebral trauma. the mri scan was performed using a philips 7 t mri with a 1-channel cylindrical rf-transmitting coil and a 16-channel receiver coil. a t2-weighted gre -sequence (fov of 70 â 70 mm, tr: 60 ms, te: 25 ms, fa: 15, slice thickness: 0.3 mm, scan time: 58 minutes) and a t1-weighted gre sequence (fov of 70 â 70 mm, tr: 7,7 ms, te: 3,5 ms, fa: 8, tfe-factor: 219, tfe dur. shot: 1754,4 ms, tfe dur. acq: 1685,3 ms, slice thickness: 0.55 mm, scan time: 9 minutes) were performed. after scanning, the head was fixed in a 10%formaline solution, the brain was removed from the skull and a microscopic study using hestaining of histological sections was performed. on mri, there was significant haemorrhage visualised in the left cerebral and cerebellar hemispheres, which were confirmed by macroscopic and microscopic examination. mr image quality was influenced by susceptibility artefacts of blood and air. high resolution t2-weighted images of the left and right cerebellar hemisphere allowed delineation of anatomical areas corresponding to zones of high neurons concentrations on histology. these areas correspond to the areas identified in human neuroanatomy as nucleus dentatus, fastigii, emboliformis and globosus. in humans these structures are responsible for the equilibrium, the muscular tonus and the coordination of movements. haemorrhage and traumatic damage of these areas may explain the clinical signs of this dog. discussion/conclusion: uhf mri is a promising tool for identification, illustration and description of small anatomical structures in dogs. post-mortem application of this technique can be a potent help to neuro-anatomists and neuropathologists for describing anatomical details and addressing microscopic examination in the light of abnormalities detected. secondly, if scan times and cost can be reduced in the future, using such systems in a clinical way can make diagnosis and prognosis more precise and appropriate due to the possibility to visualise neurological structures that can not be visualised at 1.5 or 3 t, because image quality and spatial resolution increase with magnetic field strength. a 5-year-old 36 kg intact male german shepherd dog was referred to the veterinary teaching hospital with a 15 days history of right hind limb lameness without previous history of trauma. on physical examination, the right thigh muscles were atrophied and signs of pain and swelling were noted on the right stifle. the rest of the examination and blood analysis were unremarkable. radiographs of the right stifle were taken. multiple foci of lysis with amorphous periosteal reaction were observed within the patella. there was an increase of periarticular soft tissue opacity. differential diagnoses included primary neoplasia of the patella and osteomyelitis (bacterial or fungal). an echo-guided aspiration of the joint fluid was performed. cytological results suggested a mixed inflammatory and neoplastic lesion, but infectious etiology could not be ruled out with cytology. samples from a biopsy of the patella were submitted for histopathology and microbiological culture. numerous poorly-stained yeast-like organisms were isolated and identified as cryptococcus neoformans. discussion/conclusion: survey radiographs are the primary tools for investigating osteomyelitis. radiographs may reveal foci of lysis, periosteal reaction, sequestra and moderate soft tissue swelling. primary or secondary neoplasias are considered the main differential diagnoses of osteomyelitis. patellar osteosarcomas have been rarely described in dogs, and radiographic findings are very similar to those found in fungal osteomyelitis. ultrasound examination can detect fluid collections and surface abnormalities of bone, whereas ct scan can reveal small areas of osteolysis in cortical bone, small foci of gas and minute foreign bodies. mri has great sensitivity, specificity and accuracy for the detection of osteomyelitis. although imaging studies help to distinguish osteomyelitis from other differentials, histopathology and microbiological culture continue to be the gold standard for definitive diagnosis. in conclusion, cryptococcosis should be considered as a differential diagnosis of osteolytic patellar lesions. introduction/purpose: the purpose of this study was to evaluate and compare the radiographic efficacy and safety of a non-ionic dimeric and isotonic iodinated x-ray contrast medium iodixanol [visipaque320 mg i/ ml (amersham health cork, ireland)] and a non-ionic monomer contrast medium iohexol [omnipaque 300 mg i/ml (nycomed, spain)] in feline cervical myelography. materials and methods: five adult healthy cats were studied after injection of iodixanol (0.5 ml/kg) and iohexol (0.5 ml/ kg) into the cerebellomedullary cistern through the atlantooccipital space. ventrodorsal and left to right lateral radiographs of cervical, thoracic and lumbar vertebrae were obtained before and 10, 20, 40, 60 minutes after injection. after completion of the study, the radiographs obtained were evaluated and compared independently by a radiologist who was unaware of the types of contrast agents. myelographic quality was assessed by numerical scoring method [0 (no contrast) to 4 (excellent myelogram)]. statistical analysis (nonparametetric test) was performed by spss package. diagnostically adequate radiographic examinations were obtained with both agents. adequate opacity in thoracic and lumbar vertebrae was obtained after 10 and 20 minutes post injection for both contrast agents. after 20 minutes contrast agents had reached the end of lumbar vertebrae column. there was no statistical difference between both contrast medias. evaluation of each of the radiographs showed good to excellent opacification. no adverse effect occurred up to one week after end of the study. discussion/conclusion: in conclusion, iodixanol and iohexol proved to be safe and effective contrast materials for myelographic studies in cats. introduction/purpose: interpretation of thoracic radiographies is difficult for beginners. image and computer graphic processing with quantitative analyses of image features could be of help. the goal of this study was to evaluate the accuracy of two semi-automatic analyses: the vhs 1 and the nca. materials and methods: forty sets of thoracic radiographs of poodles were divided in two groups: (i) images from dogs with no clinical signs of cardiopulmonary disease (n ¼ 10), and (ii) images from patients with proven cardiac disease (n ¼ 30), confirmed by echocardiography to be caused by degenerative mitral valve disease. 74% had severe cardiac morphological changes (la and/or lv enlargement), 6% had moderate cardiac morphological changes, 17% had mild changes and 3% (only one dog) had a normal cardiac silhouette size. vhs and nca measurements were performed in right lateral view with computing techniques, by one experienced veterinary radiologist (a) and two trainees (b and c). all the observers had prior information of each group composition. to determine nca (v 2 ), the contours of the heart and of a square, which base corresponds to one fifth of the distance between five vertebrae (from t 4 to t 8 ), were drawn, and the ratio of both areas was obtained. the interobserver measurements were compared using simple linear regression analysis. the accuracies obtained from the specificity and sensitivity functions were considered. group i vhs measurements of all observers had statistically comparable values and the general average could be used. group ii vhs and area related nca measurements of group i and ii had significant different observer values, in these cases only observations of the experienced radiologist were processed. in groups i and ii the vhs had normal distributions, ranging respectively from 9.18v to 10.70v and from 9.60v to 14.10v, and having a mean value (aesd) of 10.07v (ae0.44) and 11.69v (ae1.31). the optimal threshold value of vhs was 10.7v which corresponded to an accuracy of 85%. in groups i and ii the nca had normal distributions, ranging respectively from 16.51v 2 to 21.20v 2 and from 19.03v 2 to 42.16v 2 , and having a mean value (aesd) of 19.13v 2 (ae1.58) and 27.87v 2 (ae6.58). the optimal threshold value of nca was 21.20v 2 which corresponded to an accuracy of 91.7%. discussion/conclusion: the accuracy of normalized cardiac area was approximately 7% greater than the one of the vhs approach. therefore, the nca appears to be more accurate than semi-automatic vhs method to classify the cardiac silhouette from poodles as normal or enlarged. the use of nca measurement showed more difficulties and variable results in observers of trainee group (b and c.). 1 j.w buchan, j. bücheler. vertebral scale system to measure canine heart size in radiographs. journal of the american veterinary medical association, v. 206, n. 2, p. 194-199, 1995 the aim of this study was to assess the appearance of the feline spleen on abdominal radiographs and to examine intra-and inter-observer agreement. right lateral and ventrodorsal projections of the abdomen of 50 cats with no evidence of splenic disease were independently assessed by 4 individuals (2 specialist radiologists and 2 specialist surgeons) blinded to patient details. assessment criteria comprised borders (not visible, visible but not sharp, sharp), visibility (head, body and tail visible), and shape (not visible, triangular/ folded over/double thickness, rectangular/single thickness). both intra-and inter-observer agreement was calculated using cohen's kappa and the intra-class correlation coefficient. the effect of patient and radiographic variables on the appearance of the spleen was tested using the chi-squared test. the consensus score of the lead assessor assessed that, on the vd and lateral radiographs respectively, the borders were invisible (4 vs 17), visible but not sharp (20 vs 22) and sharp (25 vs 10). the visibility of parts of the spleen were: head (43 vs 21), body (39 vs 14) and tail (34 vs 10). the spleen was triangular/double thickness or rectangular/single thickness for the head, (16 þ 23 vs 20 þ 0), body (19 þ 20 vs 0 þ 14) and tail (4 þ 29 vs 8 þ 2). the shape of the spleen was not visible for head: (7 vs 29), body (11 vs 36) and tail (16 vs 40). there was 1% total disagreement in the consensus score. kappa values ranged from 0.324 to 0.864. of the 7 variables assessed on vd radiographs, agreement was moderate (9) and good (12) and on lateral radiographs, agreement was fair or moderate (9) and good or very good (12). kappa values for inter-observer agreement ranged from à0.006 to 0.852. of the 7 variables assessed on vd radiographs, agreement was poor or worse (6), fair or moderate (29) and good or very good (7) and for lateral radiographs, agreement was poor or worse (6), fair or moderate (24) and good or very good (12), with no difference in these categories between projections (p ¼ 0.409). there was a significant association between age and the visibility of splenic borders (p ¼ 0.047) and the visibility of the head (p ¼ 0.021) on the lateral projection for assessor 3. there was a significant association between the body condition score and the visibility of parts of the spleen on the vd projection for assessors 1 (body, p ¼ 0.001) and 2 (head, p ¼ 0.001; body, p ¼ 0.049; tail, p ¼ 0.015) assessor 4 found the borders of the spleen less visible in sedated/ anaesthetised animals on the vd view (p ¼ 0.048) and assessor 2 found the head more visible on the vd projection (p ¼ 0.030) in sedated or anaesthetised animals. the spleen is commonly visible on radiographs, although its appearance may vary between individuals and according to assessor. j. hall, k. lee, s. priestnall, c.r. lamb. the royal veterinary college, university of london introduction/purpose: pseudoaneurysm is a blood-filled cavity adjacent to an artery following disruption of the arterial wall as a result of iatrogenic or traumatic puncture. a patent channel to the artery lumen persists and blood continues to flow into a pseudoaneurysm, hence rupture may lead to severe bleeding. there are few reports of pseudoaneurysm in animals. pseudoaneurysm has been observed most frequently in humans after femoral artery catheterisation (ahmad et al. 2008 ). pseudoaneurysm following a cat bite puncturing the radial artery of an elderly woman has been reported (levis & garmel 2008). materials and methods: case report results: an 8 year old male neutered maine coon cat presented initially with two puncture wounds on the medial aspect of the carpus, suspected to be the result of a cat bite. the wounds were treated conservatively but there was a persistent, focal 3 â 1.5 cm fluctuant subcutaneous swelling on the craniomedial aspect of the right distal radius. the manus was diffusely swollen. there was no palpable thrill or bruit. there was no lameness, evidence of pain on palpation or regional adenopathy. no bone lesions were found radiographically. aspiration of the fluctuant swelling produced fluid consistent with sterile whole blood. ultrasonography of the antebrachium demonstrated a cavitary swelling with a thin regular wall and content characterised by a sedimentation, producing an anechoic upper layer and a uniformly echogenic lower layer. on the distal aspect of the swelling, pulsatile blood flow with a communication to the adjacent radial artery and swirling of the blood within the cavity were visualised. non-selective angiography of the right antebrachium showed extravasation of contrast from the radial artery into the fluctuant swelling. good collateral blood flow to the distal limb was evident. diagnosis was radial artery pseudoaneurysm. the lesion was exposed surgically and resected after ligation of the radial artery. histopathology demonstrated haemorrhage and fibrin surrounded by a thick fibrous granulating capsule of mature fibroblasts and focal areas of inflammatory cells (lymphocytes, plasma cells and macrophages) consistent with a pseudoaneurysm. at follow-up examination 12 days postoperatively, all swelling had resolved. discussion/conclusion: as in the present case, ultrasonography usually enables prompt, non-invasive diagnosis of pseudoaneurysm. when the ultrasound findings are equivocal or the anatomy is not well defined, angiography or computed tomography may be useful. in humans, a pseudoaneurysm may resolve spontaneously without treatment or may require compression, ultrasound-guided thrombin injection or surgery. in the absence of any veterinary reports on which to base treatment in the present case, surgical resection was considered a safe and definitive option. c.m.r. warren-smith, k. roe, b. de la puerta, k. smith, c.r. lamb. the royal veterinary college, university of london introduction/purpose: tumor seeding is the spread of viable tumor cells as a direct result of an interventional procedure such as surgery or biopsy. tumor seeding along needle tracts in animals is an infrequent event, most often associated with transitional cell carcinoma (1) . seeding from a pulmonary adenocarcinoma has been reported in a cat (2) . materials and methods: case report results: a 7 year old, female spayed cairn terrier had cardiac pacemaker implantation as a treatment for sick sinus syndrome. thoracic radiographs obtained at follow-up examination 6 months later showed a soft tissue mass in the left caudal lung lobe. on computed tomography (ct) the mass appeared as a well-defined rounded structure, approximately 1.7 â 2 cm diameter with a uniform density. no other masses were detected by ct. cytology following ultrasound-guided fine needle aspiration (fna) of the mass was diagnostic of pulmonary carcinoma. the tumor was subsequently resected surgically. no signs of metastasis were seen at surgery. histopathological examination of the resected specimen confirmed adenocarcinoma. at follow-up examination 12 months later a 2.5 cm calcified mass was found radiographically within the soft tissues to the left of the 7th thoracic vertebra. a repeat ct scan showed a large calcified mass affecting the soft tissues of the thoracic wall dorsolateral to the left 5-9th ribs. there was moderate enhancement of the mass following intravenous contrast administration. the location of the mass corresponded exactly to the previous fna tract. repeat fna of this mass was again diagnostic of adenocarcinoma with similar cytological features as the original pulmonary mass. the owners declined further invasive treatment. palliative meloxicam was administered. at 12 month follow-up the dog had developed a cough and mild exercise intolerance. repeat thoracic radiographs showed a marked increase in the size of the mass and lysis of the adjacent ribs. the dog continues to receive palliative meloxicam. discussion/conclusion: as in the present case, tumor seeding in needle tracts usually becomes evident clinically 2-16 months following the original fna (3). in the present case, there was no sign of intrathoracic recurrence or metastatic spread of the pulmonary tumor following surgical resection, hence the needle tract seeding was a significant complication that assumed a prognostic importance. although the risk of tumor seeding following fna is small, it seems prudent to consider this possibility when planning fna or biopsy and to warn owners of this possibility when such procedures are considered a necessary part of a diagnostic work-up. introduction/purpose: mri is the best imaging modality for diagnosis of lesions of the axillary region, but due to limited availability, high costs and necessity for anesthesia less applicable. the aim of the study was to characterize the ultrasonographic appearance of soft tissue masses in the axillary region and to determine the value of ultrasonography (us) in diagnosing tumors of the brachial plexus. a retrospective analysis of soft tissue masses in the brachial plexus region in dogs referred to the small animal surgery at the justus-liebig university giessen between 1989 and 2009 was conducted. dogs with progressive forelimb lameness, neurologic deficits, muscle atrophy, pain, or a combination of these signs, were examined clinically, neurologically and ultrasonographically. linear/convex 7.5-15 mhz transducers were used in conscious and sedated dogs. diagnoses were confirmed by fna, biopsy, necropsy or mri. in 286 patients the axillary region was examined (31 bilaterally) of which 199 axillary regions appeared normal on ultrasound. in 118 (41%) a mass was identified of which 26 showed typical ultrasonographic appearance of lipomas. in the remaining cases, cytology/histopathology revealed 11 fibrosarcomas, 8 metastases of mammary gland carcinomas, 8 undifferentiated sarcomas, 4 histiocytic sarcomas, 3 nerve sheath tumors, 3 carcinomas, 2 lymphosarcomas, 1 melanoma, 1 hemangiosarcoma, and 1 mastocytoma. other diagnoses were inflammatory lymphadenopathy (11), hematoma (6), abscess and traumatic avulsion of the brachial plexus (each 2). twenty nine cases were not available for histopathology. in one case the diagnosis of a peripheral nerve sheath tumor was verified by mri. within the limits of this study, and the available histopathology, there appeared to be no clinically utilizable relationship between the ultrasonographic appearance and the histological interpretation. discussion/conclusion: us detected a lesion in $40% of the examined animals with clinically suspected alterations in the region of the brachial plexus, of which lipoma, fibrosarcoma and inflammatory lymphadenopathy were the most common. us allowed detection of non-clinically evident masses and further evaluation of palpable masses. in addition, us-guided fna or biopsies may allow accurate diagnosis of the lesion, are minimally invasive, and can safely and easily be performed without harm to nearby vessels/nerves. disadvantages of us are the limited evaluation of proximal parts of the nerves, nerve roots and spinal cord due to anatomy. furthermore, a general overview of the region is not possible like on mr images. false negatives can be caused by tumor size, localization and number of involved nerves, experience of the examiner, and quality of the equipment. false positives may occur due to confusion with normal axillary lymph nodes, vessels or artifacts. thus, we conclude that us is an effective and practicable method to examine the axillary region for soft tissue masses. piotr debiak, wojciech lopuszynski 1 , anna lojszczyk-szczepaniak. department and clinic of animal surgery laboratory of radiology and ultrasonography, 1 department of pathological anatomy, faculty of veterinary medicine, university of life sciences in lublin, poland introduction/purpose: among the companion animals and livestock, testicular tumors are most common in dogs. the most frequent are interstitial cell tumor (ict), sertoli cell tumor (sct), and seminoma (sem) 1 . the objective of our study was the imaging modality-based assessment of the frequency and localization of metastases in dogs with testicular tumors. the study involved 42 dogs of different breeds, aged 6-13 years, whose ultrasound evaluation of testes identified focal lesions in the parenchyma. abdominal ultrasound evaluation and thoracic radiographs (in 3 projections) were performed to exclude/confirm metastases. on the basis of diagnostic imaging, dogs without metastases were neutered. dogs with metastatic lesions found in organs were euthanized and necropsy procedures were performed. tissue samples of testicular lesions and altered internal organs obtained during necropsy were divided for routine histology. on the basis of the histopathologic examination, the animals were assigned into 4 groups: i-15 dogs with ict, ii-11 dogs with sem, iii-9 dogs with testicular sct, iv-7 dogs with two histopathologically different testicular tumors (3 dogs with ict/sem, 4 dogs with sem/cst combination). the presence of metastases from the testicular tumors was detected by imaging procedure and confirmed histopathologically in 2 cases (4,8%), namely: one dog with sct (group iii), and one dog suffering from sem/sct (group iv) with seminoma metastases. abdominal ultrasound examination visualized in these dogs irregularly enlarged lymph nodes of the iliosacral lymph center. the dog with sem/sct tumors had enlarged inguinal lymph nodes and those from the lumbar lymph center. the enlarged lymph nodes were of oval shape, nonhomogeneous opacity with no hyperechogenic hilus. the radiographic evaluation of the dog with sct showed the presence of pulmonary metastases. the necropsy revealed micronodular lesions along the testicular cord spreading onto the omentum in both cases. in the case of sct the histopathological assessment has confirmed metastases to the lymph nodes, omentum and lungs. discussion/conclusion: our study indicates a relatively low risk of metastases from testicular neoplasms in dogs. we observed rare metastases from sct and sem tumors, whereas metastases from ict did not occur. however, focal lesions in testicular parenchyma require thoracic and abdominal imaging to exclude metastases. a diagnostic ultrasound examination of sem and sct metastatic altered lymph nodes does not indicate inflammatory reactions. unfortunately, micronodular lesions of the testicular cord may not be diagnosed by ultrasound evaluation. introduction/purpose: in humans, duplication of the ureter is the most common unrinary tract anomaly while it appears to be very rare in domestic animals. in the present report we describe the presence of a duplicated ectopic ureter in a 9 year old labrador. a 9 year old male neutered labrador presented with a history of chronic urinary tract infections, malodorous urine and occasional dribbling of urine noted over the past 2 years. work up prior to referral had shown a recurrent e.coli infection. treatment with antibiotics alleviated the symptoms. on clinical examination no obvious abnormalities were detected and haematology and biochemistry were unremarkable. abdominal ultrasound and intravenous urography (ivu) were performed. abdominal ultrasound showed a tubular fluid filled structure with peristalsis measuring up to 2 cm in diameter. it was extending from the cranial pole of the left kidney towards the bladder neck and no insertion into the bladder was evident; the tubular structure was still visible to the left side of the bladder neck just cranial to the pelvic inlet. this was consistent with an ectopic ureter. the right kidney appeared normal. a contrast urinary study was performed one month and a half later, following resolution of the urinary infection. a pneumocystogram performed previous to the ivu showed an air filled tubular and tortuous structure of up to 3 cm in diameter extending from the region of the prostatic urethra to the left kidney. during intravenous ureterography the left renal pelvis appeared slightly distended compared to the right. the right ureter was normal. a left ureter, with only slightly larger diameter than the right and with normal insertion in the bladder was also seen. the distended air filled structure did not show detectable filling with contrast during the ivu but some contrast reflux could be seen at its caudal aspect during a retrograde urethrogram. a duplicated ureter was suspected. surgery confirmed the presence of a duplicated left ureter with both left ureters terminating at the bladder wall but only the smaller one could be directly catheterised via the ureteral papilla, confirming thus the ectopic termination of the dilated one. the distended ureter was dissected and resected. the dog recovered uneventfully. discussion/conclusion: duplicated ureters are common urinary tract anomalies in humans. but only 2 reports in dogs and 1 in a cat could be found in the literature. in one of the dogs an incomplete ureteral duplication was found while in the other dog a renal and ureteral duplication with normal termination at the bladder was present. so the present report describes for the first time a duplicated ectopic ureter in a dog. ultrasound allowed identification of an ectopic ureter while the pneumocystography and ivu showed the presence of a normal left ureter along with the ectopic one. the combination of both techniques was important to reach the diagnosis. introduction/purpose: detection and characterization of tumor vascularity by using contrast ultrasonography is useful for differential diagnosis of liver tumors. sonazoid is a new ultrasonic contrast agent for detection of liver tumors. in ultrasonic contrast imaging in livers, the arterial vessels including tumor feeding artery are contrasted immediately after sonazoid bolus injection. it is not easy for doctors to distinguish the inflow time of arterial vessels and tumor vessels because of the narrow time window. we therefore proposed a new imaging technique to visualize inflow-time of contrast agents into vessels for further tumor diagnosis. in this study, we established a localized tumor model by inoculating vx2 tumor into rabbit livers. a female japanese white rabbit inoculated with vx2 by intramuscular injection was supplied by sankyo labor service corporation (tokyo, japan) as a tumor source. seventeen female japanese white rabbits, weighing 2-2.5 kg, were used as recipient animals. for tumor implantation into the liver, a small midline incision was made in the recipient animals and the tumor was injected into the exterior left lobe of the liver (sasaki 2006). contrast ultrasound was done on the 14th, 21th, 28th day after tumor implantation. vx2-bearing rabbits were fasted for 24 hours prior to experiments and were anesthetized with a mixture of ketamine and medetomidine. during the experiments, anesthesia was maintained by oxygen and isoflurane. the liver of each rabbit was carefully examined through the skin using a linear diagnostic imaging probe (eup-l65, hitachi medical co., ltd., tokyo, japan) operated by an ultrasonic scanner (eub-7500, hitachi medical co., ltd., tokyo, japan). the contrast images with pulse inversion were recorded at a rate of 15 frames per second immediately after sonazoid bolus injection for 60 seconds. in order to prevent the breathing movement of the liver during recording of contrast images, breathing was suppressed by pancuronium bromide i.v. infusion. animal experiments were conducted in accordance with guidelines for the care and use of laboratory animals, faculty of agriculture, tokyo university of agriculture and technology. to compare the inflow-time of sonazoid into tumor vessels and the other vessels, the time course of grayscale intensity of each pixel was measured and the time (frame) which reached 80% of maximum intensity was calculated by using software (matlab, mathworks, natick, ma). then the inflow-time mapping was constructed by coloring each pixel according to the each inflow time. by inflow-time mapping, the tumor feeding artery and liver artery can be separately observed in vx2 tumor bearing rabbit liver. portal veins and liver veins are also distinguished because of the difference of inflow times. discussion/conclusion: the inflow-time mapping constructed according to the different inflow time of contrast agent into each pixel would be useful to visualize tumor vascularity and helpful for differential diagnosis of liver tumors. references: sasaki k, medan ms, azuma t, kawabata k, shimoda m, umemura s: effect of echo-guided high-intensity focused ultrasound ablation on localized experimental tumor. j. vet. med. sci. 68 (10) in present study, kidney dimensions and volume were measured using radiography and ultrasonography and compared with real measurements immediately after necropsy to determine correlations between radiographic, ultrasonographic and real measurements (real size of kidney). the study was performed on 10 intact mongrel dogs referred to the veterinary teaching hospital for euthanasia for reasons other than abdominal disease. excretory urography was performed with iodixanol (visipaque 320, amersham health cork, ireland) and the renal length and width were measured on ventrodorsal radiographs. length, width, height and volume of kidneys were determined by ultrasonography, in two different positions (lateral and dorsal recumbency) for each kidney. length, width and height of kidneys were measured during celiotomy and after necropsy. volumes of kidneys were measured by water displacement. all of measurements were compared with linear regression analysis (spss package). the gold standard was real dimension of kidneys, measured during celiotomy and immediately after necropsy. there were positive and significant correlations between ultrasonographic and real measurements of renal length, width, height and volume. correlation indices were 0.853 and 0.773 for right and left renal volume, respectively. sonographic dimensions and volumes were smaller compared to the real size during celiotomy and after necropsy. there were also positive and significant correlations between radiographic and necropsy measurements of renal length and width, while radiographic measurements of length and width were greater than the necropsy measurements. there were no significant differences between two positioning of renal ultrasonographic measurements. discussion/conclusion: it is concluded that renal measurements were underestimated using ultrasound and overestimated using radiographs. it seems there is no other study to show correlation between renal volume measured by ultrasonography and real one which compare effect of positioning on renal mensuration in ultrasonography. introduction/purpose: all processes of bone healing depend from blood supply and the revascularization process. related to injury of blood vessels haemorrhage, initial hematoma, and blood clotting cascade and fibrinolysis cause local changes of the physiological blood flow and contribute to initiation of local inflammation. angiogenesis and the significant increase of blood supply in bone fractures of limbs is a continuous subject to research. unsuccessful healing has been a motivator for many scientists and clinicians dealing with this problem to investigate the process of normal bone healing and search for new methods to stimulate the healing process. the objective of this study is to identify and describe changes of blood flow parameters in popliteal artery after experimental osteotomy and osteosynthesis of the tibia in sheep using external bone plate fixation in comparison with blood flow of untouched limb. materials and methods: study group consisted of 8 sheep of both sexes and same breed. the mean age was 3 years (ae0.25) and the study duration was 4 weeks. the measurements were performed in 4 sheep after tibial osteotomy and osteosynthesis with zespol external bone plate method and 4 control sheep that were kept under same conditions. duplex doppler examinations of popliteal artery right before ramification into cranial and caudal tibial artery were made using philips envisor c ultrasound system. radiographic examinations were performed simultaneously with no correlation to the final results as a supplementary study of changes in fracture healing. the study has been approved by the ethical committee of the wroclaw university. changes of resistivity index (ri) depending of time elapsed after surgical procedures were noticed. in the first 24 h obtained values were slightly higher than before surgical procedures reaching values of 1.13 to 1.34 and increasing about 0.01 to 0.19. in the next 48 h ri significantly decreased 0.1 to 0.49 in comparison with presurgical results reaching values of 0.67 to 1.10. peak systolic velocity (psv) values were highly different in each sheep and oscillated between 40 and 91.3 cm/s. discussion/conclusion: results are presented with reference to the values of blood flow in the same vessels of healthy sheep since normal values and their changes in bone fracture and surrounding soft tissue disruption are lacking. initial increase of ri values and its later decrease correspond accordingly to the initial (right after injury) phase and inflammatory phase of fracture healing. in the last 2 weeks of study normalization of obtained values was noticed corresponding to the callus formation and bone remodeling phase of fracture healing. psv values did not follow a specific pattern and no correlation to the time elapsed was found. introduction/purpose: high-resolution ultrasonography is considered an optimal image technique to assess normal anatomy and abnormalities of the peripheral nerves. ultrasound has been used for imaging of peripheral nerves in dogs. however, to the authors' knowledge, information regarding the appearance and ultrasonographic approaches of peripheral nerves in the cat has not been documented. the aim of the present study was to determine the ultrasonographic appearance and approaches to assess the brachial plexus in cats. materials and methods: anatomical nerve study: the dissection of the brachial plexus was carried out in six forelimbs. the landmarks used for anatomical location were axillary artery, scapulo-humeral joint and transverse processes of c5, c6, and c7. vascular injection and criosections: red latex was introduced through the thoracic aorta in two cadavers, which were frozen at à201c for 24 hours and then to à801c for 24 hours more. cross sections were made from cervical spine to elbow. photographs of each slide were taken to provide the interpretation of the ultrasonographic images. ultranosographic nerve study ''in vitro'': the brachial plexus were ultrasonographically evaluated using a 4-13mhz liner array transducer in four fresh feline cadavers. the accuracy of the ultrasound localization was demonstrated by injecting ink around the targeted nerves and immediately dissected. ultranosographic nerve study ''in vivo'': three live healthy adult experimental cats were sedated to perform the ultrasonographic examination of the brachial plexus using the same technique described in the ''in vitro study''. the anatomical dissection of the brachial plexus allowed establishing the anatomical landmarks to locate the nerves by ultrasound. the cervical spinal nerve roots were visualized on paravertebral approach. the brachial plexus was localised using the axillary artery as anatomic landmark on the axillary approach. musculocutaneous, radial, median and ulnar nerves were individually identified on medial humeral approach. the nerves appeared as hypoechoic tubular structures with an echotexture of discontinuous hyperechoic bands surrounded by a hyperechoic rim. discussion/conclusion: the axillary artery was the anatomical landmark used for localization of the brachial plexus. the different components of the brachial plexus were identified as hypoechoic structure with internal echoes and surrounded by a hyperechoic rim on medial humeral approach. references: guilherme s., benigni l. ultrasonographic anatomy of the brachial plexus and major nerves of the canine torathic limb. vet radiol ultrasound. 2008. 49 (6) introduction/purpose: diagnostic ultrasonography has been used to define cutaneous layers and changes of skin thickness in relation to hydration status and fluid distribution. recently, skin thickness has been measured in shar pei dogs, a breed considered unique because of its folding and thickening of the skin, with a linear 13 mhz transducer. 1 it was demonstrated that skin thickness in the shar pei is greater than in beagles. this was caused by abnormal dermal deposition of mucin, a substance predominantly constituted by hyaluronic acid (ha). the aim of the present study was to understand how changes in dermal components could likely contribute to differences in dermal echogenicity and to relate them to the histological findings. materials and methods: 10 shar pei dogs from breeders and 10 beagles from the veterinary faculty of uab used as controls were enrolled in this study. shar pei group included 6 intact females and 4 intact males with a mean age of 2 years, all with the characteristic increase of skin thickness and bundles of wrinkles extending on the forehead, withers and hind legs. beagle group included 7 intact females and 3 males of which one spayed, with a mean age of 5 years. dogs were considered healthy on the basis of clinical examination, cbc count, total proteins analysis and urinanalysis. ultrasonographic examination was made with a 13 mhz linear-array transducer. the ultrasound beam was maintained strictly perpendicularly to the skin surface on frontal, withers, sacral and metatarsal regions. biopsy specimens were taken from the same skin areas and stained by haematoxylin and eosin s(h&e), alcian blue at ph 2.5 and masson's thrichrome stains. in all dogs a defined hyperechoic line was observed at the interface between the coupling gel and the skin, which corresponds to the epidermal entry echo. a homogeneous hyperechogenicity with a fine echotexture was observed in the epidermis-dermis interface in the shar pei group. in 6 out of 10 beagles from the control group a double-layered appearance of the dermis were observed. in these dogs the superficial layer was more echoic than the deeper layer. by h&e, collagen fibers were demonstrated to be separated by a pale grey-pink substance corresponding to mucinous material in shar pei dogs. by alcian blue stain, in the dermis of shar pei scattered collagen fibers were between a network basophilic material, considered a characteristic aspect of acid glycosaminoglycans such as ha, whereas by masson stain collagen fibers stained of a turquoise material. all these findings were not present in the skin of beagles. discussion/conclusion: in shar pei, dermal hyperechogenicity, as in human studies, was related to ha-dependent deposition and its ability to form a viscoelastic network together with collagen and elastic fibers. the presence of a diffuse, intense dermal distribution of ha between collagen fibers was further confirmed by the histological results. in beagles, the distinct bands observed with ultrasound in the epidermis-dermis layers were hypothesized to be related to differences in dermal fluid storage in the interstitium separating the collagen fibers, such as reported in previous studies. 2à3 in conclusion, ultrasound is a useful diagnostic tool to demonstrate dermal changes in shar pei dogs. high frequency ultrasonography could be considered a valid alternative to other more invasive methods of investigation such as biopsies, to measure the degree of ha dermal deposition. introduction/purpose: non-cardiac thoracic changes are common in dogs and imaging is of importance in the evaluation of these animals. ultrasound is a method that can be used to better understand the nature of these lesions, however, prior knowledge of the ultrasonographic anatomy of the region is necessary. this study aims to determine the non-cardiac thoracic structures that can be evaluated by ultrasonography in normal dogs. ultrasonographic study of non-cardiac thoracic structures of two normal dogs obtained in the veterinary department at the federal university of viçosa, minas gerais, brazil. radiographic examination of the thorax of each animal was obtained in order to exclude thoracic abnormalities. the ultrasonographic examination was performed with the animal in both lateral positioning and each intercostal space was evaluated. during ultrasonographic examination of the thorax the following structures were visualized: skin, intercostal muscles, ribs, parietal pleura and pulmonary pleura. the image of normal lungs was a smooth hyperechoic line representing the pulmonary pleura and can be visualized as sliding line under the thoracic wall as the animal breathes (sliding sign). because of the reflection of the sound beam after the pulmonary pleura, reverberation artifacts were visualized as a series of parallel hyperechoic lines. discussion/conclusion: the evaluation of the thoracic cavity is difficult because the normal lung, filled with air, does not allow transmission of sound waves due to the marked difference in acoustic impedance between soft tissue and air. furthermore, the ribs produce a strong posterior acoustic shadow, making the exam more difficult. thus, intrathoracic structures, such as the mediastinum and normal lung parenchyma are not visualized by ultrasound examination. if pleural fluid is present or a disease replaces the air in the lung parenchyma an acoustic window will be provided. introduction/purpose: renal diseases are usual in small animals, especially in cats. there are few reports describing values for hemodynamic renal vasculature derived by duplex doppler ultrasonography in normal cats. the purpose of this prospective research was evaluating normal dopplerfluxometrics parameters of renal arteries (ra), interlobar arteries (ia) and abdominal aorta artery (ao) in adult healthy persian cats. materials and methods: fifty renal units of 25 persian cats (13 females and 12 males, age range 12-60 months, mean 30 months) were selected for normal by clinical and biochemical examination; for normal systemic blood pressure, and normal anatomy with b-mode ultrasonography. it was performed color mapping of renal vasculature and pulsed doppler of both ra, ia in both kidneys at three sites (cranial, middle, caudal), and ao. all vessels were measured resistive index (ri). early systolic acceleration (esa) of ra and ia in both kidneys was obtained at spectral mapping. it was also obtained ratio indices between ar/ao, and ai/ar velocities. results of ao measurements were psv 53.17 ae 13.46 cm/s and mean diameter of 0.38 ae 0.08 cm. the mean ra diameter of fifty renal units was 0.15 ae 0.02 cm. considering velocimetric values in both renal arteries the mean obtained was psv 41.17 ae 9.40 cm/s and ri 0.54 ae 0.07. esa of ra mean obtained was 1.12 ae 1.14 m/s2. superior reference value calculated was 3.40 m/s2. renal-aortic ratio mean obtained was 0,828 ae 0,296. results of ia measurements were psv 32.16 ae 9.33 cm/s and ri 0.52 ae 0.06. esa of all ia mean obtained was 0.73 ae 0.61 m/s2. superior reference value calculated was 2.0 m/s2. renalinterlobar ratio mean obtained was 1.45 ae 0.57. discussion/conclusion: this research was performed with selected cats as normal, healthy and same ranging of age. ri obtained was similar that referred in literature. some conditions that leave to a lost of complacency and increase vascular resistance, can affect the waveform at doppler spectral mapping but not ri. literature suggests that ri have poor sensitivity for detection of renal disease. esa parameter of renal and intrarenal arteries provides information of spectrofluxometric alterations of distal vascular bed. to our knowledge, no reports are available describing normal values of esa to renal vasculature in persian cats. it was established a new ratio between renal artery peak systolic velocity and interlobar artery peak systolic velocity. this index was developed based on well-known doppler identifiable effects of stenosis, undependable of the cause. more studies would be necessary to verify hemodynamic behavior of this index in pathological conditions in cats as the effect of age, nephropathies or systemic pressure in these dopplervelocimetric parameters. introduction/purpose: cerebrovascular diseases in dogs seem to be increasing in advancing age. these diseases are defined as brain abnormalities caused by blood supply impairment. although the strokes are considered important causes of neurological symptoms in dogs, reports in veterinary literature are unusual. the purpose of this study was to describe the underlying causes and ultrasonographic findings of cerebrovascular diseases in small breed dogs, and comparing them to the postmortem findings. 1 medical records of transcranial doppler sonography (tcds) examinations performed between 2007 and 2008 in 512 dogs with clinical signs of central nervous system disease were reviewed. the criteria for selection of the 52 patients reported here were: small breed dogs with no predilection for sex, showing an acute onset of clinical signs 2 (nystagmus, head tilt, hemiparesis, sudden blindness) with no progressive focal cerebral dysfunction and diagnosis of cerebrovascular disease confirmed at postmortem examinations within 30-60 days after imaging studies. tcds examinations were performed by the same operator. dogs were restrained by the owner, without sedation. hair clipping wasn't often required and acoustic coupling gel was applied above the zygomatic arch to obtain temporal and occipital windows in all dogs. tcds examinations were taken to evaluate brain parenchyma anatomy and echotexture as well as identifying the ventricular system and detecting focal lesions. color doppler flow mapping and pulsed doppler spectral analysis were performed to identify the circle of willis and obtaining the resistive index (ri). underlying causes of cerebrovascular diseases were subdivided as follows: 1) cerebral amyloid angiopathy (27%); 2) endocrinopathies (25%) such as diabetes, cushing syndrome and hypothyroidism; 3) coagulopathy (19%); 4) granulomatous meningoencephalitis (11%); 5) schnauzer hyperlipemia (6%); 6) tumors (6%). transcranial ultrasonography detected focal encephalic lesions in 22 dogs; diffuse lesions were observed in 20 dogs and 10 dogs showed no abnormalities on b-mode scan. these dogs presented low ri values for one or more arteries studied. duplex doppler ultrasound detected higher ri values in 43 dogs. only 4 animals showed normal doppler spectral parameters, with ri values ranging from 0,45 to 0,55 3 . discussion/conclusion: results showed that there is no sexual predilection in canine cerebrovascular disease, but older dogs were more often affected, mean age 9 years (range 15 months-18 years). correlation between tcds and histologic results indicates that focal lesions detected by tcds were nonspecific findings and could be associated with several causes including hemorrhagic mass and connective tissue apposition. diffuse decrease in echogenicity was related to inflammatory diseases and/or edema. diffuse increased echogenicity was usually related to aging changes. tumor and granulomatous meningoencephalitis detected by spectral analysis also determined arterial hemodynamic changes. focal lesions were correlated to local artery hemodynamic changes. tcds provided hemodynamic information of cerebral circulation adding to b-mode features. 1 department and clinic of veterinary surgery, the faculty of veterinary medicine cerebrovascular disease. veterinary clinics north america small animal practice transcranial doppler ultrasound analysis of resistive index in rostral and caudal cerebral arteries in dogs introduction/purpose: in compare to other diagnostic techniques, ultrasonogeraphy is relatively inexpensive, noninvasive, and allows definition of ocular and retrobulbar anatomy and, with the advent of doppler imaging, permits measurement of the blood velocity parameters of the orbital and ocular va-sculature1. the aim of this study was to evaluate feline ocular arteries using doppler imaging results: mean psv and edv were 14.3 cm/s and 6.1 cm/s respectively for lpca, 12.8 cm/s and 5.5 cm/ s for spca, 13 cm/s and 4.2 cm/s for aca and 21 cm/s, 8.9 cm/s)for pra. discussion/conclusion: doppler imaging has the potential for determining no invasively and consecutively the blood velocity parameters found in orbital and ocular diseases including orbital inflammations and neoplasia, vascular diseases including systemic vascular disease (hypertension)vasculopathies, anemia doppler imaging of the ophthalmic vasculature of the normal dog, blood velocity measurement and reproducibility key: cord-006869-g2q1gpp0 authors: nan title: neurocritical care society 7th annual meeting date: 2009-10-08 journal: neurocrit care doi: 10.1007/s12028-009-9282-0 sha: doc_id: 6869 cord_uid: g2q1gpp0 nan eighty-five patients were enrolled, 53 underwent therapeutic hypothermia, and 53 had a poor outcome. baseline characteristics did not differ between groups, except for the use of sedatives: 83% of hypothermia versus 60% of normothermia patients (p=0.02). corneal reflex, motor response and neuron specific enolase (nse), performed sub optimally in both the hypothermia and normothermia groups. however, all predictors accurately predicted poor outcome (fpr 0%) in patients without sedation regardless of whether they received hypothermia *numbers indicate percentages (95% ci). ‡ data not available for all patients. sedation is a confounder in the prognostication of comatose survivors after cpr. patients treated with hypothermia are more likely to receive sedation in proximity of their 72-hour neurological examination. hypothermia did not affect the accuracy of predictors of poor neurological outcome in this limited data set. methods: 27 continuous eegs performed in a pediatric icu were transformed into 8-channel cdsa and aeeg displays. 3 neurophysiologists and 3 eeg technologists were trained to identify seizures using cdsa and aeeg. participants were then presented with only the cdsa or aeeg displays and asked to mark events that they suspected to be seizures. their performance was compared to seizures previously identified using the conventional 13-21 channel eeg recording. the 27 eeg recordings contained 553 discrete seizures over 487 hours. the sensitivity for seizure identification and false-positive rates across all recordings are shown below. values are median (range). false-positive rate (# / hour) sensitivity (%) false-positive rate (# / hour) 75.0 (66.7-86.7) 0.03 (0.00-0.14) 74.0 (60.3-83.9) 0.04 (0.00-0.15) for individual recordings, however, the median sensitivity for seizure identification varied from 0% to 100%, and the median false-positive rate varied from 0/hour to 2.67/hour. factors reducing the sensitivity included focal and low amplitude seizures. factors increasing the false-positive rate included movement and electrode artifacts, and non-ictal eeg waveforms such as periodic epileptiform discharges and a burst-suppression pattern. cdsa and aeeg are equally sensitive and specific tools for seizure identification among critically ill children. their performance is likely even better in a clinical context, when reviewers have access to the underlying raw eeg. these findings support the use of cdsa and aeeg as screening tools, with the caveat that low amplitude and focal seizures are liable to be missed using these techniques. 3 intermountain medical center, salt lake city, utah, united states, 4 johns hopkins hospital, baltimore, md, united states recent studies suggest that glucose variability is an important predictor for mortality in a mixed critically ill population, however, the relationship of glucose variability with sich remains ill defined. we sought to evaluate the relationship between glucose variability on in-hospital mortality during the acute phase of sich. we performed a retrospective chart review of consecutively admitted patients with sich with a minimum of 3 glucose readings during the first 5-icu days. data extracted included: patient characteristics, clinical features, glucose values/insulin use, and outcomes. blood glucose indices assessed over the 5 days included: average glucose levels (glucavg), standard deviation of glucose (glucsd), coefficient of variance (gluccv), and peak glucose (glucmax). statistical assessment of the glucose indices was assessed in relationship to in-hospital mortality. there were a total of 2765 glucose readings in 154 patients with an overall mortality of 26%. univariate analysis showed the only significant baseline patient characteristics were lower admission gcs and higher apache ii in the nonsurvival group. admission glucose (181±99 vs. 129±41; p=0.002), glucavg (160±74 vs. 125±24; p=0.005), glucsd (41±22 vs. 27±16; p<0.001), gluccv (26±11 vs. 20±9; p=0.007), and glucmax (244±104 vs. 179±62; p=0.001) were significantly higher in the nonsurvival compared to the survival group (mg/dl, respectively). logistic regression analysis showed that significant predictors for in-hospital survival include admission gcs (or 1.323; 95% ci 1.198-1.460; p<0.001), glucsd (or 0.962; 95% ci 0.942-0.982; p<0.001), and gluccv (or 0.947; 95% ci 0.913-0.983; p=0.004). findings from this study suggest that a large variability of glucose during the acute phase of sich is associated with higher in-hospital mortality. the variability appears to be a more important predictor for outcomes than admission glucose or average glucose levels. the proportion of deaths was higher among patients in the intensive arm but this was not statistically significant (36% vs. 25%, p=0.34). when good versus poor outcome at 3 months was dichotomized to mrs score 0-2 versus 3-6, respectively, there was no difference in outcome between the two groups (76.2% vs. 75% had a poor three month outcome, p = 1.0). there was also no difference in icu or hospital los or days on mechanical ventilation. hypoglycemia (<60mg/dl) and severe hypoglycemia (<40mg/dl) was more common in the intensive arm (48% vs. 11%, p=0.0006) and (4% vs 0%), respectively. there was no benefit to intensive insulin therapy in this small critically ill neurologic population. previous studies of glycemic control in non-neurologic icu patients have shown conflicting results. this is the first glycemic control study specifically examining critically ill neurologic patients and functional outcome. given these results and the increased resources required to implement intensive insulin therapy, it cannot be recommended over conventional control. to improve organ donation conversion rates, neurointensivists at a level ii trauma, community hospital and the local organ procurement organization (opo) decided to diminish decoupling. decoupling is when the explanation of brain death by the physician is separated from the request for organ donation by the family support coordinator (fsc). the fsc is not present for the final explanation of declaration of brain death and the physician familiar to the family, typically, is not present for the request. we were concerned that in the transition of physician to fsc, conversion was being lost. data was retrospectively reviewed from 2007-2008 when decoupling was still occurring and compared to data thus far from 2009 where the physician and fsc were present together for both the final explanation of brain death (by physician) and request for organ donation (by fsc). we also compared data from two similar local hospitals that have not changed decoupling. all first person consent donors were removed from the data. in 2007-2008, our hospital's conversion rate of eligible to actual donors was 44% and 37% respectively. in the first six months of 2009, where decoupling was diminished, the conversion rate was 84%. the conversion rates for two other local hospitals of similar potential and patient mix were 42% (2007), 59% (2008) , and 43% (2009) (community based hospital); and 56% (2007), 60% (2008) , and 38% (2009) (university based hospital). the presence of the physician familiar to the family during the organ donation request may enhance organ donation conversion in non-first consent potential donors. physicians should consider working with the opo and fsc to try this process especially if conversion rates for organ donation are low. previous studies suggest that dynamic autoregulation in the posterior cerebral artery (pca) is less efficient compared to the middle cerebral artery (mca). we examined the role of cerebral vasodilation due to metabolic activation (i.e. visual stimulus) on autoregulatory characteristics in the two vascular territories. blood flow velocity (bfv) in the pca and mca and mean arterial pressure (map) were measured continuously in 45 healthy volunteers (62±3 years) while seated with eyes open. additional 20 subjects (60±5 years) were examined with eyes closed and open. cerebrovascular resistance index (cvr i ) was calculated as the ratio of map to mean bfv in the pca and mca arterial territories. autoregulation was assessed using transfer function gains in both the pca and mca territories in the low (0.03 -0.07 hz), high (0.07 -0.15 hz) and cardiac (~ 1 hz) frequency ranges. the effects of vascular territory (pca vs. mca) or visual activation (eyes-closed vs. eyes-open) on bfv, map, endtidal co2, cvr i , and transfer function coherence, gains, and phases were assessed by using a repeated-measures two-way anova, respectively. with eyes open, gains were significantly higher in the pca compared to the mca in the low (pca: 1.41±0.09 vs. mca: 1.18±0.07, p=0.003) and high (pca: 2.06±0.12 vs. mca: 1.61±0.08, p=0.0001) frequencies. opening eyes increased bfv and reduced cerebrovascular resistance index in the pca but not mca. this vasodilation in the pca was associated with increased gain in the low (autoregulatory) frequency while mca gain did not change (pca: 0.89±0.14 vs. 1.31±0.17, mca: 1.24±0.16 vs. 1.16±0.11, p=0.02). dilation of the pca territory during visual cortex activation resulted in increased pca transfer function gain without changing mca gain. thus, impaired autoregulation in the pca reported in previous literature is likely the result of metabolic vasodilation and not an inherent difference in the autoregulatory characteristics of the posterior circulation. various scales have been devised for the prediction of vasospasm following aneurysmal rupture. all such tools require the measurement of sah burden by computed tomography to predict the likelihood of symptomatic vasospasm. especially prominent in these scales is their reliance upon a subjective assessment of clot thickness which allows for variability in grading across raters. the current study seeks to compare the inter-rater reliability of the fisher and newer frontera scales when a rigid definition of thick clot is used. 50 cases of subarachnoid hemorrhage were randomly selected from our radiographic archives. initial head cts were independently reviewed by two raters and a score for both the fisher and frontera scale was assigned to each study. the following criteria were established to characterize thick clot: 1. hemorrhage in any major cistern appearing on two contiguous slices; 2. hemorrhage occupying > 50% of any major cistern on a single cut; 3. contiguous hemorrhage with a density approximating that of bone. hemorrhage was scored as "thick" if any two of the three criteria were met. the degree of agreement in scores between raters was then assessed by way of the spearman's rho and cohen's kappa for inter-rater reliability. for both the fisher and frontera scales, a high degree of inter-rater reliability was demonstrated with rho values of .849 (p=.01) and .903 (p.01) respectively. when cohen's kappa was employed, respective values of 0.837 and 0.723 were obtained. these kappa values, which reflect the use of a stringent definition for thick subarachnoid hemorrhage, were stronger than those previously reported by ah. kramer et.al. with the use of a stringent definition for thick subarachnoid hemorrhage, an assessment of subarachnoid clot burden can be made that shows a high degree of reliability across observers. although ventilator-associated pneumonia (vap) carries significant mortality there is scarce data on vap in the neurosurgical intensive care unit (nsicu). we sought to determine the clinical factors associated with vap in the nsicu. we analyzed all admissions to the nsicu requiring mechanical ventilation for at least 48 hours to determine factors associated with vap. we collected demographics, medical history, admission diagnosis, admission glasgow and four coma scale, tracheostomy need, ventilator days, length of stay, and mortality. for statistical analysis we performed fishers exact test (categorical variables) and students t-test (continuous variables). we used the centers for disease control vap definition. we analyzed 119 admissions to the nsicu over one year. the sample was comprised of 80 males and 49 females with a median age of 55 (20-87). the median gcs was 9 (3-15) and the median four scale was 10 (4-16). the median length of stay was 8 days . diagnosis included subarachnoid hemorrhage (32%), head trauma, (17%) intracranial hemorrhage (17%), subdural hematoma (8%), spinal cord injury (10%), neoplasms (8%), and others (8%). the incidence of vap was 22.6%. mortality was significantly higher (p < 0.001) among patients with vap (17%) than in non-vap patients (8%). there was no difference in clinical risk factors, admission diagnosis, and need for tracheostomy. the mean age of vap patients was 44 and that of non-vap patients was 54. age < 50 was associated with vap (p< 0.008). the only clinical variables associated with vap were mechanical ventilation for > 5 days and four score < 14 (p = 0.03 and 0.05 respectively). in the nsicu vap is frequent and carries significant mortality. duration of mechanical ventilation and four coma score predict vap. poster 6 blood pressure decreases due to general anesthesia for intra-arterial therapy for acute ischemic stroke are associated with decreased functional relative hypotension after large vessel stroke is associated with poor outcome. general anesthesia (ga) causes peripheral vasodilation and cardiac depression, leading to a decrease in systemic blood pressure. in initial analysis of the merci registry-a prospective, uncontrolled cohort of patients treated with the merci retriever-functional outcome after stroke was worse in those patients intubated for the procedure as compared with those in whom conscious sedation or deep sedation was performed. we hypothesized that the poor functional outcomes in intubated patients resulted from decreased systemic blood pressure. the study population consisted of all patients enrolled at our institution in the merci registry from october 2007 to july 2009. during the study period, all ia stroke interventions were performed under ga. data regarding demographics, stroke severity (nihss on presentation), recanalization (tici grade), and functional outcome at 90 days (modified rankin scale; mrs) were prospectively collected. we retrospectively reviewed the blood pressures on presentation, prior to intubation and after intubation. : 58 patients were identified; of these, 45 had adequate records of blood pressure before and after intubation as well as 90 day follow-up assessments. the average age was 64 and 49% were male. compared with pre-intubation baseline, significant reductions in sbp (149.2 vs 133.3, p<.001) and map (101.2 vs 93.5, p<.001) were observed following intubation. controlling for well established predictors of outcome (nihss, age, location of vessel occlusion, and recanalization), the first sbp and dbp recorded immediately after intubation were significantly correlated with mrs (p=0.03, p=0.039) with lower measurements associated with poor functional outcomes. blood pressure declined significantly as a result of general anesthesia, and lower sbp and dbp following intubation were associated with worse functional outcomes. these findings suggest that blood pressure should be aggressively supported in acute stroke patients treated undergoing ia mechanical thrombectomy. posttraumatic vasospasm (ptv) is an under-recognized cause of ischemic damage following traumatic brain injury (tbi), but little is known about its pathogenesis and risk factors. although ptv significantly differs from aneurysmal vasospasm [1, 2] , it shares certain characteristics [1] [2] [3] [4] that may provide insight into its pathogenesis. in particular, the risk of aneurysmal vasospasm is increased in patients with fever [5] [6] [7] [8] [9] [10] or leukocytosis [10-12], but these relationships have not been previously explored in ptv. a review of 394 consecutive patients with tbi yielded 46 patients with severe tbi that survived beyond 48 hours. eight patients developed clinically significant posttraumatic vasospasm (csptv), defined as unexplained decline in neurological function or brain tissue oxygenation with ct angiogram evidence of arterial vasospasm. temperature and serum leukocyte counts were compared in severe tbi patients with and without ptv. admission temperature was significantly higher in patients that developed csptv (37.58 0.6ºc vs. 35.67 0.3ºc, p=0.005), and fever on admission (t>38ºc) was associated with significantly increased likelihood of vasospasm (or=22.2). csptv did not occur in patients with hypothermia (t<36 ºc) on admission, while 75% of those with fever (t>38ºc) developed csptv. admission leukocyte count was significantly higher in patients that developed csptv (20.64 2.8 k/mm 3 vs. 14.72 1.0 k/mm 3 , p=0.019). 21.9% of patients with leukocytosis on admission (wbc>12k/mm 3 ) developed csptv, compared to 7.14% of patients without leukocytosis. hyperthermia on admission correlates with increased likelihood of developing clinically significant ptv. serum leukocyte count on admission is higher in patients who subsequently develop csptv, suggesting that activation of inflammatory pathways and/or early infection may be involved in the pathogenesis of vasospasm. the observation that csptv did not occur in patients with admission temperatures below 36ºc suggests a possible protective role for early hypothermia. subarachnoid hemorrhage (sah) frequently causes stunned myocardium (sm). the predictors of sm and its impact on clinical course and outcome are not fully defined. we evaluated 674 consecutive sah patients enrolled in the sah outcomes project from february 2002-june 2009. 144 patients were excluded due to history of cardiac disease, 79 were excluded due to non-aneurysmal sah. sm was defined as wall motion abnormalities +/-elevated troponins. demographic, clinical, and outcome data was compared between those with and without sm. results: 56% (n=256) of patients were hunt & hess (hh) grade 3-5. modified fisher score was >=3 in 55% (n=254). sm was diagnosed in 16% (n=71). on univariate analyses, sm was associated with loss of consciousness (loc) at onset, hh grade, hijdra score, posterior aneurysm location, female gender, tobacco non-use, bmi, ivh, systolic bp, heart rate (hr), glucose, and wbc count. in a logistic regression accounting for race and age, female gender (p=0.04), loc at onset (p<0.001), posterior aneurysm location (p=0.001), hr (p=0.001), systolic bp (p=0.002), hh grade (p<0.001) & tobacco non-history (p=0.007) were independent predictors of sm. sm was associated with in-hospital development of fever, hyperglycemia, pneumonia, anemia, seizures, global cerebral edema (gce), sodium dysregulation, and arrhythmia. after accounting for age & gender, arrhythmia (p<0.001), fever (p=0.002), and gce (p<0.001) were independently associated with sm. after adjusting for gender, age and known risk factors for poor outcome, sm was an independent predictor of mrs > 3 and death at 3 months. chronic brain atrophy is regionally specific and is regionally associated with reductions in oxidative brain metabolism but not ischemia. the temporal lobe exhibit the greatest extent of atrophy, which may be related to the extent of initial trauma. leão's spreading depression (sd) of electrocorticographic (ecog) activity describes a propagating wave of neuronal/astroglial depolarization in cerebral grey matter. sd occurring in normally perfused cortex may be benign, but similar peri-infarct depolarizations (pid) cause ischemic lesion growth. here we present results of a pilot study to determine the association of depolarizations with clinical outcome in traumatic brain injury (tbi). at five hospitals, subdural electrode strips were placed in 56 patients who required craniotomy for surgical management of tbi. sd and pid events were identified by criteria of fabricius et al. (brain 129:778-90, 2006) in ecog recordings made during intensive care for a median duration of 71 hr. six-month egos scores were dichotomized to good (5-8; n=26) and poor (1-4; n=30) outcomes. in 33/56 (59%) patients, 600 depolarizations occurred. of these, 411 were sd type, 121 were pid, and 80 were mixed. the proportion of poor outcomes was 35% (8/23) in patients with no depolarizations, compared to 57% (12/21) in patients with sd and 83% (10/12) for patients with pid. the occurrence of pid and either type of depolarization were both significantly associated with worse outcomes (fisher exact test, p=0.02 and 2 , p=0.02, resp.), while sd alone was not ( 2 , p=0.14). there was no association of pupil reactivity ( 2 , p=0.61), gcs motor score ( 2 , p=0.51), pre-hospital hypotension ( 2 , p=0.79), or subarachnoid hemorrhage ( 2 , p=0.56) with outcome. ages of patients with good (40±19 s.d.) vs. poor (48±16) outcome did not significantly differ (p=0.09). these data suggest that depolarization activity is significantly associated with poor outcome, with predictive power at least as great as established outcome predictors. prevention of depolarizations by pharmacologic or physiologic therapy may represent a novel strategy to improve tbi outcomes. an increased sample size is required for improved statistical power and to determine the independence of depolarizations from co-variates. introduction: vasospasm (vs) represents a substantial source of morbidity and mortality in patients with subarachnoid hemorrhage (sah). transcranial ultrasound (tcus) velocities indicating vs in the anterior cerebral artery (aca) are not well established. the purpose of this study is to identify aca velocities that correlate to ipsilateral aca infarction. the aca mean velocities of 250 consecutive sah patients undergoing routine twice daily tcus were prospectively collected. the maximum (max), minimum (min), and first (fir) mean velocity value for each vessel was determined, as were the ratios for max/min and max/fir. this process was performed for the entire group, and then for only patients having at least 7 days of readings. determination of aca territory infarction was made by evaluation of serial head ct scans performed up to day 21 following the ictus. velocity comparisons were made between patients having and those not having aca territory infarctions on ct. for the entire group, data was available for 443 vessels, 21 of which had associated infarction. max velocity was somewhat greater in patients with aca infarctions (118cms/s vs 101cms/s, p=.058), and min velocities were substantially greater (46cms/s vs 35cms/s, p=.001). the group having at least 7 days of tcus constituted 357 vessels, 15 of which had associated infarction. max velocity was again somewhat greater (127cms/s vs 109cms/s, p=.069) and min velocity was again significantly greater (45cms/s vs 35cms/s, p=.002). no correlation was observed for fir, max/min, or max/fir. patients ultimately developing aca infarctions have greater min velocities and tend to have greater max velocities. since only the use of max velocities is practical, our findings suggest that velocities between 110-120cms/s may identify those vessels at risk for infarction, which is consistent with the available literature. cerebral infarction following subarachnoid hemorrhage (sah) contributes to morbidity and mortality. vasospasm (vs) has traditionally been considered the main cause, yet recent literature suggests other potential etiologies. anterior cerebral artery (aca) infarctions may result in permanent deficits of intellect and behavior. the purpose of this study is to document the prevalence of aca infarctions and to characterize the etiology of these infarctions in patients with aneurysmal sah. 250 consecutive sah patients underwent review of cerebral ct scans as close to 3 weeks after the ictus as possible so as to identify sah related aca infarctions. earlier scans were reviewed in patients found to have aca infarctions to determine the timing of the infarction. vs related infarctions were defined as those beginning at least 4 days after the ictus. infarcts occurring less than 4 days after the ictus were considered to be non-vs related. imaging was available for 237 patients (474 aca territories). overall, 6.8% of patients developed aca infarctions in 4.6% of aca territories. of these, only 1.6% of patients and 1.1% of territorial infarcts were deemed likely due to vasospasm. most aca infarct patients (56%) had aca/acomm aneurysm ruptures. of patients with aca infarction and aca/acomm aneurysms, 89% had infarcts within the first 4 days (p=.095). all bilateral aca infarctions with aca/acomm aneurysms had infarctions within 4 days of the ictus. aca infarctions are not rare in patients with sah. patients with aca/acomm aneurysms were more likely to have aca infarcts in the acute phase, prior to the usual onset of vs. the etiology of these infarctions remains to be determined, but may be related to vessel thrombosis at the time of hemorrhage, procedural/operative complications, or early vs. telemedicine holds promise as a technology-intensive method of providing rapid acute neurology expertise to local hospitals with available ct scanning, and has been proposed as a way to increase access to limited specialty expertise in a cost-effective manner. we here report the experience of a multi-state telemedicine company, working in joint effort with academic hospitals, providing acute neurological consultations to community-based hospitals. specialists on call (soc) is a california-based telemedicine company providing 24/7 specialist physicians consultations to urban, suburban and critical access hospitals via videoconferencing technology. neurological consultations are conducted by board-certified neurologists. consults requests are responded within 15 minutes. initially, the specialists discusses the case by telephone and in a second step, the video-conference is started. teleneurological exam is conducted following established and validated guidelines, especially for nihss. recommendations and further steps are discussed with patients, family members and consulting physician. between january 2008 and may 2009, a total of 5825 teleneurology consults were performed, among 56 community hospitals in 6 states. only 2 hospitals had over 300 beds (391 and 511), the rest ranged between 22 and 254 beds. stroke was the diagnosis in 3675 cases (63.1%), of which 3491 (95%) were acute ischemic events (aie) (stroke or tia) and 184 (5%), intracranial hemorrhages. 346 (9.9% of aie) received thrombolytic therapy with intravenous tpa. seizure was the diagnosis in 213 patients (3.65% of the total) and other diagnosis (including headache, dizziness, vertigo and chronic pain) in 1937 (33.25%) patients. telestroke consultation can be useful in increasing the use of intravenous tpa at community hospitals without access to adequate on-site stroke expertise. besides thrombolytic decisions, teleconsultation can improve the care of other neurocritical conditions, including seizures, or intracerebral hemorrhage and triage to centers with neurocritical-care capability. increased intracranial pressure (icp) is associated with poor outcome in acute brain injury. in this study we examined how episodes of increased icp (>20mmhg; >5minutes) affected brain metabolism. twenty-one patients (mean age 50.67 + 11.41 years) with severe brain injury (gcs<8) were studied prospectively. lactate, pyruvate, and glucose were measured each hour using cerebral microdialysis (cma). brain oxygen (pbto 2 ), mean arterial pressure (map), icp and cerebral perfusion pressure (cpp) were recorded continuously. linear mixed effects models were used to examine the relationship between episodes of increased icp and the lactate:pyruvate ratio (lpr). there were 467 episodes of increased icp, 298 episodes of compromised pbto 2 (<20mmhg) and 137 episodes of brain hypoxia (pbto 2 <10mmhg). median icp (25% -75% iqr) was greater during brain hypoxia (19.5 [37.0] vs. 16.0 [12.0]; p <0.001). gee models indicated that icp >30mmhg was associated with more than double the odds of brain hypoxia (or= 2.5; 95% ci: 1.1, 5.8, p=0.034) or compromised pbto 2 (or= 2.1; 95% ci: 1.2, 3.7, p=0.007). however the frequency of increased icp (>20mmhg) was similar among patients with compromised pbto 2 (p= 0.070) or brain hypoxia (p=0.73) compared to normal pbto 2 . only half the patients with brain hypoxia had increased icp. elevated lpr (>20) was rare (n=36 [4.6%] of icp episodes). median lpr (25% -75% iqr) was greater during episodes of brain hypoxia than normal pbto 2 (7.7 (7.7) vs. 2.8 (0.8), p<0.0001) and only slightly greater in episodes with compromised pbto 2 compared to corresponding episodes with normal pbto 2 (3.3 (2.2) vs. 2.8 (0.8), p=0.016). lpr did not increase when icp was >20mmhg. evidence for brain energy dysfunction is very rare when icp is >20mmhg and any icp effect on lpr may be indirect and depend on pbto 2 . rafael badenes, pablo gonzalez, laura alcover, armando maruenda, javier belda hospital clinico universitario, valencia, spain this was a pilot study to compare the cerebral neurochemical changes in patients with traumatic brain injury (tbi) who underwent conventional blood glucose level (bgl) control and intensive bgl control with continuous titrated insulin. this prospective, randomized study was conducted in 30 traumatic brain injury patients in a surgical and trauma intensive care unit. patients admitted over an 18-month period with tbi were prospectively divided into two groups according to the method used for bgl control: the 'intensive' group consisted of patients who underwent continuous titrated insulin infusion to maintain a lower normoglycemic level of 4-8 mmol/l, and the 'conventional' group consisted of patients whose bgl was maintained at between 8.1 and 10.0 mmol/l using conventional 'sliding scale' bolus subcutaneous insulin administration. data on cerebral haemodynamics, interstitial brain oxygenation (ptio(2)) and neurochemical monitoring were collected via microcatheters inserted in the penumbral region. we analyzed 2844 cerebral microdialysis samples. in 15 patients treated with intensive insulin therapy, there was a reduction in microdialysis glucose by 77% of baseline concentration compared with a 8% reduction in 15 patients treated with a conventional blood glucose level control. intensive insulin therapy was associated with increased incidence of microdialysis markers of cellular distress, elevated glutamate (44+/-34% vs. 8+/-14%, p<.01), elevated lactate/pyruvate ratio (40+/-37% vs. 14+/-22%, p<.03) and low glucose (26+/-17% vs. 11+/-15%, p<.05), and increased global oxygen extraction fraction. cerebral microdialysis glucose was lower in nonsurvivors than in survivors (0.46 +/-0.23 vs. 1.04 +/-0.56 mmol/l, p < 0.05). intensive glycaemic control using insulin induced a decrease of cerebral glucose and an increase in microdialysis markers of cellular distress. in patients with severe brain injury, tight systemic glucose control is associated with increased mortality. brain tissue oxygen (bto2) monitoring is used in severe traumatic brain injury (tbi) patients. how cerebral hypoxia should be treated and its response to treatment is not clearly defined. we examined which medical therapies restore normal bto2 in tbi patients. severe tbi (gcs less than 8) patients were enrolled in a prospective observational cohort study. intracranial pressure (icp), cerebral perfusion pressure (cpp) and bto2 were monitored. episodes of cerebral hypoxia (bto2 less than 25 mmhg) and medical interventions and therapies that improved bto2 were identified. three hundred seventy nine episodes of cerebral hypoxia were recorded and treated in forty nine patients (mean age 40 +/-19 years). medical management successfully reversed 72% of the cerebral hypoxia episodes. ventilator manipulation, cpp augmentation, and sedation were the most frequent interventions. increasing fio2 restored bto2 80% of the time. cpp augmentation and sedation were effective in 73% and 66% cerebral hypoxia episodes, respectively. icp reduction using mannitol was effective in 73% of treated episodes. phenylephrine was the most frequent vasopressor administered and improved bto2 74% of the time. other interventions including head repositioning, airway suctioning, and blood transfusions, were effective in 66%, 88%, and 50% treated episodes, respectively. successful medical treatment of cerebral hypoxia was associated with improved outcome. survivors had a 71% rate of response to treatment (n=38) and nonsurvivors had a 44% rate of response (n=11; p=0.01). cerebral hypoxia occurs in tbi patients despite traditional practices to maintain cpp. medical interventions other than those to treat icp and cpp can improve bto2, increasing the number of therapies for severe tbi in the icu. poster 17 intravenous dantrolene for the treatment of cerebral vasospasm after subarachnoid hemorrhage -final results of a prospective phase i cerebral vasospasm (cvsp) after subarachnoid hemorrhage (sah) is the major cause of disability and death. treatment options are limited. dantrolene blocks ryanodine receptor-mediated intracellular calcium release from the sarco-endoplasmic reticulum. it attenuates cerebral vasoconstriction, potentates the action of nimodipine on cerebral vessels and is neuroprotective in animal models. we performed a prospective phase i study examining the safety and effects of a single-dose of dantrolene on cvsp after sah. in an irb approved, prospective, open-label single-blinded phase i study, sah patients with elevated transcranial doppler (tcd) velocities and lindegaard indices suggesting cvsp were enrolled. after baseline tcds by a single, trained operator, patients receive a one-time infusion of dantrolene over 60 minutes with dose escalation (first five patients 1.25mg/kg, the following five patients 2.5mg/kg). infusions, ventilator and ventriculostomy settings were kept unaltered, so that physiological data could be followed. hr, bp, icp, cpp, cvp and body temperature were recorded at infusion start (time 0 ), every 10min during the infusion and with every tcd thereafter. serum abg, chem7 and osmolarity were measured at time 0 and 135min, and lfts at time 0 and 24hrs. tcds were repeated at 45, 60 and 135min after time 0 . statistical analysis was performed with repeated measures anova for the physiological values and change ( ) in systolic, mean and diastolic tcd in the vessel in cvsp from time 0 , followed by post-test bonferroni's multiple comparison test with bonferroni p-value adjustment for significant findings. laboratory values were analyzed by wilcoxon matched pairs test. ten patients (n=5 each group with 1.25mg/kg and 2.5mg/kg dantrolene) were enrolled. over the entire study period, hr, map, dbp, icp, cpp and body temperature remained stable, except for sbp which decreased (p= 0.015). posttest bonferroni's multiple comparison test with p-value adjustment (p=0.001) showed a trend towards a difference between time points 40 and 90min (mean -10.3mmhg), and 50 and 90min (mean -10.3mmhg), although this was not significant. significantly different laboratory changes were na (mean -2.2 meq/l, p= 0.0052), cl (mean -2.7 meq/l, p= 0.0056) and alkaline phosphatase (mean -11.4 mg/dl, p=0.039); the degree of change, however, was considered clinically insignificant. none of the other laboratory values changed. systolic and mean tcd velocities decreased significantly over time compared to time 0 (systolic p= 0.0051; diastolic p= 0.0601; mean p= 0.0245). post-anova linear trend testing indicates the magnitude of change: systolic (slope -4.1, p= 0.0005); diastolic (slope -1.7, p= 0.0102) and mean tcd (slope -2.4, p= 0.0058). a one-time infusion of dantrolene appears safe, although the mild changes in na, cl and alkaline phosphatase warrant monitoring. most importantly, transaminases did not change. dantrolene decreases tcd velocities over time, presumably due to inhibition of cerebral vasoconstriction. we have insufficient data to comment on the duration of this effect. our results warrant further study with repeated or continuous dantrolene dosing for treatment or prevention of cvsp after sah or other vasoconstriction syndromes. status epilepticus carries a mortality rate up to 77%. newer, intravenously (iv) applicable antiepileptic agents might be powerful adjunctive therapies. we report our experiences with iv levetiracetam in a prospective patient cohort with status epilepticus. we treated 27 patients with convulsive status epilepticus with an institutional protocol consisting of iv lorazepam followed by iv phenytoin, iv levetiracetam as third line agent or second line agent if there were contraindications for iv phenytoin, and iv propofol and/or midazolam as fourth line agents. primary outcome was treatment success of iv levetiracetam. secondary outcome measures were time to treatment success, modified rankin scale (mrs) at 6 and 12 months, and complications. of the 27 patients 22 had cerebral structural abnormalities, 4 an infection, and 1 hyponatremia as underlying etiology for status epilepticus. median age was 70 (range 30-97) years, 15 patients were male. baseline gcs was 5 (3) (4) (5) (6) (7) (8) (9) (10) (11) (12) . levetiracetam successfully treated status epilepticus in 6 patients. median time to treatment success was 480 (10-16337) minutes in all patients. at 6 months 11 patients had died, support had been actively withdrawn in 3 patients. the mrs was 0 in 4 patients, 1 in 4 patients, 2 in 1 patient, 3 in 2 patients, 4 in 2 patients and 5 in 3 patients. at 12 months, 1 patient with a mrs of 3 had progressed to 4. the most common complications included hyperglycemia (78%), hypotension (59%), acute renal failure (26%), anemia (33%), thrombocytopenia (30%), urinary tract infection (26%), and seizure recurrence (19%). levetiracetam offers a feasible alternative strategy to break status epilepticus as adjunctive third line therapy in a paucity of patients before administration of sedatives with a broad spectrum of adverse effects and needs to be studied in a standardized trial. stroke is the third leading cause of death in industrialized nations.the treatment pathway for ischemia is often determined by assessing the extent of permanent damage aided by imaging modalities such as mri.diffusion weighted imaging (dwi) is an accepted mri technique that is sensitive to water diffusion.the restriction of water in damaged cells is used as a surrogate measure of cell death.although cells may have taken on water,this surrogate measure may be inaccurate,frequently leading to overestimation of the severity of ischemia.measures of sodium are reported to be more accurate indicators of cell death and can also be used to determine stroke onset time because of a linear relationship between ischemia and sodium concentration.we have developed a multinuclear coil and radiofrequency current source that permit simultaneous high-speed proton and sodium imaging so that treatable ischemia can be better ascertained. an 8-channel,broadband,radiofrequency,phased array and current source were built enabling targeted,accelerated,and simultaneous spectroscopic imaging of water,helium,and sodium on a 1.5t ge mr scanner.it was tested on phantoms of known sodium and water concentrations and in rats with known inhaled helium concentrations. high quality imaging of protons and sodium in phantom models of known sodium concentration were obtained.additionally, high quality helium imaging in rats demonstrated the ability of the system to image other nuclei and proved the quantitative and qualitative imaging capabilities of the array in vivo. mars imaging provides a new, simultaneous multinuclear approach to determine the extent of ischemia quickly and quantitatively.high quality images with this system can be obtained in humans with the same hardware and can be used with standard 1.5t mr scanners. septic shock is often associated with relative vasopressin (avp) deficiency that may be related to impaired avp synthesis and release by the neurohypophyseal system, which includes the neurohypophysis and magnollecular neurons of the paraventricular and supraoptic nuclei. neurohypophyseal system has never been assessed in human septic shock and only partially in experimental sepsis. we investigated avp synthesis and release by the neurohypophyseal system in septic rats and in human septic shock. design: ex vivo human and animal study. setting: university research laboratory in the human study, post-mortem examination of the neurohypophyseal system was performed in patients who died from septic shock (n=9) or other causes (n=10). in the experimental study, sepsis was induced by fecal peritonitis in conscious, fluid-resuscitated male adult wistar rats. rats either early died spontaneously from septic shock in average at 24 hours (septic early death, n=10) or were sacrificed in average 36 hours after induction of sepsis (septic, n=10). post-mortem examination was performed in both groups. comparisons were made against sham operation controls (n=8). avp protein and mrna were assessed by immunohistochemistry and in-situ hybridization. in both septic shock patients and septic rats with early death, the avp content in the neurohypophyseal and supraoptic magnocellular neurones was decreased while it was increased in the paraventricular magnocellular neurones. no significant change was observed in avp mrna expression in either paraventricular or supraoptic magnocellular cells. in septic shock, avp post-transcriptional synthesis and transport are altered in the supraoptic and paraventricular magnocellular neurones, respectively. this suggests that supraoptic and paraventricular nuclei are liable to distinct pathogenic mechanisms, which may account for relative avp deficiency. introduction: dual brain death (dbd) examination has been historically followed to determine irreversible brain damage. a policy was introduced in our hospital to utilize single brain death examination (sbd) including an apnoea test and a confirmatory test for cerebral blood flow in patients with catastrophic neurological injuries to determine brain death. we investigated if organ procurement would be affected by sbd. the database of gift of life (the designated organ recovery organization for michigan), was screened for our institution patients meeting brain death criteria between jan 2007 and july 2009. for each patient, age, sex, primary cause of mortality, number of brain death examinations performed, type of confirmatory tests used to declare brain death, medical exclusions for organ donation and number of organs procured was obtained. continuous variables were analyzed using the student t-test and categorical variables using fischer's exact test with p values set at 0.05. seventy patients met brain death criteria between january 2007 and july 2009 and 12 were excluded due to incomplete records. there was no difference between the age and sex composition between the two groups. twenty seven patients were diagnosed with brain death using sbd while 31 were diagnosed using dbd. twenty four patients with sbd and 26 with dbd were eligible for organ donation (p=0.7119). 14 each of eligible sbd and dbd patients donated organs (p=1.00); 43 organs were procured from each group (p=1.00). single brain death examination did not preclude the rate of organ donation in our patient cohort. dual brain death examination can be substituted by a single brain death examination along with a confirmatory test for cerebral blood flow in patients with catastrophic neurological injuries without affecting the rate of organ donation. this may result in a less time delay before declaring death and minimize physician workload. etiologies for spontaneous intracerebral hemorrhage (ich) or intraventricular hemorrhage (ivh) vary. mri can often identify underlying vascular lesions, but conventional catheter angiography remains the gold standard. guidelines for the use of catheter angiography are non-specific. we aimed to determine the diagnostic yield of catheter angiography in addition to mri in patients with ich or ivh who met pre-defined criteria. consecutive patients with spontaneous ich or ivh were enrolled. in addition to non-contrast brain ct and laboratory testing, all patients underwent gadolinium enhanced mri/mra. catheter angiography was pursued if the following criteria were met: 1. lobar ich or isolated ivh and age 65 years or 2. deep ich and no history of hypertension and age 45 years or 3. any other indication based on the opinion of the treating neurointensivist. of 160 prospectively enrolled patients, 58 (36%) met criteria for catheter angiography. seven were excluded from angiography because a definitive ich cause was established by mri and 2 because of a coagulopathy explaining the ich. forty-four (28%) patients underwent catheter angiography, which identified the ich etiology in 13 (30%). in 12 of these, the diagnosis was already suspected based on mri, but in 4 cases catheter angiography increased the diagnostic confidence. in one patient a small avm was diagnosed by angiography alone. thirteen patients (8%) had both contrast angiography and pathology. of these, 8 had a vascular abnormality as the cause of the ich. five of these were diagnosed by angiography. in one patient the pathology showed an avm while the angiogram and the mri were negative. two patients with cavernous malformations were diagnosed by mri alone. the diagnostic yield of catheter angiography in spontaneous ich or ivh is limited if patients also undergo gadolinium enhanced mri/mra. patients with anticoagulation-related intracerebral hemorrhage (ich) commonly are treated with fresh frozen plasma (ffp) for anticoagulation reversal. one risk of ffp is thought to be related to volume overload and pulmonary edema (ped). however, this has neither been validated, nor quantified compared with the natural risk following ich. we hypothesized that patients with anticoagulation-related ich are at higher risk of ped in-hospital, and that this increased risk would be related to dose of ffp used. retrospective review of a prospectively collected cohort of consecutive patients with primary ich presenting to a single center between august 1994-may 2006. of 989 included patients, 53% were male, and mean age was 73 +/-12 years. 22% were on warfarin at presentation, with a median inr of 2.7 (iqr 2.1-3.6). of these patients, 81% received ffp, at a median dose of 5 (iqr 3-8) units. overall, 78 patients (7.9%) developed ped, at a median time of 4 (iqr 1-8) days after presentation, and these patients showed a longer hospital length of stay [median 17 (iqr 11-31) days vs. 7 (iqr 4-12) days, p=0.001]. anticoagulated patients were at higher risk of developing ped during hospitalization (14% vs. 6%, p=0.001). patients receiving ffp were also at higher risk than those who did not (15% vs. 5%, p<0.001). in multivariable analysis with a cox proportional hazards model, use of ffp was an independent predictor of developing ped (hr 1.08 per unit given, 95% ci 1.04-1.13), and the effect of warfarin fell out of the analysis when ffp was included. patients with anticoagulation-related ich are at increased risk of ped during hospitalization, accounted for by ffp use. each additional unit of ffp confers an approximately 8% increased risk of this complication. ventilator associated pneumonia (vap) is an infrequently studied morbidity in neurointensive care, despite high historical rates ranging from12.8 to 27.4 infections per 1000 device days. in comparison, mean rates in medical icu's have been substantially lower: 7.3-7.5. in our neurocritical care unit (nccu), vap incidence was initially near the national nosocomial infection surveillance (nnis) 75 th percentile for neurosurgical icus (31.9 infections per 1000 ventilator days) necessitating an evidence-based performance improvement initiative to reduce vap rates. prospective surveillance study of vap incidence in a 22-bed nccu over a 10 month period. vap rates were defined by national healthcare safety network (nhsn) criteria. interventions included an aggressive hand hygiene campaign, use of the ventilator bundle, oral care every 4 hours, and introduction of the hi/lo endotracheal tube. ventilator bundle compliance was assessed. : 5281 patient days with a total of 2235 ventilator days were monitored. in september 2008, concomitant to an acinetobacter outbreak, vap rates were 30 infections per 1000 ventilator days. by january 2009, hand hygiene compliance had increased from 36 to 80% and rates were 25. following institution of frequent oral care in combination with the emphasized vap bundle, by may 2009, rates had decreased to 16. at this point, all new intubations performed in the unit employed the hi/lo ett. by june 2009, vap incidence decreased to 11.7 infections per 1000 ventilator days (< 10 th nnis percentile). compliance with components of the ventilator bundle ranged from 55% to 97%. despite caring for patients at high risk of vap, concerted efforts with multiple evidence-based performance measures and interventions can significantly reduce the incidence of infection. feedback with compliance may be essential to maintain low vap rates. the use of hmg-coa reductase inhibitors (statins) has increased among subarachnoid hemorrhage (sah) patients for cerebral vasospasm prophylaxis. statins increase risk of myopathy, but additional factors may also be causative. myopathy rates in this group of critically ill patients are not well characterized. sah patients were prospectively entered into an institutional database; those with myopathy were retrospectively identified. serum creatine kinase (ck), aldolase (at time of suspected myopathy diagnosis), and catecholamines (at admission), muscle biopsy results, and medication administration records were evaluated. four (3.7%) of 109 aneurysmal sah patients treated between jan 1, 2008 through july 31, 2009 were newly diagnosed with myopathy. two were hunt/hess 3, and 1 each: grade 4 and 5. one was fisher 3, others were fisher 4. all had symptomatic hydrocephalus, were treated endovascularly with paralysis paraprocedurally, given simvastatin 80mg daily within 24 hours of sah (none had prior statin use). all were insulin resistant, requiring high dose sliding scale insulin. two received steroids. all had elevated catecholamines. maximum ck levels (u/l) were 91, 208, 370, and 714, respectively. aldolase was checked and elevated in 3 patients. the forth underwent muscle biopsy revealing necrotic fibers; this patient had the lowest maximum ck. the myopathy rate in this cohort is 30 times higher than that reported in healthy patients treated with statins. since all sah patients did not receive statins, this rate is underestimated and much higher than reported in other trials evaluating statins in sah, assuming risk is solely attributable to statins. the contribution of other etiologic variables (critical illness, paralytic, steroid) is not clear, and potentially are additive. aldolase may be an additional means of identifying subclinical cases. these findings need to be confirmed and pathogenic factors better elucidated. neurocritical care is a relatively new discipline and its practitioners come from a variety of backgrounds. salaries are likely to differ based on primary appointment, geographic location, practice setting, and time spent on clinical effort. it is not known how many neurointensivists practice full-time critical care, and it is likely that many also have responsibilities as consultants, researchers and administrators. a survey will be emailed to all members of the neurocritical care society. information that will be collected regarding salary, icu directorship, primary appointment, practice setting, hospital type, geographic location, percent effort on clinical responsibilities, sources of income including salary incentives, patient population, board certification and subspecialty training, etc. the results will be reported at the meeting and compared to the previous survey done by the authors. the information gathered in this survey enhances the understanding of the current practice of neurocritical care throughout the united states. this data may be valuable to neurointensivists during contract negotiations, to hospital administrators trying to assess the feasibility of hiring a neurointensivist, and to neurologists-in-training as a way of generating interest in neurocritical care as a career choice. therapeutic hypothermia (th) is being implemented with an increase for multiple indications in the neuro-icu. the risk of developing renal dysfunction with th is thought to be low, but is not clearly defined in neurologic patients. retrospective chart review of prospectively identified patients. per institutional th protocol, patient's goal temperature was 33 0 c. baseline serum creatinine (cr) level and creatinine clearance (crcl) were obtained and followed at least daily during th and rewarming. data was evaluated for changes in cr and crcl during and following th induction and any impact these changes had on treatment. thirty five patients received th (for post-cardiac arrest and intracranial pressure control related to subarachnoid haemorrhage, intracerebral haemorrhage or traumatic brain injury). maintenance of goal temperature varied from 4 to 120 hours. nine (26%) had an increase in cr and crcl within normal limits; of these, 3 occurred following induction, 5 occurred during th maintenance, and 1 during rewarming. three (9%) patients had an elevation in cr above normal limits; all of these elevations arose after beginning rewarming, and none led to chronic renal failure. there was a direct relationship in the change in cr and crcl (p<0.0001). of the 3 patients who had an abnormal change in cr, 1 had an abnormal change in crcl. overall, 34% of the patients demonstrated some form of elevation in cr and decrease in crcl. no patient experienced clinically significant changes in renal function requiring changes in therapy. this cohort experienced changes in renal function that were not associated with clinical relevance. the majority of changes occurred during th or rewarming and were not chronic. any contribution of th induced muscle injury to cr changes would need to be assessed with future study. initial hematoma size, coagulopathy, and hypertension are recognized predictors of hematoma progression in intracerebral hemorrhage (ich). we aimed in our study to assess if the absolute number of wbc and/or increase in the wbc number within 24 hours of progression can predict hematoma progression. data of consecutive patients with primary, supratentorial ich, admitted within 24 h of onset were reviewed, identifying patients with progression (wp) and no progression (np). hematoma progression was defined as 30% increase of hematoma size, subsequent intraventricular bleeding or increase of the preexistent amount of intraventricular blood. we compared the two groups for demographic data, risk factors, admission neurological status, neurological deterioration occurence, and wbc, coagulation profile, and blood pressure (bp) at admission or within 24 hours of hematoma progression, using univariate and multivariate analysis. we identified 221 cases (np) and 45 (wp). baseline variables were similar, except for the systolic bp that was higher in wp than in np group (192 + 32 mmhg versus 181 + 28 mmhg, p=0.01). neither wbc at admission (9. 9 + 0.7 x 10 3 /mm3 versus 12. 3 + 1.6 x10 3 /mm 3 , p=0.17) nor the variation of the wbc admission -within 24 h of progression (0.78 + 1.87 x10 3 /mm3 versus 1.77 + 2.47 x 10 3 /mm3, p <0.15) was significantly different between the np and wp groups. neurological deterioration and mortality were more frequent in the wp than np group (60% versus 23%, p<0.0001; 38% versus 24 %, p=0.05 respectively). logistic regression showed that the change in wbc from admission to within 24 hours of progression and systolic bp were associated with hematoma progression (wald statistic 5.72, p<0.02; wald statistic 4.60, p <0.03). the variation of wbc within 24 hours of progression and systolic bp seem to be independent predictors of hematoma progression. heparin-induced thrombocytopenia (hit) is a dreaded complication of heparin related products. we analyzed the risk factors and outcomes of subarachnoid hemorrhage (sah) patients in whom hit was suspected and either confirmed as present or absent by platelet factor 4 (pf4) antibody test. all patients with presumed aneurysmal, non-traumatic sah and a pf4 test were identified through the massachusetts general hospital's research patient database. charts, laboratory values and images were analyzed retrospectively. we identified 166 patients with sah who were tested for hit. of these patients, 42 (25%) had a positive antibody test. there was no difference between mean platelet nadirs of hit+ and hit-patients, 147 93 vs. 153 86 th/mm 3 , respectively. univariate analysis identified gender, magnesium prophylaxis, fisher group 3, clipping vs. coiling, presence of angiographic spasm, number of vasospasm treatments and day of hit testing as potential risk factors associated with hit. a multivariate analysis showed that female gender (or 8.2, 95%ci 2.0-33.2), greater number of vasospasm treatments (or 1.5, 95%ci 1.2-2.0), later day of hit testing (or 1.2, 95% 1.1-1.3) increased the risk of hit and coiling reduced the risk compared to clipping (or 0.2, 95%ci 0.1-0.7). those patients in whom hit was present had more infarcts on ct, longer icu and hospital stays and worse modified rankin scores on discharge. the presence of hit in sah has adverse consequences and is more likely in female patients, who have undergone aneurysm clipping and require more than one endovascular vasospasm treatment. coagulopathy-associated intracerebral hemorrhage (cich) leads to over 50% mortality and is associated with secondary thromboembolic (te) complications. rapid coagulopathy reversal improves cich outcome. activated factor viia (fviia) rapidly reverses coagulopathy and causes local hemostasis, but is associated increased te. we examine a large case series of cich patients treated with fviia to determine te rates in this population all cich patients are treated with standardized protocol with emergent intravenous vitamin k, fresh frozen plasma (ffp), and are eligible for fviia 40 mcg/kg. we identified consecutive fviia-treated cich patients from database from 2003-2008 and identified 80 patients. 12 were excluded for no identifiable coagulopathy or fviia use for severe trauma. 68 were analyzed. we collect data on diagnosis, coagulopathy etiology, history of ischemic heart disease (cad) and te. we examined the incidence of troponin elevation, ekg changes, symptomatic coronary ischemia, venous thrombosis, and stroke following fviia use. subjects had average age 67.4 years. over 80% had abnormal ekg on presentation. 18% fviia-treated cich patients had history of venous thrombosis (dvt) or pulmonary embolism (pe), 25% had cad, 51% had atrial fibrillation, and 18% stroke. troponin elevation above 1.0ng/ml developed in 16% patients. only 1/68 patients developed clinically symptomatic cardiac ischemia. 6% developed dvt/pe, and 1/68 (1.5%) developed ischemic stroke. there is a trend towards correlation of cad history with degree of troponin elevation (p=0.55). coagulopathy-associated ich patients have high burden of prior ischemic heart disease and venous thromboembolism. though low level troponin elevations occur, incidence of fviia-related symptomatic cardiac ischemia, stroke, or venous thrombosis is low in fviia-treated cich patients. this low incidence justifies a prospective controlled study to evaluate risk versus benefit of fviia use for emergent coagulopathy reversal in cich. assessing neurological function is important in critical illness, but in sedated patients neurological examination is considered to be non interpretable. this prospective multicentre observational study assessed neurological responses in critically ill patients who required to be sedated with midazolam (± subfentanyl). their relationship with 28-day mortality and altered mental status (delirium or coma within three days after sedation discontinuation) was also assessed. daily neurological examination included the glasgow coma scale, the assessment to intensive care environment score (atice), eye position and movement, pupil size and response to light, corneal reflex, oculocephalic response, grimace to noxious stimuli and cough reflex. at awakening, mental status was assessed with using atice or confusion assessment method for the icu ( neurological examination is interpretable and may be useful for prediction of outcome of critically ill sedated patients. daniel evans 3 , gail tudor 2 , deborah cushing 1 , jeffrey florman 1 , david seder 1 1 maine medical center, portland, me, united states, 2 husson college, bangor, me, united states, 3 we evaluated complication rates, outcomes, and the cost of care of patients with good-grade (hunt and hess grades i-iii) aneurismal subarachnoid hemorrhage (ggsah) admitted directly to an intermediate care unit (imc). retrospective chart review of all ggsah admitted to a tertiary referral center from 2000 to 2008. we recorded demographics, vital signs, and pertinent aspects of the hospital course. a multivariate logistic regression model including hunt and hess grade was employed to evaluate for association between admission location and radiographic or clinical vasospasm or infarction. among 139 ggsah admissions to imc or the intensive care unit (icu), mortality was 6.5%. thirty-three grade i patients (60%), 15 grade ii patients (31%), and 4 grade iii patients (11%) were admitted directly to imc. none of these patients died, and 2 (4%) suffered cerebral infarction. factors associated with imc admission were lower hh grade (p<0.001), gcs of 15 (p<0.001), and no ventricular drain placement (p=.013). age, medical comorbidities, and clipping vs. coiling were not associated with admission location. eight patients (15%) admitted to imc were subsequently transferred to icu. patients admitted to icu were more likely to die (10% vs. 0%, p=.015), to suffer respiratory failure (24% vs 4%, p=.002), and fever (47% vs 19%, p=.001). in multivariate logistic regression, imc admission was unrelated to vasospasm or infarction. admission to icu was associated with higher median patient charges ($92,346.47 vs. $64,286.04, p<0.001). we found no evidence that imc admission (primarily among hunt and hess i and ii patients) was associated with increased morbidity, and the in-hospital mortality rate of imc admissions over 8 years was zero. given the higher cost of care among patients admitted to icu, it may be appropriate to consider imc admission for selected patients. wei xiong, matthew koenig, xiaoxu kang, xiaofeng jia, adrian puttgen, nitish thakor, romeryko geocadin johns hopkins university, baltimore, md, united states neurologic injury from cardiac arrest (ca) continues to be a significant problem, in part due to the lack of real-time monitoring of brain injury and recovery. somatosensory evoked potentials (sep) are a reliable marker of poor outcome because they are relatively resistant to physiologic and therapeutic perturbations. we tested the hypothesis that early recovery of cortical sep would be associated with better outcome after resuscitation from ca. sixteen adult male wistar rats were subjected to asphyxial cardiac arrest. half underwent 7 mins of asphyxia (group ca7) and half underwent 9 mins (group ca9). continuous seps from median nerve stimulation were recorded from these rats for 4 hours immediately following ca. additional serial seps were recorded at 24, 48, and 72 hours after ca. clinical recovery was evaluated using the neurologic deficit scale (0 -80, normal = 80), which was performed at 24, 28, and 72 hours after ca (primary outcome measure). all rats in group ca7 survived to 72 hours, while only 4 rats in group ca9 survived to that time. mean nds values in the ca7 group at 24, 48, and 72 hours after ca were 58.6, 61.6, and 63.5; while in group ca9, they were 41.3 (pvalue 0.001), 51.0 (p-value 0.024), and 54.5 (p-value 0.101), respectively. the n10 (first negative peak at approximately 10 ms) amplitude differed significantly between the two groups within 1 hour after ca. rats that suffered longer ca durations showed later recovery of n10. the n10 latency was similar between the two groups. although early recovery of n10 showed a trend towards better 72-hour nds scores, this was not significant. a smaller n7 peak was consistently observed to recover earlier in all rats, which may represent the thalamic component of sep. the delayed recovery of n10 is associated with longer ca times in rats. early recovery of n10 shows a trend towards better outcomes. n7, which may represent thalamic activity, reappears much earlier than cortical responses (n10), suggesting thalamocortical desynchrony in early recovery. sep after ca is a dynamic and promising tool to monitor early neurologic recovery after ca. evidence suggests a role for inflammation in vasospasm after subarachnoid hemorrhage (sah). recent studies suggest that systemic inflammation may lead to vasospasm. to test the hypothesis that systemic inflammation worsens vasospasm we evaluated the effect of lps on vasospasm. c57bl/6j mice received either 150 ug/animal lps i.p., or saline. 24 hours later, animals had either sah induction or sham surgery. in a separate group, neutrophils were depleted prior to lps administration. to test whether neutrophils in the csf from the sah are required for vasospasm, we injected blood from lps-sensitized, neutrophil-depleted mice to the csf of lps-sensitized, non-depleted mice and the converse (adoption studies). at 24 hours post injection, animals were perfused with saline, formalin and india ink, and the brains were removed for quantitative evaluation of basal cerebral vasculature for vasospasm. the mean differences in diameter of mca segments at 1 mm distal to bifurcation were compared. a separate set of animals were perfused with saline and formalin for immunohistochemical staining of neutrophils and microglia. in saline-injected animals with sah, the mean vessel diameter was significantly smaller compared to the salineinjected sham group. there was no difference in the means of vessel diameter between saline-or lps-injected sham groups. lps injection in the animals with sah exacerbated the vasospasm. neutrophil depletion prior to lps ameliorated vasospasm. neutrophil extravasation into the brain and microglial activation was increased in the lps group compared to controls but was reversed by neutrophil depletion. in the adoption studies, depletion of neutrophils in the csf blood ameliorates vasospasm but neutrophil depletion in the systemic circulation did not. systemic inflammation induced by lps exacerbates vasospasm. the effect is reversed by neutrophil depletion in the csf. this suggests that inflammation in the brain is a more important contributor than systemic inflammation in vasospasm. malnutrition in the intensive care setting is associated with increase mortality presumably secondary to increased infections. acute ischemic and hemorrhagic stroke patients in the icu often experience a delay of enteral nutrition due to delays in swallowing evaluation and diagnostic procedures that require a period of food abstinence. serum albumin levels are often used as markers for malnutrition. this study was retrospective analysis of patients admitted from january/december 2006 with the diagnosis of ischemic or hemorrhagic stroke. the goal of the study was to determine the association between albumin levels less than 3.5mg/l during the first 48 hours of icu admission and mortality. t-tests were used to identify significant difference between means. chi-square tests were used to examine the distribution of categorical variables across discharge statuses. after identifying variables that were significantly different, a logistic model was built to determine if admission day albumin levels are independently associated with mortality. there was no difference in mean serum albumin levels between non-survivors (3.6mg/l) or survivors (3.7mg/l (p=0.1089)). there was no difference between non-survivors and survivors in day 3 albumin levels or in the change from day 1 to day 3. a logistic model controlling for age and dyslipidemia (factors significantly or marginally significantly elevated in non-survivors) showed that admission day albumin was not an independent predictor of outcome. in our study, there was no correlation between serum albumin levels and mortality. we did not analyze the incidence of infections in this study population. this study validates the may 2009 critical care medicine guidelines on nutrition support in the icu. they concluded that albumin was not a valid nutrition assessment tool in the icu. future studies should examine the relationship between hypoalbuminemia, prealbumin levels and the incidence of infections in the stroke patient population. tnf-is an inflammatory cytokine that plays a central role in promoting the cascade of events leading to an inflammatory response. recent studies have suggested that tnf-may play a key role in the formation and rupture of cerebral aneurysms, and that the underlying cerebral inflammatory response is a major determinate of outcome following subrarachnoid hemorrhage (sah). we studied 14 comatose sah patients who underwent multimodality neuromonitoring with intracranial pressure (icp), cerebral microdialysis, and brain tissue oxygen (pbto 2 ) as part of their clinical care. continuous physiological variables were time-locked every 8 hours and recorded at the same point that brain interstitial fluid tnf-was measured in brain microdialysis samples. significant associations were determined using generalized estimation equations. each patient had a mean of 9 brain tissue tnf-measurements obtained over an average of 72 hours of monitoring. tnf-levels rose progressively over time. predictors of elevated brain interstitial tnf-included higher brain interstitial fluid glucose levels ( =0.066, p<0.02), intraventricular hemorrhage ( =0.085, p<0.021), and aneurysm size >6 mm ( =0.14, p<0.001). there was no relationship between tnf-levels and the burden of cisternal sah; concurrent measurements of serum glucose, or lactate-pyruvate ratio. brain interstitial tnf-levels are elevated after sah, and are associated with large aneurysm size, the burden of intraventricular blood, and elevation brain interstitial glucose levels. experimental studies have demonstrated that tumor necrosis factor-(tnf-) plays a crucial role in the onset of hemolysis-induced vascular injury and cerebral vasoconstriction [1] . we hypothesized that tnf-measured from brain interstitial fluid would correlate with the severity of vasospasm following aneurysmal subarachnoid hemorrhage (asah). from a consecutive series of 10 asah patients who underwent cerebral microdialysis (md) and evaluation of vasospasm by computed tomographic angiogram (cta) or digital subtraction angiography (dsa), tnf-levels from md were measured at 8 hour intervals from sah days 4-6 using enzyme-linked immunosorbent assay (elisa). a blinded attending neuroradiologist independently evaluated each cta and dsa and assigned a vasospasm index (vi). five patients had vi<2 and 5 patients had a vi>2, where the median vi was 2 (range 0-18). median log tnf-area under the curve (auc) was 1.64 (pg/ml)*day (interquartile range 1.48-1.71) for the vi<2 group, and 2.11 (pg/ml)*day (interquartile range 1.95-2.47) for the >=2 group (p<0.01). in this small series of poor-grade asah patients, the area under the curve of tnf-levels from sah days 4-6 correlates with severity of radiographic vasospasm. further analysis in a larger population is warranted based on our preliminary findings. mild therapeutic hypothermia (th, 32-34ºc) reduces mortality and improves neurologic outcomes after ventricular fibrillation cardiac arrest (ca). the relationship between time to achieve th and outcomes remains undefined. we hypothesized that a shorter interval from ca to achieve th would be associated with improved neurologic outcome. we retrospectively reviewed all subjects with in-or out-of-hospital ca treated with th between november 2006 and april 2009 at our institution. the time to target temperature was defined as the interval between witnessed ca and first measurement of hypothermia ( 34 ºc) and further categorized as early (< 6 hours) or delayed (> 6 hours). outcomes were assessed at the time of death or discharge by the cerebral performance category score (cpc). good neurologic outcome was defined as cpc 1 or 2. fisher's exact test was used to assess the univariate relationship between time to target temperature and neurological outcome. 33 patients were treated with th after in-hospital (39%) and out-of-hospital (61%) ca. subjects that did not reach target temperature or with unwitnessed ca were excluded. of the remaining patients, 42% (11/26) survived to discharge and 35% (9/26) achieved a good neurologic outcome. five patients (5/26) reached early target temperature; 80% (4/5) of those had a good neurological outcome. 24% (5/21) of subjects with delayed target temperature achieved a good neurological outcome. the univariate relationship between time to target temperature and neurological outcome was statistically significant (p=0.034). attaining th within 6 hours of in-or out-of-hospital ca is associated with a greater likelihood of a good neurological outcome at discharge. time from ca to achieved th should be included as a clinically important covariate in future studies of predictors of outcome after ca. cerebral autoregulation tests have gained importance for the assessment of patients with a variety of brain disorders. in critically ill patients, testing of dynamic autoregulation is safe and practical, but the ability to respond to steady state change in blood pressure is probably more clinically relevant. the purpose of this study was to compare static autoregulation testing with two different dynamic autoregulation tests (cuff deflation and carotid compression tests) in patients with severe traumatic brain injury. twenty-two studies were performed in 21 tbi patients. changes in middle cerebral artery flow velocity (mcafv) were observed by transcranial doppler. static autoregulatory index (sari) was determined from the steady-state response of mcafv to phenylephrine-induced rise in blood pressure. dynamic autoregulatory index (dari) was determined by the cuff deflation method as described by aaslid (1989) and the transient hyperemic response ratio (thrr) was calculated as described by smielewski (1996) . these dynamic tests were performed in triplicate at baseline prior to inducing hypertension with phenylephrine, and the 3 values were averaged to give a single index value. since the anatomy of the brain injury varied from patient to patient, the autoregulatory indices were summarized for the worst and best sides of the brain based on the appearance of the initial ct scan. the sari averaged 36.7+23.2 on the side of the brain that was more injured, and 35.9+14.8 on the less injured side. thrr was closely correlated with the sari, both on the side that was more injured (r=.637, p=.011) and on the less injured side (r=.647, p=.005). the dari was significantly correlated with sari only on the side that was more injured (r=.615, p=.004). these data suggest the ability of dynamic autoregulation to predict static autoregulation may vary with the type of test chosen. published guidelines from the american society for gastrointestinal endoscopy considers peg tube placement a high-risk procedure for bleeding and recommends discontinuation of clopidogrel, 7 to 10 days before peg placement. unfortunately the perioperative time period is associated with increased ischemic events, length of stay (los) in the hospital and resource consumption. this is a retrospective review of prospectively collected data that sought to examine the safety of peg tube placement in patients while on clopidogrel alone or in combination with aspirin. 10 patients admitted into our neuro-icu who met the set criteria during the period january 2008 to july 2009 were included in the study. mean duration on antiplatelet therapy prior to peg placement was 7 days. one patient had a new stroke during hospitalization, unrelated to the procedure. no post-operative complications, bleeding or neurologic changes were noted in any of the patients. relevant blood indices remained largely unchanged. although peg tube placement is considered a high-risk procedure for bleeding, in the absence of pre-existing bleeding disorder it may be safe to perform this procedure in patients taking clopidogrel. there may be no need to consider reversion to aspirin alone, in those on combination therapy. timely placement of peg tubes in this subgroup of patients may reduce their los and decrease the risk of new ischemic events. introduction: hunt and hess grade 5 sah is accompanied by high rates of mortality and severe disability. mortality in these patients is driven by withdrawal or limitation of care. some patients do enjoy good functional outcomes. we seek to describe the frequency and predictive factors for good outcome following grade 5 sah. we will also describe risk factors for limitation of care following grade 5 sah. we identified 171 consecutive patients with sah and worst hunt and hess grade of 5 within 24 hours of admission (mean age 58 years; 67% female) in a prospectively collected registry of 1154 aneurysmal sah patients. the frequency of good outcome (modified rankin 0 through 3) at 12 months was calculated. we performed univariate analysis of pre-admission and admission characteristics to identify associations with good outcome. independent risk factors were identified through multiple logistic regression analyses. we performed a multivariate analysis of risk factors for limitation of care. good functional outcome occurred in 25 (15%) of patients. white ethnicity (or5.1 95%ci1.5-17.2), employment at the time of sah (or4.5 95%ci1.1-19.1), lack of limitation of care (or40.5 95%ci4.9-337.2), and normal papillary reactivity on admission (or5.8 95%ci1.5-23.1) were independently associated with good outcome. in a subgroup of 77 patients in whom care was not limited, 24 (31%) had good outcomes; white ethnicity(or6.3 95%ci1.8-21.8), employment status(or13 95%ci2.7-63.1), and absence of fever(or6.5 95%ci1.4-30.7) independently predicted good outcome. among patient characteristics analyzed, admission gcs(p<0.01) predicted limitation in care. a substantial proportion of patients with grade 5 sah who receive full medical support enjoy a good recovery at 12 months. age, pre-morbid co-morbidity, and clinical and radiographic measures of hemorrhage severity do not predict good outcome in our study, but socioeconomic factors may. intracerebral hemorrhage (ich) is the most lethal type of stroke. hypertensive ich (hich) is the most frequent ich subtype. we aimed to evaluate predictors of 30-day mortality after hich. retrospective cohort. this study was approved by our irb. we found 64 patients with hich amongst patients admitted to our hospital from july 2004 to june 2007. mortality was 18% (n = 12). thirty-two patients (50%) were male, and 53 (82%) were black. mean age was 52 ± 12 years (4 patients were 80 years). initial pulse pressure 79 ± 28 mm hg, and mean gcs score was 11 ± 4. mean ich volume was 30 ml (range, 0.1 to 253 ml) measured on first head ct scan with the use of the abc/2 method, and 26 patients (40%) had intraventricular hemorrhage (ivh). fifty-five patients (86%) had supra-and 9 patients had infra-tentorial ich. the mean ich score (hemphill, et al. stroke. 2001;32:891-897) was 1.3 points (range, 0 to 5 points). one of 25 patients with ich score of 0, and 7 patients with scores of 4 or 5 died. in univariable logistic regression modeling, all independent predictors used to develop the ich score, except age 80 years (p = 0.7419), were associated with 30day mortality: initial gcs (p = 0.0001), ich volume (p = 0.0014), ivh (p = 0.0036), and infra-tentorial ich (p = 0.0197), and the ich score (p = 0.0003) accurately predicted mortality at 30 days. in multivariable logistic regression analysis, only gcs alone was predictive of 30-day mortality. the roc/auc analysis demonstrated that gcs was a powerful predictor of mortality with an auc = 0.91. gcs 8 was the most powerful predictor of mortality. our study suggests that gcs 8 is a powerful predictor of 30-day mortality after hich. further research is warranted. pneumocephalus is found in 66% of postcraniotomy computed tomographies of the head (ctoh) and is considered a benign complication of surgery. occasionally, however, it may lead to lethargy, headache and, if under tension, signs of elevated intracranial pressure or brain herniation. high percentage supplemental oxygen is frequently used as a treatment, but data regarding its effectiveness are very limited. postcraniotomy patients admitted to the neuro-intensive care unit with pneumocephalus received 100% fio2 on-off every 3 hours for at least 24 hours (treatment subgroup). during the off period, this subgroup, as well as the controls remained on room air (or 30% fio2 if mechanically ventilated). the assignment to each subgroup was based on the neurosurgeon's preference. the intracranial air volume on the ctoh was measured before and after the intervention via an image j analysis package. twenty-two treated patients and 11 controls (mean age 62 and 60 years, 41 and 55% women, respectively) were identified. the most common diagnoses were subdural hematoma (in 32% vs 27% for the treatment and control subgroups, respectively) and tumor (27% in both). there was no difference in the number of ventilated patients or in those with external ventricular drainages, in the lapsed period between the initial and final ctoh and the initial and final volume of air between the two subgroups. the percentage of air volume change (after adjustment for the lapsed time) and the rate of air absorption were significantly higher in the treated group (71 23% vs 45 35%, p = 0.013 and 2.6 1.97%/hour vs 1.25 0.8%/hour, p = 0.007, respectively). this pilot study suggests that intermittent oxygen administration in patients with craniotomy decreases the pneumocephalus volume and increases the rate of intracranial air absorption. in a recent publication (wijdicks et al. neurology. 2008 oct 14;71(16):1240-4), the safety of apnea testing in the declaration of brain death was evaluated at a single tertiary care center. one major conclusion was that apnea testing was safe in hemodynamically compromised patients in most circumstances and rarely aborted. determinants of apnea test completion failure are unknown. we calculated the alveolar-arterial oxygenation gradients (a-a gradient) in the previously studied cohort. arterial blood gas values were obtained prior to the initiation of apnea testing. patients that completed the procedure during the declaration of brain death were compared to those whose studies were aborted. statistical analysis was performed using nonparametric wilcoxon rank-sum test. of the original 228 patients studied, a-a gradients were calculated for 205 patients. seven of these patients had aborted apnea testing because of hypoxemia and/or hypotension. seventy-nine percent of patients that completed apnea testing had gradients larger than 100 mm hg compared to 86% in those whose study was aborted, 21% versus 71% with gradients greater than 300 mm hg, and 9% versus 43% with gradients greater than 400 mm hg. the a-a gradient median values for completed and aborted apnea tests were 183 mm hg (range: -150 -620) and 325 mm hg (range: 80 -561), respectively (p value= 0.038). the apnea test can be performed safely in most hemodynamically compromised individuals with large a-a gradients undergoing brain death evaluation. a larger percentage of patients that failed completion of apnea testing had significantly greater a-a gradients. predicting apnea test failure with this respiratory parameter warrants further validation in a larger population. cerebral glucose metabolism and energy production are affected by serum glucose levels. the objective of this study was to assess whether serum glucose variability and the ratio of cerebral-to-serum glucose are associated with cerebral metabolic distress and outcome after severe brain injury retrospective cohort study conducted in a neurological intensive care unit of a university hospital. we studied 46 consecutive comatose patients with subarachnoid or intracerebral hemorrhage, traumatic brain injury, or cardiac arrest who underwent cerebral microdialysis and intracranial pressure monitoring.continuous insulin infusion was used to maintain target serum glucose levels of 80-120 mg/dl. general linear models of logistic function utilizing generalized estimating equations were used to relate these predictor variables to cerebral metabolic distress (defined as a lactate/pyruvate ratio [lpr] 40) and mortality. the ratio of brain-to-serum glucose was calculated every 1 to 2 hours. daily serum glucose variability was expressed as the standard deviation (sd), mean amplitude glycemic excursion (mage), and glycemic lability index (gli) of all serum glucose measurements. a total of 5187 neuromonitoring hours and 300 days were analyzed. after adjustment for glasgow coma scale scores, cerebral perfusion pressure, and serum glucose levels, brain/serum glucose ratios below the median (0.12) were independently associated with increased risk of metabolic distress (adjusted or=1.4 [1.2 -1.7], p<0.001). increased serum glucose variability was also independently associated with higher risk of cerebral metabolic distress (adjusted or=1.7 [1.3 -2.4], p<0.001 for sd and adjusted or=1.2 [1.02 -1.4], p=0.03 for mage). low brain/serum glucose ratios and all three measures of increased serum glucose variability were also independently associated with in hospital mortality after adjusting for age and apache-ii scores (all p 0.03) reduced brain/serum glucose ratios and increased serum glucose variability are associated with cerebral metabolic distress and increased hospital mortality after severe brain injury. in critically-ill neurological patients, cerebral perfusion may be optimized by manipulating cerebral perfusion pressure and cardiac output. the objective of this study was to investigate the relationship between cardiac output (co) response to a fluid challenge and changes in brain tissue oxygen pressure (pbto2) in patients with severe brain injury prospective observational study conducted in a neurological intensive care unit of a university hospital. normal saline (500ml) or albumin 5% (250ml) boluses were given according to a standardized fluid management protocol. the relationship between co and pbto2 was analyzed using generalized estimating equations with an exchangeable correlation structure we studied 78 fluid challenges administered to 17 consecutive comatose patients that underwent multimodality monitoring with co, intracranial pressure (icp), and pbto2. diagnoses included subarachnoid hemorrhage (n=10), intracerebral hemorrhage (n=3), cardiac arrest (n=2), traumatic brain injury and status epilepticus (n=1 each). of the 78 fluid boluses analyzed, 34 (44%) resulted in a 10% increase in co. median absolute (+5.4vs+0.7 mmhg) and percent (20% vs 3%) changes in pbto2 were greater in co responders than in non-responders. in a multivariable model, a co response was independently associated with pbto2 response (adjusted or 15.4, 95%ci 1.9-122.0, p=0.01) after adjusting for mean arterial pressure, icp and end-tidal co2. stroke volume variation showed a good ability to predict co response with an area under the roc curve of 0.85 and a best cutoff value of 8%. bolus fluid resuscitation resulting in augmentation of co can improve cerebral oxygenation after severe brain injury little current data exists regarding outcome, cost and length of stay after subdural hemorrhage (sdh). we sought to examine predictors of discharge disposition, icu and hospital length of stay (los) and direct, indirect, icu, surgical and imaging charges for sdh. a retrospective review was conducted of acute, chronic and subacute sdh patients, aged >18 years admitted to our hospital between 2001-2008. disposition was characterized as dead or poor (discharged to a nursing home, hospice, subacute or chronic care facility). multivariable logistic regression analysis was performed to identify predictors of each outcome variable. of 216 sdh patients, the median age was 73.5 (19-95), and the median admission glasgow coma scale (gcs) was 14 (3) (4) (5) (6) (7) (8) (9) (10) (11) (12) (13) (14) (15) . the sdh was characterized as acute in 65 (36%), subacute in 77 (44%), chronic in 22 (13%) and acute, subacute and chronic in 12 (7%). craniotomy was performed in 108 (50%) of patients, burrhole drainage in 22 (10%) of patients and both in 9 (4%) of patients. death occurred in 29 (13%) of patients and poor outcome in 66 (31%). significant predictors of death or poor outcome included age, admission gcs and hospital los (all p<0.05). surgery was protective against poor outcome (odds ratio [or] 0.3, 95% confidence interval [ci] 0.1-0.8, p=0.010). median hospital los was 8 (1-99) days and median icu los was 3 (0-70) days. both were associated with gcs (all p<0.05). median total direct charges for hospitalization were $11,106 ($686-$172,556). icu and hospital los were significant predictors of direct charges, overhead, imaging and surgical charges (all p<0.001). herniation, sdh thickness, type of sdh, type of surgery and gender did not predict discharge disposition, cost or los. despite good admission neurological status, death or poor discharge outcome is common after sdh. though surgery mitigates against poor discharge disposition, los and charges remain high. sathees thayapararajah, bryan young, irene gulka, ahmed al-amri, sujit das lhsc, university of western ontario, london, on, canada introduction: acute fulminant hepatic failure (afhf) is common in tertiary care centers with transplant facilities. cerebral edema frequently threatens the lives of such patients. we reviewed 25 cases of afhf in the neuroicu, noting the incidence of cerebral edema with ct scans and factors associated with mortality. patients were captured through hmri classification of acute liver/hepatic failure. chart review included tabulation of: demographics, inr; serum bilirubin, creatinine, albumin; in-hospital mortality. ct scans were re-read with blinding to clinical information and catalogued for changes in sulcal markings, ventricular size and gray-white differentiation (gwd). inclusion criteria: age greater than 12 years, encephalopathy, hepatic failure within 8 weeks of onset of liver disease, ct scans of head performed. acetaminophen toxicity was the most common etiology (9 cases). twelve patients had cerebral edema on ct, including 8 of the 9 with acetaminophen toxicity. decreases in sulcal markings and ventricular size preceded conspicuous alterations in gwd. fourteen died, including all 12 with cerebral edema. none of the hematological or biochemical variables correlated significantly with mortality. acetaminophen toxicity is a common cause of afhf; this combination has a strong association with cerebral edema. early development of cerebral edema occurs in almost all the afhf cases with acetaminophen overdose and can be detected in its early stages. this facilitates management for prevention of fatal brain herniation. afhf patients develop the changes on brain parenchyma within 24 hours of onset of symptoms, during grade i-ii encephalopathy, most strikingly with aod. levetiracetam is increasingly being considered for seizure prophylaxis following tbi. although its acquisition cost is higher than phenytoin, the complete cost of therapy remains unknown as levetiracetam does not require therapeutic drug monitoring and has less pharmacokinetic variability. we developed a cost-minimization model to compare total costs associated with phenytoin and levetiracetam when used for seizure prophylaxis following tbi. five scenarios were tested based on drug, initial method of administration (iv vs. po) and whether or not po conversion occurred. factors considered in the analysis were drug costs, monitoring costs and likelihood of achieving a therapeutic concentration. treatment duration consisted of 7 days. for arms that included po transition, po therapy began after day 2. decision trees were developed and a single-payoff method was used to identify the least costly scenario. hospital acquisition costs using 2008 us dollars were used to assess all costs. the scenario associated with the lowest cost was iv phenytoin followed by po levetiracetam ($109/patient). this was followed by iv levetiracetam transitioned to po levetiracetam ($142), iv phenytoin transitioned to po phenytoin ($152), iv phenytoin ($161) and iv levetiracetam ($397). the factor associated with the most variability in the model was timing of po transition. a two-way sensitivity analysis which altered timing of po transition revealed iv phenytoin followed by po levetiracetam as the least costly scenario except when iv to po transition occurred after day 1. in this scenario, iv levetiracetam followed by po levetiracetam was preferred. iv phenytoin followed by po levetiracetam will result in the lowest overall cost when used for a total 7-day course in patients with tbi. this illustrates the importance of considering all costs associated with a therapy when evaluating the total cost of medication therapy. the joint commission accreditation standards require hospitals to develop policies which address donation after cardiac death (dcd). optn/unos published the "model elements" for dcd protocols that describe suitable dcd candidates to primarily have "non-recoverable and irreversible neurological injury" resulting in ventilator dependency; a description we suspected to be highly inaccurate. we sought to more accurately clinically characterize those considered dcd eligible to facilitate constructive improvement of relevant policies and processes. local opo quarterly audits over 27 months identified 49 patients who were considered eligible for dcd and died within the requisite 90 minutes of treatment withdrawal (dcdep). all cases were reviewed to determine the frequency/nature of any neurological abnormalities and whether they were "non-recoverable and irreversible." we also characterized the mechanism of respiratory failure and death. 27 (55%) of dcdep had an identified neurological injury. only 10/49 (20%) had "non-recoverable and irreversible neurological injuries. 25/49 (51%) of dcdep were seen by a neuro-specialist, and 23/49 (47%) had brain imaging. 9/49 (18%) had a neurological injury that could compromise ventilatory drive, and at least 6/49 (12%) died of airway compromise with variable approaches to palliative care regarding sedation and oral airway usage. 1. 45% of dcdep had no neurologic injury. 2. only 9 patients (18%) had neurologic injuries that could be correctly characterized as "non recoverable and irreversible" leading to "ventilatory dependency." 3. airway compromise is an important cause of death in dcdep and demands better uniformity of palliative care to assure equivalent treatment of dying patients independent of "donor status." 4. the published "model elements" for dcd protocols do not accurately represent the patient population. ventilator-associated pneumonia (vap) is the most common nosocomial infection among medical intensive care unit (icu) patients and associated with increased mortality and length of stay (los). neurologic disease is a risk factor for vap development, but the relationship between vap and outcomes in neurologic patients remains largely unknown. all mechanically-ventilated patients over a two-year period with neurovascular disease were included. data collected included patient demographics, dates of admission and discharge, los, and ventilator hours. vap was defined using standard published criteria. comparisons between neurologic patients who did and did not develop vap were made using univariate and multivariate analysis. of 585 intubated neurovascular patients, 24 (4.1%) developed vap. compared with those who did not develop vap, those with vap were younger (51.8 ± 13.9 versus 58.8 ±15.9, p=0.03), had increased los (32.6 ± 29.2 days versus 14.5 ± 7.8, p<0.001), and more ventilator hours (272 ± 257 versus 85.9 ±140, p<0.001). there was no difference in mortality between patients with and without vap (25.0% versus 28.3%, p=0.72). vap was not an independent predictor of mortality in a multivariate model (or 1.11, p=0.855). subsequent case-control analysis of patients with and without vap demonstrated an increase in transports for cross-sectional head imaging (6.8 transports versus 4.9, p=0.03). vap in neurocritical care patients is associated with increased los and ventilator hours, but does not lead to increased mortality, contrary to prior studies in medical icu patients. the significance and frequency of vap in neurologic patients is different from patients in other icus because reasons for intubation vary. neurologic patients with vap have more imaging-related transports compared to controls, suggesting an association with ventilator disconnections. 3 introduction: ich causes the highest mortality of all strokes. admission to a neuro-icu has been associated with reduced mortality following ich. this is leading to several hospitals routinely transferring ich patients to hospitals with neuro-icus. however, delays in optimizing management prior to and during transfer often leads to deleterious consequences. our objective was to compare functional outcomes in ich patients admitted to our neuro-icu directly from our ed with inter-hospital transfer admissions. records of consecutive spontaneous supratentorial ich patients admitted to our neuro-icu were reviewed. patients with ich related to trauma or underlying lesions (brain tumors, aneurysms, avm) were excluded. we compared outcomes at discharge in patients admitted directly from our ed and inter-hospital transfers (iht) using dichotomized modified rankin scale. other factors potentially impacting outcomes such as age, ich volume, ivh volume and admission gcs were included in the multiple logistic regression analysis. 125 patients were included in the analysis (ed 61.6%; iht 38.4%). there were no significant differences between the 2 groups in mean age (ed 63.4 +/-13.1; iht 63.4 +/-15.2, p 0.96), ich volume (ed 31.4 +/-37.6; iht 33.5 +/-42.8, p 0.76), ivh volume (ed 6.0 +/-11.2; iht 8.0 +/-14.5, p 0.38) and gcs (ed 11.3 +/-3.7, iht 10.9 +/-3.5; p 0.44). 57.2% ed patients had good outcomes at discharge compared to 37.5% iht. this difference was statistically significant following univariate (p=0.034, 95% ci=0.2151-0.9416) and multivariate analysis (p=0.028, 95% ci=0.1338-0.8896). odds (adjusted) of ed admissions having good outcomes was 3 times higher than inter-hospital transfers. ich patients brought to the neuro-icu directly from our ed had significantly better outcomes than inter-hospital transfers. although this could possibly be caused by delays in optimizing ich management, other equally plausible hypotheses need to be prospectively tested. isis duran, storm liebling, michael moore, andrew naidech northwestern university, chicago, united states hospital acquired pneumonia (hap) is a significant cause of morbidity and mortality. hap increases costs, impacts quality metrics and will soon be designated as a medicare "never event". the us centers for disease control have published standard guidelines for the diagnosis of pneumonia, but few confirmatory data exist. we sought to determine the inter-rater reliability of diagnosing pneumonia by cdc criteria in patients admitted for brain hemorrhage. patients with intraparenchymal or subarachnoid hemorrhage admitted to our neuro/spine icu in 2007 were included in this irb-approved study. utilizing cdc criteria, pneumonia was diagnosed prospectively by a neurointensivist and institutional infection control (ic) personnel. following a thorough review of the electronic medical records, chest radiographs, and microbiology results, a neurocritical care fellow and a pulmonary critical care attending physician made an independent retrospective assessment of the diagnosis. analysis of the inter-rater reliability of the diagnosis of pneumonia was performed using kappa statistics. one hundred three patients were identified. the male:female ratio was 42:61. pneumonia was diagnosed in 5 patients by ic personnel, 10 by the neurointensivist, 24 by the fellow, and 26 by the pulmonologist. overall inter-rater reliability was poor, with a median kappa value of 0.22 [0.13-0.44]. the highest inter-rater agreement was between the fellow and the pulmonologist (kappa=0.58), while the lowest was between the pulmonologist and ic personnel (kappa=0.05). the diagnosis of hap by cdc criteria, despite highly trained reviewers and clear diagnostic criteria, had poor interrater reliability in a sample of high risk patients. the diagnosis of hap should not be a measure of quality of care, nor should it be used as a determinant of payment unless the inter-rater reliability can be markedly improved. recent studies have reported excess hospitalization costs for aneurysm coiling compared to clipping after subarachnoid hemorrhage (sah). we aimed to compare categories of charges, length of stay (los), and discharge disposition in patients who underwent surgical versus endovascular aneurysm repair. a retrospective review was conducted of spontaneous sah patients between 7/2001-3/2009. charges captured in the hospital database and were categorized as direct, overhead, icu, surgical and radiographic/angiographic. analysis was adjusted for age, hunt-hess grade, aneurysm size, aneurysm location and los. discharge disposition and los were compared between clipped and coiled patients using logistic regression or mann whitney u-nonparametric test. of 264 sah patients, 90 (34%) were clipped and 131 (50%) were coiled. coiled patients were significantly older (58 versus 54 years; p=0.008), and had larger aneurysms (6 versus 5mm; p=0.005). there were no differences in hunt-hess grade, aneurysm location, or modified fisher score. compared to coiled patients, median radiographic/angiographic charges were lower in the clipped group ($5063 versus $11,803, adjusted or [aor] 0.04, 95% ci 0.01-0.2, p<0.001), but median surgical charges were higher ($4,686 versus $0, aor 5398, 95% ci 139-208,870, p<0.001). total median direct charges were similar ($29,247 for clipped versus $32,056 for coiled patients, p=0.209), as were icu direct charges ($12,364 versus $12,581, p=0.263) and overhead ($10,847 versus $12,240, p=0.093). median icu los (11 days for each group) and hospital los (16 days for each group) were similar as were discharge dispositions after adjusting for age, hunt-hess grade and aneurysm size: 9% of clipped patients died versus 14% of coiled patients (p=0.719) and 20% versus 30% had a poor discharge disposition (p=0.581). though surgical and radiographic/angiographic charges differed between sah patients who had surgical versus endovascular repair, icu charges, overhead and total direct charges were similar as were icu and hospital los and discharge disposition. osmotic diuretics and hypertonic saline (hs) are commonly used to treat traumatic brain injury (tbi). the untoward effects of mannitol, including hypotension, rebound intracranial hypertension, decreased potency and effect duration have lead to research of alternative treatments. hypertonic saline has been increasingly used to treat cerebral edema, however, efficacy and safety of repeated boluses has not been established. this preliminary prospective trial assesses the ability of single 50 ml 14.6% saline bolus to lower icp without losing potency while maintaining hemodynamic stability. thirty-five individual boluses of 14.6% saline were given in 5 tbi patients (aged 21-53) during a 4-month period. included tbi patients sustained icp elevation (>30mmhg x 30 minutes) despite full sedation, paralytics, temperature control and minimal stimulation. starting at bolus initiation, icp, cerebral perfusion pressure (cpp), heart rate (hr), systolic blood pressure (sbp), sodium level (na), and serum osmolality (sosm) were recorded regularly for 12 hours. if repeated boluses were given in the same patient (icp re-elevated >30mmhg x 30 minutes), recording of parameters was restarted at a new zero time-point to assess the effect of each bolus individually. statistical analysis included power analysis, normalization testing, anova (analysis of variance) and scheffe test. within 10 minutes of administration a statistically significant decrease in icp was sustained up to 12 hours (power >90%, p<0.05). mean icp at initiation declined from 43 mmhg to <20 mmhg by 25 minutes (>50% reduction, p<0.05). the mean cpp before treatment increased from 58 mmhg to 81 mmhg by 20 minutes (40% rise, p<0.05). mean hr and sbp remained constant. sodium levels ranged from 134 to 175 and sosm from 297 to 362. small volume 14.6% saline boluses can be used repeatedly in patients with tbi to significantly lower icp and improve cerebral perfusion. repeated boluses resulted in a sustained magnitude and duration of icp reduction up to 12 hours. introduction: intraventricular hemorrhage (ivh) can result from different etiologies all are intracranial in location. in this unique case we describe a case of ivh secondary to an extracranial vascular source. retrospective chart analysis for a patient that was taken care of at our institution's neurocritical care unit with cerebellar hemorrhage. patient was a 55 year old male who presented with severe headache and imbalance. ct scan revealed a cerebellar hemorrhage and minimal intraventricular hemorrhage. patient underwent suboccipital craniectomy with evacuation of the hematoma. patient had an external ventricular drain (evd) placed in the or through the occipital horn. patient recovered over the following few days with minimal neurological deficits. suddenly patient suffered from a profuse bleeding from the scalp site of the evd. bleeding was controlled by pressure and suture. next day patient suffered from a similar episode. during the control of the bleeding the patient deteriorated neurologically and had to be intubated. patient ct scan showed massive intraventricular hemorrhage. angiography revealed an occipital artery pseudoaneurysm that was the cause of the bleeding and probably resulted from the evd insertion. the aneurysm was coiled without complication and patient was discharged later to long term care facility. pseudoaneurysms of the external carotid artery branches could result from trauma induced during evd insertion. in the presence of evd tract the hemorrhage that occurs from these pseudoaneurysms could track along under pressure to cause intracranial hemorrhage. this is an unusual and unfortunate experience that we wanted to raise awareness about. veena yashaswi, ravi patel, adham kamel, jonathan naysan, juliuse gene latorre, tara ramachandran, ziad el-zammar, yahia lodi upstate medical university, syracuse, ny, united states surgical treatment of fusiform intracranial aneurysm is extremely difficult and associated with poor outcome. endovascular stent-assisted treatment of fusiform intracranial aneurysm without sacrificing the parent artery has been introduced into clinical practice recently as an alternative option. objective: the objective of our study is report our experience of stent-assisted treatment of fusiform intracranial aneurysm. consecutive patients who underwent stent-assisted treatment for fusiform intracranial aneurysm were enrolled from 2004 to 2006. patient's demographics including the hunt & hess grade, fished scale, location and size of aneurysm including the rate of radiographic evidence of aneurysm occlusion were collected. additionally a 90 days outcome measurement was obtained using glasgow outcome scale (gos). five female patients, median age 40 years (ranges 10 to 67) with five unruptured symptomatic intracranial fusiform aneurysms were treated with neuroform stent. four of which required staged coiling in addition to stenting and one required stenting only. three aneurysms were located at the internal carotid artery (two at the carotid bifurcation, one at the origin of ophthalmic artery) one at the middle cerebral artery and one at the vertebral artery. there was no intraoperative or post operative complication related to the stent-assisted treatment. immediate near complete occlusion was observed in one and subtotal occlusion in 4 cases. in 12 months follow-up angiography, complete occlusion of aneurysm was observed in 2 patients (vertebral artery 1 and carotid bifurcation 1), near complete occlusion in two (carotid ophthalmic one and carotid bifurcation one) and subtotal in one (middle cerebral artery). good outcome was observed in all 5 cases (gos 5). endovascular stent-assisted repair not only provides a safe alternative option for the treatment of intracranial fusiform aneurysm, but also improve progressive occlusion of aneurysm with good outcome. wilson cueva, obi iwuchukwu, fernando goldenberg, agnieszka ardelt, jeffrey frank university of chicago medical center, chicago, il, united states hyperammonemia is a well recognized precipitant of cerebral edema (ce) and an important cause of death in acute liver failure. however, isolated hyperammonemia can occur in patients with enzymatic deficiencies important for ureagenesis. extreme hyperammonemia from newly diagnosed ureadysgenesis in adults has been reported, most often leading to disabled outcome or death from ce. we present the clinical, therapeutic and outcome details of two patients with newly symptomatic ureadysgenesis-induced hyperammonemia who developed profound ce and intracranial hypertension (ich). both are the only survivors ever reported with their degree of extreme hyperammonemia (peak 1608 and 881 mcg/dl) with normal neurological outcome. case-1: a healthy 49 year-old male developed seizures followed by profound encephalopathy associated with ammonia level of 881 mcg/dl without liver failure. case-2: after a successful lung transplant, a 36 year-old man developed severe encephalopathy associated with ammonia level of 1608 mcg/dl without liver failure. ornithine transcarbamylase deficiency was discovered in case 1 and acquired glutamine synthetase deficiency was suspected in case 2. steroids provoked symptomatology in both cases leading to severe ce and ich. both required intracranial pressure monitoring, cerebral perfusion pressures directed therapy, promotion of ammonia clearance (cvvhd, lactulose), catabolism limiting treatments (hypothermia, insulin administration, infection control, nourishment), protein restriction, and the use of alternative pathway therapy. both patients fully recovered. -hyperammonemia should be suspected in patients presenting with unexplained ce even in the absence of liver failure. -multidimensional contemporary neurocritical care strategies can optimize survival and improve functional outcome from this historically disabling and deadly condition. -extreme hyperammonemia should not deter aggressive proactive management in these patients now that we report normal neurological outcome in these unique survivors. we is a known neurological complication of thiamine deficiency. although it usually manifests among alcoholics, na patients with either malabsorption, poor dietary intake, severe vomiting or increased metabolic demands are prone to develop we. we present three clinical cases in whom typical brain mri and pathology findings led to the diagnosis of na-we. case-1: 65 year-old na female became comatose after a two months history of severe vomiting secondary to a gastrointestinal disease. case-2: 53 year-old na female with breast cancer became comatose in the setting of 3 weeks history of severe vomiting after chemotherapy. case-3: 68 year-old na female became comatose status-post cardiac arrest of very short duration, not enough to explain the severity of the encephalopathy. severe alteration of the level of consciousness without focal deficits was the prominent clinical finding in all patients; nystagmus was present in case 2. brain mri showed t2/flair signal abnormalities in bilateral mamillary bodies, thalamus and periaqueductal area in cases 1 and 2 and an autopsy in case 3 revealed findings consistent with we. despite intravenous thiamine supplementation, cases 1 and 3 did not improve clinically and eventually expired. case 2 had complete neurological recovery within the first 48 hours of treatment with intravenous thiamine. -we should be considered in all patients with unexplained confusion or deteriorating mental status even in the absence of a prior history of alcohol abuse. -in the presence of atypical or incomplete clinical picture of we, appropriate brain mri findings can help establishing the diagnosis. -early diagnosis of we is critical given that the success of the treatment depends on the urgent thiamine supplementation. -failure to recognize and treat we may result in devastating neurological outcome. arterial venous carbon dioxide removal (avco2r) is a technique that uses a pumpless extracorpeal circuit for carbon dioxide removal. avco2r has been used in adult and pediatric patients with severe hypercapnea. the system is placed at bedside using the seldinger technique to cannulate the femoral vessels. normally this system requires anticoagulation but can be performed without anticoagulation. case reports of avco2r used to control ph and pco2 after neurotrauma. a male suffered extensive head injury after mvc progressing to brain death. organ harvest was planned. because of extensive lung injury complicated by hypercapnea and academia, donor viability was in jepody with paco2 rising to 88 and ph of 7.18. avco2r was placed for ph and carbon dioxide control. the paco2 and ph promptly corrected to 42 and 7.38. after a brain death exanimation he remained on avco2r until organ harvest. a male presented with a cervical injury at the c-5 level. imagining showed cervical fractures, disc herniation and cord contusion involving c-4 to t-1.the patient developed respiratory distress. chest x-ray revealed ards. in aprv the ph was 6.8 and pco2 of 125. the patient had a subsequent cardiopulmonary arrest. after successful resuscitation avco2r was started. within 3 hours the ph and pco2 were 7.21 and 57 without manipulation of the ventilator settings. he was on aco2r for 6 days and eventually weaned off mechanical ventilation after surgical decompression and fusion and discharged to rehabilitation. neither case required anticoagulation. 1. avco2r is a simple extracorpeal technique that can be used to manage life threatening hypercapnea in patients with critical neurologic illness or injury 2. the technique can be inserted at bedside and used without anticoagulation continuous renal replacement therapy (crrt) is preferred over intermittent hemodialysis (ihd) in patients with acute brain injury (abi) due to increased intracranial pressure (icp) seen during ihd [1, 2] . despite the preference for crrt in this patient population limited data is available on icp changes during therapy. there is some support for the early stability of icp for patients with fulminant hepatic failure that underwent continuous arteriovenous hemofiltration [3, 4] . retrospective observational study (over a 3 year period) of patients with abi and icp monitoring whom also underwent crrt. icp and fluid volumes were analyzed for the 12 hours before and after initiation of crrt. four patients met criteria. table-1 describes the sample population. three patients had developed refractory intracranial hypertension (rih) prior to initiation of crrt (2 in pharmacologic coma) and 1 patient developed intracranial hypertension on ihd that resolved with crrt. no changes in medications were made in the 12 hours prior to starting crrt except pentobarbital coma was initiated one patient six hours prior to crrt without lowering of icp. no attempts were made to lower icp in the 12 hours following crrt. a decline in icp was seen at 1, 4, and 12 hours following initiation of crrt in rih patients ( given the decrease in icp at one hour and relatively small percentage of total fluid balance removed, it seems unlikely that fluid removal or improved systemic oxygenation decreased icp. early improvement in icp may be due to removal of cytokines and myocardinal depressants seen with ultrafiltration and membrane absorption which is maximal during the first hour of filter use due to filter charge [5] . given the mortality and morbidity associated with rih, further research is warranted. isoflurane, an inhalational anesthetic, is an alternative treatment for refractory status epilepticus (rse). it is effective, has rapid onset of action, and is easily titrated to produce burst-suppression patterns on the electroencephalogram. little is known regarding potential human toxicities caused by isoflurane. we present two cases of prolonged rse treated with prolonged high dose isoflurane who developed abnormal t2 hyperintensity lesions on magnetic resonance imaging (mri), which improved after taper or discontinuation of isoflurane. we report two patients with prolonged refractory status epilepticus who were treated with prolonged high-dose isoflurane (defined as an average end tidal concentration > 1.5% for seven or more days) and developed new changes on brain mri. we collected demographic information, daily dosing of all antiepileptic medications and anesthetics received. we reviewed and analyzed the results of serial mri scans. patient one had prolonged rse for 140 days and was treated with isoflurane for 85 days with 1975.2 % concentrationhours. patient two, currently hospitalized, has had rse for at least 210 days and was treated with isoflurane for 34 days with 1382.4 % concentration-hours. in both patients, serial brain mris showed progressive t2 signal hyperintensity involving bilateral thalami, cerebellar hemispheres, and cerebellar vermis after treatment with 2-3 weeks of high dose isoflurane. these findings improved following taper and/or discontinuation of isoflurane. these cases raise the possibility that isoflurane is neurotoxic when used in high doses for prolonged time periods. though we cannot be certain of the exact cause of brain lesions, the timing of their appearance after isoflurane initiation and subsequent improvement after taper or discontinuation suggest a possible association with isoflurane. further studies are needed to clarify the safety of prolonged isoflurane use in rse cerebral edema is common in severe brain injury and can lead to harmful elevations in intracranial pressure (icp). hyponatremia, typically associated with excess levels of vasopressin (adh), frequently complicates acute brain injury and can worsen edema and icp. conivaptan, a vasopressin-receptor antagonist, has been shown to correct hyponatremia in these high-risk patients by inducing loss of free water (aquaresis). it is unknown whether raising sodium with a bolus of conivaptan can also acutely reduce icp. we prospectively assessed the change in serum sodium (na + ), icp, and cerebral perfusion pressure (cpp) after a bolus of conivaptan was given for the treatment of hyponatremia in a patient with cerebral edema associated with traumatic brain injury (tbi). a 22-year old suffered severe tbi with left carotid dissection, complicated by hemispheric infarcts and worsening edema. conivaptan 20 mg iv was given as a bolus when na + rapidly dropped to 128meq/l. its aquaretic effect peaked between 3 and 5 hours after the dose, with hourly urine outputs of 1100 ml/hour. eight hours postadministration, na + had risen to 146 meq/l. icp had been stable at 13-15 mm hg for several hours prior and remained in this range for the first 2 hours after conivaptan, but then fell to 3 mm hg at 4 hours, remaining 5 mm hg after 8 hours. cpp, initially stable at 60-70 mm hg, rose to 94 mm hg after 4 hours. a single bolus of conivaptan not only resulted in rapid correction of hyponatremia but also a significant fall in icp temporally associated with peak aquaresis. confirmation of this novel osmotic effect is required, as is further delineation of the role of such agents in the management of brain edema. financial support: the authors have received speaking honoraria from astellas pharma. seizures are a known complication of aneurysmal subarachnoid hemorrhage (sah). they can increase cerebral metabolic demand and lead to cardiopulmonary compromise. this could be detrimental in the setting of delayed cerebral ischemia (dci), when brain tissue is vulnerable to further reductions in oxygen delivery or increases in demand. an association between seizures and worsening ischemia could influence the decision to use antiepileptic drug (aed) prophylaxis in patients with vasospasm. case report of a patient who developed irreversible neurological deficits and cerebral infarction immediately after a seizure in the setting of initially stable vasospasm with dci. a 64 year-old woman developed confusion, aphasia, and right hemiparesis on day 7 after sah. angiography confirmed severe anterior circulation vasospasm. the patient responded to hypertensive therapy with almost complete resolution of her ischemic neurological deficits. on day 10, however, she had a single generalized seizure and required intubation after brief oxygen desaturation. she had a concurrent drop in blood pressure, necessitating an increase in previously stable dose of vasopressors post-ictally she developed recurrent aphasia and worsening hemiparesis which did not resolve despite further hemodynamic augmentation. subsequent head cts revealed new infarcts in the left anterior and middle cerebral artery territories. she had received prophylactic phenytoin for only the first 3 days of her icu stay per our sah protocol. aed prophylaxis is typically used early after sah when risk is high and a seizure may precipitate aneurysmal rebleeding. this case illustrates how a seizure occurring later, in the setting of vasospasm, can lead to decompensation of dci with potential for irreversible infarction. therefore, patients with vasospasm may benefit from extended duration of prophylaxis to prevent such complications. dural sinus thrombosis is a rare cause of stroke. anticoagulation is the preferred treatment; however, some patients experience rapidly progressive neurological deficits and poor outcomes despite adequate anticoagulation. mechanical thrombectomy via a trans-femoral approach is an effective alternative treatment, but technical limitations can make this approach impossible in some patients. we report two cases in which angiojet® (medrad-interventional/possis) thrombectomy was performed via a transjugular approach. in the first patient, trans-jugular access was preferred due to the presence of bilateral deep vein thromboses in the femoral and iliac veins and an inferior vena cava filter. in the second patient, the trans-femoral approach was impossible due to the length of the catheter (135cm xmi), which was insufficient to access to the anterior two thirds of the superior sagittal sinus via a trans-femoral approach. in both patients, the trans-jugular access was obtained utilizing direct ultrasound and fluoroscopic guidance. a stabilizing guidewire was placed to deliver the angiojet® catheter to the superior sagittal sinus. the first patient was a 67 year-old woman with heparin-induced thrombocytopenia, a large intracranial hemorrhage and refractory increased intracranial pressure. the second patient was a 32 year-old man who presented with dehydration and a rapidly declining neurological exam. in both patients, antegrade blood flow was restored within the dural sinuses after mechanical thrombectomy via the trans-jugular approach. computed tomography scans after thrombectomy did not show evidence of increased hemorrhage and there were no complications from the procedure. the first patient died despite successful thrombectomy from other complications of her underlying disease. the second patient made a full recovery. mechanical thrombectomy has been shown to be a successful treatment for dural sinus thrombosis for patients with progressive symptoms despite adequate anticoagulation. the trans-jugular approach is a valuable alternative variation of mechanical thrombectomy in patients who have contraindications to the trans-femoral approach. we retrospectively reviewed data from patients with stbi admitted to the neuroscience icu (nsicu) of an urban tertiary care level 1 trauma center who had a cerebral oxygen monitor (licox ) in place and were administered inhaled nitric oxide (ino) per institutional protocol. data were collected from bedside flow sheets. two patients met inclusion criteria. patient #1 was admitted after a motor vehicle collision with stbi and pulmonary contusions. she developed adult respiratory distress syndrome (ards) on hospital day #3 requiring ino at 20 ppm. prior to ino therapy, pbto2 was 36.8 mm hg, pao2 = 63 mm hg and icp = 8 cm h2o; within 3 hours of ino initiation, pbto2 climbed to 76 mm hg (+106%), pao2 rose to 266 (+322%), and icp remained 8 cm h2o (+0%). patient #2 sustained a stbi and pulmonary contusions after a motorcycle collision. he developed ards on hospital day #3 requiring ino at 20 ppm. prior to ino therapy pbto2 was 19.3 mm hg, pao2 = 67 mm hg and icp = 9 cm h20; within 3 hours of ino initiation, pbto2 rose to 43mm hg (+122%), pao2 rose to 181 mm hg (+170%) and icp climbed to 18 cm h2o (+200%). patients admitted to the nsicu after stbi may develop complex physiologic derangements, including ards. the use of ino may benefit both cerebral and pulmonary dysfunction, and may warrant further investigation. amar dhand, kazuma nakagawa, wade smith, tarik tihan university of california, san francisco, san francisco, ca, united states introduction: ventricular free wall rupture is a fatal complication of myocardial infarction (mi). although described in mi patients who receive thrombolytic therapy, this complication is not well known in ischemic stroke patients who receive intravenous (iv) t-pa. here, we report a patient who had cardiac rupture and hemopericardium immediately following iv t-pa administration. case report. a 93-year-old woman with history of coronary artery disease presented with acute onset of left hemiparesis and right gaze preference (nihss 13). ct angiography showed right middle cerebral artery (mca) occlusion at the bifurication, a filling defect in the left atrial appendage suggestive of left atrial thrombus, and right segmental pulmonary embolism. an electrocardiogram showed st elevations in the v5-v6 distribution with initial troponin i level of 8.08 ug/l. iv t-pa was administered 1 hour from symptom onset. one hour after completing t-pa infusion, the patient suddenly became unresponsive, bradycardiac, and rapidly demonstrated an asystolic arrest. given the established dnr/dni status, she was not resuscitated. autopsy study showed subacute myocardial infarction (2-4 days old), rupture of the anterolateral wall of the left ventricle, and 200cc of hemopericardium. pathological study of the brain showed an old hemorrhagic infarction in the left occipital lobe, evidence of remote hypoxic/ischemic injury and 30% occlusion of the basilar artery, but no evidence of intracranial hemorrhage. this case report illustrates a fatal cardiac complication of iv thrombolytic therapy that was used for acute ischemic stroke treatment in the setting of subacute myocardial infarction. the speculated mechanism of this phenomenon is alteration of collagen metabolism by thrombolytic therapy. although mi is not an absolute contraindication for iv t-pa administration, clinicians should be aware that cardiac rupture may occur when iv t-pa is given to patients with concomitant stroke and mi. anti-nmda-receptor encephalitis (nmdare) is a rare autoimmune encephalitis associated with antibodies that antagonize nmda receptors. although nmdare is an uncommon disorder, we present 3 confirmed cases treated in our neuro-icu over 6 months. we report three cases of nmdare including the first reported case during pregnancy. all patients were women between 19 and 39 years of age. all had a prodrome of psychiatric symptoms and had orofacial and limb dyskinesias at presentation. each developed progressive unresponsiveness, required mechanical ventilation secondary to hypoventilation and had autonomic instability. one required a transvenous pacer for symptomatic bradycardia. all were evaluated for ovarian teratoma. all underwent oopherectomy. two were found to have ovarian teratomas by pathology. patients were treated with a combination of ivig, steroids and plasma exchange. all patients improved and were discharged from the hospital to inpatient rehabilitation. one patient was 14 weeks pregnant at admission. she delivered via cesearean section at 37 weeks gestation. the neonate had mildly increased tone but appeared otherwise healthy and was discharged home at 9 days. the csf of the neonate was negative for nmda antibodies. nmdare is a reportedly rare cause of encephalitis which may be more common than reported. it has characteristic features that should not go unrecognized. high suspicion for ovarian teratoma is appropriate. imaging may not accurately differentiate between benign cysts and teratoma. oopherectomy for any ovarian abnormality may be reasonable, given poor correlation of pathologically confirmed teratoma with radiographic imaging. this is the first reported case of nmdare during pregnancy. nmda receptors play an important role during fetal development and the long-term sequelae for children exposed to nmdar antibodies in utero are unknown. csf hypovolemia is typically diagnosed in patients presenting with positional headaches. however, severe intracranial hypotension and brain sagging may cause orthostatic coma. we present a case that illustrates this uncommon presentation. a 50yr old male who presented with acute onset of headache, nausea, vomiting and disequilibrium. extensive diagnostic work-up, including head ct, mri/mra and lp, was initially unremarkable. his headaches became progressively worse with a prominent postural component. a csf leak was suspected at the lumbar level diagnosed with ct myelogram and treated with a blood patch at the outside hospital with temporary resolution of his symptoms. a repeat mri/mra revealed bilateral subdural hematomas without mass effect and diffuse dural enhancement, consistent with decreased csf pressure. due to worsening level of consciousness, the patient underwent urgent evacuation of the left subdural without any change in his mental status subsequent imaging showed reaccumulation of the hematoma. over the next few days, the patient became increasingly stuporous and had an acute respiratory decline requiring intubation. the patient was subsequently transferred to our institution. head mri revealed dramatic sagging of the brain showing the pontomedullary junction at the opening of the foramen magnum. there was reproducible improvement in his cognitive status and cheyne stokes breathing with trendelenburg positioning. he underwent a repeat ct myelogram which showed a csf leak at t3 and possibly at c5-c6. the csf leaks were repaired with localized blood patches with significant improvement in his neurological exam. csf hypovolemia may cause coma from distortion and downward displacement of the thalamus-brainstem structures. evacuation of subdural fluid collections-typically without mass effect-may be detrimental in these patients contributing to further reduction of csf volume. instead, identification and treatment of the responsible csf leak is curative. infection with human immunodeficiency virus (hiv) has been associated with the development of intracranial aneurysms. although the pathogenesis of aneurysm formation in hiv infected patients is unclear, one purported mechanism is direct invasion of cerebral vessels by the virus itself. here, we report a unique case of an hiv infected patient whose intracranial aneurysm rapidly enlarged during a period of anti-retroviral therapy non-adherence. case report. a 39 year-old hiv infected female (cd4 count 181 cells/ml) was admitted with a subarachnoid hemorrhage. cerebral angiography revealed a dilating vasculopathy of multiple large intracranial vessels along with fusiform aneurysms of the right and left proximal anterior cerebral arteries (aca). a saccular aneurysm measuring 4 x 2.5 mm arose from the right fusiform aca aneurysm and was successfully treated with endovascular coiling. four weeks later, the patient was re-admitted with a decreased level of consciousness. head ct revealed recurrent subarachnoid hemorrhage. the patient had not adhered to her anti-retroviral therapy and her cd4 count upon re-admission was 108 cells/ml (hiv load 671 copies/ml). cerebral angiography revealed enlargement of the previously coiled aneurysm which now measured 6 x 5 x 3.5mm. infectious vasculitides were excluded with serum and cerebrospinal fluid (csf) testing, including negative blood and csf cultures, negative serum and csf antibodies for syphilis, and negative serum antibodies and csf polymerase chain reaction for varicella zoster virus. the co-occurrence of rapid aneurysmal enlargement with non-adherence to antiretroviral therapy suggests an elevated hiv burden may accelerate vasculopathy. rapid enlargement and re-rupture of intracranial aneurysms may be seen in hiv infected patients with an elevated viral burden. identifying the unique clinical and radiological features of hiv vasculopathy may lead to earlier recognition and novel therapeutic approaches. patients with de novo refractory status epilepticus are often referred to as having norse. the clinical course is often prolonged (range: 6-68 days), and morbidity and mortality is high (50%). cjd is a rare cause of refractory convulsive and non-convulsive status epilepticus. we describe here a patient with norse who had probable sporadic cjd. 72 year old, 65 kg, caucasian female with a past medical history of systemic hypertension, pulmonary hypertension, and prior pulmonary mai complex presented to the er with delirium and accelerated hypertension. initial examination revealed encephalopathy. patient had 3 generalized tonic clonic seizures, with rapid progression to status epilepticus which was refractory to dilantin (150 mg tid), keppra (1000mg bid), phenobarbitone (60 mg tid), midazolam (6mcg/kg/min), and propofol (75mcg/kg/min) infusion. she was then put in pentobarbital coma (6 m/kg/hr) for 48 hours, and was found to be refractory to withdrawal of pentobarbital. on day 19 of her status epilepticus the patient had an episode of massive pulmonary hemorrhage and went into pea, from which she couldn't be revived. workup for norse including mri brain, ct chest, abdomen and pelvis, failed to reveal any evidence of stroke, press, neoplasm, meningo-encephalitis. paraneoplastic antibody panel was negative. toxicology, metabolic, haematological, vascular, and immunological workup was negative. csf analysis revealed a wbc of 16, protein 51 and glucose 68 and protein 14-3-3 was positive. to our knowledge this is the first case report of norse complicating cjd. norse complicating cjd is associated with high mortality. our case is also unique for its acute onset, absence of myoclonus, and absence of extra pyramidal features commonly seen in cjd. in patients with refractory status epilepticus with no obvious cause, cjd should be considered in the differential diagnoses. predicting recovery after cardiac arrest continues to challenge neurointensivists. updated 2006 aan practice parameters add two new evidence-based elements to traditional clinical examination criteria 1) absence of bilateral n20 response on sseps and 2) neuron-specific enolase (nse) > 33 µg/dl as measured within 3 days. concurrently moderate hypothermia has emerged as an efficacious therapy, with the possibility of modifying the predictive power of criteria established independent of such intervention. case: a 71 year old woman undergoing breast lumpectomy was resuscitated following interoperative asystole. rosc was secured by 5 mins; but she arrived to nsicu comatose with only minimal pupillary and corneal reflexes. moderate hypothermia with target temperatures of 32-34 o c was achieved by 2 hours and maintained for 24 hours before slow re-warming. at 48 hours, n20s were bilaterally present, but nse was 35 µg/dl. brain mri at day 7 was normal. over 5 weeks she remained comatose with absent motor response requiring aggressive therapy for bouts of refractory non-convulsive status epilepticus. she continued to have intermittent transient myoclonic movements 4 months after cardiac arrest. eye opening without awareness of surroundings began at icu week 5 with gradual return to consciousness. subsequently she has made slow steady improvement, conversing appropriately with memory of family names and past experiences. now 4 months post-arrest on the inpatient rehabilitation unit she moves all extremities with 3-4/5 muscle strength. her most recent fim score is 57. prognostication after cardiac arrest remains complex. application of hypothermia may alter the validity of predictors established previously. confounders and convergent evidence must be considered over any single data point. as in the past, time remains the final arbiter of certainty. near infrared spectroscopy is a non-invasive method of monitoring cerebral oxygenation. by employing time and spatial resolution of several light wavelengths, cortical blood flow, volume and oxygenation can be quantified (cerebral oximetry). we present a case utilizing cerebral oximetry in a patient with cerebral vasospasm after subarachnoid hemorrhage (sah) with concurrent use of brain tissue partial pressure of oxygen (pbto2) monitoring. a 46 year old woman developed severe diffuse vasospasm following sah. we monitored intracranial pressure (icp) as well as tissue oximetry (pbto 2 ) via licox (integra) catheter placed in the distribution of the left mca. over a 24-hour period during the third day of vasospasm, cerox (ornim) monitoring was applied over the left fronto-temporal area to evaluate the relationship between pbto 2 and non-invasive cerebral oximetry. there were 12 episodes of pbto 2 desaturation (<20 mmhg for >5 mins) over the period of dual monitoring. over 80% of these pbto 2 desaturations were preceded by >20% decline in cerox values from baseline. there were 22 episodes of cerebral oximetry desaturation (<50% for >10 mins). less than 50% of cerox desaturations were temporally related to a decline in pbto2 to less than 20 mmhg. hemoglobin was stable at 10 mg/dl and icp was well controlled (<15 mmhg) during the entire 24 hours. in this subject, desaturations of pbto 2 appeared to be related to desaturations by non-invasive cerebral oximetry; the converse was not the case. perhaps cortical oxygen desaturations (cerox) occur with increased frequency compared to subcortical oxygen desaturations (pbto 2 ) in diffuse vasospasm after sah. cerox monitoring may provide an enhanced understanding of oxygen delivery and utilization during periods of ongoing cerebral ischemia. further studies are required to substantiate these findings. status epilepticus refractory to conventional anti-epileptic drugs typically carries a poor prognosis, but patients may recover well if seizures can be stopped. case reports suggest that electroconvulsive therapy (ect) may stop seizures in patients with refractory status epilepticus, and we sought to examine its effectiveness in a series of patients. three consecutive patients with refractory status epilepticus at our institution were treated with ect after other therapies had failed. all 3 patients were women, with age ranging from 26 to 41 years, and none had a significant medical history. extensive diagnostic testing was unrevealing, and all patients were empirically treated for infectious and autoimmune encephalitis. ect was begun because of ongoing seizures despite potent combinations of conventional anti-epileptic drugs, multiple trials of complete eeg suppression with anesthetic agents, and trials of more infrequently used therapies such as inhaled anesthetic agents and ketamine. ect stopped seizures in 2 of 3 patients. one patient recovered completely, and in outpatient follow-up had a normal neurological examination and a score of 30 on the mini mental state examination. the second patient was left with mild cognitive impairment and epilepsy, but returned to independent living. in the third patient, seizures continued despite ect, and care was withdrawn at the family's request. autopsy revealed evidence of active meningoencephalitis despite treatment with antiviral therapy and high-dose steroids. ect stopped seizures in 2 of 3 patients with refractory status epilepticus. our results and those of prior case reports suggest that ect may be an effective therapy for refractory status epilepticus, and warrants further study for this indication. wendy wright, bill asbury, susan samuel, jane gilmore, owen samuels emory university hospital, atlanta, ga, united states conivaptan, an avp-receptor antagonist, has been used in neurocritical care patients to treat euvolemic hyponatremia. therefore, it would stand to reason that the aquaretic effect of conivaptan could also be used to induce a state of therapeutic hypernatremia. therapeutic hypernatremia is one of the standard modalities for the treatment of cerebral edema. conivaptan bolus +/-continuous infusion was administered to three patients with cerebral edema in the neurocritical care unit. all patients were initially treated with conventional measures to induce therapeutic hypernatremia, yet were not meeting the desired serum na goal. conivaptan was used in these patients to augment the effects of hypertonic saline. one patient received a single 20 mg bolus of conivaptan in addition to 23.4% nacl and his [na] increased an average of 3 meq/l. one patient received a single 20 mg bolus in addition to 23.4% nacl + 3% nacl + nacl tablets + fludrocortisone and his [na] increased an average of 6meq/l. a third patient received conivaptan boluses + infusion in addition to 3% nacl and his [na] increased an average of 3 meq/l. fluid balances were not adversely affected in any of these patients. conivaptan added to hypertonic saline therapy appears to be a rational strategy for achieving therapeutic hypernatremia in patients with cerebral edema without adversely affecting fluid balance. further study is needed to assess the effects of conivaptan on intracranial pressure, cerebral perfusion pressure and intravascular volume. financial support: dr. wright has served as a consultant for astellas pharma us delayed cerebral ischemia from vasospasm is an under-recognized, yet potentially treatable cause of morbidity and mortality in meningitis. while cerebral vasospasm has been documented via transcranial doppler sonography in patients with meningitis, few reports document vasospasm by cerebral angiography in this population. we report two patients who suffered neurological decline resulting from angiographically documented vasospasm during treatment for meningitis. the first patient was a 51-year-old woman who developed acute aphasia and hemiplegia during treatment for meningitis. formal cerebral angiography demonstrated left anterior circulation vasospasm. she was treated with verapamil into the left internal carotid artery and aggressive hypervolemia and hypertension. within 12 hours, she was neurologically normal. the second patient was a postpartum woman with meningitis who presented with aphasia and hemiplegia. magnetic resonance imaging showed areas of diffusion restriction consistent with her examination. although she initially made clinical improvement with antibiotic therapy and was discharged, she re-presented days later with severe left anterior circulation vasospasm and massive left hemisphere stroke and later died. in our cases, as well as those described by the tcd literature, neurological decline and vasospasm occurred within 12 days from the diagnosis of meningitis. this suggests that the "window" for vasospasm secondary to meningitis may be similar to that of vasospasm from sah. the development of focal neurologic symptoms in patients with meningitis should prompt radiographic evaluation for vasospasm. current treatment algorithms do not include the routine use of cerebrovascular imaging during treatment for meningitis, and thus this potentially treatable complication may be under diagnosed. prospective studies evaluating cerebrovascular complications in acute meningitis using neuroimaging coupled with directed hypervolemichypertensive therapies should be undertaken and may lead to a reduction in the persistently high morbidity and mortality associated with this common disease. opsoclonus-myoclonus syndrome (oms) is typically associated with a paraneoplastic syndrome or viral encephalitis. various locations, including the crerebellum, have been proposed as anatomic correlations to this syndrome. oms as a result of posterior reversible encephalopathy syndrome (pres) has not been previously described. a 60 yo man with past medical history of poorly control hypertension, hyperlipidemia, and peripheral neuropathy presented with confusion and visual difficulties. initial exam demonstrated a fever of 101, bp= 170/70 (max 210/110), and lethargy. laboratory studies revealed acute renal insufficiency (ari) (cr=1.6) and rhabdomyolysis (cpk=845). mri showed faint hyperintensities in the cerebellum and paieto-occipital subcortical areas (image 1). the patient subsequently developed agitation with diffuse multifocal myoclonus and pronounced opsoclonus. repeat mri (image 2) showed extensive hyperintensities in the subcortical hemispheres bilaterally and in the cerebellum, consistent with pres (image 2). eeg showed diffuse slowing, and lp showed elevated protein (124mg/dl). csf cultures, vdrl, lyme antibody, listeria antibodies, west nile virus pcr, hsv pcr, and jc virus pcr were all negative. ct scan with contrast of the chest, abdomen and pelvis, revealed no neoplasms. results of serum paraneoplastic antibodies are pending. elevations in spep and upep were determined to be due to monoclonal gammopathy of unknown significance. we present a unique case of pres presenting as oms. involvement of the cerebellum may have been causative in this case. the most likely explanation for the development of pres was hypertension with ari. the acute onset, negative viral studies and body ct scan, resolution of symptoms with control of hypertension and reversal of ari, and the characteristic mri findings all supported pres as the cause of oms. we describe the clinical, imaging, and follow-up details of two patients who developed bsevad in the peripartum period to enhance the early recognition of this uncommon but important and potentially disabling complication. both patients were initially misdiagnosed with post-dural puncture headaches (pdph). both patients were in their thirties (ages 31 and 38), had epidural anesthesia, and developed their symptoms within days of delivery. patient #1 developed postural headache within 24 hours of delivery, and patient #2 developed severe neck pain and bioccipital headache 5 days after delivery. both received epidural blood patch for presumptive diagnosis of pdph without any significant relief. patient #1 developed nausea, vomiting, and ataxia 8 days postpartum with a follow-up mri revealing acute bilateral cerebellar infarcts and a unilateral pontine infarct. patient #2 performed unusual physical positions during her pushing phase of labor (drawing provided). initial neuroimaging with ct, mri brain in both were reported as normal. however, 4-vessel cerebral angiography in both patients revealed bsevad. both patients did well with medical therapy without sequelae. the risk factors, diagnostic clues, and therapeutic considerations are discussed. 1. bsevad is a rare peripartum complication. 2. bsevad presents with clinical features that resemble pdph but have some distinguishing features to facilitate differentiation. 3. bsevad can lead to stroke similar to non peripartum cerebral arterial dissections. 4. early recognition of this rare complication can potentially lead to protecting patients from devastating posterior circulation strokes. the late-onset form of pompe's disease presents generally with limb girdle weakness. respiratory failure develops later and is the most frequently reported cause of death. we describe a case of late onset pompe's disease emphasizing the need to incorporate this rare entity into the differential diagnosis of patients with ventilatory failure a 35 year old man presented with progressive weakness and shortness of breath. 4-5 years previously he noticed gradual lower extremity weakness. he began having difficulty breathing while lying flat. he was admitted to the neuroicu due to progressive respiratory failure. neuromuscular junction disease, neuropathy and typical myopathies were excluded. emg: normal nerve conduction studies. needle exam showed complex repetitive discharges, myotonic discharges and fibrillation potentials consistent with a myopathic process. muscle biopsy: myopathic changes associated with features of a vacuolar myopathy with abnormal glycogen accumulation and markedly increased acid phosphatase reactivity consistent with acid maltase deficiency. dried blood spot serum assay for acid -glucosidase was undetectable. pompe's disease is a rare condition that is now recognized as a treatable entity. therefore, it should be included in the differential diagnosis of adult patients with gradually progressive myopathy and respiratory muscle weakness. its treatment, enzyme replacement with recombinant human alpha-glucosidase (rhgaa), although not yet fda-approved for patients over 18 years of age, has shown significant clinical benefit when started early in the course of the disease. owing to the success of therapeutic hypothermia (th) post cardiac arrest, additional indications are now being explored. this case report documents successful application of th for treatment of refractory intracranial hypertension due to poor grade subarachnoid hemorrhage (sah) without the need for decompressive hemicraniectomy. a 22-year-old male (da) became unconscious after complaining of a bad headache. in the ed, da was listed as unresponsive to all stimuli. ct revealed a hunt/hess grade 5 sah. an aneurismal clipping was performed the following day. on day 4, he experienced severe vasospasm not amendable to angioplasty and refractory to osmotherapy, cerebrospinal fluid drainage, and mild hyperventilation. at one point the intracranial pressures exceeded 100 mmhg and his left pupil became fixed and dilated. a ct showed extensive edema and a worsening midline shift. it was then decided to initiate th in anticipation for worsening vasospasm. once the target temperature of 33 degrees c was achieved, the icp stabilized. attempts to re-warm on days 8 and 10 led to increases in icp therefore aborted. finally, on day 13 (th day 9), da was re-warmed successfully. ct results that originally showed a large area of edema and midline shift was resolved. da was extubated day 17, a vp shunt was placed on day 18 and discharged to home after a rehabilitation stay with a good neurological recovery on day 48. considering the mortality of a high grade sah can exceed 70%, we believe th contributed significantly to a good neurological outcome. a recent study described the need for a decompressive hemicraniectomy prior to attempting mild hypothermia. our case report documents successful application without invasive surgery and may be an option for others. amaurosis is an uncommon complication of pregnancy encountered by neurologists. two common causes of blindness in during the peripartum period are: (1) reversible posterior leukoencephalopathy syndrome (rpls), and (2) preeclampsia. case report: a 31-year old woman delivered twins at 35-weeks because of severe preeclampsia. in the early postpartum period, she developed altered mental status, and by postpartum day #2, she was responsive only to first name, unable to follow commands, and increasingly combative. blood pressures were elevated up to 179 mmhg systolic, and 120 mmhg diastolic. she had limited vision by absence of blink response to confrontation bilaterally. head ct and eeg were unremarkable. based on findings on cerebral magnetic resonance imaging (mri), a diagnosis of hypertensive encephalopathy was made. however, the occipital lobes are clearly spared. her condition substantially improved, and by postpartum day 4 she was able to cooperate with visual acuity and funduscopic examinations. visual acuity was 20/800 bilaterally. bilateral fundi showed discrete patches of retinal whitening located between the arterioles and venules, few retinal hemorrhages, and normal optic discs .by discharge, her blood pressure and mental status were at baseline, her vision improved to 20/200, and repeat mri showed resolution of the earlier findings. cause of blindness in this patient was related to purtscher's retinopathy. we believe that this is the first documented case of a patient with a hypertensive encephalopathy and purtscher's retinopathy. this observation indicates that transient visual loss in the setting of elevated systemic blood pressures does not have to be cortical in nature. continuous eeg monitoring of neurocritical care patients is becoming more common. over 20% of critically ill patients with altered sensorium are diagnosed with non-convulsive seizures or status epilepticus. as continuous eeg is increasingly used with critically ill patients, it is important for practitioners to recognize artifacts that may mimic clinically relevant pathologic discharges. we describe a newly discovered artifact from an invasive hemodynamic monitoring device. seven patients who had a ref/ox (edwards lifesciences) continuous cardiac output pulmonary artery catheter (cco) placed for hemodynamic monitoring and were simultaneously monitored with continuous eeg were retrospectively identified. all patients were cared for in a 20 bed neuroscience icu in an urban level 1 trauma center. all eegs were interpreted by a board certified epileptologist. all patients' eegs demonstrated a distinctive artifact believed to be associated with the cco catheter. this artifact has not been previously described with other pulmonary artery catheters. the eeg was characterized by an intermittent high amplitude, narrow complex, spike-like artifact followed by a high amplitude slow wave. it is hypothesized that this signal results from current flow to the thermal element of the catheter. neurocritical care patients frequently undergo multi-modality monitoring. this newly identified eeg artifact with cco monitoring has an appearance that may be confused with epileptic spike/wave discharges or burst suppression. the impact of this potential artifact generated by the use of cco devices requires further characterization. as neurocritical care patients increase in complexity and are subjected to more invasive monitoring, the identification of new eeg artifacts may become more common. the diagnosis of gullian-barre syndrome (gbs) is based on a combination of clinical and laboratory features. gbs typically presents as a monophasic, subacute, symmetrically, predominantly motor neuropathy. in rare cases, gbs can present with acute quadriparesis and cranial nerve involvement. we report two cases of patients who presented in a state mimicking brain death with complete dysfunction of efferent nerves which turned out to be fulminant gbs. two cases with rapidly progressive weakness presented to our institution with very rapid deterioration requiring mechanical ventilation. over a very short course of time, both patients became paralyzed with complete absence of brainstem reflexes. brainstem function tests were performed as part of full neurological examination which revealed that both patients had non-reactive mydriasis with complete internal and external ophthalmoplegia. rest of the neurological exam including deep tendon reflexes showed no reponse. due to lack of identifiable cause of patient s condition, further diagnostic test were carried out. both patient s underwent csf analysis which revealed evidence of albuminocytological dissociation. a diagnosis of severe guill i a n-barre syndrome with involvement of peripheral and cranial nerves was suspected. electrophysiological studies were performed that showed this was suggestive of severe, axonal, sensorimotor peripheral polyneuropathy with profuse ongoing denervation in bulbar, cervical and lumbosacral innervated muscles. extensive laboratory evaluation including gq1b antibody were carried out. after prolonged course, both patients made some functional recovery. both these cases proved that in rare cases, gbs can present with signs of coma and absent brainstem reflexes. brain-death protocols require that before the declaration of brain-death, an etiology needs to identified that could explain the clinical picture and all reversible causes are excluded. these cases illustrate the importance of electrophysiologic, laboratory and imaging studies in patients with suspected brain death where a cause is not clearly determined. hyperperfusion syndrome is a serious complication after carotid revascularization procedure associated with poor outcome, developing between day 1 to 14 days after procedure. in addition to increased cerebral blood flow, clinical manifestation include headache, seizure and intracerebral hemorrhage. equally rare is stent thrombosis especially in patients who were adequately treated with antiplatelets prior to procedure. distinction between the two condition requires prompt diagnosis to achieve good outcome. case report and medical record review 85m presented with acute l hemiparesis and was treated with iv tpa. nihss was 7 on admission and 0 after 24 hours. ct brain did not show any acute infarction. cerebral angiogram showed 70% r ica stenosis.the patient underwent r carotid stenting on day 5. postprocedure map was maintained between 80-100 mmhg using oral and iv antihypertensive agents. 12 hours post procedure the patient developed l hemiparesis, dysarthria, right gaze preference and l hemianopia. blood pressure was augmented to map 100-120 mmhg while en route to ct/mri and angiography for suspected acute stent occlusion. patient's hemiparesis worsened. ct brain showed unilateral subtle r hemispheric edema but no hemorrhage. mri showed patchy dwi along r hemisphere with subtle cortical and meningeal enhancement. emergent angiography showed patent stent. blood pressure was immediately controlled to map 70-90 mmhg and patient improved. within 48 hours, patient was ambulatory. repeat ct brain did not show any acute infarction. 6 months after discharge, he was asymptomatic. hyperperfusion syndrome can develop even with relatively controlled blood pressure post-carotid revascularization. emergent vascular imaging is necessary to differentiate acute stent occlusion from hyperperfusion syndrome so that appropriate measures may be done. when aggressively managed, symptoms associated with hyperperfusion syndrome are fully reversible if not associated with hemorrhage. fulminant hepatic failure (fhf) or diffuse anoxic injury can lead to the development of cerebral edema and increased intracranial pressure. hypothermia has been utilized in both clinical scenarios in attempt to prevent the development cerebral edema and manage elevated intracranial pressure. in this case, we sought to determine a correlation between brain and core temperatures in specifically in intravascular therapeutic hypothermia (iht) this observation was conducted in a 32 year-old woman with grade iii hepatic encephalopathy (he) due to fhf. iht using coolgard® icy catheter (zoll medical) was started immediately as the patient progressed to grade iii he. esophageal and foley temperature probes were utilized for recording core body temperature. monitoring of brain temperature and intracranial pressure was conducted via licox® system (integra). goal temperature range for iht was between 32-34° c. brain and core temperatures were recorded hourly during iht which was a period of 87 hours. data was collected and plotted to show correlation between the three temperatures over time. measurements were obtained over the course of 87 hours to log temperatures. the results showed: brain temperature: y=-0.0068x +32.425. r 2 =0.1915. bladder temperature: y = -0.0045x +32.311. r 2 =0.08689. esophageal temperature: y = -0.0053x +32.322. the results show a direct linear correlation between brain, esophageal, and bladder temperatures accurate correlation between brain and core temperatures was demonstrated during ihs. further investigation using larger number of subjects is needed to confirm this. the cerebral circulation is normally pulsatile except for short periods of time in patients subjected to extracorporeal circulation, commonly used during cardiac surgery. a new generation of left ventricular assist devices (lvad) generates continuous, non-pulsatile blood flow. in patients with implantable continuous flow lvad (cflvad), peripheral arterial pulsatility will exist as long as the native heart is capable of maintaining enough contractility to generate some stroke volume during systole. we explored the intracranial circulation with transcranial doppler (tcd) in 8 patients that had a cflvad implanted and were neurologically intact. doppler insonation was performed through the routine temporal and occipital bone windows and proximal intracranial vessels were surveyed. transthoracic echocardiogram was performed in all patients to assess the lv function. 4/8 patients (50%) that had some preservation of the native heart function exhibited an intracranial flow pattern consisting of: high end diastolic flow velocity, very low pulsatility index and sometimes a sinusoidal wave appearance coincident with the native heart's systolic contraction. 4/8 patients (50%) that had extremely poor heart contractility exhibited a distinctive pattern of continuous flow where it was impossible to distinguish between systolic and diastolic flow. with the advent of new mechanical cardiac support for patients with end-stage heart failure, new peripheral and cerebral blood flow patterns develop and clinicians need to be aware of these distinctive and novel findings. this scenario opens an enormous opportunity to understand and better characterize a new physiological situation. it could also limit the usefulness of bedside tcd as a complementary method for the diagnosis of cerebral circulatory arrest given the lack of pulsation, known generator of the isolated systolic spikes or the "to and fro" pattern considered pathognomonic findings of the absence of intracranial circulation. edgar samaniego 1 , gregory kapinos 2 the advanced cardiovascular life support (acls) and advanced trauma life support (atls) provider courses are excellent resuscitation tools directed towards respiratory and hemodynamic stabilization, nevertheless, survival rates with good neurological outcome are dismal. the neurological content of acls and atls training manuals was reviewed. an advanced neurological life support (anls) course is proposed based on the deficiencies of acls and atls (table) . the neurological content of acls is 11% and covers only ischemic stroke, with no mention of hemorrhagic stroke or other neurological emergencies. the neurological content of atls is 6%, with a brief description of intracranial hemorrhages, increased intracranial pressure and spinal cord injuries management. both courses overlooked frequent devastating neurological emergencies like status epilepticus, anoxic encephalopathy, acute paralysis and meningitis. many basic concepts of neurological critical care management are missing in advanced resuscitation courses. we advocate the creation of an anls provider course to improve neurological outcomes of patients who undergo resuscitation. animal studies have shown that even a temperature elevation of one degree celsius can worsen neuronal injury after brain ischemia. since the skull acts as a thermal insulator, we hypothesized that decompressive hemicraniectomy lowers brain temperature by facilitating the heat convection from the brain to its surrounding air. fifty patients with severe brain injury (tbi=40, ich=10) requiring continuous brain temperature monitoring (licox, integra lifesciences, plainsboro, nj) from january 2007 to march 2009 were retrospectively studied and grouped into "hemicraniectomy" (n=22) or "no hemicraniectomy" group (n=28). the core body (t core ) and brain (t br ) temperature measurements were recorded at 1-min intervals over 12 ± 7 icu days. as a surrogate marker for the degree of external heat loss from the brain, t br-core was calculated as the difference between t br and t core with each recording. t-tests were used to initially assess the difference between groups. then, in order to account for clustering of observations in individual patients, generalized estimating equations (gee) were used to assess association of hemicraniectomy with t br-core , adjusting for core body temperature and diagnosis. ). however, after adjusting for intraindividual variability using gee, only higher core body temperature, but not hemicraniectomy, was associated with difference in t br-core (p=0.001 for t core ; p=0.53 for hemicraniectomy). this suggests that the t br-core temperature difference is larger at higher body temperature. substantial variability exists in the brain-to-body temperature gradient across patients and core body temperatures. however, this difference is not due to the presence of a hemicraniectomy. the assumption is often made that young people would want decompressive hemicraniectomy after a large stroke as a life-saving measure. however, this assumption favoring aggressive life-saving treatment, and the perception of quality of life after neurological disability, have not been adequately studied. we conducted a cross-sectional questionnaire-based survey that consisted of demographic information (age, sex, race, marital and family status, religion, income, education level, access to healthcare), and attitude towards neurological disability (based on the highest acceptable modified rankin scale (mrs) that they would be "willing to live with"). young adults in the los angeles county were surveyed and grouped by whether or not they would want hemicraniectomy after a large stroke despite a high likelihood of disability. findings from the two groups were compared using student's t-test and chi-square test. logistic regression analysis was used to determine the factors predicting willingness to accept decompressive hemicraniectomy. in this pilot study, 64 young adults (mean age: 24±6) were surveyed. the highest acceptable mrs (0-5) participants felt "willing to live with" were: 9.4% (0), 28.1% (1), 28.1% (2), 21.9% (3), 9.4% (4), 3.1% (5) . despite a high likelihood of severe disability, 44 of 64 (69%) reported they would undergo hemicraniectomy after a severe stroke. neither the demographic factors nor the highest acceptable mrs were associated with the willingness to seek aggressive treatment and hemicraniectomy. the results from our preliminary study support the commonly held assumption that young adults are generally willing to accept decompressive hemicranietomy as a life-saving measure. however, a substantial subset (~30%) were not willing to accept this aggressive measure, which emphasizes the importance of discussing the individual's previously stated wishes, even in the young population. further study in larger populations is needed to better characterize the factors impacting young adults' decisions regarding aggressive care. .154) , but a trend was noted for ne levels (p=.073), and a significant correlation was seen for dhpg (p=.018). our study supports the theory of a cns mediated adrenergic mechanism for nc, based on the presence of increased csf levels of ne and its dhpg metabolite. recent studies have suggested that recurrent stroke during aspirin treatment might have been caused by biochemical aspirin resistance (bar). we hypothesized that patients with bar would develop early recurrent ischemic lesions (erils) on diffusion-weighted imaging (dwi) more than those without bar. we included 120 consecutive patients who: 1) were admitted to our center within 24 hours of stroke onset; 2) had a final diagnosis of acute ischemic stroke, confirmed by dwi, or tia; 3) underwent follow-up dwi within seven days after initial dwi; 4) received aspirin therapy; and 5) underwent tests for bar. aspirin was administered to patients soon after initial imaging study. bar was measured using the veryfynow rapid platelet function assay-aspirin (accumetrics inc., san diego, ca). an aru 550 was defined as bar. erils were defined as new lesions on followup dwi with decreased apparent diffusion coefficient, which were not detected on initial dwi scans. the bar is associated with the development of erils during the first week after development of ischemic stroke. this suggests that increased thrombogenicity is one of important mechanisms of erils and that aggressive antiplatelet therapy is warranted during the acute phase. in this study we examined the effects of mannitol 20% on brain metabolism and brain tissue oxygenation (pbto2) in severely brain-injured patients with intracranial hypertension. twenty-two episodes of raised intracranial pressure (>20 mm hg) resistant to standard therapy that required infusions of mannitol were prospectively studied in 13 comatose patients with multimodality monitoring of intracranial pressure (icp), pbto2, and microdialysis. we compared mean arterial blood pressure (map), icp, cerebral perfusion pressure (cpp), pbto2, and brain lactate, pyruvate, and glucose using cerebral microdialysis, for 3 hours preceding and 4 hours after hyperosmolar therapy. time series data were analyzed using a multivariable general linear model (glm) utilizing generalized estimating equations (gee) for model estimation to account for within-subjects and betweensubjects variations over time. 1 g/kg of 20% mannitol solution led to a maximal reduction of icp at 30 minutes (from 27 ± 13 to 19 ± 16 mm hg, p <0.001). cpp increased at a peak of 45 minutes (from 73 ± 18 to 85 ± 22 mm hg, p = 0.002) after mannitol infusion was started, whereas map and pbto2 did not change significantly. compared to lactate-pyruvate ratio (lpr) at the time of osmotherapy (44 ± 20,) , mannitol resulted in a an 18% decrease over 2 hours (to 35 ± 16, p = 0.002). brain glucose levels remained unaffected. mannitol effectively reduces icp and augments cpp, and appeared to benefit oxidative metabolism as measured by the lpr. twenty-eight comatose sah patients that underwent multimodality monitoring with intracranial pressure and microdialysis were studied. mc was defined as lactate/pyruvate ratio (lpr) 40 and brain glucose <0.7 mmol/l. time series data were analyzed using a multivariable general linear model with a logistic link function for dichotomized outcomes. multimodality monitoring included 3178 hours of observation (mean 114 ±65 hours per patient). in exploratory analysis, serum glucose significantly decreased from 8.2 mmol/l (148mg/dl) 2 hours before to 6.9 mmol/l (124 mg/dl) at the onset of mc (p<0.001). reductions in serum glucose of 25% or more were associated with new onset mc (adjusted odds ratio [or] 3.6, 95% confidence interval [ci] 2.2-6.0). this association was independent of the absolute serum glucose level. in a second model we chose an elevation of the lpr by 25% or more as the outcome variable. again, reductions in serum glucose of 25% or more were independently associated with an lrp rise (adjusted or 1.6, 95% ci 1.1-2.4). all analyses were adjusted for significant covariates including glasgow coma scale and cerebral perfusion pressure. acute reductions in serum glucose, even to levels within the normal range, may trigger brain energy metabolic crisis and lpr elevation in poor-grade sah patients. hyponatremia develops in up to one-third of patients after subarachnoid hemorrhage (sah), and is usually attributed to cerebral salt wasting or siadh. our goal was to identify risk factors for hyponatremia after sah, and to determine its impact on outcome. we analyzed 1015 consecutive sah patients enrolled in the columbia university sah outcomes project between july 1996 and june 2006. hyponatremia was defined as sodium level 130 meq/l occurring at any point during hospitalization. multivariate analysis was performed to identify risk factors for hyponatremia. functional disability was evaluated at discharge and 12 months with the modified rankin scale (mrs, score 4-5) and barthel index (bi, score <90) the frequency of hyponatremia in or cohort was 13% (131/1015). hyponatremia developed on median post bleed day 6 with most cases occurring between days 2 and 9. logistic regression adjusted for gender and initial hunt hyponatremia occurs in 13% of sah patients, is predicted by older age, fever, renal failure and hydrocephalus, and is associated with reversible functional disability at discharge. failure to correct hyponatremia my potentially interfere with rehabilitation and recovery after sah. previous studies have reported that younger patients have a higher incidence of clinical deterioration from vasospasm after subarachnoid hemorrhage. we sought to determine the relationship between age, with the incidence of vasospasm defined by angiographic, tcd, or clinical criteria. we analyzed 1000 consecutive sah patients enrolled in the columbia university sah outcomes project between july 1996 and june 2006. vasospasm was assessed using angiography and/or a mean flow velocity greater than 120 cm/s in any vessel. symptomatic vasospasm was defined as clinical deterioration (i.e. a new focal deficit, decrease in level of consciousness, or both) and asymptotic vasospasm included a new infarct on ct that was not visible on the admission or immediate postoperative scan. a tcd velocity greater than 120 cm/s was observed in 50% of patients and of the patients that had follow-up angiography performed (48%), 52% of those patients had vessel narrowing consistent with angiographic vasospasm. in contrast symptomatic vasospasm was observed in only 17% of all patients with 11% of patients suffering infarction attributed to vasospasm. in total 21% of patients had either symptomatic vasospasm or asymptomatic infarction from vasospasm. multivariable logistic regression revealed that after accounting for disease severity (hunt & hess) , modified fisher score, gender, and history of smoking, younger age was significantly related to the occurrence of angiographic (or: 2.3, 95% ci: 1.5-3.4) and tcd>120cm/s (or: 3.4, 95% ci: 2.4-4.9) spasm, but was not significantly associated with symptomatic vasospasm (p=. 23) or delayed infarction from vasospasm (p=. 51). our data support the findings that younger patients are more likely to experience vasospasm defined by tcd and angiography than older patients, but in our cohort we did not observe a higher incidence of clinical vasospasm or infarction. aggressive treatment of tcd-based and angiographic vasospasm with intra-arterial vasodilators or balloon angioplasty may mitigate the effect of age. post-traumatic vasospasm (ptv) occurs in 20-50% of patients with severe traumatic brain injury (tbi), and is an independent predictor of neurological outcome. although ptv incidence has been associated with injury severity, there are conflicting reports regarding patterns of intracranial hemorrhage that may correspond with development of posttraumatic vasospasm. some authors report that subarachnoid hemorrhage or subdural hematoma is necessary to develop ptv, while others have reported significant ptv in the absence of these lesions. we performed a review of prospectively collected ct scan data from 394 consecutive head injured patients treated at a tertiary level i trauma center. rotterdam ct score data was reviewed from all patients in the tbi registry, and admission head ct scans from patients with severe tbi (gcs 8) with (n=8) and without (n=37) clinically significant ptv (csptv) were re-evaluated by a 'blinded' investigator. csptv was defined as demonstrated neurological decline with ct angiographic evidence of arterial vasospasm. rotterdam ct score significantly correlated with the development of csptv(p=0.03). the components of this score were further investigated. we found no correlation between epidural hematoma, subdural hematoma, midline shift, or cisternal compression and the development of csptv. the presence of intraparenchymal hemorrhage (p=0.02) and cisternal subarachnoid hemorrhage (p=0.035), however, significantly correlated with risk of csptv. all cases of csptv were diffuse in anatomic distribution, and, therefore, did not correlate with side of maximal injury. rotterdam ct score, intraparenchymal and cisternal subarachnoid hemorrhage on admission ct are significantly correlated with the incidence of csptv. this suggests that risk of cerebral vasospasm following traumatic brain injury is increased not only in subarachnoid hemorrhage, but also intraparenchymal hemorrhage, and that rotterdam ct score may be a useful metric for assessing risk of csptv in severe tbi patients. we reviewed 394 patients from a tertiary level 1 trauma center tbi registry and identified 10 patients with clinically significant ptv (csptv), defined as demonstrated neurological decline with ct angiographic evidence of arterial vasospasm. patient charts were reviewed to characterize the natural history, treatment and efficacy of treatment in csptv. treatment strategies for patients with csptv included observation, "triple-h" therapy, oral statins, intra-arterial verapamil infusion and tba. the decision to pursue intra-arterial therapy was based on severity of spasm and clinical exam. observation alone was used in patients with mild, diffuse spasm on cta and rapid clinical improvement (n=2), whereas those with persistent signs of spasm all underwent medical therapy (n=7). intra-arterial verapamil infusion was used in patients with moderate to severe spasm (n=5). tba was performed in patients who had severe and diffuse spasm (n=2). in all cases, therapy was effective in reducing (n=4) or reversing (n=5) ptv. three month functional outcome data revealed no significant differences between patients with and without csptv. treatment of ptv is effective in reducing or reversing arterial vasospasm. a variety of therapies exist, which should be chosen based on clinical exam and the degree and distribution of spasm. although it is unknown if treatment improves outcome, our data suggest that patients with csptv have similar outcomes to those without csptv when they are adequately treated. a clinical pathway is presented to aid in the screening, diagnosis, and treatment of ptv. tracheostomy and gastrostomy are common procedures in patients suffering neurologic insults. we report our current data of these procedures performed simultaneously at bedside by a neurointensivist using percutaneous techniques. database of all tracheotomies, gastrostomies and combined procedures performed by the neuro-critical care team was retrospectively analyzed. also, satisfaction surveys by nursing and house staff were employed to reassess and refine the service. all procedures were completed at bedside in the neurointensive care or other intensive care units utilizing two critical care fellows, an intensive care nurse and a respiratory therapist under the direction of the neurocritical care attending. the team followed each patient daily and reported any complication until discharge. complications were categorized as major (requiring additional surgical intervention) or minor (no additional surgical intervention). to date the team has performed over 75 combined percutaneous tracheostomy and gastrostomiesin patients with primary neurologic pathology. there were two major complications and five minor complications reported. the neurologic pathology was mixed as was the,age and weight ranges combined tracheostomy and peg tube placement can be performed safely by a neurointensivist complications rates are low and no catastrophic events reported. attendings, house staff and nursing supports the continuation of this programs the neuro-critical care service now performs the majority of these procedures in our institution based on the success of the service, non-neurologic related services are consulting the neuro-critical care team to perform these procedures. introduction: traumatic brain injury (tbi) is a complex disease state that includes disruption of the blood-brain barrier (bbb) and inflammatory changes. angiopoietins are a family of growth factors integral in maintaining endothelial integrity and controlling inflammation. angiopoietin i (ang1) induces phosphorylation of the tie2 ligand enhancing endothelial integrity. angiopoietin ii (ang2) inhibits this action. in animal models, ang2 is up regulated in tbi while ang1 appears unchanged. injury models in other tissues suggest that the ratio of ang1 to ang2 may be significant. little is known about their role in humans with tbi. we collected csf from patients with tbi (6 patients) and compared it controls (4 patients). individual levels and ratios were compared. each non-tbi csf had < 5 cells/um, negative gram stain and cultures and normal protein and glucose levels. csf samples were collected from the tbi group within 24 hours of drainage placement.. ang1 and ang2 were analyzed using an elisa method and reported in pg/ml. the levels of ang1 in the control group and tbi group were not significantly different (p value of 0.37). there was significant increase in ang-2 in the tbi group (p = 0.001). comparing the ratios of ang1 and ang2, ang1 was 6 times higher (1:6) in the control group than in the in the tbi group (0.95:1). this data correlates with animal data that shows an increase in ang2 after tbi. this data further demonstrates a significant change in the ratio of ang1 to ang2 after tbi. what happens over time and how this relates to severity and prognosis is yet to be investigated. restoring an ang-1 to ang-2 ratio to normal may be a therapeutic strategy worthy of investigation. external ventricular drains (evd) and intracranial pressure monitoring equipment are used frequently in neuroscience intensive care units. because of the potential for the development of nosocomial infection prevention is important. current practice varies from using no antibiotics to continuous antibiotics while devices are in place. there is inadequate foundation to support a particular practice. to define practice patterns, a survey was sent to >8,000 neurosurgeons, critical care, neurocritical care, and infectious diseases specialists. the same survey was also submitted to members of the neurocritical care society but filtered to exclude redundancy. ten percent of practitioners solicited responded to the survey. eighty seven percent of respondents were from north america, followed by asia, europe, and south america. twothirds practiced in academic centers and had > 10 years experience. seventy seven percent of respondents were neurosurgeons, followed by neurocritical care, infectious diseases, and critical care. o 25% peri-operative abx o 37% use none. one third of respondents use antibiotic coated evd's there are differing practices among the specialties surveyed. a majority of the respondents use abx for the duration the devices are in place. there are differences in practice among respondents based on specialty, geography, years of practice and type of practice. eighty percent of respondents think a randomized trial comparing abx strategies is needed. retrospective chart review of prospectively identified patients. per institutional protocol, patients were cooled to a nadir of 33 0 c. baseline prothrombin time (pt), partial thromboplastin time (ptt) and platelet count were obtained and followed at least daily during th and rewarming. data was evaluated for the development of new abnormalities following th induction. thirty six patients received th for various clinical indications, including cardiac arrest and intracranial pressure control (related to subarachnoid hemorrhage, intracerebral hemorrhage, ischemic stroke, and traumatic brain injury). duration of goal temperature maintenance varied from 4 hours to 120 hours. after induction of th, 6/36 (16.7%) showed abnormal pt, 5/36 (13.9%) had abnormal ptt, and 4/36 (11.1%) patients developed thrombocytopenia (platelet count <150,000/µl). in those developing abnormalities, normalization was not seen for any parameter within 48hrs of rewarming. overall, 22% of the patients demonstrated some form of new abnormality following th, none of which had clinically significant bleeding episodes. overall, 30-day mortality was 72%; no mortality was attributable to th. we concur with the previously reported findings that th is associated with coagulation abnormalities. a high proportion of patients were found to demonstrate such abnormalities, which persisted following rewarming; the exact clinical significance of these findings is not clear. in addition to this standard laboratory testing, changes in radiographic imaging may serve as a more sensitive adjunctive measure to evaluate the significance of th related coagulopathy. transtentorial herniation (tth) is a clinical syndrome consisting of pupillary dilatation with loss of pupillary light reflex and decreased level of consciousness in the setting of a large intracranial mass lesion. reversal of tth is defined as return of pupillary light reflex with or without immediate improvement in level of consciousness. the role of renal function in the mechanism of hypertonic therapy remains unclear. we evaluated the efficacy and safety of 23.4% saline in tth in patients with end-stage renal disease (esrd) on hemodialysis. patients with clinically defined tth and esrd on hemodialysis treated with 23.4% saline (30 to 60 ml) were included in the analysis of a retrospective cohort. of 254 subjects over 7 years, we identified 6 patients with esrd that had 11 tth events. lesions were related to stroke (n=1), intracerebral hemorrhage (n=4), and subdural hemorrhage (n=2). all patients received a 23.4% saline bolus, along with mannitol (91% of events), hypertonic saline maintenance fluids (82%), ventriculostomy (n=1), and hemicraniectomy (n=1). clinical reversal of tth occurred in 10/11 events (91%); 2 of 6 patients survived to discharge. in 4 patients, icp recording of 6 tth events showed a reduction from icp of 41 3.8 mmhg (mean sem) with tth to 20.8 3.9 mmhg (p=0.05) one hour after the 23.4% saline bolus. serum sodium increased from 141.4 mmol/l to 151.1 mmol/l 24 hours after 23.4% saline bolus (p=0.001). no patients were undergoing hemodialysis at the time of the tth event, and the post-infusion serum creatinine did not change. treatment with 23.4% saline was associated with rapid clinical reversal of tth and reduction in icp in this small cohort of patients with esrd. this finding supports that hypertonic saline may be effective in cases of esrd. introduction: intubated patients with subarachnoid hemorrhage (sah) may spontaneously hyperventilate despite minimal ventilatory support. the impact of this is unclear, although hypocapnea may be harmful in traumatic brain injury. we set out to determine the incidence of spontaneous hyperventilation in patients with sah and its association with clinical outcomes. we identified consecutive, intubated patients with spontaneous sah from clinical databases (2006) (2007) (2008) . demographics, clinical and ventilation data (for the first 10 days post-bleed) were collected. hypocapnea was defined as an arterial pco2 <= 35 mmhg. primary outcomes were (1) the presence of symptomatic vasospasm (defined by both angiographic vasospasm and clinical symptoms); (2) death in the intensive care unit. associations between hypocapnea and outcomes were explored with multivariate analysis. we identified 99 patients with sah and a median duration of ventilation of 4 days [iqr 1-12]. hypocapnea was observed on at least one day in 91 patients (92%), and 68 patients (69%) had at least 1 pco2 <30mmhg. all hypocapnea was associated with alkalemia. ventilatory support was minimal (cpap or ps 5cm h2o) in 68% of hypocanea measurements. sedation normalized pco2 in 63% of cases, and use of neuromuscular blockade was rare. median duration of hypocapnea (at least one pco2 <=30mmhg each day) was 3 days [iqr 2-6]. duration of hypocapnea was associated with increased odds of symptomatic vasospasm (or 1.24 for each day with hypocapnea; p=0.02) after adjusting for fisher ct grade. duration of hypocapea was not associated with icu mortality after adjustment for apache ii and wfns grade (p=0.88). the incidence of spontaneous hyperventilation is high in intubated patients with sah, despite minimal ventilator support. duration of hypocapnea was independently and statistically significantly associated with symptomatic vasospasm. few studies have evaluated physician-family interactions and decision-making in the neurocritical care unit (nccu). we sought to determine if the icu team's use of a structured checklist for family conferences (fc) would improve family satisfaction. we conducted a prospective pilot pre-and post-intervention study. we designed an 18-item checklist of key content for fc conducted with the intent of making significant patient management decisions. phase i was observational, with a nurse covertly documenting the key content covered during the fc. phase ii was interventional. we asked the icu team to use the checklist during fc to cover all key content. a family member and the icu team member completed an immediate post-fc written survey, and the fs-icu 24, a family satisfaction survey, was mailed to the family 3 months after nccu discharge. 12 families enrolled (7 phase i; 5 phase ii), with patient age 57 ± 20 years, apache iii score 66 ± 30 and nccu los 20 ± 20 days. 8 patients died (4-pi; 4-pii). median key content covered was 10 items in phase i and 12 items in phase ii (p=0.5). in phase ii, icu team member self-report of key content was higher than documented content (18 vs. 12 items; p=0.1). post-fc survey scores increased from 87.5 (phase i) to 100 (phase ii) (p=0.4). the fs-icu 24 decision-making subscale median score was 92.5 in phase i and 85 in phase ii (p=0.8). use of a fc checklist in the nccu marginally improved coverage of key elements in family conferences, however post fc family satisfaction was improved. further evaluation of the influence of checklists on patient outcomes and family satisfaction for family conferences in the nccu is warranted. h. adrian püttgen 1 , jai madhok 3 , xiaofeng jia 2 , anil maybhate 2 1 johns hopkins university medical institutions, baltimore, md, united states, 2 johns hopkins university school of medicine, baltimore, md, united states, 3 johns hopkins university, baltimore, md, united states sep's represent the brain's response to sensory electrical stimulus. current clinical methods require averaging a large number of sep waveforms for meaningful prognostication. automated sep monitoring could be used as a noninvasive bedside tool for conditions that severely affect somatosensory conduction due to elevating intracranial pressure (icp) such as cerebral oedema or intracerebral haemorrhage. 3 adult wistar rats were used in this pilot study. to model intracranial hypertension, a latex micro-balloon (300µl maximum volume) was surgically inserted into the epidural space via a burr hole on the left hemisphere (2mm off the sagittal suture). using a micro-pump, the balloon was slowly inflated with water at 20µl/min for two 5min periods with a 10min pause. seps were recorded after electrically stimulating the hind limb at 0.5hz. icp was recorded using a transducing catheter inserted in the subdural space over the right hemisphere. balloon inflation was accompanied by a steady increase in the icp. the increase in icp beyond a certain level was accompanied by the sudden disappearance of sep's within a few seconds (2 to 3 sweeps). in our pilot experiments, the peak to peak amplitude of the sep dropped steeply from about 496+65µv to 115+52µv before a complete and sudden disappearance when the balloon volume reached approx. 200+27µl. this pilot study demonstrates the effect of an intracranial mass on the integrity of the somatosensory pathway. the finding of a threshold of lesion magnitude after which further expansion causes a dramatic disappearance of sep points to the possibility of using continuous sep for monitoring rapidly evolving mass lesions such as cerebral oedema or intracerebral haemorrhage. we studied the feasibility of intracortical electroencephalography (ice) including quantitative eeg (qeeg) analysis for the detection of vasospasm in a series of poor-grade sah patients. from a consecutive series of sah patients who underwent ice placement, the alpha/delta ratio (8-13 hz/1-4 hz; adr) was calculated at twenty second intervals from the ice and scalp eeg recordings. percent changes between averaged values over 4-6 hours of the baseline eeg and the eeg prior to angiography were calculated. the entire continuous qeeg recording for each patient was then reviewed to determine optimal automated alarm criteria. ice recordings revealed an improved signal-to-noise ratio when compared to surface eeg recordings. the adr calculated from the ice decreased between baseline eeg and follow-up eeg on average by 42% (mean adr decrease 0.56±0.07 to 0.32±0.03) for those with vasospasm (n=3) compared to 17% (0.62±0.06 to 0.51±0.03) for those without vasospasm (n=2). a sustained decrease in the adr by at least 25% from baseline for a minimum of 4 hours occurred in patients with vasospasm 1-3 days before angiographic confirmation of vasospasm. this was not seen in patients without angiographic vasospasm. eeg recordings from ice are promising to reliably detect vasospasm in severely brain injured sah patients. absence of artifact allows for automated qeeg analysis of ice recordings. raising the head-of-bed (hob) js a very important step in taking care of critically ill patients, particularly in the neurocritical care, as it influences abdominal pressure, decreases incidence of pneumonia associated with aspiration secondary to the decrease in gastroesophageal reflux and reduces intracranial pressure, improving cerebral perfusion pressure. nevertheless, this relatively simple maneuver is still not widely applied. after explaining the goals of raising the hob individually, each health-care worker (hcw) attending in our 8-bed neurocritical care service was requested to position the hob between 30 and 45 degrees. as our beds are able to measure hob angulation, it was later conferred. after this simple procedure, hcw were again explained and a folder was distributed. it contained a questionnaire and pictures of hob at 15, 30, 45 and 60 degrees. later on, they were again requested to position hob at the adequate position. the first poll revealed that 22 out of 23 participating nurses did not or only partially knew the reasons hob should be positioned between 30 and 45 degrees and almost 70% of the attempts resulted in failures. among physicians, 87.5% only partially knew the reasons. they could rightly position hob in 56% of the attempts. after the questionnaire, every and each one of the hcw could name the reasons of hob positioning and almost 90% of the attempts resulted in right results. hcw should be constantly reminded the importance of simple tasks in the care of neurocritical patients. hob elevation should not be regulated by random trials. automatic beds are very important devices, particularly when some features are present, such as hob angulation and, even though it could seem an expensive device, it will finally allow cheaper and less risky expenditures. posterior reversible encephalopathy syndrome (pres) can be caused by hypertensive crisis and is often associated with rapid fluctuations in blood pressure (bp). the role of these bp changes in the pathogenesis of pres has not been formally studied. we sought to analyze the relationship between blood pressure (bp) fluctuations and the occurrence of pres. consecutive hospitalized patients who developed pres were compared with randomly selected controls matched for age, gender, and history of hypertension. systolic bp (sbp) and diastolic bp (dbp) were collected every 2 hours for 48 hours before developing pres symptoms. sbp, dbp, mean arterial pressure (map), and pulse pressure (pp) changes over a 48-hour window was summarized for each individual by calculating an m value as described by service et al (1970) . m values were compared using wilcoxon signed rank test. tests were two sided and p values less than 0.05 were considered statistically significant. we analyzed the bp profiles in 25 cases of pres and 25 controls. median age of pres patients was 54 years (range 31-72). 14 of them (56%) had pre-existing hypertension. hypertensive encephalopathy was considered the etiology of pres in 13 patients (52%). at symptomatic onset of pres, mean sbp was 182 ± 20 mmhg (range 218-145), dbp 95 ± 16 mmhg (range 134-62), map 124 ± 15 (range 152-93), and pp 87 ± 18 (range 123-46). while bp was higher in pres cases, hypertension severity was variable and bp fluctuations were not significantly more common than in controls (p values for sbp, dbp, map, pp were 0.38, 0.79, 0.25, 0.73, respectively). bp fluctuations do not appear to be more common in hospitalized patients who develop pres compared with matched controls. other predisposing factors must therefore contribute to the development of pres. technologies allowing emergent detection of focal cerebral hypoxia would be of great utility in the treatment of ischemic stroke by facilitating diagnosis, tracking reperfusion, and identifying re-thrombosis. non-invasive brain oxymetry using near-infrared reflectance spectroscopy (nirs) technology incorporated into the invos device (somanetics, troy, mi), provides direct measurement of regional oxyhemoglobin saturation (rso2) within the cerebral cortex. this study utilized the invos device to determine the predictive value of cortical rso2 monitoring in the assessment of ischemia in patients presenting with large hemispheric strokes. patients exhibiting acute ischemic strokes involving proximal mca or ica occlusions on ct angiography were enrolled prospectively. the invos device was applied according to the manufacturer's recommendations. rso2 data was recorded at 10 s intervals for at least 10 hr in each patient. concomitant vital signs, hgb, oxygen saturation, pao2, and paco2 were collected. three out of 5 patients underwent emergent cerebral angiography. a neuroradiologist, blinded to the invos results, evaluated all ct, ct perfusion, and cerebral angiography studies. ct perfusion imaging confirmed large hemispheric strokes in all patients. mean time from symptom onset to start of rso2 monitoring was 7 hours (range =3-12). data analysis consistently demonstrated mean ro2 saturation levels on the ischemic hemisphere to be either the same or higher than that of the non-ischemic hemisphere. rso2 levels were independent of bp, hgb, oxygen saturation, pao2 or paco2 levels. cerebral angiography demonstrated significant collateral flow over the affected hemisphere despite deep large vessel occlusions. these findings suggest that nirs technology has limited utility in the assessment of patients with acute ischemic stroke. patency of cortical collaterals and increased tissue oxygen extraction during ischemia, among other factors, may offset a decrease of cortical rso2 within the affected hemisphere. venous thromboembolism is a common problem in critically ill patients. neurosurgical patients even though at higher risk; often do not receive timely pharmacological thromboprophylaxis for fear of bleeding risks. recent literature points towards the safety and efficacy of early prophylaxis (scd's + heparin/lovenox); however this has not been tested extensively in a randomized controlled trial. a retrospective chart review of patients with a primary diagnosis of subarachnoid hemorrhage (sah), intracerebral hemorrhage (ich), and subdural hematoma (sdh) admitted from january 2008 to june 2009 was conducted for icd-9 codes of dvt and or pe, and for presence of associated risk factors. all patients received intermittent compression devices (scd's) on all patients from time of admission to time of discharge, surveillance doppler ultrasound evaluation of both lower extremities once every week, and doppler screening of symptomatic upper extremities. overall incidence of dvt was 6.92% (n=260). the incidence of dvt was 8.69% in sah, 5.42% in ich, and 8.06% in sdh. the incidence of pe was 0.76%.the presence of intraventricular hemorrhage was seen in 83.3% of patients with sah who had dvt. this study shows almost double the incidence of dvt than reported in the recent literature. picc line and central lines were associated with higher incidence of dvt.the timing of the diagnosis of dvt falls in a time window where intracranial bleeding risks from anti-coagulation are far less than in the acute stage. this study will provide us a unique cohort of patients whom we can compare in a prospective manner to patients who will receive subcutaneous heparin along with scd's in the future, since we are changing our policy to implement heparin thromboprophylaxis. the presence of intraventricular hemorrhage (ivh) is predictive of worse outcomes following aneurysmal subarachnoid hemorrhage (sah) [1] . however, the amount of ivh can vary considerably. no previous studies have assessed the association between actual hematoma volume (in ml) and subsequent complications or outcomes. we performed a cohort study involving 152 consecutive patients with concomitant sah and ivh. with investigators blinded to subsequent events, ct scans were graded using two systems. first, to determine the volume of ivh, we used the ivh score, recently shown to correlate exceptionally well with computerized volumetric assessment [2] . second, to examine the relative amount of subarachnoid blood, we applied the sah component of the hijdra score [3] . using logistic regression to adjust for sah score and other potential confounders, we assessed the association between ivh volume and poor neurological outcomes (glasgow outcome scale 1-3), as well as symptomatic vasospasm and delayed infarction. compared with patients who had a favourable outcome, those with poor outcomes had significantly larger baseline ivh volumes (mean 3.8 ml vs. 11.8 ml, p=0.001). in the multivariable analysis, ivh volume remained an independent predictor of poor neurological outcome (or per ml: 1.11, 1.04-1.18, p=0.01). patients in the highest quartile for ivh volume were far more likely to progress to poor outcomes compared with those in the lowest quartile (or 4.09, 1.32-12.65, p=0.01). in contrast, ivh volume was not associated with either vasospasm or delayed infarction. interobserver agreement in the determination of ivh score was good. volume of ivh is a strong, independent predictor of death and poor neurological recovery, even when one adjusts for the amount of concomitant subarachnoid blood. future studies should assess whether measures aimed at accelerating the clearance of ivh (e.g. intraventricular thrombolysis) can modify this association. andrew naidech, kimberly levasseur, storm leibling, rajeev garg, michael shapiro, michael ault, sherif afifi, hunt batjer northwestern university, chcago, il, united states while many icus have implemented protocols for tight glucose control, there are few data on relative hypoglycemia and neurologic outcomes. we addressed the hypothesis that lower glucose leads to worse neurologic outcomes after subarachnoid hemorrhage (sah). one hundred seventy-two (172) consecutive patients were treated with a protocol designed to achieve serum glucose 80 -110 mg/dl. we prospectively ascertained patients on admission and recorded medical history and clinical events. glucose measurements from the hospital laboratory were electronically retrieved. (a separate analysis of bedside glucose results found similar results.) cerebral infarction was prospectively documented with neuroimaging. outcomes were assessed with the modified rankin scale (mrs) at 14 days, 28 days and 3 months. worse neurologic injury at admission (p<0.001) and a history of diabetes (p=0.002) were associated with increased glucose variance. patients with radiographic cerebral infarction (81 ± 15 vs. 87 ± 16 mg/dl, p=0.02), symptomatic vasospasm (78 ± 12 vs. 84 ± 16 mg/dl, p=0.04) and angiographic vasospasm (79 ± 14 vs. 86±16 mg/dl, p=0.01) had lower nadir glucose, but maximum and mean glucose were not different. glucose < 80 mg/dl was earlier and more frequent in patients with worse functional outcome (p<0.001). progressive reductions in nadir glucose were associated with increasing functional disability at 3 months (p=0.001) after accounting for neurologic grade and mean glucose. severe hypoglycemia (<40 mg/dl) occurred in one patient. in patients with sah, nadir glucose below the <80 mg/dl is associated with cerebral infarction, vasospasm, and worse functional outcomes in multivariate models. protocols for target glucose 80 -110 mg/dl effectively control hyperglycemia, but may place patients with sah at risk for vasospasm, cerebral infarction and poor outcome even when severe hypoglycemia does not occur. andrew naidech, rajeev garg, storm liebling, kimberly levasseur, micheal macken, stephan schuele, hunt batjer northwestern university, chicago, il, united states there are few data on the effectiveness and side effects of anti-epileptic drug (aed) therapy after intracerebral hemorrhage (ich). we tested the hypothesis that aed use is associated with more complications and worse outcome after ich. we prospectively enrolled 98 patients with ich and recorded aed use as either prophylactic or therapeutic along with clinical characteristics. aed administration and free phenytoin (pht) serum levels were retrieved from the electronic medical record. patients with depressed mental status underwent continuous eeg monitoring. outcomes were measured with the nih stroke scale and modified rankin scale (mrs) at 14 days or discharge, and the mrs at 28 days and 3 months. we constructed logistic regression models for poor outcome at 3 months with a forwardconditional model. seven (7%) patients had a clinical seizure, five on the day of ich. pht was associated with more fever (p=0.03), worse nih stroke scale at 14 days (23 [9-42] vs. 11 [4] [5] [6] [7] [8] [9] [10] [11] [12] [13] [14] [15] [16] [17] [18] [19] [20] [21] [22] [23] , p=0.003) and worse mrs at 14 days, 28 days and 3 months. in a forward-conditional logistic regression model pht prophylaxis was associated with an increased risk of poor outcome, or 9.8 (1.4-68.6) p=0.02, entering after admission nih stroke scale and age. excluding patients with a seizure did not change the results. levetiracetam was not associated with demographics, seizures, complications, or outcomes. pht was associated with more fever and worse outcomes after ich. posterior reversible leukoencephalopathy syndrome (pres) is characterized by seizures, headache, encephalopathy and visual disturbances associated with reversible vasogenic edema on brain imaging. status epilepticus (se) has been infrequently described as an initial manifestation of pres. the clinical and radiological features of patients with pres and se have not been well described. patients with se were identified from a mostly prospectively collected database of patients (n=113) with pres. we collected data on general demographics, clinical presentation, history of epilepsy, peak systolic and diastolic blood pressures, and predisposing conditions. brain mris were analyzed independently by two neuroradiologists for lesion location and distribution, severity, presence of hemorrhage and presence of restricted diffusion. of 113 patients with pres, 20 (18%) presented with se. only 2 had a prior history of epilepsy. mean peak sbp was 199 mm hg (160-268) and mean dbp was 109 mm hg (60-144). etiologies of pres included hypertension (n=13), cytotoxic medications (n=3), sepsis (n-2) and other (n=2). renal failure was present in 11 (55%) cases and 5 (25%) had pre-existing chronic kidney disease. twelve patients (60%) had a history of autoimmunity. among 19 patients with brain mri, 8 (42%) demonstrated mild edema and 11 (58%) had moderate-severe edema. the cortex was involved in only 2 patients (11%). almost all had edema in the parietal-occipital region (n=18, 95%). when compared with the rest of our pres cohort, we did not identify any significant clinical or radiological predictors of se. se is not an infrequent presentation of pres. its occurrence is not correlated with the severity of radiologic edema and the great majority of patients actually lack cortical involvement. recognition that pres may present with se is important because, besides anticonvulsants, appropriate treatment requires identifying and treating the underlying cause of pres. hypervolemia is known to lead to peripheral and pulmonary edema however the effect on intracranial pressure (icp) following traumatic brain injury (tbi) is unclear. there is no direct evidence in humans linking hypervolemia independently to elevated icp. compelling evidence suggests that fluid restriction should be avoided and limited evidence suggest significant hypervolemia may be associated with worse outcome following tbi [1] . the use of fluids and vasopressors to elevate cerebral perfusion pressure (cpp) >70mmhg has been to shown to increase the risk of pulmonary complications (but not clearly effect icp) following tbi and is not recommended by guidelines [2, 3, 4] . despite this, some ancillary monitoring protocols recommend elevating cpp to treat episodes of cerebral hypoxia. retrospective observational cohort study of severe tbi patients admitted over a 2-year period to a neuro-trauma unit. data extracted: characteristics; fluid balance; development of refractory intracranial hypertension (rih); pulmonary complications; use of vasopressors; ancillary monitoring. patients with unsurvivable injuries, early withdrawal of care or the development of refractory intracranial hypertension (rih) within 24 hours were excluded. forty-one patients with mean age 35.2; 73% male; 73% automobile accidents; 61% polytrauma; average best gcs of 6.4 (a subgroup presented with higher gcs with declined secondary to neurological injury). rih was associated with lower fluid balance but not hypervolemia (overall q1= 50%, iq = 21%, q4 =27%). an early low fluid balance and hypervolemia both are associated with more pulmonary complications. the use of vasopressors, and to a lesser extent licox monitoring is associated with a higher incidence of pulmonary complications and possibly rih. [tables 1-4] 33% (3/9) 50 % (10/20) 90% (9/10) q1 = first quartile, iq = interquartile, q4 = fourth quartile; rih = failure of first tier therapy by brain trauma foundation; pulmonary complications = ards or pulmonary edema with p/f ratio <300; use of vasopressors = for > 48 hours and > 12 hours to maintain cpp > 70mmhg following severe tbi hypovolemia should be avoided as it's associated with increased icp and pulmonary complications [1] . extreme hypervolemia should be avoided, if possible, to minimize pulmonary complications. ancillary monitoring protocols should be used with caution, as the components that may improve outcome versus those that may harm are incompletely defined. without correction for patient demographics, severity of illness, and head ct findings further conclusions cannot be made. invasive mechanical ventilation is required in one third of patients with guillain-barré syndrome (gbs). there are few early indicators of subsequent progression to respiratory failure. adrenal function has rarely been studied in patients with gbs. we assessed the relationship between plasma cortisol level and gbs related complications, notably respiratory failure. plasma cortisol levels were measured before (t0) and 60 minutes (t60) after corticotrophin test in 93 gbs patients at admission, 16 (17%) of which were ventilated within 24 hours from admission, 17 (18%)ventilated after the 24 th hour and 60 (65%) never ventilated. the volume of subarachnoid hemorrhage (including intraventricular blood) following aneurysmal rupture is associated with the development of vasospasm. intraventricular catheters (ivc) facilitate cerebral spinal fluid (csf) drainage and may reduce the incidence or severity of vasospasm but little evidence exists from which clinicians may determine the best practice. the purpose of this study was to provide the foundation for designing a trial that will explore how different methods of csf drainage may impact outcomes in these patients. this observational pilot study enrolled 34 adult sah patients. data was collected through chart abstraction. attending neurosurgeons determined whether each patient's ivc was primarily left open to drain csf resulting in intermittent icp monitoring (drain-first group), versus an ivc that was primarily set to monitor icp resulting in intermittent csf drainage at a set pressure threshold (monitor-first group). subjects were primarily female (68%), mean 54 years old. subjects in the drain-first group (n=22) and the monitor-first group (n=12) had similar hunt/hess (p=0.43) and fisher scores (p=0.69). although there are no statistically significant differences between groups, this pilot study was not designed to test a hypothesized difference. the monitor-first group had lower mean csf output (115 vs 132 ml/day), lower rates of vasospasm (42% vs 68%), lower incidence of complication (25% vs 64%), shorter length of stay (18 vs 21 days), and lower modified rankin scores at discharge (3.6 vs 3.8). this observational study suggests that the method of ivc management may impact clinical outcomes. although the monitor-first group method appears to be favourable, it is difficult to attribute differences in a non-randomized trial. a larger randomized controlled clinical trial is now in progress. introduction: subarachnoid hemorrhage (sah) patients whose initial angiogram does not locate a bleeding source are often classified as having perimesencephalic hemorrhages. however, many patients do not fit into this benign picture and are non-perimesencephalic, angiogram-negative sah (npan-sah). though the conventional angiogram remains the gold standard for diagnosis, multiple non-invasive imaging tests, beyond a second angiogram, are often performed in the acute evaluation of npan-sah. with irb approval, we retrospectively reviewed 226 non-traumatic sah patients admitted to our institution from january 1, 2007 to june 1, 2009. hunt-hess and fisher scores, in-hospital complications, and imaging data were abstracted from medical charts. non-perimesencephalic angiogram-negative sah has a worse prognosis compared to perimesencephalic sah. additional non-invasive neuroimaging provided no diagnostic yield in either patient population. guidelines suggest an ideal time from injury to surgical decompression of less than four hours in patients with acute traumatic subdural or extradural haematoma. previous audits at our centre showed this standard was not consistently achieved. we looked for a relationship between the length of this time interval and adverse neurological outcome at six months. we retrospectively reviewed all patients with acute traumatic subdural (asdh) or extradural (aedh) haematoma transferred to our neurosurgical centre over a three year period (december 2005-november 2008) for emergency surgical decompression. we identified the time elapsed from presentation at the emergency department to commencement of surgical decompression. we then assessed neurological function at six months post surgery using a glasgow outcome score. we were able to include 59 patients in our study (35 asdh, 24 aedh). the mean time from presentation to surgery was 7:52 hours. at six months 52.5% of patients had a good neurological outcome (gos 1-3), 47.5% had a poor outcome . of those presenting with gcs <9, 33% had a good outcome compared to 65% of those with an admission gcs of 9 or above. achieving definitive surgery within four hours of presentation, let alone injury remains elusive. we were unable to associate prolonged length of transfer time with worse neurological outcome at six months. our study was retrospective and the numbers were small. our unit accepts a significant number of patients from outside its normal referral area, meaning there may already be a significant delay in many cases. in most cases there was no single identifiable reason for delay and a few cases showed that transfer could be achieved very rapidly. sah patients who had hunt-hess grades 3-5, a ventriculostomy, and tcus performed for at least 7 days were included in this study. csf 1ml was collected from each patient during the first 72 hours and assayed by hplc for levels of epinephrine (epi), norepinephrine (ne), and dihydroxyphenylglycol (dhpg). mca vs was defined as a mean velocity (mv) > 120cms/s with a mca/ica ratio of >3 at any time. analyses were calculated on a per-case and per-vessel basis. of the initial 40 patients included, 15 were excluded due to incomplete data as a result of early mortality or absent bone windows. from the remaining 25 patients, 3 had only ipsilateral bone windows, resulting in a total of 47 vessels amenable to insonation. mean age was 58yo, and 65% were female. ct scores (frontera et al.) were 1=3%, 2=24%, 3=5%, & 4=68%. on a per-case basis, patients with mca vs were younger (49yo vs 64yo, p=.003), but no correlation was observed between mca vs and adrenergic levels. on a per-vessel basis, hh grade tended to correlate with mca vs (p=.084), but again no association was observed between mca vs and adrenergic levels. no connection was seen between csf adrenergic levels and mca vs. our study is limited by small numbers, but our findings are consistent with the available literature whereby the association between the sympathetic nervous system and vs remains uncertain. marek mirski 1 hospital of the university of pennsylvania, philadelphia, pa., united states, 2 johns hopkins medical institutions, baltimore, md., united states dexmedetomidine is an alpha-2 adrenoreceptor agonist with sedative, analgesic and anxiolytic properties approved for the intubated adult patient in the icu setting. it possesses well described attributes for the neurological population; a rapid ability to sedate and awaken the patient allowing continuing neurologic assessment and no relevant respiratory depression. properties including neuroprotection, cardioprotection and renoprotection have been proposed and investigated in various settings. demonstrated clinical benefits in the icu neuroscience setting are just emerging. this synopsis reviews the literature in regards to clinical studies conducted to evaluate dexmedetomidine in the neurosciences. characteristics of the studies were categorized by study design, setting, patient population, and comparisons to other agents. human clinical studies were identified through a search of pubmed from 1997-2009. key words include dexmedetomidine, nicu, neurocritical care and cea. study designs include randomized, observational, retrospective and case series. twenty-seven studies were included in the final analysis. the majority are case-studies or anecdotal and the literature consists of mostly surgical patients vs. the icu population. the leading hypothesis is that dexmedetomidine is safe and efficacious in the neurosurgical population and may provide neuroprotection. consistent findings are the attenuation of hemodynamic and endocrine response, smoother extubation and facilitation of neurological assessment. dexmedetomidine has gained popularity in applications beyond its labeled indication and dosage, in various icu's, and in special populations. the literature points to gained acceptance and favorable conditions for sedation without toxicity on cns parameters and a rapidity of onset and offset. there is brevity of literature which demonstrates positive outcomes in the neuroscience setting and the primary data does not represent level 1 or 2 evidence. more studies should be done to validate this drug for common use as there appears to be great advantages in the neuroscience population. the hijdra scale was developed to quantify the volume of blood following aneurysmal subarachnoid hemorrhage (asah). we investigated the relationship of hemorrhage quantity utilizing the hijdra scale and aneurysm size among patients with asah. we prospectively followed up a cohort of sah patients annually to document outcome events after obtaining informed consent. we abstracted demographic, clinical, and past medical history data by chart review on a subset of patients with documented asah after excluding those with cryptogenic, traumatic, and non-aneurysmal sah. the primary outcome of interest, hemorrhage quantity, was analyzed as both an ordinal measure (small, moderate, large) using tertiles and a dichotomous measure using the median. proportional odds logistical models for ordinal response measures and simple logistical regression for dichotomous responses were constructed to investigate the relationship between hemorrhage quantity and aneurysm size. from 03/2008 to 05/2009 a total of 73 patients were enrolled in the rush university sah database. of these, we identified 53 patients with documented asah; 75% were female; 44% white, 37% black, 17% hispanic; and the mean age was 60 ±13 years. the mean ruptured aneurysm size was 5.7 mm and the median hijdra score was 18 (range 0-28). we found no relationship between ordinal (p=0.49) and dichotomous (p=0.42) hemorrhage quantity and aneurysm size. no relationships were found between hemorrhage quantity and age, sex, race, apache ii score, and history of anti-platelet use. there was a trend for significance among patients with a past medical history of hypertension and having large hemorrhage quantity (or 3.03, 0.96-9.52; p=0.06). we found no relationship between aneurysm size and quantity of hemorrhage among patients with asah. future studies should focus on clinical variables such as hypertension and their role in hemorrhage quantity. stroke is the third leading cause of death in the united states. among the stroke subtypes intracerebral hemorrhage (ich), subarachnoid hemorrhage (sah), and ischemic stroke (is), ich and sah are associated with the highest mortality, followed by is. most deaths due to stroke occur within the first 30 days, though it is unclear if any specific stroke subtype carries a significantly higher risk of early mortality (within the first 48 hours from presentation) when compared to the other subtypes. with irb approval, we retrospectively reviewed 80 stroke patients transferred to our institution between november 2007 and april 2009 who died during hospitalization. we collected data including primary diagnosis, confirmed by ct or mri, and time from presentation to our institution to death from any cause. among the 80 in-hospital stroke deaths, ich was the diagnosis in 49 (61%), sah in 18 (23%), and is in 13 (16% amongst in-hospital stroke deaths, ich was the stroke subtype associated with the highest likelihood of early mortality. this may indicate the severity of the disease process and a lack of effective early therapeutic measures available for ich. cerebral vasospasm is a common complication of sah and remains a major cause of death and disability after aneurysm rupture. the enos promoter (-786t>c) cc genotype has been associated with a three-fold increased risk of angiographic cerebral vasospasm, however, its effect on adverse neurologic outcomes after sah has yet to be determined. we hypothesize that enos genotype would predict worse outcome, likely through its effect on risk of vasospasm. subjects included 284 patients with confirmed aneurysmal sah enrolled in a longitudinal cohort study. we analyzed data from 90 subjects for whom we had genotype information as well as 6-month follow-up assessment. patients who died prior to follow-up were excluded. univariate analyses used chi-square, wilcoxon ranksum or students t-test for the individual predictor variables. modified rankin scale score (mrs) was our primary outcome. logistic regression analysis for poor outcomes (mrs >2) included genotype and adjusted for age, sex, race/ethnicity, and hunt-hess grade. of the 284 subjects, 18% were dependent or severely disabled (mrs > 2) at 6 months. older age, higher hunt hess grade and presence of vasospasm were associated with poor outcomes. the enos (-786t>c) cc genotype was associated with mrs>2 with an adjusted or of 1.67 (95%ci 0.54-5.18). our results support a trend between enos (-786t>c) cc genotype and 6-month poor functional outcome (mrs>2). although these results are not as robust as the association with angiographic cerebral vasospasm, it demonstrates the ability to integrate genetic information with clinical outcomes. limitations are primarily the small sample size and ability to adequately adjust for all clinical factors that could influence outcome. whether the effect on outcome of enos genotype is related to cerebral vasospasm risk will require further study. therapeutic hypothermia has been utilized in various brain injury models, including aneurysmal subarachnoid hemorrhage (sah). hypothermia has been used to treat refractory cerebral edema or severe vasospasm in this setting. however, there is very little data on hypothermia as a prophylactic measure before potential complications of sah have occurred. we evaluated the safety and feasibility of prophylactic hypothermia in patients with aneurysmal sah. we conducted a retrospective chart review of patients admitted with aneurysmal sah at a tertiary stroke center from july 1, 2007 to june 30, 2009, who were also treated with induced hypothermia. only patients who had hypothermia initiated prior to symptomatic vasospasm onset were included. a total of 10 out of 103 patients were treated prophylactically with mild hypothermia (32-34 degrees celsius). three patients presented with hunt and hess grade i-iii, and seven patients with grade iv-v sah. average time at initiation of hypothermia was on sah day 1 (range day 0-3). six (60%) patients underwent treatment of aneurysm by endovascular coiling or surgical clipping within 72 hours of symptom onset. the average duration of hypothermia was 10 days (range 1-27 days). nine (90%) patients developed evidence of vasospasm on computed tomography angiography or transcranial doppler. five (50%) patients survived to discharge. causes of death included irreversible global hypoxia from cardiac arrest (2), severe refractory cerebral vasospasm (1), and malignant mca infarction (2) . all four patients with grade v sah died. when these patients were excluded, of the remaining 6 patients, 5 (83%) survived to discharge, and 1 (17%) died. prophylactic hypothermia may be effective and safe in selected patients with aneurysmal sah. additional studies are needed to further define timing and parameters for therapeutic hypothermia in this setting. melatonin and pinoline are indolamines which have shown an antioxidative direct and indirect protection effect in vitro and in vivo models. fourteen 8-week-old male, c57b16 mice underwent reversible middle cerebral artery occlusion ischemia (1.5 hours) followed by 22 hr of reperfusion. the animals received pinoline (15 mg/kg i.p.; n=4), melatonin (30 mg/kg i.p.; n=5) or vehicle (n = 5) at ischemia, immediately upon reperfusion, and at 3 and 4.5 hr post-ischemia. another three animals in each group received the same doses but were sacrificed at 4.5 hours and used for protein oxidation quantification by western blot. rectal temperature, surgical time, time to ischemia and time to reperfusion were recorded continuously. initial neurological damage by modified stroke score was grossly assessed at ischemia, reperfusion, and at 24 hr. infarction volume was quantified using 2, 3, 5-triphenyltetrazolium chloride (ttc) staining, digital photography, and imaging analysis software. means (± sd) were calculated and compared using student's t-test or anova. p 0.05 was set as statistically significant. total hemispheric infarction volume was reduced in the pinoline and melatonin-treated mice compared with the nontreated group (19 ± 7% vs. 36 ± 13%; p < 0.05) and (34 ± 8% vs. 53 ± 7%; p < 0.01) respectively. pinoline score was 1.40 vs. 1.80 in the control group at 24h. no statistical difference was observed in the melatonin group. optical net intensity ratio was statistically significance at cortical level on the 40kd band in the melatonin and 50 kd on the pinoline groups. pinoline and melatonin treatment appeared to confer neuroprotection on a cerebral ischemia in vivo model. although its anti-ischemic mechanism needs to be elucidated, both molecules are potent free radical scavenging properties may offer a potential therapy. manisha gupte, jay joshi, sayona john, shyam prabhakaran, vivien lee rush university medical center, chicago, il, united states the "weekend effect" phenomenon suggests that admission day of the week is an independent predictor of mortality. we evaluated the effect of weekend admission on sah in-hospital mortality at a single academic center. with irb approval, we retrospectively reviewed 226 consecutive sah patients admitted to our institution from august 1, 2006 to june 1, 2009. weekend was defined as saturday or sunday. data was collected on day of the week admission, in-hospital mortality, aneurysm type and treatment. ct images were reviewed by the study neurologist and scored for fisher grade. of 226 sah patients admitted to our institution, 152 (67%) were female. the mean age was 57.5 years (range, 21 to 90). ct brain fisher score was as follows: fisher 3 (72%), fisher 2 (14%) and fisher 4 (10%). the cerebral aneurysm distribution was acom (24%), pcom (13%), mca (9%), multiple (6%), and angiogram negative (18%). surgical clipping was performed in 52 (23%) and endovascular treatment was performed in 99 (44%). the overall sah in-hospital mortality rate was 23%. weekday admission accounted for 73%, and weekend admission occurred in 26%. age, fisher grade, and treatment modality were not significantly different between weekday versus weekend admission. the mean time from admission to treatment of aneurysm was 1.04 days and did not differ significantly by weekend versus weekday admission (p 0.8). mortality rate was 25% for sah patients admitted on a weekend versus 22% for sah patients admitted on a weekday (p 0.6). the weekend effect does not appear to be a significant factor in mortality outcomes of sah patients. the time to definitive aneurysm treatment does not appear to be impacted by weekend admission. the ich score is a simple clinical-radiographic scale in patients with intracerebral hemorrhage (ich) that helps estimate 30-day mortality. we hypothesize that the ich score can be applied to patients with warfarin ich (w-ich) to help estimate thirty-day mortality. anemia is a highly prevalent condition among hospitalized patients. we hypothesize that patients with acute cerebrovascular disease and anemia on admission have poor prognosis in terms of death, length of stay and disposition. a retrospective analysis of patients admitted to our institution with acute stroke (ischemic, hemorrhagic, subarachnoid hemorrhage) between october 2007 and march 2008 was performed. they were dichotomized based on hematocrit levels of < 36, >/= 36 for women and <39 and >/=39 for men using the who definition of anemia. covariates used include diagnosis, demographic information and past medical history. the best admission hematocrit cutoff points for distinguishing between those with increased risk of death, disposition to snf (skilled nursing facility), increased los (length of stay) were identified. of the 201 patients, 106 (52.7%) were female with a mean age of 61.4 years. of these 54 patients (26.9%) were anemic. ten patients died and nine were dispositioned to snf. while the relationship between disposition and anemic status was not significant (p=0.14), there was evidence that those who died were more likely to be anemic (p=0.025). los did not differ statistically between anemic and those without anemia. none of the variables were statistically significant on univariable analysis for mortality. anemia on admission did not predict death, disposition to snf or los, but there was a tendency that patients who died were more likely to be anemic. the admission hematocrit cutoff point for distinguishing risk of death, disposition to snf was slightly lower and increased los was higher than the who definition of anemia. abciximab, a glycoprotein iib/iiia receptor inhibitor (gpiib/iiia), is used during neuroendovascular procedures both to prevent and treat ischemic sequelae. experience with abciximab in this setting is limited and major bleeding complications, including fatal intracranial hemorrhage (ich), are of particular concern. we report our multicenter experience with ich following administration of abciximab during neuroendovascular procedures. we identified neuroendovascular procedures in which abciximab was used at three academic institutions from november 2000 through april 2009. cases of periprocedural ich were identified and pertinent demographic, historical, procedural, laboratory, and radiographic data were collected. clinical outcome was measured by the glasgow outcome scale (gos) either at death or discharge. abciximab was used in 51 neuroendovascular procedures; 9 ich cases (17.6%) were identified. procedures performed and indications for abciximab use varied. route of abciximab administration included iv bolus only (n=4), ia bolus and iv infusion (n=3), iv bolus and iv infusion (n=1), and iv infusion without preceding bolus (n=1). all patients but one received periprocedural antiplatelet, anticoagulant, or thrombolytic agents. all ich were detected within 7 hours of abciximab administration, (except patient 4; 40 hours); 5 were detected within 3 hours. ich patterns varied and included subarachnoid hemorrhage (sah) with intraventricular hemorrhage (ivh) (n=5); intraparenchymal hemorrhage (iph) with ivh (n=2); sah, ivh, and iph (n=1); and a combination of sah, ivh, iph, and subdural hemorrhage (n=1). four patients died following ich (i.e. gos score of 0); gos scores at discharge for the remaining cases were 3 (n=3), and 5 (n=2). ich was common (17.6%) after neuroendovascular procedures using abciximab and was associated with a 44% mortality. future management strategies should focus on earlier recognition of gpiib/iiia-related-ich; development of direct gpiib/iiia antidotes; comparisons with shorter-half-life gpiib/iiia drugs; and identification of optimal abciximab dose and route. cerox 3110 is a novel noninvasive brain and tissue oxygen saturation monitor based on nirs and ultrasound technology. the purpose of this prospective observational study of patients with both traumatic and non-traumatic brain injuries is to determine if the cerox 3110 correlates with existing measures of cerebral oxygen metabolism which are currently used as part of regular care in the management of patients with severe brain injury. we enrolled patients with severe brain injury (tbi = 6, ich = 4) who had at least one invasive cerebral oxygen monitor in addition to an intra-cranial pressure monitor. cerox 3110 adhesive patches were placed bilaterally over the frontal regions of the scalp and optical probes were attached to the patch clips. monitoring with cerox 3110 continued for up to 7 days. high density physiological data, e.g., map, brain tissue oxygen, jugular venous saturation, icp, were collected at q 1 minute intervals into our neurocritical care database. physiological data were then merged with cerox 3110 measurements. ten patients requiring invasive neuromonitoring were enrolled during this 3-month study period. the duration of noninvasive recording was 1-10 days (mean= 4 days) with maximum length of uninterrupted recording being 72-hours. cerox 3110 measurements ranged from 24-84.5% (mean = 57%) on the left and 30-77% (mean = 56.2%) on the right. in this group of patients, the brain tissue oxygen tension ranged from 7.4-98.2 mm hg, the jugular venous saturation was 36.5-98% and the cerebral blood flow varied from 0.6-122 ml/100gm/min. continuous monitoring with cerox 3110 is safe and feasible in neurocritical care setting. it has the potential of providing information about cerebral metabolism needed for close monitoring and management of patients with severe brain injury deep vein thrombosis (dvt) is a common complication of intracerebral hemorrhage (ich) and has been associated with immobility in the lower extremities. [1] atherosclerotic risk factors (hypertension, diabetes mellitus (dm) and hypercholesterolemia) are associated with arterial thrombosis and have been postulated play a role in venous thrombosis. [1] we hypothesized that a history of atherosclerotic risk factors increases the risk of dvt in ich patients. retrospective analysis of patients diagnosed with spontaneous ich at our institution between january 2005 and december 2007 was performed. demographics, history of hypertension, dm or hypercholesterolemia; systolic blood pressure at presentation; presence of immobility or hemiparesis and diagnosis of dvt were collected. logistic regression analysis was used to predict the risk of dvt. 62 of 114 patients with spontaneous ich were immobile and were selected for analysis. all patients had sequential compression devices applied on admission. the overall incidence of dvt diagnosed by lower extremity doppler was 29% and pulmonary embolism was 3.2%. mean time to diagnosis of dvt was 16.9 (sd 12.2) days. after stepwise logistic regression analyses, significant predictors of dvt in immobilized ich patients were, history of hypercholesterolemia (or 3.57 p=0.0092) and sbp on admission >180 (or 5.14 p=0.0442). immobilized ich patients with a history of hypercholesterolemia were three times more likely to develop dvt. a sbp >180 on admission was five times more likely to predict dvt. thus atherosclerotic risk factors may play a role in the pathophysiology of dvt in immobilized ich patients, suggesting a possible etiopathologic link between arterial and venous thrombosis. acute ischemic stroke due to the occlusion of the internal carotid artery (ica) is associated with malignant stroke and poor outcome. without revascularization of ica perfusion to the middle cerebral artery (mca) and anterior cerebral artery (aca) is not possible. objective: objective of our study is to evaluate the technical feasibility of emergent carotid artery revascularization using stent and to evaluate the impact of stenting in distal cerebral perfusion. from an established stroke database consecutive patients with acute ischemic stroke who underwent emergent carotid stenting and thrombolysis/clot retrieval of the mca and aca from july 2007 to december 2008 were enrolled. patients' demographics including presenting national institute of health stroke scale (nihss), degree of revascularization, hemorrhagic conversion and 30 days outcome data using glasgow outcome scale (gos) were collected. successful ica stenting was possible in 20/21 (95%) patients. the average age of patients was 62 years (ranges 40-93) and average nihss was 18 (ranges 9-29). carotid stenting facilitated successful revascularization of the mca and aca using tpa and merci clot retriever device in 18 patients (85.7%), 14 (67%) of which has achieved complete recanalization in the mca and aca. in complete recanalization group a 4 point or higher nihss improvement was observed in 11/14 (78.5%) patients. symptomatic intracranial hemorrhage was observed in 9.5% patients. seven of 14 patients who achieved complete recanalization had a good outcome. five of 7 patients who did not achieve complete recanalazation of the mca and aca died and had nihss 20. nihss 20 was associated with incomplete recanalization of the mca and aca with poor outcome. emergent carotid revascularization is not only technically feasible in patients with acute ischemic stroke due to the carotid occlusion, but it also facilitates successful renalization of the mca and aca. further study is necessary. stent-assisted coiling of wide neck intracranial aneurysm requires therapeutic dose of antiplatelets to prevent stent thrombosis. stent-assisted coiling of the ruptured intracranial aneurysms also requires a loading of both loading dose of aspirin and plavix. objective: to report any potential complication associated with the use of both aspirin and plavix in stent-assisted coiling of ruptured wide neck intracranial aneurysm. consecutive patients who underwent stent-assisted coiling for ruptured wide neck intracranial aneurysm were enrolled from 2005 to 2009. patient's demographics including the hunt & hess grade, fished scale, use of ventriculostomy catheter, location and size of aneurysm were collected. any complication such rupture of aneurysm, ventriculostomy associated hemorrhage or systemic bleeding was recorded. additionally a 30 days outcome measurement was obtained using glasgow outcome scale (gos). results: 21 patients with mean age of 50 ± 13 underwent stent-assisted coiling. a loading dose of plavix (300 mg to 375 mg) and aspirin 325 mg were given prior to stent placement. 14 patients received ventriculostomy catheter, 11 cases before and 3 cases after the procedure. there was no intraoperative ruptured of aneurysm or hemorrhage related to ventriculostomy or systemic hemorrhagic event. there were two episodes of stent thrombosis; one was an asymptomatic which developed during stent-assisted coiling procedure and resolved spontaneously, the other was symptomatic required intra-arterial administration of thrombolytic. there was no mortality and good outcome was observed in 85% of patient. stent-assisted coiling of the ruptured wide neck intracranial aneurysm using therapeutic dose of aspirin and plavix is not associated with increased bleeding complication such as rupture of aneurysm or intracranial hemorrhage related to ventriculostomy. however, the thromboembolic events remain the main challenge in stent-assisted coiling of ruptured intracranial wide neck aneurysm. therefore, antiplatelets should not be withheld prior to a stent-assisted coiling of ruptured wide neck aneurysm. we have used mild therapeutic hypothermia in patients with severe traumatic brain injury. in this study we investigated the effects of hypothermia on brain tissue oxygenation. brain tissue oxygen tension (pbto 2 ) in addition to intracranial pressure (icp), cerebral perfusion pressure (cpp), and jugular venous saturation (sjo 2 ) were monitored in 12 consecutive patients with a glasgow coma scale score of 4 to 7 (ages 16 to 64 years). patients were cooled to a target temperature of 35.0 o c. patients with good recovery and moderate disability on the glasgow outcome scale were regarded as having favorable outcomes. a retrospective review of a six-month period in a university nccu was performed where patients were treated according to the above hypothesis. anticoagulation was usually started with heparin 5000 units sq q12 hr within the first 48 hours and increased to 5000 units sq q 8 hr after 48 hours. anticoagulation was increased in many cases to enoxaparin 30 mg sq q 12 hr after another 48 hours. of the 542 patients who received care during the six-month period, 41 patients (7.5%) were diagnosed with lower extremity dvt that were asymptomatic in 90% of the cases. ivcf's were placed in 27 patients (65% of those with dvt). two patients were diagnosed with pulmonary emboli (.4%). there were no fatal pulmonary emboli. there were no significant bleeding complications or ivcf complications. surveillance lower extremity venous dopplers every 5-7 days, scd's, cs's, and escalating doses of anticoagulation as is tolerated and safe lower the risk of dvt in this high risk population and identify early asymptomatic dvt. fatal pe can be prevented with ivcf placement and more aggressive anticoagulation as permitted by the diminishing risk of bleeding as time passes from the acute injury. heparin induced thrombocytopenia (hit) is a common yet under-recognized condition in the neuro icu. it is caused by an autoimmune reaction to heparin-platelet factor 4 (pf4) complexes which causes activation of platelets and leads to thrombosis. patients with aneurysmal subarachnoid hemorrhage treated by endovascular means are exposed to large doses of unfractionated heparin and therefore may be at high risk for hit. the medical records of 117 consecutive patients with aneurysmal sah were reviewed. diagnosis of hit was made by clinical determination. clinically diagnosed hit is common in the sah population. patients with hit are at higher risk for cerebral infarction, in-hospital mortality and disability. a high suspicion for hit is appropriate in patients with aneurysmal sah treated by endovascular means. mild hypothermia (32-34°c) 1 has been investigated in a variety of neurologic diseases and disorders. since the 1990s research has shown that hypothermia provides vital neuroprotection after sustaining brain/spine injury from a trauma, stroke, or cardiac arrest. hypothermia reduces increased icp and improves neurologic outcomes. [1] [2] [3] [4] translation of the research to clinical practice poses many challenges such as determination of the most effective method of cooling, maintaining hypothermia, and slowly re-warming back to normothermia. a neuro hypothermia protocol was instituted in march 2008. 20 patients underwent mild hypothermia using a hydrogel-pad cooling system. this retrospective study analyzed the data related to induction start times and associated variables (bmi and bsa) and sought to determine whether any correlation existed between the variables and degree/hour induction to goal temperature -33 + 0.2°c. additionally, data was collected related to hours at 33°c and assessment of device control of ascent rate to 37°c. using the pearson correlation coefficient and the bonferroni standard correction method, 20 patient charts were reviewed and data assessed to determine the statistical relevance of several variables: gender-males, age 43, bmi 23.5, bsa 1.866, induction start temperature 36.3, target temperature 33.1, hour to target temperature 2.5, and temperature descent of 1.4 degrees/hour. it was determined that there was a significant statistical association between temperature changes (degrees/hour) and bmi/bsa values. the p-values for the bmi was determined to be .0096 and the bsa .00235. target temperatures were maintained at 33°c with minimal variances. the ascent to 37°c was controlled at 0.05 °c/hour for the brain injured patients and 0.25°c/hour for the spinal cord injured patients. the final analysis of the data revealed that an individual's bmi and bsa does directly affect both the induction of hypothermia and the controlled re-warming back to the targeted normothermic goal. mechanical ventilation is associated with worse outcome after intracerebral (ich) and subarachnoid hemorrhage (sah). we sought to examine the predictors of duration of mechanical ventilation. we prospectively identified patients with spontaneous ich and sah who required invasive mechanical ventilation. ventilator settings and measurements were recorded daily from the initiation of ventilation. complications were prospectively recorded. data are presented as mean +/-sd or n(%) when appropriate. variables for multiple linear regression were chosen with a stepwise algorithm (in order of decreasing significance). patients with aneurysmal sah of all clinical grades were prospectively studied. regional anterior alpha power was quantitatively analysed. we assessed alpha power and variability using the product of standard deviation and mean power over a 6-hour duration, repeated along a window sliding by 30 minutes and graphically displayed. an independent clinician predicted the status of patients as improvement, deterioration or no change from the previous day. this was first done using only clinical data. ceeg trends prior to that day were then presented and another prediction made. results were compared with the true clinical states that were determined independently. clinical evolution in patients who were treated for vasospasm was correlated with daily mean alpha power. coiling followed by clot evacuation is associated with a faster time to aneurysm protection and similar outcome, los, and cost as clipping and evacuation. this may be a viable alternative treatment strategy. using cdsa, icu nurses were the most sensitive at identifying seizures, however they also demonstrated the highest false-positive rate. neurophysiologists and eeg technologists demonstrated slightly lower sensitivity, and much lower false-positive rates. however, on individual eeg recordings performance varied greatly, with group median sensitivities ranging from at 0% to 100%. neurophysiologists, eeg technologists and bedside nurses demonstrated comparable performance in seizure identification using cdsa. the observed differences in sensitivity and false-positive rates between different groups of reviewers are smaller than the variability in their performance on individual eeg recordings. coagulation disorders are common after traumatic brain injury (tbi), and may contribute to morbidity and mortality (1) . these disorders are complex and dynamic over time, making clinical evaluation of coagulation status of the patients difficult (2) . thromboelastography (teg) has been suggested as a tool for rapid assessment of such states. teg is a test of clot formation and lysis, providing a holistic assessment of clot formation time and strength. it is an easy to perform, point of care test that enables clinicians to differentiate hypo or hypercoagulability, and the factors contributing to each, and evolution over time. the aim of this work is to show the contribution of teg to the evaluation of coagulopathies in patients with isolated tbi. we have retrospectively inspected teg records and routine coagulation studies from patients with isolated tbi, and checked for signs of either bleeding tendency or signs of hypercoaguilation ten patients with isolated traumatic brain injury were evaluated using teg. reasons for tests included workup of suspected bleeding, assessment of hypercoagulable states, or planned invasive procedures. three of these patients showed increased ly30, indicating thrombolysis, and two patient showed prolongation of the r value, indicating prolonged clotting time. two patients showed increased maximal amplitude (ma), indicating a hypercoagulable state. thromboelastography is a useful adjunct tool in the assessment of coagulation status in isolated tbi patients, and may help in clinical decision making in such patients. further work, relating thromboelastography results, prognosis and management are warranted. christine hartney, kathryn keim, diane sowa, richard temes rush university medical center, chicago, il, united states the objective of this study was to compare differences in resting energy expenditure (ree) results of critically ill neurology patients based on gender, body mass index (bmi) class and race. this study was a retrospective chart review of patients admitted to the neurosciences intensive care unit at an urban medical center who were started on enteral nutrition support. the research methods received approval from the institutional review board for human studies. the differences between gender, bmi class and race may not have been detected as a limitation of the sample size. research is needed to further explore the relationship among gender, bmi class and race and use of established predictive equations for the critically ill neurology patient. many critically ill neurologic and neurosurgical patients undergo a significant change in functional status or require end-of-life care. therefore, palliative care is an integral part of care provided by neurocritical care physicians and midlevel providers. at times, the needs of the patients and families can overwhelm these clinicians, whose focus is often on curative measure, so there may be a benefit to integrating a formal palliative care consultation service into the neuroicu. an anonymous survey was conducted among the four neuro icu physicians and nine nurse practitioners regarding the integration of a palliative care consult service into the neurocritical care service. the survey consisted of seven "yes" or "no" questions and a write-in section for comments. all 13 providers thought that it was helpful to have the palliative care consult team in the icu, and that they provided added support not just for families, but to the physicians and nurse practitioners. 1/13 respondents stated that palliative care was only appropriate for families that wanted to decelerate care. only 4/13 responded that they were aware of the existence of formal criteria that were designed to trigger the consultation of the palliative care team. feelings were mixed regarding nurse-driven consults, with only 4 respondents feeling that this was appropriate. in general, the formal palliative care consult service was felt to be a welcome addition. clearly, the existence of formal criteria to trigger a palliative care consult had not been emphasized enough to physician and midlevel providers, and the concept of nurse-driven consults was not accepted by the majority of number of providers. additional comments obtained will be used to improve the process by which palliative care services are obtained. most clinical trials in traumatic brain injury (tbi) have failed to demonstrate a therapeutic benefit. one factor implicated in these failures is an inadequate estimate of the smallest clinically meaningful beneficial effect -the minimal important difference (mid). in this study we surveyed the neurocritical care society (ncs) membership to determine an mid for tbi clinical trials. a survey approved by the ncs research committee was developed to assess the mid that would lead physicians to recommend a new therapy for tbi patients. the survey was distributed online to all ncs members with a 1-week response period. there were 125 responses (15.4%) from 814 ncs members. respondents included neuro-intensivists (61.2%), neurologists (29.3%), and neurosurgeons (13.8%); 75% were in academic practice on average 10.8 years. two-thirds (62.6%) cared for 4 to 14 severe tbi patients monthly and 43.3% had participated in tbi clinical trials. one third believed that 50% of patients would consent to minimal risk trials. the preferred primary outcome measures were mortality, glasgow outcome score (gos), and gos extended, while the sf-36, neuropsychological measures and sliding dichotomy were the least preferred. the preferred secondary outcome measures were intracranial pressure (icp) control, therapeutic intensity level (for icp) and repeat imaging. organ dysfunction scores and biomarkers were least preferred. a reduction in unfavorable outcome of 10% (iqr 5-10%) was reported as the mid needed to introduce a new therapy. mid rather than "number needed to treat" was the preferred method to describe trial efficacy. in this ncs survey, the preferred primary outcome measure for tbi trials was mortality or gos. a 10% reduction in unfavorable outcome is considered the mid. this information can be used to help define sample size for future tbi clinical trials. compare the quality and sensitivity of electroencephalography signals (eeg) obtained with a disposable template system to eeg obtained by certified eeg technicians. prospectively acquired eeg data were obtained in 8 hour blocks (matched pairs) from leads placed by a certified eeg technician vs. those placed using a disposable template system (brainet®). quality measures included start and end recording of impedance, elapsed time from physician's order to first recorded eeg, and a blinded subjective evaluation of data quality. all segments of data were de-identified and will be read by a blinded reviewer highly experienced in eeg interpretation. analysis from the first 13 subjects of a 100 subject trial is presented here. average impedances in the brainet® group were within recommended guidelines, but were slightly higher than technician applied leads. groups had similar impedance variance, lead failure rates, and maximal difference in impedance at the beginning and at the end of the 8 hour blocks. the difference in mean time to first eeg for the brainet® group (98 mins) vs. technician applied leads (323 mins) was statistically significant (p<0.003). evaluation of sensitivity is pending collection of the remaining data sets. preliminary analysis indicates the use of a disposable template system that allows a non-technician healthcare provider to place eeg leads is feasible and safe. no significant differences in eeg quality during 8 hours of recording were found, and use of brainnet® leads was associated with a significant reduction in the time from order to the first page of eeg data. this preliminary assessment does not allow for conclusions about the overall quality and sensitivity of disposable template leads; the complete set of eeg segments needs to be collected and undergo blinded review. outcome following aneurysmal subarachnoid hemorrhage (sah) is related to various demographic and clinical factors. biomarkers are an increasingly employed means for determining outcome in neurologically injured patients. the purpose of this study is to correlate cerebrospinal fluid (csf) adrenergic compound and metabolite levels to clinical and outcome measures. 40 consecutive sah patients with ventriculostomy had csf collected 1ml within 3d of onset. csf was assayed for epinephrine (epi), norepinephrine (ne), and dihydroxyphenylglycol (dhpg) by hplc. levels were compared to various demographnic, clinical, and radiological measures, and to mortality at 30 days. mean age was 58yo and 65% were female. hh grade was 3 in 53%, 4 in 42%, and 5 in 5%. no correlation was found for age, but women had greater dhpg levels (658pg/dl vs 408pg/dl, p=.022). dichotomized hh score demonstrated greater epi levels in g4/5 patients compared to g3 patients (32pg/dl vs 14pg/dl, p=.033). patients who died had also greater epi levels (38pg/dl vs 16pg/dl, p=.039) yet lower dhpg levels (421pg/dl vs 635pg/dl, p=.064), but regression analysis incorporating hh grade eliminated these associations. in sah, women demonstrate greater elevations in the ne metabolite dhpg, and greater elevations in epi are present in hh grade 4/5 patients. patients who die have greater csf epi levels which appears related to the severity of the disease. gail pyne-geithman, opeolu adeoye, jordan bonomo, carolyn koenig, jed hartings, lori shutter university of cincinnati, cincinnati, oh 45267, united states as in clinical neurocritical care (ncc) practice, effective ncc basic science research requires organized interdisciplinary collaboration. the purpose of this abstract is to share our experience in building a basic science collaborative to facilitate the efforts of others and foster discussion regarding engagement of basic scientists in the neurocritical care society (ncs) and ncc research efforts. our institution is active in interdisciplinary ncc clinical practice and fellowship training, in addition to conducting various clinical trials relevant to ncc. collaborating with the clinicians is a core of basic scientists who are working to integrate their funded research into the fabric of care in the neurosciences icu. the composition of the team is truly interdisciplinary, spanning multiple clinical and basic science departments and colleges within our institution. frequent meetings among ncc physicians, surgeons, research nurses in the division of clinical trials and basic scientists have resulted in fruitful collaborations in teaching, research and funding. clinical responsibilities of fellows and residents limits time for bench research, so joining an existing project allows time and resources to be used productively. ncc fellows are teamed with a basic science mentor, and these collaborations often continue beyond the tenure of the fellowship. the basic scientists benefit, as current basic research needs to have translational potential to the clinical setting. basic scientists attend clinical rounds, reinforcing the benefits of truly translational research. gaining a reputation for quality research that enables consistent funding and earns respect from the ncc community requires engagement and input of basic scientists. individual institutions can solicit interested basic scientists to join in their research planning and execution and augment the training of residents and fellows, thus preparing the next generation of research-trained clinicians. the methodist hospital, houston, texas, united states the purpose of this study was to evaluate the association between tight glucose control and the incidence of ventriculitis in neuro intensive care unit with evds the hospital's computer system was used to identify patients admitted between january 1, 2006 and december 31, 2008 to the neuro icu with documented evd placement. patients' 18 years of age or older and deemed to require insulin therapy by the admitting physician were included in the study. we excluded patients if they had evd placement or documented csf infections before admission to the unit, were treated with antibiotics a week prior to admission, and length of icu hospitalization less than seven days. the primary outcome measure was evd related infection. the secondary outcome measures were in hospital and icu length of stay and in hospital death the association between glucose control and positive csf cultures was described using the morning blood glucose for seven consecutive days stratified based on the number of blood glucose readings that fell between 80-120 mg/dl. the binary logistic regression model showed that patients with a higher percent of readings in tight blood glucose range were more likely to have cns infection (odds ratio 1.05; p <.01). the secondary outcomes could not be measured because we did not have enough readings to stratify our data into categories contrary to our hypothesis, the results from our study suggest a possible association between tight blood glucose and an increase in evd related infections. at this time we are unable to make recommendations based on these results given the inherent limitations of our study ; i.e., small sample size, retrospective design, single centered and single morning blood glucose reading to assess glucose control following aneurismal subarachnoid hemorrhage (sah) half the patients' die and only one third of survivors make a full recovery. the optimal hemoglobin (hgb) after sah, however, is uncertain. higher-goal hgb and more red blood cell transfusion (rbct) lead to worse outcome in general critical care. clinical series suggest that rbct may increase vasospasm risk and exacerbate outcome after sah. however other studies suggest that a higher hgb may be associated with better outcome and less cerebral infarction after sah. we now will examine the hypothesis that patient outcome after sah is better when an hgb level of 8.5g/dl rather than an hgb of 11g/dl triggers transfusion. we propose a multi-center, prospective, phase iii randomized, clinical trial involving adults admitted to university based nicus within 48 hours of sah.. eligible sah patients will be randomly assigned to one of two treatment groups, 1) restrictive (hgb of 8.5g/dl) or 2) liberal (hgb of 11.5g/dl) transfusion triggers stratified by center and sah severity. the primary objective is to determine if sah subjects who have a restrictive transfusion trigger during the first 14 days of care, are more likely to have a favorable 6-month outcome than subjects transfused with a liberal trigger. the trial is designed to detect an overall absolute difference of 10% in the proportion of favorable outcomes (glasgow outcome score of good or moderate disability). secondary objectives include: 1) determine if a restrictive policy is associated with less vasospasm. 2) examine the relationship between hgb and 6 month outcome and cerebral infarction. the number of randomized subjects is expected to be 758. the number of randomized subjects is expected to be 758. to date 25 centers have agreed to participate. this group will receive administrative, statistical and data coordinating support from the university of pennsylvania center for clinical epidemiology and biostatistics. the proposal is under review at the nih. background: brain death (bd) is diagnosed clinically by documentation of coma, absence of brainstem reflexes, and apnea unresponsive to hypercarbia. in argentina (like other countries) other confirmatory tests are required as a part of the diagnostic criteria. the utility of cta with cerebral perfusion was reported by qureshi in 2000 and then evaluated by combes et al and they found 30% false negative rate for the test; moreover, greer et al reported one case of false positive. in spain, otero has reported a sensitivity of 100% in a series of 6 patients who had cta and ct perfusion. accuracy of cta and ctp must be assessed. we propose that cta and ctp is a reliable confirmatory test for bd, with particular interest in cases where barbiturates or other cns depressant drugs difficult to diagnose clinically or by electrophysiological studies. prospective multicenter study to determine the accuracy diagnostic of brain death with cta & ctp in patients with suspicion of bd according clinical criteria (cc) defined by neurological criteria, apnea test; compared with electrophysiological methods and tcd evaluation. all adults of at least 18 years of age who meet the cc of bd. intensive care unit, emergency department, neurocritical care unit, stroke unit in hospitals with availability of tcd, eeg and multi-row ct 24 hours. in patients with cc of bd, we will be performing ctp and then cta. all the case will be made an eeg and tcd evaluation main outcome measure: evidence of cerebral circulatory arrest. absence of cerebral perfusion sensitivity and specificity, ppv and npv for cta & ctp compared with cc, eeg & tcd. accuracy of cta & ctp in patients with recent utilisation of cns depressor or nm blockers to confirm bd before eeg and tcd. complications rate associated with the use of contrast. renal failure post contrast use. we need at least 100 patients to to achieve a sample size that allows the analysis of sensitivity, specificity and construction of roc. not started. funding is needed to support the project. quantitative diffusion-weighted imaging mri (dwi) in comatose post-cardiac arrest survivors holds promise as a prognostic tool. between 1 and 5 days more than 10% of brain volume with an adc value < 650x10-6mm2/sec identifies poor outcome patients with 100% specificity and 81% sensitivity (ann neurol 2009;65:394-402). this threshold needs validation in an external dataset. we hypothesize that the capacity for recovery of consciousness in comatose cardiac arrest survivors can be predicted with quantitative dwi. multicenter observational study of dwi mris in comatose cardiac arrest survivors obtained between 1 and 5 days after the arrest. patient data will be recorded using a web-based data entry form including baseline characteristics, neurological examinations, results of neurophysiological testing, cause of death, and 30-day outcome. patients may be entered retrospectively and prospectively. brain dwi scans will be blindly analyzed centrally and an outcome measure (survival versus death or vegetative at 30 days) will be assigned. patients who remain comatose after cardiac arrest and who have undergone dwi between 1 and 5 days after the arrest. main outcome measure: the specificity of the predefined dwi threshold (adc of 650x10-6 mm2/sec) for prediction of poor outcome (defined as death or failure to recover consciousness at 30 days). the sensitivity of the predefined dwi threshold in comparison with the 72-hour neurological examination and, if available, sseps and peak serum levels of neuron specific enolase. assuming a 37% survival rate, and 100% specificity of dwi for poor outcome, 250 patients are needed to achieve a 0% false positive rate for poor outcome with a 95% confidence interval of 0 to 5%. centers are invited to participate. several investigators have expressed interest. background: there have been several randomised controlled clinical trials of weaning from mechanical ventilation which has shown quicker weaning and shorter ventilation time in abrupt discontinuation of mechanical support as opposed to gradual step-wise withdrawal. however, there have been no substantial trials of ventilatory weaning in acute brain injury patients or those with neuromuscular diseases. the neurocritically ill patient on mechanical ventilation will require slower step-wise weaning from mechanical ventilation. multicenter, randomized, non-blinded phase 2 trial feasibility and safety trial. all patients in the neurocritical care unit expected to be on mechanical ventilation for more than 5 days. routine scheduled post-operative patients and patients transferred from outside hospitals already on mechanical ventilation for more than 24 hours will be excluded. neurocritical care unit. patients will be randomized to slow step-wise simv wean versus pressure support wean on cpap. length of time on mechanical ventialtion pneumonia, urgent re-intubation, hypoxia from previous studies in the medical intensice care units, 400 patients, half with acute brain injury, half with neuromuscular diseases. despite the use of appropriate antimicrobial therapies, the morbidity and mortality associated with bacterial meningitis remains high. cerebrovascular complications from meningitis, including vasospasm, have been shown to contribute to this poor outcome. several series have reported tcd velocity elevation correlates with clinical decline and occurs in up to 51% of patients with bacterial meningitis. to date no systematic large trial has been completed to detect or treat this complication. 1. phase ii: clinically significant vasospasm in bacterial meningitis results in higher mortality compared with those with normal tcd velocities. 2. phase iii goal directed therapy: triple h, intra-arterial verapamil and angioplasty will increase survival in patients with bacterial meningitis at high risk for vasospasm. patients admitted to the icu with the diagnosis of bacterial meningitis. phaseii: bacterial meningitis enrolled within 24 hours of diagnosis. subjects receive baseline cta of head/neck, daily tcds, angiography when mean velocities >180, daily nihss, mortality rate at one month, and mrs at 3 months. significant vasospasm will be defined as angiographic vasospasm with corresponding increased nihss of at least 2 points. phaseiii: target population from phase ii. all subjects will undergo testing and data collection as outlined in phase ii. subjects randomized to aggressive vasospasm treatment vs. standard-care. in the treatment group, vasospasm will be treated with goal-directed therapy. one month mortality. independent predictors of the presence of vasospasm. rankin score at 3 months. phase ii and iii: inference of portions (alpha0.05, beta0.8, delta0.15, n=220subjects) current status: big idea. the outcome of devastating neurologic disease like massive ischemic stroke, intracranial hemorrhage, status epilepticus, and subarachnoid hemorrhage is presumed to be poor. mortality in studies may be influenced by premature withdrawal of care, and not by natural history or chronic complications. if these patients are given maximal supportive care chronically, their outcome will be better than expected based upon commonly accepted morbidity/mortality. randomized, controlled non-blinded clinical trial. patients with devastating neurologic conditions as listed above who require mechanical ventilation (mv) and feeding tube placement (tf). neurocritical care unit of major tertiary care centers as part of a multi-center trial. families are offered usual standard of care-either withdrawal of care or full supportive care. for those not certain about which course to take, enrolment is offered. the trial would necessarily require initial full supportive care such as tracheostomy and feeding tube placement. the patients are randomized to one of two treatment regimens: 1) aggressive, long-term supportive care involving treatment of intercurrent medical complications and full resuscitation; 2) basic supportive care including mv and tf but not involving these aggressive measures. modified rankin scale at one, two, and five years. continued need for mv/tf, barthel index, correlation with initial hospital care in a specialized neurocritical care unit. assuming a 50% event rate (severe disability or mortality) in the control group and expecting a 20% relative risk reduction (about 10% absolute risk reduction), the estimated sample size with an 80% power and an alpha of 0.05 is 400 patients total (200 in each arm). proposal status. how to structure randomization in concert with ethical principles and which supportive measures can be ethically restricted must be determined. intervention: continuous veno-venous hemofiltration via femoral access with total effluent rate of 35ml kg -1 h -1 , blood flow rate between 100-300ml/min, high permeability glycerine free polyethersulfone membrane, filter change every 24 hours, pre-filter replacement fluids: prismasate bgk 4/0/1.2 (osmo 296) and sodium-citrate anticoagulant. fluid management per attending physician. minimum duration of 36 hours with termination after 12-24 hours of icp control or at 96 hours. secondary outcome measures: change in icp at hours 4 and every 12 hours thereafter; neurological outcome (glasgow outcome scale score dichotomized unfavorable (1,2,3) / favorable (4,5)); cytokine removal and complications. power analysis: a sample of size 24 will be obtained to attain a power of 0.8 at 5% level of significance current status: idea phase renal replacement therapy in the patient with acute brain injury renal replacement therapy for the patient with acute traumatic brain injury and severe acute kidney injury early changes in intracranial pressure during haemofiltration treatment in patients with grade 4 hepatic encephalopathy and acute oliguric renal failure continuous arteriovenous hemofiltration in patients with hepatic encephalopathy and renal failure cytokine removal during continuous hemofiltration in septic patients fluid thresholds and outcome from severe brain injury adult respiratory distress syndrome: a complication of induced hypertension after severe head injury prevention of secondary ischemic insults after severe head injury combination therapy with hypothermia for treatment of cerebral ischemia clinical study of mild hypothermia treatment for severe traumatic brain injury management of pitfalls for the successful clinical use of hypothermia treatment multicenter trial of early hypothermia in severe brain injury guidelines for the management of severe traumatic brain injury. 3 rd edition none s198 neurocrit care early decompressive craniectomy for patients with severe traumatic brain injury and refractory intracranial hypertension--a pilot randomized trial renal replacement therapy for the patient with acute traumatic brain injury and severe acute kidney injury continuous renal replacement therapy for refractory intracranial hypertension introduction: many authors suggest using pentobarbital when elevated intracranial pressure or seizures are refractory to other agents. due to the lack of outcome data after the use of this agent, we investigated the outcomes of patients treated with pentobarbital over the past five years. patients were identified using a pharmacy database that tracks inpatient medication dispensing at our tertiary referral center. all patients, older than 18, cared for in adult icus, who received pentobarbital between 2004 and 2008 were included. inpatient mortality was compared between patients older and younger than 40 as well as those who required vasopressors using fisher's exact test. twenty-two patients received pentobarbital. the mean patient age was 43 (sd=16). just over half (55%) were men. pentobarbital was used in 64% of the patients to treat intracranial hypertension; the remainder were treated for refractory status epilepticus. the most frequent underlying disorders were toxic-metabolic disease processes.fourteen patients (64%) died in the hospital. care was withdrawn in 55%. of the 8 patients (36%) who were alive at the time of discharge: 3 (14%) were discharged to acute rehabilitation, 2 (9%) to an extended care facility, 1 (5%) to sub-acute rehabilitation, 1 (5%) to hospice, and 1 (5%) to home.hypotension, renal failure, and pneumonia were common (40-86%) in patient receiving pentobarbital. there was no significant association between inpatient mortality and reason for pentobarbital use. age and need for vasopressors were not significantly associated with in hospital mortality. pentobarbital use was associated with significant morbidity and mortality (greater than 60%), but 18% of patients were discharged home or to acute rehabilitation facilities. further study is needed to better clarify the risks and benefits of pentobarbital to treat refractory intracranial hypertension and status epilepticus. the neurologic mechanism leading to unresponsiveness after acute traumatic brain injury is not well understood. posturing reflex examination in evaluating comatose patients is ubiquitous. the reliability of this practice has not been systematically evaluated. from the trauma service registry at a level 1 trauma center, all admissions between from 7/1/1999 to 6/30/2007 where the patient had a head component of the abbreviated injury score >1 were identified. from this group of 3,478 patients, the records of the 193 patients with a glasgow coma scale (gcs) 8 on presentation and a brain ct scan performed in the ed were evaluated. ct scans were scored for injury by location and the motor component of the gcs (gcs m ) was noted from ed documentation. the study population was young (mean age 38.4) and predominantly male (84%). the gcs m was 2 (indicating extensor posturing or no response) for 127 patients and >2 (indicating flexor response or better) for 66 patients. on univariate analysis, intra-axial injury above the thalamus did not correlate with the gcs m (42 with gcs m 2, 18 with gcs m >2, p=0.545). a second analysis of intra-axial injury above the midbrain again showed no reliable correlation with gcs m (54 with gcs m 2, 25 with gcs m >2, p=0.079). patients with extensor or worse exams were less likely to have a glasgow outcome score >3 (41 (32%) with gcs m 2 , 33 (50%) with gcs m >2, p=0.018). gcs m responses of flexor or worse did not reliably correlate with injuries at the level of the thalamus or below. however, lower gcs m was still associated with poor gos. this study points to a need for reinvestigation into the neuroanaotmic basis for posturing and unresponsiveness to enhance the understanding and improve acute management of these patients. jeff chen, sandy cecil, patrick chen, susan rowland, sarah callaway, david adler legacy emanuel medical center, portland, oregon, united states since the cma 600 cerebral microdialysis analyzer received fda approval for clinical use in 2005 in the united states, cerebral microdialysis has gained increasing acceptance as an adjunct in the multimodality monitoring of the brain after traumatic brain injury, subarachnoid hemorrhage, and stroke. we describe a single institutional four year experience with cma 600 and recent iscus flex . the cma 600 and iscus flex analyzers, cma 107 pump, and cma 70 microdialysis catheters were obtained from cma microdialysis (solna, sweden). perfusion fluid cns (artificial csf) was perfused at 0.3 ul/min, and samples collected hourly. lactate, pyruvate, glucose, glycerol, and glutamate levels were entered into the icu pilot program along with neurophysiologic parameters to analyze relationships/trends. all cerebral microdialysis catheters were implanted by board certified attending neurosurgeons at a single community-based hospital. catheters were implanted directly into the brain via a 1mm diameter corticectomy at the time of craniotomy. catheters were placed via twist drill hole/bolt when craniotomies were not performed. status epilepticus (se) affects 150,000 americans yearly. 30-50% of cases fail initial therapy. refractory cases requiring midazolam, pentobarbital, or propofol fail in 8-21% of patients. outcome is independent of the anaesthetic agent or extent of eeg suppression. hypothermia (ht) in rodent models of se abates epileptic discharges and neuronal death. case reports demonstrate ht as an effective adjunctive or primary treatment for refractory se (rse). ht effectively treats rse. multicenter, randomized, non-blinded phase iia trial of ht in rse evaluating target temperature and duration. inclusion criteria: rse patients failing initial benzodiazepines and phenytoin treatment, >18yo, and >35 o c upon admission. exclusion criteria: immunosuppression, active infected, unstable cardiac rhythm, coagulopathy, se secondary to cardiac arrest/anoxia, active chf, pregnancy, in-place ivc filter, or dnr/dni status. eeg monitored patients with rse will be randomized. controls will be managed at the intensivist's discretion. remaining patients will be varied by ht duration (12hr v 24 hr) and target temperature (32-33 o c v 31-32 o c). initially, seizure will be treated with midazolam while endovascular cooling catheters are placed, and a cold saline bolus is given. at goal temperature, midazolam will be weaned to off or the lowest dose necessary for absence of seizure activity. anaesthetic medication requirements and seizure burden (i.e. seizure frequency, duration, and number), from achieving goal temperature until icu discharge, as compared with control. total iv anaesthetic icu duration vasopressor/inotrope requirements modified rankin score at discharge infectious, device, and coagulopathic complications power analysis: > 225 patients (> 45 each arm) would be 80% powered to detect a 15% difference in ht vs control (alpha=0.05), and a 20% difference of each arm vs control (alpha=0.0125), in the primary outcome measures of anaesthetic and seizure burden. a phase i study is underway at washington university and henry ford hospital. this study remains unfunded. traditional dogma has mandated that brain injured patients with a glasgow coma score of < 8 need to remain intubated for airway protection. recent prospective studies have suggested that in brain injured patients with intact airway reflexes, prolonged intubation leads to an increase in nosocomial pneumonias and worse outcomes. a recent randomized trial suggested randomization of brain injured patients into early and delayed extubation is safe and feasible. brain injured patients with a gcs <8 and intact airway reflexes will not have worse outcomes if extubated early compared to a similar extubation group with delayed extubation until their gcs becomes >8. multi-center non blinded randomized phase 2 trial. a non inferiority trial of immediate versus delayed extubation accounting for a 0.5 change in modified rankin scores would require 110 patients in each treatment arm for 80% power. immediate extubation in stable brain injured patients with intact airway reflexes as evaluated by an airway care score. hospital discharge modified rankin score. hospital and icu length of stay, nosocomial pneumonias, reintubations. all intubated adult patients with severe brain injury defined as a gcs< 8 are potentially eligible. exclusion criteria includes: patients < 18, lack of surrogate informed consent, intubation for therapeutic interventions, anticipated medical or neurological worsening, intubation for airway edema, or prolonged intubation > 2 weeks. a feasibility trial has been completed and published. the study is in search of centers and funding. outcome of patients with ich is dismal. the majority of patients succumb in the first 48 hours to the effect of the hemorrhage causing tissue shifts and herniation. furthermore, many are comatose, ventilator-dependent because of alteration of consciousness brought upon by pressure on midline diencephalic structures. both early hemostatic therapy and surgical evacuation failed to improve outcome simple yet large decompression with durotomy in patients with large, unilateral hypertensive capsulo-ganglionic ich preceded by administration of rfviia for stabilization of clot and thereby prevention of hematoma growth upon decompression should result in less hematoma expansion (safe), reduce pressure on midline structure, and improve mentation and overall outcome study design: randomized, controlled but not blinded, feasibility and safety multi-center trial patients with spontaneous, hypertensive large ( 25 ml) ich located in the putamen and internal capsule with evidence of mass effect on midline structure ( 5mm septum pellucidum shift), who are not moribund (decerebrate posturing, absent pupillary light and oculocephalic reflexes), and who present within 8 hours from onset of bleed are eligible to be enrolled. patients should have no contraindication to receiving rfviia. patients are screened upon arrival to the er or nicu if transferred directly there intervention: 80mcg/kg rfviia is given prior to patients undergoing a large, fronto-temporo-parietal decompressive craniotomy with durotomy without clot evacuation. further care like blood pressure control and osmotic therapy will not be standardized. hematoma expansion, improvement in midline shift by 50% deterioration by 4 points on nihss within first 24 hours following decompression, good outcome at 3 months (mrs 3), icu and hospital los, days on mechanical ventilation with a beta level of 0.9 and alpha 0.02, an assumed hematoma expansion rate of 26% in the non intervention group (fast trial placebo group hematoma growth rate) and 15% in the intervention group, 152 patients are needed to be randomized not initiated yet cerebral vasospasm (cv) after aneurysmal subarachnoid hemorrhage (asah) remains a significant cause of morbidity. intravenous nicardipine has been previously studied clinically as a neuroprotectant, and shown to decrease the incidence of angiographic and symptomatic vasospasm in asah, and has the potential to avoid rescue intraarterial rescue therapy and the resultant complications. hypertensive hypervolemic vasodilatory hhvd for cv will result in a reduction in duration cv, fewer delayed ischemic neurologic deficits (dinds) and better functional outcome. randomized placebo controlled trial of hhvd versus hh therapy. patients with asah, ages 18-80, without a history of coronary artery disease (cad), ischemic cardiomyopathy, neurodegenerative disorder, or chronic kidney disease not on hemodialysis. intervention: hhvd therapy using norepinephrine and continuous nicardipine infusion at 2mg/hr initiated at the onset of cerebral vasospasm, for a duration of 7 days. intracranial hypertension (ih) is the most powerful predictor of poor outcome in severe tbi. indomethacyn (im) is a cox inhibitor with a potent vasoconstrictive effect in cerebral arterioles that has been used in tbi, avm's and intracranial neoplasm. there is a little of evidence that supports its utility in the treatment of ih with special emphasis in type a waves in patients with an impaired cerebral vasoreactivity, improving both cerebral perfusion and response to other second-tier therapeutic tools. however, large, prospective, randomised and controlled studies have not yet been performed to confirm its benefit in patients with tbi the im could be effective to treat refractory ih in severe tbi with impaired cerebral autoregulation and poor response to other therapeutic strategies. im can improve indices of cerebral haemodinamics and cerebral oxygenation decreasing neuronal ischemic damage. this therapeutic approach can reduce til to control intracranial pressure, also the length-of-stay in icu can be reduced too. im can improve long term functional outcome in severe tbi. multicenter, randomized controlled trial to evaluate the efficacy and safety of im in patients with severe tbi that presents intracranial hypertension which have reached a therapeutic intensity level that includes second-tier therapies (ie,deccompresive craniectomy, controlled hypothermia, etc) all patients (older than 18 years old) that presents with glasgow coma scale 8 or <, with icp above 20 torr and with any evidence of hyperaemia (tcd, sjvo2, avdo2 etc) or increased cbv (ct perfusion, etc) despite standard therapy (includes mechanical ventilation, evacuation of intracranial mass, profound sedation, osmotherapy, etc). intensive care unit or neurocritical care unit or neurotrauma unit at a hospital that has multimodal monitoring modality (icp, cpp, etco2 or pco2, sjvo2 or ptio2, tcd etc) and neuroimaging with evaluation of cbv (ct perfusion, etc) indomethacyn 0.6 -0.8 mg/kg at loading dose, followed by continous infusion 0.3 -0.5 mg/kg/hr or placebo in patients who develop high icp despite standard therapy for icp control. icp control (reduction of icp below 20 torr or 15 torr in dc), normalization of cerebral oxygenation (avdo2, sjvo2 or ptio2). improvement of cerebral perfusion measured by cuantitative or cualitative methods neurological outcome (egos) at discharge, 30, 90, 180 and 365 days. overall mortality at month 1, 6 and 12 qol at month 1, 6 and 12 evidence of long-term ischemic damage we need a sample of at least 100 patients to find statistically significative difference between intervention and placebo group. not started. financial supports is needed. hyperglycemia is very common in acute brain injury (abi) from ischemic stroke, hemorrhage or trauma and is associated with poor outcome. tight glucose control is effective in improving outcome in medical/surgical icu but its role in abi is uncertain. studies investigating brain metabolism using microdialysis showed increased brain metabolic crisis with tight glycemic control. currently the optimal glucose control for patients with acute brain injury is unclear. aggressive hyperglycemia management will result in improved outcome in abi compared with standard glucose management. multicenter, randomized, single-blinded phase ii feasibility and safety trial. inclusion criteria: patients admitted to icu for management of abi with high likelihood of requiring at least 72 hours of intensive care. absence of health care proxy to sign consent. patient with do not resuscitate and do not intubate orders on admission history of allergy or known contraindication to insulin moderate to severe baseline disability (pre-abi modified rankin scale 3 or greater) severe terminal concurrent medical illness with expected survival of less than three months. neurocritical care unit. treatment arm will receive continuous insulin infusion targeting blood sugar level 100-140mg/dl. control group will receive subcutaneous insulin injection and/or insulin infusion targeting blood sugar level 180-200 mg/dl. modified rankin scale at 6 months rate of medical complications, including infection, new neurologic abnormality, hypoglycaemia and in-hospital mortality.length of icu, hospital stay. based on our retrospective study with expected good clinical outcome of 50% and 25% relative difference in outcome between groups, the study will need 150 patients in each arm with 80% power and 5% two-sided alpha level. protocol complete. for submission for funding. rebleeding on the first day following asah is as high as 9-17%, and approximately half of these occur within 6hrs of onset. unanticipated delays in asah diagnosis and result in failure to secure aneurysms during the period of maximal rebleeding. a novel approach of acute antifibrinolysis (<72h duration) has demonstrated safety, however, there have been no trials powered to demonstrate a difference in long-term outcome. therefore, a clinical trial evaluating the impact of -aminocaproic acid (eaca) on outcome following asah is warranted. acute treatment with intravenous eaca will improve twelve-month outcome in patients with asah. neurological emergency treatment trials (nett)-based multi-center, randomized, double-blind, placebo-controlled phase-iii trial. all adult asah patients presenting to nett facilities will be screened for enrollment. patients must receive study drug within 12h of asah onset. those with aneurysm-negative sah, anticipated treatment within 4h, or recent thromboembolic disorder will be excluded. subjects will be enrolled and treatment initiated in the emergency department and continued during transfer and the referral-center intensive care unit. patients will receive an intravenous placebo or eaca. a 4g loading dose, will be followed by infusion of 1g/hr, to a maximum 72h. favorable 12-month modified rankin score(1-3) the barthel and lawton scales(disability scales), sip(quality-of-life scale), and a psychometric battery(cognitive/intellectual domains) will be assessed as secondary outcomes. known sequelae of asah and antifibrinolytic therapy including rebleeding, vasospasm, hydrocephalus, and thrombotic complications will be tracked. based on a 2 analysis with =0.05 and a power of 80%, 900 subjects will be randomized. this calculation is based on conservative estimates from past studies that demonstrate 9% increase in favorable outcome for patients receiving acute eaca. based on a 2 analysis with =0.05 and a power of 80%, 900 subjects will be randomized. this calculation is based on conservative estimates from past studies that demonstrate 9% increase in favorable outcome for patients receiving acute eaca. additionally, there are also associated nonlinear hospital system factors, hi, probably accounting for positive preclinical and single center studies, followed by multicenter failure. the severity regression equation can now be described asthis leads to the notion that the current widely accepted methods of evaluating single facet therapy to attenuate such multifaceted complex problems is generally a fruitless waste of public resources which has produced innovation paralysis.preclinical studies have demonstrated the potential for dramatic breakthrough level neuroprotection with a multifaceted approach but a rational systematic method for introduction of multifaceted therapeutic bundles is needed. multifaceted neuroprotective bundles can be used to demonstrate robust neuroprotection. can the plan-do-study-act (pdsa) qi method be used to incrementally add and evaluate individual facets of neuroprotective therapeutic bundles? single center pdsa therapeutic bundle development followed by multicenter randomized trial of a therapeutic bundle. patients with acute tbi or brain ischemia syndromes setting: ed, or, and icu multi mechanism multifaceted therapy incrementally and sequentially implemented during active post insult secondary pathophysiologic processes. surrogates for functional outcome with sequentially added facets in a therapeutic bundle ongoing evaluation of functional neurologic outcome. none yet background: refractory intracranial hypertension (rih) is associated with death or poor neurological outcome in 80-85% of patients and clinical equipoise often exists among management [1] . for patients with cerebral edema or intracranial hypertension who require renal replacement therapy, continuous (crrt) modes are preferred due to limited data showing improved intracranial stability over traditional intermittent hemodialysis (ihd). this is attributed to better cardiovascular stability, less rapid fluid shifts, bicarbonate and osmolality changes as well as more biocompatible, and highly permeable membranes [2] . anecdotal reports have suggested improvement in intracranial pressure (icp) [3 and verbal] during crrt and we have observed this in 3 patients (table 1 , figure 1-3 patients with persistent disorders of consciousness, defined as the absence of response to simple orders, 7 days after the event unexplained by sedation. signed informed consent. inclusion of tbi and non tbi comatose patients (ischemia, sah, hematoma and cerebral anoxia). neuroicu. mri under mechanical ventilation. inclusions during 3 years. follow up at 6 months and one year by phone interview. electronic crf. multimodal mri with mrs (pons and csi) and dti under mechanical ventilation. 10 controls per center. predictability of dichotomized gos at year using a composite index combining clinical data and quantified indicators from mrs (naa/cr in specific brain regions) and dti. design of specific algorithms according to the etiology of coma. with 220 subjects, 79% of power to detect a variable with an or by standard deviation of 1.55 ( = 5 %, bilateral test, proportion of patients with poor outcome = 33%, nquery advisor® 4.0). 10% of lost to follow-up within 1 year and 5% of drop-out. total tbi to be included = 250. same reasoning for non tbi patients. founded in france 400 000 €. 10 european actively including patients following a similar protocol. 281 patients already included (tbi 154 patients, anoxia 40, intracerebral hematoma 27, sah 51, arterial ischemia 9). mortality rate at one year 26 %.financial support: none key: cord-009713-sxd4t2tz authors: nan title: poster presentations date: 2020-01-10 journal: dev med child neurol doi: 10.1111/dmcn.14411 sha: doc_id: 9713 cord_uid: sxd4t2tz nan what are the perspectives and understanding of healthcare professionals including occupational therapists on treatment and care of babies with infantile spasms and early-onset epilepsy? a qualitative design dm middleton university of roehampton-online, birmingham, uk objective: to explore the perspectives and understanding of allied healthcare professionals (occupational therapists, physiotherapists, speech & language therapists) that work with children and epilepsy in order to guide and advocate for this population group. methods: a qualitative study design using interpretive thematic analysis with the data from participants in 10 semi-structured interviews. results: the professionals had worked across acute and community settings and had previous experiences of working with children with epilepsy with some awareness of these needs. there were 5 themes that emerged: (1) housing and social needs, (2) epilepsy, psycho-social and mental health needs, (3) therapy approaches, (4) training for allied healthcare professionals, and (5) adolescents, young girls, women and epilepsy. conclusions: there are gaps in service provision for certain areas and will be shared within the presentation. epilepsy requires additional considerations for safety that other conditions may not require. it is crucial in the interests of public health for children and families with epilepsy to be able to advocate for resources and their specific needs. poster no. 004 time to onset of cannabidiol (cbd) treatment effect and resolution of adverse events in patients with dravet syndrome: pooled analysis of two randomised controlled trials solution) at 10mg/kg/day (cbd10; gwpcare2) or 20mg/ kg/day (cbd20; both trials) or placebo for 14 weeks. cbd treatment started at 2.5mg/kg/day and reached 10mg/kg/day on day 7 and 20mg/kg/day on day 11. percent reduction in cumulative convulsive seizure frequency for each treatment day (including previous treatment days) and timing of adverse events (aes) were assessed. results: overall, 194 patients were randomised to cbd and 124 to placebo. cbd led to significantly greater percent reductions in convulsive seizure frequency than placebo in gwpcare1 (cbd20 39% vs placebo 13%, p=0.0123) and gwpcare2 (cbd10 49%, cbd20 46% vs placebo 27%, p=0.0095 and p=0.0299). in the pooled data, treatment differences in seizure reduction emerged during titration and were maintained throughout the study, with nominal significance (p<0.05) achieved by day 13 for cbd10 and day 12 for cbd20. onset of the first reported ae occurred during titration in 60% of patients with aes. aes resolved within 4 weeks of onset in 40% of patients and by the end of the study in 60%. increases in alt/ast (>39 upper limit of normal) occurred in 3 (5%) patients for cbd10, 25 (19%) for cbd20, and 1 (1%) for placebo; all were on concomitant valproate. all elevations resolved, either spontaneously while continuing cbd, after discontinuing cbd, or after reducing cbd, valproate, and/or clobazam dose. conclusions: cbd treatment effect (seizure reductions and aes) may occur early, during titration. the majority of aes resolved during the study. poster no. 005 low dose fenfluramine hydrochloride oral solution provides long-term, clinically meaningful (≥50%) reduction in seizure frequency in dravet syndrome: interim analysis of a long-term openlabel extension study objective: to characterize long-term safety and durability of effect for adjunctive fenfluramine (ffa) in treating dravet syndrome (ds). methods: patients (2-18y) with ds entered a long-term openlabel extension (ole) (1503) after completing one of two phase 3 studies: study 1 (14wks; placebo or ffa 0.2 or 0.8mg/kg/d [max, 30mg/d] or study 1504 (15wks; placebo or ffa 0.5mg/kg/d [max, 20mg/d]) . stiripentol was excluded in study 1 but mandatory in study 1504. in 1503, patients received ffa 0.2mg/kg/d for month 1; dosing was titrated to effect thereafter. effectiveness and tolerability were assessed at months 1, 2, and 3, then at 3-month intervals. results: at interim analysis (13-mar-2018) , 158/187 patients continued into ole; 89% completed 12 months of ffa (mean dose, 15.2mg/d; median duration, 400d [range, 71-703d] ). during the entire ole, median percentage change in monthly convulsive seizure frequency (mcsf) for ffa vs pretreatment phase 3 study baseline was -63.6% (p<0.001); clinically meaningful (≥50%) and profound (≥75%) mcsf reduction from baseline were 63% and 41%. at month 12, median and mean longest interval between convulsive seizures were 26 and 60 days (range, 2-589d); 71% of caregivers and 83% of investigators rated patients 'much improved/very much improved'. the most common adverse events included appetite decrease, pyrexia, nasopharyngitis, and diarrhea. no valvular heart disease or pulmonary hypertension was observed in any patient. conclusions: treatment with ffa resulted in robust, sustained reductions in mcsf and was generally well tolerated. no valvular heart disease or pulmonary arterial hypertension was observed in any patient at any time. ffa may be an important, novel antiepileptic drug for long-term ds treatment. poster no. 006 zx008 (low dose fenfluramine hydrochloride oral solution) provides long-term, clinically meaningful reduction of convulsive seizure frequency in young (<6 years old) dravet syndrome participants: analysis from a long-term open-label study results: a total of 42 of 158 (26.6%) participants who enrolled in the ole were <6 years old upon entry into the phase 3 studies. the median baseline monthly convulsive seizure frequency (mcsf) before double-blind treatment was 10.7 seizures/month (range, 4.0-147.3 ) in this patient subgroup (<6y). at the time of the ole interim analysis, the median decrease in mcsf in the <6 years subgroup over the entire observation period compared to baseline was -75% (p<0.001) compared with -64% in the overall study population (2-18y). the most frequently reported adverse events included pyrexia, upper respiratory tract infections, decreased appetite, and diarrhea. no valvular heart disease or pulmonary arterial hypertension was observed. conclusions: treatment with zx008 provided sustained, clinically meaningful reduction in mcsf in ds participants <6 years old. importantly, effective control of seizures in this young age group might be expected to mitigate the negative neurodevelopmental outcomes reported to be associated with treatment-refractory seizures. the improving provision of epilepsy care for children in england and wales methods: all relevant health boards and trusts (hb/t) were invited to register to participate and identify a hb/t lead. a snapshot survey was completed via a bespoke online platform by the hb/t lead describing local provision as of april 2018. data was analysed by the rcpch including regional and national aggregates and longitudinal comparison to previous 2012, 2014 reports. results: 148 hb/t with a paediatric epilepsy service across england and wales registered to participate and submitted data. 94.6% (140/148) of hb/t employed a consultant paediatrician with expertise in epilepsy; 77.7% (115/148) had some epilepsy specialist nurse (esn) provision; 85.8% (127/148) had a defined epilepsy clinic seeing patients at secondary level. 92.6% (137/148) of hb/t had agreed referral pathways to tertiary paediatric neurology services. satellite paediatric neurology clinics were hosted in 77.0% (114/148) of hb/t. conclusions: there are improvements in the overall numbers of epilepsy nurse specialists, paediatricians with expertise and specific clinics for children and young people with epilepsies. the findings led to comprehensive recommendations to hb/ t and commissioners, informed updates to the epilepsy best practice tariff and themes within the nhs long term plan. poster no. 008 diagnosing and managing seizures on picu: an explanatory sequential mixed methods approach tonic clonic seizures. awake and sleep eeg showed temporal focal slowing. she was labelled as non lesional focal epilepsy after a normal mri scan and was discharged on keppra. she had multiple admissions with cluster of brief seizures at the age of 12, 16, 25, 26, 34, 38 and 46 months associated sometimes with febrile illness with poor response to intravenous aed's. she was diagnosed with autism at 42 months. 2nd child: 38 months old younger sibling had seizure onset at 9 months. seizures were tonic in nature, brief, multiple and in clusters over a period of 2 to 3 days. eeg's showed non-specific slowing during seizures. array cgh revealed chromosome 3p26.1 microdeletion. keppra was commenced and increased but recurrent cluster of seizures at the age of 15, 19 and 24 months required admission with poor response to iv aed's. family history revealed that half-sister (biological father's daughter who had epilepsy and global developmental delay) was diagnosed with pcdh 19 epilepsy. gene tests were requested on both siblings and both were heterozygous for pcdh 19 mutation. she had delayed social and communication skills from 2 years with a diagnosis of autism at 30 months. 3rd child: 1 year old half sibling (father's 4th child from 3rd relationship) has tested positive for pcdh 19. her development is normal and so far there have been no seizures. conclusions: pcdh 19 epilepsy is increasingly recognised as one of the early onset infantile encephalopathies. gene testing is likely to yield a diagnosis with a family history or with a typical phenotype. poster no. 010 seizure, developmental and cognitive outcomes in children post hemispherotomy tt tay 1 , dr reed 2 , vj josan 3 , sr rust 4 , jt tan 5 1 university of manchester, manchester, uk; 2 neuropsychology team, paediatric psychosocial service, royal manchester children's hospital, manchester, uk; 3 neurosurgery, salford royal nhs foundation, manchester, uk; 4 paediatric neuropsychology, royal manchester children's hospital, manchester, uk; 5 paediatric neurology, royal manchester children's hospital, manchester, uk introduction: patients with focal refractory epilepsy secondary to structural hemispheric changes have been shown in retrospective studies to have significantly improved seizure outcomes following hemispheric disconnection. the aim of this study was to report the seizure and cognitive outcomes in our cohort and investigate prognostic factors for seizure outcomes. methods: this was a single-centre retrospective study on children and adolescents who had hemispherotomy for refractory epilepsy in the royal manchester children's hospital between 2008 and 2017. results: twenty-two patients were included with median (range) age of seizure onset and of surgery of 4 (0-168) and 72 (13-217) months respectively. median (range) time from seizure onset to surgery was 38.5 (12-172) months. the most common aetiologies were antenatal/perinatal middle cerebral artery infarct (n=6) and malformations of cortical development (n=6). at 1 year after surgery and at last follow-up (median [range] 38 [2-107] months), 50% (10/20) and 32% (7/22) achieved complete seizure freedom. the number of anti-epileptic medications decreased for 10 (45%) at last follow-up. lateralisation of ictal and interictal eeg (p=1.00, p=0.11), aetiology (p=0.75), age of first seizure (p=0.45) were not associated with seizure recurrence. five who had formal neuropsychological testing using the wechsler intelligence scale for children (wisc) showed improvement in cognitive abilities across all subsets post-surgery. ten children showed reduction in median vineland adaptive behaviour score, from 58 to 49.5, indicating a failure to progress rather than regression of skills. nine (45%) had newly reported behavioural or psychiatric issues including sleeping problems, challenging behaviours, autistic spectrum disorder. sixteen (84%) were reported by parents/carers to show improved verbal abilities postoperatively while the rest had unchanged verbal abilities. conclusions: we present a cohort of children with early onset seizures who had hemispherotomy at a relatively early age. our cohort showed good seizure outcomes and cognitive improvements. there were no prognostic factors for seizure outcome identified in this small group. the mri phenotype of atp1a3-related disease contrast, all ahc patients with mri abnormalities (83%) had a hypoplastic corpus callosum. the only patient with normal mri was the patient carrying mutation p.g497r, associated with a mild clinical phenotype. of the patients with clinical ataxia (n=7), 5 (71%) had cerebellar atrophy on mri; 2 patients with cerebellar atrophy were not ataxic. two (67%) of the 3 patients with severe intellectual disability had cerebral atrophy. conclusions: atp1a3 mutations have subtle radiological findings, clustering around callosal dysmorphisms, as well as pontine and cerebellar abnormalities that seem to form distinctive mri phenotypes for ahc and capos. study of larger cohorts is required to more accurately define mutation-specific phenotypes and allow for quantitative analysis. poster no. 012 long-term safety and efficacy of adjunctive perampanel in paediatric patients (aged 4 to <12y) with partial-onset seizures (pos) or primary generalised tonic-clonic seizures (pgtcs) in study 311 r flamini 1 , a patten 2 , ly ngo 3 1 pediatric and adolescent neurodevelopmental associates, atlanta, ga, usa; 2 eisai ltd., hatfield, hertfordshire, uk; 3 eisai inc., woodcliff lake, nj, usa objective: study 311 (nct02849626) was a multicentre, openlabel, single-arm study of perampanel oral suspension (0.5mg/ ml) in paediatric patients (aged 4 to <12y) with pos (with/ without secondarily generalised seizures [sgs] ) or pgtcs. here, we report long-term (1y) safety and efficacy data of adjunctive perampanel in paediatric patients from study 311. methods: this analysis included cumulative data from all enrolled patients in the core study (23wks of treatment) and extension phase a (52wks of treatment). assessments included monitoring of treatment-emergent adverse events (teaes), median percent change in seizure frequency per 28 days from baseline, and 50% responder and seizure-freedom rates. results: of 180 patients enrolled in the core study (pos, n=149; sgs, n=54; pgtcs, n=31), 136 patients entered extension a. of these, 14 patients discontinued extension a; most common primary reasons for discontinuation were adverse events (3.7%) and inadequate therapeutic effect (2.9%). for all patients, mean (standard deviation [sd] ) time since diagnosis was 5.7 (2.9) years and mean (sd) duration of exposure was 41.5 (17.3) weeks. during baseline, 55.6% of patients received two concomitant anti-seizure medications. teaes were reported in 162 (90.0%) patients; somnolence was the most commonly reported (27.2%). median percent reductions in pos, sgs and pgtcs frequencies at weeks 1-13 were 43.0%, 57.9% and 79.3%, respectively; these were maintained at weeks 40-52 and were 69.4%, 73.8% and 100.0%, respectively. seizure-freedom rates for pos, sgs and pgtcs at weeks 40-52 were 13.0%, 24.4% and 38.5%, respectively. conclusions: long-term (1y) adjunctive perampanel is generally safe, well tolerated and efficacious in paediatric patients aged 4 to <12 with pos (with/without sgs) or pgtcs. poster no. 013 long-term adjunctive perampanel and healthrelated quality of life (hrqol) in paediatric patients (aged 4 to <12y) with partial-onset seizures (pos) or primary generalised tonicclonic seizures (pgtcs): study 311 ea portillo 1 , a patten 2 , g meier 3 , m malhotra 3 , ly ngo 3 1 paediatric neurology unit, department of paediatrics, hospital universitario virgen del roc ıo, sevilla, spain; 2 eisai ltd., hatfield, hertfordshire, uk; 3 eisai inc., woodcliff lake, nj, usa objective: study 311 (nct02849626) was a multicentre, openlabel study of adjunctive perampanel oral suspension in paediatric patients (aged 4 to <12y) with pos (with/without secondarily generalised seizures [sgs] ) or pgtcs. we report long-term (1y) hrqol data using the euroqol 5 dimensions-youth (eq-5d-y) scale from study 311. methods: this analysis included cumulative data from all enrolled patients in the core study and extension phase a (23 and 52wks of treatment, respectively). eq-5d-y was assessed at baseline, week 23 and week 52, and included five domains (mobility, self-care, doing usual activities, pain/discomfort, feeling worried/sad/unhappy). the eq-5d-y visual analogue scale (vas) was also assessed; increases in vas correspond with improvements. data are for observed cases. results: all 180 enrolled patients were included in the eq-5d-y analyses. the proportion of patients reporting 'a lot of problems' was similar during baseline vs week 52: mobility, 20/112 (17.9%) vs 13/68 (19.1); self-care, 44/112 (39.3%) vs 23/68 (33.8%); doing usual activities, 27/112 (24.1%) vs 18/68 (26.5%); pain/discomfort, 4/115 (3.5%) vs 2/70 (2.9%); feeling worried/sad/unhappy, 4/113 (3.5%) vs 1/70 (1.4%). outcomes were also similar for 'no problems' during baseline vs week 52: mobility, 64/112 (57.1%) vs 43/68 (63.2%); self-care, 42/112 (37.5%) vs 27/68 (39.7%); doing usual activities, 53/112 (47.3%) vs 34/68 (50.0%); pain/discomfort, 78/115 (67.8%) vs 50/70 (71.4%); feeling worried/sad/unhappy, 80/113 (70.8%) vs 52/70 (74.3%). mean (standard deviation) change in eq-5d-y vas from baseline at week 52 was 5.1 (16.6). conclusions: long-term adjunctive perampanel treatment (up to 1y) does not negatively affect hrqol (based on all eq-5d-y domains) in patients aged 4 to <12 years with pos (with/without sgs) or pgtcs. poster no. 014 efficacy and safety of adjunctive perampanel for partial-onset seizures (pos) in adult, adolescent and paediatric populations (studies 304, 305, 306, 311) . in study 311, 149 patients received perampanel ≤12mg/day (without enzyme-inducing anti-seizure medications [eiasms] ) or ≤16mg/day (with eiasms) (23-week treatment period). efficacy assessments included median percent change in seizure frequency/28 days from baseline, 50% responder rate and seizure-free rate. safety assessments included the incidence of treatment-emergent adverse events (teaes). results: the median percent reduction in seizure frequency/ 28 days was greater with perampanel at 4 (23.3%), 8 (28.8%) and 12mg/day (27.2%) vs placebo (12.8%; p<0.01) in adolescent/adult patients and was 40.1% in paediatric patients. the 50% responder rate during the maintenance period was greater with perampanel at 4 (28.5%), 8 (35.3%) and 12mg/ day (35.0%) vs placebo (19.3%; p<0.05) in adolescent/adult patients and was 46.6% in paediatric patients. seizure-freedom rates were greater with perampanel at 4 (4.4%), 8 (3.5%) and 12mg/day (4.1%) vs placebo (1.0%; p<0.05) in adolescent/ adult patients and was 11.5% in paediatric patients. teaes occurred in 61.7%-89.0% of adolescent/adult patients with perampanel 2-12mg/day (vs 66.5% in placebo patients), and in 89.9% of paediatric patients. teaes observed in pediatric patients were similar to those reported in adolescents and adults. conclusions: these studies suggest perampanel is efficacious and generally safe in paediatric, adolescent and adult patients with pos (with/without sgs). methods: patients who completed either of the rcts could enter this ole trial (gwpcare5/nct02224573). patients received gw pharmaceuticals' plant-derived highly purified cbd medicine (100mg/ml oral solution). the primary endpoint was safety. the secondary efficacy endpoints were median percentage change from baseline in drop and total seizure frequency. results: overall, 99% (366/368) of eligible patients with lgs entered the ole. median follow-up was 150 weeks (3d to 179wks); 119 patients (33%) withdrew. mean age: 16 years; 33% ≥18 years; 54% male. baseline median seizure frequency/28 days: 80 drop seizures; 168 total seizures. during the extended follow-up, the incidence of adverse events (ae) was 96%; serious aes 42%; aes leading to discontinuation 12%. most common aes (≥20%): diarrhoea, convulsion, pyrexia, somnolence, vomiting, upper respiratory tract infection, and decreased appetite. aes of alanine aminotransferase increased occurred in 8% of patients. there were 11 deaths; none deemed treatment-related by the investigator(s). median percentage reductions in seizure frequency (12-wk windows over 156wks) was 48-71% for drop seizures and 48-68% for total seizures. conclusions: long-term treatment with add-on cbd in patients with lgs produced sustained seizure reductions, with no new safety concerns. poster no. 016 management of status epilepticus in children with dravet syndrome jaa holland, u rajalingam paediatrics, hinchingbrooke hospital, huntingdon, uk objective: status epilepticus is reported to be the second greatest cause of mortality in children with dravet syndrome. we aimed to review the evidence on convulsive status management in children with dravet syndrome to guide local practice. methods: literature review. results: pubmed search using search terms 'dravet' or 'scn1a' and 'status epilepticus' returned 149 results, of which 8 were relevant. only one of these articles presented specific data on reported effectiveness of medications used in acute seizure management; this was based upon retrospective questionnaire data and defined status epilepticus as seizures lasting 30 minutes or longer. here, the most efficacious agents reported to terminate such seizures within 10 minutes were intravenous barbiturates (16 of 19 patients) and benzodiazepines (60 of 102 patients). rectal benzodiazepines, chloral hydrate and intravenous phenytoin or lidocaine were reported as less effective. the remaining articles presented expert and consensus opinion, all advising early administration (some at seizure onset) of buccal or intravenous benzodiazepines. provision of rescue medication for home use, with individualised plans, is recommended. one author advocated giving three doses of benzodiazepines sequentially. an article summarising a consensus panel described sodium valproate as a preferred second line option where benzodiazepines are ineffective, but there was no overall agreement on other possible medications. several articles advised caution in using phenytoin in acute seizure management. one source discusses possible harm from high dose barbiturates. conclusions: status epilepticus management for children with dravet syndrome should feature early, rapidly acting benzodiazepine administration. for second line treatment, phenytoin and barbiturates are commonly used in 'standard' status epilepticus management protocols, but there are potentially concerns around their use in this patient group. these concerns, however, appear largely theoretical. in the absence of evidence favouring a specific management protocol, individualised care plans should be designed with involvement of patients and their carers. poster no. 017 zx008 (low dose fenfluramine hydrochloride oral solution) significantly reduces frequency of generalized tonic-clonic seizures in dravet syndrome: pooled analysis from two phase 3 clinical trials jh cross 1 , a gil-nagel 2 , b gunning 3 , d battaglia 4 , k riney 5 , g farfel 6,7 , a mistry 6,7 , b galer 6,7 , g morrison 6,7 , a gammaitoni 6,7 , k pagano 6,7 1 great ormond street hospital, london, uk; 2 servicio de neurologia, hospital ruber internacional, madrid, spain; 3 stichting epilepsie instellingen, zwolle, the netherlands; 4 gemelli hospital, rome, italy; 5 mater children's hospital, brisbane, qld, australia; 6 zogenix, inc and int, emeryville, ca, usa; 7 zogenix, inc and int, maidenhead, uk objective: zx008 (low dose fenfluramine hcl oral solution) significantly reduced the frequency of convulsive seizures in patients with dravet syndrome (ds) in two phase 3 clinical trials. we conducted a pooled analysis of these trials to analyze the effect of zx008 on the frequency of tonic-clonic seizures (tcs), recently identified as a major risk factor for sudden unexpected death in epilepsy. methods: the frequency of generalized tcs and focal-to-bilateral tcs in patients with ds enrolled in one of two phase 3 clinical trials of zx008 added to current antiepileptic drug regimens were analyzed. results: 206 patients (55% male, mean age 9y) were enrolled and randomized to placebo (n=84), or zx008 0.8 (n=40), 0.5 (n=43), or 0.2 (n=39) mg/kg/day. the median baseline monthly frequency of generalized tcs ranged from 8.0 to 12.3/month in the four dose groups, and decreased during treatment by 80%, 64%, and 48% in the zx008 0.8, 0.5, and 0.2mg/kg/day groups, respectively, and by 10% in the placebo group. focal-to-bilateral tcs were experienced by fewer patients and had a median baseline frequency of 2.0 to 4.7/ month. during treatment, median percentage reductions in focal-to-bilateral tc frequency were 97%, 33%, and 69% in the zx008 0.8, 0.5, and 0.2mg/kg/day groups, respectively, and 39% in the placebo group. most common adverse events included decreased appetite, diarrhea, and fatigue. no valvular heart disease or pulmonary arterial hypertension was seen in any participant at any time. conclusions: zx008 substantially reduced the frequency of tcs. zx008 may be an important, effective new treatment option for ds patients. objective: mutations affecting tbc1d24 have been associated with an expanding spectrum of phenotypes including developmental delay, hearing impairment, doors syndrome and a range of epilepsies. a number of different movement disorders, including ataxia, spasticity and episodic paroxysmal dystonia have also been described. here we report two unrelated patients with biallelic tbc1d24 variants, in whom exerciseinduced dystonia was a major disease feature. methods: both patients were diagnosed through whole-exome sequencing. clinical information was obtained by a review of the medical notes, clinical correspondence and available video footage. results: both patients were found to have compound heterozygous mutations in tbc1d24, associated with an episodic dystonic/dyskinetic movement disorder reliably triggered by exertion. in the case of patient 1, exertion of specific body parts induced specific localised symptoms: for example, singing would precipitate orolingual dyskinesia. both girls experienced truncal dystoniaspecifically, lateral flexion of the trunkbrought on by prolonged walking. both girls also had epilepsy; of note, the exercise-induced movements and postures were captured on eeg and had no ictal correlate. conclusions: although tbc1d24 mutations are an established genetic cause of epilepsy, our study further confirms that not all paroxysmal events in people with tbc1d24 mutations are epileptic in nature. tbc1d24 should be included in the genetic differential diagnosis of patients with complex neurological syndromes associated with paroxysmal exercise-induced dyskinesia. objectives: heterozygous de novo rhobtb2 mutations have recently been reported in developmental and epileptic encephalopathy, but the associated movement phenotypes are not fully delineated. in order to better define the expanding phenotype and movement disorder in rhobtb2-related disease, we report a series of 9 unrelated patients presenting with complex movement disorders as well as epilepsy and developmental impairment. methods: cases were identified both in the uk (through the neurogenetic services at great ormond street hospital and the national hospital for neurology and neurosurgery, london), and from international collaborating centres. data were collected retrospectively by the patients' clinicians, using a standardised proforma. results: nine individuals were identified, aged from 2 to 55 years. 8/9 had epilepsy. of these, 4/8 had achieved seizure freedom at their last review. the commonest seizure types were focal onset with impaired awareness and/or focal to bilateral tonic-clonic seizures. 7/9 also had a paroxysmal movement disorder, which included hemiplegic or asymmetrical episodic weakness in 5/7, generalised dyskinesia in 4/7, episodic focal dystonia in 3/7 and episodic ataxia in 3/7. all individuals affected by a movement disorder had at least two different types of episodes. movement disorders improved significantly after treatment with carbamazepine in three children. cognitive ability varied from average to severe intellectual disability and in all but one case, developmental delay predated the onset of epilepsy. conclusions: rhobtb2 mutations cause a complex neurological phenotype associated with both epileptic and non-epileptic paroxysms. paroxysmal events occurring in people with known rhobtb2 mutation should therefore not be assumed always to be epileptic in nature. our study confirms that a wide variety of movement disorders are reported, including some which fall within the spectrum of alternating hemiplegia of childhood (ahc). rhobtb2 should thus be considered as a potential gene for ahc, other complex movement disorder phenotypes and epilepsy-dyskinesia syndromes. poster no. 020 evaluating seizure recognition and the use of electroencephalography in the paediatric intensive care unit objective: in the paediatric intensive care unit (picu), seizures are challenging to detect given patient complexity, comorbidity and sedation. this has led to both over-and under-treatment of seizures. there is growing literature on the use of continuous electroencephalography in picu, considered gold standard but not universally available, but little on standard electroencephalography (eeg). this study aims to investigate the indications for eeg requests, their efficacy and the use of antiepileptic drugs (aed) in picu, hypothesising a difficulty in clinically differentiating between epileptic and non-epileptic events and suboptimal use of aeds. methods: this retrospective study examined eeg reports over 2 years at a tertiary picu. data was collected on participant characteristics, eeg indications and findings and aed use. results: 185 eeg reports from 142 participants were included. median age was 6 months (iqr 1mo-3y 6mo). indications for eeg (often multiple per eeg) included suspected clinical seizures (64%), suspected subclinical seizures (21%), prognostication (28%) and suspected encephalopathy (8%). 63% of participants with suspected seizures were sedated and 43% of all participants were encephalopathic. clinical episodes suspected to be seizures were captured in 41/141 eegs. only 22% of these were eeg-confirmed seizures. captured movements shown not to be seizures are qualitatively described. 6% of patients with suspected seizures had electrographic seizures with no clinical correlate. most confirmed seizures were in participants without pre-existing epilepsy. antiepileptic(s) were changed prior to 25/35 captured events. seizures were present in 28% of these cases, while 60% had neither clinical nor electrographic seizure activity. 7/8 participants with confirmed clinical seizures had aeds changed. conclusion: it is challenging for clinicians to differentiate between seizure and non-seizure movements in picu. moreover, there are issues of over-medication and low event-capture rate with eeg. we propose a multidisciplinary education strategy and investment in ceeg to address these issues. introduction: glucose transporter 1 deficiency syndrome (glut1-ds) is a rare neurometabolic disorder causing impaired glucose transport into the brain. in the majority of patients, it is caused by an autosomal dominant heterozygous mutation in the scl2a1 gene. ketone bodies generated by a ketogenic diet (kd) provide the brain with an alternative energy source and is gold standard therapy. we report our experience for our cohort of patients at royal manchester children's hospital. methods: retrospective case note review of 14 patients with glut1-ds at royal manchester children's hospital from 2004 to 2019. results: 14 patients -8 male, 6 female. age range 3 to 19 years. average age at diagnosis was 6 years 3 months (range 4mo-9y). there was a history of seizures in 11 of 14 patients with average seizure onset of 2 years 6 months. seizures types were absences (5/11), generalised tonic-clonic (3/ 11), myoclonic (2/11), myoclonic astatic (1/11), tonic (1/11) and focal to bilateral tonic-clonic (1/11). ketogenic diet was used in all patients for a range of 4 months to 10 years 7 months. no significant adverse effects occurred that required discontinuation. six patients complying with kd are seizure free and not taking antiepileptic drugs (aeds). one of these patients had occasional tonic-clonic seizures with illness and loss of ketosis but has been seizure free for >18 months. five patients are non-compliant with kdtwo have good seizure control with aeds, potentially limiting motivation, and two (siblings) have a parent with glut1-ds and learning difficulties. learning difficulties were reported in 10 patients. other symptoms included ataxia (8/14), dysarthria (5/14), tremor (4/14) and dystonia (4/14). one patient presented with episodic hemiplegia. conclusions: patients with glut1-ds are a heterogeneous group leading to challenges in diagnosis, management and prognosis. ketogenic diet has been effective in managing this cohort but compliance was a limiting factor. objective: to conduct a survey regarding the management of relapse in children epilepsy in following weaning off aeds. methods: we conducted an online survey in the east of england (eoe) via the eastern paediatric epilepsy network (epen) regarding the management of relapse in children epilepsy after weaning aeds. epen is a network of paediatricians and nurse specialist with eoe who manage lead in management children with epilepsy within all the dgh's in the region. the questions in the survey asked about various aspects of management of patients after relapse, including the choice of anti-epileptic medication restarted, if started, any further investigations undertaken, and finally, the length of aed treatment before a second attempt at weaning might be considered. results: we received 17 responses from paediatricians in 16 dgh's across eoe. there was a large degree of variation in the responses to all of the questions in the survey. the frequency and semiology of seizures on relapse seemed to play a key role in decision making, as did the thoughts and views of the family and patient themselves. it was interesting to note there was a variation in response to whether any further investigations would be undertaken and if these were deemed necessary. most clinicians responded that they would continue aeds for another 2 years before attempting weaning again. conclusions: there is variability in the management of epilepsy relapse in the eoe and we suspect that this may also be the case nationally. to investigate this further, we would envisage extending the survey nationally, via open ukwhich is an organisation that links the various regional paediatric epilepsy networks across uk. this would enable establishing a standardized guideline for management of epilepsy relapse in the future. objective: de novo dominant mutations in dhdds were recently identified as a cause of developmental and epileptic encephalopathy. dhdds encodes dehydrodolichyl diphosphate synthase, which is essential for dolichol monophosphate synthesis and protein glycosylation. we report two half-siblings with a new pathogenic, maternally inherited dhdds missense variant, c.614g>a(p.arg205gln), identified through whole-exome sequencing. method: case note and literature review. results: sibling 1, aged 11 years, presented at 11 months with global developmental delay, hypotonia and frequent absences with eyelid myoclonia. from age 3, she developed atonic drop attacks, myoclonic seizures, tremor, ataxia and facial dyskinesia. dyskinesia and mobility deteriorated from age 7 and she is now largely non-ambulant. severe learning disability with possible cognitive deterioration and insatiable appetite are also features. sibling 2, aged 9 years, developed blank spells associated with eyelid flickering at 12 months and atonic drop attacks aged 5. development delay is present, but progress is greater than her sibling. dyskinesia, tremor, ataxia and deterioration in mobility are features. neither is dysmorphic. eegs on both showed bursts of irregular generalised spike wave associated with head nods and eyelid flutter. photosensitivity was not shown but both were treated with anti-epileptic medication. mri scans are normal. clobazam and zonisamide improved seizure control in both. mother has mild learning difficulties, tremor and dyspraxia. she had generalised tonic clonic seizures, from age 14 to 18 years, well controlled with lamotrigine. compared to the six known cases in the literature, our report confirms atonic seizures and dyskinesia as important features of this disorder, in addition to common characteristics of myoclonic component to seizures, hypotonia and tremor. learning disability is of variable severity. conclusions: this is the first report of familial inheritance of dhdds related developmental and epileptic encephalopathy and describes variable severity of the phenotype within family members. the features described are consistent with those previously observed. objectives: to evaluate whether the duration of treatment has an effect on the relapse rate in children with cae attending a paediatric neurology centre in cyprus, and whether the eeg can be used as a prognostic tool. methods: electronic patient database review of patients with cae, who have discontinued treatment attending the paediatric neurology clinic between years 2008-2017. results: fourteen patients with cae, off treatment were identified (7 male). age at presentation ranged from 3 to 9 years (median 6.5y). all patients underwent an eeg to confirm diagnosis and those who presented with seizures other than absences were excluded. twelve patients were treated with valproic acid (depakine) and 2 with ethosuximide (zarontin). in 10, absences resolved on first line monotherapy, whilst 4 were refractory requiring combination therapy. positive family history was present in 2 (non-identical twins), attention deficit in 2, and learning difficulties in 1 patient. all initial eegs were consistent with cae, patients also underwent an eeg post seizure control to confirm resolution. mean time to seizure cessation was 3.9 months, mean duration of treatment 2.2 years; 4 patients discontinued treatment after 1 year of seizure freedom. prior to withdrawing treatment all patients had an eeg (normal 6, mildly abnormal with brief generalised discharges 6, photosensitivity 1, brief electrographic absence 1). relapse occurred in 3 patients who required re-instigation of treatment. mild abnormalities on eeg prior to coming off treatment did not correlate with a higher relapse rate. there was no difference in relapse rate in patients on treatment for 1, 2 or more years. patients were followed up for a mean of 7.8 years. conclusions: treating patients with cae for less than 2 years does not affect relapse rate provided patients are seizure free, also confirmed by eeg normalisation, which may be used as an additional predictor. background: mutations in unc80, encoding part of the unc79-unc80-nalcn channel complex, causes autosomal-recessive severe infantile encephalopathy, this is a rare case of profound global developmental delay with psychomotor retardation. only 19 individuals have been reported to date. unc80 deficiency is characterized by hypotonia, strabismus, oral motor dysfunction, postnatal growth deficiency, and developmental delay. the majority of individuals do not learn to walk. all individuals lack expressive language. additional features can include nystagmus, extremity hypertonia, a highpitched cry, repetitive and self-stimulatory behaviours, constipation, clubfeet, joint contractures, and scoliosis. there is no loss of skills suggestive of neurodegeneration. case presentation: 11-year-old, with a recent confirmed diagnosis of unc80 gene mutation and microcephaly. she had profound global developmental delay, learning disability, bilateral squint with cortical blindness, seizure disorder, sleep apnoea, head drops, movement disorders, feeding difficulty, scoliosis and constipation. term baby with normal anti-natal history. induction of labour for iugr. good apgar, at birth but developed respiratory distress with cardiac problems. birth weight 2050 g. neurologically: floppy with reduced muscle tone and microcephaly. had a short neonatal admission and discharged with cardiac, endocrine, neonatal and neurodevelopmental delay follow-up. she had no spoken words and communicated by crying. she was only able to sit transiently and never walked. she was wheelchair bound with gmfcs, macs, cfcs and edacs level 5 each, needing full 24-hour support from patents and carers. ddd study confirmed unc80 gene mutation, her cousin was also noted to have same gene mutation via exome sequencing and with similar clinical picture. conclusion: early diagnosis is key for genetic counselling for further children and ensuring global support as reported individuals span ages from birth to 15 year. the diagnosis is established in a pro-band with developmental delay and hypotonia by identification of bi-allelic pathogenic variants in unc80 on molecular genetic testing. poster no. 026 cognition and disease burden in scn1a positive dravet syndromea 10-year follow-up study development, disease burden and sleep profile of patients with dravet syndrome. methods: this is a follow-up to a 2009 study previously involving 141 ds patients with detailed developmental and clinical information available. participants completed a structured postal questionnaire on epilepsy severity and disease burden, the adaptive behavioural assessment system (abas-3), the sleep disturbances scale for children, pediatric quality of life inventory (pedsql) and the strength and difficulties questionnaire. results: 123/141 from the original cohort were contactable and 70 (57%) of carers completed the outcome measures. the developmental quotient at follow-up was significantly lower compared to the earlier study (p=0.001), and 89% of affected individuals had a severe or profound learning disability. we observed the steepest decline in cognitive functioning in those that were youngest (age 0-5y) at original study onset (p=0.001). poorer developmental quotients correlated with early onset of initial developmental concerns (rs=0.31; p=0.037), later mobility problems (rs=0.30; p=0.015), higher levels of behaviour problems (rs=0.26; p=0.043) and worse pedsql scores (rs=0.31; p=0.015). carers health and wellbeing was negatively affected in 98% of cases and in 90%, at least one of the two carers quit their job due to their child's illness. sleep problems as measured by total sleep scale score were reported in 40% of patients, whilst 71% had at least one abnormal sleep scale category. only 49% of individuals with abnormal sleep scores received treatment. rs=spearman rho correlation coefficient. conclusions: this study highlights the ongoing cognitive decline in ds, particularly affecting younger patients, alongside often untreated sleep problems and a significant disease burden on primary carers. with new therapeutic opportunities on the horizon, early interventions appear crucial to avert the observed severe cognitive decline. poster no. 027 forced normalisation as a factor in behaviour deterioration on the ketogenic diet e hassan 1 , vj whiteley 2,3 , hj tan 1 1 department of neurology, royal manchester children's hospital, manchester, uk; 2 therapy and dietetics, royal manchester children's hospital, manchester, uk; 3 school of health and society, university of salford, salford, uk introduction: there have been a number of reports that demonstrate a correlation between improved seizure management and deterioration of behaviour with psychosis in adults and children. forced normalisation is a concept where there is deterioration in behaviour when better seizure control is achieved with antiepileptic drugs (aeds) or epilepsy surgery. the ketogenic diet (kd) is a treatment option for children with refractory epilepsy with approximately 50 to 60% showing at least 50% reduction of seizures and 15% of those patients reaching seizure freedom 6 months after treatment. although forced normalisation has been discussed in literature following aeds and neurosurgical interventions, it has not been reported following the use of kd. cases: of the 195 children that have commenced on kd over the last 7 years at royal manchester children's hospital, 59.5% responded to the diet (at least 50% improvement in seizures) and 10.8% were non-compliant. we present 6 patients under the care of the kd service, whose behaviour deteriorated on kd when seizure reduction was >50%. the behaviour changes described by parents included poor sleep, unsettled, agitation, head-banging and shouting. five out of the six patients stopped kd treatment, with subsequent improvement in behaviour. conclusions: there are reports that patients on the ketogenic diet with seizure freedom show improvement in their behaviour, unlike our small cohort whose behaviour deteriorated. forced normalisation has been explored in paediatric patients as a cause for behaviour deterioration following surgical and medical management for intractable seizures. the associated factors of deteriorating behaviour have not yet been explored in depth with the ketogenic diet. objective: we wanted to determine how lacosamide was being used in children locally, and what their outcomes were at a year. methods: we undertook a registered, retrospective, clinical audit using hospital electronic records. we ascertained every patient aged <18 years who had been dispensed lacosamide january 2016-january 2018. the electronic health records were reviewed, and data collected using a standard proforma, including: patient demographics, age of seizure onset, seizure type, ecg and mri findings, baseline seizure frequency, seizure frequency 2, 6, and 12 months on lacosamide, maximum dose prescribed (mg/kg/day), and adverse effects at 2, 6, and 12 months. results: 20/42 (48%) patients were male, the median age was 9 years (range 2mo to 17y), with a mean age of onset of 3 years (range 2mo to 11y). 35/42 (83%) had epileptiform activity on eeg and 24/42 (57%) had an abnormal mri. 24/ 42 (57%) had focal seizures. 27/42 (64%) had a minimum of one seizure a week. 28/42 (66%) had previously tried 3 or more antiepileptic drugs (aeds), and 38/42 (90%) had drug resistant epilepsy prior to starting lacosamide (already failed 2 previous aeds). all patients had lacosamide alongside another aed. the mean daily dose of lacosamide was 7.3mg/kg/day (range 1.3-20.6). at 12 months, 15/42 (36%) of patients reported a >50% reduction in seizure frequency. 36/42 (86%) remained on lacosamide 1 year after starting, and 9/42 (21%) experienced an adverse side effect. conclusions: in this local audit, lacosamide was mostly prescribed for drug resistant epilepsies and was used in polytherapy. a third of patients saw a significant reduction in seizure frequency on lacosamide, although some were also started on other treatments during this period. most patients remained on lacosamide after 12 months, and about 1 in 5 experienced one or more adverse side effect. cacna1a is a large gene which encodes for the alpha subunit of a neuronal ion channel and it is expressed widely throughout the central nervous system (cns). pathogenic variants in this gene have been associated with many phenotypes. most commonly episodic ataxia type 2 (ea2) and spinocerebellar ataxia type 6 (sca6). rarer phenotypes include, familial hemiplegic migraine, paroxysmal tonic upgaze, epilepsy, and intellectual disability with autism. here we present the case of an 8 month old girl who presented with new onset paroxysmal abnormal eye movements during an intercurrent illness. the referring clinicians felt these episodes may be epileptic. however, an electroencephalogram (eeg) captured these movements which were non-epileptic downbeat nystagmus. all other initial investigations including cerebrospinal fluid glucose and neurotransmitters were normal as was her neuroimaging. over the next year her nystagmus became constant. she had otherwise normal development. at 16 months her gait was noted to be abnormally unsteady and broad based (even accounting for age). the nystagmus and ataxia changed in severity from day to day, she could have 4 to 5 more severe days followed by 4 to 5 better days, they never completely resolved. she had no family history of abnormal eye movements or ataxia. subsequent genetic testing revealed a cacna1a c.3787g>a p(glu1263lys) missense variant described only twice previously in ea2, both with very different phenotypes to our patient. neither of her parents carried the same genetic variant. this case is the first reported case of this cacna1a variant presenting as downbeat nystagmus followed by ataxia. both her age of presentation and her initial presenting features are very different to the typical phenotypes associated with this gene. it broadens the phenotype of cacna1a, and also broadens the differential diagnoses associated with abnormal eye movements in infancy. the importance of following up as yet undiagnosed patients who may go on to develop new and revealing symptoms is highlighted. objective: to undertake a questionnaire-based survey retrospectively exploring parents'/carers' recall of, and views on, the safety and risk advice given at the time of their child's epilepsy diagnosis. methods: questionnaires were distributed throughout scotland via scottish paediatric epilepsy network (spen). parents'/ carers' of 5 to 12-year-old children were asked to complete the questionnaire prior to their seizure clinic appointment. results: 178 questionnaires were suitable for inclusion. seizure burden was evenly distributed: 37% <1 seizure/month, 23% >1 seizure/month, 22% >1 seizure/week and 18% had absences only. respondents could recall post-diagnosis information being provided on: water safety (50%), taking medication regularly (91%), sports/activities (57%), seizures in sleep (62%), first aid (78%), prolonged seizures (53%) and/or sudep (45%). there was no statistically significant difference in the duration of epilepsy diagnosis between those who could recall information being given (m=3.77y, sd 2.747) and those who could not (m=4.138y, sd 2.84; t test p=0.42). the majority of information was given via clinic discussions (75%). 46% received written information, 28% directed to websites and/or independent search (12%). most information was 'just right' (71% water safety, 94% on taking aed regularly, 68% on sports/activities, 68% on seizures in sleep, 83% on first-aid for seizures). approximately 30% of respondents want more information on seizures in sleep, water safety and sports/activities. 46% of respondents felt worried following information about seizures in sleep, 57% about prolonged seizures and 67% regarding sudep. conclusions: a substantial proportion of parents'/carers' do not recall receiving safety information on epilepsy despite this being standard practice through spen. this appears to be unrelated to the duration of their child's epilepsy. repeated timely reinforcement may be of benefit. a high proportion of parents'/carers' felt concerned following information provided on nocturnal seizures, prolonged seizures and sudep. this should be recognised with support in place for further discussions. poster no. 031 seizure outcome in responsive vagus nerve stimulation therapy in children and young people v rasiah, n barnes, s carter, k das, r robinson, z tahir, s varadkar great ormond street hospital for children nhs foundation trust and ucl gosh institute of child health, london, uk aim: vagus nerve stimulation (vns) therapy is an established treatment for pharmacoresistant epilepsy. newer responsive-vns (rvns) systems use ictal-tachycardia detection as a biomarker of seizure onset and automatically deliver additional stimulation on detection to abort the seizure. we reviewed the seizure outcomes in children and young people (cyp) implanted with rvns at great ormond street between 2012 to 2018. methods: data were collected prospectively on 41 patients who had an aspiresr â rvns inserted during time period of 2012 to 2018. reduction in seizure frequency and severity, wean of medications and treatment complications or side-effects were assessed at time-points of 1 year, 18 months, 2 years and 3 years post-implantation. results: 41 cyp (mean age 11.9y) had rvns inserted. at 1 year, 34% (14/41) had a positive response graded as >50% reduction in seizure frequency or severity (i.e., duration), 32% (13) had benefit though <50% benefit, and 32% (13) of cyp were non-responders. this increased at 18 months to 41% (14/29) of children showing response >50%, a further 41% showed response 50% and only 17% (12/29) non-responders. response was over-all sustained, with response lessening in only 2 children between 18 months and 2 years. reduction of medication burden was achieved in 22% (9/41) (not attempted in all cyp). no patients achieved seizure freedom. replacement of vns from an older model to rvns showed further benefit. complications were infrequent: 12% (5/41). device removal for infection was required in one child of small body size; successful replacement was possible within the year. conclusions: vns is a useful treatment option for cyp with pharmacoresistant epilepsy. seizure outcomes with rvns in cyp are better than with standard vns. response is sustained. benefit may not be seen by 1 year; therapy should be continued until at least 18 months. in our patients who responded later than 1-year, further optimisations of duty cycle and current were made. replacement of older vns. devices with rvns led to additional benefit. these findings are consistent with reported outcomes from adult series, though seizure freedom is not seen in cyp. in our centre, cyp who seemed to benefit most were those whose epilepsy was of structural aetiology and those with focal seizures, although our numbers were not large enough to assess the significance of this. poster no. 032 atp1a3 mutation in twins presenting with apnoeic episodes, suspected seizures and possible dystonic events objective: we report the case of monochorionic diamniotic twins presenting at the age of 5 months with infantile seizures and apnoeic episodes. the eiee gene panel revealed a mutation in the gene atp1a3, supporting the clinical diagnosis of alternating hemiplegia of childhood (ahc). methods: case report. results: twin r presented with staring episodes, eye deviation and tonic posturing of limbs. episodes occurring mainly in clusters, affecting either side and requiring rescue medications for termination. profound apnoeic episodes needing resuscitation were also noted. twin s presented few weeks later with a very similar presentation. developmentally making satisfactory progress with twin r showing only very mild delay. the array cgh from twin r was normal. several investigations were performed including two normal standard eegs, a normal sleep eeg, a normal ecg, an echo showing a small pfo and an mri scan demonstrating a left sided mesial temporal lobe sclerosis. similar mri findings were reported in twin s. investigations such as urine organic acids and amino acids, plasma amino acids, carnitine, acylcarnitine, transferrin glycoforms, mucopolysaccharidosis screen, ammonia and lactate were all normal. pyridoxine was tried with no improvement, levetiracetam was added and afterwards changed to carbamazepine. sodium valproate was commenced eventually after an episode of prolonged clinical seizure. the eiee gene panel revealed a de novo atp1a3 mutation in both twins. flunarizine was commenced following this result. a video telemetry managed to capture both epileptic and non-epileptic episodes in twin r. the epileptic episode was characterised solely as apnoeic episode due to a left temporal seizure activity spreading onto the opposite hemisphere which is concordant with the imaging finding of left mesial temporal sclerosis. conclusions: knowledge of the atp1a3 mutation allowed clinical correlation of a diagnosis of ahc, matching the wide clinical spectrum of ahc including paroxysmal dystonia and epilepsy. poster no. 033 epilepsy in a child development centre population pc kenyon, njv cordeiro, gl duffy rainbow house child development centre, irvine, ayrshire, uk objective: to assess all the cases in a child development centre (cdc) population with epilepsy, to enable characterisation of the caseload. methods: all case notes of children with an epilepsy diagnosis coded on the cdc database were retrospectively reviewed for demographic, investigation and treatment data. results: 67 children were identified. 27% were diagnosed before a year of age, and over half before their third birthday. 84% of patients had an eeg, and of these, 70% had an abnormal eeg. 55% had genetic testing performed, and of these, 86% had a genetic cause of their epilepsy identified. 78% had an mri scan, and of these, 69% had a structural cause for their epilepsy identified. 90% had global developmental delay, and 90% had a diagnosis of learning disability. one third have a diagnosis of cerebral palsy, 16% have autism spectrum disorder, and 13% have a hemiplegia. 66% are seizure free, the majority of whom have their epilepsy controlled with one medication. 12% had adherence concerns identified. conclusions: compared to a general paediatric epilepsy clinic, this group of children were diagnosed earlier in life, had higher rates of genetic or structural causes identified, and were less likely to be seizure free. results: case 1. a 4-year-old with autism spectrum disorder (asd) developed hand waving in front of her face in bright light from 3 years. multiple myoclonic seizures occurred with screen use and her family live in complete darkness. eeg demonstrated photosensitivity, generalised spike-slow wave after hand waving and 3-3.5hz spike-wave with myoclonia. clonazepam has been commenced. case 2. a 10-year-old with learning difficulties and a family history of generalised seizures presented aged 6 years with forehead rubbing leading to loss of part of her eyebrow. eeg showed photosensitivity and the generalised spike-wave of absences and eyelid myoclonia (em). sodium valproate was used but replaced with lamotrigine due to weight gain. case 3. a 4-year-old with a family history of generalised seizures presented aged 2 years with hand waving in front of her face, requiring her nursery to provide a dimly-lit setting. eeg demonstrated generalised polyspikewave, 3-hz spike-wave and myoclonia with photic stimulation. lamotrigine was ineffective and replaced with sodium valproate. case 4. an 11-year-old with likely asd developed hand waving in front of her face in bright light aged 4 years, triggering generalised tonic convulsions (gtc). she had a non-induced gtc in dappled sunlight. there was on-going anxiety and thoughts of self-harm. eeg showed photosensitivity and bursts of spikes-polyspikes. lamotrigine was ineffective; seizures stopped with sodium valproate. conclusions: the self-induced seizures of sunflower syndrome are difficult to treat and are associated with physical, psychological and social impairments. sodium valproate is the most effective medication which may be problematic in this predominantly female patient group. what are the information needs of parents whose child is diagnosed with glutaric aciduria type 1 to help preserve neuro-developmental outcome? objectives: to assess the information needs and support of parents at the time of diagnosis of ga1 in their child, and how to support them in preventing metabolic decompensation and preserving neuro-developmental function. methods: a focus group with five parents was conducted using a topic guide to direct the discussion, which was recorded and fully transcribed. data were analysed using thematic analysis. two researchers were involved in initial coding of data and key analytic decisions. results: two main themes were identified. 'understanding the condition' explored parent's needs to understand the scientific complexity of ga1 and to be aware of the 'worst case scenario' associated with loss of metabolic control, and brain injury. parents reported clinicians did not give then enough information on the ga1, and were forced to use other information sources, sometimes seeking out scientific papers. information on managing crises was insufficient, with parents not understanding what the doctor meant about commencing the emergency regime when their child was 'sick'. parents reported living in terror of their child experiencing metabolic decompensation and permanent brain injury. 'managing the condition' explained how parents coordinated and controlled the involvement of other carers and outlined parents' need to be active partners in medical management to feel in control. parents wanted to know the results of regular biochemical tests for reassurance, but found they were not easily accessible. parents could not leave their child in the care of another adult because they did not have sufficient knowledgeable about ga1 or were known to 'cheat' by offering the child food they should not have. the transition into school was a particular challenge. conclusions: the study highlights the importance of addressing parents' initial and ongoing informational needs so they can fulfil their role and protect their child from metabolic decompensation and permanent brain injury. poster no. 036 normal transferrin isoelectric focusing in a child with cog4 related congenital disorder of glycosylation objectives: congenital disorders of glycosylation (cdg) are a large group of rare multisystem diseases caused by defective linkage of oligosaccharides to newly synthesised proteins or lipids. several cdg subtypes are the result of mutations in subunits of the conserved oligomeric golgi (cog) complex. this includes cog4-cdg, an autosomal recessive disorder caused by pathogenic variants in the cog4 gene. in the two cases previously reported transferrin isoforms were abnormal, consistent with defective n-glycosylation. methods: we describe a 3-year-old female born to non-consanguineous parents. she presented with severe global developmental delay, dysmorphic features, postnatal progressive microcephaly, complex epilepsy, rhizomelia, spastic quadriplegia, and feeding problems from early infancy. results: mri brain showed global cerebral atrophy, predominantly supratentorial, with relative cerebellar sparing. trio exome sequencing and analysis identified compound heterozygous cog4 variants in the proband, a maternally inherited pathogenic splice site variant c.1061+1g>a and a paternally inherited likely pathogenic splice site variant c.1647+5g>a. messenger rna analysis showed that the c.1647+5g>a variant caused aberrant splicing, with skipping of exon 12 and the introduction of a premature stop codon in exon 13, likely to result in nonsense mediated decay. analysis of transferrin isoforms was normal (by both isoelectric focussing and mass spectrometry). since cog4-cdg also affects o-glycosylation apolipoprotein ciii (apociii) isoelectric focussing was undertaken, however this too was normal. conclusions: transferrin and apociii isoelectric focusing are screening tests for n-and o-glycosylation defects. however, both have their limitations and some cases of cdg have normal transferrin or apociii glycoforms escaping those screening tests. this is the first case of a patient with cog4-cdg with normal biochemical markers to be described. this case also demonstrates the diagnostic power of next generation sequencing for rare metabolic disorders, where the biochemical screening may be inconclusive. poster no. 037 developmental delay in a young infant with nonclassical combined malonic and methyl malonic aciduria (cmamma) caused by homozygous missense mutation in acsf3 gene kd dayasiri 1 , eg goh 1 , sk kodagali 1 , jb baruteau 2 , ga anand 1 1 oxford university hospitals nhs foundation trust, oxford, uk; 2 great ormond street hospital, london, uk introduction: acylcoa synthetase family member 3 (acsf3) activates malonylcoa and methymalonylcoa into their respective thioesters. acsf3 deficiency causes non-classical cmamma, a rare inborn error of metabolism characterised by presence of methyl malonic acid in higher concentrations than malonic acid in urine. the reversal is seen with classic cmamma caused by malonylcoa decarboxylase deficiency (mcd). case report: 5-and-a-half-month old male infant second born to consanguineous south asian parents presented with severe failure to thrive and recurrent vomiting. his older sibling who had failure to thrive and neuro-developmental delay died at 7 months without a genetic diagnosis. initial blood tests revealed metabolic acidosis, pancytopenia and coagulopathy. neuroimaging was unremarkable. subsequent evaluation revealed normal levels of methionine, homocysteine and red cell folate. significant methylmalonic aciduria with mild malonic aciduria without evidence of other abnormal metabolites (propionyl-coa metabolites: hydroxypropionate, and methylcitrate or tiglylglycine) in urine suggested the diagnosis of non-classic cmamma, confirmed by homozygous missense variants in acsf3 gene revealed by trio-exome sequencing. neurodevelopmental assessment at 8 months revealed global developmental delay with general hypotonia; gross motor (4-6mo); fine motor (4-6mo); speech (5-6mo) and social (under 6mo), and without any regression. carnitine was supplemented to avoid secondary depletion caused by the excretion of mma. parents were advised to avoid prolonged fasting and to provide emergency regimen (powdered carbohydrate drink mix) in the event of acute deterioration. conclusions: this report describes an unusual paediatric presentation of non-classic cmamma. urine organic acids allows identification of increased ma and mma excretion and highly suggestive of the diagnosis, thus avoiding additional investigations determination of urinary mma/ma ratio can help differentiating between classical and non-classical forms. methods: we conducted retrospective case note analysis of the five paediatric cases with confirmed diagnosis of the late onset pompe disease, referred to the highly specialised metabolic service. results: three of five patients (current age 14-22y) presented with delayed motor milestones in early childhood (mean age: 3.3y). one patient initially presented with episodes of thigh pain and high ck. in addition, when 10 years he re-presented with recurrent abdominal pain with high ck. the remaining one presented with muscle pain upon exercise with high ck. all apart from one had muscle weakness affecting limb girdle muscles and axial muscles. the remaining one presented with proximal muscle weakness by the age of 19 years. all patients remained ambulant, one developed scoliosis and two were on non-invasive ventilation. cardiac involvement as ventricular dysfunction requiring targeted treatment was observed in one. pathology showed vacuolated deposits in three patients and non-specific myopathic changes in one. four are on enzyme replacement therapy (ert) and tolerated well. conclusions: late onset pompe disease is a multisystem disease and should be considered in cases of isolated respiratory problems, lower back pain, rigid spine, and myopathy or exercise intolerance with elevated serum ck if these symptoms cannot be attributed to another disorder. poster no. 039 delay in diagnosis and misdiagnosis of ataxiatelangiectasia: a systematic review pubmed, scopus). the cochrane library was also searched. the search protocol is available. the inclusion criteria were: all dates, all languages, all ages, human participants and clinical relevance. the exclusion criteria were: no reference to ataxia-telangiectasia within the article, not an original article, animal studies, article not clinically relevant. results: search returned 184 541 articles; 13 868 titles and abstracts were reviewed after removing 170 673 duplicates. full text review includes 1106 articles of which 343 case series and 459 case reports were identified (12 518, exclusions; 244, articles not found or not accessible). mean age of first sign or symptom of a-t in 563 cases reviewed to date was 31.4 months (range -11d to 312mo). the mean age of diagnosis in 209 cases in which it has been reported was 81.4 months (range -22d to 624mo). there was a mean time of 34.9 months from presentation to clinician, to diagnosis of a-t (range -0 to 306mo, median 11mo) in the 71 cases in which this was reported. 20/563 (3.6%) cases had a documented alternative diagnosis prior to the diagnosis of a-t. 10/20 (50%) of these children were incorrectly diagnosed with cerebral palsy and 3/20 (15%) with hyper-igm syndrome. the mean delay from incorrect diagnosis to a diagnosis of a-t was 87 months with the longest delay 306 months. conclusions: this study is the first comprehensive systematic review of scientific literature on ataxia-telangiectasia. we aim to describe the natural history of the condition and, along with results from the natural history of a-t (n-hat) study, systematically define, where possible, the conditions presentation, course, and prognosis. (80%) people with a-t presented with gait ataxia or disturbance, and 13/751 (1.7%) with truncal ataxia. the most common presenting feature in cases without ataxia were developmental delay, or regression, and choreoathetoid movements. the second most common neurological presenting sign was dysarthria in 118/751 (15.7%) cases, and at least 2 of these had no associated ataxia. dystonia was a presenting sign in 37/751 (4.9%) cases, including 3/37 (8.1%) with no associated ataxia. 64/751 (8.5%) initially presented with no neurological signs or symptoms. conclusions: this study is the first comprehensive systematic review of scientific literature on ataxia-telangiectasia. these results show that 91.5% of people with a diagnosis of a-t presented initially with at least one neurological sign or symptoms. this completed review will lead into the natural history of a-t (n-hat) study, a longitudinal, retrospective and cross-sectional study. the role of serum oxysterol in the diagnosis of niemann pick c m alcheikh, g connolly, n cluskey, s osullivan royal hospitals belfast health and social care trust, belfast, uk introduction: neimann pick c is a neurovisceral disease that is caused by cellular cholesterol trafficking disruption. historically, the diagnosis of niemann pick c was made using filipin staining and skin fibroblast cultures. recently genetic testing of npc1 an npc2 genes are available. mutations of either gene also affect cellular trafficking of cholesterol and detecting oxidative cholesterol metabolities can also be diagnostic of nieman pick c. serum oxysterol can be used as a first line test with subsequent genetic confirmation and has a positive predictive value of >97%. methods: we present a case of an 11-year-old boy who was referred to genetics initially with absence of up gaze, severe restricted downward gaze, developmental delay, regression of skills and frequent falls. in the last 1 year his parents and school observed progressive deterioration of his symptoms with gelastic cataplexy, markedly decreased tone, increasing difficulty with memory loss and slurred speech. these symptoms are strongly suggestive of niemann pick c disease and oxysterols were requested which showed elevated oxysterol level of 128.7ng/ml (normal range 9.6-37). he was started on miglustat. genetics confirmed the diagnosis. results: overall the child's parents report that since commencing the miglustat he is more confident and they have recently seen him hop and skip which they haven't seen in quite a while. conclusions: oxysterol is suitable biomarker for neimann pick c disease and can be used as first line with the genetic confirmation of gene npc1 and npc2 at later stage. as modifying treatment with miglustat is available it is important to attempt diagnosing the condition as early as possible and oxysterol level can be used as screening test for neimann pick c when clinically suspected. introduction: biotinidase deficiency is a rare autosomal recessive inborn error of biotin metabolism. biotinidase catalyses biocytin to biotin, a deficiency of which can present with neurological symptoms including hypotonia, seizures, feeding difficulties, lethargy, optic atrophy, and sensorineural deafness. case: a 9-week-old female presented with a 4-week history of seizures and developmental delay. examination revealed generalised and axial hypotonia and delayed smile. she continued to have seizures despite initial treatments including levetiracetam and carbamazepine. mri brain was normal and initial interictal eeg on day 1 post admission revealed no significant abnormalities. ambulatory eeg on day 10 showed a focal onset epileptic seizure with sharp and slow wave activity originating predominantly from the left occipito-parietal region. normal investigations included paired plasma and csf glucose, lactate and culture, csf neurotransmitters, microarray and epilepsy gene panel. on day 11 post admission her biotinidase result was reported showing no activity. biotin was commenced at 10mg once daily and her seizures abruptly stopped. she was discharged home on day 14 and weaned off levetiracetam and carbamazepine. her development was normal at 12-month follow-up. genetic testing was declined by the family. discussion: biotinidase deficiency can present from the neonatal period up to 10 years of age with a mean age of 3.5 months. in recent years our understanding of pathogenic changes in the biotinidase gene has increased through sequencing for novel mutation. this has important implications for families and consideration should be given to offering affected families genetic counselling. treatment is available with oral biotin that rapidly improves symptoms, with seizures usually resolving within days and other symptoms showing improvement within weeks. objective: we present a previously well 16-year-old boy with a known m.3271t>c mutation experiencing 2 weeks of vomiting, lethargy and exercise intolerance. method: he was mildly dehydrated, fully consciousness but tachycardic and hypotensive. his ph was 7.28 with be -17.3, hco3 9.4 and lactate of 16.4. electrolytes, fbc and inflammatory markers were normal. he was admitted to picu for fluid management and sodium bicarbonate. tachycardia persisted during the first 24 hours though he remained stable. he had a good urine output, was on non-invasive monitoring and an echocardiogram was normal. his gas lactate ranged from 14.1 to 16.8. the following day he deteriorated with kussmaul respirations, tachypnoea, increased tachycardia and hypotension. venous blood revealed a ph 7.14, pco2 1.6 hco3 11.3 be -19 and lactate 18.5. he became unresponsive with refractory hypotension and multiorgan failure. arterial blood showed a ph 6.8, pco2 5.3 and a lactate >20 with indeterminable be or hco3. for over 24 hours he had a blood lactate level of >20. rhabdomyolysis and acute kidney injury occurred with a ck of >200 000 requiring haemofiltration. encephalopathy, with multiple white matter microhaemorrhages on mri brain, and acute liver failure, with thrombocytopenia and coagulopathy, ensued. multiple inotropes were required. the prognosis was very guarded. off sedation he was unresponsive, apnoeic and areflexic however an eeg showed an alpha rhythm which prompted on-going heroic efforts. he required prolonged haemofiltration, ventilation and inotropes with 26 days intensive care. results: the patient made an astounding recovery. he required 1 month of neurorehabilitation and returned to his cognitive baseline, achieving a grades at gcse 5 months later. liver and renal dysfunction resolved. conclusions: this case demonstrates that mitochondrial metabolic crises in melas can be severe and result in profound acid-base derangements. our patient was expected to not survive but uniquely did so without significant neurodisability. neuronal ceroid lipofuscinosis in children from central africa gl fisher, n shah, p watts, ja te water naude noah's ark children's hospital, university hospital wales, cardiff, uk objective: the effective and rapid diagnosis of neuronal ceroid lipofuscinoses (ncls) has become more relevant with the advent of disease-modifying treatments. some ncls have a more stereotyped clinical presentation: we describe two cases in a non-consanguinous family, originally from the democratic republic of the congo, with variant ncl. methods: retrospective case series. results: the index case was initially diagnosed with a focal epilepsy: on review this child had myoclonic seizures in the context of a slow developmental decline, with mild spasticity. ophthalmology was not diagnostically helpful, and a putative diagnosis of ncl was suggested by lymphocyte inclusions. neither enzyme nor dna analysis was available at that stage, although dna was retained. a brother presented with nystagmus and visual inattention in 2017: examination showed myoclonic jerks with a bull's eye maculopathy and an abnormal peripheral retinal vascular leak. mri imaging showed some element of cerebellar atrophy, which on review was also the case with his brother's scans. some lymphocytes (20%) contained fingerprint bodies, suggestive of variant ncl. this was confirmed by dna sequencing which was consistent with a diagnosis of mfsd8/cln7-related ncl. the identical dna alteration was also found in the index case. conclusions: ncl is not described in children from central africa: the presentation, investigations and laboratory findings and evolution are consistent with that for other children with variant ncl. obesity screening of patients affected by duchenne muscular dystrophy (dmd) in a tertiary paediatric neuromuscular centre and the effectiveness of metformin use in weight control in those with confirmed insulin resistance m neocleous 1 , s spinty 1 , r madhu 1 , p dharmaraj 1 , c degoede 2 , k cooke 1 , c greaves 1 1 alder hey hospital, liverpool, uk; 2 royal preston hospital, preston, uk objective: to assess whether patients affected by duchenne muscular dystrophy (dmd) who are currently followed up in alder hey hospital, uk are receiving obesity screening when clinically appropriate. to assess whether metformin use in those who are insulin-resistant, has been effective in controlling weight. methods: using the neurology department records, a list of patients with dmd currently under our services and those transitioned to adult services in the last 5 years, was generated. the patient record system, meditech, was used to collect patients' demographics, latest weight/height value and bmi. for patients classified as overweight/obese, completion of obesity screening was assessed as well as initiation of appropriate treatment (metformin). for patients on metformin, the following parameters were collected: weight pre and post-steroids, age of start of excessive weight gain, confounding variables and medications, weight/height/bmi at initiation of metformin and at 6-monthly intervals, side-effects, cessation of medication and reasoning. results: sixteen out of 90 patients were found to be above the 98th weight centile. in 38 patients, weight was at 3 or more centiles above height. using the non-dmd standardised bmi classification, 47 patients were identified as being overweight/ obese. 16 patients received obesity screening; 7 were found to be insulin resistant. 4 of those were started on metformin. 7 patients overall were started on metformin. 2 of those exhibited overall weight loss. 3 patients were found to have gained weight and 1 patient showed weight increase up to 18 months post-metformin initiation with subsequent weight loss. conclusions: there is a need for a validated and agreed bmi classification in dmd. screening for insulin resistance in this patient group should be considered for implementation as standard practice, especially if patient is classified as overweight/obese. a larger-scale study would be required to assess the effectiveness of metformin in this patient population. objective: niemann-pick disease (npd) is an autosomal recessive metabolic disorder with a prevalence of 0.4 to 0.6/100 000 worldwide, marked by varying degrees of lipid storage and foam cell infiltration in tissues, associated with hepatosplenomegaly, pulmonary insufficiency or central nervous system involvement. npd type a and b are allelic disorders caused by mutations in the sphingomyelin phosphodiesterase-1 gene, smpd1 (11p15.1-15.4), characterized by a primary deficiency of acid sphingomyelinase activity, resulting in an accumulation of sphingomyelin. in contrast to npd-a, npd-b is the milder, lateronset form, with no neurological involvement. in this paper, we report on three paediatric cases with npd-b who present an atypical phenotype marked by neurological involvement. methods: the three patients were diagnosed at the age of 1 with hepatosplenomegaly. the first is a girl who presented psychomotor regression at the age of 3 and epileptic seizures at the age of 10. she died at the age of 15. the second is an 8 years old girl who presented growth retardation, kyphosis and neurodevelopment regression since the age of 6. the third is a 15 years old boy with a mild phenotype marked by developmental delay and an aggressive behaviour. splenectomy was performed at the age of 8. results: genetic testing was performed, and all patients presented mutations of the smpd1 gene, confirming the diagnosis of niemann-pick type b. the c.1177t>g(p.trp393gly) mutation was common in all cases. in addition, heterozygous mutations c.573delt(p.ser192alafs*65) and del c.560_606del were found in the first and second case, respectively. conclusions: all cases present a complex phenotype, marked by psychomotor regression which is atypical for npd type b. the severity of the disease seems to be correlated to the genetic mutation-the most severe phenotype was associated with c.573delt. further work is necessary to more clearly delineate genotype-phenotype relationship in npd. objective: acute encephalitis syndrome (aes) is a group of symptoms and signs, which help diagnose encephalitis. since there is no definite treatment for most, role of fluids seems crucial. therefore, the objective of our study was to describe the association of low admission weight and weight loss in the hospital (as clinical marker of dehydration) with outcome of patients of acute encephalitis syndrome. to describe the association between changes in weight and blood lactate levels (at admission and discharge as indicators of hydration and acid base status) and outcome in children with acute encephalitis syndrome. methods: all children aged 1 month to 14 years with fever and altered sensorium and/or new onset seizures from september 2011 to september 2012 attending kanti children's hospital, kathmandu, nepal were recruited. weight-for-age (wfa) using z score and serum lactate were assessed at admission and discharge. total fluid input and output was monitored daily. results: of the 92 patients, 62% had low admission wfa or lost weight-after-admission (lwaa) (group a) and 38% no low wfa or didn't lwaa (group b). there was 19 times risk of death and 7 times risk of bad outcome (death or sequelae) in group a compared to b. bad outcome was significantly associated with less admission wfa, more fluid deficit, and trend for higher admission serum lactate. death was significantly more in those with low wfa, more lwaa, longer illness, more 5% dextrose and 0.5 normal saline, higher sodium and higher urea at admission. methods: we conducted a prospective cross-sectional study recruiting children aged between 1 month to 14 years attending kanti children's hospital, kathmandu, nepal with altered sensorium and two of the following: fever, seizure, focal neurological deficit, csf pleocytosis, electroencephalogram and computer tomography suggestive of encephalitis, over 1 year. in these patients, ve was if csf cell count was <1000cells/ mm 3 (lymphocyte predominance) and absence of non-viral pathogens in the csf or blood. bm was csf cell count >1000cells/mm 3 (polymorph predominance) and csf protein >0.45g/l and csf/plasma glucose <40%, and/or positive gram stain and/or bacterial culture. je was ve with ≥40units of anti je-igm in the csf and/or serum. all cns infections were defined as, suspected cases by treating clinician with or without fever with lp showing csf cells >4/mm3. results: out of 38, bm was found in 47%, je 21% and other causes in 32%. although who definition of aes was not significantly associated with all cns infections (p=0.069), it was significantly associated with ve (p<0.001, sensitivity 74%, specificity 93%, ppv 94%, npv 70%) and bm (p<0.001, sensitivity 30%, specificity 7%, ppv 33%, npv 6%). conclusion: we validate who aes definition of bm and ve as a significantly useful screening tool for children with these diseases specially in resource poor settings, endemic areas and where confirmatory tests were not easily available. objective: the aim of this case series is to raise awareness of this autosomal recessive encephalopathic syndrome that presents after birth in the multi-ethnic population in england. although aicardi goutieres syndrome (ags) is rare, its importance lies in the fact that that its presentation may be mistaken for other neurological conditions associated with congenital infections. results: all 6 of the patients were seen in our paediatric outpatient neurology clinic. the age of presentation ranged from the neonatal period to the first 20 weeks of life. all 6 patients were of pakistani origin and 5 were from consanguineous marriages. they all had an uneventful antenatal period with normal birth weight and head circumference. the initial presentation seems to be of poor feeding and irritability. further observations include truncal hypotonia, limb spasticity intermittent dystonic posturing coinciding with the onset of poor head growth and chilblains. 3 of our patients had abnormal movements with diffuse slow wave electroencephalogram activity. nystagmus with visual inattention and poor visual acuity were a typical finding in all of them by the age of 3 months. the ct scans showed cerebral calcification in all of them and mri suggested brain atrophy. the most striking abnormality was a raised level of csf interferon-alpha (infa) in an absence of other infection or metabolic disorder. csf inf a is a reliable diagnostic marker and can thus be used to differentiate patients with ags from other conditions. three of our patients had the same gene mutation, rnaseh2c. conclusions: ags is a rare disorder, however in patients from consanguineous marriages that depicts microcephaly, poor tone and global developmental delay, diagnosis of ags should be considered. as ags is a progressive neurological condition, early support and prognosis can be provided for affected families. t thomas 1 , ht yeo 1 , sv barron 1,2 1 paediatric neurology, kk hospital, kampong java, singapore; 2 university of newcastle, newcastle, uk objective: we report the association of mild encephalopathy with a reversible splenial lesion (mers) with a primary dengue virus infection. this case implies the existence of a wider spectrum of neurological involvement in dengue virus infections. case description: a 12-year-old girl presented with acute confusion, dysarthria and bilateral limb weakness following a 4-day history of fever. symptoms resolved after 2 hours; neurological examination was completely normal. she later experienced a second episode of slurred speech, dysphasia and right arm weakness which lasted an hour. a contiguous lesion involving the genu, body and splenium of the corpus callosum and bilateral posterior periventricular white matter was evident on the mri brain scan, with restricted diffusion and t2-hyperintensity. cerebrospinal fluid analysis showed no inflammation and polymerase chain reaction assay for respiratory viruses was negative. her clinical and radiological features were consistent with mild encephalopathy with a reversible splenial lesion (mers). on day 2 of admission, she developed a generalised maculopapular rash with leukopenia (white blood cell count 1.819109/l) and thrombocytopenia (platelets 1359109/l). serology (igm/igg) for dengue virus was negative and a positive dengue ns1 antigen was thus indicative of a primary dengue virus infection. she was given fluid rehydration and advised bedrest. at discharge (day 6 admission) she was well with no sequelae. conclusions: mers is a mild form of virus associated encephalopathy (vae), which are a spectrum of clinico-radiological syndromes associated with common childhood viral infections. the clinical and neurological symptoms in our patient occurred early in the course of illness (typical to vae) as opposed to after or late in the illness as is typical for postinfectious encephalopathy syndromes associated with dengue virus infections (e.g., acute disseminated encephalomyelitis). shouldering the burden of sepsis norfolk and norwich university hospital nhs trust, norwich, uk; 2 sheffield children's hospital, sheffield, uk aim: we report a case of a 15-year-old boy who presented with right brachial plexus neuritis secondary to meningococcal group b sepsis. brachial plexus neuritis or neuralgic amyotrophy (also known as parsonage -turner syndrome) is a rare disorder affecting the brachial plexus. it can be caused by various infectious agents and is characterized by acute onset of intense pain in the shoulder and arm followed by weakness, sensory loss and atrophy. methods: a 15-year-old boy, previously fit and well presented to the emergency department with an acute onset of excruciating pain in his right shoulder, radiating down his arm and hand with associated paresthesia. few hours later, he developed an evolving non-blanching purpuric rash to the chest, back, shoulder and right arm. he gradually developed weakness in the right arm and sensory loss over the ulnar aspect of the right hand. he then began to complain of headache, photophobia with subsequent vomiting. he was treated for meningococcal sepsis with intravenous ceftriaxone and received three fluid boluses for hypotensive shock with vitamin k correction for his associated coagulopathy. he received analgesia for right shoulder pain. results: blood cultures and blood pcr confirmed neisseria meningitidis group b type, nt subtype. mri of the shoulder showed inflammation consistent with brachial plexus neuritis with motor impairment affecting the right side c4 to t1 myotomes and sensory impairment involving the right c6 dermatome. the patient was treated with oral prednisone and gabapentin whilst receiving neurorehabilitation from physiotherapy and occupational therapy. he made a very pleasing recovery after few months and currently has no motor or sensory deficit of his right shoulder and arm. conclusion: brachial plexus neuritis should be considered in the differential when a child presents with sudden onset pain and weakness of the shoulder and arm. in review of literature, brachial plexus neuritis associated with meningococcal infection has not been described previously. to the best of our knowledge, this is the first reported case of its kind. introduction: previous cohort studies on paediatric multiple sclerosis (ms) have reported very low frequencies for a primary progressive ms course (ppms) ranging from 0 to 7%. an age-dependent increase in the rate of primary-progressive courses has been well described in the adult ms population. objectives and methods: we describe five patients presenting prior to the age of 18 years and fulfilling the 2017 mcdonald criteria for ppms. patients were identified from the national hospital for neurology and neurosurgery (nhnn) and the uk childhood inflammatory demyelination (uk-cid) network. results: patients presented at a median age of 15 years (range: 11-17y), with at least 1-year history of progressive deterioration of their balance (n=2) or progressive worsening of lower limb function (n=3). over time, all patients developed lower limb spasticity, three patients developed cognitive difficulties, three had visual problems, three had bladder involvement. median edss at 2 years was 5 (range: 4 to 7). cerebrospinal fluid (csf) oligoclonal bands were detected in all 4 patients tested. dissemination in space on first mri was seen in all patients with peri-ventricular (n=4), cortical juxtacoritcal (n=2), infratentorial and spinal cord (n=4) lesions. all patients showed new lesions on repeat mri imaging. contrast enhancement was present in 3 out of 4 (75%) during the disease course. three patients had genetic investigations to exclude other mimics. a trial of iv methylprednisolone was unsuccessful in 3 patients. all patients were on symptomatic treatment for spasticity and pain, including oral/intra-thecal baclofen, gabapentin and sativex. conclusions: given the rarity of primary progressive course in paediatric ms, presentation with progressive neurological symptoms and signs in young people should prompt evaluation for genetic causes. nevertheless, our five patients presented with clinical, mri and immunological features consistent with a diagnosis of primary progressive multiple sclerosis. objective: clinical course in nmdar-antibody encephalitis is variable and difficult to predict. we aimed to identify clinical features in the presenting disease episode associated with worse functional outcome and/or relapsing disease course. methods: systematic review of the literature was conducted to identify published cases with individually reported data. clinical and treatment characteristics at first episode, outcome at ≥12 months, and monophasic vs. relapsing disease course were recorded. results: 1651 cases were identified from 693 articles (73% female; 48% ≤18 years old at onset). 91% received immunotherapy at first episode: corticosteroids in 81%, ivig in 66% and therapeutic apheresis in 33%. second-line immunotherapies were used in 32% at first episode, most frequently rituximab (17%), cyclophosphamide (5.1%), or both (7.2%); emerging second-line treatments (intravenous/intrathecal methotrexate, subcutaneous/intravenous bortezomib, intravenous tocilizumab) were used in 1.8%. life-threatening adverse events or death related to immunotherapy occurred in 1.9%. in a univariate analysis of 682 cases with ≥12 months follow-up data, poor final outcome (defined as modified rankin scale [mrs] score 3-6) occurred in 30% and was associated with very young or elderly age at onset, movement disorder, decreased consciousness, autonomic dysfunction, mechanical ventilation, higher mrs score in the acute phase, longer hospital stay, extreme delta brush on eeg, abnormal mri, csf pleocytosis and elevated csf protein (all p<0.05). a subset of 198 cases followed up for ≥36 months were analysed to identify associations with relapsing course, which occurred in 29%. in univariate analysis, factors protective against relapse were <30 days delay in first-line immune therapy, therapeutic apheresis, ivig, rituximab and other second-line treatments at first episode (all p<0.05). conclusions: worse functional outcome of nmdar-antibody encephalitis is associated with very young or elderly age at onset and worse disease severity in the acute phase. relapsing disease course is associated with delayed or insufficient early immunotherapy. objective: we describe three children with familial hemophagocytic lymphohistiocytosis (fhlh), who presented with an atypical chronic demyelinating illness. an initial working diagnosis of 'clippers' (chronic lymphocytic inflammation with pontine perivascular enhancement responsive to steroids) was made in two cases. methods: retrospective case series. results: case 1: an 11-year-old girl presented with diplopia and squint with evolving ataxia. mri showed multiple enhancing white matter lesions in the pons, medulla and cerebellum raising the possibility of 'clippers'. her symptoms and neuroimaging responded only partially to treatment with ivig and steroids. genetic testing revealed a compound heterozygote mutation in the rab27a gene consistent with griscelli syndrome type 2 with fhlh. case 2: a 5-year-old boy had nocturnal headaches with a squint evolving over time. mri showed demyelination and swelling predominantly in the cerebellum. significant radiological resolution with steroids was followed by recurrence of demyelination on weaning steroids. a brain biopsy lesion was consistent with 'clippers'. genetic testing revealed a heterozygote variant in the stxbp2 consistent with fhlh v. case 3: a 9-year-old girl had a 7-month of intermittent fevers, deranged lfts and recurrent bilateral optic neuritis responsive to steroids/ivig. mri brain showed multiple areas of demyelination largely in the subcortical white matter. oligoclonal bands were positive in the csf. she developed a pleural effusion, high ferritin, deranged coagulation, lymphadenopathy and a rash found to be a cutaneous t-cell lymphoma. genetic testing revealed a homozygous mutation in the unc13 gene consistent with fhlh 3. all three children are awaiting stem cell transplantation. conclusions: fhlh can present with an isolated atypical demyelinating illness or with neuroimaging suggestive of 'clippers'. there may be no signs of systemic inflammation. we propose that all children with atypical recurrent cns inflammation and presentations consistent with 'clip-pers' undergo genetic panel testing for fhlh and natural killer cell functional testing. objective: the most common paediatric presentation of mog-ab disease is with acute disseminated encephalomyelitis (adem), or optic neuritis (on). with increasing recognition of the association of mog-abs with seizures in children, we present a case series of affected children. methods: retrospective anonymised case note review of affected children presenting between 2005-2019, from 5 uk paediatric neurology centres. patients were followed up for median of 6 years (range 0.5-16). results: 15 cases (7 female) of mog-ab-positive epilepsy patients were identified; median age at first presentation was 6 (range 2-14y). the most common preceding mog-ab disease was multiphasic adem (mdem 6; adem 3; adem-on 2; adem and transverse myelitis 1; nmosd 2; on 1). median time to recurrent seizure onset was 3 months (range 0-60). focal epilepsy/seizures were most common (12/15). eeg abnormalities were found in 14/15 patients, all demonstrated slowing/encephalopathy which was generalised or focal; epileptiform discharges were reported in 3 patients. brain mri was abnormal in all patients (8 with multifocal hazy/ poorly marginated lesions involving grey and white matter; 4 leukodystrophy-like pattern, 2 cortical encephalitis and 1 reported with subtle changes in brainstem). 8 patients received immunotherapy, all required at least 1 anti-epileptic drug (aed) and 8 children continue to have on-going breakthrough seizures. median mrs (modified rankin scale) at last follow-up was 1 (range 0-3), indicating no significant disabilities despite symptoms in clinical examination, age appropriate behaviour and development. conclusions: focal epilepsy is more common and more likely to follow an mdem presentation in children with mog-abs. with the relapsing nature of mog-ab disease there is a high risk of long-term cognitive impairment. further preclinical studies are urgently required to determine whether this epilepsy is due to ongoing inflammation or as a result of the mri changes commonly seen. this will help inform future management decisions regarding immunotherapy. poster no. 056 maternal mid-gestation cytokine dysregulation in mothers of children with autism spectrum disorder autism spectrum disorder (asd) is a developmental disorder characterised by a spectrum of deficits in social interactions/ communication combined with stereotypical, repetitive behaviours. recent evidence suggests maternal immune activation (mia) during pregnancy may predispose offspring to asd. the aim of this study was to examine the mid-gestation cytokine profile in mothers of children with a subsequent asd diagnosis. maternal-child dyads were recruited to a prospective population-based pregnancy study; the scope study, new zealand. children with confirmed diagnosis of asd at 6 years were enrolled in the nested cohort, along with matched neurotypical controls. cytokine concentrations (pg/ ml; mean [sem]) were examined in maternal serum samples taken at 15 and 20 weeks gestation using mesoscale discovery proinflammatory, cytokine and chemokine assays. of 2032 mothers recruited to the scope-nz study, 16 children completed follow-up and had reported asd at 6 years. these were analysed alongside 16 neurotypical matched controls. downregulation of il-17a occurred at 20 weeks gestation in cases when compared to controls (mean [sem]). 2-way anova revealed a relationship between il-17a concentration and weeks' gestation f(1,49)=4.183; p=0.0462, and also il-17a concentration and asd status f91,49)=7.801; p=0.0074. posthoc uncorrected fisher's lsd revealed a significant difference between cases (-0.3846 [0.1426] ) and controls (-0.1207 [0. 05068]) at 20 weeks gestation p=0.0160. ifnc is also downregulated at 20 weeks gestation in cases when compared to controls. 2-way anova revealed a relationship between ifny concentration and weeks gestation f(1,53) =5.692; p=0.0206. posthoc uncorrected fisher's lsd revealed a significant difference between cases (0.347 [0.0215] ) and controls (0.4345 [0. 1685]) at 20 weeks gestation p=0.0476. we have shown altered cytokine expression at 20 weeks gestation in mothers of children who progress to develop asd. this adds to the growing body of evidence that maternal immune regulation may play a role in foetal neurodevelopment. objective: acute disseminated encephalomyelitis (adem) is an immune mediated inflammatory cns disorder, predominantly affecting white matter, with a wide differential (1). here we describe a rare mimic of adem that is essential to consider in order to avoid a catastrophic outcome. case history: a 12-year old girl presented with a 2 day history of confusion, dysarthria, ataxia and left-sided squint, preceded by 2 weeks of general malaise and headache. examination confirmed encephalopathy and a left third cranial nerve palsy. mri brain was suggestive of adem and mri spine was normal. a recommended work up for adem was performed. rapid resolution of her symptoms occurred following intravenous methylprednisolone for 3 days. 2 years later she presented with acute left lower limb ischaemia and underwent emergency embolectomy of a popliteal arterial obstruction, with myxomatous material identified. preoperative echocardiogram confirmed a large atrial mass which was surgically removed. pathology confirmed an atrial myxoma (am). retrospective review of her initial mri images concluded that embolic phenomena from the am was the most likely explanation of her first presentation. conclusions: am is a very rare primary cardiac tumour and left sided am can embolise to the cerebrovascular system. early identification of am is important as, untreated, it can cause multiple embolic events and sudden cardiac death. 12% of adults with am present with neurological symptoms and this can mimic multiple sclerosis. am presenting with acute neurological symptoms masquerading as adem in paediatrics has not been previously reported. careful follow up is essential as late neurological complications (including cerebral arterial aneurysms) are recognised. this case highlights that adem is a diagnosis of exclusion and that mimics for acute focal neurology with encephalopathy and t2 hyperintensities on mri require careful consideration, including embolic phenomena. clinical examination alone does not exclude am and consideration of echocardiography is recommended. we describe an 8 year old boy with a rare demyelinating disorder: balo's concentric sclerosis. a routine optician review raised concerns about papilloedema in an asymptomatic child. a ct brain identified a well-demarcated high-density lesion in the left posterior frontal lobe with surrounding oedema. mri brain with contrast identified the lesion had central rim enhancement and slight diffusion restriction. alternating layers of high and low signal intensity gave it an 'onion bulb' appearance. the differential included balo's concentric sclerosis, a single demyelinating lesion, or a tumour. routine blood tests were unremarkable. csf oligoclonal bands were normal as were other csf indices. markers of immunology, including ana, anca, anti-mog, anticardiolipin, and aquaporin 4 antibodies were all negative, with normal complement levels. esr was mildly elevated when taken during an episode of acute tonsillitis. imaging 3 months later demonstrated an increase in the size of the lesion. a biopsy revealed inflammatory demyelinating pathology mediated by a perivascular and parenchymal t-and b-lymphocyte infiltrate and macrophage activity with associated demyelination lacking a perivenular distribution. there was no evidence of neoplasia, vasculitis, granulomas, or viral infection (including negative pcr testing). no treatment with corticosteroids was given, and the child remained asymptomatic. imaging, at 9 months from presentation, revealed the lesion had substantially reduced in size. there was still a rim of enhancement. as with all single demyelinating lesions, it is difficult to predict the clinical course. we opted to adopt a 'wait and see policy' and offer surveillance imaging and clinical review. balo's concentric sclerosis is a rare demyelinating disease, characterized by concentric lamella of alternating demyelinated and partially myelinated tissues. mri shows one or more concentrically mulitlayered ring-like lesions, usually in the cerebral white matter. most case reports describe cases predominantly in young adults, with few reports of cases in children. objective: cognitive and acquired neurodevelopmental deficits have been reported in children with opsoclonus-myoclonus syndrome (oms) and are associated with more severe and relapsing disease course. however, there is a paucity of data regarding cognitive dysfunction in children with stable neurological disease. we report on serial cognitive assessments of 4 children with oms demonstrating evolving cognitive dysfunction with milder disease course. methods: retrospective analysis of clinical features at presentation, investigations, treatments, clinical course including relapses and neuropsychological testing. results: four children (m:f 1:1) diagnosed with oms between 17 and 35 months were followed up for 4 to 10 years. neuroblastoma was identified in one child. oms severity scores ranged between 8 to 12/15 at presentation. patients underwent immunotherapy in accordance with european oms protocol. all patients were in remission by 7 months (range 4-13mo), with treatment maintained for 1 year. one child remained relapse free whilst 3 other children had one clinical relapse which was immunotherapy responsive again. in all cases, progressive cognitive dysfunction was reported despite being in remission and stable off treatment for 20 months (range of 12-31mo; 3 oms score 0/15 and one 2/15). sequential neuropsychological testing scores showed mean declines in fsiq of 16 (13-19) , viq of 24 (20-27) and piq of 17 (-2 to 30) between time of oms remission/stable disease and longer term follow-up time point (4-10y). conclusions: our cases demonstrate progressive cognitive dysfunction occurring in children with oms who have a milder disease and long after completion of treatment. children continued to develop but with a widening gap in comparison with peers. damage to cerebellar-cortical circuits at onset of the disease that becomes more apparent with time or indeed persistent ongoing low grade inflammation may explain this deterioration. the past decade has seen increasing cases of acute flaccid paralysis (afp) associated with enterovirus d68 (evd68) infection. it presents in clusters approximately every 2 years. we report three cases of afp due to evd68 that presented in november-december 2018. cases: two patients developed afp following a viral upper respiratory tract infection and one developed lower limb hypotonia and weakness during an inpatient admission with refractory epilepsy. two required admission to the paediatric intensive care unit for respiratory compromise and required tracheostomy ventilation. mri showed acute flaccid myelitis (afm) consistent with evd68 in 2/3 cases, consisting of central cord t2 hyperintensity in the cervical region over multiple segments with subsequent enhancement of the thalamus and cauda equina on follow-up imaging in one patient; and ventral surface enhancement of the conus and cauda equina in another. mri in the third patient was normal. electromyography and nerve conduction studies were normal in two patients but revealed a severe generalised motor axonal poly-neuronopathy in the third. two patients received intravenous immunoglobulin, corticosteroids or plasma exchange therapy and showed slow motor improvement in a distal to proximal pattern. the one patient without mri changes had received long-term oral corticosteroids but received no additional treatment and returned to baseline neurological function within 4 weeks. discussion: our cases demonstrate the range and clinical course of peripheral neurological presentations secondary to evd68 infection. we highlight the importance of sending repeat samples from multiple sites when the diagnosis is suspected, given that initial samples tested negative, and of sending samples to a national surveillance laboratory for confirmatory testing. ongoing national and multinational surveillance studies will hopefully continue to advance our understanding and treatment of this disease. poster no. 061 nmda receptor encephalitis a potential complication of biologic therapy for juvenile idiopathic arthritis? n abbassi 1 , t rossor 1 , r close 2 , a skippen 1 , k armon 2 , p bale 2 , g ambegaonkar 1 1 paediatric neurology, addenbrookes hospital, cambridge, uk; 2 paediatric rheumatology, addenbrookes hospital, cambridge, uk a 12-year-old girl presented with headaches, confusion and agitation, followed by seizures. she had presented at 20 months with polyarticular arthritis and was managed over subsequent years on methotrexate alone (2y) with added etanercept (anti-tnf alpha, 5y), tocilizumab (anti il-6, 2y) and abatacept (cd 80/86 t-cell modifier, 3y prior to presentation). flares of disease following a period of control necessitated the changes in monoclonal antibody therapy. at this presentation she was managed on methotrexate, abatacept and 5mg prednisolone for polyarticular rheumatoid factor negative juvenile idiopathic arthritis (jia). at presentation the patient was agitated, non-verbal and had one generalised seizure. examination demonstrated acute confusion, with increased tone, brisk reflexes and bilateral clonus in her lower limbs. iv ceftriaxone, acyclovir and clarithromycin were commenced. full blood count, liver function tests and inflammatory markers were unremarkable. infective serology was non-contributory. csf was unreactive with normal protein and jc virus pcr negative. mri brain 5 days after presentation showed increased t2 and flair signal intensity in the white matter of the right parietal lobe, in-keeping with an inflammatory process. eeg showed diffuse slowing with delta brush. she commenced iv methylprednisolone, followed by prednisolone. she continued to deteriorate and underwent plasmapheresis for treatment of presumed nmda receptor encephalitis, subsequently confirmed by anti-nmda receptor antibodies in serum and csf. she was commenced on rituximab (b-cell depletion, anti-cd 20), and continued to undergo plasmapheresis over the course of 4 weeks. she gradually improved and was discharged home after a 10-week inpatient stay. several adult and two paediatric cases of nmda receptor encephalitis are reported in patients on biologic therapy for autoimmune disease. autoimmune diseases are more common in those already affected by one autoimmune condition. it is unclear what contribution an autoimmune history or immunomodulation made on the development of this condition. introduction: the incidence of acute flaccid myelitis (afm) associated with enterovirus infection occurring in biennial clusters since 2012 has been reported in the us (bmj 2018, 18; 363:k5246) and recently in europe. previously, cases with transverse myelitis (tm) with anterior-horn cell or peripheral nerve involvement have been collectively termed tm-plus (neurology 2016; 87;s46-s52). we aimed to identify cases of tm-plus from a retrospective cohort of children to identify potential cases of 'undiagnosed' afm, and to evaluate the clinical and radiological features alongside long-term outcome. methods: consecutive cases of children (<16y of age) who presented to a large paediatric neurosciences centre from 2009 to 2016 fulfilling the transverse myelitis consortium working group criteria modified for the paediatric population (neurology 2015; 84:341-349) were retrospectively evaluated for additional features of anterior horn-cell involvement (fulfilling criteria for afm (current treat options neurol (2017) 19: 48)) or peripheral nervous involvement; and were collectively evaluated with the contemporary tm-plus cohort (2016) (2017) (2018) . results: 25 cases of tm were identified, 7 of which were excluded from further analysis; ms (n=6), adem (n=1). 8 cases of tm-plus were identified, 4 before 2016 and 4 after, all associated with a viral prodrome. flaccidity (n=8) and asymmetry (n=6) was noted at presentation, with corresponding nerve conduction studies revealing a motor axonopathy with sensory sparing (n=6) and anterior horn cell involvement confirmed in 3 cases. all cases with anterior horn cell involvement had poor outcomes while both cases with good outcomes had peripheral involvement and normal mri brains. conclusions: tm-plus was detected in our cohort from 2009 to 2016 with biennial clusters noted in 2016 and 2018. the clinical presentation, investigations and long-term outcomes appear consistent in both groups. acute necrotising encephalopathy is more severe when associated with influenza background and objective: acute necrotising encephalopathy (ane) is a rare but potentially life-threatening condition associated with viral infections. a familial and recurrent form (ane1) has been identified by mutations in the nuclear pore ran binding protein (ranbp2). we report the morbidity and mortality when associated with influenza infection. methods: we performed a review of paediatric ane cases from 1999 to 2019 evaluating the clinical, biochemical, microbiological and neuroimaging appearances as well as outcomes. results: the cohort comprised 6 children (2 boys), age ranging from 8 months to 3 years 9 months (<2y n=5), of which 4 had a confirmed genetic diagnosis and 2 were ranbp2 negative. there were 13 episodes of encephalopathy, with recurrences in 3 cases (2 ane1). 10 of these episodes had infectious aetiology identified: coronavirus n=2, parainfluenza n=1, adenovirus n=2, h influenzae n=1, influenza (h1n1 n=3, h3n2 n=1). clinical features of fever and encephalopathy were consistent (100%), and seizures and sixth nerve palsies prominent (50% each). csf revealed absent pleocytosis, normal-elevated protein and negative virology. symmetric involvement of the thalami bilaterally was present in all cases, and all ane1 cases were associated with haemorrhage and external capsule/claustrum involvement (100% specific and sensitive). the outcome following influenza infection was striking, death n=1, vegetative n=2, 4 limb motor and movement disorder n=1. 2 of these cases had previous episodes of encephalopathy with noninfluenza infection and did have recovery, albeit with moderate to severe disability. all 3 cases were never immunised against influenza infection and suffered grave outcomes. conclusions: influenza infection in ane has the poorest outcome therefore vaccination should be a mandatory consideration for the known cases of ane. introduction: acute flaccid paralysis (afp) is characterized by a rapid onset of limb weakness. we describe six cases of afp in children aged 9 months to 3 years of age who presented to a tertiary paediatric neurology service in the east of england over a 5-year period from november 2013-november 2018. retrospective analysis of the six cases was performed, reviewing their clinical course and management, as well as their radiological, electrophysiology and laboratory results. results: case 1, a 9-month-old boy, presented in november 2013 with a viral urti requiring escalation of care to picu due to a significant respiratory compromise. only on subsequent recovery was the child found to have a unilateral upper limb flaccid paralysis. this child was positive for enterovirus serotype d68. cases 2 and 3 in our series presented in 2016 with acute weakness of the lower limbs with an mri brain and spine showing enhancement of the lumbar spinal roots. both have made a good recovery. enterovirus was not detected in either case. the final three children in our series presented in autumn 2018 with weakness of a unilateral upper limb following a viral urti, with all three being positive for enterovirus. unfortunately, they have shown minimal recovery of motor function of the affected upper limb. one child, a 3year-old girl, showed a more severe clinical course involving a prolonged period of intensive care and a tracheostomy for long-term ventilation. she has undergone neurorehabilitation and an upper right arm nerve transfer. conclusions: in our case series, four patients presented with an acute viral urti associated with an upper extremity weakness, and subsequently all four were positive for enterovirus. clusters of acute limb weakness in paediatric patients have been linked to outbreaks of non-polio enteroviruses, termed acute flaccid myelitis (afm). objective: to present an interesting case of recurrent anti-mog demyelinating disease and provoke discussion regarding possible immunomodulatory therapy. methods: a 14 year old girl presented, initially at 5 years of age, with headache and vomiting. she was initially treated as atypical tuberculosis meningitis based on csf cell counts, but later developed a 6th nerve palsy and was diagnosed with optic neuritis. anti-mog antibodies were positive and they were commenced on iv methylprednisolone. she clinically improved and was discharged on weaning oral prednisolone, antibodies were negative following treatment. results: a few months later she had her first relapse, with an acute decline in visual acuity. an mri showed new lesions in her optic chiasm and both optic nerves with associated bilaterally reduced visual evoked potentials. she was again treated with iv methylprednisolone, with rapid improvement, followed by a switch to weaning oral prednisolone. anti-mog antibodies were negative following treatment. she was symptom free for 7 years until her second relapse, when she presented with facial palsy, swallowing difficulties and slurred speech. mri showed brainstem and periventricular white matter demyelination, with positive anti-mog antibodies. she was again treated with iv methylprednisolone, followed by oral prednisolone, but was maintained on low dose prednisolone as her anti-mog antibodies remained weakly positive despite being symptom free. these were stopped at patient request due to low mood and abdominal pain in february 2019, with no recurrence of symptoms as yet. repeat mog antibodies have been sent and are awaited. conclusions: this case shows an interesting relapsing/remitting pattern of anti-mog demyelinating disease, which appears to be very steroid responsive, however on her second relapse her anti-mog antibodies remained weakly positive despite steroid therapy. discussion is welcomed on whether prophylactic immune modulation therapy should be considered with this child, such as azathioprine, mycophenolate mofetil or rituximab. objective: to highlight the utility of early mr imaging in children presenting with acute severe encephalopathy and to consider whether there might be a subgroup of children with myelin oligodendrocyte glycoprotein antibody (mog-ab)associated demyelination who might be candidates for early intense immunomodulation. methods: we report two cases with mog-ab-associated acute demyelination who relapsed with new neurological symptoms after initial steroid therapy had been discontinued. results: two toddlers were initially admitted to intensive care with acute encephalopathy and acute symptomatic seizures. both had an initial ct head during picu admission; one was reported normal; the other was suggestive of diffuse cerebral oedema. both children improved with supportive care only and were discharged home within a week. both children presented again over the following 2 to 4 weeks with new neurological symptoms but without encephalopathy. mr imaging demonstrated demyelination and they were treated with steroids. both children relapsed as steroids were being weaned and/or stopped. repeat mr imaging at this stage demonstrated new enhancing lesions. it was subsequently found that both children were mog-ab positive. conclusions: reliance on cranial ct imaging in the context of a young child with acute encephalopathy and seizures can be misleading. prediction of the severity of mog-ab-associated demyelinating syndrome at onset is challenging. mr imaging in the acute phase with early follow up imaging may identify this subgroup. case: hb is a 7 year old boy who presented with sudden onset diplopia and painful ophthalmoplegia, following a 12 day history of frontal headache. on examination, he had a left vith nerve palsy, partial left iiird nerve palsy and normal right eye movements. the remainder of his neurological and general systems examination was normal. his initial ct head scan and pre-contrast mri of the brain were normal. he was discharged from the local hospital following normal blood tests and imaging. clinical course: nine days later, his symptoms worsened including severe vomiting, worsening frontal headache and photophobia. he was treated for a possible underlying infective cause with ceftriaxone and acyclovir. given the broad underlying differential diagnoses, hb had extensive infectious and immunological blood workup which was unremarkable. a repeat mri brain scan with contrast revealed a lesion in the left cavernous sinus, possibly of vascular origin. differentials included cerebrovascular venous sinus thrombosis, tumour and inflammatory causes such as tb, sarcoid and zoonoses. hb continued to be conservatively managed and completed his course of ceftriaxone and acyclovir. repeat mri imaging 2 months later showed some resolution of the lesion and a diagnosis of tolosa-hunt syndrome was provisionally made. hb's symptoms continued to improve and further repeat mri scan 6 months later showed ongoing resolution of the lesion. discussion: according to the ichd-3 beta classification of tolosa-hunt syndrome, hb fulfilled the diagnostic criteria given his presentation of unilateral headache, granulomatous inflammation of the cavernous sinus on mri, palsies of ipsilateral iiird, ivth and vith cranial nerves. steroid use has been reported to be beneficial although more evidence is required in the paediatric population, refractory cases may respond to azathioprine and methotrexate. objective: we present a case of internuclear ophthalmoplegia unresponsive to steroid treatment which clinically improved with folinic acid supplementation. method: a retrospective chart review. results: our patient presented with acute internuclear ophthalmoplegia, ataxia and bilateral ptosis. she had a background of hypoplasia of the corpus callosum and optic atrophy with visual impairment, learning difficulties and asd. mri brain demonstrated symmetrical high signal intensity in the region of the medial longitudinal fasciculus and periaqueductal grey matter. she was investigated to exclude an inflammatory cause and was treated with high dose steroids. follow up mri did not show any improvement post steroids and there was no clinical improvement. subsequent csf investigations showed a low level of 5-methyltetrahydrofolate of 35nmol/l (normal range 72-172nmol/l). she was commenced on folinic acid 15mg once daily and her symptoms improved. on follow up her eye movements had significantly improved as had her ptosis. follow up mri brain showed partial resolution of the areas of abnormal signal in the periaqueductal grey matter. conclusion: internuclear ophthalmoplegia is a sign usually associated with an inflammatory or demyelinating cause. our case did not respond to steroid treatment but has associated low levels of 5-methyl tetrahydrofolate and has responded to treatment with folinic acid. this is sometimes associated with underlying mitochondrial disorders but muscle biopsy in this case did not show any evidence of mitochondrial disease. mri brain has shown partial resolution of the abnormal signal in the periaqueductal grey matter. introduction: paediatric intracranial aneurysms are rare. the pattern of disease is different to that in adults and there is far less literature available. i provide a case as an example of the presentation and progress of a child with a dissecting vertebrobasilar artery aneurysm. presentation: 11-year-old boy presented to his local hospital with sudden-onset headache, photophobia and vomiting. bloods and observations were normaldischarged. symptoms recurred more severely the following day. managed as meningitis. 4 lumbar punctures were 'bloody' and considered failed. mri brain 2 days post-admission demonstrated a vertebrobasilar aneurysm. transferred to the regional neurosurgical centre. transfer to neurosurgical/neurovascular centre: cerebral angiography revealed dissecting vertebrobasilar aneurysm (1298910mm). fusiform component extending beyond aici/ pica origins. wide-necked saccular component. procedure and progress: loaded with aspirin and clopidogrel. underwent endovascular procedure the following daycoil embolization, flow-diverting stent to the aneurysm. ongoing low dose dual anti-platelet therapy. made an excellent recovery with no neurological deficits. further imaging -x-ray cervical spine for possible arcuate foramen or atlantoaxial instability, normal. ultrasound liver/spleen, normal. discharged home 10 days post-transfer. patient background: past medical historyunder the gp for 18 months of headaches. traumasignificant fall from bicycle 2 years before with forced lateral flexion of the neck. posited that this may have been a contributing factor in aneurysm development. no significant family history. lifestylean active boy, enjoys weightlifting and motocross. weightlifting also posited as a contributing factor. conclusions: i provide a case which i hope will raise awareness of paediatric intracranial aneurysms and stimulate discussion concerning their management and aetiology. poster no. 070 cavernoma in children: cddft experience of two cases d jayachandran, s chandraiah darlington memorial hospital, cddft, darlington, uk aim: to report two cases of congenital cavernoma diagnosed in children presenting with neurological symptoms. cases: case 1: 10-year-old female presented with multiple left facial focal seizures in the form of twitches with full awareness. there was no family history of epilepsy. a typical event was captured lasting 70 seconds during the awake eeg and was reported as focal seizure arising from right hemisphere. an mri brain scan showed 2 popcorn balls lesions within the frontal/fronto parietal lobes, one on each side (right>left) with evidence of bleeding. she remains seizure free on carbamazepine. ccm gene results are awaited and neurosurgeon opinion was not for intervention and for local follow up. case 2: 12-year-old male had presented with confusion at 7 years of age. he also had transient loss of vision, vomiting, headaches with a few minutes unresponsive episode during admission. with a diagnosis of migraine, he had an mri brain scan as op that showed multiple cavernous haemangiomas in the cerebrum and cerebellum with the largest demonstrating a fluid level in the left parieto-occipital region. family history revealed that father had seizures secondary to brain cavernomas. he was positive for krit1 (ccm1) mutation. neurosurgeons advised active monitoring and he presented again at 12 years with focal onset seizures with impaired awareness. eeg was normal but mri showed a new cavernoma in the left temporal horn with bleeding. he remains well on carbamazepine with a plan for yearly mri scans. conclusions: congenital cavernomas of brain can be sporadic or familial, can be multiple and in any location including brain stem and can result in physical disability secondary to bleeding. in the majority of cases bleeding is spontaneous and diagnosed on mri scans after a neurological event. objective: foxp1-related intellectual disability syndrome is characterised by developmental delay, variable physical features and autism. diagnosis has increased with better access to broad genetic testing. we present a case report of a child with foxp1 mutation whose presentation was notable for significant cerebral venous ectasia. case: child s presented aged 1 year with gross motor delay (not sitting or weightbearing) along with relative macrocephaly (91st-99th centile), strabismus and prominent superficial forehead veins. intracranial imaging was arranged in which ct angiogram raised a possibility of an arteriovenous fistula. subsequent catheter angiography excluded this but demonstrated extensive tortuous cerebral venous ectasia. the venous ectasia was not felt to explain her developmental difficulties. initial genetic testing including microarray and pik3ca and pten analysis was normal. s made some developmental progress but remained globally delayed compared with her peers. reanalysis of her dna against a panel of genes associated with intellectual disability identified a de novo heterozygous pathogenic variant in the foxp1 gene, c.1507c>t, p.(arg503ter) (east anglian medical genetics service). discussion: foxp1 acts as a transcription factor and is likely to be involved in the development of many different tissue types. a wide range of genetic aberrations affecting foxp1, including point mutations and large structural anomalies, lead to overlapping clinical phenotypes. this patient demonstrates many relevant clinical features including developmental delay with autistic traits, relative macrocephaly with a prominent forehead, strabismus and early gross motor developmental delay. however, descriptions of associated neurovascular anomalies in foxp1 syndrome are scarce, with a single case report recording a venous angioma and none of cerebral venous ectasia to our knowledge. foxp1 follow up studies and whole exome or genome sequencing may help determine whether there is an additional genetic cause for this child's cerebral venous ectasia or whether it is foxp1 related. objective: a 2017 rcpch guideline was published to increase awareness of stroke in children and standardize best practice. the need for urgent (within 1h) ct angiography in children presenting with suspected stroke and criteria for thrombolysis were set out. we aimed to review the acute management and investigation of pais in children (1mo to 16y) since the introduction of the guideline with an emphasis on identifying candidates for thrombolysis. methods: retrospective notes review in a single regional neurology centre over a 20-month timeframe. results: eighteen cases were identified (8f:10m) with two mortalities. age range 2 months-13 years (mean 4.8y). 10/ 18 presented in peripheral hospitals and 8/18 in the regional centre. no cases had pednihss score documented on presentation. 9/18 had dedicated vascular imaging (cta/ mra) on initial imaging. 12/18 presented with a hemiparesis, 2/18 with seizures, 2/7 dysphasia, 1/7 headache, 1/7 ataxia. 5/18 cases had a stroke post cardiac surgery, 5/18 idiopathic stroke, 3/18 post varicella angiitis, 2/18 arterial dissection, 2/18 cardiomyopathy and 1/18 embolic stroke as a complication of central line insertion. 5/18 presented with an acute hemiparesis with a clear time of onset. no cases received thrombolysis. 1/5 was imaged within 1 hour of presentation. 1/5 had vascular imaging (mra or cta) on presentation. 1/5 cases was discussed acutely with paediatric neurology; this case was not suitable for thrombolysis due to cardiomyopathy. in retrospect the other 4/5 cases were suitable candidates for thrombolysis. conclusions: the results highlight the continued need for enhanced awareness of paediatric stroke as a medical emergency. most acute strokes will present to peripheral hospitals. therefore, there is a need for regional multidisciplinary integrated pathways amongst emergency department physicians, paediatricians and radiologists to ensure prompt vascular neuroimaging and discussion with a paediatric neurologist about the possibility of thrombolysis in suspected pais. poster no. 073 'a nudge, a fall and a weakness'a common but missed cause of paediatric stroke r shyam 1 , r bahri 1,2 , a kumar 1 , v jain 1 1 department of paediatric neurology, santokba durlabhji hospital and medical research institute, jaipur, india; 2 norwich medical school, university of east anglia, norwich, uk objective: this study retrospectively analysed paediatric strokes with further evaluations and outcomes of strokes related to minor injury, to isolate characteristic features and outcomes in these patients. methods: paediatric patients (6mo to 15y age), presenting with acute stroke between january 2015 to january 2019 were retrospectively recruited from a tertiary care hospital in north india. from this cohort, strokes following minor injury were analysed for clinical profile, investigations and outcomes (measured by international paediatric stroke study scoring system, ipss). results: of the total 114 cases, 50 (43.8%) were post-minor injury (m: f 2.5:1; mean age 14.2ae3.4mo). of the remaining (n=64; mean age 5ae4.5y) most common aetiologies were moya-moya disease (n=10, 15%) and transient unilateral arteriopathy (n=8, 12%). the post-minor injury group revealed a median time of 60 minutes from trauma to stroke onset. more than 1/3rd (36%; n=18) had transient episodic hemi-dystonia on the hemi-paretic side after a median of 4 days of symptoms onset. 90% (18/20) of children where results were available had anaemia. ct head in all (n=50) showed calcification of the lenticulo-striate vessels. subsequent brain mri (n=20) confirmed ct findings of basal ganglia ischaemia. mr angiogram and thrombophilia screen (n=6) done in the first few patients were normal and hence not pursued subsequently. follow ups of 44/50 (6-48mo; median=12mo) showed good recovery in the majority (66%; n=29/44). the median ipss score for these children was 0.5. conclusions: trivial injury leading to basal ganglia stroke was the most common cause of paediatric stroke, occurring exclusively in less than 2 year-olds. ct head was diagnostic (calcification in lenticulo-striate blood vessels and ischemia) with no further information revealed from vascular imaging or thrombophilia work-up. children were commonly anaemic, a potential causative association. often transient episodic hemidystonia of the hemiparetic side after a few days was witnessed. neurological outcomes in most children with this entity is good. introduction: rcpch launched guidance on paediatric stroke in march 2017. we present a series of paediatric patients who presented with stroke following this publication. we audited this group of patients against the key standards of the rcpch guidance. methods: we retrospectively analysed cases between april 2017 and april 2019. we identified cases from a neurology database and audited acute management using rcpch guidance 2017 as standard. results: we identified 11 children with stroke in the last 2 years. ages ranged from 21 months to 16 years with a mean age of 8 years at presentation. 7 children had haemorrhagic stroke and 4 had ischaemic stroke. the majority involved the anterior cerebral circulation (10/11). underlying aetiology was identified in 6 patients, 5 of whom had haemorrhagic stroke. 2 of the patients died. only 2 out of 11 patients had brain imaging within an hour of presentation. only one patient was eligible for thrombolysis, however due to contraindication she underwent thrombectomy. discussion: stroke pathways are well developed in adult services. due to the rarity of stroke in childhood and challenges with recognising symptoms, treatment is often delayed. symptoms in children need a high index of suspicion. the findings of this audit support the development of an all wales paediatric stroke pathway. we aim to facilitate activation of the stroke pathway when children present with the fast symptoms. we also hope to increase awareness of stroke in childhood. withdrawn. objective: stroke is a common childhood neurological disorder, affecting at least 400 children in the uk each year. the majority of children have residual sequelae across a wide domain of functions, with significant personal and societal consequences. recent rcpch guidelines have proposed criteria for hyperacute treatments; this would require rapid recognition of the potential diagnosis by clinicians. here we describe the acute care pathway of a group of children with confirmed arterial ischaemic stroke (ais). methods: parents of children aged >28 days and <18 years referred to gosh (ais) (2015-2019) were approached and sent a questionnaire exploring their experience of navigating through the healthcare system on initial presentation. responses were tabulated where possible and reported as frequencies; qualitive results were thematically coded and categorised for analysis. results: 41/90 eligible parents responded. 999 and the gp were the first port of call for the majority (n=12 for each). ten parents stated they had 'no idea' what initial symptoms might represent. when directly asked if they had suspected a stroke, nearly 2/3 stated 'no'. f.a.s.t features (f: face a: arm s: speech t: time) were noted in a third of patients and only 10 patients were given a diagnosis of stroke at first presentation. on initial discharge, a correct diagnosis of stroke was provided to 21 patients. notably, the need for improved education of paediatric stroke, for healthcare providers was raised by nearly 50% of parents surveyed. conclusions: the study demonstrates the need for further education to be delivered in pre-hospital, primary and secondary healthcare settings for recognising acute stroke in children. this will be an essential step in the delivery of hyperacute treatments. background: hereditary spastic paraparesis refers to a heterogeneous group of inherited neurodegenerative disorders characterized by progressive lower limb spasticity and weakness. there is marked genetic heterogeneity in hsp with all modes of inheritance described for the different loci and causative genes implicated up to now. we present a case of a child with a complex diagnosis of hsp with a homozygous missense mutation in nt5c2 underlying hereditary spastic paraplegia spg45. case presentation: this child had initially been diagnosed as having bilateral cerebral palsy with diplegic pattern and gmfcs ii. he had gross motor and speech and language delay. there was a family history of consanguinity. mri scans had initially been described as showing evidence of periventricular leukomalacia and he had been referred for consideration of sdr. following tertiary assessment there were clinical concerns that the overall diagnosis may need to be reexplored. review of his mri scans demonstrated similarities to a case series of hsp with a rarer form of hsp (spg45). he subsequently tested positive for spg45 nt5c2. a second case with similar clinical findings has now been identified in our region. mri scan findings will be presented. summary: spg45 is a rare but important cause of a cerebral palsy phenotype and testing for nt5c2 should be considered in the differential diagnosis and investigation of patients presenting with cp. recommendations on patient suitability for sdr has focused on children functioning at gmfcs level ii or iii. sdr has been considered for gmfcs levels iv and v however the decision to progress can be challenging. the goals in these children are significantly different with the focus being around comfort and pain relief rather than mobility. we describe the case of a boy with a mixed pattern movement disorder involving 4 limbs which had initially been managed with oral medications baclofen, trihexiphenidyl and intramuscular botulinum toxin. due to the child having a vp shunt the family didn't wish to consider itb pump. despite optimisation of oral medications and intramuscular botulinum toxin spasticity was a significant issue adversely impacting on quality of life. escalation of baclofen was unsuccessful due to loss of head control and duration of action of botulinum toxin injections appeared to be limited to 4 to 6 weeks before tone increased again. this resulted in significant difficulties with moving and handling. in view of this the option of selective dorsal rhizotomy was explored. the goal was to improve ease of personal care and sleep. post-operative outcomes greatly exceeded the family expectations. along with a reduction in tone in the lower limbs they were delighted to report several unexpected improvements. these included: improved functional ability with the left upper limb which facilitated switch access; improved truncal control making moving and handling easier; a reduction in extension posturing which had been particularly problematic pre-operatively; significant improvement in sleep; improved mood. this resulted in the local team exploring eye gaze technology with him. these functional benefits have significantly improved the quality of life for not only the patient but his family. further research into the benefit of sdr in this group of patients should encompass care and comfort outcomes, sleep assessment and measurement of pain. introduction: clonidine has become increasingly repurposed for the management of childhood dystonia. one potential advantage of clonidine is the availability of patches for transdermal delivery. we aimed to review the use of transdermal clonidine patches in our institution. methods: a retrospective notes review of children and young people (cayp) with dystonia issued transdermal clonidine patches as identified from pharmacy records. results: a total of 45 cayp were identified, median age at initiation of clonidine of 7 years 5 months (range 10mo to 14y and 5mo). prior to initiation of patches 43/45 cayp were already receiving clonidine, including 5 acutely receiving iv clonidine infusions. one child with difficult iv access experiencing an acute deterioration of dystonia was lost to follow up following transfer to local services. the commonest indications for transdermal clonidine were concerns about 'on/off' effect of enteral doses (n=23) and concerns about enteral absorption (n=17). transdermal clonidine was discontinued by 5/44 cayp (3 as patches wouldn't adhere, 1 receiving patches as a temporary bridge from iv to enteral clonidine and 1 due to severe local cutaneous reaction). one additional clonidine naive child experienced significant hypotension with a 0.75µg/kg/hour transdermal dose but tolerated a reduced dose of 0.25µg/kg/hour. follow up for the remaining 39/44 children ranged from 2 months to 6.5 years (median 1y). the median transdermal dose was 1.67µg/kg/hour (range 0.25-8.05µg/kg/h). additional enteral clonidine was used by 25/44 cayp. efficacy of transdermal clonidine was difficult to determine, but 18/44 cayp retrospectively scored 2 on the clinical global improvement-scale, suggesting significant improvement. conclusions: in cayp receiving enteral clonidine switching to transdermal clonidine patches appears to be well tolerated, with 88.6% of cayp continuing with longer term use. further prospective work is required to determine the efficacy and safety profile of transdermal clonidine. objective: to review the indications for and outcomes following itb for children and young people (cayp) at our centre. methods: 42 patients were identified undergoing itb pump insertion from 2006 to 2015. 35 had reports available. a retrospective note review was performed, with data extracted using a standardised data collection proforma. results: median age at itb pump insertion was 9 (range 4 to 18). hypertonia was described as dystonia, spasticity and/or dyskinesia. median length of follow up was 3 years (range: 1mo to 9y). choice of outcome measure was dependent upon the goals identified for surgery. care provider child health index living with disability (cpchild) data was available for 23 cayp at baseline and 18 cayp at 1 year. cpchild improved from a median score of 45.5 to 58.2 at 1 year (p=0.03, wilcoxon signed rank test). burke-fahn-marsden dystonia rating scale (bfmdrs) data was available for 12 cayp at baseline (median: 92.5 for motor, 30 for disability), 10 cayp at 1 year (median 98.25 for motor, median 28 for disability), all with a clinical picture of dystonia. gross motor function measure (gmfm) was available for 9 cayp at baseline (median=40), 8 cayp at 1 year (median 47) and 7 cayp beyond 1 year (median=43.1). gmfm and bfmdrs were not statistically significant. pain was measured with paediatric pain profile, available for 14 cayp at baseline, 6 cayp in 1 year and 3 cayp beyond 1 year. median of most troublesome pain improved from 29 at baseline to 17 in 1 year. conclusions: for a heterogeneous cohort of cayp with motor disorders, itb appeared to improve ease of care and comfort, indicated by change in cpchild. multiple measures are required to fully capture benefits seen in this cohort, which should be focused on their individual needs for intervention. objective: to evaluate neurosurgical interventions and outcomes in the management of hemidystonia. methods: the pubmed database was searched including terms 'hemidystonia', hemi-dystonia', 'unilateral dystonia', 'dystonia and (pallidotomy or thalamotomy)', 'dystonia and (dbs or 'deep brain stimulation')' and 'dystonia and (itb or 'intrathecal baclofen')', up to may 2019. papers were included if written in english and presenting outcome data for human participants undergoing a neurosurgical intervention for management of hemidystonia. reference lists of included papers were also reviewed. individualised patient data was extracted. to facilitate comparison across patients with and without validated dystonia scale scores individual patient outcomes were categorised on a 6-point scale ranging from 'worsened compared to baseline' to 'very marked improvement'. results: we identified 53 reports meeting inclusion criteria, describing 144 unique patients (20 <18y of age). ablative methods (85/144 cases) most commonly targeted the thalamus, and dbs (59/144 cases) the gpi. in recent years dbs is reported far more commonly then ablative surgery. reported follow up ranged from 6 months to 10 years. one patient underwent itb but no further individual data was available. out of the 144 cases 82 had individual outcome data. objective measures were available in 38 dbs and 7 ablation cases, most commonly the bfmdrs. reported outcomes in dbs patients were 2/47 worsening compared to baseline, 4/47 no change, 13/47 slight improvement, 10/47 moderate improvement, 9/47 marked improvement and 9/47 very marked improvement. for the ablative cases 0/35 worsened, 12/35 no change, 6/35 slight improvement, 10/35 moderate improvement, 3/35 marked improvement and very marked improvement. complications were reported in 2 dbs cases (1 shielded battery syndrome, one infection) and 7 ablative cases (2 depression and 5 transient hemiplegia). conclusions: available evidence for the neurosurgical treatment of hemidystonia is of low quality, but suggests generally positive results, with few complications reported. introduction: acute flaccid myelitis (afm) is a recently characterised condition causing multiple muscle paralysis and life-changing disability in children. no medical treatment is effective. however, recovery of denervated muscle function is possible via nerve transfer surgery. such treatment is complex, specific to the individual and should be carried out by specialist teams. objective: to describe the clinical features, management and outcomes of nerve transfer surgery following the 2018 afm outbreak. methods: retrospective analysis of patients with afm treated with nerve transfer surgery in 2019. surgical criteria: persistent motor deficits (paralysis) 6 months post onset with neurophysiologic signs of denervation and donor nerve availability. results: eight patients (m=f, aged 26-75 months; mean 40) were referred between march and july 2019. at initial onset/ infection: 6/8 had involvement of all four limbs and trunk and 4/8 had involvement of the phrenic nerve. mean date of initial assessment within specialist centre was 10.5 months post onset (range 4-38). at this time 7 had upper limb paralysis (4 right, 3 left) and 1 had bilateral lower limb paralysis. following consultation, 1 declined surgical intervention and 2 are awaiting surgery. 5/8 patients have proceeded to surgery: 4/5 cases presented with three-or-more nerve root involvement. 10 nerve-transfers have been performed (median 2 per patient). no surgical complications were encountered. early clinical functional outcomes from this cohort following surgery are currently being collated and evaluated and will be presented in full at conference. conclusion: this study supports international experience that nerve transfer surgery can improve functional outcomes in afm. the delivery of care in the nhs requires coordination and referral to specialist centres. experiences with this cohort will inform decision making and improve patient outcomes and family expectations during the next outbreak of afm. poster no. 083 a catastrophic case of acute flaccid myelitis t chakrabarty 1 , c lundy 1 , g doherty 1 , d bhattacharya 2 , p moriarty 1 , d peake 1 1 royal belfast hospital for sick children, belfast, uk; 2 royal victoria hospital, belfast, uk objective: acute flaccid myelitis (afm) is a rare but serious neurological condition characterised by acute onset of flaccid weakness in one or more limbs with distinct abnormalities of the spinal cord grey matter on magnetic resonance imaging (mri) and without any features suggesting an upper motor neuron disorder. in recent years, there has been a global increase in the incidence of afm associated in some cases with a non-polio enterovirus, ev-d68. the long-term prognosis in most cases remain poor. we present a severe case of afm in a 3-year-old boy with catastrophic consequences. method: retrospective review of clinical course, neuroimaging, treatment and neurorehabilitation. results: a 3-year-old boy presented with clinical encephalitis. he deteriorated over 24 hours and developed an encephalopathy, multiple cranial nerve deficits, and complete flaccid paresis requiring picu support. csf 2 weeks apart showed a resolving lymphocytic pleocytosis with increased protein (0.5 to 0.92 g/dl). serial mri brain and spinal cord showed extensive signal abnormality involving thalamus, dorsal pons, medulla, cervical cord, conus along with cauda equina. nerve conduction studies were consistent with a severe acute motor axonal neuropathy. eeg showed a posterior dominant encephalopathy. infective (including edv-68), metabolic, immunological (aqp4 and mog abs) and genetic (ranbp2) tests were negative. immunomodulation therapies (methylprednisolone, ivig, and plasma exchange) resulted in no clinical improvement. resolution of signal changes in the thalami, brainstem and spinal cord along with mild generalised cerebral atrophy was noted in repeat mri after 3 months. 10 months following presentation he remains fully ventilated with no significant motor improvement despite intensive rehabilitation including use of passive range of movement devices and functional electrical stimulation. conclusion: this is one of the most severe cases of afm, representing the wider spectrum of afm involving encephalopathy, dominant bulbar signs and quadriparesis. mirror movement disorder (mmd) is a rare movement disorder with a prevalence of less than 1 in a million in which involuntary symmetrical movement is observed in the limb contralateral to the voluntary limb movement. we report 2 children with an mmd. case 1: a 15-year-old girl following an uneventful pregnancy and normal delivery, born to nonconsanguineous parents presented with difficulties with fine motor activities like writing. parents noticed from age of eight that her left hand would make similar movements to her right hand in activities like writing, combing etc. maternal grandfather has mmd. case 2: a 9-year-old girl following an eventful pregnancy and normal delivery to non-consanguineous parents presented with an mmd at age of 5 years first noticed whilst writing and this continues affect her activities of daily living. there is no family history of mmd. both children are neurodevelopmentally normal and have normal mri brain and spine. mmd have been described congenitally due to prenatal insult before 28 weeks gestation, kallman syndrome and klippel-feil syndrome or as an acquired due to hemiplegic stroke and parkinson's disease in adults. pathogenesis is thought to be due to lesions in supplementary motor area, corpus callosum or cervical lesions. mutations in dcc and rad51 gene are present in 35% of the cases. the multimodal mri and neurophysiological studies have revealed that the motor system is completely disorganised with abnormal crossing at brain stem level and abnormal communication between both brain hemispheres in these children. there is a positive family history in some cases. the upper limbs are commonly involved. diagnosis is usually clinical and treatment is symptomatic with support at school and limiting repeated complex and sustained movements involving both hands. poster no. 085 acute spinal cord infarction in children: a review of the presentation, aetiological investigations and outcomes in 6 children m shehata, ar hart, cd rittey, e davies department of paediatric neurology, sheffield children's hospital nhs foundation trust, sheffield, uk aims: acute spinal cord infarction is poorly understood in the paediatric population. we reviewed cases presenting to a single paediatric neurology centre in uk between 2010 and 2019 to explore common themes of presentation, aetiology and outcome. material and methods: cases of spinal cord infarction presenting to a single centre were identified from our spinal database and medical records were reviewed to determine clinical presentation, aetiological investigations, management and outcomes. results: six children/young people were identified, 2 male, 4 female, age range 3 to 14 years. 4 participants presented with symptoms after seemingly trivial movements or trauma, including: being kicked in the back whilst playing football, bending forwards to tie hair up, getting up to walk in the garden, and performing a crab gymnastic movement. 2 had no obvious precipitants. initial presentation was neck or back pain in all patients, progressing to bilateral lower limbs weakness, sensory deficit, lost reflexes, and urinary/bowel involvement. mri imaging failed to reveal the diagnosis when performed early in 1 participant. the level of lesions for each participant were: t2-3; t2-6; t2-t12; c2-t6; c1-t8; and isolated to the conus. aetiological investigations, including thrombophilia screens, failed to reveal a cause in any participant. 2 initially received steroids because the differential diagnosis included an inflammatory disorder. 2 patients received aspirin, 5/6 gained motor improvement but none returned to normal. all had residual bladder problems, 5 had bowel sequelae. conclusions: spinal cord infarction may be related to minor trauma or movements. the association with a chiari 1 malformation is previously described in adults. outcome is poor. although motor improvement can be seen, children do not return to normal functionally. aetiological investigations and treatments vary within a single centre. national recommendations are required to standardise practice. cost of care for long-term ventilation patients r belderbos, v kumar, l alkhalidi east lancashire nhs trust, lancashire, uk background: advances in neonatal and paediatric intensive care have increased the survival of children with life threatening or life limiting conditions. there has been a significant rise in children on long-term home invasive ventilation. high profile cases have been in the media recently with debate on whether such interventions should be implemented focussing on ethics but without evidence of cost benefit analysis. children on long-term invasive ventilation are a high cost group with complex and varying underlying medical conditions requiring input from multiple teams, including 24 hour carers, medical and multidisciplinary team input as well as recurrent hospital and picu admissions. in addition, the cost of equipment and drugs makes this a costly intervention. in any limited healthcare system rationing decisions have to be made: drug and other therapies are subject to health economic analyses. this study aims to assess cost per annum for ltv and a cost benefit analysis. objective: identify patients on ltv including comorbidities. assess cost of ltv to quantify cost-benefit analysis. measure outcomes: death/admissions/recovery. methods: review of patients requiring home long-term invasive ventilation july 2009-july 2019. analysis of costs: clinic visits, hospital admissions, costs of equipment; cost of medication. outcomes and quality of life: mortality, admissions and length of stay; decannulation, ability to communicate and mobility analysis; ability of parents to work. results: 9 patients: 3 died (aged 1, 7 and 15y), 4 decannulated, 3 ongoing ltv (aged 15mo, 19 and 22y), 5 night package £140 000 pa, accessories £12 000 pa, replaceables/service £92 000, average cost home ltv around £350 000 pa. conclusions: ltv ventilation is an expensive treatment: its use should be analysed on a cost benefit analysis in a similar way to other available treatments. objective: to assess the feasibility of recruiting to a study, performing and interpreting aeeg in preterm infants, and to assess family and staff members' views. methods: a prospective feasibility study. 7 preterm neonates between 26 and 30 weeks postmenstrual age were recruited for continuous aeeg monitoring using adhesive electrodes whilst receiving nicu care. we studied optimal methods of attaching leads, impedance data, number of electrode changes, and preliminary aeeg findings. staff and parents were asked for feedback on the process and their involvement. results: we recruited 36.8% of eligible babies. nuprep and sorbaderm were the most effective combination for skin preparation. the aeeg recording was good quality if staff were engaged and knew when electrodes needed to be changed. four of the seven (57.1%) babies showed seizure activity on aeeg, none of which were diagnosed clinically. babies with seizures were born earlier, had lower birthweights, and had more complications than babies without seizures. feedback showed parents and staff were positive, although staff reported caring for the baby was harder. 75.0% of parents and 87.5% of staff would 'definitely' recommend the study to parents with a premature baby. conclusions: the use of continuous aeeg in preterm neonates in feasible, with similar recruitment rates to other studies in the department, and a positive experience for parents and staff. a high rate of electrical seizures was detected. background: the 'magnetic resonance imaging (mri) to enhance the diagnosis of fetal developmental brain abnormalities in utero' (meridian) study showed improved diagnostic accuracy and confidence for detecting fetal neurological abnormalities compared to ultrasound. the additional information provided by in utero mri altered prognosis in 44% of women. the meridian study did not report whether the neuro-developmental prognoses given to women varied between clinicians or were accurate. objectives: to assess the variation in prognosis given to pregnant women by clinicians in feto-maternal units for 5 different fetal brain abnormalities. methods: we contacted one clinician at each of the meridian feto-maternal units and asked what percentage chance of normal neuro-developmental outcome they would give pregnant women for 5 fetal neurological abnormalities: isolated ventriculomegaly 10 to 12 mm; unilateral hypoplasia of the cerebellar hemisphere, isolated hypoplasia of the cerebellar vermis, isolated cisterna magna, and isolated blake's pouch cyst. respondents were asked to give a percentage chance of normal outcome, although some used free text to answer. results: responses were received from 14 senior obstetricians in 14 feto-maternal units. there was general agreement for isolated mild ventriculomegaly with respondents replying that 90 to 95% would have normal developmental outcome. wider variation was seen for posterior fossa abnormalities, with the suggested chance of normal outcome for one condition ranging from 10 to 90%. conclusion: estimating long-term neuro-developmental outcome based on antenatally detected neurological abnormalities is challenging due to limited high-quality data. our data highlights there is high variation in outcomes offered by different clinicians for the same abnormality. further work is needed to determine what advice is given by obstetricians on the potential developmental outcomes of a wide range of fetal brain abnormalities in current practice, how well these agree with published evidence, and whether the involvement of paediatricians with experience in neuro-developmental disorders improves prognostication. background: in-utero mri (iumri) detects fetal brain abnormalities more accurately than ultrasonography (uss) and provides additional clinical information in around half of pregnancies. there is little published data on whether postnatal neuroimaging beyond 6 months of age changes the diagnostic accuracy of iumri nor its ability to predict developmental outcome. methods: families enrolled in the meridian study whose child survived to 3 years of age were invited to have a case note review and assessment of developmental outcome with either the bayley scales of infant and toddler development, the ages and stages questionnaire or both. a paediatric neuroradiologist, blinded to the iumri results, reviewed the postnatal neuroimaging if the clinical report differed from iumri findings. diagnostic accuracy was recalculated. a paediatric neurologist and neonatologist categorised participants' development as normal, at risk, or abnormal, and the ability of iumri and uss to predict developmental outcome were assessed. results: 210 participants had case note review, of whom 81 (38.6%) had mri after 6 months of age. the diagnostic accuracy of iumri remained higher than uss (absolute differ-ence=25%, 95% ci 21% to 29%, p<0.0001). developmental outcome data was analysed in 156 participants: 111 (71%) were normal, of whom 56 (51%) had a normal or favourable prognosis on uss and 76 (69%) on iumr (difference in speci-ficity=18%, 95% ci 7% to 29%, p=0.0008). no statistically significant difference was seen in infants with abnormal outcome (difference in sensitivity=4%, 95% ci -10% to 19%, p=0.727). conclusions: iumri remains the optimal tool to identify fetal brain abnormalities. it is less accurate at predicting developmental outcome, although iumri is better at identifying children with normal outcome than uss. further work is needed to determine how the prognostic abilities of iumri can be improved. poster no. 090 introducing hypothermia or not decision algorithm (honda) guideline in the assessment of neonates following hypoxic insult at birth in a district general hospital a sproule, j courtney, m mcgowan ulster hospital, belfast, uk introduction: hypoxic-ischaemic encephalopathy (hie) accounts for up to 30% of cases of cerebral palsy. hie can be caused by multiple events and occurs in 2/1000 births. hypoxic insult at the time of birth can result in an encephalopathic state characterised by: need for resuscitation at birth, neurological depression, seizures and electroencephalographic abnormalities. the toby study demonstrated that induction of moderate hypothermia within 6 hours of birth for 72 hours duration in infants who had perinatal asphyxia resulted in improved neurologic outcomes in survivors. therapeutic hypothermia is the only proven neuroprotective treatment for hie. an assessment tool was required as there was no standard proforma for neurological assessment for babies with a low cord ph (<7.1) in our district general hospital (dgh). this was to ensure that all infants who met the toby criteria received the appropriate treatment within the recommended timeframe. methods: the honda assessment tool was developed for use in the tertiary neonatal intensive care unit. this assessment tool was adapted to use in a dgh as a guideline. the honda included the criteria from the toby study with a user-friendly flow chart. a comprehensive neurological examination is outlined with text and images to ensure reliable and repeatable findings by different clinicians over time. results: the honda tool ensured a standard algorithm was used to assess those infants who had a hypoxic insult at birth. it has standardised record keeping and repeated neurological examination of at-risk infants. conclusions: the honda is a comprehensive and userfriendly algorithm to ensure those infants who meet requirement for therapeutic hypothermia are being appropriately identified and treated. poster no. 091 foetal exposure to misoprostol and mobius syndrome s tilib-shamoun, a siddiqui, v ramesh king's college hospital, london, uk background: mobius syndrome is a rare condition comprising a collection of specific congenital anomalies, usually congenital lower motor neuron 6th and 7th cranial nerve palsies. hydrocephalus, cerebellar hypoplasia, orofacial and limbs deformities have been reported in some. the literature links mobius syndrome to early foetal exposure to misoprostol, a synthetic prostaglandin e analogue widely used for medical termination of pregnancy. for abortions it is used by itself or with the anti-progestogen mifepristone; the combination is 97% effective during the first trimester of pregnancy. the mechanism by which misoprostol disrupts brainstem development resulting in hypoplasia or absence of central brain nuclei is not elucidated as yet. suggested mechanisms include selective vulnerability to hypo-perfusion and ischaemic injury of the foetal brain stem due to direct disruption of the foetal vasculature or to global foetal hypoxia because of uterine contractions and placental ischaemia. clinical case: we report a case of an infant with known exposure to misoprostol from failed medical termination of pregnancy (top) at 12 weeks gestation, who presented with an abnormally increased head circumference, multiple lower motor neuron cranial nerve palsies (7, 11 and 12th cranial nerves). his mri scan showed hydrocephalus due to cerebral aqueduct stenosis, inferior vermian hypoplasia and loss of bulk of the right facial collculus of the pons. conclusions: it is vitally important to counsel expectant mothers following exposure to misoprostol and failed top of possible congenital anomalies if the woman elects to continue with the pregnancy. poster no. 092 neurological examination in unwell neonates: health care professionals' perspectives a fadilah, ar hart department of paediatric neurology, sheffield children's hospital, sheffield, uk objective: to explore health care professionals' opinions of neurological examination in unwell neonates. methods: a questionnaire designed to assess views on examining unwell neonates neurologically was distributed to all uk neonatal and paediatric neurology units. questions included likert scales, with scores ranging from 0 to 6. scores of 4 to 6 were taken to be positive, 1 to 3 negative or equivocal. answers were compared between consultants and other staff members using chi-squared testing, with p<0.05 assumed statistically significant. results: 192 responses were received, although not every question was answered. 106/192 (55.2%) responders were based in general paediatrics, 60/192 (31.3%) in tertiary neonatal units, and 18/192 (9.4%) in paediatric neurology. 92/192 (47.9%) were consultants. 59/192 (30.7%) performed a neurological examination in all unwell neonates, 114/191 (59.7%) in most. 84.8% of consultants felt confident performing a neurological examination, compared to 57.0% of other health care professionals (p<0.05). consultants were also more confident at interpreting the results and using them to formulate management and prognosis (all p<0.05). 140/192 (72.9%) did not find a high-quality neurological examination documented routinely in medical notes of half or more unwell neonates. 86/167 (51.5%) reported using the classical neurology examination adapted for neonates, 22 (13.3%) used the hammersmith neonatal neurological examination or an adapted version. the most difficult aspects were fundus and cranial nerve examination. the most frequently cited challenges were: effect of medication; difficulties in interpretation; equipment and lines; experience; time limitations; and risks of handling unwell neonates. 124/171 (72.1%) wanted a new standardised neurological examination for unwell neonates; 9 (5.2%) did not. conclusions: non-consultant grade health care professionals feel less confident performing a neurological examination in unwell neonates. all responders highlighted a number of challenges to performing and interpreting the results. around three-quarters of responders want a new, standardised neurological examination for unwell neonates, which could address these challenges. use of re-standardised griffiths scales of child development (3rd edition) in a healthy cohort at 4 to 5 months of age objective: the griffiths scales of child development (gscd) is an established tool for the developmental assessment of children from birth to 6 years. in 2016, the gscd underwent significant revisions, and was re-standardised using contemporary cohorts. to date, no studies have reported on its use in healthy children post-marketing. our aim is to examine the use of the gscd-iii in a healthy population of infants aged 4 to 5 months and to provide the first published data on the use of the revised griffiths-iii. methods: in a prospective observational study of healthy, fullterm infants, participants were recruited into a randomized controlled trial of infant massage. griffiths iii assessments were performed by aricd-trained practitioners across 5 subscales and a general development quotient (gd) at 4 to 5 months. results: 178 children were considered in the analysis, male: female ratio 101/77. mean (sd) birth weight was 3.53 (0.46) kg and mean birth gestational age was 39.8 weeks (sd 1.22). mean (sd) age at assessment was 4.5 (0.3) months, with 98 (55.1%) children being assessed according to 4/12 rounded norms, and 80 (44.9%) to 5/12 norms. no difference was found in either arm of the study in any subscale. scores were considerably greater than average (dq 90-109) in all subscales but particularly subscales b, d and gd. mean (sd) developmental quotients (dq) in a=121.0 (15.9); b=130.7 (11.6); c=119.0 (9.7); d=127.0 (8.4); e=123.3 (11.1) and in gd=128.3 (10.1). using the published cutoffs, we found that 97.2% (n=173) of our cohort scored 'above average' or greater in gd. conclusions: we have provided the first data on the use of griffiths-iii in a healthy cohort. scores were higher than expected across all sub-scales. this may be due to the characteristics of our cohort but raises concern that griffiths-iii may overestimate ability in young infants. objective: metabolic investigations are important in the investigation of children with disordered development. the aim of this audit was to determine if paediatric metabolic investigations were ordered as per current best practice evidence at tallaght university hospital, dublin, republic of ireland. methods: we used recommendations from seven publications to guide this audit and identified indications for performing metabolic investigations. we reviewed metabolic investigations sent on paediatric patients at tallaght university hospital from 1 january 2018 to 31 december 2018. we identified the clinical indication for investigating patients by reviewing dictated clinic letters available on the hospital intranet and confirmed investigation results by reviewing scanned copies available on the hospital intranet. we compared the indications for metabolic investigations with published expert guidelines. results: metabolic investigations were performed on 254 patients from 1 january 2019 to 31 december 2018. six patients had inconclusive results and were referred to the metabolic team at temple street children's university hospital dublin for further assessment. there have been no metabolic diagnoses made to date as per tallaght university hospital dictated letters. of the 254 patients, 104 had a diagnosis of autism spectrum disorder (asd). of those with asd, 33 had a confirmed or suspected intellectual disability. 158 patients (62%) met best practice recommendations for metabolic investigations. of the 96 patients who did not fulfil recommendations, 71 (74%) were for children with asd. conclusions: we identified two areas that could improve patient care by optimising diagnostic yield and improving resource utilisation at the hospital. first, we recommend clinicians send targeted investigations and avoid blanket investigations for children with disordered development, including asd. second, we recommend clinicians include relevant clinical details on request forms to improve diagnostic yield. finally, we question the value of metabolic investigations for intellectual disability in the absence of other clinical risk factors or comorbidities and suggest this requires further study. the early developmental course of babies with sturge-weber syndrome n thapa 1 , t fosi 2,3 , v siyani 3 , j sloneem 3 , h richardson 3 , s aylett 2,3 1 university college london medical school, london, uk; 2 ucl great ormond street institute of child health, london, uk; 3 neurodisability, great ormond street hospital, london, uk background: sturge-weber syndrome (sws) is a rare neurocutaneous condition which arises from a mutation in g protein subunit alpha q. the hallmark is leptomeningeal angiomas often associated with a facial port-wine birthmark. seizures, stroke-like episodes and hemiplegia are common clinical presentations. objective: to describe clinical features of infants with sws under 3 years and their developmental trajectory in relation to seizure onset. methods: a retrospective case note review was conducted on 90 children aged below 3 years with sws under clinical review at our centre. the medical history and standardised developmental test results (language, cognition, motor and visuospatial skills) contained in patients' assessment reports were analysed. results: common clinical features of children with sws aged under 3 years were: seizures in 81 patients (90%), hemiplegia in 52 patients (57.8%) and glaucoma in 42 patients (46.7%). their developmental trajectory was a decrease in the mean percentiles (for language, cognition and motor skills) and mean developmental quotients (for visuospatial skills) over the first 36 months. infants with unilateral brain involvement had significantly higher cognitive percentiles than those with bilateral brain involvement (p<0.01), but both groups showed the aforementioned pattern. children with epilepsy had worse language (p=0.039) and cognitive outcomes (p=0.004) than children without seizure onset. there was seizure onset in the first year in 62 infants (78.5%). in these patients, earlier seizure onset was associated with a higher language percentile (p=0.041) at age 36 months or at the time of seizure onset. conclusions: following treatment of early seizures in sws language recovery appears to occur over time relative to cognition. the functional plasticity of language might account for these observations. it is proposed that seizure prevention and optimal seizure control in the crucial first year of life will benefit cognitive and language development in patients with sws. objective: rett syndrome (rtt) is a rare neurodevelopmental disorder primarily affecting females, characterized by loss of speech, stereotypies, abnormal hand movements, motor and cognitive impairment. diagnosing rtt before regression occurs remains a challenge and there is an increasing interest in early diagnosis, due to the ongoing gene therapy clinical trial in rtt. methods: retrospective case notes review. the patient was born at term after induction of labour for reduced movements, with meconium-stained liquor, but was well. poor crying and suck noted at birth with gradual deterioration of feeding, with frequent chest infections, necessitating peg-feeding at 6 months. peripheral/axial muscle weakness and hypotonia were noted at this time. mri brain showed mild underopercularisation of sylvian-fissures; thin corpus-callosum. mrs, mri spine, echocardiogram, and eeg were normal. vitamin b12 deficiency was found, treated with hydroxycobalamin. sleep study showed hypoventilation with frequent apnoeas and low respiratory rate, leading nocturne bipap. emg was myopathic. muscle biopsy showed marginal loss of complex-i activity in the respiratory-chain-enzymes analysis. results: videofluoroscopy showed delayed swallow and disorganised pharyngeal stage leading to peg feeding. over the following months, no regression noted but only minimal motor progression seen; she was interactive and smiled. at 12 months, regression in her motor abilities was notedshe stopped fixing, following and smiling with progressive microcephaly and hand writhing movements. eeg showed epileptic encephalopathy with tonic/myoclonic jerks. whole-exomesequencing showed a de-novo pathogenic mutation in the mecp2 gene (nm_004992.3:c.1157_1200del,p.[leu386fs] ) and the diagnosis of rtt was confirmed. after 3 months, she restarted smiling and fixing/following and making motor progress but continues to have seizures. conclusions: this case illustrates early-onset features in atypical rtt with central breathing abnormalities, bulbar insufficiency, generalized hypotonia before regression. evidence of mitochondrial dysfunction is in keeping with recent reports suggesting neuronal redox imbalance in rtt as one of the disease pathogenic contributors. objective: neurodegeneration with brain iron accumulation (nbia) comprises a group of rare genetic disorders characterized by progressive extrapyramidal and other neurological symptoms due to focal iron accumulation in the basal ganglia.1 b-propeller protein-associated neurodegeneration (bpan) is the most recently identified subtype of nbia caused by heterozygous variants in wdr45 at xp11.23. we report a new subtype of bpan caused by a de novo wdr45 variant in a 6-year-old girl. methods: case report on a new subtype of b-propeller proteinassociated neurodegeneration (bpan) caused by a de novo wdr45 deletion in a 6-year-old girl and review of the literature. results: we report a 6 year old girl with bpan due to a large (5824 bp) de novo chrx:g.48,930,034_48,935,858del (hg19) deletion in wdr45, presenting with early-onset global developmental delay, hypotonia, seizures, and speech apraxia. the patient presented at the age of 10 months with hypotonia and motor developmental delay, following a normal birth history, and at 14 months developed complex partial seizures and later on steroid-responsive electrical status epilepticus of slow-wave sleep (eses). she has made minimal developmental progress and has remained profoundly globally developmentally delayed and cognitively impaired, and has still not achieved independent ambulation. conclusion: we have described the clinical, neurophysiological and neuro-imaging findings in a 6-year-old girl, the unique combination of which may assist in the diagnosis of further similar cases. bpan is an exceedingly rare, severe and debilitating disorder with a broad spectrum of clinical heterogeneity and variable age at presentation with early-onset symptoms. early detection and diagnosis are very important in order to offer proper genetic counselling to affected families and provide symptomatic treatment to patients. next-generation broad-spectrum genetic analyses will enable early detection of bpan in the paediatric age group in order for patients to be diagnosed prior to reaching adulthood. introduction: how to measure the effectiveness of an early intervention program in low resource setting. can assessments lead to interventions? and with improvements leads to new interventions, can new assessment lead to new interventions? can this system be measured for its effectiveness and improved based on feedbacks and results? an attempt to set up child development centres in low resource countries using software, apps and e-learning. method: 5 years of data in early interventions was analysed in lucknow, india. in phase 1, 527 children with non-progressive neurological problems were given best available local interventions. only 8% compliances and improvement were seen. based on the feedback algorithms were written to create individual profile of children based on their skills (uk curriculum of excellence), disability score, information processing preference, educational and behaviour problems. based on the score each child generates an individualised profile and an intervention plan delivered by app for parents (p-bac-drv) and app (t-bac-drv) at child development centres. the assessment is repeated every 2 months and new individualised profile is generated with new set of intervention. in total more than 2000 interventions are developed, and the algorithm helps in deciding which main areas to target at one time. result: the current system in low resource settings have either no service or results are close to 10% prevent disability in non-progressive neurological problems. our system has shown to prevent disability in about 60% of children. supported by government start up initiative the program has won in top 40 data innovations in india. conclusion: use of technology to provide training, exams and support professionals in the low resources areas is the solution to provide effective services. pattern recognition is the key delivered by software and auto audits has been placed to measure and improve the system. introduction: medical advances in the treatment of cns tumours has enhanced survival but also impacted on levels of residual morbidity and participation. service provision has not increased alongside the improvement in survival, with many patients not being able to return to their previous level of activity and participation following their oncology treatment. nice cancer services for children and young people 2014 state: 'children and young people who have had a central nervous system malignancy should receive a specialist neuro-rehabilitation care package'. robbie's rehab, a charity funded physiotherapy service embedded within the southampton children's hospital therapy service, launched june 2017, provides supplementary physiotherapy for children diagnosed with brain and spinal tumours under the care of southampton children's hospital. objective: to accurately identify and quantify the need for this service. method: prospective data was collated and reviewed june 2017-may 2019. results: year 1: 30 patients; year 2: 32 patients. 94 new episodes of physiotherapy (average 3.9 per month), 303 direct clinical contacts. reasons for accessing the service: need for enhanced intensity of rehabilitation on discharge (n=23), enhanced inpatient rehabilitation (n=18), bridge the gap whilst awaiting community services (n=11), change in symptoms (n=12), pre-op assessment (n=5), support for palliative care planning (n=7), support for complex social and emotional needs (n=8), disease progression (n=7), higher level rehabilitation not fulfilling community criteria (n=12), facilitate access to local exercise facilities (n=13), within oncology clinic for assessment/one-off treatment (n=8), post-op assessment (n=11), individualised goal orientated participation (n=4). 8 patients had an estimated 2 weeks reduction in acute bed days. conclusions: robbie's rehab referrals are for a variety of multifactorial reasons with rereferral often needed within their pathway. it has enabled earlier discharge, improved transition to community services and opportunities for therapy access previously not available. results: our proband presented at 5 weeks with marked stridor and bulbar weakness after a normal pregnancy. he subsequently developed respiratory failure requiring nocturnal bipap and was found to have a type i laryngeal cleft. initially he met developmental milestones but at 5months developed features of axial weakness with further regression at 9months with limb weakness and loss of deep tendon reflexes. emg confirmed denervation in genioglossus, as well as proximal and distal limb muscles without evidence of neuropathy. genetics for smn1 gene and smard were negative. inherited peripheral neuropathy 56 gene panel testing identified a heterozygous missense variant c. 631t>c, p.(cys211arg) in exon 5. the variant is predicted to alter a highly conserved amino acid, has not been reported before and has not been identified in control databases. in silico prediction tools supports the pathogenicity of the variant. mutagenesis of the equivalent amino acid in mice produces impaired motor control and denervation. conclusions: the gars gene encodes an ubiquitously expressed glycyl trna synthetase which has an integral role in protein synthesis in all eukaryotic cells. missense gars mutations can lead to distal hereditary motor neuropathy as well as a sensorimotor neuropathy phenotype (cmt2d) typically with adolescent or early adulthood onset. objective: to discuss sma, which is one of the differentials in a hypotonic child and bring to light the diagnosis is not always cerebral palsy (cp). method: descriptive case report. results: case 1: 4-month-old girl admitted to icu with severe pneumonia. case 2: 9-month-old boy, both admitted to the intensive care unit with severe pneumonia. case 3: 15-month-old girl, presented to outpatient with progressive 'floppy' limb weakness and swallowing and breathing difficulties. case 4: attended opd with worsening respiratory distress, difficulty feeding, difficulty managing secretions. all 4 had perinatal histories of uncomplicated deliveries but subsequent early respiratory distress and oxygen requirement for the first few days of life. all had been 'floppy' since birth, with severe gross motor delay, feeding difficulties, poor weight gain and recurrent chest infections. cases 2, 3 and 4 had been diagnosed with cp despite having normal neuroimaging. examination of all 3 children was similar and consistent with clinical diagnosis of sma. findings included an alert, interactive child; frog-legged posture; 4-limb hypotonia and weakness with legs more affected than arms; absent deep tendon reflexes; bell-shaped chest; and tongue fasciculation. genetic testing for all confirmed homozygous deletion of exon 7 of the smn1 gene. in all the cases creatinine kinase levels were normal, ruling out myopathy. conclusions: the incidence of sma is 1/10 000 livebirths. it can be diagnosed clinically from pathognomic features when genetic testing is unavailable and should be considered in any hypotonic child, irrespective of perinatal history. a wide clinical spectrum that ranges from early death to near-normal adult life exists. families must be counselled regarding implications of this genetic diagnosis. correct early diagnosis and multidisciplinary intervention can vastly improve outcomes. poster no. 102 syros studylong-term reduction in rate of respiratory function decline in patients with duchenne muscular dystrophy (dmd) treated with idebenone l servais 1 , c lawrence 2 , oh mayer 3 , cm mcdonald 4 , u schara 5 , t voit 6 , e mercuri 7 , gm buyse 8 respiratory function decline in dmd is caused by the underlying weakness and degeneration of the respiratory muscles leading to impaired inspiratory and expiratory effort and associated complications. idebenone reduced the rate of respiratory function decline over 52 weeks in the phase iii delos trial. syros is a long-term study in former delos patients who transitioned to idebenone under expanded access programs following a variable untreated period. here, we aimed to characterize the long-term effects of idebenone on respiratory function. patients were managed according to routine clinical practice. respiratory function was assessed by calculating the annualized decline in forced vital capacity (fvc) and peak expiratory flow (pef), expressed as percent predicted (%p). comparisons were made between treated and untreated periods and to matched external controls. data on bronchopulmonary adverse events (baes) and hospitalizations were collected. data from 18/64 former delos patients were available. at delos baseline, mean (sd) age and fvc%p were 13.3 (2.7) years and 58.7% (17.6%); all patients were glucocorticoid non-users and 83.3% were non-ambulatory. patients were treated for an average (min-max) of 4.2 (2.4-6.1) years compared to an average untreated period of 2.1 (1.1-5.5) years. the annual rate of fvc%p decline was almost halved (3.8% vs 7.4%) when comparing these periods. for the external comparisons, declines remained lower across all treatment years (up to 6y) compared to the matched group of untreated patients. comparable results were seen for pef%p. the risk of baes was reduced by 68% during longterm idebenone treatment versus untreated periods, leading to fewer hospitalizations due to respiratory causes (0.06 vs 0.15 events per year). long-term treatment with idebenone results in a consistent and sustained reduction in the rate of respiratory function decline for up to 6 years. two placebo-controlled trials of 52-week duration (phase ii delphi, phase iii delos) showed that idebenone consistently reduced respiratory function decline rate in patients with advanced dmd. long-term data from the delphi-extension (delphi-e) study and syros (delos patients who transitioned to idebenone under an expanded access program) are now presented. the aim was to assess the consistency of the long-term effect of idebenone on respiratory function across both placebo-controlled trials and their respective long-term data collections. 11 delphi-e and 18 syros patients with abnormal (<80%) forced vital capacity (as percent predicted, fvc%p) were treated with idebenone for an average of 2.0 and 4.2 years respectively. annualized fvc%p decline rates were compared to untreated patients from syros or matched external controls (matched for baseline fvc%p) from the cinrg duchenne natural history study (cinrg-dnhs). mean (sd) baseline age was 13.6 (2.3) and 13.3 (2.7) years in delphi (n=11) and delos (n=18), respectively, and fvc%p was 47.2% (19.7%) and 58.7% (17.6%). for the first 2-year period, where data were available for both studies, the average annual decline rate was comparable in treated patients (4.5% and 5.4% in delphi-e and syros) and lower than in untreated syros patients and external controls (7.9% untreated and 8.1% in cinrg-dnhs). during years 3 to 6, the annual decline rate was consistently lower than for matched controls. treatment with idebenone resulted in a sustained reduction in the rate of decline in respiratory function across both placebo-controlled 52week studies and across both long-term data collections, with follow-up time of up to 6 years. the consistency observed across 2 independent datasets adds to the robustness of the treatment effect of idebenone and its potential to modify the course of respiratory function decline in dmd. poster no. 104 a rare mutation in dync1h1 causing a mixed clinical phenotype of spinal muscular atrophy with lower extremity predominance and hereditary spastic paraplegia: a case series in a family el goh 1,2 , s jayawant 3 , g anand 1 objective: to describe the identification of a rare mutation in the dync1h1 gene as a cause of a mixed clinical phenotype of spinal muscular atrophy with lower extremity predominance (sma-led) and hereditary spastic paraplegia (hsp). methods: case series of three family members (father and two sons) across two generations. results: there was a history of early childhood-onset, progressive lower limb muscle weakness and atrophy. no relevant family history of neuromuscular disorders was reported on both the paternal and maternal sides of the family. examination revealed markedly diminished tone and power in the lower limbs, with wasting and a positive crossed adductor reflex. there were no abnormalities detected in the upper limbs and sensation was preserved throughout. neurophysiological testing showed moderate to severe chronic denervation of the lower limb muscles with sparing of the peripheral sensory nerves. hsp panel was negative but charcot-marie-tooth (cmt) panel demonstrated a heterozygous sequence change in the dync1h1 gene: c.1808a>t p.(glu603val), which was present in all affected family members. discussion and conclusions: mutations in the dynein gene are typically associated with sma-led or cmt. a mixed sma-led and hsp phenotype has previously been shown to be caused by mutations in bicd2. bicd2 encodes a golgin, which is a component of dynein-based transport, and plays a key role in mrna transport during oogenesis and embryogenesis. we present the first case series of a mixed clinical phenotype of sma-led and hsp occurring due to a mutation in dync1h1. this was the first observation of the c.1808a>t p.(glu603val) variant at our laboratory and was not listed in the genome aggregation database, suggesting an extremely rare variant. opening the lid on unilateral ptosis in paediatric nf1 e hassan 1 , e witter 1 , z mughal 2 , l robinson 3 , d weisburg 3 , sa roberts 4 , e hupton 3 , j eelloo 3 , e burkitt wright 3,5 , s garg 3 , l lewis 3 , dg evans 3,5 , sm stivaros 3,6,7 , g vassallo 1,3,5 introduction: neurofibromatosis type 1 (nf1) is a genetic disorder with a birth incidence of 1 in 2-2700 individuals and prevalence of around 1 in 4000 worldwide. ptosis is a welldocumented feature in this condition and is known to be associated with plexiform neurofibromas or in the noonan phenotype, with bilateral ptosis. unilateral ptosis in the absence of a plexiform neurofibroma is not a common feature in nf1. we describe a number of patients with nf1 who demonstrated unilateral ptosis. methods: a retrospective cohort study was carried out using the patient database within the nf1 service based in st mary's hospital, manchester, uk. children and young adults aged 2 to 18 years with nf1 were identified via the patient database and patients with a presentation of ptosis were identified. results: six children with unilateral ptosis were identified, four females and two males (ages 2-18, mean=9.5y). five had unilateral ptosis affecting the right and one the left, with no differences observed between sporadic or familial disease. five patients had complex disease; however, none had any other associated complication to account for the unilateral ptosis apart from nf1. they did not meet the diagnostic criteria for noonan syndrome, and none had plexiform neurofibromas in the orbital or peri orbital area. discussion: it is unclear why there is an increased incidence of unilateral ptosis in our cohort of nf1 patients, in the absence of plexiform neurofibromas and noonan's syndrome. ptosis in nf1 has been associated with a noonan syndrome phenotype in nf1 patients. the general hypotonia and myopathy observed in these patients could also factor into the causes for ptosis. further research is necessary to investigate the aetiology of increased unilateral ptosis in nf1 patients. objective: sma is a severe neuromuscular disorder characterised by progressive muscle atrophy and weakness. scoliosis is a highly prevalent complication and surgery is almost invariably required in 'sitters'. data on secondary outcomes are limited, and this study investigates post-surgical respiratory (fvc%) and motor function, weight gain, pain and satisfaction. methods: we retrospectively reviewed the notes of 33 patients who never walked or lost ambulation (sma type ii/iii) who successfully underwent scoliosis surgery at great ormond street hospital: spinal fusion (25), magnetic (4) or traditional (4) growth rods. we performed phone interviews and run a focus group for families on pre and post-surgical satisfaction. results: median follow-up before and after surgery was 3.9 (0.9-12.3) and 3.7 (0.4-10.5) years respectively. mean annual rate of fvc% decline improved post-surgery in sma ii: -2.8 versus -7.4 (p<0.001), with similar trajectories in sma iii. mean annual rate of hammersmith functional motor scale's scores decline did not change significantly (-1.2 vs -1.6, p<0.001), while the revised upper limb module's scores showed a less progressive deterioration (-1.3 vs -2.3, p=0.07). a negative deviation from previous weight curve after surgery was observed in 17/33 requiring food supplements (5); one/4 with significant weight loss (>5% of total weight) needed gastrostomy. pain was frequently documented, especially hip pain (13/33) requiring painkillers (8), intra-articular steroids (2) and surgery (1). nine/10 families participating in the phone interview reported major improvements in posture, physical appearance, self-image; all rated the procedure as very successful. however, 7/10 did not report significant improvements in quality of life due to reduced mobility and increased unmet care needs. five families attended the focus group reporting on both positive and negative aspects of their experiences. conclusions: this study provides relevant data and suggestions to improve the current multidisciplinary approach of scoliosis surgery in children with sma. poster no. 107 sunfish part 1: 18-month safety and exploratory outcomes of risdiplam (rg7916) treatment in patients with type 2 or 3 spinal muscular atrophy (sma) objective: spinal muscular atrophy (sma) is a severe, progressive neuromuscular disease caused by reduced levels of survival of motor neuron (smn) protein due to deletions and/or mutations of the smn1 gene. while smn1 produces fulllength smn protein, a second gene, smn2, produces only low levels of functional smn protein. risdiplam (rg7916/ ro7034067) is an investigational, orally administered, centrally and peripherally distributed small molecule that modulates smn2 pre-mrna splicing to increase smn protein levels. sunfish (nct02908685) is an ongoing, multicentre, double-blind, placebo-controlled study (randomised 2:1, risdiplam:placebo) in patients aged 2-25 years, with type 2 or 3 sma. methods: sunfish part 1 (n=51) is a dose-finding study assessing the safety, tolerability and pk/pd of risdiplam; pivotal part 2 (n=180) assesses the safety and efficacy of the risdiplam dose level that was selected based on results from part 1. sunfish part 1 included patients of broad age ranges and clinical characteristics (functional level, scoliosis and contractures). an interim analysis of part 1 (data cut-off, 06 july 2018) showed a sustained, >2-fold increase in median smn protein versus baseline after 1 year of treatment. adverse events were mostly mild, resolved despite ongoing treatment and reflective of the underlying disease. despite not being designed to detect efficacy, risdiplam improved motor function measures over 12 months versus natural history. results: safety, tolerability and pk/pd will be reported from all patients in part 1 who have received treatment with risdiplam for a minimum of 18 months. updated part 1 exploratory efficacy data, including motor outcome measures, will also be presented. the clinical benefit of risdiplam is being assessed in part 2, which is ongoing worldwide. objective: ryr1 encodes the skeletal muscle ryanodine receptor, an intracellular calcium-release channel that is crucial to excitation-contraction coupling in muscle. gene variants can cause heterogeneous myopathies, including dominantly inherited central core disease. both autosomal dominant (ad) and autosomal recessive (ar) pattern of inheritance have been reported. methods: retrospective case notes review. results: sibling 1: female, presented during the first year of life with motor developmental delay. at 4 years of age she is able to sit unsupported and crawl but not stand or walk. she has facial weakness, but no feeding difficulties or ophthlamplegia. she has axial and proximal weakness with antigravity power in neck flexors and hip flexors (mrc 3/5) and sub-gravity power in hip abductors/extensors and knee flexors/extensors (mrc 2/5). there are severe hip, knee and ankle fixed contractures. power and joint range is normal in upper limbs. muscle biopsy showed type-1 fibre predominance and core-like structures. sibling 2: female, presented at birth with feeding difficulties. at 3 months of age she is fully nasogastric fed. there is no facial weakness or ophthlamplegia. she has good head control with active head lift in prone, and antigravity power in hips, knees and ankles. she has mild hip and knee contractures and shoulder girdle weakness. both siblings have been confirmed to be heterozygous for a ryr1 pathogenic frameshift variant (c.12063_12064dupca p.(met4022fs)) inherited from father and a likely pathogenic missense variant (c.14598g>c p.(lys4866asn)) inherited from mother. both parents are asymptomatic. conclusions: the clinical and pathological features of ad ryr1-related myopathy are well recognized but much less is known about ryr1-related disorders secondary to an ar pattern of inheritance. we report two siblings with ar ryr1related myopathy with similar genotypes but different phenotypic features demonstrating intra-familial variability and expanding current knowledge on this disorder. results: our probands were the second and third children of consanguineous irish parents who were fourth cousins. antenatally, reduced fetal movements and amniotic fluid was noted with both probands. at birth, both had arthrogryposis and the second sibling required prolonged intubation at birth. both had significant developmental delay; a more severe phenotype in the younger. on examination, both had myopathic facies, inability to bury eyelashes, full eye movements, high arches palates, drooling, a weak cry, micrognathia but a preserved suck. they both had long thin fingers, with thumbs held adducted and dimpling of elbows and hands. peripheral reflexes were absent but there were good anti-gravity movements of the lower limbs. both were noted to have pectus excavatum and progressive scoliosis. muscle biopsies showed dystrophic features of fibrosis, hypertrophy and atrophy of fibres and variation in fibre size with increased fibrous connective tissue. occasional central cords and multiple mini cords were also seen in the second proband. whole exome sequencing identified the compound heterozygote mutation (ttn c.95076delc in combination with ttn c22226c>tp. (ser7409leu) and ttn c.40405g >a p. (asp13469asn)). conclusions: mutations in the titin gene (ttn) have been implicated in several skeletal and or cardiac phenotypes to date. each individual variant of the compound heterozygote has not been reported as pathogenic mutations and have been detected in the general population at 0.7% frequency. however, the presence of the triple count may certainly account for the severe phenotype of our probands. poster no. 110 gene-replacement therapy (grt) in spinal muscular atrophy type 1 (sma1): long-term follow-up from the onasemnogene abeparvovec phase 1/2a clinical trial objective: sma1 is a rapidly progressing neurologic disease caused by biallelic survival motor neuron 1 gene (smn1) deletion/mutation. the smn grt onasemnogene abeparvovec (formerly avxs-101; approved in us) treats the genetic root cause of sma and is designed for immediate, sustained smn protein expression. in a phase 1/2a trial (start [cl-101]; nct02122952), sma1 patients received a one-time onasemnogene abeparvovec infusion at low dose (cohort 1, n=3) or high dose (cohort 2, n=12), and demonstrated improved outcomes versus natural history. no patients in start received nusinersen during the 24-month follow-up after dosing. sma1 patients in start could rollover into a long-term follow-up study (study lt-001; nct03421977). primary objective: long-term safety. methods: sma1 patients have annual visits (5y), then phone contact (additional 10y). patient record transfers are requested. safety assessments include medical history and record review, physical examination, clinical laboratory evaluation, and pulmonary assessments. efficacy assessments include developmental milestone evaluation to determine maintenance of the highest achieved milestone in the parent study. results: as of 8 march 2019, 13 patients (cohort 1, n=3; cohort 2, n=10) had enrolled in study lt-001 and had a baseline visit. for patients in cohort 2, the mean (range) age and time since dosing were 3.9 (3.4-4.8) years and 3.7 (3.3-4.3) years, respectively. all patients in cohort 2 (10/10) were alive. no developmental milestones achieved in start were lost, and new milestones have been achieved, supporting the durability of onasemnogene abeparvovec. updated data will be presented. conclusions: one-time onasemnogene abeparvovec administration at the high dose continues to provide prolonged and durable efficacy with milestone development in lt-001. poster no. 111 micu1-myopathy: a mitochondrial disorder that mimics a congenital muscular dystrophyreport of 2 siblings with variable phenotypes m fernandez, m sa, v gowda evelina london children's hospital, london, uk objective: micu1 encodes a selective calcium-channel subunit within mitochondrial inner membrane whose function is essential for buffering cytosolic ca2+ transients and activating atp production. mutations in micu1 have been reported in 20 different families with muscle weakness, fatigability and developmental delay, with normal lactate despite being a mitochondrial disorder and persistently elevated creatine kinase (ck) usually in the range of congenital muscular dystrophies (cmd). the phenotypic spectrum is highly variable and keeps expandingother features include progressive extrapyramidal signs, learning disabilities, nystagmus and cataracts. we report the clinical features of 2 siblings from a consanguineous family with the homozygous c.1078-1g>c splicing mutation in micu1. methods: retrospective case notes review. results: sibling 1: boy, older sibling, presented aged 7 years. he had short stature which was investigated when found to have ck of 13 000iu/l. he complained of occasional cramps. muscle biopsy showed mild dystrophic changes with reduced alpha-dystroglycan that indicated a possible congenital disorder of glycosylation. his mri brain was normal. he was diagnosed with autism. sibling 2: girl, diagnosed antenatally with cerebellar hypoplasia, confirmed postnatally as inferior-vermis hypoplasia. presented at 5 years with occasional cramps, mild tightness of tendo-achilles, and ck of 3500iu/ l. her height and weight were on 2nd centile. muscle mri showed a small area of high signal in the left adductor magnus related to a group of normal vascular structures. neurophysiology studies were normal. no other systemic involvement was seen in either of them. next generation sequencing revealed the micu1 mutation described. conclusions: our work expands the phenotypical spectrum of micu1 deficiency and highlights the variability in patients within the same family. targeted analysis of the micu1 gene in patients with high ck levels resembling a cmd picture may be warranted, even in the absence of prominent muscle features. the role of dystrophin brain isoforms on early motor development and motor outcomes in young children with duchenne muscular dystrophy half of patients have central nervous system (cns) manifestations. two dystrophin isoforms, dp140 and dp71, play an important role in cns function. those lacking dp140 have a more severe cns phenotype, most marked in those lacking dp140 and dp71. our objective is to determine whether lack of dp140 and dp71 also has an adverse impact on early motor development. methods: the northstar ambulatory assessment (nsaa) is a scale of motor function. clinical information for 320 dmd participants was classified by dmd mutation location and effects on isoform expression as follows: dp140+_dp71+ (dp427 absent, dp140/dp71 present), dp140-_dp71+ (dp427/dp140 absent, dp71 present) and dp140-_dp71-(dp427/dp140/dp71 absentall isoforms affected). results: amongst 4 to 6 year olds, median total nsaa scores were lower in the dp140-_dp71+ (p=0.0088) and dp140-_dp71-groups (p=0.0001) than the dp140+_dp71+ group, most markedly in the dp140-_dp71-group. for example, for 6-year olds, median total nsaa scores were 26 (dp140+_dp71+), 23 (dp140-_dp71+) and 17 (dp140-_dp71-). amongst 4 to 6 year olds, a lower percentage of participants achieved a full score of 2 (normal, achieves goal without assistance) for the nsaa sub-items in the dp140-_dp71+ (p<0.0001) and dp140-_dp71-(p<0.0001) groups than in the dp140+_dp71+ group, most markedly in the dp140-_dp71-group. for example, amongst 4-year-olds, percentage of visits for which a full score was recorded for jump were as follows: 56% (dp140+_dp71+), 19% (dp140-_dp71+) and 0% (dp140-_dp71-). conclusions: in addition to the known cns phenotype, young dmd patients lacking dp140 also exhibit lower median total nsaa scores and greater early motor delay, most markedly seen in those lacking both dp140 and dp71 (lacking all dystrophin brain isoforms). this has important implications for patient prognostication and clinical trial design. background: most commonly known as a rare subtype of guillain-barr e, miller fisher syndrome (mfs) has evolved since it was first described in 1956. the syndrome is characterised by a triad of ophthalmoplegia, ataxia and areflexia but clinical variations do occur. it occurs more often in men than woman (ratio 2:1) with the average age of onset 43.6 years. mfs is associated with positive anti gq1b antibodies, which is concentrated in cranial nerves iii, iv and viexplaining the link with ophthalmoplegia. clinical case: we present an unusual case of a 2-year-old boy with background of macrocephaly and pre-existing developmental delay with a previous mri which showed mild signal change in periventricular white matter bilaterally. he was admitted with a subacute history of proximal muscle weakness and fatiguability. he had no obvious focal neurological signs apart from intermittent lid hopping and ptosis. differential diagnosis included myasthenia, demyelinating disorders or an underlying pre-existing luecodystrophy. anti gq1b antibodies were checked along with extensive metabolic investigations, lumbar puncture, muscle biopsy, anti-cholinesterase and antimusk antibodies along with repeat mri. all investigations were negative including mri which showed no significant change from previous. the only findings were strongly positive anti gq1b antibodies. in the interim, the patient was started on trial with pyridostigmine with significant clinical improvement. conclusion: atypical variants of mfs should be a differential in children with subtle eye signs without ophthalmoplegia. lid hopping and fatiguability should raise the suspicion of mfs and anti gq1b antibodies should be tested. pyridostigmine has been reported to be effective in mfs. potential utility of muscle mri in congenital myasthenia syndrome secondary to agrn mutation found on whole exome sequencing (wes) congenital myasthenia syndromes (cms) are caused by genetic defects affecting neuromuscular transmission, resulting in muscle weakness and fatigability. agrin, an extracellular matrix molecule released by the nerve is essential at the neuromuscular junction. the large coding gene agrn, has a number of exons and with increasing variants found on wes, it is time consuming and complex to undertake functional studies to define pathogencitiy. previous reports of agrn mutations have a phenotype with prominent distal leg weakness and changes in the soleus on mri. we describe a differing presentation and striking changes on mri, especially in the posterior compartment of the thigh. a 10-year-old presented with deterioration in his gait and difficulty climbing the stairs. he was born at term, via a normal vaginal delivery. his parents were consanguineous, and he had three well siblings. he was reported to walk by 2 years. on examination he had a waddling gait and was unable to run or hop. he had proximal weakness with a positive gowers sign, together with weak eye closure. muscle biopsy showed non-specific myopathic features, however an mri of the lower leg found widespread fatty muscle atrophy of the thigh and calf with relative preservation of the adductor longus, rectus femoris and semitendonosis. wes revealed an agrn mutation (c.5952_5963del) and a homozygous mutation in the nebulin gene (not felt to be clinically relevant). single fibre emg confirmed electrodecrement on repetitive nerve stimulation. the patient has been commenced on treatment with salbutamol. our patient had very distinctive changes on mri and nonspecific muscle biopsy changes. muscle mri changes prompted further genetic testing when symptoms fitted a clinical diagnosis of a congenital myasthenic syndrome. with increasing variants found of unknown significance in these patients, collation of mri imaging to try and elucidate patterns of changes will be important. mcardle disease (glycogen storage disease type v) is an autosomal recessive condition caused by pathogenic mutations in both copies of the muscle glycogen phosphorylase (pygm) gene encoding the muscle-specific isoform of glycogen phosphorylase, 'myophosphorylase' exclusively affecting skeletal muscle. it is the commonest form of glycogenosis. mcardle disease shows significant clinical variability, with symptoms ranging from mild discomfort during exercise to marked muscle weakness and rhabdomyolysis with myoglobinuria. the second wind phenomenon is unique to mcardle disease and consists of improved exercise tolerance with a decrease in heart rate after a rest. despite the majority of patients recalling symptoms during the first years of life, mcardle is infrequently diagnosed in children, 66% of patients being diagnosed after 20 years of age according to a recent review. here we report two patients diagnosed with mcardle disease at the age of 11 and 6 years respectively. case one presented with fatigue and inability to increase pace of walking from the age of 4. hills lead to earlier fatigue. she was able to participate in gymnastics and dancing. presentation was with fluctuating ck levels (700 to 28 000). she had no second wind phenomenon or myoglobinuria. case two presented at 6 years with a history from 18 months of reduced exercise tolerance and myalgia after low intensity physical activity with no evidence of myoglobinuria or second wind. on formal assessment there was no evidence of muscle weakness or functional impairment. ck was persistently raised ranging from 650 to 4000. in the light of symptoms and ck levels a rhabdomyolysis panel was requested in both cases leading to diagnosis. objectives: to explore characteristics of anxiety experienced by young males with duchenne muscular dystrophy (dmd) using: 1. qualitative analysis of focus group discussions with dmd boys and their parents. 2. parent-report scales of anxiety/emotional problems. methods: eight boys aged 7 to 18 years with dmd and 14 dmd parents participated in separate child and parent focus groups. perspectives on anxiety were elicited using semi-structured discussions, and framework analysis was applied to identify themes. scores on five parent-report scales were determined and scales were compared for content and sensitivity. results: from group discussions, six characteristics of anxiety were recurrently reported: catastrophic conclusions; rigidly held anxieties; extreme distress; unexpected/unfamiliar; social anxieties; physical changes and needs. many features echo the anxiety phenotype in autism spectrum disorder (asd). four further themes described relevant contextual factors: individual, family, social and environmental responses. from parent-report scales, younger dmd boys (7-11y; n=12) had significantly higher total, general and social anxiety scores compared to population means on at least two scales (p<0.01; p<0.01; p<0.05). the older dmd group (12-18y; n=6) trended towards higher scores in total, general and separation anxiety (p=0.10; p=0.06; p=0.051) compared to population norms. different scales varied in their diagnostic sensitivity and item content, which may influence their utility in dmd. conclusions: anxiety can be a pervasive and impactful issue in dmd. it appears to have some shared traits with anxiety in asd and may be influenced by situational factors, such as living with a disabling, life-limiting condition. screening with standard anxiety scales may not accurately capture the full spectrum of the phenotype in dmd, therefore further evaluation to determine optimal screening instruments in dmd is warranted. however, multi-modal assessments tailored to dmd are key to identifying those in need of support to optimise the mental well-being of young people with dmd. objective: as part of the clinical psychology service in paediatric neurology we developed a tic management group to support young people and their parents to develop positive coping in relation to their tics. the group combined psychoeducational, emotional regulation and habit reversal therapy (hrt) components. this evaluation aimed to establish the effectiveness of these groups in reducing tics and associated distress. method: twenty-eight children, aged 9 to 13 years and their parents attended one of seven tic management groups facilitated between february 2015 and november 2018. these children had been referred to the clinical psychology for support with tics. each group consisted of 5 weekly, 1-hour sessions with a review session 4 weeks later. a parent group was held in parallel. both the young persons and parent groups were facilitated by the clinical psychology team. homework tasks were provided to support hrt skill practice and consolidation of learning of the group content between sessions. the following pre and post group measures were completed by the young people and their parents: the paediatric index of emotional distress, the yale global tic severity scale, the parent tic questionnaire and session rating scales. measures were collated and descriptive data reviewed. results: 96% of children found the group was helpful in the management of tics. 57% of children were 'less bothered by their tics'. 70% of children felt more confident in controlling their tics. parents reported a greater understanding of tics and a reduction in the severity of their child's tics. conclusions: results indicate the tic management group is effective in building young peoples' understanding of tics, confidence in tic management whilst providing peer support. the findings also indicate that parents found the groups informative and valued the opportunity to share experiences with others. background: patients with epilepsy often have deficits in cognitive, physical, psychological and social functioning, and treatment should aim to alleviate these deficits. epilepsy surgery is considered for medication refractory epilepsy with aims to improve patient quality of life. a recent study highlighted the importance of a multidisciplinary workup prior to epileptic surgery, including a neuropsychiatric assessment. part of this assessment should identify patient expectations of epilepsy surgery, so that these can be addressed peri-operatively. at king's college hospital (kch), london, these assessments are routinely performed by the paediatric liaison service as part of the children's epilepsy surgery service (cess). aim: to analyse retrospective data of pre-operative patient and carer expectations between october 2018 -september 2019 at kch. methods: a record of patient and carer expectations is routinely recorded as part of kch cess neuropsychiatric assessments. the responses were compiled and analysed using qualitative content analysis. results: a preliminary survey of 12 cases with an average age of 11 (range 5-15) identified 15 responses that were grouped into broader classifications (cognitive, seizure experience, social process, school experience, mental state and general improvements). simple analysis showed carers most often expected surgery to reduce the need for medications (42%), ablate seizures (33%), increase school performance (25%), independence (25%) and overall quality of life (25%). this compared to child responses, where the most common expectations were a reduction in lifestyle restrictions (42%), a cure for epilepsy (33%), decrease in medications (25%) and increased independence (25%). conclusion: consideration of both child and carer expectations during pre-epilepsy surgery neuropsychiatric assessments is important in order for services to manage each individual's expectations. unmanaged unrealistic expectations may lead to a negative psychological outcome for either child or carer. expectations should be weighed up against an individual's clinical profile. poster no. 119 neural correlates of conversion hemianaesthesia in an adolescent: a novel fmri case study m ray, a zaman, t alam leeds teaching hospital nhs trust, leeds, uk aim: to highlight the novel functional magnetic resonance imaging (fmri) findings in an adolescent with rare conversion hemianaesthesia. methods: we hereby report a right-handed 14y old boy who presented with inability to perceive sensations on the right half of body without any motor weakness causing him to have frequent injuries on his right leg as well as burns on his right hand without realizing. when he wore a jacket, he felt warm on one side of the body more than the other. his birth and developmental history were non-contributory. neurological examination was unremarkable except for right hemisensory disturbance. the mri of brain and spine, peripheral nerve conduction studies and somatosensory evoked potentials did not show any evidence of dysfunction were normal. he underwent fmri on a 3t philips achieva. the paradigm consisted of stimulating both the right and left hands and feet with three dissimilar stimuli (cold, brushing, pin-prick-pain) . the order of the stimuli was pseudorandomised and after each stimuli delivery, feedback was obtained. results: both the hand and foot sensory motor cortices were successfully stimulated. irrespective of which hand was being stimulated, there was left hemisphere sensory motor cortex dominance (with the brushing and cold stimuli), however selfreport from the participant confirmed detection of stimuli on the left-side only. there was more sensory-motor activation when the stimuli were delivered to the right hand. pain stimuli successfully activated parts of the 'pain matrix', furthermore enhanced attention effects (frontal pole activations) were observed with right-sided stimulation (supports lack of stimuli detection ability). the pain stimuli were more effective on the hands than foot, reflected by increasing activation and also self-report from the participant. conclusions: the fmri findings are unique and support the evidence of neuroplasticity and the current study paves the way for future studies investigating conversion hemianaesthesia. poster no. 120 chronic paroxysmal hemicrania presenting as facial pain in a child with autism and bipolar disorder: diagnostic challenges case presentation: a boy diagnosed with disintegrative psychosis aged 3, revised to autism with bipolar disorder, had been on carbamazepine with risperidone for poor mood control. withdrawal of risperidone produced tardive oromotor diskinesia responsive to clonidine. aged 11, when mood improved on aripiprazole, carbamazepine was withdrawn. he then presented with episodes of distress preceded by withdrawal, unilateral but not side-locked facial flushing, with additional flushing of neck, back and wrists. behaviours included hitting wrists off walls, chewing of hard objects and requesting pressure to his head. episodes occurred 8-9 times/ day, lasting 2-60 minutes. he showed rhinorrhea and tearing, attributed to crying, during events. the attacks self-terminated. results: mri and electroencephalogram were normal. failed pharmacological trials included paracetamol, amitriptyline, gabapentin and oxcarbazepine. diclofenac provided mild pain relief and morphine reduced the incidence of attacks. reintroduction of carbamazepine resulted in improvement at 30mg/kg/day but did not eliminate pain. sequencing of scn9a was normal. a plan to wean morphine alongside a trial of indometacin, initially at 25mg twice-daily was successful at 50mg twice-daily. episodes ceased, including all autonomic features. exacerbation at 4 weeks occurred in context of an intercurrent illness and was managed with an additional dose of indometacin. conclusions: cph is underreported in the paediatric age group. in our case, the patient's inability to describe events, and an additional psychiatric diagnosis added complexity. the possibility of pain as a cause for early psychotic breakdown in a developmentally vulnerable child cannot be excluded. criteria emphasising side-locked headache and autonomic features, and not recognising associated symptoms elsewhere may also delay recognition in children. objectives: piih can be a challenging condition to diagnose and manage with risks of misdiagnosis, permanent sight loss and frequent comorbidities. we aimed to review our practice to identify areas of uncertainty to help formulate important questions to address within a clinical guideline. methods: a single centre retrospective case notes review of all cases referred to neurology with suspected piih (papilloedema confirmed by a consultant ophthalmologist in all cases) during an 18-month period. results: 14 (12f: 2m) cases were identified. age range 8 to 15 years. mean 13 years. 8/12 had a bmi >98th centile. one case was referred to an obesity service. 6/14 had a comorbid headache disorder and 4/14 had anxiety/depression. all cases had neuroimaging (13 mri, 1 ct) with 4/14 having dedicated venography. in 2/14 cases lumbar punctures (lp) were conducted under general anaesthesia (ga). in 4/14 cases lp was not done; 2 due to presence of a chiari malformation and 2 due to procedural failure related to body habitus. intracranial pressure (icp) monitoring was done in one of these four cases. all children were treated with acetazolamide as first line therapy. frusemide, zonisamide and topiramate were also used in single cases. 5/14 children had repeat lps due to failure of resolution of symptoms. 2/14 cases had sight threatening piih with permanent visual loss in one case. 5/14 cases were discussed with neurosurgery. one child with evolving visual failure had an emergency ventriculo-peritoneal shunt. conclusions: important questions raised were: should all obese children with piih have access to a specialised obesity service? should all children have dedicated venographic imaging? how reliable is measuring csf opening pressure under ga? where lp is not possible should icp monitoring always be done? should repeat lps be done for persistent symptoms? should csf diversion surgery be restricted to cases of sight threatening piih only? objective: to describe a case of revesz syndrome due to a de novo missense variant in tinf2. case report: a male infant was born at 35 weeks gestation by emergency lscs due to maternal hypertension and reduced amniotic fluid. from 32 week's gestation, reduced fetal growth was identified. the proband was born by at 35 weeks. birth weight was 1.7kg (0.4th-2nd centile) and occipitofrontal circumference (ofc) was 31.7cm (2nd-9th centile). he spent 15 days in the scbu. he developed thrombocytopenia (nadir: 679109/l), which resolved pre-discharge. periventricular calcifications on cranial ultrasound prompted torch screen and ophthalmology review. a right pre-retinal haemorrhage with overlying organised vitreous haemorrhage was identified, which remained stable on subsequent reviews. aged 8 weeks, he was smiling, fixing and following with good head control. aged 5 months, he developed new wobbly eye movements and was no longer fixing or following. bilateral retinal detachments were identified. ct and subsequent mri showed diffuse calcification within the thalami, posterior limb of the internal capsule, deep white matter, cerebellar atrophy and thin corpus callosum. findings on examination included ofc of 0.4th centile, rotatory nystagmus and central hypotonia. whole-exome sequencing identified a pathogenic de novo variant in tinf2 (c.845g>a, p.arg282his). he subsequently developed thrombocytopenia and anaemia and is transfusion dependent. discussion: trf1 interacting nuclear factor-2 (tinf2), protein regulates telomerase and prevents telomere shortening. revesz syndrome is a severe form of dyskeratosis congentia, with multi-system involvement and early onset in-utero. revesz syndrome is characterised by intrauterine growth retardation (iugr), microcephaly, cerebellar hypoplasia, bilateral exudative retinopathy, intracranial calcifications and progressive bone marrow failure. revesz syndrome is distinguished from hoyeraal-hreidarsson syndrome by the presence of retinopathy. telomere disorders should be considered in infants with a background of iugr, thrombocytopenia, retinopathy and intra-cranial calcifications with a negative torch screen, as early features mimic congenital infection. objective: currently the most commonly reported neurological complication of sca is overt stroke. reversible cerebral vasoconstriction syndrome may be more frequent in patients with sickle cell anaemia than reported at present. the scarcity of prevalence studies however makes it difficult to improve diagnostic accuracy in these patients. methods: a 16-year-old ghanaian female was rushed to the paediatric emergency room with first episode of sudden severe global headaches initially started 8 hours prior to arrival. the headache was so excruciating that she described it as her heart was beating in her head. there was associated neck pain, back pain, dizziness, and vomiting. there was no fever or dark urine. she was first diagnosed with sickle cell anaemia (genotype ss) at 2 years of age after she was treated for dactilitis. she had since then been in her usual state of health with no history of blood transfusions or surgeries or admissions. she was compliant with her medications (folic acid 5 mg daily). a physical examination and all investigations were also normal. on day six of admission patient had a generalized tonic clonic seizure with some degree of left sided weakness after having her bath. this was aborted with intravenous diazepam and a magnetic resonance imaging (mri) of the brain was requested. the mri of the brain revealed diffuse narrowing of the cerebral arteries with no areas of bleeding or oedema. reversible cerebral vasoconstriction syndrome was therefore suspected. results: the headache rapidly improved after starting nimodipine and repeat angiography at 3 months showed no vasoconstriction, confirming the diagnosis. on follow up she is doing well academically with no neurological deficits. conclusions: the true incidence of rcvs in patients with sickle cell is uncertain, thus sensitizing medical practitioners is important. introduction: status dystonicus (sd) is a life-threatening disorder of generalised, painful dystonic movements and muscular spasm in patients with severe neurodisability. while rare, it may be complicated by rhabdomyolysis, multi-organ dysfunction, and death. infection, pain, gord, and medication failure are common triggers, but in approximately one-third of cases, sd is idiopathic. mordekar et al. (2017) identified a series of 11 patients in whom sd occurred secondary to gi dysfunction. assisted feeding (e.g., via gastrostomy), and aberrant bowel peristalsis may trigger the onset of sd. this was a retrospective analysis which aimed to estimate an incidence rate for feed-induced sd (fisd). methods: patients presenting to sheffield children's hospital over a 5-year period with sd were identified. episodes were studied to assess for the nature of the onset of sd and as to the likelihood that the trigger was feed related. incidence of fisd as a proportion of total sd was calculated and or calculation performed to explore relative risk of sd between individual trigger factors. results: twenty-four individual episodes of sd were identified. 13 (54%) arose from non-feed-related sources (nfisd), and 11 were felt to be fisd (46%). 6 additional patients were entered into a feed-induced dystonia (fid) group, whom showed clinical evidence of dystonia in relation to gi sources, but not sd. with the exception of infection, the relative risk of sd secondary to gi dysfunction was significantly higher than pain/gord and medication failure combined (or 0.11 (95% ci 0.02-0.56) and 0.05 (95% ci 0.01-0.44) respectively). conclusion: gi dysfunction coupled with severe neurodisability could serve as a trigger in a number of previously idiopathic sd cases through disruption of the neuro-enteric axis. however, overlap between triggers for fisd and nfisd, and significant variation between groups is evident, in addition to a lack of statistical study power. large, prospective studies are needed in the future to corroborate with these findings. poster no. 125 dystonia can twist the patient, physician and the scans: hypermanganesemia, a rare cause of dystonia in children r kumar, s ali liaqat national hospital, karachi, pakistan introduction: manganese (mn) is a chemical element with symbol mn and atomic number 25. mn in the environment can cause toxicity with dystonia and other movement disorders. waterborne mn has a greater bioavailability than dietary manganese. according to results from a 2010 study, higher levels of exposure to mn in drinking water are associated with increased intellectual impairment and reduced intelligence quotients in school-age children. we have recently reported a suspected autosomal recessively inherited syndrome of hepatic cirrhosis, dystonia, polycythemia, and hypermanganesemia in cases without environmental mn exposure. the rarity of the disease can become a challenge for the physicians to recognize this as a cause of dystonia in children. it also has a characteristic finding on mri with t1 hyperintensity in basal ganglia rather than on t2. case report: we present a case of a 6-year-old girl with dystonia who was previously healthy. she has been suffering from this for the last 6 months and currently one of her 4 years old sister started showing similar symptoms. physical examination revealed marked dystonia (score of 24 on baryalbright dystonia scale) and polycythemia (haematocrit 65). magnetic resonance imaging (mri) brain showed basal ganglia hyperintensity on t1 weighted images. hypermanganesemia was suspected and samples send for serum level which came out to be high. water samples were tested, which came out to be normal. chelation was done and the dystonia improved. conclusions: dystonia in children should be thoroughly investigated and rare, treatable causes should not be ignored. objectives: sodium valproate is used primarily for the treatment of epilepsy in children. it is a well-established teratogen, with 4 in 10 babies at risk of developmental disorders and 1 in 10 babies at risk of birth defects. this risk has been known since the 1970s and yet it is estimated that since then 20 000 children in the uk have been left with disabilities as a result. in 2016, the medicines and healthcare products regulatory agency released guidance for its use, which included a risk acknowledgement form. patient safety alerts were issued in 2017 asking all organisations to identify females taking this medication. we aimed to identify all girls taking sodium valproate in the south eastern trust under paediatrics requiring annual risk assessment; patients under the additional care of a neurologist; patients receiving an annual review. methods: patients were identified through paediatric epilepsy nurse records and data collected through the electronic care record and medical notes from august 2018 to december 2018. results: 24% (n=30) of girls with epilepsy currently taking sodium valproate, 73% under the age of 10 years, 37% profound learning difficulties/disability and considered to be at low risk of pregnancy, 7% (n=2) potentially currently at risk, 81% were under the additional care of a neurologist, 87% reviewed in the past year. conclusions: sodium valproate must not be considered first line treatment in girls with epilepsy and >75% of girls in our trust are not receiving it. of those receiving it, the majority are felt to be low risk due to young age and/or profound disability. we identified two patients at risk and steps were taken to ameliorate this. we have demonstrated good awareness; however lifelong education of families is crucial to reducing the burden of fetal valproate syndrome. rett syndrome (rtt) is neurodevelopmental disorder affecting approximately 1 in 10 000-15 000 live female births, most commonly associated with mutations in the mecp2 gene. hand stereotypies and gait disturbance, as well as spasticity and dystonia, have been noted in rtt since the first descriptions of the syndrome. objective: this review aimed to explore the prevalence of reported movement disorders in rtt. data sources and extraction: pubmed and embase databases for papers describing features of movement disorders in rett syndrome. papers were selected for inclusion to be reviewed if they included description of case report, cohort or case-series of patients with rtt which included a description of clinical features of their movement disorder. selected papers were divided into 3 epochs: (i) pre-1999, (ii) 2000 to 2009, and (iii) 2010 onwards. results: 32 studies (13 in the first epoch, 10 in the second epoch and 9 in the third epoch) reported on movement disorders including stereotypies in rtt patients. hand stereotypies were almost universal in reported cases, diminishing but not disappearing over time. gait disturbance and ataxia/tremor were also very common (>50% cases). elements of hypertonia were also common, increasing with age. in earlier descriptions spasticity was commonly described, with more frequent reference to dystonia/rigidity in more recent reports. myoclonus and choreoathetosis are uncommonly reported in rtt. conclusions: movement disorders beyond hand stereotypies are common in rtt, most notably tremor. hypertonia is a common feature seen in rtt, increasing in prevalence with age, and with an apparent change in nomenclature over time, (i.e., early epoch spasticity, late epoch dystonia). dystonia was specifically reported in 229/417 cases. further work is required to explore the relative contribution of dystonia and rigidity to hypertonia in rtt, as well as the impact of these impairments when present. introduction: headache is the common complaint in children, and the source of it, a great deal of worry for general practitioners and parents. one of the commonest causes of headache in paediatrics is migraine. methods: a prospective study was conducted to evaluate the demographic data, clinical spectrum and grading the child with migraine by using the paediatrics migraine disability assessment (ped-midas) questionnaire and to start prophylactic treatment for those with the higher grades in the department of paediatrics in tertiary care hospital. all children with migraine from age 5 to 18 years were included while all other types of headache cases were excluded. results: total 112 children with migraine were studied. approximately 80% children complained of bilateral frontotemporal headache in which 69.64% presented with throbbing type. other associated features were photophobia, phonophobia, nausea and vomiting. 75% had skipped meal, followed by altered sleep and exam stress as aggravating factors. 94.6% required medication for headache relief. headache duration and frequency was approx. 17 days and 9 days/month. 57.1% cases were diagnosed migraine without aura and 42.9% cases were diagnosed as migraine with aura. loss of full school days due to headache was approx. 2 days for period of 3 months. based on ped-midas score, 50% of children with migraine had grade i disability while 42.9% and 7.10% cases had grade ii and grade iii disability respectively. correlation of ped-midas score with frequency and severity were significant (p<0.001) while with duration of headache was insignificant (p<0.245). conclusions: all patients with higher ped-midas grade are warranted prophylactic treatment. both ped-midas scores and grading can be successfully used for assessing the migraine disability and its easier, less time consuming, bedside diagnostic tool, can be used widely in routine clinical evaluation and management. objective: to review the cases referred to this uk-wide study of children with possible variant creutzfeldt-jakob disease (vcjd) and report the differential diagnosis in children presenting age 10 years or older. methods: children meeting the case definition for progressive intellectual and neurological deterioration (pind) were identified via the british paediatric surveillance unit. details were obtained by standard questionnaire. results: between april 1997 and august 2019, 4589 children had been notified to the study. 2068 were found not to meet the pind case definition. 2006 had an underlying diagnosis to explain their deterioration, with over 210 different disorders including 6 vcjd cases (the last identified in 2000). there were 104 children who presented to clinicians when aged 10 years or over, including all the 6 vcjd cases. of the other disorders in this age group the commonest were: mitochondrial cytopathy 16, adrenoleukodystrophy 9, lafora body disease 8, huntington's disease 7, neuronal-ceroid lipofuscinoses 6, niemann-pick type c 6, metachromatic leukodystrophy 4, sspe 4, wilson's disease 4. when reviewed in 2017 there was no underlying diagnosis in 225 pind cases; 108 of them had diedonly 14 underwent autopsy. the recent identification of the first patient with vcjd who was mv heterozygous at prnp codon 129 reinforces the need for continued vcjd surveillance, particularly as a study of archived appendix samples from uk hospitals published in 2013 indicated that approximately 1 in 2000 of the uk population is carrying abnormal prion protein in the gastrointestinal tract. in the absence of a validated vcjd screening test the pind study remains the only means of performing systematic surveillance of the neurodegenerative diseases that make up the differential diagnosis of vcjd. objective: transient lesions in the splenium of corpus callosum (scc) are rare findings in mri brain in paediatrics. in literature, it has been described as reversible splenial lesions syndrome (resles) and mild encephalitis/encephalopathy with reversible splenial lesions (mers). the condition has diverse aetiology and widely variable neurological presentation but the prognosis is usually favourable. we present two cases of resles with predominantly expressive dysphasia but varying causal associations. method: retrospective review of resles case series exploring clinical course, investigations, neuroimaging, treatment and recovery. result: case 1: a 15 year-old-girl presented with confusion, fever and low oxygen saturation. she had alagille syndrome and partially corrected tetralogy of fallot. her neurological manifestations were expressive dysphasia, dysarthria and difficulties with spatial awareness. interestingly she was able to use occasional words that were abusive in nature. mri showed prominent focus of abnormal signal and restricted diffusion in scc. her blood culture grew staphylococcus aureus and echo revealed infected shunt. treatment involved shunt replacement and prolonged iv antibiotics. repeat mri showed resolution of splenial lesions. she continued to improve neurologically. case 2: a 9 year-old-girl presented with paroxysmal episodes of head turning, head drop and staring for a few seconds. she refused to feed. she showed emotional lability with expressive dysphasia but preservation of expletives. neurologically she was intact. mri brain showed high signal with restricted diffusion in scc. her blood and csf investigations including mog, aquaporin, nmdar, lyme antibodies were negative except asot was 400. her eeg was normal. she received a course of ivig and azithromycin. her repeat mri showed resolution of the lesion in splenium. she made complete recovery over next few months. conclusion: splenial lesions are rare but clinically significant but not 'non-specific'. expressive dysphasia is a prominent symptom. awareness of resles/mers will avoid unnecessary investigations and assist in the prognostication. background: the evidence-base on managing paediatric-headaches is sparse resulting in wide variation in practice with nice guidelines commencing over 12 years of age. this study aims to evaluate outpatient management of paediatric headaches. objective: to investigate paediatric headache referrals to a tertiary hospital over a 1-year period, exploring patient demographics, headache type, role of neuroimaging, management and outcome. methods: this prospective study reviewed headache referrals for the year 2018-2019. the data was collected following weekly emails to relevant clinicians. the patient demographics, headache classification, imaging, management and outcome were collated on a proforma from the electronic patient-records. results: there were 99 patients. the median age of patients at first outpatient appointment was 12 years (range 3-17y); 63.6% were female. incidence of headaches increased with age. female preponderance of headaches existed in all age groups and was most substantial post-puberty with a 2.4:1 female-to-male ratio in patients aged 13 to 17 years. migraine was the most common diagnosis, affecting 46.5% of patients. 51% of referred patients underwent a brain mri scan, all of whom had a normal neurological examination. no mri scans found pathology contributing to headache presentation. 91% of patients were discharged from neurology clinic after first or second neurology appointment. non-pharmacological management was the most common intervention and consisted of: headache diary, lifestyle advice, education, relaxation techniques. the most common medications prescribed bar simple analgesia were sumatriptan (12%), propranolol (9%) and pizotifen (9%). conclusions: a multidisciplinary and biopsychosocial approach to managing paediatric headaches, consisting of non-pharmacological and pharmacological methods resulted in a positive outcome, with majority discharged from tertiary care after first appointment. prescription of sumatriptan and propranolol first line for acute and prophylactic management respectively, was in accordance with current clinical recommendations. the role of mri scanning for paediatric headaches requires further exploration and perhaps more stringent guidelines. objective: the head-up tilt test (hutt) is the gold standard autonomic function test for identifying disorders of blood pressure (bp) and heart rate (hr) regulation, specifically with excessive falls in bp and or hr, as well as excessive postural tachycardia (pt). the 10 minute active standing test (ast) is quicker and easier to apply, e.g., in an outpatient clinic, and may be more sensitive in demonstrating pt. we aimed to compare the yield of these abnormalities when using ast vs hutt. methods: this was a retrospective, clinical notes review, and registered clinical audit of unselected consecutive children and young people undergoing hutt immediately preceded by an ast. results: data was available on 86 children and young people, 56 (67%) female, aged 3 to 18 years (median 14). 12/84 (14%) with complete data sets for the first 10 minutes of hutt and the ast had abnormally large drops in bp and or hr on hutt. only 1/12 positive on hutt was also positive on ast. however, an additional 6/84 (7%) were positive on ast but not on hutt, giving 18/84 (21%) positive in total. 8/86 (9%) with hr data sets for 10 minute hutt and ast had abnormally large rises in hr on hutt. only 3/8 positive on hutt were also positive on ast. however, an additional 10/86 (12%) were positive on ast but not on hutt, giving 18/86 (21%) positive in total. while hutt yielded more cases with significant falls in bp and or hr than ast (14% vs 8%), combining the tests gave the highest yield (21%). while ast yielded more cases with significant rises in hr than hutt (15% vs 9%), combining the tests gave the highest yield (21%). conclusions: we recommend routinely undertaking a 10 minute ast prior to the 45 minute 60°hutt, in children and young people. objective: the aim of our work is to describe the respiratory function trajectories and their correlation with motor function in a cohort of spinal muscular atrophy type 2 and non-ambulant sma3 paediatric patients. methods: this is a retrospective 9-year study in patients recruited in the ismac natural history study (uk, italy, us). the following respiratory data were collected: lung function data (forced vital capacity absolute (fvc) and fvc% predicted, non-invasive ventilation (niv) requirement. recumbent or ulnar length were used as surrogate for height in fvc%pred. calculation. comorbidities affecting lung function such as aspiration were collected. anthropometrics and motor function scores as hammersmith functional motor scale (hfms), revised performance of upper limb (rulm) were noted. we excluded patients in interventional clinical trials and nusinersen therapy. results: data were available for 437 patients: 348 sma2, 89 sma3. mean age at first visit was 6.9 (ae4.4) and 11.1 (ae4) years for sma2 and 3. 180/215 (84%) sma2 and 39/49 of significant lesions. a review of practice of asking routine or non-urgent mri requests should be considered in view of an unlikely significant result. retrospective review of brain magnetic resonance imaging referrals in children less than 12 years (r[20] ) is an ultrarare disease characterised by drug-refractory epilepsy, cognitive impairment and behavioural problems. non-pharmacological treatments should be considered alongside antiepileptic drugs (aeds) early after diagnosis to benefit prompt seizure control and preserve cognitive function. we aimed to understand the use and experience of ketogenic diet therapy (kdt) in r(20) by patients families carers (pfcs) and healthcare professionals (hcps), assessing its efficacy and safety, and contrasting nhs kdt service provision with patient demand. methods: literature searches were conducted on use of kdt in r(20) and similar complex epilepsies. two surveys were developed to gather demographic, diagnostic and clinical care information. surveys were qualitative and descriptive with patient and expert collaborators assessing content accuracy and readability. responses were discussed at a patient and expert workshop. results: the number of responses (42 pfcs, 23 hcps) was considered significant given the ultra-rare status of r(20). 50% of pfcs had tried kdt. seizure activity, behaviour and cognitive outcomes were ranked equally important by hcps and pfcs. significant improvement in seizure activity, cognition and alertness were reported; side-effects were typically mild but with one report of increased seizure frequency. the high rate of comorbidities, older age at presentation, behavioural problems and cognitive impairment can make implementing kdt in r(20) challenging. pfcs report quality of life would be most improved with reduced aed side-effects; hcps report they would consider reducing or withdrawing aeds where kdt is successful. conclusions: kdt may not be suitable for every r(20) patient, but there is a strong consensus that it should be considered as an early intervention. in the uk, nhs kdt services are predominantly available for paediatric patients, with very limited adult access. a detailed health economic analysis illustrating reduced acute care costs and improved quality of life may encourage more widespread kdt implementation. objectives: whole exome sequencing (wes) with a 2-week result turnaround time has become available on the nhs for children in an intensive care setting. we aimed to determine the diagnostic utility and impact on clinical care of wes in a regional paediatric neurology centre. methods: retrospective case notes review. results: six cases (4m, 2f) were identified. three patients were dependent on long-term respiratory support. a pathogenic mutation was detected on wes in 5/6 cases (83%). one case required 'reverse phenotyping' with an abnormal transferrin glycoform electrophoresis confirming that two heterozygote variants of the rtf1 gene were consistent with a congenital disorder of glycosylation (cdg). no other variants of unknown significance were found. three children presented with neonatal onset epileptic encephalopathy (two cases had scn2a, one case wwox), one child with intractable epilepsy from 2 months of age (rft1 mutation associated with cdg) and one child with hypotonia and ventilator dependence after a respiratory infection at 4 months of age (ighmbp2 mutation associated with spinal muscular atrophy with respiratory distress). wes found no pathogenic mutation in a 3-year-old with intracranial calcification, microcephaly, epileptic encephalopathy and severe developmental regression. in 5/6 cases other single genes/panels had been sent prior to initiation of wes with multiple single genes/panels sent in 3/6 cases. in 3/6 cases wes detected the gene thought most likely based on clinical phenotyping on the request form. conclusions: wes has a high diagnostic yield in this cohort of patients. reaching a prompt diagnosis facilitated withdrawal of care in one case (ighmbp2) and helped to exclude an epilepsy surgery hypothesis in four cases as well as guide prognosis in all cases. wes should be considered as a cost-effective alternative when multiple single genes and/or genetic panels are being sent off in parallel due to clinical urgency. objective: the care provided in the time surrounding the death of a child shapes long-term memories and has potential to impact on the grieving process. there are no specific guidelines for picu staff in relation to what good care looks like at this time. we sought insight into practice across the uk to build an evidence base, improve care provided and share good practice. conclusions: from the survey feedback, we found this was an area that all units believe can be improved. in relation to acps, we hope this will be more widely introduced. we know that 60% of patients admitted to picu are life limited. these difficult conversations with family help guide management, understand wishes, and formal documentation ensures all staff are aware. several units with higher uptake of hospice/home care found early conversations with families beneficial. units with a dedicated palliative nurse stated this allowed more time with families. we believe this should become a standard of care. staff training is limited in most units. for something so difficult and frequently encountered, it is vital we equip staff better. prioritising children with epilepsy in the first seizure clinic cp white, s brown, ka hapgood, s tuohy children's epilepsy service, morriston hospital, swansea, uk objective: rising demand for limited first seizure clinic appointments was leading to increasing waiting times and the feeling that children with epilepsy were waiting too long for their first assessment. concern was also expressed that families were not receiving our first seizure leaflet or given instructions about capturing any further episodes either on video or by making a written record when initially seen. methods: from april 2018 all families were sent a letter acknowledging the referral and asking them to contact the specialist epilepsy nurse if they had any concerns prior to the appointment. later modifications included a seizure information leaflet and a seizure record document. we have analysed the results of the first year of using this system. patients were identified from the clinic database and further information was obtained by reviewing clinic letters. results: our initial concern that the specialist nurse would be inundated with phone calls from worried parents were not realised as only 13% (14/104) of parents contacted the service before their appointment. these were invariably parents whose children had had a second episode (10/14). 8 had had further generalised tonic clonic seizures. 11 children had eegs performed before their first appointment. this included all the children given a diagnosis of epilepsy. 71% of these children (10/14) were given a diagnosis of epilepsy made compared to 19.5% of other referrals (p<0.01). although a higher percentage of families who were reminded about videoing any further episodes did so the difference between the two groups was not statistically significant. unfortunately, overall waiting times were not affected. conclusions: a simple change to the way in which the service is delivered has led to earlier identification of those children with epilepsy. we are looking at other ways of improving the accuracy and timeliness of the appointments. introduction: paediatric idiopathic intracranial hypertension (iih) is an uncommon disorder and presentation is varied with children presenting to paediatricians, paediatric neurologist, and ophthalmologists. there are many areas of diagnosis and management where evidence is limited. a national adult evidence and consensus-based guideline was published in 2018. no national paediatric guideline exists to aid the further investigations and management of the cases. the iih meeting at the bpna conference in 2017 and january 2019 set the scene for collaborative work on this topic. aim: to develop a national paediatric iih guideline based on the available literature such as modified dandy criteria, friedman 2013 classification and icdh-3 classification and consensus amongst various members of bpna chan group, members of rcpch, ophthalmology, neurosurgery and radiology, and patients. methods: a core children's headache iih guideline development group was established and has met at four national special interest group meetings between november 2017 and september 2019. topics discussed include incidence of papillioedmea, csf dynamics in iih, bpnsu iih data, ophthalmology good practice, regional iih pathways in uk and setting up of the delphi process. the paediatric iih study day in september 2019 with invited patient/parent representatives highlighted the impact on families with the disorder with need for better communication about the disorder, clear guidelines and sharing of good practice amongst clinicians. an email list of bpna chan group, rcpch members, ophthalmologists interested in the guideline was created. results: a set of 55 statements were drafted for delphi consensus work. these are currently being reviewed by the core guideline development group prior to being circulated to the wider working group. conclusions: goal setting for the next process with the delphi process to work with the core committee and a wider working group will be presented at the bpna conference 2020. objective: nhs england's marginal rate emergency threshold (mret) and readmission fund funded the chameleon project 2018 (twitter account: @chameleonproje1), to improve children's end of life care. this funded a lead disability paediatrician with expertise in paediatric palliative care (10h/wk), a children's palliative care nurse (3d/wk) a network administrator (2d/wk), and additional hours for paediatricians in the critical care, oncology, and neonatal units, and in each of the local district general hospitals (total 18h/wk). methods: tools were developed to aid identification of children in the last year of life and to support anticipatory care planning. the team attended ward rounds and provided teaching sessions, advice and support. children who died an expected death in the 12 months of the project were ascertained from the child death review teams. non-elective admissions, bed days, and costs were tabulated. we also evaluated the documentation of care plans and post bereavement family feedback questionnaires. results: 29 children died an expected death. the same number died during the previous 12 months. the median number of non-elective admissions reduced from 2 to 1 per child, specialist ward bed days reduced from 504 to 251 (50% reduction). for children admitted to picu in the last 12 months of life, the total picu bed days reduced from 342 to 184 (46% reduction), the median length of stay reduced from 21 days to 11 days, and the maximum length of stay reduced from 141 days to 38 days. the percentage of children who died an expected death who had documented anticipatory care plans rose from 50% to 72%. conclusions: the network of clinicians with expertise in paediatric palliative care working together across a region improved anticipatory care planning and reduced admissions and bed days for children in their last year of life: better care with reduced costs. child a, a boy with speech and language delay, presented at 2 years of age with self-resolving episodes of floppiness, ataxia, and disorientation. there was associated muscle weakness and drooling. these unusual episodes occurred 3 to 4 times per week and were often triggered by excitement, especially physical and emotional overstimulation. they lasted from a few minutes to an hour, with no residual deficit. episodes could also be triggered by having late meals (fasting episodes). investigations including an mri/mra brain, eeg, sleepdeprived eeg and video telemetry did not reveal any significant abnormalities. metabolic and endocrine tests were normal. as his presenting symptoms were consistent with episodic ataxia, possibly a periodic paralysis spectrum, a trial of acetazolamide was given, which showed some improvement in the number and severity of the episodes. at 8 years of age, genetic sequencing results revealed child a has a recessive 23kb deletion within the long arm of chromosome 22, band q11.21. this is a homozygous intragenic deletion within the tango2 gene. tango2 is a 'transport and golgi organization 2' homolog. the function of tango2 is unknown; however, in previous studies, depletion in drosophila s2 tissue culture cells was observed to cause fusion of the golgi with the er. a recent study of 14 individuals with tango2, illustrated that child a has a clinical phenotype which is consistent with those previously reported in the literature. although seizures are present in 75% of individuals with tango2, child a has not had any seizures to date. although no effective treatments for this rare condition are known, early diagnosis is important so that individuals and their families are aware of the potential encephalomyopathic crises and arrhythmias which occur. further research in elucidating the structure and function of the tango2 protein may lead to effective therapies in the future. objective: hie affects around 1.68/1000 live births. prognostication relies on clinical progress, neurophysiology, neurological examination, and magnetic resonance imaging (mri). there is limited information on the relationships between mrs brain results and visual appearances of the brain on mri and clinical features. this work studied the use of mrs in this cohort. methods: mrs is used routinely in all neonates with hie in our unit, so approval for this service evaluation was obtained from our clinical governance department. we identified neonates with hie between jan 2010 and march 2016 who had mri and mrs in the first 7 days of life. medical notes were reviewed, and mri results categorised as normal or abnormal. mrs results and clinical features were compared between mri groups using parametric or non-parametric testing. correlation and regression analyses studied relationships between clinical features and mrs results. p-values of <0.05 were assumed to be significant. results: 82 participants were identified, 19 were excluded because they did not meet our inclusion criteria. data from a total number of 63 neonates were analysed using r studio. babies with abnormal mri scans had significantly lower birth weight (p=0.018), gestational age (p=0.037), and higher scores in the sarnat staging scale (p=0.04). the analysis of the mrs data also revealed that these babies had lower levels of n-acetylaspartate (naa) in their parieto-occipital region (p=0.006), as well as higher levels of lactate and lactate to choline both in the parietooccipital region (p=0.032 and p=0.007 respectively). finally, these significant mrs variables were significantly correlated with time to normalisation of lactate in single linear regression. background: more children and young people are surviving with an acquired central nervous system injury (traumatic or non-traumatic). the first nhs england (nhse) specialist specification for paediatric neurorehabilitation services was written in 2013. evidence for benefits of early neurorehabilitaion after adult stroke are compellingevidence for early neurorehabilitation in cyp is emerging. methods: service information was collected from all england and wales pnr units in 2019. results: 15/17 units contributed. activity is increasing (464 (2012/13); 530 (2013/14); 595 (2014/15). 10/17 (60%) are major trauma units (50%) have dedicated coordinators. several units cannot offer daily therapy. most units discharge cyp home. conclusions: considerable neurorehabilitation in-patient activity is taking place but there remains an absence of secure funding, adequate staff, dedicated beds, key members of the mdt, protected time for pro-active patient specific discharge planning. neurorehabilitation is an integral part of the neuroscience clinical pathway and our children deserve a fully resourced service as described in the service specification. tuberculosis/sarcoidosis (1). out of the sub-categories, the group of refractory seizures/status epilepticus were most likely to have repeated imaging with either ct or mri within 3 years (80%), followed by the group of ventriculo-peritoneal shunt blockage (77%), space occupying lesion (20%) then head injury (14%). out of 5 patients with refractory seizures/ status epilepticus, 4 were already known to have epilepsy. also, most repeated imaging included a subsequent head mri. conclusions: most common indications for ct head were head injury and shunt blockage (as this was a neurosurgical centre). the groups most likely to have repeated imaging were refractory seizures/status epilepticus and shunt blockage. with children presenting with known epileptic seizures in the emergency department, it is important to consider clinical data and seek to devolve decision to image. poster no. 150 isolated radial nerve palsy, a rare presentation of congenital wrist drop c duggan, n mcsweeney cork university hospital, cork, ireland isolated congenital radial nerve palsies are a rare phenomenon and typically spontaneously recover within 6 months. the true incidence is not known, but in a recent study 2.6% of infants presenting to a brachial plexus injury clinic had an isolated congenital radial nerve palsy. patient a is a 10-week-old male who presented at birth with a left sided wrist drop following a non-traumatic elective caesarean section at 38+5/40. his birthweight was 4.23kg (91st centile). movement of the wrist and digits were impaired to absent with preservation of function at the shoulder and elbow. there was a nodule noted in the left upper limb, anatomically superficial to the radial nerve. it was a normal pregnancy with no antenatal or postnatal issues. he attended physiotherapy and occupational therapy who provided a splint. on examination at 10 weeks, there was weakness of the extensors of the left wrist. the 3rd, 4th and 5th digits remained fully flexed at rest and could be extended passively but not actively. extension of the thumb and index finger had recovered at 10-week review. function at the shoulder and elbow joints were preserved with normal flexion of the wrist and digits. a scar was noted superficial to the radial nerve at the same location as the lesion described at birth. the remaining systemic and neurological examinations were normal with typical development and appropriate growth. the working diagnosis at present is an isolated radial nerve palsy likely caused by in-utero compression. the nodule and scar noted above are consistent with lesions described in a previous case series. these were hypothesised to be areas of fat necrosis secondary to compression; resulting in the palsy. patient a's lack of further neurology such as a generalised brachial plexus palsy makes a birth injury less likely. further investigations and follow-up are awaited. background: valproate is an effective antiepileptic medication. if a woman becomes pregnant while taking valproate, her baby is at risk of congenital malformations (1 in 10) and developmental disorders (4 in 10). furthermore, it is associated with an increased risk of autism spectrum disorder and adhd. in 2018, the nhs/hse recommended new restrictions on the use of valproate, including a national pregnancy prevention program (prevent) and avoidance in prescribing to female patients of childbearing potential unless other treatments are ineffective or not tolerated. objective: to review the use of valproate in a well-defined population of at risk females with moderate to profound intellectual disability (id). identify the patients at risk and imbed the guideline into our practice. methods: a retrospective chart review was carried out of all girls aged between 6 and 18 years, attending the daughters of charity disability service (doc) in dublin, ireland. data such as diagnosis, valproate use, degree of id/gross motor function classification system (gmfcs), documentation of menarche and discussion regarding risk of valproate use were recorded. results: in total 9 females aged between 6 and 18 years where identified as currently using valproate out of 73 charts reviewed (12%). of the 9 patients identified, 2/9 had moderate id (gmfcs iii) and 7/9 had severe to profound id (gmfcs iv-v). 3/9 had menarche documented. 2/9 had the risk of valproate discussed. conclusions: in our cohort, a significant number of girls remain on valproate. 22% complied with new guidelines regarding discussions around the risks of valproate; highlighting the 78% of patients in need of counselling. an annual risk acknowledgement form was placed in their charts to prompt discussion next visit. in children with intellectual disability, conversations regarding contraception are difficult but essential. if valproate is used, then the risks must be fully understood by parents and carers. evaluation of the management of children up to age of 10 years with cerebral palsy in southend university hospital large district university general hospital against nice guidelines (nice guidelines ng62). methods: clinic notes of all 42 registered children with cerebral palsy (cp) up to 10 years of age as of june 2019 were included in the study. this was because there was no early data on children above 10 years age. results: 22 patients were age 0 to 5 years and 20 patients age 6 to 10 years. 15 were male and 27 females. 11 had hemiplegic, 3 quadriplegic, 18 diplegic and 10 dystonic cp. only 27 (64%) had gmfcs levels recorded. 11 (26%) were <28 weeks, 18 (42%) were 29 to 36 weeks and 13 (31%) were term. mri head findings: white matter changes including pvlin 29 (69%), 3 (7%) hie changes, 3 (7%) basal ganglia changes, 3 (7%) congenital brain malformation, 2 (4%) infarction. 1 migrated to area with no mri report. all the children received multidisciplinary team (mdt) input including physiotherapy. comorbidities werechildren on medications for gastro-esophageal reflux -9 (with 6 peginsertions). for epilepsy -5, for dystonia/spasticity -5, for constipation -12, for poor salivary control -2. behavioral issues noted in 7 and 1 was on adhd medications. 8 had botulinum toxin injections and 4 had selective dorsal rhizotomy for spasticity. documented discussion of diagnosis with family was in 28 (66%) patients and none in 14 patients (31%). only 50% patients had vitamin d levels checked. conclusions: management was in line with nice guidelines. they all had mdt input. there is a need to improve documentation of -evidence of discussion with parents, gmfcs level by age 2 ½ years plus, hip surveillance from age 2 years for gmfcs level iii to v and annual vitamin d levels especially for gmfcs level iii to v, peg fed and children on multiple anti-epileptic medications. poster no. 153 intracranial hypertension in children: an updated systematic review l di genova 1 , n desai 2 , s esposito 1 , p prabhakar 3 1 pediatric clinic, department of surgical and biomedical sciences, universit a degli studi di perugia, perugia, italy; 2 department of paediatric neurology, great ormond street hospital nhs foundation trust, london, uk; 3 neurosciences, great ormond street hospital nhs foundation trust, london, uk objective: our goal is to provide an overview on paediatric intracranial hypertension. methods: given that the last update of the diagnostic criteria of idiopathic intracranial hypertension was published in 2002, a thorough medline search of all english articles was conducted between 2002 and 2019. results: intracranial hypertension may be primary, with a paediatric annual incidence ranging between 0.63 and 0.71 per 100 000 children or arise from a secondary cause. misdiagnosis or delayed intervention can lead to poor quality of life and morbidity. in 2013, this condition was reconsidered, due to new accepted values for opening pressure and advances in neuroimaging; the importance to develop effective therapeutic strategies in order to prevent blindness was thus highlighted. to date, the main strategies described involved both medical and surgical approaches; nevertheless, there have been no paediatric intervention studies. disease monitoring plays a key role in the definition of the best timing and modality of treatment. recently, a risk stratification has been proposed with the aim to facilitate an adequate evaluation and proper care of children with intracranial hypertension: visual monitoring could represent an objective tool to manage these patients. in recent years, important evidence for the efficacy of acetazolamide emerged in the idiopathic intracranial hypertension treatment trial. surgical treatment is the modality of choice in children with worsening vision impairment, intractable headaches despite maximal medical management or in case of intolerance to medical therapy. conclusions: there are poor evidences about paediatric intracranial hypertension's outcomes. unfortunately, children's quality of life is heavily influenced by pain and permanent vision loss. standardized therapeutic strategies remains uncertain, highlighting the need for longitudinal studies to identify the best treatment in childhood. in order to alleviate symptoms and prevent permanent chronic sequelae, careful clinical evaluation and ophthalmological monitoring could be a useful guide to better manage this medical condition. objective: cerebral sinovenous thrombosis in childhood is a life-threatening neurological entity with uncertain epidemiology, potentially complicated by secondary intracranial hypertension. in the literature, there is a lack of evidence supporting the main strategies to approach both these medical conditions. our objective is to highlight the value of a prompt diagnosis aiming to define a tailored management approach based on children monitoring. methods: we review the main findings regarding cerebral sinovenous thrombosis and intracranial hypertension in children through illustration of a case with otogenic sinus thrombosis and secondary intracranial hypertension. results: a 7-year-old boy developed a local venous sinus thrombosis because of the spreading of a primary infective process from his middle ear into the sigmoid sinus complex, facilitated by anaemia and dehydration. the venous outflow disturbances led to secondary intracranial hypertension. the management aimed to treat cerebral thrombosis with anticoagulants and intracranial hypertension through medical and surgical strategies. the insertion of the lumbar-peritoneal shunt was necessary when medical approached failed and visual function deterioration was evident. careful clinical evaluation and ophthalmological monitoring helped us in the tailoring of the best treatment with the aim to alleviate symptoms and prevent sequelae of increased intracranial pressure. in the literature, no paediatric intervention studies regarding the main strategies to reduce intracranial pressure have been published. moreover, there is a lack of evidence supporting the safety of anticoagulation therapy, reducing the possibilities to safely manage cerebral thrombosis in childhood. conclusions: in children, a multidisciplinary approach is essential to manage both cerebral thrombosis and intracranial hypertension and ensure an optimal follow-up, aiming to prevent visual and therapy-related complications, possible relapses and their early diagnosis. from our perspective, monitoring our patient with clinical manifestations and visual status helped us to plan the best timing and modality of treatment and intervention. yearly rate of progression of fvc% predicted (available in n=260) was 3.6% in sma2 and 3.5% in sma3. in sma2, fvc% predicted declined steeply from 5 to 15 years of age, followed by a levelling. conversely, in sma3 patients fvc% predicted declined slower but steadily from 10 years of age. 136/298 (46%) sma2 and 8/71 (11%) required non-invasive ventilation due to respiratory infections or hypoventilation conclusions: the results of this ongoing collaborative work suggests that in sma2 and 3 lung function declines from age 5 and 10 respectively. lung and motor function correlate well in both sma2 and 3. this data will help the assessment of the long-term efficacy of new treatments for sma this review aims to study the appropriateness of mri brain referrals following implementation of local changes to improve compliance to the nice cg150 standard. methods: following an earlier survey (es; 01/06/16 -30/06/ 17) of mri brain referrals for headaches in children over 12 years, key recommendations included adding pop-ups in the neuroimaging request system (ice) of nice cg150 and headsmart clinical guideline v2 as well as verbal consent obtained from senior paediatrician before request was made. following these implementations, requests for mri brain were analysed during 01/06/2018 -31/12/2018 in the same district general hospital. referral was deemed compliant if the nice guideline cg150 standard were met. results: 50 children were referred for mri brain scan (mean 7/ month vs 10/month in es). 43 (86%) referrals were compliant (vs 67% compliance in es). 13 (26%) referrals were 'urgent' (vs 30% urgent es) and 37 (74%) 'routine' or non-urgent (vs 68% routine es). 12 (92%) of urgent referrals (vs 35% es) and 31 (84%) of routine referrals (vs 65% es) were compliant mri brain guidelines for neuroimaging in less than 12 years exist (headsmart clinical guideline v2 and nice epilepsy qs27) but are limited. this study aimed to assess current practice of mri brain referrals in children under 12 years. methods: retrospective review of mri brain referrals in children under 12 years performed between mri brain scans were done (m:f 1.1:1) 92 (43%) referrals under headsmart and 33 (36%) of these were urgent requests; significant brain abnormality was seen in 26 (79%) in urgent and 1 (0.01%) in nonurgent cases. 45 (21%) referrals under epilepsy qs27 and 12 (27%) were urgent requests; significant brain abnormality in 2 (17%) in urgent and 2 (6%) in non-urgent cases. 78 (36%) were miscellaneous requests and 24 (31%) were urgent; significant brain abnormality in 8 (33%) in urgent and 13 (24%) in non-urgent cases. overall mri brain showed significant abnormality in urgent requests (52%) compared to non-urgent requests (11%) poster no. 147 investigating factors that influence unplanned admissions and a&e attendances in those with pre-existing neurological conditions in childhood s dowsell 1 , k kananaviciute 1 , r parslow 1 , am childs 2 1 university of leeds, leeds, uk; 2 paediatric neurology, leeds general infirmary, leeds, uk objective: previous papers have shown increasing demands and costs to the nhs in relation to the inpatient care of children with neurological conditions. unplanned admissions may reflect a lack of effective care and have been shown to correlate with high outpatient clinic did not attend (dna) rates 2. the aim of this study was to determine factors underlying unplanned admissions and accident & emergency (a&e) attendances in a cohort of patients under the care of the leeds regional paediatric neurology service over a 3-year period. methods: all children <18 years who had paediatric neurology outpatient appointments in 2013 were identified using hospital databases. clinical and demographic data was extracted from electronic case notes. those without a definitive neurological diagnosis or who had moved to adult services during the study period were excluded. the cohort was cross referenced to a&e databases and admission records from 2015 to 2018. poisson regression was used to identify any correlation between specific predetermined factors to assess their influence on a&e attendance and admission rates. results: a cohort of 291 patients was established and 53 had a total of 82 unplanned admissions during the study period. 183 patients had a&e attendances with a total of 570 attendances. higher dna rates, younger age and certain diagnostic categories correlated with increased rates of unplanned admissions. the role of emergency care plans in preventing admission was unclear as only 27/147 patients with epilepsy had care plans in place. conclusions: this study confirms the association between increased rates of a&e attendances and unplanned admissions in children with specific neurological disorders and high dna rates. this is relevant for service planning as it highlights the need to target scarce resources towards 'higher' risk patients with more complex diagnoses where more integrated care and support may prevent or reduce unplanned hospital attendances.poster no. 148 audit comparing great ormond street hospital headache clinic diagnoses and management of patients aged 12 to 17 years to nice clinical guidelines a ward 1,2 , p prabhakar 1 1 neurology, great ormond street hospital, london, uk; 2 university of glasgow, glasgow, uk introduction: between 16/4/18 and 15/4/19 the gosh headache clinic saw 85 new patients aged 12 to 17 years. the nice clinical guideline 150 (cg150) on the diagnosis and management of headaches in over 12s covers tension-type headache, migraine, cluster headache and medication overuse headache. this audit aims to compare gosh diagnosis and management to those of the cg150. methods: using the patient list from the headache clinic data was gathered by accessing outgoing clinic letters via epic. raw data was collected on; age, gender, description of headache (pain location, quality, intensity, duration and frequency) and associated symptoms, triggers, previous imaging, previous and current treatments. the management data collected include: diagnosis and treatments offered, as well as whether gosh offered lifestyle advice, psychology, occipital nerve block or riboflavin. this data was then compared to cg150. results: 37 (62.7%) of diagnoses made by gosh matched the cg150 diagnosis. 22 (37.3%) diagnoses differed, with 14 of these due to discrepancy between chronic/episodic and/or presence of aura and 6 due to the vague diagnoses of migraine-type, new daily persistent, migrainous etc. fitting the cg150 definition of chronic migraine. all but one patient was managed in line with the guidelines. 76.9% of patients had brain imaging prior to attending the clinic, with 21.7% of these reporting positive findings. discussion: despite 22 patients' diagnosis differing between gosh and cg150, all but one patient was managed in line with the guidelines. this is likely due to nice recommended management being the same for any type of migraine. improvements could be made in documentation of frequency and duration of headache and aura, as well as more routinely offered lifestyle advice, psychology and riboflavin recorded in outgoing clinic letters. objective: to review the purpose of ct head requests from emergency department of a busy tertiary hospital as part of quality improvement. due to increasing evidence of ct scan radiation predisposing to leukaemia and brain tumours, it is best to keep ct scans to the minimum if clinically indicated. this project reviewed the indications for ct head and also looked at patients who had repeated ct or mri head scans within 3 years. methods: data was collected retrospectively looking at a snapshot period of 3 months between september-november 2018. patients were <18 years of age and they had a ct head from emergency department at king's college hospital, london. trauma patients were excluded. data was collated with aid of the neuro ct department 'cris' system. results: out of 56 patients, reasons for ct included: head injury (29), ventriculo-peritoneal shunt blockage (13), refractory seizures/status epilepticus (5), space occupying lesion (5), orbital cellulitis (1), intracranial haemorrhage (1) objectives: mutations in kif1a are associated with a wide range of neurological disorders, ranging from hereditary spastic paraparesis (hsp) to sensory neuropathies to a severe infantile neurodegenerative disorder. collectively, they are extremely uncommon but likely to be under-recognised. we aim to report the spectrum of kif1a-related disorders from a single tertiary neurology centre, with a view to improving understanding and awareness of these rare conditions. methods: affected individuals known to great ormond street hospital were identified through liaison with consultants involved in the care of children and young people with movement disorders. clinical information was collected through a retrospective review of case notes. results: twelve individuals in 9 families were identified. all had heterozygous kif1a mutations including three previously unreported variants. severity ranged from a fatal neonatalonset disorder with contractures, absence of visual development, and agenesis of the corpus callosum on mri to hsp with preservation of ambulation into the second or third decade of life and entirely normal mri. upper motor neuron signs were found in 10/12 children and a primarily sensory neuropathy was present in 9/11 children assessed. 3/12 children also had extrapyramidal signs (dystonia). some degree of learning difficulties and/or disorders of mood or behaviour were present in all children. optic atrophy, mr brain white matter changes and epilepsy were also common, especially in those children who were more severely affected overall. conclusions: kif1a related disorders are so diverse that it is arguably misleading to consider them as a single disease entity. features common to the majority of affected patients include upper motor neuron involvement, and neuropathy (even in the absence of an obvious sensory deficit), with high risk of other neurological and neurobehavioural comorbidities. objective: ataxia with oculomotor apraxia type 2 (aoa2) is a slowly progressive, autosomal recessive disease characterised by the triad of ataxia, oculomotor apraxia, and sensorimotor neuropathy that results from mutations in the gene encoding senataxin (setx), a dna/rna repair protein essential for genomic stability. we investigated a 16-year old male with a history of unsteady gate for genetic and molecular changes associated with aoa2. in this report we describe a case of aoa2 with two clear pathogenic setx mutations, one of which is novel, as well as two further setx changes likely to be in cis polymorphisms that have previously been reported as pathogenic. methods: two independent lymphoblastoid cell lines obtained from the patient were used for western blotting of senataxin and protein markers of other autosomal recessive cerebellar ataxias. the setx gene was sequenced to identify possible disease-causing mutations. results: western blotting showed reduced levels of senataxin. serum afp level was elevated at 15lg/l (normal 0.0-7.0lg/l). genetic sequencing revealed two clear pathogenic setx mutations. one of these was a novel mutation, c.2990delg; p.(cys997phefster32), a deletion causing a reading frameshift resulting in truncation and loss of expression of senataxin protein from this allele. the other, c.6638c>t; p.(pro2213leu) was a missense mutation within the helicase domain which has previously only been reported in the homozygous state in a japanese aoa2 patient. two further sequence changes, c.1807a>g; p.(asn603asp) and c.1957c>a; p.(gln653lys), were also identified in our patient. conclusions: the reduced senataxin expression and elevated afp levels support a diagnosis of aoa2 in our patient. genetic analysis found a novel pathogenic mutation and documented the first case of another pathogenic mutation in the helicase domain outside of japan. the case contributes to the growing diversity of setx mutations known to be responsible for aoa2. key: cord-022659-chwk2bs4 authors: nan title: abstracts: poster session date: 2004-10-08 journal: ann neurol doi: 10.1002/ana.410320224 sha: doc_id: 22659 cord_uid: chwk2bs4 nan an immune etiology has been postulated for acute cerebellar ataxia of childhood (acac) since it frequently follows viral infections. we analyzed serum and cerebrospinal fluid (csf) from 6 acac patients for antibody cross-reacting with cerebellar neurons. serum and csf were obtained within 7 days of onset of pancerebellar ataxia from subjects aged 3.5 to 11 years. varicella infection preceded 4 cases. results of enhanced cranial ct scans were normal; csf demonstrated 2-122 cells/mm3 with sterile cultures. serial dilutions from 1 : 20 of serum and undiluted csf were screened for antineuronal antibody by indirect immunofluorescence (iif) using frozen, unfixed normal human cerebellum. serum (1 : 400) was examined further for antineural antibody by western immunoblotting using purified cerebellar neuronal extracts as antigen. serum from age-matched, neurologically normal pediatric inpatients served as the control group for iif and immunoblot experiments. in acac patients, no antineuronal immunoreactivity was observed by iif. immunoblots demonstrated no consistent pattern of immunoreaction when comparing acac to controls, though 1 patient exhibited distinct bands at 200 kd (neurofilament protein) and 54 kd. although antecedent infection suggests an immune etiology for acac, our preliminary results do not support a humoral mechanism for this disorder. ingrid taff; joseph zito, robert gould, and steven pavlakis, great neck and manhasset, ny in a 20-month period we studied 69 patients between the ages of 7 weeks and 2 1 years with magnetic resonance angiography (mra). studies were performed on a 1.5t magnet (siemens magnetom sp) with a circular polarized head coil. a three-dimensional time-of-flight technique was utilized. occasionally, images were obtained after gadopenetate dimeglumine infusion. two-dimensional projection images were calculated using a maximum intensity projection algorithm and recorded on laser film. sixty-seven patients also had routine mri. a sampling of vascular lesions was demonstrated. nineteen patients had clinical and mri evidence of stroke. mra revealed intracranial vascular occlusion in 2 patients, diminished focal cerebral flow in the affected area in 4, and generalized ipsilateral underdeveloped cerebral circulation in 4. a moya-moya vascular pattern was found in 4 and sickle-cell vasculopathy was found in 1 patient. seven mras were normal. seventeen vascular hamartomas were demonstrated including 2 vene of galen malformations, 7 arteriovascular malformations, and 8 venous angiomas. three aneurysms were found. thirty-one mras were normal. we find m u to be a valuable adjunct to routine mr imaging in the evaluation of pediatric patients with potential cerebrovascular disease. it demonstrates a spectrum of pathology, is noninvasive, and allows for serial follow-up examinations. angiography in pediatric cerebrovascular disease p4. thalamic change in acute encephalopathy of adult rats. twelve weeks after grafting, clinical and histological studies were performed. we developed a protocol for evaluating functional deficits that follow spinal cord injury in the rat. the survival, growth, differentiation, and parenchymal integration of the graft were documented histologically on semi-thin section. animals that received the transplants demonstrated qualitative and quantitative improvements in several parameters of locomotion. donor tissue integrated most often with the host spinal cord at interfaces with host gray matter; however, some implants also exhibited sites of fusion with damaged host white matter. we suggest embryonic rat spinal cord transplantation may be a useful treatment of spinal cord injury and a possible therapeutic strategy in human spinal cord injury and amyotrophic lateral sclerosis. the basic neuropathophysiology of hemineglect after unilateral cerebral lesions is still not clear. one theory holds that degraded perceptual processing occurs in the damaged hemisphere due to intrahemispheric deficits. another holds interhemispheric interaction at fault, with the intact hemisphere actively inhibiting spatial cognitive processes in the damaged one. we tested 11 adult macaca fascicuhris with acute neglect on a task in which the whole visual surround was restricted to 15 degrees from central fixation, and a second in which an opaque lens occluded the eye either ipsilateral (ipsi) or contralateral (contra) to the lesion. using paired t tests, in the first task there were no differences in reaction time to the ipsi and contralesional hemifields. in the second, there was no change in extent of the ipsilesional field (obtained with the contralesional eye occluded), as compared to its extent without occlusion. the contralesional field, however, improved significantly ( p < .03) with the ipsilesional eye occluded. since reducing sensory input to both hemispheres leads to no worsening of hemineglect, but reducing sensory input to the intact hemisphere alone leads to improvement of hemineglect, we conclude that adverse interhemispheric interactions play a major role in the pathophysiology of hemineglect. we assessed the sensitivity and applicability of a new, cornbined cognitive and mood screening battery for multiple sclerosis (ms). sixty consecutive, untreated clinically active ms patients, 30 each relapsing-remitting and chronic progressive, underwent the battery and head mri upon entering 2 concurrent treatment trials. the battery combines the faust-fogel brief cognitive screen and visual analogue dysphoria scale, both previously validated in other neurological diseases. cognitive domains tested were immediate and delayed sentence and word-pair recall, verbal fluency, and conflicting response suppression. patients marked ''usual mood" along a "happy-sad" cartoon continuum. relapsing patients were program and abstracts, american neurological association 235 younger (32.8 vs 41.2 yr mean), with shorter ms durations (6.4 vs 11.3 yr), and had lower kurtzke disability scores (1.7 vs 5.8). modified qualitative mri grading (lesion burden, confluence, localization) was compared. half as many relapsing patients (43% vs 83%) scored ''abnormal'' cognitively, despite similar "sadness" rates (20% vs 23%). subjective dys-~ phoria in both groups correlated with denser periventricular lesion burdens. the battery was well tolerated and easily administered within 10 minutes without special equipment. this combined cognitive and mood screening battery is sensitive and convenient for clinically active ms. alternate forms of the battery are needed for repeatability. questionnaires may be reliable and valid supplements to laboratory tests for brain-damaged patients, as they can be applied to situations for which laboratory testing is not possible. we investigated the usefulness of informant-based data in alzheimer's disease (ad) by comparing caregivers' subjective evaluations of 83 probable a d patients' performance on an abbreviated version of the memory self-report questionnaire to objective evaluations derived from an extensive battery of neuropsychological tests and to clinicians' evaluations. similar information was obtained from 39 healthy agematched controls. caregivers' subjective appraisals of patients' memory correlated significantly with objective measures of secondary memory, with all cognitive variables, measures of activities of daily living, and clinicians' evaluations of dementia staging. scores were independent of clinical indicators of depression. the abbreviated memory questionnaire showed good reliability, internal consistency, and external validity. its positive predictive value is 63.5 and its negative predictive value is close to 100%. results suggest that (1) informant-based questionnaires may be useful for obtaining valid information on cognitive ability outside of laboratory settings; (2) the scale reflected more than just memory functions; and (3) the scale may be promising for screening cognitive difficulties in epidemiological or clinical settings. although neglect along the horizontal dimensions of extrapersonal space is well recognized, there are only a limited number of observations documenting neglect along the vertical and radial spatial dimensions. we report an investigation of neglect along the 3 principal dimensions of extrapersonal space in a patient with bilateral mesial temporo-occipital infarctions. neglect was assessed by asking the patient and controls to bisect lines of 4 lengths oriented in 3 directions with respect to the body: horizontal, vertical, and radial. our patient showed significant neglect of upper vertical and far radial space, as well as neglect of left hemispace. his line bisection errors were consistently in a direction opposite the slight directional biases shown by controls for all 3 line orientations ( p < .05). the magnitude of the patient's bisection errors increased by moving the lines toward the neglected sectors of 3-dimensional space. neglect of upper vertical and far radial space was also evident on line cancellation tasks. our results suggest that following focal brain injury, neglect may be observed along all 3 dimensions of extrapersonal space. these findings provide further empirical support for functional specialization within inferior and mesial temporooccipital regions for attending to upper vertical and far visual space (previc, 1990) . p12. posterior cortical atrophy: degenerative disease with primary visuospatial and visuosemantic deficits a. kertesz, m . polk, and a. kirk, london, ontario, and saskatoon, saskatchewan, canada posterior cortical atrophy is a recent, and heidenhahn's disease is an old, label for a miscellaneous group of patients with imaging or pathological and clinical evidence of visuocognitive deficits and cortical atrophy localized to the posterior cortex. the extent of this cortical localization and the nature of the pathological findings are not fully agreed upon, but spongiform degeneration and alzheimer pathology have been described. detailed examination of patients who are representative of the problem and have uniquely specific deficits is presented. one patient had visual associative agnosia, prosopagnosia, and transcortical sensory aphasia. lexicosemantic experiments of categorization, word retrieval, and comprehension of auditory and visual stimuli showed a specific impairment of visuoverbal semantics. a striking preservation of phonological, orthographic and visual structural input, and intercategory dissociations was demonstrated. consistency of errors argued for specific loss of semantic knowledge. another patient with apraxia, primary visuospatial deficit, agraphia, and amnesia at the beginning had predominantly right-sided posterior cortical atrophy, demonstrating further fractionation of the entity and the striking specificity of visuospatial function. the behavioral specification of degenerative disease is clinically and theoretically important. permanent neurological deficits after ischemic stroke are mainly determined by the location and size of the infarct. clinical recovery also depends on the functional state of adjacent brain tissue, where both neuronal loss and deactivation without gross morphological damage may affect flow and metabolism to a varying degree (g. mies et al, stroke 1983; 1422-27) , and where the ability to respond to stimulation by appropriate neuronal recruitment may be impaired. therefore, degree of resting hypometabolism and of responsiveness to functional activation may provide a measure of prognosis. in 26 patients (age 60.7 10.9 yr) with aphasia consequent to ischemic stroke of the dominant hemisphere, regional cerebral metabolic rate of glucose (rcmrgi) was measured at rest and in 17 of them also during spontaneous speech, using positron emission tomography (pet) of 2-(f18)-fluoro-2-deoxy-~-glucose (fdg). the pet study and a standardized neuropsychological test battery to assess the main aspects of language were performed around the fourteenth day after the stroke, and the language functions were assessed again 3 to 5 months later. performances in various dimensions of language 2 weeks and 3 to 5 months after stroke were related to rcmrgl in topographically meaningful areas at rest and during activation using wilcoxon-rank program and abstracts, american neurological association 237 sum test and multiple regression analysis. severity of aphasia was assessed by the token test, which showed a bimodal distribution to slight and severe, and a lower representation of moderate cases. global and all regional cmrgl at rest and during activation were significantly correlated to scores in token test at first and second examination, with the highest correlation coefficients ( -0.7 to -0.61) for broca's, wernicke's, and left temporoparietal regions. for performance after 3 to 5 months, the relationships were still significant with lower coefficients. verbal fluency also was correlated to kmrgi, but with lower coefficients that slightly increased for the recovery state. language performance at different stages in the course after ischemic stroke was significantly related (r = 0.84 for token test, r = 0.93 for verbal fluency). however, there exists a high variability in recovery that may be explained by stepwise regression of metabolic values. significant effects were observed only for cmrgl of the left hemisphere outside the infarct (partial r' = 0.21) at rest and for cmrgl within the infarct (0.27), the contralat-era1 mirror region (0.16), and broca's region (0.17) during activation, with a sum of all partial weight factors of 0.46 at rest and 0.72 during activation. our results furnish 2 indicators for recovery of aphasia: the resting metabolism of the left hemisphere outside the infarct, and the activated metabolism in residual tissue within the infarct and in languagerelated areas. although the hemispheric metabolism at rest might be related to neuronal loss and thereby to the brain's reserve capacity, the extent of metabolic activation indicates neuronal recruitment and the capability of neuronal networks for functional recovery. heparin therapy for acute myocardial infarction: the timi-i1 pilot and randomized trial combined experience m . a. sloan, t . r. price, m . l. tevrin, and s. forman for the timi investigators, baltimore, m d of 3,924 myocardial infarction (mi) patients treated with rt-pa and heparin, 29 (0.7%) developed ischemic cerebral infarcts (ci). all ci patients had detailed neurological evaluations and 27 (939%) had c t scans. age range was 40 to 74 years (mean 60 yr), 25 were male, and 22 were caucasian. electrocardiographic location of mi was anterior in 22 (76%) and nonanterior in 7 (249%). six cis occurred within 6 hours; 1 between 6 and 12 hours; 2 between 12 and 24 hours; 4 between 24 and 48 hours; 13 during the second week; and 3 others distributed over the 4 weeks after study entry. six of 29 cis did not involve cerebral cortex; 9 (319%) had multiple cis. of 24 cis thought to be embolic in origin, 17 had at least 1 cardiac abnormality (mural clot, wall motion abnormality, aneurysm, or transient atrial fibrillation) known to be associated more specifically with embolism than just the diagnosis of myocardial infarction. eight of 27 (30%) with ct scans had hemorrhagic conversion of varying degrees. the time of occurrence and sites of ci after rt-pa and heparin therapy for acute mi are similar to those reported in the prethrombolytic area. nancy futrell andjeanne m. riddle, detroit, m i photochemical irradiation of the carotid artery of rats has been used to induce endothelial damage, producing a nonocc h i v e thrombus (that apparently embolizes spontaneously) thrombi and emboli and multiple cerebral infarcts. evidence for embolism generally has a presumptive component. to document further that cerebral infarcts in this model are indeed due to embolism, we studied the ultrastructure of the carotid thrombi and the presumed cerebral emboli using scanning and transmission electron microscopy (sem, tem). the right carotid artery of 9 wistar rats was irradiated with a laser (632 nm, 200 mw/cm2, 15 min) following the injection of the photosensitizing dye photofrin 11, 12.5 mgikg. rats were sacrificed from 1 to 24 hours later. endothelial damage with formation of a fragmenting thrombus, composed mainly of platelets and erythrocytes (with no fibrin in most areas), was present in the carotid arteries of all rats by sem. sem was done on 36 cerebral vessels, 3 1 containing peripheral blood elements, with single (1) and aggregated (6) platelets (causing occlusion in 3), single (10) and aggregated (10) erythrocytes (without occlusion), and single (1) and aggregated (3) leukocytes (without occlusion). tem demonstrated that the platelet aggregates did not adhere to the cerebral endothelium. the endothelial surface of all cerebral vessels was normal, which provided additional evidence that the mechanism of cerebral infarction in this model is embolism. model of repetitive ischemia: this effect is significantly enhanced when combined with mild hypothermia ashfaq shuaib and elisabeth sechocka, saskatoon, saskatchewan. canada there is considerable evidence that glutamate release resulting in activation of postsynaptic receptors (especially nmethyhaspartate) is a major mechanism of ischemic neuronal injury. in vivo experiments have shown that a more severe release of glutamate may be responsible for the excessive damage seen with repeated ischemic insults. we have shown that in cell cultures the effect of brief repeated insults is more severe than a single insult of similar duration. in the present study, we tested the protective effects of cgs-19755 in a cell culture model of single ischemic and multiple-insult paradigm. in the multiple-insult paradigm, in some cultures cgs-19755 was combined with mild hypothermia to see if this would offer additional protection. cgs-19755 offered a dose-dependent protection in cell cultures exposed to a single ischemic insult. cgs-19755 was protective to cultures exposed to repeated ischemic insults. the protective effects were enhanced significantly when they were combined with hypothermia, resulting in almost complete protection of the cultures. the combination of therapies appears to be a valuable strategy in neuronal protection during cerebral ischemia. toby i. gropen, i . prohovnik, t . k. tatemirhi, z. sharif; and m. hirano, new york, n y although a rare syndrome, mitochondria1 encephalomyopathy, lactic acidosis, and stroke (melas) may offer a unique insight into stroke mechanisms. we report novel observations in a patient with melas studied with serial and quantitative cerebral perfusion after stroke using """tc-ceretec spect and '3ixe rcbf. a 24-year-old man with melas presented with left-sided headache, generalized seizures, fluent aphasia, and right hemianopia. serial ct and mri showed infarction of the posterior left hemisphere in a multiterritorial distribution. spect performed 15 days after stroke showed 20 to 30% greater flow in the infarct than in normal brain, which reversed 109 days after stroke. quantitative rcbf (m2 isi, reflecting mostly gray matter), when corpatients died. we recommend ct evaluation in all patients who have a seizure or lose consciousness during the peripar-tum period. despite intensive management, mortality is high. seizures should not be attributed to eclampsia without careful neurological assessment. when prenatal care is sought, women should be counseled about the dangers of cocaine to themselves as well as to their babies. changes in circulating blood volume following stephan a. mayer, matthew e. fink, laura lenniban, louise m. klebanoff; auis beckford, lsak prohounik, william young, and robert a. solomon, new york, n y reduction of blood volume (bv) has been implicated as a risk factor for delayed cerebral ischemia (dci) due to vasospasm after aneurysmal subarachnoid hemorrhage (sah). volume expansion guided by target filling pressures has gained popularity as a means of preventing or reversing dci; however, the adequacy of central venous pressure (cvp) as a reflection of bv in this setting remains unclear. we measured bv and cvp concurrently in 10 patients (5 males, 5 females; mean age 57 yr) 1 day after craniotomy (mean 3.5 days after sah) and an average of 5.5 days later. the mean bv (mllkg) measured using chromium5'-labeled red blood cells (rbcs) fell from 69.7 to 55.3 (normal range 55-80), a reduction of 21% ( p = .05, paired student's t test). despite this, mean cvp (mm hg) remained unchanged (7.1 vs 7.9). similar reductions of plasma volume (2 1%) and rbc volume (24%) accounted for no change in mean hematocrit (33.2 vs 33.5). bv fell 25.7% among grade iiiliv patients (n = 5 ) compared to 14.7% among grade 1/11 patients (n = 5). a moderate correlation between bv and cvp ( r = .48, p = .16) was found only with the first set of measurements. time-related alterations in venous capacitance, myocardial contractility, or systemic vascular resistance may explain our findings. axel rosengart, louis r. caplan, michael s. pessin, atherostenosis of the extracranial vertebral artery (ec-va) has rarely been studied systematically in series of patients with acute vertebrobasilar strokes or transient ischemic attacks. we identified by conventional angiography and neuroimaging (ct, mri, ultrasound, mr angiography) 45 patients with ec-va disease among 154 patients with posterior circulation ischemia. patients with cardiac sources of emboli were excluded. the probable etiologic mechanisms were: group a: vertebral artery origin (vao) atherostenosis with embolism-19 patients; group b: vao atherostenosis with hemodynamic spells-7 patients; group c: 1 patient with vao atherostenosis and both intra-arterial embolism and hernodynamic spells; group d: ec-va dissection-8 patients (6 unilateral, 2 bilateral); 1 patient had perioperative compromise of the ec-va with presumed intra-arterial embolism; group e: vao disease in addition to other distal vascular lesions-9 patients (2 with intracranial va and 7 with basilar artery [baf occlusive disease). ec-va disease is not always benign. vao atherostenosis and dissection of the ec-va are sources of intra-arterial emboli. hemodynamicrelated ischemia occurs with bilateral and unilateral va disease but is often transient. vao atherostenosis is often accompanied by severe occlusive disease of the intracranial va and ba. program and abstracts, american neurological association 239 sebastian e. ameriso, vicky l. y. wong, andvas gruber, hidemi ishii, and mark fisher, los angeles and la jolla, c a , and kanagawa, japan hemostasis abnormalities are associated with ischemic stroke. these changes typically are demonstrated in antecubital venous blood samples and may not necessarily represent changes within the vasculature of the brain. the purpose of this study was to identify potential differences in hemostatic profile from samples of cranial versus noncranial venous sites in patients with acute ischemic stroke. eight patients were studied within 7 days of acute brain infarction. some patients were studied on 2 separate days. blood was drawn from the external jugular vein and immediately thereafter from an antecubital vein without the use of tourniquet. we measured hematocrit, leukocyte count, platelet count, fibrin d-dimer (cross-linked fibrin fragment), plasminogen activator inhibitor-1 (pai-1, an important antifibrinolytic protein), and anticoagulant proteins thrombomodulin and activated protein c. a jugular-to-antecubital ratio was calculated for each paired blood sampling. thirteen paired samples were obtained from the eight patients. external jugular-to-antecubital ratios (mean to-antecubitat ratio for pal 1 was significantly different from 1 ( p < 0.05), with higher concentrations in jugular samples. in conclusion, levels of hemostatic proteins measured from cranial venous blood may differ from antecubital samples in patients with acute ischemic stroke. in animal models of transient cerebral ischemia, the effects of repetitive insults are more severe than a single ischemic episode of similar duration. we used the cell culture model of ischemia to determine if the effects of repetitive ischemia are similarly more severe in this model of ischemia. for cell culture, we used fetal mice cortical astrocytic and postnatal cerebellar (glutamatergic) granular neurons and cerebral gamma-aminobutyric acid (gaba)ergic cells. lactic dehydrogenase (ldh) (activity per gram protein) release in the medium was used as a measure of cellular damage. compared to a single insult, there was a large increase in ldh release during repetitive ischemia in astrocytes (233 vs 7 5 , p < 0.02) and granular cells (129 vs 41, p < 0.001) (highly significant) and a modest (but significant) increase in the cortical neurons (11.6 vs 7.5 p = 0.05). the demonstration that repetitive ischemia produces more severe damage in cell culture would suggest that the mechanisms are not predominantly vascular. cell culture could prove useful to study the mechanisms of neuronal damage with repetitive ischemia. we studied the spontaneous recovery of neurological function after acute ischemic stroke using a standardized stroke nih stroke scale scale ( n i h stroke scale) to assess the extent of improvement, differences in stroke types, and early predictors of later outcome. we performed serial neurological assessments on admission; 24, 48, and 72 hours after admission; and 7 to 10 days and >30 days after admission. twenty-six patients had presumed embolic occlusion of the middle cerebral artery (mca) and 14 had a clinical diagnosis of lacune. admission score was better in the lacune group compared to the mca group. the mean scores for all patients improved by the 7to 10-day and the >30-day examination, but the degree of improvement was greater in the mca group than in the lacune group at >30 days ( p < 0.004). the degree of change at 7 to 10 days correlated with the change in score at 24 hours ( r = 0.45, p < 0.05) and 48 hours ( r = 0.86, p < 0.05). most patients improve after acute ischemic stroke, but to variable degrees and at different rates. david w. desmond, thomas k. tatemichi, miguel figueroa, dew'itt t . cross, and yaakov stern, new yovk, n y to investigate the effects of lacunar infarction (li) on cognitive function, we examined 57 li patients 3 months after stroke (age = 71.6 ? 9.0 yr; education = 9.2 2 4.7 yr) and 241 stroke-free nondemented control subjects (age = 70.6 k 6.5 yr; education = 12.4 k 4.5 yr) with a battery of neuropsychological tests. li was defined as a presenting infarct of 5 2 cc and a mean volume of any additional subcortical infarctions of 5 2 cc on ct scan. using multiple regression analyses, with significance set at p < .01 to minimize the risk of type i error, we considered the role of li as a correlate of performance in multiple cognitive domains. controlling for the effects of demographic factors, vascular risk factors, alcohol use, and depression within the multivariate models, li was a significant independent correlate of deficits in memory ((3 = -.40, p = .0002), verbal (p = -.28, p = .0025), visuospatial (p = -.51, p < .oool), abstract reasoning (p = -.31, p = .0029), and attentional skills (p = -.50, p < .0001). we further investigated the effects of infarct number, volume, and location, as well as atrophy, on global cognitive function within the li group. the only significant independent correlate of global cognitive performance was a preponderance of left-hemisphere infarctions (p = -.07, p = ,0454). these results suggest that li may produce dysfunction in multiple cognitive domains, particularly when the left hemisphere is differentially involved. p30. increased intracranial atherosclerotic stroke in hispanics and blacks from northern manhattan ralph l. sacco, christina zamanillo, t . shi, andj. p. mobr, new york, ny intracranial atherosclerosis has been found to be more frequent in blacks compared to whites, whereas hispanics have rarely been characterized. among 2 10 consecutive patients from northern manhattan over age 39 hospitalized at the presbyterian hospital from 1990 to 1991, cerebral infarction occurred in 32 whites, 84 blacks, and 74 hispanics. all patients had at least one c t scan, 96% had duplex doppler, 94% transcranial doppler, and 12% angiography. strokes were classified as atherosclerotic (ath), cardioembolism, lacunar, and as infarcts of undetermined cause. ath was further subdivided into extracranial (eath) or intracranial (iath) . overall, the frequency of ath was similar in the three racelethnic groups (white 2096, black 16'96, hispanic 2096) . the distribution of the atherosclerosis, however, was different in whites compared to blacks and hispanics. whites had more eath stroke than blacks and hispanics (white 17%, black 7 % , hispanic lo%), while iath was similar in blacks and hispanics and greater than in whites (white 394, black 895, hispanic 10%). nonwhites have more iath stroke than whites. the similarity in the distribution of atherosclerosis between blacks and hispanics argues for shared environmental risk factors, rather than genetic differences. ethnic differences in stroke risk factors may help explain differences in infarct subtype. we studied 10 mild to moderate alzheimer's disease (ad) patients with a series of "0 water bolus positron emission tomographic (pet) activation studies, and compared them to similar studies in 10 age-matched normal controls. for each group, pet images were mapped onto the subjects' mri scan, and results of a particular activation condition were averaged across the group. naming a series of pictures (line drawings of animals) minus counting abstract designs as a baseline produced strong activation of the anterior cingulate gyrus only in the ad group. silent reading of words minus viewing a baseline series of "xs" similarly showed strong activation of the anterior cingulate gyms in the ad subjects but not the normals. naming 1 block (activation condition) of 80% unnamed pictures, minus a second block (baseline) of easily named pictures, demonstrated much greater cingulate activation in the ad patients, for naming of the more difficult pictures. we conclude that this cingulate activation may reflect the greater involvement of an attentional network (of which the anterior cingulate is a part) in tasks requiring a higher degree of "mental work" on the part of ad patients. dementia in alzheimer's disease j. w. pettegrew, k. panchalingam, w. e. klunk, and r. j alzheimer's disease (ad) predominantly affects the brain, resulting in the loss of multiple cognitive abilities. some studies suggest the membranes of peripheral cells are involved in the disease. to investigate erythrocyte membrane molecular dynamics in ad patients and age-matched controls, we investigated erythrocyte membrane molecular motion at the surface (fluorescamine), aqueous-hydrocarbon interface (dppe-ans), and hydrocarbon core (1219j-as; ppc-dph) by steady-state fluorescence anisotropy measurements of 16 probable ad patients (5 males; 11 females) and 20 (1 1 males; 9 females) age-matched controls. cognitive function was assessed by the mini-mental, mattis, and blessed scales. we found that intergroup comparisons revealed decreased motion at the surface ( p = 0.001) and aqueous-hydrocarbon interface ( p = 0.03) and increased motion in the hydrocarbon core ( p = 0.01) of the moderately to severely impaired ad patients compared to the controls. in the ad patients, there were significant correlations between decreasing membrane surface motion and worsening blessed scores (males p = 0.05; r = 0.7; femalesp = 0.04; r = 0.5). these findings suggest that molecules are being produced in the brain of ad patients that gain access to the circulation. these molecules insert into the erythrocyte membrane and secondarily alter erythrocyte membrane molecular motion. the production of these molecules correlates with the dementia and could contribute to the molecular pathophysiology of the disease. parkinson's disease (pd) and alzheimer's disease (ad) are 2 common disorders of old age and may therefore coexist. the prognosis in demented pd patients is poor and early recognition of such cases is therefore desirable. the objective of this study was to identify characteristics that distinguish pd + ad from pd patients during early stage. all patients were clinically evaluated over a 22-year period . clinical diagnosis of dementia was made only when unequivocal clinical evidence of progressive decline in memory and cognitive function was documented, and pathological diagnosis of ad and pd was made using standard criteria. twentysix patients who had only pd or pd + ad were identified; 20 had no dementia and at autopsy had pd. six patients had clinical evidence of parkinsonism and dementia and at autopsy had 2 distinct pathological findings-pd and ad. these 6 cases could be classified as having simultaneous or sequential evolution of pd + ad. those with sequential onset had pd before age 65 years but were inexplicably functionally disabled early on, whereas those with simultaneous onset manifested pd after age 65 years. pd + ad patients had rapid disease progression, shorter survival, poorer drug response, and more side effects of levodopa than pd patients. to study the prevalence ofwhite matter lesions in the general elderly population, and to investigate whether white matter lesions were relatively frequent in subjects with classic vascular risk factors and with hemostatic risk factors, magnetic resonance scans were obtained of 11 1 participants, aged 65 to 85 years, of the rotterdam elderly study. the subjects for the imaging study were a random sample from the general population, stratified by age and gender. t2-weighted images were obtained in the axial plane. white matter lesions were considered present when moderate or severe periventricular hyperintensities or when more than 5 small focal lesions or focal confluent lesions were found. overall, 27% of subjects had white matter lesions. the prevalence and severity of le-program and abstracts, american neurological association 241 sions increased with age. history of stroke or myocardial infarction, presence of peripheral arterial disease, factor viic activity, and fibrinogen level were each significantly and independently associated with the presence of white matter lesions. significant relations with actual systolic as well as diastolic blood pressure, with a history of hypertension, and with plasma cholesterol were observed only for subjects between 65 and 74 years. this study suggests that white matter lesions in the elderly may be related not only to the classic cardiovascular risk factors. but also to hemostatic factors. joan m. swearer, paula nelligan, hanno muelher, beatrice woodward, and david drachman, worcester, ma although behavioral disturbances occur frequently in alzheimer's disease and other dementing disorders, little is known about the factors that predict their development or predispose to their occurrence. in the present study we examined 2 sets of possible predictive/predisposing factors retrospectively for behavioral disturbances in 35 mildly to severely demented, community-dwelling patients. the factors examined included: individual distinguishing features (age, gender, age of onset, premorbid personality traits, prior psychiatric history) and dementia severity (dependence in activities of daily living [adls) and self-care, duration of dementia, global disease severity). spearman correlations and t tests were used to assess the relative influence of these factors on the occurrence of 3 types of aberrant behaviors: aggressive behaviors, disordered ideation, and motor abnormalities. forty percent of the patients exhibited aggressive behaviors, 77% exhibited disordered ideation, and 63% had motor abnormalities. neither a prior history of psychiatric disorders nor premorbid personality traits were associated with the occurrence of the target behaviors. dependence in adls and self-care and greater global severity were associated ( p < .01) with the frequency and severity of aggressive behaviors, disordered ideation, and motor abnormalities. these results suggest that severity of dementia is a consistent and reliable factor in the development of aberrant behaviors, whereas preexisting personality traits are not. dementia of the alzheimer t y p e w. j. burke, a. ranno, w. h . roccafrte, s. p. wengel. b. l. bayer, and n . k. willcockson, omaha, ne l-deprenyl is an irreversible inhibitor of mao-b that has been reported to cause modest improvements in short-term memory and behavioral symptoms in persons with dementia of the alzheimer type (dat). thirty-eight subjects meeting research criteria for mild d a t were enrolled in a placebo-controlled, double-blind trial of r-deprenyl at a dose of 5 mg twice a day. subjects underwent extensive clinical and neuropsychological assessments at entry, and at 2 and 8 months. after 8 months, subjects taking both l-deprenyl and placebo showed a significant decline in their scores on the mini-mental state examination, the clinical dementia rating (cdr) scale, and the sum-of-boxes score derived from the cdr. when the change in scores on these clinical measures was examined across the 2 groups, there was no significant difference. there were no significant differences within or between groups on several behavioral measures including the brief psychiatric rating scale and the cornell rating scale for depression in dementia. neuropsychological testing demonstrated no significant differences berween groups based on mean score change. l-deprenyl did not affect cognition or behavioral symptoms of dat in this 8-month study. k. marder, m-x. tang, r. ottman, l. cote, y. stern, and r. mayeux, new york, n y the etiology of dementia in parkinson's disease (pd) is probably multifactorial but there may be a shared susceptibility for p d and alzheimer's disease (ad). reliable risk factor interviews were conducted with informants of 15 1 nondemented p d patients (pd-d) and 65 demented p d patients (pd + d) enrolled in a longitudinal community study of pd. p d + d were older (78.9 yr) than pd-d (71.4 yr) and had later age at onset of motor signs (71.1 yr) than pd-d (64.8 yr) ( p < ,001). the frequency of smoking, alcohol use, head injury, and family history (fh) of pd did not differ but fh of ad was significantly more frequent in the pd + d group (or 2.25, ci 1.01-5.01). using stepwise logistic regression, only age of onset of motor signs 2 6 5 (or 2.86), education <8 years (or 2.53), and the interaction of age of onset of motor signs and fh of a d (or 3.49) were independent predictors of dementia in pd. to address variable years at risk for development of dementia, life table analysis revealed the cumulative risk of a d to age 90 in first-degree relatives of p d + d was .312, and .119 in pd-d relatives ( p < .05). cox proportional hazards analysis controlling for the differences in ages of the relatives of both groups yielded a rate ratio of 2.06 (ci 1.2-3.7) for the development of a d among p d + d compared to pd-d relatives. we conclude that a genetic susceptibility to a d may raise the risk for dementia in patients with pd. differentiated from alzheimer's disease? john c. mowis, elizabeth grant, rita canfield, eugene rubin, and daniel mckeel, jr, st louis. mo vascular dementia (vd) is believed to account for 20 to 30% of all us cases of dementia; however, pathologically confirmed cases are quite rare. this discrepancy suggests that current diagnostic criteria lead to the clinical overdiagnosis of vd. twenty v d subjects (mean age 78.5 yr; 9 men, 11 women) were diagnosed solely on the basis of the presence of dementia, a history of stroke(s), and a documented relationship of stroke to onset andlor course of dementia; ischemic scores (is) and neuroradiographic findings were not used for diagnosis. compared with 89 subjects (mean age 75.2 yr; 34 men, 55 women) with dementia of the alzheimer type (dat), there were no significant group differences for comparable clinical dementia rating stages of dementia for measures of language, activities of daily living, or general cognition. the vd group scored significantly higher than the dat group on the modified is (f [91, 64] = 138.2, p < ,0001). all 27 autopsied d a t subjects had verified alzheimer's disease (ad); 8 also had cerebral infarctions. the 3 autopsied v d subjects had 168, 160, and 55 cc of brain tissue affected by stroke; 1 (168 cc) also satisfied histological criteria for ad. we conclude that (1) the clinical features of vd and a d overlap considerably; (2) diagnostic criteria based on the temporal association of stroke with dementia may have predictive value for vd; and (3) the frequent coexistence of a d and strokes indicates that refinement of criteria is needed to distinguish "mixed" and "pure" vd. clinicopathological correlation remains essential for any study of putative vd. left-handedness has been proposed as a marker for decreased survival in the general population, but possible effects of handedness on longevity in alzheimer's disease (ad) have not been examined. we hypothesized that left-handed ad patients would evince more rapid deterioration and therefore die at an earlier age than right-handed patients. subjects were 103 demented patients consecutively confirmed at autopsy to meet nincds-adrda criteria for "definite" ad. handedness was determined from structured interviews with primary caregivers and validated for most subjects with the edinburgh inventory of handedness. age at onset of dementia symptoms retrospectively determined by caregivers was used to calculate the duration of illness at the time of death. because of reported gender differences with regard to longevity, we first partialled out effects of gender before using hierarchical regression procedures to test the hypothesis. four of 46 men and 2 of 57 women with definite ad were left-handed. the mean age at onset did not differ significantly between handedness groups (f [ l,loo] = .82), but the mean duration of symptoms ( alterations in the optical properties of brain can be used to detect pathological changes in patients with alzheimer's disease (ad). using time-resolved spectroscopy (trs) and phase-modulation spectroscopy (pms), we measured the absorption (ua) coefficient, scattering (us) coefficient, and mean photon pathlength (pl) of red light directed through the base of the frontal lobes of 28 patients with ad and 11 age-matched control subjects. the measured values and the asymmetry index (ai) (an indication of the symmetry of the measurements between the left and right side of the brain) were correlated with the severity of disease as determined by mini-mental state score. there were significant differences between the ad and control group for ua, us, pl, and the standard deviation of ai. there was no correlation between the mms score and ua, us, or pl. however, the highest asymmetry index values were seen in moderately impaired patients , which suggests that the asymmetrical nature of the pathological process detected by optical spectroscopy is most marked during this stage of the illness. this noninvasive technique may provide a convenient method to detect and monitor the pathological changes that occur in the brain of patients with ad. disease p41. memory impairment in very mild alzheimer's a memory impairment is often the earliest indication of alzheimer's disease (ad). we investigated 3 components of disease learning and recall to determine which aspect of memory function is impaired the earliest in incipient ad. using the mayo clinic alzheimer's disease patient registry, which is a longitudinal prospective project on ad and normal aging, we identified 34 patients with very mild ad (i.e., with a mini-mental state score of 24 or greater) and 34 age-and sex-matched controls. we assessed performance on 2 memory measures: the rey auditory verbal learning test and the buschke free and cued selective reminding test (fcsrt). the 3 parameters evaluated included a measure of acquisition, total learning over trials (tl), and delayed recall (dr). on the fcsrt, an index of facilitation of performance with semantic cues (sc) was assessed. results indicated that all 3 indices, tl., dr, and sc, were capable of separating the mild ad group from the controls ( p < 0,001). using a linear discriminant analysis with stepwise variable entry, the measure that assessed the patient's ability to use semantic cues (sc) was the most sensitive parameter for separating the 2 groups ( f = 15.38, p < 0.0002), and the acquisition parameter (tl) was also useful at adding some additional predictive power (f = 8.48, p < 0.005). the delayed recall measure, however, did not add anything to the previous 2 measures. it appears that very early ad can be detected using appropriately structured memory tasks, and these procedures can be helpful in identifying at-risk individuals. alzheimer's disease (ad) has an insidious onset that is difficult to date reliably. we developed a standardized interview to provide objective criteria for dating the onset of 7 different symptoms (memory complainr, performance problems, language deficits, disorientation, depression, behavior problems, and psychosis), yielding an estimated disease onset date. inrerrater reliability (icc = 0.99;p < ,001) and interinformant reliability (icc = 3 5 ; p < .001) for the onset of first symptom was high. interrater agreement for the order in which symptoms appeared was high (icc = 0.72-0.98) as was interinformant reliability for all symptoms except memory complaint. the interview was administered to 2 16 patients with ad. mean estimate duration of illness was 4.26 years k 3.47 years and correlated significanrly with problems in instrumental activities of daily living. sixty-six percent had memory complaint and 45% had performance problems as their initial symptom. this technique provides a reliable characterization of disease onset. longitudinal studies will determine if particular onset symptoms differentially predict disease progression. the purpose of this study was to determine whether there is an excess of white matter disease (wmd) in alzheimer's disease (ad). brun and englund (1986) reported an excess of wmd in brains of patients with ad vs age-matched controls. there have been reports both confirming (bowen et al, 1990; fazekas et al, 1990) and refuting (leys, 1990) these findings using ct and mri in patients with clinically diagnosed ad. postmortem t2-weighted mri scans and program and abstracts, american neurological association 243 neuropathology were graded on 9 brains of pathologically confirmed ad subjects and 6 brains of age-matched neuropathologically normal controls. white matter lesions were scored on a 0 to 3 scale (none, mild, moderate, severe) separately for periventricular (pvl) and deep white matter (dwm) areas in mri scans and lux01 fast blue (lfb)-stained brain sections. correlations between mri and neuropathology were good ( r = 0.61 for pvl, r = 0.66 for dwm). pvl scores were higher in ad than in normal subjects on mri (ad: 2.2 l 0.9 vs controls: 0.2 rfr 0.3; p < .005). on pathology the difference in scores did not reach significance (ad: 1.3 2 0.7 vs controls: 0.5 * 0.4; p = 0.2). similarly, dwm scores were higher in ad subjects than normals on mri, but not neuropathology. in conclusion, ad brains have a significant excess of wmd on mri compared to controls. although the pvl and dwm scores for pathological sections are not different in the 2 groups, mri is much more sensitive than lfb-stained sections for wmd. thirteen autopsy cases of progressive supranuclear palsy (psp) were investigated for clinical-neuropathological correlations and heterogeneity. we reviewed clinical records of 11 men and 2 women aged 61 to 89 years (mean age 72 yr) with disease duration ranging from 4 to 12 years. most patients had classic features of psp including ophthalmoplegia, postural instability, and extrapyramidal signs. dementia was eventually observed in 9 of the 13 patients (67%). six of 9 patients (67 %) on whom adequate initial documentation was available presented with memory loss or behavior change. five of the 13 patients (395%), including 4 with an initial presentation of memory loss, were diagnosed clinically as having alzheimer's disease (ad) rather than psp; neuropathological diagnoses in these cases varied: i had combined ad-psp; 1 had ad-psp combined with parkinson's disease (pd) changes; 1 had psp-pd; and 2 had "pure" psp. the 2 patients with concomitant pd changes showed lewy bodies in the substantia nigra, locus coeruleus, nucleus basalis, and neocortex. the remaining 8 patients were clinically diagnosed as having psp; neuropathological diagnoses in these cases included 4 with "pure" psp and 4 with psp that also met neuropathological criteria for ad (psp-ad). these findings emphasize the clinical and neuropathological heterogeneity in psp. the neuropsychological battery developed for the consortium to establish a registry for alzheimer's disease (cerad) is currently used in many research studies to index the cognitive impairments of alzheimer's disease. in spite of its widespread use, normative informarion on the battery, important for interpretation of performance, has not been available. we report norms for the cerad battery based on a large sample of elderly control subjects (n = 398; white men and women; ages 50-89 yr) enrolled in the national study of cerad. performance on the neuropsychological measures was examined separately for subjects with high (2 12 yr) and low (< 12 yr) education. distribution of scores and basic descriptive information (means and sd) for each measure were determined. significant age and sex effects were observed on most cognitive measures in the highly educated group. in contrast, no significant age effects were observed in the low education group. effect of sex was not explored in this group due to the limited sample size (n = 48). further exploration of cerad performance in normal controls from underrepresented groups including minorities, residents of rural communities, and individuals with low education is in progress. intraneuronal inclusions of cytoskeletal proteins appear in several neurological diseases; for example, the neurofibrillary tangles of alzheimer's disease contain a cytoskeletal protein, tau. because the previously described slowing of axonal transport in aged animals might lead to accumulation of cytoskeletal proteins in nerve-cell bodies and axons, we assessed the abundance of 2 major cytoskeletal proteins in brain tracts of rats at age 4 months or 25 months. immunoassay was performed with monoclonal antibodies to alpha and beta tubulin and to nf-l (the core neurofilament protein) by published methods. samples were dissected in a standardized fashion and 2-mrn pieces of the following tracts were assayed: optic nerve, corticospinal tract (medulla), superior cerebellar peduncle, l5 dorsal root, and l5 ventral root. between 4 months and 25 months, the nf-l content approximately doubled in each brain site. tubulin substantially increased at of aged rats all sites except the fimbria-fornix. in contrast, tubulin did not change in the spinal roots. nf-l increased slightly in the ventral but not the dorsal root. this tendency of senescent brain neurons to accumulate cytoskeletal proteins in their axoplasm may predispose them to formation of intraneuronal inclusions in various degenerative diseases. we performed a prospective study of preoperative magnetic resonance imaging (mri) in 13 consecutive patients with intractable partial epilepsy who underwent a stereotactic resection of an extrahippocampal temporal lobe foreign-tissue lesion, "lesionectomy," between june 1986 and january 199 1. interpretation of the mri studies was performed by an investigator blinded to the presurgical evaluation, surgical outcome, and pathology. hippocampal formation (hf) atrophy was assessed using mri-based volumetry (n = 10) and visual grading of the h f (n = 13). mri-detected hf atrophy has been shown to be a reliable marker of moderate to severe mesial temporal sclerosis (mts) (cascino gd, et al, ann neurol 1991; 30:31-36 evidence from experimental animals indicates that endogenously produced platelet-derived growth factor (pdgf) is an important regulator of glial proliferation and differentiation. because of the striking degree of glial proliferation in chronic epilepsy, we sought to determine whether cultured glia from human epilepsy tissue would be responsive to pdgf. the effects of pdgf on dna synthesis, proliferation, and relative distribution of a2b5(+) glia were studied in a cell culture derived from temporal lobe white matter of adult epilepsy lobectomy tissue. by immunocytochemistry, glial fibrillary acidic protein (gfap) was detectable in 90% of cells in untreated or 4-day pdgf-treated (10 ng/ml) cultures, which confirmed their astrocytic nature. in contrast, a2b5( +) cells increased from 10 to 30% in untreated cultures to 75% after pdgf treatment, which suggested that type 2 astrocytes (a2b5[ + 1, gfap[ +]) had been elicited. dna synthesis of cells resembling oligodendrocyte-type 2 astrocyte (0-2a) progenitors occurred within 24 hours after program and abstracts, american neurological association 245 pdgf treatment as evidenced by nuclear incorporation of brdu in bipolar a2b5( +) cells. these studies demonstrate that expansion of adult human gfap( +) astrocyte populations is sensitive to regulation by pdgf. further, these data imply the existence of pdgf-responsive 0-2a progenitor cells in astrocyte-rich cultures derived from human epilepsy tissue. ( we have recorded vagal and esophageal-evoked potentials after electrical (e) and balloon (b) stimulation in 10 epileptic patients who had vagal stimulators for the control of intractable epilepsy and the results were compared with esophagealevoked potentials in 10 healthy controls and 3 diabetic patients. the vagal and esophageal-evoked potentials showed similar configurations with 3 major positive and negative potentials. the amplitudes of the responses habituated rapidly over 30 trials at 2 per second up to 1 per 6 seconds. latencies were shorter from the upper esophagus (20 cm above lower esophageal sphinctereles]) cf. lower esophagus ( 5 cm above les) yielding conduction velocities of 5 to 7 meters per second but conduction was significantly slower in the diabetics. the vagal-evoked potentials have validated the use of esophageal-evoked potentials as a practical method of assessment of the integrity and speed of conduction in vagal afferent pathways in man. ronald e. kramer and neil l. rosenberg, englewood. co seizure disorders were analyzed in patients in whom toluene was the sole or major drug of abuse. toluene abuse is increasing; therefore, physicians should gain experience with its neuropathological and ciinical sequelae. a retrospective chart review found 15 patients meeting criteria. the average patient age was 28 years; abuse onset averaged 16.7 years; abuse averaged 10.7 years; and 11 patients were male. ten were daily, 3 were weekly, and 2 were intermittent users. seizures occurred in 2. one suffered a single generalized tonic-clonic seizure without recurrence and without treatment. his we characterized the clinical dose-response curves for relief of parkinsonism and production of dyskinesias as a function of plasma levodopa and 3-0-methyldopa levels in 6 patients with parkinson's disease (pd) and fluctuating responses to oral levodopa/carbidopa. dose response to graded intravenous levodopa was measured after overnight drug withdrawal on 2 occasions, first after chronic, intermittent oral levodopa/ carbidopa and second after 3 to 5 days of continuous intravenous levodopa. continuous intravenous levodopa shifted the dyskinesia dose-response curve to the right, and reduced maximum dyskinesia activity, but did not significantly alter dose response for relief of parkinsonism. improvement in dyskinesia was apparent by the second day of continuous levodopa, during which ratios of plasma dopa/3-0-methyldopa remained constant. our results support the hypothesis that relief of parkinsonism and production of dyskinesias occur by separate mechanisms. continuous dopamine-mimetic therapy should be sought as a therapeutic goal for advanced pd. dopa-responsive dystonia (drd) is a distinct subset of idiopathic dystonia with diurnal fl uctuation and a dramatically beneficial response to l-dopa. it has hitherto been considered an autosomal-dominant disease with reduced penetration (mckusick no. 12823) . we studied an arabic family of 67 members with d r d spanning 6 generations. we examined 43 members and 6 of their spouses. l-dopa was withheld for 24 hours from patients in treatment. five family members had generalized dystonia with diurnal auctuation ( i male, 4 in an arabic family females). dystonia started between the age of 2 and 7 years with gait difficulty and involvement of the legs. mri, eeg, evoked potentials, and screening for wilson's disease were negative. an excellent response to l-dopa was noted in all 5 patients with continued long-term clinical stability for as long as 17 years. the 5 patients were the products of 2 consanguineous marriages, and their 7 siblings were normal. the patients were descendants of the same great-great-grandparents. this pedigree suggests an autosomal-recessive type of inheritance. we believe this is the first report of d r d with an autosomal-recessive type of inheritance. a. achiron, m . gornish, h . goldberg, i . ziv, r. djaldetti, y. zoldan, h. smka, and e. mekzmed, petah tiqva, israel freezing gait is an incapacitating symptom that occurs often in advanced parkinson's disease and also in other neurological disorders, eg., multiinfarct state, multisystem atrophies, and normotensive hydrocephalus. we evaluated, videotaped, and rated 18 patients (15 men, age 74 k 6,60-82 yr) who developed pure progressive freezing gait during 2.5 2 1.9, 0.5-6 years. severity was mild in 4 with sudden motor blocks mainly when confronted with obstacles; moderate in 9 with gait arrests upon any attempt to initiate walking and changing direction, requiring a walking stick or partial external assistance; and severe in 5 with total inability to start walking, requiring a walker, massive assistance, or a wheelchair. in all, freezing was associated with postural instability. they could mimic normal gait when seated or lying prone and could overcome arrests by the "walking over lines" maneuver. neurological examination was otherwise normal with no signs of dementia, parkinsonism, or pseudobulbar palsy. ischemic risk factors including ischemic heart disease, hypertension, and diabetes occurred in 7 and previous strokes in 6. brain c t and mri were normal or showed mild cortical atrophy in 12 and putative lacunae in only 6 patients. none responded to levodopa or dopamine agonists. progressive pure freezing gait should be recognized as a separate nonparkinsonian neurological entity. it may be due to degenerative or ischemic non-nigral brainstem lesions. we describe 19 patients with causalgia and dystonia, triggered by peripheral injuries in 15 patients and occurring spontaneously in 4 patients. the injury was often trivial. the mean age at presentation was 28.6 years. the legs were affected in 12 patients, and the arm was affected in the remaining 7 patients. all had burning pain, allodynia, and hyperpathia, along with vasomotor, sudomotor, and trophic changes. all developed typical dystonic muscle spasms in the affected part. the spasms typically were sustained, producing a fixed dystonic posture, in contrast to the mobile spasms characteristic of idiopathic torsion dystonia. dystonia always followed the causalgia and was painful. there was spread of the causalgia and of the dystonia from its initial site both in the affected limb and to other extremities, the latter in a hemiplegic, transverse, and triplegic distribution. all forms of conventional treatment failed to relieve either the pain or the dystonia. we suggest that functional changes in the corticobasal ganglia-thalamic system are responsible for this painful dystonic syndrome. program and abstracts, american neurological association 247 holiday for parkinson's disease: a controlled clinical trial r. kurlan, c . m . tanner, c. g. goetz, j . sutton, p. carvey, c. deeley, l. cui, c. itvine, and m . mcdemzott, rochester, ny, chicago, il, and san jose, c a the efficacy and mechanisms of levodopa (ld) drug holiday for parkinson's disease (pd) remain controversial. we performed a double-blind, randomized study with 11 advanced pd patients (5 men, 6 women; aged 52-79 yr) with entry criteria of inadequate response to ld plus dose-limiting ld-induced side effects (dyskinesias, hallucinations, and confusion). subjects were assigned to: (1) 100% placebo for ld (complete drug holiday) or (2) 50% ld and 50% placebo for ld (50% drug reduction) for 6 days. after subsequent open-label ld dose optimization, subjects were followed to end point (defined as the time when entry criteria were again satisfied or a maximum of 1 year). median survival time to end point was not significantly different for the complete drug holiday (182 days) and 509% drug reduction (100 days) groups ( p = 3 5 ) . aspiration pneumonia occurred in 2 complete drug holiday patients and no significant morbidity occurred with drug reduction. after a 100-mg dose of ld, clinical and pharmacological responses were no different before and after drug holiday ( p = .75) or reduction ( p = 254). subject to the limitations of our small sample size, we conclude that complete drug holiday is associated with greater morbidity and confers no major advantage over 50% drug reduction. we found no evidence of significant alterations of pharmacokinetic or pharmacodynamic properties of ld after drug holiday or reduction. ( (pc) of the substantia nigra on t2-weighted images. the narrowing of the pc signal has been attributed either to atrophy of the pc or to increased deposition of iron in this region. we have studied details of iron distribution in the midbrain of 8 formalin-fixed human brains by scanning pixe analysis. three p d brains, 1 juvenile pd brain, and 4 control (amyotrophic lateral sclerosis) brains were studied. in the controls, the iron content of the pars reticulata (pr) was almost equal to that of the red nucleus (rn), but that of the pc was less than 50% of the pr. in parkinsonian brains, the iron content in the pc was significantly higher than in the controls. the iron content ratios of pc/pr and pc/rn in parkinsonian brains were significantly higher than in the controls. these findings suggest that iron deposition increases in the pc of parkinsonian brains. the difference in the pattern of iron content corresponds to the intensity profile pattern noted on mri. mri findings in parkinsonian patients may reflect a change in the iron distribution pattern. (jankovic and brin, nejm, 1991) . such resistance within 2 exposures is not likely due to toxin antibody formation. of 61 cd patients evaluated per protocol receiving 2 or more botox tx under multichannel emg monitoring, 7 (11.5%) showed no benefit after the first and second tx, despite mild neck weakness on static muscle testing and, in some instances, emg signs of denervation. the 54 responders (16 men, 38 women) had younger age onset cd (mean 45 yr vs 60 yr), but similar duration (mean 10 yr vs 9 yr) compared to the 1 male and 6 female nonresponders (in contrast to jankovic and schwartz, arch neurol, 1991) . both groups had similar degrees of severity and tx dose (mean 200 iu, range 112.5-300). although disparate group size prohibits statistical analysis, some interesting comparisons include: nonresponders were more apt to have extranuchal dystonic sites (72% vs 33%), antecollis (29% vs 4%), dark eyes (57% vs 19%), women with elevated antinuclear antibody titer (67% vs 24%), history of intracranial operation (29% vs o%), significant for age focal mri abnormality (5 of 6 vs 3 of 19). history of cervical operation (6 patients) did not limit responsiveness. rates of prior remission, perinatal stress, antecedent trauma, left-handedness, and family history of movement disorder were similar for both groups. antecollis presents problems for optimizing tx to affected muscles, but central mechanisms may play a role in why some patients with focal dystonia do not improve with botox tx from the outset. enrico fazzini, new york, n y with parkinson's disease does deprenyl have a symptomatic effect on patients with untreated and l-dopa-treated parkinson's disease (pd)? once deprenyl is started, how long is it before another medication is needed to control symptoms of continued disease progression? there has been controversy over whether deprenyl has effects on delaying disease progression (nejm 1989; 321:1364) and/or in alleviating the symptoms of pd. one hundred seventy-five patients already taking l-dopa (group 1) and 33 patients who had never taken l-dopa (group 2) were treated with deprenyl 10 mg/day. unified pd rating scale (updrs) scores were measured before and after deprenyl. patients were followed until pd symptoms progressed to the point of requiring additional medication. one hundred eighteen of 175 (67%) patients in group 1 (reduced updrs mean activities of daily living [adl) 11 to 9, motor [mtr] 30 to 22) and 29/33 (88%) patients in group 2 (reduced updrs mean adl 11 to 6, mtr 26 to 20) reported symptomatic benefit. an average of 12 months' duration was found in both groups before further medication adjustments were needed. deprenyl provides symptomatic benefit for an average of 12 months in the majority of patients with p d regardless of whether or not they are being treated with l-dopa. yasuo iwasaki, masao kinoshita, toshiya shojima, and ken ikeda, tokyo, japan, and cleveland, oh in parkinsonian patients we measured fasting plasma amino acids in 30 parkinson's disease patients and 30 controls matched for age and sex. all patients were receiving l-dopa and they were free of any medications other than l-dopa. normal controls were free of any medication. there were no differences in diets between patients and controls. fasting blood specimens were collected in heparinized tubes and immediately were centrifuged at 20,000 g for 10 minutes. analysis of plasma amino acids was performed by automated ion-exchange chromatography with lithium-based buffer and an amino-acid analyzer. parkinsonian patients had significant elevations of aspartate, glutamate, and glycine. the other amino acids were not significantly different from those in controls. n o correlation between severity or activity and degree of abnormality in plasma level of amino acids in patients was established. we conclude that excitatory amino-acid metabolism is altered in patients with parkinson's disease. bonnie e. levin, rachel tomer, and william weiner, miami, fl disease there is evidence linking obsessive-compulsive symptoms (ocs) to basal ganglia dysfunction. we investigated the presence and severity of ocs in a sample of 44 patients with an unequivocal diagnosis of idiopathic parkinson's disease (pd) using the leyton obsessional inventory. ocs was found in the majority of the patients, with 24 (55%) scoring above the normative cutoff for the symptom score and 32 (73%) scoring above the normative cutoff for the trait score. when severity of oc symptoms was correlated with a battery of neuropsychological measures, significant relationships were observed between ocs and a preponderance of tests associated with right-hemisphere functions. these findings were observed especially on those tests with a strong frontal lobe component (block design: r = -.50; embedded figures: r = -.534; set shifting: r = -.42; and perseverative responses: r = .58; p < .005 for all measures). in all cases, the more severe oc symptoms, the poorer the performance. a similar trend was observed between the leyton trait scores and the cognitive measures. these findings suggest that ocs is present in a subgroup of pd patients, which may reflect greater compromise of right-hemisphere basal ganglia-frontal lobe pathways. intraclass correlations (iccs) were calculated for the total motor score and for each individual sign. results indicated excellent agreement (icc > .7) for the total motor score, resting tremor, gait, arising from a chair, and speeded, repetitive movements; good agreement (icc > .5) for rigidity, action tremor, posture, postural stability, and bradykinesia; and poor agreement (icc < .2) for speech and facial mobility. a factor analysis was then performed on updrs motor scores for 146 pd patients from a community-dwelling cohort. three factors were extracted by principal components analysis with subsequent varimax rotation, accounting for 63.5% of the total variance: factor 1-balance and stability (posture, postural stability, gait, arising from a chair, and bradykinesia); factor 2-rigidity and motor speed (rigidity, speech, facial mobility, rapid alternating movements, leg agility, hand movements, and finger tapping); factor 3-tremor (resting and action). these results indicate that the updrs motor examination is reliable between raters and measures the cardinal signs of pd. an open pilot study was performed to evaluate the efficacy of botulinum a toxin (botox) injections for disabling hand tremors. a previous report on the use of botox for hand tremors suggested that it was helpful, but relied on subjective clinical rating scales. the extent of normal clinical fluctuations or a placebo response could not be determined. to investigate these issues more objectively, 7 patients with parkinson's disease and 1 with essential tremor with refractory hand tremors underwent electromyographically guided intramuscular injections of botox into wrist flexors and extensors. patients without great medication-related tremor fluctuations were selected. results before and after botox were determined by comparing (1) patient perceptions of functional improvement, (2) clinical assessments using the unified pd rating scale for tremor and the webster rating scales, and (3) physiological measurements using accelerometric analysis of hand tremors of tremor frequency, amplitude, and waveform characteristics. all patients reported some improvement, ranging from mild to marked with a mean of 2.6 on a 0 to 4 (4 = marked) global rating scale. however, only 3/8 patients showed a significant improvement in the clinical rating scales, confirmed by >50% reduction in tremor amplitudes. these findings show that most patients reported improvement not confirmed by the clinical or physiological measures. efficacy of botox injections for tremors is implied, but controlled trials are needed before this procedure can be generally recommended. christopher g. goetz and glenn t . stebbins, chicago, i l we tested whether hallucinations, motor disability, and cognitive decline were risk factors for nursing home placement in advanced parkinson's disease (pd) and whether these effects were independent or synergistic. between 1987 and 1991, we identified 11 patients admitted to long-term nursing homes. using case control methodology, we matched each for age, pd duration, and sex with 2 control pd patients remaining at home. parkinsonism was assessed by the motor and activities of daily living subscales of the unified p d rating scale (updrs); hallucinations and dementia were determined by scores 2 2 on the thought disorder and intellectual impairment items of the updrs. tests of synergy were based on a mantel-hentel model. hallucinations were a significant risk factor with odds ratio = 18.0, x2 = 17.0, p < ,001. motor impairment alone and cognitive impairment alone were not significant risk factors for nursing home placement (x2 for motor severity = ,00084, p > .05, and x2 for cognitive impairment = .0023, p > .05). furthermore, combined odds ratios for hallucinationslmotor severity and hallucinations/cognitive impairment showed no synergy of effect (x2 <1.0 for both,p > .05). of the 3 variables studied, hallucinatory behavior is the most prominent and independent risk factor for nursing home placement in these patients; the data suggest that aggressive control of hallucinations may be warranted to prevent nursing home admission. temperature-sensitive paramyotonia congenita phenotype* louis j . ptacek, philip mcmanis, hzrbert kwiecinski, alfred george, robert barchi, launce gouw. and mark leppert, salt lake city, u t , rochester, mn, warsaw, poland, and philadelphia, pa the periodic paralyses are a group of autosomal-dominant muscle diseases sharing a common feature of episodic paralysis. in one form, paramyotonia congenita (pc), the paralysis is temperature-sensitive, usually occurring with muscle cooling. electrophysiological studies of muscle from patients with pc have revealed temperature-dependent alterations in sodium channel (nach) function. this observation led to the identification of 2 distinct mutations in an s4 segment of a skeletal muscle nach in 3 unrelated pc families. we describe the use of the single-strand conformation polymorphism (sscp) technique to define a third allele specific to pc patients in an additional family. this aberrant pattern, though distinct from the first 2, occurs in the same exon of this nach gene. sequencing is currently underway to define the molecular alteration causing this aberrant pattern. two additional families with the pc phenotype have been sampled and do not demonstrate these 3 sscp variants. we are currently searching for new mutations in these 2 families to define further the molecular heterogeneity of this temperature-sensitive pc phenotype. parag mehta and roger w. kukz, brooklyn, n y abnormal accumulation of calcium (ca) in myofibers is thought to play a role in pathogenic myonecrosis. attempts at reducing intracellular ca content with ca channel blockers in duchenne muscular dystrophy (dmd) have been clinically unsuccessful. dantrolene, however, which acts at the sarcoplasmic reticulum to inhibit ca release from intracellular stores, has produced dramatic reductions in serum creatine kinase (ck) in dystrophic mice and more recently in dmd. we investigated the effect of low-dose dantrolene in a group of 20 patients with limb girdle dystrophy (lgd), dmd, and other myopathic disorders. all subjects received dantrolene in incrementing doses from 25 to 100 mg daily over a 6to 12-week period. mean baseline ck was compared to ck with dantrolene treatment. dramatic reductions in serum ck levels averaging 50% were seen at 50to 100-mg doses in lgd patients (8). dmd patients (3) and patients with other myopathies (9) showed a similar but less dramatic reduction in ck. three of the weakest patients complained of increased fatigue while taking 100 mg, which suggests that higher-dose dantrolene may confound longer-term trials assessing clinical muscle strength and function. dantrolene in dosages well below conventional antispastic doses has a dramatic effect on serum ck and possibly myofiber necrosis in lgd, other dystrophies, and other muscle disorders. p77. antigen-specific therapy in myasthenia gravis: myasthenia gravis (mg) is mediated by anti-acetylcholine receptor (achr) antibodies, believed to be t-cell dependent, and antigen-specific therapy would be preferable to current nonspecific immunosuppression. exposing mouse t-cell clones to mhc class i1 molecules complexed with relevant antigen on planar membranes induced proliferative unresponsiveness (quill and schwartz, 1987) , and soluble mhc class i1 molecules complexed with myelin basic protein (mbp) peptide resulted in unresponsiveness of specific tlymphocyte clones in vitro (sharma et al, 1991) . we have used our well-defined dr4-restricted t-cell clone (ong et a [, 1991 ) isolated from an mg patient and specific for p138-167 of the achr alpha subunit. overnight incubation of these t cells with a soluble p138-167 : dr4 complex substantially inhibited the subsequent response to challenge with soluble antigen and presenting cells. in contrast, antigen response after preincubation with dr4 complexed to an irrelevant peptide (mbp 1-14), soluble dr4 alone, or an experimental approach studied in vitro p138-167 alone (at equimolar concentrations) did not differ appreciably from that in untreated cells. the p138-167:dr4 complex had no effect on other non-achrspecific cell lines/clones. these results suggest that the use of soluble mhc-peptide complexes may be an approach to selective immunotherapy in mg patients. p78. high-dose intravenous immunoglobulin in the shawke a. soueidan and marinos c. dalakas, bethesda, md inclusion body myositis (ibm) is a severe disabling inflammatory myopathy with characteristic clinical and histological features. it is commonly suspected when a patient with presumed polymyositis does not respond to available immunotherapies. the need for an effective treatment in patients with ibm prompted the present pilot study using high-dose intravenous immunoglobulin (hd-ivig), an apparently effective immunomodulating agent in several autoimmune neuromuscular disorders. we treated 4 patients with muscle biopsy-proven ibm with up to 2 monthly infusions of 2 gml kg ivig. after the first infusion, 3 of the 4 patients showed definite functional improvement consisting of independent ambulation, fewer falls, and increased ability to lift weights. the muscle strength of the proximal and less atrophic muscle groups improved by one grade mrc scale (from 4 to 5), whereas the distal and atrophic muscles remained unchanged. the improvement, sustained up to 7 months, was greater in patients with the most severe endomysial inflammation. we conclude that hd-ivig may be the first promising agent that can improve the strength of certain muscle groups in patients with ibm. because ivig is prohibitively expensive, the present encouraging results warrant a large-scale controlled therapeutic study. hays, and n . lutov, new york, n y , and milan, italy anti-myelin-associated glycoprotein (mag) antibodies from patients with neuropathy cross-react with the glycolipid 3-sulfated glucuronyl paragloboside (sgpg). among 24 patients tested by enzyme-linked immunosorbent assay and western blot, 15 had highly elevated antibody titers (56,400) to both mag and sgpg, 2 had highly elevated titers to mag alone, and 7 had highly elevated titers to only sgpg. immunostaining of normal nerve myelin by the antibodies correlated better with anti-mag than anti-sgpg activity. twenty-one of the patients, including patients in all 3 groups, had predominantly sensory or sensorimotor neuropathy, and biopsy specimens revealed deposits of igm and complement on affected myelin sheaths. three patients presented with motor syndromes, all with antibodies specific for sgpg; 1 had a predominantly motor demyelinating neuropathy, 1 had upper and lower motor neuron signs and peripheral neuropathy, and 1 had amyotrophic lateral sclerosis confirmed post mortem. all 3 had deposits of complement on peripheral nerve myelin sheaths. these studies suggest the following: (1) that anti-mag or sgpg antibodies may differ in their fine specificities and biological activities, (2) that anti-sgpg antibodies also may occur in motor neuron diseases, complicating the clinical presentation, and (3) that both mag and sgpg should be used as antigens in testing for autoantibody activity in peripheral neuropathy. david b. williams, john steele, ulla-katrina craig, sandra bryant, peter o'brien, and leonard kurland, newcastle, new south wales, australia, mangilao, guam, and rochester, m n continuing surveillance of neurodegenerative diseases in the mariana islands reveals changes in frequency and clinical characteristics since the 1950s that resemble those in other known western pacific foci (kii peninsula, japan, and irian jaya, new guinea). recent surveys of patients 50 years and older were conducted on rota, tinian, and yigo, guam. possible cases of dementia, parkinsonism, and amyotrophic lateral sclerosis (als) were identified by local trained personnel using a questionnaire, world health organization neurology test, and cognitive screening. those who failed the screening were examined by a neurologist. in the small populations of rota and tinian, there were no definite cases of als compared to i to 3 cases present in previous surveys. the high prevalence of parkinsonism-dementia complex (pdc) was unchanged and dementia was increased compared to earlier surveys. in yigo, als and pdc continue to be prevalent; however, the als patients are predominantly long-term survivors (> 10-year disease duration). in areas of previous high prevalence of als/pdc, dementia (as pdc) was associated with extrapyramidal signs, whereas in areas of previously low prevalence of als/pdc, dementia alone, possibly of alzheimer type, predominated. these observations help to confirm previous reports of changing clinical patterns, but suggest that the geographic distribution of the (presumed) environmental etiological agent for als/pdc remains stable after almost 40 years. p. v . fragokz, 0. frongillo, m. michisanti, g. antonini. derangements of the cardiac conducting system are the most common features of heart involvement in myotonic dystrophy (md). in view of chis 65 patients with various grades of md (43 males and 22 females, mean age 37 yr) underwent 12-lead ecg and holter monitoring. in 31 patients (48%), almost all with a severe grade of md, 1 or more conduction defects were found: first-degree atrioventricular block (i-avb) in 21 cases, second-degree avb in 1 case, right bundle branch block in 3 cases, left anterior hemiblock in 2 cases, left bundle branch block in 2 cases, and trifascicular block in 1 case (pacemaker implanted). an 18-year-old boy had a chronic atrial fibrillation with slow ventricular rate; he died suddenly while awaiting electrophysiological study. thirty-seven patients were followed over a mean period of 40 months (range 11-75 mo). a 54-year-old woman experienced a myocardial infarction and was excluded from subsequent considerations. conduction defects de novo appeared in 6 patients: i-avb in 5 and i-avb plus 11-avb (mobitz i and i1 type) in 1. nine patients, all with i-avb at initial evaluation, showed deterioration of their defects' conduction: a bifascicular block was observed in 6 cases and a trifascicular block in 3 cases (pacemaker implanted). conduction defects may run a malignant course in md, mainly in patients with more severe grades of the neuromuscular disease; thus, a close cardiological evaluation is mandatory for a proper therapeutic approach in single cases. hiroshi mitsumoto, surest5 kumar, kevy h. levin, robert w. shields, jr, michelle secic, asa j . wilbourn, and rajendra g . desai, cleveland, oh, and santa ana, ca twenty patients with amyotrophic lateral sclerosis (als) entered a pretreatment study with monthly quantitative isometric muscle strength tests (4 muscles in each extremity) and quantitative tufts scales including vital capacity, bulbar diadochokinetic rate, timed water drinking, timed rising from a chair, and timed walking 5 meters. after 4 to 6 months of pretreatment observation, the patients received 400 mg/kg intravenous immunoglobulin (ivig) (gamimune-n, miles) every month for up to 12 months. during the study period, 5 patients died and 2 patients withdrew from the study. the slope of each variable's changes over time before and after the ivig treatment were compared statistically. none of the quantitative scales showed significant change with ivig. however, the slope of the upper extremity muscle strength revealed improvement with ivig treatment ( p = .002 and .013, right and left, respectively). when all extremities were combined, the slope was also significantly improved with ivig ( p = .035). lower extremity muscle strength alone showed similar trends but no statistical significance. electrophysiological and immunological data were also analyzed. our results warrant a double-blind, controlled study with ivig for the treatment of als. leber's hereditary optic neuropathy (lhon) is a mitochondrial disorder with predominantly optic nerve abnormality. it can be associated with dystonia, ataxia, encephalopathy, cardiac abnormalities, and other less well-characterized neurological syndromes. we describe 2 members of a family with lhon with a slowly progressive motor polyneuropathy. a 22-year-old man and his 11-year-old sister have had mild motor impairment since early childhood. a gait disorder and distal muscle weakness became evident at puberty. the girl, but not the man, also has blindness, distal numbness, type i diabetes mellitus, and short stature. physical examination showed in both: bilateral foot drop, limb hyperreflexia but absent ankle reflexes, distal sensory loss, and a slight brownish scaly skin discoloration over the forearms. only the girl had clonus and optic nerve atrophy. the man had peripapillary telangiectasias. the jaw jerk was normal in both. motor nerve conductions in both showed absent tibia1 and peroneal responses, whereas other motor and sensory nerve conductions were normal. emg revealed denervation, more so distally. muscle biopsy findings showed recent denervation and previous denervation followed by reinnervation. n o raggedred fibers were observed with the modified trichrome and sdh stains. brain mri was normal in both. cerebrospinal fluid in the girl was normal. blood samples from both patients and maternally related family members revealed a mitochondrial dna point mutation at position 11778 (d. c. wallace). in this family, only 1 male had lhon; 3 females had lhon and 2 others, including the patients' mother, were asymptomatic carriers. this association of chronic motor neuropathy and hyperreflexia with lhon appears to be a distinct syndrome. the pathogenic mechanism by which the mitochondrial dna defect causes the neuropathy (and other neurological deficits) requires analysis. duchennelbecker muscular dystrophy henry j . kaminski, mazen al-hakim, r. john leigh, bashar katirji, and robert l. ruff; cleveland, oh fast-twitch extremity muscle fibers are preferentially affected in duchenne/becker muscular dystrophy (dbmd). since saccades are thought to be mediated by fast-twitch fibers, saccadic velocities would be expected to be decreased among these patients. to investigate involvement of extraocular muscle (eom) by dbmd, we studied with infrared oculography 3 patients who were wheelchair-bound and able to perform only minimal activities of daily living. saccades were slightly slowed but were within 95% confidence limits of normal. all 3 patients showed square wave jerk movements (swj). in 2 patients, the frequency of the swj exceeded that of normal subjects, which suggested central nervous system dysfunction. clinical neuroophrhalmological examination of 7 other dbmd patients was normal. this investigation is the first study of ocular motility in dbmd and demonstrates that eom function is relatively preserved even in far advanced patients. eom is composed of a heterogenous mix of fiber types that differ in anatomical and physiological characteristics from extremity muscle. study of eom in dbmd may prove to be useful in understanding why some muscles are resistant to dbmd and in characterizing properties that limit muscle degeneration. (supported by nih grants ey09186, ey067 17, the department of veterans affairs, and the evenor armington fund.) since patients with myotonic dystrophy (mtd) exhibit a marked resistance to insulin effect on glucose uptake and an impaired handling of the insulin-sensitive amino acids, it is possible that muscle wasting in mtd may reflect a derangement of insulin action on muscle protein metabolism. increased muscle protein breakdown in mtd would be expected if the normal inhibitory effect of insulin on protein catabolism is impaired. the forearm perfusion technique combined with measurements of 3-methylhistidine (3-mh) arteriovenous (a-v) differences by high-performance liquid chromatography provides a unique method to investigate skeletal muscle myofibrillar protein degradation in vivo. we studied 3-mh (a-v) and efflux from the forearm muscles in 8 men moderately affected with mtd and 10 normal men. efflux values (q) were calculated as the product of 3-mh (a-v) times forearm plasma flow measured by the indicator dilution technique. forearm 3-mh release (estimated as {a-v} or q) of mtd patients did not differ significantly from normal controls. we conclude that myofibrillar degradation is not increased in mtd even when measured in a muscle compartment selectively affected by wasting. the possibility of an impaired anabolic action of insulin in mtd has yet to be determined. to study the relationship between the ragged red fibers (rrf) and age, we have reviewed 500 muscle biopsy specimens prospectively. patients with well-established mitochondrial myopathy syndrome and with myopathies known to produce secondary rrf were excluded. the number of ragged red fibers (rrf) was counted under 40 x (lpf) magnification. rrf were identified by the modified trichrome and sdh stain. for the final analysis, the sdh staining was used. the frequency of rrf was analyzed in relation to patients' ages. the frequency of cases with more than 1 rrf increased with aging: 0% in the first decade, 16% in the fourth decade, and 55% in the eighth decade. the frequency of cases with more than 10 rrf also increased with aging: 0% in the first three decades, 4% in the fourth decade, and 19% in the eighth decade. of 25 patients with well-established mitochondrial myopathy syndrome, 24 had more than 10 rrf under lpf. the number of rrf in muscle increases with aging, indicating that mitochondrial activity in muscle is affected by aging. this finding may complicate the diagnostic criteria of mitochondrial myopathy in older individuals. ten rrf under lpf seems to be a reasonable cutoff point for the diagnosis of mitochondrial myopathy. schwartz-jampel, a rare autosomal-recessive syndrome characterized by short stature, myotonia, skeletal abnormalities, and peculiar facies, was reported by aberfeld in 1965. the same sibship was earlier reported by schwartz and jampel in 1962 with emphasis on blepharophimosis. as of this writing about 30 cases have been reported in the literature. most of the features of this syndrome are believed to be secondary to primary muscle disease. several peripheral electrophysiological studies showing features of myotonia have been reported. we describe 4 patients with schwartz-jampel syndrome showing evidence of central conduction disturbance documented by somatosensory-evoked potentials (seps). median nerve seps showed normal latencies to erb's point and n-13 in all. interpeak latencies between n13 and n19 were prolonged in 3 with complete block in 1. emg showed typical myotonic discharges in all. motor nerve conduction velocities, visual and brainstem auditory-evoked potentials, ct, and mri were normal in all. seps in the parents were normal. we believe this is the first report documenting evidence of central nervous system (cns) involvement in schwartz-jampel syndrome. schwartz-jampel syndrome and myotonic dystrophy may have similar cns ''lesion'' as sep abnormalities also have been shown in myotonic dystrophy. epidemiological studies have associated consumption of certain batches of l-tryptophan (lt) with development of the eosinophilia-myalgia syndrome (ems). 1,1 '-ethyledenebisltryptophan) (ebt or peak e), a derivative of lt, is a trace contaminant associated with implicated batches of lt. three female lewis rats received ebt, 4 mg per 100 gm daily, by intraperitoneal injection. four control rats received unimplicated lt. n o peripheral eosinophilia, rash, or weakness were observed in either group. one rat from each group died during the experiment (control-bowel infarct; ebt-death under anesthetic). after 132 days, forelimb and hindlimb muscles of the remaining animals were frozen and fixed for program and abstracts, american neurological association 253 ultrastructural and histological studies. two ebt rats had a myopathy involving soleus with a perimysial infiltrate containing lymphocytes, macrophages and sparse eosinophils, and necrotic fibers; the other showed few necrotic fibers in gastrocnemius. occasional eosinophils were seen in fascia in both animals given ebt but not in controls. fiber-type specific quantitative analysis of the microvasculature showed no decrease in the capillary index. ultrastructural examination revealed an increase in the size of microvessels in ebt animals. no denervation or reinnervation were demonstrated. the perimysial inflammation replicates an important feature of human ems and supports the epidemiological evidence that ebt is the causative agent of the disease. britta ostermeyer-shoaib, bernard m. patten, and tetsuo ashizawa, houston, t x five women (patients 1-5) developed motor neuron disease (mnd) 10 years (range 2-23 yr) after receiving silicone gel-filled breast implants. at explant in 4 patients, 2 had both and 2 had the left implant ruptured with silicone spilled into tissue. one woman (patient 6) developed amyotrophic lateral sclerosis (als) 5 years after numerous injections of free silicone into her face. biceps muscle biopsy specimens in all 6 showed neurogenic atrophy. patient 1 developed als with bulbar involvement and died 7 years later of respiratory failure. she had anti-gm1 antibodies and autopsy findings confirmed the diagnosis of typical als. patient 2 developed als, but also fatigue, myalgia, arthralgia, and skin rash. she had anti-gm 1 antibodies, antisilicone antibodies, positive antinuclear antibodies (ana), and decreased serum igg, iga, and c3, but increased igm and creatine phosphokinase (cpk) and chronic inflammation was revealed in muscle biopsy specimens. patient 3 developed als, but also had hair loss, skin rash, fatigue, headache, sjogren's syndrome, and positive ana. patient 4 developed als, but also had myalgia and arthralgia. patient 5 developed lower mnd, but also fevers, arthralgia, and joint stiffness. she had anti-gm1 antibodies, positive ana, antimyelin antibodies, and decreased serum igg and iga with chronic inflammation shown in nerve biopsy findings. patient 6 developed a steroidresponsive and steroid-dependent als with bulbar involvement. she had a monoclonal gammopathy in the cerebrospinal fluid and increased cpk. we suggest that silicone acts as an adjuvant that damages motor neurons via an indirect autoimmune mechanism. implants and silicone injections into the face p90. silicone adjuvant breast disease: more forty-five women developed mixed sensory-motor neuropathy (35), motor neuron disease (5), multiple sclerosis (2), multiple sclerosis-like syndrome (2), or myasthenia gravis (1) 7 years (range 1 mo-23 yr) after receiving silicone-gel breast implants (38), saline-filled silicone-covered breast implants (6), or direct injections of silicone into the breast (1). most patients had, in addition, severe fatigability, myalgia, arthralgia, morning stiffness, skin rash, lymphadenopathy, sjogren's syndrome, and short-term memory problems. laboratory results revealed in most of the women decreased or increased serum immunoglobulins, autoantibodies, a serum monoclonal gammopathy, or oligoclonal bands in cerebrospinal fluid. at explantation in 34, 14 had both and 7 had 1 implant neurological cases ruptured. biopsy of the fibrous implant capsule in most patients showed foreign-body giant cells containing refractile material consistent with silicone whether or not the elastomer shell was ruptured, indicating silicone bleed. the major finding on surd nerve biopsy was loss of myelinated fibers, on biceps muscle biopsy was neurogenic atrophy, and on pectoralis muscle biopsy was myositis with vasculitis and free silicone in some. we suggest that silicone may provoke damage to nerve and muscle, probably indirectly promoting autoimmunity. james f. howard, jr, m . kathleen donovan. and m. susan tucker, chapel hill, nc urinary symptoms of urgency and incontinence have been reported only rarely in patients with myasthenia gravis (mg) and then most often in association with myasthenic crisis. we report the case of a 31-year-old woman who in december 1987 had the onset of chest pain and was found to have a lymphocytic thymoma. in june 1989 she developed urinary incontinence, was found to have an open bladder neck. and underwent a suspension procedure for stress incontinence in january 1990. eight months later she developed exertional fatigue and a diagnosis of m g was made. in july 1991 there was a recurrence of urinary incontinence. these symptoms clustered toward the end of the day and at trough mestinon dose. neuro-urophysiological studies demonstrated her previous open bladder neck, the inability to sustain a pelvic floor contraction, and increased bladder wall contraction. singlefiber electromyography (sfemg) recordings from the anal sphincter demonstrated a mean consecutive difference (mcd) of 88 ysec, and 11% of fiber pairs had impulse blocking while recordings in the extensor digitorium communis muscle were normal. following a course of plasma exchange, there was significant clinical improvement with a reduction in the frequency of urinary incontinence, and improvement in anal sphincter sfemg studies (mcd, 60 ysec with no blocking). this case demonstrates that in those myasthenic patients with predisposing bladder outlet dysfunction, urinary incontinence may be a manifestation of worsening mg. diana m. escolar, mohamed eldaly, and jaime rich, boston, m a debate still exists as to the role of antibody versus celmediated factors in the pathogenesis of guillain-barre syndrome (gbs). we describe a patient with increased proportion of circulating t cells and a t-cell lymphoma who developed gbs and responded to intravenous immunoglobulin (ivig). a 57-year-old man with t-cell lymphoma drveloped gbs by clinical, nerve conduction, and cerebrospinal fluid criteria. he had an elevated proportion of t cells and markedly reduced b cells with a normal cd4/cd8 ratio. he responded rapidly to ivig, with return of nearly normal motor function in 1 week. three weeks later, he relapsed and his vital capacity dropped. ivig was again administered and within 24 hours he nearly recovered. a third relapse, 2 1 days later, again responded to ivig. he has remained asymptomatic with ivig maintenance. the role of t-cell lymphocytes in initiating experimental autoimmune neuritis has been shown by adoptive transfer experiments. this patient with t-cell neoplasia may represent an analogous model in hu-guillain-barre syndrome mans supporting the role of t-cell (cell-mediated) autoimmunity in the pathogenesis of gbs. ivig therapy may act primarily by inhibiting the t-cell-mediated attack on myelin. p93. sympathetic skin response: age effect it is frequently stated that the sympathetic skin response (ssr) can be elicited in all normal subjects, but the age of the investigated population usually is not considered to be a significant factor. we have examined the ssr in the upper and lower limbs of 100 normal subjects, aged 20 to 88 years (5 5 of them males). the ssr was elicitable in the lower limbs in all subjects under the age of 60 years and in the upper limbs in all subjects younger than 70 years. in contrast, it could be elicited in the lower limbs in only 345% and in the upper limbs in 655% of octogenarians. the amplitude of the response, though highly variable, showed a remarkable decline with age, both in the upper ( p < 0.0001, r = 0.51) and in the lower ( p < 0.0001, r = 0.65) limbs. these results indicate that age affects both the elicitability and the amplitude of the ssr. this has to be taken into consideration when evaluating the autonomic function in the elderly. we reviewed records of patients appearing to have motor neuron disease (mnd) to whom we recommended immunosuppression over 4 years (17 of 2 10 m n d patients). atypical findings engendered hope rhat they might have treatable neuropathy. electrophysiological studies were mainly consistent with mnd, but also showed conduction block or other evidence of relatively mild peripheral nerve disease in 12. sensory symptoms were present in 7 ; 1 or more reduced or absent deep tendon reflexes in 6; elevated cerebrospinal fluid protein in 8; and nonspecific abnormalities on sural nerve biopsies in 6 of 7. anti-gm1 levels were measured in 6 (including 1 who improved), but none was significantly elevated. immunosuppression included cyclophosphamide (12 patients); prednisone (10); plasma exchange (4); intravenous gammaglobulin (1); cyclosporine (1); and total lymphoid irradiation (1). seven treated patients died, 6 worsened, 1 remained stable for 2 years, and 1 improved. two patients declined treatment. one died and the other did not worsen in 3 years. we conclude that immunosuppression by our methods is, at best, rarely effective in atypical mnd. we studied serum antiglycolipid antibodies by enzymelinked immunosorbent assay in 11 patients with typical miller fisher syndrome (mfs), 6 patients with atypical mfs who were lacking in some of the 3 cardinal signs, 4 patients with guillain-barrc syndrome (gbs) with ophthalmoplegia, 20 patients with gbs without ophthalmoplegia, 20 patients with multiple sclerosis (ms), and 17 patients with other immunological disorders (oid) including systemic lupus erythematosus, polymyositis, and mixed connective tissue disorder. all patients with typical mfs had increased activity of igg antibody against ganglioside g q l b in the early phase, and it reduced with time. such anti-gqlb igg activity also was detected in 5 of the 6 patients with atypical mfs and in 3 of the 4 patients with gbs with ophthalmoplegia. in atypical mfs, the only patient without increased anti-gq1 b igg activity demonstrated normal eye movement with ptosis, whereas eye movement was impaired in the other 5 patients. no patients with gbs without ophthalmoplegia, ms, or oid had increased anti-gqlb igg activity. these findings suggest the close association between increased anti-gql b igg activity and impaired eye movement in mfs and gbs. serum anti-gqlb igg activity possibly plays a role in impaired eye movement in mfs. our goal is to develop an assay that can be used to monitor a relevant immune effect of interferon p (ifnp) in multiple sclerosis (ms) patients during the course of ifnp immuno-' therapy, since recombinant ifnp is being tested in multicenter clinical trials. this report extends our prior studies of the inhibitory effect of ifnp on t-cell activation. peripheral blood mononuclear cells (pbls) from 11 healthy donors and 10 clinically stable ms patients were studied. pbl cultures were stimulated with cona, mab to cd3, or with the phorbol ester pma in the presence of the calcium ionophore ionomycin. parallel cultures were studied in the presence of ifnp, 100 uiml. t-cell activation was monitored by determining the percent cells positive for il-2 receptor (il-2r) using facs analysis, or with a sensitive enzyme-linked immunosorbent assay for ifny. ifnp markedly inhibited il-2r expression induced by cona, by mab to cd3, or by pma and ionomycin, which activate t cells via different pathways. the results suggest that ifnp inhibits t-cell activation by actions independent of membrane receptors. we observed significant inhibition of cona-induced t-cell il-2r expression in both ms patients (20.6% inhibition, p < 0.05) and controls (26.8% inhibition, p < 0.05). there was no significant difference in percent inhibition between ms and controls, but there was more variance among the ms patients. variability of biological effects of ifnp on t cells may relate to differential therapeutic responses to exogenously administered ifnp in ms patients. preliminary experiments suggested that ifnp inhibited ifn gamma secretion by pbl stimulated with cona. ifnp inhibits a number of events associated with t-cell activation, in both normal and ms t cells. response to ifnp appears more variable in the ms cases. immunological monitoring of t-cell activation in patients receiving ifnp may assist in understanding the observed therapeutic responses and planning clinical protocols. myelin destruction is associated with many central nervous system disorders, such as multiple sclerosis, head trauma, and ischemic injury. inflammatory cells, monocytes/macrophages, and polymorphonuclear leukocytes (pmn) may me-program and abstracts, american neurological association 255 diate myelin injury, and lipid peroxidation may be an important mechanism. inhibiting myelin oxidation could have substantial benefit, so we evaluated the ability of a 21-minosteroid, u74500a, to inhibit myelin oxidation by monocytes and pmn. fresh rat brain myelin was harvested by multiple sucrose gradient, ultracentrifugation steps, and the final product was confirmed to be pure myelin by sds-page electrophoresis. human monocytes or pmn were obtained from 5 healthy, unmedicated volunteers by gradient separation techniques. monocytes (1.47 x lo6 cells/ml) and pmn (3.40 x lo6 cells/ml), myelin (460 pg protein/ml), and lipopolysaccharide (100 pg/ml) were incubated for 16 hours with or without 100 wm u74500a in 1-ml wells. myelin oxidation was evaluated by a thiobarbituric acid reactive substance assay for production of malondialdehyde (nmol/ ml). myelin oxidation by monocytes was 1.80 +-0.35 (mean 2 standard error of mean) without u74500a and was reduced to 0.76 ? 0.15 by 100 pm u74500a ( p < .005). pmn-mediated myelin oxidation was 1.89 _t 0.44 without drug and 0.64 ? 0.10 with drug ( p < 0.02). these results demonstrate that u74500a markedly inhibits monocyte-and pmn-mediated myelin oxidation and suggest that the 21aminosteroids may help disorders associated with inflammatory cell-induced myelin injury. microglia cells participate in the pathological reactions of the cns to multiple insults including trauma, inflammation, and neuronal degeneration. functional roles for these cells could include mediating tissue in jury, promoting repair, or modulating immune responses. with regard to the latter, we have observed that the majority of adult human-derived microglia express major histocompatibility complex (mhc) class 11 molecules under basal culture conditions, in contrast to astrocytes derived from the same surgical biopsy specimens. all morphological subtypes of the microglia (ameboid, bipolar, and ramified) expressed mhc class i1 molecules, indicating a discordance between morphology and mhc antigen expression as markers of microglia activation. the microglia actively ingest myelin constituents, as assessed using fluorescein-labeled myelin basic protein and laser confocal microscopy. autologous t cells (e') freshly isolated from the systemic blood and cocultured with candida antigen underwent active proliferation in the presence of 1 to 10% microglia, indicating the functional capacity of the microglia to serve as antigen-presenting cells. y-interferon augmented both mhc class 11 expression and functional antigen-presenting capacity. these results indicate the potential of the adult human microglia to promote immune reactivity within the cns. protein (mbp) neutralize anti-mbp purified from multiple sclerosis cerebrospinal fluid active phases of multiple sclerosis (ms) are associated with increased titers of intrathecally produced antimyelin basic protein (anti-mbp). anti-mbp can be purified by antigenspecific affinity chromatography from csf igg of patients with acute relapses of ms. eighteen synthetic peptides of human myelin basic protein (h-mbp) containing between 8 and 25 amino-acid residues and covering the entire length of the molecule were synthesized by the fmoc method. purified anti-mbp was reacted with increasing amounts of h-mbp as well as each of the 18 peptides in an initial liquid phase assay, and subsequently titers of f anti-mbp in all resulting mixtures were measured by a solid-phase radioimmunoassay . purified anti-mbp was neutralized by h-mbp and 6 of the 18 synthetic peptides containing overall residues corresponding to 61 to 106 of h-mbp. the remaining 12 synthetic peptides covering both the amino and carboxyl terminals of h-mbp did not significantly react with purified anti-mbp from these patients. in conclusion, anti-mbp purified from csf of ms patients has affinity for epitopes located between residues 61 and 106 of h-mbp. in a double-blind study involving 70 patients, we recently demonstrated that 4-aminopyridine (4-ap) is superior to placebo in the treatment of multiple sclerosis (ms) (ann neurol, in press). the related agent 3,4-diaminopyridine (dap) also appears to be effective. to enable a preliminary comparison, 14 patients, who in our previous study had not benefitted from 4-ap, were now treated (4 wk) with dap (up to 1.0 mg/kg/day) for 4 weeks in an open-label fashion. instruments for assessment and registration of side effects were the same as in the previous trial. the optimal dose of dap was 56.4 mg/day compared to 30.7 mg/day for 4-ap. significant changes in the edss (1.0 point or more) were not found, whereas significant improvements in neurophysiological parameters were found (no difference between 4-ap and dap, allp > 0.05). subjective side effects during 4-ap (8 patients) mainly suggested cns-function disturbance (dizziness and gait disturbance) and during dap (10 patients) mainly suggested peripheral nervous system-function disturbance (paresthesias). systemic tolerability clearly was diminished for dap compared to 4-ap, with 2 patients withdrawing because of severe gastric complaints and 1 developing liver function abnormalities. these data suggest that 4-ap is more valuable than dap in the treatment of ms. cy clophosphamide/methylprednisolone therapy in multiple sclerosis multiple sclerosis (ms) is a presumed autoimmune disease in which various forms of immunotherapy have been attempted. mri studies show the disease to be more chronically active than is clinically evident, thus a single treatment is unlikely to provide lasting benefit. recently, the northeast cooperative treatment group found that pulse cyclophosphamide (700 mg/m2 every other month for 2 years) slows progressive ms. we initiated a pilot study to determine the effect of a more intensive and prolonged pulse therapy regimen in both progressive and earlier stages of the disease. pulse therapy was given after induction with either iv cyclophosphamide/corticotropin (600 mg/m2 x 5 over 8 days) or iv methylprednisolone (1 gm x 7 over 7 days). patients received a single iv dose of cyclophosphamide (800-1,400 mg/m2) adjusted to produce leukopenia plus 1 gram of iv methylprednisolone monthly for a year, every 6 weeks for the next year, and every 2 months in the third year. another group received pulse methylprednisolone without cyclophosphamide. as of this writing, 128 patients have been treated, of which 24 have completed 3 years. interim analysis shows that patients treated with pulse methylprednisolone were more likely to become treatment failures than those treated with pulse cyclophosphamide/methylprednisolone (78% vs 45%) independent of induction therapy. withdrawal due to toxicity, however, was higher in the pulse cyclophospharnide group. current regimens involve methylprednisolone induction alone followed by pulse cyclophosphamide/methylprednisolone, analogous to lupus nephritis pulse therapy. this regimen can be given solely on an outpatient basis, does not cause alopecia, and is more amenable for use in earlier stages of the disease. to determine the incidence of pathologically confirmed malignancy in multiple sclerosis (ms) patients in funded clinical trials of cyclophosphamide (ctx) and of azathioprine (aza), data were collected longitudinally using telephone interviews, written questionnaires, physical examinations, and medical records for ctx and aza patients from a community in-hospital and out-patient ms clinic in fargo, nd. in the ctx study (goodkin et al, arch neurol 1987; 44: 823-4327) , 5 1 clinically definite (cd), chronic progressive ms patients were enrolled. twenty-four were controls and 27 received a mean induction dose of 6.08 grams. fourteen of the induced patients then received boosters every other month for 24 months resulting in a mean total dose of 15.92 grams. no malignancies were detected. in the aza study (goodkin et al, neurology 1991; 41:20-25) , 54 c d relapsing ms patients participated. twenty-five were controls and 29 received 3 mgtkg of aza daily by mouth adjusted to maintain a white blood count of greater than 3,50o/cmm for 2 years (mean dose 2.6 mg/kg). two of 29 aza patients developed resectable skin cancers: 1 basal cell (bcc) at 18 months and i squarnous cell (scc) at 43 months. the incidence of developing a bcc or scc was not significantly increased after initiating therapies as compared to the untreated ms controls (aza: fisher exact testp value = 0.49). no other malignancy has been detected during 46 to 100 months of clinical follow-up. allergic encephalomyelitis paula dore-dufly, ruth washington, and robert h. swanborg, detroit, m i postcapillary endothelium at sites of inflammation undergoes many changes referred to as activation. activated endothelial cells (ec) exhibit increased surface expression of immunorelevant proteins (icam-1; ncam, elam, and mhc class i and class i1 antigens [ags)). the sequence of events that characterizes ec activation may be important in susceptibility, induction, and perpetuation of experimental allergic encephalomyelitis (eae). in this study we examine expression of ec activation antigens in central nervous system (cns) microvessels in response to interferon gamma (ifn-y). cns microvessels from sjl and bio.s mice were incubated for 18 hours in ifn-y (500 u/ml), fixed, permeabilized, and then stained with an antibody that recognizes class i, class i1 mhc antigens, icam-1, and factor viii. relative fluorescence intensity was determined using a laser cytometer. results indicate that microvessels from all strains tested expressed no detectable icam-1 and class i1 ags. little class i antigen and transferrin receptors were expressed. upon stimulation with ifn-y, sjl microvessels exhibited increased surface expression of all ec activation ags. b1o.s microvessels exhibited icam-1 and class i mhc but mhc class i1 ags were not upregulated. results indicate that there are strain differences in the ec response to ifn-y. resistance of b1o.s mouse ec to activation by ifn may be a factor in decreased susceptibility or induction of eae, or both. protein-t-cell line-mediated experimental to investigate a possible pathogenic role of interferongamma (ifn-y) in experimental allergic encephalomyelitis (eae), an immunocytochemical study was undertaken to localize this cytokine in the spinal cord of lewis rats in which eae was produced by adoptive transfer of myelin basic protein-specific t cells. one pm-thick cryosections of spinal cord were labeled with monoclonal antibodies (mab) db-1 and db-12 recognizing different epitopes of rat ifn-y. in the spinal cord of naive rats, mab db-i, but not db-12, stained processes of astrocytes, suggesting that astrocytes contain a protein with an epitope cross-reacting with ifn-y. in rats with at-eae, numerous ifn-y-positive cells stained with both mab db-1-and db-12-positive cells were present from days 3 to 7 after cell transfer and had disappeared on day 10. at day 2 they entered the spinal cords predominantly through subpial vessels. ifn-y-positive cells could be identified as w3/13+ leukocytes as well as ed1-positive macrophages. as in naive rats, astrocytes in at-eae were labeled only with mab db-1, but not db-12. we never observed labeling of motor neurons with these mab. the transient presence of ifn-y in the rat spinal cord at the onset of at-eae suggests a pathogenic role of this cytokine in acute immune-mediated demyelination of the cns probably as a local stimulus for expression of mhc class i1 antigens and adhesion molecules, as well as for the release of tnf-a and toxic oxygen radicals from macrophages and microglia. immune responses to stress or heat shock proteins are implicated in the pathogenesis of several autoimmune diseases, including multiple sclerosis (ms). we examined the hypothesis that antigens in myelin cross-reacted with stress protein antigens. two techniques were used: immunocytochemistry and western blotting. frozen histological sections were prepared from normal human central and peripheral nervous system tissues. sections were incubated with 4 murine monoclonal antibodies to different mycobacterial stress proteins. antibody binding was determined using avidin-biotin complexed antimurine antibody linked to alkaline phosphatase. program and abstracts, american neurological association 257 a monoclonal antibody to the stress protein sp65 from m . leprae strongly stained both central and peripheral nervous system myelin. no myelin staining was noted with antibodies to sp70 or sp17. proteins from purified central and peripheral nervous system myelin were separated by sds-page. western blots were prepared using a monoclonal antibody to sp65 and a polyvalent rabbit antibody to myelin basic protein (mbp) as primary antibodies. antibody binding was determined using antimurine or antirabbit igg antibody coupled to alkaline phosphatase. strong staining of central but not peripheral mbp by the anti-sp65 antibody was observed. the rabbit anti-mbp antibody stained both central and peripheral nervous system mbp. the presence of antigenic epitopes shared by a stress protein and the potential autoantigen, mbp, supports the hypothesis that immune responses to stress proteins may be involved in the pathogenesis of presumed autoimmune diseases such as ms. (1). of 5 patients with borderline or positive csf lyme titer, 3 received parenteral ceftriaxone. all had later relapses consistent with ms. one patient received a month of oral doxycycline. the fifth patient had a negative western blot and was not treated. we conclude that an incidental borderline or positive lyme serology in an ms patient is unlikely to indicate neurological lyme disease. borderline serologies should be documented to rise on later testing; positive serologies should be confirmed by retest in a different laboratory or by western blot. csf abnormalities suggestive of neurological lyme disease (pleocytosis, protein elevation, intrathecal lyme antibodies) are distinct from those suggestive of ms (ogb, elevated igg index, mbp). in such patients antibiotic treatment may be appropriate, but will not alter disease course. when designing and analyzing therapeutic trials for multiple sclerosis (ms), investigators commonly compare the proportion of patients in the experimental and control groups who worsen one or more steps on the disability status scale (dss) or expanded dss during the study (typically 2 years' duration). however, the intervals between the scores in the dss may not be equal. it may be easier to change by one or more steps in the lower end of the scale (e.g., dss = 1-3) than in the midportion of the scale (e.g., dss = 4-6). to evaluate this possibility, we compared the proportion of patients who worsened by one or more steps in the 2 years after entering our program with dss = 3 or with dss = 6. fifty-one percent (29157) natural history data may be useful for designing therapeutic trials for multiple sclerosis (ms). since 1971, we have collected such data in a standard format on patients in the ucla multiple sclerosis research and treatment program. t o describe the course in our group, we have performed survival analysis (kaplan-meier) of patients with 3 or more assessments who entered the clinic with disability status scale (dss) scores of 1 to 7 (n = 395). an increase of one or more steps in the dss score persisting for more than 3 months defines worsening. median times to worsening for a dds at entry of 1 to 5 were approximately 2 years (range 1.7-2.2); but were 4.6 years for dss 6 and 3.6 years for dss 7. for those starting at dss 6 (n = 129), only 13% worsened by 1 year, 26% by 2 years, and 39% by 3 years. the percent worsening when starting at dss 3 (n = 61) were 41%, 48%, and 54%, respectively. these variable rates of worsening (i.e., time spent at each starting level) influence therapeutic trial design. including patients with dss 6 or 7 will increase the sample size and study duration. for testing nontoxic agents, we recommend enrolling patients with dss 1 to 5. for more toxic treatments, we suggest dss 3 to 5. (partially supported by usphs grant ns 087 1 1, the conrad n. hilton foundation, and various donors.) pi 12. cholinergic antagonists and p-adrenergic agonists inhibit experimental allergic encephalomyelitis in an additive manner mark a. jensen, avertano noronha, and bawy g. w. amason, chicago, il lymphoid organs receive a sympathetic (sns) and possibly a parasympathetic innervation. lymphocytes express padrenergic and cholinergic receptors and thus are sensitive to regulation by these neurotransmitters. the severity of experimental allergic encephalomyelitis (eae) is increased in sns-ablated animals. local parasympathectomy decreases plaque-forming responses in submandibular nodes. p,-adrenergic receptors are upregulated on cds t cells in progressive multiple sclerosis, as are m,-muscarinic acetylcholine receptors on cd4 t cells. we examined the effect of isoproterenol, a p-adrenergic agonist, and scopolamine, a cholinergic antagonist, on the course of eae in lewis rats. eae was induced by injection of 0.1 ml of incomplete freund's ad juvant containing guinea pig spinal cord (25% wlv) and m. tubercdosis (3 mgiml) in one hind footpad. scopolamine (6.6 mglkg, twice daily) and/or isoproterenol(o.15 mglkg, twice daily) or saline were injected subcutaneously starting on the day of immunization. scopolamine or isoproterenol alone reduced severity ( p < 0.05, t test) and duration ( p < 0.05, t test) of disease compared to controls. the combination of scopolamine and isoproterenol further reduced disease severity compared to either agent alone ( p < 0.05, x2 test), suggesting an additive protective effect of cholinergic antagonists and p-adrenergic agonists in eae. antigen-presenting cells a . conrad, v. sanders, p. schmid, and w. w . tourtellotte, los angeles, c a tissue is cryopreserved by the method of tourtellotte; this procedure minimizes or eliminates ice artifacts and preserves surface protein markers. the dissected plaques are lightly fixed in 5% paraformaldehyde and then suspended in 30% sucrose. blocks are mounted in oct, cryosectioned at 20 p,m, and picked up on gelatinized slides. the activity of plaques is determined by the presence or absence of myelin debris (antimyelin basic protein stain or lux01 fast blue) or presence or absence of neutral lipids indicating myelin digestion as seen by oil red 0 (oro) staining and the presence or absence of a class i1 major histocompatibility complex antigen (evidence for an antigen-presenting cell) on macrophages or microglia as seen by immunocytochemically staining for hla-dr (hb104 atcc). the following is our classification of the activity of multiple sclerosis (ms) plaques. type i, the most active, is defined as an area of hypercellularity, positive for hla-dr with no o r 0 staining or staining for myelin debris. type 11, or active, is defined as an area of hla-dr-positive cells that stain mildly with o r 0 at the plaque edge but positive for myelin debris; evidence for demyelinating activity <72 hours (prineas; raine). there is an inner area of plump cells that are positive for hla-dr and oro. type 111, or modestly active, is defined as a "shelf" of plump hla-dr-positive cells at the edge loaded with program and abstracts, american neurological association 259 oro-stained neutral lipid but a paucity of or no myelin debris. a region of hypocellularity is observed at the center of plaque. type iv, least active or inactive, is defined as scattered hla-dr-positive cells at plaque edge with little or no o r 0 staining and no evidence of myelin debris. the frequency of plaque types was determined from a random sample of 97 ms tissue blocks from 23 patients who died of ms. ten percent of the plaques were type i; 20%: were type 11; 209% were type 111. the majority of plaques (505%) were inactive (type iv). accordingly, it is necessary to classify the demyelinating activity of ms plaques for protocols designed to investigate etiopathogenesis. do these results suggest that whatever causes ms can be eradicated in half of the demyelinating areas by the time of death? p114. localization of g d l b ganglioside antigen in the human peripheral nervous system susumu kusunoki, atsuro chiba, tadashi tai, and lchiro kanazawa, tokyo, japan serum antibodies against ganglioside gm 1 and/or g d l b frequently are detected in autoimmune neuropathies such as rnultifocal motor neuropathy, igm paraproteinemic neuropathy, and guillain-barre syndrome. some of them bind to gm1 or g d l b monospecifically but the others cross-react with both of the antigens. to investigate respective localizations of gm1 and g d l b antigens in the human peripheral nervous system (pns), immunohistochemical study of dorsal root ganglia (drg), dorsal roots, ventral roots, and sympathetic ganglia (sg), which were obtained from human autopsy specimens, was performed by using 2 mouse monoclonal antibodies, each monospecific to gm1 and gdlb. ggr12, monospecific to gd1 b, immunostained nerve cell somas and axons of drg, sg, and dorsal and ventral roots. ggrl2 also recognized some myelin, including paranodal areas. however, gmb16, monospecific to gm1, did not bind to either neuron or myelin. thus, serum anti-gdlb antibody can bind to neurons and some myelin in the human pns. further study is necessary to identify the localization of gm 1 antigen, because previous biochemical studies have shown that gm1 is also present in the human pns. the purpose of this study was to compare t4 and t8 lymphocytes in migraine patients versus controls, and a review of the literature was done. fifty-six migraine patients, aged 18 to 53, were tested, as were 19 controls. the t4 :t8 ratio in migraine patients was 2 : 1 1, compared to 1 : 60 for controls. suppressors (t8) were reduced from 918 in controls to 482 in migraine patients. helpers (t4) decreased from 1,436 in controls to 985 in migraine patients, and total ?' lymphocytes decreased from 2,513 to 1,698. previous studies have revealed similar differences in t lymphocytes, with higher t4 : t8 ratios being found in both migraine and tension-type headache patients. in food-induced migraine, an increase in circulating immune complexes was noted, with increased t4 levels. differences in serotonin binding to mononuclear cells have been noted in migraine patients. a decreased sensitivity of the lymphocyte beta-adrenergic receptor in migraine patients was suggested by one study. after lymphocyte incubation with il-2, the natural cytotoxic response is augmented in cluster patients. the percentage of lymphocytes expressing receptors for il-2 was decreased in cluster patients in a fur-review of the literature ther study. this il-2 receptor defect was independent of whether the clusters were present. there is a loss of highaffinity binding sites for serotonin on lymphocytes in both episodic tension and chronic tension headaches. we used positron emission tomography (pet) to measure local cerebral blood flow in 6 volunteer subjects while they performed tasks of memory-guided saccades and a visual fixation control. tasks were performed continuously for 70 seconds during emission scans, after bolus injection of h2lso. eye movements were verified with electrooculography. areas of significant increase in regional blood flow between tasks were matched to three-dimensional reconstructions of brain magnetic resonance images of each subject. compared to the visual fixation control, saccade tasks evoked bilateral activation in the posterior superior parietal lobule with extension into the inferior parietal lobule. activation was also seen bilaterally in an area of frontal cortex immediately rostra1 to the precentral gyrus extending from the superior frontal gyrus to the inferior frontal sulcus. the increased blood flow in the posterior parietal cortex most likely corresponded to enhancement of visual attention required during saccades, while that in the frontal lobe, which included the frontal eye fields, indicated activation for saccade motor output. pamela blake, alexander s. mark, martin kolsky, and jorge kattah, washington, dc fifty patients with third cranial nerve (cn) palsy underwent precontrast and postcontrast mri to assess the utility of this study in this clinical context. mri demonstrated an appropriate lesion in 32 cases. six patients had brainstem lesions (2 infarcts, 1 mass lesion, 1 cryptic vascular malformation, 1 hemorrhagic shearing injury, 1 with compound q toxicity). lesions of the cisternal segment of the nerve were present in 12 patients (4 aneurysms, 4 lymphomas, 1 ophthalmoplegic migraine, 1 viral meningitis, 1 coccidiodomycosis, 1 nerve avulsion), with enhancement of this segment in 7 patients. fourteen patients had cavernous sinus lesions (2 lymphomas, 2 nasopharyngeal carcinoma, 4 tolosa-hunt syndrome, 2 cavernous carotid aneurysms, 3 pituitary apoplexy, 1 aspergillosis). eighteen patients, all with history of diabetes or vascular disease, had normal mri results, suggesting microvascular infarction of c n 111. in patients with cn i11 palsy, mri can detect the presence of brainstem or cavernous sinus lesions and often can suggest their cause. mri with contrast enhancement can demonstrate involvement of the cisternal segment of cn i11 in patients with inflammatory or infiltrative processes that previously could not be radiographically demonstrated. our study suggests microvascular infarction does not cause nerve enhancement on contrast-enhanced mri. we describe 2 patients with acute hyperglycemic, hyperosmolal, nonketotic stupor who had ocular flutter or opsoclonus clinically. these are the fourth and fifth adult patients reported with the acute onset of stupor and opsoclonus; all patients had nonketotic hyperglycemia and hyperosmolality (rapid eye movement sleep also causes stupor and saccadic eye movements). three of the 5 patients had myoclonic jerks in addition to opsoclonus. in the 5, opsoclonus began when glucose and osmolality acutely increased, and completely resolved when glucose and osmolality became normal, showing that opsoclonus is a specific and reversible effect of the metabolic disorder and implying that either acute hyperglycemia or hyperosmolality directly causes opsoclonus. since acute hyperosmolality caused by nacl or sucrose can cause a similar syndrome in experimental animals (trans am neurol assoc 1962; 87:33-36) and infants, hyperosmolality is probably more important. opsoclonus is thought to be due to abnormal activity of saccadic "burst" cells in the pons. acute hyperosmolality may cause spontaneous saccades by disinhibiting burst cells from normal "pause" cell inhibition or by directly activating burst cells. the combination of acute deterioration in mental status and either ocular flutter or opsoclonus should suggest acute hyperosmolality, in particular, nonketotic hyperglycemia. neural cell adhesion molecule (n-cam) and the related cell adhesion molecule l1 play significant roles in axon outgrowth and mediation of cell-cell contact in development, and after peripheral nervous system injury. to understand the role of these molecules after injury in the adult cns, we studied alterations in n-cam and l1 in the rat brain's response to entorhinal cortex (erc) lesion. post lesion, reactive synaptogenesis and axonal sprouting follow a well-defined temporal course in restoring the synaptic density of the dederented outer two-thirds of the hippocampal dentate gyrus molecular layer (ml) to near prelesion levels. we found striking regionand lamina-specific staining of n-cam and l1 in the normal hippocampus and marked alterations in these molecules after injury. embryonic n-cam, present in high amounts during development but expressed at very low levels in the adult hippocampus, was massively re-expressed in the denervated zone; the embryonic form was still heavily expressed 60 days later, when synapse number returned to >so% of prelesion levels. l1 staining, normally evenly distributed through the ml of the dentate, was completely lost in the outer ml, which is denervated by the erc lesion. this staining had not returned by 60 days after lesion. neural cell adhesion molecules play a role in specificity of neural connectivity both in development and after injury. in reactive synaptogenesis and axonal sprouting after injury, both ontogenetic (the reexpression of embryonic epitopes) as well as uniquely adult sequences of repair are utilized. following hemispherectom y" a. pascual-leone, h . t. chugani, l. g. cohen, j . p . brasil-neto, e. m . wassermann, j . and m. hallett, betbesh, md, and los angeles, ca we studied 7 subjects, aged 18 months to 32 years, who underwent hemispherectomy 6 months to 25 years earlier for intractable epilepsy. all had a spastic hemiparesis contralateral to the resected hemisphere, which was present presurgically. we used focal transcranial magnetic stimulation to map the areas of the preserved hemisphere targeting the abductor pollicis brevis (apb), the biceps, and the deltoid ipsilaterally and contralaterally. in 2 subjects who had hemispherectomy after age 10, the same area targeted ipsilateral and contralateral muscles. in the remaining 5 subjects, who were more functional, 2 areas targeted ipsilateral muscles. one area coincided with the contralateral representation, but stimulation induced motor-evoked potentials (meps) of lower amplitude and longer latency in the ipsilateral muscles. the other area, 2 to 4 cm anterolaterally, targeted exclusively ipsilateral muscles and stimulation induced meps of normal amplitude and latency. this separate ipsilateral representation was more distinct in subjects studied a long time after the hemispherectomy and in those who were younger at the time of the operation. these results show evidence of motor reorganization after hemispherectomy. better motor function is associated with topographically differentiated ipsilat-era1 and contralateral representations, which may depend on age at the time of hemispherectomy and the time since then. cynthia l. comella, glenn t . stebbins, nancy brown-toms, and christopher g. goetz, chicago, il in a single-blind, crossover study, we evaluated the effect of an intensive outpatient physical rehabilitation program (re-hab) on the severity of parkinson's disease (pd). the re-hab program consisted of 3 2-hour sessions per week for 4 weeks. sixteen patients completed 2 phases, a rehab phase and a control phase, separated by 6 months. the order of participation in each phase was randomized. all patients were evaluated using the unified pd rating scale with subscales for mentation (ment), activities of daily living (adl), and motor function (mot) by an investigator blinded to the rehab phase of the patient. all patients were evaluated immediately before and after each phase. pd medications were not changed during any phase. following the re-hab phase, there was significant improvement in adl score (pre-rehab 12, post-rehab 8, p = .005 wilcoxon) and in mot score (pre-rehab 26, post-rehab 2 1, p = ,008 wilcoxon), but no change in ment score. after the con-trol phase, there was no significant change in any outcome measure. this is the first controlled, crossover study of an intensive rehab program in pd. it demonstrates that re-hab improves objective motor function and adl scores. sensitive and quantitative measurements of leg weakness, one of the most common deficits in multiple sclerosis (ms) patients, can be made using specialized extremity testing equipment. to determine whether such determinations could be used in clinical trials, 6 ms patients with leg weakness that had been stable for at least 2 months were evaluated every 60 days over a 4-month period. each testing session was carried out at the same time of day and medication dosages and schedules were kept constant (only 1 patient was taking baclofen and his dosing remained constant). quadriceps and hamstrings strengths were measured in isometric contraction in a mechanical testing apparatus (kincom). variability for each series of determinations was expressed as the standard deviation of the mean as a percent of the mean. the overall variability then was expressed as the mean of the individual variabilities. the mean variability for the strength determinations over 4 months was 5.74 k 5.3896, and only one series of determinations out of 28 had greater than 20% variability. these results suggest that quantitative strength determinations might be useful in clinical trials, and early experience in trials of aminopyridines will be discussed. polymyositis (pm) is an inflammatory myopathy of unknown cause, but the accumulating data strongly suggest an autoim-mune pathogenesis. the histological picture is of muscle fiber necrosis and inflammation, whereas in postviral fatigue syndrome (pfs), a disorder characterized by severe fatigue with myalgia and psychiatric symptoms, the histological picture of muscle is essentially normal. enteroviruses have been implicated on epidemiological and serological studies in both. we have used the polymerase chain reaction (pcr) and an enteroviral-specific probe and found persistent enteroviral genomic material in both pm and pfs muscle biopsy specimens. furthermore, we used a radiolabeled full-length cdna probe derived from coxsackie b1 in an in situ technique to look for viral d n a in pcr-positive cases. coxsackie genome was clearly identifiable in the muscle biopsy specimens of patients with pm but negative in pcr enteroviral-positive cases of pfs. the virus excites an inflammatory reaction only in pm. a murine animal model for pfs developed in our laboratory showed positive muscle pcr using enterovirus probes and a conspicuous increase in interleukin 6 within the brain. these results provide major clues in the search for the etiology of these two puzzling disorders. human t-lymphotropic virus type i (htlv-i) is a cause of adult t-cell leukemia and tropical spastic paraparesis. in a specific population of iranian jews originating from the city of mashad, there is a high incidence of htlv-i infection (1 1.5%) and associated t-cell leukemia. we evaluated the incidence of possible correlation between htlv-i infection and spastic paraparesis in israeli mashadi-born jews. we have examined 41 mashadi-born immigrants in a mashadi community center (16 men, 25 women, mean age 66 t_ 13.7 yr) and 40 non-mashadi iranian-born jews. blood samples were tested for htlv-i antibodies by particle agglutination test. the polymerase chain reaction (pcr) was used to amplify htlv-i sequences of d n a from peripheral blood mononuclear cells. twelve mashadi-born immigrants (295%) were seropositive for htlv-i. in 10 of those serologically positive for htlv-i (83%), neurological examination revealed spastic paraparesis of varying severity. none of the non-mashadi iranian jews were seropositive for htlv-i or had clinical signs of spastic paraparesis. these results support other studies of htlv-i-associated myelopathy. the high incidence of htlv-i-associated spastic paraparesis in the mashadi community might be related to their unique history of a high rate of intermarriage among members of this ethnically segregated group. further epidemiological studies are underway to evaluate the incidence of htlv-i in mashadi families as well as in mashadi-originating jews born in israel, to identify whether infection might be genetically transmitted. lymphotropic virus t y p e i-associated acute t-cell leukemia/lymphoma william j . harrington, jr, william a. sheremata, susan snodgrass, and mark raven, miami, fl human t-cell lymphotropic virus type i (htlv-i)-associated acute t-cell leukernia/lymphoma (atl) is thought to produce important c n s disease infrequently. we wish to correct this impression by presenting neurological findings in 15 patients seen between 1989 and the present. all had positive western blots to htlv with polymerase chain reaction confirmation of htlv-i infection. only 2 had a concomitant human immunodeficiency virus infection. all were black, aged 31 to 86 years, 7 were men and 8 women. all but 3 americans came from the caribbean nations of haiti (51, dominican republic (l), jamaica (6), and trinidad (1). sexual transmission was the risk factor for htlv-i for all except for 1 intravenous drug user. all patients were systemically ill. three had preceding neurological abnormality (1, 8 months, and 14 yr) and 8 had major neurological disease concomitantly. two of these had tumor masses demonstrated in brain and 1 in the spinal canal. one had a minor facial sensory abnormality; only 3 had no deficits. we conclude that cns disease is commonly associated with atl, and that in the us atl occurs principally in caribbean natives. a. nath, v . hartloper, and m . furer, winni$eg, manitoba, canada microglia and astrocyte cultures were established from human fetal brain. microglia were infected with human immunodeficiency virus (hiv) strains, hiv,, or hiv,,,, resulting in a rising titer of p24 antigen in the supernatants. multinucleated giant-cell formation, vacuolar changes, and rising levels of lactate dehydrogenase in the supernatants were seen, indicating a cytopathic infection of microglia. astrocytes were infected with free virus or cocultivated with an hiv-infected lymphocyte cell line (hut-78). after a productive phase (rising titers of p24 antigen and detection of hiv antigens by immunocytochemistry), the cells went into a latent phase where hiv could be detected only by dna polymerase chain reaction. a 10-fold increase in astrocytes staining for hiv antigens was seen after cocultivation with hut-78 cells. lymphocytes adhered to astrocytes by 3 hours of cocultivation. no adhesion was seen to microglia. fusion of plasma membranes was seen on electron microscopy. infected astrocytes did not show cytopathic or morphological changes. cell-to-cell contact may be important in viral transmission to astrocytes. hszao-huei chen, steven b. stein, wing kong, and raymond p. roos, chicago, i l one of our goals is tq delineate molecular determinants for disease phenotypes produced by theiler's virus (tv), a mouse picornavirus. the identification of these genes and gene products may clarify viral pathogenesis and also lead to the identification of genes that are important in normal cns function and nonviral cns disease. members of the gdvii subgroup of tv cause an acute, fatal neuronal infection, whereas members of the to subgroup are less neurovirulent and produce a demyelinating persistent infection. our studies of infectious tv cdna clones have demonstrated that the gdvii 1 b(vp2)-2c segment is critical for neurovirulence. several other areas of the genome, including the 5' untranslated region (s'utr), also affect tmev-induced disease. the 5'utr of poliovirus, another picornavirus, has a critical role in paralysis; this effect on neurovirulence is believed to result from an altered translational efficiency related to bind-region ing of neural cell proteins. tv 5'utr has an unusual predicted secondary structure, even for picornaviruses. our studies demonstrate that the tv 5'utr affects translational efficiency and has a distinctive protein-binding pattern. investigations of the tv 5'utr may clarify features of translational regulation of cns genes in general. p129. coronaviruses infect primate brain from g a y f. cabirac, ronald s. murray, galen cai, kristen hoel, and kenneth soike, englewood, co, and covington, la recently, we described finding coronavirus (cv) rna and antigen in active demyelinating plaques of multiple sclerosis (ms) brain tissue (murray et al, ann neurol, in press). molecular analysis showed the cv rna to be more closely related to murine cvs than to human cvs. we then demonstrated that, following intracerebral inoculation, the murine cv jhm and the putative ms isolate cv-sd could infect and cause demyelination in primate brain (murray et al, virology, in press). we now have data showing that murine cv can infect primate brain following intranasal or intravenous routes of inoculation. standard virology, histopathology, and the molecular analysis of viral cytotropism will be presented. we conclude that cvs related to murine cvs can infect primate cns from peripheral routes and warrant consideration as potential human pathogens. probes (gag, pol, or enw). eleven were white and 9 were black. a history of transfusion was obtained in 8, and sexual risk of transmission was present in 8 but not in 4 others. fulminant disease occurred in 4 transfused men 3 months to 4 years later but such disease was only seen in 1 woman (in 1 month). in contrast, 2 of 3 women with multiple sexual partners had rapid progressive disease. the male-to-female ratio was 4 : 4 for transfusion association and 5:3 for those at sexual risk but 0:4 for unknown risk, transfusion is an important risk for tsp/ham and the diagnosis must be considered in all gait problems, regardless of the "diagnosis."transfusion association should decrease with regular testing of blood donors, but this will not affect the risk of sexual transmission. spastic paraparedhtlv-i-associated myelopathy (tsp/ ham). it is unclear why htlv-i infection causes atl in some individuals and tsplham in others. differences in the genome of viral isolates or immunological and host factors have been hypothesized to play a role in disease expression. at present there are no animal models of tsplham and no suitable animal models of htlv-i infection that can address these issues. we transplanted severe combined immunodeficient (scid) mice with peripheral blood mononuclear cells (pbm) from tsplham patients in an attempt to produce htlv-i disease. two weeks after transplantation of pbm from 2 tsplham patients, we detected anti-htlv-i igg in serum samples of 7 of 8 scid mice by enzyme immunoassay using sonicated whole virus. five weeks after transplantation, we detected anti-htlv-i igg to p19, p24, gp46, or gp61168 in serum samples of 5 of 7 scid mice by immunoblot of disrupted virus. these findings suggest that scid mice may be valuable in the study of molecular and pathological determinants of htlv-i-induced disease. theiler's virus produces an encephalomyelitis in susceptible mice. during the course of the disease, specific regions in the cns become infected. compared to the immunocompetent mouse, the nude mouse provides a useful model where viral dissemination can be studied in the absence of functional t lymphocytes and antibodies. we investigated the distribution and spread of the da strain of theiler's virus in the cns of nude mice. by immunohistochemistry, the hippocampus, arnygdaloid nuclei, entorhinal cortex, cingulate cortex, thalamus (anteroventral nuclei), midbrain, and spinal cord all contained viral antigens by 2 weeks after infection. in addition, the olfactory nuclei, mamillary body, hypothalamus, basal ganglia, and nucleus raphe dorsalis often were involved. in the brain, the limbic system was the site commonly infected by theiler's virus. the time course of virus dissemination varied depending on the site of initial virus infection, though the final distribution of virus was the same. olfactory bulb injection, which is a direct inoculation into the olfactory pathway, resulted in more rapid spread than did cortex injection. we demonstrated the constant presence of viral antigen in the limbic system and a different kinetics of viral dissemination between the two different routes of intracerebral inoculations. these results suggest that limbic structures and their connections are important to the dissemination of theiler's virus. 1-associated myelopathy in a northwest native indian d. foti, d. werke, g. dekaban, g. p. a . rice, andj. oger, vancouver, bc, and london, ontario, canada a 59-year-old indian of the oweekeno tribe was admitted for investigation of a myelopathy. initially symptomatic with midthoracic radicular pain, she developed progressive spastic paraparesis over 1 year with mild sensory symptoms and urinary retention. mri of the cord and brain were normal. csf showed elevated protein (930 mgll), 13 lymphocytes, and weak oligoclonal banding with evidence of intrathecal igg synthesis. antibodies to human t-lymphotropic virus type i (htlv-i) were positive by enzyme-linked immunosorbent assay and western blot on both serum and csf. presence of htlv-i was demonstrated by polymerase chain reaction of blood lymphocytes. htlv-i-associated myelopathy, or tropical spastic paraparesis, is endemic in southern japan, the caribbean basin, and several tropical islands but has not been reported in natives of northwest canada. this patient's only risk factors for htlv-i infection were 3 blood transfusions 30 years previously. ongoing familial and epidemiological studies as well as virus sequencing should indicate if this case represents an indigenous or an imported infection. caused by herpes simplex virus type 1 lawy blankensbz) and herbert 0. newton, columbus, oh myeloradiculitis occasionally occurs secondary to herpes simplex virus type 2 (hsv2) infection, but rarely has been reported after herpes simplex virus type 1 (hsv1) infection without encephalitis. we describe a 30-year-old man who developed cervical myelopathy and radiculitis, never developed symptoms of encephalitis, and had positive hsvl spinal fluid cultures. h e initially developed extremity weakness and incoordination, numbness, paresthesias, and neck pain. evaluation was negative except for mri results, which showed a high-signal lesion centrally within the cervical cord. the weakness, sensory loss, and radicular pain progressed over several months. subsequent mri showed extension of the high-signal abnormality and mild enlargement of the cervical cord. symptoms stabilized briefly with dexamethasone but soon worsened, and were accompanied by paroxysmal kinesiogenic dystonic episodes of his arms and right leg. repeat evaluation was unrevealing except for the spinal fluid, which grew out hsv1. the patient was treated with dilantin and a i-month course of intravenous acyclovir, with slow improvement of neurological status and resolution of the dystonic episodes. this case illustrates that hsvl can cause a myelopathy with a subacute and protracted course, requiring serial was more frequent in the middle-aged group ( p < 0.0001, p = 0.001). history of hypertension, previous strokes, diabetes mellitus, and antithrombotic treatment was similar, as were sex ratio, qualifying event type (transient ischemic attack or nondisabling stroke), and angiographic features; stenosis severity in either side and presence of ulceration were all similar. in elderly patients, ecad is associated with symptomatic cardiac disease (scad or af), whereas in middleaged patients it is associated with precursors of generalized atherosclerosis (smoking and hyperlipidemia). to identify the anatomic factors correlating with dementia in patients with lacunar infarctions, we examined digitized ct data on 58 elderly patients (mean age = 71.6 yr; education = 7 yr) who presented with acute lacunar infarction. dementia was diagnosed in 13 patients (22.4%) based on neuropsychological tests given 3 months after stroke onset. the following ct variables were assessed: infarct location and number, total infarct volume, brain parenchymal and csf areas at 3 levels, and width of the frontal horn, third ventricle (tvw), and lateral ventricle plus their ratio to the intracranial width. atrophy and leukoaraiosis were rated semiquantitatively using a standard scoring method. in the group overall, mean infarct volume was 0.64 cc and mean infarct number was 3.8. in univariate analyses, dementia was significantly related to infarct volume, number, tvw, bilaterality, and infarct predominance on the left side, but not to leukoaraiosis or atrophy. in a regression model adjusting for demographic factors, the ct variables correlating independently with dementia status were infarct number (p = 0.37, p = .01) and the presence of left cerebral infarcts (p = 14.17, p = .002). we conclude that the most important ct variables related to dementia in lacunar stroke are lesion multiplicity and the presence of lesions on the left side. brain ischemia results in potassium (k+)-induced voltageregulated presynaptic calcium (ca") accumulation, which may contribute directly to neuronal in jury presynaptically, and also promote excessive release of excitatory neurotransmitters leading to cell damage postsynaptically. k+-induced depolarization of brain synaptosomes may be used as an in vitro model to study the therapeutic potential of pharmacological agents to alter ischemia-induced presynaptic ca2 + accumulation. we preincubated gerbil cerebral cortical synaptosomes in r56865 (janssen pharmaceutical) at concentrations of to lo-' m, subsequently depolarized the synaptosomes with k + , at concentrations of 5 to 6 0 mm, and measured intrasynaptosomal ca2' ([ca2+]) with the fluorescent indicator fura 2. r56865 had no effect on ecaz'i in nondepolarized synaptosomes, but significantly (<.01, student t ) depressed depolarization-induced {ca2+] at to lo-' m in a dose-dependent fashion. the greater the degree of depolarization employed, the greater degree of depression in [ca2+] was seen at each dose of r56865. since r56865 had no effect on [ca2+] when utilizing ca2+-free incubation media, it was demonstrated that r56865 prevents depolaritation-induced [ca2 ' ] increase by blocking voltage-regulated influx. because r56865 appears to block voltage-regulated presynaptic ca2' accumulation, it should be further evaluated as a potential therapeutic agent after cerebral ischemia. sneddon's syndrome (ss) is a focal and diffuse arthropathy affecting mainly the vascular wall of the skin and cerebral arteries. etiology is not determined. we studied 37 patients with ss (27 females, 12 males), aged 15 to 56 years. clinical, radiological, and immunological studies were done. all patients developed cerebrovascular disorders: ischemic stroke in 82%, transient ischemic attack (tia) in 64%, and ischemic stroke and tia in 46%. cerebral scan showed small and medium (less than 3 cm) ischemic lesions in 77%. these lesions were superficial in the cerebral cortex (57%); deeper in the centrum semiovalis, internal capsule, and basal ganglia (18%); and both superficial and deeper (25%). ultrasound and angiogram studies revealed obstruction of intracranial arteries in 30%, and of extracranial arteries in 3%. partial or complete improvement of cerebrovascular symptoms was observed in 81%. immunological studies showed increased content of b-cell lymphocytes ( p < 0.05), increased levels of igm ( p < o.oool), and circulating immunocomplexes ( p < 0.0001). anticardiolipin antibodies were increased (58%) and lupus anticoagulant detected (5 1%). cerebrovascular disorders in ss that lead to small ischemic cortical lesions have a good prognosis. pathogenesis of this syndrome may be related to antiphospholipid antibodies. the cheiro-oral syndrome is characterized by pure sensory deficit limited to the hand and mouth. this syndrome has been described in diverse lesions of the parietal operculum and brainstem, but occurs most commonly due to lesions of the contralateral thalamus, and suggests a humuncular representation of sensation in the ventral posterior lateral (vpl) and ventral posterior medial (vpm) nuclei. we describe a 54-year-old hypertensive woman who presented with sudden onset of numbness of the left side of her body. examination revealed a left hemisensory deficit to all modalities that spared the hand and peri-oral regions. cat scan and mri demonstrated an acute infarction of the posterolateral right thalamus, with a rim of preservation adjacent to the internal capsule. pure hemisensory loss with sparing of the hand and mouth ("inverse cheiro-oral syndrome") has not been reported previously, and complements previously published studies of the cheiro-oral syndrome in demonstrating somatotopic sensory representation in the thalamus. to examine the relationship between depression and dementia after stroke, we administered the 17-item hamilton depression rating scale (hdrs) and neuropsychological tests to 237 elderly patients 3 months after ischemic stroke. using dsm-111-r criteria, we found dementia in 57 (24.1%). hdrs score was 5.0 -t 4.6 overall, and higher in demented compared to nondemented patients (6.2 2 5.0 vs 4.6 t 4.5, p = 0.025). the frequency of depression (total hdrs score >11) was also higher with dementia (17.5% vs 7.8%, p = 0.03). however, demented patients did not differ from nondemented patients on ratings of depressed mood. instead, hdrs items for psychomotor retardation, reduced work activities, and impaired insight best distinguished the 2 groups. in multiple regression analysis, stroke severity (p = 0.23, p = 0.0003) was the most important correlate of hdrs score; dementia status was not correlated independently. mean scores on mini-mental state examination and neuropsychological tests assessing memory, orientation, verbal, spatial, attentional, and abstract reasoning skills did not differ by depression status. although weakly related to intellectual impairment, hdrs score in our stroke sample was most importantly associated with stroke severity. higher scores on hdrs in demented stroke patients may be explained by physical and cognitive symptoms that are expected with dementia. these findings do not support a causal link between depression and dementia, and argue against the importance of "depressive pseudodementia" as an explanation for intellectual decline after stroke. to investigate the pathophysiological mechanism of the white matter lesions in progressive subcortical vascular encephalopathy (psve) of binswanger type, we measured regional water partition coefficient (pc) (reflecting water content) and effective p h (pht) (weighted average of intra-and extracellular ph) with dynamic positron emission tomographic technique using 0-15 co,, o,, and c-11 co,. si-multaneously, regional cerebral blood flow (rcbf) and regional cerebral metabolic rate of oxygen (rcmro,) were evaluated. eight subjects (3 normal, 3 psve, 2 multiple infarction) were examined. in the white matter lesions in psve, corresponding to high-intensity areas in t2-weighted images of mr, the pc increased and pht was unchanged or decreased, whereas both rcbf and rcmroz declined. the ratio of white matter pc to gray matter pc was 0.92 in psve and 0.87 in normals. in the frontal gray matter, the pc decreased in psve, whereas rcbf and rcmroz also decreased. these results suggest that tissue water content increases in the white matter lesions in psve reflecting the edematous status of the damaged regions. elevated pht with high pc may reflect the increase of extracellular water of the tissue. measurement of pc and pht provides useful information about the pathogenesis of psve. stroke has been the second most common cause of death in korea but its risk factors (rfs) have not been studied intensively, so the rfs or causes were investigated prospectively in 1,507 consecutive stroke patients who were admitted to the chungnam national university hospital, taejon, korea, between 1989 and 1991. they included 775 cases of cerebral ischemia (ci) (51.4%), 467 cases of intracerebral hemorrhage (ich) (31.0%), and 265 cases of subarachnoid hemorrhage (sah) (17.6%). control data were obtained from 209 healthy spouses of the patients. multivariate analyses showed that hypertension (ht) was the strongest rf for all stroke types and was followed by old age, diabetes mellitus (dm), smoking, high-density lipoprotein cholesterol, and fibrinogen. the rfs for atherothrombotic ci included old age, ht, dm, smoking, fibrinogen, and cholesterol. for lacunar infarcts, ht, dm, old age, fibrinogen, alcohol abuse, smoking, and female sex were the significant rfs. ht was the cause of ich in 347 (74.3%) and alcohol abuse (44, 9.4%) and vascular anomalies (32, 6.9%) followed. most alcoholassociated ichs occurred characteristically in the posterior fossa. frequencies of hospital admission of ich patients correlated positively with diurnal variation of temperature ( r = 0.5229, p < 0.001). aneurysmal rupture was the cause of sah in 222 patients (83.8%). three major sites of 247 aneurysms identified on cerebral angiograms were the anterior communicating artery (83, 33.6%), the middle cerebral artery (70, 28.3%), and the posterior communicating artery (56,22.6%). thirty-nine patients (14.7%) had no identifiable cause of sah. in korea curvilinear subinsular lesions have been noted on ct but the underlying pathology is unknown. we reviewed the cranial mr scans (1.5 tesla ge machine) of 49 serial patients over the age of 60 who had no cause for mr hyperintensities (hi) other than age or vascular risk factors. seven (14%) had linear subinsular h i (sihi). four of 7 (57%) patients with sihi and 4 of 42 (12%) without sihi had marked periventricular h i compatible with subcortical arteriosclerotic encephalopathy (pvhi) ( p < 0.05). patients with sihi were older (75.3 yr) than patients without sihi (69.1 yr) ( p < 0.05). four of 7 (57%) patients with sihi had hypertension program and abstracts, american neurological association 267 or vascular risk factors. a further patient with diabetes, hypertension, and the opercular syndrome (bilateral facial, pharyngeal, and lingual weakness) had subinsular lesions on ct. the brain arteries were injected postmortem with a lead/ gelatin suspension, and mr of the whole brain and x-ray films of the brain slices were taken. bilateral sihi were seen on mr and corresponded with linear cavitary infarction pathologically, which on microangiograms was found to lie in the border-zone between cortical and basal penetrating arteries. we conclude that sihi are associated with older age and pvhi, and can be due to infarction in a deep watershed territory and can be associated with clinical deficits. hemodilution-treatment results in 12 consecutive cases james l. frey, phoenix, az because precipitous neurological deterioration occurred during blood pressure reduction in a seminal case of lacunar infarction, 11 subsequent patients with partial or evolving lacunar deficits were treated with hemodilution and blood pressure nonintervention to test the hypothesis that lacunar strokes represent perfusion failure. isovolemic hemodilution was performed using hetastarch with target hematocrit of 30 to 33. results of pretreatment ct brain scans, carotid ultrasound, and echocardiograms were normal. nine patients recovered normal neurological function, and 2 regained complete functional independence in close temporal correlation with hemodilution. mri brain scans demonstrated appropriate single white matter lesions in 9 cases. no specific risk factor combination could be identified. n o patient has had recurrent stroke in follow-up from 12 to 30 months. response to hemodilution suggests a hemodynamic pathophysiology. successful treatment requires (1 } blood pressure nonintervention and (2) hemodilution prior to severe clinical deterioration. the hemodynamic classification for the carotid-cavernous sinus fistula (ccf) is important for the implication of prognosis and therapy, but satisfactory objective criteria for such differentiation is still lacking. retrospectively, we studied the application of extracranial duplex sonography in 9 cases of ccf with emphasis on the hemodynamic parameters of resistivity index and flow volume. a correlation was made with the angiographic findings in an attempt to evolve an objective hemodynamic classification by this noninvasive method. the alterations in membrane metabolism and structure could be the primary etiological event in alzheimer's disease (ad) that results in the clinical and neuropathological findings. to investigate in vivo brain membrane phospholipid and highenergy phosphate metabolism in probable ad patients and control subjects, the building blocks (pme) and breakdown products (pde) of membranes and the high-energy phosphates pcr and atp were measured noninvasively by in vivo brain 31p mrs in 11 probable ad patients ( 5 males; 6 females) and 18 controls (9 males; 9 females). all subjects were assessed by mini-mental, mattis, and blessed scales. we found that, at clinical onset, ad females had elevated pme ( p = 0.004), decreased pcr ( p = 0.001), and decreased atp ( p = 0.03). similar changes were not seen in ad males at clinical onset, but the severely demented ad males had increased atp ( p = 0.05). correlation analysis for the ad patients revealed that increasing dementia was associated with decreasing pme ( p = 0.05; r = 0.4), increasing pde ( p = 0.08; r = 0.4), increasing pcr ( p = 0.05; r = 0.4), and increasing atp ( p = 0.02; y = 0.5). similar metaboliccognitive correlations were not seen in the controls. these results demonstrate alterations in membrane and energy metabolism at the earliest clinical stages of ad. increasing dementia correlates with markers of membrane degeneration and decreased utilization of high-energy phosphates. both of these findings suggest the dementia in ad is secondary to membrane changes resulting in synapse loss. alzheimer's disease: postmortem mri and histological correlates fen-lei f. chang, j. e. purisi, c. r. jack+ jr, and r. c. petersen, rochester, mn hippocampal atrophy, defined by mri-derived volumetric measurement, has been useful in differentiating alzheimer's disease (ad) patients from normals. since several studies have demonstrated anatomical and functional gradients along the rostral-caudal (r-c) axis of the hippocampus, it is tempting to speculate on the existence of a differential distribution of morphometric changes along this axis. the hippocampi from 19 patients with clinically and pathologically confirmed ad were studied by postmortem mri and by reconstruction of serial histological sections. there was good correspondence between these two methods. the r-c length of the hippocampus in ad was preserved compared to normal. this length was longer on the left, both in normals and ad. the adassociated atrophy was due primarily to the reduction of the coronal cross-sectional area of the hippocampus. with increasing hippocampal atrophy, volume reduction was more prominent in the rostral area (pes hippocampus). this nonuniform reduction in volume may be associated with different connectivity patterns between rostral and caudal hippocampus. the purpose of this study was to determine the neuropathological validity of nincds-adrda criteria (nac) for probable and possible ad. mckhann et al (1985) provided clinical criteria for the categories probable ad and possible ad. the validity of these categories has not yet been reported. a retrospective, blinded evaluation of the complete neurological history, examination, neuroimaging, laboratory, and psychometric data was done for 68 subjects from the state of florida brain bank. pathological classification, which was blind to clinical diagnoses, was in 3 categories: pure ad, ad + , and other dementias. ninety-three percent of probable ad (n = 42), whereas only 75% of possible ad (n = 26) patients, had ad or a d + ( p = 0.1). pure ad was found in 62% of probable ad and 38% of possible ad patients ( p = 0.1). pathological evidence of coexisting parkinson's disease was present in 14% of all ad brains. these results suggest differential predictive power of nac for probable and possible ad, as suggested by the labels. nac are, therefore, usefui for research and clinical purposes. our prior study of falls in the elderly had shown significantly more white matter low attenuation (wmla) on ct scan among fallers than nonfallers, but no association between wmla and cognitive impairment among nondemented subjects. as these subjects were followed over time, it appeared that fallers were becoming demented at a more rapid rate than nonfallers. as a result, we analyzed the relationship between wmla and rate of change on the blessed test of information, memory, and concentration (bimc) in a combined cohort of 144 subjects from the falls study and from a longitudinal study of dementia and normal aging. we selected 61 of these 144 subjects whose initial bimc score was less than 25 (i.e., not already severely impaired) and who had at least 4 yearly bimc evaluations. ct scans were scored on an 8-point ordinal scale for hemispheric wmla. linear regression was used to summarize the rate of change for each subjects' test scores. the rate of change on bimc was 2.3 points per year with standard error (se) of 0.2 among subjects who eventually became demented; nondemented subjects declined at 0.4 points per year with se of 0.2. multiple regression analysis was performed with initial bimc score and wmla as the independent variables and rate of change of bimc as the dependent variable. wmla accounted for 16% of the variance (partial r = 0.396, t = 3.26, p < .05). these data suggest that elderly subjects with wmla may be at increased risk for rapid cognitive decline. such as g proteins and adenylate cyclase. the activities of adenylate cyclase, and of the g protein-associated enzyme activity, low-km glutamyl transpeptidase (gtpase), were assayed in membranes prepared from the postmortem brains of 8 alzheimer-diseased and 8 age-matched control subjects. both basal and fluoroaluminate-stimulated adenylate cyclase activities were significantly reduced in ad frontal cortex compared to control subjects ( p < 0.01; two-tailed student's t test). in addition, a significant, though smaller, reduction in basal gtpase activity also was detected in ad frontal cortex ( p < 0.05). in contrast, no significant change in the activity of either enzyme was detected in the hippocampus. the stimulation of gtpase activity by muscarinic and gababreceptor agonists was not altered significantly by the presence of alzheimer's disease. however, the degree of stimulation was much lower in human tissue compared to that observed using fresh rat brain, suggesting that the ability of receptors to activate g proteins declines post mortem. these results suggest that alzheimer's disease causes alterations in some key components involved in signal transduction. the association of lobar hemorrhage (lh) with cerebral amyloid angiopathy (caa) and that of caa with alzheimer's disease (ad) are well known. to determine how frequently lh and caa occur in ad, we reviewed 13 patients with cerebral or cerebellar hemorrhage and caa. five patients were treated surgically, none was demented, 2 died, and 1 came to autopsy. eight patients died of lh and came to autopsy. of the 9 autopsied patients, 3 had ad, both clinically and neuropathologically. they comprised 1.2% of 258 cases of autopsy-confirmed ad in our laboratory. none of the other patients were known to be demented. five had senile plaques, with or without neurofibrillary tangles, in the hippocampus, and occasional senile plaques in the cortex, but none met the consortium for establishing a registry for alzheimer's disease neuropathological criteria for ad. ad patients were 70, 85, and 85 years old and the ages of the 10 nondemented patients ranged from 63 to 87 (mean = 73.1 yr). seven were younger than 75 years of age. despite the frequent occurrence of caa in ad, we found that lh was uncommon. in addition, most of our patients with lh and caa were not demented and tended to be younger than ad patients with lh. these results indicate that the hf is involved primarily in acquisition or leaning processes and less so in retrieval of previously learned information. these findings relate to memory and structural brain changes found in normal aging. alzheimer's disease y . stern, l. stricks, g. alexander, 1. prohovnik, and there is an inverse relationship between parietotemporal cerebral blood flow and years of education in alzheimer's disease (ad) patients matched for clinical severity, which suggests delayed clinical manifestation of ad in patients with higher education (stern et al, soc neurosci abs 1771). we classified the lifetime primary occupations of 5 1 ad patients using the dictionary of occupational titles of the us department of labor and derived 6 factor scores describing intellectual, interpersonal, and physical job demands. after controlling for age, education, age at onset, illness duration, and dementia severity (mental status and activities of daily living), relative perfusion in the parietotemporal region (assessed using 133-xenon inhalation) showed significant correlations with job complexity (pl: r = -.36, p < .008) and interpersonal (p3: r = -.44, p < .001) factor scores. in a stepwise multiple regression, job complexity and interpersonal skills increased explained parietotemporal flow variance by 7.5% ( f = 4.7, p < .05) over that explained by demo-graphic and severity indices; physical demands then accounted for another 11.5% of the variance ( f = 8.4, p < .01). we conclude that occupational demands, similar to but independent of education, may provide a reserve that delays the clinical expression of ad. richard mayeux and ming-xin tang, new york, n y risk factors for alzheimer's disease (ad) were collected from 223 patients with ad and 278 healthy elderly controls in an urban community population consisting of 3 ethnic groups: black, hispanic, and white. advanced age (>80 yr) (or = 10.7; 75% ci 6.2-19.1) and head injury with loss of consciousness (or = 2.70; 1.2-7.3) were associated with ad, controlling for all known putative risk factors. factors such as low education (<8 yr) (or = 1.5; 0.8-2.6) and family history of ad (or = 1.7; 0.7-3.0) were not found to be significantly related to ad. head injury occurred in 15.7% of the patients and 6.?% of controls. most (70%) head injuries in the patients with ad occurred after age 50, prior to disease onset. in controls with head injury, 5592 had experienced a head injury before age 50. the duration of unconsciousness was consistently longer in patients with ad than in the controls. the overall effect in each ethnic group was similar (or,, 2.5; 1.3-4.8). these results confirm and strengthen the previously described putative relationship between head injury and ad. we also conclude that both the severity and the timing of the head injury as well as the frequency of head injury in the population at risk may be important factors in understanding the causal relationship between head injury and ad. the purpose of this study was to determine how native language affects the cutoff scores in screening tests for dementia. there is a paucity of data o n this issue at present. screening tests used in the study were: folstein mini-mental state (mms); clockdrawing (clock); preparing a letter for mailing (mail); 4-item grocery list (list); and hamilton depression scale (ham). the subjects included 175 (74 demented) native english speakers (eng) and 72 (22 demented) native spanish speakers (spa) with memory complaints. diagnosis of dementia was determined by neurological, neuropsychological, and psychiatric evaluation. age and gender were unrelated to mms. in spa only, education was positively related to mms. ham scores were higher in deand 0.77 (spa); c d and list did not add discriminative power to mms for eng but did so for list in spa. mms discriminates between demented and nondemented far better in english than in spanish speakers. only mail adds discriminative power to mms. a. heyman, g. fillenbaum, s. mirra, and participating cerad neuropathologists, durham, nc, and atlanta, ga the clinical diagnosis of alzheimer's disease (ad) has become more accurate in recent years due to the application of specific clinical criteria, wider use of neuroimaging procedures, and greater expertise among physicians. we report the frequency of clinical misdiagnosis of ad among 52 patients who at autopsy were found to meet the rigorous clinical diagnostic criteria imposed by the consortium to establish a registry for alzheimer's disease (cerad) study. these patients included 31 men and 21 women (mean ages 78 and 76 yr, respectively) who were among the group of 95 patients who died in 13 cerad medical centers in the us between 1987 and 1991. the clinical diagnosis of ad was neuropathologically confirmed in 47 (88.5%) of the 52 cases. of these 47 cases, varying degrees of concomitant cerebrovascular disease were present in 26% and coexisting parkinson's disease changes were found in 19%. in 4 of the 5 patients without neuropathological evidence of ad, the diagnoses were: lobar atrophy, diffuse lewy body disease, nonspecific neurodegenerative changes, and mesocorticolimbic dementia, respectively. the fifth patient showed no morphological abnormalities. on the basis of these results, it would appear that application of strict diagnostic criteria, as well as the use of brain scans and detailed clinical and neuropsychological tests by experienced clinicians, cannot yet distinguish some types of primary degenerative dementias from alzheimer's disease. we designed a scale that measures an underexplored facet of functional decline in alzheimer's disease (ad): the patient's dependence on others for supervising or performing activities. two hundred twenty-three informants for patients with mild ad (clinical dementia rating [cdr] = 1 for 200; cdr = 2 for 23) were interviewed and dependence was staged from 0 to 5. interrater reliability was assessed by separate interviews of 20 informants; agreement was 100% for dependence stage. dependence stage differed significantly at the 2 cdr levels (chi square = 41.0, p < .01) and correlated significantly with modified mini-mental state (mmms) ( r = -.30, p < .001) and blessed dementia rating scale-part 2 (bdrs) ( y = .41, p < .001). seventy-eight percent of patients in a health-related facility were at stage 3 or higher vs 25% of patients living at home. in a multiple regression model, both the bdrs and dependence scale accounted for unique portions of the variance in mmms, suggesting that they assess unique aspects of functional ability. dependence increased significantly in 118 patients retested at 1 year. we conclude that the dependence scale is reliable and relates to both disease severity and progression. formal assessment of dependence should prove useful for studies of the natural history of ad as well as for clinical trials. cortical-basal ganglionic degeneration (cbgd) is a disorder characterized by an asymmetrical akinetic-rigid syndrome and cortical signs such as apraxia, alien limb phenomena, and cortical sensory loss. dementia has been present in many cases, but always as a late manifestation. we report 2 cases pathologically consistent with cbgd, presenting as primary degenerative dementia, fulfilling nincds-adrda criteria for probable alzheimer's disease (ad). the first patient presented with changes in memory and personality, language dysfunction, decreased verbal output, and shuffling gait. follow-up examinations over 3 years showed progressive dementia, wide-based gait, and frequent falls. the second patient presented with complaints of memory loss. neuropsychological examinations showed progressive deficits in memory, attention, calculations, and visuospatial functioning. no movement disorder developed over 6 years of follow-up. at autopsy, both patients had typical changes of cbgd and lacked pathological features of ad. definitive diagnosis of cbgd rests on both clinical and pathological criteria. cbgd should be considered in the differential diagnosis of patients with dementia resembling that found in ad, especially if extrapyramidal signs are present. a quick, easily administered and scored test for praxis is desirable in evaluation of neurological patients. during 2 months in 1991, each patient seen in the outpatient setting by the principal investigator (e. k.) received 1 of 2 praxis screening batteries. thirty-six patients were tested with a short battery. eleven had normal cognition based on neurological history, examination, and a short test of mental status. twenty-five had cognitive decline (cd). handedness, male/ female ratio, education, and mean age were similar in both groups. mean time of completion of the test was 102 2 10 seconds in normals and 136 * 41 seconds in patients with cd. total scores (maximum 50) were 47.6 * 1.8 in the normals and 41.2 2 9 in the cognitively declined patients. twenty-five other patients, 12 with cd and 13 with normal cognition, were tested with a longer battery containing oral/ facial, upper and lower limb, axial, sequential, and imitation subtests (maximum score 110). normals completed the battery in 297 i 56, and cognitively declined patients completed the battery in 359 ? 53 seconds. of the various subtests, tests of sequential praxis were performed most poorly by patients with cd: 8.3 * 1.8 in normals vs 4.9 * 3.0 in patients with cd. oral/facial praxis was least affected by cd: olivopontocerebellar atrophy (opca) is generally understood to be a nondementing neurodegenerative disorder affecting the cerebellum, lower brainstem, and spinal cord. one of us (s. k.) recently reported that postmortem cerebral cortex from patients with dominantly inherited opca shows a widespread reduction of cholinergic markers similar to that observed in alzheimer's disease (ad). we were interested to determine the status of other neurotransmitter systems in opca postmortem cerebral cortex. samples of frontal, parietal, temporal, and occipital cortex were dissected from 10 confirmed cases of opca and 11 age-matched controls. after processing, neuropeptide levels were measured by radioimmunoassay. concentrations of somatostatin were significantly reduced by 42 to 58% in 3 of the 4 cortical areas of opca brain that were examined. the area that was spared was the inferior temporal gyrus, a region in which somatostatin levels are markedly reduced in ad. levels of neuropeptide y were normal in all 4 areas, while concentrations of cholecystokinin, vasoactive intestinal polypeptide, and substance p were significantly increased in 2 of the 4 areas. these data show widespread neuropeptide changes in the cerebral cortex of opca postmortem brain. in contrast to cholinergic markers, the pattern of neuropeptide changes is different from what is observed in ad. it has been postulated that demise of the corticomotoneuron is the initial event in amyotrophic lateral sclerosis (als) and that the anterior horn cell dies as the result of antegrade glutamatergic excitotoxicity (muscle nerve 1992;15:219). excitability of the corticomotoneuronal system can be tested by measuring threshold-to-cortical magnetic stimulation and the motor-evoked potential (mep)/compound muscle action potential (cmap) ratio, which estimates the number of corticornotoneurons stimulated. cortical threshold and mep/ cmap ratio were measured in 39 patients early in the course of als. the mean time interval from onset of first symptoms was 8.5 months. mean threshold and mepicmap ratio measured 64.2 f 16.6% and 22.0 rfr 21.2%, respectively. in 12 (30.8%) patients, threshold was paradoxically low (<55%, mean 49.1 +. 4.3%) and in 7 (17.9%) patients there was no response. there was a significant ( r z = 0.698) inverse power relationship between cortical threshold and mep/cmap ratio given by 84.1 x mep/cmap-'j. six months later, 7/24 (29.2%) patients still had low thresholds but the mean mep/ cmap ratio had dropped to 24.9 ? 24.5% and in 33.3% there was no response. we conclude that early in als the corticomotoneuronal pathways are abnormally excitable. this may explain early cramping and fasciculation, which characteristically diminishes as als progresses. one of the distinct clinical features in patients with amyotrophic lateral sclerosis (als) is loss of elasticity of skin. however, little is known concerning the biochemical nature of skin elastin in als. in our study, 2 cross-links unique to elastin, desmosine and isodesmosine, were measured and compared in skin tissue (left upper arm) from 10 patients with als and from 7 age-matched controls. the contents of desmosine and isodesmosine were decreased significantly ( p < 0.01 and p < 0.01, respectively) in patients with als (mean * sd, 0.94 ? 0.33 and 0.74 * 0.30 nmol/mg dry weight; range 0.36-1.51 and 0.27-1.33 nmol/mg dry weight, respectively) as compared with those of controls (mean 2 sd, 1.43 * 0.30and 1.17 2 0.21;range 1.11-2.03 and 0.92-1.52, respectively), and were negatively and significantly associated with duration of illness in patients with with amyotrophic lateral sclerosis als ( r = -0.77, p < 0.01, and r = -0.65, p < 0.05, respectively). the ratio of desmosine and isodesmosine was constant (1 : 3) in all samples analyzed. the decline in skin desmosine and isodesmosine is more rapid in als than in normal aging. thus, cross-linking of skin elastin is affected in als. (supported in part by n i h grants de 18522, de 11233, de 08611, ar 19969, ar 30587, and nasa grant nag-2-181.) pl69. natural history of amyotrophic (1) collection of large numbers of twin pairs in disease of low prevalence is difficult. to circumvent this, we devised a new approach termed the "death discordant twin pair" method. eleven thousand deaths from motor neuron disease (mnd) were extracted from the office of population censuses and surveys during 1979 to 1789. birth indexes from 1900 onward were searched for possible twins. for each twin so identified (13 1 pairs), the national health service central registry located the relevant family practitioner committee and thence the co-twin's general practitioner. the search produced: (1) 53 living co-twins; (2) 5 embarked; (3) 60 dying as adults or infants; (4) 3 not mnd; and (5) validity of the accuracy, sensitivity, and specificity of the world federation of neurology (wfn) subcommittee on motor neuron disease working group criteria for the clinical diagnosis of amyotrophic lateral sclerosis (als) has been tested against neuropathological criteria in 36 autopsied patients (neurology, in press). integration of clinical and electrodiagnostic data to meet wfn criteria for possible, probable, and definite als was studied in this samegroup. patients received 1.7 ifr 1.1 (mean * standard deviation) electromyograms (emgs) per patient and included 1.7 2 0.9 emg levels (bulbar, cervical, thoracic, lumbar) per patient. proportionately fewer emgs were performed as the level of diagnostic certainty at presentation increased: suspected (34.3%), possible (31.4%), probable (25.7%), definite (8.6%). in only 4.8% of all patients studied did the first emg alone change the level of diagnostic certainty of the diagnosis of als. only 16.7% of patients presenting with suspected als alone or with possible or probable als were associated with a change in level of diagnostic certainty following 1 or more emgs. however, although increasing the number of emgs performed per patient may be associated with an increasing chance of increasing the level of diagnostic certainty (22 emgdpatient = 33.3%; 2 3 emgdpatient = 60.0%), selection of the level of emg analysis was more crucial. the "el escorial" criteria emphasize the importance of emg evidence of lower motor neuron involvement in a limb with clinical upper motor neuron signs. our analysis of emg studies in autopsy-confirmed als patients suggests that complete evaluation of bulbar and thoracic levels for lower motor neuron changes and complete evaluation of motor unit recruitment patterns are important for the integration of emg data with clinical data in the application of the "el escorial" criteria for the diagnosis of possible, probable, and definite als. sibships on guam annette grefe, john steele, linda flares, and stephen waving, birmingham, al, and umatac and mangikao, guam reports in the 1950s indicated that 40% of guamanian chamorro patients with amyotrophic lateral sclerosis (als) gave october 20 a positive family history. subsequent investigators have inferred that purely genetic factors are not responsible for guamanian als or its clinical variant, parkinsonism-dementia complex (pdc). we report the first 4 chamorro sibships selected in an ongoing study of 17 1 familial aggregations. the basis for the initial selection was that the youngest patient in the sibship had als. age of onset was 30 to 46 years (mean 35 yr). fourteen of 23 persons in these sibships were affected. others in the sibship developed pdc, progressive supranuclear palsy, or pure dementia later in life (mean 61 yr, range 50-74 yr). these cases developed 14 to 47 years (mean 25 yr) after onset of disease in the first sibling. the age at onset of the first case and the intervals between earliest and latest cases in such sibships may help to determine minimal and maximal latency (i.e., interval between exposure to an exogenous agent and onset of symptoms). our observations suggest that exposure may have occurred early (before age 30) with varying and often long latency (up to 47 yr). we also find that variability of clinical expression may be correlated with the age at onset. concentrating on the study of familial cases on guam may enhance the identification of the etiologic agent(s) of this prevalent and tragic disorder. the spinocerebellar ataxias are an uncommon group of genetic disorders that have been well characterized in north america and europe. information concerning these conditions in africa and other parts is scant. to address this problem, a large-scale survey has been undertaken in the cape province of south africa. in this investigation, more than 500 persons in 18 affected families have been appraised and investigated and phenotypic features have been analyzed in detail. linkage studies have been undertaken in 4 families with similar phenotypes in which the condition was transmitted as an autosomal-dominant trait. human lymphocyte antigen (hla) typing was carried out on 79 members of the 4 families and linkage analysis was undertaken using the liped program to analyze the data with a correction factor for age of onset. maximum lod scores were: family a: 4.13 (0 = 0.005); family b: 0.6 (0 = 0.001); family c: 0.50 (0 = 0.30); family d: 0.0 (0 = 0.50). these results indicate linkage to hla in 1 out of 4 families. these findings provide support for the concept of genetic heterogeneity in these phenotypically homogeneous families. pcr typing with the reportedly more closely linked d6s89 locus is now being undertaken in these south african families. h.-p. hartung, g. f. hoffmann, and g. becker, wunburg, heidelberg, germany recently, l-2-hydroxyglutaric acidemia has been described as a novel metabolic disorder in 6 children. we report the occurrence of this disease in adults. one of 2 brothers developed at the age of 10 an abnormal gait and dysarthria; in the other 1, clumsiness and walking delay were noted at age 3. symptoms progressed and at the time of admission, when the patients were 33 and 39 years, neurological examination revealed a spastic ataxic gait, limb ataxia, dysmetria, dysarthria, dystonic posturing, and mental retardation. ct and mr imaging revealed subcortical white matter changes with loss of arcuate fibers, folial atrophy, and leakage in the cerebellar vermis, as well as atrophic changes in the cerebellar hemi-acidemia program and abstracts, american neurological association 273 spheres. on biochemical screening, highly elevated concentrations of l-2-hydroxyglutaric acid were found in csf, plasma, and urine. the pathological accumulation of l-2hydroxyglutaric acid in these 2 adults, along with the clinical picture characterized by cerebellar, extrapyramidal, and pyramidal symptoms and oligophrenia, and the neuroradiological findings of severe loss of myelinated arcuate fibers in subcortical white matter, conform with what previously has been described in the few neuropediatric cases. the biochemical abnormality underlying accumulation of this organic acid remains elusive. this study was undertaken to differentiate primarily affected areas from functionally suppressed areas due to remote effect in aphasic patients with focal brain degeneration, using an activation method with 0-15 water, in comparison with [sf]2-fluoro-2-deoxy-~-g~ucose (fdg) positron emission tomographic examination at rest. the subjects were 2 patients with slowly progressive aphasia showing contrasted clinical symptoms (nonfluent type vs fluent type). regional cerebral metabolic rate of glucose (cmrglu) was measured with intravenous injection of 130mbq of f-18 fdg at rest. regional cerebral blood flow (cbf) was measured with intravenous bolus injection of 1.5gbq of 0-15 water in 3 different conditions: at rest, under repetition tasks, and under naming tasks. changes of cbf were evaluated between a resting condition and task-performing conditions. regional cmrglu was decreased focally in both broca's and wernicke's areas similarly in these cases in spite of the difference in clinical symptoms, whereas the patterns of regional cbf changes were different. the fluent patient showed prominent activation in the bilateral frontal areas on repetition tasks. the nonfluent patient showed, whereas the fluent patient did not show, focal activation in the left occipitoparietal area on a naming task. evaluation with an activation method can provide detailed information about the pathophysiological process and the location of primary lesion. defective complex i activity has been linked to huntington's disease (hd) and parkinson's disease (pd). intrastriatal injection of inhibitors of complex i reproduces the pathological features of hd, and the neurotoxin mpp+ kills dopaminergic neurons by inhibiting complex i. defects in complex i have been reported in hd and pd, but the distribution of this enzyme in the brain is unknown. to map complex i in brain quantitatively, we developed an assay using e3h)dihydrorotenone to label the enzyme in tissue sections. this high-affinity binding is saturable and is displaceable by rote-in brain none and mpp+. using 100 pm rotenone to define nonspecific binding, more than 95% of binding is specific. highest levels of binding are found in kidney, followed by myocardium. moderate levels of complex i are seen in striated muscle and some brain regions. within the brain, binding varies more than 20-fold and is heaviest in the cerebellar molecular layer and dentate gyrus. lower levels of binding are found in cortex and striatum and very low levels are located in substantia nigra. this assay may help to clarify the role of complex i in neurodegenerative disorders. ( in 1988, 4 patients with medically intractable parkinson's disease underwent autologous adrenal medullary-to-caudate transplants at the university of california-los angeles (ucla). these persons had been followed for several years before operation at 3-or 4-month intervals. at each visit, their disability had been rated on the quantified ucla scale and the hoehn and yahr stage of disease. these provided a longitudinal assessment of the progression of disease in each patient, which could be compared to the rate of progression in the cohort of cases followed at ucla for 15 years. in addition, the unified parkinson's disease rating scale provided supplementary data for the immediate preoperative and subsequent postoperative evaluations. the hours "off" also were recorded for the preoperative and postoperative periods. after operation, the same evaluations were performed by the neurologist who previously had cared for the patients. the longitudinal postoperative data revealed that at 1 to 4 months after operation, all 4 patients improved. after 4 years, 3 continue to be less disabled than their preoperative baselines. the progression of their disease, while still evident, is nonetheless proceeding at a slower rate than before transplant. the fourth patient had brief improvement shortly after operation, but then rapidly worsened to his previous level. his disease has continued to progress at a rapid pace, unchanged from progression before operation. individuals at risk for huntington's disease h . p. h . kremer, w. shtybel, b. snow, c. clark, j . theilmann, m . r. hayden, and w. in huntington's disease (hd), caudate hypometabolism as demonstrated by positron emission tomography (pet) is a well-established feature in symptomatic patients. in individuals at risk, however, conflicting findings are reported. since 1984 we have performed 61 pet scans in 44 asymptomatic persons at risk for hd (age 27-76 yr) . linkage analysis with 9 independent dna probes or subsequent evolution to clinical hd (in 5 patients) allowed a risk estimate for 35 subjects. twenty were considered to be at increased risk (?85%), 14 at decreased risk (<15%), and in 1 individual no modification could be given. nine subjects were not tested. a pet scan was considered abnormal if either the caudate/thalamus ratio or the caudate/whole-brain ratio of rcmrglu was more than these criteria, 8 scans in 6 individuals were abnormal. none had received a decreased risk. comparison of the ratios of increased risk, decreased risk, unmodified risk, and control subjects failed to show statistically significant differences (analysis of variance). follow-up of 3 persons with an abnormal scan showed conversion to symptomatic status within 5 years after the first abnormal scan. this result suggests that an abnormal pet scan in a person at risk for h d heralds the onset of choreic movements. robitaille, m . el-awar, b. clark, l. scbut, m. ball, l. young, r. currier, and k. sbannak, toronto, ontario, and montreal, quebec, canada; pittsburgh, pa, minneapolis, mn, portkmd, or, and jackson, ms we measured the levels of dopamine in striatum of 14 patients with end-stage dominantly inherited olivopontocerebellar atrophy (opca). on average, dopamine levels were reduced in putamen ( -5396, as compared with controls), caudate ( -35%), and nucleus accumbens ( -31%). however, individual patient values showed a wide variation (normal to -9996), indicating that striatal dopamine loss is a common, but not constant feature of opca. seven patients had marked putamen dopamine loss (-62 to -8195) but without corresponding severe substantia nigra cell damage; this suggests a "dying-back'' phenomenon in which nerve terminal loss precedes cell-body degeneration. in this regard, opca may offer the possibility of examining nigrostriatal dopamine neuronal degeneration at an early stage. although 2 patients were found to have severe nigral cell loss with near total ( -95 to -99%) striatal dopamine loss, none had depression in parkinson's disease (pd) has been correlated with low cerebrospinal fluid (csf) levels of 5-hydroxyindoleacetic acid (5-hiaa). l-dopa may precipitate or exacerbate depression in 30% of pd patients. to determine if l-dopa affects 5-hydroxytryptamine (5ht) metabolism, 8 patients were studied. four had pd. of these, 2 were taking l-dopa and both were depressed. the diagnoses in the remaining 4 were progressive supranuclear palsy (psp), striatonigral degeneration (snd), normal pressure hydrocephalus, and pseudoseizures with depression. neuropsychological examinations and lps of all 8 patients were done. three patients were started on l-dopa (the 2 previously untreated pd patients and the psp patient) and retested 3 days later. one pd patient started on l-dopa became depressed. mood in the others was unchanged. csf was analyzed for 5ht and 5-hiaa. 5ht could not be detected in the csf of patients who were not taking l-dopa, but was easily detectable in all of the patients who were taking l-dopa. 5-hiaa levels were low in the untreated pd patients, and also in the patients with psp, snd, and pseudoseizures with depression. 5-hiaa levels were even lower in the l-dopa-treated patients. the ratio of 5-hiaa:5ht (an index of 5ht turnover) was lowest in the l-dopa-treated pd patients who were depressed. low csf 5-hiaa in untreated pd may reflect depletion of brain 5ht. l-dopa may induce depression by inhibiting 5ht turnover in 5ht-depleted brain. p18 1. ventroposterolateral medial pallidotomy in the e. fazzani, m. dogali, a. ben;, d. eidelberg, j. gianutsos, t. kay, b. newman, s. loftus, d. samehon, and l. laitinen, new york, n y , and stockholm, sweden in patients with parkinson's disease (pd), as a consequence of low dopamine there exists an increase in inhibitory output from the globus pallidus. ten patients (5 men and 5 women) with pd received unilateral (6 right, 4 left) ventroposterolateral medial globus pallidotomies (vplmp). the average patient age was 61 years (range 55-73 yr), and the average duration of disease was 14 years (range 6-24 yr). patients fluctuated between "on" chorea and "off" parkinsonism. hoehn and yahr stage "on" was i1 in 7 , 111 in 3; and "off" was i11 in 5, iv in 2, and v in 3 patients. unified pd rating scale (updrs) score averages 12 hours off medicines (12hom) were activities of daily living (adl): 20 and motor (mtr): 40 preoperatively (preop). capit score averages preop 12hom were pronation-supination (ps): 3 1 seconds (s), finger tap (ft): 31s, board (b): 39s for the most affected contralateral side, and gait: 57s (2 patients could not walk). re-examination was done 2 to 5 days after pallidotomy. updrs scores 12hom decreased an average of 60%. three patients had major bilateral improvement in bradykinesia. rest tremor, prominent in 3 patients, also was diminished. capit scores 12hom decreased to ps: 19s, ft: 20s, b: 22s; the average gait of the 8 patients who could walk preop improved to 36s. there were no side effects. vplmp leads to an immediate overall significant improvement in patients with pd. s. kish, y . there is a growing interest in the genetic aspects of parkinson's disease and other basal ganglia disorders. we have studied 3 families whose ancestors immigrated to north america from contiguous regions of northern germany and southern denmark. the pedigrees contain 77, 206, and 376 individuals spanning 6, 7, and 8 generations with 7,6, and 9 affected members, respectively. autosomal-dominant inheritance is clearly present in 2 families and probable in the third. typical levodopa-responsive parkinsonism with bradykinesia, rigidity, resting tremor, and impaired postural reflexes uniformly develops in affected individuals from all 3 families. n o downgaze impairment, pyramidal signs, sensory disturbances, cerebellar dysfunction, or orthostatic blood pressure changes have been observed. dementia, however, has developed in a few elderly individuals, especially in 1 family. laboratory studies are normal. mri shows moderately enlarged ventricles and cortical atrophy. 6-fd positron emission tomography demonstrated reduced striatal uptake in 1 examined patient and normal uptake in l individual at risk. autopsy of only 1 subject has been performed (in 1975). brain weight was 1,380 grams and there were no obvious gross abnormaliprogram and abstracts, american neurological association 275 tuesday, october 20 ties, but microscopic examination was limited. further research on these 3 families is planned. electrophysiological study s. maurri, m . cincotta, a. ragazzoni, g. descisciolo, and f. barontini, florence, ltah many neurophysiological examinations were conducted of a 32-year-old woman with familial mirror movements. n o other neurological abnormalities were detected. examination included voluntary electromyographic (emg) activity from various muscles, f-wave as well as short-and long-latency reflex responses of the thenar muscles from electrical stimulation of the median nerve, mapping of motor-evoked potentials (meps) to transcranial magnetic stimulation, movement-related cortical potentials (mrcps), and somatosensory-evoked potentials (seps). emg documented mirror activity in the upper limbs, most marked in the muscles of both hands. onset latency of emg activity in response to an auditory stimulus was identical in active and mirror muscle. long-latency responses from median nerve stimulation were recorded on contralateral as well as ipsilateral thenar muscles. short-latency reflexes and f wave were strictly ipsilateral. unilateral scalp magnetic stimulation evoked bilateral responses at similar latencies in the thenar muscles; midline scalp stimulation activated no responses. scalp distribution of median nerve seps and of mrcps associated with self-paced thumb abduction were normal. our findings suggest that congenital inherited mirror movements in otherwise normal subjects can be generated by corticospinal fibers pro jecting to ipsilateral motoneurons of the spinal cord. we have previously identified dysphagia and constipation (both slow transit and defecatory dysfunction types) as common gastrointestinal (gi) problems in parkinson's disease (pd). since apomorphine has been shown to be capable of terminating off-periods when injected subcutaneously, we have evaluated the effects of apomorphine injection on objective parameters of dysphagia and bowel dysfunction in pd patients. nine subjects underwent the following battery of studies to characterize their pd features, swallowing, and bowel function: gi assessment survey, unified pd rating scale, videoesophagram, colon transit study, defecography, and anorectal manometry. specific abnormalities on the studies were noted and the most abnormal study was repeated after subcutaneous administration of 6 mg apomorphine. all individuals were pretreated with domperidone 20 mg four times daily for 3 days prior to apomorphine administration. improvement in both esophageal motility and deglutition was noted in the 1 individual in whom videoesophagram was repeated. for the other 8 patients, defecography or anorectal manometry was performed. significant improvement in specific parameters was demonstrated after apomorphine administration, but 2 individuals experienced syncope during radiographic procedures. we conclude that subcutaneous apomorphine administration holds promise as a potential therapeutic approach to dysphagia and, especially, bowel dysfunction in pd, but that further investigation and refinement are necessary. asymmetrical effect of unilateral thalamotomy or subthalamotomy on tremor in parkinson's disease nico diedericb, christopber g. goetz, glenn t . stebbins, harold l. klawans, k. nittner, a. kozrlosakis, p. sanker, and v . strum, cologne, germany, and chicago, il in the past, stereotactic operation was a regular treatment for unilateral tremor in parkinson's disease (pd). however, follow-up studies were usually short term and always unblinded. we examined 17 pd patients in long-term follow-up (mean 10.9 yr after operation) who underwent unilateral thalamotomy for parkinsonian tremor. we used videotapes and the unified parkinson's disease rating scale to blindly compare tremor ipsilateral and contralateral to the side of operation. since the patients were specifically selected for stereotactic operation because of asymmetric tremor, we reasoned that a sign of long-term efficacy would be current postoperative reversal of tremor side predominance. upper extremity tremor was significantly better contralateral to the side of operation compared to the ipsilateral side ( z = 3.29; p < 0.023). for the lower extremities the difference was not statistically significant. in chronic follow-up, stereotactic operation improved the absolute magnitude of arm tremor or ameliorated its rate of progression. since asymmetric bradykinesia and dyskinesia were not prerequisites for the choice of surgical side, we cannot make any conclusion about longterm impact of operation on these features. subtle extrapyramidal signs resembles that of patients with parkinson's disease m . richards, k. marder, l. cote, y . stern, and r. mayeux, new york, n y to investigate the relationship between extrapyramidal signs (eps) and cognition, eps severity and neuropsychological function were assessed in 307 normal elderly individuals and 130 nondemented patients with idiopathic parkinson's disease (pd) from a community-dwelling cohort in new york city. multivariate analysis of variance (manova) indicated poorer neuropsychological performance ( p = .001) in pd patients on verbal memory, orientation, verbal fluency, visuomotor construction, and psychomotor speed, but not naming, abstract reasoning, or matching. controlling for eps severity abolished these differences. one hundred fourteen (37%) of the normal individuals had subtle eps (mostly postural abnormality, bradykinesia, or rigidity) but no identifiable neurological disorder. manova indicated poorer neuropsychological test performance ( j = ,001) in these individuals than in normals without eps on verbal memory, orientation, abstract reasoning, naming, verbal fluency, matching, and psychomotor speed but not visuomotor construction. we conclude that: (1) cognitive impairment in pd is specifically associated with eps, and (2) a similar association occurs in individuals with subtle eps but no neurological disorder. whether this represents a preclinical stage of pd or ad is yet to be determined. disease in olmsted county, minnesota emre kokmen, fatma sibel ozekmekci, c. mary beard, and peter c. o'brien, rochester, m n , and istanbd, turkey there have been many studies of prevalence of huntington's disease (hd) in diverse populations around the world. to study the incidence, we took advantage of the availability of detailed health care records for the population of olmsted county, mn, from mayo clinic, its affiliated hospitals, olmsted medical group, county hospital, state hospital, records of solo practitioners, nursing homes, death certificates, and autopsy records. we reviewed all records with a diagnosis of hd, huntington's chorea, chorea major, and chorea otherwise unidentified, and sought evidence for progressive chorea, progressive cognitive and/or behavioral dysfunction, and family history compatible with autosomal-dominant inheritance with onset of symptoms in the period between january 1, 1950, and december 31, 1989 , while the patient lived in the geographic boundaries of olmsted county. we found 3 males and 6 females who met these criteria. average annual incidence rate (age/sex adjusted to 1960 us white population) for hd for this 40-year period was 0.3 cases/ year/ 100,000 population. we also estimated prevalence by taking account of in-migration, out-migration, and deaths. the agelsex adjusted (1960) prevalence for 1-1-60 was 7.51 100,000 and for 1-1-90 it was 2.4/100,000. the small number of cases caused the instability of the prevalence rates, but our rates are similar to rates reported in other populations. alton e . btyant, 111, l. breeden hollis, john a. hamjian, john d. wooten, ill, and francis 0. walker, nc we described 4 patients with unusual episodic movement disorders and normal diagnostic work-ups: a 34-year-old woman who had recurrent episodes of tonic jaw deviation and forced right-eye closure; a 30-year-old woman who developed unexplained pain and subsequent spells of tonic inversion of the left leg; a 61-year-old man who presented with a bizarre episodic right-arm tremor; and a 15-year-old woman who experienced intermittent abdominal undulations. examination of the affected body part provoked or enhanced symptoms in all patients. using suggestion and placebo activation in the form of a medicated patch, intravenous saline, or cervical massage, we first induced and then aborted typical episodes of their abnormal movements. postinduction discussions of the procedure led to a marked reduction in the frequency of attacks in 2 patients. activation procedures are useful in diagnosing psychogenic disorders because they demonstrate that situational, not medical, factors govern the expression of the abnormal behavior. we speculate that patients who are refractory to simple suggestion may respond to induction because it offers the potential of validating their symptoms. as in the case of psychogenic respiratory distress or pseudoseizures, positive induction can assist in counseling and symptom control. had alzheimer's disease with parkinsonism (adp), 1 had essential tremor (et), 1 had cerebellar tremor in multiple sclerosis (ms), and 1 had tardive dyskinesia (td). clozapine was used either to treat psychosis (20 pd, 2 adp, 3 dys, 1 td) or tremor (1 5 pd, 1 et, 1 ms). two pd patients were retrospective analysis of 38 patients counted twice, 1 who was treated for psychosis and then tremor and 1 who was treated on 2 separate occasions for psychosis with different responses. all 3 dys patients improved, 2 with complete resolution of their dystonia on changing antipsychotic drugs. the patients with et (75 mg) and ms (25 mg) improved mildly but sedation and clumsiness caused drug discontinuation in the ms patient. one adp patient (112.5 mg) responded well and the other became sedated and confused (25 mg). the p d responses for psychosis at a dose range of 6.25 to 400 mg daily were good (5), very good (2), and excellent (8), whereas 4 were intolerant. pd tremor responses were good (51, very good (4), excellent (2), and poor (3) at doses of 12.5 to 100 mg daily. one patient died of unrelated causes shortly after initiation of the drug. adverse effects included sedation, weight gain, hypersalivation, fainting, clumsiness, transient granulocytopenia, and "spasms" necessitating discontinuation in 9 patients (7 pd, l td, and l ms). tourette's syndrome and attention-deficit disorder patients s. m. silverstein, p. g. coma, d. palumbo, l. west, and r. kurlan, rochester, n y impaired attention is a common comorbid behavioral feature of tourette's syndrome (ts) and a key clinical feature of attention-deficit hyperactivity disorder (adhd). however, the pattern of attentional impairments reported in adhd has not been observed in ts. we therefore compared 17 ts patients (9 male, 8 female; mean age 32 ? 11 yr), 17 adhd patients (8 male, 9 female; 36 * 12 yr), and 17 normal controls (8 male, 9 female; 3 1 ? 9 yr) on specific neuropsychological (np) and computer-administered tasks of attentional ability. adhd, but not ts, subjects performed significantly worse than controls on the n p tasks (digit symbol, perceptual speed) and had a trend toward poorer performance on a computerized measure of attention. however, both the adhd and ts groups had significantly greater test performance variability on some, but not all, tasks and had more subjects with deviant scores. among ts patients, higher scores on an obsessive-compulsive disorder (ocd) inventory and a greater number of adhd symptoms correlated significantly with poorer performance on the attentional tasks. moreover, ts patients with observed tics during testing had greater attentional impairment than those without tics. these results suggest that: (1) many adult ts patients do not have impaired attention; (2) attentional impairment in ts differs from that observed in adhd; and (3) attentional impairment in ts is associated with the full neurobehavioral spectrum of ts (i.e., tics, ocd, and adhd). frank r. sharp, cathleen miller, thomas rando, and steven greenberg, san francisco and palo alto, c a six patients are described with choreoathetoid movements and marked proprioceptive sensory loss. one patient had a traumatic injury to the right parietal cortex that produced severe proprioceptive sensory loss and choreoathetosis in the left arm. another patient had a left thalamic infarction that resulted in profound proprioceptive sensory loss and chorea on the right side of the body. two patients had cervical spinal cord disease, proprioceptive sensory loss, and diffuse choreoathetosis. another patient had dorsal root ganglionitis associ-a hypothesis program and abstracts, american neurological association 277 ated with small-cell lung carcinoma that produced diffuse loss of all sensory modalities and chorea. the last patient had an ulnar sensory neuropathy and choreic movements of the fifth finger. lesions anywhere along the pathway that transmits limb proprioception may cause pseudochoreoathetosis. furthermore, choreoathetosis without sensory loss caused by focal lesions of striatum may occur because of disruption of cortical proprioceptive inputs to striatum-perhaps explaining why most focal lesions of striatum do not produce chorea. sporadic inclusion-body myositis (s-ibm) and autosomalrecessive hereditary inclusion-bod y myositis (h-ibm) are of unknown cause and pathogenesis. in both there are muscle fibers with rimmed vacuoles containing 15to 21-nm cytoplasmic tubulofilaments (ctfs) and denervation atrophy; in s-ibm, but not h-ibm, there is a varying degree of inflammation. vacuolated fibers contain ubiquitinated inclusions (askanas 1991) and congo-red positivity indicating amyloid (mendell 199 1). because immunoreactive p-amyloid precursor protein (app) and p-amyloid protein (p-ap) are constituents of ubiquitinated senile plaques in alzheimer's disease (ad) brain, we studied immunolocalization of app and p-ap fibers in ibm muscle using antibodies against: (1) non-p-ap fragments of app, viz. (a) c-terminus (residue 676-695 courtesy d. selkoe) and (b) n-terminus (residue 45-62 courtesy b. frangione and d. levartovsky); (2) p-ap (sequence 8-17, courtesy g. glenner, and sequence 1-40 courtesy d. selkoe); (3) ub (chemicon). in 13 of 13 ibm patients, including one h-ibm, 100% of the vacuolated muscle fibers contained large or several small app and p-ap immunoreactive (ir) inclusions, which by double-labeling fluorescence were closely colocalized with each other and with ub-ir. none of 18 control muscle biopsy specimens (including 7 polymyositis) contained app-ir, p-ap-ir, or ub-ir inclusions characteristic of ibm. control experiments utilizing omitted, replaced, or absorbed primary antisera were negative. p-ap, a product of proteolytic cleavage of app, is receiving attention regarding the pathogenesis of ad. our study provides (1) the first demonstration of app and p-ap accumulations in abnormal human muscle, and (2) raises the possibility that in ibm muscle and ad brain rhey may form from similar cellular events. jeffrrey d. rothstein, lin jin, and ralph kuncl, baltimore, m d the pathogenesis of motor neuron death in amyotrophic lateral sclerosis (als) is unknown. accumulating evidence suggests that the disease is characterized neurochemically by a derangement in the control of neurotransmitter glutamate metabolism: csf levels of glutamate and aspartate are ele-of motor neuron degeneration vated and their high-affinity transporter is defective in brain and spinal cord. inefficient glutamate transport, and subsequent chronic increase in extracellular glutamate, could be responsible for selective motor neuron death. to test the hypothesis that chronic defects in glutamate uptake can produce motor neuron toxicity, we developed a tissue culture model employing organotypic rat spinal cord maintained under conditions of chronic glutamate uptake inhibition. slices (300 pm) of lumbar spinal cord from 8-to 14-day-old rat pups were cultured on millicell membranes. chronic uptake inhibition was produced by culturing tissue in the presence of threohydroxyaspartate (tha) or pyrrolidine-dicarboxylic acid, both known to be specific inhibitors of glutamate transport. tha produced chronic elevation of glutamate in the medium and produced motor neuron toxicity after 25 to 30 days in culture using 100 pm tha, and after 18 days using 500 pm tha, as determined by assay of tissue choline acetyltransferase (chat) activity and by histological analysis of 1-micron plastic sections. motor neuron toxicity was completely blocked by the non-n-methybaspartate (nmda) antagonists cnqx or nbqx, but not by the nmda antagonist mk-801. this model demonstrates that the chronic loss of glutamate transport in als can produce motor neuron degeneration and that motor neurons appear to be susceptible to non-nmda-mediated glutamate toxicity. guillain last year, we described a distinct acute paralytic syndrome in children and young adults from northern china and differentiated it from guillain-barre syndrome (gbs) by epidemiological, clinical, and nerve conduction (nc) features. to distinguish chinese paralytic syndrome (cps) from gbs more clearly, we measured nc in 21 cps patients (mean 8 yr, range 1.5-35 yr) and in 21 gbs patients from johns hopkins (mean 14 yr, range 5-24 yr). sensory nc was normal in all (n = 62) but 1 nerve of cps patients, whereas sensory nc was frequently abnormal in gbs patients: median nerve, 63%; ulnar nerve, 87%; and sural nerve, 21%. motor n c also differed between the groups. in all nerves, distal latency (dl) was significantly longer in gbs than in cps. for example, in the median nerve, mean dl was 8.6 ms (se 1) in gbs and 2.8 ms (0.2) in cps ( p < 0.005). motor conduction velocity was significantly reduced in gbs median and ulnar nerves compared with cps nerves. f-wave latency was significantly longer in gbs median nerves than in cps nerves. these data support the distinction both clinically and electrodiagnostically between cps and north american gbs. the use of n c may be especially important in field epidemiological studies in separating the 2 disorders. clinical manifestations and gene analysis of the first japanese kindred yoshihide sunada, teruo shimizu, lchiro kanazawa, and toru mannen, tokyo, japan familial amyloidotic polyneuropathy type iv (fap iv) has been clustered in the finnish population and only a few cases have been reported from the netherlands. denmark, and united states. we describe the first japanese family with fap iv. the family originates from nagano prefecture, a mountainous district in the middle part of japan, and has no relationship to the finnish population. this family has 42 members in 3 generations, and 14 individuals are affected with slowly progressive cranial neuropathy and corneal lattice dystrophy. the genetic trait is autosomal-dominant. polarizing microscopy and immunohistochemistry show abundant amyloid deposits reactive to an anti-gelsolin monoclonal antibody. direct sequence analysis of a dna fragment spanning codon 187 of the plasmagelsolin cdna from the propositus, and restriction analysis using a modified pcr from other family members demonstrate a single base substitution, g to a at the first base of codon 187, which is identical to the mutation of finnish fap iv. this suggests that the mutation causes the fap iv phenotype regardless of ethnic background. gene expression focal puncture injury has been used as a model to study degenerative and regenerative responses of skeletal muscle. previous studies have demonstrated the ultrastructural and metabolic effects of muscle injury. however, the early genomic response to focal injury is presently unknown. we asked whether the immediate early genes (iegs) or early response genes-~$268, c-jun, nur77, and junb-are responsive to muscle injury. these iegs encode transcription factors and are expressed rapidly after cell-surface stimulation. we have previously shown that surgical denervation and neural stimulation of muscle induced differential patterns of ieg expression. in this study, we produced injury of mouse gastrocnemius muscle by injection of 20 c1.1 of normal saline. we used the contralateral (uninjected) muscle as a control and examined the milna levels of each of these 4 iegs. we found that ~$ 2 6 8 and junb levels were increased at 1 and 4 hours and returned to basal levels by 24 hours. in contrast, mrna levels of nur77 and cjun remained unchanged. this pattern of ieg response is distinct from that seen after muscle stimulation or denervation. the selectivity of this pattern suggests that ieg expression may play a role in the response of muscle to injury. amyotrophic lateral sclerosis (als) is a degenerative disease that leads to the restricted loss of motor neurons (mn). the reason for the selective death of mn remains unknown. we hypothesize that mn-enriched or mn-specific genes are important for normal m n function and that their disturbance may play a role in the pathogenesis of als. we have produced clonal hybrid cells derived from embryonic and neonatal spinal cord m n for the study of m n gene properties. some of these hybrid mn clones express traits typical of mn, such as high levels of choline acetyltransferase enzyme activity and message, glycine receptor message, and neurofilament and neural cell adhesion molecule proteins. we are using molecular techniques to identify novel mn-enriched or mn-specific genes in these cells. with this strategy, we have identified several cdna clones preferentially expressed in mn hybrid cells but not in the parental neuroblastoma cells by differential hybridization of an embryonic mn hybrid cdna phage library. we are extending these observations by performing subtraction hybridization experiments. these results suggest that mn-enriched or mn-specific genes can be identified, and may lead to a greater understanding of the etiology of als. there is a syndrome of slowly progressive, mid-adult-onset fasciculating progressive muscular atrophy (pma) affecting upper more than lower limbs, without bulbar or corticospinal signs, more often in males, associated with igm monoclonal gammopathy, and no nerve conduction block. two such men, ages (a) 59 years and (b) 64 years, duration 11 and 3 and one-half years, csf protein 28 and 60, had failed to achieve sustained improvement with: prednisone, cyclophosphamide, total-body irradiation, and multiple lymphoplasmaphereses in a; and interferon alpha 2a in b. intravenous immunoglobulin (ivig), 0.4 gm/kg/day, has provided dramatic benefit, sustained and increasing for >5 and >4 months to date. (there is a continuing base of depotestosterone, 200 mg weekly, which initially alone provided very minimal improvement.) strength increase was evident at 1 and 3 days after the first course of 5 daily ivig infusions. it further increased for 2 to 2 and one-half weeks after treatment, and then began to diminish. repeat 5-day treatment 3 weeks after the first course resulted in summated improvement, now sustained and enhanced by an average of 1 treatment per week. quantitated strength testing by a blinded observer has shown a 2-fold to >loo-fold gradually increasing muscle function in all limbs. patient a regained the ability to feed himself, get out of a chair, walk unaided, and go up steps; quantitated hip flexors increased 2-and 20-fold. patient b regained the ability to feed himself, take care of personal toilet needs, walk securely, and drive 500 miles; quantitated hip flexors increased 5-fold, and biceps flexions increased from 0 with no weight to > 130 reps while holding 10-pound weights. bukhara jews: a new cluster with typical oculopharyngeal muscular dystrophy (opmd) is a rare, late-onset myopathy with autosomal-dominant inheritance. its ultrastructural hallmark is the finding in muscle fibers of intranuclear tubular filaments of 8.5-nm outer diameter. most opmd cases were described among french canadians; in france, the homeland of their ancestors, the prevalence is 1/200,000 (brunet et al, 1990) . in israel's central area live approximately 40,000 jews who have immigrated from the bukhara and samarkand regions in uzbekistan. they represent a homogeneous ethnic group with its own language and community life. among them we have identified opmd in 15 families (55 affected individuals). the inheritance, clinical, electrophysiological, and histological features of these pa-tients are similar to those described in other pdts of the world, with typical intranuclear inclusions seen on electron microscopy. the minimal estimated prevalence of opmd in this population is approximately 1 : 7 5 0 . this cluster of opmd among bukhara jews is the second largest in the world. because many bukharian families are large, they may be suitable for linkage genetic studies. human muscle during ontogenesis e . scarpini, g. conti, p. l. baron, and g. myoblast transfer has been proposed recently as a possible therapy for duchenne muscular dystrophy patients. because immune rejection can represent a major problem in myoblast implantation, immunological characteristics of human muscle should be investigated. previous studies showed that human muscle cells cultured in vitro can constitutively express human lymphocyte antigen (hla) class i, but not hla class 11. furthermore, human y-interferon induces the surface expression of hla class i1 on mononuclear myoblasts, but not on multinucleated myotubes. however, whether the cells produce and present the antigen by themselves or take this material from the environment, where it could be released by infiltrative cells, is not yet clear. in this study, we analyzed hla molecules at the protein level by immunocytochemistry with monoclonal antibodies against different hla-dr epitopes and hla-abc molecules on frozen serial sections of human muscle during development and at the adult stage. human muscle infiltration by macrophages and monocytesmacrophages also were studied with m718and leum3specific monoclonal antibodies at the same stages of development. our results show that during muscle development and maturation, hla-dr and hla-abc antibodies do not label muscle fibers but some m718-and leum3-positive cells within the muscle. these data can be useful to understand the role of infiltrating monocytes-macrophages in the muscle immune response. mounting evidence suggests that excitotoxicity, mediated via the glutamate receptor, is involved in the pathogenesis of amyotrophic lateral sclerosis (als), as well as in other neurological diseases. we therefore initiated an open label, phasen i trial of highdose dextromethorphan (dm), a noncompetitive, selective n-methybaspartate antagonist, in als. patients began with 2 mg/kg/day, divided into 4 doses, and incrementally escalated their medication to 10 mg/kg/day or their maximum tolerable dose. thirteen patients, all extensive metabolizers of dm, were enrolled. total daily doses ranged from 4.75 to 10 mg/kg. major side effects were lightheadedness (8), slurred speech (7), and fatigue (6). no biochemical, hematological, or neuropsychiatric abnormalities occurred after up to 6 months of maximal therapy, except for depression in 1 patient. plasma kinetics of dextrorphan (dt) (the major metabolite of dm) were studied after an acute oral dose of 2.5 mg/kg dm. median elimination halflife was 2.5 hours. plasma dt concentration peaked at a median of 2 hours, with a median cmax of 14.4 pm. median amyotrophic lateral sclerosis cerebrospinal fluid/plasma dt ratio was 9.796. this study demonstrates the feasibility of long-term, high-dose dm therapy. we are now conducting a phase i1 study of highdose dm in als, designed to assess its efficacy. polyneuropathy: a chronic inflammatory demyelinating polyradiculoneuropathy variant? d. cros, k. h. chiappa, s. patel, and s. gominak, boston, ma, we describe 4 patients (3 men, 1 woman) with a pure, adultonset sensory neuropathy. the course was chronic in all cases. three patients had a relapsing-remitting course over 2 to 22 years with several attacks every year; the onset was gradual and followed by a plateau in the fourth patient. all patients had positive and negative sensory symptoms, and 2 had positive motor symptoms (fasciculations). in all patients, muscle power was normal at the time of peak deficit. all were areflexic and had large fiber sensory deficits, and 3 patients had sensory ataxia. three patients had elevated csf protein, whereas the csf was normal in 1 patient. mri demonstrated marked thickening of the lumbosacral spinal roots in 1 patient. motor conduction studies were normal in all patients, and mild f-response abnormalities were noted in 2. neurophysiological investigations of the sensory pathways were abnormal in all. three patients had several studies over a 2-year period. sensory nerve action potentials were unobtainable in 2 patients, and normal in the others. median and tibial somatosensory-evoked potentials showed conduction slowing consistent with demyelinating lesions affecting the peripheral sensory pathways, either globally or focally in the proximal segments. two patients appeared to respond to plasma exchange or intravenous immunoglobulin therapy, or both. glial fibrillary acidic protein cells in experimental motoneuron disease raul n . mandler, pam c. allgood, and james a. wallace, albuquerque, nm neuronal degeneration in human and animal motoneuron disease has been emphasized, but glial phenotype alterations have not been studied as extensively. we carried out a developmental and topographic study of astrocyte expression in the wobbler mouse model of motoneuron disease. wobbler mice and normal littermates were studied at 3, 4 , 5 , and 6 weeks of postnatal development. anesthetized animals were perfused intracardially with paraformaldehyde. spinal cords were dissected and landmarks were identified carefully for systematic study. sections were stained with monoclonal antibodies against glial fibrillary acidic protein (gfap) neurofilament and neuron-specific enolase. cell quantitation was done with video-enhancing microscopy. in symptomatic animals, marked increases in gfap staining were found in rostral and caudal spinal cord areas. quantitation studies revealed a 15to 20-fold increase in gfap+ cells in the wobbler. we conclude that gfap+ cells are markedly increased in the wobbler mouse at cervical, thoracic, and lumbar areas. this cell may also be relevant in motoneuron disease pathogenesis. ( indirect evidence suggests that polio virus may persist in the human cns years after initial infection and may be a cause for the post-polio syndrome. to evaluate whether the polio virus genome can be detected in the cns of patients with previous polio infection, we identified 11 patients who had died with autopsy findings and clinical history consistent with poliomyelitis. rna was extracted from paraffin-embedded sections of brain or spinal cord and subjected to reverse transcription followed by dna amplification by polymerase chain reaction (rt-pcr) using primers specific for heat shock protein 70 (hsp70) and a conserved region of the polio viruses. hsp70 mrna could be detected in all specimens, indicating that amplifiable rna had been isolated. in no specimens could polio virus rna be detected. this study suggests that polio virus does not persist in the human cns in quantities detectable by the sensitive pcr method. with cmt type 11, seen at mayo clinic rochester between 1981 and 1991, for the frequency of selective calf weakness in cmt type 11, the form of cmt most similar clinically to distal sma. anterior compartment weakness exceeded calf weakness in 49 patients (74%); anterior and posterior involvement was equal in 16 (24%). calfweakness exceeded anterior compartment weakness in 1 patient (2%). selective calf weakness in distal sma thus helps distinguish this disorder from cmt type 11, and similarly from distal sma with weakness resembling cmt, in that we are unaware of the 2 distributions in distal sma occurring in the same family. given the possibility of genetic heterogeneity, linkage studies of distal sma probably should include patient selection criteria such that the distribution of leg muscle weakness is homogeneous. p206. conjugal amyotrophic lateral sclerosis: amyotrophic lateral sclerosis (als) is a sporadic neurodegenerative disorder of unknown cause. unusual cases may provide etiologic clues. we report a married couple, both of clue to etiology? whom developed als in 1 year. the couple grew up in southeastern pennsylvania and attended the same schools. they married after high school and have 2 healthy children. in september 1990, a 38-year-old woman noted right-hand weakness and associated fasciculations that progressed to the entire right upper extremity. by january 1991, the lower extremities were asymmetrically weak and fasciculating. she then developed left-arm weakness, d ysarthria, dysphagia, and emotional incontinence. she had hyperreflexia and bilateral extensor plantar responses. then, in may 1991, her husband, aged 38, noted difficulty whistling, which progressed to frank dysarthria. later, he developed dysphagia, emotional incontinence, and weakness, wasting, and fasciculations in the upper extremities. hyperactive gag, jaw, and limb reflexes were present. in both, electrodiagnostic testing revealed widespread evidence of lower motor neuron degeneration. numerous laboratory tests were normal. although these cases may represent a chance association, the development of als in a young husband and wife suggests a possible environmental cause. the authors welcome suggestions about these cases from the neurological community. conduction block in demyelinating neuropathies usually is assessed from differences in the sizes of surface-recorded maximum m-potentials evoked by supramaximal stimulation at successively more proximal sites along the course of motor nerves. as the maximum m-potential is comprised of many bitriphasic surface-recorded motor unit action potentials (muaps), differences in the relative latencies between muaps may lead to phase cancellations, reducing the m-potential size and rendering any quantitative assessment of the extent of conduction block relative to phase cancellation difficult. cooling a muscle (not the nerve), however, by as much as 15â°c increases the negative peak durations of muaps by as much as 2 to 3 times and moves the point at which maximum phase cancellation might occur to some theoretical point well proximal to the spinal roots. in 5 cases of guillain-barre syndrome (gbs) studied to date, cooling produced little change in percent reductions in m-potential negative peak areas between successively more proximal sites of stimulation. this finding suggests that "true" conduction block rather than interpotential phase cancellation best explains reductions in m-potential size at successively more proximal sites of stimulation in gbs. associated with trimethoprim-sul famethoxazole rare cases of primarily motor polyneuropathy have been associated with the use of sulfonamides. the incidence of polyneuropathy has diminished substantially with the abandonment of earlier methylated compounds. we describe 2 patients who developed allergic phenomena, including a skin rash and debilitating, painful sensory and autonomic polyneuropathy within days of receiving trimethoprimsulfamethoxazole. in 1 patient, examination revealed resting tachycardia, marked blood pressure orthostasis and near-program and abstracts, american neurological association 281 syncope, hyporeffexia, urinary incontinence, and reduced sensation distally in the lower extremities. his cerebrospinal fluid was acellular with a protein of 141 mg/dl. the other patient showed a resting tachycardia, sluggish pupils, reduced distal vibration perception, and hyperpathia of hands and feet. conventional nerve conduction studies demonstrated normal motor results in both patients, absent or reduced sensory amplitudes in the first patient, and normal sensory results in the second. autonomic studies identified profound abnormalities in testing of sympathetic skin potentials, sinus arrhythmia, and valsalva's ratio. in both cases, nerve biopsy was not performed for fear of exacerbating the patient's hyperpathia. subsequent hemodynamic and electrophysiological testing showed improvement in autonomic function, paralleling the patients' clinical amelioration. although uncommon, a painful, sensory and autonomic, partially reversible polyneuropathy may develop after the use of trimethoprim-sulfamethoxazole. the remote effects of botulinum a toxin injections into vocalis muscles for treatment of focal laryngeal dystonia were investigated using single-fiber electromyography (sfemg). botulinum a toxin injections have been proven effective therapy for various dystonic disorders including focal laryngeal dystonia, blepharospasm, and torticollis. previous sfemg studies have demonstrated remote effects of the toxin in noninjected muscles after treatment for both blepharospasm and torticollis. these effects include an increase in fiber density, mean jitter (mcd), and percentage of fiber pairs with increased jitter. other researchers have postulated that the distant effects of this toxin may be related in part to the dose of botulinum toxin injected. to investigate this hypothesis we have studied patients treated for focal laryngeal dystonia because the amounts of toxin required are 1/25th to 1/1ooth of the doses used to treat other dystonias. using electromyographic (emg) guidance, bilateral injections of 2.5 or 5.0 mouse units of botulinum a toxin were injected into each vocalis muscle of 11 patients. each patient had significant improvement in phonotory function within 48 hours after injections and have been followed serially (usually within 3 weeks and again at 2 mo) after injections, with sfemg recordings of the left extensor digitorum communis and sternocleidomastoid muscles. five patients have had more than 1 series of injections over the 10 months since we began this study. sfemg studies have revealed no significant change in the fiber density, mean mcd, or percent of fiber pairs with normal jitter in either muscle. in conclusion, our studies support the hypothesis that the presence of remote effects of botulinum toxin may be related, in part, to the amount of toxin used. the c57bl/6/01a mouse exhibits the remarkable characteristic of prolonged survival of axons separated from their cell bodies (slow wallerian degeneration). previous work has demonstrated that the axon itself is responsible for the phenotype of prolonged survival. we investigated whether the lack of rapid axonal degeneration after axotomy in this substrain is due to an inability to break down cytoskeletal components, a process that is normally accomplished by activation of intrinsic calcium proteases. segments of desheathed sciatic nerves from normal and ola mice were incubated for 2 hours under conditions that disrupt the axolemma (freeze/ thaw or in 1 % triton x-loo), allowing external calcium free access to axoplasm. nerves were analyzed by western blot for neurofilament (nf) proteins and by electron microscopy. in high-calcium media (1 mm caci,), nf immunoreactivity was lost and axoplasm was reduced to watery debris in both substrains, whereas in egta-buffered media, axoplasm was preserved. these results demonstrate that calcium-activated proteases are present and can be activated in ola nerves. the defect in these mice that allows for prolonged survival of transected axons is likely in the mechanism for calcium entry into the distal stump. the mechanism by which the analogue of adrenocorticotrophic hormone, acta4-9, prevents cisplatinum (cp) neurotoxicity is unknown. murine n1e. 115 neuroblastoma cells and neural crest-derived, squirrel fish erythrophore cells tuesday, have similar vesicular transport mechanisms to human neural cells. they were used to study the effects of cp and acth4, on cellular transport. differentiated n 1e. 1 15 cells were treated 1 hour prior to observation with serum-free media (sfm, control); sfm/cp 5 pg/ml; or sfm/cp 5 pg/ml and 100 ng/ml acth4-,. organelle transport was studied (7 neurites and 100-140 organelles per condition) using computer-enhanced video microscopy. mean fast anterograde (1.00 k 0.07 pmsec-' vs 1.65 * 0.07 pmsec-') and retrograde (0.67 2 0.04 pmsec-' vs 1.19 +-0.05 pmsec-') transport were decreased in cp-treated compared to control cells ( p < 0.0001). in cp/acth4,-treated cells, mean anterograde (1.46 +_ 0.07 pmsec-') and retrograde (1.13 2 0.04 pmsec-') velocities were greater than in cp cells ( p < 0.0001). velocities in control and cp/acth4, cells were not statistically different. erythrophore pigment granule transport was observed in a blinded study, using similar techniques. mean aggregation velocity was greater in control (1.99 k 0.09 msec-') and cp/acth4, (1.97 f 0.07 msec-')-treated cells compared to cp (1.43 * 0.07 msec-') cells ( p < 0.0001). incubation with cp for 1 or 72 hours affected velocities equally, but acute exposure was more easily reversed by control or acth,, containing media. there is striking inhibition by cp in cross-species models of organelle transport. this can be prevented by acth4,. erythrophores allow future study of individual transport components. neurotrophin to investigate signal transduction pathways involved in neurite growth, the cytoplasmic regions of p7sngfr, the common neurotrophin receptor monomer, were searched for a motif analogous to the predicted secondary structure of the tetradecapeptide mastoparan. potential sequences were modeled using a semi-empirical molecular mechanical force field approach. the sequence rat ~7 5~~~ 367-379 represents a highly conserved amphiphilic domain predicted to be involved in neurotrophin signal transduction via g-protein mechanisms. to test this prediction, peptides containing sequences homologous to p7 5ngfr 367-3 79 were examined for effects on trophic factor-induced survival/differentiation responses of rat pc12 pheochromocytoma cells, chick embryo drg neurons, and chick embryo ciliary neurons. a peptide identical to ~7 5~~~ 367-379 accelerated the neurite growth response to nerve growth factor (ngf) of pc12 cells and drg neurons in a time frame that paralleled uptake into cells, but mastoparan did not influence ngf-mediated neurite growth. millimolar mg+ + and benzalkonium chloride, known to block the actions of mastoparan, blocked the effect of the peptide on ngf-mediated neurite growth by pc12 cells. peptides mutated to alter cationic amino acid relationships or amphiphilicity were less effective than the peptide in accelerating ngf-mediated neurite growth. these observations complement and extend evidence suggesting a pivotal role of ~7 5~~~ in ngf-mediated signal transduction. these studies complement and extend evidence suggesting a pivotal role of p7sngfr in neurotrophin signal transduction and evidence that activation of intracellular signalling processes involving specific g-protein mechanisms are involved in neurotrophin-mediated neurite growth. crushing the hypoglossal nerve causes hypoglossal motor neurons to decrease expression of choline acetyltransferase (chat) and begin expressing p75ngfr, the low-affinity ngf receptor. these changes are evident within 3 days after the injury and continue for several weeks. inhibition of axonal transport by vincristine applied to uninjured nerves causes loss of chat expression without induction of ~7 5~~" . we sought to determine if topical vincristine would alter p7sngf' expression after nerve injury. hypoglossal nerves were surgically exposed unilaterally in anesthetized rats and crushed. one week later, rats were reanesthetized and the same nerves were re-exposed. vincristine or saline was applied at the crush sites by soaking a strip of cotronoid wrapped around the nerves. one week later, rats were anesthetized and perfused with aldehydes. frozen sections from the brainstems were stained by indirect immunoperoxidase to demonstrate chat and ~7 5~~~' . saline-treated controls showed decreased chat and abundant ~7 5~~" in hypoglossal motor neurons ipsilateral to the crush injury. vincristine-treated animals showed no chat and no p7tngf'. we interpret these results as indicating that a signal originating from the injury site maintains ~7 5~~" expression after nerve injury. catecholamines have been reported to be toxic to embryonic-derived rat neurons and glia via the formation of reactive oxygen species (rosenberg, 1988) . we tried to determine whether oligodendrocytes (ol) from adult 6-month-old rat brain are similarly susceptible. toxicity to ol was examined using light microscopy and galactocerebroside immunohistochemistry where the relative number of surviving ol and their extent of process formation were graded. five days of exposure to norepinephrine (ne) and epinephrine (epi) at 10 and 100 fm produced significant toxicity ( p < 0.05, analysis of variance [anova)) to adult rat ol; this toxicity was evident by 24 hours of exposure. treatment with catalase (50 p,g/ml), a free-radical scavenger enzyme, completely prevented the toxicity of catecholamines. to ascertain whether astrocytes, which have free-radical scavenging capacity, could prevent the catecholamine-induced injury to ol, rat ol were seeded on neonatal rat astrocytes. under such conditions, the toxicity of n e and epi was reduced significantly ( p < 0.05, anova). these findings suggest that impairment of this protective function of astrocytes may render ol and its myelin membrane susceptible to free-radical-mediated damage. lyme neuroborreliosis is an increasingly prevalent disorder, but the diagnosis generally has been indirect. thus, the pres-ence of other manifestations of the infection, consistent findings on neurological exam or lumbar puncture, or presence of csf antibody have been used rather than direct isolation or identification of the organism from the csf. we have previously developed polymerase chain reaction with hybridization (pcr/h) to identify borrelia burgdorferi in the blood and organs of infected mice, and found that the assay was equivalent or, in some cases, preferable to culture (ann neurol 1991; 30:302) . the assay used for primers oligos derived from a sequence of genomic b. burgdovfri d n a expressed on a plasmid by rosa and schwan. a two-stage nested pcr was performed on csf samples in which the d n a was isolated in a variety of ways. pcr products were subsequently hybridized with a digoxigenin-labeled internal probe by slotblot hybridization. the sensitivity of the assay was excellent, being <o. 1 fg of purified b. burgdoorfevi dnaiml of csf, and 1 to 10 spirochetes per ml of csf when "spiked" csf was tested. the assay then was applied to a battery of csfs stored over the past 15 years in patients with definite, probable, and possible lyme neuroborreliosis. the lack of pcr/h positivity in some patients with definite and probable disease signifies that the spirochete does not reside in the lumbar csf in all patients with lyme neuroborreliosis, and may be concentrated in the meninges or parenchyma. progenitor cell line on transplantation into the adult murine brain t . kitagwcbi, d.-h. chui, and t . tabira, tokyo, japan several multipotent neural cell lines were generated via retrovirus-mediated v-myc transfer into primary culture cells of the septum of embryonic murine brains (the retroviral vector, kindly provided by d r c. l. cepko, boston, ma). two of those cell lines, when transplanted back into 6to 8-week-old mice by stereotaxic operation, integrated into the septum in a nontumorigenic manner. the implanted cells, which had been labeled with pkh26 dye, could be identified in animals up to at least 10 weeks after transplantation. immunocytochemical analysis demonstrated that the transplanted cells were seen assuming a round morphology and no processes. they did not stain with any glial or neuronal markers except for a2b5 and hnk-i, in the same way as in vitro. interestingly, after 10 weeks of implantation, the cells were located discretely in the transplanted site and displayed a small and round morphology with fine processes. most of the transplanted cells showed immunoreactivity with monoclonal antibodies directed against neuronal markers such as neurofilament and map2. these data indicate that the immortalized cell lines might be useful in characterizing factors that regulate cell type differentiation in the mammalian nervous system. (supported by a grant from the science and technology agency of japan.) related to serum response factor in human brain and muscle dana leifer, dimitri krainc, racbael neve, roger bveitbavt, and stuart a. lipton, boston, m a we have identified cdna clones for a novel transcription factor that is expressed at high levels in human fetal brain and skeletal muscle, but not in a variety of other tissues, as demonstrated by northern blotting. sequence analysis indicates that the clones appear to have 2 alternatively spliced forms and have extensive homology with human serum re-sponse factor (srf) and a family of related transcription factors that has representatives throughout eukaryotic evolution in species from yeast to man. srf is thought to have a role in regulation of immediate early genes and of muscle-specific genes. in gel mobility-shift assays, the srf-like proteins coded for by our clones bind specifically to the myocytespecific enhancer binding factor-2 (mef-2) regulatory element, a dna sequence that has so far been found to be functionally important in the promoter and enhancer regions of a variety of muscle-specific genes. moreover, our srf-like proteins specifically activate transcription of reporter genes containing the mef-2 element. given the abundant expression of our clones in human brain as well as in muscle, our results suggest that these proteins may have a significant role in development not only of muscle but also of brain. a host of quantitative eeg studies, most of which employed variations of the fast-fourier transform, have been made on isolated clinical entities such as the epilepsies, metabolic syndromes, and sleep with varying degrees of satisfactory correlations. using a time domain wave-by-wave computer program that simulated the logical approach of the clinical electroencephalographer, we have studied more than 300 unselected routine neurological clinic and ward patients. the presenting problems ranged from headache to major cerebral involvement. employing the dichotomy of normal and abnormal, the computer-read eegs agreed with the routine eeg, the clinical manifestations (including imaging techniques), and neuropathological findings in 90% of all cases. this high level of correlation, which approached that achieved by welltrained eegers reading the same records, was obtained by solely utilizing the background eeg activity. such results became possible only when the computer program was so organized that the "raw" computed and original oscillograph records were made to match closely. the diagnosis, with topographically diagramed localization, was printed automatically as the final step of the program. our data strongly suggest that routine computer reading of the human eeg is feasible, reliable, and potentially useful. protein accumulation in damaged neurites and microglial cells abnormal accumulation or abnormal processing of amyloid precursor protein (app), or both, may be critical to the development of p-amyloid protein (bap) deposits. however, alzheimer's disease (ad) has another pathological hallmark, which is the appearance of neurofibrillary tangles. the question is, therefore, to clarify the possible relationship between altered app metabolism and neurofibrillary degeneration. one classic method for inducing neurofibrillary tangles is the administration of aluminum salts. although these tangles are morphologically different than those seen in ad brain, this phenomenon has given rise to the hypothesis that aluminum might be an environmental factor in the causation of ad. this theory is controversial, but the animal aluminum model remains one of the few ways that long-lasting neuroskeletal changes can be induced. to explore the effects of aluminum salts on app metabolism, we examined app immunodistribution in rat brain injected intraventricularly or intrastriatally with aici,. we found a long-lasting accumulation of app in affected neurites, as well as in activated microglia/macrophages. abnormal neurites also showed argentophilic changes, neurofilament accumulation, and alz-50 immunoreactivity. the results support the hypothesis that interruption of axoplasmic flow by aluminum salts, as by other means, can lead to both app accumulation and neuroskeletal alterations. p223. nondemyelinating conduction slowing of myelinated fibers due to inactivation of n a channel takanori yokota, yukinobu saito, and tadashi miyatake, tokyo, japan in 4 patients with acute or chronic inflammatory demyelinating polyradiculoneuropathy, the marked improvement of motor-nerve conduction velocity without change of amplitude or configuration of the compound muscle action potentials (cmaps) was observed in 3 days. to investigate the mechanism of the rapid improvement of nerve conduction, the influence of na channel blockade on nerve conduction was studied. in 4 healthy volunteers, the recovery of the cmap and sensory nerve action potential (snap) of median nerve stimulation were recorded after the intravenous infusion of 100 mg of lidocaine. after the loading, cmap and snap were reduced rapidly in amplitude and were slowed in latency. after the recovery of amplitude of cmap and snap, the nerve conduction velocities were improved gradually in 2 hours with the amplitudes and configurations of cmap and snap unchanged. this indicated that myelinated nerve conduction velocity could be slowed by the inactivation of na channels without demyelination or conduction block. the prolongation of rising time in depolarization of axonal membrane potential should be one of the mechanisms of this conduction slowing due to inactivation of na channels. paraneoplastic cerebellar degeneration (pcd) in gynecological and breast cancers frequently is accompanied by an autoantibody response (type i or "anti-yo") reacting with 34and 62-kd cytoplasmic antigens of cerebellar purkinje cells. sakai et al, using a cerebellar library (stratagene), recently have isolated a cdna clone expressing a 52-kd protein recognized by igg from a patient with pcd and uterine carcinoma (sakai et al, ann neurol 1990; 28:692) . this clone is believed to share some homology with the message encoding the 62-kd protein recognized by type i sera. because pcd17 was isolated using serum from a single patient, however, it is not known whether the expressed protein of pcd17 is recognized uniformly by all patients with type i antibody response. e. coli strain xl1-blue transformed with pwr590-2 containing the snabiihindiii fragment of pcd17, pwrsbo-pcdl?sn, was induced using isopropylthiogalactoside. bacterial lysates were electrophoresed on 10% sds-page gels and analyzed by western immunoblot program and abstracts, american neurological association 285 methods using sera and csf from patients with pcd associated with gynecological and breast malignancies who exhibited type i antibody response. the 52-kd expression product was labeled by 818 sera and 414 csf samples tested from antibody-positive patients but was not labeled by sera or csfs from controls. our studies demonstrate that the 52-kd protein expressed by pcd17 contains epitopes that are consistently recognized by both systemically and intrathecally produced antibodies from patients with pcd accompanying gynecological and breast malignancies. tax01 is a novel antitumor drug that has demonstrated impressive clinical activity in breast, ovarian, and lung cancers. although sensory neuropath y has been described secondary to both taxol alone and taxol-cisplatin combination, detailed neurophysiological and pathological studies have not been described. nineteen patients with solid tumors were treated with combinations of taxol (135-350 mg/m2), cisplatin (75-100 mg/m2), and granulocyte colony-stimulating factor (g-csf) (5 pglkglday). sequential neurological examinations, nerve conduction studies (ncs), and quantitative vibration testing (qst) were performed during and after treatment. eighteen of 19 patients developed sensorimotor neuropathy and 3 developed myopathy. thirteen were symptomatic with numbness or weakness and 17 had abnormal results on neuromuscular examination. ncs showed absent or prolonged h-reflexes (14), reduced peroneal motor amplitude (14), reduced sural sensory amplitude (13), and myopathic motor unit potentials in proximal muscles (3). qst results were abnormal in 7 of 15 tested patients. muscle biopsy specimen in a patient with myopathy showed features of a toxic myopathy. the neuropathy was worse with higher cumulative dosages of taxol (>600 mg), with higher single doses of taxol(>300 mg/m2), or with a preexisting neuropathy. we conclude that sensorimotor neuropathy and myopathy are dose-limiting neurotoxicities of combined cisplatin and taxol use, now that neutropenia can be controlled with neuropathy and myopathy g-csf. central nervous system lymphoma casilda balmacedz and lisa deangelis, new york, ny ally periventricular and may seed the csf by direct growth through the ependyma. we reviewed the csf profile of 83 non-acquired immunodeficiency syndrome (aids) patients (pts) with pcnsl. all pts had lumbar puncture (lp) and 46 had multiple samples from an ommaya reservoir. definite lm involvement was identified with a positive csf cytology, lymphomatous lm infiltration on a surgical specimen, or mri with gadolinium showing lm tumor. probable lm lymphoma was diagnosed in pts with suspicious or atypical csf cytology. there were 41 women and 42 men with a median age of 57 (range 20-81 yr). at diagnosis, mean white blood cell count was 49/mm3 (range 0-5,5 10); mean lumbar csf protein was 103 mgldl (range 3-1,893); and mean ventricular csf protein was 32 mgldl (range 4-265). glucose was always normal. nineteen of 57 pts sampled had oligoclonal bands, and 42/65 had elevated pz microglobulin. at diagnosis 43 (52%) had an abnormal csf cytology: 22 positive, 16 suspicious, and 5 atypical. one pt had pathological infiltration of the lm and 1 had lm tumor on spine mri for a total of 45 (54%) pts with definite or probable lm lymphoma. in 43 pts with abnormal cytology, the abnormality was found in 30143 (70%) lps and 32/55 (58%) of the ommaya and ventricular specimens. in 8 pts the lumbar cytology was the only abnormal specimen despite multiple ventricular samples, and in 10 only the ventricular csf was abnormal. thirty-six of 83 (43%) pts developed recurrent tumor afrer treatment. forty-two percent (15136) of all patients with relapse had lm recurrence. lm recurrence was accompanied by brain recurrence in 9 pts, systemic in 1, ocular in 1, both systemic and ocular in 1, and isolated in 3. at diagnosis 59/83 patients received treatment directed against the lm. of these, 8 (14%) had meningeal recurrence whereas 7 of the 24 (29%) patients who did not receive this treatment had lm recurrence. lm involvement by pcnsl is frequent, may be missed on a single csf sample, and requires specific therapy at diagnosis. sixty-three solid cancer patients with a single brain metastasis were prospectively randomized for neurosurgery and radiotherapy combined (arm 1) or radiotherapy alone (arm 2). they were stratified for lung or nonlung cancer and for active versus stable or absent extracranial disease. world health organization performance status was 9. age, sex, performance status, and location of brain metastasis were divided evenly over both groups. one-month mortality was 7% in arm 1 and 6% in arm 2. median survival of 11 months after combination therapy was significantly better compared to 6 months after irradiation alone ( p < .04). it made no difference whether they had lung or nonlung cancer. the largest difference between both treatment arms was observed in patients with stable or absent extracranial disease (12 vs 7 mo, p < .02). when systemic disease activity was present, median survival was 5 months irrespective of treatment arm. functional independent survival was 1 to 2 months shorter than overall survival and was significantly better for patients with stable extracranial disease after combined therapy. multivariate analysis showed that age was also an independent prognostic factor. patients older than 60 years had a hazard ratio for dying of 2.8 (p. 004). we will detail the type and pattern of neurological complications in t-cell non-hodgkin's lymphoma (nhl), and review how they differ from those associated with b-cell nhl, and the lymphomas in general. this study is the first step in a process to characterize these tumors to determine if special staging or cns prophylaxis are indicated in any of the subtypes of t-cell lymphoma. we recently have encountered 5 women with breast cancer and an unusual sensorimotor neuropathy. the neuropathy was the major clinical problem. in 4 women the initial symptom was severe itching, 3 generalized and 1 first localized to the involved breast and then generalized. all developed distal extremity numbness and burning that very slowly progressed proximally, and in 2 became generalized. four complained of painful muscle cramps in the extremities ( 4 ) and jaw (1). all had mild extremity weakness, distal (5) and proximal ( 1 ) . three women developed symptoms up to 21 months prior to cancer diagnosis, 1 shortly after diagnosis, and 1 5 years after diagnosis. four women had disease confined to the breast and regional lymph nodes, and 1 had metastatic disease in remission. although annoying, symptoms were generally not disabling. three women stabilized or had slight improve-associated with breast cancer ment with cancer treatment, and 2 continue to gradually progress while in cancer remission; 1 required a cane to ambulate after 9 years due to sensory ataxia. one who developed cancer relapse had concurrent neurological relapse. one woman treated with high-dose immunoglobulin did not improve. none had significant weight loss. laboratory abnormalities included elevated erythrocyte sedimentation rate (28-60) in 3, antinuclear antibody 1:40 in 1, csf with lymphocytic pleocytosis (7-14 white blood cellslmm) in 3/ 4 and elevated protein (5 1-97 mg/dl) in 414 available. emgi ncv showed mild sensory-to-motor polyneuropathy in 314 available. none had detectable antibodies against peripheral nerve or dorsal root ganglia. the etiology of sensorimotor neuropathy in these patients is unknown, but it may represent a distinct paraneoplastic syndrome that can herald the onset of, and parallel the course of breast cancer. our objective was to determine whether ceramide induces differentiation of anaplastic glioma cells. sphingomyelin hydrolysis resulting in ceramide production has been linked to differentiation of leukemia cells. t9 rat anaplastic glioma cells, seeded at 2 x lo4 cells per well, were grown in serum-a glioma cell line program and abstracts, american neurological association 287 free media. on day 4, cells were photographed, scored for processes longer than one cell body, and counted. c2 ceramide changed plump cells to flattened cells with many long processes: ceramide treatment increased the percentage of cells with processes from 22 2 4% (sd) to 49 * 12% (n = 4, p < 0.01). control cells grew to 6.3 x lo5 cells/well 2 0.6 x lo5 cells; ceramide-treated cells grew to 1.6 x lo5 ? 0.6 x los (n = 4, p < 0.0005). although one ceramide analog reproduced the c2 ceramide-associated changes, the optical isomer of this analog did not, demonstrating stereospecificity. cerarnide did not decrease cell viability by trypan blue. ceramide inhibits proliferation and induces process formation in a glioma cell line, causing it to assume a more differentiated phenotype. cerarnide or its analogs represent possible future therapeutic agents that would inhibit the growth and affect differentiation of anaplastic gliomas. [bashir, mod pathol 1990; 3(4) :429-434)). this is similar to the pattern seen in ebv-infected human b cells and unlike the uniform latent infection seen in burkitt's lymphoma. we tested the hypothesis that long-term passaging of ebv-immortalized human b cells in immunodeficient mice leads to emergence of a uniform nonlytic pattern of ebv infection associated with appearance of the malignant profile. ebv-infected normal human b cells were serially passaged intracerebrally in severe combined immunodeficient cb17 mice (5 x 10' cells per mouse, 5 mice per passage for a total of 10 passages). frozen mouse brain sections from each passage were stained with vca antibody (ebv lytic cycle) and hybridized with biotinylated bamh1-w sequence of ebv. all injected animals developed tumors as previously described (bashir, lab invest 1991; 65(6):702-709) . tumor cells continued to express vca and showed latent and lytic hybridization patterns with bamh,-w after 10 passages despite exhibiting monoclonality (surface immunoglobulins) and random chromosomal changes. lytic infection of immortalized b cells with ebv is stable, resembling brain lymphomas in aids, and unlike the latent infection seen in burkitt's lymphoma. a previously healthy 73-year-old man developed diplopia and incapacitating, diffuse weakness over a period of 6 weeks. examination showed a "one-and-a-half'' syndrome of horizontal gaze paresis, patchy severe weakness with atrophy and fasciculations, absent tendon reflexes in the legs and right biceps, and decreased vibration sense in the feet. csf contained a mild pleocytosis, elevated protein, and oligoclonal igg bands. electrophysiological testing indicated a generalized sensorimotor axonal neuropathy with diffuse denervation. small-cell lung carcinoma was diagnosed by bronchoscopy. prednisone produced mild subjective improvement. chemotherapy was begun but the patient developed fatal septicemia. serum was negative for anti-hu or anti-gm1 with paraneoplastic encephalomyeloneuritis antibodies. serum and csf contained high titers of igg antibodies reacting specifically with a protein antigen of approximately 130 kd in immunoblots of human cerebral cortical neuronal nuclei or of human purkinje cells. this pattern of autoantibody reactivity was not present in sera from any of 37 other patients with small-cell lung carcinoma, 17 of whom had paraneoplastic encephalomyeloneuritis and anti-hu antibodies, nor was it present in many patients with other neurological disorders. the patient's serum has been used to probe a human cerebellum expression library and to isolate a cdna clone that is being characterized. acute encephalopathy is the problem in 17% of neurology consultations reported at mskcc. we studied 94 patients (5 1 prospectively and 43 retrospectively) to determine clinical findings, causes, and outcome. fifty-five were women and 39 were men, and the average age was 63 years. all patients had cancer: lung (20%), gastrointestinal tract (19%), breast (12%), and others (49%), forty-two patients (45%) were delirious on admission and delirium developed an average of 12 days later in 55%. encephalopathy occurred postoperatively in 24%. symptoms included confusion (92%), lethargy (59%), agitation (5 1 %), hallucinations (29%), and seizures (10%). signs included deficits in attention (44%), memory (385%), language (15%), lateralizing signs (50%), and asterixis (33%). the average mini-mental status test (mms) score was 12 (30 = normal). a single cause for delirium was found in only 4% of patients with an average of 4 etiologies per patient. metabolic abnormalities were found in 89% of patients, and were a primary cause in 44%; disseminated intravascular coagulation contributed to delirium in 11%. cns metastases were found in 32% and were a major cause of delirium in all. fifty percent of the patients had fever/ systemic infection, but sepsis was present in only 4%; only 1 patient had cns infection. medication contributed to delirium in 97% but was a primary cause in only 29%. the 30-day mortality rate was 3 1 % and delirium improved in 68% (average mms = 23). patients with cancer have multiple, potentially treatable causes of delirium. delirium is associated with a high death rate, though patients generally improve. radiation therapy for brain tumors d. w. dodick, b. mokri, k. k. unni, g. m. miller, and e. g. shaw, rochester, m n osteosarcoma in a previously normal bone is a rare but recognized remote effect of radiation therapy. any bone in the field of radiation can be affected. involvement of cranial bones is exceedingly rare. we could identify only 4 patients (2 men and 2 women) with postirradiation osteosarcoma of the calvarium seen at the mayo clinic over a 50-year period, from 1931 to 1991. all had received radiation for brain tumor, osteosarcoma had appeared in the field of radiation in all, the interval from radiation therapy to the appearance of sarcoma ranged from 7 to 23 years, and diagnosis of sarcoma was confirmed histologically in all cases. the patients' age at the diagnosis of the brain tumor ranged from 18 to 41 years. the nature of the brain tumor was unverified in 2 cases, was a low-grade ependymoma in the third case, and a pilocystic astrocytoma in the fourth case. one patient is still alive 12 months after the diagnosis of the sarcoma. she received chemotherapy and subsequently underwent resection of the osteosarcoma. one patient died postoperatively after partial resection of the sarcoma. the other 2 patients died 7 months and 15 months after the diagnosis of the osteosarcoma despite additional radiation therapy in the former and aggressive chemotherapy in the latter. element-la2 fusion gene as a potential marker of neural tumor differentiation lawrence recht, chiffon wu, and louis j. degennam, worcester, ma inducing cancers to differentiate into more benign differentiated tumors represents a novel oncological strategy. to establish a model that would permit assessment of this phenomenon at a molecular level, we created and have partially characterized a murine neuroblastoma line that has been stably transfected with a synthetic fusion gene containing the promoter element of the rodent synapsin i gene (synapsin i regulatory element isre)). in vivo, this promoter directs the neuron-specific expression of the synapsin i gene in normal adults. the gene also is expressed in varying amounts in neuronal tumors including neuroblastoma. in the synthetic fusion gene, the sre has been linked to the lacz gene that encodes bacterial p-galactosidase. a simple histochemical assay for p-galactosidase therefore provides a specific marker of the expression of the fusion gene. our preliminary experiments as of this writing have shown that it is possible to detect p-galactosidase activity in the transfected neuroblastoma cells both in vitro and in transplanted tumors. it appears possible therefore that this transfected neuroblastoma cell line can provide a useful model system with which to assess the effects of differentiation therapies. larger lesions (>18 cm2), and larger midline shifts (>4 mm). twenty-eight of 36 (78%) patients with prior has had bt has compared to 25 of 75 (33%) patients without prior has. in 8 patients, their bt h a was similar to their previous ha but was more frequent or severe. we conclude that has in bt patients are common but usually not severe. nausea, vomiting, an abnormal neurological examination, or a change in prior headaches warrant further investigation. cairncross and macdonald showed that procarbazine, lomustine, and vincristine (pcv) are effective for recurrent anaplastic oligodendrogliomas (ao) (ann neurol 1988; 23:360-364) . pcv now has a major role in management of all forms of oligodendrogliomas (0), but the biological basis for this response is unknown. to evaluate one subset of possibilities, we studied 14 patients (6 ao, 8 0) with a ct method that permits measurement of blood-to-tissue transport (kj, tumor-to-blood transport (k2), and vascular volume (v,) (ann neurol 1991; 30:581-587) . pcv was used to treat 11 of the 14 patients. k, (~1 grr-' min-') values were highly variable for whole tumor, ranging from 1.49 to 14.37 (mean 4.87 k 4.17) with no difference between a 0 and 0. k2 and v, were also highly variable. k, of tumor-free brain was 1.40 to 2.69 (mean 1.89 ? 0.50). in comparison to malignant astrocytomas, which have a mean k, in the range of 21.0 with some as high as 33.9, a 0 and 0 appear to be much less permeable. this suggests that the efficacy of pcv may be due to factors other than capillary transport, such as tumor-cell sensitivity. frameless stereotactic localizer gene h. barnett, donald w. komos, and charles p . steiner, cleveland, oh extent of tumor resection has been shown to correlate with prognosis in malignant gliomas. although frame-based stereotactic techniques can provide information regarding tumor margin, they are often unwieldy and require expensive and elaborate computing systems. a frameless stereotactic neurosurgical localizing system was designed that overcomes these liabilities. this armless, frameless, stereotactic pointing device provides real-time three-dimensional localization information during operation. in addition to assisting in placement of a trephine craniotomy, it allows volumetric resection of the tumor with virtually complete excision of even large irregularly shaped tumors. mean error on localizing a point in space using this system has proven to be less than 2 mm. a technical description of the system as well as surgical results are presented. to investigate the effect of age on response rate to chemotherapy and time to progression (ttp) and death ('itd) in patients with recurrent astrocytomas and malignant astrocytomas, we reviewed case records and scans of 143 patients who received chemotherapy at the university of michigan with bischloroethylnitrosourea or procarbazine. three age groups were studied: (1) <39 yr (n = 64); (2) 40-60 yr (n = 56); (3) >60 yr (n = 23). tumors were grouped as grade 2r+ 3 (recurrent grade 2 plus grade 3, n = 72) or grade 4 (n = 7 1). serial computed tomographic or magnetic resonance scans were analyzed in a blinded fashion and graded as progressive disease (pd), stable disease (sd), or partial response (pr, >25% decrease in size). the pr rates for the 3 age groups were 58%/32%/0% for grade 2r+ 3 tumors ( p = 0.023) and 40%/10%/5% for grade 4 tumors ( p = 0.011). median 'itp was 3112316 weeks for grade 2 r + 3 and 221 16/10 weeks for grade 4. median ltd was 53/48/19 weeks for grade 2r+ 3 and 36/31/24 weeks for grade 4. we conclude that age is an important prognostic factor with respect to likelihood of response to chemotherapy, duration of response, and survival irrespective of grade. cheryl p. harris and kurt a. jaeckle, salt lake city, ut intravascular malignant lymphomatosis (iml), a b-cell lymphoma confined to small venules and capillaries, often presents with neurological symptoms. this disease is uniformly fatal (5-month mean survival); no successful treatment has been identified. we observed marked reproducible neurological improvement after plasmapheresis in a 43-year-old woman with iml. presenting with a cauda equina syndrome, she progressed over 1 year with neurological, hepatic, and hematological disease. persistent laboratory abnormalities included a high sedimentation rate (140 mm/hr), coagulopathy, hemolytic anemia, and elevated liver enzymes. extensive evaluations for infectious, autoimmune, and neoplastic processes, including bone marrow examination, were inconclusive. because of neurological progression, empiric therapy with high-dose steroids followed by cyclophosphamide was initiated without response. plasmapheresis (250 ml/kg in 6 exchanges) effected resolution of encephalopathy and normalization of the coagulopathy and sedimentation rate. neurological progression recurred within 2 weeks of pheresis; 6 repetitive courses reproduced neurological response. finally, progressive dementia ensued, and a decision was made to cease pheresis; the patient died 5 days later, 16 months after presentation. autopsy disclosed diffuse intravascular cd-20 positive malignant lymphoma cells in small vessels of all organs. although the mechanism is unknown, the serendipitous discovery of response to plasmapheresis in this patient warrants further consideration. morphine is an effective analgesic in the rat after injection into a number of discrete brainstem regions, including the periaqueductal gray (pag), the locus coeruleus (lc), and the nucleus raphe magnus (nrm). early work with morphine gray and the nucleus raphe magnus established the existence of synergy between the brainstem and the spinal cord in rats. more recently, studies from our laboratory revealed synergy between two brainstem structures, the pag and the lc. in the current study, we explored the analgesic interactions between the pag and the nrm using indwelling cannulae. first, we established morphine dose-response curves and calculated the ed,, independently in the pag (1.9 pg) and the nrm (2.5 pg). we then simultaneously injected various morphine doses into both regions. injecting morphine at 1 pg into either the pag or the nrm did not elevate tailflick latencies above baseline values. however, administered into both regions simultaneously, the 2 1-pg doses produced an 80% maximal response, corresponding to more than a threefold increase of baseline latencies. a fixed morphine dose of 1 pg in the pag shifted the morphine dose-response curve fivefold in the nrm (ed,, 0.5 pg), whereas a fixed nrm dose of 1 fg shifted morphine's dose-response in the pag approximately twofold. together, these results clearly show synergistic interactions for morphine between the pag and the nrm. the presence of synergistic interactions between brainstem nuclei as well as between the brainstem and the spinal cord underscores the complexity of opioid analgesic systems. p244. the glutamate uptake inhibitor ~-trans-2,4-pyrrolidine dicarboxylate is neurotoxic in neonatal rat brain john d. e. barks and faye s. siloerstein, ann arbor, m i important evidence of the neurotoxicity of endogenous glutamate (glu) in mammalian brain was provided by the observation that dl-threo-3-hydroxyaspartate, a high-affinity glutamate uptake (hagu) inhibitor, was neurotoxic in adult rodent striatum (j neurochem 1985; 44:247) ; however, the absence of neurotoxicity in neonatal brain was interpreted as evidence that immaturity of glutamatergic innervation limited the potential role of endogenous glu as a neurotoxin in the immature brain. yet, considerable data provide indirect support for the hypothesis that glu can be neurotoxic at this stage. to resolve this issue, we assessed the neurotoxicity of a novel, selective hagu inhibitor, ~-trans-2,4-pyrrolidine dicarboxylate (l-pdc) (j med chem 1991;34:717), in postnatal day (pnd) 7 rats (n = 8). l-pdc (ph 7.4) was stereotaxically injected into right anterior striatum (str) (568 nrnol, n = 2) or through dorsal hippocampus into posterior str (568 nmol, n = 4; 150 nmol, n = 2). animals were killed 5 days later, and neuropathology was assessed in cresyl violet-stained sections. after anterior injections, focal neuronal necrosis was evident in dorsal str; high-dose posterior injections caused prominent hippocampal lesions with pyramidal layer thinning and focal necrosis in dorsal thalamus, while 150 nmol produced small foci of pyramidal cell loss. in both groups, focal cortical necrosis and callosal cysts were apparent adjacent to the injection track. l-pdc-induced brain injury provides direct support for the hypothesis that endogenous glu may be neurotoxic in the developing brain. (sax et al, ann neurol 1991; 30:311a) . the signs and symptoms of 7 of these patients lessened for 12 to 22 months. furthermore, a patient with a severe oral-lingual biting dyskinesia improved when taking doses up to 300 milligrams per day for 4 months. we noted no-significant adverse reactions, although 4 patients had mild but labile elevations in sgop and sgpt. one patient receiving opioid analgesics for pain inadvertently failed to discontinue the naltrexone but noted no reduction in the pain-alleviating effects of the analgesic. although hyperkinesia, especially of midline functions, as well as quality of life improved for the hd patients, their cognitive deficits remained unaffected. these observations suggest that chronic naltrexone is a safe and effective agent to treat chorea, dysphagia, and oral dyskinesia in hd for periods longer than a year. furthermore, they indicate that naltrexone can be effective in ameliorating oral-lingual biting tardive dyskinesia. these findings support our previous hypothesis that endogenous opioids play a role in rhe modulation of the dopamine system in hyperkinetic stereotypic movement disorders. a. jon stoessl, elizabeth szczutkmuski, and hanna fydvszak, london, ontario, canada we previously have demonstrated (psychopharmacology 1989; 98:372-379 ) that intraperitoneally (ip) administered cholecystokinin (cck)-8s suppresses vacuous chewing mouth movements (vcms, a putative mode1 of tardive dyskinesia) in rats exposed to chronic neuroleptics. as cck is not thought to cross the blood-brain barrier in significant amounts, its site of action in this paradigm is unclear. other behavioral and neurochemical effects of ip cck are blocked by vagotomy. male sprague-dawley rats were administered fluphenazine decanoate (flu; 25 mg/kg im) or its vehicle every 3 weeks for approximately 20 weeks. cck (10, 20, or 50 ng intracerebroventricularly) had no effect on neuroleptic-induced vcms. another group of neuroleptic-treated rats was subjected to bilateral subdiaphragmatic vagotomy or a sham procedure. cck-8s (10, 30, or 50 pg/kg intraperitoneally) suppressed neuroleptic-induced vcms in shamoperated animals, which confirmed our previous results. in vagotomited animals, chronic flu failed to induce vcms and cck was without effect in vehicle-or neuroleptictreated animals. these data suggest that the effects of cck on flu-induced vcms may be mediated peripherally, and that vagal pathways may be important for generating this response. (supported by the ontario mental health foundation and the ontario ministry of health.) p247. excitotoxic amino acids are not involved in dopaminergic neurotoxicity of m p t p eldad mehmed, jutta rosenthal, and avinoam reches, petah tiqva, tel aviv, and jerusalem, israel the dopaminergic (da) neurotoxicity of 1-methyl-4phenyl-1,2,3,6-tetrahydropyridine (mptp) is mediated via its oxidation in cns to mpp + , which enters da neurons and poisons mitochondrial complex i. da neuronal damage induced by direct nigral mpp+ injection is prevented by pretreatment with n-methyl-d-aspartate receptor antagonists, which suggests that excitatory amino acids are involved in mptp toxicity. since local mpp + application may produce nonselective nigral damage, we examined whether excitotoxins have a role in toxicity of systemically administered mptp. c57 black mice were injected intraperitoneally, once, with mptp.hci(40 mg/kg) and decapitated 5 days later. groups of animals underwent the following pretreatments: (i) decortication 1 week prior to mftp; (2) intracerebroventricular injections of the excitatory amino acid receptor antagonists 2-amino-phosphonoheptanoate and d-glutamyl-glycine; and (3) intraperitoneal injections of the calcium channel antagonists nimodipine, diltiazem, and flunarizine 30 minutes prior to mptp. mptp produced marked striatal da depletions. decortication, destroying glutamatergic corticostriatal projections, intracerebral amino acid receptor antagonists, and systemic calcium channel antagonists did not protect mice against mptp toxicity; mptp-induced striatal da decreases were similar to those given the neurotoxin alone. this study suggests that excitotoxins are not involved in the mechanism of mptp toxicity. scopolamine-induced cognitive deficits k . j . meador, m . e. allen, p. franke, e. e. moore, and d. w. loring, augusta, ga a unique neurophysiological role for thiamine in cholinergic systems has been suggested. total thiamine content in cholinergic nerve terminals is comparable to that of acetylcholine, and the phosphorylation state of thiamine changes with release of acetylcholine. thiamine binds to nicotinic receptors and may exhibit anticholinesterase activity. based on these observations, we investigated the effects of pharmacological doses of thiamine on the cognitive deficits induced by the anticholinergic scopolamine in 13 healthy young adults using a randomized, double-blind, placebo-conrrolled, double crossover design. cognitive tests included the p3 eventrelated potential and free recall memory for a verbal paragraph. conditions included baseline (bl), thiamine 5 gm by mouth and scopolamine .007 mg/kg intramuscularly (b1 + scop), and lactose by mouth and scopolamine (plac + scop). testing was performed 3 hours post thiamine or placebo, and 1.5 hours post scopolamine. thiamine significantly reduced the adverse effects of scopolamine on p3 latency (f [i, 121 = 11.84, p 5 .005) and percent recall memory ( f el, 12) = 10.62, p 5 .007). means (+sd) and p3 latency (ms) were bl = 335 (24), b1 + scop = 360 (29), and plac neurol 1990; 27: 186-192) . we previously reported that cff improved in 11 of 17 ms patients (65%) given el-970 orally in divided daily doses ranging from 7.5 to 52.5 mg (stefoski et al, neurology 1991; 41:1344 -1348 . subsequent analysis revealed that in 14 of the 17 patients cff improvements and reversals followed in a phase-locked trend the rising and falling serum concentrations of el-970, including 3 patients whose changes remained below the 15% increase needed to qualify for the improved category. these results resemble the phase-locked effects of temperature on neurological function in ms. the cff changes, because they so closely reflect variations in serum concentration, suggest that el-970 tissue levels closely follow those in serum and that el-970 rapidly crosses the blood-brain barrier. efficacy of el-970 in ms is also predicted to have a close relationship to serum levels. p250. development of a n internal standard detectable by proton and phosphorus-3 1 nmr and hplc w. e. klunk, k. panchalingam, r. j . mcclure, and j . w. pettegrnu, pittsburgh, pa comparison of quantitative results from different analytical techniques can prove difficult due to the peculiarities of the particular techniques and the lack of a common standard applicable to all of the techniques. recently, both in vivo and in vitro nuclear magnetic resonance (nmr) have been applied to the quantification of a large variety of metabolites. although nmr can be applied to the study of living tissue, the question arises of how this technique compares with more traditional techniques such as high-pressure liquid chromatography (hplc). although this question can be addressed partly by studying perchloric acid (pca) extracts, it is difficult to directly compare this in vitro nmr data with results from hplc. to address this question, we have developed an internal standard that can be quantified directly by in vitro phosphorus-3 1 nmr, proton nmr, and by 9-fluorenylmethyl chloroformate (fmoc) derivatization followed by separation by hplc. a variety of aminophosphonic acids were studied by 3'p nmr, 'h nmr, and hplc. promising compounds were added to pca extracts of human brain. the optimal compound was found to be 3-aminopropylphosphonic acid (app, ho3p-ch2-ch,-ch2-nh2). app is easily detectable by all 3 techniques, falls well outside of the region of interest in phosphorus-31 nmr, and is well resolved by proton nmr at 500 mhz. it is easily separable from the phosphomonoesters and phosphodiesters observable by hplc and from the amino acids that occur in brain in significant concentrations. app appears to be a useful internal standard in the study of phosphorus and amino acid metabolites by in vitro 31p nmr, 'h nmr, and hplc. theories of sentence comprehension hypothesize at least a grammatical component that establishes the relationship among words in a sentence, and a semantic component that determines the meanings of these words. we used positron emission tomography (pet) to quantify regional cerebral blood flow (rcbf) in 12 neurologically intact subjects during their detection of a letter target, a grammatical target, or a semantic target in the same written sentences. a mixedmodel analysis of variance (anova) revealed significant main effects for region (f e30, 210) = 19.32; p < .001), condition (f 12, 143 = 3 . 9 6 ;~ < .05), and a significant region times condition interaction ( f {go, 4203 = 1.46; p < .05), but there were no differences between individual subjects. subsequent anovas revealed increased rcbf in a unique set of brain regions during the subjects' response to a grammatical probe when compared to their response to a letter probe of the same sentences. a unique distribution of rcbf also distinguished response to the semantic probe from response to the grammatical probe and the letter probe. other brain regions apparently contributed to performance for several activation conditions. these findings support the hypothesized dissociation of specific linguistic components based on their unique cerebral topographical representation, and that a distributed network of brain regions subserves sentence comprehension. cerebral music processing-a comparison study of musically trained and naive individuals louis s. russo, jr, jachonville, fl we performed topographical mapping of brain electrical activity in 6 right-handed symphony musicians and 5 righthanded, musically naive individuals during various musical tasks; namely, listening to solo piano music, silent singing of familiar music, and silent reading of unfamiliar music. fast-fourier transform ( f r ) of electrocortical activity was carried out during task performance and the eyes-open resting state. data were analyzed using a computer-assisted model. increases in regional beta activity of greater than 3 standard deviations from the resting state were considered significant of activation. during audition, the musicians showed activation in the right posterior parietotemporal region; the naive showed no change from the resting state. during silent singing, the musicians showed bitemporal activation, r > l; the naive showed activation in the right mid-and posteriortemporal regions alone. during silent sight reading, the musicians showed a major activation in both temporal regions, l > > r, the naive showed only a marginal change in the posterior temporal-occipital regions. these data suggest that music processing is primarily a right cerebral function in untrained individuals and a bilateral function in musicians. musicians, in contrast to the naive, show progressively more left brain activation as task complexity increases. the present study analyzes language profiles in 10 patients who presented with primary progressive aphasia (ppa) without global dementia for at least 2 years. language and cognitive impairment were evaluated using the western aphasia battery (wab) and the mattis dementia rating scale (drs). expressive language disability with reduced speech fluency and anomia, but preserved language comprehension and nonverbal cognition, were typical features in early stages. spontaneous speech was significantly more impaired in ppa than in anomic aphasia after left-hemisphere stroke and in language impairment in probable alzheimer's disease (ad) ( p = 0.0004). the profile of aphasia suggests that ppa tends to affect anterior parts of the language-dominant cortex first. neuroimaging generally showed mild to moderate brain atrophy. in 2 patients atrophy involved especially the left frontal progressive aphasia cortex. follow-up examinations that were done in 7 patients 1 or several years after the first assessment revealed continuous, most often rapid deterioration of language impairment. two patients died 3 and 4 years after the onset of ppa. neuropathological examination showed ad in 1 patient and pick's disease in the other patient. beverly clarke, adrian upton, markad kamath, and helene griff;., hamilton, ontario, canada eight patients implanted with a cyberonics neurocybernetic prosthesis model 100 to stimulate the vagus nerve were assessed for changes in cognitive performance. the patients had complex partial seizures for more than 10 years, with more than 6 per month. patients were 34 years * 7.8 sd old. cognitive evaluation included response time to a randomized light signal appearing on a switch box (test a); test b, in which the signal appeared bilaterally; and test c, in which a response to the signal was required while the patient simultaneously ignored a second signal. data were collected and analyzed using an apple i1 e computer and switch pad. all patients were taking therapeutic levels of 3 anticonvulsant medications and dosages were constant. testing occurred 10 times during a day preoperatively (day l), 2 weeks postoperatively with the stimulator on (day 2), and 3 months after turn-on (day 3). patients were randomized into high-and low-frequency stimulation groups (hfg and lfg). hfg parameters were 30 hz, so0 msec pulse width (pw), and lfg 1 hz, 130 msec pw. examiners were blinded as to group. student's t-test analyses of mean differences between groups and individual measurements showed a significant difference between hfg and lfg for test c ( p < 0.05). lfg showed a significant improvement for tests a, b, c between day 1 and 2, and for test c between day 2 and 3. no group effect was seen between day 1 and 3 in the lfg. individual measurements showed improvement for test b ( p < 0.05) for the hfg between day 1 and 2, test b ( p < 0.0s) between day 2 and 3, and tests a and b ( p < 0.01) and ( p < 0.05) day 1 vs 1. the lfg group improved between days 1 and 2 and 2 and 3. between day 1 and day 3, the lfg showed improvement only for test b ( p < 0.001). chronic stimulation of the vagus nerve improves cognitive function in epileptic patients and this improvement is more marked with low-frequency stimulation. a. guidotti, and j. d. rothstein, bologna, itah, washington, dc, and baltimore, m d we reported idiopathic recurring stupor (irs) in a patient with stuporous episodes without known causes and reversed by flumazenil, a specific benzodiazepine (bz) antagonist. ictal plasmdcerebrospinal fluid (csf) showed increased bz-like activity (ann neurol, in press). recently, an endogenous bzreceptor ligand (endozepine [ez]) has been purified from mammalian brain with properties similar to diazepam. it acts like diazepam to potentiate gamma-aminobutyric acidmediated postsynaptic inhibition. we hypothesized that irs might be due to an excess of this substance. irs was diagnosed in 2 patients, 41 and 58 years old, who had recurring stupor or coma episodes lasting hours to days. ictal brain ct/mri, kidney, liver, heart, blood glucose, ammonia, and osmolality were normal. eeg showed fast 13-hz background activity while the patients were unreactive to stimuli, reversed by flumazenil. ictal serum or csf revealed an enormous increase of the ez in both patients, with levels as high as 400 nm, compared to 5 to 10 nm in control serum/csf. interictal csf or serum in irs contained ez levels similar to control csf and serum. irs may be due to excess ez. the cause for increased ez is unknown. parkinson's disease: evidence from word learning murray grossman, jenger mickanin, barbara schaefr, kris onishi, matthew b. stern, steven gollomp, and howard hurtig, philadelphia, pa several reports have suggested that patients with parkinson's disease (pd) have intellectual impairments in several domains such as memory, but few studies have explored difficulties in language processing. we investigated the ability of 20 nondemented pd patients with mild motor impairments to learn about the grammatical and semantic information represented in a new verb. the new verb was presented to patients in a sentence-picture matching context, and we probed their recall of the verb 10 minutes later. a sentence judgment task assessed grammatical knowledge by asking patients to judge the new verb, known verbs, and pseudowords used appropriately or incorrectly in a sentence. we found that 65% of pd patients were significantly impaired in their grammatical appreciation of the new verb (f [i, 331 = 17.03;p < 0.003). this was not related to their motor disorder or neuropsychological performance. a picture classification task used pictures illustrating specific aspects of the new word's meaning to evaluate semantic knowledge. pd patients were as accurate as controls at deciding whether a picture illustrated the meaning of the new verb (f (1, 331 = 0.lo;p > 0.10). only 1 pd patient (5%) had difficulty sorting pictures. selective difficulty recalling only grammatical aspects of a new word suggests that the word learning impairment in pd cannot be entirely explained by poor memory. instead, in agreement with other recent findings, pd patients may be impaired in some aspect of grammatical processing in language. we discuss the hypothesis that defects in the frontocaudate axis in pd underlie this impairment. neuropsychological performance on both verbal and nonverbal tasks is reported to differ between healthy men and women. some of these cognitive differences are postulated to reflect differences in interhemispheric and intrahemispheric cerebral organization. our preliminary study indicated that women with alzheimer's disease (ad) performed worse than men on a composite neuropsychological battery, even after effects of potentially confounding variables were considered (buckwalter et al, j clin exp neuropsychol 1992; 14:23) . to explore further the nature of gender-associated differences in ad, we analyzed data from a verbal and a nonverbal task (the boston naming test and drawings from the spatial quantitative battery supplement to the boston diagnostic aphasia examination) for 22 men and 23 women who met nincds-adrda criteria for "probable" ad. prior to ana-grip strength 9 kg [range 1.5-20 kg]). the electrophysiological examination showed improvement with reversal of conduction block in 3 patients and was unchanged in 4. an apparent response to the placebo was seen in 3 patients. improvement after ivig therapy was maintained for variable durations (3-20 wk) and reoccurred with subsequent infusions. an equally effective response was documented after infusion of a single ivig dose of 1 gm/kg. we conclude that ivig therapy is effective in some patients with cidp, even after long duration of illness. the best responses were observed in patients with recent relapse. a single high-dose treatment may be equally effective. the object of this study was to examine whether borrelia burgdorjeri antigens could be detected in csf in the absence of detectable antibodies to b. burgdorjeri (the etiological agent of lyme disease). osp a is a 31-kd antigen that is specific for 8. duvgdorferi osp a was probed using western (immuno) blot and specific mouse monoclonal antibodies. polyclonal lyme antibodies were detected in csf using standard micro enzyme-linked immunosorbent assay. seven patients had osp a in csf without detectable lyme antibodies. there were 3 men and 4 women aged 20 to 58 years (mean 38 yr). disease duration ranged from 2 weeks to 8 years. neurological syndromes included confusion with acute flulike illness, optic neuritis, hemiparesis with inflammatory brain lesion, encephalitis, headache with erythema migrans, bilateral facial nerve palsies, and encephalomyeloradiculitis. three patients had csf abnormalities. in 4 patients csf parameters were otherwise completely normal. possible explanations for undetectable csf lyme antibodies included early infection (3 patients), prior antibiotics (2 patients), and prior steroids plus antibiotics (1 patient). in 1 patient there was no obvious explanation. we conclude that osp a, a specific antigen of b. burgdorferi, may be present in csf without a detectable humoral response. the diagnosis of neurological infection with b. bwgdorjeri should not require a positive csf serology. mollaret's meningitis: demonstration by polymerase chain reaction a 29-year-old man was seen in september 1991 for his fourth episode of aseptic meningitis over a 4-year period. the episodes conformed to criteria for mollaret's meningitis as published by bruyn, straathof, and raymakers, and subsequently by others; they lasted about 1 week, and were characterized by fever, headache, meningismus, lymphocytic pleocytosis, elevated protein in cerebrospinal fluid (csf), and spontaneous resolution without residua. extensive prior evaluations had failed to uncover a cause. the patient was otherwise well and neither he nor his wife had any history of sexually transmitted diseases. suspicion of herpes simplex virus (hsv) arose due to a single transient, raised skin rash several weeks earlier that failed to yield virus on culture. the patient was treated with acyclovir, which resulted in rapid resolution of symptoms. though culture and immunological studies of csf and blood again were unrevealing, polymerase chain reaction (pcr) studies of csf confirmed the presence of hsv type 2. we suspect that herpes simplex virus is a more common cause of recurrent aseptic meningitis than current culture and immunological techniques would suggest. pcr offers increased diagnostic sensitivity for neurotropic viruses and should be considered in patients with recurrent meningitis of cryptic etiology. differentiation by inorganic lead: a role for protein kinase c j. lutewa, j. p. bressler, r. r. indurti, l. belloni-olivi, and g. w . goldstein, baltimore, m d microvascular endothelial function in developing brain is altered by inorganic lead. this may result from changes in protein kinase c (pkc) modulation. we examined the effects of inorganic lead on an in vitro model of neural endothelial differentiation. astroglial-induced endothelial differentiation into capillary-like structures was inhibited by lead acetate with 50% maximal inhibition occurring at 0.5 pm lead. inhibition was independent of effects on cell viability or growth. we examined the effects of lead on cellular pkc pools under conditions that inhibited capillary-like structure formation. membranous pkc increased in c6 astroglial and neural endothelial cells after exposure to lead acetate. exposing c6 cells to 5 p,m lead for 16 hours increased membranous pkc by 150% as determined by immunoblotting. membranous pkc increased in response to as little as 50 nm lead and saturated at 1 pm. phorbol esters were used to determine if pkc modulation was mechanistically related to lead's inhibition of capillary-like structure formation. 12-myristate 13-acetate (10 nm) inhibited endothelial differentiation by 65 * 5%, whereas 4-alpha-phorbol 12,13didecanoate was without effect. these findings demonstrate that inorganic lead may induce cerebral microvessel dysfunction by interfering with pkc modulation in microvascular endothelial or perivascular astroglial cells. w. f. brown, b. v . watson, j . garland, g . c. ebers, and n . desai, london, ontario, canada gait difficulties in multiple sclerosis (ms) are commonly accompanied by fatigue and dyspnea. possible explanations for the latter include weakness andlor dyssynergia of the respiratory muscles, including possible abnormalities in central pathways regulating respiration. this study examined central and peripheral motor conduction to the diaphragm in 15 ms patients whose gait was notably labored and accompanied by breathlessness. peripheral conduction was assessed by measuring the latency and size of the surface-recorded diaphragmatic maximum m-potential responses to supramaximal stimulation of the phrenic nerve in the neck, and central motor conduction by comparable measurements in response to magnetoelectrical stimulation over the vertex. peripheral motor conduction was normal. the most striking abnormalities were in central motor conduction. cortical stimulus-evoked diaphragmatic responses were absent on both sides in 3 patients, and unilaterally in l patient, whereas in 5 others the latency of the cortical stimulus-evoked response was increased and the size clearly reduced and entirely normal in only 3 patients. these studies show that central conduction program and abstracts, american neurological association 295 to the diaphragm is commonly abnormal and may play a role in the fatigue and dyspnea experienced by ms patients. six men (40-53 yr) developed myelopathy that progressed slowly over several months and was characterized by asymmetrical, incomplete spinal cord syndrome manifested at the sensory level at the trunk, mild spastic paraparesis, and urinary incontinence. the spinal cord lesions at appropriate levels were recognized by mri as enhancing lesions in 4 of the men. coxiella burnetii infection was confirmed in the blood of all patients by immunofluorescence microscopic assay (ifa) and transmission electron microscopy (tem). in 2 patients, we detected c. burnetti by tem and ifa using csf of the patients inoculated onto fresh peripheral blood lymphocytes. four patients who were treated with appropriate antibiotics responded with either partial resolution of symptoms or arrest of further neurological progression. in 3 patients the lesion was shown on mri to have decreased in size. in summary, we report 6 cases of transverse myelopathy associated with c. barnetti infection. this is the first report, to our knowledge, of coxiella-related chronic myelopathy. we present a series of patients with different labyrinthine lesions diagnosed by mri. twelve patients with sensorineural hearing loss were studied by gadolinium-enhanced mri, including 3-mm contiguous t1-weighted images through the labyrinth. ten patients had enhancement of the cochlea or vestibule, or both. all patients with cochlear enhancement had severe neural sensory hearing loss. all patients with vestibular enhancement had severe vestibular symptoms. the patients' final diagnosis included viral labyrinthitis (3 patients), syphilitic labyrinthitis (2 patients), bacterial labyrinthitis (1 patient), and vestibular neuromas (3 patients). one patient had an acoustic neuroma extending in the basal turn of the cochlea. the enhancement in patients with vestibular neuromas was brighter and there was slight mass effect in comparison with the patients with inflammatory labyrinthine lesions. one patient had hemorrhage within the vestibule from an adjacent temporal bone hemangioma. one patient with ct-proven cochlear otosclerosis had pericochlear areas of enhancement on gadolinium mri. mri can diagnose a variety of labyrinthine lesions that correlate very well with the patient's clinical symptoms. gadolinium should be used routinely in patients with suspected labyrinthine disease. the diagnosis of meniere's disease and endolymphatic hydrops remains a diagnosis of exclusion. few radiographic findings have been correlated with the clinical symptoms of this entity. we describe 9 patients with symptoms of hearing loss or vertigo, or both, who demonstrated enhancement of the endolymphatic sac on gadolinium-enhanced mri. no enhancement was noted in a series of 20 controls with no symptoms of hearing loss and vertigo. enhancement in the brain correlates with inflammatory or neoplastic conditions. we thus can speculate that enhancement of the endolymphatic sac reflects an inflammatory process in this location that may interfere with the normal resorption of indulin and secondary hydrops. in addition to excluding an acoustic neuroma and a labyrinthine schwannoma (which clinically may be confused with meniere's disease), contrast-enhanced mri may provide objective evidence in favor of labyrinthine hydrops. it was intermittent (62%) but progressive. the ha was mild to moderate in severity; it was the worst symptom in only 24 (459%) and the first symptom in 32 (60%) patients. has were worse in the morning in 19 (36%) and interfered with sleep in 17 (32%) patients. unlike true tension-type has, bt has were worse with bending over in 17 (32%), with valsalva's maneuver in 12 (23%), and nausea or vomiting were present in 21 (40%) patients. an abnormal neurological exam was found in 38 (72%) patients with has and 43 (74%) patients without has lyzing the effects of gender, we used a hierarchical regression procedure to control for possible effects of subject age, education, age at onset of dementia symptoms, dementia duration, and family history of dementia. significant gender effects were found for the verbal task ( p < 0.005) (mean boston naming test score of 2 1.4 for women and 34.4 for men), but not for the drawing task. we conclude that verbal abilities are more severely affected in women than in men with ad, a difference that may in part reflect premorbid gender-associated differences in cerebral hemispheric organization. hemispatial placement is known to affect line bisection in patients with neglect. whereas placing stimuli in neglected space increases bisection error, placing stimuli in nonneglected space attenuates error. the effects of hemispatial placement on line bisection were examined in 4 patients with chronic neglect (over 5 months after stroke). all patients had large (frontotemporoparietal), unilateral, right-hemisphere lesions. each patient bisected lines of different lengths (24, 26, 28 , and 30 cm) in 3 hemispatial conditions (30 cm left of midline, midline, and 30 cm right of midline). like previous reports, when patients bisected lines in left hemispace, a consistent (20/24 trials) left-sided neglect was observed (2.6 cm). however, when lines were bisected in center space, misbisections occurred on either side of the midline; and, unlike previous studies, when lines were bisected in right hemispace, a consistent (20/24 trials) right-sided neglect was observed (2.0 cm). the magnitude and directional consistency of line bisection errors were significant. neither visual field defects nor limitations in reaching accounted for the results. recovery in chronic neglect may involve a realignment of limited attentional resources favoring the body's midline. consequently, performance in both hemispatial fields can be biased toward midline, resulting in neglect of opposite directions. despite agreement that depression is the most common neuropsychiatric symptom associated with multiple sclerosis (ms), many aspects of this emotional change are unclear. one of the more controversial issues concerns the relationship between severity of ms and depression. this relationship is used to evaluate whether depression is an integral or reactive symptom of ms. examination of this relationship is complicated by the presumed overlap between somatic features of depressive and neurological symptoms in ms. to clarify this situation, we examined the relationship between severity of ms and 4 categories of depressive symptoms using the beck depression inventory (bdi). eighty-nine patients and 47 normal controls were examined. for certain comparisons, patients were classified as mild (extended disability status scale of 0-2) or moderatelsevere (3) (4) (5) (6) (7) (8) . results indicated that total bdi scores and the depressive symptom categories (mood, self-reproach, vegetative, and somatic features) were elevated in patients with ms, but the extent of these elevations was not related to severity of disease. these results suggest that depression in ms is not a simple reaction to physical disability. furthermore, clinical examination of depressive symptoms is straightforward and not confounded by severity of ms. neurological involvement in wegener's granulomatosis was studied in 324 consecutive patients diagnosed at the mayo clinic. one hundred and nine patients (34%) had neurological involvement. peripheral neuropathy was seen in 53 (16.4%), cranial neuropathy in 2 1, external ophthalmoplegia in 16, cerebrovascular events in 13, seizures in 10, and miscellaneous involvement in 25. the mean age and sex ratio did not differ in those with or without neurological involvement. among the patients with peripheral neuropathy, 42 had multiple mononeuropathy, 6 had distal symmetric polyneuropathy, and 5 had unclassified peripheral neuropathy. multiple mononeuropathy was one of the major presenting symptoms in 8 patients. kidney involvement was significantly higher in the patients with peripheral neuropathy compared to those without it (p < 0.001). among the cranial nerves, the second, sixth, and seventh nerves were affected most frequently. multiple cranial nerves were affected in 8 patients. unusual neurological manifestations among the miscellaneous group included spastic paraparesis, temporal arteritis, homer's syndrome, and papilledema. this is the first comprehensive study on the frequency and distribution of neurological involvement in wegener's granulomatosis. chronic inflammatory demyelinating polyneuropathy: a double-blind placebo-controlled crossover study treatment with high-dose intravenous human immunoglobulin (ivig) has been reported to be beneficial in some patients with chronic inflammatory demyelinating polyneuropathy (cidp), yet most observations have been nonblinded. we examined the effect of ivig therapy in 10 patients (6 men, 4 women) with cidp in a double-blind, placebo-controlled crossover study. disease was chronic progressive (n = 5 ) or chronic relapsing (n = 5) and of variable duration (4 mo to 2 1 yr). the diagnosis was confirmed by electrophysiological (10) and nerve biopsy (7) examinations. the trial consisted of two 28-day periods each. patients were randomly treated with ivig (0.4 mg/kg/day) or placebo on 5 consecutive days and followed. function was assessed by a quantitative neurological disability score, functional grade, grip strength measurement, and electrophysiological examinations at the beginning and end of each treatment period. with ivig therapy, significant improvement was documented in 7 / 10 patients (improvement in neurological disability score mean key: cord-006876-v2m5l5wz authors: nan title: neurocritical care society 14(th) annual meeting date: 2016-08-11 journal: neurocrit care doi: 10.1007/s12028-016-0301-7 sha: doc_id: 6876 cord_uid: v2m5l5wz nan in this exploratory analysis, csf levels in the progesterone treated group were variable and not as supratheraputic compared to serum levels. this study highlights an additional factor that needs to be considered in the designing of clinical trials in tbi. not only does the heterogeneity of the injury and subsequent outcome measures need to be refined, but the biomarker of pk levels also needs to be analyzed in csf as well as serum to determine if the treatment is reaching the target organ, the brain. arctic ground squirrels (ags) are extreme hibernators capable of withstanding months of freezing temperatures by suppressing metabolic rate. hibernation is characterized by hypoxia and low cerebral blood flow and interrupted by bouts of arousal in which perfusion is quickly restored. curiously, ags do not experience reperfusion injury which is hypothesized to be reflected in altered transcriptional signatures in an in vitro model of reperfusion injury. to investigate the influence of ischemia/reperfusion on ags neuronal stem and neural progenitor cells (nsc/npcs), we exposed ags and murine nsc/npcs to control conditions, hypoxia, oxygen and glucose deprivation or glucose deprivation alone or following return to normal conditions to model reperfusion. cell viability and cell cycle state were assessed by automated cytometry; metabolic phenotype by in vitro oxygen consumption and extracellular acidification rate. to determine novel genes involved in ags resilience to reperfusion injury, a cdna library was constructed in a mammalian expression vector and introduced into murine nscs that were then assayed for viability after ischemia/reperfusion. ags nsc/npcs demonstrated marked resistance to ischemia/reperfusion injury compared to murine nsc/npcs. this survival phenotype is associated with suppressed mitochondrial oxidation and altered cell cycle regulation. ags genes regulating mitochondrial function strongly modulated murine nsc/npc viability following ischemia/reperfusion injury. a dynamic ability to suppress mitochondrial oxidation may underlie resilience to reperfusion injury in ags by promoting a quiescent cell cycle phenotype. development of therapeutic agents suppressing mitochondrial oxidation may induce a protective phenotype and promote survival following reperfusion injury. high throughput imaging of motor system connectivity in the mouse brain. stroke results in profound alterations to architecture in the brain, particularly the corticospinal tract (cst). some plasticity may contribute to functional recovery, while other changes may be maladaptive. studies of cst connectivity have been limited by standard imaging methods which do not allow visualization and analysis of global axonal connectivity in the brain. we employed two novel imaging methods to visualize axonal projections to forelimb musculature. first, a pseudorabies viral (prv) vector carrying green fluorescent protein (gfp) was injected into the left forelimb flexor in naïve 10-12 week-old c57 mice. prv was transported retrogradely and transynaptically, labeling neurons in the motor cortex and other regions of interest. whole slide imaging was performed using an automated slide scanner (nanozoomer, hamamatsu photonics k.k., hamamatsu city, japan) producing images of serial coronal sections, allowing visualization of multiple levels of the brain in a single slide image. for serial two-photon tomography (stpt), utsw whole brain microscopy facility used a tissuecyte 1000 imaging system (tissue vision, somerville, ma) which uniquely performs automated sectioning and fluorescent imaging of the brain to produce 3-dimensional images with micronlevel resolution. this allows for unprecedented visualization of axonal connectivity in the whole brain. we have imaged motor systems in the brain of uninjured mice using two different methods, each with distinct benefits. whole slide imaging allows for quantification of regions of interest in the brain on a single slide, while stpt produces a highly detailed image that improves our understanding motor systems in 3-d space. future directions will investigate changes in connectivity following stroke injury and during recovery, allowing a greater understanding of the complexity of plasticity and how it contributes to beneficial and pathological circuit remodeling after injury. andexanet alfa (anxa) is a modified recombinant factor xa (fxa) derivative that sequesters direct fxa inhibitors and reverses their anticoagulation effects. non-specific prothrombin complex concentrates (pccs) have been proposed as potential reversal strategies. the objective of these studies was to compare 3-factor (bebulin) and 4-factor (kcentra®) pccs, approved for reversal of warfarin, with anxa in reversing anticoagulation effects of rivaroxaban in a rabbit model of bleeding. nzw rabbits were treated with rivaroxaban (iv, 1 mg/kg) and 30 min later, either pccs (3-factor pcc: 60 or 120 mg/kg; 4-factor pcc: 25, 50, or 100 iu/kg) or anxa (75 or 125 mg/rabbit) was administered iv. liver injury was then induced with 10 1-cm incisions following laparotomy, and blood loss was measured for 15 min. plasma concentrations of unbound (active) and total rivaroxaban, as well as pharmacodynamic (pd) parameters (anti-fxa activity, pt, and aptt) were determined. anxa reduced blood loss in rivaroxaban-anticoagulated rabbits to levels seen in non-anticoagulated rabbits. in rabbits treated with anxa, anti-fxa activity and unbound rivaroxaban were reduced dosedependently by >95% and >90%, respectively, within 5 minutes, and both parameters correlated with reduction in blood loss. in contrast, 3-factor or 4-factor pccs had no significant effect on any of these markers in rivaroxaban-anticoagulated rabbits. anxa effectively reversed the anticoagulation activity of rivaroxaban in a rabbit model of bleeding. in contrast, pccs showed no reversal activity as assessed by blood loss or pd markers. these results suggest that use of non-specific pccs as reversal agents for direct fxa inhibitors are not likely to be as effective as specific reversal agents that target fxa inhibitors. investigation of anxa vs. pcc to reduce hematoma expansion in models of intracranial hemorrhage is warranted. outcomes after resuscitation from cardiac arrest (ca) remain poor. preventable secondary injury from ongoing brain tissue hypoxia (bth) may worsen injury burden. unfortunately, markers to allow individualized, real-time care optimization are lacking. we performed a randomized crossover trial in a swine model of opioid-induced ca to 1) determine the prevalence of bth with standard care (stdc), and 2) test whether neuromonitor-guided goal-directed care (ngdc) can prevent bth. female swine (25-30kg) were anesthetized with propofol and fentanyl. we placed femoral arterial and venous sheaths, a continuous cardiac output pulmonary artery catheter (edwards lifescience) and a right frontal intracranial access bolt (hemedex) with probes for brain tissue oxygen (pbto2), pressure (raumedic), microdialysis (mdialysis70), cerebral blood flow (cbf) (hemedex), and an 8-contact electroencephalographic depth electrode (adtech). we induced apnea with 30mcg/kg fentanyl, extubated the animal and began acls 9min after apnea. after 1h stabilization, animals with return of spontaneous circulation (rosc) were randomized to three alternating 6h care blocks: stdc (mean arterial pressure>65mmhg, oxygen saturation 94-98%, cardiac output>75% baseline) or ngdc (pbto2>20mmhg, cbf>20ml/100g/min). animals were euthanized at 18h post-rosc. our primary outcome was the effect of care block on pbto2, which we analyzed at 1min resolution using generalized estimating equations with robust standard errors. overall, 8 of 17 animals achieved rosc after 13±3min. pbto2 was higher during ngdc than stdc (p<0.001) and did not differ during ngdc from pre-arrest. pbto2 was <20mmhg more during stdc than ngdc (40% of minutes vs 1%, p<0.001). cbf was lower during ngdc than stdc (p<0.001), and lower in both arms than pre-arrest (both p<0.001). brain tissue hypoxia was common in this cardiac arrest model and prevented by neuromonitor-guided goal-directed care. lower cbf and higher pbto2 during goal-directed care implies preserved hypoxic cerebral vasodilation and diffusion-limited oxygen delivery. future work will incorporate electroencephalographic and metabolic injury markers. sage-547 is a proprietary formulation of the endogenous neurosteroid allopregnanolone, being studied as a potential adjunctive therapy for the treatment of super-refractory status epilepticus (srse) . srse refers to a condition of persistent seizures that have failed treatment with first-, second-and third-line treatments. in preclinical models, prolonged seizures reduce the surface expression of synaptic gabaa receptors, exacerbating neuronal excitability and limiting target sites for gabaergic treatments (eg. benzodiazepines). here we present preclinical data describing the pharmacological properties of sage-547 that support its further development as a potential treatment for srse. gaba-evoked currents were examined in vitro with whole cell patch clamp recordings in cells expressing -pilocarpine model of refractory status epilepticus (pouliot 2013) was used to examine in vivo anticonvulsant activity. sage-547 or pentobarbital was administered intravenously 60 minutes after the onset of pilocarpine-induced seizures, a time point when benzodiazepines are ineffective in animal models (pouliot 2013). sage-547 potentiated both synaptic-vitro, with ec50s of 60 nm and 80 nm, respectively. the concentration-gabaa receptors by sage-547 was 16,000-fold more potent than that observed with pentobarbital alone. when sages were also observed in the rat model of rse. when sub-active doses of sage-547 and pentobarbital were combined, electrographic seizure activity was significantly reduced. in vitro, sage-547 potently modulated both synaptic-type and extrasynaptic-type gabaa receptors, and the maximal potentiation at these receptors was further augmented by the co-application of pentobarbital. this enhanced in vitro potency and maximal effect at gabaa receptors provides further support for the development of sage-547 as a potential treatment for srse. vasospasm has long been considered the primary mechanism underlying delayed cerebral ischemia (dci) in subarachnoid hemorrhage (sah), but increasing evidence shows that other processes such as cortical spreading depressions and inflammation. we propose that abnormal neural activity in the form of epileptiform abnormalities, we term ictal-interictal continuum abnormalities (iicas), may contribute to dci. these abnormalities may increase metabolic demands in injured brain tissue, thereby contributing to metabolic crisis and secondary neuronal injury. here, we investigate whether the presence of iicas predict dci development. we analyzed eeg reports from 124 icu patients with moderate-severe non-traumatic sah. continuous eeg data was recorded with daily review to identify electrographic seizures and interictal patterns. we tallied daily seizures, sporadic epileptiform discharges, lateralized or generalized periodic discharges (lpds and gpds), and lateralized or generalized rhythmic delta activity (lrda and grda). delayed cerebral ischemic events were also marked. cumulative distribution curves and iica-to-dci time plots were calculated. iicas are more prevalent in patients who develop dci, especially when they begin several days after the onset of sah. all iica types except generalized rhythmic delta activity occur more commonly in patients who develop dci. in particular, iicas that begin later in hospitalization correlate with increased risk of dci (lrda day 9, ed day 6, lpds day 12, gpds day 5) most iicas also precede the onset of dci. we next trend features of discharges to identify those most closely associated with dci and will present our preliminary findings. iicas represent a new marker for identifying early patients at increased risk for dci. moreover, iicas might contribute mechanistically to dci and therefore represent a new potential target for intervention to prevent secondary cerebral injury following sah. up to 80% of patients resuscitated from cardiac arrest remain in a coma, and the ability to predict longterm neurologic recovery in these patients is limited. quantitative analysis of electroencephalography (qeeg) is objective and may facilitate outcome prediction. consecutive patients with hypoxic-ischemic coma were enrolled. continuous eeg was obtained on all patients. eeg was post-processed and analyzed by fourier transform. spectral analysis was conducted on artifact-free contiguous 5-minute eeg epochs from each hour. whole band (1--4 hz) --suppression ratio were computed as quantitative metrics of eeg for the entire eeg recording, and then statistically compared during the last 6 hours of eeg. sedation, level of arousal, and body temperature were also analyzed. good outcome (good neurologic outcome, gno) was defined as consciousness recovery at any point in the acute hospitalization. ten subjects were included in the study, with ceeg durations ranging from 12 -72 hours of recording. the mean age was 49.6 years (18-65). there were significant differences in alpha power (1.39 (0.66 -1.79) vs 0.27 (0.17 -0.48), median (iqr), p<0.05, gno vs poor neurologic outcome [pno] ), delta power (2.78 (2.21 -3.01) vs 0.55 (0.38 -0.83), median (iqr), p=0.01, gno vs pno), burst suppression ratio (0.66 (0.02-2.42) vs 73.4 (48.0 -97.5), median (iqr), p=0.01, gno vs pno), and multiple measures of variability between gno and pno patients. quantitative spectral analysis of continuous eeg may be predictive of consciousness recovery in patients with hypoxic-ischemic coma. higher alpha power, lower burst suppression ratio, and higher variability were all correlated with good outcome. because the media plays an important role in educating the public and impacting public perception on medical topics, we sought to evaluate whether mainstream media provides education or misinformation to the public about brain death through review of articles on two recent highly publicized brain death cases: 1) the jahi mcmath case, in which a teenage girl was declared brain dead and her family refused to allow organ support to be discontinued; and 2) the marlise muñoz case, in which a pregnant woman was declared brain dead and the hospital refused to terminate organ support until they were ordered to do so by a judge. media websites of 2014 using the search terms, "jahi mcmath" and "marlise muñoz." each article was evaluated to determine whether it contained 1) teaching points, or 2) misinformation, defined as misleading, incomplete, or incorrect information. we reviewed 208 unique articles. the subject was referred to as being "alive" or on "life support" in 72% (149) of the articles, 97% (144) of which also described the subject as being brain dead. a definition of brain death was provided in 4% (9) of the articles. only 7% (14) of the articles noted that organ support should be discontinued after brain death declaration unless a family has agreed to organ donation. reference was made to wellarticles and 47% (16) of these implied both patients were in the same clinical state. mainstream media provides poor education to the public on brain death. because public understanding of brain death impacts organ and tissue donation, it is important for physicians, organ procurement organizations, and transplant coordinators to improve public education on this topic. neurocrit care (2016) 25:s1-s310 post-operative hemorrhage: a possible predictor of delirium in brain tumor patients post-operative delirium after brain tumor resection is frequent, difficult to manage, and may increase chart review of patients admitted to the neurologic intensive care unit (nicu) after brain tumor resection. we also evaluated the effect of agitated delirium on length of stay. medical records of nicu admissions form 2013-2015 were reviewed to identify cases and controls. cases were defined as patients with no pre-existing neuropsychiatric history who experienced significant agitated delirium post-operatively, defined by requirement for treatment with neuroleptics (quetiapine or dexmedetomidine) <48 hours after surgical resection. we compared these patients to a control group comprised of randomly selected patients admitted after brain tumor resection who did not experience agitated delirium. in a multifactors: sex, age, tumor location, pathology, postpost-operative hemorrhage, use of steroids and prophylactic anti-epileptics, particularly levetiracetam. there were 48 cases and 49 controls. multivariate analysis revealed male sex (o.r 3.47; 95% ci 1.17-10.32; p=0.025) and a post-operative course complicated by hemorrhage within the resection cavity (o.r 10.13; 95% ci 3.27-31.64; p<0.001) as significant predictors of agitated delirium. the icu length of stay was significantly longer in those with agitated delirium (6.3±5.1 days vs. 1.8±1.4 days; p<0.001). neurointensivists caring for post-operative patients with brain tumor may consider resection site ctor for developing agitated delirium. future studies may investigate -operative bleeding and delirium and the long term outcome of these patients. cardiac arrest is a leading cause of death and disability, and predicting outcome in these patients is a challenge. optic nerve sheath diameter (onsd) on brain ct correlates closely with intracranial pressure. therefore in this study we studied correlation between onsd measured on the initial brain ct in patients after cardiac arrest and outcome. this is a retrospective study of patients with cardiac arrest admitted to the medical intensive care unit at our hospital between 2009 and 2014. pati arrest were included. demographics, neurological status on arrival and day 14 and outcomes were collected. onsd on brain ct was measured bilaterally 3mm behind the optic nerve head and averaged for each patient. a total of 71 patients were included. mean age was 66±13.6 years, 54 patients (76%) were male. 46 patients (65%) suffered out-of-hospital cardiac arrest. mean glasgow coma scale (gcs) on admission was 4.35±1.96 (range 3-9; median 3). return of spontaneous circulation (rosc) time was 15.63±9.37 intervention. 70 patients (98.59%) underwent therapeutic hypothermia. 17 patients (23.9%) had seizures. average modified (19.7%) had a good outcome (mrs 0-3). average duration from rosc to ct was 1.3±2.04 days. mean onsd in patients with gcs 3-8 at day 14 was 5.76±0.69mm, while in those with gcs 9-15 at day 14, onsd was 5.81±0.72mm (p=0.78). mean onsd in patients with mrs 0-3 at discharge was 5.56±0.62mm, while in those with mrs 4-6 was 5.88±0.71 (p=0.28). there does not appear to be a significant correlation between the onsd o cardiac arrest and outcome at day 14. traumatic brain injury (tbi) is a major public health problem. while the association between subarachnoid hemorrhage and systolic dysfunction (sd) has been established, the effect of tbi on the incidence of early sd in previously healthy patients following moderate-severe tbi, and 2) to describe the longitudinal change in we conducted a prospective cohort study among mild and moderate-severe tbi patients admitted to a level 1 trauma center with these inclusion criteria: 1) age < 65 years, 2) no severe non-tbi injuries, 3) no prior cardiac disease, and 4) minimal comorbidities. transthoracic echocardiograms were performed at <24 hours, 3-4 days, and 7-9 days following tbi. systolic function was assessed using fractional shortening (fs), and sd was defined as fs<25%. descriptive statistics were used to compare the mild and moderate-severe tbi groups. multivariable linear regression was used to compare fractional shortening between groups. 64 patients were studied (32 mild tbi and 32 moderate-severe tbi). both groups were young (36.2 years mild tbi and 36.5 years moderate-severe tbi) and mostly male (69% mild tbi and 84% moderatesevere tbi). early sd was present in 7 (22%) moderate-severe tbi patients and 0 (0%) mild tbi patients (p<0.01). on multivariable regression, moderate-severe tbi was associated with an absolute 4.2% reduced fs compared to mild tbi (95% ci 0.8% -7.6%, p=0.02). all patients with early sd recovered to normal systolic function by 7-9 days injury ( figure 1 ). sd is common early after moderatehospitalization. tbi severity is independently associated with worse systolic function. early echocardiography is a safe, applicable, and feasible procedure following tbi and may aid clinicians with hemodynamic management post tbi. sophie samuel. department of pharmacy. memorial hermann medical center, houston, tx, usa. paroxysmal sympathetic hyperactivity (psh) is a neurological condition that occurs most frequently after traumatic brain injury (tbi). sympathetic hyperactivity can manifest as increased heart rate, blood pressure, respiratory rate, temperature, sweating and posturing activity. in 2014, a consensus statement and probability of diagnosis. the objective of this study is to report the incidence, frequency and severity of psh symptoms in the acute setting after tbi using the new diagnostic criteria. this was a retrospective study from july 2014-august 2015. included were all adult patients admitted to a tertiary care intensive care unit with a primary diagnosis of tbi and a length of stay longer than 14 days. symptoms were recorded. the most frequent symptom was tachycardia (53%), followed by tachypnea (47%), hypertension (26%), 2 symptoms occurring simultaneously and 68% had symptom -6) vs 8(3-12); p=0.02] and at day 14; [10(7-14) vs 14(14-15); p<0.01.] medications often used to control symptoms included, anti-pyretics, opioids, beta---38) vs 17(14-26); p=0.03], but no difference in mortality. symptoms of sympathetic hyperactivity were seen commonly after tbi in the acute setting. using a admitted with a hospital length of stay greater than 14 days. hypertonic saline (hts) appears to be more effective than mannitol in reducing raised intracranial pressure (icp) after severe traumatic brain injury (tbi). in this study we investigated which agent had superior combined effects on icp and cerebral perfusion pressure (cpp). the brain trauma foundation tbi-patients who received only hts were identified and matched with patients who received mannitol only (1:1 and 1:2 match). the two groups were matched for age, pupillary reactivity, glasgow coma scale (gcs), ct abnormality, craniotomy and occurrence of hypotension on day 1. univariate analysis was performed to compare combined average and duration of icp>25mmhg (icphigh) and cpp<60mmhg a total of 25 patients with severe tbi, who received only hts were identified and matched with 25 (1:1) and 48 (1:2) patients who received mannitol only. in the 1:2 group 1 hts patient was excluded, as there was no corresponding match in mannitol group. the mean age, gcs, incidence of abnormal pupils, hypotension, abnormal ct, craniotomy and day of icp insertion were similar in the groups. there was no difference in number of days of icp monitoring (p=0.09, 0.46; 1:1, 1:2 groups). osmolar doses were comparable; all patients in hts group received 3% hts except one who received 23.4%. in 1:1 match, number of days with cpplow (2.0±1.7 vs. 3.6±2.8, p=0.03) was significantly lower in the hts group. in p=0.01) were significantly lower in the hts group. these results were reproduced in the 1:2 analyses. hts is superior in its combined effect on icp and cpp after severe tbi when compared to mannitol. statins constitute a class of medications commonly used in the treatment of elevated cholesterol. however, in experimental studies statins also have other non-cholesterol mediated mechanisms of action, which may have neuroprotective effects. the purpose of this study was to determine if administration of atorvastatin for 7 days after injury would improve neurological recovery in patients with mild traumatic brain injury (mtbi). the hypothesis was that atorvastatin administration would reduce post-concussion symptoms and also -injury would be safe. 140 patients with mtbi were placebo for 7 days starting within 24 hours of injury. assessments of post-concussion syndrome, postthe rivermead post-concussion symptoms questionnaire at 3 months was the primary outcome. enrollment in the trial was stopped early because of difficulty in recruiting sufficient numbers of subjects. 52 patients with mtbi were enrolled; 28 patients received atorvastatin and 24 received placebo. the mean rivermead score was 7.6 for the atorvastatin group compared to 9.2 for the placebo group at 3 months post-injury [f(1,4) = .1855, p=.6687)]. the change in the rivermead score between baseline and 3 months was also analyzed. the mean change in score was a decrease of 8.1 for the atorvastatin group and 10.7 for the placebo group [f(1,47)=.4132, p=.5235]. no serious adverse events occurred, and there was no significant difference in the incidence of adverse events in the two treatment groups. atorvastatin administration for 7 days post-injury was safe, but there were no significant differences in neurological recovery after mtbi with atorvastatin. association between comorbidities, nutritional status, and anticlotting drugs and neurological outcomes in geriatric patients with traumatic brain injury an essential part of the management of traumatic brain injury (tbi) is the mitigation of secondary insults to the brain such as sustained increases in intracranial pressure (icp). it would be beneficial to be able to predict increased icp so as to facilitate safe transport of patients. given the role of neuro-inflammation in increases in icp. after admission. receiver operating characteristic (roc) curves were used to compare the predictive elevation of icp above 20 or 30 mmhg for 5 min or more in the following 6 hours. 250 serum samples from 24 patients were matched to subsequent 6 hour periods of monitoring.. ni-vs the predictive capacity of a combined model of ni-vs and il4 level over ni-vs alone in predicting icp elevation to >20 mmhg (0.8 vs 0.77, p30 mmhg (0.91 vs 0.79 p <0.005). levels when combined with physiological data. even without invasive monitoring, predictions about measurements. head injury neuroworsening (nw) after traumatic brain injury (tbi) is a major cause of added morbidity, however, there is no reliable way to predict nw. we hypothesized that autonomic nervous system dysfunction (ans) measured by analysis of plethysmograph variability (ppgv) in the first hour after presentation may predict nw in the initial 48 hours after tbi. and head abbreviated injury score(ais)>1. patients with systemic trauma were excluded. nw was defined as any of the following occurring in the first 48 hours: new asymmetric pupillary dilatation (>2mm), 2 point gcs decline, interval worsening of ct scan as assessed by the marshall score, or requirement for neurosurgical intervention. the beat-to-beat variation of the ppg, and ppg morphologic features were calculated to quantify the ans impact on the physiological status. multivariate stepwise logistic regression was used to develop predictive models of nw. there were 205 patients (mean age 43 years old, gcs 13, iss 12, 27% women) who met criteria between december 2011 and may 2013. nw occurred in 24(12%) patients. ppgv analysis at 15 (ppg15) and 60(ppg60) minutes post-admission demonstrated predictive capability for nw(p<0.01). ppgv15 was able to better discriminate nw as compared to a baseline model of age, sex, initial vs (roc 0.91 v. 0.78, p=0.01). ppgv60 better discriminated future nw as compared to the model of age, sex, admission vs and gcs (roc 0.98 v 0.86,p=0.02), and marginally better than a model combining admission vs, gcs, and marshall score on ct(roc 0.98 v 0.91,p=0.05). ans dysfunction assessed by continuous ppg waveform analysis in the first hour represents a nonclinical factors to more accurately predict nw, potentially leading to automated algorithms for earlier therapeutic interventions. tanzania severe traumatic brain injury (tbi) is the number one cause of death and disability among young adults worldwide. formulation and subsequent adherence to the brain trauma foundation (btf) guidelines has been associated with reduced mortality after severe tbi. in this study we studied epidemiology and treatment of severe tbi at a tertiary referral hospital in tanzania in reference to the btf guidelines. patients with tbi hospitalized at bugando medical centre, a tanzanian tertiary referral hospital were recorded in a prospective registry. demographics, cause of trauma, clinical characteristics, hospital care, and mortality were recorded for 14 days and on the day of discharge. between september 2013 and october 2015, of 371 patient 47.8%) were hospit pressure (icp) monitoring were not performed for any patient. thirty-eigh pre-hospital and routine icu care, ct imaging, blood pressure and icp monitoring are underutilized or unavailable in the management of severe tbi in the tertiary referral hospital setting. tbi associated mortality is significantly higher than that in high-income countries. improving outcomes after severe tbi will require concerted investment in pre-hospital care as well as improvement in availability of neuroimaging, icu resources and expertise in multidisciplinary care. establishment of comprehensive traum elevated intracranial pressure (icp) is thought to mediate secondary brain injury by decreasing cerebral perfusion pressure (cpp) and reducing cerebral blood flow. clinical trials targeting icp thresholds have not demonstrated benefit. we hypothesized that stratifying elevations in icp based on their effect on cpp would be feasible with the use of continuous, time-resolute neuromonitoring data. we studied a convenience sample of five patients undergoing intracranial neuromonitoring after severe traumatic brain injury per our institutional protocol. patients had a parenchymal icp monitor time-synced with continuous arterial blood pressure. waveform data were recorded into moberg cns monitors, and second-bywere identified and their duration was measured along with cpp. elevations were stratified into those that exhibited a reciprocal decrease in cpp (icp[neg] ) and those with stable or elevated cpp (icp [preserved] ). the mean patient age was 33; three were male. a total of 290 individual elevations in intracranial pressure were observed over a monitoring duration of 31,573 minutes. we found icp elevations that reciprocally decreased cpp (icpneg) were identifiable using bedside neuromonitoring devices, and that these elevations resulted in a cpp drop of nearly 17 mmhg, despite a similar maximum icp despite a shorter duration. the majority of these icp elevations occurred in patients with poor outcome, and may represent a target for aggressive icp lowering therapy. mild traumatic brain injury (mtbi) is defined as an initial glasgow coma scale (gcs) 13-15. current recommendations include a follow-up computed tomography (ct) scan of the head prior to discharge. often, imaging and neurological exam remains stable, questioning the role of routine repeat imaging. a retrospective chart review was completed on tbi patients evaluated at a level 1 trauma center between august 2009 and december 2015. inclusion criteria included: initial gcs 13-15, blunt head injury, and available repeat imaging. exclusion criteria included gcs <13, penetrating trauma, those that required immediate surgery, or those without repeat imaging. a total of 198 patients were included in the analysis. statistics were done with mann-u whitney or chi-square testing. age was 49.3±21 years. there were 123 males and 75 females. the most common mechanism was falls (43.9%), followed by motor-vehicle collision (22.7%), motor-cycle accident (12.6%), assault (9.1%), pedestrian--related (5.6%). polytrauma occurred in 42.6%, better, 59.1% were stable, 24.7% were worse. only 19 patients (19.6%) exhibited neuro-exam changes, where 16 patients received repeat imaging which ultimately demonstrated stable findings. ultimately, only one patient required a neurosurgical procedure, an external ventricular drain, due to significant decline. age, gender, mechan neuro-exam changes. on the other hand, neuro-exam changes significantly correlated with ct changes (p = 0.01). repeat imaging tend to show worse findings when associated with neurological changes. on the other hand, results for repeat imaging were variable without neurological changes and generally did not alter repeat imaging is only warranted for neurological changes that may necessitate a neurosurgical procedure. create a meaningful tool, we explored family members' and physicians' perspectives on prognosis communication during goals-of-care discussions for citbi patients employing mixed-methods. we conducted semi-structured interviews with 16 citbi surrogate decision--1 trauma centers, and 20 attending physicians representing geographic (northeast,mid-atlantic,south,west,midwest] and subspecialty diversity (neurocritical care,neurosurgery,trauma,palliative care). two independent reviewers analyzed transcribed interviews using deductive and inductive approaches (nvivo-software). the sample size was determined by theme saturation. prognosticated outcomes expressed as percentages, and 100% preferred prognosis in a "more direct" manner. surrogates favored percentages because they were "more clear, more concise, and less confusing". in contrast, 75% of physicians stated that they do not use precise percentages when discussing prognosis in citbi due to distrust in the predictive accuracy of existing data: "better have damn good data to do that with, and most often, we do not." physicians also voiced concern over families' judgment…they become simplified and [these numbers are] used against you later." the dissimilar preferences for the use of percentages and numbers during prognostication represent an important difference between surrogates and physicians. these findings have a direct impact on the design of a goals-of-care sdm tool for citbi. a future goals-of-care decision aid will require iterative decompressive craniectomy (dc) is not a new procedure, however, it has gained momentum in recent years, in the management of refractory intracranial hypertension. however, the timing of dc has not been -based guidelines for the optimal timing of dc has resulted in a wide variability in practice patterns. in most instances, dc has been performed based on neurosurgical evaluation of the patient with or without intracranial pressure (icp) monitoring and evidence of increased shown variable outcomes in emergency (within 4 hours of injury) neurosurgical procedure in traumatic brain injury (tbi). the purpose of this study was to evaluate the impact of emergency dc on in-hospital mortality following blunt tbi. craniectomies performed on patients with a blunt mechanism of head injury within twenty-four hours of admission, were included in the study. in-hospital mortality was the main outcome of interest. 942 patients qualified for the study. 669 patients (71%) underwent a craniectomy within 4 hours (emergency group)and 273 patients (29%) had craniectomy performed between >4hours hours to 24 hours following hospital arrival (late group). propensity matched analysis identified 268 pairs of patients in both groups. the mean standardized differences were less than 10% after matching. there were no significant differences in mortality [odd ratio 1.018, ci (0.689 [0.004, 95% ci (-0.078, 0.085), p=1.00] and length of stay between the groups [hazard ratio, 0.770, 95% ci (0.56, 1.059], p= 0.108]. no difference was seen on in-hospital mortality between patients operated within 4 hours versus patients operated between 4 and 24 hours of admission. spreading depolarizations (sds) are pathological waves of neuronal depolarization that occur in 56% of patients with traumatic brain injury (tbi) who require surgical treatment of focal lesions. the incidence of sds in non-surgical tbi i (deeg) placed at bedside via burrhole. we hypothesized that the incidence of sds recorded using deeg in non-surgical patients would be similar to that documented in surgical tbi. -penetrating tbi who did not require urgent neurosurgery on admission. all patients underwent bedside burrhole placement of intracranial pressure, tissue oxygen, regional blood flow and deeg monitors via a single quad-lumen bolt per institutional protocol. data were recorded on moberg cns with dc-coupled amplifiers. over a 12--19; 80% male; gcs range 3-7) underwent monitoring for a mea -43.5 hours, beginning 11.0 hours (median, quartiles: 8.1-(80%) monitoring devices were placed in nonpatients had focal pathology in the monitored lobe, w died, including those with sds. there were no significant hematomas or infections related to invasive neuromonitoring. the incidence of sds detected with deeg placed in non-dominant frontal lobe was lower than previously reported with injury-targeted placement of subdural strips in surgical tbi patients. this may be due to targeting to injured periinnate incidence of sd in patients with non-surgical or more diffuse injuries. targeted placement of subdural electrodes through burr holes may be warranted in non-surgical tbi patients. university of utah general surgery, salt lake city, ut, usa. traumatic brain injury (tbi) is a prevalent condition that is responsible for a significant amount of disability and healthcare expenditures. clinicians can and do use the impact prognostic calculations to inform o examine self-reported individual and institutional use of the impact prognostic calculations in an effort to identify trends and effects on treatment. we conducted an international and multidisciplinary survey examining self-reported awareness and use of the impact prognostic calculator. factors associated with awareness and use of the calculator including provider specialty, years in practice, personal and institutional volume of tbi patients treated, and institutional trauma level were als voluntary and anonymous survey in an email. study data was collected and managed using redcap. 76 respondents (49.7%) were aware of the calculator, only 5.3% (4) said that they often, and 48.7% (37) said they sometimes used it. volume of tbi cases and specialty both were positively associated with awareness and use of the calculator. 42 providers often or sometimes used calculator, 88.1% (37) stated that it had some influence on their care for the patients. 88.1% used the information to better of care and 19% used it to provide more aggressive care. of those aware, still only slightly more than half (54%) used it. the use of the impact calculator was mainly to better communicate with patient family, but a portion, 26.2% and 19% of providers, said it influenced their care in other ways. these results provide direction to increase awareness and use of the impact prognostic calculations. the brain trauma foundation guidelines suggest individualizing cerebral perfusion pressure (cpp) goals based on tissue oxygenation (pbto2), pressure reactivity (index; prx), and metabolism (lactate-pyruvate ratio; lpr). our objectives were to investigate practices pertaining to bedside hemodynamic and neuromonitoring in tbi patients, and to analyze differences among "neurointensivists" (nis; defined as clinical electronic survey of 22 items including a tbi case-scenario; endorsed by sccm (9,000 recipients) and esicm (on-line newsletter) in 2013. chi-square test was used to compare proportions of responses between nis and ois with a significance p< 0.05. there were 655 responders (66% completion rate); 422(65%) were classified as ois and 226(35%) as nis. use of neuromonitoring-derived variables to optimize cpp in patients with severe tbi, for the entire cohort: pbto2 (18%), transcranial doppler(tcd) (12%), jugular venous bulb (11%), ct perfusion(ctp) (4%), prx (4%), and lpr (3%). nis use more pbto2 (28% vs. 10%, p=0.0001) and ctp (7.6% vs. 2.5%, p=0.012). more nis have a hemodynamic protocol (44.5% vs. 33.3%, p=0.007) for tbi, use more arterial waveform analysis (45% vs. 35%, p=0.019), and bedside ultrasound (37% vs. 27.7%, p=0.023), while more ois monitor mixed venous oxygen saturation (54.1% vs. 45%, p=0.045). in the case scenario of raised icp, low pbto2, and preserved pressure autoregula (vasopressor use 34.5% nis vs. 23% ois, p=0.014). "neurointensivists" employ more hemodynamic and neuromonitoring to patients with tbi. intracranial pressure and cpp remain cornerstones of management, however the use of other physiologic variables -specific pp goals. the predominant experience of penetrating traumatic brain injury (ptbi) derives from battlefield settings, but the civilian experience in western settings in patients treated after 2005 is limited to only small and single-center studies. as a result, outcome predictors of civilian ptbi in modern trauma and neurocritical care settings are poorly defined. the aim of this study was to identify predictors associated with survival in a contemporary, large, diverse two-center ptbi cohort, and to develop a parsimonious survival prediction score for civilian ptbi. our cohort comprised 415 ptbi patients retrospectively identified from the local trauma registries at two u.s. level-1 trauma centers, of which one was predominantly urban and the other predominantly rural. predictors of in-hospital and 6-month survival identified in univariate and multivariable logistic regression were used to develop the simple surviving penetrating injury to the brain (spin) score. at hospital discharge and 6-months post ptbi was 42.4%. motor glasgow coma sub-score, pupillary reactivity, self-inflicted injury, transfer from other hospital, female sex, injury severity score and inr were independently associated with survival (all p<0.001; area-under-the-curve 0.962). important radiological factors associated with survival were also identified but their addition to the full multivariable would have resulted in model overfitting without much gain in the area-under-the-curve. we developed the spin score, a logistic regressionafter ptbi. while external validation is warranted, this clinical survival prediction tool may provide important information to guide families and physicians during intervention-and goals-of-care decisionreal-time visualization of the cumulative pressure and time dose of intracranial pressure in individual traumatic brain injured patients. the 'dose' of intracranial hypertension, a summary measure of duration and intensity of elevated intracranial pressure (icp) episodes, is associated with worse outcome in traumatic brain injury ( retrospective analysis of minute-by-minute icp monitoring data from a large multicenter database of tbi population-based color-coded plots by güiza et al, where 'bad' icp episodes are red, and 'good' icp episodes are blue. the icp insult currently experienced by the patient, together with his icp episodes of the previous 6 hours, and the cumulative icp burden since icu admission, are shown. when playing these minute-by-minute snapshots consecutively, an animation is created showing the current and cumulative burden of icp of the patient. we present the clinical course of 2 patients, 1 with good outcome (gos 5), and 1 who died (gos 1). clinical trials aiming at aggressively treating icp below a fixed threshold of 20 mmhg have given thresholds, could present a new way to define secondary injury by icp, and a future target for therapy. the proposed method visualizes the current and cumulative time and pressure burden of icp for individual patients, which could help a neuro-intensivist in identifying when a patient is currently in a state of potentially harmful elevated icp, or when his outcome is at a turning point. acute blood pressure variation and mortality in severe traumatic brain injury we retrospectively evaluate 249 temperations (282hematomas) from april 2011 to march 2015 operated by one young neurosurgeon. during the operation, we made sure to put the burr hole the highest, not to drainage tube into the right position. we scaled the amount of hematoma by hand free roi using head ct before operation and also the next day to evaluate the improvement rate. the recurrence rate was 8.03% (20 cases). the average amount of air contaminated was 12.3ml and the improvement rate was 56.1%, both of which didn't relate to the recurrence. no relevance among the recurrence rate, the amount of air contaminated and the hematoma improvement rate could be found. though the amount of air contaminated during temperation doesn't relate to the recurrence rate, it was useful to scale the hematoma improvement rate and the amount of air in order to objectively assess the d recurrence became less, which suggest that we need to investigate the operation for chronic sundial hematoma further after we operate more. the aim of this prospective observational study was to evaluate if trans-cranial doppler (tcd) ultrasonography can be used as an inference tool of cerebral hypoxic episodes in patients with moderate to severe traumatic brain injury. recruited patients had serial tcd studies to assess blood flow velocity of the middle cerebral artery (mca). measurements were done on bilateral mcas as soon as logistically possible after the insertion of pbto2 monitoring, once a day for a total of 5 days, and during dynamic challenge tests when feasible. multiple physiologic parameters were registered concomitantly with each tcd measurement, with a particular focus on determinants of pbto2 and potential confounding factors. we studied 17 consecutive patients with a total of 85 tcd studies, of which 29 (34%) were performed 5-14.5h) after tbi. when considering all readings, we found no correlation between pbto2 and mca's readings > 24h. for value level, icp, and cpp. to correlate with brain tissue hypoxia and could be use as a screening tool to help minimise timesensitive secondary injury during that period. otherwise, vmean is not correlated to pbto2. a precise assessment of brain condition after severe traumatic brain injury (tbi) is crucial to reduce secondary injuries and sequelae. multimodal neuromonitoring permits to assess multiple systemic and brain parameters, but these data are complex to interpret continuously, especially in the overwhelmed environment of intensive care unit (icu). computerized decision support systems (cdss) can assist the clinicians in optimizing care. this study aims to evaluate an algorithm for classifying the cerebral condition, as a first step in the development of a cdss. the study was approved by the local research ethics committee. patients with severe tbi (glasgow coma score < 8) with a monitoring of intracranial pressure and brain tissue oxygenation pressure were eligible. data were extracted from the existing icu electronical medical records (semi solutions médicales). an incremental learning fuzzy minparameters online was implemented. the different cerebral status categories included: control condition, ntracranial hypertension. previously validated and published datasets were used to train the system. the system was then tested with the patients' data and compared to a classification made by two clinical experts. eight 2-hour recording periods from adults with severe tbi were analyzed. the pathophysiological status was appropriately classified by the cdss in (median) 93 % (interquartile: 91-97%) of time. every critical event was detected, but brief misclassifications were frequently observed during the transition periods. in this preliminary cohort of patients with severe tbi, the cdss was able to adequately classify the brain condition in a large proportion of time, but some errors occurred during brief transitional periods. further training of the cdss with a larger dataset may improve the system accuracy, which should be tested in a larger patient population. mild traumatic brain injury (tbi) is a commonly seen pathology at trauma centers. neurosurgical consultation is a routine practice; however, the vast majority do not require surgical intervention or invasive monitoring during the entirety of their hospital stay. in certain trauma centers, neurologycentered neurocritical care solely evaluate and manage mild tbi. we provide a retrospective analysis of this practice at our level 1 trauma center. a retrospective chart review was completed on tbi patients evaluated at a level 1 trauma center between september 2009 and december 2015. inclusion criteria included; initial gcs 13-15, blunt head injury, available repeat imaging, and management by neurology-centered neuro-intensivists. exclusion criteria included gcs <13, penetrating trauma, those that needed immediate surgery, those with neurosurgical consultation, and those without available imaging. a total of 87 patients were included in the final analysis. age was 48.8 ± 21 years. there were 50 males and 37 females. the most common mechanism was falls (51.7%), followed by motor-vehicle collision (16.1%), motor--related (8.0%), assault (6.9%), and pedestrian-60.9% were stable, 24.1% were worse. only 10 patients (11.5%) exhibited neuro-exam changes, where 7 patients received repeat imaging which ultimately demonstrated stable findings. no patients required a neurosurgical procedure. average hospital stay was 2.8 ± 3.7 days. neurology-centered neuro-intensivists can manage mild tbi appropriately without official neurosurgical consultation. this practice can streamline tbi management and potentially reduce hospital costs. bulic, natasha n. renda, may m. kim-tenser, gene g. sung, benjamin b. emanuel. usc, los angeles, ca, usa. measurements of optic nerve sheath diameter (onsd) using bedside ultrasound (us) have been shown to correlate with clinical and radiologic signs and symptoms of increased intracranial pressure (icp). eleven patients (7 males, 4 females) with traumatic brain injury (tbi) and gcs<9 were evaluated. all patients had extraventricular drainage (evd) monitors, 9 right and 2 left. three patients had right decompressive hemicraniectomy, 4 had left hemicraniectomy, 2 had suboccipital craniectomy and 2 did not have decompression. a total of 29 examinations were obtained with invasive icp measurements, pulsatility indices (p balance were recorded. twenty-nine ocular uss were performed on 11 individual patients. in 14 ons assessments, bilateral onsd was 5.7 mm, while icp was 13mmhg, however, later developed icp 37mmhg within 24 hours. another patient had bilateral ons 5.8mm, while icp was 16mmhg, however, later developed icp of >30mmhg within 24 hours. two patients had bilateral ons measurement> 3.8mm with corresponding icp >20mmhg all patients with onsd20mmhg had ons >5.7mm. although, patients with ons >5.7mm and icp 20mmhg within the next 24h. there was no correlation between pi on tcd, thus tcd was not useful in this dataset. there was no correlation between increased temperature or elevated blood pressure with icp> 20mmhg. this small sample size suggests that onsd may predict future icp elevations, however, a larger sample size is needed to confirm these results. the precise threshold differentiating normal and elevated intracranial pressure (icp) is variable among individuals. in the context of several pathophysiologic conditions, elevated icp leads to abnormalities in global cerebral functioning and impacts the function of cranial nerves (cns), either or both which may contribute to ocular dysmotility. the purpose of this study is to assess the impact of elevated icp on eye watching a 220-second continuously playing video moving around the perimeter of a viewing monitor. pupil position was recorded at 500 hz and metrics associated with each eye individually and both eyes together were calculated. linear regression with generalized estimating equations was performed to test performed at icp levels ranging from -3 to 30 mm hg in twenty-three patients (twelve female, eleven male, mean age 46.8 years) on fiftycorrelating with cranial nerve function linearly decreased with increasing icp (p-value 12 mm hg was 0.798. intracranial pressure. increasingly elevated icp was associated with increasingly abnormal eye tr physiologic impact of elevated intracranial pressure. this represents a new non-invasive automatable means for assessing the physiologic impact of elevated icp. use of shared decision--of-care decisions in critically-ill traumatic brain injury (citbi) offers the hope to decrease variation and bias in goals-of-care discussions. sdm guidelines demand the inclusion of an evidenceand acceptance of the "international-mission-for-prognosis-and-analysis-of-clinical-trials-in-tbi"(impact)-model by physicians holding such discussions with citbi families. we conducted a mixed-methods study with semi-structured interviews in 20 attending physicians representing geographic (northeast,mid-atlantic,south,west,midwest) and subspecialty diversity (neurocritical care, neurosurgery, trauma, palliative care). we explored methods of prognosis derivation and communication, citbi outcome model use, and, specifically, awareness and perceived utility of the impact-model. we analyzed transcripts in nvivo-software with the investigator-triangulated-inductive--approach. theme saturation determined the final sample size. overall,42% of physicians use the impact-model, 25% were not aware of it, and 50% don't rely on any tbi outcome models. positive impact-model views included: "helpful in getting an idea where your confidence should be"; "to ground physicians a little bit"; "reduces the variability of prognosis that a large some participants "do not thin only"; "those calculators are about populations; they're not about individuals, use of those calculators for this purpose is a perversion of the original construct". we identified substantial physician variability in the awareness of, use, and attitude toward the impactmodel, which crucially informs the development and successful implementation of future goals-of-care sdm tools in citbi. the analyses of acute subdural hematoma using acute subdural hematoma (asdh) is associated with cerebral contusion and laceration of bridging veins following a head injury, however a few cases of asdh without head injury had been reported. the purpose of this study was to detect the difference of traumatic asdh and non-traumatic one. 204 cases of asdh hospitalized at our institute from march 2014 to march 2016 were retrospectively reviewed. traumatic groups were 189 patients (92.6%), and non-traumatic groups were 15 patients (7.4%). the results were statistically analyzed by logistic regression to use the various factors: age, gender, glasgow coma scale (gcs) score, the presence of light reflection, danti--coagulation agents, neurological outcome and so on. neurological outcome was evaluated using glasgow outcome scale, and it was classified into two groups: the good prognosis group (gr, md) and the poor prognosis group (sd, vs, d). traumatic groups were mean age 67.8 ± 19.7 years, and were comprised of 121 males and 68 females. non-traumatic groups were mean age 74.5 ± 19.5 years, and were comprised of 6 male and 9 females. there were significant difference in patients` characteristics, the presence of light reflection, d-dimer and neurological outcome (p <0.05). non-we will be described the detail of them and collect further cases in the future. traumatic brain injuries (tbi) are of significant importance due to increased morbidity and mortality. we retrospectively analysed tbis to assess clinical profile and factors predicting in-hospital mortality. electronic database at a private, urban tertiary care centre was screened (2011 to 2016) to include all tbi -hospital mortality outcome were assessed. mean age of population was 39.2 ±17.2 years with 81.8% being males. most injuries (90%) resulted from road traffic accidents (rtas). bleeding from either ear, nose or throat (ent) was most common presentation (29.2%) followed by vomiting (25.8%) and convulsions (7.5%). on presentation, severe brain d subdural (36.7%) haematoma was most common followed by sub-arachnoid (25.8%), extradural (16.7%) and intracerebral (2.5%). threatened airway was observed only in 7.5% cases. bony trauma (25%) followed by face (14.2%) ,chest (3.3%), and spine injuries (0.8%) were associated injuries. in-hospital in-hospital mo 4.82, 50.88; p<0.0001), tachycardia (or 3.0, 95% ci 1.21, 7.43; p=0.014) and with development of hyponatremia (or 5.0, 95% ci 2.17, 11.53; p<0.0001) or fever (or 3.18, 95% ci 1.29, 7.61; p=0.010) during hospitalization. ventilator support was necessary in 29 (23%) cases out of which 16 (55%) died. hospital stay (days) did not vary significantly in survivors and non-survivors (5.5±4.0 vs 8.5±7.8, p=0.156). development of hyponatremia or fever and requirement of assisted ventilation were associated with -hospital mortality. casey 1 we established a team that included attending physicians, fellows, advanced practice providers (app), specific guidelines. we surveyed staff regarding team communication and discussion of qsis during rounds. we designed a dgt that defined team member roles, structured communication patterns, and prompted standard discussion of qsis. following implementation, we evaluated team compliance with the dgt, as well as rates of catheter-associated urinary tract infections (cauti) and ventilatorassociated pneumonias (vap). 11% respiratory therapists). for most qsis, a minority of staff reported that these were always addressed during morning rounds (% staff indicating qsi "always" addressed: 14% pressure ulcers, 19% code status, 33% cam icu, 36% mobility goal, 46% central line catheter removal, 50% urinary catheter removal, 66% dvt prophylaxis plan, 69% ventilator weaning). shared understanding of daily goals between nurses and physicians was reported by 58% of staff, with a significant difference between nurse 33%), p = 0.047. dgt audits spanning 212 patient days demonstrated median compliance greater than 80% for discussion of all qsis. there was an 11% reduction in cautis (95% ci 3%, 19%), p = 0.011, and a trend towards reduction in vap that was not significant. team discussion of qsis can be enhanced by dgts. by promoting adherence to evidence-based best practice, dgts may reduce hospital-associated infections. follow-up is ongoing to determine the impact of dgts on clinical outcomes and team communication. catheter-associated urinary tract infection (cauti) is the most common health-care associated infection accounting for > 560,000 nosocomial infections annually (gould,2016) . according to the center for disease control, cautis are also a leading cause of secondary blood stream infection resulting in development related to cognitive, motor, and sensory deficits. neuroicu's goal was to eliminate cautis, defined as a rate of zero. with initial efforts (2008 ( catheter days (titsworth et al, 2012 . in february, 2016 neuroicu launched a patient-centered quality improvement effort to further reduce cautis. the neuroicu interdisciplinary comprehensive unit safety program (cusp) performed an extensive literature review of evidence based best practices specific to urinary catheter management. a preexisting, staff nurse driven urinary catheter management protocol was revised to better fit the needs of the neurocritical care population, including assessment of and interventions for acute and chronic scan assessments to every 4 hrs, revision of urinary d-ofconducted daily rounds to evaluate the necessity and management of indwelling urinary catheters. after three months of implementation, compliance with use of the neuroicu's urinary catheter management algorithm (ucma) was greater than 95%, urinary catheter utilization was reduced from 65% to 38%, and cauti rates were reduced to zero. implementing a neurocritical care patient-centered, interdisciplinary approach to urinary catheter management significantly impacted urinary catheter utilization, cauti rates, and unit culture. dedicated neurointensivists have previously been shown to improve various outcome measurements in patient and family satisfaction. the purpose of this study is to evaluate the impact of newly appointed neurointensivists on quality outcome measures in a nsicu. this is an observational cohort study of adult patients (>18 years) in a 10-bed nsicu at an academic, tertiary care center evaluating quality outcome measures pre-and post-neurointensivists. outcome measurements include catheter associated urinary tract infection (cauti), central line blood stream infection (clabsi), ventilator associated pneumonia (vap), patient acuity, mortality, and length of stay (los). patient satisfaction questionnaires from discharged patients were compared to historical controls. tentiveness of doctors; 5) recommend the hospital to others. statistics include 1-sample binomial and n-1 chi-squared (categorical) and t-test (continuous). for questionnaire data, 1considered significant. 2547 total patient days occurred pre-and 2560 days post-neurointensivist coverage. patient acuity decreased 24.2% (p=0.043). cauti (66%, p=0.084), clabsi (100%, p=0.32), central line days (16.5%, p<0.0001), ventilator days (18.7%, p=0.3), and vap (200%, p=0.15) also decreased. these saved the hospital an estimated $65,000 based on health services advisory group data. 89 questionnaires were returned. patient satisf on physicians' attentiveness (p=0.03). patients recommending the hospital to others increased 67% (p=0.03). dedicated neurointensivists positively impact quality outcome metrics, particularly significantly improving patient satisfaction. future studies should evaluate the direct impact of neurointensivists on medicare reimbursement from improved patient satisfaction. bertan hallacoglu, tanmayi t. oruganti, chandran c. seshagiri. research & development, boston, ma, usa. cephalogics has developed a wearable diffuse optical tomography (dot) imaging device to help clinicians monitor perfusion and oxygenation from multiple brain regions on the bedside in disease states the system to changes in cerebral tissue oxygenation (scto2) induced by hyperventilation in a pig and human subjects. dot sensor was positioned on the pig's head along the sagittal line, and the second sensor was positioned on the hind leg muscle for monitoring systemic tissue oxygenation (ssto2). dot measurements were performed continuously during baseline (8 mins, paco2 = 40mmhg), transient hypercapnia (4 mins, paco2 = 15mmhg), and recovery (25 min, paco2 = 40mmhg) periods controlled by the respiratory rate of the ventilator. dot data were recorded to a laptop for off-line analysis. sto2 -sd) were computed for comparison of results across measurements. the approach was also investigated in three human volunteers, who were instructed to hyperventilate during dot recordings. --6%), consistent with reports of reduced cerebral blood flow during hypocapnia. in contrast, ssto2 estimates -1%), indicating elevated systemic perfusion. both parameters fully recovered to baseline values during the recovery period. scto2 response to hyperventilation in human volunteers were consistent with the results in pig. hypercapnia induced reduction in scto2 was noninvasively imaged in human subjects and a pig despite the large scalp-cortex distance in pig. the results of this study demonstrate the sensitivity of the cephalogics' dot system to scto2 values and its ability to separate scto2 from systemic perfusion. brittany doyle, michael m. rogers, daiwai d. olson, venkatesh v. aiyagari. ut southwestern, depts. of neurological surgery, neurology and neurotherapeutic, dallas, usa. multidisciplinary rounds play a pivotal role in optimizing care in the neurosciences critical care unit (nccu). care providers were frustrated with inconsistency and the need for manual data entry to conduct multidisciplinary rounds. the purpose of this project was to develop an integrated computerized form that incorporated "smart" features within epictm. the nccu nursing council collaborated with the physicians to design a standardized system-based approach to multidisciplinary rounds, and the elements that would be addressed within each system. input was collated from nursing, neurology, neurosurgery, pharmacy, and critical care into a paper version which was beta tested before the epic tool was officially rolled out. the rounds template is now a perpetually editable note with fields that include drop-down menus, copy--populate with up-to-date data (e.g., icp values, lab values). while there was a learning curve to the use and un -led rounds became much more efficient, comprehensive, and less frustrating for the entire healthcare team. within four months, nursing management saw the benefit of such a standardized tool for clear communication and the tool also became the standard for nurse-to-nurse handover at change of shift. efficient and orderly presentation of information during multidisciplinary rounds is greatly assisted by the use of a standardized electronic tool. having all of the current, relevant data available in a single location has greatly improved the quality of nurse-led neurocritical care rounds. this tool can be replicated and customized to the needs and patient populations of other units and hospitals. the degree of burst suppression on continuous critical care eeg (cceeg) monitoring is used to guide dosing of intravenous anesthetic drugs (ivads) in the treatment of refractory elevated intracranial pressure (icp) and refractory status epilepticus (se). however, medication titration is performed only as frequently as cceeg review (potentially as little as 2-3 times a day). quantitative eeg (qeeg) may provide a continuous, objective assessment of the level of burst suppression that would allow for more precise and rapid titration of ivads. compared software-generated qeeg burst suppression ratio (qeeg bsr) with three raw eeg variables as determined by two board-certified neurophysiologists (r1 and r2): bursts per minute (bpm), total burst duration per minute (bd) and average inter-burst interval (ibi) for 10 one minute segments per patient. a total of 90 eeg segments were analyzed. agreement between readers was very high for the three raw eeg variables: bpm, bd and ibi (correlation coefficient 0.92, 0.96, and 0.95, respectively). the best correlation was observed between bd and qeeg bsr (-0.93 for both r1 and r2). the correlation between bpm and qeeg bsr (-0.80 r1 and -0.75 r2) and ibi and qeeg bsr (0.70 r1 and 0.65 r2) was not as strong. left and right hemispheric qeeg bsr did not differ statistically from the generalized qeeg bsr (p=0.11 and 0.08, respectively) despite the presence of focal intracranial pathology. the depth of therapeutic burst suppression can be accurately assessed by generalized qeeg bsr. although cceeg bursts per minute is the most commonly used cceeg metric of burst suppression, it shows a lesser correlation with qeeg bsr than total burst duration per minute. there is little operational data on optimal neuro-icu physician staffing. this prospective study evaluated the introduction of night-time in-hospital neurocritical care fellows (ncfs) in an urban academic hospital. the goal was to determine if the new staffing model enhances patient care and provider and patient satisfaction. irb approval was obtained. the new staffing model was rolled out on 9-1-2015. 121 providers (ncfs; neurology residents and attendings; neurosurgery residents, physician assistants, advanced practice nurses and attendings; neuro-icu nurses) were surveyed. a pre-roll out survey of providers' perceptions of the existing model (night-time ncf coverage from home with on-call in-hospital neurology residents and neurosurgery physician assistants or residents, not dedicated to the neuro-icu) was administered prior to new model roll-out. two follow-up surveys, a separate night-shift nurses survey, and patient (or surrogate) surveys were administered between 9-1-15 and 5-10-16. surveys were electronic and responses were voluntary and anonymous except for the night-shift nurses survey which was paper, required, and anonymous. response rates were 52% (pre-roll out), 28% (first follow-up), and 25% (second follow-up). 93% of providers indicated pre-roll out that night-time in-hospital ncfs would be beneficial; 94% (first follow-up) and 92% (second follow-up) indicated satisfaction with the new staffing model. major reasons for satisfaction included: physician response to emergencies, physician -nurse communication, and patient outcome. the reason for dissatisfaction was decreased educational opportunity for residents. 94% of night-shift nurses reported preference for the new model. 62% of 72 patients (or surrogates) agreed to participate: 87% reported satisfaction with the care they received in the icu; dissatisfaction was not more than 92% of providers were satisfied with a new staffing model featuring night-time in-hospital ncfs. additional studies are necessary to determine optimal neuro-icu physician staffing with increasing patient and treatment complexity and decreasing resources. therapeutic plasma exchange (tpe) is a first-line therapy for guillain-barre syndrome, myasthenia gravis, chronic inflammatory demyelinating polyneuropathy and polyneuropathy associated with paraproteinemias. tpe is also a second-line therapy for neuromyelitis optica, chronic focal encephalitis, and acute multiple sclerosis. the therapy is also used in autoimmune encephalopathies, refractory status care service has provided a neurointensivist run tpe program using membrane-based technology with the gambro® prismaflex system. a benefit of a neurointensivist managed membrane -based service is lower direct costs compared to centrifugal-based therapies. since a consultation to another service (often available during business hours) is avoided, delays in therapy can be reduced (potentially further decreasing costs) and the therapy is also available for emerging indications such as refractory status epilepticus. this review is of the initial 15 patients treated with tpe in our neurocritical care unit between april 2015 and may 2016. all patients were treated with 5% albumin with a targeted exchange of 1.2 to 1.5 plasma volumes. overall dosing, timing, indications as well complication were reviewed. indications for therapy included guillain-barre syndrome, myasthenia gravis, autoimmune encephalitis, refractory status epilepticus, autoimmune vasculitis, and parainfectious transverse myelitis. all patients received a minimum prescription of 1.2 plasma volumes and had the therapy started sooner than historical controls. no changes in nurse staffing were required for the therapies and we report no bleeding, infectious or access related complications. mild coagulopathy was seen in most patients after previously not available. a neuro-intensivist lead tpe program is feasible and safe. the therapy can be delivered more timely and can be offered for a wider variety of indications. a cost analysis of the program is now underway. specialty neurocritical care improves hospital length of stay and mortality in patients with critical neurologic illness. however, clinical practices are often informed by studies focused on mortality or gross functional outcome. both staff and family members face uncertainty about neurological outcome, which performing detailed followup for all patients admitted to the university of cincinnati neurosciences intensive care unit (nsicu). all patients admitted during a twotrained outcome scale-extended (gose), cognitive outcome using the teleph and quality-of-life using the euro-qol. we assessed the duration of each follow-up call in order to determine feasibility. n=50 patients were admitted to the nsicu; mean age was 59; 63% were male. overall follow-up was obtained in 80%; 64% of survivors were contacted. disposition from nsicu included: home (20%), acute rehab (27%), long-term care (24%), hospice (4%). in-hospital mortality was 16%. median gose (iqr) was 4 (3-7) and median mrs (iqr) was 3 (1--30. an average of 13:28 (mm:ss) was required for each assessment; comprehensive assessments required 21:54. overall, a total time of approximately 11 hours was required for 50 patients. our pilot study demonstrated feasibility of following patients admitted to the nsicu. these findings have the potential to guide in-hospital care and out-of-hospital resources when used as a quality improvement metric, and to provide valuable information for retrospective research. our neurocritical care unit restructuring provided an opportunity to revise our staffing model. the prior model ratio of 1:2 resulted in at least one nurse experiencing a 1:3 ratio when high acuity patients -specific data to support a higher staffing. prospective observational study of nursing time using the 28-item therapeutic intervention scoring system (tiss-28) and manual timing of discrete nursing interventions including off-unit transport. baseline data was obtained to include measures of nursing experience. measures of central tendency and regression analysis was performed using sas v9.4. the average time to complete a neurologic assessment was 4.17 minutes; the average time to chart a neurologic assessment was 4.05 minutes. for time spent off the unit the average time spent traveling to ct was <20 minutes, average time spent in mri was 80 minutes twice a day, average time in ir was 82.5 minutes. we found that nursing experience was not associated with patient acuity, duration of assessment, nor time spent doc ents. assessment time was associated with documentation time. moreover, higher acuity was a predictor of both assessment time and documentation time. the data were used to support an increased acuity model with 3 nurses having planned 1:1 ratio. neurologic critical are patients require more hands on nursing care and time spent in diagnostic testing than an average critical care patient. neurocritical care units staffing ratios should be adjusted to provide time to ensure nursing care is complete. melissa panter, sonja s. stutzman, daiwai d. olson, venkatesh v. aiyagari. utsouthwestern/neurocritical care, dallas, usa. venous access is a basic yet critical component of care. determining which venous access devices (vad) to use depends on the type, duration, and frequency of infusion. prolonged continuous infusion of drugs or fluids, benefit from midline peripheral catheter (midline) or a peripherally inserted central catheters (picc). midlines are safe and effective but use is declining in favor of piccs, which have similar insertion costs and added benefits, such as the delivery of toxic drugs harmful to peripheral veins. however, an infection associated with a picc is classified as a central line associated blood stream infection which has important financial implications for the hospital. therefore, it is important that the type of vad be specifically tailored based on -physician collaborative study to design and test a decision support tool to assist clinicians in determining the appropriateness of the piccs vs midlines for patients. this study has three phases. first, a retrospective chart review of vad decisionexamine the current degree of appropriateness for each type of vad for each specific patient scenario. next, we will design a decision support tool to help decide which vad should be used. the tool will be developed based on expert clinician, pharmacist review and a review of the literature. finally, we will their patients. the first phase of the study is ongoing and we will present the results of the retrospective part of the study and the decision support tool at the annual neurocritical care society meeting. a decision support tool to guide clinicians choosing between different types of vad will help improve current clinical practice and patient outcomes. clinical trials in neurocritical care require a predictable set of baseline, monitoring, treatment, and clinical outcomes data. however, interoperability standards restrict automated real-time streaming of this data, resulting in inefficiencies performing clinical trials, preventing real-time clinical trial oversight and constraining collaborative research. we investigated available data systems and developed a conceptual e. examining current traumatic brain injury interventional trials, we considered technical interoperability -based clinical trial oversight and collaborative analytic research. we elaborated a vendor-neutral interoperability schema for data extraction, repositories, analysis, annotation, and visualization. the proposed conceptual solution is described. nodes of data acquisition include: 1) continuously streaming devices including physiologic monitors and infusion pumps; 2) discrete data from highpenetrance ehr and laboratory platforms; and 3) biospecimen, radiology, and clinical outcomes repositories. an application program interface performs function calls to utilize individual episodes of data. a data management system queries and manages multiple patient records for batch processing of ondemand or prefor real-time or post-hoc assessment of raw and derived parameters (e.g., percent time in target range or on-protocol compliance). we enumerate the variety of current nodes requiring interoperability interfaces, and propose an open standard to promote a highly efficient platform for n -based clinical research, featuring automated case report form data extraction, a programmable interface for oversight and early warning detection, and a platform for annotation and crowdsourcing of novel algorithms. this conceptual architecture for a modular, vendor-neutral, data collection and management system for -based clinical trials in neurocritical care and offer new functionality for real-time oversight and collaborative analytics. improving cancer is a devastating illness; with a rise in brain and spine tumors specialized care is more important that ever. with advances in technology and treatment strategy, those too ill to previously receive care reased acuity has translated to the need for higher levels of hospital care. recognizing the unique expertise required to care for this emerging population, the decision was made to merge neurology and oncology specialties within critical care. the purpose of this poster is to describe the admission criteria, patient population, utilized technology, staffing model, and patient outcomes of a newly created neuro-oncology critical care unit (nccu). in january 2014, a 24 bed neurocritical care unit was opened in a midwestern academic medical center. six of the beds housed within this 24 bed unit were designated and budgeted to the oncology medical center. separate nursing staff and management teams were created to support the care within the unit while maintaining close collaboration with university hospital nccu nursing teams. while nursing teams are distinct, nurse practitioners, neurointensivist, and other multidisciplinary team members are shared between both services. to evaluate the benefit of patient diagnosis, care needs, nccu length of stay (los), number of ventilator acquired pneumonias (vaps), urinary tract infections (utis), and central line acquired bloodstream infections (clabsis). at the time of this submission, specific results are still being tabulated. merging access to academic research trials and oncologic and neurointensive specialists, this has created an environment that promotes care reflective of the most up to date evidence based practice. through the utilization of creative staffing and focused onboarding, this unit has been able to treat this subspecialized population holistically utilizing a multidisciplinary approach to minimize hospital acquired complications and los. in 2014, the neurocritical care society (ncs) published a consensus statement in support of multimodal neuromonitoring, emphasizing the essential need for systems to integrate data in meaningful ways to t barrier to the integration of data from multiple group on neurocritical care informatics was established in 2015; it includes experts from the clinical and research side of neurocritical care and representatives from medical device manufacturers. through an open meeting and continued discussion, a recommendation document "medical device connectivity" was produced. its objective is to provide guidance to medical device manufacturers desiring to design a communication protocol that allows external systems to acquire data from their devices. our research on this project uncovered a high percentage of errors in medical device protocols as well as undocumented characteristics and safety issues. the group developed recommendations for providing robust communications as well as address usability and safety concerns. the document outlines the content that should be transmitted which includes device identification, protocol version identification, patient identifier, events, alarm conditions, system status, data labels, and units. finally, it must be thoroughly documented and validated by the manufacturer. multimodal monitoring (which requires medical device connectivity) reportedly improves quality of care through reduction of errors and increased detection of adverse events. however, widely adopted connectivity are on the horizon. in the meantime, the document created in this project will provide guidance for manufacturers in their communications protocol development. in doing so, they will then further the ncs's recommendations on device connectivity for multimodal monitoring. warfarin-related intracranial hemorrhage (ich) is associated with increased mortality due to higher rates of hematoma expansion. current guidelines recommend rapid anticoagulation reversal using intravenous vitamin k and prothrombin complex concentrate (pcc). previous studies show high prevalence of incomplete anticoagulation reversal with 3-factor pcc. we therefore sought to assess the impact of pcc type in reversing warfarin in ich patients. this was a retrospective study of 89 ich patients (47 traumatic and 42 non-traumatic) with warfarinassociated coagulopathy who were admitted to a level ii trauma center between january 2010 and september 2015 and received at least one dose of 3-factor or 4-factor pcc. post-pcc inr of £1.2 was considered successful inr reversal. multivariable model using logistic regression was performed to assess the impact of pcc type on successful inr reversal after adjusting for age, sex, bmi, and baseline inr. overall, the prevalence of successful inr reversal was 72.2%. there was a higher proportion of patients with successful inr reversal in those who received 4-factor pcc than 3-factor pcc (53.8% vs. 18.4%, respectively, p=0.005). in the multivariable model, 4-factor pcc (or 18.1; 95% ci: 3.1 to 106.5) and baseline inr (or per unit of inr 0.4; 95% ci: 0.19-0.84) were independent predictors of successful inr reversal. the change in inr post-pcc was significantly greater in those who received 4-factor pcc than 3-factor pcc (3.60 ± 4.16 vs. 1.26 ± 1.11 respectively, p<0.0001). 4-factor pcc more reliably reversed warfarin in ich patients compared to 3-factor pcc. cortical spreading depolarizations (csds) as highly active metabolic event commonly occur in patients with intracerebral hemorrhage (ich) and may contribute to secondary brain injury. fever is an independent predictor for unfavorable outcome after ich and may trigger csds. here, we investigated the dynamics of brain-temperature (tbrain) relative to csds and core-temperature (tcore). twenty comatose patients with ich and multimodal electrocorticograpy (ecog) monitoring were prospectively enrolled. a subdural ecog strip was placed adjacent to the evacuated ich. a combined intracranial pressure (icp) and tbrain probe was inserted in the white matter ipsilateral to the ich. monitoring data were averaged to 5-minute-means for longitudinal analysis and to one-hour-means. -burden was defined as % of temperature >38.0° c per 24-hours. data were analyzed using gee-models and are presented as median and interquartile range (iqr). during 3097 hours (173 hours [81-csds occurred in clusters. baseline tcore and tbrain were 37.3°c (36.9-37.8) and 37.4°c (36.7-37.9), respectively. tbrain but not tcore significantly increased 5 minutes preceding the csds by a median of 0.2°c (0.1--0.4]; p<0.001) but not tcore (p=0.34) was higher during clusters compared to episodes of single csds. csds probability was highes or=1.2 per %; tcore: p<0.001; or=1.1 per %) independent of map and icp. csds were triggered during episodes of fever. our data suggest an association between csds and cerebral heat production, especially during clusters. integration of ecog monitoring in trials investigating prophylactic normothermia after ich may help to understand the potential beneficial effect of this intervention. anticoagulation reversal is recommended for patients with intracerebral hemorrhage (ich) on vitamin k antagonists. we propose a window for reversal of vitamin k antagonists, in which ich volume remains below the average growth in a control population on follow up imaging a retrospective review of neuro icu patients at henry ford from 2013-2014 was conducted on patients with the icd9 code for diagnosis of ich. inclusion criteria: brought to ed at onset of symptoms, either not on anticoagulation or were on warfarin with therapeutic inr, and had received pcc administration. fifty eight total patients were identified. patients were approximately matched for gcs on admission, ich w -1cc difference in volume estimation. forty-seven control patients were identified: mean age 67 (44-92), gcs on admission 11 (3-15), sbp 170, ich volume on admission 20.28cc, ich volume on repeat scan 23.94cc, change in ich volume 21.45%, and mean time between initial and stability scans was 1150 minutes. eleven patients on vkas were identified who underwent reversal with 4-factor pcc. mean age 74 (58-88), gcs on admission 11 (3-15), sbp 149, ich volume on admission 31.81cc, ich volume on repeat scan 42.42cc, and time between scans was 630 minutes. average inr on presentation was 4.71. all patients on warfarin patients who had pcc administered before 195 minutes (7) had a mean change in ich volume of 16.95%. patients who had reversal completed after the 195 minutes (4) had a mean change in ich volume of 60.28%. (p value= 0.0032). we propose a potential "recommended reversal time" of less than 200 minutes for vitamin k antagonists in our institution. limitations of study include small sample size. the full outline of unresponsiveness (four score) is a validated scale that provides the essentials of a coma examination by incorporating motor response, eye opening and eye movements, brainstem reflexes, and respiratory pattern. we incorporated the four score into the existing ich score and consecutive patients admitted to our institution from 2009-2012 with spontaneous ich were reviewed. using patient age, hemorrhage location, hemorrhage volume, evidence of intraventricular extension and gcs, the ich score was calculated. the four score was then incorporated into the ich score as a substitution for the gcs (ich-four score). the ability of the two scores to predict mortality at 1 month was then compared. in total, 274 patients met inclusion criteria. the median age was 73 years (iqr 60-82) and 138 (50.4%) were male. overall mortality at one month was 28.8% (n=79). the area under the roc curve was 0.6 (95% ci 1.11-2.08) for the ich score, and 0.6 (95% ci 1.02-1.86) for the ich-four score. for ich scores of 2, 3, 4 and 5, one-month mortality was 18.8%, 29.0%, 44.7% and 66.7%. in the ich-four score model, mortality was 20.6%, 27.8%, 39.6% and 75.0% for scores of 2, 3, 4 and 5, respectively. the ich score and the ich-four score predict 1-month mortality with comparable accuracy. as the four score provides additional clinical information regarding patient status, it may be a reasonable substitute for the gcs into the ich score. depressive symptoms in patients with intracerebral hemorrhage (ich) are common and are associated with worse outcomes. it is not well described how often depressive symptoms are appropriately ascertained and treated in a multicenter cohort, and whether this is a potential target for improving outcomes. we retrieved diagnostic codes from four university health systems across chicago (multicenter cohort). separately, we prospectively screened for depressive symptoms (nih patient reported outcomes measurement information system, promis, t score 60), in patients at one prospectively assessed cohort center at one, three and twelve months after ich onset. we compared detection rates of depressive symptoms between the two samples. diagnostic codes for depressive symptoms up to three months after ich onset were recorded in 132 of 3422 (3.8%) of the multicenter cohort versus 26 of 116 (22.4%) in the prospectively screened cohort (or 7.20, 95% ci 4.5 -11.5, p < 0.0001). results were similar considering depressive symptoms up to 12 months after ich, 140 of 3422 patients in the multicenter (4.0%) versus 36 of 116 prospective patients (31.0%; or 10.55, 95% ci 6.87 -16.2, p < 0.0001). in the multicenter cohort less than 10% of patients months of ich onset. the prevalence of depressive symptoms in survivors of ich is more common than would be suggested treated and ssris may be an under-utilized therapeutic option. vitamin k antagonist (vka)are associated with higher mortality than primary ich. prompt reversal of international normalized ratio (inr) with prothrombin complex concentrate (pcc) may promote hemostasis and decrease hematoma impact of an electronic order set designed to standardize and facilitate more timely reversal of coagulopathy in vka-associated ich. we identified all adults that received pcc for vka-associated ich from june 2012 to march 2015 at ucsf medical center, which included a period before and after an electronic order set became available in 2014. we abstracted baseline demographics and clinical data from electronic medical records. the primary outcome was time from radiographic identification of ich to administration of pcc. secondary outcomes included pcc dosing accuracy based on actual weight and baseline inr as well as time from pcc order to follow-up inr. we identified 31 patients that received pcc for vka-associated ich, including 17 patients before and 14 patients after the order set became available. baseline demographics and clinical features were similar. order set use was associated with a significant decrease in the time from identification of ich on imaging to the administration of pcc (median 45 vs. 83 minutes; p=0.02), more accurate doses delivered (92.9% vs 29.4%; p<0.01), and a shorter time from the pcc order to follow-up inr (median 85 vs 164 minutes, -hospital mortality were similar in the two groups. an electronic order set for administering pcc for vka-associated ich was associated with significantly faster time to pcc administration and increased accuracy in dose administered. andrew naidech, alan a. long, kathryn k. muldoon, rajbeer r. sangha. northwestern medicine, chicago, il, usa. crucial to identify patients. both active contrast extravasation ("spot sign") and lower platelet activity have been associated with hematoma growth. we tested the hypothesis that patients with a spot sign had lower platelet activity. we prospectively identified patients with acute ich, measured platelet activity on admission, routinely obtained ct angiography and graded the presence or absence of a spot sign. we limited the analysis to patients who underwent ct angiography within 12 hours of ich symptom onset. platelet activity was measured with the verifynow-asa (accumetrics, ca). non-normally distributed data were compared with the mann-whitney test, and binary variables with chi-squared or logistic regression. -14.2 years, 51% were women and 73% had a history of hypertension. sixteen (9.6%) had a positive spot sign. a spot sign was associated with lower platelet activity (479 [433 -532] vs. 563 [456 -637] aru, p=0.03, where <=550 aru indicates an aspirin effect). of 16 patients with a spot sign, 13 had platelet activity <=550 aru. platelet activity <=550 aru was associated with increased odds of a spot sign (or 5.7, 95% ci 1.55 -20.7, p=0.009). the presence of a spot sign on ct angiography was associated with lower platelet activity, suggesting a hematoma growth. introduction: clot dissolution is a biochemical process catalyzed by enzymatic proteins, requiring a specific temperature range for optimal function. clear iii, a randomized, double-blinded, placebocontrolled trial tested whether extraventricular drainage (evd) plus intraventricular alteplase improved outcome by removing ivh compared to evd plus saline. methods: retrospective assessment of prospectively collected temperature data q4h over first 7 days post randomization. blinded assessment o functional outcome (mrs4-6). results: median (interquartile range) daily temperature was 37.5 (37.4, 37.6)°c and did not differ between -6 (vs. 0at 30 days [37.42 (37.11, 37.72) vs. 37.20 (36.98, 37 .43), p37.5°c was significantly associated with faster ivh clot lysis rate (spearmans rho 0.12; p=0.006), but despite significantly higher temperatures, patients with mrs4-6 (vs. mrs0-3) had significantly lower average percentage ivh removal at day 30 (51.23±45.77%vs. 63.06±28.72%, p<0.001) and 180 (48.82±51.47% vs. 58.34±31.02%, p=0.008). temperature functional outcome of 1.91 (95%ci:1.45-2.52) and 1.54 (95%ci:1.26-1.90) at 30 and 180 days respectively, and was an independent predictor of poor functional outcome at day 30, but not 180 after adjustment for early infection and other severity predictors. associated with faster clot lysis rate, but also with poor functional outcome. negative associations with of 162 ich patients, 26 patients (16%) had waich and received kcentra. the inr ranges were: 1.4-1.9 in 5 patients (19%), 2.0-3.9 in 17 (65%), 4.0-6.0 in 1 (4%) and >6.0 in 3 patients (12%). within 30 minutes of -minute repeat inr ranges were 1.4-1.5 and 1.0-1.1, respectively. ffp was administered to 1 (20%), 3 (18%), 0 (0%) and 1 (33%) patient in each group for a persistently elevated inr. at 6h post-pcc, inr reversal occurred in 100%, 69% (rest had inr 1.4), 100%, and 67%, respectively. at 24h and one had dic following pcc administration. in this small case series of waich patients, inr correction with kcentra was adequate except for those with inr 1.4prevalence of stroke following craniotomy or craniectomy for spontaneously intracranial hemorrhage intensive care resources, particularly, neuroscience intensive care resources are limited and costly. in most institutions in the country, all intracerebral hemorrhage (ich) patients are admitted to the neuroscience intensive care unit. we sought to identify what criteria will allow us to determine which primary intracerebral hemorrhage patients will not need admission to an intensive care unit (icu). we studied retrospectively 423 patients with primary ich from january 2013 to the end of dec 2015. we reviewed multiple admitting characteristics: demographics, hematoma volume, location of hemorrhage, any brain compression, blood pressure, respiratory status, inr, glasgow coma score (gcs). the reasons for neuroscience intensive care unit admission requirements are the need for mechanical ventilation, hydrocephalus, increased intracranial pressure, low gcs score, hematoma expansion, or the unit, and who did not require any icu care intervention. this group had the following characteristics: supratentorial ich, ich volume 12. we called this criteria the "non-admission criteria for patients with primary intracerebral hemorrhage". 423 patients were identified as primary ich. 69 patients (16.3%) fulfilled the non-admission criteria to the neuro-intensive care unit. of 69 patients 27 patients (39.1%) discharged home, 31 patients to acute rehab facility (44.9%), 10 patients discharged to snf (14.5%), 1 patient died (1.5%); elderly patient with existing dnr comfort care orders. none of the 69 patients had to be readmitted to neuroscience intensive care unit, and none required neurosurgical procedure. we propose that ich patients that fulfill the non-admission criteria do not have to be admitted to an icu and can safely be monitored in a step down unit this represented about 16% of ich patients at our tertiary academic medical center. future prospective studies are required to validate the criteria. joseph r. blunck, justin j. shewmaker. saint lukes hospital / pharmacy, kansas city, mo, usa. current guidelines recommend the use of 4-factor prothrombin complex concentrate (pcc) rather than fresh frozen plasma for reversal of warfarin-related intracranial hemorrhage (wrich). there is no consensus regarding an optimal pcc dosing strategy, but limited data suggest that pcc dosing should be based on weight and international normalized ratio (inr). in november of 2013, our health system implemented a wrich reversal protocol with a 4-factor pcc dosing nomogram that utilized fixed-dose options of 2000, above or below 4. the purpose of this study is to evaluate the effectiveness and safety of this simplified 4-factor pcc dosing protocol. patients given 4-factor pcc for wrich reversal in our health system were retrospectively identified with billing codes. chart review was completed to evaluate the primary endpoint of achieving a post treatment evidence of a venous thromboembolic event, time to goal -hospital mortality. we identified 82 wrich patients from november 2013 through april 2016 that were reversed with our simplified 4-factor pcc dosing protocol. seventy-seven (93.9%) patients achieved a post reversal goal -six (68.3%) patients received a pcc dose equivalent to rounded pi dosing and the mean (sd) dose difference between groups was 2321 (365) units vs. 2256 (528) units, protocol vs. pi dosing, respectively. one patient (1.2%) had a thromboembolic event that occurred 20 days post reversal. a simplified 4-factor pcc dosing protocol is a safe and effective strategy for wrich reversal. -hospital, 1 year and 10 year mortality, and has been influences functional outcomes. we sought to evaluate the association between cci and outcomes in patients with primary intracerebral hemorrhage (ich). patients admitted to our center with primary-ich from 2008-2013 were included. demographic and clinical data were collected. the primary outcome measures were the proportion of patients with discharge mrs (dmrs) of 4-6, death and poor discharge disposition (any disposition other than home or inpatient-rehabilitation). crude and adjusted logistic regression were used to evaluate the association between cci and outcomes. 383 patients were identified. there were 37 (9.7%) patients with a cci of 0 or 1, 242 (63.2%) patients with a cci of 2-5, and 104 (27.2%) with a cci of 6 or greater. while the continuous cci was not significantly associated with a dmrs of 4-6 (or 1.08, 95% ci 0.99-1.19, p=0.09), it was associated with disposition. the odds of poor disposition increased 18% with each increase in cci (or 1.18, 95% ci 1.08-1.28, p=0.0003). the odds of death increases 12% with each point increase in cci (or 1.12, 95% ci 1.02-1.23, p=0.021). after adjusting for baseline ich score, cci remains significantly associated with poor disposition (or 1.13, 95% ci 1.00-1.27, p=0.042), however the association between cci and death was not statistically significant (or 1.05, 95% ci 0.91-1.21, p=0.52). in contrast to previous studies, cci was not associated with poor short-term functional outcome or inhospital mortality in ich patients after adjusting for ich score. however, it was significantly associated with poor discharge disposition. this suggests that cumulative comorbidities only predict disposition in ich, because the ich score strongly impacts poor functional outcome and in-hospital mortality. accurate assessment of renal function remains a unique challenge in patients with intracerebral hemorrhage (ich). mathematical estimates of creatinine clearance (crcl) routinely used are often inaccurate in this setting. subsets of critically ill patients have been shown to exhibit a hyperdynamic response leading to an enhanced renal clearance. no studies exist evaluating the directly measured creatinine clearance of patients with ich. this was a single-center prospective observational study of adult patients with ich admitted to the nsicu between january 2015 and july 2015. eight-hour urinary creatinine clearances were performed daily to directly measure crcl until the patient no longer had a foley catheter or the patient left the nsicu. urinary -gault equation. statistical significance was defined as p-value < 0.05. thirty patients with ich were enrolled in the study. the study sample was 60% male with a mean age of 70±13.7 years. the median admission ich score was 3 (iqr 2 -4) with a mean ich volume of 64±64.1 ml. the median admission gcs was 7.5 (iqr 5 -13) and median admission sofa score was 4.5 (iqr 2 -additionally, the mean urinary crcl was significantly higher than the estimated crcl each individual study patients with ich consistently experienced urinary crcl greater than estimated crcl predicted based on -gault equation. as renally eliminated medications are routinely dosed based on mathematical estimates of renal function, further study is needed to optimize medication regimens in this patient population to prevent underexposure. the cognitive reserve hypothesis suggests that variations in patient pre-morbid status such as education, occupation and brain morphology influence outcome. this has been extensively validated in patients with alzheimer's disease. an important component of cognitive reserve is brain morphology, which can be quantified with measures such as whole brain-or gray matter volume. this study examines use of novel measures of brain morphology to measure cognitive reserve in patients with sdh. 56 patients with ct-documented sdh were screened. we identified patients who had a clinically indicated post-morbid mri, telephone interview for cognitive status (tics) and barthel index (bi) at discharge and follow-up. mri was used to measure several volumes such as whole brain-, gray matter-, left vs right caudate-, hippocampal and intraventricular csf volume using a freesurfer pipeline. primary outcome measures were tics at 3 and bi at 12 months results: -up. regional -213) (sd), ----9 at discharge and 3 -8.3 at follow-up (3--6.4) at 12 mo. we found a positive correlation between intraventricular csf volume and bi at 12mo (r = 0.77, p=0.04). there was also a significant correlation between left caudate volume and bi at 12months. brain morphology did not correlate with tics outcome at 3 months. quantitative imaging can be used to predict functional outcomes in patients with intracranial hemorrhages. as we continue enrollment we hope to generate meaningful no and brain tumors. christian hernandez, vivien v. lee, bichun b. ouyang, torrey t. birch. rush university medical center/department of neurological sciences, chicago, il, usa. it remains unclear which patients with intracerebral hemorrhage (ich) benefit from surgical hematoma evacuation, and the patient factors associated with the decision to pursue surgical intervention are largely early surgical intervention for ich and to investigate if an age bias exists at our institution. one hundred and twenty consecutive patients who were admitted to the neurosciences intensive care unit with primary ich between april 2010 and january 2012 were retrospectively reviewed. multivariate regression analysis was used to analyze if select patient factors were associated with the decision to pursue early surgical intervention. in total 120 patients were analyzed; 60 patients (50%) were female (mean age 65.6 ± 13.3), 104 patients (87%) had supratentorial ich, and 17 patients (14%) underwent hematoma evacuation. in univariate analysis age, race, and gender were not significantly a intervention. the only factors associated with hematoma evacuation were gcs score and ich volume. after controlling for significant variables, multivariate analysis showed that the only factor associated with surgical intervention was ich volume (or 24.74, p=0.0002) . surgical intervention did not affect discharge disposition (p=0.31), but was associated with a longer length of stay (14 vs 6 days, p=0.001). in this analysis, ich volume was the only predictor of hematoma evacuation in patients with primary ich. age and sex did not influence patient selection for surgical intervention. surgical treatment did not affect patient disposition at discharge, but was associated with longer hospitalizations. further investigation is needed to determine which patients with ich benefit most from early hematoma evacuation. studied. we investigate factors associated with admission systolic blood pressure (sbp), including hemorrhagic transformation (ht) and discharge outcome. this is a retrospective study of consecutive ais patients presenting from april 2014 to march 2015. demographic and clinical data were collected. admission sbp was divided into three tiers: 165. the primary outcome measure was in-hospital mortality. seven hundred seventy six patients were included (meanwere 287 patients with sbp>165 (40.0%), 251 with sbp 140-165 (32.3%), and 238 with sbp165 were ry of hypertension (87.1%; p165. premorbid use of antihypertensives did not differ among the three groups. there were no differences in proportion of ht (15.7% vs. 18.7% vs.12.6%; p=0.1462). although patients treated with iv-tpa were evenly distributed among tiers (14.4% vs. 13.6% vs. 15.7%), more patients with sbp165 had mrs 3-6 (p=0.0382). compared to sbp165 was associated with lower odds of in-hospital mortality (or 0.536, 95%ci=0.295-0.975, p=0.041). this remained significant after adjusting for age and nihss (or 0.431, 95%ci 0.193-0.962, p=0.0399). normal presenting sbp (<140) in patients with ais was associated with worse discharge functionaloutcome and higher in-hospital mortality. these differences may be related to other associated medical conditions such as pre-existing heart failure. further research is needed to define the ideal range to maintain sbp after ais. between april 2009 and february 2011, 237 patients with non-traumatic, non-aneurysmal and nonmalignant parenchymal cerebral icb were identified. the associations of nihss at presentation (nihssp), nihss at 48 hours (nihssd2), size of icb, comorbidities, and infection with los were investigated retrospectively. the mean age for the 237 patients was 68.7±13.8 years and 52% were male while most patients were white (68%). the most prevalent comorbidity was hypertension (83% nihssd2 is a useful measure of los and should be collected for patients with icb. nihssd2 at upper teens present most challenges to discharge and should be the aggressive focus for discharge planners. incidence of infection and ventilator need is high in this population, adding to the challenges. although oral factor xa inhibitors (fxai), used for the prevention and treatment of venous racranial hemorrhage (ich) than warfarin in clinical studies, intracranial bleeding is still associated with high morbidity and mortality. moreover, there are no specific guidelines for managing these bleeds other than empirical institution-based hemorrhage protocols. there is a need to understand the real-world management, outcomes, and resource utilization of fxai-associated major bleeding in order to potentially improve morbidity and mortality in these patients. five us medical centers participated in a retrospective study of patients admitted to the hospital with lifethreatening bleeding on or after january 2014 while on apixaban, rivaroxaban, or low molecular weight heparin (lmwh). baseline characteristics, treatment patterns, outcomes, and resource utilization were assessed. ich patients were reviewed and are reported specifically. this interim report includes 33 major bleed patients, including 8 ich. the majority of ich were hypertensive [7(88%)], 3(38%) were on concomitant anti-platelet with fxai, 2(25%) were diabetic and 2 e ich was spontaneous (57%) and trauma (43%). in the management of ich bleeding, 50% of patients received clotting factors (e.g. pcc), whereas 25% received interventions (e.g. radiological embolization). within 30 days of discharge, 5 (63%) died, 4 of which occurred during the admission. for the 3 patients who did not die, length of hospitalization was 3.5(3.1-47.0) days, with only 1 discharged patient restarting on an anticoagulant. this study provides a real-world picture of patients receiving fxais or lmwh, experiencing lifethreatening intracranial bleeds. despite efforts to restore hemostasis, mortality remains high and substantial healthcare resources are expended. this highlights the need to develop specific strategies for managemen prophylactic seizure medications are not recommended by guidelines for patients with intracerebral hemorrhage, yet are prescribed to nearly 40% of them. there are few data on disparities in their use. we tested the hypothesis that there are differences in the administration of seizure medication, specifically we electronically retrieved information from patients who were diagnosed with intracerebral hemorrhage from healthlnk, a multi-center electronic repository in chicago, il, from 2006-2012 ("multicenter cohort"). from 2007 through 2015, we prospectively identified patients with intracerebral hemorrhage at one site ("prospective cohort"). there were 3,422 patients in the multicenter cohort from four sites. the use of levetiracetam varied with -americans (or 1.71, 95% ci 1.43 -2.05, p<0.0001). in the prospective cohort (n=450), hematoma location, older age, depressed consciousness, larger hematoma volume and no alcohol abuse were -americans to receive levetiracetam (or 1.9, 95% ci 1.25 -2.89, p=0.002). african-americans were more location was independently associated with levetiracetam administration (p<0.00001) disparities in the use of levetiracetam and they are confounded by hematoma location, a datapoint not typically available in administrative datasets. deviation from guidelines for the use of seizure medications is common and rational, and any impact on outcomes is uncertain greater gains in late recovery for intracerebral hemorrhage patients with more debilitating initial injury. multiple intracerebral hemorrhage (ich) studies have examined differences between discharge and 3month outcome. however, few studies have examined late recovery specifically between 3-and 12month endpoints. the aim of this study was to identify potential factors predicting late recovery in ich patients. twenty-four patients diagnosed with primary ich at yale-new haven hospital were prospectively enrolled between july 1, 2014 and july 1, 2016. outcomes were assessed using barthel index (bi) at discharge, 3 months, and 12 months. repeated-measures regression analysis was conducted using age, admission glasgow coma scale (gcs), ich volume, intraventricular extension, and ich location, to compare outcomes at discharge, 3 months, and 12 months. there was a significant improvement across time points (p = 0.005), with follow-up testing showing improvement between discharge and 3 months (p < 0.001), discharge and 12 months (p = 0.036), and 3 months and 12 months (p = 0.021). regression testing resulted in a significant relationship of time (p = 0.002), time x gcs (p = 0.003), time x ich volume (p < 0.001), time x ich location (p < 0.001). plots show increased late recovery (i.e., between 3 and 12 months) for patients with lower gcs scores, larger ich volume, and deep ich location. patients with more devastating initial ichs show greater gains in late recovery between 3 and 12 months. these results suggest initial disability at 3 months may not represent overall recovery and support continual follow-up out to one year. while extensive studies have examined the outcomes of intracerebral hemorrhage (ich) patients under the age of 80, few studies have examined outcomes in an elderly cohort (>80 years). the aim of this case-control study was to determine the independent effects of age on outcome after ich. nineteen ich patients prospectively identified at yale-new haven hospital above the age of 80 were matched against 19 patients below age 80, based on ich location (lobar, deep, cerebellar, brainstem), ich volume (> 30cc), presence of intraventricular hemorrhage (ivh), and admission gcs (0-4, 5-12, 13-15). the matched groups were compared via univariate analysis to examine differences in morbidity while there was no difference in pre-ich disability (mrs > 1; p > 0.05), at 3 months elderly patients exhibited higher morbidity (mrs > 3, p = 0.023). despite these differences, there were no differences in overall mortality between groups at discharge or at 3 months and no differences between barthel index at 3 months. despite greater morbidity as defined by mrs, elderly patients with ich do not significantly differ from younger patients in mortality rates or ability to perform activities of daily living at discharge and 3 months. these results may warrant further studies to provide more accurate prognostication after ich in elderly populations. hypertension after intracerebral hemorrhage (ich) is associated with hematoma expansion, morbidity and mortality. there are currently no recommendations to standardize the critical care approach to acute blood pressure (bp) management in ich. we performed a large retrospective cohort study to examine practice variability in bp management in acute ich. care center using local get with the guidelines data. we abstracted time-stamped clinical variables including all documented bp measurements, and medications administered, as well as hematoma location from the electronic medical record. all acute ich patients are admitted to the neuroicu and comanaged by neuro-intensivists and vascular neurologists. we used descriptive statistics to summarize overall population and treatment characteristics. -14) years, and 47% were female. and 1% other. electronic medical record data were available in 497 subjects, of which 303 (61%) received continuous infusion for bp control within 72 hours of admission (56% nicardipine, 9% clevidipine). a systolic bp goal was charted in 283 (57%) and ranged from 120 to 220mmhg. these goals were modified in 72% during the same admission (64% increased, 8% decreased). overall, 48 unique oral antihypertensives were administered (31% received a beta-an ace inhibitor, and 11% a diuretic). hypertension requiring continuous antihypertensive infusion is common after ich. there is high practice variability in bp targets and choice of antihypertensive medications. a prospective study of a systematic and protocolized approach to antihypertensive medication use in ich is necessary to determine if reducing practice variability improves outcomes. intracranial hemorrhage (ich) has long been thought to be a devastating consequence in the setting of end-stage liver disease. due to its association with abnormal coagulation, the prognosis is thought to be poor, and frequently leads to withdrawal of care. our aim with this study was to assess the true overall mortality rate of ich in end-stage liver disease and compare it to mortality of ich in the general population. all patients > 18 years of age admitted to mayo clinic from 2005 to 2015 with a subsequent diagnosis of non-traumatic ich and end-stage liver disease were identified. patients presenting with primary epidural, subdural, intraventricular, or subarachnoid hemorrhage were excluded. using actuarial methods, 7 day, 30 day, and 1 year mortality rates were calculated. 112 patients with simultaneous diagnosis of ich and end-stage liver disease were identified. 46 of the patients were female (41%) and 66 patients were male (58%). the mean age at diagnosis was 62 years. the mean systolic blood pressure in the mortality cohort was 162 mmhg, compared to 160 mmhg in the survival cohort. the 7 day, 30 day, and 1 year mortality rates were 23%, 32%, and 49% respectively. ich associated mortality in end-stage liver disease does not significantly differ when compared to ich mortality in the general population. the mean systolic blood pressure at presentation did not specifically correlate with an increased incidence of ich associated mortality. these findings are important in the practice of neurocritical care, confirming that poor prognostication and expedited withdrawal of care should be reconsidered. future directions will include mortality adjusted by hemorrhage location, size, and presence of intraventricular extension. kcentra® (human prothrombin complex concentrate) is the first fda-approved non-activated 4-factor prothrombin complex concentrate for the urgent reversal of vitamin k antagonist agents in adults with acute major bleeding. the recommended dosing is based upon the units of factor ix, which can vary within each vial (range from 20vial size to reduce waste and some based upon the exact factor ix content. this variation in dosing may be associated with complications in care and has never been evaluated. underdosing of the medication can lead to suboptimal response and overdosing the medication can cause thromboembolic events. the purpose of this observational trial is to assess the current prescribing practices of kcentra® in neurocritical care unit patients across the united states and evaluate the impact on patient response and safety. additionally we plan to characterize current approaches to repeat dosing. this was a retrospective observational study of adult patients across 39 centers who received kcentra for reversal of warfarin-related bleeding between january 1, 2014 and december 31, 2015. descriptive statistics and tests for comparison will be utilized to evaluate differences in dosing, outcome, and the occurrence of adverse events. statistical significance will be defined as p-value < 0.05. data collection is ongoing but the full results will be presented during the meeting. result of this study will document the real-world use of kcentra® in patients with severe life threatening bleeding and assess the impact of variations in prescribing practices on patient responses. there is a paucity of data regarding this topic and combining data from multiple neurocritical care units will be timely in identify optimal dosing strategies. perihematomal edema (phe) associated with intracerebral hemorrhage (ich) has been suggested to have an impact on both mortality and functional outcomes in spontaneous, supratentorial ich. there have been no studies examining the impact of phe in infratentorial hemorrhage. the aim of this study was to evaluate the impact of absolute phe volume as well as phe expansion rate in cerebellar hemorrhages at the time of discharge and at 3 months. 9 patients diagnosed with primary cerebellar ich at yale new haven hospital were prospectively enrolled between july 1, 2014 and july 1, 2016. patients were evaluated using mrs and bi at discharge and 3 months. ich and edema volumes on ct were measured using a semi-automated threshold based approach and phe expansion rate was the difference between initial and follow-up phe volumes divided scale (gcs), ich volume, intraventricular (ivh) volume, edema (phe), and phe expansion rate from baseline to first follow up ct scan before decompression (6h window). at discharge, patients with higher morbidity (mrs > 3) exhibited higher ich volume (p = 0.012) and phe volume (p = 0.005) on admission ct and a trend for greater rates of phe expansion (p = 0.086). these differences were not significant at 3 months and when adjusted for ich volume. plots suggest an association between higher phe rate and lower bi scores at 3 months. phe may have a clinically significant impact in patients with cerebellar ich at time of discharge, but these results are limited by a small sample size. these results warrant further studies and suggest therapies to ameliorate edema may be a treatment option for cerebellar ich. yahia thrombolysis and adjunctive stent retriever thrombectomy (srt) is associated with better perfusion and outcomes. despite benefit, 39% to 68% of patients had poor outcomes. thrombectomy in ais with lao within 3 hours is performed as secondary after iv thrombolysis, which may be associated with delay. the purpose of our study is to evaluate the safety, feasibility, recanalization rate and outcome of primary str within 3 hours without intravenous thrombolytic in ais from lao. srt as an alternative to iv rtpa. consecutive patients who underwent primary srt for lao within 3 18 patients with lao; mean age 62.83±15.32 years and mean nihss 16±4; chose primary srt after informed consent. near complete (tici2b in 1) complete (tici3 in 17) was observed in all (100%) patients. recanalization from symptoms and groin puncture was 188.5±82.7 and 64.61±40.14 minutes respectively. immediate post-thrombectomy, 24 hour and 30 day nihss score was 4.44±3.75, 1.9±3.2 and 0.28±0.9 respectively. asymptomatic perfusion related hemorrhage developed in 4 patients (22%). 90 days outcomes; mrs0 50%, mrs1 44.4%, and mrs2 5.6%. our study demonstrates that primary srt in ais from lao occlusion is not only safe and feasible, but associated with complete recanalization and good outcome. further study is required. currently, no reliable predictive tools are available to determine which patients with a large hemispheric infarction (lhi) will progress to cerebral herniation (ch). we sought to determine whether continuous measurements of blood pressure variance (bpv), heart rate variance (hrv), and entropy within 3 hours of admission would enhance the ability to predict future ch in lhi patients. patients presenting within 24 hours of onset from an internal carotid artery (ica) or middle cerebral artery 2013 and november 2015. patients with ch were matched 1:1 by age and nihss with patients who did not have ch. shannon entropy and standard deviation were used to measure the instability of hr and between groups. a model predicting ch utilizing the admission factors of age, gender, nihss, intraarterial (ia) therapy, and thrombolysis was compared to an admission model enhanced with bpv, hrv and entropy 3 hours after admission. data from 40 patients were analyzed (median age 60 years old, median nihss 19, 43% women). there were no differences in the proportion of patients with a left hemisphere syndrome (45%), undergoing ia therapy (25%) or thrombolysis (43%) between groups. ch was observed a median of 3 days after the ictus. at 3 hours after admission, median measures of bpv, hrv and entropy were significantly higher in the ch group (p<0.001). a model of admission factors enhanced with physiologic data was better able to predict ch than a model with admission factors alone (roc:0.77 v. 0.63, p=0.04) poster 88 early recognition of which patients with large hemispheric infarction (lhi) will develop malignant cerebral however, the early time-course of edema has not been adequately studied. we applied volumetric in the first 24 hours, prior to development of midline shift (mls). we identified 38 lhi patients with scans within six hours of onset and subsequent scans early (6 while all 6 recently published endovascular stent-retriever randomized clinical trials (rcts) were positive, their designs differed considerably particularly with regard to the extent of intravenous rt-pa use prior to thrombectomy. here, we assessed whether rtwe adapted a method previously published by us to develop a pooled outcome model relating percent utilization of rt-presenting > 11,000 subjects and a range of 0-100% utilization of rt-pa. we correlated percent rt-pa and baseline -2) and mortality. this model includes ± p<.05 statistical interval surfaces to assess whether a trial's outcomes surpasses the variability of the pooled sample (neurology 85:274-83, 2015) . stent retriever rcts were compared against the model. the mrs model showed excellent fit: r-square=0.83, p<0.001. each stent retriever trial's outcomes exceeded mrs 0improvement varied dramatically according to %rt-pa, with the greatest improvement in those with 100% rt-pa use. when we included all case series and testing their outcomes at their baseline nihss and percent rt-pa use, shortest overall treatment times also related to improved outcomes (p=.011). mortality trends were similar in that lowest mortality was seen in those trials with highest rt-pa use and the trial with higher than expected mortality had the lowest rt-pa use. an outcome model including % iv rt-pa permitted analysis of stent-retriever therapy compared to a large sample. best outcomes were related to higher rt-pa utilization and shorter treatment times, suggesting a strong treatment interaction between modalities. based on these results, until studied prospectively, iv rt-pa, if administered rapidly, should not be bypassed prior to thrombectomy. intra-arterial mechanical thrombectomy (iamt) is currently considered the standard therapy for acute thrombectomies performed under general anesthesia (ga) may adversely affect functional outcomes. we report our experiences with iamt performed routinely under ga at the montreal neurological hospital (mnh). this is a retrospective analysis of adult patients admitted to the mnh from january 2015 to april 2016 with ais from proximal intracranial occlusions of the anterior cerebral circulation. all patients were assessed both clinically and radiologically. forty-two patients underwent iamt for ais. twenty-eight patients were included for analyses (4 had procedures under conscious sedation, 10 had missing 3 months assessment). clinical outcomes were (mrs) 3outcomes (mrs 0--good and poor outcome groups respectively. sixty-eight percent of the good outcome group received iv tpa, as compared to 50% in the poor outcome group. patients in the good outcome group were also more 58% in the poor outcome group]. intraprocedural map drops below 60 mmhg observed in 3 patients in the good outcome group versus non in the poor outcome group. in our small retrospective single centre study about thrombectomy for ais under ga, our 3-month outcomes are comparable to larger studies where thrombectomies were done under conscious sedation. pending the results of ongoing prospective trials about the use of ga during iamt for ais, our results do not support the reservations derived from recently published retrospective data on the use of ga in this context. conservative initial management of young adults with severe hemispheric stroke in a comprehensive stroke center reduces decompressive craniectomy rates pooled european trial results of early decompressive craniectomy (dc) did not require radiographic mass effect at the time of dc. early surgery for supratentorial cerebral hemorrhage does not improve recovery or survival compared to initial conservative medical management. early vs delayed dc for hemispheric a prospective inpatient neurosurgical database from october 2007 to march 2015 was queried for neurocritical care admissions for hemispheric -60 under irb approval. a retrospective chart review was conducted using a structured questionnaire using the electronic medical record. we identified 30 patients who met the inclusion criteria for the pool were managed with medical treatment only (mto) with average maximal septal shift of 5.2 mm and pineal shift of 3.1 mm. twelve patients (40%) underwent dc with average maximal septal shift of 6.8 mm and group, mto, and dc were respectively: mr 0-3 60% vs 67% vs 50%; mr 4-5 27% vs 17% vs 42%, and death 13% vs 17% vs 8%. four patients in the mto group declined dc; 3 died and one survived with mr of 4. no patients developed brainstem herniation prior to referral for decompressive craniectomy. surgical complications death or survival with severe disabilities. time of recanalization since symptoms is a strong predictor of outcome in patients who underwent stent retriever thrombectomy from middle cerebral artery occlusion. 3 hours since symptoms have not been clearly investigated especially, those with large artery occlusion (lao) and underwent stent retriever thrombectomy (srt) . objective: to identify the predictors of outcome in ais patients from middle cerebral artery (mca) occlusion with large clot burden (lcb >8 mm) and underwent srt, who recanalize less than 3 hours versus more than 3 hours since symptoms. software was used to analyze the data. 21 ais patients who underwent srt in mca; age 70.62±13.94 years and mean admission nihss 17±5. complete (tici3) and partial (tici2b) recanalization was observed in 90.50% and 9.50% respectively onset was 230±160 minutes. presenting nihss of 16.76 dropped to 7, 5 and 2 at immediate, 24 hours and 30 days post srt respectively. good univariate analysis, recanalization time, immediate and 24 hours post srt nihss were predictors of outcome (p-value= 0.0039, 0.003 and 0.043 respectively). in multivariate analysis, time of recanalization since symptoms (p-value=0.01) and baseline mrs (p-value=0.01) continued to be the predictors of good outcome. our study demonstrates that patients with lao from mca who recanalize less than 3 hours of symptoms onset have good chance of good outcome compared to those who recanilize more than 3 hours. therefore, all ais patients with lao should offer early srt to achieve a good functional outcome. further studies are required. jennifer a. frontera. neurological institute, cleveland clinic, cleveland, oh, usa. prospectively collected data of heartmate ii (n=332) and heartware (n=70) lvad patients from a single blood stream infection [bsi]), specific pathogens mann-whitney u, chi--wise logistic regression analyses. of 402 patients, lvad infection occurred in 158 (39%) including: bsi in 107 (27%), wound infection in 31 infect p<0.05). driveline and wound infection were not a -4.5, associated with bsi (aor 2.6, 95%ci 1.3-5.1, p=0.005). there was no association with any specific infectious pathogen. precautions to mitigate i demonstrate a causal relationship. the frequency of dysphagia is greater than 50%. the early clinical evaluation of swallowing disorders can help define approaches and avoid oral feeding, which may be detrimental to the patient. the aim of this study was to identify predictive clinical factors associated with enteral tube feeding in acute ischemic our database were reviewed. clinical early ct score (asp association. of the 326 patients, 84 used enteral feeding tubes (25.8%). the mean age (70.2 years -sd 13.1), mean gcs (12.7 -sd 2.1), mean nihss (12.6 -sd 5.6), and aspect score (8.8 -sd 1.8) were significantly higher in the tube group. logistic regression showed that only age (odds ratio [or], 1.03; 95% confidence interval [ci], 1.00-1.6. p=0,025), nihss score (or, 1.15; 95% ci, 1.05-1.25, p= 0,001) and nihss 10 (dysarthria) subscore (or, 2.2; 95% ci, 1.2-4.05, p=0,011) were independent predictors of enteral tube feeding. a 3in conclusion, combining information about age, nihss, nihss 10 subscore, may be a useful predictor kyushu university, fukuoka, japan. tissue plasminogen activator (te designed and developed an information and communication ipads, pcs, and bigdepartments before the patient's arriva number of calls is reduced. we compared the number of times that emergency room (er) nurses called for computed tomography (ct) or magnetic resonance imaging (mri) between before and after the system introduction. before this system, er nurses called for ct or mri an average 3.8 and 4.2 times, respectively; after system introduction, the average number of times decreased to 1.2 and 1.8, respectively. therefore, this system -pa. also, it automatically records the transitions between could improve treatment times for iv tclinical trial to confirm the tool's efficacy. an important and controversial issue of peri-(est) is the management of sedation and airway. according to retrospective data the widely favored intubation and general anesthesia (ga) appears associated with worse functional outcome compared to "conscious sedation" (gs) in the non-intubated state. siesta is a prospective, monocentric, outcome assessor-blinded, 1:1 randomized, parallel-group interventional study comparing non-intubated vs. intubated patients receiving est for acute ischemic endpoint is the improvement of the national institute of health s enrolment of the intended 150 patients has been completed. sixty of the recruited patients are female these patients, 64% received pre-procedural rtpa. seventy-eight patients were randomized to cs, 11 (14%) of these had to be converted to ga during the procedure. we will present preliminary results of the study, including the primary endpoint improvement in nihss after 24 hours and selected secondary endpoints. the aim of this study is the prospective randomized investigation of potential advantages of the nonin young chung. departments of neurology1, seoul national university bundang hospital, seongnam, korea, republic of. cerebral edema during therapeutic hypothermia us hypothermia. the authors retrospectively reviewed 21 patients with large hemispheric infarction who were treated with therapeutic hypothermia and hyperosmolar therapy from 2011 to 2014. patients who were dead or underwent hemicraniectomy was defined as failure of therapeutic hypothermia. infarction size was measured as sum of restricted area in diffusion weighted imaging which were performed on admission. b -ct was carried out regularly after onset of therapeutic hypothermia. shift of septum pellucidum, pineal gland and choroid plexus calcification were measured in b-ct. seventeen patients were enrolled after exclusion of 4 patients whose b-ct was inadequate to evaluate. ten patients were successfully treated with therapeutic hypothermia (group success, n=10). six patients were dead and 1 patient had hemicraniectomy (group failure, n=7). initial infarction size between two groups was not significantly different. both septum pellucidum shift (sds) and pineal gland shift (pgs) were significantly different in groups on 2.5±0.5 days after onset of therapeutic hypothermia (mean sds 5.0 vs. 14.9mm ; mean pgs 2.3 vs. 7.9mm). specificity and positive predictive values for the failure calcification shift was not significantly different in groups during therapeutic hypothermia. degree of progression of cerebral edema on 2.5±0.5 days after onset of therapeutic hypothermia helps to excellent in predicting fatal outcome. the main limitation of this study include its retrospective singlecenter nature, which may limit generalizablility of the study. aminocaproic acid for reversal of tissue plasminogen activator (tpa) related hemorrhagic transformation in acute ischemic stroke. -thrombolytic ich. aminocaproic acid (aca) inhibits binding of plasminogen to fibrin, hence inhibiting fibrinolytic property of tpa. there is limited report a case series of aca use for reversal of post-tpa ht. we reviewed the and identified patients treated with iv tpa. patients with post-tpa ht who received iv aca were identified. data on demographics, clinical characteristics, nihss, ich score, new thrombotic events during hospitalization, and hospital and intensive care unit (icu) length of stay (los) were collected. a total of 36 patients developed post-tpa ich, 12 of which received aca. 58% of patients were male, mean age of 70.5±9.8 years. patients received tpa within a mean time of 153±43 minutes from symptom onset, pre-tpa mean nihss was 11.6 ±5.7. mean time for ht after tpa administration was 2.6±0.7 hours, with a hematoma volume of 45.5±58.3 mm3. in addition to aca, 92% received cryoprecipitate, 67% platelets, and 17% fresh frozen plasma transfusions. 50% of patients had no hematoma expansion and 33% developed a new thrombotic event. mean hospital los was 18±15 days and mean icu los was 14±9 days. at the time of discharge 25% had an mrs of 4, 33% mrs 5 and 42% mrs 6. in this retrospective case series 50% of patients had hematoma expansion despite receiving aca, while 33% had a new thrombotic event. further research is warranted to determine the utility of aca for the treatment of post-tpa ht. large vessel occlusion (lvo). while studies have analyzed difference in blood clot constructs, limited data is available understanding the effect of prior anti-platelet use on endovascular therapy (evt) for ias patients with lvo in the middle cerebral artery (mca). we aimed to determine if prior anti-platelet use had effect on evt procedure time, recanalization rate, and functional outcome measured by the modified a retrospective chart review was conducted of 63 consecutive ais patients who underwent evt of lvo of mca at the university of kansas medical center from 2008-2014. outcomes were measured using total procedural and fluoroscopy time, procedural recanalization score using the modified thrombolysis in cerebral infarction score (tici), time to recanalization, incidence of sich, and 3-month mrs. univariable and multivariable analysis were performed. .05 for all) were similar between antiplatelet use versus those without. in separate multivariable models (adjusting for all significant variables), antiplatelet use was not associated with tandem ica occlusion, total procedure time, fluoroscopy time, good recanalization, or 3-month mrs. no impact was found of prior antioutcomes in ais patients undergoing evt. these findings should be further confirmed in a larger database and prospective cohort study. the study evaluated the effect of a neurology-specific heparin infusion protocol with more frequent ptt monitoring and a narrower goal ptt range (1.5x normal) on rate of hemorrhagic or thromboembolic events. this is a retrospective cohort study evaluating patients before (october 2011-september 2013) and after (october 2013-september 2014) implementation of a neurology-specific heparin infusion protocol. all patients >18 years old receiving intravenous heparin with a diagnosis of acute ischemic st evaluated for inclusion. primary outcomes are time to first therapeutic ptt and time to therapeutic ptt range. secondary outcomes include rate of intracranial hemorrhage, rate of thromboembolic events, protocol compliance, number of subtherapeutic and supratherapeutic ptt values, time to initiation of oral anticoagulation, duration of heparin infusion, and number of heparin titrations. time to therapeutic ptt range was 18.7 hours in the pre-protocol group (n=108) and 17.9 hours in the post-protocol group (n=22) (p=0.049). number of ptt values per patient was 20.2 in the pre-protocol group and 33.8 in the post-protocol group, of which 27.5% and 44.4% were therapeutic, respectively. percentage of supratherapeutic ptt values was 22.2% and 16%, respectively (p=0.025). time to first ptt, time to first therapeutic ptt, and percentage of subtherapeutic ptt values were not significantly different. assessment of secondary clinical outcomes is ongoing. our neurology-specific heparin protocol resulted in a faster time to therapeutic ptt range with a higher percentage of therapeutic ptt values and fewer supratherapeutic ptt values. investigation regarding change in incidence of hemorrhagic and thromboembolic complications is ongoing. hospital moyses deutsch, in the southern city of são paulo is indicated for the use of rtpa intravenously ctive to demonstrate experience the use of intravenous retrospective study, in all cases of isch 2011 to february 2016. protocol indicates the use of alteplase patients with inclusion criteria, the period between the onset of symptoms and hospital admission up to 4.5 hours and no contraindication to the use of thrombolytics, nihss calculated on admission and 24 hours after thrombolysis. computed tomography (ct) on admission and after 24 hours.evaluation required by neurological telemedicine hospital israelita albert einstein shortly after the conclusion of the tc cranio. trough has been triggered in 51 cases. time between onset of symptoms and drug administration, 19 patients less than 90 minutes, 37 patients between 90 and 180 minutes, 8 patients 180-360 minutes .the average nihss at admission was 18, with 42 patients showed a reduction of 5 or more the points nihss score within the first 24 hours. 8 patient non-symptomatic intracranial hemorrhage and 6 symptomatic intracranial hemorrhage and 9 deaths during the period. all patients receiving alteplase in the recommended time interval and underwent ct cranio control. some cases were not triggered by the evaluation of neurology telemedicine. there was improvement in nihss score similar percentage observed in reference studies. the protocol implementation has been adequate excellent support of telemdicina neurology team. good profitability of time and therapeutic efficacy. the mortality that correlated with the severity of patients and the nihss admission. this data ratifies the intracerebral hemorrhage (ich) is approximately 6% and non-ich bleeding over 5%. hypofibrinogenemia occurs in approximately 5% of tpa-treated patients and i cryoprecipitate is often used to restore fibrinogen levels, despite limited published evidence. cryoprecipitate has several limitations, including the need for abo matching, thawing, and concerns regarding potential transmission of viral pathogens. riastap, a purified fibrinogen concentrate, is a promising alternative to cryoprecipitate for the reversal of hemorrhage post-tpa. the objective of this study was to evaluate the safety and efficacy of riastap for the treatment of post-tpa hemorrhage. a single-center retrospective observational analysis was conducted to evaluate patients who received riastap for the treatment of postmeasure was reversal of hypofibrinogenemia. hypofibrinogenemia was defined as a fibrinogen level < hospital mortality. eleven patients were included in our analysis. the average dose of riastap administered was 3,443 units. five patients had hypofibrinogenemia prior to riastap administration, with a mean fibrinogen level (iqr 123 to 150). the six patients who were not hypofibrinogenemic at baseline had minimal effect on fibrinogen levels post--14.8 to 57). one patient was diagnosed with a deep vein thrombosis 10 days post-riastap administration and no infusion reactions were reported. in-hospital mortality occurred in 45.5% of our patient population. riastap administration successfully and safely treated hypofibrinogenemia in patients with post-tpa hemorrhage. casey catheter-associated urinary tract infections (cauti) are the most prevalent hospital-acquired infections (hai), and account for more than 560,000 cases annually and 13,000 deaths per year. cauti is the most common hai in neuroscience intensive care units ( immobility and urinary retention. we implemented a team-driven multimodal quality improvement initiative to reduce cauti and catheter-utilization rates in the nsicu. we convened a multidisciplinary cauti prevention team including nurses, advance practice providers, physicians, and infection control specialists. we developed a cauti surveillance program that involved review cauti and catheter utilization rates. we applied root cause analysis to target improvement opportunities, and implemented interventions including best-practice catheter insertion techniques, modification of bowel regimen, and guidelines for timing of catheter removal. we also implemented a daily goals tool to prompt standardized team communication surrounding catheter removal on morning interdisciplinary rounds. we performed poisson generalized linear model analyses, controlling for linear time trends and testing with sandwich errors. we analyzed data before and after implementation of interventions, spanning a time period of 28 months. --0.58), as did mean catheter days per --33.2). we observed a 68% reduction in cauti rate adjusted by catheter days (95% ci 6%, 89%), p = 0.035. there was an 11% reduction in catheter utilization rate adjusted by patient days (95% ci 3%, 19%), p = 0.011. a team-driven multimodal approach to cauti reduction resulted in significant decreases in cauti and catheter utilization rates in the nsicu. team-driven interventions enhance communication and shared -up is ongoing to evaluate sustainability. non-neurological complications involving a single or multiple organ systems during intensive care in critically ill patients of traumatic brain and spine injuries is significant cause of poor prognosis but often not well managed. the aim of this study was to assess the frequency of such complications in neuro icu and assess their impact on morbidity and mortality. a prospective observational study on 200 patients of varied demographic profile admitted in neuro icu over a period of 6 months for injury and associated multisystem involvement was conducted. significant predefined parameters addressing the non-neurological complications occurring during their icu stay were recorded including disturbances and bleeding complications. the study period was from admission to the icu till the discharge from the icu or demise. 63% of patients developed respiratory complications in the form of chest infiltrate (50%) and atelectasis (10.31%). 35.5% of patients suffered from cardiovascular complications. 37% of patients had dyselectrolytemia, commonest being hypernatremia due to hypovolemia (70%). sepsis was observed in 23.5%. bleeding diathesis and acute renal injury were observed in 22% & 3.5% of patients respectively. 17% of the patients succumbed to injury out of which 64.7% was due to non -neurological cause. further results will be discussed in detail with inferences at the meeting. intensivists in neuro icu must consistently assess and treat the non-neurological complications in traumatic brain and spine-injured patients and deliver appropriate care to bring down the mortality and morbidity and improve outcome. neurocrit care (2016) 25:s1-s310 transcranial doppler (tcd) is a useful ancillary test in neurologic critical care for monitoring patients at with elevated intracranial pressure and cerebral vascular resistance. the normal values of cerebral blood flow velocity and pis are significantly distorted by nonpulsatile blood flow, as in patients on venoarterial extracorporeal membrane oxygenation (va-ecmo) circulation. this analysis evaluates changes in pi measurements in patients on va-ecmo following cerebral vasodilation, vasoconstriction, increased intracranial pressures, or cerebral circulatory arrest. data from 11 tcds in 8 patients on va-ecmo in the cedars sinai medical center cardiac surgical icu were reviewed. mean pis were calculated for each patient using gosling's pi formula. the values obtained were compared with ejection fractions (ef) obtained within 24 hours of tcd. pis were globally low or absent in all 11 tcds. the non-demonstrable pi seen in one patient is from severely diminished cardiac function, resulting in tcds were performed at the initiation and conclusion of va-ecmo cannulation. the pi values for these tcds correlated directly with changes in efs. also, an abrupt rise in pi to normal value was seen with placement of a total artificial heart and return of pulsatile circulation. we demonstrate that patients on mechanical circulatory support demonstrate low-absent pis on tcds. ion or cerebral circulatory arrest. moreover, rising pis in patients with improving cardiac function should not be confused with elevated intracranial pressures. venous thromboembolism (vte) prophylaxis in underweight patients with neurologic injury remains unaddressed by recent guidelines and primary literature. this study aimed to describe vte prophylaxis strategies employed in this population and compare the impact of underweight and non-obese patients on thrombotic and bleeding events. underweight and non--care unit from september 1, 2009 to july 31, 2015 were retrospectively identified. underweight was defined as a body -obese as a bmi 18.6excluded if they received >1 vte prophylaxis regimen, had an icu length of stay <72 hours, or received vte prophylaxis for <48 hours. patients were stratified to non-obese and underweight groups and subsequently matched 2:1, on age and diagnosis. prophylaxis regimen, prevalence and type of the most common regimen in the underweight (n=107) and non-obese (n=214) groups was unfractionated (ufh) 5000 units subcutaneously every12hrs (69.1% vs. 83.6%; p=0.003). only underweight patients received ufh 2500 units subcutaneously every12hrs (17.8% vs. 0.0%; p<0.0001). non-obese and underweight patients had no difference in the proportion of overall bleeding (5.6% vs. 10.3% p=0.204) and thrombotic events (6.1% vs. 2.8% p=0.204) while receiving vte prophylaxis. further analyses revealed a statistically significant difference in the proportion of underweight patients that developed intracranial hematoma expansion while receiving prophylaxis versus non-obese patients arge dispositions were seen between groups. current practice does not reflect a consistent dose reduction for neurologically-injured, underweight patients. caution should be considered when using increased doses of ufh in neurologically-injured patients. continued assessment of vte prophylaxis is needed to confirm these findings. patients in the neuro intensive care unit (nicu) commonly need vasopressor infusions for various reasons. the traditional approach is to insert central venous catheters (cvc) for this purpose. cvcs carry among others. phenylephrine is a commonly used vasopressor in the nicu. the purpose of this study was to evaluate the safety of phenylephrine infusion through peripheral intravenous catheter (iv). retrospective review of consecutive patients admitted to the neuro icu and administered phenylephrine infusion through peripheral iv line. one hundred patients, mean age 66 years (sd ± 14) were included in the analysis. fifty-four (54%) were men. eightydisease. the most common indications of phenylephrine were hemodynamic augmentation (37%), multifactorial transient post-operative hypotension (28%) and hypotension due to other causes (22%). most common location of iv line was proximal upper extremity (28 % antecubital, 28% forearm) with gauge of the iv line between 18 (45%) and 20 (44%). average maximum rate of phenylephrine infusion duration of 19 hours (sd ± 18, range 1 to 114). central line was eventually placed in 16% due to physician preference and in another 5% due to a change of vasopressor to norepinephrine. there were 2 any complications. infusion of phenylephrine through peripheral iv appears safe when used in moderate doses for the short term and can be considered in lieu of placing a central line solely for this purpose. this may reduce the complications associated with central lines. osmotic therapy continues to be standard care in the medical management of cytotoxic cerebral edema. the long term use of monotherapy is often limited by side effect profile. the combination of low dose mannitol and hypertonic saline may provide synergistic effect by combining mechanisms of action, while limiting dose-related toxicities of either agent. we investigated safety and efficacy endpoints for combination therapy. a single-center retrospective cohort study from august 2014 to december 2015. identified patients were administered combination mannitol and hypertonic saline for >48 hour duration. the primary outcome criteria, sodium fluctuation, and central pontine myelinolysis. 31 patients (mean age 55±14, 52% male) were identified. underlying neurological injury included 44% brain injury. 52% had neurosurgical management. the average number of mannitol doses given was 22, and the average duration of hypertonic saline was 110 hours. the range of mannitol dose was 0.14 -0.6 percentage of osmotic therapy doses were held for pred mannitol, 17% held hypertonic saline). aki occurred in 10 (32%) patients (9 -stage 1 aki, 1 -stage 3 central pontine myelinolysis. low dose combination osmotic therapy was tolerated with no central pontine myelinolysis and rare sodium fluctuations; however transient low grade aki was common. further study is needed to evaluate the relative efficacy of single and combination osmotic therapy in the neurocritical care population. clinical characteristics of nonconvulsive status epilepticus diagnosed by simplified continuous eeg monitoring at an emergency intensive care unit. the clinical characteristics of nonconvulsive status epilepticus (ncse) presenting in icu in japan is limited. our institute provides a noninvasive monitoring system of two-channel simplified continuous eeg (seeg) for the bedside monitoring of cerebral activities. the present study aimed to elucidate the clinical characteristics of ncse in patients with altered mental status (ams). this single-center retrospective study comprised 149 patients who were hospitalized between march 1, 2015 and september 30, 2015 at the emergency intensive care unit (icu) of the kagawa university hospital. primary outcome was the ncse incidence. the secondary outcome was the comparison of duration of icu stay, hospital stay, and a favorable neurological outcome (fo), as assessed using the tal between the groups with and without ncse. fo and poor neurological outcomes (po) were defined as mrs scores of 0-2 and 3-6, respectively. simplified continuous electroencephalogram (seeg) was monitored in 36 patients (median age, 68 years; 69.4% males) with acute ams. ncse was observed in 11 (30.1%) of the 36 patients with ams. rates of fo, duration of icu stay, and hospital stay were not significantly different between the ncse and non-ncse groups (p = 0.45, p = 0.30, and p = 0.26, respectively). approximately 30% of the patients with ams admitted to emergency icus developed ncse. the outcomes of ams patients with and without ncse did not differ significantly when appropriate medical attention and antiepileptic drugs were initiated. seeg monitoring may be recommended in patients with ams in emergency icu to obtain early detection of ncse followed by appropriate intervention. approximately 200,000 people per year will need mechanical ventilation secondary to neurological injury resulting in significant mortality. delaying liberation in neurologically impaired patients otherwise ready for liberation is a source for significant hospital charges. there is no clear guideline to suggest one spontaneous breathing trial (sbt) over another in predicting the liberation success. zero pressure support and zero positive end expiratory pressure (peep) or zeep is a traditional method assessing patient's readiness for mechanical ventilation liberation. however, neurologically injured patients with was to assess mechanical ventilation liberation in patients who failed zeep and subsequently passed pressure support trial. retrospective analysis of liberation in 134 intubated patients in a neurosciences intensive care unit. all patients were initially challenged with zeep. if passed, patients were liberated from mechanical mcnemar's exact test. p value <0.05 was considered significant. 134 adult (>18 years old) patients were included. the majority of patients were successfully liberated from mechanical ventilation using 30 minute zeep trial alone (n=123, 91.7%). eleven (8.21%) patients failed .74%) required reintubation. ten (7.46%) this study shows that the majority of patients can be successfully liberated from mechanical ventilation successful liberation from mechanical ventilation. neurocrit care (2016) 25:s1-s310 vancomycin establishey using nonmem software by the department of pharmacy of nanjing drum tower hospital in neurosurgical intensive care unit patients. according to the patient's gender, age, body weight, serum creatinine (scr), serum albumin (alb), the actual measured value. during the period from march 2013 to march 2014, 42 patients including 25 male and 17 female, whose age is 53±14 years old (22-78 years old), were grouped and 53 copies of blood concentration of vancomycin were measured. the average concentration was 10.9m the actual measured value (r=0.857, p<0.001), the mean absolute percentage error (mape) was 0.4079. neurosurgical intensive care unit patients for drug value prediction and drug dosage guidance. but because of coma, the body weight estimation has errors (about 30%). the renal function sometimes changed by contrast agent and diuretic drug has an impact on predictive results. by adjusting methods, accurate prediction rate increased to nearly 70%. xi liu-deryke, sindhuri s. avula, jason j. vilar. florida hospital orlando/pharmacy department, orlando, fl, usa. little data exists concerning clevidipine in this population. large variations in bp during the first 24 hours is an independent predictor for poor outc aneurysmal subarachnoid hemorrhage (asah) admitted to neuroscience intensive care unit from january 2012 through december 2015 were identified retrospectively. patients were included if they received clevidipine or nicardipine for initial acute bp management, and bp goal was defined by the prescribers. bp variability was measured by standard deviation (sd) of mean arterial pressure (map) over the first 24 hour of therapy. seventy three patients were included in the analysis (clevidipine n=18; nicardipine n=55). admission and 25% asah. baseline map between clevidipine and nicardipine group was comparable (102 vs. 109 mmhg). the number of bp recordings was similar between groups (clevidipine 22 vs. nicardipine 24; p=0.51) and the average time to goal was 116 minutes and 47 minutes, respectively (p=0.15). the average map during the first 24 hours was similar (clevidipine 86 vs. nicardipine 84 mmhg; p=0.26). although not statistically significant, clevidipine group had a higher percentage of bp above goal compared to nicardipine group (24.6% vs 9.8%; p=0.09). there was no significant difference in bp variability between clevidipine and nicardipine group (sd 11.6 vs. 13.5 mmhg; p=0.09). our study did not find a difference in bp variability between clevidipine and nicardipine following acute long corrected qt interval (qtc) has been associated with malignant ventricular arrhythmias specifically present in neuro intensive care unit (nicu) patients. in addition to medical causes, acute neurologic insult has been shown to cause multiple neuro-cardiac manifestations including qtc prolongation. prevalence ge and surgical icu patients which have different disease processes compared to nicu. retrospective review of consecutive patients admitted to the neuro icu and having abnormal qtc interval. ninety-five patients, mean age 66 years (sd ± 14) were included in the analysis. fifty four (54%) were men. average duration of hospitali (47%), subdural hemorrhage (13%), and cerebral hemorrhage (12%). fiftycardiovascular disease, 30% had abnormal ejection fraction. thirty-seven patients (39%) needed abnormalities were observed throughout the hospitalization and patients frequently received qtc prolonging drugs. mean qtc was 495 ms (sd ± 37, range 450-659). there were 6 episodes (6%) of nonsustained ventricular tachycardia which did not lead to any immediate consequences. one patient had cardiac arrest following anesthesia for hemicraniectomy. initial rhythm was asystole followed by fine ventricular fibrillation and therefore could not be clearly attributed to prolonged qtc. there were no episodes of tdp. -sustained ventricular tachycardia was observed without leading to cardiac arrest. no episodes of tdp were observed in these patients. deep venous thrombosis (dvt) of the lower extremities is a common cause of morbidity and mortality among neurologically injured patients. the data on incidence and prevalence rates of dvt among high medical or surgical intensive care unit with very limited information on patients in neuro-intensive care units (nicu). the aim of the present study is to assess the incidence and prevalence of deep vein thrombosis among patients admitted with acute neurologic injury. our institution routinely conducts ultrasound screening within 24 hours of admission and -month period. data was abstracted and analyzed to assess the prevalence of dvt in this period. we excluded patients presenting with superficial vein thrombosis, hematoma and chronic venous scarring. over a period of one year; the prevalence of dvt was 6.1% (n=161). of the 161 cases that were diagnosed with dvt; more than one-half (54.7%) presented with dvt at the time of admission. 73 patients (45.3%) acquired dvt during hospitalization. majority of the patients with dvt at the time of admission are caucasian males with mean age 72 and mean saps ii score of 34.2, ranging between 13 and 71. prevalence of dvt at the time of presentation to the neuro icu is relatively high. further research is s148 neurocrit care (2016) 25:s1-s310 practice guidelines recommend that practitioners should not prescribe prolonged prophylactic systemic antibiotics (ppsa) after neurosurgical procedures, even if drains are left in place. we sought to evaluate 1) current practice patterns related to ppsa administration to neurosurgical patients with drains and devices and 2) practitioner perception about the need for ppsa in this population. we surveyed members of the neurocritical care society on use of ppsa (defined as maintenance antibiotics after the time of insertion) and personal perception about the need for ppsa in patients with intraparenchymal monitors, subdural drains, subgaleal dra -pratt spinal drains, and lumbar drains. of 52 respondents, routine institutional use of ppsa was reported by 29fewest respondents reported use with subgaleal drains and the most respondents reported use with -pratt spinal drains with instrumentation. respondents had varying personal opinions on the need while the lowest (19%) was for patients with subgaleal drains. it is on the use of ppsa in patients with neurosurgical drains is necessary to optimize patient care. transition to comfort measures only (cmo) in an intensive care unit (icu) is a common but delicate process that requires a well-organized multi-disciplinary and multi-professional care model. the goal of this survey was to understand potential deficiencies and inconsistencies in the transition to cmo in order to develop a process to improve the quality of care provided to patients at their end-of-life. after obtaining irb approval, a web-based questionnaire was distributed to attending physicians, residents, fellow trainees, bedside nurses, respiratory therapists and spiritual care team members, who deliver care to patients in neurological, medical, trauma-surgical, and burn intensive care units at the university of washington's harborview medical center. overall survey response was 46.2% (297 out of 725). the concept that transition to cmo is a multidisciplinary process was not universal with only 9.5% of all bedside nursing and respiratory therapists feeling invited and actively engaged in the discussion about cmo. the majority of respondents (75%) encountered at least one 'less than ideal' transition to cmo. deficiencies identified included gaps d interprofessional conflict (6.5%). most participants (75%) agreed that a formalized process might reduce round the transition to cmo. we identified several barriers towards an optimal, collaborative transition to cmo in icus at a large academic medical center, highlighting the need for a formalized process. such a process would ensure communication between various disciplines and professions, and offer healthcare providers opportunities for dialogue to address all the issues resulting in a smooth transition to cmo. dexmedetomidine's propensity to cause bradycardia is well documented in non-neurocritically ill patients. e units (icu) when defined as heart rate (hr) <60 bpm. neurocritically ill patients have been excluded from all randomized trials. the aim of this study is to assess the development of bradycardia in patients with neurologic injury who have received dexmedetomidine for sedation in the icu. was done via nursing driven protocol with no loading doses. primary outcome was the incidence of bradycardia (hr <60 bpm) during first administration. secondary outcomes were percent decrease in hr from baseline and time to event analysis using cox regression. mortality in the icu was collected. a total of 202 patients were included (61% male, mean age 55 years, mean saps ii 42). the most bradycardia occurred in 80 patients (39.6%). the average maximum dose was higher in patients who infusion duration did not vary. baseline hr was lower in bradycardic patients (87±21 bpm vs. 96±17 bpm, p=0.001) and a larger mean percent decrease in baseline hr was observed (32.8% ±15.7 vs. 3.5% ±20.8). median time to first bradycardic event was 11 hours [7.5-15.0] which was significantly impacted by baseline hr (hazard ratio 0.83; 95% ci, 0.72-0.95; p=0.006). mortality was significantly lower in patients who developed bradycardia, 3.75 vs. 14.7% (p=0.017). these data indicate that bradycardia associated with dexmedetomidine occurs considerably among the neurocritically ill. future assessment of clinicall development would further contribute to the limited data of dexmedetomidine use within this patient population. medical complications after subarachnoid hemorrhage. medical complications occur frequently after subarachnoid hemorrhage (sah). their impact on outcome has been previously described, but was not validated in international series of sah. we evaluated 139 consecutive patients admitted to a tertiary hospital in brazil with sah from january -6) at discharge. we calculated the frequency of medical complications according to prespecified criteria and eva of poor outcome. thirty-six% had a poor outcome; mortality was 12.6%. the most frequent complications were hyperglycemia (37%), fever (14%), pneumonia (1.4%), hypotension (<90 mm hg systolic) treated with vasopressors (3.6%) and venous thromboembolism (1.5%). hyperglycemia (odds ratio [or], 9.0; 95% confidence interval [ci], 1.7-47.8; p=0.01) significantly predicted poor outcome after adjustment for age and hunt-hess grade. hyperglycemia affected more than one third of patients with sah and was significantly associated with poor functional outcome. critical care strategies directed at maintaining normoglycemia may improve outcome after sah. s152 neurocrit care (2016) 25:s1-s310 blood pressure (bp) can be measured in critically-ill patients using non-invasive (oscillometric) blood pressure (nibp) and intra-arterial blood pressure (iabp) monitoring. the accuracy of nibp compared to the "gold standard," aibp, has been questioned. nibp monitors generally tend to over-read at low values and under-read at high values compared to iabp. previous studies exploring nibp-iabp correlations have generally been performed on patients not receiving continuous infusions of vasoactive medications. since many critically-ill patients receive vasopressors and antihypertensive agents, we wanted to study the relationship between simultaneously-measured nibp and iabp recordings in this patient population. we prospectively identified patients (n=25, target n=70) admitted to a neurosciences icu, who had simultaneous iabp and nibp monitoring while receiving intravenous infusions of manually abstracted via retrospective chart audit. covariate and demographic variables were also abstracted and entered into an electronic spreadsheet. statistical analysis performed using sas v9.4. initial results from 25 subjects (60% caucasian, 56% male, mean age 60.3 years, mean bmi 30.3), observations. independent-samples t-tests showed a significant difference between nibp vs iabp readings: ([sbp: m=125 vs 130mmhg respectively; p50mmhg (1.7%)]. bland-altman plots demonstrated good inter-method agreement between nibp-iabp measures (when visually excluding outliers) and -aibp sbp differences at higher blood pressures. preliminary analysis indicates a statistically significant difference between nibp-iabp readings for patients on vasoactive medications. yet when visually excluding outliers, there is good inter-method agreement. data from the entire cohort will be available for presentation at the ncs annual meeting and will be helpful in choosing appropriate bp monitoring methods for patients on vasoactive infusions. new-onset refractory status epilepticus (norse) is an important syndrome often associated with a poor outcome. the aim of the present study was to review norse cases in our hospital and to determine the main factor that may improve patient outcomes. we retrospectively reviewed our hospital medical records and database of electroencephalograms (eegs) over a 3 years period (may 2013-may 2016). in our facility, we performed 24-h continuous eeg monitoring using the international 10-20 system. of the monitored patients, we excluded those who were meningitis, herpes encephalitis, and history of epilepsy. we discussed their causes and neurological outc (go) was defined as a mrs score of 0-2, whereas a poor neurological outcome (po) was defined as a score of 3-6. moreover, we attempted to determine the main factor that influenced the neurological outcomes. we identified 785 patients who had undergone eeg, and identified six norse patients among them. the on arrival was 9. all patients were diagnosed with limbic encephalitis and all had nonconvulsive status treatments, such as steroids, were delayed in all po patients. on the basis of our data, the cause of all norse cases was limbic encephalitis. in po patients, definitive treatments, such as pulse steroid therapy, were delayed. this is a relatively small study. further research is needed to identify the factors which could improve outcomes. multi-drug resistant organisms (mdro) are an increasing concern in health systems. pathogens such as pseudomonas aeruginosa, acinetobacter baumanii, and carbapenamase-producing enterobacteriaceae hold highest mortality rates especially when the central nervous system is involved. when mdros are cultured treatment options are becoming limited and reliance on medications such as colistin and aminoglycosides is becoming more prevalent. however, penetration of these therapies into the central nervous system is concerning therefore local administration is a potential concomitant therapy. this study was a retrospective chart review from 2009 to 2015 for all patients with documented mdros who received intraventricular colistin. seven patients from 2009 to 2015 met inclusion criteria. the average age of the patients included was 49 years old, 4 were males, and the median length of intensive care unit stay was 30 days. the dose of colistin used for each patient was 10 mg via intraventricular route. the duration of therapy ranged from 2 -14 days and all cerebrospinal fluid cultures were sterile at 7 days after administration of colistin. each patient received concomitant systemic antibiotics while receiving intraventricular colistin. six of the seven the use of intraventricular colistin was not associated with any reported adverse events. the use of intraventricular colistin was associated with positive clinical outcomes with no reported adverse effects. myasthenic crisis: epidemiology, economics and opportunities for change -a single center retrospective analysis. avinash b. kumar, vikram v. tiwari, kevin k. scharfman, justin j. calabrace. vanderbilt university medical center, nashville, tn, usa. myasthenia gravis (mg) patients are admitted to the icu for myasthenic crises characterized by immunoglobulin (ivig) or plasmapheresis and supp and care flow maps of patients admitted to our institution this is an irb-approved, retrospective cohort study of patients admitted to a tertiary neuro icu. we included adult (age > 18 years), with a diagnosis of mg who received plasmapheresis or ivig therapy. the demographics and clinical data were summarized for patients in the ivig and plasmapheresis cohorts. we also compared the icu and hospital los and in addition the hospital cost data for patients in both cohorts. the final cohort included 153 hospital encounters for 82 individual patients (46 female) admitted between 2006-14. the mean age on admission was 56.9±19.7 y. there was no significant difference between c ventilation; the median duration of mv was 7.5d (range 1-34). the median readmission rate was 1.5± 0.5. ). 13 patients had multiple crisis readmissions (>2). this cohort was socially challenged ( 5 divorced,8 analysis included 33 patients (16 in ivig cohort and 17 in plasmapheresis cohort). the mean hospital costs (variable direct-technical) in ivig cohort was approx. $5000 more than the plasmapheresis cohort. there was no statistically significant difference between in the limited financial analysis. 56.25% of patients were either medicare or medicaid patients, 21.25% wer the disease burden on patients and hospitals of this orphan condition are significant and continues beyond the icu. evidence based care pathways need to be explored for the management of this high resource utility disease. botulism is a rare potentially fatal and treatable disorder caused by a bacterial-produced toxin that affects the presynaptic synaptic membrane resulting in a characteristic neuromuscular dysfunction. it is caused by either the ingestion of the toxin or the bacteria, inhalation, or wound infection. we present our we report 15 consecutive cases of botulism presenting to university medical center of el paso. medical records where reviewed to obtain demographic information, clinical presentation, treatment and outcome. in popping and had abscesses in the administration areas. by history the most common 3%, ophthalmoplegia 53%, ptosis 46%. interestingly enough, in those patients with the documentation the pupils were reactive in 46%. all patients required mechanical ventilation and all were treated with the trivalent antitoxin. thirteen patients were disc derivatives (mostly 6-monoacetylmorphine and 3-monoacetylmorphine) was associated with the development of botulism. its presence in the us-mexican border is not surprising since is frequently produced in latin america. its association with the development of botulism should be recognized early to allow a prompt diagnosis and treatment with the antitoxin. a clinical feature worth noting is the presence of normal pupillary light reflex in nearly half of patients thus a normal pupillary response should not be used as a finding to exclude botulism. in clinical trials limits the discovery of effects that may be particularly relevant to underrepresented populations. clear iii, a 500presented an opportunity to evaluate african american (aa) enrollment. investigators across 61 u.s. hospitals screened 8,587 patients over a 5-year period: 25% aa; 4.3% asian; 0.5% native american; 0.3% pacific islander; 69.7% white; 0.2% mixed race; and 10.8% not reporting. the mean age for aas was younger at 57.9 (sd: 0.6) vs. 65.7 (sd: 0.4) for whites (p=0.001). the randomized-to-screened ratio for aas was 8.7 vs. 3.5% for other racial groups (p<0.001). higher 3.6%, p=0.26); northeast (7.8% vs. 2.9%, p<0.001); south (8.2% vs. 4%, p=0.003); and west (8.9% vs. 3.8%, p=nonsignificant). african americans were less frequently excluded due to non-hypertensive etiology (16.9% vs. 26%, p<0.001), not having ventricular drainage (22.1% vs. 25.4%, p=0.031), dnr status (18.4% vs. 25.2%, p=0.027) and unstable bleeding (13.9% vs. 25.1%, p=0.024); and more frequently excluded for prior disability (32% vs. 24.9%, p=0.23), larger hemorrhages (26.7% vs. 24.8%, p=0.44), and by investigator decision (46.5% vs. 24.9%, p<0.001). of the 119 patients who refused consent, aas accounted for 44.1% vs. 49.5% of whites. in an unadjusted logistic model, the odds ratio for successful enrollment of aas was 2.74 (p<0.001) vs. whites, and 2.45 (p<0.001) after adjustment for age and hispanic ethnicity. the age <49, 50-59 and 60-69 subgroups maintained higher adjusted odds ratios than whites at 2.60 (p<0.001), 2.20 (p<0.001) and 2.43 (p<0.001) respectively; the above 70 subgroup was not significantly different. others have reported difficulty enrolling aas into clinical trials. clear iii suggests this may be a misperception s158 neurocrit care (2016) 25:s1-s310 pipeline that utilizes machine-learning algorithms to integrate clinical data and quantitative eeg (qeeg) trends, providing continuous estimation of prognosis. a collaboration involving two academic centers in the u.s. assembled a retrospective clinical and eeg database of adult subjects with cardiac arrest and return of spontaneous circulation who underwent continuous eeg monitoring. four qeeg features were included in the model: regularity, tsalis entropy, alpha-to-delta ratio, and voltage <20 uv. only the first 48 hours of eeg data were evaluated in this analysis. poor outcome was defined as cerebral performance category of 3-5 at discharge. ten fold cross validation resampling method was utilized, and model performance evaluation metrics were area under roc curve (auc), sensitivity, and specificity. the algorithm provided an hourly estimation of poor clinical and eeg data was available for a total 173 subjects. mean age was 55.3 years and overall mortality was 55.7%. one hundred and twenty subjects (69.4%) had poor outcome. our multiparametric qeeg method achieved optimal performance for mortality prediction at 24 hours (auc 0.75), with a sensitivity of 86% and specificity of 66%. optimal poor outcome prediction performance was achieved at 26 hours (auc 0.72), with a sensitivity of 88% and specificity of 70%. at a false-positive rate of 0%, the sensitivity for poor outcome was 53%. alpha-delta ratio and voltage <20uv were independently associated with mortality and poor discharge outcome at 24 hours (p<0.05). employment of machine-learning methods in qeeg analysis allows early and robust outcome prediction in cardiac arrest. this approach has potential to facilitate real-time individualized prognostication in cardiac arrest. secondary brain injury may be a significant barrier to survival following extracorporeal membrane oxygenation (ecmo) for, otherwise reversible, cardiorespiratory failure. prevalence of brain injury phenotypes on neuroimaging were described in our prior wor neurological injury on outcomes in adult patients on ecmo. a retrospective cohort of ecmo-treated adults. clinical and outcome data was obtained from electronic chart abstraction of clinical and physi of decannulation. 27% (n=18) of ct scans and 93% (n=13) of mris had abnormal findings. intracranial hemorrhage was seen in 20% patients with neuroimaging. in addition, 86% of mris revealed diffuse significant difference in survival to hospital discharge and mean modified with or without neuroimaging during ecmo (64% vs.54%, p=0.2; mrs, 4.8±1.5 vs. 4.8±1.3, p=0.9). however, in the group undergoing neuroimaging, normal scans were associated with better survival to hospital discharge (79% vs. 21% p<0.001) and lower mrs (4.4±1.3 vs. 5.5±1.0, p=0.002). 12 (20.6%) of survivors who did not get neuroimaging and 3 (8%) of those who got neuroimaging achieved abilty to perform independent adl at discharge (p=0.08). all 3 patients with ability to perform independent adl in neuroimaging group had normal scans. 20 (34%) of survivors who did not get neuroimaging and 8 (21%) of those who got neuroimaging were discharged home (p=0.1). all 8 surviving patients in the neuroimaging group who were discharged home had normal scans. secondary brain injury in ecmosurvival and functional outcomes. a prospective study has been planned to better understand mechanisms mediating this effect. neurocrit care (2016) 25:s1-s310 re-verse ad is an ongoing, phase 3, cohort study evaluating the extent to which idarucizumab, a humanized fab fragment specifically reverses dabigatran's anticoagulation effect in patients with serious bleeding or requiring urgent interventions. dabigatran is a direct acting oral anticoagulant approved for -valvular atrial fibrillation and venous thromboembolism treatment and prevention. in re-ly, dabigatran 150 and 110 mg bid were associated with significantly lower annualized rates of intracranial hemorrhage (ich) than warfarin (0.32%, 0.23% and 0.76%, respectively). nonetheless, the mortality rate with ich in the context of any anticoagulation remains high, probably reflecting the effect of hematoma expansion. whether idarucizumab improves clinical outcome in dabigatran-treated patients this analysis of the first 90 patients enrolled in re-verse ad focuses on patients with ich. patients presenting with ich were given intravenous idarucizumab 5 g as two 2.5 g bolus infusions administered effect, based on central laboratory determination of dilute thrombin time (dtt) or ecarin clotting time (ect). we compared the clinical outcome of this re-verse ad interim analysis with dabigatran-treated ich patients in re-ly. in this interim analysis, 18 patients with dabigatran-associated ich were enrolled in re-verse ad. complete reversal of anticoagulation was observed by dtt and ect within minutes of idarucizumab administration. preliminary results from this interim analysis indicate that the mortality rate of ich patients re-ly. idarucizumab reversed anticoagulation in ich patients and appears to improve mortality rates in dabigatran-treated patients with ich versus historical controls from re-ly. results from additional patients in re-verse ad will provide further information on the effects of idarucizumab reversal in patients with ich. ****permission was not granted to print this abstract**** s162 neurocrit care (2016) 25:s1-s310 callie electroencephalography (eeg) has clinical and prognostic importance for comatose survivors of cardiac arrest. recent interest in quantitative eeg (qeeg) analysis has grown. the qualitative effects of sedation ing effects of sedatives on qeeg are poorly characterized in anoxic injury. we hypothesize that sedation would decrease amplitude-integrated eeg would predict neurological recovery. we routinely monitor comatose post-arrest patients with eeg for 48this prospective study, we included consecutive eeg-monitored patients who had protocolized sedation interruptions, excluding those with contraindications to interruption such as seizure or hemodynamic instability. we used persyst v12 to quantify sr, aeeg, and adr and calculated medians for 10min immediately prior to sedation interruption and the last 5min of interruption. we used nonparametric tests to determine if the qeeg signal changed pre-to post-and whether this differed by outcome (cerebral performance category 1-2 at hospital discharge vs 3-5). of 101 screened subjects, 22 met inclusion criteria (median age 58 years, 73% male). sedation regimens varied (18 propofol; 13 fentanyl; 5 midazolam). median duration of sedation interruption was 35min, and did not differ by sedative type. pre-interruption, higher adr and aeeg and lower sr predicted favorable outcome. post-interruption, sr decreased (median change -0.85, iqr: -12.0 to 0), aeeg increased (0.38, (p=0.01), but aeeg and adr changes did not differ by outcome. in acute anoxic brain injury, sedation increases sr and decreases aeeg. larger decreases in sr with sedation interruption predict worse outcomes, which may reflect a susceptibility of deafferentated cortex to suppress in response to sedation. ashley r. hedges, gary g. davis, brianne b. wolfe, erin e. lingenfelter, gregory g. hawryluk, safdar s. ansari. university of utah hospital and clinics, salt lake city, ut, usa. for patients presenting with subarachnoid hemorrhage (sah) or traumatic brain injury (tbi), levetiracetam has begun to emerge as a preferred alternative to phenytoin for seizure prophylaxis following initial presentation. however, the optimal dose of levetiracetam has not been determined. a retrospective review of electronic medical records identified patients that received levetiracetam for seizure prophylaxis for sah or tbi in a level one trauma center from may 12, 2014 to october 30, 2015. the goal of this research was to quantify the combined seizure incidence (including both clinically observed seizures and those confirmed by electroencephalogram) in patients receiving levetiracetam 500 mg twice daily compared to levetiracetam > 1000 mg total daily dose. among 139 patients captured, 50% were male, with a mean age of 53 years old. for patients receiving seizure incidence was observed, 11.5% vs 1.3%, in patients receiving levetiracetam 500 mg twice daily this was observed despite no difference in potential confounders, includ trend towards increased levetiracetam failure rates was observed in the lower dosing scheme of 500 mg twice daily. t electroencephalograms ordered (22 vs 16, p=0.18). no difference in adverse effects were observed our project suggests that patients may benefit from a standardized levetiracetam dosing scheme of 1000 mg twice daily. treating intraventricular hemorrhage (ivh) with a fibrinolytic (ivf) therapy such alteplase via a catheter is becoming an increasingly popular intervention. with the conclusion of the clear iii trial a larger cohort of patient data is available to update past meta analyses. mortality and good functional outcome after thrombolytic treatment was reviewed in patients with hypertensive ivh. a literature search was performed from 1970 to march 2016 to collect all literature on ivh treatment with ivf. seventeen papers meeting our inclusion and exclusion criteria were collected for further analysis. ivh patients with vascular abnormalities and traumatic injuries were excluded. mortality and functional outcome was assessed to compare ivf treated and control groups in all publications. there was a significant difference in mortality favoring the treatment group at 30 days, 180 days and 365 days (95%ci, 0.43-0.75; p=0.000; 95%ci, 0.45-0.82; p=0.001; 95%ci, 0.50-0.90; p=0.008). pooling mrs and gos good functional outcomes, there was a significant difference favoring the treatment group at 30, 90, and 180 days (95%ci, 0.80-0.96; p=0.003; 95%ci, 0.41-0.68; p=0.000; 95%ci, 0.73-0.96; p=0.012). there was a non-significant trend in mrs scores favoring the treatment group. a significant difference in gos score favoring the treatment group was found at 30, 90, 180, and 365 days (95%ci, 0.61-0.95; p=0.016; 95%ci, 0.36-0.70; p=0.000; 95%ci, 0.52-0.88; p=0.0003; 95%ci, 0.54-0.95; p=0.019). treatment of hypertensive ivh with thrombolytic may improve functional outcome and reduce mortality compared to control groups as early as 30 days, a trend that continues to 365 days for mortality and 180 days for functional outcome. different effect sizes are generated when different functional outcome tools, such as mrs and gos, are used. an aging population and increasing use of anticoagulants and antiplatelet agents to prevent ischemic hematoma (ssdh) and sdh related to trauma (tsdh). we sought to study the association of antiplatelet agent and warfarin use in sdh patients admitted to our neurosurgical icu. warfarin were studied. neurosurgical methods of sdh evacuation and re-evacuation were studied as well as hemostatic factors such as international normalized ratio (inr) within the first 24hrs, blood products and hemostatic agents given to reverse coagulopathy or antithrombotic effects. demographic information such as age, gender and comorbidities were noted and indication for antithrombotic agent. we excluded major trauma (level 1) associated with sdh at our center. from january 2006 to may 2016, we admitted 188 sdh patients, of which 46.8% required evacuation (88 ->12, mean = 2.9), and 58 on (33%) underwent redo evacuation (range in days 1-(date range 1-10 days). 24 hour inr rates in warfarin related sdh were all <1.5 except for 6. of these 6, only one patient required re-operation. mort in our patient population, sdh was associated with a need for evacuation in 46.8% of all patients, of which a higher rate of reagents. mortality was also higher in the warfarin associated sdh patients. consecutive patie complications were prospectively enrolled. medical critical care attendings (micu), neurocritical care attendings (nicu), residents (res), and nurses (rn) predicted the following: 1) 6-month functional -month quality of life (qol). patients were followed up at 6 months and their functional status and qol were compared to the predicted values. functional outcomes were dichotomized to good (mrs 0-3) vs. poor (mrs 4-6). 179 (of 365) patients had 6-month mrs predicted by all 4 provider groups. fifty-four (30%) patients had good outcome and 125 (70%) had poor outcome. the micu, nicu, res, and rn providers had similar predictive values (95% ci) for accurately predicting good outcome (65% (52-76), 62% (51-72), 70% (55-83), and 64% (50-76), respectively). nicu was most accurate in identifying poor patient outcome, 97% (91-99), followed by micu 89% (74-86), rn 86% (78-91), and res 83% (75-89) (p=0.025, 0.005, and <0.001, respectively). when patients who transitioned to comfort measures only (n=65) were excluded from the analysis, the nicu team was more accurate at predicting poor outcome. fifty-three survivors had qol predicted by all 4 provider groups. the accuracy of qol predi neurocritical care attendings are better than healthcare providers without neurological training at predicting poor 6-month functional outcome in neurocritical care patients. however, the overall predictive accuracy for 6-month mrs and qol was similar between healthcare provider teams. there are significant limitations in providers' ability to predict long-term functional outcomes. patients with severe acute brain injury (sabi) raise important palliative care considerations associated with sudden, devastating injury and uncertain prognosis. the goal of this study was to explore how family members, nurses and physicians experience the palliative and supportive care needs of patients with sabi receiving care in the neurosciences intensive care unit (neuro-icu). design: semi-structured in-person interviews were audiotaped, transcribed, and analyzed using thematic analysis. setting: thirty-bed neuro-subjects: forty-seven interviews were completed regarding 15 patients receiving care in the neuro-icu with family members (n=16), nurses (n=15) and physicians (n=16). hope varied depending on the par away, generally in the process of conveying prognosis, while families expressed hope as an action that supported coping with their loved one's acute illness and its prognostic uncertainty. (2) participants described the loss of personhood through brain injury, the need to recognize and treat the brain-injured patient as a person, and the importance of relatedness and connection, including personal support of families by clinicians. in their pursuit to recognize and preserve personhood, physicians used stories from patients and families to inform them about patient identities, while nurses focused on providing supportive, empathetic care to patients and families. support for hope and preservation of personhood challenge care in the neuro-icu as identified by families and clinicians of patients with severe acute brain injury. specific practical approaches can address these challenges and improve care to meet the needs of patients and families in the neuro-icu. despite increasing evidence that early mobilization strategies are effective, we showed patients were not adequately mobilized in two argentinean hospitals. we implemented a progressive-mobility protocol and examined its feasibility, safety and applicability in our neurocritical patients. prospective observational implementation study of a progressive-mobility protocol for neurocritical patients admitted to icus of two university hospitals in argentina. all patients were evaluated twice daily for level of movement and clinical stability. patients progressed as tolerated from passive movement implementation baseline to icu patients admitted in months 3-4 after implementation began (two month start-up phase not analyzed). there were 33 pre-implementation patients with 348 assessments (40% post-operative, 28% traumatic -implementation patients with 444 measurements (55% postpopulations: median age 53 years (95% ci 44-57), nearly 60% were men. mobilization was 16.4 times -27.4) after protocol implementation. two thirds of pre-implementation patients (65.2%) were not mobilized compared with only 9.2% post-implementation (p<0.001). among mechanically ventilated patients, 82.2% of pre-implementation assessments showed no mobilization vs. 8.6% post. post-implementation patients with an endotracheal tube had a lower rate of mobilization (78.9%) than ventilated patients with a tracheostomy (94.3%). passive movement, turns and full assistance to sit up and transition out of bed to chair was achieved for 64.2% and 26.6% achieved higher levels (3, 4, 5) . mobility sessions with the physical therapist were < 20 minutes in 90% of the cases. no mobility-related adverse events occurred. mobilized following protocol implementation. this prospective study demonstrated that early and progressive mobility among neurocritical care patients in argentina is feasible and safe. psychiatry, geriatrics, and oncology have adopted comprehensive approaches to predict outcomes accounting for important constructs such as spirituality and resilience. critical illness often occurs as a sudden catastrophic event leaving patients with significant long-term cognitive, behavioral and neurological disturbances. impact of resilience and spirituality on recovery in this setting has not been investigated. we have designed a study to validate two important scales, connor davidson resilience scale-10 and brief rcope spirituality scales for surrogate responders. hours with one or two surrogate responders will be included. this prospective cohort study will collect demographic, laboratory and radiographic data in a redcap database. for every patient enrolled, the cd-risc-and a behalf, themselves, and for each other. each patient will complete two resilience and two spirituality scale cd-risc and three spirituality scales . the scales will be administered to the patient ,if possible, prior to discharge; at 3 months and at 12 months. if patient ing followup. cars study has screened 44 patients in 35 days, enrolling 30 patients. common diagnoses include subarachnoid hemorrhage (8), cns malignancy (5), intracranial hemorrhage (3), unruptured aneurysm (3), subdural hematoma (2). based on current enrollment, this unique methodology for surrogate validation of scales is feasible. by august 2016, an anticipated 150 subject will be recruited. surrogate validation of quantitative measurements of resilience, spirituality can provide new insight into prognostication and patient centered critical care. active family engagement in the intensive care unit (icu) could improve patients' and families' experience with care, interactions with the healthcare team, and outcomes. this study examined the perceptions and attitudes of family members regarding increased engagement with passive mobilization of neurocritical care patients. an educational video on passive mobilization of icu patients was developed to engage family members to participate as valued members of the healthcare team. an anthropologist and a nurse or physician (study team) invited family of neurocritical care patients in an academic medical center icu in argentina their perceptions of engagement with care. a multidisciplinary team (3 mds, 2 rns, 2 anthropologists) completed the analysis. thirty-two family members (53% female) of 16 icu patients participated. the study team observed and the family participants reported to be positively surprised by: the format of learning by video that was different from how they usually received daily information; the information in the video was more detailed than anything previously taught; the invitation to watch the video and engage in patient's care was new and unexpected as was the opportunity to provide opinions on how to improve the video instruction. a newly authorized them to touch the patient and participate in care. they reported increased hope about prognosis and perceived an improved relationship with the healthcare team. only one family member considered the video irrelevant. family members' attitudes and perceptions toward this low cost approach to engagement were positive. this approach to teaching and engagement may help humanize the complex icu environment. 70-80% of americans believe in the concept of miracles. we hypothesize that a belief in miracles leads to consultation rate of palliative care. addressing a patient or family's belief in miracles and understanding what a miracle signifies early in the neurothe critical illness resilience and spirituality (cars) study is a prospective cohort study currently -icu at mount sinai hospital with an expected length of stay of at least 48 hours and surrogate responders. as part of the study, all recruited patients and their families primary outcome is tracheostomy and peg tube placement. secondary outcomes include length of stay, full code status, and palliative care consultation. these groups will be matched with regards to the disease specific sever regression will be used to compare rates of the primary and secondary outcomes. the cars study has screened 44 patients screened and enrolled 30 patients so far. of those enrolled, the most common diagnoses include subarachnoid hemorrhage (8), cns malignancy (5), intracranial hemorrhage (3), unruptured aneurysm (3), subdural hematoma (2). this is an ongoing study, we anticipate recruiting 150 patients by the end of august, 2016. belief in miracles could potentially influence continuation of aggressive measures in a shared decisionparadigm in the neuro-icu. mary m. barden, teddy t. youn, carolina c. maciel, sonya s. zhou, david d. greer. department of neurology, yale-new haven hospital, yale school of medicine, new haven, ct, usa. withdrawal of life-sustaining therapy (wlst) for predicted poor neurological outcome is a common cause of death among post-cardiac arrest patients. recent guidelines recommend against wlst before 72 hours post-arrest. early wlst perpetuates a self-fulfilling prophecy that may contribute to premature death in some patients who otherwise would have survived with good neurological recovery. a retrospective cohort of resuscitated cardiac arrest patients from january 2011 to march 2016 at a single tertiary academic medical center was reviewed. patients were evaluated for outcomes at hospital discharge and (when applicable) the timing of and reason for wlst. prognostic indicators including clinical examination, electrophysiology, and neuroimaging were analyzed and findings were compared to day of wlst. of 144 patients, 64 (44%) had wlst due to perceived poor neurological prognosis. median day of wlst for this reason was post-arrest day 6. when stratified according to treatment with targeted temperature management (ttm), the median day of wlst remained day 6 for both ttm-treated and non ttm-treated groups. of patients with wlst, the phrase "no chance for meaningful recovery" was used in documentation for 23 (36%), mri results were cited as indicative of poor neurological prognosis for 16 (25%), and pupillary light reflex was present day 3 post-arrest (or day 3 post-complete rewarming) in 35 (55%). in a retrospective cohort of resuscitated cardiac arrest patients, wlst for predicted poor neurological outcome was the most common cause of death. the median day of wlst was post-arrest day 6. many patients with wlst had present pupillary reflexes on day 3 post-arrest (or day 3 post-complete wlst in the setting of indeterminate prognostic indicators undermines accurate neurological prognostication of post-cardiac arrest patients and perpetuates a self-fulfilling prophecy of poor outcome. brain injury global hypoxic ischemic brain injury (hibi) is a major cause of death and disability worldwide. invasive monitoring of brain function enables goal-directed treatment strategies that optimize cerebral physiology, reduce secondary brain injury (sbi), and potentially improve outcomes. we report a series of patients with hibi where intracranial monitors were placed to guide clinical management. retrospective analysis of 7 patients with hibi cared for at a large academic center over a 3 year period. all patients received therapeutic hypothermia (th) to 33°, continuous eeg monitoring, and had a bundle of invasive monitors placed through a multi-lumen cranial bolt. the full bundle consisted of an icp monitor, brain oxygen (pbto2) monitor, cerebral blood flow (cbf) probe, and cerebral microdialysis probe. 4 patients received the full bundle, while the others received a partial bundle. patients were treated using a tiered algorithm designed to optimize cerebral physiological parameters. precipitants of hibi included cardiac arrest (5 patients), airway occlusion during anesthesia induction (1 patient), and hanging (1 patient). mean patient age was 45 years. average time between initial injury and probe placement was 37 hours. average duration of monitoring was 6.7 days. no adverse events occurred after monitor placement. episodes of deranged cerebral physiology-including intracranial hypertension, brain hypoxia, cerebral glycopenia, metabolic crisis, and reduced perfusion leading to treatment changes occurred in 6 of 7 patients. they occurred up to 10 days after initial injury, and in all cases would have otherwise been clinically silent. 4 of 7 patients died in the hospital. the surviving patients all regained consciousness and were discharged to acute rehabilitation facilities. we did not find invasive intracranial monitoring after hibi appears safe and identifies physiological states associated with sbi. goal directed treatment utilizing multi-modality monitoring in hibi merit further study. is associated with worse patient outcomes; however, it can be difficult to reliably detect. delirium prevention is therefore a potentially beneficial strategy and is most effective in patients who are at high to evaluate whether the advanced practice providers (app's) would both use the dps and also find the dps easy to use. during a 6--bed neurocritical care unit at a large -stratify consecutive admissions of patients with ais a descriptive statistics. the apps completed a 14-item questionnaire that included the system usability scale (sus) and open-ended questions to determine the usability of the dps, as well as to assess for facilitators and barriers for the use of the dps. no individual patient data was collected. patients admitted with ais and ich (n=20) were assessed by the app's using the dps. compliance with dps use was 90 of apps (n=2). the sus score (76.7) was mid-point between "acceptable" and "excellent." facilitators and barriers for use of the dps were identified. the dps was easy to use and was consistently used by the app's. adoption of the dps with this patient population can be a first step to identify the most atthis vulnerable population. the intensive care unit is a complex learning environment with variability in a number of external factors. prior studies of neurology residency training in the neurological intensive care unit have focused on general exposure. this study aims to evaluate resident perception of neurocritical care training. an online survey was sent to program directors and neurocritical care members for distribution to neurology residents. the survey consisted of 20 free-text or selection style questions that focus on resident perception of neurocritical training. statical analysis for group differences was completed with t or fisher exact tests a total of 95 responses (4.7% response rate) was obtained. of those responders, 54 completed a freetext question regarding needed improvements to neurointensive care training. 53% responded with needs for educational changes, and these responders did not differ from other responder in average required practitioners (61% vs 81% p=0.15), and neurocritical care attendings (97% vs 93% p=0.59). this is the first study to examine neurology residents' concerns with neurocritical care rotations. there is little neurocritical care educational materials focused to neurology residents, but the emergency assess the neurocritical care educational training priorities during neurology residency are warranted. our institute had several cases of conflict come to light in the evaluation of patients being evaluated for death by neurological criteria. provider understanding and awareness of clinical guidelines was found to be low across all sub-specialties. it was deemed important to follow appropriate procedures based on published guidelines and a standardized process to provide appropriate care for each patient, optimize icu resource utilization and strengthen provider and public trust. due to medical, legal and ethical issues involved , an institutional standard was called for . -specialties about discrepancies, we revised the institutional policy to reflect emphasis of educational gaps and reflect the latest published guidelines and practice updates . we created an education module , a standardized template in electronic medical to allow escalation in case of conflicts . the project led to increased participation and satisfaction amongst the clinical providers in the icus when n education source to evaluate patients with a consistent approach based on published practiced parameters. we observed a trend in decrease in length of stay and variance for brain dead patients since donation referrals as well timely initiation and effectiveness of family discussions in irreversibly confirming this is in a survey model. a standard care pathway towards evaluation of patients with death by neurological criteria can be successfully implemented at an institutional level in a tertiary care academic medical center. establishing and maintaining optimal brain perfusion is a crucial endpoint for resuscitation and postcardiac arrest care. a recently fda-approved device that employs laser and pulsed doppler now provides clinicians with the cerebral flow index (cfi), a non-invasive measure of brain perfusion. we sought to determine if cfi provided by the ornim c-flow device can be used as a simple and valid measurement of brain perfusion after resuscitation in cardiac arrest patients. we performed a single-center prospective observational inception cohort study of adult patients with cardiac arrest starting in october 2015. comatose patients with sustained return of spontaneous circulation (rosc) within 60 minutes of maneuvers were included. the ornim cflow was connected as soon as feasible after rosc. clinicians were blinded to cfi values. primary outcome was survival at discharge and secondary outcome was neurological assessment using the cerebral performance categories (cpc) scale at discharge. a total of 24 patients have been enrolled as of may 2016. half (46.1%) were out-of-hospital arrests and neurological outcome (cpc 1 or 2). mean interval between arrest and start of monitoring was 15 hours with a mean duration of 47 hours. adequate signal was available 83.4% of the monitoring time. mean cfi in survivors was 62.3, compared to 54.6 in non-survivors (p value 0.07). patients with good neurological outcome at discharge also had a higher mean cfi, although the small sample size precludes any conclusion. our results demonstrate that cerebral perfusion monitoring using the ornim cflow after cardiac arrest is feasible. it also suggests that higher cfi might be associated with survival at discharge. as enrollment progresses and more data are collected, further insight on the potential role of cfi as a neuromonitoring tool might emerge. tuberculous meningitis (tbm) is the most devastating form of tuberculosis, yet rates of neurological complications and mortality are uncertain in high-income countries. we used administrative claims data on all admissions at nonfederal hospitals to identify adult patients with tbm in california between 2005 --2013 , and florida between 2005 -2013 . our outcomes of interest were mortality and the fo seizure, hydrocephalus requiring a ventriculoperitoneal shunt, vision impairment, and hearing impairment. kaplan-meier survival statistics were used to assess the cumulative rates of neurological complications and death. we identified 806 patients with tbm, of whom 54.8% (95% ci, 50.9-58.7%) developed at least one neurological complication or died. more than two-thirds of these complications occurred during the initial hospitalization for tbm. individual neurological complications were not uncommon: the cumulative rate of -16.9%), the rate of seizure was 18.8% (95% ci, 15.4-22.8%), and the rate of ventriculoperitoneal shunting was 8.4% (95% ci, 6.4-10.9%). vision impairment occurred in 21.6% (95% ci, 18.5-25.1%) of patients and hearing impairment occurred in 6.8% (95% ci, 4.9-9.4%). the mortality rate was 21.5% (95% ci, 18.4-24.9%). nd death even in high-income countries such as the united states. neuropalliative care in peru: emergence from the conspiracy of silence the development of palliative care in peru remains limited, particularly for non-oncologic services such as palliative and end-of-life care in patients, families, nurses and physicians in a specialized neurological institute in lima, peru. we used a mixed methods approach consisting of 70 surveys and 21 qualitative, semi-structured interviews that were recorded, transcribed and analyzed using thematic analysis. surveys identified a substantial need for palliative care in the neurological institute (63% of doctors and of do emerged from qualitative interviews evolved around communication about end-of-life choices in neurologic disease. knowledge about advance directives was limited among both clinicians and families, and prognosis, and who should tell them. however, the perception that a physician should be honest, and that suffering and pain should be avoided at all times was unanimous. barriers to transparency in patientphysician communication included (1) expectation of cure with medical treatment; (2) families' trust in god training in communication, symptom management and end-of-life care; and (4) a paternalistic culture. participants identified several challenges specific to palliative care in neurologic disease. in a country without a palliative care training program and no legal basis for advance directives, families and clinicians are emerging from a culture of silence about serious diagnoses and end-of-life care choices. our findings emphasize the need for palliative care education for neurology providers and the public in peru. a trained physician must perform the brain death examination in a systematic fashion in order to recognize and prevent potential sources of error. given the infrequency at which brain death presents in a hospital setting, clinicians may not always have the opportunity to observe a brain death examination during their training. in this study, we plan to evaluate the effect of medical specialty and expertise on documentation errors. we performed a retrospective chart review of 118 brain death examinations between jan. 1 2014 to july 31st 2015 at the university of pittsburgh medical center presbyterian. physician specialty and training level, documentation errors, and confirmatory tests such as cerebral blood flow (cbf), electroencephalography (eeg), and computed tomography angiography (cta) were collected from medical records. exams. ams carried out. the most common completion of documentation by at least one examiner. attending physicians, residents and fellows were responsible for 47% ( neurology and neurosurgery residents have limited exposure to the brain death examination. regardless communication with patients and their families is of central concern in healthcare. however, evidence shows that it is often poorly addressed, especially at times of rapid health status changes and periods of clinical uncertainty. acute neurological emergencies pose an inherently unique challenge in communication. while emerging studies have addressed communication gaps and strategies to improve them in various critical care settings, none have assessed this issue in acute neurological emergencies ongoing irb approved prospective observational study in a 24 bed neurocritical care unit in tertiary care academic medical center all patients admitted to the unit and all clinical providers participating in their care screened for inclusion. direct observation of discussions between clinical providers and families by a questions addressing the satisfaction, understanding of treatment options, impact on health care decisions and ways to improve communication five patients have been enrolled in the study, so far. the results are analyzed for concordance between tween answers is considered between all participants for general satisfaction with the communication (as well as family's understanding of treatment options explained to them by the physician. some disagreement on the impact of the discussion on health care decisions. qualitative domains identified by families as areas of good ical radiographic images. domains identified as needing improvement included explanation of medical circumstances and need for private room for discussions. we observed general satisfaction with communication. further enrollment will help elucidate any definitive areas of improvement and impact of communication on health care decisions. laith maali, sheema s. khan, mahmoud m. ismail, rhys r. brooks, vishnumurthy v. shushrutha hedna. the university of new mexico, albuquerque, nm, usa. cerebral venous thrombosis (cvt) usually accounts for < in their demographics, etiology, clinical features, radiological presentation, and mortality have not been previously explored. a systematic search was performed for publications in pubmed usi thrombosis", "cerebral vein thrombosis" and "cortical vein thrombosis". a total of 600 relevant studies were abstracted with strict selection criteria and a total of 7048 patients' data were used for the final analysis. linear correlation was used for our descriptive analysis. cases reported were europe-3152, asia-2722, north america-852, africa-122, australia-121 and south america-79. overall male to female ratio was 1:2.2, among clinical characteristics headache was the most common symptom and hematological factors were the most common etiology. location of the thrombosis was described mostly in the transverse sinus. intercontinental differences in relation to demographics, etiology, clinical features, radiological presentation, and mortality were identified. cvt can have significant disparity in their demographics, etiology, clinical features, radiological presentation, and mortality when compared from one continent to another. it is important for the worldwide physicians to recognize these differences and to follow the most recent guidelines, diagnostic methods and treatment to insure the best outcome and prognosis. timely communication is critical for high quality care in the intensive care unit(icu). published literature in surgical icus quotes up to 81% of patient caregivers receive prognostic information with mean prognostic interval 1.7 ± 2.8 days since icu admission prognostication in acute neurological injuries is challenging and uncertainty may delay communication. we assess occurrence and timeliness of goals of care communication in a neurocritical care unit prospective observational study by surveying nurses in a 22 bed neurocritical care unit in tertiary level eriod. data was also collected during daily morning multidisciplinary huddle and verified by verbally surveying the nurses. survey results were analyzed for 97 patients and 185 patient encounters. in 99.4% encounters , the nurses felt the patient's treatment plan matched patient-centered goals of care in 79.3% encounters, a provider family discussion had occurred in the last 24 hours. within the 1st 24 hours of icu admission, 40.2% patients were identified to need goals of care discussion in the multidisciplinary huddle, only 61.5% had such a discussion. for patients needing goals of care addressed, a discussion occurred on an average 1.3 ± 0.6 days since icu admission. dichotomized by age, 73.7% patients younger than 65 years old had a discussion , if one was needed, while only 50% older than 65 years had one. when dichotomized by gender, 66.7% of males and 81.4% of females had a provider discussion. 68.4 % females compared to 55% of males received a discussion on goals of care if identified as needed within 1st 24 hours of icu admission. our data shows timely communication of goals of care in the neurocritical care unit with a mean time comparable to published literature. however, there appear to be demographic disparities that warrant further research. cerebral vasomotor reactivity reflect prognosis after cardiac arrest sungeun lee. ajou university school of medicine / department of neurology, suwon, korea, republic of. neurological prognostication after cardiac arrest is a difficult problem. since several studies reported good effect of target temperature management (ttm), prognostication after cardiac arrest was delayed and became complex. recently, some reports presented that impaired cerebral autoregulation was correlated with neurologically poor outcome. the aim of this study was to determine whether vasomotor reactivity (vmr) test by transcranial doppler (tcd), reflecting cerebral hemodynamic status, affected accuracy of neurological prognostication in post cardiac arrest patients. since january 2016, 8 patients were enrolled after cardiac arrest. patients who performed vmr test during ttm period were included and patient with unstable vital sign or malignant findings in brain ct, such as massive subarachnoid hemorrhage or severe brain edema, or poor temporal windows. primary outcome was cerebral performance category scale (cpc) at discharge. vmr test used breath-holding method during 40 seconds. carbon d analysis. other conventional prognostication test, such as eeg, sep, et al., was performed after 72 hours from rewarming time. we divided patients between good (cpc 1-2) and poor (cpc 3-5) outcome group and compared results from prognostic test between two groups. potential, and electroencephalography after 72 hours from rewarming time were presented favorable results in good outcome group. (p<0.001) vmr during breath-holding technique during ttm period also was more increased in good outcome group at right (41.10 ± 1.15 % vs. 12.17 ± 3.01%, p<0.001) and left (36.47 ± 6.48% vs. 7.23 ± 10.65%, p<0.001) middle cerebral arteries. the present study shows that vasomotor reactivity is preserved in patients with neurological good outcome. to evaluating cerebral hemodynamic status by vmr test seems to be useful tool for early prognostication after cardiac arrest. michelle l. lozano, susan s. yeager. the ohio state university wexner medical center, columbus, oh, usa. as the numbers and opportunities for advanced practice providers (apps) in neurocritical care units (nccus) has increased, the integration of these providers into the health care setting has become a greater challenge. currently no data exists to support h comfort levels before and after completion orientation. this prospective, pre and post observational study was sent to 10 newly hired nccu apps within an academic medical center. a one hundred-item survey was created to evaluate self-reported experience cus. baseline data was collected from each app. next, apps were integrated into the nccu utilizing a three month orientation program which fused a series of didactic, simulated, and precepted experiences. after e survey tool. student's t test statistics were utilized to compare before and after experience and comfort levels with items identified as necessary to perform in the nccu app role. as utilization of apps in the nccu becomes more prevalent, integration processes need developed to practice. a structured approach enables identification of high priority areas to assist with initial and and comfort levels. results indicate that further education and exposure to items such as neurologic imaging may be helpful. limitations of this study include subjective data from a small, self-reported, single institutional sample. further research of larger, more diversified sample representation is needed to validate whether these results can be generalized to other nccus. yasuhiro kuroda, kenya k. kawakita, toru t. hifumi. department of emergency medicine, kagawa university, miki, japan. brain damage after return of spontaneous circulation (rosc) varies among studies and patients despite an established modality enabling proper evaluation. evaluation of brain injury after rosc is needed for the determination of the inclusion criteria of neurocritical care, especially of targeted temperature management. literatures are reviewed and summarized. the association between admission glasgow coma score (gcs) motor score and neurologic outcome after rosc (day 0) is an independent predictor of good neurologic outcome at 90 days in patients sustaining out-of-hospital cardiac arrest who receive therapeutic hypothermia: gcs motor score 1, n=130 (52.2%); score 2-3, n=23 (76.7%); score 4-5, n=20 (87.0%), p<0.01 (hifumi 2015 2201). recently no significant differences of neurologic outcome at 30 days after hospital admission was observed between mild therapeutic hypothermia and control in the subgroup of gcs motor score 5 or 6. these data show that initial gcs motor score examination immediately after rosc can at least provide baseline objective prognostic data for decisions by healthcare professionals. neurological signs such as gcs, brain stem reflex, respiratory status, and degree of shivering are potential variables that can be incorporated into a predictive model for a more precise evaluation of brain injury in cardiac arrest survivors undergoing ttm. effect of targeted temperature management should be evaluated depending on the brain injury in pcas. cydni n. williams, jennifer j. wilson. oregon health and science university, department of pediatrics, portland, or, usa. -level estimates of et utilization in pediatric ais, and explore demographic and clinical characteristics, associated interventions, and outcomes. retrospective cohort analysis of the kids' inpatient database evaluated et utilization in children with ais and age >28days, identified by diagnosis and procedure codes. analyses were weighted for national estimates and compared with chi-square and t-tests. among 3184 pediatric ais patients, 38 (1%) received et. anterior circulation occlusions were seen in 89% of et patients. et patient age ranged 2versus 30%, p<.001) was more common and seizure was less common (11% et versus 31%, p=.004) in et patients. average age was higher with et (14 versus 10 years, p<.05). other patient demographics, hospital characteristics, and critical care procedures were similar. thrombolytic agents (tpa) were common with et (51% et versus 2% overall). intracranial hemorrhage was similar (14% et versus 8%, p= .12), and varied by tpa (22% et with tpa, 10% tpa only, 7% et only, 8% neither). there was a nonsignificant trend toward poor outcome (death, discharge to nursing facility, tracheostomy, or gastrostomy) was seen between poor outcome and et (68% et versus 39%, p=.004). et in pediatric ais is uncommon, utilized mostly in older children and those with paresis. though hemorrhage was uncommon, this data suggests caution with et and tpa combination. associations between et and poor outcome may reflect disease severity bias. more research on outcomes with et in pediatric ais is needed. luis p. lee, michael m. leoncio, balagangadhar b. totapally. nicklaus children's hospital / pediatric critical care department, miami, fl, usa. and cerebral edema is the most serious complication leading to morbidity and mortality. we queried a nationally representative database to determine epidemiologic data of cerebral edema in children with dka. an analysis of the healthcare cost and utilization project's kids inpatient database for the year 2012 was performed. the database was filtered using icd-9 diagnosis codes for dka (250.10, 250.11, 250.12, 250.13 ) and cerebral edema (348.5) from the age of 1 month to 20 years. we examined these procedures, outcome and mortality rates. sample weighing was employed to produce national estimates. chi-square test, mann whitney u test and binary regression analysis were performed using spss to analyze the data. a total of 38,972 patients with dka were discharged during 2012. females were 55%. racial distribution -19) years. cerebral edema was present in 188 (0.5%) children. the overall mortality rate was 0.08%, but the mortality rate in children who developed cerebral edema was higher at 6.7% (or: 151; 95% ci: 73-310). mortality was higher in children who had a major operative procedure (1.13% vs 0.07%; or 16, 95% ci: 6-45) and in those with medicaid compared to private insurance (0.11% vs 0.04% p=0. 031) and lower in number of chronic conditions, and hospital charges were significantly higher among non-survivors but there was no difference in the age. the overall mortality rate in children admitted with dka is 0.08%. cerebral edema prevalence is 0.5% and it increases mortality significantly. mullai baalaaji, sunit s. singhi, muralidharan m. jayashree, arun a. bansal. pediatric intensive care unit, department of pediatrics, pgimer, chandigarh, india. near-infrared spectroscopy (nirs), a non-invasive modality to measure regional cerebral oxygenation (rso2), is being increasingly used to monitor cerebral tissue oxygenation. we studied relationship of rso2 with cerebral perfusion pressure (cpp) and intracranial pressure (icp) in children with acute cns infections to determine if rso2 could be used as non-invasive surrogate for cpp. in a prospective observational study we enrolled 31 children, aged < 12 years, with raised icp due to acute cns infections after approval by institutional ethics committee. they were monitored simultaneously for rso2 of both frontal--5100c, covidien-iic), invasive blood pressure, and icp using intraparenchymal fibre-optic catheter (codman). linear trends and correlation coefficients were used to define relation of rso2 with icp and cpp. a total of 3378 paired values of rso2, icp and cpp were analysed. the linear trends during the first 72 hours revealed no significant correlation between changes in rso2 and changes in icp and cpp from baseline (r2=0.007,0.012 for icp and cpp respectively). however, the trend was not uniform -48% patients had no correlation between rso2 and cpp, 29% showed a positive correlation and 23% showed a negative correlation. subgroup analysis revealed that strength of correlation between rso2 and -0.421,p20 mmhg and normal cpp were 6.1(3.4-11.1,p50% respectively. rso2 has complex interaction with icp and cpp; the changes in icp and cpp could not predict changes in rso2. however, the odds for normal cpp was significantly higher when rso2>50% and this cut-off could be used as a non-invasive target for age appropriate cpp. refractory status epilepticus is persistent seizure activity despite treatment with one first-line and one second-line anti-epileptic medication, while seizure activity >24 hours is considered super-refractory. functional outcome for children with these conditions is not well defined. this study describes functional outcome for children with refractory and super-refractory status epilepticus proposing that prognosis will be variable with high mortality. survivors will be and technology dependence. this retrospective chart review evaluated children age 0-18 years who received pentobarbital infusion at texas children's hospital pediatric intensive care unit from 2004-2015 for status epilepticus. outcome was defined using pediatric cerebral performance category score (pcpc) at time of discharge and at the most recent clinical evaluation per the medical record. additional measures included mortality, need for medical technology (tracheostomy or gastrostomy tube), seizure burden, and number of seizure medications at discharge. 42 children met inclusion criteria. in-hospital mortality was 31%, secondary to withdrawal of support (54%), brain death (31%), or cardiac arrest (15%). highest mortality occurred in acute hypoxic ischemic injury (p= 0.04). of survivors, 39% returned to baseline pcpc at discharge while 46% demonstrated tracheostomy and 7 children underwent gastrostomy tube placement. seizures persisted at discharge for most patients with no prior frequency. most children required additional home seizure medications. long-term follow-up was documented for 22 survivors up to 9 years after discharge. 32% demonstrated improved pcpc and 18% showed decline including 3 additional deaths. mortality in this population was high. functional outcome in survivors was variable. some children returned to neurologic baseline by time of discharge and for those who did not, continued functional improvement was possible over time. their s -injury. in addition to standard anatomic imaging, mr sequences obtained "often or always" included: diffusion--perfusionpediatric tbi subjects received an acute mri within 30 days post-injury. fifteen adapt sites, accounting for over 50% of adapt enrollment, committed to recruit adapt subjects for a non-sedated mri scan at one year post -tbi. conclusion: collection of 400-600 acute mri scans from the 1000 subjects enrolled in adapt to study associations between acute mri findings and functional outcome is potentially feasible. allowing for 20% mortality and 50% recruitment rate, recruitment of 100-150 adapt subjects from 15 adapt sites for a follow-up mri to study relationships between advanced mri measures and neurocognitive function is potentially feasible and would represent the largest such study conducted to date. antimicrobial prescribing practices and antibiotic resistance following neurosurgical drain placement: a single-center observational study andrea j. passarelli, hasan h. alhasani. christiana care health system department of pharmacy, newark, de, usa. the use of systemic antibiotics for the duration of neurosurgical drain placement has not been associated with reduced rates of drain related infection (dri) and may contribute to the development of antimicrobial resistance and clostridium difficile infection (cdi). we sought to describe antimicrobial prescribing practices, incidence of dri, and development of antimicrobial resistance and cdi after neurosurgical drain placement at our institution. this was a single center study including adult patients status post ventriculostomy or ventriculoperitoneal shunt or ommaya reservoir, and use of an antibiotic impregnated drain. bacterial cultures and c. difficile pcr during the index admission and 90 days post-discharge were collected. antibiotic resistance was defined as an organism resistant to the prophylactic agent. prolonged prophylaxis was defined as antibiotics continued for >48 hours after drain placement. eighty-one patients with 107 drains were included. the median duration of prophylaxis was 3.3 days and cefazolin was most commonly prescribed agent (85%). three of 48 patients with evds developed dri. prolonged vs. perioperative prophylaxis. of non-dris 60% were resistant to the prophylactic agent used. e. coli, k. oxytoca, and s. aureus had higher rates of resistance to cefazolin compared to our institutional antibiogram, although not statistically significant. no patients developed cdi. the use of prolonged prophylaxis was not associated with a reduced reduction in dri. most bacterial isolates were resistant to the prophylactic agent used. we suggest that antibiotic prophylaxis for neurosurgical drain placement be limited to one preoperative dose within 60 minutes of the procedure the objectives of this study are to evaluate our institution's practice for initiating seizure prophylaxis postoperatively and establish a standard of care. adult patients who underwent cerebrovascular surgery from august 2013 to july 2015 were screened for study inclusion. patients who received lev postoperatively were compared to those who did not receive lev. clinical seizures and data were obtained from retrospective review of electronic medical records. the primary outcome was seizure occurrence in the first 7 days after surgery. secondary outcomes of the 160 patients included in the study, there were 115 in the no lev group and 45 in the lev group. two seizures occurred in the no lev group while no seizures occurred in the lev group (2 vs 0, p=0.373). there were no differences between surgery type, intraoperative blood loss or proportion of asah. of the 25 patients with asah, 64% were not on lev and 1 seizure occurred. of 19 patients with intraparenchymal or intraventricular extension, 63% were not on lev. average length of stay was prolonged for the lev group (12 vs 7 days, p<0.001). the majority of patients did not receive lev postoperatively and there was no difference in seizure developing a standardized approach for initiating lev may decrease variability in practices and streamline postoperative care. post-operative pain control after craniotomy: a meta-narrative review craniotomy is commonly performed for the treatment of a variety of conditions including brain tumors, aneurysms, and vascular malformations. despite significant advances in the quality and efficacy of neuroanesthetic care, there are no evidence-based guidelines for the management of post-operative pain after craniotomy. uncontrolled poststay, increased hospital care costs, and poor health-dencebased clinical decision rules, clinicians often rely on institutional or expert-based opinions to guide their decisionon opioid use, there an urgent need to evaluate existing pain management protocols. hence, we conducted a meta-narrative to evaluate heterogeneity in current practices regarding management of postoperative pain after craniotomy. a meta-narrative review was performed utilizing th terms "pain" and "craniotomy". a total of 344 articles and 16 systematic reviews were resulted. inclusion criteria were studies from 2004-2016, randomized controlled trials, retrospective studies, systematic reviews, case reports, case series published in english were included. of these, 230 articles and 7 systematic reviews were included in the final analysis. there is a paucity of randomized controlled trials to develop evidence based peri-operative pain management protocols in craniotomy patients. there is evidence to suggest that scalp infiltration with local anesthetic may improve post-operative pain scores immediately after surgery. the perioperative use of nonsteroidal anti-inflammatory medications may improve pain scores without a subsequent increase in management of post-operative pain after craniotomy remains a challenging problem for clinicians and patients. there is an urgent need to conduct well designed randomized controlled trials to guide perioperative pain management in craniotomy patients and to use opioid sparing techniques for improving patient outcomes. symptomatic plateau waves are characterized by paroxysmal neurological symptoms suggestive of elevated intracranial pressure such as depressed level of consciousness, pupillary dilatation, and dysautonomia in a patient with an intracranial mass lesion. cli seizures, syncope, or new brain injury. noninvasive cerebral blood flow can be measured using ultrasound-tagged infrared spectroscopy; continuous eeg is sensitive to changes in blood flow. we report two patients without invasive intracranial pressure monitoring who demonstrated changes in blood flow and eeg during symptomatic plateau waves. case series. case 1 was a 24 year-old man with fungal ventriculomeningitis. after a prolonged hospital course, he developed an entrapped 4th ventricle and began to experience periods of complete unresponsiveness with anisocoria, clonus, and tachy-or bradycardia lasting between 10 and 20 minutes. episodes resolved after decompression and ventricular stent placement. case 2 was a 49 year-old woman with intraventricular meningioma who underwent partial resection with entrapment of the right lateral ventricle. on post-operative day 7 she developed multiple episodes of unresponsiveness, diaphoresis, clonus, tachy-or bradycardia lasting 10 to 20 minutes, culminating in a persistent episode requiring urgent craniotomy. in both patients, ceeg was started to assess for seizures and ornim device was used to characterize blood flow. in each, symptomatic plateau waves were accompanied by decreased blood flow, followed by attenuation of faster frequencies on the ceeg. symptomatic plateau waves may be characterized noninvasively by using surface measurements of blood flow and ceeg. this case series demonstrates that decreases in bifrontal blood flow lead to depressions in ceeg during these symptomatic plateau waves. noninvasive measurement of blood flow in conjunction with ceeg provides an adjunct to invasive icp monitoring in patients with mass lesions at an open--sseefficacy of sage-547, a proprietary formulation of allopregnanolone, in patients with super-refractory status epilepti line agents (tlas) while sage-(none attributed by the safety committee to sage-547). post-hoc analyses evaluated the pharmacological effects of sage-547 and the effect of sage-547 administration in the context of multiple antiepileptic drugs (aeds), pressors, and tlas. here we examine the hemodynamic properties of sage-547 in the study patients, with the goal of further understanding the clinical context of sage-547 administration in this critically ill population. burst suppression we maintenance of the tla. key exclusion criteria were anoxic brain injury and very short life expectancy. at enrollment, patients received an average of 3.0 aeds and 1.4 tlas with an average status epilepticus duration of 9.2 days. hemodynamic measurements (heart rate, systolic and diastolic blood pressure) were collected at screening, pre-dose, during sage-547 treatment (15, 30, 45, 60 minutes; 2, 4, 8, 24, 48, 72, 96 , 120 hours) and followwas examined. twenty-five patients received treatment with sage-547. during the study, mean changes in hemodynamic parameters from baseline were limited, both for patients receiving the standard (n=19 patients) and high (n=6 patients) sage-547 dose. regarding hemodynamic parameters, sage-547 was well tolerated in the srse patients studied, suggesting for further study that sage-547 may not elicit immediate or sustained hemodynamic changes in srse patients. real-world studies regarding use of benzodiazepines in pre-hospital and emergency department (ed) was to analyze benzodiazepine usage patterns in se by emergency medical services (ems) and the ed of an inner-city hospital. and september 2015 to ems and hospital ed were reviewed. the associated outcomes of interest were endotracheal intubation, hospital admission, and seizure recurrence. data was analyzed via descriptive statistics. of 44 patients analyzed, 43 (97.7%) had a history of epilepsy. benzodiazepine utilization varied; ems preferred midazolam (69.2%) while the ed used lorazepam most often (91.3%). benzodiazepine dosages used were lower than recommended; median dose of midazolam administered by ems was only 5 mg and median dose of lorazepam in the ed was 2 mg. patients received 2.7 ± 2.1 benzodiazepine doses on average. seizure activity was aborted with benzodiazepines alone in 22 (50.0%) patients and recurred in 12 (27.3%). twenty-three (52.3%) patients were intubated, all post-arrival. there was no observed correlation between number of benzodiazepine doses given and baseline characteristics, decision to intubate, or incidence of seizure recurrence. all 44 patients were admitted and 30 (68.2%) were admitted to the icu. we observed consistent underdosing of benzodiazepines used for the treatment of se by both ems and the ed. there was lower than expected achievement of seizure cessation and intubation rates were higher than reported in previous studies. further investigation is needed to identify the barriers to optimal benzodiazepine selection and dosing for se patients at our institution. super-refractory status epilepticus (srse) refers to a condition of persistent seizures that have failed treatment with first-, second-and third-line treatments. sage-547, a proprietary formulation of the endogenous neuroactive steroid allopregnanolone (a potent positive allosteric modulator of synaptic and extrasynaptic gabaa receptors in animal models), is being developed for the treatment of patients with srse who have not responded to standard treatment regimens. 547-sse-201 was an open-label, phase -547 in patients with srse. the present analysis explores the pk properties of sage-547 over the course of the trial. sage-547was administered as a 5-day continuous intravenous infusion to 25 patients with srse and receiving third line agents (tlas) for seizure or burst suppression. patients received either a standard dosing regimen (n=19) or a high dose regimen (n=6) and were subsequently weaned off tlas and sage-547. the standard dose was chosen, based on a modeling approach, to achieve a mean plasma exposure roughly equivalent to the highest endogenous concentrations measured in the third trimester of pregnancy (~157 nm). since women tolerate this endogenous level without apparent adverse effects, 150 mean (sd) steadyand for the high dose regimen wa -state concentrations were approximately dose proportional between the standard and high doses, indicating that clearance was dose-independent of infusion to allow determination of half-life or volume of distribution. in this study of patients with srse, sage-547 clearance was not dose-dependent and plasma concentrations were in line with target exposures. jennifer a. creed, christa c. swisher. duke university medical center / department of neurology, durham, nc, usa. ****permission was not granted to print this abstract**** seizures after resuscitation from cardiac arrest predict worse outcomes, but there is no evidence that treating seizures improves outcomes. we leveraged existing practice variation to compare the effectiveness of aggressive electroencephalography (eeg) and antiepileptic drug (aed) use to infrequent spot eeg and aed use. we performed a retrospective cohort study including comatose post-arrest patients at two academic centers from 2011-2014. the same critical care group staffs both, but center 1 uses continuous eeg (ceeg) monitoring and aggressively treats malignant eeg patterns while center 2 uses infrequent spot eegs and rarely treats with aeds. we classified each patient's daily eegs from admission until death, malignant," or "not performed." we abstracted covariates and outcomes from our prospective registry, e rhythm, arrest location, survival to discharge and functionally favorable survival. we used multi-level mixed-effects logistic models to test for an association of center with outcomes after adjusting for eeg and clinical covariates. we included 824 subjects (center 1:513, center 2:311). center 1 subjects were younger, arrested more often out-of-hospital and had higher illness severity (all p<0.01). overall, 366 (71%) center 1 subjects were eeg-monitored (median 2 days (iqr 1-4d)), 196 (38%) had a malignant pattern observed and 227 median of 1d (iqr 1-1d), 62 (20%) had malignant patterns observed (less frequent myoclonic status epilepticu center comparisons). in multilevel modeling, there was no significant center effect on outcomes. after cardiac arrest, treatment at a center using aggressive ceeg monitoring and aed treatment is not associated with better outcomes at discharge. phenytoin dosing adjustment for obesity may not be necessary effective loading with weight-based dosing of phenytoin for therapeutic levels is necessary in several emergent settings. practices for dosing obese patients, those >1.3 x ideal body weight (ibw) vary, including using total body weight (tbw), adjusted body weight (adjbw; correction factor 0.4), and the abernathy formula (correction factor 1.33). our objective was to determine whether dose adjustments were necessary for obese patients. charts were reviewed retrospectively from two tertiary medical centers from september 2014 to august 2015. we included all admitted patients older than 18 years of age, initiated on iv fosphenytoin for any reason, with therapeutic post-load level (total phenytoin of 10-in pre-mean weight-based loading doses were compared for obese and non-obese patients who achieved postload levels in the therapeutic and high therapeutic range (total level 15-20, free 1.5-2.0), using welch's two-sample t-tests. a total of 56 patients, 39 non-obese and 17 obese, met inclusion criteria, including 20 non-obese and 7 obese patients who achieved high therapeutic levels, desired for ongoing status epilepticus. the mean -obese and 16.4 (95% ci: 14.5, 18.2) for obese patients (t29=2.4, p = 0.02). dose to achieve high therapeutic levels was 20.2 (95% ci: 19.3, 21.0) for non-obese and 18.1 (95% ci: 15.9, 20.3) for obese patients (t9=2.1, p = 0.06). our results suggest that adjustment calculations of fosphenytoin loading dose for obese patients may not be necessary, thus can all patients into high therapeutic range, especially desirable in status epilepticus, while not harmful in other patients. stephen sage-547 is a proprietary formulation of allopregnanolone. sage-547 was studied in an open-label nical study of patients with super-refractory status epilepticus (srse). the primary -547. -547 in resolving srse in these patients. to further understand the specific patient and treatment-related parameters which may affect outcomes in this study, we performed a post-hoc analysis on the completed data set. in this open-label, single-treatment with sage-547. key efficacy outcome measures were: 1) successful wean off of tla(s) after hour 48; and 2) subsequent successful taper off sage-547 after hour 96, without recurrence in the 24hour period following treatment. a total of 25 patients received open-label treatment with sage-sage-547. response rate appeared consistent across varying patient demographics (gender, age, ethnicity) and baseline treatment regimens. overall, 64% of patients experienced at least 1 serious adverse event (sae) and 6 patients died during the trial. no saes and no deaths were attributed by the safety committee to sage-547 administration. there was little evidence of a relationship between response rate and patient demographics (gender, -trial supports further investigation of sage-547 in srse, and can inform inclusion criteria for future trials. the clinical efficacy and safety of sage-547 in the treatment of srse is being evaluated further in an ongoing phase 3, randomized, placebo-controlled trial. jocelyn y. cheng. drexel university college of medicine, philadelphia, pa, usa. in catastrophic neurologic injury, withdrawal of care (woc) is often considered. while woc is based on the perception of poor prognosis, the question of whether it creates a self-fulfilling prophecy has been raised. though studied in traumatic brain injury epilepticus (se) is unclear. the goal of this study was to describe the final cause of death in adults with se, and determine the impact and associated clinical characteristics of woc on mortality rates. a single-center retrospective study at an urban academic medical center was conducted between age;gender;glasgow coma scale (gcs);acute physiology and chronic health evaluation-ii (apache-ii);history of epilepsy;etiology of se;refractory se (rse);in-hospital mortality; and cause of death. -tests were used as appropriate. binary logistic regression analysis adjusted for covariates, and p <0.05 was considered significant. of 151 subjects, 68 male, mean age 59 years, there were 61(40.4%) in-hospital deaths, 45(74%) due to woc. the remaining causes were cardiogenic(n=11,18%) and respiratory(n=2,3.2%), with sepsis, brain death and seizures individually comprising 1.6%(n=1 each). excluding woc, in-hospital mortality fell to -group without cardiac arrest (ca), inof which 14%(n=15) was due to woc; mortality decreased t the total cohort, there was no significant difference in baseline characteristics excepting metabolic seizure were more common in woc subjects. metabolic etiology (or:6.50,p=0.005) and ca (or:4.40,p=0.018) remained significantly associated with woc after univariate but not multivariate adjustment. withdrawal of care is a major determinant of mortality in se, and is associated with metabolic dysfunction clinical decision an open--sse-201) evaluated the safety and efficacy of sage-547, a proprietary formulation of allopregnanolone, in patients with super-refractory status epilepticus (srse). entry criteria were designed to maximize patient treatment opportunities. the objective of this post-hoc analysis was to demonstrate sage-547 activity despite heterogeneity of srse causes and high comorbidity burden. d-line agent (tla; with anoxic brain injury or very short life expectancy were excluded. -76 years) and mean status epilepticus duration was 9.2 days (range 3-20 days). probable srse causes included infection, hemorrhage, worsening cgi-s score. all patients required 1-2 tlas and 1-5 aeds at baseline. up to 8 weans from tlas were sage-547 at the end of 5 da six patients (24%) died from underlying srse cause or associated comorbid conditions. no saes were attributed by the safety committee to sage-547. mean numbers of baseline wean attempts, comorbid conditions, and srse episode duration were comparable between responders and non-responders. activity despite the heterogeneity of cause of srse and comorbidity burden. delayed neurologic deterioration (dnd) from vasospasm is associated with poor outcome after subarachnoid hemorrhage. continuous eeg (ceeg) monitoring has lead to detection of eeg patterns of uncertain clinical significance -ictal-interictal continuum (iica). these have been associated with acute brain injury but variably predict outcome. we describe the types and prevalence of iica eeg patterns in patients who develop angiographic vasospasm and discharge outcomes retrospective study of adult patients with non-traumatic subarachnoid hemorrhage admitted at emory university hospital neuro-icu from january 2013-february 2016 who underwent ceeg. ceeg were recorded using 10-20 electrode placement and interpretation of the iica eeg patterns using the american clinical neurophysiology society research terminology. in 131 sah patients, 95(73%) were female and hypertensive 88 (67%). majority had poor grade sah (40% hh grade 3, 24% grade 4 and 17% grade 5). moderate to severe angiographic vasospasm were detected in 74 (56%) patients 5.7 days after admission. ceeg was initiated 4.17 days after admission. periodic discharges (pds) occurred in 42(32%) patients, 14(33.3%) of which were generalized and 19 (45.2%) lateralized. rhythmic delta activity (rda) occurred in 33(25.10%) with 26(78.7%) generalized. stimulus induced rhythmic discharges (sirpids) were seen in 9 (6.8%) and electrographic seizures in 5(3.80%) patients. vasospasm was common in patients with any iica patterns (77.5% vs. 22.4% p=0.36), pds (77.5% vs. 22.4% p=0.56) and rdas (84.3% vs. 15.6% p=0.12). rdas were common in patients with discharge mrs 0-4 (59.3% vs. 40.7% p=0.12) and pds were equally seen across all outcomes (50% vs. 50% p=0.56). the observed trends were not statistically significant. iicas such as pds and rdas were common in patients who developed vasospasm but seen equally with a larger sample size is needed to support these findings. ncs and (ncse) have been reported in 8-25% of critically ill patients. whether patients with ncse should be treated as aggressively as patients with convulsive status remains controversial. this study sing on its correlation with patients' outcome and possible predictors. in this retrospective study n=261 patients underwent ceeg at mount sinai neurological and neurosurgical icu (nsicu). ceeg data according to acns guidelines was collected. outcome was evaluated by mortality, glasgow outcome scale (gos), glasgow coma scale (gcs). we compared 29 seizures were detected in 41% of subjects and 11% experienced of cg (p=0.000 or 27.8 ci 5.53of cg (p=0.019, or 4.93, . considering clinical predictors, only gaze deviation and subtle facial movements were significant (p=0. 003 or 4.7, p= 0.000, . mortality and mean hospitalization length were not different. outcome was significantly different in nsicu with mean gcs being 8 in ng and 11 in cg (s for p= 0.004), but was not significantly different at discharge, as mean gos was 2 in ng and 2.4 in cg (p=0.076). our findings show that patients' history of epil rstand prognostication in these patients. raquel farias-moeller, archana a. pasupuleti, luca l. bartolini, amy a. kao, brittany b. cines, jessica j. carpenter. children's national health system, washington, dc, usa. super refractory status epilepticus (srse) ensues when there is no improvement of seizure control in response to anesthetic therapy or seizure recurrence after reduction of anesthetic agents. there is no consensus on standard of care for srse. ketogenic diet (kd) has reported success but technical challenges exist including inability to feed patients, concomitant steroid use, persistent acidotic states and ur step-by-step approach to initiation and continuation of kd in the picu. patients with srse who had kd initiation in the picu were identified from a prospective neurocritical care database with irb approval. data from the hospital course was supplemented by review of the electronic medical record. descriptive analysis was performed. neurointensivists used our step-by-step guideline to start patients on kd. nine children with srse who had kd initiated in the picu were identified. the mean age was 5.4 years (sd 2.24). median number of days to start kd from detection of seizures was 13 . mean time nine children remained on the kd for 3 months or longer. the median number of aeds trialed before kd was started was 4 [iqr 3-4] and the median number of continuous infusions was 2 [iqr 2-3]. after initiation of kd most patients were weaned off continuous we demonstrated the feasibility of a practical approach to initiation of kd in the picu for children with srse. these children were successfully weaned off continuous anesthetic infusions. larger studies, both in children and adults, are needed to determine the effectiveness, safety and tolerability of kd in the management of srse as well as its ease of implementation. although overall mortality of status epilepticus is high, baseline patient characteristics and co-morbidities may help to predict outcomes and shape treatment decisions. two previously published scores exist to predict outcomes: the status epilepticus severity score (stess) and the epidemiology-based mortality score in status epilepticus (emse). however, a comparison of the two scores has not previously been completed in an american population. we hypothesize that both scores will adequately predict the primary outcome of in-hospital death. we performed a retrospective analysis of all cases of status epilepticus admitted to the neuro-critical collected data on age, comorbidities, eeg findings, and seizure history. the primary outcome was inhospital death. a sensitivity and specificity analysis was completed, in addition to a student's t-test for a comparison of the two scores. forty-six patients were admitted to the nccu for management of status epilepticus during june 2014 and january 2016, 13 of which experienced in-hospital death. the median age of the sample was 60, with approximately half of the sample (52.6%) having 3 or more comorbidities. the two most common etiologies were cryptogenic (n=9) and acute cerebrovascular events (n=7). while the sensitivity of both emse and stess were very high (100% and 90% respectively), the specificities were very low (28.6% and 42.9% respectively). a student's t-test between those who experienced in-hospital death and those who did not was only significant for emse at the p<0.1 level (p=0.055). the specificity of emse and stess for our external validation did not correlate with previous studies; however, both tools are sensitive. the emse and stess may be useful to predict outcomes of status epilepticus in populations with few comorbid conditions, but are less helpful when patients have multiple medical problems. in 2012, the acns published critical care eeg terminology in an effort to improve clinical research and management of patients requiring continuous eeg (ceeg) monitoring. we sought to understand the familiarity of providers in our neurocritical care (ncc) program with this terminology two years after implementation at our institution. we administered a 21 question web-based survey to ncc fellows, advanced practice providers (apps), tanding of acns terminology, and clinical eeg application. there were 5 attending physicians, 4 ncc fellows, and 13 apps. attending physicians and apps had a median of 4 (range: 3, 13) and 2 years (range: 0.25, 15) experience since most recent post graduate training, respectively. all data is reported for apps and physicians respectively as percentage correct. highest rated component of the ceeg report that influenced patient management was "conversation with lected by 92.3% of apps and 100% of physicians. set forth by the acns and highlight the importance of communication between ncc providers and epileptologists as well as areas of potential education for providers of all training levels. carbamazepine (cbz), an oral antiepileptic drug (aed), is a potent inducer of cytochrome p450 (cyp) (eg, phenytoin, fosphenytoin, phenobarbital, valproic acid, levetiracetam, or lacosamide) to reduce the -drug metabolism (reduced efficacy or toxicity). an iv cbz formulation has been developed; study ov-1015 (nct01079351) evaluated bioequivalence and 13181a (nct01128959) evaluated tolerability. both studies were similarly designed. eligible adult patients received a stable oral cbz regimen (400daily dosage (divided doses q6h) during the confinement period (ov-1015: 15-or 30-min infusions q6h for 7 days, patients in the 15-min group were eligible to receive four 2-to 5-min infusions on day 8; 13181a: 15-min infusions q6h for 4 days, then one 5-min infusion on day 5). oral cbz was resumed for 30 days (13181a: 28 days). bioequivalence of iv to oral cbz was evaluated in ov-1015; tolerability data were pooled. in ov-1015, 30-min iv cbz infusions were within the 80%-125% bioequivalence range vs oral cbz; 15min infusions exceeded the upper limit for maximum plasma concentration. in both trials, 203 patients switched to iv cbz (30-min: n=43; 15infusion was dizziness (19%); infusion-site reactions (12%) were the only new aes experienced by patients vs oral cbz. seizure control was maintained during the switch. to avoid potential drug toxicity reactions, it is beneficial to maintain patients on cbz. iv cbz administered as multiple 30-min infusions was bioequivalent to oral cbz. iv cbz was well tolerated. treatments for aneurysmal subarachnoid hemorrhage (asah) remain inadequate. eg-1962 is a sustained release formulation of nimodipine for intraventricular delivery in order to avoid dose-limiting -label, dose escalation study of a single intraventricular dose of eg-1962 that was designed to determine the maximum tolerated glasgow outcome scale (www.clinicaltrials.gov identifier: nct01893190). subjects with asah repaired by clipping or coiling were randomized within 60 hours of asah to eg-1962 or oral nimodipine if they were world federation of neurological surgeons grade 2 to 4 and had a ventricular catheter. cohorts of 12 subjects received 100, 200, 400, 600, 800 or 1200 mg eg-1962 (9 per cohort) or oral nimodipine (3 per cohort). plasma nimodipine concentrations were sustained for 21 days. the maximum concentration, steady state concentration and area under the curve for the first 14 days increased with increasing dose of egbetween males and females. plasma nimodipine concentrations following eg-1962 administration did not exceed plasma concentrations of oral nimodipine 60 mg every 4 hours at steady state. cerebrospinal fluid nimodipine concentrations with eg-1962 were orders of magnitude higher than in plasma or with oral nimodipine. subjects treated with eg-1962 (n=45) had a median intensive care stay 3.5 days less and hospital length of stay 2.5 days less than subjects treated with enteral nimodipine (n=18 , table) . intraventricular eg-1962 produced sustained, dose-dependent nimodipine plasma concentrations and shortened intensive care and hospital length of stay. improved clinical outcome support conduct of a pivotal phase 3 study of eg-1962. increasing exposure to ionizing radiation for medical diagnostics and treatment has raised questions about possible long term effects. this study describes the effective dose of ionizing radiation exposure in patients with aneurysmal subarachnoid hemorrhage (asah). thirty-five asah patients admitted to a university hospital between jan 1, 2015 and december 31, 2015, greater than 18 years old, and discharged alive were included. the primary objective was to calculate the mean total effective dose of ionizing radiation (tedir) in asah patients. secondarily, the number of asah patients with a calculated tedir greater than the annual and cumulative maximal permissible radiation dose (mprd) as described by the national council of radiation protection and measurements (ncrp) and the international commission on radiological protection (ircp) was determined. factors associated with greater than maximal exposure limits were evaluated. tedir exposure ranged from 5.7-89.2 millisievert (msv), with a mean (sd) of 32.1 (21.79) msv. seven , the presence of vasospasm (p<0.01), external ventricular drain (evd) (p <0.01), or ventriculo-peritoneal shunt (vps) (p< 0.05) were statistically significant factors for increased tedir in asah. demographic data, previous medical history, and location of aneurysm were not statistically significant. univariate analysis representing the degree to which tedir increases for each of these factors revealed hh class (3 or 4) 20.2 (p<0.01), vasospasm 24.4 (p<0.01), evd 22.3 (p<0.01), vps 21.5 (p<0.05). in multivariate analysis representing the degree in which the tedir increases, only vasospasm 26.1 (p<0.01) and evd 14.4 (p<0.01) were statistically significant factors. following asah, patients with severe disease requiring vasospasm treatment and shunting are at warranted. patients with aneurysmal subarachnoid hemorrhage (sah) have high morbidity and mortality related to cerebral ischemia and infarction. in this study we explored the reversibility of reduction in cerebral blood flow (cbf) after sah. we conducted a retrospective analysis using prospectively collected ct perfusion (ctp) data from sah patients. patients were grouped as good (hunt hess 1-2) and poor grades . ctp data were compared at baseline (0-4 days after aneurysm rupture) and follow-up (>5 days). cbf at baseline was comparable between good and poor grade patients (39.06±9.75 vs. 38.16±11.00 -up there was an improvement from baseline in both groups (42.27±9.08 and 40.23±9.53 respectively, p=0.06). however, in hypoperfused areas, rcbf was significantly lower in poor grade patients compared to good grade (24.71±9.06 vs. 31.25±10.60, p=0.003) and significantly lower than global cbf in both groups (p<0.001). at follow-up, only poor grade patients demonstrated an increase in rcbf (29.02±9.55, p=0.01) while in good grade patients, rcbf remains unchanged (31.79±9.86, p=0.41). the absolute improvement in rcbf was significantly greater in poor grade patients ow-up in both groups was not statistically different in the two groups (p=0.09) but significantly lower than global cbf (p<0.001). regional hypoperfusion occurs after sah. in good grade patients there is no recovery in rcbf while in poor grade patients there is partial recovery implying a biphasic response with a reversible and an irreversible reduction in rcbf. this has not been previously described in the literature and may implicate two distinct mechanisms responsible for rcbf reduction after sah. aneurysmal subarachnoid hemorrhage (asah) is an important cause of morbidity and mortality, with patients susceptible to a variety of medical complications. external ventricular drains (evds) are commonly used for intracranial pressure monitoring and csf drainage; however, this puts asah patients -associated infections (vais). many preventative strategies have been proposed and implemented over the last 20 years. using the nationwide inpatient sample (nis) database, this study examines trends in evd usage, vai rates, and mortality over a 12-year period. in this retrospective analysis, data from the nis was obtained for the period of january 1, 2000 through december 31, 2011 using international classification of diseases, 9th revision (icd-9) codes. analysis was performed using sas 9.4 surveymeans. primary outcomes of interest were rates of evd use, vai and in-patient mortality, as well as hospital length of stay. during the study period, there were 422,168 asah admissions, with evd placement reported in 15.8% of cases. there was no change in either evd use or rate of vai (mean vai rate of 5.91% over the 12 years). no change in hospital length of stay was observed. from january 1, 2000 to december 31, 2011, despite a variety of vai-preventative strategies advocated for and implemented, the national vai rate in asah patients has not changed; however, mortality has declined by a mean arr of 0.83% per year over the study period. this may reflect improved neurointensive care provided to this critically ill population. stable vai rates may reflect incomplete adoption of effective preventative strategies, or use of ineffective o study has previously examined these trends in asah. the purpose of this study was to determine the effect of routine use of dexamethasone on delayed cerebral ischemia and poor outcome (death and severe disability) after aneurysmal subarachnoid hemorrhage (asah). this is a single center, observational cohort study comparing patients with asah admitted to a tertiary referral center from 2013 to 2015. a variation in practice patterns for the use of dexamethasone 4-6 mg every 6 hours after asah exists in our institution depending on neurosurgeon preference. patients were followed prospectively for the occurrence of complications including delayed cerebral ischemia (dci), e (bad outcome defined as a mrs of 4-6) and 3 months (bad outcome defined as mrs of 3-6). out of the 173 patients, 59 (34%) patients received dexamethasone during the first 72 hours of admission. significant factors associated with steroid use were females (41% v 21%;p=0.01) and aneurysm clipping verses coiling (55% v 27%;p<0.01). there was no difference in hh, fisher grade, incidence of infections, or incidence of dci (34% v 23%;p=0.15). steroid use was significantly associated with bad outcome at discharge (72% v 50%;p=0.01), but no difference at 3 months (34% v 31%;p=0.7). when examined separately for coiled and clipped patients similar trends were found in both subgroups. steroid use was associated with a longer hospital length of stay (los). in multivariable regression analysis steroid use was significantly associated with worse outcome (or 3.6;p<0.01) when controlled for age, hh grade and type of surgical intervention. the study did not detect any benefit in the use of steroids in reducing the incidence of delayed cerebral ischemia in acute aneurysmal subarachnoid hemorrhage. however, steroid use was significantly associated with longer los, and worse functional outcome at discharge. antiplatelet therapy for the prevention of peri-coiling thromboembolism in high risk patients with ruptured intracranial aneurysms thromboembolic events (tee) during or after coiling of intracranial aneurysms is the most frequent procedural complication, resulting in permanent neurologic disability in a subset of patients. in unruptured aneurysm patients, there is evidence supporting the use of periprocedural antiplatelet therapy to prevent tee. whether patients with ruptured aneurysms and subarachnoid hemorrhage should also be given peri-coiling antiplatelet therapy is less clear. we reviewed a prospective registry of 169 endovascularly treated aneurysm patients to delineate angiographic features associated with periprocedural tee. we then performed a controlled before-andangiographic feature associated with tee) to evaluate whether selective aspirin administration would reduce the rate of periprocedural thromboembolism without increasing major hemorrhagic complications. small parent artery diameter, an incorporated branch, intraprocedural thrombus formation, and parent rate of periprocedural tee, from 53.8% in the control group to 10.6% in the aspirin-treated group (p = 0.001). tee reduction in the aspirin-treated group continued to be statistically significant even when ith tee in other large studies with an adjusted or of 0.16 (95% ci 0.03 -0.8). there were no major systemic hemorrhagic -bleed, symptomatic intracranial hemorrhage, or major external ventricular drain (evd)-associated hemorrhage (p = 0.3). significantly reduce the rate of peri-coiling tee without increasing major systemic or intracranial hemorrhages. neurocrit care (2016) 25:s1-s310 muhammad k. athar, umer u. mukhtar, umer u. shoukat, david d. boorman, fred f. rincon, matthew m. vibbert, syed s. shah, jacqueline j. urtecho, jack j. jallo. thomas jefferson university hospital, philadelphia, pa, usa. fever is frequent in patients with subarachnoid hemorrhage (sah). differentiating infectious fever from central fever can be challenging. it is important to diagnose the cause of fever in the neurological intensive care unit (nicu) because of the detrimental effects of fever on brain injured patients. we hypothesized that procalcitonin (pct) could be useful to distinguish central fever from infectious fever in patients with sah. prospective, chart review study conducted in the nicu between december 2012 and september 2015. was clinical infection defined as positive cultures (blood, urine, sputum, mini bal, csf, and c. difficle toxin) or infiltrate on chest x-ray within 3 days of onset of fever. sixty-twenty--0.5, and 16 had pct >0.5. out pct >0.5. using multiple logistic regression, pct between 0.1-0.5 had an odds ratio of 5.34 (95% ci 1.20-23.73), pct >0.5 had an odds ratio of 64.82 , and a maximum temperature odds ratio of 1.825 (ci 1.095-3.042). using pct >0.5 alone had an odds ratio of 10.11 (95% ci 2.51-40.74). -pv: 70.0% with a sample prevalence of 42.4%. roc curve area: 78.2%. fever in sah patients. the test has high specificity and npv so it can be a valuable toll to rule out infectious fever in nicu. intraventricular hemorrhage (ivh) due to subarachnoid hemorrhage (sah) has been associated with fever, hydrocephalus, and shunt dependence. the modified graeb score (mgs) as an enhanced measure of intraventricular hemorrhage has been shown to correlate wit intracerebral hemorrhage (ich) as well as shunt dependency in sah. we evaluated the mgs's association to complications during hospital stay and impact on functional independence at discharge in sah patients. retrospective review was performed of prospectively collected data for consecutive sah patients enrolled into the university of maryland recovery after cerebral hemorrhage (reach) study. hunt and hess (hh) grade, global cerebral edema (gce), and infarct on admi team of neurointensivists. mgs was calculated from each patient's admission ct scan and dichotomized according to a cutoff value based on the median value for our sample. clinical complications during each admission were recorded, and independence of performing adl's was obtained from physical and occupational therapy notes. statistical analysis was performed using univariate and multivariate logistical regression. ninety-eight sah patients from july 2014 to november 2015 were reviewed for this study. mgs was calculated in 83 patients and dichotomized based on a median cutoff value of 5. hh, gce, and admission infarcts were not found to be significantly associated with high mgs. on univariate analysis, elevated mgs was significantly associated with hospital acquired infections (uti, pneumonia, and sepsis, p<0.03), fever (p=0.02), hypotension (p=0.002), hypernatremia (p=0.046), symptomatic vasospasm (p<0.03), and new i independence with adl's (p=0.02). severity of ivh as measured by mgs is associated with multiple in-hospital complications. the mgs can be used as an independent predictor of loss of independence of adl's on discharge for patients with sah. ed cerebral ischemia (dci) and brain injury following subarachnoid hemorrhage (sah). while systemic corticosteroids may mitigate inflammation and promote fluid and salt retention following sah, there is limited evidence on the impact of corticosteroid administration on outcomes following sah. corticosteroids are frequently administered in clinical practice following sah for the management of post-operative cerebral edema and refractory headache. our goal was to examine the impact of corticosteroid use following sah on the occurrence of dci and poor functional outcome at discharge. retrospective analysis of data from a single center sah registry on patients admitted between 2010-2015 who survived >24 hours. a logistic regression model was created with multiple potential predictors of outcome and steroid use, and with corticosteroid use as the response variable. patients were divided into quartiles based on the propensity score. the impact of corticosteroid use on the outcome of interest (dci then poor functional outcome at discharge) was then determined while controlling for the propensity score quartile. co-variates in analysis included age, gender, ethnicity, history of diabetes or statin use, aneurysm location, aneurysmal vs non-aneurysmal bleed, treatment modality, hunt hess, modified fisher. a total of 440 patients with aneurysmal and nonaneurysmal sah were included in this analysis. corticosteroids were administered in 166 (37.7%). dci occurred in 122 (27.7%). poor outcome (mrs>3 at discharge) occurred 174 (39.5%). following propensity score analysis, corticosteroid use was not associated with dci (p=0.826) but was associated with a significant reduction in poor outcomes at discharge (p=0.038, or 0.609, 95% ci 0.381-0.972). corticosteroid use following sah was not associated with a reduction in dci but was associated with an approximately 40% reduction in the odds of poor functional outcome at discharge. a clinical trial of corticosteroids initiated in the early period following sah may be warranted. besides the impact of the initial bleeding, cv remains the leading cause for mortality and morbidity after successful cian therapy? data of 30 patients with cian were analyzed with regard to onset of multimodal neuromonitoring, if one or both hemispheres were monitored and for the integration of neuromonitoring values in decision 6 months after sah using the glasgow outcome scale (gos). ct-scans were reviewed for infarctions at time of discharge. 24 patients were in the favourable outcome group (gos4-5), 6 patients showed unfavourable outcome (gos 1-3). in 4 patients of the gos 1-3 group neuromonitoring was implanted in the hemisphere with the highest transcranial doppler (tcd) values. additional monitoring was installed contralaterally if tcds increased. in 3 of those patients, contralateral pbto2 values were ischemic and angiography revealed severe cv in the non cian treated hemisphere. ct scans of those 3 patients revealed significant infarctions in the hemisphere that was not initially monitored. the 24 patients with gos 4-5 were monitored bilaterally at early timpo small infarctions but no territorial infarct was seen at discharge. a delay in bilateral multimodal neuromonitoring might facilitate delayed cerebral ischemia (dic). this might be due to a delayed detection of a mismatch between oxygen supply and consumption. in addition severe cv is not always detectable in tcd and might thus be diagnosed too late to initiate a successful cian therapy. in contrast, new severe cv or relaspses of cv after stop of cian therapy are detected efficiently if bilateral neuromonitoring is in place and the values are acted upon accordingly. the effects of short versus longer duration prophylaxis of levetiracetam on cognitive / functional outcomes in aneurysmal subarachnoid hemorrhage and risk of development of delayed seizures tamara majic, dela d. amoussou, chrystal c. reed, asma a. moheet. cedars sinai medical center, los angeles, ca, usa. chart review performed on 136 patients admitted from january 2010 to december 2015 with asah, who received levetiracetam seizure prophylaxis 500 mg bid or greater for <3 days versus 7 days or more. we compared the length of icu stay, delta gcs at discharge, mrs (30 vs 90days), and incidence of delayed seizures --1.05 ; p < 0.453) lengths of icu stay for short-duration levetiracetam therapy was 1 --6.54 for long-duration (p<0.378). length of icu stay in low dose --6.6 days (p < 0.1). preliminary data for early and late onset seizures delayed seizures occurred with longer duration prophylaxis preliminary data suggests delayed cerebral ischemia was universally present in patients with delayed seizures. the incident rate of dci was higher in patients with early seizures (40%) vs without seizures (20 %) between low dose and high dose, and between short duration and long-duration levetiracetam therapy. length of icu stay is shorter in subjects treated with low dose levetiracetam vs high dose, which may suggest that a low dose levetiracetam may have a lower adverse effect profile. the presence of delayed ischemia may warrant a longer duration prophylaxis. the longer duration prophylaxis does not seem to reduce the incidence of delayed seizures, although a longer duration of study is warranted. in spite of improvements in mortality and physical disability for aneurysmal subarachnoid hemorrhage for 'delayed brain injury' often attributable to the direct neurotoxic and neuroinflammatory influence of the initial hemorrhage burden. these processes can result in global brain atrophy and commonly manifests as new cognitive disability including deficits with memory, executive function, and language. heparin exerts a wide range of interactions postulated to antagonize multiple pathophysiological mechanisms implicated in asah. here we review low-dose iv heparin (ldivh) as a promising treatment for preventing 'delayed brain injury' in asah survivors and inform on a new multi-center randomized trial. recent studies evaluating ldivh in asah are reviewed. the astroh study is an open-label, blindedadjudication, randomized phase ii trial. the primary efficacy outcome is mean montreal cognitive assessment (moca, 0-30, normal 26-30) scores at the 90-day follow-up and 88 patients will be enrolled over 2 years at 9 academic medical centers. the primary safety outcome is any major bleeding or clinically relevant non-major bleeding. one-year outcomes are also being assessed. ldivh significantly reduced neuroinflammation, demyelination, and transsynaptic apoptosis in a rat sah model. in a retrospective study 43 ldivh patients were compared to 43 well-matched controls. ldivh subjects had 9% clinical vasospasm and 0% vasospasm related infarction compared to 47% and 21% respectively in controls (p=0.0002 and p=0.003). in another retrospective cohort study ldivh patients (n=25) had mean moca of 26.4 compared to 22.7 in controls(n=22) (p=0.013). multivariate analysis confirmed ldivh positively influenced moca scores when controlling for factors that negatively influenced cognition. the astroh study is active and enrolled its first subject in april, 2016. ldivh is a promising treatment for asah and is currently being investigated in a multi-center randomized trial (astroh), nct02501434. gastrointestinal bleeding (asah) patients and to determine the effect of gib on in-hospital complications and outcomes. gib in asah patients and to determine the effect of this complication on other in-hospital complications and outcomes. the incidence of gib in asah hospitalizations (n=239,808) was 1,363 per 100,000 patients with 24.7% requiring blood transfusions. multivariate independent predictors of gib included: age 55-64 gib in asah is uncommon and is influenced by patient demographics and preexisting comorbidities and significantly increases disability and mortality. twenty-six consecutive asah patients undergoing multimodal neuromonitoring including cmd were studied. interventions of full-strength enteral nutrition (en) after >4 hours without any feeding preceding en were identified. parameters of systemic and cerebral metabolism and insulin dose were timeand analyzed together with continuous variables to study the effect of en on brain metabolism (glucose, lactate, pyruvate and glutamate). out of 208 interventions in total, 145 were excluded because of simultaneous parenteral supplementation or missing values, leaving 63 interventions in 17 patients eligible for analysis. the mean en--glucose significantly increased from perfusion pressure (cpp), baseline serum and brain glucose levels, the baseline metabolic profile [brain metabolic di and independent of the insulin dose given during the intervention. the increase of cmd-glucose was strongly dependent on the delta increase of serum glucose (median during the intervention (p<0.01). although probe location influenced absolute cmd-glucose-levels (p<0.001), significant increases were even observed in perilesional brain tissue (p<0.001). no change in cmd-lactate, cmd-pyruvate, cmd-lpr or cmd-glutamate levels were observed (p over 0.4). brain glucose levels increased during enteral feeding independent of cpp, baseline glucose levels, insulin administration, and probe location. despite this increase, no additional metabolic improvement was observed. the clinical benefit of interventions ta needs to be investigated in a prospective approach. mean platelet volume (mpv) is a common daily laboratory investigation in subarachnoid hemorrhage diseases and is postulated to signify increased systemic thrombogenicity. similarly, diabetics have elevated mpv suggestive of associated vasculopathic complications through increased thrombogenicity. with non-aneurysmal sah (nasah) as compared to aneurysmal sah (asah). hence, we investigated if vasculopathy. we reviewed charts of patients admitted with the diagnosis of sah between january 2011 and december 2015. we compared proportions using fisher's exact tests, and constructed roc curves to find threshold values for admission mpv that had the best combination of sensitivity and specificity to predict nasah versus asah. of the 237 patients who met the inclusion criteria 200 were asah. diabetic patients who presented with diabetic patients, a threshold value for mpv of 8.97fl yielded the best combination of sensitivity and specificity to predict asah vs nasah (auc=0.6; 95% ci 0.5, 0.7). using this threshold, sah is more -similar mpv association was not observed among diabetic patients presenting with sah. mean mpv at admission did not differ between diabetic patients who presented with asah (9.1fl) and those who presented with nasah (8.9fl, p=0.36). nonng with sah. aneurysmal subarachnoid hemorrhage (asah) is associated with mortality rates up to 20%, and up to one half of survivors suffer from long term neurologic disability. though several clinical scores have been developed to predict in-hospital mortality and long term outcomes, there is no universally accepted score. create a new predictive model. we conducted a retrospective chart review of patients admitted with asah to a single neurocritical care unit from september 2011 to february 2016. we excluded patients with non-aneurysmal sah (including trauma, avms, and mycotic aneurysms). demographic and clinical variables collected included age, admission gcs, admission apache ii score, hunt and hess score, presence of delayed cererbral ischemia, and hospital acquired infections. our outcome measure was glasgow outcome scale at discharge. we created a penalized logistic regression model to determine predictors of outcome. we assessed performance by estimating the area under the roc curve (auc). of 204 patients reviewed, 160 met inclusion criteria. the mean age of the cohort was 58 years. 69.4% (n=111) of patients were female. the mean apache ii score on admission was 14.4 (median 13.5). majority of patients (n= 97, 60.63%) had a discharge gos of 3. a combination of 5 predictors performed optimally: age, admission apache ii, gcs, use of mechanical ventilation and presence of hospital acquired infections. the mean auc of the model was 89%. at the point of maximum-accuracy on the roc curve, the sensitivity was 96%, and specificity was 68%. clinical features at admission and during hospitalization can predict outcomes in patients with asah. clinical characteristics from the first few days of the hospital admission, such as hospital acquired infections, can be added to existing models, to improve outcome prediction scores. subarachnoid hemorrhage (sah) patients may experience supply-demand mismatch of cerebral metabolism from seizures, vasospasm, cortical spreading depolarization, hydrocephalus, or cerebral edema. previous studies have focused on non-neuronal measures of cerebral autoregulation. we examine the impact of various neurocritical interventions by examining anecdotally identified intracranial eeg (ieeg) responses considered clinically impactful as well as systematic examination of repeated interventions within patients. sah patients of hunt-hess grade 3-5 underwent 1) clinical multimodality neuromonitoring utilizing brain tissue oxygen cerebral oximetry, cerebral blood flow, spencer depth electrode, and fiberoptic icp through a quadconsent using time-synchronized monitoring (cns-210, moberg research). we reviewed clinician anecdotes of treatment responses to vasopressors, endovascular vasodilators, anti-seizure pharmacotherapy, nimodipine, and ventriculostomy adjustments. we then assessed each patient's response to multiple grouped interventions using spectral features including alpha-to-delta ratio (adr) normalized to pre-intervention baseline (nadr). paired t-tests and scatter plots, respectively, demonstrated the impact of interventions and blood pressure on nadr. 12 patients had available post-sah ieeg data over 22 months. of 5 patients with post-procedural brain responded with an increase in ieeg alpha activity power. two patients developed a decline in adr associated with asah-related vasospasm, one who had eeg improvement after endovascular spasmolysis. two patients developed scalp-negative ieeg seizures, both electroclinically improving with anti-seizure pharmacotherapy. grouped interventions showed heterogeneous responses to vasopressors and one patient with a significant, repeated response. nimodipine had no consistent discernible peri-dose impact on nadr. we display scatter plots showing the peri-intervention patient-specific correlation between mean arterial pressure and nadr. patients with aneurysmal sah may develop neuronal impairment rescuable by neurocritical care interventions. our data show these responses are patient-and statemodels of dynamic sah pathophysiology. introduction: (dci), may be an important determinant of outcome following subarachnoid hemorrhage (sah). potentially, early treatment measures such as control of intracranial pressure, blood pressure management and initiation of nimodipine may mitigate ebi. our objective was to study the impact of delayed presentation to medical care on the occurrence of dci and poor outcomes following sah. retrospective analysis from a single center sah registry. patients admitted between 2011 and 2015 for nontraumatic sah, who survived more than 24 hours were eligible for inclusion. [vr1] the explanatory variable of interest was time from symptom onset to diagnostic ct, dichotomized at 72 hours. covariates included age, gender, ethnicity, hunt-hess grade, modified fisher grade, hypertension, aneurysm location and treatment modality. the primary outcome of interest was poor functional outcome at discharge (defined as models were constructed with the outcomes of interest as the response variables. a total of 315 patients were included. the median time to diagnosis was 9.0 hours (interquartile range 3.9-16.9). twenty-four patients (7.6%) presented greater than 72 hours from onset. poor functional outcome at discharge occurred in 138 (43.8%) and dci in 86 (27.3%). multivariate analysis revealed no association between delayed presentation and either dci (p = 0.289) or poor functional outcome at discharge (p = 0.7). hours from symptom onset to diagnosis as a continuous variable also did not reveal a significant association with dci or poor functional outcome. delayed presentation to medical care beyond 72 hours is not associated with either dci or poor functional outcome at discharge following subarachnoid hemorrhage. a treatment bundle including extracorporeal cardiopulmonary resuscitation (ecpr) combined with targeted temperature management (ttm) may improve outcome of cardiac arrest (ca) patients, however, prognostication for these patients still remains challenging. we sought to examine the prognostic value of amplitude-integrated electroencephalogram (aeeg) for ca patients during ecpr and ttm. this was a single-center, retrospective analysis of adult ca patients treated with ecpr and ttm under aeeg monitoring with subhairline montage. intra-arrest cooling was immediately initiated with cold fluid infusion and extracorporeal cooling method and maintained at 34 °c for 24 h. patents underwent intraaortic balloon pumping (iabp) and percutaneous coronary intervention (pci) if needed. neurological outcome was assessed with the cerebral performance category (cpc) scale at hospital discharge. ecpr was conducted in 17 patients (age 57.8 [24-84] years, 82% male) amongst 73 ca or post-ca comatose patients since november 2012. the initial cardiac rhythm was refractory ventricular fibrillation in 14, pulseless electrical activity in 2, and asystole in 1. the cause of ca was cardiogenic; 10 underwent pci and 9 needed iabp support. collapse-to-ecpr time was 34.3 min. initial aeeg patterns were; flat trace (n=4); low voltage (n=6); suppression-burst (sb) (n=2); electrographic status epilepticus (ese) recovery (cpc 1-2). their aeeg pattern was continuous in 1, low voltage in 3, and ese in 1. among 3 rn of spontaneous circulation. patients with ese recovered after antiepileptic administration. ecpr was withdrawn in 6 patients based on clinical and prolonged flat aeeg findings. continuous aeeg adds early prognostic information for ca patients with ecpr under ttm. the suppression ratio (sr) is a processed eeg variable estimating the percent of an eeg epoch (0-100) that is suppressed. sr has been associated with neurologic outcome after several types of brain injury and using different technologies including full montage eeg recordings and simplified processed eeg monitors. we compared sr during targeted temperature management (ttm) after cardiac arrest, using two independent blinded assessment tools. a convenience sample of adult patients treated with ttm after cardiac arrest were enrolled to compare and the full montage continuous eeg using natus equipment with persyst magicfor 0.5 seconds). machine times were recorded to synchronize, and sr results were recorded once for each subject at a time without stimulation or artifact using correlation and altman-bland analysis. 20 adults were enrolled in this study with a median age of 56 years, 14 (70%) were male. during sr -46) for persyst sr 1.7 (0.2-41). comparing medtronic and persyst sr, the spearman correlation was 0.88 (p<0.0001), and altman bland testing revealed a bias of 0.6 with 95% limits of agreement -3.7 to 4.8. bedside estimation of suppression ratio during ttm after cardiac arrest showed excellent agreement when measured with the medtronic bispectral index monitor and the full montage natus ceeg monitor though the impact of therapeutic hypothermia on neurological outcomes remains controversial, there is strong evidence that pyrexia is detrimental. posthypothermia fever experienced by cardiac arrest patients is of particular concern. this abstract examines the ability of an esophageal heat transfer device (ehtd) to maintain core temperature below 38°c in critical care patients, with a focus on posthypothermia fever in post cardiac arrest (pca) patients. de-identified data for subjects who received temperature management using an ehtd were collected with a condition appropriate for active temperature management. core temperature readings for each patient were recorded at least hourly; if measurements were recorded more frequently, temperature over an hour span was averaged. patient data was analyzed to determine what proportion of measurements were above 38°c. data from a total of 26 patients was collected, including 23 post-cardiac arrest patients and 3 fever reversal cases. a total of 934 core temperature measurement events (over an average of 35.9h per patient) were included in the analysis. 927 (99.3%) were below 38°c, 7 recorded measurements exceeded 38°c, and no data were recorded for 4 time points. of the 254 measurements recorded posthypothermia, 252 (99.2%) remained below 38°c. esophageal temperature modulation using an ehtd appears to be an effective method for fever prevention and reduction. visual representations of the pca subset showed an upward trend in temperature after 10-18 hours of maintaining target temperature, but before active cooling ended. this suggests that many of these patients might have become febrile in the absence of active temperature management. achieving and maintaining normothermia (nt) after subarachnoid hemorrhage (sah) or intracerebral hemorrhage (ich) often requires surface or intravascular cooling devices that are associated with a significant burden of shivering. we describe a new, closed loop esophageal cooling device (ecd: --0.50 c) and the shiver burden during the maintenance of nt. we enrolled mechanically-ventilated patients with sah or ich with refractory fever (>38.3 c). temperature and bedside shivering assessment scale (bsas) were recorded every 15 minutes for the time above 38 c, median bsas and cumulative number of anti-shivering interventions per patient was recorded prospectively. all patients received magnesium, buspirone, and acetaminophen as baseline anti -shivering interventions. ten patients (7 ich, 3 sah) were enrolled between october 2015 and april 2016. the median gcs at initiation was 6 (4----0.2 m2, and 70% were women. there was a temperature reduction at 120 minutes (mean 38.7c to 37.9c, p=0.005) and 90% of patients achieved nt (median time = 4.5 hrs.; range: 0.5 -38 hours). nt was maintained for median 91 --28%) time above > e time. the median number of total shiver interventions per patient was 5 (1 -22) throughout the ttm time period. no device related complications were noted. the ecd successfully achieved and maintained nt with a low shiver burden and may be a feasible option for nt in this critically-ill population. we present a case of toxic leukoencephalopathy in a young woman taking a thermogenic dietary supplement. a 30 year old female with unremarkable pmh except being on a diet drug "remuvik" presented with a 2 day history of severe headache, blurry vision, photophobia, phonophobia, nausea, vomiting and brief intermittent hand spasms. neurological exam was notable for mild right finger-to-nose ataxia and diffuse hyperreflexia. initial mri demonstrated extensive bilaterally symmetric t2 hyperintensities of the corpus callosum and periventricular white matter. csf profile was unremarkable. labs were unremarkable except for serum sodium of 127 meq/l. approximately 18 hours later, patient became unresponsive with bilaterally fixed-dilated pupils and decerebrate posturing. she was intubated and 100gms of mannitol was emergently administered with concern for cerebral edema. iv lorazepam was also given. a stat ct head showed diffuse cerebral edema. an external ventricular drain was placed emergently and 3% nacl was started. continuous eeg was negative for seizures. next day she started following commands and on day 5 she was discharged home with normal neurological exam. given her presentation and mri findings, she was diagnosed with acute toxic leukoencephalopathy due to thermogenic diet pill "remuvik". patient had been taking the diet drug for 6 months and had lost 30lbs. the main ingredients in remuvik are listed as resveratrol, caffeine-free green tea and l -carnitine while the remaining ingredients are unknown. similar presentation with another diet drug "thermatrim" has been previously reported. these products are not fda regulated and are easily available to the general public. the acute cerebral edema with decompensation was thought to be due to hyponatremia caused by remuvik. while the mechanism of leukoencephalopathy is not well understood and further investigation is needed, spreading awareness is the key to prevent serious adverse effects of such unregulated products. baclofen is a frequently used muscle relaxant. we report a case of, low dose baclofen causing reversible gped's (generalized periodic epileptiform discharges). on review of literature, baclofen toxicity/overdose has been associated with burst suppression patterns on eeg, with one case report of baclofen toxicity causing gped's. to the best of our knowledge there have not been reports of low dose baclofen induced significant eeg changes. case reportthe patient is an 87 year old woman, with poor baseline functional status from advanced dementia and limb contractures, on coumadin for old dvt/pe, with sub-therapeutic inr, was admitted with new onset seizures secondary to venous infarcts over bilateral parieto-occipital areas, due to extensive venous sinus thrombosis. she was monitored on continuous video eeg and initiated on antiepileptic medications, vimpat and dilantin. eeg recording initially demonstrated occasional sharp waves, maximal in the left frontal region. however, because of excessive emg artifact caused by hypertonia, the patient was started on baclofen 5 mg. within 24 hours patient's mental status deteriorated and eeg recording demonstrated gped's with periods of suppression. due to concern for drug adverse reaction, baclofen was discontinued. the eeg reverted to pre-baclofen pattern, while her mental status slowly improved. she was provided supportive care and ultimately discharged to a rehabilitation facility. in this elderly dementia patient, with low seizure threshold from the acute cerebral insult, low dose of baclofen was enough to induce encephalopathy and gped's. the absence of any metabolic disturbances along with rapid resolution of clinical and electroencephalographic abnormalities after discontinuation of the drug supports the hypothesis that these findings may be the direct cerebral toxic effect of baclofen. iatrogenic encephalopathy with baclofen should be considered in the differential for elderly patients with low cognitive reserve rotational vertebrobasilar insufficiency, also called bow hunter's syndrome after the symptom-inducing head position adopted when aiming a bow, is a rare cause of posterior circulation ischemia. we present a case of an 84-year-old woman who presented to barnes-jewish hospital with several days of episodic vertigo and gait instability. two weeks prior to presentation she had fallen and struck her head. imaging revealed a complex c1 fracture as well as an odontoid fracture with posterior displacement. she began having positional spells characterized by loss of consciousness, gaze deviation, fencer posturing, and sonorous breathing. review of clinical records and literature review. the spells were initially highly concerning for seizures. the patient was monitored on continuous video eeg, however no seizures were detected during typical spells. a ct angiogram revealed an occluded right vertebral artery at the level of c2 with diminutive vs. absent posterior communicating arteries isolating the posterior circulation. subsequent mr angiography revealed a patent right vertebral artery with no evidence of stroke. catheter cerebral angiography demonstrated a patent left vertebral artery. turning the head 15 degrees during the procedure, however, elicited a typical spell and completely occluded the left vertebral artery. the patient underwent occipitocervical fusion, but unfortunately suffered a multifocal posterior circulation stroke and was discharged with hospice care. we present an unusual case of rotational vertebrobasilar insufficiency that mimicked a classic sezure semiology and presented several diagnostic dilemmas in the icu. in this case, traumatic injury resulted in likely bilateral positional vertebral artery occlusion with resultantly profound brainstem ischemia. bow hunter's syndrome should be considered in all cases of positional neurological spells, particularly in the setting of neck injury. optic nerve sheath diameter (onsd) measurement using ultrasound has been proposed as a reliable method for non-invasive assessment of intracranial pressure (icp). we report a case of using onsd to monitor icp in a tbi patient with elevated icp undergoing medical treatment with acetazolamide. we hypothesize that a difference in onsd could be detected with ultrasound before and after treatment. patient is a 31 year old man with mild tbi due to assault. his head ct reveals a long calvarial fracture extending along the superior sagittal suture line and posteriorly into the left parietal bone, as well as a large epidural hematoma overlying the frontoparietal vertex near midline, and causing inferior displacement and extrinsic compression of the superior sagittal sinus. his physical exam reveals a young man with right orbital ecchymosis who is sleepy but easily arousable with a gcs of 4 5 6 and no motor deficits. dilated fundus exam by ophthalmology reveals grade 2-3 papilledema consistent with elevated icp. the patient complains of persistent headaches and nausea that is unremitting. acetazolamide was started to decrease icp. we measured onsd with a sonosite ultrasound device prior to start of acetazolamide and 2 days afterwards. two measurements were taken on each eye, one in the horizontal and vertical orientation each. the average onsd was 6.4mm on the right eye and 6.4mm on the left eye prior to initiation of treatment. on the day after treatment onsd was 4.65mm on the right and 5.1mm on the left eye. the patient's headache improved and nausea resolved. the next day onsd was 3.5 mm on the right and 3.6mm on the left eye. headache and nausea completely resolved. this case report affirms that ultrasound measurement of onsd could be used reliably to assess icp noninvasively during the course of treatment for elevated icp. manoj k. mittal. kansas university medical center/ neurology, kansas city, ks, usa. timing of brain death evaluation could be crucial in maintaining organ perfusion for donation. a new bedside cerebral blood flow monitor (cflow monitor from ornim) has not been previously studied for determining the timing of brain death examination. we present here a case illustrating the role of bedside blood flow monitoring in determining the timing of brain death evaluation. a 73 year-old-woman presented with acute right middle cerebral artery stroke and bilateral internal carotid artery occlusions. she was not a candidate for intravenous thrombolysis or endovascular therapy due to unknown time of symptoms onset. her initial nihss was 19 (right gaze deviation, mild aphasia, mild dysarthria, left facial droop, left hemiparesis, left sided decreased sensation and neglect). day-2, she got intubated for hypoxic respiratory failure. day-3, ct head showed cerebral edema with midline shift of 8 mm. patient was not a decompressive hemicraniectomy candidate. day-5, patient was comatose. day-7, patient lost bilateral pupillary reflex. ct head showed worsening midline shift of 17 mm with right uncal herniation, bilateral anterior cerebral artery and left posterior cerebral artery stroke, and brainstem compression. day-9, bedside cerebral blood blood flow monitoring was started with right sided cerebral blood flow index (cfi) of 16 and left side cfi of 35. patient met criteria for brain death except that she was still breathing over the ventilator. patient was extubated for comfort measures. after 60 minutes patients stopped breathing. her cfi dropped <10 bilaterally. patient underwent cardiac arrest after 10 minutes and then both cfi were <8. patient was not a candidate for organ donation. bedside cerebral blood flow monitoring may assist in determining the timing of brain death evaluation in comatose patients with imminent brain death. patients with cfi <10 may be considered for brain death evaluation. our finding needs further confirmation. aneurysmal subarachnoid hemorrhage patient. icus are high cost in the u.s., comprising about 17% of the us gdp. pressure is being placed on hospitals and intensivists to reduce costs, including earlier palliative care engagement to shorten length of stay.. as the u.s. migrates to a value-based system, further pressure will be made on reducing prolonged and expensive icu interventions, similar to quality adjusted life year (qaly) cutoff values to justify costs. a young 23 year old man presented with worst headache of his life, and was found comatose by ems and referred to our neuroicu. he had a 2.2cm giant basilar asah with intraventricular hemorrhage. the aneurysm was coiled endovascularly with external ventricular drain placed. he required therapeutic hypothermia, osmotherapy, induced hypertension and balloon angioplasty and intraarterial verapamil for refractory basilar and bilateral middle cerebral artery vasospasm. he had refractory intracranial pressure from global cerebral edema and around post-operative day #13 required bifrontal craniectomy. later percutaneous tracheostomy, peg tube, and ventriculoperitoneal shunting were performed. his total costs exceeded $300,000 u.s. dollars. one year later, his modified rankin scale was zero, and he went to college. his qaly (quality adjusted life year) for the rest of his year was 0.833 given a utility of 1. his physicians felt he should live to a normal life expectancy of 77 years of age, q is quality of life weight = 1 (perfect health, utility =1), l is residual life expectancy =54 more years. his qal-expectancy 2,3 is about 54 life-years gained which divided over his life span is about $5,555/year and less than the current cms reported value of $9,500 per year. this case exemplifies how high cost care can be delivered to deliver cost-effective, high quality care and underscore the need for integrated high-complexity neuroicu care. early mobility in the intensive care unit setting is associated with a number of positive effects including improved quality of life. though there is a strong body of evidence supporting early mobility in medical intensive care units, the benefits of very early mobilization after acute stroke are yet unclear as early hemodynamic variability in patients with impaired cerebral auto regulation is of concern. another potential barrier to early mobilization is the presence of an external ventricular drain (evd) for cerebrospinal fluid diversion and intracranial pressure (icp) monitoring. this case demonstrates hemodynamic and icp responses to progressive, device assisted mobility interventions during the acute phase of intracerebral hemorrhage (ich) in the setting of persistent elevations of icp requiring two evds. a 55 year-old man was admitted to the neuroscience critical care unit with an acute thalamic ich and intraventricular hemorrhage requiring placement of two evds. starting on day 3 following ich onset, the patient underwent progressive mobilization following the johns hopkins nccu activity and mobility algorithm. range of motion exercises were performed initially, progressing to supine cycle ergometry followed by incremental verticalization using the tilt table (sara combilizer®arjo huntleigh inc.,il). blood pressure, heart rate, oxygen saturation, and icp were recorded before, during and after the mobility interventions. no adverse neurologic effects were noted during these mobility interventions. recorded hemodynamic variables and icp remained within the set goals throughout. moreover the patient was able to tolerate 45 degrees of verticalization on the tilt table. progressive, device assisted early mobilization was feasible when titrated by skilled healthcare professionals in a critically ill hemorrhagic stroke patient with evds. studies on larger patient samples are needed to improve our understanding of the hemodynamic and neurophysiologic responses to establish safety of progressive early mobilization of critically ill patients with acute stroke. anand venkatraman, ayaz a. khawaja, angela a. shapshak. university of alabama at birmingham / department of neurology, birmingham, al, usa. we describe a case of a patient with uncontrolled hypertension (htn) and prior intracranial hemorrhage (ich) who developed an intracranial hemorrhage shortly after consuming redline, a heavily-caffeinated energy drink. a 57-year old caucasian male with prior history of ich and chronic untreated htn was transferred to our service for evaluation of 1.8x1.3cm ich in the left thalamus. blood pressure had been elevated in the emergency room there and he had been started on a nicardipine infusion. nih stroke scale was 1. ich score was 0. admission labs were normal. urine drug screen was negative. on questioning, patient revealed that symptoms had started within 2 hours of consumption of 1 bottle of redline, an energy drink. he was not a regular user but did consume it whenever he needed to get a lot of work done. mri of the brain did not show any vascular malformation or other lesion. multiple remote hemorrhages were seen in the subcortical areas. we stared lisinopril and weaned off his nicardipine infusion. he was discharged with minimal deficits. the high caffeine content is the most likely component of the drink that led to the ich, given that high caffeine consumption is linked to increased risk of hemorrhagic strokes. caffeine also has effects on platelet aggregation and endothelial function that could raise stroke risk. generalizability is limited by the fact that the patient had uncontrolled htn and prior ichs. however, given that 15% of adults in the usa have uncontrolled htn, and given that ich account for 10-15% of all strokes, a large population is at risk. to our knowledge this is the first report of intracranial hemorrhage following consumption of an energy drink. consumers must exercise caution, especially in the setting of uncontrolled risk factors. elena schmidt, varada v. nair, gene g. latorre. suny upstate university hospital / department of neurology, syracuse, ny, usa. often times medications given in emergency cases have unintended consequences, sometimes posing even more harm than the reason for their administration. we report a case of a young lady with history of anaphylactic reaction who received i.m. epinephrine after developing allergic reaction to antibiotic, resulting in bilateral intracerebral hemorrhage (ich). our case is of a 42 year old female with history of anaphylactic reaction who had been recently started on cephalexin for orbital cellulitis. she was sent to ed after having a syncopal event in the doctor's office. while in ed, the patient was administered 0.3 mg of 1:1,000 epinephrine i.m. because of suspected anaphylactic reaction. shortly after, she complained of nausea, vomiting and developed right sided weakness and numbness. immediate ct head revealed two areas of ich, within the left parietal and right occipital lobes. extensive work-up ensued, with cta head and neck (negative for vessel anomalies), cerebral dsa (negative for vasculitis), mri brain w/wo contrast (negative for malignancy or amyloid angiopathy), ct thorax and abdomen (negative for malignancy). serum studies for vasculitis work-up were also unrevealing. echocardiogram did not show evidence for chronic hypertension such as lv hypertrophy. although there have been reports in the literature of spontaneous intracranial hemorrhage (intraparenchymal or subarachnoid) after various ways of epinephrine administration, in our patient's case, the extensive work-up done to exclude other etiologies stands out. this strengthens the hypothesis that epinephrine, causing an acute spike in blood pressure, ultimately led to spontaneous ich. in addition, the case of our patient is unique in that she developed two areas of ich, in a location typical for posterior reversible encephalopathy syndrome (pres), a syndrome known to be caused by significant elevation in blood pressures, suggesting a common underlying pathophysiology. careful consideration of indications should occur before administering such potentially harmful treatments. "last known normal" (lkn) time remains the standard for determining the onset of acute ischemic stroke and appropriateness of providing acute therapies. as older adults become more familiar with social media platforms, these applications may become a source of recognizing when a patient was lkn. we report an 82 year-old woman who was "found down" at home. the patient lived independently, and was able to crawl to a telephone for help. on arrival to the emergency department, she had a right middle cerebral artery syndrome with an nih stroke scale of 17. she had a decreased level of arousal and severe dysarthria which precluded assessment of her lkn. the patient's son reported that he had last seen her normal 9 hours prior, placing her outside the time window for acute therapies. however, the patient's granddaughter reported that the patient had been logged into facebook <1 hour prior to her admission "chatting" and commenting on photos. "timestamps" of comments left on photos by the patient provided exact times of the patient's activity. the only logical means of being able to perform these relatively high-functioning tasks would have been if the she was normal at the time of posting, thereby establishing her lkn. the patient was treated with systemic t-pa followed by endovascular therapy for a proximal m1 occlusion. the patient had rapid improvement of her stroke symptoms. she was discharged home with an nih stroke scale of 2. this patient's recent use of the social media was critical in determining the patient's lkn, leading to lifesaving acute stroke therapy. providers should be aware that social media may serve as a useful source of symptom onset information. in this case, it led to good outcome and discharge home. bilateral recurrent artery of heubner (rah) infarctions have been seldomnly reported in the literature. even more so for those cases that have occurred subsequent to neurosurgical extensive resections of large invasive olfactory groove meningioma. rah, a branch of the anterio-inferior cerebral artery, supplies anterior limb of the internal capsule, anterior caudate, putamen and globus pallidus. infarction typically results in contralateral paresis of the arm and face. other symptoms can occur i.e. choreiform movements, abulia, attention disorder, impaired memory, apathy, decreased spontaneity, depression, dementia etc. we present a case of bilateral rah infarcts as a complication of a large olfactory groove meningioma resection. we did an extensive chart review of our patient during post-operative neurointensive care unit stay, rest of the hospital stay and discharge follow up at 1 month. our patients brain mri done as a part of routine post-operative imaging showed bilateral caudate head infarcts in the territory of rah. post-operative exam was significant for a left hemianopsia and right super quadrantopsia with color desaturation. patient did not experience any new weakness or movement related problems. he did have changes in cognition (forgetfulness & irritability) along with a subjective loss of sense of smell but these were consistent with his pre-op assessment. olfactory groove meningioma's comprise 10% of all intracranial meningiomas, are slow growing and tend to engulf and compress neighboring structures. most common complications of olfactory groove meningioma resections are post-operative cerebral edema, csf leak, seizures, cns infections, hydrocephalus and rarely brain ischemia. bilateral rah infarction, although rare has been reported in literature in association with vascular anomalies and other stroke risk factors. cerebral infarction involving the aca territories remains a known adverse complication of large olfactory groove meningioma resections, but bilateral infarcts due to these have not been reported before. angioinvasive aspergillus associated stroke in an immunocompetent host. aspergillus vasculitis is an under-recognized cause of stroke in immunocompetent hosts, especially when other risk factors are present. we present a case of autopsy proven angioinvasive aspergillus causing strokes in an immunocompetent host, and review the characteristic imaging findings to aid diagnosis. 59-year-old female developed cardiogenic shock after three-vessel-coronary artery bypass grafting (cabg) using saphenous vein grafts requiring intra-aortic balloon pump placement. this was complicated by aortic dissection, and she underwent replacement of the ascending aortic arch. refractory cardiogenic shock ensued for which she underwent placement of veno-arterial extracorporeal membrane oxygenation. postoperatively, she was noted to be in coma, and a non-contrast ct of the brain showed small multiple small ischemic strokes bilaterally. with persistent multi-organ failure, she was ultimately transitioned to comfort care and passed. autopsy revealed multiple perivascular petechial hemorrhagic infarcts involving white matter, deep gray matter and cerebellum on gross specimen. histopatholgic study showed aspergillus associated acute and chronic inflammation of blood vessel, and surrounding gliosis. aspergillus was also found in coronary grafts and kidneys. aspergillus associated cerebral vasculitis was considered less likely, as cabg, extracorporeal membrane oxygenation (ecmo) device-related thrombosis and acute mi were the leading differentials for stroke here, and no obvious immunosuppression was evident. cerebral aspergillosis can occur from direct spread from sinus infections or through hematogenous mode, and seemed to have originated from coronary grafts in this case. aspergillus has a predilection for posterior circulation arteries, and lacunar-type infarcts or petechial hemorrhages within the midbrain, thalami, or corpus callosum are characteristic. these findings should raise suspicion for aspergillus, especially without objective evidence of other mechanisms of stroke. early initiation of anti-fungal therapy may improve the likelihood of survival, and confirmatory testing in the form of blood vessel imaging, csf analysis and fungal blood cultures should be performed in suspected cases. autoimmune ganglionopathy: a rare cause of cardiac arrest kelly braun. neurological institute, cleveland clinic, cleveland, oh, usa. autoimmune autonomic ganglionopathy is a rare disorder characterized by pandysautonomia that occurs as a result of autoantibodies to ganglionic nicotinic acetylcholine receptors. we describe a 27 year old male with autoimmune ganglionopathy previously treated with ivig who suffered cardiac arrest and anoxic brain injury as a complication of this disorder. the patient had a history of multiple autoimmune diseases (dm1, autoimmune hepatitis, hashimoto's thyroiditis, celiac disease, antiphospholipid syndrome and ulcerative colitis). to alleviate his pre-syncopal lightheadedness related to dysautonomia, he would typically kneel and place his head on his folded arms. the patient was found unresponsive in this position in pea arrest. he underwent cpr followed by therapeutic hypothermia (34°c x 24h). the initial exam off sedation showed an obtunded patient with intact pupillary and corneal reflexes, but no tracking or command following. though he moved all extremities spontaneously, the movements were not purposeful and had a choreiform quality. notable labs were an elevated achr ganglionic neuronal antibody (5.44 nmol/l on hospital day 8 and 3.10 nmol/l on hospital day 15; normal < 0.02 nmol/l). mri brain showed symmetric diffusion restriction and flair changes throughout the brainstem, thalami and cerebellum, however there was no cortical diffusion restriction. eeg showed generalized intermittent rhythmic slowing, which was maximal bifrontally. he was treated with methylprednisolone 30 mg daily for 23 days and transitioned to prednisone 40 mg daily. at the time of discharge to an acute rehabilitation facility, the patient followed most simple commands and moved all of his extremities against resistance, though he was noted to have diffuse hypotonia. to our knowledge, this is the first reported case of cardiac arrest attributed to autoimmune autonomic ganglionopathy. while rare, this is a serious complication of this syndrome. bibhukalyani das, shantanu s. shubham. institute of neurosciences kolkata, kolkata, india. global burden of tuberculosis is still high particularly in developing world. india is the largest tb burden country accounting for 1/5th of the global incidence.cns tuberculosis is the most severe form of infection with microbacterium tuberculosis.emergence of mdr(multi drug resistant) tuberculosis has compounded the risk and adverse outcome. fatality rate of mdr tb meningitis is 57% with significant functional impairment in most of the survivors. mortality >90% if patient is hiv positive. we report a case of 15 yrs old girl from eastern india case of mdr -cns tuberculosis with a protracted clinical course of 2 years. she developed a whole range of complications including hydrocephalus, optochiasmatic arachnoiditis with secondary optic atrophy, multiple tuberculomas, cerebellar and brainstem tubercular abscesses and siadh with hyponatraemia. our case is notable for few rare complications in the form of transverse sinus thrombosis secondary to chronic meningitis necessitating oral anticoagulation . the patient also developed various side effects of long term att such as -(i) att induced hepatitis. (ii) moxifloxacin induced seizures and re-adjustment of antiepileptics due to interaction with antitubercular drugs. she was managed with 9 antitubercular drugs (5 first line drugs) along with second line drugs (amikacin, levofloxacin, cycloserine, ethionamide) her clinical course was complicated by obstructive hydrocephalus requiring evd, vp shunt and shunt revision . developed acute sdh possibly secondary to shunt and required surgical drainage . later she developed posterior fossa tubercular abscess and needed craniectomy. pus from tubercular abscess grew mtb resistant to rifampicin and isoniazid. so the patient was maintained on second line drugs, ultimately succumbed to hospital acquired pneumonia. cns tuberculosis if associated with multiple medical, surgical complications, impose real critical care challenges compounded by mdr which often encountered in a developing country like india. megan lange, rebecca r. horrell. university of maryland medical center, neurocritical care unit, baltimore, md, usa. super-refractory status epilepticus, defined as seizures persisting despite anesthetics, is associated with high morbidity and mortality. here we present two cases of super-refractory status epilepticus intractable to aggressive therapies, including but not limited to anesthetics, electroconvulsive therapy, and immunotherapy. in both cases, the patients developed sepsis and cardiac arrest following prolonged hospitalizations with subsequent termination of seizure activity and improvement in electroencephalogram findings and neurologic exams. a review of the literature revealed a variety of publications describing super-refractory status epilepticus as a result of sepsis or cardiac arrest, but there is limited data describing either complication as therapeutic for status epilepticus. we propose that the systemic effects associated with profound sepsis, or the brief electrographic silence occurring in the setting of cardiac arrest could have played a role in halting seizures in these patients. we describe two theories regarding the potential mechanism by which cardiac arrest or sepsis could play a role in termination of seizures. exploration into specific mediators involved in these conditions and their relationship to status epilepticus could uncover therapeutic targets. targeted therapies could demonstrate promise in effectively treating super-refractory status epilepticus, thereby improving morbidity and mortality rates. ticagrelor is approved for prevention of cardiovascular events in adults with acute coronary syndrome (acs)1. we present a patient with sah who developed thrombus during coiling procedure that was treated with abciximab followed by ticagrelor and aspirin, with potentially devastating consequences. a 64-year-old male presented after sudden onset severe headache. imaging revealed sah from a ruptured basilar tip aneurysm. the patient was neurologically intact with mild confusion, but declined during transfer and required intubation. an external ventricular drain was placed for hydrocephalus. during cerebral angiogram with coil embolization, a thrombus formed on the coil. intra-arterial abciximab was used with resolution of thrombus. he was extubated post procedure. aspirin and ticagrelor (90 mg twice daily) were prescribed. the following day, the patient became increasingly lethargic with an increased respiratory rate (30s). he reported no perception of increased work of breathing. portable chest radiograph demonstrated only mild pulmonary edema. he did not have an oxygen requirement. venous blood gas demonstrated a ph 7.52 with a pco2 of 27, suggesting a respiratory alkalosis. transcranial dopplers demonstrated normal velocities, but the patient was considered for cerebral angiogram given a high concern for vasospasm with his neurologic exam. ticagrelor was stopped the following day. the patient's tachypnea and mental status rapidly improved. ticagrelor reversibly inhibits the platelet p2y12 adenosine phosphate receptor and is indicated for prevention of cardiovascular events in adults with acs. in patients with both cerebral hemorrhage and a need for antithrombotic therapy, this reversible agent may become more widely used. dyspnea is a known side effect of ticagrelor, occurring in 13.8% of patients (p<0.001).1 dyspnea causes respiratory alkalosis and the resulting hypocapnea results in vasoconstriction. in this case, mental status change after administration of ticagrelor suggests that patients at risk for vasospasm may be particularly vulnerable to its side effects. over the past 20 years, the americas have experienced waves of emerging and re-emerging arboviruses that cause neuroinvasive disease, including west nile virus, chikungunya virus, zika virus, and dengue virus. these viruses pose great challenges for traditional candidate-based infectious disease diagnostics that already fail to identify a causative pathogen in approximately 50% of encephalitis cases. we present the case of a 14 year-old girl with a history of renal transplant managed with mycophenolic acid, tacrolimus and prednisone who presented to an emergency department with two days of high fevers, chills, upper back, neck pain and rash followed by encephalopathy. one month prior to presentation she attended summer camp by a lake in the angeles national forest, california. her hospital course was complicated by status epilepticus. cerebrospinal fluid (csf) analysis demonstrated a mixed neutrophilic and lympocytic pleocytosis. mri of the brain demonstrated symmetric t2 hyperintensities and edema in the bilateral thalami and leptomeningeal enhancement in the thalamus, cerebellum, brainstem, cervical spine and caudal equine. an extensive diagnostic work-up for infectious causes of encephalitis was performed and only identified epstein-barr virus. research protocol. unbiased mds of rna extracted from her csf and processed through a custom bioinformatics pipeline identified west nile virus. subsequently, convalescent serum serologies confirmed west nile virus infection. this case provides a first proof-of-principle that mds can detect even low level arbovirus burden in the csf of a patient with acute meningoencephalitis. given the rapidly changing landscape of viral causes of encephalitis in the americas, the ability of mds to comprehensively detect a huge array of microbes with a single assay may make it an optimal method for early identification of emerging causes of viral encephalitis, including in the transplant patient population. cladophialophora bantiana is a dematiaceous mold with a predilection for causing central nervous system infection, particularly in normal hosts. there is no standard therapy and mortality rates from this disease remain extremely high approaching 70%. here we describe a case involving a 59 year-old immunocompetent man who presented with new onset seizures. brain imaging revealed bifrontal ring enhancing lesions concerning for abscess.the patient underwent surgical debridement of the lesions and bilateral intracavitary treatment with amphotericin b using ommaya reservoirs for several months. after approximately 16 months of treatment which included surgical debridement , oral voriconazole and intracavitary amphotericin b, our patient is off all antifungals and no longer receiving intracavitary treatment. he remains fully functional with a nonfocal neurologic exam, being monitored with serial brain mris. due to rare incidence of cerebral phaeohyphomycosis, there are no clinical trials to help formulate standardized treatment guidelines despite its high mortality . this case places emphasis on an early aggressive multimodal approach for treatment of cerebral phaeohyphomycosis using a combination of surgical debridement, intracavitary antifungal injection, and oral antifungal therapy. does neurocritical care need to improve outreach to non-neuro specialties? firas abdulmajeed, mb. chb, bart b. nathan, md, fcns. university of virginia/ department of neurology, charlottesville, va, usa. the number of neuro-critical care(ncc) fellowship positions has been increasing yearly. the number of applicants has plateaued over the last 3 years, leaving many programs with unfilled fellowship positions. the demand for neurointensivists is on the rise. trainees have come from neurology traditionally, with a limited number from internal medicine (im). we hypothesize that the relative paucity of im fellows was in part due to insufficient knowledge of ncc. we surveyed im residency programs in the united states, asking program directors to forward our survey to their residents. on another survey, ncc fellowship directors were asked: 1) how many trainees and how many faculty hires from im and/ or em have they had within the last five years internal medicine residencies survey results: we obtained 102 individual responses, 98 responses were complete. how long is the ncc fellowship? n=100 12% 1 year 41% 2 years 47% 3 years residents of what specialty can apply to a ncc fellowship? n= 97. 73% (neurology, neurosurgery, anesthesiology, im and em) 11% neurology only 15% neurology, neurosurgery and anesthesia knowledge of san francisco matching system? n=92 48% yes. 52% no do you know about the application cycle for the ncc match? n=93 10% yes. 90% no knowledge of emergency neurological life support? n= 92 7% yes 93% no ncc fellowships' directors survey results: 20 of the 52 programs responded fellows with im/em background that were trained within the last 5 years: 12/10 neuro-intensivists with im/em background hired: 6/7 im residents appear to have little knowledge of ncc fellowship. a lack of awareness of enls could affect the quality of care provided for neurological emergencies. additionally, for the specialty to grow and fill unmatched fellowship positions,current training and outreach strategies to non-neurology trainees may need to be improved somatosensory evoked potentials (sseps) are a sensitive, minimally invasive technique used to identify injury from the posterior columns of the spinal cord to the somatosensory cortex. the role of sseps as a neuromonitoring tool, in the neuroicu has not been well established. we present a case using sseps as a neuromonitoring tool illustrating electrical improvement along with clinical and radiographical improvement in a symptomatic chiari i malformation. 18 year old female who was 2 months postpartum after vaginal delivery with epidural analgesia presented with headaches, diplopia and nausea/vomiting. after arrival to er, she acutely developed flaccid quadriparesis with ophthalmoplegia and loss of airway while awake and following commands. given the concern for intracranial hypotension, we administered mannitol, hyperventilated and placed in trendelenburg position. head ct showed cisternal effacement in the setting of a likely pre-existing chiari 1 malformation with cerebellar tonsillar. decompressive surgery was not an option initially given her dysautonomia and neurologic instability whenever the patient was not in trendelenburg. during her prolonged course, she had two mris of her brain and spinal cord which showed chiari i malformation with syrinx at c4 and presyrinx down to t2. there was cervical spine venous engorgement and csf block at the level of the foramen-magnum. she was evaluated with serial sseps which initially showed low amplitude n20 response that improved with her clinical improvement. ssep is a minimally invasive method to electrically assess the somatosensory pathway integrity from the spinal cord, brainstem and cortex. given its sensitivity to the function of the dorsal columns of the spinal cord and medial lemniscus of the brainstem, sseps may be a useful monitoring adjunct to follow the evolution of posterior fossa lesions in patients that may not tolerate other means of monitoring and/or transportation, such as mri. review of prospectively maintained patient database identified one case of status epilepticus in a patient with cns-ptld. we present a case report with literature review. a 74-year old hispanic woman with a history of renal transplant 19 years prior, presented with episodic confusion and gait ataxia progressing over two weeks. she was on immunomodulation with mycophenolate. patient had witnessed periods of behavioral arrest. continuous electroencephalography (ceeg) demonstrated right temporal sharps and 8-20 second epochs of bi-frontal 14-18 hz activity, some of which were associated with non-stereotyped movements of her left shoulder and trunk, suggestive of se. she received benzodiazepines followed by levetiracetam (renal dose) and phenytoin load for seizure control. mri brain without contrast demonstrated multifocal infiltrative t2-hyperintense white matter lesions, most prominent in right temporal lobe. csf analysis demonstrated 2 rbc, 63 (l 88%) wbc, 80 protein, 71 glucose, culture and gram stain were negative. there were 4 unmatched csf bands with an unremarkable cytology. csf pcr was positive for ebv and viral load was detected at 1458 copies/nl. other csf microbial assays including jcv were negative. stereotactic right temporal brain biopsy demonstrated areas of necrosis, axonal disruption, loss of myelin with polytypic plasma cells, cd20 and cd30 positive b cells and cd3 positive t cells on immunohistochemistry consistent with a diagnosis of polymorphic ptld. despite treatment with dexamethasone and rituximab, patient continued to remain critically ill and eventually received palliative measures. among transplant recipients, pcns-ptld is rare but debilitating with varied neurological presentation. high degree of suspicion, early diagnosis and treatment are paramount for survival. cortical myoclonus caused by activation of cortical areas subjacent to multiple subdural hematomas is an unusual mechanism of epilepsy. we report the case of a patient with an extra axial bleeding and myoclonic seizures evaluated with ictal fdg-pet. case report a 59 year old male was admitted to our hospital because of worsening symptoms of cardiac failure of chagasic etiology. due to hemodynamic instability he was treated with the placement of an intraortic balloon pump. sixteen days after hospital admission, he presented intermittent generalized myoclonic jerks. on initial examination he was alert and oriented to time and place, had preserved strength in all limbs, although presenting with very frequent clusters of myoclonus. initial investigation with a head ct showed multiple foci of extra axial bleeding, distributed over the frontal and parietal areas. the electroencephalogram (eeg) confirmed the suspected diagnosis of myoclonic seizures, exhibiting generalized polispike-slow wave complex. due to the multiplicity of bleeding sites, with no obvious reason for spontaneous bleeding other than regular anticoagulation, the patient was submitted to a whole-body fdg-pet in order to exclude the possibility of dural metastatic implants. fdg-pet showed areas of cortical hypermetabolism adjacent to the bleeding foci, probably reflecting an epileptogenic mechanism of cortical activation. there was no evidence of hypermetabolism directly over the extra-axial areas of bleeding, what ruled out the hypothesis of dural metastasis. a diagnosis of spontaneous subdural hematomas associated to anticoagulation was given after all other causes were excluded. the patient was treated with sodium valproate and had sustained improvement of the myoclonic seizures. the bleeding areas were eventually reabsorbed, but the patient died from complications of cardiac failure. our report is the first to illustrate the mechanism of cortical activation leading to epileptic status in a patient with multiple subdural hematomas detected by ictal fdg-pet. to present a case of early onset myoclonic status epilepticus (mse) after cardiopulmonary arrest with incomplete resolution of myoclonus and good cognitive outcome. a 20 year-old man presented status post cardiopulmonary arrest and cpr in the field with return of spontaneous circulation (rosc) after arrival to the hospital and cardioversion. the patient was intubated and treated with therapeutic hypothermia, but developed clinical mse with normal eeg within 12 hours. he was aggressively managed with propofol, levetiracetam, and fentanyl. initial mri demonstrated diffuse hypoxic ischemic injury. mri on the 9th day of admission demonstrated improvement but a new white matter lesion in the splenium of the corpus callosum. after multiple unsuccessful attempts to discontinue fentanyl and 15 days of treatment, the patient was given a poor prognosis based on the 2006 aan mse practice parameters and was placed on do not escalate care orders. propofol was slowly decreased; however the patient improved significantly throughout hospitalization with improved language and cognitive examination and only mild residual reflex myoclonus at the time of discharge. mri imaging had completely resolved by the 19th day of hospitalization. the patient's final diagnosis is lance-adams syndrome of action myoclonus incompletely controlled with levetiracetam. aggressive and prolonged treatment including therapeutic hypothermia in young patients with early onset mse was effective despite aan practice parameters. this patient survived with good cognitive outcome and with relatively modest deficits. further research is needed to assess whether improvements in intensive care unit capabilities over the past decade may contribute to improved outcome in young patients with cardiac arrest and whether practice parameters should be revised. at the start of this protocol, the serum sodium was 148 and one-hour urine output was 1 liter. this protocol was continued for 48 hours. endocrinology was consulted and recommended changing to ddavp. serum sodium was 149[np1] and one-hour urine output 320 cc prior to first dose of ddavp university of washington, department of surgery, seattle, wa, usa. earlier feeding results in improved outcomes in adults with severe traumatic brain injury (tbi) and in the overall pediatric intensive care unit (picu) population. current practices of nutrition initiation in children with tbi are not well described. this multicenter study evaluated timing and factors associated with nutrition initiation in children admitted to picus with tbi. we hypothesize that severely brain injured patients would have a delay in initiation of enteral nutrition. we retrospectively analyzed the multicenter pediatric trauma assessment and management database (ptam) from 2013. patients with severe tbi were defined as glasgow coma scale (gcs) <9 with n in this group was compared injury, abdominal procedures were compared between the two groups. chi square and fisher exact tests were used for dichotomous variables; non-parametric tests were used for continuous variables. multivariable regression analysis with a stepwise procedure was performed to ascertain the best set of variables associated with delayed initiation of enteral nutrition. of 423 patients admitted to the five ptam picus with severe tbi, 285 (67%) were fed < 24 hours from admission. patients with gcs <9 were fed a median 45.1 hours from admission (iqr 22.0-72.6) compared to 10.3 hours (iqr 3.8regimen, higher injury and illness severity scores and lower minimum gcs were significantly associated with feeding initiation > 24 hours. on multivariable analysis, scheduled bowel regimen, higher prism score and lower minimum gcs were significantly associated with nutrition initiation > 24 hrs. lower gcs is independently associated with delayed initiation of enteral nutrition in children with tbi, independent of severity of injury or abdominal injury. all patients that suffered ca within 24 hours of sah onset were identified from a prospectively collected characteristics, and outcomes of those with and without ca in the setting of sah using binary logistic regression. only 2% (n=38) of sah patients had ca within 24 hours of the bleed. 55% (n=21) of those with ca had f these patients died while in the hospital. three patients had a ventricular fibrillation (vfib) arrest, and one of these patients (n=14), and half of these patients survived. 79% of patients were comatose after the arrest, most of which underwent cooling (goal temperatures 32-34). 37% of deaths in our cohort were from withdrawal of life support (n=11). increased aneurysm size (or 1.08 for each 1mm, 95% ci 1.01-1.15), amount of sah (or 4.97, , and global cerebral edema (or 3.35, ci 1.06-9.65) were associated with noncomatose patients and those with vfib arrests may have a better prognosis. acute herniation at the time of bleeding as indicated by large volume sah and global cerebral edema may be the underlying mechanism of most early cardiac arrest in sah patients. early identification of delayed cerebral ischemia (dci) following aneurysmal subarachnoid hemorrhage (sah) could allow more effective intervention. statistical methods that predict dci using variables collected routinely during icu care such as trends in vital signs and laboratory values have shown promise in recent studies. however, these studies have not all employed methods to guard against model overfitting. in this study we use cross validation to obtain minimally-biased estimates of the value of passively collected icu variables for predicting dci. early identification of delayed cerebral ischemia (dci) following aneurysmal subarachnoid hemorrhage (sah) could allow more effective intervention. statistical methods that predict dci using variables collected routinely during icu care such as trends in vital signs and laboratory values have shown promise in recent studies. however, these studies have not all employed methods to guard against model overfitting. in this study we use cross validation to obtain minimally-biased estimates of the value of passively collected icu variables for predicting dci. dci occurred in 34% of patients. penalized logistic regression selected 9 features for inclusion in the final predictive model, derived from gcs, heart rate, mean aterial blood pressure, respiratory rate, spo2, ventricular drainage, and sodium data. the mean auc of the model was 83%. potentially clinically relevant (sensitivity, specificity) points on the roc curve included (73,89)% and (90,52)%. dci occurred in 34% of patients. penalized logistic regression selected 9 features for inclusion in the final predictive model, derived from gcs, heart rate, mean aterial blood pressure, respiratory rate, spo2, ventricular drainage, and sodium data. the mean auc of the model was 83%. potentially clinically relevant (sensitivity, specificity) points on the roc curve included (73,89)% and (90,52)%. subarachnoid hemorrhage (sah) remains a highly morbid disease leading to > -related year of life lost before age 65. mechanisms of sah-related early brain injury and vasospasm remain microrna (mir)-26a is released in response to hypoxia and promotes angiogenesis. we hypothesize that higher levels of mir-26a is associated with outcome in human sah. functiona -up every 3 months. good functional outcome is defined as mrs50% reduction in caliber of any vessel on post-sah day 7 cerebral angiogram. in 56 sah subjects we compared csf and plasma mir-26a by quantitative pcr on post-sah days 1, 3 and 5 between outcome groups. data are normalized using log-transformation and then compared using student's tstudy population has mean age of 55. 62% has hunt and hess (hh) grade >3. good outcome at 6 months is associated with higher plasma mir-26a levels on post-sah day 3 (p=0.0007) and day 5 (p=0.04). after adjusting for important predictors of outcome (hh grade; age), plasma mir-26a on post-sah day 3 remains strongly associated with outcome (p<0.0001). plasma mir-26a levels were not associated with vasospasm. mir-26a is present in csf and is elevated in sah compared to controls (p<0.0001), but csf mir-26a showed no association with functional outcome or vasospasm status. higher plasma mir-26a level at post-sah day 3 is independently associated with 6-month sah outcome. mechanistic experiments are necessary to determine whether mir-26a expression is neuro-protective in sah. validation studies in larger, independent cohorts are necessary to validate mirna-26a as a accurate assessment of renal function remains a unique challenge in patients with aneurysmal subarachnoid hemorrhage (asah). mathematical estimates of creatinine clearance (crcl) routinely used are often inaccurate in this setting. patients with asah have been shown to exhibit a hyperdynamic response leading to an enhanced renal clearance. no studies exist evaluating the directly measured creatinine clearance of patients with asah over time. this was a single-center prospective observational study of adult patients with asah admitted to the nsicu between january 2015 and july 2015. eight-hour urinary creatinine clearances were performed daily to directly measure crcl until the patient no longer had a foley catheter or the patient left the nsicu.-gault equation. statistical significance was defined as p-value < 0.05. fifty patients with asah were enrolled in the study. the study sample was 68% female with a mean age of 57.2±10.7 years. the median hunt and hess grade was 3 (iqr 2-4) and the median modified fisher grade was 3 (iqr 3-4). additionally, the median admission gcs was 12.5 (iqr 6-14) and median admission sofa score was 2 (iqr 2-4). the mean urinary crcl over the study period was 147.9±50.2 patients with asah consistently experienced urinary crcl greater than estimated crcl predicted based on -gault equation. as renally eliminated medications are routinely dosed based on mathematical estimates of renal function, further study is needed to optimize medication regimens in this patient population to prevent underexposure. agitated delirium is frequently encountered after acute brain injury, but data is limited in patients with nces of agitation in these patients. via records of antipsychotic or dexmedetomidine administration, and agitation was confirmed via chart study team. outcome was assessed at 12 months using interview for cognitive status (tics), and lawton-iadl score. agitation developed in 52 of 309 patients (16.8%) and was most common in the first 72 hours after admission, and in patients with hunt and hess grades 3 and 4. agitated patients were significantly more in half of these patients a complication appeared to occur within 24 hours of the onset of agitation. patients with agitation had increased icu and hospital lengths of stay, but this was not significant after controlling for other predictors of length of stay. for patients with hunt and hess grades 1-4, agitation was not independently associated with functional impaired at 12 months compared to those without agitation after controlling for other predictors (lawton >8; p = 0.03, or 2.7, 95% ci 1.1-6.8). patients with sah frequently experience agitation requiring medical treatment, especially early in their clinical course, and especially in non-comatose patients with higher clinical grades. agitation is also associated with the development of multiple hospital complications, and may have an independent impact on long-term outcomes. seizures after subarachnoid hemorrhage (sah) are a frequent complication. sah patients are typically prescribed prophylactic anti-epileptic drugs (aed) for three to seven days. phenytoin has fallen out of favor as aed prophylaxis due to its association with worsened outcome as well as drug interactions. newer aeds including levetiracetam are more commonly used despite an incomplete understanding of their effect on outcome. retrospective analysis was performed of prospectively collected data for 97 consecutive sah patients enrolled into the university of maryland recovery after cerebral hemorrhage (reach) study between -hess (hh) and modified fisher score (mfs) was adjudi a team of neurointensivists. retrospective analysis of cumulative dose of levetiracetam was divided into groups of low-dose (=12,000mg) using the median as a cutoff. concordance and discordance was noted. pearson chi-square was used. association of levetiracetam dose and quetiapine use as a surrogate of in-hospital delirium was also investigated. multi-variate logistic regression was used to determine predictors of ability to perform activities of daily living (adls) in 78 survivors. 97 asah patients from july 2014 to november 2015 were reviewed for this study. cumulative levetiracetam dose was calculated in 89 patients and dichotomized into high-dose (>=12,000mg) or lowdose groups. hunt-hess was found to be significantly associated with high-dose levetiracetam. on multivariate analysis, high-there is a trend towards increased use of quetiapine in the high-dose levetiracetam group. full analysis will be provided at time of presentation. an extended course of levetiracetam is an independent predictor of loss of independence in activities of daily living after sah. there is also a trend toward increased delirium. larger, prospective studies are necessary for a more complete understanding of the impact of seizure prophylaxis on functional outcome after subarachnoid hemorrhage. myocardium: a case series and review of the literature. intra-aortic balloon pump (iabp) counterpulsation has been used to maximize cerebral blood flow in patients with subarachnoid hemorrhage (sah), refractory vasospasm and evidence of cardiac dysfunction. neurogenic stunned myocardium (nsm) pr lv dysfunction. we present 9 cases with sah, vasospasm and iabp placement, including 7 cases with nsm. we also reviewed the literature with the goal of examining the safety of iabp for cardiac dysfunction after sah, outcomes and selection criteria for its use. we searched for cases of sah and iabp placement at the university of kansas medical center (kumc) from 2008 to 2015. 9 patients met criteria and all had a secured aneurysm, refractory vasospasm and echocardiograms prior to iabp placement. we collected demographics, vitals, ekg, troponin, medications, iabp and icu complications, discharge and follow-up mrs. however, at follow-r outcome. literature review identified 17 patients -up. our results indicate that patients that have iabp placement in the setting of sah, vasospasm and cardiac dysfunction may have a good outcome if they are younger, have evidence of reversible nsm and avoid icu complications including pe, uti and sepsis. the patients level of mobility and independence at discharge may not be indicative of overall functional improvement. a significant complication of non-traumatic sub-arachnoid hemorrhage (nt-sah) is the development of delayed cerebral ischemia associated with cerebral vasospasm. milrinone, an inotrope and a phosphodiesterase inhibitor, has been used intravenously, intra-thecally and intra-arterially as a delayed cerebral ischemia treatment and prophylaxis. the purpose of the current study is to systematically review the available evidence on its efficacy for that indication. articles from medline, embase, cochrane library, clinicaltrials.gov, reference lists of relevant articles, and gray literature were searched. study selection criteria were used and strength of evidence was graded. neurological outcomes and side effects were assessed. of 158 articles identified, 18 studies met the selection criteria and analyzed. the level of evidence varied and was generally low. this systematic review helped determine the current state of evidence for the efficacy and safety of milrinone in the management of delayed cerebral ischemia in the context of nt-sah. the available evidence is promising but of generally low quality suggesting the need for a randomized controlled trial. blood lactate variability: a strong independent predictor of neurological outcomes in patients with aneurysmal subarachnoid hemorrhage blood lactate levels during intensive care unit (icu) management of patients with aneurysmal subarachnoid hemorrhage (sah) can be used as an indicator of not only volume status but also aerobic glycolysis caused by excessive catecholamine levels and impaired lactate clearance. to determine whether blood lactate variability (lv) can predict neurological outcomes in patients with sah, we assessed the standard deviation (sd) of blood lactate level of each patient during icu stay. we retrospectively reviewed all patients at the age of 18 years or older who were consecutively hospitalized in kagawa university hospital with sah and at least five arterial lactate measurements between january 1, 2009 and may 31, 2015. patients were divided into two groups with a mean lactate to identify independent predictors of unfavorable neurological outcome. unfavorable neurological outcomes occurred in 44.2% of a total of 122 patients. in both groups, there were increases in unfavorable neurological outcomes with increasing sd of lactate (quartile 1, 25%; that sd of la correlated with unfavorable neurological outcomes (p < 0.01). multiple logistic regression analysis showed that sd of lactate (odds ratio, 9.07; 95% confidence interval, 2.06-47.6, p < 0.01), age, and h&k grade were independent predictors. this study demonstrated that increased lv was an independent predictor of unfavorable neurological outcomes in patients with sah. the main causes of mortality and morbidity after aneurysmal subarachnoid hemorrhage (saha) are rebleeding and delayed cerebral ischemia secondary to cerebral vasospasm. the use of milrinone, an inotropic and vasodilator agent, is described in as one option to treat vasospasm in patients with refractory symptoms. our objective was to describe the experience of our neurocritical care service with the use of milrinone in accordance with the montreal protocol for patients with refractory vasospasm. a retrospective study based on data obtained from medical records of patients suffering from saha and refractory vasospasm treated with milrinone from february 2015 to february 2016. from 70 saha patients admitted to our hospital during the study period, 8 were identified with refractory were female and 50 % of patients were pre-hypertensive. a total of 62% of the patients had hunt-hess scores between 1-3 and 75 % scored 3 or 4 in the modified fisher scale. vasosespam was identified after --9.2 days. in 75% of the patients hypertension was induced with norepinephrine as an initial treatment. the mean duration of the treatment -4.6 days. two cases were treated with intra-arterial milrinone and angioplasty. the most common adverse event during the use of milrinone was hypotension (50%). death occurred in 2 patients. favorable functional outcome at the discharge was observed in 37% of the cases. in conclusion, the use of milrinone seems to be a safe option in the treatment of delayed cerebral ischemia secondary to vasospasm, especially in services where the availability of endovascular treatment is not a routine. (sah). however, pathomechanism and etiology of this elevation leading to poor outcomes remains uncertain. this study investigated the effect of troponin elevation on multi-organ dysfunction and outcomes in patients with sah. admitted to the neuroscience intensive care unit from july 2013 to january 2016. among 307 patients, 209 patients were eligible for inclusion with investigation of serum troponin level at admission. troponin elevation (> elevation were older (59.1 ± 14.4 vs 53.0 ± 12.8 years; p < 0.01) and more often had a loss of consciousness (31.0% vs 16.7%; p < 0.01), symptomatic hydrocephalus (42.3% vs 23.2%; p = 0.01), and a higher hunt-hess score (3.4 ± 1.1 vs 2.6 ± 0.9; p < 0.01) and modified fisher score (3.4 ± 0.6 vs 3.0 ± 0.7; p < 0.01) at ictal period. during hospitalization, patients with troponin elevation more often had a respiratory failure (31.0% vs 18.1 dysfunction (21.1% vs 8.0%; p = 0.01) and more often treated with vasopressure (25.4% vs 13.8%; p = 0.01) and longer duration of mechanical ventilation (3.7 ± 6.2 vs 1.6 ± 3.3 day; p = 0.04) than those without troponin elevation. troponin elevation in the acute stage of sah is associated with multi-organ dysfunction. thus troponin to mitigate early brain damage in subarachnoid hemorrhage (sah), we have been treating world federation of neurological surgeons grade (wfns) grade 5 patients with therapeutic hypothermia (th) for 7 days immediately after onset. management after rewarming was problematic since fever in sah is associated with vasospasm and poor outcome. we studied the feasibility and safety of endovascular cooling to maintain prophylactic normothermia following initial th in patients with severe sah. th (core body temperature 34.0 °c) was initiated, using surface cooling, immediately after the diagnosis of wfns grade 5 sah was made. the ruptured aneurysm was surgically clipped as soon as feasible. around postoperative day 7, after rewarming to 36 °c, an endovascular catheter with 2 cooling balloons jugular vein and connected to xp® temperature management system (asahi kasei zoll medical corp.) for 7 days. prospectively collected data were analyzed. 6.7 days. nine patients developed shivering with increased temperature and were given acetaminophen and dexmedetomidine. there was no evidence of vasospasm or additional cerebral infarction during endovascular cooling, and no catheter-related sepsis or thromboembolic event. after removal of the cooling catheter, vasospasm-related cerebral infarction and fatal bacterial meningitis related to spinal drainage occurred. three-month outcomes were good recovery (n=2), moderate disability (n=4), severe disability (n=2); vegetative state (n=1), and death (n=2). elimination of fever burden in the first 14 days after onset was safe and feasible with combined surface and endovascular cooling in patients with wfns grade 5 sah. disease processes. this study examines: 1) the relationship between admission lactate and the clinical and radiographic severity of asah, and 2) whether levels predict outcomes including vasospasm, delayed cerebral ischemia (dci), and inpatient mortality. this is a retrospective analysis of 75 consecutive asah patients with lactate drawn on admission.compared to those with normal levels. differences between groups were compared using chi-square tests for categorical variables, and independent t-tests for continuous variables. spearman correlations were calculated between lactate levels and mean values for continuous variables. elevations in lactate were associated with admission gcs, hunt & hess (hh) grade, fisher score, serum white blood cell count (wbc), troponin i (tn), glucose, and ventilator-free days (vfd). positive correlation was found between lactate and hh, fisher score, wbc, tn, and glucose. an inverse correlation existed between lactate and gcs, and vfd. compared to survivors, non-survivors had significantly higher lactate levels. all results were considered significant with a p-value <0.05. no association between lactate and the development of vasospasm or dci was found. higher admission serum lactate is positively correlated with hh grade, fisher score, serum wbc, tn and glucose, but negatively correlated with admission gcs and vfd. presence of an elevated lactate was also predictive of inpatient mortality. this is the first report of correlation between early lactate and asah severity, and conflicts with prior results suggesting an association between lactic acid and the development of dci. further studies are needed to determine whether lactate elevations relate to hypovolemia, acute inflammatory response, elevated sympathetic outflow, or other cause. with malignant cerebral infarction with high osmotic pressure therapy. some patients need decompressive hemicraniectomy or expire due to cerebral herniation after ttm. hence this study was performed to determine associated factors in case of failure of ttm in patients with malignant cerebral infarction. from january 2011 to december 2014, a study was performed in patients with malignant cerebral infarction occurred within 24 hours at neurological intensive care unit. all patients were diagnosed hyperosmotic fluid therapy and ttm. we defined failure of ttm to cases treated by decompressive hemicraniectomy or death due to brain herniation. a total of 21 patients, ttm were failed in 12 patients. failures of ttm were common in patients without recanalization after thro ( fever occurs in 20-50% of critically ill neurological patients, and small temperature elevations are correlated to increased morbidity. it is therefore crucial to acutely control the temperature of such patients. systems currently available are resource intensive and not always readily available in units, resulting in delays in treatment. emcools pads and are composed of multiple cooling units filled with graphite and water, with an adhesive underside that allows for efficient heat transfer. pads are stored at -18 c, and are available for immediate use. the retrospective analysis of the emcool device included all subjects that had the device applied in the neuroscience intensive care unit (nsicu), with consistent temperature data recorded. preliminary subarachnoid hemorrhage (50%), intracerebral hemorrhage (17%), subdural hemorrhage (17%), and pituitary tumor (17%). all subjects were febrile ( treatment period. the bedside shivering assessment scale was recorded at each application. c, t60avg = 37.9 c) drop in temperature at 60 mins c) achieved at 55 mins. unconscious patients displayed a much higher rate of cooling at t60 as c). of the total subjects, 33% had shivering events upon application (bsas 2), device. preliminary results show the emcools pads are an effective and safe method to control temperature elevations in neurologically critically ill patients. all even numbered posters will present on friday all odd numbered posters will present on saturday all poster sessions are in prince george exhibit hall a from 5:30pm superior sagittal sinus thrombosis (ssst) accounts for only 0.5-1% of all strokes, with a traumatic etiology representing an uncommon occurrence. current guidelines advocate treating ssst with anticoagulation regardless of etiology, though efficacy is controversial and not yet studied in the traumatic brain injury (tbi) patient population. we recognize the importance of alternate treatment modalities of post-traumatic ssst, particularly surgical alternatives, and the dilemmas faced with anticoagulation therapy in the trauma population. we report a case of a 22-year-old male admitted with ssst who suffered severe tbi secondary to a pedestrian versus automobile collision. imaging demonstrated bifrontal and right temporal lobe hemorrhagic contusions, scattered subarachnoid hemorrhage, diffuse cerebral edema, multiple nondepressed skull fractures, and ssst. on post trauma day two, the patient clinically deteriorated; an external ventricular device (evd) was placed, and therapeutic heparin drip was started, despite the presence of intracranial hemorrhage and risk of evd-related hemorrhage. the patient developed refractory elevated intracranial pressure (icp) mandating initiation of pentobarbital to achieve burst suppression on continuous electroencephalography (ceeg) and serial administration of 23.4% hypertonic bolus and mannitol for two weeks. hemicraniectomy and endovascular treatment were entertained though not pursued due to anticipated complications associated with concomitant anticoagulation therapy. anticoagulation was briefly interrupted for evd removal on post trauma day 17. he was extubated on post trauma day 20 and transitioned to warfarin. repeat imaging showed complete recanalization of the superior sagittal sinus. the patient was discharged to inpatient rehabilitation after a 28-day hospital course. management of ssst secondary to tbi remains controversial as these patients present with multiple confounding factors, further complicated by the lack of treatment guidelines. further studies are needed to determine which independent or combined medical and surgical treatment modalities will decrease morbidity and mortality in this patient population. takotsubo cardiomyopathy (tc) is known to occur in patients with subarachnoid haemorrhage (sah) but is rarely reported in patients with traumatic brain injury (tbi). here we present a tbi patient with complicated clinical course developing severe tc and compared to previously published reports. case report and literature review. a 73 years-old-woman was admitted to our tertiary care hospital because of tbi with admission glasgow coma scale score of 14. computed tomography (ct) scanning of the brain revealed an acute subdural hematoma and traumatic sah over left hemisphere and a small left frontal hemorrhagic contusion. six hours later she deteriorated and head-ct showed significant progression of right frontal hemorrhage with intraventricular expansion and a midline shift. hematoma evacuation was immediately performed. postoperatively the patient developed cardiogenic shock necessitating an increasing dose of noradrenaline, neosynephrine and dobutamine to achieve a cerebral perfusion pressure of >65mmhg. echocardiography demonstrated severe left ventricular myocardial dysfunction suggestive for tc, supported by raised troponin-t and nt-probnp levels and abnormalities in ecg. continuous infusion of levosimendan was added and maintained for 28 hours which led to stabilization allowing noradrenalin to be decreased the following days. repeated echocardiography 8 days later showed normalized cardiac function. the patient's condition gradually improved and was extubated after 11 days fully awake with mild left facial-brachial weakness. here we present a complicated case of tc with tbi developing cardiogenic shock within 24 hours of admission. we will compare the patient's tc characteristics and clinical course with published cases (n = 16) of tc with tbi. further studies of tc in patients with tbi and the utility of levosimendan is warranted. management of post-operative central diabetes insipidus (di) is focused on replacing urine output with free water. this may not always be sufficient, and desmopressin (ddavp) is needed. the use of ddavp, however, is known to cause profound changes in sodium particularly if the triphasic response postpituitary surgery is occurring. herein, we report a case using a dilute vasopressin bolus protocol in managing hypovolemia in acute, post-operative, central di. case report comparing two protocols for di management. statistical analysis was performed on serum sodium, urine specific gravity, and urine output using student t-test. p<0.05 was considered significant. anti-programmed cell death 1 (pd-1) antibodies are an effective treatment option for nsclc and other cancer entities. anti pd-1 antibodies including nivolumab can induce immune-related adverse events (iraes) in a number of organ systems. neurological iraes can be life-threatening and necessitate appropriate investigation and management by a neurologist. myasthenic syndromes have rarely been described. here we present a case of a man who developed a lambert eaton myasthenic syndrome thought to be a nivolumab-related immune adverse event. a 90-year-old man on nivolumab for metastatic nsclc developed asymmetrical ptosis followed by facial diplegia, dysarthria and dysphagia and fatigable limb weakness. he had clinical features of lambert eaton myasthenic syndrome with striking truncal, shoulder and pelvic girdle fatigable weakness that demonstrated a temporary increase in strength during the first few contractions. he developed neuromuscular respiratory failure requiring noninvasive positive pressure ventilation. his muscle reflexes were initially absent and after repeated attempts could be elicited. his mri brain was normal, csf was within normal limits and his serum and csf antibodies against ach receptors, musk and voltage gated calcium channels were negative. he weakened after an initial 1mg/kg dose of prednisone. plasma exchange resulted in a significant improvement of his weakness and the ability to wean the patient off noninvasive positive pressure ventilation. it is important to recognize that neurologic immune-related adverse events associated with nivolumab can cause lambert eaton myasthenic syndrome. early recognition and aggressive treatment with plasma exchange can be life-saving. neuroendocrine tumor (net) of middle ear is extremely rare. many names have been ascribed to these seemingly benign neuroendocrine lesions including middle ear adenoma (mea), adenomatous tumor and carcinoid tumor (ct). 'neuroendocrine adenoma' has also been used to better describe the histologic nature of these tumors. here we present the first case of carcinoid tumor of middle ear (ctme) complicated by dural sinus thrombosis and bony metastasis. a 73 year old man presented with right sided facial palsy for 4 hours and progressive hearing loss for 2 months. physical examination revealed perforated right tympanic membrane with visible purulent material. ct scan of the head showed a small right cerebellar infarct. the mri demonstrated right cerebellar hemorrhagic venous infarct and a heterogeneous middle ear mass extending into the internal auditory canal. mrv revealed thrombus in the right sigmoid and transverse sinus.cervical spine mri revealed diffuse osseous metastases .the histology and immunohistochemistry (ihc) after surgical resection was consistent with ctme. proliferation rate of>75% was seen by ki67 staining. he suffered massive intracranial bleed on heparin therapy and passed away. the nets of head neck region are divided in 3 categories based on histology and ihc. 1) well differentiated ct, 10/10 hpfs and ki-67>20%. although regional metastasis is not uncommon, only 2 cases of distant metastasis have been reported in the past. our patient was diagnosed to have atypical carcinoid but the ki-67 was >70% which is consistent with small cell cancer. the new classification system that takes the ihc and presence of metastasis into consideration to classify these tumors is much more clinically relevant. more research is necessary to find out the biological markers for better prognostication of this rare cancer. sung m. cho.neurological institute, cleveland clinic, cleveland, oh, usa. acute transverse myelitis is an acquired inflammatory spinal cord disorder, which can be due to infection, autoimmune disorders, or malignancy, however, the cause is often unknown despite an extensive workup. we describe a rare case of acute transverse myelitis caused by coxsackie b3/b4 virus. a 36-year-old male with no past medical history presented with a viral prodrome of flu-like symptoms followed by severe headache, neck stiffness, photophobia, encephalopathy and paraplegia. mri of the brain with contrast was unremarkable, but mri of the spine showed an extensive longitudinal, nonenhancing t2 cord signal change from c6-t11 without hemorrhagic components. lumbar puncture revealed 203 rbc, 214 wbc, 143 protein, and 46 glucose (95 mg/dl serum glucose). extensive serum and csf work-up was negative for hiv, wnv, ebv, cmv, lyme, vzv, hsv, nmo antibody, ace, paraneoplastic panel, cytology, cryptococcus, and csf bacterial and fungal cultures. ct chest and blind transbronchial needle lymph node biopsy were negative for sarcoidosis. serum coxsackie b3 (1:320) and b4 (> 1:640) antibody titers were significantly elevated. the patient was treated with intravenous methylprednisolone 1000 mg for 5 days along with plasmapheresis for 5 sessions. the patient had improvement in lower extremity strength during his hospital stay and was discharged to a rehab facility on a steroid taper. at one-month follow up, the patient had complete recovery of lower extremity strength as well as bowel and bladder function and was ambulatory. at 3-month follow-up, mri and csf studies were markedly improved. transverse myelitis due to coxsackie has been reported in serotypes b2, b5, a9, a10, however only three cases of b3 or b4 related transverse myelitis have been reported and this is the first case, to our knowledge, with both b3 and b4 related transverse myelitis. external ventricular drains (evds) are necessary for select patients admitted to the neurointensive care unit (nicu). evds are critical to the management of diseases such as subarachnoid hemorrhage, traumatic brain injury, and acute hydrocephalus. we report a case of a woman with poor-grade aneurysmal subarachnoid hemorrhage who experienced inadvertent intraventricular non-iodinated contrast injection during vasospasm evaluation with ct angiography. we provide a review and analyses of adverse evd related injections reported in the literature and summarize management recommendations. a pubmed search was performed for unintended evd injections from 1927 to 2016. unique cases were selected and classified by the type of inadvertent injection and location of the event. acute management was categorized by the use of evd manipulation, lumbar drain placement, and supportive medical therapies. cases involving ventriculoperitoneal shunts, ommaya reservoirs, or other intrathecal device systems were excluded. a total of seven unique cases were identified, four involving contrast administration and three involving medication administration. the sentinel event in five cases occurred outside of the nicu. acute management with evd manipulation was employed in six cases; three of these cases also used lumbar drains. three cases necessitated intubation. our patient received prophylactic dexamethasone and levetiracetam, underwent immediate evd manipulation, and placement of a lumbar drain. continuous eeg monitoring and daily head cts were performed until intraventricular clearance was noted at 72 hours. acute management of inadvertent intraventricular injections entails immediate evd manipulation and possible lumbar drain placement to facilitate rapid csf clearance of injected substances. intubation may be required immediately depending on exposure. inadequate distinction between compatible drain tubing and relative inexperience of providers managing the evds likely contributed to the errors in these cases. the increased incidence of these events outside of the nicu suggests additional safety measures may be warranted when patients with evds travel off-unit. an unusual presentation of isolated brain abscess in non-traumatic convexal subarachnoid hemorrhage: a case report to present a unique case of isolated brain abscess presenting as non-traumatic convexal subarachnoid hemorrhage (csah) six days before radiologic signs could be seen. to our knowledge only one other case of csah due to brain abscess has been reported thus far. a 42-year old man with no past medical history or prior trauma presented with acute onset of transient left hemianesthesia lasting ten minutes. computed tomography (ct) of the head revealed csah. we were presented with a diagnostic dilemma when magnetic resonance imaging (mri) of the brain, magnetic resonance angiography (mra) of the head and neck, magnetic resonance venography (mrv) and conventional angiography failed to show the cause of csah. the patient was discharged in a stable condition, but returned six days later with worsening symptoms, including left hemiparesis. repeat mri with contrast revealed a cerebral abscess in the same location as the prior csah. csah without clear evidence of trauma due to abscess is a rare occurrence. we suggest in cases of csah where imaging techniques present no abnormalities, follow-up imaging within seven days should be considered. jonathan marehbian, diane d. chan, david d. greer.yale new haven hospital, department of neurology, new haven, ct, usa. spinally-mediated reflex movements can be present in brain dead patients. however, abnormal movements have long been a challenge in the clinical determination of brain death. in this report, we describe delayed plantar extension with noxious nail bed stimulation that has not been previously described in brain death. a 28-year-old male suffered severe anoxic brain injury following respiratory failure due to heroin overdose. his clinical exam and apnea testing were consistent with brain death with the exception of a reproducible delayed plantar extension with noxious nail bed stimulation. ancillary testing with technetium 99m nuclear scan (spect) demonstrated no cerebral blood flow, confirming that the finding was spinally-mediated. novel movements are important to document in order to aid in the timely determination of brain death, and to avoid unnecessary and potentially confounding ancillary testing. the mechanism underlying delayed plantar extension is likely spinally mediated. vascular perforation during a neuroendovascular procedure is an unexpected and feared complication, which can lead to fatal outcomes. a prompt recognition and initiation of treatment are paramount. endovascular strategies to address this complication have been widely described. however, the goals of therapy in the neurointensive care unit (neuroicu) remain unclear. we report two cases in which endovascular strategies associated with aggressive intensive care resulted in a good clinical outcome at discharge. case report. vessel perforation occurred in 2 patients during neuroendovascular interventions: a left-carotid stenting and an ica-aneurysm embolization with balloon-assisted coiling. once contrast extravasation was demonstrated, heparin was immediately reversed and endovascular strategies were performed to minimize the complications. sah was present in the initial head ct in both cases. in the neuroicu, targets of therapy were a) systolic blood pressure (sbp) <110 mmhg, b) mechanical ventilatory support, and c) seizures and vasospasm prophylaxis with phenytoin and nimodipine respectively. one of the patients developed mild hydrocephalus and left upper extremity weakness, with mri showing tiny right hemispheric strokes, while the other one, did not show any focal deficit. both patients were discharged home few days later with mrs of 2 and 0, respectively. iatrogenic vascular perforation is an uncommon complication that occurs secondary to inadequate manipulation of the catheter, guide wire, devices, or forceful contrast injection. clinical care strategies aim to prevent fatal outcomes. we recommend reversing heparin; provide an adequate ventilatory support, maintain a strict control over the sbp, and seizure and vasospasm prophylaxis. but, larger studies are required to determine the standard of care since endovascular therapy is rapidly becoming first-line of treatment for neurovascular conditions. cerebral hyperperfusion syndrome (chs) symptoms range from severe unilateral headache to seizures, focal symptoms and intracerebral hemorrhage, usually occurring follow carotid endarterectomy (cea)/ carotid stenting (cas). we describe a case of a patient who developed chs after spontaneous recanalization of carotid intra-stent thrombosis. case report. 68 years old african american male who had recently placed left cervical stent was transferred to baptist medical center with new evidence of intra-stent thrombosis. he was started on heparin drip and sbp was augmented with levophed for sbp>160. two days later, the patient developed excruciating headache followed 6 hours later by acute onset of right upper extremity and face twitching associated with severe hypertension. the bp was controlled, protamine was given to reverse heparin and keppra was loaded to treating seizures. cta at this time showed recanalization of carotid in-stent stenosis and ctp confirmed hyperperfusion of frontal and parietal lobe with neither evidence of new ischemic area nor bleeding. fortunately, inspite a delay in diagnosis by 6 hours, patient did not suffer intracranial hemorrhage. most patients who develop chs will have complete recovery if it is discovered and treated early.aggressive prophylactic blood pressure control is the main treatment. for those who are diagnosed late and those progressing to ich, the prognosis can be devastating with mortality rates up to 50%. considering the importance of blood pressure control in the cerebral hemodynamic, studies have been done, trying to find a better tool to predict the best bp target in order to prevent chs. near infrared spectroscopy (nirs) is a non-invasive and reliable technique that monitor the cerebral hemodynamic. had nirs been deployed during anticoagulation, the diagnosis of cerebral hyperperfusion syndrome would have been made at the onset of headaches and would have avoided the development of seizures and potentially a life threatening hemorrhage. the triphasic response: water imbalance after neurosurgery : a case reportbibhukalyani das, indranil i. ghosh.institute of neurosciences kolkata, kolkata, india. water balance disorders after neurosurgery are well recognized, but detailed reports of the triphasic response are scarce. we describe a 30-year-old woman, who developed the triphasic response with hyper and hyponatraemia after resection of craniopharyngeoma. a 30-year-old female (no previous medical history, no medication, normal electrolytes and endocrine parameters) with mri showing s/o craniopharyngeoma underwent neurosurgery using a subfrontal approach to resect the craniopharyngeoma while leaving the pituitary stalk intact (according to the surgical notes). within a few hours of an uneventful postoperative recovery she started having polyuria and hypoosmolar urine with hypernatremia. being normoglycaemic and not on any diuretics a diagnosis of central diabetes insipidus was made treated with desmopressin nasal spray and drinking water ad libitum. improvement occurred over the next postoperative day when desmopressin was discontinued. on the third day she developed with hypoosmolar hyponatremia along with seizure treated with 3% saline and fuid restriction. two days later polyuria returned and was ultimately discharged with desmopressin tablets and advice to take fluids ad libitum. na this case illustrates the dramatic and sudden changes in water balance that may occur after neurosurgery. the pathophysiology of the triphasic response appears to be early hypothalamic dysfunction, subsequent release of vasopressin from the degenerating pituitary and, finally,depletion of vasopressin stores. it has been difficult to identify patients at risk, but predisposing factors appear to relate both to the disease (macroadenoma, microadenoma, craniopharyngioma) and to the surgery (degree of manipulation). successful prevention probably involves a psychological switch by not waiting until frank dysnatraemia has developed, but to act as soon as urine output and tonicity change. this requires an index of suspicion for treating and consulting physicians and specific instructions to nursing staff, especially in nonintensive care settings. refractory status epilepticus (rse) has high mortality and is difficult to treat. when traditional therapies fail ketamine may be considered. ketamine is associated with limited reports of adverse cardiac events during anesthesia, but not during treatment for rse. we evaluated occurrences of cardiac arrhythmias associated with ketamine. retrospective chart review of neurocritical care patients in a tertiary academic medical center who received ketamine infusion for rse between october 2010 and april 2016. ten patients were admitted to a neurologic intensive care unit and received ketamine infusion for rse. etiology of rse included autoimmune/infectious process (8), ischemic stroke (1) and subarachnoid hemorrhage (1). of the ten patients who received ketamine, three had documented cardiac events without prior cardiac history. one patient remained clinically stable and did not require intervention. another patient required escalating doses of ketamine infusion (maximum 6mg/kg/hr) for rse secondary to presumed leptomeningeal disease, had an asystolic event and expired. the third patient was on low dose ketamine (0.07mg/kg/hr) for rse secondary to subarachnoid hemorrhage, and developed multiple arrhythmias including recurrent episodes of asystole. once ketamine was discontinued the patient stabilized. arrhythmias are not uncommon in critically ill patients, but this is the first report of cardiac arrest associated with the use of ketamine for rse. although sympathomimetic properties of ketamine may provide vasopressor sparing effects, which reduce the need for vasopressors to counteract the hypotension commonly seen with other anesthetics used in rse, it may put patients at risk for cardiac arrhythmias. in addition, ketamine has direct negative ionotropic effects and may raise pulmonary artery pressures. caution should be employed when ketamine is used in rse in patients with other independent risk factors for cardiac events. a 36 year-old veterinary technician with headache and fever for 2 days presented with altered mental status and myoclonic jerking. initial lp showed 21 white cells and elevated protein (71 mg/dl). recurrent clinical seizures occurred for 6 days prior to transfer to our institution. his exam demonstrated diffuse hyperreflexia and coma; eeg demonstrated up to 2.5hz frontally-predominant rhythmic delta but no unequivocal seizures. extensive workup revealed no evidence of infectious, toxic, or immune-mediated encephalitis. mri demonstrated bithalamic injury and a region of questionable periventricular nodular heterotopia in the right parietal region. subsequently, he developed recurrent clinical and unequivocal electrographic seizures from the right parieto-occipital region. five periods each lasting >48 hours of anesthesia-induced eeg burst suppression failed to stop seizures, qualifying him as super-refractory status epilepticus. after 6 weeks of failure to wean from anesthetia, invasive monitoring for seizure localization was carried out using strips and depth electrodes. multiple seizures were recorded, localizing to the medial occipital lobe, which was subsequently resected along with the region of pathologyconfirmed heterotopia. seizures gradually improved, requiring 7 anti-seizure drugs and a ketogenic diet. he regained consciousness with preserved higher cognitive functions (language, memory) and personality 6 months later as his antiseizure drugs were successfully decreased. his motor recovery was limited by critical illness myoneuropathy. new-onset focal super-refractory status epilepticus may respond to surgical resection in extreme cases. close collaboration with a multidisciplinary team of epileptologists and neurosurgeons can lead to resolution of seizures and eventually recovery. in patients with leptomeningeal metastases (lm) and elevated intracranial pressure (icp), transient neurologic events secondary to plateau waves -temporary elevations in icp -may occur. there is a paucity of clinical reports correlating video-eeg with definite or presumed plateau waves in patients with lm. case report and literature review. pubmed was queried for 'leptomeningeal metastases and eeg', 'leptomeningeal metastases and plateau waves' and ' leptomeningeal metastases and intracranial pressure'. a 48-year-old woman was transferred to our hospital for further care of a pituitary microadenoma noted on outside imaging. she had a history of hodgkin lymphoma treated with radio-chemotherapy. during her admission, she developed episodes of confusion and video-eeg monitoring was initiated. while there were no electrographic seizures, several events, between 5 to 10 minutes in duration, of delayed or absent verbal responses, eye rolling, staring and alternating gaze preferences to both sides were noted. all these coincided with abrupt onset of marked background slowing, evident through generalized 2-3 hz delta, mixed with some theta frequencies. review of outside and repeat imaging with mri of the brain with contrast revealed brain and leptomeningeal metastases. cerebrospinal fluid examination showed raised opening pressures and malignant cells, leading to a subsequent diagnosis of primary signet ring cell cancer. we found one additional report describing video-eeg correlates of presumed plateau waves in patients with lm. our clinical description of transient neurologic events in this patient adds to the current literature of paroxysmal manifestations owing to raised icp in patients with lm. awareness of this clinical phenomenon may serve as a surrogate of raised icp before clinical signs of the same develop in patients with lm. it may also help delineate the cause of raised icp due to cns metastases in a patient with a corresponding history of cancer. background: terson's syndrome is the development of intraocular hemorrhage (ioh) in association with subarachnoid hemorrhage (sah). we report a case of terson's syndrome and review the literature. case report: a 48yr woman presented with severe neck pain and somnolence. ct imaging showed fisher grade 3 sah with aneurysms in the right internal carotid and posterior communicating arteries. she developed low pressure hydrocephalus treated with ventriculostomy. on hospital day 12 she developed vision loss. ophthalmologic examination demonstrated bilateral vitreous hemorrhages with near complete fundoscopic resolution by day 19. over the next 4 months she underwent pars plana vitrectomy (ppv) of the left eye two times. current vision od 20/20, os 20/50. discussion: the incidence of terson's syndrome among patients with sah is documented to be between 8-40%. in prospective studies, ioh was found in up to 28% of patients with sah compared to only 3% in retrospective studies suggesting under-reporting. this is likely because ioh is found more often in higher severity bleeds where patients cannot self-report visual loss due to decreased loc. patients with ioh are more likely to have worse neurologic outcomes and die more often than those with lower grade bleeds without the development of ioh. along with fundoscopy, hand held ultrasound may be used for bedside diagnosis. erm development is the most common intraocular complication from terson's syndrome and occurs in 15-78% of patients. complete or near complete return of visual acuity is less likely without surgical intervention. visual acuity has been show to recover better and faster if ppv is performed within 90 days. there is no literature on incidence of visual loss after acute phase of sah. conclusions: routine evaluation with imaging and fundoscopy may help in detecting ioh sooner in the clinical course and has the potential to decrease long-term morbidity. iatrogenic underfeeding in critically ill patients is often unrecognized and underestimated. an international prospective study of 201 critical care units showed patients received only 61.2% and 57.6% of prescribed calorie and protein needs. the inability to initiate enteral nutrition within 24-48 hours of icu admission or frequent interruptions of the enteral regimen lead to insufficient nutrient delivery and a compounding energy deficit. an increase in infectious complications is associated with negative energy balance in patients with subarachnoid hemorrhage (sah). a quality initiative project was developed at mayo clinic florida to measure time to reach enteral nutrition target and common interruptions of enteral nutrition. the target subjects were mechanically ventilated patients in medical and transplant icu; however the quality measure has recently extended to the neurocritical care unit. data collected included clinical diagnosis, sofa and apache ii score, subjective global assessment (sga) score, nutric score, enteral tube type and regimen, and reason and duration for interruption of nutrition. a 76 year old subject with sah and posterior fossa avm resection was deemed low nutrition risk with sga score a and nutric score 4. enteral nutrition was initiated via nasoenteric tube within 25 hours of intubation. target enteral goal rate was reached within 16 hours. the patient received 100% of calorie/protein needs 9 of the 12 days. the most common enteral interruption was for procedure; primarily head ct, for longest duration of 155 minutes. the interruption of enteral nutrition in neurocritical care patients is likely unavoidable due to procedures. these disruptions, however, need not result in iatrogenic underfeeding. neurocritical care units may utilize volume-based enteral protocols to allow nurses to compensate for lost nutrition with increased enteral rate. neurogenic pulmonary edema is challenging to manage in the context of aneurysmal subarachnoid hemorrhage (asah) due competing priorities between organ systems. we present a case of refractory neurogenic pulmonary edema due to asah necessitating extracorporeal membrane oxygenation (ecmo). case report. a 30 year-old female with a history of hypertension and diabetes presented neurologically intact with hh2f3 asah due to a left posterior communicating artery aneurysm. she underwent coil embolization on sah day 2 and remained intubated after the procedure due to development of flash pulmonary edema. transthoracic echo demonstrated normal left ventricular function. on sah day 3 after unplanned extubation, she was temporized on noninvasive ventilation until reintubation the following day. she progressed to severe ards requiring high-dose sedatives and paralytics which obscured her neurologic exam. on sah day 7, a 9 day course of intrathecal nicardipine was initiated for elevated left mca transcranial doppler velocities. on sah day 8, her respiratory status further declined and veno-venous ecmo was initiated as rescue therapy after head ct did not demonstrate new hemorrhage or infarct. throughout the 7 day ecmo course, a low-dose heparin infusion was utilized along with vasopressors to optimize cerebral perfusion pressure (cpp). she was decannulated on sah day 15. surveillance ct head demonstrated left-sided ischemic infarcts in multiple vascular territories. on sah day 42, she was discharged to an outside facility for ventilator weaning. upon discharge, she was alert and followed commands with her left arm, however she was aphasic without movement of her other extremities. veno-venous ecmo was performed in an asah patient after coil embolization. although the patient did not develop intracranial hemorrhage, her course was complicated by severe vasospasm and delayed cerebral ischemia (dci). while ecmo is a rescue therapy for severe hypoxemia, its effect on cpp remains uncertain and may potentiate dci. key: cord-006880-9dgmdtj8 authors: nan title: neurocritical care society 10th annual meeting: october 4 7, 2012 sheraton denver downtown hotel denver, colorado date: 2012-09-19 journal: neurocrit care doi: 10.1007/s12028-012-9775-0 sha: doc_id: 6880 cord_uid: 9dgmdtj8 nan ahrq guidelines for venous thromboembolism (vte) prophylaxis recommend risk stratification of patients and tailoring prophylaxis to that risk. while anticoagulation is a mainstay of optimal vte prophylaxis after trauma, little data exists to determine when tbi patients warranting neurosurgical intervention become candidates for such treatment. our group sought to determine the natural evolution of intracranial hemorrhage in these high risk patients and identify factors contributing to early radiographic stabilization. all tbi patients undergoing craniotomy and/or intracranial monitoring and surviving at least 24 hours were followed prospectively from feb 2010 to nov 2011. radiographic stabilization was defined as the time between injury and the final ct scan that showed no worsening during the hospital stay. kaplan meier (km) curves were used to compare time to stabilization by type of intervention. binary logistic regression was used to identify covariates contributing to stabilization within 72 hours of injury. for the overall cohort (n=127), km curves showed no difference in time to radiographic stabilization by type of neurosurgical intervention. significant associations were found between stabilization at 72 hours and higher presenting gcs (or:22.8, 95%ci 2.9-180.4), younger age (or:0.96, 95%ci 0.92-0.99), and male gender (or:13.2, 95%ci 2.1-84.3). subjects with a presenting gcs of >11 (n=32) had an 81% ppv for radiographic stabilization by 72 hours after injury. the auc for the logistic regression model was 0.929. sentinel headache refers to discrete thunderclap headache in the weeks preceding hospital admission for sah. a large proportion of these events are thought to represent aneurysmal bleeding events. repeat hemorrhages have been found to increase the extent of vasospasm in experimental models, and are often assumed to increase the risk of delayed cerebral ischemia (dci) in humans (the "double bleed effect"). cerebral performance category (cpc) is a standard outcome measure after cardiac arrest, but has limited ability to discriminate between mild and moderate brain injury. we hypothesized that many cardiac arrest survivors with good cpc scores would have significant deficits on blinded neurocognitive testing. patients initially comatose after cardiac arrest treated who awoke after therapeutic hypothermia (th) were evaluated by a neuropsychologist prior to hospital discharge with the repeatable battery for the assessment of neuropsychological status (rbans), a well-validated tool that assesses function in multiple domains compared to standardized normal values. 18 patients admitted between nov 2011 and may 2012 awoke after th, 9 completed the rbans evaluation after leaving the icu and ready for discharge. median age was 59 yrs (range 47-76), 100% male, 7 had initial rhythm vt/vf, median time to rosc was 10 minutes (range 1-88). seven patients had a cpc of 1, 1 patient had a cpc of 2, and 1 patient had a cpc of 3. seven patients were discharged home and 2 to acute rehab. attention and delayed memory were severely abnormal half of the patients (below 5 th percentile), language and visuospatial domains were affected less often in 22% of the patients (below 5 th percentile). on cumulative scores of all domains, all patients scored below the 16 th percentile compared to age and education adjusted scores, regardless of cpc score. cardiac arrest survivors with cpc scores considered 'good' frequently had severely abnormal neurocognitive function just prior to hospital discharge. the cognitive domains most frequently affected were attention and delayed memory. more sophisticated testing with tools such as rbans may better identify components of cognitive dysfunction after cardiac arrest which may be targets for additional therapeutic intervention and be a more meaningful tool for long-term follow-up studies. introduction quantitative brain diffusion-weighted imaging (dwi) mri may help predicting the degree of functional recovery in patients ain volume with an apparent diffusion coefficient (adc) <450x10 -6 mm 2 /sec differentiated between cardiac arrest survivors who regained an independent lifestyle and those with impaired functional outcome. we aimed to validate this threshold in an external dataset. dwi mris of comatose post-cardiac arrest patients were obtained between 25-120 hours post-arrest. survivors who regained consciousness by day 14 were assigned to one of two recovery groups: good recovery (discharged to home) and impaired recovery (discharged to a skilled nursing facility, rehabilitation facility or another hospital). the quantitative dwi data were obtained blinded to patient outcomes. the brain masks were semi-automatically created on the b0 images using medical image processing, analysis and visualization program (mipav). the adc values of each voxel within the brain were determined. data of 111 patients from five us centers (columbia, mgh, mayo clinic jacksonville, northwestern, and stanford) with adequate mris were analyzed. of these, 30 (27%) patients regained consciousness and survived to discharge: mean age 55±18 years, 47% female, arrest duration 18±13 minutes, 73% of patients received therapeutic hypothermia, mri obtained at 69±24 hours post-arrest. the median (iqr) percentage of brain volume with adc<450x10 -6 mm 2 /sec was 0.02% (0.01-0.2) in patients with good recovery (n=9) and 0.2% (0.1-0.4) in patients with impaired recovery (p=0.03). an adc<450x10 -6 mm 2 -99) sensitive and 24% (95%ci 9-48) specific for good recovery. the results of this validation study support earlier findings that quantitative dwi mri in comatose post-cardiac arrest patients is a sensitive prognostic test to predict the degree of functional recovery in post-cardiac arrest survivors. according to the universal determination of death act, death in the united states is determined in accordance with accepted medical standards, which can be national, regional, or local. as a result, significant variability in brain death (bd) determination has been reported among the best hospitals across the country. we tested the hypothesis that similar variability exists in individual states, such as michigan. michigan health and hospital association and gift of life of michigan (the local organ procurement organization) databases were reviewed for hospital bd policies. only hospitals with > 50 beds and an intensive care unit were included. several bd determination process variables were extracted and analyzed with descriptive statistics. results 61/66 hospitals had bd policies, 1 did not and in 4 it was unclear. ten different combinations of physicians allowed to perform the exam were included. in 8.5% there were no prerequisites to initiate bd and in 23.7% no established cause mentioned. ten different temperatures to initiate bd exam were required. five different arterial blood carbon dioxide levels to establish positive apnea test were cited. a single bd exam was requested in 23.3% of policies, a dual in 63.3% and a single or dual in 13.3%. confirmatory tests were optional (51%), recommended (8.5%) or mandatory (20%). electroencephalogram was the most common confirmatory test (90%) and ct angiogram the least common (7%). we report significant variability in the bd hospital policies in michigan despite published guidelines from the american academy of neurology. if one accounts for additional variability in the strict implementation of these policies at the bedside level, the urgency for a uniform state-wide bd policy becomes even more obvious. intrathoracic pressure regulation (ipr) therapy is a novel therapy that non-invasively modulates pleural pressures to take advantage of the physiological benefits that occur by creating pressure differentials in the thorax. after each positive pressure breath ipr lowers intrathoracic pressure to subatmospheric levels relative to the rest of the body. this intervention enhances cardiac preload and output and decreases intracranial pressure (icp). we hypothesized that ipr therapy which has been previously shown to increase calculated cerebral perfusion pressures would also increase cerebral blood flow (cbf) in a porcine model of elevated icp. in this pilot study, four isofluorane anesthetized pigs (29.8 ± 1.2 kg) were subjected to a focal brain injury by epidural insertion of an 8 french foley catheter into the left hemisphere which was slowly filled with saline to simulate a traumatic brain injury with elevated icp. in the right hemisphere, a thermal diffusion probe was used to measure cbf (hemedex, inc., cambridge, massachusetts) while a millar catheter was used to measure icp. once a stable elevated icp was confirmed, ipr therapy was applied at a level of -12 cmh 2 o for 30 minutes. end tidal co 2 was held constant at 40 mmhg by adjusting the respiratory rate during ipr use. tbi is a major risk factor for the development of alzheimer's disease (ad). in previous animal and human studies, an increase in the expression of amyloid precursor protein (app) after tbi was found to correlate with the disruption of neuronal activity, beta-amyloid plaque formation, cognitive decline, and even death.to date, no interventions used at decreasing amyloid plaque load after tbi have been identified. in this study, using the controlled cortical impact device we produced a severe head injury in 4 month old 5xfad mice. at 30 minutes and 12 hours after injury, the 5xfad mice were treated intraperitoneally with either placebo or resveratrol (anti-oxidant; 100 mg/kg). at 1 month after injury, the animals were intracardially perfused with 0.9% saline followed by 10% phosphate-buffered formalin. the whole brain was removed, sliced, and stained for beta-amyloid levels using immunohistochemistry. in addition, tunel+ cells were measured at the indicated time-points to determine the level of neural injury. in this study we found that treatment with resveratrol at 30 minutes and 12 hours post-injury resulted in a significant reduction in beta-amyloid plaque load near the injury zone (parietal cortex) (p<0.01) and hippocampus (p<0.05). also, the mice treated with resveratrol had reduced (p<0.002) tunel+ staining. while a multitude of etiologies may lead to coma, treatments for coma remain elusive. the hypothalamic orexin pathway, critical in sleep/wake cycles, can stimulate multiple areas of the brain and provides a potential pharmacologic target towards improving arousal after coma. we used a post-cardiac arrest (ca) rodent coma model to assess whether postresuscitative orexin-a intracerebroventricular (icv) infusion after bolus injection would provide immediate and long term arousal after ca. seventeen adult wistar rats (male, 300-350gms) were implanted with a icv cannula attached to an osmotic pump. one week later, rats underwent baseline eeg followed by 7-minute asphyxial ca. forty-five minutes after resuscitation, rats were randomized to either orexin-a (n=8) or saline (n=9) icv bolus and infusion. eeg was monitored continuously for 4 hours after ca, and for 30 minutes at 24hrs, 48hrs, 72hrs, and 12 days post-ca. behavioral testing (neurologic deficit scale; nds) was also conducted at these times. eeg was quantitatively analyzed using information quantity (iq), an entropy based nonlinear previously established by us. rats receiving orexin-a almost immediately exhibited higher iq when compared to saline (0.731±0.028 vs. 0.613±0.021; p<0.01). this acute improvement in iq appeared with slowest sub-bands (e.g.ð) improving first followed progressively by faster sub--ca. moreover, orexin--band at 72hrs (1.160±0.039 -band at 72 hrs (0.911±0.032 vs 1.023±0.041; p<0.05). behaviorally, orexin-a allowed rats to perform significantly better on the nds at 4hrs (38.3±3.2 vs. 30.1±1.9; p<0.05); 24hrs (67.1±4.1 vs. 49.8±3.8; p<0.01); 48hrs (73.4±4.3 vs. 61.0±3.6; p<0.05), and 72hrs (75.0±3.3 vs. 65.2±2.9; p<0.05). heart rate variability (hrv) characteristics have been associated with outcome after traumatic brain injury. we sought to determine if hrv characteristics in the first 72 hours after subarachnoid hemorrhage (sah) are associated with hospital morbidity and mortality. continuous ekgs recorded (240hz sampling) during the first 72 hours post-sah was analyzed in 323 of 449 consecutively admitted patients between 2006 and 2011. admission clinical scores, radiographic, surgical, ventilation and the pan-tompkins algorithm was applied to identify the qrs complex. fft calculations were generated for the following -0.4hz), low frequency (lf: 0.04-0.15hz), very low frequency (vlf: 0.003-nerated sample entropy and 1/f --minute (fft<0.04hz), or 60-minute individual multivariable logistic regression analyses of hospital morbidity and mortality controlling for admission hunt and hess grade, apache ii physiological sub-score, age, and mechanical ventilation status were conducted. dialysis disequilibrium syndrome (dds) is characterized by varying central nervous system manifestations secondary to cerebral edema that most often occurs after the first round of hemodialysis (hd). literature suggests that underlying brain injury may predispose patients to the development of dds. however, the pathophysiology has yet to be elucidated. herniation from hd is thought to be exceedingly rare with current dialysis methods and has not been reported in the era of modern neurointensive care. we present a case series of three patients with acute neurological injury undergoing hd in the intensive care unit that rapidly developed fatal brain edema, secondary to dds, even after several previous uneventful rounds of hd. three patients, ages 17, 45 and 51 years, with traumatic brain injury, hypertensive intracerebral hemorrhage, and ischemic stroke underwent hd in the intensive care unit. the number of dialysis sessions prior to the development of dds was 1, 3 and 5. all three patients developed clinical signs of herniation within minutes to hours of hd. ct scans showed global cerebral edema with both transtentorial and tonsillar herniation. aggressive osmotherapy with mannitol and supersalt were ineffective in reversing the massive edema and all three patients died. two of the patients had a significant reduction of the bun (65% and 45%) while the third had only a modest reduction. our case series illustrates the potential dangers of hd in patients with acute neurological injury who have a high potential for worsening cerebral edema. it also reaffirms that dds with fatal cerebral edema can occur even after several rounds of hd and with current hd techniques. utilization of continuous veno-venous hemofiltration instead of hd may prevent the rapid shifts of osmoles and prove safer in neurologically injured patients. traumatic coma is believed to be caused by disruption of the ascending reticular activating system (aras), a complex network of arousal pathways projecting from the brainstem to the hypothalamus, thalamus, and basal forebrain. there is a critical lack of diagnostic tools for detecting which components of the aras network are disrupted in traumatic coma. we aimed to determine whether an advanced mri technique, high angular resolution diffusion imaging (hardi), can detect disruptions in the brainstem arousal network that are implicated in the pathogenesis of traumatic coma. we used hardi tractography to analyze neural network connectivity in two postmortem brains: one from a 62-year-old woman who died three days after traumatic coma, and one from a 53-year-old woman who died of non-neurological causes. both specimens were scanned as dissected blocks of the brainstem, hypothalamus, thalamus, and basal forebrain on a small-bore, high field (4.7 tesla) mri scanner. hardi tractography analyses were performed to compare the structural integrity of each component pathway of the aras network in the traumatic coma and control specimens. upon completion of imaging, both specimens were sectioned and stained for correlative histopathological analysis. hardi tractography revealed that specific components of the aras network, including known cholinergic, glutamatergic and noradrenergic projections connecting the brainstem to the thalamus and basal forebrain, were severely disrupted in the traumatic coma specimen, as compared to the normal specimen. these disruptions were consistent with histopathological tissue tears and axonal swellings. by contrast, connectivity between the brainstem and hypothalamus, and within the thalamus itself, was partially preserved in the traumatic coma specimen. hardi tractography can detect disruptions in specific components of the aras network that are implicated in the pathogenesis of traumatic coma. this advanced imaging technique may be used to elucidate the neuroanatomic basis of coma in individual patients. refractory intracranial hypertension (rich) is associated with high mortality rates and is the final pathway of many neurocritical entities, such as severe traumatic brain injury (stbi). objective: to determine modifications in intracranial pressure (icp) and cerebral perfusion pressure (cpp) following indomethacin (indo) infusion after rich secondary to stbi. indo was administered in a loading dose (0.8 mg/kg/15 minutes), followed by continuous infusion (0.5 mg/kg/h) in patients with icp>20 mmhg for more than 20 minutes who did not respond to first line therapies. changes in icp and cpp were observed. clinical outcome was assessed at 30-day according to glasgow outcome scale (gos). analysis of indo safety profile was also conducted. differences in icp and cpp values were assessed using repeated-measures anova with an a-level of p<0.05 twenty-nine consecutive stbi patients (26 men and 3 women) with a mean age ±sd 36±17 years wereincluded. median posresucitation gcs score at admission was 6 (iqr: 4-7) with a predominance of grade iv in marshall ct classification. our findings support the effective and feasibility of indo in reducing icp and improving ccp in rich patients. future studies to evaluate different doses, lengths of infusion and longer-term effects together with effects on outcome are needed. hematoma expansion after acute intracerebral hemorrhage (ich) occurs most frequently in patients presenting within 3 hours of symptom onset. therefore, most investigational therapies have been tested only in patients presenting ultra-early in their disease course. however, the majority of ich patients present outside this time window or with an unknown time of onset. we investigated the prevalence of hematoma expansion in these patients with delayed presentation and assessed the accuracy of the ct angiography (cta) spot sign for identifying risk of hematoma expansion. we performed a prospective cohort study. 391 consecutive ich patients undergoing cta and follow-up head ct were enrolled over ten years. cta spot sign readings were performed by two experienced readers and hematoma expansion was assessed using semi-automated software. expansion was defined as an increase in volume of >6 ml or an increase of >33% from baseline ich volume. hematoma expansion occurred in 18% of patients. when stratified by time from symptom onset to initial ct, hematoma expansion rates were: 39% within 3 hours; 11% between 3-6 hours, 11% beyond 6 hours (but with known onset), and 20% in patients with an unknown symptom onset time. of patients who developed hematoma expansion, only 38% presented within 3 hours. the accuracy of the spot sign in predicting hematoma expansion was 0.67 for patients presenting within 3 hours, 0.83 between 3 to 6 hours, 0.88 after 6 hours and 0.76 for patients presenting with an unknown onset time. a substantial number of patients destined to suffer from hematoma expansion present either late or with an unknown time of symptom onset. the cta spot sign accurately identifies patients destined to expand regardless of time from symptom onset, and may therefore open a path to offer clinical trials and novel therapies to the many patients who do not present acutely. intraventricular fibrinolysis has been shown effective in clearing intraventricular hemorrhage (ivh) in small series of patients. we present our experience with using fibrinolytics over 12 years. retrospective analysis of prospectively collected data of patients with ivh admitted to two neuro-icus and treated with rt-pa instillation (one patient with tenecteplase) via intraventricular catheter (ivc) until the 3 rd and 4th ventricles were cleared of blood. all patients were treated by the same neurointensivist with the same instillation protocol but different doses of drug based on individual patient characteristics. the graeb and leroux semi-quantitative scales were used to measure the amount of ivh before and after the last dose. 55 patients (mean age 58.6 years, 58.2% male) were admitted with a median gcs 8. thirty-one had intracerebral and 17 aneurysmal subarachnoid hemorrhage, 4 brain tumors, 1 head trauma, 1 arteriovenous malformation.and 1 primary ivh. t-pa was administered at a total dose of 5.1±4.7mg (individual doses ranging between 0.5 to 4 mg), with 1 st dose 57.1±55.7 hours from admission and for a duration of 3.2±2 days. the pre-fibrinolysis graeb and leroux scores were 8.1±1.8 and 11.3±2.5 and decreased post fibrinolysis to 4.6±1.8 and 5.3±2.6 (p<0.001). a significant correlation between total fibrinolytic dose and difference in pre-post amount of ivh was found for the leroux scale (pearson 0.413, p <0.002). three patients had small tract bleeds (<3cc, with one bleeding profusely at the incision site requiring transfusion) and one had extension of ich in the upper midbrain. no patient developed ventriculitis. the total dose of t-pa was lower in 11 patients who received shunt, compared to 44 who did not (3.3±2.5 vs 5.6±5, p<0.039). eighteen (32.7%) patients had -up of 27.2±27.3 days. in our large series of patients, intraventricular fibrinolysis significantly decreased ivh with minimal complications. distinguished poster 10 ___________________________________________________________________________________ white matter lesions significantly impact on outcome after aneurysmal subarachnoid hemorrhage (asah). brain extracellular tau is indicative for axonal injury, associated with poor neurological outcome after severe traumatic brain injury, however has not been elucidated so far in patients with asah. twenty-five consecutive asah patients monitored with cerebral microdialysis (cmd) and brain tissue oxygen tension (p b to 2 ) were included. cmd total tau, phospho-tau-181 and beta-amyloid 1--42) levels were analyzed at a 12hours interval until d3 and 24-hours interval until d9 using an elisa-technique (innogenetics). statistical analysis was performed with non-parametric tests and a mixed effects model as appropriate. median age was 56y (47-67y) and admission hunt&hess grade ranged from 3 to 5. cmd-tau, phospho-tau--42 were detectable in all patients. probe location in perilesional tissue revealed a higher overall cmd-tau level (p<0.05) -42 and phospho-tau. cmd-tau positively correlated with cmd-lactate (r=0.59, p<0.001). brain hypoxic (p b to 2 were associated with increased cmd-tau levels (p<0.05). no correlation was found between other variables besides a higher phospho-tau level and cmd samples categorized as brain hypoxic hyperlactatemia. patients with poor outcome -tau level during hospital-course (p<0.05) but no difference in phospho-tau--42 (adjusted for disease severity). cerebral tau is elevated after asah and associated with perilesional probe location and poor 3-months functional outcome. association with brain-morphological abnormalities and neuropsychological deficits need further investigations. neurocrit care (2012) 17:s1-s337 to date only two studies have evaluated anemia status in acute intracerebral hemorrhage [ich] . on admission anemia [oaa] was associated with larger hematoma volume and lower hemoglobin levels during hospital stay were related to poorer outcome. it remains unknown whether anemia impacts outcome primarily through its effects on ich volume or itself has independent effects. this retrospective analysis included 174 consecutive patients with spontaneous supratentorial intracerebral hemorrhage. clinical data including the pre-admission-status, neuroradiological, initial presentation, treatment, and outcome were evaluated through institutional databases, patient's medical charts and by mailed questionnaires. multivariate logistic and graphical regression analyses were calculated to evaluate associations of oaa with functional outcome and to determine independent effects of oaa. oaa was associated with larger ich volume (29.9cm³ versus 13.6cm³, p=0.001), greater extent of intraventricular hemorrhage [ivh] (p=0.044) and poorer neurological status on admission (p<0.001). further, oaa showed a true positive and accurate association with larger hemorrhage volumes (roc: p=0.001,auc>0.7). multivariately, for all patients despite age, only oaa could be elucidated as independent predictor of unfavorable functional outcome (mrs > 3) at 90 days (or=3.179;p=0.0435). comparison of separate multivariate models revealed: for oaa-patients no independent predictor could be identified, whereas in non-oaa patients ich volume demonstrated known independent effects on functional outcome (or 1.05;p=0.031). within this study oaa was shown to be a significant predictor of an unfavorable functional outcome and has independent effects beyond its accurate association with larger hemorrhage volumes. oaa appears to be a very relevant and previously unrecognised predictor of functional outcome at 90 days. the recognition of anemia and its treatment could possibly open up new therapeutic avenues to decrease the rate of functionally dependent patients after ich. this strongly supports the need of prospective interventional studies to evaluate the influence of anemia in patients with intracerebral hemorrhage. in patients with suspected subarachnoid hemorrhage and negative brain imaging, lumbar puncture is recommended. this test is frequently complicated by false-positive results due to a traumatic tap. we hypothesized that blood precipitating in the thecal sac following non-traumatic subarachnoid hemorrhage would be visible on mri. a prospective database for subarachnoid hemorrhage was searched for patients who received mr lumbosacral spine imaging during admission for subarachnoid hemorrhage. electronic chart review was completed. all mr studies were read and interpreted by a neuroradiologist. patients (n=10) with subarachnoid hemorrhage underwent delayed mri imaging of the lumbosacral spine an average of 10 days (range 1-21 days) after the onset of symptoms. the median hunt-hess grade for this cohort was 3 (range 2-5). the median fisher grade was 3. blood precipitating in the thecal sac was visible in 8 out of 10 patients (80%). the density of blood compared to csf was hyper-intense on t1 (bright) and hypo-intense on t2 (dark). the blood was most evident at l5 and s1 levels and layered in a dependent fashion. delayed ct head non-contrast obtained at the time of the mri ls spine demonstrated resolution of subarachnoid hemorrhage in 9/10 patients and a small amount of isodense intraventricular hemorrhage layering in the occipital horns was detected in 4/10 patients. delayed neuroimaging with ct head after subarachnoid hemorrhage has a high false negative rate. mr imaging of the lumbosacral spine detected persistent blood products settling in the thecal sac despite clearance of subarachnoid blood on ct head imaging. mr lumbosacral spine imaging could serve as a 'virtual lumbar puncture' in patients with suspected subarachnoid hemorrhage. stroke patients receiving iv tpa can be admitted to an icu or a stroke unit (su) but su admission may be more costefficient. we compared icu admission vs su admission in tpa-treated patients. during the initial 3 years of this retrospective study, patients were admitted to the icu as we lacked a su. in the following 2 years, patients were admitted to a new su. demographics, medical history, nihss, treatment interventions, neurologic and medical complications, and mortality were collected to determine if icu admission resulted in better outcome and less complications. categorical variables were analyzed with fishers exact test and continuous ones with proportion of the means test (t-test). we compared 71 icu admissions and 104 su admissions. icu admission included 54% males and su admission included 59% males (ns). median age for icu and su admission was 69 and 70 respectively (ns). admission nihss was 11 for icu patients and 9 for su patients (ns). the median length of stay in the icu was 1 day (as per protocol) and the median su length of stay was 4 days. intravenous anti-hypertensives (bolus) were used in 30% of icu patients and in 18% of su patients (p= 0.09) and continuous infusions in 11% of icu patients and 6% of su patients (p=0.04). initial nihss scale of > 15 predicted need for mechanical ventilation (p=0.002). intracranial hemorrhage occurred in 3% of icu and 3% of su patients (ns). complications (pneumonia, venous thromboembolism, sepsis, or death ) did not differ. there was no difference in the proportion of patients with mrs of 1 or less in the two groups (38% vs 36%). admission to the su resulted in savings of $ 70,000 per 100 patients/day. patients receiving tpa can be safely admitted to a su resulting in significant cost savings. patients with nihss > 15 are likely to need icu admission for mechanical ventilation. stroke patients with dysphagia have a high incidence of aspiration, which may lead to pneumonia. evidence suggests that ace inhibitor use may decrease the risk of pneumonia via their inhibitory effects on substance p degradation. the objective of this study was to investigate the association between ace inhibitor use and the development of pneumonia in hospitalized stroke patients. a retrospective case-control analysis was performed. eligible patients (n=1927) were individuals admitted to saint louis university hospital with a diagnosis of acute ischemic stroke, spontaneous intracerebral hemorrhage, or non-traumatic subarachnoid hemorrhage between march 1 st , 2009 and november 30 th , 2011. patients greater than 89 years of age, who died or were discharged to hospice within 5 days of admission, or who had a baseli excluded. cases were patients with an icd-9 code for pneumonia or antibiotic treatment course for at least 7 days with a positive respiratory culture. controls were patients without pneumonia matched using primary diagnosis, baseline demographics, history of prior stroke, diabetes, hypertension, heart failure, and initial nihss scores. ace inhibitor use, length of stay, discharge disposition, and other pertinent data were collected and analyzed using descriptive statistics, chisquare, and logistic regression. there is growing evidence supporting the role of inflammation in aneurysmal subarachnoid hemorrhage (asah) pathophysiology and it is of great interest to elucidate which immune mechanisms are involved. methods 9 asah patients (sahp) and 28 healthy control subjects (cs) were enrolled prospectively. the protocol was authorized by the ethics committee of our hospital and all subjects (or patient next of kin) signed an informed consent. the median age of sah patients was 48 years (34-67) and of control subject was 45 years (25-76). we assessed leukocytes subpopulations and their activation status by multiparametric flow cytometry in cerebrospinal fluid (csf) and peripheral blood (pb) of sahp at the same time and in pb of cs. we found an increase in cd16+-monocytes percentage (p=0.035) in csf compared with pb in sahp and a decrease in pb of sahp compared with cs (p=0.016). sahp also showed a marked increase in the expression of cd69 (activation antigen) in pb cd4+t cells compared with cs (p=0.002). additionally, csf cd4+t cells showed a decreased expression of cd4 (p=0.0001) and cd3 (p=0.008) (activation markers) compared to pb cd4+t cells in sahp. similarly, pb cd8+t cells in sahp showed an increased expression of cd69 compared with cd8+t cells of cs (p=0.002). csf cd8+t cells showed a decreased expression of cd3 (p=0.008) and an increased expression of cd69 compared with pb cd8+t cells (p=0.002). b and nk cells were decreased in sahp compared with cs (p=0.0001 and p=0.0001 respectively). as far as we know this is the first report that analyzes leukocytes subsets in csf and pb in patients with asah. our data suggests not only csf leukocytes recruitment (from the blood) but also an increase status of activation at this level. overall, these results indicate that asah probably stimulates both the innate and adaptive immune responses. subdural hematoma (sdh) is a common diagnosis in neurosurgical and neurocritical practice. comprehensive outcome data and management guidelines are lacking for non-traumatic sdh. thus, we aimed to determine factors associated with in-hospital mortality in a large sample of patients with non-traumatic sdh. using the nationwide inpatient sample, we included adults with a primary diagnosis of acute non-traumatic sdh (icd-9 code, 432.1) hospitalized in the united states between 2007 and 2009. demographics, comorbidities, craniotomy treatment and discharge outcomes were identified. univariable and multivariable analyses were performed to identify predictors of in-hospital mortality. of 14093 patients with non-traumatic sdh, the mean age was 71.4 (sd 14.8) with 62% male, and 22.2% admitted during the weekend. surgical evacuation was performed in 51.4% of patients; 7.4% (16.9% of patients requiring surgical evacuation) required a second craniotomy. death during hospitalization occurred in 11.8% of patients. factors significantly associated with higher in-hospital mortality included increasing age, female sex, comorbidities (congestive heart failure [chf] , coagulopathy, renal failure, liver disease), mechanical ventilation during the first 4 days (mv), premorbid warfarin use, repeated sdh evacuation, and admission during the weekend. craniotomy was associated with decreased in-hospital mortality. in multivariable analysis, age (or 1.02, 95% ci 1.02-1.03), female sex (or 1.13, 95% ci 1.01-1.28), chf (or 1.42, 95% ci 1.22-1.68), warfarin use (or 1.50, 95% ci 1.28-1.77), mechanical ventilation (or 18.21, ) and weekend admission (or 1.19, 95% ci 1.04-1.36) were independent predictors of inhospital mortality. surgical sdh evacuation was a strong independent predictor for decreased mortality (or 0.46, 95% ci 0.40-0.52). one in nine patients with non-traumatic sdh dies during hospitalization. of several predictors of mortality, the weekend effect and the decision for or against surgical evacuation are potentially modifiable factors. further investigation may lead to improvement of management practice and better outcomes. to determine the burden of structural damage of the central nervous system (cns) in patients who died in the setting of non-neurological critical illness. critically ill patients who died in the medical, surgical or cardiac icus over a 10 year period and underwent autopsy were included. patients with known cns lesions, cardiac arrest, and those from neurological icus were excluded. brain specimens were reviewed by a neuropathologist and classified according to location and lesion type (infarct, hemorrhage, inflammation). acute brainlesions were found in 60 of 97 patients studied. mean gcs at admission was lower in patients with neuropathological findings (11.3 vs. 12.8; p=0.0329). the most common sites of injury were cortex (35.1%) and hippocampus (28.9%). infarcts (56.7%), hemorrhages (13.4%), and signs of inflammation (9.3%) were the most frequent findings. patients with septic shock and ali/ards had more lesions than patients without these critical illnesses, albeit these differences were not statistically significant. ischemic brain injury is prevalent in patients dying from non-neurological critical illness and may occur secondary to cns hypoperfusion. efforts to optimize brain oxygen delivery during critical illness may be neuroprotective. after ca, microcirculatory reperfusion disorders develop despite adequate cerebral perfusion pressure. increased blood viscosity strongly hampers the microcirculation resulting in plugging of the capillary bed, arteriovenous shunting and diminished tissue perfusion. the rheologic properties of blood depend on hematocrit and plasma constituents, mainly acute phase proteins. the aim of the present study was to assess blood viscosity in relation to cerebral blood flow in patients after a cardiac arrest. we performed an observational study in 10 comatose patients after cardiac arrest. patients were treated with mild therapeutic hypothermia for 24 hours and passively rewarmed to normothermia. blood viscosity was measured ex-vivo at 0, 6, 12, 24, 36, 48 and 72 hours after admission using a contraves ls300 viscometer. mean flow velocity in the middle cerebral artery (mfv mca ) was measured by transcranial doppler (tcd) at the same time points. the median viscosity on admission was 9.12(8. 19-11.19 )mpa.s, remained stable at 9.13(7.57-10.51)mpa s and 9. 70(8.50-11.42 )mpa s at 3 and 6 hrs respectively (p=0.47). from 6 hrs after admission viscosity decreased significantly to 3.66(3.12-4.04)mpa s (p<0.001). median mfv mca was low (27.0(23.8-30 .5)cm/s) on admission, and significantly increased to 63.0(51.0-80.0) cm/s at 72 hrs (p <0.001). there was a significant association between the viscosity and the mfv mca (p=0.0019). median hematocrite was 0.41 (0.36-0.44)l/l on admission and subsequently significantly decreased to 0.32 (0.27-0.35) l/l at 72 hrs (p <0.001) in contrast, acute phase proteins such as crp and fibrinogen increased during admission (from 2.5(2.5-6.5)mg/l to 101(65-113.3)mg/l and 2795 (2503-3565)mg/l to 6195(5843-7368)mg/l respectively (p <0.001). viscosity decreases in the first 3 days after cardiac arrest and is strongly associated (correlated) with an increase in cerebral blood flow. since viscosity is a major determinant of cerebral blood flow, repeated measurements may guide therapy to restore cerebral oxygenation after cardiac arrest. initial hemorrhage burden is an independent predictor for delayed cerebral ischemia (dci) in patients with aneurysmal subarachnoid hemorrhage (sah). among the different definitions of blood burden, cisternal plus intraventricular hemorrhage volume (cihv) has been regarded as the most sensitive blood volume definition in predicting dci. however, it is not clear whether clot clearance is associated with dci. quantitative analysis of hemorrhage volume and clot clearance was made in consecutive 116 patients who were scanned within 24 hours from onset. cistenal plus intraventricular hemorrhage volume (cihv) was calculated for clot burden analysis. serial cihv was measured up to 7 days after sah onset. clot clearance was calculated up to 7 days as a percentage of residual clots compared to the initial scan. initial clot burden and clot clearance were compared in patients with and without dci. included patients were 55.5 ±15.2 years old with female preponderance (65.5%, (76/116)). dci was developed in 34 patients (29.3%). conventional risk factors were not different between patients with and without dci including age, sex, ht, dm, smoking, admission h&h scale and apache score. patients with dci had higher cihv (22.1ml, ) compared with those without dci (14.5 ml, iqr (8.58had higher odds for dci (or 4.3, 95% ci (1.3 -14.0, p = 0.015). however, clot clearance rate was not different between patients with and without dci (day 3: 48.2% vs. 57.8%, p = 0.12, day 5: 77.2% vs. 75.6%, p =0.75, day 7: 80.5% vs. 82.1 %, p= 0.43). quantitative clot clearance rate using cihv is not associated with the development of dci while initial cihv is an independent predictor for dci. the majority of patients who die from subarachnoid hemorrhage have withdrawal or limitation of care and a focus on comfort at the end of life. ethnic disparities at the end of life has been examined in general critical care settings but not specifically in brain injured patients. patients with aneurysmal subarachnoid hemorrhage were prospectively followed in an observational database from august 1996 to january 2011. demographic information including ethnicity was collected from medical records and self reported by patients or their family. significant in-hospital events including care withheld or withdrawn (comfort measures only, cmo) and mortality was recorded prospectively. included were patients of white, black or hispanic race. 1255 patients were included in our analysis: 650 whites, 218 blacks and 387 hispanics. age was the only baseline characteristic that was different between groups. whites (56±15 years) were older than blacks (52±14 years) and hispanics (53±15 years). no difference in morality was seen: 18% in whites, 19% in blacks, 18% in hispanics. cmo was more commonly ordered for whites (14%) than blacks (10%) and hispanics (9%) (p=0.04). in multivariate analysis controlling for age and initially hunt-hess grade hispanics were less likely to have cmo orders than whites (or, 0.6; 95%ci, 0.4-0.9; p=0.02). of the 229 patients who died 77% of whites had cmo orders compared to 54% of blacks and 49% of hispanics (p<0.01). in multivariable analysis controlling for age and hunt-hess, blacks (or, 0.3; 95%ci, 0.2-0.7; p<0.01) and hispanics (or, 0.3; 95%ci, 0.2-0.6; p<0.01) were less likely to die with cmo orders than whites. multiple assessment measures are used to evaluate post-aneurysmal subarachnoid hemorrhage (asah) outcomes / complications. the use of a common measure has not been established, thus choosing which measure to control for becomes difficult when conducting multivariable analysis in clinical research. we compared odds ratio (or) and positive predictive value (ppv) to determine measures with strongest associations with post-asah complications / outcomes. subjects (n=559) with asah were recruited from an ongoing study with 21measures were assessed on admission: hunt and hess (hh), fisher, claassen, glasgow coma scale (gcs), world federation of neurological surgeons (wfns), and nih stroke scale (nihss). dependent variables were measured as follows: delayed cerebral ischemia (dci) was defined as clinical deterioration due to cerebral ischemia, moderate/severe vasospasm was diagnosed using sonography/angiogram, infarction was diagnosed via head ct scan. three and 12month outcomes were assessed by barthel index and modified rankin scale (mrs). logistic regression and spearman correlation were used. when predicting vasospasm and dci (controlling for age, gender, clipping/coiling), fisher scale had the largest ors (1.83 and 2.1), with a ppv of 61.8% and 60.9% (p<.01), respectively. when predicting infarction, hh had the largest or (1.36) with a ppv of (51.6%); p=.02. all scales were significantly associated with poor mrs (4-6); p<.0001. for 3 and 12-month poor mrs, fisher scale had the largest or (3.2 and 3.1) with a ppv of 51.5% and 36.4%, respectively. admission nihss had the largest correlation coefficient (-.36) with 3-month barthel index while wfns had the largest correlation coefficient (-.35) with 12-month barthel index (p<.05). fisher scale has the strongest association with vasospasm, dci and mrs, while hh has the strongest association with infarction. we recommend clinical studies control for fisher when investigating vasospasm, dci, and mrs and for hh when investigating infarction to determine independent risk factors. to date, there has been a shortage of evidence-based quality improvement initiatives that have shown positive outcomes in the neurosurgical patient population. a single-institution prospective intervention trial with continuous feedback was conducted to investigate the implementation of a urinary tract infection (uti) prevention bundle to decrease the catheterassociated uti rate. all patients admitted to the adult neurological intensive care unit (neuro icu) during a 30-month period were included. the study consisted of two 1-month pre-intervention observation periods (approximately 1200 catheter days) followed by a 30month intervention phase (20,394 catheter days). a comprehensive evidence-based uti bundle encompassing avoidance of catheter insertion, maintenance of sterility, product standardization, and early catheter removal was enacted. the urinary catheter utilization rate dropped from 100% to 73.3% during the intervention phase (p <0.0001) without any increase in the rate of sacral decubitus ulcers or other skin breakdown. the rate of catheter-associated uti was also significantly reduced from 13.3 to 4.0 infections per 1000 catheter days (p <0.001). there was a linear relationship between the decreased quarterly catheter utilization rate and the decreased catheter-associated uti rate (r2 = 0.79, p <0.0001). this single-center prospective study demonstrated that a comprehensive uti prevention bundle along with a continuous quality improvement program can significantly reduce the duration of urinary catheterization and rate of catheterassociated uti in a neuro icu. continued efforts to reduce ca-uti beyond the study resulted in sustained reductions when all components of the bundle were in place and daily foley rounds were maintained as a nursing intervention. matrix metalloproteinases (mmps) are extracellular proteolyic enzymes that may modulate the neuroinflammatory response to brain injury. we sought to determine the effect of mmps on pro-inflammatory cytokine production following severe traumatic brain injury (stbi). as part of a prospective cohort study, 8 adults with stbi underwent multimodal monitoring with high cutoff, cerebral microdialysis and arterial and jugular venous bulb catheters. the concentration of mmps and pro-inflammatory cytokines were measured in microdialysate and blood over 6-days. interleukin-1-alpha (il-1), il-1-beta, il-6, il-10, and tumor necrosis factor-alpha (tnf-alpha) concentrations were initially high in microdialysate and then declined to low levels. the microdialysate concentration of il-8 also declined after first being high, but then increased between 84-and 90-hours. with the exception of il-5, il-10, and tnf-alpha, the cytokine blood concentration was low to undetectable. using generalized estimating equations, we observed a positive change in the microdialysate concentration of il-8 [(2.59 pg/ml)/(pg/ml); 95% ci, 1.12 to 4.05] with an increase in the mmp-9 microdialysate concentration. in contrast, a significant increase in the microdialysate concentration of mmp-9 was seen with an increase in il-1-alpha [(34.67 pg/ml)/(pg/ml); 95% ci, 23.43 to 45.91] and il-1-beta [(4.41 pg/ml)/(pg/ml); 95% ci, 3.67 to 5.15]. in blood, a significant change in mmp-9 occurred during an increase in the levels of il-1-beta [(16304.15 pg/ml)/(pg/ml); 95% ci, 824.73 to 31783.57] and il-8 [(2934.10 pg/ml)/(pg/ml); 95% ci, 1335.75 to 4532.25]. although il-10 levels were higher in cerebrospinal fluid (csf), no major difference in mmp or cytokine concentration was observed between arterial and jugular venous blood or, for the three patients who were also fitted with csf drainage catheters, between cerebral microdialysate and csf. stbi is associated with a substantial central cytokine or neuroinflammatory response, which may influence or be influenced by production of mmps. severity classification of traumatic brain injury (tbi) has traditionally been based on the glasgow coma scale (gcs), with mild tbi being defined as 13-15. however, there is often a subset of "mild" tbi that requires surgical intervention. the current study examines this subgroup to decipher any symptomatology that may be helpful in identifying who these patients may be. this observational cohort study included consecutive adult patients presenting with a tbi. independent variables included vomiting, seizure, loss of consciousness (loc), alteration of consciousness (aoc), and post-traumatic amnesia (pta); these were tested for correlation with surgical intervention, the dependent variable. data were entered into redcap, a clinical data capture system housed in our center for translational science institute. the z-test for proportions was used to determine significance of symptomatology. statistical analyses were performed in jmp 9.0 for the mac. of the total mild tbi cohort (n=1,088), 57% were male. the median age was 39 (iqr: 24-59, r: 18-96). thirty seven patients required surgical intervention. symptoms significantly associated with surgical intervention on univariate regression included vomiting (p=0.0320), and aoc (p0.0448). multiple regression analysis revealed that time (length of) loc (p=0.0118) and pta (p<0.0022) were also significantly correlated with surgical intervention. age was also a statistically significant predictor of surgical intervention (p<0.0001). these pilot data suggest that older patients, as well as patients who present with vomiting, loc, or pta, have a significant likelihood of requiring surgical intervention. this calls attention to proactively seeking these data and ensuring adequate neuroimaging for all patients with tbi, regardless of gcs score at presentation. the prevalence of chronic subdural hematoma (sdh) is expected to increase with an aging population and increased use of anticoagulants. we aimed to develop a tool to predict mortality after sdh. a prospective study was conducted between 2008-2011 of patients with chronic subdural hematoma (n=102) admitted to a tertiary neuro-icu. three-month mortality data was collected. after testing admission demographic, radiographic and -8, 9-14, 15 ; p=0.001) and herniation (p=0.022) were found to be independent predictors of death in multivariate logistic regression analysis. a score was composed (0-4) with each variable weighted based on its independent strength of association with mortality (b value) as -14=1, gcs 3-8=2, herniation=1 point. overall, 24% of patients died and 3-month mortality increased with each point of the sdh score (0=0%, 1=8%, 2=41%, 3=60%, 4=100%). the sdh score predicted death (or 5.3, 95% ci 2.5-11.5, p<0.0001) with an area under the curve of 0.821, sensitivity 87.5%, specificity 69.2%, ppv 47% and npv 95%. the hosmer and lemeshow and nagelkercke r 2 for this model were 0.380 and 0.362, respectively, indicating a strong model. sdh evacuation reduced the odds of death by 80% when added to a multivariate model including age, gcs and herniation (adjusted or 0.2, 95% ci 0.1-0.8, p=0.025). the sdh score allows for a reliable prediction of mortality for patients with chronic sdh. this score may help risk stratify patients for surgical treatment. we developed a novel method capable of determining the degree of conformance of observed morphological changes of intracranial pulses with their expected patterns associated with global vasodilatation and vasoconstriction, respectively. these patterns were formed as a template consisting of pulse morphological changes during co 2 tests that were consistent for multiple subjects. we used this novel pulse morphological template matching (pmtm) algorithm to study 1) the incidence of cerebral vasoconstriction/vasodilatation associated with lpr increase episodes; 2) how likely cerebral vasoconstriction/vasodilatation could lead to or lag behind lpr increase. we studied 4318 microdialysis data samples collected in an average interval of 1.3 hours from 30 severe tbi patients. the lpr increase episodes were automatically identified using a moving time-window of 4 hours. the pmtm algorithm was applied to the continuous intracranial pressure (icp) signal time-synched to the identified lpr episodes. across all subjects, more than half of the lpr increase episodes are not associated with any detectable cerebral vasoconstriction or vasodilatation (p = 1e-5). comparing lpr episodes with either vasoconstriction or vasodilatation, it was more likely that vasoconstriction rather than vasodilatation occurred during an lpr increase episode (p = 0.008). also for 3 out of 30 subjects with dominant number of vasoconstrictive lpr episodes, a causality relationship between vasoconstriction and lpr increase were observed, i.e., vasoconstriction occurred in one hour before lpr increase started. across the 30 tbi subjects studied, the incidence of either vasoconstriction or vasodilatation associated with lpr increase was low. however, about 10 percent of subjects had a dominant number of lpr increase episodes associated with cerebral vasoconstriction. furthermore, cerebral vasoconstriction occurred within one hour preceding lpr increase. placement of an intracranial pressure (icp) monitorto guide the management of severe traumatic brain injury (tbi) patients has been historically performedby neurosurgeons. trials have suggested decreased morbidity and mortality with timely resuscitationand rigorous treatment of intracranial hypertension. we hypothesize that icp monitors can be placed by non-surgeon neurointensivists, with placement success and complication rates comparable to neurosurgeons. we retrospectively reviewed the medical records of tbi patients who required insertion of parenchymal icp monitors from may 2010 to december 2011 in a large level i trauma center. monitor placement was performed by 4 neurointensivists (board certified by the abim in critical care medicine and by the ucns in neurocritical care). patient data recorded are age, gender, ct findings, icp monitor placement location and length of placement, complications related to the icp monitor, and patient outcomes. twenty seven (27) these findings were comparable to published outcomes from neurosurgeon placements. we believe that insertion of parenchymal icp monitors should be considered a core skill for neurointensivists and should be included in neurocritical care fellowship training. insertion of icp monitors by neurointensivists is safe and may aid in providing prompt monitoring of patients with severe tbi. use of computers at the bedside for trending primary signals like icp or cpp brings obvious advantages in neuro-critical care unit. software can be extended to calculate secondary indices reflecting underlying pathophysiological phenomena, like disturbance of cerebral compensatory reserve and vascular reactivity. during 2003-2011 more than 400 severe tbi patients were monitored using icm+ software. various modalities were used, including icp, abp, pbtio2, nirs, tcd blood flow velocity, brain temperature, etc. from icp and abp waveforms secondary indices were extracted. compensatory reserve was assessed using moving correlation index between slow changes in pulse amplitude and mean icp (rap). pressure reactivity index (prx) was calculated as moving correlation between mean icp and abp. 'optimal cpp' (cppopt) was estimated as cpp corresponding to the best cerebrovascular reactivity within the period of past 4 hours. trending compensatory reserve showed that usually it is good (rap around 0) in the first few hours after admission (rap around 0), with gradual deterioration triggered by aggravating brain edema. in most cases rap stayed close to +1 (impaired reserve). it decreased to negative values (exhausted reserve) on top of plateau waves and in refractory intracranial hypertension, indicating critical icp. prx proved to be highly variable, responding to changes in abp, icp and ventilation. it deteriorated on top of plateau waves, and at extreme values of cpp. in cases of refractory intracranial hypertension, deterioration of reactivity seemed to preceed the elevation of icp above 30 mmhg. cppopt fluctuated during the monitoring period. absolute distance between current cpp and cppopt was strongly associated with outcome. too low cpp (below cppopt) correlated with greater mortality rate (p<0.0001) and too high cpp -with greater rate of severe disability (p<0.025). individual observations of secondary indices calculated by icm+ software help in better interpretation of primary signals in intensive care of tbi patients. financial support: the software for brain monitoring icm+ is licensed by the university of cambridge (cambridge enterprise). authors ps and mc have a financial interest in a part of the licensing fee. to determine the differences in hospital outcomes among adult mild traumatic brain injury (tbi) patients where the severity of tbi is defined by glasgow coma scale (gcs) score. this is a retrospective chart review of consecutive adult who came to the ed department of a tertiary care hospital in north central florida. the tbi severity was classified according to gcs score, with patients with gcs score of 13-15 categorized as having mild tbi. outcome variables such as admission status, icu admission status, in-hospital death and 3-month death among patients with different mild gcs scores of 13, 14, and 15. we had a total of 809 mild tbi patients in the specified period of time. the majority of this cohort had a gcs of 15 (697 or 86.1%). this was followed by a gcs of 14 (84 or 10.4%) and gcs score of 13 (28 or 3.5%). there was a statistically significant difference between mild tbi with gcs 13, 14, 15 (p<0.0001, anova) with the outcomes of hospital admission (92% vs. 67% vs. 30%), icu admission (61% vs. 31%, vs. 9%), in hospital death (4% vs. 4% vs. 0.3%), and 3 month death rate (7% vs. 5%, vs 1%). there is a 30% increase in hospital admission rates for each point decrease in gcs score. the 3-month death rate nearly doubles with each incremental decrease in gcs score. there is a significant difference in outcome within "mild" head trauma across the continuum. to characterize the patterns of presentation of children with head trauma to the pediatric emergency department. this is an observational cohort study that sought to collect injury and outcome variables with the goal of characterizing the very early natural history of pediatric traumatic brain injury in children over the age of 3 years. statistical analyses were performed using jmp. cohort (n=351) . similar multivariate model showed that as children grew older, they were more likely to be admitted in hospital because of a tbi as a result of recreational activities (p=0.0002) and traffic accidents (p<0.0001), and less likely due to sport tbis (p=0.0003) with adjr 2 =14%. 42% of the children who were admitted ended up in icu with mean icu-los of 1 day with an iqr of 0-3. one percent had an in hospital death. kids with amnesia were significantly more likely to be admitted to the icu (p=0.0018, r 2 =11%). children who got admitted to icu (p=0.0012) and were older (0.0262), were significantly more likely to be readmitted to the hospital within 30 days. these preliminary data suggest that pediatric brain injury is not without significant morbidity. the objective of this study was to identify pre-hospital markers of in-hospital mortality in traumatic brain injury (tbi) patients due to fall. this study was an observational cohort study performed at a level-1 trauma center. study subjects included all adult arriving in emergency department with history of tbi due to fall over a period of 20months. study variables were symptoms such as vomiting, seizure, loss of consciousness (loc), alteration of consciousness (aoc) & post-traumatic amnesia (pta), glasgow coma scale (gcs) scores, vitals, pre-hospital glucose. jmp 10 for windows & z-test of proportions were used to perform statistical analysis. the study cohort comprised of 612 adult (median age of 49yrs and iqr of 28-68). in-hospital death (ihd) was observed in 5% (n=28) of the total cohort, with male ihd=19 (68%) greater than female ihd=9 (32%). pta (25%,p<0.0001),loc (64%, p<0.0422) & aoc (54%, p<0.0001), higher pre-hospital glucose (p=0.0048) were individually found to be much more significantly associated with ihds versus the whole cohort. multivariate regression analysis showed significant correlation with ihds with: 1) higher age (p<0.0001) when adjusted for severe gcs. 2) vomiting (p=0.0131) and longer duration of loc (p=0.0236), when adjusted for rest of the symptoms. 85% of patients presenting to ed with vomiting (p=0.0373) had gcs score=15, and 3% of that sub-group suffered ihd patients presenting to emergency department with higher blood glucose and symptoms such as pta, aoc, longer duration of loc & vomiting, were more likely to have worse outcome of in-hospital deaths compared to rest of the patients. hence identifying these symptoms in fields might help to make key decisions for providing intensive care and improving the overall patient outcomes. to determine which symptoms affect severity in pediatric traumatic brain injuries (tbi). study design-this observational cohort study was performed at a level one trauma center that has a dedicated pediatric emergency department. consecutive patients age 4-17 were included. the age cutoff of 4 years was used because it was decided that younger children may not be ale to report their symptoms, particularly to endorse aoc (alteration of consciousness) or pta(post-traumatic amnesia). the dependent variables were vomiting, seizures(sz), loc (loss of consciousness), aoc, and pta at the time of the head injury. the independent variable was ed tbi severity based of the glasgow coma score, with mild being defined as 13-15, moderate as 9-12, and severe as less than 8. the median age of the cohort was 13 with an interquartile range of 7 to 16. 59% were boys. in the univariate model, all symptoms except vomiting were statistically significant: seizures (p=0.0437); loc (p=0.0139); aoc (p<0.0001), pta (p<0.0001). multiple regression analysis of these factors revealed all of variables to retain statistical significance. the r 2 coefficient of determination was 33%, which means that almost one-third of the variance can be explained by just these five factors (symptoms), suggesting that our multivariate model is a robust one. symptoms at time of head injury in children including seizure, loc, aoc and pta were statistically significant predictors of the severity of tbi. this data allows clinicians to judge the severity of the tbi depending on the symptoms at presentation. these pilot data may be useful in designing clinical care algorithms. icp dynamic system of an injured brain is susceptible to various acute changes disturbing the system homeostasis that should be detected by icp monitoring. such a capability is particularly useful for comatose patients. our aim was to demonstrate a novel approach to detect acute deviation from steady state of an icp dynamic system without involving significant mean icp changes. steady state of icp dynamic systems is reflected as icp pulses of similar mean icp resembling each other. therefore, a steady state indicator can be calculated by quantifying inter-pulse distances after matching their mean icp. besides euclidean distance and pearson correlation, geodesic distance was introduced as a novel metric. these different metrics were evaluated on three types of continuous icp: 1) those between two consecutive imaging studies showing new acute ventricular enlargement for slit ventricle syndrome patients undergoing a trial of shunt externalization and clamping (svs+); 2) those between consecutive brain imaging studies from patients under the same trial without ventricular enlargement (svs-); 3) overnight recordings from patients with suspected normal pressure hydrocephalus (nph). it was expected that both svs-and nph recordings represent steady state. we observed that only geodesic distance correctly differentiated between svs+ and svs-and between svs+ and nph while avoiding discriminating between svs-and nph. it was also found that 45% svs+ cases, none of svs-, and 3.8% of nph cases had a multimodal geodesic distance histogram. pulses with a large number of distant pulses at similar mean icp for the five multimodal-histogram svs+ cases fell in short time windows indicating that acute ventricular changes may have occurred in these confined time windows during which no significant changes of mean icp occurred. geodesic inter-pulse distance is a promising metric to quantify distance intrinsic to the underneath geometric structure of icp signals. patients with severe traumatic brain injury have multiple causes for acute respiratory decompensation. computed tomography pulmonary angiography (ctpa) is being used extensively to evaluate acute cardiorespiratory changes. we reviewed the use of ctpa in critically ill patients with traumatic brain injury to evaluate the results and their impact on patient care. all adult trauma patients with traumatic brain injury who were admitted to our level 1 trauma center intensive care units for greater than 48 hours, were identified (january 2007-december 2010). those who underwent ctpa for acute respiratory decompensation were reviewed to determine the findings of these studies and the resulting interventions. we identified 881 patients that met these criteria [196 admitted to neurosurgery/neurocritical care(ncc) , 685 admitted to trauma service(ts)]; 86 of these patients underwent ctpa studies for acute physiologic changes (ncc-10, ts-76, p=0.013). ts patients were significantly younger with higher severity of injury and longer length of stay. pertinent clinical finding were identified in 81 of the 86 (94%) studies; and included atelectasis/collapse 52 (60%), pleural effusion 18 (21%), pneumonia 9 (10%) and pulmonary embolus 14 (16%). these results prompted 153 targeted interventions, most frequently consisting of modifications of ventilator therapy (58,67%), a change or initiation of antibiotic therapy (31,36%), mini-bal (21,24%) bronchoscopy (16,19%), vena cava filter (10,12%), and anticoagulation (5,6%). no change in patient management occurred after 10 studies. agreement, for different findings, between chest x-ray and ctpa ranged from 46-98%. patients admitted to a ts are more likely to undergo a ctpa evaluation. ctpa is a useful tool in the evaluation of critically ill patients with acute physiologic decompensation beyond the diagnosis of pe. the results of these studies provide significant insight into the underlying pathology in this patient population and offer an opportunity to direct subsequent patient care. somatosensory evoked potentials (ssep) provide valuable information of the neurophysiological state of the patient throughout a surgery and the errors in the surgical procedure are easily noticed. it is hence important to analyze and monitor the ssep during scoliosis surgery in a minimum amount of time. the study uses pca-walsh algorithm to analyze posterior tibial nerve ssep and compare with the conventional signal averaging method in twelve surgical procedures. the tibial ssep from twelve different subjects were recorded and assessed throughout the respective surgeries using a unique pca-walsh algorithm by using only 10 trials at a time and compared the extracted ssep information with conventional method. the ssep were recorded in two bipolar channels c 3 -c 4 and c z -f z throughout the surgery and analyzed remotely using an automated software pca-walsh algorithm. the results are compared with the actual clinical information and presented with the merits. in all the twelve cases, the algorithm results presented consistency throughout the surgery with an average accuracy of 91.5% when compared to the conventional method, which takes several hundred trials. the average variation in time latency was 4.4% and in amplitude was 23.7%, well within the limit of 50% following the clinical criteria. the pca-walsh algorithm is capable of automated extraction of the tibial ssep during a surgery using a minimum number of trials. the analysis using the algorithm was successful and proved conclusive to the clinical information through the different surgical procedures. the faster recording and analysis of ssep signals provides a much better perspective for neurophysiological monitoring through the surgical procedure. the authors appreciate the support provided by the national science foundation under grants cns-0959985, hrd-0833093, cns-1042341, and cns-0426125. the authors are also thankful for the clinical suppo certain admission characteristics are known predictors of adverse outcomes in moderate-severe traumatic brain injury (mstbi) patients, but explain only 1/3 of outcome variability. retrospective studies suggest that non-neurologic organ failure may contribute to 2/3 of all deaths after mstbi, but actual incidence rates of intensive care unit (icu) complications and their impact on outcome are not known. we examined the incidence rates of pre-specified medical and neurological icu complications, and their impact on in-hospital mortality and functional outcome at hospital discharge. in a prospective observational study, 183 consecutive mstbi patients from a single level i trauma center between 11/2009-5/2012 were analyzed. poor outcome was defined as glasgow outcome scale 1-3.multivariable logistic regression was utilized to adjust for admission characteristics and icu length-of-stay. the mean age was 51 years, 71% were men, and the median glasgow coma scale and injury severity scores were 4 and 29, respectively. the five most common medical icu complications were: hyperglycemia (77%), fever (62%), hypotension requiring vasopressors (40%), systemic inflammatory response syndrome (38%), anemia requiring transfusion (32%). neurological icu complications were: intracranial pressure crisis (icp; [51% of n=72 with icp monitor in place]), brain edema (38%), herniation (38%), intracranial rebleed (36%), clinical seizure (12%). among medical complications, hyperglycemia was associated with poor outcome (or 2.6; 95% ci 1-6.9]) while cardiac complications (e.g. cardiac arrest, arrhythmia, acute myocardial infarction) were associated with death (or 6.1; 95% ci 1.8-20.6). when combining medical with neurological icu complications, brain edema (or 5.1; 95% ci 1.5-18) was associated with poor outcome, while cardiac complications and brain edema were associated with death (or 6.9; 95% ci 1.5-31.6 and or 11.3; 95% ci 3-43, respectively). icu complications are very common after mstbi. we identified specific potentially modifiable predictors of adverse outcomes after mstbi. confirmation of our findings in a larger cohort is warranted. too much oxygen may increase oxygen free radical production, possibly triggering cellular injury and apoptosis. although laboratory investigations support the potentially detrimental effects of hyperoxia exposure after tbi, clinical data are lacking. we retrospectively identified tbi patients admitted to our neuro-icu between july 2009 and february 2012. we identified a total of 169 patients with complete data including gcs, apache ii, age, gender, abg within 24 hours of injury, and outcome (glascow outcome scale-gos at discharge from the hospital). patients were divided into 2 groups defined a priori based on pao2 on the first abg values obtained after injury. hyperoxia was defined as pao2 of 245 mm hg or greater, and normoxia as pao2 between 60 and 240. poor outcome is defined as gos of 1-3. the patients in the normoxia group (n = 102) and the hyperoxia goup (n = 63) were matched on baseline characteristics, age ( among a small number of patients admitted to the neuro-icu following traumatic brain injury, patients with arterial hyperoxia had a trend towards worse outcome compared with patients with normoxia. this provides scientific rationale for large prospective clinical trials of controlled oxygenation in tbi patients. elevated intracranial pressure (eicp) contributes to secondary injury in stbi, therefore its control is paramount. boluses of hypertonic solutions are usually used to reduce icp but the impact of early continuous infusions has not been widely explored. we conducted this study to compare the effect and security of hypertonic saline 3% (hs3%) infusion vs normal saline. all stbi patients arriving to the emergency room within 3 hours of trauma were enrolled to receive an isovolumetric infusion of hs3% or normal saline (placebo) during 72 hours. icu physicians and investigators were blinded to the sodium levels during the trial. main endpoint: number of eicp episodes (>20mmhg). secondary endpoints: neurologic outcome (gos, mrankin), electrolyte and osmolality levels, and adverse events (ae). twenty non-penetrating shbi patients were included. median age was 33.5 years (iq25-75:26.5 -41.5). median iss was 29(iq25-75:25-34). we didn´t find significant differences for the total number of episodes of eicp at 72h between groups (6, iq25-75:1-9 vs. 14, iq25-75:0-23, p=0.49); however, when we analyzed patients with at least one episode of eicp we found a significant low number of eicp episodes in hs3% group (9, iq25-75:2-9 vs. 22, iq25-75:17,5-40,5; p=0.003). we found a sodium plateau at 42h of infusion (hs3%:151.8±5.8 vs. control:139.2±6.2meq/l, p=0.02) which lasted until the beginning of weaning from hs3%. the most frequent ae was hypokalemia and no patient had renal failure. the sixmonth gos and mrankin scores had a non-significant tendency towards better outcomes in hs3% group. an early infusion of hs3 is feasible and seems to be safe in stbi patients. serum sodium kinetics showed a plateau after 42h of hs3% infusion with no consequences in renal function and no rebound effects after tapering. hs3% continuous infusion could reduce eicp episodes and it could conduct to better neurologic outcomes at six months. traumatic brain injury causes diffuse shearing of long fiber tracts. this can be detected by quantitative dti imaging even in patients who have primarily localized contusions. in our population the cingulum, cotricospinal tracts and external sagittal striatum were preferentially affected compared to age and gender matched controls. these findings support the use of advanced mri to assess the degree of injury and inform prognosis and goals for rehabilitation. neurocrit care (2012) 17:s1-s337 most deaths following severe traumatic brain injury (tbi) are associated with a decision to withdraw life-sustaining therapies (wlst)(1). however, the incidence and the impact of wlst in clinical trials is unknown. this systematic review was performed to assess if and how wlst are dealt with in clinical trials involving patients with severe tbi. we searched medline, embase, cochrane central, biosis and cinahl databases and references of included studies. all randomized controlled trials (rcts) published over a 10-year period (january 2002 (january -2012 , in one of 18 selected journals in general medicine, critical care medicine and neurology/neurosurgery were considered for eligibility if 8) and reporting data on mortality. our primary outcome was the assessment of wlst. secondary outcomes were the timing of evaluation, justification for wlst, proportion of wlst among deaths, factors that may have influenced the wlst and risk of bias of rcts. two reviewers selected rcts and collected data independently using a standardized case report form. from 3737 citations retrieved, 37 rcts were included (n=15,460, ranging from 11 to 10 008 patients). 24 were single center rcts and 13 were multicenter. the incidence of wlst was reported in 4 studies (10.8%). three studies reported crude numbers of patients, 3 studies reported the timing of wlst and 3 studies reported the justification for the decision to wlst. 16 studies were considered at high risk of bias, 1 study at low risk of bias and 20 studies did not give enough information to conclude on the risk of bias. wlst was rarely reported in rcts involving patients with severe tbi over the last decade. considering the variation of wlst in clinical practice, we suggest that wlst should be systematically reported in rcts performed in tbi. reference : 1. turgeon et al. cmaj 2011. previous pediatric brain injury studies have considered fevers as discrete events instead of as a "temperature dose." we sought to evaluate the population size difference captured at various fever thresholds in severely brain-injured pediatric patients, considering fever burden in terms of degree-hours; and to compare fever burden in pediatric traumatic brain injury (tbi) vs. cardiac arrest (ca). charts from brain-18y, admitted in 2005-8 within 24 hrs of admission were included. no temperature modulation protocols existed in the pediatric icu during this period. 7-day core temperatures were used to generate areas-under-the-curve (auc) above fever thresholds of 37.5, 38, 38.5, and 39 o c. these were normalized for different lengths of stay. 46 charts met inclusion criteria, with mean patient age 7.2y (range 2d -18y). diagnoses distributed (non-exclusively) as 19 ca, 14 accidental tbi, 9 non-subarachnoid hemorrhage (sah) intracranial bleeds, 3 sah, 4 strokes, 4 non-accidental tbi, 4 ca after tbi, and 11 other cns pathologies. cohort mortality was 50%, with 30% suffering brain death. fever burdens were measurable in 93% of patients over 37.5 o c, in 80% over 38 o c, and in 39% over 39 o c. normalized fever burdens at these thresholds were statistically different by 1-way anova (p<0.0001), with all fever burdens being statistically less than at 37.5 o c. remarkably, a shift in threshold from 37.5 to 38 o c resulted in a 56% reduction in measured fever burden. fever burdens fell from a peak of 6.9 ± 11.2 o c-h on day 1 to 1.7 ± 3.0 o c-h on day 3 after admission. accidental tbi (n=14) and ca (n=19) patients did not experience different fever burdens above 37.5 o c. measured fever burden is markedly affected by shifting the threshold from 38 to 37.5 o c. tbi and ca appear to induce similar fever burdens. pediatric fever burden reference values will allow more quantitative comparisons in severely braininjured children. little is known about the natural history of function after traumatic brain injury. our objective was to track the stability of drs scores over time and to identify factors associated with worsening drs scores. we collected disability rating scale (drs) scores, which capture the cognitive ability to perform activities of daily living such as communication, motor response, feeding, toileting, overall functioning and employability, longitudinally on severely brain injured patients in neurosurgery clinic. multivariable logistic regression was used to identify patient factors that were independently associated with changes in drs score over time. 65 patients with severe brain injury had more than one drs score collected. of these patients, 27 had worsening scores over time. changes in scores ranged from -8 to 9 (mean -0.3, standard deviation 3.4). this represented a change from partial/no disability to moderate disability for 3 patients and from moderate to severe disability for 3 patients. 8 patients improved from moderate to partial/no disability while only one patient improved from severe to moderate disability. using multivariable logistic regression, there were no patient factors that were associated with worsening drs scores including gender, age, comorbidities, race, insurance status, mechanism, injury severity score, gcs or final disposition. while half of worsening drs scores were seen within the first 100 days after discharge, 14 were seen 3 months or more after the hospital stay, with one seen over a year after hospital discharge. for the most part, drs scores were stable over time. a group of patients were identified who experienced significant decline in function as far out from discharge as a year. this preliminary study highlights the need to identify those at risk for decline and to set up mechanisms for long-term follow-up for those patients in need. the identification of traumatic axonal injury (tai) lesions that undergo neuronal recovery could improve prognostication in patients with traumatic brain injury (tbi) and facilitate the development of novel therapies for preventing secondary axotomy. we aimed to determine whether diffusion tensor imaging (dti) detects neuronal recovery after tai. we retrospectively identified 7 tbi patients (5 severe, 1 moderate, 1 mild) who underwent at least 2 acute-to-subacute dti scans and who had at least 1 tai lesion in the corpus callosum (cc), as defined by hyperintensity on dwi or t2 flair. the median number of days from tbi to image acquisition was 2 (range 1-7) for the first dti scan and 26 (range 14-88) for the second scan. tai lesions were manually outlined on the acute dwi datasets and then coregistered to the subacute datasets to measure longitudinal changes in lesional fractional anisotropy (fa) and apparent diffusion coefficient (adc). "neuronal recovery" within a tai lesion was defined on the final scan by mean lesional fa within 2 standard deviations of published normal fa values for the cc. initial fa and adc values in lesions with and without neuronal recovery were compared (unpaired t-test). eleven cc tai lesions (7 splenium, 2 body, 2 genu) were identified. fa recovered in 3 splenium lesions (0.63+/-0.03 [mean+/-sd]) and 1 genu lesion (0.53) on the final scan. three of these 4 lesions were flair hyperintense, 3 were associated with gre microbleeds, and 3 were initially adc hypointense. splenium lesions with neuronal recovery did not differ significantly from lesions without recovery for fa (0.65+/-0.06 vs. 0.49+/-0.15, p=0.14) or adc (568+/-45 vs. 772+/-222 x10^-6 mm^2/s, p=0.19) on the initial scan. dti may detect neuronal recovery within tai lesions, as indicated by subacute normalization of fa. acute dti biomarkers of tai reversibility were not identified in this preliminary analysis. increased intracranial pressure (icp) in patients with traumatic brain injury (tbi) is associated with higher mortality and poor outcome. mannitol and hypertonic saline (hts) have both been used to treat high icp, but it is unclear which one is more effective. we compared the effect of mannitol and hts on lowering cumulative icp burden after severe tbi. the brain trauma foundation tbi-trac® new york state database was used for this retrospective study. a total of 26 patients with severe tbi who received only hts were identified. 26 patients who received only mannitol were matched for age, pupillary reactivity, occurrence of hypotension on day 1. univariate analysis was performed to compare icp burden, cumulative hyperosmotic doses, number of icu days (wilcoxon signed rank test), and two-week mortality (mcnemar test). icp burden was defined as the total number of days with icp spikes (icp>25mmhg) expressed as a percentage of total number of days of icp monitoring. cumulative hts and mannitol doses were converted to osmolar doses for comparison. the mean age and gcs were similar in the two groups (36.26 vs. 38.79 years; 5.50 vs. 5.27; hts vs. mannitol, respectively) . 25 patients received 3% hts and 1 received 23.4% hts. all patients in the mannitol group received 20% mannitol. there was no difference in number of days of icp monitoring (p=0.49) or number of icu days (p=0.95) in the two groups. icp burden was significantly lower in hts group vs. mannitol group (14.67% vs. 33.62%. p=0.02). there was no significant difference in the cumulative dose of hts and mannitol (p=0.2), and two-week mortality in the two groups was similar (p=0.32). hts is more effective in lowering cumulative icp burden after severe tbi compared to mannitol. this did not translate into reduction in two-week mortality, possibly due to the small sample size. spreading depressions (sds) have been consistently associated with hypoglycemia in animal studies. the frequency of these depolarization events, while influencing infarct size, also appears to be influenced by the plasma glucose concentration during experimental ischemia. low cerebral dialysate glucose have also been correlated with sd events in humans. we hypothesized that low serum glucose should be associated with an increase in the frequency of sd events in human acute brain injury. to determine the relationship between serum glucose and cortical spreading depolarizations (sds) after traumatic brain injury (tbi), subdural electrode strips were placed on peri-contusional cortex in 103 patients from 4 centers who underwent craniotomy following tbi. prospective electrocorticography was performed during neurointensive care with retrospective analysis of hourly serum glucose data. patients were divided into those with sds and those without and the distribution of glucose values among these two groups were compared using the 2-way kolmogorov-smirnov method. in 61 patients (59%), 1682 sds (spreading depressions and peri-infarct depolarizations) were observed. the probability of a depolarization occurring increased significantly as a function of rising serum glucose (p<0.000008). median glucose values in patients with and without sds was 7.6 and 7.0 mmol/l, respectively. among patients with sds, glucose values recorded within 60 minutes of the onset of an sd were higher than those occurring <75 minutes before an sd (p<3.8e-13) ( figure 1 ). serum glucose does not appear to affect the generation of sds as it does in animals but paradoxically may be elevated. this may reflect a stress response to the initial acute brain injury and critical illness or a physiologic mechanism to increase glucose supply during sd events in which cerebral glucose utilization is increased. overall, the data suggest that plasma glucose is being managed within appropriate levels in this study group. to determine difference in tbi severity and abnormal radiologic findings in different age groups. this was an observational cohort study on all adult patients (>18yrs) arriving to the emergency department, with a history of traumatic brain injury as a result of "fall" at a level 1 trauma center in the southeastern united states. data collected included ed gcs score and head ct results. abnormal ct scans have the presence of either an intra-cranial bleed and/or cranial fracture. there were 612 patients in the cohort with history of fall with median age of 49yrs (iqr of 28-68). we divided them into two age groups: group a: 18-55yrs(60%) & group-b: >55yrs(40%). group a comprised mostly of males (66%) compared to females, meanwhile group b was equivocal in gender composition (51% male). out of the whole cohort of 612 patients, 92% patients had head ct performed. out of these, 46.74% (n=265) showed an abnormal head ct. age group b (65%) had a significantly greater percentage of abnormal ct scans compared to group a (34%) (p<0.0001). among abnormal ct scans, group a (50%) had a significantly greater percentage of skull fractures than group b (22%) (p=0.0084). among patients with mild and moderate tbi (gcs>9), group b (64%) was more likely to have an abnormal ct scan than group a (24%) (p<0.0001), however, there is no significant difference between likelihood of abnormal head ct between group a and b for severe tbi. younger adults are at a higher risk of cranial fractures after a fall related tbi, probably due to severe mechanisms of injury. on the other hand elderly population with mild tbi mostly due to ground level falls had worse outcomes on ct scans. accumulating pre-clinical data suggests that matrix metalloproteinase (mmp) expression following cerebral trauma contributes to brain injury. we sought to characterize the temporal mmp response to severe traumatic brain injury (stbi) in humans and its relationship with outcomes. we conducted a prospective cohort study that included 8 adults with stbi. high-cutoff, cerebral microdialysis and arterial and jugular venous bulb catheters were used to measure the concentration of mmps and other markers over 6-days. the concentration of mmp-1 was initially low in microdialysate and blood, but increased between 96-and 156-hours. mmp-2 blood levels were high and stable throughout the study while blood levels of mmp-3 were initially low and then gradually rose. in microdialysate, mmp-2 and -3 increased and then peaked between 42-and 48-hours. mmp-7 also increased in microdialysate following stbi while its levels were low and stable in blood. mmp-8 and -9 were initially high in microdialysate and then slowly decreased over time. while the concentration of mmp-9 was also initially high in blood and then progressively declined, the mmp-8 blood level increased with time. among the patients that also had cerebrospinal fluid (csf) drains, marked and sometimes opposite concentration trends were observed for mmp-7 in microdialysate versus csf. generalized estimating equations suggested that significant changes in mean microdialysate concentrations of mmp-1, -2, -3, and -8 and mmp-1, -2, -3, and -9 occurred with increases in microdialysate glucose and the lactate pyruvate ratio, respectively. moreover, the mean microdialysate level of mmp-8 increased with intracranial pressure (icp) [(49.27 pg/ml)/mmhg; 95% confidence interval, 9.03 to 89.51] while that of mmp-7 decreased with cerebral perfusion pressure (cpp) [(-3.25 pg/ml)/mmhg; 95% confidence interval, -5.92 to -0.58]. monitoring of mmps following stbi is feasible, and their expression may be associated with cerebral metabolism, icp, and cpp. to determine significance of laboratory markers for in-hospital death after fall related adult traumatic brain injury. this was a consecutive cohort observational study done at a level-1 trauma center serving surrounding 12 counties. cohort consisted of all adult patients (> 18yrs) arriving to the ed with a history of fall. study variables were lab values of the following parameters on ed admission: sodium, potassium, bicarbonate, lactate, blood glucose, inr, aptt, wbc, rbc, platelets; along with pre-hospital glucose values in the field. study cohort comprised of 612 adult subjects arriving at ed with history of fall with median age of 49yrs (iqr of 28-68). in-hospital death (ihd) was observed in 5% (n=28) of the total cohort, with male ihd=19 (68%), and female ihd=9 (32%). older age groups [>55yr] (8%, n=252) had higher incidence of in-hospital deaths compared to younger age group 18-55yr (2%, n=360) with p=0.0004 (ci= 0.0267-0.0933). in a univariate regression model higher levels of: pre-hospital glucose (p=0.0048), ed blood glucose (p<0.0001), lactate (p=0.0445), inr (p=0.0048), aptt (p<0.0001) and wbc (p<0.0001) were significant individual predictors of in-hospital death. while lower levels of bicarbonate (p<0.0001) and rbc (p<0.0001) were significant individual predictors of in-hospital death. the following multivariate regression models showed statistical significance with higher probability of in-hospital death: 1) higher: ed blood glucose (p=0.0014), aptt value (p=0.0035) | lower: bicarbonate (p=0.0482), rbc (p=0.0087) with adj.r 2 =19% 2) higher: aptt value (p=0.0019) and wbc count (p=0.0035) 3) higher: aptt value (p=0.0112), older age (p=0.0033) | lower rbc (p=0.0220) and gcs scores (p<0.0001) with adj.r 2 =29% lab parameters such as ed blood glucose, rbc count, wbc count, bicarbonate level & aptt level are individually or simultaneously important predictors of in-hospital death in adult tbi patients with history of fall. traumatic brain injury (tbi) is an epidemic with severe consequences. brain tissue oxygen tension (pbto2) monitors detect secondary injury and direct clinical therapies to mitigate damage. blood transfusion is one therapy often used, however its effect in tbi patients is not well defined. we studied pbto2 data in patients who received transfusion after tbi. sixty-nine severe tbi patients were consecutively admitted to a neurocritical care unit and received pbto2 monitoring as part of standard clinical care for this unit. data were collected from electronic medical records as entered by the bedside nurse. patients were managed according to the brain trauma foundation guidelines. transfusions were identified through nursing comments. hourly pbto2 values were analyzed for up to six hours after starting transfusion. other factors were also analyzed for their potential influence on pbto2 readings. of 69 patients, 19 received a total of 28 transfusions in the setting of pbto2 monitoring. two groups were identified: transfusions that led to an increase in pbto2 and those that did not. six transfusions resulted in increased pbto2, with an average increase of 11.5 mm hg. twenty-two transfusions did not: of these 12 were unchanged and 10 decreased. the groups did not differ in age (mean 33.5 and 33.6, respectively), maximum temperature (mean 98.7 and 97.6), minimum cerebral perfusion pressure (mean 61.2 and 60.0), or initial glasgow coma scale (gcs) (mean 4.3 and 5.2). blood transfusion is often used in the critical care setting. the effect of transfusion on brain tissue oxygen tension is variable. age, temperature, cerebral perfusion pressure, and initial gcs were not useful in distinguishing patients who benefited from transfusion. pbto2 only rises in a minority of patients; therefore additional prospective studies are needed to evaluate which patients are likely to benefit from transfusion. mannitol use in patients with traumatic brain injury can lead to acute renal failure and may worsen outcome. the purpose of this study is to determine the rate of acute renal failure (arf) among patients treated with mannitol and its impact on outcome in a multicenter review. we analyzed a one-year data (2005) (2006) from the premier database, a nationally representative hospital discharge database in the united states. we compared baseline and clinical characteristics of patients with traumatic brain injury (tbi) treated with mannitol in the first 7 days of admission who developed arf to those who didn't. length of stay, cost of hospitalization and discharge status were ascertained. from a total of 2388 admissions with a diagnosis of traumatic brain injury requiring mannitol within the first 7 days of admission, 8% (n=178) of patients had arf. arf is a common complication of tbi treated with mannitol. it is associated with longer length of hospital stay and increased rates of in-hospital mortality. the result highlights the importance of using alternative therapy to hyperosmotic agents such as hypertonic saline in treatment of tbi patients at risk for acute renal failure. cervical spine immobilization (csi) is a relative contraindication for percutaneous dilatational tracheostomy (pdt) because of the inability to extend the neck, making tracheal puncture at the correct level more challenging. patients with csi routinely undergo pdt at our institution, however, with both traditional bronchoscopic as well as with real-time ultrasound (rtu) guidance. our objective was to review the incidence of complications related to pdt in patients with csi versus patients without csi. we reviewed the records of consecutive patients who underwent pdt performed by a single operator at our neurocritical care unit between 6/2008-5/2012. all patients requiring tracheostomy are screened for eligibility for pdt by the attending neurointensivist on service. we recorded the percentage of patients who successfully underwent pdt vs requiring conversion to surgical tracheostomy, the specific guidance used (bronchoscopy, rtu) and all short-and long-term complications including placement of the tube above the first tracheal ring. a total of 112 patients underwent pdt performed by a single neurointensivist. all patients screened by the operator underwent an attempt at pdt, and all patients successfully completed the procedure without conversion to surgical tracheostomy. ninety-eight of 112 (87%) did not require csi and 14 (13%) required csi. in the csi group, bronchoscopy alone was used in 6/14 (43%) and bronchoscopy plus rtu in 8/14 (57%). no complications occurred in the csi group. in the no-csi group, there were 3 (3%) complications (one tracheal granuloma and two tube dislodgments within 7 days). no other short or long term complications were recorded. all tubes were placed below the first tracheal ring. it is feasible to safely perform pdt in patients with cervical spine immobilization using bronchoscopic and real-time ultrasound guidance. following traumatic brain injury (tbi), increased serum biochemical marker levels reflect the extent of neurological damage, prognosis and clinical outcomes. effective tbi management strategies are lacking. despite the neuroprotective effects of therapeutic hypothermia after cardiac arrest, its tbi use remains controversial. delays in achieving target temperatures in human trials taking 6-12 hours (nabish-i; nabish-ii) may have contributed to the lack of benefit. we hypothesized prompt, rapid induction of hypothermia, immediately following tbi would lower predictive serum biomarkers of brain injured swine. sixteen domestic cross-bred pigs (34-35 kg) were subjected to a 5 atm (100 ms) fluid percussion tbi. eight injured animals were cooled to 32°c within 90 minutes of injury and maintained for 48 hours using transpulmonary hypothermia. eight control animals were maintained at 37°c using similar doses of inhalational and intravenous general anesthesia. brain temperature was monitored with camino.® serum markers of tbi: s-100 calcium binding protein b (s-100b), neuron-specific enolase (nse), glial fibrillary acidic protein (gfap) and phosphorylated axonal form of the neurofilament subunit nf-h (pnf-h) were measured prior to injury and seven times over 96 hours. surviving animals were euthanized and necropsied five days post-injury. at 3, 6, 24 and 96 hours, s-100b, nse and pnf-h, were lower in the hypothermia group vs. controls. gfap levels were decreased at 96 hours. after injury, peaks and troughs of the biomarkers occurred at various intervals. s-100b levels were reduced in both groups during the initial 36 hours post-injury, with control levels increasing at 48 hours. early initiation and rapid cooling of brain temperature to 32-33°c for 48 hours was associated with attenuated s-100b, nse, gfap and pnf-h levels in swine. general anesthesia was associated with early mitigated s100b levels. prompt therapeutic hypothermia and prolonged anesthesia may offer neuroprotection after tbi. mild traumatic brain injury (mtbi) from blast exposure represents a significant threat to military personnel. until now there has been no way of knowing what the individual service member experienced during an exposure. we report the first individual measurements recorded during combat operations and how those readings were used to assist evaluation of the injured service member. the nato role-3 hospital, kandahar afghanistan received the index case of a service member (sm) exposed to an improvised explosive devise (ied) blast while wearing a blast dosimetry system composed of 3 blast gauges placed on the back of the helmet, chest, and shoulder. the gauges include status lights that allow immediate feedback for injury risk via colored lights: green = negligible (<4 psi peak), yellow = moderate (between 4 and 16 psi), and red = severe (16 psi and above). in addition, time traces of the overpressure and 3-axis acceleration are recorded and available for download through a micro-usb port. the sm's gauges were initially checked 1 hour 24 minutes after the blast, demonstrating a yellow status light. the blast data downloaded from the gauges demonstrated a consistent exposure of 5.5 msec composed of a primary flow immediately followed by a secondary wave. the head gauge recorded a peak overpressure of 13.1 psi and impulse pressure of 9.5 psi-sec. there was 1 msec of sustained pressure above 4 psi from the primary flow. all 3 gauges demonstrated similar blast profiles, including a secondary reflective wave. these measurements are firsts in both the recording of an individual's exposure during a blast related attack and the use of that data for patient triage and medical evaluation. blast gauges measure environmental exposure and do not diagnose mtbi, however; they do provide clinicians with important information in the evaluation of patients subjected to blast. to consider the definition of initial signs and symptoms to compare outcomes after "severe" traumatic brain injury regard to mechanism of injury. design-this study included all adult patients who presented to ed at a level-1 trauma center with severe (gcs score<9) traumatic brain injury. from the total cohort(n=126), 47% suffered tbi because of "fall" and 54% due to traffic accident(mvc). significant proportion of each sub-group was comprised of males (72% in-mvc with median-age=39; 74% in-falls with median-age=53) · for all the patients arriving to ed after a traffic accident with severe gcs: 88% had loc, 62% had aoc, 15% had pta, 100% got admitted to hospital, 94% had an abnormal head ct (bleed/fracture), 91% got admitted to icu, 49% had some neuro-surgical intervention and 29% patients died in hospital. · for all the patients arriving to ed after a history of fall with severe gcs: 87% had loc, 70% had aoc, 23% had pta, 97% got admitted to hospital, 93% had an abnormal head ct (bleed/fracture), 90% got admitted to icu, 42% had some neuro-surgical intervention and 35% patients died in hospital. · decrease in systolic blood pressure (p=0.348) and increase in diastolic blood pressure (p=0.0329) are more likely to have a fracture after a traffic accident in severe tbi. increasing of blood pressure p=0.0256) and decreasing of pulse (p=0.0381) is significantly associated with icu admission after a fall. comparing data for two most common mechanism of injury in severe tbi suggest that some vital signs and symptoms have significant impact with outcomes depends on mechanism of injury. these observations should be studied in larger cohort to find more significant association between mechanism and outcomes. cerebral edema is the one of the most significant predictors of poor outcome after traumatic brain injury. it is still unclear what the pathophysiological and cellular mechanisms and predictors of post-traumatic edema are. the exponential growth in genetic information has opened an avenue for investigation in traumatic brain injury and implicated specific genes in the pathophysiology of post-traumatic injury edema. two examples are the aquaporin-4 and cacna1 genes, which respectively encode water and calcium channels. the aquaporin-4 gene on chromosome 18q11.2-12.1 encodes the aquaporin-4 protein (aqp4) water channel. aqp4 is one of the bidirectional high capacity water channels that is primarily expressed in astrocytic foot processes in the central nervous system at the blood-brain barrier and is thought to be critical for brain water homeostasis. experimental studies showed that aqp4 deficient mice had significantly reduced cerebral edema and better survival in a water intoxication model. the cacna1 gene on chromosome 19p13 encodes the a1a subunit of a neuronal calcium channel. patients with familial hemiplegic migraine and delayed fatal cerebral edema and seizures from minor trauma have been found to have mutations in cacna1, which are hypothesized to enhance development of cytotoxic edema. a missense mutation is reported to enhance risk of delayed fatal cerebral edema. hypothesis: the cacna1 gene missense mutation s218l and aqp4 polymorphisms will be over-represented in patients with post-traumatic cerebral edema. to perform full exon sequence analysis of these two genes in 20 well-defined cases of excessive cerebral edema. our long term goal is to systematically investigate genetic variants as determinants of risk of excessive cerebral edema. patient recruitment is currently ongoing. it is hoped that this will further elucidate secondary mechanisms of injury specifically in the formation of post-traumatic edema and lead to targeted therapies in the future. microwave occurs when improvised explosive devices was exploded. however, the effect for brain by microwave has not been clarified. under general anesthesia, s-d rats were irradiated by head-focused microwave by microwave fixation system (model mmw-05/ muromachi kikai co., ltd.), which were classified in three groups (3.2kw/ 0.1sec (i), 2.6kw/ 0.1sec (ii), 2.0kw/ 0.1sec (iii), and sham group) by intensity (n=3 in each group). vital signs were evaluated, arterial blood gas was examined, and we checked pathologic findings by hematoxylin-eosin (he) stain immediately after microwave irradiation, post 3 hours, 6 hours, 24 hours, 72 hours, 1 weeks, and 2 weeks in each group. blood pressure was elevated transiently immediately after irradiation, and recovered in short period. pao2 was unchanged in post-irradiation phase, except in group i. in he stain, neuron was degenerated and left out especially in cerebral cortex and hippocampus, microglia cells were accumulated in these regions. these pathological changes were observed frequently and earlier, when irradiation was intense. the result was firstly reported that head-focused microwave irradiation induced brain injury in s-d rats, and this brain injury was related with intensity of microwave. pathological change was impressive because it was occurred gradually and progressive. further study will be required, whether this type of brain injury is similar with traumatic brain injury, or cerebral ischemia or not, and the study of behavioral effects of microwave irradiation is necessary, especially when the intensity of irradiation was not severe. the efficacy of decompressive craniectomy (dc) in the treatment of moderate-severe traumatic brain injury (mstbi) is a topic of debate in neurocritical care. despite the recently published randomized dc in diffuse tbi (decra) trial, it is still unclear when and for which tbi patients this procedure should be considered. in order to assess the utility of dc in evidence-based clinical practice, we present a matched case-control study that compares surgical and non-surgical outcomes among patients with mstbi. we conducted a retrospective analysis of mstbi injuries treated at a single level i trauma center from 2009 to 2012. twenty mstbi patients aged between 18 and 67 years, who underwent dc, were enrolled. paired controls that underwent medical therapy only were selected according to glasgow coma scale (gcs) score and age. primary lesion type, pupil reactivity, hypotension, hypoxia and icp crisis were secondarily considered in matching cases with controls. we focused on mortality, glasgow outcome score (gos) score upon hospital discharge and gos score at 3 months as the primary measures of outcome. in the dc group, we found that 35% of patients died; 15% had a favorable outcome at discharge (4 or higher on gos); and 10% had favorable outcome at 3 months. in the control standard-care group, we found that 30% of patients died; 25% had favorable outcome at discharge; and 35% had favorable outcome at 3 months. pupil reactivity and gcs score on admission were the variables highly correlated with mortality. statistical analysis will be available at the meeting and presented for the first time. in this cohort, undergoing dc did not seem to confer a mortality benefit to patients with mstbi. good recovery after mstbi was observed in a larger percentage of the non-surgical group, which is consistent with the findings of the decra trial. each year in the united states, over 1.4 million patients present to emergency departments as a result of traumatic brain injury (tbi). severity classification of tbi is based on the glasgow coma score (gcs), with severe tbi being a gcs score between 3 and 8. there is always a subset of "severe" tbi that requires surgical intervention. the current study examines this subgroup to decipher any symptomatology that may be helpful in identifying who these patients are. the objective is to determine which if any factors predict the need for surgical intervention in patients with severe traumatic brain injury (tbi). this study is a subgroup analysis of the larger cohort of consecutive adult tbi patients that presented to the ed. our sample included only severe tbi patients (gcs<9). besides descriptive analysis, logistic regression analysis was done to determine the significant predictors of surgical intervention in this subset of patients. lab values (sodium, potassium, bicarbonate, lactate, blood glucose, wbc, rbc, platelets, inr, aptt) and symptoms (such as-seizures, vomiting, loss of consciousness, alteration of consciousness, post-traumatic amnesia) were the dependent variables compared with surgical intervention (independent variable). of the total severe tbi cohort (n=126), 40% required surgical intervention. presence of abnormal head ct (bleed in 93% of the total cohort) is significantly associated with surgical intervention (p=0.0131). vomiting (p=0.0173), lactate (p=0.0326), higher wbc (p=0.0400) and lower platelet count (p=0.0430) individually showed significant association with surgical intervention on a univariate regression model. these data suggest that abnormal head cts, particularly those that result from bleeding, as well as lactate, platelet count, wbc count and vomiting are significantly associated with surgical intervention. the association of lab values with likelihood of undergoing surgical intervention is an interesting future research point. to study the potential usefulness of initial vital parameters and laboratory evaluations to predict short term prognostic this is an observational cohort study of all adult patients who came to the emergency department(ed) of a tertiary care hospital, in a 20 month period during 2008-2010. for the purpose of analysis, we considered initial vitals and lab values available for all patients. we individually compared vitals (pulse and mean arterial pressure-map) and laboratory values [sodium(na + ), potassium(k + ), bicarbonate(hco 3 -), glucose, wbc, rbc, platelets, inr) for the following prognostic variables: abnormal head ct finding(yes/no), hospital admission (yes/no), icu admission, in-hospital death, hospital length of stay(hlos), and 3-month mortality using t-tests and correlations. the significant variables were then entered into a logistic regression model (for categorical variables) and a multiple regression model (for continuous variables) simultaneously to determine significant predictors of prognostic outcomes. significance level was set at p=0.05. increase in glucose(p=0.004) and wbc(p<0.001) lead to a higher likelihood of having an abnormal head ct, when controlling for map and hco 3 -; increase in glucose (p=0.001) and wbc (p=0.02), and decrease in hco 3 -(p=0.009) and platelets(p=0.006) increases the likelihood of getting admitted, when controlling for map, k + , and rbc; increased glucose(p<0.001), decreased hco 3 -(p=0.01) and decreased platelets(p=0.03) increases chances of in-hospital death, when controlling for wbc and inr; increased glucose(p=0.004), increased wbc(p<0.001), and decrease in rbc(p=0.005) increases hlos, while controlling for pulse, k + , and hco 3 -. the study indicates that some initial vitals and lab values can help to determine the prognostic outcomes in adult traumatic brain injury. though our study is limited by a single-site patient population, the interesting findings warrant further research efforts in this specific area. ultrasonic assessment of optic nerve sheath diameter (onsd) as a non-invasive measure of intracranial pressure (icp) has been evaluated in the literature as a potential valid technique for rapid icp estimation in the absence of invasive intracranial monitoring. the technique can be challenging to perform and little literature exists surrounding intra-operator variability. in this study we propose an examination of onsd utilizing a variety of novel ocular models, to both define the ability of the ultrasound linear array probe to capture different known onsd, and to assess intra-operator variability with the technique. here we present the model and data. we designed ocular models composed of gelatin spheres and variable three dimensional printed cylinders, which simulate the globe of the eye and variable onsd's respectively. these models will then be suspended in a gelatin background. operators will then utilize the linear array ultrasound probe on these models in order to determine onsd of 3 sizes, with 10 measurements each in order to assess intra-operator variability with the technique. our optic nerve sheath model offers ultrasound images comparable to in vivo, and is quick to manufacture. analyzing the data, we removed the first two measurements from the series of ten. we defined those as "practice attempts" with the technique. for the onsd models, the means were: 2.59mm with sd of 0.34mm (95% ci of 0.24), 5.55mm with sd of 0.33mm (95% ci of 0.23), 8.18mm with sd of 0.34mm (95% ci of 0.24). utilizing the standard linear array ultrasound probe for onsd measurements in our model provided reliable results with minimal intra-operator variability across variable sheath sizes. knowing this, we can further apply this novel model of onsd to us teaching and training courses with confidence in its ability and the techniques ability to produce consistent results. the objective of this study was to identify factors (signs and symptoms after injury, vital parameters, and glucose) that can be used as predictors of an intracranial bleed. this will improve identification and treatment of patients who present to the emergency department (ed) with tbis. this is an irb approved observational cohort study done at a level 1 trauma center, and included all adult patients presenting to the ed following a tbi. data for patients presented during study variables included age, loss of consciousness (loc), seizure (sz), vomiting, alteration of consciousness (aoc), post-traumatic amnesia (pta), glucose level, pulse, and blood pressure (bp). all variables were tested for association with intracranial bleeding using chi-square tests of independence, t-tests, and then significant variables were included in a regression model. limitation of study were chart review and a single ed. the cohort consisted of 1,241 patients, of which 92% (n=1124) had a ct scan of head. 43% of total patients had an abnormal head ct, and 80% of those had an intracranial bleed. statistical analysis indicated that loc (p=0.0005), aoc (p=0.0001), pta (p<0.0001) and advanced age (p=0.0002) were significantly correlated with having a bleed. vomiting and sz were not statistically significant. among patients who had head cts, both pulse and systolic blood pressure decreased between the first and second measurements; both pulse(p=0.001) and bp(p=0.045) decreased significantly less in patients with bleeds compared to those without bleeds. additionally, higher ed glucose level was associated with having a bleed (p<0.0001) on head ct. these data indicate that older age, loc, aoc, pta, and elevated glucose levels can be used as predictors of intracranial bleeds. sustained elevation of pulse and systolic blood pressure may also be indicative of a bleed in tbi patients. patients with moderate-severe traumatic brain injury (mstbi) commonly die from withdrawal of support, likely as a consequence of an unfavorable outcome prognosis provided to the family by the treating physician. it is unknown whether prognostication may lead to self-fulfilling prophecies, and whether the presence of intensive care unit (icu) complications may accentuate possible provider bias. in this study, we surveyed clinicians caring for patients with mstbi to examine the variability of outcome prognostication and the influence of icu complications on these predictions. we conducted an anonymous electronic survey of clinicians, including faculty members (neurology, neurosurgery, trauma, anesthesia/critical care), neurology house staff, icu affiliate practitioners and neuroicu nurses at a single level i trauma center. the survey included three tbi case vignettes and their respective icu courses. questions were designed to assess the utilization of known tbi prognostic models, relative importance of icu complications for outcome prognostication and aggressiveness of care recommended by the survey participant. a total of 152 surveys were distributed by email or paper, and 51 have been returned. so far, we have found that 51% of participants consider medical icu complications as very important in tbi prognostication. age, icu course and head ct findings are the prognostic variables considered most important to outcomes. 68% of non-critical care neurologists are uncomfortable providing tbi prognostication. case responses suggest that clinicians tend to recommend aggressive care (surgery), but predict unfavorable outcomes. the survey is ongoing, but complete results will be available at the meeting and presented for the first time. we have discovered great variability in outcome predictions made by clinicians with different levels of experience in treating mstbi. self-fulfilling prophecies may exist among mstbi outcomes. outcome studies should focus not only on admission variables, but also on icu complications in order to guide clinicians in providing prognostication. the objective of this study was to identify pre-hospital factors that are associated with worse severity of head injury in order to help physicians identify when tbi treatment may be necessary. this is an observational cohort study that included adult patients presenting to the(ed) following a motor vehicle collision. study variables included age, gender, seatbelt use, loss of consciousness (loc), seizure, vomiting, alteration in consciousness (aoc), and post-traumatic amnesia (pta). severity of tbi was classified according to the glasgow coma scale, with mild defined as 13-15, moderate being 9-12, and severe being anything less than 9. the gcs was obtained both in the pre-hospital and ed settings. the cohort of 451 was 57% male. the median age was 34 (iqr: 23-49, r: 18-91). the breakdown of severity in the prehospital setting (n=290) was 74% mild, 7% moderate, and 19% severe. in the ed (n=380), the breakdown was 79% mild, 4% moderate, and 17% severe. pre-hospital factors significant for the z-test included seatbelt (sb) use, loc, aoc, pta, and gender. males, patients who did not wear seatbelts, and patients who had a positive loc, aoc, or pta were more likely to sustain a moderate or severe tbi. having a seizure was also significantly associated with increased tbi severity (p=0.001). (see table 1 ) additionally, the data show that the likelihood of having an abnormal head ct increases with age (p<0.0001). although vomiting was associated with greater tbi severity, the results were not statistically significant. early symptoms such as loc, aoc, seizures, and pta are early predictors of worse severity in patients who sustain a head injury during their motor vehicle collision. age, male gender, and lack of seatbelt use also correlate with greater tbi severity. identifying crucial symptomatic predictors of icu admissions, icu length of stay and mortality rates in traumatic brain injury (tbi) patients with history of fall. retrospective chart analysis was performed on all adult patients arriving to emergency department with history of fall at a level one trauma center for parameters like vomiting, alteration of consciousness (aoc) & loss of consciousness (loc) after tbi; post-traumatic amnesia (pta) and history of seizures before or after injury, along with outcomes such as icu admission & icu length of stay. from the total cohort (n=612), 26% (n=139) of patients were admitted to icu, most of them were males(73%,p=0.0017). aoc was found to be strongly associated with icu admission (57%, p<0.0001)[including the patients who had brief loss of consciousness of <30mins(52%)], and 3month mortality rates(p=0.0287) when adjusted for mild gcs scores. · icu length of stay was higher in patients admitted to icu with aoc (p=0.0482) and pta (0.0076). icu admissions had higher 30day readmission (p=0.0006), in-hospital death (p<0.0001) and 3month mortality rate (27%, p<0.0001). · 86% of patients were found to have intra-cranial bleed when presented to ed with aoc(p=0.010), and 75% of these patients were admitted to icu. on a multivariate regression model analysis, patients who had abnormal head ct with mild gcs on ed presentation had higher 3month mortality rates (p=0.0066) when adjusted for age. patients with symptoms such as alteration of consciousness and post-traumatic amnesia after traumatic brain injury as a result of fall are more likely to be admitted to icu with significantly longer icu length of stay. mild traumatic brain injuries in fall patients should not be overlooked in daily practices because of significant mortality rates. cardiovascular disturbances remain a leading cause of morbidity and mortality in patients with acute spinal cord injury (asci). asci patients often develop symptomatic and potentially life-threatening bradycardia. our practice has been to use albuterol elixir prophylaxis in asci patients, taking advantage of its side effect profile associated with a typical dose of 4 mg tid or qid, to prevent further symptomatic bradycardia. evidence of efficacy with this regimen is, however, lacking. we set out to determine whether treatment with oral albuterol would decrease the frequency of bradycardic episodes in patients with asci. we retrospectively identified adult patients admitted to university of new mexico hospital between 2006-2011who sustained an asci and received oral albuterol therapy. the frequency of bradycardic events (hr <60 bpm) before and after initiation of albuterol was collected. we compared the number of bradycardic events before and after albuterol within each subject using the wilcoxon signed rank test. bootstrap methods were used to further validate our findings. we identified 11 asci patients who had evidence of symptomatic bradycardia before the initiation of the albuterol therapy, including hypotension and in 2 cases bradycardic cardiac arrest. the median number of bradycardic events was 17 (6.5, 42 iqr) before albuterol and was 4 (0, 11 iqr) after albuterol. we found that patient's had a significantly lower number of bradycardic events after the initiation of albuterol (p = 0.012). ten patients experienced less bradycardic events. the median difference was 12 less bradycardic episodes. bootstrap estimates of the median difference were consistent with our initial analysis. albuterol appears to be an effective means of treating bradycardia in patients with acute spinal cord injury. severe traumatic brain injury (tbi) is frequently associated with eeg changes like epileptiform discharges, seizures; periodic lateralized epileptiform discharges pleds or paroxysmal delta activity. we report a case of tbi with generalized 3hz spike and wave pattern that did not represent seizures a 21y old girl without epilepsy history presented after being involved in a motor accident. initial gcs was 10 and remained the same over the next 2 days. ct showed contusions with small left subarachnoid hemorrhage. phenytoin was started for seizure prophylaxis. on day 3, she improved clinically, however, on day 5 she had fluctuating consciousness and continuous eeg monitoring was initiated. various antiepileptic medications were tried over the next several days including lacosamide, valproate, topiramate, levetiracetam and ethosuximide (eth) without significant change clinically or on eeg. she started improving clinically on day 7 but became extremely drowsy on day 8, all meds except eth were weaned. she showed improvement and was discharged to rehab on day 14. a prolonged eeg after 2 months was normal and eth was weaned off. she continues to do well almost one year after and is maintaining her school grades at pre-injury level. the patient's initial eeg (day 5 post injury) showed generalized 3hz spike and wave pattern occurring every 1-3 seconds which continued for 2 days despite treatment with various anti epileptics as described. on day 7 eeg pattern changed to generalized rhythmic delta activity(1-2hz) especially during arousal. mri during the stay showed micro hemorrhages in both frontal lobes and right temporal lobe reflective of diffuse axonal injury. a 3hz spike and wave pattern mimicking absence seizures can be seen on eeg transiently after tbi, however its clinical significance is unclear. whether it needs to be aggressively treated or not cannot be conclusively established but the longterm prognosis appears to be benign. free radical-induced lipid peroxidation (lp) has been demonstrated to lead to the formation of isoprostanes from arachidonic acid and neuroprostanes from docosahexaenoic acid. lp is common after traumatic brain injury (tbi) and constitutes one of the key mechanisms of pathology related to secondary injury after tbi. one of the consequences of lp is the compromise of neuronal calcium (ca ++ ) homeostasis, leading to ca ++ overload and activation of the proteolytic -spectrin. the purpose of this project is to characterize the concentration--spectrin degradation after tbi. this study is a prospective, single-center study of adult moderate to severe tbi patients. inclusion criteria are age >18yo, closed head injury, within 24 hours of tbi, and glasgow coma score (gcs) <12. serial samples from urine, blood, and cerebrospinal fluid (csf, when available) are obtained for up to 2 weeks after injury. demographic data and pertinent clinical information are also collected. the biomarkers (5 & 15 f 2t -isoprostanes, f 2 -isofurans and f 4 -neuroprostanes) are measured via -spectrin breakdown products (sbp) by western blot analysis. we have enrolled fifteen patients to date. preliminary results suggest that the study population is typical of tbi (mean age 30.4 years, 73% male, median admission gcs 7). serum and csf 5 & 15 f 2t -isoprostane values are above published values for normal individuals, with csf values peaking at 24 hours after tbi. sbp are also measured in elevated amounts in csf compared to non-tbi controls (in whom they are not measurable). preliminary data suggests that serum and csf isoprostane values are elevated after tbi. continued patient accrual, further sample analysis, and comparison to control groups is needed to more precisely define the effect of tbi on the time course of lp biomarkers. traumatic intraventricular hemorrhage (tivh) is generally considered to be associated with moderate to severe traumatic brain injury and a significant mortality rate. there exists, however, a rare subset of individuals who manifest with isolated traumatic intraventricular hemorrhage and have a good prognosis and outcome. we present a case of an 18-year old female who suffered polytrauma and an isolated ventricular hemorrhage following a traumatic fall while mountain climbing. her history indicated mild transient confusion and amnesia occurring around the time of the fall. her glasgow coma score was 15, her neurologic exam was normal and she had no neurologic complaints other than positional lightheadedness and nausea. a comprehensive exam was notable for a right hip dislocation, nasal fracture, l4 vertebral body fracture, right apical pneumothroax and pulmonary contusion. computed tomography of the head showed an acute hemorrhage in the left lateral ventricle prompting concerns for traumatic brain injury. no additional pathology was noted on a follow-up magnetic resonance imaging. repeat ct scan showed mild interval decreases in the size of her ventricular hematoma. the patient was discharged one week after admission and had developed no neurologic complications. she was diagnosed with concussion and isolated intraventricular hemorrhage. isolated intraventricular hemorrhage is a rare complication of traumatic head injury that can have a good prognosis and outcome. the case shows the difficulty in categorizing this particular condition within the current spectrum of traumatic brain injury and specifically highlights shortcomings with classification systems that utilize neuro-imaging abnormalities to determine severity of injury. traumatic intracranial aneurysms (tias) are distinctly uncommon, comprising fewer than 1% of all cerebral aneurysms. tias that develop following blunt head injuries present the clinician with both diagnostic challenges and clinical difficulties. the natural histories of giant intracranial aneurysms are generally grave owing to mass effects, severe hemorrhage, and distal thromboembolism. case report. we present the case of a 68-year-old male was involved in an accident in which he suffered severe head injury from a falling heavy iron hammer. the immediately unenhanced head computerized tomography showed hemorrhagic contusions, subarachnoid hemorrhage, skull fracture and basal fracture. he had been in a deep coma ever since. the computed tomographic angiography (cta) revealed a giant aneurysm of right internal carotid artery about one month after the blunt head injury. the aneurysm was measured 6.5cm at its maximal diameter on image. of note, the patient failed to improve the following day and died on the fiftieth hospital day. giant tias are very rare but fatal complications of blunt head injury probably related to effects of vessel wall trauma and possibly a combination of neurological deterioration. in our case, the involved mechanism was suspected to be related to skull base fractures or resulted from stretching of the artery across the process during the impact. cta has a high sensitivity of about 97.2% and a high specificity of about 97.9% for diagnosing cerebral aneurysms (including traumatic aneurysms). apart from this, cta permits 3-dimensional visualization of aneurysms and assesses surrounding intracranial structures that are not visible on dsa. therefore, although 2-dimensional digital subtraction arteriography is currently the diagnostic gold standard in cerebral aneurysmal disease, fast and noninvasive cta may be preferred in the acute setting of tias. julio cabrera 1 , corina puppo major burnt patients require large volumes of fluid replacement due to a generalized increase in permeability and edema caused by cytokines. fifty percent of the administered fluids produce edema in "preserved" tissues. multiple organ edema follows fluid replacement. escharotomy is frequently performed to decompress limbs and thorax, but not neck. our objective was to describe and diagnose neck-head compartment syndrome in patients with neck circumferential burns and/or neck edema by 1) suspectng it and 2) confirming diagnosis with the help of transcranial doppler (tcd) ultrasonography, searching for a high resistance pattern in cerebral blood flow velocity at basal cerebral arteries. tcd examination was performed before and after escharectomy in two both patients presented a neck-head compartment syndrome, evidenced by the cerebral hemodynamic repercussion of neck compression: hypoperfusion with an increased resistance pattern in dtc. p1: secondary compartment syndrome due to massive fluid replacement; without circumferential burn. p2: compartment syndrome in circumferential neck burn. tcd confirmed the clinical suspicion of cerebral hypoperfusion, guiding the decision to perform surgical decompression to treat it, and helped to assess the results of the decompressive surgery. introduction 23.4% hypertonic saline is used for the treatment of increased intracranial pressure (icp) and in the prevention and reversal of brain herniation syndromes. the use of hypertonic saline in the management of combat related penetrating and severe traumatic brain injury is described. 23.4 % hypertonic saline effectively managed icp with decreased risk of hypovolemia and secondary hypotension compared with mannitol. 23.4% hypertonic saline also preserved cerebral blood flow, decreasing the risk for secondary cerebral ischemia in acute neurotrauma patients, where hyperventilation is contraindicated. the nato hospital, kandahar afghanistan treated eleven (11) patients with twenty-seven (27) doses of 23.4% saline from 3-march 2012 to 25-april 2012. hypertonic saline was used to treat acute elevation in icp, as well as to maintain an elevated serum sodium concentration during periods of cerebral edema. all patients were treated with initial conservative icp management. external ventricular drains were placed and drainage of 5-10cc of csf was performed in an attempt to maintain icp before using hypertonic saline. patients with life-threatening clinical signs of elevated icp secondary to brain edema or acute neurologic deterioration were potential candidates for 23.4% hypertonic saline therapy. 30-60ml of 23.4% sodium chloride was administered via a central line infusion. 23.4% hypertonic saline was successful in acutely reducing icp. a 30ml bolus of 23.4% saline predictably increased the serum sodium levels allowing reliable titration and maintenance of serum sodium levels and efficient management of the patient's volume status (30cc of 23.4% = 250cc of 3%). penetrating and severe closed head injuries have the potential to lead to neurologic emergency as a result of brain edema associated with primary tbi or following neurosurgical intervention. in a combat tbi population, 23.4% hypertonic saline demonstrates a clinical benefit over alternative treatments by decreasing the risk of secondary cerebral injury during the management of elevated icp and was well tolerated. unintentional death was the ninth leading cause of death among elderly patients. given their comorbidity profile, many of them are also on antiplatelets or anticaogulants. we sought to characterize the burden of "pro-bleeding" medications such as antiplatelets and anticoagulants in the population aged over 55 who sustain a head injury. this observational cohort study was conducted at a level one trauma center that has a 12 county catchment area serving over 1 million. the trauma acuity is high, with over 50% of our patients haveing iss scores over 15. the age cutoff of 55 for "elderly" is based on our trauma alert activation criteria. thirty-nine percent of the cohort was on at least one type of anticoagulant or antiplatelet, as follows: warfarin 8%, aspirin 21%, clopidogrel 10%, asa+dipyridamole 1%, heparin/lmwh 3%.a third of the cohort required icu admission. icu length of stay ranged from 1-37days. patient in particular, on warfarin had a significantly longer icu length of stay (p=0.05) when adjusted for inr level. the median inr for the whole cohort was 1.0 with an iqr of 1.0 to 1.20. the median inr amongst those on warfarin was 2.3 with an iqr of 1.7 to 2.6. patients on an antiplatelet or anticoagulant agent were significantly more likely to have an abnormal head ct (p=0.05). 11% of the patients who were on warfarin needed some sort of anti-coagulant reversal to minimize bleed. patients on warfarin were more likely to undergo neurosurgical intervention (p<0.0001) when compared to cohort not on warfarin. antiplatelet and anticoagulant drugs can confer additional morbidity to persons who sustain a tbi. it may be important to recognize this early, and prepare for higher level care needs. introduction therapeutic hypothermia (th) is know to cause immune suppression. determining the degree of immune suppression at the bedside is often difficult or impossible. immune cell function (icf) measures the concentration of atp from circulating cd4 cells following in vitro stimulation with phytohemagglutinin (pha) as an indicator of immune cell function. icf is often used in solid organ transplant programs to modulate the immunosuppressive treatment. we propose the use of ifc to determine the degree of immune depression in the patient treated with th. immune cell function, cylex inc, columbia, md was obtained in three populations of patients: group 1: patients treated with th, ifc obtained while at target temperate, 33 degrees c group 2: patiients that were admitted to the care of the neurocritical care team, requiring icu care. group 3: patient from sanford renal transplant program with stable immunosuppressive therapy. the average icf of group 1 were 195, of group 2, 316 and of group 3, 197. patient being treated with th have a profoundly depressed icf. the level of immunosuppression is equal to if not greater that those with solid organ transplants. according to the cylex data a level of less than 225 represents an immune suppressed state. this does not appear to be a phenomenon of the critically brain injured patient since those without th had a normal icf while further studies are in process, this data has effected out practice. we now treat patients on th as immunosuppressed patients. very early prediction of neurological outcome after cardiac arrest (ca) remains challenging. several single center studies have suggested that bispectral index (bis) can predict outcome for patients treated with therapeutic hypothermia (th). we evaluated the ability of bis to predict outcome in a multicenter study. 3 medical centers prospectively enrolled comatose ca patients treated with th. outcome was defined as good (go) if cerebral performance category (cpc) score was 1-2, and poor (po) if cpc 3-5 at hospital discharge (hd) and at 6 months (6m). bis data was assessed blind to outcome for initial value after first dose of neuromuscular blockade (nmb -bisi) and at 6 hours post-rosc (bis6). 256 patients were enrolled with a mean age of 60 (sd 16) years, 70% were male, 68% witnessed, initial rhythm was vt/vf in 48%, pea in 26%, asystole in 23%, and time to rosc was 24.7 (16) minutes. at hd, 71 (28%) had go with similar age as po but shorter median time to rosc at 15 (iqr 10-24) mins vs 25 (14-34, p=0.003). go patients also had more vt/vf as initial rhythm and witnessed ca (p<0.001), and more males (p=0.01). on roc curve comparisons, both bisi (auc 0.80) and bis6 (auc 0.80) performed better than time to rosc (auc 0.65) or age (auc 0.50) -p<0.002 for all comparisons. among ca-th treated patients, this is the first multicenter trial to confirm that bispectral index values after first dose of nmb and at 6 hours post-rosc predicted outcome better than time to rosc, rhythm, or age. bis appears promising as a tool to predict outcome very early after ca, and may be helpful during clinical trials to stratify the severity of brain injury sustained during ca. hypotension negates the cerebral protective effect of therapeutic hypothermia (th). myocardial depression, "cold-induced diuresis," and hypokalemia can lead to refractory hypotension during the maintenance phase of th. intravascular volume replenishment and inotropic infusion are effective but cause wide swings in heart rate, blood pressure, cardiac output and acid-base status. we propose the use of vasopressin as a physiologically appropriate agent to correct hypothermiainduced hypotension. hypothesis: in swine, the investigators tested the hypothesis that an infusion of vasopressin would restore blood pressure to normal levels during th. six domestic cross-bred pigs (34-35 kg) were subjected to a 5 atm fluid percussion injury to the brain followed by systemic hypothermia (32°c) for 48 hours. the animals were turned side to side and to sternal recumbency every six hours. during phase i (first 24 hours), the blood pressures were maintained in the normal range with intermittent doses of epinephrine and fluid boluses. during phase ii (second 24 hours), continuous vasopressin infusion (0.04 ug/min) was added to maintain blood pressure. the number of episodes of hypotension (map <55 mm hg), the volume of fluids (liters), and the total dose of epinephrine (mg) used during both phases were compared using student's paired t-test (p>0.05). in all animals, the infusion of vasopressin effectively mitigated the occurrence of hypothermia-induced hypotension. the episodes of hypotension (8.3±2.1 v 4.0±1.7), the total volume of fluids (15.3±2.1 v 10.6±2.3), and the total dose of epinephrine (2.6±1.1 v 0.6±0.3) administered were significantly reduced during phase ii. in order to maximize the benefits of th, hypotension must be avoided. animal studies show that despite hypothermia, hypotension causes cerebral cortical tissue depletion of atp and phosphocreatine and an increase of lactate and nadh levels. the infusion of a low dose of vasopressin reverses these anomalies and effectively mitigates hypotension. hypotension, hyperoxia, and hypoxia early after the return of spontaneous circulation (rosc) are each associated with increased mortality, while early hypertension is associated with good outcome. we assessed these variables and their relationship to outcome in cardiac arrest (ca) survivors treated with therapeutic hypothermia (th). with irb approval, we reviewed prospective and retrospectively collected data in a single-center database of patients undergoing th after ca. demographics and clinical factors were compared among patients with cpc 1-2 (good outcome) and cpc 3-5 (poor outcome) in a bivariate model. various definitions of hypotension, hypertension, hypoxia, and hyperoxia were evaluated. we constructed logistic regression models including potential confounders and the variables of interest. among 265 patients, age, vt/vf rhythm, shorter time to rosc, witnessed arrest, bystander cpr, and stemi on initial ecg were each strongly associated with good neurological outcome, as were a lower peak neuron-specific enolase level and higher bispectral index (bis) score after neuromuscular blockade. hyperoxia (pao 2 > 300mmhg) was common (present in 45.5 with good and 35.9 with poor outcomes, respectively) as were hypoxia (pao 2 <60mmhg) and hypotension. none of these factors was a predictor of outcome. logistic regression models intended to adjust for the potential confounding influences of age, time to rosc, heart rhythm, witnessed arrest, and bystander cpr, also did not identify a relationship between the variables of interest and outcome. our data did not confirm the previously described relationship between post-resuscitation factors and outcome. this may reflect an inadequate sample size, but it is also possible that post-resuscitation hemodynamic and biochemical factors are minimally important to outcome, compared to the duration and type of the arrest. further investigation in larger data sets is warranted. determining the presence of an infectious process during therapeutic hypothermia (th) can be difficult. in addition, differentiating central vs systemic fever is difficult in the brain injured patient. procalcitonin (pct) was been used to guide the use of antibiotics in sepsis and pneumonia in patients that are critically ill. we propose the use of pct to predict the presence of a systemic infection in patients during th. all patients treated with th had pct measured at the start of th. all patients were cooled with the medivance arctic sun 2000. when the water temperature was <10 degree c, pct and two sets of blood cultures (bc) were drawn. sputum cultures (sc) were obtained if there was a change in sputum or during bronchoscopy. antibiotic use was determined by the neuro-intensivist results 14 patients were evaluated; 2 ich, 7 tbi, 1 cva and 4 cardiac arrest (ca). a total of 49 pcts were obtained. one patient (7%) had positive bc, pct of 2.48; 8 patients (57%) had positive sc. remaining 5 patients had negative bc and sc. all 4 ca patients had increased pct > 1.49 (normal <0.08) of which 3 (75%) had positive sc and none had positive bc. of the remaining 9 without positive bc (64%), 5 (55%) had positive sc, all had pct <0.39. of the 4 (44%) patients without positive sc, all had pct <0.25 pct is a reliable method to exclude an infectious process in patients being treated with th that have not had a ca. while further studies are warranted, a pct <0.25 appear to exclude both pulmonary and blood infections, while a pct <0.39 appears to exclude a blood stream infection. from this data, pct is not a good marker for infection in the ca patient. therapeutic hypothermia (th) has become widely accepted practice for neuroprotection and improved mortality in comatose survivors of out of hospital v-fib cardiac arrest. evaluation for appropriateness of th is now part of acls algorithm. its use in non-shockable rhythms such as pea and asystolic arrest is less well established. we present our center's experience with th after cardiac arrest and review the clinical and electrophysiological parameters that may impact prognosis. this is retrospective review of medical charts including patients undergoing th after cardiac arrest at a single center from 2010 through the first quarter of 2012. demographic and clinical data were collected. continuous eeg results were reviewed by two independent epileptologists who were blinded to the outcome of the patients. eegs were graded based on the synek scale for grading severity of eegs. patient's neurologic outcome will be assessed by grading cerebral performance category (cpc) score at the time of discharge. multivariate regression analysis will be performed on the data to identify parameters that would affect prognosis in cardiac arrest after cooling. fifty-eight patients were identified from our database. the overall rate of survival to discharge was 45%. the survival rate for v-fib arrest was 80% whereas the survival rates for asystolic arrest and pea arrest were 50% and 33%, respectively. results from the multivariate analysis will be forthcoming. our results affirm the predominant view that th indeed improves outcomes after cardiac arrest. in particular with ventricular fibrillation and pulseless ventricular tachycardia arrest, we have seen very encouraging results. patients with pea/asystolic arrest fared worse but outcomes are still improved compared to historical control. since 2002, mild therapeutic hypothermia (mth) has been the standard of care when spontaneous circulation returns after a witnessed, out-of-hospital ventricular fibrillation arrest[1]. at our institution, we have initiated mth for approximately fifty patients since february 2010. a knowledge, attitude, and practices survey was conducted querying neurology residents and attendings, emergency medicine (em) residents and attendings, and internal medicine (im) residents. our aim was to identify areas of weakness so that we could strengthen the overall awareness of the utility and benefit of mth. the survey consisted of nineteen multiple choice questions, ranging from asking how many times the participant had initiated mth; to parameters for the protocol; to how it impacts survival. the surveys were completed by: ten neurology residents and five neurology attendings; twelve em residents and two em attendings; and twenty im residents. all of the neurology residents and em physicians surveyed had been the primary provider for a post-arrest patient who underwent mth. the neurology residents unanimously agreed that mth after resuscitation from a shockable rhythm is standard of care, however only 86% of em physicians and 63% of im residents agreed. 38% of em physicians and 15% of im physicians answered that mth may be initiated in cases presenting after either a shockable or a non-shockable rhythm. 60% of the participants acknowledged that ventricular fibrillation portends the most favorable outcome. nearly 80% of participants agreed that ideal rosc is less than thirty minutes. three-quarters of physicians indicated the goal temperature as 32-35°c; however, half of the neurology residents and 33% of neurology attendings answered this incorrectly. in conclusion, this survey has revealed a general understanding of mth, however, each specialty has its deficiencies. we can now educate each subset of physicians in a problem-focused manner. early quantitative assessment of non-contrast brain computed tomography (ct) using specialized software correlates with outcomes of cardiac arrest survivors. 1 the proposed algorithm compared hounsfield units (hu) in the putamen (pu) to the posterior limb of the internal capsule (plic), but the work has not been validated in patients treated with therapeutic hypothermia (th) or using standard software and equipment. we included ca survivors treated with th who underwent ct in the first 72h after resuscitation (rosc). hu were averaged bilaterally at two levels in the pu and plic, and the pu/plic ratio calculated by a board-certified radiologist using a ge lightspeed vct 64 slice scanner and agfa pacs system. receiver-operator characteristic (roc) curves were constructed, evaluating pu or pu/plic to predict poor outcome (cpc 3-5) at hospital discharge (hd) and 6 months (6m). 84 patients had median age 58 years, 66% male, 81% out-of-hospital ca, 68% witnessed, 41% vt/vf, 32% pea, and 26% asystole. median (iqr) time to rosc was 17 (10-28) minutes. 59/84 (70%) patients had po. when stratified by outcome, ct performed 2.4 (1.2-10) hrs after rosc showed similar hu measurements for plic (26.3 po vs 26.7 go, p=0.6) but lower hu in pu (32.7 vs 34.1, p=0.01) and pu/plic (1.24 vs 1.27, p=0.02). hu values for pu and pu/plic both predicted outcome: roc area under the curve (auc) for pu = 0.68 (95%ci 0.55-0.80) and pu/plic = 0.66 (0.54-0.79). among 78 patients with 6m outcome data, pu predicted outcome (32.7 po vs 34.0 go, p=0.035) with auc =0.66 (0.53-0.80), but pu/plic did not. early after ca, hounsfield unit measurements in the putamen, and the pu/plic ratio were lower among patients with poor outcome, but the magnitude of the differences was small, and clinical utility uncertain. additional study is warranted. global cerebral edema following aneurysmal subarachnoid hemorrhage (asah) is associated with 50% in-hospital mortality. therapeutic hypothermia (th) is recommended for reduction of intracranial pressure (icp) based on class i evidence; however safety in prolonged states remains poorly studied. we retrospectively reviewed all cases of refractory icp elevation at the mayo clinic florida neurointensive care unit (nicu) from 2008-2012 who received adjunct th for more than 48 hours. primary safety endpoints were qtc prolongation, development of bacteremia, and coagulopathy. additional outcomes included in-hospital mortality, hospital/nicu length of stay, and functional status at 6 months. 17 patients with asah and/or intracerebral hemorrhage underwent adjunct th. median age was 44; 8 were male. on admission, median apache2 was 16, and wfns was higher than 3 in 14, all being modified fisher 3-4. 10 required barbiturates in addition to sedation, paralysis and hyperosmolar therapy. th was initiated on a median of hospital day 2 and continued for a median of 7 days (minimum=4, maximum=23). mean icp over 24 hours prior to th was 15.6mmhg(sd=3.8; range 10.6-24.2), decreasing to 11.1mmhg(sd=3.9, range 6.1-21.1) over the first 24 hours of th. 16 patients had external ventricular drains placed and 10 required decompressive craniectomy on average day 6 hospital stay (range 0-13). safety data showed torsades-de-pointes in 1, mean qtc prolongation of 59 with mean lengthening of aptt by 2.7. 4 patients had bacteremia on admission with new infections (urine, sputum, blood) documented in 6 during th. overall, 11 (65%) survived to discharge. median nicu/hospital length of stay was 27/32. average modified rankin score at follow up was 3.4. hypothermia greater than 48 hours as an adjunct to standard icp reducing therapies appears feasible in patients with refractory intracranial hypertension. however, definitive safety of prolonged th would require direct comparison with similar cohort. refractory raised intracranial pressure (ricp) secondary to intracerebral hemorrhage (ich) and severe subarachnoid hemorrhage (sah) is a life threatening condition. treatment for ricp typically induces hypothermia (th) and decompressive hemicraniectomy (hct). however, direct comparison of the efficacy of these two therapies is lacking. data from this study may help determine the sequence of therapies that might improve outcomes in this patient population. in the present study using retrospective design, we tested the hypothesis that for patients with ricp, th is as effective in reducing icp as hct, using functional outcome at discharge as defined by modified rankin scale (mrs) as the primary outcome. we retrospectively reviewed all adult patients admitted to the neurointensive care unit from 2009 to 2012 with sah and ich with resultant elevated icp, who survived the first 24 hours after admission. exclusion criteria included: pupillary anisocoria, limitation of care within 24 hours of admission; or hemicraniectomy or craniotomy with clot evacuation prior to icp monitoring were excluded. initial review included 11 patients (th=4 and hct=7). based on univariate analysis, admitting gcs score was higher with hct (5 vs 8, p=0.13), but other baseline demographic and clinical characteristics were similar. th group had longer icu los (19 vs 9), los ventilation (19 vs 9), and higher cost. however, discharge mrs (5 vs 5,p=0.46) was similar. our initial analysis indicates longer icu care and overall cost with th, but similar functional outcomes at discharge. subsequent analysis will include inclusion of additional patients, icp comparison and adjustment for baseline characteristics. malignant middle cerebral artery(mca) infarction is devastating ischemic stroke, which the mortality rate is up to 80%. therapeutic hypothermia is one of the most promising neuro-protective therapies. successful result of hypothermia for cardiac arrest renewed interest in therapeutic hypothermia for stroke. the purpose of this study was to assess whether therapeutic hypothermia can reduce the cerebral edema and can improve the functional outcome in patients with malignant mca infarction. we reviewed retrospectively patients with malignant mca infarction presented within 24 hours of symptom onset in a single center hypothermia registry. after informed consent, patients who had refused decompressive hemicraniectomy were treated with therapeutic hypothermia and monitored in the neurocritical care unit for complications. a modified rankin scale(mrs) and national institutes of health stroke scale(nihss) were obtained at 3 months after symptom onset. eleven patients with a mean age of 70±8 years and an nihss score of 18.5±4.3 were treated with therapeutic hypothermia(33±1 ). seven of eleven patients were mca infarction, and four was ica t-occlusion. the mean time from symptom onset to initiation of hypothermia was 33.0±21.5 hours and the total duration of hypothermia was 103.1±66.6 hours. noncritical complications included shivering(n=11), bradycardia(n=7), hypertension(n=7), pneumonia(n=6), and arrhythmia(n=5). electrolyte imbalances were common during the hypothermia (hypernatremia;n=4, hypokalemia;n=9, hypophosphatemia;n=11). mortality rates was 18%(n=2) and the mean nihss at discharge was 19.2±13.5. the mean mrs at 3 months was 4.5±1.4 in all patients and 4.2±1.4 in survivals. this result shows that therapeutic hypothermia can prevent the progression of cerebral edema and improve functional outcome in acute malignant mca infarctions and ica t-occlusion. long duration hypothermia more than 3 days appears feasible and safe in these patients. therapeutic hypothermia may be a good alternative therapeutic option to early decompressive hemicraniectomy. large clinical trials are needed whether hypothermia will be a best treatment to improve functional outcome. therapeutic hypothermia (th) is know to cause immune suppression. determining the degree of immune suppression at the bedside is often difficult or impossible. immune cell function (icf) measures the concentration of atp from circulating cd4 cells following in vitro stimulation with phytohemagglutinin (pha) as an indicator of immune cell function. icf is often used in solid organ transplant programs to modulate the immunosuppressive treatment. we propose the use of ifc to determine the degree of immune depression in the patient treated with th. immune cell function, cylex inc, columbia, md was obtained in three populations of patients: group 1: patients treated with th, ifc obtained while at target temperate, 33 degrees c group 2: patiients that were admitted to the care of the neurocritical care team, requiring icu care. group 3: patient from sanford renal transplant program with stable immunosuppressive therapy. group 1, 13 patients, average icf: 195 group 2: 12 patients, average icf: 316 group 3: 22 patients, average icf, 197. patient being treated with th have a profoundly depressed icf. the level of immunosuppression is equal to if not greater that those with solid organ transplants. according to the cylex data a level of less than 225 represents an immune suppressed state. this does not appear to be a phenomenon of the critically brain injured patient since those without th had a normal icf while further studies are in process, this data has effected out practice. we now treat patients on th as immunosuppressed patients. therapeutic hypothermia (th) has become a first-line therapeutic modality in patients suffering from traumatic brain injury and cardiac arrest. shivering induced by th reduces the ability of the cooling device to achieve target temperature. this can lead to increased intracranial pressure (icp) and increased metabolic demand. the bedside shiver assessment score (bsas) has been validated in identifying and grading shivering. however, the bsas cannot identify microshivering which is visually undetectable shivering that is thought to have the same detrimental physiologic consequences as shivering. continuous 21 channel eeg (ceeg) can detect microshivering but is labor intensive, requires specialized training to interpret results and is expensive. we propose that the philips eeg with compression spectral array 2 lead (philips 2) can be utilized to detect microshivering as effectively as ceeg but is more cost effective. the philips 2 was placed by the bedside nurse. the lead placement varied depending on underlying injuries. patients were assessed utilizing the bsas and the philips 2. if high frequency activity increased on the philips 2, the patients were assessed using the bsas. if the bsas was 0 then 5-10mg of vecuronium was given to intubated, sedated patients. both patient temperature and water temperature were recorded. two patients with tbi were evaluated. the water temperature decreased and the patient's temperature increased during the periods of high frequency activity on the philips 2. after vecuronium, the high frequency activity ceased, water temperature increased and core temperature returned to the previously set level. the philips 2 is a relatively low cost device when compared to ceeg that can be applied and monitored by the nursing staff to detect microshivering. additionally, we were able to validate that control of microshivering improved the th device's ability to achieve and maintain the patient's temperature goal. therapeutic hypothermia is widely accepted as a standard of practice for out of hospital cardiac arrest (ohhca). however, its implementation is still highly variable in different hospital settings. most of the current data comes from centers of excellence. we wanted to evaluate performance of implementation of "hypothermia protocol" (hp) including its complications and outcomes in our large referral community based hospital. we conducted retrospective chart review of 30 patients who underwent hp from 2008-2011. data collected included demographics, time of cardiac arrest, time of arrival to er and time to induction of hp, methods used for induction, complications and outcomes. out of the 30 patients, 16 patients (53%) had pulse less electrical activity (pea), 13 (43.3%) patients had ventricular tachycardia/fibrillation, and 1 (3.33%) had complete heart block as the initial rhythm. average time to arrive to er was 30 minutes. almost 60% of patients had ht induction in ed, 35% (%) in icu and 6.66% outside of the hospital. average time to initiate ht from the initial event was 1hour and 56 minutes. average time to achieve the target temperature from the initial event was 2 hours. inner cool was the most common modality used in 46.6 (%). lactic acidosis (19.7%) was the most common complication encountered, followed by hypotension (12%), coagulopathy (12%) and seizure (12%) trend of improved outcomes with less renal failure, coagulopathy, seizure was observed with shorter induction times. time to achieve target temperature had no effect. initial rhythm, age and gender also had no impact on the outcome. shorter induction time appears to decrease complications and improve outcomes. using multiple cooling modalities also appeared to have better outcomes. however larger studies are needed to confirm this observation. earlier induction of mild therapeutic hypothermia improves survival and neurological outcome and decreases incidence of some of the complications. introduction secondary brain injury after aneurysmal subarachnoid hemorrhage (asah) is a major cause of mortality. mild hypothermia (32-33 0 c) may protect against cerebral ischemia and edema in asah patients. the aim of this study is to describe the use of ct perfusion (ctp) characteristics to initiate re-warming in patients with secondary brain injury after asah. we performed a retrospective review of all patients admitted to a large comprehensive stroke center between 2000 and 2012 with asah who were treated with hypothermia and received ctp imaging. mild hypothermia (32-33 0 c) was started because of severe vasospasm, increased intracranial pressure or cerebral edema. baseline characteristics, including clinical severity grading by hunt hess (hh) and fisher scales, were collected. clinical outcomes were measured by discharge modified rankin score (mrs) and disposition. ctp was performed with a 64-slice scanner. twenty patients fulfilled inclusion criteria. in 18/20 (90%) patients, re-warming was based on favorable ctp characteristics and in 2/18 (10%) based on favorable tcd findings. the mean duration of hypothermia was 10.5 days. five patients were re-warmed due to normal ctp, despite tcd findings suggesting moderate to severe vasospasm. 15 patients, re-warming was initiated given improving tcd findings and despite less favorable ctp data (most showing "matched" abnormalities of decreased cbv, cbf and increased mtt). clinical outcomes were worse in this group; mrs better outcome was seen in all patients in whom re-warming was initiated based on normal ctp. in these patients, there was a discrepancy between ctp and tcd data. poor outcome was associated with abnormal ctp regardless of tcd findings. ctp may be a useful tool to guide treatment of asah patients receiving hypothermia. diagnosis of pediatric brain death (pbd) continues to be a significant challenge. new guidelines for pbd diagnosis were published in pediatrics in 2011. we recently conducted a mailed survey to assess current understanding of these new guidelines and general perspectives about pbd among a convenience sample of midwest usa physicians. we developed a 23 item survey. items included 6 demographic questions, 1 question about familiarity with the guidelines, and 16 questions concerning perceived discrepancies and other attitudes toward the guidelines. we mailed our survey to 319 physicians at 10 university hospitals: 102 pediatric intensivists, 143 neonatologists, 13 adult neurointensivists, and 61 pediatric neurologists, three weeks after the initial mailing, we followed up with a reminder by mail and/or phone. we performed fisher's exact test to assess statistical significance of responses among different specialties. after 10 weeks, we had a 17% response rate. respondents included 8 pediatric neurologists, 2 neurointensivists, 26 pediatric intensivists, and 20 neonatologists. twenty percent of respondents were unfamiliar with the new pbd guidelines (neonatologists were least familiar). twenty-three percent stated they were 'not comfortable' making a pbd diagnosis and 85% deemed it was either preferable or essential to obtain a neurointensivist or pediatric neurology consultation for pbd assessment. there was general agreement that the current intervals for the required 2 exams were appropriate in children (delineated by age). interestingly, 66% allowed patients to remain ventilated for a significant period of time after pbd declaration. we found that a significant number of pediatric physicians are not familiar of the new pbd guidelines and there remains some variability in the assessment of these patients. pediatric neurologists or neurointensivists are still considered an important part of the process of pbd determination. the mid-position fixed pupil (mpfp) is an imperfect reference to the mid-size pupil that occurs with the complete loss of neural influence from devastating midbrain injury (primary or secondary) and death (brain and cardiopulmonary). for this reason, proper recognition and interpretation of the mpfp is critical to the neurological localization/diagnostic process and a vital element to the clinical verification of brain death. while the description of the size range of the mpfp has been dogmatically passed down from numerous classical texts (4-7 mm) for decades, it has not been accurately quantified. modern pupillometry offers accurate quantification of pupil size. using a portable infrared pupillometer (forsite, neurooptics inc., irvine, ca), within 24 hours after death, we evaluated the pupil size of dead patients who did not have any previous eye surgery, known eye disease, or use of eye medications. 50 pupils were evaluated in 25 dead patients (mean age 66) an average of 13 hours after death. the pupil size range was 2.26 -5.46 mm, with a median size of 4.21mm (sd of 1.8mm). 30/50 pupils (60%) were <4 mm and none were > 5.5 mm. 8/25 patients (32 %) had a side-to-side difference of at least 0.5 mm. thankfully none were reactive! the mpfp is generally smaller than classically described and 95% fall between 2.31 and 6 mm. 60% of mpfp's are less than 4mm. we never found any mpfp's more than 5.5 mm. subtle but frequent side-to-side asymmetry (> 0.5 mm) existed in approximately 30% of the dead patients. with our continued work we can finally achieve a more quantitative description of the important finding of the mpfp so that it can be incorporated into our definitive texts, enveloped into our understanding, and applied to our clinical practice. brain death diagnosis is clinical in uruguay. it is defined as the irreversible loss of brain stem functions. ancillary tests are needed as confirmatory tests in selected cases: 1) impossibility or contraindication to perform clinical testing (barbiturates, facial trauma, etc.); 2) non demonstrable structural lesion; 3) unknown coma etiology; 4) difficulties to wait for a second clinical test. the most used confirmatory test is transcranial doppler (tcd) ultrasonography. objectives: to study 1) the clinical characteristics of patients in whom brain death could not be diagnosed clinically; 2) tcd ultrasonographic patterns; 3) number of cases in which tcd aided in management. epidemiologic and observational study. patients included: those in who brain death was suspected but the clinical examination of brain stem reflexes and/or apnea test could not be performed for different reasons. period: from 2000 to 2010. the variables studied were demographic and clinical characteristics, tcd sonographic patterns. cerebral circulatory arrest was diagnosed when the patterns found were systolic spikes, reverberating flow, and no-flow (if a previous study had demonstrated ultrasound permeability of skull windows) in bilateral anterior sectors and posterior sector. continuous flow or systolic peaks were negative for the diagnosis of cca. 445 patients in who the clinical diagnosis of brain death was not possible or needed to be confirmed. 75% adults. 62% were men, with an average of 38 y.o. in adults, and 5 y.o.in children; structural etiology 85%. etiology: traumatic 45%; vascular 30%; anoxic-ischemic 15%, infectious 6%, toxic-metabolic 1%, other 3%. cca was confirmed in 75%, systolic spikes in 84%. cca was discarded in 20%. in this group the study was repeated in 9%, confirming cca in 75%. it was not concluding in 5%. dtc helped in the decision to how to continue the management of the patient in 95% of the cases, diagnosing cca in 81%. there is an awkward physician and cross-institutional variability in the approach to brain death (bd) diagnosis and all of its ramifications; physiological, logistical, and psychosocial. physician variability is related, in part, to a basic knowledge deficit and inexperience. however, public confidence in the reality of bd relies on consistent and accurate diagnosis and the physician's facility with the management of its implications. our full-day (8 hour) brain death simulation workshop (bdsw) was designed to enhance confidence with bd diagnosis and management. it included a didactic lecture and seven learning stations: case study analysis (recognizing brain death mimics), a high fidelity mannequin simulation (bd examination including cold water calorics and apnea testing, hemodynamic management, and diabetes insipidus management), family discussions with professional actors trained to provide feedback, and four relevant content stations. each participant was observed by a neurocritical care expert, each receiving one-on-one and group feedback. 23 physicians participants from 3 continents participated in the bdsw with 12 expert faculty. all participants felt much more confident with brain death diagnosis and management. at least 60% were humbled by the station on "discussion of brain death with families", recognizing their need to practice communicating about brain death effectively. 90% felt better equipped to contemporize their local policies and advocate for enhanced uniformity of practice. our bdsw provides a model comprehensive training experience that had a favorable impact on trainee confidence and their interest and capacity to advocate for better uniformity and training of peers. 2. the bdsw can be part of a future tiered approach to credentialing experts in this important clinical area. 3. we are conducting the 2 nd bdsw on november 12, 2012 with improvements based on the 1 st workshop. neurocritical care experts must embrace the primary responsibility for preserving the integrity of bd diagnosis and educating our colleagues. the use of carbogen in apnea testing to declare brain death may facilitate achieving the prerequisite pco2 needed to confirm apnea testing by establishing a target end point that is typically reached faster and has been shown to limit adverse effects. as the use of extracorporeal membrane oxygenation (ecmo) in adults increases, so does the need to perform apnea testing while on ecmo. however, traditional apnea testing on critically ill patients is compounded by lung derecruitment and hemodynamic instability rendering an aborted apnea test or worse, cardiac arrest and death. the literature on apnea testing of patients on venous-arterial (va)-ecmo is minimal. per hospital protocol, a carbogen mixture (97% oxygen and 3% carbon dioxide) was delivered through the ventilator for an apnea test on a 25 year old female on va-ecmo. the ventilator's mandatory rate was set at 2 breaths/minute to adequately deliver the carbogen mixture through the artificial airway. a carbogen formula was used to calculate a target end-point of an etco2 of 70 mmhg for a positive apnea test. an abg was drawn prior to the apnea test and again once the target etco2 was achieved. pre-apnea abg: 7.40/36/322/98%. the etco2 goal was reached within 8 minutes and the post-apnea abg was drawn: 7.22/61/86/93%. the patient remained hemodynamically stable throughout the apnea test which was confirmed as a positive apnea test. the use of carbogen in apnea testing on a patient receiving va-ecmo demonstrates the possibility of performing a successful apnea test for declaration of brain death. although more investigation is needed, this case demonstrates the ability to perform apnea testing on critically ill and unstable patients while maintaining hemodynamic stability which preserves the option for organ donation. drowning victims have historically been eliminated from consideration for lung donation as aspiration may cause direct pulmonary toxicity, often confounded by significant neurogenic pulmonary edema. a significant minority of these patients (10-15%), aspirate only minimal amounts of water into their lungs, protected by severe-persisting laryngospasm (dry drowning), but progress to brain death due to significant anoxic injury. historically, even with limited evidence of aspiration,transplant centers do not consider evaluating drowning victims as lung donors. however, as the division between the number of eligible recipients and available donor organs continues to grow, criteria for acceptable donor organs are expanding. once an absolute contraindication for lung donation, this practice has persisted on a per case basis but is reported infrequently with somewhat mixed results. we analyzed the unos registry of donors for lung and heart-lung transplant from january 1, 1991 to december 31, 2011 (n=53), and then examined survival outcomes from lung transplant recipients from donors who suffered drowning between 2001 to 2011 recipients (n = 39) to outcomes previously reported from lung transplant recipients during that period. for recipients of lungs from donors with drowning as cause of death, unadjusted survival at one drowning victims, even when initially resuscitated, often suffer significant anoxic injury and death by neurologic criteria. while the management of drowning victims as organ donors may present additional challenges, with proper donor selection, the use of lungs recovered from carefully screened donors after drowning appears to be a safe option for the expansion of the donor pool. racial disparity in health care utilization and outcomes is an area of substantial concern. a study performed in the 1990's in our neuro-icu found that nonwhites were half as likely to withdraw life-sustaining therapy (wlst). this may be explained by differences in socioeconomic status (ses), cultural preference, lack of end-of-life planning, or trust in the health-care system. to better understand the basis and evolution of this disparity, we analyzed it over two more recent epochs (determining whether it has improved over time), while specifically accounting for ses. we extracted data from a prospective neuro-icu database on all ventilated patients with gcs of 8 or less between 2002 and 2009. we analyzed how the rate of wlst was affected by age, race, gender, insurance and socioeconomic status (quintiles based on median household income of residence zip code), marital status, receipt of surgical/icu interventions, gcs and apache ii. we then compared ses-adjusted disparity for wlst (non-whites vs. whites) in 2002-2004 with 2007-2009 . non-whites accounted for 715 of 2062 patients (36%) and were younger, less likely to be married (29% vs. 54%), insured (28% vs. 37%), and reside in upper-income zip codes (all p<0.001). rate of wlst was lower in non-whites (21% vs. 30%, p<0.001), despite comparable overall hospital mortality. after controlling for ses and other confounders, non-white race was still associated with lower odds of wlst (aor 0.61, 95% ci 0.47-0.79). this disparity was prominent in the earlier epoch (aor 0.45, 0.28-0.74) while race was no longer a statistically significant marker in the more recent cohort (aor 0.75, 0.52-1.09). race appears to influence the likelihood of wlst in severely brain-injured patients independent of ses. this disparity, which has been attenuated over the past decade in our icu, may be related to cultural differences or barriers relating to end-of-life planning or trust. multiple parameters have been associated with outcome in comatose post-cardiac arrest patients. anecdotal observations suggest that patients who are cooler upon ed arrival tend to have poorer outcomes; if arrival temperature correlates with outcome, it may serve as an additional tool for patient prognostication. we performed a retrospective analysis of a prospectively collected data set from 80 comatose post-cardiac arrest patients to determine if a relationship exists between arrival temperature and outcome. of the 80 patients, 38 patients (48%) with out-of-hospital cardiac arrests and with arrival temperatures recorded prior to initiation of hypothermia treatment were included and divided into those with good outcomes (16 subjects; mrs =>3) or poor outcomes (22 subjects; mrs =<4 or death) at 6 months; 6 subjects (3 poor outcome survivors and 3 who progressed to brain death) remained when patients whose poor outcome (death) was due to withdrawal of care were removed from the poor outcome group. analysis using a two-tailed unpaired t-test on 16 subjects with good versus 6 with poor outcomes demonstrated a significant difference in temperature on ed arrival: mean temperature of patients with good outcomes was 36.2 o c (sd=0.9 o c), while that of patients with poor outcome was 34.8 o c (sd=1.6), p=0.01. when patients who died due to withdrawal of care were included in the analysis, a strong trend in difference between the two groups remained, but was not statistically significant (p=0.07). low body temperature upon ed arrival correlates with poor outcome in post-cardiac arrest patients and may serve as an additional prognostic variable. cooler temperatures may merely reflect longer lapsed time before return to normal circulation; alternatively, they may be a result of poor temperature regulation in more severely brain injured patients. further investigation of this issue with a larger patient pool is warranted. diencephalon injury (di) has been described in neurocritical care. consciousness alterations (ca), dysnatremia, hemodynamic instability, fever, muscle dystonia are signs of di. these symptoms are non-specific. the goal of the study was to describe structure of acute diencephalon dysfunction syndrome (adds) on the model of isolated acute di. this retrospective study evaluated all patients operated in 2006-2010. inclusion criteria: adult patients in stable preoperative condition; sellar region tumors (srt); complicated postoperative period. exclusion criteria: intra-cranial complications, not related with direct di (epi-, subdural hematomas, brain ischemia). organ dysfunctions and dysnatremia were registered. 83 patients were included, 7 excluded. all had ca and dysnatremia. hemodynamic dysfunction developed in 52 patients, respiratory dysfunction in 50 patients, ileus in 51 patients, thrombocytopenia in 21 patients, renal dysfunction in 3 patients, hepatic dysfunction in 1 patient. there were 5 groups. first (n=12) had ca, dysnatremia. icu los was 8.5 days. glasgow outcome scale (gos) 4 had 11 patients; gos 3: 1 patient. second group (n=11) had ca, dysnatremia, one somatic organ dysfunction (sod). icu los was 13 days. gos 4 had 5 patients, gos 3: 6 patients. third group (n=12) had ca, dysnatremia, two sod. icu los was 23.5 days. gos 4, 5 had 3 patients; gos 3: 5 patients; gos 1: 4 patients. fourth group (n=25) had ca, dysnatremia, 3 sod. icu los was 22 days. gos 4, 5 had 6 patients; gos 3: 8 patients; gos 1: 11 patients. fifth group (n=12) had ca, dysnatremia, 4 sod. icu los was 40.5 days. gos 4 had 4 patients; gos 3: 1 patient; gos 1: 7 patients. sixth group (n=4) had ca, dysnatremia, 5 sod. icu los was 7.5 days. all died. adds consists of ca, dysnatremia, and at least one sod. severity of adds depends on number of sod. intracranial pressure (icp) monitoring is widely used in the management of patients with traumatic brain injury. icp monitoring may also be useful in other situations characterized by high icp, including cardiac arrest survivors (cas) after return of spontaneous circulation (rosc). however, no prospective study has examined the incidence of raised icp among cas. this pilot study will examine the feasibility of screening for elevated icp in cas admitted to the toronto western hospital (twh) in 2013 -using the non-invasive technique of optic nerve ultrasonography (onus) --to identify patients with elevated icp, who might benefit from invasive icp monitoring to optimize their management after they survive cardiac arrest. evidence of elevated icp will be examined by 2 blinded ultrasonographers(usf) who will measure the optic nerve sheath diameter (onsd) in both eyes of all cas every 12 hours from rosc. all findings will be defined in a dichotomous method (elevated/not elevated). primary outcome: incidence of major protocol violations, defined as the inability to attain 5 of 6 onus recordings during first 72 hours at the specified time point (every 12 hours) by each usf. for every major protocol violation, an audit will be done to understand the reason for the violation and tailor the protocol to improve compliance in future studies. advances in resuscitation medicine have demonstrated an improvement in patient outcomes in cas by the implementation of th. the exact mechanism of action of th is not well understood and has been postulated to partially involve a decrease in icp. no prospective data currently exists linking th with icp. using onus as a non-invasive modality, we have designed a single centre feasibility study to assess the ability of onus to measure icp in cas, as well as to aid in sample size calculations for a larger multicentre prospective cohort study. a preliminary study demonstrated that >10% of whole brain volume with an apparent diffusion coefficient (adc) <650x10 -6 mm 2 /sec identified poor outcome (death/vegetative state) with 100% specificity and 81% sensitivity. we aimed to validate this threshold in an external dataset. a multicenter retrospective observational study of dwi mris of comatose post-cardiac arrest patients obtained between 25 and 120 hours post-arrest was performed. poor outcome was defined as death or persistent coma at day 14. imaging was processed in a blinded fashion using medical image processing, analysis and visualization program (mipav). the brain was semi-automatically outlined on the b0 images using a levelset algorithm. the adc values of each voxel within the brain were determined. outcomes were assessed blinded to quantitative dwi information. treating physicians were not blinded to the mri scans, but they were unaware of the quantitative dwi analysis. data from 111 patients from five us centers were included: mean age was 59±16 years, 36% female, arrest time 24±19 minutes, 59% of patients received hypothermia, and mris were obtained at 68±24 hours post-arrest. thirty-two percent had a good outcome. the median (iqr) percentage of brain tissue with adc<650x10 -6 mm 2 /sec was 3.7% (2.1-5.8) in good and 29.1% (9.5-47.0) in poor outcome patients (p<0.001). an adc<650x10 -6 mm 2 /sec >10% was 93% (95% ci 76-99) specific and 73% (95% ci 61-81) sensitive for poor outcome with a positive predictive value of 97% (87-99) and a negative predictive value of 56% (41-70). the odds ratio of having a poor outcome if >10% of brain had an adc<650x10 -6 mm 2 /sec was 38 (95%ci 8-171). quantitative dwi mri in comatose post-cardiac arrest patients holds great promise as a prognostic adjunct between 2 and 5 days after arrest. predicting outcome for comatose post-cardiac arrest patients is challenging and compounded by the use of therapeutic hypothermia and sedative agents. brain mri is a potential attractive prognostic adjunct not affected by drugs or metabolic derangements; however, most proposed methods require image post-processing. we assessed the prognostic value of color apparent diffusion coefficient (cadc) maps. consecutive post-cardiac arrest patients remaining comatose after resuscitation were prospectively enrolled. cadc maps were created by assigning adc values to 8 colors ranging from red to blue. the treating teams did not see these maps. two raters independently and blinded reviewed the cadc maps and predicted 3 month outcome as poor (glasgow outcome scale (gos) 1-2), or good (gos of 3-5). both raters were "trained" by viewing examples. the agreement between raters and the predictive performance of the cadc maps were assessed. 112 cadc maps of 94 patients (56% with poor, 44% with good outcome) were reviewed: age 59±15 years, 36% females, 69% underwent therapeutic hypothermia, median (iqr) arrest duration 20 min (14-30), and time between the arrest and mri 82 hours (60-141). kappa for agreement on predicting favorable vs. unfavorable outcome was 0.76. for the two reviewers, the sensitivity for predicting poor outcome was 0.85 (95% ci 0.73-0.92) and 0.78 (0.66-0.87), the specificity 0.81 (0.66-0.90) and 0.74 (0.59-0.86), and the true positive predictive rate 86% (74-93%) and 81% (69-89%), respectively. for mri scans acquired between 25-120 hours after the arrest (i.e. the time-interval when adc changes are most apparent), the specificity improved to 0.87 (0.68-0.96) and 0.77 (0.57-0.89), respectively. mri color adc maps are easy to interpret and may be useful for predicting outcome of comatose post-cardiac arrest patients in the first 5 days after the arrest. color adc maps do not require post-processing and can be created in realtime. there are few reports of outcome in patients with fat embolism syndrome with diffuse mri abnormities. we report the outcome of 2 patients with fat embolism syndrome. case 1 a 21-year-old previously healthy gentleman had a right femur fracture from a motor vehicle accident. he had acute respiratory failure 24 hours later requiring intubation. chest x ray showed bilateral lung infiltrates. neurological examination showed patient comatose with intact brainstem reflexes and extensor posturing. on day 3, he had fever, tachycardia, profuse sweating, and diffuse petechial rash. mri brain showed diffuse restricted diffusion lesions. he started to open his eyes in 2 weeks and underwent tracheostomy and feeding tube placement. at 6 month follow up he only had mild memory problems. case 2 a 42-year-old previously healthy gentleman had a gun shot in the left foot. over the next 10 hours he became stuporous. x ray showed multiple fractures including calcaneus, soft tissue swelling and subcutaneous emphysema. over the next 7 hours he worsened and displayed extensor posturing. mri brain showed diffuse innumerable tiny infarcts. patient was noted to have episodic fever, profuse sweating, and severe tachycardia. patient had spontaneous eye opening next day and underwent tracheostomy and gastrostomy. he was transferred to a long term facility. patient improved substantially and at 6 months follow up he was independently living at home with minor neurologic deficits. substantial improvement may occur in comatose patients with fat embolism syndrome despite paroxysmal sympathetic hyperactivity syndrome and significant mri abnormities. malignant pertussis is a rare life-threatening illness characterized by severe respiratory failure, extreme leukocytosis, and pulmonary hypertension. during 2011, an outburst of whooping cough was experienced at montevideo, uruguay. we present the cases of two infants, 5 and 7 months old, suffering malignant pertussis, admitted to a university pediatric intensive care unit (picu) for severe acute respiratory failure associated with severe leukocytosis. both children showed signs of profound coma and bilateral arreactive dilated pupils while being aggressively treated. both of them showed a transcranial pattern of cerebral circulatory arrest (cca) on transcranial doppler (tcd).to our knowledge, a pattern of cca has not been previously reported like mode of death secondary to neurologic injury in this disease. both cases were very similar: a 5-month-old boy, incomplete vaccinatinon, malnourished. a 7 month-old girl, vaccinated. both had suffered at one and 4 months-old, severe bronchiolitis caused by respiratory syncytial virus, both needed 7 days of mechanical ventilation. both were admitted to icu with cough, fever, increased work of breathing, hypoxemia and were mechanically ventilated. they presented respiratory acidosis, hipoxemia, extreme leukocytosis greater than 100000, bilateral hyperinsuflation in chest x-ray. echocardiography: pulmonary hypertension, 50-60 mmhg spap, circulatory failure, anuric renal failure. bordetella pertussis was diagnosed with pcr of airway secretions treatment: blood exchange transfusions, milrinone, maximum dose inotropic drugs, peritoneal dialisis. after one week arreactive dilated pupils and profound coma were evident. brain death was suspected, sedation and muscle blockers were interrupted. neurologic exam confirmed brain death. tcd showed sysytolic spykes in bilateral middle cerebral arteries, basilar artery, confirming cca. necropsy performed in case 2 showed bilateral pneumonia, small pulmonary artery branches thrombosis, neuronal necrosis, with brain edema, and renal tubular necrosis. the mode of death in these two cases was brain death, with cca. the probable pathophysiologic mechanisms were related to hyperviscosity and cardiac failure. davf's can be associated with benign or aggressive symptoms based on location and venous drainage. cerebral venous ischemia is a reversible process emphasizing the importance of early recognition and treatment of davf's. in a geographically isolated region with limited neuroscience intensive care unit (nsicu) capacity, neurointensivists are often challenged to allocate resources and triage intracerebral hemorrhage (ich) patients. we sought to assess the factors impacting the neurointensivists' triage decision for nsicu admission after ich. consecutive patients hospitalized for ich between 2006 and 2010 at a tertiary center that has the only 8-bed nsicu for the state, geographically isolated from the nearest nsicu (>2,000 miles away), were studied. multivariable logistic regression models were used to test for predictors of nsicu admission, adjusted for each component of the ich score, transfer from another hospital, initial systolic blood pressure (sbp) >180 mmhg, and early do-not-resuscitate (dnr) order. among a total of 397 consecutive patients hospitalized for ich, 204 patients (51%) were admitted to the nsicu while 193 patients (49%) were admitted to a non-nsicu unit. the ich patients were more likely to be admitted to the nsicu if they had hematoma volume >30 cm 3 (or 3.37, 95% ci 1.85-5.81), intraventricular hemorrhage (or 2.35, 95% ci 1.39-3.96), glasgow coma scale (gcs) score of 5-12 (or 4.45, 95% ci 2.47-8.02), gcs score of 3-4 (or 8.75, 95% ci 3.25-23.54), infratentorial hemorrhage (or 3.25, 95% ci 1.56-6.77), transfer from another hospital (or 2.82, 95% ci 1.51-5.28), and sbp >180 mmhg (or 2.22, 95% ci 1.35-0.51, 95% ci 0.27-0.96) and early dnr order (or 0.34, 95% ci 0.16-0.72). the triage decisions for nsicu admission after ich were based on clinical severity, age and early dnr status. a prospective study is needed to help establish a safe triage algorithm for ich patients in a region with limited neurocritical care capacity. using a semi-automatic threshold based volumetry algorithm. neurological status (nihss) was recorded daily and outcome was assessed at discharge using the modified rankin scale (mrs). the difference of phe volumes between day 1 and day 5-8, representing the edema growth (phe delta ), correlated significantly with the mrs at discharge (p=0.034; f=14). this correlation was still significant, when ich volume on admission was controlled. other factors that showed a significant association with outcome at discharge were nihss (anova: p>0.0001, f=15.36) and ich volume (anova: p>0.0001, f=37.99) on admission. in a multivariate regression model only the initial nihss remained a significant predictor of functional outcome. phe growth showed a weak trend towards significance (p=0.1). phe growth at the first days after symptom onset may influence early functional outcome after spontaneous ich. treatment strategies aimed at reduction of phe burden after ich may take advantage of this finding. assess the use of a 3-factor prothrombin complex concentrate (pcc, profilnine®), compared to fresh frozen plasma (ffp) in establishing hemostasis in warfarin associated intracranial hemorrhage (ich). dmitted to unc health-systems between 4/1/10 and 8/31/11 that received pcc, ffp, or both in conjunction with phytonadione for the treatment of warfarin associated ich. patients who received a factor product other than profilnine®were excluded. data collection included hematoma expansion, achievement of inr reversal (inr <1.5), 30-day mortality and endpoints related to safety (thromboembolic events, infection, and transfusion related acute lung injury). of the 29 patients included, 5 patients received pcc alone, 9 patients received pcc plus ffp and 15 patients received ffp alone. hemorrhage expansion occurred in 4 of 5 patients (80%) in the pcc group, 4 of 9 patients (44%) in the pcc plus ffp group and 4 of 15 patients (27%) in the ffp group (pcc versus ffp, p=0.018; pcc plus ffp versus ffp, p=0.262). inr reversal occurred in 100% of patients in the pcc alone group, 100% of patients in the ffp alone group and 7 of 9 patients (78%) in the combination group. this study assessed the impact of profilnine®, ffp, or the combination, on achieving hemostasis based on hematoma expansion. profilnine® achieved inr reversal but appeared to be less effective than ffp in preventing hemorrhage expansion. fever after ich is common and associated with poor outcome. however, the impact of therapeutic temperature modulation (ttm) to treat fever after ich is unclear. we performed a case-control study of ttm in ich patients with fever. patients undergoing ttm with advanced temperature modulating devices were prospectively enrolled in our ttm database from 2006-2010 (ttm group). target temperature was 37c in all cases. controls were matched in severity by ich score and retrospectively obtained from a period (2001) (2002) (2003) (2004) before our routine use of ttm for ich. primary outcome was discharge modified rankin score. we enrolled 40 patients in each group. median ich score was 3 (range 1-4 therapeutic normothermia is associated with increased length of mechanical ventilation and nicu stays, but is not associated with improved discharge outcome. spontaneous intracerebral hemorrhage (sich) is a dynamic process with significant growth in over one-third during the first 24 hours. catheter-based evacuation of sich plus recombinant tissue plasminogen activator (rtpa) is a novel surgical approach for which optimal timing of stereotactic catheter placement and clot aspiration are not known. we investigated factors associated with significant ich expansion (>33% or 12.5cc volume increase) on prerandomization ct scans of 117 patients meeting criteria for the mistie trial, a multi-center phase ii clinical trial, evaluating safety and efficacy of minimally invasive surgery plus thrombolytic to treat ich. subjects randomized to surgery underwent stereotactic clot aspiration followed by injections of rtpa through the hematoma catheter every 8 hours, up to 9 doses, or until a clot reduction endpoint. median diagnostic ich volume was 35.6cc (iqr 24.7). overall, 18.8% of patients exhibited significant hematoma expansion at a median of 20.6 (iqr 13.3) hours from symptom onset. predictors of hematoma growth were smaller diagnostic ich volume (or 0.88; p=0.001), longer interval from symptom onset to pre-randomization ct (or 1.07; p=0.008), non-lobar location (or 0.22, p=0.05), lower initial platelet count (or 0.98; p=0.03), and lower initial hematocrit (or 0.84; p=0.002). age, gender, admission blood pressure, initial coagulation parameters, hematoma shape and density scores did not predict hematoma expansion. end of treatment hematoma expansion occurred in 3/117 (2.6%) patients of whom 2 had early ich expansion and 2 underwent surgical intervention. stabilization of hematoma growth can be anticipated within 24 hours of symptom onset in patients considered for minimally invasive surgery using the mistie protocol. smaller initial ich size, deep location and lower hematocrit and platelet counts were independent determinants of significant ich expansion before surgery. patients with early expansion may represent a group at higher risk for re-expansion with clot aspiration and thrombolytic therapy. financial support: daniel f. hanley received funding from nih grant r01 ns046309. thin-section noncontrast ct (ncct) provides a measure of thrombus composition based on hounsfield units (hu) and may predict resistance to thombolytics in acute ischemic stroke. hematoma composition may affect thrombolytic efficacy of tissue plasminogen activator (tpa) in acute intraventricular hemorrhage (ivh). we assessed the value of hematoma hu quantification as a predictive marker of ivh clearance after intraventricular tpa administration. serial ncct was performed on 52 patients who received intraventricular tpa as part of the clear ivh trial (clot lysis: evaluating accelerated resolution of ivh) and 12 controls with ivh treated with external ventricular drainage (evd) alone. a blinded investigator calculated hu values for ivh volumes on admission, day 3-4 and day 6-9 ncct for each patient. median ivh volume on admission for tpa-treated patients was 38.3(iqr 34.1)cc, and decreased to 4.9(14.5)cc at day6-9. mean(sd) hu for ivh was 52.1(4.3) on presentation and decreased significantly to 50.1(4.5) on day3-4, and to 45.1(4.95) on day6-9. ivh hu count was significantly correlated with ivh volume at all ct timepoints: admission:p=0.002; day3-4:p<0.001; day6-9:p<0.001. there was no correlation between admission serum platelet count, fibrinogen level or hemoglobin and clot hus. only csf protein was positively correlated with ivh hu (p=0.03). total ivh hus were significantly lower in tpa-treated (vs. control) patients at day6-9 (p=0.001), but not at day3-4. change in ivh volume from admission to day3-4 was positively correlated with higher initial hu in tpa-treated patients (p=0.04), but hu was not significant after adjustment for ivh volume and tpa treatment. hounsfield unit counts of ivh decrease significantly over the first week on ncct and the decrease is greater in tpatreated patients. unlike thrombus hus in large intracranial vessels, ivh hus are not associated with erythrocyte or platelet concentrations. higher hu is not an independent predictor of success of intraventricular thrombolysis. although neurocardiogenic myocardial injury is well described among patients with spontaneous intracerebral hemorrhage (sich), it has not been investigated systematically in patients with acute subdural hemorrhage (asdh). we sought to investigate the prevalence and characteristics of myocardial injury in patients with asdh. consecutive adult patients with a diagnosis of asdh admitted to the rush university neurosciences intensive care unit were analyzed. myocardial injury, defined as troponin i elevation (> 0.09ng/ml) on admission or during hospital course, was identified. electrocardiograms (ecg) and echocardiograms, obtained within the first 24 hours and read by a cardiologist blinded to the patient's history, were retrospectively reviewed. a total of 107 patients were admitted with asdh between 12/2009 and 11/2011. the mean age was 66 years (sd 17 years), and 63% were male. comorbidities included hypertension (78%), diabetes mellitus (32%), coronary artery disease or prior myocardial infarction (37%), congestive heart failure (10%), coronary artery stent or bypass procedure (21%). ecgs were normal in 24%. non-specific st-t morphologic changes, qrs changes or sinus arrhythmias were seen in 71%. st-elevations suggestive of myocardial infarction were not seen. of 17 patients with elevated troponin, 13 had known severe cardiac disease, and 4 had severe medical complications (sepsis, renal failure, hepatic failure and acute lymphoma crisis). diffuse ecg changes ("cerebral t waves") and echocardiographic findings suggestive of neurogenic stunned myocardium (reversible wall motion abnormalities, apical ballooning) were not seen. although we found ecg changes to be common after asdh, myocardial injury was only observed in the context of concomitant cardiac or medical disease. classic neurogenic cardiac findings (cerebral t waves, neurogenic cardiomyopathy) were not observed. while myocardial injury in sich often is attributed to neurocardiogenic causes, these are unlikely prominent mechanisms in patients with asdh. other cardiac or medical causes are common and should be excluded. prognostication in intracerebral hemorrhage is complex and mortality remains high. while tools such as the ich score have been developed to assist with prognostication, physicians clearly use additional parameters in clinical practice. though do-not-resuscitate orders do not indicate the withholding of any treatment other than cpr, they are associated with increase risk of death in patients after ich. we sought to understand early dnr (<72hours) designation in patients with hope of moving toward more precise tools for prognostication. patients admitted to the neurological intensive care unit from july 2007 to december 2010 with a diagnosis of supartentorial ich were identified. data for all patients were collected retrospectively. patients without a dnr order throughout their admission were compared to patients who received a new dnr order in the first 72 hours of admission. patients with pre-existing dnr orders were not included. 157 subjects were included in the study with 18.4% made dnr within 72 hours of admission to our nicu. factors showing a significant correlation with a new dnr order included advanced age, caucasian race, or residence in a skilled nursing facility. history of malignancy, atrial fibrillation, current use of antihypertensives or warfarin, or alcohol abuse predicted a dnr order. ich resulting in a low admission glasgow coma score, high ich score, intraventricular extension and blood volumes greater than 30ml correlated with a new dnr order. while individual elements of the ich score correlate with a new dnr order in this population, other characteristics were also associated with an early dnr order. early dnr orders may create a self-fulfilling prophecy if limitations of support are instituted without a clear understanding of who may benefit from aggressive care. thus, identification of factors that providers believe to be life-limiting may serve as a starting point to avoid early limitations in aggressiveness of care. intracranial hypotension is caused by low cerebrospinal fluid (csf) pressure, clinically distinguished by orthostatic headaches and neurologic signs. subdural effusions and even hemorrhage can be a secondary effect. known causes include dural punctures as well as spontaneous csf leaks. treatments are guided towards repairing the cause of the hypotension. a 74 year-old man on coumadin for a mechanical aortic valve was transferred to our institution for evaluation of bilateral sdh. he presented twenty-four hours earlier with sudden-onset severe headache and normal neurological exam. upon transfer, he was noted to be drowsy, with a left third cranial nerve palsy. he endorsed a postural headache that worsened upon standing. mri of the brain showed small subdural effusions with subacute hemorrhage and minimal mass effect, as well as severe distortion of the midbrain with narrowing of the ventricular system, crowding of the basal cisterns and extensive pachymeningeal enhancement. mri of the spine did not demonstrate a csf leak but showed a small perineural cyst at t11. the patient's headache and exam findings initially improved with lying flat. a trial of elevating his head of bed failed, with the patient further developing decreased level of arousal, frontal release signs, and recurrent left third nerve palsy. two attempts at lumbar epidural blood patch (ebp) did not lead to sustained improvement, but a thoracic-directed ebp led to durable and complete resolution of the headache and neurologic deficits. intracranial hypotension should be considered as a cause for subdural hemorrhages in the absence of trauma. clues include postural headaches and clinical evidence of brainstem dysfunction and radiographic evidence of brainstem distortion out of proportion to the size of the sdhs. ebps directed at suspected csf leaks can be effective when nondirected lumbar ebps fail. multiple guidelines recommend the reversal of oral anticoagulation when a patient experiences an intracranial hemorrhage (ich). both activated prothrombin complex (apcc) and recombinant factor vii activated (rfviia) have been utilized to reverse warfarin-associated coagulopathy. however, there have been no direct comparisons of these agents. this was an irb approved, retrospective cohort analysis of patients with ich. patients were included if they received either apcc (at least 500 units) or rfviia (at least 1 mg), if they had a discharge diagnosis of intracranial hemorrhage, and if they received warfarin prior to admission. patients were excluded if they were less than 18, or did not have documented pre-treatment and post-treatment inrs. the primary endpoint for this study was the change from pretreatment inr and post-treatment inr in the apcc group and rfviia group. secondary endpoints included change in ct measured hemorrhage volumes, icu length of stay (los), hospital los, mortality, icu discharge gcs, and thromboembolic adverse events. a total of 60 patients were included in the analysis. of those, 35 received apcc and 25 received rfviia. baseline demographics were comparable; however, patients in the apcc group had a higher rate of atrial fibrillation (68% vs. 40%; p=0.028). when compared over time, both apcc and rfviia significantly reduced the inr (p<0.005); however, there was no difference in the amount of change observed between the two groups (p=0.72). in addition, we saw no significant differences with regard to icu los, hospital los, mortality, icu discharge gcs, or thromboembolic adverse events. over time, an increase in ich volume was observed in both groups. in patients with intracranial hemorrhage, apcc and rfviia are associated with rapid reversal of warfarin-associated coagulopathy; however, these agents may not slow ich growth. accurate prognostication of patients with intracerebral hemorrhage (ich) is critical because it may affect aggressiveness of care and patient outcome. ich prediction models help stratify patients according to their chance of a good or poor outcome. we compared the accuracy of neurointensivists' prediction of functional outcome to outcome prediction by the ich score. adult spontaneous ich patients with an admission gcs >5 were prospectively enrolled. the treating neurointensivist predicted the 3-month modified rankin scale score (mrs) within 2 days of hospital admission. none of the neurointensivists used the ich score routinely to help predict outcome. patient outcomes were dichotomized to good (mrs 0-3) and poor (mrs 4-6). neurointensivists' predictions were compared to the ich score using the actual 3-month mrs as the reference. of 116 prospectively enrolled patients, 101 were included: 2 withdrew consent and 13 were lost to follow-up. neurointensivists' overall accuracy was 79%, which was higher than the accuracy of the ich score at a cut-off of >1 (67%; p=0.06) or >2 (58%; p=0.001). at a cut-off >1, the sensitivity for poor outcome prediction did not differ, but the neurointensivists' specificity for poor outcome was greater (92% vs. 66%; p<0.001). conversely, at an ich score cut-off >2 the specificity for poor outcome prediction did not differ, but the neurointensivists' sensitivity for poor outcome was greater (67% vs. 25%; p<0.001). the results were similar if, instead of the original ich score, a modified ich score was used as the comparison that had been developed on the same patient cohort. neurointensivists at our institution predict ich outcome overall with 79% accuracy. generally, predictions for poor outcome are more accurate than those for good outcome. outcome predictions for the individual patient by the treating neurointensivist are more accurate than those based on ich prediction models. there is continued controversy regarding glycemic control and its effect on outcomes for patients with ich as well as other icu patient populations. the relationship between ichsize and glycemic control has not been clearly defined. a retrospective review of 87 patients with supratentorial ich and no history of diabetes between 2003 and 2007 was performed. admission blood glucose (bg) as well as bg at 24, 48 and 72 hours was measured while all patients were maintained on the same sliding scale insulin regimen. statistical analysis was performed to compare admission ich size to admission bg and subsequent bg control. bg>120mg/dl (mean 172 ±60) and mean ich size 87.4 ± 78.1. average bg levels over 72 average bg levels over 72 hours were 106 ±35mg/dl. elevated admission bg was significantly correlated with admission ich size (p=0.001). average bg levels over 72 hours trended towards, but were not significantly correlated with admission ich size (r =0.19, p=0.078). in nondiabetic patients, elevated admission glucose is significantly associated with ich size. poor outcomes associated with elevated glucose may be associated more with extent of cerebral insult than with glycemic control. the benefits of marriage on health have been known for over 150 years. more recently, married couples have been found to have a lower risk of cancer, dementia, and heart disease. we aimed to explore the effects of marital status on outcome after intracranial hemorrhage. a prospective study was conducted between 2008-2011 of patients with subarachnoid hemorrhage (sah, n=118), intracerebral hemorrhage (ich, n=130) and subdural hemorrhage (sdh, n=133), admitted to the neuro-icu at a tertiarycare academic hospital. marital status was coded as married versus single, widowed, divorced or separated. modified rankin score and barthel index were compared between the two groups at 3-months using multiple logistic regression analysis. of 371 patients, 198 (53%) were married, 84 (23%) were single and 89 (24%) were widowed, divorced or separated. women were less likely to be married, and smoking was less common among the married (both p<0.01). there was no difference in age, insurance or employment status, race, education, days to diagnosis, or history of heart disease, diabetes, hypertension, trauma or coagulopathy. after adjusting for age, admission gcs, apache physiologicalsubscore, gender, tobacco and bleed type, marriage was significantly protective against death or severe disability (mrs 4-6; adjusted or 0.5, 95%ci 0.3-0.9, p=0.028) and predicted better activities of daily living (barthel index), (aor 2.0, 95%ci 1.1-3.9, p=0.032). there was no difference in discharge disposition, length of stay or hospitalization costs. marriage is protective against death or severe disability and predicts better activities of daily living among patients with intracranial hemorrhage. warfarin associated intracranial hemorrhage leads to poor outcomes. we studied the influence of a standardized emergent warfarin reversal protocol incorporating prothrombin complex concentrates (profilnine sd®) on time to achieve the protocol was implemented in 2010. sixty three patients (25 pre and 38 post protocol) from 2009-2011 with intracranial -protocol patients received recombinant factor 7 a (rfviia); post protocol patients with inr 1.6 -4 and >4 received 25 and 35-50 units/kg of profilnine sd® respectively. hemorrhage volumes were measured on consecutive ct scans using mipav semi-automated software. groups were similar for baseline median inr (2.5 vs 2.7), nihss (1 vs 2), follow-up ct time (7.6 vs 7.4 hours) and hemorrhage volumes (7.5 vs 5.2 cc) but differed in hemorrhage type: ich (36% vs 53%) and sdh (48% vs 18%), p=0.03. treatments also differed: vitamin k (80% vs 97%, p=0.03), profilnine sd® (0% vs 61% p=<0.001), rfviia (24% vs 3% p=0.01) and number of plasma units (5 vs 3, p=0.001).time to target inr was similar (13.3 vs 10.1 hours) driven by pre-protocol rfviia use (rfviia used vs not, 13.3 vs 22.5, p=0.03) and this led to inr rebound in <24 hours. excluding rfviia, the post protocol group normalized inr faster (22.5 vs 10.4 hours, p=0.036). the post protocol group had less absolute (6.3 vs 1 cc p=0.01) and relative hemorrhage growth (95% vs 29% p=0.03) without any thrombotic events. despite comparable mortality (24 vs 28%), post-protocol survivors more frequently achieved mrs 0-3(66 vs 52% p=ns). a standardized emergent warfarin reversal protocol is not only safe but leads to faster inr normalization, less hemorrhage growth, plasma conservation and possibly better neurological outcomes. perihemorrhagic edema (phe) after intracerebral hemorrhage(ich) may exceed the initial hematoma volume by 100 to 600% respectively and thereby lead to increased intracranial pressure (icp), clinical detoriation or even herniation. intravenous hypertonic saline (hts) has been shown to reduce phe formation after ich. clinical data suggest that hts may be superior to mannitol in lowering icp. eusi and asa guidelines recommend the use of intravenous mannitol up to a serum osmolality (so) of 320 mosmol/kg or hst in order to reduce elevated icp. we aimed to investigate the effect of mannitol and so on the evolution of phe after ich. nineteen patients with supratentorial spontaneous ich treated with 20% intravenous mannitol solution (125-250ml every 6h) for 5-10 days and 19 controls who did not receive mannitol or any other osmotic agents during the course of treatment were identified retrospectively from our institutional ich database. patients treated with mannitol and controls were matched for ich-volume (±5ml). phe volume was calculated on ct scans using a semiautomatic threshold based volumetric algorithm. diagnostic ct scans and follow-up scans performed on days 1, 2-3,4-6,7-9 and 10-12 were analyzed. so, concentration of sodium and glucose were obtained from patient records. the matching resulted in similar ich-volumes in both groups (mannitol: 24.9±14.4ml, controls: 22.6±22.8ml). mean age was 71(53-83) years in the mannitol group and 64(31-85)years in controls (p=0.1). initial relative phe did not differ significantly in both groups (mannitol: 1.25±0.6, controls: 1.01±0.7, p=0.24). there was no effect of mannitol treatment on the course of phe (f=0.83,p=0.37). there was no significant correlation between so and relative phe at any timepoint of follow-up. we found no effect of mannitol use and so on the evolution of phe. other underlying mechanisms may explain the shortterm effect of mannitol boluses on icp in patients with spontaneous supratentorial ich. when operating at maximum intensive care unit (icu) bed capacity where allocation of critical care resources is required, physicians may be pressured to initiate do-not-resuscitate (dnr) orders in patients with intracerebral hemorrhage (ich). we sought to assess the relationship between early (<24 hours from admission) dnr orders and neuroscience intensive care unit (nsicu) bed capacity in patients admitted with acute ich. we retrospectively studied consecutive patients hospitalized for ich between 2008 and 2010 at a tertiary center that has the only 8-bed nsicu for the state, geographically isolated from the nearest nsicu (>2,000 miles away). multivariable logistic regression models were used to test for predictors of early dnr orders, adjusted for each component of the ich score and nsicu bed census on admission. nsicu bed census was dichotomized to full (all beds occupied) vs. not full (at least 1 available bed). among 206 maximum icu bed capacity on admission is not associated with the decisions to initiate early dnr orders in ich patients. this suggests that physicians were not preferentially initiating early care limitation when critical care resources were becoming scarce. dural arteriovenous fistulas (davf) are rare, acquired cerebrovascular lesions consisting of abnormal vascular connections between arteries that normally supply the dura and veins that drain the brain parenchyma -that is to say, arteries not associated with the brain parenchyma manage to drain via the dural venous sinus system. the clinical consequences of these lesions are typically hemorrhage, seizure, or venous congestion. venous congestion may present acutely with hemorrhage or subacutely with signs and symptoms such as progressive cognitive decline, seizures, or encephalopathy. parkinsonism, tinnitus, and intracranial hypertension have also been described. case report with review of literature. we describe a 61-year-old man with no past medical history who developed subacute onset dementia with bithalamic t2 hyperintensity on mri without restricted diffusion. subsequent intraventricular hemorrhage resulted in emergent transfer to our institution's neurocritical care unit for an emergent diagnostic cerebral angiogram of a borden ii/cognard iib davf with immediate angiographic embolization and obliteration. davfs are lesions with significant risk of aggressive neurologic devastation related to venous congestion and subsequent hemorrhage. the severity of davfs requires clinicians to be aware of these lesions and of their common and uncommon presentations. little is known about the ability of prognostic scores to predict outcome in patients with secondary intraparenchymatous intracranial hemorrhage (iph). our objective was to describe the clinical characteristics, ich scores at presentation and prognosis in patients with secondary iph. we performed a post-hoc analysis of prospectively collected data of consecutive patients admitted to a tertiary hospital with iph. the characteristics of patients with secondary iph were compared to those of patients with spontaneous iph. patients with secondary iph had either a positive underlying vascular lesion identified as the iph etiology or impaired coagulation at presentation (a platelet count <50,000 per cubic mm, an inr > 3.0, or an aptt > 80 than seconds). a total of 71 patients with iph were admitted to our hospital from january-2009 to january-2012. of those, 10 patients (14%) had a secondary iph (2 cavernomas, 5 arteriovenous malformations, 1 dural fistula, 1 reversible vasoconstriction syndrome and 1 sacular aneurysm patients with secondary iph had lower ich scores at presentation and lower in-hospital mortality than patients with spontaneous iph. despite lower ich scores at admission, patients with secondary iph had similar functional outcomes when compared to patients with spontaneous iph. larger studies should focus on specifically developing better prognostic tools in such patients. a large number of studies in traumatic brain injury patients have shown efficacy of hypothermia for control of icp and if used for prolonged duration, has shown to improve mortality and functional outcome. for other neurologic catastrophes, due to a risk of rebound edema during re-warming, medical complications and other factors, it has either not been commonly used or been used when most of other options are exhausted. this is a retrospective analysis of 8 patients with massive ich (blood volume of > 60 ml), of non traumatic etiology, dominantly in brain parenchyma. all patients had intracranial pressure monitoring via external ventriculostomy catheter. hypothermia was induced and maintained at target temperature via non-invasive, surface cooling pads. modified rankling score (mrs) was recorded at 4 months after the ictus in all survivors. patient ages ranged from 37 to 53 years. cause of ich was hypertension in 7 patients and ruptured aneurysm in one patient. duration of treatment ranges from 5-14 days. target temperature required to adequately control icp ranged from 32-34 c. two patients (25%) survived with good recovery (mrs of 2), one (12.5%) with moderate disability (mrs of 3), two (25%) with moderately severe disability and three (37.5%) died. most common side effect of hypothermia was hypotension requiring pressors in five (62%), electrolyte imbalance in 4 (50%), pneumonia in 3 (37%), thrombocytopenia in 3 (37%) patients. all complications were successfully treated and major complications of treatment (bleeding diathesis, septic shock syndrome, death) were not observed. controlled hypothermia for up to 14 days is safe and feasible for the treatment of cerebral edema and intracranial hypertension in young patients with massive (> 60 ml of blood volume) non traumatic ich. however, prolonged duration of treatment may be required for definitive control of icp. this study serves as a template for future efficacy trials. intracerebral hemorrhage (ich) accounts for 10% to 15% of strokes and is associated with substantial morbidity and mortality. it remains controversial whether surgical intervention or a conservative approach is the best option for treating ich. we assessed the hypothesis that early surgical intervention in patients with primary supratentorial ich may serve to improve 30-day outcome. a total of 97 patients with primary supratentorial ich, in whom surgical intervention was indicated for hematoma removal according to the guidelines, were admitted to our hospital during a continuous 12-month observation period. patients with the consent to the surgical intervention (n=35) underwent surgery within 24 hours of symptom onset and the others (n=62) were given the conservative treatment. the outcome was the proportion of patients who had an unfavorable outcome (persistent vegetative state or death), as assessed on the basis of the glasgow outcome scale (gos) at 30 days. the 30-day mortality rate was 51.5% (standard error, 5.1%). there was no significant difference in outcome between the two treatment groups. after adjustment for other significant covariates, although a lower unfavorable outcome was found in surgical group but the difference was not significant (odds ratio = 0.725). among the confounding factors, presence of intraventricular hemorrhage (ivh) and low glasgow coma scale (gcs) score on admission were independently associated with poor outcome 30 days after ich (both p <0.001). we found no benefit for early surgical intervention over conservative treatment in patients with primary supratentorial ich. presence of ivh and low gcs score were strong predictors of poor outcome in these patients. given the high morbidity and mortality associated with intracerebral hemorrhage (ich), family members and healthcare providers base early supportive management decisions, at least partly, on expected prognosis. in the comatose patient with ich, this short term prognosis is most overtly characterized by regaining of consciousness. a retrospective consecutive cohort of 51 patients, between 2006 and 2011, with ich and admission glasgow coma scale that were associated with regaining of consciousness after coma in ich. variables associated with awakening in univariate analysis were tested in multivariable logistic regression. the group that awakened had higher initial gcs scores, smaller ich volumes, and less ivh, but was similar in other baseline characteristics. early dnr orders, in the first 24 hours, tended to be used more frequently in patients who ultimately remained comatose, but the difference was not statistically significant. admission gcs, volume of ich, and presence of ivh identified in univariate analysis were tested along with age and gender as potential confounders of outcome in multivariable analysis. higher admission gcs score was associated with an increased likelihood of awakening from coma (or 4.9 [95%ci 1.9-13] per category, p=0.001). 87% of patients with initial gcs of 7-8, 40% with initial gcs of 5-6, and 20% with initial gcs of 3-4 regained consciousness. awakening from coma, in the cohort of 27 patients who regained consciousness, occurred in 59% of patients by day 2, 89% by day 7, and 96% by day 9. gcs score is the single most important predictor of early awakening in patients who present in coma after ich. patients who regained consciousness typically did so within the first 9 days of hospital admission. intracerebral hemorrhage (ich) is an infrequent but severe complication in pregnant women with hypertension, it accounts for 50% of all deaths related to cerebral complications in this group. a-32-year-old female, g2p1 at 34 weeks of gestational age, with prenatal care, no relevant past medical history, presented for a follow-up visit. she was admitted with bp 150/90 mmhg, and treated with iv labetalol; the preeclampsia work-up was negative, bp range between 150/90 and 180/110 mmhg. approximately 10 h after admission, she complained of diffuse headache, nausea, vomiting, and epigastric pain. headache symptoms increased follow by focal seizure and progression to generalized tonic-clonic seizures. magnesium sulphate and phenytoin were administered to control the seizure, immediate blood analysis revealed dic. the diagnosis of eclampsia was made, and emergency csection followed. the airway was secured with rapid sequence technique; a healthy infant was delivered under general anesthesia. the patient remained comatose 1 hour after surgery with gcs 4, 90 minutes later she demonstrated a decerebrate posture with non-reactive pupils. a non-contrast ct-scan revealed an intracerebral hematoma. dic was treated, and neurosurgeon performed a right frontotemporal craniotomy. a postoperative ct scan confirmed the resolution of the ich. the patient opened her eyes and started responding to commands by the third day, on day 7 she was extubated and the gcs was 9. by the 3rd week, the patient was transferred to rehabilitation, where she remained for 4 weeks. at 3 years, she regained a full cognitive recovery. this case emphasizes that even short time hypertension should be treated aggressively to prevent ich. the prompt intervention of a multidisciplinary team (obstetric, neurosurgery, and anesthesiology) is required to ameliorate the devastating effects of eclampsia and ich. although hypertension is the commonest cause of non-traumatic intracerebral hemorrhage (ich), it is important to rule out other causes. most patients with ich have an elevated bp on presentation but many are unaware if they have longstanding hypertension. echocardiographic abnormalities may be revealing in such circumstances. we studied the incidence of echocardiographic abnormalities and their usefulness in determining the etiology of ich in these patients. we conducted a retrospective study of echocardiographic abnormalities in ich patients admitted to a tertiary university hospital between jan 2008 to oct 2011 who also had a cerebral angiogram. subjects with and without underlying vascular location (categorized as typical hypertensive location or not), history of hypertension and the presence of the following echocardiographic abnormalities: left ventricular hypertrophy (lvh), diastolic dysfunction (dd), systolic dysfunction (sd), hyperdynamic ventricular function (hvf), wall motion abnormalities, atrial enlargement (ae) and valvular abnormalities using chi-square test and fisher exact test. we then conducted a multivariate logistic regression analysis including variables with a p<0.25 in the univariate analysis. a total of 303 subjects were admitted with an ich. 159 subjects had an echocardiogram and of these, 130 also had an angiogram (conventional angiogram: 72, ct angiogram: 32, mr angiogram: 26). the echocardiogram was abnormal in 89.2% (93.2% with a history of hypertension p=0.006). common abnormalities were: lvh (43.1%), dd (42.3%), hvf(18.5%), sd (13.1%) and ae (12.3%). of these, only dd (p=0.049) was significantly associated with absence of underlying vascular abnormalities on a univariate analysis. on multivariate analysis, none of the echocardiographic abnormalities showed a significant association. echocardiographic abnormalities, mainly lvh and dd are commonly seen in ich patients, however none of these abnormalities are independently associated with an absence of underlying vascular anomalies. stroke in the hiv+ population is a growing problem, though it is unclear whether hiv is an independent risk factor. we describe a series of hiv+ patients with intracerebral hemorrhage (ich). we reviewed records of all patients with diagnoses of ich and hiv/aids admitted to an academic, inner-city hospital between 2005 and 2011. patients with traumatic hemorrhage, ischemic stroke with hemorrhagic conversion, hemorrhagic neoplasms, toxoplasmosis with hemorrhage, subarachnoid hemorrhage, and extra-axial hemorrhages were excluded. we reviewed demographics, risk factors, laboratory tests, and neuroimaging. outcomes at 90 days were determined by modified rankin scale (mrs). six hiv+ patients (83% male, mean age 51) met inclusion criteria, with 1 patient having recurrent hemorrhages; 50% were black, 33% hispanic, and 17% of other racial groups. all patients met criteria for aids. risk factors included: prior stroke (17%), diabetes (33%), hypertension (33%), smoking (50%), and illicit drug use (33%). only 1 patient was taking antithrombotic medication. the co-prevalence of hcv was 50%. admission blood pressure was >140/90 in 3/6 patients. laboratory evaluation demonstrated 1 patient with a prolonged inr (>1.3) and 3 patients with thrombocytopenia (<150). the hemorrhages were lobar in 4/6 and deep in 2/6. only 3 patients had vessel imaging; one had an avm and none demonstrated aneurysm or vasculitis. at 90 days, four patients were deceased and the two survivors had mrs of 4 and 5. in this cohort, hiv-associated ich occurred only in aids patients. outcomes were uniformly poor, with 100% of patients having a htn and unexpected predominance of lobar hemorrhages in younger patients, suggesting a distinct mechanism of ich. in 1988 gregory call and marie fleming reported four patients with what appeared to be a reversible form of cerebral vasoconstriction. since then a number of authors have reported reversible cerebral vasoconstriction syndromes (rcvs), often in association with potential etiological precipitants. the major complication of rcvs is ischemic stroke, but hemorrhagic strokes can also occur, eventually leading to permanent sequelae and even death. recent reports and case series have suggested that intracranial hemorrhages may be frequent in rcvsand its presentations may range from cortical subarachnoid hemorrhages to intracerebral hemorrhages and subdural hemorrhages. we report two cases of rcvs in middle age women, with hemorrhagic strokes caused after the prescription of dipirone, isometheptene and anhydrous caffeine, with putaminal hemorrhage, and lobar frontal hemorrhage. both cases showed complete reversion of arterial vasoconstriction weeks later by the transcranial doppler. despite the reversibility of the vascular constrictions that characterize rcvs, brain lesions are observed in up to 81% of the patients.most of these lesions are of ischemic nature; however hemorrhagic phenomena are not uncommon and have only been reported in 5%-12% of the cases. isometheptene has been described as a trigger for rcvs in only a handful of patients, all of whom were women in the postpartum period. even though rcvs diagnosis demands evidence of complete reversibility of the vasospasms, differential diagnosis with sah can be made by the identification of classic rcvs triggers and assessment of the vascular patterns brain arteries. magnesium (mg) has been hypothesized to have a neurprotective effect against cerebral ischemia. several ongoing studies are examining the effect of exogenous magnesium in reducing disability and maintaining normal cerebral function. we examined initial endogenous mg levels in patients with spontaneous intraparenchymal hemorrhage (iph), in order to determine if higher mg blood serum levels would confer neuroprotective benefit. this is a retrospective study on patients admitted to a university affiliated community hospital. demographic data were obtained from a prospectively collected registry database. initial magnesium levels were gathered retrospectively from the registry database. we included all patients with iph in our analysis. for evaluating the severity and outcome of the patients with iph we used the university of california san francisco intracerebral hemorrhage (ucsf ich) score on admission / 24 hours to quantify stroke severity and mrs on discharge to measure outcome. we employed correlation coefficients (spearman's rho) and the mann whitney test for analysis of the data. spss version 11 was used for data processing. our review identified 74 patients with a diagnosis of iph. the serum mg levels in patients with iph negatively correlated to ucsf ich score on admission (p=0.01, r= -0.37) and at 24 hours (p=0.007, r= -0.40). there was a trend towards better outcomes at discharge in patients with higher mg levels (p=0.1, r= -0.25). higher levels of endogenous serum mg were found to confer reduction in iph severity and progression. initial serum mg levels could serve as an early predictor of iph severity. a larger prospective study is warranted to study the effect of endogenous mg on outcomes in patients with iph. spinal dural arteriovenous fistulas (davfs) account for 70% of all vascular spinal malformations. the incidence is 5-10/million/year in the general population although it is generally under-diagnosed. men are affected five times more often than women and the mean age at the time of diagnosis is 55-60 years. spinal davfs generally do not present acutely and are very rarely located in the cervical region. we present a case of atypical acute spinal cord infarct secondary to a cervical davf. case report and extensive literature search carried out to understand spinal davfs. this 60 year old gentleman presented to our neurocritical care unit with bilateral upper extremity weakness and right lower extremity weakness proceeded by upper back and neck pain. the patient rapidly deteriorated to near quadriplegia and respiratory failure requiring prolonged artificial ventilation. initial studies included normal mri of the brain and ct angiogram of the head and neck. mri of the spine revealed abnormal signal intensity within the anterior cervical cord from c3-c7 levels in the distribution of the anterior spinal artery. there were no flow voids to suggest dilated perimedullary vessels. however, given the clinical picture, a spinal angiogram was obtained and demonstrated a cervical davf supplied by a dural branch vessel originating from the left vertebral artery. understanding spinal vascular anatomy is important for diagnosis of spinal davfs. our case is unusual because 1) acute evolution of quadriplegia and respiratory failure, 2) lack of any abnormal vessels seen on mri, and 3) ischemic changes restricted to the anterior spinal artery distribution. the case emphasizes the importance of proceeding with spinal angiography if the clinical suspicion of davf is high. early detection and management can lead to improved functional outcome. although coma is a syndrome commonly associated to catastrophic brain injury, this patient population remains poorly characterized. the chief goal of therapy is aimed at reversal of coma. despite this urgency, there is paucity of data regarding the factors that predict emergence. we characterize a population of patients with new onset of coma in the neuro-icu and describe clinical and structural factors that predict emergence. prospective longitudinal consecutive cohort of patients, enrolled in an intensive care setting. three hundred patients met investigation enrollment criteria between may 2010 and july 2012. a brain lesion was identified at the onset of coma in most patients (92%). frequent etiologic factors were cerebrovascular (65%), seizures (18%), trauma (15%), cns infection (12%), or other (7%). the most frequent cerebrovascular factors were any ich (40%), ivh (34%) and sah (33%), either alone or in combination. emergence from coma was predicted by a higher initial gcs (emergence=9[3-13] vs. no emergence=5.5[3-11] p<0.0001), seizures as presenting disorder (emergence=26% vs. no emergence=9% p=0.025), and a trend to lesser frequency of ich component (emergence=31% vs. no emergence=50%, p=0.06). the importance of mass effect as measured by midline shift reversal and cisternal compression resolution is presented in a separate poster. mortality in this cohort is 45%. the population of patients with acute coma is highly heterogeneous. however clinical and structural factors predict emergence. a higher initial gcs predicted recovery of coma. structural cerebrovascular lesions with less ich component had a tendency toward higher rates of recovery. non-structural treatable causes of coma such as seizures were associated with higher rates of recovery. mortality and disability remain dismal in this population. optimal blood pressure (bp) control in intracerebral hemorrhage (ich) patients remains controversial. aggressive bp reduction may limit hematoma expansion, but may also cause hypoperfusion and ischemia. we investigated the relationship bp lowering in the first 24 hours and the presence of diffusion weighted imaging (dwi) lesions on mri. we prospectively enrolled consecutive patients presenting with an acute spontaneous ich. brain mris were reviewed for the presence of lesions with reduced diffusion attributable to tissue compression, vessel compression, or hypoperfusion ipsilateral to the hematoma. bps were recorded on hospital presentation, and at 6, 12, 18, and 24 hours. of 160 eligible patients, 136 met inclusion criteria: age: 63±17 years; hematoma volume: 10 ml (iqr 4-33); admission nihss: 6 (iqr 2-16); ich onset to maximal bp reduction 18 hours (iqr 12-18); and ich onset to mri: 37 hours (iqr 25-75). dwi lesions were detected in 50% of patients: 79% of patients had lesions attributed to tissue compression, 21% to vessel compression, and 12% to hypoperfusion (some patients had multiple lesion types). dwi lesions were associated with larger hematoma volumes (32 vs. 12ml, p <0.001); higher admission mean arterial pressures (map) (125 vs. 113mmhg, p=0.006); and greater average map reductions (25 vs. 17%, p=0.006). after controlling for ich volume using logistic regression: for every 10% of map reduction, the risk of dwi lesions increased (or 1.28, 95% ci: 1.01-1.62); for each 30% reduction in map the risk of dwi lesions more than doubled (or 2.3, 95% ci 1.05-4.83). the proportion of patients with dwi lesions increased as the maximum percent map reduction increased in a dose dependent fashion. ischemic brain lesions in patients with spontaneous ich are common and associated with hematoma volume and bp lowering. aggressive bp lowering may contribute to ich associated ischemic lesions. financial support: sources of funding: this research was supported by the nih (r01 ns034866) to cacw, and the stanford school of medicine medical scholars program to jtk. coma is a major cause of death, disability and economic burden to the health care system. acutely comatose patients with primarily neurologic injury are at risk to develop neurologic and systemic complications. in this study, we seek to identify the timing of medical complications and their impact on mortality in acutely comatose patients admitted to neurocritical care unit. one hundred patients with acute coma for at least 12 hours or longer were enrolled prospectively in the study from may 2010 to jan 2011. major neurologic and systemic complications were identified prospectively and the frequency and timing of each major complication was established. of the 100 patients studied, mean age was 59±18.4 years and 53% were females. a mean of 3.3±2 complications occurred. in this cohort of patients with coma, there were more non-neurological (55%) versus neurological (45%) complications. most complications (58%) were noted in the 3-4 day interval. further characterization of these complications is essential to the care of comatose patients in the nccu. pathophysiology of brain dysfunction associated with sepsis is still poorly understood. our purpose was to study the metabolic alterations and mithocondrial dysfunction in a clinically relevant model of septic shock. twelve anesthetized, invasively monitored, and mechanically ventilated pigs were allocated to a sham procedure (n = 5) or sepsis (n = 7), in which peritonitis was induced by intra-abdominal injection of autologous faeces. animals were studied until spontaneous death or for a maximum of 24 hours. in addition to global hemodynamic and laboratory assessment, intracranial pressure and cerebral microdyalisis were assessed 6, 12, 18 and 24 hours after sepsis induction. after death, brain were removed and brain homogenates were studied to assess mithocondrial dysfunction. all septic animals developed a hyperdynamic state associated with organ dysfunction. in the septic animals, there was a progressive increase in l/p ratio and glycerol, as well as a progressive decrease in brain glucose concentration during the study period. the comparison between control and septic animals and the analysis of brain homogenates are undergoing. in this model of peritonitis, cerebral metabolism was derranged, with increasing levels of l/p ratio and decreasing levels of brain glucose during study period. these alterations may play a role in the pathogenesis of sepsis-associated encephalopathy. at sanford usd medical center, neuro critical care (ncc) patients are frequently treated with continuous infusions of 3% sodium chloride. it has been observed that this patient population often develops iatrogenic hyperchloremic metabolic acidosis, frequently managed with intravenous sodium bicarbonate. upon notification of a nationwide intravenous sodium bicarbonate shortage (march 18 th , 2012), our ncc providers were forced to explore other potential options for managing this acidosis. it was decided that our ncc patients would be initiated on enteral sodium bicarbonate at the time continuous 3% sodium chloride was started. a retrospective chart review of ncc patients 18 years and older, initiated on continuous 3% sodium chloride with enteral sodium bicarbonate tablets from march 18 th , 2012 to june 4 th , 2012 were evaluated. data collected included demographics and the following while in the intensive care unit (icu): baseline serum sodium, chloride, and bicarbonate; type of injury; acidosis defined as serum bicarbonate level <20, or lower than baseline; and volume of 3% sodium chloride and bicarbonate administered. of the 11 patients identified, 27.3% developed iatrogenic metabolic acidosis during icu stay. average duration of continuous 3% sodium chloride infusion was 6 days (range 1 -22 days) with an average volume of 3% sodium chloride dispensed of 5,000 mls (range 500 -32,000 mls). three patients evaluated developed an acidosis during icu stay, of which 2 were hyperchloremic at the time of acidosis. only 1 patient required intravenous sodium bicarbonate, however the patient had been off hypertonic saline for more than 1 day. enteral sodium bicarbonate appears to be an effective method at preventing iatrogenic hyperchloremic metabolic acidosis when initiated along with continuous infusions of hypertonic saline in ncc patients. this may be a method to conserve intravenous sodium bicarbonate during drug shortages. further studies are needed. fever is common in neurocritically ill patients. it can be from central causes, inflammatory, infectious, and other conditions. a method to differentiate infectious from non-infectious fever would allow for appropriate initiation of empirical antimicrobial therapy. apart from avoiding unnecessary antimicrobial usage, this approach can save health-care costs and limit the development of antimicrobial resistance. procalcitonin is a peptide precursor of the hormone calcitonin. procalcitonin levels rise as a proinflammatory response to bacterial infections. numerous studies have evaluated procalcitonin levels utility in the initiation and discontinuation of antibiotics in the inpatient setting; however, there is a paucity of studies regarding the use of procalcitonin levels in neurologically ill patients. this study examines the effectiveness of a procalcitonin-guided algorithm in a neurocritical care unit. a modified prorata trial procalcitonin algorithm was developed and utilized prospectively. patients that met criteria of 1) admission into the neurocritical care unit 2) age > 18 years 3) temperature > 101 f in the last 24hrs 4) no obvious source of infection were enrolled. depending on the procalcitonin level and the presence of new sirs criteria antibiotics were initiated per our algorithm. radiographical, microbiological, laboratory, and clinical outcomes were recorded to determine the accuracy of the procalcitonin algorithm in the decision to initiate or modify patient's antibiotic therapy. results from the first 20 enrolled patients found the procalcitonin algorithm had 67% sensitivity and 88% specificity in predicting bacterial infections as the etiology of fever with a positive predictive value of 89%. the study population included intracranial hemorrhage (55%), ischemic stroke (20%), and others (25%). 60% of the study population had infectious fever while 40% had non-infectious fever. interim results suggest a procalcitonin-guided algorithm may be a valuable tool in differentiating infectious from noninfectious fever in the neuro-icu. further research is needed; data collection is ongoing. posterior reversible encephalopathy syndrome (pres) is defined by acute neurologic symptoms caused by vasogenic cerebral edema. recurrence of pres is thought to be rare and has not been well described. patients prospectively diagnosed with pres from 2005-2012 were pooled with retrospectively identified patients diagnosed with pres from 1999-2005 at an academic referral center. detailed clinical information and radiologic imaging results were collected. patients without clinical or radiographic resolution between episodes and patients without brain imaging available for review were excluded. of a total of 189 patients with pres, 12 (6%) had recurrence. one patient had four episodes, one patient had three, and ten patients had two episodes each, resulting in 27 total pres episodes. seven patients (58%) had an autoimmune disorder. the average time between episodes was 14 months. acute hypertension was present in 22 of 27 episodes. of these, mean blood pressure was 198/116 mmhg. etiologies of pres included hypertension (n=15), cytotoxic medications (n=2), sepsis (n=2), and multifactorial (n=5). renal failure was present in 13/27 episodes, and was acute in 5. clinical symptoms included headache (n=17), seizure (n=17), visual disturbances (n=9), encephalopathy (n=9) and focal deficits (n=1). only one patient (8%) had the exact same clinical symptoms with recurrence. ten patients had mri at each episode of pres. vasogenic edema affected the same brain areas at each episode in 5 patients. in the rest, some affected regions were similar, but additional regions were different between pres episodes. none had entirely new areas of involvement. pres recurred in approximately 6% of our patients. in the majority, clinical symptoms differed at recurrence compared to the initial episode. in all patients, radiologic patterns of vasogenic edema in the repeat episode were similar to those in the initial pres episode, but also affected other brain regions in approximately 50%. ventilator-associated pneumonia (vap) is a common complication in comatose patients. diagnosis in this population is unreliable despite physician training and validated criteria leading to potential misdiagnosis and inappropriate antimicrobial use. we investigated clinical features associated with misdiagnosis of vap and excess antibiotic days (ead). ventilated comatose patients (glasgow coma scale motor score <6) suspected of having vap were prospectively identified in a neurocritical care unit in 2011. vap was retrospectively diagnosed using centers for disease control (cdc) criteria by two neurointensivists and an infection control practitioner. appropriateness of the nccu team's vap diagnosis and therapy was performed using clinical, microbiologic and radiographic data. of 173 comatose patients, 34 cases were treated as possible vap by the nccu team. of these, 13 patients had vap by cdc criteria. vap and non-vap groups did not differ in age, admission gcs, total ventilator days or mean total antibiotic days (11.38±9.0 (vap) vs. 13.23±7.9 (non-vap); p=0.53). clinical features significantly associated with vap (vs. non-vap) were change in sputum character, tachypnea, oxygen desaturation, persistent infiltrate on chest xray and positive sputum microbiology. two-thirds (66.7%) of non-vap patients received pneumonia targeted antibiotics for >8 days vs. 30.1% of vap patients (p=0.04), contributing 88 eads, including 66 vancomycin days, 22 piperacillin-tazobactam days and 44 cephalosporin days. median days from intubation to starting antibiotics was 1 (non-vap) vs. 4 (vap) days (p = 0.13). no pre-specified factors were associated with inappropriate continued vap treatment. inappropriate diagnosis and treatment of vap resulted in a cumulative 141 eads in one year in the nccu. clinical differences between patients without vap who had antibiotics continued or discontinued were minimal, suggesting that clinician behaviors contribute to unnecessary prescribing. strategies to improve the diagnosis of and antibiotic use for vap in comatose patients is needed. management of hyponatremia in patients with acute brain injury can be challenging. the oral vasopressin receptor antagonist has been studied extensively in other disease process but not in acute brain injury. we report our experience regarding the efficacy and safety of tolvaptan, an oral vasopression v 2 -receptor antagonist, for the correction of hyponatremia in acutely brain-injured patients. tolvaptan for the correction of euvolemic or hypervolemic hyponatremia. baseline serum sodium concentration was 128.9 ± 3.1 meq/l. seven patients received 15 mg of tolvaptan once (singledose-users), and 11 patients received another 15 mg on the next days (double-dose-users). 24 hours after tolvaptan administration, serum sodium concentration increased by 5.5 ± 2.1 meq/l in single-dose-users (p = 0.016) and 5.3 ± 5.0 meq/l in double-dose-users (p = 0.004). 48 hours after administration of first dose of tolvaptan, serum sodium increased by 7.4 ± 2.2 meq/l in single-dose-users (p = 0.016) and 9.9 ± 5.5 meq/l in double-dose-users (p = 0.002). during four days of observation, the increases in the average area under the curve of the serum sodium concentration was 5.2 ± 1.9 meq/l in single-dose-users (p = 0.016) and 7.8 ± 4.2 in double-dose-users (p = 0.002). urine output increased by 2.3 ± 1.9 l during the first 24 hr in single-dose-users (p = 0.038). no significant changes in fluid balance, serum creatinine and glasgow coma scale were observed. of four patients who underwent neuro-monitoring, intracranial pressures, cerebral perfusion pressures and mean arterial pressure did not change significantly compared with their baseline values. tolvaptan was effective and well-tolerated for the correction of hyponatremia in patients with acute brain injuries. validation can be done with further studies. patients with acute brain injury but normal lung function often undergo intubation and subsequent tracheostomy for the concern of airway protection. we previously described patients with primary brain injury and encephalopathy who fail extubation demonstrated signs of disrupted ventilation usually with periods of prolonged hypoventilation. we examined the clinical characteristics of patients with a tracheostomy who are readmitted to the icu with respiratory decompensation. retrospective review of patients admitted to the neurocritical care unit (nccu) of a tertiary care hospital who underwent tracheostomy from september 2009 to june 2011. of 90 patients who received tracheostomies during their admission to the nccu, 38 (42%) were successfully transferred to the floor, 22 (25%) were readmitted to the icu, and 30 (33%) had other dispositions such as discharge to rehabilitation and withdrawal of care. there were a total of 28 readmissions, 12 due to respiratory decompensation and 3 due to cardiopulmonary arrest. hypoventilation is commonly seen in neurological patients who receive a tracheostomy. potential predictors of respiratory decompensation and readmission of these patients include their brainstem reflexes and respiratory patterns as assessed by the four score as well as their duration of mechanical ventilation. twenty-two percent of neurocritically ill patients may become hypernatremic. moderate-severe traumatic brain injury (mstbi) patients may develop hypernatremia possibly from diabetes insipidus (di) or osmotherapy for brain edema treatment. retrospective studies suggest that hypernatremia (serum sodium [sna] >160 mmol/l) may be associated with an increased risk of death. however, these studies failed to adjust for di and the use of osmotherapy. we examined the impact of mean and peak sna on in-hospital mortality and functional outcome at hospital discharge, adjusted for these important variables. in a prospective observational study, 144 consecutive mstbi patients from a single level i trauma center between 11/2009-2/2012 were analyzed. poor outcome was defined as glasgow outcome scale (gos) 1-3. multivariable logistic and ordinal regression was utilized to adjust for admission characteristics, injury severity, icu length-of-stay, brain edema, osmotherapy (mannitol/hypertonic saline), and di. firth's method was used in logistic regression models to accommodate small sample sizes. the mean age was 51 years, 70% were men, and the median glasglow coma scale and injury severity scores were 5 and 32, respectively. higher mean and higher peak sna were significantly associated with worse outcomes, both when using the dichotomized (or 1.3; 95% ci 1.1-1.5 for mean and or 1.1; 95% ci 1-1.2 for peak sna) and ordinal gos (or 0.8; 95% ci 0.7-0.9 for mean and or 0.9; 95% ci 0.86-0.98 for peak sna). for every 5 mmol/l increase in mean sna and every 12 mmol/l increase in peak sna, patients worsened by one gos category. our results suggest that higher sna values are associated with worse neurological outcome, independent of osmotherapy, brain edema and di. it will be important to determine which sna might be "too high". while autonomic instability occurs as part of anti-n-methyl d-aspartate (anti-nmda) receptor encephalitis, anti-nmda receptor encephalitis is not a recognized cause of the clinical syndrome of paroxysmal sympathetic hyperactivity (psh). we present a case of anti-nmda receptor encephalitis in which psh was a cardinal feature. a 31-year-old woman had a generalized tonic-clonic seizure, and then developed progressively worsening neuropsychiatric symptoms, including mania, hallucinations, echolalia, and suicidal ideation. diagnostic work-up revealed anti-nmda receptor antibodies detected in the serum and in the cerebrospinal fluid (csf). one week after symptom onset, the patient experienced intermittent episodes of sinus tachycardia, hypertension, tachypnea, diaphoresis and extensor posturing. the episodes were both spontaneous and stimulus responsive (for example, during endotracheal suctioning). the episodes, consistent with psh, were initially treated with dexmedetomidine, which was titrated to effect. gabapentin and propranolol were added later for symptom control, but eventually weaned off as her symptoms abated approximately six weeks into the illness. we believe that the autonomic instability associated with anti-nmda receptor encephalitis may often be psh. psh often goes unrecognized in patients outside of the setting of tbi, thus specific psh management strategies may be overlooked in other contexts. anti-nmda receptor encephalitis may represent the functional companion to the structural lesion encountered in tbi. recognition of psh in this setting is important to guide the management of the autonomic instability, but may also have mechanistic implications. a 34-year old male with history of motor vehicle accident s/p frontal sinus surgery was admitted with streptococcus pneumoniae meningitis and altered mental status. upon admission, he was febrile with leukocytosis. head ct showed left sinus opacification and csf studies were consistent with bacterial meningitis. despite broad-spectrum antibiotics and interval improvement in his head ct and csf studies, his mental status continued to decline. shortly after icu admission, he became lethargic with a new right-sided hemiparesis. cta revealed diffusely narrowed intracranial arteries most compatible with vasospasm and mri was consistent with multiple areas of infarction. his neurological exam continued to deteriorate necessitating intubation for airway protection. tcds showed bilateral mca vasospasm. initially, vasospasm was managed with nimodipine, hypertension, and euvolemia. systolic blood pressure was artificially elevated with vasopressors, inotropes, and ultimately with methylene blue. despite aggressive medical management, there was little improvement clinically. therefore, he received four sessions of angiography with intra-arterial verapamil. after the final intra-arterial verapamil treatment, he demonstrated angiographic and clinical improvement. we conclude that patient's cerebral vasospasm was a direct complication of streptococcus pneumonia meningitis. intra-arterial verapamil appears to be effective in treating pneumococcal meningitis induced symptomatic cerebral vasospasm. however, there is limited data to predict its vasodilatory sustainability and optimal treatment intervals. pneumococcal meningitis is the leading cause of bacterial meningitis beyond the neonatal period. clinical and experimental research had demonstrated that vascular alterations are common in bacterial meningitis and are associated with stroke. despite the introduction of the pneumococcal vaccine, availability of effective antibiotics, and advances in adjunctive strategies, mortality and morbidity rates associated with arterial complications secondary to pneumococcal meningitis remain high. this case is noteworthy because to our knowledge this is the first reported case of pneumococcal bacterial meningitis induced vasospasm that has been successfully treated with intra-arterial verapamil. xuemei cai 1, 3 osmotic myelinolysis is a life threatening problem associated with rapid correction of chronic hyponatremia. the brain cannot readily restore organic osmolytes; thus rapid correction of serum osmolality leads to cellular shrinkage causing axonal dissociation from myelin sheaths. current guidelines state that serum sodium (sna) should be corrected at a rate not exceeding 6-10meq/l/day but when extracellular volume depletion is the cause, vasopressin suppression after saline treatment increases risk of rapid overcorrection. there is no standard of care that directs treatment once osmotic myelinolysis occurs. we report a case of a patient who developed clinical symptoms of osmotic myelinolysis syndrome who was successfully treated with re-induction of hyponatremia which led to complete neurological recovery. a 71-year-old woman on thiazide treatment for hypertension developed protracted vomiting and diarrhea for several days followed by confusion and lethargy. in the emergency department, sna was 107meq/l. she received isotonic saline and over the next 12 hours, sna rose 21meq/l. on hospital day two, her neurological condition deteriorated rapidly with development of mutism, increased tone in all extremities, hyperreflexia. osmotic myelinolysis syndrome was diagnosed on clinical grounds. she was given desmopressin with 5% dextrose in water (d5w) to rapidly lower her lower her sna. her neurological status improved at a sna of 115meq/l. thereafter, sna was slowly uptitrated with desmopressin and 3% normal saline. she made a complete neurological recovery. mri performed at discharge and one month later showed no abnormalities. overcorrection of sna in chronic hyponatremia is a common iatrogenic problem which can lead to osmotic myelinolysis syndrome, a highly morbid and oftentimes fatal neurological condition. our case supports immediate re-induction of hyponatremia in patients with symptoms suggestive of osmotic myelinolysis at a time when imaging may be unremarkable and complete neurological recovery is achievable. posterior reversible encephalopathy syndrome (pres) is manifested by acute neurological findings with evidence of vasogenic edema on brain imaging possibly due to cerebral vascular endothelial dysfunction. the epidemiology of pres in pediatric critical care has not been well described and it may be under recognized and thus prompt treatment delayed. we performed a retrospective review of all patients with diagnosis of pres over 18 month period (january 2010 to june 2011) in a pediatric critical care unit (pccu) at a tertiary care university hospital. data from hospitalization and 6 month follow up were reviewed. there were 1221 admissions to pccu and 141 neurology service consultations during the study. six patients were diagnosed with pres (incidence -1 in 203 pccu admissions) with median age 17 years (mean±sd; 14.8±5.74 years). all patients presented at onset with generalized tonic-clonic or clonic type seizures that lasted up to 12 hrs and returned to baseline mental status in 2-7 days. other clinical features were headache and visual impairment. risk factors preceding the onset of pres included anemia [hemoglobin 8.6±1.6 g/dl], azotemia, hypertension, hypernatremia, hypocalcemia, hypomagnesemia, and recent use of chemotherapy (azathioprine, cyclophosphamide, tacrolimus and mycophenolate mofetil). brain mri demonstrated increased t2/flair signal within the parieto-occipital white matter in all 6 patients, frontal lobe changes in 5 patients and vertebro-basilar system changes in 2 patients. no regions of restricted diffusion were seen on diffusion weighted imaging. at 6 month follow up, no patients had residual neurological deficits from pres and neuroimaging revealed significant resolution of white matter signal changes. pres is associated with multiple disease states including systemic lupus erythematosus, sickle cell disease, sepsis, recent use of cytotoxic medications and renal failure. knowledge of the risk factors associated with pres, its clinical presentation, and characteristic mri findings may lead to more rapid recognition and treatment. adults with neurological injury are at increased risk for tracheobronchial foreign body aspiration. this report will present a case of silent foreign body aspiration in a patient who presented to the emergency department with status epilepticus. case report and review of the literature. an 87 year-old african american man presented to the emergency department with status epilepticus. seizures were controlled with intravenous lorazepam and fosphenytoin, and the patient was intubated for airway protection. on day four following admission to the neurosciences critical care unit, a routine magnetic resonance imaging (mri) scan demonstrated susceptibility artifact from a metallic focus which completely obscured the spine structures at c4-c5. upon review of the patient's previous imaging, numerous abnormalities were reported on daily chest x-rays and a foreign body was identified within the trachea on a thoracic ct from admission. a bronchoscopy was performed which revealed a watchband within the trachea and right mainstem bronchus. tracheobronchial foreign body aspiration should be considered in patients with unexplained respiratory symptoms, and a high degree of clinical suspicion should be maintained in patients with neurologic impairment. abnormalities on chest xray and computed tomography should prompt an early pursuit of the diagnosis in high-risk patients. mri, although generally considered to be a safe imaging modality, could be potentially harmful to patients with unidentified foreign bodies. hypokalemic periodic paralysis (hypopp) is a disease characterized by muscle weakness or paralysis secondary to low serum potassium levels. neurogenic diabetes insipidius (di) is a condition where patient excretes large volume of diluted urine due to low level of anti-diuretic hormone (adh). here, we report a case of hypopp in a patient with neurogenic di. a 30 year-old right-handed hispanic male was admitted for seizures after developing a dental abscess. this patient had a history of pituitary adenoma resection at the age of 12 with subsequent pan-hypopituitarism for which he was on hormonal supplementation. on hospital day three, he developed sudden onset of quadriparesis with motor strength in upper extremities 0/5 bilaterally and 1/5 in both lower extremities and absent deep tendon reflexes throughout. his routine laboratory studies showed severe hypokalemia of 1.6 meq/dl. nerve conduction study (ncs) revealed absent compound motor action potentials with normal sensory potentials. electromyography (emg) revealed no abnormal insertional activity or spontaneous activity. some muscles demonstrated no volitional motor units and a few others had decreased recruitment in distal small motor units. following aggressive correction of the hypokalemia he regained his full strength and repeat emg showed normal motor units, normal recruitment, but no myotonic discharges. ncs showed return of compound motor action potentials in all nerves tested. hypopp remains an important differential in an acute case of paralysis and acute management is important. we report a case of a 57-year-old caucasian male who presented to a community hospital with complaints of flu-like symptoms. he underwent pulmonary-vein isolation for chronic atrial fibrillation thirty days prior to admission. his history includes left frontal and right parietal ischemic infarcts, mitral valve repair, coronary artery bypass grafting, patent foramen ovale closure, and coronary artery disease. approximately 30 hours prior to arrival, he developed nausea, vomiting, fatigue and confusion. he was febrile and appeared encephalopathic. a telemedicine stroke consultation recommended transfer to a tertiary care facility. while the initial concern was for acute cerebral ischemia, he did not meet exclusion criteria for thrombolytic therapy. the patient received aggressive initial hydration and broad spectrum intravenous antibiotics for coverage of meningitis. blood cultures, complete blood count, comprehensive metabolic panel, urinalysis, stool culture and a lumbar puncture were performed. interestingly, his blood cultures remained persistently positive for gram positive cocci in chains and clusters. occult stool was positive and his oral gastric tube demonstrated bloody drainage. the remainder of his laboratory work was unremarkable. ct scan of his head revealed old ischemic infarcts without hemorrhage or hypodensity. the patient continued to decompensate in the neurointensive care unit where he eventually required intubation. a ct scan of the chest was highly suspicious of a left atrial-esophogeal fistula. cardiothoracic surgery was notified of the atrio-esphogeal fistula and he was taken to the operating room for a right thoracotomy with repair of the fistula and intercostal muscle flap. post-operative mri brain demonstrated innumerable air emboli and diffuse areas of ischemic infarction. atrio-esophageal fistula is a very rare complication following pulmonary vein isolation, and because prognosis is dependent upon prompt surgical correction, neurointensivists should be aware of this entity financial support: none propofol infusion syndrome (pris) is a rare but devastating complication of high dose administration of diprivan in children and young adults which presents with metabolic acidosis, rhabdomyolysis and fatal cardiac dysrhythmias. we report a case of pris in a 20-year old, previously healthy, postpartum female who received a high dose diprivan infusion for 48 hours at an outside institution for the treatment of presumed refractory convulsive status epilepticus. patient received diprivan100mcg/kg/min for the first 24 hours. diprivan was increased to 150mcg/kg/min to achieve burst suppression on the electroencephalogram. diprivan was stopped after 48 hours due to lactic acidosis. subsequently patient developed renal failure and elevation of ck up to 140,000.she was transferred to our institution for continuous hemofiltration and possible extracorporeal membrane oxygenation (ecmo).after transfer she developed atrial fibrillation, ventricular tachycardia and fibrillation. an ecmo catheter was placed when she was in ventricular fibrillation for 60 minutes. after starting ecmo the patient developed asystole for 8 hours, requiring a transvenous pacemaker. her cardiac dysfunction improved rapidly and ecmo was discontinued after 5 days. the patient started to follow commands consistently at 14 days after the onset of fulminant pris. mri of the brain showed a subacute right posterior cerebral artery infarct attributed to cardiac embolism. the patient left intensive care unit after 3 weeks. close metabolic and cardiac monitoring should be applied when a patient is on high-dose of diprivan(>80mcg/kg/min). diprivan should be stopped as soon as unexplained metabolic acidosis, rhabdomyolysis and cardiac dysrhythmias are noticed, and transfer the patient to a center with continuous hemofiltration and ecmo capabilities should be considered. ecmo can be a lifesaving intervention in patients with fulminant pris. postpartum cerebral angiopathy (pca) is a rare pregnancy complication. pca is often a benign condition that resolves spontaneously, but can lead to stroke or death. the purpose of this case study is to describe events that transpired in the care of a patient with severe persistent pca, for whom unconventional treatment was initiated because conventional treatment failed. retrospective and current chart reviews were conducted, including relevant medical history. objective data related to the patient's condition were reviewed. we examined the evolution of medical and nursing care as the patient's condition deteriorated despite aggressive conventional therapy, and reviewed ensuing events: multidisciplinary collaboration to search for other viable treatment options, consultation with colleagues from another major medical center regarding their experience with nicardipine and recommendations on off-label use for pca, and decision-making including the family about whether or not to administer intraventriuclar nicardipine. multiple disciplines (i.e., doctors, nurses, and pharmacists) and family members contributed to the complex decision to initiate unconventional treatment. we administered 2 mg intraventricular nicardipine every eight hours for seven days. using transcranial dopplers, cerebral arteriograms, and clinical assessment data, we evaluated the effectiveness of this unconventional treatment. after seven days, we discontinued the nicardipine, while continuing standard treatment to maintain hypertension and hypervolemia. currently, the patient is expected to make a full recovery with few residual stroke deficits. a multidisciplinary approach, including the family in the decision-making process, enabled creative problem-solving for a challenging clinical situation. when conventional methods failed, our team collaborated to think outside the box and take a calculated risk, altering the course of our patient's condition from critical toward survival and recovery. the objective was to determine the diagnostic yield and safety of brain mri in critically ill patients with icu-acquired acute brain dysfunction. patients in the medical and surgical icus who developed acute brain dysfunction and underwent brain mri were included. patients with preexisting brain disorders and those from neurological icus were excluded. mri scans were analyzed by three specialists trained in neuroimaging. outcome variables included glasgow outcome scale at discharge (1-3 categorized as unfavorable and >3 as favorable) and death. 146 patients underwent brain mri for evaluation of encephalopathy, seizures, focal deficit. signs of parenchymal brain abnormalities were detected in 130 patients (89%) including white matter hyperintensities in 71.2% and acute cerebral infarcts in 40.4%. results from brain mri led to modification of diagnosis and treatment in 53% of cases. patients with mri defined lesions were more likely to have an unfavorable outcome. there were no adverse events from transportation to the radiology site or from mri performance. in icu patients with acute brain dysfunction, mri is a safe noninvasive diagnostic tool that often leads to substantial modification of diagnosis and treatment. structural brain injury contributes significantly to the pathogenesis of cerebral dysfunction during critical illness and should be taken into account even if other reasons for encephalopathy are presumed. central nervous system (cns) and intraventricular infections are a devastating complication for patient admitted to an intensive care unit. the use of intrathecal (it) antibiotics for the treatment of cns infections has been reported in small case studies. our purpose was to report patients who have received it antibiotics for intraventricular infections in our facility and discuss our findings. retrospective case series of patients who received intrathecal antibiotics in combination with systemic antibiotics for treatment of intraventricular cns infection over the past 7 years. basic demographic and clinical measures were collected from the hospital data base. seven patients received it antibiotic therapy for cns infection. admitting diagnoses were head trauma (1), intracranial hemorrhage (4), and subarachnoid hemorrhage (1). one patient had an infected ventriculoperitoneal shunt. all of the patients received an external ventricular drainage device during admission prior to developing cns infection. time from hardware placement to first positive csf culture for 1 patient was 4 days; 2 patients were positive with first csf; 2 were within 14 days; and 1 had his vp shunt in place for 36 days prior to positive cultures. pathogens cultured from csf included klebsiella pneumoniae, acinetobacter baumannii and vancomycin-resistant enterococcus faecalis in 2 patients each, and methicillin-resistant staphylococcus aureus in 1 patient. the intrathecally instilled antibiotics were colistin, streptomycin, tobramycin and vancomycin. two of the patients cleared csf cultures in 1 day, 1 patient cleared in 3 days, 2 patients cleared in 6 days and 1 took 26 days to clear csf. based on this small case series we found it antibiotic adjunct therapy as a viable option for treating cns infections as most of our patients cleared csf within 6 days of treatment initiation. further studies are warranted to support our findings. we report a case of an esthesioneuroblastoma or olfactory neuroblastoma (onb) presenting with frontal lobe dysfunction and hence depression with rapidly declining mental status resulting from hydrocephalus and stroke meningitis. this is a 48year old man who presented with fever, headache and ams. he had 12 months history of progressive headache, face pain, rhinorrhea, nasal congestion and depression. ct head showed destruction of the cribriform plate by a mass arising from the right nasal cavity with extension into the right inferior frontal cranial fossa. an evd was placed emergently for elevated icp. he was also found to have multiple strokes in the right basal ganglia and corpus callosum. an incidental mycotic aneurysm was seen at the right posterior cerebral artery. labs showed wbc of 23, sodium of 122, potassium of 3, bicarbonate is 30. a lumbar puncture was performed which showed evidence of bacterial meningitis. a diagnosis of onb was established by histopathology and confirmed by immunohistochemistry. on staging, the mass was classified as a kadish stage c tumor. he underwent coiling of the pseudo aneurysm of right pca and maxillary embolization, followed by bifrontal craniotomy and endovascular resection of tumor onb is a rare malignant tumor of neuroectodermal origin and is thought to arise from the olfactory epithelium. symptoms are related to nasal obstruction, orbital extension, invasion of thecribriform plate, paraneoplastic syndromes with hypercalcemia and hyponatremia and can cause frontal lobe dysfunction. physical examination generally reveals a vascular, polypoid mass located in the nasal cavity. mri helps to differentiate tumor from other causes of nasal obstruction. they typically stain for neuron-specific enolase (nse). there has been no standardized rct done due to rarity of the tumor but traditionally the mainstay of treatment in such locally advanced patients is combinedotolaryngologic and neurosurgical craniofacial resection followed by adjuvant radiotherapy. we describe a case of delayed ptld in a 51 year old diabetic patient with esrd several years after multiple solid organ transplants; a successful pancreatic transplant and a rejected renal transplant. she initially presented with mild left hemiparesis and was found to have enhancing and non-enhancing both supra and infra tentorial lesions, without evidence of disease in the graft, skin or bone marrow. the histological diagnosis of ptld was made after a right frontal brain biopsy. she had intercurrent worsening of left hemiparesis post biopsy due to hemorrhagic transformation of one of the lesions. the patient initially responded to a decrease in immunosuppressive medications which included tacrolimus and cellcept however, she eventually also required rituximab and whole brain radiation to maintain remission. in this case report we highlight the manifestations of cns ptld, dilemmas in diagnosis and various strategies for management. this can be a fatal complication of solid organ transplants if not recognized and treated early. dysautonomia has been well associated with guillain barre syndrome (gbs). the dysautonomic effects of gbs may cause a variety of reversible clinical syndromes associated with sympathetic dysfunction including pres and takotsubo cardiomyopathy. pres can be a presenting feature following gbs treatment with intravenous (iv) immunoglobulins or may present later in recovery. dysautonomia resulting from gbs is the most likely explanation for this assocication while another possible mechanism can be the influence of cytokines, produced in the context of gbs, on the permeability of blood brain barrier. in this abstract we highlight a self limited case of pres presenting as an early complication of gbs. case: our patient was a 57 year old female with hypertension who presented to an outside hospital with alteration in mental status. she had developed bilateral lower extremity weakness and difficulty ambulating for 3-4 days prior to admission. she reportedly had an upper respiratory infection about 2 weeks prior to presentation. at the time of transfer to our hospital the patient had a generalized tonic clonic seizure and was started on keppra. she had a fluctuating mental status from being awake to stuporous. bilateral lower extremity power was 2/5 in all muscle groups. initially, deep tendon reflexes were 1+ in lower extremities but after a few hours she became areflexic in lower extremities with 1+ reflexes in upper extremities and downgoing plantars. mri brain t2/flair images showed lesions consistent with pres. csf showed cyto-albuminologic dissociation and diagnosis of gbs was made. she was started on a 5 day course of iv ig. she was discharged to a rehab facility with some improvement in her paraparesis and no recurrent seziures. this case report illustrates that patients can develop pres as a complication of gbs perhaps due to dysautonomia but pres may be self limited in this setting. data exists describing the outcomes of critically ill patients with specific conditions in specialty intensive care units (icu) versus general icus. severe sepsis and septic shock(ss/sh) outcomes have not been robustly evaluated in community hospitals between specialty icus. we chose to evaluate whether patients admitted to icus with ss/sh would have higher mortalities in neuroscience (ns) and cardiac (cards) icus versus general medical surgical icus (msicu). intensivists. the variables collected include age, time to antibiotics, intravenous fluids given, central line placements, code status, vasopressor requirements at 6 hours and mortality. chi-square analysis was used to compare mortality rates. icus who were directly admitted from the ed were ns 39% (n =12), cards 36%(n=34), msicu 33% (n=34) p=.38. the mortality rate for patients admitted with ss/sh was similar independent of the type of the icu the patients received care in. a multivariate analysis needs to be done to confirm these outcomes neurocrit care (2012) 17:s1-s337 s193 thromboembolism is a known and feared complication of administering prothrombin complex concentrates (pcc) but the true incidence is unknown. most data is in regards to mi, dvt, pe and dic with little reported on ischemic stroke. this is the first known report in the literature of acute basilar thrombosis after reversal of anticoagulation with pcc. we present a 77 year old women with acute basilar thrombosis after reversal of anticoagulation using pcc (profilinine sd). she was admitted with a hemodynamically stable lower gi bleed with a supratherapeutic inr of 10. she was taking coumadin for a recent pulmonary embolus. anticoagulation was reversed using profilnine sd 4950 units (47 u/kg) and vitamin k 10 mg intravenously. 2 hours later she developed left facial weakness, quadraparesis and anarthria. ct brain showed no early ischemic changes. ct angiogram showed occlusion from the mid-basilar to the basilar apex with normal vertebral arteries from the origin to the site of occlusion. factor ii activity was elevated with normal activity of factor vii, ix and x. tte showed normal wall motion and ejection fraction without evidence of thrombus or shunt. pcc protocols for reversal of anticoagulation are used with increasing frequency, even in non-emergent situations. thromboembolism is a known complication of administration, even with modern formulations of pcc which include anticoagulants. risk of thromboembolism increases with doses above 40 u/kg and with repeated dosing. the cause of thrombogenicity remains uncertain. accumulating data indicates the importance of factor ii (prothrombin) which has a linear relationship with thrombin generation. our case suggests that given potentially fatal thromboembolic complications, pcc administration should be weighed against the need for rapid correction of coagulopathy. more discussion is needed regarding complications of pcc administration, optimal dosing and uniform production of pcc products on the market. endovascular reperfusion reduces infarct volume to improve clinical outcome; however treatment effect may be diluted by subsequent care. an exploratory analysis was done to determine if discharge disposition impacted 90 day mrs after definitive reperfusion therapy. in our study, patients discharged to snf & ar after thrombectomy have similar medical & neurological severity at admission and similar final infarct volumes at discharge. despite these similarities, patients discharged to snf had a significantly lower probability of achieving a good neurological outcome. further study is required to determine if ar should be considered in more patients to improve clinical outcomes. patients with acute ischemic stroke develop respiratory failure due to airway compromise from loss of protective reflexes or cerebral swelling. in such patients, traditional weaning parameters poorly predict successful extubation. failure of extubation increases complications, prolongs hospitalization and increase cost of care. we hypothesize that predictive factors can be identified in determining ischemic stroke patients with respiratory failure who can be successfully extubated. between january 2007 to december 2010, 166 consecutive patients admitted to a metropolitan academic stroke center with acute ischemic stroke and were mechanically ventilated within 48 hours of admission were reviewed after irb approval. patients who were intubated for procedures only, extubated within 48 hours, or placed on comfort measures were excluded, leaving 42 patients for analysis. statistical analysis was done using sas 9.1 and univariate or multivariate logistic regression was performed when appropriate. of the included patients, the average age was 65.3 ± 11.5 years, and 27 (64.3%) were male. the median admission nihss was 13.5 and majority of patients had cardioembolic (20) or large vessel atherosclerotic (20) strokes. 17 patients had posterior circulation stroke (40.5%). eleven patients failed extubation (26.2%). acute basilar occlusion was found to be a strong predictor of extubation failure (or=21.3 95%ci: 2.7-167 p=0.004) when adjusted for age, stroke severity and duration of mechanical ventilation. increasing age and higher nihss showed trend toward increased risk for extubation failure but did not reach statistical significance. hospital length of stay doubled, icu length of stay tripled, and total hospital cost doubled in patients who failed extubation. patients with respiratory failure due to acute stroke from basilar occlusion were more likely to fail extubation. patients who fail extubation had longer icu and hospital stay doubling the cost of care. further studies are needed to determine whether preemptive tracheostomy may be beneficial in this group of patients. early detection of patients likely to develop malignant middle cerebral artery (mca) infarction (mmcai) is essential to enable timely decision for promising interventions (e.g., decompressive hemicraniectomy). this study was designed to evaluate whether quantitative eeg (qeeg) could predict mmcai within 6 hours of stroke onset. this prospective, observational cohort study enrolled 67 patients with a mca infarct. all of them underwent eeg monitoring within 6 hours after symptom onset. subsequently, their raw eeg data were quantitatively analyzed and the qeeg parameters including (delta+theta) / (alpha+beta) ratio (dtabr) and brain symmetry index (bsi) were computed based on the power spectral density. patients were classified in the mmcai group if they had decline of consciousness with radiological signs of space-occupying brain edema, whereas the others were allocated into the non-mmcai group. for the 2 groups, we compared the above qeeg parameters, and clinical and imaging variables. univariate and multivariate discriminant analysis was used to determine the most accurate predictors of mmcai. of the 67 patients included, 37 developed mmcai. univariate analysis showed that the values of dtabr and bsi, the nihss scores on admission and a hypoattenuation on admission cerebral computed tomography (cct) scans > 50% mca territory were significant predictors of mmcai. the further logistic regression analysis identified bsi > 0.49 (odds ratio [or] 10.32, 95% confidence interval [ci] 6.78 to 16.19; p = 0.001) and the infarct size > 50% mca territory on cct scan at admission (or 5.17, 95% ci 1.76 to 11.51; p = 0.009) as independent predictors, and bsi > 0.49 was the better predictor, which achieves a positive likelihood ratio (lr) of 11.3 (95% ci 3.81 to 33.67) and a negative lr of 0.11 (95% ci 0.04 to 0.33). quantitative eeg allows the early prediction of mmcai, and can help in the selection of patients for decompressive hemicraniectomy. financial support: none the modified rankin scale (mrs) is a 6-level outcome scale used to assess level of function in neurological disease. its utility is underscored by widespread use in stroke outcomes assessment, but the basic levels of function encoded by the mrs are not specific to stroke. still, poor interobserver reliability and the requirement for expert and face-to-face interviews are problems in determining an mrs score. we have developed a 9 question "yes/no" questionnaire, the mrs-9q, and an online mrs calculator to quickly and accurately determine the mrs. we hypothesize that (1) the mrs-9q has acceptable interobserver reliability, (2) the mrs-9q can be administered equally well in person or over the telephone, (3) the mrs-9q can be administered accurately by personnel without clinical expertise, and (4) the mrs-9q allows application of the mrs to a broad range of neurological conditions. the mrs-9q was administered by form or telephone. a web-based tool calculated the mrs and performed error checking. part 1 compared the mrs-9q to an mrs structured interview (n=80). part 2 compared mrs-9q administration by telephone and by paper form (n=80). part 3 compared administration by an expert interviewer with administration by a non-expert (n=83). part 4 examined reproducibility over 2 weeks (n=84). agreement was very good in all study parts. in part 1 (mrs-9q vs. mrs-si), k was 0.80 and k w was 0.96. in part 2 (telephone vs. paper), k was 0.83 and k w was 0.95. in part 3 (expert vs non-expert), k was 0.72 and k w was 0.93. in part 4 (reproducibility), k was 0.76 and k w was 0.93. the mrs-9q can reliably determine the mrs by paper survey or over the telephone. importantly, the mrs-9q survey does not require the participation of trained experts-excellent results are obtained when non-medical study personnel administer the survey. potentially inappropriate medications (pims) are medications that may increase cognitive burden and impact clinical outcomes in elderly icu patients. this study evaluates the use of pims and outcomes in elderly stroke patients. this is a retrospective study of p july 2011. number of pims, length of stay (los), and changes in gcs and rass scores were evaluated. fisher's exact test was used to compare groups. of 112 a significantly longer nsicu los and worse outcomes. introduction ais patients often have acutely elevated bp requiring iv antihypertensives (ivah). previous work shows aha/asa recommended antihypertensives used to reduce bp in ais commonly results in polypharmacy and its consequences: overshoot hypotension and increased mortality. this study evaluates the association between ivah polypharmacy and both clinical and economic outcomes in ais. premier, a us hospital administrative database. patients with ms-drgs 61 to 66 and a primary ais icd-9 code (433.x1 or 434.x1) were included. patients were matched in a 1:1 fashion utilizing propensity score methodology controlling icu admission, baseline characteristics, and pre-existing conditions. from january to december 2009, 9203 study patients received at least one ivah on day one or two of hospitalization and 28.2% of those received more than one ivah. after matching, 1886 patients remained in each group. patients in gp1 had a lower mortality rate than gp2 (9.6% vs 12.9%, p=0.0012), lower vasopressor use (4.3% vs 5.8%, p=0.0313), shorter los (median 4 days vs 5 days, p<0.0001), and lower total hospital costs (median $8,138 vs $9,622, p<0.0001). t-pa use was similar between groups (14.1% vs 15.0%, p=0.46). polypharmacy to treat acute hypertension is associated with worse clinical and economic outcomes in ais regardless of tpa administration. recent evidence suggests precise and reliable bp control is critical during the entire stroke pathway of care. currently recommended ivah do not reliably manage bp as single agents. in order to avoid polypharmacy and improve outcomes and costs, the ideal ivah drug needs to reliably manage and maintain precise bp control as monotherapy. financial support: authors are employees of the medicines company which markets an iv antihypertensive agent. mean corpuscular hemoglobin concentration (mchc) is a red blood cell indicie that is obtained as part of a complete blood count (cbc). mchc values reflect individual red blood cell (rbc) hemoglobin (hgb) content, and are directly affected by changes in hgb production and dna synthesis. recently another hematologic indicie: the red cell distribution width (rdw), has been shown to be an independent predictor of outcome in patients with stroke. we sought to determine if mchc on admission could be predictive of clinical outcome. this is a retrospective study on patients admitted to a university affiliated community hospital. initial mchc data were gathered retrospectively from the registry database. we included both ischemic and intraparenchymal hemorrhage (iph) stroke patients in our analysis. for evaluating the severity and outcome of the patients with ischemic strokes we used nihss on admission and mrs on discharge respectively. in iph patients, we utilized the university of california san francisco intracerebral hemorrhage (ich) score on admission / 24 hours to quantify the severity of the stroke and mrs on discharge to measure the outcome. we used correlation coefficients (spearman's rho) and the mann whitney test for analysis of the data. spss version 11 was used for data processing. our review identified 74 patients with a diagnosis of iph and 543 with a diagnosis of ischemic stroke. the mchc values in the iph group positively correlated to ucsf ich score on admission (p=0.01, r=0.29) and at 24 hours(p=0.006, r=0.31), as well as to mrs at discharge (p=0.02, r-0.27). the mchc levels for ischemic stroke patients correlated weakly and negatively to nihss on admission (p=0.001, r= -0.14) and d-mrs (p= <0.001, r= -0.17). mchc levels on admission correlate significantly with clinical measures of stroke severity and disability. mchc could serve as an early predictor for outcome in different stroke subtypes. in the absence of specific guidelines, there is considerable variance in pre-procedural intubation practices for endovascular treatment of acute ischemic stroke. the purpose of this study is to understand and characterize the variance in pre-procedural intubation practices and identify the reasons that influence the choice of pre-procedural intubation practices among treating physicians. we selected 10 random cases from a prospective database of patients undergoing endovascular treatment for acute ischemic stroke and prepared a case summary providing pertinent demographic, clinical, and imaging data. twenty clinicians independently reviewed the case summaries and responded to whether they would intubate any of the 10 patients and identified the reasons for their choices. clinicians were also asked to identify their training background (neurology, neurosurgery or radiology trained endovascular specialist, vascular neurologist or neuro-intensivist). reasons for intubation and agreement between clinicians for each case were ascertained. the decision to intubate the patient was made in 63 of 200 total clinical scenarios. the major reasons identified by the physicians for pre-procedural intubation were high national institute of health (nih) stroke scale scores on admission 26.9% (n=17), labored breathing or desaturation 23.8% (n=15), less than optimal respiratory status of patients combined with drowsiness or reduced level of consciousness 14.3% (n=9), inability to follow command such as due to aphasia 12.7% (n=8), seizures 1.6% (n=1), and no reason 20.6% (n=13). overall agreement between clinicians regarding decision of pre-procedural intubation among the 10 case scenarios was 30. the decision of pre-procedural intubation varies widely among clinicians. due to recent data that suggests that decision of pre-procedural intubation may impact on patients' outcomes, better standardization of such practices is required. hyperglycemia has been shown to be associated with worse outcomes, increased hemorrhage rates, and increased mortality in patients with acute ischemic stroke (ais). we evaluated the effect of admission hyperglycemia on 90-day functional outcome, mortality, and hemorrhage rates in patients undergoing multimodal endovascular therapy (met) for ais. retrospective review of glucose on admission was performed in 638 patients undergoing met between 1996 and 2012 in a tertiary care academic medical center. demographic data, diabetic status, nihss score, radiologic studies, and recanalization timi grade were analyzed, amongst other known predictors of hemorrhage and poor outcome. mean age was 66.5+13.5 and mean nihss 16.9 + 6.7. hyperglycemia was present in 310 ( admission hyperglycemia in patients undergoing met is associated with poor 90-day functional outcome and higher rates of in-hospital death and hi. in non-diabetic patients, hyperglycemia was only associated with increased mortality and hi. despite equivocal results for induced normoglycemia, this data justifies a prospective trial for moderate glycemic control in this patient population. previous studies suggest that low cholesterol levels are associated with higher rates of hemorrhage after acute ischemic stroke (ais). we studied the effect of serum lipoproteins and premorbid statin use on the rate of hemorrhage in ais patients treated with multimodal endovascular therapy (met). retrospective review of statin use and lipoprotein levels on admission including ldl, hdl and total cholesterol (tc) was perfomed in 601 patients undergoing met between 1996 and 2012 in a tertiary care academic medical center. demographic data, nihss score, radiologic studies, and recanalization timi grade were analyzed, amongst other known ldl <100 mg/dl was associated with a higher incidence of ht (or 1.67, 95% ci 1.21-2.07, p= 0.025). hdl >60 was associated with higher rates of ph (or 1.32, 95% ci 1.07-1.76, p=0.045). tc levels and premorbid statin use were not associated with higher rates of hemorrhage. statin use, ldl, hdl and tc were not independently associated with functional outcome at 3 months. patients with hemorrhage and tc <200 had significantly higher rates of good functional outcome compared to those with tc >200 (or 1.33, 95% ci 1.05-1.55, p=0.035). there was no significant association between statin use and rates of hemorrhage or functional outcome in patients presenting with ldl <100. low ldl and high hdl levels are associated with increased rates of hemorrhage after met for ais. statin use had no effect on post-intervention hemorrhage or functional outcome regardless of admission lipid levels. despite the association between low ldl and hemorrhage, statin use in patients with a low ldl was not associated with poor outcomes. this data justifies further study of the effect of continuation and early initiation of statin therapy in this patient population. mexican americans (mas) have shown lower post-stroke mortality compared to non-hispanic whites (nhws). limited evidence suggests race/ethnic differences exist in intensive care unit (icu) admissions following stroke. our objective was to investigate the association of ethnicity with admission to the icu following stroke. cases of intracerebral hemorrhage and acute ischemic stroke were prospectively ascertained as part of the brain attack surveillance in corpus christi (basic) project for the period january, 2000 through december, 2009. logistic regression models fitted within the generalized additive model framework were used to test associations between ethnicity and icu admission and potential confounders. an interaction term between age and ethnicity was investigated in the final model. a total 1,464 cases were included in analysis. mas were younger, more likely to have diabetes, and less likely to have atrial fibrillation, health insurance, or high school diploma than nhws. on unadjusted analysis, there was a trend toward mas being more likely to be admitted to icu than nhws (34.6% versus 30.3%; or=1.22; 95% ci 0.98-1.52; p=0.08). however, on adjusted analysis, no overall association between ma ethnicity and icu admission (or=1.13; 95% ci 0.85-1.50) was found. when an interaction term for age and ethnicity was added to this model, there was only borderline evidence for effect modification by age of the ethnicity/icu relationship (p=0.16). no overall association between ethnicity and icu admission was observed in this community. icu utilization alone does not likely explain ethnic differences in survival following stroke between mas and nhws. the medicines company, parsippany, nj, usa the relationship between blood pressure variability and inpatient outcomes and costs following ais is not well understood. using data from >100 us hospitals (cerner health facts®), we identified all admissions between 1/1/2009 and 12/31/2010 of -9-cm diagnosis codes 433.x1, 434.x1). in patients with principal diagnoses of ais, time of initial clinical presentation was designated "index time"; for those with secondary diagnoses of ais, index time was in-hospital onset of stroke symptoms. we calculated blood pressure variability (bpv) as maximum difference (md) (i.e., highest -lowest recorded bp) in the 3-hour period following index time. patients were igh"] vs <median value ["low"]). we examined rates of hemorrhagic transformation, in-hospital mortality, and total in-hospital charges in the two groups. a total of 322 admissions satisfied all selection criteria (high bpv: 166; low bpv: 156); patients were comparable with respect to age (mean age, 71 years), gender, and comorbidities. patients with high bpv were nominally more likely to experience hemorrhagic transformation (1.8% vs 1.3%; p=0.70) and to die in hospital (4.2% vs 3.2%; p=0.63), respectively. they also had significantly higher total in-hospital charges ($32,536 vs $23,856; p<0.01). highly variable blood pressure during the 3 hours following ais is associated with increased total in-hospital charges. further research is needed to better understand the degree to which better early hypertensive management may improve patient outcomes. financial support: our research was funded by the medicines company. mr. berger, mr. moynahan, and dr. oster are employed by policy analysis inc., an independent contract-research organization with previous and ongoing previous work from our group revealed an association between lower end-tidal carbon dioxide (co 2 ) values with worse outcomes in intubated, mechanically ventilated patients undergoing intra-arterial procedures for acute ischemic stroke. based on that observation, we hypothesized there might also be an association between lower arterial co 2 and outcomes in this patient group. we retrospectively reviewed the charts of participants in a national, multi-center mechanical thrombectomy trial. all patients were intubated and mechanically ventilated at the time of their intra-arterial intervention per protocol at our institution. arterial blood gasses (abg) were typically obtained post-procedurally at admission to the icu as part of admission laboratory panel. demographics, hospital course data, arterial blood gasses and outcomes (90-day modified rankin score) were collected. descriptive statistics (median and intraquartile range for continuous variables; counts and percentages for categorical variables) were used to describe clinical data. categorical variables were compared using fisher's exact tests, and ordinal comparisons were made with the wilcoxon-mann-whitneytest. significance was set at : mrs0-4; vs. unfavorable: mrs 5-6. seventy-five patients were identified as part of the registry, though 14 were excluded from this analysis (13 had no recorded abgs, 1 lost to follow up). patients with an unfavorable outcome were older (73 [59-81] v. 58 [53-70] , p=0.01). in the unfavorable group, median pco2 levels were statistically significantly lower than those with a good outcome (38 [35-41] v. 42 [39-43] , p=0.01). our results suggest that there may be an association between lower pco2 values and outcome in intubated, mechanically ventilated ischemic stroke patients. one possible explanation is that hypocapnea facilitates cerebral vasoconstriction, worsening ischemia and possibly enlarging the ischemic penumbra. this association should be further interrogated in a prospective, controlled trial. although ischemic brain tissue should appear particularly dependent on the main oxygen carrier hemoglobin (hb), optimum hb and hematocrit (hct) levels in neurointensive care unit (nicu) patients with severe ischemic stroke (is) are still unknown. research thereof and of the best red blood cell (rbc) transfusion regimen is neglected. here, we aimed to investigate associations of hb/hct dynamics and transfusion activity with nicu variables and outcome in nicu patients with ischemic stroke. patients with is were retrospectively assessed if admitted to the nicu for at least 3 days and mechanically ventilated. assessment involved clinical characteristics, rbc transfusion events, and laboratory parameters such as hb, hct, creactive protein, blood count, creatinine. mortality and functional outcome (by mrs) were assessed prospectively by telephone interview at 3, 6 and 12 months after discharge. statistics were descriptive and explorative, i.e. involved correlation / variance tests for associations between hb, hct levels, transfusion events and outcome (linear regression analysis, t-test). 109 patients were analyzed. 62% had anterior circulation, 38% posterior circulation ischemic stroke with a median nihss of 17 and a median apacheii of 22. median nicu stay was 14 days, median ventilation time 244 hours. baseline hb and hct were 13 g/dl and 0.38, mean decrease over nicu stay was 30% leading to minimum hb and hct of 9 g/dl and 0.26, respectively. mrs at day 90 was 3 (6%), 4 (14%), 5 (46%) and 6 (=dead, 34%). a first preliminary analysis did not reveal any consistent associations between severity of anemia or transfusion activity and outcome. anemia is frequent in nicu patients with ischemic stroke. at present, this retrospective analysis does not support a more aggressive rbc transfusion practice. more detailed subgroup analysis results will be presented at the time of the meeting. although not clinically validated, physicians frequently use imaging to help predict neurologic and cognitive outcome after hypoxic-ischemic injury to the brain following cardiac arrest. we systematically reviewed the current literature investigating the accuracy of imaging in predicting outcome in adult patients who are comatose after cardiac arrest. the electronic databases of medline via pubmed, embase via ovid, and the cochrane database of systematic reviews were searched using combinations of the search terms "cardiac arrest," "cardiopulmonary resuscitation," "brain hypoxia," and "neuroimaging." eligible studies were reviewed in detail and classified by level of evidence (loe) and methodological quality as defined by the international liaison committee on resuscitation (ilcor). 802 articles were identified, 72 of which met inclusion criteria and were reviewed in detail. 65 articles found imaging to be helpful in accurately predicting outcome: 15 were categorized as loe p3 (10 good, 3 fair, 2 poor quality), 30 loe p4 (6 good, 12 fair, 12 poor quality), and 20 loe p5 (5 good, 3 fair, 12 poor quality). 8 articles found imaging to not be helpful in accurately predicting outcome: 2 were categorized as loe p2 (1 good, 1 fair quality), 3 loe p3 (all poor quality), 3 loe p4 (1 good, 1 fair, 1 poor quality). 1 article was found to be equivocal, categorized as loe p4 (fair quality). no loe p1 trials have been performed and although two loe p2 studies exist, they do not compare different modalities and have limited generalizability in the clinical setting. there is insufficient evidence to recommend routine use of imaging to predict outcome in comatose cardiac arrest patients. further studies are needed to determine the utility of imaging in this setting, and should include comparison with already validated methods of prognostication such as the clinical exam and electrophysiology. in acute ischemic stroke, factors affecting blood pressure (bp) levels in the first few hours after onset are not well known. the rise in bp levels can be a mechanism to compensate for vessel occlusion and to ensure the viability of penumbral brain tissue (pbt). between january 2006 and december 2009, data of 206 consecutive acute ischemic stroke patients admitted to florence nightingale stroke unit within the first 12 hours and evaluated with stroke mri were analyzed. potential early correlates of bp levels were analyzed with multivariate logistic regression technique. age, gender, hypertension (ht) history, treatment for ht, onset to door time, nihss, level of consciousness, stroke type and stroke etiology, pwi/dwi mismatch, index proximal vessel occlusion (ipvo), were included in the analyses. a pwi/dwi mismatch, a potential indicator of pbt, was considered as present if estimated at least to be approximately 20% by eyeballing the lesion. index pvo was defined as symptomatic occlusion or 70-99% stenosis of carotid or vertebrobasilar artery system vessels. high bp level was defined as sys>140mmhg or dys>90 mmhg at admission. two hundred-six patients (119 male; mean age 69; range 20-96 years) were evaluated. hundred and four patients (50, 5%) had high bp at admission. in univariate logistic regression analysis, women (p: 0,023), age (p: 0,083), tacs (p: 0,035), hypertension history (p: 0,054), ipvo (p: 0,081) were associated with high bp values. only tacs (or: 2, 667; 95% ci: 1,290-5,513) was independently associated with high bp readings at admissions in multivariate analysis. we did not find any argument to state that high admission blood pressure is a compensatory response following brain tissue ischemia. intravenous recombinant tissue plasminogen activator (iv r-tpa) has revolutionized the management of acute ischemic stroke. however, symptomatic intracranial (6%) and severe systemic (1.6%) hemorrhagic complications after thrombolysis remain a concern. we present a rare complication of r-tpa and underscore the importance of close monitoring after thrombolysis. the clinical history, laboratory, and imaging studies were reviewed. a 46 year old man with psoriasis and morbid obesity presented with acute aphasia and right hemiplegia. he had fallen as a result, striking his right eye. his examination demonstrated right periorbital ecchymosis without ptosis, expressive aphasia, leftward gaze deviation and corresponding hemianopsia, and right facial weakness and hemiplegia. his summated nih stroke scale (nihss) was 13. initial cranial imaging demonstrated no blood, though did show an abnormal hyperdensity within the proximal left middle cerebral artery territory. he received iv-tpa 2 hours from symptom onset with significant neurological improvement within 20 minutes of thrombolysis. 30 minutes after initiation of iv r-tpa, he rapidly developed periorbital edema with ecchymosis leading to complete ptosis of the right eye. repeat cranial imaging showed an enlarging retro-orbital hematoma. an emergent lateral canthotomy was performed of the right eye to rapidly decompress the optic nerve. within 3 days of thrombolysis and successful orbital decompression, as visualized on repeat cranial imaging, he made near full neurologic and visual recovery. to our knowledge, this is the first reported case of a near catastrophic hemorrhagic ocular complication after iv r-tpa therapy for acute ischemic stroke. despite the suspected trivial nature of injury, thrombolytic treatment should proceed with caution in the setting of any trauma. this report highlights the importance of careful inspection and maintaining a high index of suspicion and vigilance for unanticipated complications after thrombolytic therapy. in the setting of acute or evolving stroke, outcome may be dependant on the urgent re-establishment of cerebral perfusion.options for restoring cerebral blood flow include the intra-venous or intra-arterial administration of thrombolytic agents, mechanical thrombolysis, and urgent carotid endarterectomy. there is very limited experience with emergency extracrannial-intracranial (ec-ic) bypass in this setting. we reviewed the medical records and neuroimaging studies of 20 consecutive patients who underwent urgent ec-ic bypass in the face of acute cerebral ischemia. none were considered appropriate candidates for endovascular therapy. ages ranged from 21 to 74 years, average 48.5 years. average follow-up was 6.2 years. preoperative angiographic evaluation identified critical narrowing of the supraclinoid ica in 8, the m1 segment of the middle cerebral artery in 10, and the cervical/petrous ica in 2. all had progressive, refractory symptoms associated with enlarging areas of ischemic changes on diffusion-weighted mri despite maximal medical therapy including anticoagulation and antiplatelet agents, blood pressure elevation, and fluid resuscitation. all patients underwent urgent sta-mca anastomosis. in every case, bypass resulted in stabilization of the progressive ischemic symptoms; in 3 cases, revascularization was followed by rapid, dramatic improvement of preoperative deficit. five patients awoke with transient worsening of their preoperative neurological deficit which improved over 24-48 hours. no patient demonstrated a significant new area of ischemia on mr imaging. emergency ec -ic bypass for acute ischemic injury was both safe and effective in our experience. this population was characterized by relatively young patients with severely limited collateral circulation. in this series of 20 carefully selected patients, bypass was successful in arresting ongoing ischemic symptoms, and in some cases, resulted in rapid neurological improvement. the ability for clinicians to predict outcome is of paramount importance when treating and counseling stroke patients and families. the dragon score is used to predict outcome in patients with anterior circulation strokes that have received intravenous tpa. we sought to determine if the dragon score could be applied to patients undergoing endovascular stroke therapy. charts for patients with interventions performed by a single operator (mfs) from january 2011 to march 2012 were reviewed. presenting symptoms were used to derive the dragon score. outcome predictability was compared to the findings in the original dragon score paper. twenty-four patients underwent endovascular stroke treatment; fourteen patients presented with anterior circulation ischemic strokes. five patients had only endovascular treatment, and 9 patients had both ivtpa and endovascular treatment. the total average time from onset to termination of the endovascular procedure was 367 minutes. in the 5 endovascular alone patients, 3 patients survived with a mean dragon score of 6.00 and mean discharge mrs of 3.00. of the 9 patients who received both intravenous and endovascular therapy, 8 survived with a mean dragon score of 4.25 and mean discharge mrs of 2.25. four of the 11 surviving patients had greater than 90% specificity for poor outcome (mrs 5-6) based on the original paper. these patients however demonstrated a good recovery with an average mrs of 2.25. despite the extended window for treatment and recanalization, patients who receive acute endovascular stroke therapy appear to have similar outcomes to the predicted outcome using the dragon score. furthermore, our study showed that patients who were expected to have poor outcome had the potential to improve clinically. this study reinforces the benefit of endovascular stroke therapy. intracranial arterial stenosis are relatively common findings of stroke patients in asia area. we reviewed stroke database to investigate clinical risk factors related to intracranial arterial stenosis, including carotid disease, and peripheral arterial disease which reflects advanced atherosclerosis. acute stroke patients at the national health insurance corporation ilsan hospital from january 2008 to december 2010 with available transcranial doppler(tcd) examination, carotid ultrasound and ankle-brachial indexes(abi) formed the analysis cohorts. retrospective review was performed. a total of 642 patients were included during that period, 212 patients with incomplete tcd study due to poor insonation windows were excluded(33%). according to tcd criteria, 3 groups of intracranial arterial stenosis are defined: 0 vessel stenosis is in 220 patients(51%), 1-2 vessels in 125 patients(29%), more than 3 vessels in 85 patients(20%). as the arterial number of intracranial stenosis increased, abi is decreased(p=0.013) and the size of carotid artery plaque is increased(p=0.011). among the risk factors, diabetes, age, past stroke history are increased(p=0.0000, p=0.006, p=0.05) and hdl cholesterol showed tendency of decrease(p=0.033). however hypertension, smoking, total cholesterol, ldl cholesterol, triglyceride and sex are not correlated with intracranial arterial stenosis. among the acute stroke patients, about a half of them have intracranial arterial stenosis and these patients tend to have higher burden of advanced atherosclerosis as evidenced by a higher prevalence of diabetes, large sized plaques of carotid artery and peripheral arterial occlusive disease. dedicated neurocritical care service in an acute-icu setting with specialized neuro nurses and physicians improves the quality of care and patient outcomes. we aimed to find out the impact of specialized focused neurocritical service as compared to a general surgical/medical icu setting in a community hospital. we retrospectively reviewed data from 2005-2011, on 165 patients who received endovascular treatment (iatpa, thrombolysis, mechanical thrombectomy, with or without intra and extra cranial stenting) in order to achieve recanalization. patients were divided into two groups: group a (n=58) general med/surg icu care in 2005-2008 and, group b (n=107) focused neurocritical care 2009-2011. functional outcome data (mrs 90 days) between the 2 groups was compared through patient records. group a patients were cared for with general surgical/medical icu care nurses while group b patients were cared for by a specialized core group of 12-16 nurses specifically trained in neurocritical care. both groups were comparable in terms of age, sex, admission nihss and co-morbidities (hypertension, hyperlipidemia, diabetes, ccf, a.fib, other). group a mrs 0-2 (n=22) 38%, group b mrs 0-2 (n=45) 42%. group a mrs 3-4 (n=14) 23%, group b mrs 3-4 (n=18) 17%. group a mrs 5 (n=12) 20%, group b mrs 5 (n=22) 21%. mortality for both groups was comparable at 20% (group a n=12; group b n=21). functional outcomes of fully independent patients (mrs 0-2) improved from 38% to 42% when a focused neurocritical care nursing service was implemented as compared to standard medical icu nursing care. strict adherence to neurocritical care protocols and proper attention to co-morbidities is the key to improved outcomes in critically sick acute stroke patient populations. in-hospital strokes remain a significant source of morbidity for patients. paradoxical embolism has been implicated as a potential source for these strokes. to date, there is only minimal literature regarding paradoxical embolus as a cause for stroke in the hospitalized patient. over a one-year period we studied in-patient stroke alerts and their etiologies at our institution. the hypothesis of this study is that strokes in hospitalized patients are caused by paradoxical emboli. this is a retrospective analysis of prospectively collected in-hospital stroke team calls (n=93) over a one-year period. we excluded patients on the stroke service or on neurologic floors including the neurological intensive care unit. we further excluded patients that were found to have stroke-mimics by consensus. from these patients, we collected demographic information and results of transthoracic echocardiograms (tte) and lower extremity (le) duplex. the categorical data was analyzed using chi-square on jmp 9.0. a confirmed acute ischemic stroke was found in 57 (61%) of the in-hospital stroke alerts. the majority of stroke alerts in our institution were from the cardiology and cardiothoracic services (71.9%). a tte and le duplex were available in 98.2% and 43.9%, respectively. two patients were identified with a patent foramen ovale (pfo) and nine with a deep venous thrombosis (dvt). one patient was found to have both a dvt and pfo which was presumed as the source of embolus. overall, there was no significant association of in-hospital stroke and presumed paradoxical embolus. the present study shows no association of in-hospital strokes and paradoxical emboli. this study is limited by the infrequent ordering of le duplexes in this at risk population but is strengthened by the available tte results. posterior circulation stroke (pcs) is associated with high mortality and poor outcome. this single centre, retrospective analysis evaluates long-term mortality and functional outcome in pcs patients treated with/without revascularization therapy (rt). between january 2006 and december 2009, dataof82 consecutive pcs patients admitted to florence nightingale stroke unit within the first 12 hours were analyzed. after evaluation with mri, eligible patients with pwi/dwi mismatch selected with eye-balling technique were treated with rt. ninety days modified rankin score (mrs) and mortality were the main outcome. eighty-two patients (48 male; mean age 68; range 27-92 years) were evaluated. the mean onset to door time was 258 minutes (sd:243). seventy-eight patients were examined with mri while 4 patients were examined with ct. twenty-one patients received rt; intravenous thrombolysis in 11, endovascular multimodal revascularization in 6 and bridging therapy in 4 patients. mean nihss score was 8 (range:0-38) [treated group (tg):13(2-38); untreated group (utg):7(0-32) p:0,009]. arterial occlusion was present in 43(7%)(tg:61,1%;utg:37,7%; p:0,104). mean door to treatment time was 152 minutes (sd: 282).mean onset to treatment time was409minutes (sd:281).mean discharge nihss score was 6 (range:0-32) [tg: 9(0-30); utg:5(0-32) p:0,009]. discharge mrs 0-1 ratio was 47,6% (tg:23,8%; utg:55,7%; p:0,013). the inhospital mortality rate was 8,5% (tg:14,3%; utg:6,6%; p:0,365). first month (tg:38,6%; utg:57,1%) and 3 rd month (tg:46,7%; utg:50%). mrs 0-1 ratio (p:0,174 vs. 1, respectively) also 1 th month (tg:21,1%; utg:11,9%) and 3 rd month (tg:26,7%; utg:17,9%) mortality (p:0,286 vs. 0,696, respectively) were similar between groups. in posterior circulation stroke, despite severe clinical manifestations at admission and hospital discharge, after long term follow up, the outcome in patients treated with revascularization therapy is similar to those patients with benign outcome and not necessitating any revascularization therapy from the outset. we present a case series that highlights the feasibility of decompressive hemicraniectomy (dhc) in pediatric patients with ischemic stroke. a retrospective chart review identified 3 cases of ischemic stroke at texas children's hospital between 2008-2012 where dhc was performed for high intracranial pressure (icp) after standard medical therapy failed to lower icp. information was obtained about patient characteristics on admission, radiological features of the stroke, surgical procedures, complications of the dhc and cranioplasty, and clinical outcomes. we also surveyed published literature on dhc for pediatric patients with ischemic stroke. there was no mortality in this case series. case 1 had a modified rankin score (mrs) of 3 at a follow up visit after 36 months. case 2 had mrs of 1 at a follow up visit after 36 months. cranioplasty was complicated by epidural abscess in his case. case 3 had mrs of 3 at a 24 months follow up. review of literature identified 7 other published case series consisting of 14 cases of dhc in pediatric patients with ischemic stroke. detailed analysis of these cases is presented in the tabular form. this case series highlights the fact that dhc can be performed safely and effectively in pediatric patients with ischemic stroke with potential lifesaving and improved functional outcome. decompressive hemicraniectomy should be considered as a therapeutic option for refractory elevated icp following large hemispheric strokes in the pediatric population. basilar artery occlusion (bao) is a devastating neurological disease that can be difficult to diagnose due to its protean manifestations, and the initial ct will often not reveal an acute infarction. we present a patient with bao who was initially diagnosed with lyme disease. a 67 y/o female presented with neck pain, an unsteady gait, partial facial paralysis, and mild dysarthria. she was noted to have an erythematous area on her neck that contained a tick. the initial head ct was negative. lyme disease was diagnosed and ceftriaxone and doxycycline were initiated. within 24 hours, her symptoms progressed to hemiparesis and aphasia. a stat mri demonstrated the absence of flow in the basilar and left vertebral arteries with restricted diffusion in the pontine and mid-right parietal regions. the patient was transferred to a primary stroke center, but she was outside the window for stroke rescue. acute lyme disease is characterized by lymphocytic meningitis, cranial neuropathy (particularly facial palsy) and radiculoneuritis. though these symptoms usually take weeks to occur, the initial tick bite may not be recognized thus precluding an accurate evaluation of the time course. bao may present with a similar constellation of symptoms including headache, facial paralysis, and transient paresis called the "herald hemiparesis" of bao. the fluctuating course of early bao may be confusing and a high index of suspicion is required. intra-arterial lytic therapy, mechanical thrombolysis, or a combination is recommended up to 12 hours of symptom onset. recanalization is paramount to preserving neurologic function. unfortunately, she arrived at our institution outside the window for invasive therapy. her symptoms continued to progress to a locked-in state and she was transferred to a ltac facility. the neurological manifestations of bao may be confused with other diagnosis and a high index of suspicion is required. metabolic abnormalities negatively influence outcome in patients with traumatic brain injury, subarachnoid hemorrhage, hemorrhagic stroke and ischemic stroke with or without thrombolytic therapy. the prognostic value of many potentially correctable physiologic markers in stroke patients receiving thrombolysis is unknown. twenty-one consecutive acute ischemic stroke patients treated with tissue plasminogen activator (tpa) were retrospectively studied. multiple metabolic and physiological variables including blood urea nitrogen, creatinine, sodium, potassium, chloride, calcium, phosphorous, magnesium and body temperature were analyzed. independent t test was used to compare mean scores of these variables and determine their effect on outcome. functional status at discharge was the primary outcome measure, being fully or partially independent determined as good outcome and fully dependent or dead as poor outcome. secondary outcome was the presence of hemorrhagic conversion. seventeen patients had good outcome, mean age 66, while 4 patients had poor outcome, mean age 81. hyperthermia and admission acute physiology and chronic health evaluation (apache) ii score were associated with poor outcome (p<0.05). hemorrhagic conversion occurred in 4 patients and was associated with hyperthermia, higher simplified acute physiology score (saps) ii score and hyponatremia (p<0.05 for all). this single-center, retrospective study suggests that mild hyperthermia, hyponatremia and higher apache ii and saps ii scores are associated with poor functional outcome and hemorrhagic conversion in patients with acute ischemic stroke treated with tpa. further study is required to determine if correcting these variables influences outcome. alterations in electrolyte balance and other basic physiologic indicies such as glucose have been implicated in the pathophysiology of coronary heart disease. however, the relationship between the electrolyte levels and other physiologic indicies measured immediately after an acute ischemic stroke has not been clearly delineated. objective: the aim of the present study was to test whether changes in a patient's basic metabolic panel modify the severity or outcomes of acute ischemic stroke. the study is a retrospective study on ischemic stroke patients admitted to a university affiliated community hospital. demographic data were collected from the data registry. values were obtained within one hour of presentation for serum sodium (na), potassium (k), glucose (gluc), chloride (cl), magnesium (mg), bicarbonate (hco3), bun, and creatinine (cr). as well glomerular filtration rate (gfr) and temperature values were also recorded. severity and outcome were measured using the nihss on admission and the mrs on discharge respectively. correlation coefficients (spearsman's rho) and the mann whitney test were employed in the analysis of the data. spss version 11 was utilized for data processing. results 543 consecutive acute ischemic stroke patients met the study criteria. serum ca (p=0.05, r= -0.08) and gluc levels (p=0.02, r=0.09) were significantly correlated with the mrs. serum cl, ca, bicarbonate, temperature and bun were significantly correlated with nihss on admission measurements (p=0.03, 0.002, 0.003,0.01; r=0.09, -0.13, ;0.13; 0.10 respectively). mg showed a negative trend of correlation with the nihss on admission as well (p=0.06; r=-0.08), suggesting a protective effect of higher mg levels. the study shows that initial metabolic parameters, such as serum mg, ca, hco3, bun, and temperature may potentially allow for early prediction of the severity and outcome in patients with ischemic stroke. hypersomnolence is not typically appreciated as a focal neurologic finding, though bilateral thalamic infarcts may present with hypersomnolence as the only neurologic manifestation. a 52 year old man presented with acute onset confusion, somnolence and slurred speech. his neurological examination was notable for somnolence, bilateral ptosis and dysarthria. routine laboratory investigations and csf analysis were unremarkable, aside from a urine toxicology screen which was positive for opiates. initial head computed tomography (ct) with ct angiography of the head and neck were unrevealing. magnetic resonance imaging was contraindicated as the patient had an automatic internal cardiac defibrillator (aicd). a working diagnosis of opiate intoxication was made in light of the urine toxicology results. because the patient failed to improve over the ensuing 24 hours, a repeat head ct was obtained which revealed bilateral medial thalamic infarctions. while hypersomnolence is often associated with toxic-metabolic disorders, it may rarely be the result of acute arterial stroke. in the context of stroke, hypersomnolence can be accompanied by other symptoms including weakness, paresthesias, memory impairment, sectoranopsia, and personality changes. the feature of hypersomnolence is usually the result of an infarct of perforators arising from the posterior cerebral artery, specifically the paramedian,and tuberothalamic arterial branches, which are involved in irrigation of the reticular, and intralaminar nuclei of the thalamus that are involved in arousal. concomitant neurologic signs may not be present or may be difficult to elicit in this setting as patients are often unable to participate in the neurologic exam. acute stroke should therefore be considered in the differential diagnosis of hypersomnolence. failure to consider stroke as a potential eitiology may lead to delay in acute or secondary stroke prevention. metals play key roles in epigenetic events in living organisms. zinc, cadmium, lead, selenium, calcium, magnesium, sodium, and potassium have been found to be associated with stroke risk in nhanes and other studies. the central hypothesis of this pilot study is that metals and metalloproteins may determine and distinguish stroke phenotype (ischemic vs. hemorrhagic). stroke patients at the university hospital emergency department (ed) were enrolled in a plasma banking project. after irb approval and informed consent, blood draws were performed in the ed, and demographic and clinical information recorded. we analyzed 29 plasma samples collected within 12hours of symptom onset. we used the proteomic techniques of affinity chromatography (to remove the abundant proteins albumin and igg), followed by size exclusion chromatography (sec -to eliminate low molecular weight compounds and fractionate the proteins), inductively coupled plasma mass spectrometry (icpms -to identify differentially expressed metalloproteins in plasma) and electrospray mass spectrometry (to identify the tryptic peptides known to represent specific proteins in the plasma). the areas and standard deviations of the chromatograms for the metalloproteins for stroke mimics (n=10), ischemic (n=10) and hemorrhagic (n=9) stroke patients were calculated using origin software. differences between sec-icpms peak areas of the metalloproteins for the ischemic, hemorrhagic and mimic samples were examined using two-sample t-test and box chart statistics. mg, al, mn, cu, zn, se, mo and pb were studied. significantly different metals were mg, al, mn, cu and se. box chart statistics performed for the sec-icpms metalloprotein peak area data revealed significant differences in all metalloproteins except al. tryptic peptide mapping identified significant differences in metalloproteins. sec-icpms detected differences in fractions of specific metal containing proteins in the plasma of stroke patients and patients who presented with a stroke mimic. ongoing efforts are aimed at identifying potential biologically relevant stroke biomarkers from the current list of differentially expressed proteins. retrospective chart review of patients admitted to the neurocritical care unit from august 2010 to august 2011 who developed icp crises (>20 mm hg for >5 minutes) and were treated with 23.4% hts. only data for the first ever treatment with hts were collected. patient demographics, onset and duration of action, lowest icp achieved and use of adjunctive therapies were recorded. descriptive statistics and correlation analysis were performed. complete data were available for 19 patients. ten subjects (52%) were female, the mean age was 52 + 18 years. glasgow coma scale (gcs) was 6 + 3 and 13 (68%) patients concomitantly received therapeutic hypothermia and pentobarbital coma. a 67+ 29.4% reduction in icp following administration of 23.4% hts was observed (absolute change: 19 + 9.4 mmhg). the mean time to icp <20 mmhg was 41 + 25 minutes and time to rebound icp >20 mmhg post-hts administration was 120 minutes in 75% of our cohort. following treatment the mean improvement in gcs was 2 + 2. a dose-response curve was generated. 23.4% hts was associated with a 67% reduction in icp values in critically ill neurology/neurosurgery patients. time to clinical endpoint of icp <20 mmhg was 41 minutes and in 75% of patients the duration of action was 120 minutes. an improvement of 2 points in gcs was also observed. the first description of a dose-response curve for 23.4% hts in humans is reported. over a ten year period, we accumulated a prospective dataset of 500 severely brain injured patients with multimodality monitoring (brain tissue oxygen monitoring and outcomes project). patients' data existed within individual excel files with heterogeneous fields. as different research subprojects arose, additional excel files were created to support new data extraction from clinical records. several issues were apparent: (1) merging and querying data was time-consuming and rate-limiting in research productivity; (2) users were unable to make uniform changes to all files; (3) different users could not simultaneously enter data, (4) auditing data entry was difficult. our goal was to convert the dataset into a relational database, to enhance clinical research efficiency. microsoft access was used to build a database with a relational backend structure and a graphical user interface (gui) frontend. a reporting tool was built for analysis, preview, printing, and customized queries. extract-transfer-load functions were programmed to create seamless data integration between the access database and the enterprise-wide clinical data warehouse (e.g. laboratory values, radiology results). it took approximately 640 man-hours to audit existing excel data, and to load distilled data from 500 excel files into structured database tables. it took approximately 480 man-hours for application implementation and testing. the gui supported multiple simultaneous users' during data auditing, enforced validation rules that corrected data entry in realtime, and centralized user account management. we have provided 20 research queries to date. excel has limitations as a tool for clinical research informatics. a relational database that is built with pre-defined rules, fields, and tables dispenses with the time-consuming step of merging and cleaning data and makes large dataset queries and analyses more efficient. it allows straightforward integration with other relational databases such as enterprise-wide clinical data warehouses, enabling expansion of queries into other clinical information systems. financial support: elsa lin is a data analyst whose salary was partially supported within the past twelve months by a grant from integra (brain tissue oxygen monitoring) for the specific purpose of creating a relational objective of this case study is to report a case of central nervous system (cns) histoplasmosis presenting as an ischemic pontine vasculitis and chronic basilar meningitis. histoplasmosis, a disease caused by fungus histoplasma capsulatum, primarily affects immune-suppressed patients and commonly involves the lung but occasionally can have variable cns presentations. a thirty-five year old caucasian immune-competent male came with worsening of aphasia and confusion after having presented four weeks prior with dysarthria, gait ataxia and bilateral upper extremity weakness. he was diagnosed with bilateral pontine ischemic strokes secondary to small vessel vasculitis and but had limited response to high dose steroids. cerebral spinal fluid (csf) examination showed elevated protein, low glucose and elevated cells suggestive of meningitis and he was started on empiric antibiotics and trials of repeat intravenous (iv) steroids. follow-up imaging revealed obstructive hydrocephalous and he underwent successful ventriculo-peritoneal (vp) shunt placement. his csf culture came back positive for h. capsulatum. csf histoplasma antigen and urine antigen were also positive. he was initially treated with ambisome but changed to voriconzaole secondary to renal insufficiency and was eventually continued on itraconazole. at one year, the patient good clinical improvement and follow-up cultures were negative. while pulmonary involvement of histoplasmosis in immune-suppressed patients is common, systemic presentation of this fungal infection in immune-competent patients is exceeding rare. clinicians should consider cns histoplasmosis on the differential diagnosis in atypical stroke cases, particularly those with chronic basilar meningitis. there is increasing incidence of dengue fever in our country and encephalopathy is the most common neurological manifestation of severe infection. however, recent studies have shown that there is increasing evidence for dengue viral neurotropism. dengue encephalitis, a distinct clinical entity have been found to be associated with the neurovirulence involving serotypes den-2 and den-3. the objective of this study is to report the clinical course, laboratory, and radiographic findings of dengue encephalitis that did not go through the usual state of dengue fever. management of this specific viral infection will likewise be discussed. case presentation and report with literature review. a20-year old filipino male, methamphetamine and marijuana user was admitted to our hospital because of seizures preceded by headache and fever. he was managed as a case of viral meningitis supported by cranial mri findings and csf studies. after nearly 5 days, he clinically deteriorated initially from a very agitated, restless and combative state progressing to frank stupor. body temperature was uncontrollably high. repeat csf studies revealed elevated pressure, lymphocytosis, normal protein and sugar, and positive igm dengue virus. serum study for dengue virus igm capture elisa was also positive. other significant tests ruled out malaria, hiv and nmda antibody as source of encephalitis. after intravenous steroids were started, on top of antipsychotics, clinical symptoms were noted to eventually resolve. we theorize that dengue encephalitis should be considered in the differential diagnosis of acute viral meningoencephalitis though the classical manifestations of dengue may not exist. while dengue infection may be endemic in asian countries, this should be considered in other parts of the world especially when patients rapidly deteriorate in the course of the disease. immunecompetence definitely play a vital role in the recovery. steroid therapy may be life saving in very severe cases. intracranial monitors can help guide the care of patients with severe brain injury. the devices are invasive and so may be associated with complications. furthermore, accurate interpretation of the monitors' data is needed to be of potential benefit. in this study we asked whether experience influences "device failure" or interpretation. retrospective analysis was performed on a prospective database that included 500 patients (median age 48; range 14-90) with severe brain injury and who received intraparenchymal multimodality monitoring through a triple lumen bolt (licox imp#). a total of 698 triple lumen bolts were placed during an 8-year period. device failure was defined as: 1) broken or bent (n=20; 2.87%); 2) improper placement (n=11, 1.57%); and 3) ineffective (no response to o 2 challenge n=11, 1.57%). there were 27 (3.8%) devices thought to provide "incorrect" data but subsequently were found to be accurate, i.e. improper data interpretation. there was a decline in device failure over the entire study period. each calendar year was divided into quartiles. device failure incidence was 30%, 10%, 55% and 5% per quarter, i.e. was greatest during the third quarter during the time of academic and staff changeover (or 10.77; p = 0.0131). in addition, improper data interpretation was greatest during the 3 rd quarter. our data suggest that experience with multi-modality monitors is associated with a reduced incidence of device failure or improper data interpretation. educational efforts may reduce the need for device replacement. financial support: peter leroux funding from integra for research. while efforts to "go green" and promote sustainability are well-established in many sectors, there has not been an adequate push toward such practice in the healthcare and medical fields. healthcare accounts for 11% of all commercial energy use, 4 bil pds of waste, and 8% of greenhouse gas emissions in the us. these figures requires significant for efforts to be implemented; we each subscribe to, "first, do no harm" demands that these negative environmental impacts be addressed and mitigated immediately. the intent of this report is to investigate and analyze the opportunities the healthcare industry has to embark on sustainable practices. we analyzed green architecture for new healthcare campuses and renovation of outdated facilities, submit efficiency and cost analyses of disposable versus reusable textiles, and offer observations on innovative technologies being developed to promote sustainability. this study was conducted after an extensive review of published literature, verified statistical reports presenting the cost-effectiveness and improved efficiency of pursuing an sustainable model of healthcare delivery. in cluded is a cradle-to-grave analysis of multiple facets of the healthcare/sustainability field, and addresses a number of specialist-specific avenues, including critical care and anesthesiology. energy-efficient building options -including rooftop gardens and alternative power sources -can cut energy consumption by 60%. healthcare providers in all fields are making efforts toward lowering the carbon footprint of hospitals by reducing greenhouse gas emissions and utilizing resourcing, second use and extensive recycling techniques and efforts. extensive life cycle assessments (lcas) prove that reusable medical textiles and tools are dramatically less expensive environmentally and financially than their disposable counterparts. while efforts are being made to promote sustainability in healthcare, more must be done. the evidence is clear: environmentally-conscious endeavors save money and help lessen the stress placed on the environment. for such a heavy-hitting culprit of consumption, the healthcare industry simply must begin implementing "green" practices based on already-present data. standard metabolic prediction equations have been validated in general critical care populations, but have not been well studied in the neurologically critically ill. we sought to determine whether: 1) standard prediction equations accurately predict caloric requirements in neurocritical care patients; 2) variation in resting energy expenditure (ree) exists among different subpopulations of neurocritical care patients; and whether the same factors influence ree among different neurocritical care subpopulations. indirect calorimetry measurements were retrospectively reviewed for 58 mechanically-ventilated patients admitted to the neuro icu from january 2009 to june 2012. the measured ree data were compared to the predicted basal energy expenditure (bee) calculated with the modified penn state university (psu-m) equation. patients were classified into 3 neurological subtypes, stroke (n=27), status epilepticus (n=14), and other (n=17). traumatic brain injury (tbi) patients were not included. of the entire cohort, median measured ree was 1432 (iqr 1215-1689) kcal/d and median predicted bee was 1519 (iqr 1318-1708) kcal/d. the predicted bee correlated well with the measured ree (coefficient 1.00; p<0.001) in the overall cohort. there was no significant difference in the predicted calorie requirement for stroke or status epilepticus. however, there was a suggestion that patients with status epilepticus were relatively hypometabolic (defined as ree <90% of the predicted bee) compared to other subgroup populations [or=3.2; 95% ci (0.95-10.8); p=0.06]. factors significantly associated with ree include: maximum 24 hour temperature, administration of intravenous sedation, body mass index (bmi) and sex. age and hospital day of ree were not predictive of energy expenditure. the psu-m predictive equation accurately estimates caloric needs for patients with non-tbi neurological injury. patients with status epilepticus may be hypometabolic relative to other neurologically injured patients, which may be due to use of multiple sedatives in this subpopulation. further research is needed to confirm these findings. the american society of anesthesiology provides guidelines for preoperative fasting for healthy patients undergoing elective procedures. these guidelines are often extrapolated to the critically ill population for procedures and extubation. we tested the hypothesis that npo practice differs between subspecialty, institution and practitioner-type. after irb approval, we conducted surveys of the memberships of the society of critical care medicine (sccm), neurocritical care society (ncs), and american burn association (aba) regarding their npo practice in critically ill patients. survey questions included frequency of use of nasogastric (ng) vs. nasoduodenal (nd) tubes, npo time prior to procedures, and npo time prior to extubation. responses were analyzed with stata 12.0, using a one-way analysis of variance by ranks. we received a total of 1402 responses (9% response rate) encompassing practitioners from medical, surgical, neurosurgical (130 responses), pediatric, cardiac, burn, trauma, and multidisciplinary icus. 106 respondents (7.6%) report 100% use of ng tubes, whereas 62 (4.4%) report 100% use of nd tubes. excluding responses from pediatric icu practitioners, the npo practice in nicus for intubated and non-intubated patients with nd tubes undergoing procedures is similar to respondents from other icus except the burn icu (p<0.001). there is no difference in npo practice of patients with ng tubes undergoing procedures across all icus. nicu respondents report the most commonly used npo time prior to procedures is 6 hours for intubated patients with nd tubes (33.1%) and 8 hours for those with ng tubes (40.9%). for burn icu respondents, the most commonly reported npo time for intubated patients with nd tubes prior to procedures is 0 hours (54.9%), while 8 hours is reported for those with ng tubes (37.7%). npo practice in critically ill patients varies across the subspecialty units. further research is necessary to develop evidence-based guidelines for npo practices in the critically ill patients. patients intubated for primary neurological reasons represent a unique critically-ill population. extubation failure rates in primary brain injury (pbi) patients are 18-38% compared to 13-18% in the general critical care population. these populations have never been directly compared. we hypothesized that intubated pbi patients would have higher rates of extubation failure compared to non-pbi patients. retrospective cohort of intubated patients admitted to the medical intensive care unit or the neurocritical care unit in a tertiary-care university hospital between october 1, 2008 and september 30, 2010. extubation failure was defined as requiring endotracheal intubation at 48 hours, 72 hours and one week. of the1684 . failing extubation at 72 hours did not put patients at increased risk for vap. total ventilator days were similar between pbi and non-pbi patients. pbi patients who failed at 72 hours did not have a significant increase in ventilator days, intensive care unit days or mortality. our data indicates pbi patients are at increased risk for extubation failure compared to non-pbi patients. future prospective study is warranted to determine predictors of extubation failure at 72 hours in pbi patients. peripherally inserted central catheters (picc) is been routinely used instead of central venous catheter (cvc) in our intensive care unit (icu) patients, that includes critical neurologic/neurosurgical patients. there are a number of studies has been done to evaluate risks of picc placement in general medical and surgical icus. a retrospective analysis to determine risk of large vein thrombosis due to picc in neurologic sub-population of patients in a general medical/surgical icu. charts and venous ultrasound studies of patients admitted to icu primarily for neurologic condition were reviewed. out of 183 consecutive patients, 54 underwent picc insertion. 10 (18.5 %) had clinical and ultrasound evidence of large venous thrombosis attributed to picc. the presence of a picc line conferred a relative risk of 4.78 for the development of a dvt. patients with picc lines had a longer duration of stay in the icu (mean days = 12.2 +/-8.3) when compared to patients without picc lines (mean days= 3.2 +/-2.4) t(57) = 7.9, p <.001. routine placement of picc instead of cvc is associated with increased risk of thrombotic events in large veins in neuro critical sub population of a general icu, which may be associated with longer icu stay. more caution should be exercised before routinely using picc instead of cvc. there are many potential obstacles to guideline adoption and compliance in clinical practice. the purpose of this research was to develop a computer-readable format for clinical pathways, guidelines, and research protocols such that they could be rapidly distributed, displayed at the bedside, and driven by patient context. the goal is to increase guideline compliance and reduce errors made at the bedside. we collected 12 institutional clinical practice guidelines from the abstract authors, 7 guidelines from professional societies (including the neurocritical care society), and one multi-center research protocol (boost-ii). we analyzed each to look for common constructs that would form the basis of a computer-readable care path "language". we also reviewed previous attempts at computer-readable guidelines to discover what might be applicable to our system. the analysis showed considerable variation in the way guidelines are put to practice at the bedside. despite this, we found a set of generalized patterns that were used to develop a care path representation (language) that could encapsulate the content of the guidelines. structured goal-oriented steps, alarm and time couplers, and a "monitoring cycle" were designed and represented in an xml-based language. a scripting method for decision logic also was developed. software was written to read the xml script, display the care path "flow-chart", provide interaction with the health care provider, and links to related instructional content. integration with real-time multimodal monitoring data allows the care path to be driven by the context of the patient. this abstract outlines the first part of a larger project to develop an open-standard guideline format and display software that will decrease the time to adoption of neurocritical care guidelines and increase compliance in clinical practice. financial support: funding received by moberg research from nih/ninds and us army/tatrc to carry out this work. one of the authors (r moberg) is president and owner of moberg research. the objective of this study was to develop empiric treatment guidelines for patients admitted to the neurosciences intensive care unit based on unit specific antimicrobial surveillance. a prospective chart review was performed from october 2011 to april 2012 of all adult patients admitted to the neurosciences intensive care unit with positive cultures from any site. in addition to culture data and antimicrobial sensitivities, time of admission, diagnosis, placement of an external ventriculostomy device (evd), duration of cefazolin prophylaxis and risk factors for healthcare-associated infections (hai) were collected. hospitalization within 30 days, residency in an extended care facility or hemodialysis at the time of admission were considered hai risk factors. cultures were analyzed as those occurring before or after day 7 of nicu stay. patients residing in the unit as a result of overflow were excluded. a total of 50 patients and 130 positive culture results were included and analyzed by duration of icu stay <7 days (n=69) or > 7 days (n=61). evd placement and cefazolin prophylaxis were present in 65% of patients for a mean of 8.2 days. at <7 days, methicillin-resistant staphyloccous aureus (mrsa) was the most common pathogen in patients with risk factors for hai. at <7 days without risk factors, the most common pathogens were methicillin-sensitive staphylococcus aureus (mssa) (n=8) and enterobacter (n=5) in the sputum and enterococcus (n=4) in the urine. a further analysis revealed theseisolates emerged after day 5 of admission in patients receiving cefazolin prophylaxis. beyond 7 days, sputum isolates predominated and consisted of gram negative pathogens (n=18), mssa (n=11) and mrsa (n=12). selective pressure from cefazolin prophylaxis was apparent in unit surveillance and emerged at or after 5 days. based on these results, institutional empiric antibiotic treatment regimens were adjusted to cover these pathogens after day 5 of nicu stay. the direct thrombin inhibitor dabigatran etexilate is approved for the prevention of stroke and systemic embolism in patients with non-valvular atrial fibrillation. despite the clinical benefits of dabigatran, hemorrhage remains a feared complication due to the lack of reversal agent and limited experience with interventions to reverse dabigatran's anticoagulant effect. in addition, reliable laboratory tests to measure the degree of anticoagulation associated with dabigatran are not widely available. an interprofessional team developed institutional protocols for the management of dabigatran and dabigatran-associated hemorrhages. clinical and neuroimaging data was collected from four patients with dabigatran-related subdural hematoma, subarachnoid hemorrhage and/or intracerebral hemorrhage who were treated between november 2011 and april 2012. data collected includes age, gender, past medical history, renal function, coagulation and hematology parameters, computed tomography findings, blood products or clotting factors administered, and hemodialysis parameters, if applicable. the patients ranged in age from 79-90 years. all patients were inappropriately prescribed dabigatran due to age over 75 years, renal insufficiency, increased bleeding risk, and/or an unlabeled indication. serial evaluation of each patient's coagulation assays was conducted in order to quantify the degree of anticoagulation. three of the four patients received emergent hemodialysis and one patient received recombinant activated factor vii. two patients received blood products, including ffp and platelets, with no observed clinical change. all patients survived to hospital discharge. though this case series is small, it demonstrates the importance of thoroughly evaluating a patient's renal function, bleeding risk, and concomitant medications to determine the appropriateness of dabigatran therapy. it is imperative for clinicians to understand dabigatran's pharmacokinetics and recognize the major factors that increase dabigatran exposure. increased age and renal insufficiency seemed to play a significant role in the hemorrhagic cases we encountered. post-surgical cerebral venous sinus thrombosis is extremely rare. the management of this complication is challenging for neurointensivists; since anticoagulation may increase the risk of bleeding after craniotomy. a previously healthy, 21 year-old male was found to have a right cerebellopontine angle mass on brain magnetic resonance imaging (mri) during headache evaluation. he underwent a prolonged surgery with retrosigmoid craniotomy and resection of an acoustic schwannoma in left lateral decubitus position. immediately post-operatively, the patient had a seizure. brain ct-scan showed hyperdensity in the right transverse sinus suggestive of thrombus. cerebral angiogram confirmed occlusion of the superior sagittal sinus (sss) torcula and bilateral transverse sinuses. intravenous heparin was initiated; however, due to further deterioration with brain herniation, endovascular administration of tissue plasminogen activator (rt-pa) assisted with thromboaspiration with penumbra catheter was performed, followed by continuous infusion of rt-pa (1 mg/hr) via microcatheter in the sss for 2 days. a repeat angiogram showed near complete recanalization of the sinuses. heparin was continued, but he developed heparininduced thrombocytopenia, and was switched to bilvalirudin. his hospital course was complicated with intraventricular hemorrhage, acute respiratory distress syndrome, methicillin-resistant staphylococcus aureus (mrsa) bacteremia, and takasubo's cardiomyopathy. he had residual right facial nerve palsy and hemiparesis related to pontine ischemia. his prothrombin gene mutation was positive for one copy. he was ambulating with assistance prior to discharge to acute inpatient rehabilitation. cerebral venous sinus thrombosis is a rare complication of retrosigmoid resection of cpa tumor. aggressive treatment with endovascular rt-pa administration into the venous sinuses may be life-saving, but carries significant risks in the fresh post-operative period. many lives have been lost due to the loss of the airway in critically ill patients. the introduction of the video laryngoscope has been a useful tool that has saved many lives in recent years. one of the limitations of the video laryngoscope is that despite being able to see the vocal cords and the airway beyond it may be difficult to advance the endotracheal tube into the airway. we present a novel approach using a bougie to simplify this problem. a cohort of ten patients in a community critical care unit with difficult airways were intubated using this new technique in a nonrandomized fashion over a period of six months. a video laryngoscope was used in each case with patients sedated and paralyzed with usual agents used for rapid sequence induction. historically, the bougie when used with standard laryngoscopes is introduced into the airway by line of sight and the endotracheal tube is advanced over the bougie. with a video laryngoscope a direct line of sight is not available and passing the bougie is challenging because of a 90 degree angle from the open mouth to the airway. this new technique involves lubricating both the metal stylet with the 90 degree turn and a 15 french x 70 cm bougie and advancing them to the end of the endotracheal tube. the bougie is then advanced into the airway through the endotracheal tube under direct vision through the video laryngoscope. the endotracheal tube is then advanced into the airway over the bougie. all ten patients were intubated without difficulty and without complication. this new technique should be considered as an option in securing the airway in critically ill patients. further validation testing by other investigators is warranted regarding this new technique to determine if a randomized controlled trial is justified. francis r. ventilator-associated pneumonia (vap) remains a problem in traumatic brain injury and high-risk surgery patients. we use early non-bronchoscopic broncho-alveolar lavage (screening-bal) in the surgical intensive care unit (sicu) to identify ventilated patients with bronchiolar bacteria prior to 48 hours. we reviewed results of these screening-bals in neurotrauma patients from 3/2011 to 6/2012. all ventilated patients in the sicu underwent screening-bal 36-48 hours after intubation; quantitative cultures (>10 4 cfu/ml) were used to identify positive specimens. clinical pneumonia was defined as clinical pulmonary infection score (cpis)>6 and subsequent positive diagnostic-bal. continuous and dichotomous data were compared from the screening-bal results and clinical diagnosis of pneumonia. screening-bals were performed in 47 neuro-trauma patients (mean iss 19.9 ± 6.11) with an average head abbreviated injury score (hais) of 3.83 ± 0.94. thirty-three of these were positive for organisms (70%). twenty-four clinical pneumonias were diagnosed and in 20 of these patients the causative organism identified was the same organism in the screening-bal (83.3% agreement; kappa 0.357; p = 0.02). one patient with a negative screening-bal developed clinical pneumonia. the median day to develop pneumonia was 3.5 (2, 13). the hais was higher in patients with a positive screening-bal (4.06 ±0.7 vs. 3.29 ±1.2; p = 0.03). there were no significant differences in the age, icu length of stay, iss, or hais in patients with a positive screening bal vs. the patients that developed a clinical pneumonia. positive screening mini-bal results are associated with the development of vap by the same organism. screening bal in neuro-trauma patients may be a mechanism to identify patients who are at-risk for developing pneumonia later in their hospitalization and early identification of the causative agent. further studies are warranted to determine if intervention on these results changes clinical course. human rabies is a relatively rare disease in the united states, with approximately 2 cases diagnosed annually. the most common exposure in the u.s. relates to bats, however canines and other animals have also been implicated. the typical incubation period from exposure to development of symptoms is 2-3 months, while periods of up to 6 years have been described. we present an atypical case of human rabies presenting after a prolonged incubation period in the united states. we describe a case of a 40 year old brazilian man without prior medical history who presented with progressive sensory symptoms leading to encephalopathy and ultimately death. extensive workup revealed no other causes of his symptoms, and brain tissue samples sent to the cdc at the time of his death confirmed a diagnosis of rabies by direct fluorescent antibody testing. in addition, sequencing of the virus confirmed a variant found in canines in brazil. the patient had not traveled to brazil in over 8 years, and had no confirmed exposure other than an encounter with a wild dog in brazil without reported bites or scratches before immigrating. because the viral genotype has not been previously identified among animals in the united states, this case represents the longest confirmed human rabies incubation in the united states to date. characterization of the illness revealed loss of evoked potentials, electroencephalography amplitude attenuation, mr spectroscopy changes of the deep nuclei, and an atypical inflammatory response on pathologic testing. we speculate that either an atypical immunologic response or the patient's recent anabolic steroid use may have mediated delayed progression. this case underscores the importance of keeping human rabies in the differential diagnosis of rapidly progressive encephalomyelitis, even without an exposure history, or with a remote exposure history. the full outline of unresponsiveness (four) score has been validated as an alternative to the glasgow coma scale (gcs) in the evaluation of stuporous and comatose patients and predicts long-term outcomes. the utility of serial four score and gcs by nurses in detecting changes in neurologic exam in the neurocritical care unit (nccu) and whether high frequency monitoring after the first assessment is beneficial has not been studied. the electronic charts of 50 consecutive patients with surgical and non-surgical brain pathology admitted to a nccu were reviewed, yielding 2881 observations of gcs, fourscore, and cranial nerve assessments. changes in neurologic exam promoting notification of a provider were abstracted from nursing notes. of 50 patients (m:f:28:22, age: 54+2 yrs), 25 had semi-elective neurosurgery, 8-ischemic/hemorrhagic stroke, 6encephalopathy/infection, 4-subarachnoid hemorrhage, 4-traumatic brain injury, 2-seizures, 1-other. admission median gcs was 14(iqr-5); median fourscore was 16(4). comparison of 2881 q2-4h fourscore vs. 311 qdaily fourscore readings showed no significant difference in fourscore by frequency of measurement (p=0.61). in 23 occurrences of change in neurologic exam resulting in provider notification, changes in mean fourscore and gcs from 4 hours prior to the event were 1.2(sd-2.4) and 1.2(2.1) respectively; p=1.00). from 2 hours prior to event, changes in mean fourscore and gcs were 0.9(2.1) and 1.1(2.1) respectively; p=0.41). in one cerebral herniation event, neither scheduled fourscore nor gcs changed. use of the fourscore for serial monitoring and early detection of worsening of neurologic condition performs similarly to gcs and is less sensitive than subjective assessment of trained nccu nurses. the utility of incorporating the fourscore into the on-going nursing assessment paradigm of all nccu patients requires further evaluation. there may be subsets of patients or conditions (with lower sumscores than in our cohort) for which daily or more frequent monitoring has predictive value. a technique for real time, non-invasive blood flow monitoring would be a major asset to clinicians in neurocritical care. we studied the ability of a new hybrid technology employing ultrasound tagged near infrared spectroscopy (ut-nirs) to detect changes in cerebral blood flow (cbf) as compared to measurements by 133 xenon single photon emission computer tomography ( 133 xe-spect). twelve healthy volunteers were enrolled in the study. a cerox monitor (ornim medical ltd. israel) provided continuous ut-nirs monitoring of regional tissue oxygen saturation (sto 2 ) and regional cerebral blood flow index (cfi). 133 xe-spect (ceraspect; dsi, waltham, ma, usa) was then used to measure cbf at baseline, 15 minutes and 60 minutes after acetazolamide injection. ten subjects completed the study. significant increases in cbf as measured by both ut-nirs cfi and 133 xe-spect cbf were noted 15 minutes after acetazolamide injection. at 60 minutes following injection, 133 xe-spect cbf had returned to baseline while ut-nirs cfi remained elevated compared to baseline. a significant correlation between ut-nirs cfi and 133 xe-spect cbf values was found at 15 minutes but not 60 minutes after acetazolamide injection. specificity and sensitivity for detecting an increase in cfi following acetazolamide injection were calculated using a receiver operating curve (roc), with an area under the curve of 0.95 (+/_ sem 0.001). no statistically significant changes in ut-nirs sto 2 were noted following acetazolamide injection. ut-nirs cfi can detect increased cbf following acetazolamide injection, correlates with a gold standard, 133 xe-spect, and the roc curve analysis demonstrates excellent discrimination. the difference in the measurements at 60 minutes may be explained by different ratios of gray matter to white matter in the regions of interest as assessed by the two techniques. ut-nirs cfi can be more sensitive to changes in cerebral perfusion than simple regional tissue oximetry. financial support: dr gress is a member of the scientific advisory board of ornim medical ltd and holds stock options in the company. level of coma has traditionally been measured clinically (e.g. glasgow coma scale, four score, etc.), or with neurodiagnostic tests (e.g. eeg). developing more objective, longer term measures of coma could improve quantitation of arousal and modification of response to therapy. we used a post-cardiac arrest (ca) rodent coma model to test 3-d bodily acceleration as a wireless, continuous measure of early movement during coma arousal, and compared it to eeg based markers validated previously. five adult wistar rats (male, 300-350gms) underwent eeg electrode implantation 1wk prior to asphyxia-induced 7min ca. four hours after resuscitation, rats were attached to a wireless eeg-accelerometer system. wideband and sub-band eeg were analyzed to yield iq, an entropy based and previously validated measure of coma arousal. we defined activity as the variability in 3-d acceleration as quantified by the standard deviation of acceleration. we found a significant positive linear correlation between accelerometer activity and full band eeg iq (r=0.60± 0.23, mean ± sd). when eeg sub-bands were divided into two categories (0.3-50hz and 50-150hz), accelerometer activity had better correlation with higher frequency sub-bands (r=0.27±0.10 vs. r=0.46±0.21). during individual sub-band analysis, we were able to find a moderate correlation with the higher frequency iq 50-90hz (r=0.49±0.20). these results suggest that 3-d acceleration based activity, measuring early subtle movements during coma arousal, correlates with eeg iq. this relationship was stronger for higher frequency sub-bands. this suggests that subtle motor activity quantitated by an accelerometer may be an acceptable indirect measure of arousal. such accelerometer-based systems also have the advantage of being more objective and affordable while also offering longer term monitoring. therefore, accelerometer-based monitoring for coma arousal may have clinical applicability in intensive care units. recent literature emphasizes the impact of vancomycin concentrations on patient outcomes, especially in serious infections such as central nervous system infections (cnsi) and pneumonia. achieving adequate concentrations is challenging in the critically ill due to changes in volume of distribution and clearance. we investigated the impact of a pvds in our neurologic units. retrospective chart review comparing outcomes of pvds (rph-group) to pre-implementation control group (md-group). adult inpatients receiving vancomycin on neurologic units (neuro icu and floor) were included in a 6 month pre/post period. rph-group patients receiving vancomycin not consulted to pvds were excluded. outcomes evaluated number of vancomycin levels and proportion within goal range (10-25 mcg/ml). in md-and rph-groups, 113 and 123 patients were enrolled, respectively. rph-group had a higher percentage of patients with weight >100 kg and crcl >50 ml/min. icu patients accounted for 47% and 61% of the md-and rph-groups, respectively. common indications were cnsi and pneumonia in both groups. 209 levels were drawn in md-group versus 228 levels in rph-group. a higher percentage of levels were within goal range in rph-group (68%) versus md-group (52%, p = 0.0005). amongst patients with cnsi, rph-group had a higher percentage of levels within goal range (65% vs. 51%, p = 0.08). icu patients in rph-group had a higher percentage of levels within goal range (69 vs. 59%, p = 0.108). in icu patients, younger age (p = 0.083) and crcl >50 ml/min (p = 0.061) trended toward initial subtherapeutic levels despite receiving ~25 mg/kg/day of vancomycin. implementation of the pvds in neurologic units resulted in higher attainment of therapeutic concentrations. in icu patients, addition of a loading dose or higher daily doses of vancomycin may need to be employed by the pvds to ensure achievement of target concentrations. intraventricular therapy (ivt) with polymyxin b (polyb), an antibiotic with similar pharmacological action to colistin (polye), by external ventricular derivation (evd) has the main goal of offering major bioavailability of the drug, since its use by intravenous and direct action are restricted by the blood-brain barrier, with penetration of only 25%. the patient of the present report had arterial venous malformations followed by hemorrhagic stroke, which caused elevated intracranial pressure. the objective is to show an example of the effect of ivt polyb in a patient with meningoencephalitis infection by multidrug-resistant gram-negative bacteria (a. baumannii and p. aeruginosa), that are common in the icu. a literature review was made on the subject of therapy with polyb about the pharmacological characteristics, nephrotoxicity and neurotoxicity. a comparative table of the resistance profile of the strain treated in this study was created, with the intrinsic resistance of the species. also, the development of liquor evolution (culture and routine) of the patient before the treatment was monitored, until negative liquor. the effectiveness of evd, the colonizer germ and monitoring of the serial aspects of the liquor were analyzed. the patient was treated with intravenous and intrathecal administration of polyb (ivt) from november 14th to november 28th. on 11/14/2008, therapy with intravenous polyb was started: 1500000ui(20.000ui /kg/d) once a day, on every day of treatment; and ivt by evd: 50000ui in solution once a day during the first three days, and on alternate days during all the treatment. as a result of the use of intrathecal polyb associated with intravenous, effectiveness was proven in the routines of liquor negative for such germs, not showing any reports of neurotoxity and nephotoxity. ivt polyb proved to be very efficient on treating meningoencephalitis quickly. no toxic effect was associated with the drug. enhancing the level of alertness in comatose patients after acute brain injury is a very challenging problem. the use of alerting agents like modafinil is reasonably established for tbi patients in the chronic phase but not in the acute settings. we retrospectively reviewed the use of these agents at our center over a five year period to determine efficacy and use patterns in the acute brain injury settings. a chart review for patients who were admitted to the nicu at dumc during (2007) (2008) (2009) (2010) (2011) and treated with an enhancing agent (modafinil, methylphenidate) for decreased level of alertness secondary to an acute brain injury. electronic records were then reviewed to confirm the intended use of the agent, and a number of clinical data elements was recorded. 99 patients were found to meet study criteria and data elements were extracted. 85 patients received modafinil, 14 received methylphenidate. the average gcs was 8 on admission and 9 at discharge. average delay in trialing alerting agents was (10.3) days and in most cases the agents were used within a few days of withdrawal of care or discharge to hospice. outcomes varied widely with (50.5%) going to nursing home, (24.2%) going to rehab, 10.1% going home and 16.2% to hospice or death. sah was the most common injury (33.3%) followed by ich (23.2%), sdh (7.1%) and tbi (6.1%). review of documented gcs during acute hospitalization showed no significant changes during the period of alerting agent trial for any diagnosis other than tbi. in tbi a significant 3 points improvement was seen on average. our data showed that starting methylphenidate or modafinil for the purpose of improving the level of consciousness in acute brain injury patients is not effective except for patients with traumatic brain injury. based on these observation alternative agents like l-dopa should be explored. nurses in the neurocritical care unit (nccu) are responsible for performing serial neurological exams to establish baseline and potentially detect patient deterioration. nurses spend considerable time doing frequent neurological checks but the current neurological exam is open to subjectivity. we want to quantify the agreement between nurses doing these exams. over the course of one week we tracked the neurological exams of 51 patients admitted to the neurocritical care unit. we compared exams between the off-going and on-coming nurses. each exam consists of 13 single elements, loc, orientation, right and left pupil size, reaction and description, characteristics of speech/communication and motor response in all four extremities. grouping right and left pupils gave 10 element-groups. we examined 186 change of shift (cos) opportunities. when there was more than one variation of an element-group a thorough chart review was performed to identify clinical indicators, such as medications given, to determine if there was a true clinical explanation for the variation. cos exams were the same between nurses 49% of the time whereas 20% of exams had a single variation and 31% contained 2 or more single variations. of the 42 cos opportunities with multiple variations in element-groups only 7 exams showed a clinical reason for the change. that leaves 35 exams with multiple unexplained variations. this accounts for 19% of overall total exam opportunities. nearly 20% of the time nurses do not agree on the neurological exam of a patient when examined before and after cos. inconsistency in terminology and methods between nurses may hinder accurate communication. a comprehensive literature search did not reveal a standard neurological exam for nccu nurses. further discussion needs to take place between neuro-nurses across the nation with the goal of defining terms and developing a national standard for the serial neurological exam performed by nurses. electrical impedance spectroscopy (eis) is novel, portable, easy-to-implement device that aims to provide rapid, affordable point-of-care detection, assessment, and monitoring of acute brain injury. an adaptation of "passive" electroencephalography (eeg), eis relies on non-invasive measurement and modeling of the conduction of minute electrical currents applied transcranially across a spectrum of frequencies. our purpose was to test of the feasibility of eis to distinguish the impedance differences between normal subjects and brain injury attributable to acute/subacute intracranial hemorrhage or subacute ischemic stroke. we performed a prospective, observational, proof-of-principle study of 9 patients admitted to our neurosciences intensive care unit for ischemic stroke or intracranial hemorrhage, and 4 healthy volunteers. 15-minute eis recordings were obtained for each patient. the eis device delivered a small "white-noise" alternating current through a pair of stimulation electrodes; voltages were recorded across three bilaterally symmetric electrode pairs in an eeg montage. log-log plots of impedance (y-axis) as a function of current frequency (x-axis, range 100hz-100khz) were produced for each set of electrodes per patient. mean age was 68 years (range 42-90); 61% (8/13) were female. of these 9 brain-injured patients: (a) among all 4 patients with subacute hemorrhage (days old), impedances dropped at higher current frequencies; (b) among all 4 patients with subacute ischemic stroke (days old), impedances increased at higher frequencies; and (c) in one patient with acute hemorrhage (hours old), impedances were not significantly different at higher frequencies but evolved to the subacute hemorrhage pattern (a) at a day-6 follow-up recording. all brain-injured patients were distinguishable from normal control volunteers. eis is a noninvasive, portable diagnostic modality that has potential for clinical applications in multi-modal neuromonitoring and far-forward battlefield/ambulance arenas for diagnosing and monitoring acute and subacute brain injured patients. future development requires clinical validation, standardization, hardware and software optimization, and graphical user interface development. financial support: this work is supported by national institute of biomedical imaging and bioengineering point of care center for emerging neurotechnologies (poc-cent), subaward 5u54eb007954-04 and by an "innovation gra hypertonic saline (hs) improves cerebral edema, blood flow, and is inexpensive. however, use of hs is complicated by reports of induced renal dysfunction and associations with increased blood-stream infection. we hypothesize hs alters renal perfusion leading to a state of relative renal insufficiency. with institutional review board approval, we retrospectively reviewed our hospital's use of hs since march of 2005, and prospectively since october 2010. comparisons were made between admission diagnoses, changes in creatinine (cr), and formulation of hs received (3% nacl, 3% nacl/sodium acetate mix, and 23.4% nacl) to patients receiving normal saline or lactated ringers. intervariable associationswere calculated between using pearson's correlation coefficients. 1329 patients of the retrospective portion were identified. the data presented represents the first 230 patients with data. there were significant differences in the apache ii scores and glasgow coma scale (gcs) scores between the different formulations of hs. the overall correlation of chlorine (cl -) and sodium (na + ) with creatinine (cr), and within each of the saline types, were not significant. when dichotomized by the diagnosis, significant correlations appear. traumatic brain injury (tbi) patients demonstrated moderate correlation between na + & cr of 0.45. stroke patients demonstrated small correlations between na + & cr, and c l-& cr (0.19 for both). patients receiving hs outside the neurocritical care unit (nccu) demonstrated a small but significant correlation between cl and cr at 0.29. patients receiving hs have lower gcs and higher apache ii scores. elevations of na + or cl in stroke, na + in tbi, and cl in non-nccu patients correlating with elevations in cr. as reductions in renal function predict mortality, therapies precipitating kidney injury are concerning. cl -, a potent renal vasoconstrictor, reduces renal blood flow. prospective comparisons of hs formulation and renal function are needed to further assess if formulation affects outcome and cost. first recognized after rapid initiation of nutrition in prisoners of war during world war ii, refeeding syndrome (rs) is the manifestation of fluid and electrolyte disturbances precipitation systemic dysfunction. here we report a case of rs in a patient with duchenne's muscular dystrophy (dmd). a case report and literature review. a 23-year-old male with past medical history of dmd, chronically ventilated and feed via a percutaneous endoscopic gastrostomytube, presented with pneumonia, sepsis, and status epilepticus. he was treated with broad spectrum antibiotics, early goal-directed therapy, and 18 hours of electrographic seizures suppression with a midazolam infusion. admission labs demonstrated a minimally low albumin (3.4 g/dl), mild hypokalemia (3.1mmol/l), and the presence of urinary ketones. enteral nutrition was started post-admission day (pad) one. pad 2 found elevated serum glucose and precipitous drops in potassium, phosphate, calcium, and magnesium refractory to replacement. pad three attempts to wean the patient to his home ventilator setting failed, and he remained encephalopathic. enteral nutrition was changed to a more elemental, peptide-based formulation, and multivitamin with thiamine was added. electrolyte abnormalities persisted. pad 4, it was learned the family had reduced the patient's daily enteral nutrition by approximately half over six months to have him fit within his wheelchair. learning this, enteral feeds were reduced by half, advanced at a reduced rate reaching goal in 2 days, and electrolyte abnormalities resolved commensurately. over the next three days, the patients mental status returned to baseline and ventilation improved. no cardiac or hemodynamic complications occurred, but his infections resolved slowly. a significant concern in the critically ill, the constellation of problems associated with refeeding syndrome have systemic implications. these are centered on increased cellular uptake of phosphorus following the reintroduction of carbohydrates. the role of dmd in refeeding syndrome is uncertain, and has not been previously reported. to determine hospital mortality and complication rates associated with surgical clipping and endovascular coiling of cerebral aneurysms in children, and to evaluate the trend of utilization of these procedures over the recent years in various us hospitals. from the kid's inpatient sample database for the years 1998 through 2009, we identified a cohort of children admitted with the diagnoses of intracranial aneurysms and aneurysmal subarachnoid hemorrhage. hospital-associated complications and in-hospital mortality were compared among the clipping and coiling treatment groups. a multivariate logistic regression analysis was used to identify independent variables associated with hospital mortality. cochrane-armitage test was used to assess the trend of hospital utilization of these procedures in various hospital subtypes. after data cleansing, 1120 children were included in the analysis. two hundred (18%) children had aneurysm clipping and 920 (82%) had endovascular coiling procedures. the coiled group was younger (11.29 ±6.57 versus 14.49 ± 4.88)and had even gender distribution. hospital mortality was higher in the clipped population, 6.09% versus 1.65% (adjusted odds ratio 3.02; 95% ci 1.24, 7.36; p = 0.002). in addition, hydrocephalus, status epilepticus and pulmonary complications were higher in the clipped population (p <0.001). lastly, the length of hospital stay as well as the hospital charges was higher in the clipped population (p <0.0001). the rate of hospitals' use of the endovascular coiling has increased in various types of hospitals over the years included in this study (p <0.0001). the trend in mortality rates among the clipped population remained higher (5.4%-6.2%) compared to the coiled group (1-2.4%). endovascular coiling of cerebral aneurysms in children is associated with fewer deaths and complications, shorter hospital stay, and less hospital charges compared to clipping. the trend of hospitals' utilization of coiling procedures has increased during the recent years. understanding and managing complex physiologies is a critical, but difficult, problem in the neruologicial-icu. most of the information that must be assimilated in the icu exists at the level of raw data, individual test results and observations, and individual clinician notes. this mass of data obscures a holistic view of the patient, hides the development of trends, makes it difficult for clinicians to notice interactions between different variables. graphical displays and patient summaries enhanced or outperformed traditional text displays in numerous studies (elson & connelly, 1997; balas et al. 1991) , but this work hasn't yet been extended to support intracranial pressure (icp). the aim of this effort was to develop an interactive icp-specific data visualization using cognitive engineering principles. the visualization is designed to transform and consolidate complex multimodal physiological data into integrated interactive displays. we have developed a drill-down interactive visualization to enable clinicians to manage icp and identify blood pressure target goals that will ensure adequate cerebral perfusion and thereby create and maintain an optimal physiologic environment for the comatose injured brain to heal. using high-resolution physiologic monitoring data, this drill-down screen depicts the status of cerebral autoregulation using methods well described in the clinical literature (czosnyka, smielewski et al. 2001; jaeger, schuhmann et al. 2007 ) additionally, the drill-down provide graphical display of bloodpressure, intracranial pressure, and brain oxygen tension over time. with this interactive visualization, along with medication and lab data, the clinician can determine the target brain oxygen tension for a specific patient and whether to intervene on blood pressure, intracranial pressure or a combination of both in order to achieve a brain oxygenation goal (i.e., goal-directed therapy). the next step in this project is to conduct an experiment comparing this visualization against standard methods. nicom is a novel technique of monitoring hemodynamic status which is based on bioreactance technology. ventricular outflow causes changes in the phase of radiofrequency waves as they cross chest. measuring the phase shift enables calculation of flow. technique is entirely non-invasive. retrospective analysis of collected data. we describe the use of nicom in a tertiary care neuroscience intensive care unit. 41 patients were monitored on the nicom from january 2011 until june 2012 for an average of 8 days. diagnoses of patients monitored on nicom were: sah -11, ischemic stroke -9, ich 6, tbi -5, sdh-3, brain tumor-2, spinal surgery-2 and others. 48% of patients were on mechanical ventilation, 31% were treated with pressors. in the first 48 hrs of monitoring, there were 32 plr (passive leg raising) tests and 2 fluid challenges performed to measure fluid responsiveness. 22 patients (53%) were fluid responsive and 16 (39%) had an intervention. selected cases will be presented nicom system is safe and can be useful in the neuroicu setting. it can be used in intubated patients with sepsis, unexplained hypotension, hypertensive therapy in sah or during hypothermia therapy. it is also useful in non intubated, alert patients, were fluid status has to be monitored closely. although nicom is a seemingly simple-to-use technology, there were multiple clinical challenges including education of the staff, proper test performance and consistent charting. inconsistent machine calibration, use of compression stockings during a plr, and untimely sensors changes were the main problems. in the neuroicu patients with increased icp, use of fluid challenge can be safer than plr. repeated staff training resulted in more consistent data. limited information is available regarding the current state of informatics in various ncc units. we sought to assess the current state and needs for informatics infrastructure to help determine priorities and future directions of informatics research in neurocritical care. a survey instrument was developed and with the support of the neurocritical care research consortium chair, distributed to the 152 participants/registrants of the 2 nd neurocritical care research conference. a response rate of 47% (72 of 152) was achieved. most responders worked in an academic medical center (93.1%), level 1 trauma center (70.4%) and/or mixed multi-bed (mean=18.7) neuromedical/neurosurgical icu (72.2%), commonly treating ich (97.2%), sah (95.8%), ischemic stroke (86.1%), and traumatic brain injury (69.4%). acquiring, integrating, storing and analyzing mm data in a comprehensive informatics architecture for clinical and research use is stated as important but is rarely achieved due to financial and technical barriers. a centralized dissemination of technical assistance and a societal statement prioritizing informatics to advance ncc research may help facilitate future adoption. access to neurocritical care units (nccus) in the mountain west is geographically limited. we evaluated practice patterns among providers in this region and hypothesized that hospital size and distance from nccus impact decisions to transfer patients with critical neurological illness. surveys were sent to hospital providers with varying degrees of access to nccus in the mountain west, to examine what factors influence decisions to transfer patients with critical neurological illness. the survey queried location, hospital size, locally represented specialties, patterns of transfer, frequency of illness presentation, influences for and against decisions to transfer such as timeframes and perceived futility, and awareness of nccus and services they provide. 151 responses were received. responses were grouped by distance from the closest nccu and by hospital size. results showed that futility in outcome has a strong influence on decisions against transfer for smaller hospitals and hospitals that require air transport (p<0.05). notably, distance required to transfer is not a strong factor in the decision to transfer patients (p=0.168). for larger hospitals and hospitals within ground transport range of a nccu, patient condition, patient risk during transfer, and specialized intensivist support are less influential in transport decisions. patient transfer for critical neurological illness originates from hospitals with varying size and geographic access to nccus. while distance required to transfer does not appear to be a significant limitation, perceived futility in outcome is a strong influence against deciding to transfer. among providers in smaller hospitals at greater distance from nccus, significantly more providers have never heard of nccus or services provided. these findings suggest that therapeutic nihilism regarding critical neurological illness in smaller hospitals at greater distances from nccus influences patient outcomes. patients and providers in these locations may be significantly impacted by further education about neurocritical care and implementation of tele-neurocritical care services. neurocritical care is a multidisciplinary specialty whose participants originate from diverse medical backgrounds. review of the growing body of literature is essential for clinicians and strategies for continuing education may be expected to be unique for this field. this exploratory survey aims to define how the neurocritical care team (ncct) educates itself. a fifteen question survey was sent to all neurocritical care society members and responses were gathered over a one month period. basic statistical analyses of rates and comparisons of response rate proportions were conducted. 187 surveys were returned (17%). 62% of respondents were physicians, 27% were non-physician team members, and 11% were physicians in training. regardless of background or training, individuals seek published literature through a combination of electronic-print media outlets (72%) rather than a singular approach. however, 85% spend the most time reading journal articles. 59% of ncct members review the same journals monthly and allocate individual manuscript time contingent upon interest. neurocritical care (91%), critical care medicine (67%), and new england journal of medicine (54%) are the most commonly reviewed journals. 38% of ncct members do not attend a journal club. academic neurointensivists (75%) and fellows (77%) are most and nurses are least (31%) likely to attend. participation in ncc subspecialty (33%) or general critical care (32%) clubs is more common than neurology (12%) or neurosurgery (10%). responders rate national meetings (39%) as their most influential educational experience. attending physicians (34%) are more likely than trainees and non-physicians (14%) to consider personal literature review most valuable (p <0.05). 62% of all ncct members attended last year's ncs annual meeting, compared to sccm (32%) and regional conferences (35%). ncct members infrequently attended (<20%) general topic neurological or neurosurgical national conferences. despite diverse backgrounds, ncct members seek continuing medical education through common subspecialty specific methods. financial support: none the contributions and perceptions of staff regarding nurse practitioners (nps) and physician assistants (pas) in neuroscience icus throughout the country are not well known. the objectives of this study were to determine the impact of neuroscience nps and pas and assess demographics of icus. all members of the neurocritical care society were asked to complete a survey to obtain their perception regarding the addition of nps and pas to the icu team. participants rated the abilities of nps and pas to promote a team environment, anticipate or prevent neurologic deterioration, address patient or staff concerns in a timely manner, safety, and communicate effectively on a 1-5 likert scale. in addition, members were asked to provide basic demographics and background information on the type and size of icu, type of providers in charge, and the role of nps and pas in their icu, including procedures performed, documents written, and number of patients per provider. both quantitative and qualitative data was collected and analyzed. a mantel-haenszel chi square and ordinal logistic regression model were used to determine the relationship between the background information and the perception of the abilities of nps and pas. the study cohort composed of 15% of ncs members. additional responsibility of nps and pas was associated with higher scores in safety, ability to promote a team environment, address patient or staff concerns, communication, and most importantly the ability to anticipate or prevent a neurologic deterioration (p<0.0001 for all). number of nps and pas, number of years of employment of nps and pas, number of procedures, and amount of documentation also positively affected safety. additional responsibility of nps and pas has strong potential to improve staff, patient, and family satisfaction, safety, and prevent neurologic deterioration. nps and pas should be utilized to the full extent of their role. we conducted a survey study in an academic, co-managed neuro icu to explore family satisfaction regarding the care of their surviving loved ones and compared results with concurrent data from the hospital's closed medical icu (micu). over 38 days, we administered the family satisfaction-icu instrument to neuro icu and micu patients' families at time of icu discharge. those whose loved ones passed away during icu admission were excluded. the capture rates of families from the neuro icu and micu were 65.3% (79 surveys) and 62.5% (45 surveys in our neuro icu, patients' families could be more satisfied with several aspects of care. further study is needed to determine (1) whether a closed neuro icu model improves family satisfaction and (2) whether instituting a system in which the neurointensivist team regularly meets with all available families daily improves perceptions of shared decision making, even in routine situations. non-funded prospective patient registries at any given institution rely largely on volunteer clinical personnel. presupposing that an all-inclusive database would be self-defeating in this type of environment, we designed and implemented a quality improvement (qi) database with intentional iterative design. neurointensivists identified by consensus the injury/disease related events and procedures that were most important to track for qi and for judging clinical intensity of our unit. we compiled a list of syndromes that were either commonly studied by principal investigators or were common primary diagnoses in our unit. for each syndrome, we identified commonly accepted grading or intensity scores. the clinical and translational science awards electronic data entry module, redcap, facilitated data collection. consecutive patients in our icu were entered upon discharge. weekly meetings served to adjudicate disease classification, grading scores (frequently based on consensus imaging review), and discharge disposition. opportunities to enter free-text items were allowed to enhance the intentionally iterative design. in quarterly reviews, we removed items that were consistently left blank and added standardized items corresponding to consistently annotated free-text items. since its implementation in january 2011, the neurocritical care qi patient registry has accrued 2589 separate entries. consensus-driven iterative changes to the registry have resulted in complete data entry. participation at weekly registry meetings has been consistent and enthusiastic, routinely drawing 5-6 physicians (2-3 fellows, 2-3 attendings). 3 qi projects have been enabled to date. resource limitations may be a practical hindrance to achieving all-inclusive databases outside of funded clinical studies. an iterative design driven by consensus in the described approach can result in a rich database with complete data entry and continued volunteer participation. future incorporation of supplemental information sources via enterprise-wide clinical data warehouses may achieve more complete databases that comply with standardized ideals such as the common data elements. many neurology residency programs have begun implementing mandatory rotations through neurocritical care (ncc) as part of the curriculum. the added experience was thought to be beneficial for residents after graduating the program; however, we wondered how it might affect residents and patients during residency. we thought to survey residents about their programs and the amount of time they spend in ncc rotations. we also wanted to know how they felt the extra time spent in these rotations affected their consulting habits, and therefore their ability to manage cases on their own. all neurology residents in the united states were the target population for this survey. a list of 126 neurology residency programs was obtained from the american medical academy's freida database. the names and email addresses of program directors were generated, and they were contacted by email with a link to an online survey. the respondents were 101 neurology residents (37 pgy-2, 37 pgy-3 and 27 pgy-4 residents). of the respondents, 73.7% stated that ncc was a mandatory rotation in their program while the remaining 26.3% said that it was not. of those who had mandatory ncc rotations, 47.9% said they were for 6-8 weeks duration, while 55.1% agreed they should be 6-8 weeks long. when asked how often they ask for consultations from other specialties, residents who had mandatory rotations through ncc were more likely to say they usually do not consult other specialties, while those who did not have mandatory rotations were more likely to consult for all non-neurological issues. the survey results demonstrated that neurology residents who have mandatory rotations in ncc are more confident in their abilities to manage their own patients. this is thought to promote continuity of care and may reduce medical errors as well as healthcare cost. a botulism epidemic in a maximum-security prison cell-block posed numerous logistical dilemmas for which telemedicine served as a bridge to management. inmates in a high-security prison cell-block brewed batches of "pruno" by fermenting fruit, raw potato, and granulated sugar in reusable bags that were passed throughout the cell-block. one of the batches was contaminated with type a botulism. twenty-nine inmates were potentially exposed, but the actual exposures were initially indeterminable due to the inmates' fears of incrimination. the index case developed nausea, emesis, diplopia, and ptosis approximately six hours after exposure and presented to the emergency department (ed) two days later with generalized weakness, dysarthria, dysphagia, hypophonia, and dyspnea. he required intubation and was admitted to the neurocritical care unit (nccu). four additional inmates presented with similar symptoms within several hours of the index case. two required intubation and all were admitted to the nccu. within twenty-four hours of admitting the first five cases, nine additional inmates developed symptoms. five were evaluated in the ed; three were admitted to the nccu and two were discharged to the prison infirmary and monitored using telemedicine. two patients were initially evaluated and monitored with telemedicine at the prison. the remainder of the cell-block was evaluated by prison infirmary staff. botulinum toxin type a was confirmed with bioassay and cultures in these patients, but classic electrodiagnostic findings were absent. the eight inmates admitted were treated with hepavalent botulinum antitoxin (h-bat). obtaining the antitoxin required collaboration with the cdc for transport from several sites around the country. inmates were followed post-discharge using telemedicine and showed improvement. this botulism epidemic presented a logistical logjam. initial telemedicine evaluation and subsequent monitoring played a key role in managing nccu access and optimizing security resources for the prison, ed, and nccu. intrahospital transport of neurocritical care unit (nccu) patients is associated with accidental line removal, unplanned extubation, and hemodynamic instability. further, because patients must be accompanied by a nurse during intrahospital transport, there is an inherent reduction in home unit staffing which reduces direct patient care and monitoring for other nccu patients. the purpose of this project was to assess the impact of a neurocritical care transport nurse (ntrn) on patient safety, improved direct patient care time and improved staff satisfaction. the 3-month ntrn pilot program was initiated in our 16 bed nccu. for three months, the ntrn worked five 8-hour shifts per week. the ntrn accompanied patients during intrahospital transports, assisted with admissions, functioned as resource nurse in the nccu, and relieved nurses for meal breaks. data was collected in real time and included time-inmotion data, adverse event records, and a pre-post work-flow surveys. the ntrn completed 103 intrahospital transports with were zero safety events. the mean length of time for intrahospital transport prior to the pilot was significantly greater than transport by the ntrn (87 vs. 28 minutes; p<.001). the mean time it took nurses to stabilize a new admission/post-op patients was reduced from 85 minutes to 28 minutes. staff surveys were overwhelmingly positive with 89% of nurses reporting the ntrn saved them time; 24% reported increased opportunity for meal breaks, and 71% attributed reduced overtime due to the ntrn program. individual nurses reported that the ntrn program saved them an average of 47.5 minutes each shift (8.7 hours per shift). the ntrn pilot program was associated with fewer safety events, increased staff satisfaction, more rapid attention to patient needs and reduced overtime. the program should be implemented full time and evaluated for potential costsavings. many factors are associated with time delays to reperfusion in endovascular treatment for acute ischemic stroke (ais). we assessed if a prototypical neurointensive care unit layout where both the angio suite and ct scanner are inside the unit can reduce times to reperfusion. we compared time from ct to groin puncture (gp) in patients that were transferred from outside hospitals (osh) directly to the nicu versus those who went through our emergency department (ed). we retrospectively reviewed 230 patients from a prospectively maintained database from october 2010-june 2012 who underwent endovascular therapy for ais. a univariate analysis was performed to compare the patients' characteristics between the two populations and to identify differences in time intervals between ct imaging and gp. a total of 195 patients were included in our analysis. 125 (64%) patients were from osh. patient characteristics in both groups were similar except for osh patients had significantly less history of hypertension (67% vs 81%, p<0.02) but had longer time intervals from last known normal to gp (median 310 mins vs. median 221mins, p <0.01) and lower pretreatment aspects (48% <8 vs. 25% <8, p <0.01). patients' transferred from osh had significantly lower times from inhouse ct to gp as compared to patients from the ed (44.2 +/-33mins vs. 114 +/-58mins). although there was an increased number of non-contiguous multimodal imaging studies performed on ed patients compared to those from osh (37% vs 5%, p<0.01), exclusion of these patients still resulted in a significant shorter time frame between ct to gp (41.9+/-27 mins vs. 95.8+/-40.3 mins) among osh transfers. the design of an integrated biplane angio suite within the nicu reduces the times from ct imaging to gp, thereby lowering the times to reperfusion, and potentially, patient outcome. sepsis is a challenge for the intensive care unit (icu), being the main cause of death during hospitalization. it was performed a longitudinal and individualized intervention authorized by the hsja ethics committee applying the campaign 'simple actions save lives' in which 105 educational adhesives worked as a guide for washing hands and flags for high contaminated locations. a decontamination routine of monitors, control panels, ventilators and infusion bombs was established every 12 hours; and continued education for the health team was intensified during the intervention. two groups were created, patient enrollments in periods of 45 days before and after the intervention, more than 24 hours of hospitalization: group a with 18 patients and group b with 15 patients. the hospital infection incidence decreased by 40% and vap by 39.6%. urine culture was positive in 33,3% of those patients (n=5) in group a and in 16.7% (n=1) in group b (a 50.1% decrease ). the cultures of catheter tip were positive in 68.8% (n=22) of catheters in group a, which used 32 catheter in total, and none in group b, which used 13 catheters. the sepsis incidence decreased by 39.6%. septic shock was detected in 16.6% (n=3) of patients in group a. there was a drop of the costs between groups (r4,479.28, 10.5%). the cost of campaign material was r$50.00. this intervention was a simple form to decrease the related number of infections in the neurovascular icu, having spent irrelevant values when compared to treatment of these clinical tables. intracranial pressure (icp) management guidelines have been established; however there is no data documenting actual icp management practices in the united states, or the degree to which clinicians comply with existing guidelines. the primary aim of this study is to explore nursing and medical practice patterns associated with icp monitoring and management. a prospective multi-center non-randomized observational design was used.the study sample was composed of consented nurse/patient dyads, with 2 dyads enrolled per study site. study patient subjects included were over age 18, had icp monitoring in situ, and were diagnosed with intracranial pathology. nurse subjects included were those assigned to the patient, who routinely worked in the unit, and had completed their orientation training. each dyad consented to a 2 hour observational period, where data was collected on nurse interventions for icp management. dyads (n=28) were enrolled at 16 hospitals between august 2009 and may 2012. patients were primarily male 68%, mean age of 47 years, and non-hispanic. nurses were primarily female 90%, non-hispanic, and a mean of 7.7 years of critical care experience. we observed 11 distinct nursing/medical interventions hypothesized to reduce icp. although csf diversion and limiting stimulation were the most frequently used interventions, there was not a consistent hierarchical approach to initiating icp reduction interventions. wide variances in nursing and medical treatment patterns were observed for icp treatment threshold, first-line therapy, and the order in which interventions were initiated. despite established guidelines, variability exists throughout the u.s. in how physicians and nurses monitor and manage icp. more research is needed to compare intervention techniques to determine the impact these differences have on outcomes in patients requiring icp management. administrative data are being increasing being used to measure quality of care, for public reporting, and in pay for performance. administrative data are inexpensive, readily available, and target clinical outcomes. the aim of this study was to evaluate the use the use of administrative data in identifying potentially preventable events and iatrogenic complications in patients admitted to an academic medical center with a primary diagnosis of acute stroke. administrative data for all adults patients (> 18 years of age) with a discharge diagnosis of stroke 431, 433.01, 433.10, 433.11, 433.21, 433.31, 433.81, 433.91, 434.00, 434.01, 434.11, 434.91, and 436) were evaluated from january 2010-december 2011 for complications based on administrative data by looking at secondary diagnoses that were not present on admission using data from the university healthsystem consortium database. both the agency for healthcare research and quality (ahrq) quality indicators (qis) for inpatient conditions and known codes for other complications such as catheter associated urinary tract infection, pneumonia, and deep vein thrombosis or pulmonary embolus (not associated with surgery) were used to identify potential events. of the 600 cases reviewed, many cases had at least one complication. the leading cause of potentially preventable events were related-to-infection (central line associated bloodstream infection, sepsis, catheter associated urinary tract infection, and aspiration and/or hospital-acquired pneumonia). the ahrq qi only captured a fraction of the events. patients with subarachnoid hemorrhage had the highest mortality, followed by intracranial hemorrhage. several of the deaths occurred in low risk patients and had at least one potentially preventable complication. when reviewing flagged records, a small number of events reflected opportunities to improve documentation and/or coding, with the majority of remaining events associated with opportunities for improvement. administrative data may be a useful adjunct to quality improvement efforts. financial support: co-deputy project lead for the ahrq qi project (ahrq sub-contractor). continuous video-eeg (cveeg) monitoring is often utilized in the evaluation of impaired consciousness. nonconvulsive seizures may be distinguished from metabolic disorders when triphasic waves (tw) are recorded. however, rhythmicity detected on cveeg may call into question the presence of electrographic seizures. the following case describes the transient resolution of rhythmic tws after acute administration of glucose in a patient with hypoglycemic encephalopathy. case report reviewing clinical, laboratory and electroencephalographic features of a patient with metabolic encephalopathy secondary to hypoglycemia. a 66-year-old woman with type-1-diabetes and treated osteomyelitis of the foot presented with altered mental status. she was intubated and stuporous. cranial nerves were intact. all four extremities withdrew to noxious stimulation. plantar responses were flexor. mri brain exhibited leptomeningeal enhancement consistent with meningitis. serum bg=392mg/d, and csf glucose=16mg/dl. 1 month after antibiotic treatment, she was following commands. repeat mri revealed complete resolution of leptomeningeal enhancement. during recovery, she developed sudden onset stupor with left facial movements, and underwent cveeg monitoring. eeg showed generalized, polymorphic delta/theta slowing intermixed with tws, without electrographic correlate of facial movements. during cveeg, tw activity increased in rhythmicity and frequency, coinciding with worsening hypoglycemia, with a nadir bg=14mg/dl. electrographic activity was not induced or exacerbated by stimulation. administration of 50 ml of d50 (25 g d-glucose) resulted in transient resolution of tws within minutes, which corresponded to a bg=64mg/dl. however, background slowing remained on cveeg, with gradual reemergence of infrequently occurring tws despite normoglycemia. mental status returned to baseline approximately 72 hours after bg stabilization. rhythmic triphasic wave activity due to hypoglycemia may be distinguished from electrographic seizures after acute correction of bg, with corresponding transient resolution of triphasic waves. however, clinical response to correction of metabolic dysfunction may be delayed for up to 72 hours. continuous-iv-midazolam (civ-mdz) is recommended for treatment of refractory status epilepticus (rse) but doses are controversial. here we compare a historical cohort (n=29) treated with low dose to a subsequent cohort of 100 patients treated with high dose civ-mdz for rse. following the analysis of the historical cohort (1996 -2000 neurology 2001,57(6) :1036-1042) we changed our protocol for rse allowing for higher civ-mdz doses and collected 100 consecutive cases (2002) (2003) (2004) (2005) (2006) (2007) (2008) (2009) (2010) (2011) . exclusion criteria: cardiac arrest; prior treatment with a different civ-aed. we collected data on baseline characteristics, civ-mdz doses, seizure control, complications, hospital course, and outcome. high dose was compared to low dose civ-mdz on an intention to treat basis using logistic regression analysis with the significance level set at p<0.05. baseline characteristics were similar between groups. median maximum civ-mdz dose was 0.4 mg/kg/h (iqr 0.2, 1) for the high and 0.2 mg/kg/h (iqr 0.1, 0.3) for the low dose group (p<0.001), but duration of civ-mdz was the same between the two groups (median 72 hours). "withdrawal seizures" (within 48 hours after civ-mdz discontinuation) were less frequent in the high dose group (15% vs 64%, or 0.10; 95%-ci 0.03-0.27). "breakthrough seizures", "ultimate civ-mdz failure", and complications were not different. discharge mortality was lower in the high dose group (40% vs 62%, or 0.30, 95%-ci 0.11-0.81) after controlling for age, etiology, and apache-2 scores. at 3 months, mortality was similar between the two groups. lower death or vegetative state rate for those treated with high dose civ-mdz was seen at 3 months (74% vs 96%; or 0.14; 95%-ci 0.02-1.07), but this finding is limited by missing 3-month functional outcome data in both groups. high dose civ-mdz treatment for rse can be performed safely in an icu setting and may be more efficacious in controlling seizure activity. outcome data are promising and warrant further prospective study. the clinical utility of free valproic acid (vpa) levels is unclear, and the actual free fraction (ff) of vpa in hospitalized patients is not well established. our goal was to assess and compare the total levels, free levels, and ff of vpa in inpatients and outpatients and to determine factors that may influence the ff. retrospective chart review of 437 paired total and free vpa levels in 220 inpatients and 41 outpatients. demographical, laboratory, and concomitant interacting medication data were collected and analyzed. paired total and free levels were categorized based on their status in regards to the therapeutic range (i.e., subtherapeutic, therapeutic, or supratherapeutic) and whether the paired levels were concordant or discordant (e.g., both levels in therapeutic range, or mismatched). linear regression was used to assess the impact of variables on the ff. logistic regression was used to determine if variables predicted the likelihood of having discordant paired levels. inpatients had a significantly higher median ff compared to outpatients (31.1% vs. 15.5% respectively; p <0.0001). total levels were found to be a poor predictor of free levels (r 2 = 0.34) in hospitalized patients. inpatient free levels were discordant with the therapeutic status indicated by the total level 68% of the time. in a linear regression model, albumin (p <0.0001), total protein (p <0.0001) and co-administration of phenytoin (p=0.003) and carbapenems (p=0.001) were found to significantly and independently impact the ff. multiple logistic regression indicated albumin as a significant predictor of the total and free levels being discordant in regards to therapeutic status (or 0.13 [95%ci 0.07-0.25], p<0.001). inpatients had a significantly higher ff compared to outpatients. inpatient free levels were frequently discordant with the total levels in terms of the therapeutic status. decreasing albumin was a significant predictor of discordance between the free and total levels. increased continuous eeg utilization in the icu has generated an interest in faster acquisition and interpretation of eeg data. limited electrode arrays (lea) coupled with quantitative algorithms have been leveraged for this purpose. however, previous studies with lea's have suggested an inherent error rate produced by a reduced number of electrodes. the aim of the current project was to test a novel lea and determine if multiple montages could correct any error rate. with approval from our irb, 250 short de-identified eeg segments were retrospectively collected from clinical ceeg archives. segments contained one of five primary findings: normal, diffuse slowing, periodic epileptiform discharges (peds), seizure and burst suppression. all files were reformatted into an 8 electrode array containing a lateral chain and central electrode bilaterally. segments were distributed to four experienced neurophysiologists in two phases. in phase 1, segments were interpreted in a single anterior-posterior bipolar montage and compared to the original read. in phase 2, fifty frequently misread segments from phase 1 were reinterpreted using four additional montages. in phase 1, 1000 eeg interpretations were reviewed yielding a sensitivity of 73% for seizure and 70% for peds, burst suppression, and normal. the specificity was greater than 90% in all cases. the sensitivity and specificity for diffuse slowing was 90% and 75%. in phase 2, 150 eeg interpretations were collected with no significant improvement noted in the detection of any eeg finding. in agreement with past studies, this trial suggests that leas contain a base error rate engendered by the reduced number of electrodes. this error rate is maintained regardless of the number of available montages. the implication of these findings suggests that studies examining the use of lea's for use in seizure detection and neurophysiologic algorithms should calculate an error rate specific to the electrode array before algorithm testing. the incidence of nonconvulsive status epilepticus (ncse) and other electrographic features in comatose post-cardiac arrest syndrome patients treated with therapeutic hypothermia (th) is still under investigation. the objective of this study is to determine the incidence of ncse and other electrographic features and correlate with neurologic outcome and survival. review of consecutive subjects treated with th and receiving continuous eeg (ceeg) monitoring between may 2009 and december 2010. demographic data, survival, and functional outcomes using cerebral performance category (cpc) scale were prospectively recorded. forty eight patients were included, with mean age of 63 years (sd 15), majority were males (n=26, 54%) and experienced out-of-hospital cardiac arrest (n=28, 58%). ventricular fibrillation was the initial cardiac rhythm in 20 patients (42%). all patients received th. twenty seven patients (56%) died. seventeen patients (35.4%) had good neurologic outcome (cpc 1 or 2). ncse occurred in 2 patients (4.2%), both of whom died. periodic epileptiform discharges occurred in 6 patients (12.5%), 5 (83%) of whom had poor neurologic outcome or death (cpc 3-5) compared to 62% poor outcome in whom periodic epileptiform discharges did not occur (nonsignificant). burst suppression occurred in 15 patients (31.2%), all (100%) of whom had poor neurologic outcome or death compared to 48.5% poor outcome in whom burst suppression did not occur (p <0.05); and severe background attenuation occurred in 10 patients (21%), 9 (90%) of whom had poor neurologic outcome or death compared to 58% poor outcome in whom severe background attenuation did not occur (p<0.05). ncse occurred in 4.2% of post-cardiac arrest patients undergoing therapeutic hypothermia. outcomes are poor in postcardiac arrest patients undergoing therapeutic hypothermia with ncse, burst suppression or severe background attenuation. larger prospective studies are needed to further evaluate and characterize ceeg findings in comatose postcardiac arrest patients undergoing th. encephalopathy is a frequent occurrence in the critical care setting. previously, we have shown that patients with a primary neurologic injury and encephalopathy are at high risk for ceeg seizures. patients with a presumed metabolic etiology of encephalopathy have been poorly characterized. the purpose of this study was to identify the frequency and underlying etiology of ceeg seizures that occur in critically-ill patients with a presumed metabolic etiology. we retrospectively reviewed prospectively collected ceeg and clinical data on consecutive patients monitored from january 1, 2007, to december 31, 2011. we identified those patients with ceeg seizures (n=570) and included in this study only those patients with metabolic etiologies. eeg seizures were defined as evolving rhythms in frequency, distribution, and/or morphology at 2 hz or greater for more than 10 seconds duration. statistical analyses were performed with jmp 9.0. sixty-six (11.6%) patients were identified as having metabolic causes for ceeg seizures with the most common etiology being sepsis (50.0%) which linearly increased (r 2 =0.64) in detection from 3 in 2007 to 17 in 2011. other etiologies included liver failure (15.2%), posterior reversible encephalopathy syndrome (pres; 13.6%), electrolyte/glucose derangement (10.6%), drug overdose/withdrawal (9.1%), and renal failure (1.5%). 80.3% of the ceeg seizures were without clinical signs. a linear increase in ceeg seizures occurred with a decrease in level of consciousness (r 2 =0.98). the majority (56.1%) of patients were eventually discharged for rehabilitation, but 36.4% expired prior to discharge. this retrospective study shows an increase of ceeg detected seizures in patients with a presumed metabolic etiology from 2007 to 2011. this increase in seizures is likely due to increased targeted monitoring. this highlights the value of using ceeg database information to target at risk populations. our results should guide the use of ceeg monitoring in the metabolic patient particularly those with septic encephalopathy. medically induced burst suppression on eeg is often seen in critically ill patients who are sedated for treatment of status epilepticus, cerebral edema, and in patients with anoxic brain injury or post cardiac arrest undergoing hypothermia treatment. previous studies have demonstrated that the majority of these patients have poor prognosis. we decided to investigate if specific eeg patterns during burst suppression in these patients would correlate with different outcomes. we retrospectively identified 40 patients with medically induced burst suppression out of 732 patients who had continuous eeg monitoring (ceeg) from january 2010 through december 2011 in our neuro icu. neonates and children were excluded. all eeg tracings were independently reviewed by two electroencephalographers and classified into discrete seizures, status epilepticus (se), interictal epileptiform discharges (ied), burst suppression, and epileptic bursts defined as burst suppression with ied within the burst activity. primary outcome was cerebral performance categories (cpc) at hospital discharge. of the 40 patients, 20 were identified to have epileptic bursts-one se, eight anoxic brain injury, two ischemic stroke, 4 hemorrhagic stroke, five other medical conditions. the mortality rate of patients with epileptic bursts was 70% compared to 55% for those without. only 10% in each group had good neurologic recovery defined as cpc score of 1-2. patients with epileptic bursts on average had longer duration of monitoring (7 days versus 4) due to refractory seizures and, subsequently, increased number of aeds (2.9 vs 1.8) used. similar to previous findings, the patients in our study had poor prognosis. our findings additionally show that epileptic bursts in this patient population correlated with more refractory seizures and a higher mortality rate. the presence of epileptic bursts may be used as an adjunctive indicator for prognosis in patients who are in medically induced burst suppression. larger population study is underway. epidemiologic studies in epilepsy using large administrative databases depend on accurate icd-9-cm classification. we sought to determine the accuracy of icd-9-cm code 345.3 (grand-mal status) for diagnosing status epilepticus (se) after hospital admission. a case-control study at an academic institution was conducted. twenty-one subjects with discharge icd-9-cm code 345.3 (grand-mal status) and 42 consecutive admissions without the code of interest were randomly selected. se was defined as neurologist documentation of continuous clinical seizure activity for five minutes or longer and/or two or more discrete clinical seizures without inter-ictal return to baseline (clinical diagnosis) and/or eeg consistent with se by board certified neurophysiologist interpretation (eeg diagnosis). all 21 cases and none of the controls met our pre-defined criteria of se. therefore, the sensitivity, specificity, positive predictive value (ppv), negative predictive value, and accuracy of the code was 100%. when the diagnosis relied on clinical criteria alone, the sensitivity decreased to 82% with ppv of 100%. when the diagnosis was made by eeg criteria alone the sensitivity decreased to 55% and ppv of 100%. the icd-9-cm code 345.3 is both accurate and specific for the diagnosis of se after admission at an academic institution. clinical definitions of se and the prevalence of the disease may affect the sensitivity and ppv of icd-9-cm code 345.3 for the diagnosis of se. the results of our study require further validation in other cohorts. refractory status epilepticus (se) has been linked to significant morbidity and mortality. when pharmacological treatment fails, ketogenic diet has shown to suppress seizure activity in children and is gaining acceptance as an adjunctive treatment in adults. while case reports exist, there are no standard guidelines for implementing ketogenic diet in adult neurocritical care patients. the purpose of this abstract is to demonstrate a standard guideline for ketogenic diet utilization in a neurocritical care unit. a performance improvement project was undertaken to standardize ketogenic diet administration in enterally fed neurocritical care patients with medically refractory se. the guidelines include patient selection, team communication, patient monitoring, family education, patient transitions out of intensive care and measures for patient outcome from this treatment. patients admitted with se are initiated with standard pharmacologic treatment; if treatment does not result in se cessation, then ketogenic diet is reviewed. discussion with the patient's family is required to review long-term implications and potential lifestyle choices related to diet after critical illness. a standard checklist within the guidelines assures communication to all necessary organizational departments including appropriate consults. daily monitoring and discussion in patient rounds evaluates daily patient progress. team communication is focused on diet tolerance, medication carbohydrate content, concurrent pharmacologic se management and patient progression. since 2008, after implementation of the standardized guideline, seven adult se patients have been treated with ketogenic diet. mean age was 43.3 years; range 26-69 years; two patients were male. ketosis was achieved in six of seven patients and five of six patients sustained resolution of se after ketosis was achieved. our organizational experience indicates that coordinated team care, family education, goal planning and a standardized guideline contribute to successful implementation of ketogenic diet. further research is needed to determine overall effectiveness of this therapy. status epilepticus (se) is a potentially life-threatening condition that is frequently under-recognized, may be refractory to initial treatments, and often requires admission to general intensive care units (icus) we hypothesized that admission of patients with se to the neurosciences icu (nicu) vs the medical icu (micu) might correlate with surrogates for improved patient outcome. we performed a single-center, retrospective cohort study of patients with se admitted to the nicu vs the micu in our institution between 2005-08. admission to either icu depended on bed availability and emergency medicine preference. clustering methods were used for analyses, taking into account multiple visits of the same patient. there were 168 visits for 151 patients with definite or probable se [46 (27%) in the nicu and 122 (73%) in the micu]. apache ii scores were significant higher in the micu group (17.5 vs 13.4, p=0.003). more continuous eegs were ordered in the nicu (85% vs 30%, p<0.001). ceeg was ordered more frequently in complex partial/non-convulsive and less in convulsive clinical presentations. the nicu had a higher rate of complex partial/non-convulsive se and the micu of generalized convulsive se (41% vs 21% and 57% vs 76%, p<0.033). admission diagnoses differed, with the nicu having a higher rate of stroke and the micu a higher rate of toxometabolic etiologies (39% vs 12% and 11% vs 21%, p<0.002). after adjusting for covariates, no difference was found in the icu or hospital length-of-stay and modified rankin scale at discharge. management differences occurred in micu vs. nicu-managed se, possibly based on variabilities in presentation and etiology. however, no reduction in length-of-stay or different discharge outcomes between the icus was found. hongki song 1 , taechon kang 1 , dongjin shin although levetiracetam(lev, 2s-(oxo-1-pyrrolidinyl)butanamide, keppra®, ucb pharma) has been reported to be well tolerated and effective in se refractory to benzodiazepine (bdz), there was little preclinical or clinical data concerning the outcomes of lev in comparison to dzp, and vpa in se-induced neuronal death. to address this relevant lack of information, we have performed the preclinical study to investigate the effect of diazepam (dzp), valproate (vpa), and lev alone, and the efficacy of lev as an add-on treatment with dzp on the se-induced neuronal death. dzp and vpa. however, it is noticeable that lev as an add-on drug with dzp could not alleviatese-induced neuronal damage as compared to effective to protect neuronal damages from se, as compared to dzp. in contrast to lev, vpa(50 and 100 mg/kg) as an add-on drug with dzp significantly reduced se-induced neuronal damage as compared to dzp alone, and showed the similar effect of vpa (150 mg/kg) alone. these findings indicate that, unlike vpa, lev may negatively interact with dzp, and suggest that lev may be more effective to prevent se-induced neuronal death as a first line drug than as a second line therapy after bdz treatment, and that lev as an add-on drug with bdz may not provide any additional benefit to outcome of se. temkin and colleagues found that phenytoin exerted a beneficial effect by decreasing the rate of seizures by 73% during the first week after a traumatic brain injury. the purpose of this study was to determine the need for monitoring and titrating to therapeutic free phenytoin levels in patients receiving phenytoin for prophylaxis within 7 days following a traumatic brain injury. this was a retrospective study of 93 patients for a traumatic brain injury (tbi), who met the inclusion criteria and received phenytoin for seizure prophylaxis for 7 days following injury. eligible patients were divided to two arms: patients with phenytoin levels (n=34) and patients without levels (n=59). the primary outcome measure was the incidence of seizures in those that were monitored for free phenytoin levels and those that were not monitored for free phenytoin levels. the secondary outcome measure was the appropriateness of phenytoin dosing in regards to initial loading and maintenance dose. a total of 2 seizures occurred in the entire study population. both seizures transpired in patients with phenytoin levels. patient 1 was diagnosed with a seizure event on day 2, with free phenytoin obtained on day 3 at a therapeutic level of 1.85 mg/l. patient 2 had a witnessed seizure on day 6, with free phenytoin level obtained on day 5 also within therapeutic range at 1.61 mg/l. there was no incidence of seizure in patients who were not monitored for phenytoin levels. inconsistent phenytoin loading and maintenance doses were identified. this study suggests that monitoring phenytoin to therapeutic levels for seizure prophylaxis did not demonstrate a decrease in the occurrence of seizures. we are unable to make recommendations given the inherent limitations of our study. a large prospective, randomized trial is needed to clarify the need for monitoring phenytoin to therapeutic levels. seizure prophylaxis for nontraumatic intracerebral hemorrhage (ich) and aneurysmal subarachnoid hemorrhage (sah) is common practice in the intensive care unit(icu). typical antiepileptics include phenytoin (ptn) and levetiracetam (lvt). previou studies have suggested worse long term outcomes with icu ptn use, but such data is lacking for lvt. in addtion, few studies have compared lvt to ptn for seizure prophylaxis in ich or sah patient in the icu setting. we hypothesize that seizure prophylaxis with lvt, as compared to ptn, for patients admitted with ich and sah will result in similar outcomes at hospital discharge as measured by the modified rankin scale (mrs). this study is a single center retrospective review from 2009-2012, to ultimately include approximately 250 adult patients with the diagnosis of sah or ich who received seizure prophylaxis with either lvt or ptn. basic demographic, past medical history, severity of illness scales; length of mechanical, icu and hosital length of stay; seizure occurrence, use of continuous electroencephalogram, data will be collected, in addition to other variables. patients with prior seizure history or seizure on presentation, do-not-resuscitate hours within 24 hours of icu admission, will be excluded. to date, our analysis includes 42 patients (lvt =31 and ptn =11). comparing ptn to ltr, univariate analysis of demographics, baseline clinical characteristics and outcomes were similar between the two groups (all p>0.05). in our initial univariate analysis, functional outcome at discharge was similar between ptn and lvt when used for seizure prophylaxis in patients admitted with ich or sah. subsequent analysis will include additional patients (approximately 250) with multivariate adjustment. cerebral microbleeds (cmbs) are commonly found in patients with microvascular pathology such as primary intracerebral hemorrhage, cerebral amyloid angiopathy, and ischemic stroke. however, to our knowledge, there have been no reports of cmbs or their acute appearance in patients with status epilepticus (se). here we describe two patients admitted to our neuro-intensive care unit with generalized tonic-clonic seizures. laboratory tests were unremarkable except for mild pleoc onset and did not showed abnormal findings. seizures continued despite multiple anti-epileptic drugs including phenytoin, valproic acid, topiramate, clonazepam, pregabalin, lacosamide, phenobarbital, levetiracetam, and continuous infusion of propofol, ketamine and midazolam (up to 1.4 mg/kg/hr in the first patient and 2.9 mg/kg/hr in the second patient). followup 3.0-tesla susceptibility-weighted imaging revealed 63 new cmbs (44 lobar [9 frontal, 12 parietal, 19 temporal, 2 occipital, and 2 insular], 13 deep [3 corpus callosum and 10 deep/periventricular white matter], and 6 infratentorial [5 brainstem and 1 cerebellum]) in the first patient (performed 29 days after initial imaging) and 14 new cmbs (11 lobar [3 frontal, 4 parietal, 2 temporal, and 2 occipital], and 3 deep [1 corpus callosum and 2 deep/periventricular white matter]) in the second patient (performed 41 days after initial imaging). multimodal neuromonitoring was available between initial and follow-up imaging in the second patient and suggested metabolic distress (lactate-pyruvate ratio >40), cerebrovascular dysautoregulation (pressure reactivity index >0.2), brain tissue hypoxia (brain tissue oxygen partial pressure <15 mmhg), and fluctuations of blood pressure (variance, 163 mmhg) and cerebral perfusion pressure (variance, 180 mmhg). cmbs may develop acutely in patients with refractory se, which may point towards microvascular disturbances in refractory seizures. further prospective studies are necessary to explore the pathophysiology and clinical implications of new cmbs in se. synthetic cannabanoids, often sold as "spice" and various other labels, are a popular product sold in incense shops and through the internet. when inhaled, consumers often report experiences similar to marijuana use, and have thus become a popular street substitute for marijuana. unfortunately, with increasing use, there has been an increase in the number of patients presenting to emergency departments due to toxic effects of these products. we describe a 24 year old gentleman with history of bipolar disorder but no history of neurological disease who presented to the emergency department with altered mental status and tachycardia who subsequently had a witnessed tonic-clonic seizure. patient received appropriate workup for his potential toxicity. we also performed a literature search on "spice" incense found in his backpack on presentation. patient had admitted to smoking "spice" incense on questioning. patient's negative drug screen, negative workup, as well as symptomatic improvement on phenytoin supported the source of his seizure as the toxic effect of inhaled "spice". we also on literature review discovered several other cases similar to this patient's case. "spice" or synthetic cannabanoid-induced toxicity is an emerging etiology of new-onset seizure and does not appear on conventional drug screens. critical care professionals should be aware of this product to recognize and appropriately treat this toxicity. refractory status epilepticus (rse) is associated with high morbidity and mortality. etiological heterogeneity and refractoriness to treatment remain a challenge for the treating intensivist. here we present a patient with rse and folic acid (fa) deficiency. brain metabolism was hourly analyzed using cerebral microdialysis (cma600-analyzer; cma71-catheter). fa concentrations of brain extracellular microdialysate (famd-ec) and serum (faserum) were analyzed using elecsysfolateiii® -assay. in vitro recoveryof fa was calculated using cerebrospinal fluid (csf). a 47-year-old male was referred to our neurocritical care unit with se refractory to levetiracetam (3g/d) valproic-acid (1.5g/d) and 0,7mg/kg bw/h midazolam continuous infusion. the patient had a history of short bowel syndrome (sbs) after small intestine resection five months prior. admission electroencephalography showed continuous rhythmic epileptiform activity over the right hemisphere despite adding ketamine continuous infusion (0,6mg/kg bw/h) and lacosamide (400mg/d). neuroimaging demonstrated diffusion-weighted-imaging (dwi)-hyperintensities over the right hemisphere. csf was normal, common causes of rse were unlikely after extensive laboratory and csf studies. fa serum was found to be lower (3.4μg/l; 4.6-18.7 μg/l) at day two of rse. after thiopental anesthesia (48 hours) and parenteral fa substitution (10mg/d), the patient was successfully weaned without electrographic or clinical seizures. repeated imaging of the brain at day 10 showed improvement of dwi-hyperintensities. glutamate levels in md ec decreased overtime. the patient could be extubated and fully recovered to the functional level before rse. fa serum increased by 241% to 11.6 μg/l, post hoc analysis of fa md-ec revealed an increase by 77% (from 2.2 μg/l to 3.9 μg/l). in vitro recovery of fa was 21%, therefore calculated fa brain / fa serum ratio was initially 3, which is comparable to previous animal studies. brain extracellular folic acid can be measured using cerebral microdialysis. although causality cannot be proven, fadeficiency may have influenced the course of rse in our patient. the management of inter-ictal eeg patterns such as sirpids (stimulus-induced rhythmic, periodic or ictal discharges) in comatose intensive care unit (icu) patients remains poorly understood whether these are secondarily injurious to brain or simply a of marker of underlying brain injury. we describe 2 cases of brain-injured patients with sirpids with ictal spect imaging and in regards to aggressive neuroicu management and patient outcomes. case series, n=2. case #1-a 67-year old female suffered a cardiac arrest and remained comatose after 3 days. continuous icu eeg demonstrated nonconvulsive seizures (ncsz) and status (ncse) with up to 3hz maximal bilateral centroparietal head spike and wave by day #6 which was refractory to initial iv levetiracetam, iv lacosamide, iv phenytoin but finally responded to iv phenobarbital load (30mg/kg) and propofol infusion. sirpids were noted despite these medications with any form of tactile or auditory stimulation. we performed ictal (stimulation provoked sirpids) and interictal technetium-99-spect which was negative for hyperintense focus. case #2-a 67 year old female was admitted comatose for subarachnoid hemorrhage secondary to aneurysm rupture. she received a left-sided hemicraniectomy with operative clipping of the aneurysm and drainage of a small left subdural hematoma. on postoperative day (pod) #1, ceeg showed left frontotemporal sharp waves. she was placed on leviteracetam, lacosamide, benzodiazepine, propofol infusion, and phenytion. by pod #6, ceeg revealed left frontal sharply countoured discharges when the patient was stimulated by nail bed pressure on examination, consistent with sirpids. by pod #15 an ictal spect scan showed broad areas of hypoperfusion in the left hemisphere due to infarcts but there were no findings suggestive of a seizure focus scintigraphically. spect-scan negative sirpids may be helpful in terms of deescalating aggressive brain-metabolic suppressive therapies such as propofol and barbiturates, but larger, outcome-based studies are needed. thromboelastography (teg) is point-of-care test that allows for rapid global assessment of coagulation. teg analyzes whole blood, not plasma, which better accounts for the effects of cellular components on hemostasis. we sought to determine whether there is evidence of hypercoagulability by teg and whether it correlates with discharge outcome after aneurysmal subarachnoid hemorrhage. ten patients with moderate-to-severe sah were prospectively enrolled in an irb-approved observational study of serial thromboelastography. teg analysis, using kaolin activated citrated samples, was performed on post-bleed days 1, 3, 5, 7 and 10. thrombus velocity curves, including the maximal rate of thrombin generation (mrtg), time to maximal rate of thrombin generation (tmrtg), and total thrombin generation (ttg), were plotted for each patient. a hypercoagulable state was defined a priori as a g value of >11 dynes/cm2 or a maximum amplitude (ma) of greater than 70mm. secondary outcome measures included discharge disposition. mean age of patients was 59.1+/-11.6 years. 7/10 patients were women and 4/10 were discharged home. the mean g parameter was within the normal range (9.59 dynes/cm2) on day 1, demonstrated a hypercoagulable profile on day 3 (11.3 dynes/cm2), peaked on day 5 (13.8 dynes/cm2), remained hypercoagulable on days 7 (12.3 dynes/cm2) and day 10 (12.0). the day 5 g value was significantly different from the day 1 value (p=0.04 thromboelastography may identify a transient hypercoagulable state that peaks around post-bleed day 5 in patients with sah. this state reflects accelerated thrombin generation and correlates with discharge disposition. defining a hypercoagulable state in patients with sah may lead to better risk stratification and novel therapeutic interventions. financial support: this study is supported in kind by haemonetics. they supply 2 teg machines, kits and reagents. they have neither participated in study design nor are they aware of these preliminary results. intravenous sedation has been associated with impaired cognitive recovery following critical illness but its influence on recovery following asah remains unknown. data from consecutive patients with asah admitted to columbia-presbyterian hospital and enrolled into the shop database between 08/1996-1/2009 were analyzed after exclusion of deaths and unemployment prior to hemorrhage. employment status at 1 year was obtained through self report or through patient surrogate and trichotomized (same level, decreased level, unemployed). proportional odds models were used to test the association between the use of continuous intravenous sedation with employment and cognitive function at 1 year after controlling for baseline demographics (age, race, occupational level, admission hunt hess grade) and hospital complications (pneumonia, infarction from vasospasm). proportional hazards model was used to examine the association of sedation with time to return to work. 417 patients who had the primary outcome data of employment status at 1 year were analyzed. in multivariate analysis, exposure to continuous intravenous sedation was significantly associated with worse employment status at one year (or=0.46, ci=0.28-0.78, p=0.004). poor judgment (or=0.51, ci=0.27,-0.94, p=0.03) and apathy (or=0.34, ci=0.21-0.55, p<0.0001) at one year were significantly associated with worse employment status but not with sedation exposure. with multivariate proportional hazards model, sedation was a significant risk factor of unemployment (hr=0.59, ci=0.38-0.91, p=0.02). among those who returned to work within 1 year, patients who received intravenous sedation returned to work significantly later than those who did not (median 107 vs. 90days, p=0.04). patients who received continuous intravenous sedation following asah had worse one year employment status and returned to work later. although poor judgment and apathy was associated with worse employment status, they were not associated with sedation exposure. future studies should investigate the effects of intravenous sedation exposure on cognitive and functional recovery following brain injury. despite an improvement in mortality, many survivors of asah still have significant disability and impairment in quality of life. we investigated predictors of unemployment at 1 year among survivors of asah. data from consecutive patients with asah admitted to columbia-presbyterian hospital enrolled into the shop database between 08/1996-01/2009 were analyzed after exclusion of deaths and unemployment prior to hemorrhage. employment status at 1 year was obtained through self-report or through patient surrogate and trichotomized (same level, decreased level, unemployed).pre-morbid occupational level was trichotomized (full time, part time, housewife). proportional odds models were used to test the association between baseline demographics, pre-morbid and discharge functional status with employment status at one year. proportional hazards model was used to test the association of these factors with time to return to work. a total of 417 patients had the primary outcome data of employment status at 1 year. 192 patients (47%) remained unemployed, 63 patients (15%) worked at a decreased level, while 162 patients (38%) were employed at the same level. after controlling for age, modified fisher scale, and discharge functional status, ethnicity (p=0.0001) and pre-morbid occupational level (p<0.0001) were significantly related to employment status. hispanics (or=0.32, ci=0.19-0.53) were less likely to be employed than other minority groups with caucasian as the reference group. caucasians working full time pre-morbidly provided the greatest odds for employment (or=5.35, ci=2.69-10.64) over part time employees (or=2.12, ci=1-4.5) and housewives (reference) among those who returned to work at 1 year follow-up, patients who were employed at the same level returned to work sooner that those employed at a decreased level (median: 90 vs. 149 days, p=0.02). unemployment among survivors of asah remains problematic, especially among certain underrepresented minorities. future studies should investigate modifiable factors which impede successful reintegration to the work force. cerebral vasospasm after aneurysmal subarachnoid hemorrhage (sah) remains a major cause of death and disability. delayed cerebral ischemia (dci) after sah is likely multi-factorial, but eventually leads to altered cerebral blood flow (cbf) and cerebral infarction. neurointerventional treatment is used for medically refractory vasospasm, but with limited data on efficacy and impact on cbf and clinical/dci outcomes. patients with sah scheduled for neurointerventional treatment of refractory vasosasm were consented for intraprocedural cbf monitoring. we measured regional cbf using two sodium iodide scintillation scalp detectors approximating the cortical vascular territory of the treated vessel. a 1.0 ml saline bolus of 1-2 mci of 133-xe is injected through the coaxial catheter immediately before and after endovascular treatment. tracer washout is recorded under stable physiologic conditions for 1.5 minutes. cbf is calculated using the initial slope index, the monoexponential slope of tracer washout from 20-80 seconds after isotope injection. data were analyzed including standard corrections for remaining activity and physiologic parameters (cortexplorer cbf2a, ceretronix, denmark). mean arterial blood pressure, paco2, serum hemoglobin, and delivery of anesthetic agents were monitored. we calculated change in cbf expressed as a mean + standard deviation using repeated measures anova before and after endovascular treatment. a total of 23 sah patients with refractory vasospasm were enrolled in the study. moderate to severe angiographic spasm was reported in 83% of subjects. treatment included ia verapamil in 17(74%), angioplasty only in 3(13%), and both in 3(13%). mean change in cbf was 9 + 11 ml/100gm/min, an average of 26% change in regional cbf. in our prospective study of 23 patients with endovascular treatment for refractory vasospasm, we detected a mean change of 26% in quantitative cbf using the intra-arterial 133-xe washout method. without significant radiographic evidence of large vessel change at the time of measurement, increases in cbf may be related to the microcirculatory effects of treatment. early detection of cerebral vasospasm (vs), a common complication of subarachnoid hemorrhage (sah) enables prompt initiation of treatment. screening and detection of vs is done by repeated neurological examinations and transcranial doppler (tcd) monitoring, while angiograms are used for definitive diagnosis. this study aims to test the ability of a novel nirs based cerebral-oximetry method to detect vs in the post sah period. -hess score of 2-4 were enrolled. patients underwent neurological examinations, tcds and had 20-60 minute nirs monitoring sessions daily. whenever vs was suspected, angiography was performed. clinical event was defined as the combined endpoint of angiographically proven vasospasm, flow velocity >130 m/s over mca or aca territories, or neurologic deficit manifested rformed using the cerox3210, utilizing ultrasound tagged light (utl). pathologic cerebral oximetry was defined as having cerebral saturation below 50% for more than 15% of recording time and aut >500 second%. 20 patients were analyzed, 2 of whom had angiographic vasospasm. these were correctly detected by both nirs and tcd. of 9 combined events over the aca territory, nirs detected 8/9 events. nirs also detected desaturations in 3/12 remaining cases, when no clinical or imaging event was detected. of 12 combined events over mca territory, 8 had an increase in desaturation auc, and 5/8 cases with no event had increase in desaturation events. both cases of angiography proven vasospasm were detected by nirs as an increase in desaturation auc, and by tcd as increase in flow velocities. cerebral oximetry using utl based nirs is comparable to tcd in detecting cerebral vasospasm, and may be superior in early detection of clinical neurologic worsening. extracellular fluid volume (ecfv), the main determinant of total circulating blood volume, is determined by the mass balances of na+ plus k+ (mbnk). in patients with aneurysmal subarachnoid hemorrhage (asah), diminished ecfv and reduced circulating blood volume are risk factors for worsened neurologic outcomes. maintenance of a normal ecfv based on nurse entered fluid balance (fb) has been reported to be difficult. the purpose of this study was to describe the time course of fluid and electrolyte mass balances over 10 days in a cohort of patients receiving hypervolemic or normovolemic therapy. data from a randomized trial were secondarily analyzed. the intensive management of pressure or volume expansion in subarachnoid hemorrhage trial randomized 20 patients to receive either a normovolemic or hypervolemic fluid management protocol. the standardized fluid management protocol included maintenance iv fluids with rate adjustments or boluses based on 4-hourly fluid balance and cvp (when available) with a target net positive fluid balance of 1-2 l in the hypervolemia group, and <0.5 l in the normovolemia group. mbnk was calculated using published formulae. fb and estimated mbnk were compared between groups using random-effects generalized least square regression. baseline characteristics were similar between groups. fb was higher in the hypervolemia group than in the normovolemia group (mean difference: 713 ml/day, 95%ci:136-1290, p=0.015). mbnk was also higher in the hypervolemia group (mean difference: 90 meq/day, 95%ci:2-178, p=0.045). average daily fb did not reach the target in the hypervolemia group. mbnk was negative on 3/10 days in the hypervolemia group, and 9/10 days in the normovolemia group. hypervolemic therapy resulted in higher net fb and mbnk compared to normovolemic controls, but was relatively ineffective at generating a consistently positive fb or expanded ecfv. our results support the notion that hypervolemia is difficult, if not impossible, to maintain in asah patients. exposure to hyperoxia is commonly seen but it is largely unknown whether hyperoxia is beneficial or harmful in patients with subarachnoid hemorrhage (sah). we hypothesized that hyperoxia may be associated with increase in the risk of delayed cerebral ischemia (dci) and poor 3-month outcome after sah. we analyzed data from single center, prospective, observational cohort database between 1996 and 2011. patient nical ventilation, and 4) arterial partial pressure of oxygen (pao 2 ) measurements. patients expired within two weeks were excluded. hyperoxia was defined as the highest quartile of an average area under the curve of pao 2 until the development of dci (pao 2 mmhg) or until the post-bleed day 14 (pao 2 three months. of 252 patients, no baseline characteristics were clinically contributing to hyperoxia. ninety-seven (38.5%) patients developed dci. outcome data were available in 202 patients, and poor outcomes were observed in108 (53.5%) patients. the hyperoxia group had significantly higher incidence of dci (p = 0.001) and poor outcome (p = 0.009). after adjusting for modified fisher scale, hyperoxia was independently associated with dci (adjusted or, 2.70; 95% ci, 1.49-4.87; p <0.001). after adjusting for age, smoking, alcohol consumption, previous stroke, previous heart disease, hunt-hess scale, aneurysm size, acute physiology and chronic health evaluation ii score, serum glucose, hyperoxia was found to be independently associated with poor outcome measured at 3 months (adjusted or, 2.80; 95% ci, 1.23-6.39; p = 0.014). our data suggest that exposure to hyperoxia after sah is associated with dci and poor 3-month outcome. exact mechanism and the clinical implications can be explored by further investigations. advances in management of aneurysmal sah (asah) including refinement of neurosurgical techniques, availability of endovascular options and evolution of neurocritical care have led to improved outcomes following aneurysmal sah. we evaluated outcomes in asah patients admitted to our institution(s) over the past 2 decades. prospectively collected data of aneurysmal sah patients admitted to the johns hopkins medical institutions between 1991-2009 was reviewed. we compared surivavl to discharge and functional outcomes at first clinic appointment post discharge (30-120 days) in patients admitted between 1991-2000 (phase 1=p1) and 2000-2009 (phase 2=p2) respectively using dichotomized gos (good outcome: gos 4-5). 1134 consecutive asah patients were included in the analysis (p1 46.4%; p2 53.6%). there were higher rates of poor grade hunt & hess (p1 23%, p2 28%; p<0.05), admission gcs <8 (p1: 14%, p2 21%, p<0.005), known medical comorbidites (p1 54%, p2 64%; p=0.005), associated intraventricular hemorrhage (p1 47%, p2 55%, p<0.05) and an older population in phase 2 (p1: 51.5, p2 53.5; p <0.05) admissions. overall in-hospital mortality was low (18.3%) and there was no significant difference between the 2 periods in survival to discharge (p>0.05). good outcomes were more common in phase 2 (71.5%) compared to phase 1 (65.2%); this difference was statistically significant after correction for other confounding factors following multivariate analysis (p<0.001) with 2-fold greater adjusted odds of good outcomes in phase 2. our institutional experience over 2 decades confirms that patients with asah have shown significant outcome improvements over time. hyponatremia in hospitalized patients has been associated with increased mortality, while chronic mild hyponatremia may impair attention and gait. hyponatremia after aneurysmal subarachnoid hemorrhage (sah) is common, yet its effect on cognitive outcome remains unclear. we aim to demonstrate the domain-specific cognitive effect of hyponatremia on patients after sah. we retrospectively analysed data from 1333 consecutive patients enrolled in our columbia university sah outcomes project between april 1996 and november 2010. subjects were excluded if withdrawal of care of death occurred in the first three days. hyponatremia was defined as a sodium level <130 meq/l at any time during hospitalization. univariate and multivariate analyses were performed by a poisson regression, and a preset alpha of <0.05 was set for statistical significance. a total of 1195 were included in the study. hyponatremia developed in 185 subjects (15%). their mean age was 54 years (sd+/-15), and 65 subjects were men (35%). median time to onset and nadir of hyponatremia were 7 (iqr 3-10) and 8 days . univariate analysis associated hyponatremia with worsened modified rankin scale at discharge (rr=1.107, ci 1.022-1.199), three-month telephone interview of cognitive status (tics) (rr=0.908, ci 0.847-0.974), three-month barthel index (rr=0.908, ci 0.833-0.989), and three-month lawton instrumental activities of daily living (rr= 1.130, ci 1.006-1.269). after adjustment for age, gender, hunt and hess grade, rebleeding, delayed neurologic ischemic deficit, and generalized cerebral edema, hyponatremia was associated with worsened three-month tics (rr=0.932, ci 0.870-1.000). by one year, hyponatremia was not associated with either functional or cognitive impairment. hyponatremia-related injury after sah appears to be associated with cognitive rather than functional impairment at three months. early and aggressive reversal of hyponatremia may expedite cognitive recovery among survivors of sah. financial support: dr ortega is supported by the spotrias fellowship funded by the national institute of neurological disorders and stroke (ninds)-p50 ns049060.dr mayer consults for actelion pharmaceuticals.there are no studies have shown that decreased quality-of-life (qol) after sah is a significant problem. the factors that predict poor qol after sah remain unclear. we sought to identify predictors of a poor quality of life 12 months after sah. we prospectively studied 12-month qol in a cohort of 1200 patients consecutively admitted with sah between july 1996 and may 2010. admission clinical scores, radiographic, surgical, and acute clinical course was documented during hospitalization. twelve months after sah qol was assessed using the sickness impact profile (sip). reduced qol was defined as two standard deviations below population-based normative values on the sip. univariate statistics were used to identify candidate predictors of poor qol, and to identify significant concurrent symptoms. backwards stepwise logistic regression was used to generate multivariable models of reduced qol. at 12 months, 35% of survivors who participated in the follow-up survey (272/784) reported reduced qol. univariate admission factors associated with reduced qol were non-white race/ethnicity, high school education or less, poor clinical grade, loss of consciousness, hydrocephalus, pneumonia, and cerebral infarct from any cause. multivariable analysis revealed that poor hunt-hess grade (or 3.1; ci 95% 2.3-4.4), non-white race/ethnicity (or 2.5; ci 95% 1.8-5.5), and 12 years or less of education (or 1.5; ci 95% 1.1-2.1) were significant admission risk factors for poor qol. common significant co-morbidities associated with poor qol at 12 months included greater unemployment, not currently driving, more financial difficulties, current symptoms (e.g., headaches), marital difficulties, fear of recurrent sah, and dissatisfaction with rehabilitation. poor qol affects as many as one-third of sah survivors, and is predicted by poor admission clinical grade, non-white race/ethnicity, and lower educational status. further research is needed to determine if improved access to support and rehabilitation services for high-risk patients groups can improve qol after sah. biochemical mediators alter cerebral perfusion potentially resulting in neurological decline and delayed cerebral ischemia (dci); a significant cause of morbidity and mortality following aneurysmal subarachnoid hemorrhage (asah). estrogens (estrone-e1 and estradiol-e2) are mediators that have demonstrated neuroprotective properties that could play a role in dci however few studies have evaluated the impact of estrogens on outcomes in humans following asah. this study sought to examine the association between cerebrospinal fluid (csf) e1 and e2 levels and dci following asah. csf samples were collected after hemorrhage on 36 adult asah patients [14-males, 11-pre and 11-post-menopausal females) admitted to the nv-icu enrolled in a nih study (ro1nr004339). up to 5 csf samples per patient were selected for analysis representing days 1-10 after hemorrhage. samples were analyzed for e1 and e2 using liquid chromatography-tandem mass spectrometry. dci was operationalized as radiographic/ultrasonic evidence of impaired cerebral blood flow accompanied by neurological deterioration. statistical analysis using sas(v9.2) included group based trajectory and multiple logistic regression. e1 was detected in more csf samples than e2 (83% vs 33%). group based trajectory identified 2 distinct populations over time for both e1 (42% e1 high) and e2 (52% e2 high) values using censored normal model. non-weighted chisquare analysis identified differences between e1 trajectory groups by hh (p=.03) and dci (p=.06). using log metabolite levels, higher csf e1 measurements were associated with higher hh (p=.03) and fisher (p=.06) scores. csf e1 levels were not associated with dci (p=.24). there were no differences between csf e2 and severity of injury or dci.there was a significant relationship between csf e1 and e2 concentrations (p<.001). these findings provide evidence that estrogen metabolites are measureable in csf and may be associated with severity of injury. future studies are warranted to further explore these findings and their association to outcomes. high-grade spontaneous subarachnoid hemorrhage (sah) patients are monitored in the icu for up to 14 days, as they are at risk for complications. the diagnosis of treatable complications such as vasospasm of cerebral arteries, cardiac arrhythmias and neurogenic stress cardiomyopathy is often delayed by the limitations of monitoring capabilities. we hypothesized that changes in heart rate variability (hrv) would correlate with the onset of these conditions following sah. we applied computational methodology to a cohort of 25 sah patients in a single neurointensive care unit, examining hrv profiles to identify biomarkers of vasopasm, cardiomyopathy and impending respiratory failure. hrv was quantified for individual 5 min epochs of the electrocardiogram waveform (200 hz). qrs complexes were identified and the interbeat (rr) interval time series was constructed. mean, standard deviation and coefficient of variation of rr intervals, as well as the ratio of low frequency to high frequency power spectral density and standard poincare statistics were quantified. vasospasm occurred in 5 (20%), stress cardiomyopathy in 5 (20%) and respiratory failure in 9 (36%) of patients. in a sah patient with takotsubo's cardiomyopathy and respiratory failure, we found a decrease in hrv that predated the discovery of cardiomyopathy as well as the onset of respiratory distress by several hours. the early clinical detection of vasospasm, cardiomyopathy and impending respiratory failure from on-line ekg hrv analysis would be of tremendous clinical value. in the face of changing autonomic influences in the critically ill postaneurysmal subarachnoid hemorrhage patient, the finding of an early signal prior to clinical detection of respiratory failure is encouraging. a larger and more highly annotated dataset may be required to increase the signal to noise ratio to realize the clinical potential of hrv-based biomarkers. retrospective analyses have found an association between transfusion and vasospasm, medical complications and mortality in subarachnoid hemorrhage (sah) patients. yet, none of those studies assessed the timing of transfusion, whether it occurred before, or, after vasospasm or complications. we sought to clarify whether transfusion could be considered a cause or consequence of vasospasm and complications. this interim analysis indicates that transfusion is not associated with vasospasm or infection when timing of transfusion is considered; fluid overload was more common after transfusion. the most dismal sequelae of aneurysmal subarachnoid hemorrhage (asah) are the development of cerebral vasospasm and consecutive delayed infarctions. their severity is linked to the clinical grade of the initial hemorrhage and the amount of blood in the basal cisterns. together, they represent the major cause of unfavorable clinical outcome and death in asah patients. from retrospective data, a promising method to reduce the incidence of vasospasm is the use of a lumbar drain to remove the blood from the subarachnoid space. the recently completed lumas trial addressed the safety of this approach in good-grade asah patients (1). however, so far prospective data from subjects being at high risk for vasospasm and delayed infarction is lacking. we present the protocol of the earlydrain study, a prospective randomized multicenter trial comparing an intervention group with early continuous lumbar csf drainage to a control group receiving standard neurointensive care only (2). eligible for participation are adults suffering from asah of all clinical grades who receive aneurysm treatment within 48 hours of ictus. primary endpoint is the modified rankin score at six months. secondary endpoints include mortality, angiographic vasospasm, cerebral infarction, transcranial doppler sonography (tcd) mean flow velocity and rate of shunt insertion at six months after hospital discharge. the earlydrain study had recently been launched and, at abstract submission, 34 patients of 300 planned were enrolled. interim safety analysis did not reveal any concern on the use of lumbar drains after aneurysmal sah. up to now, ten centers in germany, switzerland and canada are participating. interested centers willing to join and contribute are still much appreciated. patients with aneurysmal subarachnoid hemorrhage (asah) require management in centers with neurosurgical expertise necessitating emergent interhospital transfer (iht). our objective was to compare outcomes in asah ihts to our institution with asah admissions from our institutional emergency department (ed). data for consecutive patients with asah admitted to johns hopkins medical institutions between 1991 and 2009 were analyzed from a prospectively obtained database. we compared in-hospital mortality and functional outcomes at first clinical appointment post-asah (30-120 days) using dichotomized glasgow outcome scale (good outcome: glasgow outcome scale 4-5) in ed admissions with ihts. a total of 1134 consecutive patients with asah were included in analysis (ed 40.1%, iht 59.9%). direct ed admissions had a higher incidence of poor hunt and hess grade (4/5) and major medical comorbidities, with no significant differences between the 2 groups in age, intraventricular hemorrhage, and hydrocephalus. in-hospital mortality for ed admissions (14.9%) was significantly lower than that for ihts (20.5%), with 1.8 times greater adjusted odds of survival after multivariate analysis (p = .001). emergency department admissions had nearly 2-fold greater odds of good outcomes (odds ratio, 1.89; p b .001) after multivariate analysis. our institutional ed sah admissions had significantly better outcomes than did ihts, suggesting that delays in optimizing care before transfer could deleteriously impact outcomes. left ventricular (lv) systolic abnormalities occur commonly after subarachnoid hemorrhage (sah). cardiomyopathy associated with sah can include either predominate apical lv systolic dysfunction (cm-apical) or predominate basal lv systolic dysfunction (cm-basal). we aimed to determine if outcomes and diastolic function were different between patients with various forms of lv dysfunction after sah. patients hospitalized for sah between 2000 and 2008 were eligible for our study. those patients with a history of heart failure, myocardial infarction, or a documented acute coronary process were excluded. echocardiograms were reviewed and a wall motion score was provided for each of 16 lv segments. patients were classified as cm-apical if the average wall motion score for apical segments was greater than the average wall motion score for basal segments. patients were classified as cm-basal if the average wall motion score for basal segments was greater than the average wall motion score for apical segments. 198 of 583 patients with sah had an echocardiogram. 142 patients had normal lv function, 32 cm-apical and 24 cmbasal. the in-hospital mortality was not different between those with no echocardiogram or those with an echocardiogram who had normal lv function, cm-apical or cm-basal. patients with cm-apical were more likely to have shock and pulmonary complications, whereas patients with cm-basal were more likely to have sepsis. during a median follow up of 5.4 years, patients with cm-apical had the worse survival. patients with cm-apical and cm-basal had impaired lv relaxation as compared to those with normal lv systolic function. in-hospital mortality is not different between those patients with normal lv systolic function, cm-apical, or cm-basal. cmapical is associated with shock and pulmonary complications and a worse long term survival. further work evaluating the response to medical intervention and the differences in hemodynamic profiles of patients with cm-apical and cm-basal is warranted. therapy using sodium nitroprusside (snp) intrathecal (intraventricular) aims for a more effective approach for prophylaxis and treatment of cerebral vasospasm associated to a subarachnoid hemorrhage (sah). qualitative study whose objective was to analyze clinical cases to specific approach for cerebral vasospasm related to sah. two patients, the first one is a 62 years old female with aneurysm rupture of the left posterior communicating artery, sah fisher iii, hunt hess 2. the second one is 46 years old male with artery rupture of the middle cerebral artery, sah fisher iii, hunt hess 2, both were submitted to embolization, leading to acute hydrocephalus, in which external ventricular drainage (evd) was established. through the evd, a prophylactic intrathecal protocol was instituted (2ml snp with 10,5 ml of normal saline 0,9% solution applying 2 ml nps through the evd each 12 hours for 1 hour by infusion pump). patients evolved well with no neurologic or motor sequel and with a modified rankin scale = 0. the third patient was a 37 years old male with aneurysm rupture in anterior communicating artery, sah fisher iii, hunt hess 4, severe vasospasm per operative in the left middle cerebral artery (mca), treated by angioplasty with balloon. starting the treatment protocol of cerebral vasospasm by lombar catheter: dosage 50 mg (2ml) snp, solution with 4ml snp at 6 ml of normal saline 0,9% applying 4ml through the lombar catheter each 12 hours for 1 hour by infusion pump. patient without complication with modified rankin scale = 1. the cost for prophylactic therapy for 14 days was u$ 627,86; if the patient had developed clinical vasospasm, the cost for a 14 day treatment would be an average of u$ 15.287,80, having a great impact on morbidity, mortality and cost of hospital stay. angiography does not reveal a source of bleeding in 10-15% of those with subarachnoid hemorrhage. these patients usually have a benign course and favorable outcome, especially those with a perimesencephalic pattern of bleeding (pm-sah); more diffuse bleeding has been associated with higher risk of vasospasm and neurological disability. we evaluated whether amount or pattern of bleeding better predicts risk of neurological complications and outcome. methods 114 angio-negative sah patients were prospectively studied over seven years. six were excluded when a vascular etiology was identified on repeat angiography. pattern of bleeding, amount of cisternal (hijdra score) and ventricular blood (ivh score), and ventriculomegaly (bicaudate index) were assessed. neurological outcomes included hydrocephalus, angiographic vasospasm, and delayed ischemic neurological deficits (dind, based on clinical deterioration). functional outcome was assessed at 1-year using the modified rankin scale (mrs). bleeding was perimesencephalic in 60(56%), diffuse in 28(26%), cortical in 7 and ct-negative in 13. patients with diffuse bleeding had higher hijdra (12[iqr 7-17] vs. 5[3-8]) and ivh scores (2[0-7] vs. 0[0-2]), and bicaudate index (0.19[0.14-0.24] vs. 0.14[0.11-0.19]) than those with pm--v (18% vs. 5%, p=0.05) and require ventriculostomy (54% vs. 18%) and shunt placement (29% vs. 3%, both p=0.001). moderate-severe angiographic vasospasm developed in 29% diffuse vs. 13% pm-sah (p=0.08), while dind only occurred in those diffuse bleeding (14%). neither hijdra nor ivh score was higher in those developing vasospasm, across or within bleeding patterns. those with diffuse sah were less likely to be discharged home (68% vs. 90%, p=0.01) or achieve minimal disability (mrs 0-2, 83% vs. 96%, p=0.11). angio-negative sah can result in hydrocephalus, vasospasm, cerebral ischemia, and residual disability. this is more likely in those with diffuse bleeding, a disparity not explained by a greater volume of cisternal or intraventricular bleeding. independent of the cholesterol lowering effects of hydroxymethylglutaryl conenzyme a reductase inhibitors(statins), there has been much debate about their protective effect against delayed cerebral ischemia (dci). various ongoing trials are aimed at assessing their effectiveness against dci after primary subarachnoid hemorrhage (sah). there is scanty literature on dci in patients who were on statins prior to the occurrence of sah. a retrospective chart review was done after approval from the institutional review board. data was collected from july 2009 to april 2012 using the icd code for sah. patients with sah secondary to avm, trauma and surgery were excluded. demographics, baseline characteristics and occurrence of clinical dci were collected. admission home medication list was used to identify patients on statins prior to admission. all statistical analysis was done using sas. a total of 147 patients with primary sah were included. out of 147 patients, 23 (15.6%) were on home statin. only 2 (9%) patients within this group developed dci while 40 (32.2%) patients in the statin naive group developed dci (p=0.02). this difference persisted even after correcting for age (p=0.03), sex (p=0.03), race (p=0.03), smoking (p=0.03), history of diabetes (p=0.02), stroke/tia (p=0.03), peripheral vascular disease (p=0.04), hypertension (p=0.03), hyperlipidemia (p=0.01), home calcium channel blocker use (p=0.03) and fisher grade (p=0.02). a multivariate logistic regression analysis with backward selection further confirmed that the only significant factor affecting vasospasm was prior statin use (p = 0.03). the above findings suggest that prior statin use reduces the rate of dci after sah. though the known confounders were taken into consideration, the possibility of unknown confounders cannot be completely excluded. a larger prospective study may be required to verify these effects. the potential clinical implication of this would be to put patients with unruptured and untreated aneurysms on long-term statins. patients sometimes report that surviving a near-death experience results in enhanced appreciation of the preciousness and joy of life. we sought to determine how frequent the "stroke of insight" phenomenon occurs after sah. we prospectively enrolled 1200 sah patients between 1996 and 2009 and followed up survivors with a telephone interview at 3 and 12 months. patients were asked "do you enjoy life more, about the same, or less than you did before your brain hemorrhage?" surrogate responses were not analyzed. global functional outcome was evaluated with the modified rankin scale (mrs) and qol with the sickness impact profile (sip). of 764 survivors who responded to the survey, the majority (59%, n=449) reported that they enjoyed life more since the hemorrhage, whereas only 12% enjoyed life less. enhanced life enjoyment was associated with female gender and white (versus non--hess grade. patients with enhanced life enjoyment were more likely to report improved marital status (18% versus 11%, p<0.0001), and were less likely to have rumination on their illness (p<0.001). improved life enjoyment was associated with better sip qol scores (9.7 ± 11.5 versus 14.1 ± 14.4, p<0.001), but had no relationship with concurrent disability on the mrs (p=0.13). remarkably, 31% of those reporting that they enjoyed life more were unable to walk without assistance (mrs 4 or 5). the majority of sah survivors enjoy life more after their hemorrhage. increased life enjoyment has no relationship with physical disability and handicap, but is associated with improved qol. informing patients of the "stroke of insight" phenomenon may be a simple and effective way to set positive expectations and promote recovery after sah and similar life-threatening illnesses. parenteral diclofenac infusion is commonly used in neurocritical patients and has been shown to effectively decrease body temperature after aneurysmal subarachnoid haemorrhage (asah). hemodynamic side effects and in specific the effect on brain homeostasis are understudied. twenty-one asah patients with multimodal neuromonitoring of intracranial pressure (icp), brain tissue oxygen tension (p b to 2 ), and cerebral metabolism (microdialysis, md) receiving parenteral diclofenac infusions were analyzed in a prospective observational cohort study. 75mg diclofenac diluted in 100cc normal saline was administered at the discretion of the attending neurointensivist. we analyzed core body (cbt) and brain temperature (bt) over 12 hours and hemodynamic (cardio-, cerebrovascular) and cerebral metabolic parameters over 4 hours after intervention. ten-minuteaverage files of cardio-and cerebrovascular parameters and hourly files of md datasets were analyzedusing a generalized estimating equation.a pre-intervention baseline was calculated for every parameter. one-hundred-twenty-three parenteral diclofenac infusions over 34min (iqr 20-45min) were analyzed. cbt and bt decreased to a minimum of 37.5± 0.6°c and 37.3± 0.5°c, 7h and 6h after diclofenac infusion (baseline 38.3°c± 0.6°c and 37.9± 0.5°c, respectively, p<0.001). hemodynamic side effects included a 10% reduction of map (by 10±12mmhg) and cpp (by 9±13mmhg) resulting in increased use of vasopressors in 26% of interventions (p<0.001). p b to 2 significantly decreased from 28±15mmhg baseline by 12% (p<0.001) resulting in brain tissue hypoxia (p b to 2 <20mmhg) in 37% of interventions and 38% (n=8) of patients. in none of the interventions with baseline p b to 2 above 30 mmhg, brain tissue hypoxia was observed. baseline-p b to 2 below 30 mmhg was independently associated with brain tissue hypoxia during intervention (p<0.001). there was a trend towards higher brain tissue lactate-pyruvate ratio and lower pyruvate after parenteral diclofenac after sah is associated with hemodynamic side effects and may result in brain tissue hypoxia without significantly affecting brain metabolism. the impact on outcome needs further investigation. delayed cerebral ischemia (dci) is a complication of subarachnoid hemorrhage (sah) with significant mortality/morbidity. digital subtraction angiography (dsa) can detect cerebral vasospasm which is a surrogate marker for dci. there is emerging data that perfusion computed tomography (ctp) is useful in detecting dci. we have compared the utility of ctp and dsa in detecting dci. patients with primary sah admitted to two academic institutions between july 2009 and april 2012 were identified. patients with clinical dci who underwent dsa or ctp (image processing through vitrea®) were included. the area of perfusion abnormality was traced out to generate cerebral blood flow (cbf), mean transit time (mtt) and cross sectional area. abnormal cbf and mtt values were compared to normal symmetrical areas in the opposite hemisphere. dsa reports were reviewed to identify radiologic vasospasm. out of 154 patients, 43 had clinical dci(27.9%). in those with dci, 16/18 patients that underwent ctp had abnormalities (88.9%) compared to 34/39 patients that had vasospasm on dsa (87.2%; p=0.85). median abnormal cbf was 21.6 (6.3-40.9) ml/100 gm/sec compared to 41.7 (19.3-70.7) ml/100 gm/sec in area of normal perfusion (p=0.001). median abnormal mtt was 7.5 (5.1-15) seconds compared to the normal area of 4 (2.2-6) seconds (p<0.001). median interhemispheric cbf and mtt difference was 14.4 (3.8-48.6) ml/100 gm/sec and 2.7 (0.9-12.3) seconds respectively. median area of abnormal perfusion was 8.6 (2.7-52.1) cm 2 . seventeen patients underwent ctp and dsa. a normal ctp excluded vasospasm on dsa. perfusion abnormalities involving an area of less than 7.5 cm 2 did not have vasospasm on dsa. ctp is a useful indicator of dci and is comparable to dsa. in patients with clinical dci and a normal ctp, dsa is unlikely to pick up vasospasm. as the area of perfusion abnormality increases (greater than 7.5 cm 2 in our subset of patients), dsa is more likely to show vasospasm. aneurysmal subarachnoid hemorrhage (asah) is more common in women than in men. current knowledge on potential gender differences after an asah occurred is sparse, albeit of clinical relevance. retrospective cohort study including patients with asah admitted to a neurovascular center at a major academic center at the university hospital of bern, switzerland. patients below age 16 and with non-aneurysmal sah were excluded. we included 120 consecutive patients with asah between january 03, 2009 and february 26, 2011. women were older than men (median age 57 years [interquartile range [iqr] 49-67] versus 54 [iqr 44-59], respectively, p=0.01), and progressively overrepresented with increasing age (69.2% of women for the whole cohort). of note, in the swiss population the proportion of both genders between 40 and 64 years is similar, with women being slightly overrepresented at older ages. global disease severity at admission, measured by the acute physiology and chronic health evaluation (apache) ii score, was higher in women than in men (median score 18 points versus 14 [iqr 10-19], p=0.006) even after correction for age. the apache ii score independently predicted an unfavourable outcome and mortality as opposed to gender. we found no differences between genders in the adopted aneurysm-securing strategy, intensive care interventions (administered drugs, rates of endotracheal intubation, tracheostomy, length of mechanical ventilation and placement of an external ventricular drainage). women and men with asah confirmed to be similar in terms of medical history, clinical / radiological severity of asah, complications and outcome. in conclusion, this study confirms that women with asah outnumbered men, especially at higher age. global disease severity on admission is higher in women and predicts, independently from gender, unfavourable outcome and mortality. finally, this study finds new relevant similarities between genders. complications of aneurysmal subarachnoid hemorrhage (asah) may include hypertension and neurogenic myocardial stunning. subsequent management often involves beta blockade. high fisher grade asahs may also be complicated by cerebral vasospasm, which could have pathophysiologic influence from sympathetic nervous system stimulation or inhibition. we investigated any relationship of beta blockade to the incidence of radiographic vasospasm in asah by retrospectively examining 219 adults admitted to the sicu at loma linda university medical center between 8/2004 and 9/2010, excluding those who expired within 3 days of admission because of inability to assess outcomes. three groups were isolated relevant to beta blockade: 77 were never beta blocked (no/no), 123 were started on a beta blocker after admission (no/yes), and 18 were continued on their home beta blockers (yes/yes). records were analyzed for the development of vasospasm with or without resultant infarction, death, and discharge status. outcomes were evaluated using multivariate analysis through logistic regression and adjusted for potential confounders. odds ratios were calculated setting the or for no/no patients to 1. one hundred and forty five patients had vasospasm, 47 consequently infarcted, and 53 died or required care in a longterm facility. patients in the no/yes group had significantly increased radiographic vasospasm ]. however, despite increased incidence of vasospasm, these patients had significantly fewer deaths or need for long term care [or 0.17 (0.05-0.64)], with decreased tendency for infarcts ]. in the yes/yes group, there was a trend toward increased vasospasm ] that led to infarction )], with decreased mortality or need for long term care in a facility [or 0.13 (0.01-1.30)]. the use of beta blockers in asah is associated with increased incidence of radiographic cerebral vasospasm. however, despite the increased rate of vasospasm, the use of beta blockers was associated with improved discharge characteristics. patients with subarachnoid hemorrhage (sah) frequently undergo continuous electroencephalography (ceeg) monitoring in the icu. we describe commonly encountered eeg patterns in sah patients with clinical correlation. patients with primary sah admitted to two academic institutions between july 2009 and april 2012 were identified. records were reviewed to note the presence of intraventricular hemorrhagic extension (ivh), intracerebral hemorrhagic extension (ich), location of subarachnoid blood, occurrence of delayed cerebral ischemia (dci), patient outcomes and length of stay (los). eeg reports were reviewed and classified as to the presence of arrhythmic continuous slowing (acs), rhythmic and periodic slow activity of triphasic morphology (tw), epileptiform activity (ea), and coma pattern. patients with metabolic causes for tw were excluded. of 154 patients, 49 had a routine eeg or ceeg monitoring.thirteen (26.5%) exhibited non-metabolic tw, 16 (32.7%) had ea, 18 (36.7%) had acs, 1 patient had coma pattern and 1 had normal eeg. the presence of subarachnoid blood around the basal cisterns did not influence eeg patterns.in patients with ivh, the presence of tw patterns was significantly more common than other patterns (69.2% vs.41.7%;p=0.04). ea was associated with dci (56.3%) as compared to non-epileptiform patterns (31.7%;p = 0.04).ea was more common in patients with ich without statistical significance(31.3% vs.18.2%;p=0.2). median los in patients with tw, ea and acs were 27 (10-93), 24.5 (7-115) and 20.5 (11-68) days respectively without significant difference. patient outcomes were similar among all groups. non-metabolic tw are scantly reported in the literature and typically associated with diencephalic and brainstem lesion. in patients with sah, the presence of ivh and not cisternal blood was associated with non-metabolic tw. dci was significantly associated with the generation of epileptiform activity and the presence of ich seemed to favor an epileptiform pattern. eeg patterns did not influence los or outcome in our subset of patients. adenosine is an endogenous purine nucleoside that causes transient heart block in the av node when administered parenterally. we describe our experience with 25 cases of severe intraoperative aneurysm rupture in which adenosine was administered to allow for control of the intraoperative bleeding. over a 10 year period, we have treated approximately 2000 aneurysms with open microsurgery. two-thirds were unruptured. severe intraoperative aneurysm rupture that could not be readily controlled occurred in 25 cases. 24 of the aneurysms had recently bled, 1 case was an unruptured aneurysm. in all cases, the amount of bleeding precluded safe application of temporary clips. an intravenous infusion of adenosine (6 mg) was given in all cases. in 16, there was significant bradycardia and hypotension culminating in a brief cardiac pause (5-25 seconds), allowing for rapid dissection and clipping of the aneurysm. in 4 cases, there was bradycardia and hypotension, but no cardiac arrest. in 5 cases, there was limited bradycardia and hypotension, and a second dose (12 mg) was required to slow the heart enough to allow for aneurysm treatment. in such cases, the adenosine allowed us to clear the field adequately to apply temporary clips in a precise fashion, and then to clip the aneurysms properly. poor response to the initial dosing was not related to patient size or other identifiable factor. adenosine has been used safely in our experience to allow for management of severe intraoperative aneurysm rupture. in most cases, there is a meaningful cardiac pause. in some instances, patients are less sensitive, and the dose must be repeated to achieve the desire effect. no adverse cardiac or pulmonary events were associated with the use of adenosine in our series. intraventricular hemorrhage (ivh) is an established independent predictor of poorer outcome in subarachnoid-and intracerebral-hemorrhage. though, limited knowledge exists regarding the pathophysiologic mechanisms that may lead to cerebral injury and poorer outcome. this is the first report presenting in vivo data on cerebral perfusion and brain tissue metabolism during the occurrence of ivh and after intraventricular fibrinolysis (ivf). a 78-year-old woman with severe subarachnoid hemorrhage (sah), hunt&hess grade 3, modified fisher scale 4, was admitted to our neuro-critical care unit. within the first 24 hours an extraventricular drainage was placed and a left-sided mca aneurysm was coiled. after obtaining informed consent from the legal attorney, the patient received invasive multimodal neuro-monitoring, consisting of a cerebral blood flow (cbf)-and microdialysis-probe placed into the ipsilateral frontal white matter. within 8 hours after probe placement we observed a significant drop of cerebral blood flow (cbf below 20 ml/100g/min) and an increase in l/p-ratio without significant changes in cerebral perfusion-or intracranial-pressure. imaging revealed a re-hemorrhage into the ventricular system with blockage of the foramina of monro and acute hydrocephalus. consequently, therapeutic ivf was undertaken with 1 mg of rtpa which lead to sufficient clot resolution. after ivf we normalization of cerebral perfusion and metabolism. this is the first report on ivh and its potential mechanisms that may contribute to secondary injury in the human brain. a decrease of cerebral blood flow and disturbance of cerebral metabolism was documented during the occurrence of ivh, supporting existing hypotheses of global impairment. moreover, we could document profound treatment effects of ivf leading to a restored cbf and a stable aerobic metabolism in the investigated brain tissue. many patients with aneurismal subarachnoid hemorrhage (sah) present with acute, labile, hypertension and may be at risk for rebleeding. clevidipine, a novel, ultra-short acting dihydropyridine has been used in cardiac surgery, acute hypertensive emergencies and patients with intracerebral hemorrhage, but not in sah patients. the clash study (clevidipine in aneurismal subarachnoid hemorrhage) is a prospective evaluation of the efficacy and safety of clevidipine in controlling systolic blood pressure (sbp) before the aneurysm is secured. the primary endpoint is the number of patients achieving sbp target within 30 minutes. post-hoc, sbps pre-infusion, during-infusion and postinfusion were compared using a generalized estimating equation. we present the first 5 patients enrolled: 2 men and 3 women, mean h&h 2 and fisher 3.4, 3 aneurysms coiled and 2 clipped. mean sbp upper and lower goals were 154 ± 5.5 and 122 ± 4.5 mmhg. analyses included 1,587 sbp data points. all patients reached sbp target within 13.3 ± 6 min using an infusion rate of 9.3 ± 8.9 mg/hour. the mean preinfusion, during-infusion and post-infusion sbps were 165.5 ± 2.55, 146.4 ± 2.48 and 159.3 ± 11.5 mmhg (pre-infusion vs during-infusion p <0.05, pre-infusion vs post-infusion p <0.49, during-infusion vs post-infusion p <0.27). after the 1st sbp control readings, sbp was above the upper target goal 17.9 ± 18.8% and below the lower 12.3 ± 16.3% of the time. icp did not increase during infusion (n=2). no patient rebled. in one patient the infusion was stopped temporarily 3 times due to sbp below the target range. there were 7 (0.4%) sbp values <100 mmhg and none <90 mmhg. clevidipine controlled sbp in all patients with sah in <30 min and kept sbp within the selected range in 69.8% of the time without any patient rebleeding. financial support: research grant from the medicines company to conduct this study. aneurysmal subarachnoid hemorrhage (asah) is associated with numerous adverse sequelae. patients who survive the initial hemorrhage are at high risk for delayed secondary brain injury, including cerebral infarction, neuronal cell death, white matter abnormalities, and hydrocephalus. resulting in focal neurological deficits, cortical dysfunction, and both longterm cognitive and psychosocial deficits referred to as sah-induced "delayed neurological deficits" (dnds). review of the literature revealed that heparin had previously been advocated to reduce complications of asah. here, we report on our favorable experience with the use of heparin prophylaxis in the management of patients who are at a high risk for developing sah-induced dnds. a retrospective chart review of 235 patients that presented to the university of maryland medical center were reviewed between january 2006 and may 2011. inclusion criteria were patients with fischer grade iii sah due to rupture of a true saccular aneurysm and were treated by surgical clipping within 48 hours of the patient's ictal event. exclusion criteria were patients who had a localizing deficit related to an intracerebral hematoma from the ictal event. included in this study were 43 patients that were started on an intravenous infusion of heparin and an additional 43 patients that served as matched controls. none of the patients exhibited heparin-induced thrombocytopenia (hit). the heparin regimen used appeared to be safe. patients administered low-dose iv heparin experienced significantly fewer occurrences of ischemia-related ct hypodensities as well as symptomatic vasospasms than case controls. retrospective analysis of our clinical experience with constant iv infusion of low-dose heparin in patients at high risk for sah-induced dnds indicates early use of low-dose iv heparin infusion may be safe and perhaps beneficial in patients having undergone surgical clipping. further study with a double-blind placebo-controlled trial is warranted to establish the role of heparin in the prevention of sah-induced dnds. subarachnoid hemorrhage patients (sah) may experience cardiac biomarker elevation in serum troponin and b-type natriuretic peptide (bnp). we hypothesized that elevations in these cardiac biomarkers after sah are predictive of increased patient mortality. we retrospectively reviewed the medical records of all non-traumatic sah patients admitted from march 2011 to march 2012 including medical history, modified fisher scale on initial head ct scan, initial glasgow coma scale (gcs), serum troponin t and bnp within 24hrs of admission. survival data was dichotomized as either alive or dead by chart follow-up. values (>91pg/ml) versus normal values against alive or dead status. we identified 78 sah patients, 73 with initial measured troponin, and 55 with initial measured bnp.the mean age was 58 (range 18-92) and 38% male. modified fisher grade was 0-2 in 47%, and grade 3-4 in 46%. the initial gcs mean was 11 (range 3-15), 91% of patients had intracranial aneurysm, while 9% were 'angiogram-negative' sah. twenty sah patients died, with a mean of 19 days post sah (range 1-107), six from cardiopulmonary or multiple organ failure, 5 from sah, and 9 unknown/other. elevated troponin was seen in 23% (17 of 73) with a mean = 0.46 (range, 0.1-5.23), and elevated bnp in 49% (27 of 55 patients) with a mean = 388(range, 92-2480). patients with elevated levels of troponin had a greater chance of death (p=0.009). patients with elevated levels of bnp also had a higher mortality (p=0.002). the data demonstrate a statistically significant association with elevated cardiac biomarker elevation and risk of subsequent death after sah, which occurs not only during the immediate post sah period but after initial hospitalization. delayed cerebral ischemia (dci), length of stay and glasgow outcome scale (gos) following angiogram-negative sah (ansah) are infrequently and inconsistently described in the literature. furthermore ansah are generally considered to have a better prognosis than aneurysmal sah (asah). ansah subgroups include benign perimesencephalic sah (pmh) and aneurysmal-type or diffuse sah. we report and compare outcome data of patients presented with diffuse ansah and diffuse asah. a retrospective chart review of 139 patients who presented to 2 academic institutions between july-2009 and april-2012 who met the criteria for diffuse spontaneous sah were reviewed. the patients were further divided into ansah (n=25) and asah (n=114). delayed cerebral ischemia rates, length of stay and discharge gos were compared and analyzed between two groups using sas statistical software. discharge gos scale was dichotomized in good outcome (gos 4-5) out of 139 patients, a total of 25 (17.9%) patients meet the criteria of diffuse ansah and 114 (81.9%) meet the criteria of diffuse asah. demographics and baseline characteristics including age, sex, race, hypertension, diabetes, gcs on presentation, hunt & hess score and fisher grade among two groups were comparable. overall 25% (n=5) of ansah and 32% (n=37) of asah showed dci (p=0.33). mean length of stay was 17 days in nasah and 19 days in asah. good outcome was seen in 72% (n=18) in nasah and 61% (n=70%) in asah groups (p=0.36). in our patient cohort of ansah, 25% of patients had dci. even though it is less then asah group it is considerably higher then previously reported in the literature. furthermore length of stay and discharge gos between two groups were comparable. this study indicates that diffuse ansah is not a 'benign' condition and warrants a low index of suspicion for complications with a multidisciplinary approach to management. transcranial doppler (tcd) is a common method used to measure cerebral blood flow velocities and estimate flow resistance related to intracranial pressure (icp). we present the case of a patient with subarachnoid hemorrhage and clipped aneurysm, who, while undergoing tcds, rebled. a 68 year old man presented with sudden-onset severe headache and neck pain. ct of the head showed a subarachnoid hemorrhage (sah) with intraventricular extension and obstructive hydrocephalus. an anterior communicating artery (acom) aneurysm was found and clipped and a ventriculostomy was placed. after surgery there was an interval decrease in the sah. eight days after the original event the patient re-bled during a tcd test because of clip failure. tcd waveforms were captured before, during the bleed and post treatment with mannitol and csf drainage from the ventriculostomy. prior to the bleed. icp was 8mm hg, the left mca flow velocity was 62 cm/sec and the pulsatility index (pi) 1.0. during the bleed the icp increased to 54 and pi to 1.7-2.0, with the waveform showing a narrow peak and decreased diastolic and mean velocity. mannitol 75 g was given and the ventriculostomy was opened to drain. within 5 minutes the icp decreased to 14 mm hg, the pi improved to 1.4, the waveform widened and the velocities returned to previous levels (video will be provided with the abstract showing the tcd changes). repeat ct of the head showed increased sa blood and extensive new intraventricular hemorrhage; catheter angiogram a malpositioned clip. the acom aneurysm was coiled successfully. we present this unique case of tcd capturing the dynamics of a real-time intracranial aneurismal bleed with significantly elevated icp. our data demonstrated the tcd pi, flow velocities and waveforms changed dramatically during the rebleeding and improved quickly with treatment. transcranial doppler (tcd) is the least invasive method to detect cerebral vasospasm but is unable to interrogate vessels beyond the circle of willis and is highly operator-dependent. we tested a novel technique whereby we record the miniscule pulsation of the skull gated with cardiac contraction and compared it to tcd in patients with subarachnoid hemorrhage. skull accelerometry was performed using a prototype device designed by jan medial, inc. (mountain view ca). the device has 6 highly sensitive accelerometers that couple through plastic feet to the patient's scalp, arrayed with 2 detectors over the forehead, 1 at midline occiput, 1 each over the temporal bones, and 1 on the patient's vertex. they are held in place with a plastic strap. paired tcd recordings and accelerometry epochs (typically 15 minutes of recording) were compared in patients with and without spasm. a total of 62 accelerometry recordings were obtained in 20 subjects with subarachnoid hemorrhage who had paired tcd recordings. this allowed 186 distinct pairings of data sets (right, left, posterior). a unique signature was identified by a fast fourier transform waterfall technique revealing a shift in accelerometry signals to higher frequencies (representing a "bruit" of sorts) in patients with tcd identified vasospasm. an analytic model was created based on the first 124 recordings, and validated using the remaining 62 recordings. this revealed 86% sensitivity and 82% specificity for detection and localization of spasm. highly sensitive skull accelerometry detects a shift toward higher vibration frequency in patients with vasospasm-a cranial "bruit". this technique may be a highly sensitive tool for the detection of cerebral vasospasm following subarachnoid hemorrhage. a prospective, blinded validation study is on going to measure this novel tool's performance characteristics in a larger sample of patients. financial support: research grant from jan medical, inc. j.n. is 45 year-old hispanic male prisoner previously healthy presented to our institution altered due to diffuse subarachnoid hemorrhage (fisher grade iv) and a bi-lobed "mickey mouse" right m2 middle cerebral artery (mca) ruptured aneurysm. initially, j.n.'s hunt and hess grade level of 1 on arrival, but declined to a 4 in the ed. j.n. was intubated and an external ventricular device was placed. the anatomy of the aneurysm was complex in nature measuring 8mm in maximal dimension with the superior lobe measuring 3.5mm and the inferior lobe measuring 3.0mm. based on the complex anatomy of the aneurysm, a 4-vessel angiogram was planned to treat the aneurysm with a trans-arterial coil-embolization approach. a 4x15mm septal balloon was used with a synchro microwire, with the balloon been placed across the neck of the inferior aneurysm. the superior aneurysm was accessed with a sl-10 microcatheter and coiled in the usual fashion. the sl-10 microcatheter was then re-directed to the inferior aneurysm and coiled similarly. post-angiographic images showed complete obliteration of the aneurysm with a small neck residual to protect en passé branches. evaluation of the literature is scant with reports of bi-lobed aneurysm with the classic description of "mickey mouse" or "mirror" aneurysm. trans-arterial coil-embolization provided a safe, rapid, and effective method for coiling a complex bilobed aneurysm with no major thrombo-embolic events. trans-arterial coil-embolization is a procedure used in the treatment of gross hematoma and fistula in human and the veterinary population. to our knowledge, there is no report of trans-arterial coil embolization for the treatment of bi-lobed aneurysm posted within the usual medical research engines. our institution is presenting a novel endovascular technique in the treatment of a classic bi-lobed mickey mouse aneurysm. j.n. was able to recover fully and eventually discharge to the infirmary in federal prison. the routine practice of therapeutic hypothermia is advocated in the management of comatose survivors of out-of-hospital cardiac arrest (ohca), particularly if ventricular fibrillation is the initial rhythm. potential benefits of hypothermia were evaluated for comatose survivors after ohca due to aneurysmal subarachnoid hemorrhage (sah). following return of spontaneous circulation (rosc), therapeutic hypothermia was induced for comatose sah patients except for those with devastating brain damage on brain ct and cardiac arrest over 10 minutes. immediately after diagnosis and evaluation of cardiac function, cooling was promptly initiated by nasogastric lavage with iced water and surface cooling under general anesthesia. the ruptured aneurysm was obliterated by surgical clipping with wide decompressive craniectomy. core temperature was maintained at 33-urokinase was injected via cisternal drain and nicardipine and fusdil hydrochloride were intravenously administered to prevent cerebral vasospasm. clinical outcome was assessed according to the glasgow outcome scale (gos) 3 months later. six women, aged between 44 and 62 years, were eligible during the past 12 years. their glasgow coma scale was 3 after resuscitation. electrocardiogram on arrival was asystole in 2 and pulseless electrical activity in 4 patients. myocardial stunning was detected in 5 patients by echocardiogram. surgery and hypothermia treatment were uneventfully conducted. postoperative mri revealed extensive cerebral ischemia in 2 and vasospasm-related ischemic lesion in 1 patient. their gos was good recovery in 1, severe disability in 2, persistent vegetative state in 1, and death in 2 patients. therapeutic hypothermia was feasible for ohca patients due to sah. since neurogenic stunned myocardium could be a possible cause of cardiac arrest in sah, beneficial effects of induced hypothermia are expected just like cardiogenic cardiac arrest. appropriate prognostication methods are warranted for decision making to treat or not. autonomic shift (as), characterized by increased sympathetic nervous system activation, has been implicated in neurologically mediated cardiopulmonary dysfunction and immunodepression following stroke. however direct measurement of autonomic nervous system dysfunction is difficult to obtain routinely in critically patients. we investigated the prevalence of as defined by readily available clinical parameters and determined the association of as with subsequent infection in a cohort of patients with aneurysmal sah (asah). data were obtained from a single center cohort study of asah patients admitted from january 1, 2007 through april 1, 2012. as was defined as at least one early routine clinical marker of neurologically mediated cardiopulmonary dysfunction (based on electrocardiogram, echocardiogram, cardiac enzyme testing or clinical diagnosis of neurogenic pulmonary edema). exclusion criteria were beta-blocker treatment a known pre-existing abnormal electrocardiogram. multivariable logistic regression models were developed to evaluate the association between as and subsequent infection after adjusting for other covariates. a total of 167 patients were included (mean age 56, 27% male). autonomic shift was seen in 66/167 (40%), and infection was seen in 80/167 (48%). autonomic shift was associated with subsequent infection on unadjusted analysis (or=2.11, 95% ci 1.12, 3.97). however, on multivariable analysis adjusting for other predictors of infection, there was no significant association between as and subsequent infection (or 1.36, 95% ci 0.67, 2.76). age, clinical grade, aneurysm location and presence of ich were all identified as independent predictors of infection following asah. we identified evidence suggestive of as based on readily available clinical markers in 40% of patients with asah. however, as defined by these clinical criteria was not an independent predictor of infection. additional studies may be warranted to determine the optimal definition of as and to determine the clinical significance of this finding. we have previously studied the effects of falling temperature on the incidence of asah at our institution over 6737 days observing 1,175 asah. we previously reported that every degree decrease in temperature was associated with 0.6% increase in risk of asah [relative risk (rr), 1.006, p = 0.016]. we looked within the same data using other metrics to identify patterns in temperature changes which might result in physiological stress that increases the incidence of asah admissions at our institution. we developed a mathematical equation based on the premise that 70 degrees fahrenheit is the ideal external temperature for humans. our formula measured the variation above or below 70° as a percentage of 70° for every day of 6737 days of observation. the relationship of absolute differences between tmax and tmin was examined to see if daily temperature variation was associated with increasing incidence. the odds ratio for incident asah relative to 70° was 0.746 (ci 0.587 -0.948) p= 0.016. likelihood of incident asah increased as the ratio of tmax to 70° fell below zero (i.e. experienced colder temperatures). intraday variation as measured by the absolute difference between tmax and tmin was strongly associated with increasing incidence, p=0.001, or 0.987, ci (0.979-0.995). a smaller, not larger, difference between tmax and t min was associated with increased likelihood of asah admission. colder daily maximum temperatures relative to 70° f, and smaller intraday temperature fluctuations are associated with increased asah admissions at our institution. smaller daily temperature ranges correspond to seasonal periods with the least daylight in this region, and may represent sudden arrival of cold weather in warm months. both metrics support the hypothesized increased likelihood of asah with falling environmental temperatures. these new methods may assist in the development of new algorithms for asah predictions based on temperature. near-infrared spectroscopy (nirs) is a noninvasive means of measuring cerebral regional mixed arteriovenous (av) brain oxygenation. we hypothesized that frontal nirs would correlate against more established modes of vasospasm monitoring and systemic variables for severe aneurysmal subarachnoid hemorrhage (asah). case report we describe a 23 year old male who presented with coma (gcs= 8, e4m3v1t) after severe asah (modified fisher 4) from a ruptured giant basilar aneurysm (2.2 cm x 2 cm) who developed severe diffuse vasospasm with no change on clinical examination. frontal nirs monitoring was applied in addition to map, cpp, cbf (hemedex tm ), cardiac output (co), spo2, core temperature, continuous quantitative eeg (qeeg) with alpha delta ratio (adr) monitoring, along with daily tcd. the patient developed severe diffuse vasospasm and underwent angioplasty of the mca, aca, and pca arteries and received intra-arterial verapamil. pearson's correlation coefficient was used to analyze trends in variables pre-and post intervention. values were recorded over a four-day period. calculated correlation coefficients revealed invasive cbf to right nirs r=0.375 (p=0.002) and left r=0.162 (p=0.2) but was contralateral to the cbf probe, co to right nirs r=0.692 (p=0.04) and left r=0.620 (p=0.07). coefficients with weak or negative correlation included arterial map to right nirs r=-0.492 (p=0.26) and left r=-0.241 (p=0.56), noninvasive map to right nirs r=-0.210 (p=0.59) and left r=0.214 (p=0.58), spo2 to right nirs r=-0.349 (p=0.36) and left r=-0.227 (p=0.56). noninvasive map to arterial map r=0.713 (p=0.04), noninvasive map to cpp r=0.781 (p=0.01), and arterial map to cpp r=0.869, (p=0.005). nirs correlates with ipsilateral invasive cbf values (r=0.37, p=0.002) and trends with cardiac output. nirs did not correlate with map, cpp, spo2, tcd or qeeg adr data. larger prospective studies are needed to validate these preliminary results. this case report describes the use of intraventricular nicardipine in a pediatric patient for the treatment of severe cerebral vasospasm following sah from traumatic pica dissection. intraventricular nicardipine has been suggested as an adjuvant to standard therapies in adults with aneurysmal sah but its use has not been described in pediatric patients. a 12 year-old boy was transferred from an outside hospital for treatment of severe sah following sports related head injury. he was found to have a dissecting pica psuedoaneurysm which was treated endovascularly. bilateral ventricular drains had been placed for hydrocephalus. his neurological examination declined on hospital day 9 and ct angiogram demonstrated severe vertebrobasilar vasospasm. intraventricular nicardipine was administered in addition to treatment with transluminal balloon angioplasty, induced hypertension and nimodipine. the patient received 2 mg intraventricular nicardipine twice daily for 2 days and the dose was then increased to 4 mg every 6 hours for a total of 8 days. both ventricular drains were clamped for 30 min following administration. he tolerated doses without hemodynamic effects, elevations in intracranial pressure or evidence of ventriculitis. after improvement in clinical examination and mean cerebral blood flow velocities by tcd, intraventricular nicardipine was stopped. he was discharged to acute rehab and was ambulatory and preparing to restart school at age appropriate grade level at 3 month follow up. intraventricular nicardipine was safely administered in this 12 year-old patient with severe vasospasm following sah with a good outcome. intraventricular nicardipine should be considered as an adjuvant to standard therapies for vasospasm in pediatric patients, though further studies are needed to evaluate safety and efficacy in both pediatric and adult patients. the benefit of early tracheostomy has been well described. patients with aneurysmal subarachnoid hemorrhage (asah); however, represent a distinct population to which traditional weaning parameters may be difficult to apply. the purpose of this study is to identify admission characteristics of asah patients that predict need for tracheostomy. this was a retrospective cohort analysis of 209 consecutive asah patients. we excluded patients with a history of symptoms longer than 72 hours prior to transfer, expired within 72 hours, or no ct scan available prior to cerebral angiography. we collected data including: demographics, co-morbidities, neurologic exam, labs, ejection fraction % on echocardiogram, modified fisher scale, and hijdra scale. chi-square or wilcoxon tests were performed where appropriate with subsequent multivariate analysis of statistically significant variables. the data set included 35 tracheostomy patients and 174 non-tracheostomy patients. [5] [6] [7] [8] [9] [10] [11] [12] ,p=<0.0001). the modified fisher and all components of the hijdra scale were significantly higher in the tracheostomy group. the bicaudate index was significant (0.16vs.0.14,p=0.0224); however, presence of hydrocephalus using this index was not. in the multivariate analysis older age, lower albumin, higher pco2 and presence of ventricular blood by hijdra scale remained significant predictors. neurologic status on admission, advanced age, burden of systemic illness, and intraventricular hemorrhage are associated with increased risk of tracheostomy. further research in this patient population on the benefits of early tracheostomy (lower mortality, less ventilator days and less intensive care unit days) is warranted. patients with subarachnoid hemorrhage(sah) have variable outcomes, some of these leading to major disability. established guidelines advocate administration of nimodipine to patients with sah. several recent trials have investigated the utility of statins and magnesium, however there has not been much data showing clinical benefit. we present data of patients with primary sah who had therapy with magnesium, nimodipine and simvastatin for prevention of delayed cerebral ischemia (dci). patients with primary sah admitted to two academic institutions between july 2009 and april 2012 were identified. all patients received therapy with magnesium, nimodipine and simvastatin for dci prophylaxis. outcomes were categorized as good in those with glasgow outcome scales (gos) of 4-5 and poor in those with gos 1-3. chi-square analysis was used to compare outcomes between age, sex, race, hunt-hess scores (1-3 vs 4-5), presence of vasospasm and glasgow coma scale (gcs) on presentation (below or above 12). of 149 patients identified with primary sah, 65.77% had a good outcome. the mean age for patients with a poor outcome was 60.76 (sd 13.95) when compared to 53.95 (sd 13.12) in patients with a good outcome (p=0.004). among those with a gcs 13-15 on admission, 84.7% had a good outcome while in those with less than 12 only 15.3% had a good outcome (p<0.0001). when comparing hunt-hess scales, 81.9% of those with grades between 1-3 had good outcomes, while 73.6% of patients with grades 4-5 had poor outcomes (p<0.0001). among those who developed dci, 24.5% had a good outcome as compared to 38.8% had poor outcomes (p=0.036). age and race failed to show any difference in patients with good and poor outcomes. we present our data on therapy with nimodipine, magnesium and statin for prophylaxis against dci. age, admission gcs, hunt-hess scale and occurrence of dci were predictors of patient outcome. intraoperative rupture during the surgical treatment of a previosuly unruptured intracranial aneurysm is a rare event. we describe our experience with intraoperative aneurysm rupture in this setting. we reviewed all cases of unruptured aneurysms treated by a single surgeon from july, 1997 to june, 2011 and identified those patients who suffered intraoperative aneurysm rupture. of 1275 unruptured aneurysms treated during this period, there were 6 instances of intraoperative aneurysm rupture (0.47%). in our experience, rupture occurred during dissection of either a perforator (2 cases) or a major efferent vessel (2 cases) from the aneurysm dome or of the dome from adherent overlying cortex (1 case). in one instance, the aneurysm ruptured during removal of the anterior clinoid process. in 4 cases, blunt rather than sharp dissection was being employed. in 3 cases, bipolar electrocautery and gentle tamponade successfully sealed the rupture point. in 2 cases, a clip placed across the bleeding site well up on the dome of the aneurysm controlled the bleeding and allowed for completion of the dissection and proper clipping. in the last case, the administration of adenosine was utilized to stop the bleeding and allow for proper clip placement. intraoperative angiography confirmed adequate aneurysm obliteration in each case. there were no clinical consequences associated with these intraoperative ruptures. intraoperative rupture during elective surgery for a previously unruptured aneurysm is uncommon. in our experience, rupture was typically associated with blunt dissection on the dome of the aneurysm. the use of bipolar electrocautery, clipping of the bleeding point, or intravenous adenosine infusion were successfully used to control bleeding in our cases. the neurovascular surgeon should be prepared to address this unlikely event, should it occur. aneurysmal subarachnoid hemorrhage (asah) is a life-threatening form of hemorrhagic stroke which is more common in women than men, typically between ages 30-60. over the course of our nursing practice, we have observed a trend of pre-menopausal asah female patients who experience the onset of their menses during the initial week of hospitalization. we became curious as to whether there is a correlation between asah and an earlier onset menses than a normal 21-28 day cycle. retrospective, single-center review of the medical record of pre-menopausal females ages 18-55 years who were admitted to our neuroscience intensive care unit with the diagnosis of asah. chart review was specific to documentation of the onset of menses during the first week of hospitalization, medical/gynecological history with regard to last menstrual period, usual menstrual cycle characteristics, contraceptive use, past surgical history, and pertinent medications. over a 13 month period (june 2011-june 2012), we identified 103 asah patients with 58 being female. of the female asah charts screened, we found 15 study patients. nine of 15 (60%) females had documentation of starting their menses during their initial week of hospitalization for asah, much earlier than a normal range of the menstrual cycle of 21-28 days. one patient had menses documented on hospital day 12. this small retrospective study suggests that asah may disrupt the "normal" menstrual cycle of pre-menopausal females. to our knowledge, this is the first description of this gender and disease specific phenomenon. a prospective study is planned to better understand the role asah has on hypothalamic-pituitary-ovarian-uterine physiology. introduction 10-20% of patients with spontaneous subarachnoid hemorrhage can have normal cerebral angiogram. vasospasm, hypoperfusion or thrombosis may hide the aneurysm. dynact is a promising new technique which may help in these cases. we present a case report that highlights the ability of dynact in identifying a thrombosed aneurysm that was undetected with routine cerebral angiogram. a 60 year old female presented with the worst headache of her life. ct scan of the brain showed subarachnoid hemorrhage (sah) in suprasellar cistern, extending into the anterior interhemispheric fissure, bilateral perisylvian, prepontine cistern and right perimesencephalic cisterns along with extension in to the third and fourth ventricles. after the placement of an external ventricular drain, the patient was immediately taken to angio suite where a biplane cerebral angiogram showed 1-2 mm saccular aneurysm at right middle cerebral artery bifurcation and an unremarkable vasculature otherwise. repeat imaging using dynact showed the presence of a 3 mm ruptured and thrombosed aneurysm at the right mca bifurcation. the thrombosed aneurysm was visualized and clipped surgically. this case report highlights the promising utility of dynact in identifying the culprit aneurysms. treatment of severe cerebral vasospasm in subarachnoid hemorrhage remains challenging. with failure of noninvasive therapy, endovascular modalities may be undertaken, albeit with limited efficacy; balloon angioplasty can be used only for proximal, focal spasm and intra-arterial calcium-channel blocker (ccb) bolus infusion has transient vasodilatory effects. we present a patient with severe vasospasm after subarachnoid hemorrhage, who demonstrated significant angiographic improvement with continuous infusion of intra-arterial verapamil over 24 hours. a female in her mid-30's with sickle cell anemia presented with a hunt and hess 5, fisher grade iv subarachnoid hemorrhage secondary to a ruptured right posterior communicating artery. on initial assessment, the patient was localizing with only her upper extremities. the aneurysm was completely coil embolized and standard triple-h therapy maintained. on post-bleed day 7, the patient developed left-sided hemiplegia. angiography demonstrated critically severe, diffuse right anterior and posterior circulation vasospasm. angioplasty could not be performed due to microwire and balloon inaccessibility of stenosed anterior and posterior circulation vessels. subsequently, two microcatheters were positioned with their respective tips in the petrous right internal carotid artery (ica) and v2 segment of the right vertebral artery for continuous machine controlled intra-arterial verapamil infusion. dosing consisted of administering 2 mg/hr verapamil into the right vertebral artery and 4 mg/hr into the right ica. the patient was placed on a heparin drip and taken to the neurointensive care unit for monitoring. after 24 hours of continuous ia verapamil infusion, angiography demonstrated significant improvement in right anterior and posterior circulation vasospasm, with only residual diffuse moderate stenosis. unfortunately, no corresponding clinical improvement was noted. prolonged infusion of intra-arterial ccb's may provide extended angiographic improvement in severe vasospasm refractory to conservative treatment and unsuitable for balloon angioplasty. with systematic study of such techniques, optimal agents and dosing for sustained vasodilation and clinical optimization may be defined. vasospasm remains a significant cause of morbidity after subarachnoid hemorrhage (sah), inducing delayed ischemic events. sah typically results in numerous complications including severe, treatment-refractory headache. fioricet® (acetaminophen 325mg/butalbital 50mg/caffeine 40mg) is a commonly used analgesic medication for the treatment of headache in sah. caffeine has been shown to reduce cerebral blood flow. the purpose of this study was to determine if there is an association between fioricet® administration and early vasospasm. a retrospective, medical record review was conducted, and patients were identified using the university health consortium (uhc) database. patients were included if they had an aneurysmal sah with a presenting hunt and hess grade of i-iv. data points included occurrence of clinical vasospasm, daily amount of fioricet® and other analgesics, daily pain scores, and patient demographics. a univariate analysis was performed to determine the association between extent of fioricet® exposure and early vasospasm (within the first 7 days) after sah. a multivariate analysis was performed accounting for amount of fioricet® use, patient age, and hunt and hess grade. the population characteristics were typical of the sah population. patients who experienced clinical vasospasm received more fioricet® than those who did not have vasospasm (mean 5.09 + 3.2 tablets/day versus 3.66 + 3.3 tablets/day (p=0.02)). the odds ratio for vasospasm with regards to fioricet® use when controlled for age and hunt and hess grade was 1.1 (95% ci 0.96 -1.27). the multivariate analysis did not yield any statistically significant associations with vasospasm. there was a significant association between fioricet® exposure and vasospasm in our univariate analysis. however, when correcting for age and sah severity, the association is not significant. thus, the data do not currently support a clear causal association. this preliminary data will be used to support a comparative study investigating headache treatment in sah. isolated complete third nerve palsy (tnp) in the setting of a subarachnoid hemorrhage (sah) is most commonly seen secondary to a posterior communicating artery (pcom) aneurysm. however, this same clinical picture with a negative angiogram and otherwise negative imaging studies becomes extremely rare. although trauma has been described as one of the most common causes of isolated tnp, concomitant post-traumatic sah and late onset isolated complete tnp has never been reported. we report a case of a delayed onset complete tnp after traumatic sah. case report. a 61 year-old male with type-2 diabetes mellitus presented to the emergency department with painless diplopia and left eye ptosis three days after sustaining a fall with closed-head injury without loss of consciousness. his non-contrast head ct scan showed a fisher 4 grade subarachnoid hemorrhage. upon arrival and throughout his hospitalization, the patient had a glasgow coma scale (gcs) of 15. his neurological exam revealed findings consistent with isolated complete thirdnerve palsy (tnp) involving the pupil. his neurological examination was otherwise normal. diagnostic digital subtraction angiography (dsa) was negative as it was his brain mri for aneurysm or vascular lesion. mri did however show traumatic sah pattern and small subdural hematomas consistent with trauma. laboratory findings (esr, crp, ace, c-anca and p-anca) did not raise suspicion of secondary vasculitic or ischemic causes of tnp. the patient was discharged five days after admission with no further complications but without any improvement of tnp signs and symptoms. this case illustrates an atypical presentation of traumatic sah with delayed-onset, isolated complete tnp. to our knowledge, this is the first case with these features described in the literature. his atypical presentation may represent the combination of both diabetes and traumatic injury to the cranial nerve iii in the subarachnoid space, rather than either etiology alone. diringer section of neurocritical care improved clinical outcomes after aneurysmal subarachnoid hemorrhage (asah) have been demonstrated for patients treated at high volume centers. these centers treat only 50% of all asah. it is common for asah patients to be transferred to high volume comprehensive stroke centers after presentation to a community hospital. this study aims to determine if the hospital of presentation has impact upon asah outcomes. a 3-year retrospective analysis of asah treated in a comprehensive stroke center was undertaken. the comprehensive stroke center consisted of a neurocritical care unit, dedicated vascular neurosurgeons, and endovascular and neurocritical care specialists. demographic and outcome data were collected on all asah patients who had a confirmed and secured aneurysm, survived > 10 days from admission, and completed tcd monitoring and observation for complications of vasospasm. univariate and multivariate analyses were evaluated for differences in mortality, complications, incidence of vasospasm, discharge disposition, and length of stay. 107 patients were included (31 direct and 76 transfer). baseline parameters known to influence outcome (age, medical complications, glasgow coma scale, fisher and hunt and hess grade) were similar between the two groups. transferred patients developed ultrasound defined vasospasm more frequently (58% versus 32%; p<0.05) and had a greater delay in time to surgery (3.9 versus 2.4 days; 0<0.05). adjusting for key predictors, direct admit patients spent 3.9 fewer days in the icu compared to transferred patients (t=-2.7, p=0.009). multivariate analysis showed that the likelihood of vasospasm was significantly higher for transfer patients (or 3.46, ci: 1.2-10.3, p = 0.03). longer in-hospital stays and decreased rates of home discharge were observed in transferred patients (p<0.01). mortality rates were not statistically different (transfer 22.6%, direct 14.5%, p=0.31). asah patients admitted directly to a comprehensive stroke center have better outcomes than those transferred from lower acuity facilities. numerous advances have been made in the management of subarachnoid hemorrhage (sah) and its complications, including symptomatic vasospasm. however, the optimal management of vasospasm in patients without neurological deficit remains uncertain. we performed an electronic survey of members of the neurocritical care society (ncs) to elucidate clinical practice in this regard. an electronic survey with ten questions about different aspects of sah management was formulated. our institutional review board and ncs approved the survey. three scenarios were presented for good grade sah patients without evidence of delayed cerebral ischemia (dci): those with either normal tcd values, vasospasm on tcd, or vasospasm on angiography. 144 members answered the survey (response rate of 15%). up to 45% of respondents utilized transcranial doppler (tcd) measurement to diagnose vasospasm, while 80% (95% ci, 72-86%) used clinical examination and 82% (95% ci, 75-88%) used angiography (ct or catheter). in good grade sah patients with no evidence of dci, 90% (95% ci, 84-95%) of respondents indicated using nimodipine in all three scenarios. in the subset with normal tcd values, 10% (95% ci, 5-16%) recommended use of hypervolemia, 4% (95% ci, 2-9%) hemodilution and 1% (95% ci 0-5%) induced hypertension. however, in the subset with vasospasm on angiography and no referable clinical symptoms, 50% (95% ci 42-58%) recommended the use of hypervolemia, 26% (95% ci, 19-34%) hemodilution, 48% (95% ci, 40-56%) induced hypertension and 43% (95% ci, 35-52%) endovascular therapy with intra-arterial vasodilators, angioplasty or stents. from the sample above, it appears that good grade sah patients without neurological deficit but radiological vasospasm are treated aggressively. this is not supported by current literature or guideline recommendations, which imply little benefit of aggressive therapy in such patients. further studies are needed on the optimal management of this subset of patients, in whom the effects of vasospasm remain unclear. key: cord-017031-i10q2569 authors: brix, gunnar; kolem, heinrich; nitz, wolfgang r.; bock, michael; huppertz, alexander; zech, cristoph j.; dietrich, olaf title: basics of magnetic resonance imaging and magnetic resonance spectroscopy date: 2008 journal: magnetic resonance tomography doi: 10.1007/978-3-540-29355-2_2 sha: doc_id: 17031 cord_uid: i10q2569 in this chapter, the basic principles of magnetic resonance imaging (mri) and magnetic resonance spectroscopy (mrs) (sects. 2.2, 2.3, and 2.4), the technical components of the mri scanner (sect. 2.5), and the basics of contrast agents and the application thereof (sect. 2.6) are described. furthermore, flow phenomena and mr angiography (sect. 2.7) as well as diffusion and tensor imaging (sect. 2.7) are elucidated. in this chapter, the basic principles of magnetic resonance imaging (mri) and magnetic resonance spectroscopy (mrs) (sects. 2.2, 2.3, and 2.4), the technical components of the mri scanner (sect. 2.5), and the basics of contrast agents and the application thereof (sect. 2.6) are described. furthermore, flow phenomena and mr angiography (sect. 2.7) as well as diffusion and tensor imaging (sect. 2.7) are elucidated. the basic physical principles of the nuclear magnetic resonance (nmr in medical literature: magnetic resonance [mr] ) can be understood in depth and in detail based on quantum mechanics. in sect. 2.2, however, another description is attempted that is almost physically exact and uses only a few simple arguments of quantum mechanics. in turn, the presentation will be more complex, but still can be understood with only basic knowledge in physics. for this reason, this synopsis should precede the detailed description in the following sections to guide the reader. mr examinations are possible if atomic nuclei of tissue of interest possess a nuclear magnetic moment µ. atomic nuclei with odd numbers of nucleons (here: protons, neutrons) do possess such magnetic moments. the nucleus of the hydrogen atom consisting of only one proton is the simplest atomic nucleus with an odd number of nucleons and thus has the biggest magnetic moment of all nuclei. its natural abundance of almost 100% and its ubiquitous occurrence and the high mobility of water protons in living matter are further prepositions for using low-sensitivity nmr method for imaging in human subjects. this low sensitivity compared with other imaging methods-e.g., positron emission tomography-cannot be emphasized enough. the sensitivity difference of this both methods is several orders of magnitude (~10 5 -10 6 ). this fact has to be taken into account when magnetic resonance imaging is envisioned for specific probe imaging, nowadays known as molecular imaging. in spite of the abovementioned low sensitivity of mr, proton imaging is possible in humans because of the high magnetic moment, ~ 100% abundance, high concentration, and high mobility of protons in tissue. the following consideration will be restricted to the hydrogen nuclei only. the basis of the magnetic resonance imaging is a simple resonance phenomenon. in a magnetic field, free environmental magnetic moments of a specimen are not oriented at all; however, in an external magnetic field the magnetic moments are no longer randomly oriented. the application of an external magnetic field b0 forces the magnetic moments µ to align along the magnetic field. due to basic physics principles, the orientation has two quantum states with respect to the external magnetic field: first the parallel, and second the antiparallel state, both of which have different magnetic energies em, and its energy difference being ∆em = γ · ħ · b0, and γ, ħ being the gyromagnetic ratio and planck's constant, respectively. in thermal equilibrium, both states possess different occupation numbers, with the low-energy parallel state having higher probability of occupation than does the low-energy antiparallel state, resulting in a macroscopic and therefore measurable net magnetization parallel to the orientation of the external magnetic field. this thermal equilibrium state can be distorted by irradiation with alternating electromagnetic field having a radiation energy erf identically to the energy-splitting ∆em caused by the magnetic field, and the radiation energy being erf = ħ · ω0, and ω0 being the resonance frequency of the spin system-the so-called larmor frequency. due to the resonant irradiation, the spin system takes up additional energy that can be dissipated only if the system is coupled to its microenvironment. this coupling strength is described by the so-called t1 relaxation time (also known as longitudinal or spin-lattice relaxation time). an equivalent for the coupling of the spins to each other is the t2 relaxation time (also known as transversal or spin-spin relaxation time). for tissues, typical t1 relaxation times for tissues are between 100 and 2,000 ms and t2 relaxation times between 10 and 1,000 ms. mr imaging utilizing pulsed nmr-this means the alternating electromagnetic field, the so-called radiofrequency (rf) field-is applied only for a short period of time (in general, pulses are some milliseconds). the short rf pulse excites the spin system via a transmitter coil. after irradiation of the nuclear spin system, a receiver coil can detect a damped time-dependent signal with a frequency of ω0. this signal is called the free induction decay (fid) . the damping of the signal is ruled by the t2 relaxation times, and the period by the strength of the external magnetic field (constant magnetic moment assumed). in practical terms, not only does the t2 relaxation time influence the damping of the signal, but also the technically related inhomogeneity of the external magnetic field. the signal damping caused by the inhomogeneity is called t2* relaxation time, and is in general much stronger than that caused by t2 relaxation times. only special pulse sequences (e.g., spin-echo sequences) can eliminate the influence of the inhomogeneity of the external magnetic field and thus allow the measurement of the t2 relaxation times specific to the substance/tissue. the influence of t2 relaxation times is mainly limited to the amplitude of the signal. preposition for the image reconstruction (sect. 2.3) is the exact information about the mr signal's origin. this spatial information can be generated by space-dependent magnetic fields additionally applied along the three space coordinates. these space-dependent magnetic fieldscalled magnetic field gradients-are small as compared with the main external field and are generated by special coils mounted in the bore of the magnet. due to these additional magnetic field gradients, the total magnetic field is slightly different in each volume element (voxel) and in turn, so is the resonance frequency of the spin system in each voxel. as a result, irradiation with a rf pulse of defined frequency ω′ excites only those nuclei in such voxels where the larmor frequency ω0 given by the field strength matches the resonance condition. suitable changes of the field gradients allow moving a volume element in space, fulfilling this condition. keeping in mind that the signal intensity of a volume element is given by the number of the spins in the volume element, the relaxation times of the tissue and the specific measurement parameters (e.g., pulse repetition time, echo time etc.), this signal intensity is assigned to the corresponding picture element (pixel). in this manner, the region of interest can be sampled by moving the volume element through space, and successively, an image with respect to pixels can be constructed. this method requires a long time to acquire images, assuming every experiment needs about 1 s to measure a voxel and a pixel, respectively. thus, the measurement of an image 128 × 128 pixels will require more than 16,000 s to complete. nowadays, 2d-, 3d-, and/or phase encoding methods as well as half-fourier methods are applied, allowing data acquisition times of minutes or even less. special fast imaging techniques (e.g., flash, rare, epi sequences) allow further reduction of the acquisition time (cf. sect. 2.4) . in contrast to x-ray computed tomography, where the attenuation is governed purely by the electron density, as mentioned above, in mri the signal intensity is a complex function of the proton density and the t1, t2, and t2* relaxation times. additionally, the signal intensity-and hence the image contrast-can be influenced by the measurement parameters (e.g., echo time, repetition time) set at the scanner. the knowledge of these interrelations of the different parameters influencing the signal intensity and hence the image contrast is mandatory in interpreting mr images correctly. the mr scanner is a complex system (sect. 2.5). its main components are the magnet, the rf system, and the gradient coils. the entire system is controlled and supervised by a computer. the development of mr imaging was only possible after the development of fourier trans-form nmr as well as fast computers calculating fast fourier transformations within minutes. the development of large-bore superconducting magnets of ≥ 0.3-1.5 t in the 1980s accelerated the development and the application of mri in clinical practice. nowadays, 3-t scanners are in routine clinical use. scanners with ≥ 7 t are installed and will further accelerate the development of mri and mrs. most of the magnets are made of solenoid coils. other magnet types, like scanners with helmholtz coils configuration, give better access to the patients; however, are installed mostly for special purposes, e.g., in an operation suite. mr scanners with conventional resistivity magnets and fields smaller than 0.5 t are rarely used, except in countries with short supplies of helium or other restrictions that may not allow installation of a superconducting system. the risk of side effects is assumed low if the magnetic fields are ≤ 1.5 t, except for the danger caused by ferromagnetic subjects accelerated into the magnet. nevertheless, at fields of 1.5 t and even ≥ 3 t, the knowledge about side effects is rare, especially the long-term exposure due to high static magnetic fields, gradient fields, and rf fields to organisms. the problems concerning safety are extensively discussed in sect. 2.9. in the early days of mri, the simplicity and wide range with which to manipulate contrasts in mri by changing the imaging parameters led to the conclusion that development of mr contrast agents is dispensable. however, experience taught that contrast media significantly improve mr diagnostics, not only in the central nervous system, but also in other diagnostic procedures. in contrary to x-ray contrast agents, where absorption is the dominating physical effect producing the contrast, mr contrast media are based on other principles. the paramagnetic and/or super-paramagnetic properties of the contrast media influence the relaxation times of tissue, or change contrast by obliterating the signal of protons and thus increase contrast. whereas in x-ray the contrast is proportional to the concentration of the contrast medium, in mr the dependency on the concentration is in general much stronger than linear -most often exponential. mr-contrast media are described in sect. 2.6. the intrinsic sensitivity of nmr to motion was already observed early in the 1950s. in mr imaging, motion, in particular flow, is often recognized as artifacts. however, these phenomena can be used to measure flow and/or represent the vascular system. two effects are used for these kinds of measurements, the time-of-flight phenomenon (or the wash-in/wash-out effect) or the spin-phase phenomenon. in time-of-flight measurements, moving spins are excited at one location (in the vessel), and detection of the spins is performed downstream at another known location (slice). the delay time between excitation and detection can be used to calculate the flow velocity. several modifications of the method exist (e.g., presaturation, bolus tracking), and are used depending on the setup of the measurement and sequences used. the spin-phase phenomenon can be used for angiographic imaging as well. the phase of the transverse magnetization of moving spins along a field gradient changes according to the larmor equation. these phase-shift effects are observed for flow in all directions. the phase changes are prone to different flow parameters (e.g., velocity, turbulences, acceleration, etc.) and on the pulse sequences used. the signal variations produced by the two effects can be used to produce images of the vascular structures. using phase-sensitive effects, magnitude subtraction is a common procedure: dephased and rephrased image are acquired sequentially and are subtracted. using time-offlight effects, mostly maximum-intensity projection is used to construct images of the vasculature. the angiographic techniques are described in detail sect. 2.7. diffusion-weighted and -tensor imaging is a method applied first for clinical problems in brain, e.g. stroke, characterization of brain tumors, multiple sclerosis, etc. molecules in gases and fluids undergo microscopic random motions due to the thermal energy proportional to the temperature of the gas or fluid. if the molecules-in this context only water molecules are considered-are imbedded in a structure, for instance in tissues, the random walk motion may be restricted by the cellular tissue structure and hence reduce diffusion constants. if the structure of tissue has a preferred direction, diffusion will no longer isotropic; the diffusion will have higher components in the preferred direction of tissue. this kind of diffusion is called anisotropic diffusion. in mathematical terms, the anisotropic diffusion can be represented by a tensor. the so-called apparent diffusion coefficient can be measured, and the anisotropy of the diffusion can be determined and contains information about the structure of tissue. the basics of diffusion imaging are elucidated in sect. 2.8. g. brix all nuclei with an odd number of protons and/or neutrons possess in their ground state a non-zero angular momentum or nuclear spin i, which results from the intrinsic angular momentums and the orbital angular momentums of the constituent protons and neutrons. as with any other angular momentum at the atomic and nuclear level, the angular momentum vector i is quantized. this quantization is described by the following fundamental postulates of quantum physics: • quantization of the magnitude: the magnitude (length) |i | of the angular momentum vector can only take the discrete values |i| = ħ i(i + 1), with ħ being the planck's constant (ħ = 1.05 × 10 -34 js) and i the spin quantum number, which is either integer or half-integer. • quantization of the direction: the component iz of the angular momentum vector i along the direction of an external magnetic field is quantized. for a given value of i, only the discrete values of iz= mħ are admitted, where m is the magnetic quantum number which is limited to the values -i, -i + 1, . . . , i -1, i. in total, there are thus only 2i + 1 orientations of the angular momentum vector i allowed. example: figure 2 .2.1 illustrates spin quantization in form of a vector diagram for a nucleus with the spin quantum number i = 3/2. in this case, there are 2i + 1 = 2 · 3/2 + 1 = 4 orientations of the spin vector i with the magnitude (length) i(i+1) |i| 3/2 · (3/2+1) 15/4 ћ ћ ћ allowed. remark: the spin quantum number i is frequently referred to as "nuclear spin, " which means that the maximum (minimum) component of the vector i along the chosen axes is ħi (-ħi). the angular momentum i of an atomic nucleus is always related with a magnetic moment μ. this nuclear magnetism forms the basis of magnetic resonance. remark: an atomic nucleus can be imagined as a rotating, positively charged sphere ( fig. 2.2 .2). the rotation of the charge results in a circular electric current, inducing a magnetic dipolar field. both the direction and magnitude of the magnetic field are characterized by the magnetic moment μ. in the simple model considered, the vector μ is collinear with the mechanical angular momentum of the sphere. surprisingly, in quantum physics this simple relationship is even valid when the angular momentum is an inherent property of a particle (e.g., an electron or a nucleus) which is not associated with a mechanic rotation. as shown by a large number of experiments, there is a linear relationship between the nuclear magnetic moment and the nuclear spin μ = γ i. (2.2.1) the proportionality constant γ is denoted as gyromagnetic ratio and is a characteristic property of a nuclide. whereas all nuclei with i ≠ 0 can be used in principle for spectroscopic mr examinations, the nucleus of the hyin the classical model, the rotation of a charged particle, described by its angular momentum i, results in an electric current, which induces a magnetic dipolar field. direction and magnitude of this field are described by the magnetic moment μ. the vector μ is directed collinear to the angular momentum i of the sphere (magnetomechanic parallelism) drogen atom, which has a spin quantum number of i =1/2, is almost exclusively used in mri due to two reasons: • it is the most abundant nucleus in biological systems. • it has the largest gyromagnetic ratio of all stable nuclei. in the absence of a magnetic field, all allowed orientations of the magnetic moment μ = γ i are energetically equal. this corresponds to the well-known fact that a bar magnet can be positioned arbitrarily within the field-free space; its potential energy is independent of its orientation. however, if the nucleus is located in a homogenous static magnetic field with the magnetic flux density b 0 (magnitude, b 0 = |b 0|) directed along the z-axis of a coordinate system, the nucleus has the additional potential energy splitting of the energy levels of a nucleus with the spin quantum number i = 3/2 in an external magnetic field with the flux density b 0. the energy difference between the four equidistant nuclear zeeman levels is δe = ħω0 = γħb 0 the b field represents the "real" magnetic field that interacts with the magnetic moments of the nuclei. the relation between the two magnetic field quantities is explained in sect. 2.2.8.1. when considering an isolated magnetic moment within a static magnetic field, one will find that transitions between the different energy levels are prohibited due to the law of energy conservation. transitions can exclusively be induced by an additional time-dependent electromagnetic rf field that interacts with the magnetic moment, the effect is known as magnetic resonance (mr). in mr, transitions are induced by a magnetic rf field b1(t) with the angular frequency ωrf, which is irradiated perpendicular to the direction of the static magnetic field b 0 . such a time-dependent magnetic field, however, can only induce transitions fulfilling the selection rule ∆m = ±1, i.e., transitions between neighboring energy levels. as a consequence, the energy erf = ħωrf of a photon of the rf field must be identical with the energy difference δe = ħω0 = γħb 0 between two neighbored energy levels, which yields the resonance condition ωrf = ω0 = γb 0. (2.2.4) remarkably, planck's constant ħ does not occur in this fundamental equation of magnetic resonance. this indicates that the basic principles of magnetic resonance can-not only be described by quantum physics, but also by a classical approach, which is mediated by the intuitive semi-classical model described in the next section. in an external magnetic field, a cylindrical permanent magnet-characterized by a magnetic moment μ-experiences a mechanical torque that tends to align the permanent magnet parallel to the external magnetic field and thus minimize the potential energy of the system. however, in the case that the permanent magnet rotates around its longitudinal axis and thus possesses an angular momentum ("magnetic gyroscope"), it cannot align parallel to the external field due to the conservation of the angular momentum. in this situation, it experiences a torque perpendicular to both the direction of the magnetic field and the angular momentum, which results in a rotation (precession) of the magnet on a cone about the direction of the external b 0 field (see fig. 2 .2.4b). the frequency of this precession, the larmor frequency, corresponds to the resonance frequency ω0 given by eq. 2.2.4. magnetic field can be illustrated by a mechanic analog. when a child's spinning top is deflected so that its axis is not parallel to the top and the nucleus is that the nucleus possesses an intrinsic angular momentum i, whereas the angular momentum l of the top has to be initiated mechanically the direction of the gravitational field, it will continue rotating around its axis, but the axis itself will start rotating-the top precesses on a cone around the direction of the gravitational field ( fig. 2.2 .4a). it should be mentioned, however, that the child's top and the nucleus differ with regard to the fact that the child's top has to be spun, whereas the nucleus possesses an intrinsic angular momentum. the quantization of direction of the nuclear magnetic moment μ can be integrated into this classical description by limiting the angle between the field axis and the precession cone to the discrete values which relate to the 2i + 1 orientations of the angular momentum i permitted. for a spin-1/2 nucleus, this results in a double-precession cone as shown in fig. 2 .2.5. however, this semiclassical model is rendered questionable, because the classical concept of a continuous trajectory in space is hardly compatible with the quantization of physical quantities. for instance, what would the trajectory of the vector μ look like when transitions between the various precession cones, reflecting discrete energy levels, are induced by an rf field, such as for a spin-1/2 nucleus, the transition from the lower to the upper precession cone (cf. fig. 2 .2.5)? is it possible to assign to the vector μ a well-defined direction in space at any point in time, and would this direction change over time? if so, then this negates the postulate of discrete energy and angular momentum levels. this aporime can only be solved by a rigorous quantum mechanical treatment of the system. however, when considering only the mean values of physical quantities averaged over a large ensemble of nuclei-which can only be measured in a real mr experiment-it becomes obvious that the models and laws of classical physics are valid. in field-free space, the magnetic moments of nuclei in a macroscopic sample are randomly oriented due to their thermal motion and thus mutually compensate each other. in a homogeneous static magnetic field b 0, however, only 2i + 1 discrete orientations of the magnetic moments with respect to the direction of the external field are permitted, the energy levels of which differ according eq. 2.2.3. in thermal equilibrium, the population of the 2i + 1 levels (spin states) is described by the boltzmann statistic: the lower the energy em = -γħb0m of a state with the magnetic moment μz = γħm in the zdirection, the greater is the occupation number. example: let us consider an ensemble of hydrogen nuclei in a static magnetic field of the flux density b0 = 1 t. according to the boltzmann statistic, more nuclei will occupy the state of the lower energy (m = +1/2, µz parallel to b 0) than the state of the higher energy (m = -1/2, µz antiparallel to b 0) (fig. 2.2.6 ). however, as compared with the thermal energy, the difference between the two energy levels is extremely small, so that the difference in the occupation numbers of the two levels is very small. at body temperature of 37°c, the difference in the occupation numbers with respect to the total number of spins is as low as 0.000003 ! fig 2. 2.5 double-precession cone for a nucleus with the nuclear spin quantum number i = 1/2. the two permitted spin states (precession cones) are characterized by the magnetic quantum numbers m = ±1/2 origin of the nuclear magnetization. in thermal equilibrium, the distribution of an ensemble of spin-1/2 nuclei on the two allowed precession cones is described by the boltzmann statistic. the occupation number of the state of the lower energy (m = +1/2, µz parallel to b 0) is somewhat higher than that of the state of the higher energy (m = -1/2, µz antiparallel to b 0) which leads to macroscopic (bulk) magnetization m0 although the difference in the occupation numbers is extremely small, it results in a measurable bulk magnetic moment along the direction of the b 0 field due to the large number of nuclei in a macroscopic sample ("nuclear paramagnetism"). the macroscopic magnetization in thermal equilibrium is described by the magnetization vector m0, which is defined as the vector sum of the nuclear magnetic moments per unit volume v. the magnitude of the equilibrium magnetization m0 is given by where n is the total number of nuclei in the sample, t the absolute temperature of the sample, and k boltzmann's constant (k = 1.38 · 10 -23 j/k). the ratio ρ = n/v is called spin density. as both the body temperature and the spin density cannot be altered in living beings, the equilibrium magnetization m0 can only be increased according to eq. 2.2.5 by increasing the magnetic flux density b0. the equilibrium state of a spin system can be disturbed by a magnetic rf field b 1(t) with a frequency ωrf equal to the larmor frequency ω0, which tilts the magnetization m. whereas a nuclear magnetic moment μ can only take 2i + 1 discrete orientations relative to the static magnetic field b 0 (quantization of direction), the macroscopic magnetization m can take any direction in space and change it steadily. the action of a magnetic rf field b 1(t), which rotates with the larmor frequency ω0 around the direction of the static b 0 field, can be analyzed most effectively in a rotating frame, i.e., a coordinate system that rotates with the larmor frequency around the z-axis ( fig. 2.2.7) . the change to a rotating frame with the axes (x′, y′, z) has two advantages: • as the x′-y′-plane of the rotating frame is synchronized with the rf field, the b 1 vector remains stationary in this frame. in the following analysis, we will assume that the static b 1 field points along the x′-axis ( fig. 2.2.7 ). • as shown in sect. 2.2.2.2, a nuclear magnetic moment μ precesses with the larmor frequency ω0around the direction of the b 0 field (see fig. 2 .2.5). of course, this holds equally for the sum of the nuclear magnetic moments, i.e., for the macroscopic magnetization m. therefore, an observer observing the precession of the magnetization m from the rotating frame will come to conclude that the position of the magnetization does not change. from his point of view, the magnetization behaves as if the b 0 field is absent (larmor's theorem). summarizing both reflections, it can be concluded that the dynamics of the magnetization m in the rotating frame is determined only by the static b 1 field. if it points toward the x′-axis, then the magnetization m will precess around the x′-axis ( fig. 2. 2.8a). analogous to eq. 2.2.4, the frequency ω1 of this precession is given by ω1 = γb1. (2.2.6) when looking at this simple rotation of the magnetization m in the y′-z-plane of the rotating frame from a laboratory frame of reference (x, y, z), the movement is superimposed by a markedly faster rotation (b0 > b1) around the z-axis. thus, within the laboratory frame of reference, the tip of the vector m moves in a helical manner on the surface of a sphere around the b 0 field; the length of the vector m remains constant ( fig. 2.2.8b ). if the magnetization m points toward the static field b 0 before the rf field b 1(t) is switched on, the magnetization m is rotated from the equilibrium position under the influence of the rf field during the duration tpby the flip angle: (2.2.7) if the duration tp of the rf field is chosen to rotate the magnetization in the rotating frame by 90°, then this radiofrequency field in a stationary and in a rotating frame of reference. in the stationary frame (x, y, z) the magnetic rf field b 1(t) rotates with the angular frequency ωrfin the x-yplane around the z-axis. if one observes this rotation from a rotating frame (x′, y′, z) , which rotates with the angular frequency ωrf around the z-axis, the vector is stationary. typically, the rotating frame is chosen in such a way that the b 1 field points in the x′-direction pulse is denoted as 90° or π/2 pulse ( fig. 2.2.9a ). accordingly, the magnetization m is rotated by 180° when the duration of the rf pulse is doubled at the same flux density b1. this pulse, which inverts the magnetization from the positive to the negative z-direction, is called 180° or π pulse ( fig. 2. 2.9b). remark: precisely speaking, a short rf pulse with the carrier frequency ωrf will excite not only the nuclei that exactly fulfill the resonance condition ωrf = ω0, but also nuclei whose resonance frequency slightly differs from ωrf. this is because the frequency spectrum of an rf pulse of finite duration consists of a continuous frequency band around the nominal frequency ωrf (fig. 2.2.10 ). the width of the frequency distribution is inversely proportional to the duration tp of the pulse: the shorter the pulse, the broader the frequency spectrum is be distributed around ωrf. if the rf field is irradiated over a very long period (tp → ∞), the spectrum will be quasi-monochromatic. to simplify the following analysis, the magnetization m is separated into two components: the longitudinal magnetization mz, which is parallel to the direction of the static magnetic field b 0 , and the transverse magnetization mxy, which is perpendicular to it ( fig. 2.2.11 ). in the laboratory frame the transverse magnetization mxy precesses with the larmor frequency ω0; in the rotating frame it remains stationary. it is instructive to describe the effect of a 90°/180° pulse on an ensemble of spin-1/2 nuclei within the semiclassi-cal model described in sect. 2.2.2.2. as can be shown, the magnetic rf field induces transitions between the two permitted spin states (precession cones) until the occupation numbers are either identical (90° pulse) or inverted (180° pulse). furthermore, irradiation of a 90° pulse results in a phase synchronization of the nuclear magnetic moments of the sample, which yields a macroscopic transverse magnetization mxy, the magnitude of which is equal to that of the equilibrium magnetization m0. figuratively speaking, this means that the precession of the transverse magnetization mxy can be described as a common (phase coherent) precession of a "spin package" (fig. 2.2.12 ). up to this point, we have assumed that interactions of nuclear spins between one another and with their environment can be neglected. however, this assumption is not valid for real spin systems, as the magnetization returns to its equilibrium (mxy = 0, mz = m0) after rf excitation. this process is called relaxation. two different relaxation processes have to be distinguished: • the relaxation of the longitudinal magnetization mz characterized by the longitudinal or spin-lattice relaxation time t1 • the relaxation of the transverse magnetization mxy characterized by the transverse or spin-spin relaxation time t2 . fig 2. 2.8 resonance excitation. a in a rotating frame of reference, which rotates with the larmor frequency ω0 around the direction of the b0 field, the magnetization m precesses with the frequency ω1 around the stationary b1 field. b in the stationary frame this simple rotation is superimposed by the markedly faster rotation around the z-axis. therefore, the tip of the vector m moves in a helical manner on the surface of a sphere fig. 2. 2.9 90° and 180° pulse. if one chooses the rotating frame so that the rf pulse is irradiated along the x′-axis, the magnetization m will be rotated (a) by a 90° pulse along the y′-direction and (b) by a 180° pulse to the negative z-direction 2.2 physical basics 1 in real spin systems, every nucleus is surrounded by other intraand intermolecular magnetic moments, which are in motion due to rotations, translations, and vibrations of molecules as well as exchange processes. these processes induce an additional fluctuating magnetic field blok(t) at the position of a given nucleus, which has to be added to the external field. as the movements and exchange processes are random, the fluctuating fields differ in time from nucleus to nucleus-in contrast to the coherent rf field blok(t) irradiated from the outside. as any other temporal process, the locally fluctuating magnetic fields blok(t) can be decomposed into its frequency components. remark: the decomposition of a function into harmonic (i.e., sinusoidal) basis functions is denoted as fourier analysis, the mathematical operation that gives the intensity (amplitude) of the harmonic basis functions as fourier transformation. if the given function is periodic with period t, it can be decomposed into a sum of sinus and/or cosine functions with the discrete frequencies ω, 2ω, 3ω . . . (ω = 2π/t ). in contrast, a nonperiodic function has a continuous spectrum of frequencies. the contribution of the different frequency components to the fluctuating local field blok(t) is described by the spectral density function j(ω). a general feature of this function is that the more rapidly the molecular motion is, the broader the frequency spectrum ( fig. 2.2.13 ). rf pulse in the time and frequency domain. a rf pulse with carrier frequency ωrf and duration tp. b fourier transformation of the rf pulse. due to its finite duration, the frequency spectrum of the pulse is not monochromatic, but contains an entire frequency band, which is distributed around the nominal frequency ωrf phase synchronization by a 90° pulse. the 90° pulse leads to a synchronization of the phases of the magnetic moments μ of the nuclei in the sample (spin packet), which results in a macroscopic transverse magnetization mxy, the magnitude of which corresponds to that of the longitudinal magnetization before irradiation of the 90° pulse. in the figure, only the part of the magnetic moments of the sample which are distributed in an anisotropic manner on the precession cone is shown fig. 2.2.11 definition of the longitudinal and transverse magnetization. as the macroscopic magnetization m precesses in the stationary frame around the z-axis, it is beneficial to split it into two components: the rotating transverse magnetization mxy and the longitudinal magnetization mz in order to understand the effect of the fluctuating local magnetic fields blok(t) on a spin system, the components parallel and perpendicular to b0 have to be discussed separately. whereas the parallel component exclusively contributes to t2 relaxation, the perpendicular component influences both t1 and t2 relaxation: • the field component perpendicular to the b0 field induces-in analogy to the external rf field b1(t) -transitions between the energy levels (precession cones) of an individual spin. the probability of these transitions depends on the intensity of the frequency component of the fluctuating fields that oscillates at the larmor frequency ω0: the higher the spectral density j(ω0), the more transitions are induced. as fig. 2.2.13 shows, j(ω0) assumes a maximum when the limiting frequency ωg of the spectral density function is comparable to the larmor frequency ω0. the described relaxation process allows the excited spin system to emit and absorb photons of energy ħω0 until the boltzmann distribution of the energy levels is reached. the energy difference between the excited and the equilibrium state is dissipated to the surrounding medium or "lattice. " since the change in the occupational numbers of the spin states (precession cones) is related with a change in the macroscopic longitudinal magnetization mz, the described mechanism contributes to longitudinal relaxation. moreover, it contributes to t2 relaxation, as the locally induced transitions between the precession cones destroy the phase coherence between those spins which form, as a spin-package, the macroscopic transverse magnetization (cf. fig. 2.2 .12). • the component of the fluctuating field blok(t) oriented parallel to the z-axis locally modulates the static field b0 at the position of a nucleus and thereby changes the precession frequency ω0 of its nuclear magnetic moment μ. since the local fluctuations seen by the nuclei are spatially uncorrelated, the precessing magnetic moments within a sample lose their phase coherence, which causes the transverse magnetization to decay (see fig. 2.2.12) . given the fact that the effect of the high-frequency components of the fluctuating field vanishes when averaged over time, only the quasistatic frequency components, the intensity of which is approximately given by j(ω = 0), have a measurable effect on the transversal magnetization (see fig. 2.2.13) . as no transitions between the energy levels (precession cones) are induced by the described relaxation mechanism, the longitudinal magnetization mz remains unchanged, which means that the mechanism solely contributes to transversal relaxation. the qualitative discussion of the relaxation mechanisms reveals that their effectiveness depends on two different factors, namely on the magnitude and the temporal characteristics of the field fluctuations. the dependence from the magnitude is utilized when using paramagnetic con-trast agents (see sect. 2.6), which possess unpaired electron spins and consequently a magnetic moment. when considering the fact that the magnetic moment of an electron amounts to 658 times the magnetic moment of a proton, one can easily understand why even the slightest amounts of paramagnetic substances can lower the relaxation times considerably. for spin systems with a sufficiently high molecular mobility, relaxation processes can be described by exponential functions with the time constant t1 or t2. the longitudinal magnetization increases exponentially toward its equilibrium value mz = m0, the transverse magnetization decreases exponentially toward mxy = 0. figure 2. 2.14 shows the exponential relaxation of both magnetization components after excitation of the spin system by a 90° pulse and gives a simple interpretation of the relaxation times t1 and t2: • the longitudinal relaxation time t1 gives the time required for the longitudinal magnetization after a 90° pulse to grow again to 63% of its equilibrium value m0. • the transverse relaxation time t2 gives the time required for the transverse magnetization after a 90° pulse do drop to 37% of its original magnitude. schematic representation of the density function j(ω) for three substances with a different thermal mobility of the constituting atoms or molecules. a if the atoms or molecules move very slowly (such as in solids), the intensity of high-frequency components is very low. b this is different in fluids. in this case, the atoms or molecules move very rapidly, so that the spectral density function contains high-frequency components to a significant degree. c at a given frequency ω0 the intensity j (ω0) will attain a maximum if the cut-off frequency ωg of the spectral density function approximately corresponds to the given frequency ω0. at low frequencies, j (ω) is nearly independent on the frequency, so that the density of the quasi-static frequency components can be approximated by j (ω = 0) 1 dephasing of the transverse magnetization. the transverse magnetization mxy of the sample is split up into several magnetization components, which precess with slightly differing larmor frequencies around the direction of the b0 field. a immediately after the 90° pulse, all magnetization components are aligned parallel. b-d afterward, the components dephase due to their different larmor frequencies, and thus the macroscopic transverse magnetization decays the process of transverse relaxation can be described intuitively on the macroscopic level. to this end, the transversal magnetization mxy is split into different magnetization components, or spin packets. whereas the spins of each spin packet precess with the same larmor frequency, the spins in different packets slightly differ in their lamor frequencies. right after excitation, all components of the magnetization point toward the same direction; shortly afterward, however, some parts precess more quickly than others around the direction of the b0 field. due to this fact, the components fan out (dephasing), and the resulting transverse magnetization decreases ( fig. 2.2.15 ). in real mr experiments always macroscopic samples are examined, so that not only the fluctuating local magnetic fields, but also spatial field inhomogeneities of the external field b0, introduced by technical imperfections, contribute to the transverse relaxation. as both effects superpose on one another, the resulting effective relaxation time t2* is always shorter than the real, substancespecific transverse relaxation time t2. relaxation times in solids and fluids differ markedly (fig. 2.2.16) . whereas the longitudinal relaxation in solids can take hours or even days, in pure fluids it only takes some seconds. this difference is because the spectral density function j(ω0) at the larmor frequency is much larger in fluids than it is in solids, in which the low-frequency components dominate (see fig. 2 .2.13). for the same physical reason, the t2 relaxation time in solids usually only amounts to some microseconds, whereas in fluids it is only slightly shorter than the longitudinal relaxation time t1. soft tissues range, based on their consistency, between solids and pure fluids: with regard to their relaxation be-havior, they can in general be treated as viscose fluids. table 2 .2.2 summarizes representative proton relaxation times for different biological tissues. due to the considerable differences in the tissue relaxation times, it is possible to acquire mr images with an excellent tissue contrast even when the proton densities of the tissues or organs only slightly differ from one another. when interpreting the relaxation times, two aspects have to be taken into account: • the relaxation time t1 of biological tissues strongly depends on the larmor frequency, whereas the relaxation time t2 is nearly independent of the frequency. when comparing t1 values, one therefore needs to consider the magnetic flux density b0 at which the t1 measurement was done. • relaxation processes often consist of multiple components, so that the description by a mono-exponential function is only a rough approximation. the relaxation times given in table 2 .2.2 therefore only represent weighted mean values of an entire spectrum of exponential functions, characterizing the relaxation behavior of protons in different cell and tissue compartments between which the water exchange is slow. however, at the timescale relevant for mri, relaxation processes of most tissues can be approximated rather well by a single exponential function. an exception is fat-containing tissue (such as subcutaneous fatty tissue or bone marrow), which demands at least two exponential functions to be considered for the parameterization of the relaxation processes observed. figure 2.2.17 shows the general setup of an mr experiment; technical details will be presented in sect. 2.5. the sample to be examined is located within a very homogeneous static magnetic field b0, which is created either by a permanent magnet or by a (superconducting) coil. the rf field required for the excitation of the spin system is generated by a transmit coil connected to the rf transmit system. this rf coil is positioned in such a way that the radiofrequency field b1(t) is irradiated perpendicular to the b0 field into the sample volume. remark: whereas atomic nuclei with a nuclear spin quantum number of i ≥ 1 can interact with both the electric and the magnetic component of the electromagnetic rf field, spin-1/2 nuclei are only affected by the magnetic component b1(t) of the rf field. after excitation of the spin system by an rf pulse, the precessing transverse magnetization mxy in turn induces a weak alternating voltage in a receiver coil, which in general is identical to the transmit coil ( fig. 2. 2.18a). the measured voltage is amplified, filtered, digitalized, and fed to the computer of the mr system. the measured mr signal s(t) has the form of a damped oscillation (fig. 2.2.18b ), which is denoted as the free induction decay (fid). the fid signal has the following characteristic features: • it oscillates with the larmor frequency ω0 of the stimulated nuclei. • it decays in time with the time constant t2*. • its initial amplitude is proportional to the number n of the excited spins in the sample (n = ρv ∝ m0v; cf. eq. 2.2.5). if the sample contains nuclei of a certain type whose resonance frequency slightly differs due to intramolecular interactions (see sect. 2.2.8), the mr signal induced in the receiver coil will consist of several interfering decay curves. however, such a curve is rather complicated to analyze and interpret. therefore, the detected curve is usually spit up into its frequency components (fourier analysis, see sect. 2.2.5.1) and presented as frequency spectrum. both types of description are merely different representations of the same data, which can be transformed into one another mathematically by a fourier transformation. example: figure 2 .2.18b,c illustrates the relation between the description of the mr signal in the time or frequency domain by the example of a substance whose mr spectrum only shows one resonance line. principle setup of an mr experiment. the object to be measured is placed within a homogeneous static magnetic field b0. excitation of the spin system is performed by an rf field b1(t) irradiated perpendicularly to b0 by an rf coil. after excitation, the mr signal of the sample is detected by an rf coil and transferred via a receiver channel to the computer of the mr system. (for details, see sect. 2.5) for quantitative analysis of an mr spectrum, the following features are important: • the center of the resonance curve is at the larmor frequency ω0. • the full width δω at half maximum of the curve is related with the characteristic time constant t2* of the fid by the relation δω = 2/t2 * . • the area under the curve is approximately proportional to the number of excited nuclei in the sample. in an mr experiment, only the rf signal can be determined by measurement, which is induced by the rotating transverse magnetization mxy in the receiver coil (cf. sect. 2.2.6). nevertheless, a large variety of mr experiments can be realized that differ in the way by which the spin system is excited and prepared by means of rf pulses before the signal is acquired. a defined sequence of rf pulses, which is usually repeated several times, is called a pulse sequence. in the following, three "classical" pulse sequences are described that are frequently used for mr experiments (imaging sequences are described in sect. 2.4): • the saturation recovery sequence • the inversion recovery sequence • the spin-echo sequence. the saturation recovery (sr) sequence consists of only a single 90° pulse, which rotates the longitudinal magnetization mz into the x-y-plane. the fid signal is acquired immediately after the rf excitation of the spin system. after a delay time, the repetition time tr, the sequence is repeated. the sr sequence is described schematically by the pulse scheme (90°-aq-tr) (aq = signal acquisition period; fig. 2.2.19a ). if the repetition time tr is long compared to t1, the magnetization m relaxes back to its equilibrium state (see fig. 2.2.14) . in this case, the initial amplitude of the fid, even after repeated excitations, does only depend on the equilibrium magnetization m0 and does not show any t1 dependency. however, if the repetition time tr is shortened to a value that is comparable to t1, the longitudinal magnetization mz will not fully relax after excitation, and the following 90° pulse will rotate the reduced longitudinal magnetization mz(tr) = m0[1-exp(-tr/t1)] into the x-y-plane (fig. 2.2.19b, c) . under the assumption that the transverse magnetization after the repetition time tr has been decreased to zero (tr >> t2*), the following expression is obtained for the initial amplitude ssr of the fid signal: which exclusively depends on the relaxation time t1 and the number n of the excited spins in the sample. free induction decay (fid) and frequency spectrum. a after excitation of the spin system by a 90° pulse the magnetization mxy precesses with the larmor frequency ω0 around the direction of the b0 field and induces an electric voltage in the receiver coil. b the measured fid signal s(t) has the form of a damped oscillation, the frequency of which is given by the larmor frequency ω0. the decay of the signal is defined by the time constant t2*. c a fourier transformation of the fid signal gives the frequency spectrum of the mr signal. the resonance curve has its center at the larmor frequency ω0; its full width at half maximum (fwhm) is related with the characteristic time constant t2* of the fid by the relation δω = 2/t2 * in the inversion recovery (ir) method, the longitudinal magnetization is inverted by a 180° pulse (inversion pulse), which is followed after an inversion time ti by a 90° pulse (readout pulse). immediately after the 90° pulse, which rotates the partially relaxed longitudinal magnetization mz(ti) into the x-y-plane, the fid signal is acquired (fig. 2. 2.20). the ir sequence is described by the pulse scheme (180°-ti 90° aq). the initial amplitude sir of the fid signal is directly proportional to the longitudinal magnetization immediately before irradiation of the read-out pulse, just as is the case in the sr method. in contrast to saturation recovery sequence. a pulse scheme of the sr sequence (aq: signal acquisition). b the 90° pulse rotates the actual longitudinal magnetization into the x-y-plane. during the repetition time tr, the longitudinal magnetization relaxes toward the equilibrium magnetization m0. the speed of this process is described by the longitudinal relaxation time t1. note that by the first 90° pulse, the equilibrium magnetization m0 is rotated into the x-y-plane, whereas the subsequent 90° pulses rotate the reduced longitudinal magnetization mz(tr) = m0[1 -exp(-tr /t1)]. c temporal evolution of the transverse magnetization mxy in the rotating frame. d induced mr signal ssr(t) inversion recovery sequence. a pulse scheme of the ir sequence (aq: signal acquisition). b initially, the longitudinal magnetization is inverted by the 180° pulse (inversion pulse), which is followed after an inversion time tiby a 90° pulse (readout pulse), which rotates the existing longitudinal magnetization mz(ti) into the x-y-plane. after the 90° pulse, the longitudinal magnetization relaxes toward the equilibrium magnetization m0. c temporal evolution of the transverse magnetization mxy in the rotating frame. d induced mr signal sir(t) the sr sequence, however, the change in the longitudinal magnetization is twice as high and thus-in analogy to eq. 2.2.8-the following expression is obtained (compare figs. 2.2.19b and 2.2.20) ssr ∝ n (1-2e -t i /t 1 ). (2.2.9) the derivation of this relation is based on the assumption that the spin system is in its equilibrium state before it is excited by the inversion pulse. when repeating the ir sequence, one has therefore to make sure that the repetition time tr is markedly longer than the relaxation time t1. remark: if the ir sequence is repeated several times with different inversion times ti, it is possible to sample the temporal course of the longitudinal magnetization step by step, since the initial amplitude of the fid signal is directly proportional to the longitudinal magnetization at time ti (see fig. 2.2.20) . this procedure is applied frequently in order to determine the relaxation time t1 of a sample according to eq. 2.2.9. as explained in sect. 2.2.5.2 the temporal decay of the transverse magnetization mxy is caused by two effects: fluctuating local magnetic fields and spatial inhomogeneities of the magnetic field b0. the transverse magnetization mxy therefore relaxes not with the substance-specific relaxation time t2 but rather with the effective time constant t2* (t2* < t2). when determining the relaxation time t2, it is therefore important to compensate the effect of the field inhomogeneities. this can be done, as e. hahn has already shown in 1950, by using the so-called spinecho (se) sequence. this sequence utilizes the fact that the dephasing of the transverse magnetization caused by b0 inhomogeneities is reversible since they do not vary in time, whereas the influence of the fluctuating local magnetic fields is irreversible. in order to understand the principle of the se sequence with the pulse scheme (90° τ 180° τ aq; see fig. 2 .2.22a), we initially neglect the influence of the explanation of the spin-echo experiment in the rotating frame. for the sake of simplicity, the substance-specific transverse relaxation is not been considered in this figure. a the 90° pulse rotates the longitudinal magnetization into the x′-y′plane. b,c in the course of time, the magnetization components, which form together the transverse magnetization mxy, dephase so that the transverse magnetization decays with the characteristic time constant t2* (see fig. 2 .2.15). d,e irradiation of the 180° pulse along the x′-axis mirrors the dephased magnetiza-tion vectors at the x′-axis. as neither the precession direction nor the precession velocity of the magnetization components are altered by the 180° pulse, the components rephase and thus the transverse magnetization increases. the regeneration of the transverse magnetization is called a spin echo. f at the time te = 2τ, all magnetization components point into the same direction again. due to the rephrasing effect of the 180° pulse, the amplitude mz(te = 2τ) of the spin echo is independent of the static inhomogeneities of the b0 field fluctuating local magnetic fields and solely consider the static magnetic field inhomogeneities. immediately after the 90° pulse, all magnetization components composing the transverse magnetization mxy point along the y′-axis ( fig. 2.2.21a ). shortly afterward, some components precess faster, others more slowly around the direction of the b0 field, so that the initial phase coherence is lost (see fig. 2.2.15) . when looking at this situation from a rotating frame, one observes a fanning out of the magnetization components around the y′-axis (fig. 2.2.21.b, c) . if a 180° pulse is applied after a time delay τ along the x′-axis, the magnetization components will be mirrored with respect to this axis ( fig. 2.2.21d) . however, the 180° pulse does not change the rotational direction of the magnetization components, but merely inverts the distribution of the components: the faster components now follow the slower ones ( fig. 2. 2.21e). after the time t = 2τ, all magnetization components again point to the same direction, and the signal comes to a maximum ( fig. 2.2.21f ). the 180° pulse thus induces a rephasing of the dephased transverse magnetization, which causes the mr signal to increase and to generate a spin echo (fig. 2.2.22 ). after the spin-echo time te = 2τ  , the echo decays againas the original fid does-with the time constant t2*. due to the rephasing effect of the 180° pulse, the spinecho signal sse(te) is independent from the inhomogeneities of the static magnetic field: the loss of signal at the time t = te as compared to the initial signal sse(0) is determined exclusively via the substance-specific relaxation time t2. if one irradiates a sequence of k 180° pulses at the times τ, 3τ, 5τ, …, (2k-1)τ, one can detect a spin echo in between the subsequent 180° pulses (fig. 2. 2.23). the envelope of the echo signals sse(2τk) (k = 1, 2, 3, …, k) decays exponentially with the relaxation time t2. sse ∝ n e -2τk/t 2 . (2.2.10) the major advantage of this multi echo sequence consists in the fact that the t2 decay can very effectively be detected by a single measurement ( fig. 2. 2.23). all the considerations so far have been based on the assumption that the external magnetic field b0 created by the rf coil is not altered by the electrons surrounding a nucleus. however, this is not the case as the electrons interact with the applied external magnetic field. in biological tissues in which atoms are covalently bound, two related effects need to be considered, the diamagnetism and the chemical shift. diamagnetism is a general feature of matter and is because electrons attempt to shield the interior of the sample against the external magnetic field. in electrodynamics, this effect is described by lenz's law. it states that the current induced in a circuit by the change of a magnetic field is directed in such a way that the secondary magnetic field induced by the electric current weakens the primary magnetic field ( fig. 2.2.24 ). if a sample is positioned in an external magnetic field, a current is induced in the electron shell of the atoms and molecules, whose magnetic moment is directed against the external magnetic field, following lenz's law. however, in contrast to the electrons within a macroscopic circuit, the electrons in the electron shell are "frictionless, " which means that an induced electron current remains constant until the external magnetic field changes or until the sample is removed from the magnetic field. the sum of the induced magnetic moments of the electrons per volume is-similar to the nuclear magnetization m-denoted as electron magnetization me. for averaging, the volume has to be chosen in such a way that, on the one hand, a great number of atoms and molecules is contained, and, on the other hand, that it is small compared to the volume of the sample (for example, 1 µm 3 water contains about 3.3 · 10 10 water molecules). the magnetization me thus represents a macroscopic quantity per definitionem. remark: due to practical reasons, distinction is made in electrodynamics between free and bound currents: free currents are experimentally controllable and are linked to macroscopic circuits, whereas bound currents are linked to atomic and molecular magnetic moments in matter. the field related to free currents is denoted as magnetic field h (unit: ampere/meter), the field created by the total current, i.e. by both the free and the bound current, as magnetic flux density b (unit: tesla). at every point in space, the vector quantities h, b, and me are related by the dimensionless proportionality constant χ is called the magnetic susceptibility. for diamagnetic substances, χ is, according to lenz's law, always negative and has a very small absolute value (e.g. water: χ = -0.72 · 10 -6 ). when putting a diamagnetic sample into an originally homogeneous magnetic field, a magnetization me is induced according to eq. 2.2.12, which itself creates a magnetic field that counters the primary field. therefore, the field distribution of the magnetic flux density b differs both inside and outside of the sample from the original field distribution. example: figure 2 .2.25 shows the field distribution of the magnetic flux density b inside and outside of a homogeneously magnetized sphere (χ = constant), which has been brought into an originally homogeneous field b0. inside the sphere, the magnetic flux density b is given by b = (1+2χ /3) b0. it should be noted, however, that the homogeneously magnetized sphere represents an ideal case in which the b field is homogeneous on multi echo sequence. a pulse scheme (aq: signal acquisition). b decay of the echo amplitudes as a function of time. the signal decay is determined exclusively by the substance-specific transverse relaxation time t2, whereas the decay and the regeneration of the fid are essentially determined by technically conditioned field inhomogeneities lenz's law. when a circuit is approached to a bar magnet with the magnetic flux density b, a current i is induced in the circuit. this current induces a magnetic dipolar field, which is directed in such a way that it weakens the primary magnetic field. magnitude and orientation of the dipolar field are described by the magnetic moment μ its inside, whereas in general, the b field is also inhomogeneous inside the object. the discussion provides three important aspects with respect to mr examinations of humans: • the distribution of the magnetic flux density b in the human body depends on the position, size, form, and magnetic susceptibility of all tissues and organs of the body. • at the interface between tissues with different magnetic susceptibilities, there are local field inhomogeneities. • the distortion of the external magnetic field caused by the body adds to the technical imperfections of the external field b0. in mri, susceptibility-related inhomogeneities of the static magnetic field inside the body are obviously unavoidable and can result in image artifacts. in spectroscopic examinations, however, this problem can be reduced by acquiring only mr signals from small, morphologically homogeneous tissues regions. furthermore, one has the possibility to locally adjust the b field by means of external shim coils generating a weak additional magnetic field, so the homogeneity within the examined region fulfils the demands. when speaking of the homogeneity of the b field within a given region of the body, this relates to the average macroscopic field; on the microscopic scale, the magnetic field is always inhomogeneous. the larmor frequency of a nucleus is determined by the local magnetic field blok at the position of the nucleus, not by the macroscopic field b, which has been averaged over a small but microscopically large volume surrounding the nucleus. denoting the perturbation of the mean field b at the position of a nucleus caused by the surrounding electrons of the molecule by δb, we get the relation blok = b + δb. (2.2.13) as experimental and theoretical investigations have shown, the small local field perturbation δb is proportional to the macroscopic field δb = -σb, (2.2.14) which yields the following expression for the resonance frequency of the nucleus, considered the dimensionless "shielding constant" σ gives the relative resonance frequency shift that is independent of the magnitude of the magnetic field. this shift depends on the distribution of the electrons around the nucleus and thus has different values in different molecules. the magnitude of the additional field δb at the position of a nucleus generally depends on the orientation of the molecule relative to the macroscopic field b. in molecules that rotate rapidly, such as in fluids and soft tissues, the chemical shift anisotropy vanishes, so the quantity σ in eq. 2.2.14 could be defined as a direction-independent constant. this quantity describes the shielding effect of the electron shell averaged over all spatial directions. as the absolute value of the frequency shift cannot easily by measured, it is usually determined relative to the resonance frequency ωr of a reference substance. the difference (ω -ωr) of the resonance frequencies is expressed as dimensionless constant relative to the frequency ω0 = γb0 of the mr system in parts per million (ppm). the chemical shift δ provides information about how the atom with the nucleus under study is bonded in the molecule and thus makes mr spectroscopy a powerful tool for the determination of the structure of molecules as well as for the investigation of biochemical processes. for the 1 h nucleus, which is surrounded by only one electron, the chemical shift is about 10 ppm; for atoms with several electrons (e.g., 13 c, 19 f, and 31 p) it can amount to several hundreds of ppm. to resolve these small differences in frequency it is necessary to use a strong and homogeneous static magnetic field (b0≥ 1.5 t, ∆b/b0< 0.1-0.5 ppm depending on the nucleus). variation of the magnetic field by a diamagnetic sphere. distribution of the b field inside and outside a homogeneously magnetized sphere, which was positioned in an originally homogeneous magnetic field. it should be noted, however, that field variations caused by biological tissue are markedly weaker than illustrated here if the object to be imaged, such as the human body, is divided into small cuboidal volume elements (i.e., voxels), the task in mr imaging is to distinguish the signal contributions of the voxels to the detected summation signal from one another and to present them in form of sectional images (tomograms). this can be achieved by superimposing the homogeneous magnetic field b0 by an additional magnetic field with a well-defined dependence on the spatial position, so the larmor frequency of the mr signal becomes a function of space. in practice, image reconstruction is achieved almost exclusively by means of magnetic gradient fields. these are three additional magnetic fields b x , b y , and b z , whose field vectors point toward the z-direction and whose field strengths depend linearly on the spatial position x, y, or z, respectively ( fig. 2. 3.1). if the z-components of the three magnetic gradient fields are denoted by b x , b y , and b z , the fields can be expressed as where the proportionality constants g x , g y , and g z describe the magnitude or steepness of the orthogonal gradient fields. remark: the magnetic gradient fields are shortly denoted as x-, y-, or z-gradients. what is meant are magnetic fields b x , b y , and b z , the magnitude of which varies linearly along the x-, y-, or zaxis, respectively (see fig. 2 .3.1). in order to avoid image distortions, the magnitude of the gradients has to be chosen in such a way that the local field variations are markedly greater than the local inhomogeneities of the main magnetic field b0; typical values are between 1 and 50 mt/m. technically, the gradient fields b x , b y , and b z are produced by three coil systems (gradient coils), which can be operated independently from one another. example: assuming a patient diameter in the x-direction of x = 30 cm, a magnetic flux density of the static field of b0 = 1 t, and a gradient strength of g x = 10 mt/m, the magnetic field b = b0 + g x x will increase within the patient (-x/2 ≤ x ≤ + x/2) linearly from 0.9985 to 1.0015 t. in mr imaging, the magnetic gradient fields are used in two different ways: • for selective excitation of the nuclear spins in a partial body region (e.g., a slice). • for position encoding within an excited partial body region (e.g., a slice). for image reconstruction, the homogeneous magnetic field b0shown in a is superimposed by additional magnetic fields b x , b y , and b z , so-called gradient fields, the field vector of which points into the z-direction and the magnitude of which (length of the black arrows) depends linearly on the spatial coordinate x, y, and z, respectively. b and c show the field distributions in case the field b0 is superimposed by a gra-dient field b y and b z , respectively. the open arrows indicate the direction of the field variation, whereas the constants g y and g z represent the magnitude of the field variation per unit of length. if the z-components of the two magnetic gradient fields are given by b y and b z , then the gradient strengths are defined by g y = δb y /δy and g z = δb z /δz, respectively an mr signal can principally only be detected from the volume in which the nuclei have been excited before by an rf pulse. this fact is used in planar imaging methods, in order to reduce the primarily 3d reconstruction problem to a 2d one by selectively exciting only nuclei in a thin slice of the body. remark: depending on the type of the selectively excited partial body volume, one distinguishes between single-point, line, planar, and volume sampling strategies (fig. 2.3 .2). as the intensity of the detected mr signal is proportional to the number of nuclei within the excited volume, the different strategies markedly differ in the time required for the acquisition of qualitatively comparable mr images. due to the long measurement time, single-point and line scanning techniques have not been successful in clinical practice. in order to excite a distinct slice of the body selectively, the homogeneous static magnetic field b0 is superimposed with a gradient field (slice-selection gradient) that varies perpendicular to the slice, i.e., for an axial slice a gradient field in longitudinal direction of the body. due to this superposition, the larmor frequency ω of the nu-clei varies along the direction of the gradient. if we consider, for instance, a z-gradient with magnitude g z , the larmor frequency is given by (see fig. 2 .3.1c): consequently, an object slice z1 ≤ z ≤ z2 is characterized by a narrow frequency interval γ(b0 + g z z1) ≤ ω ≤ γ(b0 + g z z2). if one irradiates an rf pulse, the frequency spectrum of which coincides with this frequency range, only the nuclei within the chosen slice will be excited ( fig. 2.3.3) . for the definition of a body slice, this has two implications: • the width d = z2 -z1 of the slice can be varied by changing either the bandwidth of the rf pulse, i.e. the width of the frequency distribution, or the gradient strength g z . • the position of the slice can be altered by shifting the frequency spectrum of the rf pulse. the practical realization of the concept of slice-selective excitation requires not only the shape of the rf pulse but also the switching mode of the slice-selection gradient to be carefully optimized: the main magnetic field b0 is superimposed with a magnetic gradient field b z = g z z in z-direction (slice-selection gradient), so the larmor frequency ω(z) = γ(b0 + g z z) of the nuclei depends linearly from the spatial coordinate z. the slice z1 ≤ z ≤ z2 within the object is thus unambiguously described by the frequency interval ω(z1) ≤ ω(z) ≤ ω(z2). if one irradiates an rf pulse with a frequency spectrum that corresponds to this frequency interval, only the nuclei within the chosen slice will be excited • pulse modulation: as shown in fig. 2 .2.10, the frequency spectrum of a rectangular rf pulse consists of several frequency bands with varying intensities. if such a pulse is used for the rf excitation, the profile of the excited slice is defined insufficiently. in order to obtain a uniform distribution of the transverse magnetization over the slice width, the shape of the selective rf pulse is modulated so that the frequency spectrum becomes as rectangular as possible ("sinc pulse, " see fig. 2 .2.23a). • compensation gradients: if one imaginatively dissects an object slice into several thin subslices, then the magnetization components of all subslices will be deflected by the same angle from the z-direction when an optimized rf pulse is used for slice-selective excitation. however, the magnetization components will be dephased at the end of the excitation period tp, since the larmor frequencies of the distinct subslices differ from one another as the slice-selection gradient is switched on. this effect can be compensated by reversing the polarity of the gradient field for a well-defined period after rf excitation ( fig. 2. 3.4b). after selective excitation of a partial body region, the mr signal from each voxel within this volume, e.g., a slice, needs to be spatially encoded. this can be achieved by two techniques: frequency and phase encoding of the mr signal. the principle of both encoding techniques will be explained in the following by the example of an axial slice parallel to the x-y-plane. for the sake of simplicity, relaxation effects are neglected in this connection. if the body to be imaged is placed in a homogenous magnetic field with the flux density b0, the magnetization components of all voxels in the excited slice will precess with the same frequency around the direction of the b0field. thus, the frequency spectrum consist of only a single resonance line at the larmor frequency ω0 = γ b0 -it does not contain any spatial information. however, if a magnetic gradient field, e.g., b x = g x x, is switched on during the acquisition phase of the mr signal ( fig. 2. 3.5), pulse modulation and gradient refocusing. a in order to obtain an approximately rectangular slice profile, one uses an rf pulse, the envelope of which is not rectangular but modulated in time. b if one dissects a thicker slice of the object into several thin subslices, an optimized rf pulse will deflect the magnetization of each subslice by the same angle from the z-direction, but the magnetization components are dephased after rf excitation, because the larmor frequencies in the subslices differ. if a 90° pulse with duration tp is used for slice-selective excitation, then the dephasing effect can be compensated in good approximation by inverting the gradient field after excitation for the duration tp/2 readout or frequency-encoding gradient. in frequency encoding, the main magnetic field b0 is superimposed with a gradient field (here b x + g x x) during the acquisition of the rf signal, so the precession frequency of the transverse magnetization in the selectively excited slice becomes a function of the coordinate x the larmor frequency is related to the position x (see fig. 2 .3.1) by the resonance condition or in other words, nuclei in parallel strips oriented perpendicular to the direction of the readout (or frequencyencoding) gradient will experience a different magnetic field and thus contribute with different larmor frequencies ω(x) to the detected mr signal of the excited slicethe spatial information is encoded in the resonance frequency. in order to determine the contribution of the distinct frequency components to the summation signal, a fourier transformation of the measured fid has to be performed (cf. sect. 2.2.6). the intensity i(ω) of the resulting spectrum at the frequency ω is proportional to the number of nuclei precessing with this frequency, i.e., to the number of nuclei that are according to eq. 2.3.3 at the position x = (ω γb0) / γ g x . the frequency spectrum of the fid signal therefore gives the projection of the spin density distribution in the excited slice onto the direction of the readout gradient ( fig. 2. 3.6). remark: when explaining the concept of frequency encoding, we assumed that there is only one resonance line in the frequency spectrum of the excited body region in the absence of the readout gradient. if this assumption is not fulfilled, i.e., if the spectrum contains several resonance lines due to chemical shift effects described in sect. 2.2.8.2, then these frequency shifts will be interpreted by the decoding procedure (i.e., the fourier analysis) of the fid signal as position information. consequently, the spin density projections of molecules with different chemical shifts are shifted in space against one another. in 1 h imaging, the situation is rather easy, as only two dominant proton components contribute to the mr signal of the organism, the protons of the water molecules and those of the ch2 group of fatty acids. as the resonance frequencies of the two components differ by about 3.5 ppm (fig. 2.3.7) , fat-and water-containing structures of the body are slightly shifted against one another in readout direction. this chemical-shift artifact becomes apparent predominantly at the interfaces between fatand water-containing tissue. from a technical point of view, the fid signal s(t) can only be sampled and stored in discrete steps over a limited period of time taq. consequently, there is only a limited number n = taq /δt of data points that can be used for fourier transformation. due to this reason, the spatial sampling interval δx of the spin density projection is limited too. the following relations hold between the number n of data points, the maximum object size x, the spatial sampling interval δx, the temporal principle of frequency encoding. if the fid signal from a slice is measured in the presence of a gradient field b x = g x x (see fig. 2.3.5) , then nuclei in strips oriented perpendicular to the direction of the gradient contribute with different larmor frequencies ω(x) = γ(b0 = g x x) to the measured mr signal. the contribution i(ω) of the distinct frequency components to the summation signal can be calculated by a fourier transformation of the fid signal. as the intensity i(ω) of the resulting spectrum at the frequency ω is, on the one hand, proportional to the number of nuclei precessing with this frequency, and, on the other hand, the spatial information is encoded in the frequency, the fourier transformation yields the projection of the spin density distribution within the considered object slice on the direction of the readout gradient in vivo 1 h spectrum of a human thigh at 1.5 t. the two resonance lines can be attributed to protons in water and in the ch2 groups of fatty acids sampling interval ∆t, and the gradient strength g x (sampling theorem): example: if the fid signal is sampled 256 times at ∆t = 30 µs in the presence of a magnetic gradient field of the strength g x = 1.566 mt/m, then the resolution along the x-axis is ∆x = 1.953 mm, and the maximum object size that can be imaged is x = nδx = 50 cm. with frequency encoding, the mr signal is sampled at discrete points in time tn = nδt (1 ≤ n ≤ n). according to eq. 2.3.3, the transverse magnetization at the position x precesses under the influence of the readout gradient until the time tn by the angle the spatial information is therefore encoded via the frequency ω(x) in the phase angles φn(x) (1 ≤ n ≤ n). however, the same phase angles can be realized by increasing the gradient strength gn x = nδg x in equidistant steps δg x at a fixed switch-on time of the gradient. this equivalent approach is called phase encoding. the concept of phase encoding can easily be realized by applying a magnetic gradient field, e.g., b x = g x x, for a fixed time tx before the fid signal is detected (fig. 2.3.8) . under the effect of this phase-encoding gradient, the magnetization at the position x precesses by the phase angle the parameter kn = γgn x tx = γnδg x tx is named spatial frequency. after switching off the phase-encoding gradient, the magnetization components of the voxels in the slice precess again with the original, position-independent larmor frequency ω0 = γb0 around the direction of the b0 field-now, however, with position-dependent phase angles φn (x). this is to say, in phase-encoding, all magnetization components of the excited voxels contribute to the detected mr signal with the same frequency ω0, but with differing phases φn (x). in order to calculate the projection of the spin density distribution in the slice onto the direction of the phase-encoding gradient, the chosen sequence is repeated n times with different spatial frequencies kn = n(γ δg x tx) = nδk (1 ≤ n ≤ n) (fig. 2.3.9 ). however, in contrast to frequency encoding, during phase encoding not the entire fid is sampled, but only the mr signal s(kn, t0) at a definitive time t0. after n measurements (sequence cycles), the spin density projection can be calculated by a fourier transformation of the acquired data set s(δk, t0), s(2δk, t0), s(3δk, t0), …, s(nδk, t0 in practical mri, techniques of image reconstruction have prevailed that merely differ only in the way the aforementioned techniques of selective excitation and spatial encoding are combined. phase-encoding gradient. in phase encoding, a gradient field (here b x = g x x), the magnitude of which is increased in equidistant steps ∆g x at each sequence cycle, is switched on for a fixed time tx before the fid signal is acquired. this method, which p. lauterbur used in 1973 to generate the first mr image, is based on a technique of image reconstruction used in computed tomography. its basic idea is easy to understand: if projections of the spin density distribution of an object slice are available for various viewing angels φn (1 ≤ n ≤ n), the spin density distribution in the slice can be reconstructed by "smearing back" the (filtered) profiles over the image plane along their viewing directions (fig. 2.3.11 ). this approach can be implemented easily by making use of the frequency-encoding technique by repeating the sequence shown in fig. 2 .3.5 several times while rotating step by step the direction of the readout gradient in the slice plane. in order to reconstruct a planar image of n × n picture elements (pixel), a minimum of n projections with n data points each is needed. the stepwise rotation of the readout gradient by the angle δφ=180°/n is performed electronically by a weighted superposition of two orthogonal gradient fields. the projection reconstruction method is easy to understand, but both mathematical description and data processing are rather complex. furthermore, it carries the disadvantage that magnetic field inhomogeneities and patient movements result in considerable image artifacts. due to these reasons, the fourier techniques described in the following sections are preferred for the reconstruction of mr images. principle of phase encoding (displayed in the rotating frame). as shown in fig. 2. 3.8, a phase-encoding gradient g x is switched on for a fixed time tx before the fid signal is acquired (aq). a-d the sequence is repeated several times at equidistantly increasing gradient strengths. under the influence of the gradient field b x = g x x, the magnetization components of the different voxels in the slice precess with different larmor frequencies. if the gradient is switched off after the time tx, all components rotate again with the original, position-independent frequency ω0 = γb0 around the direction of the b0 field. however, magnetization components which precess more quickly during the operating time tx of the gradient field, will maintain their advance compared with the slower ones. this advance is described by the phase angle φ(x) = γg x xtx of the different magnetization components. the figure shows the dependence of the phase angle φ(x) on the gradient strength g x and the spatial coordinate x schematically for four different gradient strengths (g x = 0, ∆g x , 2 ∆g x , and 3∆g x ) and three adjacent voxels (with the magnetization vectors m0, m1, and m2). as shown in b, the magnetization m1 will rotate at the position x1 under the influence of the gradient field by the phase angle φ(x1) = 45° and the magnetization m2 at the position x2 by the phase angle φ(x2) = 90° comparison between frequency and phase encoding. with both encoding techniques, the transverse magnetizations of all voxels within the excited slice contribute to the detected mr signal; the spatial information is encoded in both cases by the different phase of the magnetization components, which was formed by the influence of a magnetic gradient field (here b x = g x x) up to the moment of signal detection. in order to calculate the projection of an object onto the direction of the gradient, the mr signal s has to be measured n times (e.g., n = 128 or 256), with the phase difference between the magnetization components of the different voxels varying in a well-defined way form measurement to measurement. the difference between the two encoding techniques merely consists in the technique with which the data set {s1, s2, . . . , sn} is acquired. a with frequency encoding, the mr signal is sampled at equidistant time steps ∆t in presence of a constant gradient field (in the figure ∆g x ). as the magnetization components of the voxels within the excited slice steadily dephase under the influence of the gradient field, there is a different phase difference between them at every point in time tn= n∆t (1 ≤ n ≤ n), so the whole data set {s1, s2, . . . , sn} can be detected by a single application of the sequence. the figure shows the first three values of the signal. it should be noted that only the temporal change of the mr signal caused by the gradient field is shown here, whereas the rapid oscillation of the signal with the larmor frequency ω0 = γb0 as well as the t2 * decay of the signal is neglected. b with phase encoding, a phase-encoding gradient is switched on for a fixed duration tx before the fid signal is acquired. the magnitude of this gradient is increased at each sequence repetition by ∆g x . during the switch-on period of the gradient field, the magnetization components of the different voxels precess with different frequencies so that a phase difference is established between them which is proportional to the magnitude of the gradient applied (see fig. 2.3.9) . after switching off the gradient, all components rotate again with the original, position-independent frequency ω0 = γb0 around the direction of the b0 field. in the chosen description, one therefore observes an mr signal sn that is constant over time. in order to acquire the entire data set {s1, s2, …, sn}, the sequence needs to be repeated n times with different gradient strengths g x = n∆g x . the figure shows the dependence of the mr signal from the gradient strength schematically for three different gradient strengths (g x = 0, ∆g x , 2∆g x ). if the product of the gradient strength and the switch-on time of the gradient up to the time of signal detection is equal in both encoding techniques, the phase difference between the various magnetization components at the time of signal detection is also identical and thus the same mr signal is measured. the product of the two quantities is indicated in the figure by the dark areas in the planar version of fourier imaging, just as in projection reconstruction, the spins in a slice are selectively excited by an rf pulse in the first step. afterwards, however, spatial encoding of the spins in the slice is not done by a successive rotation of a readout gradient, but by a combination of frequency and phase encoding using two orthogonal gradient fields. if we consider an axial slice parallel to the x-y-plane, then these gradients are g x and g y (fig. 2. 3.12). the sequence is repeated n times for different values of the phase-encoding gradient gn x = nδg x (1 ≤ n ≤ n), with the mr signal being measured m times during each sequence cycle at the times tm = mδt (1 ≤ m ≤ m) in the presence of the readout gradient g y . thus, one obtains a measurement value for each combination (kn, tm) of the parameters kn = γnδg x tx and tm = mδt, i.e., a matrix of n × m data points. a 2d fourier transformation of this data set, the so-called hologram or kspace matrix (see fig. 2 .4.26), yields the mr image of the slice with a resolution of n × m pixels. in order to extend the 2d fourier method to a 3d one, the slice-selection gradient is replaced by a second phaseencoding gradient as shown in fig. 2. 3.13. this means that the rf pulse excites all spins in the sensitive volume of the rf coil and that the spatial information is encoded exclusively by orthogonal gradients-by two phase-encoding gradients and one frequency-encoding gradient. the spatial resolution in the third dimension is defined by the strength of the related phase-encoding gradient and the number k of the phase-encoding steps. depending reconstruction by back projection. the figure shows three different projections of two objects in the field of view. if many projections are acquired at different viewing angles, an image can be reconstructed by (filtered) back projection of the profiles. for the measurement of the various projections, the frequency-encoding technique is used, with the readout gradient rotating step by step fig. 2. 3.12 typical pulse and gradient sequence in 2d fourier imaging. g z is the slice-selection gradient, g x the phase-encoding gradient, and g y the readout gradient on the choice of these parameters, the voxels have a cubic or cuboidal shape (isotropic or anisotropic resolution). in order to acquire a 3d k-space matrix with n × m × k independent measurement values, the imaging sequence needs to be repeated n × k times. a 3d fourier transformation of the acquired 3d k-space matrix yields the 3d image data set of the partial body region excited by the rf pulse. based on this image data set, multiplanar images in any orientation can be refor-matted, which offers-among others-the possibility to look at an organ or a body structure from various viewing directions. in addition to the described conventional fashion of filling the k-space in fourier imaging, there are a number of alternative strategies. • spiral acquisition. as will be described later, the epi sequence is commonly using an oscillating frequencyencoding gradient. if both, the phase encoding as well as the frequency-encoding gradient are oscillating with increasing gradient amplitudes, the acquired data points will be along a spiral trajectory through k-space. that is why such an acquisition is called spiral epi. • radial acquisition. if the direction of the frequencyencoding gradient is rotated as described in sect. 2.3.4.1, the k-space trajectories will present a star. • blade, propeller, multivane. these hybrid techniques sample k-space data in blocks (so-called blades) each of which consists of some parallel k-space lines. in order to successively cover the entire k-space, the direction of the blades is rotated with a fixed radial increment. this sampling strategy offers some advantages. since each blade contains data points close to the center of the k-space, patient movements can, for example, be easily detected and corrected. to reconstruct mr images from alternative k-space trajectories by means of a conventional 2d or 3d fourier transformation, it is necessary to re-grid the sampled kspace data to a rectangular grid. data acquisition by 2d imaging techniques can be carried out very efficiently when considering the fact that the time required for slice-selective excitation, spatial encoding, and acquisition of the mr signal is much shorter than the time needed by the spin system to relax at least partially after rf excitation, before it can be excited once again. the long waiting periods can be used to excite-in a temporally shifted manner-adjacent slices and to detect the spatially encoded mr signal from these slices. thus, mr images from different parallel slices can be acquired simultaneously without prolongation of the total acquisition time (fig. 2. 3.14). example: let us consider that 50 ms are needed for excitation, spatial encoding, and data acquisition per sequence cycle and that the sequence is repeated after tr = 1,000 ms. then mr data from 20 adjacent slices can be acquired simultaneously without prolonging the measurement time. typical pulse and gradient sequence in 3d fourier imaging. g x and g y are the phase-encoding gradients and g z the readout gradient however, when using the multiple-slice technique, one has to consider that the distance between slices may not be too small, as the slice profile usually is not rectangular, but bell shaped. in order to avoid repeated excitation of spins in overlapping slice regions, the gap between adjacent slices should correspond approximately to the width of the slice itself. images from adjacent slices can be obtained in an interleaved manner by applying the sequence twice: in the first measurement, data are acquired from the odd slices and in the second from the even slices ( fig. 2. 3.15). 14 principle of the multiple-slice technique. in most 2d imaging sequences, the time t required for slice-selective excitation, spatial encoding, and detection of the mr signal is markedly shorter than the repetition time tr. the long waiting periods can be used to subsequently excite spins in parallel slices and to detect the spatially encoded signals from these slices consideration of the slice profile by the multipleslice technique. the profile of a slice is generally not rectangular but rather bell shaped. the thickness (th) of the slice is therefore usually defined by the full-width at half-maximum. in order to prevent overlapping of adjacent slices in the multiple-slice technique, a sufficient gap (g) between the two adjacent slices has to be chosen (g ≥ th). often the distance (d = g + th) between the slices is indicated instead of the gap g. images from adjacent slices can be detected without overlap by using in a first step a sequence that acquires data from the even slices and in a second step a sequence that acquires data from the odd slices. in both measurements, the gap g should be identical with the slice thickness th (d = g + th = 2th) the main advantage of mr imaging, apart from the flexibility in slice orientation, is the excellent soft-tissue contrast in the reconstructed mr images. it is based on the different relaxation times t1 and t2 of the tissues, which depend on the complex interaction between the hydrogen nuclei and their surroundings. compared to that, differences in proton densities (pd) are only of minor relevance, at least when considering soft tissues. the term proton density in mr imaging designates only those hydrogen nuclei whose magnetization contributes to the detectable image signal. essentially, this refers to hydrogen nuclei in the ubiquitous water molecules and in the methylene groups of the mobile fatty acids (see sect. 2.3.3.1 and fig. 2 .3.7). hydrogen atoms, which are included in cellular membranes, proteins, or other relatively immobile macromolecular structures, usually do not contribute to the mr signal; their fid signal has already decayed to zero at the time of data acquisition (t2 << te) (brix 1990 ). another important contrast factor is the collective flow of the nuclei. the influence of flowing blood on the image signal will be discussed in sect. 2.7 separately, in the context of mr angiography. whereas the image contrast of a ct scan only depends on the electron density of the tissues considered (as well as on the tube voltage and beam filtering), the mr signal and thus the character of an mr image is determined by the intrinsic tissue parameter pd, t1, and t2 as well as by the type of the sequence used and by the selected acquisition parameters. this variability offers the opportunity to enhance the image contrast between distinct tissues by cleverly selecting the type of sequence and the corresponding acquisition parameters, and thus to optimize the differentiation between these tissue structures. however, the subtle interplay of the many parameters bears the danger of misinterpretations. in order to prevent these, several mr images are always acquired in clinical routine, with different sequence parameters that are selected in such a way that the tissue contrast of the various images is determined mainly by a single tissue parameter; in this context, one uses the term t1-, t2-, or pd-weighted images. sometimes, one even goes one step further to calculate "pure" t1, t2, and pd parameter maps on the basis of several mr images that were acquired with different acquisition parameters. the advantage in doing this consists of the fact that the image contrast on the calculated parameter maps is usually more accentuated than in the weighted images. the calculated tissue parameters can furthermore be used to characterize various normal and pathological tissues. however, experience has shown that a characterization or typing of tissues by means of calculated mr tissue parameters is only possible with reservations (bottomley et al. 1987; higer and bielke 1986; pfannenstiel et al. 1987 ). this may be due not only to the insufficient measurement and analysis techniques used, but also to the fact that morphological information of the mr images as well as the clinical expertise of the radiologist have been left aside in many cases. these considerations indicate that each mr practitioners should be aware of the dependence of the image contrast on the selected type of imaging sequence as well as on the sequence and tissue parameters in order to fully benefit from the potential of mri and to avoid misinterpretations. the term imaging sequence designates the temporal sequence of rf pulses and magnetic gradient fields, which are used to determine the image contrast and for image reconstruction, respectively. the foregone section has made intuitive use of the term image contrast in order to describe the possibility to distinguish between adjacent tissue structures in an mr image. we will now define this term. if one describes the signal intensities of two adjacent tissues structures a and b with sa and sb, the image contrast between the two tissues can be expressed by the absolute value of the signal difference cab = |sa sb| (2.4.1) or by the normalized difference (2.4.2) remark: the delineation of a tissue structure depends, of course, also on the signal-to-noise ratio (s/n) as tiny, weakly contrasted structures can be masked by image noise. some authors therefore proposed to use the contrast-to-noise ratio for evaluating the detectability of a detail. however, the explanatory power of this quantity can hardly be objectified since the contrast-detail detectability strongly depends on the signal detection in the human retina as well as on the signal processing in the central visual system of the observer. in the following, we will therefore use the absolute contrast defined in eq. 2.4.1. example: in order to analyze the influence of the tissue and acquisition parameters on the image contrast by an example, we will consider in the following the contrast between white and gray brain matter. representative tissues parameters, which have been measured for a patient collective at 1.5 t, are summarized table 2 .4.1. in clinical routine, the spin-echo (se) sequence is still a frequently applied imaging sequence, due to two reasons: • it is rather insensitive to static field inhomogeneities and other inaccuracies of the mr system. • it allows for the acquisition of t1-, t2-, and pdweighted images by an appropriate choice of the acquisition parameters tr and te. of about 3t1. usually, however, the sequence is repeated much earlier, so that the longitudinal magnetization will be reduced at the beginning of the next sequence cycle compared to the equilibrium magnetization by the t1 factor [1 exp(-tr / t1)]. accordingly, the t1 contrast of an se image can be varied by the choice of the repetition time tr. in fig. 2 .4.2a, the t1 factor is plotted for white and gray brain matter. as this example shows, the t1 contrast reaches a maximum if the repetition time tr is between the t1 relaxation times of the two tissues considered. if tr is markedly longer than the longer t1 time, then the t1contrast vanishes. • t2 dependence: the influence of the t2 relaxation process on the signal intensity is described by the t2 factor exp (-te / t2) in the signal equation. for a given t2 time the signal loss is the bigger, the longer the echo time te becomes. in fig. 2 .4.2b, the t2 factor is plotted for white and gray brain matter versus the echo time te. the contrast will reach a maximum when the echo time te ranges between the t2 relaxation times of the two tissues considered. for small te values (te << t2), the contrast approximates zero, as the signal intensities in this case are independent of t2. and gray (gm) brain matter. as can be seen, the t1 contrast between the two tissues approaches 0 for very long as well as for very short repetition times. the highest t1 contrast is obtained for tr ~ 750 ms, i.e. for a repetition time in between the t1 times of the two tissues considered (see table 2 .4.1). b the same considerations hold for the t2 factor exp(-te /t2). the t2 contrast maximum is at te ~ 100 ms influence of the acquisition parameters tr and te on the contrast behavior of an se image. the figure shows the interplay of the longitudinal and transversal relaxation for this sequence at the example of white (wm) and gray brain matter (gm) for a fixed repetition time of tr = 1.000 ms. in the left part, the temporal evolution of the longitudinal magnetization mz during the recovery period (0 ≤ t ≤ tr) is depicted. at t = tr, the partially relaxed longitudinal magnetization is flipped into the x-y-plane by the 90° excitation pulse. the t2 relaxation of the resulting transversal magnetization mxy is plotted in the right part as a function of the echo time te. as can be seen, there is a reversal behavior of the t1 and t2 contrast. for te = 83 ms, the contrast is 0, so that the two types of brain matter cannot be differentiated in the relating se image in spite of differing tissue parameters (see fig. 2 .4.5d). note that the detected mr signal is directly proportional to the transversal magnetization mxy in general, adjacent tissues differ in all three tissue parameters pd, t1 and t2, so the different factors of the se signal equation, which can partially compensate one another, need to be considered altogether. this holds even more as the relaxation times are usually positively correlated, i.e., the tissues with longer t1 times usually also have longer t2 times. in order to illustrate this statement, fig. 2 .4.3 shows the course of the longitudinal and transverse magnetization for both white and gray brain matter for a repetition time of tr = 1,000 ms. as can be seen, the transverse magnetization of both substances-and therefore the signal intensities (sse ∝ mxy)-are identical at an echo time of te = 83 ms, so the tissues cannot be distinguished on the related se image in spite of different tissue parameters. fig. 2 .4.4 shows the contrast between white and gray matter as a function of both the repetition and echo time. as expected, there are two regions with a high tissue contrast, which are separated by a low contrast region (cf. fig. 2 inversion time ti as well as a on the repetition time tr. in order to optimize the t1 contrast, the inversion time ti is usually varied, whereas with the parameter td, respectively tris chosen as high as possible (td >> t1), to allow the recovery of a considerable longitudinal magnetization after rf excitation. the maximum range of values of the t1 factor is between -1 and +1, thus being double the range of values of the se sequence. there are two types of ir sequences depending on signal interpretation: if only the absolute values of the signal are considered (magnitude reconstruction, irm), the range of values is limited de facto to the interval between 0 and 1, as in the se sequence. if this mode of data representation is chosen, then the t1 factor will initially decrease to 0 and then converges toward the equilibrium magnetization m0. figure 2 .4.7 shows the dependence of the t1 factor from the inversion time ti for both possible modes of data representation for white and gray brain matter (tr = 3,000 ms). as this example reveals, the neglect of the sign of the t1 factors in the absolute value representation leads to a destructive t1 contrast behavior in the region between the zeros of both t1 functions considered. an ir sequence differentiating between parallel or antiparallel alignment of the longitudinal magnetization at the time of the excitation pulse is called phase sensitive. for evaluation of the tissue contrast, the pd and t2 dependence of the image signal sir needs to be included in the considerations, too. figure 2 .4.8 demonstrates this with an example. in this figure, the tissue contrast between white and gray brain matter is plotted as a function of the echo time te for ti= 800 ms and tr = 2,400 ms. for the chosen ti value, there is a reversal behavior of the t1 and t2 contrast, as the relaxation times of the two tissues if the last-mentioned mode of data representation is used, there will be a destructive t1 contrast behavior in the region between the zeros of the two tissue curves. the t1 contrast maximum in the considered case is at ti~ 760 ms, i.e., in between the t1 times of the two tissues considered (see table 2 .4.1) examined are positively correlated, i.e., the substance with the longer t1 time also has a longer t2 time. in order to fully grasp the complex interplay between the different tissue and acquisition parameters as a whole, the image contrast between white and gray brain matter is plotted in fig. 2 the influence of the acquisition parameters te, ti, and td on the contrast of an ir image is summarized in table 2 .4.3. in order to maximize the t1 contrast (t1-weighted image), the ti time should be between the t1 times of the two tissues considered, and the echo time te should be chosen as short as possible. as even for the acquisition of t1-weighted images, relatively long repetition times are needed (td >> t1), the ir sequence requires much more time than the se sequence. advantages occur mainly when the image signal of a given tissue structure shall be suppressed, e.g., the retrobulbar fatty tissue for the evaluation of the optic nerve. in this case, the acquisition parameter ti needs to be chosen so that the t1 factor of the tissue to be suppressed is approximately 0 (fig. 2 remark: an ir sequence with a very short ti time is called stir (short-tau inversion recovery) sequence. if the ti time is selected to suppress the signal from liquor, the sequence is called flair (fluid-attenuated inversion recovery). influence of the acquisition parameters ti and te on the contrast behavior of the ir sequence (absolute value representation). the figure shows the interplay of the longitudinal and transversal relaxation for this sequence at the example of white (wm) and gray brain matter (gm) for a fixed inversion time ti = 800 ms and a fixed repetition time tr = 2,400 ms. the left part shows the temporal evolution of the longitudinal magnetization mz during the inversion phase (0 ≤ t ≤ ti). at t = ti, the partially relaxed longitudinal magnetization is flipped into the x-y-plane by the 90° excitation pulse. the t2 relaxation of the resulting transversal magnetization mxy is plotted in the right part as a function of the echo time te. in the case considered, there is a reversal behavior of the t1 and t2 contrast, so that the contrast between the two brain tissues rapidly reduces with prolonged echo time. note that the detected mr signal is directly proportional to the transversal magnetization mxy • in some cases, the imaging sequence is repeated several times (e.g., naq = 2 or 4), in order to improve the signal-to-noise ratio ( . this is especially valid for t1-weighted se images, which have a relatively low s/n ratio due to the short repetition time. example: based on these considerations, the following representative acquisition times are obtained for se images: t = 2.1 min for a t1-weighted image (tr = 500 ms, nph = 256, naq = 1) and t = 10.2 min for a t2-weighted and/or a pd-weighted image (tr = 2,400 ms, nph = 256, naq = 1). by using the multiple slice technique described in sect. 2.3.5, one can simultaneously acquire mr images from multiple parallel slices within the given acquisition times, but the overall acquisition time required for the acquisition of the images will not be reduced. in clinical practice, this basic limitation of conventional imaging sequences leads to the following problems: • depending on the clinical question, the time needed for a patient examination ranges between 15 and 45 min. • this demands high cooperation from the patient, as the patient will be asked to remain motionless during the examination in order to assure the comparability of differently weighted mr images. • critically ill patients may not be examined full scale or might not fit for examination at all. • the image quality is impaired by motion artifacts (such as heart beat, blood flow, breathing, or peristaltic movement). this problem is especially acute in patients with thorax and abdominal diseases, as mr images in general cannot be acquired completely during breath hold, as is the case in ct. • dynamic imaging studies are limited. to overcome these limitations, several methods aiming to shorten the acquisition examination times have been developed. they can be categorized into two groups, depending on whether the repetition time tr or the number of sequence cycles nph needed for phase encoding is reduced (see eq. 2.4.5). the two strategies will be discussed in the following sections at the example of some selected imaging sequences. an almost complete overview of the clinically used fast imaging sequences will be provided in sect. 2.4.6. the long scan times of conventional imaging sequences are due to the fact that the 90° excitation pulse rotates the entire longitudinal magnetization into the x-y-plane, so the pulse sequence can only be repeated when the longitudinal magnetization has been-at least partially-recovered by t1 relaxation processes. to acquire mr images with an acceptable s/n, the sequence repetition time tr has to be of the order of the t1 relaxation time. this basic problem in conventional imaging can be prevented, however, by using an rf pulse with a flip angle of α < 90° to excite the spin system, so that only a part of the longitudinal magnetization mz will be rotated to the x-y-plane, nevertheless, one obtains a relatively large transverse magnetization. example: if, for instance, a flip angle of α = 20° is used, then the longitudinal magnetization mz will be reduced by 6%, whereas the transverse magnetization mxy amounts to 34% of the maximum value (fig. 2.4.11) . in order to discuss the principle of low-flip angle excitation, we will initially neglect the gradient fields needed for spatial encoding and consider the simple sequence shown in fig. 2 .4.12a. it consists of a single rf pulse with a flip angle α<90° and a spoiler gradient, which destroys the remaining transverse magnetization after the acquisition of the fid. remark: as an alternative to spoiler gradients, the phase of the rf excitation pulse may be varied with every sequence cycle, in order to prevent the buildup of a steady state for the transverse magnetization (rf spoiling). if the considered sequence is repeated several times, then the spin system already reaches a dynamic equilibrium after a few sequence cycles. figure 2 .4.13 shows the transient behavior of the longitudinal magnetization in white the value of the steady-state longitudinal magnetization depends not only on the flip angle α of the excitation pulse, but also on the repetition time tr and the longitudinal relaxation time t1. it will be smaller when α becomes bigger. for α = 90°, the longitudinal magnetization reaches the steady-state value m z ss = m0 [1-e -t r /t 1 ] after the first excitation, as expected. however, the mr signal is not given by the longitudinal magnetization but by the transverse magnetization mxy at the time of data acquisition. by using eq. 2.4.6 the amplitude s of the mr signal can be described by (2.4.7) whereas the factor exp (-te/t2*) describes the decay of the fid signal during the delay time te, the factor sinα gives the fraction of the steady state magnetization m z ss , which is rotated in the x-y-plane (see fig. 2 .4.12b,c). to illustrate this relation, fig. 2 .4.14 shows the signal intensity s as a function of the ratio tr/t1. from this plot, two important statements can be derived: • as compared with conventional 90° excitation, lowflip angle excitation yields considerably higher signal values for short repetition times. • when using low-flip angle excitation, the signal is already independent of t1 for tr < t1. the signal increase realized by low-flip angle excitation in combination with short repetition times is obtained, however, by omitting the 180° pulse generating a spinecho, as the 180° pulse not only inverts the phase of the transverse magnetization, but also the longitudinal magnetization (see fig. 2 in contrast to the conventional imaging sequences, the nomenclature of the gre sequences is not unified, but is handled differently by different manufacturers. in the following, the fundamentals of gre imaging will be discussed in detail at the example of two representative sequences denoted by the acronyms flash and truefisp. the excitation of the spin system and position encoding are identical in both sequences; they differ only in that the transverse magnetization is destroyed after acquisition of the mr signal in the flash sequence (spoiled gre sequence), whereas it is maximized in the truefisp sequence (refocused gre sequence). this difference, however, leads to an entirely different contrast behavior. dephasing of the transversal magnetization caused by the slice selection and the readout gradient is compensated by two additional inverted gradients, so that a gradient-echo occurs. the figure shows the deand rephasing process of two magnetization components (a,b), which are at different positions and therefore precess under the influence of the gradient-fields with different larmor frequencies. φx, φy, and φz are the corresponding phase angles however, this does not imply that for this angle the tissue contrast between two structures is at its maximum. in fig. 2 .4.18 the tissue contrast between white and gray brain matter is plotted for te << t2*, i.e., exp(-te / t2) ≈ 1, as a function of the repetition time tr and the flip angle α. for low flip angles, two contrast regions can be distinguished: for short tr times, the t1 contrast dominates (t1-weighted images), for longer tr times, the pd contrast (pd-weighted image). example: in order to illustrated the discussed contrast behavior, fig. 2 the influence of the acquisition parameters on the contrast of a flash image is summarized in table 2 .4.4. in 1986, oppelt et al. introduced a gre sequence with the acronym fisp (fast imaging with steady precession), which considerably differs in its contrast from the flash sequence. this sequence was later renamed to truefisp (see below). the pulse and gradient scheme of this sequence is shown in fig. 2 .4.20. instead of the spoiler grainfluence of the acquisition parameters tr and α on the t1 contrast of a flash image. for low excitation angles α, there will only be a considerable t1 contrast (here between white and gray brain matter) when short repetition times are selected. if the flip angle is increased, the t1 contrast maximum will shift to a higher tr value dient of the flash sequence, refocusing gradient pulses are introduced in slice-selection direction as well as in the direction of frequency and phase encoding, through which the transverse magnetization is not destroyed after the data acquisition of the mr signal, but rather rephased or refocused (fig. 2.4 .21). as practice has shown, the truefisp sequence is very susceptible to inhomogeneities of the static magnetic field, which are rendered visible as disturbing image artifacts. a more favorable behavior is achieved by omitting the gradient pulses (which have been shaded darkly in fig. 2. 4.20) . in this case, only the dephasing of the transverse magnetization caused by the slice selection and phase-encoding gradient is completely compensated. this realization is called fisp sequence. in the truefisp sequence, not only the longitudinal, but also the transversal magnetization reaches an equilibrium state after several sequence cycles. as both magnetization components are different from zero at the end two different contrast regions can be distinguished for low flip angles: for short tr times, the t1 contrast dominates (t1-weighted image), for longer tr times, the pd contrast (pd-weighted image). if the flip angle is increased, then the t1contrast curve will gradually approach the known contrast behavior of the se sequence (α = 90°). correspondingly, long repetition times need to be chosen in order to acquire pdweighted or t2-weighted images of a sequence cycle, they will be mixed by the following rf pulse, i.e., a part of the longitudinal magnetization is flipped into the x-y-plane and a part of the transverse magnetization into the z-direction. consequently, both magnetization components dependent on t1 and on t2. the t2 dependence increases proportional to the magnitude of the transverse magnetization remaining at the end of the sequence cycle (i.e., with decreasing tr/t2 ratio). vice versa, this means that the fisp signal for high tr values (tr>>t2) will approximate the flash signal. remark: the difference in the latter case merely consists in the fact, that in the flash sequence the transverse magnetization is rapidly destroyed by a spoiler gradient after the acquisition of the fid, whereas in the fisp sequence it decays with the time constant t2. therefore, the flash sequence is more useful for the acquisition of t1-weighted and pd-weighted images than is the fisp sequence. as the discussion has shown, the characteristic signal behavior of the fisp sequence manifests itself only for very short repetition times. for this special situation, the dependence of the signal intensity of the fisp sequence on the tissue parameters t1, t2, and pd can be described due to the complex gradient switching, the dephasing of the transversal magnetization caused by the three gradients is completely compensated after acquisition of the gradient-echo, so the transversal magnetization is restored before irradiation of the subsequent excitation pulse. the figure shows the deand rephasing process for two magnetization components (a,b), which are at different positions and therefore precess with different larmor frequencies under the influence of the gradient fields. φx, φy, and φz are the corresponding phase angles. at the end of the sequence, both magnetization components are in phase again (φx = φy= φz = 0), independent of their spatial position pulse and gradient scheme of the truefisp sequence. α flip angle of the excitation pulse, g z slice-selection gradient, g x phase-encoding gradient, g y readout gradient. instead of the spoiler gradient used in the flash sequence, there are refocusing gradient pulses in all three gradient directions, so that the transversal magnetization after acquisition of the gradient-echo is not destroyed but reconstructed (see fig. 2.4.21) . in practice, the gradient pulses (marked darkly) here is frequently omitted in order to reduce the susceptibility of the sequence for artifacts leading to a fisp sequence approximately by the expression , (2.4.10) which is independent of the repetition time tr. as this equation shows, the signal intensity of a fisp image for tr<<t2 and te<<t2 depends only on the ratio of the tissue-specific relaxation times t1/t2, not on absolute values. the fisp sequence is therefore also denoted as t1/t2-weighted gre sequence. 10 is plotted as a function of the flip angle α for different t1/t2 ratios. as one can see, the signal intensity at a given flip angle is the bigger the more similar the relaxation times t1 and t2 are. the absolute maximum is obtained for α = 90° and t1 = t2. for a given value of t1/t2, the t1/t2 factor is maximized, when the flip angle is given by (2.4.11) if the phase coherence and thus the steady-state magnetization are disturbed by flow, as is the case in blood vessels or in liquor spaces, then the signal maximum will be shifted toward lower excitation angles. . for a given flip angle α, the signal intensity will be the bigger, the smaller the ratio t1/t2 is in practice, flip angles between 70° and 90° and repetition times between 35 and 50 ms are used for the acquisition of t1/t2-weighted truefisp images. in these images, tissues with lower t1/t2 ratio (i.e., fatty tissue and liquor) are more signal intensive than are tissues with high t1/t2 ratio (e.g., white and gray brain matter). for the acquisition of t1-weighted and pd-weighted images, the flash sequence is better suited than is the truefisp sequence. opposite to conventional imaging sequences (i.e., the se and the ir sequence), the dephasing of spins due to static magnetic field inhomogeneities cannot be compensated in gre sequences, due to the missing rephasing 180° rf pulse (see sect. numerical examples are given in table 2 .4.5. in mr imaging, local field inhomogeneities have essentially three reasons: they increase with the distance from the center of the magnet and can cause severe signal losses in the outer zone. when using gre sequences, one therefore has to remember that the body region to be analyzed should not be too far away from the center of the magnet. example: in modern mr tomographs, the magnetic field inhomogeneity over a sphere of 50 cm diameter is smaller than 5 ppm. assuming that the magnetic field changes linearly with distance to the center of the magnet, a magnet field inhomogeneity of about 0.02 ppm per pixel is obtained for a matrix size of 256 × 256 and a field of view of 50 cm (table 2 .4.5). • para-or ferromagnetic implants. such implants (e.g., prostheses or clips) cause strong magnetic field inhomogeneities in the surrounding tissues. as a consequence, t2* times of these tissues are drastically reduced which results in signal losses in the vicinity of the implants. in these cases, conventional imaging techniques have to be used, which are less susceptible to field inhomogeneities. • susceptibility effects. as discussed in sect. 2.2.8, the magnetic field distribution within the human body depends on the position, size, form, and magnetic susceptibility of the various tissues and organs in the body. whereas the magnetic field is locally homogeneous in larger uniform organs or tissue regions, there are local field inhomogeneities at the interfaces of anatomical structures, which differ in their magnetic susceptibility. they can be strong enough to cause-via a reduction of the t2* times-signal losses in the vicinity of the interface. one can observe this effect in gre images mainly in the vicinity of air-tissue interfaces, such as in the lung or in paranasal tissues. even though susceptibility artifacts are unavoidable in gre imaging, they can be minimized by two techniques: by shortening the echo time te of the sequence and by reducing the voxel size, especially the slice thickness. by both means the average field inhomogeneity per voxel is reduced. as shown in fig. 2 .3.7, the 1h spectrum of the human organism consists of two dominant peaks, whose resonance frequencies differ due to the chemical shift by about 3.5 ppm. the two resonance peaks are assigned to hydrogen nuclei in water molecules and those in methylene groups of fatty acids. if both components contribute to the mr signal of a tissue, for instance fatty tissue or bone marrow, then a modulation of the signal intensity of these tissues can be observed in gre imaging in dependence on the echo time te. this interesting phenomenon is due to the fact that the transverse magnetization of the water component precesses after rf excitation a little faster than the fat component, so both magnetization components are oriented parallel or antiparallel in regular intervals (fig. 2.4.24) . as the detected gre signal is proportional to the vector sum of the two magnetization components, this periodic behavior manifests in a modulation of the signal intensity: the intensity is at its highest when the two components are oriented parallel; it is at its minimum when they are antiparallel. the amplitude of the signal modulation depends on the ratio of the two signal components. example: at a magnetic flux density of b0= 1.5 t, the frequency difference between the fat and the water component is about δω / 2π = 220 hz. this implies that the two magnetization components are oriented parallel or antiparallel after rf excitation in equidistant time intervals of δτ = π / δω = 2.3 ms. figure 2 .4.25 illustrates the signal modulation at 1.5 t for a realistic example. in 2d fourier imaging, the mr image is reconstructed via a fourier transformation from the acquired raw data set, the k-space matrix. even though for the reconstruction of an mr image with n × n pixels a raw data matrix with n × n data points is required, it is sufficient to measure only the first n/2 rows of the raw matrix, when the symmetry of the k-space is taken into account (half-fourier technique) (feinberg et al. 1986 ). to illustrate this aspect, fig. 2 .4.26 shows a raw matrix that has been acquired with the se sequence shown in fig. 2 .4.1. the data points of the k-space matrix are positioned symmetrically to the center of the matrix. due to this fact, it is sufficient to measure only the data points of the upper half of the k-space and to fill the lower half through (conjugate) point reflection of the measured data in the center of the matrix (fig. 2.4 .27). temporal evolution of the transversal magnetization in fatty tissue. in fat-containing tissues, two pools of hydrogen nuclei contribute to the mr signal, whose resonance frequencies differ by about 3.5 ppm. they are assigned to 1 h nuclei in water and in methylene groups of fatty acids. as the transversal magnetization of the water component (m xy w ) after rf excitation precesses slightly faster than the methylene component (m xy f ), the two magnetization vectors are oriented a parallel or b antiparallel in regular intervals. the figure shows this in a rotating frame, in which the transversal magnetization of the fat component does not rotate modulation of the gre signal in fat-containing tissues. at a magnetic flux density of 1.5 t, the difference between the resonance frequencies of the water and methylene protons is about 220hz, so that the transversal magnetization of the two proton components is oriented parallel or antiparallel every 2.3 ms (see fig. 2.4.24) . this periodic behavior results in a modulation of the measured gre signal: the signal intensity is at its maximum if the two transversal magnetizations are parallel; it is at its minimum if they are antiparallel remark: in order to generate this raw data matrix row by row, the sequence has been repeated n times for different values of the phase-encoding gradient g x = n∆g x (n / 2 < n ≤ n / 2) with the se signal being measured n times in the presence of the readout gradient in equidistant steps ∆t symmetrically to the echo time te at each sequence cycle (see fig. 2 .4.28a). with this technique, the number of sequence cycles nph required for phase encoding can be halved without reducing the spatial resolution, which-according to eq. 2.4.5-also implies a 50% reduction of the acquisition time. the reduction of acquisition time, however, results in a reduction of the s/n ratio by the factor 2. remark: in practice, some more rows of the k-space matrix are acquired, which makes it possible to perform a phase correction. due to this reason, the reduction of the acquisition time is slightly less than 50%. the measurement time can also be reduced by sampling only the central segment of the k-space matrix. however, fourier transformation of such a sparsely sampled k-space matrix yields an image that is only coarsely sampled (i.e., has large voxel dimensions) in the phase-encoding direction(s). this may result in severe partial volume effects in case of small tissue structures, such as vessels in mr angiography. the nominal resolution of the reconstructed image can be improved when the "missing" lines of the k-space are "zero filled" before fourier transformation. this approach, denoted as fourier interpolation, increases the number of pixels in the reconstructed image and thus the image resolution, but does not, of course, improve the physical resolution of the imaging process. nevertheless, this trick improves the appearance of the reconstructed images and reduces partial volume effects. fourier interpolation is routinely used in 2d imaging as, for example, to display a 512 × 512 image matrix reconstructed from a k-space matrix with only 256 × 256 the missing points are generated through (conjugate) point reflection of the measured data in the center of the matrix (see fig. 2.4.26) . c after this preparatory step, the mr image can be reconstructed as usual by a 2d fourier transformation of the k-space matrix measurement points. the concept can be extended to 3d imaging, in particular to compensate for the sparse sampling of the k-space matrix in the direction of the second phase-encoding gradient (slab direction). a special application is the vibe (volume interpolated breath-hold examination) technique, which is being used to reconstruct images from a sparsely sampled k-space matrix acquired with a fast 3d imaging sequence within a single breath hold. what happens, when the number of phase-encoding steps nph-and thus the image acquisition time-is halved, while the sampling interval of the phase-encoding gradient, here ∆g x , is doubled? according to the sampling theorem discussed in sect. 2.3.3.1, the field of view fovx that can be imaged in x-direction without reconstruction errors is inversely proportional to ∆g x . therefore, the fovx is also halved by the modified sampling strategy. in contrast, the spatial resolution ∆x = x/n is not changed. the modification discussed has thus-apart from a reduction of the s/n ratio due to the reduced number of measurements-no effect on the reconstructed mr image, as long as the object size x in direction of the phase-encoding gradient is less than fovx /2. however, if the object size x is greater, then this will result in aliasing artifacts, i.e., the portions of the object outside of the reduced field of view get mapped to an incorrect location inside this field of view. the reason is that at these positions the phase angles ϕ induced by the phase-encoding gradient are greater than 2π or 360°) and thus cannot be distinguished from phase angles in the interval 0-2π  (see fig. 2 .3.9) that encode positions inside the reduced field of view. the missing information, however, can be obtained by using two adjacent coil elements in an rf receive array with non-overlapping sensitivity profiles, each of which detects the mr signals from only one half of the full field of view. this strategy is called parallel imaging. obviously, the number of phaseencoding steps nph-and thus the acquisition time-can be further decreased if receive arrays with more than two coil elements are used (see sect. 2.5). parallel imaging offers the major advantage that it can be combined with any existing imaging sequence (e.g., se, gre, and echo planar imaging sequences) and that the contrast behavior of the sequence used is not changed. when implementing parallel imaging techniques, one has to deal with the problem that the sensitivity profiles of the coil elements are not rectangular but rather overlap. to avoid image artifacts arising from this fact, sophisticated image reconstruction techniques have been developed. they can be classified into two major groups, image-based reconstruction (e.g., sense, or sensitivity encoding) and k-space-based reconstruction techniques (e.g., grappa, or generalized autocalibrating partially parallel acquisitions). the basic idea of the echo planar imaging (epi) technique, described by p. mansfield in 1976 (mansfield et al. 1976 ), aims at generating a series of spin or gradient-echoes in a short period of time after excitation of the spin system by an rf pulse, which are differently phase encoded by an appropriate gradient-switching scheme. in this way, possible sampling schemes for the k-space matrix. a in the conventional 2d fourier technique, only one row of the k-space matrix is acquired per sequence cycle so that n sequence cycles are required to completely construct the raw data matrix. b in the single-shot echo planar technique, all rows of the k-space matrix are detected in one single sequence cycle. the figure shows one possible sampling strategy. c in segmented k-space sampling, several rows of the k-space matrix are acquired per sequence cycle. the figure indicates the rows of the raw matrix that are acquired in one sequence cycle in gray all rows of the k-space matrix can be acquired within one single sequence cycle. the various published versions of the epi technique only differ in the way the phase-encoding gradients are switched, i.e., in what order the data points of the raw data matrix are sampled. one possible sampling scheme is shown in fig. 2 .4.28b. the limiting factor evidently is the speed with which the transverse magnetization decays after rf excitation. if the acquisition time is markedly longer than the decay constant (t2 or t2*, respectively), the different rows of the k-space matrix are differently t2 or t2* weighted, depending on the sampling scheme. this means that distinct spatial frequencies are over-and others are underweighted. in order to prevent this problem, the entire data set needs to be acquired within a time interval, which is comparable to the decay constant of the transverse magnetization. the epi technique therefore challenges the gradient system. the mentioned problems in epi can be avoided by sampling only few rows of the k-space matrix during each sequence cycle. if ne echoes are generated per excitation, then the number of sequence repetitions necessary to completely fill the raw data matrix and, in consequence, the acquisition time can be reduced by the factor 1/ne as compared with the conventional 2d fourier technique. in contrast to the epi technique, the demands on the gradient system for this so-called segmented k-space sampling strategy are much lower. in mr imaging, there are two major pools of hydrogen nuclei that contribute to the image signal: the 1 h nuclei of freely moveable water molecules and those of the ch2 groups of mobile fatty acids (see fig. 2 .3.7). in contrast, the mr signal from hydrogen nuclei which are bound in relatively immobile macro-molecular structures (such as proteins, cell membranes, etc.) cannot be detected due to their very short t2 times (cf. sect. 2.2.5.3). nevertheless, they affect indirectly the magnetization of the "free" 1 h nuclei in water and thereby also modify the image signal. based on these facts, different methods have been developed, which offer the possibility to modify the magnetization detectable in mr imaging by preparation pulses. as already discussed in sect. 2.3.3.1, the chemical shift of about 3.5 ppm between 1 h nuclei in water and fatty acids becomes evident in the fact that fatand water-containing tissue structures of the body are slightly shifted against one another. this image artifact, which is especially pronounced in epi, can be avoided by reducing the contribution of the fatty acids to the mr signal. one possibility to reduce the signal from fatty acids has already been discussed in relation with the stir sequence (see sect. 2.4.2.2), in which the magnetization is prepared (here inverted) by an inversion pulse. if the inversion time is chosen so that the longitudinal magnetization of the fatty acids is almost zero at this point in time, only the water pool will contribute to the stir image (see fig. 2 .4.10b). a drawback of this technique is, however, that the inversion time is determined by the t1 time of the 1 h nuclei in fatty acids, and thus the t1 contrast of the images cannot be chosen freely. this problem can be avoided by utilizing not the specific relaxation properties of fatty tissues (see table 2 .2.2) for fat suppression, but the chemical shift between 1 h nuclei in water and in fatty acids. the latter strategy offers the opportunity to selectively saturate the magnetization of the fatty acids by frequency-selective rf pulses, so-called chess (chemical shift selective) pulses, and to use the remaining magnetization of the water pool for image generation. in the simplest case, the chess pulse is a frequency-selective 90° pulse, which flips the longitudinal magnetization of the ch2 groups into the x-y-plane, where it will be dephased by a spoiler gradient (frahm et al. 1985; haase et al. 1985) . however, this places high demands on the homogeneity of the magnetic field within the patient; in order to separate the two resonance lines, the field homogeneity must be better than 3 ppm. in practice, this condition can only be rendered if the homogeneity of the magnetic field is adjusted by a special shim procedure before the examination of the patient. in order to avoid this procedure, optimized chess pulses for fat suppression have been developed (e.g., binominal pulses). in biological tissues, there are two pools of hydrogen nuclei that differ markedly regarding their biophysical properties: 1 h nuclei in water molecules with high mobility ( 1 hf, or free water protons), and 1 h nuclei in macromolecules with reduced mobility ( 1 hr). whereas the t1 relaxation times of the two pools do not differ markedly (t1 > 100 ms), the t2 times differ strongly (see fig. 2 .2.16). the t2 times of the 1 hf nuclei are generally higher than 40 ms, whereas for 1 hr nuclei they are less than 100 µs due to the strong dephasing effect of neighboring spins. the different t2 times are mirrored in the 1 h spectrum (fig. 2.4.29) . as the width ∆ω of a resonance line is inversely proportional to the t2 time (see sect. 2.2.6), the 1 hf pool has a line width of a few hertz, whereas the spectral width of the 1 hr nuclei is more than 10 khz. it is crucial that the two 1 h pools interact due to intermolecular processes (spin-spin interaction) and/or chemical exchange processes (wolff and balaban 1989). due to this reason, any change in the magnetization in one pool results in an alteration of magnetization of the other pool. this effect is called magnetization transfer (mt). to utilize this effect for mr imaging, the magnetization of the 1 hrpool is saturated by frequency-selective preparation pulses (saturation transfer). due to the mt effect, this leads to a significant reduction of the mr signal of 1 hf nuclei and thereby to a reduction of the image signal. in the simplest case, the frequency spectrum of the preparation pulse is defined by a rectangular function below and/or above the resonance frequency of the 1 hf pool, as is shown in fig. 2 .4.29. when doing this, the offset frequency has to be chosen big enough, so that local variations of the resonance frequencies of the 1 hf nuclei due to inhomogeneities of the static magnetic field and differences in tissue susceptibilities do not lead to a direct effect on the 1 hf magnetization. mt preparation pulses are often used in mr angiography to increase the blood-tissue contrast. this interesting application is based on the fact that the mt effect reduces the 1 hf magnetization of stationary tissue, whereas the magnetization of the flowing blood is not affected. imaging in magnetic resonance is based on spin warp imaging but is commonly referred to as fourier imaging. the main underlying principle is the use of magnetic field gradients to prepare the slice-selective excitation and to phase and frequency encode the signal that is induced by the rotating transverse magnetization. the motivation of continued sequence development is fuelled by the aim to improve the tissue distinction and the shortening of measurement time. in recent years, a great number of sequences have been developed (see table 2 .4.6), each of which are utilized in routine clinical applications. the following paragraph provides a systematic overview of the sequence families. schematic depiction of a 1 h spectrum of biological tissues. apart from the resonance line of 1 h nuclei in free water ( 1 hf), with a low spectral line width (< 20 hz), there is a broad underground due to 1 h nuclei in macromolecules with reduced mobility ( 1 hr), the mr signal of which cannot be detected directly because of their short t2 times. note that the spectral widths are not depicted in true scale. the frequency spectrum of a mt preparation pulse is marked in gray a first sequence classification can be performed in assigning the type of sequence in either a spin-echo or a gradient-echo group. the main difference between se and gre is the influence of susceptibility gradients on image contrast. in general, in gre imaging susceptibility gradients lead to a faster decay of the signal, whereas in se imaging dephasing mechanisms that are fixed in location and consistent over time are refocused by the 180° refocusing rf pulse. se image contrast depends on the tissue specific transversal relaxation time t2, whereas gre image contrast is a function of the transversal relaxation time t2*. some gre techniques utilize the excitation pulse also as a refocusing pulse, causing spin-echo components to contribute to the image contrast. within the se and the gre group, the contrast can be manipulated by preparing the longitudinal magnetization prior to starting the imaging sequence or prior to the measurement of a fourier line. in multi-echo imaging, the transverse magnetization is refocused and reutilized after the collection of a fourier line, omitting the necessity of a further excitation for the collection of another fourier line. this method is applicable within the se group as well as the gre group. again, a preparation of the magnetization is generating another sequence family. using only one excitation and multiple phase-encoded echoes to acquire all required k-space lines without a further excitation is called a single-shot technique. figure 2 .4.30 shows an overview scheme that provides one possible sequence-classification. within 3d gre with low-flip angle excitation and "spoiling" after data acquisition of a single fourier line and fourier interpolation in the direction of partition encoding combines the half-fourier method with a tse sequence to a degree at which only a single excitation pulse suffices to fill the raw-data matrix with following spin-echoes, one applies the so-called haste technique (half-fourier single-shot turbo spin-echo). the mix of spin-echoes with gradient-echoes or, more precisely the acquisition of gradient-echoes within an se envelope leads to the tgse (turbo gradient-echo sequence) sequence, also called grase (gradient and spin-echo). as expected, with the introduction of gradient-echoes within a multi-echo spin-echo sequence, the contrast behavior is also t2* related. this sequence is also called a hybrid. similar to the se sequences, the gre sequences can be grouped into: • conventional gre sequences (e.g., flash, fisp, truefisp, dess, ciss, psif) • gre sequences with preparation of the magnetization (e.g., turboflash, mp-rage) • multi-echo gre sequences (e.g., medic, segmented epi) • multi-echo gre sequences with preparation of the magnetization (e.g., segmented dw-se-epi) • single-shot gre sequences (epi) • single-shot gre sequences with preparation of the magnetization (e.g., dw-se-epi) as indicated above, conventional gre sequences can be further divided into: • ssi group (steady-state incoherent), which only aims at a steady state in the longitudinal magnetization (e.g., flash, spgr, t1-ffe) and • the ssc group (steady-state coherent), during which the steady state of the transversal magnetization equally contributes to the signal (e.g., fisp, truefisp, grass, fiesta, ffe, bffe). acronyms of the ssi group are flash (fast low-angle shot), spgr (spoiled gradient-recalled acquisition in the steady state), and t1-ffe (t1-fast field echo). in the ssc group there are truefisp (fast imaging with steady precession), grass (gradient-recalled acquisition in the steady state), and ffe (fast field echo). within the ssc group, there is a slow transition toward spin-echoes, as excitation pulses do not only excite, but also refocus various echo paths of a remaining or refocused transverse magnetization. the extreme form is psif (a backward-running fisp), also named ssfp (general electric) or t2-ffe (philips). in these techniques, the excitation pulse of the following measurement operates as a refocusing pulse for the transverse magnetization of the previous excitation. the contrast is t2 weighted, as the effective echo time amounts to almost two repetition times. a combination of fisp echo and psif echo is called dess (double-echo steady state), and having the fisp and psif echo coincide in time will result in a ciss (constructive interference steady state) or a truefisp sequence. the same preparation of the magnetization utilized for se techniques can be applied to gre techniques. with a very rapid gre sequence (rage, or rapid acquired gradient-echoes), with the aim of measuring as fast as possible, the tr is set to a minimum and consequently so is te, and the excitation angle is set to an optimum (ernst angle) in order to generate as much signal as possible. to reestablish a t1 weighting, a saturation or inversion pulse is applied, but not prior each fourier line as in se imaging, but at the beginning of the whole measurement. those techniques are called turboflash, fspgr (fast spoiled gradient-recalled acquisition in the steady state), tfe (turbo field echo) or, placing the inversion within the partition loop of a 3d sequence, mp-rage (magnetization prepared rapid acquired gradientechoes). as is the case in fast se sequences, gre sequences also can make use of multi-echo acquisitions. medic (multiecho data image combination) uses multiple echoes for averaging, thus improving snr and t2* contrast. the classical form of a single-shot gre technique, during which the raw data matrix is filled after a single excitation with several phase-encoded gradient-echoes, is called epi (echo planar imaging). simply collecting the free induction decay with multiple phase-encoded gradient-echoes is called fid-epi. placing the gradient-echoes beneath an se envelope is called se-epi. the most common magnetization prepared single shot gradient-echo technique is the diffusion-weighted spinecho echo planar imaging sequence (dw-se-epi). the idea of using multiple phase-encoded spin-echoes to fill the k-space more rapidly as compared with conventional imaging has surfaced as early as 1986, with the acronym rare-rapid acquisition with relaxation enhancement ( fig. 2.4 .31). the number of applied echoes is directly proportional to the potential reduction in measurement time. the overall image contrast is dominated by the weighting of those fourier lines acquired in the center of k-space (effective echo time). the qualities of the early images were not close to the quality of conventional t2-weighted se imaging. in the course of hardand software developments, mulkern and melki "re-discovered" multi-echo se imaging during a search for a fast t2-localizer, creating the acronym fse (fast spin-echo). siemens and philips use the acronym tse for turbo spin-echo. since the higher spatial frequencies, the "outer" k-space lines, are usually acquired using late echoes, early concern has been that small objects might be missed. fortu-nately, the time saving achieved with the use of multiple echoes has been utilized to improve the contrast by selecting longer repetition times and to improve the spatial resolution by increasing the matrix size. both measures have more than compensated the effect of an under-representation of high spatial frequencies within the k-space matrix. t2-weighted tse has replaced conventional spinecho imaging in all clinical applications. the acquired phase-encoded echo train can also be used to create pdweighted and t2-weighted images similar to conventional dual-echo spin-echo imaging. the use of phase-encoded echoes for the k-space of the pd-weighted image as well as the k-space of the t2-weighted image is customary and this procedure is called shared echo. t1-weighted tse imaging is also an option for some applications, although additional echoes will increase (unwanted) t2-weighting. t1-weighted tse imaging is rarely applied to the central nervous system as the use of additional echoes prolongs the time needed for a single slice and the number of necessary slices may not fit into the desired tr. for the genitourinary system (uterus, cervix, bladder, etc.) about three echoes are used to improve snr or to reduce measurement time. in areas where the amount of t1-weighting is less of an issue, e.g. t1weighted imaging of the cervical and the lumbar spine for degenerative disease, tse is usually used with an echo train length (etl) of five echoes. the same protocol is applied for enhanced and unenhanced studies of suspected vertebral metastases. t1-weighted tse imaging for the abdomen is not an issue, since the restriction of the measurement time down to a breath hold period is suggesting t1-weighted gre imaging. the remaining point of concern in comparing tse imaging with conventional se imaging is the reduced sensitivity to susceptibility artifacts. hemorrhagic lesions appear less suspicious on tse imaging as compared with conventional se imaging. the fourier transformation assumes a consistent signal contribution for all fourier lines. any violation of this assumption will lead to overor under-representation of spatial frequencies, with a correlated image blurring. although tse violates this assumption in using multiple phase-encoded echoes to r structure of the tse sequence. excitation, refocusing, frequency, and phase encoding are done as in the conventional se sequence. the dephasing done for the purpose of spatial encoding is rephased prior to generating another spin-echo using a 180° rf pulse followed by another phase-encoding step fill the k-space, where the signal amplitude of the echoes diminishes following t2 decay, there are several parameter that can be utilized to minimize the artifacts related to the t2 decay-related k-space asymmetry: • first, especially for t2-weighted imaging, the signal amplitudes for the late and closely spaced echoes can be approximated as being constant. tse sequences are mainly used for the acquisition of t2-weighted images. as lesions usually have a long t2 relaxation time, the signal loss caused by the t2 decay does not play a major role during data acquisition. • second, the matrix dimensions used in tse imaging are usually higher as compared with conventional se imaging. this will significantly minimize the risk of missing small objects. • third, in t2-weighted tse imaging, the repetition time is increased considerably, which leads to a remarkable improvement in contrast, again reducing the potential risk of missing small objects due to k-space asymmetry. in a typical tse protocol, 13-15 echoes per excitation are used for imaging, implying a theoretical shortening of measurement time of the factor 13-15. in practice, the shortening is about the factor 2-6. longer repetition times are selected for improved pd and t2 weighting, and larger image matrices are used for improved spatial resolution, diminishing the potential shortening of the measurement time when using multiple phase-encoded echoes. as the mentioned influence on the space encod-ing is only present in the direction of the phase encoding, the effect can be demonstrated by exchanging of the frequency-and phase-encoding gradients. figure 2 .4.32 shows this in the example of the cauda equine. apart from use for high-resolution images, tse sequences are also applied in cardiology, as shown in fig. 2 fast spin-echo imaging demonstrates two essential differences in imaging appearance as compared with conventional spin-echo imaging: fat appears bright, and there is a reduced sensitivity to hemorrhagic lesions. the bright appearance of fat is related to the j-coupling. the so-called j-coupling (see sect. 2.2.9) of the carbon-bound protons provides a slow dephasing of transversal magnetization in conventional se imaging, in spite of the refocusing pulse. if the refocusing pulses follow shortly after image of the cauda equina, acquired with a tse sequence with a the phase-encoding direction from left to right, and b the phase-encoding direction from head to foot. the longitudinal structures of the relatively thin nerves will be better visible, if the frequency-encoding direction is perpendicular to the nerve fiber. the resolution in frequency-encoding direction is not influenced as much by the t2 decay as by the resolution in phase-encoding direction one another, as is the case in tse imaging, the j-coupling will be overcome; the dephasing will be suppressed. consequently, fat tissue appears brighter in the tse image than it does in a conventional image. if desired fat saturation or fat suppression (see sect. 2.4.5.1) can be utilized to suppress this appearance. the susceptibility-related artifact of hemorrhagic lesions in spin-echo imaging is due to diffusion in between excitation, refocusing, and data acquisition. reducing this diffusion time by rapidly succeeding refocusing pulses will also reduce the related artifacts, thus making tse imaging less sensitive for hemorrhagic lesions. the tse sequence, like the conventional se technique, can be used with an inversion pulse for preparation of the longitudinal magnetization. thus, it becomes possible to yield a suppression of the fat signal, based on the short relaxation time of fat (see fig. 2 .4.10b). relaxation dependent fat suppression using an inversion pulse prior to the fast spin-echo train is routinely used to demonstrate bone infarctions and bone marrow abnormalities like bone marrow edema, e.g., in sickle cell anemia. this fat suppression scheme is also used in genitourinary applications, where the high signal intensity of fat may obscure contrast-enhanced tumor spread. since only the fat suppression is desired, the used inversion recovery technique is not phase sensitive, only the magnitude of the longitudinal magnetization is used. the acronym used in this case is tirm (turbo inversion recovery with magnitude consideration). the structure of a turbo inversion recovery (tir) sequence is presented in fig. 2 .4.34. the reduction in measurement time due to the utilization of multiple phase-encoded spin-echoes permits the use of inversion times in the order of 2 s, keeping the measurement time acceptable. an inversion time of 1.9 s will provide a relaxation dependent suppression of the cerebral spinal fluid (csf) signal ( fig. 2.4 .35). the utilization of a long inversion time is called fluid-attenuated inversion recovery, or flair. in combination with tse imaging (the structure of a 3d tse sequence is presented in fig. 2 .4.36), the technique is called turboflair or simply tirm. since csf has the longest t1 relaxation time, the longitudinal magnetization within all other tissues will be aligned parallel to the main magnetic field, and it is not necessary to have a phase sensitive ir method for this application. the attenuated csf signal allows a better differentiation of periventricular lesions and has demonstrated a superior sensitivity for focal white matter changes in the supratentorial brain, whereas posterior fossa located lesions can be missed. the turboflair method apparently allows the identification of hyperacute subarachnoid hemorrhage with mr, precluding the need for an additional ct. the time-consuming ir method has been used in the past for studying the development of white matter tracts in developmental pediatrics. this technique has been replaced using an inversion pulse prior to a spin-echo train of a tse sequence. the selected inversion time (~350 ms) allows a better delineation of small differences in t1 relaxation times, e.g., for the documentation of the development of the pediatric brain. the improved tissue characterization between gray matter and white matter tracts allows, e.g., the demonstration of mesial temporal sclerosis and visualizing hippocampal atrophy. for this application a so-called phase-sensitive inversion recovery is required to differentiate nuclear magnetization aligned parallel to the magnetic field as compared with antiparallel alignment at the time of excitation. the according acronym is tir. the residual transverse magnetization after measuring a single fourier line, or, in case of multi-echo imaging, after measuring the "package" of fourier lines, is usually spoiled. a later-introduced concept refocuses the transverse magnetization at the end of the echo train and uses an rf pulse to "restore" the residual transverse magnetization back to the longitudinal direction. the method "improves" the recovery of the longitudinal magnetization for tissue with long relaxation times, allowing a further shortening of the repetition time without loss of contrast. the technique is called restore (siemens), fast recovery fast spin-echo frfse (ge) and drive (philips). it does not make a difference whether the magnetization is prepared after the measurement of a fourier line or at the very beginning of a new excitation cycle. for this reason it is justified to list restore as a turbo spin-echo scheme with preparation of the longitudinal magnetization. multi-echo spin-echo imaging has the potential to acquire t1-and/or t2-weighted spin-echo imaging of the beating heart within a breath hold. the only obstacle that needs to be addressed is the significant flow artifacts caused by the flowing blood. the introduction of dark-blood preparation scheme finally revolutionized cardiac mr imaging. with this preparation scheme, it is now possible to acquire t1-and t2-weighted images of the beating heart within a breath hold, without any flow artifacts. the magnetization of the whole imaging volume is inverted nonselectively, followed by a selective reinversion of the slice. this is done at end diastole, with the detection of the qrs complex. during the waiting period to follow, most of the reinverted blood will be washed out of the slice, being replaced by the inverted blood-and the spin-echo train acquired again toward end diastole will show "black" blood. a double inversion pulse will even allow not only the black-blood preparation, but also the suppression of fat signal, which will be helpful in characterizing fatty infiltration of the myocardium in arrhythmogenic right ventricular dysplasia (ard). single shot, per definition, refers to a single excitation pulse and the use of multiple phase-encoded echoes to fill the required fourier lines. the original rare has been published as a single-shot spin-echo technique. other acronyms found in the literature are ss fse for single-shot fast spin-echo (ge) or ss tse of single-shot turbo spin-echo (philips). the combination with a half-fourier technique allows a further reduction in measurement time and has been named haste: half-fourier acquired single-shot turbo spin-echo. as elaborated on earlier, the first and the last data point of a fourier line are characterized by the transverse magnetization of adjacent voxel pointing into opposite direction. the same situation is found for the first and last fourier line within k-space, considering the transverse magnetization within adjacent voxel aligned in the direction of phase encoding. k-space is symmetrical. although this hermitian symmetry is ideal and reality is slightly different, it has been claimed, that the deviation from the ideal situation are only of coarse nature and that a few (e.g., eight) fourier lines measured beyond the center of k-space should be sufficient to correct for this insufficiency. as an example for a 128*256 matrix, a single-shot spin-echo technique using the half fourier approach would use 128 /2 + 8 = 72 phase-encoded echoes to fill the k-space. the measurement time using this acquisition method is about a second per slice. the high numbers of echoes suggest that this technique is only useful for t2-weighted imaging and the blurring effect due to signal variation in k-space as a result of t2 decay will be prohibitive for high resolution studies. nevertheless, it is an alternative, even in the brain, for a fast t2-weighted study for patients who are not able or willing to cooperate. since it is the perfect technique to visualize fluid-filled cavities, haste is used, e.g., for mrcp (magnetic resonance cholangiopancreatography). a typical result of this sequence is shown in fig. 2 .4.37. progress in hardware development and the correlated improvement in image quality, together with the pioneering research within this field have recently led to an impressive increase in haste utilization for obstetric imaging. although sonography remains the imaging technique of choice for prenatal assessment, the complementary role of mr imaging is getting more and more important in the early evaluation of brain development of the unborn child or even in the early detection of complications within the fetal circulatory system. the search for shorter measurement times for faster imaging led to the group of gradient-echoes (gre) in 1983. an mr signal can be detected immediately after the excitation pulse. that signal is the free induction decay (fid). in addition to the spin-spin interaction causing the t2 relaxation, other dephasing mechanism will contribute to the image contrast, dephasing mechanisms that are based on differences in precessional frequencies due to magnetic field variations across a voxel. the main sources of local magnetic field variations are differences in tis-sue-specific susceptibility values. since these dephasing mechanisms are fixed in location and are constant over time, they are refocused using a 180° rf refocusing pulse in se imaging. omitting this pulse will lead to a contribution of these dephasing mechanisms to the image contrast. the observed tissue specific relaxation parameter is then called t2* rather than t2. with t2´ being both machine and sample dependent. although the missing 180° rf refocusing pulse will cause a rapid dephasing of the transverse magnetization and with that a rapidly dephasing mr signal, the echo time can be reduced as well and so can the repetition time. the shorter echo time will allow, in most cases, a detection of a signal despite the rapid dephasing of the transverse magnetization. since the echo is now formed by using a bipolar gradient pulse in the direction of frequency encoding, these techniques are called gre. with shorter repetition times an extension of phase encoding for the direction of slice or slab selection can be considered, and 3d imaging becomes feasible. the short excitation pulses used in common gre imaging will result in a less perfect slice profile as compared with the slice profile achieved with a 90-180° combination of longer rf pulses as typically utilized in se imaging. as a result, there will be significant contributions of the low angle-excited outer regions of a slice, explaining the basic difference in contrast between a gre image as compared with an se image, even if a 90° excitation angle is utilized. similar to the spin-echo sequence acquisition scheme, there is residual transverse magnetization left at the end of the acquisition of one fourier line-and similar to the spoiling of the transverse magnetization at the end of the measurement in se imaging, the same process can be applied to gre imaging as well. spoiling can be done with a gradient pulse, distributing the transverse magnetization evenly, so that the next excitation pulse will not generate a stimulated echo. or the phases of the excitation pulses can be randomized in order to avoid the buildup of a steady state for the transverse magnetization (rf spoiling). spoiled gradient-echo imaging has been introduced as fast low angle shot (flash), t1-weighted fast field echo (t1-ffe), or spoiled gradient recalled acquisition in the steady state (spgr). flash imaging allows multislice imaging in measurement times short enough to allow breath hold acquisitions. since the contrast mainly depends on the t1 relaxation time, flash images are usually called t1 weighted. in clinical routine, flash sequences have been introduced for diagnosing cartilage lesions (fig. 2.4 .38), for abdominal breath-hold t1weighted imaging (fig. 2.4 .39), and in dynamic contrast enhanced studies. as has been discussed in sect. 2.4.3.2, not only the amplitude of the signal can be controlled, but also the basic contrast behavior can be influenced. for instance, when using an extremely small excitation angle and moderate repetition times, one can minimize the influence of the t1 relaxation time (see fig. 2.4.17) . thus, one can obtain the alternative to spoiling the residual transverse magnetization after the end of the fourier line acquisition is to rephase what has been dephased for spatial encoding. this was introduced as fast imaging with steady precession (fisp) (oppelt et al. 1986 ), later to be called true-fisp. the original implementation and publication of fisp uses a gradient refocusing in phase encoding as well as in frequency-encoding direction and slice-select direction. as this sequence was susceptible to artifacts at the time, the implemented and released fisp sequence, still used today, is only refocused in the direction of phase encoding, and no refocusing in readout and slice-selection direction. such a sequence has been called roast (resonant offset acquired steady state [haacke et al. 1991] ). for the fisp sequence, the phase encoding is reversed after the acquisition of the fourier line, undoing the dephasing that was applied for spatial encoding. this approach will lead to a steady state not only for the longitudinal magnetization, but also for the transverse magnetization-for tissue with long t2 relaxation times. differences in fisp contrast as compared with flash applications will only be visible for short repetition times; large excitation angles and will only enhance signal within tissue with long t2 relaxation times. general electric introduced this technique as gradient-recalled acquisition in the steady state (grass). philips is using the fast field echo (ffe). if one rephases at the end of the measurement of a fourier line, all parts of the transverse magnetization that have been dephased for spatial encoding and if one compensates in advance for the dephasing to be expected while the slice selection gradient is switched on, one obtains the truefisp sequence ( fig. 2.4.41 ). this technique combines the advantages of the fisp sequence and the psif sequence, with further echo paths contributing to the overall signal. a clinical application of this sequence is shown in fig. 2 .4.42. this original approach of refocusing all transverse magnetization at the end of the mea structure of the truefisp sequence. the sequence seems to be "balanced" due to a symmetry in time. all components of the transverse magnetization are refocused at the end of the measurement, leading to a steady state surement of one fourier line will not only cause a steady state for the transverse magnetization, but also the next excitation pulse will also operate as a refocusing pulse. the excitation pulse will not only convert longitudinal magnetization to transverse magnetization, but will also generate a spin-echo. the sequence seems to be symmetric, balanced. the challenge is to get all the generated echoes to have one phase, otherwise the echoes will destructively interfere, causing band-like artifacts. the po-sitions of these bands also depend on the starting phase of the rf pulse. adding another acquisition with a phase shifted rf will lead to a technique called constructive interference steady state technique, (ciss), or phasecycled fast imaging-employing steady-state acquisition (pc-fiesta, the acronym used by ge). since ciss contains spin-echo components, the technique is even useful in regions with significant susceptibility gradients, e.g., nerve imaging at the base of the skull. since this technique is a fast technique with hyperintense appearance of fluid filled cavities, it is primarily applied to study abnormalities of the internal auditory canal. the originally published fisp is the truefisp, where all the dephasing is reversed and even the slice selection gradient is preparing the dephasing to be expected during the first half of the next excitation pulse. the truefisp technique is a fast gradient-echo sequence with spin-echo contributions leading to hyperintense appearance of all tissues with long t2 relaxation times. the technique is primarily used se signal. such a sequence is called double echo steady state (dess, fig. 2.4.45) . the dess sequence is routinely used in orthopedic imaging (fig. 2.4.46) . it links the advantages of the fisp sequence with the additional signal enhancement of the psif sequence for tissues with long t2 (e.g., edema and joint effusion). in fast cardiac imaging, for cine snapshots of the beating heart. general electric is using the acronym fiesta for the same technique. philips is using bffe (balanced fast field echo) as the acronym for his technique. the previously mentioned spin-echo component of a balanced technique can be isolated and can be used to generate an image. the psif sequence shown in fig. 2 .4.43 appears to be violating the causality at first: a fisp sequence running backward. the signal inducing transverse magnetization is produced with the first excitation at the end of the first cycle, refocused with the second excitation at the end of the second cycle, and inducing a signal at the beginning of the third cycle. the effective echo time therefore amounts to almost two repetition times. the resulting images consequently show a remarkable t2 weighting. (note that in this case, it is a spin-echo and not a gradient-echo.) the psif sequence is insensitive to susceptibility gradients. in contrast to ciss, the psif is very sensitive to flow and motion, thus it is not applied for iac imaging but rather used as an adjunct to demonstrate abnormal csf flow pattern. general electric is calling this technique simply steady state free precession (sffp), while philips is using the acronym t2-ffe. imaging of the cochlea (fig. 2.4 .44) is no longer performed with psif but rather with ciss, due to the intrinsic flow insensitivity of the latter. when combining a fisp image with a psif image, one obtains an image with a t2* weighting via the gre signal and a t2 weighting via the in theory, all the magnetization preparation schemes previously applied for the se group can also be applied for the gre sequences. however, it has to be kept in mind that gre sequences are usually using shorter te and shorter tr than se imaging does, and therefore some preparation schemes should be slightly altered. as, for an example, the fat saturation scheme: the time necessary for a spectral saturation pulse followed by a gradient spoiler will add up to the slice-loop time for an otherwise short tr gre sequence. a feasible modification is to skip the fat saturation for a few slices-this is referred to as "quick fat sat. " although a slice-dependent recovery of the fat signal is observed, the compromise is in general acceptable, since the fat signal stays low and more slices can be measured per tr. the quality of a spectral saturation pulse depends on the overall homogeneity within the imaging volume. in addition, the spectral fat saturating rf pulse is very close to the water resonance, causing a loss in overall snr. for a nonselective excitation, it is theoretically possible to also simply excite either fat or water using the tissue specific larmor frequency. in practice, such an approach is very prone to artifacts due to imperfect field homogeneity within the volume of interest. better results in water excitation or fat excitation have been achieved with binomial pulses (1-1, 1-2-1, or 1-3-3-1). the mechanism of e.g., a 1-2-1 rf pulse is described as follows, leading finally to a 90° rf excitation pulse for just water. after an initial 22.5° rf pulse, there will be a waiting period, allowing the magnetization within fat to fall behind the magnetization of water. at the point of opposite position of the magnetizations, a 45° excitation angle will than move the magnetization within water to a 67.5° position with respect to the longitudinal direction, whereas the magnetization within fat will be flipped back to the 22.5° position. after the previously mentioned waiting period, another 22.5° excitation pulse will accomplish the 90° excitation for water, while the magnetization of fat will be restored to the longitudinal position, not contributing to the mr signal. another advantage of these binomial pulses is that they can be either executed using nonselective rf pulses or selective rf pulses. in the latter case, they are called spatial spectral frequency or simply composite pulses. inversion pulse prior to the measurement to improve t1 contrast short tr, short te gre imaging, utilizing the ernst angle leads to pd-weighted images rather than t1-weighted images. in se imaging, the t1 contrast is improved by placing an inversion pulse prior to the acquisition of the fourier line. this approach is not feasible in gre imaging, since the inversion time would be much larger than the commonly used repetition times. in fast gre imaging, an inversion pulse is used prior to the whole imaging sequence (fig. 2.4.47) . that concept has been introduced as turboflash (snapshotflash (haase et al. 1989) , fast spgr (fspgr) or turbo field echo (tfe)). the minor drawback is that the longitudinal magnetization, and consequently the generated transverse magnetization, will change throughout the measurement. the resulting violation of k-space symmetry will cause an under-or over-representation of some spatial frequencies producing a slight image blurring, typical for turboflash imaging. when using this method, one has to consider the following three facts: 1 the longitudinal component of the macroscopic magnetization will recover after the inversion pulse with the t1 relaxation time. this relaxation process also takes place during data acquisition. the various measured fourier lines will have different t1 weightings. the image contrast is dominated by the t1 weighting of the fourier line measured at the center of k-space. 2 the recovery of the longitudinal magnetization is influenced by the excitation angles of the rapid gre data after an inversion pulse and an inversion time, the small-angle excitation is repeated several times until the raw data matrix is filled acquisition. in order to minimize this influence and to obtain a maximum effect of the preparation-pulse on the image contrast, the rapid gre acquisition needs to be executed with small excitation angles. 3 every fourier line is measured with a different phase encoding gradient and contains the spatial information of the object in direction of phase encoding. the k-space symmetry is significantly violated due to the change in signal contribution for each spatial frequency measured as a consequence of t1 relaxation during sampling. as a result, the images appear to be blurred, with imprecise edges and coarse signal oscillations parallel to the edges. with the introduction of short tr gradient-echo acquisition schemes, 3d imaging became feasible. the application of an inversion pulse prior to a 3d acquisition scheme is not very promising, since the preparation of the longitudinal magnetization would vastly diminish during the relatively long measurement time and the significant number of low angle excitation pulses. a feasible alternative is to repeat the preparation of the longitudinal magnetization in either the partition-encoding loop, or the phase-encoding loop. although the timesavings would be larger for placing the inversion pulse prior to the longer phase encoding loop, fortunately at the time it was only possible to place the inversion pulse prior to the partition-encoding loop. fortunately, because the previously described turboflash-artifact based on the overand under-representation of k-space lines is now omitted. the phase-encoding gradient is prepared; the inversion pulse is set followed by a rapid execution of the partitionencoding loop, during which the amount of longitudinal magnetization will change according to the course of the t1 relaxation (recovery influenced by the low-angle excitation pulses). after this, the next phase-encoding line is prepared, the inversion pulse set, and again the whole partition loop executed. the amount of signal within each partition is identical for all phase-encoding steps and the k-space is again symmetric, resulting in artifact-free images. this technique has been introduced as magnetization prepared rapid acquired gradient-echoes (mp-rage, mulger and brookeman 1990) (fig. 2.4 .48). figure 2 .4.49 shows as a typical application of the mp-rage sequence showing the medial-sagittal t1-weighted slice out of 64 of an examination covering the entire skull in less than 5 min. the sequence had some promise to replace the conventional t1-weighted spin-echo imaging of the brain, since it allows the gapless coverage of the whole brain in less than 6 min. but, it is a gradient-echo sequence. susceptibility gradients especially at the base of the skull will cause geometric distorted representation of the anatomy or even signal voids. another disturbing effect is the appearance of contrast enhancement in active lesions. due to the commonly "squishy" content of lesions, the appearphase-encoding gradient activated during readout period. such a technique would be called fid-epi, since signal sampling is done during free induction decay. another variant is placing the gradient-echoes under an se envelope (fig. 2.4.51 ). in this case the central k-space contains a t2 contrast, in opposition to the t2* contrast of the fid-epi version. the se-epi sequence shows a lower sensitivity for susceptibility gradients. fig. 2.4 .51 shows a se-epi with an alternative approach to phase encoding. in this example, phase encoding is done using gradient "blips" during the ramping time of the frequency-encoding gradient. such a technique is called blipped epi. after an excitation pulse, multiple gres are generated using an oscillating frequency-encoding gradient. in this example the phase encoding is achieved with a low-amplitude, constant phase-encoding gradient throughout the measurement rf fig. 2.4 .51 se-epi sequence. after an excitation and refocusing-pulse, multiple gres are generated using an oscillating frequency-encoding gradient. the phase encoding is achieved in this sequence using small gradient pulses (blips) during ramping of the frequency-encoding gradient ance is usually isoto hypointense in t1-weighted imaging. mp-rage allows better control over t1 weighting, potentially causing the lesion to be more hypointense as compared with se imaging. in conjunction with contrast uptake, lesions will show up hyperintense on t1-weighted se imaging. they may or may not show up hyperintense on mp-rage imaging. the appearance has been reported to be inconsistent, likely to be due to the better t1weighting (a hypointense lesion may show up isointense after contrast uptake). the rapid acquisition of a gradient-echo or steady state sequence following an inversion is sometimes referred to as single-shot technique. this is not quite correct since as many low angle excitation pulses are applied as fourier lines are needed to fill the k-space. but the singleshot nomenclature allows a differentiation compared to the segmented, or multi-phase, imaging of the beating heart. similar to the stir approach used in fat signalsuppressed imaging, the inversion pulse prior to a singleshot technique enables the nulling of signal for a specific tissue (depending on the t1 relaxation time). the turboflash technique is used to study the firstpass of a contrast bolus through the cardiac chamber, showing a delayed enhancement in perfusion restricted ischemic myocardium. the inversion time is adjusted, so that normal myocardium will give no signal. in the early phase normal myocardium will be perfused with the t1-shortening contrast agent, whereas the perfusion restricted ischemic myocardium will remain hypointense. the same method of tissue signal nulling can be applied to the truefisp. this technique has been used to demonstrate the late enhancement of infarcted myocardium. an advantage for the truefisp versus turboflash is that the additional signal contributions due to refocusing and balancing (spin-echo components), allowing a higher bandwidth acquisition correlated with a shorter te, a shorter tr, and therefore a shorter measurement time (~450 ms). in addition, the truefisp has a significant lower sensitivity to flow and motion artifacts as compared to the turboflash, leading to (almost) artifact-free images. both methods are currently evaluated regarding their value in characterizing myocardial viability. the single-shot gradient-echo imaging is echo planar imaging (epi). similar to tse imaging, epi makes use of several phase-encoded echoes to fill the raw data matrix (fig. 2.4.50 ). there are multiple ways to acquire the data. a single excitation can be utilized, followed by multiple phase-encoded gradient-echoes with a small, constant addressing a different way of k-space sampling, both, the frequency-encoding" gradient and the "phase-encoding" gradient may oscillate, causing a spiral trajectory through k-space. such a method is known as spiral epi. the quotation marks are used to indicate that the magnetic field gradients do no longer have the apparent meaning of frequency and phase encoding. the high sensitivity of epi to local field inhomogeneities is utilized in (brain) perfusion imaging and for monitoring the oxygen level to identify cortical activation in bold (blood oxygenation level-dependent) imaging. in spite of many limitations, the epi sequences have attained high clinical potential in functional imaging and in perfusion studies. the preparation of the longitudinal magnetization is not only possible with the previously described multi-shot techniques, but also with the single-shot version. single shot, per definition, means one excitation pulse and multiple phase-encoded gradient-echoes for sampling of all fourier lines. the primary preparation scheme for singleshot gradient-echo imaging is diffusion weighting. any magnetic field gradient in the presence of a transverse magnetization will cause the larmor frequency to be a function of location. sometimes this effect is desired, as in any phase encoding, and sometimes it is a byproduct of another desired functionality, e.g. the frequency encoding. to rephase or refocus the dephased transverse magnetization, a magnetic field gradient of opposite polarity can be used prior to the frequency-encoding gradient. but, this will only work if the transverse magnetization does not change the position in the meantime, as is the case for diffusion. if the transverse magnetization changed positions, then the phase history will be different as compared with stationary tissue at that new location, and the rephasing will be insufficient. insufficient rephasing will result in a reduced signal. the signal drop is characterized by with b being a system or method specific parameter, and d being the diffusion coefficient for the tissue. the method specific parameter b is a function of the gradient amplitude g used, the duration δ for each amplitude and the temporal distance ∆ between the two gradient amplitudes. ∆ is also called the diffusion time. a typical value for b = 1,000 s/mm 2 . a sequence illustration is given in fig. 2 .4.53. the result of the application of such a technique to a patient with an acute infarction is shown in fig. 2 .4.54. diffusion-weighted imaging allows an evaluation of the extent of cerebral ischemia in a period where possible interventions could limit or prevent further brain injury. the diffusion anisotropy potentially measured with this method allows the mapping of neuronal connectivity and offers an exciting perspective to brain research. the turbo gradient spin-echo sequence (tgse), also called gradient and spin-echo (grase) is a combination of multiple gradient-echoes that are acquired within multiple se envelopes of a tse sequence, as shown in fig. 2 .4.55. this method holds several advantages in comparison to the "simple" tse sequence: the use of several phase-encoded gradient-echoes has the potential of further shortening measurement time. figure 2 .4.56 shows a transversal t2-weighted head image with a matrix size of 1,024, which has been measured with a tgse sequence in 2.56 min. another advantage is the fact that with the use of several gradient-echoes per spin-echo envelope, the gap between the refocusing pulses widens. therefore, the j-coupling remains intact. fat appears darker, and the contrast approaches the contrast of conventional se sequences. further, the enhanced sensitivity toward the susceptibility gradients that has been introduced with the gradient-echoes allows for a better depiction of blooddecay products, similar to conventional se-imaging. clinical mr systems come in various types and shapes; however, the fundamental components of a clinical mr tomograph are essentially the same. these are: • the magnet: the magnet creates a static and homogeneous magnetic field b0, which is needed to establish a longitudinal magnetization. • the gradients: the gradient coils generate additional linearly ascending magnetic fields that can be switched on and off. the gradient fields allow assigning a spatial location to the received mr signals (spatial encoding). for an image acquisition three independent gradient systems in x-, y-, and z-direction are required. • the radio frequency (rf) system: to rotate the longitudinal magnetization from its equilibrium orientation along b0 into the transverse plane, an oscillating magnetic field b1 is required. this rf field is generated by a transmitter and coupled into the patient via an antenna, the rf coil. radio frequency coils are also used to receive the weak induced mr signals from the patient, which are then amplified and digitized. • the computer system: measurement setup and image post-processing are performed by (distributed) computers that are controlled by a host computer. at this host computer, new measurements are planned and started and the reconstructed images are stored and analyzed. a schematic of the components of a clinical mr system is shown in fig. 2 .5.1; more detailed descriptions can be found in the works of oppelt (2005) , vlaardingerbroek et al. (2002), and chen and hoult (1989) . in the upper part, a cross-section through a superconducting magnet can be seen, with field-generating magnet windings embedded in a cryostatic tank. closer to the patient, the gradient coil and the whole-body rf coil are located outside the cryostat. the magnet is surrounded by an electrically conducting cabin (faraday cage) which is needed to optimally detect the weak mr signals, without rf background from other rf sources (e.g., radio transmitters). in the lower part, the computing architecture and the hardware control cabinets are shown. a hardware computer controls the gradient amplifier, the rf transmitter, and the receiver. the received and digitized mr signals are passed on to an image-reconstruction computer, which finally transfers the reconstructed image data sets to the host computer for display and storage. to generate the main magnetic field three different types of magnets can be utilized: permanent magnets, resistive magnets, and superconducting magnets (oppelt 2005; vlaardingerbroek 2002; chen 1989) . the choice of an individual magnet type is determined by the requirements on the magnetic field. important characteristics are the field strength b0, spatial field homogeneity, temporal field stability, patient accessibility, as well as construction and servicing costs. as outlined in sect. 2.2 a high magnetic induction is desirable as the mr signal s is approximately proportional to b0², and the signal-to-noise ratio (snr) increases approximately linearly with b0. it is thus expected that with increasing field strength the measurement time can be substantially decreased. the field strength is limited however for the following reasons: • for tissues in typical magnetic fields of 0.5 t and higher, the longitudinal relaxation time t1 increases with field strength. if the same pulse sequence with identical measurement parameters (tr, te, etc.) would be used at low field and high field, the t1 contrast would be less pronounced in the high-field image, since image contrast typically depends on the ratio of tr over t1. to achieve a similar t1 contrast with a conventional se or gre pulse sequence, tr (and thus the total measurement time) needs to be increased. • the resonance frequency ω0 increases linearly with field strength according to ω0 = γ b0. at higher frequencies the wavelength of the rf waves are of the order of or even smaller than the dimensions of the objects to be imaged. under these circumstances, standing waves can be created in the human body, which manifests in areas of higher rf fields (hot spots) and neighboring areas of reduced rf intensity. these unwanted rf inhomogeneities are difficult to control, as they are dependent on the geometry and the electric properties of the imaged object. • the power that is deposited in the tissue during rf excitation rises quadratically with ω0 (and thus with b0). to ensure patient safety at all times during the imaging procedure the specific absorption rate (sar), i.e., the amount of rf power deposited per kilogram of body weight, is monitored and limited by the mr system. with increasing field strength, the rf power generated by a pulse sequence increases, and thus the flip angle needs to be lowered to stay within the guidelines of sar monitoring. since most pulse sequences require certain flip angles (e.g., a 90-180° pulse pair for an se), the rf pulses need to be lengthened at higher field strength to reduce the rf power per pulse. additionally, the time-averaged power can be lowered by increasing the tr. • at field strengths above 1 t, only superconducting magnets are used for whole-body imaging systems. these magnets become very heavy and expensive. a typical 1.5-t mr magnet weighs about 6 t, whereas a 3-t magnet already has a weight of about 12 t. shielding of the stray fields, which is, e.g., necessary to avoid (1) that is filled with liquid helium. the cryotank also houses the primary magnet coils (4) together with the shielding coils (2) that create the magnetic field. the cryotank is embedded in a vacuum tank (3). in a separate tubular structure in the magnet bore, the gradient coil (5) and the rf body coil (6) are mounted. an mr measurement is initiated by the user from the host computer. the timing of the sequence is monitored by the hardware computer, which controls (among others) the rf transmitter, rf receiver, and the gradient system. during the measurement, the rf pulses generated by the transmitter are applied (typically) via the integrated body coil, whereas signal reception is done with multiple receive coils. the digitized mr signals are reconstructed at the image-reconstruction computer, which finally sends the image data to the host for further post-processing and storage interference with cardiac pacemakers, becomes increasingly difficult. • the absolute differences in resonance frequency between chemical substances increase with field strength. this effect is beneficial for high-resolution spectroscopy, as high field strengths allow separating the individual resonance lines. during imaging, however, a substantially increased chemical shift artifact (i.e., a geometric shift of the fatty tissues versus the water-containing tissues) is seen, which can only be compensated using higher readout bandwidths. • differences in magnetic susceptibility between neighboring tissues create a static field gradient at the tissue boundaries. the strength of these unwanted intrinsic field gradients scales with b0. therefore, increasingly higher imaging gradients are required at higher field strength to encode the imaging signal without geometric distortion; however, gradient strengths are technically limited. on the other hand, in neurofunctional mri (fmri) the increased sensitivity at higher field strengths is utilized to visualize those brain areas where local susceptibility differences in the blood are modulated during task performance. in the clinical environment, magnetic field strengths between 0.2 and 3 t are common. low-field mr systems (b0 < 1 t) are often used for orthopedic or interventional mri, where the access to the patient during the imaging procedure is important. high field strengths between 1 t and 3 t are used for all other diagnostic imaging applications. recently, whole body mr systems with field strengths up to 9.4 t have been realized (robitaille et al. 1999) . with these systems, in particular neurofunctional studies, high-resolution imaging and spectroscopy as well as non-proton imaging (e.g., for molecular imaging) are planned, since these applications are expected to profit most from the high static magnetic field. in the following, the three different types of magnet are described that are used to create the static magnetic field. permanent mri magnets are typically constructed of the magnetic material ndbfe. permanent magnet materials are characterized by the hysteresis curve, which describes the non-linear response of the material to an external magnetic field. if an external field is slowly increased, the magnetization of the material will also increase until all magnetic domains in the material are aligned-at this point the magnet is saturated, and no further amplification of the external field is possible. if the external field is then switched off a constant, non-vanishing magnetic field remains in the material because some of the domains remain aligned. permanent magnets offer very high remanence field strength. permanent magnets require nearly no maintenance because they provide the magnetic field directly without any electrical components. permanent magnets often use a design with two poles, which are either above or below (fig. 2.5.2) or at the sides of the imaging volume. within this volume the magnetic field lines should be as parallel as possible (high field homogeneity), which is achieved by shaping of the pole shoes. due to their construction, the magnetic field is typically orthogonal to the patient axis, whereas high-field superconductors use solenoid magnets with a parallel field orientation. magnetic field lines are always closed; therefore, an iron yoke is used in permanent magnets to guide the magnetic flux between the pole shoes. with increasing field strength permanent magnets become very heavy (10 t and more), and the high price of the material ndbfe becomes a limiting factor. additionally, to achieve high temporal field stability the material requires a constant room temperature, which should not vary by more than 1 k. for these reasons, permanent magnets are typically used only for field strengths below 0.3 t. if an electrical current is flowing through a conductor, a magnetic field is created perpendicular to the flow direction that is proportional to the current amplitude. unfortunately, in conventional conductors (e.g., copper wire) the electric resistance converts most of the electric energy into unwanted thermal energy and not into a magnetic field. therefore, a permanent current supply is required to maintain the magnetic field and to compensate for the ohmic losses in the wire. additionally, to dissipate the thermal energy resistive magnets need permanent water cooling as their power consumption reaches several 100 kw. resistive magnets use iron yokes to amplify and guide the magnetic field created by the electric currents. the iron yoke is surrounded by the current-bearing wires so that the field lines stay within the iron. in the simplest form, the closed iron yoke has a gap at the imaging location and the magnet takes the form of a c-arc, which can also be rotated by 90° to provide a good access for the patient (fig. 2.5.3 ). other magnet designs use two or four iron posts that connect the pole shoes. the magnetic field of a resistive magnet is typically not as homogeneous as that of a superconducting magnet of the same size. to achieve high field homogeneity within the imaging field-of-view, the diameter of the pole shoes should not be less than 2.5 times the desired diameter of the imaging volume (dfov), and the pole separation should be more than 1.5 dfov. at a typical pole separation of 45 cm, the imaging volume would thus have a diameter of 30 cm, and the pole shoe diameter amounts to 75 cm. resistive magnets are susceptible to field variations caused by instabilities of the electric power supply. to minimize this effect the magnetic field of the magnet can be stabilized using an independent method to measure the field strength (e.g., electron spin resonance). the difference between actual and desired field strength is then used to regulate the current in the magnet in a closed feedback loop. to create magnetic fields of more than 0.3 t with a bore size of 60 cm or more, today, typically superconducting magnets are utilized (fig. 2.5.4) . in principle, these magnets operate in a similar fashion as resistive magnets without iron yoke-superconducting magnets also generate their magnetic field by wire loops that carry a current. instead of copper wire, superconductors use special metallic alloys such as niobium-titanium (nbti). the alloys completely lose their electric resistance below a certain transition temperature that is characteristic for the material; this effect is called superconductivity. the transition temperature itself is a function of the magnetic field, so that lower temperatures are required when a current is flowing through the wire. unfortunately, an upper limit for the current density in the wire exists, which is also a function of the temperature and the magnetic field. to maintain the required low temperatures cooling with liquid helium is typically necessary (t < -270°c). the imaging volume of the mr system is typically kept at room temperature (t = 20°c), whereas the surrounding superconducting wires require temperatures near the absolute zero (-273.15°c). to maintain this enormous temperature gradient, the field-generating superconducting coils are encased in an isolating tank, the cryostat. the cryostat is a non-magnetic steel structure that contains radiation shields to prevent heat diffusion, heat conduction, and heat transport. if this isolation is not working properly and the wire is locally warming up over the transition temperature, then this section of the wire will become normally conducting, and the energy stored in the current will be dissipated as heat. the heat will then be transported to adjacent sections of the wire, which will also lose their superconductivity. this very rapid process is called a quench. when the magnet wire is heating up the liquid helium will evaporate, and the cryofig. 2.5.3 iron-frame electromagnet 0.6-t mr system (upright tm mri, fonar) with a horizontal magnetic field. this special construction of the mr systems allows for imaging in both upright and lying positions. this flexibility is especially advantageous for mr imaging of the musculoskeletal system 2.5 technical components stat is exposed to an enormous pressure. to prevent the cryostat from exploding, a so-called quench tube is connected to superconducting magnets with helium cooling, which safely guides the cold helium vapor out of the magnet room. recently also ceramic superconducting materials on the basis of niobium-tin (nb3sn) alloys have been used to make superconducting wires. the brittle nb3sn alloys show a higher transition temperature (-263°c) and thus do not necessarily require liquid helium cooling. if the cryostat is equipped with a good thermal vacuum isolation, a conventional cooling system (e.g., gifford-mc-mahon cooler) can be used to maintain the temperature. this technology has been realized both in a dual-magnet system (general electric sp, b0 = 0.5 t) and a low-field open mr system (toshiba opart, b0 = 0.35 t). because a helium-filled cryostat requires more space than does a system without helium, these magnets can be installed in smaller areas than can comparable magnets with helium. in the recent years, several mr magnets have been equipped with helium liquefiers to regain the evaporated helium gas in the magnet. once filled with helium these so-called zero boil-off magnets can operate in principle without any additional helium filling. magnets without helium liquefiers require replenishment of the helium at intervals between several months and 1-2 years, depending on the quality of the cryostat and the usage of the mr system. the most widespread form of a superconducting magnet is the solenoid, where the windings of the superconducting wire form loops around the horizontal bore of the cylindrical magnet. at a typical inner bore diameter of 60 cm for clinical mri systems, solenoid magnets can create very homogeneous magnetic fields with varia-tions of only a few parts per million (ppm). because the relatively bulky magnet structure limits access to the patient, shorter magnets of 1.5 m length with wider diameters of 70 cm have been designed (siemens magnetom espree, b0 = 1.5 t) (fig. 2.5 .5). in these magnets, obese patients can be imaged more conveniently, claustrophobic patients feel more at ease and some mr-guided percutaneous interventions might become feasible. another variant of the solenoid is a dual magnet mr system consisting of two collinear short solenoid magnets (general electric sp, b0 = 0.5 t) here the imaging area is located in between the two magnets and even intra-operative mr imaging is possible. recently, also two-pole systems with a magnet design similar to low-field resistive magnets have become, which offer a good patient access in combination with higher field strengths ( fig. 2.5.6) . outside a superconducting magnet, the field strength his falling off with the inverse third power of the distance (1/r ³) so that the stray fields can extend far outside the mr room. magnetic fields in commonly accessible areas must not exceed 0.5 mt, because higher fields can affect pace makers and other active electric devices (fig. 2.5.7) . for this reason, two shielding technologies have been utilized to reduce the magnetic fringe fields. with passive shielding ferromagnetic materials such as steel are mounted near the magnet. this shielding technique confines the field lines to the interior of the shielding material, and the stray fields are reduced. unfortunately, the amount of shielding material rapidly increases with increasing magnetic field, and between 400 t and 600 t of steel are required to shield a 7-t magnet (schmitt et al. 1998) . with active shielding a second set of wire loops is integrated in the cryostat of the magnet. the shielding fig. 2.5.4 conventional 1.5-t superconducting mr magnet (magnetom symphony, siemens) with a magnet length of 160 cm and a free open-inner bore diameter of 60 cm. the system is equipped with an in-room monitor (left), which allows controlling the mr system from within the rf cabin coils create a magnetic field in the opposite direction of the imaging field so that the stray field falls off more rapidly. the shielding coils have a larger diameter than do the field-generating primary coils. thus, the desired magnetic field within the magnet can be maintained by increasing the current in both coil systems. additionally, the shielding coils and the primary coils repel each other (lorentz forces), which requires a magnet design with more stable coil formers. the attractive forces acting on paramagnetic or ferromagnetic objects near such an actively shielded magnet are significantly higher than near an unshielded magnet; device compatibility and safety should thus always be specified with regard to the investigated magnet type. and an open-bore diameter of 70 cm. the additional 10 cm in bore diameter over conventional mr system with solenoid magnets and the shorter magnet length offer a better access to the patient, so that, e.g., percutaneous interventions can be performed in this magnet structure to localize the mr signals emitted by the imaging object, a linearly increasing magnetic field, the gradient g, is superimposed on the static magnetic field b0. the gradient fields are created by gradient coils that are located between the magnet and the imaging volume (schmitt et al. 1998 ). for each spatial direction (x, y, and z) a separate gradient coil is required, and angulated gradient fields are realized by linear superposition of the physical gradient fields. in a cylindrical bore superconducting magnet, the gradient coils are mounted on a cylindrical structure, which is often made of epoxy resin. this gradient tube reduces the available space in the cryostat from typically 90 cm, without gradient coils, to 60 cm, with gradient coils. the functional principle of a gradient system is best illustrated by a setup of two coaxial wire loops with a radius a that are separated by a distance d (fig. 2.5.8 ). if the two coils both carry the same current, however, in counterpropagating directions, their respective magnetic fields cancel at the iso-center of the setup. at distances not too far from iso-center the magnetic field will increase linearly, which is exactly the desired behavior of a gradient field. to achieve this linear gradient field the condition d = 3a must be met (maxwell coil pair) (jin 1999) . in commercially available gradient system, much more complicated wiring paths are utilized, which are optimized using the so-called target field approach (turner 1993). this often results in wire patterns that, when plotted on a sheet of paper, resemble fingerprints (fingerprint design). nevertheless, a common feature of all gradient systems is the absence of current at the cen-tral plane, which allows separating the gradient coils, e.g., for c-arc-type magnets. the quality of the gradient system is characterized by several parameters: the maximum gradient strength gmax, the slew rate smax, the homogeneity, the duty cycle, the type of shielding, and gradient pulse stability and precision. today, clinical mr systems have maximum gradient strengths of up to gmax = 40 mt/m at bore diameters of 60 cm. even higher gradient strengths of 80 mt/m and more can be realized when so-called gradient inserts with smaller diameters are used (e.g., for head imaging). the maximum gradient strength is limited by the capabilities of the power supply of the gradient system-modern gradient systems use power supplies that can deliver voltages up to 2,000 v and currents up to 500 a. another limiting factor for gmax is gradient heating: with increasing current through the gradient coil, the windings heat up to levels at which the gradient could be destroyed. therefore, to remove the heat from the gradient tube, pipes are integrated in the gradient coils for water-cooling. the maximum slew rate smax is the ratio of gmax over the shortest time required to switch on the gradient (rise time). when the current in the gradient coil is increased during gradient switching, according to lenz's law the coil will produce a current, which opposes the change. thus, it counteracts the switching process, and the rise time cannot be made infinitely short. during mr imaging, however, it is desirable to have very short rise times (i.e., high slew rates), as these times only prolong the imaging process. clinical mri systems have slew rates between 10 mt/m/ms and 200 mt/m/ms. if the gradient coil is connected to a capacitance via a fast switch, very short rise times can be achieved, as the inductance of the gradient coil and the capacitance form a resonance circuit. such a resonant gradient system has the disadvantage that the characteristic frequency of the resonance circuit determines the possible rise times. additionally, gradients can only be switched on after the capacitances have been charged. resonant gradient systems have nevertheless been successfully applied to epi studies, in which the sinusoidal gradient waveforms are beneficial, and multistage resonant systems have been utilized to approximate the trapezoidal gradient waveforms (harvey 1994) . when the gradient is switched on, the maximal rate of field change is observed at the ends of the gradient coil (i.e., fovmax/2): db/dt = smax fovmax/2. a changing magnetic field induces currents in electrically conducting structures in its vicinity-outside the gradient coil this structure is given by the cryostat, and on the inside the patient can act as a conductor. to avoid these parasitic currents (eddy currents) in the cryostat, which in turn create magnetic fields counteracting the gradients, often a second outer gradient structure is integrated in the gradient tube. the inner and outer gradient coils are designed so that their combined gradient field vanishes everywhere outside the gradient coil, whereas the desired gradient amplitudes are realized on the inside. this technique is called active shielding, and is conceptionally similar to the active shielding of superconducting magnets (mansfield and chapman 1986; harvey 1994) . gradient-induced currents in the human body pose a more severe problem, as these currents can potentially lead to painful peripheral nerve stimulation or, at higher amplitudes, to cardiac stimulation (mansfield and harvey 1994; schaefer 1998; liu et al. 2003) . these physiologic effects are not only dependent on the amplitude, but also on the frequency of field change. for clinical mr systems, different theoretical models have been established to determine the threshold for peripheral nerve stimulation. to make the best use of the available gradient system some fast pulse sequences (e.g., for contrast-enhanced mra or epi) operate very close to these threshold values. as individuals are more or less susceptible to peripheral nerve stimulation, for some patients the individual threshold might be exceeded, and they experience a tickling sensation during fast mr imaging. this physiologic effect currently prohibits the use of stronger gradient systems. since the field change is lower at shorter distances from iso-center, peripheral nerve stimulation can be avoided if shorter gradient systems are used. unfortunately, a shorter gradient system only covers a limited fov, and the anatomical coverage is compromised. to overcome this limitation a combined gradient system with a shorter, more powerful inner coil and a longer, less intense outer coil has been proposed (twin gradients) (harvey 1999 ). such a system can be used, e.g., to rapidly image the beat-ing heart with the small coil, or to acquire image data from the surrounding anatomy at lower frame rates. when the gradient system is mounted in the mr magnet, strong mechanical forces act on the gradient tube, which are proportional to the gradient current. these forces are generated by the interaction of the gradient field with the static magnetic field and thus increase with b0. the permanent gradient switching creates time-varying forces that lead to acoustic noise. several techniques have been proposed to reduce noise generation, which in some cases can exceed dangerous sound pressure levels of 110 db. the wire paths in the coil can be designed in such a way that the forces are locally balanced, the gradient tube can be mechanically stabilized, the gradients can be integrated in a vacuum chamber to prevent sound propagation in air, or the gradient system can be mounted externally to reduce acoustic coupling to the cryostat (pianissimo gradient, toshiba). another possibility to reduce acoustic noise is to limit the slew rates in the pulse sequences to lower values than technically possible; in some pulse sequences (e.g., spin-echo sequences), this does not significantly affect the pulse sequence performance, but severely increase patient comfort. shimming is a procedure to make the static magnetic field in the mr system as homogeneous as possible. inhomogeneities of the magnetic field that are caused during the manufacturing of the magnet structure can be compensated with small magnetic plates (passive shim). after a localized measurement of the initial magnetic field, the position of the plates is calculated, and the plates are placed in the magnet. this procedure is repeated until the desired homogeneity of the field is achieved (e.g., 0.5 ppm in a sphere of radius 15 cm). during mr imaging, objects are present in the static magnetic field that distort the homogeneous static field. field distortion is caused by susceptibility differences at the tissue interfaces and is thus specific for each patient. to at least locally compensate these field distortions, adjustable magnetic fields are required (active shim). if the field distortion is linear in space, then the gradient coils can be used for compensation. for higher-order field variations, additional shim coils are required. typically, shim coils up to fifth order are present in an mr system. higher-order shimming is particularly important for mr spectroscopy, where the field homogeneity directly affects the spectral line width. to optimize the shim currents, an interactive measurement process (the shim) is started after the patient is positioned in the magnet. during active shimming the field homogeneity is measured (e.g., using localized mr spectroscopy or a field mapping technique), and the currents are then adjusted to improve the field homogeneity (webb and macovski 1991). the radiofrequency (rf) system of an mr scanner is used to both create the transverse magnetization via resonant excitation and to acquire the mr signals (oppelt 2005; vlaardingerbroek et al. 2002; chen and hoult 1989 ). the rf system consists of a transmit chain and a receive chain. in the following, the details of the rf system are described. the mr signals, which are acquired by the rf coils of the mr system, are typically very low. to optimally detect these low signals, any other electromagnetic signals (e.g., radio waves) must be suppressed. therefore, the mr system is placed in a radiofrequency cabin (also called a faraday cage), which dampens rf signals at the resonance frequency by typically 100 db and more. in low-field mr tomographs, the rf screening is sometimes realized as a wire mesh that is integrated in the mr system. this has the advantage that rf-emitting equipment such as television screens can be placed very close to the mr unit. at larger magnet dimensions, these local screens are often not suitable. here, the whole mr room is designed as an rf cabin, and the screening material is integrated into the walls, doors, and windows. for screening often copper sheets are used, which are glued to the wall panels, or the cabin consists completely of steel plates. to be able to transmit signals to and receive signals from the rf cabin, openings are integrated in the cabin. in general, one distinguishes between so-called filter plates, which contain electronic filters and open waveguides. waveguides are realized as open tubes with a certain length-to-diameter ratio, which is dependent on the wavelength of the rf frequency. waveguides are used to deliver anesthesia gases to the rf cabin and to guide the quench tube out of the shielded room. at the beginning of the transmit chain the rf transmitter is found, which consists of a synthesizer with highfrequency stability and an rf power amplifier. the lowpower synthesizer oscillates at the larmor frequency. its output signal is modulated by a digitally controlled pulse shaper to form the rf pulse, which is then amplified by the power amplifier. for typical clinical mr systems, the transmitter needs to provide peak power output at the larmor frequency of 10 kw and more. besides high peak power, the rf transmitter should also allow for a high time-averaged power output, as several pulse sequences such as fast spin-echo sequences require rf pulses at short repetition times. the rf power is then transferred into the rf cabin via a shielded cable, and is delivered to the transmit rf coil. to guarantee a safe operation of the transmitter and to limit the rf power to values below the regulatory constraints for the specific absorption rates (sar), directional couplers are integrated in the transmission line. these couplers measure the rf power sent to the rf coil as well as the reflected power. high power reflection is an indicator of a malfunctioning of the connected coil, which could endanger the patient. if the reflected power exceeds a given threshold (e.g., 20% of the forward power), then the rf amplifier could be damaged by the reflected rf power and the transmitter is switched off. to couple the rf power of the rf transmitter to the human body an rf antenna is required, the so-called rf coil. before mr imaging starts, the coil is tuned to the resonance frequency of the mr system (rf tuning). simultaneously, the properties of the connecting circuitry are dynamically changed to match the resistance of the coil with the imaging object (loaded coil) to the resistance of the transmit cable (rf matching). once the coil is tuned and matched, the transmitter is adjusted. during this procedure, the mr system determines the transmitter voltage required to create a certain flip angle. for a given reference rf pulse shape sref (t), the transmitter voltage uref is varied until the desired flip angle αref (e.g., 90°) is realized. during the subsequent imaging experiments, use is made of the fact that the flip angle is linearly proportional to the (known) integral over the rf pulse shape, so that the required voltages can be computed from the reference values by linear scaling. radiofrequency coils are categorized into transmit (tx) coils, receive (rx) coils, and transmit/receive (txrx) coils. tx coils are only used to expose the imaging object to an rf b1 field during rf excitation, whereas rx coils detect the weak echo signal emitted from the human body-only if a coil performs both tasks, is it called a txrx coil. a typical example of a txrx coil is the body coil integrated into most superconducting mr systems; however, in some modern mr systems, it is used as a tx coil only due to its suboptimal receive characteristics. rx-only rf coils are the typical local coils found in mr systems that possess a (global) body coil, and local txrx coils are used in all other mr systems without a body coil (ultra-high field, dedicated interventional systems, openconfiguration low field). during signal reception, the oscillating magnetization in the human body induces a voltage in the rf coil. for an optimal detection of this weak signal, the rf coil should be placed as close to the imaging volume as possible. for this reason, optimized imaging coils exist for nearly any part of the human body. the largest coil of an mr system is typically the body coil (if present), which is often integrated in the magnet cover. to image the head or the knee, smaller volume resonators are used, where the imaging volume is in the interior of the rf coil ( fig. 2.5.9 ). flexible coils exist, that can be wrapped around the imaging volume (e.g., the shoulder). small circular surface coils are used to image structures close to the body surface (e.g., eyes). unfortunately, the sensitivity of these coils is rapidly decreasing with distance from the coil center, so that they are not suitable for imaging experiments, where a larger volume needs to be covered. during rf transmission, rx coils need to be deactivated, because a tuned and matched rx coil would ideally absorb the transmitted rf power, and a significant amount of the rf energy would be deposited in the coil. to avoid any electronic damages, the coil is actively de-tuned during rf transmission; this is often accomplished by fast electronic switches (e.g., pin diodes), which connect a dedicated detuning circuitry. to combine the high sensitivity of small surface coils with the volume coverage of a large volume resonator, the concept of the so-called phased-array coils has been introduced (roemer et al. 1990) . a phased-array coil consists of several small coil elements, which are directly connected to individual receiver channels of the mr system. the separate reconstruction of the coil elements is technically demanding, because a full set of receiver electronics (amplifiers, analog-to-digital converters) as well as an individual image reconstruction are required for each coil element. the signals of the individual coil elements are finally combined using a sum-of-squares algorithm, which yields a noise-optimal signal combination. under certain conditions when snr can be sacrificed, also a suboptimal image reconstruction can be achieved by a direct combination of the coil element signals, which reduces the number of receive channels and shortens the image reconstruction time. to be able to manually adjust snr versus reconstruction overhead, special electronic mixing circuits have been introduced which allow combining, e.g., three coil elements into a primary, a secondary, and a tertiary signal (total imaging matrix tim, siemens). in a phased-array coil, the coil elements are positioned in such a way that an induced voltage in one element does not couple to the adjacent element-this can be achieved by an overlapping arrangement of the coil elements (geometric decoupling). phased-array coils with up to 128 elements have been realized; however, typically the number of elements ranges between 4 and 32. today, mri systems with 32 independent receiver channels are available, at which up to 76 coil elements can be positioned simultaneously. the individual coil elements can be selected manually or automatically to achieve the highest possible snr for a given imaging location. phased-array coils are not only required to achieve a high snr. the individual coil elements can also be used to partially encode the spatial location in the image; this procedure is called parallel imaging. the simplest version of parallel imaging uses two adjacent coil elements with non-overlapping sensitivities. if one wants to image the full fov covered by both coils only fov/2 needs to be encoded, since each coil element is sensitive over this distance only. if the phase-encoding direction is chosen in this direction, the phase fov can be reduced by a factor of 2, which in turn halves the total acquisition time. in practice, the sensitivity profiles of the coil elements overlap and more sophisticated techniques such as smash sodickson and manning 1997) or sense (dumooulin et al. 1993 ) are required to reconstruct the image. nevertheless, in parallel imaging the intrinsic spatial encoding present in the different locations of the imaging coils is exploited to reduce the number of phase encoding steps. various receive coils on the patient table of a clinical 1.5-t mr system (magnetom avanto, siemens) with 32 receive channels and the possibility to connect a total of 76 coil elements. the head coil with 12 coil elements is combined with a neck coil (4 elements), and the remaining parts of the anatomy are imaged with multiple flexible anterior phased-array coils (2 × 3 elements) and the corresponding posterior coils, which are integrated in the patient table. for smaller imaging volumes dedicated surface coils (flexible coil, open loop coil, small loop coil) can be used, which share a common amplifier interface because the phase encoding direction is different for different slice orientations, the optimal phased-array coil for parallel imaging offers coil elements with separated sensitivity profiles in all directions. for mr spectroscopy and non-proton imaging, rf coils with resonance frequencies for the respective nuclei are required. these non-proton coils can also incorporate a coil at the proton resonance frequency to acquire proton images without the need for patient repositioning. double-resonant coils are also important in situations when both frequencies are used at the same time as, e.g., in decoupling experiments. for interventional mri, dedicated tracking coils have been developed that are attached to the interventional devices (e.g., catheters or needles). the signal from these coils can be used for high-resolution imaging (e.g., of the vessel wall), but it is often only utilized to determine the position of the device (doumoulin et al. 1993) . in these tracking experiments, the signal of the coil is encoded in a single direction using a non-selective rf excitation, and the position of the coil in this direction is extracted after a one-dimensional fourier transform. the mr signal received by the imaging coil is a weak, analog, high-frequency electric signal. to perform an image reconstruction or a spectral analysis, this signal must be amplified, digitized, and demodulated. the signal amplification is typically performed very close to the imaging coil to avoid signal interference from other signal sources. if the rf coil is a txrx coil, then the signal passes a transmit-receive switch that separates the transmit from the receive path. the amplified analog signal still contains the high-frequency component of the larmor frequency. to remove this unwanted frequency component, the signal is sent to a demodulator, which receives the information about the current larmor frequency from the synthesizer of the transmitter. after demodulation, the mr signal contains only the low-frequency information imposed by the gradients. finally, the analog voltage is converted into a digital signal using an analog-to-digital converter (adc). over the recent years the conversion into a digital signal has increasingly been performed at an earlier stage in the receiver chain (e.g., before demodulation), and all subsequent steps were carried out in the digital domain. at the end of the receiver chain, the digital signal is then handed over to the image reconstruction computer. the computing system of an mr tomograph is typically realized by a system of distributed computers that are connected by a local high-speed network. the requirements for the computing system are manifold: for the user of the system it should provide an intuitive interface for measurement control, image processing, archiving, and printing. during sequence execution, the computers should control the hardware (i.e., gradients, rf, adcs, patient monitoring, etc.) in real time. additionally, the computing system must reconstruct and visualize the incoming mr data. since a single computer cannot perform all of these tasks at the same time, typically three computers are used in an mr system: the host computer for interaction with the user, the hardware control computer for real-time sequence control, and the image reconstruction computer for high-speed data reconstruction. the host computer provides the interface between the user and the mr system. through the mr user interface, the whole mr system can be controlled, mr measurements can be started, and the patient monitoring is visualized. at the host computer, the incoming images are sorted into an internal database for viewing, post-processing, and archiving. the internal database stores and sorts the images by patients, studies, and series. the database is often connected to the picture archiving and communication system (pacs) of the hospital, from where it retrieves the patient information to maintain a unique patient registry. a 256 × 256 mr image typically requires about 130 kb of storage space, and for each patient investigation between 100 and 1,000 images are acquired. on an average working day between 10 and 30 patients can be examined. the data of all of these patients need to be stored in the database so that a storage volume of about 4 gb per day should be provided. with increasing matrix sizes and image acquisition rates, these numbers can easily be multiplied by factors of 10 and more. the host computer is also used to transfer the acquired data to archiving media such as magneto-optical disks (mod), tapes, compact disks (cd), digital versatile disks (dvd), or external computer archives (typically, the pacs). data transfer is increasingly accomplished using the image standard dicom (digital imaging and communications in medicine), which regulates not only the image data format, but also the transfer protocols. it is due to this imaging standard that images can be exchanged between systems from different vendors and can be shared between different modalities. for post-processing, typically different software packages are integrated. in mr spectroscopy, software packages for spectral post-processing are available to calculate, e.g., peak integrals automatically. for mr diffusion measurements, the apparent diffusion coefficient can be mapped. with flow-evaluation software, the flow velocities and flow volumes can be assessed. to visualize threedimensional data sets often multi-planar reformatting tools or projection techniques such as the maximum intensity projection (mip) are used. all of these software packages retrieve the image data from the integrated image database, into which the calculated images are finally stored. dedicated computer monitors are connected to the host computer for image visualization, which fulfill the special requirements for diagnostic imaging equipment. in addition, these screens must not be susceptible to distortions due to the magnetic field; for this reason liquid crystal monitors based on the thin-film transistor (tft) technology are increasingly used. for interventional mr, shielded monitors for in-room image display have been designed, where the monitor is shielded against electromagnetic interference. these monitors can be used within the faraday cage of the mr system without interfering with the image acquisition. the control of the imaging hardware (i.e., the gradients in x, y, and z, the rf sub-system, the receiver, and the patient-monitoring system) requires a computer with a real-time operating system. compared with conventional operating systems where the instructions are processed in an order and at a time that are influenced by many factors, a real-time operating system ensures that operations are executed on an exactly defined time scale. this real-time execution is necessary to maintain, e.g., the phase coherence during spin-echo mri or to ensure that a given steady state is established during balanced ssfp imaging. during sequence execution, the different instructions for the hardware are typically sent by the control program to digital signal processors (dsp) that control the individual units. thus, new instructions can be prepared by the control program, whereas the actual execution is controlled close to the individual hardware. to ensure that enough hardware instructions are available, many time steps are computed in advance during sequence execution. for real-time pulse sequences, this advance calculation needs to be minimized to be able to interactively change sequence parameters such as the slice position (controlled by the rf frequency) or orientation (controlled by the gradient rotation matrix). in real-time sequences, the information about the current imaging parameters is thus retrieved not only once at the beginning of the scan, but continuously during the whole imaging experiment. the reconstruction of the data arriving at the adcs is performed by the image-reconstruction computer. to estimate the amount of data this computer needs to process the following estimate can be used: during high-speed data acquisition about 256 raw data points (i.e., 256 × 16 bytes) arrive per imaging coil at time intervals of tr = 2 ms, so that with 10 rx coils a data rate of 20 mb/s results. these incoming data need to be rearranged, corrected, fourier transformed, combined, and geometrically distorted before the final image is sent to the host computer. to perform this task today multiprocessor cpus are used to perform some of these tasks in parallel. in particular, the image reconstruction for multiple coils lends itself naturally to parallelization, since each of the coils is independent of the other. additionally, some manufacturers are including simple post-processing steps into the standard image reconstruction. since the reconstruction computer does not provide a direct user interface, these reconstruction steps need to be designed in such a way that no user interaction is necessary. this is the case for the calculation of activation maps in fmri, for mip calculations under standard views in mr angiography, or for the calculation of the arrival time of a contrast agent bolus in perfusion studies. at the end of the image reconstruction, the image data are transferred to the host computer via the internal computer network. special mr imaging techniques require additional mr components that are not necessarily available at any mr scanner. these components often monitor certain physiologic signals such as the electrical activity of the heart (electrocardiogram, ecg) or breathing motion (fig. 2.5.10) . typically, the measured physiologic signals are not used to assess the health status of the patient but to synchronise the image acquisition with the organ motion, since heart and breathing motion can cause significant artifacts during abdominal imaging. synchronization of the image acquisition is performed either with prospective or retrospective gating. with prospective gating (or triggering), the imaging is started with the arrival of a certain physiologic signal (e.g., the r wave in the ecg). therefore, the physiologic signal is post-processed (e.g., thresholding and low-pass filtering) to create a trigger signal when the physiologic condition is present. with retrospective gating, the measurement is not interrupted, but data are acquired continuously, and for each measured data set, the physiologic state is stored with the data (e.g., the time duration after the last r wave). during image reconstruction, the measured data are sorted in such a way that images are formed from data with similar physiologic signals (e.g., diastolic measurements). the advantage of the retrospective over the prospective data acquisition is the continuous measurement without gaps that could lead to artifacts in steady state pulse sequences. the post-processing effort of retrospectively acquired data is higher because data need to be analyzed and sorted before image reconstruction. additionally, on average more data need to be acquired as compared to prospective triggering to ensure that for each physiologic condition at least one data set is present (over-sampling). to measure the ecg in the mr system mr-compatible electrodes made of silver-silver chloride (ag/agcl) are used. the measurement of the ecg in an mr system is difficult, because the switching of the gradients can induce voltages in the ecg cables that completely mask the ecg signal. this effect can be minimized, if short and loopless ecg cables are utilized. short ecg cables are additionally advantageous since long cables with a loose contact to the skin can be the cause for patient burns that are induced by the interaction with the rf field during rf excitation (kugel et al. 2003) . to reduce this potential danger to a minimum, ecg systems have been developed that amplify the ecg signal close to the electrodes, and which transmit the ecg signal to the mr system either via optical cables (felblinger et al. 1994) or as an rf signal at a frequency different from the larmor frequency. with this technology, ecg signals can be acquired even during echo planar imag-ing when gradients are permanently switched on and off (ives et al. 1993) . it should be noted that the ecg signal in the mr system significantly differs from the signal outside the magnet. the electrically conducting blood is flowing at different velocities in the cardiac cycle. within the magnetic field the blood flow induces velocity-dependent electric fields (hall effect) across the blood vessels, which in turn change the electric potentials measured at the ecg electrodes. typically, the t wave of the ecg is augmented, an effect that is more pronounced at higher field strengths (kangarlu and robitaille 2000) . for this reason, the ecg acquired in the mr system should not be regarded as of diagnostic quality. pulse oximeters measure the absorption of a red and an infrared light beam that is sent through perfused tissue (e.g., a finger). the absorption is proportional to the oxygen content, so that devices can determine the partial oxygen pressure (po2). additionally, the pulsation of the blood leads to a pulse-related variation of the transmitted light signal, which is used in the mr systems to derive a pulse-related trigger signal (shellock et al. 1992 ). since the pulse wave arrives at the periphery with a significant delay after the onset of systole, it is difficult to use the po2 signal for triggering in systolic mr imaging. pulse oximeters consist solely of non-magnetic and non-conduction optical elements, so that they are not susceptible to any interference with the gradient or rf activity. fig. 2.5.10 whole-body imaging with array coils covering the patient from head to toe (exelart vantage tm , toshiba). since not all coils are in the imaging volume of the mr system at the same time, a lower number of receiver channels (here: 32) are sufficient for signal reception 2.5 technical components to detect breathing motion, several mechanical devices such as breathing belts or cushions have been introduced. essentially, all these systems are air filled and change their internal pressure as a function of the breathing cycle when they are attached to the thorax of the patient. the pressure is continuously monitored and is used as an indicator for breathing status. as with the pulse oximeters, these systems are also free of any electrically conducting elements, so that no rf heating is expected. however, in clinical practice breathing triggering can pose a problem in long-lasting acquisitions since patients start to relax over time, and the initial breathing pattern is not reproduced. an alternative approach to the measurement of the breathing cycle is offered by the mr itself: if a single image line is excited in head-foot direction through the thorax (using, e.g., a 90° and 180° slice that intersect along the desired line), then the signal of this line has high contrast at the liver-lung interface. this diaphragm position can be detected automatically and can be used to extract the relative position in the breathing cycle. this technique is called a navigator echo (ehman and felmlee 1989) , since an additional echo for navigation needs to be inserted into the pulse sequence. similar approaches using lowresolution two-or three-dimensional imaging can be used to correct for patient motion in long-lasting image acquisitions such as fmri (welch et al. 2002) . here, the change in position is determined and used to realign the imaging slices (prospective motion correction). for neurofunctional studies, electroencephalogram (eeg) systems have been developed that can be operated in the mr tomography (muri et al. 1998) . compared with the ecg, the voltages induced during brain activity are about 100 times smaller in eeg recording, which poses a significant detection problem (goldman et al. 2000; sijbersa et al. 2000) . blood pulsation, patient motion, as well as induced voltages during gradient and rf activity can cause spurious signals in the eeg leads, which obscure the true eeg signal. to remove the imaging-related artifacts, dynamic filtering can be used, which removes all signal contributions associated with the basic frequencies of the mr system. a large variety of mr systems with different magnet types, coil configurations, and gradient sets is currently available for diagnostic and interventional mr imaging. to choose from these systems, the desired imaging applications as well as economic factors need to be considered: a small hospital might with few mr patients might want to use a low-field permanent magnet system with low maintenance cost, whereas a university hospital with a diverse patient clientele and high patient throughput should better offer a high-field mr system with state-ofthe-art gradient systems. physiologic monitoring and triggering units. the three electrodes of the ecg system as well as the tube of the breathing sensor are connected with a transceiver that transmits both signals to the patient monitoring unit of the mr system. the optical pulse sensor is attached to the finger, and the signals are guided via optical fibers to the detection unit. for increased patient safety the ecg system must be used together with a holder system (not shown here), which provides additional distance between the ecg leads and the patient body 12. 14. muri rm, felblinger j, rosler km, jung b, hess cw, boesch c (1998) during the pioneer period of mr imaging, expectations were that the high inherent contrast in mr imaging makes the use of contrast agents superfluous. however, increasing use of the modality in the clinical setting has revealed that a number of diagnostic questions require the application of a contrast agent. similar to other imaging modalities, the use of contrast agents in mr imaging aims at increasing sensitivity and specificity and, thereby, the diagnostic accuracy. the main contrast parameters in mr imaging are proton density, relaxation times, and magnetic susceptibility (ability of a material or substance to become magnetized by an external magnetic field). mr imaging contrast agents focus upon relaxation time and susceptibility changes. most of them are either paraor superparamagnetic. the most efficient elements for use as mr imaging contrast agents are gadolinium (gd), manganese (mn), dysprosium (dy), and iron (fe). the magnetic field produced by an electron is much stronger than that produced by a proton. however, in most substances the electrons are paired, resulting in a weak net magnetic field. gd with its seven unpaired electrons possesses the highest ability to alter the relaxation time of adjacent protons (relaxivity). for mr contrast agents, differentiation between positive and negative agents has to be made. paramagnetic contrast agents gd and mn have a similar effect on t1 and t2 and are classified as positive agents. since the t1 of tissues is much higher than the t2, the predominant effect of these contrast agents at low concentrations is that of t1 shortening. thus, tissues that take up gdor mn-based agents become bright in t1-weighted sequences. on the other hand, negative-contrast agents influence signal intensity by shortening t2 and t2*. superparamagnetic agents belong to this group and produce local magnetic field inhomogeneities of the local magnetic field. t2 is reduced due to the diffusion of water through these field gradients. magnetite, fe3o4, is such a paramagnetic particle. coated with inert material (e.g., dextranes, starch), it can be used for oral or intravenous applications. in addition to the classification in positive or negative agents, mr contrast agents can be differentiated according to their target tissue. the targeting of an agent is determined by the pharmaceutical profile of the substance. in the clinical environment, we differentiate currently three classes of agents: • unspecific extracellular fluid space agents • blood-pool and intravascular agents • targeted and organ-specific agents unspecific extracellular fluid space agents. low-molecular-weight paramagnetic contrast agents distribute into the intravascular and extracellular fluid space (ecf) of the body. their contrast effect is caused by the central metal ion. all approved ecf agents contain a gd ion, which contains seven unpaired electrons. because gd itself is toxic, the ion is bound in highly stable complexes. the different complexes and the physicochemical properties of all clinically used agents are listed in table 2 .6.1. the agents are not metabolized and are excreted in unchanged form via the kidneys. bound, they form low-molecular-weight, water-soluble contrast agents. gadopentetate dimeglumine (magnevist, bayer schering pharma, berlin, germany) and gadoterate meglumine (dotarem, laboratoires guerbet, aulnay-sous-bois, france) are ionic high-osmolality agents, whereas gadodiamide (omniscan, ge healthcare, buckinghamshire, uk) and gadoteriol (prohance, bracco imaging, milan, italy) are non-ionic low-osmolality agents. due to the low total amount of contrast agent usually applied in mr imaging, no difference in tolerance between both classes could be demonstrated (oudkerk et al. 1995; shellock 1999 ). an estimated 50% of ecf agents (as for example in gadopentetate dimeglumine, size 590 da) is cleared from the vascular space into the extravascular compartment on the initial passage through the capillaries. two agents in the group of ecf agents have to be mentioned separately. gadopentate dimeglumine (mul-tihance, bracco imaging) is an agent with a weak protein binding (about 10%) in human plasma. the bound fraction of the agent has a higher relaxivity than does the unbound fraction. in sum, the relaxivity of gadopentate dimeglumine is 50% higher as compared with gadopentetate dimeglumine at 1.5 t/37°c in plasma. the effect of higher relaxivity is highest at low field strengths (table 2.6.1). the concentration of the contrast agent is 0.5 mol/l. gadopentate dimeglumine was primarily developed as a liver-specific mr imaging agent, and is currently approved both in the indication detection of focal liver lesions and in mr angiography. most of the injected dose of gadopentate is excreted unchanged in urine within 24 h, although a fraction corresponding to 0.6-4.0% of the injected dose is eliminated through the bile and recovered in the feces (spinazzi et al. 1999 ). the second particular ecf agent, gadobutrol (gadovist, bayer schering pharma) is approved in a higher concentration (1 m) than all other available mr imaging contrast agents. in addition, gadobutrol has a higher relaxivity than most extracellular 0.5 m contrast agents on the market (table 2.6.1). the higher concentration has revealed to be particularly useful for mr perfusion studies and mr angiography (tombach et al. 2003 ). stay within the intravascular space with no or only slow physiologic extravasation. the agents can be used for firstpass imaging and delayed blood-pool phase imaging. the prolonged imaging window allows more favorable image resolution and signal-to-noise ratio. the absence of early extravasation also improves the contrast-to-noise ratio. the pharmacokinetic properties of blood-pool agents are expected to be well suited to mr angiography and coronary angiography, perfusion imaging, and permeability imaging (detection of ischemia and tumor grading). currently, three types of blood-pool agents are being developed: 1 gd compounds with a strong but reversible affinity to human proteins such as albumin 2 macromolecular-bound gd complexes 3 ultra small or very small super-paramagnetic particles of iron oxide (uspio and vsop) there are important differences between the three groups regarding pharmacokinetics in the body, i.e., distribution and elimination. gd compounds with a strong but reversible affinity to human proteins such as albumin exhibit prolonged plasma elimination half-life and increased relaxivity. the elimination is done by glomerular filtration of its unbound fraction. given that there is equilibrium between the bound and unbound fraction in the presence of albumin, the excreted molecules are immediately substituted due to dissociation of agent from the agent-albumin complex. two agents with affinities to albumin were developed and tested in clinical trials: gadofosveset (vasovist®, bayer schering pharma) 80-96% bound in human plasma (lauffer et al. 1998 ) and gadocoletic acid (b22956/1, bracco imaging), with a protein binding of approximately 95% in humans (cavagna et al. 2002; la noce et al. 2002) . currently, gadofosveset is the only blood-pool agent approved (for mra in europe). all other contrast agents with blood-pool characteristics are in clinical or in earlier phase development. gadofosveset is a stable gd diethylenetriaminepentaacetic acid (gd-dtpa) chelate substituted with a diphenylcyclohexylphosphate group. the mean plasma concentration at 1, 4 and 24 h after the 3.7 ± 0.2 4.0 ± 0.2 3.5 ± 0.2 3.7 ± 0.2 5.0 ± 0.3 5.5 ± 0.3 bolus injection of 0.03 mmol/kg body weight dose were 56%, respectively 41% and 14% of the concentration reached 3 min after injection. the mean half-life of the distribution phase (t1/2α) was 0.48 ± 0.11 h. relative to the reported clearance values of the non-protein-bound mri contrast agents, the clearance values of gadofosveset are markedly slower. gadofosveset is provided in a concentration of 0.25 mol/l and a dose of 0.03 mmol/kg body weight is recommended for mra (perrault et al. 2003) . as a further benefit, gd compounds with a strong, but reversible affinity to human proteins provide a long-lasting blood-pool effect even when small amounts of the substance leak out of the vasculature. the blood-pool effect persists because albumin remains highly concentrated in plasma while it shows a two-to three-times lower concentration in the extravascular space. thus, even when vasovist® leaks from the vasculature, the receptor-induced magnetization enhancement (rime) effect within the vascular spaces ensures that the signal enhancement in the blood dominates the mri contrast. in rabbits, enhancement with gadofosveset persisted at relatively constant levels from two minutes to up to 1 h, whereas the enhancement of ecf had virtually disappeared within 60 min (lauffer et al. 1998 ). the second blood-pool agent with binding to human serum albumin, gadocoletic acid has been tested in coronary mra (paetsch et al. 2006) . compared with gadofosveset, the slightly higher percentage of bounded agent may result in a lower percentage of extravasation and a further decreased elimination period. macromolecular gd-based blood-pool agents are large molecules with sizes between 30 and 90 kda. they are eliminated rapidly by glomerular filtration. due to their large size, they do not extravasate into the interstitial space. the two agents used in clinical trials were gadomer (schering) and p 792 (laboratoires guerbet, aulnay-sous-bois). gadomer contains multiple gd molecules (24 gd atoms, mr 35,000). p792 is a monodisperse monogadolinated macromolecular compound with mr 6.47 kda, based on a gadoterate meglumine core (port et al. 2001) . four hydrophilic arms account for its intravascular properties. in a preclinical study, p792 allowed acquisition of high-quality mr angiograms. image quality was rated as superior for p792 in the postbolus phase images compared with ecf agents. the intravascular properties lead to an excellent signal in the vasculature with limited background enhancement (ruehm et al. 2002 ). the first clinical use of uspio was done in specific parenchymal organ imaging due to the incorporation of uspio/spio into cells of the reticuloendothelial system of the liver, bone marrow, spleen, or lymphatic tissue. these particles produce a strong augmentation of the local magnetic field. predominant shortening of t2 and t2* produces a loss of signal intensity on mr images. the agents that have been developed as blood-pool agents provide different characteristics with a predominating t1 effect and a prolonged intravascular residence time due to the small size of the particles. nc 100150 (clariscan, ge healthcare) was the first uspio tested for mra (taylor et al. 1999 : weishaupt et al. 2000 . it is a strictly intravascular agent with an oxidized starch coating and has an approximate diameter of 20 nm. the half-life is 45-100 min, and it has shown to reduce blood t1 to below 100 ms (wagenseil 1999). another iron oxide particle mr contrast agent in the phase of clinical development is vsop-c184 (ferupharm, teltow, germany). it is classified as a vsop with a core diameter of 4 nm and a total diameter of 8.6 nm. vsop-c 184 is coated with citrate. the relaxivities in water at 0.94 t are (t1) 20.1 and (t2) 37.1 l/[mmol*s]. the plasma elimination half-life at 0.045 mmol fe/kg was 21.3 ± 5.5 minutes in rats and 36.1 ± 4.2 minutes in pigs, resulting in a t1 relaxation time of plasma of <100 ms for 30 min in pigs (wagner et al. 2002) . qualitative evaluation of image quality, contrast, and delineation of vessels showed that the results obtained with vsop-c184 at doses of 0.025 and 0.035 mmol fe/ kg was similar to those of gadopentetate dimeglumine at 0.1 and 0.2 mmol gd/kg. vsop-c184 is suitable for firstpass mra and thus, in addition to its blood-pool characteristics, allows for selective visualization of the arteries without interfering venous signal (schorr et al. 2004 ). another uspio is sh u 555 c (supravist, bayer schering pharma), an optimized formulation of carboxydextran-coated ferucarbotran (resovist; bayer schering pharma), which was formerly identified as sh u 555 a, with respect to t1-weighted mr imaging. sh u 555 c has a mean core particle size of about 3-5 nm and a mean hydrodynamic diameter of about 20 nm in an aqueous environment. relaxivity measurements yielded an r1 of 22 s -1 (mmol/l) -1 and an r2 of 45 s -1 (mmol/l) -1 at 40°c and 20 mhz in water (reimer et al. 2004 ). the efficacy of mri contrast agents is not just determined by their pharmacokinetic properties (distribution and time dependence of their concentration in the area of interest), but also by their magnetic properties, described by their t1 and t2 relaxivities. for all commercially available mri contrast agents, relaxivities are published and listed in the respective package inserts. however, the most commonly used field strength for relaxation measurements (0.47 t) is different from the currently most frequently used field strength of clinical mri instruments (1-3 t). rohrer et al. evaluated in a well-conducted and standardized phantom measurement study the t1 and t2 relaxivities of all currently commercially available mr contrast agents in water and in blood plasma at 0.47, 1.5, 3, and 4.7 t, as well as in whole blood at 1.5 t (rohrer et al. 2005) . they quantified significant dependencies of relaxivities on the field strength and solvents (table 2 .6.2). protein binding leads to both increased field strength and solvent dependencies and hence to significantly altered t1 relaxivity values at higher magnetic field strengths. mr contrast agents are in clinical use since 1988, and a wide experience is reported. severe or acute reactions after single intravenous injection of gd-based ecf agents are rare. in two large multiple-year surveys including, respectively, 21,000 and more than 9,000 examinations, an incidence of acute adverse reactions between 0.17 and 0.48% were reported (li et al. 2006 : murphy et al. 1996 . the severity of these adverse reactions was classified as mild (75-96%), moderate (2-20%), and severe (2-5%). typical nonallergic adverse reactions include nausea, headache, taste perversion, or vomiting, and typical reactions resembling allergy include hives, diffuse erythema, skin irritation, or respiratory symptoms. the incidence of severe anaphylactoid reaction is very low and was reported to be between 0.0003 and 0.01% in the literature (de ridder et al. 2001; li et al. 2006 : murphy et al. 1996 . the reported life-threatening reactions resembling allergy were severe chest tightness, respiratory distress, and periorbital edema. known risk factors for the development of adverse reactions are prior adverse reactions to iodinated contrast media, prior reactions to a gd-based contrast agent, asthma, and history of drug/food allergy. concerning liver-specific contrast media, a higher percentage of associated adverse reactions were reported for mangafodipir trisodium (7-17%) and ferumoxides (15%) (runge 2000). the recently approved bolus-injectable agent ferucarbotran (resovist, bayer schering pharma) has proven a better tolerance profile during the clinical development compared to ferumoxides. even bolus injections caused no cardiovascular side effects, lumbar back pain, or clinically relevant laboratory changes (reimer and balzer 2003). for the two approved gdbased agents gadopentate dimeglumine and gadoxetic acid, far fewer patients have been examined to date. according to the results of the clinical trials conducted for the approval of both agents, they are comparable to gdbased ecf agents in terms of safety (bluemke et al. 2005; halavaara et al. 2006; huppertz et al. 2004 ). post-marketing surveillance of gadopentate dimeglumine reporting approximately 100,000 doses revealed an overall adverse event incidence of <0.03%, with serious adverse eventss reported for <0.005% of patients (kirchin et al. 2001 ). in the class of blood-pool agents, only gadofosveset (bayer schering pharma) has been approved recently in some european countries. the tolerance of the agent must be estimated based on the clinical trials. based on these data, gadofosveset is well tolerated, and the incidence and profile of undesired side effects is very similar to ecf agents (goyen et al. 2005; petersein et al. 2000; rapp et al. 2005) . magnetic resonance contrast agents, particularly the gd-based agents, are extremely safe (niendorf et al. 1994) and lack in the usually applied diagnostic dosage the nephrotoxicity associated with iodinated contrast media. nevertheless, health care personnel should be aware of the (extremely uncommon) potential for severe anaphylactoid reactions in association with the use of mr contrast media and be prepared should complications arise. nephrogenic systemic fibrosis (nsf) is a rare disease occurring in renal insufficiency that only has been described since 1997. in 2006, a first report about a potential relationship with intravenous administration of gdbased mr contrast medium gadodiamide was published (us food and drug administration 2007). nsf appears to occur in patients with kidney failure, along with high levels of acid in body fluids (a condition known as metabolic acidosis) that is common in patients with kidney failure. the disease is characterized by skin changes that mimic progressive systemic sclerosis with a predilection for peripheral extremity involvement that can extend to the torso. however, unlike scleroderma, nsf spares the face and lacks the serologic markers of scleroderma. nsf may also result in fibrosis, or scarring, of body organs. diagnosis of nsf is done by looking at a sample of skin under a microscope. the risk of nsf in patients with advanced renal insufficiency does not suggest being the same for all gdbased contrast agents, because distinct physicochemical properties affect their stabilities and thus the release of free gd ions (bundesinstitut für arzneimittel und medizinprodukte [federal institute for drugs and medical devices] 2007). some gd-based contrast media are more likely than are others to release free gd 3+ through a process called transmetallation, with endogenous ions from the body (thomsen et al. 2006 ). these agents have the largest amount of excess chelate. gadodiamide and gadoversetamide differ from other gd-based contrast media because of an excess of chelate and is more likely to release free gd 3+ as compared with other agents. cyclic molecules offer better protection and binding to gd 3+ , compared with linear molecules (thomsen et al. 2006 ). the non-linear, non-ionic chelates gadodiamide and gadoversetamide seem to be associated with the highest risk of nsf (broome et al. 2007; sadowski et al. 2007) . the recommendations to prevent development of nsf are nonspecific (us food and drug administration 2007): • gd-containing contrast agents, especially at high doses, should be used only if clearly necessary in patients with advanced kidney failure (those currently na not applicable requiring dialysis or with a glomerular filtration rate (gfr) = 15 ml/min or less). • it may be prudent to institute prompt dialysis in patients with advanced kidney dysfunction who receive a gd contrast mra. although there are no data to determine the utility of dialysis to prevent or treat nsf in patients with decreased kidney function. the use of contrast agents in neuroimaging is an accepted standard for the assessment of pathological processes, which utilizes the extravasation of contrast agents through a compromised blood-brain or blood-spinal cord barrier. compared with contrast-enhanced ct, mr imaging with gd-based contrast agents is far more sensitive and depicts even subtle disruptions of the blood-brain barrier that are caused by a variety of noxious agents as, for example neoplastic or inflammatory processes and ischemic stress. moreover, mr contrast agents are increasingly used to evaluate brain perfusion in clinical practice for a variety of applications, including tumor characterization, stroke, and dementia. the contrast-enhanced brain perfusion mr examination is based on a magnetic susceptibility contrast phenomenon that occurs owing to the t2 and t2* relaxation effects of rapidly intravenous bolus-injected contrast agents. the contrast agents in current use are the standard ecf gd chelates (table 2.6.1). these extracellular agents show no appreciable differences in their enhancement properties and biologic behavior (akeson et al. 1995; brugieres et al. 1994; grossman et al. 2000; oudkerk et al. 1995; valk et al. 1993; yuh et al. 1991) . they equilibrate rapidly between the intraand extracellular spaces of soft tissues and enter central nervous system lesions only at sites of damaged blood-brain barrier. the standard dose for mr imaging of the central nervous system is 0.1 mmol/kg body weight; however, it has been shown that a higher dose of gd chelate-based contrast agents may help reveal more subtle disease states of the bloodbrain barrier regardless whether caused by tumors or by inflammatory lesions (bastianello et al. 1998; haustein et al. 2003; yuh et al. 1994) . this raises the question, in how far gd contrast agents with a higher concentration as for example gadobutrol or agents with a higher relaxivity as for example gadopentate dimeglumine help to increase the sensitivity and accuracy to detect lesions as compared to standard gd chelates. for gadobutrol, no comparative studies to standard gd chelates exist up to now; however, based on smaller cohorts it can be assumed that the higher amount of gd, which can be achieved by the higher gd concentration, is of value for lesion detection and characterization (vogl et al. 1995) . moreover, based on animal experiments the amount of gd in gliomas was higher after injection of gadobutrol in comparison to gadopentetate dimeglumine although identical doses of gd per kilogram body weight were injected for both contrast agents (le duc et al. 2004) . gadopentate dimeglumine proved significantly superior tumor enhancement of intraaxial enhancing primary and secondary brain tumors at a dosage of 0.1 mmol/kg body weight as compared with the same dosage of gadopentetate dimeglumine (knopp et al. 2004) . similar results were also obtained in comparison of gadopentate dimeglumine with other contrast agents as well as in special populations as for example in pediatric patients (colismo et al. 2001 (colismo et al. , 2004 (colismo et al. , 2005 . the increased contrast enhancement resulted also in an increased number of detected brain metastases. dynamic susceptibility-weighted (dsc) contrast agent-enhanced mr imaging is increasingly used for the assessment of cerebral perfusion in many different clinical settings, such as ischemic stroke (parsons et al. 2001) , neurovascular diseases (doerfler et al. 2001), brain tumors (essig et al. 2004) , and neurodegenerative disorders (bozzao et al. 2001) . unlike mr angiography, which depicts the blood flow within larger vessels, perfusion-weighted mr techniques are sensitive to perfusion on the level of the capillaries. the technique is based on the intravenous injection of a t2*-relaxing contrast agent and subsequent bolus tracking using a fast susceptibility-weighted imaging sequence. after converting voxel signal into concentration values, parametric maps of regional cerebral blood volume (rcbv) and blood flow (rcbf) can be calculated by unfolding tissue concentration curves and the concentration curve of the feeding artery. the contrast agents used for dynamic susceptibility-weighted mr perfusion are usually standard gd chelates; however, the dosages of gd per kilogram of body weight as well as the value of higher concentrated agents have been widely discussed. during the first pass of the gd chelate, the high intravascular concentration of gd causes the t2* effects, which can be measured by rapid imaging techniques. the length and the peak concentration of the bolus seem to have influence on the resulting measured signal with a highly concentrated small bolus of contrast agent being advantageous for mr brain perfusion imaging (essig et al. 2002; heiland et al. 2001) . in between the standard gd chelates, no notably different behavior of the available agents has been published up to now. the recommended dose for dsc perfusion mri is in the range of 0.15-0.30 mmol/kg body weight, with most authors preferring a value of 0.2, because the volume of the bolus gets too high when higher dosages are applied (bruening et al. 2000) . therefore, the use of higher concentrated contrast agents or agents with higher relaxivity are also interesting for cerebral perfusion mri. again, studies were able to demonstrate the value of the 1 m gabobutrol and gadopentate dimeglumine. tombach et al. (2003) showed that 1 m gadobutrol resulted in a significantly improved quality of the perfusion examination in comparison to 0.5 m gadobutrol at the same dosage of 0.3 mmol/kg body weight. the results were explained by the sharper, more concentrated bolus, which could be achieved due to the smaller injection volume. essig et al. directly compared 1 m gadobutrol and 0.5 m gadopentate dimeglumine at 1.5 t with a similar dosage of 0.1 mmol/ kg body weight and found no significant differences between the two agents (essig 2006) . the benefit of a double dose of 0.2 mmol was observed only as a trend; however, it was not considered to be of clinical relevance. similar results in a comparison between the two agents were recently obtained also on a 3-t system (thilmann et al. 2005) . for both agents sufficient high-quality perfusion examinations can be achieved with an acceptable injection volume, which is helpful for their clinical application in daily practice and can be considered superior to standard gd chelates (essig et al. 2004; thiman et al. 2005; tombach et al. 2003) . in a limited number of proof-of-concept studies, uspio were also used in neuroimaging (corot et al. 2004; manniger et al. 2005) . the long blood-circulating time and the progressive macrophage uptake in inflammatory tissues of uspios are two properties of major importance for pathologic tissue characterization. in the human carotid artery uspio, accumulation in activated macrophages induced a focal drop in signal intensity compared with unenhanced mri. the uspio signal alterations observed in ischemic areas of stroke patients is probably related to the visualization of inflammatory macrophage recruitment into human brain infarction, since animal experiments in such models demonstrated the internalization of uspio into the macrophages localized in these areas. in brain tumors, uspio particles that do not pass the ruptured bloodbrain barrier at early times post injection can be used to assess tumoral microvascular heterogeneity. twenty-four hours after injection, when the cellular phase of uspio takes place, the uspio tumoral contrast enhancement was higher in high-grade than in low-grade tumors. several experimental studies and a pilot multiple sclerosis clinical trial in 10 patients have shown that uspio contrast agents can reveal the presence of inflammatory lesions related to multiple sclerosis. the enhancement with uspio does not completely overlap with the gd-chelate enhancement. during the last few years magnetic resonance angiography (mra) has been established as a non-invasive alternative to conventional x-ray angiography in the diagnosis of arteriosclerotic and other vascular diseases (meany et al. 1997; meany 1999) . with the exception of imaging intracerebral vessels (gibbs et al. 2005; ozsarlak et al. 2004 ), contrast-enhanced techniques have revealed superiority over non-contrast-enhanced techniques as the time-of-flight (tof-mra) or phase-contrast (pc mra) technique (sharafuddin et al. 2002) . the main advantages over unenhanced techniques are the possibilities to acquire larger volumes, allowing, e.g., demonstration of the carotid artery from its origin to the intracranial portion, shorter acquisition times, and reduced sensibility to flow artifacts. contrast-enhanced mr angiography can be performed during the first-pass of a contrast agent, preferably in breath-hold technique, after rapid bolus injection or during steady-state conditions after injection of vascular specific blood-pool agents. most experiences were reported for first-pass mra after injection of ecf contrast agents. the demands on the agent are a high influence on the signal intensity on blood after injection and the possibility of fast and compact bolus injection. the most commonly applied group of contrast agents are 0.5 molar ecf. in the last years, two novel ecf agents with innovative properties were used for mra. the first one, the 0.5 m contrast agent gadopentate dimeglumine offers a higher t1 relaxivity. in studies in which gadopentate dimeglumine is compared at equal dose with other gd-based mr contrast agents without relevant protein binding in plasma, gadopentate dimeglumine has consistently shown significantly better quantitative and qualitative performance (goyen and debatin 2003) . even at lower doses compared with gadopentetate dimeglumine injected at a dose of 0.2 mmol/kg body weight, the greater relaxivity of gadopentate dimeglumine provides higher intravascular signal and signal-to-noise ratio (pediconi et al. 2003) . thus, gadopentate dimeglumine can be considered to have a very favorable risk-benefit ratio for mra. the second one, gadobutrol is available in 1 m concentration. in combination with a higher relaxivity compared to other ecf agents, the agent has revealed in quantitative evaluations a significant increase in signalto-noise and contrast-to-noise ratios in comparison to gadopentetate dimeglumine in pelvic mra and in whole body mra (goyen et al. 2001 (goyen et al. , 2003 . better delineation of arterial morphology was reported especially for small vessels, but no statistically significant difference in image quality could be seen. two different options for injection have been described: reduction of the injection rate by 50% compared to injection protocols using 0.5 m ecf (equimolar dosing) or reduction of the injection time by 50%. the equimolar dosing mainly exploits the higher relaxivity potential of gadobutrol. in this case, the injection duration is identical to a corresponding protocol using a 0.5m contrast agent a similar bolus geometry, and contrast delivery in the roi is obtained (e.g., in a 70-kg-weighing patient 7 ml of gadobutrol are injected at 1 ml/s compared with 14 ml of gadopentetate dimeglumine injected fig. 2.6.1 whole-body mra of a healthy volunteer after bolus injection of gadofosveset (0.025 mmol/kg body weight). firstpass and steady-state acquisition acquired immediately (a) and 10 min (b) after injection of the contrast agent. t1-weighted 3d gradient recalled echo sequence (tr/te/α 3.1/1.1/25, spatial resolution 1.6 × 1 × 1.5 mm). first-pass imaging depicts exclusively the arteries. steady-state imaging shows an enhancement of both arteries and veins. due to the higher concentration of the contrast agent during first-pass imaging the absolute level of enhancement is higher (a) at 2 ml/s). hence, well-known protocols can be adopted with good results. the second option keeps the injection speed unchanged in comparison to the 0.5 m agent protocol, resulting in shortening of the initial bolus duration by a factor of two (fink et al. 2004 ). the philosophy is to use a very compact, high-relaxivity bolus and to fully exploit the potential of 1 m gadobutrol. this approach is particularly recommended in conjunction with very fast acquisition techniques, e.g., time-resolved (often referred to as 4d) mra. although the effective bolus geometry in the respective roi is broadened, dependent on individual physiology and mainly influenced by the lung passage, this approach requires higher demands on precise bolus timing and is recommended to users with advanced mra experience and ultrafast imaging equipment. in addition, a further approach was reported by reducing the amount of contrast agent by a factor of two in abdominal mra (vosshenrich et al. 2003) . the injection speed was kept constant in comparison to a 0.5 m agent protocol, resulting in very short total bolus duration. vosshenrich et al. used an amount of 0.1 mmol/kg body weight. they compared the examinations qualitatively and quantitatively to exams acquired after injection of gadopentetate dimeglumine (0.2 mmol/kg), and concluded that for mra of the hepatic arteries and the portal veins, gadobutrol can be used at half the dosage as recommended for a standard 0.5 m contrast agent. the concept of contrast-enhanced mra based on ecf agents has some limitations. the primary problem is the rapid extravasation of the contrast agents limiting acquisition time and therefore spatial resolution as well as contrast-to-noise-ratio. to improve spatial resolution it is necessary to prolong imaging time. intravascular contrast agents are able to overcome the restrictions of spatial resolution. the longer acquisition period can be used to decrease voxel size, to repeat measurements, or to trigger acquisitions by ecg and/or respiratory gating. the second limitation of currently used mra is the quantification of artery stenoses, which still seems to be inferior to invasive catheter angiography. the cause is the inferior spatial resolution in mra using ecf agents, with which the increase of spatial resolution is limited by the acquisition time during first-pass (arterial phase). with intravascular contrast agents, a longer data acquisition during the distribution phase is possible. the spatial resolution can be increased on a similar level compared with catheter angiography and, therefore, the accuracy of stenosis quantification is significantly increased. optimally, a blood-pool agent permits a long acquisition window including first-pass mra as well as the possibility of separate imaging of arteries and veins by timing the injection and data acquisition. gadofosveset, the first mr blood-pool agent approved for clinical use, permits both a high-resolution approach with a long acquisition windows and first-pass contrast-enhanced mra (fig. 2.6 .1). the approval was based on the data of clinical trials in all different types of arterial vessels including high-flow vessels with large diameter (e.g., the pelvic arteries), low-flow vessels (e.g., foot arteries), and high-flow vessels with a small diameter (e.g., the renal arteries). ecf contrast agents are widely used in mr imaging of soft-tissue lesions. the enhancement in either inflammatory or neoplastic lesions makes their use inevitable for the detection and characterization of soft tissue lesions. relevant anatomical sites that in the daily clinical practice are subject to mr imaging are the female breast and the soft tissue related to the musculoskeletal system. for the female breast, mr imaging with extracellular contrast agents (mr mammography) is nowadays widely used for the detection and for the characterization of unclear breast tumors morris et al. 2002) . the histopathological basis of the different enhancement patterns in breast masses is not yet fully understood; however, it is well known that angiogenesis with the formation of new vessels, is an important aspect (knopp et al. 1999 ). the amount of angiogenesis and contrast agent extravasation is considered different for several benign and malignant lesions; however, the visible phenomenon of different enhancement is usually too small to be analyzed only visually. the discrete changes of contrast-agent enhancement are usually evaluated by using a semiquantitative evaluation with region-of-interest measurements at different time-points (kuhl et al. 2005) . the thereby achieved enhancement kinetics, as represented by the time-signal intensity curves, differ significantly for benign and malignant enhancing lesions, and are used as an aid in differential diagnosis. usually four to six measurements with an interval of 1-2 min are applied in the daily clinical practice (kuhl et al. 1999; pediconi et al. 2005) . a recently published study showed that the temporal resolution for the assessment of time-signal intensity curves is not as critical as the spatial resolution; therefore, the recommendations for the dynamic postcontrast mr imaging tend toward a 2-min interval with a high spatial resolution (e.g., full 512 imaging matrix) (kuhl et al. 2005) . a more detailed evaluation of perfusion parameters needs, however, a very high temporal resolution in a range of 3-5 s. first results for the differentiation of unclear breast tumors in an investigational setting are very promising; however, due to the high temporal resolution only single slices can be measured, which is not feasible for daily practice (brix et al. 2004) . usually standard gd chelates at a dose of 0.1 mmol/ kg body weight are used for contrastenhanced mr mammography. first results indicate that the use of the high-relaxivity mr contrast agent gadopentate dimeglumine in the same dosage can achieve a superior detection and identification of malignant breast lesions at mr imaging as compared with gadopentetate dimeglumine. however, up to now gadopentate dimeglumine is not officially approved for this indication. there are also first approaches to perform mr mammography with blood-pool contrast agents. a major limitation of ecf is that they extravasate nonselectively from the vasculature into the interstitium of both normal and pathological tissues in the breast. it is hypothesized that the degree of microvascular endothelial disruption inherent to cancer vessels with the resulting extravasation of macromolecular contrast agents may predict tumor aggressiveness and tumor grade more accurately that with standard gd chelates (daldrup-link and brasch 2003; daldrup-link et al. 2003) . first results with uspio have shown an improved characterization of unclear breast tumors at the expense of tumor enhancement, which is important for tumor detection. an interesting approach is also the use of small molecular gd chelates, which bind reversibly to plasma proteins as for example gadofosveset. this might allow for a sensitivity and specificity due to the presence of small and large molecules (daldrup-link et al. 2003) . the assessment of microvascular changes in experimental breast tumors seem not to be reliably depicted with theses agents in contrast to the macromolecular albumin-gd-(dtpa)30 (daldrup-link et al. 2003; turetscheck et al. 2001) . however, clinical experience on breast tumors does not exist now. although potential diagnostic applications have been investigated with various sized albumin-gd-dtpa, this contrast agent is considered a poor candidate for development as a clinical drug due to slow and incomplete elimination and a potentially immunologic toxicity (daldrup-link and brasch 2003) . for soft-tissue or bone lesions in the musculoskeletal system, the application of extracellular gd-contrast agents has become a clinical standard for characterization, staging of the local extent, biopsy planning, and the therapy monitoring (verstraete and lang 2000). the basic principle of contrast-enhanced imaging is as described above the distribution of the gd chelates in the intravascular space, showing enhancement in tumors with dense vascularity and neoangiogenesis as well as distribution into the extracellular space. for these clinical standard applications, there seem to be no relevant differences in the diagnostic performance between the different extracellular gd chelates, similar to neuroimaging. the role of gd-enhanced mri for exact tissue characterization is still very limited. a differential diagnosis in between different sarcomas, nerve sheath tumors, or other mesenchymal tumors is not possible based on the contrast agent behavior up to know. the differentiation between benign and malignant tumors is also often very limited, even with tools like dynamic time-resolved contrast-enhanced mri (verstraete and lange 2000). nevertheless, surrogate parameters for angiogenesis like histological tumor-vessel density can be correlated with this method (van dijke et al. 1996) . one major limitation is the extravasation of standard gd chelates through the intact endothelium so that pathological extravasation in tumor vessels disrupted endothelium cannot be separated from the physiological distribution. therefore, the experimental studies mainly focus on contrast agents which show no or only minor physiological extravasation. different studies-mainly in the animal-experimental stage-were able to show that characterization in benign and malignant tumors, evaluation of angiogenesis, and even tumor grading is feasible with blood-pool contrast agents (daldrup et al. 1998; kobayashi et al. 2001; preda et al. 2004a, b) . there have been promising results with albumin-gd-(dtpa); however, as mentioned above this agent is unlikely to be available for diagnostic use in humans (daldrup et al. 1998; daldrup-link and brasch 2003) . similar to breast tumors, uspio have also been utilized for the evaluation of perfusion and for the characterization of soft-tissue tumors in the past (bentzen et al. 2005 ). the basic group of contrast agents for hepatobiliary imaging is the group of ecf gd-based contrast agents. however, there are also tissue-specific contrast agents available, which allow for an increased detection and characterization of focal and diffuse liver disease. liver-specific contrast agents can be divided into two groups: on the one hand, there are iron-oxide particles (spio, or superparamagnetic particles of iron oxide), which are targeted to the reticuloendothelial system (res) to the so-called kupffer cells. these agents cause a signal decrease in t2/t2*-weighted sequences by inducing local inhomogeneities of the magnetic field. on the other hand, there is the group of hepatobiliary contrast agents, which are targeted directly to the hepatocyte and are excreted via the bile. these agents cause signal increase in t1-weigthed sequences by shortening of the t1 relaxation time. in europe there are five different liver specific contrast agents available on the market (table 2.6.3). the basic principle behind spio is the fact, that there are usually no kupffer cells in malignant liver tumors, in contrast to the normal liver parenchyma and to solid benign liver lesions. therefore, in the liver specific phase, which starts for ferucarbotran after about ten min and for ferumoxide after about 30 min, high contrast is produced in between malignant liver lesions and normal liver parenchyma. due to the signal loss in normal liver parenchyma the malignant lesions are contrasted as hyperintense lesions in t2*-weighted and t2-weighted sequences against the dark liver parenchyma. the first spio on the market in europe has been ferumoxide (endorem®, guerbet, aulnay sous bois, france). since 2001 in most european countries and in asia the bolus-injectable ferucarbotran (resovist®, bayer schering pharma ag, berlin, germany) is available. with regard to the basic principle of imaging there is no difference between the two agents; however, direct comparative studies have not been performed so far. the most striking advantage of ferucarbotran is the better workflow due to the possibility to inject ferucarbotran as a bolus. bolus-applicability is possible for ferucarbotran due to the different particle sizes and the coating of the particles; this is also responsible for the fewer rate of side effects (especially fewer events of severe back pain), which are encountered with ferucarbotran. in earlier clinical trials the effects of spio particles were evaluated almost exclusively on t2-weighted fse and t2 * -weighted gre sequences, whereas usually not much attention was paid to the t1-effects. however, the effect of spio particles on proton relaxation is not confined to t2 and t2 * . they also influence t1 relaxivity with increased signal intensity on t1-weighted gre sequences at low concentrations (chambon et al. 1993 ). this gave raise to the hope, that with the bolus-injectable ferucarbotran vascularity of focal liver lesions could be depicted; however, investigations have been shown, that the ferucarbotran-enhanced early dynamic examination with t1-weighted sequences does not permit to evaluate lesion vascularity, since (with exception of the cotton-wool paddling of hemangioma) the expected enhancement pattern cannot be seen with reliability (zech et al. 2005) . with regard to the t2 /t2* effects there might be differences between both agents, which could be related to the different average particle size of both agents (approximately 150 nm for ferumoxide and 60 nm for ferucarbotran). with help of spio-enhanced mr an accurate liver lesion detection can be achieved. there have been several studies comparing spio to ct during arterial portography (ctap), which has been considered as best practice and reference standard. these studies showed detection rates of more than 90% (ba-ssalamah et al. 2000; vogl et al. 2003) . in comparison to ctap this detection rate was comparable; moreover, spio-enhanced mr is more specific than ctap, in which false positive lesions are encountered frequently. the above cited references investigated spio-enhance mr in a mixed collective of patients; publications focusing on the cirrhotic liver showed, that in these patients the combination of spio and extracellular gd-contrast agents have to be considered as the gold-standard for lesion detection (ward et al. 2000) . with regard to lesion characterization spio particles can be of help for the differential diagnosis of focal liver lesions based on the cellular composition and function of the different lesions (or rather based on different kuppfer cell density and function). when the same mr sequence is acquired pre-contrast and after a definite time interval, then the signal loss in normal liver parenchyma and in different focal liver lesions can be quantitatively evaluated. this is helpful for the differentiation of benign and malignant lesions; when a threshold of 25% signal loss is chosen, than lesions with less signal loss are of a malignant nature with over 90% sensitivity and specificity (namkung and zech et al. 2007 ). however, the sequence must have the same parameters (including the same acceleration in case parallel imaging is used), since application of parallel imaging makes systematic changes in the spread of image-noise (zech et al. 2004 ). the second important group is the group of hepatobiliary contrast agents. the basic principle behind this group of contrast agents is the specific uptake directly into the hepatocyte. since the agents all shorten the t1 relaxation times, they cause a signal increase in normal liver parenchyma and in solid benign lesions, whereas in malignant lesions like metastases no specific uptake can be seen. these lesions contrast as hypointense lesions against the bright liver parenchyma. approved agents in europe are the manganese-based agent mangafodipir trisodium (teslascan®, ge healthcare), and the gd-based agents gadopentate dimeglumine and gadoxetic acid (primovist®, bayer schering pharma). mangafodipir has the drawback that it must not be administered as a bolus, but only as a short infusion; therefore, dynamic studies are not possible with mangafodipir. however, the liver specificity is high and the high uptake in normal liver parenchyma enables imaging of, e.g., metastases with high contrast to the surrounding liver parenchyma. gadopentate dimeglumine and gadoxetic acid are injectable as boluses. with both contrast agents, a valid early dynamic examination is feasible, allowing differentiation of lesions with regard to their hyper-or hypovascularity (huppertz et al. 2005; petersein et al. 2000b ). due to the lower liver specificity of gadopentate dimeglumine, the imaging time-point of the liver-specific phase starts about 40 min after injection; whereas gadoxetic acid allows for imaging at 20 min after injection. this can be of value with regard to the workflow in the mr department. similar to the situation at spio agents, direct comparative studies between the agents have not been published yet; therefore, the following remarks again hold true for all hepatobiliary contrast agents. however, with regard to lesion characterization, only gadoxetic acid has the official approval to be used for this indication. all three hepatobiliary agents are approved for lesion detection. in comparison to spio agents, the potential advantage of hepatobilary agents is the fact that t1-weighted sequences usually can be performed with less acquisition time, less artifacts, and substantial higher spatial resolution. this holds true especially for t1-weighted 3d-gre sequences derived from mr angiography sequences as, for example, vibe, or volumetric interpolated breathhold examination (siemens medical solutions, erlangen, germany), or lava, for liver acquisition with volume acceleration (ge healthcare). in how far these high-resolution sequences with a slice thickness of usually below 3 mm allow further increasing the detection of small (<1 cm) malignant lesions has to be investigated in the future. the present date for the hepatobiliary agents was acquired mostly with conventional 2d-gre sequences and a slice thickness between 6 and 8 mm; however even in this setting the detection of lesions <1 cm was improved in comparison to baseline mri and spiral ct (bartolozzi et al. 2004; gehl et al. 2001; huppertz et al. 2004; peterseing et al. 2000b ). an earlier trial showed slight superiority of spio-enhanced mri versus hepatobiliary mri in detection of liver metastases; however, the potential advantaged of modern t1-weighted 3d gre sequences were not available for this evaluation (del frate et al. 2002) . a recent evaluation showed comparable detection rates between these two contrast agent groups (kim et al. 2005) . for the diagnosis of solid benign liver lesions (as focal nodular hyperplasia [fnh] and hepatocellular adenoma), the basis is still the extracellular contrast agent behavior with flush-like, mostly homogenous arterial hypervascularization and fast, but only faint washout, being in portovenous and equilibrium phase mostly slightly hyperintense (and not hypointense in contrast to the strong washout in malignant lesions). contrast agents used for patients with suspected solid benign lesions must enable that this information can be acquired. therefore, spio agents or mangafodipir alone are not sufficient for this indication; however, especially spio can contribute to the diagnosis of these lesions in combination with extracellular contrast agents, which have to show the abovementioned enhancement pattern. with spio agents solid benign lesions typically show liver-specific uptake of the substance in the range of normal liver parenchyma, thereby allowing the differentiation from malignant lesions as for example hepatocellular carcinoma (hcc). with regard to the differential diagnosis between fnh and adenoma, results in a limited number of patients indicated that the quantification of iron uptake can be helpful for this issue, because in our cohort, adenoma showed stronger iron uptake in comparison to fnh, with only minimal overlap of the percentage sig-nal intensity loss (psil) measured in a t2-weighted fse sequence with fat-sat (namkung and zech et al. 2007 ). with the hepatobiliary contrast agents gadopentate dimeglumine and gadoxetic acid, diagnosis of fnh and adenoma is also possible on the one hand based on the extracellular contrast phenomena, on the other based on the liver specific uptake of the agents into these lesions (grazioli et al. 2001 (grazioli et al. , 2005 huppertz et al. 2005) . there is also valid data indicating that the differentiation between fnh and adenoma is feasible with hepatobiliary contrast agents. therefore, with the bolus-injectable agents of this class a timeand presumably cost-effective diagnosis can be achieved (fig. 2.6.2) . in patients with extrahepatic malignoma, confirmation or ruling out of liver metastasis is often crucial for the therapeutic management. moreover, the exact staging of metastatic disease of the liver is getting more and more important, since sophisticated, stage-adapted therapeutic regimens with different options from atypical liver resection over local ablative minimally invasive treatment (e.g., radiofrequency ablation) up to extended liver resection exist. therefore, contrast agents used for this indication have to provide an excellent detection rate for focal liver lesions; however, the characterization of these lesions is also important, especially the differential diagnosis of small cystic metastases and small benign cysts or atypical hemangioma. after injection of extracellular contrast agents, the vascularity can be differentiated in hypo-und hypervascular metastases. hypovascular metastases appear as hypointense lesions in the portovenous phase, whereas hypervascular metastases appear as hyperintense lesions in the arterial-dominant phase. in contrast to the enhancement pattern of benign lesions, the nodular "cotton-wool"-like paddling in hemangioma or the homogeneous enhancement of fnh or adenoma metastases typically show a heterogeneous, ring-like enhancement with strong washout in the portovenous and equilibrium phase, resulting in first hyper-, and then hypointense lesions. however, in very small lesions the morphology of vascularization between the different enfig. 2.6. 2 mr images of a 27-year-old male patient with a formerly unclear liver lesion. the primary mr examination (upper row) with gadopentetate dimeglumine and ferucarbotran shows a lesion (arrow) with strong arterial enhancement in the gd-enhanced t1-weighted 3d-gre sequence (a) (tr, 5.02 ms; te, 1.77 ms; flip angle 15°) and ongoing washout in portovenous and equilibrium phase (not shown). the t2-weighted fse sequence with fat-saturation 10 min after application of ferucarbotran (b) depicts the lesion as nearly liver isointense. the calculated percentage iron uptake compared to the pre-contrast t2-weighted sequence was about 40%, showing the benignity of the lesion. based on these imaging features and the lobulated margins as well as the central scar, the diagnosis of a fnh was made. the follow-up study (lower row) was performed with gadoxetic acid after a single bolus injection. in the t1-weighted 3d-gre sequence (same parameters as above) in the arterial phase (c), the same enhancement characteristics as the in prior study can be delineated. in the delayed t1-weighted 2d-gre sequence (d), the presence of hepatocytes is proven due to the liver-specific enhancement. note the excellent delineation of the central scar in the delayed images. in contrast to the upper row, the followup study gave information about vascularity and tissue composition, with a single contrast agent injection only tities is getting more and more similar, so that the present or missing liver-specific uptake is an additional criterion for differentiation. several publications have shown that detection of metastasis is feasible with the highest accuracy with help of liver-specific contrast agents, regardless if spio or hepatobiliary. according to the literature for detection of liver metastases, all liver-specific agents can be used with a very high diagnostic reliability and superiority to merely extracellular mri or spiral ct (bartolozzi et al. 2004; ba-ssalamah et al. 2000; del frate et al. 2002; gehl et al. 2001; huppertz et al. 2004; kim et al. 2005; petersein et al. 2000b; vogl et al. 2003) . a difficult situation is liver imaging in cirrhotic liver. it is known that extracellular agents are helpful for detection and characterization of hcc nodules, the sensitivity is with t1-weighted 3d-gre sequences 76 and 75% specificity (burrel et al. 2003) . moreover, for diagnosis a hcc according to the accepted guidelines, hypervascularity has to be demonstrated. therefore, a valid early dynamic phase is a mandatory part for imaging in the cirrhotic liver. because regenerative nodules, which can be found frequently in the cirrhotic liver, also can show hypervascularity differentiation between these nodules and hcc nodules, it is a crucial issue for the management of patients suffering from liver cirrhosis. this is the reason that liver-specific contrast agents play an important role for imaging of the cirrhotic liver. it has been demonstrated that hcc shows no relevant uptake of spio particles in contrast to benign regenerative nodules (bhartia et al. 2003; imai et al. 2000; ward et al. 2000; namkung and zech et al. 2007 ). since in the cirrhotic liver fibrotic areas are present frequently, spio alone are not sufficient to evaluate the cirrhotic liver. a reasonable approach for the diagnosis of hcc based on imaging alone is the correlation of hypervascularity and missing or at least decreased iron uptake (bhartia et al. 2003; ward et al. 2000) . however, there is also an indefinite area of overlapping phenomena between dysplastic nodules and well-differentiated hcc, which is the reason for false negative findings-meaning well-differentiated hcc with substantial iron uptake (imai et al. 2000) . with regard to lesion detection, the availability of high-resolution mr sequences gives advantages for gd-enhanced arterial-phase imaging alone (kwak et al. 2004) or in combination with spio as double contrast (ward et al. 2000) . imaging with hepatobiliary contrast agents is considered as inferior in comparison to spio agents in the cirrhotic liver, mainly due to substantial overlapping in the liver-specific uptake between well-differentiated hcc and regenerative nodules. the assessment of lymph node affections by extranodal tissue, i.e., lymph node metastasis, is currently based on morphologic parameters including, lymph node size, shape, irregular border, and signal intensity inhomogeneities (brown et al. 2003; zerhouni et al. 1996) . for all parameters, no clear cut-off values or cut-off characteristics can be defined. the definition of a cut-off value in individual studies is the result of finding a compromise between sensitivity and specificity (e.g., larger values around 10 mm give a high specificity but low sensitivity, whereas the reverse of low specificity and high sensitivity is observed when smaller diameter <10 mm are defined). the use of unspecific gd-based extracellular contrast agents has not revealed to overcome this limitation. lymphotropic mr contrast agents were, therefore, developed to increase the diagnostic accuracy of positive lymph node involvement. currently, none of these agents is approved for clinical use, and the experience with different formulations is limited to clinical studies. the most frequently used agents are uspios. they are administered intravenously and, as a result of their small diameter and their electrical neutrality, pass the first lymphatic barriers, i.e., the liver and the spleen. in the lymphatic nodes, they are phagocytosed by local macrophages. in healthy lymphatic tissue, the local concentration of iron oxides is resulting in a significant decrease of t2 and t2* relaxation, resulting in a marked decrease of signal in t2and t2*-weighted sequences. in contrast, metastatic tissue replacing the lymphatic tissue shows no relevant uptake of uspio, and no relevant change in signal intensity can be observed. gradient-recalled echo t2-weighted sequences are considered the most accurate to detect the signal loss in nonmetastatic nodes. the application of uspios offers not only the possibility to differentiate between tumorfree, reactive (koh et al. 2004 ) and tumor-positive lymph nodes, but enables to depict micrometastasis in case sequences when high spatial resolutions are used (harisinghani et al. 2003) . one representative of the group of lymph node-specific uspio, ferumoxtran-10 (sinerem ® guerbet, paris, france) is infused after dilution. the recommended dose is 2.6 mg fe/kg body weight. the optimal time-point for postcontrast imaging is 24-36 h after application. during their clinical development, uspios have shown to be effective in staging lymph nodes of patients with various primary malignancies (deserno et al. 2004; jager et al. 1996; michel et al. 2002; nguyen et al. 1999) . the usual way for diagnosis is to perform an initial precontrast scan and to compare the images with postcontrast images acquired 24-36 h after infusion of uspios for signal changes between both time-points. the type, onset, and intensity of adverse events after application of ferumoxtran-10 was evaluated in phase iii studies and seems to be similar to those related to infusion of ferumoxides (anzai et al. 2003) . in patients with esophageal or gastric cancer, uspios revealed a sensitivity of 100% and specificity between 92.6 and 95.4% (diagnostic accuracy between 94.8 and 96.2%) for diagnosis of metastatic nodes (nishimura et al. 2006; tatsumi et al. 2006) . in patients with carcinomas of the upper aerodigestive tract, application of ferumoxtran-10 has shown to increase the sensitivity from 64 to 94% while maintaining a specificity of 78.9%, compared with precontrast imaging (curvo-semedo et al. 2006 ). in patients with rectum cancer, uspios have shown wellpredictable signal characteristics in normal and reactive lymph nodes, and were able to differentiate the latter from malignant lymph nodes (koh et al. 2004) . dissimilarly, keller et al. studied females with uterine carcinoma and were able to show high specificity, but a low sensitivity for metastatic lymph nodes; mainly micro-metastases around 5 mm diameter were missed. a possible way to further improve the diagnostic accuracy for detection of small positive lymph nodes could be the use of 3-t high magnetic field strength scanner resulting in a lower spatial resolution (heesakkers et al. 2006) . different results were published concerning the necessity of both pre-and postcontrast images. whereas the majority of clinical publications using uspio for lymph node imaging used both pre-and postcontrast images and stets et al. (2002) were able to statistically prove the advantage of preand postcontrast studies, harisinghani et al. (2003) were showed that on ferumoxtran-10-enhanced mr lymphangiography, contrast-enhanced images alone may be sufficient for lymph node characterization. however, a certain level of interpretation experience seems to be required before contrast-enhanced images can be used alone. both uspios (rogers et al. 1998) and spios (maza et al. 2006) can alternatively be administered with subcutaneous or submucosal injection. this application route is able to identify sentinel lymph nodes and lymphatic drainage patterns (fig. 2.6.3) . additionally, high diagnostic accuracy of interstitial mr lymphography using blood-pool gd-based agents has been described (herborn et al. 2002 (herborn et al. , 2003 .using different macromolecular agents or gd-based agents with high protein binding in animal models, herborn et al. were able to show that the differentiation of tumor-bearing lymph nodes from reactive inflammatory and normal nodes based on a contrast uptake pattern assessed qualitatively as well as quantitatively is possible. in difference to the intravenous administration, subcutaneous injection gives the possibility to acquire the mr images as early as some min after application. the use of gd-based non-lymphotropic blood-pool agents induced a relatively short and inhomogeneous lymph node enhancement (misselwitz et al. 2004) . with the aim to become more specific, a new generation of lymphotropic t1 contrast agents was developed and tested in animal models after subcutaneous injection. these perfluorinated gd chelates were able to visualize fine lymphatic vasculature, even the thoracic duct in animal models (staatz et al. 2001 ). bowel mr contrast agents are generally classified as either positive (bright lumen) or negative (dark lumen) agents. in addition to enteral contrast agents especially approved for mr imaging, several existing pharmaceutical agents, such as methyl cellulose, mannitol, and polyethylene glycol preparations, licensed for other enteric application than mri, have also been exploited. fig. 2.6. 3 lymphatic drainage of a mucosal melanoma in the left nasal cavity to a lymph node located in the left submandibular region. mr images (upper row) and spect images (lower row). a concordant alignment of hot spots caused by the skin markers on the spect images with the vitamin e caps on the mr images (yellow arrows). b accurate sentinel lymph node localization (blue arrow) after subcutaneous injection of ferucarbotran (mg fe/kg body weight). t2*-weighted 2d gradient-recalled echo sequence tr /te /a 997/15/90. homogeneous signal intensity decrease in the depicted lymph node (arrow) indicates normal lymphatic tissue and, thereby, metastatic involvement can be ruled out (maza et al. 2006) the specific demands for enteral contrast media include: for enteral and rectal application a special formulation of gadopentetate dimeglumine was developed (magnevist enteral, schering). the agent contains a total of 15 g mannitol/l to prevent the absorption of the fluid simultaneously introduced in the gi tract, thus allowing homogeneous filling, distension, and constant gd concentration during the entire examination period. in the early development, an increase in diagnostic accuracy in examinations of the pancreas in the diagnostics of abdominal lymphoma and in pelvic mr imaging was shown (claussen et al. 1988 ). negative agents provide desirable contrast to those pathologic processes that are signal intense. they have been shown to improve the quality of images obtained by techniques such as mr cholangiopancreaticography (mrcp) and mr urography by eliminating unwanted signal from fluid-containing adjacent bowel loops, thus allowing better visualization of the pancreatic/biliary ducts and the urinary tract. an alternative to oral spios was described by using ordinary pineapple juice. it was demonstrated that pineapple juice decreased t2 signal intensity on a standard mrcp sequence to a similar degree than a commercially available negative contrast agent (ferumoxsil) (riordan et al. 2004) . oral spio preparations usually contain larger particles than injectable agents do. in europe, two spio preparations with the inn code ferumoxsil are approved for oral use: lumirem (laboratoires guerbet, france) with a particle size of 300 nm, and (oral magnetic particles) abdoscan (ge healthcare) with a particle size of 350 nm. they are coated with a non-biodegradable and insoluble matrix (siloxane for lumirem and polystyrene for abdoscan), and suspended in viscosity-increasing agents (usually based on ordinary food additives, such as starch and cellulose). these preparations can prevent the ingested iron from being absorbed, particles from aggregating, and improve homogeneous contrast distribution throughout the bowel. if spio particle aggregating occurs, magnetic susceptibility artifact may result, especially when high magnetic field strength and gradientecho pulse sequence are used (wang et al. 2001) . lumirem is composed of crystals of approximately 10 nm; the hydrodynamic diameter is approximately 300 nm (debatin and patak 1999) . the recommended concentration is 1.5-3.9 mmol fe/l. oral spio are administered over 30-60 min, with a volume of 900 ml for contrast enhancement of the whole abdomen, and 400 ml for imaging of the upper abdomen. oral spio suspensions are well tolerated by the patients (haldemann et al. 1995) ; the iron is not absorbed and the intestinal mucosal membrane is not irritated. combination of gd-enhanced t1-weighted sequences and t2-weighted sequences after oral contrast with spio has revealed highest accuracy in the evaluation of crohn's disease (maccioni et al. 2006) . furthermore, it has been shown that mri with negative superparamagnetic oral contrast is comparable to endoscopy in the assessment of ulcerative colitis. in difference to patients with crohn's disease, the double-contrast imaging does not provide more information than single oral contrast (de ridder et al. 2001) . in mrcp, negative oral contrast agents can be given before the examination to provide non-superimposed visualization of the bile and pancreatic ducts. there is no negative influence of the oral contrast agents on the diameter of the ducts (petersein et al. 2000a). in cardiac mri, contrast agents are obligatory for the assessment of myocardial perfusion, for the evaluation of enhancement of cardiac masses, and for the evaluation of myocardial viability. in addition, contrast agents are frequently used when mr angiography of the coronary arteries is performed. myocardial perfusion imaging is a promising and rapidly increasing field in cardiac mr imaging. in comparison to radionuclide techniques, mr imaging has several advantages, including higher spatial resolution, no radiation exposure, and no attenuation problem related to anatomical limitations. the examination is performed after rapid intravenous administration (e.g., 3-5 ml/sec) of a contrast agent and evaluation of the first-pass transit of the agent through the myocardium. with the use of fast scan techniques, perfusion imaging can be performed as a multislice technique, with imaging of three to five slice levels per heartbeat, possibly allowing coverage of the entire ventricle. from a series of images, signal intensity-time curves are derived from regions of interest in the myocardial tissue for generation of parametric images. the majority of data are published using ecf agents. in clinical practice, most investigators are using fast t1-weighted imaging and bolus injection of doses of 0.025 up to 0.05 mmol/kg body weight (edelman 2004) . for the evaluation, both quantitative and qualitative approaches can be used. in case of ecf agents, generally semiquantitative assessments are applied. to quantify myocardial perfusion a calculation was published by wilke et al. on the basis of first-pass data acquired after fast bolus injection of 0.025 mmol/kg body weight of ecf agents (wilke et al. 1997) . in practice, gd concentrations between 0.2 and 1.2 mmol/l result in a linear progression of the mr signal compared with the concentration of the agent itself. above this dose, the maximal relative increase in signal intensity begins to saturate (schwitter et al. 1997) . when the evaluation is performed by visual evaluation, a higher dose of 0.1-0.2 mmol/kg should be preferred to reach better myocardial enhancement and image quality. good correlation between the perfusion reserve with mr imaging and the coronary flow reserve with doppler ultrasonography could be proven. blood-pool agents have the potential to be applied for quantitative measurements also because their volume of distribution is limited to the intravascular space. a requirement for quantitative perfusion measurements is that the relation between the measured signal intensity on the mr images and the contrast agent concentration in the blood is known (brasch 1991) . there are two major differences between first-pass curves obtained from blood-pool agents and extracellular contrast agents. first, blood-pool contrast agents reach a lower tissue signal because their volume of distribution is limited to the intravascular space (wendland et al. 1997; wilke et al. 1995) . second, there is a better return to baseline for blood-pool contrast agents. the wash-in kinetics and the signal intensity in the myocardial tissue depend on the concentration of the contrast agent, the coronary flow rate, diffusion of the contrast agent into the interstitium, relative tissue volume fractions, bolus duration, and recirculation effects (burstein et al. 1991) . absolute quantification of myocardial perfusion has been performed in animal models using nc100150. a high absolute quantification correlation was found between mri and contrast-enhanced ultrasound (johansson et al. 2002) . delayed enhancement allows direct visualization of necrotic or scarred tissue and is an easy and robust method to assess myocardial viability. by measuring the transmural extent of late enhancement, a prognosis toward the degree of functional recovery of cardiac tissue may be possible. although several studies have been aimed at describing the mechanisms of late enhancement, these could not be fully explained up to now. the extent of late enhancement possibly depends on the time-point after injection as well as the time-point after myocardial infarction. relevant publications about delayed enhance-ment are reporting data after the administration of 0.5 m ecf agents in a dose range of 0.1-0.2 mmol/kg. ecf agents are probably more efficient in assessing the cellular integrity when they are distributed homogenously through damaged myocardium (wendland et al. 1997) , but homogenous distribution is not always the case, as in microvascular obstruction (kroft and de roos 1995) . differences exist between the distribution patterns of extracellular and blood-pool agents, and hypo-enhanced cores may be observed earlier using blood-pool agents (schwitter et al. 1997) . the sensitivity of blood-pool agents for myocardial infarction and, therefore, their potential value for the evaluation of myocardial viability, is unknown. a different strategy to determine myocardial viability is the use of necrosis-specific mr contrast agents. gadophrin-2 and -3 (schering) have shown to possess a marked and specific affinity for necrotic tissue components and showed persistent enhancement in necrotic tissue (40 min to 12 h in myocardial infarction). in preclinical studies, the agent has not proven superiority in estimation of infarcts compared with ecf agents, and the further development of the agent was, therefore, not continued (barkhausen et al. 2002) . to depict coronary arteries in mri, both unenhanced and contrast-enhanced techniques are used. a frequently performed contrast-enhanced examination strategy with acquisition of multiple 3d slaps in breath-hold depicting each coronary artery separately was primarily described by wielopolski et al. (1998) . for 3d coronary mr angiography, however, the contrast between blood and myocardium in relation to the inflow of unsaturated protons is reduced. thus, the use of an intravascular contrast agent may be particularly convenient due to the t1 relaxation time reduction in blood. the application of ecf agents has proven to be most effective for breath-hold acquisitions. however, the concentration of ecf agents declines rapidly as they extravasate into the interstitial space, thereby reducing the contrast between blood and myocardium. newly developed strategies use high-resolution free-breathing mr sequences for coronary mra. in this situation, ecf agents are less beneficial due to the relatively long acquisition time of these free breathing 3d sequences. this problem can be solved by the use of intravascular contrast agents. an additional benefit from application of a blood-pool agent is a longer acquisition window, which may be used to further increase both the signal-to-noise ratio and/or image resolution (nassenstein et al. 2006) . in an animal model use of the macromolecular gd-based agent p792 with a free-breathing technique allowed more distal visualization of the coronary arteries than did an ecf agent or non-enhanced mr images (dirksen et al. 2003 ). colosimo c, demaerel p, tortori-donati p et al (2005) comparison of gadopentate dimeglumine (gd-bopta) with gadopentetate dimeglumine (gd-dtpa) for enhanced mr imaging of brain and spine tumors in children. (2002) barkhausen j (2006) (2000b) one of the strengths of mri is the ability to visualize soft tissues with different image contrasts. additionally, various two and three-dimensional mr imaging techniques for morphologic and functional examinations exist. among the functional techniques the visualization and measurement of blood flow is of particular interest, since nearly all physiologic processes rely on an adequate blood supply. as with many other mr imaging techniques, the sensitivity of mri to blood flow was first observed in artifacts visible near larger blood vessels. to suppress these artifacts new imaging methods have been investigated. in a further refinement of these techniques the artifact (here: the blood flow) has been made the primary source of the imaging technique; thus, in search for new methods of flow artifact suppression the blood flow itself became the contrast-generating element. the delineation of the vascular tree with mri, mr angiography (mra), is such a development: in t1-weighted 3d gradient-echo data, it was observed that the blood vessel signal of the margin partitions was significantly higher than at the center of the image stack. furthermore, signal voids were seen in regions of turbulent flow, and in blood vessels with pulsating flow, ghost images of the vessel were visible in phase encoding direction. in the following, the underlying physical phenomena of these artifacts will be discussed, as they form the basis for time-of-flight mra, phase-contrast mra, and mr flow measurements. since the pioneering work of prince (1994) , many mr angiographies are acquired using contrast-enhanced acquisition techniques. in contrast-enhanced mra, the signal difference between the bright blood vessel and the dark surrounding tissue is induced by a reduction of the blood's t1 relaxation time. again, this technique has evolved from an unwanted vascular signal artifact in spin-echo images acquired after contrast agent injection into a major mr application. with the development of new contrast agents with a longer half-life in the vascular system, the so-called intravascular contrast agents, contrast-enhanced mra has been developed even further. in this section, techniques for mra with either intravascular or extracellular contrast agents will be presented. the visualization of the blood vessels with mri relies particularly on the specific properties of blood. blood consists nearly entirely of liquids, so that blood has a very high spin density and thus yields a strong mr signal. the t1 time of blood is long compared to that of other tissues (e.g., 1 200 ms at 1.5 t) (gomori et al. 1987) , and it depends on its oxygenation state. long t1 values are a disadvantage in t1-weighted acquisition strategies as the signal decreases with increasing t1. this disadvantage can be converted into an advantage if the blood signal needs to be suppressed (black-blood angiography) for visualization of the vessel walls. furthermore, using an inversion (or saturation) recovery technique, the prepared magnetization can be tracked for a longer time, as the preparation persists much longer than in other tissues; this is the basis of arterial spin labeling techniques. typical t2 values are of the order of 150-200 ms (at 1.5 t). this t2 value is long enough to provide a high signal in the blood vessels using dedicated t2-weighted image acquisition strategies. with conventional t2weighted spin-echo techniques, mr angiographies are difficult to acquire since the motion of the blood needs to be compensated; nevertheless, t2-weighted mra pulse sequences for imaging of the peripheral vasculature have been reported (miyazaki et al. 2000) . another approach is the use of balanced ssfp pulse sequences, where the contrast is dependent on the ratio of t1/t2-these fast pulse sequences have found a widespread use in the visualization of the cardiac system. in addition to the relaxation times, blood velocity is an important parameter. in healthy arterial vessels velocity values between 100 cm/s (e.g., in the aortic arch) and 30 cm/s (e.g., in the intracranial vessels) are common, whereas much lower values are found in the venous vasculature. high blood flow velocities lead to a pronounced inflow of fresh, unsaturated magnetization into an imaging slice, which increases the signal in the blood vesselsthis is the well-known time-of-flight contrast. furthermore, the velocity in the arterial system is not constant but changes as a function of time in the cardiac cycle. this pulsatility can be exploited to separate arterial from venous vessels, if image data are acquired with cardiac synchronization. all of the presented mra techniques rely on these properties of the blood; some exploit only one of them, whereas others use a combination of them to increase the vascular contrast even further. in any mr pulse sequence, the magnetization in a measurement slice is exposed to a series of radio frequency (rf) pulses. if the magnetization does not move out of the measurement slice (e.g., in static tissue) it approaches a so-called steady state which, for a spoiled gradient-echo pulse sequence, depends on the flip angle, the repetition time tr, and the relaxation times t1 and t2. the steady state magnetization is smaller than the magnetization at the beginning of the experiment-it is partially saturated. fresh, unsaturated blood flowing into the imaging slice is carrying the full magnetization and thus generates a significantly higher mr signal (fig. 2.7 .1); this is known as time-of-flight (tof) contrast (anderson and lee 1993; potchen et al. 1993) . a major disadvantage of tof mra is the sensitivity to blood signal saturation: the longer the inflowing blood remains in the measurement slice, the more its signal is saturated. in situations where the blood vessel is oriented over a long distance parallel to the imaging slice (or 3d slab), the inflowing magnetization is progressively saturated. thus, blood appears bright near the entry site but is seen less intense with increasing distance from this position. to maintain the tof contrast over the whole imaging volume tof mra should therefore be performed as a 2d acquisition with thin slices or, if a 3d acquisition technique is preferred, in the arterial vasculature where high-flow velocities result in fewer saturation pulses for the arterial blood. the inflow effect can be maximized if the measurement slice is oriented perpendicular to the blood vessel. this is often possible for the straight arterial vessels (e.g., the carotids in the head), but can be difficult for extended vascular territories with tortuous vessels. in 3d acquisitions of larger vessel structures, the saturation effect can be partially compensated, if the flip angle is increased from the entry side of the slab to the exit side (fig. 2.7.2) . thus, the saturation effect is less pronounced during entry, and the magnetization is still visible when it enters smaller vessels that are far away from the entry side. often, an rf pulse with a linearly increasing flip angle is utilized (tilted optimized non-saturating excitation, or tone [nagele et al. 1995] ). for an optimal vessel contrast the blood flow velocity, the repetition time, the mean flip angle, and the slope of the rf pulse profile are important parameters. in 2d tof mra, a very strong tof contrast can be achieved, if the slice thickness d is chosen such that the magnetization flowing with a velocity v is completely replaced during one tr interval, i.e. d ≤ tr · v. at a typifig. 2.7. 1 transient longitudinal magnetization, which is subjected to a series of excitation pulses (30°) at a repetition time of 30 ms after entering the readout slice at t = 0 during tof mra. the longer the blood spins remain in the slice the more they are saturated, and a differentiation between blood and surrounding tissue becomes difficult fig. 2.7 .2 3d tof mra data set of the intracranial vasculature in lateral (top) and axial (bottom) maximum intensity projection. to minimize saturation, a tone rf pulse was used for excitation, and the signal from static brain tissue was additionally suppressed using magnetization transfer pulses cal tr of 10 ms and a blood flow velocity of 40 cm/s, the slice thickness should thus not be larger than 4 mm. with these small slice thicknesses, the data acquisition in larger vascular territories such as the legs is very timeconsuming, and patient movements cannot be excluded during the several minutes of scan time. patient movements lead to artificial vessels shifts between the imaging slices, which are particularly observed in orthogonal data reformats-these artifacts can mimic pathologies such as stenoses and thus significantly reduce the diagnostic quality of the data sets (fig. 2.7.3) . 3d tof mra is advantageous over sequential 2d tof mra because an isotropic spatial resolution in all directions can be achieved. to reduce the saturation effects in 3d tof mra not only one thick, but also several thinner 3d slabs are acquired consecutively. thus, the saturation effects are smaller for the individual slabs and a stronger tof contrast is seen. unfortunately, the flip angle in fast 3d acquisitions is not constant over the slab, but is declining towards its margins. this inhomogeneous excitation results in a higher signal for the stationary tissue at the slab margin, providing an inhomogeneous signal background in lateral views of the data. combined with a higher tof contrast at the entry side compared with the exit side, spatially varying signal intensity is seen in lateral views of the whole data set (venetian blind artifact). to reduce this artifact, overlapping 3d slabs are acquired (multiple overlapping thin slab acquisition, or motsa [parker et al. 1991] ), and the marginal slices of each slab are removed; however, this results in an increased total scan time. to increase the contrast between the blood vessels and the surrounding tissue in tof mra, often magnetization transfer pulses are included in the pulse sequences (edelman et al. 1992 ). using off-resonant rf pulses, the magnetization transfer contrast (mtc) selectively saturates those tissues where macromolecules are present. for brain tissue, these additional rf pulses can reduce the signal from background tissue by 40% and more, which increases the conspicuity especially of the smaller blood vessels. the use of magnetization transfer pulses however increases the minimally achievable tr and, thus, the total acquisition time. additionally, through the integration of the mtc pulses more rf power is applied to the patient, so that the regulatory power limits for the specific absorption rate (sar) might be exceeded, an effect that is more pronounced at higher field strengths. nevertheless, mtc is often included in intracranial tof mra protocols where longer trs can be an advantage, as long trs additionally reduce the saturation effect. the flow velocity in arteries is typically not constant but varies over the cardiac cycle. thus, the tof contrast is a function of time, so that for image acquisition times that are longer than one cardiac cycle, a signal variation during k-space sampling is present. this periodic signal variation results in phantom images of the blood vessels in phase encoding direction after image reconstruction: the so-called pulsation artifacts or ghost images (haacke and patrick 1986; wood and henkelman 1985) . to avoid pulsation artifacts, the image acquisition can be synchronized with the cardiac cycle using ecg triggering, which typically prolongs the total acquisition time, as only part of the measurement time is used for data acquisition. another option to reduce pulsation artifacts is to saturate the inflowing blood in a slice upstream of the imaging slice. therefore, a slice-selective rf excitation is applied in a (typically parallel) saturation slice, so that the magnetization of the inflowing blood is significantly reduced. spatial presaturation avoids pulsation artifacts; however, the interior of the blood vessel now has a negative contrast, and the positive tof contrast is gone. another important ingredient of a tof mra pulse sequence is flow compensation (cf. paragraphs on flow measurements, below): the movement of the spins causes an additional velocity-dependent phase shift that is seen in tof mra data sets without flow compensation as a displacement. if multiple velocities are present as in turbulent flow, the different phases can cause signal cancellation (intra-voxel dephasing) that manifests, e.g., as a signal void behind a stenosis (saloner et al. 1996) . with special compensation gradients the velocity-depentof mra data sets of the arterial vasculature in the neck. due to swallowing, the blood vessel can move from one acquisition to the next, and the edges appear with discontinuities in the lateral views of the maximum intensity projection dent phase shifts can be reduced; however, this typically prolongs the echo time te. tof mra is susceptible to several artifacts and is strongly dependent on a sufficient inflow velocity of unsaturated blood. therefore, 3d tof mra techniques are typically only used in the head, where the arterial flow velocities are high and enough time is available for imaging. for abdominal studies, tof techniques are of minor interest, because long measurement times are not possible due to respiratory motion. in conventional tof mra, the difference in longitudinal magnetization between the saturated stationary tissue and the unsaturated inflowing blood is exploited to create a positive contrast between blood and tissue. with arterial spin-labeling techniques, a similar approach is taken to the visualization of the inflowing blood; however, here only a certain fraction of the inflowing blood is tagged (or labeled) and subsequently visualized, whereas in tof mra all inflowing material is detected (detre et al. 1994) . spin-labeling pulse sequences consist typically of a labeling section, during which an rf pulse is applied to the spins upstream of the imaging slice (fig. 2.7.4) . for labeling often adiabatic inversion pulses are used, which are less susceptible to motion during the inversion and that allow inverting the magnetization even in rf coils with a limited transmit homogeneity (e.g., a transmit/receive head coil). after an (often variable) inflow delay time ti, during which the labeled blood is flowing into the vascular target structure, the signal in the imaging slice is acquired. for signal reception different image-acquisition strategies can be employed such as segmented spoiled gradient-echo (flash), fast spin-echo (rare, haste), or even echo planar imaging (epi). note: this image data set contains both the signal from the labeled blood and the static background tissue. in a second acquisition, the entire pulse sequence is repeated without labeling of the blood, and a second image data set is acquired. to selectively visualize only the labeled blood the two data sets are subtracted; since the signal intensity of the blood differs in both acquisitions, a non-vanishing blood signal is seen, whereas the signal contribution from static tissue cancels. if the phase of the second image data set is shifted by 180° compared to the first, labeled data set, the images can be added (the minus sign is provided by the phase), and the technique is called signal targeting with alternating radiofrequencies (star) (edelman et al. 1994) . in clinical mri systems, arterial spin labeling (asl) is typically implemented with the described labeling pulses, which are applied only once per data readout; this approach is also termed pulsed arterial spin labeling (pasl). another method for asl uses a small transmit coil for the labeling pulse, which continuously applies an rf pulse to the arterial vessel, and thus achieves a much higher degree of inversion. unfortunately, these continuous asl techniques often cannot be used in a clinical mr system due to the regulatory constraints for the maximum rf power applied to the patient (sar limits). asl techniques are typically applied to study perfusion in the brain and other organs, where the inflow delay is chosen long enough for the labeled blood to have reached the capillary bed (golay et al. 2004 ). unfortunately, the labeling in the blood does not persist for much longer than one t1 time (i.e., 1-2 s at 1.5 t), and the signal differences are generally very small (2-5% of the total signal), which makes perfusion measurement asl a time-consuming procedure. another application to asl is the time-resolved visualization of blood flow, e.g., in intracranial malformations (essig et al. 1996) , where saturation effects limit the diagnostic quality of conventional 3d tof mras. here, dynamic asl data sets are acquired at a series of inflow delays to visualize the transit of the labeled bolus through the nidus of the malformation, and, more importantly, the arrival of the blood in the draining venous vessels, concept of arterial spin labeling: magnetization is prepared (e.g., using a slice-selective inversion pulse) in a section of the artery (red). after an inflow delay of several hundred milliseconds, the magnetization has reached the imaging slice (green), and an image is acquired. the procedure is repeated without preparation, and the two data sets are subtracted to remove the signal background from static tissue that cannot be seen on the tof data sets (fig. 2.7.5) . in addition to a morphologic representation of these blood vessels, transit-time measurement of the blood becomes feasible, which could be used as an indicator, e.g., for an increase in vascular resistance after a radiation therapy. mr angiographies can also be acquired using the special contrast properties of blood. in balanced steady state free precession pulse sequences (bssfp, truefisp, fiesta), an image contrast is created that depends on the ratio of the relaxation times t1 and t2 (oppelt et al. 1986) . for blood, this ratio is high, and thus the interior of the blood vessels are shown with higher signal intensity than the surrounding tissue. unfortunately, other liquid-filled spaces such as the ventricles also appear with a bright signal, so that conventional mra post-processing strategies such as the maximum intensity projection cannot be used to visualize the vascular tree (fig. 2.7.6) . despite their short repetition times and balanced gradient schemes, these pulse sequences are susceptible to flow artifacts caused by intra-voxel dephasing, which can be compensated using flow-compensation gradients (storey et al. 2004; bieri and scheffler 2005) . another problem with balanced steady state pulse sequences is the susceptibility to off-resonance artifacts: since both transverse and longitudinal magnetizations contribute to the mr signal, perfect phase coherence must be main-tained within one tr to establish the desired contrast. in off-resonant regions, this phase coherence is perturbed, and a contrast variation is seen in the form of dark bands. the banding artifacts can be reduced using a repetition time that is shorter than the inverse of the off-resonance frequency, i.e., for a 200-hz off-resonance, the tr should be shorter than 5 ms. off-resonance frequencies scale with field strength, so that banding artifacts become an increasing problem at higher field strengths. nevertheless, fast balanced ssfp pulse sequences are increasingly used in mra studies of the heart and the neighboring vessels in combination with ecg triggering to visualize the vascular anatomy and to assess. in conventional spin-echo images, one often observes that the interior of the blood vessels is darker than the surrounding tissue. this so-called black-blood contrast is caused by an incomplete signal refocusing of the 180° pulse. compared with tof mra with gradient-echo sequences, where the inflow of blood causes signal amplification, spin-echo sequences attenuate the signal from flowing blood because spins leave the imaging slice between the 90° excitation pulse and the 180° refocusing pulse, and thus do not contribute to the mr signal. therefore, blood signal attenuation can be increased with a longer spacing between the two rf pulses, i.e., with longer echo times te. to further suppress signals from slowly flowing blood near the vessel walls, often addifig. 2.7 .5 tof mra (top) and timeresolved dynamic mra with arterial spin labeling (bottom) of an intracranial arteriovenous malformation. in the tof mra, the nidus of the malformation is clearly seen, but the draining vein can hardly be identified because the inflowing blood is already completely saturated when it arrives in this part of the avm. in the three asl images acquired 100, 600, and 1 200 ms after signal preparation, the filling of the nidus and the drainage through the vein is clearly visible tional strong gradients are introduced in the black-blood pulse sequences, which cause an increased intra-voxel dephasing and thus suppress the signal (lin et al. 1993) . a different technique for blood signal suppression makes use of an inversion recovery blood signal preparation (edelman et al. 1991 ): similar to arterial spin labeling a non-selective 180° inversion pulse is applied; however, the signal in the imaging slice is reinverted by a subsequent slice-selective inversion pulse. with this preparation ,the magnetization of the blood (and of all other tissues) outside the imaging slice is selectively inverted. after a delay-time that is chosen to achieve a zero crossing of the longitudinal magnetization of the inverted blood, an image is acquired. if the blood has been completely exchanged during the delay, then the signal of the labeled blood is nulled and only the static tissue is visible. this technique is often used in combination with cardiac triggering to visualize, e.g., the myocardium (fig. 2.7.7) . in cardiac black-blood applications, both techniques are combined, which is possible, because data are acquired during diastole when the heart is nearly at rest, whereas the signal preparation is applied during systole. in this image blood is seen with high signal intensity; however, the surrounding tissue also appears with a strong mr signal. in the ascending aorta, signal voids are seen which are caused by turbulent flow, and banding artifacts are visible in the subcuta-neous fat. nevertheless, balanced ssfp sequences provide good angiographic overview images in very short acquisition times, without the need for contrast agent injection. in the contrastenhanced data acquisition, a better background suppression is possible, and the projection image of the 3d data set clearly delineates the aorta and the adjacent vessels fig. 2.7 .7 ecg-triggered dark blood image of the heart acquired with a single-shot fast spin-echo technique (haste). the blood signal both in the heart and in the cross-section of the descending aorta is completely suppressed the tof contrast relies on the increase in signal amplitude due to the inflow of unsaturated magnetization. in addition to elevated signal amplitude, the spin movement can also create a change in the phase of the mr signal. if a gradient is turned on and blood moves along the gradient direction (here: the x-direction), the phase ϕ(t) of the mr signal is given by: (2.7.1) here, the motion x(t) of the magnetization is expressed as a taylor series, and only the constant term (i.e., the initial position x0) and the linear term (i.e., the velocity v0) are considered. the two integrals m0 and m1 solely depend on the gradient timing and are called the zeroth and first moment of g(t). the next higher order term is proportional to the acceleration of the spins; however, the proportionality constant m2 only becomes large if long time scales are considered; thus, the estimation of the spin phase from the zeroth and first moments is justified for gradient-echo sequences with short echo times. if the gradient timing is modified such that the first moment is zero, the gradients are called flow compensated. flow compensation is important ingredient in many mr pulse sequences: if a range of velocities is present in a single voxel, then the mr signal amplitude is attenuated due to the incoherent addition of the signals. with flow compensation, the individual signals all have the same phase, and the signals of the different velocities add up coherently. flow compensation is especially important in regions of high velocity gradients as, e.g., turbulent jets or in highly angulated vessels. in general, both m0 and m1 will be non-vanishing, and the phase of the signal will become proportional to the local spin velocity. unfortunately, many other factors such as off-resonance, field inhomogeneity, or chemical shift also affect the spin phase, so that a direct velocity measurement is not possible with a single mr experiment alone. to create an mr image that is dependent on the local velocity, a minimum of two image acquisitions are required. in the first, velocity-sensitized acquisition a gradient timing is used with a carefully selected, nonvanishing first gradient moment (the zeroth moment is defining the spatial encoding, i.e., the k-space trajectory). in a second, flow-compensated acquisition, a gradient timing is chosen that cancels m1. if the two phase images are directly subtracted, the result is a phase difference image that is linearly dependent on the spin velocity: this is the basis of an mr flow measurement (bryant et al. 1984) . since phase data are only unambiguous in the angular range of ±180°, so is the velocity information in an mr flow measurement. to avoid artifacts due to multiple rotations of the spin phase (so-called wrap around artifacts), the first moment needs to be chosen such that the maximum velocity in the image creates a phase shift of 180°. in general, this velocity is set via the so-called velocity encoding, or venc, parameter in the pulse sequence. higher venc values require weaker encoding gradients, which can be realized in shorter echo times. despite an inadequate choice of the venc value, mr flow measurements are susceptible to phase noise, which is present in regions of low signal amplitude. if the snr is 1 or less, the phase in the image is nearly uniformly distributed between -180° and +180°; under these conditions a meaningful flow measurement is not possible. unfortunately, phase noise is also often present near blood vessels (e.g., in the air-filled spaces of the lung, close to the pulmonary vessels). here, the measurement of velocity values requires a very careful placement of the regions of interest (rois) to avoid systematic errors from included noise pixels. in a conventional flow measurement, velocity encoding is typically performed in slice-selection direction only, because the orthogonal placement of the flow measurement slice induces a high tof signal in the cross-section of the vessel lumen. additionally, a parallel orientation of the velocity encoding direction with the image plane makes the image acquisition susceptible to systematic errors due to displacement, as, e.g., the readout gradient are used for both spatial encoding and velocity measurement simultaneously. flow measurements in arterial vessels are often performed with cardiac synchronization to account for the pulsatility of the blood flow. cardiac synchronization can be performed by prospective ecg triggering or retrospective ecg gating. with prospective triggering, data acquisition is started by a trigger signal, which is generated by the ecg electronics during the qrs complex of the ecg (fig. 2.7.8) . after data have been acquired for a certain number of cardiac phases, the measurement sequence is stopped until a new cardiac trigger signal is detected. in retrospective gating, image data are continuously acquired, and the time between the last trigger and the current data set is stored. later, data are resorted into predefined time intervals (bins) in the cardiac cycle, and the images are reconstructed. prospective triggering is less time-consuming during image reconstruction and is very precise in the delineation of the cardiac activity; however, a temporal gap at the end of the cardiac cycle is required and thus flow measurements at late diastole are difficult. prospective gating uses continuous image acquisition, and the magnetization steady state is always maintained. unfortunately, more data need to be acquired than with prospective triggering to ensure a sufficient coverage of the cardiac cycle, and a temporal blurring due to the interpolation is seen in the velocity data. when the complex image data of the two acquisitions are subtracted instead of the phases, and the magnitude of the difference is displayed, a so-called phase-contrast mra image is created (dumoulin 1995) . this pc mra image is not only dependent on the velocity of the spins, but also on the signal amplitude in both acquisitions; thus, every pc mra data set always has an overlaid tof contrast (fig. 2.7.9 ). an advantage of pc mra is the fact that signal background of the surrounding stationary tissue is almost completely suppressed, and vessels can be traced further into the vascular periphery than with tof mra, with comparable measurement parameters. in pc mra, often not only the velocity in one spatial direction is encoded, but in all three directions. since separate velocity-encoded acquisitions have to be performed for each direction, the measurement time of a pc mra is twoto fourfold longer than that of a tof mra. a careful selection of the venc value is especially important in pc mra. if, e.g., the maximum velocity in the imaging slice is twice the venc value, a phase shift of 360° (or 0°, which cannot be distinguished) is created. under these conditions, the velocity-encoded and the velocity-compensated acquisition have the same phase, and no pc mra signal would be observable. as blood does not flow with a constant velocity and velocity values can be reduced by pathologies (aneurysms) or increased (stenoses), the optimum choice of venc value is often difficult. because pc mra is more time-consuming, is susceptible to artifacts, and suffers from the same signal saturation as tof mra, it is rarely used in clinical routine. with tof and pc mra techniques, the blood motion is used to create a signal difference between the vessel lumen and the surrounding tissue, whereas contrastenhanced mra utilizes the reduction of the longitudinal relaxation time t1 after administration of a contrast agent. when a contrast agent is injected, the t1 of blood is shortened from t1blood = 1.2 s (for b0 = 1.5 t) to less than 100 ms during the first bolus passage (first pass). the relaxation rate r1 (i.e., 1/ t1) is a function of the local contrast agent concentration: (2.7.2) the proportionality constant between contrast agent concentration c and the change in relaxation rate is called the relaxivity r1. the relaxivity is different for each contrast agent typical values range from 4 to 10 mmol -1 s -1 . in general, high relaxivities are desirable because lower contrast-agent concentrations are needed to achieve the same change in image contrast. to enhance the signal in the contrast agent bolus and to suppress the signal background from static tissue, heavily t1-weighted spoiled gradient-echo sequences (flash) with very short repetition times (tr < 5 ms) and high flip angles (α = 20°-50°) are used (fig. 2.7.10) . the use of short trs is advantageous because very short acquisition times of only a few seconds can be achieved even for the acquisition of a complete 3d data set. these short acquisition times are needed, because the contrast agent is progressively diluted during the passage, which reduces the vessel-to-background contrast. short acquisition times are also favorable because mra data sets can thus be acquired in a single breath hold; for this reason, contrast-enhanced mra techniques are especially suited for abdominal applications (prince 1996; sodickson and manning 1997) . to ensure isotropic visualization of the vascular territories, typically 3d techniques are used for data acquisition. conventional 3d techniques have measurement times of several minutes, so that even with short repetition times larger parts of the k-space data are acquired after the contrast agent concentration has fallen to levels where only a weak signal enhancement is observable. for this reason, the measurement times are reduced using partial k-space sampling, parallel imaging, and view sharing between subsequent 3d data sets (sodickson and manning 1997; wilson et al. 2004; goyen 2006) . in general, contrast agents can be categorized into extracellular agents that can leave the blood stream and intravascular agents that are specifically designed to remain in the vascular system. historically, the first approved mr contrast agent was gd-dtpa (gadopentate dimeglumine, magnevist, schering, germany), an extracellular agent, which has the paramagnetic gd 3+ ion as the central atom in an open-chain ionic complex (chelate). over the years, several similar extracellular agents such as gd-bt-do3a (gadovist, schering), gd-dota (dotarem, guerbet, france), gd-bma (omniscan, ge healthcare), gd-hp-do3a (prohance, bracco imaging, italy), and gd-bopta (multihance, bracco, italy) have been approved for clinical use, which only slightly differ in the stability of the gd chelates, pharmacokinetic properties, and safety profiles. in general, the most recently approved contrast agents have higher relaxivities and thus allow acquiring mra data sets with higher contrast at the same dose or with similar contrast at lower dose. only recently, the first intravascular contrast agent gadofosveset trisodium (vasovist, schering) has been approved for clinical use in europe (goyen 2006 ). this fig. 2.7.9 phase-contrast images encoding flow in head-foot (top) and left-right (center) direction, and phase contrast mra image (bottom). in the flow images, a velocity-sensitive and a velocity-compensated data set are subtracted, whereas the pc mra image is generated by complex subtraction of the respective signal amplitudes. note, that the pc mra image has nearly no background signal from static tissue molecule has a diphenylcyclohexyl group, which is covalently bound to a gd complex, which creates a reversible, non-covalent binding of the molecule to serum albumin that significantly prolongs the half-life of the agent in blood to about 16 h. after injection of the agent, at first a more rapid decline of concentration is observed, because the fraction of the contrast agent bound to albumin is dependent on the contrast agent concentration; thus, a steady-state concentration is established after the unbound fraction is renally excreted. both extracellular and intravascular agents can be imaged during the first pass of the contrast agent, when a high vessel-to-background contrast is present, whereas intravascular contrast agents additionally allow angiographic imaging during the subsequent steady state. the t1 shortening is dependent on the contrast agent concentration, which is getting smaller already a few seconds after infusion of the contrast agent, as the contrast agent bolus in the blood is increasingly diluted and, for the extracellular agents, the contrast agent is extravasculized. therefore, contrast-enhanced mra techniques usually use pulse sequences with very short acquisition times (ta < 30 s). the short passage time of the contrast agent bolus of a few seconds requires that imaging be precisely synchronized with the contrast agent infusion. the transit time of the bolus from the point of injection (usually a vein in the arm) through to the vascular target structure (e.g., the renal arteries) varies significantly with the heart rate and cardiac output and can be difficult to predict. therefore, various synchronization and acquisition tech-niques have been proposed for a reliable mra data acquisition: an automatic technique to start the 3d mra data acquisition (smartprep™, general electric) uses a fast pulse sequence before the 3d mra, which continuously acquires the signal in the vascular target region . after administration of the contrast agent, this signal exceeds a certain signal threshold, and the 3d mra acquisition is automatically started. if the signal threshold is selected too low, image noise can mimic a bolus arrival and the measurement is triggered too early, whereas a too high value of the threshold can lead to an omission of the data acquisition. with the test bolus technique, a small bolus of a few milliliters of the contrast agent is infused, and the passage of the bolus is imaged near the target vessel with a fast time-resolved 2d mr measurement (earls et al. 1997) . the trigger delay td for the subsequent 3d measurement is then calculated from the transit time of the bolus tt and the acquisition time of the 3d mra ta as: td = tt necho × ta. here, necho denotes the fraction of ta before the center of k-space is acquired (fig. 2.7 .11). as in the automatic start of the sequence, fluoroscopic previews (carebolus™, siemens medical solutions) image the contrast bolus during its passage; however, here fast 2d sequences are used with real-time image reconstruction and display riederer et al. 1988; wilman et al. 1997) . once the bolus has reached the target region, the operator of the mr scanner manually switches to the predefined 3d mra pulse sequence, which is then executed with minimal time delay. fig. 2.7. 10 signal intensity as a function of t1-contrast in a spoiled gradient-echo pulse sequence (flash). at high flip angles and short repetition times the signal from tissue (t1 > 300 ms at 1.5 t) is nearly completely saturated, whereas a high intraluminal signal is seen due to the high concentrations of the contrast agent • multiphase mra time-resolved mra has been increasingly used to completely avoid manual or automated synchronization. multiphasic acquisitions consecutively acquire 3d mra data sets during the bolus passage so that the optimal vessel contrast is obtained in at least one of the data sets. various methods of measurement acceleration are combined to ensure adequate temporal resolution; these include parallel imaging, asymmetric k-space readout, and temporal data interpolation (korosec et al. 1996; fink et al. 2005 ). nevertheless, timeresolved mra data sets are usually of a lower spatial resolution than are optimally acquired mra data with bolus synchronization (fig. 2.7 .12). artifacts arise, if the 3d mra data acquisition is not perfectly synchronized with the bolus passage. the appearance of these artifacts depends on the relative timing of the k-space acquisition and the concentration-time curve of the contrast agent. if the bolus arrives too late in the target vessel, then the center of the k-space has already been sampled and large structures, such as the interior of the blood vessel, appear dark, whereas fine structures, such as vessel margins, have a high signal if the bolus arrives during sampling of the k-space periphery. if the data acquisition is started too late, then the bolus has already reached the target vessel and the contrast has partly disappeared -thus, the signal is significantly reduced compared with an optimally synchronized data acquisition (maki et al. 1996; wilman et al. 2001; svensson et al. 1999) . another disadvantage of suboptimal bolus timing is the fact that the bolus may have passed from the arterial to the venous system in some vascular regions (e.g., the extremities) so that both veins and arteries are seen in the images. this venous contamination makes the interpretation of the image data difficult in cases where arterial and venous vessels are parallel to each other. the variation in contrast agent concentration over time also results in a reduction in the achievable image resolution (fain et al. 1999) . the spatial resolution of an mr image sampled with cartesian data acquisition is always uniquely defined by the measured number of k-space lines. with increasing number of k-space lines (i.e., larger k-space coverage), finer image details are encoded in the image. this so-called nyquist scanning theorem only applies if the signal intensity is constant during data acquisition. even with perfect synchronization with the contrast agent bolus, the contrast agent concentration is only optimal during acquisition of the central k-space lines. later on, the concentration is reduced and the peripheral k-space regions are acquired with significantly reduced signal intensity (fig. 2.7.13 ). this different weighting of the k-space regions results in a reduction in spatial resolution (blurring), which is mathematically described by the point-spread function, psf. the psf is the image of a point object for linear imaging systems, it is used to describe the imperfections of the image acquisition system. the psf depends on the acquisition time, the contrast agent dynamics, and the measurement parameters of the pulse sequence. the deviation from an ideal psf is particularly visible in those spatial directions that are acquired with the lowest sampling velocity. in conventional 3d acquisition, this is either the phase encoding direction or the partition encoding direction. to eliminate this asymmetry and to fig. 2.7 .11 test bolus measurement in the heart (blue) and the aorta (red) of a patient. for an optimal visualization of the aortic arch, a time delay of 16 s is required between contrast agent injection and the acquisition of the central k-space lines evenly distribute the blurring in both spatial directions, elliptical scanning of the phase and partition encoding steps has been proposed (bampton et al. 1992; , where the encoding steps are acquired along an elliptical path, starting from the center of the k-space. using the signal-time curve of a test bolus, the signal variation during data acquisition can be avoided. therefore, an injection scheme is calculated for the signal-time curve using linear system theory, where the injection rate is modulated such that there is a constant contrast agent concentration (i.e., an ideal psf) in the target region throughout the data acquisition. this technique requires a programmable contrast-agent injector and additional computations, and the constant concentration can only be achieved in a limited target volume. another option for reducing the intensity changes is to induce a blood flow stasis for a brief period after contrast agent inflow. this can be achieved in the peripheral blood vessels, without endangering the patient using an inflatable cuff, which temporarily blocks the blood flow during data acquisition; this technique has been used successfully applied to contrast-enhanced mra studies of the hand (zhang et al. 2004 ) and the legs (zhang et al. 2004; vogt et al. 2004) . in addition to reducing t1, an mr contrast agent always also reduces t2 (and t2*). the reduction in t2* can lead to a significant signal reduction in the mra image at high contrast agent concentrations; often the venous vessel through which the bolus is infused are seen dark in the mra data sets (albert et al. 1993) . to avoid these ar-tifacts, the contrast agent concentration or the echo time te can be reduced. besides reducing t2*, the contrast agent also causes a concentration-dependent resonance frequency shift. radial or spiral k-space data acquisitions especially susceptible to these frequency shifts that cause blurring artifacts, which can be compensated using dedicated off-resonance correction algorithms. contrast-enhanced mra studies are also susceptible to artifacts known from tof mra. in particular, pulsation artifacts are visible in contrast-enhanced measurements (al-kwifi et al. 2004) . intra-voxel dephasing is observed, although the effect is much lower due to the shorter tes used here. to keep the acquisition time short, generally flow compensation is not integrated into contrast-enhanced mra pulse sequences, because the additional gradients significantly prolong the measurement time. contrast-enhanced mra offers substantial advantages over tof or pc mra, because the saturation effects seen in tof mra are almost completely avoided. thus, extended vascular structures for example in the abdomen or the extremities can be visualized with a few slices oriented parallel to the vessel. the short acquisition times of contrast-enhanced mra allow breath-held acquisitions (ta < 30 s), which significantly reduces motion artifacts . the dynamic information of multiphase 3d mra contains information about vascular anatomy, flow direction (e.g., in aortal aneurysms), tissue perfusion (e.g., in the kidney), and vascular anomalies, which might not be visible on a single mra data set. using intravascular agents, the contrast agent concentration in the blood is maintained over time spans of minutes to hours. in general, the same pulse sequences can be applied for mra with intravascular contrast agents as with the extracellular contrast agents, as they share the same contrast mechanism; however, as the concentration of intravascular contrast agent in blood attains an equilibrium state after a few re-circulations (typically 20-40 s), mra data sets can also be acquired over longer acquisition times. this prolonged acquisition window can be used to increase the image resolution, because an ideal psf can be achieved and, thus, no blurring should be present (van bemmel et al. 2003a; grist et al. 1998) . because data acquisition does not have to be synchronized with the contrast agent bolus, data acquisition can be started once the contrast agent concentration has reached equilibrium. the contrast agent injection does not need to be performed with a contrast agent pump, but can be infused manually via a venous access port even prior to the mr examination. with intravascular contrast agents, the acquisition time ta is not limited by the transit time of the bolus, and data sets can be acquired over much longer acquisition periods. with longer acquisition times, special trigger and gating techniques (ecg triggering, respiratory gating, navigator echoes [ahlstrom et al. 1999] ) to suppress motion artifacts are required. if image data are acquired in the equilibrium phase, venous overlay is a fundamental problem in mra with intravascular contrast agents (fig. 2.7 .14). venous contamination particularly makes those images hard to interpret that are calculated through a projection technique such as the maximum intensity projection (mip), because here, the depth information is lost. a separation of arterial and venous vessels is possible with the help of dedicated post-processing software. therefore, a region in an arterial vessel is identified and a region-growing algorithm is used to find all connected regions. unfortu-nately, when arteries and veins are in close proximity the algorithm may artifactually connect arterial to venous vessels. with equilibrium-phase mra, data sets of intravascular contrast agents, these artifacts are easier to avoid than in first-pass studies because of the higher spatial resolution. nevertheless, for direct arteriovenous connections or shunts, a manual correction of the segmentation is always required (van bemmel et al. 2003b; svensson et al. 2002) . the use of intravascular contrast agent is not limited to the equilibrium phase, but can be combined with a first-pass study during the initial contrast agent injection to obtain both the dynamics of the contrast agent passage as well as the vascular morphology (grist et al. 1998) . additionally, the dynamic information can be utilized to separate arteries from veins in the high-resolution equilibrium-phase 3d mra data sets (bock et al. 2000) . although the long half-life of the intravascular contrast agent is advantageous for intraluminal studies, it can become a problem if a dynamic study has to be repeated. with extracellular contrast agents, this is possible within a few minutes, whereas up to several hours have to be waited after a study with an intravascular contrast agent. in practice, intravascular contrast agents are still advantageous for mra, as they allow combining high spatial resolution in the equilibrium phase with dynamic information during first passage. additionally, these contrast agents can be used to quantify perfusion (prasad et al. 1999) or to delineate vessels during mr-guided intravascular procedures (wacker et al. 2002; martin et al. 2003 ). various techniques for mr angiography and mr flow measurements exist that make use of the different physical properties of blood: flow, pulsation, or signal variation following administration of contrast agent. tof mra is often used in anatomical regions where a high inflow is fig. 2.7 .14 surface rendering (left) and mip (right) visualization of an abdominal mra with an intravascular contrast agent. the three-dimensional character of the data set is better captured with the surface display, whereas the finer details are better visualized on the mip. the presence of venous signal is making the interpretation of the data more difficult; however, a significantly higher spatial resolution can be achieved with intravascular contrast agents present, and long measurement times can be tolerated. phase-contrast flow measurements provide a quantitative assessment of blood flow when combined with cardiac triggering. contrast-enhanced studies are favorable in abdominal regions and the periphery, where saturation effects are a limiting factor for tof mra. intravascular contrast agents further extend the capabilities of contrastenhanced mra because high-resolution data sets can be acquired over an extended time. diffusion in the context of diffusion-weighted mri or diffusion tensor imaging (dti) refers to the stochastic thermal motion of molecules or atoms in fluids and gases, a phenomenon also known as brownian motion. this motion depends on the size, the temperature, and in particular on the microscopic environment of the examined molecules. diffusion measurements can therefore be used to derive information about the microstructure of tissue. in mri, stochastic molecular motion can be observed as signal attenuation. this was first recognized in the nmr spin-echo experiment by e.l. hahn in 1950 (hahn 1950 , long before the invention of actual magnetic resonance imaging. a number of more sophisticated experiments were described in following years that allowed the quantitative measurement of the diffusion coefficient (carr and purcell 1954; torrey 1956; woessner 1961) . of particular importance is the pulsed-gradient spin-echo (pgse) technique proposed by stejskal and tanner in 1965 (stejskal and tanner 1965) that is described in detail in sect. 2.8.3.1. diffusion as an imaging-contrast mechanism was first incorporated in mri pulse sequences in 1985 (taylor and bushell 1985; merboldt et al. 1985 ) and applied in vivo in 1986 (lebihan et al. 1986 ). its great potential for clinical mri became evident in around 1990, when diffusionweighted images were recognized to be extremely valuable for the early detection of stroke (moseley et al. 1990a,b; chien et al. 1990 chien et al. , 1992 . areas of focal cerebral ischemia appear hyperintense in diffusion-weighted images only minutes after the onset of symptoms (see also chap. 3, sect. 3.4) . having thus been pushed into publicity, diffusion-weighted imaging was evaluated in many other applications such as the characterization of brain tumors (tien et al. 1994; sugahara et al. 1999; okamoto et al. 2000) and of multiple sclerosis lesions (cercignani et al. 2000; filippi and inglese 2001) , but none of these reached the clinical significance of stroke diagnosis. mainly due to limitations of image quality, there are considerably fewer publications about diffusion-weighted imaging outside the central nervous system. examples of these are studies with the purpose of differentiating osteoporotic and malignant vertebral compression fractures (baur et al. 1998 (baur et al. , 2003 herneth et al. 2002) or benign and malignant lesions of the liver (moteki et al. 2002; taouli et al. 2003) and the kidneys (cova et al. 2004) . molecular diffusion is a three-dimensional process and is-depending on the tissue microstructure-in general anisotropic, i.e., the extent of molecular motion depends on spatial orientation. a physical quantity called the diffusion tensor is required to fully describe anisotropic diffusion. mri techniques to measure the diffusion tensor have been introduced in the 1990s (basser et al. 1994; pierpaoli et al. 1996) and gained considerably more popularity when tracking algorithms were proposed for three-dimensional reconstruction of white matter fiber tracts (mori et al. 1999; conturo et al. 1999) . today, diffusion tensor imaging is a valuable research tool with applications, e.g., in neurodevelopment snook et al. 2005) , neuropsychiatry (taber et al. 2002 , sullivan and pfefferbaum 2003 , or aging (moseley 2002 , sullivan and pfefferbaum 2003 , sullivan et al. 2006 ). all molecules in fluids or gases perform microscopic random motions. this motion is called molecular diffusion or brownian motion after robert brown (1773 brown ( -1858 , who observed a minute motion of plant pollens floating in water in 1827 (brown 1866) . these pollens were constantly hit by fast-moving water molecules, resulting in a visible irregular motion of the much larger particles. due to brownian motion, a tracer such as a droplet of ink given into water will diffuse into its surroundings, resulting in spatially and temporally varying tracer concentrations, until the ink is diluted homogeneously in the water. however, brownian molecular motion does not require concentration gradients, but occurs also in fluids consisting of only a single kind of molecule. the molecules of any arbitrary droplet of water within a larger water reservoir will stochastically disperse into their surroundings; this process is called diffusion or, to emphasize that the observed molecules do not diffuse into an external medium, self-diffusion. it should be noted that diffusion always refers to a stochastic and not directed motion and is strictly to be distinguished from any kind of directional flow of a liquid. the molecules in fluids or gases perform random motions due to their thermal kinetic energy, ekin, which is proportional to the temperature, t: ekin = -2 3 kt (k = 1.38 × 10 -23 j/k is the boltzmann constant). this energy corresponds to a mean velocity 1 m e v kin 2 = for a molecule of mass m; in the case of water at room temperature (t = 300 k), the mean velocity is about 650 m/s. due to frequent collisions with other particles, however, mol-strictly speaking, we calculate the square root of the mean value of squared velocity, i.e., mean (ν�) , which is slightly different (by a factor of 3π / 8 ≈ 1.085, i.e., by 8.5%) from the actual mean value of the velocity due to the asymmetry of the maxwell distribution. ecules do not move linearly in a certain direction but follow a random course that can be visualized in a randomwalk simulation as shown in fig. 2 .8.1a. this figure also demonstrates that, macroscopically, the mean displacement or diffusion distance, s, after a time t is much more interesting than is the linear velocity of the molecule. the mean diffusion distance of a particle is proportional to the square root of the diffusion time t and is described by the diffusion coefficient d: . this relation is shown in fig. 2. 8.1b for a water molecule with a diffusion coefficient of d = 2.03 × 10 -3 mm 2 /s at a temperature of 20°c. since diffusion is a stochastic process, the diffusion distance after the time t is not the same for all molecules but is described by a gaussian probability distribution as illustrated in fig. 2.8.2 . as shown in this illustration, after a diffusion time t most molecules are still found at or close to their original position; the diffusion distance s, corresponds to the standard deviation of the shown distributions. typical diffusion distances for free water molecules at room temperature are about 25 µm after a diffusion time of 50 ms and 110 µm after 1 s. in contrast to free diffusion in pure water ( fig. 2.8.3a) , the water molecules in tissue cannot move freely, but are hindered by the cellular tissue structure, in particular by cell membranes, cell organelles, and large macromolecules as shown schematically in fig. 2 .8.3b. due to additional collisions with these obstacles, the mean diffusion distance of water molecules in tissue is reduced compared to that of free water, and a decreased effective diffusion coefficient is found in tissue called the apparent diffusion coefficient (adc). obviously, the adc depends on the number and size of obstacles and therefore on the cell types that compose the tissue. hence, diffusion properties can be used to distinguish different types of tissue. examples of diffusion coefficients in different tissues and in fluids at different temperatures are summarized in table 2 .8.1. not only does the number and size of organelles influence diffusion, but also the geometrical arrangement of the cell membranes. in particular, the diffusion of water molecules can reflect an anisotropic arrangement of cells as indicated in fig. 2 .8.3c. since cell membranes are barriers for diffusing molecules, water diffuses more freely along the long axis of the cell than perpendicular to it (beaulieu 2002) . hence, the adc measured in the direction parallel to the cellular orientation will be greater than that measured in an orthogonal direction. this property, the dependence of a quantity on its orientation in space, is called anisotropy. it has proven useful to illustrate the diffusion properties by spheres for isotropic diffusion and by three-dimensional ellipsoids for anisotropic diffusion as shown in fig. 2.8 .3d-f. these shapes visualize the probability density function of diffusion distances in space. isotropic diffusion can be completely described by its (apparent) diffusion coefficient, d, which corresponds to the radius of the sphere (fig. 2.8.3d,e) . more quantities are required for a complete description of anisotropic diffusion, e.g., three angles that define the orientation of the ellipsoid in space, and the length of the three principal axes describing the magnitude of the diffusion coefficients. in physics or mathematics, a quantity that corresponds to such a three-dimensional ellipsoid is called a tensor. the physical object called tensor can also be explained by comparing it to more commonly known objects such as scalars and vectors. a scalar is a quantity that can be measured or described as a single number; typical examples are the temperature, the mass, or the density of an object. in imaging, the image intensity, e.g., in a t2-weighted image, is a scalar: a single number is required for each pixel to describe the intensity. as demonstrated in the last example, scalars can be spatially dependent and be visualized as intensity maps; another example is a temperature map of an object that describes the temperature as scalar quantity for each spatial position of an object. other physical quantities cannot be described by a single number, such as the velocity or acceleration of a particle in space or the flow of a liquid. these quantities are vectors and require both a direction in space and a magnitude to be fully described. a vector is typically visualized as an arrow. for example, in the case of velocity, the direction of the arrow describes the direction of motion and the length of the arrow represents the magnitude of the vector, e.g., as measured in meters/second. such an arrow can be mathematically described by three independent numbers: either by its length and two angles defining its orientation or by three coordinates (x-, y-, and z-component of the vector). these coordinates are often presented as a column or row vector, e.g., v = (vx vy vz). vectors as well as scalars can depend on the spatial position; a flowing liquid can be described by a velocity vector at each position. a full data set consisting of a vector (i.e., an arrow) at each point in space is called a vector field. some quantities such as the molecular diffusion cannot be fully described as scalars or vectors; they are tensors. as mentioned above, the diffusion properties can be depicted by a three-dimensional ellipsoid and therefore require six independent numbers to define the direction and length of all axes. these six values are visualized in fig. 2.8.4 as the three lengths of the axes defining the shape of the ellipsoid and the three angles describing its orientation. however, instead of using angles, tensors can equally well be described by six coordinates arranged in a symmetric 3 × 3-matrix in analogy to the three coordinates of a vector. these coordinates are called dxx, dyy, dzz, dxy, dxz, and dyz and form the matrix representation this matrix is called symmetric because the elements are mirrored at the diagonal. of these matrix elements, only the diagonal elements, dxx, dyy, dzz, can be measured directly in mri and correspond to the diffusion in the x-, y-, and z-directions; the off-diagonal elements must be determined indirectly from further measurements as described in sect. 2.8.4. in the case of isotropic diffusion, i.e., if the ellipsoid is a sphere, then this matrix has a very simple form, because a single diffusion coefficient suffices to describe the diffusion. this diffusion coefficient is found on the diagonal of the matrix, and all off-diagonal elements are zero: the diffusion tensor has some properties that are important to understand in order to measure and interpret diffusion imaging data. the mean diffusivity, i.e., the diffu-sion coefficient averaged over all spatial orientations, can be derived from the trace of the diffusion tensor, i.e., the sum of its diagonal elements: . an mri measurement of the mean adc is therefore also called trace imaging. to analyze the non-isotropic properties of the diffusion tensor, a process called diagonalization of the tensor is used. the meaning of tensor diagonalization can be visualized as finding the three axes (i.e., their length and orientation) that define the ellipsoid in fig. 2.8.4 . mathematically, the tensor matrix is transformed into a form where all off-diagonal elements are zero: since six parameters are still required to fully describe the tensor, in addition to the three diagonal elements, three vectors, v1, v2, v3, are determined which are called eigenvectors. the eigenvectors, which are always orthogonal and have unit length, define the orientation of the ellipsoid and are shown as thick grey arrows in fig. 2 .8.4d. the ratios of the diffusion eigenvalues describe the isotropy or anisotropy of diffusion. in the case of isotropic diffusion, all eigenvalues are the same, d1 = d2 = d3, and diffusion is represented by a sphere; see fig. 2 .8.5a. if the largest eigenvalue is much greater than the two other eigenvalues, d1 >> d2 ≈ d3, then the tensor is represented by a cigar-like shape as in fig. 2 .8.5b. in this case, diffusion in one direction is much less hindered than in the other directions and is sometimes called linear diffusion; this is typically found in white matter fiber tracts, where the motion of water molecules is restricted by the cell membranes and the glial cells perpendicular to the fiber tract orientation. the orientation of the fiber tracts is described by the eigenvector v1 belonging to the large eigenvalue, d1. if two large eigenvalues are much greater than the third one, d1 ≈ d2 >> d3, then the diffusion tensor is represented by a pancake-like shape; see fig. 2.8.5c . this tensor corresponds to preferred diffusion within a twodimensional plane, which can occur in layered structures and is referred to as planar diffusion. in order to describe the diffusion anisotropy quantitatively, several anisotropy indices have been introduced to reduce the diffusion tensor to a single number, i.e., a scalar, measuring the anisotropy. most frequently used is fig. 2.8.4 tensor visualized as three-dimensional ellipsoid: six independent numbers are required to define a tensor, three lengths (eigenvalues), d1, d2, d3, corresponding to the length of the principal axes of the ellipsoid (shown three-dimensionally in a and in two-dimensional sections b), and three angles, α, β, γ, describing the spatial orientation of the axes (c,d) . the eigenvectors of the tensor are shown as thick gray arrows in d the fractional anisotropy (fa), defined as where d = -1 3 (d 1 + d2 + d3) is the mean diffusivity. the fractional anisotropy ranges from 0 (isotropic diffusion) to 1 (maximum anisotropy) and can be interpreted as the fraction of the magnitude of the tensor that can be ascribed to anisotropic diffusion . a similar index is the relative anisotropy (ra), defined as the relative anisotropy is the magnitude of the anisotropic part of the tensor divided by its isotropic part and ranges from 0 (isotropy) to 414 . 1 2 ≈ (maximum anisotropy). in order to scale the maximum value of the ra to 1 as well, a normalized (or scaled) definition with an additional factor of 2 1 is sometimes used (and often called ra as well): less frequently used indices of anisotropy are the volume ratio (vr), all these anisotropy indices can be used to describe the diffusion anisotropy (kingsley and monahan 2005) , but fractional anisotropy may be considered the preferred index that is currently most frequently used. some typical values of these indices are compared in table 2 .8.2; fa, ra, nra, and vf start with 0 for isotropic diffusion and increase with increasing anisotropy. the volume ratio is 1 in the case of isotropic diffusion and decreases with increasing anisotropy. to introduce diffusion weighting in mri pulse sequences, today almost exclusively a technique proposed by stejskal and tanner in 1965 (stejskal and tanner 1965) is used. the basic idea is to insert additional gradients (usually referred to as diffusion gradients) into the pulse sequence in order to measure the stochastic molecular motion as signal attenuation. originally, these were two identical gradients on both sides of the refocusing 180° rf pulse of a spin-echo sequence: the so-called pulsed-gradient spin echo (pgse) technique. however, to simplify the explanation, we will replace this scheme with two gradients with opposite signs that do not require a 180° pulse in between, as shown in fig. 2 .8.6. the contrast mechanism is the same for both gradient schemes. as illustrated in fig. 2 .8.6, the diffusion gradients superpose a linear magnetic field gradient over the static field, b0. since the larmor frequency of the spins is proportional to the magnetic field strength, spins at different positions now precess with different larmor frequencies and, thus, become dephased. if the spins are stationary (no diffusion, i.e., diffusion coefficient d = 0) and remain at their position, the second diffusion gradient with opposite sign exactly compensates the effect of the first one and rephases the spins. hence, without diffusion, the signal after the application of the pair of diffusion gradients is the same as before (neglecting relaxation effects). in the case of diffusing spins, the second diffusion gradient cannot completely compensate the effect of the first one since spins have moved between the first and second gradient. the additional phase the spins gained during the first diffusion gradient is not reverted during the second one. consequently, rephasing is incomplete after the second diffusion gradient, resulting in diffusion-dependent signal attenuation. as can be deduced from this explanation, the signal attenuation is larger if the diffusivity, i.e., the mobility of the spins, is larger. quantitatively, the signal attenuation depends exponentially on the diffusion coefficient, dg, in the direction defined by the diffusion gradient gd: where s0 is the original (unattenuated) signal and s(dg, b) is the attenuated diffusion-weighted signal. the b-value, b, is the diffusion weighting that plays a similar role for diffusion-weighted imaging as the echo time for t2weighted imaging: the diffusion contrast, i.e., the signal difference between two tissues with different adcs, is low at small b-values and can be maximized by choosing the optimal b-value as discussed below. the b-value is expressed in units of s/mm 2 and depends on the timing and the amplitude, gd, of the diffusion gradients: as illustrated in fig. 2 .8.6, δ is the duration of each diffusion gradient, and ∆ is the interval between the onsets of the gradients; γ is the gyromagnetic ratio of the diffusing spins. a typical b-value used for diffusion-weighted imaging of the brain is 1,000 s/mm²; for other applications b-values range between 50 s/mm 2 (dark blood liver imaging) and about 20,000 s/mm 2 (imaging of the diffusion q-space [assaf et al. 2002; wedeen et al. 2005] ). to obtain b-values of about 1,000 s/mm 2 , diffusion gradients are required to be much longer (e.g., δ = 25 ms) and have larger amplitudes (e.g., gd = 25 mt/m) than normal imaging gradients applied in mri; hence, diffusion-weighted imaging can be demanding for the gradient amplifiers and is often acoustically noisy. the formula for the b-value given above is valid only for a pair of stejskal-tanner diffusion gradients. the diffusion weighting of arbitrary time-dependent diffusion gradient shapes, gd(t), applied between t = 0 and t = t, can be calculated according to (stejskal and tanner 1965) by applying diffusion gradients, diffusion-weighted images can be acquired in which the signal intensity depends on the adc, e.g., structures with large adc such as liquids appear hypointense. to quantify the adc at least two diffusion-weighted measurements with different diffusion weightings (i.e., different b-values) are required as shown in fig. 2 .8.7. by determining the signal intensity at the lower b-value, s(b1), and the higher b-value, s(b2), the adc can be calculated as this can be done either for the mean signal intensities in a region of interest or pixel by pixel in order to calculate an adc map as in fig. 2.8.7 . the adc can also be calculated from more than two b-values by fitting an exponential to the measured signal intensities or by linear regression analysis applied to the logarithm of signal intensities. it should be noted that diffusion-weighted images generally exhibit a mixture of different contrasts. many diffusion-weighted pulse sequences require relatively long echo times between 60 and 120 ms because of the long duration of the diffusion preparation. thus, diffusion-weighted images are often also t2-weighted, and it can be difficult to differentiate image contrast due to diffusion and t2 effects. this is a typical problem in diffusion-weighted mri of the brain and known as t2 shinethrough effect (burdette et al. 1999) . a further consequence of the long minimum echo times due to the diffusion preparation is the relatively low signal-to-noise ratio of diffusion-weighted images. the combined effects of diffusion weighting, which particularly decreases the signal of fluids, and of t2 weighting, which predominantly reduces the signal of other (non-fluid) tissue, results in globally low signal intensity on diffusion-weighted images. therefore, signal-increasing techniques such as increasing the voxel volume or (magnitude) averaging are often required for diffusion-weighted mri. in addition, adc calculation can be corrected for the decreasing signal-to-noise ratio at higher b-values (dietrich et al. 2001a) . the range of b-values chosen for a diffusion-weighted mri experiment should depend on the typical diffusion coefficients that are measured and on the signalto-noise ratio of the diffusion-weighted image data. as a rule of thumb, the signal attenuation should be at least in the case of diffusing spins, rephasing is incomplete since spins have moved between the first and second gradient; thus, diffusion-dependent signal attenuation is observed (red arrow) fig. 2.8.7 acquisition of two images with different diffusion weightings (b-values b1 and b2) in order to calculate an adc map. note the large signal attenuation in csf at the higher b-value, b2, and the correspondingly high diffusion coefficient in the adc map 2.8 diffusion-weighted imaging and diffusion tensor imaging about 60%, i.e., the product of diffusion coefficient and the b-value range, bmax-bmin, should be approximately 1 (xing et al. 1997) . this corresponds to a b-value difference of about 1,000-1,500 s/mm 2 in brain tissue with adcs between 0.6 × 10 -3 and 1.0 × 10 -3 mm 2 /s. however, the choice of the largest b-value is frequently limited by signal-to-noise considerations, and thus, the maximum diffusion weighting is often reduced in order to maintain sufficient signal-to-noise ratio. a second point to consider is the choice of the lowest b-value. although a b-value of 0 is often chosen, a slightly higher value of, for example, 50 s/mm 2 can be advantageous in order to suppress the influence of perfusion effects (lebihan et al. 1988; van rijswijk et al. 2002) . historically, the first mri pulse sequences with inserted diffusion gradients were stimulated-echo (taylor and bushell 1985; merboldt et al. 1985) and spin-echo sequences (lebihan et al. 1986 ); a schematic spin-echo pulse sequence with diffusion gradients is shown in fig. 2 .8.8. in this diagram, diffusion gradients are added for all three spatial directions (readout, phase, and slice direction); however, they are usually switched on in only one or two of the three directions at a time. since spins are refocused by a 180° pulse, both diffusion gradients have the same polarity. the main disadvantages of the diffusion-weighted spin-echo sequence are that it requires long acquisition times of many minutes per data set and is extremely sensitive to motion. examples of images acquired with a diffusion-weighted spin-echo sequence are shown in fig. 2.8.9a ,b. the volunteers were asked to avoid any movements, but no head fixation was applied; severe motion artifacts degrade the images. these artifacts are caused by inconsistent phase information of the complex-valued raw data; stimulated-echo, and spin-echo sequences are particularly sensitive to these effects because the diffusion preparation must be repeated for each raw data line and different states of motion will occur during these diffusion preparations. more details about the motion sensitivity of diffusion-weighted sequences and about approaches to reduce these artifacts are described in the following section. with techniques such as cardiac gating and navigator-echo correction, image quality of diffusion-weighted spin-echo sequences can be dramatically improved (fig. 2.8.9c,d) . today, the most commonly used pulse sequence for diffusion-weighted mri (particularly of the brain) is the single-shot echo planar imaging (epi) sequence with spin-echo excitation. the diffusion preparation of this sequence is the same as in the conventional spin-echo sequence of fig. 2 .8.8, but instead of acquiring a single echo after each excitation, the full k-space can be read. the advantages of the diffusion-weighted epi sequence are a very short acquisition time of less than 200 ms per slice and its insensitivity to motion. however, the image resolution is typically limited to 128 × 128 matrices and echo planar imaging is very sensitive to susceptibility variations as demonstrated in fig. 2.8.10a ,b-different susceptibilities of soft tissue, bone, and air, cause severe image distortion and signal cancellation close to interfaces between soft tissue and air or bone. these effects can be reduced with new imaging methods known as parallel imaging or parallel acquisition techniques (see sect. 2.4) . the underlying idea is to use several receiver coil elements with spatially different coil sensitivity profiles to acquire multiple data sets with reduced k-space sampling density in the phase-encode direction. these data sets are used to calculate a single image corresponding to a fully sampled k-space during post-processing. reducing the number of phase-encode steps shortens the epi echo train, decreases the minimum echo time as well as the total acquisition time, and increases the effective receiver bandwidth in the phase-encode direction. as a result, susceptibility-induced distortions are reduced as shown in fig. 2 .8.10c,d. alternatively, the accelerated acdiffusion-weighted imaging of the brain is almost exclusively performed with single-shot epi sequences (with or without parallel imaging). other organs or body areas, however, are less suited for echo-planar single-shot acquisitions because of much more severe susceptibility effects that often result in images of non-diagnostic quality. depending on the slice orientation and receiver coil system, these distortions can be reduced either with parallel imaging as described above or with segmented (i.e., multi-shot) epi sequences that assemble the raw data from multiple shorter echo trains (holder et al. 2000; ries et al. 2000; einarsdottir et al. 2004) . a disadvantage of this approach is the increased motion sensitivity since several excitations (and diffusion preparations) are required for a single data set, resulting in potentially inconsistent phase information; segmented epi sequences are therefore often combined with additional motion correction techniques. several other pulse sequences have been proposed for diffusion-weighted imaging. diffusion gradients can be added to single-shot fast spin-echo sequences with echo trains of multiple spin-echoes (see also sect. 2.4) such as haste or rare sequences (norris et al. 1992) . however, the additionally inserted diffusion gradients cause an irregular timing of the originally equidistant refocusing rf pulses. in combination with motion-dependent phase shifts, this violates the cpmg condition, which requires a certain phase relation between excitation and refocusing pulses. thus, in order to avoid artifacts, various modifications to diffusion-weighted fast spin-echo sequences have been suggested such as additional gradients (norris et al. 1992) , a split acquisition of echoes of even and odd parity (schick 1997) , or modified rf pulse trains (alsop 1997) . these modified diffusion-weighted singleshot fast spin-echo sequences are fast and insensitive to motion; disadvantages are a relatively low signal-to-noise ratio, and a certain image blurring that is characteristic for all single-shot fast spin-echo techniques. they have been applied in the brain (alsop 1997; lovblad et al. 1998) , the spine (tsuchiya et al. 2003, clark and werring 2002) , and in several non-neuro applications such as imaging of musculoskeletal (dietrich et al. 2005) or breast (kinoshita et al. 2002) tumors. in contrast to echo-planar fig. 2.8.9 diffusion-weighted spin-echo acquisitions (b = 550 s/mm²) of two healthy and cooperative volunteers. a,b uncorrected images acquired without cardiac gating. c,d images after navigator echo correction acquired with cardiac gating fig. 2.8 .10 images acquired with a diffusion-weighted epi sequence. a,b conventional epi sequence exhibiting severe distortions (arrows). c,d epi sequence with parallel imaging (acceleration factor 2) showing reduced susceptibility artifacts. (for better visualization of artifacts, only images without diffusion weighting (b = 0) are shown) imaging, these techniques are insensitive to susceptibility variations and, thus, particularly suited for applications outside the brain. another, however only infrequently used alternative to echo-planar sequences are fast gradient-echo techniques (flash, mp-rage) with diffusion preparation (lee and price 1994; thomas et al. 1998) . a special sequence type that has successfully been employed for diffusion-weighted imaging is based on steady-state free-precession (ssfp) sequences (see also sect. 2.4). pulse sequences known as ce-fast or psif sequences (the acronym psif refers to a reverted fast imaging with steady precession, i.e., fisp, sequence) have been adopted to diffusion-weighted imaging by inserting a single diffusion gradient (lebihan 1988; merboldt et al. 1989) . however, in contrast to all previously described sequences, the diffusion weighting of this technique cannot be easily determined quantitatively. the observed signal attenuation does not only depend on the diffusion coefficient and the diffusion weighting, but also on the relaxation times, t1 and t2, and the flip angle (buxton 1993) . since these quantities are usually not exactly known, the adc cannot be determined. instead, these sequences have been used to acquire diffusion-weighted images that are evaluated based only on visible image contrast. a general advantage of diffusion-weighted psif sequences is the relatively short acquisition time due to short repetition times of about 50 ms. thus, they exhibit only low motion sensitivity. the most important application of this sequence type is the differential diagnosis of osteoporotic and malignant vertebral compression fractures (baur et al. 1998 (baur et al. , 2003 . other applications include diffusion-weighted imaging of the brain (miller and pauly 2003) and the cartilage (miller et al. 2004 ). as mentioned above, an unwanted side effect arising in virtually all diffusion-weighted pulse sequences is extreme motion sensitivity (trouard et al. 1996; norris 2001) . by introducing diffusion gradients, the pulse sequence is made sensitive to molecular motion in the micrometer range, but it also becomes susceptible to very small macroscopic motions of the imaged object since the diffusion gradients do not distinguish between stochastic molecular motion and macroscopic bulk motion. hence, even very small and involuntary movements of the patient, e.g., caused by cardiac motion, cerebrospinal fluid pulsation, breathing, swallowing, or peristalsis, can lead to severe image degradation due to gross motion artifacts. typical appearances of these artifacts are signal voids and ghosting in phase-encode direction. several techniques and pulse-sequence modifications have been proposed to reduce the motion sensitivity of diffusion-weighted mri. on the one hand, any kind of motion should be minimized. depending on the body region being imaged, this can be achieved by improved fixation of the patient to the scanner, by imaging during breath hold, or by applying cardiac gating. effects of motion can also be reduced by decreasing the acquisition time of a pulse sequence, i.e., by using fast acquisition techniques. this is particularly effective if singleshot sequences such as echo planar imaging techniques are applied. most motion artifacts in diffusion-weighted imaging arise from inconsistent phase information in the complex-valued raw data set. this is caused by different states of motion in the repeated diffusion preparations of the acquisition. in single-shot sequences, only a single diffusion preparation is applied, and thus inconsistent phase information is avoided. it should be noted, however, that even single-shot sequences might be affected by inconsistent phase information if complex data of several measurements is averaged. instead, only magnitude images should be averaged in diffusion-weighted mri in order to improve the signal-to-noise ratio. another approach to reduce motion artifacts is to correct for motion-related phase errors in the acquired raw data. this can be done using navigator echo-correction techniques (ordidge et al. 1994; anderson and gore 1994; dietrich et al. 2000) . the navigator echo is an additional echo without phase encoding acquired after each diffusion preparation. in the absence of motion, all navigator echoes should be identical. thus, by comparing the acquired navigator echoes, bulk motion can be detected, and degraded image echoes can be discarded or a phase correction can be applied. more advanced navigator-echo techniques acquire several navigator echoes in different spatial directions (butts et al. 1996) or use spiral navigator readouts (miller and pauly 2003) . certain pulse sequences are self-navigated, i.e., a subset of the acquired raw data can be used as navigator echo without the need for an extra navigator acquisition. examples are pulse sequences with radial or spiral k-space trajectories that acquire the origin of k-space in every readout (seifert et al. 2001; dietrich et al. 2001b ). an improved self-navigation is possible with the propeller diffusion sequence, which repeatedly acquires a large area around the origin of k-space (pipe et al. 2002) . some image reconstruction techniques have been proposed that do not use the often-inconsistent phase information of raw data at all. in sequences with radial k-space trajectories, images can be reconstructed by filtered back projection of magnitude projection images (gmitro and alexander 1993) . another spin-echo-based approach known as line-scan diffusion imaging assembles the image from one-dimensional lines of magnitude data (gudbjartsson et al. 1996) . in addition to substantially reduced motion sensitivity, repetition times and thus image acquisition time can be considerably reduced since the one-dimensional lines are acquired independently of each other. on the other hand, the signal-to-noise ratio of line-scan sequences is substantially lower than that of conventional acquisition techniques and the spatial resolution of this approach is limited as well. a second unwanted side effect of diffusion-weighted sequences is eddy current effects caused by the extraordinarily long and strong diffusion gradients. eddy currents are induced electric currents in coils that occur after switching magnetic fields on or off. these currents then create unwanted additional gradient fields resulting in shifted or distorted images and in incorrect diffusion weightings. whereas most mri gradient systems compensate very well for eddy current effects after the switching of short gradients typically used for imaging, the longer diffusion gradients are often not well compensated. hence, diffusion-weighted images are sometimes distorted depending on the diffusion weighting and the direction of the diffusion gradients, resulting in artifacts on adc maps such as enhanced edges. to avoid these artifacts, several techniques have been suggested. diffusion gradients can be shortened by using bipolar diffusion gradients (alexander et al. 1997) or by adding additional 180° pulses during the diffusion preparation (reese et al. 2003) ; eddy currents can be partially compensated for by an additional long gradient before the 90° excitation pulse (alexander et al. 1997) ; or diffusion-weighted images can be acquired twice with diffusion gradients of opposite polarity (bodammer et al. 2004) . other eddycurrent correction schemes are based on the acquisition of diffusion gradient-dependent field maps and data correction in k-space (horsfield 1999; papdakis et al. 2005) . in general, (automated) image registration as the first step of postprocessing is recommended to reduce influences from both patient motion and eddy-current effects. imaging with the stejskal-tanner diffusion preparation as described above in sect. 2.8.3.1, is only sensitive for molecular diffusion parallel to the direction of the diffusion gradient. the diffusion preparation causes a dephasing of spins that move in the direction of the applied field gradient, i.e., between positions with different magnetic field strengths as illustrated in fig. 2 .8.6. molecular motion perpendicular to this direction does not contribute to the signal attenuation. in general, the diffusion displacement of spins depends on the considered spatial direction; e.g., protons of water molecules in nerve fibers move more freely parallel to the fiber direction than they do in perpendicular directions. this dependence of the diffusion on spatial orientation can be measured by applying diffusion gradients in different spatial directions, e.g., separately in slice, readout, and phase direction as demonstrated in fig. 2.8.11 . the resulting diffusion-weighted images show substantial signal differences in areas with strong anisotropic diffusion such as the corpus callosum. the signal intensity of the corpus callosum is decreased if diffusion gradients in the left-right direction (readout direction in the example) are applied, but increased for diffusion gradients in the head-foot (slice) direction or the anterior-posterior (phase-encode) direction. this finding is explained by the fact that water molecules diffuse more freely in the left-right direction (parallel to the nerve fibers) than they do in perpendicular directions, i.e., the effective diffusion coefficient is greater in the left-right direction than it is in other directions, and thus the signal attenuation is increased. this orientation dependence is visible in the adc maps as well: the adc in the left-right direction of the corpus callosum is increased compared to the adcs in perpendicular directions. other areas such as gray matter or the csf do not show significant differences depending on the diffusion gradient direction, indicating approximately isotropic diffusion. if the mean (or average) diffusivity of molecules in tissue is to be measured, then diffusion coefficients for all spatial directions must be averaged as shown in fig. 2.8.11d ; the corresponding adc map is given by the mean value of the three direction-dependent maps. since the direction-independent or mean adc of tissue is proportional to the trace of the diffusion tensor, this measurement is also referred to as diffusion trace imaging. the measurement of such a direction-independent diffusion-weighted image can be very important to avoid misinterpretation of hyperintense areas due to high anisotropy as tissue with generally reduced adc such as areas of focal ischemia. therefore, diffusion-weighted stroke mri is generally based on isotropically diffusionweighted images. if only a single direction-independent diffusionweighted image is required for diagnosis, it appears disadvantageous to perform three orthogonal diffusion measurements at the cost of three-times-increased acquisition duration. it should be noted that it is not possible to simply apply gradients in all three directions simultaneously for this purpose; this results in a single magnetic field gradient in diagonal direction, which is again only sensitive for diffusion parallel to this diagonal. however, the stejskal-tanner diffusion preparation can be extended by a more sophisticated series of gradient pulses in different directions to achieve an isotropic diffusion weighting within a single diffusion measurement (wong et al. 1995; mori and van zilj 1995; chun et al. 1998; cercignani and horsefield 1999) . isotropically diffusion-weighted images can thus be acquired by either a single or three orthogonal diffusion preparations. however, three measurements are not yet sufficient to determine the properties of diffusion anisotropy in all cases. for example, if a nerve fiber is oriented diagonally to all three coordinate axes, then the diffusion attenuation in this fiber will be the same for the three measurements and cannot be distinguished from isotropic diffusion. the measurement of the full diffusion tensor (cf. sect. 2.8.2.2) is required to cope with these more general cases. in spite of this limitation, some studies have used the ratio of the largest and the smallest of three perpendicular diffusion coefficients as an estimation of the anisotropy (holder et al. 2000) . however, this approach should be regarded as an inferior method in comparison to diffusion tensor evaluation and is generally not recommended. to determine the diffusion tensor, i.e., to fully measure anisotropic diffusion, more than three diffusionsensitized measurements with diffusion gradients in different spatial directions are required. however, only the diagonal elements of the tensor, i.e., dxx, dyy, dzz, can be measured directly; these elements are exactly the direction-dependent adcs determined in the example above. the other three (off-diagonal) tensor components dxy, dxz, dyz do not describe diffusion in a spatial direction but the correlation of diffusion in two different directions; they cannot be measured directly, but must be calculated as linear combinations of several measurements. the minimum number of measurements required to determine the full diffusion tensor can be deduced from the form of the diffusion tensor matrix: the tensor has six independent components dxx, dyy, dzz, dxy, dxz, dyz and, thus, at least six independent diffusion measurements are required. each of these measurements is based on images of at least two different b-values; in order to reduce the total number of measurements, usually a b-value of 0 is chosen as a direction-independent reference. thus, this reference image has to be acquired only once instead of separately for each diffusion direction. a possible and frequently used choice of seven diffusion-weighted acquisitions that are sufficient to determine the diffusion tensor (basser and pierpaoli 1998 ) is shown in fig. 2.8.12 . none of the six tensor components dxx, dyy, dzz, dxy, dxz, or dyz is measured directly by this gradient scheme; instead, all components must be calculated as linear combinations of the diffusion coefficients in these six directions. this calculation is based on the so-called b-matrix (basser and pierpaoli 1998 ), a symmetric 3 × 3 matrix describing the diffusion weighting for an arbitrary diffusion gradient fig. 2.8.11 diffusion-weighted imaging in different spatial directions. a diffusion gradients in slice (s), readout (r), and phase (p) direction; the row vectors (s, r, p) denote the selected gradients. b corresponding diffusion-weighted images. c calculated adc maps corresponding to the diffusion directions in a and images in b. d averaged adc map; all adcs are in units of 10 -3 mm 2 /s. note the differing contrast in the diffusion-weighted images and adc maps depending on the diffusion gradient direction (e.g., in the corpus callosum) where gg denotes the dyadic product of these two vectors. this matrix is used to describe the signal attenuation due to the diffusion gradient as where bd denotes the matrix product of the b-matrix and the diffusion tensor matrix. the elements of the diffusion tensor dij can be determined by solving a system of linear equations, since the b-matrix and the signal attenuation are known. the result of this calculation is shown in fig. 2.8.13 . the three calculated diagonal elements correspond to the direct adc measurements of fig. 2.8.11 . the off-diagonal elements are generally much lower than the diagonal elements (note the differently scaled intensity maps) are and are close to zero in areas with predominantly isotropic diffusion (gray matter and csf). a simple protocol for diffusion tensor imaging consists of one reference measurement without diffusion weighting (b-value is 0) and six diffusion-weighted measurements with different gradient directions. these gradient directions should be "as different as possible, " i.e., pointing isotropically in all spatial directions. a typical b-value for dti measurements of the brain is 1,000 s/mm 2 . averaging of multiple acquisitions is frequently performed to increase the snr especially of the images with diffusion weighting. however, all these parameters (b-values, diffusion directions, number of averages) have been evaluated in a number of studies with the aim of optimizing the accuracy of diffusion tensor data. several studies investigated the optimum choice of the b-values both for conventional diffusion-weighted imaging and for diffusion tensor imaging. although the results of these studies vary to a certain extent, generally b-values in the range between about 900 and 1400 s/ mm 2 have been found to provide the highest accuracy of diffusion measurements in the brain (jones et al. 1999; armitage and bastin 2001; kingsley and monahan 2004) . the optimum number of averages depends on the b-values, which influence the signal attenuation and, thus, the signal-to-noise ratio of the diffusion-weighted images. in general, a higher number of averages are recommended for the acquisition with the high b-value than for the reference image with low b-value or without fig. 2.8.12 diffusion tensor imaging a choice of diffusion gradients (s slice, r readout, p phase direction; the row vector denotes the selected gradients and their polarity) and b corresponding diffusionweighted images for the determination of the diffusion tensor. note the different contrast in the diffusion-weighted images depending on the diffusion gradient direction (e.g., in the corpus callosum) 1 any diffusion weighting. as shown by jones et al. (1999) for their choice of b-values, the optimum ratio of the total number of acquisitions with high b-value and low bvalue is about 8.4. the number of diffusion gradients and their directions has also been investigated in several studies. generally, the accuracy of diffusion tensor data, especially of the diffusion anisotropy and main diffusion direction, is improved when the number of different diffusion directions is increased (jones et al. 1999; papadakis et al. 2000; skare et al. 2000; jones 2004 ). if the number of different directions is fixed, then the accuracy of the measurements can be increased by choosing an optimized set of diffusion directions (skare et al. 2000; hasan et al. 2001) . no final consensus about the optimum number and choice of directions of diffusion gradients has yet been established, but protocols with 20 or more diffusion directions are currently recommended by many research groups. the diffusion tensor contains complex information about the tissue microstructure that is best visualized as a threedimensional ellipsoid as discussed in sect. 2.8.2.2. however, diffusion tensor data may be insufficient to describe tissue in certain geometrical situations. a well-known example is the crossing of white-matter fibers within a single voxel as illustrated in fig. 2.8 .14. water diffusion in such voxels cannot be fully described by a single ellipsoid, i.e., by the diffusion tensor. to overcome this limitation, more complex measurement techniques such as high-angular resolution diffusion imaging (hardi) (frank 2001; tuch et al. 2002) and q-ball imaging (tuch 2004 ) have been proposed. all these techniques use a large number of different diffusion directions (e.g., between 43 [frank 2001 ] and 253 [tuch 2004 ]) distributed isotropically in space. diffusion data is measured with high-angular resolution in order to determine the spatial distribution of diffusion in more detail as indicated in fig. 2.8.14d . a further generalization of diffusion tensor measurements loosens the assumption of gaussian diffusion, which was illustrated in fig. 2 .8.2. if diffusion is severely restricted, e.g., by cell membranes, no or very few molecules will move through this border; the probability distribution of diffusion distances will be limited to distances within the cell volume and will no longer be gaussian. the exact displacement probabilities in restricted diffusion can be measured with methods called q-space diffusion imaging (assaf et al. 2002) or diffusion spectrum imaging (wedeen et al. 2005) . both techniques require the acquisition of images with a large number of different b-values and, in the case of diffusion spectrum imaging, of different diffusion directions; e.g., the total number of diffusion measurements reported by wedeen et al. (2005) is 515. obviously, this large number of measurements severely limits the applicability of these new techniques in clinical studies; the studies should therefore be regarded as experimental work. another approach to overcome the limitations of models based purely on gaussian diffusion has been proposed by jensen et al. as diffusional kurtosis imaging (jensen et al. 2005) . diffusion data is acquired for several b-values over a large range between 0 and 2,500 s/mm 2 similarly to the way data is acquired in q-space imaging, but with a different mathematical model of the non-exponential decay. this method is related to several other studies that investigated diffusion properties in tissue at high b-values and found non-mono-exponential diffusion attenuation curves (inglis et al. 2001; clark et al. 2002) . this observation has frequently been attributed to the simultaneous measurement of water molecules in different environments such as the intracellular and the extracellular space; however, no final agreement on the interpretation of these data has been established (sehy et al. 2002) . diffusion tensor data calculated from the measurements shown in fig. 2.8.12 ; all diffusion coefficients are in units of 10 -3 mm 2 /s. a the three diagonal elements dxx, dyy, and dzz, and b the off-diagonal elements dxy, dxz, and dyz of the tensor matrix. note the different intensity scales for diagonal and off-diagonal elements. some remaining eddy-current artifacts can be seen as enhanced edges in the maps of the off-diagonal elements diffusion tensor imaging results in a large amount of data-a full diffusion tensor, i.e., a symmetric 3 × 3 matrix, is determined for each pixel of the image dataset. due to this complex data structure, there is no simple way to visualize the complete diffusion tensor as a single intensity or color map. it would be straightforward to display the six independent elements of the tensor as separate maps as shown in fig. 2.8.13 ; however, this would not be very helpful for the interpretation or quantitative evaluation of diffusion tensor data. instead, several techniques are used to reduce the diffusion tensor information to simpler datasets that can as easily be displayed and interpreted as other imaging data. most results of imaging examinations are presented as either signal intensity images or scalar parameter maps. these images and maps have the advantage that they can easily be manipulated, e.g., the contrast can be interactively adjusted, and they can be quantitatively evaluated by statistics over regions of interest. in order to obtain similar parameter maps of diffusion tensor data, a single scalar reflecting a certain tensor property must be calculated. the most important examples of such scalars are the mean diffusivity or trace of the diffusion tensor and the anisotropy of the tensor. the mean diffusivity of a diffusion tensor measurement, i.e., the diffusion coefficient averaged over all spatial directions, is displayed as parameter maps in fig. 2.8.15a ,b. the same data can be displayed either as an intensity-coded map (fig. 2.8.15a ) or as a color-coded map (fig. 2.8.15b ). both maps illustrate, e.g., the high diffusivity of csf and the typical adcs of about 0.7 × 10 -3 mm 2 /s in the white matter. many different scalar measures have been proposed to describe diffusion anisotropy, cf. sect. 2.8.2.3. the two most important are the fractional anisotropy and the relative anisotropy shown in fig. 2.8.15c ,d. the maps are very similar; both show the high anisotropy of white matter as hyperintense areas in contrast to low anisotropy in gray matter or csf. these two scalars derived from the diffusion tensor are by far the most important quantities for the clinical evaluation of diffusion tensor data. the vast majority of clinical studies based on diffusion tensor imaging determine the mean diffusivity and the anisotropy in regions of interest in order, e.g., to statistically compare these data between certain patient groups or between patients and healthy controls. the mean diffusivity and the anisotropy contain certain important information about the diffusion tensor; if the diffusion tensor is visualized as ellipsoid, then the diffusivity reflects the volume of the ellipsoid and the anisotropy its deviation from a spherical shape. however, any information about the main diffusion direction, i.e., the orientation of the longest axis of the diffusion tensor ellipsoid, is missing. this direction corresponds to the microstructural orientation of tissue, e.g., the orientation of white-matter tracts, and is determined as the eigenvector of the largest eigenvalue of the tensor (c.f. sect. 2.8.2.2). there are two common methods to visualize the direction of this eigenvector: color coding and direct vector display. the direction can be color-coded using the redgreen-blue (rgb) color model. each direction in space is defined by a three-component vector v = (vx vy vz) . if this three-component vector is interpreted as an rgb color specification, vectors in x-direction, v = (1 0 0), appear as red pixels, vectors in y-direction as green pixels, and vectors in z-direction as blue pixels. eigenvectors in other directions are displayed as (additive) mixtures of different colors, e.g., the vector v = (1 0 1) as mixture of red and blue, yielding violet pixels. the resulting color map is finally scaled with the diffusion anisotropy, since the fig. 2.8. 14 the diffusion tensor cannot represent diffusion properties in voxels with crossing nerve fibers. voxels with a single predominant fiber direction (a,b) show diffusion tensor ellipsoids whose longest axes correspond to the fiber orientation. voxels with crossing fibers (c) result in a diffusion tensor ellipsoid with reduced anisotropy pointing in an averaged fiber direction. advanced methods such as high angular resolution diffusion imaging (d) can resolve different fiber orientations within a single voxel 2.8 diffusion-weighted imaging and diffusion tensor imaging 1 main diffusion direction is of interest only in areas with high anisotropy. some examples of these color-coded vector maps are shown in fig. 2.8.16 . the red color of the corpus callosum demonstrates that the nerve fibers are predominantly oriented in the left-right direction. white-matter areas in green and blue are oriented in the anterior-posterior direction and the head-foot direction, respectively. alternatively, the main diffusion direction can be directly displayed by a small line in each pixel; some authors refer to this technique as whisker plots. this visualization is on the one hand more intuitive than color coding, but on the other hand difficult to display for large areas because of the large number of pixels (and hence lines) of a complete image. an example is shown in fig. 2.8.17 ; the magnified area shows again the corpus callosum, where the diffusion directions follow the anatomical orientation of the nerve fibers. a general problem and limitation of the visualization of the main diffusion direction is that it is based on the assumption of linear diffusion, i.e., the diffusion ellipsoid is supposed to have a cigar-like shape. this is usually true in white matter tracts, but may lead to deceptive graphical depictions at crossing fibers or if diffusion is described by a planar tensor. another disadvantage is that vector maps are difficult to compare or to evaluate statistically. it is also possible to visualize the full diffusion tensor using the diffusion ellipsoid introduced in sect. 2.8.2.2. as in the vector plots, it is often difficult to visualize the entire amount of data belonging to a single image slice at once. therefore, this 3d tensor visualization is usually combined with tools to zoom into the illustration and fig. 2.8.15 parameter maps displaying scalar quantities calculated from the diffusion tensor. direction-independent mean diffusivity shown as gray-scaled map (a) and as color-coded map (b); the diffusion coefficients are given in units of 10 -3 mm 2 /s. (c) fractional anisotropy and (d) relative anisotropy fig. 2.8.16 color-coded visualization of main diffusion orientation in four different slices (a-d). the main diffusion direction (orientation of the longest axes of the diffusion ellipsoid) is shown in red, green, and blue for left-right, anterior-posterior, and head-foot orientation, respectively, as indicated in e. the green rim at the frontal brain is caused by remaining eddy-current and susceptibility artifacts to rotate the slice in order to view the tensors in specific areas of the brain, as demonstrated in fig. 2 .8.18. the ellipsoids are additionally color-coded to emphasize the direction of their longest axis (the main diffusion direction); their brightness is scaled by the anisotropy. thus, the ellipsoid visualization combines features of the techniques described in the previous sections and, e.g., csf is displayed as large but relatively dark spheres (denoting a high diffusion coefficient and low anisotropy), while the tensors in fiber tracts appear as bright elongated ellipsoids corresponding to linear diffusion in a single predominant orientation. the exact depiction of the tensor information is not standardized but may look different depending on the tools used. an alternative visualization may substitute the ellipsoids by cuboids with equivalent dimensions as shown in fig. 2.8.19 . the presented information is the same as before, but the computational cost required to display cuboids is substantially lower than with smooth ellipsoids. thus, interactive manipulation of the 3d datasets may be faster using the cuboid visualization. close inspection of the main diffusion directions in figs. 2.8.17 or 2.8.19 suggests that the shape of white matter tracts can be reconstructed by connecting several diffusion directions in an appropriate way. this process is illustrated in fig. 2.8 .20, based on a magnification of fig. 2.8.17 . by choosing a start point and following the main diffusion direction, trajectories can be constructed that visualize the fiber tracts of white matter. a typical example is shown in fig. 2.8 .21, where a seed region was placed within the corpus callosum, and all fibers through this seed region were reconstructed. the color of the fibers reflects the local anisotropy in this case, but various other color schemes could be used instead. fiber tracking or diffusion tractography was developed in the late 1990s (mori et al. 1999; conturo et al. 1999; mori and van zijl 2002; melhem et al. 2002) , and a multitude of different algorithms to reconstruct fibers have been proposed since then. most techniques include data interpolation to increase the spatial resolution, and all require certain criteria to decide when the tracking of a fiber should be stopped (e.g., at pixels with low anisotropy or at sudden changes of diffusion direction). fiber tracking is usually based either on a single-region approach, in which all fibers are tracked that go through a user-defined region of interest, or on a two-region approach where connecting fibers between two regions are reconstructed. fiber tracking depends on good image quality, with sufficient signal-to-noise ratio and without substantial distortion artifacts. increased noise can reduce the calculated anisotropy (jones and basser 2004) and, thus, the length of the reconstructed fibers. image distortions cause a mismatch of anatomical fiber orientation and the measured diffusion direction and thus can lead to erroneous tractography results. therefore, parallel imaging and eddy-current correction techniques can improve the results of white-matter tractography. it is generally assumed that isotropic spatial image resolution is preferable for fiber tracking applications. a typical protocol suggested by jones et al. acquires data of the whole brain in isotropic 2.5 × 2.5 × 2.5 mm 3 resolution (jones et al. 2002b) . fiber tracking is a valuable tool to visualize white matter structures of the brain. however, it is still very difficult to evaluate tractography results quantitatively, to assess the accuracy of reconstructed fibers, or to compare the results of different examinations. first approaches to these questions include the spatial normalization of tenfig. 2.8.19 three-dimensional visualization of the full diffusion tensor as colorcoded cuboids; the cuboids are colored as in fig. 2 (jones et al. 2002a ) and the determination and visualization of uncertainties of diffusion tensor results (jones 2003; jones and pierpaoli 2005) . fig. 2.8.21 reconstruction of white matter tracts starting at a seed region in the corpus callosum. visualization was performed with the "dti task card" provided by the mgh/mit/hms athinoula a. martinos center for functional and structural biomedical imaging (ruopeng wang) risks and safety issues related to mr examinations with the rapid development of mr technology and the significant level of growth in the number of patients examined with this versatile imaging modality, the consideration of possible risks and health effects associated with the use of mr procedures is gaining increasingly in importance. as described in detail in the previous chapters, three types of fields are employed: • a high static magnetic field generating a macroscopic nuclear magnetization • rapidly alternating magnetic gradient fields for spatial encoding of the mr signal • radiofrequency (rf) electromagnetic fields for excitation and preparation of the spin system in the following, the biophysical interaction mechanisms and biological effects of these fields are summarized as well as exposure limits and precautions to be taken to minimize health hazards and risks to patients and volunteers undergoing mr procedures. in the recent past, a number of excellent reviews and books related to this topic have been published. for details and supplementary information, the reader is referred to these publications quoted in the following and to the bibliographies given therein. because no ionizing radiation is used in mri, it is generally deemed safer than diagnostic x-ray or nuclear medicine procedures in terms of health protection of patients. in this context, a fundamental difference between ionizing and non-ionizing radiation has to be noted: radiation exposure to ionizing radiation-at least at the relatively low doses occurring in medical imaging-results in stochastic effects, whereas biological effects of (electro)magnetic fields are deterministic. a stochastic process is one where the exposure determines the probability of the occurrence of an event but not the magnitude of the effect. in contrast, deterministic effects are those for which the magnitude is related to the level of exposure and a threshold may be defined (international commission on non-ionizing radiation protection [icnirp] 2002). as a consequence, the probability of detrimental effects caused by diagnostic x-ray and nuclear medicine examinations performed over many years accumulate, whereas physiological stress induced by mr procedures is related to the acute exposure levels of a particular examination and does, to the present knowledge, not accumulate over years. in the recent past, regulations concerning mr safety have been largely harmonized. there are two comprehensive reviews by international commissions that form the basis for both national safety standards and the implementation of monitor systems by the manufacturers of mr devices: with μ0 = 1.257 × 10 -6 vs/m the magnetic permeability in vacuum. due to the covalent binding of atoms, electron shells in most molecules are completely filled and thus all electron spins are paired. nevertheless, these diamagnetic materials can be weakly magnetized in an external magnetic field. as described in sect. 2.2.8.1, this universal effect 1 is caused by changes in the orbital motion of electrons in an external magnetic field. the induced magnetization is very small and in a direction opposite to that of the applied field (χ < 0). paramagnetic materials, on the other hand, contain molecules with single, unpaired electrons. the intrinsic magnetic moments related with these electrons tend-comparable to the much weaker nuclear magnetic moment (cf. sect. 2.2.3)-to align in an external magnetic field. this effect increases the magnetic field in paramagnetic materials (0 < χ < 0,01). in ferromagnetic materials-such as iron, cobalt, or nickel-unpaired electron spins align spontaneously with each other in the absence of a magnetic field in a region called a domain. these materials are characterized by a large positive magnetic susceptibility (χ > 0,01). biomolecules are in general diamagnetic and contain at most some paramagnetic centers. in almost all human tissues, the concentration of paramagnetic components is so low that they are characterized by susceptibilities differing by no more than 20% from that of water (χ = -9,05 · 10 -6 ) (schenck 2000 (schenck , 2005 . as a consequence, there is virtually no effect of the human body on an applied magnetic field (b ≅ μ0 h ). there are several established physical mechanisms through which static magnetic fields can interact with biological tissues and organisms. the most relevant mechanisms are discussed in the following. even in a uniform magnetic field, molecules or structurally ordered molecule assemblies with either a field-induced (diamagnetic) or permanent (paramagnetic) magnetic moment mmol experience a mechanical torque that tends to align their magnetic moment parallel (or antiparallel) to the external magnetic field and thus to minimize the potential energy ( fig. 2.9.1a ). orientation effects, however, can only occur when molecules or molecule clusters have a nonspherical structure and/or when the magnetic properties are anisotropically distributed. moreover, the alignment must result in an appreciable reduction of the potential energy (emag ∝ mmol b) of the molecules in the external field with respect to their thermal energy (etherm ∝ kt). at higher temperatures, as for example in the human body, the alignment of molecules with small magnetic moments is prevented by their thermal movement (brownian movement) . in a non-uniform magnetic field, as for example in the periphery of an mr system, paramagnetic and ferromagnetic materials, moreover, are attracted and thus can quickly become dangerous projectiles (fig. 2.9.1b) . magneto-hydromechanical interactions. static magnetic fields also exert forces (called lorentz forces) on moving electrolytes (ionic charge carriers) giving rise to induced electric fields and currents. for an electrolyte with charge q, the lorentz force, which acts perpendicular to the direction of the magnetic field, b, and the velocity, v, of the electrolyte is given by (2.9.3) since electrolytes with a positive or negative charge moving, for example, through a cylindrical blood vessel orientated perpendicular to a magnetic field are accelerated into opposite directions, this mechanism gives rise to an electrical voltage across the vessel, which is commonly referred to as blood flow potential (fig. 2.9 .2). moreover, the induced transversal velocity component also interacts with the magnetic field according to eq. 2.9.3, which results in a lorentz force that is directed antiparallel to the longitudinal velocity component. at very high magnetic field strengths, this secondary effect can reduce the flow velocity and the flow profile of blood in large vessels (tenforde 2005) . theoretically modeling of magneto-hydromechanical interaction processes was performed by tenforde (2005) based on the navier-stokes equation describing the flow of an electrically conductive fluid in the presence of a magnetic field using the finite element technique. induced current densities in the region of the sinoatrial node are predicted to by greater than 100 ma/m 2 at field levels of more than 5 t in an adult human. moreover, magneto-hydromechanical interactions were predicted to reduce the volume flow rate of blood in the human aorta by a maximum of 1.3, 4.9, and 10.4% at field levels of 5, 10, and 15 t, respectively. magnetic effects on chemical reactions. as shown by in vitro studies, several classes of organic chemical reactions can be influenced by static magnetic fields under fig. 2.9 .1 magneto-mechanical effects. a orientation of a molecule with a magnetic moment m in a uniform magnetic field. b attraction of a paramagnetic or ferromagnetic object in a non-uniform magnetic field. the direction of the acting forces f is indicated by arrows appropriate, non-physiological conditions (grissom 1995; world health organization [who] 2006 ). an established effect consists in the modification of the kinetics of chemical reactions with radicals as intermediate products, brought about by splitting and modification of electron spin states in the magnetic field. an example is the conversion of ethanolamine to acetaldehyde by the bacterial enzyme ethanolamine ammonia lyase. radical pair magnetic field effects are thus used as a tool for invitro studies of enzyme reactions (who 2006). for individual macromolecules, the extent of orientation in strong magnetic fields is very small. for example, measurements on dna in solution have been shown that a magnetic flux density of 12 t is required to produce orientation of about 1% of the molecules (maret et al. 1975) . in contrast, there are several examples of molecular aggregates that can be oriented to a large extend by static magnetic fields, such as outer segments of retinal rod cells, muscle fibers, and filamentous virus particles (icnirp 2003; who 2006 ). an example of an intact cell that can be oriented magnetically is the erythrocyte. it has been shown that both resting and flowing sickled erythrocytes align in fields of more than 0.35 t with their long axis perpendicular to the magnetic flux lines (brody et al. 1985; murayama 1965) . highashi et al. (1993) reported that normal erythrocytes could be oriented with their disk planes parallel to the magnetic field direction. this effect was detectable even at 1 t, and almost 100% of the cells were oriented when exposed to 4 t. on the other hand, calculations performed by schenck (2005) yielded that all of these orientation effects observed in vitro are probably too small to affect the orientation of the equivalent structures in vivo. however, although biophysical models make it possible to roughly estimate the magnitude of static magnetic field effects, the reality is so complex that calculations can in principle not rule out physiological effects (hore 2005) . based on the evidence at present, there is no strong likelihood of major physiological consequences arising from radical-pair magnetic field effects on enzymatic reactions. reasons against are the efficacy of homeo-static buffering and the fact that the contrived conditions needed to observe a magnetic field response in the laboratory are unlikely to occur under physiological conditions (hore 2005) . there have been only a few studies on the effects of static magnetic fields at the cellular level. they reveal that exposure to static magnetic fields alone has no or extremely small effects on cell growth, cell cycle distribution, and the frequency of genetic damage, regardless of the magnetic flux density. however, in combination with other external factors such as ionizing radiation or some chemicals, there is evidence to suggest that a static magnetic field modifies their effects (miyakoshi 2005) . with regard to possible effects on reproduction and development, no adverse effects of static magnetic fields have been consistently demonstrated; few good studies however have been carried out, especially to fields in excess of 1 t (icnirp 2003; saunders 2005; who 2006) . several studies indicate that implantation as well as prenatal and postnatal development of the embryo and fetus is not affected by exposure for varying periods during gestation to magnetic fields of flux densities between 1 and 9.4 t (konermann and mönig 1986; murakami et al. 1992; okazaki et al. 2001; sikov et al. 1979 ). on the other hand, mevissen et al. (1994) reported that continuous exposure of rats to a 30-mt field slightly decreased the numbers of viable fetuses per litter. electric flow potentials generated across the aorta and other major arteries by the flow of blood in a static magnetic field can routinely seen in the ecg of animals and humans, exposed to fields in excess of 100 mt. in humans, the largest potentials occur across the aorta after ventricular contraction and appear superimposed on the t-wave amplitude of the ecg. different animal studies demonstrated effects of static magnetic fields on blood flow, arterial pressure, and other parameters of the cardiovascular system, often at fields with flux densities much less than 1 t (saunders 2005). the results of these studies, however, have to be interpreted with caution because it is difficult to reach any firm conclusion from cardiovascular responses observed in anaesthetized animals (saunders 2005; who 2006 ). on the other hand, two recent studies on humans exposed to a maximum flux density of 8 t (chakeres et al. 2003; kangarlu et al. 1999 ) did not yield clinically relevant changes in the heart rate, respiratory positively and negatively charged electrolytes moving with a velocity v through a blood vessel oriented perpendicular to a magnetic field are accelerated into opposite directions and thus induce an electric voltage uh across the vessel (blood flow potential). cross-hatches indicate the direction of the magnetic field into the paper plane 2.9 risks and safety issues related to mr examinations 1 rate, diastolic blood pressures, finger pulse oxygenation levels, and core body temperature the only physiologic parameter that was found to be altered significantly by high-field exposure was a change in measured systolic blood pressure. this is consistent with a hemodynamic compensatory mechanism to counteract the drag on blood flow exerted by magneto-hydrodynamic forces as described in sect. 2.9.2.2 (chakeres and de vocht 2005) . various behavioral studies yielded that the movement of laboratory rodents in static magnetic fields above 4 t may be unpleasant, inducing aversive responses and conditioned avoidance (who 2006) . such effects are thought to be consistent with magneto-hydrodynamic effects on the endolymph of the vestibular apparatus (who 2006) . this is in line with reports that some volunteers and patients exposed in static magnetic fields with flux densities above 1.5 t experienced sensations of vertigo, nausea, and a metallic taste in the mouth (chakeres et al. 2003; kangarlu et al. 1999; schenck 2000 schenck , 2005 . moreover, some of them reported on magnetophosphenes occurring during rapid eye movement in a field of at least 2 t, which may be attributable to weak electric fields induced by movements of the eye, resulting in an excitation of structures in the retina (reilly 1998; schenck 2000) . two recent studies evaluated neurobehavioral effects among subjects exposed to static magnetic fields of 1.5 and 8 t, respectively, using a neurobehavioral test battery. performance in an eye-hand coordination test and a near-visual contrast sensitivity task slightly declined at 1.5 t (de vocht et al. 2003) , whereas a small negative effect on short-term memory was noted at 8 t (chakeres et al. 2003) . taking also into account the results of other neurobehavioral studies, it can be concluded that there is at present no evidence of any clinically relevant modification in human cognitive function related to static magnetic field exposure (chakeres and de vocht 2005) . there are only a few epidemiological studies available that were specifically designed to study health effects of static magnetic fields. the majority of these have been focused on cancer risks. in 2002, the international agency for research on cancer (iarc) (2002) reviewed epidemiological studies focused on cancer risks. generally, these studies have not pointed to higher risks, although the number of studies was small, the numbers of cancer cases were limited, and the information on individual exposure levels was poor. therefore, the available evidence from epidemiological studies is at present not sufficient to draw any conclusions about potential health effects of static magnetic field exposure (feychting 2005; who 2006) . some epidemiological studies have investigated reproductive outcome for workers involved in aluminum industry or in mri. kanal et al. (1999) , for example, evaluated 1,421 pregnancies of women working at clinical mr facilities. comparing these pregnancies with those occurring in employees at other jobs, they did not find significant increased risks for spontaneous abortions, delivery before 39 weeks, reduced birth weight, and male gender of the offspring. however, no studies of high quality have been carried out of workers occupationally exposed to fields greater than 1 t. although there are initial experiences concerning the examination of volunteers and patients in ultra-high mr systems with magnetic flux densities of up to 8 t, most clinical mr procedures have been performed so far at static magnetic fields below 3 t. as summarized in sect. 2.9.2.3, the literature does not indicate any serious adverse health effects from the exposure of healthy human subjects up to a flux density of 8 t (icnirp 2004). however, because movements in static magnetic fields above 2 t can produce nausea and vertigo, both the iec standard and the icnirp recommendation (table 2.9.1) regulate that mr examinations above this static magnetic flux density should be performed in the controlled operating mode under medical supervision. the recommended upper limit for the operating mode is 4 t, due to the limited information concerning possible effects above this magnetic flux density. for mr examinations performed in the experimental operating mode, there is no upper limit for the magnetic flux density. in a safety document issued in 2003, the us food and drug administration (fda) (2003) deemed mr devices significant risk only when a static magnetic field of more than 8 t is used. according to faraday's law, a time-varying magnetic field b(t) induces an electric field e(t), which has two important characteristics: the field strength is proportional to the time rate of change of the magnetic flux density, db(t)/dt, and the field lines form closed loops around the direction of the magnetic field. time-varying magnetic fields are used in mriamong others-to spatially encode mr signals arising from the different volume elements within the human body. to this end, three independent gradient coils are used to produce magnetic fields directed parallel to the static magnetic field b0 = (0, 0, b0) with a field strength varying in a linear manner along the x-, yand z-direction as shown in fig. 2. 3.1. for the special case of a spatially uniform magnetic field directed in the z-direction, bz(t), the electric field strength along a circular (conductive) loop of radius r in the x-y-plane is given by (2.9.4) this equation reveals that the electric field strength in the considered circular loop increases linearly with its radius as well as with the rate of change, db(t)/dt. this model gives, for example, the electric field induced by the magnetic gradient field b = (0, 0, g z · z) of the z-gradient coil. in contrast, the distribution of the electric fields induced by the time-varying magnetic gradient fields b = (0, 0, g x · x) and b = (0, 0, g y · y) is much more complex, since the magnetic flux density of these fields is not uniform over the x-y-plane. moreover, the generation of these gradient fields is inevitable connected due to fundamental principles of electrodynamics with the occurrence of magnetic fields directed in the xand y-direction, i.e., b = (bx, 0, 0) and b = (0, by, 0), respectively. although these "maxwell terms" are of no relevance for the acquisition of mr images, they have to be considered carefully with respect to biological effects. the distribution of electric fields induced by timevarying magnetic fields directed parallel and perpendicular to the long axis of the human body is schematically shown in fig. 2.9. 3. the precise spatial and temporal distribution of the electric fields in the human body, of course, strongly depends on both the technical characteristics of the gradient coils implemented at a specific mr system and the morphology of the body region exposed, and thus cannot be described by a simple mathematical expression. for worst-case estimations, however, it can be assumed that the electric field induced by a non-uniform magnetic field is equal or smaller than the electric field produced by a uniform magnetic field with field strength equal to the maximum magnetic flux density of the nonuniform field (schmitt et al. 1998) . for a uniform magnetic field, the electric field strength reaches, in general, a maximum when the magnetic field is orientated perpendicular to the coronal plane of the body (see fig. 2 .9.3, right) since the extension of conductive loops is largest in this direction (reilly 1998) . in conductive media, such as biological tissues, the internally induced electric field e(t), results in circulating eddy currents, j(t). both quantities are related by the electric conductivity of the medium, σ, (2.9.5) calculation of the current distribution in the human body is complicated due to widely differing conductivities of various tissue components. for rough estimations, however, the body can be treated as a homogeneous medium with an average conductivity of σ = 0.2 s/m (reilly 1998 ). according to eqs. 2.9.4 and 2.9.5, for example, a current density of 20 ma/m 2 is induced at a radius of 20 cm by a rate of change in the magnetic flux density of dbz/dt = 1 t/s. fig. 2.9 .3 schematic representation of the electric field induced by time-varying magnetic fields b(t) that are directed parallel (left) and perpendicular (right) to the long axis of the human body. the electric field lines form closed loops around the direction of the magnetic field 1 the magnetic flux density of gradient fields used in mri is about two orders of magnitude lower than that of the static magnetic field b0. therefore, time-varying magnetic fields produced by gradient coils in mri can be neglected compared to the strong static magnetic field as far as interactions of magnetic fields with biological tissues and organisms are concerned (cf. sect. 2.9.2.2). in contrast, however, biophysical effects related to the electric fields and currents induced by the magnetic fields have to be considered carefully. in general, rise times of magnetic gradients in mri are longer than 100 µs, resulting in time-varying electric fields and currents with frequencies below 100 khz. in this frequency range, the conductivity of cell membranes is several orders of magnitude lower than that of the extra-and intracellular fluid (foster and schwan 1995) . as illustrated in fig. 2 .9.4, this has two important consequences. first, the cell membrane tends to shield the interior of cells very effectively from current flow, which is thus restricted to the extracellular fluid. second, voltages are induced across the membrane of cells. when the electric voltages are above a tissue-specific threshold level, they can stimulate nerve and muscle cells (foster and schwan 1995) . theoretical models describing cardiac and peripheral nerve stimulation have been presented by various scientists (i.e., by irnich, mansfield, and reilly) . a detailed discussion of the underlying assumptions of the different models and the differences between them can be found, among others, in (schaefer et al. 2000; schmitt et al. 1998 ). the best approximation to experimental data is given by a hyperbolic strength-duration expression (2.9.6) which relates the stimulation threshold, expressed as rate of change db/dt of the magnetic flux density, with the stimulus duration t, i.e., the ramp time of the magnetic gradient field (schaefer et al. 2000; schmitt et al. 1998 ). a hyperbolic model comparable to eq. 2.9.6 was first established by g. weiss in 1901 for an electric current pulse and the corresponding electric charge. this "fundamental law of electrostimulation" has been confirmed meanwhile in numerous studies for neural and cardiac excitation as well as for defibrillation (schaefer et al. 2000) . as shown in fig. 2.9 .5, the threshold for the strength of a stimulus decreases with its duration. the asymptotic stimulus strength, b • ∞, for an infinite duration is denoted as "rheobase"; the characteristic response time constant, τc , as "chronaxie". it should be mentioned that according to a model presented by irnich et al. stimulation depends on mean (rather than peak) db/dt changes and is thus independent on the special shape of the gradient pulse (schaefer et al. 2000) . in current safety regulations, however, exposure limits are unanimously expressed as maximum db/dt values. in accordance with the biophysical mechanisms described in the previous section, there is now a strong body of evidence suggesting that the transduction processes through which induced electric fields and currents can influence cellular properties involve interactions at the level of the cell membrane (icnirp 2003) . in addition to the stimulation of electrically excitable tissues, changes in membrane properties-such as ion-binding to membrane macromolecules, ion transport across the membrane, or ligand-receptor interactions-may trigger transmembrane signaling events. cardiac and peripheral nerve stimulation. experimental studies with magnetic stimulation of the heart have been carried out since about 1991, with the introduction of improved gradient hardware for epi. experiments fig. 2.9.4 in the frequency range below 100 khz, the conductivity of cell membranes (σm) is several orders of magnitude lower than that of the extraand intracellular fluid (σext and σint, respectively) so that the induced electric fields (and also the resulting electric currents) are mainly restricted to the extracellular fluid (eext > eint). as a result, electric voltages are generated across the membrane of cells that can stimulate nerve and muscle cells were not performed of course with humans, but rather with dogs. the data, which are listed and reviewed by reilly (1998) , reveal that magnetic stimulation is most effective, when it is delivered during the t wave of the cardiac cycle. moreover, excitation thresholds for the heart are substantially greater than that for nerve as long as the pulse duration is sufficiently less than the chronaxie time of the heart of about 3 ms. therefore, the avoidance of peripheral sensations in a patient provides a conservative safety margin with respect to cardiac stimulation. bourland et al. (1991) determined a mean value of 14.1 ± 6.7 for the ratio of cardiac (the induction of ectopic beats) to muscle stimulation in dogs for a pulse duration of 530 µs, which is quite close to the theoretical heart/nerve ratio of 14.0 estimated by reilly (1998) . various studies yielded that the cardiac threshold variability of healthy persons is surprisingly low, which is confirmed by experimental and clinical experience that pacing thresholds are rather uniform (schmitt et al. 1998 ). drugs and changes in electrolyte concentrations can lower thresholds, but not below about 80% of the normal value (schmitt et al. 1998 ). peripheral nerve stimulation has been investigated in various volunteer studies. a systematic evaluation of the available data was presented by schaefer et al. in 2000 . they recalculated published threshold levels-often reported for different gradient coils and shapes in different terms-to the maximum db/dt occurring during the maximum switch rate of the gradient coil at a radius of 20 cm from the central axis of the mr system, i.e., at the border of the volume normally accessible to patients. in fig. 2.9 .6, the recalculated threshold levels are plotted for the y(anterior/posterior) and z-gradient coils (superior/inferior) as compared to model estimates by reilly. as expected, y-gradient coils have lower stimulation threshold for a given ramp time than x-gradient coils since the x-z cross-sections of the body are usually larger than are x-y cross-sections. by fitting the hyperbolic strength-duration relationship defined in eq. 2.9.6 to mean peripheral nerve stimulation thresholds measured by bourland et al. (1999) in 84 human subjects, schaefer et al. estimated the following values for the rheobase/chronaxie: 22.1 t/s/0.365 ms for the y-gradient and 31.7 t/s /0.378 ms for the z-gradient. as shown in fig. 2.9 .6, the db/dt intensity to induce a sensation that the subject described as uncomfortable or even painful was significantly above the sensation threshold. bourland et al. (1999) also analyzed their stimulation data in the form of cumulative frequency distributions, that gives for a db/dt level the number of subjects that had already reported on perceptible, uncomfortable, or even intolerable sensations. they found that the db/dt level needed for the lowest percentile for uncomfortable stimulation is approximately equal to the median threshold for perception. the lowest percentile for intolerable stimulation occurs at a db/dt level approximately 20% above the median perception threshold. time-varying magnetic fields can also result in the perception of magnetophosphenes due to the induction of electrical currents, presumably in the retina (cf. sect. 2.9.2.3). a unique feature of phosphenes, which are not considered to be hazardous to humans, is their low excitation threshold and sharply defined excitation frequency of about 20 hz as compared to other forms of neural stimulation (reilly 1998) . in general, a combination of magnetic gradient fields from all three gradient coils is used in mri. in this case, the biological relevant time-varying magnetic field is approximately given by the vector sum of the magnetic field components. a detailed discussion of the effect of stimulus shape, number of stimuli, and other experimental setfig. 2.9 .5 hyperbolic strength-duration expression that relates the stimulation threshold, expressed as rate of change db/dt of the magnetic flux density, with the stimulus duration t, i.e., the ramp time of the magnetic gradient field. the asymptotic stimulus strength, b • ∞, for an infinite duration is denoted as rheobase; the characteristic response time constant, τc , as chronaxie 2.9 risks and safety issues related to mr examinations tings on stimulation thresholds can be found in (reilly 1998; schmitt et al. 1998 ). a comprehensive review of the current scientific evidence on biological effects of low-frequency electromagnetic fields in the frequency range up to 100 khz has been published by icnirp in 2003. the majority of the reviewed studies focus on extremely low-frequency (elf) magnetic fields associated with the use of electricity at power frequencies of 50 or 60 hz. according to the icnrip review, cellular studies do not provide convincing evidence that low-frequency magnetic fields alter cell division, calcium homeostasis, and signaling pathways. furthermore, no consistent effects were found in animals and humans with respect to genotoxicity, reproduction, development, immune system function, as well as endocrine and hematological parameters. on the other hand, a number of laboratory and field studies on humans demonstrated an effect of low-frequency magnetic fields at higher exposure levels on the power spectrum of different eeg frequency bands and on sleep structure. in the light of cognitive and performance studies yielding a number of biological effects, further studies are necessary to clarify the significance of the observed effects for human health. over the last two decades, a large number of high quality epidemiological investigations of long-term disease endpoints such as cancer, cardiovascular and neurodegenerative disorders have been performed in relation to time-varying-mainly elf-magnetic fields. following the mentioned icnirp review (2003), the results can be summarized as follows. among all the outcomes evaluated, childhood leukemia in relation to postnatal exposures to 50 or 60 hz magnetic fields at flux densities above 0.4 µt is the one for which there is most evidence of an association. however, the results are difficult to interpret in the absence of evidence from cellular and animal studies. there is also evidence for an association of amyotrophic lateral sclerosis (als) with occupational emf exposure although confounding is a potential explanation. whether there are associations with breast cancer and cardiovascular disease remains unsolved. from a safety standpoint, the primary concern with regard to rapid switching of magnetic gradients is cardiac fibrillation, because it is a life-threatening condition. in contrast, peripheral nerve stimulation is of practical concern because uncomfortable or intolerable stimulations would interfere with the examination (e.g., patient movements) or would even result in a termination of the examination. in the current safety recommendations issued by iec (2002) and and icnrip (2004), maximum db/dt values for time-varying magnetic fields created by gradient coils is limited for patient and volunteer examinations performed in the normal and the controlled operating mode by the db/dt level of 80% and 100% of the mean perception threshold for peripheral nerve stimulation, respectively. to this end, mean perception threshold levels have to be determined by the manufacturers for any given type of gradient system by means of experimental studies on human volunteers. as an alternative, the following empirical hyperbolic strength-duration expression for the mean threshold for peripheral nerve stimulation (expressed as maximum change of the magnetic flux density in t/s) can be used: (2.9.7) in this equation, teff is the effective stimulation duration (in milliseconds), i.e., the duration of the period of monotonic increasing or decreasing gradient. a mathematical definition for arbitrary gradient shapes can be found in the iec standard (2002). time-varying magnetic fields used for the excitation and preparation of the spin system in mri (b1 fields, cf. sect. 2.2.4) have typically frequencies above 10 mhz. in this rf range, the conductivity of cell membranes is comparable to that of the extra-and intracellular fluid, which means that no substantial voltages are induced across the membranes (foster and schwan 1995) . due to this reason, stimulation of nerve and muscle cells is no longer a matter of concern. instead, thermal effects due to tissue heating are of importance. energy dissipation of rf fields in tissues is described by the frequency-dependent conductivity σ(ω), which characterizes energy losses due to the induction and orientation of electrical dipoles as well as the drift of free charge carriers in the induced time-varying electric field (foster and schwan 1995) . the energy absorbed per unit of tissue mass and time, the so-called specific absorption rate (sar, in w/kg), is approximately given by where e is the induced electric field, j the corresponding current density, and ρ the tissue density (cf., 2.9.3.1). absorption of energy in the human body strongly depends on the size and orientation of the body with respect to the rf field as well as on the frequency and polarization of the field. theoretical and experimental considerations reveal that rf absorption in the body approaches a maximum when the wavelength of the field is in the order of the body size. unfortunately, the wavelength of the rf fields used in mri falls into this "resonance range. " in order to discuss the effect of various measurement parameters on rf absorption, let us consider a simple mr sequence with only one rf pulse-such as a 2d or 3d flash sequence. in this case, the time-averaged sar can approximately be described by the expression (2.9.9) according to this equation, the time-averaged sar is proportional • to the square of the static magnetic field, b0, which means that energy absorption is markedly higher at high-field as compared to low-field mr systems • to the square of the pulse angle, α, so that a sequence with a 90° or even a 180° pulse will result in a much higher sar value than a sequence with a low-angle excitation pulse • to the duty cycle, tp / tr, of the sequence, e.g., the ratio of the pulse duration tp and the repetition time tr of the pulse or sequence • to the number of slices, ns, subsequently excited within the repetition time of a 2d sequence (multi-slice technique, cf. sect. 2.3.5; ns = 1 for 3d sequences) in case of a more complex mri sequence with various rf pulses, e.g., a spin-echo or a turbo spin-echo sequence, the contribution of the different rf pulses to patient exposure has to be summed up. the most relevant quantity for the characterization of physiological effects related to rf exposure is the temperature rise in the various body tissues, which is not only dependent on the localized sar and the duration of exposure, but also on the thermal conductivity and microvascular blood flow (perfusion). in case of a partial-body rf exposure, the latter two factors lead to fast temperature equalization within the body (adair 1996) . based on the bioheat equation, it can be shown (brix et al. 2002) that for this particular exposure scenario the temperature response in the center of a homogenous tissue region, which is larger in each direction than the so-called thermal equilibration length, λ, is given by a convolution of the exposure-time course, sar(t), with a tissue-specific system function, exp (-t/τ), (2.9.10) where τ is the thermal equilibration time, ta the constant temperature of arterial blood, and c the specific heat capacity of the tissue. for representative tissues, equilibration lengths and times are between 1.5 and 12 mm and 0.2 and 25 min, respectively (brix et al. 2002) . both parameters are inversely related to tissue perfusion and thus vary considerably. in case of a continuous rf exposure, the temperature rise even in poorly perfused tissues is less than 0.5°c for each w/kg of power dissipated. using a simple model of power deposition in the head, athey (1989) showed that continuous rf exposure over 1 h is unlikely to raise the temperature of the eye by more than 1.6°c when the average sar to the head is less than 3.2 w/kg. more complex computations were performed by gandhi and chen (1999) for a high-resolution model of the human body using the finite-difference time domain in order to assess sar distributions in the body for different rf coils. their calculations indicate that the maximum sar averaged over 100 g of tissue can be ten times greater than the whole-body average sar ("hot spots"). established biological effects of rf fields used for mr examinations are primarily caused by tissue heating. therefore, it is important to critically evaluate the numerous number of studies focused on temperature effects, from the cellular and tissue level to the whole-body level, in-cluding potential effects on vulnerable persons. in contrast, non-thermal (or athermal) effects are not well understood but seem-as far as this can be assessed at moment-to have no relevance with respect to the assessment of adverse effects associated with mr examinations. non-thermal effects are those which can only be explained in terms of mechanisms other than increased random molecular motion (i.e., heating) or which occur at sar levels so low that a thermal mechanism seems unlikely (icnirp 1997) . as summarized in a review by lepock (2003) , relative short exposures of mammalian cells to temperatures in excess of 40-41°c result in a variety of effects, such as inhibition of cell growth, cytotoxic changes, alteration of signal transduction pathways, and an increased sensitivity to other stresses such as ionizing radiation and chemical agents. this suggests that damage is not localized to a single target, but that multiple heat-labile targets are damaged. extensive protein denaturation has been observed at temperatures of 40-45°c for moderate periods. the most sensitive animal responses to heat loads are thermoregulatory adjustments, such as reduced metabolic heat production, vasodilatation, and increased heart rate. the corresponding sar thresholds are between about 0.5 and 5 w/kg (icnirp 1998) . the observed cardiovascular changes reflect normal thermoregulatory responses that facilitate the conduction of heat to the body surface in order to maintain normal body temperatures. direct quantitative extrapolation of the animal (including primate) data to humans, however, is difficult given the marked species differences in the basal metabolism and thermoregulatory ability (who 1993) . at levels of rf exposure that cause body temperature rises of 1°c or more, a large number of additional, in most cases reversible, physiological effects have been observed in animals, such as alterations in neural and neuromuscular functions, increased blood-brain barrier permeability, stress-associated changes in the immune system, and hematological changes (icnirp 1998; michaelson and swicord 1996; who 1993) . thermal sensitivities and thresholds for irreversible tissue damage from hyperthermia have been summarized by dewhirst et al. (2003) . the most sensitive organs to acute damage are the testes and brain as well as portions of the eye (lens opacities and corneal abnormalities). the sar threshold for irreversible effects even in the most sensitive tissues caused by rf exposure, however, is greater than 4 w/kg under normal environmental conditions (icnirp 1998) . effects of heat on embryo and fetus have been thoroughly reviewed by edwards et al. (2003) . processes critical to embryonic development, such as cell proliferation, migration, differentiation, and apoptosis are adversely affected by elevated maternal temperatures. therefore, hyperthermia of animals during pregnancy can cause embryonic death, abortion, growth retardation, and developmental defects. especially the development of the central nervous system is susceptible to heat. however, most animal data indicate that implantation and the development of the embryo and fetus are unlikely to be affected by rf exposures that increase maternal body temperature by less than 1°c (who 1993). in humans, epidemiological studies suggest that an elevation of maternal body temperature by 2°c for at least 24 h during fever can cause a range of developmental defects, but there is little information on temperature thresholds for shorter exposures (edwards et al. 2003) . humans possess comparatively effective heat loss mechanisms. in addition to a well-developed ability to sweat, the dynamic range of blood flow rates in the skin is much higher than it is in other species. studies focused on rf-induced heating of patients during mr procedures have been summarized and evaluated in a review by shellock (2000) . they indicate that exposure of resting humans for 20-30 min to rf fields producing a whole-body sar of up to 4 w/kg results in a body temperature increase between 0.1 and 0.6°c (who 1993) . of special interest is an extensive mr study reported by shellock et al. (1994) . in this study, thermal and physiologic responses of healthy volunteers undergoing an mr examination over 16 min at a whole-body averaged sar of 6.0 w/kg were investigated in a cool (22°c) and a warm (33°c) environment. in both cases, significant variations of various physiologic parameters were observed, such as an increase in the heart rate, systolic blood pressure, or skin temperature. however, all variations were in a range that can be physiologically tolerated by an individual with normal thermoregulatory function (shellock et al. 1994) . generally, these studies are supported by mathematical modeling of human thermoregulatory responses to mr exposure (adair 1996; adair and berglund 1986, 1989) . it should be noted, however, that heat tolerance or thermoregulation may be compromised in some individuals undergoing an mr examination, such as the elderly, the very young and people with certain medical conditions (e.g., obesity, hypertension, impaired cardiovascular functions, diabetes, fever, etc.) and/or taking certain medications (e.g., beta-blockers, calcium channel blockers, sedatives, etc.) (donaldson et al. 2003; goldstein et al. 2003; icnirp 2004; shellock 2000) . some regions of the human body, in particular the brain, are particularly vulnerable to raised temperatures. mild-to-moderate hyperthermia (body temperature less than 40°c) induced thermal stress. for example, it affects cognitive performance (sharma and hoopes 2003) and can produce specific alterations in the cns that may have long-term physiological and neuropathological consequences (hancock and vasmatzidis 2003) . there have been a large number of epidemiological studies over several decades, particularly on cancer, cardiovascular disease, and cataract, in relation to occupational, residential, and mobile-phone rf exposure. as summarized in a review published by the icnirp standing committee on epidemiology (ahlbom et al. 2004) , results of these studies give no consistent or convincing evidence of a causal relation between rf exposure and adverse health effect. it has to be noted, however, that the studies considered not only have too many deficiencies to rule out an association but also focus on chronic exposures at relatively low levels-an exposure scenario that is not comparable to mr examinations of patients. as reviewed in the previous section, no adverse health effects are expected if the rf-induced increase in body core temperature does not exceed 1°c. in case of infants, pregnant women, or persons with cardiocirculatory im-pairment, it is desirable to limit body core temperature increases to 0.5°c. as indicated in table 2 .9.2, these values have been laid down in the current safety recommendations (iec, icnirp) to limit the body core temperature for the normal and controlled operating mode. additionally, local temperatures under exposure to the head, trunk, and extremities are limited for each of the two operating modes to the values given in table 2 .9.2. however, temperature changes in the different parts of the body are difficult to control during an mr procedure in clinical routine. therefore, sar limits have been derived on the basis of experimental and theoretical studies, which should not be exceeded in order to limit the temperature rise to the values given in table 2 .9.2. as only parts of the body-at least in the case of adult patients-are exposed simultaneously during an mr procedure, not only the whole-body sar but also partial-body short-term sar the sar limit over any 10-s period shall not exceed 3 times the corresponding average sar limit a partial-volume sars given by iec; icnirp limits sar exposure to the head to 3 w/kg b partial-body sars scale dynamically with the ratio r between the patient mass exposed and the total patient mass: normal operating mode, sar= (10-8 . r) w/kg; controlled operating mode, sar = (10-6 . r) w/kg c in cases where the eye is in the field of a small local coil used for rf transmission, care should be taken to ensure that the temperature rise is limited to 1°c sars for the head, the trunk, and the extremities have to be estimated by means of suitable patient models (e.g., brix et al. 2001 ) and limited to the values given in table 2 .9.3 for the normal and controlled operating mode. with respect to the application of the sar levels defined in table 2 .9.3, the following points should be taken into account: • when a volume coil is used to excite a greater field-of view homogeneously, the partial-body and the wholebody sars have to be controlled: in the case of a local rf transmit coil (e.g., a surface coils), the local and the whole-body sar (iec 2002). • partial-body sars scale dynamically with the ratio r between the patient mass exposed and the total patient mass. for r → 1 they converge against the corresponding whole-body values, for r → 0 against the localized sar level of 10 w/kg established by icnirp for occupational exposure of head and trunk (icnirp 1998). • the recommended sar limits do not relate to an individual mr sequence, but rather to running sar averages computed over each 6-min-period, which is assumed a typical thermal equilibration time of smaller masses of tissue. but even if mr examinations are performed within the established sar limits, severe burns can occur under unfavorable conditions at small focal skin-to-skin contact zones. the potential danger is illustrated in fig 2.9 .7 by the case of a patient who developed third-degree burns at the calves after conventional mr imaging. in this case, the contact between the calves resulted in the formation of a closed conducting loop and high current densities near the small contact zone. therefore, patients should always be positioned in such a way that focal skin-to-skin contacts are avoided (e.g., by foam pads) (knopp et al. 1998 ). to protect volunteers, patients, accompanying persons, and uninformed healthcare workers from possible hazards and accidents associated with the mr environment, it is indispensable to perform a proper control of access to the mr environment. the greatest potential hazard comes from metallic, in particular ferromagnetic materials (such as coins, pins, hair clips, pocketknives, scissors, nail clippers, etc.), that are accelerated in the inhomogeneous magnetic field (cf. sect. 2.9.2.2) in the periphery of an mr system and quickly become dangerous projectiles (missile effect). this risk can only be minimized by a strict and careful screening of all individuals entering the mr environment for metallic objects. every patient or volunteer should complete a detailed questionnaire prior to the mr examination to ensure that every item posing a potential safety issue is considered. an example of such a form can be found, for example, in shellock and crues (2004) , or can be downloaded from http://www.mrisafety.com. next, an oral interview should be conducted to verify the information of the form and to allow discussion of any question or concern that the patient may have before undergoing the mr procedure. an in-depth discussion of the various aspects of screening patients for mr procedures and individuals for the mr environment can be found in various publications by shellock (e.g., shellock 2005; shellock and crues 2004) and the webpage mentioned above. here only a condensed summary of the most important risks and contraindications can be given. all patients (and volunteers) undergoing mr procedures should-at the very least-be visually (e.g., by using a camera system) and/or acoustically (using an intercom system) monitored. moreover, physiologic monitoring is indicated whenever a patient requires observation of vital functions due to a health problem or whenever the patient is unable to communicate with the mr technologist regarding pain, respiratory problems, cardiac stress, or other difficulty that might arise during the examination (shellock 2001) . this holds especially in the case of sedated or anesthetized patients. for patient monitoring, special mr-compatible devices are available (shellock 2001) . pregnant patients undergoing mr examinations are exposed to the static magnetic field, time-varying gradient fields and rf fields. the few studies concerning the combined effects of these fields on pregnancy outcome in humans following mr examinations have not revealed any adverse effects, but are very limited due to the small numbers of patients involved and difficulties in the interpretation of the results (colletti 2001; icnirp 2004) . it fig. 2.9 .7 current-induced third-degree burns due to a small focal skin-to-skin contact between the calves during the mr examination. (from knopp et al. 1998, with permission by springer-verlag) is thus advised that mr procedures may be performed in pregnant patients, in particular in the first trimester, only after critical risk/benefit analysis and with verbal and written informed consent of the mother or parents (colletti 2001) . the standard of care is that mr imaging may be used in pregnant woman, if other non-ionizing forms of diagnostic imaging (e.g., sonography) are inadequate or if the examination provides important information that would otherwise require exposure to ionizing radiation (e.g., fluoroscopy or ct) (colletti 2001; shellock and crues 2004) . in any case, however, exposure levels of the normal operating mode should not be exceeded and the duration of exposure should be reduced as far as possible (icnirp 2003) . mr examinations of patients with implants or metallic objects (such as bullets, pellets) are always associated with a serious risk, even if all procedures are performed within the established exposure limits summarized in the previous sections. this risk can only be minimized by a careful interview of the patient, evaluation of the patient's file and contacting the implanting clinician and/or the manufacturer for advice on mr safety and compatibility of the implant (medical devices agency 2002). in any case, mr procedures should be performed only after critical risk/benefit analysis. it should be noted that having undergone a previous mr procedure without incident does not guarantee a safe subsequent mr examination, since various factors (type of mr system, orientation of the patients, etc.) can substantially change the scenario (shellock and crues 2004) . in the case of passive implants-e.g., vascular clips and clamps, intravascular stents and filters, vascular access ports and catheters, heart valve prostheses, orthopedic prostheses, sheets and screws, intrauterine contraceptive devices, etc.-it has to be clarified if they are made of or contain ferromagnetic materials. as already mentioned, strong forces act on ferromagnetic objects in a static magnetic field. these forces (astm 2005a) may result in a movement and dislodgment of ferromagnetic objects that could injure vessels, nerves or other critical tissue structures. comprehensive information on the mr compatibility (astm 2005b) of more than 1,200 implants and other metallic objects is available in a reference manual published by shellock (2005) and online at http://www. mrisafety.com. mr examinations are deemed relatively safe for patients with implants or objects that have been shown to be non-ferromagnetic or weakly ferromagnetic (shellock and sawyer-glover 2001) . furthermore, patients with certain implants that have relatively strong ferromagnetic qualities may safely undergo mr procedures when the object is held in place by sufficient retentive forces, is not located near vital structures, and will not heat excessively (shellock and sawyer-glover 2001) . however, such examinations should be restricted to essential cases and should be performed at mr systems with a low magnetic field strength. examinations of patients with active implants or lifesupport systems are strictly contraindicated at conventional mr systems, if the patient implant card does not explicitly state their safety in the mr environment. in addition to the risks already mentioned above, there is the possibility that the function of the active implant is changed or perturbed, which may result in a health hazard for the patient. clinically important examples are cardiac pacemakers, implantable cardioverter defibrillators, infusion pumps, programmable hydrocephalus shunts, neurostimulators, and cochlear implants, etc. (medical devices agency 2002; shellock and sawyer-glover 2001) . the induction of electric currents by rf fields during imaging in implants made from conducting materials can result in excessive heating and thus may pose risks to patients. excessive heating is typically associated with implants that have elongated configurations and/or are electronically activated, as for example the leads of cardiac pacemakers or neurostimulation systems (shellock and crues 2004) . the same holds for electrically conductive objects (e.g., ecg leads, cables, wires, etc.), in particular when they form conductive loops in the bore of the mr system. to avoid severe burns, the instructions for proper operation of the equipment provided by the manufacturer of the implant or device have strictly to be followed. practical recommendations concerning this issue can be found in (shellock and sawyer-glover 2001) . in various reports, transient skin irritations, cutaneous swellings or heating sensations were described in relation to the presence of both permanent (cosmetic) and decorative tattoos. these findings seem to be associated with the use of iron oxide or other metal-based pigments that are prone to magnetic field-related interactions and/or rf-induced heating, in particular when the pigments are organized as loops or rings. according to a survey performed by tope and shellock (2002) , however, this side effect has an extremely low rate of occurrence in a population of subjects with tattoos and should not prevent patients-after informed consent-from undergoing a clinically indicated mr procedures (shellock and crues 2004) . as a precautionary measure, a cold compress may be applied to the tattoo site during the mr examination (tope and shellock 2002) . real-time position monitoring of invasive devices using magnetic resonance adaptive technique for highdefinition mr imaging of moving structures electrocardiogram acquisition during mr examinations for patient monitoring and sequence triggering acquiring simultaneous eeg and functional mri the modular (twin) gradient coil-high resolution, high contrast, diffusion weighted epi at 1.0 tesla resonant trapezoidal gradient generation for use in echo planar imaging monitoring the patient's eeg during echo planar mri biological effects and health implications in magnetic resonance imaging hazardous situation in the mr bore: induction in ecg leads causes fire on the induced electric field gradients in the human body for magnetic stimulation by gradient coils in mri active magnetic screening of coils for static and time-dependent magnetic field generated in nmr imaging limits to neural stimulation in echo planar imaging nmr probeheads for biophysical and biomedical experiments: theoretical principles and practical guidelines contrastenhanced mri of the central nervous system: comparison between gadodiamide injection and gd-dtpa evaluation of neck and body metastases to nodes with ferumoxtran 10-enhanced mr imaging: phase iii safety and efficacy study imaging of myocardial infarction: comparison of magnevist and gadophrin-3 in rabbits detection of colorectal liver metastases: a prospective multicenter trial comparing unenhanced mri, mndpdp-enhanced mri, and spiral ct detection of focal hepatic lesions: comparison of unenhanced and shu 555 a-enhanced mr imaging versus biphasic helical ctap sensitivity of enhanced mr in multiple sclerosis: effects of contrast dose and magnetization transfer contrast evaluation of retroperitoneal and pelvic lymph node metastases with mri and mr lymphangiography intravascular contrast agent-enhanced mri measuring contrast clearance and tumor blood volume and the effects of vascular modifiers in an experimental tumor hepatocellular carcinoma in cirrhotic livers: double-contrast thin-section mr imaging with pathologic correlation of explanted tissue efficacy and safety of mr imaging with liver-specific contrast agent: us multicenter phase iii study diffusion and perfusion mr imaging in cases of alzheimer's disease: correlations with cortical atrophy and lesion load rationale and applications for macromolecular gd-based contrast agents microcirculation and microvasculature in breast tumors: pharmacokinetic analysis of dynamic mr image series gadodiamide-associated nephrogenic systemic fibrosis: why radiologists should be concerned morphologic predictors of lymph node status in rectal cancer with use of high-spatial-resolution mr imaging with histopathologic comparison effects of three different doses of a bolus injection of gadodiamide: assessment of regional cerebral blood volume maps in a blinded reader study randomized double blind trial of the safety and efficacy of two gd complexes (gd-dtpa and gd-dota) public assessment reports increased risk of nephrogenic fibrosing dermopathy/nephrogenic systemic fibrosis and gd-containing mri contrast agents mri angiography is superior to helical ct for detection of hcc prior to liver transplantation: an explant correlation factors in myocardial "perfusion" imaging with ultrafast mri and gd-dtpa administration preclinical profile and clinical potential of gadocoletic acid trisodium salt (b22956/1), a new intravascular contrast medium for mri superparamagnetic iron oxides as positive mr contrast agents: in vitro and in vivo evidence oral contrast media for magnetic resonance tomography of the abdomen. iii. initial patient research with gd-dtpa detection of intracranial metastases: a multicenter, intrapatient comparison of gadopentate dimeglumine-enhanced mri with routinely used contrast agents at equal dosage a comparison of gd-bopta and gd-dota for contrast-enhanced mri of intracranial tumors pulmonary mr angiography with ultrasmall superparamagnetic iron oxide particles as a blood pool agent and a navigator echo for respiratory gating: pilot study susceptibility changes following bolus injections pulsatile motion effects on 3d magnetic resonance angiography: implications for evaluating carotid artery stenoses time-of-flight techniques. pulse sequences and clinical protocols centric phase-encoding order in three-dimensional mp-rage sequences: application to abdominal imaging level-set-based artery-vein separation in blood pool agent ce-mr angiograms blood pool contrast-enhanced mra: improved arterial visualization in the steady state flow compensation in balanced ssfp sequences separation of arteries and veins in 3d mr angiography using correlation analysis measurement of flow with nmr imaging using a gradient pulse and phase difference technique tissue specific perfusion imaging using arterial spin labeling phase contrast mr angiography techniques hepatic arterial-phase dynamic gadolinium-enhanced mr imaging: optimization with a test examination and a power injector fast selective black blood mr imaging improved time-offlight mr angiography of the brain with magnetization transfer contrast signal targeting with alternating radiofrequency (star) sequences: application to mr angiography cerebral arteriovenous malformations: improved nidus demarcation by means of dynamic tagging mr-angiography theoretical limits of spatial resolution in elliptical-centric contrast-enhanced 3d-mra time-resolved contrast-enhanced three-dimensional magnetic resonance angiography of the chest: combination of parallel imaging with view sharing (treat) perfusion imaging using arterial spin labeling nmr relaxation times of blood: dependence on field strength, oxidation state, and cell integrity steady-state and dynamic mr angiography with ms-325: initial experience in humans reducing motion artifacts in two-dimensional fourier transform imaging time-resolved contrast-enhanced 3d mr angiography black blood angiography the effects of time varying intravascular signal intensity and kspace acquisition order on three-dimensional mr angiography image quality the effects of incomplete breath-holding on 3d mr image quality steady-state imaging for visualization of endovascular interventions non-contrast-enhanced mr angiography using 3d ecg-synchronized half-fourier fast spin-echo nonlinear excitation profiles for three-dimensional inflow mr angiography fisp-a new fast mri sequence mr angiography by multiple thin slab 3d acquisition first-pass renal perfusion imaging using ms-325, an albumin-targeted mri contrast agent gadolinium-enhanced mr aortography body mr angiography with gadolinium contrast agents contrast-enhanced abdominal mr angiography: optimization of imaging delay time by automating the detection of contrast material arrival in the aorta sense: sensitivity encoding for fast mri mr flouroscopy: technical feasibility central intraluminal saturation stripe on mr angiograms of curved vessels: simulation, phantom, and clinical analysis simultaneous acquisition of spatial harmonics (smash): fast imaging with radiofrequency coil arrays flow artifacts in steady-state free precession cine imaging image artifacts due to a time-varying contrast medium concentration in 3d contrast-enhanced mra separation of arteries and veins using flow-induced phase effects in contrast-enhanced mra of the lower extremities venous compression at highspatial-resolution three-dimensional mr angiography of peripheral arteries use of a blood-pool contrast agent for mr-guided vascular procedures: feasibility of ultrasmall superparamagnetic iron oxide particles high-resolution magnetic resonance angiography of hands with timed arterial compression (tac-mra) improved centric phase encoding orders for three-dimensional magnetization-prepared mr angiography elliptical spiral phase encoding order: an optimal, field-of-viewdependent ordering scheme for breath-hold contrast-enhanced 3d mr angiography fluoroscopically triggered contrast-enhanced three-dimensional mr angiography with elliptical centric view order: application to the renal arteries quantitative evaluation of nonrepetitive phase-encoding orders for firstpass, 3d contrast-enhanced mr angiography parallel imaging in mr angiography mr image artifacts from periodic motion decreased venous contamination on 3d gadolinium-enhanced bolus chase peripheral mr angiography using thigh compression elimination of eddy current artifacts in diffusion-weighted echo planar images: the use of bipolar gradients phase insensitive preparation of singleshot rare: application to diffusion imaging in humans analysis and correction of motion artifacts in diffusion weighted imaging utilizing the diffusion-tonoise ratio to optimize magnetic resonance diffusion tensor acquisition strategies for improving measurements of diffusion anisotropy high b-value q-space analyzed diffusion-weighted mri: application to multiple sclerosis mr diffusion tensor spectroscopy and imaging microstructural and physiological features of tissues elucidated by quantitative-diffusion-tensor mri a simplified method to measure the diffusion tensor from seven mr images diffusion-weighted mr imaging of bone marrow: differentiation of benign versus pathologic compression fractures diffusion-weighted imaging of bone marrow: current status the basis of anisotropic water diffusion in the nervous system a technical review eddy current correction in diffusion-weighted imaging using pairs of images acquired with opposite diffusion gradient polarity diffusionweighted mr imaging of the liver of hepatitis c patients on the particles contained in the pollen of plants; and on the general existence of active molecules in organic and inorganic bodies diffusion-weighted interleaved echo planar imaging with a pair of orthogonal navigator echoes the diffusion sensitivity of fast steady-state free precession imaging effects of diffusion on free precession in nuclear magnetic resonance experiments an optimized pulse sequence for isotropically weighted diffusion imaging pathologic damage in ms assessed by diffusion-weighted and magnetization transfer mri mr diffusion imaging of the human brain mr diffusion imaging of cerebral infarction in humans single-shot diffusion-weighted trace imaging on a clinical scanner diffusion tensor imaging in spinal cord: methods and applications a review in vivo mapping of the fast and slow diffusion tensors in human brain tracking neuronal fiber pathways in the living human brain diffusion-weighted mri in the evaluation of renal lesions: preliminary results reducing motion artefacts in diffusion-weighted mri of the brain: efficacy of navigator echo correction and pulse triggering noise correction for the exact determination of apparent diffusion coefficients at low snr diffusion-weighted imaging of the spine using radial k-space trajectories a comparative evaluation of a rare-based single-shot pulse sequence for diffusionweighted mri of musculoskeletal soft-tissue tumors diffusion-weighted mri of soft tissue tumours overview of diffusion-weighted magnetic resonance studies in multiple sclerosis anisotropy in high angular resolution diffusion-weighted mri use of a projection reconstruction method to decrease motion sensitivity in diffusion-weighted mri line scan diffusion imaging spin-echoes comparison of gradient encoding schemes for diffusion-tensor mri diffusion-weighted mr imaging in normal human brains in various age groups vertebral metastases: assessment with apparent diffusion coefficient diffusion-weighted mr imaging of the normal human spinal cord in vivo mapping eddy current induced fields for the correction of diffusion-weighted echo planar images visualization of neural tissue water compartments using biexponential diffusion tensor mri diffusional kurtosis imaging: the quantification of non-gaussian water diffusion by means of magnetic resonance imaging determining and visualizing uncertainty in estimates of fiber orientation from diffusion tensor mri the effect of gradient sampling schemes on measures derived from diffusion tensor mri: a monte carlo study squashing peanuts and smashing pumpkins": how noise distorts diffusionweighted mr data confidence mapping in diffusion tensor magnetic resonance imaging tractography using a bootstrap approach optimal strategies for measuring diffusion in anisotropic systems by magnetic resonance imaging spatial normalization and averaging of diffusion tensor mri data sets isotropic resolution diffusion tensor imaging with whole brain acquisition in a clinically acceptable time selection of the optimum b factor for diffusion-weighted magnetic resonance imaging assessment of ischemic stroke contrast-to-noise ratios of diffusion anisotropy indices diffusion-weighted half-fourier singleshot turbo spin-echo imaging in breast tumors: differentiation of invasive ductal carcinoma from fibroadenoma intravoxel incoherent motion imaging using steady-state free precession mr imaging of intravoxel incoherent motions: application to diffusion and perfusion in neurologic disorders separation of diffusion and perfusion in intravoxel incoherent motion mr imaging diffusion imaging with the mp-rage sequence turbo spin-echo diffusionweighted mr of ischemic stroke diffusion tensor mr imaging of the brain and white matter tractography self-diffusion nmr imaging using stimulated echoes mri of "diffusion" in the human brain: new results using a modified ce-fast sequence nonlinear phase correction for navigated diffusion imaging steady-state diffusion-weighted imaging of in vivo knee cartilage self-diffusion in normal and heavy water in the range 1-45° diffusion weighting by the trace of the diffusion tensor within a single scan fiber tracking: principles and strategies a technical review threedimensional tracking of axonal projections in the brain by magnetic resonance imaging diffusion tensor imaging and aging a review early detection of regional cerebral ischemia in cats: comparison of diffusionand t2-weighted mri and spectroscopy diffusion-weighted mr imaging of acute stroke: correlation with t2-weighted and magnetic susceptibility-enhanced mr imaging in cats diffusion-tensor imaging of cognitive performance evaluation of hepatic lesions and hepatic parenchyma using diffusion-weighted reordered turboflash magnetic resonance images diffusion tensor imaging of normal and injured developing human brain a technical review implications of bulk motion for diffusion-weighted imaging experiments: effects, mechanisms, and solutions on the application of ultra-fast rare experiments diffusion-weighted echo planar mr imaging in differential diagnosis of brain tumors and tumor-like conditions correction of motional artifacts in diffusionweighted mr images using navigator echoes minimal gradient encoding for robust estimation of diffusion anisotropy ) k-space correction of eddy current-induced distortions in diffusion-weighted echo planar imaging diffusion tensor mr imaging of the human brain multishot diffusion-weighted fse using propeller mri reduction of eddy current-induced distortion in diffusion mri using a twice-refocused spin-echo diffusion tensor mri of the spinal cord diffusion-weighted mri in the characterization of soft-tissue tumors splice: sub-second diffusion-sensitive mr imaging using a modified fast spin-echo acquisition mode evidence that both fast and slow water adc components arise from intracellular space high-resolution diffusion imaging using a radial turbo-spin-echo sequence: implementation, eddy current compensation, and self-navigation condition number as a measure of noise performance of diffusion tensor data acquisition schemes with mri diffusion tensor imaging of neurodevelopment in children and young adults spin diffusion measurements: spin-echoes in the presence of a time-dependent field gradient usefulness of diffusion-weighted mri with echo planar technique in the evaluation of cellularity in gliomas diffusion tensor imaging in normal aging and neuropsychiatric disorders selective age-related degradation of anterior callosal fiber bundles quantified in vivo with fiber tracking the future for diffusion tensor imaging in neuropsychiatry evaluation of liver diffusion isotropy and characterization of focal hepatic lesions with two single-shot echo planar mr imaging sequences: prospective study in 66 patients the spatial mapping of translational diffusion coefficients by the nmr imaging technique a quantitative method for fast diffusion imaging using magnetization-prepared turboflash mr imaging of high-grade cerebral gliomas: value of diffusion-weighted echoplanar pulse sequences test liquids for quantitative mri measurements of self-diffusion coefficient in vivo bloch equations with diffusion terms analysis and comparison of motion-correction techniques in diffusion-weighted imaging diffusion-weighted mri of the cervical spinal cord using a single-shot fast spin-echo technique: findings in normal subjects and in myelomalacia q-ball imaging high angular resolution diffusion imaging reveals intravoxel white matter fiber heterogeneity mapping complex tissue architecture with diffusion spectrum magnetic resonance imaging effects of diffusion in nuclear magnetic resonance spin-echo experiments optimized isotropic diffusion weighting optimised diffusion-weighting for measurement of apparent diffusion coefficient (adc) in human brain (eds) handbook of biological effects of electromagnetic fields. crc, boca raton on the thermoregulatory consequences of nmr imaging risks and safety issues related to mr examinations thermoregulatory consequences of cardiovascular impairment during nmr imaging in warm/humid environments epidemiology of health effects of radiofrequency exposure standard practice for marking medical devices and other items for safety in the magnetic resonance environment athey tw (1989) a model of the temperature rise in the head due to magnetic resonance imaging procedures z-gradient coil and eddycurrent stimulation of skeletal and cardiac muscle in the dog. society for magnetic resonance in medicine sampling and evaluation of specific absorption rates during patient examinations performed on 1.5-tesla mr systems estimation of heat transfer and temperature rise in partial-body regions during mr procedures: an analytical approach with respect to safety considerations induced alignment of flowing sickle erythrocytes in a magnetic field: a 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case-crossover pilot study united nations environment programme/word health organisation/international radiation protection association: environmental health criteria 137, electromagnetic fields (300hz to 300 ghz) risks and safety issues related to mr examinations grazioli l, morana g, kirchin ma, schneider g (2005) accurate differentiation of focal nodular hyperplasia from hepatic adenoma at gadopentate dimeglumine-enhanced mr imaging: prospective study. radiology 236: 166-177 grossman ri, rubin di, hunter g et al (2000) magnetic resonance imaging in patients with key: cord-000843-e1bn79ui authors: nan title: ecr 2011 book of abstracts a postgraduate educational programme date: 2011-03-01 journal: insights imaging doi: 10.1007/s13244-011-0078-3 sha: doc_id: 843 cord_uid: e1bn79ui nan for pet-ct, the ct exam is generally performed as standard whole-body exam from the base of the skull to the upper thighs. standard parameters are non-ionic iodinated intravenous contrast material at 0.5 g/kg bodyweight with a venous delay of 70 seconds after injection and 3-5 mm thick continuous axial reconstructions with medium soft convolution kernels. ct images frequently contain important diagnostic information beyond mere 'anatomic landmarking', so generally a diagnostic, contrast enhanced normal-dose ct should be performed except if a recent diagnostic ct scan is available for fusion. then, a low-dose ct is sufficient for attenuation correction. a difference from routine ct protocols is the expiratory position to match the respiratory position of pet acquisition. also, negative oral contrast material should be applied and the whole body should be included in the field of view to allow effective attenuation correction of pet images. diagnostic reading has to include lung, soft tissue and bone windows. optimally, the assessment should be performed by one reader evaluating ct and pet images simultaneously on multiplanar reformats. learning objectives: 1. to get acquainted with standard ct examination parameters for oncological imaging including the requirements for an effective attenuation correction. 2. to see the diagnostic value of ct beyond 'anatomical landmarking'. 3 . to learn effective ways to interpret pet-ct examinations. nuclear medicine perspective t. beyer; zurich/ch combined pet/ct images were first proposed as early 1984. since 1998 pet/ ct became available for broader clinical testing. since its commercial introduction in 2001 more than 5'000 pet/ct systems were installed worldwide. pet/ct is a logical and technical consequence of early, manual or semi-automatic efforts to align functional and anatomical images for easier and improved diagnosis. pet, or positron emission tomography, is an emission tomographic imaging method based on the application of radioactively labelled biomolecules in order to measure and quantitate signalling or metabolic pathways. ct, computed tomography, on the other hand, uses an external ionising radiation transmission source to generate projection data of the transmitted radiation, thus helping to generate high spatial resolution images of the anatomy of the subject. both sets of information can be combined easily in a pet/ct, whereby both the pet and ct components can be operated in close spatial proximity within a single gantry without cross-talk effects. through the combination of ct and pet overall examination times of oncology pet studies are reduced by 30%. in addition, pet instrumentation has been advanced to include time-of-flight measurements for improved signal-to-noise ratio, extended axial field-of-view-coverage for higher sensitivity and novel image reconstruction for improved contrast. today, high-quality one-stop shop staging with pet/ct is possible in 10 min, or less. learning objectives: 1. to illustrate the origin of combined pet/ct imaging. 2. to motivate the strength of pet: high spatial sensitivity, quantification and functional information. 3. to appreciate the difference between "contrast" and "tracer" imaging. 4. to highlight novel developments in pet imaging: time of flight (tof), extended axial field-of-view. computed tomography is the main contribution to diagnostic medial radiation exposure to the public. in the year 2001, ct accounted for only 6% of all radiationassociated examinations; however, at the same time it accounted for 47% of the total radiation exposure. since the beginning of this century numerous international surveys had been performed with the aim to define diagnostic reference levels in european countries. radiation exposure by ct has increased particularly by cardiac ct examination, what has caused awareness to utilise all strategies for radiation protection in ct. modern ct scanners are equipped with automated anatomical or organ sparing exposure control. it is the ct investigators responsibility to check the clinical indication, limit the scan range and decide for the appropriate scan protocol with the least radiation exposure. newer technical developments in ct scanner hard and software will enable to further reduce the dose from ct. all these strategies are essentially necessary since the number of ct investigations and the scope of clinical indications are expanding with advancing medical progress. learning objectives: 1. to understand the meaning of diagnostic reference values. 2. to become aware of dose intense ct protocols. 3 . to learn about strategies for radiation protection in ct. nuclear medicine perspective s.p. mueller; essen/de different radiopharmaceuticals labelled with positron emitting radioisotopes are used to study a multitude of molecular processes using a positron-emissiontomography (pet) scanner which nowadays is typically integrated with a ct scanner (pet/ct). this lecture will enable the attendee to comprehend that the radiation exposure from pet depends on the biodistribution and kinetics of the radiopharmaceutical, the physical half-life of the positron emitting radioisotope used for labelling, and the injected activity, leading to an understanding that there is no generic "radiation exposure from pet or pet/ct". learning objectives: 1. to learn that the comparison of doses for different radiopharmaceuticals is based on the concept of the effective dose which expresses the total stochastic risk from the non-uniform radiation exposure to individual radiosensitive organs in terms of a uniform whole body radiation dose. 2. to understand that the effective dose from certain radiopharmaceuticals may be reduced by simple means, e.g. if it is renally eliminated by frequently voiding the bladder, and that the effective doses for the most prevalent radiopharmaceuticals lie within the typical range of other diagnostic nuclear medicine tests and compare favourably to the radiation exposure from the ct portion of a whole-body pet/ct scan. pet and pet/ct are non-invasive, 3-dimensional imaging modalities which have become standard of care in patients with malignant lymphomas. these modalities have been extensively studied for staging, restaging, monitoring response to therapy, surveillance after definite treatment, and assessment of transformation. more recently, pet tracers have been suggested as surrogate markers for cancer drug development. learning objectives: 1. to understand in which clinical scenarios pet and pet/ct imaging are superior to standard imaging modalities or other diagnostic tests. 2. to learn the diagnostic accuracy and predictive potential of pet and pet/ct for staging/restaging hodgkin's disease and non-hodgkin's lymphoma. of the examination. therefore, for oncologic applications, pet-ct has already gained widespread acceptance for the initial staging of cancer, the management of recurrent cancer, and for monitoring the response to therapy. the development of a large variety of radiotracers is an evolving procedure. the most frequent used radiotracer in clinical practice, 18 f fdg, is based on the identification of the fundamental aspects of tumour glucose metabolism. new radiotracers, with promising potential for pet-ct, are also currently available to visualise specific cellular and molecular tumour pathway and more being developed. learning objectives: 1. to appreciate the advantage of a combined pet-ct technique. 2. to consolidate our knowledge of optimal examination protocols and to be aware of the pitfalls that may be encountered using this technique. 3. to understand the indications for pet-ct in the diagnosis, staging, and therapy monitoring of a large variety of gi tumours. 4. to become familiar with the different radiotracers to obtain a tailored and personalized diagnosis for the large variety of gi tumours. a-013 13 integrated positron emission tomography (pet)/ct provides combined metabolic and anatomic information of malignancies. the addition of ct to pet for urogenital purposes is very useful. ct should be performed with oral and intravenous contrast agent administration as a full diagnostic technique. if performed under these conditions, this technique can help to avoid pet pitfalls including focal retained activity in ureters and urinary bladder, and increased uptake in physiologic and benign pelvic processes such as endometrial uptake in the menstrual phase, leiomyomatosis, endometriosis or infection. we will describe the use of pet/ct in the characterisation, staging and surveillance of urogenital malignancies including kidney, prostate, bladder, uterine cervix, endometrium and ovaries. pet/ct is internationally accepted as the most useful surveillance imaging tool in patients with ovarian cancer, and its use as a problem-solving modality has also rapidly grown in the rest of urogenital malignancies. learning objectives: 1. to learn the appropriate protocols and settings of a diagnostic ct in pet/ct for urogenital purposes. computed tomography remains the workhorse of clinical cross sectional imaging due to its good availability, enormous speed, high spatial resolution and sufficient tissue contrast to evaluate most diseases based on morphology. compared to pet and spect, room for improvement remains in sensitivity and specificity for certain diseases and, compared to ultrasound and mri, in dynamic imaging. however, already today there are new ct techniques which can provide diagnostically equivalent information as spect or pet but with higher spatial resolution, in shorter acquisition time and without radioactive tracers. one of these techniques is ct perfusion imaging with repeated low-dose acquisitions of the same organ. with this method, a detailed evaluation of brain perfusion is feasible e.g, for stroke assessment, or of tumour perfusion, e.g. to assess early therapy response. another option is dual energy ct which does not require additional dose but can provide additional important diagnostic information similar to pet or spect. examples are the evaluation of lung ventilation und perfusion with xenon gas and iodine contrast. for oncological imaging, the evaluation of tumour perfusion based on spectral identification of iodine is an attractive option to increase specificity without additional dose or radioactivity. similarly, it is feasible to assess myocardial perfusion along with coronary ct angiography. for some diseases, even the molecular substrate can be identified with this technique, e.g. uric acid in gout patients. these new techniques provide significant advantages in oncological imaging and may further add to disease characterisation if combined in pet-ct. learning objectives: 1. to understand the strengths of current ct technology in oncological imaging based on morphology. 2. to learn about the diagnostic value of ct beyond anatomical referencing. energy ct as options to improve disease characterisation. tracers beyond fdg in daily routine m. beheshti; linz/at the ability of positron emission tomography (pet) to study different biological processes opens up new windows for both researches and daily clinical use. addition of computed tomography (ct) to pet improves detection efficiency and results in better localization of the lesions. the aim of this review is to consolidate knowledge of oncological applications of pet tracers other than [(18)f]fluoro-2-deoxy-d -glucose] (fdg) in the daily clinical practice. fdg, as a non -specific tracer, has limited value in the assessment of different cancers such as prostate cancer, neuroendocrine tumours (net), brain tumours, hepatocellular carcinoma (hcc), and some types of breast cancers. hence, due to high sensitivity of pet in performing non-invasive functional studies, further investigations and developments are warranted for defining specific pet radiotracers and theirs clinical applications regarding different tumour entities. oncological non-fdg pet tracers can be generally categorized into 3 groups: those labeled with f-18, c-11 and other non-fdg tracers. fluorine-18 and c-11 are labeled with different amino acids, substrates involved in fatty acid synthesis, protein synthesis, amino acid transport substrate and tracers linked to nucleic acid synthesis. these tracers are also labeled with specific ligands for receptor imaging. the other non-fdg a-024 16 with the increasing use of abdominal cross-sectional imaging, incidental adrenal masses are being detected more often. the important clinical question is whether these lesions are benign adenomas or malignant primary or secondary masses. benign adrenal masses such as lipid-rich adenomas, phaeochromocytomas, myelolipomas, adrenal cysts and adrenal haemorrhage have pathognomonic cross-sectional imaging appearances. however, there remains a significant overlap between imaging features of some lipid-poor adenomas and malignant lesions. the nature of incidentally detected adrenal masses can be determined with a high degree of accuracy using computed tomography and magnetic resonance imaging alone. positron emission tomography is also increasingly used in clinical practice in characterising incidentally detected lesions in patients with cancer. the performance of the established and new techniques in ct, mri and to a lesser extent pet, that can be used to distinguish benign adenomas and malignant lesions of the adrenal gland will be reviewed. with the increasing use of imaging, incidentally detected renal masses are very common. while masses detected by ct or mr usually can be properly classified, renal masses detected by ultrasound frequently require further workup. the following considerations determine the diagnostic workup: simple cysts are very common but may present atypically. renal cell carcinomas may be cystic but usually display at least a small solid component. renal cell carcinomas have a bad prognosis when metastasized but metastases hardly every develop before the tumour has reached 3 cm in diameter. differentiation between solid tumours by imaging alone is exceedingly difficult, save for the identification of angiomyolipomas in adults. this course will discuss suitable diagnostic algorithms based on the initial presentation of the mass. typical imaging findings of various benign and malignant renal masses will be presented. the role of the bosniak classification will be illustrated. newer developments such as a waitand-see approach or primary biopsy for small solid renal masses will be discussed. learning objectives: 1. to learn how to detect and characterise a renal mass. 2. to understand how to apply adequate protocols according to the clinical situation. the wrist and hand are characterised by variability of bones, fibrocartilage, ligaments, muscles and neurovascular structures. coalitions (most commonly lunotriquetral, prevalence of 0.1%), ulnar impaction positive variance of the ulna, carpe bossu and an accessory medial lunate facet associated with osteoarthritis are typical variants of bone. the triangular fibrocartilage complex (tfcc) and the interosseous ligaments often present with small defects. radial tfcc defects are present in 64% of symptomatic but also in 46% asymptomatic wrists. in addition, their prevalence increases with age, apparently without increasing symptoms. accessory muscles are common and may clinically mimick a neoplasm. disease may also be mimicked by imaging artifacts. magic angle effects cause increased tendon signal and may thus lead to the incorrect diagnosis of tendinopathy. the lunate appears to be more dorsally tilted on sagittal mr images than on standard radiographs (radiolunate angle ~20° larger on mr images). this value increases to ~37° if the wrist is positioned in ulnar deviated as is commonly the case when the wrist is examined in the "superman position", with the arm above the head. magic angle artefacts are commonly encountered in the wrist. the extensor and flexor pollicis longus are especially prone to such artefacts, due to their oblique course approaching the critical 55° with regard to the b 0 field. in conclusion, variability is rather the rule than the exception in the hand and wrist. only part of the findings have clinical meaning. technical aspects add another dimension of variability. learning objectives: 1. to become familiar with the normal anatomy. 2. to be able to identify normal variants. 3 . to appreciate the range of pitfalls that may simulate pathology. the imaging of the trauma stratifies the severity and the treatment strategy. the leading modalities in low-energy trauma are x-ray and ultrasound. the different approach has to be used in high-energy trauma -the silent life-threatening injury must be actively searched. although the first examination on the site of the accident could estimate whether the severe trauma is present, the imaging must confirm or exclude it. besides fast transport to the trauma centre has the extraordinary impact on survival the diagnostic algorithm. the installation of ct, ultrasound and x-ray directly within the emergency department is extremely important for the trauma management. if the focused assessment sonography for trauma (fast) is replaced by whole body ct, the life-threatening injury is detected at fastest. protocol includes imaging of non-enhanced ct head and cervical spine followed by the contrast-enhanced ct of the entire thorax, abdomen and pelvis, in cases of lower extremities trauma covering whole body. ct could be performed also under resuscitation, because whole imaging takes about three to five minutes. following findings listed recently according to their impact on survival must be confirmed or excluded: intracranial injury, cervical spine trauma, aortic injury, overpressure pneumothorax, severe bleeding in the abdominal cavity, organs injury, peripheral vascular trauma, bone trauma; the trauma team including anaesthesiologist, surgeon and radiologist discusses the findings and plans of the treatment. over the last two decades, spiral-ct has become a highly reliable imaging modality to diagnose haemorrhage in trauma, while the role of catheter angiography has changed from a diagnostic to a therapeutic modality. traumatic injuries of the heart and aorta lead to sudden death occurring at the accident site, whereas uncontrollable haemorrhage from larger arteries and parenchymal organs is the most frequent cause of mortality during the first 4 h following severe trauma. in patients with ruptured aorta or major arteries, stenting and temporary balloon occlusion may contribute to saving lives, while transcatheter embolisation may prevent exsanguination in haemorrhage from visceral organs, arteriovenous fistulas, and secondary onset haemorrhage. however, a haemodynamically stable patient is a prerequisite for all angiographic interventions. definite haemostasis using the above-mentioned techniques can be obtained in 80-100% (major and periphery arteries) and 82-100% (visceral organs), respectively. possible complications following angiographic haemostatic interventions depend very much on the treated vessel bed but are, in general, as low as 5%. learning objectives: 1. to understand potential treatment options and when to treat and when not to treat. a s15 c b d e f g h to current best practice, restriction of opinions to one's own expertise, expression of opinions that take into consideration all of the material facts, and the readiness to change that opinion if additional information becomes available. any unusual, contradictory or inconsistent features of the case should be highlighted. the expert should highlight whether a proposition is a hypothesis (in particular a controversial hypothesis) or an opinion deduced in accordance with peer-reviewed technique, research and experience accepted as a consensus in the scientific community. he/she should indicate whether the opinion is provisional (or qualified), stating the qualification and the reason for it, and identify what further information is required to give an opinion without qualification. when there is a range of opinion on any question to be answered by the expert, (a) the range of opinion should be summarised, (b) highlight whether that range of opinion includes an 'unknown cause' (because of limited facts of the case or limited research/peer-reviewed publications), and (c) give reasons for the opinion expressed. reprints of scientific publications will assist the court, but will also enable the attorneys to undertake a more robust cross examination! learning objectives: 1. to learn about imaging findings in relation to whether or not abuse has occurred. 2. to understand in which cases the diagnosis of child abuse should be raised in the radiology report. 3. to become familiar with the terms that should be used when highly specific imaging indicators are identified in an otherwise normal infant. the radiologist at the eye of the storm 17:14 imaging plays a central role in the diagnosis of child abuse. is there any risk of the radiologist having a detrimental impact on either the welfare of the patient or the judicial process by either under-diagnosing or over-diagnosing child abuse? ovarian cancer continues to be a challenge to radiologists and clinicians, as it is one of the most lethal female tumours. this is mainly due to its diagnosis in an advanced stage in the majority of patients. however, new developments can be observed: new insights in tumour biology, advances in imaging and new concepts of ovarian cancer treatment and surveillance. furthermore, a multidisciplinary expert team approach has also substantially changed the management of patients with suspected ovarian cancer. the findings of radiology are becoming pivotal in a more individualised patient care. the role of radiology includes (a) characterisation of sonographically indeterminate adnexal masses, (b) staging as guidance for surgery and treatment planning (including identification of sites of non optimal resectabilty) in suspected ovarian cancer, (c) assessment of recurrent disease, and (d) in selected cases image-guided biopsy. in this session we provide an update on the aetiology and current concepts of treatment of ovarian cancer and on the contribution of radiology in characterisation and staging in patients with the working diagnosis of ovarian cancer. the panel discussion will focus on the role of radiology in multidisciplinary conferences in suspected ovarian cancer. session objectives: 1. to learn about new concepts in etiology and treatment of ovarian cancer. 2. to become familiar with optimised imaging protocols to diagnose ovarian cancer. 3 . to learn about the value of ct and pet/ct as a basis for treatment planning in ovarian cancer. 4. to appreciate the role of the radiologist in multidisciplinary consensus conferences. session objectives: 1 . to learn about current imaging practices in the evaluation of suspected child abuse. 2. to learn about imaging changes which permit a firm diagnosis of child abuse. 3. to become familiar how to construct a comprehensive report providing evidence of child abuse. how to image and detect patterns of skeletal injury indicating child abuse p.k. kleinman; boston, ma/us (paul. kleinman@childrens.harvard.edu) in infants, skeletal injury may form the basis for the diagnosis of abuse. the first step is the acquisition of a skeletal survey utilising meticulous technique adhering to a rigorous imaging protocol. a proper interpretation is ensured when the radiologist is familiar with the various patterns of skeletal injury, their specificity for abuse and those entities which may simulate inflicted injury. appreciation of the lesion morphology, the fundamental pathologic alterations and mechanism of injury are essential in assessing the significance of the findings and placing them in the clinical context. dating fractures poses a significant challenge, but in most cases, injuries can be placed in a certain time frame, especially if a follow-up skeletal survey is obtained. although radiography forms the basis of skeletal imaging, ultrasound, ct, scintigraphy and mri may clarify findings and optimise diagnosis and management. the radiology report must be constructed with care and the language should be crafted with the expectation that the radiologist may be called to testify in court, a daunting challenge in an often highly adversarial environment. learning objectives: 1. to learn about the appropriate imaging protocols and quality for skeletal survey in suspected child abuse. 2. to learn about patterns of skeletal injury typical of child abuse. 3 . to become familiar with findings that point to alternative diagnoses. imaging strategies to fully determine intracranial injury resulting from child abuse c. adamsbaum, c. rey-salmon; paris/fr (c.adamsbaum@svp.ap-hop-paris.fr) radiologists play a key role in the early diagnosis of abusive head trauma (aht). symptoms are various and may range from coma to asymptomatic children. changing elements of the history provided previous injuries, bruising in non-ambulatory children and delay in seeking care raise a high index of suspicion. the most common finding in aht is of multifocal subdural haematomas over the cerebral hemispheres, the convexity, the posterior interhemispheric fissure and the posterior fossa. the haematomas are often associated with hypoxic-ischaemic injury and retinal haemorrhages. ct is the first diagnostic examination to be used for patients with acute injury. it can reveal intracranial haemorrhage, fracture and soft tissue swelling with a high degree of sensitivity. ct should be repeated after a time interval if the findings are doubtful or if there is a discrepancy with the neurological picture. mri (including t1, t2, t2*, diffusion sequences and cervical spine examination) is required to fully determine intracranial injury as it can exquisitely demonstrate hypoxic-ischaemic injuries by showing areas of cytotoxic oedema. it is impossible to date precisely a haematoma whose pattern is influenced by numerous factors. however, the main point is to determine the presence of 'age-different' lesions. this not only provides a strong argument for the diagnosis but also suggest repetitive violence and thereby, a high risk for further injury unless protective action is undertaken. brain imaging must be performed in all siblings younger than 2 years, living in the same conditions as the index case. learning objectives: 1. to learn about imaging protocols designed to: a) detect acute treatable conditions b) depict fully and determine the timing of all injuries. 2. to become familiar with imaging findings that are highly suggestive of child abuse. 3 . to learn about head trauma that may simulate child abuse. what is the information required by any court and how the radiological reports should be phrased s. chapman; birmingham/uk (stevechapman@doctors.org.uk) this presentation will describe the role of a paediatric radiologist as an expert witness (as opposed to a witness to fact). the expert has an overriding duty to the court that takes precedence over any obligation from whom the expert has received instructions or by whom the expert is paid. particular duties include advice that conforms a-040 16:05 ovarian cancer: update and role of radiology j.a. spencer; leeds/uk (johnaspencer50@hotmail.com) ovarian cancer is known as the 'silent killer'. it is usually diagnosed late and most women have disease disseminated to the peritoneum (and/or pleura) at presentation. standard treatment comprises cytoreductive surgery followed by platinumbased chemotherapy. an alternative is neoadjuvant chemotherapy followed by interval debulking surgery (ids) then completion chemotherapy. data from the eortc 55971 trial show this to be as effective as the standard of care. there are strong genetic predispositions to ovarian, fallopian tube and primary peritoneal cancers. there is linkage with breast cancer in women with brca gene mutations and with colon cancer with the hnpcc gene. ongoing trials are screening women in the general population and at high risk of the disease. these use the serum tumour marker ca125 followed by us as screening tools. mr imaging is an effective tool to assess sonographically indeterminate adnexal masses and offers an earlier diagnosis of cancer than interval reassessment with us. ct is the most commonly used modality for assessment of disease extent prior to surgery. image-guided biopsy is necessary prior to starting neoadjuvant chemotherapy. the eortc 55955 and mrc (uk) ov05 trials of women with treated ovarian cancer have shown no outcome advantage for women treated early at 'ca125 relapse' of disease versus later with clinical or ct evidence of relapse. this questions the role of ca125 in follow-up and argues against investigation of the 'ca125 +ve, ct -ve' woman with more expensive and scarce imaging resources such as ct-pet and dcemr. learning objectives: 1. to become familiar with clinical features of ovarian cancer. 2. to learn about the etiology of ovarian cancer, including genetic predisposition and the current research into screening. 3. to become familiar with new concepts of treatment ovarian cancer and surveillance of the treated patient and their impact for the use and choice of imaging modalities. imaging of adnexal masses: is it feasible to diagnose ovarian cancer? i. thomassin-naggara; paris/fr (isabelle.thomassin@tnn.aphp.fr) adnexal masses can be depicted by many imaging modalities (us, ct, mr and pet-fdg). however, the characterisation of adnexal tumours is mainly based on two techniques: us and mri. for complex adnexal masses, mr imaging add to conventional criteria of malignancy common to all imaging modalities (bilaterality, tumour diameter larger than 4 cm, predominantly solid mass, cystic tumour with vegetations, and secondary malignant features, such as ascites, peritoneal involvement, and enlarged lymph nodes) specific features based on the characterisation of the solid tissue (including vegetation, thickened irregular septa, and solid portion) of the adnexal tumour. signal intensity of solid tissue on t2 sequence (fibrous tissue), perfusion (neoangiogenesis), and diffusion (cellularity) are combined to make a decision tree analysis. low t2 signal, absence of high b1000 signal, and time intensity curve type 1 are predictive of benignity whereas high t2 signal and time intensity curve type 3 are predictive of malignancy. combining common classical features and specific mr features for predicting malignancy, mr imaging has a high degree of accuracy (96%) for characterising complex adnexal tumours. this high diagnostic confidence rate may help young women wishing to preserve childbearing potential to opt for conservative surgery and avoid the systematic removal of benign complex adnexal masses in menopausal women. learning objectives: 1. to understand the role of ultrasonography in assessing and managing complex adnexal lesions. 2. to learn how to optimise the mri protocol and how to improve the characterisation of indeterminate complex adnexal masses. 3. to understand the added value of functional sequences (dce mri and dwi) in diagnosing adnexal masses. the european and american guidelines include breast ultrasound in a restricted diagnostic scenario for breast cancer diagnosis. the fourth edition of the european guidelines (2006) reviewed in 2008 refers to us in only twice. acr in its 2007 acr practice guideline reduces breast ultrasound examination to seven situations. evaluation of the axilla and ultrasound as a screening tool on high risk women is considered an area of research. the progression of us makes guidelines become obsolete very fast. its application still remains pending on the results of clinical trials. image smoothing on sono-ct or multiple frequency transducers will produce images, eventually with more diagnostic information. second tissue harmonics will produce sharper and more clear images. cad systems, doppler and contrast doppler will help in diagnosis. 3d with the new software and automatic probes constitute a very promising work in progress. they will make a dramatic change in our workload. the radiologist will be released of performing the exam, to review the images in the workstation. sonoelastography has evolved from the manual to the actual automatic shearwave. this system measures the transversal transmission of sound in biologic tissues. it is a new and promising technology, probably more objective and non-operator dependant, that is able to differentiate benign from malignant conditions. all of these systems will be reviewed and evaluated for its actual situation. the problem now is how to introduce new terms, new descriptors, and new technologies in the bi-rads system, once clinical evidence is demonstrated. diffusion-weighted mri (dwi) is a promising technique in oncology. it can be used for in vivo quantification of the combined effects of capillary perfusion and diffusion. using echoplanar imaging (epi), dwi is possible with fast imaging times minimising the effect of gross physiologic motion from respiration and cardiac movement. in this lecture, we will discuss the acquisition, post-processing and quantification methods and results of dwi in abdominal and pelvis tumours. we will also review the mechanisms associated with diffusion changes in tumours. mri-pathologic correlation will be shown. finally, limitations and future directions of the technique will be reviewed. diagnostic potentials -as well as limitations -associated with morphological cross-sectional imaging on the one hand and functional imaging on the other are increasingly well understood. it has become obvious that in many cases both kinds of imaging complement one another. hence, hybrid pet/ct imaging must be considered one of the most promising new developments in medical imaging. however, some questions have to be raised and challenges have to be met to avoid overrating pet/ct in oncology. pet/ct with [18 f]-2-fluoro-2-deoxy-d-glucose (fdg) as a radioactive tracer has been reported to be more accurate than either imaging modality alone and sometimes even more accurate than ct and pet read side by side. however, the clinically important question should rather be the following: does this higher accuracy have an impact on patient management? furthermore, some tumours do not have an increased glucose metabolism making them fdg-pet negative. the most recently launched line of pet/ct scanners combines high-definition pet with high-end multislice ct. these imaging systems not only provide a higher diagnostic accuracy based on detection of smaller lesions with ct and pet, but also offer integration of complex ct protocols into the pet/ct scan. these protocols include ct perfusion, three-dimensional ct image reconstruction or virtual fly-through. the aim of this talk is to give an overview concerning pet/ct in oncology. the mechanism of radionuclide uptake, different tracers, the indications of pet/ct in oncology and its accuracy will be addressed. learning objectives: 1. to understand why uptake of the tracer provides information on the viability of solid tumours. 2. to learn whether pet/ct is able to give reliable quantitative information. 3 . to know whether pet/ct is a valuable tool for tumour response to treatment. to gain additional functional information. functional imaging techniques such as diffusion tensor imaging and tractography as well as fmri are increasingly used and relied on in clinical practice. with diffusion tensor imaging and tractography the location, course and integrity of the major white matter tracts can be depicted, while with fmri the brain's cortical function is visualised. despite major technical advances, these techniques are still time consuming, labour intensive and have several limitations. they therefore need to be used and interpreted with care. the purpose of this lecture is to review the functional anatomy of the brain in a clinically relevant context and to illustrate when additional functional imaging techniques may be indicated. the most important eloquent brain areas are addressed and include the motor, visual and language systems. routine clinical cardiac mri requires speed and efficiency as a result of physical motion. consequently, the challenges and benefits of rapid mri are nowhere more apparent than in the field of cardiovascular mr imaging. to meet these challenges, one must balance the competing constraints of signal-to-noise ratio (snr), contrastto-noise ratio (cnr), spatial resolution, temporal resolution, scan time, and image quality. one of the main determinants of snr is the static magnetic field strength. hence, cardiovascular mri at 3.0 t or more holds the promise to overcome some of the snr limitations and to extend the capabilities of cardiac mri. all studies in cardiac mri at higher field strength have proven the feasibility of cardiac mri for the comprehensive assessment of cardiac morphology and function. the studies demonstrated a significant snr increase, but also outlined image-quality problems associated with b 1 -field inhomogeneities and specific absorption rate (sar) constraints. with regard to acquisition speed, parallel imaging mri capabilities form an important enabling factor, especially if enough snr is available. therefore, the combination of higher field strength and parallel imaging strategies may help to overcome several of the present limitations in cardiac mri like cardiac perfusion and coronary artery imaging. the present indications, advantages and limitations of cardiac mri at 3.0 t will be discussed. the risks associated with the exposure of ionising radiation has raised increasing concerns in the radiological community. the recent years have shown an overall increase in the use of ct for the imaging of the heart and the coronary arteries. the downside of this increased use of cardiac ct is the increase in the collective radiation dose with cardiac ct which have been reported to be associated with an effective radiation dose of 20 msv or more. increased awareness of the radiation dose with cardiac ct led to the development of several effective radiation dose reduction strategies including prospective ecg gating technique, anatomy and ecg-based tube current modulation, high pitch acquisition, and adaptation of the ct scanning parameters to the body habitus. however, the dose reduction strategies should be selected carefully on an individual patient basis in order to avoid serious image quality impairment by noise and artefacts. the lecture outlines the different radiation dose saving techniques currently used in clinical practice, the anatomy of the brain is often perceived as being complicated. especially the cortex is seen as an irregular arrangement of variable structures, which are difficult to differentiate and to identify. we will review the overall subdivision of the brain into lobes and describe their boundaries and their major gyri and sulci. we will then describe the location of specific functions. 1. primary sensorimotor cortex: motor is located in the precentral gyrus, sensory in the postcentral gyrus around the central sulcus (cs), hence the importance of always correctly identifying the cs. we will present 4 interlocked methods to identify the cs in the axial plane (a) knob, (b) lateral axial, (c) medial axial, (d) gyral/cortical thickness and 3 to identify it in the sagittal plane (a) lateral sagittal, (b) hook, (c) medial sagittal. 2. primary auditory cortex (a1): centred at the postero-medial part of heschl's gyrus (hg), we will present simple landmarks in each of the 3 planes: (a) axial: adhaesio interthalamica, (b) sagittal: omega/heart shape of hg, (c) coronal: omega shape of hg. 3 . primary visual cortex (v1): centred on the calcarine sulcus, we will discuss the characteristic shape that allows the identification of this structure in all 3 planes. at the end of this lecture, you will know the subdivision of the cortex; the methods and landmarks necessary to identify the primary sensorimotor, speech, auditory, and visual areas. magnetic resonance imaging (mri) has undergone a rapid development in the last decade with numerous new techniques. nevertheless, pattern recognition of brain lesions based on signal intensities on conventional mr sequences (t1-and t2-weighted, flair) is the first step in diagnostic "work up". good examples for pattern recognition are lesions with t1-shortening ("bright" on t1wi) such as: fat containing lesions (lipoma), melanoma, lesions with colloid content, calcifications, and haemorrhagic metastatic lesions. t2-shortening ("dark" on t2wi) in enhancing lesions is suggestive of lymphoma and certain infections (tuberculosis, fungal abscesses). flow void (absence of signal) reflects high velocity flowing blood or csf, and will help in diagnosing vessel abnormalities and related pathologies. the purpose of this lecture is to refresh knowledge on patterns and normal variants useful for clinical practice. a simplified "pipeline" consisting of easy consecutive steps will be introduced. learning objectives: 1. to learn important normal variants of different structures and lesions in the brain. 2. to learn about recognition patterns that might be helpful in suggesting the most likely etiology of common brain lesions. 3. to consolidate the key imaging findings in different types of lesions and normal variants. a-051 17:00 c. clinical symptoms correlated to brain anatomy m. smits; rotterdam/nl (marion.smits@erasmusmc.nl) diagnostic neuro-imaging heavily depends on a thorough understanding of brain anatomy in relation to the brain's function. clinical neurological symptoms and deficits not only give us an indication of the brain area(s) involved but may also direct us towards the use of specific imaging techniques, such as diffusion tensor imaging and tractography, as well as functional magnetic resonance imaging (fmri). specific imaging findings, on the other hand, may direct clinical management in a neurologically intact patient, such as the decision to resect a brain tumour in or near an eloquent brain area. again, specific imaging techniques may be used evaluation of response to treatment allows an early assessment of tumour response typically after 2-4 cycles of chemotherapy. this evaluation is most commonly performed with pet/ct during therapy for high grade non-hodgkin's lymphoma. this review presentation looks at the potential roles that ct, regional mri and whole body mri do and could play in response evaluation from a radiology perspective. the presenter is a radiologist who is clinical director of a medium volume pet/ ct centre. the talk focuses on discrepancies between ct and pet findings in tumour response and on tumours or situations where ct is the primary modality to determine tumour response. potential roles for whole body mri in response evaluation and assessment of solid tumours by mri are examined. at a general level, the role of the radiologist as part of the multidisciplinary oncology meeting (mdm), including when and where to use image-guided biopsy in response evaluation and the use of recist versus precist criteria is discussed. the aim of the presentation is to outline the role of ct in tumour response evaluation in the era of pet/ct and to explore potential roles particularly for whole body mri in tumour assessment. the presenter hopes to encourage radiologists to get fully involved in mdm discussions regarding ct, mri and pet/ct evaluation. learning objectives: 1. to learn the standard method (tumour measurements) for the evaluation of tumour response to treatment. 2. to understand the limits of international standard. 3. to become familiar with methods that provide functional or structural information, like perfusion ctmr or dw-mri. evaluation of tumour response to therapy: the role of nuclear medicine a. chiti; milan/it (arturo.chiti@humanitas.it) the high costs and possible side effects of chemotherapy and radiation therapy treatments favour the use of effective ways to monitor the treatment efficacy in oncology. molecular imaging demonstrated to be effective in evaluating the response after and during the course of therapy, in order to assess chemo-sensitivity and chemo-resistance of a particular neoplasm. the use of pet-ct in this setting can vary from very sophisticated and complex quantitative evaluation to simple qualitative analyses. in malignant lymphoma, international criteria for monitoring response to therapy have recently been revised, and fdg now plays a central role in defining tumour response. in a variety of solid tumours, studies have indicated that fdg pet-ct may provide early and accurate assessment of tumour response, suggesting that it could play a significant role in personalising the treatment of malignant tumours. performed during and after therapy for hl and aggressive nhl, fdg pet results have a high prognostic value and correlate with survival. fdg pet has been incorporated into revised response criteria for aggressive lymphomas, and several ongoing trials are under way to investigate the value of treatment adaptation based on early fdg pet results for hl and aggressive nhl. many technical aspects must be taken in consideration to avoid critical errors in evaluating response. from patient preparation to image acquisition a series of possible pitfalls must be avoided. in the clinical practice, the most widely used parameter is the suv, which can improve the accuracy of qualitative image assessment in many clinical settings. learning objectives: 1. to understand why pet-ct can be used to assess tumour viability. 2. to become familiar with the principles of signal quantification and to discuss its advantages and limits. 3 . to learn about the incoming tracers that might enhance the role of pet-ct in the evaluation of tumour response. alzheimer's disease: the role of radiology j. alvarez-linera; madrid/es (jalinera@ruberinternacional.es) neurobiological changes in alzheimer's disease (ad) occur in an stereotypical pattern that begins in the medial temporal lobe (mtl) years before the clinical manifestation (brain reserve). brain atrophy is a marker of neurodegeneration that reflects the neurobiological disorder and is correlated with the neuropsychological changes at all stages of the disease. other imaging markers may reflect changes in microstructural (diffusion), functional (perfusion) or metabolic (mrs) domains that would provide additional information but are awaiting wider validation. in the early stages of ad, the most effective mri markers are those that reveal atrophy in mtl, particularly the measures of the hippocampus. the mtl atrophy mea-the required conditions in whom they may be successfully used, and how these techniques could be implemented in the daily clinical practice. proper linking of the data acquisition to the patients ecg is among the crucial prerequisites for successful cardiac imaging. while cardiac ct data acquisition itself does not impose any effect on the patients' ecg, inherent physical effects in the mr environment does show impact on the ecg trace and may hamper proper r-peak delineation. in addition, patient-related factors such as arrhythmia might affect image quality (iq). dose saving strategies in cardiac ct limit the possibilities of retrospective iq optimisation and as such more emphasis is recommended prior to data acquisition which is mainly related to patient selection/heart rate control. in cardiac mr a high amplitude ecg without influence of magnetic or scanning effects is of outmost importance. arrhythmia also remains a challenge that might be overcome by arrhythmia-rejection algorithms or real-time imaging. suboptimal contrast enhancement ought to be avoided by proper planning and timing as the majority of post-processing algorithms is based on signal behaviour. in the unfortunate situation of suboptimal contrast enhancement often only the use of standard post-processing tools is possible while semi-automated tools for cardiac post-processing may fail or necessitate substantial user interaction. the use of straight forward visualisation techniques is recommended for diagnosis while complex visualisation tools may add on confidentiality but are mainly suited for case presentations. coronary evaluation is typically performed using centerline tools allowing for the easy assessment of cad. while these tools potentially allow for estimation of the degree of diameter and area stenosis, accuracy though may still be limited. this is the second session between esr and eanm at each society's annual congress. few would argue but that patient's interests are best served by crossfertilisation and open communication between specialties. this is particularly true for radiology and nuclear medicine. this session elaborates on clinical scenarios where cross-fertilisation between both specialties is particularly important. the session will elaborate the radiologist and nuclear medicine perspectives on two common clinical scenarios, i.e. tumour response to therapy and evaluation of alzheimers disease. session objectives: 1. to appreciate how nuclear medicine and radiology provide complementary information. 2. to learn how each method can enhance the mutual performance of the radiologist and nuclear medicine physician. 3 . to learn about recent advances in the field of tumour evaluation and early detection of alzheimer's disease. shown on mdct-images in the axial, coronal, and sagittal plane. variants of the normal anatomy, which are important to describe and to know are also shown. some of these variants are also delineated on mr images. in the second part of the lecture, the different expressions of congenital malformations of the external and middle ear will be explained. the different findings of the severity of the malformations will be shown and their importance for further clinical-therapeutical procedures will be explained. imaging investigation of cholesteatoma is required before surgery. if no surgery has been performed previously, ct will provide information about the location of the lesion (epi, pro, meso, retro, hypotympanum), the partial or total destruction of the ossicles, and possible extension to the inner ear. if there is no doubt about any of these factors ct is sufficient. in doubtful cases an mri examination is performed to confirm or refute the presence of cholesteatoma using t1 sequences without iv contrast medium, and diffusion weighted imaging with or without high resolution t2, depending on the age of the patient. in postoperative recurrent cholesteatoma, mri is becoming the modality of first choice for detecting cholesteatomas, appearing : low in signal on t1 sequences, high in signal on diffusion weighted imaging. however, care is required since performing diffusion weighted imaging without t1 may lead to false positives. a granuloma with a slightly or markedly increased t1 signal is often associated with a high signal on diffusion. measurement of adc is useful for detecting cholesteatomas, infected cholesteatomas or abscess. finally whilst mri is the first examination in the follow-up of postoperative patients, the use of contrast medium is not necessary in most of the cases. a-062 17:00 c. implants and postoperative findings in the middle ear b. verbist; leiden and nijmegen/nl many conditions which affect the function of the middle ear may require surgical intervention. postoperative imaging will be requested either to evaluate complete removal of diseases (eg in cholesteatoma) or because of new, persisting or recurrent complaints of the patient (e.g. vertigo after stapes replacement). in this presentation, different surgical procedures will be reviewed including the indications for a certain surgical approach as well as the different types of prosthesis. the normal postoperative imaging appearance of the most common surgical techniques will be shown. it will be discussed whether ct or mri should be performed to answer the clinical questions. an overview of possible failures and complications will be given. the management of patients with vascular malformations is often suboptimal. the reasons for this are many but include confusion regarding classification, uncertainty about the most appropriate imaging of the various forms of malformation and a sures are helping to propose new diagnostic criteria for ad, allowing a diagnosis of probable ad in predementia stages, when memory loss criteria are attached to imaging criteria (mri or pet) or measures of amyloid/tau in csf. the use of atrophy markers (global or mtl) increases the effectiveness in clinical trials (both by reducing the size of the sample and increasing the statistical power) and is therefore contributing significantly to the development of new treatments. the association of multiple markers of structural and functional imaging (mri and pet) and the use of advanced computational analysis techniques will allow better management of ad but it needs a broader validation and know the most efficient combination of biomarkers at each stage of the disease, including the preclinical period. scientists, researchers and clinicians all benefit from molecular imaging in dementia providing exciting new insights into their basic biology and pathophysiology. targeting specific aspects of neurotransmission, metabolism, inflammation or plaque formation -just to mention some of the current molecular approaches -increasingly gains impact on establishing the correct diagnosis, following the course of dementia or developing cns drugs. this talk will highlight the molecular targets and major pet and spect tracers for application in dementia, and will update on the results of the clinical imaging studies published in recent years. typical imaging patterns of alzheimer's disease (ad) will be discussed, including also the diagnostic discrimination from other types of neurodegenerative dementias such as frontotemporal dementias, lewy body dementia, and others. assessment of mci patients and the probability of transition in manifest dementia (predominantly ad) will be addressed together with its prognostic relevance. furthermore, recent advances in analysing tools which further improved the high diagnostic accuracy already reached by visual assessments will be presented. even though in competition with other modalities, ‚standard fdg' pet has shown to be a robust and both, sensitive and specific marker in the diagnostic work-up of dementia. fdg information will be markedly extended in clinical practice by specific amyloid imaging in the near future when these tracers are approved and thus generally available. learning objectives: 1. to become familiar with the nuclear medicine method that enables detection and evaluation of alzheimer's disease. 2. to learn about the potential development of functional studies using nuclear medicine. 3. to understand how nuclear medicine and radiology can provide complementary information. symptoms may require explanation and reassurance only. lesions with a mainly cutaneous element may be treated with laser. deeper lesions are usually treated with several episodes of sclerotherapy. agents such as alcohol, polidocanol and std will be discussed and the relative advantages and issues explained. informed consent is vital, and the approach to this will be outlined. high flow lesions are frequently associated with severe cosmetic changes, invasion of surrounding tissues, haemorrhage, and high output cardiac failure. lesions may be life threatening. in the extremities peripheral ischaemia and ulceration due to steal of blood by the arteriovenous malformation is common. informed consent will again be discussed, as potential for major complications is high. key to endovascular management of these lesions is an understanding of the nidus, arterial inflow and venous outflow. the role of liquid and solid embolic agents and specifics of transarterial, venous and direct approaches will be discussed. avms pose a major problem regarding classification and treatment. a case report discussed by the panellists demonstrates how these patients should be approached. the importance of establishing an interdisciplinary outpatient clinic is also presented. the most important organisational steps for providing an efficient clinical service are given. in addition, the most common pitfalls and complications of treatment are illustrated. computer-aided detection/diagnosis (cad) is recognised as a workstation or a system developed in order to assist the radiologists (clinicians) in performing their daily diagnostic tasks. clinically implemented cads are available at workstations and (if dicom compliant) may serve as a plug-in to pacs. the three-layer cad system includes: (1) image analysis procedures whose development requires a medical and technical knowledge, (2) a database module that is managed by experienced radiologists and it professionals, and (3) graphical user interface (gui) that enables a user-friendly access to the data, the processing tools, and the results. a modern cad development involves a multidisciplinary team whose members are experts in medical and technical fields. a close collaboration of all experts is required at all stages of system life-cycle. at each stage the physicians knowledge and experience are indispensable. it includes medical analysis of the diagnostic problem, data collection, image analysis evaluation, and clinical verification. design, testing, and evaluation have to be successful in order to ensure cad implementation in a daily clinical routine. in this session three experts will share their experiences in the area of the overall cad architecture, its evaluation, validation and acceptance by clinicians, advantages and restrictions of solutions and clinical implementation in lung, breast and colon cancer. reading paradigm (primary, concurrent, second) in oncology as well as results of cad clinical implementation will be presented. perspectives in clinical cad implementation in diagnosis and treatment will be discussed. patients presenting with vascular malformations mostly are nomadic and hopeless individuals looking for help. finally having reached a "multidisciplinary specialistgroup" after a sometimes long and misleading trip throughout the ocean of "singleplayers" of different specialities these patients do not ask for any more diagnostics -they strongly claim for therapy. vascular malformations are congenital lesions, although merely seen at birth they become evident throughout the individuals growth. these developmental errors can affect all components of the vascular tree in any area of the body. the therapeutic goal must be defined rather as "control" than "cure" of this disease. to make this point understandable for both patients and collegues a fundamental understanding of the pathogenesis and natural course must be created. in special cases of complex vascular malformations the precise diagnosis and the information about all potential side-effects as well as risk-factors of progression enables these patients to manage their daily life. therefore, indications for treatment vary depending on the specific type of slow flow or high flow lesion, location, pain, functional and cosmetic impairments and general side-effects of each particular lesion, since no single specialist has enough knowledge to diagnose or treat vascular anomalies beyond the border of his distinct speciality multidisciplinary working-groups emerged at these interdisciplinary interfaces. their common language in classifying and their overall understanding of pathogenesis, prognosis offer these mostly hopeless patients a custom-fit treatment addressing their symptoms. imaging of vascular malformations should be directed by clinical assessment of the type of malformation to be expected, clinical symptoms and need for treatment. in order to make the proper decision of the required imaging modality or treatment, it is essential that the (interventional) radiologist is a member of a dedicated vascular malformation team. imaging needs to be tailored to the individual patient although general rules can be applied. duplex ultrasound together with a clinical assessment is often sufficient to make a proper diagnosis. this is especially true for the paediatric population. if more information about the extent of the lesion is needed, mr is often used in case of low flow lesions (venous/lymphatic), and mra or cta in case of high flow lesions. angiography is mandatory if an avm is diagnosed and treatment is planned. high frame rate imaging and selective injections are the only options for a proper evaluation of the nidus architecture of the avm. there are exceptions that warrant deviating from the above general rules. in this lecture, both the general rules and the exceptions will be discussed. at the onset of the 21 st century humankind is focusing its attention on a very small molecule, as controlling co 2 in the atmosphere is becoming a major goal, economically, socially and politically. yet, there is another small molecule which is going to play a more prominent role in the near future. h 2 o, especially in its liquid form, the 'blue gold', is just indispensable to our lives. water makes 60 to 70% of the human body weight and is crucial to the working of the biological machinery. still, how such a tiny molecule with its 105° 'magic' angle could have been at the origin of life remains largely a mystery. different organisms have adopted different strategies in the way they get the most out of water, depending on their environment, and water contributes to the biodiversity. faulty mechanisms in the use of water by tissues may lead to severe diseases or death. clearly, water deserves to be seen as the prime 'biological molecule', and radiologists have long recognised its importance from the days of 'dry' (bone and air) radiology to the advent of ct which allowed contrast from 'wet' tissues to be explored. with mri one went one step further, as magnetisation of water is the sole source of contrast. life has led to intelligence, and recent mri studies have suggested that water may also actively contribute to the mechanisms underlying brain function. could the 'molecule of life' also be the 'molecule of the mind'? clearly, water must be radiologists' best friend. learning objectives: 1. to comprehend how the structure of the water molecule makes it important to life. 2. to understand the importance of water in biological and cellular processes. 3. to become familiar with the different ways water is responsible for image contrast in radiology. a. the role of cad in modern-day imaging a. todd-pokropek; london/uk (a.todd@ucl.ac.uk) the use of cad in medicine is an important and growing area of research. firstly good data must be acquired including not just images but associated information. the first step in that of preprocessing, notably (but not only) noise reduction. the data are then passed onto the segmentation step. often this step is semi-automatic requiring some manual intervention. conventional edge detection methods are not often of value, but active shape and appearance models, the use of markov random fields etc are commonly used. the next step is that of feature extraction both of shape and texture. these data are then submitted to one of several classifiers such as artificial neural networks (including mtanns) support vector machines (svm) and data reduction using principle and independent component analysis, and multiple voting techniques such as adaboost are also of value. the output may simply be returned to the observer (clinician) or as further input for a decision support system. examples considered will be in breast imaging (mammography), lung nodule detection, virtual colonoscopy and lumber spine. the use of the cad system as a simultaneous assistant or as a second reader is important. the use of cad in therapy is of increasing important. the assessment of such cad system (evaluation and validation) is still controversial. the difficulty of bringing systems both instrumentation and software for use in clinical practice in often underestimated and there have been some notable failures. some example of 'failures' will be given. ct colonography has evolved rapidly and disseminated widely over the last decade. the ability to provide an accurate whole colon examination with near perfect completion rates, use of reduced laxative bowel preparations and extra-colonic organ review has attracted very considerable interest amongst the wider radiological and gastroenterological community. inclusion of ct colonography in several core radiological training programmes confirms its evolution from super-specialist technique (performed in only a few centres) to mainstream. however, evidence supports highly variable performance, which is perhaps unsurprising given the complexity of both technique and interpretation methods -both which require specific training. notably, attendance at a training workshop generally represents the beginning of a radiologist's experience of ct colonography. indeed, most delegates rapidly progress from unconscious to conscious incompetence, acknowledging the need for a planned implementation strategy prior to offering ct colonography in their routine clinical practice. thankfully a decade of intensive research and large volume clinical experience has equipped the radiological community with knowledge and experience to inform successful ct colonography implementation strategies. by combining this experience with training and accreditation practices developed for colonoscopy, the prospect of a robust quality assurance framework is realistic and necessary to reassure both service commissioners and the general public alike. step one: the publication of international ct colonography standards, co-authored by eminent radiologists from across europe and beyond has been achieved. this talk will review the likely next steps. computer-assisted detection (cad) for ct colonography is now widely available in europe from a number of different vendors. this presentation will detail factors that potential users will need to know in order to properly evaluate cad systems, use them in clinical practice, and evaluate their likely impact. the different ways in which the performance of cad systems can be assessed will be discussed and the difference between weak methodologies (e.g. internal validation) and more valid assessments (e.g. external validation) will be explained. now that the diagnostic performance of ct colonography has been well-established, this state-of-the-art symposium will deal with issues related to the implementation ct colonography in day to day clinical practice. the lecturers will deal with the diagnostic performance of ct colonography, the technical requirements necessary to obtain high quality diagnostic data, the factors that underpin a high-quality service (including reader training), how implementation differs across different countries, and the possible impact of new developments, including computer-assisted detection (cad). two decades ago spiral ct technology initiated a new era in diagnostic imaging with virtual colonoscopy or ct colonography (ctc) as a major innovation. introduced by david vining in 1994, ctc was rapidly endorsed as a potential tool for colorectal cancer screening. after an initial pioneering period defining the basic ctc principles, the advent of multi-slice ct significantly improved spatial and temporal resolution, allowing for isotropic image reconstruction with detailed 3d rendering of the colonic wall and very short acquisition times, reducing motion artefacts. furthermore, application and refinement of (ultra-) low dose technique almost completely tackled the issue of radiation dose. these improvements have resulted in the perfect optical colonoscopy imitator with reliable fly through of the colon in a timely manner. consecutively, the primary 3d reading paradigm with 2d problem-solving is getting more and more adepts, although in experienced hands primary 2d-read with 3d-problem solving is a solid contender. to improve depiction of the colonic wall new 3d visualisation methods were developed. these technical improvements with the application of state-of-the-art ctc technique have resulted in a very good performance of polyp detection. in three multi-centre studies, totalising 3775 patients, sensitivity ranged between 78-91% and 90-92% and specificity between 84-93% and 84-98% for lesions > 6 mm and > 10 mm, respectively. finally, it may be expected that further refinements of cad, laxative-free ctc with electronic cleansing and dual energy ct will bring ctc to the next level and will enhance it as the reliable and cost-effective tool for colorectal cancer screening. learning objectives: 1. to review the evolution of ct colonography since its introduction, with a focus on data acquisition and methods of data visualisation and interpretation. 2. to review the currently achievable test characteristics of ctc (sensitivity, specificity, accuracy) via reference to current trial data. 3. to become familiar with imminent developments that may further enhance ctc test characteristics. astinitis and extension of infection from adjacent spaces (neck, pharynx, pleura or retroperitoneum). typical cases including the role of radiologic findings with respect to sensitivity and specificity, and important differential diagnosis will be discussed. the distinction between a parapneumonic pleural effusion and an empyema based on radiologic findings is often impossible. features suggesting a "complicated" course requiring interventional or even surgical treatment at some point will be discussed. features of empyema and lung abscess at ct will be illustrated as well as ct indices of severity of empyema and its effect on the underlying lung that allow some prediction of functional outcome after surgical decortication. an empyema necessitatis describes a chronic empyema that attempts to decompress through the chest wall. infectious agents include tuberculosis, actinomyces, staphylococcus and various types of fungi. it has to be differentiated from other mostly neoplastic diseases that cross fascial planes such as lymphoma or pancoast tumour. most lymphomas arise in lymph nodes or other lymphatic tissues. extranodal lymphomas arise in tissues normally devoid of lymphoid tissue. involvement of so-called extranodal organs is a common finding after staging investigation, however, and a substantial part of nhl even arises in these sites. the latter form is often referred to as primary extranodal nhl. splenic lymphoma is common in both hodgkin disease and non-hodgkin lymphomas but it may be difficult to detect by imaging techniques because lymphoma nodules in the spleen are often smaller than 1 cm. splenic enlargement alone is not a good indicator of lymphomatous involvement. primary hepatic lymphoma is rare compared with disseminated diseases at both nodal and extranodal sites. several forms of hepatic involvement can be seen including mass lesions/nodules, diffuse infiltrative form and extrahepatic involvement of the hepatic ligament. lymphomatous involvement of liver hilum nodes often infiltrates along the hepatic artery and portal vein toward the head of the pancreas and produces an infiltrative bulky mass that involves the liver, pancreas and duodenum. primary pancreatic lymphoma is very rare and can be difficult to differentiate from pancreatic adenocarcinoma. definitive pathological diagnosis of lymphomas is often obtained using image-guided biopsy. this noninvasive procedure is important as the prognosis and management of lymphomas differ greatly from that of adenocarcinoma or metastatic diseases. staging (ann arbor classification or modifications) and response to therapy is primarily by ct. community acquired pneumonia (cap) is a major health care problem because of their high morbidity and mortality rates. patients exposed to non-hospital risks who develop pneumonia have been traditionally categorised as having communityacquired pneumonia (cap). healthcare-associated pneumonia (hcap) is a new designation for pneumonias affecting individuals residing in non-hospital health care facilities, patients undergoing outpatient procedures or therapies, and patients who have been recently discharged from the hospital setting. when the diagnosis of cap or hcap is suspected, imaging studies are mandatory for the evaluation of affected patients. a nosocomial pneumonia is defined as one not acquired in a hospital or a long-term care facility. it occurs most commonly among icu patients, predominately in individuals requiring mechanical ventilation. pulmonary infection is a major cause of morbidity and mortality in patients with impaired immune function. increasing numbers of patients are becoming immunosuppressed, because of solid organ and hematopoietic stem cell transplantation, the use of immunosuppressive agents for treating a host of inflammatory diseases, or congenital and acquired diseases such as acquired immune deficiency syndrome (aids). mildy impaired host immunity as it occurs in chronic debilitating illness, diabetes mellitus, malnutrition, alcoholism, advanced age, prolonged corticosteroid administration and chronic obstructive lung disease have also been regarded as predisposing factors of pulmonary infections. the rapid diagnosis and treatment of pulmonary infections are essential. combination of pattern recognition with knowledge of the clinical setting is the best approach to pulmonary infectious processes. acute mediastinitis is a potentially life threatening but fortunately rare condition that requires prompt diagnosis and treatment. spontaneous or iatrogenic oesophageal rupture is the by far most common cause. other causes include post-surgical medi-ask the patient for those information. at the time of mr imaging plain films and/ or results of an ultrasound exam of the shoulder, if possible, should be available. however, only such prerequisites allow to run a tailored examination protocol and to support the orthopaedic colleague with the needed answers for further adequate therapy. the patient has to be placed in the magnet in a pleasant situation to avoid artefacts due to patients movement, which usually cause motion artefacts. it is very important to explain to patients to keep quiet during the whole examination, because artefacts may need repetitions of sequences, and lead so to prolongation of total examination time. furthermore, they make diagnosis more difficult and eventually more or less inaccurate. lastly, sequence repetitions decrease patient throughput and therefore cost effectiveness. imaging in three orientations (axial, paracoronalparallel to the supraspinatus tendon, and parasagittal -parallel to the glenoid cavity) using t1w (pdw) and/or t2w sequences have to be performed. in case of specific questions regarding lesions of the labrum intraarticular administration of contrast agent (mr arthrography) should be considered, which is sometimes (different from country to country) possible after discussion with referring orthopaedic surgeon only. mr imaging (mri) and mr arthrography are the primary diagnostic imaging modalities applied to patients with degenerative, traumatic and sports-related shoulder lesions. in this categorical course the characteristic mr imaging and mr arthrographic features of articular pathologies of the shoulder, in particular, instability-associated injuries, rotator cuff tears and biceps tendon lesions are discussed. beside lesion detection the radiological analysis comprises the understanding of the underlying pathomechanism and recognition of possible interrelations between different type of lesions (for example, secondary impingement and associated lesions of the posterosuperior labrum). the use of classification systems for specific lesions is introduced in order to improve the radiological report. a reasonable structure for written reports is discussed comprising a brief and clear description of pathological findings with subsequent interpretation and categorisation of findings with a view of therapeutic decision making. tissue changes in the treated neck by surgery and/or radiotherapy (rt) make the detection of residual or recurrent tumour more difficult. clinical evaluation of the neck is also hampered by these changes. therefore, any (non-invasive) method helping in the detection of recurrence is welcome. in order to evaluate the treated neck, radiologists should be familiar with expected post-rt findings. histological changes post-rt will be discussed in combination with imaging examples. this knowledge will enable radiologists to recognise non-expected findings post-rt. non-expected post-rt findings can be caused either by tumour recurrence, or by complications of treatment (e.g. chondro-radionecrosis). imaging examples will be shown. especially after surgery, including various types of neck dissection, lymphatic drainage patterns of the head and neck are altered. it is important that radiologists are aware of these changes. imaging examples will be shown. ct and/or mr-findings in the treated neck may be inconclusive. in these cases, there may be an additional role for metabolic (pet) imaging. at present, the position of metabolic imaging in the imaging protocol for the treated neck is unclear. information from the recent literature will be discussed. also, examples from daily practice will be shown, with emphasis on the importance of base-line imaging after treatment and the timing of such base-line scans. this knowledge will help in understanding the current indications and limitations of post-treatment metabolic (pet) imaging of the head and neck. an increasing number of functional and metabolic imaging options reflecting relevant aspects of tumour biology have rapidly been incorporated into clinical trials and, progressively, into clinical practice. while tumour staging according to the tnm system still rules most decisions regarding treatment choice in head and neck cancer, biological information from the tumour and its microenvironment has proven to have important predictive and prognostic value heading for a tailored and individualised patient's management. ct, mr and pet are the mainstay imaging modalities to access tumour extent, both of the primary tumour, lymphatic and distant metastases and for early depiction of recurrence during patient's follow-up. hypoxia and angiogenesis, the major driving forces for tumour aggressiveness, long linked to chemo and irradiation treatment failure, can now be imaged both by pet (18 f-miso or 60cu atsm) or mri (bold and pwi, respectively). this information is being used to define biological tumour volumes, to tailor conformational and intensity modulated radiation treatments and to select patients for specific treatments such as radiosensitizers, hypoxia selective cytotoxic and antiangiogenic drugs. overexpression/amplification of egfr (epidermal growth factor receptor) are common genetic abnormalities in scc linked to increased cell proliferation and worse prognosis. imaging techniques reflecting cell proliferation/ density (18 f-flt -desoxyfluorothymidine-and diffusion-weighted mri) can be used to select patients for treatment with egfr inhibitors. this special focus session will review the use of these imaging modalities both prior, during and after treatment of head and neck cancer focusing on their specific advantages and accuracies in these different settings. contrast-enhanced ct and mri are routinely used in order to determine the precise localisation, size and anatomic extent of the primary lesion. on the other hand, positron emission tomography (pet) is the most sensitive and specific technique for in vivo imaging of metabolic pathways and receptor-ligand interactions in the tissues. a common question is which of these techniques should be used in a particular patient. the most widely used technique is ct, as it has a number of important advantages over mri, like wide availability, relative low cost and short examination time. however, ct also has a number of disadvantages compared to mri: relative low soft tissue contrast resolution, severe image quality degradation by dental fillings or other metallic foreign objects, and radiation exposure. pet in combination with ct and/or mri has a good sensitivity and specificity for the detection of primary tumour and for nodal staging as well as for detection in a single examination distant metastases, occult tumours, second synchronous tumours, and for radiotherapy planning. by combining pet with ct and mri studies, either sequentially or synchronous performed, the diagnostic accuracy is significantly higher. in those situations, it has been proven that magnetic resonance (mr) imaging is a valuable adjunct to delineate the pathology. in non-pregnant woman the radiological evaluation is less difficult. still, a multimodality approach may be needed in certain cases. in this lecture, radiological features of non-gynaecologic emergencies such as acute appendicitis, diverticulitis, renal calculi and pyelonephritis will be discussed. the purpose is to discuss the role of imaging and the potential of different methods applicable in childhood uti -with a focus on us. the imaging task in uti has changed, and new questions arouse for radiology. in addition, growing economical demands pressurise radiology to restrict imaging to those conditions where an evident benefit has been demonstrated. this efficacy-oriented approach is difficult in children due to the lack of evidence-based data. thus, controversies exist on if, when and how to investigate childhood uti, trying to minimise procedures and reduce burden on children and health budgets without missing important conditions that may pose a threat to the kidney. furthermore, modern imaging with new methods, applications and potential (e.g. contrast-enhanced voiding urosonography = ce-vus) may influence the imaging algorithm. the in utero and post-natal follow-up of foetuses with urinary tract dilatation has provided lots of information about the proper management of urinary tract malformations. nowadays, affected neonates are evaluated following standardised charts panel discussion: the three musketeers were actually four 09:44 ct, mr and pet: how to choose between modalities in head and neck cancer patients. an increasing number of imaging modalities reflecting functional and metabolic aspects of tumours have rapidly been incorporated into clinical practice. these modalities provide additional information on tumour vascularisation/ angiogenesis (ct and mr perfusion); on tumour metabolism, hypoxia and proliferation (pet using different radioactively labelled substances) and on tumour architecture and cellular density (dwi). hybrid imaging, pet-ct and, in the near future pet-mr, can provide morphologic, metabolic and functional information in a one-stop-shop examination. the choice of the best modality (ies) to answer specific questions in the diagnosis, follow-up and in the prediction of response to treatment and prognosis will be addressed. acute abdominal and pelvic pain in pregnant women may be the manifestation of various gynaecological and non-gynaecological conditions. the correct diagnosis of the causes of acute pain during pregnancy is critical to minimise maternal-foetal morbidity and mortality. although ultrasound (us) is the primary imaging investigation in the diagnostic evaluation of the pregnant patient, the role of magnetic resonance (mr) imaging in the evaluation of foetal and maternal diseases in pregnant patients continues to expand. mr imaging offers different potential advantages in comparison to us for evaluating acute abdominal and pelvic pain; these include multiplanar imaging capabilities, a higher soft tissue contrast and the ability to detect and distinguish blood from other fluid collections. when us is equivocal or nondiagnostic, mr imaging is a valuable complement to determine the exact aetiology of acute abdominal pain. the intrinsic safety and the accuracy of mri in diagnosing abdominal and pelvic disease make it an excellent choice for triage of pregnant patients with acute abdominal and pelvic pain. mr imaging provides important information that influences patient management, and it is important for the radiologist to recognise the mr imaging appearance of the common causes of acute abdominal and pelvic pain during pregnancy. this lecture will discuss the use of mr imaging for maternal diseases that cause acute abdominal and pelvic pain during pregnancy. moreover, this lecture will discuss the different mr imaging techniques to use, and will show how to detect and to differentiate the gynaecologic and non-gynaecologic causes of pain during pregnancy. in this lecture, the role of imaging in the evaluation of gynaecologic emergencies will be presented. a combined approach using both clinical findings and imaging features is necessary. accurate evaluation is important as failure to make a diagnosis may lead to serious consequences. presenting symptoms, such as pelvic pain or vaginal bleeding or discharge, may overlap with pregnancy-related emergencies and with non-gynaecologic abdominal emergencies. the range of conditions to be considered include ovarian cyst emergencies (cyst rupture, haemorrhage or torsion), infective conditions (bartholins' or vulval abscess, pelvic inflammatory disease or tubo-ovarian abcess) and acute bleeding (from inflammation, neoplasm, or trauma). pain may be related to the menstrual cycle, as in endometriosis or ruptured corpus luteum, or may be unrelated, such as in fibroid or ovarian torsion or pelvic inflammatory disease. the imaging features of these acute abnormalities will be reviewed and discussed in the context of the differential diagnoses. the major functional imaging tools for tumour management are obtained with dynamic contrast-enhanced imaging, diffusion-weighted mr imaging, and mr elastography. these acquisitions allow understanding of tumour angiogenesis and perfusion, and tumour architecture. dynamic contrast material-enhanced imaging allows assessment of perfusion parameters. diffusion-weighted mr imaging provides information that reflects tissue cellularity and the integrity of cellular membranes. mr elastography evaluates the mechanical properties of tissue such as stiffness and viscosity. to date, tumour detection is mainly based on morphologic features. however, changes in perfusion parameters have been shown as early parameters of liver metastases detection in patient with colorectal carcinoma or breast carcinoma. tumour characterisation is usually based on morphologic features. yet, perfusion parameters have been shown to correlate with microvascular density and tumour differentiation helping tumour characterisation. furthermore, apparent coefficient diffusion (diffusion-weighted mr imaging) and stiffness and viscosity (mr elastography) are significantly different in benign and malignant tumours. despite these differences, these last parameters usually do not allow definitive subtyping. functional imaging starts playing a major role in non-surgical treatment follow-up especially with targeted cancer therapy. changes in perfusion parameters, apparent coefficient diffusion, and stiffness and viscosity are observed in responders. interestingly, these changes appear promptly after treatment initiation. these functional variables are not included in recist 1.1 but might be part of response criteria in the next future. many examples of functional imaging for tumour management will be provided. learning objectives: 1. to understand the potential of functional imaging in tumour detection. 2. to understand the potential of functional imaging in tumour characterisation. 3 . to learn about the future use of functional imaging in treatment planning and follow-up. (among others, thanks to the esur-espr working group). at birth, a confirmatory ultrasound is performed in order to evaluate the type and degree of the malformation. urinary tract dilatation are separated into mild, moderate and marked. mild and moderate dilatation will be followed by us. voiding cystogram and functional studies will be performed only if the dilatation is significant or persists. the prognosis is usually good. patients with marked dilatation would be managed more "aggressively". their work-up would be initiated as soon as diagnosed in order to diagnose cases that need therapeutic manoeuvre. for them voiding cystogram, anatomical and functional studies cannot be skipped and are important for the prognosis. long-term follow-up are needed to prevent further damage. learning objectives: 1. to learn which infants with antenatal diagnosis of urinary tract dilatation require imaging and when. 2. to become familiar with the most important differential diagnosis. 3 . to learn about the imaging strategies in these infants. c. renal and pararenal masses: basic rules p. tomà; rome/it (paolo.toma@opbg.net) the differential diagnosis of renal and pararenal masses firstly depends on the age of the child. wilms tumour (nephroblastoma) is the most common abdominal tumour in 1-8 years old (80% of cases in children less than 5 years old -peak age 3.6 years). renal non-wilms tumours represent a significant proportion of renal tumours in children, especially in children aged less than 6 months or greater than 12 years. neuroblastoma most commonly arises from the adrenal gland but can arise anywhere along sympathetic chain; it is the most common tumour in children under 2 years of age (90% of cases in children less than 5 years -mean age < 2 years). adrenal adenomas and carcinomas also occur in childhood. us is the initial imaging modality to investigate an abdominal mass in children. ct or mri is used to confirm the us findings and not uncommonly add new, valuable information. concerning wilms tumour there is a very diverse approach to treatment according to geographical location. this variation in therapeutic attitude has consequences for the choice of imaging modality at diagnosis. neuroblastoma staging includes also 123i-mibg, and laboratory investigations (bilateral bone marrow aspirates with histochemical tests and urine catecholamine level measurements). we focus on the points under discussion: revision to the staging of neuroblastoma, the problems inherent in distinguishing nephrogenic rests from wilms tumour and the approach regarding small lung nodules in children with wilms tumour. the principle of bi-rads 3 imaging finding should be that of "quasi-benign" type, i.e. with a very low associated risk of malignancy (< 2%), opening the possibility of a short-term imaging follow-up as an alternative to imaging-guided needle biopsy. however, a number of issues should be regarded as relevant to radiologists and patients. 2) radiologists' differences in classification. 2. when needle biopsy is optioned, vacuum-assisted biopsy under stereotactical guidance for mammographic only findings (typically, microcalcifications) and core-biopsy for sonographic findings should be used; fine needle aspiration cytology should be avoided due to the high probability of benign lesions which need larger tissue samples. 3. when short-term follow-up (typically, 6 months) is optioned, the same technique on which the bi-rads 3 lesions was initially detected should be used. 4. in the screening setting, short-term follow-up option is commonly not considered and the reader is forced to give a dichotomic reading (recall/not recall). 5. the choice between the two options should be clearly discussed with the patient, including the psychological cost of waiting six months to get a conclusive report, and a really informed consent should be obtained. 6. till now, there is insufficient evidence for using tomosynthesis or mri for evaluating mammographic or sonographic bi-rads 3 findings. the premise behind the bi-rads 3 classification is to identify a group of low risk lesions that can be safely placed on follow-up rather than biopsy. in practice this can be very difficult and is anachronistic to the principles of the european population screening programmes where the radiology objective is to diagnose or discharge. the panel will discuss these dilemmas. starting in the late 1980s an american college of radiologists task force developed the concept of guidelines to standardise mammography reporting: breast imaging reporting and data system (bi-rads). there is evidence that over time there have been improvements in consistency of use, sensitivity, specificity and positive predictive value. however, bi-rads 3 'probably benign; short interval follow-up recommended; less than 2% risk of malignancy' has always been the most difficult and controversial, with the highest levels of discordance between classification and recommendation, wide variation in both intra-and inter-observer agreement and a 2007 literature review demonstrating ppv for malignancy of between 0 and 8%. management of breast disease has moved on a great deal since the 1990s. in the main driven by increasing specialisation associated with population screening programmes. nowadays a specialist breast radiologist works with a wide variety of needle options at his hip to such an extent that the breast multi-disciplinary team increasingly feels that failure to obtain a non-operative diagnosis of discrete lesions is unacceptable. in this setting, and mindful of the medico legal consequences of 'delayed diagnosis', is there still room to allow a patient to leave the one stop clinic without a definitive diagnosis? as the leaders of the diagnostic team we also have to take account of the emotional and psycho-social consequences for our patients as well as the financial costs to patient and the healthcare economy. breast imaging reporting and data system (bi-rads) was developed for standardising reporting and include mammography, ultrasound, and mri. bi-rads category 3 "probably benign finding -short-interval follow-up suggested" should have less than 2% risk of malignancy. category 4 has been subgrouped into 4 a, 4b, and 4c, and this influence the classification of bi-rads 3. mammographic bi-rads 3: three nonpalpable findings in this category include clusters of punctate microcalcifications, well-circumscribed and noncalcified solitary masses, and benign-appearing asymmetric density. digital mammography will increase detection of amorphous microcalcifications and the number of bi-rads 3 (or 4 a) lesions. intramammary lymph nodes and calcified fibroadenomas are bi-rads 2 lesions. ultrasonographic bi-rads 3: a most important bi-rads 3 lesion is a solid oval mass ("tumour") with gently lobulations, circumscribed margins, and parallel orientation. using strict criteria, the negative predictive value is approaching 99%. two other lesions are nonpalpable "complicated cyst" and clustered microcysts. the "complex" cyst, i.e., a mass with cystic and solid components, should be classified as bi-rads 4. mri bi-rads 3: there is lack of evidence which mri findings should be categorised bi-rads 3. nonmass-like enhancement (nmle) and enhancement kinetics are unique to mri. lesions less than 5 mm ("foci") need no assessment. a challenge is mri-detected tumours < 10 mm as morphologic analysis is of limited value. benign kinetic curves may justify short-term follow-up. in high-risk women, mri-guided vacuum-assisted biopsy should be considered. in conclusion, bi-rads 3 is justified in diagnostic settings but should be avoided or kept at a minimum in screening. what will be the standard machine and field of the future? l. darrasse; orsay/fr (luc.darrasse@u-psud.fr) improving the sensitivity has still been an essential issue in mri, because the signal from nuclear spins relies on extremely weak magnetic interactions dominated by thermal fluctuation. to push the signal-to-noise ratio upward, the basic routes have been (i) to increase the field strength, (ii) to improve the signal detection with radiofrequency coils and (iii) to enhance the signal dynamically with contrast agents or alternative preparation techniques. the first route is the most obvious one, driven by the trends in analytical mr spectroscopy and small-animal mri. going up to or even above 7 t represents a considerable challenge, both technically and in view to renew the mr equipment market. however, this way is limited by safety issues, radiofrequency penetration concerns and susceptibility artefacts. alternatively, improving the radiofrequency system relies on a complex electrodynamics background, where tissue conductivity and different sources of noise have to be considered. during the last half-period of mri development, radiofrequency coil arrays have appeared as a powerful mean to improve the signalto-noise and to accelerate the spatial encoding process, even able to overcome some pitfalls with high-field mri. finally, the topics of an optimal field strength has always been highly controversial because the contrast mechanisms, on which the diagnostic information is mainly founded, are essentially field-dependent. basically, the contrast mechanisms tend to be dominated, respectively, by macromolecular cross-relaxation at low field, and by susceptibility-weighted diffusion at high field. an emerging question is then to address different pathologies or organs with either general-purpose or dedicated mri systems. learning objectives: 1. to learn about the possibilities of gaining a jump in signal. 2. to understand the respective strategies of field increase and coil improvements. 3. to consider the probable system in 2020. will new technologies allow a jump in sensitivity? j. hennig; freiburg/de (juergen.hennig@uniklinik-freiburg.de) imaging technologies have made breathtaking progress for several decades and in all aspects of medical imaging -mr, ct, us and pet. amongst the current developments in mri there are several areas which hold promise to redefine the boundaries of sensitivity. ultrahighfield mri with field strengths of 7 t and more starts to reveal insights into tissue microstructure so far inaccessible to mr (or any other technique). this is still under intense technological development with some key issues to resolve notably safety issues related to the high radiofrequency power. the unique contrast and resolution does hold promise for highly relevant applications such as neurodegenerative disease, small vessel disease, ms and others -although definite clinical studies for a ‚killer application' are still lacking. 13c-hyperpolarisation of metabolites such as pyruvate, succinate, bicarbonate, etc. lead to an increase in detection sensitivity by factors of 10-100,000. finally, the development of targeted probes is progressing extremely rapidly and for all imaging modalities. most of this work is aimed at preclinical research, but the tremendous impact of the new insight in translational research promises to be of high impact for clinical application. will these technologies allow a jump in sensitivity? yes and no. image quality, contrast and sensitivity will grow significantly. the biggest impact will, however, lie in the combination of the new possibilities with other data -imaging as well as non-imaging. a true change in paradigm will only be achieved if the current parcellated knowledge about various aspects of the disease is unified into a comprehensive picture. learning objectives: 1. to review the recent developments in rf-coils and gradients. 2. to learn about the new measurements technologies. 3. to envision how these new tools will allow a huge gain in sensitivity. will new mr contrast probes compete with pet? s. aime; turin/it (silvio.aime@unito.it) purpose: molecular imaging is a new science that will have a tremendous impact in the development of innovative diagnostic tools. in the first stage of its enrolment, it has relied massively on pet/spect and optical imaging technologies because of the superior sensitivity of their probes. in the long-term, mri/mrs approaches may recover a central role, provided that further sensitivity improvements will be attained. high sensitivity mri probes have been designed and tested for molecular imaging applications. in the case of paramagnetic based systems they rely on improved design of the coordination cage as well as on the encapsulation/incorporation in proper nanocarriers. for multiple detection studies, cest as well hyperpolarized c-13 containing molecules have been considered. results: as molecular imaging is the evolution of biologists' in vitro work that has revolutionized the way living cells and intact tissues were investigated, mri multiplex-visualization of biological processes appears to be a key task for the forthcoming years for an efficient translation of such outstanding achievements. the search for frequency-encoding mri contrast agents represented by cestand hyperpolarized c-13 containing molecules have opened the interesting perspective of detecting more than one agent in the same anatomical region. this task is largely precluded to nuclear probes. moreover merging mri and nanotechnology allows the attainment of high sensitivity systems also with the classical relaxation agents. conclusion: recent achievements in amplification procedures allow to tackle the intrinsic insensitivity of mri probes to make them more competitive in the arena of molecular imaging applications. the use of imaging to monitor response to treatment has become central in the care of patients with cancer. it is crucial therefore that radiologists involved in the management of patients with cancer understand the place of imaging within the clinical context of the management of patients with cancer; that they are aware of the criteria of the accepted current criteria for assessing response and are familiar not only with new developments in imaging that act as a surrogate end-point for evaluating the success of treatment but are also aware of how imaging is used to predict the likely response early in the patient's pathway. this session will concentrate on all these aspects on the use of cancer imaging in monitoring response to treatment in patients with cancer. we are in the era of targeted cancer therapy, whether by small molecules derived from knowledge of the molecular pathogenesis of tumours, or from biological therapies emerging from our understanding of immunology and cell biology. these approaches convey new challenges for the monitoring of response. small molecule therapeutics often stabilise tumours for significant periods without producing clear reduction of masses, and for these the assessment of surrogate endpoints takes on increasing importance. the measurement of pharmacodynamics is central to early phase trials in which confirmation of on-target effects is required to determine the biologically effective dose, and in many cases this is best done by functional imaging. biological therapeutics such as monoclonal antibodies and cellular immunotherapy also need novel approaches for the determination of their actions in vivo, particularly as they are frequently tested in the setting of low level disease. randomised trials are underway to assess the contribution of functional imaging, in particular ct-pet as a means to guide therapy. the emerging data suggest that there are broad variations in accuracy, both according to the disease in question and the context in which studies are performed, even before factors such as imaging quality control and standardised reporting are included. for the future, standardisation of techniques and common quality control will play a vital part in advancing our understanding in this rapidly evolving field. tas. there is regression of portions of these arches, but several remnants normally persist. any failure in this process can result in congenital anomalies of the aorta or pulmonary vessels. these anomalies can be categorised into aortopulmonary anomalies, systemic arterial anomalies, and pulmonary artery anomalies. the aortopulmonary anomalies comprise truncus arteriosus, hemitruncus arteriosus, aorticopulmonary window, patent ductus arteriosus, and transposition of the great arteries. the systemic arterial anomalies include the anomalies of the aortic arch, of which the most common is a left aortic arch with aberrant right subclavian artery. double aortic arch is the most common cause of a vascular ring and is characterised by left and right aortic arches arising from the ascending aorta and encircling the trachea and oesophagus. a right aortic arch can have three "subtypes": aberrant left subclavian artery, mirror image branching, or isolated subclavian artery. the first type is the most common one and is the second most common cause of vascular ring. aortic coarctation, pseudocoarctation and interruption of the aortic arch are other systemic arterial anomalies. the most important pulmonary artery anomalies are idiopathic dilatation of the pulmonary trunk, absence or proximal interruption of a pulmonary artery, pulmonary arterial stenosis, and pulmonary sling. cardiovascular magnetic resonance (cmr) imaging has become integrated into the assessment pathways for congenital heart disease in both paediatric and adult patients. cmr provides a powerful tool, giving anatomical and haemodynamic information that echocardiography and catheterisation alone do not provide. extracardiac anatomy, including the great arteries, systemic and pulmonary veins, can be delineated with high spatial resolution. vascular and valvular flow can be assessed, shunts can be quantified, and myocardial function can be measured accurately and with high reproducibility, regardless of ventricular morphology. finally, cmr surpasses both catheterisation and echocardiography in providing high resolution, isotropic, three-dimensional (3d) datasets. this allows for reconstruction of data in any anatomical imaging plane, giving complete visualisation of complex congenital cardiac anomalies, without the use of ionising radiation. in the congenital heart disease, cmr can be justified for any patient in whom clinical or echocardiographic data are insufficient for monitoring, decision-making or surgical planning. due to the complexity of both the anatomy and physiology of congenital heart disease, it is essential to have a systematic approach for cmr when assessing these patients. with the development of novel ct scanners, especially the dual source ct, novel strategies of examining congenital heart disease became possible. especially newborns and infants younger 3 years of age are difficult to examine, since compliance cannot be expected. also young children are especially susceptible to ionizing radiation and should be exposed as little as possible. in a first step the course will illustrate the underlying technical principle how to examine children in < 1 sec with sub msv exposure. also the course will teach how to avoid sedation in children of any age. in a second step the course will show how to apply contrast media in children of all ages and what strategy to use. in a third step the course will show how to appropriately choose scanning parameters for the ct scan since the size and weight varies considerable in children as there are small to date newborns with < 2 kg body weight up to adolescents with a body weight > 60 kg. since little comprehensive data is available how to examine with an optimal compromise between sufficient image quality and unnecessary radiation overexposure the data of the erlangen study will be presented and discussed. in a forth part typical indications for the exam are shown and how to interpret the exam. also limits for the exams are shown. in a final step a comparison with mri is shown which method is used for which pathology. in this session contrast-induced nephropathy and nephrogenic systemic fibrosis will be discussed. measures to reduce the incidence these adverse effects will also be presented. the pathophysiology of cin is complex and not well understood. basically, a misbalance between vasodilatation and vasoconstriction takes place inside the kidney after intra-arterial or intravenous cm administration. furthermore, increased oxygen demand of tubular cells due to increased reabsorbtion of sodium and water is a second mechanism, leading to transient medullar ischaemia. identifying the patient at risk is the first step in prevention. knowledge of the patient's medical record and a recent basic kidney function are mandatory. high-risk patients should receive prevention. two major topics in cin prevention are the questions whether iso-osmolar cm cause significantly less cin than low-osmolar cm and whether hydration schedules with nahco 3 give significantly less cin than hydration schedules with nacl 0.9%. currently up to 50% of all mri examinations worldwide are performed using contrast agents, either an extracellular agent or an organ-specific agent. the extracellular mri contrast agents are chelates that contain the paramagnetic ion gadolinium which strongly affects the relaxation properties of water protons, leading to changes in tissue contrast. gd-dtpa was the first extracellular agent to be introduced in clinical practice. since the introduction of gd-dtpa in 1988, various gadolinium chelates with different chemical properties became available for clinical use. for many years, it was believed that gadolinium-based contrast agents (gbca) a s33 c b d e f g principles in the use of conventional/anatomic imaging for response assessment l. schwartz; new york, ny/us (lschwartz@columbia.edu) the standard way to assess a patient's response to chemotherapy is to use computed tomography (ct) to measure tumour size using uni-dimensional (recist) or bi-dimensional (who) criteria. this methodology has changed little in the past 30 years despite the emergence of new therapies and advances in imaging technology. measuring the changes in the size of tumours in one or two dimensions does not always capture the effects of novel therapies on primary tumours and metastases. radiographic changes in the size of tumours treated, for instance, with epidermal growth factor receptor tyrosine kinase inhibitors such as gefitinib or erlotinib or inhibitors of angiogenesis such as bevacizumab do not necessarily occur at the same magnitude or speed as observed in those individuals treated with standard cytotoxic therapies. with these newer agents, tumours respond by undergoing cystic change, central necrosis, and density changes that may not be captured by conventional measurements of the largest lesion diameter. learning objectives: 1. to understand and appreciate the use of conventional/anatomic imaging for response assessment in clinical practice as well as in clinical trials. 2. to understand general and disease-specific challenges associated with response assessment at imaging. 3. to recognise potential improvement in imaging and image post-processing for response assessment. pet in monitoring response w. weber; freiburg/de pet imaging and specifically pet/ct with the glucose analogue fluorodeoxyglucose (fdg) has been evaluated in a significant number of studies to monitor tumour response in patients undergoing chemotherapy, radiotherapy or targeted therapies. the clinical value of for differentiation of residual or recurrent viable tumour and therapy-induced fibrosis or scar tissue has been established for malignant lymphomas and various solid tumours. furthermore, there are now several reports suggesting that quantitative assessment of therapy-induced changes in tumour fdg-uptake may allow prediction of tumour response to chemotherapy and targeted drugs very early in the course of therapy. in non-responding patients treatment may be adjusted according to the individual phenotype of the tumour tissue. current studies investigate whether fdg-pet can be used to "personalise" treatment and to reduce the side effects and costs of ineffective therapy. in addition to fdg, several other imaging probes are in clinical studies to monitor tumour response to therapy. these include among others [ 18 f]fluorothymidine (flt) for imaging of cellular proliferation, [ 18 f]fluoromisonidazole for assessment of tumour hypoxia and radio-labelled rgd-peptides for angiogenesis imaging. preclinical and early clinical trials with these imaging probes are encouraging, but need to be confirmed in larger clinical trials. learning objectives: 1. to understand how image acquisition and reconstruction influence visual and quantitative analysis of pet studies. 2. to describe current criteria for assessing tumour response in lymphoma and solid tumours and recognise the limitations of these criteria. 3. to understand how differences between scanner models can influence response assessment by pet. panel discussion: why does the radiologist need to understand the importance of monitoring response and how it is done? 09:45 monitoring the response to treatment has become a critical part of the management of patients with cancer. the markedly improved diagnostic performance of crosssectional imaging in delineating the extent of malignancy has meant that imaging has become increasingly important as a surrogate end-point. these two factors have resulted in an increasing need for a standardisation of the criteria of response both in therapeutic trials and in clinical practice. it is vital that all radiologists imaging patients with cancer are familiar with the limitations, pitfalls and strengths of these changing criteria and also are aware of the possibility of using imaging to evaluate the changing molecular make-up of the cancer. stent-grafts is steadily increasing. therefore, knowledge of this treatment option is fundamental to provide basis for procedure planning and a meaningful radiological reporting. imaging plays a crucial role in the assessment of patients with aortic aneurysms. eligibility for endovascular treatment depends very much on detailed anatomical knowledge of the aorta, its branches and vascular access through the iliac arteries. we will review the role of imaging modalities: us, ct, mr for detection and evaluation of anatomy of thoracic and abdominal aneurysms. the strength and weakness of each modality will be reviewed and inclusion criteria for endovascular aortic aneurysm repair will be presented. the precise sizing of the stentgraft obtained from the images is certainly one of the most critical points of the endovascular procedure and a condition of its success. although it is a minimally invasive treatment it is associated with complications. there is a strong need for general radiologists to know about the most prevalent normal and abnormal findings of the post-treatment aorta. the session will end with discussion addressing the central role of imaging in pre-and post-treatment evaluation of the patients with aortic aneurysms. indications for and experience with placement of endovascular stent grafts in the thoracic aorta are still evolving. recent advances in imaging technologies have drastically boosted the role of pre-procedural imaging. the accepted diagnostic gold standard, digital subtraction angiography, is now being challenged by the state-ofthe-art computed tomography angiography (cta), magnetic resonance angiography (mra) and trans-oesophageal echocardiography (tee). among these, technological advancements of multidetector computed tomography (mdct) have propelled it to being the default modality used, optimising the balance between spatial and temporal resolutions and invasiveness. mdct angiography allows the comprehensive evaluation of thoracic lesions in terms of morphological features and extent, presence of thrombus, relationship with adjacent structures and branches as well as signs of impending or acute rupture, and is routinely used in these settings. in this presentation, we review the current state-of-the-art radiological imaging for thoracic endovascular aneurysm repair (tevar), especially focusing on the role of mdct angiography. after analysing the technical aspects for optimised imaging protocols for thoracic aortic diseases, we will discuss pre-procedural determinants of candidacy, and how to formulate interventional plans based on cross-sectional imaging. the purpose is to present the essential principles of endovascular repair of abdominal aortic aneurysms (evar). abdominal aortic aneurysms (aaa) larger than 5.5 cm should be treated. inclusion criteria for evar include satisfactory aneurysm neck morphology and suitable access vessels. preprocedural imaging involves cta from the diaphragm to the femoral arteries. several devices may be used to cover a wide range of anatomy. evar procedures are generally performed as combined procedures by teams of vasculr surgeons and interventional radiologists. patients are followed up indefinitely by cta (or ultrasound) and plain radiography. the periprocedural mortality is three times lower compared with surgery. late mortality rates are similar between surgery and evar. quality of life issues favour evar in the short and medium term. early published series reported high complication and reintervention rates for evar, although these have reduced with increased experience and improved device technology. gene-reporter imaging has been used to monitor cell-based therapies in neurology. one of the most promising applications of molecular imaging principles is the targeting of amyloid deposition in the patients with alzheimer's disease. it is hoped that early diagnosis of the neurodegeneration may lead to better therapies. the advent of hybrid-imaging will be associated with the need for multimodal contrast agents exploiting the imaging characteristics of the involved instrumentation for more differentiated visualisation of structure, physiology, and biology. learning objectives: 1. to understand the working mechanism and radiation of current clinical tracers. 2. to become familiar with the potential clinical indications and applications. 3 . to learn about potential new tracers. panel discussion: what specific precautions are mandatory in order to guarantee contrast media safety to patients and healthcare professionals? 09:44 current contrast agents are safer than previous products. however there are still safety aspects to consider, including patient's kidney function, thyroid metabolism, allergy, radiation exposure, or specific medical history, and there is no such thing as total or complete safety. while these simple precautions may appear obsolete in the era of sophisticated technical approaches, these issues are still quite complex and crucial in maintaining a high safety level. the discussion will give guidelines and tips for achieving a high level of safety when using contrast agents. room q the abc of evar magnetic resonance imaging (mri) is the best tool to explore white matter disorders (wmd), including the most common demyelinating disease: multiple sclerosis (ms). the formation of demyelinating lesions is related to an "inflammatory attack". new techniques as diffusion tensor imaging (dti), perfusion weighted imaging and uspio enhancing can explore earlier and more specifically lesions formation. acute demyelinating lesions may resolve (remyelination) or persist as "chronic black holes". chronic demyelinating lesions lead to axonal injury and wallerian degeneration. a diffuse neurodegenerative process leading to cerebral atrophy is actually a major landmark in ms. conventional mri sequences allows visualisation of white matter lesions (seen as hyper t2/flair lesions, low signal t1 lesions and possible gadolinium contrast enhancement), presently the basis of ms diagnosis. ms follow-up is usually clinic but imaging could provide prognosis and therapeutic parameters ("surrogate markers") even if disease progression and axonal loss are independent from "lesion load". mr spectroscopy, dti or magnetization transfer imaging (mti) provide measurement of diffuse tissue damage in clinical research, and may correlate to disease progression, as well as brain volume measurement. after exclusion of alternative diagnosis (mri "red flags" as other wmd), mri lesions dissemination in space and time criteria are the main points in ms diagnosis. the widely used revised mcdonald criteria may be replaced by more simple and efficient magnims criteria. such criteria could allow starting "modifying disease treatments" as soon as the first "clinical isolated syndrome". since blood oxygenation level-dependent (bold) signal changes have been observed using mri and modulated using neuronal stimuli, functional mri (fmri) has quickly become the most popular non-invasive functional neuroimaging technique in clinical practice and cognitive neuroscience. indeed, high-field mr scanners and bold-sensitive sequences are now widely accessible in both clinical and research settings. bold signal that relies on deoxyhaemoglin concentration is detectable without injection of external contrast media. the colourful activation maps combined with three-dimensional brain anatomy may have also made this imaging method as much attractive as controversial. numerous applications of fmri have been suggested in medicine. after a 15-year long history in clinical practice and thousands of scientific papers even in prestigious journals, the role of fmri remains mostly dedicated to map eloquent cortex before a neurosurgical procedure. in fact, bold fmri is challenging because the relationship between the neuronal response to a stimulus and the activation blobs relies on neurovascular coupling, haemodynamic response, mr signal detection, and complex time-series analyses. besides an obvious and partially elucidated complexity, and several concerns on the interpretation of experimental paradigms in cognitive neuroscience, fmri is based on a robust physiological and physical framework. bold signal is reproducible across subjects and mr scanners. fmri requires a rigorous methodology to acquire and analyse data, an advanced knowledge in sulcogyral and functional neuroanatomy to estimate spatial displacement and reorganisation in patient with focal lesion, and a solid experience in bold imaging to distinguish artefacts and potential confounds from appropriate results. learning objectives: 1. to know the key points of quality in fmri. 2. to know the main pitfalls in fmri interpretation. 3 . to learn more about advances in fmri of brain perfusion. a-120 09:21 the role of imaging in follow-up k.a. hausegger; klagenfurt/at (klaus.hausegger@lkh-klu.at) the goal of surveillance after evar is to prevent late rupture eurysm. high pressure els (type i and type iii el) are risk factors for late rupture therefore have to be treated. type-ii, iv and type v (endotension) els are low pressure els with a low rupture risk. thus, it is essential not only to detect els but also to classify els correctly. until recently stent graft surveillance has been performed with contrast enhanced multislice ct (msct), typically 1, 3, 6 and 12 months after evar and thereafter in yearly intervals. however, although msct proved to be a very effective in fu cumulative radiation exposure, repetitive contrast medium load and increasing work load have to be seen critically. therefore, alternative surveillance protocols especially including ultrasound have been evaluated. several studies have shown that a risk-adjusted follow-up regime might be most efficient. patients with low risk of aneurysm-related mortality after evar have a normal 1-and 6-month msct scan and sack shrinkage at 12 months. in these patients regular contrast enhanced us in yearly intervals have been proven to be safe for further fu. a one yearly non-enhanced low-dose ct or a plain film may be recommended to detect distortion or migration of the stent-graft. patients with a persistent type ii el after one year need to be followed more closely and imaging modality is chosen depending on the character of the el. in most cases el classification can be made correctly by msct or us; however, sometimes dsa may be needed. panel discussion: the key role of imaging in endovascular aortic aneurysm repair 09:44 many patients with aortic aneurysms are currently treated endovascularly. therefore the number of patients imaged pre and post-procedurally is increasing. radiologists evaluating aortic aneurysms with different modalities should know the key imaging features to look for in pre-treatment as well as follow-up examinations. j.-p. pruvo; lille/fr (jppruvo@chru-lille.fr) neuroimaging is one of the fields of radiology with the most exciting recent advances. moreover, these advances show dramatically important clinical applications. some are useful for the specialised neuroradiologist, but most are critical for the general radiologist as well. in this session, we will try to address some of the most relevant issues: white matter disorders are common diseases. expertise of the radiologist is important in detecting the disease, and in the evaluation of the activity after treatment. with this respect, standardisation of criteria is desirable for appropriate medical decisions. functional imaging is a fascinating insight into the human brain. it opens new horizons and has found many applications in the evaluation of psychiatric diseases, and in the planning before treatment of brain lesions, among other potential applications. although it is obvious that we ignore much more than we know, this field is already one of the most exciting topics in neuroradiology. although these methods are still in the field of specialists, everybody should be aware of the possibilities of functional imaging of the brain and its recent developments. stroke is by excellence a clinically relevant problem. because it is an emergency situation, time really matters, and we have more than one imaging tool to explore these patients, it is mandatory to provide strong recommendations and guidelines for the radiologist, in accordance with the clinical situation and with the treatment options. at the end of this session, the attendees will be aware of important advances in the domain of neuroradiology, and will take home very important landmarks for their own clinical practice. jaundice is rare in children but imaging has a major role to establish the cause which differs according to age. in the neonatal period the leading cause is biliary atresia (ba) which consists of the obliteration of the extrahaepatic bile duct (bd) without dilatation of intrahaepatic bd and requires urgent surgical treatment to reduce the need for liver transplantation. ba must be considered when there are persistent white acholic stools and firm hepatomegaly. us shows the absence of dilated bd and in a few cases a cyst at the porta hepatis or findings of the splenic malformation syndrome, but often it is not conclusive. mrcp has not yet proved to be reliable for the diagnosis of ba. other neonatal cholestases include medical intrahepatic causes which can be identified by biological tests or histological findings and rare causes of extrahepatic obstruction with dilated bd such as lithiasis, choledochal cyst or spontaneous perforation of bd. in childhood, us easily identifies all causes of extrahepatic obstruction by showing dilated bd; the main causes include choledochal cyst (the most frequent congenital malformation, defined by an abnormally long common bilio-pancreatic channel), cholelithiasis, tumoural compression, sclerosing cholangitis, portal vein obstruction, postsurgical or posttraumatic stenosis… in all these cases, in our experience, mrcp has become the modality of choice and has replaced invasive procedures which are nowadays reserved for treatment. mdct may be useful in rare instances, for example, to differentiate calculi and aerobilia after surgery. imaging protocols and illustrative cases will be presented. neonatal bowel obstruction generally presents within hours of birth. the diagnosis of bowel obstruction is clinical but imaging is vital to determine the cause. the plain radiograph will distinguish upper from lower intestinal obstruction. the radiograph alone is diagnostic in duodenal atresia and jejunal atresia and the baby may be taken directly to surgery. if the radiograph shows multiple dilated loops of bowel, more than 4 loops, then the obstruction is distal ileal or colonic. the radiograph may give some clues as to the possible cause, such as a large fluid level in the dilated loop proximal to an atresia. contrast enema, usually with low osmolar water soluble contrast, is used in most cases, however, to determine the cause of lower intestinal obstruction because the management of this is different for different causes of obstruction. meconium ileus and ileal atresia are the commonest ileal causes of obstruction and hirschprung's disease and meconium plug syndrome are the commonest colonic causes of obstruction. colonic atresia is rare and imperforate anus is a clinical diagnosis. radiologically guided reduction is used to treat meconium ileus. intestinal obstruction in the older neonate may be due to volvulous, pyloric stenosis, duodenal stenosis or omphalomesenteric band. in the baby born prematurely, obstruction may be caused by stricture secondary to necrotising enterocolitis. radiographs and contrast studies are also used to evaluate these conditions. learning objectives: 1. to learn about the most common causes of neonatal obstruction. 2. to understand the role of plain radiography in establishing the diagnosis. 3. to know when upper and lower gi contrast studies are indicated and the contrast medium used. stroke around the clock: will the challenger (ct perfusion) beat the champion (diffusion mri)? in patients admitted for a suspected stroke, time management is the most important criterion for therapeutic decisions. less than four hours and a half, all patients admitted in emergency for an acute neurological deficit without impairment of consciousness (nih < 25) and presented with a brain ischaemia of less than one third of the territory of the middle cerebral artery should receive iv thrombolysis. brain imaging must exclude bleeding and quantify the extent of ischaemic damages. between 4.5 and 6 hours after onset of symptoms, intravenous thrombolysis and/ or intraarterial mechanical or chemical thrombolysis may be indicated in selected cases. the assessment of ischaemic penumbra and vessel permeability is particularly important for the therapeutic decision. this may be evaluated either by mri or ct. mri is the technique of choice that should be used whenever possible because of the absence of irradiation and iodine-related side effects, the optimal anatomical coverage, the detection of lacunar infarct and its sensitivity for evaluating ischaemic brain damages of the posterior fossa. imaging protocol should include flair (fluid attenuated inversion recovery), t2*, diffusion/perfusion and mr angiographic sequences. in case of unstable patient or if mri is not available, a non-contrast ct scan must be performed and completed by perfusion ct and ct angiography. the main advantages of this technique are the short time of data acquisition and the absolute quantification of perfusion due to the linear relation between attenuation and concentration. pneumonia is a common cause of attendance to hospital. chest infections in children are usually viral and self limiting, but sometimes chest infections can be prolonged or repeated. there are many underlying causes for this, for example, congenital anatomical causes, underlying patient susceptibility, inhaled foreign bodies and unusual organisms. one of the more common causes seen in hospital is when pneumonia has become complicated by empyema. very rarely other conditions such as kawasaki's disease or tumours can masquerade as pneumonia. this session will review these conditions together with the benefits and limitations of plain radiography. it will also consider times when other imaging modalities such as ct and ultrasound can help to guide diagnosis and treatment. in children, congenital heart disease (chd) is more frequent than acquired heart disease. diagnosis and subsequent management of patients with chd relies heavily on different and often multiple complementary imaging modalities. serial assessment of the morphology and function of the heart and thoracic vessels is needed at various stages of care. although chest radiography is frequently used for monitoring the cardiorespiratory status and complications that may arise during clinical care or intervention, it rarely provides a complete diagnosis. echocardiography, as first line imaging modality, often provides all information required for diagnosis and follow-up, especially in small children with good acoustic windows. contrastenhanced computed tomography (ct) and magnetic resonance (mr) imaging are valuable for detailed three-dimensional evaluation of the extracardiac vasculature and cardiac anatomy. in addition to being radiation free, mr has the advantage to provide both morphologic and functional information with the use of different techniques including ecg gated gradient-echo cine imaging, gadolinium-enhanced angiography and velocity-encoded phase-contrast imaging. a comprehensive mr evaluation including quantitative measurements of ventricular volumes and function as well as blood flow in vessels and across valves can give important information on long-term sequelae of the underlying cardiac defect, the significance of residual lesions, and potential complications of surgery. it is also valuable for planning and timing of future interventions. today, ct and mr have become the next line of investigation when echocardiography does not provide sufficient information, while catheter angiography is reserved for the assessment of coronary arteries, measurements of pulmonary vascular resistance and interventional procedures. over the past years, diagnostic imaging has witnessed a veritable explosion in the modalities available for studying patients. when applied to the study of the thorax, they contribute to earlier detection of abnormalities and greater diagnostic accuracy. yet, the conventional radiographic examination of the chest continues to be the most commonly performed imaging study and, when properly interpreted, continues to demonstrate a wealth of information. for a correct interpretation of the chest radiograph, several premises should be met by the radiologist: a proper knowledge of the anatomy and semiology of the thorax, stressing the need for a lateral projection, understand the importance of reviewing previous studies and try to avoid unnecessary cross-sectional studies. this lecture will address the radiological approach to imaging children of all age groups presenting with cough. this is a common symptom with very diverse causes, from acute viral infection to complex vascular and intrinsic congenital tracheal anomalies and can be the presenting symptom of acute (rapidly fatal if not managed adequately) and chronic effects of foreign body aspiration. the various causes of cough vary with age and whether cough is acute, sub-acute or chronic. this has effects on radiological investigations deployed, and thence on subsequent clinical management. we will present a pragmatic approach to radiological investigations in this diverse set of patients, using simple algorithms and illustrate the more important (and often rarer) causes of cough with discussion around deployment of examinations that are fit for purpose using alara principles. guidance on imaging algorithms and ct technique will be given to children with this important presenting symptom of myriad diverse pathological processes. the attendee will learn the value and optimal use of imaging with tips on optimising ct technique as fit for purpose. learning objectives: 1. to learn about the differential diagnoses in the very young child and in older children. 2. to learn which imaging modalities best help to determine the final diagnosis in the various age groups. 3. to understand radiation protection requirements in chest ct examinations. clinical examples of dual energy ct l.s. guimarães; viseu/pt (luis.s.guimaraes@gmail.com) dual energy (de) computed tomography (ct) allows the discrimination of different materials, which has several clinical applications. the ability to differentiate calcium from uric acid renal stones allows the identification of patients that will benefit from drugs that alkalinise urine. a musculoskeletal application of the same technique is in tophaceous gout, where the crystals can be differentiated from bone. postprocessing of ct angiography images can be facilitated using de techniques to identify and remove the calcium signal. such an approach removes both bones and calcified plaques. "virtual non-contrast" images can be obtained by identifying and removing the iodine-containing voxels of contrast-enhanced ct images, simulating non-contrast images and potentially eliminating the need for some non-contrast acquisitions, but it should be realised that small misclassifications could result in missing tiny caliceal tip stones, for example. dect also allows the utilisation of low energies without the prejudice of unacceptable noise. since iodine signal is significantly higher at low energies, disease conspicuity can be improved. this is particularly beneficial in the liver (for hepatocellular carcinoma identification), in the pancreas (for visualisation of hypo-and hypervascular lesions), and in enterography (to increase the identification of hyperenhancement). the approach for displaying the enhanced iodine signal may be one of blending information from the two energies (into a single grey-scale image), or via an iodine-only view. further validation of dual energy techniques and their limitations is needed to understand the patient populations in which such techniques can be utilised and where conclusions based on dual energy data can be trusted. ct perfusion imaging is a quantitative technique that employs rapid sequences of ct images after bolus administration of intravenous contrast material to measure a range of physiological processes related to the microvasculature of tissues. ct perfusion parameters can provide surrogates for tissue hypoxia as well as the physiological processes such as vasodilatation that represent vascular responses to hypoxia. although the basic techniques for dce-ct have been available for decades, more recently a range of technological advances have contributed to the greater applicability of perfusion ct in the clinical environment including wider ct detectors, shorter gantry rotation times, 'table-toggling', radiation dose reduction and software corrections for image mis-registration due to respiratory or other patient motion. consensus guidelines are now available for the acquisition and processing of ct perfusion studies for the brain and body. to date, the main applications of ct perfusion imaging in stroke have been the confirmation of stroke diagnosis and extent, identification of penumbra and selection of patients for thrombolysis. the main applications in oncology have been in lesion characterisation, risk-stratification and assessment of treatment response. computed tomography (ct) systems have provided three-dimensional (x, y, z) data since their clinical introduction in the 1970s. this session will address the extension of ct imaging into the fourth and fifth dimensions. the rapid acquisition capabilities of modern ct scanners open the door to the fourth dimension -time -where a time-course ct scan can provide clinical information about blood flow, perfusion and other physiological measures regarding organ function. the door to the fifth dimension -energy -is opened by dual energy image acquisition techniques, which are made possible by dual source ct scanners or rapidly switching x-ray source ct scanners. dual energy ct images can be manipulated to provide quantitative information with regard to the elemental composition of tissues, which, in turn, can be used to differentiate between bone and iodine contrast, with many other applications possible as well. modern ct scanners now provide multidimensional data sets characterised as i (x, y, z, t, e), and the additional information provided by these five-dimensional data sets provide genuinely useful clinical information which add to the diagnostic potential of computed tomography. x-ray computed tomography (ct) usually measures the attenuation of the patient or object cross-section in question at a fixed chosen voltage value; the result is presented as the linear attenuation coefficient µ expressed in hounsfield units (hu). dual energy ct (dect) acquires data at two different mean energies and evaluates the differences in attenuation. dual energy ct imaging has been a topic since the 1970s. the acquisition modes have changed over the years from two separate scans at different voltages to single scans with rapid kv-switching, and dual source ct operating with different voltages and pre-filtrations. these concepts will be explained in detail including future options of energy-discriminating detectors. the basic physics principles remain the same for all acquisition schemes. the two independent measurements allow separating two tissue characteristics contributing to attenuation. for example, low and high effective atomic number material densities can be determined in the so-called basis material decomposition. arbitrary combinations such as monoenergetic or electron density and effective atomic number images can then be provided. these will be illustrated and explained by examples such as differentiation between plaque and contrast agent or virtual unenhanced abdominal organ imaging. dect meanwhile offers quite a number of accepted clinical applications which will be covered in a separate talk. ous lesions (adenomas) and curable early-stage cancer, screening for crc has high potential for reducing incidence and mortality of the disease. nevertheless, the benefit of population-based crc screening needs to be weighed against potential risks, psychological distress and required resources since only a minority of the population develops the disease and may thus benefit from screening. several industrialised countries offer faecal occult blood testing as a primary screening tool, with positive test results being followed up by colonoscopy. some countries, such as the united states and germany, also offer colonoscopy as a primary screening tool. while the results of randomised controlled trials regarding screening colonoscopy are still outstanding, there is evidence from observational studies that support its effectiveness in population-based crc screening. recent evidence suggests that colonoscopy, when performed in the community setting, is more effective in protecting from neoplasms in the left colon and rectum than in the right colon. decision-analytic models support the (cost)-effectiveness of screening colonoscopy but results vary, among others, according to compliance, (country-specific) cost estimates and screening schedules. learning objectives: 1. to learn about the incidence and prevalence of colorectal cancer and its precursors in the target population of screening. 2. to understand the rationale for colorectal cancer screening. 3. to become familiar with estimated (cost) effectiveness of colorectal cancer screening when using optical colonoscopy as a primary screening tool. facts from the statistician (true for once?): how accurate is ct colonography the issue of diagnostic accuracy of ctc for crc and polyps has been debated for a long time, because of the conflicting results published in the literature. those results led researchers to design three important studies: two large, multicenter trials testing the performance of ctc in comparison with cc in asymptomatic individuals (acrin and impact) and one randomised, double-arm trial (siggar) conducted on symptomatic patients with the aim to detect crc. both the acrin and impact reported per-patient sensitivity of 90% for polyps > 10 mm and 78-84% for polyps larger than 6 mm; per-patient specificity was extremely high, over 85%, independent of lesion size. the major drawback of the acrin was represented by the poor positive predictive value (ppv) (23% for polyps ≥10 mm); a definitely better ppv was documented in the impact trial (62% for lesions larger than 6 mm) as well as in studies obtained in high-experienced centers. however, the negative predictive value in both the acrin and the impact was rather high, approaching 100%; this is extremely important in order to reassure negative patients about the significance of the examination. excellent results were also obtained in the munich colorectal cancer prevention trial, a single-center study where around 300 asymptomatic subjects underwent low-dose ctc in comparison with other screening tests (cc, sigmoidoscopy and fobt). despite the good results there are still some open issues: the significance of diminutive (< 6 mm) polyps, the management of intermediate (6-9 mm) lesions and the detection rate for non-polypoid, flat lesions. colonoscopy is a very useful and important method to examine the colon. in recent years virtual colonoscopy has become a popular alternative to optical colonoscopy. disorder of the colon includes colorectal cancer, which is one of the most common cancers worldwide and presents a threat to life since the mortality is almost 50%. colorectal cancer screening has been shown to be an efficient method to find early forms of colorectal cancer and also to reduce mortality in this disease. in this session we will discuss the various methods used to examine the colon, how useful they are and the economy behind using them. facts from the epidemiologist: incidence, prevalence, rationale for screening, standard results of optical colonoscopy. colorectal cancer (crc) is the third most common cancer in the world, with about 1 million new cases and more than 500.000 deaths per year. incidence of crc strongly increases by age and is higher in men than in women. the lifetime risk differs between countries and is about 7% in the united states. because most cases of crc develop from removable precancer-stabilisation complex system a dual echo t2/dp sequence could be performed in a sagittal-oblique plane drawing an imaginary line which on an axial image used as reference plane, is done perpendicular to popliteous tendon. gradient echo (ge) sequences are useful in cartilage and traumatic pathology. t2-weighted sequences understimate cartilage thickness since cortex and cartilage have the same signal. pd sequences may have the similar signal for cartilage and adjacent joint fluid, obscuring defects; fat suppression solves this. if available, acquisitions performed in orthostatism could give further information in the assessment of meniscal and patello-femural pathology. learning objectives: 1. to understand the influences of patient positioning, scan parameters and magnet/coil technology on image quality. 2. to learn how to optimise scan protocols to maximise patient throughput without compromising diagnostic quality. 3. to recognise how and when to modify scan protocols to answer specific clinical questions. this talk will review appearances of normal anatomic variants identified at mri of the knee including discoid meniscus, transverse meniscal ligaments meniscal flounce, ossicles, and pseudotears. subsequently the talk will focus on diagnostic pitfalls reflecting both imaging technique and variations in anatomy such as the effect of motion, imaging plane and anatomic variations in patella shape. mri of the knee is one of the most frequent performed investigations, thus indicating that common abnormalities need to be familiar to the general radiologist. a simple and straightforward method of enabling assessment of clinically relevant anatomical entities is based upon a (pre)structured radiology report. use of speech recognition facilitates implementation of pre-structured reporting in a kiss manner. since one now is enabled to structure the report, using digital tools, terminology used should be discussed between the reporting radiology department and the clinical partners. it is mandatory that the important message, the clinical relevance of the information that radiologists put in their report, is understood by the referring clinician in the same manner as it was meant to be. we should consider the background of our referring physician, and tailor our report, both in chosen terminology as well as detailed information. when working in a centre in which both specialised orthopaedic surgeons as well as general practitioners (gps) or sports physicians are referring for mri, each of the three needs a tailored report, especially considering advise for secondary referral: gps and sports physicians will need different approach, compared to medical specialists. also, the knowledge of terminology used should be considered. the presentation focuses on common encountered pathologies, considering common abnormalities. emphasis is given to common abnormalities, and pitfalls that should be dealt with. some sports specific entities are discussed. implication of clinical correlation is stressed. the presentation will include casebased clinical illustrations. learning objectives: 1. to review the imaging appearances of common abnormalities. 2. to understand the use of terminology to describe pathological findings. 3. to learn how to structure a radiological report to ensure clarity and brevity. of view and the "third eye" colonoscope are under investigation. at the moment, however, the combination of both, exact diagnostic and sufficient therapeutic action at the same time, is the reason why optical beats virtual in this particular indication. since its evolution ct colonography has been advocated as a safe well tolerated alternative to colonoscopy, particularly in the context of colorectal cancer screening. notably perforation rates are lower than those of colonoscopy and cardiovascular effects are less. however, patient preference studies have produced mixed results and it is not clear if standard ctc will increase compliance with screening. furthermore, issues over apparent inferior sensitivity for polyp detection compared to colonoscopy, need for prolonged radiologist education and radiation dose exposure have been cited as barriers to widespread implementation in a screening context. technical developments in recent years are beginning to address these issues. use of reduced laxative regimes supplemented with faecal tagging have shown good results with superior patient acceptability. software developments have also speeded up dataset analysis -notably panoramic or "virtual pathology" 3d views reducing or eliminating hidden areas within the colon. furthermore, computer-aided detection software is increasingly fit for purpose and good data show a positive effect on radiologist performance both in the research setting and day to day clinical practice. this presentation will review the data on patient preference and safety and highlight developments in those areas in which ctc holds advantages over conventional endoscopic techniques. discussion will focus not only on colon cancer screening but also the on data supporting ctc in older symptomatic patients who are at higher risk of adverse events during colonoscopy. learning objectives: 1. to review the patient safety of ct colonography and conventional colonoscopy. 2. to review advanced computer techniques for maximising visualisation of the colon during ct colongraphy including 3d visualisation methods and computer aided detection. 3. to review the data on ct performance with particular emphasis on patientfriendly reduced laxative regimens. 4. to consider patient preference data. osteoporosis, osteomalacia, hyperparathyroidism and paget's disease have conventionally been considered the disease entities that comprise metabolic bone disease. the lecture will follow this convention and discuss the imaging characteristics that suggest osteoporosis in the elderly or anorexia nervosa in younger patients by the distribution of fractures and marrow changes as well as the role of bone mineral density evaluations in osteoporosis. oncogenic osteomalacia will be discussed in the context of appropriate imaging for detecting the tumour and emphasise the basic biochemical abnormality that most radiologists should be familiar with that leads to the diagnosis. radiologists most frequently encounter hyperparathyroidism in renal osteodystrophy with over a million patients worldwide kept alive by dialysis. dialysis-induced imaging changes such as amyloid and the spectrum of findings from long-term dialysis will be shown and demonstrated. paget's disease is on the decline. its distinctive mri signal characteristics in uncomplicated cases, in contrary to most bone lesions encountered in clinical practice, will be explained. learning objectives: 1. to get an overview of the entities that are considered in the realm of metabolic bone disease. 2. to understand common, less common and rare findings. 3 . to learn about some imaging findings that occur as a consequence of treatment. osteoporosis is of great socioeconomic impact, as approximately 30% of all postmenopausal women have osteoporosis in developed countries. ageing of populations worldwide will be responsible for a major increase of the incidence of osteoporosis in postmenopausal women. in 1994, the who working group defined osteoporosis according to measurements of bone mineral density (bmd) using dual energy x-ray absorptiometry (dxa) as a bone density t score at or below 2.5 standard deviations (t score) below normal peak values for young adults. the relative risk of a fracture is between 1.3 and 1.6 for each unit decline in spine or total hip t score. due to limitations of the t-score concept a 10-year risk calculating tool has been developed by the who to determine intervention thresholds. fragility fractures are, however, not only related to bone mineral density (bmd). trabecular bone microarchitecture is a significant determinant of the bone's mechanical properties and is thus of major clinical relevance in predicting fracture risk. trabecular bone structure analysis can be based on images from multidetector computed tomography, high-resolution peripheral computed tomography, highresolution mri and projection radiography. advantages and disadvantages of the different methods depend on radiation, costs, availability and a reasonable time for in vivo scanning. the purpose of this refresher course is to demonstrate bone ablation. the main aim of thermal tumour ablation is to destroy the tumour using ionic movement to kill the malignant cells without damaging adjacent vital structures. multiple sources of energy have been used to induce cell death. rf energy is an electromagnetic one. radio waves emanate from the non-insulated distal portion of the electrode. heat is produced by resistive forces (i.e., ionic agitation) surrounding the electrode as the radio waves attempt to find their ground. other type of ablations (using different wave lengths) include microwave, electoporosis, laser and radiofrequency ablation is still seeking its place among bone interventional techniques. this presentation is an overview, in an area of non-vascular interventions in the spine and the appendicular skeleton. it will explain the patient selection, indication and possible approaches to a bone lesion. available material will be discussed, as well as possible combinations of them in order to yield maximum results, while reducing possible drawbacks. over the last two decades, open nephron sparing surgery has become the preferred surgical alternative to nephrectomy for treatment of patients with a single, small (< 5 cm) localised renal mass and a normal contralateral kidney. because 25-49% of newly diagnosed small renal masses are identified incidentally on crosssectional imaging, often in elderly patients, less invasive surgical nephron sparing alternatives have been advocated, including laproscopic partial nephrectomy and laproscopic cryoablation, for select tumours in an effort to reduce surgical mortality and morbidity while preserving renal function. percutaneous image-guided ablation offers potential advantages over surgical methods including the minimally invasive nature of the procedure, less mortality and morbidity than surgery, shorter hospital stay, and quicker recovery. local tumour control rates of up to 95% have been reported for small tumours. central tumours and tumours greater than 3 cm in diameter are more difficult to successfully treat with local tumour progression occurring 25% of central tumours. tumours larger than 3 cm in diameter typically require overlapping ablations and incomplete treatment can result from residual tumour at the ablation interfaces. while in some reports, local tumour progression occurred in up to 20% of tumours larger than 3 cm, in contrast, others have shown that all exophytic tumours, despite their size, can successfully be treated using multiple overlapping ablations and complete treatment may require more than one ablation session. the most clinically relevant and potentially avoidable complication is ureteral injury with resultant obstruction of the intrarenal collecting system. percutaneous image-guided radiofrequency ablation (rfa) represents as a safe and effective minimally invasive procedure in selected patients with unresectable or medically inoperable lung malignancies. when adequately performed, in selected patients, the procedure is associated with over 95% immediate technical success rate and relatively low incidence of major (8-15%) and minor complications (20-40%). pneumothorax represents the most frequent complication (up to 60%) but presentation, the worse the outcome in adulthood. avn is a significant complication. ct/mr assists orthopaedic planning. imaging strategy: plain radiographs. small children localise pain poorly. whole limb radiographs may be needed. us detects hip effusions but cannot differentiate pus from effusion. nuclear medicine may need sedation for scanning phase. a full bladder may obscure the pelvis. mr is sensitive for soft tissue pathology and marrow disease included in the area imaged. radiographs are needed before mr, which is insensitive for bone detail. other causes: spinal problems -discitis, avulsions of muscle origins, trauma -toddler's fracture, diffuse bone disease, localised bone disease; blind areas: spine, pelvis/sacroiliac joints. learning objectives: 1. to learn about the imaging approach to the child with suspected developmental hip dysplasia. 2. to become familiar with the differential diagnosis in the older child with a limp. 3. to learn which imaging modalities best help to arrive at a diagnosis. skeletal injuries are the most common findings noted on imaging studies in cases of child abuse. in infants, certain lesions, such as the classic metaphyseal lesion and posteromedial rib fractures are sufficiently characteristic to point strongly to the diagnosis of inflicted trauma. other fractures are less specific for abuse, but when correlated with other imaging findings and clinical information, their presence may add strong support for the diagnosis. many of the most specific injuries produce subtle radiographic alterations, and meticulous technique, adhering to a strict imaging protocol, is vital in providing optimal detection of the fractures. in recent years, increasing attention has been given to those conditions that may simulate inflicted injury. a variety of normal variants, naturally occurring diseases and accidental injuries may be confused with the findings of child abuse. other conditions, real or hypothetical, may be suggested by consultants in medico-legal proceedings. to be credible, a witness must be prepared to counter reckless and irresponsible testimony given by uninformed or biased medical "experts". to ensure that investigators and finders of fact are provided with testimony that is clear, concise and accurate, the radiologist must be fully informed and prepared to address the radiologic alterations and their significance to a reasonable medical certainty. learning objectives: 1. to learn in detail the investigation of a child with suspected non-accidental injury. 2. to learn about the typical skeletal injuries seen on plain radiography and the differential diagnosis. 3. to understand when further imaging is required and which imaging modality is best. acute osteomyelitis and septic arthritis are diagnostic and therapeutic emergency in children. diagnosis remains challenging because of their variable expression (acute, subacute, chronic stages, causative agents and hosts). imaging strategy relies on a multimodality approach including radiographs and ultrasonography as first line examinations with a complementary role for bone scintigraphy and mri. mri is especially useful for misleading challenging presentations (such as axial skeleton, pelvis and calcaneus osteomyelitis) and for detection of reversible osteocartilaginous ischaemia requiring urgent surgical drainage. juvenile idiopathic arthritis (jia) is an heterogeneous group of chronic inflammatory disorders that are classified on their mode of onset (systematic, pauci and polyarticular diseases). it is a diagnosis of exclusion and imaging plays a major role in the differential diagnosis. radiographic scoring systems of jia are different from adult scoring systems with less emphasis on joint space narrowing. doppler-ultrasonography and mri play an increasing role in a the assessment of disease activity and response to treatment. learning objectives: 1. to learn about the imaging approach to a child with suspected osteomyelitis and septic arthritis and to outline the classical features. 2. to learn how best to investigate a child with suspected arthropathy and the specific findings. 3. to understand the differential diagnoses of bone and joint infections. semiquantitative scoring method. vertebral morphometry is based on radiographs or scans from dxa-machines calculating ratios of vertebral heights with normal values to identify vertebral fractures. great need for early, accurate and reliable imaging indicators of tumour response to anti-angiogenic drugs which is ultimately defined by overall survival rate, but is mostly based on changes in number and size of measurable tumour "targets", i.e. blood vessels. thanks to its characteristics of high temporal and spatial resolution in limited fields and lack of ionising radiation and side effects (i.e. easy repeatability), contrast-enhanced us (ceus) is currently the simplest and also most reliable imaging modality for detection, analysis and quantification of intratumoural macro-and microvascularity (up to 40 μm in diameter). even minimal changes can be easily detected and quantified with ceus during anti-angiogenic treatments: early disappearance (or severe reduction) of tumoural vascularisation is highly predictive of complete (or significant) response even before tumour volume decreases. initial clinical studies were conducted on hypervascular hepatic metastases (e.g. metastases from gists), but recently also hypovascular hepatic metastases and primary cancers of different organs are being assessed. for the quantitative analysis of tumour vascularity changes several parameters (peak intensity, time-to-peak intensity, area under the curve, etc). are currently being investigated and specific perfusion software connected to working stations are being developed and clinically tested. the clinical application of mr-mammography (mrm) in the last 26 years has shown that this imaging tool has had significant diagnostic advantages in the field of breast diagnosis, e.g. the proof of small breast cancers, the differentiation between scar and recurrent tumours, the detection of multifocality/multicentricity, the search for primary tumours, the delineation of implants, etc. the clinical use of mr-mammography is steadily increasing. however, many still describe a "high sensitivity but a low specificity", which is wrong. achieving a high quality is not an easy task; a lot of teachers have to be learned and considered. this refresher course is focussing on high quality concerning technical and diagnostic aspects, especially focussing the question of improving specificity. dynamic contrast enhanced computed tomography (dce-ct) is a noninvasive method showing haemodynamic changes in living tissue in various oncologic and non-oncologic applications. recently, it has gained an increased popularity for studying malignant tumour blood supply and formation of new vessels, also known as angiogenesis, that plays a critical role in the growth of cancer. technical remarks: repeated rapid ct scans are acquired at the same location to allow determination of time-attenuation curves (tac). several quantitative parameters are assessed: tumour blood flow (tbf) (ml/min/100 g), tumour blood volume (tbv) (ml/100 g), permeability surface product (psp) (ml/min/100 g) and mean transit time (mtt) (s) are calculated using dedicated perfusion software. indication: perfusion ct may be used by the distinction of benign from malignant lesions when conventional methods are unreliable, may improve staging by demonstrating occult hepatic metastases, may guide biopsy to the tumour region most likely to be of highest grade. several tumours with higher perfusion are more sensitive to the chemoradiation than that with lower perfusion. findings at dce-ct images after chemoradiotherapy are a significant predictor of early tumour response and overall survival. its applications have been stimulated by the development of anti-angiogenesis therapy for monitoring the effects of therapy and additionally may be used as a noninvasive tool in detection of hepatic toxicity of chemotherapy. in the future, new prognostic information could impact clinical management. studying the response of cancers by measuring changes in their blood flow may provide useful information on oncologic patients for managing cancers in the future. advanced imaging is now widely utilised in the research and clinical settings. in the clinical setting, qualitative, semi-quantitative and quantitative approaches such as review of colour-coded maps to roi analysis and analysis of signal intensity curves are being applied in practice. we will also compare the relative advantages for t1 dce mri with t2* dsc mri in the estimation of perfusion and permeability metrics in the clinic as well as some more automated histogram analysis methods. the role of advanced imaging in the characterisation of tumour biology and different pathologies will be reviewed. differentiating between recurrent tumour and therapeutic necrosis is often a challenge. we will review the role of advanced imaging and also the effects of anti-angiogenic therapies on tumour microvasculature/microenvironment resulting in changes in diffusion, perfusion and mrs. pseudophenomenon has made conventional imaging with gadolinium contrast agent almost obsolete necessitating mechanistic techniques to differentiate entities such as pseudoprogression which is seen more commonly as a result of therapy with temozolomide and radiation for high grade gliomas as well as pseudo-response and pseudo-pseudoprogression. lastly to combine and apply these different imaging techniques in a multi-parametric algorithmic fashion in the clinical setting can be shown to increase our diagnostic specificity and confidence. learning objectives: 1. to become familiar with different advanced mr techniques used in brain tumour imaging. 2. to learn the role of permeability, perfusion, diffusion imaging and mr spectroscopy in characterising brain tumour biology and differential diagnostics. 3. to become familiar with a complete imaging protocol, which can be implemented in a multi-parametric algorithm fashion in brain tumour diagnosis. monitoring and prediction of treatment response p.c. maly sundgren; lund/se (pia.sundgren@med.lu.se) high-grade gliomas have a poor survival rate despite improvements in surgery, radiation and chemotherapy. a contributing factor to the poor survival is the inability of currently available imaging techniques to accurately delineate the tumour which results that targeted focal treatment my not be effective. conventional imaging is not able to give an early assessment of the effectiveness of radiation and/or chemotherapy. early identification of patients with a poor treatment response or who suffer from tumour recurrence can be of great advantage: it provides the opportunity to adjust individual more rapidly, and sparing patients unnecessary morbidity, and breast mri has shown diagnostic sensitivities of 94-99% for invasive breast cancer; however, specificities have been reported significantly lower with values between 37% and 86%. the specificity of breast mri is in a routine clinical setting based on the evaluation of morphologic features and relative "slow" dynamic characteristics of enhancing lesions. the only moderate specificity that is achieved using these characteristics can result in a significant number of false positive findings during, for instance, screening or pre-operative imaging. these findings will often require short-term follow-up, target ultrasound with biopsy or even mri-guided biopsy. fast dynamic imaging, spectroscopy and diffusion weighted imaging (dwi) have been described to have potential for improving the specificity of breast mri. the use of fast dynamic imaging sequences result in a more accurate evaluation of the initial enhancement of the lesion. in combination with pharmacokinetic modelling this can result in a more quantitative evaluation of enhancement. in proton-mr spectroscopy (mrs) the presence of a choline signal, a cell-membrane precursor, in breast lesions can be used to differentiate benign from malignant lesions. the specificity of mrs varies between 67 and 100% in literature (average 87%). dwi has also shown potential in differentiating between benign an malignant lesions, but, like with other techniques, varying specificity values are reported ranging between 46% and 93%. in this presentation the value of these techniques for improving the performance of breast mri will be discussed. although bedside chest radiograph is one of the less elaborate imaging examinations in our diagnostic armamentarium, it remains the most frequent radiologic procedure performed in intensive care patients. despite its limitations chest imaging is an important tool in the management of the critically ill patient. though the advent of digital radiography has vastly contributed to improved image quality of the bedside radiographs, optimal positioning and technique remain a real challenge for the performing technologist. in addition, the interpretation of chest radiography in the critically ill patient poses a challenge for the radiologist, because findings are frequently unspecific and lung opacifications have similar appearances in a variety of different cardiopulmonary pathologies. clinical information and an interdisciplinary approach are therefore crucial for optimal interpretation of these chest radiographs. the american college of radiology has established expert recommendations for the use of bedside chest radiography. current recommendations suggest that routine daily chest radiographs should be reserved for patients with acute cardiopulmonary problems and in patients receiving mechanical ventilation. acquisition of a portable chest radiograph is recommended after insertion of endotracheal tubes, central venous catheters, pulmonary artery catheters, chest tubes, and nasogastric tubes. therefore, knowledge of correct positioning of catheters, tubes, and monitoring devices and of various malpositions and associated complications is essential for the interpreting radiologist. chest ultrasonography (chus) is a useful imaging tool in patients at intensive care units, because of its simplicity and reproducibility. however, there are some limitations such as low specificity of some crucial sonographic signs and limited searching area (soft tissues, pleural cavity and lung consolidations). the icu patient can be examined in supine or sometimes in lateral or partly lateral position using intercostal spaces as an acoustic window. supine analysis of the anterior chest wall rules out pneumothorax, while lateral approach detects clinically relevant pleural effusion and parenchymal consolidations. chus is a method of choice in detection as well as in characterisation and volume estimation of free and/or loculated pleural fluid. with chus we can explore and characterise lung consolidations from the moment they reach the visceral pleura. they can be in contact with pleural line or can be observed through an effusion. however, in case of subcutaneous emphysema and/or diffuse oedema of soft tissues the lung parenchyma can not be reliably assessed. also, in the question of pulmonary embolisms in critically ill patient, chus could be contributive. sometimes small pleural effusion can be visible with some peripheral lung tissue consolidations indicating minute pulmonary infarction. typical pulmonary infarction is triangular tissue consolidation with air bronchogram and absence of doppler blood flow signals within consolidated lungs but cect for confirmation is mandatory. chus exploration of the diaphragm can reliably evaluate respiratory movements since pleural effusion even substantial does not affect the amplitude of diaphragmatic excursion. learning objectives: 1. to understand the advantages and limitations of bedside thoracic ultrasonography. 2. to learn about the us findings of pleural and parenchymal diseases suitable for bedside ultrasonography. 3. to review current guidelines for estimation of pleural effusion volume. delay in initiation of other maybe more effective treatment. in recent years, different functional imaging approaches such as dynamic contrast-enhanced (dce) and dynamic susceptibility-weighted contrast (dsc) mri, diffusion-weighted imaging and spectroscopy have been complementary used for diagnosis and treatment response. in this lecture different advance mr and ct imaging methods as well as the traditional way of monitoring to assess treatment response will be discussed. in addition, a novel recently published promising technique will be described -the parametric response mapping (prm), a novel voxel-wise analytical method of monitoring physiological and environmental changes in a tumour volume during treatment will be presented and compared to the traditional methods used. finally, the aim of the lecture is to consolidate the present knowledge and novel ideas in brain tumour imaging for future monitoring of treatment response and the possibility and limitations for future individualisation of cancer therapy. learning objectives: 1. to gain an understanding of the present traditional model for the treatment cycle for brain tumours and how they are monitored. 2. to learn about different imaging biomarkers for early assessment of brain tumour treatment response that might result in individualisation of cancer therapy. 3. to consolidate present knowledge and ideas in brain tumour imaging for future brain tumour therapy and monitoring of response. radiation necrosis and pseudo-progression vs recurrent tumour pseudophenomenon has made conventional imaging with gadolinium contrast agent almost obsolete necessitating mechanistic techniques to differentiate entities such as pseudoprogression which is seen more commonly as a result of advanced multimodal therapeutic concepts. advanced, non-enhanced and contrast enhanced mr imaging techniques include mr-spectroscopy, perfusion mr imaging, dynamic contrast enhanced mri and diffusion tensor mr. in the presentation we will analyse the application of those techniques in brain tumour assessment with focus on the post-therapeutic brain to differentiate therapy induced from tumourinduced changes. the results of the available studies in literature, all with relatively limited patient numbers, indicate that the combination of functional mri proved to be useful in the post-therapeutic workup of gliomas, lymphomas and metastatic disesease. the typical patterns of tumour recurrence and the different therapyinduced effects will be presented. in perfusion (dsc-mri) and dynamic contrast enhanced magnetic resonance imaging (dce-mri) the signal intensity measurements of the tumour reflect a composite of tumour perfusion, vessel permeability, and the extravascular-extracellular space. in contrast to conventional enhanced mri, which simply presents a snapshot of enhancement at one time point, both techniques permits a fuller depiction of the wash-in and wash-out contrast kinetics within tumours, and this provides insight into the nature of the bulk tissue properties on its microvascular level. with the strong demand in drug development the identification of biomarkers that can assess tumour microvascular properties noninvasive dynamic mri is the method of choice to assess tumour response and to identify atypical tumour response findings. indications and spectrum of pathological findings functional abnormalities of the pelvic floor represent a significant health-care problem, as they affect approximately 15% of older multiparous women. moreover, nearly 300.000 surgeries in united states are annually performed to correct those disorders. the success of medical and surgical therapies relies on the correct classification of dysfunction and identification of the pelvic compartments involved. clinical classifications of pelvic floor abnormalities are primarily topographic, rather than functional. however, as the pelvic floor muscles tend to act as a unique functional entity, their dysfunction usually leads to dysfunction of more than one organ system (genitourinary or gastrointestinal), resulting in a wide spectrum of symptoms variably associated, including dysuria, urinary incontinence, uterine prolapse, anal or pelvic pain, obstructed defaecation, rectal prolapse or faecal incontinence. because of the variability of symptoms and complexity of physio-pathological mechanisms, diagnosis of pelvic floor disorders is usually achieved by combining different diagnostic tools. dynamic mri of the pelvic floor has emerged as an alternative and effective modality for assessing and understanding of these disorders. it currently offers a complete morphological and functional evaluation of all three compartments at the same time. constipation and pelvic organ prolapse are the most common indications for a dynamic mri. the physio-pathological features of the main pelvic floor disorders and their mri findings will be shown in detail. mr images and movies, with particular regard to posterior pelvic floor abnormalities, such as rectocele, rectal invagination and prolapse, enterocele, descending perineal syndrome and spastic pelvic floor syndrome, will be illustrated and discussed. the ability to perform and interpret dynamic pelvic floor imaging is essential for the modern gastrointestinal (and indeed urogynaecological) radiologist. the other speakers in this session will be reviewing indications, pathologic findings, clinical relevance, and mr technique. although i will detail the mr and fluoroscopic techniques used at my institution, i will focus on the specific technical and diagnostic advantages and disadvantages of both dynamic pelvic mr and conventional fluoroscopic evacuation proctography (defecography). many practitioners wising to initiate this type of imaging will wish to know what modality to chose and existing practitioners using fluoroscopy will possibly be interested in migrating their practice to mr. i will illustrate what imaging findings are best imaged by each technique, continually referencing this to whether the finding is ultimately important to the referring clinician or not. using examples from our own research programme and clinical practice, i will illustrate why we have migrated our practice exclusively to dynamic mr. although dynamic pelvic mr imaging is increasingly used for imaging pelvic floor disorders, the crucial question is whether the technique can completely replace conventional techniques. although mr imaging provides excellent soft-tissue contrast which is a particular advantage when imaging the pelvis, it has to be acknowledged, that the examination is performed in supine position and not in physiological sitting position. this presentation will review the ultrasound appearances of pleural disease in ward and itu-based patients, and will discuss the indications for pleural procedures and the complications associated with them. the use of colour doppler to aid the diagnosis of effusions will be discussed, as will the identification of septations and the need for intrapleural fibrinolytic therapy. the advantages of guided versus blind drain insertion will be presented, and the benefits of large versus small bore drains will also be discussed. pelvic floor function and structure is complex. imaging has a key role in guiding the clinician in managing patients with incontinence, constipation, difficult rectal evacuation and pelvic organ prolapse. dynamic imaging is of particular interest for assessment of the pelvic floor since this kind of imaging gives a near physiological data set of what is happening and gives us a better understanding of the multifactorial causes of pelvic floor dysfunction. whereas conventional evacuation proctography was over years standard of reference for dynamic imaging of the pelvic floor, dynamic mr imaging of the pelvic floor is gaining increasing acceptance among radiologists and clinicians. however, dynamic mr imaging of the pelvic floor is (due to the architecture of most the clinically mr magnets) usually performed in supine position which does exclude the axial load on the pelvic floor. the lack of a physiological patient positioning during dynamic pelvic floor mr imaging is still brought into discussion if dynamic mr imaging of the pelvic floor can replace conventional techniques or not. the pelvic floor is a complex anatomic and functional unit. in clinical routine a simple anatomic concept of the female pelvic floor has gained acceptance. especially for treatment planning, the female pelvic floor may be separated into three functional compartments: the anterior compartment (bladder and urethra), the middle compartment (vagina, cervix, uterus, and adnexa), and the posterior compartment (anus and rectum). intact structure of the pelvic floor is a basic prerequisite for a normal mechanism of defecation and continence. over the last years, mr imaging has gained increasing acceptance as imaging modality for evaluation of the pelvic floor, which enables a global and integrated approach to the pelvic floor. using static t2weighted sequences the morphology of the pelvic floor can be visualised in great detail. a rapid half-fourier t2-weighted, balanced steady state free precession (bssfp), or gradient-recalled echo (gre) sequence are used to obtain sagittal images while the patient is at rest, during pelvic squeeze, during pelvic strain and to document the evacuation process. on these images the radiologist identifies the pubococcygeal line (pcl) (which represents the level of the pelvic floor). in normal findings, the base of the anterior and the middle compartment are above the pcl at rest, and the pelvic floor elevates during contraction. during straining, although most clinical diagnostic imaging studies employ anatomic techniques such as computed tomography (ct) and magnetic resonance (mr) imaging, much of radiology research currently focuses on adapting these conventional methods to physiologic imaging as well as on introducing new techniques and agents for studying processes at the cellular and molecular levels in vivo, i.e. molecular imaging. molecular imaging promises to provide new methods for the detection of minimal changes in diseased tissue and support for personalised therapy. although molecular imaging has been practiced for over 20 years in the context of nuclear medicine, other imaging modalities have only recently been applied to the noninvasive assessment of physiology and molecular events. nevertheless, there has been sufficient experience with specifically targeted contrast agents and high-resolution techniques for mr imaging and other modalities that we must begin moving these new technologies from the laboratory to the clinic. several projects relevant to oncology will be discussed with emphasis on how they were/will be moved from the bench to the clinic. aortic dissection is increasingly managed by endovascular means. it is important for all radiologists to understand the benefits and disadvantages of varying imaging modalities in the differential diagnosis and the fundamental anatomical requirements for assessing suitability for endovascular repair. the causes, detection, classification and complications of aortic dissection will be discussed followed by a panel discussion of imaging strategies which give the best information for diagnostic work-up, endograft planning and monitoring of patients during and after treatment. with the introduction of targeted therapeutics and personalised therapy regimen there is increasing need to improve diagnosis of diseases in a way that insight into pathophysiological and molecular regulation is provided. in this context, molecular imaging can be of tremendous help in basic research, drug development and the clinics. many interesting approaches of molecular imaging have been tried in small animal models. new methods and tools have been identified, which are easy enough to handle, aceptable in its costs and, most importantly, reliable enough to be translated to clinical practice. unfortunatenly, as soon as they have entered the clinics they are often not classified as molecular imaging anymore. among those are mr-spectroscopy, spio/uspio enhanced liver and res imaging but also contrast agents like gd-eob-dtpa and most applications for pet/spect. other interesting applications such as targeted ultrasound imaging are already established tools in preclinical research and very close to first clinical use. near infrared optical imaging is another example of a rapidly developing technology and first clinical devices and dyes (e.g. to detect arthritic lesions) are availibe now. it can be expected that with the availability of targeted and activatable probes the acceptance and the use of optical imaging methods will further rise. most proably, this will initially happen in context with intraoperative diagnosis and endoscopy. in summary, it is the aim of this talk to give a realistic overview on the available molecular imaging tools and on their potential for preclinical research and patient use. cardiovascular diseases remain the number one cause of morbidity and mortality, both in the developed and developing countries, and in men and women alike. it is expected that these numbers will continue to increase in the coming decades due to escalating proportions of obesity and the aging population. atherosclerosis is the major cause for cardiovascular disease. since in about 50% of cases a stroke or acute myocardial infarction is the first symptom of atherosclerosis, it is of paramount importance to identify patient at high risk. a first step in the identification is the use of clinical risk profiling, such as the framingham risk score, which has an area under the curve (auc) of about 0.8 using roc analysis. however, clinical risk profiling alone is not sufficient to identify individual patients at imminent risk to develop a cardiovascular event in the near future. a next step in a more precise identification of the patient at risk is the development of serum biomarkers for atherosclerotic disease. however, so far serum biomarkers have failed to contribute substantially to improve the auc in the prediction of cardiovascular events using roc analysis. a major step forward in risk stratification is provided by the rapid development of cardiac computed tomography, which offers a rapid visual access to the coronary tree, at low radiation dose and in a patient friendly manner. however, for the identification of the vulnerable plaque we need to go beyond anatomical imaging, and use molecular imaging tools. in the lecture i will discuss the different targets for molecular imaging within the vulnerable plaque, such as inflammation, apoptosis and angionenesis. imaging of these substrates of plaque vulnerability may offer opportunities for a precise identification of the patient at risk, at the individual level. the aim of the lecture is to familiarise the audience with the specific paediatric conditions in trauma radiology. it will be described the major pathophysiologic differences in childhood and the consecutive altered injury pattern. the standard radiological imaging protocol for various involved body regions and different trauma settings/varying queries will be described, with suggestion for standardised diagnostic algorithams in some typical settings. special regard will be given to radiation protection and the potential of imaging modalities such as ultrasound, multi-detector ct as well as mri in paediatric trauma patients. the roll of the lecture is to provide some basic guidelines for young radiologists and general radiologists who less often have to deal with paediatric patients. learning objectives: 1. to become familiar with the major pathophysiologic differences in childhood trauma 2. to standardised diagnostic algorithm in some typical settings in field of pediatric trauma. basic principles in the interpretation of signal intensities on t1-and t2weighted images g. wilms; leuven/be (guido.wilms@uz.kuleuven.ac.be) the signal intensities of normal structures and pathological findings on conventional t1-and t2-weighted mr images depend on many factors. the amount of water, proton density, chemical structure and/or binding, presence or absence of flow (of blood or csf), calcification, fat, blood degradation products, melanin, mucine and even air are all factors that influence the signal characteristics. t1-and t2-lenghtening is the rule in most tumoural, vascular and infectious lesions and therefore is rather unspecific. t1-and t2-shortening can be due to the presence of fat (lipoma), melanin (melanoma and metastasis of melanoma), mucine (metastasis of sigmoid carcinoma), colloid material (colloid cyst, rathke cleft cyst) and even calcification (falx!). t1-shortening with t2-lengthening can be due to cholesterine (cholesterol granuloma, craniopharyngioma), high protein content (tumoural cysts), and methaemoglobin (late haemorrhage, thrombus). t1-lengthening and t2-shortening is almost exclusively due to deoxyhaemoglobin. acute haemorrhage and meningioma can be iso-intense on t1-weighted images, while some meningiomas and micrometastases can be iso-intense on t2-weighted images. absence of signal can be due to high-velocity flowing blood (aneurysm, avm, hypervascular tumours), high velocity flowing csf (normal pressure hydrocephalus, cortical bone or extensive calcification, air and a large amount of iron (coils, clips). it is concluded that the simple use of a combination of t1-and t2-signal intensities on conventional mr images can be used to arrive at the diagnosis and differential diagnosis of brain lesions. complications occurring after acute aortic dissections should be separated into those related to the disease per se and those related to post-treatment conditions. life-threatening complications related to the disease should be familiar as immediate consequences for treatment may ensue. most of these are either located in the aortic root or related to mal-perfusion syndromes. the aortic root with very thin walled structures of the sinus of valsalva is located within the pericardial sac. the structure is prone to rupture and may produce life-threatening pericardial tamponade or present clinically as sudden onset of severe aortic regurgitation. all imaging modalities suitable for diagnostic workup in such conditions have to be rapidly accessible and performable. this precludes lengthy mr imaging procedures and renders ultrasound and ct as the mostly used modalities. the condition that has to be recognised as the most important inductor of malperfusion syndromes in the descending aorta is the progression of dissection into aortic branches and the true lumen collapse. both conditions are easily discernible with ct imaging. complications related to treatment should be sub-classified into those after pure surgical treatment and those related to endograft repair. the acute surgical complication with most deleterious effects is related to spinal cord ischaemia. the condition also applies to endograft repair. it is therefore beneficial for the radiologist involved either in pre-surgical imaging or interventional treatment to acquire thorough knowledge of the spinal cord blood supply. endograft complications of interest encompass endoleak formations, stent migrations and endoluminal stent collapse. learning objectives: 1. to learn the most common complications. 2. to learn the most appropriate imaging strategy for diagnosis. 3. to understand the clinical significance of the most common complications. which imaging modality is best for endovascular management? 17:14 the various imaging modalities for establishing the diagnosis of acute non-traumatic dissections will be discussed. the panellists will present recommendations for diagnostic work-up with special respect to differential diagnosis such as acute myocardial infarction and acute pulmonary embolism. also, the problem of sizing the endograft and planning the procedure will be addressed. the panellists will discuss strategies for detection of complications and for monitoring patients following treatment. the quality of radiographs is determined by many parameters from both technical and clinical origin. during the presentation, we will make an overview of the particular features of x-ray tubes and plain films that affect the quality of the radiological image. the training session will start from very simple x-ray tubes and film, and gradually introduce more sophisticated, state-of-the-art technology. we will briefly explain concepts such as focal spot, heel effect, beam quality, filters, grid, film sensitivity, automatic exposure control, etc. from a practical point of view. the european commission and selected research groups have developed criteria to judge the quality of the images and we will show how they can be used to improve the daily practice. a more technical evaluation of quality is possible with images of test objects, some of which are very straightforward and interesting if problems have to be retrieved. x-ray quality should be at a high level every day. therefore quality control procedures have a role. one example evaluates the stability of the imaging chain by means of acquisitions of homogeneous blocks of pmma. we will illustrate typical findings with repercussions on the radiological practice, and show that the fight against artefacts is a never ending process. both with film and digital detectors, radiologists should be aware that quality management and quality control procedures are needed. quality has to be organized, and quality control procedures have to be automated and included in the routine practice. there are diverse underlying causes for "diagnostic mistakes". missed lesions due to inadequate technique, "satisfaction of search" or lack of perception have to be differentiated from interpretative mistakes of lesions that have well been seen but erroneously interpreted due to the lack of experience, misconception or overlap of findings that complicates the differential diagnosis. each of these underlying reasons require a different approach to avoid them or reduce their risk of occurrence. the first type of mistake arises more often when interpreting chest radiographs and refers to the detection of mostly small focal parenchymal densities but also to the interpretation of mediastinal and hilar contours. by analysing typical cases, visual "tricks", helpful display techniques and strategies for systematic review and analysis will be outlined that are thought to be helpful in reducing the risk of "missing" a lesion. the second type of mistake mostly represents a problem of interpreting parenchymal abnormalities seen on ct. since the lung has limited means to "react" against an injury, many radiologic findings are aspecific. interpretation of pathology of parenchymal changes is based on pattern analysis, the knowledge of disease distribution and additional findings of pleura and mediastinum. in many cases, an interdisciplinary approach of radiologists and clinicians is essential for correct interpretation. cases will be analysed to illustrate difficult differential diagnosis occuring in daily routine (e.g., infectious pneumonia versus organising pneumonia) and key features helping in going into the right interpretative direction will be outlined. emphasis will lie on focal lung disease rather on the interpretation of diffuse interstitial lung diseases. learning objectives: 1. to learn about visual tricks and strategies to overcome typical perception errors in chest radiography. 2. to become familiar with overlaps of morphologic findings of focal parenchymal lesions frequently occuring in daily routine when interpreting thoracic ct. 3. to recognise those additional findings that represent the "helpful clue" for correctly narrowing the differential diagnosis. panel discussion: what have we learned from our mistakes? 09:44 interpreting the results of imaging studies is more and more challenging and time consuming due to the large volume of data to evaluate, compare and post-process. moreover, errors in the interpretation of imaging studies can have significant effects on patient care, particularly in acute medicine and oncology. so the question is how to be aware of the potential pitfalls that may be encountered in the realisation and the interpretation of imaging studies and how to avoid them or to learn from them. acute pancreatitis remains a potentially life threatening condition with an overall mortality rate of 5%. its outcome is strongly related to a precise and timely diagnosis, a correct estimate of severity and subsequent appropriate treatment. radiologic imaging, particularly ct, plays a key role in staging the severity and therefore helps guiding therapeutic decisions. management of interstitial or edematous pancreatitis is supportive while severe or necrotising pancreatitis requires intense monitoring and specific therapies. the latter has a higher mortality and guarded prognosis, since it may lead to organ failure, infection, pseudocyst formation and extrapancreatic parenchymal and vascular complications. a number of severity indices have been established to determine the prognosis of acute pancreatitis, based both on clinical and imaging criteria. a ct-based severity index has become the main prognostic method to predict outcomes. this course reviews relevant imaging findings of various stages of acute pancreatitis and its complications by ct, including special conditions such as groove pancreatitis and autoimmune pancreatitis. currently established and modified severity indices are reviewed to learn how to estimate prognosis and guide therapy. interpreting the results of imaging studies is more and more challenging and time consuming due to the large volume of data to evaluate, compare and post-process. radiology errors are inevitable, affect all radiologists and may be defined as a mistake that has management implications for the patient. errors can be broadly classified into technical errors, active errors (errors in perception, judgment or knowledge) and errors of communication. the majority of errors are false-negative interpretations and occur during interpretation of ct examinations. good communication between the referring physician and the radiologist is essential. unfortunately, only a small minority of radiologists keep a personal record of their errors. patient safety should benefit from the repeat organisation of "error meetings" through the act of collective learning. radiologists and radiology departments must continue to improve the process of recording and addressing errors. a-185 08:58 radiologists do make mistakes, diagnostic errors can be the cause of severe consequences to patients or, luckily, in many cases, they can be corrected. learning from mistakes is quite important since understanding why a mistake has been made help to avoid it in the future. during this lecture a series of mistakes made in the field of gu will be presented and causes which have lead to each of them will be analysed. dyspnoea is a common symptom in patients presenting to the emergency room. in almost two-thirds of all cases, dyspnoea is caused by either a pulmonary or a cardiovascular disorder. imaging in patients with dyspnoea depends mainly on the clinical presentation and the medical history of the patient. chest radiographs are a cost-effective and rapid test for the evaluation of patients with dyspnoea, with a fair sensitivity and specificity. for this reason, chest radiographs are usually performed early in the diagnostic evaluation of patients with acute and chronic dyspnoea. chest radiographs enable the diagnosis of frequent causes of dyspnoea of pulmonary origin, such as pneumonia, pneumothorax, pleural effusions, interstitial lung diseases, and emphysema. the diagnosis of cardiovascular disorders, such as pulmonary venous hypertension, cardiomyopathy, as well as valvular diseases, is also facilitated by chest radiographs. if chest radiographs, clinical studies, and laboratory tests, however, are non-diagnostic or equivocal, ct is indicated. ct offers high sensitivity and specificity for the evaluation of pulmonary embolism and for diseases of the pulmonary parenchyma and the airways. high-resolution ct represents the method of choice for the evaluation of suspected diffuse lung disease. additional expiratory scans are useful for the evaluation of mosaic perfusion and air-trapping. chronic pancreatitis (cp) is an inflammatory disease of the pancreas, with irreversible morphologic changes and fibrotic replacement of the gland, which progressively result in loss of exocrine and endocrine function. cp is morphologically characterised by irregular sclerosis associated with destruction and permanent loss of the exocrine parenchyma which may be either focal, segmental or diffuse. the primary symptoms of cp are abdominal pain and maldigestion, which may be physically and socially debilitating, although it is acknowledged that chronic pancreatitis can occasionally be painless. a classification based on the causes of cp is useful in order to better define the therapeutic interventions. however, morphological changes of the pancreatic ducts are the main rule of thumb for the classification in order to better compare the results of the treatment. imaging techniques have a role both on the diagnosis -especially in the early phases of the disease -and on the classification of cp, either for the grading of the disease, to explain the aetiology -even for rare forms -and to differentiate the focal mass from ductal adenocarcinoma. ct, mri and ercp have a specific role in the assessment of cp, due to the different capacity of the techniques to explore the pancreatic gland. however, thanks to heavily t2w sequences, mri has a competitive role with ercp, which actually has more an interventional role in case of obstructive cp. finally, mri thanks to secretin test and dwi sequences is able to give a non-invasive assessment of pancreatic exocrine function. complications of pancreatitis may include fluid collections and pseudocysts, vascular complications such as arterial pseudoaneurysm or thrombosis of the portal venous system, and stenosis of common bile duct and pancreatic duct. inflammatory fluid collections in the context of acute pancreatitis often resolve spontaneously. drainage may become necessary in the presence of clinical complications such as abdominal pain, compression of adjacent organs by large pseudocysts, or if superinfection of a pseudocyst occurs. depending on clinical, morphologic, or technical factors, drainage may be accomplished with image-guided external catheter placement, by endoscopic internal (transgastric) drainage or by internal surgical drainage. arterial pseudoaneurysm carries the risk of acute intra-or extraperitoneal bleeding, and transarterial embolisation is usually indicated when pseudoaneurym is detected. strictures of the common bile duct secondary to chronic pancreatitis may require percutaneous or endoscopic retrograde intervention. learning objectives: 1. to review interventional techniques that are used to manage fluid collections in the setting of pancreatitis. 2. to compare the results with those obtained by surgical and/or endoscopic approach. 3. to learn about algorithms used for clinical decision making, and for treatment evaluation and follow-up. 4. to understand major shortcomings and complications and how to avoid them. discussion 09:45 ants include the presence of accessory muscles, a low-lying peroneus brevis muscle belly, pseudosubluxation of the peroneus brevis tendon, and a bifurcated or mildly crescentic peroneus brevis tendon. accessory muscles in the ankle area include in the lateral aspect the peroneal tertius and peroneal quartus, in the medial aspect the flexor digitorum accessorius longus, and posteriorly the peroneocalcaneus internus, tibiocalcaneus internus and accessory soleus. as variations are commonly seen in asymptomatic ankles, matching with clinical symptoms is important. pitfalls include pseudoloose bodies in the ankle joint, pseudolipomas, and artefacts such as the "magic angle" effect, chemical shift, susceptibility, motion, "ghost" and partial volume averaging. knowledge of normal anatomy, pitfalls and variants, aids radiologists in making the precise diagnosis of various disorders. the aetiology of dyspnoea is varied. it may be due to pulmonary or pleural disease, cardiac pathology or extrathoracic causes. imaging is an useful adjunct in the diagnosis of majority of cases of dyspnoea. in this lecture we will present selected cases which will demonstrate the usefulness of different imaging modalities, emphasising when cross-sectional imaging is indicated. learning objectives: 1. to review typical cases illustrating the role of imaging modalities in the differential diagnosis of dyspnea cases. 2. to motivate the audience by the use of voting pads to be involved in the diagnostic process. 3. to highlight the conclusion that may be drawn on the basis of the discussed cases. the term bone marrow oedema was introduced to describe ill-defined bone marrow hypointensity on t1wi and hyperintensity on t2wi and water sensitive sequences. bone marrow edema can be found in many similar unrelated disorders, such as bone contusions, osteonecrosis, inflammatory or degenerative disease, being a non-specific mri abnormality representing a diagnostic challenge for radiologist. recently has been demonstrated that bone marrow oedema might be a prognosis marker for oa (osteoarthritis) and inflammatory disease, and could be used as a powerful predictive tool for treatment options. therefore our role as radiologist is to try to increase specificity to help patient management and decrease progression. subchondral bone marrow lesions (bmls) are a hallmark of osteoarthritis (oa) on mri. radiologically, bmls in oa are understood as non-cystic subchondral areas of ill-defined hyperintensity on t2w images and of hypointensity on t1w images, but only water-sensitive fat-suppressed sequences depict the lesions to their maximum extent. bmls are observed regularly in conjunction with adjacent cartilage alterations. higher grades of cartilage loss are associated with higher prevalence and greater volume of concomitant bmls. as the disease progresses, an increase in bml volume is seen in the same region subchondrally in many patients, which is positively correlated with an increase in cartilage loss and radiographic joint space narrowing. cysts are strongly associated with bmls in the same subregion and develop within non-cystic bmls. the published data on the natural history of bmls are ambiguous but recent reports showed that the majority of subchondral bmls may regress or resolve completely. note that progression and regression of bmls may be observed within the same knee simultaneously. histologic correlation studies showed that the lesions consisted of a mixture of different tissue patterns with only little oedema. specific changes in bone mineralisation and remodelling in areas of bmls have been shown, and they appear sclerotic compared to unaffected regions from the same individual. differential diagnoses of oa-related bmls include traumatic bone contusions and fractures with or without disruption of the articular surface. osteonecrosis, inflammation, idiopathic bmls, red marrow and post-surgical alterations should also be considered. learning objectives: 1. to learn about the basic physiopathology of oa and its relation with bme. 2. to analyse the distribution and natural history of bme in oa. 3. to understand the differential diagnosis and relevance of bme in staging oa and as a marker of prognosis. b. bme and early inflammatory disease a.j. grainger; leeds/uk (andrew.grainger@leedsth.nhs.uk) marrow oedema is identified as a feature of many forms of inflammatory and mechanical arthritis, but has been most studied in the inflammatory arthritides and particular in rheumatoid arthritis. it was first reported as a feature of ra as far back as 1986. work has been undertaken both using human specimens and specimens from animal models which suggest that marrow oedema seen on mri in ra corresponds to areas of inflammation been associated with invading pannus, lymphocytic aggregates and hypervascularity. there is also evidence that the marrow lesions seen on mri in ankylosing spondylitis correspond to histopathological inflammatory change. marrow oedema has been shown to be an important predictor the recent technological advances of ctu and mru have had an exceptional impact on the assessment of chronic/intermittent obstruction. imaging studies should help answer the clinical questions raised concerning the presence, level, and cause of obstruction. in this session, the recommended techniques of ctu and mru will be described and their relative merits and limitations reviewed. 3d ct images should be used as an adjunct to the transverse images, instead of a replacement, because volume-rendered images best depict the lumen and not the wall of the urinary tract. thin-section reformatted ct images likely are as sensitive as transverse images in the detection of urinary tract abnormalities. mru is being increasingly used because it provides excellent anatomic and functional imaging in a single setting. it has proved particularly valuable in pregnant women and children. the relative advantages of static-fluid mru and excretory mru will be discussed. the main aetiologies of chronic/intermittent obstruction will be illustrated, including intraluminal diseases (stones, clots, etc.), wall abnormalities (transitional cell carcinomas, tuberculosis, etc.) and extraluminal diseases (pelvic and retroperitoneal tumours, retroperitoneal fibrosis, gi tract diseases, etc.) upj syndrome is the most common site of urinary tract obstruction in children. vessels crossing a ureteropelvic junction obstruction contribute to the degree of hydronephrosis in up to 46% of these patients. demonstration of these vessels and their location anterior or posterior to the obstruction facilitates surgical planning. at the end of the lecture, attendees will become familiar with moderate or severe urinary obstruction and their various features and causes. 1. technological advances in both computed tomography (ct) and magnetic resonance (mr) imaging have improved the diagnostic imaging of the urinary tract, surpassing ultrasound and the intravenous urogram. multidetector computed tomography urography (ctu) is defined as ct examination of the kidneys, ureters and bladder with at least one imaging series acquired during the excretory phase of contrast enhancement. mr urography (mru) can be performed using heavily t2-weighted sequences without contrast material or t1 spoiled gradient -recalled echo sequences during the excretory phase after administration of gadoliniumbased contrast material. in adults, ctu or mru is now the preferred examination. technical aspects of image acquisition and processing will be explored and technical tips relating to protocol design given. 2. the typical and atypical appearances of upper urinary tract urothelial tumours and bladder cancers will be demonstrated. a method of fluoroscopic biopsy of upper tract tumours is described for validation of the imaging diagnosis. 3. early and accurate diagnosis of urinary tract tumours helps optimise prognosis but conventional investigative pathways are complicated and lengthy, utilising multiple imaging tests and many diagnostic algorithms exist without rigorous evaluation. ctu offers a single imaging test of high diagnostic accuracy with the potential to replace multiple alternative imaging tests in the diagnostic pathway, improve patient experience, improve diagnostic performance and accelerate diagnosis. mru is a promising technique that may be used for the initial evaluation of patients at high risk for developing upper-tract urothelial carcinoma when ctu or intravenous urography is contraindicated. rhage and periventricular echodensities. the posterior fontanelle approach improves the detection of grade ii haemorrhage in 30% more cases than the anterior fontanelle, and the mastoid fontanelle approach is essential for diagnosing cerebellar haemorrhage. ventricular dilatation is the main complication of intraventricular haemorrhage and resolves spontaneously in approximately 65% of cases. the main challenge with periventricular echodensities is to differentiate them from classical periventricular leukomalacia. when cysts appear during follow-up, the diagnosis is straightforward. mri is considered to be more sensitive than us for evaluating white-matter damage. congenital brain malformations including ventricular dilatation of diverse aetiologies, corpus callosus agenesis and posterior fossa malformations are usually diagnosed prenatally. mri complements us for this purpose. acquired abnormalities arise mainly from infections and hypoxic-ischaemic injury. although mr is considered the gold standard, us still plays an important role in the study of hypoxic-ischaemic lesions when used to its full capacity. depending on the duration and severity of the hypoxic insult, patterns different from those seen in premature infants may be observed. brain malformations are conditions where the brain has not formed properly during pregnancy. these problems in brain structure are almost often (with some exceptions) associated with neurological and developmental problems. often, brain malformations are part of syndromic complexes that require a multidisciplinary approach. malformations may be caused by inherited genetic defects, spontaneous mutations within the genes of the embryo, or effects on the embryo due to the mother's infection, trauma, or drug use. classification schemes are currently shifting from a morphological to a genetic approach. the most frequent congenital brain abnormalities may be categorised into anomalies of the corpus callosum and telencephalic commissures, holoprosencephalies and related entities, malformations of the cerebral cortex, and malformations of the cerebellum. these congenital brain defects are diagnosed either from direct physical examination or from imaging studies including ct and mri. prenatal mri offers a viable method to improve detection and characterisation of these entities in utero. learning objectives: 1. to learn about the common supra-and infratentorial congenital abnormalities. 2. to learn when mri is required and the appropriate imaging protocol. 3. to learn if and when ct is still useful in the investigation of congenital anomalies. in addition to predicting bone destruction for erosion, marrow oedema is independently predictive of joint space loss and therefore cartilage destruction. it also correlates well with other measures of disease activity. we have applied dynamic contrast enhancement techniques to show that treatment with anti-tnf therapy brings about a reduction in contrast uptake in areas of marrow oedema in patients with ra. in the seronegative arthritides marrow oedema in the spine in ankylosing spondylitis has been shown to be predictive of future changes and of response to treatment. diffusion weighted imaging of marrow lesions in ankylosing spondylitis can also be used to show a treatment response, seen as a change in the apparent diffusion coefficient. bone marrow oedema, also referred as bone contusion or bone bruise, is frequently identified at magnetic resonance imaging after an injury to the musculoskeletal system. it may result from a direct blow to the bone, compressive forces from adjacent bones impacting one another, or from traction forces that occur during an avulsion injury. its location reflects the mechanism of injury, which allows for a focused search for predictable patterns of associated internal derangements. it is seen in any joint but are particularly common in the knee reflecting mechanisms such as pivot shift, hyperextension, contrecoup or dashboard injuries, as well as lateral patellar dislocation. in a context of trauma, bone marrow oedema, identified at mr imaging as areas of poorly marginated signal intensity alteration (best seen on fat-suppressed sequences) in the cancellous bone and marrow, represents areas of oedema and haemorrhage secondary to trabecular injury. it can be seen as soon as one hour after trauma and usually resolves in the following six to eight months, except in case of subsequent chondral lesion. learning objectives: 1. to learn about bhe physiopathology in trauma scenario, direct and indirect mechanism. 2. to recognise bme as a footprint that allows other soft tissue injuries to be ruled out. 3. to analyse whether bme can be a value tool for follow-up. can we still use the term bme or should we be more specific? 09:44 the term bone marrow oedema was introduced to describe ill-defined bone marrow hyperintensity on t2 weighted images. since then many studies have demonstrated that it can be found in many similar unrelated disorders, such as bone contusions, osteonecrosis, inflammatory or degenerative disease, and that it is a non-specific mri abnormality. it has been demonstrated that bone marrow oedema might be a prognosis marker for oa (osteoarthritis) and inflammatory disease, and could be used as a powerful predictive tool for treatment options. therefore our role is to increase specificity to help patient management and decrease progression. room e2 sonography is an essential tool for studying the neonatal brain. brain scans are usually performed via the anterior fontanelle; however, a more complete assessment of the brain can be achieved using the posterior and mastoid fontanelles, high-resolution linear array transducers and colour or power doppler. the most common lesions in premature infants are intraventricular/periventricular haemorat initiation, tumours in a pre-vascular phase are supplied by oxygen and nutrients that diffuse from pre-existing normal vessels. when the tumour reaches a critical size of approximately 1-4 mm diameter, the resultant ischaemia leads to secretion of angiogenic factors. these factors, such as vascular endothelial growth factor (vegf), recruit and maintain tumour vessels. "new" vessels (neovasculature) exhibit increased blood volume and permeability compared with normal vessels. various new specific therapies in oncology target tumour vasculature or tumour neoangiogenesis. it is not uncommon that these targeted therapies have pronounced cytostatic and not predominantly cytotoxic effects. this limits the usefulness of size-based morphological tumour response assessments. of newer magnetic resonance imaging (mri) modalities, perfusion mri has emerged as a valid marker of tumour-induced blood vessels and their function. mri perfusion measures the vascularity within a tumour, as well as its component heterogeneous parts. of parameters which can be measured to date, blood volume and permeability are commonly applied in patient studies. blood volume measures the aggregate size of the vascular space, while the permeability function informs about the integrity of vessels and their ‚leakiness' to contrast agents. we will describe the use of mr perfusion to monitor such new therapies and discuss its specific advantages and limitations in comparison to ct perfusion protocols. pet-based strategies for targeted treatment-monitoring in oncology will be briefly mentioned, with prospect on the significance of combined vascular and metabolic imaging for further optimising non-invasive response assessment in specific anticancer therapies. after a brief review of physical and technical principles of diffusion-weighted mr imaging and pet-ct, the lecture describes the ability of these techniques in evaluating functional parameters in tumour tissue. diffusion-weighted sequences have been used in an attempt to further increase the diagnostic capability of baseline and dynamic mr study by providing functional information. diffusion-weighted mr imaging is based on the random microscopic movement of molecules that can be quantified by means of apparent diffusion coefficient (adc). in the early post-treatment period after loco-regional therapies, tumours may not change in size. recent studies demonstrated that water diffusion can be used to differentiate viable and cellular regions from necrotic area in the tumour, regardless morphologic or dimensional changes. moreover, new classes of antitumour therapy have been developed that have an antiproliferative effect, inducing a delay in tumour shrinkage. diffusion mr imaging can be promising in this clinical setting as a biomarker to predict early response to systemic chemotherapy. on the other hand, pet/ct, combining the functional and the structural imaging approach, was shown to be superior regarding conventional imaging modalities in the identification of intrahepatic and extrahepatic metastases. less experience and less publications are available for pet-ct in monitoring tumour response after interventional therapies, but the ability of pet-ct to measure early metabolic changes could make this technique useful in the development of novel anticancer drugs. until now, in oncology, only the recist criteria based on anatomical measurement of the tumour size are used for drug trials or in clinical practice because this is a standardised way to assess the tumour response that allows the calculation of the progression-free survival (pfs) or the time to progression (ttp) that are usually accepted as surrogate end point for overall survival. however, tumour follow-up evaluation using only morphology is usually delayed and with the emergence of new numerous and very expensive targeted therapies there is now a need to move beyond morphology to find new ways to assess tumour responses or progression not only for clinical trials but also in clinical practice to maintain or to change quickly a treatment. this is the aim of the functional imaging using ultrasound, ct, mri or pet. the ultimate goal of these technique is to find biomarkers able to predict the likely course of disease, irrespective of treatment (prognostic biomarkers) or able to forecast the likely response to treatment (predictive biomarkers); before (baseline values of a parameter) or during the treatment (dynamic variation of the parameter during the follow-up). during this session the presenters will discuss the technical issues and the results obtained today using ultrasound with share-waves or microbubbles, functional ct, dynamic contrast enhanced mri, diffusion weighted mri and pet-ct. the candidate biomarkers will be presented as well as the limits and the problems that are still to be overcome. a. us and ceus m. claudon; vandoeuvre-les-nancy/fr (m.claudon@chu-nancy.fr) for tumour evaluation, the main advantages of ultrasound (us) associate a high frame rate and a large range of data and parameters potentially extracted from the signal backscattered from tissues. beyond morphology, elastography is a first modality, based on in vivo estimation of the mechanical properties of tissues. data on displacement or strain of tissues and lesions can be obtained by manual external compression, but shear wave generation techniques allow for a quantitative and more precise estimation of their visco-elastic properties. in oncology, clinical evaluation included first breast. contrast-enhanced us (ceus) is obtained after intravenous administration of microbubbles which are pure blood pool contrast agents. ceus is capable for detection, characterisation and follow-up of tumour lesions, based on enhancement profiles during bolus, destruction-replenishment, or contrast burst depletion imaging. quantification of perfusion in normal tissues and lesions may be obtained by extracting various blood flow and blood volumerelated parameters from time-intensity curves. protocols have entered validation processes to improve reproducibility. as a predictive technique, ceus is a promising tool for monitoring changes of haemodynamic parameters and evaluating the early response during chemotherapy or antiangiogenic treatment. it is helpful in the guidance and follow-up of lesions treated by radiofrequency or cryoablation. recent advances of us and ceus include 3d/4d real-time imaging with matrix technology, and the evaluation of targeted agents, to be released on site after bubble destruction by the us beam. interventional radiology (ir) is the part of clinical radiology based on the percutaneous or endoluminal treatment of widespread conditions. the procedures performed by the interventional radiologists require a deep level of knowledge of clinical imaging and specific training in patient management and care. technical skills are also needed because complex devices and materials are used in some procedures. therefore, specific training programmes are required to address the training needs for the interventional radiologist. a multidisciplinary approach is required (based on team work) with defined levels in patient care. ir procedures have become the treatment of choice for many conditions as an alternative for some surgical procedures. even for some conditions without a defined treatment are now being treated by ir. thus, it is a discipline with a great deal of interaction with other clinical specialities that requires a clear definition. ir specialists have to receive recognition in the patient care process and their activity has to be known by the medical community. the recognition of ir as a subspecialty of clinical radiology by the uems will contribute to the development of specific training programmes in the european community and will promote training centres with certified specialists. interventional radiology (ir) procedures are complex and require specific training to ensure good results. in the uk, a curriculum for subspecialty training was established in 1998 specifying the required knowledge, training and core procedures expected of trainees. this curriculum has undergone several reforms since that time. however, training is not uniform throughout europe and this stimulated the development of a europe wide ir training document to ensure similar training in all countries as a way of ensuring good medical practice. radiology training is based on 3 years of common radiology training and 2 years of subspecialty training with an option for further specialist training in the 6 th year. regular appraisals and assessments of trainees' performance should guide progress at local training institutions with the aim that competence is assessed formally at the end of training by a european board examination. this qualification will be recognised thoughout europe and ensures that the required proficiency in ir procedures has been attained. competence in the core skills for ir occurs during the first 3 years of training. in the next 2 years, trainees undertake modular training depending on their areas of interest and ultimate goals. the majority of this training is practical, supervised training in interventional suites and theatres, with clinical exposure. simulators play a role alongside the more traditional training methods and allow early training in a more forgiving environment away from the patient. development and validation of such simulation models is progressing. discrimination of individual x-ray quanta, i.e. the detectors can 'see' the colour of the x-rays. different materials attenuate the energy spectrum in their own characteristic way. by comparing the measured spectra with the spectrum emitted from the x-ray tube the penetrated material can be characterised. colour x-ray imaging can be used in breast imaging to detect, for example the uptake of an iodinated contrast agent to show the vasculature of a tumour while reducing the impact of the structures from the surrounding tissue. it can also be used to estimate the breast density and as a material decomposition technique to separate the digital mammogram into compositional images, showing different material types separately. colour x-ray imaging can, for example be realised with pulse height discrimination in a photon counting detector, multiple exposures with different x-ray tube settings or filtering the x-ray beam before or after the object. the most simple form of colour x-ray is dual energy where two images are acquired at different x-ray energies. lung cancer staging is based on imaging techniques in combination with tissue diagnosis and surgical exploration. the tnm staging system describes the local tumour extent (t1-t4), presence or absence of lymph node metastases (n0-n3) and distant metastases (m0/m1). different combinations of t-, n-and m-factors translate into tumour stages (stages ia-iv). therapeutic decisions and assessment of prognosis are based on these tumour stages. recently, the tnm system has been modified: tumour size is now used more precisely for t staging: tumours <= 2 cm: t1a, > 2-3 cm: t1b, > 3-5 cm: t2a, > 5-7 cm: t2b, > 7 cm: t3. satellite tumour nodules in the same lobe are now classified as t3 (previously t4) and in a different lobe of the ipsilateral lung as t4 (previously m1). satellite nodules in the contralateral lung (previously m1) and pleural or pericardial metastases (previously t4) are now classified as m1a, whereas distant metastases outside the chest are classified as m1b (previously m1). also, the tnm staging system should now be applied not only to non-small cell lung cancer (nsclc) but also to small cell lung cancer (sclc). during this refresher course the different t-, n-and m-stages will be presented including the recent changes and examples will be presented and discussed with the audience. therapeutic strategies in different tumour stages will be described and key decisions highlighted. the accuracy of different imaging procedures and findings will be presented and the role of biopsy in specific clinical scenarios will be discussed. x-ray computed tomography (ct) has been proposed and evaluated recently as a potential alternative method for breast imaging. efforts so far showed success with respect to contrast-enhanced dynamic imaging, but suffered from limited spatial resolution. respective efforts and clinical results will be reviewed. the new concept presented here builds upon micro-ct scanning approaches and aims at providing both high spatial resolution at around 100 µm for micro-calcification imaging and advanced dynamic scan capabilities with continuous acquisition and scan times of about 10 seconds for differential diagnosis of lesions. to achieve this, spiral scan modes, slipring technology, high-resolution detectors and high-power micro-focus x-ray tubes are demanded. the concept has been evaluated and confirmed by simulations and basic experiments; feasibility studies are expected by the end of 2011. colour x-ray imaging can best be described as the x-ray analogy to optical colour imaging. in optical imaging the wavelength -the energy -of the light gives the different colours that we see. emerging x-ray detector technologies enable energy maintenance of confidentiality of patient information. in contrast, more hierarchical cultures often defer to elders for decision-making whereas communal cultures may involve community leaders in a shared decision-making process. gender and religious issues can also affect the provision of high-quality procedures with same gender care being a requirement within some cultural groups and gowning procedures that maintain cultural values frequently being an expectation. in addition, in many countries in the developing world, radiation still has mystique and fear associated with it, affecting participation in screening programs and recruitment to medical radiation technology educational programs. this presentation will present findings from a variety of countries and cultures that will help to contextualise these issues through a cross-cultural imaging lens. first line image interpretation is now commonly used in the united kingdom. for many years radiographers have used a system commonly known as "red dot" in order to identify to the referring clinician that an abnormality has been recognised on a radiographic image. this has more recently evolved into radiographer comment where the radiographers' experience in recognising abnormalities can help referring clinicians. junior doctors are often inexperienced at image interpretation, thus this system can assist in ensuring that a higher percentage of fractures and injuries are observed and the appropriate treatment obtained. this presentation will demonstrate the fundamentals of basic image interpretation of the cervical, thoracic and lumbar spine in a trauma situation. it will include basic anatomy, mechanism of injury, common fractures and soft tissue signs. using these principles this will encourage radiographers to use the comment system, both developing the radiographer's role and helping to improve patient care. two fasciae cross the suprahyoid neck: the superficial cervical fascia (scf) and the deep cervical fascia (dcf). the latter can be divided into three parts and these layers define different fascial spaces or compartments. the descriptions of these compartiments in the literature vary almost as much as those of the fasciae themselves. in addition, the names of the formed compartiments vary within the literature. despite these controversies, the knowledge of these compartiments is inestimable for correct differential diagnosis of pathologies that arise in the suprahyoid neck. with the utilisation of cross-sectional imaging, it has been noticed that growth of some tumours appears restricted by fasciae and knowledge of the anatomy of these fasciae allows not only prediction of growth patterns. by allocation of a tumour to a certain compartiment the number of differential diagnosis drop dramatically due to the fact that in different compartiments different types of tissue occur. in addition, the exact localisation of infectious disease of the suprahyoid neck may predict further intracranial or mediastinal spread. even though the number management of cancer patients, imaging pitfalls must be recognised to avoid both false-positive and false-negative interpretation. the principles and good practices of pet/ct will be explained. normal distribution of fdg, pitfalls and normal variants will be presented. specific examples will be discussed to demonstrate how the combined information of images of human anatomy upon which biological information within body structures is added improves delineation of disease, can guide surgical and radiation planning and biopsy. advances in technology result in new training requirements for radiologists who should promote close collaboration with nuclear medicine specialists. the metabolic syndrome refers to the clustering of cardiovascular risk factors including diabetes, obesity, dyslipidaemia and hypertension. the association between metabolic syndrome and cardiovascular diseases raises important questions about the underlying pathological processes. insulin resistance and visceral obesity have been recognised as the most important pathogenic factors. metabolic syndrome generally precedes and is often associated with type 2 diabetes. cardiovascular risk reduction in individuals with metabolic syndrome should include (1) control of obesity, diet and physical activity and (2) control of the individual components of metabolic syndrome, especially atherogenic dyslipidaemia, hypertension, hyperglycaemia and prothrombotic state. appropriate management of metabolic syndrome should be able to prevent the progression from impaired glucose tolerance to frank diabetes and thus to prevent the increasing prevalence of type 2 diabetes and vascular diseases. each 1% increase in hba1c is associated with a 28% increase in risk of incident pad. diabetes is also highly associated with progression of pad and especially with the development of critical limb ischemia. rigorous control of blood glucose prevents the microvascular complications of diabetes, although similar benefits on the macrocirculation have not been ascertained. patients with diabetes and pad should have an aggressive control of blood glucose levels with a hba1c goal of < 7.0% or as close to 6% as possible. in the new tasc paper this recommendation is graded as c, meaning that it is based on evidence obtained from expert committee reports or opinions and/or clinical experiences of respected authorities, while there are no applicable studies of good quality. peripheral arterial disease (pad) is a common cardiovascular complication in patients with diabetes. in contrast to non-diabetic pad, it is more prevalent and, because of the distal territory of vessel involvement and its association with peripheral neuropathy, it is more commonly asymptomatic. diabetic pad thus may present later with more severe disease and have a greater risk of amputation. the pervasive influence of diabetes on the atherothrombotic milieu of the peripheral vasculature is unique. the abnormal metabolic state accompanying diabetes results in changes in the arterial structure and function. the proatherogenic changes include increases in vascular inflammation and derangements in the vascular cellular components, alterations in blood cells and haemostatic factors. these changes are associated with an increased risk for accelerated atherogenesis as well as poor outcomes. in contrast to the focal and proximal atherosclerotic lesions of non-diabetic pad, in diabetic patients the lesions are more likely to be more heavily calcified, diffuse, and distal, sparing the proximal vessels and mainly affecting the more distal arteries in the calf and, in a later stage, the foot. by identifying a patient with subclinical disease and instituting preventative measures, it may be possible to avoid acute, limb-threatening ischaemia. the primary imaging modality to be used should be duplex ultrasound, due to its non-invasive nature, lower risks and costs. ct-angiography and mr-angiography are now replacing dsa as standard imaging methods, providing a non-invasive assessment of the localisation and extension of a vascular lesion and allowing an accurate planning of endovascular and/or surgical treatment. of spaces in the literature varies from seven to fourteen, the use of seven spaces or compartiments seems to be helpful for a sufficient diagnostic approach using cross-sectional imaging. anatomic landmarks and the radiologic appearance in a non-pathologic suprahyoid neck and a pathologic involvement of the suprahyoid compartiments will be reviewed extensively in a coherent manner. the anatomy of the suprahyoid neck is complex and the spectrum of diseases is wide. to improve studies of the neck, radiologists should become increasingly more familiar with the anatomy and expected pathology in the various spaces. this familiarity provides crucial information required for the selection of treatment options and therapeutic planning. in addition, radiologists should be aware of situations when diagnostic inaccuracies may lead to serious consequences and complications. for example, surgical approach to a deep lobe parotid tumour as though it is a parapharyngeal lesion will in all likelihood result in facial nerve injury. mri artefacts such as complex flow-induced increase in signals may be mistaken as a lesion prompting an unnecessary operation. an awareness of such pitfalls helps to improve the quality of imaging studies. this presentation highlights some pertinent anatomical knowledge that may help to improve the diagnostic accuracy of neck studies and at the same time explain the existence of pitfalls that may ruin imaging studies. three layers of the deep cervical fascia define the suprahyoid neck compartments, which include: prevertebral, retropharyngeal, carotid, masticator, parapharyngeal and pharyngeal mucosal space. knowledge of the structures inherent to these spaces will provide the radiologist with an accurate basis for differential diagnosis. also, expanding lesions will distort or displace adjacent structures and fascia in predictable fashion, which is crucial in defining the site of origin. both mri and ct are frequently used in the imaging of suprahyoid neck lesions. the introduction of functional imaging has also given some benefits. primary and secondary, benign and malignant processes occupying major suprahyoid neck spaces will be discussed, with regard to crucial findings necessary for appropriate treatment selection and treatment planning. since correct diagnosis requires close collaboration with ent surgeons, clinical findings will also be discussed, together with practical information needed for surgery. in vivo proton mr spectroscopy is a non-invasive mr technique that is routinely used to assess a number of paediatric neurologic conditions. it is based on the fact that protons belonging to different metabolites resonate at slightly different frequencies (chemical shift). using water suppression and volume localisation techniques we can obtain a spectrum (single voxel) or spectra (si) containing metabolite peaks corresponding to predetermined anatomical site(s). in paediatrics the majority of spectroscopy is performed in the brain and the metabolites detected usually are: n-acetyl aspartate, n-acetyl aspartyl glutamate, creatine and phosphocreatine, choline containing compounds (free choline, acetylcholine, phosphocholine, cytidine diphosphate choline and glycerophosphocholine), myoinositol, myoinositol monophosphate and glycine, aminoacids (glutamine, glutamate and gaba), lactate, lipids and macromolecules. these metabolites participate in fundamental metabolic pathways and their levels are being disturbed by various pathologies. thus, mr spectroscopy has a vast field of application including paediatric tumours, infarction, hypoxia, ischaemia, infection, inflammation, metabolic disorders neurological disorders and trauma. in many cases, it can redirect or narrow differential diagnoses; in selected instances, it may provide the key finding that points to a final diagnosis. however, mr spectroscopy alone is usually not specific, but can be very helpful especially in combination with other clinical, diagnostic and other mr methods. finally, particular caution is needed in data evaluation because spectral appearance and concentrations of the most prominent metabolites are affected by (a) experimental and preprocessing factors and (b) brain development. stroke in children is most often of ischaemic origin and thrombophlebitis is the second cause of stroke in children. stroke is considered as rare compared to the adult population. however, numerous aetiologies impose to look for a cause through series biological investigations. the goal of brain imaging is to confirm the diagnosis of stroke, to evaluate the extension of ischaemia and mostly to participate in the search of a cause for the stroke. prognostic is mostly related to the aetiology. a lot of cases are performed under general anaesthesia leading to limited indications of mra in the acute phase compared to adult. the role of cta at the acute phase is mostly to confirm thrombophlebitis and is the primary method to assess intracranial vessels at the acute phase of haemorrhage of arterial or venous origin. it is also the primary method to assess arterial vessels at the neck level (especially when dissection is suspected). cta permits to confirm or rule out arterial lesion that was suspected on mr: indeed, cases with pitfalls are numerous with mr angiography. the role of mra, also always performed in the acute phase or follow-up of vascular diseases, is not as clear as cta role because of artefacts especially in young children. the role of angiography (dsa) is finally limited to prove vasculitis when the other methods are not contributive and in cases of arterial or arterio-venous malformation to plan the treatment (endovascular procedure versus surgery or radiosurgery). diffusion tensor imaging (dti) studies demonstrate progressive apparent diffusion coefficient (adc) decrease within grey and white matter areas starting from foetal life as sign of brain maturation; meanwhile, fractional anisotropy (fa) increases in some white matter structures. changes in fa and adc, together with radial and axial diffusivity values, during cell proliferation-migration and during myelination, well correlate with modifications known from developmental histologic studies. acute adc decrease (i.e. ischaemia) can be detected already in foetal stroke and its measure is pivotal in monitoring neonatal hypoxic-ischaemic encephalopathy. adc calculation allows also to assess acute osmotic and metabolic anomalies in neonate (i.e. hypernatremia, hypoglycaemia, etc.). early fa decrease, with radial and axial diffusivity changes, is observed in white matter areas as sign or early wallerian degeneration after acute brain damage. chronic regional white matter fa reduction is detectable in sequelae of periventricular leukomalacia or adjacent to malformative cortex. also, in children with neurodevelopmental delay (autism, adhd, dyslexia, etc.). fa reduction and radial or axial diffusivity changes have been demonstrated, but in these conditions not on a single case basis rather in cohort quantitative studies. finally, building fiber tracking and colour coded (rgb) maps from dti data may help in better characterising suspected structural anomalies on a single case basis (i.e. corpus callosum, hippocampal fornix, optic radiation, cerebellar peduncles malformations, etc.). however, the potentials of fiber tracking applications still need to be fully exploited, especially in view of future higher spatial resolution image acquisitions. learning objectives: 1. to understand the relationship of adc-fa values with the structural characteristics of the normal developing brain. 2. to understand adc-fa value changes in paediatric cns diseases. 3 . to learn about the potential impact of fibre tracking in clinical paediatric neuroradiological practice. congenital pulmonary malformations may involve the lung parenchyma, bronchi, arterial supply, and venous drainage. the pulmonary developmental abnormalities that most commonly result in clinically significant complications in neonates and children are hypogenetic lung syndrome, bronchopulmonary sequestration (bps), congenital lobar emphysema (cle), bronchial atresia, congenital cystic adenomatoid malformation (ccam), and bronchopulmonary foregut cysts. it should be noted that there is often considerable overlap between these conditions and that multiple lesions may be identified in the same patient either separately or as hybrid lesions. the aim of this presentation is to illustrate the characteristic imaging manifestations of the most important congenital lung diseases and their main differential diagnosis. emphasis will be given to pre-natal diagnosis using ultrasound or magnetic resonance imaging (mri) and post-natal diagnosis using mri or low dose ct in multidetector scanners. ultrasonography (us) is the primary screening modality in prenatal imaging. its diagnostic accuracy is usually very high so that the indications for foetal mri should be very rare. in some countries, because us is considered of secondary importance and is not exploited as much as it could be, there is a progressive shift from us to mri as a prenatal imaging modality. consequently, there are many discrepancies regarding the relative contributions of foetal us and mri in the prenatal literature. the main indications for foetal mri will be discussed, with emphasis on the central nervous system, which remains the main field of application. in daily practice, the technique of foetal mri has not changed during the last decade and most diagnoses can be assessed using t1, t2 and t2* sequences. the basic technique and patient preparation will be described. new techniques, based on a functional or a metabolic approach, have been developing during the past few years but their impact on daily practice is still very limited. many studies have underlined the high diagnostic contribution of foetal mri compared with us. however, the diagnostic accuracy of mri has not been studied in large series. comparison between pre-and postnatal data or between foetal mri and pathological findings make it possible to define the main limits of foetal mri. regarding the brain, migration or cortical development disorders are often overlooked or underdiagnosed. a tight collaboration between colleagues practicing prenatal us and mri should increase diagnostic accuracy, both modalities being complementary. founded on september 15, 1948, the brazilian college of radiology comprises 23 regional societies and ten thousand associates. the college is a branch of the brazilian medical association (amb) acting as its scientific department of radiology, imaging diagnosis and radiotherapy. it collects, under the same umbrella medical professionals and legal entities in the field of diagnosis and treatment using imaging methods and/or ionising radiation. session objectives: 1. to get an introduction to the practice of radiology in brazil. 2. to understand the importance of radiology as a method for diagnosing diseases in brazil. granulomatous interstitial lung disease: hrct path correlation c.i.s. silva; salvador/br (c.isabela.silva@gmail.com) granulomatous interstitial lung diseases are a group of lung diseases in which granulomas are an important component of the histologic findings. the most common conditions are hypersensitivity pneumonitis and sarcoidosis. hypersensitivity pneumonitis is very common in brazil because of the warm and humid climate in most regions and a large number of birds. the prevalence of sarcoidosis in brazil seems to be lower than that in north america and europe. other ubiquitous causes of granulomatous interstitial lung disease include intravenous talcosis, drug reactions, and some forms of vasculitis (e.g. churg-strauss syndrome). the aim of this presentation is to illustrate the characteristic high-resolution ct and histologic manifestations of the most common granulomatous interstitial lung diseases and to summarise the main differential diagnosis based on the pattern and distribution of abnormalities seen on high-resolution ct. learning objectives: 1. to become familiar with the characteristic high-resolution ct and histologic findings of the most common granulomatous interstitial lung diseases (hypersensitivity pneumonitis and sarcoidosis). 2. to learn about the most helpful features in distinguishing the granulomatous interstitial diseases from other parenchymal lung diseases. a-233 11:00 the most common granulomatous lung diseases are fungal infections and tuberculosis. these infections are particularly prevalent in brazil, the most common fungal infection being paracoccidioidomycosis (south american blastomycosis). histoplasmosis and coccidioidomycosis may occur but they are uncommon. paracoccidioidomycosis is the most frequent endemic systemic mycosis in latin america, being seen particularly in brazil, argentina, colombia, and venezuela. the lungs are the main target organ of p. brasiliensis organisms, and infection of the lungs is the leading cause of morbidity and mortality in these patients. fungal infections need to be considered not only in patients living in endemic regions but also in patients who have travelled to these areas. although the prevalence of pulmonary tuberculosis has decreased in brazil in recent years it remains one of the most important causes of pulmonary morbidity and mortality. the aim of this presentation is to discuss the radiologic manifestations of the granulomatous pulmonary infections with emphasis in paracoccidioidomycosis and tuberculosis and to summarise the main differential diagnosis. magnetic resonance imaging (mri) is a highly sensitive technique that provides complementary information to conventional breast imaging (i.e. mammography and ultrasonography) for the detection of multinodular disease and for the assessment of primary tumour extent. the use of mr breast imaging has increased considerably in the past decade. although its use is well established for some indications, e.g. detection of unknown primary and assessment of uncertain disease extent, breast mri is still under investigation for other applications such as preoperative assessment in patients eligible for breast conserving therapy on the basis of conventional imaging and clinical examination. despite its superior ability to visualise disease spread, recent studies have shown increased rates of mastectomy without reduction in positive surgical margins or local recurrence rates. nonetheless, a shift in paradigm is occurring, focusing on the use of breast mri to reduce involvement of healthy tissue in breast-conserving therapy. this paradigm involves new methodology to optimise the transfer of information to the surgeons and radiation oncologists. new technological developments, such as diffusion-weighted imaging (dwi) and magnetic resonance spectroscopy (mrs) provide new insights to establish a link with underlying biology of the tumour. contrast-enhanced mri, dwi and mrs are examined for their ability to extract prognostically relevant information to individualise therapy to individual patients and tumours. this overview aims to summarise the current status of breast mr imaging and new developments geared towards providing therapists with patient-tailored information for treatment decision, treatment guidance and therapy response. this talk will review the current literature and clinical use of foetal mri in cases with ventriculomegaly. the initial part will discuss antenatal ultrasound in the detection, categorisation and diagnosis at the 20-week anomaly scan. the role of foetal mri will be discussed including which cases may benefit most from foetal mri when the resource is limited. the timing of the foetal mr with relation to gestational age and the value of further foetal mr scans at a later gestational age will also be discussed. this is still a controversial and debated area especially when the resource is limited or there are financial constraints. the current literature will be discussed on the issues around foetal mri in cases with ventriculomegaly both isolated ventriculomegaly and ventriculomegaly associated with other abnormalities. finally, this section will conclude by looking at the common associated abnormalities seen in cases referred with ventriculomegaly. the final section will discuss the role of foetal mr in imaging the posterior fossa, an area often difficult with ultrasound especially in the later stages of pregnancy. again the current literature will be discussed and the use of foetal mr in clinical practice. the concluding time will be used to summarise the referral pathway used by local centre in the uk. this will differ with other uk centres and centres worldwide. hopefully, time will allow an open discussion on this at the end of the session. learning objectives: 1. to learn about the differential diagnoses of ventriculomegaly identified on foetal ultrasonography. 2. to learn when mr should be performed and its value when compared to ultrasonography. 3. to understand the value of mri in assessing posterior fossa abnormalities. prenatal diagnosis involves obtaining genetic, anatomic, biochemical and physiological information about the foetus and analysing whether there are any alterations that might have repercussions during the foetal period or after birth. magnetic resonance imaging (mri) has been useful in the diagnosis of foetal anomalies for many years. thoracic abnormalities play an important role in infant morbidity and mortality. survival after birth depends largely on adequate lung development during gestation, and various pulmonary problems can affect foetuses. heart defects are present in 8 of 1000 live births, and up to 25% of these are associated with other malformations. other thoracic anomalies (tracheoesophageal malformations, chest wall defects, and tumours, amongst others) can also cause morbimortality. congenital abdominal anomalies can affect many organs. it is essential to determine the location and morphological characteristics of the lesion to ensure an accurate diagnosis. mri's excellent contrast resolution between tissues is very useful in the diagnosis of these conditions. prenatal diagnosis also makes it possible to detect anomalies that can be difficult to recognise clinically in newborns but require early treatment to minimise possible complications.this presentation stresses the importance of diagnosing chest and abdominal problems before birth and analyses the usefulness of mri in this context. learning objectives: 1. to learn about the mr protocol when investigating the foetal chest. 2. to recognise the situations in which mri is helpful in assessing chest abnormalities. 3. to understand the value of mri when compared to ultrasonography in assessing congenital renal and gastrointestinal abnormalities. a s65 c b d e f g h structured reporting: improving the quality of radiology reports c.e. kahn; milwaukee, wi/us (kahn@mcw.edu) the radiology report communicates the results of an imaging procedure and provides the enduring legal record of the procedure. structured reporting uses standardised language and predefined formats to create reports. structured reports can integrate information collected during the imaging procedure, such as clinical data, technical parameters, measurements, annotations, and key images. in this presentation, well defined structured reporting describes its advantages and disadvantages, and identifies the motivations for its adoption. this session will discuss how structured reporting can make it easier to retrieve reported information, evaluate the appropriateness of exams, and aggregate data across health care enterprises. structured reporting can support radiology quality improvement, research, and education, and has the potential to improve the quality of communication between radiologists and their referring colleagues. beyond air-space disease is secondary to occupation of the acini and alveoli by oedema, exudates or malignant cells. it presents in the chest radiograph as ill-defined densities which tend to coalesce. the presence of an air bronchogram is pathognomonic. when the disease is widespread it shows the typical "butterfly" appearance. airthe pixel data set of modern imaging is transformed into a life altering insight for the individual patient through the radiologic report. a good report is patient and service centred, and forms the basis of the reciprocal relationship between radiologist and referring clinician. it is a creative process with serious scientific purpose and becomes part of the permanent record in a person's life. its primary role is communication of diagnostic and procedure-related imaging information but it has many vital adjunct roles in quality service delivery. in current practice of multidisciplinary care the report content must be of value to all the stakeholders beyond radiology. structured reports must have uniformity where possible to permit data-mining and audit whilst preserving the individual radiologist practice and style and the individual nature of each patient's health. report design has a particular role in modern alerting and safety-net systems when unexpected or critical imaging findings are discovered. the properly written report can be vital in medico-legal defence to reflect good practice. ultimately guidelines and standards on reporting must be meaningful to the users and appropriate to local resources, systems and needs. learning objectives: 1. to comprehend the role of the modern radiological report. 2. to understand the role of the report in communication and patient safety. 3. to become familiar with structured report formulations. structured reporting: european perspective r. silverio; grosseto/it (rsilverio@sirm.org) in the last decade, we observe an increasing interest in structured report (sr). this is a part of the dicom standard, where the technical and clinical information are organised in a standard format so that it can be retrieved and reused for clinical, statistical and research scopes. structured reports have three important features: a "structured" format, with fixed paragraphs, heading and subheading in which to describe technical data and clinical findings, impressions and conclusions; a consistent, "itemised" organisation, leading to a better way of reporting, even with automated speech recognition systems; and the possibility, or rather the need, of a common, shared language. when defined terms from a standard lexicon are associated with imaging reports, the information in the report becomes more accessible and reusable. moreover, sr allows the interoperability between the dicom world and the complex sphere of the e-health (electronic patient record, patient care, etc). it is possible to convert a radiological report created as sr in a cda2 (clinical document architecture) document. this clinical document will be used in every computerised healthcare application, as well in the several regional e-health projects (epsos, elga, calliope, renewing health, etc). promoted by european community. integrating the healthcare enterprise (ihe) initiative is as a key partner in fostering the adoption of structured report. in short, question of whether sr will be adopted by radiologists is now a question of "when", not "if." learning objectives: 1. to become familiar with structured report. 2. to keep up to date on the developments of e-health projects in europe. acute mesenteric insufficiency (ami) is due to arterial or venous occlusion. arterial ami is an emergency. the typical patient is elderly, may have atrial fibrillation and has recent onset intense visceral pain disproportionate to clinical signs. ct is the mainstay of diagnosis and may be supplemented by ct angiography (cta). waste no time if arterial ami is suspected. average mortality rates of 71% (59-93%) have been reported and symptom duration before therapy is an independent predictor of mortality. age > 70 years, metabolic acidosis and renal failure are other danger signs. interrupt routine ct lists; ensure that these patients are scanned as soon as possible -neutral oral contrast and high-dose iv contrast are essential. ct appearances should be correlated with serum lactate as acute arterial occlusion without reperfusion may produce falsely 'normal' bowel wall thickness. early diagnosis and aggressive surgical intervention combining bowel resection with revascularisation offer the best prognosis. venous ami may present with a more chronic, intermittent course of pain, fever, abdominal tenderness and ascites. therapy is bowel resection and anticoagulation. ischaemic colitis occurs in elderly patients with atherosclerosis spontaneously or after aortic aneurysm repair. this invited lecture explores the groundbreaking use of ct for studying antiquities and artworks from a wide range of cultures, irrespective of their age or material. dr. marc ghysels, a former interventional radiologist, comes from a family of artists and collectors. about ten years ago he set up a private radiology practice in brussels where he analyses antiquities and artworks. over the years he has built an international reputation among collectors and art dealers as well as museum curators and experts working in auction rooms. art specialists call on his radiological skills and knowledge to authenticate antiquities, and more specifically to show: what methods were used to make the works, what damage they have suffered over the years, how much restoration has been done, and to expose the many tricks used by forgers to deceive not only the discerning eye of the collector but also the methods of scientific analysis more commonly used than ct scans. his presentation will highlight the prominent role of ct as a nondestructive test to explore selected artworks made in wood, terracotta, stone, and ivory. acute abdominal organ ischaemia may be caused by hypovolaemic shock, spasm (ergotism), embolisation and aortic dissection. embolisation is the most common cause. it occurs typically in elderly patients with atrial fibrillation, after myocardial infarction or due to a thoracic aortic aneurysm (taa). the primary diagnosis is made by ct with contrast enhancement which can also demonstrate cardiac thrombi or a taa. interventional treatment can be performed with a thrombectomy device or fibrinolysis with recombinant tissue plasminogen activator (rt-pa; 10 mg loading dose, 5 mg/hr infusion dose). acute aortic dissection may cause dynamic compression of the true lumen with occlusion of the ostium of the visceral arteries (floating visceral sign). the primary diagnosis is made by ct. occlusion of the primary entry tear with a thoracic aortic stentgraft may decompress the false lumen followed by reexpansion of the true aortic lumen followed by reperfusion of the visceral arteries. chronic abdominal ischaemia in younger patients may be due to fibromuscular dysplasia, takayasu arteritis or neurofibromatosis. in the elderly it is usually caused by arteriosclerosis. the patient may have post-prandial abdominal pain (angina abdominalis), diarrhoea and/or weight loss. due to the collateral circulation, symptoms usually occur only if more than one of the major arteries (celiac trunk, superior and inferior mesenteric artery) is narrowed. the diagnosis can be made by color doppler ultrasound (cdus), ct and mr with contrast enhancement. endovascular treatment is done by pta and stent placement. to learn what to include in the report of cns infections for the treatment planning. 4. to learn how to report follow-ups and treatment monitoring of cns infections. finding of a palpable mass in the abdomen always raises the possibility of an important clinical problem. a potentially life-threatening process, especially malignancy is the major concern. the list of differential diagnosis of "abdominal mass" is a very long one. in the process of differential diagnosis the most common approach is to evaluate the patient according to the gender, age, patient history and co-existing clinical and laboratory findings. the accompanying symptoms and signs and the location of the abdominal mass are the key indicators in the clinician's way of thinking in the process of differential diagnosis. for instance, a palpable mass with acute abdomen or intestinal obstruction will be assessed differently than a mass found incidentally. imaging is commonly required to confirm or ascertain the diagnosis. cross-sectional imaging is required to accurately evaluate a palpable abdominal mass in most situations. ultrasound and computed tomography have each been used successfully in evaluating patients with palpable abdominal mass. although each modality is appropriate in most situations, the advantages and disadvantages of each modality in certain situations will be addressed and the appropriateness criteria will be reviewed in this lecture. knowledge of a detailed clinical history is as important to the radiologist as to the clinician. its impact on the diagnostic accuracy in the interpretation of the images will also be addressed. a palpable abdominal mass has a long list of benign and malignant differential diagnoses. these diagnoses may be as different as a hydatid cyst of the liver, a volvolus, an aneurysm, or a giant renal cell carcinoma. the diagnostic approach is based on two major steps: first, the affected organ must be indentified. second, the differential diagnosis must be established based on imaging characteristics. the choice of ultrasound, ct or mri should be based on location and size of the mass. despite the fact that ultrasound is frequently used as a first step, the overview and anatomic orientation in large masses may be hampered, making ultrasound a better technique for image-guided biopsy than for primary diagnosis. in the vast majority of cases, multidetector ct is the first technique of choice. a thin-section protocol should be used to allow for high-quality multiplanar imaging. a pre-contrast scan is usually not required but can be helpful in suspected hemorrhage. for most upper and middle abdominal masses, biphasic imaging in the arterial and portal phase is recommended in order to establish the relation of the mass to the vasculature and to assess vascularity. in the small pelvis, mr is the superior imaging technique. otherwise, mri is mainly used for problem-solving. this course will discuss how to use the various imaging tool efficiently to narrow the differential diagnosis, decide about the need for biopsy and establish a suitable therapy. the most common viral infection of the brain is herpes encephalitis (hsv1). it is a necrotising encephalitis with a a mortality of more than 50%. on imaging studies lesions will be seen in the "limbic system", i.e. the temporal lobes, hippocampi, insular cortex and cingulate gyrus. they appear as hypodensity on ct, t2-and flair hyperintensity on mri, possibly with haemorrhagic transformation. diffusion is restricted in the early phase. enhancement occurs at a later stage. human immunodeficiency virus (hiv) infection is a multifocal giant-cell encephalitis eventually leading to a progressive leuco-encephalopathy. on mr atypical focal or diffuse symmetrical signal abnormalities are seen neither with mass-effect nor with enhancement and typically sparing the u-fibers. spectroscopy can show an increase of myo-inositol. progressive multifocal leuco-encephalopathy (pml) is due to reactivation of the jc polyomavirus in immunocompromised patients, 10% of which are hiv positive. on mri "scalloped" multifocal asymmetrical lesions are seen with minimal mass-effect and without enhancement. new treatments of hiv, especially highly active antiretroviral therapy (haart) can lead to a paradoxical worsening of patients due to the immune reconstitution inflammatory syndrome (iris). on mri mass lesions are seen with diffuse patchy enhancement. cerebral toxoplamosis appears as multiple enhancing lesions with marked perilesional oedema. calcification is possible. prion diseases are caused by a proteinaceous infectious particle leading to creutzfeld-jacob disease in humans. diffusion weighted mr-images show high signal intensities in the cortex and the basal ganglia. abnormalities on t2-weighted images and flair occur at a later stage where atrophy is mostly prominent. to learn how to assist clinicians for the diagnosis and differential diagnosis of bacterial and parasitic cns infections. susceptibility effects, increased radiofrequency (rf) field inhomogeneity and more pronounced magnetic shielding effects. in the mean time, many investigators have proposed strategies to optimise imaging protocols and to decrease sar levels and to reduce artefacts including optimised coil and hardware design, in combination with parallel imaging and modulation of refocusing flip angles. many clinical applications in neurology and angiography for high field mri that were recently being investigated showed benefits over 1.5 t. however, as of to date, virtually no prospective comparative studies have been performed and published that could help to estimate whether or not there would be any clinical benefit of 3.0 t msk over 1.5 t. although many authors described the improved snr of msk imaging at 3.0 t allowing for higher spatial resolution this has not been prospectively investigated with comparison to 1.5 t. further studies have to show whether the improvement in speed and resolution will also translate into increased patient throughput and earlier depiction of disease in msk applications at 3.0 t. ultrasound is the best imaging modality for evaluation of acute scrotal conditions. mri is used only rarely, when us findings are equivocal and in cases of suspected infarction. ct is used exceptionally, for example, to detect air in the scrotal wall. high-frequency transducers with modern software like compound imaging and native harmonic, and very good colour sensitivity for low flow in small vessels provide excellent insight into testicular morphology and vascularisation. it is very important to distinguish testicular torsion from the acute inflammation, as it has important therapeutic and even medicolegal consequences. in testicular torsion rapid diagnosis is vital, and salvage rate is directly related to timely operation. torsion is more common in younger patients and orchiepididymitis is more common in adults. infection usually starts at the epididymis and then spreads to testis the patient presenting with an abdominal mass represents a common clinical problem. clearly, the differential diagnosis is large and obviously will depend on the age and sex of the patient as well as location of the mass. of course history and clinical examination are mandatory, but formal diagnosis will usually rest on radiological interpretation. contrast examinations have now been replaced by cross-sectional imaging and endoscopy and it behoves the clinical radiologist to be aware of the advantages and limitations of these methods in order to reach a diagnosis. particular difficulty may be encountered when the mass is so large that it is difficult to determine the organ of origin. the purpose of this interactive case discussion is to explore the relative merits of ultrasound, ct, mr and endoscopy in establishing a diagnosis in two different cases. the cases concerned are: 1. a 21-year-old man who presents with a right iliac fossa mass, but is otherwise asymptomatic. 2. a 54-year-old woman who presents with anaemia and a large upper abdominal mass. active audience participation will be encouraged by means of key pads in order to respond to issues raised during the debate. the most straightforward expectation from 3 t mri scanners is a gain in snr that could be translated in improving spatial resolution and/or reducing imaging time at an at least constant cnr. together with field strength, susceptibility effects, chemical shift and t1 increase and t2 and t2* decrease. also, relaxation properties of contrast agents are modulated. rf power deposition is higher at 3 t and is often a limiting factor in sequence parameter optimisation. hence, the need to optimise mri sequence protocol parameters at 3 t. for cartilage, muscle, synovial fluid and fat, t1 increases by between 14% and 22%, t2 decreases by between 10% and 37% and r1 of gd chelates decrease by 5% to 10% when b0 increases from 1.5 t to 3 t. in most applications reduced t2 and increased t1 work synergistically towards a reduced snr. since the change in relaxation times is not linear for the different tissues, cnr varies with field strength, too. a relatively straight forward approach is to lengthen tr in order to compensate for longer t1 and to shorten te to compensate for shorter t2 (*). in non-fat-sat images bandwidth needs to be increased to control chemical shift effects. because of the better fat and water peak separation, 3 t often helps improve frequency-based fat saturation but may also be greatly impaired by field inhomogeneities in the presence of metallic materials. field strength (b0) and appropriate dedicated multi-element coils are the hardware prerequisites to bring high resolution (hr) isotropic imaging into clinical routine. depending on the age of the child, hip symptoms may predict a variety of diseases. in the infant, developmental dysplasia and infection should be considered. after the age of 4, irritable hip most commonly due to transient synovitis is the commonest disease but infection is the more worrying condition. perthes disease affects some and this condition overlaps into those over 8 who may have a slipped upper femoral epiphysis. fractures and rare cases of osteonecrosis and chondrolysis are a concern in the adolescent. in the young and indeed in most cases, ultrasound provides a useful first line test. aspiration of effusion may be both diagnostic and therapeutic. in the older child and, especially when sufe is a risk, conventional radiographs with an external rotated "frog leg" view is very important. despite the logistics problems in children, there is an important role for mri especially in cases where the initial imaging does not explain the symptoms. i will review the imaging pathways and provide examples of common diseases. i will also discuss how to manage the difficult case and show recent audit data on detection rates and clinical management. fai refers to a conflict between the proximal femur and the acetabulum. both an abnormal shape of the proximal femur (fai of the "cam-type": aspheric femoral head with a laterally increasing radius and/or a waist deficiency of the femoral neck) and the acetabulum (fai of the "pincer-type": acetabular retroversion or a deep acetabulum) or a combination of the two may be present. for a long period the fai may be asymptomatic and the only clinical finding will be an impaired internal rotation of the hip joint. later as the disease progresses, cartilage damage (outside-in abrasion of the acetabular cartilage/cartilage delamination) and labral tears occur. labral tears are most common in the anterosuperior aspect of the acetabulum. a typical labral tear is an incomplete detachment with a tear located at the base of the labrum. anatomic variants such as a sulcus may be present and should be distinguished from tears. a sulcus is common at the junction of the labrum with the transverse ligament and is generally located beyond the equator of the hip joint. insufficiency fractures about the hip commonly occur in the region of the femoral neck. another site vulnerable to overuse is the symphysis pubis. often, a bone marrow oedema pattern around the symphysis pubis is observed. a characteristic finding is the "secondary cleft sign", which reflects a partial tear of the adductor tendon aponeurosis at the symphysis pubis. understanding age-related changes is essential for interpretation of imaging studies. age is a risk factor strongly correlated with osteoarthritis (oa) which is the most common hip joint disease seen in adults. the diagnosis of oa is based on a combination of radiographic findings and characteristic subjective symptoms. the lack of a radiographic consensus definition has resulted in a variation of the that is painful and hypervascularised on colour doppler imaging. in cases of torsion b-mode findings are non-specific, while on colour doppler flow is absent in complete torsion, but may be present and diminished in incomplete torsion, or increased in intermittent torsion. in cases of trauma ultrasound is important to diagnose haematoma, haematocele to evaluate integrity of testis and assess whether the testicular fracture is present or if the surgery is needed in cases of testicular rupture. imaging is helpful in cases of rare causes of the acute scrotum, such as fournier gangrene, testicular appendage torsion, vasculitis, and also in evaluation non-scrotal causes of symptoms, like in cases of renal colic, abdominal inflammatory and traumatic conditions, etc. a scrotal mass is an important clinical problem and a source of anxiety to the patient. radiologists play an important role in the management of these cases, since imaging is required to provide information about precise anatomical location of the lesion, its size and extension and, possibly, to elucidate the nature of the disease. the us and mri findings of the many different scrotal tumours will be presented in this lecture. special attention will be given to two topics. the first are the possibilities offered by imaging to differentiate among the different pathologies, especially to differentiate between benign and malignant lesions. the second will be the problem of the small, non-palpable, indeterminate testicular mass. such lesions have been shown to be relatively frequent. prevalence of malignancy varies widely in the literature, and orchidectomy seems not justified in all cases. the use of contrast-enhanced mri and of advanced us techniques (contrast-enhanced us and elastography) may help to narrow the differential. furthermore, the use of intraoperative us to guide removal of non-palpable testicular nodules can help to perform conservative surgery in lesions with no malignant potential. learning objectives: 1. to understand the typical imaging appearance of benign and malignant scrotal tumours. 2. to review differential diagnosis of intra and extratesticular scrotal tumours and the impact of imaging. c. imaging of the penis m. bertolotto; trieste/it (bertolot@univ.trieste.it) ultrasonography (us) is the first-line imaging modality in patients with penile disease. using high-end equipment after pharmacologically induced erection penile anatomy is well defined and virtually all clinically significant penile vessels can be evaluated in normal and in impotent men. the superior soft-tissue contrast resolution afforded by mr imaging provides an opportunity to advance imaging evaluation of the penis in selected cases. in the clinical practice, erectile dysfunction is the most frequent penile abnormality which is investigated with doppler us. the clinical role of this evaluation, however, reduced after the introduction of oral medications for impotence. differentiation among different forms of erectile dysfunction is mainly based on evaluation of doppler waveform changes in the cavernosal arteries. peyronie's disease is the most frequent cause of penile induration. imaging is often required to evaluate the extension of the plaques, involvement of the penile septum, and relationship between the plaques and penile vasculature. in patients with penile traumas, imaging allows accurate evaluation of albugineal tears, extra-albugineal and cavernosal haematomas, vascular lesions producing high flow priapism and other pathological changes. compared with us, mr imaging has some advantages in identification of small albugineal tears, and is more accurate in identification of urethral or spongiosal involvement. other situations in which penile imaging can be required are circumscribed or diffuse cavernosal fibrosis, tumours, priapism, severe inflammation, and evaluation of postsurgical complications. most of these conditions are first investigated with us; mr imaging is optimal for tumour staging. endocrine tumours of the pancreas are derived form the apud cell system. they often show early clinical sign related to the hormones produced by these tumours. the usually very specific symptoms raise the suspicion of an endocrine tumour of the gastro-entero-pancreactic tract and initiate imaging studies for tumour detection. in this setting usually the pancreas is among the most frequent tumour sites. since endocrine active tumours of the pancreas usually show a strong vascularisation, they can be differentiated from other solid tumours of the pancreas -including adenocarcinoma of the pancreas. metastases in the pancreas are very rare -however, they represent a potential differential diagnosis either for non-functioning neuroendocrine tumours or for adenocarcinoma of the pancreas. since the evaluation of the whole pancreas is crucial, transabdominal ultrasound plays an only limited role for the detection of endocrine pancreatic tumours. usually mri and ct -alone or in combination with specific nuclear medicine tracers in pet -are needed for accurate diagnosis and staging of these tumours. published incidences and prevalence of oa. the progression of oa traditionally has been measured using radiographic joint space width (jsw). weight-bearing radiographs centered on the hip are the most reproducible and reliable ones. the sequence of degeneration includes the following radiographic findings: joint space narrowing, osteophyte formation, subchondral sclerosis, and cyst formation. current definitions of radiological oa based on reduced jsw and osteophytes display predictive validity for clinical hip oa. radiographs are also useful for assessing developmental dysplasia and other congenital disorders which may lead to early oa. there are cases though, that radiographs show minor changes and the clinical suspicion of early disease can be confirmed with more sophisticated imaging methods, such as ct and mri. ct is helpful for additional measurements such as femoral and acetabular abnormal version which might lead to oa. femoroacetabular impingement has been shown to cause labral and chondral lesions and leads to oa. prompt recognition of abnormal head-neck junction on radiographs enables proper conservative or surgical treatment planning. mr arthrography is the method of choice for assessing the labra whereas ct arthrography might be used as an alternative for articular cartilage assessment. cystic tumours of the pancreas include a variety of masses which can be classified into cystic tumours of the exocrine pancreas, cystic tumours of the endocrine pancreas, cystic tumour-like lesions of the exocrine pancreas. in order to simplify the approach only the relatively common cystic tumours -the intrapapillary mucinous tumours (ipmt), the serous cystoadenoma (sc) and the mucinous cystoadenoma (mc) -will be considered. ipmt are characterised by ductal dilatation. imaging characteristics of ipmt are best displayed at mr-cholangiopancreatography. on the basis of the extent, these tumours can be divided into ipmt of the main duct (or central), ipmt of the secondary ducts (or peripheral) and mixed ipmt. central and mixed ipmt have a malignant behaviour and therefore need to be treated surgically, while peripheral ipmt have a benign behaviour and, in general, need only follow-up. sc are characterised by a microcystic architecture in most cases. imaging features are typical in cases of microcystic appearance and consist of small amounts of fluids interspersed within multiple septae of a "sponge like" mass. the differential diagnosis with a mucinous cystoadenoma is difficult in cases with a oligo-macrocystic appearance. mc appears as a uni-oligolocular cystic mass, with a simil-ovaric stroma in the tail of the pancreas. imaging features include a cystic mass with a definite wall and inner septae. when calcifications and enhancing nodules are present, a mucinous cystoadenocarcinoma has to be suspected. therefore, a careful evaluation of imaging features of pancreatic cystic tumours is needed to differentiate benign form malignant masses. learning objectives: 1. to understand the classification and management of cystic pancreatic tumours using rad/path correlation. 2. to learn how to provide a differential diagnosis and how, when and why imaging techniques should be used. 3. to review pathological and imaging findings of intra-ductal cystic tumours. 4. to learn how to deal with the incidental pancreatic cyst. a s71 c b d e f g the evolving role of the radiologist p. brader; vienna/at (peter@brader.md) in the past two decades, enormous strides have been made in medical imaging and many new technologies and agents are now available for breast cancer research, clinical trials and patient care. advances in experimental and clinical breast imaging are likely to improve our knowledge of how breast cancer arises at the cellular level, which will help not only to identify and locate tumours but also to assess the activity of biological processes within these tumours. this recent and concomitant progress, in imaging in general, and in breast imaging in particular, has been facilitated by the convergence of molecular cell biology, pathology, chemistry, physics and engineering in a multimodality and multidisciplinary way. the challenge for radiology is to begin thinking at the molecular level. it is, therefore, important that the next generation of radiologists become more involved in multidisciplinary research and clinical work, and that younger radiologists receive special training in diagnostic imaging and nuclear medicine, as well as a solid understanding of physics, radiochemistry, pathology and biology. applying this approach to breast cancer patients should allow earlier detection, stratification of patients for treatment, and objective evaluation of new therapies. the outcome will be considerably better management and care of those with breast cancer. breast cancer is the leading cause of cancer death among women worldwide. imaging plays a key role in the early detection of breast cancer. mammography is an accepted screening modality with some limitations such as over-treatment. to overcome these limitations research is going on to characterise breast cancer more accurately. currently researchers are working on different strategies spanning the spectrum from tomography-based systems to mri and even molecular imaging. this panel discussion will focus on these different strategies. the auditorium will learn if in 2025 imaging still plays a major role in breast cancer detection or whether a simple blood test will eventually solve the problem. breast cancer is the leading cause of cancer death among women world wide. imaging plays a key role in the early detection of breast cancer. mammography is an accepted screening modality with some limitations such as over treatment. to overcome this limitations, research is going on to characterise breast cancer more accurately. currently researchers are working on different strategies spanning the spectrum from tomography-based systems to mri and even more molecular imaging. this panel discussion will focus on these different strategies. the auditorium will learn if in 2025 imaging still plays a major role in breast cancer detection or a simple blood test will eventually solve the problem. is mammography still an accepted modality for breast cancer imaging in 2025? m.j. yaffe; toronto, on/ca (martin.yaffe@sunnybrook.ca) x-ray mammography is currently the only imaging modality that when used in routine screening has been demonstrated to contribute to reduced mortality in women in the age range 40-74. but, the accuracy of mammography is limited with respect to both sensitivity and specificity. digital mammography has provided increased sensitivity in women with dense breasts and three-dimensional methods such as digital breast tomosynthesis or dedicated breast ct promise to yield further improvement. however, these techniques are dependent on detecting rather gross physical changes as masses, microcalcifications or architectural distortions develop and, therefore, their ultimate potential is limited. it is likely that before 2025, detection tools that are more specifically targeted to molecular characteristics or early functional changes associated with cancer will be clinically available. these may be either in the form of an imaging test, based on a specific biomarker for the cancer or possibly an innocuous test designed to sense a circulating biomarker in the blood or urine. in the latter case, a positive test would be followed by an imaging study to provide localisation for therapy. such tests could not only detect the presence of disease but would also provide prognostic information to guide the type and aggressiveness of therapy so that overtreatment could be avoided. promising imaging techniques based on targeted imaging with ultrasound, x-ray contrast agents, mr and radio-labelled agents are already under investigation. by exploiting new molecular or functional signals one of these is almost certain to replace mammography before 2025. can we assess cell density of tumours with imaging techniques? d.-m. koh; sutton/uk imaging is increasingly used to define endpoints of clinical trials in oncology. tumour cellular density may be inferred by diffusion-weighted mr imaging (dw-mri) and measurement of the t2 relaxation time. dw-mri is unique as the mechanism of contrast is based on differences in the mobility of water between tissues, which can be quantified by the apparent diffusion co-efficient (adc). tumours are frequently more cellular compared with their tissue of origin which impedes water diffusion, resulting in increased conspicuity on dw-mri and lower adc values. studies have shown negative correlations between histopathologically determined cell density and adc in several tumour types, including prostate cancer, soft tissue sarcomas and cerebral tumours. dw-mri is sensitive for tumour detection, especially for disseminated peritoneal disease, liver and bone metastases. whole body dw-mri with background suppression (dwibs) is an emerging technique that has shown substantial promising for staging of lung cancer, prostate cancer, lymphoma and multiple myeloma. effective treatment results in reduction in cell density due to cell lysis, apoptosis and necrosis, leading to a rise in adc value. adc increase has been observed within 30 days of anti-tumour treatment (including chemotherapy and radiotherapy); and as early as one to two weeks after treatment. quantitative adc measurements may also be prognostic as tumours with higher pre-treatment adc have been shown to respond poorer to chemotherapy and radiotherapy. nevertheless, a number of challenges still have to be overcome to qualify adc as a response and prognostic biomarkers in a multi-centre setting across different imaging platforms. angiogenesis is an essential process whereby tumours derive vascular supply from adjacent tissue, to sustain tumour growth and metastatic spread. newer targeted antiangiogenic therapies differ significantly from current cytotoxic therapies for cancer. the methods of dose selection are either invasive, such as biopsy and histology, or time consuming, such as tumour shrinkage and time to disease progression, both of which take months to assess and fraught with other limitations. moreover, cancer is a very variable disease, which means that some patients will respond to a particular therapy while others will not. there is, therefore, a great need to establish surrogate markers for drug response that are both rapid and reliable, not only for clinical trials of new drugs but also to aid in the selection of optimal treatment for individual patients. multiparametric imaging techniques provide a non-invasive insight into tumour cell density, vascularisation, and biochemistry. imaging data have the potential to provide information on disease profiling pertaining to diagnosis, prognosis, selection of therapy, monitoring of response to therapy, and pharmacokinetic information of drugs. undoubtedly, these methods hold great promise, but how can we standardise these techniques, in terms of acquisition parameters and image analysis (post-processing), and validate imaging parameters as biomarkers in multicenter international cancer trials. beginning with a review of the frequently used response evaluation criteria in solid tumours (recist), the development and optimisation of new imaging parameters as biomarkers of treatment response and optimised monitoring of tumour therapy in multicenter eortc clinical trials will be presented. dw-mri is sensitive for tumour detection; adc is affected by the different cellular density of a tumour. still, a number of challenges need to be overcome to qualify adc as a response and prognostic biomarker in a multicenter setting. the large variety in primary tumours and imaging methods, as well as the large variety and continual evolution of imaging equipment, point towards the need for a concerted design of imaging protocols in order to assure that these protocols are applicable to multicenter trials. furthermore, reliable evaluation of imaging data requires imagers experienced in the area of the definite cancer targeted in this trial and in the use of imaging tools for lesion quantification. from this session, a roadmap for future collaboration between eortc and esr combining different imaging modalities will emerge. session objectives: 1. to prove that advanced multiparametric imaging techniques play a crucial role in the diagnosis, staging, treatment monitoring and follow-up of oncological patients. 2. to explore avenues for future collaboration between eortc and ecr. 3. to suggest input of radiologists in the design and implementation of multicenter trials. the eortc imaging group: vision and strategy on cancer imaging s. stroobants; antwerp/be (sigrid.stroobants@ua.ac.be) response to cancer treatment is evaluated by subsequent assessments of target lesions and is defined as a significant decrease in measurable tumour dimensions (who, recist). the new targeted therapeutics which cause cytostasis rather than cytotoxicity have challenged volume-based response criteria and tumour regression is increasingly recognised as an unreliable end point. new imaging modalities looking at tumour biology, like positron emission tomography (pet) or diffusion weighted (dw) and dynamic contrast enhanced (dce) magnetic resonance imaging (mri) or increasingly used to identify subpopulation of patients most likely to respond. recently, new response criteria were introduced that incorporate fdg-pet (recist 1.1 for solid tumours and new cheson criteria for lymphomas). since imaging is becoming increasingly important in novel trial design, the eortc decided to invest in an imaging platform. eortc has established a medical imaging exchange infrastructure allowing to store imaging data linked to the clinical databases. a functional imaging expert group is set up to review protocols, organise central review and develop specific initiatives for imaging biomarker validation. eortc is part of the quicconcept consortium that within the eu innovative medicine initiative (imi) will try to validate the use of novel pet probes and dw-mri as biomarkers for apoptosis and proliferation. functional imaging techniques can only evolve successfully into biomarkers that are clinically valuable and important for drug development, when there is agreement on the standards for measurement and analysis and working groups are set up in collaboration with the different professional organisations (esr, eibir, eanm) to set up imaging guidelines. conditions such as ttts in twin pregnancies and foetal demise. the living foetus can also suffer from abnormal blood supply to the cns, and thus showing small or even large hemispheric infarcts. other diffusion technique, dti is also used to demonstrate the white matter formation of the foetal brain. mrs is also used in the evaluation of the foetal brain. the values of the naa, choline and the existence of lactate are different than the values in the paediatric and adult brain. learning objectives: 1. to explore the new imaging techniques for the study of the foetal brain. 2. to understand the use of diffusion-weighted imaging in the foetal brain. 3. to become familiar with the accurate use of t1-weighted sequences in the foetal brain. 4. to understand the possibilities of tractography in the fetal brain. the paediatric central nervous system is a complex structure undergoing rapid development. as such, there is a rapid, continuous modification of what is "normal" in relation with age and the stage of development. knowledge of the normal patterns of brain development in the clinically relevant ages from 0 to 18 years is necessary to interpret neuroimaging findings correctly. knowledge of embryology and normal variants is also greatly helpful. mr imaging equipment and parameters need to be adjusted and optimisation for paediatric studies. pitfalls often occur from the misunderstanding of normal conditions that are perceived as abnormal based on a comparison with the appearance of the normal brain in adults. this includes, for instance, the evaluation of the brain in the first 2-3 years of life during the course of the process of myelination. a summary of the most frequent conditions that may lead to misinterpretation of findings will be provided here. learning objectives: 1. to understand a different approach to neuroimaging in the developing paediatric brain and spine. 2. to appreciate that, despite the wide and potentially complex spectrum of diseases seen in neuropaediatrics, most interpretations can be made through the thoughtful application of basic neuroradiological analytical techniques. 3. to be aware of certain areas where common pitfalls, myths and misunderstandings occur. the ability to develop more aggressive treatments of acute neurological disorders in children is nowadays improving; however, infants and children are often uncooperative, clinical signs are not always easily localised, and diagnosis and therapy may be both delayed. effective imaging of the central nervous system assumes an increasingly important role in the evaluation of these critically ill children. this lecture will review the main indications to perform a neuroimaging procedure in children with a neurological emergency. with didactic purposes, acute conditions will be classified in traumatic and non-traumatic (ischaemic and haemorrhagic stroke, infection and acute metabolic disorders). differential diagnosis will be discussed based on representative cases selected from the daily routine in a paediatric tertiary hospital. the varied neurological complications that can occur in the child admitted at the intensive care unit will also be presented in a didactic manner, including pres (posterior reversible encephalopathy syndrome), acute liver failure, osmotic demyelination syndrome, hypoglycaemic encephalopathy or induced neurotoxicity. eventually, some peculiarities in oncologic and immunosupressed children, particularly opportunistic infections, will be highlighted. practical algorithms with the preferential use of either ct or mri will be developed for each section. ct continues being the primary modality for trauma, although it should be better used in cases of non-available mri in the other acute conditions to save radiation in children. mr imaging is nowadays better for imaging these children owing to the new techniques that can be used, such as diffusion imaging (di), spectroscopy, arterial spin labelling (asl) or susceptibility-weighted imaging (swi). learning objectives: 1. to learn the characteristic neuroimaging findings that may be useful in establishing differential diagnoses. 2. to understand the various neurological complications that can occur in the intensive care unit and to become familiar with their most typical imaging patterns. 3. to consolidate knowledge of the best neuroimaging protocols for the acutely ill child and establish the main indications for the use of mr imaging, particularly diffusion and spectroscopy. challenges for morphologic imaging in oncology trials: reproducibility and reading f.e. lecouvet; brussels/be (frederic.lecouvet@uclouvain.be) beside clinical endpoints and biological or molecular parameters, beside emerging perfusion or diffusion imaging techniques, morphologic imaging remains the cornerstone of the evaluation of treatment response in the majority of primary or metastatic tumours. the large variety in cancers and imaging methods, as well as the large variety and permanent evolution in imaging equipments, raises the need for a concerted design of imaging protocols to guarantee transposability of these protocols to multiple centers. the reliable evaluation of imaging studies obtained in trials requires readers experienced in the area of the definite cancer targeted in this trial, and in the use of imaging tools for lesion quantification. the imaging group of the eortc targets this optimisation of imaging protocols. first, the different "organ groups" of the eortc will benefit from the availability of expert radiologists in the different fields of oncology, involved in the choice and tuning of adequate and generalisable imaging tools from the beginning of trials design. the design of ct or mri studies should target acquisition parameters transposable in a large number of centers; there is no need for "cutting edge" protocols for a reliable assessment of response in a majority of cancer patients. second, the central review of imaging studies will be possible based on the involvement of expert radiologists, and on a robust imaging platform that guarantees availability, quality control, and "side by side" evaluation of baseline and follow-up examinations. principles and limits of response evaluation by morphologic imaging in oncology will be illustrated. a practical approach to hrct of the chest for diagnosis of diffuse lung diseases includes: recognition of the abnormalities, definition of their distribution within the secondary lobule or the lung, identification of associated findings. when combined with the patient clinical history, these 3 steps allow to shorten the list of differential diagnoses and may sometimes lead to a specific diagnosis. a reticular pattern consists of multiple lines as the result of interlobular septal thickening, intralobular lines or cystic walls of honeycombing. when present as a predominant abnormality, thickening of interlobular septa has a limited differential diagnosis which includes pulmonary oedema/haemorrhage, lymphangitic spread of cancer, sarcoidosis and alveolar proteinosis. honeycombing represents destroyed and fibrotic lung tissue containing numerous cystic airspaces with fibrous walls and is considered a ct feature of established pulmonary fibrosis. when honeycombing is present, uip is likely the histologic pattern and ipf is the most likely diagnosis, in the absence of a known disease. a nodular pattern consists of multiple rounded opacities 2-10 mm in size. the distribution of nodules is the most important factor in making an accurate diagnosis. a centrilobular predominance of nodules that typically spare pleural surfaces is a frequent sign of bronchiolitis and airway disease. a perilymphatic distribution is most frequently seen in patients with sarcoidosis, silicosis and lymphangitic spread of cancer. a random distribution with nodules diffusely and uniformly distributed can be the result of infection, haematogenous metastases and other rare diseases such as langerhans cell histiocytosis. the diffuse interstitial lung diseases (dilds) are a heterogeneous group of disorders which principally affect the lung parenchyma. basic hrct patterns are common to many disease processes and are usually non-specific. however, their distribution and their temporal evolution are often characteristic enough for diagnostic purposes. increased lung opacity: air-space consolidation, by definition, occurs when alveolar air is replaced by fluid, cells, or other material. on hrct, consolidation results in an increase in lung opacity associated with obscuration of underlying vessels. conversely, ground-glass opacity is defined as: "... hazy increased attenuation of lung with preservation of bronchial and vascular margins". the significance of ground-glass opacity depends on the clinical scenario. cysts and decreased lung opacity: a cyst appears as a round parenchymal lucency or low-attenuating area with a well-defined interface with normal lung. lung diseases characterised by cysts include langerhan´s cell histiocytosis, lymphangioleiomyomatosis, lip, postinfectious pneumatoceles, and amyloidosis. recently, lung cysts have been reported in association with extrinsic allergic alveolitis. honeycombing is a process characterised by the presence of cystic spaces.the determination of the presence or absence of honeycombing on hrct in patients with idiopathic interstitial pneumonia is of great importance. honeycombing may have an atypical distribution particularly in asbestosis, sarcoidosis, non-specific interstitial pneumonia (nsip), drug-related fibrosis and hypersensitivity pneumonitis. hrct is now an integral component of the clinical investigation of patients with suspected and established interstitial lung disease. a knowledge of the close relationship between histopathological changes and ct appearances. learning objectives: 1. to understand the different patterns on hrct scans of the chest. 2. to learn about a systematic approach to differential diagnosis of diffuse lung diseases. 3. to review key imaging findings. how do we report ct of the chest? 17:14 the radiology report is often the primary method of communicating imaging findings to the referring physician. practical guidelines on how to report ct scans of the chest for diffuse infiltrative lung diseases will be provided by the panel. emphasis will be placed on both report content and style in order to provide the clinician a tool for good patient care. with the advent of volumetric data acquisition and with increasing knowledge of patho-radiological correlations, hrct has further matured over the last decade and provides the radiologist with an excellent tool for accurately demonstrating gross lung anatomy and precisely analysing abnormal findings. the radiologic diagnosis of many pulmonary abnormalities is based on an assessment of their pattern and distribution. while the pathologist has the advantage of being able to evaluate specimens microscopically, the radiologist is confined to the assessment of more gross disease. however, the radiologist is able to examine the entire lung providing him with information about the distribution of disease and about additional diagnostic clues in mediastinum and pleura. both together, characterisation of the gross findings and knowledge of their distribution represent the key features for arriving at a confident diagnosis. session objectives: 1. to become familiar with the standardized and internationally accepted terminology for describing and analysing hrct findings. 2. to learn how a structured analysis of the predominant pattern and its distribution represent the key for making a specific diagnosis in the best case scenario or to understand how it helps to narrow the differential diagnosis. 3. to promote the understanding how the variability of manifestations of some diseases can cause an overlap of findings being responsible for difficulties the radiologist encounters when categorizing diffuse diseases of the lung parenchyma. a. most radiological reports consist of a ‚descriptive part' in which the radiologist describes the findings and a short ‚conclusion part' containing the interpretation of what is seen. both parts are filled with ‚jargon'. some terms are typical radiological ‚language' while others refer to terminology also used by clinicians and pathologists. some terms are purely descriptive but others may contain already some interpretation of what is seen and hence narrow the differential diagnosis. the meaning of a term may also change over time. it is very important that both radiologists and the readers of their reports speak the same language and know and understand the meaning and full content of each term. this is especially important when radiological findings in patients with diffuse lung diseases are described and interpreted. diagnosis of diffuse lung disease is indeed largely based on the recognition and description of the appearance pattern of the disease because this often allows developing an appropriate list of differential diagnosis. members of the fleischner society have introduced a glossary of terms for thoracic imaging. this presentation will emphasise on the importance of such a glossary for both describing and interpreting chest images. special attention will be given to the terms used to describe the different patterns in diffuse lung diseases: (1) reticular and short linear opacities, (2) nodular opacities, (3) increased lung opacity and (4) cysts and decreased lung opacity. a s75 c b d e f g h the purpose is to describe ethical dilemmas related to the use of radiation in finnish radiographer's work in diagnostic imaging. the data were collected during the spring and summer of 2008, and it consisted of thematic interviews of diagnostic radiographers (n=8) whose working experience varied from 4 to 31 years. the data were analysed by the method of data-oriented qualitative inductive content analysis. ethical dilemmas related to the use of radiation were found to concern justification and optimisation principles, which were found to be inadequately implemented by radiographers. the background factors of these dilemmas were found to be both dependent on and independent of the employee, resulting in worsened well-being at work and in seeking for change. the current processing methods of dilemmas were found to be insufficient, and suggestions for better processing methods were made. the results suggest that there may be shortcomings in radiographers' knowledge of radiation usage. attitudinal problems within the work community seem to maintain ethical shortcomings. instead of ethically inadequate routines and passing the baton to other professionals, radiographers should be encouraged in committing themselves into responsibility and safety culture. respondents repeatedly described powerlessness and inability to intervene in ethical problems. the common cold is one of the most frequent illnesses in europe and the united states. although most cold are mild and resolve within a short time period, colds cost billions of dollars per year, mostly due to lost time at work and school. the common cold is a group of symptoms caused by one of a large number of viruses. rhinoviruses cause the greatest number of colds; there are more than 100 different varieties of rhinovirus. the average adult experiences two to three colds per year, while children average 8-12 colds per year. in most cases, colds do not cause serious illness. most colds last for 3-7 days, although many people continue to have symptoms (coughing, sneezing and congestion) for up to 2 weeks. some viruses that cause the common cold can also depress the immune system or cause swelling in the lining of the nose or airways; this can lead to bacterial infection. one of the more common complications is sinusitis, which is usually caused by viruses and rarely (about 2% of the time) by bacteria. however, it can be difficult to distinguish bacterial sinusitis from sinusitis caused by a cold because the signs and symptoms can be similar. however, due to the fact that a runny nose can also result from inflammation, trauma, foreign body and other abnormal processes, including tumours, an excellent diagnostic workup is necessary. the purpose is to examine the relationship between man and technology within radiography without considering man and technology as separate entities. the study is designed as an observational study which took place in a danish radiological department. it involved 20 examinations followed up by three semi-structured interviews. through emergent narratives radiographers construct a practice in which the relationship between man and technology is marked by a struggle of domination of one over the other. the struggle expresses itself through two competing plots: a diagnostic plot with a prevailing, but not merely chronological structure mostly composed of events tied to pathology. the life story, in opposition, plots the examination as a significant experience in the patient's life, transforming it into events stretching towards a future yet unknown. most often the radiographers contributed to the domination of man over technology through active engagement of their narrative alertness. errors and failure to keep the time schedule can, however, lead the radiographers to a change of perspective that makes them displace man from the scene of radiography by playing on the premises of technology. in several stories technology can be labelled ‚setting' while the patient plays the main role. the radiographers act with the patient as point of origin, but they reason with technological arguments. hence, the human aspects of radiography constitutes an underground practice, which is not explicitly articulated valuable. this creates a field of tension between man and technology, with risk of technological dominance. the private life of everyone of us as well as the everyday practice of our profession is deeply embedded in ethical/deontological aspects which play a critical role into: our profession, the relationship with our patients, with our colleagues, with the health care team we work with, and with ourselves. the radiographer's everyday practice has to take this aspects into account. ethics finds its origins in the fusion of three different sources, as if it were a compromise between: the species we belong to, the society we live in, and ourselves. yet, we are not obliged to abide to these three elements. it is through our actions that we decide how to behave in certain situations. and this is the reason why every single action towards the others gathers importance, the simple rites when individuals meet play a pivotal role in the creation of a relationship with the others. shaking hands, greeting and using polite forms of speech, all these actions are ethically important, they allow us to catch the benevolence of our interlocutor and to discourage any possible hostility. what would happen if our professional identity were perceived and acknowledged through the way we can interact and relate to others? in this case, the work no longer ennobles the man, but it is the man, through his actions, who ennobles his profession. behaving ethically towards one's own profession, towards the others and towards ourselves, is it, or could this be the common ground of european professional ethics? whenever a diagnostic x-ray examination of a pregnant patient is considered to be necessary, conceptus dose estimation is an important step in assessing the risks to the unborn child. accurate estimation of conceptus dose is also needed after inadvertent irradiation of a pregnant patient from a diagnostic x-ray procedure. several methods have been developed to estimate conceptus dose from radiologic examinations. when the uterus is remote from the directly exposed tissues, the conceptus is exposed to scattered radiation and its dose is negligible (< 1 mgy). examinations involving the abdomen-pelvis may deliver higher dose to the child. variations in maternal body size and uterus position should be taken into account to obtain accurate conceptus dose estimation. multidetector ct (mdct) scanners have replaced conventional ct technology. conceptus doses from abdominal mdct range from about 13 to about 31 mgy during the first post-conception weeks for a scan acquired at 120 kvp, 200 mas with a pitch of 1.0, depending on maternal body size and uterine position. multi-phase abdominal ct examinations may deliver relatively high doses to the unborn child. doses to the conceptus below 100 mgy should not be considered a reason for termination of pregnancy. the risk to the embryo/foetus for stochastic effects is assessed on the basis of dose using appropriate risk factors. although these risks from a single diagnostic procedure are low for the majority of diagnostic x-ray examinations, it is important to ensure that doses are kept as low as reasonably achievable. learning objectives: 1. to learn how to manage and counsel pregnant patients in case of (a) intentional and (b) accidental exposure. 2. to learn how to estimate conceptus radiation dose from diagnostic x-ray examinations. 3. to learn how to assess the radiogenic risks to the embryo/foetus from diagnostic x-ray examinations. epithelial cells. the mucociliary transport drains each sinus in a specific pattern through its ostium to the nasal cavity and ensures a constant flow of mucus containing bacteria and particulate matter. functional endoscopic sinus surgery (fess) aims to enlarge the preformed ostia to allow physiologic drainage. preoperatively, anatomic variants have to be ruled out or shown by ct to avoid injury. special emphasis lies on the ostiomeatal unit, a complex anatomic region at crossroads of mucociliary drainage from frontal, anterior ethmoid and maxillary sinuses (uncinate process, haller, agger and frontoethmoidal cells, inverse turbinate). description of the level of the cribriforme plate in relation to the roof of the ethmoid is another key element in a report to avoid skull base injury (keros i-iii). preoperative identification of variations in the location of the optic nerve and the cavernous portion of the internal carotid artery is also mandatory. furthermore, the close proximity of the sinuses to neighbouring structures and their thin bony walls predispose to certain pathways of spread. runny and stuffy noses may be due to a long list of pathologic conditions, which require distinct imaging strategies and treatment options. acute rhinosinusitis, for example, is normally managed by gps without any imaging study. occasionally, signs and symptoms suggest orbital or intracranial complications: in such cases msct allows a prompt diagnosis and is preferred to mri for wider availability and faster acquisition. persistence of signs/symptoms for longer than 12 weeks classifies rhinosinusitis as chronic (crs); the condition may or may not be associated with the presence of nasal polyps. in patients affected by crs cross-sectional imaging aims at precisely depicting bone structures and air conduits. in detail, imaging shows the anatomic arrangement of sinus drainage pathways and their patency, maps anatomic variants that may facilitate crs or increase surgical risk, depicts bone changes induced by crs or by the mechanical pressure exerted by polyps. these tasks are better accomplished by ct, even more so after the advent of multislice technology allowed multiplanar reconstructions along oblique planes. after surgery, imaging is required when signs/symptoms recur -to asses presence and extension of crs or nasal polyps -or when late complications are suspected -such as mucosal synechiae impairing mucus drainage or mucocele. mri plays a limited role in sinusitis because it fails to demonstrate thin bone structures; nonetheless, its use is advocated in aggressive inflammatory diseases (such as invasive mycoses and wegener's granulomatosis) to demonstrate the involvement of deep spaces of the face and of the skull base. sinonasal tumours are rare and comprise only 1% of all malignancies. the clinical and radiological challenge is to differentiate malignancy from benign or inflammatory changes. most malignant tumours present at advanced stages. malignant tumours are most common in the 5 th -7 th decades and have a male preponderance. squamous cell carcinomas are the most prevalent (80%) followed by adenocarcinomas. squamous cell carcinomas are most common in the maxillary sinus, next the nasal cavity and ethmoid sinuses, while adenocarcinomas are most often seen in the ethmoid sinuses, and commonly caused by occupational exposures, e.g. nickel and hardwood workers. inverting papilloma is one of the most common benign tumours and have been associated with human papillomavirus. ct should be the first modality in paranasal sinus imaging, while complementary mri before and after gadolinium i.v. is mandatory to differentiate tumour from inflammatory disease. a general rule is that tumours more often have unilateral extension and that malignant tumours usually erode the bone. however, malignancy may mimic benign tumours with thickening or remodelling of the adjacent bone. while ct is superior to demonstrate changes in the bone, mri can differentiate tumour from inflammatory changes and demonstrate tumour invasion and perineural spread. malignant tumours are: squamous cell carcinoma, adenocarcinoma, adenoid a s77 c b d e f g h b. x-ray imaging and pregnancy: justification and optimisation of exposure p. vock; berne/ch (peter.vock@insel.ch) as outside pregnancy, justification and optimisation are the main steps to be done when an imaging examination using ionising radiation is considered during pregnancy. however, the risk concerns the embryo/foetus in addition to the mother which means that justification has to be more critical whenever the uterine dose is not neglectable. the practical approach to an examination in any woman of child-bearing age starts by ruling out pregnancy, whether by taking history or by a laboratory test. when pregnancy cannot be ruled out, further steps will depend on the type of examination needed and the urgency of diagnostic clarification. ultrasound is the alternative to be preferred when it can answer the clinical question. but even among x-ray examinations, the uterine dose is varying widely which asks for a careful selection, optimisation and, maybe, for postponing the test. once pregnancy is confirmed, the major question is whether the specific type of diagnostic examination will include the uterus in the primary radiation field. examinations not involving the uterus by direct radiation -despite a potentially significant exposure by scattered radiation -can usually be performed without a relevant risk to the embryo/ foetus. the situation is more critical when the uterus is within the examination field and when therapeutic interventions are considered. the presentation will discuss the practical approach to these different situations, the influence of the stage of pregnancy, optimisation methods and the choice between alternative methods in some frequent clinical situations. this paper explores the risks to the foetus when magnetic resonance imaging (mri) is used. mri uses three main components to produce images from inside the body: a static magnetic field; a pulsed radio-frequency (rf) fields and time-varying gradient electromagnetic fields. the exact frequencies of these fields depend on the mri system purchased, for example; a 0.5t scanner uses 21 mhz rf, a 1.5 t system uses 63 mhz and a 3 t system uses 127 mhz rf. there is also a wide range of options for gradient strengths and slew rates to be considered as well. the overall exposure for the foetus depends ultimately on the imaging sequence used and the area being scanned. this paper will discuss particular hazards that need to be addressed for pregnant women including biological effects of the static and time-varying magnetic fields, heating effects of the rf pulses and acoustic noise generated by the spatial encoding gradients. the circumstances for foetal exposure in mri will also be discussed including the following situations: the patient may not be aware that she is pregnant, likely to be in the first trimester; the mother is referred for direct foetal imaging after ultrasound (normally second or third trimester); the expectant mother may need diagnosis; research on pregnant volunteers. the exposure for pregnant staff working in mri is also an essential consideration. finally, how to minimise the exposure for the foetus during mr imaging will be discussed. a b c d e f g h in terms of cerebral perfusion (rcbf, rcbv, mtt and ttp) and cell metabolism (cytotoxic versus vasogenic oedema, diffusion restriction). the fundamental goals of stroke imaging in the acute phase are: 1. to rule out intracranial haemorrhage, and other non-stroke causes of the patient's symptoms; 2. to show occlusion of a major blood vessel, e.g. by ct or mr angiography; 3. to demonstrate ischaemic brain tissue (cytotoxic oedema), e.g. by diffusion-weighted mri; 4. to reveal tissue blood flow and to identify areas of salvageable brain tissue ("penumbra"), e.g. by perfusion ct or mri; 5. to select candidates for thrombolytic therapy within the critical 3 to 6 hour time window. the purpose of this presentation is to review how new developments in neuroimaging improve our understanding of the pathophysiology of acute stroke and to demonstrate that multiparametric techniques now play a crucial role in the rapid diagnosis, clinical management, therapy and outcome prediction of patients with an acute stroke. organisation is crucial to the practice of dethrombosis. the first step is to grasp the fact that ischaemic stroke is an emergency. stroke victims require an organisation similar to that provided for heart attack patients. patients must be taken to hospital in an ambulance manned by a specifically trained crew. ideally equipped with a mini ct scanner recently made available. this device provides an immediate morphological scan and ct angiogram to be sent by satellite to the reference hospital so that the problem will be clear and the medical team ready on the patient's arrival. clinical and neurological assessment of the patient must be undertaken immediately along the lines of uk practice implementing a simple, clear and rapid procedure. if the clinical, ct and ct angiography findings indicate intra-arterial treatment, responsibility shifts to the neuroradiology team, organised to work a 24 hour shift, at the hospital or at least on call. dedicated imaging systems must be available: a multi-layer ct device (ct angiography and perfusion studies). dedicated angiography suite is essential. a flat panel system would be ideal. there is growing evidence supporting the availability of an mr system. this device would certainly enhance the possibilities of a stroke unit but it is not essential in the initial stages. a stroke unit should be based on a dedicated facility, with emergency access separate from the general emergency room, dedicated equipment, dedicated ambulances and appropriate links including a dedicated ward and a rehabilitation unit essential to the success of the project. learning objectives: 1. to learn about the benefits and risks in stroke intervention. 2. to consolidate knowledge of different methods of intervention in stroke therapy. 3. to learn about the different imaging methods used to decide on and perform stroke intervention. where do we stand in stroke therapy today? 09:44 stroke is a common health problem with high socio-economic costs. in recent years much effort has been focused on finding ways to ensure early intervention as well as new methods not only for early detection but for early treatment. the discussion will focus on where we stand today and whether we think stroke imaging and treatment will advance further. during the last decade imaging of stroke has developed from a minor field dealing with a barely treatable disease to one of the most dynamic parts of neuroradiology. the routinely treatment with intra-venous thrombolysis within the 4.5 hour time window and the continuously expanding treatment of severe strokes with intra-arterial thrombectomy have lead to increasing requests from clinicians and interventional neuroradiologists to provide imaging information for treatment guidance. all radiologists involved in the management of stroke are facing mainly three demands: first, to have good knowledge of the causes and the pathophysiology of ischaemic stroke and a proper understanding of the current models for infarct development, as a prerequisite for rational decision making and efficient communication with the clinicians. second, to be able to choose and to use appropriate imaging modalities for the acute work up of patients with stroke and to be aware of the benefits and drawbacks of ct and mri. finally, is good knowledge about the therapy options mandatory in order to be able to support the clinicians in the time critical treatment decision. this session will try to cover these three demands in order to give an overview on the current status and the opportunity to discus future perspectives. a. aetiology and pathophysiology of stroke r. von kummer; dresden/de (ruediger.vonkummer@uniklinikum-dresden.de) "stroke" is the commonly used diagnosis for disturbances of brain blood supply due to ischaemia, haemorrhage, or venous obstruction. it is evident that "disturbances of blood supply" in stroke patients do not represent a useful concept in order to develop effective treatment. it is the radiologist's task to describe the acute brain pathology, its conditions (pathophysiology), and its aetiology to give directions for specific treatment and prophylaxis. the approach is vascular and brain tissue imaging. brain ischaemia is the cause of stroke in about 85% of patients, intracranial haemorrhage in 15% of patients. arterial obstruction causing brain ischaemia is thrombotic or embolic. it can as well be caused by arterial wall dissection or inflammation. arterial wall diseases and heart diseases including a patent foramen ovale are sources for brain embolism. the obstruction of a brain supplying artery causes brain tissue ischaemia of various degrees depending on the capacity of collaterals supplying the same arterial territory. the chances for collateral compensation depend on the site of obstruction and the development of collateral vessels. neurons cannot tolerate low cerebral blood flow (cbf) below 10 ml/100 g x min for more than 20 minutes and develop first cellular then irreversible ionic oedema. they survive, but do not function with low cbf between 10 and 20 ml/100 g x min. enhancement of cbf in such regions, e.g. by arterial recanalisation can mean functional recovery. the imaging diagnosis of damaged brain is therefore the first aim in acute ischaemic stroke patients. focal liver lesions are part of our everyday practice because radiologists performing various types of examinations may encounter them without being aware of any clinical condition rising the suspicion of these changes. in a situation like this several important decisions are to be made by the radiologists, like: is the lesion clinically significant, is the lesion benign or malignant, are additional imaging examinations necessary, does it require medical, surgical or interventional radiological action, should it be, and if yes, how frequently followed up, etc. for providing a well-established answer to these questions the reporting radiologist has to be familiar with medical history and results of former examinations (physical, laboratory, imaging, etc.); consider the age, gender, physical condition, eating and drinking habits, potential drug abuse of the patient; bearing in mind the prevalence and statistical probabilities of different pathologic conditions. with all this information at hand the thorough analysis of images obtained by different modalities will allow a rather reliable differential diagnosis and a well-established planning of therapy of the incidentally detected lesions. learning objectives: to learn more about the clinical conditions that may result in the appearance of focal liver lesions. 2. to be informed about the clinician's way of thinking in the process of differential diagnosis. the spectrum of differential diagnoses is broad in the liver. therefore, incidentally discovered liver lesions represent a challenging clinical situation. fortunately, there are specific imaging features for the most common benign and malignant liver lesions (such as, e.g. hemangioma, fnh, cysts, vascular pseudolesions, hcc and metastases) so that a minimal-invasive diagnosis with a biopsy is not needed in a lot of cases. in ultrasound, the echogenity and recently also the contrast agent behaviour are used for liver lesions characterisation. in ct, attenuation and also contrast agent behaviour are used for characterisation. mr imaging offers several options including t1-and t2-weighted images, use of chemical shift imaging, gre sequences with long echos and diffusion weighted images, so that tissue components such as fat, water, glycogen, iron, etc. can be evaluated already in the pre-contrast examination. beside the evaluation of dynamic signal characteristics in the early dynamic phase after contrast agent application, mr can utilize also tissue-specific contrast agents dedicated to the res or to the hepatocytes. other modalities such as angiography, pet or other nuclear medicine methods usually only play a minor role nowadays in the evaluation of incidental liver lesions in nononcological patients. in oncological patients the clinical consequences and also the range of diagnoses and pre-test probabilities are different from the non-oncological group; therefore, the demands to imaging are even higher. in case of atypical presentation of otherwise benign liver lesions such as sclerosed hemangioma close follow-up or even biopsy can be necessary in such a setting. thyroid nodules are common. in 4-8% of adults nodules can be palpated and at ultrasonographic examination nodules are seen in 10-41%. most nodules are benign, the eventual diagnosis in patients with a palpable nodule is carcinoma in only 5% of cases. the incidence of thyroid carcinoma is low. papillary carcinoma is the most common type and is found in 75-80% of thyroid cancer. lymph node metastases in thyroid carcinoma are primary to the paratracheal and prelaryngeal nodes (level vi), and the upper (level iii) and lower (level iv) jugular nodes. malignancy should be suspected when there is rapid growth, a firm or fixated mass, when enlarged lymph nodes are present or in case of vocal cord paralysis. in patients with multiple thyroid nodules the cancer risk per patient is not altered. ultrasound is the primary imaging technique in patients with a palpable thyroid nodule. it is best performed with the patient supine, the neck slightly extended and using a high frequency linear-array transducer. several ultrasonographic features are more often associated with benign or malignant nodules. however, while some ultrasonographic features may strongly suggest malignancy it may be very difficult to rule out malignancy by means of these features alone. ultrasound-guided fine needle biopsy can be performed in an attempt to differentiate between benign and malignant nodules. unfortunately, even with ultrasound guidance, an important number of cytological examinations will be non-diagnostic. in addition, in follicular lesions it is usually impossible to differentiate cytologically between benign and malignant follicular nodules. learning objectives: 1. to learn about the optimal settings for us examination of the thyroid. the neck is host to a large variety of benign and malignant diseases ranging from simple cysts to acute inflammation with complications to highly malignant sarcomas and imaging plays an important role to assess the nature and the extention of disease. patient history and clinical findings will decide which imaging technique is best suited to resolve the diagnostic dilemma. ultrasound is recommended to differentiate between a cystic or solid lesion, to guide fna, being quick and accurate. pathologic flow within or around a lesion can be assessed adding doppler technique. in acute illnesses with anticipated complications, such as a deep neck abscess, contrast-enhanced ct is required to evaluate local extention and demonstrate spread from the neck deep to the mediastinum. mri is indicated to assess non-inflammatory, subacute or chronic diseases, such as vascular malformations, branchial cleft cysts, benign and malignant soft tissue tumours, brachial plexus pathology and neurologic diseases. vascular malformations are easily depicted with mri using t2 sequences in different image planes. persistent fistulas of the branchial system can also be depicted by mri running from the anterior border of the sternocleidomastoid muscle to the lateral pharyngeal wall. assessing the origin of a soft tissue tumour has major implications for surgery. staging a malignant soft tissue tumour must comprise the skull base and upper mediastinum including local extention, pathologic neck nodes and perineural spread. follow-up during chemotherapy and postoperative monitoring of malignant disease are important indications for (mr) imaging, the more so in young patients, diminishing ionising radiation. learning objectives: 1. to identify different compartments in the neck. 2. to be able to choose the optimal imaging technique relating to request. 3. to become familiar with the most common pathology in adults and children. 4. to be able to address a short list of differential diagnoses. patients (92%) and by ultrasound in 95 patients (93%). the activity of the disease was assessed correctly in 91% patients by ultrasound, compared to 74% patients by enteroclysis. there was no statistically significant difference. bowel us is a useful investigation for the diagnosis and follow-up of patients with crohn´s disease. learning objectives: 1. to learn about us techniques used in the assessment of patients with inflammatory bowel disease. 2. to learn tips for interpretation of us in the diagnosis and follow-up of patients with inflammatory bowel disease. 3. to understand the pros and cons of using us, including ceus, in the diagnosis and follow-up of patients with inflammatory bowel disease, including assessment of disease activity. 4. to appreciate the accuracy, reproducibility and usefulness of us compared with other imaging techniques in assessing patients with inflammatory bowel disease. a-304 08:58 the use of computed tomography (ct) in the diagnostic imaging of patients affected by inflammatory bowel disease (ibd) has a long standing history. ct techniques such as ct-enteroclysis and ct-enterography have been reported as efficient tools for a radiological assessment of disease. the state-of-the art methods will be reported and their potentialities in diagnostic accuracy discussed in different clinical type of ibd. the acute setting of unknown ibd could be demanded as well to ct examination performed in emergency without endoluminal contrast medium administration. the ct appearance of the intestinal wall of the segments involved by an active disease could be not correctly interpreted if the knowledge of basic and classic typical findings of ibd is not combined to consider different pathologic entities that could affect the intestine, offering similar but not even equal signs. the entire abdominal background needs to be evaluated according to the clinical symptoms, signs, laboratory parameters and history of the patient. ct examination could be an efficient tool to determine the degree of disease activity in patient with known ibd as well as to assess the presence of an acute inflammatory disease of the intestine in patients with unknown ibd affection. the actual role of ct in the early diagnosis of ibd, in disease staging and detection of complications as well as monitoring therapy in follow-up will also be considered and discussed. learning objectives: 1. to learn about state-of-the-art ct techniques for the assessment of patients with inflammatory bowel disease. 2. to learn tips for interpretation in terms of diagnosis and differential diagnosis of inflammatory bowel disease. 3. to discuss the value of ct in determining disease activity and monitoring therapy. the aim of this lecture is to give an overview of the techniques and typical findings for imaging crohn's disease (cd) with either multidetector row computed tomography (mdct) or with magnetic resonance imaging (mri) and compare the two different modalities. optimal imaging of cd begins with the preparation phase. the small bowel has to be distended for a concise examination. this can be done either invasively, i.e. enteroclysis or orally, which is named enterography. there is much debate on which of these two preparation methods is better. for the administered intraluminal contrast, best is water with some additives, which are neutral in ct and biphasic in mr. imaging in mdct is done 40 sec and 70 sec after iv administration of iodinated contrast with a thin collimation. all image data are reconstructed in axial, coronal and sagittal planes. the aim of imaging in cd should be to establish the following: (1) presence, severity, and extent of the disease; (2) its activity; and 3) extra-intestinal complications. both modalities have proven to be a good tool to evaluate the extent, the activity of the disease and the presence of extraluminal complications. both are also able to identify the type of the disease, being either the active/inflammatory, the fistulising/perforating, the fibrostenosing or the reparative/regenerative type. the challenge for mri is mostly the in-plane resolution of the image data whereas radiation dose is for ct. incidental lesions are frequently discovered during routine radiographic evaluations. correlation with clinical history and additional confirmatory imaging is essential to the development of an accurate, focused differential diagnosis and for appropriate management. the objective of this presentation is to describe the imaging findings associated with incidentally found liver lesions and to review those clinical and radiologic features, which should be considered in development of an ordered and accurate differential diagnosis. learning objectives: 1. to introduce typical cases illustrating the role of imaging modalities in the differential diagnosis of unexpected liver lesion cases. 2. to motivate the audience by the use of voting pads to be involved in the diagnostic process. 3. to highlight the conclusion that may be drawn on the basis of the discussed cases. the diagnosis of ibd is based on complex evaluation of clinical signs, endoscopic appearance, radiological imaging, laboratory tests and histology. besides crohn's disease (cd) and ulcerative colitis (uc) the modern classification advises to use the term ibdu (ibd unclassified) colitis to those 10% of cases, where the distinction between cd and uc is impossible based on the results of multiple exams. these cases are usually clinically more severe, with humbler therapeutic results. the new classification of cd types includes besides the phenotype (b1: inflammatory non stenosing non penetrating, b2: stenosing, b3: penetrating) the age (a1: ≤16 y, a2: 17-40 y, a3: > 40 y) the location (l1: ileum, l2: colon, l3: ileocolic, l4: upper gi tract) and p perianal involvement. in uc the most important clinical factors are extent, type and severity. the classification includes length and clinical types as acute, relapse-remission and chronic continuum. the radiological imaging in cd is needed for lesions not reachable by the endoscope, for categorising, for follow-up and detecting complications. different modalities fit best for these different tasks. the goal of imaging in uc is rather to help differential diagnosis and detection of complications. while in uc there are good correlation between laboratory and endoscopic signs of activity and severity so there is not much need for radiological activity indices, in cd the clinical activity does not correlate with the histological changes. although cdai is widely used for clinical studies, it includes several subjective factors, thus radiological activity indices may be of help. crohn's disease is more likely a systemic disease governed by a shift in the immune response, thus affecting the whole malt system. bowel ultrasound is a quick, simple and effective investigation. the method is simple and requires no bowel preparation. we use both -convex (c 5-1 -overview, anatomical orientation) as well as linear transducer (l 12-5 -preferred, incl. ceus, l 17-5 -children and very slim patients, l 9-3 -tdps, deep structures). we examine patients in supine position, first small bowel, than mesentery and large bowel. finally, we examine the terminal ileum and cecum or the areas of anastomoses. we assess folds, hastrum, wall thickness, vascularity, echogenity of the surrounding fat, the presence of nodes and peristalsis. in some cases we use intravenous contrast (ceus). at least four studies have prospectively compared the diagnostic accuracy of us with radiological studies, endoscopy or surgery in those with suspected crohn's disease. in these studies, the sensitivity of us ranged between 84% and 90% and its specificity reached 98% and 100%. in our prospective study we investigated patients by ultrasound and enteroclysis. we established the diagnosis by enteroclysis in 94 the central venous vasculature and particularly the upper venous system may be obstructed by either benign or malignant lesions. malignant central venous obstructions are mainly due to bronchial carcinoma, mediastinal metastasis, mesothelioma or lymphoma. the most common cause for benign central venous obstruction is haemodialysis related; other benign reasons are rather uncommon but increasing due to the omnipresent use of permanent central venous access catheters as well as implantable cardiac rhythm management devices. the incidence of haemodialysis-related central venous obstruction resulting in angioplasty is described to be more than 10 times higher compared to, for example, pace-makerinduced stenosis. in any case, early detection and treatment of complications are essential to provide adequate care. contrast venography for many years has been the standard of reference; yet this procedure has its shortcomings. sonography is not consistently reliable for detection of central pathologies, owing to difficult access to these vessels. today contrast enhanced ct is employed to define the site of the obstruction and the presence of possible thrombosis and reveal surrounding soft tissue alterations. mri is of comparative or even higher sensitivity and specificity in evaluating the patency of the central veins. the efficacy and safety of stent placement in central venous occlusion of benign and malignant origin lead to rapid relief. stenting provides fast symptomatic help. repetitive percutaneous intervention can prolong the cumulative patency. thrombolysis may be required to improve the final result, should, however, not be employed as a sole means for revascularisation. us and mr are excellent imaging techniques for studying tendons and muscles. during this integrated session we will review the advantages and disadvantages of us and mr for the diagnosis and follow-up of sports injuries. tricks of both techniques will be addressed, together with some useful guidelines for specific sports injuries. ultrasound is being used at the pitch side and in sports medicine practice as an adjunct to clinical practice. with this in mind there are a number of questions that will be answered in these talks. 1. when us and mri are the primary imaging and when they are complimentary. 2. what advances have there been in us and mri imaging to help advance our use of these techniques in tendon and muscle injury. 3. should we be aspirating haematomas and using autologous blood injections or prp to treat tendon or muscle disease. 4. can we predict the athletes return to sport? a-310 08:35 muscle imaging is inherently complex and presents unique morphologic challenges and continuing integration of dynamic, physiologic and functional capabilities. in sports medicine, ultrasound (us) has proved to be an excellent tool to evaluate muscle strain and contusion injuries in athletes providing good correlation with clinical findings. in the acute phase, us has nearly equal sensitivity to mr imaging to diagnose muscle strains, except in the first few hours after the injury, when fresh haemorrhage and oedema have similar echogenicity to normal muscle and strains may go unnoticed. later in the process, us has been shown to be a useful tool in assessing the sequential stages of muscle repair, showing progressive resolution of blood fluid products, decrease in oedema and formation of scar tissue, thus aiding rehabilitation planning. dynamic us during muscle contraction can be valu-3. to compare the diagnostic accuracy of ct versus mri in crohn's disease. 4. to learn about a strategy for the use of ct and mri in the radiological workup of patients with inflammatory bowel disease. five good reasons for the radiologist to be at the forefront 09:44 the chairman and speakers will debate the optimum imaging paradigms according to (1) the clinical indication, (2) assessment of those with suspected but as-yetundiagnosed disease, (3) staging of the small bowel in those with newly diagnosed crohn disease, (4) evaluation of response to therapy and (5) assessment of those with long standing disease. the optimum approach to assessing and monitoring disease activity will be discussed. deep vein thrombosis (dvt) is a common condition which can lead to possible lifethreatening pulmonary embolism (pe). the primary imaging modality nowadays is duplex ultrasound. in cases where the pelvic veins and/or the vena cava is involved, a venous-phase ct is helpful to determine the exact extend of the clot burden. standard therapy for dvt is anticoagulation. however, if there is a contraindication or a complication (bleeding) to anticoagulation a vena cava filter is a good option to prevent pe. a filter should also be considered if a catheter directed thrombolysis is performed. with the new optional filters the filtration can be terminated either by removing the filter or by converting the filter into a stent. one problem which was observed with these optional filters is that (too) many of them are left in place. despite a low complication rate of filters, a filter may cause an increased risk of further dvt, or a caval occlusion and in rare cases even a migration or penetration is possible. therefore, patients with optional filters should be followed and filters should be retrieved when clinically no longer needed. varicose veins are an early manifestation of venous insufficiency of the lower limbs which can also lead to skin changes including extensive ulceration. it is a very common problem affecting up to 30% of adults in europe. patients presenting with venous insufficiency must first be assessed by a history and clinical examination to determine the presence and extent of the disease. a duplex ultrasound examination is essential to determine the cause from which an appropriate treatment plan can be decided. depending on the patients wishes and their funding options it is perfectly reasonable to treat all stages of the disease even if just cosmetic. treatment aims to eliminate the reflux in all contributing veins starting proximally and moving distally. surgery used to be the commonest treatment offered to patients but this has been largely superceded by endovenous methods which have significant advantages including: no general anaesthesia, outpatient based, no cuts, no scars, low recurrence, rapid convalesence. there are several endovenous methods using laser, rf, foam sclerotherapy and most recently steam heating and a combined mechanical/sclerosant system (clarivein (r)). laser and rf give almost identical results and 95% permanent truncal vein closure is to be expected. foam sclerotherapy is cheaper and quicker but long-term results are poorer and patients often have to return for repeat procedures. having ablated the main truncal veins using laser or rf at least 50% of patients require additional treatments for residual varicosities, e.g. microavulsions or foam sclerotherapy. adenocarcinoma is the most common pancreatic malignancy, affecting the head in 60-70%. mdct is very effective in detection and staging of adenocarcinoma, with a sensitivity of up to 90% for detection and accuracy of 80-90% for staging, but it has limitations (detection of small cancers, characterisation). mri is a problem-solving tool in equivocal ct to depict small cancers. mri with mrcp helps to differentiate between adenocarcinoma and focal pancreatitis. the "duct penetrating sign" at mrcp is indicative of an inflammatory mass. examination protocols for mdct include oral administration of 1-1.5 l of water ("hydro-ct"), iv contrast administration of 2 ml/kg b.w. (app. 140-150 ml), a flow rate of 4-5 ml/s, and a biphasic scan in parenchyma and venous phases. mri protocol should include non-fatsat and fat-sat t1w gre, t2w tse, dwi, mrcp, and contrast-enhanced sequences. gadoliniumenhanced t1w 3d-gre are helpful for assessment of vessel infiltration and cystic tumours, whereas mangafodipir-enhanced sequences improve delineation of small tumours. in patients with locally advanced tumours, neoadjuvant chemoradiation may be used for tumour downsizing to make it amenable to radical surgery. however, pancreatic cancer often does not shrink after tumour response, which renders mdct or mri unreliable for tumour assessment in this setting. pet/ct may play a role in this indication. in conclusion, ce hydro-mdct is an excellent and robust tool for pancreatic cancer detection and staging. mdct in combination with mri or eus provides high accuracy for characterisation of tumours. further improvement is needed to assess tumour response after neoadjuvant chemoradiation. ct is the established imaging technique for evaluation of pancreatic adenocarcinoma. mri, however, can play a major role in this disease. technical advances of mri including parallel imaging techniques, multichannel receive coils of the abdomen, dynamic gadolinium-enhanced t1-weighted fat sat 3d gre sequences, 3d mrcp sequences, mangafodipir-enhanced mri and diffusion weighted imaging (dwi) have greatly improved the results of mri in the assessment of pancreatic tumours. standard imaging sequences include t1-weighted gre with fat saturation, in-phase and opposed phased t1-weighted, axial single-shot turbo spin-echo (tse) and coronal/oblique 2d and/or 3d mr cholangio-pancreatography (mrcp) pulse sequences, post-gadolinium-enhanced 3d t1-weighted fat sat sequence and dwi with multiple b values. mr imaging may be useful as subsequent examination for: (1) detection of small non-contour-deforming tumours with isoattenuated appearance at ct, (2) evaluation of local extension and vascular encasement, (3) detection of the presence of lymph node and peritoneal metastases, and (4) detection and characterisation of associated liver lesions and liver metastases. diffusion-weighted imaging may be helpful as a complementary imaging method in the differentiation between mass-forming focal pancreatitis and pancreatic adenocarcinoma. due to its superior soft-tissue contrast compared with ct, mri ap-able to monitor the healing process. local complications, such as vein thrombosis, irritation of adjacent neurovascular bundles, chronic haematoma and myositic ossificans can be demonstrated with this technique as well. however, us tends to underestimate the extent of injury and the abnormalities seen disappear more quickly when compared with mr imaging. at least in elite athletes, mr imaging seems, therefore, to play a more significant role in management of muscle injury, particularly when decisions regarding the time at which the patient can return to play are needed. by contrast, us is more accessible, and cheaper than mr imaging. in most clinical settings, us should be regarded as the first-line imaging choice for assessing skeletal muscle injury. learning objectives: 1. to understand the mechanism of injury of muscles in athletes. sports activity can affect tendons due to chronic overuse or acute injury. both can result in complete tendon rupture. us is helpful in precise assessment of rupture severity and extend, but enables alsofor assessment of tendon degeneration, where rupture of individual collagen fibres stimulates a chronic cycle of reparative response caused due to repetitive microtrauma. in chronic tendinopathy histopathological changes, such as hypoxic, mucoid, calcifying, or lipoid degenerations are present. us enables for differentiation of partial tears, tendinosis, tenosynovitis or paratendinosis, because of active and passive dynamic examination possibilities, and high-resolution capability when using high frequency probes. us developments as power doppler us, sonoelastography and contrast enhanced us allow further for new insights into tendinopathy. with the use of us, tendon changes can be diagnosed before they become symptomatic and a reduction of tendon load and initiation of treatment before the condition becomes chronic seem to gain important place in therapeutic regimes. furthermore, us-guided therapies are advisable over blinded-guided injections to minimise side effects and to allow an accurate targeted therapeutic approach. although diagnosis of acute muscle injuries in athletes is usually clinical, magnetic resonance imaging (mri) is a very helpful adjunct tool in this setting, showing the location, extent and severity of the injury and thereby streamlining the management of the patient. portability of ultrasonography (us) on the playfield in the acute setting is not matched by mri, which nevertheless has distinct patterns of grade 1-3 muscle strains; however, it is usually with nonacute and deeper injuries of the muscles that mri is especially helpful. presence of bone contusion, stress reaction, or stress fracture is readily displayed by mri and this is practically beyond the limits of us. evolving haematomas, fibrosis, scarring, and myositis ossificans are sequelae of direct or indirect muscle injury which are usually outlined in a single field of view by mri. delayed onset muscle soreness and chronic exertional compartment syndrome, as well as acute and chronic stages of muscle denervation changes, are readily diagnosed with mri. by providing an understanding of distinct muscular denervation changes, mri may actually noninvasively point to the entrapped or involved nerve and guide medical or surgical intervention. foci of mucoid degeneration within the muscle, myotendinous junction, or tendon itself are readily shown by mri, which thereby displays potential sites of failure during sport activities. diffusion tensor imaging may have a role in displaying the subtle architectural disruptions of directly or indirectly injured muscles. learning objectives: 1. to understand the specific role of mri in the evaluation of muscle and tendon injuries in athletes. 2. to recognise imaging patterns of tendon abnormalities in athletes: acute and over-use injuries. 3. to review different mechanisms of muscle injuries: direct and indirect. 4. to understand how mri might be used in the management of athletes. when a defect occurs in the bowel wall, air will appear within the peritoneal cavity, most frequently due to perforated peptic ulcer and perforated sigmoid diverticulitis. in most perforating gastrointestinal conditions however, the -imminent-perforation is walled-off by neighbouring bowel loops, mesentery and especially by the omentum, nick-named "policeman of the belly". if this walling-off process occurs timely and effectively, no or only minimal free air will appear. the most important causes of walled-off gastrointestinal perforation are appendicitis, peptic ulcer disease, sigmoid diverticulitis, bowel malignancy, crohn disease and -often underdiagnosed-accidently ingested sharp foreign bodies, as toothpicks, fish bones, chicken bones, etc. the extent to which the perforation is walled-off, determines the eventual course of the disease. the us hallmark of -imminent-perforation is inflamed fat around the involved bowel structure. inflamed fat on us corresponds to what is often called "dirty fat" on ct scan: hypodense fat is interspersed with hyperdense streaks. this represents oedema or cellular infiltration of the fatty mesentery and omentum, which have migrated towards the site of the imminent perforation in an attempt to seal it off. on us inflamed fat is recognised as hyperechoic, non-compressible fatty tissue often interspersed with hypoechoic streaks. if fluid collections occur within the inflamed fat, this implies abscess formation. inflamed fat is an important and valuable sign in perforating gastrointestinal conditions. if found in the absence of bowel pathology, the diagnosis is usually epiploic appendagitis or omental infarction. mdct is an extremely powerful tool when the search for a gi perforation is required. the high spatial and contrast resolutions make mdct the most accurate imaging method to identify even small amount of free intraperitoneal air. there is general consensus about the acquisition of a contrast-enhanced scan acquired during the portal venous phase of enhancement (delay of around 60-70 sec). controversies are still present in the literature about the utility of a pre-contrast scan as well as the need for a preliminary administration of an oral soluble iodinated cm or for an enema or gaseous distention of the distal gi tract. image reviewing needs the use of a workstation because multiplanar reformations have been demonstrated to improve the detection of small amount of free air. an appropriate window setting is mandatory and it makes mdct 100% accurate for identification of free air and almost 90% accurate in the identification of the precise site of perforation. the aim of the examination is not only to assess the presence of free air but also to detect the site of perforation: this is an extremely useful clinical information especially if surgeons decide to perform a laparoscopic repair. several ct signs have been described, able to guide the diagnosis and to differentiate between a perforation originating in the upper gi tract (stomach and duodenum), in the small bowel or in the colon. evidence-based radiology' (ebr) is based on best current evidence, traditionally acquired radiological expertise, the alara principle and the values of referring doctors and patients. any appropriately trained radiologist can formulate an answerable question, search the literature, appraise the retrieved evidence, apply their findings to local practice and evaluate the results. this presentation will describe and illustrate the 'ebr' process. patients with chronic pancreatitis (cp) may present with features resembling pancreatic carcinoma, for which cp is a risk factor with an incidence of 5.9% after 20 yrs. ebr methods were applied to the problem of differentiating mass-forming cp from pancreatic adenocarcinoma. a focused question and literature search found no secondary literature or imaging guidelines. primary literature searching found 53 relevant papers, 9 comprised current best evidence. for ct, time-attenuation curve characteristics had a sensitivity of 94% and a specificity of 83% for carcinoma. for mr, dynamic time intensity curve characteristics were only reported in a descriptive study but the duct penetrating sign (mrcp) had a sensitivity of 85% and a specificity of 96%. for pet/ct, 18 f-fdg had a sensitivity for carcinoma between 86% and 96% with specificity of 87%-100%. for eus/fna, the sensitivity for carcinoma in pre-existing cp was consistently low (54-74%), but the specificity was 100%. simple bayesian analysis was used to establish the best order in which to apply these studies in practice. an algorithmic approach will be presented. the presentation will also consider other 'grey areas' in the field of pancreatic adenocarcinoma imaging using ebr methods. learning objectives: 1. to learn about evidence-based methods of literature searching and appraisal. 2. to understand how these methods can be used to produce diagnostic algorithms using the differentiation of pancreatic adenocarcinoma from mass-forming chronic pancreatitis as an example. 3. to learn about diagnostic algorithms based on different clinical scenarios (local and distant staging, advance versus early disease) involving multiple imaging techniques. 08:30 -10:00 room f1 the hole in the guts in recent years, continuing trends in radiology have diminished the importance of plain films of the abdomen significantly. ultrasonography and mdct are applied with enormous success to the investigation of many abdominal conditions in the emergency setting. in the eyes of the radiologist, plain films, therefore, seem irrelevant in the presence of such powerful imaging procedures. surprisingly, referring physicians, mostly surgeons, gastroenterologists and urologists, still request plain films although the potential of mdct is obvious to them as well. in their perception, the plain film is either a definitive examination before initiation of treatment (e.g. stone at the ureteropelvic junction in us proven hydronephrosis) or a preliminary study prior to mdct or surgery (exclusion of pneumoperitoneum or ileus). in the present climate of cost and radiation consciousness this trend may continue. moreover, many surgeons, gastroenterologists, urologists, etc. have greater skills in reading plain films than in understanding mdct. therefore, the radiologist should poration. all these techniques remain investigational at this time for the treatment of breast cancer. the limitations of and challenges associated with each ablation technique and the issues raised by early pilot studies, which have so far prevented these techniques from replacing standard surgical techniques, will be discussed. in the elderly the co-existence of several diseases, the prevalence of involutional and degenerative aspects, together with physical and cognitive problems represent 'the norm'. it is therefore important to know how to distinguish the healthy elderly from those in need of treatment to avoid overdiagnosis and overtreatment. so the question is how to be aware of the potential and limits of diagnostic imaging and its applications in geriatric patients. brain development occurs rapidly during the last trimester of pregnancy and continues at a rapid pace in the first two years of life. more subtle maturation, for example in the white mater, occurs well into the third decade of life, as evidenced by diffusion tensor imaging (dti). evidence of brain degeneration is occurring soon afterwards and includes mild brain volume los, reductions in white mater integrity on dti, widening of virchow-robin spaces and accumulation of incidental white matter lesions (wml). severe wml and incidental cerebral microbleeds (mbs) are associated with know cardiovascular risk factors and while the concurrent impact may be subtle in terms of cognition, they carry a poor prognosis in the long run. the same is true for silent cerebral infarcts, which increase the risk of dementia. neurodegenerative (general brain volume loss, ventricular dilatation and hippocampal atrophy) changes also occur well before the onset of clinical signs of dementia. in genetically predisposed subjects (e.g. apoe4 carriers) abnormal (compensatory) brain activity on functional mri and increased (compensatory) cerebral metabolism on fdg-pet have been observed that predict subsequent cognitive decline. more recently, pet studies employing amyloid tracers have shown abnormal binding in a significant proportion of cognitively elderly, suggesting that these subjects are at risk to develop alzheimer's disease -the pace of which is currently undetermined. the objective of percutaneous needle biopsy of the breast is to obtain an accurate preoperative diagnosis with a low upgrade rate post-surgery. indications arise in both symptomatic and screen-detected lesions. a range of biopsy needle designs are available and their selection depends on being aware of the range of needle design types, their advantages and limitations. cutting needles, guns, vacuum systems and mr compatible devices will be discussed. guidance technique for ultrasound, x-ray stereotaxis and mr-guided procedures is extremely important, beginning with patient positioning and anaesthesia prior to commencing the procedure. accurate needle placement under direct vision using high frequency ultrasound probes, x-ray stereotaxis with digital systems and mr guided -with the option of using a cad system for distance calculation -will be presented. typical imaging signs and potential pitfalls of each technique, both anatomical and technical, will be highlighted. methods to increase accuracy including the use of meticulous technique, adequate sampling and correlation of specimen pathology with imaging findings at multidisciplinary meetings are essential. there is always the possibility of a false negative biopsy results in any type of percutaneous image-guided needle biopsy (fnac, core biopsy, vacuum-assisted biopsy). the risk depends upon the quality of the harvested cytologic or histologic material. the quality is closely related to the amount of material collected and the accurate targeting of a lesion. some lesions are at a higher risk of underestimation (sizes < 5 mm, architectural distortions, microcalcifications, stellate lesions) than others (i.e. focal lesions). the false-negative rates for microcalfications using vacuum-assisted biopsy were reported to be 1.2%, for mass lesions 0.8%. using ultrasound-guided 14 g-core needle biopsy the false-negative rates were reported to be in the range of 2.5%. radiologic-histologic correlation plays a key role in the definite and correct judgement of the diagnostic result. in case of imaging-histologic discordance re-biopsy, possibly using larger needle diameters, or even open biopsy should be considered. the european guidelines for quality assurance of breast cancer screening and diagnosis define outcome parameter for breast biopsies. guidelines from the european society of breast imaging published in 2007 define the standards and skills necessary to perform these procedures. documentation standards should be used (b1-b5) to allow continuous yearly evaluation of the individual institution results and quality improvement. the aim of any needle biopsy is to get as much, i.e. representative material as possible. nevertheless, a certain amount of underestimation, caused by lesion type (adh, dcis, lin, papilloma, for example) will remain and has to be reflected. the presentation will discuss the role of large vessel arteritis within the spectrum of thoracic vascular diseases. it will detail the pathological entities and their morphological, functional, and clinical characteristics. it will present typical ct and mri findings and discuss key elements to the differential diagnosis. it will finally discuss the clinical relevance of this diseases, with a special emphasis on overall evolving importance of thoracic vascular disorders. severe haemoptysis can occur in about 5% of patients. it is associated with high mortality due to asphyxiation, if not treated, and needs urgent and comprehensive evaluation of the lung parenchyma, airways, and thoracic vasculature. multidetector row ct angiography is a very useful noninvasive imaging modality for initial assessment of haemoptysis in stable patients. it can accurately identify the source and the most common predisposing causes of haemoptysis (bronchiectasis, chronic bronchitis, lung malignancy, tuberculosis and fungal infection) and the effects of haemorrhage on the lungs and airways. moreover, the combined use of thin-section axial and complex reformatted images allows clear depiction of the origins and trajectories of abnormally dilated systemic arteries that may be responsible for the bleeding in over 90% of cases requiring intervention with arterial embolisation or surgery. nonbronchial arteries may also represent an important cause of haemoptysis. the road maps of dilated bronchial and nonbronchial arteries provided by ct angiography represent a useful guide for endovascular treatment. ct angiography is a quick and noninvasive tool that is helpful in the diagnosis and management of haemoptysis. disorders that affect the elderly population. some misleading radiological presentations typically occurring in this population will be also presented. in the elderly the coexistence of several diseases, the prevalence of involutional and degenerative aspects, together with physical and cognitive problems represent 'the norm'. it is therefore important to know how to distinguish the healthy elderly from those in need of treatment to avoid overdiagnosis and overtreatment. so the question is how to be aware of the potential and limits of diagnostic imaging and its applications in geriatric patients. fast development in the area of imagining modalities demands a lot of work in dose and image quality optimisation and management. deterministic harms have been reported both in interventional and diagnostic radiology. there are also some special groups (e.g. children) which need a lot of attention and especially tight indications for x-ray examinations. radiation dose and image quality optimisation can be applied with small steps in everyday clinical work as a part of self assessment, if the safety culture is agreed by all professionals. the vendors put the settings high in order to reach the best image quality. after installation the settings must be re-evaluated before starting clinical use of the equipment. also, the sensitivity of aec (automatic exposure control) must be turned according the detector. using the air gap (30 cm) instead of grid, e.g. in hip axio-lateral project or scoliosis, dose decrease can be even two thirds. the role of radiographer is expanding to new areas. quality assurance and dose and image optimisation could be parts of the expanded role. the new technical solutions in imaging offer a lot of possibilities for dose reduction, if we want, but there is also danger of dose creeping if the doses are not followed up frequently. the management and legislation offer the basics but the work must be done among those who are working in radiological departments. commitment to the safety culture on all levels in medical radiation offers better care and procedures with lower doses to the patients. radiological procedures are performed because of medical benefits to patients, but they also cause some harm because of the dose. if medical benefit overweighs detriment the procedure is justified. the purpose of the optimisation is then to adjust the procedure in a way to maximise the ratio of benefit over harm. question is who is responsible to do it and how it can be done. who should participate: we believe there is a major role of radiographer as she/he is present at each and every radiological procedure performed. but it is absolutely mandatory for them to understand benefits of the procedure and understand harm (dose). radiographer's position is the connection between radiologist, medical physicist and vendor's engineers. radiologists usually do not have in depth knowledge of technology and dose and physicists and engineers on the other hand do not understand in depth the medical aspects of procedure. radiographers must also understand operational possibilities of every x-ray machine. to get to know them they should be there at the acceptance of the x-ray machine and talk to service engineers and applicators. they should also talk to physicist when he/she is doing tests. and finally simulation of procedure(s) using different phantoms is the best way to understand how machine parameters are affecting image quality and dose. in presentation, some examples for different modalities will be given. learning objectives: to gain knowledge about how to start with optimisation of radiological procedures. 2. to understand the basics of quality control (qa) for radiographic modalities and how to use experience acquired from qa in daily work. 3. to become familiar with guidelines and applications for good radiological practice and how to implement them in the optimisation process. 4. to consolidate knowledge of technology of radiographic modalities and the use of materials in daily practice according to guidelines, and to be familiar with the radiographers responsibility in the field of radiation protection. the availability of magnetic resonance (mr) scanners operating at 7 t and above has already proved beneficial for mr imaging and spectroscopy of the human brain and promises similar benefits in the human body. these advantages result from the increases with the magnetic field of the intrinsic signal-to-noise ratio, blood oxygenation level dependent (bold) contrast, which forms the basis of the vast majority of functional mr imaging (mri) experiments, and chemical shift dispersion. these gains can be exploited in improving the spatial and/or temporal resolution of anatomical and functional mri experiments and in increasing the spectral resolution in volume selective spectroscopy or chemical shift imaging. operation at the increased magnetic field also offers easier access to t 2 * -contrast and improved implementation of susceptibility-weighted imaging (swi) in which the phase of gradient echo images provides information about local variation of magnetic susceptibility. in the brain, such variation appears to be dominated by differences in iron concentration and myelin content, so that high-field swi may provide useful information about the progression of neurodegenerative disease. the elevated t 1 relaxation times at 7 t also offer benefits for arterial spin labelling and time of flight angiography. current and potential future applications of high-field mri in clinical and pre-clinical studies in a number of areas and will be discussed in this presentation, along with the barriers to wider usage of 7 t systems for clinical studies. the purpose is to present and discuss the role of imaging in non-traumatic acute abdomen, with particular focus on ultrasound (us). the neonatal gi tract emergencies, associated with specific disorders and imaging strategies, are excluded. acute abdomen in children refers to a wide variety of conditions ranging from benign disorders, such as gastroenteritis, to threatening disease, such as midgut volvulus or intussusception. the recognition of a surgical emergency requires usually, after a competent clinical evaluation, an imaging investigation in order to avoid negative or unnecessary surgery. abdominal plain film is known as poorly sensitive in most situations, except bowel occlusion. ultrasound requires experience and a thorough examination but has demonstrated a high sensitivity and specificity for diagnosing bowel obstruction, midgut volvulus, intussusception, acute appendicitis, over the recent years the clinical mri field strengths have gradually been increased to 3 tesla; however, whole body mri systems with higher fields of up to 9.4 tesla have become available in experimental settings. compared to clinical field strengths, mri at very high magnetic fields has several advantages but also some unique challenges. with increasing field strength the signal-to-noise ratio increases, which can be used to either increase the spatial resolution in the images, or to acquire the images more rapidly. unfortunately, the energy deposited in the human body via the rf excitation scales quadratically with the field strength. thus, the specific absorption rate (sar) is a critical factor in all rapid imaging protocols, and requires the design of rf pulses with low sar, (e.g. verse pulses). inhomogeneities of the rf field which are induced by standing wave phenomena have to be compensated, and make the design of efficient spin echo pulse sequences very difficult. at higher field also the field inhomogeneities become larger and stronger imaging gradients are required to overcome the susceptibility-induced image distortion. stronger gradient systems are difficult to manufacture, and the usable gradient slew rate is limited by peripheral nerve stimulation thresholds. furthermore, stronger and faster gradients become very loud at high fields, and special measures for sound protection are required. despite these limitations, high-field mri offers image with very high resolution, it provides unique contrasts, a better spectral separation of the resonance lines and high signal for non-proton applications. clinical mri usually aims to depict anatomic regions of interest with uniform coverage and contrast behaviour. to this end it is essential to use suitably homogeneous radiofrequency (rf) magnetic fields for spin excitation, refocusing, and saturation. traditionally, such uniform transmit fields are generated by volume resonators based on quasi-stationary electrodynamics, which, however, gradually cease to apply as clinical mri explores high field strengths of 3 t and beyond. the concomitant increase in operating frequency entails shorter rf wavelength and increasing tissue interactions, which render the tailoring of rf fields substantially more complex and patient-dependent. one promising response to this challenge is to depart from volume resonators and perform rf transmission by multiple, individually fed transmitter elements. with such transmit arrays the effective rf field can be tailored on a per-patient and per-scan basis by adjusting the relative magnitude and phase of driving the elements (rf shimming). in advanced imple-08:30 -10:00 room z neural stem cells are in the process of finding their translation into the clinic. however, it is well-known that the cells by themselves do not regrow lost tissue. to this end, neural stem cells need further support and guidance. tissue engineering is using biomaterials to provide a structural support for cells, but can also incorporate the release of factors that guide the fate of transplanted cells. ideally, an in vivo imaging approach would encompass all these processes. we here demonstratethe use of a 19 f mri contrast agent to detect clinical-grade human neural stem cells non-invasively over 7 days within a tissue cavity formed by stroke. to provide structural support for these transplanted cells within the tissue cavity, cells were mixed with an engineered de-cellularisedextracellular matrix (ecm). using diffusion mri, we were able to detect the presence of the ecm within the stroke cavity. this approach hence provides a novel approach as to how we can study transplanted cells and tissue regeneration in vivo by mri. our lab has been among the first to exploit dendritic cell (dc) therapy to treat melanoma patients. over the past years, immunological responses are increasingly reported and clinical responses have consistently been observed. moreover, dc therapy often has much milder side effects than standard chemotherapy. a key hurdle in the development of the dc therapy is accurate delivery of the cells to lymph nodes (lns), or their successful migration from the site of injection to lns. in particular, tools for measuring cell migration in vivo are necessary. ideally, we would be able to quantify the number of dcs at the relevant site, with high resolution anatomical context to allow differentiation of lns and the possibility of longitudinal data acquisition. furthermore, functional data on the ensuing immune response is also required. towards these ends, we have been working on developing imaging techniques to study dcs in vivo, for example with scintigraphy on 111 in-labeled dcs, and magnetic resonance imaging (mri) on iron-labelled dcs. scintigraphy is quantitative, but it is restricted to the relatively short half-life of the radioisotope and is unable to resolve individual lns. mri allows high resolution anatomic localisation, but the use of contrast agents such as iron oxide is not quantitative. our recent work has focused on imaging the functionality of these dcs using positron emission tomography (pet) to study ln activation. finally, we have also developed in vitro assays that closely mimic in vivo dc migration in 3d scaffolds imaged using quantitative 19 f mri, as a substitute for in vivo optimization. we plan on applying 19 f mri to the tracking of dcs in vivo, as the technique allows both quantification and high-resolution anatomic detail. hypertrophic pyloric stenosis, etc. it enables some differential diagnosis such as infectious ileocolitis, ischaemic colitis, henoch schonlein purpura, complicated meckel diverticulum or duplication, etc. or even pyelonephritis. it can provide some findings suggesting mesenteric adenolymphitis, viral gastroenteritis, etc. the us findings will be described as well as the potentialities and limitations of us in each of these conditions. the accurate knowledge of the clinical findings together with the results of us will guide the need for another imaging modality: enhanced ct in case of suspected appendicitis with inconclusive us, upper gi series in an infant with bilious vomiting and impossibility to display the mesenteric vessels, etc. at last, some aspects of pancreatic and biliary tract emergencies will be shown. the purpose is to discuss the role of emergency imaging in acute paediatric gu conditions, with particular focus on the potential of ultrasound (us). besides gu tract trauma conditions such as urosepsis, renal failure, renal colics, ovarian or testicular torsion with all the respective relevant differential diagnoses have to be considered and urgently addressed adequately. particularly with respect to radiation protection (alara-principle) and due to the superb us potential in childhood, us is often used as the primary imaging tool. in many conditions us will reveal all treatment relevant information and no additional imaging is necessary in the acute setting. however, in other conditions such as severe (multiple) trauma ct remains the best primary imaging tool, however, only by using age-adapted ct protocols. the work-up and follow-up may also require imaging, usually achievable by us and partially by mri, scintigraphy and/or cystography. all these lead to imaging algorithms that differ from adults. the most important conditions, their imaging appearance, the potential pitfalls and some important methodical details will be presented, also discussing the recommended dedicated paediatric imaging algorithms. in most paediatric acute gu conditions us is adequate as the first and often sufficient imaging modality. rarely other imaging is necessary particularly in the acute setting -except for ct in severe (multiple) trauma. all imaging should be indicated with respect to therapeutic consequences and the alara principle, and proper paediatric protocols as well as methododical skills (e.g., dedicated paediatric us) should be provided 24 hours throughout the year. learning objectives: 1. to learn about the diagnostic imaging approach in acute urinary tract disease. computed tomography (ct) is the imaging method of choice in the evaluation of abdominal injury after blunt trauma in haemodynamically stable children. an unstable patient needs to be stabilised prior to ct or to proceed directly to surgery. evaluation with ct allows for accurate detection and quantification of injury to solid and hollow viscera, and can also identifies an active haemorrhage. ct can help prioritise optimal management by diagnosing the major or most life-threatening site of haemorrhage or injury. ct can also demonstrate associated bony injury to ribs, spine, and pelvis. a normal ct examination may prevent other unnecessary explorations. the decision for operative intervention in the small percentage of children who require surgical haemostasis is primary made based on clinical criteria and not on ct findings. interventional techniques deeply changed approach to treatment of diseases. in each country, interventional radiology practice establishment varies according to local factors, but following a standard strategy seems better to set up this facility. according to above-mentioned points, i decided to establish this specialty in our hospital since 1996 as the pioneer center in interventional radiology iran. at first the procedures included percutaneous laser disc decompensation (pldd), and vertebroplasty followed by vascular procedures such as uae in later years. now, we are performing all interventional procedures in our country including aortic stent and all neurointervention procedures. the following items will be discussed: 1. prepare step by step strategies for establishing intervention. 2. solving issues regarding interventions procedures. 3. modified techniques for lowering costs to cover interventions in poor people. 4. setting of fellowship courses. 5. co-operation with dedicated and pioneer international centers such as using neocrylate for treatment of brain aneurysms in conjunction with ucsd for the first time on human. when presenting our experience we want to review how we should start interventional radiology in developing countries. fibroids are the most common benign tumours of the uterus during female reproductive age. uterine artery embolisation (uae) is a procedure in which using embolic particles (pva, gelfoam, etc.) we block blood supply to uterine fibroids. it has been reported as a relatively safe, effective, and durable nonsurgical alternative method diminishing fibroid-related symptoms. uae is typically performed in both uterine arteries by an experienced interventional radiologist. after uae, reduction in menorrhagia has been reported as 80-93% and the mean decrease in fibroid size varies from 50% to 78% in the literature. complications including amenorrhoea are frequency ranging from 1% to 7% in the literature. uae may be followed by menopause in 1% of the cases. nevertheless, it is usually encountered in women in their late 40s. it seems that the future of uae depends on optimal selection of patients based on the prediction of volume-shrinkage, the outcome of fertility, and the long-term efficacy. although pregnancy is possible after embolisation, neither fertility preservation nor its improvement can be definitely guaranteed. women who desire to become pregnant should definitely be cautioned about potential complications during pregnancy. in this presentation we are going to review the position of uae in iran and to present our experience about the efficacy, and safety of uae. besides, we will discuss some methods of dose reduction during uae and the effects of uae on fertility and pregnancy outcome. purpose: labelling pancreatic islets (pi) with superparamagnetic markers enables their detection as hypointense spots on magnetic resonance (mr) images. we tracked pi transplanted into the liver and quantified their signal loss in liver tissue using mr imaging over a six-month period. methods and materials: pi were labelled with ferucarbotran 5 μl/ml for 6-44 hours and transplanted into the portal vein in 8 c-peptide negative recipients (12 infusions). the liver was examined prior to transplantation and subsequently 1 day and 1, 2, 4 and 24 weeks after transplantation using a 3 t mr scanner. results: in all recipients significant c-peptide levels and near-normal hba1c values were achieved with 50-80% insulin dose reduction. no side-effects related to the labelling procedure were documented. a significant decrease in the number of islet spots was detected at 1 week post-transplantation (on average 60%) with a subsequent only slight decrease for up to 24 weeks. in two subjects with a labelling period of less than 6 and 10 hours respectively only a few islet spots were detected corresponding to poor islet visualization in phantoms labelled for the same period of time. conclusion: pi visualization was successful in all recipients but was less efficient if the labelling period was less than 16 hours. a significant decrease in islet spots occurred at 1 week post-transplantation suggesting early islet destruction or impaired engraftment. then, the decrease in islet spot numbers slowed and islets were still detected at 24 weeks post-transplantation. data shows that mr detection of ferucarbotran-labelled islets correlates with sustained c-peptide production. areolar complex), the presence of other imaging findings (extension to the skin, inflammatory cancers) and the status of regional lymph nodes. this information influences the type of treatment given to the patient and it is very important to gather as much information as possible in order to obtain a one-step surgical excision with free margins at pathology. on the basis of this information and on discussions held in multidisciplinary meetings, markers will be placed wherever needed in order to locate the exact distribution of the tumour(s). the different parts of a structured report (clinical data relevant to the report, technical description of the diagnostic or the interventional modality, pitfalls during the exam, description of breast composition, description of lesions, categories and overall assessment) should always be included in order to guarantee that all the important information is there. breast imaging, like other subspecialties in radiology, is a multimodality area of knowledge where it is vital to integrate the information obtained through diagnostic and interventional procedures in order to supply the clinician with a body of data that is useful and straightforward. liver metastases are of the most difficult therapeutic challenges in oncologic managements. surgery is frequently impossible due to disease extent and systemic chemotherapy usually fails. in other body parts, the combination of radiotherapy and systemic chemotherapy is used for several types of malignancies. we successfully adopted a novel image-guided form of this combination for such masses referred to as radiochemoembolisation, which substantially intensifies the treatment locally. patients underwent transarterial radiochemoembolisation with chemotherapy protocol of mitomycin, doxorubicin, and cisplatin and embolisation with radioisotope particles of 32 p. the effectiveness of method was determined by comparing contrast-enhanced ct images, pre-and post-intervention. treatment response was evaluated using recist criteria. we also used some arbitrary criteria such as tumoural mean density and enhancement pattern. for stable and partial-response cases, the procedure was repeated. we did not repeat the treatment for progressive diseases. complete-response cases were only followed. after completing treatment sessions, regardless of the tumour source, considerable amount of patients showed substantial response. in terms of recist criteria, a significant portion of patients gained at least a "partial response". but the decrease in tumour density and the appearance of non-enhancing tissues were more promising. radiochemoembolisation is an effective method for the treatment of patients with unresectable hepatic metastases. although this study lacks a control group, it shows the effectiveness of the treatment. literature review showed the response to treatment with regard to recist criteria had been better in our study comparing with studies only used chemoembolisation or radioembolisation. , which showed the superiority of digital mammography for younger and perimenopausal women, as well as those with dense breasts; the national ct colonography trial (nctct), demonstrating the equivalence of ctc with colonoscopy; and the national lung screening trial (nlst) which has preliminarily reported a 20% decrease in lung cancer-specific mortality associated with annual ct screening. acrin's current focuses include the assessment of emerging imaging biomarkers for the prediction of and monitoring of response to treatment and the extension of its activities to disease processes beyond cancer. according to the second approach, termed as ‚dark lumen mrc', dense barium or tapped water is used to distend the colon in conjunction with post-gadolinium 3d gradient echo with fat-saturation sequences. the colonic wall and the corresponding polyps exhibit high signal intensity as a result of gadolinium uptake while the colonic lumen presents with low signal intensity. mr imaging of the pancreas and bile ducts relies upon a combination of t2-w and t1-w strategies in order to safely acquire anatomic, cross-sectional and functional information. tissue-imaging strategies include free breathing t2-w imaging (obtained with echo-train spin-echo sequences with or without fat saturation) and breath-hold 3d-gradient echo t1-w imaging (obtained with fat saturation) without gadolinium and in the capillary phase and in the interstitial phase post-gadolinium. this combination is valuable in the assessment of the full spectrum of pancreatic diseases and malignant bile duct obstruction. hardware improvements (gradients) and the advent of more sophisticated phased-array coils and parallel imaging capabilities in modern mr scanners allowed to increase the spatial and temporal resolution of "conventional" t2-w and t1-w sequences. furthermore, it provided the possibility of adding high-b-value diffusion weighted imaging (dwi) to our routine protocol in order to increase the sensitivity of mri in detecting malignant and inflammatory diseases. to obtain conventional mrcp imaging thick-slab heavily t2-w tse sequences or 3d heavily t2-w tse sequences may be used. advantages and limitations of both sequences will be underlined. functional bile duct imaging is obtained imaging modality or technique for this problem. increasing technological capabilities and knowledge of how to optimise ct/mr contrast utilisation provides better ways to characterise tumours than ever before such that key clinical specialties outside of radiology now recommend nonbiopsy imaging diagnosis of hcc to triage patient treatment. radiologists must work extra diligently to learn the clinical issues, triage points and implications that are associated with specific clinical presentations and imaging findings. the perfect test that does not require cognitive interpretation of the constellation of imaging findings with integration of the patient clinical presentation to optimise patient care is not in our near future. this lecture emphasises historical advances in liver imaging and how data in the literature impacted patient care decisions in ways that may be different than expected from radiologists. an emphasis on pathologic-imaging correlation will be used to put apparent disparate published results in proper perspective to allow radiologists to meaningfully interact with clinical colleagues in determining optimal patient treatment. liver mri is undertaken to assess the liver parenchyma, vasculature, and biliary system. it is necessary to use a variety of unenhanced and contrast-enhanced mr pulse sequences to achieve lesion detection and characterisation. a set of t1-, t2-w and dwi sequences is now standard for lesion delineation and assessment of liver fat and iron content. in-phase and opposed-phase t1-w gre images show focal or diffuse fatty infiltration and focal sparing. a fat-suppressed t2-w tse sequence is robust and provides high tumour contrast, with 3.0 t units now allowing acquisition of isotropic 3d-tse sequences. the quite popular t2-w half-fourier single-shot tse (e.g., haste) pulse sequences show anatomic detail (including bile ducts), but lack lesion contrast. in case of suspected iron overload (i.e., haemosiderosis and haemochromatosis) an additional t2*-w gre is recommended. acquisition of dwi patient transport into the radiology department, contact to other potentially infectious persons, and things such as breath-holding are reasonable burdens and dangers to immunocompromised patients. when searching the focus of fever, imaging should help to identify an affected organ system in order to eventually guide invasive procedures to identify underlying micro-organism or non-infectious disease. equally relevant is the exclusion of its involvement with a reasonable specificity. depending on local epidemiology, organ system, and the clinical signs and symptoms, suspected differential diagnosis can be derived from image patterns. some of these diagnoses might be exclusion diagnosis, others might require invasive procedures including time consuming and costly analysis to be verified. invasive procedures, however, require adequate hemostasis, which is usually not available for a substantial duration due to pancytopenia in patients who underwent chemotherapy. if imaging fails to derive the underlying disease confident and conclusively in a fast way, clinicians might need to treat on an empirical basis. empirical treatment plays a major role in immunocompromised or severely ill patients at risk, because mortality rises within hours of untreated disease. on the other hand, empiric treatment causes relevant toxicity and substantial costs, while imaging might become cost-effective. using contrast agents that are taken up by hepatocytes and excreted through the biliary system in combination with volumetric t1-w sequences. we use this technique in postoperative complications and to elucidate complex biliary anatomy. functional imaging of the pancreas is obtained by combining mrcp along with hormonal stimulation with secretin. in addition, secretin improves anatomic delineation and allows mri quantification of fluid production by the exocrine pancreas. despite the advance of cross-sectional techniques, the chest radiograph remains a basic tool for the initial approach to heart diseases. in this lecture we will present our current approach to evaluate cardiac pathology in conventional radiography illustrating it with selected cases. the basic approach consists of seven steps, evaluating the size and shape of the cardiac silhouette, cardiac calcifications, pulmonary circulation and lung changes, great vessels and implanted devices, all of them correlated with the clinical findings. looking at the heart on a chest film may be considered at a first glance as wasting time since, today, many other techniques are available today to offer an impressive luxury details of the morphological and functional evaluation of heart. nevertheless, the chest film remains often the first modality performed in many situations in which symptoms can be both from pulmonary or cardiac origin and then, careful analysis of heart may avoid rough mistakes in patient management. acquired and congenital pericardial or cardiac abnormalities may be responsible for a deformity of the cardiac silhouette and lead to explore the patient by a chest ct. ct with fast scanning capabilities can acquire images of the thorax with reduced cardiac motion artefacts, improving the evaluation of the heart in the course of a thoracic ct. unexpected findings of cardiac structures on both unenhanced and enhanced acquisition can dramatically influence the patient's clinical management. in many situations, a chest ct is performed without cardiac gating and it may be necessary to complement the initial examination by a gated acquisition to provide a more dedicated analysis. the normal appearance of cardiac structures and the most common cardiac abnormalities should be known by all the radiologists. various conditions such as idiopathic and acquired cardiomyopathy, ischaemic heart disease, valvular dysfunction can be identified even on non-gated scans. pulmonary diseases may also involve pericardium and cardiac structures and this should be clearly identified. learning objectives: 1. to learn how to detect and characterise cardiac abnormalities in the chest radiograph. 2. to learn how to detect and characterise cardiac abnormalities on chest ct. 3. to learn the limitations of the interpretation of cardiac abnormalities on ungated chest ct. 4. to learn when further evaluation is required. nal in discs and vertebrae to the adult shape and signal pattern will be reviewed. the normal pattern of unfused bony segments and apophyses in the child and fusion to the mature adult form will be reviewed. normal variants such as persistent segmentation/non-union leading to limbus vertebrae and dysraphism will be reviewed. intervertebral discs, vertebral body endplates, posterior elements and bone marrow show a wide degree of variation and the borderland of normal variant versus pathological abnormality is often difficult to navigate. common borderland findings such as schmorl's nodes versus scheuermann's disease will be discussed. transitional vertebrae as such are normal but incomplete transitional changes are associated with clinical symptoms. even without associated pathological changes the terminology of transitional vertebrae is a common pitfall. simple coping strategies will be reviewed. various imaging artefacts can have an influence on image interpretation though lumbar spine mr imaging is more resistant to these than imaging of the cervical and thoracic spine. this talk will review an approach to imaging complications of total hip replacements. the talk will briefly review surgical techniques and types of prostheses. the talk will subsequently review early and late complications of prostheses and focus on the integrated use of all modalities including radiographs, aspiration arthrography, scintigraphy and mri in achieving a diagnosis. there are many surgical techniques to repair meniscal tear, focal cartilage defect, cruciate ligament tear, malalignment, fracture, osteoarthrosis, etc. conventional radiography, ct-scan, ct-arthrography and mri play an important role in evaluation of the knee after surgery or arthroscopy. indications for postoperative imaging are infection, persistent pain and dysfunction. every radiologist should be familiar with "normal" imaging findings after arthroscopy, osteosynthesis, ligament reconstruction, osteotomy, knee prosthesis and meniscal or (osteo)chondral repair, but also recognise the main complications after knee surgery or arthroscopy. orthopaedic hardware is usually evaluated on plain radiography or ct, and only a relative contraindication for mri. microscopic metal artefacts and fibrotic scarring are frequently seen along the course of the instrumentation tract. after partial meniscectomy, an obtuse angle at the apex of the meniscus and increased signal intensity of the remnant part of the meniscus are normal findings, whereas fibrillation and recurrent tear may explain the complaints of the patient. various intra-and extra-articular reconstructive procedures exist for anterior and posterior cruciate ligament reconstruction. besides the neoligament, an osseous tunnel, screws and metal artefacts are also visible. postoperative findings of the extensor apparatus include a thickened patellar tendon, focal myxoid degeneration, fibrosis and focal defects, e.g. after harvesting tendon tissue for acl reconstruction or after release of the lateral patellar retinaculum for 'unstable' patella. accelerated osteoarthritis may be a late postoperative finding. mri very well depicts incorporation and alignment of osteochondral auto-or allografts, and the position, morphology and integrity of the meniscus after repair or transplantation. to evaluate postsurgical patients it is important to know the primary clinical diagnosis, the surgical treatment, the interval since surgery, and patients' current clinical symptoms. radiography is the most common imaging modality to evaluate the postoperative ankle, particularly in traumatic cases; after reduction and fixation of a fracture or dislocation it is generally carried out as routine. ultrasonography is highly sensitive and specific in postoperative tendon assessment, thanks to the superb resolution, and the opportunity for dynamic evaluation of tendon integrity. chest drains (28-30 fr) with underwater seals achieved decompression of pleural fluid collections. recent literature suggests small bore drains may be adequate, with image guidance playing an important role. pleural space anatomy, including fissural locations will be revised. aetiology of transudates, exudates and empyemas, along with typical clinical presenting features are outlined. various examples of plain film, ultrasound, multi-detector computed tomography and mri appearances of pleural collections and their aetiologies are presented. selection of patients, image guidance methods, catheter size, insertion technique, pitfalls and procedure complications are discussed. importance of physician-radiologist liaison with respect to catheter management and catheter dwell times is emphasised. pleural space fluid collections are common clinical entities that radiologists can accurately diagnose as well as successfully treat. overview of aetiology, radiological appearances and method of image-guided drainage of infected pleural fluid collections is provided. pelvic abscess drainage may employ more difficult access routes due to anatomic restrictions. the procedure may carry a higher risk of complications compared to simple abdominal drainage. to optimise patient preparation, correction of coagulation deficits, optimisation of antibiotic treatment, and sedation or anesthesia may be needed. the usual access routes for deep pelvic abscesses are the anterolateral and the posterior transgluteal approach. in selected cases, a transvaginal or transrectal approach may be the safer and more efficient option. depending on the viscosity of the drained fluid, the presence of necrotic solid tissue and gas, different sizes of drainage material may be needed. do not hesitate to employ large drainage catheters if indicated. an overview of the available material will be given. intestinal laceration is a major complication which can be managed percutaneously in selected circumstances. often, the weakest part of percutaneous drainage is the postinterventional management. it is advocated that the management is actively guided by the interventionalist who ensures that the drainage is properly handled, rinsed, and cleaned, that follow-up imaging is performed at the right intervals, and who is also responsible for indicating drain removal. chest ct and mri are commonly performed to evaluate patients with acute chest pain. a number of imaging techniques are available that may cover the entire chest, including the cardiovascular system. the radiologist will encounter more and more cardiovascular disease that was not visible with ungated ct and mri techniques. the differential diagnosis of acute chest pain may include over 30 possible diagnoses, a substantial number related to cardiovascular disease. it is important to recognise chronic and acute coronary disease, myocardial infarction and its complications, left ventricular function, pericardial disease, atrial disease and large vessel disease. case material will be presented and discussed using both ct and mri techniques to illustrate the spectrum of usual and more unusual cardiovascular pathology that should be considered in the differential diagnosis of unexplained chest pain. pulmonary hypertension (pht) remains a disease difficult to diagnose because the clinical findings are nonspecific, often leading to a delayed diagnosis. once recognised, it is necessary to determine the underlying cause and to estimate the severity of pulmonary hypertension. among the noninvasive methods of assessment of pht, ct angiography (cta) now plays an important role in the diagnosis and post-therapeutic management of pht. numerous recent technological advances of multidetector-row ct technology (mdct) have reinforced the clinical impact of this technology by introducing new tools for the morphological evaluation of small-sized pulmonary arteries and pulmonary capillaries, the latter being accessible with dual energy ct and often referred to as pulmonary "perfusion". the role of ct now also includes the possibility to investigate the presence of pht on the basis of functional parameters, such as the distensibility of the pulmonary arterial wall, and to integrate cardiac functional information, with great interest towards right ventricular function. the major clinical impact of these new scanning modes is that morphology and function can be obtained from the same data set, with no restriction on the diagnostic performance of high-resolution ct angiographic images. the purpose of this lecture is to review these new trends in imaging of pht and estimating right ventricular function through practical clinical situations, including the most common causes of pht. ct scans of the chest are usually performed and reported as if the lungs were the only organs in the thoracic cage. however, the heart and pulmonary arteries can show significant abnormalities either as associated findings of the parenchymal disease or as incidental findings. so the recommendation is: do not forget the heart and pulmonary vessels when reporting a ct scan of the chest. mri has rapidly become important in post-operative assessment of the ankle, because it provides high soft-tissue contrast, multiplanar capability and osseous structures visualisation. it shows signal changes of ligaments and tendons, hypointense subchondral sclerosis, subchondral bone marrow oedema, joint effusion, capsular thickening, fibrosis, and synovitis. mri has also an important role in the evaluation of post-surgery ankle pain due to impingement syndrome and in the hindfoot chronic instability related to postoperated sinus tarsi syndrome; it demonstrates the anatomy of sinus tarsi, chronic synovitis and nonspecific inflammatory changes, synovial cysts, fibrosis and subtalar joint effusion. it is important also in the follow-up of tumours and tumour-like conditions of bone and soft tissues after surgery. computed tomography is the most valuable method to define the osseous anatomy of the postoperative ankle, so it is important in the follow-up of the operated osteochondral lesions of the talus. ct allows the evaluation of irregularities or degenerative changes, and progressive degenerative arthritis; however, ct usually fails to evaluate soft tissue's ankle lesion. the development of subsecond mdct scanners with high temporal and spatial resolution has significantly reduced scanning times and now it is possible to have very good quality images of the heart during routine chest ct examinations. therefore, the importance of looking at the heart and pulmonary vessels on a ct scan performed for non-cardiac reasons will be emphasised. anatomic cardiac details that every radiologist should know will be discussed in the first talk; the presentation is aimed mainly at the non-cardiac radiologist. it will review normal cardiac anatomic details, as routinely encountered on modern multi-detector ct studies. it is now possible to delineate much of the intracardiac anatomy on a contrast enhanced study and significant pathology may also be evident on non-enhanced ct examinations. important incidental findings and their clinical relevance will be discussed in the second talk. unexpectedly, cardiac abnormalities may be diagnosed when lung disease is clinically suspected and vice versa; the focus of this presentation will be the comprehensive evaluation of lung and heart/large vessels diseases.the strong correlation existing between pressure in the pulmonary artery system and dilatation of the pulmonary trunk and central branches will be discussed in the last talk. ct is considered more useful than echocardiography because it can depict the cardiac structures in all patients including those with extensive parenchymal abnormalities. at the end of the presentations we should try to answer the question about the routine reporting of cardiovascular findings on ct scan of the chest. a. anatomic cardiac details that every radiologist should know s.p.g. padley; london/uk (s.padley@ic.ac.uk) this presentation is aimed at the non-cardiac radiologist. it will review normal cardiac anatomic detail, as routinely encountered on modern multi-detector ct studies. it is now possible to delineate much of the intracardiac anatomy on a contrast enhanced study, and significant pathology may also be evident on non-enhanced ct examinations. this study will primarily review normal cardiac anatomy, including cardiac chambers, valves and coronary vessels. the typical radiological appearances of innocent incidental intra-pericardial abnormalities will then be reviewed. important incidental pathology will be discussed in the next talk. liver fat, inflammation, and fibrosis are important pathological features in patients with diffuse liver disease. the clinical gold standard for assessing these features is liver biopsy. due to its invasiveness and sampling variability, however, liver biopsy is suboptimal for screening, monitoring, and clinical research. there is, therefore, a need to develop biomarkers to assess liver fat, inflammation, and fibrosis non-invasively. in recent years, many quantitative imaging techniques have been developed, refined, tested, and made available. the question becomes: are these techniques ready for routine clinical use or are they most appropriate for research? in this special focus question, we will begin with a brief overview of diffuse liver disease and discuss basic concepts of biomarker validation and qualification. dr. reeder then will discuss conventional and state-of-the-art imaging-based biomarkers of liver fat. dr. cobbold will discuss the current status of non-invasive biomarkers for liver inflammation. dr. van beers will discuss ultrasound-and mr-based biomarkers of liver fibrosis, with emphasis on techniques such as transient elastography and mr elastography that measure visco-elastic properties of liver tissue. we will conclude with a panel discussion asking the question: are the repeatability, reproducibility, and robustness of the non-invasive biomarkers presented in this session adequate for routine clinical implementation? session objectives: 1. to review the clinical importance of diffuse liver disease. 2. to understand that key features of diffuse liver disease include fat accumulation, inflammation, and fibrosis. 3. to understand the need for non-invasive biomarkers to assess fat, inflammation, and fibrosis. 4. to review basic concepts in biomarker validation and qualification. quantification of liver fat s.b. reeder; madison, wi/us (sreeder@wisc.edu) intracellular deposition of fat within hepatocytes (steatosis) is a common condition of the liver. fat is the histological hallmark of non-alcoholic fatty liver disease (nafld) but also may occur with alcohol abuse, viral hepatitis, hiv and genetic lipodystrophies, and chemotherapy. nafld alone afflicts an estimated 20-80 million in the us and is a rapidly growing condition in other western societies, paralleling the expanding epidemics of obesity and diabetes type ii. this talk will review the clinical, pathogenic and histological features of liver fat, including an overview of fatty liver disease and diseases where fat is an important disease feature. next, it will review the current use and limitations of non-targeted biopsy in diffuse liver disease, and why quantitative non-invasive biomarkers of liver fat and iron would be beneficial. currently available conventional magnetic resonance imaging techniques that attempt to detect and quantify liver fat will then be discussed, as well as known confounding factors that corrupt the ability of conventional methods to quantify fat. this lecture will then describe emerging quantitative imaging methods for accurate and precise quantification of liver fat, and the advantages offered by these methods address in comparison with conventional methods. finally, remaining challenges and unsolved problems for quantifying liver fat will be discussed. conventional mri techniques, such as t2w and gadolinium-enhanced t1w sequences, which are highly sensitive for detecting demyelinating plaques, are recognised as the most important paraclinical tool for diagnosing multiple sclerosis (ms). however, the changes seen on mri in patients with ms are not diseasespecific, as focal white matter t2 hyperintense lesions (thl) are also commonly observed not only in the elderly but also in middle age and young patients, and in a large list of different disorders such as hypoxic-ischaemic vasculopathies (atherosclerotic and hypertensive small vessel disease, cadasil, fabry's disease and susac's syndrome), cns vasculitis, sarcoidosis, adult forms of leucoencephalopathies, trauma and radio chemotherapy, and acquired metabolic conditions (hepatic encephalopathy, alcoholism), among others. while it is recognised that a combination of findings from clinical history, physical examination and laboratory tests is commonly required to correctly establish a firm and clear aetiological diagnosis of thls, a detailed analysis of different mri features should also be considered essential, e.g. lesions shape, size, and distribution; contrast-uptake; and associated structural lesions (microbleeds, infarcts, spinal cord, brainstem and cerebellar involvement, …). in addition to these conventional mri-based features, non-conventional mr techniques (diffusion, mrs and perfusion) may also provide in some cases useful diagnostic information. knowledge of these features will assist the diagnostic work-up of patients presenting with thls, and should be considered a first step to take full advantage of the potential of mri, and in doing so should result in a reduced chance of misdiagnoses and facilitate the correct diagnosis of sometimes treatable disorders. learning objectives: 1. to be aware of the limited specificity of brain multifocal t2 abnormalities. 2. to learn about recognition patterns that might be helpful in suggesting the most likely etiology of brain multifocal t2 lesions. 3 . to learn about the role of spinal cord imaging and advanced neuroimaging techniques for the differential diagnosis of brain t2 hyperintense lesions. 4. to be able to establish a neuroimaging diagnostic strategy in patients with multiple brain t2 lesions of unknown origin. breast imaging reporting and data system (bi-rads) was developed by american college of radiology in order to set standards for mammography reporting, common terminology and data collection. bi-rads is being used widely for over a decade and many studies have assessed the validity of the system. an important component of bi-rads is the lexicon which gives descriptors of specific imaging features that facilitate image interpretation and unify the reports. two main titles for these descriptors are about masses and calcifications. an asymmetry is called a mass when it is seen in two projections. a mass is defined with its shape, margin and density. definition of a mass with these three modifiers would help the radiologist to determine the type of the mass and probability of its malignancy. calcifications are divided into three categories by their shapes and another descriptor is defined for their distribution. the first category is for typically benign calcifications. the other two are for probably malign calcifications where biopsy should be suggested. the distribution modifiers for calcifications can also play an important role in assessing the probability of malignancy. bi-rads defines 7 assessment categories from 0 to 6 for the final report that facilitate data management for yearly audits. category 3 is the transition zone between malignant and benign lesions where the suspicion for malignancy should be less than 2% and requires short-term follow-up. bi-rads morphology and distribution descriptors are effective in assessing the risk of malignancy with a reasonable positive predictive value. the breast imaging reporting and data system (bi-rads ® ) for ultrasound (us) was developed by the american college of radiology (acr) and published in 2003. although this lexicon was created to achieve a consensus among radiologists when describing breast abnormalities, clinical practice shows substantial intraobserver agreement but only moderate interobserver agreement. most problems are reported for descriptors related to shape (when trying to classify abnormalities containing lobulations and/or elliptical with not-parallel orientation), echo pattern and margin. especially mass margin is a critical feature for determining whether a lesion should be biopsied or not. other problems are related to the final assessment, including difficulties in applying the subcategories and the relatively high percentage of false negative cases for lesions interpreted as category 3. many computer-aided diagnosis software have shown the potential to improve performance amongst less experienced readers and decrease interobserver variability; still they do not solve all the problems. the bi-rads ® lexicon is actually under advanced revision by an international panel and ellen b. mendelson chairs the us subcommittee. revision is reviewing both descriptors and categories; it will include also new parameters linked to the evolution of us technology as colour flow mapping and elastography. troubles. characterisation of aml is possible, based on identification of its fatty content mainly using ct. when microscopic, this component may be missed and biopsy is required with immunostaining. mr imaging may be helpful using chemicalshift sequences but thresholds, to rule-out clear cell carcinoma, have to be better defined. presence of necrosis or calcifications rules-out diagnosis of aml. amls must be treated if haemorrhagic, painful or if diameter exceeds 4cm. embolisation is the main nonsurgical method, using microparticles, alcohol and/or coils but postembolisation syndrome must be prevented. volume regression may require all agents whereas aneurysm occlusion requires coiling. the effect on volume and on haemorrhagic risk is substantial making surgery as an alternative method for nephron sparing purposes. secondary surgery is required in less than 10% of embolisation. rf ablation is also possible but its efficacy is still under evaluation. the number of small renal tumours is increasing due to the large amount of imaging examinations of the kidneys performed with various modalities and the true increasing incidence of renal cancer. conservative therapy of small renal tumours is now widely recognised as the reference technique for the treatment of these small lesions. the increasing rate of chronic renal failure in the elderly and the efficacy of conservative therapy to treat cancer as demonstrated by the urologists performing partial nephrectomy and tumourectomy emphasise the role of percutanaeous minimally invasive ablative procedures, particularly in patients with surgical contraindications. radiofrequency ablation and cryotherapy are the two most developed techniques, but new technical approaches are under development such as microwave ablation, electroporation, etc. the evaluation of the success of the procedure relies on imaging techniques showing the lack of enhancement within the lesion and the size and shape of the necrotic covering the entire tumour area. the techniques, indications, results, and complications of both radiofrequency ablation and cryotherapy will be discussed. a variety of diseases including neoplasms, but also infectious, inflammatory, vascular and traumatic processes, may present as focal intracranial mass lesions. modern neuroimaging, primarily with mri, enables differentiation of these entities allowing for accurate diagnosis in almost all cases. the requirements are appropriate image acquisition and detailed analysis of imaging findings, while pertinent clinical information may be very helpful in certain cases. the distinction is frequently broad, between different disease processes, such as with tumefactive demyelination versus neoplasm, which is often sufficient for clinical decision making and patient management; at times this may be more specific, approaching histological diagnosis, such as with pilocytic astrocytoma versus medulloblastoma. this presentation will go briefly over the imaging techniques and various disease processes, while heavily concentrating on the differentiating features of intraaxial primarily non-haemorrhagic mass lesions. the emphasis will be on the key distinguishing imaging features, such as presence or absence of mass effect or vasogenic oedema, signal intensity characteristics, presence and pattern of contrast enhancement, as well as diffusion and perfusion features. decision making process will be discussed. a number of cases with intracranial masses will then be reviewed and analysed, using a step by step approach, accentuating the most reliable distinguishing findings. the role of mr imaging in adult gliomas consists of many steps. (1) is there a lesion in the brain? (2) is the lesion a tumour? (3) is the tumour a glioma? (4) is it a high-or low-grade glioma? (5) if there is a suspicion and a biopsy is planned, which part of the tumour should be targeted at biopsy. (6) how the surgery should be performed to avoid injury to functional areas of the brain (e.g. motor cortex). (7) if there is need for adjunctive radiotherapy, how the extent of the tumour should be defined? (8) after radiotherapy, if a new enhancing lesion occurs, is it a recurrent neoplasm or radiation necrosis? conventional anatomical mr imaging is not always powerful enough to answer these questions. however, with advanced mr imaging techniques such as diffusion mr (including tractography), perfusion mr, mr spectroscopy and functional mri (fmri) we can answer the above questions reliably in most cases. the purpose is to gain numerical information of accuracy in the treatment of localised prostate cancer and calculate the necessary size of the safety margin around the clinical target volume (ctv-ptv). in addition, the purpose was to evaluate the accuracy in treatment set up with patients with high bmi to find out whether patients with high bmi need a larger safety margin. portal imaging was used to measure off-line random set-up error from bony structure. the sample size was 40, i.e. all the patients who received radiation treatment for localised prostate cancer in landspítali -university hospital (lsh) 2006. a total of 3032 portal images were acquired. in 2010, the task was repeated for 38 patients having gold fiducial markers in the prostate. the calculated 3-d imrt safety margins in lsh 2006 was to be 15.8 mm. correlation is with high bmi and set-up errors in medio lateralis (m-l) direction (r=0.21). this indicates that a patient with an increased pelvic circumference has a tendency to have more set-up errors. reformed procedural workflow resulted in more acceptable calculated margins in 2010. when corrected on line 3 times per week the margin is to be 7.2 mm and 3.0 mm if corrected 5 times per week. in conclusion, for delivery of 76-78 gy to the prostate with imrt and spare surrounding healthy tissue effort is needed to secure the accuracy in the overall procedure of treatment planning and delivery. learning objectives: 1. to gain knowledge on how to improve the target accuracy in treating prostate cancer with radiation therapy using electronic portal imaging. 2. to understand the importance of gaining numerical information of accuracy in the treatment of clinically localised prostate cancer and how to use the information to calculate the necessary size of the safety margin around the clinical target volume. 3. to become familiar with the preparation needed before starting treatment with imrt and be aware that there is a need to look at all the treatment elements including the technical side, quality, education, staff and patients. 4. to consolidate knowledge of radiation therapy for prostate cancer and the meaning of giving high dose to the target while minimising radiation dose to healthy tissue. b. image-guided radiation therapy: when imaging meets therapy a. sarchosoglou; athens/gr (anastasia71@hotmail.com) the aim of this presentation is: to understand the necessity of imaging in the delivery of external radiotherapy; to be familiar with the technology of image-guided radiation therapy and to to gain knowledge about the implementation of 3d igrt. the aim of radiotherapy is to deliver high dose to target volume while minimising the dose to surrounding healthy tissues. however, during treatment delivery many uncertainties may arise that can result in higher toxicity and poor local control. thus, it is crucial to monitor and adjust if necessary, the actual treatment. image-guided radiation therapy is the process where images are taken immediately prior or during a course of radiation treatment, to assess and improve the accuracy of therapy. manufactures have developed a number of systems to perform igrt providing the options of ionising radiation images/non-ionising imaging technology and gantry mounted/room mounted equipment. 3d igrt can be performed by acquiring computed tomography images on the treatment unit. these images are matched with reference images from planning ct and potential discrepancies are recognised, calculated and corrected by couch shifts giving optimal results. such advanced technologies require quality assurance systems to be in place and high trained personnel. when properly implemented, igrt meets the aim of radiation therapy. imaging provides confidence to radiation therapy to be aggressive, to fight cancer. imaging promises radiation therapy a great future with improvements in clinical outcomes and patient survival! multicentre trials have shown that ct colonography is ready for widespread clinical use. however, these studies have also highlighted the inconsistent performances of ct colonography, with divergent results being recorded in different centres and between readers. inter-observer and inter-centre variability may be related to reader experience but it is also affected by how ct colonography is performed. while faecal tagging has been accepted universally as the proper way to prepare patients for ct colonography, there is no consensus on which tagging agent is better, on the timing of contrast agent administration and on whether laxatives should be administered and in what dosage. in a similar way it is not yet clear which is the best way to obtain colon distension, whether by administering spasmolytic agents routinely or by changing patient's decubitus. standardising bowel preparation and technique is one of the most important goals that need to be achieved for ct colonography to be universally accepted and this presentation will attempt to deal with the issue using an evidence-based approach. the evaluation of ct colonography (ctc) studies is based on detection, interpretation and reporting of colonic findings. it is performed on a computer workstation equipped with dedicated ctc software by a primary 2d or a primary 3d approach. in either case, the alternative viewing technique must be available for rapid correlation and characterisation of suspicious findings. primary 2d evaluation is based on "lumen tracking" by interactively scrolling through the axial slices and multiplanar reformatted images, focusing only on the air-distended colonic lumen from one end to the other one. primary 2d evaluation provides information about the attenuation of findings during the search process and is time-efficient. primary 3d evaluation is based on 3d virtual endoscopy in an antegrade and retrograde fashion and increases both, the conspicuity, especially of small and medium-sized polyps, and the duration of visualisation. the use of advanced 3d displays like virtual dissection or unfolding techniques may reduce the interpretation time for primary 3d evaluation. computer-aided detection (cad) algorithms used as a 2 nd reader were shown to reduce the number of perceptual errors by pointing out possible abnormalities that might otherwise be missed. colonic findings are characterised by their morphology, their attenuation characteristics, and by their mobility. knowledge of ctc imaging features of common colonic lesions and artefacts is necessary for characterisation of findings and differentiation between definite colonic lesions and pseudo-lesions. standardisation of ctc reporting facilitates classification and communication of findings and the comparison with previous studies, thereby better assisting physicians in making appropriate management decisions. the revolutionary development in multidetector ct (mdct) technology during the past decade has contributed to a substantial increase in its diagnostic applications and accuracy in children. a major drawback of mdct is the use of ionising radiation with the risks of radiation-induced side effects, of which the induction of secondary cancer is the most important. therefore, justification and optimisation of paediatric mdct is of great importance in order to reduce these risks as much as possible (‚as low as reasonably achievable' principle). optimisation of paediatric mdct starts with a solid understanding of all technical aspects of ct, including the most relevant scan parameters, dose reduction techniques and technique of iv contrast material administration. furthermore, due to the smaller size and lack of visceral fat in young children the interaction and absorption of radiation will be different which will influence the choice of the various technique and scan parameters. although all these issues are pivotal for a successful ct examination, it may become worthless if the importance of pre-scan issues such as justification and patient preparation are ignored. after a short overview concerning the current knowledge on radiationrelated risks in children, this lecture will focus on several aspects relevant for mdct optimisation in children. issues such as justification, patient preparation, technique and scan parameters will be addressed. finally, some guidelines for radiation dose level-based ct protocols will be given. the purpose is to present an overview of the safety hazards and safety protocols related to infants undergoing mri examinations. mri infrastructure-dependent safety hazards originating from: (a) static and fringe magnetic fields, (b) gradient subsystems, (c) radiofrequency subsystems and (d) acoustic noise sound pressure will be reviewed and discussed. safety hazards related to upcoming technological issues and future trends concerning mri will be presented. the current status of the organisations responsible to the problems of mr safety will be reviewed. which authority is responsible and where the responsibility is addressed to (directives, legislation policies, etc). an optimised protocol related to a variety of clinical mr sequences in reference to temperature measurements, emf measurements, sar and acoustic noise figures using basic commercially available infrastructure will be presented. 2d/3d tse sequences with different etl's, 2d/3d gre, 2d/3d ssfp and se/gre epi sequences with multi-(b) diffusion gradients and 3d tof mr angiography sequences will be examined. in vitro measurements of snr, spatial resolution and scan times will be performed for each clinical mr sequence. a comprehensive mri equipment operational policy (optima: (etl, tr, te, b-value, epi factor etc).) for a safety protocol for infants undergoing mri is proposed. recommendations for safe infant mri examinations will be summarised and presented. conclusion: mri equipment can operate safely for infant imaging but require policies and procedures beyond those required for standard diagnostic mri examinations. learning objectives: 1. to get an overview of the three basic safety hazards related to infants undergoing mri examinations. 2. to become familiar with safety hazards related to upcoming technological issues and future trends. 3. to learn about a safety protocol that could be applied in mri examinations for infants. a s105 c b d e f g h perfusion imaging. new possibilities arise in mri almost every day. imaging algorithms are to provide the correct diagnosis in the shortest time with the lowest expenses and harm to the patient. mri is the first method of choice in neurological diseases with two exceptions: acute stroke and acute trauma, ct providing the necessary information, more available and with easier patient care. adequate imaging protocols optimally visualise the anatomical region of interest and pathological processes, optimise the comparison between serial examinations and provide the information in reasonable examination time. appropriate and well understood clinical information is indispensable (neuroradiology means good clinical knowledge combined with expertise in imaging methods and their evaluation). complicated protocols are superfluous without competent clinical background but adequate information must be provided to experienced clinicians. basic protocols help to gather important information but do not exclude additional necessary methods. examples to be demonstrated are mri protocol for the pituitary, epilepsy, multiple sclerosis and spine. the up-to-date concepts of image evaluation and interpretation will be demonstrated for brain ct, brain mri and spinal mri, including the importance of follow-up. the body and conclusion part of the structured neuroradiological report will be discussed. consultation with other neuroradiologists and with clinicians is the final tool to reach the goal: to help in recovering the patients' health. ten authentic and original typical clinical cases illustrating the importance of imaging modalities in the differential diagnosis of focal neurological symptoms from headache to epilepsy will be presented while respecting the privacy of the patient. the spectrum of pathologies includes vascular, inflammation, metabolic, degenerative diseases, congenital malformations and neoplasms of the central nervous system. each case story will be described shortly in a standard form followed by demonstration of typical ct and/or mri images. in some cases, conventional mri will be supplemented by multi-voxel mr spectroscopy, dti, mr tractography images, and morphological pictures. follow-up images will be presented where appropriate. several diagnostic options will be offered for attendants. the audience will be asked to participate in the diagnostic process by the use of voting pads. after highlighting of final diagnosis the basic differential diagnostic considerations will be briefly summarised and emphasised from the clinical and imaging point of view for each presented case. learning objectives: 1. to introduce typical cases illustrating the role of imaging modalities in the differential diagnosis of focal neurological symptoms. 2. to motivate the audience by the use of voting pads to be involved in the diagnostic process. 3. to highlight the conclusion that may be drawn on the basis of the discussed cases. diagnostic quality mri of soft tissue masses can be performed using a variety of magnetic equipments and a variety of field strengths. regardless of system design, efforts should be made to maximise signal-to-noise ratios (snr) using the most appropriate coil to include the lesion and associated oedema. fov should be tailored to the size of the patient and the size of the mass. it is important to obtain images in at least two planes through the lesion. slice thickness vary depending on the size of the lesion and interslice should be not more than one-half of the slice width. imaging matrix should be balanced to in-plane spatial resolution. parallel while ctc has achieved excellent results in average risk individuals with regard to detection of clinically relevant polyps, it has not yet been implemented on a large scale in colorectal cancer (crc) screening programmes. this is mainly due to the fact that it uses ionising radiation. there is uncertainty about adequate screening strategies and the risk of radiation-induced malignancy. this presentation will summarise recent results of ctc in a screening setting, will look at the dose associated with ctc, and summarise calculations of radiation-associated risk of malignancy. the key question is whether low doses from ctc will cause relevant negative effects in the screening population. the lecture will also feature a comparison between ct and mr colonography, an imaging test that might be able to provide high sensitivity crc screening without ionising radiation. from headache to epilepsy… or from "normal", physiological "headache" to life threatening pathological conditions. when do we need "neuroimaging" and what is the optimal diagnostic work-up? the radiologist must and should remain first of all a medical doctor: he/she should keep close contact with the clinical world and always keep an active dialogue with the referring clinician. indeed, medical imaging has become more and more sophisticated but also more expensive. imaging is not a "screening procedure" in brain pathology but should be performed in order to confirm a clinical, suspected diagnosis keeping still in mind that differential diagnosis must be considered as well. imaging plays also a unique role in lesion evaluation and treatment monitoring. the radiologist must answer precise questions about the patient's suspected pathological condition and if necessary, discuss the imaging findings with the clinician in order to narrow the differential diagnosis. each mri or ct must be performed with a clear knowledge of the clinical question and the suspected pathology. therefore, the radiologist will make the proper choices of imaging techniques especially with mri where imaging sequences have become numerous. headaches and seizures are symptoms only and may be present in multiple and very diverse pathological conditions as infectious, neoplastic, haemorrhagic, vascular diseases: by knowing the clinical history a good "clinically conscious" radiologist will undoubtedly be of greater "added value"! learning objectives: 1. to learn more about the clinical conditions causing focal neurological symptoms. 2. to be informed about the clinician's way of thinking in the process of differential diagnosis. neuroradiology has a continuously changing and developing array of modalities. conventional radiography has lost its importance. angiographic practice has shifted from diagnostics to therapy. ms-md ct scanners provide high-quality ct angiography and a s107 c b d e f g h t2w-mri to localise pz-zone pca. in the t-zone, stromal nodules commonly have a low adc value simulating pca. significant differences in tumour adc values existed between patients with low-risk, and those with higher risk localised p-zone pca. with s-mri, the best accuracy for diagnosing pca is obtained by combining a positive t2w-mri and a choline+creatine/citrate ratio > 0.75. in the t-zone, s-mri has the same limitations than dce and dw-mri. multiparametric functional mri accuracy of mri to detect pca can be improved by combining different functional sequences. at the moment, it seems that the most widespread used protocol is a combination of dw and dce-mri for detection of p-zone tumours. performance of functional mri to detect t-zone pca is less well established. multiparametric mri can now be used to perform stereotaxic trus-guided biopsies after trus-mri image fusion. the role of imaging in patients with increased psa level after radical prostatectomy or radiation therapy is to aid in differentiating locally recurrent disease which can be managed with local therapy from distant metastatic disease requiring systemic therapy. although the majority of local recurrences in post-surgical patients can be detected by mri in the perianastomotic region which can also be evaluated with trus and trus-guided biopsy, some recurrences can occur at pelvic sites that are beyond the range of trus; mri has a role of labelling these sites for trusguided biopsy. the combination of an external phased-array coil and endorectal coil is recommended for detecting local recurrent cancer. current protocols involve t2-weighted mri combined with functional techniques such as dynamic contrastenhanced mri (dce-mri), magnetic resonance spectroscopy and diffusionweighted mri. in the post-prostatectomy bed, recurrences present as lobulated masses having low to intermediate signal intensity on t2-weighted images and showing early, nodular enhancement with early washout of gadolinium on dce-mri. the predominant finding after radiotherapy is a diffusely low signal intensity with an indistinct zonal anatomy where the contrast between a hypointense recurrence and benign irradiated tissue decreases. on dce-mri, peripheral zone enhancement is lower after radiotherapy and any focal enhancement should be regarded as suspicious. the overall diagnostic efficacy of dce-mri for detecting recurrent prostate cancer is better than t2-weighted mri alone. on mri, bone metastases have low and high signal intensity on t1-and t2-weighted images, respectively, and enhance after intravenous gadolinium administration. learning objectives: 1. to understand the role of mri in the follow-up of the patients with prostate cancer after radical prostatectomy or radiotherapy. in this presentation new techniques with potential clinical value will be described with a focus on prostate cancer multi-modality mr imaging. techniques such as t2w, dwi, dce and mrsi will be addressed, and their role in screening, determination of tumour aggression and localisation, mr-guided biopsy, mr-guided minimal invasive focal therapy (laser, cryo, hifu), and mr-guided radiotherapy will be discussed. examples will be shown. the major area of debate is how to approach patients with increased psa levels. the discussion has two parts: one is the patient who has not had a prior cancer diagnosis and the other one is the patient who has already been treated for prostate cancer. what is the role of mr (as well as mrs, dw mr and dynamic mr) in precluding the need for multiple biopsies? when should we stop in cases with high or increasing levels of psa despite consecutive negative biopsy outcomes? a s109 c b d e f g h and that radiation therapy and systemic treatments play a major role for curing minimal residual disease. for evaluating and predicting response to neo-adjuvant treatments, the major question is the debate between morphology (size and volume) and function (perfusion, spectroscopy and diffusion). for follow-up after treatment, considering the number of women concerned, cost benefit analyses are mandatory to offer the most efficient imaging strategies based not only on defined subgroups (risk factors of local relapse) but also over time. one of the first take home messages of this course is the multidisciplinary approach of this disease or in another way: we do not treat images but patients! a. evaluation of residual disease after excisional biopsy c. boetes; maastricht/nl (c.boetes@mumc.nl) mammography can have an additional value in evaluating if microcalcifications are left behind in the case of dcis and irradical operation. ultrasonography has proven to have no additional value in evaluating the postoperative breast, because of haematoma and scar tissue. mr imaging of the breast can of all imaging techniques predict residual disease in the most accurate way. however, false positive results can exist because of enhancing scar tissue. also, false-negative results exist, especially owing to residual low and intermediate grade dcis. it is recommended to perform postoperative breast mri in premenopausal women in the right time of the menstrual cycle, that means between the 5 th and 12 th day after the start of the menstrual cycle. unclear is how soon after the operation one should perform breast mri. if a large mass of residual disease is suspected, mri is an excellent tool to confirm this fact. but, if a mastectomy is considered, pathological confirmation before the re-operation is recommended. another imaging technique is tc-99m-mibi scintimammography. this seems a promising technique with a high sensitivity and specificity. neoadjuvant chemotherapy is regularly used for downstaging of locally advanced breast cancer. while it is equivalent to adjuvant therapy regarding overall survival and occurrence of distant metastasis, more patients are eligible for surgical treatment by less aggressive breast conservative therapy. neoplastic growth depends on blood supply with nutrients and oxygen. hypoxia-induced angiogenesis is an early step in tumour progression. mri is the imaging modality providing highest sensitivity for detection of breast cancer, highlighting tumour vascularisation by injection of t1-shortening contrast agents. characteristic differences between benign and malignant lesions are cause. ultrasound (us) and computed tomography (ct) are readily available and widely used imaging techniques for this work up. us comprises an examination of the abdomen with the graded compression technique. a transducer should be used optimised for the visualisation of the bowel. the ct protocol includes the use of intravenous contrast medium, while oral contrast medium will not be routine in many institutions. findings are bowel wall thickening (or enlarged appendiceal diameter), fat infiltration, free air and fluid collections. the present evidence on the role of imaging in appendicitis and diverticulitis is substantial and has been summarised in systematic reviews. although us is accurate in diagnosing appendicitis and diverticulitis, ct is more accurate than us. further advantages of ct are better identification of alternative diagnoses and better comparison between consecutive examinations. thereby, ct is more helpful in communicating the diagnosis to the referring physician. cost effectiveness of ct in acute appendicitis has been demonstrated as well as the positive impact on management. for colitis, the evidence is more limited and imaging has more limitations here. drawback of ct is ionising radiation exposure. an imaging strategy with initial us and ct only in inconclusive of negative us cases results in the highest sensitivity, reduces ionising radiation exposure and is cost effective. accurate and rapid diagnostic imaging is essential for the appropriate management of acute biliary tract disorders. ultrasonography (us) continues to be the first and often the only test needed to confirm suspected diagnoses affecting the ducts and gallbladder. however, there has been an increase in the overall use of computed tomography (ct) in the emergency room setting, mostly because for its widespread availability and the relative speed, ease and uniformity with which evaluations can be performed. thus, ct may be the first imaging examination performed on patients presenting with signs and symptoms that are less specific for biliary diseases. magnetic resonance (mr) imaging has similarly robust potential as ct, although its integration into the acute care setting requires greater technical and logistical effort. improved mr imaging sequences, advances in coil technology, streamlined imaging protocols, and increased technical and professional familiarity with the modality make it an increasingly attractive option when there is concern about patient radiation exposure or allergy to iodinated contrast material, as in pregnant patients with acute abdominal symptoms. mr can also be used as a problem-solving modality. in this presentation, the common and uncommon imaging appearances on us, ct and mr of acute diseases of the biliary tract and gallbladder will be reviewed. potential pitfalls to be avoided with the three modalities are also illustrated. learning objectives: 1. to learn the etiology and clinical presentation of acute inflammatory liver diseases. 2. to understand imaging strategies using us, ct and mri. 3. to know typical findings and the spectrum of differential diagnoses. pancreatitis is an abdominal condition potentially life threatening. imaging plays a key role not only in the diagnosis but also in the staging and patient management of acute and chronic pancreatitis. pancreatic inflammation and necrosis can be easily identified by imaging methods and has prognostic implications. the clinical prognostic criteria in acute pancreatitis are currently coupled with imaging criteria. ct plays a central role in the evaluation of patients with known or suspected pancreatitis. a ct-based severity index is the main prognostic method to predict outcomes. in addition, mri and mrcp play increasingly important roles in pancreatitis evaluation. integrity of the pancreatic duct can be easily evaluated by this last method, particularly if enhanced with the use of secretin. imaging appropriateness criteria determine the value of distinct imaging modalities with regard to the stage of disease. we review the modern imaging criteria for the diagnoses, staging and patient management in acute and chronic pancreatitis. we also discuss current severity indices and imaging appropriateness criteria. advancements in ct and mri technology have lead to an increasing use of these modalities in the non-invasive assessment of coronary arteries, myocardial perfusion, and cardiac function. while their role in detecting coronary artery disease and functional disorders has been widely accepted, it is still unclear whether they could be adopted in triaging patients for the best therapeutic approach. large studies have already suggested that indication for surgery and percutaneous interventions cannot be solely based on the demonstration of morphologic alterations and that such "cosmetic" interventions are not always leading to the expected outcomes. therefore, non-invasive imaging techniques have to offer more then just the detection of grades of coronary artery stenosis, of areas of infarcted myocardium, or of valvular alterations. adjustment of imaging protocols for additional evaluation of coronary flow reserve, of myocardial perfusion and contractility and of valve size, position and damage with subsequent quantification of degree of stenosis and/ or regurgitation are necessary in order to allow to choose the most appropriate therapeutic approach and thus become the "gold standard" for prognosis and pretherapeutic diagnosis of cardiac diseases. a. can ct predict the outcome of percutaneous intervention? c. loewe; vienna/at (christian.loewe@meduniwien.ac.at) the outcome of coronary revascularisation is not only defined by primary technical success but also by improvement of symptoms and quality of life. thus, despite the individual comorbidities, the outcome and thus the potential benefit of coronary revascularisation depends on many different factors, including morphology, distribution and severity of coronary lesions, myocardial viability, and ventricular function. consequently, the detection of coronary stenosis is not sufficient for planning an optimised treatment. it should be evaluated if the myocardial territory supported by the diseased artery is still vital. in addition, lesions at risk for plaque rupture (culprit lesions) should be identified and treated to avoid major coronary events. cardiac ct allows for the exact assessment of coronary morphology including length, calcification and severity of lesions. based on this morphological information, success of a percutaneous revascularisation procedure can be anticipated with high prognostic accuracy. in addition, the possibility of identification of culprit lesion by means of coronary ct has been described recently. by this, dedicated treatment of only the relevant stenosis should become possible avoiding multiple, potentially unneeded, stents. finally, even the assessment of myocardial viability by means of ct becomes possible. using all the possibilities of cardiac ct optimised treatment plan can be established, and outcome can be estimated. radiological interpretation always incurs some degree of error due to the nature of disease presentation coupled with the difficulty in diagnosis, especially where early signs of disease need to be identified such as in medical screening. early research studies of radiologists' performance concentrated upon the chest radiograph but more recent work has studied breast screening extensively, as well as mri and ct. as radiology is now almost fully digital then research has also examined observer behaviour with a range of digital images, viewing conditions, and image display presentations. it is possible that radiological interpretation will never be accomplished without some errors occurring; however, it is important that steps are taken to minimise any causes of errors as far as possible. the reported error rates found in numerous investigations across different radiological domains will be reviewed and the reasons for these will be elucidated. appropriate reporting conditions will be highlighted for different image viewing scenarios. a theoretical framework for understanding error causation, especially where abnormalities are missed will be detailed. furthermore, the underlying visual, perceptual and cognitive processes which lead to errors will be detailed and approaches to minimise error occurrence will then be proposed. the relationship between human perceptual and cognitive skills and computer imaging processing will be discussed and the usefulness of cad systems outlined as how they can best aid the radiologist from the human performance viewpoint. learning objectives: 1. to review the basic principles of perception, detection and detectability. 2. to learn about specifics of perception in medical imaging. 3. to learn how image processing can help us with the perception process. ing using graf's method led to higher treatment and follow-up rates than that based on nhi alone, i.e. 3-5% vs. 0.4-1.5% and 10-20% vs. 6-7%, respectively. however, improved examination techniques and a better understanding of the findings have led to a more tailored approach, and an extensive meta-analysis performed in 2000, including 534 papers, could not find any differences in treatment rates due to different ultrasound techniques. in this lecture i will present a crude status for us techniques used and also give recommendations for a worth while screening strategy based on present knowledge, and on work performed within the espr's ddh task force group. with technological advances in recent years, paediatric whole body imaging is now a clinically feasible and increasingly accessible technique. the two principle modalities available are pet, with or without co-registered ct images, and whole body mri (wb-mri), both of which can be utilised to evaluate widespread disease states efficiently. the main application of these techniques has hitherto been oncological; however, as these techniques become more accepted, their use is becoming more varied. pet provides functional assessment, utilising a radiotracer, most commonly fdg-18, to assess metabolic activity within tissues, with areas of greater metabolic activity depicted as increased tracer uptake. the use of combined ct-pet enables accurate specific uptake values (suv) to be determined, via attenuation correction, and anatomical co-registration which reduces perceptual errors. wb-mri primarily provides an anatomical assessment, using tissue contrast to identify pathology. this typically uses water sensitive sequences to provide high sensitivity. "physiologic" mri sequences, such as diffusion weighted imaging (dwi) can also be employed to obtain functional mri data, either qualitatively or quantitatively. there are advantages and disadvantages to both techniques, including ionising radiation exposure, acquisition times, movement and other artefacts, and reproducibility, which all need to be considered when choosing a particular technique for whole body assessment in any given paediatric patient, with the disease process being investigated also influencing the technique used. the relative merits, clinical applications and evidence base for the use of pet/ct and wb-mri in paediatrics will be discussed. near future developments, such as pet-mri will be touched upon. the practice of medical image diagnosis is currently undergoing a fast transformation. vast amounts of data can be generated in standard examinations and focus is shifting from improving the collection of relevant data for diagnosis to development of effective methods to analyse, visualise, navigate and interact with medical information. it is now becoming generally accepted in the medical community that one of the most important keys to manage the increasing information work load is the use of 3d and 4d applications. this talk will take its starting point in state-ofthe-art medical visualisation and then discuss the need for a research agenda that focuses on the development of the next generation of medical visualisation tools, emphasising the fact that these tools must be based on medical user requirement and work flow studies as well as on new technical developments. childhood osteomyelitis is a relatively rare finding in childhood with an estimated annual incidence of 1 per 5000 and is predominantly seen in young children (< 5 years). it can be caused by via haematogenous spread, contiguously from local areas of infection or from penetrating trauma or surgery. usually it is caused by bacterial infections, but occasionally fungi, viruses or parasites are causative agents. clinical findings can range from mild to severe and depends on many factors such as age, site of infection, acute versus chronic osteomyelitis, and causative agent. the crp and sedimentation rate are usually elevated; however, this is not always the case. given the variability in clinical presentation radiology plays a crucial role in the detection of osteomyelitis. although conventional radiography (cr) has a limited sensitivity and specificity for the diagnosis of osteomyelitis, its wide availability makes it the first diagnostic technique of choice in children. for further analysis both mri and radionuclide bone scintigraphy (rbs) have shown to have a high sensitivity for the detection of osteomyelitis. the advantages and disadvantages of both the techniques will be addressed. ct mostly plays a role in the diagnosis of chronic osteomyelitis or in the pre-surgical work-up. the use of radiology also allows for a differential diagnosis of osteomyelitis, based on clinical cases, an overview of this differential diagnosis will be given. the aim of this lecture is to present an evidence-based diagnostic strategy for childhood osteomyelitis. developmental dysplasia of the hip (ddh) is the most common musculoskeletal disorder in childhood, with a reported prevalence of 1-4% according to method of ascertainment and definitions used. ultrasound has enabled a detailed view of both neonatal hip stability (nhi) and morphology, and two different schools have developed; one arguing that nhi alone is the major pathology warranting splinting, the other including acetabular dysplasia as an important feature. both static (graf, morin) and dynamic (harcke) ultrasound techniques, as well as a combination of the two (modified graf (rosendahl)), have been described and are currently used. in europe, graf's ultrasound technique or a modification of this is commonly used within the german speaking countries and areas, in parts of scandinavia, the uk, italy, france, hungary and the netherlands. others use a modified morin's method while harcke's method is used only occasionally. initially, universal ultrasound screen-(helium or xenon), oxygen-enhancement or other technologies. all of these might also provide quantitative read-outs for disease and/or therapy monitoring. learning objectives: 1. to learn how ct and other imaging methods can be used to examine the structure-function relationship in sad. 2. to review the state-of-the-art imaging methods that can provide information about disease extent, disease activity and global and regional lung function in patients with sad. 3. to become familiar with the current use and the future developments of these techniques. panel discussion: signs of small airways disease can be seen on ct but when and why do they really matter? 09:44 signs of small airways disease are a frequent finding on ct especially when expiratory scans are performed in addition to inspiratory scans. when should we report these changes? are they always important, do they perhaps predict the development of more severe disease, or are there cases where they have little influence on diagnosis and therapy? when should an expiratory scan be performed? careful preoperative staging and preoperative using high-resolution mri together with preoperative multidisciplinary team discussion has been shown to reduce margin involvement by tumour from 30% to < 5% by identification of patients that require more radical preoperative therapy and surgery. the detailed demonstration of preoperative prognostic factors also recognises patients on imaging that are not at risk of local recurrence and therefore the avoidance of unnecessary preoperative therapy in a proportion of patients. the use of eus can help in the assessment of early stage flat lesions suitable for local excision and is a powerful complementary tool. pet-ct is crucial for the preoperative work up of patients undergoing radical procedures such as metastatectomy. follow-up for colorectal cancer patients at high risk for developing recurrent disease is now well established, and the emergence of specialised multidisciplinary teams, combined with a range of treatment options for recurrent disease has improved curative resection rates following metastatectomy and pelvic recurrence surgery. radiologists with a solid understanding of not only the pathological manifestations of primary and recurrent rectal cancer but also the treatment options available play a key role in enabling the appropriate selection of patients -increasing overall cure rates and reducing treatment-related morbidity. this refresher course aims to provide radiologists with an understanding of local staging of rectal cancer, the assessment of recurrent disease, and assessing response to treatment. the course will highlight how imaging underpins the key preoperative decisions for surgical and oncological treatment planning in rectal cancer. a. staging with us and ct a. maier; vienna/at (andrea.maier@meduniwien.ac.at) for rectal cancer surgery a variety of alternative operations are currently possible. furthermore, there is an increasing trend towards treating patients with radiotherapy before surgery. the choice of operation and the decision whether to employ radiotherapy is based on preoperative staging. in patients with primary rectal cancer accurate assessment of tumour extent and the presence or absence of lymph node invasion are factors for determining prognosis and risk of tumour recurrence. endorectal ultrasound (eus) is effective for t-staging. it has been recommended as the investigation of choice in the selection of potentially curative local excision. lymph node staging by this method is less precise than tumour staging. initial reports of the use of ct for tumour staging were encouraging. studies which compare ct with eus staging consistently show the latter to be more accurate for both tumour stage and lymph node stage. thus, the usefulness by the speakers at the end of the session. at the other end of the clinical and imaging spectrum to obliterative bronchiolitis is exudative small airways disease, typified by (japanese) diffuse panbronchiolitis. the exudative bronchiolitides are characterised by direct signs on hrct, notably a tree-in-bud pattern. while this is a readily appreciated and specific sign, other diseases that mimic this hrct finding will be discussed. bronchiectasis of variable severity is a usual accompaniment to both obliterative and exudative bronchiolitis and the relationship between large and small airways disease will be explored. the instances in which hrct findings of obliterative and exudative bronchiolitis co-exist are relatively few, and the differential diagnosis for this situation will be considered. in practice, hrct will often show signs of bronchiolitis (whether obliterative or exudative) limited to a segment or even subsegment, and the interpretation of the clinical significance of such a chance finding is sometimes a difficult judgement. learning objectives: 1. to become familiar with the direct and indirect signs of small airway involvement on ct. 2. to know how to correlate these signs with the pathological changes. 3. to understand the differential diagnosis with other diseases that can show similar ct findings. from pattern to diagnosis c. beigelman; paris/fr various schemes of classification of sad have been proposed according to clinical, pathologic or imaging criteria that are confusing. an optimal approach, mainly based on ct analysis of direct and indirect features, usually allows the recognition of the two main types of sad, namely inflammatory/exudative and fibrotic/constrictive/ obliterative bronchiolitis. a miscellaneous group that corresponds to bronchiolar involvement in diverse diffuse lung diseases may also be individualised. direct signs of sad that refer to direct visualisation of diseased bronchioles strongly suggest inflammatory bronchiolitis. they mainly consist in centrilobular nodules with tree in bud appearance. conversely, indirect signs mainly represented by mosaic attenuation, air trapping, bronchial wall thickening and dilation characterise fibrotic bronchiolitis. volumetric acquisition, performed a dose reaching that obtained with classical hrct protocols, may be of interest in several ways. particularly, maximum intensity projection tool may facilitate the recognition of the tree in bud pattern. the minimum intensity projection mode may optimise the recognition of the mosaic attenuation pattern requiring an appropriate contrast resolution, as well as the analysis of proximal airways. expiratory ct, optimally performed on a dynamic mode, may be useful in some conditions at a dose equivalent to around 2 chest x-rays. a combination of post-processing tools from a volumetric acquisition performed with carefully chosen parameters might therefore appear useful in the evaluation of sad. furthermore, additional co-existing findings such as ground glass opacity or other features of interstitial pneumonias may be detected. their analysis may help to recognise the cause of sad in addition to clinical data. structural changes associated with sad are difficult to depict directly on ct. indirect signs of sad, such as mosaic attenuation on an inspiratory scan and/or air trapping on an expiratory scan, are common findings. they nicely illustrate the structure-function relationship between obstruction or expiratory collapse of the small airways and the subsequent effects on ventilation (local hyperinflation) and perfusion (hypoxic vasoconstriction). these "functional" signs are thought to be more sensitive than the direct visualisation of the underlying structural changes. careful interpretation and software tools help to generate data about disease extent as well as global and regional lung function. beyond paired inspiratory-expiratory ct scanning, dynamic expiratory cine as well as perfusion and ventilation imaging on the basis of both, ct and mri, can be applied to increase sensitivity, specificity and accuracy of the diagnosis of sad. some of them are ready for routine clinical use, such as dynamic expiratory cine ct, cine mri during continuous breathing as well as gadolinium-enhanced perfusion mri. future developments in the fields of ct and mri will provide novel technical approaches for functional imaging of sad. these will include novel applications of dual energy/spectral ct using iodine-enhancement for perfusion and xenon-enhancement for ventilation enhancement as well as ventilation mri using hyperpolarised gases to understand the advantages and limitations of bi-rads in clinical practice to appreciate the potential of an automated analysis of the descriptors to trace continuous modifications required by technological advancements. 4. to review bi-rads categorisation with case illustrations a. how i do it p. richards; stoke-on-trent/uk (paula.richards@uhns.nhs.uk) 1 . always report in the same logical manner for each examination, which imprints normal pathology 'jumps out at one'. 2. evaluate all images before looking at the clinical information to prevent bias and satisfaction of search. 3. review every scout image. scoliosis transitional vertebrae and pseudoarthrosis become more obvious on coronals. single kidneys, hydronephrosis and renal tumours may explain 'back pain', especially if there are mets. 4. review any x-rays or old ivus, remembering that abdominal x-rays show the spine. 5. indications; summarise the reason for the scan. think of the differential diagnosis to exclude. 6. technique; allows one to check the levels scanned. be sure there has been no area missed between 2 studies. 7. report vertebral alignment and disc height. 8. mri just like an x-ray, i.e. there is normal alignment from d10 to s3. 9. start at the far sagittals and look at the nerve roots in the 'key hole', the pars and facets. 10. determine the worst abnormality on the axials and report the most significant findings first. check the facets at each level. 11. have a checklist of normals at the end; 'the bone marrow, cord and csf return normal signal. the conus ends normally with no pars or metastasis'. 12.opinion: explain what you think is causing the patient's symptoms. assume this is the only part read, so if there is only one kidney reiterate here. the lecture will illustrate additional information on scout images and benefits of coronal images. learning objectives:1. to understand the influences of patient positioning, scan parameters and magnet/coil technology on image quality. 2. to learn how to optimise scan protocols to maximise patient throughput without compromising diagnostic quality. 3. to recognise how and when to modify scan protocols to answer specific clinical questions.a-371 14 the lumbar spine undergoes morphological changes with age. normal appearances and relevant normal variants will be discussed. in particular, the morphological change from an almost round intervertebral disc in newborns with high water sig-postgraduate.educational.programme s102 a b c d e f g h radiotherapy is an area with a rapidly improving development of new techniques and improved possibilities for accuracy. this lecture aims to illustrate and discuss points of contact and the need for collaboration between radiotherapy and radiography. european educational programmes and working fields for radiotherapy nurses and radiotherapy technicians are compared. radiotherapy nurses and radiotherapy technicians are responsible for the administration of radiotherapy to cancer patients and for the clinical care related to the treatment. apart from prevention and treatment of side effects and psychosocial support during the treatment, it encompasses preparations, delivery and verification of the radiation dose. educational programmes differ in terms of academical level and target groups, whether it is nurses or technicians in radiology or radiotherapy exclusively. areas in the radiotherapy process where competences from radiography are needed are discussed, considering both technical development and research progresses. learning objectives:1. to gain knowledge about the differences and similarities between the areas of education and profession in radiography and radiotherapy from a historical perspective. the demand from the public for greater accountability and standards has increased the importance of audit and accreditation in modern healthcare delivery. specifically radiology departments participate in audit and accreditation by a number of entities. these include: 1. national bodies concerned with improving radiation safety particularly originating from eu 97/43 directives. 2. hospital wide accreditation surveys from state and private accrediting organisations. 3. auditing of standards from within professional bodies. 4. following from investigation of specific incidents such as misdiagnosis or radiation concerns. 5. modality-specific standards.although the specific requirements of the accrediting or auditing body may differ, the processes and practical aspects in demonstrating compliance with standards and quality improvement are generally similar. mechanisms such as outcomes, quality cycles, and performance indicators are critical in the success of any accreditation or audit program. in addition to fulfilling basic regulatory requirements, the medical physicist is playing an increasing role in developing performance indices particularly in radiation safety, clinical image quality and equipment management. the increasing role of the medical physicist in audit underpins the requirement for inclusion of audit and accreditation as part of their education. recent experience of setting up and participating in eu 97/43 directive-based clinical audit in ireland highlighted the critical need for clarity of roles and ownerships of processes to be communicated to those who are carrying out audit and those who are being audited in hospitals and dental practices. performing imaging studies in a child requires basic knowledge. the first point is to reassure and to avoid stressful/painful procedure. training of radiographer and radiologist is fundamental. explanations, presence of a parent (if not pregnant…), are preferable. specific devices may be useful for immobilisation and to avoid repeated exposures. antalgic drugs (traumatic circumstances) or sedative nitrous oxide inhalation (mcug) may be useful. x-rays exposition in relation with conventional radiology is lower than the one encountered with ct. but dose depends on type of examination and also on imaging equipment. new devices, such digital fluoroscopy with x-rays pulsed emission, flat-panel detector, slot-scanning x-ray imager need less ionising radiation than conventional screen-films devices or even photostimulable phosphor imaging plates. the scale between the higher and the lower dose for the same examination can be from ten to one. common principles of protection that apply to all x-ray imaging procedures, known as alara concept (as low as reasonably achievable), have to be used daily. act in accordance of the medical justification of the examination, without any non-ionising alternative method, remains the first step. the second one is the optimisation of each procedure, the limitation of expositions, with control of the x-ray beam adjusted to optimise the critical balance between image quality and exposure to the child. measure of the dose is mandatory to demonstrate appropriate levels on child exposure and to be sure in the future that very low radiation doses received during conventional imaging procedures will not produce adverse effects. the council directive 97/43/euratom introduced the concept of clinical audit to medical radiological (diagnostic radiology, nuclear medicine and radiotherapy) procedures. clinical audit is a systematic review of the procedures in order to improve the quality and the outcome of patient care. according to the directive, clinical audits shall be implemented in accordance with national procedures. the review of its implementation in europe has revealed a high variation of approaches and many practical problems. therefore, the european commission has published further guidelines on clinical audits in its report radiation protection no. 159 (2009). the purpose is to improve the implementation of clinical audits and to enable the member states to adopt the model of clinical audit with respect to their national legislation and administrative provisions. the guideline points out the importance of both internal and external assessments for clinical audit. it deals with all types and levels of clinical audit and gives practical guidance for application. it defines the list of topics which should be covered, while the actual criteria of good practice are discussed on generic levels only. the borderline between clinical audit and other quality assessments (accreditations, certifications, peer reviews) and regulatory inspections is also discussed. the guideline is addressed to all professional groups, hospital management, auditing organisations and regulatory bodies. it is important to recognise that the guideline is not a legal requirement. this refresher course lecture will give a summary of the ec guidelines and discuss briefly the implementation of clinical audits in europe.learning objectives: 1. to understand the purpose and essential contents of the european commission guideline on clinical audit. b. national perspective: clinical audit inspections s. ebdon-jackson; didcot/uk (steve.ebdon-jackson@hpa.org.uk) european council directive 97/43/euratom requires under article 6 (4) that "clinical audits are carried out in accordance with national procedures". implementation of this requirement across europe has been varied. this paper will reflect on the experience in the uk and will consider examples of the various initiatives undertaken in the uk by professional bodies and organisations. this will be contrasted with the role of the regulator and the aims of the inspection process with regard to compliance with the specific regulation addressing clinical audit and the remaining regulations addressing justification, optimisation, etc. examples will be provided of the type of audits undertaken within uk hospitals. a uk perspective of ec and iaea initiatives in clinical audit will be provided. percutaneous radiofrequency ablation (rfa) is a safe and effective treatment for well selected patient with hepatic tumours such as hepatocellular carcinoma (hcc) and liver colorectal metastases (lcm). an appropriate selection is crucial. it is based on clinical and technical arguments. clinically, surgical resection of the haepatic tumours remains the gold standard. indeed, survival data following rfa are not as good as surgical resection. the only exception seems to be the rfa of the very early hcc (≤3.0 cm) in cirrhosis that is not candidate for liver transplantation. most often, the rfa offers an alternative for patients with medical comorbidities, poor liver function or prior hepatectomy. technically, there are three decisive points for complete ablation. the first point is the good visualisation of the tumour either under ultrasound or un-enhanced computed-tomography (ct) examination. metallic coil placement, lipiodol tattoo and virtual ct sonography with magnetic navigation are technical tricks that allow the rf ablation of "invisible" tumour. the second point is the tumour size: in most series, a diameter less than 25-35 mm is commonly admitted as a prognostic factor. this is probably because the maximal ablation diameter is slightly larger than 40 mm with the electrode needles available now. micro-waves ablation might improve the local control by increasing the ablation diameter. the last point is the "heat-sink effect" that requires a temporary occlusion of a large vessel close to the tumour. the quality of follow-up imaging is a key factor for evaluation of tumour destruction. partial hepatectomy for liver metastases or primary liver tumours can only be performed when the future remnant liver volume (frlv) is considered large enough to avoid the risk of post-operative liver failure. in normal livers a frlv of 25-30% is considered safe whereas in compromised livers a frlv of at least 40% is required. in patients whom the flrv is considered to small, pve may be performed pre-operatively to increase the frlv. pve involves percutaneous selective embolisation of the portal venous (pv) system, usually of the right liver lobe, which leads to atrophy of the embolised lobe. this, in turn, leads to hypertrophy of the frlv. because of the dual vascular supply to the liver (arterial and portal venous), necrosis of the embolised lobe does not occur. this compensatory hypertrophy of the left lobe facilitates resection in patients in whom the frlv would otherwise have been to small to allow resection. pve is most often performed percutaneously under conscious sedation and local anaesthesia through an ipsilateral approach, using a combination of particles, such as polyvinyl-alcohol (pva) and embolisation coils. potential complications of pve include thrombosis of the contralateral pv, liver abscess formation or cholangitis and are rare. most of the hypertrophy occurs in the first 3-4 weeks after pve and increase in volume of the frlv averages 12% after this time period. ct-volumetry should be performed both before pve and after 3-4 weeks to measure increase in frlv. accurate identification and reporting on soft tissue extremity masses is essential for correct diagnosis and optimal treatment planning. this lecture focuses on the mri signs to stage and grade-characterise soft tissue mass lesions. these two objectives are the major structural components of the mri report and fit the request of the referring clinician. this implies an accurate description of these signs with appropriate terminology in the report. local staging is essential for the preoperative work up. important staging parameters are size, compartmental location, skip lesions and relationship to neurovascular structures and joints, as well as distance to the nearest joint space. grading and characterisation is complex and multifactorial and classifies the lesions as "certainly benign" (no biopsy needed) and "possibly " or "certainly malignant" (biopsy needed). grading parameters are homogeneity, (changing) signal intensities in multiple acquisition techniques and static and dynamic gadolinium enhancement pattern. these are used to define the composition of the lesion, i.e. fat, met-hb, hemosiderin, myxoid tissue, collagen, viable, cystic or necrotic components. other important grading and parameters are lesion margin, shape, perilesional invasion or destruction, multiplicity, specific location and associated findings but also age and gender of the patient. image guidance and imaging fusion techniques represent an integral element in oncologic interventions and liver surgery. in addition, several liver planning techniques such as the virtual liver surgery planer enhance simulation of a proposed liver resection. using roboter-assistance or navigational guidance combined with thermal ablation techniques such as radiofrequency ablation, significantly enhances accuracy of ablation probe placement and efficacy of ablation necrosis. furthermore, the local recurrence rate can be considerably reduced, and the amount of complete tumour ablation is significantly more likely. integrating magnetic resonance imaging, and focused ultrasound to deliver and activate nano-capsules carrying anti-cancer drugs to effectively target tumours will be another task. this will involve drugs being injected into the body in the form of tiny capsules, which are harmless until they are activated by a concentrated focused ultrasound `blast'.the mri scanner will then be used to track the passage of the drugs, visualise the target and monitor the delivery of the drug treatment. the risks associated with radiation exposure in ct is of concern to radiologists, medical physicists, government regulators, and the media. thoracic ct is a technically robust, non-invasive imaging technique for the evaluation of several traumatic and non-traumatic thoracic emergencies. technical advances in the past years have resulted in improvements in image acquisition speed, spatial resolution, and the temporal resolution. consequently, thoracic ct can now be performed rapidly in emergency conditions without substantial delay in treatment. state-of-the-art ct systems are now capable of imaging the entire thorax within a few seconds. however, radiation exposure associated with thoracic ct have been increased with the advantages of modern ct systems particularly in the evaluation of chest pain syndrome. thoracic aortic ct angiography with cardiac gating may now be considered the preferred technique for the evaluation of chest pain syndrome in selected patients but is associated with a substantial higher radiation dose than routine non-gated thoracic ct. several effective strategies have been developed to limit the radiation exposure in cardiac gated thoracic ct including prospective ecg gating techniques, anatomy and ecg-based tube current modulation, high pitch acquisition, and adaptation of the ct scanning parameters to the body habitus. in addition, several techniques are available to reduce the radiation exposure in nongated thoracic ct depending on the patient's body habitus and the clinical indication. because of advancing technical developments and increasing diagnostic utility of mdct in emergency care, its use has expanded significantly and has changed patient care, especially in chest emergencies. however, mdct has important drawbacks in cost and radiation exposure. the first presentation will discuss mdct in acute chest pain (acp). scan techniques in different scanners will be addressed. the reasons why cta/ctca can be a viable application for acp and the current evidence for cta in acp will be discussed followed by an update on indications. the next presentation will address mdct in chest trauma. its significance, the utility of this imaging method and its advantage compared to other modalities will be discussed. the examination protocol and the role of post-processing methods will be addressed. the interpretation of mdct, findings, benefits, limitations and pitfalls will be shown. the utility of chest x-ray and ultrasound as primary examinations and the indication for mdct, routine or selective, will be discussed. our last speaker will familiarise us with procedures to measure radiation dose in thoracic mdct, followed by an update of radiation exposure associated with the protocols for the different clinical indications. finally, available techniques for radiation dose reduction in ecg-gated and non-gated mdct and their effectiveness in radiation dose reduction will be demonstrated. however, the best way to reduce radiation is to perform mdct only when there is an appropriate indication and this will be the focus of the concluding panel discussion of this session. chest trauma is, particularly in younger population, a significant cause of morbidity and mortality. it is directly responsible for 20-25% of trauma-related deaths and in other 50% of deaths it is an important contributing factor. imaging methods play the key role in management of this group of patients. introduction of mdct in the last decade of the 20 th century markedly changed the diagnostic approach to the thoracic trauma. fast data acquisition and increased resolution in the z-axis enabled reliable assessment of all chest anatomical components (often together with other parts of the body) in one examination. compared to x-ray mdct defines more accurately the extent and severity of traumatic changes and may detect serious in 85% of nontraumatic cases, subarachnoid haemorrhage (sah) is the result of aneurysmal rupture. other causes of sah include perimesencephalic sah (10%) and other disorders (5%) such as arteriovenous malformation (avm), vertebrobasilar artery dissection, dural av-fistula, cortical vein thrombosis, amyloid angiopathy, … sah represents an emergency situation and diagnosis should be established asap.plane computed tomography (ct) is the initial diagnostic test of choice (wide availability, easy accessibility, high sensitivity and specificity). if ct is negative, lumbar puncture and/or mri of the brain (including flair images) and spine should be performed. 3d tof mr angiography (mra) sequences have high sensitivity and specificity in detecting cerebral aneurysms; but because of their lower spatial resolution are insufficient to analyse in detail aneurysm morphology. this in contrast with cta. both cta and mra may be proposed as a first-choice, noninvasive examination, but the negative predictive value is poor, and therefore digital subtraction angiography (dsa) is mandatory for all sah cases with negative cta or mra. catheter angiography remains the golden standard in the detection and evaluation of cerebral aneurysms (size, relationship between neck and adjacent vessels, etc). increased attenuation (ct) and hyperintense signal (flair) within the basal cisterns and sulci are a characteristic finding of sah; however, it is aspecific. pattern and location of the blood may help to locate the ruptured aneurysm; sometimes helpful when multiple aneurysms are found. pseudo-sah may be a potential imaging pitfall because it may be observed in other acute neurological conditions (cerebral edema, bacterial meningitis, etc). recurrent disease following treatment for primary breast cancer can occur in the same breast following conservation surgery, ipsilateral breast tumour recurrence (ibtr) or in the contralateral breast, metachronous contralateral breast cancer (mcbc). estimations for the rate of recurrence are between 04 and 0.8% each year. the rate of recurrence is higher than breast cancer incidence in the general population. risk factors for recurrence are young age (< 50), high grade disease, incomplete tumour excision and no radiotherapy. due to the large numbers of women who develop and survive breast cancer the cost and resource required to follow-up these women is considerable. there are variable guidelines in europe for the surveillance of women but most regimes include clinical follow-up and mammography. variations concern the frequency of mammography, the length of follow-up required, and whether clinical examination is required. the clinical effectiveness and cost-effectiveness of different surveillance mammography regimens after the treatment of primary breast cancer will be reviewed together with the results of systematic reviews. modelling of two data registries was undertaken to ascertain the survival benefit. alternative methods of surveillance will be considered such as mri with the diagnostic accuracy of the various imaging techniques considered. a summary of the economic evaluation will be presented to demonstrate the assumptions that require to be made in this complex area where there is a paucity of evidence.learning objectives: 1. to understand the risk of recurrent disease and second primary following the treatment of breast cancer. 2. to review literature on surveillance mammography and other imaging methods for detection. 3. to appreciate the range of recommendations for surveillance mammography and clinical follow-up with cost benefit analysis. the new challenge in breast cancer: evaluation of response 17:14evaluation of the treated breast is one of the major challenges in breast imaging.there is especially much debate on the evaluation of response to therapy. the best imaging modality, the best imaging criteria, timing, accuracy and limitations of imaging are currently being investigated. whether it is time to reach conclusions regarding these aspects is the issue of this panel discussion. intracranial aneurysms are abnormal dilatations of the arteries, and will be found in 1% to 14% in general population. in 90% cerebral aneurysms are saccular and develop from the arteries of the circle of willis or its major branches. aneurysms typically become symptomatic between the age of 40 and 60 years, with subarachnoid haemorrhage (sah) or intracerebral haematomas. less common are giant aneurysms usually found in middle-aged women presenting with signs more indicative of a mass lesion. ct angiography (cta) has been proven to be an excellent tool to visualise intracranial arteries. the average sensitivity of cta for the detection of intracranial aneurysms reaches 90%. post-processing allows assessment of the aneurysm with maximum intensity projections (mip) and surface-rendered 3d projections in multiple plains. mr angiography (mra) is a practical and noninvasive tool for screening of high-risk individuals for aneurysms. dsa is diagnostic method of choice for assessment of intracranial aneurysms and was considered to be a 'gold standard' for evaluation of cerebral vessels. a clear shift from invasive to noninvasive imaging of cerebral vessels has been noticed in the last decade. this lecture will discuss advantages and disadvantages of cta, mra and dsa in detection, assessment, and post-treatment evaluation of intracranial aneurysms. intracranial aneurysms have a multifactorial origin. a heterogeneous and complex group of pathogenic mechanisms including luminal, mural and extramural factors interact for the development and growth of aneurysms. there are several types of intracranial aneurysms, being the saccular the most common type. the aneurismal treatment is dependent on its type and needs a multidisciplinary approach including endovascular and microsurgical teams. endovascular treatment is recognised as the first-line treatment for most of the ruptured saccular intracranial aneurysms. there has been an enormous improvement in the endovascular technology and techniques offering a wide spectrum of treatment possibilities that broadened the variety of aneurysms that can be treated. the treatment options include the use of coils with/without the help of balloon-remodelling and/or stenting. other options include the use of covered stents, of "flow-diverter" stents, of liquid embolics, or the parent vessel occlusion. the multislice computer tomography angiography (mscta) is a reliable method for pretreatment evaluation of intracranial aneurysms. for the posttreatment evaluation, magnetic resonance angiography (mra) can be used for the follow-up of embolised aneurysms; and mscta may be used for the follow-up of surgically treated aneurysms. there are several challenges remaining in aneurysm management. in the diagnostic field, improvement of the non-invasive techniques for the diagnosis, for the morphological and haemodynamic characterisation and for the posttreatment follow-up of aneurysms is expected. in the endovascular field, technological breakthroughs to improve the occlusion rate, to increase the treatment durability, and to promote the vessel wall healing are desired. learning objectives:1. to learn about present treatment of brain aneurysms. 2. to understand the strategies for multimodal ct and mr aneurysm imaging pre and post-treatment. 3. to present the challenges for neuroimaging in the field in the near future. where do we stand in brain aneurysm treatment today? 17:14there is a significant difference in the management of patients with ruptured versus un-ruptured brain aneurysms. this panel discussion will focus on the management of patients with brain aneurysms and will with simple case presentations show the management in ruptured and un-ruptured aneurysms and discuss the involvement of the neurosurgeon in more complex cases.cone beam ct (cbct) is a method for obtaining ct-like images using a c-arm system. our aim was to investigate the accuracy of these images compared with multi-detector ct (mdct) as a gold standard in radiological imaging of abdominal aortic aneurysms (aaa). 40 patients with aaa referred for elective evar were included in a pre-therapy protocol (20 patients) and in a post-therapy protocol (20 patients). all were exposed to standard mdct and one additional cbct. image data were evaluated by two radiologists and statistically compared using a linear mixed model. first, 6 predefined arterial measurements were performed, then 9 predefined anatomical areas were assessed and scored for visibility on a scale from 1 to 4. all measurements were chosen to be relevant for evaluating of aaa before and after evar. for the arterial measurements no significant differences were found between mdct and cbct. visibility for the anatomical areas was significantly better for mdct; however, most of the cbct readings were above lowest acceptable level. visualisation of the iliac arteries was suboptimal. we think that our results support the start of clinical trials that scientifically can test the outcome without the use of mdct immediately before and after evar. the problem with poor visualisation of the distal iliac arteries might be solved with newer technology. in conclusion, the result indicates that cbct in the operation room gives sufficient image-based information to support evar in a pre-and post-therapy setting. undertaking theatre radiography can appear a daunting task for the radiographers lacking in confidence in their ability but others (like all expert practitioners) make it look easy and uncomplicated. theatre radiography requires all the knowledge, skills and abilities of a competent radiographer together with assertiveness, reflection and the ability to modify your technique at a moment's notice. there are a multitude of 'traits' which distinguish the expert from the novice. these include production of optimum images, effective use of the equipment, radiation protection, infection control, effective communication and teamworking. there is also a clear depth of knowledge together with a multitude of skills and abilities. the key to a stress-free experience is preparation. it is essential that there is a mechanism for theatre staff and the radiology department to communicate effectively and give the radiographer prior notice of all cases requiring their attendance. it is also desirable to be in the theatre when the patient arrives for their examination to enable you to check the patient's identity, pregnancy status and ensure the patient is positioned correctly to facilitate screening. there are few excuses to give the surgeon if you cannot screen the area of interest because of poor positioning of the patient and equipment. this paper will discuss the knowledge, skills and abilities required to undertake theatre radiography in a safe and proficient manner without feeling threatened by the experience. learning objectives: 1. to understand the key skills required to undertake radiographic procedures in the operating theatre. 2. to gain an insight into the interpersonal skill required for effective radiographic practice in the operating theatre. prediction of coronary revascularisation outcome represents a major clinical question because a large number of medical and surgical options have become available for ischaemic cardiomyopathy with need to identify more rigorous criteria for patient's selection. the combination in a single examination of function, stress-perfusion and tissue characterisation with t2-weighted 'oedema-sensitive' and late-gadolinium enhancement (lge) techniques supported the role of cardiac mr (cmr) as an important technique for the evaluation of patients candidates to revascularisation. besides more "traditional" indicators such as ejection fraction, end-diastolic wall thickness or endsystolic volumes, extent and distribution of myocardial scar depicted with lge has been identified as one of the most important predictors of post-revascularisation outcome with direct influence on functional recovery and on major adverse cardiovascular events (mace) due to the potential induction of arrhythmias from the scar.lge technique has been shown to be superior to nuclear medicine for the assessment of myocardial viability due to the higher spatial resolution (up to 60-fold greater than spect) and an intrinsic high contrast resolution. a further technique that could be adopted before revascularisation is stress imaging. myocardial ischaemia detected by either cmr adenosine first-pass perfusion or dobutamine-induced wall motion abnormalities has been shown to predict subsequent cardiac death whereas normal stress perfusion showed a high negative predictive value for mace. in conclusions, although as a relatively new diagnostic modality prognostic evidence is predominantly derived from singlecenter studies, cmr is increasingly becoming an important tool for risk stratification of patients before revascularisation, offering indications about outcome and mortality. cardiac valve diseases are an important public health problem, strongly linked to the general increasing age of the western population. the most frequent valve disease is aortic stenosis, for which percutaneous aortic valve replacement (pavr) is currently evolving to a feasible alternative therapy for the classical surgical approach in high-risk patients. nevertheless, careful evaluation of all aspects of this new approach is still required to avoid uncontrolled diffusion. imaging plays a key role in selecting patients who may be eligible for pavr, focusing on the evaluation of leaflet anatomy, severity of valve dysfunction, haemodynamic consequences and potential problems in the access route. while echocardiography is commonly used for both the anatomical and functional evaluation, multidetector ct (mdct) has important intrinsic advantages providing state-of-the-art 3d imaging with a high spatial resolution over a large anatomic coverage. during this course, we will discuss the advantages and disadvantages of mdct compared to other imaging modalities. the relevant anatomy of the aortic valve and annulus will be reviewed, with emphasis on correct alignment of the imaging planes, and its implications for correct reporting of the necessary measurements targeted at the clinicians need. furthermore, mdct scan protocol design will be reviewed, focusing not only on optimal implementation of common scan parameters but also on the need of ecg-triggering and its consequences. finally, we will present the current status of evidence on using mdct in pavr procedures, and discuss future challenges and perspectives. learning objectives: 1. to understand how to optimise the imaging protocol for aortic valve imaging. 2. to learn how to report the findings and what to include in the report. 3. to understand the impact of this approach on patient management. the need for quantitative image analysis in radiology is universal: computer-aided detection, segmentation for 3d volume visualisation, image enhancement, pattern recognition, etc. all need effective, robust and preferably generic (not 'ad hoc') algorithms for the computer. how to design such algorithms? a good inspiration source is the functionality of the visual system, the best investigated brain structure today. in this talk we will explain how we think the brain calculates features in images, why the retina measures at a wide range of resolutions and how we can exploit this. the visual system is strongly adaptive and self-learning. new optical recording techniques have given new insight in how the cells in the visual cortex are functioning. we will go through these functionalities step-by-step. what we discover is quite amazing. we recognise huge amounts of filter banks in the first stages of vision: many filters analyse each pixel of the incoming image at a range of scales, orientations, derivative order, for each colour, and also as a function of time. extensive feedback loops take care of optimal settings locally. we programmed these filters into the computer, and were able to build many interesting applications for computer-aided diagnosis: detection of catheters at seriously reduced levels of x-ray radiation dose, automatic polyp detection, quantitative analysis of ischaemic heart ventricle deformation, breast cancer cad, pulmonary emboli cad and analysis of in vivo microscopy images now so abundant in modern life-sciences research. postgraduate.educational.programmethe gi tract are leading causes but any tumour involving the abdominal cavity or haematological malignancy may be implicated. during treatment with chemotherapy or radiotherapy acute abdominal symptoms are common as a consequence of direct toxicity. imaging must be used as an adjunct to clinical assessment. patterns of abdominal involvement are often modified in the later phases of disease. gi tract obstruction may be due to progression or the mechanical consequences of prior surgery and is more commonly at multiple levels. perforation or fistulation may occur with either progressive disease or tumour lysis in response to therapy. cancer does not protect against the common inflammatory conditions but poor host response and the use of steroids may mask signs leading to extensive abnormality at diagnosis. bone marrow suppression increases susceptibility to infection including neutropenic enterocolitis and haemorrhage. bone marrow transplantation and consequent graft versus host disease is a potent cause of acute abdominal symptoms. ct is the major imaging technique although mr has an increasing role particularly in the assessment of the female pelvis. major determinants when considering the differential diagnosis include; the nature and initial stage of the primary, any prior anatomical modification (surgery), the nature and relationship to current treatment and the bone marrow status. this workshop will begin by describing the current limitations of mri in evaluating prostate cancer patients and will show how to overcome these with advanced imaging techniques including diffusion weighted mri (dw-mri), mr spectroscopic imaging (1h-mrsi) and dynamic contrast enhanced mri (dce-mri). the emphasis will be on the use of processing tools that are readily available for clinical practice. we will describe how to analyse images and provide a scheme for reporting findings back to surgeons/oncologists. we will show that using more than one mri tool improves imaging performance and that the relative importance of each technique remains unresolved. we will demonstrate new indications for advanced mri in prostate cancer patients. abdominal hernias are common in daily practice and can be divided into: external or abdominal wall hernias, internal hernias and diaphragmatic hernias. external hernias typically involve protrusion of abdominal contents through a defect in the abdominal wall. internal hernias involve protrusion of viscera through congenital or acquired defects in the mesentery or the peritoneum. diaphragmatic hernias involve protrusion of abdominal contents into the chest. among these conditions, the diagnosis of internal hernia is the most challenging. bariatric surgery and liver transplantation with biliary-enteric anastomosis, with the roux-en-y loop placed in a retrocolic position, are recognised predisposing factors for internal hernia development. symptoms of hernia are nonspecific and vague, and clinical and radiologic diagnosis can sometimes be challenging. immediate diagnosis is mandatory because misdiagnosis can be complicated by bowel obstruction, volvulus, strangulation, incarceration, or trauma. mdct with its multiplanar capabilities is widely believed to facilitate this diagnosis, because it is able to delineate hernia type, location, size, and shape and is particularly useful to diagnose unsuspected hernias. it also allows distinguishing hernias from masses of the abdominal wall, such as tumours, haematomas and abscesses. as a result, knowledge of the ct findings of abdominal hernias may allow early and more accurate diagnosis, with a resultant decrease in the mortality rate. the title of this talk limits the discussion of torsion to the mesentery and omentum. it has to be mentioned, however, that an abnormal twist (torsion) can involve any peritoneal reflection of those suspending and fixating hollow viscera, (e.g. stomach, small bowel, cecum, sigmoid and gallbladder), solid organs, (e.g. spleen, ovaries), or even extraperitonel (extraabdominal) organs such as the testicles, leading to the pathologic entity of volvulus or torsion of the corresponding viscous with its associated (different) imaging findings, prognosis and treatment. moreover, twisting of the mesentery and volvulus can occur secondary to a variety of conditions including congenital anomalies of intestinal rotation with variable prognosis. finally, torsion of the omentum can be either primary or secondary, also associated with different pathology, imaging findings and treatment. consequently, a broad spectrum of abnormalities ensues related to the pathophysiology of torsion which requires a detailed classification, an accurate description and the use of correct terminology making it impossible to be covered within the time limits of a presentation. therefore, focusing the discussion on to abnormal twist of small bowel mesentery and omentum will simplify the approach to avoid overlaps and confusion. this case-based lecture will present typical clinical cases of pelvic pain as well as some unusual but important causes. cases of acute and of chronic pelvic pain, and benign as well as malignant disease will be included. the audience will have the opportunity to participate in case discussion by the use of interactive voting pads. the selection of imaging modality for each clinical presentation and the importance of knowing the clinical findings at the time of the radiological interpretation will be discussed. for each case, the key radiological features will be illustrated. the essential elements of the radiology report and the key information required by the clinician will be discussed. in each case, the differential diagnosis and the need for follow-up imaging will be considered. the key teaching points for each diagnosis will be reviewed. this lecture provides a practical approach to the fundamentals of normal cross-sectional anatomy of the hip. basic knowledge necessary to identify the different portions and contents of the joint anatomy is provided. a special emphasis is on cartilaginous structures, the acetabular fossa, and capsular fibers and ligaments. functional anatomy of muscles and tendons about the hip is reviewed. the location of bursae and their association with adjacent structures is discussed. in the second part of the lecture attendees will learn how to avoid commonly seen pitfalls about the hip. a special focus on anatomic variants of the acetabular labrum simulating disease is given. osseous variants including acetabular ossicles and the superior acetabular notch will be explained and explored. debates about the role of herniation pits referred to as a normal variant are reviewed. the lecture offers an overview of muscular and tendinous variations around the hip joint. pelvic pain is an important part of clinical practice for any clinician who provides health care for women. pelvic pain may be acute, recurrent or chronic. acute pelvic pain (app) rarely lasts more than one month without crisis, resolution, or cure. pain of more than 1 or 3 or 6 months of duration is considered as chronic pelvic pain (cpp) and in many settings may be considered and treated as an illness itself. women who present with app frequently exhibit nonspecific signs and symptoms. diagnostic considerations encompass multiple organ systems, including obstetric, gynaecologic, urologic, gastrointestinal, and vascular aetiologies. as the first priority, urgent life-threatening conditions (e.g. ectopic pregnancy, appendicitis and ruptured ovarian cyst) and fertility-threatening conditions (e.g. pelvic inflammatory disease and ovarian torsion) must be considered. adolescents and pregnant and postpartum women require unique considerations. ccp is a common and significant disorder of women, with a prevalence of 3.8-12%. many disorders of the reproductive tract, gastrointestinal system, urological organs, musculoskeletal system, and psychoneurological system may be associated with ccp, the most common being endometriosis, adhesions, irritable bowel syndrome and interstitial cystitis. ultrasonography should be the initial imaging test because of its sensitivities across most aetiologies and its lack of radiation exposure. computed tomography (ct) serves an important role in patients with nonlocalizing symptoms, an indeterminate us evaluation, or in patients who require a wider search beyond the field of view available with us. magnetic resonance imaging is an extremely useful second-line modality for problem solving after us or ct. fat-suppression sequences help to establish fat-containing lesions and increase the conspicuity of inflammatory lesions. different sequences will be discussed. mr is rated below us and ct for evaluation of acute pelvic conditions, but is excellent alternative when administration of iodinated contrast media or radiation exposure is undesirable, especially in young or pregnant patients. long imaging times, limited access and cost are major drawbacks of mri. imaging findings of various gynaecologic and nongynaecologic conditions causing female pelvic pain will be presented. an overview of the interventional radiology management of painful osseus metastases will be presented. consideration will be given to patient, lesion and treatment modality selection (including radiofrequency ablation, cryoablation, microwave ablation, laser ablation, ethanol ablation, mr focused ultrasound ablation, cement osteoplasty, transarterial embolisation and combinations therein, e.g. combined radiofrequency ablation and cement osteoplasty). the evidence supporting these techniques and patient outcomes will be reviewed. molecular imaging -defined as the non-invasive assessment of biological mechanisms at molecular and cellular level -will play a major role in future disease diagnosis and treatment planning. in this context, the aim of this session is to introduce in simple terms several major research areas in molecular imaging and to discuss their future potential for clinical radiology. the differential diagnosis of hip pain is broad and includes intra-articular pathology, extra-articular pathology including referred pain from the spine, and mimickers including groin pain and pain from the joints of the pelvic ring. the diagnosis of all causes of hip pain/pathology has improved with greater use of magnetic resonance imaging (mri) to complement traditional investigations. in this session pathology involving the hip and groin will be reviewed in a systematic way which will outline an approach to the hip that will allow the reader to maximise their diagnostic ability. the review will include evaluation of bone marrow disorders such as avascular necrosis and transient osteoporosis and intra-articular pathology including labral tears and femoroacetabular impingement (arthritis and traumatic fractures will not be reviewed). extra-articular diagnoses such as bursitis, groin pain (osteitis pubis and adductor/ gracilis dysfunction) and common muscle and tendon injuries will then be reviewed. today, many procedures of bone and joint are performed under imaging control. minimally invasive procedures require less resources, time, recovery, and cost, and often offer reduced morbidity and mortality, compared to other modalities. many percutaneous techniques are available. some aim to treat pain and consolidate bone (cementoplasty). others ablate or reduce the tumour (chemical and thermal ablation techniques). the interventional radiologist with an efficient imaging-guided technique (flat panel fluoroscopy, ct, and mri) can increase the precision of the above-described procedures allowing an improvement of the results and reduction of the complications. furthermore, the presented interventions are carried out either on an outpatient basis or with 24 hours hospitalisation which contributes to the reduction of overall costs and presents a major advantage for patients of working age. some of these minimally invasive procedures can be considered as alternatives to surgery without excluding further surgical options if necessary. back pain is one of the most common complaints, it is estimated that almost 50% of working adults will experience it in any given year. diseases of peripheral skeleton may produce painful symptomatology as well. some of the algogenic structures of the spine and peripheral skeleton are lumbar intervertebral discs, facet joints and atlanto-axial/occipital joints, sacroiliac joints, nerve root dura, periosteum, ligaments, fascia. among several aetiologies which can involve these structures, spine degenerative pathology plays the leading role. nowadays, several different interventional techniques are available, each one with its specific target of action. with the right indication each of them has been proved to be effective as painkilling modality. herein, we present an up to date comprehensive overview on the interventional techniques available with their own indications. small airways and small airways diseases (sad) have attracted a lot of interest that has resulted in a large number of publications since the early 1970s. despite the several histopathological and clinical subtypes that have been described diagnosis is not always obvious. the introduction of thin section ct and the fact that this ct technique is able to depict signs of sad has not only renewed interest but has also improved insights in these disorders. in this session the direct and indirect ct signs of sad will be presented and the ct techniques that can improve their detection will be explained. correlations between pathological findings and the presence of these ct signs will be made and diseases that can mimic these ct findings will be discussed. schemes of classification of sad based on clinical and pathological findings will be discussed briefly, but most attention will be given to the radiological classification, which is based on the recognition of the direct and indirect signs of sad. algorithms that help to identify the cause of sad will be presented. finally, the use of ct and also of mr as a tool to examine the structure-function relationship in sad will be discussed. it will be shown how careful interpretation and software tools can help to generate data about disease extent and global and regional lung function. the ability to recognise direct and indirect signs of small airways disease on hrct has led to renewed interest in these elusive disorders. the "purest" of these diseases is constrictive obliterative bronchiolitis which is manifested on hrct by the indirect sign of a mosaic attenuation pattern; the differential diagnosis for mosaicism and an algorithm that helps to identify the correct cause of small airways disease will be presented. the necessity for routine expiratory hrct to make the diagnosis of obliterative bronchiolitis is controversial and will be discussed jointly whole body fluorescent imaging and bioluminescent imaging are now widely applied in small animals to study all kinds of biological and molecular processes like i.e. gene expression, tumour progression and metastasis, apoptosis, inflammation, angiogenesis, proteolysis and to follow trafficking, differentiation and fate of cells (i.e. stem-, immune-and tumour cells). this has been done mainly by using gene reporters expressing fluorescent proteins or luciferases. recently new mutated red shifted fluorescent proteins (with better light penetration and less absorption and autofluorescence) and codon optimized and mutated luciferases have been developed making optical imaging more sensitive and offering the possibility to use dual gene reporters. apart from new "smart gene reporters" there has also been a great development in injectable near infrared fluorescent (nirf) probes, especially for tumour detection. these nirf probes can either be targeted or enzyme-cleavable. these new developments has opened up the possibility to apply nirf imaging in the clinic especially to image tumour tissue and to identify sentinel lymph nodes during operation. the assessment of the tumour-free margin during cancer surgery is critical to completely remove the tumour and improve the prognosis of the patient. by injecting a tumour specific nirf probe, tumour tissue and local metastases can be visualised in real-time during operation using a dedicated nirf camera system. we now already use nirf imaging in the clinic to detect the sentinel lymph node (sln) in several types of cancers. in the current presentation preclinical and clinical applications of nirf imaging in image-guided surgery will be discussed. targeted ultrasound contrast agents have opened up the door for molecular imaging with sonography. these contrast agents, which consist of encapsulated gas microbubbles, are coated with antibodies or specific ligands. injected into the circulation, microbubbles are retained in diseased tissue where they can be detected and quantified by different approaches such as "semiquantitative 2-d" or "quantitative 3-d" imaging techniques. due to their size, microbubbles behave similar to red blood cells and remain within the intravascular space. therefore, the disease process must be characterised by specific molecular changes on the surface of the endothelial cells to be assessable by ultrasound. several angiogenic markers such as vegfr2, α v β 3 -integrins, icam-1 and vcam are known to be overexpressed by the endothelium in neoplastic, inflammatory and vascular diseases. thus, molecular ultrasound imaging seems perfectly suited to detect these markers and monitor changes which might occur during treatment response or disease progression. today, targeted ultrasound contrast agents are becoming a routinely used preclinical tool and the first application of specific microbubbles in a clinical scenario is expected for the near future. this talk will introduce into the principles of molecular imaging with ultrasound. based on recent studies, basics of tumour biology, potential endovascular targets, synthesis of molecular probes and different imaging approaches for a preclinical and clinical application of molecular ultrasound will be discussed. in this rc, a general insight of imaging in epilepsy, including indications, protocols, and the most common neuroradiological conditions to be identified, will be covered. particular interest will be given to tumours as a cause of epilepsy, and to their more relevant neuroradiological aspects. finally, the contributions of different imaging techniques in the specific context of epilepsy surgery will be reviewed. brain tumours are a common cause of epilepsy more often in adults, less in children.tumours detected in patients with chronic epilepsy are predominantly located in the brain cortex area, affecting the temporal lobe most often. any benign or malignant brain tumour can be responsible for seizures, but some are more frequently associated with epileptic symptoms. low-grade astrocytomas, oligodendrogliomas, gangliomas, dysembryoplastic neuroepithelial tumours (dnets) and glioblastomas multiforme are the tumours significantly often presenting with seizures in adult population. brain tumour-related epileptogenesis in not fully understood yet, but one can list a number of factors playing an important role in this process, including: disruption of physiological neuronal structure, tumour affection on the release of neurotransmitters and abnormal electrical activity of the brain. different imaging techniques are widely used for evaluation for neoplasms in epileptic patients. ct is reserved for acute conditions, one must remember to exclude other possible aetiologies of seizures like haemorrhage, trauma or inherited malformations. mri remains the gold standard in imaging investigation of patients with epilepsy. conventional pre-and post-contrast se sequences are mandatory to perform in every subject. newer and more sophisticated techniques such as diffusion-weighted imaging (dwi), functional studies (fmri), spectroscopy (mrs) and pet are helpful in qualification for surgery and preoperative functional mapping. mri has become established as the modality of choice for preoperative local staging of rectal cancer. the most important general advantages of mri compared to other crosssectional imaging modalities are the soft tissue contrast resolution between the propria muscle layer of the rectum and the perirectal fat, the ability to visualise the different pelvic compartments including the visceral pelvic (mesorectal) fascia and the surrounding tissues in the pelvis. high resolution t2-weighted sequences sagittal, transaxial and perpendicular to the tumour is the basic standard for morphological evaluation of the tumour, the distance of the tumour to the anal verge and for evaluation of extramural extension and the distance to the circumferential resection margin. presence of other adverse features such as extramural venous invasion and local lymph node metastases is also noted. the mr-images are ideally demonstrated by the radiologist in a local multidisciplinary conference to make sure that the information is used to select the best possible treatment for the patient. when neo-adjuvant treatment is administered, mri is usually performed both before and after treatment to assess treatment response. when planning surgery, both the pre-as well as the post-treatment images should be available for surgical planning. finally in this lecture, the potential benefits of 3 t compared to 1.5 t for pre-operative imaging of rectal cancer as well as the present role of additional techniques, such as diffusion-weighted imaging (dwi) and specific contrast agents that have been evaluated for assessment of rectal cancer will be addressed. locally recurrent rectal cancer is the main concern after rectal cancer surgery and has long been regarded as a rarely curable disease. patients were treated palliatively, and subsequent median survival was 14 months and the 5-year survival rate was 5%. however, during the past 20-30 years, more patients were considered candidates for curative treatment due to better treatment options. patients with distant recurrences from colorectal cancer, especially those in the liver or lung, have improved chances for cure with better imaging, better surgery and alternative minimal invasive treatment. in the follow-up after colorectal cancer surgery it is thus important to detect recurrences at an early stage. besides cea, imaging is often used as a surveillance tool. it is still unclear which is the most cost-efficient (imaging) tool for monitoring distant and local recurrences. this lecture aims at providing the evidence for surveillance by imaging and reviewing the guidelines for the detection of recurrences after colorectal cancer surgery. it will also discuss the role of mri for establishing resectability of locally recurrent rectal cancer and the imaging patterns and features of recurrent disease. its strength comprises a high sensitivity in detecting coronary stenosis > 50% and an excellent negative predictive value. the stringent limitation of cta lies in its confinement to anatomic grading of coronary stenosis and a lack of information regarding whether a stenosis causes reversible myocardial ischaemia indicating the need for coronary revascularisation. recently published data in animals and humans indicate that myocardial computed tomography perfusion (ctp) imaging is feasible, promising and accurate. the advantage of cta is the comprehensive evaluation of coronary arteries and myocardial perfusion defects from the same datasets, which permits both visualisation of coronary anatomy and physiology.further, ct provides information about regional and global myocardial function. the aim of this course is to understand basic principles of ct perfusion and functional imaging, to learn "how-to" perform ctp and comprehensive cta/ctp scans, to review current scientific evidence and to discuss potential clinical applications. nuclear medicine tests (spect and pet), mri and more recently mdct have been involved in myocardial perfusion imaging. in clinical practice, perfusion analysis is routinely performed with qualitative or semiquantitative assessment, both based on relative evaluation of uptake or enhancement of myocardium, considering a remote region as normal. however, the assumption of part of myocardium as normal can be wrong and cause false negatives. absolute quantification has been introduced mostly with pet perfusion imaging (water, ammonia and rubidium), but its incremental value for the clinical decision making has not been widely investigated. more recently, mr perfusion imaging has been used for quantitative analysis with different technical approach. there are some clinical scenarios where quantification can change the clinical interpretation: 1. multivessel coronary artery disease (cad), 2. balanced multivessel cad, 3. exclusion of cad in symptomatic patients, 4. microvascular disease, 5. revascularised patients. however, there are still some limitations in the use of absolute quantification: first, the setting of cutoff value for normal or abnormal perfusion; second, some clinical situations, such as heart failure patients, where perfusion is reduced and heterogeneous. finally, studies concerning the prognostic value and the cost-effectiveness are needed. epilepsy is a common disorder with a prevalence of up to 1% in the general population. epilepsies are broadly classified into generalized and focal. though most generalised seizures are controlled pharmaceutically, 30% of focal seizures are medically intractable. in this subset of patients, the overall sensitivity of mri in identifying responsible substrates is approximately 80%. the purpose of neuroimaging in epilepsy patients is to identify underlying structural abnormalities that require specific treatment (usually surgical) and to aid in formulating a syndromic or aetiologic diagnosis. in this presentation imaging findings of the most common non-neoplastic lesions responsible for focal epilepsy, namely: a. hippocampal sclerosis, b. malformations of cortical development, c. vascular abnormalities and e. gliosis, will be discussed along with their differential diagnosis and pertinent imaging pitfalls. since routine mr imaging is suboptimal in identifying epileptogenic substrates, imaging should be tailored accordingly. hippocampal sclerosis, the most common cause of mesial temporal lobe epilepsy, is best demonstrated when the temporal lobes are imaged with thin sections in coronal plane perpendicular to the longitudinal axis of the hippocampus. inversion recovery sequences best demonstrate morphology and volume loss in the hippocampus, mammilary body and fornix. t2 and flair images best demonstrate the increased signal due to gliosis. for malformations of cortical development flair is useful in assessing hyperintense signal. t1 gradient volume sequences can demonstrate subtle developmental malformations. finally, because many epileptogenic lesions are subtle and easily overlooked, a systematic diagnostic approach to mri interpretation in the clinical setting of epilepsy is helpful and will be discussed. epilepsy surgery is an effective and safe therapy for selected patients with intractable localisation-related epilepsy. when morphological mri fails to reveal focal, structural pathology (e.g. tumour, dysplasia, etc). as the putative aetiology for the seizures, other modalities may be taken into account. in the absence of structural pathology it is essential to identify the epileptogenic zone as exactly as possible in order to (a) increase the chance of a good outcome (reduction or termination of seizures) and (b) limit post-surgical sequelae. this lecture will cover some modalities that may add valuable information in this process. the need to individualise the pre-surgical evaluation and the concept of a multimodality epilepsy protocol will be discussed. the main focus will be on spect (single-photon-emission computed tomography), functional mri, pet (positron-emission tomography) and the added value of co-registration on morphological mri (e.g. siscom). briefly, ictal spect may help to identify focal areas of hyperperfusion (ictal zones). functional mri is used for several reasons. one is to determine language laterality (dominant hemisphere); another is to localise eloquent cortical structures to aid the planning of the surgical approach. pet may detect hypometabolic areas corresponding to areas involved in epilepsy. mrs (magnetic resonance spectroscopy), meg (magnetoencephalography) and intradural eeg-registration and stimulation will be mentioned. the term epilepsy covers a wide spectrum of symptoms and underlying etiologies. an essential part of the work-up of patients with epilepsy includes the radiological examination. in recent years more sophisticated methods radiological methods have emerged and the discussion will focus on how these new advanced techniques may help finding underlying causes and be of help in the pre-surgical work-up. excellence in teleradiology: key issues in workflow management j. schillebeeckx; bonheiden/be (jan.schillebeeckx@imelda.be)the healthcare market is undergoing significant change. the market is evolving from a provider centric to a patient centric model, requiring relevant data to converge at patient level in a timely and structured fashion. the push towards setting up collaborative networks for radiology is strong in most european countries. the most important challenge for teleradiology is to ensure that it develops in a manner that benefits patient care and ensures overall patient safety, and does not in any way reduce the quality of radiology services provided to the citizen. therefore, these collaborative networks require more than just it infrastructure with it support. but as important is case management, workflow management and the administrative and management support that provides all the stakeholders with operational, analytical and statistical qa reports. through a centrally operated hub, the radiology workflow is optimised to ensure throughput of cases, involving radiologists in the network, with the difference that only the services are provided by the hub to the network, not the medical acts, which remain in the hands of the radiologists. learning objectives:1. to learn about the technical needs of a teleradiology infrastructure adapted to a distributed environment. 2. to understand that teleradiology involves much more than just technology.optimising the workflow and time management are also important. 3. to appreciate how creating collaborative networks can improve the efficiency of radiology procedures and bring improved work/life balance to radiologists. to make teleradiology an integrated part of clinical radiology, it must change from being a provider of radiology reports into a close collaboration with the client radiology department. there are many different aspects on workflow in a clinical setting and the teleradiology service should adapt to these specific needs in order to make a seamless collaboration. however, there are advantages with the global aspects of teleradiology that could improve diagnostic accuracy and efficiency in the clinical setting that should be woven into the collaboration. teleradiology services have developed substantially over the last few years from limited use between hospitals and tertiary care centres for second opinions and patient transfer to the international provision of reporting services. there is no doubt that teleradiology provides a valuable service in some circumstances, but it also has a number of inherent limitations regarding the proper provision of imaging services to the patient and therefore may increase risks for the patient. we will highlight the problems that have arisen and reiterate key parts of the guidelines which were developed for the benefit of patient care. this lecture will demonstrate a multimodality approach to the imaging of salivary colic. the relevant us and mri salivary anatomy will be highlighted and the ultrasound, computed tomography and magnetic resonance appearances of salivary grafts. respectively. graft sclerosis develops in 38% of nonoccluded venous bypass vessels after 5 years and in 75% after 10 years. this sclerosis causes more than 50% luminal narrowing in approximately half of the affected vessels. non-invasive imaging of coronary bypass grafts by md-ct require information about the operative procedure. with the increasing implementation of 64slice ct scanners and beyond, it is possible to scan the heart and the full anatomic extent of grafts with sub-millimeter slice-thickness within a single breath-hold. when analysing the grafts, three graft segments should be assessed: the origin or proximal anastomosis, the body of the graft and the cardiac anastomosis, either single or sequential. recent studies have shown that graft patency and the presence of significant graft stenosis can be assessed with an accuracy of 100% using most recent md-ct technology (256/320 slice ct or dual source ct). the assessment of native coronaries with respect to the progression of cad may still be problematic in cases with severe calcifications of the native coronary arteries. in these cases, mr perfusion imaging in combination with cine and late gadolinium enhancement (lge) imaging may be helpful in detecting newly developed, stress-induced myocardial ischaemia. teleradiology services have developed substantially over the last few years from limited use between hospitals and tertiary care centres for second opinions and patient transfer to the international provision of reporting services there is no doubt that teleradiology provides a valuable service in some circumstances, but it also has a number of inherent limitations regarding the proper provision of imaging services to the patient and therefore may increase risks for the patient. we will highlight the problems that have arisen and to reiterate key parts of the guidelines which were developed for the benefit of patient care. it is now well understood that teleradiology cannot be considered just as 'telereporting', i.e. the simple interpretations of images remotely acquired and sent as a message in the bottle. teleradiology procedures, being medical acts, must ensure the full involvement of the interpreting radiologist in all phases of the well established practice of diagnostic imaging: appropriateness check, personalised acquisition protocols, access to clinical history and prior imaging examinations, communication with referring physician and patient. any obstacle that teleradiology causes to these activities may put our patients at risk (and therefore may expose us at liability suits). the presentation will describe the organisational as well as technological remedies for reducing such risk. for several decades, monte carlo simulation has been recognised as a powerful technique to simulate the transport of radiation in media, as well as to provide solutions for calculations too complex for classical approaches. several general purpose codes and databases providing particle interaction cross-sections have been developed, and with the increase in computing power, simulation has become more and more popular within the field of medical imaging. using monte carlo simulation methods, the different steps involved in the formation of a medical image can be analysed in detail, and the whole system optimised. a topic that has deserved particular attention in the past is the simulation of x-ray tubes and x-ray spectra, which is the first step in the simulation of a medical imaging system. when simulating an x-ray tube, various complex phenomena need to be taken into account, such as the electron multiple scattering, bremsstrahlung interactions, characteristic x-rays emitted from the k-shell and auger electrons emitted during a photon interaction. together with the simulation of the target material and the filtration of the x-ray beam through permanent (e.g. a be window) and added filtration (e.g. al, mo, rh, ag, etc)., this technique can lead to a good estimation of the emitted x-ray spectrum, a task which is hard to achieve with experimental methods. this review will provide an overview of the basic knowledge necessary to start the simulation of an x-ray tube as well as of how to accelerate the calculations. emphasis will be given to mammographic x-ray tubes. breast cancer screening and diagnostic imaging, as all clinical imaging, are increasingly multimodality. a number of new imaging modalities have been developed, including digital breast tomosynthesis and dedicated breast ct. they have shown promise in early studies; however, their technological complexity present obstacle for optimisation. the ultimate technology tests are clinical trials, which are, however, challenging, particularly for breast cancer screening, as large studies are needed due to the small number of detected lesions. clinical trials are costly, long, and they involve repeated exposure of women to radiation. as an alternative, we have been developing virtual clinical trials, based upon our virtual breast phantoms and simulation of phantom images. this talk will describe the development of anthropomorphic computer breast phantoms, and illustrate their use in the analysis of phantom digital mammography and digital breast tomosynthesis images. different currently used phantom designs will be compared in terms of their flexibility and realism. specific phantom requirements related to different imaging modalities will be emphasised. the role of phantoms in tissue-specific analysis of the radiation dose during mammography will be discussed. in addition to the anthropomorphic phantoms for breast imaging, the use of virtual patients in various clinical imaging disciplines will also be illustrated. learning objectives:1. to learn about requirements for anthropomorphic phantoms (virtual patients). 2. to understand the value of anthropomorphic phantoms for breast imaging. 3. to compare advantages and disadvantages of several types of anthropomorphic phantoms. 4. to learn how to estimate typical patient doses from simulations with virtual phantoms.colic will be shown and techniques for optimising the imaging of salivary colic given. the use of us, ct, mri, and both mri and conventional sialography in the imaging of salivary colic will be discussed. the role of interventional sialography and minimally invasive techniques in benign salivary gland obstruction will be demonstrated. trigeminal neuralgia is defined as recurrent episodes of lancinating pain most common in the second (v 2 ) or third division (v 3 ) of the trigeminal nerve. the pathogenesis is a neurovascular conflict by an artery or vein associated with focal demyelination of sensory fibers at the glia-schwann cell junction. apposition of demyelinated fibers induces abnormal generation and transmission of impulses. mr imaging is based on high-resolution 3d sequences: ciss/fiesta/3d t2space with coronal and sagittal oblique mpr and a 3d tof intracranial sequence with axial and coronal thin mip reconstruction to delineate the course of vessels along the trigeminal nerve form the pons, and glia schwann cell junction to the gasserian ganglion. the brainstem and brain are assessed by t2, flair and 3d isotropic gd-enhanced t1 sequences; the viscerocranium is examined by a noncontrast and coronal t1 gd fat suppressed sequence. analysis of images is focussed on recognition of displacement and distortion of the proximal trigeminal nerve by the sca, rarely by the aica, ba or petrosal, pontomesencephalic or peduncular vein. correlation of the circumferential site of distortion at the root entry zone with the somatopic representation of fibres increases the, in general, low specificity of the neurovascular contact. ruling our compressive tumours, neoplastic infiltration, inflammation or demyelination and delineating a neurovascular conflict stratifies patients for potential microvascular decompression in case of failure of medication. the purpose of this lecture is to provide an overview of the key imaging features of painful swallowing with or without associated mucosal pathology. in the presence of a mucosal lesion, painful swallowing is most often caused by infectious, neoplastic or traumatic lesions of the pharynx itself, whereas in the absence of mucosal alterations, painful swallowing is the result of functional disorders (dysfunction of the cricopharyngeus muscle), infectious, inflammatory or neoplastic diseases affecting adjacent neck spaces (retropharyngeal and paraphyrngeal space), neurologic impairment (glossopharyngeal neuralgia), carotidodynia and eagle's syndrome. the indications for ct, mri, us and videofluoroscopy will be reviewed and their respective role in the detection and precise description of the underlying cause. major emphasis will be put on how to report the findings in a comprehensive way. learning objectives:1. to recognise the most common causes of painful swallowing in patients with a normal pharynx at clinical examination. 2. to review the role of different imaging techniques in the diagnosis and treatment of painful swallowing. 3. to review the key imaging techniques in the diagnosis and treatment of painful swallowing. 4. to review the key imaging features of the most common causes of painful swallowing as seen with the respective imaging techniques.the typical hrct features of interstitial lung disease are ground-glass opacity, consolidation, pulmonary nodules, tree-in but sign, bronchiolar wall thickening, mucoid impaction, air trapping, septal thickening, mosaic perfusion and honey combing. most frequent diseases in children to be dealt with are bronchiectasis, cystic fibrosis, asthma, constrictive bronchiolitis, bronchiolitis obliterans and extrinsic allergic alveolitis and they will be demonstrated with use of a systematic approach. during the lecture we will present and validate methods to simulate radiographic images with the monte carlo software mcnp/mcnpx in a time efficient way. we will start the lecture by introducing three image detector models that can be used in mcnp/mcnpx. the first detector model that will be presented is the standard semideterministic radiography tally, which has been used in previous image simulation studies. furthermore, we will present two alternative stochastic detector models: a perfect energy integrating detector and a detector based on the energy absorbed in the detector material. the image detector models will be validated by comparing calculated scatter-to-primary ratios (sprs) with published and experimentally acquired spr values. subsequently, we will introduce a method to modify the images, generated with the mcnp/mcnpx image detector models, for the physical characteristics of a computed radiography (cr) imaging systems. the method presented in this lecture takes into account the signal intensity variations due to the heel effect along the anode-cathode axis, the spatial resolution characteristics of the imaging system and the various sources of image noise. to demonstrate the accuracy of our model we will compare the threshold-contrast detectability in simulated and experimentally acquired images of a contrast-detail phantom. thoracic trauma in children is most commonly seen in a polytrauma context, and is associated with significant morbidity and mortality. blunt trauma accounts for the majority of cases, often resultant from motor vehicle accident and pedestrian crash. common thoracic injuries include pulmonary contusion, rib fractures, pneumothorax and haemothorax. diaphragmatic and mediastinal injuries, such as aortic rupture and tracheobrocheal tear, are rare but potentially life threatening. different patterns of injury are seen in children due to anatomical and physiological differences, and these should be recognised. chest radiography is the first and most important imaging modality. mdct allows accurate diagnosis for most traumatic injuries, and is usually performed for severe chest and/or polytrauma. adapted paediatric protocols are essential. foreign body inhalation is a common paediatric domestic accident, with potential serious or even fatal consequences. clinical history is the key for the diagnosis. with a definite history, bronchoscopy is the modality of choice for both diagnosis and treatment. however, in many cases the aspiration event is not witnessed and the diagnosis is often delayed or overlooked. the majority of aspirated foreign bodies are non-opaque and imaging findings largely result from complete or incomplete airway obstruction. chest radiography is the first imaging modality. expiratory films (or lateral decubitus or fluoroscopy) are very useful to demonstrate air-trapping. chest mdct offer excellent details of the tracheobronchial tree and pulmonary parenchyma, and is usually reserved for more complex cases and/or long-standing foreign bodies. high-resolution ct of the chest is the imaging technique of choice for the evaluation of most infiltrative diseases of the chest. in children dose-adapted protocols should be used and recommendations for suitable protocols will be given in the course. the mediastinum is a region of the thorax that separates both lungs and communicates with the neck and the abdomen. these two anatomic features are very important to understand the behaviour of some diseases and their radiological manifestations. most asymptomatic mediastinal masses are benign, while clinical symptoms might raise the possibility of a malignant lesion. imaging plays a very important role, especially ct and mri. in the presence of a mediastinal mass we must ask ourselves two questions: 1. where is the mass located? the classic divisions of the mediastinum in compartments remains very useful, because it narrows the differential diagnosis. 2. is the lesion cystic or solid? pure mediastinal cysts are benign and their characterisation depends on their location. thymic cyst (anterior mediastinum), bronchogenic and duplication cysts (middle mediastinum) and menyngoceles (posterior mediastinum). solid lesions may be benign or malignant while some lesions may have a cystic component. solid lesions of the anterior mediastinum are usually thymomas, germ cell tumours or lymphomas. in the middle mediastinum most masses are of lymphatic origin but we should also include aortic or oesophageal pathology. intrathoracic thyroid usually follows the trachea and thus is situated in the upper-middle mediastinum although posterior and anterior extensions may occur. in the posterior mediastinum most masses are of neural origin. there are some locations that will typically indicate specific diagnosis or a narrow differential. such is the case of the cardiophrenic angle masses, juxtadiaphragmatic lesions and thoracic inlet pathology. colorectal cancer is common. approximately 280,000 new cases occur each year in the 500 million population of the 27 states which comprise the eu. after lung, it is the second commonest cause of cancer death resulting in approximately 140,000 deaths per annum. these relatively high mortality figures are a reflection of the fact that the disease is often advanced at the time of presentation. efforts to reduce mortality, therefore centre on early detection as well as accurate staging. the latter is particularly important in rectal cancer-the commonest site for colonic cancer. detection depends on presentation, which is often protean or non-existent; hence, the introduction of screening programs. typical diagnostic tools include the barium oenema, optical colonoscopy and ct colonography. the limitations of the barium enema have been exposed by optical colonoscopy and it can no longer be advocated in this role. ct colonography, however, rivals optical colonoscopy in the detection of polyps and tumours, although of course has no therapeutic potential. major advances in the treatment of rectal cancer include total mesorectal excision (tme) of the rectum as well as neo-adjuvant therapies such as chemo-radiation. their use depends on highly accurate staging of the primary disease, which can only be achieved by mr examination, although of course ct or pet/ct is required for the assessment of more distant metastatic disease. finally, once treated, it is essential that these patients are followed-up; usually by a regime of colonoscopy and ct. these issues will be discussed in an interactive lecture. decreased opacity of the lung may be a bilateral or unilateral process. if unilateral, it may involve an entire lung, a lobe or a segment. faulty radiological technique must always be excluded. the most common cause of unilateral decreased opacity is a previous mastectomy. bilateral decreased opacity occurs in copd and asthma. it is also caused by decreased blood flow in the lung/s. expiratory films separate the true lung causes from all the others, by demonstrating air trapping. pulmonary nodules are spherical radiographic opacities (solid and subsolid) that measure up to 30 mm in diameter. extremely common in clinical practice, pulmonary nodules, especially small ones under 1 cm in diameter, are a challenge to manage. it is important to identify malignant nodules because they are potentially curable. the first step in assessing a pulmonary nodule on a chest radiograph is to determine that it is indeed a lung nodule rather than a pleural or chest wall abnormality. it is essential to review images from previous examinations, because a solid nodule that remains stable for at least 2 years is probably benign. topics discussed in this talk include the importance of nodule size, growth rate, margin morphology, density (solid, ground-glass and part solid), calcifications or fatty components within the nodules, the significance of cavitations or bubble-like densities, enhancement patterns at dynamic contrast-enhanced ct, and findings on positron emission tomography (pet). the talk also covers the current guidelines for the management of incidentally detected nodules (solid and subsolid). this presentation has the purpose to familiarise radiologists with the spectrum of mesenteric and omental cystic masses, demonstrating the additional correlation with the underlying pathology. cystic masses of the mesentery or omentum are not common lesions; however, radiologists should be aware of these entities as well as with other cystic lesion of the abdomen. important tool for the diagnosis is to determine the organ from which the mass originates. common types of mesenteric and cystic masses include lymphangioma, enteric duplication cyst, enteric cyst, mesothelial cyst and non-pancreatic pseudocyst. other entities such as cystic mesothelioma, cystic spindle cell tumour and cystic teratoma could be located in the mesentery also. due to the overlap in the imaging features, not always the final diagnosis could be reached by imaging only and therefore histologic examination is necessary to establish the diagnosis. however, it is important for the radiologist to define the cystic nature of the mass and demonstrate the potential mesenteric or omental origin, targeting to the correct differential diagnosis of the cystic lesion. cancer cells from intraabdominal neoplasms, carried by peritoneal fluid throughout the abdominal cavity, result in widespread metastases in the form of implants, the socalled peritoneal carcinomatosis. the location of implants development is governed mostly by peritoneal fluid circulation and by specific anatomic pathways formed by peritoneal reflections. the most common sites where the peritoneal fluid may temporarily arrested facilitating implantation of cancer cells include cul-de-sac, distal small bowel mesentery, right paracolic gutter, posterior sub-hepatic space, greater omentum and sub-phrenic spaces. the role of imaging is to disclose the presence and extent of the disease -i.e. fundamental in candidates for cytoreductive surgery -to monitor response to treatment and to reveal recurrences. mdct with thin collimation and i.v. contrast material supplemented by multiplanar reconstructions is the primary imaging modality for the investigation of peritoneal carcinomatosis. ascitis, contrast enhanced smooth, nodular, or plaque-like peritoneal thickening, peritoneal nodules, plaques or masses, rounded, ill-defined soft-tissue or cystic mesenteric masses, mesenteric fixation with increased attenuation values and thickening, irregular soft-tissue permeation of omental fat or confluent solid omental masses are the most frequent ct findings of peritoneal carcinomatosis. ct has a sensitivity and specificity between 85 and 95%, depending on the size/location of implants and examination protocol used. mr imaging employing a post-gadolinium-enhanced 3d flash sequence with fat saturation may alternatively be used and it is advantageous in cases of diffused layered type of peritoneal/mesenteric involvement. diffusion mri may be of value in post-treatment imaging evaluation. primary solid tumours of the peritoneum and mesentery occur much less frequently than metastatic disease in the same location. however, these rare primary neoplasms (peritoneal mesothelioma, primary peritoneal serous carcinoma, desmoplastic small round cell tumour, mesenchymal tumours, mesenteric fibromatosis or mesenteric desmoid tumour, mesenteric sarcoma, etc.) are often first detected at ct and should be considered in the absence of a known primary organ-based malignancy. ct appearance combined with patient's relevant clinical and demographic data can help narrow the differential diagnosis for a primary peritoneal or mesenteric tumour in many cases; diffuse sheetlike thickening of the peritoneum and stellate appearance of the mesentery at ct or mri are suggestive of primary malignant mesothelioma in older men with high level of asbestos exposure. absence of an ovarian mass is mandatory in suggesting the diagnosis of primary peritoneal serous carcinoma in a post-menopausal woman. desmoplastic small round cell tumour occurs in young men and often presents with a large primary peritoneal mass with calcification. a solid mesenteric mass at ct or mri, regardless of its pre-and post-contrast appearance, occurring in a patient with familial postgraduate.educational.programme embolisation of hcc with drug eluting beads k. malagari; athens/gr (kmalag@otenet.gr)drug eluting beads have proved predictable pharmacokinetics and achievement of higher doses of the chemotherapeutic, prolonged contact time with cancer cells.in addition, research data today have shown response, and tolerance benefit of drug eluting beads compared to conventional chemoembolisation for the more advanced subgroup of bclc -class b patients. for diameters larger than 100 μm dc bead loaded with doxorubicin have proven to be more effective with respect to local response, recurrence rates and time to progression (ttp) compared to bland embolisation with similar diameters. in this session results of studies on dc bead loaded with doxorubicin for the treatment of hcc will be discussed, and guidelines for optimal clinical use will be presented. selective internal radiotherapy j.i. bilbao; pamplona/es (jibilbao@unav.es)selective internal radiotherapy, also called radioembolisation (re), consists in the delivery of beta-radiation to liver tumours using microspheres loaded with yttrium-90 (y90) that are injected into the hepatic artery or its branches. y90 is a pure beta-emitting radioisotope, with a limited tissue penetration (average: 2.5 mm and maximal: 11 mm) and a half life of 64 hours. y90 can be either incorporated or labelled into glass or resin microspheres (25 µm). once the particles are infused into the hepatic artery, they travel to the distal tumoural arterioles, from where the beta-emissions from the isotope irradiate the tumour. with traditional external beam radiation, doses are limited to 30-40 gray (gy) due to the risk of radiation-induced liver disease that may occur with higher doses. with re, tumours can receive a higher dose of radiation due to their preferentially arterial vascularisation and a higher tolerance of the non-tumoural liver parenchyma to this form of radiation. re has shown an encouraging antitumoural activity with a good safety profile in patients with hepatocellular carcinoma, even in the presence of portal vein thrombosis or invasion. local tumour growth control is achieved in the majority of patients although response rates using volumetric criteria are achieved in only 20-40% of patients. in liver-predominant unresectable metastases, there is promising evidence that re combined with systemic chemotherapy significantly extends the time to progression of liver metastases and increases objective response rates as well as enabling patients to receive systemic chemotherapy for a longer period of time. learning objectives:1. to learn about the technique, legal and safety requirements in the cathlab. 2. to understand the diagnostic and interventional procedures before radioembolisation. combined therapies before and after ablation r. lencioni; pisa/it (lencioni@med.unipi.it) image-guided rfa is currently established as the standard of care for patients with early-stage hcc when transplantation or resection is precluded. however, histologic data from liver specimens of patients who underwent rfa as bridge treatment for transplantation showed that the rate of complete tumour eradication is highly dependent on the size and the presence of large abutting vessels. combined percutaneous-transcatheter approaches that aim at increasing the ablation volume by minimising heat loss due to perfusion-mediated tissue cooling have been developed, using either a balloon catheter occlusion of the tumour arterial supply at the time of the rfa or by performing a prior tace. experimental studies in animal tumour models have shown that lowering the temperature threshold at which cell death occurs by combining sublethal heating with cell exposure to trans-arterial chemoembolisation takes advantage of the largely portal vascularisation of liver tissue, while metastatic tissue is supplied almost exclusively by hepatic arteries. the benefit of intra-arterial application of chemotherapeutic drugs is proportional to the first pass extraction of the drug by the target tissue and inversely proportional to the body clearance of the drug. these figures vary greatly with different chemical properties of the drug. intratumoural drug concentration after transarterial application (compared to intravenous application) is approximately 20x for thp-adriamycine, 5x -10x for 5 fu, 6x -8x for mitomycine, 4x for cisplatin or oxaliplatin, and 2x for doxorubicin. several trials support superiority of intraarterial 5 fu over i.v. application in response rate, and partly with a moderate survival benefit. however, with the advent of novel chemotherapeutics (mainly oxalyplatin, irinotecan), response rates of i.v. chemotherapy approached the results after i.a. 5 fu. more recently, i.a. oxaliplatin has shown a 45% response rate in a multicenter trial on non-responders to i.v. oxalyplatin. also, combinations of i.a. oxalyplatin and i.v. 5 fu and cetuximab have achieved promising response rates as first line therapy. even though intraarterial chemoembolisation alone can achieve promising response rates, the actual survival benefits are limited to date. also, the beneficial effect of additional embolization (over conventional arterial injection) remains largely unproven for a large number of different embolisation agents in hepatic metastases. in an attempt to further increase tumour uptake, chemotherapeutic agents (anthracyclines and irinotecan) have been electrostatically coupled to microspheres. irinotecan-eluting microspheres have been untilized in the treatment of crc metastases in smaller case series. due to the high parenchymal drug uptake, appropriate medications to mitigate postembolization side effects need to be emphasised. while the initial response rates were over 60% (according to easl), tumour progression was observed within 6 months in the majority of responders, suggesting potential stimulation of angiogenesis at the tumour boarders. potentially, adjuvant antiangiogenic treatment can provide an overadditive effect in these patients.primary bone tumours require both local staging and the identification of distant metastases to guide management. mr imaging is the modality of choice to determine local disease extent and allows excellent depiction of intra-and extraosseous disease. chest ct enables pulmonary metastases to be identified and bone scintigraphy allows evaluation of the presence of bone metastases. the roles of whole body mri and pet/ct in the staging of bone tumours will also be discussed. whilst imaging may allow a narrow differential diagnosis to be reached, histological confirmation of the nature of the lesion is required pre-operatively to plan appropriate treatment. image-guided biopsy may be performed using fluoroscopy, ct, mri and occasionally ultrasound guidance. the relative values of each of these techniques will be covered. percutaneous therapies are increasingly being utilised in the treatment of a number of primary bone tumours. radiofrequency ablation is the method of choice for osteoid osteoma and is now used in the treatment of chondroblastoma. alternatives include microwave therapy, cryotherapy and sclerotherapy. these percutaneous techniques may also be used for local disease control where disease recurrence is encountered. magnetic resonance imaging (mri) has evolved to become the most important diagnostic method for local staging of primary bone tumours and for detecting postoperative tumour relapse. it allows accurate preoperative staging of local tumour extent and helps to obtain adequate safety margins. mri is a noninvasive technique that can be used to obtain information regarding tumour vascularisation, metabolism, and pathophysiology, and allows early assessment of therapeutic effects of cancer drugs. one approach is dynamic contrast-enhanced (dce) mri, which measures tumour vascular characteristics after administration of a contrast medium. mri enhanced with small-molecular-weight contrast agents is extensively used in the clinic to differentiate benign from malignant lesions, as well as to monitor tumour microvascular characteristics during treatment. diffusion-weighted mri (dwi) is a more recent technique and it allows noninvasive characterisation of biologic tissues based on the random microscopic motion of water proton measurement. several studies have shown that dwi allows early detection of tumour response to chemotherapy. the use of water diffusion is a surrogate marker used to distinguish highly cellular regions of tumour from acellular and necrotic regions. whole body diffusion-weighted sequence (wb dwi) is a new promising technique feasible to evaluate multifocal disease. dwi has revealed great potential in the evaluation of patients with cancer or benign disease, as it supplies both quantitative and qualitative information of the whole body. this presentation will focus on the potential role of dwi in combination of dce mri in bone tumours as well as on the possibilities of wb dwi. in this integrated refresher course, the impact of basic and advanced imaging on the entire process, from diagnosis to treatment of bone tumours, will be addressed. diagnosis is based on understanding the imaging features from a histopathologic chemotherapeutic agents is an attractive alternate strategy to increase tumour necrosis. the efficacy of a combination therapy, including rfa plus the intraarterial administration of drug-eluting beads has been recently demonstrated, while the use of intravenously administered, thermally sensitive drug carriers is currently being explored. despite the advances in local treatment, the long-term outcome of treated patients remains unsatisfactory because new tumours emerge in about 80% of the cases within 5 years. clinical trials evaluating the usefulness of adjuvant molecular targeted therapies with anti-angiogenic and anti-proliferative activity in preventing early recurrence after successful ablation are ongoing. in this integrated refresher course, the impact of basic and advanced imaging on the entire process from diagnosis to treatment of bone tumours will be addressed. diagnosis is based on understanding the imaging features from a histopathologic perspective. staging, biopsy and image-guided treatment require an integration of imaging findings with basic knowledge of surgical-oncological principles, as well as skills. can technically driven development of advanced mr techniques change how we diagnose, monitor therapy and determine prognosis. techniques and procedures that improve patient outcome in a cost-effective way will be identified based on 3 presentations and a panel discussion. a. diagnosis: from radiographs to mri k. wörtler; munich/de (woertler@roe.med.tum.de)the diagnosis of a bone tumour is based on clinical findings, the age of the patient, the location of the lesion, its radiologic appearance, and, if imaging does not allow for a specific diagnosis, its histopathologic features. radiography remains the initial imaging modality for evaluation of the localisation of the lesion with respect to the longitudinal and axial planes of the involved bone, for the depiction of matrix mineralisations, and for estimation of biologic activity by analysing the patterns of bone destruction and periosteal response. ct can add "radiographic" information particularly in regions of complex skeletal anatomy such as the spine, pelvis and shoulder girdle. mr imaging has classically been used to determine the local extent of a bone tumour (local staging). in addition to radiography and/or ct, it can at times also be valuable in establishing the differential diagnosis, especially in cystic bone lesions and cartilaginous tumours. whole-body applications have recently gained importance in demonstrating the presence and extent of bone (marrow) involvement in benign and malignant systemic/polyostotic tumourous diseases. this course reviews the basic principles of diagnosing bone tumours in a multimodality approach (with an emphasis on conventional radiography). the different steps of morphologic analysis as well as the advantages and disadvantages of the individual imaging techniques are illustrated on the basis of pathologically confirmed cases. s130 a b c d e f g h review: (1) the biological rationale for using perfusion imaging in brain tumours, (2) methods available for the imaging of microvascular structure and function in brain tumours. we will discuss the relevant advantages and disadvantages of t1 versus t2 weighted acquisition strategies. early diagnosis and treatment of acute stroke is crucial for a favourable prognosis. while non-contrast mri is much more sensitive to ischaemia in comparison with non-contrast ct, perfusion studies make both techniques comparable. ultrafast ct scanners cover most of the brain with perfusion imaging; the scanning is faster and quality imaging results depend less on patient co-operation than in mri. however, mri enables diffusion imaging adding more specific information to the diagnostic process. because of the short time window to eventual vascular intervention, in many institutions ct is the technique of choice. besides depiction of hyperacute stroke by means of diffusion weighted imaging, mri has the advantage of performing a contrast agent-free perfusion study using a promising new technique called arterial spin labelling (asl). thus, an mri perfusion study can be performed even in patients with impaired renal functions where iodine and gadolinium-based contrast agents may be dangerous. perfusion imaging is an emerging non-invasive tool that enables evaluation of brain function via assessment of various hemodynamic measurements such as cerebral blood volume, cerebral blood flow, and mean transit time. these techniques have become important clinical tools in the diagnosis and treatment of patients with cns disorders via evaluation of brain tissue during cerebrovascular diseases, noninvasive histopathologic assessment of tumours, evaluation of neurodegenerative conditions and assessment of the effects of drugs. perfusion imaging is helpful to analyse and assist in judging the biological behaviour (especially haemodynamic features) of central nervous system diseases. qualitative and quantitative information can be obtained to evaluate pathoanatomical structures and pathophysiological changes of the lesions. cerebral blood flow (cbf), cerebral blood volume (cbv), mean transient time (mtt), permeability surface (ps), regional blood volume, microvascular permeability measurements and more information can be obtained for the diagnosis and differential diagnosis of the diseases. advantages and disadvantages of the ct perfusion imaging (ctp) and magnetic resonance perfusion imaging (mrp) in the different diseases will be evaluated in detail. hints and tips for the better applications and postprocessing will also be discussed. techniques for ct and mr, post-processing, radiation r.a. meuli; lausanne/ch (reto.meuli@chuv.ch)brain perfusion can be assessed by ct and mr. for ct, two major techniques are used. first, xenon ct is an equilibrium technique based on a freely diffusible tracer. first pass of iodinated contrast injected intravenously is a second method, more widely available. both methods are proven to be robust and quantitative, thanks to the linear relationship between contrast concentration and x-ray attenuation. for the ct methods, concern regarding x-ray doses delivered to the patients need to be addressed. mr is also able to assess brain perfusion using the first pass of gadolinium based contrast agent injected intravenously. this method has to be considered as a semi-quantitative because of the non linear relationship between contrast concentration and mr signal changes. arterial spin labeling is another mr method assessing brain perfusion without injection of contrast. in such case, the blood flow in the carotids is magnetically labelled by an external radiofrequency pulse and observed during its first pass through the brain. each of this various ct and mr techniques have advantages and limits that will be illustrated and summarised. learning objectives: 1. to understand and compare the different techniques for brain perfusion imaging. 2. to learn about the methods of acquisition and post-processing of brain perfusion by first pass of contrast agent for ct and mr. 3. to learn about non contrast mr methods (arterial spin labelling). brain tumours a. jackson; manchester/uk (alan.jackson@manchester.ac.uk) this presentation will discuss the current 'state of the art' in the use of perfusion imaging techniques in neuro-oncology. the term "perfusion imaging" is commonly used but is in fact a misnomer since perfusion and blood flow are not the only imaging biomarkers of microvascular structure and function in common use. indeed, in oncological applications measurements of proportional blood volume, endothelial capillary permeability or vessel size can be of equal or greater importance. we will reproduction is by spore formation which is prolific and therefore human respiratory tract exposure is almost constant. the spectrum of aspergillus infection includes aspergilloma (mycetoma), chronic pulmonary aspergillosis, chronic necrotising pulmonary aspergillosis (subacute invasive, chronic airway invasive), invasive pulmonary aspergillosis (angioinvasive, non-angioinvasive including acute tracheobronchitis, exudative bronchiolitis and bronchopneumonia), and allergic disease (allergic bronchopulmonary aspergillosis (abpa) and bronchocentric granulomatosis). immunocompromised individuals are particularly susceptible to invasive aspergillosis. the risk factors for invasive aspergillosis include: profound neutropenia, haematopoietic stem cell transplant recipients, solid organ transplantation, potent immunosupressive therapy, prolonged corticosteroid use and aids. invasive aspergillosis can be further subdivided into angioinvasive and non-angioinvasive forms. the imaging features of angioinvasive aspergillosis are characterised on ct by nodules with a 'halo' of surrounding ground glass opacity due to alveolar haemorrhage. in the context of neutrophil recovery, nodules may demonstrate cavitation. airway invasive aspergillosis may manifest as areas of consolidation (bronchopneumonia), nodular 'tree-in-bud' densities on ct (exudative bronchiolitis), or an acute tracheobronchitis with large airway thickening. falling rates are stabilising in europe. tuberculosis is developing new faces due to changes in host cellular immunity, such as hiv infection, immunosuppressive therapy, malignancy and due to multi-drug resistance. chest radiography plays a major role in screening, diagnosis, and response to treatment of patients with tb; however, radiographs may be normal or show only mild or nonspecific findings in active disease. ct and high-resolution ct (hrct) are more sensitive than chest radiography in the detection and characterisation of parenchymal disease, small foci of cavitation, mediastinal lymphadenopathy, and pleural complications. based on these findings, hrct is useful in determining disease activity and plays also an important role in the management of tb. radiological manifestations of primary tuberculosis are lymph node enlargement, airspace consolidation and pleural effusion. the most common findings of post-primary tuberculosis are centrilobular nodules, branching linear and nodular opacities, patchy or lobular areas of consolidation, and cavitation. miliary tuberculosis results from acute haematogenous dissemination of tb bacilli in lungs and other organs and ct-findings consist of innumerable small nodules randomly distributed throughout both lungs. airway tuberculosis is characterised by circumferential wall thickening and luminal narrowing, with involvement of a long segment of the bronchi.sensitive diagnostic tool. radiological semiotics are always useful and often very specific in addressing the diagnosis: some fundamental concepts include the peculiar pattern of vasogenic oedema, which, in opposition to what happens in the brain, tends to involve the central grey more than the peripheral white matter. distribution pattern of the lesion can also often address to aetiological diagnosis. in fact, lesions selectively involving posterior or lateral columns, asymmetrically, and sparing the central grey matter, are more typical expression of demyelinatinginflammatory diseases (multiple sclerosis, adem, devic's disease, les, behcet's disease), while selective and symmetrical involvement of both posterior columns, extended for more than 2 myelomers, and possibly associated with involvement of lateral columns, is typical expression of combined sclerosis (b12 vitamin deficit). ischaemic lesions are also usually symmetrical, but they involve both grey and white matter, extending to the anterior two-third of the cord, or, sometimes, remain limited to the central grey matter. on the other hand, selective involvement of the anterior horns is typical of poliomyelitis. early stage head and neck cancer can be cured by surgery or radiotherapy. the choice depends on the functional and cosmetic result to be expected, tumour histology, patient's condition and preference, and institutional policy. in advanced lesions, nowadays concomitant chemoradiotherapy is offered, with surgery reserved for salvage. a relatively high locoregional control rate can be obtained, at the expense of acute and late toxic side effects, and a higher incidence of treatment complications. on post-therapeutic imaging studies, treatment-induced tissue changes are often visible; these changes should not be misinterpreted as evidence of persistent or recurrent tumour, or treatment complication. after radiotherapy, the visible changes depend on the radiation dose and rate, the irradiated tissue volume, and the time elapsed since the end of treatment. basically, thickening of the laryngeal and pharyngeal walls, increased attenuation of fat planes, postirradiation sialadenitis, lymphatic tissue atrophy, and retropharyngeal oedema will be seen. these irradiation-induced tissue changes usually appear symmetrical. the acute effects of radiotherapy occur during or immediately after treatment, and usually settle spontaneously. complications of radiotherapy are usually seen months to years after the end of treatment. there is no clear consensus regarding optimal time points for surveillance, but clinical assessments are more frequent in year 1 and are performed over at least 2-3 years, during which time most locoregional failures and second primary tumours are detected. ideally for imaging surveillance at least one post-treatment baseline head and neck scan (mri/ct) should be performed at 3-6 months, and often closer surveillance is desirable. candidates for salvage surgery after (chemo) radiotherapy undergo a post-treatment scan at 6-8 weeks, followed by regular scans (4-6 months in year 1; 6-12 months thereafter, the exact time period being tailored to the patient the most recent advances of radiotherapy techniques are characterised by the increased precision with which the radiation energy is released to the target, the reduced collateral damage to adjacent non-neoplastic tissues, and the synergic viral agents are part of the spectrum of organisms which cause community acquired pneumonias. furthermore, they are thought to function as a trigger for bacterial infections in the hospital or health care setting. in addition, viruses play a significant role as causative agents for infections in the immunocompromized host. within the last years, outbreaks of viral infections have challenged regional, national and even global health care systems, have effected thousands of individuals and have resulted in significant morbidity and mortality. most of the involved viral agents represented emerging organisms with an unpredictable impact on individual and society health. the radiologic community has learned several lessons from the documented outbreaks, and radiologists around the world have contributed to the early diagnosis of the disease, the monitoring of its course, and the documentation of complications as well as of response to therapy. thus, imaging plays an important role in the diagnosis and management of these patients. in this course, epidemiologic aspects, patho-physiology and clinical features of emerging viral infections will be presented. in addition, their radiologic features and the role of radiology in diagnosis and management will be discussed. attendees will learn how to understand, recognize, report and follow patients with emerging viral infections. major changes in the treatment of head and neck neoplasms encompass the advances of endoscopic-based surgical techniques, mainly for nasosinusal and laryngeal tumours, and the application of sophisticated radiation therapy techniques, combined with chemotherapy. as most tumours arise from the mucosa of the upper aero-digestive tract, clinical surveillance is necessary to detect superficial recurrences, while morphological and 'functional' imaging techniques are indispensable to detect subclinical extra-mucosal and nodal recurrences. how can imaging techniques discriminate recurrence, inflammation, necrosis or scar? key points include the knowledge of the normal appearance of tissues (morphology and signals) on ct, mri, and pet-ct after surgery and chemo-radiotherapy. specifically, when non-surgical treatment has been used, that means to become familiar with the expected changes both of tumour and adjacent tissues. morphology-based imaging techniques are often inadequate to discriminate small recurrences from vascularised scar tissue (enhancing). ct or mri do require to be integrated by information provided by functional-based imaging techniques, fdg-pet-ct being the most established. recently, a great interest among radiologists is focused on the application of dce-ct or dce-mri and dwi-mri in the follow-up of head and neck neoplasms. in fact, several studies have credited these techniques for providing functional information about tissues (perfusion, water exchange) that help to discriminate scar from recurrences. obviously, the horizon pursued is to combine morphology and functional data in a single examination. though clearly promising, these new techniques share significant limitations, like the reproducibility of ct and mr-based functional results, their introduction and feasibility in the day practice. today, ct angiography (cta) is considered as a safe, non-invasive and wellestablished procedure for vascular imaging. modern multi-slice ct technology allows for coverage of larger vascular territories -even the whole body -in just several seconds. further technical improvements such as wide detectors of up to 16 cm width or moving table techniques are making new applications possible, such as perfusion imaging, or time-resolved ct angiography. especially with the moving table technique (the so-called "shuttle-mode"), vascular territories of up to 50 cm can be covered in a dynamic fashion, which can be helpful in the diagnosis of aortic dissections or peripheral vascular occlusive disease. on the other side, radiation exposure has to be maintained within a reasonable range applying these repeated acquisition modes. another interesting field opening new options in cta is dual energy ct (dect). a number of technical setups may allow for spectral ct imaging, such as systems with two tubes (dual source ct), ct systems with switching kv modes or with special detectors. in vascular applications, dect is especially helpful for automated bone removal, plaque removal, and potentially for "perfusion" imaging (iodine mapping). in this course, the basics of modern ct angiography will be highlighted, with a special focus on new applications such as time-resolved cta and dual energy cta. angio-3d with digital flat-panel detector has recently been adapted for use with c-arm systems and provides a higher detector quantum efficiency (dqe) than conventional detectors based on ii camera. this configuration represents the next generation of imaging technology available in the interventional radiology suite and is predicted to be the platform for many of the three-dimensional (3d) roadmapping and navigational tools that will emerge in parallel with its integration. it provides projection radiography, fluoroscopy, digital subtraction angiography, and volumetric computed tomography (ct) capabilities with the ability for immediate multiplanar post-treatment assessment in a single patient setup, within the interventional suite. such capabilities allow the interventionalist to perform intraprocedural volumetric imaging without the need for patient transportation. the clinical benefits of 2d angiography with these new systems have been assessed in the fields of cardiology and interventional radiology. these key features alone may translate to a reduction in the use of iodinated contrast media, a decrease in the radiation dose to the patient and operator, and an increase in the safety and performance of interventional procedures. proper use of this new technology requires an understanding of both its capabilities and limitations. this article provides an overview of the potential of this new technology. learning objectives: 1. to learn the basic principles of flat panel ct. 2. to review imaging protocols, results and radiation exposure aspects. 3. to become familiar with the most common applications.effect of chemo-radiotherapy. as the treatment planning becomes progressively 'tailored', strong predictive factors for the individual tumour arising in a specific patient have to be identified. these factors would ideally provide a quantitative assessment of the risks of both relapsing (in the primary, nodal or distant sites) and developing treatment-related (early or late) complications. predictors are related to tumour's characteristics (biology, metabolism, site, volume and spread) and to patient's overall clinical conditions. imaging-based predictive factors have been founded upon morphological findings (2d, volume) until the development of new techniques, which analyse 'functional' parameters like fdg-pet-ct, the most established, and perfusion-ct or dwi-mri. evidence of level a has been provided on the impact of negative predictive value of fdg-pet-ct in ruling out residual disease, whilst there is no clear data regarding the role of pre-treatment intensity of glucose metabolism (suv) in predicting the outcome after radiotherapy. this limitation can be addressed to the enrolment of tumours arising in various sites in the head and neck. a major disadvantage common not only in pet studies but also in most dce and dwi-mri studies. perfusion-ct and dwi-mr are promising techniques, as they provide information about neo-angiogenesis and water-flow in submicroscopic tissue compartments. however, these techniques still require randomised trials and confirmation studies about the reproducibility of their interesting results. in the follow-up after minimal invasive surgical techniques or chemo-radiation, a major limitation of standard morphological imaging is the differentiation of the highly vascularised scar tissue (enhancing, with mass effect) from persistent or recurrent neoplasm. is it time for integrating standard imaging with the functional information provided by dwi and/or ct or mr perfusion techniques? which evidence level are we at presently? is it now feasible in daily practice? three-tesla mri scanners offer an increased signal and contrast for mr-angiography (mra) compared to 1.5-tesla machines. mra can be performed within a shorter time enabling the acquisition of temporally resolved three-dimensional datasets with high spatial resolution. due to high signal and contrast the dose of gadolinium may be reduced. furthermore, novel imaging protocols for mra at 3.0-tesla with intravasal contrast agents and prolonged enhancement during high-spatial-resolution steady-state enable new possibilities for angiography of the upper and lower extremities including veins and vessels below the knee, spinal arteries, vascular malformations, and double-gated angiography of coronary arteries and bypass vessels to compensate for the complex cardiac motion pattern. a 3.0-tesla mri system equipped with a matrix coil system allows for whole body mra with continuous table movement, which is an applicable technique for imaging peripheral vessels without the need for planning different steps and field of view positioning, thereby considerably reducing the examination time. phase contrast magnetic resonance angiography may develop into an important, noninvasive method for obtaining quantitative information on blood flow. in addition, non-enhanced three-dimensional mr angiography using turbo spin echo (tse) imaging with non-selective refocusing pulses may be a promising imaging technique for vascular imaging in patients with renal insufficiency. the advent of minimally invasive surgery has made even more important the place of preoperative imaging assessment of patients selected for this type of surgery. in fact, the loss of tactile feed-back and the bi-dimensional intraoperative vision have limited the capability of surgeons to assess extent and anatomic relationship of a given disease, particularly cancer. preoperative planning can be further enhanced by the use of 3d models of the target anatomy, derived from ct scan dataset. in addition, dedicated technology can be implemented to introduce mixed reality environments in the operative room. using 3d helmets with built-in microcameras, the surgeons' view of the operative field can be fused with the preoperative 3d anatomy of the patient. localiser should be used, either infrared based or electromagnetic. the last step would be intraoperative navigation. this offers special problems to be addressed, due to organ shifting and soft tissue in the setting of abdominal surgery. the appropriate use of information and communication technology (ict) and associated systems is considered by many experts as a significant contribution to improve workflow and quality of care in clinical settings. a conceptual design and prototypical implementation of such an infrastructure, i.e. a therapy imaging and model management system (timms) will be introduced as a solution to a patientspecific medicine. a timms is an information technology concept and framework for the collection, organisation, and utilisation of medical information from sources such as the electronic medical record, pacs, etc. timms was originally designed as a surgical assist system, but has many general medical uses as well, including all forms of model-guided medicine and may therefore be generalised to a medical information and model management system. the architectural framework and a number of individual ict components of a timms have been realised. these include standardised interfaces for communication of patient-specific and workflow models, thereby creating a unified environment for the input and output of data, including the representation and display of information and images, as well as the electromechanical control of interventional and navigational devices. in conclusion, the patient-specific model (psm) is the central construct for a patient within a personalised medicine environment in order to provide a clinician with a real-time representation of critical information about the patient. the required information concerning the patient for model-guided therapy is extracted by timms agents and assembled within the framework of an active psm and workflow management system. the introduction of picture archiving and communication systems (pacs), through a much more effective image sharing, has dramatically changed the role of radiology both within the hospital and on a geographic perspective. historically, the latter has become apparent first with the early implementation of teleradiology applications. physicians and the general public have understood that digital images can be read, processed, and stored independently on the site of production. therefore, teleconsultation and telereporting activities have been carried out among medical users, and generic users have learnt to include radiological images in their own on-line personal health records. only later the full potentialities of multidisciplinary image sharing within the hospital have been discovered, and now it is increasingly common to see advanced integration between radiologists and surgeons for planning and guiding surgical interventions. during this session, the lecturers -exceptionally expert in their respective fields -will give insights into image sharing: from the geographical applications (teleradiology) to the hospital-based applications, with specific reference to the support to surgeons (intraoperative guidance and model-guided surgery). medical imaging is part of a changing medical environment, a changing patient environment and consequently a new medical world. in the recent decennium one of the most important changes in radiology is the conversion from analogue to digital. in no time medical images have become interchangeable through the digital highway and could be post-processed in a different location. teleradiology has become a reality since then. we have seen the maturation of commercial international teleradiology companies offering a wide portfolio of services. another aspect is the availability of image data for all medical specialties beyond radiology and beyond the regular medical disciplines. an increasing number of surgical or oncological specialties and even pharmaceutical companies increasingly use image data to prepare a strategy for operative procedures, to choose the right therapy, to decide which prosthesis to the best to use, for follow-up or for post-processing purposes. they are supported by many new techniques and software. an increasing number of medical computer applications such as complex navigation and visualisation tools based upon digital images is already in clinical use or under development. another trend is the increasing interest in e-health and telemedicine in europe, also among european policy makers. now we see mobile health that brings care directly into the patient environment. the purpose of this presentation is to give a comprehensive overview of and insight into these new developments and to create awareness among radiologists of the increasing importance of integration of medical imaging in a multidisciplinary environment. key: cord-006182-kck5e1ry authors: nan title: 17th annual meeting, neurocritical care society, october 15–18, 2019, vancouver, canada date: 2019-10-01 journal: neurocrit care doi: 10.1007/s12028-019-00857-7 sha: doc_id: 6182 cord_uid: kck5e1ry nan aging is associated with greater stroke risk and diminished stroke recovery. while the effect of aging on stroke recovery is well defined, the influence of aging on neuronal network activity and its correlation with stroke recovery is poorly understood. to study this, we performed serial whole-cortex imaging of spontaneous and evoked neuronal activity before and after stroke in young and aged mice and correlated those findings to behavioral outcomes. young (2-3m, n=13) and aged (18m, n=13) thy1-gcamp6 mice, underwent behavioral assessment and imaging before and 1, 7, 12, and 17 weeks after infarct. infarcts were induced via exposure of somatosensory cortex to a laser (25mw,10m) after injection of the photosensitive dye rose bengal. imaging followed placement of plexiglas windows and consisted of awake (15m) and anesthetized sessions (10m) with gcamp excitation via flashing of a 454nm led and acquisition via an emccd camera (16.8hz framerate). somatosensory activation was via forepaw shock (1ma at 3hz for 5s x 10 blocks). behavioral response was assessed by quantifying forepaw use during cylinder exploration (5m). aged and young mice exhibited similar baseline contralateral forepaw use (aged 31.25±2.88%; young: 26.26±2.41%) and evoked somatosensory cort 2.3±0.16 x 10-3). whole-brain gcamp6 flourescence power in delta (1-4hz) and infraslow (0.02-0.1hz) ranges was significantly (p<0.05) lower at baseline in aged mice. after stroke, aged mice developed greater long-term dependence on the unaffected limb (wk17: aged 57.12±5.77%; young: 37.99±4.73%) -3). -stroke decrement in whole-brain gcamp6 fluorescence power was observed in aged animals. stroke in aged mice is associated with a greater decrement in local network activation, global mechanisms underlying age-related differences. hypernatremia and hyperchloremia is common after moderate-severe traumatic brain injury (mstbi) from saline resuscitation, osmotherapy administration, fever with insensible losses, limited free water administration, and diabetes insipidus. in isolation, hypernatremia and hyperchloremia are independent predictors of mortality in critically-ill patients; but this association has not been studied in mstbi, or in combination as physiologically occurring in patients. we examined whether hypernatremia and hyperchloremia in combination are independent predictors of in-hospital mortality in mstbi patients. we retrospectively analyzed prospectively collected data of consecutive mstbi patients enrolled in the optimism-study over a 7-year period. a semi-automated process provided all sodium and chloride values from the index hospitalization. time-weighted-average(twa)-sodium and chloride representing their "burden" over the entire hospitalization were calculated using a published formula. univariate and multivariable logistic regression were applied adjusting for impact-model-variables as validated predictors of mstbi mortality, osmotherapy, icu length-of-stay and ventilatory days. of 458 patients analyzed, 202 (44%) died. unadjusted mortality rates had a dose-response relationship with increasing sodium and chloride (34% for twa-sodium 140-150mmol/l and 100% for twa-sodium >160mmol/l; 42% for twa-chloride 110-115mmol/l and 94% for twa-chloride >125mmol/l; all p<0.0001). separately, twa-sodium (per 10mmol/l increase adjusted-or 4.0;95%ci 2.1-7.5) and twachloride (per 10mmol/l increase adjusted-or 3.9;95% ci 2.2-7.1) independently predicted mortality. in combination, however, twa-chloride remained an independent predictor of in-hospital mortality (per 10mmol/l increase or 2.9, 95% ci 1.1-7.8), while twa-sodium did not (c-statistic 0.96; hosmer-lemeshow p<0.0001). to our knowledge, this is the first study to show that when concomitantly adjusting for hyperchloremia and hypernatremia burden, only hyperchloremia is independently associated with early mortality in mstbi. while not proving cause-and-effect, this suggests that hyperchloremia, and not hypernatremia as previously reported, deserves further attention in mstbi. if validated, this may have treatment implications for mstbi patients in the acute care phase. hyperosmolar therapy, with hypertonic sodium chloride (nacl) solution is often used in the treatment of cerebral edema and elevated intracranial pressure. recent reports have demonstrated that in patients with subarachnoid hemorrhage (sah) treated with hypertonic nacl, hyperchloremia is associated with the development of acute kidney injury (aki). we report a trial which compared two hypertonic solutions with different chloride content on the resultant serum chloride concentrations in sah patients. a low chloride hypertonic solution for brain edema (acetate), is a single center, double-blinded, double-dummy, pilot clinical trial comparing bolus dosing of 23.4% nacl versus 16.4% nacl/na-acetate for the treatment of cerebral edema in patients with sah. randomization occurred once patients who received hypertonic treatment for cerebral edema and/or elevated intracranial pressure (icp) developed hyperchloremia (serum clgroup, and 17 to the hypertonic nacl/na-acetate one. the groups were well balanced in terms of severity of the sah, age, gender and risk factors. differerences between the serum chloride and sodium measurements, assessed from randomization to maximum during the icu course, were comparable between the nacl and nacl/acetate groups (cl:3.3±6.1 vs. 1.6±3.2, p=0.36; na:6.5±4.4 vs. 9.1±6.6, p=0.18, respectively). nacl/acetate had a more prominent effect on immediate post dose sodium (increase of 1.4±2.6 vs. 2.2±2.8,p<0.01). the rate of aki was lower in the na-acetate group (53.3% in the nacl group vs. 11.8% in the na-acetate group, p=0.01). hyperchloremia preceded aki in 61.5% of the cases; however, the time interval between hyperchloremia and aki was only a median of 0.75 days ). intention to treatment analysis demonstrated that treatment with hypertonic nacl/na-acetate hypertonic versus standard hypertonic nacl solution for patients with mild hyperchloremia, resulted in less events of a -center trials are needed to corroborate these results. up to 5.3 million people in the united states are living with physical, cognitive, and psychological sequelae after tbi. patients that sustain a moderate to severe tbi (mstbi) are heavily reliant on caregivers during their inpatient stay and for post-discharge care. there are limited data on how best to support caregivers in their role. the purpose of this study was to develop a checklist based on qualitative data that can be utilized by caregivers and clinicians to re-examine the particular needs of the caregiver at different periods in the acute, subacute, and chronic timeframe. patients with mstbi and their caregivers were recruited from two intensive care units (icus) in one institution to participate in semi-structured interviews at 72 hours, one month, three months, and six months post-injury. transcripts of each interview were analyzed by two investigators who independently coded responses using a predetermined code list adapted from previously identified needs and concerns of other similar populations. based on the particular coded segments, a checklist and a list of strategies were derived to address the needs and concerns of caregivers. a total of 18 patient-caregiver dyads were enrolled from x-y, with 61 interviews completed; 53 interviews with caregivers and 8 with patients. caregiver interviews resulted in 41 unique codes that corresponded to varying caregivers' needs and concerns which were developed into a checklist and list of strategies. the needs and concerns of mstbi caregivers should be assessed over time to provide the support necessary to assist in the care of mstbi survivors. implementation of a checklist, as well as a list of strategies, can allow for tailored interventions that improve the transitions of mstbi survivors from the icu to subacute/chronic care environments. malignant cerebral edema (mce) develops in a subset of those with hemispheric strokes, precipitating neurological deterioration and death if decompressive hemicraniectomy (dhc) is not performed in a timely manner. however, prediction of which patients will develop mce is imprecise based on baseline clinical and radiographic features imaging quantifies development of cerebral edema. we employ a recurrent neural network that learns from serial clinical and imaging data to enhance early prediction of mce. we identified 105 patients with hemispheric stroke who had nihss and ct scans performed at baseline automated algorithm; midline shift (mls) was measured at the level of the septum pellucidum. we trained a recurrent neural network that incorporates sequential data and compared its performance to those of traditional models. we tried to maximize sensitivity for predicting mce (dhc or death) while optimizing prediction of those not requiring dhc (negative predictive value, npv). nine patients required dhc or died from mce. a linear classifier incorporating age, baseline nihss, and serum glucose had high npv (92%) but only 11% sensitivity for mce. a probabilistic gaussian mixed model (gmm) improved sensitivity to 44%. incorporating 24-hour nihss into gmm improved prediction (sensitivity 76%, npv 97%). the neural network was able to predict all cases of surgery and all of those not requiring surgery with 100% accuracy prediction. recurrent neural networks incorporating sequential clinical and imaging data from the first 24-hours after stroke may enhance our ability to predict which patients will need dhc. our promising pilot evaluation of this approach study requires validation in larger external stroke cohorts. aneurysmal subarachnoid hemorrhage(sah) survivors live with long term residual physical and cognitive disability. we studied whether neuromuscular electrical stimulation(nmes) and high protein supplementation(hpro) in the first two weeks after sah could preserve neuromotor and cognitive function as compared to standard of care(soc) for nutrition and mobilization. sah subjects with a hunt hess(hh) grade>1, assigned to soc or nmes+hpro. nmes was delivered to bilateral quadriceps and gastrocnemius muscles daily during two 30 minute sessions along with hpro(goal:1.8 g/kg/day) between post bleed day(pbd) 0 and 14. primary endpoint was atrophy in the quadriceps muscle as measured by the percentage difference in the cross sectional area from baseline to pbd14 on ct scan. all subjects underwent serial assessments of physical(short performance physical battery,sppb) cognitive(montreal cognitive assessment scale,moca) and global functional recovery(modified rankin scale,mrs) at pbd 14, 42, and 90. twenty-five subjects(soc=13,nmes+hpro=12) were enrolled between december 2017 and january 2019 with no between group differences in baseline characteristics(58 years old, 68% women, 50% hh>3). median duration of interventions was 12 days(range 9 -14) completing 98% of nmes sessions and 83% of goal protein intake. no difference in caloric intake between groups, but hpro+nmes group received more protein(1.5 +/-0.5 g/kg/d v 0.9+/-0.4 g/kg/d,p<0.01). muscle atrophy at pbd 14 was less in nmes+hpro group(2.8+/-2.9% vs 6.7+/-3.2% ,p=0.01). on univariate analysis, higher atrophy was correlated with lower daily protein intake (r=-0.59,p=0.002); and worse 3 month moca (r=-0.39, p=0.06),sppb(r=-0.31,p=0.1) and mrs(r=0.46,p=0.03). nmes+hpro subjects performed better on sppb(p=0.03), were observed to have a lower mrs(p=0.01) and obtained a higher moca(p=0.1) than soc at pbd 90. nmes+hpro may reduce acute muscle wasting in lower extremities with a lasting benefit on recovery after sah. to better understand whether nmes and/or hpro are responsible for observed benefits, a larger, multicenter study is underway. increasing authorization rates for organ donation is the best way to grow the number of organs available for life-saving transplants. in order to improve our authorization rates and thereby provide more organs for life-saving transplants, our organ procurement organization (opo) partnered with donor hospitals to -led donation conversations and intensified the focus on a collaborative donation process. ned in the the opo during the authorization process by providing a timely notification of a potential donor and by work together on the timing of the donation discussion. the overall authorization rate has improved from 49% in 2012 to 70% currently. during this time frame, --led conversations has been compelling and a significant factor in improving authorization rates. equally impactful to improved authorization rates has been a 20% increase in cases involving a collaborative donation process (measured by timely referral and collaborative mention of donation). developing a strong partnership between an opo and a donor hospital is paramount to a successful donation process. critical factors such as timely referral notification and collaboration regarding the timing of the donation discussion can positively influence authorization outcomes. moreover, we -led donation conversations will lead to further increases in authorization which results in more lives saved through donation. quantitative eeg analysis is one part of multimodal monitoring in the intensive care unit due to high temporal resolution and ease of deployment. previously we have shown that dynamical properties of eeg signals can be used to differentiate focal vs. diffuse causes of coma (kafashan et al., 2017) , and that the intrinsic reactivity of eeg signals -a measure of responsiveness of the eeg to endogenously rare events -correlates with gcs score (inri, khanmohammadi et al., 2018) . here, we explore the possibility of localizing brain lesions using these dynamical features of eeg signals. we collected retrospective data from 20 comatose patients (gcs<8) defined to have a focal injury. the patients underwent eeg recordings and imaging for routine purposes at barnes-jewish hospital nnicu. index (inri) , which consists of identifying intrinsic events, obtaining brain-state trajectories, and quantifying brain-state trajectories. we then used a neural network-based classifier to map the inri to lesion location using supervised learning paradigms with cross-validation. we used imaging to identify anatomical location of lesions and project them to a two-dimensional headmap. we trained a neural-network classifier to predict 2d lesion location from the inri dynamics of each eeg channel. we then assessed the correlation between predicted location and actual location using a cross-validation protocol. predicted locations significantly correlated with injury location (r>0.6) when compared to correlations with randomly selected patients (r~0). the results point to a systematic change in underlying neuronal-dynamics induced by brain lesions, that was captured through eeg dynamics and the concept of intrinsic reactivity. here we developed and evaluated a framework to localize brain injury through novel analysis of eeg dynamics. the results here, together with our previous work, suggest brain injuries can be detected and localized using eeg recordings. to examine whether changes in intracranial pressure (icp) waveform morphologies can be used as a biomarker for early detection of ventriculitis. of 1653 consecutive patients enrolled prospectively in a hemorrhage outcomes study from 2006 to 2018, 435 (26%) patients required external ventricular drainage (evd). only the culture-positive ventriculitis seen in 19 (4% of all evds) patients were included in current analysis. based on our es per week, and additionally if infection was suspected. evds were left open for drainage, with icp monitored hourly by clamping. using wavelet analysis, we extracted uninterrupted segments of icp waveforms. we extracted dominant-pulses from continuous high-resolution data using morphological clustering analysis of icp pulse (mocaip). then we applied hierarchical k-means clustering using dynamic time warping distance to obtain morphologically similar groupings. we applied a top-down approach to split the clusters further, which stops when the mean distance of the waveforms to the centroid is less than a pre-clusters and further-split clusters (when equipoise existed) were categorized for broad comparison by clinician consensus. we extracted 275,911 dominant pulses from 459.9 hours of evd data. 112,898 pulses (40.9%) occurred before positive culture, 41,300 pulses (15.0%) were during culture positivity, and 121,713 pulses (44.1%) occurred after clinical diagnosis was made. k-means identified 20 clusters, which were further grouped into meta-clusters: tri/biphasic (green), single-peak (yellow) and artifactual (red) waveforms. 61.8% of dominant pulses were tri/biphasic before ventriculitis, which reduced to 22.6% during and 28.4% after (p<0.0001). one day before the first positive cultures were collected, the distribution of meta-clusters changed to include more single-peak and artifactual icp waveforms (p<0.0001). the distribution of icp waveform morphology changes significantly prior to the clinical diagnosis of ventriculitis, and may be a potential biomarker. inducing normothermia with temperature modulating devices (tmds) is often associated with significant shivering. we tested the ability of a novel transnasal tmd to induce and maintain normothermia with minimal shivering in endotracheally intubated (et) cerebrovascular patients. single center study utilizing coolstat transnasal cooling device to achieve core temperature reduction by inducing an evaporative cooling energy exchange in the turbinates and upper airway thru a high flow of dehumidified air into the nasal cavity and out the mouth. primary goal was the ability to induce normothermia(t<=37.5c) within 4 hours in et patients with fever(t>=38.3c) refractory to acetaminophen. continuous temperature measurements were obtained from tympanic and core(esophageal or bladder) temperature sensors. safety assessments included continuous monitoring for hypertension, tachycardia, and raised icp(when monitored). ent evaluations monitored for any device related nasal mucosal injury. shivering was assessed every 30 minutes using the bedside shivering assessment scale(bsas). duration of device use was limited to 8 hours, as regulated by the e care for temperature management. ten subjects(median age:54 years, bmi:32.5kg/m2,60%men) were enrolled with normothermia achieved in 90% of subjects. one subject did not achieve normothermia and was later refractory to other tmds. median baseline temperature was 38.5+/-0.1 c, with a reduction noted by 4 hours(38.5 +/-0.1 v. 37.3 +/-0.8, p<0.001) and sustained at 8 hours(38.5+/-0.1 v 37.2+/-0.7, p=0.001). time to normothermia was 3.1+/-1.8 hours. the median bsas was 0(range:0 -1) with only 4 episodes necessitating meperidine across 80 hours of study monitoring. no treatment was discontinued due to safety concerns. ent evaluations noted no device related adverse findings. inducing normothermia with a novel transnasal tmd appears to be safe, feasible and not associated with significant shivering. a multicenter trial testing the ability to maintain normothermia for 24 hours is currently underway. traumatic coma is thought to be caused by disruption of the subcortical ascending arousal network (aan). this hypothesis has not yet been tested because tools to map aan connectivity in living humans have only recently become available. we implemented high angular resolution diffusion imaging (hardi) on an mri scanner in the intensive care unit to determine whether patients presenting with traumatic coma have disrupted aan connectivity. we performed high angular resolution diffusion imaging (hardi) in 16 patients with acute severe traumatic brain injury who were comatose on admission and in 16 matched controls. we used probabilistic tractography to measure the connectivity probability (cp) of aan axonal pathways linking the brainstem tegmentum to the hypothalamus, thalamus and basal forebrain. to assess the spatial specificity of cp differences between patients and controls, we also measured cp within four subcortical pathways outside the aan. compared to controls, patients showed a reduction in aan pathways connecting the brainstem tegmentum to a region of interest encompassing the hypothalamus, thalamus, and basal forebrain (patients: median 0.08, iqr [0.04, 0.1] controls: 0.1 [0.09, 0.12], p = 0.006). examining each pathway individually, brainstem-hypothalamus and brainstem-thalamus cps (pc < .05), but not brainstemforebrain cp (pc = 0.37), were significantly reduced in patients. only one subcortical pathway outside the aan showed reduced cp in patients. we provide initial evidence for the reduced integrity of axonal pathways linking the brainstem tegmentum to the hypothalamus and thalamus in patients presenting with traumatic coma. our findings support current conceptual models of coma as being caused by subcortical aan injury. aan connectivity mapping provides an opportunity to advance the study of human coma and consciousness. limited knowledge about the physiology underlying coma recovery has decreased clinicians' ability to identify patients likely to benefit from continued intensive therapy. machine learning using quantitative eeg (qeeg) has shown potential to improve outcome prediction in cardiac arrest, but the relationship between qeeg trends and coma recovery had limited evaluation in large multicenter studies. seven hospitals contributed clinical and eeg data from comatose adult subjects with cardiac arrest who underwent continuous eeg and targeted temperature management. qeeg features evaluated included background frequency, burst-suppression ratio(>50%), epileptiform discharges, and entropy. we utilized random forests to predict good (cpc1-2) vs. poor (cpc3-5) outcome at 6-months. model performance was evaluated using the auc at 12h intervals up to 72h. we analyzed 58,125 hours of eeg (+5tb) for 1,089 subjects (388 good outcomes). unfavorable eeg features were common in subjects with good or poor outcomes (epileptiform discharges: 27%, 38% and burst-suppression: 25%, 56%, respectively). epileptiform discharge frequency peaked after rewarming in subjects with good outcome (3 spikes/min at 48h), but continued increasing during cooling and rewarming for those with poor outcome (4-8 spikes/min from 24h-48h). shannon entropy was always higher in subjects with good outcome. burst-suppression strongly predicted outcome for all centers but during different times, while epileptiform discharges predicted outcomes in five centers, entropy in three, and alpha-background in only one. outcome prediction was best with qeeg during cooling rather than after rewarming (auc 0.83 vs. 0.77 at 24h and 48h, p<0.05). maximal auc at 24h for individual centers ranged from 0.54-0.86. early qeeg trends carry useful information for coma recovery prediction, but marked heterogeneity in qeeg trends across centers can limit performance and reproducibility of machine learning prognostication algorithms. coexistence of favorable and unfavorable qeeg features in the same patient is common, suggesting that generalizable models for coma recovery prediction must leverage temporal trends. human consciousness depends on ascending projections from the brainstem. brainstem lesion mapping studies have identified a coma-specific sub-region of the dorsolateral pontine tegmentum. however, loss of consciousness (loc) can also occur following injury to cortical regions remote from the brainstem, a phenomenon that commonly occurs after penetrating head trauma but remains poorly understood. andexanet alfa has been shown to reduce anti-factor xa activity however outcome studies are lacking. we compare the efficacy of four-facto -pcc) vs andexanet in patients with factor xa inhibitor related bleeding. retrospective study was performed january 2017 to march 2019, including patients with factor xa inhibitor related bleeding of whom 71 wer -pcc vs 50 treated with andexanet. outcome was analyzed using glasgow outcome scale (gos) at discharge, presented as good (score 4-5) and poor (1-3); length of stay (los) and invariables, and t-test for continuous variables. -pcc or andexanet were included in the study. bleeding source --pcc; vs andexanet 17 cases, 34% of total -pcc n=20, andexanet n=11) and trauma (45-pcc -pcc group was 7.8d vs 6.7d in the andexanet group; icu stay corresponded to 4.34 vs 4.29 days, respectively. outcomes evaluated through gos did not differ -pcc group vs 50% in andexanet group, -pcc group vs 29.4% on andexanet group, p=1). unexpectedly, in-hospital mortality was higher on andexanet group -pcc group (9.9%); with a similar trend observed in the cns subgroup. -pcc as a factor xa inhibitor related bleeding reversal agent was as effective as andexanet based on outcome scale, constituting an essential option for hemostatic control as cost differences can limit the use of andexanet. the mechanism by which early administration of tranexamic acid (txa) reduces mortality in traumatic brain injury (tbi) is poorly understood. in-vitro models suggest the glycocalyx is preserved with early txa administration, indicating that txa may inhibit glycocalyx breakdown. we hypothesized that early txa administration would result in vascular endothelial preservation as evidenced by lower levels of thrombomodulin, syndecan-1, icam, and vcam. we analyzed a subset of subjects from the prehospital txa for tbi trial, which examined the efficacy and safety of prehospital administration of txa compared to placebo in patients with moderate or severe tbi who were not in shock. blood samples were collected upon admission and at 6hrs. glycocalyx breakdown markers were quantified using a luminex analyte platform. clinical variables were compared using wilcoxon rank-sum tests for non-parametric continuous data and chitests for categorical data. differences in median marker levels were evaluated using t-tests performed on log-transformed variables. significance was set at 0.05. data from 437 patients [placebo (n=201), txa (n=236)] were analyzed. groups were well-matched for age, sex, injury mechanism, admission injury severity score, head abbreviated injury score, and presence of intracranial hemorrhage (ich) on admission ct. no differences were observed in any median marker levels on admission or at 6 hours. however, admission levels of syndecan-1 in patients with ich (n=287) who received txa were lower than those in the placebo group (254.6 pg/ml [200.7-322.0] v. 272.4 pg/ml [219.7-373 .1], p=0.05). no differences in thrombomodulin, icam, or vcam levels were detected at either timepoint in the ich subgroup. administration of txa early after injury may attenuate endothelial release of syndecan-1 in patients with moderate or severe tbi and ich, potentially suggesting a selective role for txa in endothelial gl despite a rapid increase in the use of the oral factor xa inhibitors rivaroxaban and apixaban over recent years, there remains no standard management for associated life-threatening hemorrhage. andexanet -approved reversal agent available but its place in therapy remains controversial due to its high cost and a lack of head-to-head trials comparing it to four-factor prothrombin complex -pcc). we conducted a retrospective review of adult patients admitted with ich associated with rivaroxaban or apixaban and -pcc for anticoagulation reversal between may 2018 and april 2019. the primary outcome was hemostatic efficacy using the annexa-4 study rating system (excellent, good, or poor) based on initial and repeat non-contrast ct head imaging within 24 hours. secondary outcomes included the occurrence of thromboembolic events and 30-day all-cause mortality. we excluded patients whose hematoma was surgically evacuated before the 24-hour ct or who received multiple reversal products. 22 ich patients met the inclusion criteria: 8 andexanet patients (6 spontaneous and 2 traumatic) and 14 -pcc patients (1 spontaneous and 13 traumatic). 8 (100%) andexanet patients achieved excellent -pcc patients ( -pcc patients, 2 (14%) achieved good (p=0.26) and 2 (14%) achieved poor (p=0.26) hemostasis. thromboembolic events following -pcc patients (p=0.05). thirty-day all-cause mortality occurred in 1 (13%) andexanet patient and 1 (7%) -pcc patient (p=0.67). -pcc for reversing ich associated with rivaroxaban and apixaban. limitations include our small sample size and -pcc in this population now that andexanet alfa is widely available. a quality improvement project was undertaken to understand the risks of central venous catheter associated venous thromboembolism (vte) in the neuroicu setting. all patients who were admitted to the neuroicu and required a central venous catheter from 7/1/2018 to 12/31/2018 were included in the study. all catheters were placed under ultrasound guidance using the seldenger technique. the site of catheter insertion, duration of dwell time and subtype were recorded for each catheter that was placed. catheters were categorized as cooling catheters, large bore and dialysis catheters, or standard multi-lumen infusion catheters. clinical suspicion for vte such as extremity edema or unexplained hypoxemia triggered the standard of care use of ultrasound and/or lung ct angiography for diagnosis. vtes with an appropriate chronology and in the same vascular distribution as the suspected catheter were categorized as catheter associated. 174 catheters in 104 patients were included in the analysis representing 1022 catheter*days. a total of 8 catheter related vtes were observed in our cohort. in a mixed neuroicu cohort the overall vte rate was 7.8 per 1000 patient days which is in line with prior published rates. multi-lumen infusion catheters had the highest rate of vte (8.1 ± 3.3) and cooling catheters had the lowest rate (6.3 ± 6.3). surprisingly, the highest rate of vtes was observed in catheters placed in the subclavian vein across catheter types (13.7 ± 7.8). we observed that multi-lumen infusion catheters had a higher rate of vte compared with cooling and large bore catheters. this finding may be related to longer dwell times for multi-lumen catheters (6.4 ± 4.6 vs [cooling] 4.9 ± 2.4 and [large bore] 4.8 ± 4.4). the subclavian vein was the site with the highest rate of vte which may be related to more lateral approach taken with ultrasound guided subclavian catheter placement. patients on direct acting oral anticoagulants (doacs) have high mortality after intracranial hemorrhage (ich). prothrombin complex concentrate (pcc) has been used off-label to treat ich while on doacs. pccs effect on laboratory markers of anticoagulation have varied. whether or not a change in laboratory markers of anticoagulation impact outcome is unknown. retrospective, single center design assessing patients on doacs that presented with ich and received pcc. the primary outcome is to describe changes in anti-thrombelastography (teg) parameters before and after receiving pccs. hemostatic efficacy (defined by international society on thrombosis and haemostasis criteria), and thrombosis rate are also reported. thirty five patients were included. patients were 73.6+/-9.6 years old and 54% were male. 48.5% had traumatic brain injury related hemorrhage, 37% had primary intracerebral hemorrhage, 11.4% had subdural hemorrhage, and 2.8% had subarachnoid hemorrhage. median glasgow coma score at was 0.38 units/ml +/-0.50 units/ml. on average teg r time decreased 14 +/-34 seconds and teg act time decreased 34 +/-84 seconds. hemostatic efficacy was excellent or good in 70% of patients and poor in 30%. thrombosis rate was 8.6%. overall mortality was 49%. there was a modest response in laboratory parameters after giving pcc to patients with doac associated ich. the mortality in this cohort was high. whether a laboratory response in coagulation dosing, laboratory response, hemostatic efficacy and patient outcomes. in critically ill patients with tbi, agitated behaviors may often be threatening for patients safety and for clinical teams. antipsychotics are commonly used for the acute management of these agitated behaviors. however, animal tbi models suggest that repeated use of antipsychotic agents reduce cognitive and functional recovery. it remains unknown if the use of these agents negatively impact the functional recovery of tbi patients. our objective was to describe the use of antipsychotic agents and agitation/delirium monitoring practices in critically ill tbi patients. we conducted a retrospective observational study of 9 adult icus in canada that manage tbi patients. consecutive adult patients with moderate/severe tbi admitted to icu between january 2015 and december 2016 were included. data were collected using standardized forms for up to a maximum of 21 days in icu or until transfer out of icu. the primary outcome was incidence of antipsychotic use. we included 333 patients (3037 patient-days) with a moderate (44%) or severe (56%) tbi. the majority tbi included falls (48%), mva (34%) and assaults (8%). antipsychotics were used in 44% of patients for a total 27% of patient-days. quetiapine, haloperidol, olanzapine, and risperidone were used in a 14%, 11%, 1%, 1% of patient-days, mostly for agitation, an unclear reason or delirium (16%, 8% and 3% of total patient-days, respectively). a delirium monitoring tool was used 16% of patient-days whereas the rass and sas were used in 67% and 12% of patients-days, respectively. despite uncertainties regarding their efficacy and safety, antipsychotics are frequently used in critically ill moderate/severe tbi patients in canada, mostly for the management of agitation. sedation/agitation tools are mostly used for the monitoring whereas delirium tools are more rarely used. traumatic venous sinus thrombosis (tvst) is increasingly detected on neuroimaging in acute head trauma, and may be an important contributor to elevated icp refractory to standard medical/surgical treatment, and in turn, higher morbidity/mortality and more complex icu course. we sought to identify clinical and neuroimaging features predictive of refractory icp issues in tvst patients treated in an urban level i trauma center. retrospective query of electronic radiology database from 2015 to 2018 using the phrase "venous sinus thrombosis". cases were reviewed and scored by a fellowship-trained neuroradiologist to define degree of occlusion (partial vs complete) and cause of sinus occlusion (extrinsic compression vs intrinsic thrombus vs both). additional patient characteristics included demographics, mechanism of trauma, cerebral venous sinus involvement, laterality, skull fracture, extra-axial hemorrhage and invasive neuromonitoring. refractory icp was defined as at least one spontaneous icp elevation >=5 minutes during icu stay despite use of first tier therapies for icp control. odds ratios were computed and adjusted by multivariate logistic regression for patient age, gender and initial gcs to determine association with refractory icp. among 74 patients with radiologic diagnosis of tvst, 18 developed refractory icp (18/74=24.3%). statistically significant variables associated with refractory icp included involvement of internal jugular vein (aor=6.11, 95% ci 1.65-22.62), involvement of transverse sinus (aor=6.49, 95% ci 1. 22-34.60 ) and presence of temporal bone fracture (aor=5.27, 95% ci 1. 48-18.72) . potentially protective factors included sinus pathology secondary to extrinsic compression (aor=0.23, 95% ci 0.50-0.87) and coexisting epidural hemorrhage (aor=0.33, 95% ci 0.10-1.17). involvement of the internal jugular vein or transverse sinus and temporal bone fracture may represent sensitive features of tvst predisposing to refractory icp issues, while extrinsic compression of a sinus alone was found to be protective. monitoring cerebral autoregulation in traumatic brain injury (tbi) patients can indicate an individual cerebral perfusion pressure (cpp) target for which autoregulation is best preserved (cppopt): this offers a precision medicine approach with hypothetical advantage over the current 'one size fits all' strategy. large retrospective data suggest that managing cpp close to cppopt has a benefit in outcome. a prospective evaluation of cppopt guided therapy is needed, but before performing an outcome study it is necessary to assess the feasibility and safety of such a protocol. the primary objective of cogitate (cppopt guided therapy assessment of target effectiveness) is to demonstrate feasibility of individualising cpp at cppopt in tbi patients, expressed as the percentage of monitoring time for which cpp is within 5 mmhg of regularly updated cppopt targets during the first 5 days of intensive care unit (icu) admission. secondary objectives are to investigate the safety (increases of the treatment intensity level) and physiological effects of this strategy (changes in autoregulation indexes, organ function parameters). cogitate is a phase ii non-blinded, randomised controlled trial currently ongoing in the icu of cambridge, leuven, nijmegen and maastricht. severe tbi patients requiring intracranial pressure directed therapy, are enrolled in the first 24 hours after icu admission and allocated into two groups. in the intervention group the cpp target (cppopt) is calculated using a (modified) algorithm previously described by liu x et al. 2017 and clinically reviewed 4-hourly. the control group uses a fixed cpp target (60-70mmhg). patient re have been recruited so far. randomising between a fixed and variable cpp is feasible. after completion of recruitment and follow up in terms of assessment of safety and physiological parameters, we will consider progressing to a phase iii study. selective reduction of non-classical monocytes has been associated with reduced neutrophil activation in murine traumatic brain injury (tbi) models. similarly, cd4-/cd8-t cells or double negative t-cells (dnt) may exacerbate ischemic brain injury. this study sought to assess the expression of peripherally isolated t-cells and monocytes after acute tbi. all patients admitted with primary tbi to the neurotrauma icu between november 2017 and november 2018 were eligible for study. consent was obtained and blood samples were obtained within 24 hours of injury. samples were compared to healthy age-and sex-matched controls. conventional flow cytometry techniques gating on all patients admitted with tbi to the neurotrauma icu between november 2017 and november 2018 were eligible for study. consent and blood samples were obtained within 24 hours of injury. samples were compared to healthy age-and sex-matched controls. conventional flow cytometry techniques, gating on cd3+ and cd14+ were employed to identify t-cell and monocyte populations, respectively. data were analyzed using cytometric fingerprint binning and t-sne embedding, which captures the set of multivariate probability distribution functions and generates maps that facilitate quantitative comparisons. 8 patients were compared to 10 controls. after computational analysis, 27 distinct t-cell phenotypes were identified, of which 11 were statistically significantly different between patients and controls expressed as a fraction of cd3+ cells. three of these eleven subsets had a cd4-/cd8-(double negative) phenotype that were depressed among patients: cd4-/cd8-/cd127+ 0.00058% versus 0.0060%, p=0.008; cd4-/cd8-/161+ 0.0009% versus 0.0080%; p=0.013; cd4-/cd8-/127+/161+ 0.008% versus 0.046%; p=0.003. there was a three-fold decrease in the fraction of type 3, non-classical monocytes in patients than in controls [0.068 (iqr 0.037-0.103) versus 0.02 (iqr 0.0175-0.028); p=0.04]. similar patterns in monocyte expression were observed for the 3 patients who had repeat analysis at 72 hours. in this preliminary study, there were notable reductions in dnt populations and non-classical monocytes in patients with acute tbi, which may suggest recruitment to the cns. prior studies suggest that dnt play a critical role in the perpetuation of cerebral ischemia after acute stroke and that type 3 monocytes modulate neutrophilwarranted. much of the secondary injury that occurs after traumatic brain injury (tbi) results from coagulation derangements related to disseminated intravascular coagulation (dic). extracellular vesicles (evs) are small (0.1transduction. evs are released from all cell types, including platelets, endothelium, and granulocytes which are responsible for dic. we hypothesized that specialized flow cytometry techniques could identify a unique ev signature of dic in acute tbi. 3 ev fluorescence panels were created assessing for endothelial cells (cd 144+, cd 105+), platelets (cd 41, cd41a+, cd 42b+), erythrocyte markers (cd 235+) as well as brain specific biomarkers (s100b). using a modified flow cytometry instrument for detection of small particles, side scatter signal is used to estimate ev size. samples were treated with triton, which disrupts vesicular membranes, abolishing evs. samples were prepared in trucount tubes with a known number of lyophilized beads, which enabled the determination of the plasma volume. all combinations of positive/negative expression were counted. there was no significant difference in the total number of evs in the panels between the 11 patients and 7 controls. of 84 combinatorial analyses in the first ev panel, the following were significantly elevated after bonferroni correction: cd31+/cd144+ 6.89 evs/ul plasma v 0 controls (wilcoxon rank sum p=0.009); cd 105+/cd144+ 7.64 evs/ul plasma v 0.41 controls (p=0.04); cd235+/cd41a+ 3433.6 evs/ul plasma v 501.1 controls (p=0.009). brain biomarkers were also elevated: s100b 32581.7 evs/ul plasma v. 2688.6 controls (p=0.004). evaluate whether this expression correlates with secondary microvascular brain injury. s100b evs (membrane bound, not free soluble protein) are significantly elevated in tbi patients; if reproducible, the significance of this remains to be elucidated. diabetes insipidus (di) following transsphenoidal craniotomy may lead to significant metabolic derangements. serum sodium imbalances are frequent and important; both hypo-and hypernatremia can be devastating neurologically. a project aimed at improving di management through predictive assessments and ddavp protocols could potentially improve patient outcomes. however, few predictors for the postoperative development of di have been reported. after institutional irb exemption, the records of 121 patients undergoing endonasal transsphenoidal craniotomy between july 2015 and december 2018 were retrospectively reviewed. demographics, preoperative medical or radiologic diagnoses, medications, and laboratory values as well as intraoperative blood loss, urine output, and ddavp administration were assessed for correlation with the incidence of postoperative development of di using logistic regression. development of postoperative di was defined as postoperative ddavp administration and/or ddavp use upon or after discharge from hospital. 17 of the 121 patients developed postoperative di. patients 0.037, and 0.047, respectively). similarly, patients with increased intraoperative blood loss, increased intraoperative volume administration, nd intraoperative ddavp or vasopressin administration were also more likely to develop postoperative di (pwith logistic regression modeling adjusted for associations between outcome and potential risk factors, patients having a documented or clinical suspicion for a preoperative endocrinopathy had seven times higher odds of developing postoperative di compared to their peers (p-value 0.111, 95% ci 1. 571-33.151 ). in administration, and ddavp were independently associated with an increased risk of postoperative di; the odds of postoperative di were seven times higher in patients with a documented or clinical suspicion findings. the 5 seminal mechanical thrombectomy (mt) trials had a median age of 68 years. though some of these trials included nonagenarians, there is little data on their outcomes. we aimed to compare the procedural, discharge outcomes and complications, of mt for acute ischemic stroke (ais) in patients with ais admitted to two comprehensive stroke centers were enrolled prospectively in a mt, procedural outcomes, complications, and discharge disposition were compared in propensity scorematched groups (matched for nihss, pre-stroke mrs, ivdefined as a discharge to home/acute rehabilitation. of the 3010 ais patients, 46/297 (16%) nonagenarians underwent mt compared to 159/1337 (12%) 69) were propensity score-matched with a median admission nihss of 22 and 19, and median aspects (84% vs 50%, p=0.035), whereas ica (10% vs 13%, p=0.76), and m2 (21% vs 43%, p=0.19) occlusions were similar between the two groups. time to groin puncture (100±65 vs 76±34; p=0.124), revascularization time (134±72 vs 110±54; p=0.145), complication rates (0 vs 5.1%; p=0.494) and inhospital deaths (11% vs 24%; p=0.155) were similar among the two groups. 44% of nonagenarians had we present one of the largest series of mt among nonagenarians with 89% successful recanalization rates. in propensity score analysis almost half of nonagenarians (44%) were discharged to home/rehab, which is comparable to a younger cohort (51%). aggressive management is warranted in the oldest of the old. early neurologic deterioration (end) occurs in up to one third of stroke patients and is associated with poor outcome. no consistent definition of end exists regarding degree of nihss decline and timeframe. we evaluated the definition of end, predictive factors, and 90 day outcomes in a cohort of critically ill stroke patients. this study is a retrospective review of consecutive ischemic stroke patients with nih stroke scale (nihss) intervention factors were obtained. end was defined as a delta nihss > 2 at 24 hours from admission. reperfusion was defined as a thrombolysis in cerebral infarction (tici) score of >2b, cerebral edema treatment as any icp-lowering therapy, and poor outcome as mrs >3 at 90 days. multivariable logistic regression analyses were performed to assess factors associated with end and poor outcome. 183 patients (median age 67 years, 50% women, median nihss 20) met study criteria. 23% experienced end. admission nihss, administration of tpa, receipt of intraarterial therapy, and successful reperfusion were not associated with end. end was independently associated with older age (p=0.036), sex (p=0.043), and treatment of cerebral edema (p=0.039) after adjusting for cerebral herniation and tracheostomy. poor outcome was associated with older age (p=0.001), higher delta nihss (p<0.001), not receiving tpa (p=0.015), and placement of percutaneous endoscopic gastrostomy tube (p=0.006). end patients had a higher median 90 day mrs (p<0.001). end as defined by a delta nihss > 2 at 24 hours predicts poorer outcome, but was not associated with tpa or intraarterial therapy, which contrasts with prior literature. this variance could be attributed to the end timeframe defined as 24 hours rather than the typical 48samples sizes and comparison of end timeframes could clarify observed findings. annexa-4 was a single-arm, prospective, open-label study of andexanet in patients presenting with major bleeding within patients with spontaneous intracranial hemorrhage (ich). brain imaging was performed at baseline, and at 1 and 12 hours post andexanet treatment. subdural hemorrhage (sdh) thickness and ich volumetric analysis was performed using quantomo software. co-primary efficacy outcomes were change in antiof 352 patients enrolled in annexa-4, nontraumatic ich was present in 128 patients, including intracerebral +/-intraventricular in 99 patients, subarachnoid in 5 patients and subdural in 14 patients. in this cohort, mean age was 78 years (sd 9.2) administration was 11.9 hours (iqr 7.9-15.3); median time from symptoms to ct was 2.6 hours (iqr 1.2-2.7); and median time from ct to andexanet administration was 1.8 hours ). median intraparenchymal volume was 9.5 ml (iqr 3.9-21.3). among 99 efficacy evaluable patients (baseline anti-treatment overall. in patients treated <2 hours after baseline imaging, hemostatic efficacy was 82.5%; 2-3 hours after baseline imaging, 70.8%; >3 hours, 75.0%. within 30 days, death occurred in 24 patients (18.2%). andexanet reduced anti--or apixaban-associated nontraumatic intracranial bleeding and with a high rate of hemostatic efficacy up to 12 hours after treatment. spontaneous intracerebral hemorrhage (ich) is associated with high rates of mortality. multiple scoring systems exist however the original ich score remains most commonly used. we hypothesize that patients undergoing scuba, compared to medically managed patients, would have lower 30-day mortality than predicted. we performed a retrospective observational cohort study of consecutive nontraumatic spontaneous ich patients treated at a single, tertiary care, academic center from december 2015 to june 2018. patients for each patient based on the admission ich score. a total of 100 ich patients were included. the median age was 60 (q1=53, q3=73), gcs 10 (7, 13), and nihss 17 (13, 22) . sixty-three were deep hemorrhages and 43 had intraventricular hemorrhage. median pre-operative volume was 40.9ml (27.8, 64 .3). the expected 30-day mortality was 34.7% while the observed mortality was 9%. on 180-day follow up, a mrs of 0-3 was seen in 46% of patients. patients undergoing scuba have an absolute risk reduction of 25.7% in mortality than predicted by the ich score. good outcome to moderate disability, defined as mrs 0-3, was achievable in almost half the introduction andexanet (coagulation factor xa [recombinant] inactivated-zhzo), a specific reversal agent for factor xa 9% of patients with major bleeding in the annexa-4 trial. however, little is known about the clinical factors associated with a hemostatic response in patients with intracranial hemorrhage (ich) receiving andexanet. annexa-4 was a prospective, single-arm, open-label study of andexanet in patients with acute major treatment was rated by an independent adjudication committee as excellent, good, or poor/none based on pre-specified criteria. all ich patients with evaluable he were included in the analysis. univariate and indication for anticoagulation, baseline antianti-platelet use, time from last dose to andexanet (and other time intervals), neurologic function, and hematoma characteristics were performed to identify factors predictive of he. of 227 ich patients enrolled, 219 (96.5%) had evaluable he. in patients with ich, baseline antitime from symptoms to andexanet were all significantly associated with he. in multivariate analysis, time from last dose (12.3h for excellent/good; 8.4h for poor/none), time from symptoms to andexanet (7.0h for excellent/good; 4.4h for poor/none), and time from symptoms to scan (3.8h for excellent/good; 1.6h for poor/none) were independently associated with he. in ich patients treated with andexanet in the annexa-4 study, various time intervals were predictive of hemostatic efficacy. these findings suggest that shorter time intervals are associated with lower he and are consistent with the known relationship between time from symptoms and the risk of hematoma expansion. alterations in functional connectivity are associated with persistent cognitive deficits in survivors of aneurysmal subarachnoid hemorrhage (sah), but causation remains unknown. therefore, we sought to and behavior could be assessed. we used functional optical intrinsic signal imaging to measure spontaneous hemodynamic fluctuations -operated (n=10) and sah (n=11) mice. we tested behavior using the morris water maze, open field test, y-maze, and rotarod. timepoints were from 4 days to 3 months. we used the anterior prechiasmatic injection model of sah. 0.13), and visual cortex (0.24 vs. 0.15) at day 4 following sham procedure or sah, as measured by the proportion of brain surface with a correlation coefficient >0.5 (sham vs. sah, respectively, p<0.05). -independent ng sah. a global connectivity index remained decreased until 1 month following sah (0.42 vs. 0.37, p<0.01 ). an interhemispheric connectivity index was also he hidden platform test on the morris water maze (p=0.045) and open field test (34 vs. 14 m, p=0.034) at approximately 2 weeks. there were persistent deficits on the y-maze for at least 3 months (59% vs. 48% alternation, p=0.028 with repeated measures at 1 and 3 months). there was no significant effect of sah on rotarod performance. we studied whether high-protein supplementation (hpro) and neuromuscular electrical stimulation (nmes) after subarachnoid hemorrhage (sah) could be a safe and feasible approach to reduce muscle wasting and improve long term recovery. assigned to standard of care (soc) or nmes + hpro. nmes was delivered to bilateral quadriceps and gastrocnemius muscles during two 30-minute sessions daily along with hpro (goal 1.8 g/kg/day) between post bleed day (pbd) 0 and 14. tolerability was measured during each nmes session by assessing for agitation or discomfort. safety measurements included increased heart rate, blood pressure, or intracranial pressure (when monitored) during nmes. stimulation sites were assessed after each nmes for muscle injury or skin trauma. hpro tolerability was assessed by monitoring for gastric retention or emesis. safety measures included aspiration and evidence of acute kidney injury. nmes and hpro were discontinued if subjects refused. the goals were to administer at least 80% of nmes and hpro. muscle wasting was assessed with serial ct scans of the thighs. twenty-five subjects (soc=13, nmes + hpro=12) participated with no differences in baseline characteristics (58 years old, 68% women, 50% hh>3). median intervention days were 12 (range: 9-14), with 98% of nmes sessions completed. two subjects had transient muscle soreness but no other adverse events. no adverse events were associated with hpro. the hpro group received 83% of the goal and more protein than soc (mean difference: 0.63+/-0.17g/kg/d, p<0.01). muscle atrophy at pbd 14 was greater in soc group (6.7+/-3.2% vs 2.8+/-2.9%, p=0.01). nmes and hpro are safe and feasible after sah. a larger pilot study is underway to understand whether nmes and/or hpro may beneficially impact neuromotor recovery after sah. lipocalin-2 (ngal) is released by activated neutrophils and astrocytes and mediates neuro-inflammation and iron regulation in hemorrhagic stroke models. blood ngal is an early biomarker in human ischemic l and neurofunctional outcome in sah patients. magnetic luminex assay, r&d systems) and assessed modified rankin scale (mrs) every 3 months. patients with renal or severe liver dysfunction, active malignancy or intracranial infections were excluded. poor outcome is defined as mrs>2. vasospasm was defined as >50% reduction any vessel caliber on cerebral angiogram. continuous variables were compared with student's t or wilcoxon rank sum test depending on data distribution. one-way anova was used for multi-group comparison. sah cohort has mean age of 55.1 years, 69% women, 48% with poor 3-month outcome and 55% developed vasospasm. higher plasma ngal on post--sah days 1-3 (p=0.05) and 5 (p=0.017) are associated with poor 3-month outcome. higher plasma ngal on postand ngal on post-sah days 1--0.0063) early elevation of plasma ngal on post-sah day 1 is associated with vasospasm and poor 3-month -sah 1-5 are associated with poor 3-month outcome. larger population studies are needed to validate plasma ngal as a potential sah biomarker. patients with aneurysmal subarachnoid hemorrhage (asah) are at risk of rebleeding prior to aneurysm obliteration. while placebo-controlled studies have shown that administration of either -aminocaproic acid (eaca) or tranexamic acid (txa) can decrease rebleeding, there has not been a comparison of the two in this patient population. because of a national shortage of eaca in 2017, our hospital changed to txa. the purpose of this study is to describe the outcomes of asah patients treated with either eaca or txa. this is a retrospective chart review of patients who presented with an asah between 4/1/16 and 3/31/19 and were treated with either eaca or txa to prevent aneurysm rerupture. descriptive statistics were used. there were 43 patients with asah who received eaca and 45 who received txa. the groups were eaca group and 86.7% in the txa group. the average time from admission to drug initiation was 6.0 ± 3.8 hours in the eaca group and 4.8 ± 4.0 hours in the txa group. no patient in either group experienced aneurysm rerupture after receiving the drug. similar numbers of patients in both groups had cerebral ischemia (eaca: 23% vs. txa: 24%) and extracranial thrombosis (eaca: 7% vs. txa: 9%). although txa is known to lower the seizure threshold, we found no increased incidence of seizures (eaca: 28% vs. txa 13%). there was a modest cost difference in favor of txa vs. eaca. there does not appear to be any major differences in outcomes in patients with asah treated with either eaca or txa for the prevention of aneurysm rerupture and a slight cost savings favoring txa. a larger prospective study is required to confirm these results. outcome prediction after aneurysmal subarachnoid hemorrhage (asah) is based on scores, which are determined once at admission. however, the occurrence of delayed ischemic neurological deficits (dind) depends on multiple concomitant and continuously changing factors. the goal of the study was to establish an automated analysis pipeline to predict dind from multimodal data. multimodal data (patients' history, imaging and laboratory values among others) from 105 patients with asah were analyzed. dind was defined as new ischemia or perfusion deficits in native or contrastenhanced ct/mri and/or cerebral vasospasm in conventional, ct-/mr-angiography. a ranking of the features was performed by univariate regression analysis. only cases with <10% of missing values were included in the model. among the 412 tested features, the top 26, with a false discovery rate <0.01, were selected. missing values were imput random forest machine learning algorithm was applied. the performance of the prediction was estimated on the fly by predicting the observations that were not used for building the tree ("out-ofbag") across all trees. the final data matrix contained 464 events described by 26 features from 67 patients. in the final model, the out-of-bag estimate of error rate was 23%, which reflected a 77% accuracy. the importance plot for different features revealed the importance of some parameters known in the context of inflammatory response, which is linked to the pathophysiological cascade leading to dind. these included counts of leucocytes, monocytes, neutrophils, and lymphocytes. however, other laboratory parameters, such as zinc and selenium, appeared to be of high importance in the model, which was somewhat unexpected. machine learning algorithms may be helpful to filter out predictive features from a large number. these features might be subsequently investigated regarding their predictive value on the occurrence of dind after asah. innate inflammation is a recognized mediator of dci after sah. we have shown that neutrophils and the neutrophil-derived enzyme, myeloperoxidase (mpo), mediate memory deficits in dci. how mpo affects memory is unclear. there is evidence that mpo, and its substrate h2o2, may act through astrocytes or directly on neurons. here we test mpos action on astrocytes and neurons. primary neuronal and astrocyte cultures were developed from wt and c57bl/6thy1-gcamp3 mice. to test if mpo or h2o2 are toxic to neurons or astrocytes, cells were incubated with mpo (0.8u/ml), h2o2 (0.0012%), and mpo/ h2o2 and evaluated with live/dead cell viability assay (thermofisher). to test if neuronal firing is affected by mpo, the same experimental conditions were examined in c57bl/6thy1-gcamp3 using video microscopy. neuron activation was stimulated with kcl (final concentration 10mm). addition of h2o2 led to death in neurons and astrocytes. mpo did not affect cell death in either group. interestingly, mpo/ h2o2 showed less cell death than h2o2 alone suggesting a neuroprotective benefit of mpo. in neurons, kcl administered to untreated neurons led to continuous firing as evidenced by intense calcium signal. mpo addition did not change the firing rate when compared to baseline. after 2.5 hours of mpo pretreatment, activation with kcl showed a suppressed firing rate suggesting neuronal depression. the addition of mpo/ h2o2 showed the same firing rate suppression as mpo alone. this study suggests that mpo acts directly on neurons to decrease function. in our model of neutrophilinduced development of dci, mpo is released in the meninges, diffuses to the brain parenchyma and acts directly on neurons to affect memory. this needs to be tested more thoroughly in an in vivo model of sah. how mpo specifically affects memory in neurons is an area of interest in our laboratory. delayed cerebral ischemia (dci) is a feared complication of subarachnoid hemorrhage (sah), leading to worse outcomes. electroencephalography (eeg) provides a useful, continuous monitoring tool for dci risk (claassen 2004; kim 2017; rosenthal 2018) and late-onset epileptiform discharges (ed) have high predictive value for dci (kim 2017; rosenthal 2018) . however, optimal parameters to assess ed contribution to longitudinal dci risk are unknown. we hypothesize that the evolution of ed frequency after sah can provide early identification of those at high dci risk. we analyzed continuous eegs from 124 patients with moderate to severe aneurysmal sah. ed were identified using a commercial detection algorithm (scheuer 2017). we calculated ed frequency (per hour) after sah and compared mean ed frequencies between dci and control patients. we also evaluation, we performed group based trajectory analysis (gbtm) and calculated hourly receiver operating curves (roc). ed rates were higher in both dci and control groups during the clinical dci "risk period" of day 3-14. overall mean ed frequency were significantly higher in dci patients (t-test, p=0.03), including only pre-dci ed assessment (t-test, p<0.01). hourly mean ed rates remain higher in dci patients from days 2-13. using gbtm, we identified three distinct trajectories associated with dci (79%, 52%, 37%, p=0.01), with group number selection optimized based on bayesian information criteria. hourly area under the roc (auc) calculations of ed frequency yielded a maximum performance of 0.78. natural history of ed frequency in all sah patients coincides with the "high risk" time-period of dci. patients with dci have higher mean frequencies that remain elevated throughout this dci risk period. gbtm and auc calculations suggest longitudinal analysis of discharge frequency can differentiate dci risk, but integration of other waveform characteristics are needed to optimize prediction. aneurysmal subarachnoid hemorrhage (sah) has high morbidity and mortality. time to aneurysm repair, whether earlier or later in the course of the disease, may impact outcomes. however, optimal timing remains controversial. our goal was to describe the association between time to aneurysm repair and mortality and functional outcome. this study was conducted in two reference centers -one in rio de janeiro and one in porto alegre july 2015 to march 2019, every adult patient admitted to the icu with aneurysmal sah was enrolled in the study. data were collected prospectively during the hospital stay. patients were divided into four groups according to the moment of aneurysm repair after bleeding: <3 days, 4 to 8 days, >8 days and not repaired. the primary outcome was in-hospital mortality. dichotomous variables were analyzed using twomortality as the reference group (4 to 8 days). a total of 437 patients were included. median age was 55 years, mostly female (73%). in the univariate analysis hydrocephalus, rebleeding, postoperative neurological deterioration (up to 48 hours after procedure), delayed cerebral ischemia, as well as mortality and poor outcome, were associated with the different timing of aneurysm repair. in the multivariate model for mortality, poor grade sah, hydrocephalus, post-procedure neurological worsening and dci were independently associated with higher mortality. additionally, late repair was associated with lower mortality (or 0.4) as compared with occlusion between 4 to 8 days. our study shows higher mortality in patients submitted to aneurysm occlusion procedure between days 4 and 8 after ictus, when compared to late repair. more studies are needed to define the best timing of aneurism repair in patients that are not submitted to early occlusion. the biological mechanisms that influence abnormal cortical neurophysiology after aneurysmal subarachnoid hemorrhage (sah) are uncertain. we hypothesized that soluble st2 (sst2), a plasma marker of the innate immune response, is associated with events of electroencephalography (eeg) deterioration including new epileptiform abnormalities (eas) or new eeg background deterioration. -approved biospecimen repository, we evaluated patients with at least 3 days of eeg monitoring and an early sst2 measurement (collected <5 days following sah). eas were defined as sporadic epileptiform discharges, lateralized rhythmic delta activity (lrda), lateralized periodic discharges (lpd), or generalized periodic discharges (gpd). background deterioration was defined as decreasing alpha delta ratio (adr), relative alpha variability (rav) or worsening focal slowing. the association between sst2 level and eeg-identified eas or new background deterioration was compared using the wilcoxon rank sum test. 46 patients met inclusion criteria. early sst2 was collected at mean 3.5±0.9 days after sah; 23 patients had a subsequent sst2 measurement at 10±2.5 days. 17 (37%) patients developed new eas during eeg monitoring, 21 (46%) developed new background deterioration, and 8 (17%) developed neither. median sst2 in patients developing new eas was higher (114.8 ng/ml ]) than in patients who did not develop new eas (74.7 ng/ml ], p=0.024). this association between elevated sst2 and new eas was not present for sst2 samples collected at later time points. there was no difference in sst2 levels between patients who developed new background deterioration (75.7 ng/ml ) compared with those who did not (80.1 ng/ml ], p=0.56). among patients admitted with aneurysmal sah, elevated sst2 in the first 5 days is associated with the development of new eas on eeg monitoring. this association was not present at later time points, suggesting that the early inflammatory response may be linked to abnormal cortical neurophysiology. glial-mediated inflammation occurring early after status epilepticus (se) in rodent models has been implicated in the subsequent development of spontaneous recurrent seizures (srs). while this suggests anti-inflammatory strategies may be a target for therapeutic intervention, the appropriate timing for such an intervention is unclear. the aim of this work is to define the timing of early inflammatory changes using pro-inflammatory mir-155 and anti-inflammatory mir-146a as biomarkers in a kainic acid mouse model of se. se was induced in 7-8 week old male c57bl/6j mice (n=5 per timepoint) using intraperitoneal injections of 30 mg/kg kainic acid. the onset of se was defined as the first class 3 seizure using a modified racine scale. the intensity of the se episode was estimated by the total number of discrete class v seizures observed. after 2 hours, the se was aborted with diazepam, and hippocampal tissue was harvested at 3 hr, 18 hr, 24 hr, 48 hr and 72 hr. rna was isolated using trizole (life technologies) followed by qrt-pcr analysis to define the steady-state expression levels of mir-155 and mir-146a and their targets, socs1 we observed a >4 fold increase in expression levels of mir-155, reaching peak levels at 18 hours. expression levels of mir-155 directly associated with the intensity of se. the level of socs1 mrna expression decreases after the peak expression of mir-155. as the levels of mir-146a were only conclusions mirna-155 expression shows an early increase within 3 hours of se, reaching a peak at 18 hours. mir-146a shows a non-mir-155 initiated after se to determine if this can prevent the development of srs. nurses routinely screen for changes in neurologic status with serial clinical assessments. the objective of this study was to employ mixed methods to determine inter-rater reliability (irr), protocol adherence, and acceptability of a new tool we developed called serial neurologic assessment in pediatrics (snap) compared to the glasgow coma scale (gcs). snap assesses mental status, cranial nerves, communication, and four-extremity motor function/strength, with scales for children <6-months, 6-months to 2-ye -years-old. snap was designed for use in a diverse population, including patients who are intubated, sedated, and/or have developmental disabilities. irr of independent snap assessments by pairs of trained nurses was assessed with multilevel cohen's kappa and linear weighted kappa, calculated through clustered bootstrap method to account for multiple assessments. we assessed protocol adherence with standardized observations. we conducted semi-structured interviews to assess acceptability and feas we thematically analyzed interviews in accordance with modified grounded theory framework. 45 critical care nurses performed 387 paired snap assessments on 299 patients (148 <6-months; 91 6months to 2--years). there was substantial agreement between nurses (average kappa=0.7 <6-months; 0.8 6-months to 2--years), and irr was unchanged for children who were intubated, sedated, and/or had developmental disabilities. irr was unchanged based on degree of experience using snap and for day vs. night-shift nurses. nurses had 100% protocol adherence. snap was easier to use and more precise at describing neurologic status of patients who were intubated, sedated, and/or had developmental disabilities than gcs. 88% of nurses preferred to use snap over gcs. when utilized by nurses, snap has substantial irr, excellent protocol adherence, and is acceptable and feasible to i neurologic decline. several studies demonstrate significant gender disparities in professional societies for critical care and neurology, but data for neurocritical care is lacking. we examined gender representation trends within the neurocritical care society (ncs), the largest international professional society for this subspecialty. we hypothesized that female representation has increased with achievement of gender equality in 2018. a multidisciplinary writing group obtained approval from the ncs executive committee and endorsement by the women in neurocritical care (wincc) section. after review by the rush university irb, access was granted for the following rosters: general membership, board of directors, officers, committees, annual meeting speakers, grant, fellowship and other award recipients. we differentiated between female, male and unidentified gender. available membership rosters from 2005 listed 524 members, with gender unknown for >75%. in 2018, of 2633 members 37.6% were females, 49.2% males, and 13.3% unidentified. as of 2018, 3/17 presidents (17.6%) and 4 -2018, female committee members increased from 15% to 47%; female committee chairs increased from 18% to 48%. to date, 1/15 (6.6%) christine wijman young investigator awardees were female with no female recipients of the best scientific abstract award (2007) (2008) (2009) (2010) (2011) (2012) (2013) (2014) (2015) (2016) (2017) (2018) . 36% of presidential citation awardees -80% from 2011-e representation in guidelines writing groups ranged between 5%-75% (2015-2017), and 9-45% in consensus statements writing groups (2011) (2012) (2013) (2014) (2015) (2016) . -43% (2003awardees were women. within the ncs, a longitudinal increase in female representation has occurred over the last 19 years but gender equality has not been achieved. we recommend focused efforts to facilitate inclusion and gender equity within ncs. with the push toward using large data sets in critically ill patients, the use and management of registries is becoming more relevant. clinical registries provide insight about associations and patterns in diagnosis, disease, and treatment. the integrity of the data is of utmost importance. this poster describes the quality control and data management methods for maintaining the integrity of a multicenter trial registry. we employed modifications to van den broeck's method of data organization to clean and manage the end-panic registry. the data management consisted of five phases: 1) screening phase, 2) data organization , 3) diagnostic phase, 4) treatment phase, and 5) missing data phase. the screening phase consisted of distinguishing missing and extraneous data elements, outliers, inconsistent patterns/distributions and unexpected analysis results. the data organization phase consisted of treating blank cells and highlighting errors with data input. the diagnostic phase was used to clarify the true nature of the data points, and make sure the data presented was biologically possible. the treatment phase consisted of correcting variables. the missing data phase consisted of determining whether the missing data was informative or noninformative. currently the multi-center registry houses ~3.5 million discrete data points from 3,272 patients. there was a high correlation between the texas, ohio and california locations, and npi, dvl, cvl, mcvl, and pupil size. there was a low correlation between the texas, ohio and california locations, and pupil latency and presence/absence of cataracts. missing data was informative for age, race and ethnicity, and distribution of missing data caused an inquiry into methods for collecting data and implementation plans for change. this interdisciplinary method for cleaning and managing the end panic registry was able to identify and rectify errors. we would recommend others to use the methods to build, clean and manage clinical registries. objective was to describe current state of quality improvement (qi) processes implemented in neurocritical care units (nccu). a 27-question-survey was sent to 2000 members (physician, nurses, and pharmacists) of the neurocritical care society. we describe factors affecting the presence of nccu qi, barriers to qi, awareness of stroke (stk, cstk), stroke get with the guidelines (gwtg), trauma quality improvement program (tqip) and american academy of neurology (aan) performance measures, and examined factors affecting satisfaction with current practices. the response rate was 22.5%; 73.7% of respondents were from us teaching hospitals, 87.9% practiced in dedicated neurocritical care units, and 43.4% in a program with a neurocritical care fellowship. 44.6 % reported a dedicated nccu qi program. comprehensive stroke center (rr 1.7, 95% ci 0.92-3.13, p = 0.09), dedicated nccu (rr 2.0, 95% ci 0.83-4.83, p = 0.07), and ncc fellowship programs (rr 1.41, 95% ci 0.99-2.02, p = 0.06) were more likely to report dedicated ncc qi staff. external ventricular drain infection was the most commonly tracked ncc qi metric (69.6%). respondents indicated the highest level of awareness for cstk (87.5%), stk (81.8%), and gwtg (81.8%), but indicated a relative lack of awareness for tqip (42.7%), and aan (46.2%) perform satisfaction with existing ncc qi were: presence of a hospital qi program (rr 8.81, 95% ci 1.30-59.7), p = 0.0004), presence of a formal ncc qi program (rr 4.33, 95% ci 1.47-12.7), p = 0.0003, and dedicated ncc qi staff (rr 2.23, 95% ci 1.51-3.32), p < 0.001). insufficient hospital (57.7%) and departmental support (36.5%) were reported common barriers to the successful implementation of an nccu qi program. a dedicated staffed nccu qi program occurs in a minority of neurocritical care units, and the lack of such programs may lead to clinician dissatisfaction. institutional and departmental support may be critical elements of a successful and satisfactory implementation of nccu qi. the development and implementation of a nurse driven rounding model was instituted in the neuro icu of an academic medical center to increase effectiveness of team communication, practice autonomy and integration of nursing input into the interprofessional care plan. clinical nurses and neuro-intensivists developed a structured rounding tool to guide the nursing presentation of clinical information on rounds. the interprofessional team underwent education on expectations and processes. the rounding tool underwent a number of revisions over a 24-month period based on feedback from all team members and evolving patient care priorities. all team member roles in the rounding process were clearly defined with nursing leading patient assessment and goals. nursing satisfaction surveys assessed nursing attitudes regarding autonomy, decision making and rn-md communication via a 5 point likert scale; mean values for each question domain were compared pre-and post-implementation. in total, 106 nursing surveys were analyzed, 44 pre-implementation and 62 nurses postimplementation. mean response values evidenced significant improvement across all domains in the post-implementation group: autonomy (3.70 vs 4.31, p<0.01), rn decision making (3.16 vs 4.04, p<0.01), p<0.01) . survey participation was good in both groups (68% pre-and 78% post-implementation). nursing satisfaction across multiple important domains improved following implementation of a nurse driven structured rounding model. application of a nurse-facilitated, structured model creates a standardized reliable process that can be observed by all team members in order to deliver data driven, high quality, efficient and effective care. multiple models for program development and care delivery in pediatric neurocritical care (pncc) have been proposed with varying degrees of success. here we present a unique model for building a dedicated pediatric neuro-intensive care unit (pnicu) through creation of a community of practice (cop). cop represents a mechanism for collective learning and production of repertoire of best practices through knowledge sharing, development of social capital, and support for organizational change. we utilized a bolman and deal 4-frame for organizational functioning (structural, human resources, political, symbolic) to describe the development of our pncc cop. we evaluated our pnicu with the standards outlined by the neurocritical care society (ncs) for a level 1 neuro-intensive care unit. structural factors included forming pncc leaders across specialties (neurology, critical care, neurosurgery, radiology, nursing), opening (in 2018) a state-of-the-art, unique pnicu which includes wired rooms for continuous eeg monitoring and multimodal neuro-monitoring, meeting 137/140(98%) of ncs standards. human resource factors included creating core groups of physicians and nurses with a primary role in pnicu, providing ongoing education through workshops, lecture series, and certification including enls and tncc, meeting 74/105(70%) of ncs standards. politically, a pncc fellowship-trained, board-certified physician serves as medical director coordinating conception of collaborative partnerships across multidisciplinary experts. simultaneous creation of other specialty cohorts in pediatric critical care aided in departmental acceptance for the program, meeting 4/4(100%) of ncs standards. symbolically, we set forth our shared purpose and strong commitment to foster cop that advances knowledge and best practices for pncc. using cop principles, we have accomplished many of the ncs standards over a relatively short period of time. we plan to further develop the program with particular focus on education, certification, and expansion to include allied health professionals. our roadmap may be applicable to any institution interested in developing a pncc cop/pnicu. intravenous (iv) anti-hypertensive infusions are often used acutely in patients with intracerebral hemorrhage (ich). there is a lack of standardization of titration and variation in goal blood pressure, and therefore their use is associated with increased icu length of stay (los) and cost. we examined the use of anti-hypertensive infusions in ich patients in our institution and developed a quality improvement intervention to reduce duration of infusion, icu los, and cost. patients were included if they were admitted to our icu from september 2017-march 2019 with an icd-10 diagnosis of non-traumatic ich and received iv antihypertensive infusions. interventions introduced starting in november 2018 included interdisciplinary task force formation, provider education, updated rounding checklist, and emr order with clear blood pressure target. the primary outcome measure was duration of anti-hypertensive infusions determined by retrospective chart review, and secondary outcome measures of icu los and cost data were obtained from our finance department. over 5 months, mean antihypertensive infusion duration reduced from 54.2 hours (n=66) to 37.9 hours (n=29). icu los reduced from 3.35 to 3.0 days. proportion of cases with discordant blood pressure goal documentation reduced from 46.0% to 24.1%, while discordance in documented goals to actual orders reduced from 57.1% to 27.6%. there were no significant increases in countermeasures (infusion restarts, icu readmission, and aki due to blood pressure lowering). extrapolating from finance data, and our baseline infusion duration and icu los data, iv antihypertensive infusions cost ~$36/hour. our improvement suggested $17017 in estimated cost savings in 5 months. icu accommodation cost was approximated at $262/hour, for an estimated $63823 additional cost savings. a quality improvement based intervention targeting management of hypertension resulted in reduced duration of anti-hypertensive infusions, icu los, and cost. the intervention was feasible and ongoing data collection is warranted to assess sustainability. mortality and long-term-disabilities secondary to stroke are high. educating high-risk population with early stroke symptoms has been outstanding. however, education of post-stroke consequences (requiring resuscitation codes and goals-of-care awareness) is lagging. this study evaluates the understanding of such concepts by the admitted stroke patients (high risk population) and visitors (general population). were asked to answer a preliminary question about their original code status then read a self-explanatory sheet followed by revealing their revised code and goals-of-care choices. we used within-group logistic-regression-analyses to determine changes of codes among original coders and types of novel codes among post-survey coders. this included proposition of new short-term resuscitation (str-strp [partial]) codes. we used between-group chi-square-analyses to determine differences in education between groups. the odds of changes in no-coders were 2.429, 4.957 in patients and visitors, (p-value= 0.001, <0.0001) respectively. the odds of changes in dnr-coders=0.265, 0.151, partial-coders= 0.353, 0.277, full-coders= 0.073, 0.043 times those of the no-coders respectively (p-value< 0.00001). the odds of novel-dnr-coders= 1. 429, and 3.696, 299, 379.5, 54.625, 6 .851 times those of novel-no-coders respectively (p-value< 0.00001). str-coders originated from other-codes> no-coders. between-group analyses showed 42%, 52% of patients versus visitors changed their code status respectively (p-value= 0.04519). goals-ofcare choices indicated tolerance towards temporary measures (tracheostomy and feeding-tube placement) and hemiplegic disabilities without poor mentation among the majority (~53-77%) as a target for continuing care. pre-event (stroke) documentation of code status was approved among the majority of participants (58%). there is a misunderstanding of the resuscitation codes among both admitted stroke patients and general population. however, the difference between both indicates reception of some education among the stroke patients. str-strp are a good alternatives for many people. pre-event documentation -stroke outcome awareness are needed. early integration of palliative care improves communication, decision-making and social support in patients with acute stroke in the neurocritical care unit. the primary objective of this study was to analyze how early palliative involvement impacts communication between the healthcare team and patients/families. in this ongoing prospective study, patients with moderate to severe ischemic and hemorrhagic strokes were randomized into control and intervention arms. the control arm received routine icu care and the intervention arm received an early palliative care consultation. study assessments with the patient or surrogate decision maker were obtained at day 1-3, and day 5-7 of icu care. comparisons were made for total scores on the questionnaire on communication (qoc), decisional conflict scale (dcs), and hospital anxiety and depression scale (hads). we performed an interim analysis utilizing the student's t-test and chi -square test on spss 25, with results below as mean + standard deviation. of 13 patients enrolled (7 intervention and 6 control), 50% and 44% were female (p = 0.07). the average age was 61 + 12 and 65 + 11 years (p = 0.52). the majority (83% and 57%) were ischemic strokes (p = 0.503). admission nihss was 16 + 8 and 13 + 8 (p = 0.35). there was no difference in total qoc (67 + 41, 87 + 19, p = 0.26), hads (18 + 7, 17 + 7, p = 0.79), or dcs (31 + 24, 37 + 20, p = 0.59) scores. when comparing responses to individual questions, a trend toward improvement in qoc responses was observed "using words you can understand" (p = 0.05) and "answering all questions about illness" (p = 0.08). early integration of palliative care may improve communication between healthcare providers and patients/families, specifically with regards to using appropriate language that is understandable. routine daily chest radiographs (cxr) in mechanically ventilated patients (mvp) are often performed in the icu for "monitoring" purposes, despite lack of specific indications. routine daily tests are of questionable value and may increase costs without clinical benefit. the society for critical care medicine and choosing wisely campaign promote indication-based test ordering. studies involving medical-surgical icus demonstrate that indication-based versus routine daily cxrs in mvps results in cost-savings without jeopardizing outcomes. we implemented a quality improvement initiative targeting reduction of routine daily cxrs in mvps in the nsicu. we convened an interprofessional team of attending physicians, fellows, medical students and nurse practitioners. we conducted educational campaigns promoting evidence-based cxr utilization practices. standardized discussion of indication for cxr was incorporated into rounds. iterative process improvements were adopted beginning june 2018. cxr utilization rates in mvps were measured the first 12 weeks of 2017, 2018 and 2019 and compared pre/post-intervention. hospital length of stay (hlos) was evaluated to monitor for complications resulting in prolonged hospitalization. implementation of indication-based ordering strategies decreased cxr utilization in mvps in the nsicu without increasing hlos. value-based care quality improvement initiatives can reduce costs without compromising clinical outcomes. patients transferred from nsicu to lower acuity units are vulnerable to readmissions and hospital acquired complications. standardized handoffs may help reduce this risk within academic institutions where physician trainees possess varying levels of clinical experience. we sought to implement a standardized handoff (i-pass) within inpatient neurology, focusing on high risk patient populations. residents and attendings were surveyed about inpatient handoff practices to inform implementation of i-pass. an electronic survey was administered in 2018 to residents and inpatient attendings in neurology at university of north carolina (unc). handoff practices among inpatient services (wards, consults, nsicu, and epilepsy) were evaluated. surveys assessed perceived quality of handoffs, as well as problems with handoffs leading to adverse events. surveys were sent to 30 physicians (19 residents, 11 inpatient attendings); 21 responses (12 residents, 9 inpatient attendings) were obtained (response rate, 70.0%). -six percent of residents and 81% of attendings reported that problematic handoffs had been the primary or contributing factor to one or more adverse events. overall quality of handoffs involving nsicu patients transferred to lower acuity units was reported as a concern, with 50% of residents indicating the quality of these handoffs to be poor. in ranking inpatient services for prioritization of handoff interventions, 69% of residents identified nsicu handoffs as either their first or second highest priority. we also found residents exhibited a self-performance bias, with 84% reporting that they provided all pertinent information during handoffs most of the time, and only 22% reporting that they received all pertinent information during handoffs most of the time. inpatient handoffs are perceived as problematic by residents and attendings, with handoffs involving transfer of nsicu patients identified as high priority for targeted intervention. unc neurology has since implemented i-pass protocols to improve the safety of handoffs involving nsicu patients. targeted temperature management (ttm) to 33-36c is the standard of care for post-cardiac arrest patients. recent literature has demonstrated a new trend of worsening morbidity and mortality postarrest due to under-utilization of ttm. management of post-arrest patients is a multidisciplinary health care effort, and knowledge of ttm rationale and protocol varies. normothermia (37-37.5c) also could have neuroprotective benefit in other clinical scenarios and is another indication for ttm. we hypothesized that a focused educational intervention would improve ttm protocol compliance. a multidisciplinary team developed a standard educational presentation and a 10 question exam given as a pre-and post-test to residents, fellows, and critical care nurses. baseline data on ttm use was established followed by 6 month prospective data collection post-intervention. data was extracted from arctic sun® machines on all ttm cases (post cardiac arrest and normothermia). the primary outcome was compliance with the ttm protocol measured by correct temperature target goals and appropriate duration, assessed by chi-square analysis. the secondary outcome measure was individual score improvement, evaluated by 1-variable students t test. there was a total of 62 ttm cases pre-intervention, and 51 ttm cases post intervention. there was a trend toward increased ttm protocol compliance (29% to 43%), however this was not statistically from pre-test (n=54) to post-test (n=43) after the education presentation (p<0.0001, ci 2.48 to 3.52) among all health care participants. the resident, fellow, and nursing scores increased from 57% to 88%, 62% to 90%, and 70% to 86%, respectively. educational interventions for physicians and nurses caring for post-cardiac arrest and neurocritical care patients improved knowledge gaps and helped improve compliance with ttm protocol. additional education and process improvement activities are warranted to further improve protocol compliance, which may improve patient outcome. identifying the appropriate level of care needed for a patient presenting with acute intracerebral hemorrhage (ich) is often imprecise. the utility of prior work in triaging patients is limited by exclusion of non-primary ich patients, which is often difficult to determine prior to admission. this study aims to identify which admission factors are associated with icu level of care on presentation. this is a single-center retrospective review of patients admitted to our institution with ich in 2018, regardless of etiology. all patients were admitted to the neurocritical care unit (nccu). icu level of care was defined as the need for mechanical ventilation, administration of vasoactive or insulin infusions, continuous renal replacement therapy, ventriculostomy, treatment of cerebral edema, temperature management, management of status epilepticus, or neurosurgical intervention. logistic regression was used to identify characteristics associated with icu level of care. 183 patients (median age 62, 49% female, median admission gcs 10, median ich volume 22 ml, 55% with ivh, 48% lobar, 19% infratentorial) were admitted with ich. 141 (77.1%) required intensive care. the most common interventions required were mechanical ventilation (100 patients, 69.9%), antihypertensi with need for intensive care included age (62 vs. 60), admission gcs (9 vs. 15), deep location of ich (36.4% vs. 15.6%), ich volume (28 ml vs. 8 ml), and presence of ivh (61.0% vs. 33.3%). on multivariate analysis, age (p = 0.01), admission gcs (p < 0.001), and deep location (p = 0.05) were independently associated with the need for intensive care. among all patients presenting with ich, age, admission gcs, and location of hemorrhage may help identify ich patients who need icu level of care. the impact of emergency neurological life support (enls) course on provider knowledge and selfreported comfort in management of neurocritically ill patients in a low-middle income country such as cambodia is unknown and explored in this study. in-person enls courses with english to khmer translated slides were conducted in 2 hospitals in phnom penh, cambodia in may, 2019. wilcoxon signed rank test and matched paired t-test were used to examine pre and post-course scores on translated knowledge-based multiple choice tests. a descriptive analysis was performed to evaluate provider comfort in management of neurocritically ill patients pre and post-course and amongst individual enls modules. overall, 52/57 healthcare providers participated; 27 (52.9%) physicians and 25 (47.1%) nurses. thirtythree (73.3%) had acquired base specialty training in cambodia, 23 (51.1%) had completed subspecialty training in critical care medicine and 31 (68.9%) previously cared for neurocritically ill patients. pre-test sores were 50% [iqr21]; post-test scores were 53.8% [iqr 15]. though not statistically significant, posttest scores were higher for providers who had base specialty training in cambodia (54.8 % vs. 49.9%, p = 0.06), subspecialty training in critical care medicine (55.7% vs. 50.7%, p = 0.06) and previous experience caring for neurocritically ill patients (54.9 % vs. 50%, p = 0.06). most (82%, n = 37) reported that enls training had prepared them for management of neurocritically ill patients. enls courses may enhance the knowledge and comfort of healthcare providers in managing neurocritically ill patients in low-middle income countries, however this may depend on prior experience and minimizing language barriers. the impact of enls courses on outcomes in neurocritically ill patients in low-middle income countries warrants further study. neurocritical care has become increasingly subspecialized.yet, due to limited availability of dedicated neurocritical care units (nccus), often patients may need to be admitted to icus other than nccus. this survey based study was conducted to explore self-reported knowledge in recognizing and managing some common neurological emergencies such as stroke, status epilepticus, raised intracranial pressure etc among critical care nurses at a comprehensive stroke center. in january 2019, we engaged 240 nurses from 8 icu units in this qi project-which included medical, surgical, neurocritical care, cardiac and cardiothoracic units as well as post-anesthesia care unit (pacu) and interventional radiology units. using institutional redcap anonymized surveys were sent to the nurses.information on demographic and critical care work experience was recorded. all participants answered questions with a likert type scale on their knowledge of several common neurological emergencies. 240 nurses (199 females, 41 males) participated in the survey. 112 (58%) had been working in an icu for 3 years or longer. their self-reported level of knowledge in managing neurological emergencies revealed that more than half the participants did not feel comfortable managing patients with evds, ich, sah, raised intracranial pressure, tbi and traumatic spine injury patients. more than 70% of nurses were not satisfied with their current level of training to deal with neuroemergency and supported the need for dedicated training/ study time. icu nurses report gaps in fundamental knowledge in recognizing and managing common neuroemergencies. this highlights the need for providing ongoing training and education about neuroemergencies to critical care nurses to help maintain competencies. simulation training has been increasingly adopted in critical care specialties to promote active learning and create a reproducible platform for feedback. the role of advanced simulation as a core component of training in neurocritical care remains unclear, which may be due to uncertainty about the degree of fidelity needed. our objective was to determine if trainee knowledge and/or confidence differs when using standardized patients as compared to a multi-media simulation platform in a neurocritical care concepts training course. methods 20 junior neurology residents engaged in 3 simulated neurologic emergencies: a right mca stroke case, status epilepticus case, and a pontine hemorrhage/coma case. the mca stroke and status epilepticus cases were portrayed by trained standardized patients for half of the residents (group sp), while the other half interacted with the manikin supplemented with video clips of pertinent neurologic exam findings (group mv). both groups interacted with the manikin for the pontine hemorrhage/coma case. before and after the course, residents completed a 40-question multiple-choice test on management of neurologic emergencies and a survey about their confidence in managing 15 neurologic emergencies. a detailed task checklist was used to assess decision making during the simulations. both resident groups had statistically significant higher knowledge and confidence scores after their training sessions (knowledge: pre: 49% vs post: 72%, p<0.001; confidence: average pre: 0.98 to post: 2.01, p<0.001). however, there was no statistically significant difference between the two groups in either knowledge or confidence. the task checklist demonstrated significant variations in treatment practices and provided individualized areas for teaching. this pilot study suggests that trainees' knowledge and confidence in the management of neurocritical care concepts increases following simulated encounters, regardless of whether an actor-patient or multi-media simulation platforms is used. use of a task checklist uncovered important variations in protocol adherence among novice physicians. the accurate evaluation and determination of brain death has broad consequences on life-saving organ donation, closure for families, and length-of-hospital-stay. we have observed a concerning variability of brain death testing knowledge and comfort amongst neurology attendings and trainees at our institution. we aimed to create and apply a combined didactic and simulation training program to increase the knowledge and comfort in brain death evaluation, using our approved institutional brain death policy as reference. we hypothesized that participants who attended the training would show a measurable increase in their knowledge and comfort in the clinical evaluation of brain death. an experienced neurointensivist (>15 years of clinical practice) presented a 1-hour didactic session on brain death criteria, evaluation, and pitfalls to neurology residents and attendings. a high-fidelity simulation was implemented to allow practicing the brain death examination. knowledge and comfort levels were measured before and after learners had attended both sessions using electronic -exact-tests were applied to examine changes in knowledge and comfort in brain death testing pre-and post-exposure to the educational sessions. 27 participants (9 residents, 18 attendings) completed pre-exposure, and 12 (3 residents, 9 attendings) have completed post-exposure questionnaires thus far. knowledge significantly improved from pre-to post-exposure (59% correct, range 18-91% improved to 76% correct, range 64-91%; p=0.0002). comfort levels in performing the brain death examination pre-exposure also increased from pre-to postexposure (pre: "very comfortable-30%","somewhat comfortable-37%","neutral-7%","somewhat or very uncomfortable-26%" to post: "very comfortable-50%", "somewhat comfortable-33%","very uncomfortable-17%" [p=0.005]). exposure to a single combined didactic and simulation session improved the knowledge and comfort levels immediately post--exposure questionnaire response rates, as well as measurements of knowledge retention over a 3-and 12-month period and accurate application in practice. the safety and benefit of early mobilization in general intensive care units (icu) has been found to improve outcome and decrease length of stay. however, there is a lack of literature on early mobilization in the neuro icu (nicu) specifically, due to the complexity of the patients in the nicu and their disease processes. traditionally, patients were kept on bedrest after subarachnoid hemorrhage, intracerebral hemorrhage, ischemic stroke, and neurotrama, due to neurologic limitations such as fluctuation in mental status, requirement for sedation and paresis. additional challenges associated with mobility in this population include the potential for positional changes to impact intracranial pressure physician comfort level and concern for adverse neurological outcomes such as vasospasm or increased bleeding also decrease mobilization. while it is imperative to be cautious with nicu patients, prolonged bedrest and restricted mobility come with its own set of complications including muscle atrophy, decreased activity tolerance, delirium, pressure sores, nosocomial infections and deep vein thromboses. we sought to develop an early mobilization guideline that would help multidisciplinary staff identify which patients in the nicu should be mobilized early. a nicu physical therapist and the director of the nicu identified criteria for patients who were appropriate/inappropriate for early mobilization. all patients in the nicu should be mobilized early with the exception of the following exclusion criteria: unstable respiratory status, status epilepticus, contraindication to holding sedation, rass -4, changing/worsening neuro exam, icp > 20mm hg, mean arterial pressure <65 or >110mm hg, oxygen saturation < 88%, acute myocardial infarction, >2 vasopressors, clinical vasospasm, perfusional state, guidelines on early mobilization in the nicu can optimize patient mobility while minimizing complications associated with mobilization. introduction delivery, nurses must develop leadership skills and serve as full, collaborative partners with physicians and health professionals (2011). registered nurse (rn) inclusion into rounds has been shown to: improve interdisciplinary collaboration, incorporate learning in the workplace, increase leadership skills and improve team members' perception of unit flow and culture. attending physicians, rns, neurocritical care fellows, nurse practitioners, pharmacists and respiratory therapists were surveyed via surveymonkey to examine opinions regarding current rounding processes and potential opportunities in the neurocritical care unit (nccu). responses were aggregated to create scores for each topic, with the priority areas being the lowest relative scores based on a 5-point likert scale. survey responses were collected from 43 nccu staff members (62% response rate). based on survey results, priority areas to enhance rounding satisfaction included: increasing collaborative decision making, creating entire team efficiency, completing rounds in a timely manner, increasing engagement and minimizing extraneous conversations and activities. other targeted areas for improvement included reserving time for prolonged family meetings for post-rounds, as well as focusing educational time and consistently utilizing the rounding checklist. based on areas of opportunity, a multidisciplinary committee was developed. one item created to enhance processes was the development and implementation of an rn facilitated presentation tool. to support this, a standardized presentation script and handoff tool were created and executed. six-month follow up survey results are pending at the time of submission. strategies to improve communication in multidisciplinary rounds are key to decreasing errors and improving care delivery. it is likely that a systematic data presentation by bedside rns will improve: staff perceptions of rounds, collaboration among all multidisciplinary staff members and rounding efficiency. the department of neurosurgery has a readmission rate goal of less than 9.7 for the fiscal year 2018 and less than 9.2 for the fiscal year of 2019. over the past four fiscal quarters there has been an increase in the department's readmission rate, always exceeding the institutional goal. all readmissions in the institution's dashboard for q3 and q4 for 2018 and q1 and q2 of 2019 were reviewed by way of chart review. these were divided into spine vs cranial, planned vs unplanned readmission, reason for readmission and consistency vs inconsistency with the institution's dashboard. in q3 2018 the dashboard reported a readmission rate of 10.86. the final calculated actual readmission rate was 9.32. in q4 2018 the dashboard reported a readmission rate of 11.04. the final calculated actual readmission rate was 9.27. in q1 2019 the dashboard reported a readmission rate of 10.76. the final calculated actual readmission rate was 8.02. in q2 2019 the dashboard reported a readmission rate of 10.73. the final calculated actual readmission rate was 7.30. the most common reason for unplanned n reason for planned readmissions were shunt placements after lumbar drain trials. the dashboard was correct in predicting planned vs unplanned readmissions 45.5% of the time. the coding on the backend of the institution's dashboard is missing many staged and planned readmissions and is only accurate in coding planned vs unplanned readmissions half of the time. this is resulting in falsely elevated readmission rates. despite the initial uptrend in readmissions, the actual readmission rates of the department are down trending and always below the institutional goal. this likely translates to other departments within the hospital. there needs to be a more efficient way to improve the coding and accuracy of the institution dashboards. the critically-ill neurological patients managed by specialized neurocritical care team is associated with improved outcome. in korea, limited data are available on improved outcomes after initiation of neurointensivist co-management in neurocritical care units (ncu). we evaluated the impact of a newly appointed neurointensivist on the mortality of patients admitted to the ncu. the study was conducted in 18 intensive care unit (icu) beds of a large academic tertiary care hospital. neurointensivist co-management was initiated in march 2016. the retrospective observational study compared the outcomes of patients before and after neurointensivist co-management. a total of 1211 patients were included, 647 prior to and 564 after the initiation of neurointensivist comanagement. patients admitted after neurointensivist co-management were older and had higher apache ii scores. icu mortality was significantly decreased in patients managed by neurointensivist (14.4% vs 10.5%, p=0.04). the length of icu stay and duration of ventilator days were shorted in patients without co-management. neurocritically ill patients managed by specialized neurointensivist showed better clinical outcomes despite increased severity. social media has changed the way individuals communicate with each other and has altered the way society obtains information. in the past ten years, multiple articles have been published highlighting the ability to utilize social media for education of medical, nursing and pharmacy students. to our knowledge, cross discipline education utilizing these platforms has yet to be evaluated. with over 2.23 to implement a pharmacist led, social media based nursing education program and evaluate the perceived value of this education. a curriculum consisting of basic pharmacy related issues was developed and topics were posted to the ok users weekly. a pre-and post-education survey was sent out evaluating the program's effectiveness. email. of those nurses who received the pre-and post-education survey, a total of 29% and 19% completed the survey respectively. of those who completed the survey 60% received education via -education survey, there were no statistically significant differences in nursing performance on fact based questions after receiving education (p-value > 0.05 on all 17 assessment questions). overall, 100% of the respondents reported a positive learning experience and wanted to continue this method of education delivery. the educational content. this project demonstrates the potential of utilizing social media as a means of cross discipline education; however, the solitary utilization of this platform should be used cautiously as this did not improve performance on assessment questions. consequently, targeted temperature management (ttm), either to maintain normothermia or induce hypothermia, is often advocated as a therapy to improve outcomes in brain injured patients. the physiological pathways that promote fever associated brain injury, and how these pathways might be modulated by ttm, remain unclear. this study examined the effect of fever and hypothermia on cerebrovascular pressure reactivity, a validated proxy of cerebral autoregulation. we included 72 patients treated for brain injury from a single academic center. all patients had intracranial pressure (icp), invasive brain temperature, and arterial blood pressure (abp) recorded patient, mean prx over all periods of fever (>38°c), normothermia (35-38°c), and hypothermia (<35°c) were calculated. differences in mean prx during normothermia, fever, and hypothermia epochs were then analyzed using paired student's t-test. the relationship between prx differences and total time spent normothermic was analyzed using linear regression. spent at a normal brain temperature (p = 0.0008, r2 = 0.202). in contrast, hypothermia was not associated with impaired cerebral autoregulation (p = 0.9968). this study supports the hypothesis that impaired cerebral autoregulation may be one mechanism through which fever worsens outcome in brain-injured patients. the effect of fever on cerebral autoregulation appears to be more pronounced in patients that spend a longer amount of time in a normothermic state. interestingly, hypothermia was not associated with reduced prx, suggesting that the possible benefits of therapeutic hypothermia do not occur by improving the autoregulatory state. veno-arterial extra corporeal membrane oxygenation (va-ecmo) provides hemodynamic support in patients with refractory cardiogenic shock. these patients have a 15% incidence risk of cerebrovascular complications according to the extracorporeal life support organization database. reliable neuroassessments and neuroimaging are often limited by heavy sedation and risks of transporting these patients. transcranial doppler (tcd) can be a useful tool for cerebral hemodynamic assessment in these patients. we present four va-ecmo patients where tcd spectral waveforms provided key information on cerebral blood flow despite non-pulsatile flow. interpretable spectral waveforms were obtained in three of four patients. extensive embolization obscured flow patterns in one patient but clear cerebral perfusion with non-pulsatile waveforms was seen in the rest. two of the three remaining patients had high intensity transient signals (hits), suggesting cerebral microembolization. one patient showed pulsatility in cerebral waveforms despite no gross change in cardiac output on echo that helped guide decision to initiate ecmo wean. ecmo settings included flow at 4-6 l/min, map 60-80 mmhg, and paco2 between 30-50 mmhg. mca mean flow velocities were comparable to the systemic bp, and ranged from 60-80 cm/s in three patients and 30-50 cm/s in one patient. one patient suffered cerebral edema and two expired from withdrawal of care on sedation after multisystem organ failure without a chance neurological or neuroimaging assessment. the fourth patient retained consciousness and the ability to follow commands, but died from a massive gi bleed. tcd spectral waveforms can be useful bedside tools for patients on va-ecmo to assess for cerebral perfusion patterns. presence of hits reflecting microembolization can guide perfusionists to check for pulsatile flow, their relationship with systemic hemodynamics and va-ecmo settings is needed. cranial ultrasonography has a long history of use in neonates, but inadequate windows have limited its use in adults. a hemicraniectomy provides an obvious window for point-of-care intracranial imaging, providing similar views traditionally seen on ct and mri. we describe a standard approach and settings, presenting sample imaging demonstrating key anatomic landmarks. the hemicraniectomy ultrasonography preset was created and optimized using a phased array transducer with a 4-2 mhz frequency range. imaging parameters were tested and saved for 2d grayscale mode, with an emphasis on tissue harmonic imaging, adaptive image processing, and dynamic range. axial views are obtained from the ipsilateral temporal window, approximating the pterion, adjusting the probe to display a well-aligned view using the lateral ventricles as a landmark. by convention, the probe marker is placed anteriorly. the depth and focus are set to visualize the brain he probe craniocaudally permits visualization of the entire cranial vault. parasagittal and coronal views are obtained by placing the probe at the vertex, off midline, ipsilateral to the hemicraniectomy. several structures are clearly visualized and are available as landmarks for orientation. the ventricular system can be easily identified as hypoechoic spaces similar in appearance to ct or mr imaging. the brainstem and cerebellum, with its associated folia and peduncles are also easily seen. the thalami are identified as strongly hypoechoic paramedian structures. pathologic findings that can be easily seen include hydrocephalus, hemorrhage, and edema. aneurysm clips are hyperechoic with streak artifact, and ventriculostomy catheters can be seen as subtle hypoechoic areas within the cortex. hemicraniectomy pocus can be used to visualize the intracranial vault to facilitate evaluation of structural lesions and pathology at the bedside. the authors advocate adding hemicraniectomy pocus to the neurocritical care imaging arsenal in patients where this view is available. pain assessment is a challenge in critically ill patients with impaired consciousness, either because of sedation or concomitant severe brain injury. automated pupillometry has been used to assess the response to noxious stimulation in such patients. skin conductance, which has been used in the operative setting, has not been tested in this setting yet. the purpose of the study was to compare the pupillary response and skin conductance to pain stimulation in critically ill unconscious patients. prospective ongoing study including adult (>18 years) patients admitted to the intensive care unit of a university hospital and who were unconscious (glasgow coma scale < 8 with a motor response < 5) for several reasons. automated pupillometry (algiscan, idpupillary reflex dilation during tetanic stimulation. the tetanic stimulation (100 hz) was applied to the skin area innervated by the ulnar nerve and was stepwise increased from 10 to 60 ma until pupil size had increased by 13% compared to baseline. the maximum intensity value allowed the determination of a pupillary pain index score ranging from 1 (no nociception) to 9 (high nociception): a pupillary pain peak per second ( concomitantly to tetanic stimulation. twelve patients (median age 66 [ranges=18-77] years; male gender 9/12) were included so far; eight patients had a primary brain injury (5/8 anoxic injury) and 4 others were sedated because of shock with concomitant respiratory failure. all patients were under continuous intravenous sedation and analgesia; 9/12 were on vasopressors and 6/12 on continuous neuromuscular blockade. median gcs at the moment of pain assessment was 3 [3-7] and median ppi was 6 [1-9]; 4 patients (33%) had adequate pain control. no changes of skin conductance variables were reported during pain stimulation. skin conductance was unable to detect insufficient nociception in critically ill unconscious patients. the cerebral arterial time constant (tau) reflects the time it takes to fill the cerebral arterial bed with blood during one cardiac cycle, and is derived from arterial blood pressure (abp) and middle cerebral artery flow-s with/without vasospasm (vsp) and delayed cerebral ischemia (dci) after aneurysmal subarachnoid hemorrhage (asah). (2017) (2018) . angiographic vsp and dci were adjudicated by neurointensivists. artifact-free cerebral arterial compliance and resistance. statistical comparisons were made using a two-tailed mann-whitney u-test. of 20 asah patients, 13(65%) developed vsp and 8(62% of vsp) developed dci. 4 patients had unilateral and 9 bilateral vsp (31 & 69% of vsp). one patient with unilateral vsp was available for monitoring prior to diagnosis. this patient had increased asymmetry in tau over time prior to diagnosis (slope: 0.08 s/day, r¬2: 0.94). tcd measures in 3 patients were available prior to angiographic diagnosis of bilateral vsp, showing initial marginal asymmetry similar to the unilateral vsp case, then slightly decreasing asymmetry over time (mean slope: -22cm/s higher in dci (p<0.001). tau was 0.07s greater for dci patients, however this did not reach significance (p=0.46). explore the relationship of tau asymmetries with vsp and dci after asah. these may provide further insights into the pathomechanisms of vsp and dci while also having potential as a tool for earlier diagnosis of these important complications. pupillometry is more accurate and has higher inter-rater agreement than subjective pupil size and reactivity estimation. limitations include using a single high-intensity flash to evaluate the direct pupillary response only. we present preliminary data on using virtual reality-based pupillometry (vrp) with graded-intensity flashes and bilateral pupillary recording to monitor patients with large hemispheric infarction (lhi). we utilized a virtual reality headset-based system, i-pas (neurokinetics, pittsburgh, usa) to perform pupillometry. a total of 13 homogeneous illumination flashes (0.395 to 65.4 cd/m², 0.300 sec on, 2.00-4.00 sec off) were presented to each eye while infrared cameras recorded pupillary area (mm2) continuously at 100 samples/sec. this permits measurement of latency, magnitude and velocity of direct and consensual pupil constriction and dilation at each light intensity. : we performed pupillometry as described above in 4 patients admitted with lhi from middle cerebral artery strokes. 2 patients required decompressive craniectomy (dc) during the hospital course while the other 2 patients did not require dc. bilateral graded-intensity pupillometry detected subtle changes in pupillary reactivity (peak constriction velocity in mm2/s) prior to clinical deterioration, which were very pronounced when compared to normal control performance. singleneuropupillary index (npi) did not detect a change in pupillary reactivity in all but the most severe deterioration. virtual reality-based, graded intensity pupillometry is feasible in the intensive care unit and appears ed to set cutoff values that may aid in clinical decision making. limited access to conventional eeg results in significant delays to important diagnostic information, especially in patients with suspected non-convulsive seizures (ncs). recently, the rapid response eeg technology has proven to be clinically valuable. however, the economic aspect of this new technology has not been studied in detail. we retrospectively reviewed the use of the rapid response eeg device in our small community hospital over 6 months since its launch in december 2018. we performed limited chart review and collected information regarding eeg diagnosis, length of stay, and transfer to mothership hospital. we evaluated the clinical and economic impact of the device by considering the patients' clinical outcome and the estimated cost of hospitalization (~$3000-6000/day) and transfer ($4000-20,000). metrics are not precise and are only estimates. the device was used in a total of 20 patients. the treating physician or the nurse applied the device with and one with post-anoxic burst suppression. in patients with status epilepticus, seizures were aborted successfully, and median length of stay was 8.5 (national average of 15 days). all 20 patients were treated locally without requiring transfer to the main university hospital. considering the cost of rapid response eeg infrastructure and disposables (<$30,000) compared to conventional eeg systems (~$100,000-140,000) and eeg technologists (estimated to cost ~$420,000-562,000), and estimated range of $50,000 to $266,000 in annual savings because of shorter los and lesser transfers, this new technology seems economically advantageous. rapid response eeg system enabled significantly faster and easier access to eeg and helped detect a relatively high number of patients with gross eeg abnormalities. adopting the rapid response eeg improved emergent ncs detection and treatment in a cost-effective manner. patients requiring neurocritical care frequently have neurologic fluctuations of uncertain significance. we hypothesized that severe and prolonged events of neurologic deterioration (nd) have the greatest impact on discharge neurologic status and serve as intermediate indicators of poor outcome. we extracted nurse-documented gcs scores from electronic health record (ehr) data of consecutive patients admitted to a neurosciences intensive care unit (icu) or undergoing intracranial pressure monitoring (april 2016 -1) best initial 24-hour gcs (bestgcs-24h), 2) maximum magnitude of gcs decline (maxgcsdecline), 3) duration of the episode of maximum gcs decline (dur-max), and 4) the maximum duration of any gcs decline >= 3 points (max3pt-dur). we fit a 10-fold cross-validated logistic regression model predicting the final gcs 3-10 (vs. 11-15) and tested it in a 30% hold-out sample. we then evaluated the rates of poor outcome for combinations of these parameters. ,077 consecutive admissions (4,522 unique patients) met inclusion criteria (10% with severe bestgcs-24h (3-8), 11% with moderate bestgcs-24h (9-12), and 79% with mild bestgcs-24h (13-15)). bestgcs-24h, maxgcsdecline, dur-max, and max3pt-dur, respectively, were independently associated with poor discharge gcs (or per standard deviation were 0.44[95%ci 0.08-0.98], 2.02[1.01-4.08], 1.35[1.01-2.32], and 1.27[1.01-with a 4-point maxgcsdecline, the rate of poor outcome was 57% for patients with a severe bestgcs-24h and >=24-hour max-dur; 35% for patients with a severe bestgcs-24h and <24-hour max-dur; 9.3% for patients with a mild bestgcs-24h and >=24-hour max-dur; and 2.5% for patients with a mild bestgcs-24h and <24-hour max-dur. both the magnitude and duration of nd events are independently associated with neurological status at discharge. these empiric, informatics-derived thresholds may serve as useful intermediate outcomes facilitating the testing of biological associations and therapeutic interventions aimed at promoting neurologic recovery. unit. deteriorati worsening. we hypothesized that nonearlier than clinical deterioration. we prospectively collected data from patients with acute brain injury who are at a high risk of perfusion disturbance (sah, mmd, and severe anterior circulation ischemic stroke) between may 2017 and may 2018. non--ry 3 seconds neurological worsening were assessed using perfusion imaging and were categorized as hypoperfusion group and hyperperfusion group. baseline compared. non-monitoring should be highlighted in patients with high risk of deterioration. intracranial cerebral pressure (icp) monitoring is an integral part of acute brain injury management. while invasive icp monitor is the gold standard, there are several medical conditions that preclude its placement. non-invasive icp assessment tests (e.g. optic nerve sheath diameter, optic nerve disk elevation, pulsatility index, pupillary reactivity etc) have moderate accuracy when used individually. the aim of the present study is to validate a multimodal approach for intracranial hypertension detection. in this prospective study, patients with acute brain injury who had an evd placement for both icp measurement and treatment were included since march 2019. we measured bilateral optic nerve sheath diameter (onsd) by ultrasound, bilateral optic nerve disk elevation (onde) by ultrasound, bilateral middle cerebral artery (mca) pulsatility index (pi) by using transcranial doppler and assessed pupillary reactivity with or without pupillometer as part of multimodal assessment for measuring intracranial pressure. we assessed the correlation and agreement of these values with icp measured by the evd. we included 11 measurements in 7 patients with acute brain injury. the presence of two or more values of mean onsd greater than 5 mm, unilateral or bilateral presence of onde and mean mca pi greater than 1.0 has 100% sensitivity (95% ci 0.29 -1.00) and 87.5% specificity ( 95%ci 0.47-0.99) for predicting icp greater than 15 mmhg. non-invasive multimodal assessment can be easily done by bedside, requires minimal training and seems to correlate well with increased icp. raised icp following acute brain injury is associated with poor outcome. monitoring with early detection is important in reducing sustained icp crisis. previous studies demonstrated rheoencephalography (reg) reflects cerebrovascular reactivity and may substitute invasive monitoring techniques. we hypothesized using a correlation coefficient between slow spontaneous changes in reg and systolic arterial pressure to calculate regx. reg measurements were obtained from ten patients with acute brain injury. analog waveforms of reg and arm bioimpedance pulse waves were recorded with a bioimpedance amplifier. we used the icm+ program (prx) calcu bioimpedance pulse waves (regx) instead of icp and invasive arterial pressure. visualized by previously established waveform changes on reg. a change in mean regx greater than the previous recording's mean regx value was clinically significant as opposed to absolute mean regx . one patient with a right ica infarction clinically deteriorated from moving all extremities to extensor posturing on the right and flaccid paralysis on the left with significant delta mean regx. another with bilateral aca distribution ischemic infarctions worsened from flexor to extensor posturing with significant delta mean regx. lastly, a patient with ventriculoperitoneal shunt malfunction repair improved from gcs 7 to 14 with multiple significant delta mean regx values between recordings. our series demonstrated clinical significance of patient specific delta mean regx suggesting importance of presenting mean regx for detection of changes in intracranial compliance. like presenting blood pressure and relative changes in blood pressure rather than absolute changes in blood pressure or specific values, regx was shown significant in a similar manner. regx is a realistic means of future noninvasive neuromonitoring. dialysis is characterized by markedly increased rates of stroke and cerebral micro-vascular disease, though the mechanisms by which dialysis modalities impact cerebral hemodynamics have not been well studied. this case series compares intra-dialytic cerebral hemodynamics measured by transcranial doppler (tcd) in patients receiving intermittent hemodialysis (ihd) versus peritoneal dialysis (pd). ten outpatient end-stage renal disease (esrd) without stroke were identified. tcd mean flow velocity averaged. six patients administered hemodialysis were followed over 240 minutes, with mean arterial d every 30 minutes. there was no statistically significant difference between dialyses group and no significant change over time. to quantify volatility in patient measurements over time, we calculated the coefficient of variation -sum test. to test if there was a difference in volatility between dialyses groups, we used a wilcoxon rankgroup (p <0.05). in this small case series, though cerebral hemodynamics are not significantly different among stable measures are more stable over time for patients on the peritoneal dialyses group. end-stage renal disease (esrd) patients with acute neurologic injury are at risk of altered cerebral hemodynamics during dialysis. here, we present transcranial doppler (tcd) images revealing marked intra-dialytic increased distal vascular resistance and compromised flow velocity in an esrd patient with acute traumatic brain injury. the patient underwent continuous tcd monitoring during hemodialysis to monitor intra-dialytic cerebral hemodynamics. a 73 year-old man with esrd on chronic presented with headaches after a fall. ct head revealed 6 mm right convexity acute subdural hematoma with 2-3 mm leftward midline shift and right parietal parenchymal contusion. on arrival to the neuro-icu, the patient was afebrile, hemodynamically stable, and fully oriented with no focal deficits. repeat ct head six hours from initial was stable. the patient was started on his outpatient prescription of dialysis (dialysate na 140 meq/l, blood flow rate 350 ml/min), run without heparin. within first 3 hours of hemodialysis patient developed progressive rightsided headache, which evolved to vomiting, decreased in level of consciousness, and left-sided weakness. he intermittently opened eyes to stimulation but required persistent painful stimulation to answer orientation questions. he had no changes in mean arterial pressure during hemodialysis. his serum bun had decreased from 80 to 43 mg/dl, and his serum sodium remained unchanged. emergent ct head was stable from prior. intra-dialytic tcd waveforms revealed progressively increased distal resistance to flow, measured by pulsatility index (pi) at his bilateral middle cerebral arteries (mca), and compromised mca velocities. this change was dramatic on the right, the same side as his subdural hemorrhage and cerebral contusion. esrd patients with critical neurologic injury are at risk for altered cerebral hemodynamics during dialysis. tcd ultrasonography may be a practical bedside tool to screen for patients at particular risk, and guide medical decision-making regarding dialysis prescription for esrd patients in the neuro-icu. point of care ultrasound (pocus) differs from diagnostic ultrasound in being often performed by clinicians and focused to acquire only relevant images to answer a specific clinical question. most ultrasound modalities have differentiated clinical indications where pocus is appropriate: the use of echocardiography to rule out tamponade in shock is considered pocus while the assessment of diastolic dysfunction in heart failure deserves a diagnostic exam. neuroultrasound has been used in various clinical indications like vasospasm, intracranial stenosis, collateralization, and emboli monitoring. these studies are mostly performed by sonographers as diagnostic studies. with emerging interest in assessing pocus indications, we performed a systematic literature review to identify all clinical indications of neuroultrasound and used a delphi based review by three experts to differentiate clinical indications where neuroultrasound could have point-of-care uses. two authors (lmh, gb) performed a systematic review to identify all reported modalities and clinical indications of neuroultrasound (tcd, duplex, b-mode, carotid, ocular and temporal) in medline, embase, cochrane, and scopus databases. three experts (jgd, ct, as) were surveyed using the delphi method to review each clinical indication and modality on whether it was focused on diagnosis or management and whether the clinical indication was a valid pocus. differences in opinion were settled with a final face-to-face discussion to reach a consensus. the systematic review determined 78 total clinical indications of point of care use of neuroultrasound individualized by disease and modality. in 35 indications it was considered a diagnostic adjunct, in 5 instances it was considered an aide in management, and in 38 instances it was determined to aid in both diagnosis and management decisions. there are many point of care indications of neuroultrasound in neurocritical care. this consensus opinion can guide clinicians to clinical indications where point of care use can aide in bedside diagnosis and management. in a systematic review, we reported current literatures on neuromonitoring methods in left ventricular assist device(lvad) population. we searched five databases (pubmed, embase, cochrane library, web of science, scopus, clinicaltrials.gov) related to lvad and neurological monitoring methods from inception through january 2018. of 3597 unique citations, 32 studies (2055 participants) met the inclusion criteria. the median age was 48.5(interquartile range 40.3-52.8, 67.7% male). study designs were retrospective observational studies (n=19) and prospective observational studies (n=13). neuromonitoring methods studies included transcranial dopplers(tcd) for emboli monitoring(n=13) or cerebral autoregulation monitoring (n=2), traditional neuroimaging (ct/mri) (n=7), cerebral oximetry(n=2), carotid ultrasound (n=3) and plasma vad, 4 articles studied pulsatile current evidence on neuromonitoring in lvad is limited and there is no consensus on the indication and effectiveness on use of any neuromonitoring methods. the publications have significant heterogeneity adequate power are warranted to develop an optimal neurological monitoring protocol and prevention strategy. midbrain compression secondary to cerebral edema or hemorrhage results in high mortality and morbidity. quantitative pupillometry holds promise as a bedside indicator of worsening anatomic tissue shifts. because pupil reactivity relies on an intact neural network through the diencephalon and brainstem, compression can lead to changes in pupil size and reactivity. we studied markers of compression and pupillometry within 2 hours of head ct in 35 patients with anterior ischemic stroke (ais) or supratentorial intraparenchymal hemorrhage (iph) causing mass effect. we reviewed 62 scans from 35 patients with unilateral injury from ais (>1/3 of mca territory) or iph (>30 ml). we assessed midline (mls) and pineal gland shift (pgs), as well as novel measurements of midbrain compression including interpeduncular shift (ips) and the ipsilateral and contralateral cerebral peduncle hemi-distances to the interpeduncular cistern (icphd, ccphd). multilevel modeling was used to analyze radiographic measurements with quantitative pupil metrics including pupil reactivity (dnpi) and size (dsize) differences between eyes. pupil reactivity and size differences were significantly associated with radiographic markers of midbrain noninvasive indicators of brainstem compression. evaluation of optic nerve sheath diameter (onsd) has been widely examined as both a correlate of intracranial pressure (icp), and a potential predictor of outcome after neurological injury. recent studies have evaluated sonographic measurement of onsd, yet clinical limitations to this approach persist. evaluation of onsd measurements via routine brain computed tomography (ct) imaging has been less studied, but offers potential for detection of increased icp in the absence of invasive monitoring. previous studies have employed a cross-sectional approach to onsd measurements via ct scan, primarily among patients with traumatic brain injury (tbi). however, no studies have evaluated serial correlations between ct onsd measurements and icp to evaluate strength of correlations during hospitalization, and across diagnosis types. the purpose of this study was to investigate correlations between onsd via serial ct imaging and icp among adult patients with neurological injury. retrospective cohort study of all adult patients admitted with acute neurological injury requiring icp monitoring and critical care admission. n=48. diagnosis type included tbi (33%), aneurysmal subarachnoid hemorrhage (29%), intracranial hemorrhage (18%), cranial mass (6%), and other (12%). there was a strong, positive correlation between right/left onsd across all time points (r=0.7-9, p<0.001), suggesting a consistent bilateral response. correlations were strongest between initial inpatient ct scan onsd readings and icp (r=0.5, p<0.05), but decreased over time. patients with increased icp across all diagnosis types experienced higher onsd values upon presentation to the emergency department (ed) and on serial ct scans throughout hospitalization (range 5.7mm-6.4mm, p<0.05). urements as a potential indicator of increased icp in the absence of invasive monitoring. serial ct brain imaging is often performed to evaluate for intracranial changes during hospitalization, and measurement of onsd during this imaging can contribute to decisions regarding more invasive monitoring. monitoring of burst-suppression-pattern (bsp) in electroencephalography (eeg) is relevant to control barbiturate-induced coma. currently, the assessment of bsp is based on continuous observation of the eeg with manual counting of bursts per minute (bpm) by experts, which is prone to inter-rater variability. we evaluated the reliability of a new algorithm for automatic bsp-detection compared to manual assessment in two thiopental-induced burst-suppressed patients. a bipolar 8-channel eeg-montage was recorded. the montage was bandpass filtered into typical eeg rhythms and segmented into 2 secs -moonen metric, a distance matrix between all epochs in the first hour of data from patient 1 us to cluster this matrix into 3 clusters: burst, suppression and artifact. we labelled the rest of the (test) data from patient 1 and patient 2 by training support vector machine classifier from the labels produced by clustering. the eeg was scored by a neurologist to get ground truth bpm ranges (min, max for intervals of 10 minutes to 1 hour) for both patients. the algorithm provided estimated ranges of bpm for these intervals. the pilot data shows a high correlation of automatic burst counts compared to the manual counting. we found a significant pearson correlation (patient 1: 0.84, p<0.001, patient 2: 0.83, p<0.001) and linear regression coefficient (patient 1: 0.85, p<0.001, patient 2: 0.7, p<0.001) between estimated and ground truth bpm ranges. the automatic detection of the bursts provides an objective and fast assessment of bsp. the algorithm showed a slightly lower sensitivity due to the missing detection of very short or low bursts. we are ation. ventilated neurocritically ill patients is unknown and explored in this study. a retrospective cohort study was performed on patients admitted to the neurocritical care service between 1/2/2018 and 2/26/2019, hospital-wide o2 shut down for maintenance and a switch to olerated with lowest being 21% owest spo2 of > 92% and spo2 < 92% amongst the patients in the pre and post-o2 shutdown groups. -tolerated. with the risk of hyperoxia and its potential negative effects on neuronal injury, a subset of neurocritically whole body hypothermia has been used as a treatment for patients with severe traumatic brain injury (tbi) since many years. invasive brain temperature monitoring is the most commonly practiced for target temperature management in these patients; however, complications are common due to the invasive nature of the procedure. the objective of the current investigation was to evaluate the association between brain temperatures obtained using a non-invasive sensor (accucor) and an intracranial pressure/temperature (icp) catheter during selective brain cooling in patients with tbi. aluated during a selective brain cooling over 24 hours using both a parenchymal icp catheter (raumedic -pt) and the accucor sensor, with a catheter positioned in the nasopharynx. mean temperature values for each participant were obtained along the cooling intervention. outlier values derived from the accucor sensor were detected and removed prior to comparison. the variation in brain temperatures was calculated by mean temperature differences obtained using both measuring devices for each participant. mean brain temperature values were very similar between devices: 36.04°c (35.14°c-38.36°c) for the icp catheter and 36.10°c (34.55°c-38.77°c) for the accucor sensor (p-value: 0.05, 95% ci: -1.72 to 1.84). the median temperature difference between the devices was 0.41ºc (minimum: -1.21°c, maximum: 1.18°c, p-value: 0.89). our results suggest that there were no differences between brain temperature measurements conducted using the icp catheter and the non-invasive accucor sensor. this conclusion highlights the precision of non-invasive temperature monitoring, a safe alternative to the current invasive practice. monitoring procedures. sepsis-associated encephalopathy (sae) is a multifactorial syndrome, characterized as diffuse brain dysfunction that occurs secondary to infection in the body without overt central nervous system infection. the prognosis for sae is associated with the degree of cerebral damage. we investigated the relationship between the wavelet coherence of cerebral oxyhemoglobin (oxyhb) among different channels and outcomes in patients with sae. 14 consecutive patients with sae were included. moreover, we included normal controls (n=26) for comparison. the cerebral oxyhb data were collected using functional near-infrared spectroscopy (nirsit, obelab inc.). the coherence between sections of prefrontal oxyhb oscillations in five frequency intervals (i, 0.6-2 hz; ii, 0.15-0.6 hz; iii, 0.05-0.15 hz; iv, 0.02-0.05 hz; and v, 0.0095-0.02 hz) were analyzed using wavelet coherence. in addition, we analyzed the coherence of electroencephalography (eeg) signal in three frequency intervals (delta, 2-4hz; theta, 4-7hz; and alpha, 8-13hz). we evaluated the outcomes using glasgow coma scale (gcs) cores at discharge. the patients were categorized into three groups of normal control, good outcome (gcs 13-15), and poor outcome among the included sae patients (mean age, 63.1 years; and male, 57.4%), 5 patients (35.7%) had a good outcome. in the poor outcome group, phase coherence was significantly lower compared to good outcome and the normal groups, especially for the myogenic frequency interval iii (0.63±0.16 vs. 0.68±0.19 vs. 0.28±0.06, p <0.001, respectively). however, the phase coherence of eeg signal was similar in two groups. our results demonstrated that the lower phase coherence of oxyhb in the myogenic signal, which originated from the vascular smooth muscle cells in the brain, was related to the poor outcome in sae patients. this suggests that evaluating cerebral dysfunction using wavelet coherence of oxyhb could be a useful outcome predictor following sae. external ventricular drain (evd) placement is a common procedure in the neurointensive care unit and intracranial hemorrhage (ich) is a recognized complication. in this study we sought to determine the factors associated with ich development after evd placement. retrospective study performed at a tertiary hospital. we identified all patients in whom an evd was placed over a 13 month period. electronic chart review was done to obtain basic demographics, past medical history, use of antiplatelets/anticoagulants, type of catheter placed and presence of intracranial hypertension (ih). computed tomographies were reviewed to identify evd-associated ich. ichs were classified into symptomatic (gcs decline > 2 points, intubation, outcome of death, or new focal continuous variables were analyzed with a proportion of the means test. the sample was comprised of 106 subjects, 36 had evd-associated ich. the median age was 59 years. there was no significant difference in race or gender between patients with ich and those without ich. age, catheter type, history or inpatient use of anti-thrombotics, recent surgery, tpa use, heparin use, history of hypertension, hospital outcome, prior stroke, symptomatic hemorrhages, and icp spikes were analyzed, but only age (61.1 hemorrhage and 53.6 non-hemorrhage, p = 0.023), history of antithrombotic use (19/36 hemorrhage and 16/70 non-hemorrhage, p = 0.004) and icp spikes (26/36 hemorrhage and 35/70 non-hemorrhage, p = 0.038) were significantly associated with ich occurrence. three significant factors were associated with tract hemorrhages; age, history of anti-thrombotic use, and icp spikes. two of these factors have been previously supported by prior studies however, no prior study has correlated icp spikes to evd hemorrhages. additional studies may further validate the association between icp spikes and evd-related tract hemorrhages. targeted temperature management(ttm) aimed at helping to improve neurological outcomes associated with ischemic stroke have been studied continuously. however, it is not well known whether the parameters in ttm initiation, induction, maintenance will affect neurologic prognosis. we restrospectively reviewed medical records of the patients with large hemispheric infarction(lhi) who underwent ttm at snubh neurological intensive care unit from 2011.02.13. to 2015.12.31. onset to ttm initiation, induction period, ttm maintenance duration were investigated and dichotomized. neurologic prognosis was determined by the 3 month death and modified rankin scale(mrs). a total of 49 patients were included in the study. longer onset to ttm initiation(>24 hours) was associated with less 3 month death. shorter ttm induction period(<=2 hours) was associated with less death rate, more fair outcome(mrs 0-4). ttm maintenance duration(within 5 days or more) was not statistically correlated with neurologic prognosis. shorter ttm induction period may reduce death in lhi through maximizing icp control effect. the high mortality rate in patients with shorter onset to ttm initiation is likely to be related to the severity of initial symptom(mean nihss 20 vs 16). non-pulsatile continuous blood flow can cause endothelial dysfunction and small vasculature injury. the impact of non-physiologic blood flow on cerebral autoregulatory function and brain injury has not been extensively studied. we report a case of posterior reversible encephalopathy syndrome (pres) in a patient supported by a continuous flow pump, venoarterial extracorporeal membrane oxygenation (ecmo) for acute cardiogenic shock secondary to iatrogenic ventricular septal defect (vsd). a 74 year-old male with hypertrophic cardiomyopathy was admitted for elective septal myectomy with an ascending aorta and hemi-arch replacement. the surgery was complicated by an iatrogenic vsd requiring urgent va-ecmo cannulation for cardiogenic shock. on day 6, ct brain achieved for poor neurological examination revealed extensive bilateral parietal, occipital and cerebellar hypodense lesions consistent with the typical imaging features of pres. a repeat ct brain on day 7 depicted further extension of brain injury to the bilateral frontal lobes. due to worsening neurologic status, the decision was made to place an intracranial pressure monitor and lower the ecmo flow to return to a pulsatile flow state. the patient was closely monitored for improvement with paco2 levels, serial ct scans, and neurologic examinations. repeat ct scans on pod 10 and 13 depicted improvement in the bilateral cytotoxic edema with paco2 levels improving to 34 -38mmhg at a reduced ecmo flow rate of 2.2 -3.3l/min. his neurologic examination also improved with spontaneous movements noted in all four extremities. although neurologically cleared for heparin loading, he remained too hemodynamically unstable for open surgical repair and his surrogate decision makers decided to withdraw life-sustaining therapy. our case report illustrates the limited knowledge on the consequences of ecmo's impact on cerebral dynamic cerebrovascular autoregulatory changes in real-time that occur with patients with continuous flow pumps. hospital-onset unresponsiveness (hou) may occur in patients hospitalized for non-neurological conditions; while hou tends to be a transient systemic event, it may also indicate underlying neurological problems. quantitative pupillometry provides npi (neurological pupillary index), a quantitative measurement of pupillary light reflexes that have been traditionally assessed via subjective visual impression. we determined the clinical usefulness of npi in predicting the outcomes of patients who have experienced hou. hou was defined as a newly developed altered mental status and cases coded as "unresponsive" in the acdu (alert, confused, drowsy, and unresponsive) scale. we analyzed the demographics, radiological findings, etiology of hou, npi, in-hospital mortality, and 3-month modified rankin scale (mrs) scores. a total of 345 cases in 331 patients were analyzed, out of which 214 cases (62%) had been assessed with quantitative pupillometry. cerebral herniation syndrome (chs) was found in 52 (15%) cases; higher npi was associated with decreased risk for chs (odds ratio, 0.61; 95% confidence interval [ci], 0.26-0.77; p=0.003), and no other factors were associated with the risk of chs. a total of 102 (30%) cases showed in-hospital mortality. after controlling for clinical covariates and the presence of chs, lower npi was independently associated with increased risk for in-hospital mortality (odds ratio, 0.52; 95% ci, 0.29-0.94; p=0.02). at a cutoff value of 1.8, the specificity and sensitivity of npi for predicting in-hospital mortality were 92% and 50%, respectively. multivariate analysis showed an independent association between lower npi and unfavorable clinical outcomes (common odds ratio, 0.64; 95% ci, 0.51-0.80; p=0.02). npi, a quantitative index of pupillary light reflex, was significantly associated with the risk of cerebral herniation and in-hospital mortality in non-neurological patients with hou. measuring pupillary light reflexes through quantitative pupillometry may be useful when responding to hou cases. target temperature management (ttm) improves survival and neurologic outcome and is recommended for cardiac arrest (ca) survivors by international guidelines. shivering is both an anticipated consequence and a major adverse effect of ttm. the bedside shivering assessment scale (bsas) is a simple, validated four-point scale that enables repeated quantification of shivering at the bedside. in this study, we examine the association between time to return of spontaneous circulation (ttrosc) and shivering (defined as bsas > 0). data on 30 post-cardiac arrest patients treated with ttm were collected from apache outcome database and medical records. baseline characteristics included age, apache iii scores, ttrosc (minutes), time to target temperature (ttt, minutes), and bsas > 0 (percentage of hours bsas > 0/total number of hours bsas was done). outcome was survival to hospital discharge with good neurologic outcome. group 1 and group 2 included patients with ttrosc below or above the median respectively. all patients received continuous infusions of fentanyl and sedatives (propofol, midazolam, and/or dexmedetomidine) as per our institution's protocol. compared to group 1 (n = 15), group 2 (n = 15) had similar age (57 ± 21 vs 59 ± 17, p = 0.8), similar apache iii scores (104 ± 28 vs 104 ± 33, p = 1.0), longer ttrosc (27 ± 12 vs 5 ± 2, p = 0.0001), similar ttt (485 ± 181 vs 439 ± 353, p = 0.7), more shivering (5.8 % vs 3.2 %, p = 0.03), and similar survival with good neurologic outcome (20 % vs 27 %, p = 0.7) respectively. ttrosc was strongly positively correlated with shivering (pearson correlation coefficient, r = 0.78). in comatose survivors of cardiac arrest who received ttm, longer ttrosc (indirect measure of brain injury) was associated with more shivering. these findings should be further investigated in prospective studies. pupillometry assessment of the pupillary light reflex (plr) is gradually replacing manual plr assessment. this new technology has led to a recent increase in clinical research and subsequent need to validate those results. mcnett et al. recently investigated the association between intracranial pressure (icp) and serial pupillometer values and found that pupillometry readings are different significantly in the setting of increased icp. this is a replication of the mcnett study in a larger multicenter cohort to explore these findings. data from the establishing normative data for pupillometer assessments in neuroscience intensive care (end-panic) registry include over 3,000 patients with a neurological condition. 273 subjects with documented icp readings provided 16,221 observations (daily mean icp values) which were included in this analysis. statistical analysis (sas v9.4) included descriptive statistics and to examine the differences . subject mean age was 53 years, 52% were female and 76.6% were caucasian. student t-test analysis was used to explore for differences. excepting latency and right eye npi, lower plr values were associated with higher icp (compared to low or normal icp) for all mean pupillometer/plr variables for both left and right eyes (t range [-9 .78 to 33.67]; p-value range [<0.0001 to 0.03]). the findings confirm and extend those of mcnett. patients with increased icp tend to have lower pupillometer readings. automated pupillometer is a non-invasive method that provides prediction of the icp trends which can help neurocritical care professionals in assessing patients with neurological conditions. encephalopathy is a common complication in cirrhotic patients. clinical manifestations are diverse, but few data are available on pupillary abnormalities in such patients. the aim of this study was to evaluate whether automated pupillometry could detect pupillary dysfunction in this patients' population. prospective ongoing study including the assessment of the pupillary changes to light stimulation using automated pupillometry (neurooptics, irvine, usa) in adult cirrhotic patients after icu admission. the degree of encephalopathy was scored by the glasgow coma score (gcs). severity of cirrhosis was assessed by the child-pugh and meld scores. severity of liver encephalopathy was assessed according to standard criteria. different biological variables, including ammonium (nh4), was measured to pupillary assessment. the median values of pupillometry-derived variables were collected for both eyes. -pugh and nh4 levels were found with any of the pupillometry-derived variables. no differences in pupillometry-derived variables were observed across different degree of liver encephalopathy. automated pupillometry did not show correlations between pupillary abnormalities and the severity of critically ill patients with liver cirrhosis. prognostication in comatose survivors of cardiac arrest (ca) remains challenging. the purpose of this study was to determine if early quantitative analysis of resting eeg can improve prediction of commandfollowing by post-ca day 10. we prospectively enrolled patients admitted after ca. clinical care was performed according to our institutional protocol, which includes continuous eeg monitoring. 20-minute resting eeg epochs were clipped daily; clips were excluded if seizures or other confounders were present. epochs from post-ca days 1-6 were preprocessed for artifact reduction, then analyzed for three quantitative metrics: power spectral density, permutation entropy, and coherence. we created a predictive model using partial least squares regression analysis to distinguish eeg data as from patients who would or would not recover command-following by post-ca day 10. cross-validation of results was accomplished with a 1000-times random assignment of 50% of data as training set and 50% as testing set. 368 eeg clips were analyzed from 98 patients (59.1% female, age 57.8+/-1.8 years, pre-morbid mrs 1.7+/-0.2 and cpc 1.4+/-0.1). cardiac arrests occurred out-of-hospital in 52%, witnessed in 80.4%, and had bystander cpr in 74.5%. mean time to rosc was 19+/-2 minutes, 31.4% had a shockable initial ekg rhythm, and 74.5% of patients received therapeutic hypothermia. prior to day 10, 39.2% regained consciousness and 19.4% had withdrawal of care. using eeg data alone, predictive ability (expressed as average area under the receiver operating characteristics curve) yielded auc 0.773+/comparison, the same model was constructed using clinical features (absence of pupil and corneal reflexes by day 5) or laboratory testing (peak nse level). the model combining clinical, laboratory, plus eeg data yielded auc 0.835+/-0.029, an improvement vs clinical features (auc 0.720+/-0.002, p<0.001) or nse levels (auc 0.750+/-0.03, p<0.001) alone. quantitative eeg analysis may provide adjunctive prognostic information regarding short-term recovery of consciousness. international guideline recommended pupillary light reflex (plr) and/or cortical response (n20) to short-latency somatosensory evoked potentials (sseps) at 72 hours after return to spontaneous circulation as the only strong predictors of unfavorable outcome in comatose patients after cardiac arrest. the aim of this study was to compare this algorithm with a multimodal approach including other prognostic tools. post hoc analysis of an international multicenter (n=10; n=456 patients) prognostic study on automated pupillometry in comatose post-ca patients. the primary study endpoint was the accuracy of npi in predicting 3-month unfavorable neurological outcome (uo), defined as cerebral performance category (cpc) of 3-5 (severe disability, unresponsive wakefulness or death). patients with findings on plr, sseps, npi and eeg were included; the highest nse was also recorded, whenever available. an npi <2 on day 1, a discontinuous eeg background or clinical myoclonus over the first 3 days, bilaterally absence of n20 calculated as: false positive / favorable outcome. we included 186 patients; 131 (70%) of those had uo. using the approach of guidelines, unfavorable outcome at day 3 was observed in 41/44 patients with absent plr and 63/63 with absent n20; 80/131 (61%) patients with uo were identified. using the multimodal approach, uo was identified in 15/15 patients with npi <2, in 67/81 patients with discontinuous eeg, in 50/52 patients with myoclonus and this study suggests that a multimodal approach, including npi, eeg, sseps and nse, could identify a after physicians introduced the idea to declare death based on loss of brain functionality, many countries incorporated brain death into their legal criteria for death. we sought to learn about the global legal perspective on brain death declaration (bdd). we collected legal documents about declaration of death around the world by searching national legislative databases and google. we utilized google translate to convert all documents into english then searched for references to criteria for bdd. in cases where there was conflicting information, we consulted local experts. we located legal documents on death declaration for 49 countries, 45 of which included a reference to brain death. legally stipulated criteria for bdd were identified for 32/49 countries. with respect to prerequisites for bdd legal stipulations existed in: 28/32 countries on confounders to exclude, 16/32 countries on an observation period before bdd, 19/32 countries on the minimum temperature for bdd and 8/32 countries on the minimum blood pressure for bdd. an assessment for coma was legally required in 30/32 countries. the fact that spinal reflexes do not preclude bdd was included in the legal criteria for bdd in 12/32 countries. a broad reference to an assessment for brainstem areflexia was legally mandated in 27/32 countries. the legal criteria included specific reflexes to test in 25/32 countries (pupillary 23/32, corneal 23/32, oculocephalic 18/32, oculovestibular 24/32, gag 20/32, cough 22/32, and other 4/32). every country legally required an assessment for the inability to breathe spontaneously, but only 17/32 described apnea testing in detail. the number of clinical exams required for legal bdd ranged from 1-5. ancillary testing was legally required in 9/32 countries. the legally stipulated criteria for bdd differ around the world. standardizing the global legal perspective on bdd would help prevent 1) variability in practice and 2) false bdds. up to 65% of patients monitored with pupillometry during therapeutic temperature management (ttm) after cardiac arrest will have sluggish (sl) or non-reactive (nr) pupils. the neuroimaging findings and injury patterns of these patients have not been reported. 115 adult patients treated with ttm after cardiac arrest with available pupillometry data from the neuroptics npi-200 were studied. discharge outcome was classified as poor (po) if the cerebral performance category score was 3-5, and as good if 1-2. pupil size, percent constriction, and constriction velocity were determined throughout ttm using data from the worst eye at each assessment. the neurological pupil index (npi) was scored from 0 (nr) to 5 (brisk), with values <3 considered sl. computed tomography (ct) and magnetic resonance (mr) neuroimaging was reviewed by a neuroradiologist blinded to pupillometry and outcome data. poor outcomes occurred in 34/35 (97%) patients with nr pupils during ttm, 22/34 (65%) patients with sl pupils, and 25/46 (54%) with normal (nl) pupil reactivity. pupil size did not predict outcome, but pupillometry data during ttm predicted poor outcome with auc 0.73-0.78. when nonreactive pupils were first detected, 24/35 (68%) were <5 mm. 44% of patients had ct imaging, and 30% had mr imaging a median of 102 (iqr 78-123) hours after recovery of spontaneous circulation. cerebral edema or herniation were identified in 7/19 (37%) nr vs 1/22 (5%) sl and 0/21 nl patients (p<0.001). midbrain injury identified by t2 sequences was identified in 15/41 (36%) nr/sl patients versus 3/21 (14%) nl patients (p=0.06). midbrain abnormalities were identified more often in patients with nr/sl pupils than edema/herniation (36% vs 20%, p=0.003). a minority of patients with sluggish or non-reactive pupils after cardiac arrest have evidence of cerebral edema or herniation. midbrain injury is a more common mechanism to explain this common neurologic deficit. cardiac arrest (ca) survivors are often comatose and their arousal recovery is dependent on the extent of hypoxic-ischemic injury (hii). long-term neurologic outcomes are variable, difficult to predict, and biased by withdrawal of life-sustaining therapy. somatosensory evoked potentials (ssep) remain the gold standard for predicting arousal potential, but is not broadly available. we hypothesized that early hi-resolution mri may help assess arousal recovery potential as predicted by electrophysiologic outcome. comatose survivors of cardiac arrest admitted to an icu between june 2015 and january 2018 who underwent ssep and mri were retrospectively identified. 3d-hii burden in 16 predefined regions. semi-automated region-of-interest (roi) tools in mipav were used to draw borders on dwi around the upper brainstem including the ascending reticular activating system (aras) to assess voxel intensity and derive hii volumes. our outcome of interest was ssep findings classified in two prognostic categories: indeterminate (bilaterally present n20s or unilateral presence of n20s) and poor prognosis (bilaterally absent n20s). we used paired t-tests to compare presence of signal abnormality and rois between patients with sseps predicting poor outcome or indeterminate prognosis. 42 consecutive ca survivors (mean age of 51.3, 31% female) were included. no significant differences were noted in baseline characteristics between groups though time to rosc was noted to be 9 vs 20 mins for indeterminate and poor outcomes (p = 0. extent did not predict ssep status. no significant difference was noted in the voxel intensities on adc in the midbrain or pontine tegmentum. quantitative mri measures of hii extent may be superior in predicting arousal potential in comatose survivors of ca compared with manual rating. a quantitative image analysis pipeline is being developed for measuring aras lesion burden and predicting electrophysiologic based outcomes in ca. despite promising preclinical results, the application of intra arrest therapeutic hypothermia (iath) during cardiopulmonary resuscitation have produced controversial results in clinical trials. the aim of this review was to analyze the effects of such therapy on relevant outcomes in patients suffering from out-of-hospital cardiac arrest (ca). the following databases have been searched up to 26th may 2019 for human trials: pubmed (from 1966), embase (from 1974), cinahl (from 1982), the cochrane library (from 1974) and ovid/medline (from 1966). the search strategy will use the following terms: "arrest" or "cardiac arrest" or "heart arrest" and "intra arrest" or "during cpr" or "intra cpr" and "hypothermia" or "therapeutic hypothermia" or "cooling". references from identified studies and relevant review articles have also been searched for additional eligible citations. the search has been limited to english publications and has been conducted in accordance with the international liaison committee on resuscitation (ilcor) process of evidence evaluation. a total of six human studies (n=2869; 1386 treated with iath) including four randomized controlled trial (loe 1), one retrospective and one prospective controlled study (loe 3) were identified. two studies used trans-nasal evaporative cooling and 4 others intravenous cold fluids. overall rate of return of spontaneous circulation was similar between iath patients and controls (542/ ) when compared to control group. no differences were found in the subgroup of shockable vs non-shockable rhythms. different effects on outcomes were observed according to the method used to induce iath when compared to controls. iath was not associated with improved outcomes when compared to standard of care. however, the method used to induce iath may potentially influence the beneficial effects of such intervention. amantadine may improve functional recovery in the subacute state following brain injury. we aimed to characterize eeg signatures in patients with acute brain injury (abi) receiving amantadine that did and those that did not recover consciousness. we studied a consecutive series of 44 patients with acute brain injury patients who were treated with amantadine as a neurostimulant between september 2013 and december 2017. all patients were initially comatose and underwent eeg prior to and after the initiation of amantadine. the ability to follow commands was assessed daily based on prior published methodology (claassen et al, annneurol 2016). eeg features that were assessed included sleep stages, posterior dominant rhythm (pdr), and power spectral density plots. we applied a multivariate regression model using generalized estimating equations (gee) to identify eeg features correlated with recovery of command following. eegs were analyzed by a board certified neurophysiologists. -free eeg clips), 30 patients (68%) recovered consciousness during hospitalization. ich was the most common etiology in 22 (50%) patients, followed by sah in 7 (16%) patients. on average amantadine was given for 11 +/-8 days. 14 patients (32%) had seizures, only 2 patients (14%) after starting amantadine. in our gee model, age (p=0.01), sleep structures (p=0.02), pdr (p=0.03), and cumulative dose of amantadine (p=0.03) were all associated with recovery of command following. spectral features corresponding to higher levels of anterior forebrain corticothalamic integrity correlated with higher levels of consciousness in 100% of recorded patients after 7 days of amantadine use. the best spectral pattern per patient was seen 1.5 days on average prior to recovery of consciousness. eeg may provide a biomarker that indicates subsequent recovery of consciousness in unconscious patients with an acute brain injury that are treated with amantadine. depletion of cerebral glucose (i.e., cerebral glucopenia) occurs commonly and is associated with poor outcome in traumatic brain injury and subarachnoid hemorrhage. however, the incidence of cerebral glucopenia after diffuse hypoxic-ischemic brain injury (hibi) is unknown. we characterized the burden of cerebral glucopenia after hibi and its association with markers of physiological distress and outcome. we retrospectively analyzed cerebral microdialysis data from a cohort of 22 patients with hibi. 21 patients survived sudden cardiac arrest and 1 patient had severe hypoxia after polysubstance overdose. hourly values of cerebral glucose, lactate, pyruvate, and glycerol as well as continuous intracranial pressure (icp), arterial blood pressure (abp) and interstitial brain oxygen (pbto2) were recorded. associations between average glucose/patient-day versus average lactate:pyruvate ratio, glycerol, icp, pbto2, and abp were analyzed using linear regression. burden of glucopenia (defined % time with glucose < 0.7 mmol/l) was analyzed by patient-day. the relationship between glucopenia burden and discharge outcome was analyzed using the wilcoxon rank sum test. lower cerebral glucose was associated with higher cerebral glycerol (p=0.005), higher lpr (p=0.0002), higher icp (p<0.0001), and lower pbto2 (p=0.012) levels. there was no association between abp and cerebral glucose (p = 0.12). glucopenia burden increased progressively over time and peaked by postinjury day 8. 5/22 patients had good outcome (defined as return of consciousness prior to discharge). there was no association between outcome and cerebral glucopenia burden (p = 0.4351). cerebral glucopenia is common after hibi and associates with markers of cellular distress. the burden of cerebral glucopenia progressively increases over several days and appears to peak more than 1 week after injury. although there was no association between outcome and glucopenia burden, the number of patients in this study with good outcome was low. the utility of cerebral glucose monitoring after hibi merits further study. international guideline recommends using bilaterally absence of pupillary light reflex (plr) and/or bilaterally absence of the cortical response (n20) to short-latency somatosensory evoked potentials (sseps) at 72 hours after return to spontaneous circulation to predict unfavorable outcome in comatose patients after cardiac arrest. the aim of this study was to compare this algorithm with a multimodal approach including other prognostic tools. retrospective study of adult (>18 years) cardiac arrest patients admitted from january 2016 to march 2019 and who underwent multimodal monitoring. we collected demographic characteristics and cardiac arrest data, together with sseps, the presence of burst-suppression on early eeg, a neurological pupillary index on the automated pupillometry <2 at 24 after arrest and a neuron-specific enolase (nse) 3-month unfavorable neurological outcome (uo) with cerebral we included 143 patients; 104 (73%) of those had uo. using the approach of guidelines, unfavorable outcome at day 3 was observed in 7/14 patients with absent plr, in 16/16 with absent n20 and 14/14 with combined absent pupillary light reflex and n20; 51/104 (49%) patients with uo were identified. using the multimodal approach, uo was identified in 30/30 patients with npi <2 and 36/37 patients with bs on eeg. among the others, uo was associated with absent n20 in 4/4 patients and with high nse values in 14/18 patients. this approach identified 84/104 (81%) patients with unfavorable outcome. the area under curve to predict uo for the approach of guidelines was 0.66, which increased to 0.80 with the multimodal approach. this study suggests the a multimodal approach, including npi and bs on eeg, sseps and nse, has a higher predictive value for uo than recommended predictive tools. there is a high prevalence of seizures following cardiac arrest (ca), but not well studied among survivors with good neurological recovery. we describe the prevalence of clinical and electrographic seizures, anti-epileptic use, and eeg characteristics of ca survivors with good neurological outcomes. adults with return of spontaneous circulation (rosc) after in-hospital or out-of-hospital ca between 9/2015-2/2019 were eligible. a consecutive sample of survivors with included. prevalence of seizures and antiepileptic drugs (aed) use within 12-months after discharge were collected using a questionnaire administered via in-person or phone. a board-certified clinical neurophysiologist reviewed the eeg. of 148 patients surviving to discharge, 93 (63%) with 12-months follow-up were analyzed. average age was 56±16 years, 32 (34%) were women, 81 (87%) patients had witnessed arrest, 44 (47%) received defibrillation, with an average rosc duration of 12±12 minutes, and a median cpc of 2 at discharge. there were no clinical seizures reported during hospitalization. of available 63 (68%) patients with raw eeg (median duration of 4 days), only 2 (3%) patients had electrographic seizures, 47 (74.6%) had continuous background as their best eeg pattern, 6 (10%) with discontinuous background, 5 (8%) with epileptiform discharges, and 2 (3%) patients had burst suppression pattern that recovered later to a normal eeg pattern. none of the patients had any malignant eeg patterns, 58 (92%) exhibited reactivity to a verbal or tactile stimulation and 38 (60%) had the presence of sleep structures and posterior dominant rhythms. surprisingly, 20 (13%) patients were discharged on an aed. clinical seizures and aed use were reported in 2/93 (2%) at 12-months follow up. both short and long-term seizure burden are very low among the cardiac arrest survivors with good neurological recovery. underlying factors related to high utilization of aed before discharge warrants further investigation. objective: early neuro-prognostication in the intensive care unit pediatric patients is essential to enable effective care planning, triaging level of care, and family support. in coma, the reliability of biomarkers such as electroencephalogram (eeg), anatomical neuroimaging to determine potential for consciousness and future functional capacity are less established in children. herein we present two case studies highlighting resting state functional mri (rs-fmri) as a clinically new means defining real-time brain function in the pediatric critically ill population. rs-fmri measures spontaneous low-frequency fluctuations in the blood oxygen dependent (bold) signal to investigate the networks of the brain. a standardized acquisition of data on a 3 tesla mri under light tool melodic. whole brain networks determined by independent component analysis with false discovery rate at p<0.05 to detect major brain networks. cases describe two critically ill children. one, with severe brain injury related to acute necrotic encephalopathy, and the other with diabetic ketoacidosis induced cerebral edema and uncal herniation. both had slow eeg background with sleep features approximately a week after presentation and were comatose by exam on the day of rs-fmri. rs-fmri detected normal brain function in the long-range fronto-parietal network, intact language-area networks, and default mode network. atypical networks were detected in brainstem and deep grey in both children. by hospital discharge, both children were awake and communicative with spontaneous movements. case one remain with tracheostomy with intermittent ventilation, case two had residual left hemiparesis, vision and language intact, mild cognitive deficits. in the cases reviewed, rs-mri may offer an objective measure of functional brain capacity and potential for meaningful recovery with preservation of language and long range connectivity networks in critically ill pediatric patients. provision of positive end-expiratory pressure (peep) through a conventional ventilator during apnea testing for brain death determination removes the need for additional equipment such as a peep valve, allows for use of high peep during apnea in patients with severe hypoxic respiratory failure and facilitates detection of respiratory effort on flow scalars. the advent of ventilators that permit deactivation of the apnea backup setting has made such testing possible. our goal was to examine the feasibility of peep use with conventional mechanical ventilation during apnea testing, with a focus on premature termination and inadvertent external triggering. performed without disconnection from the ventilator (dräger evita® infinity® v500), with deactivation of the apnea backup. this was a convenience sample based on availability of appropriately trained -support and peep 5-15cmh2o. apnea was confirmed by absence of chest rise and respiratory effort on the flow scalar. adequacy of respiratory stimulus was established by a co2>60mmhg and 20-point co2 rise from baseline. endpoints included early termination of the apnea test prior to 10 minutes because of patient instability, any oxygen desaturation below 90% and inadvertent external triggering. inadvertent external triggering required repeat of apnea testing. ten patients underwent apnea testing while connected to the ventilator. apnea testing for at least 10 minutes was successful in all patients. apnea was confirmed in all cases. no patient suffered oxygen desaturation below 90% or other instability. there was one instance of inadvertent external triggering caused by jostling of tubing, necessitating repeat testing. apnea testing with provision of peep through a conventional ventilator to improve tolerance is feasible. inadvertent external triggering is uncommon but may occur. despite well-defined aan guidelines on brain death declaration, there is marked variability in its practice nationally. this highlights the need for targeted brain death education initiatives. communication with surrogates or families about a brain death diagnosis and its implications is integral to brain death declaration, yet this has not been studied in a simulation setting. we developed a brain death simulation curriculum at our institution addressing knowledge and surrogate communication skill development. as part of this curriculum, multi-disciplinary critical care fellows completed a pre-curriculum multiple choice (mc) knowledge test and survey (likert 1-10 scale) evaluating comfort and confidence. a mandatory one-hour neurocritical care attending-led didactic regarding guidelines and technical aspects of brain death examination was conducted. subsequently, each fellow performed an observed brain death examination (simman3g mannequin) with feedback followed by a standardized family scenario with delivery of a brain death -simulation survey, mc questions, and provided feedback. statistical analyses used 2-tail wilcoxon signed rank test (p<.05). thirteen critical care fellows participated (neurology[1], anesthesia[5], trauma[4], pulmonary[3]). only one fellow had previous formal brain death training with the majority [80%, (n=12)] only participating in 0-5 brain death declarations. there was significant improvement across all measures: self-rated knowledge (5.6 to 7.9, pre-simulation to post-simulation, p= 0.004), knowledge relative to peers (48% to 81%, p=0.002), confidence (4.5 to 8.1, p=0.001) and comfort (4.3 to 8, p=0.001) with performing a brain death exam, and comfort with family discussion (6.5 to 8.6, p=0.01). test scores improved from 56% to 73% after simulation (p=0.004). all fellows found the curriculum beneficial (with all aspects wellreceived). critical care fellows may lack experience with brain death declaration. didactics coupled with simulation-based education can improve objective knowledge and comfort with brain death declaration and surrogate communication. there is a growing disparity between availability and demand for neurologic expertise, particularly in smaller community hospitals. telemedicine has helped to bridge this disparity with respect to cerebrovascular disease and is used increasingly to deliver other types of neurologic expertise to patients. while the nihss is widely used in telestroke, other formalized neurologic exams have not been well studied. we seek to determine whether the components of a brain death exam can be reliably performed via telepresence. patients suspected of meeting brain death criteria were enrolled from july 2017 to may 2019. standard bedside neurologic exam (bne) performed by the attending neurointensivist in accordance with our institutional protocol was compared with the telepresence neurologic exam (tne) performed by a study neurointensivist blinded to the findings of the bne and a trained bedside assistant. we analyzed the agreement between examiners regarding findings of coma, corneal reflex, pupillary light reflex, oculovestibular reflex, oculocephalic reflex, cough, gag, motor response, and apnea. we enrolled 7 patients over 22 months. proximate causes were intracerebral hemorrhage (5/7), anoxic brain injury, (1/7), and cerebral infarction (1/7). all examination components performed in the bne could be completed by tne. in 3 cases, neither examiner could assess all exam components. in 2 cases spinal cord injury precluded oculocephalic testing. in 1 case refractory hypoxia precluded apnea testing. bne and tne agreed in 100% of testable components. in 2 cases testing pupillary light reflex was reported as difficult in the tne but not the bne. all telepresence examiners reported high confidence that the exam findings were consistent with brain death. preliminary findings from our pilot study suggest that the use telepresence for brain death examination introduction traumatic brain injury (tbi) is often followed by the loss of con increases each day following the injury, but the contents of consciousness, also known as qualia, do not uniformly return. while there is some information about brain regions supporting arousal, less is known about circuits encoding contents of consciousness. some evidence supports a role for the thalamus in consciousness, but it is controversial whether it supports arousal, or has a more nuanced role in consciousness. to address this question, we combined intracranial recordings in patients recovering consciousness with neuroimaging of thalamocortical circuits. electrophysiology we recorded electrocorticography (ecog) from prefrontal cortex and anterior cingulate cortex, as well as scalp electroencephalography (eeg) from a standard 10-20 montage, during singleand parietal cortex based on coherence between the evoked responses in these regions when acc was stimulated. radiology. regions of structural damage were extracted from the post-tbi mri and diffusion tensor imaging (dti) radiographs. tractography using dsi studio™ was performed with seed regions placed in the bilateral mediodorsal nucleus of the thalamus. we found that in patients with injury isolated to the cortex and/or white matter, the cortico-cortical functional connectivity across frontoparietal networks was preserved, and these patients recovered consciousness. however, a patient with thalamic injury failed to recover consciousness, despite an increased level of arousal following injury. the functional connectivity across cortical regions was drastically lower following thalamic injury, even when the cortical damage was minimal. we propose that integration and communication of information across frontoparietal networks, which is required for contents of consciousness, is dependent on thalamic input. thus future efforts have to be focused on restoring this input. brain herniation is a deadly event that requires rapid administration of hyperosmotic agents (hoas) such as 23.4% nacl. a recent retrospective study showed that intraosseous (io) cannulation provides a safe route for rapid administration of hoas compared to central venous catheters (cvc) and peripheral intravenous catheters (piv). prospective study to measure the time-to-treatment for 23.4% nacl or mannitol via io, cvc, or piv. a data collection form ("brain code narrator") was created by nurses and providers to prospectively collect clinical data, hemodynamic measures, and time-to-treatment and administration route for hoas during brain codes. in addition, demographics, diagnosis, serum sodium (na+) and complete blood cell count, as well as immediate and delayed complications, and outcomes were collected. brain code narrator was used to collect data for 35 patients: 19 males with median (iqr) age 55(44-67) years. diagnosis included intracerebral hemorrhage (n=16), subarachnoid hemorrhage (n=9), and other (n=10). all patients were intubated. most patients were co-treated with induced hyperventilation. 23.4%nacl (30cc) via cvc and io route and mannitol (50 gm) via piv were administered during 41, 18 , and 21 events with median time-to-treatments of 4(2,5), 3(1,3) and 15(14,18) minutes, respectively (p value <0.001 for all comparisons). no adverse events, such as hypotension or tissue injury were noted. preliminary data suggest that during brain herniation, administration of 23.4% nacl via io or cvc is more rapid than iv mannitol. io cannulation for 23.4% nacl may be an alternate route of administration of hoas during brian code. additional data will be provided regarding herniation reversal and long-term hematologic abnormalities. stress hyperglycemia is common in the critically ill and is associated with poor neurological outcomes in cardiac arrest patients. it is unknown whether glycemic dysregulation have different prevalence according to cardiac arrest etiology. we hypothesized that overdose-related cardiac arrest (odca) patients are more vulnerable to hypoglycemic events given the circumstances of arrest. we retrospectively studied 243 cardiac arrest patients treated at two urban hospitals from the multimodal outcome characterization in comatose cardiac arrest (mocha) registry from 2011-2018. we examined glucose dysregulation (hypoglycemia blood glucose [bg]<80 mg/dl, hyperglycemia bg>180 mg/dl) within first 72h from arrest in odca and non-odca cohorts. statistical analyses included paired/unpaired t-tests, chi-al dysfunction was defined by scores of gosof the 243 patients, 76 (31.3%) were odca. there were no differences in bmi, gender, ethnicity, or therapeutic hypothermia (th) treatment across cohorts, but odca patients were younger (43±15 vs 59±17 year-old; p<0.0001), had lower prevalence of diabetes (21.7 vs 40.5%; p=0.007) and lower hemoglobin a1c (5.8 vs 6.5%; p=0.02). mean bg reduction from 0-24h to 48-72h in odca patients was significantly smaller (86.2±99.4 vs 148.2±106.5 mg/dl; p=0.006) despite no difference in mean peak bg. bg nadirs were lower in odca patients (77.8±28.8 vs 95.3±43.4 mg/dl; p=0.001). 113 patients developed glycemic dysregulation: 52(46%) odca vs 61(54%) non-odca; odca patients were nearly two times more likely to develop hypoglycemia (rr 1.9[1.2-3.1]; p=0.012) but had no increased risk of hyperglycemia (rr 1.0[0.8-1.2]). among patients with glycemic dysregulation, odca was associated with higher risk of in-hospital death or neurological dysfunction (or 2.9[1.0-8.4]; p=0.044). despite exhibiting blunted bg reductions to hyperglycemic treatment, odca patients were more susceptible to hypoglycemia in the first 72h postmanagement strategies should account for cardiac arrest etiology. sedation and neuromuscular blockade (nmb) in patients undergoing targeted temperature management (ttm) after cardiac arrest (ca) are recommended for patient discomfort and management of shivering. this study assessed the association between nmb use and neurological outcome in comatose survivors of ca who received ttm. data on 77 post-cardiac arrest patients treated with ttm were collected from apache outcome database and medical records. ttm of 33°c or 36°c is chosen based on critical care physician's discretion. baseline characteristics included age, apache iii scores, time to return of spontaneous circulation (ttrosc, minutes), time to target temperature (ttt, minutes), and shockable rhythm (sr, %). outcome was survival with good neurologic outcome. compared to the no nmb group (n = 22), the prn nmb group (n = 41) and continuous nmb group (n = 14) had similar age (63 ± 15 and 59 ± 22 vs 56 ± 21, p = 0.1, 0.7),similar apache iii scores (108 ± 33 and 106 ± 51 vs 111 ± 32, p = 0.7, 0.7), comparable ttrosc (16 ± 12 and 27 ± 24 vs 25 ± 22, p = 0.04, 0.8), longer ttt (526 ± 250 and 578 ± 300 vs 385 ± 158, p = 0.02, 0.02), comparable percentage of sr (17 % and 21 % vs 22 %, p = 0.4, 0.7), and similar proportion of patients with tt of 33 vs 36 (81 % and 87 vs 68 %, p = 0.3, 0.2) respectively. survival with good neurologic outcome was achieved in 41 % in no nmb group vs 32 % in prn nmb group (p = 0.5) and 36 % in continuous nmb group (p = 0.8) in the present study, in comatose survivors of cardiac arrest who received ttm, use of nmb had no effect on neurologic outcome. the apnea test is an essential examination for the determination of brain death. however, hypotension, hypoxemia, and other complications during the apnea test can affect the stability of brain-dead patients, as well as organ function for recipients. therefore, it is necessary to establish standard guidelines for apnea testing. the modified apnea test (mat) comprises delivery of 100% oxygen through the endotracheal tube connected to manual resuscitator (ambu® bag) with the positive end-expiratory pressure (peep) valve after disconnection of -nine instances of the conventional apnea test (cat) were performed in 25 brain-dead patients; 77 instances of the mat were performed in 39 brain-dead patients. the mean duration of the apnea test was 3.5 ± 1.4 minutes in the cat group and 3.0 ± 1.2 minutes in the mat group. there were no significant changes in paco2, pao2, or ph between the cat and mat groups (p = 0.341, 0.593, and 0.503, respectively). in overweight patients (body mass index prevented dramatic reductions in pao2 and sao2 (p < 0.05 for both). in the patients who had hypoxic brain injury due to hanging, differences in pao2 and sao2 in the mat group were significantly smaller than in the cat group (p < 0.05). although mat, which was invented to maintain peep, was not efficient for all brain-dead patients, it could be helpful in selected patient groups, such as overweight patients or those who had hypoxic injury due to hanging. clinicians should consider this reliable short-term apnea test. coma is a serious complication that currently has no good biological markers. the hypothalamus plays an important function in consciousness circuity. orexin a/b, a neuropeptide produced in the hypothalamus has an excitatory effect on multiple target areas in the brain. previous orexin studies ry (tbi), stroke and comatose states. the goals of our study: (1) the utility of orexin as a marker of coma recovery, (2) the correlation between orexin and recovery at 7 and 14 days, (3) correlation of orexin and glasgow coma score/score (gcs) over time, a prospective, irb approved study with a target n= 20 with a diagnosis of coma due to stroke, including hemorrhagic, and tbi, treated in the neuro critical care unit at stony brook university ho collected from an external ventricular drain (evd) and corresponding blood serum samples on days 0, 7, and 14. there was no modification to the clinical treatment of individual patients. dictive of whether patients recovered consciousness vs deteriorated. logistic regression showed the relative risk of recovery vs. deterioration: , (95%ci -299.8±44.4, 72.3±10.2, respective p-values=0.4954e-39, 0.001epredictive of initial coma severity (gcs), with a correlation coefficient, r =0.338. correlation between -0.964, -0.2881). dictive of poor overall not appear as significant as the baseline level in predicting recovery. there has been limited research over the past decade on how race impacts survival from cardiac arrest. it has been suggested that black patients are more likely to have unsuccessful resuscitation and lower rates of survival to discharge, however, it is unclear if this difference is secondary to hospital factors or patient specific factors. more research is needed on racial disparities in post-arrest outcomes at urban medical centers. multimodal outcome characterization in comatose cardiac arrest (mocha) is an irb-approved multicenter observational study. this study sample consists of 191 consecutive cardiac arrest patients treated at two urban hospitals from 2011-2018. the sample includes both patients who experienced in-hospital and out-of-hospital cardiac arrest. the outcome of interest was in-hospital mortality. associations between race and mortality were evaluated by chi-square and relative risk (rr) with 95% confidence interval. we included 123 white (64%) and 68 black patients (36% were all found to be at no increased risk for in-hospital mortality relative to other gender and race combinations. there was no difference in location of cardiac arrest (i.e., inhospital vs. out-ofthe lack of racial differences in mortality could possibly be explained by the similar rate of out-ofhospital arrests, similar initial non-perfusing rhythms, lower socioeconomic status of all patients, and strong focus of the participating hospitals on addressing racial disparities in the healthcare system. hyperglycemia is associated with poor clinical outcomes in critically ill patients, such as post-cardiac arrest (ca) patients. post-ca prognostication studies have studied clinical examinations, electrophysiology, biochemical changes, and/or neuroimaging, but studies regarding patient blood glucose levels are mostly limited to mortality outcomes. new analysis of glucose trends is needed to guide ca prognostication in order to determine favorable outcomes regarding neurologic functioning. this study was conducted using the irb-approved multimodal outcome characterization in comatose cardiac arrest (mocha) registry. the sample included 113 ca patients admitted to a university-affiliated urban hospital from 2014-2018. case selection was determined by availability of serial glucose measurements over the first 24 hours post-ca and outcome scores at hospital discharge. poor functional outcome was defined as modified rankin scale (mrs) 3-6 or glasgow outcome scale extended (gose) 1-4. statistical analysis included chi-square tests, and prognostic value was calculated by sensitivity. there was no significant difference in outcome regarding age, sex, race, or ethnicity. the study sample consisted of 31% diabetic patients, with no significant difference in outcome. patients with glucose levels >175 mg/dl at least once during the first 24 hours post-ca were associated with poor functional outc there appears to be a correlation between glucose >175 mg/dl within the first 24 hours and poor functional outcome. however, it is still difficult to reliably predict poor vs. good functional outcome due glucose management are needed to better understand this relationship. post-cardiac arrest organ injury is associated with high mortality rate after icu admission. despite improvement in the post-cardiac arrest care, temporal changes in patients' severity, intensity of care and neurological outcome remain poorly defined. the aim of this study is to describe how epidemiology of cardiac arrest characteristics, therapies and outcome have changes over years. retrospective study including adult (>18 years) cardiac arrest patients admitted from january 2004 to march 2019 after ca to a university hospital. we collected demographic characteristics and cardiac arrest data, together with main therapies and monitoring during icu and hospital mortality. a total of 878 patients (median age 64 [52-75] years; male gender 68%) were included over the study period. time to rosc was significantly longer in period i and iv when compared to others (p<0.001). icu length of stay and lactate levels on admission were also significantly higher in the period iv than others. there was a progressive and significant increase of out-of-hospital ca, non-cardiac origin of arrest and non-shockable initial rhythm from period i to period iv. also, there was a significant increase in the number of patients developing acute kidney injury and hypoxic hepatitis over time, from period i to period iv. despite a more frequent use of coronary angiography and multimodal neurological monitoring, hospital mortality increased (from period i, 50% to period iv, 70% -p< decreased (period i, 43% to period iv, 28% -p=0.01) over time. in this study, severity of anoxic injury and the incidence of post-cardiac arrest organ dysfunction increased over time. this was associated with a higher proportion of patients with poor outcome. pressure reactivity index (prx) based optimal cerebral perfusion pressure(cppopt) is associated with outcome after traumatic brain injury, but is not explored after cardiac arrest. we examined post-arrest patients who underwent invasive intracranial monitoring to explore characteristics of prx and cpp, and whether these were useful predictors of survival. we included all comatose cardiac arrest patients without primary neurological pathology that underwent invasive intracranial monitoring between 2008-2018 at our institution. cpp, mean arterial pressure(map), prx, cppopt, and deltacpp (cpp-cppopt) were calculated. systemic and brain physiologic measures were compared across the primary outcome of survival. in this pilot study we demonstrated the feasibility of acquiring cpp, prx, and cppopt for post-cardiac arrest patients. in this sample, none of the systemic and brain physiologic measures were associated with survival but the approach is limited by the bias towards poor outcomes in patients receiving monitors. interestingly, cppopt obtained from invasive intracranial monitoring generally ranged within physiologic norms. deltacpp for the single patient with good outcome was positive and small, consistent optimizing cerebral perfusion after cardiac arrest improves outcome are warranted. prognostication after cardiac arrest is challenge because of many confounding factors during hypothermia, severity of the brain injury is a key determinant of whether maximal resources, such as the use of extracorporeal membrane oxygenation (ecmo), mechanical circulatory support, or even coronary artery bypass grafting, are advisable or appropriate. therefore, early and accurate prognostication is essential for decision of therapeutic plan including maxima intensive modalities. in this study, we focused not only the prognosis estimation using mri but also initial ct-based prognosis estimation where features captured by modern deep learning (dl) technique were commonly used. we selected total 193 cardiac arrest patients having initial ct at er, and brain mri after 72 hours from cardiac arrest. diffusion weighted image (dwi, b = 1000), and apparent diffusion coefficient (adc) images calculated. cerebral performance category (cpc) scores were used as the main outcomes of survivors after cardiac arrest. both experienced neurologist and emergency medicine tried to predict the devised two cascaded deep convolutional neural networks (deep cnns). even fully experienced neurologist and emergency physician could not predict the cpc score exactly with the initial ct scan only and even additional diffusion mri (accuracy :16%-30% with initial ct only 60-70% with additional diffusion mri). by using dl technique, among 96 subjects of train set, 94 subjects had the correct prognosis score (97.9% accuracy) and among 97 subjects of test set, 96 subjects had the correct prognosis score (98.9% accuracy) with initial ct scans only. with additional diffusion mri, 99.0% accuracy and 100% accuracy. in visually equivocal initial ct scans, dl was more related to quantification than visual assessment. dl is superior and very useful for accurate prognostication especially with visually equivocal initial ct scan. cardiac arrest (ca) is associated with a high risk of dying and of neurologic impairment in survivors. target temperature management (ttm) improves survival and neurologic outcome and is recommended by international guidelines. this study assessed the association between the initial acute physiology and chronic health evaluation (apache) iii score and neurological outcome in comatose survivors of cardiac arrest who received targeted temperature management (ttm). data on 77 post-cardiac arrest patients treated with ttm were collected from apache outcome database and medical records. ttm of 33°c or 36°c is chosen based on critical care physician's discretion. baseline characteristics included age, gender, apache iii scores, time to return of spontaneous circulation (ttrosc, minutes), time to target temperature (ttt, minutes), and shockable rhythm (sr, %). outcome included hospital mortality, and good neurologic outcome (defined as discharge to home or rehab). compared to the bad outcome group (n = 50), the good outcome group (n = 27) had similar age ( in comatose survivors of cardiac arrest who received targeted temperature management, the apache iii score calculated in the immediate post-cardiac arrest period was a poor predictor of neurological outcome. brain dead patients are victims of trauma, entering the health care system through emergency department (ed).in the ed, these patients are received with injuries and de-arranged physiological conditions that depends on time sensitive treatment and have the potential for improvement with proper management. our study tries to find out the predictors at admission that contributes to brain death (bd) so that their timely intervention can prevent bd a retrospective analysis of the data related to severity of injuries, physiological parameters and laboratory investigation including ct scan of the head at the time of ed admission of each patients were assessed once they were diagnosed brain death. logistic regression analysis was employed to determine the independent factor. p value of <0.05 was considered significant. results 28 brain dead patients records at the time of admission were analysed. on univariate analysis we found glasgow coma scale (gcs) < 8, blunt trauma chest (btc),skeletal injury, intraventricular hemorrhage (ivh),skull fracture,subarachnoid hemorrhage (sah),midline shift (mls),mean blood pressure (mbp)< 60mmhg,use of ionotropes, hemoglobin (hb)< 8mg/dl,international normalization ratio(inr)> 1.5,albumin< 3mg/dl,sodium level (na)> 150meq/dl,urea > 50mg/dl significantly related to bd.on further multivariate analysis ,we found gcs< 8 (or-4.2), btc (or-2.1), ivh (or-3.4), mls (or-3.1), mbp <60 mmhg (or-3.9), inr> 1.5(or-3.1), albumin <3 mg/dl (or-2.7) and na level > 150meq/dl(or-4.3) at the time of admission are strongly associated with bd. our study tried to find the predictors at the time of admission which may contribute to bd. addressing them may prevent patient from becoming brain dead. biomedical technology in critical care is advancing at a rapid rate, offering the potential to substantially improve performance through improved efficiency and productivity. recent evidence suggests that visual assessment of pupillary size and reactivity has limited interrater reliability and accuracy, hence, we examined the introduction and implementation of an automated pupillometer in an academic neurological icu. we evaluated clinicians' perceptions about the added utility of the pupillometer to the standard visual pupillary exam. -minute bedside education and demonstration of the pupillometer by a 'superuser', we conducted usability testing at the bedside. participants completed the end-user testing methodology, where they completed specified tasks designed to test the pupillometer's features and later completed a questionnaire regarding their ease of use and interpretation of results, comfort and confidence using the pupillometer, and their behavioral intention to use the pupillometer if adopted into the clinical environment to date, 46 participants have completed 50 questionnaires. participants were allowed repeat enrollment in the study. the participant's professional designations include 41 registered nurses, 3 residents and 2 fellows and the majority have practised in the icu for 1 to 5 years. most of the participants are somewhat comfortable (24/46) performing the traditional visual pupillary exam and somewhat confident (29/46) with the results obtained from this exam. twenty-one, out of 50 responses, were very comfortable in using the pupillometer, 22/50 were somewhat comfortable, and 7/50 were neutral. if this technology is introduced into icu, the majority (31/46) will use this device to conduct pupillary exams, and 30/46 would consider changing management based on the pupillometer results. this study outlines a strategy to evaluate usability and implementation of a newly adopted technology into the critical care environment. improved implementation methods and evaluation of implementation processes are necessary for successful adoption of new technology in acute care settings. propofol infusion syndrome (pris) is a rare complication of propofol infusion. it is characterized by metabolic acidosis, rhabdomyolysis, acute renal failure, hyperlipidemia, and rapid cardiac failure. risk factors for developing pris are: propofol infusion >48 hours, dosing >4mg/kg/hr, critical illness, malnutrition, and use of vasopressors. we present a case of pris that developed after propofol infusion was turned off. a 43 year old woman with medically intractable epilepsy and developmental delay, presented with generalized tonic clonic status epilepticus. she was refractory to benzodiazepines, so she was intubated and started on a propofol infusion. at 50mcg/kg/min of propofol, she was still having generalized clonic tonic seizures. she was transferred to our neurological icu for continuous eeg monitoring. propofol infusion was increased to 180mcg/kg/min (10 mg/kg/hr) to control her seizures. she remained seizure free for 24 hours. propofol was weaned over 12 hours because she became hypotensive and required norepinephrine. when the propofol was turned off, cpk was 800, lactate was 1.3, and creatinine was 0.4. she received propofol for 36 hours. twelve hours after propofol was stopped, she developed a metabolic acidosis, lactate increased to 3.6, creatinine increased to 1.5, urine output decreased, and cpk increased to >20,000. she then developed bradycardia with wide complex qrs, which progressed to asystole. she could not be resuscitated and died. our patient developed pris after propofol infusion was off for 12 hours. she had many risk factors for developing pris, including high dose of propofol, critical illness, malnutrition, and use of vasopressors. pris can occur after propofol infusion has been stopped, and should be monitored for after the infusion has been discontinued in patients that are at increased risk. subdural hemorrhage (sdh) is a common cause of morbidity. we sought to study the impact of antithrombotic drugs on nontraumatic sdh. we retrospectively reviewed medical records of 1,211 patients admitted at massachusetts general hospital for sdh during 2017 to 2018 based on a research patient data registry. there were 78 patients without history of head trauma included in the analysis. baseline demographic and clinical characteristic data were collected. the outcomes including gcs, modified rankin scale (mrs), sdh size, sdh expansion, surgical evacuation, mortality rates, length of stay (los), bleeding and thromboembolic complications were compared between two groups. multivariate logistic regression was performed to analyze association between poor outcome (mrs 3-6) and all potential predictors (age, diabetes, conditional variable regression method was used because of relatively small sample size to avoid overfitting the model. among 78 patients included, 47 (60.3%) were on antithrombotic agents, either antiplatelets or anticoagulants, at presentation and 31 (39.7%) were not. anticoagulant and antiplatelet agents constitute 25.6% and 19.2% of nontraumatic sdh, respectively. all antithrombotic agents were discontinued on admission. nontraumatic sdh patients who were on antithrombotic agents had longer los (6.82 ± 2.94, p=0.023), higher rate of sdh expansion (or 3.85; 95%ci 1.26-11.78; p=0.025), higher rate of disability at discharge (mrs 3-6) compared to no antithrombotic group (or 12.38; 95%ci 2.5-61.05; p<0.001). on multivariate logistic regression analysis, antithombotic group had higher rate of poor outcome than no antithrombotic group (or 12.38; 95%ci 2.5-61.05%; p=0.002). use of antithrombotic agents prior to admission in nontraumatic sdh patients correlates with longer los, higher sdh expansion and increased disability at discharge. maintaining goal sodium levels in the neurocritical care population can be challenging. historically, at our institution, the supplementation of enteral sodium occurred by addition of table salt to tube feeding formulas by our dietary team. to make this therapy easier to standardize, monitor, and titrate, a new process was developed. continuous 5% hypertonic sodium chloride solutions are now administered enterally via feeding tubes. this also allows for the charting of the medication and immediate dose titrations. this pre-post analysis includes patients admitted six months prior to the implementation of the new enteral sodium process compared to patients admitted within one year after the new process change. demographic variables, as well as the indication for sodium goals, initial sodium levels, sodium level for 96-hours post-addition of enteral sodium supplementations, concomitant use of intravenous hypertonic saline, and achievability of goal sodium levels were collected. descriptive analytics were performed to compare groups. a total of 92 patients were included in the analysis: 51 in the pre-implementation group and 41 in the post-implementation group. the most common indication for goal sodium levels in both groups was traumatic brain injury with head bleed; 43 patients (84%) in the pre-implementation group and 27 (66%) in the post-implementation group. ability to maintain serum sodium concentrations (defined as the ability to maintain goal sodium without the need for intravenous hypertonic saline for >24h) within goal in the pre-implementation group was successful in 67% of patients (n=34) compared with 76% (n=31) in the post-implementation group. the use of continuous enteral 5% hypertonic sodium chloride solutions to target and maintain goal sodium levels provided similar efficacy compared to the addition of table salt to tube feeding formulas and is safer and easier to monitor and titrate. coagulation factor xa (recombinant), inactivated-xa inhibitor associated life--factor prothrombin complex concentrate (pcc) was utilized offretrospective, single center, cohort study including adult intracranial hemorrhage patients who received discharge between efficacy (defined by international society on thrombosis and haemostasis criteria), thrombotic events, icu and hospital length of stay, and mortality. andexxa, coagulation factor xa (recombinant), inactivated-zhzo is indicated for patients treated with rivaroxaban and apixaban, when reversal of anticoagulation is needed due to life-threatening or indication. there is no available literature supporting the use of this drug in acute neurosurgical emergencies. we present our experience of patients treated with andexxa who required acute neurosurgical interventions as a life saving measure. patients were identified from may 2, 2018 to may 30, 2019 using an electronic database report identifying those who received andexxa and subsequent chart review at a single center quaternary care academic medical facility. factor xa inhibitor and time of dosing. patient 1 and 3 both had an external ventricular drain placed while in the emergency room. patient 1 suffered from a cerebral hemorrhage with hydrocephalus while patient 3 was found to have a primary ventricular hemorrhage with hydrocephalus. both were treated with four factor prothrombin complex concentrate (pcc) at an outside hospital. there were no bleeding complications during the procedures. two patients had a craniotomy performed. patient 2 was diagnosed with an acute subdural hemorrhage with worsening midline shift despite receiving pcc at the outside hospital. patient four had an acute-chronic subdural hemorrhage with midline shift but did not receive pcc. in both craniotomy cases, there were no bleeding complications. andexxa was used in four patients taking apixaban or rivaroxaban undergoing lifesaving neurosurgical procedures despite no the utilization of acute extracranial and intracranial stents for the treatment of cerebrovascular pathology is increasing. the optimal antiplatelet agent and dose in this population and the utility of platelet function testing is unclear. all patients from january 2015 to april 2019 who were hospitalized and received ticagrelor to maintain intracranial or carotid stent patency in which platelet function testing (verifynow) was utilized to guide dosing were collected. relevant demographic, clinical, platelet reactivity unit (pru), and ticagrelor administration data was collected and qualitative assessment of pru results was performed. data was collected on 104 patients and the maintenance doses utilized were 30, 45, 60 (most frequent) or 90 mg bid and loading doses of 120 mg or 180 mg. a total of 18 patients' doses were titrated in order to achieve the goal pru range (50-150). among patients given a dose of 120 mg 44% had a pru in the optimal range (50-150) as compared to 11% among patients given a dose of 180 mg. twice as many patients given a dose of 180 mg as compared to 120 mg (66% vs 31%) had a pru between 10-50. among the patients whose dose was titrated the average pru prior to dose escalation was 154, the average pru subsequent to dose escalation was 103, and the average pru prior to dose decrease was 21 and the range in 55% of cases and was between 10-150 in 77% of cases. the utilization of platelet function testing to guide dose titration of ticagrelor to a desired pru range is feasible. a major limitation of this study is the lack of patient outcomes related to thrombosis or bleeding. rivaroxaban. the efficacy and safety of andexanet alfa have been evaluated in the annexa-4 study, which excluded patients receiving prothrombin complex concentrate (pcc) within the 7 days preceding enrollment. however, there have been limited reports of patients receiving both pcc and andexanet alfa for oral factor xa inhibitor-associated major bleeding, without adverse effect. while thrombotic events were observed in 10% of annexa-4 patients, potential for additive risk when combining andexanet alfa and pcc is undefined. we describe a patient who received pcc followed by andexanet alfa for an apixaban-associated intracerebral hemorrhage, who subsequently suffered devastating embolic strokes. de-identified patient data were retrospectively collected from the electronic medical record a 74-year-old male presented with acute left-sided hemiplegia caused by a large right-sided temporal lobe intracerebral hemorrhage. the patient had a history of atrial fibrillation, for which he was anticoagulated on apixaban. the patient initially received intravenous (iv) pcc 50 units/kg for prevention of hematoma expansion. the following day, minimally expanded hemorrhage was observed on repeat imaging concurrent with a measured apixaban level of 138 ng/ml (reference range 41-321 ng/ml). as a result, high dose andexanet alfa was administered as an 800 mg iv bolus, followed by an iv infusion of 8 mg/minute for 120 minutes. over the next several days, the patient's neurologic exam supratentorial strokes, likely embolic in origin. unfortunately, the patient did not survive hospitalization. the combination of pcc and andexanet alfa may carry with it substantial thrombotic risk, and cannot be routinely recommended. targeted temperature management (ttm) is used for neurological protection in patients with neurological injury but shivering during ttm can reduce therapeutic effect by increasing oxygen consumption and metabolic rate. cisatracurium used to prevent shivering has a shorter half-life than vecuronium and is not affected by liver and renal function. the objective of this study was to compare the efficacy and safety between two neuromuscular blockers in order to determine the benefit of cisatracurium. we reviewed medical records of adult neurological intensive care unit (ncu) patients who received 1st, 2011 to may 31st, 2018. the efficacy between the two groups was confirmed by the presence of shivering and the recovery time of motor function. safety was determined by the incidence of bradycardia and hypotension, the duration of antibiotic use and the mortality rate after discontinuation of the neuromuscular blocker in ncu. recovery time of motor function was assessed using 'motor power' and 'glasgow coma scale (gcs)'. a total of 103 patients were included in the study: 53 patients in cisatracurium group and 50 patients in vecuronium group. the incidence of shivering was 18.0% and 18.9% (p = 0.910) in vecuronium and cisatracurium, respectively. the median recovery time of motor function was 7.0 [3.7-20.3], 1.7 [1.0-3.3] hours (p <0.001) based on the motor power score, 6.5 [3.7-23.5] hours and 1.7 [1.0-3.3] hours (p <0.001) based on the motor response score of gcs, respectively. the safety was not significantly different between the two groups. recovery time of motor function was significantly shorter in the cisatracurium group than in the vecuronium group and there was no significant difference in the others. this study identified the benefits of cisatracurium in ncu under ttm. amantadine and modafinil are neurostimulants that may improve or accelerate cognitive and functional recovery after a stroke. this systematic review describes amantadine and modafinil administration patterns post-stroke, evaluates their impact on cognitive and functional outcomes, and identifies the incidence of adverse drug effects. an investigator-initiated medline search identified all full-text english-language publications describing the administration of amantadine or modafinil post-stroke from inception through october 5, 2018. -stroke); intervention (amantadine or modafinil treatment); comparison (not required); outcomes (cognitive or functional recovery). amantadine and modafinil administration practices, cognitive and functional outcomes, and incidence of adverse drug effects were collected according to the preferred reporting items for systematic reviews and meta-analysis protocols (prisma-p) approach. quantitative analysis was not performed due to heterogeneity in the measures of clinical effectiveness. initially, 4,109 publications were identified. eight amantadine (73 patients) and 11 modafinil (114 patients) publications were included. only 6 (8%) amantadine patients and 20 (18%) modafinil patients received treatment during an acute hospitalization. time from stroke to amantadine initiation was 25 (11, 103.5) days and the initial dose was 150 (100-200) mg/day. time from stroke to modafinil initiation was 170 (17, 496) days and the initial dose was 150 (100-375) mg/day. under-responsiveness was the most common indication for neurostimulants (n=6/19 publications; 32%). thirty-eight unique measures of clinical effectiveness were reported. a positive response in at least one measure of clinical effectiveness was reported in 75% and 82% of amantadine and modafinil publications, respectively. visual hallucinations (amantadine) and excitability/agitation (modafinil) were the most common adverse effects. amantadine and modafinil may improve or accelerate cognitive and functional recovery post-stroke, but higher quality data are needed to confirm this conclusion, especially in the acute care setting. levetiracetam is an antiseizure medication that is used in neurocritical care (ncc) patients to prevent or treat seizures. behavioral adverse events (ade) are reported to occur in approximately 10% of patients taking levetiracetam; however, the incidence of these ades in ncc patients are unknown and may be exacerbated due to their unique cns pathology. the purpose of this study is to identify the incidence of levetiracetam-associated behavioral (lab) ades in ncc patients. adult ncc patients receiving levetiracetam, admitted between november 1, 2014 and october 31, 2018, and diagnosed with tbi, sah or ich, or cerebral infarction were included in this study. criteria for determination of lab ades included the following: 1) diagnosis codes for delirium, agitation, irritability, hostility, violent behavior, insomnia, anxiety, or depression during this hospital admit; 2) administration of an antipsychotic; 3) positive cam-icu; and/or 4) physical restraints. day of lab ade onset was determined by the start date of the antipsychotic or a positive cam-icu. there were 965 patients included in this study; 52% males, median admit gcs was 13. the most common neurological injuries were ich (31%) and tbi (29%). lab ades were identified in 456 (47%) patients. these were identified by diagnosis codes in 35% of patients, with delirium, depression, and agitation being most common; 20% received an antipsychotic, 12% had a positive cam-icu, 6% had restraints ordered, and 22% had more than one determining factor. lab ades were reported a median of 2 (range 0 -29) days after levetiracetam initiation. patients with tbi had the highest reported incidence of lab ades (51%). almost half (47%) of ncc patients that received levetiracetam experienced a behavioral ade, which was of levetiracetam use in ncc patients. the recommend the use of 50 units/kg of four--pcc) or rting lower dosing strategies of apcc. in 2014, a fixed, lowimplemented at our institution. the objective of this study was to evaluate the efficacy and safety of fixed, low-dose apcc this single-center, retrospective chart review included adult ich patients who received apcc for oral tcome was achievement of ich hemostasis. hemostasis was defined as no progression of hematoma on head ct within 48 hours post-apcc. safety outcomes included in-hospital mortality and incidence of thromboembolic event (vte) within 30 days post-apcc administration or up to the time of discharge, whichever came first. -four patients receiving apcc for reversal of factor xa inhibitor associated ich (26 traumatic and 28 spontaneous) were included for analysis. median age was 77 years; 63% of patients had a past medical history of atrial fibrillation and 50% were anticoagulated with apixaban. median apcc dose was 1941 units (1808-2028 units), with a median weight-based dose of 24 units/kg (21 -29 units/kg). hemostasis was achieved in 69% of all patients with ich (73% in patients with traumatic ich, and 64% of patients with spontaneous ich). mortality rate was 20% and vte incidence was 7%. of hemostasis in the majority of patients and a low incidence of vte. ally ill patients, yet the optimal monitoring method is unknown. the purpose of this study was to describe the correlation between aptt and anti-xa levels in patients receiving prophylactic sqa retrospective chart review of patients admitted 18 years were included if they received sq--xa level drawn within 24 hours of each other. aptt and anti-xa levels were then compared to determine correlation and descriptive analyses were performed. correlation was defined as normal aptt levels (23.9-34.7 seconds) paired with undetectable anti-xa levels (< 0.1 iu/ml), sub-therapeutic aptt (34.8-75.9 seconds) with sub-therapeutic anti-xa (0.1-0.29 seconds), therapeutic aptt (76-112 seconds) with therapeutic anti-xa (0.3-0.7 iu/ml), and supra-therapeutic aptt (>112 seconds) with supra-therapeutic anti-xa (>0.7 iu/ml) levels. a total of 43 patients and 52 paired levels were analyzed. the median time between paired aptt and anti-xa levels drawn was 4.8 hours, and 40.4% (21/52) of levels were drawn within 1 hour of each other. anti-xa levels were drawn at a median of 6.2 hours after the sqpaired levels correlated, while 42.8% (9/21) of levels drawn within 1 hour of each other correlated. a spearman's correlation coefficient of 0.32 (p=0.154) was found between aptt and anti-xa levels drawn within 1 hour of each other. a sub-therapeutic aptt with undetectable anti-xa was demonstrated in 42.9% of levels drawn within 1 hour of each other. the sqanti-xa levels. there was no significant correlation between aptt and anti-xa levels in patients who received sq--sqh monitoring method in the neurocritically ill population. the utilization of acute extracranial and intracranial stents for the treatment of cerebrovascular pathology is increasing. the optimal intravenous antiplatelet agent for short-term bridging of patients who are unable to tolerate or do not respond adequately to oral antiplatelet agents is unclear. cangrelor offers potential advantages over glycoprotein iib/iiia inhibitors because response can be readily measured using platelet function testing (verifynow) and it has superior pharmacokinetics including a rapid on-set of effect and rapid clearance. patients with intracranial or carotid artery stents who were administered cangrelor for bridging purposes when oral antiplatelet agents were not feasible were assessed. relevant demographic, clinical and procedural data as well as cangrelor dosing and platelet function testing data were collected. patients had carotid artery stents. the indications for bridging were acute gi bleeding, inability to tolerate oral medications due to severe nausea/vomiting and two patients had an inadequate response to initial oral ticagrelor dosing based on platelet function testing. the dose of cangrelor utilized for all patients was 0.75 mcg/kg/min and all patients were on a cangrelor infusion for less than 48 hours. platelet function testing (verifynow) was utilized to ensure adequate platelet inhibition and all patients demonstrated adequate inhibition on the prescribed dose. no stent thrombosis or bleeding was observed. cangrelor is a reasonable option when patients with intracranial or carotid stents necessitate an intravenous antiplatelet for bridging when oral antiplatelet medications are not feasible. current guidelines for the prevention and management of pain, agitation/sedation, delirium, immobility, and sleep disruption in adult intensive care unit (icu) patients recommend a multimodal analgesia-first strategy to minimize opioid and sedative requirements and encourage early mobilization. the purpose of this study was to evaluate the success of a stepwise multidisciplinary implementation of an analgesiafirst sedation pathway followed by introduction of an early mobility protocol in a neuroscience icu (nsicu). we retrospectively evaluated mechanically ventilated adult nsicu patients admitted to a single-center academic medical center. three-month time periods were evaluated at baseline (phase i), after implementation of the sedation pathway (phase ii), and after implementation of the early mobility protocol (phase iii). total of 156 patients were evaluated: phase i (n=67), phase ii (n=40), and phase iii (n=49). we observed a progressive decrease in propofol use during each phase (i, ii and iii) (median 2243.7 mg/day versus 2065.6 mg/day versus 1360.8 mg/day, respectively; p=0.04 between phase i and iii) and increased dexmedetomidine utilization (3% versus 10% versus 42.9% of patients, respectively; p<0.0001). opioidanalgesia requirements during mechanical ventilation were similar between groups. we observed a quicker time from admission to pt evaluation between phase ii and phase iii (median [iqr] of 8 days [6] [7] [8] [9] [10] [11] versus 3 days [2-4], respectively; p<0.0001). rehabilitation therapy was provided in 59.7%, 40%, and 81.6% of patients while admitted to the icu in phase i, ii, and iii, respectively (p=0.0003) and increased number of pt sessions provided per patient (median of 1 [0-2], 0 [0-3], and 8 [1-14] sessions/patient during each phase, respectively). no adverse events related to early mobility were observed. interdisciplinary coordination and communication is necessary for effective unit-based practice changes as education alone is insufficient. a multidisciplinary approach to goal-directed therapy targeting pain management and light sedation increased opportunity for early mobility. the use of opioids in the neuroscience intensive care unit offset the balance of analgesia and reliability in performing neurological exam. in lieu of the current opioid crisis, we describe our center experience about the use of ketamine as an alternative medication with opioid sparing/lowering effect. retrospective chart review of patients admitted to nsicu with severe brain injury between november 2018 to april 2019 were performed. patients were separated into two groups of twenty by randomization and matching, each receiving either ketamine or propofol infusion. data collected includes age, gender, diagnosis, comorbidities, duration of ketamine, propofol and morphine equivalent (me) opioid dose. statistical descriptive analysis and independent samples t-test analytical analysis were performed to determine the difference of opioid use between two groups using spss software. the range of ketamine used over the mean period of 3.15 (range 1-8) days was 2-15 mcg/kg/min, while that of propofol over the mean period of 3.25 (range 1-14) days was 10-75 mcg/kg/min. 12/20 (60%) and 11/20 (55%) patients in the ketamine and propofol group required opioids respectively. the cumulative and mean morphine equivalent (me) dose for the ketamine group was 1023.8mg and 51.5mg respectively, while on propofol, it was 1527.5mg and 763.8mg. results of independent t-test analysis showed a significant p-value of 0.033, indicating significant opioid dose reduction with ketamine. it is essential to recognize the effectiveness of ketamine as an opioid sparing/lowering agent with potential analgesic-sedative medication without significant side effects. introduction different indications. however, serious complications such as i -current pulmonary embolism in patients with a contraindication to unknown. this information would be needed to determine if opportunities for improvement exists. with approval from the local investigational review board (irb), during the period of 2013-2018 were identified from the interventional radiology department. only identified patient data was manually extracted via chart review to determine patient characteristics and a total of 128 patients met inclusion criteria.61.7% were male. the most common neurocritical care diagnosis were intracranial hemorrhage(48%), ischemic stroke (16%), central nervous system (cns) neoplasm (16%) and cns trauma (9%). 47.7% of patients had at least 1 venous thromboembolism (vte) was the most common indication (53%) followed by vte with contraindication for ac (27%), primary adjunctive treatment (13%) adjunctive prophylaxis (6%) and secondary adjunctive treatment (1%). in this single center study, to anticoagulation. andexanet alfa was approved in may 2018 for reversal of life-threatening hemorrhages for patients on anticoagulation with apixaban and rivaroxaban. since its approval the reversal of direct oral anticoagulant (doac) associated intracranial hemorrhages (ich) has been controversial. the objective of this study was to describe real world utilization of andexanet alfa at a large academic health system. we retrospectively reviewed patients who received andexanet alfa for an ich. patients were included if they received andexanet alfa from its time of approval to formulary through april 29, 2019. baseline demographics, anticoagulation and reversal information was collected. a neurointensivist reviewed all imaging. intracerebral hematoma expansion was defined as > 35% increase in hematoma volume. subdural (sd) and subarachnoid hemorrhage (sah) expansion was defined as > 35% increase in maximal hematoma diameter. thirteen patients received andexanet alfa for ich. nine patients had an intracerebral hematoma, 1 patient had an isolated intraventricular hemorrhage, 2 patients had sd, and 1 patient had a sah. the median age was 75 (iqr 71-83) and 46% of patients were male. six patients were receiving a doac for stroke prevention, and a majority of patients (77%) were taking apixaban. the median glasgow coma scale was 13 (iqr 13-15), and for patients with intracerebral hematomas the median ich score was 2 (iqr 1 -3). there was follow-up imaging available for 11 patients, and 1 patient had hematoma expansion. one patient died and another had interval surgery prior to repeat imaging. no patients had in hospital thromboembolic events up to 30 days. of the 13 patients, 46% of patients would have met exclusion criteria from the anexxa-4 trial. in this small sample of patients who received andexanet alfa for ich it appears hemostatic efficacy was achieved in a majority of patients with no thromboembolic events; however, larger trials are needed. lacosamide is a monotherapy or adjunctive therapy used for treatment of partial onset seizure that enhances slow inactivation of sodium channels. uncommonly reported adverse effects include pr interval prolongation, bradycardia, atrioventricular block, and ventricular tachyarrhythmias. an 82 year-old male with history of atrial fibrillation, hypertension and aortic valve replacement on warfarin presented with an acute subdural hematoma after feeling lightheaded and falling. the patient reported having multiple recent syncopal episodes. he received prothrombin complex concentrate and vitamin k for warfarin reversal with an initial inr of 4.0. he was started on levetiracetam and home medications of metoprolol and diltiazem were continued. the next evening, he had focal seizures, was given lorazepam and transferred back to the icu. he received lacosamide 300 mg iv loading dose, and within 10 minutes had a 63 second episode of asystole. his blood pressure remained stable and he did not lose a pulse. he was given atropine x 3 doses with no response therefore transcutaneous pacing was initiated. several minutes later, he became hypotensive and was started on isoproterenol and epinephrine infusions. ekg showed complete heart block. cardiology was consulted and placed a transvenous pacer. vasopressors were eventually weaned off however neuro exam remained poor. about a week later, family made the decision to transition to comfort measures and the patient passed away. lacosamide is an anticonvulsant primarily used for partial complex seizures. only a few cases of third degree atrioventricular block have been reported in the literature. this case of extreme atrioventricular bock with a lacosamide loading dose is not common, but a drug-drug interaction with metoprolol and diltiazem was suspected. prescribing lacosamide with beta-blockers or concomitant medications that prolong the pr interval should be done cautiously due to increased risk of atrioventricular block. tissue plasminogen activator (tpa) is currently the preferred agent for treatment of acute ischemic stroke. in about 7% of cases, patients will develop life threatening intracranial hemorrhage. currently the aha/asa guidelines and ncs guidelines recommend reversal of intravenous tpa with cryoprecipitate and platelet infusion. both society recommendations are based off low quality evidence and are given weak recommendations.theoretically, the mechanism of action of tranexamic acid (txa) makes it an appealing agent for reversal of tpa ; txa competitively inhibits activation of plasmin countering the mechanism of action of tpa. the purpose of this case report is to report and support usage of txa for reversal of thrombolysis with tpa. this is a patient case report in which an extensive review of the patient chart was conducted to provide an accurate history of events. extensive literature review was compiled to reflect current therapy guidelines and the off-label use of txa for reversal of tpa. year-old male presented to a tertiary care medical center with signs and symptoms of ischemic stroke symptomatic cerebellar hemorrhage. the delay in obtaining cryoprecipitate and platelet transfusion led the medical team to discuss alternative agents for the reversal of tpa. reversal with txa was discussed based on the medication's mechanism of action. txa 10 mg/kg (1000 mg) was prepared at bedside and administered over 20 minutes. repeat head ct showed no further progression of hemorrhage and there was an improvement in the patient's neurologic condition was noted hemorrhagic transformation following thrombolysis for ischemic stroke is a life threatening emergency. txa is an appealing option for reversal of tpa as it directly counters the mechanism of tpa and can be easily and quickly accessed. this case reports further strengthens and supports its usage. drug level monitoring is essential to optimize valproic acid (vpa) efficacy and minimize toxicity. total serum vpa levels of 50-100mcg/ml are recommended, though free drug is more precisely responsible for vpa's pharmacologic effect. the interpretation of total vpa levels is complicated by the drug's complex protein binding characteristics. the use of free serum vpa levels has garnered interest, though the therapeutic range is not well defined. little is known about the relationship between free vpa levels and toxicity. we present a novel and unambiguous case of hepatotoxicity associated with elevated free vpa levels. de-identified patient data were retrospectively collected from the electronic medical record a 36-year-old male with a past medical history of refractory epilepsy was hospitalized for generalized tonic-clonic seizures. his prior home antiepileptic drugs (aeds) included carbamazepine and the vpa precursor divalproex. the patient's total and free vpa levels upon admission were 48.6mcg/ml and 4.9mcg/ml (laboratory reference range 2normal. the patient's home divalproex er dose was increased from 1000mg twice daily to vpa suspension 1250mg twice daily for his low total vpa level. on hospital day (hd) 3, the patient had a therapeutic total vpa level of 77.3mcg/ml, but an elevated free vpa level of 23.2mcg/ml in the setting concurrent with a free vpa level of 25.9mcg/ml. the patient's vpa was then transitioned to alternative aeds due to hepatotoxicity concerns. the patient's clinical status later improved, and he was discharged probability scale implicated vpa as the probable cause of hepatotoxicity in this patient. measurement of free vpa levels helps guide dosing decisions and may reduce drug-related toxicity. limited case reports of osmotic demyelination syndrome (ods) treated with intravenous immunoglobulin (ivig) with or without plasma exchange (pe) are published, demonstrating variable neurologic recovery. the combination of ivig and pe led to complete neurologic recovery of our ods patient. electronic chart review to collect data for this case report. 21-year-old male presented with asymptomatic serum sodium of 96 meq/l in the setting of intractable vomiting and decreased oral intake secondary to small bowel obstruction. his sodium was overcorrected by 21 meq/l within first 24 hours. he subsequently developed altered mental status with lethargy and became unresponsive on day 7 with flaccid quadriparesis and minimal motor response to noxious stimuli. mri of brain revealed osmotic demyelination of central pons and bilateral basal ganglia. ivig was initiated on the day when ods was confirmed on mri. his serum sodium normalized. after 4day course of ivig 2 g/kg, he could intermittently track with eyes but did not recover motor function. plasma exchange was initiated 4 days after ivig. after 2 sessions of pe, he started to move his right upper extremity antigravity and was attempting to verbalize. after 6 sessions of pe, he moved all 4 extremities antigravity, could talk although he had staccato speech and was able to ambulate with assistance. after 8 sessions of pe, he was ambulating independently; his motor strength was 4+/5 throughout. he was cognitively intact. at one month follow up in the clinic, he was neurologically completely intact, except for minimal upper extremity intention tremor. ivig with plasma exchange led to the remarkable neurologic recovery of a patient with ods. a randomized control trial comparing ivig monotherapy versus pe monotherapy versus the combination of ivig and pe is warranted to better clarify the appropriate treatment protocol in ods patients. digoxin is a commonly used drug in the treatment of heart failure patients but with no intrathecal indication. we describe a rare case of accidental intrathecal administration of digoxin during an elective caesarian section that lead to severe neurological deficits. a 34-year-old hispanic female underwent elective caesarian section with 2 separate attempts at regional spinal anesthesia with bupivacaine due to failure of achieving adequate anesthesia with the first injection. risk management discovered that patient had erroneously received digoxin as the initial injection, confirmed by therapeutic serum levels of digoxin. two hours after delivering a healthy child, the patient's mental status deteriorated and she became unresponsive. she had three witnessed generalized tonic-clonic seizures and was emergently intubated for airway protection and received keppra. twenty-four hours in, patient remained comatose, continuous electroencephalogram revealed no seizures, magnetic resonance imaging (mri) brain showed diffuse, patchy hyperintensities involving bilateral frontotemporal lobes and basal ganglia. mri spine showed extensive cervical and thoracic cord edema. cerebrospinal fluid analysis showed 476 white blood cells and protein count of 211. she received solumedrol 1000 milligram intravenous for 5 doses followed by 5-day course of intravenous immunoglobulin (ivig). eleven days in, she was extubated. at discharge, she had intact upper extremity strength, intact speech, with no sensation or motor response below t10 level. mri showed mild thoracic cord edema. at 90 day follow up, she had intact mental status and minimal improvement in motor strength and sensation below t10. this is an extremely sad case of severe neurological deficits resulting from a grave medical error. there are only 2 previously reported cases of intrathecal administration of digoxin in literature but the mri findings, duration of symptoms and neurological deficits were far more severe in our patient. neither cases reported use of high dose steroids or ivig either. neurological complications following organ transplantation can be a result of a myriad of infectious, toxic-metabolic, vascular and iatrogenic causes. given the wide range of possibilities, accurate diagnosis can be challenging. we present a case of acute hyperammonemia complicating renal transplantation. a 56-year-old female with a remote left mca stroke was evaluated for progressively worsening lethargy that started approximately a week after she had undergone deceased donor renal transplantation. her immunosuppression comprised induction with alemtuzumab plus methylprednisolone with long-term mycophenolate mofetil plus tacrolimus, and antibiotic coverage included valganciclovir, trimethoprimsulfamethoxazole and fluconazole. progressive deterioration in the level of consciousness progressing to coma with absent cough, gag reflex, sluggish pupils and no motor response resulted in the patient being intubated. neurological examination did not reveal any focal deficits besides her pre-existing right hemiparesis. pertinent investigations included an mri brain that showed no acute changes, eeg suggestive of triphasic waves and serial lumbar punctures showing elevated pressures in the 45-55 cm h2o range. level of 889 umol/l. in addition to appropriate pharmacotherapy and dietary protein restriction, the patient underwent continuous venoher mentation to baseline. additional investigations done to determine the etiology of the hyperammonemia showed the patient to be infected with ureaplasma urealyticum which was treated successfully with doxycycline and moxifloxacin. to our knowledge, this is the first report of ureaplasma urealyticum infection resulting in hyperammonemia fo management of hyperammonemia. in the absence of hepatic impairment, alternate etiologies of hyperammonemia should be sought. acute hyperammonemia requires prompt evaluation and treatment to reduce the mortality and morbidity associated with it. prevalence, characteristics, and outcomes related to ventilator associated events (vae) in neurocritically ill patients is unknown, and explored in this study. a retrospective study was conducted to examine prevalence, factors, and outcomes of patients with vae admitted to the neurocritical care service at harborview medical center between january 1, 2014 and december 31, 2018. chi-square test, analysis of variance was used to compare patients by vae status. amongst 855 neurocritically ill patients, 132 vaes occurred in 129 (15.1%) patients. most common vae was ventilator associated condition, vac, 73(55.3%), followed by infection related vac (ivac), 32(24.2%), and possible ventilator associated pneumonia (pvap), 27(20.5%). most common trigger for vae was an increase in positive end-expiratory pressure (peep). age (median 56[iqr 31], male sex (61%), and bmi (26.7%) were comparable across groups with and without vaes. patients with vae experienced higher intracranial pressures than those without vae(33.5 mmhg vs. 23 mmhg, p < 0.0001). compared to patients without any vae, patients with any vae spent longer time on mechanical ventilation (17.4 vs. 7.9 days, p < 0.001), and in the intensive care unit (16.5 vs.10 days, p < 0.001). mortality (34.1% vs. 31.3%), median hospital length of stay (26.5 vs 21 days) and discharge to home (12.8% vs. 16.3%) were similar across both groups. ventilator associated events are prevalent amongst the neurocritically ill. they are commonly triggered by changes in peep, and are associated with intracranial hypertension, increase length of mechanical ventilation and intensive care unit stay but may not affect mor associated with vae in subgroups of neurocritically ill patients and their impact on clinical outcomes warrants further examination. synthetic cannabinoids (sc) are a heterogeneous group of compounds initially developed to study the endogenous cannabinoid system. most sc interact with cb1 and cb2 receptors with much higher affinity -tetrahydrocannabinol. the popularity of sc is increasing in adolescents and young adults because of the ability to produce a marijuana-like high without being detected on routine drug screens. we hereby present a case of sc related status epilepticus, hypoxic respiratory failure, severe acute kidney injury (aki) and cerebral edema with fatal outcome. 19-year-old man with suspected sc adulteration of cbd oil presented with headache and status epilepticus. labs showed leukocytosis, triple acidosis, and tetrahydrocannabinol in urine. ct head showed diffuse cerebral edema with sulcal subarachnoid hemorrhage. intracranial pressure was elevated to 25-30 mmhg. hospital course was complicated by severe and refractory metabolic acidosis into hospitalization patient suffered cardiac arrest from pulseless ventricular tachycardia secondary to severe acidosis and metabolic derangements. after multiple attempts of resuscitation, care was withdrawn, and patient passed away. in this case, severe refractory metabolic acidosis proved to be fatal. this case highlights the many challenges in managing a critically ill patient with cerebral edema and renal failure with medically refractory metabolic acidosis. sc are undetectable on routine drug screens and exposure is difficult to establish. sc can lead to multi-organ failure and death that may result from cardiovascular events, respiratory depression, pulmonary complications, and aki. a high clinical suspicion is warranted in atrisk patients. exposure to sc may lead to cardiovascular, cerebral and renal complications that respond poorly to devise appropriate therapeutic strategies in managing such patients. benzodiazepines are the standard medication class for treating alcohol withdrawal symptoms (aws). in acute brain injury benzodiazepines may worsen delirium and its central nervous system (cns) depressant effects may decrease level of consciousness and make the neurological-exam unreliable. barbiturates have similar actions to benzodiazepines on gaba receptors and cause less cns depression. we present our center's experience with the use of phenobarbital in patients with aws and acute brain injury. retrospective chart review of twenty patients admitted in neuroscience intensive care unit(nsicu)with acute brain injury and aws was done. treatment protocol consisted of 10mg/kg ideal body weight(ibw) of phenobarbital loading dose divided into three intramuscular doses three hours apart, followed by a tapering daily oral maintenance dose for total of seven days. alcohol withdrawal symptoms were assessed using the ciwa score for severity. serum phenobarbital levels were drawn five hours after the third intramuscular dose. liver function tests were performed before loading dose and daily for -times the upper limit of normal triggered protocol discontinuation. none of the patients developed alcohol withdrawal seizures, one patient developed severe transaminitis. loading doses of phenobarbital did not cause hypotension. systemic toxicity was absent and phenobarbital serum levels drawn after the loading doses ranged between 6.0-26.7mcg/ml (normal range 10-30mcg/ml). patients decreased their ciwa score after the loading doses of phenobarbital suggesting improvement of withdrawal symptoms and there was decreased use of adjunctive medications (benzodiazepines) for management of aws. nine patients required adjunctive benzodiazepines and received 4mg or less of lorazepam. phenobarbital for management of aws was associated with minimal adverse effects and did not lead to systemic toxicity. phenobarbital can be used in patients with acute brain injury without exacerbating delirium and can decrease the need for adjunctive benzodiazepines. aneurysmal subarachnoid hemorrhage (asah) has a case fatality rate of up to 70% in patient that rebleed. cerebral arterial vasospasm (vsp) after asah is a leading reason for death and disability. nicardipine is used to treat hypertension and angina, and has been investigate for a potential use in the treatment of vsp after asah. intraventricular nicardine was used for treatment of severe asah after traditional methods failed (ie. ir, hypervolemia, permissive hypertension and intravenous inotropes). 4mg of nicardipine was mixed with preservative free saline by pharmacy to total 8ml in volume. 8ml of cerebral spinal flu drawn from the patient external ventricular device (evd). then the nicardipine solution was instilled and the evd was clamped for 60 minutes. patient had transcranial dopplers (tcds) prior to injection and 2 hours after injection and reopening of the evd. patient's vasospam temporized and neuro exam returned to pre spasm baseline. patient survived vasospam window and was transferred to long term care facility. in neuroscience icu (nsicu) maintaining balance between performing reliable neurological exam with adequate analgesia without causing significant sedation is challenging. ketamine has significant neuroprotective and anti-seizure properties. in spite of these unique neuro-friendly pharmacological profile, it's role in nsicu unit is not well defined. we describe our experience about the use of ketamine in neuro-critical care unit. retrospective chart review of patients admitted to nsicu in whom ketamine was used as first line agent for sedation and analgesia in intubated patients with varied brain injury from january 1 to april 30 2019 was performed. safety parameters collected includes blood pressure changes, intracranial pressure changes, heart rate, arrhythmias, excess secretions and apneic spells. pco2 was monitored and hypercarbia was avoided. effectiveness was measured by requirement of additional sedation-analgesic medications while receiving ketamine. twenty patients with varied brain injury who were on ketamine infusion as first line agent were selected. mean age was 62.9 years (range 22-88 years) and 12 patients were male. admitting diagnosis was hemorrhagic stroke (40%), ischemic stroke (40%), seizures (10%), carotid stenosis (5%) and tumor mass (5%). mean duration of ketamine infusion was 3.15 days (range 1-8 days) and dose range was 2-15 mcg/kg/min. no icp elevation was noted among the 5 patients where the icp was monitored. none of the patients had uncontrollable elevated blood pressures nor major fluctuation in heart rate or respiratory rate requiring discontinuation of ketamine. 13 (65%) patients had increased secretions without respiratory compromise. opioid use decreased significantly moreover additional sedation was not required while on ketamine infusion. ketamine is a safe and effective sedative-analgesic in neuro-critical care patients while at the same time allow for a reliable neurological examination to perform while on sedation. more research is warranted before it could be considered as the standard of care. oromandibular dystonia (omd) is a movement disorder characterized by involuntary, sustained muscle contractions of varying severity resulting in sustained spasms of craniopharyngeal muscles affecting the jaws, tongue, face, and pharynx that can lead to abnormal jaw opening or closing or tongue protrusion.1 these disorders are often treated with botulinum for improvement of symptoms. there is minimal literature related to omd treated for botulinum in the neurocritically ill patient population. we conducted a retrospective electronic medical record review from 2011-2018 of all brain-injured patients admitted to our neurocritical care unit who were diagnosed with omd and received botulinum toxin injections. etiology and location of brain injury along with clinical characteristics including resolution of symptoms were recorded. over a 7-year period, we injected 9 patients with botulinum type a injection (100 mouse units or m.u.) into bilateral masseter muscles for severe omd causing tongue biting/maceration and difficulty with oral care, and refractory to antispasmodics and muscle relaxant medications. among the 9 patients, 6 patients were sah, 1 patient with ich/ivh, 1 patient with bilateral brain injury after post pituitary neurosurgical procedure and 1 patient with diffuse bilateral ischemic stroke related to sickle cell disease. all patients tolerated the procedure with no immediate complications. all patients had gradual improvement of omd albeit variable and only 1 out of 10 patients required a 2nd treatment. in this small series, injection of botulinum toxin for severe omd from brain injury causing tongue injury appears to be safe, tolerable, and efficacious in reducing enteral antispasmodics/muscle relaxants. no short-term or long-term adverse effects were noted and it helped nursing with oral care over time. larger randomized controlled trials should be performed to evaluate the effectiveness and safety of treatment with botulinum in the critically ill neurologic population. the neurosurgical intensive care unit (nsicu), a level 1 trauma center in san antonio, cares for neuro critical patients. the use of central access catheters is essential for hypertonic fluid administration, vasoactive medications, and general critical care. in this unique population the risk of developing deep vein thrombosis (dvt) is higher compared to other patients due to reasons related to neurological injuries. the objective of this research was to determine the incidence and prevalence of dvt between the use of peripherally-inserted central catheters (picc) versus central venous catheters (cvc) in the nsicu. we prospectively evaluated 250 consecutive patients with a cvc or picc in the nsicu from 2017 to 2019. data was collected, by a team of apps on: surveillance vs non-surveillance ultrasounds, blood stream infections (clabsi), indwelling time, complications, and icu length of stay. a total of 97 piccs were placed for 786 catheter days, 9 patients were diagnosed with a dvt related to the catheter, rate of 1.1 per 100 catheter days. a total of 195 cvcs were placed for 924 catheter days, 3 patients were diagnosed with a dvt related to the cvc, rate of 0.3 per 100 catheter days. a total of 15 dvts were diagnosed, one symptomatic patient and remaining 14 dvts were identified during surveillance ultrasound. two complications were encountered during insertion of a cvc and picc which included development of hematoma on insertion of each catheter. the average length of stay for patients with a picc line was 11.22 days. the average length of stay for patients with cvc was 16 days. the nsicu surveillance ultrasounds identified more dvts with the use of picc lines versus cvc warranted if surveillance ultrasounds should be routinely performed for nsicu patients. mortality with acute respiratory distress syndrome (ards) is as high as 60% in patients with subarachnoid hemorrhage (sah). many of the therapeutic modalities of ards carry potential deleterious effects on icp. we are presenting a challenging case of severe ards and sah. single case report. 63-year-old male who developed a sudden severe headache. emergent workup revealed a large cerebellar hemorrhage, sah with ivh and hydrocephalus secondary to a ruptured arteriovenous malformation (avm). emergent suboccipital decompressive craniectomy followed by external ventricular drain (evd) placement were performed and transferred to our facility for further aggressive care. hospital course was complicated by severe pseudomonas pneumonia with progression to severe ventilation strategies, sedation, paralysis and inhaled nitric oxide (ino) failed to correct hypoxia. on hospital day (hd) 12 he continued to show refractory hypoxia and was placed on roto-prone® bed. continuous intracranial pressure (icp) monitoring was utilized with evd open at 5cmh2o. prone positioning was attempted for 16 hours daily. hypercarbia during prone positioning lead to elevated icp patient showed improvement of hypoxia, with termination of prone positioning and subsequent weaning of paralytics and sedation. he started following commands and was discharged to a long term care facility after avm embolization, placement of a tracheostomy, feeding tube and ventriculoperitoneal shunt. our patient made remarkable recovery from ards in the settings of obstructive hydrocephalus and sah. strict icp monitoring, ongoing ventilator adjustment and careful utilization of kinetic maneuvers for ards, including prone positioning, contributed. proning may be a consideration in patients with sah, obstructive hydrocephalus and ards with ongoing icp monitoring and ventilator adjustment, but larger scale studies are needed to explore its potential. paroxysmal sympathetic hyperactivity (psh) has been associated with worse outcomes following traumatic brain injury, possibly representing both a marker of injury severity and a source of secondary injury. prior studies suggest that psh is under-recognized and its treatment often delayed. the identification of admission risk factors for psh may facilitate earlier recognition, treatment, and targeted prevention. adults with severe tbi admitted to a neurotrauma icu for at least 72 hours and hospitalized for at least 14 days between january 2016 and december 2018 were retrospectively identified. consecutive psh-tbi patients (n=80) were identified via review of medication administration records as having been treated with propranolol and/or bromocriptine for at least 72 hours. control-tbi patients (n=160) were matched to the psh-tbi cohort for age (36+/-14 years) and gcs (median 7 (3,8) ). admission head cts were scored using marshall and rotterdam criteria. independent-samples t-tests, chi-squared, and multivariate analyses of variance were performed. age-matched cohorts did not differ by sex, race, bmi, trauma type, trauma mechanism, iss, or triss. icu admission vital signs differed between groups with psh-tbi demonstrating a higher hr (p=0.04) and a trend towards higher sbp (p=0.09), but no difference in core body temperature. neuroradiographic features associated with psh included significantly higher rotterdam ct score (p=0.01), presence of ivh/sah (p=0.02), basal cistern compression (p=0.04), and trends toward higher marshall ct score (p=0.07), presence of epidural hematoma (p=0.1), and ct dai (p=0.08). a multivariate analysis adjusting for admission gcs and sbp identified rotterdam score (p=0.003), presence of ct dai (p=0.09), and icu admission hr (p=0.03) as independent predictors of psh. admission ct findings along with hr may help predict subsequent development of psh requiring treatment. early identification, treatment, and prevention of psh may mitigate its negative impact on tbi outcomes. hyperchloremia in patients receiving chloride-containing solutions can contribute to metabolic acidosis and acute kidney injury (aki), and has been associated with increased inpatient mortality, length of stay and aki in patients with spontaneous intracranial hemorrhage. whether hyperchloremia is a risk factor for mortality in patients with traumatic brain injury (tbi) is unknown. the purpose of this study is to determine if patients that develop moderate hyperchloremia while receiving continuous hypertonic saline (hts) have a higher risk of inpatient mortality. this was a retrospective chart review of patients admitted between january 2016 and september 2018. included patients were over 16 years old, admitted to the trauma service with a diagnosis of tbi, and received continuous 3% hts for at least 12 hours for the management of cerebral edema. exclusion criteria were baseline end stage renal disease or hemodialysis, transition to comfort measures within 48 hours or inconsistent documentation. the primary objective was inpatient mortality. secondary objectives were aki, hospital and intensive care unit (icu) length of stay. after tbi, mortality was higher in patients who experienced hyperchloremia, while aki and length of stay were similar. although randomized controlled trials (rcts) did not prove benefits of hypothermia for severe traumatic brain injury (tbi), brain ct images have not been evaluated in detail in these studies. we aimed to explore the prognostic value of brain ct findings in bhypo study. bhypo study was a multicenter rct to investigate the effect of therapeutic hypothermia in patients with severe tbi. the protocol included collection of brain ct data on admission and around day 7. using the ct database, we evaluated following findings: presence of intracranial lesion (acute subdural hematoma: asdh, acute epidural hematoma, cerebral contusion, subarachnoid hemorrhage: sah, or intraventricular hemorrhage: ivh), basal cistern compression, lesion laterality, marshall ct classification, and rotterdam ct score. hematoma thickness and midline shift were also measured. unfavorable outcomes were defined gos of 1 to 3 by glasgow outcome scale (gos) assessed at 3 months. ct data were obtained from 125 patients on admission and 110 patients around day 7. there were no differences in ct findings between hypothermia group and fever control group. in the initial ct, univariate analysis showed that odds ratio (or) and 95% confidence interval (ci) for unfavorable outcomes were: shift > hematoma thickness (6.0, 1.6-23.5: p=0.0053), sah (3.7, 1.7-8.3, p=0.001), sah or ivh (3.0, 1.2-7.6, p=0.0148), absent cistern (2.9, 1.3-6.6; p=0.0077), and midline shift > 5mm (2.3, 1.1-4.9, p=0.0219). rotterdam score was significantly higher in patients with unfavorable outcome (3.7 vs. 4.5, p<0.001). regarding the day 7 ct, bilateral lesion (8.5, 3.4-21.5, p<0.001) and sah or ivh (3.3, 1.5-7.2, p=0.0025) were significant. no patients with absent cistern survived. patients were appropriately assigned in bhypo study in terms of ct findings. shift > thickness, sah, absent cistern, and rotterdam score were powerful prognosticator in severe tbi patients undergoing targeted temperature management. cerebral edema (ce) following traumatic brain injury (tbi) causes secondary injury and increased mortality. yet, conventional measurements of ce on head computed tomography (ct) inadequately accounts for ce. serial volumetrics may facilitate estimation of total brain volume. the objective of this study was to measure the reliability of this technique and identify a threshold for brain volume (bv) change which could be indicative of ce. a subset of patients (n = 18) with intracranial hemorrhage on admission ct were identified from a prospectively enrolled cohort of subjects with trauma sufficient to warrant icu admission. using medical image processing, analysis, and visualization (mipav), two independent raters calculated bv on admission and follow-up head ct scans by measuring the volume of the intracranial vault and the absolute difference (ml^3) and percent difference between the bv values of the two scans were calculated. intraclass correlation (icc) and pearson's correlations were calculated, and significance set at 0.05. the overall reliability of bv measurements between raters was excellent (initial scan icc 0. volumetric analysis to estimate bv appears to be a reliable technique across serial head ct scans. bv changes of more than 3.1% may represent a clinically significant threshold and should be further investigated. beneficial effects of therapeutic hypothermia in adults with traumatic brain injuries are controversial. we wanted to study the effect of therapeutic hypothermia (th) on outcomes after severe traumatic brain injury (tbi) in real practice using the nationwide inpatient sample in the united states. the nationwide inpatient sample was used to obtain data on all adults who had been discharged from 2005 to 2014 with a primary diagnosis of tbi who required mechanical ventilation, intracranial pressure monitoring, or craniotomy/craniectomy. the patients with th were assigned to the th group, and the rest were assigned to the control group. the primary outcome was in-hospital mortality, and the secondary outcomes included mean the length of stay, non-routine hospital discharge, mean hospital charges. only 722 patients (0.15%) out of a total of 488,231 underwent th. th group was younger (40.2 versus 54.6 years, p <.0001),had a lower proportion of females (17.8% versus 28.5%, p= 0.05) and a higher rate of in-hopsital complication of deep venous thrombosis (8.5% versus 2.0% p = 0.0098). when controlling for age, gender, comorbidities, in-hospital complications, hospital characteristics and disease severity, th was associated with an increased rate of in-hospital mortality (odds ratio, 1.71;95% confidence interval, 1.08-2.70), longer mean length of stay (24.0 vs. 11.8 days; p<0.001), and greater mean total hospital cost ($371,940vs. $134,823; p<0.001). there was no difference between the two groups in terms of non-routine discharge (odds ratio, 1.61; 95% confidence interval, 0.65-3.97), therapeutic hypothermia was associated with poorer outcomes in patients with severe tbi. our findings disfavor therapeutic hypothermia in severe tbi in routine clinical practice. it warrants further investigation in a prospective, randomized study. a rising incidence of subdural hematomas (sdh) has been attributed in part to increased use of anticoagulants and antiplatelets. anticoagulants also worsen the severity and prognosis of sdhs, but the impact of antiplatelets on prognosis is unclear. we hypothesized that antiplatelets would not affect sdh severity or outcome, while anticoagulants would be associated with more severe features and a worse functional outcome. we systematically identified and collected data on patients presenting with a new diagnosis of sdh in 2018 at a level i trauma center. we examined common markers of sdh severity in three cohorts of patients: those not on any antithrombotics, those on antiplatelets alone, and those on anticoagulants. categorical data was compared with chi-squared tests, and continuous data was compared with mann-whitney u tests. multivariable logistic regression was used to assess the impact of antiplatelet use on functional outcome at discharge, with a poor functional outcome defined as a score of 3-6 on the modified rankin scale. we identified 441 patients with a new sdh during 2018: 224 (50.8%) did not take antithrombotics, 141 (32%) took antiplatelets, and 76 (17.2%) took anticoagulants. antiplatelets were not associated with increased sdh volume, thickness, or midline shift; anticoagulants were associated with increased volume (p<0.001), thickness (p<0.001), and a trend towards increased midline shift (p=0.08). antiplatelets were associated with a better admission score on the glasgow coma scale (p<0.001). when adjusted for age and gender, antiplatelets did not affect functional outcome (or 0.84, p 0.53, 95% ci 0.48-1.44), while anticoagulants were associated with poorer functional outcome (or 2.83, p 0.008, 95% ci 1.35-6.4). despite its known association with overall sdh incidence, premorbid antiplatelet use was not associated with sdh severity or a worse functional outcome at a level 1 trauma center. the common data elements therapeutic intensity level (cde-til) score, quantifies the intensity of nursing and medical care aimed at preventing intracranial hypertension for patients with severe traumatic brain injury. we validated the cde til in our neurotrauma intensive care unit (nticu) and found the cde-til to be highly reflective of perceived and measured therapeutic burden but noted that the scale had a ceiling effect. specifically when icp was 20-25 mmhg and higher, the cde-til did not capture the escalating burden. in an attempt to eliminate that ceiling effect and to incorporate current h til (p-til). under a quality assurance approved protocol, retrospective chart review was performed on 22 adult patients with severe tbi. the til score was derived using both the cde-til and the p-til for each 12 hour nursing shift for the first 5 full days of admission. the relationship between the cde-til and p-til and the icp were investigated. reliability testing of the p-til, including interrater reliability, and validation of the p-til are ongoing. the p-til and the cde-til are highly correlated (r=0.71) and the relationship between the scores and the maximum icp are similar at icp less than 20mmhg. at higher icps however, the slope of p-til increases to 0.18 compared to the cde-til slope of 0.07 and illustrates a 2.5 times stronger correlation between the intensity of care level as measured by p-til and icp. the p-til has greater sensitivity for quantifying the intensity of therapy aimed at controlling icps, most significantly for patients with the highest icps, icps 20-25mmhg and above, making it an ideal scoring system for communicating current nursing and medical needs of individual tbi patients as well as potentially predicting post-intensive care or post-discharge needs. patients are frequently brought into neurologic intensive care units in cervical spine immobilization after sustaining ground level falls or after being "found down." currently there is no consensus regarding cervical spine clearance in these patients as they are unable to participate in neurologic examination. after normal ct scans, mri scans are frequently employed to evaluate for ligamentous injury and radiographic signs of cervical instability. we conducted a retrospective chart review of patients who were admitted to the neurologic intensive care unit between 2017 and 2018 in cervical collars after ground level falls or after being found down (presumed ground level falls). patients were included in the study if they were obtunded on admission (gcs<15) with neurologic exams consistent with their cranial pathology. all patients underwent a high definition ct cervical spine or cta of the neck and were cleared if there was no radiographic evidence of fracture or instability. between 2017-2018, eight patients were admitted to the neurologic intensive care unit that met inclusion criteria. average age at presentation was 75.75 years. cranial pathology on presentation included intraparenchymal hemorrhage, ischemic stroke, and subdural hemorrhage. all patients underwent a high definition ct cervical spine or cta neck which showed degenerative changes without fractures, subluxations or other evidence of instability such as increased atlantodental interval, or prevertebral soft tissue swelling. average follow up was 129.75 days range (1-406). there were no cases of cleared patients that suffered secondary neurologic injury or symptoms of cervical instability during the follow up period. our study illustrates that obtunded patients after ground level falls can safely be cleared of cervical spine precautions after a high definition ct cervical spine fails to demonstrate fractures, subluxations, or other evidence of cervical instability. this protocol limits the costs associated with mri scans and the risks associated with cervical immobilization. the elderly comprise the highest incidence of traumatic brain injury (tbi) hospitalizations and death, yet most tbi studies neglect the geriatric population. previous studies suggest women have better outcomes after tbi but are inconclusive. we examined differences in outcomes between sexes after tbi in the geriatric population. this is an observational study of patients 60 and older admitted with tbi to a level 1 trauma center. clinical variables including medical history, severity of injury (gcs>12, gcs9-12, and gcs<9), mechanism of injury, and ct findings were collected. good clinical outcomes were defined as a gose >4 and measured at discharge and 6 months. the chianalysis were used where appropriate. 152 subjects were included in the analysis. 66(43%) women and 86(57%) men. average age was 72.5(sd 8.9) with no significant differences between sexes. 117(77%) were mild, 15(10%) moderate, and 20(13%) severe. the most common etiologies were mechanical fall 64(42%), motor vehicle accident 22(15%), and syncopal fall 21(13.8%). no differences in severity of injury or mechanism of injury were found. on admission ct, men had more contusions (40%v22%;p=0.04) and skull fractures(21%v45%;p,0.01) compared to women. older age, and history of atrial fibrillation or congestive heart failure were associated with increased incidence of death. men were more likely to have in-hospital mortality (13%v3%; p<0.01). in multivariable logistic regression analysis controlling for other factors associated with mortality, men were significantly more likely to have in-hospital death (or-14;p=0.01). at 6 months, men were still found to have higher mortality (or-12.4;p<0.01). however, there were no significant differences in good outcomes between sexes at discharge (39%v43%; p=0.65) or 6 months (50%v51%;p=1). men have significantly higher mortality rates compared to women in the geriatric tbi population. differences are needed. partial brain tissue oxygen tension (pbto2) can be regulated by the fraction of inspired oxygen and the level of oxygen carrying capacity. we performed a systematic review of the literature using pbto2directed treatment with red blood cell transfusion (rbct) to analyze clinical and physiological outcomes as well as adverse events following rbct. we performed a systematic review following the prisma guidelines and pre-registered with the prospero database. the following terms were used: [(brain tissue oxygen or brain tissue hypoxia or pbo2) and treatment] or [(brain tissue oxygen) or red blood cell transfusion) or pbo2) or traumatic brain injury) and red blood cell transfusion]. inclusion criteria were studies in which pbto2 was measured before and after rbct. the tool used for qualitative scoring was the grade score. risk of bias was assessed via rti and robins-i. a total of 2390 articles were screened of which four articles were included in the final analysis. the intervention performed was to administer 1 to 2 units of rbc depending on the hemoglobin level and the threshold set in each study. the clinical outcome was not described in any of the studies. there was an increase in pbto2 in all the studies, but it was primarily significant when pretransfusion pbto2 was less than 15 mmhg. the grade certainty rating for the included articles was low to moderate. our review shows that a significant increase in pbto2 is primarily seen when pre-transfusion pbto2 is less than 15 mmhg. clinical outcome and adverse events were not described in any of the included studies. in view of the known adverse effects of rbct in critically ill patients and the limited available literature we found, transfusion should only be reserved as a later tier measure for pbto2 correction, and possibly only when pbto2 is less than 15 mmhg. withdrawal of life-sustaining therapy (wlst) is associated with 70% of deaths after severe traumatic brain injury (tbi). wlst frequently occurs within the first 3 days of hospitalization, when prognosis is most uncertain. while patient factors play a role in the decision, institutional practice patterns and physician perception of prognosis also contribute, as demonstrated in canadian studies. we hypothesized that the rate and timing of wlst among patients with severe tbi vary across the united states. we conducted a retrospective cohort study of patients with severe tbi admitted in 2016 to 463 us trauma centers included in the trauma quality improvement program. severe, isolated tbi was defined by diagnosis code and glasgow coma scale (gcs) score <9. patients under 18, with severe non-head injuries, or with advanced directives were excluded. centers were grouped by us census region (northeast, midwest, west, south). multiple logistic regression for wlst was performed with region, patient demographics, gcs motor score, pupillary reactivity, and midline shift as covariates. regression -hospital mortality. variability may reflect inconsistent institutional practice patterns, regional cultural differences, and the difficulty of prognostication. more reliable and standardized prognostic assessments are needed in this population. introduction: pre-injury use of antiplatelet agents may increase hemorrhage size and hematoma expansion after traumatic brain injury (tbi). however, empiric platelet transfusions may result in significant morbidity and unnecessary expense and may not be justified. we sought to determine whether a thromboelastography (teg) platelet-mapping (pm) algorithm could safely reduce platelet transfusion without clinically relevant hematoma expansion. methods: a prospective standardized teg pm-based treatment algorithm was instituted to guide reversal of antiplatelet medications in tbi patients. the algorithm established reversal thresholds for arachadonic acid inhibition (aa-inhibition >50%) and adenosine diphosphate inhibition (adp-inhibition >60%). consecutive tbi patients were enrolled and compared to a historical cohort. hematoma volume was calculated by itk-snap. conclusions: a teg-guided antiplatelet reversal algorithm may significantly reduce platelet transfusions without clinically significant hemorrhage expansion. increasing partial oxygen arterial tension is one method to increase the partial brain tissue oxygen (pbto2). however the effects of hyperoxia on clinical outcomes and adverse effects remain elusive. to investigate the effects of normobaric and hyperbaric hyperoxia on pbto2 in patients with tbi, we performed a literature review following the prisma guidelines and pre-registered with the prospero database. the following search terms were applied: [(brain tissue oxygen or brain tissue hypoxia or pbo2) and treatment] or [(brain tissue oxygen) or brain tissue hypoxia) or pbo2) or traumatic brain injury) and hyperoxia]. prospective trials and observational cohort studies were included in this review. two reviewers assessed the risk of bias of each study using the rti item bank. a total of 2390 articles were screened, of which 16 articles were included. only one study investigated the effects of combined hyperbaric/normobaric hyperoxia and another used hyperbaric as a separate intervention; the majority of studies were of normobaric hyperoxia. overall, an increase in pbto2 was observed with both normobaric and hyperbaric. clinical outcome was mostly missing; one study showed an absolute reduction in mortality and improvement in favorable outcome using glasgow outcome score at 6 months. adverse events were also only scarcely reported; 3 studies showed that hyperoxia did not induce cerebral toxicity by using markers of oxidative stress, and one study showed no evidence of pulmonary oxygen toxicity in either the hyperbaric or normobaric hyperoxia groups. normobaric and hyperbaric hyperoxia consistently induced an increase in pbto2. improvement in clinical outcome was reported in some studies but did not reach statistical significance except in one. adverse events were not adequately investigated. larger prospective studies are required to investigate the clinical outcome effects of hyperoxia, its adverse consequences, and its role in the tiered approach towards brain tissue dysoxia. early prognostication, either from clinical and/or radiological information, is an important aspect in the settings of neurocritical care with limited resources. we sought to determine the values of two radiological scoring systems in predicting the outcome of traumatic brain injury (tbi) patients, which are marshall and rotterdam ct scores in indonesia. therefore, a physician can make a better priority to provide high-yield care to all tbi patients. a retrospective cohort was conducted in a national referral hospital from july to december 2017. all tbi patients admitted to the emergency department (ed) and had an initial ct scan were included in this study. their classification of tbi and initial ct scan were reviewed and all patients were followed to see whether the patient died or alive until discharge from the hospital (in-hospital mortality). statistical analyses were conducted to find the predictive values (sensitivity, specificity, cut-off point, relative risk) of both scoring systems. of 141 tbi patients admitted to ed, there were 136 patients had an initial ct scan. most of them were categorized as mild tbi (80.9%), then moderate (14.0%) and severe tbi (5.1%). in-hospital mortality was 9.6%. with cut-off point 1 in marshall and rotterdam ct scores, their sensitivity (92.3% vs. 92.3%, respectively) and specificity (73.1% vs. 74.8%, respectively) were similar. same things also found in their relative risks, which are 24.267 (95% ci 3.256 -180.835) and 25.953 (95% ci 3. 485 -193.258 ). both marshall and rotterdam ct scores have significant values in predicting the outcome of tbi patients, thus it should be implemented in daily emergency practice to assist a physician in making further clinical decisions. midline shift (mls) in brain is a critical condition. if not diagnosed timely, it could lead to a devastating outcome. computed tomography (ct) scan is the gold standard technique to diagnose mls in neurosurgical patients. the aim of our study was to find out association between transcranial sonography [tcs] and ct scan in assessing midline shift in patients with tbi. in this prospective ongoing study, adult patients ages 18 -65 years, of either gender, with tbi were included. demographic details were noted. all patients underwent ct scan, followed by tcs. mls on tcs was determined using standard technique. we noted the mls on ct scan and time window between ct scan and tcs was also measured. consciousness was assessed using glasgow coma scale (gcs) and gcs -pupil [gcs-p] scales. descriptive data are given as mean (sd) or number. spearman's correlation test was used to detect relationship between gcs and mls assessed by ct scan and tcs, and also gcs-p. the value of p<0.05 was considered significant. a total of 16 neurosurgical patients were studied. male to female ratio was 15:1. the age was 44 [17.74] years with weight of 64.5 [10.17] kg. ten patients had gcs<8. the mean value of mls measured by tcs -0.1, p = 0.69). the correlation between tcs and ct scan with gcs was in significan respectively. however the value of gcsin patients with tbi, mls can be successfully assessed using bedside, non-invasive and non-radioactive monitor tcs when compared to a ct scan. there is a good correlation between gcs and gcs -p. early post-tbi seizures are reported to occur within 24 hours and between days 1-7 following tbi in 8.9% and 1.9% patients, respectively. early seizure prophylaxis with phenytoin in severe tbi patients is drugs with better safety profile have emerged as potential alternatives. the objective was to describe seizure prophylaxis practices in critically ill tbi patients. we conducted a retrospective observational study of 9 adult trauma icus. we included consecutive adult icu patients with moderate and severe tbi admitted between jan 2015 and dec 2016. data were collected using standardized forms. our primary outcome was the incidence of seizure prophylaxis use. we included 379 patients with a moderate (43%) or severe (56%) tbi. the majority were men (70.5%) with mean age of 54.9 (sd 21.6) an (51%) and mva (30%). a total of 30% required invasive icp monitoring. a total of 259 patients (68%) received early seizure prophylaxis, 67% for moderate and 69% for severe tbi. phenytoin, levetiracetam or their combination were used in 228 (88%), 9 (3%) and 10 (4%) of cases, respectively. twelve patients (5%) were previously treated for pre-existing epilepsy. a total of 60 (16%) patients experienced a seizure (29 at the trauma scene, 15 in er, 15 in icu and 1 on the ward). among the 118 severe tbi patients in icu for 7 days or more, anticonvulsants were continued for the recommended 7 days in 57% of cases. early seizure prophylaxis is inconsistently used in severe tbi patients in canada. phenytoin still remains the agent most used. despite the current recommendations, 31% with severe tbi did not receive prophylaxis and 43% for a shorter period than 7 days. raised icp persistently in severe tbi patients may be detrimental. however, chest physical therapy (cpt) is equally necessary for preventing secondary factors influencing the risk in these patients. this study was intended to observe the impact of short-term rise in icp with manual cpt in severe tbi patients on outcome along with hemodynamics. this was a prospective, observational trial on 92 adult patients, of either sex, aged 18-60 years, with severe tbi, on mechanical ventilatory support with continuous icp monitoring, and receiving cpt on regular basis, included in this study. the cpt was applied for 10 minutes' duration and repeated after an interval of 6 hours in between for a total 2 sessions in a day. the measurement measured intracranial pressure, cerebral perfusion pressure, heart rate, mean arterial pressure (from start of the intervention until 10 min after the intervention at 1 min interval each), and gcs after each session of cpt along with final outcome/gos at the time of discharge and 3 months. the rise in median intracranial pressure of 3.0 (-8.0, 8.5) and median cerebral perfusion pressure of 5.25 (-37, 29 .5) was significantly higher during intervention and after intervention phase. in contrast, a median heart rate rise of 7.5 (2.0, 28.5) and mean arterial pressure rise of 7.0(2.0, 29.0) were comparable. however, in patients with high baseline icp (>20 mmhg), poor outcome was noted in terms of low gose 1(1, 3), and higher mortality (40.9%) at hospital discharge or 3 months after injury. significant increase in icp in severe tbi patients post cpt for 10 minutes at a time (total 20 minutes each day) was not tolerable in this cohort. moreover, we observed significantly low gose in patients with sustained intracranial hypertension. the effect of manual technique of cpt on final (long-term) neurological outcomes remain inconclusive but with favorable respiratory outcome. survivors of moderate and severe traumatic brain injury (mstbi) require substantial care, much of which is provided by friends and family. we sought to describe the experience and unmet needs of survivors and their informal caregivers follow mstbi, particularly related to care transitions. this study was conducted in two intensive care units (icus) at a level 1 trauma center. we conducted qualitative, semi-structured interviews with both patients and informal caregivers of mstbi survivors at 72 hours, one month, three months, and six months post injury. informal caregivers were defined as friends or family who planned to provide care for the patient. patients were 18 years or older with an mstbi, and not expected to imminently die of their injuries. eighteen patient-caregiver dyads were enrolled. one patient died within 72 hours. at 72 hours, 17 caregivers were interviewed; at one-month 13 caregivers were interviewed; at three months 11 caregivers and one survivor were interviewed; and, at six months 11 caregivers and seven survivors were interviewed. three themes were identified in the qualitative analysis of caregiver interviews: caregiver burden, caregiver health related quality of life, and caregiver need for information and support. experiences varied depending on time since injury, discharge disposition, functional neurologic outcome, caregiver access to resources, and likely multiple other additional factors. interviews with survivors were not insightful secondary to post-traumatic amnesia. this study provides new information about the experience of informal caregivers during the six months after their friend or family member survived an mstbi. caregivers reported that needs evolved over time. at three to months, few moderate to severe tbi patients were well enough to be interviewed, and information obtained by survivors was not insightful. interventions to promote caregiving may be a substantial opportunity to improve patient and caregiver-centered outcomes following tbi. vasospasm following traumatic brain injury (tbi) has a high incidence and a detrimental effect on the neurological prognosis. yet, it remains a neglected, poorly understood phenomenon and there are no guidelines for its management. herein we present a case of severe vasospasm following tbi that caused secondary delayed cerebral ischemia (dci). we further appraised the current literature aiming at identifying predictors of vasospasm in tbi. a 31 y/o white woman presented to the hospital after a mechanical fall resulting in mild tbi with associated subarachnoid hemorrhage (sah). glasgow coma scale (gcs) at presentation was 15, with no neurological deficits. a non-contrast ct head revealed diffuse bilateral fronto, parietal and temporal sah without evidence of aneurysm or vascular malformations on ct angiogram (cta). toxicology screens were negative. at 72 hours from tbi patient developed acute severe headache. a repeated cta showed right internal carotid artery (ica) and middle cerebral artery (mca) vasospasm with no ischemia identified on mri brain. patient was started on nimodipine. on day-10 patient developed acute left side hemiparesis and neglect with neuroimaging evidence of a complete right mca infarct. hemodynamic augmentation therapy was initiated with partial improvement of deficits. patient subsequently developed hemorrhagic conversion of the right mca infarct. on day-25 neuroimaging revealed resolution of vasospasm. patient had residual left side neglect and anosognosia. in line with prior literature our patient developed vasospasm in the large intracranial vessels, at 72 hours from the tbi and earlier than in aneurysmal sah. however, differently from previous reports, gcs at presentation was > 9, age was > 30 and despite vasospasm developing later than 24 hours it was not associated with good outcome. eded to identify accurate predictors of vasospasm following tbi with secondary dci that could improve detection and management of this detrimental phenomenon. therapeutic hypothermia and/or cooling therapy has been hypothesized to have benefits in patients with traumatic brain injury (tbi). several systematic reviews (sr) are being performed to address this question, but their results are inconsistent. the objective of this study was to assess the methodological quality of sr that included randomized clinical trials (rcts) that assessed the effects of therapeutic hypothermia and/or cooling therapy in patients with tbi. a critical appraisal study was performed in order to assess any sr that fulfilled the inclusion criteria. an unrestricted search of the literature was carried out in march 2019 at four major electronic databases (medline, embase, lilacs and cochrane library). two independent reviewers selected the studies, extracted the data and appraised the methodological quality of the included sr using the amstar-2 (a measurement tool to assess systematic reviews) tool. an overall assessment of the confidence in the results was performed using the checklist available in amstar-2 website (https://amstar.ca/amstar_checklist.php). the confidence of the results may be graded as high, moderate, low or critically low. this grading is based on the adequacy of the sr to the 16 domains of the amstar-2. the search strategy retrieved 149 references. after the selection process, 16 sr were included. the sr were published between 2003-2018 and included 0 to 37 rcts. the overall confidence in the results from included sr was graded as critically low in 53.3%, low in 13.3%, moderate in 20%, high in 13.3%. a high number of sr addressing similar clinical questions were published in a short period of time. the methodological quality was adequate in only few sr. clinical practice guidelines should considered this result when choosing the evidence synthesis to recommend for practice. neurogenic pulmonary edema (npe) is a clinical syndrome characterized by acute onset after central nervous system injury. the aim of this study was to investigate the clinical features of npe in patients with subarachnoid hemorrhage (sah). the authors retrospectively analyzed a total of 425 patients with sah who were treated at our hospital from april 2014 to september 2017. of these 425 patients, 350 were included in this study after the application of predefined exclusion criteria. patient demographics, aneurysm size and location, clinical characteristics, and patient outcomes were reviewed and compared between an npe and a non-npe group. sixteen patients (4.6%) presented with npe at admission. among them, 10 patients (62.5%) recovered from npe immediately, and ventilatory support was withdrawn within 2 days from onset. a univariate analysis showed that patients with npe were of younger age (p=0.04), had a higher rate of vertebral (p=0.01), and lower systolic blood pressure on admission (p=0. revealed significant differences in the frequency of vertebral artery dissection (odds ratio (or) 4.83, 95% ci 1.50--13.66, p=0.04) between the groups with and without npe. no significant group differences were found in other factors, including heart rate, neurologic outcomes at discharge. vertebral art factors for npe. however, neurologic outcomes at discharge did not differ between groups, suggesting that poor outcome due to npe could be reduced by appropriate diagnosis and treatment. antibiotic-impregnated catheters (aic) are recommended for the prevention of ventriculostomy-related infections (vri). other antibiotic prophylaxis strategies following external ventricular drain (evd) placement vary widely by institution. the role of systemic antibiotics for this indication remains controversial. we retrospectively reviewed the charts of all patients having an evd placed between january 1, 2016 and december 31, 2018. after excluding patients who died or were discharged within 48 hours of evd placement or had an evd placed due to suspected meningitis, patients were categorized into the periprocedural (p) or no periprocedural (np) antibiotics group. patients were determined to have a vri if catheter and up to 7 days after catheter removal. mann-whitney u test was used to analyze descriptive data and baseline demographics. chi-squared models were used to analyze the incidence of infection. included in the no periprocedural antibiotics group (age 60 [52-69] years; 50% male) and 120 were included in the periprocedural antibiotics group (age 51 [39-62] years; 56% male). the most frequent indications for evd were subarachnoid hemorrhage (sah) [np: n=51 (54%), p: n=30 (25), p<0.001], intracranial hemorrhage (ich) [np: n=20 (21%), p: n=23 (19%), p=0.731), and other, which included colloid cysts and tumors [np: n=10 (10.5%), p: n=37 (31%), p<0.001]. there were 4 infections in the no periprocedural antibiotics group compared to 8 in the periprocedural antibiotics group (p=0.436). the most common pathogen was coagulase-negative staphylococci (n=4, 33%). the use of periprocedural systemic antibiotic prophylaxis did not significantly reduce the incidence of vri. periprocedural systemic antibiotics may not be necessary in the setting of antibiotic impregnated catheters to reduce the incidence of infection. cerebral artery vasospasm is a rare complication of craniopharyngioma resection but can have life altering consequences including delayed cerebral ischemia if not quickly recognized and managed appropriately. we present a case of craniopharyngioma resection in a 16 year old male complicated by refractory vasospasm and its management with intraventricular nicardipine. data regarding the operative management, time course, vasospasm and management was accessed retrospectively after patient discharge. a 16 year old male with recurrence of a craniopharyngioma presented with left eye vision loss and was admitted to the neurosciences intensive care unit after transsphenoidal resection. intraoperatively, the tumor was noted to be adhered to the posterior communicating artery and the left anterior cerebral artery. dense invasion into the hypothalamus was noted. this portion was carefully resected to avoid progressive lethargy. computed tomography angiography revealed new mild narrowing of the left anterior and middle cerebral arteries and bilateral posterior cerebral arteries consistent with vasospasm. the patient was treated with a vasospasm bundle including nimodipine, euvolemia, and blood pressure augmentation. over the next twenty days, the patient continued to have a variable amount of vasospasm despite aggressive medical and intra-arterial management. on post-operative day 27. nicardipine was then infused into the evd once a day for 3 days, resulting in rapid and sustained improvement in vasospasm. the mechanism of vasospasm following skull base tumor resection is unknown. presence of blood in the operative bed, direct surgical injury to the blood vessels, hypothalamic dysfunction and the release of inflammatory chemicals have all been proposed. treatment remains similar to treatment used in sah, utilizing nimodipine, euvolemia, blood pressure augmentation and intra-arterial verapamil. this case demonstrates the effectiveness of intraventricular infusion of nicardipine on refractory vasospasm. to present a rare case of bilateral internal carotid artery (ica) aneurysms presenting as trigeminal neuralgia (tn), with good outcome post surgical treatment. a 70-year-old woman presented with disabling tn for 1 year, exclusively affecting the right maxillary and mandibular divisions. symptoms did not abate with trial of adequate doses of gabapentin, duloxetine, oxcarbazepine and indomethacin. thin-cut magnetic resonance imaging (mri) brain with and without contrast showed rare contact with wide-necked aneurysms of bilateral petrous-cavernous icas producing prominent mass effect on bilateral adjacent trigeminal nerves. carotid arteriogram redemonstrated ica aneurysms with left measuring 13.1 mm x 7.70 mm and right measuring 10.5 mm x hours post procedure, tn had completely resolved. patient was started on aspirin 325 mg and clopidogrel 75 mg daily and is being tentatively planned for intervention on left aneurysm. on her 3month follow-up appointment with neurology, she reports no recurrence of tn. in cases of aneurysmal causes of tn, presence of bilateral aneurysms causing mass effect on the trigeminal nerve at its root is a rare occurrence and needs high clinical suspicion. due to the high risk of rupture associated with giant and symptomatic aneurysms, treatment should be expedited and aggressive in order to not only address symptomatic tn but also to avoid the risk of aneurysm rupture in the future. surgical clipping and endovascular coiling with or without stenting has demonstrated remarkable symptom relief in reviewed literature for other types of intracranial aneurysm. moyamoya disease is a chronic cerebrovascular disease characterized by spontaneous and progressive stenosis or occlusion of the internal carotid artery and its branches. revascularization procedures have been shown to improve cerebral hemodynamics and decrease the risk of strokes, but several postoperative complications are known to occur. we present a case with a fairly rare complication with characteristic radiological findings after surgery. a 14-year-old girl with moyamoya disease underwent left superficial temporal artery (sta)-to-middle cerebral artery (mca) anastomosis with encephalo-duro-myo-synangiosis (edms), and did right sta-mca anastomosis and edms one year after the initial surgery. the procedures were uneventful and the occlusion time was 38 minutes. she recovered from the anesthesia without neurological deficit, and mri on postoperative day (pod) 1 demonstrated no ischemic lesions and patent bypass, although swelling of the temporal muscle attached to the brain surface was noted. on postoperative day 4, she experienced a transient neurological event (left hemiparesis). magnetic resonance imaging revealed large cortical and subcortical hyperintense lesions in the middle cerebral artery territory on diffusion-weighted imaging and apparent diffusion coefficient imaging. subsequently, the radiographic findings improved within several days with resolution of the symptoms. revascularization surgery for improving a patient's hemodynamics can prevent the development of strokes, but is known to be associated with perioperative cerebral infarction and cerebral hyperperfusion causing transient neurological deterioration, delayed intracerebral hemorrhage, and vasogenic edema.this case is a reminder that hemodynamic complications can develop subacutely in patients who have undergone successful revascularization for moyamoya disease. the radiological features and mechanisms of this rare condition associated with revascularization surgery for moyamoya disease are discussed. vasospasm with delayed cerebral ischemia is a rare but known complication of endoscopic transsphenoidal resection of pituitary adenoma. this complication has rarely been reported in cases of -arterial treatment have been favorable in some cases. electronic medical record review. the patient is a 42 year old male who underwent subtotal resection of pituitary adenoma via an open right fronto-temporal approach. eight days post-resection he developed progressive headache and leftsided weakness which acutely worsened the following day. his nihss on presentation was 12, consistent with right mca syndrome. ct brain showed mass effect in the right frontal lobe with 3.5 mm midline shift. cta showed sluggish flow through right m1 branch suggestive of vasospasm. he was taken to cerebral angiogram post-op day 11 and received right ica intra-arterial verapamil and right ica and mca angioplasty. he was started on nimodipine following the procedure. his exam improved significantly over the course of 1-2 days. he was discharged home on verapamil 80mg q8 hours. at three month follow-up his nihss was 0 and his modified rankin scale was 1. in the case we present, the patient received intra-arterial treatment with verapamil and angioplasty 2-3 days after onset of symptoms. despite delayed presentation the patient ultimately achieved a favorable functional status. vasospasm and stroke post-pituitary tumor resection are complications of which patients should be adequately informed, especially when considering the possibility of good functional outcome with intraof this potentially debilitating and life-threatening complication and attention should be paid to utilizing techniques for early detection of vasospasm. neuromonitoring is an essential part of the management of neurocritical patients. many icus in developing countries manage their patients without monitoring icp. intensivists play a vital role in clinical judgments to manage their patients. raised icp are handled either by medical management or surgical procedures like decompressive craniotomy. the study aimed to see the outcome of patients with raised icp and compare medical vs surgical management in these patients without monitoring icp. a retrospective observational study was conducted among patients admitted from january to december 2018 in the icu of dhaka medical college hospital, bangladesh. patients who had etiologies of brain code, clinical presentations and or radiological findings consistent with raised icp were included. patents were grouped into neurosurgical and medical management groups. length of icu stays and mortality were observed. student's t-test and chi-square tests were used to see the statistical significance. total of 187 patients was selected. mean age was 40.51±20.5 years, and 75.4% were male. traumatic brain injury was the most common cause of raised icp (41.2%) among selected patients. 52.9% of patients were managed medically, and neurosurgical procedures managed 47.1% of patients. length of icu stay was higher in neurosurgical patients compared to medical management group (13.22±9.91 vs 10.58±8.84; p=0.56, non-significant). mortality was higher in neurosurgical patients compared to medical management group (55.7% vs 48.5%; p=0.326, non-significant). mortality was also higher in traumatic brain injury patients who underwent neurosurgery compared to medical management (58.2% vs 50%; p=0.51, non-significant). neurosurgical management didn't show a better outcome in patients with raised icp when monitoring was unavailable in a resource-limited icu. chronic kidney disease (ckd) independently increases the risk of stroke and burden of ischemic small vessel disease (svd). effects of ckd on intracranial hemodynamics remain poorly defined. this study compared svd and a transcranial doppler (tcd)-based marker of intracranial vascular resistance (pulsatility index, pi) in post-stroke patients with and without ckd. within three months of a stroke. anterior and posterior circulation pi (aca, mca, and pca) significantly correlated with mri lesion volume in all patients. ckd strongly correlated with higher distal resistance (median ckd aca pi 1. in patients with recent stroke, mri svd volume is significantly associated with anterior and posterior circulation pi. significantly higher svd lesion burdens and anterior circulation pis were observed in patients with ckd. ckd is an independent determinant of increased intracranial vascular resistance in both anterior and posterior cerebral circulations. atrial fibrillation is associated with an increased risk of stroke and systemic embolism. we investigated the prevalence of coexisting subdiaphragmatic visceral infarction (sdvi) in patients with acute ischemic stroke due to atrial fibrillation and also evaluated independent factors of acute sdvi. we enrolled a consecutive series of 100 acute ischemic stroke subjects with atrial fibrillation between mra or cta were excluded. all subjects were prospectively examined using abdominal mr imaging at 1.5t and transthoracic echocardiography (tte) within 7 days of onset. a multivariable logistic regression analysis with predefined variable (age and sex) and the potential confounders that were associated with sdvi i the mean age was 72.9 ± 9.3 years (47% males). onset-to-abdominal image time was 3.8 ± 2.1 days. among 100 patients, 23 acute coexisting sdvi (20 renal and 2 splenic infarctions and 1 superior mesenteric artery occlusion) were found in 20 patients with acute ischemic stroke and atrial fibrillation. twelve patients had a chronic sdvi; 10 renal and 2 splenic infarctions. no hepatic and bladder infarction was shown. severe significantly associated with the coexistence of acute sdvi and acute ischemic stroke attributed to atrial fibrillation in the logistic regression model. (adjusted or, 11.0; 95% ci, 1.2-98.0; p = 0.03). there was a significant relationship between the presence of acute sdvi and severe left atrial remodeling in acute ischemic stroke patients attributed to atrial fibrillation. based on these results, we suggest that abdominal mr imaging for evaluating coexisting acute sdvi should be considered in patients with acute ischemic stroke due to atrial fibrillation, especially with left atrial enlargement on tte. patients with large hemispheric infarction are likely to accumulate chloride due to commonly used hypertonic saline for lowering elevated intracranial pressure. however, the effect of chloride burden on clinical outcomes in these patients is not well studied. this study aims to investigate the impact of maximum serum chloride concentration during admission on in-hospital mortality in critically ill patients with large hemispheric infarction. we conducted a retrospective observational study of patients with large hemispheric infarction who were admitted to the neurocritical care unit, between march 2013 and june 2018. patients were excluded if they had baseline creatinine clearance less than 15 ml/min, required neurocritical care for less than 72 hours. multivariable logistic regression models were used to evaluate the association of maximum serum chloride concentration during admission with in-hospital mortality. of 106 eligible patients, 23 (21.7%) were died in hospital. compared to patients who survive to hospital discharge, those who died in hospital had higher maximum serum chloride level during admission (137.0 ± 10.8 vs 117.8 ± 10.1, p<0.001). each 5 mmol/l increase in maximum serum chloride concentration was associated with increased risk of in-hospital mortality with an odds ratio of 2.324 (95% ci, 1.622-3.330, p<0.001). after adjusting for confounders including acute physiology, age, chronic health evaluation ii (apache ii) score, baseline serum glucose, base deficit, use of mannitol, hypertonic saline, therapeutic hypothermia, and incidence of acute kidney injury, maximum serum chloride level remained an independent risk factor associated with in-hospital mortality (adjusted odds ratio for every 5 mmol/l increment, 1.966; 95% ci, 1.222-3.163, p=0.005). higher maximum serum chloride concentration was associated with higher in-hospital mortality in critically ill patients with large hemispheric infarction. these results suggest serum chloride level should be monitored as high chloride burden may cause poor outcomes on those populations. patients with acute ischemic stroke caused by large vessel occlusion may receive both ct-angiogram (cta) and digital subtraction angiogram in the process of evaluation and management of restoring perfusion. neither aha/asa stroke/imaging guidelines address indications for transcranial doppler (tcd) and/or carotid duplex ultrasonography (cus) in early stroke evaluation and most patients do not receive additional cerebrovascular imaging after reperfusion. we investigated the clinical utility of performing tcd/cus after reperfusion in guiding post-acute care stroke management. we reviewed 200 inpatient ischemic strokes admitted to a comprehensive stroke center in 2017. 41 of these had tcd/cus done and 25 had cta done prior to tcd. 24 of these underwent either tissue plasminogen activator or thrombectomy for reperfusion. these cases were reviewed by two experts (kh, qv), who were blinded to each other, to determine if tcd/cus provided any added value after cta affecting patient management. a nominal group process was performed, using a third blinded expert (as) in case of disagreements to reach consensus. the reviewers reported 10 cases where tcd/cus provided incremental value for management. value added by tcd/cus, as noted by experts, included detection of residual/recurrent mobile thrombus requiring anticoagulation, confirmation of reperfusion in a symptomatic patient, distinguishing between carotid stenosis and occlusion by showing string sign on carotid ultrasound, confirming hemodynamic significance of angiographic stenosis helping triage the need for stenting/endarterectomy, and new information on chronicity of carotid stenosis based on collateral flow patterns hence deferring further intervention. our experience shows a significant added value of performing tcd/cus in more than 40% of stroke cases in our review. the incremental information provided by ultrasound-guided further evaluation and management decisions in most of these patients. axons of the wallerian degeneration slow (wlds) mutant mice survive weeks after traumatic and ischemic nerve injuries. prior characterization of the mutant wlds protein showed that it is a fusion gene product between the non-functional, truncated n70 amino acids of ube4b and full functional sequence of nuclear nmnat1, a rate-limiting enzyme in nad+ synthesis. however, the molecular mechanisms by which the mutant wlds protein protects axons from stroke injuries remain unclear. we sought to understand how wlds is able to robustly protect axons from ischemic injuries, and in doing so possibly identify novel therapeutic targets to attenuate axonal loss in stroke. we first sought to understand the temporal and spatial requirements of wlds activity in protecting axons from ischemic injuries. to achieve this, we developed a novel tool to conditionally regulate the expression of wlds protein by modulating its post-translational protein stability. using this powerful technique, we asked how conditionally "turning on" or "turning off" wlds activity affects axonal survival following ischemic insults. moreover, as the only known function of wlds is in catalyzing nad+ synthesis, we designed a high-throughput pharmacological screen for nad+ analogs to evaluate whether the nad+ synthetic pathway mediates wlds axon protection. we found that conditional expression of wlds protein within 4-6hrs after stroke injuries was necessary and sufficient to confer axonal survival, whereas turning off wlds activity post-injury abolished axon protection. this indicates that wlds activity is a local event in the axon, and exerts axonal protection within a critical time window even after the injury has occured. we further observed that exogenous addition of nad+, but not its precursors or immediate metabolites, was sufficient to confer axonal protection, while attenuating nad+ levels abolished wlds axon protection. this suggests that nad+ is a molecular mediator of wlds axon protection in stroke. we showed that wlds activity is a local axonal event, and uncovered a critical window of 4-6hrs poststroke injury in which the course of axon degeneration can be halted or even reversed in mammalian neurons. moreover, we showed that this process is mediated by rising nad+ levels in axonal compartments through a novel nad+ dependent cell signaling cascade. these findings provide powerful insight into the molecular bases of wlds activity, and uncover new therapeutic targets to delay and potentially even reverse axon degeneration in stroke. unruptured intracranial aneurysm (uia) are incidentally found on the computed tomography (ct) or magnetic resonance angiography in about 2% of patients. because of the risk of intracranial hemorrhage (ich), the presence of uia is contraindication to intravenous thrombolysis for acute stroke. as noncontrast ct (ncct) is mostly used for thrombolytic therapy and uia is difficult to diagnose using a ncct, uia may be found after thrombolysis. among the patients with acute ischemic stroke treated with intravenous thrombolysis for 5 consecutive years in one stroke center, patients diagnosed with uia by ct angiography immediately after thrombolysis, were enrolled. characteristics of uia and clinical outcomes such as ich and modified rankin scale (mrs) score at discharge were analyzed. among 172 patients treated with intravenous thrombolysis, 8 (2.3%) patients were diagnosed with uia. ally relevant artery and 7 patients an aneurysm less than 10mm in diameter. the median value of the initial national institutes of health stroke scale score was 12 (range 5-19). the median mrs score at discharge was 3 (range 2-5). there was no patient who had ich or aneurysm rupture during admission. intravenous thrombolysis could be safe and necessary to the patients with hyperacute ischemic stroke and incidental uia. recent studies suggest that variations in the constitution of the gut microbiome contribute to atherosclerotic burden and cardiovascular disease. while many gastrointestinal (gi) diseases are known to cause disruption of the normal gut microbiome in humans, the clinical impact of gi diseases on subsequent vascular disease remains unknown. we conducted an exploratory analysis evaluating the relationship between gi disease and ischemic stroke or acute myocardial infarction (mi). we performed a retrospective cohort study using claims between 2008-2015 from a nationally composite of ischemic stroke or acute mi. stroke and mi were assessed separately as secondary outcomes. in an exploratory manner, we evaluated the association of each gi disorder in the icd-9-cm classification with our outcomes. we then categorized individual gi disorders by anatomic location, disease chronicity, and disease mechanism. we used cox proportional hazards models to examine associations with adjustment for demographics and established vascular risk factors. since this was an exploratory, hypothesis-generating study, we report only notable positive associations. among approximately 1,730,000 beneficiaries, the following gi disorders were associated with an increased risk of subsequent ischemic stroke: gastric ulcer (hr, 1.16, 95% ci, 1.06-1.26), duodenal ulcer (1.13, 1.01-1.23), gastritis and duodenitis (1.11; 1.05-1.17), disorders of function of stomach (1.16, 1.07-1.27), other disorders of stomach and duodenum (1.14; 1.03-1.27), gastrointestinal mucositis (6.76; 2.18-20.97), unspecified noninfectious gastroenteritis and colitis (1.14; 1.07-1.22) and gastrointestinal hemorrhage (1.06; 1.01-1.13). the following categories of gi disorders were associated with an increased risk of ischemic stroke: stomach disorders (1.14; 1.07-1.22), stomach and small intestine disorders (1.05; 1.00-1.09), ulcerative disorders (1.07; 1.01-1.13) and chronic gi disorders (1.08; 1.01-1.15). gi disorders were not associated with an increased risk of mi, and some demonstrated a reduced risk. several gi disorders were associated with an increased risk of ischemic stroke, but none were associated with an increased risk of mi to evaluate the relationship between serum neutrophil-to-lymphocyte ratio (nlr) levels and early neurological deterioration (end) in ischemic stroke patients with large-artery atherosclerosis (laa). we evaluated consecutive ischemic stroke patients due to laa between january 2010 and december within the first 72 hours of admission. the nlr was calculated by dividing the absolute neutrophil counts by the absolute lymphocyte counts. among the included patients (n = 349; male, 59.9%; mean age, 69 years), 18.1% (n = 63) had end events. in multivariate analysis, serum nlr level was independently associated with end (adjusted odds ratio, 1.09; 95% confidence interval [1.02 to 1.17], p = 0.016). visit time from symptoms onset, and insitu thrombosis and artery-to-artery embolization mechanisms were also found to be significant factors for end events. in the analyses regarding the relationship between serum nlr values and burden of vascular lesions, nlr levels were positively correlated with both the degree of stenotic lesions (p for trend = 0.006) and numbers of vessel stenosis (p for trend = 0.002) in a dose-response manner. we also compared the difference of serum nlr levels according to the stroke mechanisms from underlying vascular lesions. then, hypoperfusion and in-situ thrombosis mechanisms showed higher levels of nlr. however, only in-situ thrombosis mechanism had higher nlr values among the end groups compared to non-end groups (p = 0.005). serum nlr levels were associated with end events in ischemic stroke patients with laa mechanism. since nlr was also closely correlated with the relevant vascular lesions, our results indicated clues for underlying mechanisms of end events. transcranial doppler (tcd) can detect emboli in numerous cerebrovascular settings. although previous studies have suggested that microembolic signals (mes) may predict recurrent stroke, the practical significance of such findings remains unclear. this uncertainty has deterred the widespread use of embolic monitoring among clinicians. in a retrospective fashion, we investigated the real-world applicability of tcd by examining whether the presence of mes portends worsened clinical outcomes. we reviewed the charts of all ischemic stroke patients (n = 136) who underwent mes monitoring from january 2017 to december 2018. of the stroke subtypes reviewed, 35% were atheroembolic, 29% were cardioembolic, 4% were lacunar, 9% were dissection, 10% were hypercoagulable, 10% were cryptogenic, and 8% were due to other causes. 6 +/-9 mes were detected in 18% of patients. mes were detected at an average of 14.99 +/-4.72 db (with a detection threshold > 9.00 db). recurrent stroke was seen in 10% of patients (monitored over 7.2 +/-6.6 days). patients with mes were more likely to have recurrent stroke (46% vs. 2%, p < 0.001), undergo a revascularization procedure (25% vs. 6%, p = 0.005), have a longer length of stay (10 vs. 4 days, p = 0.001), and have a discharge mrs 3-6 (83% vs. 30%, p < 0.001) compared to those without mes. multivariable logistic regression analysis showed that mes was an independent predictor of recurrent stroke (or 42.1, 95% ci 6.7-265.6) and of poor discharge mrs 3-6 (or 15.7, 95% ci 4.0-61.7) despite controlling for antithrombotic treatments and stroke subtypes. in the largest series of patients who underwent embolic monitoring with tcd, mes predicted ischemic stroke recurrence leading to worsened disability and prolonged hospital stays. given that mes can provide important prognostic information, tcd with embolic monitoring may be clinically useful in the workup of ischemic stroke. expanded patient eligibility for mechanical thrombectomy (mer) of acute ischemic stroke (ais) has resulted in a proportional increase of patients who require emergency angioplasty and/or stenting (eas) to achieve recanalization. post-stenting antiplatelet medication management continues to remain a challenge due to lack of immediate effect and rapid reversibility ideal for patients at high risk of stent thrombosis and hemorrhagic complications, especially after intravenous alteplase (tpa). cangrelor is an immediate-acting intravenous p2y12 receptor inhibitor with rapid clearance and restoration of normal platelet within one hour of infusion termination. we describe our preliminary experience with administration of cangrelor in ais patients undergoing mer and requiring eas as rescue therapy. ten patients with ais who received cangrelor after mer were identified. median admission national tpa prior to mer. cangrelor drip was started immediately prior to eas. median duration of cangrelor drip was 22 hours. dual antiplatelet was given a median time of 5 hours before discontinuation of cangrelor. seven patients had repeat imaging at 3 months confirming durable vessel patency and no restenosis. none of the patients experienced clinical deterioration, symptomatic intracranial hemorrhage, or recurrent strokes during the hospital stay. one patient underwent surgical decompression but did not develop any hemorrhagic complications. median mrs at discharge was 3, and median nihss at discharge was 8. in our case series, cangrelor was observed to be a safe alternative to oral antiplatelet drugs in the immediate perioperative period among ais patients who underwent mer and required eas, , including patients who received tpa and at high risk for malignant cerebral edema or hemorrhagic transformation who may require emergency surgical decompression. the response of the neonatal brain to hypoxic ischemic injury (hi) is developmentally specific therefore therapies for brain hi cannot be standardized across the ages. while arginases (arg; isoforms arg-1/arg-2) are enzymes actively studied for their neuroprotective/neuroregenerative effects in various neurological conditions, in neonatal hi the arg effect remains unknown. to test the hypothesis that arg changes with neurodevelopment and after hi we exposed mice c57bl/6 (wild-type) to hypoxia-ischemia on postnatal day 9, as follows: permanent coagulation of left common carotid artery to induce ischemia, a 1h recovery period and exposure to 10 % oxygen/balance nitrogen at 37°c for 50 min to induce hypoxia. animals were perfused at 1h,4h,12h, 24h and day 5 with 4 % paraformaldehyde, brains were post-fixed, sectioned on a cryostat (12 um) and examined histologically with cresyl violet stain to assess the degree of damage and arg spatiotemporal localization via immunohistochemistry. arg expression was measured by western blot and arg activity spectrophotometrically. arg expression and activity increase during development, however this increase is suppressed by hi. arg-1 expression increases on day 5 after hi which corresponds to our findings of arg-1 accumulation at the penumbra site. cortical arg activity remains suppressed after hi, compared to that in the hippocampus, where it increases. spatiotemporally, arg-1 localizes into myeloid cells in cns. arg-1expression increases in microglia as early as 4h after injury and remains elevated for a prolonged time. arg-2 is localized in pyramidal neurons of the indusium griseum, fasciola cinerea, neocortex and hippocampus (ca2, ca3). arg-2-expressing cells are damaged by hi, however they do not undergo spatial changes. microglial arg-1 strongly responds to hi and may play role in neuroinflammation and neuroprotection, while argand therapeutic potential of the arg-pathway in neonatal hi. sisco: helping stroke patients with thermasuit cooling trial is a phase 2 study in ischemic stroke with rapid induction of hypothermia to 32 within one hour. this patient had induction followed by early malignant edema requiring decompressive hemicraniectomy while 33 c. this is the first report of hemicraniectomy in a therapeutically hypothermic patient. results 59 y/o woman presenting with a left mca syndrome. initial imaging demonstrated left m1 occlusion. she received iv tissue plasminogen activator (tpa) followed by thrombectomy with tici 3 recanalization within practice guidelines. she was enrolled in sisco trial. she was sedated with propofol, fentanyl, and versed for induction, reaching target temperature of 34 degrees within 60 minutes. she remained on sedation for shivering and temperature was maintained at 32 degrees with the artic sun. imaging 12 hours after stroke demonstrated completed infarct with edema, midline shift, and lateral ventricle effacement. hypertonic saline was initiated, and she underwent emergent decompressive hemicraniectomy. balancing the risk of worsening edema and coagulopathy caused by mild hypothermia, rewarming was initiated at 0.3 degrees c per hour. at the time of procedure patient was at 33.5 . a successful hemicraniectomy was performed without complications. six months demonstrated improvement with the patient returning home with modified rankin 2, and cranioplasty performed without complications. during sisco, an emergency decompressive hemicraniectomy for malignant mca syndrome was performed for a cooled patient without complication or increased bleeding. while therapeutic hypothermia has not shown an outcome benefit in previous clinical trials, these trials have had limitations rapidly reaching targeted temperature. this may have blunted the therapeutic effect. using thermasuit, patients are able to reach target temperature significantly faster. additional clinical trials are needed to determine if the therapeutic window for targeted temperature management in ischemic stroke patients improves outcome. iv rt-pa guidelines exclude therapeutically anticoagulated or thrombocytopenic patients. these exclusion criteria may limit thrombolytic therapy to patients who might benefit. the objective of this study is to determine if iv rt-pa is safe and whether it increases neurocritical care resource utilization in this patient population. retrospective analysis of iv rt-pa treated patients receiving oral anticoagulation (warfarin (inr >1.7)), novel oral anticoagulant (noac), therapeutic heparin, low-molecular weight heparin (lmwh), or with thrombocytopenia (platelets < 100k). patients were treated using smart criteria (consent obtained for off label rtafter treatment. increased neurocritical care resource utilization was defined as transfer from a primary to comprehensive stroke center solely for additional monitoring after off-label iv rt-pa use. 77 patients were identified. 35 patients received therapeutic warfarin and one had coagulopathy (unclear etiology); mean inr=2.2 (range 1.7-3). 5 received therapeutic iv heparin, 6 full dose (1 mg/kg bid) lmwh, and 18 therapeutic noacs. 12 had thrombocytopenia (mean platelet count 77k). 7 received intra-arterial (ia) rt-pa, and 8 thrombectomy. there were 3 sich (3.9%); for all sichs there were mitigating factors that contributed (undiagnosed malignancy, adjunctive ia rt-pa, incorrect time of onset). two developed hematoma at the catheter site with no clinical effect. 1 patient was transferred for the sole purpose of monitoring post off-label iv rt-pa. these data suggest that iv rt-pa can be safely administered in therapeutically anticoagulated and thrombocytopenic patients, and sich rates were similar to the ninds cohort. the use of iv rt-pa in these patients may increase eligibility for acute stroke therapy, particularly where ia therapy is unavailable. -pa in such patients does not appear to increase neurocritical care resource utilization though further study with a larger population is warranted. although proteinuria has been reported as a predictor of neurological deterioration, poor functional outcome and in-hospital mortality after ischemic stroke, scarce study investigated the relationship between proteinuria and the malignant middle cerebral artery infarction (mmcai). this study aimed to determine whether proteinuria is associated with the development of mmcai. patients with infarction in middle cerebral artery territory were reviewed. on admission, all patients underwent brain computed tomography (ct), the assessment of national institutes of health stroke scale (nihss) and alberta stroke program early ct score (aspects), and laboratory surveys, including urine analysis by using urine dipstick. patients with known intracranial lesions or possible urinary tract infection were excluded. patients with proteinuria were defined if urine dipstick demonstrates reading of 1+ to 4+, while others were defined as patients without proteinuria. chronic kidney disease (ckd) was defined if either proteinuria or estimated glome identified. mmcai was determined if a progressive conscious disturbance or signs of uncal herniation were recorded with a midline shift > 5mm on a follow-up brain ct. we screened 1047 patients, and -five (37.2%) patients developed mmcai, and 53 (43.8%) patients had proteinuria. patients with mmcai had a significant higher score of nihss, lower aspects, less likely being dyslipidemia, and more likely having ckd and proteinuria than patients without mmcai did. after adjustment for age, sex, dyslipidemia and aspects, patients with proteinuria (or= 2.658, 95%ci= 1.137 -6.216, p=0.0241) and ckd (or = 2.595, 95%ci = 1.004 -6.711, p=0.0491) had a signifi 60ml/min/1.73m2 did not. in conclusion, proteinuria is associated with the development of mmcai. we suggest that proteinuria may be considered as a clinical predictor for the development of mmcai. although tpa has been shown to improve outcome in ischemic stroke across various etiologies, tpa is contraindicated in stroke secondary to septic emboli due to a significantly higher risk of bleeding. the goal of this study is to determine the safety and short-term outcomes of acute ischemic stroke patients who underwent mechanical thrombectomy due to septic emboli from infective endocarditis (ie). in this multi-center retrospective case series, we reached out to 48 thrombectomy centers known to our principal investigator. we have so far collected data from 5 hospitals across the us to look at outcomes after thrombectomy in patients who had an ischemic stroke from infective endocarditis. 8 centers reviewed their database and did not have eligible cases. to date, we have collected a total of 10 cases (90% male; average age 53; 40% had a known history of ivdu). in 50% the valve implicated was bioprosthetic. 80% of the occlusions were m1, with the remaining being the carotid terminus (10%) and m2 (10%). microbiology revealed that 30% were caused by streptococcus, 30% staphylococcus, 30% enterococcus, and 10% were polymicrobial. the average nihss on presentation was 19.8. 60% had received tpa prior to the thrombectomy (of those, 1/3 were known to have ie). the average best nihss after thrombectomy was 8.7 (averaged across 9 cases, the other case expired from new cardiomyopathy and multi-organ failure). 60% had hemorrhagic transformation (of those, 2/3 were tpa recipients). thrombectomy may be a safer and promising option in patients with ischemic stroke secondary to infective endocarditis. more data is required to compare the outcome of patients who received thrombectomy alone versus tpa followed by thrombectomy, and data collection is ongoing. therapeutic hypothermia may be an effective therapeutic measure for malignant cerebral infarction alternative to or in combination with decompressive craniectomy. the neuroimaging marker that suggests the favorable clinical course during therapeutic hypothermia is needed to predict the outcome and/or determine best and earliest timing to rewarm the patients. we included 21 cases who received therapeutic hypothermia for malignant middle cerebral infarction in seoul national university bundang hospital between july 2017 and may 2019. we measured hounsfield unit of ischemic core in serial computed tomography scans in each patient. the nadir of hounsfield unit of each patient was calculated. the difference of the nadir by the early clinical outcome (the survival at discharge) was analyzed. the mean age was 71.6 ± 14.9 and the male comprised 61.9% (n=13). three patients underwent early decompressive craniectomy plus therapeutic hypothermia and 18 patients received only therapeutic hypothermia. the mean target temperature was 34.1 ± 0.8 . a total of 14 patients (66.6%) survived at discharge. a total of 125 computed tomography scans were analyzed (about 6 scans per patient). the mean of the nadir hounsfield unit of each patient was 19.3 ± 2.9 in the deceased patients and 16.1 ± 2.8 in the survived patients, and the difference was statistically significant (p-value = 0.034) the nadir of hounsfield unit in the ischemic core was lower in the survived group than the deceased group in malignant ischemic stroke patients who received therapeutic hypothermia. the change in hounsfield unit in serial computed tomography scan may be used to estimate clinical course and optimal timing of rewarming or rescue craniectomy after therapeutic hypothermia. the volumetric analysis using semi-automated planimetry is currently being performed to elucidate this association further. 2 mhz pulsed-wave transcranial doppler (tcd) increases the exposure of an intracranial thrombus to tenecteplase (tnk-tpa) and facilitates early reperfusion. the aim of the present study is to ascertain if tcd along with tnk-tpa could improve functional outcome in patients treated with tnk-tpa after acute ischemic stroke (ais). this is a single center, prospective, interventional study. patients with ais with national institutes of -tpa bolus) within 3 hours of symptom onset, were randomly allocated (1:1) to either 2 mhz pulsed-wave ultrasound for 120 min. (sonothrombolysis)-intervention group or only tnk-tpa group. ultrasound was delivered using a mark head frame, immediately after the bolus of tnk-tpa. the primary outcome was improvement in the modified rankin scale score at days 30 and 90. the secondary end points were the occurrence of symptomatic intracerebral haemorrhages and death. between january 2016 and march 2019, 78 patients were randomly allocated to the sonothrombolysis group and 77 patients received only tnk-tpa. at the end of 90 days, the sonothrombolysis group achieved mrs 0-2 in 38/78 (48.70 %) compared to 32/77 (41.55 %) in the tnk-tpa group. the p-value is 0.02828. the result is significant at p < 0.05. the rate of sich and mortality were 2.56 % in each group. sonothrombolysis of patients treated with tnk-tpa for ais was feasible and safe, with some clinical benefits at 90 days. the recanalization rates and outcome are better than studies done with alteplase. there was no increase in sich or mortality. tnk-tpa should be the preferred drug for thrombolysis in ais. the study should be carried out in multiple centers to see if the results of the present study can be validated. acute ischemic stroke is the second leading cause of death, especially if the patient did not receive the appropriate treatment geared towards a timely recanalization of the occluded vessels, including intravenous tissue plasminogen activator (iv t-pa) or endovascular thrombectomy. little emphasis is given to the augmentation of collateral flow to offset the deleterious effect of ischemia or lessen the progression of the penumbral tissue into infarction. we present our initial experience with such vasoaugmentation strategy in patients with acute ischemic strokes. we present o university. our series included 12 patients with acute ischemic strokes. we excluded patients with a large vessel occlusion. all other patients were included regardless of whether they received iv-tpa or not. all patients had a ct angiogram including collateral imaging and ct perfusion study at baseline. after explaining to the patients or their next-of-kin, we started the patients on a standardized protocol of milrinone (50mcg/kg bolus followed by 0.75mcg/kg/minute). outcome assessment was comparing the initial mrs and that of the mrs at discharge. chi square contingency analysis was used with a set level of significance of p < 0.05. out of the 12 patients, 7 had good collaterals and 5 had poor collaterals. one of those poor collaterals patient had good cross flow from pcom to the affected hemisphere, but still demonstrated poor collateral score. in our cohort, 8 (66%) achieved good neurological outcome of mrs of 4 or below with 3 patients (25%) achieving a discharge mrs of 0. conclusions collaterals and small infarction core. the presence of cross flow wasn't helpful. the symptomatology of delayed cerebral ischemia (dci) after aneurysmal subarachnoid hemorrhage (asah) is variable and often challenging to detect, particularly in patients with poor-grade asah. we report severe symmetric quadriparesis as a previously unreported symptom of dci. a 41-yearwas significant for intact brainstem reflexes and withdrawal in extremities. initial treatments included aminocaproic acid and external ventricular drain insertion, followed by intra-aortic balloon pump placement for stress-induced cardiomyopathy. she subsequently underwent coiling of a ruptured left anterior choroidal artery aneurysm. on post-bleed day 5, she was noted to have new onset of decreased tone and minimal complex posturing to noxious stimulation in all extremities and severe inattention. transcranial doppler and digital subtraction angiography revealed moderate left greater than right middle cerebral artery and bilateral anterior cerebral artery vasospasm and she received balloon angioplasty and intra-arterial nicardipine twice. post intervention, her quadriparesis moderately improved but she continued to have decreased tone and delayed movement initiation. on post-bleed day 11, brain mri demonstrated infarcts in bilateral medial frontal lobes, bilateral basal ganglia & subinsular cortices. on day of discharge, she was able to spontaneously raise her left arm and legs, but only minimally moved her right arm to noxious stimulation. this case report adds severe symmetric quadriparesis to the myriad of possible clinical symptoms of dci after asah. awareness of this uncommon clinical presentation could lead to timely detection and management of delayed cerebral ischemia after asah and improved clinical outcomes. brain mri to determine infarct size is common in acute stroke management. many patients cannot undergo mri imaging due to instability, or imaging contraindications. a common ct head finding postthrombectomy is contrast extravasation, thought to be secondary to "leakage" of the blood brain barrier due to ischemia. we hypothesized that extravasation volume on post-thrombectomy ct scan correlates with final infarct size. using ct head as a proxy for final infarct size may help guide clinical decision making when mri scan is not possible. we retrospectively examined a prospectively collected, irb approved stroke code database from 1/1/2014 to 7/1/2018. inclusion criteria included: anterior strokes that underwent thrombectomy, ct scan within 12 hours of thrombectomy with contrast extravasation, a mri within 5 days of the thrombectomy. demographics, diagnosis, imaging findings were extracted via chart review. we used the alberta stroke program early ct score (aspect) score, to approximate the area of contrast extravasation (ct) and area of dwi hyper intensity (mri). each region of extravasation on ct head was deducted from a score of 10, resulting in the "estimated infarct size (eis)". each region of mri dwi was was calculated. we demonstrated usefulness of aspect scoring for comparing infarct volume between ct extravasation and final dwi infarct size. post-thrombectomy contrast extravasation consistently underestimated final mri infarct volume by 30%. this relationship, if validated, may be useful to approximate mri stroke volume. dizziness is a vaguely-defined complaint involving the subjective experience of lightheadedness, disequilibrium, and room-spinning sensation. it is a frequently encountered problem in office visits and in the acute care setting, with approximately 2.5 million presentations to the emergency department annually. the differential diagnosis is broad, ranging from benign and of peripheral origin, to timesensitive and potentially fatal of central origin, including ischemic or hemorrhagic stroke and ms. it is estimated 10-40% of patients with dizziness receive stroke diagnoses . despite the low percentage, diagnosis of posterior stroke is the one most feared to be missed by clinicians. we hope to establish a clinical scoring system for timely triage of presentation with dizziness. we retrospectively reviewed charts of patients admitted at hahnemann university hospital between 2016 and 2018, following irb approved protocol. charts were chosen with primary inpatient admitting diagnosis: cerebral infarction due to thrombosis of basilar artery, dizziness and giddiness, and cerebral infarction due to embolism of post cerebral artery for a total of 176 charts. patient charts were reviewed to identify predisposing factors, 15 data points for each patient. of 176 patients reviewed, 15 were found to have infarctions involving the posterior circulation, 8.5% diagnostic yield for stroke. we collected a total of 6336 data points to understand the disease process. predisposing factors identified were chronic kidney disease, diabetes, hypertension, and hyperlipidemia. surprisingly, previous stroke was not found to predispose to posterior fossa strokes. common exam findings on presentation were hemiparesis and hemisensory loss. statistical analysis is currently in process we discuss our results in the context of previous efforts aimed at developing clinical predictors for posterior fossa stroke in patients presenting with dizziness. high hir (hypoperfusion intensity ratio) is known to correlate with core size, infarct growth and worse clinical outcomes. traditionally larger infarcts have been associated with higher rates of malignant cerebral edema and need for decompressive hemicraniectomy. patients with high hir and malignant profile (tmax >10s greater than 50% of penumbra) are associated with increased risk of malignant cerebral edema. as part of an ongoing study, we retrospectively identified all ais patients with lvo who underwent ctp imaging between january 2018 to june 2018 in our healthcare system within 24 hours from symptom imaging studies (ct or mri) were analyzed. hir was dichotomized based on proportion of greater and less than 0.5 into malignant vs favorable profile and correlation for development of malignant cerebral edema and need for hemicraniectomy was analyzed using chi-square test of proportion for nominal variables and wilcoxon ranked sum tests for the (skewed) continuous and ordinal variables. a total of 62 patients with lvo were identified with a median age of 78 (iqr 62-87), nihss of 16 . patients with high hir suggestive of a malignant profile (n=23), regardless of reperfusion, were associated with increased risk of malignant cerebral edema compared to those with a favorable profile (n=39) (p<0.0007). 9 patients with malignant hir developed malignant cerebral edema compared to 2 patients with favorable hir (rr=7.63, or=11.89). 1 patient with malignant hir underwent decompressive hemicraniectomy compared to none with favorable hir. higher hir and malignant profile, regardless of reperfusion, is associated with 7 times increased relative risk of development of malignant cerebral edema. these patients benefit from close monitoring and aggressive care for malignant cerebral edema including osmolar therapy and potential surgical intervention. we present the case of a patient with basilar artery dissection with thrombus, who underwent successful mechanical thrombectomy with stenting and was ambulatory at discharge. patient is an 85-year-old female with past medical history of ehler's danlos disease who presented with left sided weakness after being found down by her family. nihss on arrival was 14 (left sided weakness 1/5), bp 173/86, glucose 184. her cta showed a basilar angiography was notable for a basilar dissection with reocclusion, which was treated with enterprise stent placement with tici3 reperfusion. mri post intervention revealed right pontine infarct, punctate infarcts in cerebellum. her exam at discharge was notable for improvement in her left sided strength, at 4/5. she was subsequently discharged to inpatient rehabilitation. mechanical thrombectomy and stenting of the basilar artery remains a largely experimental procedure, with few guidelines and little data on outcomes. we present a case of a patient with a basilar dissection who at discharge was ambulatory and near baseline. blood viscosity (bv) is the intrinsic resistance of blood to flow and characterizes blood stickiness. several clinical and epidemiologic studies demonstrated an association between bv and the occurrence of major thromboembolic events. though bv appears significantly higher in cases of lacunar or cardioembolic strokes, relationships with demographic and laboratory findings during the acute stage of ischemic stroke are unknown. we investigated the relationship between baseline characteristics and bv within 24 hours of symptom onset in patients with acute ischemic stroke. we enrolled patients aged 40 years or older with documented histories of ischemic stroke or transient ischemic attack within 24 hours of symptom onset. a scanning capillary-tube viscometer (sctv) (hemovister, pharmode inc., seoul, korea) was used to assess the whole blood viscosity (wbv). the mean age was 69.6±12.03 years and 44.4% were female. of 189 patients, 68.3% had a history of hypertension; 27%, diabetes; 42.9%, hypercholesterolemia; 3.7%, coronary artery disease; and 18%, stroke. additionally, 40.7% were current smokers. sixty-one (32.3%) patients were taking antithrombotics regularly. multiple linear regression analysis revealed that hematocrit was positively related with increased bv and prior antithrombotic use was related with decreased bv. hematocritadjusted partial correlation demonstrated that prior antithrombotic use was significantly associated with decreased bv. prior antithrombotic use is significantly associated with decreased blood viscosity within 24 hours of symptom onset in patients with acute ischemic stroke. our findings indicate that antithrombotic medications prevent stroke by inhibiting platelet function and by changing the hemorheological profile. ischemic stroke accounts for 80% of stroke and is the second cause of death in brazil. the decision regarding thrombolytic treatment depends on clinical history, physical examination, and imaging. one challenge is the exclusion of situations called stroke mimics (sm). a total of 132 patients admitted to the stroke unit were prospectively analyzed. they received a full clinical and laboratory evaluation for the diagnosis of stroke and aiming to rule out the sm possibility. the study looked up for stroke etiology, demographical and epidemiological data, stroke-specific scales, sis, the occurrence of seizures and blood pressure lower than 150 mmhg at admission as variables of interest. the prevalence of sm and the use of thrombolytic therapy in this situation was concordant with medical literature. the risk associated with anticoagulation in acute ischemic stroke (ais) is uncertain. anticoagulation is generally not indicated for early secondary stroke prevention, but may be considered in certain conditions. we assessed the use of a weight-based institution-specific heparin nomogram in ais patients. -new haven hospital who received anticoagulation with a continuous heparin infusion in the setting of ais over a 12-month period. anticoagulation was initiated with an initial infusion rate of 10 units/kg/hr without bolus, with subsequent increases in the infusion rate by 1 unit/kg/hr, based on aptts obtained every six hours until two subsequent aptts were within goal range. we collected indication for anticoagulation, dose at therapeutic aptt, time to target aptt duration of anticoagulation, transition to oral anticoagulant therapy, cerebrovascular/cardiovascular events and major and minor bleeding complications. 61 patients were included in analysis, 52% of which were male, with a mean age of 60 ± 17 years and an average weight of 82.96 ± 17.82 kg. indications for ac were: intracardiac thrombus (31%), (sub)occlusive intra-arterial thrombus (35%), arterial dissection (18%), thromboembolic events and hypercoagulability (16%). the median time between diagnosis of stroke and initiation of anticoagulation was 53 hrs 21 mins. the time to goal aptt was 44 ± 5.5 hours with a mean infusion rate of 14 units/kg/hr at time of goal aptt. 60% of patients were transitioned to an oral anticoagulant and 3% of patients experienced a cerebrovascular event while on heparin infusion. our institution-specific heparin nomogram provides a safe anticoagulation strategy in ais, but with a longer time to reach therapeutic goal aptt range compared to previously published data. a more aggressive titration strategy with consideration of a higher infusion start rate may facilitate reaching the target aptt within a shorter time frame. vertebral artery dissection (vad) is one of the most common identifiable causes of ischemic stroke in young age patients forming intramural hematoma. vad may occur spontaneously or secondarily to trauma, infection, or underlying arteriopathy. we report 2 cases of spontaneous bilateral vad presenting with lateral medullary infarction a 51-year-old woman transferred to the emergency room with vertigo. 5 days ago, she felt severe headache on the left temporal area. on neurologic examination, ptosis, facial hypesthesia, dysmetria on the left side were noted, and dysarthria, dysphagia, right beating nystagmus were noted also. she had no past medical history and no familial history of stroke or cephalo-cervical trauma. brain mri depicted acute infarction in left lateral medulla and dissecting aneurysm of right va and near occlusion of left va on carotid enhanced mra. disease was normal. she was treated with warfarin. a 43-year-old man visited to the emergency room with headache on the right occiput. on neurologic examination, ptosis, miosis, facial hypesthesia, dysmetria on the left side and hemibody hypesthesia on the right side were noted. he had no trauma history or risk factors for stroke except hypertension. brain mri depicted acute infarction in right lateral medulla and dissecting aneurysm in the bilateral vertebral arteries on carotid enhanced mra. laboratory tests showed no abnormal findings. all results were normal for young age stroke evaluation. he was treated with warfarin. although unilateral or bilateral vad due to trauma or underlying medical conditions has been reported, spontaneous bilateral vad is rare. it can present with lateral medullary syndrome or nonspecific symptoms such as headache only. physicians should include vad in the differential diagnosis for patients presenting with brainstem neurologic abnormality or headache, especially young patients. cerebrovascular complications (cvcs) occur in 20-55% of patients with infective endocarditis (ie) and manifest as ischemic stroke, meningitis or cerebritis with 75% occurring during first 2 weeks of treatment. ct or mri brain can diagnose cvcs but are insensitive early on, precluded in critically ill patients and only demonstrate the sequelae. transcranial doppler (tcd) can identify high-intensity transient signals (hits) associated with cerebral microembolization and may have a role in detecting emboli and preventing cvcs in ie. retrospective chart review and literature review. we found 89 patients with strokes caused by ie at our institution from 12/2011 to 4/2018. tcds were obtained on 26 patients, 16 abnormal for cerebrovascular abnormalities. only 4 patients had 30 minute emboli monitoring performed of which one revealed hits. though mri studies have shown microemboli in 82% of ie patients (duval ann intern med 2010), we only found 3 studies using hits on tcds as indicators of stroke risk in ie. in a prospective study of 30 patients with left-sided ie, cvcs occurred in 83% of patients with hits on tcds versus 33% of patients who did not (p=0.021) ( lepur scand j infect dis 2009). two studies investigated 100 and 300 patients with cardiac sources of embolism and documented occurrence of hits in 36% and 23% of subjects, respectively, with highest prevalence of hits in patients with ie (sliwka stroke 1997 , georgiadis stroke 1997 . detection of hits using tcd emboli monitoring has a potential to be an important tool for identifying cases of ie at highest risk for cvcs, especially in the early stages of antimicrobial therapy. this can aid further research into preventative interventions beyond antibiotics like earlier valvular surgery or vacuum assisted vegetation extraction. therapeutic hypothermia is considered as an effective therapy to reduce cerebral edema and intracranial pressure for malignant middle cerebral artery infarction, which can be used as a life-saving treatment alternative to or combined with decompressive craniectomy. however, malignant hemispheric infarction involving whole anterior, middle and posterior cerebral artery territory has been regarded as untreatable by any measures. a 68-year-old man who had had right ventriculoperitoneal shunt for hydrocephalus since several years ago presented with global aphasia and right hemiplegia in may 2018. the brain magnetic resonance imaging showed large acute infarction involving whole left hemisphere including anterior, middle and posterior cerebral arterial territory by occlusion of distal internal carotid artery. as his family refused decompressive hemicraniectomy, therapeutic hypothermia using surface-cooling method (arctic sun® 5000) was initiated with a target temperature of 33.5 . the maximal midline shift on brain ct was approximately 15mm, five days after stroke onset, which led to foramen of monro obstruction and hydrocephalus in the lateral ventricle of the opposite side. since the hydrocephalus was controlled by draining of the cerebrospinal fluid into the ventriculoperitoneal shunt, the right hemisphere was saved and brain edema combined with midline shift gradually improved. the patient finally survived and was discharged. this case may be the first that therapeutic hypothermia successfully treated large hemispheric infarction involving 3 cerebral arteries without decompressive craniectomy. since the mass effect in our case was much larger than that of malignant middle cerebral infarction, we extended the duration of therapeutic hypothermia (33.5 ) to 7 days, which prevented herniation syndrome. another interesting point is that we could manage contralateral hydrocephalus caused by extensive midline shift, heralding a fatal clinical course in malignant ischemic stroke, using the preexisting ventriculoperitoneal shunt. current aha / asa stroke guidelines list arteriovenous malformation (avm) as a contraindication for intravenous alteplase (iv tpa) in ischemic stroke. while the associated risk of spontaneous intracerebral hemorrhage varies across the differing types of intracranial vasculature malformations, very little data or case reports exist regarding the risk of hemorrhage with intravenous thrombolytics for ischemic stroke in patients with vascular malformations. a 65-year-old male with history of cirrhosis and known atrial fibrillation (not on anticoagulation) presented with acute onset left facial droop and left hemiplegia, nihss 9. onset of symptoms were within the 4.5 hour window for iv tpa. a ct head demonstrated an aspects score of 10. iv tpa was thus initiated. cta of the head and neck revealed a right middle cerebral artery occlusion. additionally, there was a subtle tortuosity of blood vessels within the dural surface of the right temporal lobe, suggestive of possible avm. given the stroke severity, tpa was continued and successful recanalization was completed by thrombectomy of the right m2 occlusion by aspiration, with confirmation of a dural based avm. the patient did well, with no complications from tpa or thrombectomy and was discharged home with an nihss 2. the decision to administer iv tpa in patients with symptoms of acute ischemic stroke is determined by last known well time and a non-contrasted ct. vessel imaging should not delay administration of iv tpa as incidental findings may arise which may cloud the use of iv tpa in patients who otherwise may benefit from therapy. this case provides further insight that iv tpa in those with intracranial vascular malformations may be given safely with minimally increased risk. the prevalence of stroke mimics (sm) can reach 30% of presumable stroke, according to some authors. its presentation can predict the diagnosis of sm with a sensitivity and specificity of 90% and 91%, respectively. this study aimed to comparatively evaluate these data in a population hospitalized in a stroke unit. the study prospectively analyzed a total of 132 patients admitted according to the suspicion of sm, the definitive diagnosis, etiology, demographic and epidemiological data, specific scales for stroke including features and its sensitivity and specificity in a specific population. a cross-sectional analysis comprised 132 (53.1% female) patients, median age 66.5 years (56-74). the median nihss was 8 (4--2 in 87.1% of patients. twenty-four patients (18.2%) presented with initial suspicion of sm, which was confirmed in 19 (14.4%). after univariate analysis on were statistically significant (p = 0.022 and p = 0.001, respectively). the multivariate logistic regression showed that the absence of facial paralysis (or=4.57, p=0.004, 95% ci=1.60-13.03), seizure convulsion on admission (or=11.02, p=0.001, 95% ci=2.82-43.03) and blood pressure at admission lower than 150 mmhg (or=0.30, p=0.027, 95% ci=0.10specificity of 63.16% and 60.18% respectively, with an area under the curve of 0.682 (se=0.0675, 95% ci=0.55-conclusions sensitivity and specificity, probably secondary to selection bias. these data are inferior to the literature but better adapted to this study population. information collected from chart review and direct patient care. a 51 year-presented with pre-syncope, abdominal pain, and malaise. he was febrile and tachycardic, and subsequently admitted for sepsis. shortly thereafter, he experienced transient diaphoresis, expressive aphasia and right-sided weakness. mri brain showed punctate ischemic cerebellar infarcts. there was high suspicion for embolic phenomena from sepsis or he acutely decompensated to complete non-responsiveness during the echocardiogram. ct brain showed diffuse air emboli in cerebral vasculature and subarachnoid air. he was placed in the left lateral decubitus position and managed with high concentration oxygen. additionally, his antimicrobials were broadened to include fungal coverage. thoracic ct revealed free air in the mediastinum between the candidate for surgical repair of his left atrium due to hemodynamic instability. instead, he underwent urgent endoscopic esophageal stent placement. he then developed a stemi, also thought to be due to air embolus, and went into cardiac arrest with return of spontaneous circulation achieved. the following day, he developed renal failure and coded again. autopsy, in addition to massive cerebral edema and cardiac ischemia, demonstrated strep oralis bacteremia, bilateral adrenal infarcts and acute tubular necrosis. is crucial for the ability to coordinate aggressive care. open surgical repair of the left atrium and esophagus offers the best chance of survival, but its use may be limited by severe sepsis and hemodynamic instability. the efficacy of mechanical thrombectomy (mt) for acute ischemic stroke (ais) due to large vessel occlusion (lvo) is well established in the anterior circulation (ac). ais from lvo in the posterior circulation (pc) differs from the ac in myriad ways, including presentation and resistance to hypoxia. we aim to characterize the differences in risk factors and outcomes of mt for ac vs pc stroke. demographic data was collected for cases of ais undergoing mt from january 2014 to january 2018 with follow-up imaging and documented functional status at discharge. operative reports were reviewed for procedural data including stroke onset to groin puncture time, number of passes of the stent retriever, and onset to recanalization time. radiology reports of postprocedural non-contrast ct images of the head were assessed. during the study period there were 156 eligible patients (131 ac and 25 pc). atrial fibrillation (36.6% and 12.0%, p=0.017) and hyperlipidemia (42.0% and 20.0%, p=0.040) were more common in ac strokes while family history of stroke was more common in pc strokes (36.0% and 13.0%, p=0.005). mortality erence in procedural factors or hemorrhagic complications. ac stroke but not pc stroke. our data shows that pc stroke has a higher mortality rate than ac stroke after mt with no difference in procedural factors or hemorrhagic complications. the higher mortality rate in patients with pc stroke is likely inherent to severe disability from basilar artery occlusion rather than recanalization therapy. the data also support worse functional outcome in ac strokes with increasing age and number of passes. calcinosis is a dysregulation of vascular calcium deposition characterized by small vessel calcification and secondary fibrosis. the effect of systemic calcinosis on mineralization within the central nervous system is underreported and poorly understood. a 65-year old man presented to icu for possible hemorrhagic transformation of a recent left mca stroke. his medical history was notable for atrial fibrillation, end-stage renal disease, calciphylaxis on warfarin, and parathyroidectomy. his post-stroke hospital course was notable for mildly elevated serum phosphorus. the patient started apixaban two weeks post-stroke as anticoagulation for atrial fibrillation, and underwent a routine ct head one day later. the scan showed extensive high-density signal along the cortex of the recently infarcted left mca territory, initially misinterpreted as hemorrhagic transformation. the signal measured at 80-100 hounsfield units, higher than expected for acute blood. a dual-energy calcium overlap map post-processing revealed the high-density material was consistent with acute mineralization, possibly potentiated by the patient's previous calciphylaxis. this case illustrates accelerated mineralization as a mimic of acute hemorrhagic transformation. dual-energy ct is useful for differentiating hemorrhagic transformation from mineralization, and may play a special role in patients with renal disease or history of calciphylaxis. this case illustrates accelerated mineralization as a mimic of acute hemorrhagic transformation of stroke in a patient with esrd and history of calciphylaxis. dual-energy ct can differentiate between intraparenchymal hemorrhage and calcification with high accuracy using material decomposition. this imaging technique may have an especial benefit in patients with renal disease or disordered mineralization. accelerated mineralization post-stroke may worsen cerebral vessel compliance and risk of future stroke, and merits further investigation. systemic inflammatory response syndrome (sirs) without infection is a surrogate of a systemic immune response and has been related with poor outcome in several vascular diseases. we investigated associations of sirs with long-term functional outcome and contributing factors after intracerebral hemorrhage (ich). we analyzed consecutive spontaneous ich-patients from our prospective cohort-study (2008) (2009) (2010) (2011) (2012) (2013) (2014) (2015) . sirs was defined according to standard criteria: i.e. two or more of the following parameters during hospitalization: body-temperature <36°c or >38°c, respiratory-rate >20 per minute, heart-rate >90 per consisted of the modified rankin-scale(mrs) at three and twelve months investigated by adjusted ordinal shift-analyses. bias and confounding were addressed by propensity score matching and multivariable regression models. of 780 patients with ich 21.8% (n=170) developed sirs during hospitalization. sirs-patients showed more severe ich compared to without; i.e. larger ich-volumes (18.3cm³, iqr(4.6-47.2) versus 7.4cm³, iqr(2.4-18.6);p<0.01), increased intraventricular hemorrhage (57.6%,n=98/170 versus 24.8%,n=79/319;p<0.01), and poorer neurological admission status (nihss 16, iqr(7-30) versus 6, iqr(3-12);p<0.01). ich severity-adjusted analyses revealed an independent association of sirs with poorer functional outcome after three (or 1.80, 95% ci(1.08-3.00);p=0.025) and twelve months (or 1.76, 95%ci(1.04-2.96);p=0.034). increased ich-volumes on follow-up-imaging (or 1.38, 95%ci(1.01-1.89);p=0.05) and prior liver dysfunction (or 3.01, 95%ci(1.03-10.19);p=0.04) were associated with sirs. in ich patients we identified sirs to be predictive of poorer long-term functional outcome over the entire range of mrs-estimates. clinically relevant associations with sirs were documented for prior liver dysfunction and hematoma enlargement. acute major bleeding secondary to trauma is a significant complication of anticoagulated patients. in -threatening in the absence of a specific reversal agent. annexa-4 was a prospective, single-arm, open-label study evaluating the efficacy and safety of -primary efficacy endpoints were percent change from baseline in antiefficacy over the first 12 hours after treatment, as determined by an independent adjudication committee. safety outcomes (including thrombotic events and death) were evaluated over 30 days. among 352 patients enrolled in the study, 113 (32.1%) had a bleed associated with trauma (99 intracranial [ich] , 14 non-ich). mean age was 80.5 years. eighty-three patients took apixaban, 25 rivaroxaban, 4 enoxaparin, and 1 edoxaban. of the 99 ich patients, 41 (41.4%) had bleeding in multiple compartments. the mean hematoma volume in the 13 trauma patients with single-compartment intraparenchymal bleeding was 11.3 cc. among efficacy-evaluable ich patients, 58 of 70 (82.9%) had excellent or good hemostatic efficacy. the percent reduction in anti-ich patients taking apixaban and rivaroxaban, respectively. the 30-day rates of thrombotic events and mortality were 9 of 113 (7.9%) and 13 of 113 (11.5%), respectively. conclusions high rate of excellent or good hemostatic efficacy, with a relatively low occurrence of thrombotic events. these results are comparable to what was observed for annexa-4 patients with spontaneous bleeding events, and suggest that andexanet alfa could be a safe and effective treatment in the traumatic population. -factor prothrombin complex concentrates -related ich. adult patients (18 years or older) admitted to yale--related ich who evaluated at approximately 6 hours after the baseline ct scan. secondary outcomes included mortality and modified rankin score (mrs) at hospital discharge. chi-square test and multivariable logistic regression analysis were used for unadjusted and adjusted analyses, respectively. twenty--related ich were included in the s 13 patients received aa). majority of the patients were anticoagulated for atrial fibrillation (n=23, 79%). group (unadju patients (77%) in aa group (unadjusted p=0.63). there was no difference in mrs at discharge, 6 patients -3 compared to 5 patients (38%) in aa group (unadjusted p= 0.96). multivariable analyses adjusted for age, sex, race, and baseline mrs confirmed the absence of these associations (all p>0.20). in our limited sample size, there was no significant difference in the degree of hemostasis achieved, allvalidate these results are warranted. symptomatic intracranial hemorrhage (sich) following mechanical thrombectomy (mt) for acute ischemic stroke (ais) due to large vessel occlusion (lvo) is a rare but devastating complication. however, it is difficult to differentiate sich from contrast extravasation on early post-procedural computed tomography (ct). we aim to evaluate the rate of sich and whether the presence of hyperdensities (hd) on post-procedural ct predicts functional outcome after mt. demographic data was collected for cases of ais undergoing mt from january 2014 to january 2018 with available follow-up imaging and documented functional status at discharge. operative reports were reviewed for procedural data and radiology reports of ct head performed immediately, and 24-36 hours post-mt were assessed. of the 135 patients studied, 60 (44.4%, 60/135) had hd on immediate postoperative ct and 35 (25.9%, 35/135) were contrast extravasation (ce) due to resolution of hd on ct at 24patients developed new hd on follow-up ct, resulting in a total of 39 patients (28.9%) having ich and 8 (5.9%) having sich. in subgroup analysis, cardiac comorbidities were more common in ce patients than ich patients (51.4% and 23.1%, p=0.016) with no mortality or outcome differences. diabetes mellitus (dm) was more common in sich patients than those with ce and asymptomatic ich (75.0% and 30.3%, p=0.015). the mortality rate of sich patients was higher (75% vs 9.1%) and the survivors had worse discharge nihss than pat difference in procedural factors or preference for circulation between any groups. our data show that presence of hd on immediate postoperative head ct does not predict mortality and is not related to circulation or procedural factors. sich is more common in patients with dm and associated with higher mortality rate and poor functional outcome. consecutive patients admitted to the health system with tsd -pcc between may 2017 and april 2019 were analyzed. baseline demographics and outcomes were abstracted through -up ct. tsdh volume was calculated using the abc/2 method. descriptive statistics were used to analyze the -pcc and its association with outcomes. -pcc for tsdh were analyzed. the median age was 87 [56 to 100], -pcc was 27.6 units/kg. patients with he had a median dose of 24.4 units/kg (14.9 to 52.8) versus 27.7 units/kg (12.6 to 48.4) for patients without he. he was seen in 48% of patients (rivaroxaban in 2, apixaban in 13). among patients with he, 27% of patients died or went to a skilled nursing facility vs 19% in those without he. discharge to home or acute rehab was lower in those with he (73%) versus those without he (81%) doac use was associated with higher rates of hematoma expansion and worse outcomes in patients -pcc. treatments for the reversal of doac related tsdh should be investigated intracerebral hemorrhage (ich) is associated with peripheral immune dysfunction and infection. we aim to evaluate peripheral immune responses to ich and associations with infection and ich outcome. 100 consecutive spontaneous ich patients admitted to a tertiary center (12/2013-9/2015) were included. patients with secondary ich and transition to comfort measures within 24 hours were excluded. ich score, discharge modified rankin score (mrs), antibiotics use, acute clinical infections including pneumonia, bacteremia, and urinary tract infection were systematically adjudicated using modified pantheris criteria. peripheral immune dysfunction was characterized by lymphopenia and lower lymphocyte to neutrophil ratio (lnr). continuous variables were compared using student's t or wilcoxon test; univariate associations assessed using pearson's or spearman's correlation depending on distribution. ordinal logistic regression used to evaluate independent effect of lnr on discharge mrs. (jmp pro 14.0). cohort had mean age 70 years, 46% female, median ich score 1 [iqr 1-3] and median discharge mrs of 4. thirty-nine patients had suspected clinical infection treated with antibiotics, where only 11 met modified pantheris criteria for infection. lower %lymphocyte (p<0.003) and lnr (p<0.0001) on post-ich days 2-3 were associated with worse discharge mrs and higher ich scores (p's <0.01). lower mean lnr on post-ich days 1higher mean lnr on post-ich days 3-5 (p<0.003). lnr on post-ich day 2 is independently associated with mrs (p=0.0002) after adjusting for ich score and sex. acute post-ich lymphopenia and reduced lnr are associated with ich score, infection and worse discharge outcome. lnr emerged as independent predictor of ich outcomes in preliminary analysis. determine how acute lymphopenia mediates ich infection risk and outcome. prolonged length of stay (los) in the intensive care unit (icu) is associated with significant medical complications and higher costs in patients with spontaneous intracerebral hemorrhage (ich). aim of this study is to assess predictors of prolonged icu los in ich. we conducted a retrospective analysis of ich patients admitted to our institution over a seven-year period. demographics, clinical data, and laboratory studies at presentation were recorded. initial ct scans were reviewed to determine location, hematoma volume, and presence of intraventricular extension. surgical interventions, insertion of an external ventricular drain (evd), and medical complications, including infections and deep vein thrombosis/pulmonary embolism (dvt/pe) were reviewed. los was calculated based on the number of midnights spent in the icu. patients spending less than 24-hours in the icu were excluded. 130 ichs were analyzed. the mean age was 61.2 ± 14.1 years and 50.7% were females. prolonged los, defined by using the point of change and cumulative sum methodology analysis after normalization of the sample, was found to be > 8 days. intubation at presentation (p<0.01), presence of ivh (p<0.05), insertion of evd (p<0.01), surgical evacuation (p<0.01), chest infections (p<0.0.1) and dvt/pe (p<0.01) were associated with prolonged los, while location of the hemorrhage, hematoma volume, and ich score at presentation were found not to be significant. this is a preliminary analysis to identify predictors of prolonged icu-los in intracranial hemorrhage. chest infections and dvt/pe were associated with prolonged los. surgical intervention, intubation at presentation, and insertion of evd were also independent predictors. these findings suggest that early evd weaning or shunt placement, and potentially early tracheostomy could help in decreasing the icu-los in patients with ich. diffusion weighted imaging (dwi) lesions are found in nearly 50% of patients with acute spontaneous intracerebral hemorrhage (sich). however, the timing of dwi lesions after sich ictus remains unknown. the purpose of this study is to estimate the timing of new dwi lesions after acute primary sich. by establishing a time frame, potential pathophysiologic mechanisms for dwi lesions can be elucidated. between september 10, 2011 and january 15, 2017, patients were enrolled in a prospective study examining dwi lesions in acute primary sich. enrolled subjects received a research brain mri after admission blinded to the clinical teams. during the same admission, select patients received a separate brain mri as part of clinical care. subjects with 2 scans were identified from the study cohort, and their imaging evaluated for dwi lesions. when compared to the first mri scan, the presence of a new dwi lesion on the second mri scan was defined as a new dwi event. a kaplan-meier analysis was performed to estimate the time to a new dwi event from the first mri scan. among 121 enrolled subjects, 65 (53.7%) had two brain mris. mean age was 56.2 years, 60% were male, and 49.2% were african american. the median ich score was 1 (iqr 1). median time from sich onset to first mri was 1.2 days (iqr 1.2). median time from first mri to a new dwi event was 4.9 days (95% ci, 3.0 to 7.8). median time between the first and second mri was 2.1 days (iqr 2.6). our data suggest that new dwi lesions occur 6 days after sich ictus. therefore, acute interventions during the first 24 hours after sich admission may not be associated with dwi is needed to elucidate potential mechanisms associated with dwi lesions in sich. intracranial hemorrhage (ich) is a common complication in children on ventricular assist device (vad) support, though bleed severity is highly variable. this study examined factors associated with ich requiring neurosurgical intervention in this at-risk population. children aged 1 month-18 years old admitted between 2003-2018 with a diagnosis of intraparenchymal hemorrhage (iph) or subdural hemorrhage (sdh) while on vad support were identified retrospectively from an institutional database using icd-9 and icd-10 codes, after obtaining irb approval. patients requiring neurosurgical intervention (ns+) were compared with those who did not (ns-) using manniables). in total, 23 children met inclusion criteria. of those, 4/23 (17.4%) required neurosurgical intervention bleeds occurred in 3 patients (2/4 ns+, 1/19 ns-). ns+ patients were older at bleed (mean 11.7 ± 5.6 years vs 4.8 ± 5.2 years, p = 0.04). all 4 ns+ patients were taking warfarin, versus 2/19 ns-patients (p=0.03); none of the ns+ patients had supratherapeutic inr. number of antiplatelet agents did not differ between groups (1.4 ± 1.3 ns-vs 1.0 ± 0.8 ns+, p = 0.65). patients received a median of 4 ct scans (iqr 3-7) with no significant difference between surgical and nonsurgical groups (p = 0.56). among our cohort, older children and those on warfarin were more likely to require neurosurgical neurosurgical treatment, though results should be interpreted cautiously given small numbers. patients received multiple ct scans, though only a minority ultimately required neurosurgical intervention. unnecessary ct scans in this population. elevated intracranial pressure (icp), usually monitored by invasive icp-measurements, is associated with mortality in intracerebral hemorrhage (ich). the non-invasive evaluation of pupillary function using automated pupillometry is increasingly used in critical-care settings. the association of various pupillary parameters assessed by automated pupillometry with icp is unestablished, specifically the sensitivity and specificity during icp-elevation and the performance of sympathetic versus parasympathetic parameters. we enrolled 8 ich patients admitted to our neurocritical-care unit who received invasive icpmeasurement by an external-ventricular-drain (evd). we monitored parameters of pupillary reactivity [i.e. light-reflex latency (lat; s), constriction and re-dilation velocities (cv, dv; mm/s), and percentage change of apertures (per-change; %)] using a portable pupilometer (neuroptics®) as well as corresponding icp values up to every 30 minutes for the duration of hospital stay. receiver operating characteristic (roc) analysis was performed to investigate associations between changes in pupillary reactivity and elevated icp. sensitivity and specificity of sympathetic and parasympathetic pupillary parameters were analyzed to evaluate associations between pupillary reactivity and icp-elevation in 4 patients (3 women, mean age 71.5±4.2 years), without icp-elevation and no midline shift upon neuroimaging, 170 assessments were compared to 72 assessments in 4 patients (2 women, 52.0±17.2 years) during icp-levels >20mmhg and corresponding midline shift. roc-analyses revealed a significant negative association of all assessed pupillary parameters with icp-elevation. best discriminative thresholds for icp-elevation were: cv<0.8mm/s, per-change<13%, lat<0.3s, and dv<0.3mm/s. the highest sensitivity and specificity (i.e. 84.5% and 90.6%; p<0.001) for an association with concomitant icp-levels >20 mmhg were found for a combination of the parasympathetic parameters cv<0.8mm/s and per-change<13%. our data suggest an association between non-invasively detected changes in pupillary reactivity and elevated icp. parameters of parasympathetic pupillary modulation seem most reliable to indicate icpelevation. spontaneous ich (sich) remains a deadly complication from the use of direct oral anticoagulants -pcc for the reversal of doac -pcc in the prevention of hematoma expansion (he) in doac associated sich across a large health system. consecutive patients who were admit -pcc between may 2017 and april 2019 were analyzed. baseline demographics and outcomes were abstracted through retrospective chart review. he was defined as volume>33% or >12.5ml between baseline and follow-up ct. sich volume was calculated using the abc/2 method and ivh score. descriptive statistics were used -pcc and its association with outcomes. -pcc for sich. the median age was 80 (48-95), 72% were caucasian and --pcc dose of 24.9 units/kg (15.5-56.4) compared to 20.5 units/kg (15.7 to 53.4) with he. he was seen in 21% of patients (rivaroxaban in 4, apixaban in 5). among patients with he, 22% of patients died or went to a skilled nursing facility vs 26% in those without he. discharge to home or acute rehab was similar in both groups while rates of mortality and discharge disposition were similar between those with and without he, -pcc. treatments for the reversal of doac related sich should be investigated further. elderly patients with mild traumatic brain injury (mtbi) are frequently admitted to an intensive care unit (icu), which is potentially both harmful and unnecessary. however, little exists to inform early decision making to determine appropriate utilization of icu care. here we sought to elucidate factors available upon admission to identify geriatric patients who could safely be monitored in a non-icu setting. adults 65+ years admitted with isolated mtbi, defined as positive radiologic study and glasgow coma scale (gcs) 13 -15, between january 2011 -december 2016 were identified. primary outcomes were ernight stay, no surgery, no intubation, and discharged home) and glasgow outcome scale (gos). positive outcome was defined as gos 4 -5 and a total of 234 patients met criteria. of these, 27 underwent emergent neurosurgical intervention., leaving 207 for analysis. most presented with gcs 15 (77.8%) and were admitted to icu (85.5%). nearly point decrease in gcs during hospital stay. upon discharge, 89.9% were classified gos 4 -5. predictors 0.007), and no home use of anticoagulant/antiplatelet medication (p = 0.007). presence/type of a single intracranial hemorrhage (ich) was not significantly associated with outcome, but presence of bilateral or multiple lesions independently predicted poor outcome (p = 0.040). overtriage of patients to an icu is costly, resource intensive, and avoidable. here, we suggest a conservative framework to assist the determination of which patients can be safely observed in non-icu population who present with mtbi. perihematomal edema (phe) is a known predictor of outcome after intraparenchymal hemorrhage (iph), but factors contributing to edema formation are incompletely understood. tissue water uptake measured using hounsfield unit density on ct scan has emerged as a predictor of edema in ischemic stroke. the aim of this study was to examine this association in iph, where the theoretical driver for edema volume is not anoxic cellular injury, but rather exposure of tissue to blood. women's hospital were prospectively enrolled between september 2017 and march 2019. phe and hematoma were identified on ct scans performed at admission and an average of 10.5 +/-4.3 hours later. hematoma volume, hematoma surface area and phe volume were measured. net water uptake (nwu) was calculated as the percent change in phe hounsfield unit density compared to normal contralateral hemisphere. associations between variables were examined with pearson correlations and regression analyses. hematoma volume and surface area at admission were significantly associated with phe volume on the admission scan (r = 0.90, p < 0.001 and r = 0.69, p < 0.001 respectively) and at the follow-up time-point (r = 0.86, p < 0.001 and r = 0.84, p < 0.001 respectively). there was no association between nwu and phe volume at either time-point (r = 0.23, p = 0.14 and r = -0.01, p = 0.99 respectively). in multivariable analysis, hematoma volume at admission remained an independent predictor of phe volume on the followthese results suggest that, unlike in ischemic stroke, phe volume is not related to water content. rather, hematom may suggests new avenues to predict edema formation. the risk of hematoma expansion (he) in patients with recent intracranial hemorrhage (ich) receiving therapeutic anticoagulation (ac) is not known. we aim to characterize complication rates and factors associated with he in these patients. we performed a retrospective cohort study of adult patients at harborview medical center between 2014-2019, who presented with ich and were therapeutically anticoagulated within 4 weeks after the ich for a venous thromboembolic event (vte). we excluded patients with ich due to hemorrhagic conversion of ischemic stroke, venous sinus thrombosis, or an aneurysm consequently secured. we assessed the rate of he, defined as either radiographically proven expansion requiring cessation of ac, or death due to he. t-tests and chi-squared tests were used to analyze factors associated with he. -94), 20% were female. we identified 42% sdh, 30% iph, and 28% multicompartment ichs, 70% due to trauma, 14% hypertensive, and 16% other etiologies. anticoagulation was initiated an average of 10.5 +/-1.0 days after ich. overall, 18% developed he, one third of whom died. most patients (64%) experienced no complications, 10% developed minor extracranial bleeding events with ac subsequently resumed. patients with he were older (61 vs. 52), had higher gcs (12 vs. 9.2), lower hematoma volume (36% vs. 48% > 30 cc), larger maximal sdh diameter (13.2 vs 8.31 mm), anticoagulated earlier (8 vs. 10 days), and lower maximal ptt (110 vs. 122), although trends were not statistically significant. there was a marginally significant association between he and the presence of hydrocephalus (p<0.07). while ac in patients with acute ich can be safely tolerated, there is a substantial proportion demonstrating he. our analysis was limited by the sample size. larger studies are needed to identify clinical and radiographic features associated with complications. intracerebral hemorrhage (ich) is a disease that is associated with high morbidity and mortality. we examined our center's experience with surgery for ich and clinical outcomes. we prospectively enrolled patients with spontaneous ich from 2009 to 2018. patients were divided into two groups based on whether they received surgical or conservative management. surgical interventions included hemicraniectomy and/or hematoma evacuation. multivariable regression analysis was conducted to compare the clinical outcomes after adjusting for potential confounders. adjusted odds ratio (aor) or adjusted mean difference (amd) were reported. we included 442 patients, 83 (19%) had surgery and 359 (81%) did not. of the surgical group, 32 (39%) had hematoma evacuation, 7 (8%) had hemicraniectomy, and 44 (53%) had both. clinical characteristics were comparable in both groups. in the surgical group, nihss and glucose were higher and creatinine was lower compared with the nonoperative group. through multivariable analysis, we identified independent predictors of surgery in ich patients including baseline hematoma volume (aor 1.04, 95% ci 1.03-1.05; p=0.001) and enlargement with (aor 2.81, 95% ci 1.44increase in hematoma volume, there was a 4% increase in the odds of having surgical intervention. was less likely to have a favorable discharge disposition to home or inpatient rehabilitation (49% vs. 66%; p=0.01). surgery was independently associated with longer icu length of stay (amd 2.96, 95% ci 1.38,-4.54; p=0.001) and hospital length of stay (amd 3.63, 95% ci 0.73-6.54; p=0.01) after controlling for potential confounders. in our patient population, baseline hematoma volume and expansion were independent predictors for surgery in ich patients. after controlling for other variables, surgery did not impact ich outcomes and was associated with prolonged icu and hospital length of stay. moyamoya disease (mmd), an intracranial vasculopathy characterized by internal carotid artery hypoplasia, often presents with intracerebral hemorrhage (ich) presumably due to rupture of fragile collateral vessels. although mmd-related ich is generally managed similarly to spontaneous ich, we present a case in which standard management strategies may have led to an unprecedented catastrophic outcome. case report. a previously healthy 37-year-old female presented to the emergency department with right-sided weakness, dysarthria, and headache. she was intubated for airway protection. a head computed tomography (ct) demonstrated a large left basal ganglia ich. ct angiogram revealed diffuse narrowing of the entire anterior circulation with robust posterior communicating arteries. brain magnetic resonance imaging (mri) revealed prominent collateral vessels and sulcal hyperintensities ("ivy sign") consistent with mmd. given these findings, systolic blood pressure was kept under 140 mmhg for the first 24 hours. the following day, the patient's mental status gradually worsened. workup including repeat head ct, infectious and metabolic panels, as well as electroencephalogram (eeg) were unrevealing except for a decreased end-tidal carbon dioxide (co2). two days after presentation, the patient acutely developed fixed and dilated pupils. eeg concomitantly revealed slowing and attenuation of the background. repeat ct head showed new diffuse cerebral edema with tonsillar herniation. despite hyperosmolar therapy, paralytics, pentobarbital, and cerebrospinal fluid diversion, no improvement was noted. unfortunately, brain mri revealed multifocal brainstem infarcts with superimposed duret hemorrhages. herein, we report diffuse cerebral edema as a complication of mmd-related ich. we hypothesize that disruptions of delicate cerebral autoregulatory mechanisms led to extensive hypoxic-ischemic injury. in the setting of ich, aggressive blood pressure management coupled with relative hypocapnia may have likely caused vasoconstriction of poorly compliant arteries leading to worsened cerebral blood flow and ischemia. therefore, because of its complex pathophysiology, traditional blood pressure and co2 targets should be revisited in mmd-related ich. it is unknown whether admission systolic blood pressure (sbp) differs among etiologies of intracerebral hemorrhage (ich). such differences may have implications for blood pressure -lowering strategies after ich. we compared admission sbp across ich etiologies among patients in the cornell acute stroke academic registry (caesar), which has enrolled all adults with non-traumatic ich at cornell from 2011 through 2017. trained analysts prospectively collected demographics, comorbidities, and admission sbp, defined as the first recorded value in the emergency department or upon transfer from another hospital. ich etiology was adjudicated by a panel of board-certified neurologists using the smash-u criteria. we used anova to compare mean admission sbp among ich etiologies. after verification of model assumptions, multiple linear regression was used to adjust for age, sex, race, and glasgow coma scale (gcs) score. among 494 ich patients in caesar, admission sbp varied significantly across ich etiologies, ranging from 138 mm hg in those with structural vascular lesions to 167 mm hg in those with hypertensive ich (p <0.001). the overall difference in admission sbp across etiologies remained significant after adjustment for age, sex, race, and gcs score (p <0.001 by the wald test). the mean admission sbp in hypertensive ich cases was 17 mm hg (95% ci, 11-24 mm hg) higher than in ich cases of all other etiologies combined. among patients with a history of hypertension, the mean admission sbp was 12 mm hg (95% ci, 5-19 mm hg) higher in hypertensive ich than in ich cases of all other etiologies combined. in a single-center ich registry, admission sbp varied significantly among different ich etiologies. our results suggest that admission sbp is associated with ich etiology rather than simply representing a physiological reaction to the ich itself. incidence of clinical seizures after intracerebral hemorrhage (ich) has been reported to range from 2.7 % to 17 %, with the majority occurring at or near onset. in the present study, we investigate incidence of clinical seizures in ich subjects during hospitalization and evaluate whether clinical seizures are associated with poor clinical outcomes at discharge. a retrospective review of consecutive patients with ich admitted to the baylor st. luke's medical center between january 2008 and december 2012 was conducted. demographics, admission gcs, admission nihss, admission mrs, incidence of clinical seizures and clinical outcome at discharge were recorded. associations between the presence or absence of seizures and clinical outcome, measured by the glasgow outcome scale (gos), were investigated using a multivariate logistic regression model. 604 patients with ich were included. clinical seizures were identified in 15 subjects (2.5 %), presenting in a median time of 1.5 days post-admission (iqr 2). outcome was significantly worse for subjects who experienced a seizure compared to subjects who remained seizure-free, poor outcome (gos<4) was found on 73.3 % and 47.6 % respectively (or 6.45, ]; p=0.035). this increased risk was significant after controlling for gender, ethnicity, admission gcs, admission nihss, admission mrs higher in the seizure group compared to the seizure-free group, 73.3 % vs 46.3 % respectively (or 6.74, 95 % ci [1.16-39.2]; p=0.033) after adjusting for mortality and severe vegetative state (gos 1, 2) there was no statistical significant difference between both groups (p=0.9632). our study shows a significant association between clinical seizures and poor clinical outcome at hospital discharge after controlling for admission status and other type of complications; however, the presence of clinical seizures did not influence in-hospital rates of mortality. despite the well-established use of the national institutes of health stroke scale (nihss) score as a severity scale for ischemic stroke patients, it is still unclear which score is best for intracerebral hemorrhage (ich) patients. while some studies have looked at nihss and glasgow coma scale (gcs) as a predictor of mortality and 3-month mrs, there is a dearth in the literature looking at how they affect longer functional outcomes. in this study, we look at and compare how initial nihss and gcs predict 6month functional outcomes in ich patients. one-hundred patients who underwent minimally invasive ich evacuation, a standardized patient population, from december 2015 to october 2018 were retrospectively reviewed. we looked at nihss and gcs as a predictor of functional outcome at 6-months, defined as modified rankin scale (mrs) 0-3. multivariate regression models were constructed using clinical and statistical inferences to predict mrs. these variables were also correlated with 6-month mrs in multivariate analyses. of 100 patients, 33.0% (n=33) were female and the average age was 62.2 (sd=13.8). on admission, the median nihss was 17.0 (iqr 12.3-22.0) and the median gcs was 10.0 (iqr 7.0-13.0). multivariate logistical analyses showed that higher nihss predicts worse 6-month mrs, however gcs does not (p=0.001 and 0.574, respectively). correlation analysis with mrs at 6-months reveals that for every 9.17point increase in nihss, mrs increased by 1. in this cohort, the admission nihss predicts 6-month mrs in ich patients while controlling for significant covariates, while gcs does not appear to. despite its simplicity and generalizability, the gcs lacks critical ich elements that the nihss includes. the usefulness of the nihss as a predictor of ich outcomes has been questioned, since ich patients often have depressed consciousness on presentation, however we demonstrate its utility as a predictor of 6-month functional outcomes. among patients with intracerebral hemorrhage (ich), it is unclear whether red blood cell (rbc) transfusions impact outcomes. we investigated the association between rbc transfusions and inhospital mortality in patients with ich. we performed a retrospective analysis using the national inpatient sample (nis) database. we used standard diagnosis codes to identify non-traumatic ich hospitalizations from 2002 through 2011. our exposure was rbc transfusions during the ich hospitalization and the outcome was hospital mortality. we performed multivariable logistic regression to estimate the association between rbc transfusion and outcomes after adjusting for demographics, charlson comorbidity index (cci), and hospital characteristics. however, given the absence of ich severity and physiologic variable data within nis, we performed additional analyses in a separate, single-center ich cohort, adjusting for admission ich and apache-ii scores. of 619,167 non-traumatic ich hospitalizations in the nis, 22,904 (4%) patients received rbc transfusions. patients receiving rbc transfusions had more comorbidities than those not receiving rbc transfusions (cci >3: 28% vs 14%). rbc transfusion was associated with increased odds of hospital mortality (adjusted or 1.29; 95% ci 1.22-1.38). in a separate cohort of 427 primary ich patients, 32 (7%) patients received rbc transfusions during their hospitalization. rbc transfusion was not associated with hospital mortality after adjusting for ich and apache-ii scores (adjusted or 1.96; 95% ci: 0.71-5.39). rbc transfusion was associated with increased odds of hospital mortality after ich. however, underlying medical comorbidities, acute physiologic derangements, and ich severity may account for some of these ns on outcomes after ich. deep venous thrombosis (dvt) is a common cause of morbidity and mortality in patients admitted to the neuro-intensive care unit (nicu). the aim of this work is to assess the incidence of dvt in patients diagnosed with intracerebral hemorrhage (ich) and study its demographic characteristics. a retrospective chart review of consecutive patients with ich admitted to the baylor st. luke's medical center between january 2008 and december 2012 was conducted. subject demographics, admission status, incidence of dvt, hospital length of stay (hlos), intensive care unit length of stay (icu-los) and clinical outcome at discharge were recorded. data was analyzed to assess the prevalence dvt in this period. 604 patients with ich were included. dvt was identified in 53 subjects (8.8%). median time to dvt from diagnosis was 120 h (iqr 192) after the initial symptoms of ich. the mean age of patients with dvt was 59.5 (sd 1.3) and 25 subjects (47.1%) were female. 39.6 % subjects were of caucasian ethnicity, 30.2 % african-american, 18.9 % hispanic, 1.9 %asian and 9.4 % were from other ethnicities. median hlos was 20 days (iqr 16.7) and icu-los was 6 days (iqr 13.7). moreover, 59.6% of patients who presented a hospital-acquired dvt had a poor clinical outcome at discharge (gos<4). ich patients admitted to the nic large prospective trials are needed to understand the baseline characteristics of patients at risk of dvt as well as the utility of surveillance and different prophylaxis methods. studies have demonstrated an association between high average systolic blood pressure (sbp), and increased sbp variability with worse clinical outcomes in non-traumatic intracerebral hemorrhage (ich). nevertheless, the optimal blood pressure target remains elusive. we aim at introducing an alternative approach to assess blood pressure in the acute phase of ich, by using the metric of sbp dose, and showing that it provides a more robust association with clinical outcome. we retrospectively evaluated 130 ichs admitted to our institution over a seven-year period. initial ct scans were analyzed to confirm the presence of intraparenchymal blood. blood pressure was recorded at presentation and hourly for the first 24-hours. mean sbp (msbp) in the first 24-hours was calculated; sbp dose (dsbp) was calculated via the trapezoidal method from area under the curve (auc), and divided in three groups: no dsbp (no time spent above 160 mmhg), moderate dsbp (auc spent above 160 mmhg), and high dsbp (auc above 180 mmhg). discharge dispositions were used as surrogates of clinical outcome. poor outcome included death, hospice, and long term acute care hospital. -one patients (39.2%) had poor outcome. of the patients in the no dsbp group none suffered poor outcome; 20% of the patients in the moderate dsbp group, and 52% of patients in the high dsbp group suffered poor mean sbp in predicting patient outcomes (p<0.001). high dsbp in the first 24-hours was associated with worse clinical outcomes, and was a better predictor compared to msbp. blood pressure dose is a promising novel metric that deserves further study in the management of ich. despite lack of ich-specific therapies that improve outcome, current guidelines recommend treatment of ich at tertiary care centers. as such, ich comprises a large proportion of inter-hospital transfers (ihts) to comprehensive stroke centers (cscs) despite studies suggesting lack of mortality benefit and low csc resource utilization. the subset of patients who derive the most benefit from a csc is unclear. here, we create a triage model to identify ich patients who can safely avoid transfer to a csc. a retrospective cohort of patients with spontaneous ich transferred to our csc was used to develop our triage model. patients with early discharge from the neuro-icu without use of any csc resource during hospitalization were identified as low risk, non-utilizers (lr--nu were identified and used to develop a triage model which minimized the likelihood of release of patients requiring csc resource. this model was tested in a replication cohort for accuracy. the development and replication cohorts comprised 358 and 99 patients respectively of whom 78 (22%) and 26 (26%) were lr-nu. initial gcs and baseline ich volume were associated with lr-nu in multivariate analysis. presence of ivh and infra-tentorial location of ich were also included. initial gcs >13, ich volume <15ml, absence of ivh, and supratentorial location had an auc, specificity, sensitivity, ppv, and npv of 0.72, 91.4%, 52.6%, 63.1%, and 87.4% respectively for identifying lr-nu. in the development cohort and 1 patient in the replication cohort had a neurosurgical intervention. however mostly these were for non-emergent avm interventions. spontaneous ich patients with initial gcs >13, ich volume <15ml, no ivh, and supratentorial location might safely avoid iht to a csc. validation in a prospective, multicenter cohort is warranted. metastatic cardiac myxomas have many neurologic complications, including intracerebral hemorrhage. cardiac myxomas are rare intracardiac tumors. though most myxomas are benign, the risk of malignant spread to the central nervous system (cns) is well known. we describe a case of multiple recurrent intracerebral hemorrhages (ich) occurring in the setting of a recently treated cardiac myxoma. a 61-year old woman with a history of resected left atrial myxoma presented with a one-day history of left ear paresthesias. computed tomography (ct) of the head was performed and demonstrated ichs within the right frontal and parietal lobes and left cerebellar hemisphere. she had presented to an outside hospital several weeks earlier with similar symptoms with imaging demonstrating similar definitive evidence of malignancy or infection. conventional angiography was negative for vasculitis. brain biopsy showed no evidence of amyloidosis or glioma. at our institution, magnetic resonance imaging (mri) of the brain with double inversion recovery also revealed no evidence of vasculitis; however, the study was concerning for multiple cavernous malformations. underwent genetic testing. no mutations associated with familial cerebral cavernous malformations syndromes were identified. several months later, she returned to the hospital with recurrent symptoms. head ct and mri re-demonstrated multiple cavernous malformations with surrounding vasogenic edema, which were mildly increased compared with prior studies. given progression of her mri findings, concern for metastatic cardiac myxoma was raised. considering that 20-30% of patients with cardiac myxoma will have some form of neurologic complication, all should receive a comprehensive neurologic evaluation. diagnosis is made with neuroimaging and brain biopsy. primary treatment of cardiac myxoma includes surgical resection. when cns lesions are present, chemotherapy or stereotactic radiosurgery should be considered. an association between spontaneous hyperventilation, severity of disease at presentation, and poor clinical outcomes has been reported in patients with subarachnoid hemorrhage (sah). we evaluated the relationship between early breathing changes and outcomes in patients with intracerebral hemorrhage (ich). consecutive patients with spontaneous ich were enrolled in an observational cohort study conducted between 2006 and 2019 at a comprehensive stroke center. patient characteristics and functional outcome at discharge were prospectively recorded. arterial blood gas (abg) measurements and mechanical ventilation settings in the first 72 hours of admission were retrospectively collected, when available. hyperventilation was defined as pco2 <35 mmhg concurrent with ph >7.45 in spontaneously breathing patients, excluding mechanically ventilated patients not overbreathing the set rate of a control mode. we assessed for an association between early breathing changes, hemorrhage severity and hospital outcomes by univariate and adjusted analyses. early abg data were available for 220 of 632 patients. patients with abg data had more severe hemorrhages than those without (median ich score 2 versus 1, p<0.001). hyperventilation occurred in 52 (28%) of cases. there was no univariate association between hyperventilation and ich score, admission gcs score or initial hematoma volume. lower initial pco2 was associated with greater risk of in-hospital death (or 0.94 per mmhg, 95%ci [0.89, 0.996], p=0.042) after adjustment for ich score, pneumonia and mechanical ventilation requirements. spontaneous hyperventilation is less common after ich than sah (55% vs 28%, respectively) and not associated with initial disease severity. the association between lower pco2 and in-hospital mortality after ich, independent of neurologic severity and comorbid respiratory complications, is consistent with findings of greater delayed ischemia and worse outcomes in spontaneously hyperventilating sah patients. these associations may be mediated by a potentially modifiable underlying mechanism such as acute shifts in cerebral hemodynamics due to pco2 changes. ich or sah patients often undergo interhospital transfers to tertiary centers. acute clinical deterioration diversion is often implemented via external ventricular drains (evd's). the safety and efficacy of leaving the evds clamped or open during inter-hospital transfer is not known. we aimed to implement a pilot during inter-hospital transport for hemorrhagic stroke patient. under the neuroemergencies management and transfers (nemat) program, department of neurosurgery at mount sinai health system, we implemented this protocol in october, 2018. patients with ich or sah requiring evd placement prior to inter-transfer to a specialized center for ich or sah within our health system were enrolled. recommendations for icp management, for post-evd drainage h and 10 cm or lower for ich were included. evd was clamped for transportation and a dose 1 g/kg of mannitol was given just prior to transportation. icp precautions were maintained throughout transportation. 15 (6 male,9 female_ patients who underwent inter-hospital transfers for ich (n=3) and sah (n=12) after placement of evds for raised icp at the transferring hospital were included. all 15 patients required endotracheal intubation for transfer. 11/15 patients had an icp less than 15 mmhg on arrival at the receiving hospital. conclusion: protocolized care for ich and sah patients with evds and icp management during interhospital transfers for patients is safe and feasible. such a protocol could an help facilitate potentially rapid and safe life saving inter-hospital transfers for hemorrhagic stroke patients with evds in large urban health system to to hospitals with specialized definitive neurosurgical and neurocritical care. intracerebral hemorrhage (ich) during pregnancy is abound with diagnostic and therapeutic dilemmas and contributes to pregnancy-related mortality. we present a pregnant patient with ich due to moyamoya disease to highlight these issues. case report. a 40-year-old 32-week pregnant asian woman presented after developing an acute onset headache followed by loss of consciousness. in the emergency department, she was comatose with bilateral pinpoint pupils and required intubation for airway protection. initial ct head showed predominantly intraventricular hemorrhage (ivh) that emanated from the left thalamus. ct angiogram revealed highgrade stenosis of the left m1 segment with moyamoya collateralizations. due to hydrocephalus, an external ventricular drain (evd) was placed. the patient required admission to the neurocritical care unit for further monitoring of exam and vitals. continuous fetal monitoring, and ultimately, successful csection on day 3 of hospitalization was performed through collaboration with the obstetrics and gynecology (ob/gyn) team. cerebral angiogram confirmed the diagnosis of unilateral moyamoya disease as the cause of the patient's ivh. the patient was discharged initially to acute rehab and then home with minor cognitive deficits. the work-up and management of ich in pregnant patients can be challenging. moyamoya disease is a non-atherosclerotic cerebral vasculopathy that can be included in the differential diagnosis for ich in pregnant woman. the most common presentation of moyamoya disease in adults is ich, and it's mainly due to the rupture of dilated and fragile vessels in the basal ganglia, and rupture of saccular aneurysms within the moyamoya collaterals. pregnancy might increase the risk of ischemic or hemorrhagic stroke in women with moyamoya, but available data is controversial. cooperation between the neurocritical care and ob/gyn teams can assist in determining the risks and benefits of medications, imaging, and the need and timing for delivery, thus assuring optimal outcomes for the patient and infant. spontaneous intracerebral hemorrhage (ich) is severely disabling, and survivors often require extensive rehabilitation to maximize recovery. recovery for survivors discharged from index hospitalization is variable and incompletely explained by discharge functional capacity. we assessed whether discharge disposition was independently associated with long term recovery potential. patients with acute ich hospitalized at a tertiary care comprehensive stroke center between 2006 and 2019 were enrolled in a prospective, observational study that recorded demographics, standard severity s was measured by the modified rankin scale (mrs) at discharge and three months. discharge disposition were ordinalized by activity engagement level from highest to lowest as follows: home, 4; acute inpatient rehabilitation (air), 3; skilled nursing facili 2; and long-term acute care hospital (ltach), 1. ordinal regression was used to assess the prognostic association between discharge disposition and three month functional status by mrs, adjusting for the ich score and mrs at discharge. among 656 patients enrolled, 445 survived and had complete in-hospital data for analysis, and three outcomes at three months (mrs 4-6; 91.8% and 96.5% respectively), with most either bedbound or dead (58.8% and 63.2% respectively). poor outcomes were less common among patients discharged to air (39.7%) or home (9.0%). the adjusted model found that a better discharge disposition was associated with more favorable three month mrs (odds ratio 0.54, 95% ci [0.40, 0.74], p=0.00011). discharge disposition captures prognostically important characteristics in patients with intracerebral hemorrhage beyond traditional case severity and functional status measures. outcomes are poor for a large majority of patients unable to return home or qualify for acute rehabilitation. whether the prognostic characteristics requiring nursing facility care are modifiable by increasing rehabilitation services in those care environments is not known. 2018 as a reversal agent for uncontrolled or life-threatening bleeding for patients taking apixaban and rivaroxaban. approval was based on the results of interim analysis of the ongoing annexa-4 multicenter, prospective, open-label clinical trial. our institution began using the drug in august 2018. we report our clinical experience. we conducted a retrospective observational study of patients admitted to stanford medical center from -associated intracranial hemorrhage. -associated ich. the mean age was 74 (+/-10). 13 patients were male. the mean glasgow coma scale score was 14. hemorrhage types included intraparenchymal hemorrhage (9 patients), subarachnoid hemorrhage (4 patients), and subdural hemorrhage (2 patients). hemorrhage was associated with head trauma in 4 patients (40%). ten patients (67%) had "excellent" or "good" hemostasis defined by the annexa-4 criteria. three patients (15%) developed deep venous thrombosis. no patients developed pulmonary embolism or myocardial infarction. 30-day mortality was 20% (3 patients). we describe a case series of patients who received andexanet alfa for intracerebral hemorrhage at a large medical center. the incidence of intracerebral hemorrhage (ich) is 24.6 per 100,000 person years. nontraumatic spontaneous ich is usually seen in setting of uncontrolled hypertension or cerebral amyloid angiopathy and commonly occurs in basal ganglia, cerebral cortex, brainstem or cerebellum. spontaneous ich in corpus callosum with intraventricular hemorrhage (ivh) is very rarely seen and reported. we present an unusual case of corpus callosum hemorrhage with ivh associated with a reversible cerebral vasoconstriction pattern (rcvs) on cerebral angiography. the demographic information and clinical reports were obtained from electronic medical records retrospectively. select neuroimaging was obtained from neuroradiology department. year old caucasian male with a past medical history of chronic obstructive pulmonary disease, essential hypertension, and prior ischemic stroke with residual right hemiparesis presented in unresponsive state when he was discovered on bathroom floor. neurological examination on admission showed no verbal response, eyes open, with reactive pupils, and withdrawal to pain in left arm and leg. blood pressure on admission was 224/92 mmhg. computer tomography (ct) of head showed large ich in rostrum, genu and trunk of corpus callosum with intraventricular extension and hydrocephalus. he was intubated for respiratory distress and external ventricular drain (evd) was placed. he was also treated with intraventricular alteplase 1 mg injection for total of 9 doses, 8 hours apart. blood pressure was controlled with nicardipine infusion initially, a up ct head showed resolution of ivh over the next several days, however, no significant clinical improvement was seen. patient remained abulic and akinetic. cerebral angiography performed showed right pericallosal artery beading pattern consistent with rcvs. after transition to comfort care, the patient expired on the 11th day of hospitalization. spontaneous non-traumatic corpus callosum ichs are rare, and while other causes have been reported, this particular etiology is likely due to rcvs. intracerebral hemorrhage (ich) is a leading cause of disability and mortality. infections are a common complication observed in ich and might be associated with worse outcomes. we aim to evaluate the association between infections and clinical outcomes at hospital discharge. a retrospective chart review of consecutive patients with ich admitted to the baylor st. luke's medical center between january 2008 and december 2012 was conducted. subject demographics, admission status, rates of infections including; pneumonia, urinary tract infection (uti), bacteremia and clinical outcome at discharge were recorded. associations between the presence or absence of infections and clinical outcome, measured by the glasgow outcome scale (gos), were investigated using a multivariate logistic regression model. 604 patients with ich were included. infections occurred in 141 subjects (23.5%). uti was the most common infection (45.2 %) followed by pneumonia (28.8 %) and bacteremia (19.2 %). clinical outcome was significantly worse for subjects who experienced any type of infection during hospitalization, compared to non-infected subjects, poor outcome (gos <4) was found on 63.8 % and 42.8 % respectively (p=0.0168). this increased risk was significant after controlling for gender, ethnicity, ermore, an unfavorable discharge disposition -infected group, 62.4 % and 42.2 % respectively (p=0.004). our study shows a significant association between infections and poor clinical outcomes at hospital intracerebral hemorrhage (ich) is a subtype of stroke associated with a high morbidity and mortality. low serum calcium levels have been previously associated with larger hematoma volumes, hematoma expansion and worse outcomes; however, the pathophysiological mechanisms are still not well understood. a confounding effect among serum calcium and magnesium levels has been previously considered. in the present study, we investigate whether hypocalcemia is associated with poor clinical outcomes controlling for serum magnesium levels. a retrospective chart review of consecutive patients with ich admitted to the baylor st. luke's medical center between january 2008 and december 2012 was conducted. serum calcium and magnesium levels were measured during hospitalization, hypocalcemia and hypomagnesemia were defined as serum levels below 8.4 mg/dl and 1.5 m/dl respectively. associations between serum calcium level and clinical outcome, measured by the glasgow outcome scale (gos), were investigated using a multivariate logistic regression model. 510 patients with ich were included. hypocalcemia was identified in 82 subjects (16.1%). clinical outcome was significantly worse in the hypocalcemic group compared to the normocalcemic group, poor outcome (gos <4) was found in 68.9% and 43.3% respectively (p=0.0035). this increased risk was significant after controlling for gender, ethnicity, serum magnesium levels, admission gcs, admission death) was also higher in the hypocalcemic group compared to the normocalcemic group, 69.6% and 41.8 % respectively (p=0.0016). our study shows a significant association between hypocalcemia and a poor clinical outcome after association. treatment of patients with intracerebral hemorrhage (ich) typically requires advanced care at a tertiary medical center. many patients present initially to regional or local emergency departments and require interfacility transportation to a referral center. mission hospital (mh) is a community-based nonacademic 763-bed tertiary care facility with comprehensive stroke center certification. we serve as the referral center for 5 affiliated mission health hospitals and 11 regional non-affiliated hospitals across 18 counties. these hospitals are distributed throughout a mountainous and rural area with challenging terrain for transportation and limited resources for critical care transport. here, we aim to describe the current transfer paradigm and consistency of care provided during interfacility transport of ich patients prior to implementation of a dedicated ich regional interfacility transfer protocol. retrospective review of the electronic medical record was performed to identify all patients in calendar year 2018 admitted to mh with a principal diagnosis of nontraumatic ich who initially presented to another facility prior to transfer to mh. data, including demographics, transport service type, and transport sequential blood pressures, were collected. blood pressures during transport were analyzed to determine whether blood pressure exceeded our guidelines. 51 patients with ich transferred to our referral center were identified. 10/51 (19.6%) were transported via critical care transport, and 41/51 (80.4%) were transported by local ems using general adult transport protocols. 9/51 (17.6%) had uncontrolled hypertension as defined by 2 or more bp readings above our guidelines. of these, 3/9 (33.3%) were transported via critical care transport and 6/9 were transported via local ems. transport records were incomplete in 15/51 (29.4%). elevated blood pressures during transport of ich patients are common. rural health systems are challenged by lack of critical care transport capabilities. we are currently implementing a dedicated protocol for interfacility transport care of ich patients. infratentorial intracerebral hemorrhage (ich) is associated with worse prognosis than supratentorial ich; however, infratentorial ich is often excluded or underrepresented in major studies of ich. we sought to evaluate the natural history of infratentorial ich stratified by brainstem or cerebellar location using a prospective observational study inclusive of all spontaneous ich presenting to our institution. using a prospective, single center cohort of patients with spontaneous ich between 2008-2018, we conducted a descriptive analysis of baseline demographics, severity of injury scores, and long-term functional outcomes of infratentorial ich stratified by cerebellar or brainstem location. infratentorial ich occurred in 82 (13%) of patients in our ich cohort. cerebellar ich occurred in 45 (55%) and brainstem ich occurred in 32 (45%). compared to cerebellar ich, brainstem ich had significantly worse severity of injury scores, including: admission glasgow coma scale (p <0.001), ich score (p = 0.02), and national institute of health stroke scale (nihss) (p = 0.001). modified rankin scale (mrs) scores at 3 months were significantly better in patients with cerebellar ich compared to brainstem ich (median 3 [1.5 -6.0] versus median 6 [5.0 -6.0], p = 0.04). patients with cerebellar ich were more likely to be discharged home or to acute rehabilitation (or 4.7, 95% ci 1.6 -14.4) but there was no difference in in-hospital mortality (or 0.39, 95% ci 0.13 -1.12) or cause of death (p = 0.5). patients with cerebellar ich who were alive at 3 months had smaller hemorrhages and lower severity of injury on admission. patients with cerebellar ich have less severe symptoms at presentation and more favorable functional outcomes compared to patients with brainstem ich. it has been known that patients with intracerebral hemorrhage (ich) have a higher rate of acute renal tality. the factors such as medications for blood pressure control, blood pressure (bp) variations and use of contrast for imaging without history of previous kidney disease. we analyzed the records from hospitalized patients in the icu from 2008 to 2012 in a single academic center with primary diagnosis of ich and renal failure. a total of 604 were analyzed, 86 patients (14.23%) were reported to (47.6%) patients did not meet the criteria for renal risk, injury or failure and 23 (26.7%) did not have enough data for the study. antihypertensive therapy used within the first 48 hours of admission was a combination of acei, arbs and b-blockers. patients showed a wide variability in blood pressure (max-min within a day) which could not be and use of iodinated contrast, since ct without contrast was the imaging study of choice in all patients. our observations did not show an association in between bp variability, type of antihypertensive therapy or use of iodinated contrast within the first 48hrs of admission to acute renal failure in ich patients either with or without history of renal disease. a larger study may be required to support this statement. milrinone, a phosphodiesterase inhibitor, has limited data as salvage therapy for cerebral vasospasm (cvs) secondary to aneurysmal subarachnoid hemorrhage (asah). to date, no study has compared patients treated with intravenous milrinone to a control group receiving standard treatment, primarily hemodynamic augmentation. we compared cvs duration in milrinone-treated patients to a control group, and evaluated additional safety and efficacy outcomes. this was a retrospective, single center, case control study. adult patients admitted to spectrum health or inclusion. the primary outcome was duration of cvs recorded on daily transcranial doppler exams. secondary outcomes assessed efficacy and safety. efficacy endpoints included, but were not limited to: incidence of ischemic stroke, interventions to treat cvs, icu/hospital length of stay (los), and in-hospital mortality. safety endpoints included vasopressor/inotrope requirements and incidence of arrhythmias. -treated and 27 control patients. milrinone use was associated with a longer duration of cvs (p = 0.048), increased use of intraventricular medications for cvs (p=0.003), greater vasopressor requirements (p =0.01), and longer vasopressor duration (p=0.0004). there was no difference in arrhythmias or in-hospital mortality. icu los in milrinone versus control groups was 24.8 vs. 20.2 days (p=0.06) and hospital los was 25.7 vs. 21 days, respectively (p = 0.05). there were 6 ischemic strokes in the milrinone group versus 2 in the control group (p=0.11). intravenous milrinone was associated with a longer duration of cvs in asah patients, greater vasopressor requirements, and trended towards a higher incidence of ischemic stroke, though not statistically significant. prospective, randomized, controlled trials are needed to further define the risks and benefits of milrinone therapy in asah patients. aneurysmal subarachnoid hemorrhage (asah) patients sustain several physiologic changes, including a rupture. mri is potentially useful for prognostication in asah but has not been well-studied in this patient population. we present our preliminary experience with multimodal mri in the acute period after asah. we hypothesized that changes in nodes of network critical to consciousness differ between patients with good and poor outcomes. thirty-four asah patients and 10 healthy volunteers underwent multimodal mri at 3t. mri t1 images were segmented, and aslconsciousness (i.e., salience network, central executive network, default mode network). wilcoxon rankto test odds of modified rankin scale (mrs) 0-3 at 6 months. asah patients had a mean age (±sd) of 57.3±14.2 years, and controls were 26.1±5.0 years (p<0.001). prefrontal cortex -3 and 4-6). r age-matched studies with more subjects and additional mri sequences are needed to better determine mri's potential utility in asah prognostication. aneurysmal subarachnoid hemorrhage (sah) classically presents with the "worst headache of the patient's life" which can be very debilitating and persist for weeks. headache is often refractory to standard treatment, including opiates. pain is thought to be derived from meningeal irritation in the subarachnoid space. the sensory fibers in the anterior meninges are innervated by branches from the ophthalmic division of the trigeminal nerve, which is closely associated with the sphenopalatine ganglion (spg). spg blockade with local anesthetic, first described in 1908, has used as a treatment for various types of headache disorder but has not been described in sah-associated headache. treatment approach is either transnasal or transcutaneous injection. this case series describes five patients who received spg blockade for intractable sah-associated headache. patients with acute aneurysmal sah in the neurocritical care unit were offered adjunct spg blockade for headache refractory to standard treatment. patients rated pain on a 0-10 numerical scale, both before and 30 minutes after the procedure, which included either transnasal administration of ropivacaine using the tx360 device (tian medical) or transcutaneous administration of ropivacaine with decadron. ess score on admission 2 (range 2-3)); two (40%) received transnasal blockade and three (60%) received transcutaneous blockade. median pre-treatment pain score was 8 (range 6their pain within 30 minutes; the fifth reported 30% reduction of pain. transcutanous spg blockade resulted in complete pain relief in all patients. the effects were transient, and pain typically returned within 24 hours. there were no complications associated with the procedure. repetitive spg blockade is a safe and effective adjunct treatment for sah-associated headache. a larger clinical trial is planned. tranexamic acid is recommended in the first 72 hours after subarachnoid haemorrhage (sah) and before aneurysm treatment to reduce rebleeding. in brazil, patients are frequently submitted to delayed aneurysm occlusion after sah (>72 hours from ictus). the objective of this study was to evaluate the effects of tranexamic acid on hospital complications and outcome of patients with sah. all consecutive patients admitted with sah between 2016 and 2018 at a reference center were included. data were collected prospectively during the hospital stay. all sah patients within 72 hours of ictus were considered eligible for tranexamic acid (ta) up to aneurysm occlusion. we analysed 3 groups: no ta, low dose ta and high dose ta. the primary endpoint was mortality at hospital discharge. other outcomes included hospital complications such as rebleeding, delayed cerebral ischemia and adverse events such as deep venous thrombosis dvt) and pulmonary embolism (pe). one hundred forty five patients were included in the study. approximately half (53,1%) received ta, with 37(48%) receiving low dose and 40 (52%) high dose. at baseline, the high-dose ta group had more -dose group (38% vs 22%). patients in the low-dose group had lower rebleeding rates (2.7%; p=0.05) than the no-ta and high-dose ta groups. mortality was lower for the no-ta and low-dose ta groups as compared to the high-dose ta patients. moreover, patients that did not receive ta had longer icu and hospital lengths of stay. dvt/pe rates were very low in our cohort and not different between groups. our study showed that patients that received low dose of tranexamic acid had lower rates of rebleeding as compared to those that received no ta and high-dose ta. mortality was also lower in this group when compared to patients that received high-dose ta. aneurysmal subarachnoid hemorrhage (asah) carries high mortality and morbidity. symptomatic vasospasm is an important complication of asah. about thirty percent of patients with severe vasospasm do not respond to conventional management and will go on to develop delayed ischemic strokes. medical management in these patients are limited and require endovascular therapy with intraarterial vasodilators and angioplasty. milrinone has vasodilator properties and inotropic activity which has been used by intravenous and intraarterial routes for symptomatic vasospasm. in this study, we tested the safety and feasibility of intraventricular milrinone (ivm) in patients with severe vasospasm administered through the external ventricular drain (evd). a retrospective review of medical records of patients with subarachnoid hemorrhage who received ivm between 2016-2018. ivm was given at a dose of 0.87 mg in 2ml sterile saline every 8 hours through an evd that was subsequently clamped for 2h. 28 patients received ivm for refractory vasospasm. among those, 27 patients had ruptured asah and one patient had ruptured internal carotid artery pseudoaneurysm secondary to pituitary macroadenoma resection. the mean ivm doses were 13 (range 1-30 doses). only one patient (3.5%) developed ventriculitis 26 days after ivm. there were no elevations of intracranial pressures with intraventricular administration of ivm. in patients with refractory vasospasm from aneurysmal subarachnoid hemorrhage, intraventricular milrinone administration seemed to be relatively safe. prospective trials are needed to further determine the safety and efficacy. rupture of cerebral aneurysm is the most common cause of subarachnoid hemorrhage (sah). hypertension is a particularly important risk factor for growing and rupture of cerebral aneurysm. in clinical practice, the non-adherence to anti-hypertensive medications is the most important cause of uncontrolled blood pressure. the aim of this study is to evaluate the effect of non-adherence to antihypertensive medications on the long-term prognosis of patients with hypertension and ruptured cerebral aneurysm based on the nationwide health claims database in korea. this study is retrospective cohort study using the national health insurance service-national sample cohort (nhis-nsc) in korea. we included non-traumatic sah patients (icd-10; i60) with hypertension who underwent endovascular coil embolization or surgical clipping for ruptured aneurysm. the primary outcome is defined as composites of recurrent stroke, myocardial infarction, all-cause death. adherence to anti-hypertensive medications is measured by calculating the proportion of days covered (pdc) based on the prescription records, which is treated as a time-dependent variable. we performed multivariate time-dependent cox regression analysis with adjustments for sex, age, diabetes mellitus, treatment morality (coil embolization or surgical clipping), and household income. -nsc, we found 880 patients who received coil embolization or surgical clipping for aneurysmal sah. among them, 297 patients with hypertension were included for analysis. during the 3.4 years of mean follow-up period, there were 116 patients who had primary outcome. in the multivariate cox regression, poor adherence to antiindependently associated with increased risk of primary outcome (adjusted hr 1.87, 95% ci 1.17-2.97, p-value=0.009). in this cohort study with real-world data, poor adherence to anti-hypertensive medications is a strong risk factor for worse prognosis in the hypertensive patients who underwent treatments for ruptured aneurysm. there is need for greater attention to adherence to anti-hypertensive medications in the high-risk patients. tcd is routinely used in aneurysmal subarachnoid hemorrhage (sah) for vasospasm surveillance. the value of tcd monitoring in non-aneurysmal sah (nasah) is unclear. in this study we sought to determine the clinical utility of performing tcd monitoring in a cohort of patients with nasah. retrospective case series study performed at a comprehensive stroke center in a university hospital. patients with sah in whom an aneurysm or other vascular lesion was not identified were extracted from a prospective database covering a 5 year period. patients with nasah were categorized into perimesencephalic and diffuse sah based on the ct appearance. baseline demographics and clinical variables were obtained from the database. tcd results were obtained from a tcd database and conventional criteria were used to diagnose sonographic spasm. categorical variables were compared a total of 50 nasah patients were identified; 32 perimesencephalic and 18 diffuse. spasm was identified in 9/30 (30%) perimesencephalic nasah patients and 6/18 (33%) diffuse nasah patients (p=0.7542). no differences were observed between groups in age (p= 0.896 ), discharge disposition (p= 0.4707), median her score (p= 0.4119) when comparing patients with spasm to those without spasm. similarly the median number of tcds (p= 0.4119) did not differ among patients with and without spasm. the location of nasah did not influence the diagnosis of spasm (p=0.7544). sonographic spasm occurs in 30% of nasah patients but no specific clinical variable appears to influence its occurrence. the clinical significance of such finding needs further validation. complications following aneurysmal subarachnoid hemorrhage (asah) may be associated with early fluid status. this study aims to assess the relation of fluid balance and intravascular volume to outcomes including acute kidney injury (aki), delayed cerebral ischemia (dci), and vasospasm (vsp) in asah. 64 consecutive asah patients were retrospectively collected including patient demographics and admission characteristics. intravascular volume on admission was measured by ivc ultrasound. daily fluid balance in the first 14 days of admission were recorded along with changes in bun and cr. outcomes including dci and vsp were collected. spaghetti plots were used to illustrate trajectory patterns. a linear mixed effect model was used the test the trajectory of slopes. an interaction term between time and patient condition was used to test the slope difference between patient conditions. 59 of 64 patients underwent ivc ultrasound assessment of intravascular volume. 21 patients were hypovolemic on admission with ivc collapsibility index >50% or distensibility index >18%. ivc slopes were found to be different by patient m balance decreased by -64.6±28ml/hr (p=0.02) while it increased 26.8±21.7ml/hr (p=0.22) in those -54.4±27.1/hr (p=0.05) while it increased 19.2±22.5/hr (p=0.39) in those without dci (interaction p=0.04). -87.5±27.8/hr (p<0.01) in those without vsp (interaction p<0.01). patient hemodynamics on admission as determined by ivc ultrasound does not correlate with development of aki. however, fluid balance in the first 14 days of admission may be associated with outcomes in asah. early prediction of delayed cerebral ischemia (dci) will improve management of subarachnoid hemorrhage (sah) patients. we used mass spectroscopy (ms) to undertake an unbiased interrogation of plasma proteins associated with dci. this is an observational prospective single-center study of patients admitted to a tertiary care center. serum samples from patients were obtained within 24 hours post-admission. we performed analysis in 2 cohorts separately at different times. the first cohort was a retrospective cohort of 24 matched subjects (13 no-dci vs 14 dci). the second cohort consisted of 45 matched subjects (24 no-dci and 21 dci). in both cohorts subjects were matched across dci status for age, sex and modified fisher scale. we performed t-tests across dci groups in both cohorts to identify proteins with a difference in concentrations between dci groups. we selected proteins with a p-value of <0.2 for difference across dci in both cohorts as potential candidates. 2017 and 2228 proteins were identified in cohort-1 and cohort-2 respectively. we identified 23 potential candidates in cohort-1, and 225 potential candidates in cohort-2. six proteins were identified in both cohort-1 and cohort-2 (p-value cohort-1 and p-value cohort-2): complement factor h (p=0.02 and p=0.003); complement factor i (p=0.09 and p=0.021), antithrombin-iii (p=0.19 and p=0.032), histidinerich glycoprotein (hrg) (p=0.03 and p=0.09), fetuin-b (p=0.13 and p=0.13), and hemopexin (p=0.03 and p=0.19). all plasma protein levels were lower in the dci group. in our unbiased approach to identifying biomarkers of dci we identified 6 potential candidates. the compliment cascade and antithrombin-iii has previously been identified as important in the pathophysiology of sah. of interest, we also identified hemopexin (part of the cd91-heme-hemopexin scavenging system) and hrg which is associated with cerebral vessel contraction as potential -b has not been previously reported in sah. confirmatory testing needs to be performed to validate our findings. glycemic gap (gg), determined by the difference between glucose and the hba1c-derived average glucose (adag), predicts poor outcomes in various clinical settings. our main objective was to evaluate various admission factors and outcomes in relation to gg. we retrospectively reviewed prospectively collected data on 121 adult patients with aneurysmal subarachnoid hemorrhage. admission glycemic gap (agg) was defined as adag (28.7×hba1c-46.7) subtracted from admission glucose (ag). poor composite outcome was defined as death, tracheostomy, gastrostomy, and/or discharge to a nursing facility. spearman method was used for correlation. generalized linear model was used to test the difference in gg between patient categories. mixed effects model was used to test the difference in trajectory slopes in gg. area under the curve (auc) for roc curve was used to estimate prediction accuracy. sas 9.4 was used for all data analyses. the overall mean agg was 58.9±51.8 mg/dl. agg was significantly correlated with ag (r=0.91, p<0.01), gcs (r= -0.51, p<0.01), lactic acid (r=0.40, p<0.01), and procalcitonin (r=0.40, p<0.01) on admission, but not with hba1c (r=0.04, p=0.65). there was a nonsignificant trend of higher agg in those with delayed cerebral ischemia (73.1±8.7 vs. 53.2±5.5, p=0.056). patients with poor composite outcome had both higher ag (194.4±7.7 vs. 167.8±7.5, p=0.02) and agg (77.9±6.3 vs. 40.9±6.2, p<0.01 ), but the difference in agg was more profound. trajectory slope in the first 24 hours for gg did not differ in patients with poor vs. good composite outcome (-1.56±0.53/6hr vs. -1.47±0.52/6hr, p=0.9), nor did it differ for pointof-care glucose testing (-1.32±0.52/6hr vs. -1.27±0.51/6hr, p=0.95). agg had significantly better prediction accuracy than ag in predicting poor composite outcome (auc: 0.69±0.05 vs. 0.64±0.05, p=0.02). admission glycemic gap served as a better predictor of poor outcome than admission glucose. additionally, agg was correlated with ag, lactic acid, and procalcitonin, and inversely correlated with gcs. the use of standardized management protocols (smps) has been shown to improve patient outcomes for multiple neurocritical diseases. however, whether smps improve outcomes after subarachnoid hemorrhage (sah) is currently unknown. we aimed to study the effect of smps on 6-month mortality and neurologic outcomes following sah. a systematic review of randomized control trials (rcts) and observational studies was performed by searching multiple indexing databases from their inception through january 2019. studies were limited -traumatic sah reporting mortality, neurologic outcomes, and delayed cerebral ischemia (dci). data on patient and smp characteristics, outcomes, and methodologic quality was extracted into a data collection form. methodologic quality of observational studies was assessed using the newcastle ottawa scale (nos). a total of 11,260 studies were identified; 484 were assessed in full and 36 met the criteria for inclusion. two studies were rcts and 34 were observational. smps were divided into four broad domains: management of acute sah, early brain injury, dci, and general neurocritical care. the most common smp design was control of dci, with 21 studies targeting this domain. overall, studies were of low quality; most described single-centre case series with small patient sizes. observational studies scored between 3 and 8 on the 9-point nos. dci and neurologic outcomes were defined inconsistently in the literature, leading to significant challenges in their interpretation. given the substantial hetereogeneity in reporting practices between studies, a meta-analysis could not be performed. the effect of smps on sah remains unknown due to major limitations in study design and quality. notable deficiencies relate to heterogeneous definitions of dci and inconsistent application of standardized neurologic assessment scales. our study highlights the need for rigorous rcts to determine whether the use of a protocol impacts outcomes in critically ill patients with sah. elevated serum chloride has been associated with increased inflammatory markers, worsened systemic hypotension, and renal injury. little is known regarding the effects of hyperchloremia on neurological outcomes after subarachnoid hemorrhage (sah). we reviewed prospectively collected data on adult patients who were admitted for spontaneous sah from 2012 to 2016. chloride values were examined on days 1-5. hyperchloremia was defined as serum chloride of 110 meq/l or greater. the primary outcome was delayed cerebral ischemia (dci). secondary outcomes included hospital mortality and 3 month modified rankin scores (mrs). chi-square test and two sample t-test were employed to assess dci and 3 month mr analyze hospital mortality. 217 sah patients were included in the analysis, 61 (28%) developed dci and 156 (72%) did not. patients with dci had higher rates of hyperchloremia on day 3 (71% vs. 49%, p=0.005), day 4 (59% vs. 40%, p=0.01), and day 5 (51% vs. 25%, p<0.001) than patients without dci. after controlling for age, hunt and 2.16, p=0.03) and day 5 (or 2.40, p=0.01) were associated with higher likelihood of experiencing dci. good functional outcome (mrs 0-2) was seen in 119 of 158 patients (75%) at 3 months. rates of hyperchloremia were significantly lower in the good outcome group at all time points. after multivariate analysis, hyperchloremia on day 2 (or 0.24, p=0.006), day 3 (or 0.07, p<0.001), day 4 (or 0.2, p=0.0030, and day 5 (or 0.15, p<0.001) were independently associated with decreased odds of good functional outcome at 3 months. early hyperchloremia was associated with dci and worse functional outcomes from sah. the impact of chloride load and fluid management strategy on sah outcomes warrants further investigation. headache is the most common complaint of patients presenting with aneurysmal subarachnoid an efficacious adjuvant therapy in the management of sah-induced headache. we performed a retrospective chart review of patients treated for sah in the neurocritical care unit at a eceived steroids. dexamethasone (4 mg every 6 hours) is typically administered for 1-2 days in patients with headache refractory to acetaminophen and oxycodone. nursing documented numeric (0-10) pain scores were collected every two hours. we used paired t-tests to compare mean, maximum, and minimum daily pain scores on the day before and during steroid administration. we used multivariate analysis to assess for factors associated with steroid responsiveness, defined as an improvement of 1 or more points in mean daily pain score. there were 51 steroid treatment periods among 40 patients (75% female, mean age 54 ± 11.8, median hunt--two (43%) were classified as steroid responsive. mean daily pain scores decreased by 0.9 points (p = .01) during steroid administration. responders reported higher pre-treatment pain scores (5.6 vs 3.5, p = .009) and demonstrated greater decrease in mean pain scores (3.1 vs -.9 points, p < .001). there was no decrease in mean pain scores during the two days following therapy. in multivariate analysis, there was a weak signal that patients who underwent surgical clipping were more likely to have steroid responsive headaches (or 16.8, . no other demographic or clinical characteristics were associated with steroid responsiveness. a subset of patients with sah induced headache may have a favorable, transient response to steroids. tterns and influence on opioid requirements. cerebral vessel vasospasm (cvv) is a feared complication following aneurysmal subarachnoid hemorrhage (asah). there has been an association between cvv and delayed cerebral ischemia which accounts for a great deal of morbidity and mortality following asah. though the majority of patients with cvv respond to blood pressure augmentation, many patients go on to develop delayed ischemic neurologic deficits despite aggressive therapy. there is some suggestion in the literature that intraventricular milrinone (ivm) may be useful in the treatment of cvv. retrospective case series of 28 patients with asah that were treated with one or more doses of 0.87mg index (pi) and frequency of intraventricular milrinone dosing was collected. all patients were treated at cleveland clinic in the neurologic intensive care unit between 2016 and 2018. paired t-test analysis was patients in our cohort were dosed with ivm between 1 and 30 times. there were no significant differences territory. there was also no effect of ivm on cvv over time. there were no direct complications secondary to ivm in these patients. based on our results, ivm was non-therapeutic for the treatment of cvv in patients with asah. our data be conducted to evaluate the safety and efficacy of this treatment. our retrospective analysis suggests that the use of intraventricular milrinone may be non-therapeutic for the treatment of cvv. clinical and research tool for riskelement by the national institute of neurological disorders and stroke sah working group. there are few data assessing the we distributed a survey to a convenience sample of attending physicians that care for patients with questions regarding the definitions of the scale components (thin vs. thick, intraventricular blood vs no to determine the overall inter-ing. thirty-three respondents (100% neurocritical care fellowship trained, 79% ucns certified in neurocritical care, 84.8% neurologists, median 4 years (iqr 2-6) in practice, treating median of 75 patients (iqr 50-100) with sah annually from 19 institutions) completed the survey. twenty-three (69.7%) reported r measurement of thin vs. thick blood, and 42.4% correctly identified that blood in any ventricle is scored -0.072) for the 15 ct scans, which is considered poor agreement. agr regarding the definitions of the score components. the national institute of neurological disorders and stroke sah common data elements may require further clarification in order to standardize research in cerebral vasospasm leading to delayed cerebral ischemia (dci) is one of the most significant factors impacting functional outcome following subarachnoid hemorrhage (sah). although vasospasm is prevalent in this population, treatment options are limited. in recent years, several published case series have reported a positive effect of intrathecal (it) nicardipine for the treatment of vasospasm. we now report a single center one year retrospective cohort experience with intrathecal (it) nicardipine for the treatment of cerebral vasospasm following sah. all patients discharged in 2017 with a diagnosis of non-traumatic sah, either aneurysmal or idiopathic, were included in the analysis. demographics, risk factors, clinical course, radiological dci and functional outcome were analyzed. during 2017, 199 patients were admitted with aneurysmal (n=146) or idiopathic (n=53) sah. the mean age was 55.5±13.9 and 64.8% were women. low grade hemorrhage (h&h1-2) was found in 39.7%, medium (h&h3) in 37.7% and high grade (h&h4-5) in 22.6%. cerebral vasospasm was diagnosed in 41.2% of the patients, and it nicardipine was used in 83% of these patients (n=68). only 8.5% of the patients required angiography to treat vasospasm. tcd data was available for 52 patients who received it nicardipine. treatment reduced mean velocities in all arteries within one day (reduction of 6.6-15.6%, p<0.01). this effect remained through the treatment, until the vasospasm resolved. one patient suffered from bacterial ventriculitis. the overall rate of radiological dci, as found in a blinded post treatment assessment of patients' imaging, was 10.6%. in this cohort, 50.8% had a favorable functional it nicardipine is a safe and potentially effective treatment for cerebral vasospasm and prevention of the subsequent ischemic changes. we are currently expanding the analysis to prior years, however, future prospective controlled trials are still needed to evaluate the safety and efficacy of this treatment. patients remain at high-risk for vasospasm, delayed cerebral ischemia (dci), and hydrocephalus after diversion is often necessary in ma additional benefit over standard management by facilitating intracranial blood clearance and decreasing rate of vasospasm and dci, albeit with a possible increased risk of shunt dependency in historical studies. in this study, we assessed safety outcomes among patients who underwent this procedure. retrospective review of outcomes in pa cisternal drain placement at a single institution. between 2013drain placement. the median hunt-hess score was 2, but the study population skewed towards large drain dwell duration was 7.4 days. radiographic vasospasm occurred in all but one patient (97.5%) and developed meningitis/ventriculitis, none fatal. the mean length of stay in the icu was 16.3 days. sixteen patients (42.1%) were discharged home, twenty-one to acute rehab (55.3%), one to subacute rehab (2.6%), and two died (5%). among survivors, shunt-dependency occurred in 5/38 (13.2%), compared to the 5.3%-33.9% range reported in prior literature. in the study population, cisternal drains appear to be safe as measured against historical cohorts, with comparable or lower shunt-dependency rates. this suggests the viability of further prospective studies to determine the appropriate population for and role of cisternal drainage in the management of asah. estimates of seizure onset after aneurysmal subarachnoid hemorrhage (asah) vary widely, reported rates range from 1% to 28%. moreover, seizures increase mortality and disability in patients with asah regardless of common asah complications such as: rebleeding, delayed cerebral injury and vasospasm. we sought to establish the frequency of seizures in asah patients, along with their impact over prognosis, during hospitalization and upon discharge. a retrospective review of consecutive patients with asah admitted to the baylor st. luke's medical center between january 2008 and december 2012 was conducted. subject demographics, admission gcs, admission mrs, incidence of clinical seizures and clinical outcome at discharge were recorded. associations between the presence or absence of clinical seizures and outcome, measured by the glasgow outcome scale (gos), were investigated using a multivariate logistic regression model. 226 patients with asah were included. clinical seizures were identified in 7 subjects (3.1 %). outcome was significantly worse for subjects who experienced a clinical seizure compared to subjects who remained seizure-free during hospitalization, poor outcome (gos<4) was found on 71.4 % and 31 % respectively (or 6.01, ]; p=0.04) this increased risk was significant after controlling hospice, death) was more common for the seizure group compared to the seizure-free group, 57.1 % vs 27.2 % respectively, however this difference did not reach significance (or 3.89, ]; p=0.11) our results showed a low frequency of clinical seizures (3.1%) after asah, when compared to other series that have identified an increased incidence of seizures through multimodal approaches. as indexed by gos, along with a non-significant trend towards an unfavorable discharge disposition, among patients with seizures. vasospasm and delayed cerebral ischemia (dci) account for 30% of the morbidity and mortality after aneurysmal subarachnoid hemorrhage (asah). perfusion ct has been shown to be useful in identifying vasospasm, but this technique is less sensitive to microvascular perfusion changes. mr perfusion (mrp) has been increasingly used in the acute ischemic stroke population and avoids ionizing radiation. we hypothesized mrp may predict the presence of vasospasm by providing measures of impaired cerebral perfusion. we performed a retrospective cohort study with consecutive asah patients between december 2012 and august 2015. patients who underwent mrp for concern of dci followed by digital subtraction angiography (dsa) within 24 hours were included. quantitative volumetric analysis was performed at several thresholds of cerebral for the presence of a tmax>6 lesion. exact wilcoxon rank sums test was used to compare perfusion volumes between patients treated endovascularly versus not treated for vasospasm. we identified 22 patients with a total of 26 mri studies meeting inclusion criteria (17 patients treated, 9 patients not treated). no tmax>6s hypoperfusion lesion was identified in the untreated group, while 10/17 (59%) of the treated patients had at least some delay of tmax>6s (p=0.009). performance of mrp to detect vasospasm was sensitivity 0.59 (95%ci 0.33-0.81), specificity 1.0 (95%ci 0.63-1.0), ppv 1.0 (0.66-1.0), npv 0.56 (95%ci 0.31requiring treatment for vasospasm. significant perfusion delay by tmax >6s is present in patients requiring endovascular vasospasm treatment after asah. these results suggest that mrp may be a useful tool for patient triage for vasospasm therapy, and further studies are indicated for comparison to other screening methods for vasospasm. recent studies have suggested inflammation and immune dysregulation are important pathophysiology in aneurysmal subarachnoid hemorrhage (asah), and neutrophil to lymphocyte ratio (nlr) was considered as significant clinical predictor of unfavorable outcome including delayed cerebral ischemia (dci). we analyzed nlr of asah patients during ttm, and proposed that the changes in nlr may reflect therapeutic effect of ttm in asah. this retrospective single-center study included 50 asah patients from november 21, 2013 to may 30, 2018, among which 25 patients underwent ttm after surgical procedures, and other 25 patients didn't undergo ttm. target temperatures were 33.5°c to 35°c and the durations of ttm were 2 to 10 days. we reviewed the changes of nrl of each patient during ttm and identified whether they had dci, and analyzed in-hospital outcome and 3-month outcome as measured by the modified rankin scale (mrs). there was no statistically significant difference of overall outcome between ttm group and non-ttm group, but ttm group showed slightly lower rate of dci and better functional outcomes. among the patients, patient who developed dci had higher nlr, and the decreasing rate of nlr was higher in ttm group than non-ttm group. higher decreasing rate of nlr in asah patients while undergo ttm may show the therapeutic effect of ttm. monitoring the trend of nlr value may be helpful in predicting the prognosis of asah patient and estimate the efficacy of ttm for individual patient. eventually, nlr may play important role in deciding practice strategy while treating ttm in asah patients. hydrocephalus is generally regarded as a progressive or static process, but there are few reported cases of transient obstruction of the ventricular system. here, the authors present a rare case of spontaneous symptomatic obstructive hydrocephalus that self-resolved. additionally, a brief review of the literature is performed. records of the patient presented were reviewed in a retrospective manner for all relevant information. pubmed was then searched for all relevant articles. here, we discuss the case of a gentleman in his late 80's who presented with worsening confusion and lethargy in the setting of spontaneous subarachnoid and intraventricular hemorrhage. pre-hospital medication includes a daily fish oil supplement; he takes no anticoagulation or antiplatelet agents. approximately one year prior to admission, he experienced an episode of spontaneous left temporal intracerebral hemorrhage. this was attributed to amyloid angiopathy, as evidenced by multiple microbleeds observed on susceptibility weighted imaging at that time. the patient's neurocognitive status steadily declined admission, and he eventually became obtunded. in the process of transferring the patient to the intensive care unit for intubation and external ventricular drain placement, he suddenly became more awake and interactive. the patient's clinical symptoms completely resolved within 2-3 hours. no surgical intervention was undertaken. repeat head ct demonstrated that blood products seen in the third ventricle on previous imaging had now migrated into the fourth ventricle. lateral ventricular size had decreased from the prior scan. the following morning, his family members commented that the patient was back to his baseline. transient episodes of obstructive hydrocephalus have rarely been reported in the literature, and are generally associated with an inciting event such as trauma or hemorrhagic stroke. it is possible that there is a higher incidence of transient hydrocephalus, but medical/surgical interventions are performed before the condition is permitted to resolve on its own. raised intracranial pressure (icp) can be a dire consequence of extensive neurologic injury. medical management of elevated icp using intermittent doses of 23.4% hypertonic saline (hts) and/or mannitol is relatively safe and effective for treating refractory intracranial hypertension. at our institution, prior to escalating to sedation and paralysis, hts and mannitol are scheduled. in this study, we aim to describe our experience with scheduled 23.4% hts. methods doses of 23.4% hts during acute admission were included in our retrospective evaluation. only patients who received scheduled 23.4% for anticipated or acute elevated icp in the setting of high-grade subarachnoid hemorrhage (sah) were included. the primary outcome was to characterize efficacy of sustained icp control, by measuring frequency of icp >25 mmhg and need for escalation of icp management. safety outcomes included incidence of hypernatremia (sodium > 160 meq) and metabolic acidosis. seven out of 46 (15%) patients who received intermittent scheduled doses of 23.4% hts were in the setting of highwere greater than 25 mmhg and no patients required escalation of icp management for the duration of therapy. the median number of doses and duration of 23.4% hts therapy were 11 doses and 7 days (iqr 5.9than 160 meq and 2 patients (30%) developed metabolic acidosis in the setting of hyperchloremia. administration of scheduled intermittent 23.4% hts in the setting of high-grade sah is relatively safe and achieves sustained icp control without need for escalation of icp management. comparative studies of scheduled intermittent 23.4% hts vs alternative medical therapies for icp management are warranted. use of contrast-enhanced computed tomography (ct) studies to evaluate neurological disorders have increased due to its non-invasiveness, fast image acquisition, easy accessibility, and minimal complications. one such procedure is ct myelogram that delineates the extent of spinal stenosis and helps in neurosurgical planning. however, it can result in intracranial migration of contrast medium leading to contrast-induced-encephalopathy (cie). we report 2 cases mimicking as subarachnoid hemorrhage after ct myelogram who subsequently developed cie. case 1: a 68-year-old man with chronic low back pain (clbp) was evaluated for confusion, headache due to "intracranial bleed". ct showed diffuse cerebral edema and hyperdensity in the subarachnoid space. external ventricular drain (evd) was placed for suspected post-sah hydrocephalus. however, ct and ct angiogram did not show any cerebrovascular malformation. the patient developed severe encephalopathy and left hemiparesis. repeat ct head showed worsening cerebral edema and hours prior to presentation. severe cerebral edema and left hemiparesis necessitated the use of dexamethasone with improvement in clinical symptoms and examination returning to near baseline. case 2: a 64-year-old man with clbp was admitted for "sah" and associated cerebral edema with hydrocephalus. the initial presentation was confusion, double vision, and headache. ct showed diffuse cerebral edema with sulcal effacement, loss of basal cisterns and dilated lateral ventricles. ct and ct angiogram did not show a days prior to presentation. evd placed for hydrocephalus was quickly weaned off the improvement of ventriculomegaly. the patient was discharged with complete resolution of symptoms. cie should be suspected in patients with encephalopathy after ct myelogram. non-contrast ct head is to be interpreted in conjunction with clinical history to avoid unnecessary procedures that might further worsen cie. seizures and ictal-interictal continuum (iic) activity may impact recovery from acute brain injury (abi). empiric antiepileptic drug (aed) intensification for electrophysiologic activity of uncertain significance is challenging to evaluate given structural neurologic deficits, variable pharmacodynamics, and potential sedative effects. we analyzed the eeg and electronic medical records to identify electrographic biomarkers predicting clinical response to aed therapy. we ascertained patients undergoing continuous electroencephalography (ceeg) during admission for abi from a prospective big data repository of clinical data including regularly sampled glasgow coma scale (gcs) scores and med -specific spectral power (alpha 8-13 hz, theta 4-7 hz, and delta 0.5-4 hz) and graph theoretical metrics of eeg functional connectivity were compared at time intervals before and after aed therapy. 308 patients met inclusion criteria. 9,291 aed doses were administered (mean 1.64 +/-0.96 unique aeds per patient). initiating the first aed was followed by a 0.44-point average improvement in gcs (p=4.32 x10-7); initiating a second or third aed yielded no significant change, and adding a fourth, fifth, or sixth aed was followed by a 0.69-point worsening in gcs (p=0.044). improvement in gcs 6 hours after aed administration was heralded by decline in eeg delta power and rise in network density in the hour following treatment. decline in gcs was heralded by an early rise in delta power and decline in network density. patients with the highest tertile of eeg improvement (greatest combination of rising eeg density and declining delta power) had a consistently improving gcs trajectory in the 48 hours following medication administration, whereas those in the lowest tertile had a consistently worsening gcs trajectory. empirically intensifying aed treatment for disorders of consciousness after abi has diminishing benefit after the initial agent. quantitative eeg biomarkers of early treatment response appears to robustly predict clinical response following aed treatment. new-onset refractory status epilepticus (norse) describes patients with no seizure history who develop refractory status epilepticus (se). the majority progress to super refractory status epilepticus (se). we present a single-center case series of super refractory norse patients to highlight unique features of this group. retrospective chart review was performed to identify adults (age>18) admitted to the columbia university neurological icu from 2/2009-2/2016 who required continuous midazolam infusions for treatment of super refractory norse. outcome was defined as modified rankin score (mrs) at hospital discharge. descriptive statistics were performed using microsoft excel. of the 27 cases, 96%(n=26) had a prodrome prior to seizures (infectious, psychiatric or both). patient age was bimodally distributed with 56%(n=15) less than 30 years old and 37%(n=10) over 50. the most common comorbidity was an underlying autoimmune/rheumatologic condition (22%,n=6), though most patients had no pre-existing conditions (41%,n=11). the average stess score was 3 (standard deviation 1.0). the majority (77%,n=21) remained cryptogenic despite extensive testing. etiologies were identified in 22%(n=6) -4 with nmda encephalitis and two with cns infections. immunomodulatory treatment included steroids in 59%(n=15, started on average 6 days from seizure onset, range 0-30), intravenous immunoglobulin in 41%(n=11, day 16, range 1-50) and plasmapheresis in 41%(n=11, day 10, range 3-13). the average icu and hospital stays were 33 (range 2-150) and 55 (range 7-200) days, respectively. on discharge, 7%(n=2) had a good outcome (mrs 0-1), 19%(n=5) had fair outcome (mrs 2-3), 52%(n=14) had poor outcome (mrs 3-5) and 22%(n=6) died. compared to prior studies of all norse patients, our cohort with super refractory se were younger, had more frequent prodrome, longer icu and hospital stays and fewer identified autoimmune/paraneoplastic antibodies. the mortality rate was similar to prior studies, but among survivors, super refractory patients were less likely to have a good or fair outcome. we aimed to assess the management of refractory status epilepticus (rse) in developing (ding) and developed (dev) economies, as the management of this condition is resource intense and poorly standardized. investigators from 4 continents collected a large cohort study of rse patients treated between 01/2015-12/2018. case-report-forms were finalized at the 2018 annual ncs meeting. rse was defined as se that failed to respond to a benzodiazepine and at least one non-anesthetic antiepileptic agent, and was managed with midazolam (mdz) or propofol(pro). the 2018 united nations world-economic-situation-prospect was used to identify sites as being from dev or ding economies. four from dev (237 patients) economies were included. patients from dev economies were slightly sicker (stess score 3.1±1.3 vs. 2.9±1.2, p<0.05). management of patients from dev economies more frequently involved prolonged eeg monitoring (continuous 77% vs. 23%, p<0.05) but mdz (0.5±0.7 vs. 2.0±1.6 mg/kg/h) and pro (37±24 vs. 75±52 mcg/kg/min, p<0.05) doses were higher in ding economies. breakthrough seizures were more common in ding (36% vs. 53%, or 2.1, p=0.003), but no difference in vasopressor use (64% vs. 57%; n.s.) or withdrawal seizures (22% vs. 31% n.s.) was seen. hospital (32±31 vs. 54±83 days, p<0.001) and icu stays (17±21 vs. 31±26 days, p<0.001) were longer for patients in ding economies. modified rankin scale at discharge was associated with higher stess scores (p=0.003) but did not differ between ding and dev economies. direct comparisons between rse patients managed in ding and dev economies are challenging as the baseline level of illness differed but this dataset provides unique insights into differences in utilization of technology (i.e., eeg monitoring), medications (duration and dosage of anesthetics), and length of stay in different health care systems. larger follow-up studies need to explore matched cohorts and explore differences between private-public hospital settings. unlike most anesthetics ketamine acts as an nmda antagonist. we examine the efficacy of intravenous ketamine in the treatment of rse in a large series. retrospective case series of 68 status epilepticus patients admitted between 2009 and 2018 who underwent treatment with ketamine, 4 patients underwent multimodality monitoring (mmm). we compared patients with complete seizure cessation after ketamine with those without using chi-square and 2 sample t-test. mean age was 53 +/-18 years old, 46% of patients were female. seizure burden was decreased by 50% within 24 hours of starting ketamine in 55 patients (81%), with complete cessation in 43 (63%). average rate of ketamine infusion was 2.2 +/-1.8 mg/kg/h, with duration of 3.6 +/-3.9 days. average dose of midazolam was 1 +/-0.8 mg/kg/h. ketamine was started on average 1 +/-3 day after midazolam. patients without complete seizure control after initiation of ketamine (25/43 patients) were more commonly cardiac arrest patients 36% vs 21% (p=.17), and had lower stess score 3 +/-1 vs 4 +/-1 (p=.03). all other characteristics were not statistically significant between the two groups including; age, gender, ketamine infusion dosages and duration, apache score, and midazolam infusion dosages. 8 patients (12%) were weaned off pressors after initiating ketamine infusion. when compared the mmm values 24h before and after ketamine initiation, intracranial pressure values (8 +/-4 vs 10 +/-5), cerebral perfusion pressures (73 +/-14 vs 72 +/-13), cerebral blood flow (24 +/-3 vs 21 +/-9), and lactate/pyruvate ratio (45+/-21 vs 45 +/-12) were relatively stable. pbo2 values increased from 7 +/-1.5 to 17 +/-7. in our cohort ketamine infusion had a meaningful decreased in seizure burden in rse. our preliminary data also suggests that ketamine infusion didn't affect the intracranial pressure. continuous eeg (ceeg) is widely used to detect seizures (sz) in patients with acute brain injury. however, studies examining sz and epileptiform abnormalities (ea) using ceeg in acute ischemic stroke (ais) are limited. therefore, we aimed to describe the prevalence of electrographic patterns (sz and ea) in ais and its association with outcomes at discharge. retrospective chart review identified 94 patients with ais who underwent ceeg between 1/2018 and 1/2019. demographics, comorbidities and other relevant clinical factors including nih stroke scale (nihss) and treatment interventions were abstracted. ceeg closest to admission (median 2 days) was reviewed for background, sz and ea (lateralized and periodic discharges (lpds and gpds) lateralized rhythmic delta activity (lrda) and sporadic epileptiform discharges (seds). computed tomography or magnetic resonance imaging of brain closest to the time of ceeg was analyzed for midline shift, hemorrhagic transformation (ht) and cortical involvement. outcomes measures were mortality and functional outcome in modified rankin scale (mrs) (0-2 good and >2 poor outcome) at discharge. of the 94 patients, 4 had sz and 31 had ea (18.1% lpd, 8.5% lrda, 9.6% gpds and 3.2% seds). those with cortical involvement had higher rate of ea and sz compared to those with subcortical stroke (85.3% vs 60.0%, p=0.011). no difference was found in sz and ea prevalence with regards to age, sex, nihss, midline shift or ht. overall mortality was 29.8%. absence of posterior dominant rhythm (pdr) was associated with increased mortality (85.7% when pdr absent vs 56.1% when present, p=0.009). sz and ea did not affect mortality or mrs at discharge. despite high frequency of ea (33%), the risk of sz in ais was low at 4.3 % and their presence did not impact functional outcome or mortality. however, eeg background with absence of pdr was associated with increased mortality. nonconvulsive seizures (ncs) are a common complication in patients admitted to neuroscience intensive care units and are associated with worse outcomes. ncs can only be diagnosed with continuous eeg (ceeg) monitoring. intermittent conventional ceeg review by neurophysiologists typically occurs 2-3 times a day, therefore patients may be seizing for extended periods of time before the seizure is detected. our study aims to evaluate the accuracy of a quantitative eeg (qeeg) trend, the automated seizure detector (asd) in detecting patients' first seizure, which could aid in rapid detection of ncs. this retrospective study includes review of ceeg and qeeg data from adult patients admitted to a single institution neuro icu who developed ncs on ceeg monitoring. independent conventional ceeg review without qeeg by two board-certified neurophysiologists determined the first seizure occurrence for each patient (gold standard). this was compared to the seizure detection sensitivity of the p12 asd (persyst, inc., prescott az), an algorithm with no user-adjustable settings. recordings from 45 ncs patients were used. mean age was 61.2 years and 56% was female. seizures had variable durations and spatial extents. the sensitivity of p12 asd was 77.4% (95% ci 58.5-89.7) and specificity was 92.9% (95% ci 64.2-99.6). mean false alarm rate was 0.17/hour (sd 0.46) in the time elapsed from the start of ceeg recording until first seizure occurrence. overall, p12 asd accurately detected the first seizure in 69% of patients, disregarding false positives. overall, median time to clinical seizure detection was 2.0 hours (iqr 5.5 hours). this analysis shows that the persyst p12 asd may have clinically useful sensitivity and specificity in critically ill patients admitted to a neuroscience icu. in conjunction with a low false alarm rate, incorporation of qeeg asd may lead to a reduction in time for seizure recognition. the incidence of early seizures (es) in traumatic brain injury (tbi) ranges between 1-7%. however, the incidence of es after a non-severe tbi (nstbi) with traumatic hemorrhage (th) is unknown. moreover, the data about seizure prophylaxis (sp) in this population remains inconclusive. we aim to determine the incidence of es in nstbi and the efficacy of sp. we respectively reviewed all adult patients with nstbi with evidene of a th on presentation from 2015 to 2018. patients with history of epilepsy or receiving antiepileptic drugs (aed) were excluded. we collected demographic data, the type, severity and mechanism of injury; the need for neurosurgical intervention (nsi); es; and sp use. a total of 633 patients met our inclusion criteria, 94.4% had mild tbi; mean age of 70.5 years (sd 16.9); 55.3% males; and 49.1% had subdural hematoma (sdh). same level fall was the most common 310 (7.1%) patients had an es in the sp group (16 clinical) vs 5 of 310 (1.6%) in the non-prophylaxis group (all clinical) (p = 0.001). levitiracetam as sp was used in 83.5%. patients with combined sdh and traumatic subarachnoid hemorrhage or with multicompartment hemorrhage were more likely to have es than sdh alone (p = 0.02 and 0.001, respectively). nsi was not a predictor for es in our cohort. the incidence of es in nstbi patients in our cohort falls within the previously reported ragne. however, it appears to be higher compared to reported rates for mild tbi. es were more likely in the sp group, which might indicate a clinical selection bias. prospective studies are required to further determine the predictors of es and the effect of sp on outcomes in nstbi patients. patients with psychogenic non-epileptic attacks (pnea) sometimes receive aggressive treatment leading to intubation. this study aimed to identify patient characteristics that can help differentiate pnea from true status epilepticus (se). we retrospectively identified patients with pnea and se who were intubated and underwent continuous had acute brain injury or progressive brain disease as a cause of status epilepticus were excluded. we compared clinical features, treatments and outcome between patients who were intubated for pnea and those who were intubated for se. of 1,735 patients who underwent ceeg monitoring, we identified 24 and 124 patients intubated for pnea and se, respectively. compared with patients intubated for se, intubated pnea patients were more likely to (1) be <50 years of age (92% vs 40%, p<0.001), (2) be female (79% vs 39%, p<0.001), (3) be white (91% vs 29%, p<0.001), (4) have a history of a psychiatric disorder (88% vs 25%, p<0.001), (5) have no history of an intracranial abnormality (92% vs 38%, p<0.001), and (6) have a maximum systolic blood pressure <140 mm hg (67% vs 16%, p<0.001). patients with 0-2 of these risk factors had a 0% (0/88) likelihood of having pnea, those with 3-4 had a 15% (6/39) chance of having pnea, and those with 5-6 had an 86% (18/21) chance of having pnea. sensitivity for pnea among those with 5-6 risk factors was 75% and specificity was 98%. pnea in patients presenting with emergent convulsive symptoms can be predicted with a high degree of certainty based on the presence of specific demographic, past medical, and physiologic risk factors. care should be taken to avoid over-sedation and unnecessary intubation in this at-risk patient population. a recent systematic review indicates that the mortality of status epilepticus (se) is about 15.9% with a non significant downward trend in recent years. mortality has not changed much despite aggressive management. this study investigates trends and predictors of in-hospital mortality due to status epilepticus at national level in united states. we performed a cross-sectional analysis using the nationwide inpatient sample (nis), 2005-2014, of us adult hospitalizations with status epilepticus. annual rate of in-hospital mortality was calculated using nis weighting. we identified our status epilepticus patient subset from using codes (dx1 = 345.3) from the international classification of diseases, 9th edition. potential factors associated with in-hospital mortality were assessed using logistic regression. of 147,548 hospitalized patients with status epilepticus, 5,271 (3.57%) died during the index hospitalization. across 2005-2014, 3.57% of se patients died; with a downward but not statistically significant trend in-hospital mortality from 4.28% (2005) to 3.73% (2014) (p = 0.14). se patients with inhospital mortality were more likely to be women, older, and with a higher proportion of medical comorbidities, in-hospital complications and extreme loss of function as per all patients refined diagnosis al failure, apr drg severity, mechanical ventilation, tracheostomy, sepsis, pulmonary embolism, acute kidney injury and respiratory insufficiency. mortality due to se was lower than previously reported. mortality has had a non-significant downward trend in the years studied. age, female gender, medical complications and poor baseline functional status are important predictors. availability of aggressive treatment has not modified significantly mortality which requires further study. pregabalin (pgb) is an approved adjunctive treatment for focal epilepsy in adults. pgb lacks drug-drug interactions, has a favorable safety profile and can be rapidly titrated-attractive characteristics for its use in the neurocritically ill. however, data remain limited regarding its use in the icu setting. we are sharing our experience with pgb in neurocritically ill patients with refractory seizures. charts of eight adult patients admitted received pgb were reviewed retrospectively. demographics, antiseizure drug (asd) regimen, and 24h of eeg data pre-and post-pgb were analyzed descriptively. the cohort comprised eight patients (4 females) with mean age of 68.5 years. mean icu stay was 9.1 days. three patients underwent a neurosurgical procedure related to their primary admission diagnosis, an asd prior to first seizure captured on eeg. prior to pgb, patients had failed on average 3 (2-4) other asds trials. pgb was dosed 300-400mg/day in 2-4 divided doses, following a load of 75-300mg. pgb lead to a significant reduction on hourly median seizure burden: 5.1 to 1 seizure/h and 5.3 to 0.97 min/h. pgb led to complete seizure cessation in 4 patients within 24h and in 6 out of 8 within 48h of administration. pgb allowed for de-escalation of asd regimen in 5 out of 8 patients. pgb was well tolerated with the exception of mild sedation in 3 patients, which did not warrant further intervention/neurodiagnostics. in this critically ill cohort with refractory seizures, pgb successfully aborted seizures in 75% of patients. include prospective pregabalin treatment protocols. to describe the first known reported case of utilization of electroconvulsive therapy (ect) to treat super refractory status epilepticus (srse) in pregnancy. we present the case of a 21 year old caucasian female at 8 weeks gestation with pmh focal and generalized seizures who was treated for srse successfully with ect after failed pharmacological treatment. the most likely etiology of srse was sudden cessation of medications upon pregnancy. eeg showed 2 types of seizure activity: rhythmic theta waves over right temporal region with evolution and independent generalized seizures. treatment included use of approximately 12 antiepileptics including , propofol, pentobarbital, magnesium, ketamine, topiramate and valproic acid over the course of 30 days in addition to modifying epilepticus remained super refractory with appearance of mixture of sharp waves on weaning off sedation. she underwent ect with right unilateral electrode placement on day 31 with remarkable improvement in eeg pattern and resolution of srse with single session. patient was back to baseline level of awareness at the time of discharge. on follow up in clinic, she had significant improvement in seizure control with normal fetal development and delivery. treatment of status epilepticus in pregnancy is challenging given the unknown effect of prolonged sedation or hypothermia on fetal development. alternative treatments like ect, vns, dbs, ketogenic diet and hypothermia are sporadically used. use of ect is not considered first or even second line treatment in srse, despite its safe profile, especially in pregnancy. this case adds to the available literature on the success of ect for treatment of srse and puts emphasis on the need for a clinical trial regarding use of ect in srse. the importance of neurocritical care (ncc) has been recognized. but no dedicated educational system for it exists in japan. we have established version 3 of an educational ncc hands-on seminar. this study investigated its effects. this study was a prospective, before-after study using questionnaires and examinations. it was a full-day version 3. the learning concept was to identify the various methods for maintaining cerebral oxygen balance to prevent secondary brain injury. participants attended five skill sessions: intracranial pressure monitoring, trans-cranial color flow image, targeted temperature management, neuro examination, and eeg, and four scenario sessions: post-cardiac arrest syndrome, subarachnoid hemorrhage, traumatic brain injury, and non-traumatic acute weakness. they had examinations before and after the seminar. the primary outcome was the improvement on examination scores after the seminar. secondary outcomes were the degrees of satisfaction with it and confidence of participants in ncc. we evaluated the improvement of the outcome using wilcoxon signed rank test. a p-value of 0.05 or less was considered as significant. thirty-nine physicians and one nurse participated in the seminar. we excluded 19 (47.5%) participants because their answers were incomplete. we had 16 (76.2%) physicians who are in emergency or intensive care medicine, and 5 (23.8%) other professionals. their median age group was in their 30s (iqr:20-30) with median intensive care medicine experience of 2 years (iqr:1.0-5.0). the percentage of correct answers, scores in the examination, improved significantly from 70 (iqr:47.0-87.0) to 80 (iqr:63.0-93.0) after the seminar (p<0.001). eighteen (85.7%) participants were satisfied with it, and the number of professionals who could not feel ncc-confident decreased from 12 (50%) before the seminar to 0 after its completion (p<0.001). our seminar successfully improved the physicians' knowledge of ncc, and gave them more confidence in ncc. glutamic acid decarboxylase (gad) is the rate-limiting enzyme to convert glutamate to gammaaminobutyric acid (gaba). autoantibodies targeted against gad65 have been implicated in a number of syndromes with neurologic manifestations including stiff-person syndrome, cerebellar ataxia, limbic encephalitis, and epilepsy. we highlight an atypical presentation of this rare disorder with several unique features to the neurological intensive care unit. 62-year-old woman with pmh of dm, remote left insular ischemic stroke, and recent right leg dystonia presented after being found down with rightward eye gaze deviation, gtc shaking, and urinary incontinence. she required midazolam, lorazepam, loading doses of levetiracetam and fosphenytoin, and propofol infusion to achieve clinical seizure control. despite these interventions, eeg showed ncse with left temporal seizures and anterior midline epileptiform discharges. propofol was titrated to burst suppression. she had several other active medical problems including kidney injury, transaminitis, and myoclonus. seizures and myoclonus were greatly improved after the addition of clonazepam; however, she remained encephalopathic. pertinent diagnostic results included ferritin 16,130 ng/ml, ldh 2,070 units/l, il-2r 795 u/ml, b2-micr and serum gad65 ab titer 332 nmol/l. mri brain showed prominent superior frontal lobe cortical edema. bone marrow biopsy demonstrated good cellularity without malignancy. skin biopsies on three random samples were positive for perivascular dermatitis with telangiectasia. she was started on high dose steroids with subsequent progressive mental status improvement. anti-gad65 ab associated vasculitis is an exceedingly rare occurrence whose diagnosis previously involved brain biopsy. this case is unique given her acute presentation with refractory status epilepticus, systemic involvement, and diagnosis on skin biopsy. while management has involved immunotherapy, specific treatment guidelines do not exist. given her marked response to clonazepam and corticosteroids, we advocate for early initiation of gabaergic medications such as benzodiazepines and use of immunotherapy. epileptic seizures are a serious complication in patients with subdural hemorrhage (sdh), resulting in increased mortality rates. the incidence of new onset seizures in these patients is unclear. we examined the incidence for new onset seizures and status epilepticus (se) in sdh patients. we examined patients diagnosed with sdh and epilepsy between september 2015 to december 2018. we included patients with new onset seizures and extracted those who had seizures after sdh evacuation. clinical and radiographic characteristics, and outcomes of those patients were described. we screened 427 patients diagnosed with sdh, traumatic or non-traumatic. 248 underwent a surgical intervention and 23 (5%) patients had a seizure during their hospital stay. among those who had a seizure, 9 patients had prior history of epilepsy, and 14 had a new onset seizure. although sdh patients with history of epilepsy showed higher incidences of seizures than those with no history (p= 0.08), sdh patients with history of epilepsy mostly did not evolve into se and those who had no history of epilepsy usually did. there was no significant difference in patients developing se when compared to those without se between the sdh thickness, midline shift, temporal lobe involvement or age of blood (acute or chronic). seizure occurrence in patients with sdh is commonly new onset; however, they are infrequent. in addition, sdh patients with no history of epilepsy have a higher tendency to develop se as opposed to patients with history of epilepsy. larger multicenter cohort studies need to be done for evaluation of these findings. sequoia hospital in redwood city, ca implemented the ceribell rapid response eeg system in 2018 to expand its access to eeg for in-patient usage. previously, the hospital had no access to after-hours eeg and the majority of their eegs happened in the icu. this quality improvement project was initiated to understand how access to rapid eeg impacted clinical care and financial metrics across at sequoia hospital. data was analyzed for all patients who received either conventional or ceribell eeg from january 1, 2017 including the department where eeg was conducted, time of day of eeg was ordered, time when eeg began, and clinical diagnosis based on the eeg. data was also captured on patient transfer due to lack of eeg. 55% of eegs were ordered after hours after the introduction of ceribell, compared to nearly no eegs done after hours before ceribell. 25% of patients with ceribell eegs were diagnosed with seizures. in 2018, of 66 ceribell eegs, 41 eegs occurred in the in-patient unit or ed. in 50% of patients with a high suspicion of seizure, seizures were ruled out as a result of reading the ceribell eeg. the introduction of ceribell eegs has greatly expanded access to eegs at sequoia hospital. before ceribell was introduced, eegs mostly occurred in the icu and nearly all happened during regular hours. after ceribell was introduced, eeg was also heavily utilized in the ed and the in-patient unit and gave sequoia eeg access during after hours. as a result of this expanded access and earlier application of eegs, patients have been treated more appropriately. tranexamic acid (txa) is an intravenous antifibrinolytic agent that is used routinely for elective surgery. we report a case of inadvertent intrathecal injection of txa resulting in refractory status epilepticus. case report. a 71-year-old healthy female admitted for bilateral total knee replacement was inadvertently administered 300mg of txa intrathecally instead of bupivacaine. soon after administration, she intubated, administered levetiracetam, started on a propofol infusion, and transferred to the neurointensive care unit (nicu). she developed persistent spontaneous and stimulus induced generalized myoclonus refractory to propofol. midazolam infusion was added. nchct and cta demonstrated pneumocephalus, but no acute arterial or venous thrombosis or stroke. veeg revealed generalized nonconvulsive seizures occurring once per minute, not correlating with spinal myoclonus . propofol and midazolam infusions were increased to 150 mcg/kg/min and 2.6 mg/kg/hr, respectively, to achieve burst suppression, and valproic acid was added. over the following week, the drips were adjusted to suppress seizure activity. by hospital day 8, she was weaned off all infusions without recurrence of seizures. by hospital day 19, she was on levetiracetam monotherapy. she was discharged to rehab after a 22-day hospital course, and was discharged home 45 days after initial presentation. residual deficits at the time of discharge included mild cognitive impairment and gait instability. she remains seizure-free since hospital day 45 on levetiracetam 500mg bid. we report a case of refractory status epilepticus and spinal myoclonus after accidental intrathecal txa administration. with aggressive management, the patient survived with mild residual deficits. the mechanism by which txa causes status epilepticus and spinal myoclonus is hypothesized to be related to its inhibitory effects on gaba and glycine receptors, respectively. ictal bradycardia (ib) is a serious complication of temporal lobe epilepsy. if left untreated, ib can cause serious injuries related to syncope, complete heart block and death. management of this phenomenon is controversial: should you treat the seizures or the arrhythmia? we describe the management of a patient who presented with multiple syncopal episodes and found to have symptomatic bradycardia in the setting of temporal lobe seizures. a 22-year-old male with a recently resected brainstem cavernoma presented with episodes of 'spacing out', face tingling and transient periods of amnesia. he was started on topamax and lamictal. several months later, he began having multiple syncopal events (upwards of 7 a day) that eventually brought him the hospital for evaluation. he was found to be bradycardic with a heartrate in the thirties and had sinus pauses lasting up to ten seconds requiring atropine, an isoproterenol infusion and transcutaneous (tc) pacing. he was also found to have another cavernoma in the right temporal lobe. eeg revealed epileptic activity within the right anterior temporal lobe with correlation to his tc pacing and ib events. lamictal was replaced with keppra and the seizure activity was controlled. he had a pacemaker implanted, after which he did not have any further episodes of syncope and no further seizure activity. the cavernoma was resected a few months later, and he did well postoperatively. ib is an uncommon, but serious, complication of temporal lobe epilepsy. the temporal insula plays a role in the parasympathetic activity of the heart which can cause ib. it may be beneficial for patients who present with symptoms characteristic of temporal lobe seizures or repeated falls/drop attacks to have a full cardiac work up to rule out ib in order to determine if a pacemaker is warranted. the ceeg has had rapid growth within neurological monitoring within the icu, however its still disparate resource in the icus of latin america. is important to know the real situation in colombia about the accessibility to ceeg monitoring. an anonimus survey of 19 questions was conducted from october 2018 to april 2019. it was answered by intensivists from latin america, europe, asia and usa. (n=62) considering the accessibility to the ceeg, the ceeg clinical indications and the ceeg monitoring extends (hours) in the icu, we can conclude that colombia is aligned with other countries in the world. in the icus of colombia less than half of the intensivists make decisions in ¨real time¨ with the ceeg and have access to the qeeg modality. the most common cause for non-presciption of ceeg was scarce resources (equipment and human resorces support from a neurology service). cefepime is a fourth-generation cephalosporin with broad-spectrum coverage used to treat infections in critically ill patients. neurotoxic effects have been associated with cefepime, including myoclonus, reduced consciousness, and seizures. we report a case of a patient receiving cefepime who developed non-fluent aphasia and non-convulsive status epilepticus (ncse). two seizure drug trials (levetiracetam and fosphenytoin) failed before marked clinical and electrographic improvement with clobazam. other than cessation of the offending agent, there is little known about the management of cephalosporin associated non-convulsive status epilepticus. data was collected from our institution's health record. a 74-year-old female with a history of diabetes, chronic kidney disease, recent coronary artery bypass grafting, and mitral valve repair presented with pseudomonas aeruginosa cellulitis of the sternotomy site. on day six of cefepime therapy she developed non-fluent aphasia. mri brain and toxic-metabolic work-up was unrevealing. eeg was consistent with non-convulsive status epilepticus. she failed to respond to standard levetiracetam or fosphenytoin therapy. lorazepam was given with marked improvement in her eeg. clobazam was subsequently started resulting in marked improvement in the patient's language and sustained resolution of ictal pattern on eeg. epileptogenic effects of ß lactam antibiotics are thought to be due to competitive antagonism of the gabaa receptor. beside the recommendation of withholding offending agents when safe to do so, there is no guidance in the literature regarding the appropriate antiepileptic drug choices for the treatment of cephalosporin associated ncse. in this case, clobazam, a benzodiazepine, was an effective treatment. given the theorized mechanism gaba antagonism of cefepime, it is possible that benzodiazepines may ch is needed regarding the optimal seizure control for various etiologies of ncse. when treating seizures and ncse, consideration should be given to the possible mechanism of action of the suspected offending agent. hashimoto encephalopathy is a rare disease. clinical manifestations include abnormal behavior or psychosis, seizures, encephalopathy. pathophysiology is not completely known but it has been associated with autoimmune thyroiditis. we report a case of hashimoto encephalopathy with status epilepticus which responded well to steroids and relapsed following steroid taper. 20-year-old previously healthy woman was admitted with encephalopathy, new-onset seizures, and delusional behavior for past 8-10 weeks. mri brain was unremarkable. eeg showed status epilepticus with right fronto-central origin. she was treated with multiple antiepileptic medications including evaluation for infections, autoimmune and paraneoplastic etiologies revealed elevated thyroid peroxidase, antithyroglubulin and mildly elevated gad 65 antibodies. whole body ct showed no malignancy. she was diagnosed with hashimoto encephopathy. she was treated with iv steroids and ivig. her clinical improvement correlated with decrease in thyroglobulin antibody levels from15.6 to 4.4 and thyroid peroxidase antibody levels from 32.40 to 17.70. she was discharged on oral steroids and admitted again in few weeks with a relapse of behavioral issues and seizures following steroid taper. she was treated with high dose iv steroids, this time followed by rituximab with significant improvement. she was discharged again on oral steroids with very slow taper and close follow up. our patient had hashimoto encephalopathy and had relapse following taper of steroids. hashimoto encephalopathy is rare condition and is often under-diagnosed. anti-thyroglobulin and thyroid peroxidase antibodies should be checked in patients where no other etiology of new onset status epilepticus is identified. along with seizure management, they should be treated with immunomodulators. closer follow up is needed while tapering the steroids as relapse can occur with behavioral issues and seizures and they may benefit from steroid sparing long term immunomodulatory treatment. non-convulsive seizures (ncszs) and non-convulsive status epilepticus (ncse) are common in critically ill patients. both are associated with neurophysiological disturbances, and even mortality if untreated in a timely manner. [1]continuous electroencephalogram (ceeg) monitoring has been proven to be effective in diagnosing ncszs and ncses, and assessing the efficacy of treatment thus it is a vital investigation. [2] we conducted a national survey on the availability of ceeg monitoring within neuro critical care units (nccu) in the uk. to ensure accuracy the consultant in charge or st 5-7 covering the nccu was contacted by telephone and asked a serious of questions regarding their use of ceeg and reporting. 28 hospitals were identified as having either stand alone or mixed nccu. responses were obtained from 27 of the 28 units contacted. only 46% of nccus were able to perform ceeg monitoring from 9am-5pm this dropped to 39% at night. in 68% of nccus the itu consultant did not feel confident to analayse the ceeg and make treatment decisions based upon in. the inability of 54% of nccu to perform ceeg is very concerning, as a single eeg may miss episodes of status, and also makes treatment to achieve burst suppression very difficult. in addition, there appears to be a training gap in ability of icu doctors ability to interpret ceeg. commissioning standards may need to be modified to encourage take of this vital monitoring technique. in addition systems such as possibly setting up a central remote analysis site for all ceeg data for england might improve time to diagnosis and treatment whilst still remaining economically. traumatic brain injury (tbi) is the leading cause of disability in children. neuroimaging is essential for the acute evaluation of moderate-severe tbi, although its prognostic utility is unclear. magnetic resonance imaging (mri) allows for detailed characterization of diffuse axonal injury (dai), the hallmark pathology described in non-penetrating tbi. higher dai grade in adults correlates with worse outcome, but this association has not been rigorously tested in children. we hypothesize that acute rotterdam score and dai grade predict short-term functional outcome in children with acute tbi. patients admitted to stanford children's hospital for acute tbi were identified via retrospective chart review based on icd9 and icd10 codes for tbi. inclusion criteria were age >1mo and <19yrs with blunt, closed head trauma and mri brain obtained during hospitalization. exclusion criteria included history of epilepsy, prior tbi, developmental delay, and penetrating or non-accidental trauma. the first head ct and brain mri obtained during hospitalization were used for analysis of rotterdam score and dai grade, respectively. discharge destination (home versus facility) was used as a marker of short-term functional outcome. multiple logistic regression analysis on cohort of 44 children revealed that lower gcs and ventriculostomy were independent predictors for discharge to acute rehabilitation (or 1.6 and 27, respectively) versus discharge home. neuroimaging analysis revealed that more severe dai significantly correlated with discharge to a rehabilitation facility (p=0.011), while rotterdam ct score did not correlate with discharge destination (p=0.106). our study demonstrates that higher dai grade is associated with worse short-term outcome in pediatric patients understand the short-and long-term prognostic value of acute neuroimaging in pediatric tbi. , niteroi, brazil zika virus has been associated with several neurological complications. we aim to present three cases of zika associated subacute encephalitis, all requiring intensive care. all patients derived from the rio-zikv-gbs study cohort. all were diagnosed with mac-elisa and pcr for case 1: 33-year-old man admitted with lower extremities weakness and urinary retention, preceded by -capsular area, extending to the corona radiata and cerebellar peduncles. he was treated with a 5-day cycle of intravenous immunoglobulin (ivig). he was discharged one year later due to protracted weaning from mechanical ventilation. case 2: 53-year-old man admitted with lower extremities weakness, dysphagia, and dysphonia. 11 days before he presented with and middle cerebellar peduncles, extending to pyramidal tracts. he was treated with ivig. he was discharged after acute treatment and, one year later, presented only with ataxic gait. case 3: 48 year-old woman admitted with disorientation and behavioral impairment. a week before she presented with 0% mononuclear) with mild protein elevation. mri revealed hyperintense -t5 levels. she was also treated with ivig. a year later her neurological exam returned to baseline. all patients had similar clinical presentation, starting with atypical measles syndrome, later evolving to a subacute encephalitis. all showed similar radiological findings, resembling the ones observed with japanese encephalitis, another flavivirus. this new entity is likely a result of zikv-mediated autoimmune activation and it is a challenge for neurocritical care units worldwide. there are two described forms of necrotizing encephalopathy: multifocal necrotizing leukoencephalopathy (mnl) and acute necrotizing encephalopathy (ane). mnl is characterized by multiple microscopic foci of white matter necrosis and is sporadic with predilection for the pons in patients with sepsis or immunosuppression. ane is characterized by multiple foci of grey and white matter disease and is either sporadic or familial; it is typically triggered by febrile viral illness in children without evidence of cerebral infection. a case report with review of the clinical, laboratory, radiographic, and pathologic data. a 39-year-old woman with post-traumatic epilepsy was admitted with acute encephalopathy and respiratory failure secondary to h1n1 and strepotococcal pneumonia. she developed refractory hypoxemia requiring proning and eventually veno-veno extra corporeal membrane oxygenation. her neurological exam declined with no response to painful stimuli and absent corneal reflexes. continuous restricted diffusion lesions of the cerebral white matter, splenium of the corpus callosum, brainstem, cerebellar peduncles, and deep cerebellum. she died after transition to comfort care and autopsy was pursued by family. neuropathologic evaluation revealed microscopic acute and subacute necrotizing lesions throughout the white matter of the cerebrum, pons, and cervical spinal cord. there were similar lesions throughout the thalamus with sparing of other gray matter structures. there was no significant lymphocytic inflammation or meningoencephalitis. this presentation is consistent with mnl, yet the thalamic involvement is more characteristic of ane. however, ane is rare in adults and typically affects both the grey and white matter. our case affected mostly white matter with microscopic lesions in the grey matter of the thalamus. this case is unique in that it has features of both known necrotizing leukoencephalopathies without clear classification. pharmacotherapy after traumatic brain injury (tbi) aims to prevent secondary insults by optimizing brain homeostasis. to better understand the relationships between medication infusions and cerebral dynamics, we investigated their associations with cerebral compliance (cc), autoregulation (ca) and heart-rate variability (hrv). a retrospective analysis of severe tbi patients admitted to the pediatric icu who underwent brain multimodal monitoring was performed. ca, cc and hrv were estimated by using different parameters: ca by using the pressure reactivity index -a pearson correlation coefficient; cc by using the rap indexa correlation between icp and pulse amplitude; hrv by heart-rate root mean square of successive differences. analysis of variance was used to investigate cerebral dynamics differences during narcotic/sedation (dexmedetomidine, fentanyl, propofol), barbiturate (pentobarbital), vasoactive (epinephrine, milrinone, nicardipine, norepinephrine, phenylephrine) and paralytic (vecuronium, rocuronium) medication infusions. 46 children were identified (13 female; ages 0-17 years). ca values were significantly higher (i.e. larger positive values) in patients who received vasoactive infusions than those who did not (epinephrine (0.326±0.001), norephinephrine (0.150±0.001)). cc values were much larger (closer to 1) in patients who received barbiturate and paralytic infusions compared to those who received narcotic/sedation infusions (pentobarbital (0.517±0.001), vecuronium/rocuronium (0.506±0.001), fentanyl (0.371±0.001), dexmedetomidine (0.326±0.001), propofol (0.316±0.001)). hrv displayed significantly larger values in patients who received narcotic/sedation infusions compared to those who received barbiturate infusions (propofol (35.040±0.446), dexmedetomidine (34.732±0.139), pentobarbital (13.704±0.171)). these results suggest vasoactive infusions (epinephrine and norepinephrine) are associated with impaired ca, narcotic/sedation infusions (dexmedetomidine and propofol) are associated with improved cc and greater hrv, and barbiturate infusions (pentobarbital) are associated with impaired cc and less hrv after severe tbi. prospective analysis is needed to validate these associations and investigate whether these medications may be contributors or epiphenomena of altered cerebral dynamics. sleep wake disturbances (swd) after pediatric traumatic brain injury (tbi) requiring critical care admission are poorly quantified, but may have important implications for patient recovery. we conducted a systematic review to quantify swd after pediatric tbi requiring critical care, identify interventions for swd, and determine the association between swd and other post-intensive care syndrome (pics) morbidities after tbi. injury requiring neurocritical care published after 1999 and reporting a sleep or fatigue outcome. studies focused on concussion or mild tbi without differentiation of intracranial injury requiring critical care hospitalization were excluded. risk of bias was assessed for included studies. a meta-analysis was not performed due to heterogeneity of included studies. search results yielded 966 articles. abstract review yielded 126 articles, and 21 studies were included in the final analysis (17 observational, 4 case reports). we found children with tbi had significantly more swd when compared to controls. studies reported over one third of tbi patients have swd, some persisting for years after injury, but often failed to delineate phenotypes of sleep problems. most studies used subjective measures with questionnaires or interview. seven studies used a validated sleep questionnaire. three studies with 16 total patients presented objective data on swd using actigraphy (n=1), polysomnography (n=1), and electroencephalography (n=1). outside of one case report, no studies evaluated interventions for swd following pediatric tbi. swd in children surviving tbi were associated with pics morbidities including reduced quality of life, behavioral problems, and neurocognitive impairment. heterogeneity and risk of bias among studies was high. research is needed to quantify swd, including identifying phenotypes and utilizing objective measures of sleep. evaluation of pharmacological, psychological, and behavioral interventions for swd is warranted given associations between swd and pics. current guidelines for pediatric severe traumatic brain injury (tbi) recommend maintenance of mean intracranial pressure (icp) under 20 mmhg. increasing evidence has suggested that icp waveform characteristics may be important in understanding the impact of pressure on cerebral physiology. our study objective is to investigate strength of association of brain tissue oxygenation with icp waveform characteristics. retrospective analysis was performed on pediatric patients with tbi who underwent multimodality monitoring including measurements of pbto2 and icp between january 1, 2014 and january 1, 2019. data were limited to relatively normal values of pbto2 between 15 and 50 mmhg and icp values between 0 and 60 mmhg. univariate linear regression was performed to assess strength of association between pbto2 and icp waveform characteristics including, mean icp values, icp pulse amplitude (amp), and minimum and maximum values of the icp waveforms. 17 patients were identified (4 female, ages 3-19 years [mean 8.6; interquartile range 11.8 -15.6]). pbto2 was negatively associated with all 4 icp characteristics following analysis. the correlation coefficient (r) was stronger with respect to the relationship of pbto2 to amp (r = -0.34) as compared to mean icp (r = -0.08), maximal icp (r = -0.14) and minimal icp (r = -0.04). p-values were < 0.001 for all measurements. these data provide preliminary evidence that icp pulse amplitude is associated with pbto2. these findings suggest that icp waveform amplitude should receive greater scrutiny in understanding the impact that icp has on pbto2 after pediatric severe tbi though further research is necessary to confirm this finding. sarcoidosis is a systemic disease characterized by formation of noncaseating granulomas. in 5-15% of cases, sarcoid infiltrates the central nervous system causing a myriad of clinical symptoms and imaging findings. although rare, neurosarcoidosis commonly involves the brainstem, hypothalamic-pituitary axis, leptomeninges, and spinal cord, causing symptoms such as cranial neuropathies, hypopituitarism, aseptic meningitis, and seizures. based on the review of literature, neurogenic shock as a complication of neurosarcoidosis has not been previously reported. a retrospective chart review was performed on the patient's medical records to obtain laboratory results, imaging studies, and treatment modalities. we demonstrate a case of neurosarcoidosis that initially presented with neurogenic shock, seizure-like activities, and anterograde amnesia. a 28-year-old african american man with neurogenic shock and seizure-like activities was transferred to our neurointensive care unit. initial workup revealed panhypopituitarism, including hypothyroidism and central diabetes insipidus. mri of neuro-axis was significant for diffuse parenchymal and leptomeningeal enhancing lesions of unclear etiology, including the hypothalamic-pituitary axis, bilateral mesial temporal lobes, and cervical spinal cord. he was intubated for airway protection and treated with dopamine infusion for hypotension and bradycardia thought to be a manifestation of neurogenic shock from his extensive cervical spinal cord lesion. despite significant cervical cord involvement, he remained with good strength throughout. he was extubated after a short course of high dose steroids and stabilization of electrolytes and endocrine function however was found to have anterograde amnesia -pet revealed hypermetabolic lymphadenopathy throughout the neck, chest, abdomen, and pelvis without cardiac involvement. he subsequently underwent lymph node biopsy which revealed noncaseating granulomas. neurosarcoidosis is an infiltrative disease process with varied clinical and imaging presentations. although neurogenic shock is classically seen as a complication from spinal cord injuries above the t6 segment, neurosarcoidosis affecting the cervical spinal cord can also present with neurogenic shock. the primary goal of traumatic brain injury (tbi) management is the prevention of secondary injury achieved by invasive intracranial pressure (icp) monitoring. near infrared spectroscopy (nirs) is a continuous, noninvasive surrogate measure of cerebral blood flow and oxygenation making it a potentially useful adjunct in the management of tbi. we aimed to determine the association between regional oximetry (rso2) and icp in pediatric tbi. the association between rso2 and icp was estimated retrospectively in 56 pediatric patients with severe tbi. digital record using univariate dynamic structural equations modeling with a 95% credible interval (95% ci) for the standardized regression coefficients (src). 54 of 56 study patients had documented events. the association between rso2 and icp varied between patients and event type. no events triggered by changes in rso2 occurred. a significant positive (src=0.035, 95% ci=0.023 -0.046; src=0.043, 95% ci=0.030 -0.054 respectively). a negative r this was not significant (src=-0.012, 95% ci=-0.026 -0.005). during times without intracranial hypertension, changes in icp were positively associated with changes in rso2, which may be related to changes in cerebral blood flow. our results also suggest that cerebral desaturation may be seen during periods of intracranial hypertension. our data supports the utility of nirs as an adjunct to understanding changes in icp, however further research is needed to determine if these findings are clinically relevant. rapidly progressive (< 24 hours) primary angiitis of the central nervous system (pacns) has rarely been reported in the literature. most cases have resulted in death. here, we describe the neurocritical care course of a patient with rapidly progressive pacns who survives with a good outcome. data was collected prospectively through direct patient care and chart review. a 20-year-old previously healthy male presented to an emergency room in acute coma. initial head ct showed diffuse cerebral edema and a left thalamic intracerebral hemorrhage. non-contrast brain mri c perivascular enhancement suggestive of cerebral vasculitis. an external ventricular drain was placed for intracranial pressure monitoring and cerebrospinal fluid sampling, which showed a neutrophilic pleocytosis (wbc=42, 88% pmn). brain biopsy on hospital day (hd) #2 was consistent with a diagnosis of necrotizing pacns. rheumatologic evaluation was negative for systemic inflammatory disease. therapy included methylprednisolone, plasma exchange, and cyclophosphamide. his hospital course was complicated by ventilator-associated pneumonia, thrombocytopenia, cerebral salt-wasting, and malignant intracranial hypertension which was treated with hypertonic therapy, barbiturate coma, and hyperintensities and resolution of perivascular enhancement. he required tracheostomy and percutaneous gastrostomy and was discharged to a ventilator facility on hd #31. on discharge, he was awake and texting on his cell phone. at 2-month follow-up, his modified rankin score was 3. our case demonstrates that rapid diagnosis, early immunosuppressant therapy, and aggressive neurocritical support in collected on the optimal therapy of the patients with rapidly progressive pacns. , detroit, mi, united states cerebral amyloid angiopathy (caa)-related inflammation, or cerebral amyloid angiitis is an uncommon disease that presents with acute symptoms secondary to a solitary area of vasogenic edema. this series examines 6 patients presenting with acute neurological symptoms and imaging out of proportion to their exam, suggesting this is a common trend in this diagnosis. cases were collected through epic review, using slicer/dicer to select patients with both snomed diagnoses of caa and cns vasculitis, and snomed diagnosis of caa concurrently treated with prednisone 2010-19. cases: (1) 67 year old female with prior diagnosis of caa presents with transient worsening of right arm dexterity and word-finding difficulty. (2) 78 year old female presented with loss of vision in the right eye lasting for 2 hours (3) 73 year old female presents with two days of word-finding difficulty and confusion, using her car remote for her television (4) 72 year old male presenting after being unable to find words and acting out for two days (5) 65 year old male with prior diagnosis of caa presents with one day of confusion and nonsensical speech.(6) 84 year old male with history of bilateral occipital hemorrhages of cryptogenic etiology presents with two days of new onset dizziness and left hemianopsia. in each case, patient was identified to have a focal area of vasogenic edema on mri that was significant and alarming in comparison to the patient's presenting symptoms. swi mri showed numerous microbleeds elsewhere to the vasogenic edema consistent with caa. considered differentials included herpes encephalitis, melas, cadasil, and cns vasculitis due to lupus, however all patients exhibited a neurological exam less severe than expected of differentials mentioned prior. all patients were administered an oral steroid regimen with taper for an average of 4 weeks and their symptoms resolved on follow up. use of cranial ultrasound (cus) in pediatrics has been limited to neonates or infants and transcranial doppler (tcd) for stroke risk in children with sickle cell disease. we describe a clinical case showing the utility of performing cus/tcds to assess for new intracranial process in a pediatric patient where head ct was difficult to obtain due to high frequ assessment of waveforms on tcd can be a useful bedside tool in assessing progression of cerebral edema in pediatric patients unable to get a head ct. 14-month child with acute respiratory distress syndrome required veno-venous ecmo and therapeutic anticoagulation complicated by intracranial hemorrhage with intraventricular extension, 15 mm leftwards midline shift, and hydrocephalus. heparin was reversed and evd was placed. since heparin sedation/paralysis. osmotic therapy was guided by elevated icp. 3 days later, the ability to monitor icps became unreliable due to intermittent evd dra repositioning was deferred because of bleeding risk and lack of clarity whether device malfunction or unsafe because of waveforms with robust arterial diastolic flow and venous flow signifying that icp was lower than plaining unreliability of and repeat head ct showed no gross change. cus and tcd can be a useful tool to screen for high icp using midline shift and spectral waveform analysis in pediatric patients where ct may be contraindicated or challenging to obtain. the structure of intensive care has evolved as the field of medicine has created needs for specialized care. large pediatric hospitals frequently have separated cardiac icu from general pediatric icus, however further subdivision is rare, which differs from adult institutions that often have surgical and neuro icus. this subdivision capitalizes on concentration of expertise and collaboration across providers to improve patient outcomes. texas children's hospital recently opened a new pediatric icu tower and subdivided the picu into six specialty units: surgical, neurology/neurosurgery, pulmonary, hematology/oncology, medical and transitional (for patients with complex needs). we sought to retrospectively review similar patients fitting predefined neuro icu criteria both pre and post move to determine if patient outcome measures were different after cohorting patients. we conducted a retrospective review of neuro icu patients before and after our specialty icu model by comparing june-august 2017 to june-august 2018. patients were identified using local data from virtual pediatric systems (vps, llc) and outcomes collected from the electronic medical record utilizing automated data query. primary analysis included patient demographics and outcomes including icu length of stay (los), mortality, prism-3 and pim-3 risk of mortality scores. early subgroup analysis included patients with icp monitoring devices in both cohort groups. 172 and 273 patients were in the pre and post cohort group respectively, 10 of which had icp monitors in each group. median time to icp measurement was 700 (iqr 117-1598) and 574 minutes (iqr 56-980) respectively in pre and post groups (p = 0.56). icu los, mortality, prism-3 and pim-3 were not statistically different. we have developed an algorithm to capture the neuro icu population for future study. preliminary investigations will hopefully confirm patients benefit from this model after programmatic maturity is achieved. west nile virus (wnv) is a mosquito transmitted arbovirus that is endemic in the united states. only 25% with acute infection develop fevers, and only less than 1% develop neuroinvasive disease. although the presentation of acute flaccid paralysis is not uncommon, it is extremely rare to visualize the destruction radiographically. here we highlight a case of aggressive neuroinvasive disease with radiographic changes. results 67 y/o caucasian male with arthritis on methotrexate and tofacitinib presented with encephalopathy and generalized weakness. initial evaluation included mri and lumbar puncture. initial mri did not demonstrate etiology of symptoms. lumbar puncture was consistent with viral meningitis (wbc 260, rbc 350, glucose 72 and protein 62). patient was started on broad spectrum coverage. there was no growth on bacterial or fungal cultures. pcr biofire was negative for acute viruses. weakness progressed, and required intubation for neuromuscular respiratory failure. diagnostic evaluation was repeated 10 days later. repeat mri demonstrated changes on dwi and t2 weighted imaging, following the motor addition to continued acyclovir, plasma exchange was initiated for an attempt at treatment. the patient's mental status improved, and he refused further treatments including tracheostomy. he was extubated and comfort care was provided given his continued neuromuscular respiratory failure. this case demonstrates severe neuroinvasive west nile encephalitis and flaccid paralysis with radiographic findings. being immunocompromised and age increase his risk for rare presentation of aggressive disease. evidence regarding adequate caloric requirements of critically ill patients with acute brain injuries is suggesting potential risk of caloric debt in neurocritically ill patients. the primary objective of this study was to determine whether guideline recommended weight-based dosing provides adequate caloric requirements compared to indirect calorimetry (ic) measurements in this population. this was a single center, retrospective, observational case-crossover study that included adults admitted within 14 days from admission. we compared resting energy expenditure (ree) determined via ic to the lower (bmi<30 kg/m2: 25 kcal/kg and bmi 30-50 kg/m2: 11 kcal/kg) and higher (bmi<30 kg/m2: 30 kcal/kg and bmi 30-50 kg/m2: 14 kcal/kg) actual body weight-based dosing guideline recommendations. we hypothesized that guideline recommended lower-weight based nutrition will not match the caloric demand of patients with acute brain injuries. a total of 52 metabolic studies were performed in 43 patients (36% ich, 20% non-traumatic sah, 20% ischemic stroke, 16% tbi, 6% status epilepticus, 2% other etiologies). the mean age was 58+18 years, mean weighed 89+27 kg with a bmi of 30+10 kg/m2, and had mean baseline gcs of 7 + 4. on average ic was obtained on day 5 of admission. lower weight-based recommended nutrition did not provide adequate caloric needs as measured by ic adjusted for obesity (1652±485 vs 1952±611 kcal/day, p<0.001). however, higher weight-based recommendation matched the caloric demand as measured by ic (2006±563 vs 1952±611, p=0.417) . in this preliminary analysis, higher weight-based dosing for nutrition matched the caloric demand of critically ill patients with acute brain injury. our results need to be confirmed in future larger prospective studies. central venous catheter (cvc) insertion is common in neurocritically ill patents. standard practice is to obtain a chest radiograph (cxr) to evaluate for the presence of complications, such as pneumothorax (ptx) and catheter misplacement. point-of-care ultrasound (us) has been suggested as an alternative methodology to assess for these complications by using a flush test. patients admitted to our neuro icu between 6/5/18 -5/8/19 who required cvc placement were the subject of this quality improvement analysis. cvc's were placed in the internal jugular (ij) or subclavian (sc) vein followed immediately by lung us to assess for ptx. then, apical or subcostal four-chamber view of agitated saline injected through the distal port of the cvc (ie. flush test) was performed to assess for proper placement. we observed the time delay between start of agitated saline instillation and visualization of contrast in the right atrium and ventricle. this was then interpreted as appropriate (contrast present in </= 2 cardiac cycles) or not. twelve patients were included in this analysis. no patients had a ptx on us or cxr. one patient had a misplaced catheter detected by an abnormal flush test after subclavian cvc insertion using the landmark technique. this was further confirmed by us visualization of the cvc terminating in the ipsilateral ij vein. after immediate removal and reinsertion, followed by an appropriate flush test, cxr then confirmed accurate placement. ultrasound evaluation of cvc complications took < 10 minutes in all cases while it took an average of 45 minutes for the cxr to be avai a potential savings of $200.00 for each cvc inserted by avoiding the cost of a cxr. in conclusion, we demonstrated us post cvc placement to be an accurate, fast, and potentially less expensive method of confirming cvc placement compared to cxr. major professional critical care societies recommend shared decision-making using decision aids (das) to reduce surrogate decisions incongruent with patient values and preferences and decisional conflict. no das currently exist for any decisions in the neurologic intensive care unit (neuroicu), including goalsof-care decisions. using multilevel input from 88 stakeholders, we recently developed a goals-of-care da for critically-ill traumatic brain injury (tbi) patients that meets international da standards. we aimed to adapt this da to intracerebral hemorrhage (ich) and hemispheric acute ischemic stroke (ais) to widen its applicability and fulfill the shared decision-making needs of surrogate decision-makers of stroke patients. we adapted the existing goals-of-care da by replacing the tbi prognostication model with diseasespecific outcome models as recommended by da quality-standards. we selected the validated 12month ich-model and 12-month hemicraniectomy trial outcome data for ais because they include validated long-term outcome assessments. next, we performed acceptability and usability testing of both das using validated scales in family members recruited from two academic neuroicu waiting rooms. we successfully modified the das and created new icon-arrays to optimize the display of predicted outcome probabilities and uncertainties, as has been shown in risk communication studies. twenty family members from two centers participated in acceptability and usability testing. median usage time was 22±7 minutes. usability was very good (mean system-usability-scale-score =77/100). 89% of amount, balance and comprehensibility. we developed three goals-of-care das for surrogates of critically ill tbi, ich and ais patients that include disease specific icon-arrays to communicate outcome probabilities meeting international da standards. das is ongoing, in preparation for a future multicenter comparativeeffectiveness trial. our rigorous development process following international da standards may serve as a template for other neuroicu das. neurocritical care patients receiving rate-based enteral nutrition (rben) consistently received less than their full prescription of enteral nutrition (en) volume due to interruptions in feeding. rate-based en does not allow the nurse to increase the rate after interruptions leaving patients at risk for underfeeding (kim et al. 2010 , yeh & peev, 2016 . low caloric intake over time is associated with a) immunosuppression, b) impaired wound healing, c) muscle wasting, d) increased hospital and intensive care unit (icu) lengths of stay, e) increased costs, and f) increased mortality (barker et al. 2011, elke et increase the likelihood of adult neurocritical care patients receiving the predetermined goal of 85% or more of the prescribed volume of enteral nutrition over the course of the nccu length of stay through the use of a volume-based en (vben) protocol which allows the rn to increase the tube feeding rate after interruptions occur. a retrospective pre and postimplementation chart review was conducted on patients aged 18 or greater and less than 90 years with a neurological-related injury or disease process who received en for three or more days during their nccu stay. despite no significant differences in characteristics or gastrointestinal complications between the groups, there was a significant increase in the percentage of prescribed en volume delivered over the course of nccu stay of 23.15 percentage points in the vben group (m = 95.3, sd = 4.92) as compared to the rben group (m = 72.15, sd = 10.55), t(27, n = 40) = 8.89, p <<0.001, two tailed, unequal variances. vben can be safely implemented in the neurocritical care population and is associated with significant improvement in en volume delivery. pain, agitation, delirium, and machine support in the icu. a--intensive care syndrome (pics), manifest as psychological and physical debilitation that persists beyond discharge. a-neurocritically ill patients is not known. practices aligned with individual elements of the apopulation were deemed beneficial for patients within this cohort. we asked the question, does the implementation of the asystematic training on a--professional teams was implemented. baseline data, total bundle compliance, and individual element compliance were measured and analyzed using an approach adopted from the published sccm icu liberation campaign. mortality, ventilator hours, delirium, length of stay (los), and cost were compared to baseline against the third month post education to evaluate the impact of apreliminary analysis suggests that increased compliance with a-whether wholly or in part, resulted in improved value of care, as evidenced by a decrease in mortality from 7% to 4%, as well as a reduction in total icu los adjusted by acuity from 2.19 days to 1.36 days. this translated into a reduction in cost. as additional experience (and data) become available, further analysis is planned to evaluate the impact of aearly results from a systematic implementation of aand pertinent to improving patient outcomes and value of care. many neurologic diseases are incurable, and patients are faced with prognostic uncertainty, progressive decline and early mortality. as a result, acgme requires training in serious illness communication for all neurology residents; however, only 52% of programs offer formal education. to address this gap at our institution, we created a training program for neurology residents to improve their skills, attitudes, and behaviors regarding serious illness conversations we designed and implemented a 3-hour training program utilizing the serious illness conversation guide (ariandnelabs.org). the training program is comprised of a didactic session, a simulated patient experience and debriefing. residents were asked to have a goals of care (goc) conversation with family members (actors) of a patient with catastrophic stroke. a faculty facilitator observed each interaction, allowing residents to self-assess, obtain feedback from the actors and peers and then practice specific components of the conversation. residents filled out a survey both prior to and following the simulation and the faculty filled out an evaluation for each of the residents. led out a pre-survey. the majority (8/12) felt that the residency did not adequately prepare them to have goc discussions though more than 50% of residents reported feeling comfortable and confident performing these discussions. despite this confidence, the observing faculty found 10/14 residents require direct supervision and are not ready to have these conversations independently. the residents struggled with conveying prognosis, maintaining silence, and dealing with strong emotions. all residents reported the training was a helpful, rewarding experience and improved their overall abilities to discuss goc, address prognosis, and explore end-oflife issues. this small pilot study demonstrates an innovative model to improve residents' communication skills surrounding effective goc discussions even when they report increased confidence and independence in these difficult conversations. studies of patient outcomes in mechanically ventilated icu patients have discovered associations among sedative drugs, patient characteristics (demographics and illness), burst suppression (brain inactivation), and mortality. however, association does not imply causation. it remains unclear (1) whether unintentional burst suppression has a causal effect on mortality, (2) the degree to which drugs directly impact mortality, and (3) whether drugs impact mortality indirectly by causing burst suppression. patient characteristics are a possible source of confounding. we estimated causal effects of unintentional burst suppression, critical illness severity and the anesthetic sedation on in-hospital mortality in mechanically ventilated icu adult patients. this was a longitudinal study with an observational cohort of 474 adult icu patients. eeg recordings were obtained for each patient and reviewed by 2 clinical neurophysiologists per institutional protocol to determine the presence of burst suppression in each epoch (8-12 hour segment). the causal effects were estimated using causal statistical inference (pearl's do-calculus). to assess the robustness of our results towards unmeasured confounding, we performed sensitivity analysis using the e-value. 95% confidence intervals were created using bootstrapping. on average, increased drug exposure causes a 4% increase in mortality (95% bootstrapped confidence interval -.01, .1) and a 5% increase in burst suppression incidence (.01, .09). burst suppression mediates 15% of the impact of drug exposure on mortality and is associated with a 15% increase in mortality (.04, .24). increased severity of illness causes a 43% increase in mortality (.13, .66), and a 13% increase in burst suppression burden, measured by the percent of epochs during which patients experienced burst suppression (-.12, .32). unintentional burst suppression contributes substantially to in-hospital mortality. however, unintentional burst suppression appears to be affected more by patient characteristics such as severe critical illness than by high exposure to sedative drugs. infectious endocarditis (ie) is a growing health concern, with increasing incidence in the context of the opioid epidemic. we described a large case series of patients with ie at an urban, academic safety-net hospital. clinical data on patients with diagnosis of ie were entered into an endocarditis work group single-center registry. the mission of the multidisciplinary group is to optimize clinical care, especially as it pertains to cardiac surgical management. we reviewed demographic information, history of prior cardiac valve replacement, intravenous drug use (ivdu), blood culture results, and diagnostic studies (ie echocardiogram, brain ct/mr imaging, and conventional angiography). between november 2017 and may 2019, 99 consecutive patients (mean 41.2 years; aged 20-82 years; 46% male) with ie were admitted to our center. patients had a history of ivdu in 73% of cases. 37 unique microbes were isolated, most commonly staphylococcus species (33 mssa, 22 mrsa, 10 other). polymicrobial infection occurred in 33 patients. on echocardiogram, vegetations were seen on tricuspid (48), mitral (49), aortic (18), and pulmonic (2) valves. 10 patients had multi-valve involvement. 63 patients underwent brain ct or mri demonstrating-cerebral infarctions (20), subarachnoid hemorrhage (sah) (6), intracerebral hemorrhage (ich) (9), brain abscesses (3), and mycotic intracranial aneurysms (4). neurologic complications occurred most frequently in the setting of mitral valve disease (15 infarcts, 5 sah, 5 ich) and in those with staphylococcus (11) and polymicrobial infection (7). tricuspid valve vegetations were associated with 4 cerebral infarcts and 1 ich. despite frequent association with ivdu, left-sided cardiac valve vegetations were common. mitral valve involvement, staphylococcus species and polymicrobial infections were associated with increased risk for neurologic complications. neurologic complications also occurred in patients with right-sided valvular disease, suggesting a need for increased surveillance in this population. acute neurological conditions such as traumatic brain injury (tbi), cerebrovascular accident (cva), and hypoxic-anoxic injury (hai) can significantly impact a patient's functional status, and life expectancy. older adults may have poorer outcomes, especially those with premorbid conditions. studies have shown a preference for less aggressive care if patients and/or families anticipate a shorter life expectancy, or poor outcome. as such, early delivery of prognostic information and discussion of goals of care (goc) can be crucial for patients prior to transfer to a tertiary care facility. this is a retrospective cohort study of patients aged 18 and older with cva, hai, or tbi who died within 72 hours of charts were reviewed to assess documentation of pre-transfer goc discussions, code status change after transfer, prevalence of palliative care consultation, and other utilization markers. 90 patients met inclusion criteria with 52.2% being male and 47.8% female with median age 66.5. the majority of patients were transferred from an emergency department (84.4%). only 5.6% of patients had documented goc discussions prior to transfer. only 6.7% patients of patients underwent surgical intervention. after transfer, 87.8% of patients downgraded their scope of treatment to comfort measures prior to death, with this being even higher in those 65 and older (95.8%). palliative care consultation took place in only 5.6% of patients after transfer. while transfer to a tertiary medical center is sometimes necessary, only 5.6% of patients had documented goc discussions and the majority (87.8%) downgraded their scope of treatment to comfort measures after transfer suggesting a potential opportunity for earlier goc discussion and possible avoidable hospital transfers. these findings can inform the design of future interventions to improve communication and decision-making regarding goals of care in patients with high mortality neurological conditions. a neurological emergency response team (nert) was implemented at a dedicated neuroscience hospital in an academic medical center in anticipation of higher patient volumes with the extended treatment window for acute ischemic stroke. goals of the nert are to ensure safe and effective care transition into the acute care setting and a standardize approach to neurological emergency. a dedicated clinical team examined the current structure for safe & effective patient triage, monitoring and transition from the interventional neuroradiology (inr) suite to the neurocritical care unit. clinical nurses with over three years' experience in neurocritical care were vetted, trained & scheduled to provide 24/7 continuous coverage. after patients were triaged via telemedicine technology, the nert nurse was alerted via automatic text message system and prepared to receive the patient via ambulance to the inr suite. during the assembly of the inr team, the nert nurse assessed and monitored the patient and initiated diagnostic testing. upon completion of intervention, the nert initiated transfer of care to the neurocritical care unit. stroke volume and door to treatment times were evaluated pre-and post-intervention. in 2017, 289 ischemic stroke patients were admitted through the inr suite, with 74 being treated with endovascular intervention. in 2018, 560 ischemic stroke patients were admitted, with 157 patients being treated with endovascular intervention. since the implementation of the nert, average median arrival time to skin puncture for intervention decreased by seven minutes with a 50% increase patient volume. a dedicated neurological emergency response team is an effective model to support the increase in patient volume for evaluation of acute ischemic stroke intervention. this approach demonstrates the potential for efficient, safe and timely triage, intervention and care transition to the neuro icu for stroke patients. arctic ground squirrels (ags) endure harsh winter environments through hibernation. curiously, ags are resistant to stroke and other ischemic injuries independent of season or metabolic state. the details of physiologic and cell autonomous genetic adaptations underlying this metabolic resilience is largely unknown. the resilient metabolic and mitochondrial phenotype of ags neural cells was examined in vitro after exposing cells to hypoxia, hypothermia, or mitochondrial toxins and assaying for cell survival, mitochondrial morphology, and oxygen consumption rate. a cdna library prepared from ags cells and nucleofected into mouse neural cells exposed to metabolic stressors was used to perform a functional genetic screen. a bio-informatics pipeline identified screened candidates with key amino acid substitutions that may have evolved to optimize stress response function. newly described dcas9 base editors capable of substituting c->t (and g->a) were used to systematically mutate and explore the role of identified proteins in mediating the ags optimized adaptive stress response. we found that ags neural cells exhibit marked resistance to all metabolic stressors. this is associated with enhanced mitochondrial function and improved morphology. the functional genetic screen identified a network of evolutionarily-conserved ags transcripts imparting cytoprotection. use of dcas9 base editors on candidates suggested by the bio-informatics pipeline, confirmed the coordinated role of specific components of the oxidative phosphorylation (oxphos) and endoplasmic reticulum (er) stress response systems in imparting mitochondrial and neuroprotection in our in vitro model. we gained key functional insights into how specific amino acid substitutions in the machinery of the oxphos and er stress responses systems alter mitochondrial function to impart cytoprotection to metabolic insults. this detailed dissection of the ags optimized adaptive stress response pathway will serve as an template for the development of new neuroprotective treatments. acute ascending weakness with respiratory failure is a frequent syndrome encountered in the neurocritical care unit (nccu), often related to demyelinating or infectious etiology. however, here we describe a case of acute ascending weakness with encephalopathy, respiratory failure and autonomic instability that was related to confirmed endocrinological etiology. prospectively collected data was retrospectively extracted from the electronic health record in a patient known to our nccu team. a 24-year-old male with medical history of childhood meningitis was transferred to the nccu after initially presenting to an outside emergency department (ed) with a chief complaint of bilateral lower extremity weakness progressing to paraplegia over 4 hours. six hours into his course in the ed, he developed bilateral upper extremity paresis and respiratory distress. physical exam in this ed was additionally notable for areflexia and a sensory level at t7. he was intubated, initiated on ivig and methylprednisolone, and airlifted to our institution. upon arrival, telemetry showed frequent supraventricular tachycardias refractory to standard treatment. labs (including cerebrospinal fluid) were notable only for serum potassium <1.5 meq/l, thyroid stimulating hormone <0.01 uiu/ml, t3 5.2 uiu/ml (0.8--1.7). he was diagnosed with thyrotoxic periodic paralysis. at endocrinology's urging, the patient was given propranolol 1 mg iv every 10 minutes for 3 doses, propylthiouracil and hydrocortisone. in the hours following propranolol, his potassium improved, his paralysis and encephalopathy resolved, and he was ultimately extubated without difficulty <48hours after admission. review of symptoms performed after improvement revealed recent symptoms consistent with hyperthyroidism. intensivists should remain aware of the differential diagnoses that can manifest with motor weakness and respiratory failure. in this patient, severely elevated thyroid hormone led to thyrotoxicosis and subsequent profound hypokalemia. acquiring a thorough history and reviewing laboratory abnormalities remain paramount for timely diagnosis. the objective of the study is to determine the prevalence of disability among icu survivors one year after admission, and factors influencing functional outcome. we conducted a population based cohort study in the icus of the mayo clinic, rochester, mn. we enrolled consecutive patients from the mayo clinic study of aging (mcsa) and then admitted to medical or surgical adult icus at mayo clinic, rochester between january 1, 2006, and december 31, 2014. patients admitted to the neuroscience icu were excluded. we collected their demographic and clinical variables, length of icu stay, functional and cognitive status (before and after icu admission), comorbidities (components of charlson score), and apache 3 were retrieved from the electronic medical records using multidisciplinary epidemiology and translational research in intensive care (metric) data mart. one-year functional outcome was categorized using the modified ranking scale (mrs) with scores 0 to 2 representing good functional outcome. 831 cases were included and 569 (68.5%) patients were alive one year after icu admission. of them, 546 patients had one-year follow-up functional assessment and 367 (67.2%) of them had good functional outcome. on multivariable analysis, poor one-year functional outcome (death or disability) was more common among women, older patients, baseline cognitive impairment (mild cognitive impairment or dementia), higher charlson scores, and longer icu stay (all p<0.01). after excluding deceased patients, these associations remained unchanged. in addition, 120 (32.3%) of 372 patients who had post-icu cognitive evaluation, experienced cognitive decline after the icu admission. approximately two-thirds of survivors maintained or regained good functional status one year after icu hospitalization. older age, female sex, greater comorbidities, abnormal baseline cognition, and longer icu stay were associated with poor functional recovery. shared decision-making using decision aids (da) is recommended by major professional critical care societies for surrogate decision-making in the icu to reduce decisions incongruent with patient values and preferences and decisional conflict. we converted a paper-based goals-of-care da in critically-ill tbi patients to a digital da. we applied eye-tracking-technology in a single-masked randomized study to understand the effects of and optimize the da navigation design to facilitate information processing. we created two digital das: (1)unmodified conversion of the paper-da with horizontal, top-justified static navigation (control) vs. (2)vertical, left-justified navigation with page subsections and page completion checkmarks (experimental), which encourages users to view pages in order. sixteen healthy participants were randomly assigned to the two groups (n=8/group, masked to da assignment) and navigated through the das. using t-tests, we compared user disorientation and usability using validated scales, and eye movements (fixation and saccades) recorded with eye-tracking-technology. impact of navigation on usability was assessed with linear regression, adjusting for disorientation(system-usability-score= b0+ b1*disorientation). disorientation was significantly less in the experimental da (mean 6.5 vs.5.2;p=0.005;smaller values indicating increased disorientation) with no difference in usability (mean system-usability-scale scores 81 vs.78;p=0.64;scores>72 indicating good usability[range 0-100]). regression analysis revealed a significant association between disorientation and usability (p=0.01), with disorientation explaining 31% of the variation in system-usability-scale scores (adjusted r2=0.31). eye-tracking measurements revealed longer average fixation per page in the experimental da (mean 0.24s vs.0.23s;p=0.03) and a higher ratio of information processing to search per page (fixation-duration over total duration of both fixations and saccades on a page; mean 0.89 vs.0.88;p=0.0003). eye-tracking-technology suggested that the experimental navigation design significantly improved the navigation experience resulting in less disorientation and participants spending less time searching and more time processing the information. while there was no difference in subjective usability, we found a significant association between improved navigability and higher usability. high-fidelity simulation has become an important mode of learning in medical education. currently, there is little data regarding the impact of simulation-based learning in neurocritical care training. in may 2019, we presented a poster at the american academy of neurology annual meeting introducing a comprehensive simulation-based curriculum for neurocritical care training at uc san diego (ucsd). in this poster, we aim to present additional preliminary findings regarding trainee comfort levels, interest, and areas of improvement. this is a single-group pre-post study involving current residents of the ucsd department of neurology. simulation sessions consist of interactive, faculty-led, and checklist-based clinical scenarios (ischemic stroke, intracranial hemorrhage, status epilepticus, spinal cord emergencies) followed by debriefing sessions. collected data assesses for self-perceived comfort/confidence levels, future interest, and checklist item completion. between january 2017 and july 2018, 22 pgy 2-4 neurology residents participated in various simulation sessions on ischemic stroke, intracranial hemorrhage, and status epilepticus. prior to the session, 62.5% of all trainees reported no more than somewhat comfortable in treating neurological emergencies despite having received some type of neurological emergency training through didactic lectures. rtable in treating the specific simulation case in observation of each simulation session pinpointed specific areas of improvement amongst trainees on an individual basis (i.e. time to intubation after benzodiazepine administration in refractory status). preliminary results suggest that simulation-based learning is valuable and applicable in the neurocritical care training process, allowing trainees to feel more comfortable in managing acute neurological deterioration and faculty to directly observe trainee skill in a controlled setting. through this project, we hope to highlight the need for simulation-based education in neurocritical care training by providing evaluative information and generalizable curricular examples. chimeric antigen receptor (car) t cell therapy for refractory/relapsed hematologic malignancy often causes severe neurologic side effects ranging from encephalopathy and aphasia to fulminant cerebral edema and death. the cause of neurotoxicity is poorly understood. we sought to develop a score based on clinical and laboratory parameters to predict which patients would develop cart-associated neurotoxicity. all patients undergoing cart therapy at brigham and women's hospital for relapsed/refractory hematologic malignancy were prospectively studied. patients were assessed daily during their admission for cytokine release syndrome (crs) and neurotoxicity. vital signs, laboratory data, and medication administration records were extracted from the medical record. logistic regression was used to determine which clinical and laboratory features were significant predictors of developing neurotoxicity. 159 patients were included. 121 experienced crs and 73 experienced neurotoxicity. early (within 3 days after cart infusion) fever and elevated serum c-reactive protein (crp), timing of crs onset, crs grade, and treatment with tocilizumab were all significant predictors of neurotoxicity. using roc curves, optimal discriminators were defined and used to derive a score to predict neurotoxicity. one point was assigned for fever, serum crp > 79.3 mg/dl, and each dose of tocilizumab administrated, zero to four points for crs grade, and zero to three points for day of crs onset. this score ranged from 0 to 14 for our cohort and had an auc of 91%; a score >= 5 predicted neurotoxicity with a sensitivity of 82% and a specificity of 84%. bootstrap analysis was used to demonstrate robustness. we used regression analysis to develop a score that can prospectively predict which patients are most likely to suffer from neurotoxicity related to cart therapy. this score can be used for triaging and resource allocation during the care of the patients after treatment with cart therapy. when brain herniation is impending, every minute matters; so the efficient and expedient procurement of all components required for external ventricular device (evd) placement is vital to neurological preservation. the neurosurgical residents at the university of rochester medical center often struggled to assemble the appropriate supplies for an evd placement in a timely manner when patients were not yet admitted to the neuro intensive care unit (neuro icu). additionally it was difficult to track equipment use and supply costs. in response, the neuro icu's quality improvement (qi) team designed an evd "go bag" in an effort to improve delays in care, patient experience, and avoidable costs. the multidisciplinary neuro icu qi team collaborated to design a portable bag that contained all equipment necessary for evd placement. two neurosurgery residents performed time trails, in real emergency situations, by measuring the time from decision to place an evd in emergency department (ed) critical care bay, to collecting the equipment from the neuro icu and return to the bedside in the ed. times were compared with and without using the evd "go bag". the evd "go bag" decreased the time to placement of an evd by up to 17 minutes when compared to the traditional method of retrieving all evd equipment from the neuro icu stockroom. time reduction was due to the speed of gathering supplied and the ability for the neuro icu staff to bring the evd "go bag" to the patient's bedside. the evd "go bag" allowed for better tracking of monetary costs and equipment, allowing for appropriate billing and stocking of supplies. a system was developed where the bag was checked and restocked daily by the critical care equipment technicians and the neuro icu charge nurse despite a growing number of prognostication models in neurologic emergencies, prognostic uncertainty remains inevitable and plays a central role during goals-of-care decision-making for incapacitated critically ill patients. we aimed to examine surrogate decision-makers' communication needs and physicians' strategies for communication of prognostic uncertainty during family meetings for critically ill traumatic brain injury (citbi) patients. we qualitatively analyzed semi-structured interviews of 16 surrogates of citbi patients from two level-1 u.s. trauma-centers and 20 tbi expert physicians from 7 u.s. trauma-centers. open-ended questions about prognostic uncertainty were asked. interview transcripts were analyzed with the investigatortriangulated-inductive-framework-approach in nvivo-software. prognostic uncertainty was identified as the most difficult aspect of decision-making for surrogates by physicians and surrogates alike, although most surrogates had some pre-existing expectation or understanding of it. 95% of physicians observed that uncertainty is distressing for families, with 90% employing specific measures to limit uncertainty. over half of physicians described explaining the concept of uncertainty so surrogates understand that physicians can estimate the odds but not predict the future. physicians typically conveyed prognosis using a range of outcomes, and conveying certainty only for prognostic extremes. surrogates found uncertainty around prognosis was lessened when physicians explained all possible treatment options, with support from clinical data. roughly half noted that too much certainty in providing a prognosis, without a range of possible outcomes, led to distrust in the information provided by the physician, increasing decisional conflict. the vast majority of physicians admitted statistical uncertainty in deriving prognosis, particularly for patients with tbi, and cited mistrust of prognostic models when deriving long-term prognosis. most physicians felt that uncertainty around prognosis led to increased incidence of tracheostomy and feeding tube placement. these results provide foundational knowledge for physician-family communication, by identifying important gaps between surrogates' communication needs and physicians' practices about prognostic uncertainty. the rapid rise in social media utilization among both patients and healthcare providers has moved a considerable portion of conversation around health and disease to the digital space. today, roughly nine-in-ten american adults use the internet, with 79% of internet users participating in social media. the power and reach of social media platforms makes it imperative for clinicians to be aware of the trends in the public narrative around common disease processes. in this study, we analyzed the last 2.5 years of postings ("tweets") from a popular social media platform, twitter, to characterize themes and trends in the digital conversation around stroke, the leading cause of long term disability in the us. tweets under the hashtag #stroke, published from january 1st 2016 to april 26th 2019, were extracted through symplur signals, llc. a total of 836,719 #stroke tweets were qualitatively coded and sentiment analysis was performed after selection for relevance among all homographs. accounts owned by stroke-related advocacy groups were found to be the most prolific contributors of #stroke postings, with content mostly around primary stroke prevention (risks and signs). among the 100 most popular associated hashtags, over half of the tweets focused on comorbidities and the challenges of the stroke recovery process (top trending words included #aphasia, #lockedin, #survivor, #depression). our preliminary analysis describes trends in themes and stakeholder participation in the current #stroke online conversation. it also exposes important gaps in the public discourse beyond the setting of academic and research online communities, namely around existence of therapeutic treatments, availability of resources for patients and families navigating the recovery process, and possibility of successful recovery and long term outcomes. such knowledge around the digital stroke narrative may provide valuable context to intensivists and stroke clinicians interacting with patients and families affected by stroke. the field of autoimmune neurology, specifically the autoimmune encephalitides, has expanded since the early 2000's. increasingly newer antibodies to various parts of the nervous system are being identified in discovered in patients with meningoencephalomyelitis, or some spectrum of these three singular entities. data was reviewed from electronic medical records for this case report. a previously healthy 31 year-old male initially developed a case of aseptic meningitis, progressing to encephalitis and then extensive longitudinal myelitis leading to profound paresis and respiratory failure. an extensive workup was performed, including evaluation for rare infectious and ominant leukocytosis (491/μl and 328/μl) and elevated protein (> 200 mg/dl). he was treated empirically with antibiotics which were discontinued after negative results and cultures. after therapy with high dose iv steroids he had minimal improvement and pl had improvement in his symptoms. he was started high dose prednisone with plans to slowly taper after return with positive antiin review of the literature our patient had several characteristics consistent with others who were also antipsychiatric symptoms. many reports state steroids lead to remission and improvement, however in this case our patient did not have substantial recovery until after the initiation of plex. at this time it is hether these antibodies instead represent a marker of other underlying disease from cytotoxic t cell damage to astrocytes. the united council for neurologic subspecialties (ucns) accredits neurocritical care (ncc) subspecialty fellowships and certifies neurointensivists. in 2018, the american board of medical specialties (abms) approved the application for ncc subspecialty certification by american board of psychiatry and neurology (abpn) and the accreditation council for graduate medical education (agme) approved ncc fellowship training in 2019. previous studies have shown significant heterogeneity in ncc fellowship training and procedural competencies and that many programs do not have the necessary resources for a transition to acgme accreditation. in 2018, an online survey of abpn neurology diplomates was utilized to estimate the number of neurologists practicing ncc, their ncc fellowship training experiences, whether their institutions required certification in ncc, their scope of practice, and their interest in pursuing abpn certification in ncc. 300 survey respondents indicated that they practiced ncc. based upon ucns and other data, this is estimated to be at least 30% of all neurologists practicing ncc. 50% of ucns-certified ncc respondents identified the primary scope of their practice as academic involving a fellowship program, and 45% of non-ucns-certified ncc responders identified themselves as private practitioners. nearly 90% of fellowship trained ncc respondents obtained ucns certification. 55% of ucns-certified ncc respondents reported that their institutions required ucns certification, whereas 83% of non-ucnscertified ncc respondents reported no institutional requirements for certification. over 80% of respondents thought ncc training was relevant to their current clinical practice. most respondents indicated that they planned to take the abpn ncc examination, and >60% of respondents reported that abpn certification would most benefit them by improving their colleagues' perceptions about the quality of certification. ncc training and certification is valued by most neurologists practicing ncc, and most believe that abpn ncc certification will advance the recognition of the field of ncc. cerebral edema is a severe complication of acetaminophen-induced acute liver failure (apapprimary objective was to describe the characteristics of patients with cerebral edema in the setting of apapthis analysis is part of a large, retrospective observational study inclusive of apap-year period from a regional transplant center. we used standardized data collection tools and trained defined cerebral edema based on the interpretation of this ct by a blinded radiologist. we performed univariate analysis based on the presence of cerebral edema. of a total of 327 patients, 243 had data on ct brain imaging. the mean age was 39.2 ± 14.6 years, and 167 patients (68.7%) were female. of patients with neuroimaging, 35 (14.4%) had evidence of cerebral edema. patients with cerebral edema had higher average ammonia levels on day 1 of hospital admission (226, 95% ci 137 -315 vs. 90, 95% ci 75 -106 mcg/dl). patients with cerebral edema also had significantly higher meld scores by 48-hours (32.1, 95% ci 27.9 -36.2 vs. 24.6, 95% ci 22.9 -26.3). this significant difference persisted for subsequent hospital days. thirteen patients (37.1%) with cerebral edema received intracranial pressure monitoring. mortality within 28-days was 42.9% (n=15) if cerebral edema was present vs. 14.4% if absent (n=30). the odds of death within 28-days, if cerebral edema was present, was 4.5 (95% ci 2.1 -9.6). one patient with cerebral edema died awaiting transplant, and 3 received liver transplant. in this study, cerebral edema was present in 14% of patients hospitalized for apapwith higher mortality. elevated intracranial pressure and cerebral edema are leading predictors of poor outcomes and mortality in patients with head trauma, intracranial hemorrhages, or acute ischemic strokes. while hypertonic saline (hts) is the mainstay of treatment, recent trials in critically ill populations have demonstrated a reduction in kidney related adverse events with the use of balanced crystalloid groups when compared to 0.9% sodium chloride (nacl). the purpose of this study is to assess adverse kidney outcomes and risk of in-hospital mortality associated with hts in a neurocritical care population. a retrospective cohort study was conducted at a large academic medical center on 112 adult patients in the neurosciences icu who received 3% nacl and/or 23.4% nacl from july 1, 2016 to july 31, 2018. the primary endpoint was major adverse kidney events (make-30), defined as at least one component of the composite: in-hospital mortality, receipt of new renal-replacement therapy, or persistent renal ays. baseline characteristics, indication for hts, pertinent lab values including changes in serum electrolyte concentrations, total hts volume and associated sodium and chloride milliequivalents, and patient outcomes were collected. statistical analysis was performed using spss software. in the chloride increase > 5 mmol/l group, 22 patients (23.2%) experienced the primary outcome of make-30, 19 patients (20.0%) experienced in-hospital mortality and 4 patients (25.0%) experienced aki primary outcome of make-30, and 3 patients (17.6%) experienced in-hospital mortality (p= 0.62). the primary outcome occurred more often in the chloride increase > 5 mmol/l group and in-hospital mortality accounted for the majority of the outcome in both groups. this was not statistically significant due to the sample size and unbalanced comparator groups. social media has been shown to be a valuable tool to improve knowledge, attitudes, and skills. it has been theorized that the success of medical education through social media can be contributed to increased learner engagement, real-time feedback, and enhanced collaboration. we hypothesize that social media is underutilized in critical care medicine in comparison to other specialty fields of medicine and surgery. a list of medical specialties as hashtags were run through "hashtagify" software. this software crossreferences up to 500,000 data points on instagram and twitter and assigns a "popularity score" for certain topics. the phrase "critical care" was cross-referenced through a database of medical news run by doximity over a month in comparison to other topic tags. in total, 1420 articles concerning the topic "critical care" were posted on doximity news over 30 days. in comparison, there were 54 articles posted under "cardiology," 460 under "internal medicine," and 600 under "emergency medicine." with respect to hashtag utilization on social media, critical care was under-represented, with a popularity score of 38. this was in comparison to other specialties such as neurology (49), dermatology (49), emergency medicine (48), and ophthalmology (44). within the critical care hashtag, the major influencers were those representing critical care nursing. despite the large amount of news pertaining to critical care on professionally-curated forums such as doximity, there is significant under-representation in social media. within the hashtag, "critical care," the major influencers represented critical care nursing suggesting that critical care physicians are even further underrepresented. this is in line with previous research suggesting the underrepresentation of medical doctors in social media. given that social media has been shown to be a valuable tool in enhancing medical education, we believe that a greater effort should be made to engage critical care physicians on social media outlets. there is a call for increased diversity in national and international annual meeting participation in terms of attendance, committee participation, leadership, awards and speakers. the neurocritical care society annual meeting(ncs-am) speaker qualifications are not specified in the bylaws. the speakership patterns of the ncs-am have not been examined. we described the speakership patterns in ncs across a 3-year time span (2016) (2017) (2018) and delineated the trends of united states-neurocritical-care-fellowshiplongitudinal cohort study. the ncs-am conference program, a readily available online document, for the years 2016-2018, were reviewed by the study authors. speakers were identified from the conference program. our primary outcome was the trend of speaker characteristics across the 3-year time span. our secondary outcome was to determine speakership trends among united states-neurocritical-care-fellowshipinstitution of employment at the time of the meeting. a total of 422 speakers were included in this study, of which 57% were male. majority of the speakers were us-based(88%), mid-to late-career (60%) and were physicians (69%). the speakers were 12±9 years from fellowship. in 3-years, there was an increased trend towards international, non-physician and early-career speakers' trained from johns hopkins university (jhu) (47,19%), massachusetts general hospital (mgh) (44,17%) and cornell/columbia university (22,8%); while the most common sites of employment at the time of the meeting were jhu (15,6%), mgh (15,6%) and university of pittsburgh medical center (14,6%). this is the first study to evaluate speakership trends across a 3-year period of the ncs-am. diversity has ble institutional bias are unclear and deserves to be studied further to better define speaker selection in the ncs annual meeting. these data may also be utilized to explore opportunities for collaboration and diversity in future ncs-ams. urinary tract infections (utis) are the fourth most common type of healthcare-associated infection, primarily caused by instrumentation of the urinary tract. there is a 3%-7% increased risk of patients acquiring a catheter-associated urinary tract infection (cauti) for each day an indwelling urinary catheter (iuc) remains in place. in critically ill patients, iuc placement is often required for precise urine output measurement. subarachnoid hemorrhage (sah) patients often require iuc's during the cerebral vasospasm period (i.e. post-bleed day, pbd 3-12) to maintain euvolemia. this places sah patients at increased risk for developing a cauti. in our local neurosciences intensive care unit (nsicu), an infection control team observed higher cauti rates as compared to the hospital and national average necessitating changing our urinary catheter utilization policy. we report change in practice pattern with implementation of new unit policy the intermittent catheterization (ic) algorithm includes clinician review of the patient's total intake and output and current clinical status. retrospective chart review of cauti incidence (rate per 1000 catheter days) and device utilization ratio (no. urinary catheter days/ no. patient days) 12 months before and after implementation of the new policy. time periods were compared using appropriate statistical tests pre-and post-intervention the ic algorithm was implemented to reduce iuc utilization rate with aim to reduce cauti rates. the time periods studied were may 2017 to april 2018 (pre-intervention period) and may 2018 to april 2019 (post-intervention period). cauti rates decreased from 4.5±3.4 during the former time-period to 0.42±1.45 during the latter time period (p=0.0081). similarly, device utilization ratio decreased from 0.8±0.08 to 0.53±0.09 (p<0.00001). in addition, use of female and male external catheter devices were encouraged leading to increased utilization systemic team based implementation of policies can result in adoption of positive practices and reduce hospital acquired infectious complications. managing neurological emergencies, particularly overnight, is very challenging for neurology trainees at the beginning of their residency. preparation is key to ensure residents have the skills, confidence, and knowledge to manage acute scenarios. we developed a one-week immersive bootcamp to educate new neurology residents about neurological emergencies prior to the start of the academic year. the bootcamp includes the fourteen emergency neurological life support (enls) modules designed by the neurocritical care society, thirteen faculty-created didactics, nine case-based discussions, and four resident-created simulations. the bootcamp teaches residents about the management of acute ischemic stroke, acute non-traumatic weakness, anoxic brain injury, coma and brain death, intracranial hemorrhage, intracranial hypertension, meningitis, neuromuscular emergencies, status epilepticus, spinal cord emergencies, subarachnoid hemorrhage and traumatic brain injury. residents are also taught about communication with families during and after neurologic emergencies in a didactic session on breaking bad news. it is important for all neurology residents to be adept at managing neurological emergencies. however, having these skills is particularly important for residents in a military program, as residents in the military may ultimately be deployed overseas or stationed at facilities with minimal support, responsible for handling all neurological emergencies, regardless of their sub-specialty. enls training and didactics teach residents about the fundamentals of neurological emergencies. case-based discussions provide residents to act out the way they would utilize this knowledge in a risk-free environment that is translatable to acute clinical situations. the combination of enls training, didactics, case-based discussions and simulations into a one-week immersive bootcamp early in residency should, therefore, provide a solid knowledge base about management of neurological emergencies for incoming neurology residents and allow them to consolidate that knowledge leading to safe and effective management of neurological emergencies. trends and predictors of in-hospital mortality for status epilepticus: national inpatient sample study head or heart: ictal bradycardia and temporal lobe epilepsy julia bevilacqua higher dai grade correlates with worse short term outcome in pediatric traumatic brain injury anna janas; scott hamilton; zachary threlkeld; max wintermark post-intensive care syndrome amongst families of icu patients, including post-traumatic stress disorder (ptsd), is highly prevalent after patient discharge but understudied. the psychological model of "attachment theory" describes how people respond when being separated from loved ones; various "attachment styles" have been associated with the development of ptsd in other settings. adults can be "secure" (comfortable depending on others and being alone) or "insecure." the hypothesis of this exploratory study was that insecure family members of neuro icu patients would be more likely to report ptsd six months after patient hospitalization compared to secure family members. eligible participants were 111 family members of neuro icu patients at a single center who already had attachment styles (secure vs. insecure) defined via a standard survey, the relationship questionnaire, during an earlier study in 2018. over 2018-2019, these subjects were asked by mail to complete the impact of events scale-revised (ies-r) six months following discharge or patient death. participants were considered to have ptsd if ies41/111 returned a completed ies-r (37.0%). 27 (65.9%) of these subjects reported a secure attachment style vs. 1 out of 14 (14.2%) insecure respondents (p=1.0). this small study did not show a significant difference in rates of post-discharge ptsd amongst neuro icu family members with secure vs. insecure attachment styles, however was only powered to discover a large difference between groups and the rate of ptsd in our population was markedly lower than sible association in larger cohorts with an overall higher prevalence of post-discharge ptsd would be insightful. key: cord-015352-2d02eq3y authors: nan title: espr 2017 date: 2017-04-26 journal: pediatr radiol doi: 10.1007/s00247-017-3820-2 sha: doc_id: 15352 cord_uid: 2d02eq3y nan prof. michael riccabona undertook his medical school & university training at the university of innsbruck, tirol, austria, completing his md at karl franzens university in graz, austria. following an internship in neurology, surgery and internal medicine he then specialized in paediatrics at the dept. of paediatrics, university hospital in graz. there he took charge of the paediatric radiology and sonography sections at university hospital in graz, as associate professor of paediatrics. in 1993 he additionally started to specialise in radiology, becoming associate professor of radiology in 1998 -then taking charge of the subsection of paediatric sonography at the dept. of radiology, university hospital in graz, where in march 2006 he was appointed full univ. prof at the medical university graz, austria. he has a distinguished academic career and written over 200 papers, more than 50 chapters and several textbooks, and is a very popular international speaker, delivering numerous lectures at many high profile scientific meetings. he is an active member of several reputable international societies, has been chair of the paediatric ultrasound section of the austrian ultrasound society since 2003 , and president of the society of german speaking paediatric radiologists (2010) (2011) (2012) (2013) (2014) (2015) (2016) . he is a constant source of inspiration within his subspecialist areas of interest in ultrasound and abdominal radiology in children. he has been course director at several important meetings and served as president of espr in graz in 2015 and as lead of the paediatric subcommittee at ecr in 2012. he has provided inspirational leadership as chair of the espr task force on uroradiology since 2002writing state of the art guidelines and procedural recommendations to facilitate standardised best practice for imaging within paediatric uroradiology. he has been a reviewer for many international journals. he has on-going active roles in postgraduate education for medical colleagues from eastern europe, including basic ultrasound education and refresher courses, and workshops. michael riccabona is very deserving of honorary membership of espr, which reflects his seminal role within paediatric radiology in europe and his tireless dedication working for the good of children. & to discuss how to optimally adapt the various imaging techniques minimising radiation exposure and risks during diagnostic imaging in children. & to consider common restrictions, challenges, and possible solutions in paediatric radiology within the different settings in different countries, regions, continents and clinical scenarios -discussing all these aspects with colleagues, and to mingle with experts from all over the world learning from each other and fostering networking in paediatric radiology to try to grant optimal imaging for all children. an application for the 53 rd annual meeting as well as for the 39 th post graduate course has been submitted to the eaccme® for cme accreditation of this event. the eaccme is an institution of the uems (www.uems.net). the number of cme points will be announced at the espr 2017 congress website. each medical specialist should only claim those hours of credit that he/she actually spent in the educational activity. certificates of attendance will be available in the espr myuserarea after the meeting. the answers right away is: yes we can and we constantly have to. it is part of human nature to recognize problems and to find solutions. we define ideals but we also face reality. being aware of the gap in between we are constantly driven to improve. this overview will highlight some milestones and disputes throughout the 100 years of development in the use of plain x-ray imaging. it will hint on scientific literature and sources of information. and it will hint on some swiss contributions as the espr meeting 2017 will be held in davos, switzerland. fighting the glow not the fire -122 years of x-ray imaging development and improvement: in the beginning of the clinical use of x-ray imaging, there was great enthusiasm in its potential without knowing the unfavorable dangers of uncontrolled use of x-ray. the dangers were recognized and the 'beast' was tamed and domesticated. in respect to radiation protection, the most significant achievements took place in the first half of that development. throughout the recent decades, some further considerable steps in dose reduction took place mainly by the improvement of film-screen systems and the recent introduction of computed (cr) and digitized radiography (dr). even if the early computerized x-ray imaging brought a slight increase in patient doses (which was overcompensated later on by direct digital radiography) a whole new world of further advantages launched the digital era in which we live today. as we all know new dangers arose with these techniques as the uncontrolled distribution of images and thereby confidential patient data over hospital departments and across borders throughout. also, the risk of an evitable overexposure in digital radiography is a significant issue. throughout the process of taming the radiation and controlling it, today's doses are attained within the lowest range of the danger scale. this range still is perceived as a black box within which we do not exactly know which concept reflects the potential harm best. the linear no-threshold model [lnt] is acknowledged as the concept which most reliably supports the idea of radiation protection. other concepts partly oppose the linear idea and question the relevance of that dose range because there lie so much greater health benefits in the appropriate use of diagnostic x-rays. several scientists even propagate the idea that very low levels are producing health benefits instead of physical harm [hormesis model]. nevertheless, the lnt model is widely accepted as the most helpful in the context of diagnostic radiology. some recent studies were able to support the idea of potential harm at very low dose levels as they were able to prove the induction of attributable cancers in the pediatric age group. so today we are fighting the glow, not the fire. as trained medical professionals we are fully aware of the fact that there is only little potential harm to the patient by using x-rays in the current state of the art. but on the other hand, we also have to be aware of the fact that our patients and their parents still fear the fire. one of our main tasks, therefore, is to explain the risks and benefits to the patients and their advocates and to educate the public. developed straight from the first radiographic technique's digital radiography today is state-of-the-art in plain 2d-imaging. throughout the last decade, it has replaced cr and conventional radiography in many institutions. in the united states of america, one of the most developed healthcare systems, healthcare authorities propagate incentives to abolish cr and older imaging systems by making them financially unattractive. the market is fully concentrated on the spread of dr systems. momentarily there are no real milestones but many refinements of existing systems such as tomosynthesis, dual energy subtraction and advanced auto-stitching, fluoroscopy capability, basic angiography applications and 3-d cone-beam ct images are made available. combinations of these features can be found in some recently designed x-ray machines. grid-less imaging software can reduce patient dose significantly. concerning detectors, there are cr retrofit systems which will support the easy upgrade of existing systems to dr capability. wireless detectors with large internal storage, different sizes and high resolutions of 100 microns are available. dr is becoming a part of the system in the current era of full digitalization of our lives and big data, digital radiology is a cornerstone of our healthcare systems. ris and pacs as part of integrated healthcare (ihs) systems are widely disseminated. at the next step, all accessible data will be used for analyses. the major vendors of imaging systems, as well as pacs suppliers and independent companies, offer readymade software tools for reports and evaluations of all kind. the doses from different x-ray sources can be screened internally and be used for optimization purposes. they also can be sent to remote servers for dose monitoring, comparison and optimization in multi-hospital health care provider settings or to comprehensive databases like the american college of radiology dose index registry, cancer registries, or for central billing. has everything been invented? many technologies have been declared dead before a new transformation appeared. this was the case for example with single slice ct before the invention of spiral ct by willi kalender, germany and peter vock, switzerland in 1988. often the plain x-ray image was meant to be needless or redundant as newer technologies like ct or mri approached. but it still is of value because of different reasons as the low dose, high availability, well known and easy interpretation to name a few. there are some new and sophisticated techniques on the way like the "smart x-ray source" which uses coherent beams of x-rays from an array of micronsized point sources, developed by scientists at the massachusetts institute of technology (mit). the developers promise less radiation, less weight of the equipment and a far better soft tissue resolution. another promising approach is phase contrast x-ray imaging which has the potential to reduce the dose up to 1/100 of the actual value. it also has its strengths in additional soft tissue information as recent experimental publications show (paul scherrer institute switzerland) e. g. in functional evaluation of lung fluid (munich, germany). functional imaging of the lungs can also be achieved without any radiation as the development of the known concept of electrical impedance tomography highlights. this functional imaging method usually is not within the modality spectrum of radiologists. dose control and reduction -local -regional -international the most effective measures to achieve significant dose reductions in your own department are still the same strategies which are based on the "eternal rules" as we know them from our teachers: avoiding unnecessary exposures by strictly controlling the appropriateness of a referral. justification is a shared responsibility between radiologists and clinicians. there are many tools available for justification like the appropriateness criteria, guidelines or rules (like wrist or ankle rules) of several national societies and different study groups. the process of optimization is mainly in the hands of the technicians. as many studies show, the proper collimation still has the greatest effect on dose reduction. other important factors are the positioning of the patient and the shielding of radiosensitive organs which are not relevant for image interpretation so that they may be covered by lead shields. the proper use of the grid in bigger children can now partially be replaced by software solutions. in digital radiography, a profound knowledge of postprocessing possibilities is mandatory as well as the active control of the exposure indices. dose limitation procedures should be regularly checked in a team-based approach to avoid overexposure by less experienced staff or "exposure creep". existing standards should be actively used to guarantee a constant satisfactory image quality. in 2011, the image gently campaign released a safety checklist for performing digital radiography examinations on pediatric patients which is easily applicable to every radiology service. organizational improvements: at regional and national level, efforts should be made to check for best practice use in the departments and to compare and discuss imaging strategies. the establishment of national and international dose reference levels helps to keep the overall doses low and to protect the population from unnecessary overexposure. the pidrl project prepared the "european diagnostic reference levels for pediatric imaging" as part of the eurosafe project. momentarily the results of pidrl-workgroup are harmonized with international organizations. the european guidelines on drls for paediatric imaging can be accessed as a preliminary final for workshop drafts on the internet. on a worldwide basis, the world health organization has published a fundamental information brochure concerning radiation risks and the communication of health professionals and patients. health care professionals have a shared responsibility for communicating risks and benefits of imaging procedures to patients, especially in the case of pediatric patients. the document "communicating radiation risks in paediatric imaging-information to support health care discussions about benefit and risk" is intended to serve as a tool for health care providers, to communicate known or potential radiation risks associated with pediatric imaging procedures and to support risk-benefit dialogue in health care settings. as said before we are fighting the glow, not the fire. the paper of the swiss pediatric oncology group stirred a broad discussion. among other issues, there was a question if it shouldn't be a logical consequence to transfer kids from areas with higher background radiation to safer areas. the author's answers were clear: that swiss health authorities better concentrate their efforts more effectively and with greater benefit for more people by supporting prevention "toward modifiable environmental factors leading to larger numbers of deaths from several causes, such as exposure to radon, air pollution, and second-hand tobacco smoke". this leads to the conclusion that we as medical radiological professionals do have the obligation to make every effort to prevent our patients and personnel from harm of the usage or non-usage of radiation. as health specialists, we also should support the fields of prevention with broad mass effects as far as we have the opportunity. and as human beings, we are summoned to do so in respect to other beings, to our environment and to the resources we all share. radiation protection and quality improvement is just a small part of it all, but it is our field -and 'yes we can'. "communicating radiation risks in paediatric imaging. freely available at the who homepage." computed tomography: are we doing enough? e. sorantin; graz/at summary: already in 1912 the alara principle was publishedbut the implementation is still far from complete. according to the surveys of the ec tender project "pidrl -european diagnostic reference levels for paediatric imaging" the most frequent computed tomography (ct) examinations in children are, in descending order, head/neck, chest and abdomen thus counting for about 75% of all pediatric ct's. therefore it makes sense to optimize these examinations first. surveys of the "international atomic energy agency (iaea)" in 40 countries have shown, there is considerable lack of organizationeg in about 50% of facilities protocols for children were missing, indication based protocols available only in 57%, ctdi values for head and chest two to five times of those for adults. all of these simple facts indicate we are not doing enough for radiation protection in pediatric ct. actions to lower dose in ct can be categorized in organisational, optimization and alternatives. the interdisciplinary implementation of international guidelines for ct in minor head trauma with trauma surgeons could serve as an example of organisational actions. for dose optimization knowledge about dose relevant factors according the "imaging chain" is mandatory as well as adjusting kv to pediatric needs. dose influence on image quality must be known, by exploiting the fact, that, if all ct parameters are kept constant but hte slice thickness is just halve there must be an increase in noisein particular about two times more. therefore if a standard examination is reconstructed at half slice thickness and image quality is still appropriate the amount of waste radiation is in the range of 100%. therefore if the next examination will be reduced with eg 20% mas setting less will be for sure in appropriate quality and the process can be started again. after a couple of examinations the optimal dose will be reached. thus the "half slice thickness" approach is easy to do, does not need special equipment or human resources and will help to find the appropriate dose. the third point is alternatives -ultrasound and mri being the candidates in the first row. new, radiation free, techniques like electrical impedance tomography and others are already developed and can be expected to be release soon. take home points: & we are not doing enough for ct dose savingeven more than 100 years after release of alara principle & dose saving actions can be categorized inthe subtasks organisation, optimization and alternatives & "the half slice thickness approach" is an easy to do technique to elaborate the optimal dose on an particular ct machine. prenatal thoracic mr l. alamo; lausanne/ch the generalization of screening us has considerably increased the detection of congenital anomalies in utero. in the last years, important technological advances and especially, the development of fast heavily t2-weighted sequences has led to an increasing use of prenatal mri as additional diagnostic imaging method. mri is increasingly used for evaluation of thoracic pathology, including tumours and vascular malformations as well as anomalies of the diaphragm, the lungs and more recently, even of the foetal heart: -thoracic tumours and vascular malformations: the diagnosis of a congenital tumor during pregnancy involves a tremendous emotional impact for a family. the most frequently observed thoracic tumours are teratoma, myocardial rhabdomyoma and exceptionally, pleuropulmonary blastomas. mri may provide relevant additional information concerning the origin of the lesion and its real anatomical extent. -diaphragmatic pathology: congenital hernia is by far the most commonly reported foetal diaphragmatic anomaly. the large field of view and the multiplanar possibilities of mri may help to clarify the position of the herniated organs and to evaluate the severity of lung hypoplasia, considered the most important parameter for predicting outcome. other rare pathologies include eventration, paralysis and diaphragmatic lung sequestrations. -lung anomalies: congenital lung abnormalities are a heterogeneous group of pathologies consisting of isolated bronchopulmonary or vascular anomalies or a combination of both of them. congenital pulmonary airway malformation, bronchopulmonary sequestration and bronchial atresia are the most often observed pathologies but they present significant overlap imaging findings. mri allows accurate information concerning the location and extension of the lesion and the volume of the normal and abnormal lung. -heart pathology: the evaluation of the foetal heart remains extremely difficult because of its small size and high rate of battements. the unpredictable foetal motions during data acquisition and the absence of a foetal ecg signal to synchronize data acquisition are additional problems. in the last years, different approaches have been made to overcome these challenges. radiologists should know the typical imaging findings of the thoracic pathology most often observed in foetuses. prenatal mri may provide additional relevant information in a wide spectrum of congenital thoracic anomalies, but in general, it should only be performed if it is considered that additional results might influence the management of the pregnancy and/or the therapeutic approach. therefore, it is important to know the right indications for mri and to recognize the limits of the method. interruptions during embryogenesis of the muellerian or wolffian ducts result in various, potentially complex genitourinary abnormalities of a wide spectrum or combinations. multiple imaging modalities are employed to evaluate patients with these abnormalities. ultrasound is the frontline imaging modality. mr imaging is mostly reserved for complex cases and may incorporate an mr urography, too. other imaging modalities are less frequently used or provide only ancillary information. this presentation will demonstrate the utility of ultrasound and mr imaging, in particular, in the routine diagnostic imaging of patients with the wide spectrum of muellerian and wolffian duct abnormalities. & mr imaging is reserved for more complex cases. neonatal hepatic tumors and vascular malformations d. pariente, s. franchi-abella; le kremlin bicêtre/fr neonatal hepatic tumours and vascular malformations are rare but imaging plays a key role in diagnosis and treatment. the most frequent hepatic tumour is haemangioma (fig1) which often is asymptomatic but may be complicated by cardiac failure, coagulopathy or compartment syndrome. the differential diagnosis mainly includes hepatoblastoma, hematoma (fig2), abscess, mesenchymal hamartoma, choriocarcinoma in the solitary form and metastatic neuroblastoma, cirrhosis, neonatal leukemia in the multifocal form. pertinent biological data are alpha-fetoprotein (but level may be normally high in neonate), betahcg, and urinary catechol amines. hepatic vascular malformations are rarer and include intra or extra porto-systemic shunts (pss), arterio-portal fistula or complex mixed forms. intrahepatic pss may be associated with haemangioma and regress in most cases rapidly (fig3). on the contrary the extrahepatic pss which are located below the portal vein, should be urgently closed to avoid occurrence of agenesis of the portal vein. the best imaging modality is us which must be performed with high frequency probes and colour doppler to identify hepatic vessels and assess patency, direction of flow, abnormal communication. mri and ct with contrast injection may also be useful. hepatic mass in a 12 do neonate with increased crp and afp. us showing a hyperechoic mass with thrombosis of the left portal vein (black arrow) and a track (white) extending to the mass: hematoma due to malposition of an umbilical vein catheter. hemangioma of antenatal diagnosis on d1. the mass is composed of a large anterior vascular lake corresponding to a porto-systemic shunt and a tissular hyperechoic part. the infant has remained asymptomatic. intrahepatic porto-systemic shunt between the left portal branch of segment 2 (white arrow) and the left hepatic vein (black arrow) in a neonate. at 3 months of age this shunt has completely resolved. haemangioma is the most frequent hepatic tumour in the neonate and is often asymptomatic with spontaneous resolution. levels of alphafetoprotein are physiologically high in the neonate, and can be misleading. hepatic hematoma can be secondary to traumatic delivery, to coagulation disorders or to umbilical vein catheterization. intrahepatic porto-hepatic shunts are the most frequent vascular malformations and regress in most of the cases in the first year of life. us with colour doppler remains the best imaging modality in the neonatal period. imaging in crohn disease: state of the art in diagnosis, prognosis and followup n. colavolpe, a. aschero, b. bourliere-najean, c. roman, f. khachab, h. pico, m. kheiri, g. gorincour, c. desvignes, p. petit; marseille/fr summary: during the past years the inflammatory bowed diseases (ibd) have increase in frequency (1). less than twenty-five percent of them occur in children of less than 18 years (2) and crohn's disease (cd) is twice as frequent than ulcerative colitis (uc) in the pediatric age group. specific phenotypic and genotypic subtype of ibd occur in younger children. early onset (eo) pediatric ibd (before 5 years of age) represent 11% of childhood ibd (3) . uc and undetermined colitis are more frequent in this age group. eo cd showed a more frequent isolated colonic and upper gastrointestinal involvement than later-onset disease where locations are predominantly colic and terminal ileum later on childhood. some pediatric ibd specificities exist than can interfere with the imaging findings: -cd can be limited to the terminal ileum or to the colon in up to 20% of children (4) . isolated jejunal involvement is reported to occur in 5-6% of children. this location is more frequent in the youngest and is more at risk of complicated course of disease (2) . for auvin et al. (3) the small bowel is involved in 80% of cases with less involvement of the terminal ileum than in the adult population. -uc: the classical contiguous alteration of the bowel wall from the rectum to the caecum is inconstant. a macroscopic rectal sparing is reported from 5 et 30% and the absence of continuous disease from rectum to caecum (caecal patch) described in 2% of children. transmural inflammation may be present in severe form as well as terminal ileitis without granulomata (backwash ileitis) (2) . in order to assess these pathologies, and more specifically cd small bowel locations which are difficulty explored by others modalities, small bowel follow-through, barium enema, ultrasound, computed tomography and mr imaging have been widely used. among them, mr-enterography has gained worldwide acceptance due to multiple factors including: a high contrast resolution, a multiplanar ability, an absence of radiation, the possibility to explore in the same exploration the whole bowel and the extra-bowel diseases (perianal fistulae, sacroiliac joint, biliary tract), the ability to compare of side by side consecutive studies in a reproducible manner, a more easily understood exploration by the clinicians than ultrasound, and first of all for its performances. in order to technically harmonize this exploration a recent consensus statements on mre protocol has been published by the esgar and the espr societies (5) . preparation: -depending on their age children must not have solid oral intake from 2 to 6 hours prior to the examination to reduce bowel wall motility. morning mr appointment is more favorable for this purpose. no gasless fluid restriction is recommended but is reabsorbed too quickly to distend enough the small bowel. none hyperosmolar non absorbable solution is superior to another. its ingestion must start 45 to 60 minutes prior to mre. the recommended volume is 20 ml/kg with a maximum up to 25 ml/kg. explanations long before the mre concerning the importance of such absorption and the use of a refreshed product mixed with aromatized flavors will facilitate the child's participation. -the use of spasmolytic agents is optional. however, there are recommended in adults by multiple societies including esgar (5) , the society of abdominal radiology (6) and the acr (www.acr.org/ quality-safety/standards-guidelines). but, mre without antiperistaltic agents result has reached a high diagnostic confidence and excellent agreement with ct enterography for the presence of cd (7) . if used, they need to be administered immediately prior to motion sensitive sequence (t1w dynamic enhanced sequences). if the pictures obtain with these medications are of better quality, there is no evidence that they change the final diagnosis and the children's therapeutic management (8) . the use of these products increase the length of the exploration and their side effects are frequent (nausea > vomiting) which balance their visual benefice (8) . if a spasmolytic agent is used, the recommended first line spasmolytic agent is i.v. hyoscine butylbromide (0.5mg/kg i.v). the recommended second line agent is i.v. glucagon, 0.5mg (<24.9kg) and 1mg (>24.9kg), given as a slow infusion with i.v. saline at an infusion rate at 1ml/s. -no rectal enema is needed. -exploration can be performed either at 1.5tesla or 3testla. more chemical shift and susceptibility artifacts are present with the latter. prone position has been demonstrated to allow better small bowel distension than the supine one with reduction of the peristaltism but without better lesion detections (9, 10) . large multi-elements coils are needed to cover with high resolution from the perineum up to the left colonic flexure. sequences: both morphologic steady state free precession gradient echo and 2d -t2-weighted images are needed in the axial and coronal planes. fat saturation in one of this plane is recommended and maximal slice thickness of 5 mm is required. nowadays, non-enhanced then enhanced 3d t1-fat saturation weighted sequences are mandatory. slice thickness does not exceed 3 mm. enhance sequence need to be acquired at the portal phase of injection. however, in recent studies the need for gadolinium has been questioned when dwi is added to the morphologic sequences. dwi sequences have been considered optional (5,6) but we consider their place essential in pediatric practice. they must be done with high b values, from 600 up to 800 in the coronal and axial planes with 5 to 8 mm contiguous cut in free breathing. axial plane is less prone to artefact than the coronal plane. interestingly enough shenoy et al (11) report in 27 pediatric patients that dwi does not perform as well as standard mre for detection of active crohn disease but the combination of dwi and mre increases imaging accuracy for determining disease activity compared with either technique alone. seo et al (12) in 44 young adults said that dwi mre was noninferior to contrast-enhanced mre for the evaluation of inflammation in cd. based on the exploration of 130 cd adult and pediatric population, dwi proved to be efficient and would avoid gadolinium injection (14) . sirin et al. (14) report in 37 children that dwi revealed lesions that were not detectable with mre done with gadolinium injection. finally, respectively dubron et al. (15) in 48 children and neubauer et al (16) in 33 children and young adults demonstrate better performance of dwi than gadolinium enhanced imaging. like the existing mr protocols for suspected appendicitis (17) it will not be surprising to see fast mr ibd explorations becoming an alternative to emergency us as already proposed (16) . this fast mr limited to a morphologic t2 sequence in two planes associated with dwi sequences will allow a positive diagnosis and the ibd work up. apart from bowel obstruction and its spontaneous bowel distension one of the limiting factors will be the need for an oral water agent uptake in a potential surgical patient. however, it has been published in the adult literature than an oral or rectal preparation was not necessary to rule out uc (18) nor a cd (19) . the other limiting factor is the length of exploration. mre can be shorten especially if the patient's positioning is easy to do (dorsal decubitus) (20) and if there is no need for injection, either for spasmolotytic agent and for gadolinium chelates. the suppression of the iv line, the absence of potential side effects (nausea, vomiting) of paralytic agents and the decreased of repeated long apneas with no loss of significant information will be strong progresses toward the holy grail. -positive diagnosis, disease activity, prognosis and follow-up: mre has a better accuracy to detect inflammation for the small bowel than for the colon (21) . one of its goal is to try to accurately identify features of active inflammation vs fibrotic disease. this is of paramount importance since the former may respond to medical treatment and the latter may need surgical resection. however, inflammation and fibrosis are associated within the same bowel segment and progress in a parallel way making the goal difficult to reach (22) (23) (24) . in their study based on the analyze of 20 children operated for cd strictures, barkmeier et al. (24) report than strictures demonstrating >3 cm upstream dilatation with associated feces sign were highly associated with transmural fibrosis. the most severely fibrotic strictures were associated to the greatest amount of inflammation and there was no significant correlation between stricture length, mural thickness, degree of post-contrast enhancement (arterial and delayed venous phases), diffusion-weighted imaging apparent diffusion coefficient, pattern of post-contrast enhancement, or normalized t2-weighted signal intensity and histological fibrosis or inflammation scores. however, correlation with histological specimens of cd done on a other series s312 (2017) 47 (suppl 2):s297-s pediatr radiol demonstrated that the enhancement ratio of the wall is positively correlated with disease chronicity due to a possible increasing microvessels permeability and inversely correlated to acute disease (25). on the other hand, several authors have tried to correlate the adc values to cd activity. fibrotic tissue does not restrict diffusion and presents a decrease of signal at high b values and high adc values whether acute inflammation shows decrease adc values. variable thresholds from 1.6 x10 -3 mm 2 /s to 2.4 x10 -3 mm 2 /s have been proposed to separate active vs non active disease (21) . however, others authors have reported low adc value of fibrosis compare to histology (26). even if promising results have been published with high correlation with the crohn disease endoscopic index of severity (13) , adc measurements are associated with sever limitation factors including sample size overlap between the bowel wall and its atmosphere, lack of reproducibility between mri-units and mri-vendors, non-standardized sequence b-values parameters (21) . two mre scores are available to quantify the activity of cd. one is using gadolinium injection (27) and the other dwi (13) . due to the complexity of the formula, both are difficult to use in daily practice and have not been evaluated in paediatric practice. interestingly enough if a simplify mre paediatric protocol appears to become a reality, us stays a good imaging challenger and (28). in a recent meta-analysis, based on adult and pediatric series, calabrese et al (29) reported that bowel us showed 79.7% sensitivity and 96.7% specificity for the diagnosis of suspected cd, and 89% sensitivity and 94.3% specificity for initial assessment in established patients with cd. bowel us identified ileal cd with 92.7% sensitivity, 88.2% specificity, and colon cd with 81.8% sensitivity, 95.3% specificity, with lower accuracy for detecting proximal lesions. the absence of abnormal thickness wall would have a negative predictive value, high enough to exclude the need for further exploration, especially when cd is concerned (30,31). concordance between us and mre have been variably reported from excellent (32) to just correct (33). rosembaum and al (22) report that the us findings present in children operated for cd include: bowel wall thickness above 4.3 mm (mean, 6.1 mm) and an increased frequency of loss of mural stratification and fibrofatty proliferation. others us technologies are used in children to better approach the disease activity. it includes, hydrosonograpy using specific oral agents (mannitol, sorbitol, polyethylene glycol, etc…), contrast-enhanced ultrasound and dynamic contrast-enhanced ultrasound (nowadays, contrast agent is offlabel in children) (34) and elastography (35). their enthusiastic results and their efficiency to assess disease activity need to be confirmed (36). in conclusion, as we suspected 7 years ago (37), mre has dramatically modified our approach of pediatric ibd especially when considering its orientation toward a less invasive exploration and the increasing importance of dwi imaging. a cost benefice between mre and us remains to be done on this increasing disease. heterotaxy and isomerism c. lapierre; montreal/ca summary: objectives: to review the classification of visceroatrial situs to describe the associated cardiac and non-cardiac anomalies to illustrate typical findings in fetuses, neonates and children to discuss the surgical consideration and the long-term follow-up in these patients abstract: by definition, the type of situs is determined by the relationship between the atria and the adjacent organs. anatomically, the atrial chamber differentiation is based on the morphologic aspect of the atrial appendages, earlike extensions of the atria. three types of situs exist: solitus (normal), inversus (mirror image) and ambiguus. a single type of situs is present in a patient. when the situs is neither solitus nor inversus, it is referred to as situs ambiguus or heterotaxy. heterotaxy may manifest with various abnormal visceroatrial configurations that are associated with cardiac (in 90-100% of cases) and extracardiac anomalies such as splenic abnormalities, biliary atresia and intestinal malrotation. two subsets of situs ambiguus are well-recognized: right isomerism (asplenia) and left isomerism (polysplenia). in heterotaxy, the venoatrial connections are frequently abnormal. left isomerism is usually indicated by bilateral bilobed lungs, interruption of the ivc and multiple spleens. the more likely found cardiac anomalies are: pulmonary or aortic stenosis, isolated atrial and ventricular septal defects, cardiac arrhythmia due to sinus node dysfunction as well as pulmonary veins that drain into both the right and the left atria. in the presence of right isomerism, bilateral trilobed lungs, a large symmetric liver, and absence of the spleen are frequently observed. at the cardiac level, patients are more likely to have a common atrioventricular defect, a double outlet right ventricle and pulmonary stenosis. total anomaly of the pulmonary venous return and absence of coronary sinus will always be present in right isomerism. heterotaxy can be diagnosed with high accuracy by prenatal echography. a diagnosis should be suggested in the presence of congenital heart disease, visceroatrial heterotaxy and interruption of inferior vena cava with azygos continuation for left isomerism or abnormally closed juxtaposition of inferior vena cava and descending aorta in right isomerism. the mortality in fetuses is high in the presence of heart block and hydrops whereas the cardiac anomalies influence the long-term outcome. as discussed in the literature, the clinical outcomes and long-term prognosis in these patients are relatively poor when compared with non-heterotaxy patients. the risk factors are cardiac (underlying anatomy and arrhythmia risk) and non-cardiac. based on the cardiac anatomy, one of the main determinants is left versus right isomerism. with right isomerism, the cardiac malformation is more severe and an univentricular correction is more frequent. another predictor of mortality is pulmonary vein stenosis/obstruction. whatever the severity of cardiac lesions, the postoperative or discharge mortality is higher in patients with heterotaxy. prenatal diagnosis seems not improve the survival. extracardiac anomalies also contribute to the increased morbidity and mortality. three of the more challenging entities are respiratory, immunologic and gastrointestinal. recurrent respiratory infections, failed extubation or chronic respiratory failure are frequently observed in patients with heterotaxy. recent studies revealed an association between heterotaxy and primary ciliary dyskinesia which can explain the increased postoperative respiratory complications. the spleen is important for the bacterial clearance. patients with asplenia or polysplenia are thought to have "functional asplenia". so, they are at risk for sepsis and severe bacterial infection. the incidence of intestinal malrotation is high, approximately 40% to 90%. observation versus prophylactic ladd procedure and screening for asymptomatic intestinal malrotation are a growing area of debate. the trend seems to go along conservative management and surveillance of malrotation. bronchopulmonary malformations, such as congenital pulmonary airway malformation (cpam), bronchopulmonary sequestration (bps), and congenital lobar emphysema (currently known as congenital lobar overinflation [clo] ), are common congenital lung diseases. these conditions are detected prenatally, usually in the second trimester, in countries where obstetric sonography is routinely performed. the malformations are seen as hyperechoic images with respect to normal fetal lung parenchyma, with a mass effect and homogenous appearance or with coexisting cysts. the lesions usually decrease in size along gestation. a residual mass is seen on postnatal chest radiography, the first imaging technique performed, in only 40% of cases. cpam and bps are predominantly located in the posterior lower chest and can be identified postnatally on ultrasound using a small vector probe and a subcostal and subxiphoid approach. potential feeding arteries can be visualized using color or power doppler. based on clinical and sonographic findings, the differential diagnosis between congenital lung malformations and tumors such as neuroblastoma, type i pleuropulmonary blastoma, and myofibroblastic tumor will be discussed. postnatal management and imaging of newborns with congenital lung malformations is controversial, particularly in asymptomatic patients (approximately 80% of cases). chest radiography is mandatory at birth and chest ultrasound is also recommended to confirm the prenatal diagnosis. computed tomography (ct) or magnetic resonance imaging (mri) using angiographic techniques should be performed some months (8 months) after birth in asymptomatic patients. these techniques are also recommended in symptomatic newborns and before surgery to characterize the arterial supply and venous drainage in cpam and bps, as ultrasound is limited in this regard. in premature infants, sonography complements radiography in the study of prematurity-related lung diseases such as respiratory distress syndrome and its pulmonary complications (eg, pneumothorax), in predicting bronchopulmonary dysplasia, and in diagnosing transient tachypnea of the newborn when clinical and radiographic features are inconclusive. the main ultrasound finding in these conditions is visualization of numerous "b-lines", vertical narrow-based hyperechoic bands extending from the pleural surface to the end of the field of view, representing what is currently known as "sonographic interstitial syndrome". b-lines are artifacts originating from variations in the air-fluid relationship of the lung and are better seen using high-frequency linear probes . use of sonography for follow-up of these patients will reduce the number of the chest plain films performed, and therefore, the amount of radiation exposure in this vulnerable population. for proper interpretation of the sonographic findings in these conditions, the radiologist should be familiar with current related terms, such as lines a, lines b, comet tail artifact, interstitial-alveolar syndrome, septal syndrome, and white lung. trauma is the leading cause of mortality and morbidity in children after the first year of life. motor vehicle accidents are the leading cause of death from unintentional injury in children up to the age of 15. of these cases, the abdomen is the fourth most commonly injured area. in pediatric patients non-operative management of these injuries predominate, hence the importance of early radiologic assessment for appropriate clinical follow-up. anatomically, compared to adults, childrens' abdomens are more square, less muscular and with less intraperitoneal and subcutaneous fat to absorb impact. the diaphragm is more horizontal causing downward displacement of the liver and the spleen outside the protective casement of the ribs. the pelvis is smaller and hence the bladder is displaced upward, also resulting in more vulnerability to this organ. the organ surface area is larger in children and they have a smaller body mass-hence more force applied per-unit of body surface area. the ribs are flexible, and although we see fewer rib fractures, this results in more internal damage. physiologically, children maintain hemodynamic stability longer, often presenting with only mild tachycardia, even when in severe hemodynamic shock. decrease in blood pressure may not be evident before the loss of 30% blood volume. nevertheless, bleeding is less severe and operative intervention is rarely performed. mechanics of blunt abdominal trauma include organ compression from seat belt injury with the presence of erythema, ecchymossis or abrasion on the abdominal wall increasing the likelihood of internal organ injury (55% likelihood of injury). other common mechanisms include pedestrian-car collisions( 4% with intra-abdominal injuries), falls (4% with intra-abdominal injuries), or handle bar injuries (54% with intraabdominal injuries). after the child arrives in the hospital, a trauma algorithm is initiated. generally, for the unstable patient, algorithms are similar and require a rapid atls protocol, followed by a fast ultrasound to confirm free fluid prior to operation. in stable patients, institutional algorithms vary greatly between countries and in different centers. some rely solely on mechanism to determine the need for fast vs ct (not complete ultrasound), others will rely on clinical exam (in a conscious patient with reliable exam) and blood work to determine the need for imaging (ct or us) and others may chose to perform an initial us and complete the exam with a constrastenhanced us during work hours. in the literature many management prediction rules exist based on the history, physical examination, mechanism of injury and are supplemented by blood work and/or intial imaging. most are based on retrospective reviews, with only a few controlled clinical trials. however, the validity of these studies is limited because of different populations, institutional policies and variable radiological practices in terms of when imaging is performed, which modalities are most beneficial and which are less valuable, all the while, considering the utilization of the least irradiating techniques. a representative sample of such algorithms will be discussed. routine and extensive initial trauma panels are not required according to a number of studies. abdominal ultrasound and urinalysis together have been found to confirm 98% of all intra-abdominal injures, in some studies. serial haemoglobins/hematocrit is valuable for determining ongoing s315 (2017) 47 (suppl 2):s297-s pediatr radiol blood loss and assists clinical surveillance. electrolyte abnormalities are uncommon in children unless severe shock is present (metabolic acidosis). liver function tests are elevated in most cases of blunt abdominal trauma, hence, are often performed for its high sensitivity, to avoid ct if the liver panel is negative. imaging, however, is needed for grading of the potential liver injury if the liver panel is positive. abdominal xray is not useful in blunt abdominal trauma, and is usually normal. ultrasound has an important role in the pediatric community, as a sensitive and non-irradiating modality. however, this sensitivity is dependent on the type of ultrasound performed (fast vs. complete abdominal ultrasound vs. contrast-enhanced ultrasound) but also on the qualifications and experience of the performing physician. a meta-analysis of fast in pediatrics demonstrates that it has a sensitivity of 66% (grade i-ii evidence) for identifying hemoperitoneum. a negative fast is not sufficient to rule out intra-abdominal trauma. one prospective observational trial demonstrasted that 34 % of patients without free fluid on fast (performed by formally trained pediatric truama surgeons demonstrated at least grade iii liver or splenic injuries on ct). we know that pediatric ultrasound is operator-dependent, and generally an ultrasound performed by the skillful hand of a pediatric radiologist is more sensitive than that performed by surgeons or by adult radiologists. furthermore, we know that the benefits of contrast-enhanced ultrasound in pediatric trauma exist-highly accurate in visualising lesions, hence avoiding non-contributive ct imaging, however, the feasibility of providing 24-hr contrast-enhanced ultrasound by a qualified radiologist is resource intesive: both structurally and with respect to personnel. published indications for abdominal ct in stable pediatric patients included suspected mechanism of blunt abdominal trauma, significant fluid resusitation without apparant blood loss, hemoglobin <100mg/l without obvious blood loss, multisystem trauma and unreliable abdominal exam. one series with 1500 children undergoing ct for blunt abdominal trauma demonstrate postive findings in 388 (26%), of which all solid organ injuries and 96% of hollow viscus injuries were identified on ct. however, ct has its limitations: it was found to identify gastrointestinal perforation in only 47% of patients with known perforation, but with findings of free fluid, wall thickening and/or bowel dilatation. it is also less accurate in identifying pancreatic trauma, with normal scans in 33-53% of children with pancreatic trauma. again, findings of pancreatic trauma can be non-specific: free fluid or, less commonly, thickening of the gerota's fascia, presence of mesenteric fluid or of fluid between the pancreas and the superior mesenteric vein. when and where to perform ct depends on the imaging algorithms established by individual centers. generally, unstable patients with very high grade visceral injuries are taken to surgery. the stable patients are treated with non-operative management. the literature on angiographic embolization in pediatric blunt trauma is limited to case series that demonstrate a limited utility in hemodynamically stable patients with ongoing blood loss or for the definitive treatment of traumatic pseudoanevryms. a dialogue with the interventional radiologist is imperative in such cases. common imaging findings and pitfalls will be illustrated with case examples. in conclusion, a child's anatomy and physiology must be taken into account when determing the level of urgency and appropriate imaging work-up in blunt abdominal trauma. imaging of these patients cannot follow a standard algorithm as institutions vary with respect to types of personel, training, frequency of trauma, emergency department trauma protocols and availability of an in-house pediatric radiologist. ultrasound and ct have their advantages and disadvantages with associated pitfalls that the pediatric radiologist must recognize to provide an optimal diagnostic workup with minium irradiation. take home points: a child's anatomy and physiology must be taken into account when determing the level of urgency and appropriate imaging work-up in blunt abdominal trauma. imaging of pediatric abdominal trauma cannot follow a standard algorithm as institutions vary with respect to types of personel, training, frequency of trauma, emergency department trauma protocols and availability of a pediatric radiologist. ultrasound and ct have their advantages and disadvantages with associated pitfalls that the pediatric radiologist must recognize to provide an optimal diagnostic workup with minium irradiation. sport injuries d. jaramillo; miami, fl/us the growing skeleton has unique vulnerabilities to acute and chronic injuries due to sports. the practice of intensive sports during puberty and adolescence has led to a great increase in the incidence of sportsrelated injuries. during the growth spurt of early adolescence, the physis becomes weak, and is the site of fractures and avulsions (particularly in the apophyses) and of physeal widening due to repeated stresses, such as the wrist in gymnasts or the proximal humerus of baseball pitchers. both lesions can result in growth arrest. the chondro-osseous junctions of the ossifying epiphyses and apophyses are also vulnerable to avulsions, and the avulsed fragment may be entirely cartilaginous and not visible radiographically (such as in the patellar sleeve fracture). repeated trauma to epiphyses or round bones can lead to osteonecrosis (panner's disease) but more often to osteochondritis dissecans (ocd). in adolescents, ocd occurs most frequently in the medial femoral condyle, the capitellum of the elbow and the talar dome. juvenile ocd has a better prognosis than the adult form. when the skeleton begins to mature, there are fractures unique to partially closing physes such as the triplane and tillaux fracture. some sturctures have propensity to unique injuries during adolescence. a stress on the anterior cruciate ligament (acl) can lead to a tibial eminence avulsion in puberty ( figure) , an incomplete acl tear in early adolescence or a complete acl tear later. meniscal tears are almost always vertical and often involve large meniscal fragments that can flip. patellar dislocations often result in osteochondral injuries. this review will cover the main types of sports-related injuries and the imaging modalities used to diagnose them. 11 year-old with pain and popping sensation during a fall on a football game. ap radiograph is normal & it is important to take into account the specific sport in order to anticipate subtle injuries that may be difficult to detect. a. c. offiah; sheffield/uk the radiographs obtained when inflicted injury is suspected are collectively termed the "skeletal survey". a full skeletal survey should be performed in all children below 2 years of age in whom abuse is suspected. the investigation is not complete until follow-up skeletal imaging has been performed in the 11 to 14 days following the initial survey. children below one year of age should also receive a ct brain. neurological imaging in older children will depend on the clinical scenario. ct chest/abdomen is indicated when visceral injury is suspected. in terms of imaging in suspected abuse, espr has adopted the rcr guidelines. in the absence of a history of significant trauma, fractures highly specific for abuse in pre-ambulatory children include rib, metaphyseal and diaphyseal fractures. simple linear skull fractures have a relatively low specificity for abuse. the combination of subdural haemorrhage, retinal haemorrhage and diffuse cerebral oedema/encephalopathy (the so-called, "triad") suggests shaking. whereas the presence of a skull fracture implies impact. visceral injury often results from direct blunt trauma and may therefore be accompanied by anterior and/or costochondral rib fractures. the posterior rib arcs are protected by soft tissue and posterior rib fractures result from compressive/squeezing forces rather than direct trauma. the dating of fractures has a subjective element and it is more important to recognise that fractures are in different stages of healing, rather than to assign a definite age/age range to the injuries. the major differential diagnoses are accidental trauma and osteogenesis imperfecta. if rickets is the cause of the fractures, then radiology and/or biochemistry will show evidence of rickets. a low vitamin d level, in the absence of rachitic features, is not the cause of fractures. close liaison between radiologists and paediatricians is vital and any siblings/children in the same household who are below 2 years of age should also receive a skeletal survey. remember that the presence of injury does not always mean abuse and that the absence of injury does not always exclude abuse. scoliosis may be primitive, structural, particularly during adolescence; during this period, careful follow-up is mandatory, because worsening is frequent. clinical examination with evaluation of a hump (gibbosity) with a scoliometer is mandatory, with also neurological assessment. beside radiography, additional tools have been developed to avoid xray exposure: "spinal mouse", back surface topography systems, ultrasound and other computer-assisted systems. but scoliosis can also be secondary, and imaging is important to find a cause and adapt management. among the etiologies, radiologist must recognize spine malformations, dysplastic and neuromuscular scoliosis. in addition, scoliosis may also be in relation with a primitive lesion, tumor-related or not, whether the initial disease could be within the spinal canal, spinal or paravertebral. imaging studies lies first on pa and lateral full spine x-rays, if possible with a low dose device (flat panel, slot-scanning system), keeping in mind that follow-up with repetitive exposures may be necessary. reproducible measures of different curvatures help to assess the overall static spine and the importance of scoliosis with cobb angle. the assessment of axial rotation can be obtained through 3d simulations, with frontal and axial views (see figure) . morphologic evaluation of the s317 (2017) 47 (suppl 2):s297-s pediatr radiol spine is mandatory: if a secondary scoliosis is suspected, the research to etiology needs to perform ct or mri, depending on the clinical signs and the results of plain x rays evaluation. similarly, these explorations are useful in the preoperative assessment when surgical treatment is necessary. girl scoliosis, pa and lateral views with eos®, 3d simulation, coronal and axial views take home points: clinical evaluation is always the first step in subject with suspected scoliosis radiation burning is quite low with new devices, but repetitive exposures for follow-up need to carefully respect justification for x-rays exposures new tools are available to appreciate 3d spinal deformation and evaluate prognosis and surgical procedures ct and/or mri are useful in presurgical assessment and to look for etiologies in suspected secondary scoliosis malformations of the spine and spinal cord a. rossi; genoa/it summary: embryology and classification: spinal cord development occurs through three consecutive periods: (i) gastrulation (2 nd gestational week): the embryonic disk is converted from a bilaminar into a trilaminar arrangement, with formation of the intervening mesoderm; the notochord is laid down along the midline, identifying the craniocaudal embryonic axis; (ii) primary neurulation (18 th -27 th day): under the induction of the notochord, the midline ectoderm specializes into neural ectoderm. the initially flat neural plate progressively bends and folds until it fuses in the midline to form the neural tube. the primary neural tube produces the uppermost 9/10 of spinal cord; (iii) secondary neurulation (28 th -48 th day): a secondary neural tube is laid down caudad to the termination of the primary neural tube. retrogressive differentiation of the secondary neural tube results in the tip of the conus medullaris and filum terminale. defects in one of these three embryological steps produce spinal dysraphisms, characterized by anomalous differentiation and fusion of dorsal midline structures. spinal dysraphisms may be categorized clinically in two subsets: open and closed spinal dysraphisms. in open spinal dysraphisms (osd) the placode (non-neurulated neural tissue) is exposed to the environment through a cutaneous defect along the child's back. osd include myelomeningocele, myelocele, hemimyelomeningocele and hemimyelocele, and are associated with a chiari ii malformation. myelomeningocele is by far the most common of these forms; the placode protrudes through a posterior defect and is elevated above the skin surface due to concurrent dilatation of the subarachnoid spaces. closed spinal dysraphisms (csd) are covered by intact skin, although cutaneous stigmata usually indicate their presence. two subsets may be identified based on whether a subcutaneous mass is present. csd with tumefaction comprise lipomas with dural defect (lipomyelocele and lipomyelomeningocele), meningocele, and myelocystocele. lipomas with dural defect are more common; they are differentiated from one another based on the position of the cord-lipoma interface, that lies within the spinal canal in lipomyelocele, and outside the spinal canal (ie, into a meningocele) in lipomyelomeningocele. csd without tumefaction comprise complex dysraphic states (ranging from complete dorsal enteric fistula to neurenteric cysts, diastematomyelia, dermal sinuses, caudal agenesis, and spinal segmental dysgenesis), bony spina bifida, tight filum terminale, filar and intradural lipomas, and persisting terminal ventricle. the most complicated forms (complex dysraphic states), including diastematomyelia, caudal regression, and segmental spinal dysgenesis) are related to faulty gastrulation. diastematomyelia (literally, split cord) is caused by failure of midline notochordal integration, resulting into two separate hemineural plates. caudal agenesis and segmental spinal dysgenesis are related to defective notochordal formation, characterized by absence or hypoplasia of a segment of the notochord, in turn resulting into absence or hypoplasia of a corresponding segment of the spinal cord. functional neuroimaging of cns is a fast advancing field with frequent new developments in scanner's hardware, protocols, clinical indications, and post-processing techniques. for radiation safety reasons in the case of children, functional neuroimaging is mostly based on mr techniques especially designed to focus on the assessment of functional tissue characteristics, such as neuronal activity (fmri),, metabolism (mrs) and perfusion (dsc perfusion, asl). pediatric coils with multiple elements, multiple slice excitation, 3d spectroscopy, 3d asl, reduced fov (zoom) and improved motion compensation techniques are important tools available to meet the permanent challenges of pediatric mr functional imaging: fast motionless acquisitions and increased resolution. functional mri (fmri) reveals brain activation during performance of behavioral tasks, based on the blood oxygen level dependent (bold) mri signal, which is modulated by neural activity via a process of neurovascular coupling. for children, especially of younger age unable to follow a task, resting-state fmri (rfmri) can be performed and correlates brain areas with similar spontaneous fluctuations in the bold signalthereby enabling estimates of 'functional connectivity.' main clinical applications of fmri are the delineation of eloquent cortex near a space-occupying lesion and the determination of the "dominant hemisphere" for language. intense research is conducted in the areas of language organization and development, brain plasticity, and neurobehavioral disorders (e.g. adhd). magnetic resonance spectroscopy (mrs) is a noninvasive mr technique, that detects intracellular metabolites, and may provide neuroimaging biomarkers of normal biological and pathological processes or response to a therapeutic intervention. although the main field of application of mrs is the brain tumors, it has also been of particular (2017) 47 (suppl 2):s297-s pediatr radiol usefulness in assessing ischemic or traumatic brain injury and neurometabolic disorders. perfusion mr imaging methods detect signal changes that accompany the passage of a tracer through the cerebrovascular system. a less invasive approach is arterial spin labeling (asl) that uses arterial water as an endogenous tracer to measure cbf and thus it is more suitable for pediatric studies. mr perfusion is applied in the evaluation of brain tumors, neurological diseases and developmental disorders. functional neuroimaging clinical applications are expected to expand greatly in the future due to the increasing availability of their techniques, as well as the continuous advancements in the field of pediatric research. good knowledge of these techniques will become more necessary for an effective clinical practice and will enhance the role of radiology in the healthcare system. functional neuroimaging advanced techniques based on mri allow us to study complex cns processes such as cerebral perfusion (dsc, asl), metabolic activity (mrs) and brain activation (fmri). functional neuroimaging techniques already have significant clinical pediatric applications and assisted by recent advances in mr technology are expected to become even more powerful in the near future. kidney: perfusion, excretion, obstruction k. darge; philadelphia/us the functional imaging of the urinary tract entails the evaluation of the renal perfusion and excretion. in this complex process the sites of the main abnormalities could be pre-renal, renal parenchymal, renal pelvicalyceal or post-renal or even a combination at different sites. functional mr urography (fmru) is an advanced tool that not only allows the exquisite morphological depiction of the urinary tract, but also makes it possible to generate comprehensive functional data. these provide information about the function of the kidney as well as the excretion of urine from the renal parenchyma into the pelvicalyces and ureter. the functional results are mainly divided into two groups: 1. transit timesthese are recorded in minutes and a side comparison gives idea how much time it takes for the contrast to go through the renal parenchymathe longer the more abnormal in general. 2. differential renal functionsthese can be based on the enhanced renal parenchymal volume or the patalk number generated from this area and provides in percentage the split renal function. this presentation will discuss in detail the functional aspect of mr urography and demonstrate its utility in routine pediatric uroradiologic imaging. in chronic childhood lung disease (e.g. cystic fibrosis) global pulmonary function tests (pft) can be normal although lung damage is already present. moreover, in comparison to imaging, pft is challenging in young children. thus, cross-sectional imaging became more important in the past two decades. regarding morphological evaluation, multidetector computed tomography (mdct) serves as the most sensitive and reproducible modality. for functional evaluation perfusion/ventilation scintigraphy remains the reference standard. although the individual radiation burden by a single chest ct has decreased significantly in the past, radiation doses can cumulate considerably when repeated examinations are performed in a longterm follow-up. pulmonary mri exists as an alternative method, especially for paediatric patients. however, standard h+mr sequences do not demonstrate small airway disease due to inherent limitations of low signal and rapid t2* signal decay of lung tissue. for comprehensive diagnosis, functional mri offers the unique possibility to measure regional ventilation and perfusion, and mapping relaxation times and diffusion. focussing on research applications, a variety of methods are available for these purposes. in this context, ventilation imaging using inert fluorinated gas indicates to overcome the limitations of the expensive setting necessary for imaging with hyperpolarized noble gasses. regarding lung perfusion, dynamic contrast-enhanced mri (dce-mri) is the most established method in clinical practice. however, especially in children, techniques that are completely non-invasive and do not require i.v.-contrast agents administration or gas inhalation could be promising to achieve broad acceptance. concerning non-invasive methods, ventilation can be assessed by sequences with ultra-short echo times (ute), perfusion by arterial-spin-labeling (asl) and both by fourier decomposition mri (fd-mri). in conclusion, pulmonary mri offers both, the assessment of morphology and the unique possibility to measure regional ventilation and perfusion, and mapping relaxation times and diffusion. new mr techniques that are completely non-invasive are now available. however, further scientific evaluation is needed. ibd and related arthropaties d. jaramillo; miami, fl/us musculoskeletal diseases affect about 5% of patients with crohn's disease and are the most frequent extra-intestinal manifestation of inflammatory disease. the articular manifestations of inflammatory bowel disease (ibd) are one of the seronegative arthritides, although they have a lower incidence of hla -b27 than other seronegative arthritis such as ankylosing spondylitis. there are manifestations in the joints of the extremities, and findings in the pelvis, especially in the sacro-iliac joints, and spine. involvement of the extremities occurs in about 10% of patients with ibd related arthropathies, are more common with crohn's disease, and can have either manifestations related olygoarticular jia, or can have symmetrical involvement of smaller joints. the axial manifestations include ankylosing spondylitis and sacro-iliitis. sacroilliitis is typically bilateral (figure) and often has radiographic as well as mri abnormalities. enthesitis, tenosynovitis and dactylitis can occur with ibd just as they occur with other arthritides. it is important to differentiate ibd related arthritis from septic arthritis due to extension of an enteric fistula. deceased bone mineral density is a common finding in inflammatory disease. it occurs as a combination of malabsorption of vitamin d due to intestinal involvement and the effects of therapy, particularly corticosteroids. insufficiency fractures of the spine, sacrum and extremities can mimic the symptoms of arthritis. finally, ibd can be associated with chronic non-bacterial osteomyelitis, although this association is relatively rare. this review will illustrate several of the skeletal manifestations of ibd, focusing on the arthropathies. juvenile idiopathic arthritis (jia) can be defined as an arthritis of unknown cause occuring in children younger than 16 years and of at least 6 weeks duration. juvenile spondyloarthritis (jspa) is a subset of jia and is characterized by enthesitis (inflammation at the attachment of tendons, ligaments and the joint capsule), arthritis and an increased risk of axial disease. there is also a strong association with human leukocyte antigen b27. jspa accounts for approximately 10-15% of juveniles arthritis cases in europe and is the most common form of juvenile arthritis in asia. the condition is associated with significant long-term morbidity, high health-care costs and poorer outcomes compared with other forms of juvenile arthritis as well as its adult counterpart. up to 40% of patients continue to be at risk of developing ankylosing spondylitis (as) during the disease course. recognizing spondyloarthritis (spa) in children is challenging, particularly early in the course of disease, as the signs and symptoms at disease onset differ from those seen in adults. jspa typically presents with hip and lower limb arthritis in conjunction with enthesitis. inflammatory back pain as a presenting symptom is less common. as a consequence, jspa may be missed or confused with other juvenile arthritides and patients often experience prolonged delays in diagnosis. currently there is no single diagnostic or classification system that is representative of the jspa population. according to the international league of associations for rheumatology (ilar) classification system, most childhood spa's are classified as enthesitis-related arthritis (era), psoriatic arthritis or undifferentiated arthritis. recent studies indicate that there are two clinical phenotypes of era: those with early axial disease often associated with hip arthritis in addition to peripheral arthritis; and those who follow a more peripheral disease course with arthritis and enthesitis and do not develop axial disease. the ilar classification system places patients with both axial and peripheral involvement into the era subtype, and does not specifically address children who meet the criteria for as. the correct approach to the classification of era is uncertain, and this issue is confusing to both pediatric and adult rheumatologists. unlike other categories of juvenile arthritis, jspa affects boys more often than girls, and peak age of onset is early adolescence. enthesitis is a defining characteristic of jspa. it is more common and affects more sites in the paediatric population compared with the adult one. the most commonly tender entheses are the insertions of the patellar ligament at the inferior patella, plantar fascia at the calcaneus, and the achilles tendon. arthritis in jspa is typically asymmetrical, oligoarticular (< 5 joints) and involves predominantely the weightbearing joints. isolated hip joint arthritis may be the presenting feature and predicts early axial disease. involvement of the small toe joints is common in jspa but rare in other forms of jia. midfoot arthritis and tarsitis (inflammation of the intertarsal bones, overlying tendons, entheses and soft tissue) is highly suggestive of spondyloarthritis. in adults, inflammatory back pain typically heralds the onset of sacroiliitis, whereas children seldom present with symptoms of axial disease. however, according to several studies, sacroilitis can be asymptomatic in jspa and only detectable by imaging. other axial manifestations in jspa are inflammation of the lumbar apophyseal joints and interspinous ligaments, corner lesions of the spine and other sites of axial enthesitis-osteitis including the various ligamentous and muscular attachments of the pelvis. extraarticular manifestations of jspa are highly associated with axial disease and include acute anterior uveitis, bowel inflammation, psoriasis, and cardiac disease. clinical diagnosis of jspa can be difficult and the role of imaging may be more critical than in adult disease. the major goal of imaging in jspa is to identify children with early signs of axial disease, as this group is at the greatest risk for progression to as. the presence of axial disease in spa has also major implications for treatment decisions, since traditional firstline therapies appear to have minimal effectiveness in the management of axial inflammation. in addition, recent studies in adults suggest that earlier initiation of biologic agents (anti-tnfs) may slow radiographic progression. x-rays are not sensitive to acute inflammatory changes and will only show advanced disease in the sacroiliac joints. for these reasons plain radiographs are not useful in children or adolescents. ultrasound is a non-invasive, non-ionizing and relatively inexpensive technique that can be performed in a clinical setting. it is emerging as a valid diagnostic tool in spa and can be used to visualize peripheral synovitis, tendonitis and enthesitis, but the method is heavily operator-dependent and there does not yet exist a clear definition for the diagnosis and grading of enthesitis in children. secondary changes (calcifications, enthesophytes) have been observed much less in children compared with adults. there is a need for better consensus on abnormal ultrasonographic findings that define enthesitis lesions and standardization of methods. magnetic resonance imaging (mri) is a radiation free and sensitive imaging modality for detection of synovitis as well as cartilage and bone destruction. mri of the sacroiliac joints is increasingly obtained for early detection of inflammatory changes, as it shows active inflammatory (bone marrow edema, osteitis, enthesitis and capsulitis) and structural (erosions, subchondral sclerosis, subchondral fatty change and bony ankylosis) lesions of sacroiliitis long before radiographic changes become evident. in adults, mri has become the gold standard imaging modality for detecting arthritis and enthesitis. consensus definitions of lesions indicating pathology on mri are now incorporated into diagnostic criteria for adult with spa. in children and adolescents there is no gold standard mri technique and it is therefore not clearly defined whether changes s320 (2017) 47 (suppl 2):s297-s pediatr radiol seen in the sacroiliac joints are pathologic or part of normal maturation in the growing skeleton. the use of contrast enhanced imaging for the detection of active sacroiliitis on mri in jspa is a major controversy. synovial enhancement can be detected without accompanying bone marrow edema in children, and it can be argued that contrast should be administered in order not to miss the diagnosis. some authors argue that contrast administration does not change or add substantially to the mri findings made on non-enhanced scans. certainly, given the risks associated with gadolinium administration, contrast should be used with caution. perhaps the use of contrast agents should be limited to selected cases when high stir signal in the joint is the only finding in order to confirm the presence of synovitis, and when the differential diagnosis includes etiologies such as infection or tumor. the development of new mri techniques has made it possible to perform whole body mri scans (wbmri) that allow assessment of the full range of affected entheses and joints. there is limited data on the utility of wbmri in the pediatric population. it is worth noting that edema-like changes seen in the marrow of healthy children is an important potential pitfall to consider during interpretation and further studies are required in order to establish specific reference standards for mri of the pediatric skeleton. diffusion-weighted imaging (dwi) offers a new approach to detect inflammation. inflammation produces an increase in the apparent diffusion coefficient (adc) of water molecules in affected tissues. several studies in adults and a few recent studies in children have demonstrated that adc is elevated in sacroilitis versus controls and that diffusion scores correlates well with stir images. dwi is promising as a potential biomarker of disease activity in jia and presents a novel approach to contrast-free imaging of synovitis. however, further studies are needed before it can be implemented in clinical practice. jspa is distinct from adult spa and manifests more frequently as peripheral arthritis and enthesitis. symptoms involving the spine and sacroiliac joints often occures later in this population. clinical diagnosis of jspa can be difficult, and imaging therefore plays an important role in the diagnostic workup of disease. identifying early signs of axial disease has major implications for treatment decisions and mri of the sacroiliac joints is increasingly obtained for early detection of inflammatory changes. however, mri criteria for sacroilitis in children are lacking. a major controversy in imaging of sacroilitis in jspa is the use of contrast, as children can have sacroilitis without accompanying bone-marrow edema. dwi presents a novel approach to contrast-free imaging of synovitis but further studies are needed before it can be used in clinical practice.wbmri has been shown to be more sensitive than clinical examination in the assessment of both disease activity and extent, but there is limited data on wbmri in children. normal variants in the growing skeleton may mimic pathologic changes and potentially cause overdiagnosing and -staging of disease. hence, there is an urgent need to establish specific reference standards for mri of the pediatric skeleton and to develop a gold standard mri technique for the axial skeleton in children and adolescents. juvenile idiopathic arthritis o. olsen; london/uk summary: juvenile idiopathic arthritis (jia) is common (about 1:1,000 children). diagnosis and classification are based on clinical criteria. these criteria are in flux depending on 1) contemporaneous knowledge about aetiology and 2) available treatment options. radiology has currently no role in establishing the diagnosis. the clinical classification rests on whether the child has few joints affected (oligo jia), many joints (poly jia), has a condition similar to adult spondyloarthritis (entesitis-related arthritis) or other clinical presentations (systemic-onset jia, psoriatic jia, etc). radiology can potentially assess expressions of jia, such as synovitis, tenosynovitis, systemic manifestations and permanent damage caused by inflammation. it is therefore thought to play a part in gauging the disease activity. the clinical care aims at optimising the child's everyday function, reducing acute symptoms (pain, swelling, joint restriction), allowing normal growth, minimising long-term sequelae (joint deformity) and minimising adverse effects of medical treatment. medical treatment in jia is systemic (immuno-modulation) and local (steroid injection to joints and tendon sheaths). both modes of therapy may to some degree be guided by imaging. however, there currently is no evidence that any form of whole-body imaging is efficacious for guiding treatment. this means that, in principle, indication for imaging should be 1) specific clinical questions, e.g. uncertainty regarding active inflammation at specific sites, or 2) a high pre-test likelihood of inflammation at a site which is difficult to assess clinically and where imaging offers reasonable accuracy. one example of the latter are the temporo-mandibular joints where destruction is frequently seen at an early stage, often without prior symptomatic warning. there is one fundamental challenge for imaging research in jia: what is the reference standard? for lack of anything better, a standardised clinical examination is often used as 'ground truth'. the dilemma is obvious. if clinical examination is reliable and accurate, then why bother with imaging? but we think imaging offers an improvement, then we cannot use an inferior method to set the standard. this problem is not unique to jia. as is often the case, radiology in jia is all about: knowing your clinicians (i.e. the pretest likelihood for disease) being technically eloquent (e.g. using high-resolution us probes, not delaying post-contrast mri acquisitions) knowing what is normal (e.g. normal undulations in the articular surface, focal bone marrow signal variation) not being dogmatic about individual observations or measurements interpreting your findings in a clinical context the lecture will demonstrate similarities and differences among joints and modalities in children with variable-severity jia. the following points will be made: focal areas in the bone marrow with high signal (t2) and corresponding enhancement are often seen in healthy children. in isolation, these do not signify active inflammation. active synovitis in children often is not associated with (much) effusion the combination of synovial thickening with hyperaemia (us)/abnormal contrast enhancement (mri) and surrounding softtissue swelling suggests active inflammation, however there is (yet) no established system for quantifying hyperaemia/enhancement focal pits in the carpal bones do not represent erosions unless there is an associated cartilage defect radiographs are useful for detection of destructive abnormality in mri, scan fairly soon after injecting contrast. gadolinium physiologically leaks into the synovial fluid making it difficult to delineate the synovium a few differential diagnoses to keep in mind when there is mass-like swelling within or adjacent to a joint: vascular and neoplastic lesion, pigmented villonodular synovitis, synovial chondromatosis, lipoma arborescens. synovial inflammation is not always primary. even when there is an established diagnosis of jia, do consider that it may be secondary to biomechanical abnormality (erosion, osteochondral lesion, deformity). focal areas in the bone marrow with high signal (t2) and corresponding enhancement are often seen in healthy children. in isolation, these do not signify active inflammation. active synovitis in children often is not associated with (much) effusion the combination of synovial thickening with hyperaemia (us)/abnormal contrast enhancement (mri) and surrounding soft-tissue swelling suggests active inflammation, however there is (yet) no established system for quantifying hyperaemia/enhancement focal pits in the carpal s321 (2017) 47 (suppl 2):s297-s pediatr radiol bones do not represent erosions unless there is an associated cartilage defect radiographs are useful for detection of destructive abnormality in mri, scan fairly soon after injecting contrast. gadolinium physiologically leaks into the synovial fluid making it difficult to delineate the synovium pulmonary manifestation of connective tissue disorders c. m. owens; london/uk summary: connective tissue diseases are an important cause of morbidity and mortality in children with very varied presentations. nomenclature is confusing and a more appropriate descriptive term would be "multisystem inflammatory disorder +/-autoimmunity". it is important for the radiologist to be aware of the protean radiological appearances and clinical manifestations. take home points: different patterns of diffuse lung disease (eg, desquamative interstitial pneumonia, non specific interstitial pneumonia, lymphocytic interstitial pneumonia, organising pneumonia, diffuse alveolar damage) may be present in several forms of collagen vascular disease, (and indeed other rheumatological conditions such as jia) including scleroderma, systemic lupus erythematosis, juvenile dermato and polymyositis, sjogren's syndrome and mixed connective tissue disease. these will be discussed in detail with illustrations for thin section high resolution ct with histopathological correlation. the clinical presentation, prognosis and response to therapy vary depending on the histological pattern of diffuse lung disease, as well as on the underlying collagen vascular disease. whole body imaging in children: sonography, ct, mri, nuclear medicine -what and when? r. a. nievelstein; utrecht/nl there are several (benign and malignant) disease processes in children that frequently involve more than one organ system or body region. diagnostic imaging of children with such multifocal or multisystem diseases has been quite challenging, often requiring a combination of different imaging techniques for a whole body coverage. the recent technical developments in computed tomography (ct), magnetic resonance imaging (mri) and nuclear medicine (nm) have changed the role of imaging in these children revolutionary. in the past, imaging techniques have been mainly used as a tool to detect the cause of illness and to assess the extent of disease spread before, during and after therapy (i.e. structural imaging). but nowadays, it has also become possible to use imaging techniques to gain information on the biological behavior of diseases before and during therapy (i.e. functional imaging). plain radiography, ultrasonography (us) and computed tomography (ct) have been the structural imaging techniques of choice for many decades, more recently supplemented by functional imaging techniques like single-photon emission tomography (spect) and positron emission tomography (pet). a major disadvantage of most of these techniques is the use of ionizing radiation, which may be associated with induction of second cancers later during life. this small but not negligible health risk is of particular concern in children as their tissues are more radiosensitive than adults and they have more years ahead in which cancerous changes might occur. that is why there is an increasing interest in the use of alternative imaging techniques that do not use ionizing radiation. with mri it is nowadays possible to acquire images with a high spatial resolution and excellent soft tissue contrast throughout the body, which makes it an ideal radiation-free tool for the detection of pathology, especially in soft tissue, parenchymal and bone marrow locations. moreover, recent technological advances have resulted in fast diagnostic sequences for whole-body mr imaging (wb-mri), including functional techniques such as diffusion weighted imaging (dwi). as a result, wb-mri has become a clinically feasible imaging modality for diagnosis and follow-up of multifocal and multisystem diseases in children. in this scope, the recent development of integrated pet/mri systems is very interesting, combining the superior structural imaging of mri with the functional (molecular) information of both imaging techniques while decreasing the radiation dose. traditionally, whole body imaging techniques have been mainly used for oncological indications, such as staging of malignancies, and monitoring of the effectiveness of therapy. however, whole-body imaging techniques are increasingly used for the diagnostic imaging of other benign multisystem diseases and indications, including chronic recurrent multifocal osteomyelitis (crmo), rheumatological diseases, neuromuscular diseases, neurofibromatosis type 1, generalized vascular malformations, multifocal osteonecrosis after intensive chemotherapy, fever of unknown origin, and post-mortem imaging. finally, these imaging techniques may be used for the screening of children with a cancer predisposition syndrome. during this lecture, imaging protocols and indications of the different whole body imaging techniques will be discussed with a focus on their clinical application in children with benign and malignant multifocal or multisystem diseases. (2017) 47 (suppl 2):s297-s pediatr radiol appearances is important for any radiologist involved in child imaging, because we have an important role in characterizing the lesions and guiding purposeful and minimally invasive but successful diagnostic procedures. most head and neck masses in children are benign and have an inflammatory, infective, vascular or congenital cause (cf. special presentation on vascular malformations). malignant lesions are less common, however, early diagnosis is paramount as many of these cancers are readily treatable and often curable. differential diagnosis is guided by patient age, clinical presentation, tumour localisation, and imaging characteristics. while some masses such as (epi-)dermoids, fibromatosis colli and swollen lymph nodes including atypical mycobacterial infections (mott) may be readily diagnosed by clinical inspection und ultrasound, others present special diagnostic challenges. fibromatosis, for example, is a benign lesion with an often complex and potentially destructive local spread. some malignant lesions tend to be localised such as the embryonal rhabdomyosarcoma, while others may be part of a systemic disease such as lymphoma and langerhans cell histiocytosis (lchc). in case of a suspected malignancy, patients should be referred to a specialized centre which will be able to provide the full spectrum of multidisciplinary evaluation and treatment according to the guidelines of an international oncology study group. this is also important for image guided or surgical biopsies as long term outcome and survival of many of the young patients are directly associated with these initial diagnostic and therapeutic strategies. with its excellent spatial resolution in the near field, ultrasound is the method of choice for all superficial masses. an experienced paediatric radiologist will be able to identify most of the benign lesions and in other cases will be able to guide further diagnostic decisions. tumours in the midline require thorough workup to exclude an encephalocele or a dermal sinus with connection to the intracranial space. high resolution mri is required if such an extension cannot be ruled out by ultrasound or if a tumour is larger than the transducer's scan area. soft tissue tumours in the deeper parts of face and neck as well as tumours of osseous origin are also best delineated by mri. in lesions adjacent to the skull base contrast enhanced and fat saturated mr images with high spatial resolution are of utmost importance to completely depict the tumour's extension through the foramina and along the meninges (fig. 1) . ct can provide additional information on the involvement of osseous structures. embryonal rhabdomyosarcoma. high resolution mri with fat saturation after contrast injection depicts the tumour's extension through the foramen ovale (long arrow) and along the meninges (short arrows). skull base and face lesions are less frequent in children than in adults. symptoms may be subtle or unspecific. depending on their localization, clinical findings may be common (nasal obstruction, otitis…) or more disturbing (cranial nerves palsies, exophthalmos, vision loss …). clinical history and physical examination findings are important to reduce the spectrum of differential diagnosis, but imaging data are the key features to determine the nature of these lesions. ct and mri play an important role in diagnosis, treatment survey and surgery planning of skull base and face lesions. skull base and face bone lesions are either intrinsic lesions of the bone or secondary to soft-tissue tumors or pseudo tumors invasion. this lecture will focus on bone intrinsic lesions, and include soft-tissue and pseudo tumors only as differential diagnoses. computed tomography plays the role for skull base and face of plain radiograph for long bones. therefore, the same semiology may be used to determine if the lesion is slowly or rapidly growing, aggressive or looks benign. helical ct allows reconstructions with both soft-tissue and bone algorithms as well as multiplanar reformations. it gives a good visualization of the anatomy of the skull base and allows a good depiction of the bone architecture. ct is first used for the initial work up of the disease but also for surgery and therapeutic planning (endoscopic sinus surgery with navigation). however, ct analysis may be challenging in children due to growth changes: normal process of pneumatization according to age, sutures not yet fused has to be recognized. some variations in pneumatization must not be mistaken for pathology: asymmetrical pneumatization of the petrous apex and arrested pneumatization of the sphenoid mimicking intraosseous lesion are the most common. both ct and mr imaging are complementary: most preferably, contrast-enhanced mr is associated with non-contrast high resolution ct. mri allows a good delineation of bone involvement of skull base lesion due to bone marrow changes, whether ct can fail to detect subtle extension within the bone. in addition to t1 and t2 weighted sequences, the use of specific sequences and/or techniques such as fat-saturation, diffusion, dynamic-contrast-enhanced sequences, and mr angiography helps to characterize the lesions. t1 spin echo sequence is mandatory to appreciate bone marrow infiltration in adults and older children. but when red bone marrow has not yet be replaced by fatty bone marrow, in young children, this can be challenging. it is useful to know the bone marrow fatty conversion of the skull base chronology. cranial mr can also be associated to whole body mr to look for multifocal or metastatic disease. epidemiologic data concerning bone tumors of the skull base are scarce due the rarity of these lesions. they can be classified according to their location within anterior, middle or posterior cranial fossa or classified according to their origin: osteogenic (osteoblastoma, osteoma, osteosarcoma...), chondrogenic (chondroma, chondrosarcoma), fibrous ( fibrous dysplasia, fibro-s323 (2017) 47 (suppl 2):s297-s pediatr radiol osseous lesions..), notochord (chordoma), hematopoietic (leukemia, histiocytosis ), vascular (hemangioma), neuro ectodermic ( ewing sarcoma) or unknown origin (aneurysmal cyst, giant cell tumor). the aim of this presentation is to draw attention to skull base growth changes that can mimic pathology and to describe the imaging specificities of the most common bone tumors of the skull base and face in children. because conflicted nomenclature can cause confusion, accurate diagnosis and classification of these anomalies is important for proper clinical evaluation and management. many of these patients require multidisciplinary care, consequently the usage of a correct nomenclature across all disciplines is a sine qua non. the international society for the study of vascular anomalies (issva) classification, updated in 2014, offers a comprehensive classification accepted by many subspecialities. this approach/ classification has facilitated correct communication for all medical subspecialties involved in the care of these complex vascular anomalies. pediatric radiologists play a critical role in evaluating these patients since the majority present during childhood. in this presentation, we present a state of the art mri imaging protocol with exemplary cases of the most common types of vascular anomalies in the pediatric trunk and extremities, using the current issva classification. in addition, we discuss the common syndromes associated with vascular anomalies such as klippel-trenaunay and lumbar syndrome. genetic skeletal disorders (gsd's) are a heterogeneous group of syndromes characterized by an intrinsic abnormality in growth and (re-)modeling of cartilage and bone. a large sub-group of gsd's may have additional involvement of other structures/organs beside the skeleton, such as the central nervous system (cns). cns abnormalities have an important role in long-term prognosis of children with gsd's and should consequently not be missed. sensitive and specific identification of cns lesions while evaluating a child with a gsd requires a detailed knowledge of the possible associated cns abnormalities. here, we will present and discuss a pattern-recognition approach for identifying relevant neuroimaging findings in gsd's guided by the obvious skeletal manifestations of gsd. in particular, we will discuss which cns findings should be ruled out for the various gsd. to facilitate this diagnostic approach the multiple gsd are classified based on the pattern of skeletal involvement (1. abnormal metaphysis or epiphysis, 2) abnormal size/number of bones, 3) abnormal shape of bones and joints, and 4) abnormal dynamic or structural changes). skeletal involvement is defined in accordance with online mendelian inheritance in man. the spectrum of co-existing cns involvement is extracted from an extensive literature search. selected examples will be shown based on prevalence of the diseases and significance of the cns involvement. cns involvement is common in gsd's. a wide spectrum of morphological abnormalities is associated with gsd's. early diagnosis of cns involvement is important in the management of children with gsd's. this pattern-recognition approach aims to assist and guide physicians in the diagnostic work-up of cns involvement in children with gsd's and their management. not infrequently the correct radiological differentiation of skeletal and/or central nervous system findings secondary to non-accidental injury versus inherited genetic and/or metabolic disorders may be challenging. imaging findings may be non-specific, can result in incorrect diagnosis and subsequently inadequate patient management or initiation of faulty treatment. the diagnostic work-up of children suspected of non-accidental injury or genetic/metabolic disorders requires a multi-disciplinary approach involving many key players including physicans of various disciplines, nurses, psychologists, social workers and many more. a proper and detailed medical history and physical examination of the patient, collection of the relevant family history, a metabolic and genetic work up, a detailed interview of care givers, friends and family are essential for the correct and comprehensive evaluation of imaging findings. in the current session, various exemplary and possibly confusing cases will be interactively discussed with the audience by a panel of experts (susan blaser, thierry a.g.m. huisman and andrea superti-furga). goal is to offer a case based approach to challenging patients with discussion of the best diagnostic approach including differential considerations. the zikv is transmitted mainly by the bite of female aedes aegypti and aedes albopictus mosquitoes. other forms of transmission, including through sexual intercourse, blood transfusion, and neonatal, are currently under evaluation, although more elements are still needed to assess the real importance of these transmission routes 4 . the course of the zikv infection is self-limited. so far, no specific symptoms have been attributed to the disease, and a wide variety of manifestations ranging from absent to mild symptoms (in 25% of cases) have been described. when symptoms are present, they may lead to a misdiagnosis of other bacterial and viral infections, especially other arboviroses in endemic areas. the most frequently reported symptoms are mild fever, cutaneous rash, fatigue, arthralgia/myalgia, and conjunctivitis. dizziness, malaise, edema of the extremities, anorexia, retro orbital pain, photophobia, gastrointestinal disorders, sore throat, cough, sweating, and lymphadenopathy have also been reported. infection by the zikv in adults may be associated with autoimmune complications such as guillain-barré syndrome 9 . the laboratory diagnosis of zikv infection is based on the demonstration of the virus in the urine and blood using real-time reverse transcription polymerase chain reaction (rt-pcr). the main limitation of this diagnostic method is a false-negative result after the viremia is resolved. the serological diagnosis of the disease is limited due to cross-reactivity of the zikv with other viruses of the flavivirus genus, especially those causing dengue and chikungunya. physicians should be aware of this fact when the diagnosis of zikv infection relies solely on serological results. the diagnosis is also possible by igm measurement in serum, urine, or cerebrospinal fluid using enzyme-linked immunosorbent assay (elisa) 9 . the prevention against zikv infection is similar to that of other arboviroses, including vector control and mosquito bite prevention. the first major zikv epidemics were reported in the french polynesia in 2013 and 2015. at that time, some neurological changes were observed in neonates of infected pregnant women but were not associated with a maternal-fetal transmission of the virus. the growing increase in the number of cases and the severity of the infection specific to this subpopulation then led to the evidence of a congenital disease 9 . in brazil, the situation became alarming with the report of a high number of infected individuals in the second half of 2015 2, 5 . the brazilian ministry of health attributed to congenital zikv infection the 20-fold increase in cases of neonatal microcephaly in the northeastern part of the country, particularly in the state of pernambuco. this led the world health organization (who) to declare the zikv infection a "public health emergency of international concern" in february 2016 6 . the main challenge for radiologists practicing in regions of endemic zikv infection is to become familiarized with findings of congenital zikv infection in perinatal imaging studies; this is particularly important for the prenatal screening of pregnant women 3, 6 . the diagnosis of zikv infection in the fetus by neuroimaging is based on prenatal ultrasound (us), especially in the third trimester, and complemented with magnetic resonance imaging (mri). postnatal imaging was obtained by transfontanellar us, ct or mri. the main imaging findings on ct are microcephaly, an exuberant external occipital protuberance, rectification of the frontonasal angle, and a redundant scalp skin. three-dimensional (3d) reconstruction of al skull permits a better evaluation of these findings and enhances the parents' understanding of the disease. moreover, ct scan data may yield a 3d virtual physical model that can maybe obtained from ct scan data and printed onto using thermoplastic acrylonitrile butadiene styrene 7 . the aim of this study was to describe the perinatal imaging findings in cases of congenital zikv infection. we studied 18 mothers diagnosed with zikv infection from october 2015 to november 2016. they had all presented a maculopapular rash and fever during the first or second trimester of pregnancy, and their neonates presented neurological defects that were attributed to intrauterine transmission of the zikv. the maternal diagnosis of zikv infection was confirmed by serology (n=4) or rt-pcr (n=14). all patients were torch (toxoplasma, rubella, cytomegalovirus, herpes simplex) negative. prenatal us was performed every 3 weeks after the first imaging findings, and fetal mri was obtained in all cases. microcephaly was considered present when the infant's head circumference was two standard deviations below the mean value for age and sex or below the second percentile. postnatal imaging follow-up was obtained in all cases by transfontanellar us, ct or mri. we found several cns malformations, including lissencephaly, pachygyria and/or polymicrogyria, cerebral atrophy (panel 1), enlarged cisterna magna with abnormalities of the corpus callosum, ventriculomegaly, brainstem hypoplasia, malformation of the cortical development, and cortical and/or periventricular calcifications mainly in the junction between the cortical and subcortical white matter (panel 2). the skull of the infants had a collapsed appearance, with overlapping sutures and redundant skinfolds (panel 3). craniofacial disproportion was easily identifiable, and arthrogryposis was identified in one case. similar neurological findings were observed in the infected patients and seemed to differ from findings of other infectious diseases. the finding of microcephaly in neonates with congenital zikv infection seems to be only the tip of the iceberg, as several cns malformations have been identified in connection with the disease. in brazil, a spectrum of imaging findings associated with congenital zikv infection has been observed. such findings are useful in helping radiologists to identify suspected cases of the disease. panel 1: prenatal ultrasound (37 weeks) shows calcifications (arrows) and microcephaly. axial and sagittal t2 shows relative smoothness of the brain surface (arrows) and assymmetric colpocephaly. panel 2:ax t1-wi multiple cortical-subcortical fronto-parietal hyperintense foci (arrows) and markedly hypointense on swi. sagittal t2: dysgenesis of the corpus callosum, with dilation of the posterior horns of the lateral ventricles (colpocephaly). pre-and postnatal imaging in zika virus: where are we? early insights into zika's microcephaly physiopathology, from the epicenter of the outbreak: a case for teratogenic apoptosis of central nervous system. p. jungmann; recife/br early insights into zika's microcephaly physiopathology, from the epicenter of the outbreak: a case for teratogenic apoptosis of central nervous system. in mid-october 2015, intense interaction among surgical pathology and fetal medicine specialists from university of pernambuco was only focused on the dramatic and non explained ultrasonographic (us) findings and hopelessness due to lack of explanations on the odd us discoveries on the first gestational cases of zika's microcephaly. this is the field of our history of a physiopathological hypothesis on zika virus (zikv) related microcephaly when it first struck pernambuco state (pe), northeast brazil, the place that has been at the front line of the global response to the microcephaly and responsible for a large amount of data from affected children. the outbreak onset came with a sudden increase in microcephalic newborns being reported in pe state from august 2015 (panel, fig. 1) . zikv was previously thought to cause a relatively mild disease, but was recently accepted to lead to severe and diverse neurologic conditions in s329 (2017) 47 (suppl 2):s297-s pediatr radiol some children born from infected mothers and in adults 1 . the scientific community is actively trying to uncover the extent of these disorders but little has been reported on the early days of the outbreak when doctors were approaching the unknown. while evidence that zikv is related to microcephaly in newborns is accumulating, the mechanisms of how the virus affects the fetus is still uncertain. in the outbreak onset we had to face daunting challenges to search the cause of microcephaly and the emotional toll on the families. we took a very early approach from 9 microcephalic fetuses on gestation and 46 microcephalic babies on clinical follow-up from different pe areas, evaluated between 15 october and 17 december 2015 in oswaldo cruz hospital, to propose the early physiopathologic hypothesis that, a viral-related brain developmental disruption could be the basic neuropathogenesis in zikv babies instead of a direct injurious process due to viral insult followed by active inflammation. the eight pregnant women were all in the 3 rd gestational trimester and had had normal us follow-ups till week 20 th . crucially, we were facing a temporal-geographic association of cases presenting an unanticipated pattern of us alterations. because of their late alarming findings they were re-examined and the us scans revealed sudden encephalic alterations after 28 th gestational week. such devastating us clustering images were not seen here before, but are now considered as part of the "congenital zika syndrome". we observed late appearing severe dysmorphic encephalic changes in 9 out of 9 fetuses, including small skull, small brain, sub arachnoidal space enlargement, ventricular dilation, brain calcifications of varied shape and distribution, inclined frontal bone, progressive decline of head growth potential, early fontanels closure and redundant scalp (panel, figs. 2a, 2b). we had no clues on the causes and mechanisms responsible for this phenotype of severe alterations. thus, we had no explanation to offer to patients, in particular, or to the medical community. both as physicians and human beings, we were committed straightaway to continue the study of these victims of an unknown medical tragedy, engaging our expertise in fetal imaging and immunopathology. from beginning october, the first microcephalic babies were referred to the upe pediatric infectology service for initial investigation. strikingly, the newborns exhibited "healthy" appearance, excluded the microcephaly itself and motor sequels. we then looked for csf analysis of the microcephalic babies. for that, we obtained from dr. patricia travassos, a csf specialist at upe, a cohort of 120 csf samples that have been studied for signs of meningitis or encephalitis. about 87% (42 cases) of the csf analyzed looked normal for any signs of central nervous system ongoing inflammatory responses (panel, fig. 3 ). the babies had been examined by outpatient clinic dr angela rocha, from the upe hospital infectology reference center that have stated that although small, the babies were near to full term gestation (36-39 weeks gestation), had good apgar scores and variable degrees of microcephaly and neurologic impairments, i.e. contractures, spasms, irritability and in some retinal macular atrophy. during the follow-up, the babies were cared at home, breastfeeding, gaining weight and having routine vaccines. none of them expressed signs of ongoing inflammatory reaction in the cns (panel, fig. 4 ) or alterations on peripheral blood count and other routine laboratory tests up to 3 months of age. despite the striking neurological phenotype, 80% of the babies were negative for torch agents, no deaths were recorded. furthermore only in january 2016, the first evidence associating zikv to microcephaly from rt-pcr test on amniotic fluid was reported 2 . astonishingly, a particular kind of physiopathological process linked to fetal brain development was arising without clinical manifestation of inflammatory reactions or necrotic processes in these babies. unfortunately, no necroscopic samples of affected brain tissues were available to us to monitor the presence of putative neural dysgenesis and the very nature of brain calcifications background offering histological support for our hypothesis. nevertheless, with this restricted dataset we hypothesized that whatever the etiologic agent involved in these cases, its physiopathologic mechanism must trigger the cellular death programthe apoptotic process -at a particular development window on the cns, assuming clinically that the agent was not encephaalitogenic but silently tertogenic. if not, the clinical outcome of affected babies would not be so mild as far as signs of inflammation on cns was concerned. consequently, the inflammation-free clinical status of patients suggested us that a massive enhanced apoptotic cell death during the window of telencephalic expansion was the most probable physiopathologic process operating this microcephaly phenotype, with no direct direct lytic brain lesion or significant necrosis due to usual injury. furthermore, knowles and penn 3 stated that this window is very active to select the "fittest" neural cells by a constitutive apoptotic pathway. we so hypothetized that during this developmental time window, the "fit or not fit" status of the rapid, transient amplifying neural progenitors cells facing zikv, would heavily shift the selective process toward the self-elimination of virusbearing cells through apoptotic pathways. thus, zikv-enhanced constitutive apoptotic mechanisms would lead a massive loss of developing telencephalic neuronal precursors and, consequently, provoking losses of dividing cells and the arrest of further brain development. this could be particularly inferred by the absence of the characteristic morphology of late stages structures of neocortex, according with our us images of zikv microcephalics in gestation. similar processo could also be inferred to neurocrest derivatives as deformities in the viscercrany always accompany the cephalic malformation. our initial understandings based on clinical examination on the field, when no specific laboratory test, necroscopic data or experimental evidence on the disease causality were available, conducted our physiopathological approach to the "apoptosis hypothesis" for zika microcephaly that is now gaining strong support. in february, mlarkar et al 4 showed clear connection between zikv and microcephaly, presenting cns histopathologic analyses, revealing remnants of neural germinative matrix, intense gliosis, alterations in cortical ribbon, calcifications in gray and white matters without associated necrosis, encephalitis or meningitis and the presence of the virus, further supporting neurodevelopmental arrest. similar results were showed by driggers et al 5 . the ct scans from microcephalic babies from hazin at al 6 , have added details of brain development arrest with no radiological signs of brain destruction or active inflammation. finally, experimental models have provided a body of evidence f or neuroprogenitors permissiveness to zikv and viralinduced apoptotic process. tang et al 7 demonstrated by icq that the zikv infection of cortical neural progenitors attenuates their growth and increases caspase-3 activation, calling for an apoptotic process. this finding was corroborated by the up regulations of caspase-3 genes by rna sequencing. nowakowsky et al 8 demonstrated that zikv may hijack axl protein as an entryway to infection. interestingly, axl is highly abundant on the surface of neural stem cells but not on differentiated neurons in the developing brain. recently, cugola et al 9 demonstrated that zikv was able to cause cns congenital brain dysgenesis upon vertical transmission in mice. in parallel, human brain organoids infected by zikv show a reduction of proliferative zones and disrupted cortical layers, so targeting cortical progenitors and inducing apoptotic cell death with impaired development. for babies born with zikv-related microcephaly, the many expected consequences besides the evolving congenital neurosequels, are the unanticipated pattern of persistence of zikv in cns host cells, unsafe maintenance of neuron genome stability on remaining arrested populations, implying risks for brain tumors, risks for impaired adult type neuron wiring and neuron survival in an affected neuronal circuitry. in brief, evolve life with a wide vulnerable brain. the outbreak of zikv in the americas will eventually decline as herd immunity increases, but the world remains at risk of further waves of infection in affected countries and spread into new territories 1 . while experimental studies will be carried out to fully understand the pathophysiology of zikv infection in the developing fetus, our findings provide a coherent and testable physiopathological hypothesis for cns teratogenic phenotype linked to zikv congenital infection, which may be critical for the clinical care of pregnant mothers and their babies before and after birth. take home points: fetal dysmorphisms detected by ultrassonographic and mri images in congenital zika syndrome are late findings, usually after the 20 th gestational week and requires acurate analyses. clinically, zika's virus microcephaly is an infectiuos congenital condition that is not encephalitogenic but primarily teratogenic on the nervous system. the most important process leading to zika's virus microcephaly is pathologically induced apoptosis in telencephalic neuroprecursosrs cells and neurocrest precurssors cells. viral induced autophagy and low antiviral responses during the fetal period are linked to zika virus persistence in the central nervous system of affected new borns and babies a. vossough; philadelphia/us summary: susceptibility-weighted imaging (swi) has proven to be a valuable mr imaging sequence in a variety of applications. pediatric imaging has also immensely benefitted from this technique. in this presentation we will review pediatric neuroimaging applications in trauma, arterial and venous vascular disorders, hypoxic-anoxic injury, congenital malformations, congenital heart disorders, neoplasms, and pediatric degenerative disease. use of swi in pediatrics other than demonstrating hemorrhage and calcification will be reviewed. challenges in the clinical use of swi in pediatrics, interpretive pitfalls, and sources of clinical misinterpretation of swi will also be explored. we will also briefly present ongoing research and clinical use of swi in pediatrics and potentials for future collaborative investigations. & swi is highly sensitive in detection of susceptibility effects on mri. & in many cases, but not all, swi processing can differentiate between calclium and blood products. & quantitation information can also be obtained from swi with further processing. state of the art imaging of the single ventricle d.m. biko; philadelphia/us there are many congenital heart defects that result in a functional single ventricle. this may be functional or anatomical as a result of a dysfunctional valve or absent or ineffective pumping chamber. the repair of single ventricle physiology most often involves a staged reconstruction due to changing physiology ultimately resulting in a total cavopulomonary connection or fontan procedure. to appropriately image the single ventricle throughout its stages of palliation, familiarity with the physiology of the various steps in surgical palliation of the single ventricle is essential although echocardiography is a mainstay of cardiac imaging, cross sectional imaging has a vital role in the evaluation of the single ventricle. the role of ct angiography is mostly for anatomic evaluation. although it is fast and has high spatial resolution for evaluation of vasculature, ct has lower temporal resolution than mri and is unable to quantify flow. ventricular performance along with quantification of flow can be performed with mri. systemic to pulmonary collateral flow, which has been shown to result in adverse outcomes after fontan, can be quantified. valvular insufficiency and myocardial scarring can also be assessed. additionally, high anatomic vascular detail can be obtained with mri, particularly with the recent investigational use of the blood pool agent ferumoxytol. mri also has the ability to assess the lymphatics either through non-contrast t2 weighted imaging and/or dynamic contrast mr lymphangiography as lymphatic pathology may play a role in postsurgical hemodynamics in single ventricle patients. this lecture will focus on the use of ct and mri in the evaluation of the single ventricle particularly concentrating on the developing use of mri for anatomic and physiologic assessment. take home points: in single ventricle physiology, there is only one effective pumping chamber. familiarity with the physiology of the various steps in surgical palliation of the single ventricle is essential in imaging this disorder ct angiography provides high anatomic detail but limited in its assessment of physiology since it cannot quantify flow and has lower temporal resolution than mri. mri can evaluate ventricular performance, quantify flow and valvular insufficiency, and assess myocardial scarring. high anatomic vascular detail can also be obtained with mri particularly with the emerging investigational use of ferumoxytol. with non-contrast t2 weighted mri and/or dynamic contrast mr lymphangiography, lymphatic evaluation can be performed which may play a role in post-surgical hemodynamics in single ventricle patients. neuroimaging in head trauma m. argyropoulou, g. alexiou; ioannina/gr summary: objective: head trauma in children is one of the most common reasons for visiting emergency department. however, only a small portion of patients will have a traumatic brain injury. patients with moderate or severe head trauma should undergo ct scan, however, a debate exists for the indication and yield of neuroimaging for minor head trauma. we performed a systematic literature review on the accuracy of symptoms and signs in children with minor head trauma in order to identify those with severe intracranial injuries. materials: a systematic literature search of medline (2000) (2001) (2002) (2003) (2004) (2005) (2006) (2007) (2008) (2009) (2010) (2011) (2012) (2013) (2014) (2015) (2016) was performed to identify studies assessing the diagnosis of intracranial injuries in children. the authors independently performed critical appraisal and data extraction. results: we identified studies that evaluated the performance of findings for detecting intracranial injury using the reference standard of neuroimaging or follow-up examination. mechanism of injury, multiple vomiting episodes and decline in gcs score were more commonly associated with severe intracranial injury on ct. normal variations in the amount of joint fluid, ganglion cysts, bone marrow edema, and bony depressions that resemble erosions are frequent in the wrists of children. the results of a follow-up of a healthy cohort aged 6-17 will be presented. the cohort was examined twice with mr of the wrist, and the second time also with a cartilage sequence for better visualization of the bony depressions. knowledge of these normal variations is important because they can resemble disease. bone marrow edema, joint fluid more than 2 mm, and bony depressions that can resemble erosion are frequent findings in the normal wrist. take home points: bone marrow edema, joint fluid more than 2 mm, and bony depressions that can resemble erosion are frequent findings in the normal wrist. these findings can not be attributed to dissease without additional findings of synovitis. a cartilage sequence can be of use in the differentiation between true erosions and bony depressions. mri scoring of the wrist in patients with jia-current status and future perspectives c. nusman; amsterdam/nl the wrist is a frequently affected joint in patients with juvenile idiopathic arthritis. due to recent improvements in treatment strategies, permanent damage is not that common anymore. also, imaging has been playing a key role in monitoring the disease activity in the wrist of jia patients. the past years lots of efforts have been made to improve the assessment of acute and permanent changes of the jia wrist. requisites and recommendations for the mri protocol to use for of the jia wrist are available in literature. currently, the features of scoring the jia wrist are synovitis, tenosynovitis, bone marrow edema and bone erosions. the repeatability of the above-mentioned scoring features proved to be acceptable. recent studies showed that the appearance of the wrist in healthy children can mimic pathology. therefore, construct validity of the scoring features needs to be assessed by comparing wrists of healthy children with the wrists of jia patients. & construct validity of the scoring features needs to be assessed by comparing wrists of healthy children with the wrists of jia patients a novel radiographic scoring system for permanent hip involvement l. tanturri de horatio 1 , p.l. di paolo 1 , s.c. shelmerdine 2 , p. toma 1 , k. rosendahl 3 ; 1 rome/it, 2 london/uk, 3 approximately 20-50% of children with jia, particularly those with systemic onset disease, will have hip-involvement within 1-6 years after disease onset. as scoring systems for radiographic changes in children with hip involvement are lacking, we aimed to examine the reliability of potential markers and suggest a novel scoring system. a set of 75 hip-radiographs from 75 children with jia and clinical hipinvolvement: 59 seen at the outpatient clinic at great ormond street hospital (gosh), london, and 16 seen at ospedale pediatrico bambino gesù, rome, was used. all hip radiographs were scored in a blinded fashion, once by an experienced paediatric radiologist and a paediatric radiologist with minor experience in musculo-skeletal imaging in rome, and twice by an experienced radiologist and a research fellow in bergen/ london. radiographic findings suggestive of 1) destructive change (bone erosion, flattening of the femoral head, squaring of the femoral head contour, presence of sclerosis, joint space height, and 2) growth abnormality (length and width of the femoral neck, varus/valgus deformity, the ccd angle and the trochanteric-femoral head height) were assessed. assessment of erosions of the femoral head, femoral neck and the acetabulum showed moderate to good agreement for the same reader. the inter-reader agreement was, however lower. there was a high to moderate (2017) 47 (suppl 2):s297-s pediatr radiol agreement for the assessment of femoral head flattening using the mose' circle. the measurements of femoral neck length and width, the ccd and trochanteric-femoral head lengths were precise, with 95% limits of agreements within 10-15% of the mean. we have identified a set of relative robust radiographic findings suggestive of growth abnormalities and destructive change in children with hip-jia, and suggested a novel scoring system. x-ray of a 21 years-old jia patient with severe chronic hip involvement. x-ray of a 6 years-old boy with growth abnormalities on hips (bilateral coxa magna). in jia hip involvement is often a predictor of a severe disease course. radiographic findings vary according to mode of onset and age: in younger children the initial findings may be developmental rather than destructive while children with later onset jia may have destruction/narrowed joint space as the first feature. several of the commonly used radiographic findings for chronic hipchange are inaccurate. we have identified a set of relative robust radiographic findings suggestive of growth abnormalities and destructive changes in children with hip-jia, and suggested a novel scoring system. bone age assessment -statement from the msk task force k. rosendahl; bergen/no summary: age assessment is an important, yet complex and challenging issue that authorities may need to perform to determine whether an individual is an adult or a child in circumstances where their age is unknown. there is currently no method which can identify the exact age of an individual and there are concerns about the invasiveness and accuracy of the methods in use, namely analysis of documentary evidence, interviews, physical or other form of medical examination such as imaging. the main imaging methods include carpal, collar bone and dental examinations. whilst many countries make use of these methods they do not apply them in the same way and often use different combinations and/or order. one of the main reasons for this is the fact that age assessment procedures remain to a large extent determined by national legislation, with procedures evolving through national jurisprudence (ref.: european asylum support office (easo age assessment practice in europe)). the ethical and legal aspects of using bone age to determine age will be addressed in a statement from the msk task force. the ethical and legal aspects of using bone age to determine age will be addressed in a statement from the msk task force. & the application of drls should be the responsibility of all providers of x-ray imaging. this means that drls should also be applied to imaging performed outside the radiology department. & the physical quantity used to establish drls should be an easily measurable quantity, usually directly obtainable from the x-ray equipment console, obtained either by manual recording or preferably by automatic recording and analysis. organ doses and effective dose are not considered feasible as a drl quantity because these cannot be easily determined. the ultimate mission of eurosafe imaging is to support and strengthen medical radiation protection across europe following a holistic, inclusive approach. most common imaging procedures in children and their contribution to collective dose e. sorantin 1 , c. granata 2 ; 1 graz/at, 2 genova/it summary: several countries have released "diagnostic reference levels (drl)" for imaging procedures using ionizing radiation. unfortunately those drl differ in types of procedures and granularity as well as information about the proportion of pediatric patients within the different examinations are sparse. therefore an more evidence based approach seems to be feasable -meaning releasing drl first for frequent and radiation burdened examinations. therefore a survey within europe was conducted and a questionnaire was sent to key persons of the european society of pediatric radiology (www.espr.org) as well to members of a large academic, interdisciplinary, international network within the ceepus programme (central european exchange programm for university studieswww.ceepus.info). alltogether 33 centers were contacted and an response was received from 18 (54.5.%). from one center only frequencies for interventional radiology was sent. plain films: most frequent procedures are extremities (48.5%), followed by chest films (31.4%) -both account together for more than ¾. flouroscopy: voding cysto urethrography (vcu) 37.2%, followed by upper gastro intestinal (gi) series with 32.1% -again representing 2/3 of those examinations. computed tomography: head & neck 46.8%, chest 27.8%, abdomen 13.7% -together almost 90%. interventional radiology and cardiac interventions: only limited data available and procedures quite hardly standardize and comparable. it seems adviseable, that only a few procedures are suitable for drl like peripheral insertion of vascular lines, occlusion of ductus arteriosus botalli or stent implantation for coarctation. in order to estimate the contribution to the relative collective dose all values were normalized to a chest xrays (1.0) and the following numbers could be calculated: abdominal plain film 0.1, skull 0.01, ct head 2.6, ct chest 10.2, ct abdomen 4.5. the most frequent imaging procedures using on ionizing radiation are: in plain films extremities and chest xrays in flouroscopy vcu and upper gi series in ct head, chest and abdomen therefore eu wide drl should be released for those examinations. as it could be expected chest ct is the main contributor to the collective dose. since the espr abdominal (gi and gu) imaging task force has changed its name and agenda, extending from initially only genitourinary queries to also other abdominal imaging topics, new projects have been added such as for example imaging in anorectal and cloacal malformations, imaging in paediatric inflammatory bowel disease (ibd, a joint project with esgar), or paediatric abdominal ceus applications. results of these new projects will be presented in the upcoming talkshoping that again (as the last procedural recommendations and proposed imaging algorithms) our proposals and recommendations will help to standardise paediatric imaging, to reduce radiation burden, and to facilitate comparable imaging data for future research. other topics in this session are a proposal for a more standardised approach to gastrointestinal ultrasonography, and considerations on gadolinium applications in children in the light of new observations (i.e., gadolinium deposit in tissue even in children with normal renal function). the work goes ononly achievable with active participation of interested and competent members. many interesting topics for either recommendations or joint research are on the list such as addressing late decompensating pujo or specific imaging needs in ibd in early childhood; other new ones may be proposed by any task force member. thus all espr members are invited to join the group, work with us and share their expertise. (2017) 47 (suppl 2):s297-s pediatr radiol contrast enhanced us in childhood -applications in children: literature review and results from the questionnaire c. bruno; verona/it in adults, following the characterization of focal liver lesions, several applications of contrast-enhanced ultrasound (ceus) have emerged in the last two decades, since second-generation contrast agents have been introduced and approved for use in most european countries. from many points of view, children represent an ideal population for ceus, because of the absence of radiation exposure and of need of sedation. moreover, due to the small body size many anatomical targets in children can be adequately explored with high-frequency ultrasound, obtaining images with higher spatial resolution than in adults. however, to date comparatively few data on pediatric ceus are available. although very rare and usually mild, possible adverse effects of contrast agents probably limit their use in many centers. in addition, the intravenous administration of ultrasound contrast agents in children is still off-label in europe, which makes informed consent necessary in every case. finally, for unclear reasons information on this topic does not flow easily. & from the comparison between the data available, similar or better results are likely to be obtained with ceus in children than in adults, and some specific pediatric indications might be proposed. imaging in ibd-joint recommendation statement with esgar f.e. avni 1 , m. napolitano 2 , p. petit 3 ; 1 brussels/be, 2 milan/it, 3 marseille/fr the first joint esgar/espr consensus statement on the technical performance of cross-sectional small bowel and colonic imaging (1) objective: to develop guidelines describing a standardized approach to patient preparation and acquisition protocols for magnetic resonance imaging (mri), computed tomography (ct) and ultrasound (us) of the small bowel and colon, with an emphasis on imaging inflammatory bowel disease. methods: an expert consensus committee of 13 members from the european society of gastrointestinal and abdominal radiology (esgar) and european society of paediatric radiology (espr) undertook a six-stage modified delphi process, including a detailed literature review, to create a series of consensus statements concerning patient preparation, imaging hardware and image acquisition protocols in pediatric and adult patients. the delphi process is constructed as follow: step 1 questionnaire construction to includes all contents relevant to the guideline and set up of working groups; step 2 questionnaire completed by all committee member, step 3 literature search; step 4 draft consensus produced by each wg based on the literature review and questionnaire responses; step 5 committee members indicate agreement or otherwise for each individual draft consensus; step 6 acceptance of agreed statements (more than 80% of members), face to face meeting to modify statements without agreement. committee members indicate agreement or otherwise for each modified consensus statement and final consensus statements. the questionnaire was split into four broad topics, each of them treated by a subgroup including in each of them a pediatric radiologist: (1) patient preparation for mre/mr enteroclysis/cte/ct enteroclysis, (2) mre/ mr enteroclysis technique and sequence selection, (3) cte/ct enteroclysis technique, and (4) enteric us patient preparation and technique. after an extensive literature research each member were instructed to always base their statements on the retrieved literature wherever possible, and to this end graded the strength of retrieved relevant publications from i (high) to v (low) using the criteria of the oxford centre for evidence based medicine (2) during their review process. if no relevant literature was available for a particular item, members used expert opinion to construct the consensus statements. the pediatric guidelines were based on the opinion of 3 pediatric radiologists and 4 adult radiologists who have experience in pediatric practice. & it is recommended that children aged 6-9 should not eat any solid & it is recommended that the use of a spasmolytic agent is optional. unlike adult practice, the use of spasmolytic prior to mre is considered optional in paediatric patients and use is likely dependent on the age of the patient, with older children more likely to tolerate spasmolytic injection. there are data supporting the benefits of glucagon on image quality, at the expense of prolonged imaging time and precipitation of nausea in just under half of paediatric patients (3, 4) . however, high diagnostic accuracy can also be achieved without spasmolytic (5) . & it is recommended that children aged over 9years should be nil by mouth for carbonated and milk beverages for 4-6h. ingestion of still water or non-carbonated fruit juice is recommended. & it is recommended that for dedicated colonic evaluation, a standard protocol without specific modification is used. & use of a spasmolytic agent is not recommended. & the use of i.v. us contrast is not recommended. & it is recommended that scan coverage should include an abdominal and pelvic examination, including the liver. there are no specific recommendations as to the use of hydro us in the paediatric patient as practice is not well developed. if oral contrast is given prior to us, it would seem sensible to follow the recommendations for mre in the paediatric population & it is recommended that if ct scanning is used in the paediatric population, no specific preparation is usually required although administration of positive oral contrast could be considered; for example, prior to percutaneous drainage of abscesses. limitations: there is little evidence in the literature to ascertain all these proposals. the recommendations were mainly based on expert opinion. no recommendations have been proposed for children before 6 years of age. especially the benefice of mre under sedation (6) in the younger compare to us doppler need to be explored. contrast media application is essential for a number of mri studies in children. there is some evidence that gadolinium-based contrast agents (gbca) are well tolerated in infants and children. the risk of adverse reaction is no higher in children than in adults. there are only few data available about pharamakokinetics in children, especially for the use of gbca in neonates. age-adapted reference values of the glomerular filtration rate (gfr) have to be used to identify children with a potential risk. in the past few years there was some attention toward the potential cellular toxicity of gadolinium and its role in the development of nephrogenic systemic fibrosis (nsf). there were only few children identified with proof of nsf. but, particulary renal insufficiency, poor hydration, acidosis and inflammation increase the risk for nsf. because the cases of nsf have been observed with linear componds the guidelines (2017) 47 (suppl 2):s297-s pediatr radiol from the esur and the espr and others propose to avoid linear compounds and to prefer macrocyclic gbca. in the past year several studies have described observations about possible gadolinium retention in the brain; hyperintense brain structures in native t1 weighted sequences were verified -globus pallidum and dentate nucleaus -also in children undergoing multiple mri examinations with gbca application. so, repeated mr investigations within a short time should be avoided -the cumulative dose of gbca should be recorded. consider all these points, the benefit of a contrast-enhanced study should be weighted against the potential risks before administering a gbca for each child separately. but, never deny a child an indicated cemri study. use single dose application (0.05-0.1 ml/kg body weight), improve renal function and hydration, balance acidosis -and ask your pediatric nephrologist íf necessary. gadolinium-based contrast agents are safe. macrocyclic compounds should be used in children. avoid contrast media in neonates and be careful in infants. identify risk factors. avoid repetivite application. procedural recommendation: how to perform pediatric gastrointestinal us m.l. lobo 1 , m. riccabona 2 ; 1 lisbon/pt, 2 graz/at summary: ultrasound (us) is the first imaging modality applied in the investigation of abdominal complaints in children, and an increasingly valuable imaging tool in the assessment of the gastrointestinal (gi) tract in neonates, infants and children. a comprehensive us examination is a critical first-step to optimize the potential of us diagnostic yield in many paediatric gi conditions. using proper high resolution transducers and graded compression technique is an essential part of gi us examination. a methodical and systematic analysis is crucial to facilitate a thorough evaluation of the bowel segments as complete as possible: follow bowel in a cross section, complete by longitudinal and oblique views. for some bowel sections filling is essentialsuch as stomach for gastroesophageal reflux and pyloric function, and distensibility and size of the colon by enema (e.g. for query microcolon). modern us methods are valuable, but not a pre-requisite. proper documentation of abnormal size of the gi tract segments, their luminal content, peristalsis, bowel wall characteristics and its surroundings, as well as local tenderness should be noted. a proposal for recommendation on how to perform paediatric gastrointestinal us will be presented for public discussion. & careful and dedicated us examination is crucial to obtain maximum anatomic and functional information in many gastrointestinal disorders in children. & systematic and methodical analysis helps to assess the bowel as complete as possible. & satndardization of us technique is essential to optimize us diagnostic capabilities and to allow for comparable examinations wich is essential to improve future evidence-based knowledge. hominid evo-devo: reconstructing the evolution of human development c. zollikofer; zurich/ch from an evolutionary biologist's perspective, modern humans represent the only surviving species of a group of highly specialized "bipedal great apes". they evolved more than seven million years ago in africa and managed to spread over the entire globe. in this talk, i will trace the history of our species with an emphasis on key developmental innovations that underlie major evolutionary innovations. why are we born with brains that have the size of adult great ape brains? and why do we grow up so slowly and get so old? i will highlight how advanced biomedical imaging methods help addressing these questions, and show how combined fossil, clinical and great ape data yield surprising insights into the evolution of our development. to present our experience with innovative imaging in pediatric interventional radiology. imaging technologies presented will include: 1. use of bubble contrast (lumeson) for indicatons including; complex pleural effusion and abdominal collection assessment pre and post therapy, primary g tube placement, renal perfusion pre and post rena artery angioplasty, vascular patency during central venous line placement, vascular malformation therapy and biliary tube assessment. 2. intravascular us (ivus) in arterial intervention pre and post angioplasty and venous thrombolysis intervention. 3. optical coherence tomography pilot study assesssment for renal artery intervention -validation in normal subjects. currently this imagng which uses laser light technology to assess vascular mural detail at the micron level, is only validated in coronary artery intervention in adults. 4. mr overlay -a technology that fuses mr imaging with low dose fluoroscopy and can faciltate biopsy of mr positive/ct negative lesions in the ir suite. focus will be on bone lesion biopsy and vascular malformation therapy. critical structures to be avoided can be outlined on the mr and transposed onto the fluoroscopic image during biopsy. in our experience this technology has promise in the pediatric setting with significant dose reduction when compared to ct. 5. mr fusion and i guide fusion technology enables an mr positive/ct negative lesion that would require ct guided imaging to be biopsed, using low dose c -arm ct, with fusion of the ct and mri images performed using landmarks, facilitating fluoroscopically guided biopsy in the ir suite. critical landmarks/structures to be avoided can be outlined on the ct or mr and transposed onto the fluoroscopic image during biopsy path planning and orchestration. focus will be on bone lesion biopsy. 6. color parametric flow related imaging in vascular interventionthis software enables time to peak opacification of arterial or venous contrast to be color coded in time and can provide adjunctive information for assessent of perfusion change during vascular intervention such as renal artery angioplasty, dialysis access intervention and cerebral embolization. 7. mr guided intervention -this focus will be on the initial development of an mr interventional program and our initial experience with mr arthrography. discussion will also involve the use of this modality for vascular malformation sclerotherapy and other msk interventions such as biopsy and nerve injections. 8. high frequency us imaging-focus will be on the use of a 40mhz us probe in the ir suite for various indications including visualization of smaller targets such as neonatal central venous access, superficial vascular malformation therapy and thyroid fine needle biopsy. 1. participants will become more familiar with exisitng and emerging innovative imaging technologies for pediatric intervention. participants will learn about the various indications and limitations of these technologies. 3. participants will gain insight into the process of introducing new imaging modalities into their pediatric interventional practice. increasing evidence supports the notion that autism spectrum disorder is associated with anomalies of brain function and connectivity. it is also evident that there are atypicalities in development/maturation of brain systems. particular promise arises from findings of atypical electrophysiology -indexing brain neuronal activity in real time. in particular, this talk will address a characteristic electrophsyiologic signature of delayed auditory evoked response latency (at~100ms). this, and related timing anomalies, have been proposed as biomarkers for asd -with candidate use for diagnosis, prognosis, stratification and therapy monitoring. progress along each of these axes will be discussed. however, to justify the term "biomarker", we demonstrate converging evidence from spectrally-edited (megapress) mrs and diffusion-mri. mrs offers insights into neurotransmitter levels, especially gaba and glutamate, imbalance of which may be associated with anomalous electrophysiologic oscillations in the gamma band. diffusion offers insights into the white matter of the brain (auditory pathway will be illustrated) and an interpretation of diffusion parameters as an index of central conduction velocity will be offered. combining these mechanistic measures with the spectrospatio-temporal capabilities of magnetoencephalography (meg), this talk will present a state of the art review of multimodal biomarker development in asd. take home points: meg captures brain activity in space and time as well as showing sensitivity to activity at different frequencies (where, when and what) delays in cortical neuronal response latency are evidence in asd atypical coupling between diffusion evidence of conduction velocity and timing of cortical responses in shown in asd oscillatory activity is atypical in asd (elevated "noise", decreased "synchrony") diminished inhibitory neurotransmitter (gaba) levels are shown in asd disturbance of teh typical coupling between gaba and gamma-band oscillations in development leads to anomalous adult oscillatory activity (taken to index local circuit function). multimodal and longitudinal approaches may be required to tackjle the complex and heterogeneous landscape of asd the paediatric radiologist can play an important role in establishing vascular access in paediatric patients ranging from neonates to teenagers. a breadth of knowledge and skills are needed to deal with changing body morphology and varied pathology in this age range. some of the skills particular to performing and managing vascular access in children will be discussed. different devices which can be placed, their indications, advantages and disadvantages will be reviewed. choice of access vessel is important in children, because there are known long term complication such as central venous stenosis and thrombosis, which can have a huge impact for future venous procedures or potential creation of an arteriovenous fistula of the arm for dialysis. preserving venous access sites is a (2017) 47 (suppl 2):s297-s pediatr radiol key responsibility especially in children with complex medical and surgical co-morbidities. because vascular access in children has associated morbidity it's important to manage and maintain devices that are placed. the risk of infection when repairing or exchanging a broken line will be highlighted. image guided biopsy is a very frequent procedure in pediatric patients. they range from random organ parenchyma for the diagnosis of medical disease up to tumor biopsies for histopathology analysis. different imaging modalities can be used for guidance as well as different biopsy devices and needles. ultrasound guidance is the most common modality used for this purpose in the pediatric population. the success of this procedure depends on multiple factors: from pain control up to choosing the correct device and area to sample. the radiologist performing the procedure also needs to be familiar with the potential complications of the intervention, how to prevent them and how to manage them. the intention is to perform the safer procedure as possible, obtaining the best quality of sample. the goal of this lecture is to present in a didactic way technical tips to perform safe and effective image guided pediatric biopsies, which may be applicable to different groups of operators, ranging from general pediatric radiologists performing occasional biopsies up to pediatric interventional radiologists. the objectives will be: to identify the safest approach to different types of biopsies; to describe ways to obtain the better quality of sample as possible; to demonstrate the use of different approaches in challenging clinical scenarios; to illustrate new devices currently used in specific applications; to discuss potential complications and its management and to show imaging modality integration applied to biopsy planning an performance. image guided biopsy is a frequent procedure in pediatric patients. a pre-procedure planning is fundamental in the success of the intervention. the operator must be aware of the aims of the biopsy and based on this choose the best approach, device and site for sampling. preparation and competency to manage complications is mandatory. pediatric interventional oncology: big cases in little people m. heran; vancouver/ca summary: the pediatric patient presents unique challenges in diagnosis and management of oncologic disorders. interventional radiology (ir) has a prominent role in the care of these children, with improvements in imaging and equipment offering better and safer options to traditional diagnostic and therapeutic procedures. as cancer can involve any organ system, consultations to the ir service can involve any part of the body, and can be non-vascular and vascular, simple and complex. the most common ir procedures in the pediatric oncology patient are enteric tube placement/change, vascular access, and percutaneous image-guided tissue/organ biopsy. however, with the explosion of interventional oncology in the adult setting, the variety and complexity of ir in pediatric oncology has begun to increase as well. ir techniques, such as thermal ablation, transarterial pharmacotherapy, and preoperative embolization, are now increasingly discussed in multi-disciplinary conferences as complementary or primary modes of treatment of oncologic disorders or related diseases/complications. however, although the principles of these diagnostic and therapeutic ir procedures remain essentially the same in their translation from adults to children, well recognized differences in pediatric physiology and metabolism, as well as the range in weight, size, and age of children, result in a practical question of "how do we do this?" the aim of this presentation is to provide an overview of the role of ir in the pediatric oncology patient, and to highlight areas of research and innovation. vascular anomalies encompass a spectrum of disorders including vascular tumours and vascular malformations. incorrect nomenclature and misdiagnoses resulting in inappropriate treatment are commonly experienced by patients with vascular anomalies. the currently accepted method for classification of vascular anomalies is straightforward and clinically relevant. vascular malformations can be divided into high flow lesions such as arteriovenous malformation or low flow lesions such as venous or lymphatic malformations. in children, a diagnosis can often be made with the history, examination and ultrasound. the classification of vascular anomalies will be briefly reviewed with examples of commonly encountered pathologies. a multidisciplinary team approach to the management of these conditions is vital. paediatric radiologists can play a key role not only in diagnosis but also in management, principally by injection sclerotherapy of low flow lesions and embolization of the much rarer arteriovenous malformation. many sclerotherapy agents are available with sodium tetradecyl sulphate the most commonly used for venous malformations and doxycycline for lymphatic malformations. different sclerotherapy agents have different characteristics and uses which will be covered. symptomatic relief is often achieved with treatment but multiple treatment episodes may be needed to achieve the desired outcome. ensuring the child and family understand this is vital to ensure they are satisfied with the management of the condition. contrast media is commonly used during imaging in children whatever their age and whatever the pathologic conditions. still, youngest patients are vulnerable and unstable. therefore, in neonates and infants the use of s339 (2017) 47 (suppl 2):s297-s pediatr radiol contrast media should be carefully evaluated and customized putting in balance the risk versus the benefit of its use. when using contrast media in neonates and infants, several features should be highlighted: -prematures and neonates have rather immature kidneys and some contrast media might be difficult harmful -the thyroid gland in prematures may be (transitorily) depressed by iodinated contrast media -the use of high osmolar contrast may induce a fluid shift and dehydration especially in premature and neonates -most contrast media are used off label; almost none has obtained the authorization to be used in neonates. -there are very few studies evaluating the short and long term adverse reactions in neonates and infants below the age of two. fortunately these reactions seem very rare in these age groups. -using contrast extends the duration of the examination and the need for sedation different types of techniques will potentially need ingestion, instillation or injection of contrast media: 1) opacification of the entire gi tract pre-and post-operatively 2) retrograde uretro-cystography 3) contrast enhanced ct 4) contrast enhanced mr imaging 5) contrast enhanced us 6) angiography furthermore, different types of contrast media can be used to achieve these purposes 1) barium (sulfate) 2) iodinated water-soluble contrast media (hyper-, iso-or hypoosmolar) remarks regarding opacification of the upper gi tract: -the upper or lower gi tract should be opacified using water soluble contrast in the immediate postoperative period or whenever a bowel perforation is suspected. -air can be used to confirm esophageal atresia and duodenal atresia -barium should be preferred in case of t-e fistula -either barium or water soluble iodinate contrast can be used in order to opacify (sub)obstructed upper gi tract remarks regarding the opacification of the lower gi tract -iodinated iso/hypo osmolar contrast should be used to opacify the colon in case of obstruction -a higher osmolarity iodinated contrast can be used in case of suspected meconium ileus or plug; still this contrast should be used diluted and under close clinical surveillance and adequate hydration. -in some more specific cases, for instance whenever hirschprung disease or a stenosis post nectotizing enterocolitis are suspected, barium enema can be used remarks regarding ct scan -contrast enhancement may help for the global assessment of various pathologies especially in case of cardio-vascular malformations or for the evaluation of abdominal masses. any iodinate contrast among those available is acceptable in neonates. higher osmolality contrast allows to inject a lower volume -injected volumes of 1.5 ml/kg seem adequate using 22-24 gauge needles -power injectors are acceptable as long as adequate catheters can be used -allergic or side effects are very rare and should be managed similarly to adults. remarks regarding mr imaging -the use of gd chelates in neonates remains controversial as there is no data available on the long term effects of gd injected so early in life -gd should be used only when enhancement may provide additional information compared to the non-enhanced study (cns infections, tumors, cardiovascular imaging, abdominal tumors, uro-mr imaging...) -only gd with low nsf risk should be used -gd should not be used in children with renal failure remarks regarding contrast enhanced us -little is known about the use of ce-us in neonates -indications seem equal to older children -there are very few side or allergic effects -doses suggested are 0.1 ml/year of age children present varied histological types of brain tumours. it's now possible to combine different information and image techniques to improve the diagnosis of paediatric brain tumours. the multimodal approach has increased the diagnostic specificity and permits, in most cases, the pre-operative differentiation between low and grade tumours. children with low grade lesions, and in particular the less accessible tumours, would benefit the most from avoiding biopsy. in addition, preoperative spinal mri evaluation to rule out drop metastases should be performed in patients with suspected high grade tumours. in general paediatric brain tumours are less necrotic, i.e. aggressive tumours in paediatric patients tend to be more hypercellular and homogeneous. because of its ready availability and speed, computed tomography (2017) 47 (suppl 2):s297-s pediatr radiol (ct) is the first investigation generally performed for a suspected brain tumour. ct can rule out haemorrhage or calcifications, but can also be used to evaluate tumour cellularity. a hyperdense tumour on ct reflects hypercellularity and is very often high grade. medulloblastoma are, for example, typically hyperdense on ct scans and paediatric low-grade astrocytomas are almost always hypodense. mri plays a major role in the evaluation of brain tumours. in conventional mri, the "general aspect" is the single most important parameter in predicting high-grade tumours in children. the same does not hold true for low-grade tumours, of which only 67% can be predicted using the general aspect. in our previous study, hyperintensity on t2-w and the lack of diffusion changes were the most important single parameters with 83% positive prediction. embryonic tumours, such as medulloblastoma or pnet have high tumour cellularity with consequent very low adc and hypo/isointense t2 compared to the cortex. adc values derived from dwi have been shown to be decrease in highly cellular tumours. adc values cannot reliably be used in individual cases due to the substantial overlap between tumour types previously described in the literature. nevertheless, adc has a higher predictive value in children and increases the accuracy of preoperative differentiation between low grade and high grade paediatric tumours. the cut-off values for differentiating between low and high grade paediatric brain tumours are 0.7 x 10 3 mm 2 /s and 1.0 x 10 3 mm 2 /s for minimum adc and average adc values, respectively. perfusion with relative cerebral blood volume (rcbv) is considered a marker of angiogenesis and is helpful in distinguishing high and low grade tumours. however, perfusion can be difficult to perform in small children; small catheters with manual injection are therefore used in such cases (or, as an alternative, arterial labelling). it should however be taken into account that choroid plexus tumours can have high rcbvs resulting from highly leaky capillaries. mr spectroscopy (mrs) shows the metabolic profile of the tumour. high grade tumours show elevated choline (cho) -reflecting increase in cell membrane turnover -and decreased n-acetylaspartate (naa), which represents a neuronal marker. the absolute values of the mrs peaks are not used by us; we favour to normalize the signal intensities of metabolites to their values in contralateral brain tissue. mrs is helpful not only as guidance for stereotactic biopsy (cho hot spot) but also for determining whether the tumour is high or low grade. as a rule of thumb, a 200% increase of cho when compared to the contralateral brain tissue is highly suggestive of a high-grade tumour. however, in children, increased cho levels can also be found in pilocytic astrocytoma; in this case the typical aspect with cystic component and location can suggest the diagnosis, despite the mrs result. therefore, in children, high cho levels do not necessarily imply the presence of a malignant tumour. task based functional mri (fmri) can be used for pre-operative localization of the eloquent cortex together with the identification of the language and somatomotor function. in the future, small children who are unable to cooperate will probably profit from resting-state fmri. pet mri has the advantage of integrating structural mr imaging with physiologic pet. take home points: take home points although the histology of paediatric brain tumours is diverse, their general morphological aspect on mri has a very high diagnostic reliability. unlike adult grade iv brain tumours, malignant paediatric brain tumours are less necrotic, but are highly cellular with high nuclear-to-cytoplasmic ratios. adding information on signal intensities on t2w and dwi further increases the diagnostic accuracy of conventional mri. the solid areas of high-grade tumours are iso-or hypointense on t2w and hyperintense on dwi, whereas low-grade tumours show inverse signal characteristics. advanced mr techniques (perfusion and spectroscopy) provide important biological information which can be used to correctly identify grading (high vs. low) and to guide biopsy. in children high cho levels, although suggestive, do not necessarily mean a malignant tumour. experience with central review of paediatric renal tumours g. khanna; st louis/us summary: central imaging review of pediatric renal tumors has been performed in children's oncology group since 2006. to date, more than 5500 cases of pediatric renal tumors have been centrally reviewed real time by the study radiologists. the mean time for central review was <8 days. discrepancies between local and central risk stratification were identified for detection of bilateral disease and pulmonary metastasis. in addition, central archiving of images has created a rich repository of cases for future research. the role of imaging in detection of key diagnostic features in pediatric renal tumors will be reviewed. the diagnostic performance of imaging for staging, detection of vascular invasion and tumor rupture will be discussed. real time central review of imaging is feasible in pediatric oncology wilms tumor remains the most common pediatric renal malignancy, followed by renal cell carcinoma cystic nephroma typically presents as a bosniak 3 lesion, and has high association with dicer-1 mutations is there a role for dwi in nephroblastoma? a.s. littooij; utrecht/nl wilms tumour or nephroblastoma is the most common malignant renal tumour in children. ultrasound is usually the first line investigation. mri of the abdomen is often performed to further delineate the tumor and its surroundings. the addition of diffusion-weighted imaging (dwi) to the standard mri protocol may enable subtype characterisation and allows assessing treatment response beyond necrosis and volume change. overall, the survival rate in patients with nephroblastoma is relatively good and the current focus is on finding biomarkers to further improve outcomes while reducing therapy-related side effects in these children. therefore, identifying low-or high-risk type nephroblastoma might be relevant for treatment planning. diffuse anaplastic nephroblastoma and extensive blastema in residual tumour after preoperative chemotherapy may require more intensive treatment. the limited available literature suggest a linear relation between adc values and subtypes nephroblastoma at histopathology. furthermore, the addition of dwi to the standard mri protocol may detect lesions (e.g. nephrogenic rests of nephroblastomatosis) that remain undetected at post contrast t1-weighted images. unfortunately, there is a considerable heterogeneity in acquisition techniques and methods of adc measurements. nephroblastoma often contains areas of necrosis and/or hemorrhage that can demonstrate very low adc values and consequently mimic highly cellular portions of tumours. therefore these areas should be excluded from further analysis. this lecture will highlight the potential additional benefit and limitations of dwi in children presenting with renal tumour. significantly lower radiation exposure even in comparison to low-dose pet/ct, (b) the higher diagnostic accuracy as compared to pet/ct even when using diagnostic contrast-enhanced ct, (c) the unique possibility to combine distinct mr-inherent contrasts (e.g. dwi) with specific pettracers (e.g. 64cu-labeled antibody imaging) for the evaluation of novel targeted therapies, and (d) the opportunity to stage local and systemic tumour burden within a single and highly resolved examination. on the other hand, many circumstances are challenging the extensive use of pet/mri in children. in general, the availability of pet/mri systems is low, particularly for children. thus, only a few sites in europe have experience with this technique in children, and therefore the generated scientific evidence is limited. moreover, whole-body-mri is still not a broadly adopted method for the combined assessment of local disease extent and whole-body staging, potentially replacing other whole-body modalities like the bone scan. in this context, especially the detection of pulmonary metastases is biased also against pet/mri. finally harmonized sequence protocols and specific recommendations for trace dosage are not available for pet/mri. in conclusion, further efforts are needed to keep the promises of pet-mri in the daily practice. common artefacts in paediatric mri-how to recognise, avoid or take advantage of them c. kellenberger; zurich/ch summary: while mri is a robust and radiation free imaging technique for assessing anatomy and pathology of most tissues and organs throughout the body, it is inherently prone to artefacts as no other imaging modality is. mri artefacts may impair image quality potentially leading to difficulties or errors in interpretation, but in some instances can contribute diagnostic information. main sources of image degradation are motion, disturbances of the local magnetic field and other factors inherent to image acquisition. strategies to reduce effects from various kinds of motion and adjustment of sequence parameters for eliminating artefacts will be discussed. & understanding the origin and effects of artefacts encountered in paediatric mri is essential for modification of mri protocols, so that artefacts and associated errors can be avoided. & for safely and successfully imaging children with implants and devices, the composition, location and functionality of the foreign body needs to be known. injuries to the central nervous system in abusive head trauma are responsible for the primary cause of morbidity and mortality in infants. neuroradiology has an important role in diagnosis but also in depicting injury and extent of brain damage of poor outcome. computerized tomography (ct) and magnetic resonance imaging (mri) are the primary imaging techniques. ct is usually performed in the acute phase while mri is performed the following days after injury. some injuries are better identified on mri such as diffuse axonal injury and cerebral edema with susceptibility and diffusion weighted images. abusive head trauma (aht) is the primary cause of morbidity and mortality in infancy, especially during the first year of life. aht is clinically characterized by a triad consisting of subdural hematoma, retinal hemorrhage and encephalopathy caused by brain swelling (1). the most common mechanism responsible for brain damage is thought to be caused by whiplash shaking injury explaining that abusive head trauma is also referred as shaken baby syndrome. impaction, compression and penetrating injury are also possible mechanisms as well as strangulation. however because of the variability of types and severity of injury, clinical symptoms vary from subtle to severe such as alteration of consciousness or coma (2) . the most common symptoms include vomiting, seizure, lethargy, poor feeding and apnea of which vomiting and respiratory pauses are non-specific (3). poor feeding, irritability or lethargy is also nonspecific signs. however apnea and/or retinal hemorrhages seen in children with brain injury are strongly associated with inflicted trauma (4) . in contrast to acute injury some children may manifest with increased head circumference related to chronic subdural hematomas. neuroimaging is therefore playing a crucial role to assess infants and children with a suspicion of abusive head trauma. computerized tomography (ct) and magnetic resonance imaging (mri) are the primary imaging techniques. ct is performed for the initial evaluation in cases with acute symptoms to look for hemorrhagic intracranial injury as subdural hematoma. mri is more often performed in the following days to further evaluate brain injury and to look for spine and spinal cord damage (5, 6) or in the presence of normal or equivocal ct findings (7) . however brain mri may be the first option in children presenting with increased head circumference. recently the study from flom et al showed the high sensitivity of mri for intracranial hemorrhage in well appearing infants at risk for abusive head trauma suggesting mri as a screening tool with 3 pulse sequences (axial t2, axial gradient recalled echo and coronal t1 weighted inversion recovery) (8) . ct is generally performed without intravenous contrast injection with 3d volume rendering (vr) reconstructions for identification of fractures. in some cases postcontrast images are also obtained specially to rule out deep venous thrombosis especially when children present with nonspecific clinical symptoms. mri protocol should include axial t2, t2* or susceptibility weighted images, coronal t1 images, diffusion or diffusion tensor images, and postcontrast 3dt1 images including mip reconstructions to evaluate the venous structures. mr venography can also be performed. susceptibility-weighted images are usually preferred because they allow the depiction of smaller hemorrhagic dai lesions and greater number of lesions compared to gre t2 (9) . it was also reported by colbert et al (10) that the presence of micro-hemorrhages alone was useful for outcome prediction in abusive head trauma with significant poor long-term outcome. the sensitivity and specificity of microhemorrhages was also higher than the other clinical (such as retinal hemorrhages and glasgow coma scale score) and other imaging findings for prediction of outcome. diffusion tensor imaging (dti) measurements were reported in abusive head trauma by imagawa et al: decreased axial diffusivity related to axonal injury with consequent reduced mean diffusivity did correlate with poor outcomes (11) . magnetic resonance spectroscopy (mrs) is usually not part of the standard protocol. however aaen et al (12) showed that n-acetylaspartate/creatine and/or nacetylaspartate/choline ratios were decreased significantly in the corpus callosum, frontal white matter, parieto-occipital white matter, and parietooccipital gray matter in children with poor outcomes. this study mentioned above also reported that the prediction of outcome was accurate in 100% of patients by using a logistic regression model that include age, initial glasgow coma scale score, presence of retinal hemorrhage, lactate on mrs, and mean total n-acetylaspartate/creatine. functional mri, (2017) 47 (suppl 2):s297-s pediatr radiol volumetry may be performed in long-term follow up of victims of child abuse. physical abuse is associated with altered emotion with greater activation in the salience network in response to negative stimuli, that includes amygdala, thalamus, putamen and anterior insula (13) . increased responsiveness of the right amygdala to fearful and angry faces (negative stimuli) and structural changes as reduced hippocampal volume, are reported by dannlowski et al (14) . impaired attention was also reported in patients with childhood abuse (15) with reduced activation during attention tasks in the left hemispheric ventral and dorsolateral prefrontal regions. intracranial injuries include extracerebral hemorrhages and parenchymal damage as brain swelling and ischemia, venous infarction, diffuse axonal injury, contusions and intraparenchymal hematomas (7, 16) . extracerebral hemorrhages subdural hematoma is a characteristic finding of inflicted traumatic brain injury, is generally multifocal and most commonly seen along the posterior interhemispheric scissure, over de convexities at the vertex level and/ or in the posterior fossa (17) (18) (19) . subdural hematomas are most likely bilateral but may be unilateral. all locations are related to disruption of bridging veins. the identification of bridging vein rupture allows the diagnosis of traumatism in relation to acceleration/deceleration, rotational and shearing forces due to violent shaking (20) . a mixed density appearance of subdural hematomas is frequent but is also seen in accidental traumatic brain injury (21) (22) (23) . indeed this feature is often present in the very early hours following trauma and is thought to be secondary to early sedimentation of blood clots and supernatant serum. tubular high density is often seen on non-contrast ct over the convexities in abusive head trauma. this ct feature is related to a clot secondary to venous disruption (24, 25) that can end up in thrombophlebitis. this tubular high density was reported more recently as tadpole sign (26) and lollipop sign (27) respectively seen in 40 and 44% of abusive head trauma. this appearance is strongly associated to inflicted trauma and much less frequent in accidental trauma (3 out of 83 cases (3,6%) of accidental trauma in our experience). associated venous infarction is reported in 12% of cases of abusive head trauma (24) and often located in the parieto-occipital region, unilaterally at the site of venous disruption of bridging veins. subdural hemorrhages, when multiple, in the convexity and interhemispheric, or in the posterior fossa were found significantly associated with abusive head trauma in the meta-analysis reported by kemp et al (28). in addition subdural hematoma, cerebral ischemia, skull fracture, retinal hemorrhage and intracranial injury were significantly associated with abusive head trauma in the review from piteau et al (29). subarachnoid hemorrhages (sah) and epidural hematomas are also found in inflicted trauma and are not considered discriminant-imaging features. however epidural hemorrhages, isolated skull fracture and scalp swelling were reported as significantly associated with accidental traumatic brain injury (29). sah in shaking injury is usually caused by tears of the vessels within the pia and arachnoid predominantly in the interhemispheric fissure and high convexity (7). parenchymal injury parenchymal injury include brain swelling and ischemia, venous infarction (discussed above), diffuse axonal injury related to rotationallyinduced shear-strain injury with different inertia for grey and white matter due to their different specific gravities, contusions seen in deceleration trauma with friction between the skull and brain, and in blunt trauma and intraparenchymal hematomas related to lacerated vessels. brain swelling/ischemia may be related to increased blood volume (congestive swelling), increased presence of water in the nervous tissue, and the combination of both. increased water in the nervous tissue may manifest as vasogenic edema located in the white matter due to extravasation of plasma like fluid related to incompetent blood-brain-barrier and as cytotoxic edema located in the grey matter, related to ionic imbalance. cerebral edema can be recognize on ct within the 12 hours following injury as loss of gray-white matter differentiation and decreased attenuation of grey and white matter. cytotoxic and vasogenic edema are better characterized on mri with diffusion-weighted imaging. brain swelling and edema occur early after trauma with consequent underestimation of subdural hematoma. therefore imaging should be repeated (ct or mri) especially when neurologic symptoms change rapidly. brain swelling/ edema may also involve the posterior fossa and is better identified on brain mri. two frequent patterns have been reported in abusive head trauma (24). diffuse supratentorial brain swelling (infarction) involving the cortex and white matter was reported in 39% of cases and is considered as severe hypoxic-ischemic injury with poor outcome (30). watershed infarction was reported in 36% of cases and considered a less severe form of hypoxia-ischemia. apparent diffusion coefficient (adc) values are strongly associated with poor neurodevelopmental outcomes in the acute phase (within 4 days) especially basal ganglia, thalamus, brainstem, cerebral cortex, cerebellar vermis, cerebellar cortex and mean total brain (31). during the early phase up to 1 month adc values in fewer regions (basal ganglia, thalamus, brainstem and corpus callosum) were associated with poor outcome. when patients with and without parenchymal lesions are compared, the detection of diffuse lesions during the first 3 months as well as beyond 3 months is significantly associated with severe developmental outcome (32). late mri (beyond 3 months after injury) also showed that recovery depends on the extent of brain damage. patients with diffuse lesions show more severe motor and intellectual impairments and are more likely to have blindness and epilepsy than patients with focal or hemispheric lesions (32). diffuse axonal injury (dai) is related to shear-strain injury of small medullary veins and was reported in 6% of cases of abusive head trauma (24). it is encountered in trauma with sudden acceleration-deceleration associated with rotational angular forces and in shaking-impact trauma. the lesions may be hemorrhagic or non hemorrhagic (related to axonal swelling). dai is most often located in the subcortical white matter at the gray-white matter junction, corpus callosum, basal ganglia, brainstem and internal capsule. if the lesions are large enough and hemorrhagic dai may be seen on ct. however dai is usually better identified on mri with susceptibility and diffusion weighted images. the detection of changes in the basal ganglia or brainstem during the first 3 days as well as during the first month after injury is significantly associated with poor long-term outcome in survivors (30). the presence of intraparenchymal brain micro-haemorrhages detected on swi in children with abusive head trauma correlates with significantly poor long-term neurologic outcome (10) contusion is also reported in abusive head trauma and is seen in blunt trauma with impact with or without contrecoup contusion. contusions are located at the surface of the brain (crest of gyri) and may be pial and haemorrhagic (disruption of cortical arteries). they are also found in the frontal and temporal regions related to impact of the brain on the roof of the orbit, middle cranial fossa and sphenoid wing. white matter tears are also seen in the frontal and temporal area related to the vulnerability of unmyelinated and soft white matter in infants. skull fractures are seen in blunt impact and are less frequent than long bones and rib fractures in non-accidental trauma. the most common site is the parietal bone (because of bulging of parietal bones below 1 year of age). the fracture may be linear as in accidental trauma. radiologic features significant for inflicted trauma are multiple fractures, bilateral fractures and fractures that cross suture lines (28, 33). focal underlying brain damage can be seen such as subdural hematoma and hemorrhagic contusion. hypoxic-ischemic encephalopathy is seen in strangulation injury with involvement of the territories of the internal carotid artery related to their anatomic vulnerability. neuroradiology (ct and mr) is crucial for the diagnosis of trauma, to predict outcome when showing edema and hypoxic-ischemic injury. this presentation will present an update on post mortem mri (pmmr) with relevance to clinical developments over the last 2 years. in particular, reference will be made to diagnostic accuracy of pmmr across different body parts, the current limitations of post mortem mr, and protocol development at different field strengths. imaging correlates of post mortem interval are also being investigated. maceration (autolysis within intrauterine fluid) and perimortem hypoxic brain changes caused difficulties in image interpretation, which more advanced and quantitative techniques may be able to address. jawad take home points: below 500g, 1.5-t pmmr shows a significant reduction in diagnostic yield, compared with conventional autopsy, and therefore its clinical usefulness in this setting will depend on individual circumstances. 3t pmmr performs better than 1.5 t particularly <20 weeks gestation, and particularly for the chest, heart and abdomen. diffusion characteristics in different fetal brain areas are multifactorial, with maceration the strongest predictor in most areas. international pm ct protocols c.y. gerrard 1 , o.j. arthurs 2 ; 1 albuquerque, nm/us, 2 london/uk the european society of pediatric radiology (espr) taskforce and the international society of forensic radiology and imaging (isfri) pediatric working group have combined efforts to establish best practice standards for performing perinatal and pediatric post mortem computed tomography (pmct) examinations. use of pmct in the investigation of pediatric death has increased significantly in the past decade. due to quick acquisition times and the ability to acquire thin slice, high detailed images of the whole body, (2017) 47 (suppl 2):s297-s pediatr radiol many hospitals and forensic institutes have implemented pmct into daily practice. however, there lack an overall standardization of how cases are triaged and the acquisition methods when comparing institutes using pmct. in an effort to address inconsistencies in acquisition parameters, post processing, and case selection, pmct protocols were compiled from international institutes and centres currently performing pediatric imaging. this paper will describe both the uniform and divergent elements of image acquisition and procedural uses identified among the participating centres. the outcome is to provide a single source of information that can guide already established and new centres on the best practice standards for implementing pediatric pmct. take home points: describe how pediatric post mortem computed tomography (pmct) has increased in utility over the past decade. identify the differences in acquisition methods for clinical computed tomography versus post mortem computed tomography. discuss the overall consensus of case triage and scan acquisitions when comparing institutes in aggregate. provide comprehensive statement of best practice standards for pediatric pmct. post mortem imaging research: updates and future proposals o.j. arthurs; london/uk paediatric and perinatal post mortem imaging is a new and rapidly growing field, and the post mortem imaging taskforce was founded in graz at espr 2015. the pmi taskforce aims to help reach consensus and guidance regarding imaging protocols and the potential yield of post mortem ultrasound, ct and mr. the key priorities are the themes of collaboration, image acquisition, best practice guidelines, training and education, raising awareness and access to imaging. this presentation will give updates on the latest developments in perinatal and paediatric imaging, with particular focus on where the pmi taskforce can help. in particular, protocol development is underway, and the espr meeting acts as an opportunity for collaborative working and network development, to facilitate best clinical practice and welcome new members. arthurs oj et al., espr post mortem imaging task force: where we begin. pediatr radiol (2016) ; 46: 1363 -1369 take home points: post mortem imaging is an exciting sub-specialty which requires a combination of in depth fetal medicine, perinatal autopsy and pediatric imaging knowledge to help shape and grow the clinical and research arena. dedicated personnel have an opportunity to create the evidence-based behind a growing clinical service, with clear benefits to patients, families and referring clinicians. abstracts appear as submitted to the online submission system and have not been checked for correctness and completeness. sequences, are an emerging tool for evaluating intracranial vessel disease. improved survival due to emended treatment protocols results in an increasing number of long-term medulloblastoma survivors who experience delayed treatment effects. microbleedings, developement of cavernomas, vasculitis and atherosclerotic lesions are cerebrovascular structures affecting sequelae of the applied radiochemotherapy. this study evaluates radiation-induced intracranial vascular changes. twenty-two long-term pediatric medulloblastoma survivors (mean age 25.8 years, range 10-53 years; mean years after primary radiochemotherapy 16.3 years, range 1-45 years) underwent mri. the scan protocol included precontrast 3-dimensional time of flight (tof)magnetic resonance angiography (mra), precontrast 2d t1-and 2d t2-vwisequences and postcontrast 2d t1-vwi-sequences of the medium and large intracranial arteries. vessel wall thickening, contrast enhancement and luminal narrowing were analyzed. additionally precontrast t1-, t2-swi and t1-weighted images of the supra-and infratentorial brain were acquired. results: vwi-sequences: vessel wall changes could be found in 12 (54%) and 14 patients (63%) of the right and left ica, respectively. for the ba 4 (18%) patients revealed vessel wall changes; for the left and right va 2 (9%) patients were detected with vessel wall changes, respectively. in the tof angiography no alteration of the ica, ba or vas could be identified. in total vessel wall changes for the vertebrobasilar system and the icas could be found in 16 (72%) patients. swi-sequences: all patients (100%) revealed swi lesions, the smallest lesion measuring less than 2 mm, the biggest up to 5 mm. sixteen patients (72%) were presented with lesions > 4 mm, suspicious for cavernomas. to ensure quality of life in long term childhood medulloblastoma survivors, monitoring of long-term effects, like vascular changes after rct is gaining in importance. high resolution mri, including swi and vwisequences could be used here for. this study images, asymptomatic vessel wall alterations in former childhood medulloblastoma patients through vwi sequences and micro bleedings through swi sequences. vessel wall alterations, revealing rct induced arteriosclerosis, can lead to symptomatic intracranial stenosis which is associated with ischemia, furthermore micro bleedings and cavernomas can lead to intracranial hemorrhage. however further studies are needed to standardize mri sequence protocols to ensure a high standard follow up protocol, detecting clinically still asymptomatic vascular changes. fast "black-bone" mr imaging in evaluation of craniofacial abnormalities: comparison with high resolution ct z. habib, a. talib, c. parks, s. avula, l.j. abernethy; liverpool/uk to evaluate the feasibility and diagnostic value of a fast field echo, "black bone" mri sequence in children with craniofacial abnormalities. a fast "black bone" mri sequence has been used in addition to standard brain mri in 16 children (mean age 17 months, age range 3 months to 5 years and 5 months) referred to the supra-regional craniofacial surgery unit at alder hey children's hospital, liverpool, uk. a subgroup of 10 of these patients with complex craniofacial abnormalities additionally had high resolution volume ct performed at the same visit. "black bone" mr imaging was performed on philips ingenia 3t and 1.5t scanners, using a 3d fast field echo sequence (tr=8.3 ms, te=4.6 ms, flip angle 5 0 ). this sequence can be performed with an acquisition time of less than 2 minutes. the "black bone" sequences were assessed for accuracy in evaluating the patency of the sagittal, coronal and lambdoid sutures, and, where applicable, were compared with high resolution ct. the fast "black bone" mri sequence was shown to be technically feasible in all cases. the resultant images successfully demonstrated both patent sutures, which were confidently seen, and prematurely fused sutures which were confidently not seen. visualisation of patent sutures was found to be further enhanced by the use of minimum intensity projection. in the subgroup of patients with complex craniofacial abnormalities, comparison with high resolution volume ct confirmed good sensitivity for patency of cranial sutures. there was complete agreement in 50 out of 50 sutures assessed. the "black bone" mr images were also found to produce good-quality surface-rendered images and were also suitable for 3-d printing of models for pre-operative planning. fast "black-bone" mri has proven to be technically feasible and to demonstrate cranial suture patency with good agreement with high resolution ct. additionally "black-bone" mri can be used to produce good quality surface-rendered images and 3-d printed models for surgical planning. main symptom of mucopolysaccharidosis type iva (mps iva) is progressive systemic skeletal dysplasia. this is routinely monitored by cerebral and spinal mri. the vascular system is generally not in the primary focus of interest. in our population of mps iva patients we observed vessel shape alterations of the vertebrobasilar arteries, which has not been described before materials: mri-datasets of 26 patients with mps iva acquired between 2008 and 2015 were eligible for retrospective analysis of the vertebrobasilar arteries. the vessel length and angle of the basilar artery (ba) and both vertebral arteries (va) were analyzed. a deflection angle between 90°and 130°in the vessel course was defined as tortuosity, less than 90°as kinking. the results were compared to an matched control group of 23 patients not suffering from mps. the deflection angle [°] of the va and ba was significantly decreased in the majority (85%) of mps iva patients (fig. 1) mps iva is associated with significantly increased tortuosity of vertebrobasilar arteries. therefore the vascular system of mps iva patients should be monitored on routinely basis, as vessel shape alterations had been associated with dissections, leading to a higher risk of cerebrovascular events. in the pediatric population, intraspinal cysts (arachnoid or neurenteric cysts) are rare lesions mainly located in the thoracic region, whose acute onset is not well described in the literature. (2017) 47 (suppl 2):s297-s pediatr radiol we present a series of four children seen in the last two years as spinal cord emergencies and discuss the clinical aspects, imaging diagnosis, and management approaches, particularly in the emergency setting. a comparison of our cases with those reported in the literature is also provided. as in other types of spinal cord lesions, mr imaging is the diagnostic procedure of choice, because of its potential to demonstrate the exact location and extent of the cyst and its relationship to the spinal cord, valuable information for planning surgical treatment. this is a retrospective review of 4 cases of pediatric intraspinal cyst occurring in 4 boys and 1 girl, aged 2 to 6 years, treated at our institution between 2014 and 2016. onset was sudden in all cases and mimicked transverse myelitis or infarction. all our affected patients had no preceding history of trauma and presented with signs of spinal cord compression-back pain and less commonly abdominal pain-followed by weakness. all patients underwent emergent mr imaging, including t1, t2, t2*, 3d ciss, diffusion imaging and enhanced t1 sequences, mainly in the sagittal and axial planes. in each sequence, mr imaging showed a well-defined cystic lesion with signal intensity similar to cerebrospinal fluid, and secondary spinal cord compression that was severe in most cases. blood remnants were not visualized within or around the arachnoid cyst in any patient, which correlated with the absence of trauma antecedents. three of the four cysts were located in an anterior position relative to the spinal cord, and only one was located posteriorly; this latter had an associated subdural effusion. none of our patients had an associated neural tube defect. all patients were urgently treated with cyst wall fenestration or resection. the symptoms improved in all except one patient, whose symptoms did not abate, but ceased to progress. a prompt emergent diagnosis with mr imaging is important, as the symptoms can resolve if surgical treatment is performed before the spinal cord becomes irreversibly damaged. urgent surgery is essential in these cases, particularly if progressive neurological dysfunction develops over the course of spinal cord compression. the outcome following surgical fenestration or excision is excellent in most cases. nevertheless, a long-term imaging follow-up is recommended to detect possible recurrence. the objective of this study was to evaluate the usefulness of multiparametric quantitative mri model for myelination quantification in children. twenty-two children (age range: 9-5,400 days) were scanned with multiparametric quantitative mri. total volume of myelin water fraction (mwf) (msum), the percentage of msum within the whole brain parenchyma (mbpv), and the percentage of msum within intracranial volume (micv) were obtained. mwf values of brain regions were acquired by drawing regions of interests. the values were fitted to representative models of myelin maturation. spatiotemporal pattern of mwf mapping was visually assessed. values of msum, mbpv, and micv well fitted to a developmental model of myelination. mwf of brain regions well fitted to a developmental model with high r 2 values: pons (r 2 =74.6), middle cerebeller peduncle (r 2 =75.5), genu of corpus callosum (r 2 =93.6), splenium of corpus callosum (r 2 =79.7), thalamus (r 2 =85.8), frontal white matter (wm) (r 2 =95.7), parietal wm (r 2 =95.1), temporal wm (r 2 =93.7), occipital wm (r 2 =94.5), and centrum semiovale (r 2 =82.1). mwf mapping followed the known spatiotemporal pattern of myelination. multiparametric quantitative mri is a useful tool for mwf quantification in children. retinoblastoma is the most common intraocular tumour of childhood. it is a highly malignant. retinoblastoma is curable. if detected while still confined to the globe and if there are no metastatic risk factors, the child will nearly always survive following appropriate treatment. our aim is to assess diagnostic accuracy of preoperatively performed magnetic resonance (mr) imaging for detection of tumor extent in patients with histopathologically proved retinoblastoma. local ethics committee approval and informed consent were required for reviewing of patients' images and records. fifty-eight eyes in 30 girls and 27 boys with retinoblastoma (mean age at diagnosis was 23 months ±18.9) were reviewed on unenhanced t1wi, t2wi, and gadolinium-enhanced t1-weighted mri with and without fat suppression. mri parameters such as anterior chamber hyperintensity, involvement of choroid, ciliary body, optic nerve, sclera, orbital fat, and pineal gland were determined. maximum tumor diameter was measured and correlated to metastatic risk factors. imaging and pathologic findings were compared. choroidal invasion was suspected with mr imaging in 47/58 eyes; findings were false-positive in 6 eyes and false-negative in two (accuracy, 86.2%; sensitivity, 95.3%; specificity, 60%). mr imaging findings were true-positive in 10 of 17 eyes with proved prelaminar optic nerve invasion (60% sensitivity) and false-positive in 7 (82.9% specificity, 75.8% accuracy). postlaminar optic nerve invasion was correctly detected in 23 eyes; 4 eyes were false positive, in other 4 eyes, this metastatic risk factor was missed (accuracy, 86.2%; sensitivity, 85.2%; specificity, 87%). of nine eyes with histologically proven scleral invasion, 5 eyes were true positive . in the other 4 eyes, scleral involvement was missed on mri (accuracy, 93%; sensitivity, 55.6%; specificity, 100%).extraocular fat invasion was suspected on mri in 5/58 eyes. of these, findings were truly positive in 4 eyes (80%) and in 1 eye (20%) was incorrect (false positive) (accuracy, 98.3%; sensitivity, 100%; specificity, 98%).anterior chamber hyperintensity on t1-weighted mr images obtained after contrast agent administration correlated well with main mri and histolopathology findings. tumor size (assessed in our study by the maximum diameter in mm) was statistically associated with postlaminar optic nerve invasion (ρ=.002) and choroidal invasion (ρ=.007). mr imaging shows promising role for tumor staging and detection of metastatic risk factors. tumor diameter, measured with mr imaging, is associated with postlaminar optic nerve and choroidal involvement. patterns of the cortical watershed continuum of term gestation hypoxic ischaemic injurythe "wish-bone sign" a. chacko 1 , s. andronikou 2 , s. vedajallam 1 , j. thai 2 ; 1 east london/za, 2 bristol/uk objective: background partial-prolonged term hypoxic ischaemic injury (hii) involves the cortical and subcortical watershed zones of the brain, which are visually difficult to conceive. new innovative methods of demonstrating watershed cortical atrophy using flattened maps of the brain surface gives added insight into distribution of the watershed zone by demonstrating the entire brain surface. aim determining and validating patterns of hii sustained at birth in term infants using cross-sectional mri and the innovative mercator and scroll map views of cortical surface anatomy, to define the distribution of the watershed zones in children with partial-prolonged injury. one hundred paediatric mri brain scans with an mri and clinical diagnosis of chronic term hypoxic injury were read by 3 radiologists independently. all sites of abnormality were recorded and patterns classified. (2017) 47 (suppl 2):s297-s pediatr radiol patients with partial-prolonged and combined patterns were evaluated using mercator and scroll map reconstructions, generating schematics of the watershed zone. predominant patterns of disease were partial-prolonged and acuteprofound types. the watershed zone was demonstrated, on the derived maps, representing a continuum of involvement in the shape of a 'wish-bone' extending bilateral from frontal lobes to posterior parietal lobes in band-like fashion along the para-falcine cortex and intersected by another band of atrophy in the peri-rolandic regions extending along peri-sylvian cortices. this is defined in schematics as a visual aid. predominant patterns of injury in term hypoxic ischaemic injury are described and quantified, with the 'wish-bone sign' introduced to describe the typical distribution pattern of partial-prolonged hii in the watershed zone. correlation of brain edema degree and biochemical parameters in pediatric posterior reversible encephalopathy syndrome with hematologic/oncologic diseases t. akbas 1 , s. ulus 2 , b. karagun 1 , t. arpaci 1 , c. kalayci 2 , b. antmen 1 ; 1 adana/tr, 2 istanbul/tr posterior reversible encephalopathy syndrome (pres) often associated with hypertension is characterized by typical transient parietooccipital predominantly brain edema on magnetic resonance imaging (mri) with neurological symptoms such as seizures, headache and visual disturbances. even if endothelial dysfunction, increased blood-brain barrier permeability and hyper-hypoperfusion remain as controversial mechanisms to explain, the pathophysiology of pres is unremain. the aim of our study was to investigate the correlation between brain edema degree on mri and serum biochemical parameters such as lactate dehydrogenase (ldh), albumin (alb), creatinine, uric acid (ua) and urea. a total of 27 pediatric hematology and oncology patients (19 male, 8 female, aged 3-17, mean age: 11 years 6 months) diagnosed with pres during treatment and after hematopoietic stem cell transplantation (hsct) were included in this retrospective study. underlying diseases were beta thalassemia (n:14), aplastic anemia (n:4), acute lymphoblastic leukemia (n:4), acute myeloid leukemia (n:3), lymphoid leukemia (n:1) and burkitt's lymphoma (n:1). pres was seen after undergoing hsct in 21 patients. the brain edema degree according to specified anatomical regions on fluid attenuation inversion recovery (flair) mri sequence was scored by two radiologists blinded to patients' records. the levels of serum biochemical parameters at onset of symptoms were correlated with score of brain edema degree on mri. serum ldh concentration was statistically correlated with the score of brain edema degree (spearman's rho correlation, r=0.459, p=0.016). no relationship was found between other biochemical parameters and the score of brain edema degree. our results suggest that increased serum ldh as a marker of endothelial dysfunction is the main biomarker for development of brain edema in pediatric pres patients under treatment and after hsct with underlying hematologic and oncologic diseases. objective: gadolinium based contrast agents (gbcas) have been associated with increasing signal intensities in deep brain nuclei on unenhanced t1-weighted brain imaging. until now, most studies have been performed in adults, while results on pediatric patients are sparse. therefore, the aim of this study was to evaluate if there is any difference between signs of gadolinium retention in pediatric and adult patients. in this irb-approved, single center retrospective study, we extracted all patients with at least 5 contrast-enhanced mris archived on pacs between 2009-16. all patients with gadobenate dimeglumine only enhanced mris were reviewed. seventy-six pediatric patients with the most injections and 86 adult patients with the most injections were included in the final evaluation. therapies were documented. t1 signal intensity measurements for the initial and last unenhanced brain mris were performed for dentate nucleus, pons, globus pallidus and thalamus. signal intensity ratios for dentate-to-pons (dnp) and globus pallidus-to-thalamus (gpt) were calculated and correlated with number of injections and time interval as well as therapy. differences between adults and pediatrics were assessed. mean age for the pediatric group was 9.3 years compared to 47.7 years in the adults. no significant difference was found for gender distribution (47 vs. 43% females) and follow up time (3.1 vs. 3 years). there was no difference concerning the signal intensities on first and last mri in children and adults (p=0.81/0.84, respectively). for each additional year of follow-up the change in ratio increases by 0.016 for adults but only 0.002 for peds (p=0.002). comparing therapies, in children a statistically significant difference between patients with and without former radiation was found (p<0.001) while there was no difference in adult patients with and without therapy (p=0.65). children and adults show a similar increase in t1 signal in deep brain nuclei ascribed to gadolinium deposition. in children, radiation and chemotherapy) seem to have a higher influence on gadolinium deposition. this correlation cannot be found in our adult cohort, indicating therapies have no (additional) influence. kearns-sayre syndrome (kss) is a rare mitochondrial dna-deletion syndrome characterized by early onset (<20 years), progressive external ophthalmoplegia and pigmentary retinopathy, often associated with cerebellar ataxia, muscle weakness, bilateral sensorineural hearing loss and cardiomyopathy. pyramidal symptoms may be present in kss, but they are poorly reported in the literature. through this case series, we aim to evaluate the concordance with the imaging patterns proposed by literature, correlating them with clinical and laboratory data, and to investigate possible microstructural damage with diffusion tensor imaging (dti) and magnetic resonance spectroscopy (mrs). we evaluated eight patients (8-19 years of age) with genetically confirmed diagnosis of kss. all pts. were studied with 3t/1.5t mri. in 5/8 pts. the study was completed by mrs and in 7/8 by dti imaging with reconstruction of cortico-spinal tracts (cst) using a 2-rois approach. a t-test comparative study between mean fractional anisotropy (fa) of cst in the 7 kss patients with dti and a group of 4 healthy controls was performed. cst reconstruction in a patient suffering from kss (images a-c), compared to an healthy control (images d-f). the dti study showed significantly reduced fa values, pointing out a possible microstructural damage. the disease showed an mr pattern of mixed white and gray matter signal abnormality, with periventricular and/or subcortical white matter hyperintense lesions, which in 1/8 patient presented a "tigroid pattern" (fig.2 ) three patients displayed a disease extension to the cervical spinal cord. (fig.2 ) dwi images demonstrated restricted diffusivity in almost all lesions (fig.3) , with persistence of low adc values. mrs study documented a high lactate peak in 2/8 pts. and a naa reduction in 5/8 pts; an increment of gsh was noted in one patient (fig.3) . the t-test comparative study of cst showed a significant reduction of mean fa value in kss patients compared to healthy controls (p= 0,004). involvement of the spinal cord (a-c, yellow arrows). comorbidity was suspected in "a" (myelitis). below (d-f): pale nuclei (d, green arrows) and subcortical white matter (e) alterations. right image displays the "tigroid pattern" (purple arrow). mrs showing the presence of a gsh peak, which may suggest an augmented antioxidative activity within the encephalic tissue. below: dwi hyperintensity in many regions of the brain in patients suffering from kss, due to diffusion resctriction. the integration of neuroimaging with clinical data can implement the diagnosis of mitochondrial diseases such as kss. according to our experience, comorbidities can delay the achievement of a correct diagnosis. the finding of an altered signal in the spinal cord of 2/8 pts. may suggest a new possible localization of the disease, while in one patient was referable to myelitis (fig.2, a) the evidence of a "tigroid patter" in should be taken in count in the differential diagnosis with lysosomal disorders. the presence of a prominent gsh peak may represent an augmented antioxidant activity, which may correlate with a more favorable outcome. an involvment of cst can be speculated even if pyramidal symptoms are poorly represented in kss. remotely distractible, magnetically controlled growing rod (mcgr, fig. 1 ) system has been developed to allow for gradual lengthening on an outpatient basis. this allows for safe spinal lengthening with continuous neurologic monitoring and real-time feedback by the patient. this study aims to evaluate retrospectively our ultrasound (us) geometric method and his accuracy compared with the plain radiograph (gold standard) for assessing mcgr distractions. this is a retrospective study that includes patients with early-onset scoliosis undergoing multiple consecutive distractions after mcgr implant. the rods length was measured for with us, for each distraction (3-months interval), and compared with plain radiograph follow-up (1-year interval). all patients included were treated with dual-rod systems. distraction length was monitored by a senior radiologist with us at each visit, one rod at a (2017) 47 (suppl 2):s297-s pediatr radiol time, before and after magnetic lengthening, with our geometric measurement method (fig.2) . low-dose upright two-projections radiograph were taken immediately after surgery and at 1-year intervals and measured by two radiologists (1 and 10 years of experience respectfully) (fig.3) . we compared measurements with the wilcoxon signed-rank test. from january 2014 to october 2016, a total of 5 patients (4 females and 1 male), which diagnoses included mitochondrial encephalopathy syndrome (n=1), spina bifida (n=1), ataxia of unknown cause (n=1), juvenile idiopathic scoliosis (n=1) and trisomy 8 (n=1), with a mean of 10 distractions per patient (standard deviation [sd] ±1,2), were recruited. fifty distractions for each system (95 measurements in total) were performed, targeting different lengths of distraction (from -2.0 mm to +4.6 mm) on each occasion. a total of 21 sets of plain radiographs were taken. from these, 18 sets of data points were used for correlation analysis. the mean distracted length per year on plain radiographs was 10,1 mm (sd ± 3,8 mm) and the mean distracted length on us per 6-months interval was 4,5 mm (sd ± 2,9 mm). excellent correlation was observed between radiographic and ultrasound measurements. in particular, correlation between rx measurements and ultrasound was excellent both for junior (0.001<p<0.005, w=70) and senior radiologist (p<0.001, w=28,5). there were no rod's breaches identified neither in ultrasound or radiographs in this series. the measured changes in rod length between the two imaging modalities were highly correlated. thus, ultrasonography is at least as accurate as radiographs in measuring changes in rod length. our geometric measurement method adds reproducibility to an effective, non-ionizing and lowcost procedure for monitoring distraction of mcgr in children population. refuting child abuse denialistshealing rickets is clearly different from child abuse metaphyseal fracture a.e. oestreich; cincinnati/us objective: child abuse denialists, who testify against the diagnosis of child abuse, often claim that radiographic findings generally recognized by pediatric radiologists as likely due to abusive trauma are instead a consequence of rickets, including healing rickets. in particular, bucket handle transverse bony density at metaphyses are declared by some denialists to be identical to the pattern of healing rickets. i demonstrate by reviewing the details of these different patterns that this is an incorrect declaration. additionally, concave distal ulna margins alone are not a sign of rickets. rickets is radiologically distinct from classic metaphyseal fractures. i reviewed medicolegal documents and published articles by several well known physicians who claim that certain children suspected of having suffered child abuse instead demonstrate rachitic bone disease. their statements and images in support of their opinions are critically reviewed and contrasted with known examples of rickets, including healing rickets. at the physeal region of long bones in rickets, the zone of provisional calcification (zpc) is not calcified and the normal metaphyseal collar shaftward from that zone is not maintained. in metaphyseal fractures from abuse, the zpc and collar are maintained. in early healing rickets, the zone of provisional calcification calcifies first, giving a transverse calcification separated from the already ossified metaphysis. this calcification is different from a bucket handle fracture pattern without signs of rickets. moreover, concave distal margin of the ulna without other signs of rickets is seen in about 20% of normal infants. repeatedly, denialists have testified against the diagnosis of child abuse, claiming rickets in the absence of radiographic evidence -i critique one well known child abuse is a serious diagnosisclaiming by denialists of an alternate diagnosis, such as rickets, when radiographically no rickets is present, should be refuted. a clear understanding of the differences between abuse fractures and rickets is obligatory. when no rickets is seen at other growth sites, including seeing the presence of zones of provisional calcification, rickets is not present. simultaneous multi-slice turbo spin echo: a 2-fold time-saving alternative to conventional tse in mr imaging of the pediatric knee s. benali, a. gholipour, p.r. johnston, s.d. bixby; boston/us objective: simultaneous multi-slice (sms) is a novel iteration of parallel imaging in mri that reduces acquisition time at least two-fold over conventional turbo spin echo (tse) acquisitions. the aim of this study is to determine whether 2-dimensional (2d) sms tse can replace conventional 2d tse in imaging of the knee in pediatric patients without compromising diagnostic quality. this was an irb-approved retrospective study. subjects included all pediatric patients referred for routine 3-tesla mri of the knee between october through december 2016. mri examination consisted of institutional basic protocol with both traditional t2 tse and sms t2 tse in axial and sagittal planes with fat suppression. two anonymized study folders were created for each subject, one containing all basic sequences (basic exam), and one in which t2 tse sequences were substituted with t2 sms sequences (sms exam). two pediatric radiologists independently and blindly reviewed each study and noted presence or absence of 15 pre-determined abnormalities (table 1) . discrepancies between radiologists were settled by consensus. qualitative assessment was performed using a likert scale to evaluate edge blurring, contrast resolution, image noise, and flow artifact. thirty-five subjects comprised the study population (mean age 14.6 years, range 8-20, 26 female, 9 male). diagnostic performance was assessed by comparing findings (table 1) from basic exam to sms exam based on absolute agreement and cohen's kappa statistic. for all findings, the proportion of absolute agreements between basic and sms exam was >0.96 for reader 1, > 0.88 for reader 2, and 1.00 for consensus between readers. kappas for consensus reads were 1.00 on all 15 structures (p< 0.001, lower 95% confidence limit >0.97). for reader 1, kappas were 1.00 for 14/15 structures (p< 0.001) and 0.00 for pcl. for reader 2, kappas were 1.00 for 14/15 structures (p< 0.001) and 0.45 for cartilage defects. paired t-test was used to compare mean likert scores for image quality characteristics. for both readers, sms was preferred for flow artifacts whereas tse was preferred for the three remaining image quality characteristics (p< 0.05). our primary assessment suggests that sms t2 tse is comparable to standard tse in terms of diagnostic performance in the evaluation of the pediatric knee despite modest decrease in overall image quality. the 2-fold decreased acquisition time of sms is a significant advantage which is felt to offset the mild decrease in image quality, particularly as it increases the likelihood that children will tolerate the examination without motion. mri for sacroiliitis in children: panel findings and inter-observer evaluation using standardised reporting k.e. orr 1 , m.j. bramham 1 , s. andronikou 2 ; 1 plymouth/uk, 2 bristol/uk there is little evidence regarding mri for diagnosing sacroiliitis in children with juvenile idiopathic arthritis (jia). the limited literature presents varied opinions but no published recommendations for standardisation of reporting. axial disease in jia responds poorly to conventional first-line treatments but identifying these children using history and examination findings is unreliable. standardised mri reporting (2017) 47 (suppl 2):s297-s pediatr radiol may improve diagnosis and selection of patients in whom newer biologic treatments are indicated. the aim was to use a standardised reporting proforma based on published definitions for recording mri findings in suspected sacroiliitis to evaluate inter-observer agreement and determine the reliability of findings according to specific sequences. ninety-nine sacroiliac joint mris (198 joints) were included, 80 were initial examinations and 19 were follow-up mris. the age range was between 6.6 and 20.3 years (mean age 15.4 years). three readers retrospectively reported all 99 mris using the standardised proforma. 'reader 1' was the study group panel while readers 2 and 3 were specialist paediatric radiology consultants working in the united kingdom. readers were blinded to additional clinical information and other imaging. inter-reader variation was evaluated for the presence of bone marrow oedema, erosions, effusions, ankylosis, sclerosis and enhancement, as well as the presence or absence of sacroiliitis. the quality of mri examinations was evaluated, including presence and adequacy of sequences performed and alignment of the coronal/oblique studies. mri findings were correlated with clinical details and final diagnosis. there is significant variability in sacroiliac joint mri protocols. refinement of these to include only necessary sequences based on inter-reader reliability and reinforcement of good positioning will improve reporting and result in universal standardisation. there is inconsistency in current reporting practice of sacroiliac joint mri in children but increasingly, clinicians rely on imaging to select patients with sacroiliitis and guide appropriate treatment. using a standardised reporting proforma may improve the quality and consistency of reporting. ultrasound-guided steroid tendon sheath injections in juvenile idiopathic arthritis s. peters, d.a. parra; toronto/ca objective: juvenile idiopathic arthritis (jia) is the most common chronic rheumatic disease in childhood. tenosynovitis is one of the manifestations of jia, which can explain the absence of response to treatment when adjacent joints are injected. steroid injection is one of the treatment options for tenosynovitis and it has been shown to be effective in the literature. utilizing ultrasound (us) guidance for injections into tendon sheaths has shown clinical advantage to conventional blind injections in the adult rheumatoid arthritis population. the aims of this study are to: (a) identify tendon sheaths most commonly treated in our patient population with jia referred for steroid injections; (b) describe technical aspects of the procedure; (c) characterize sonographic appearance of tenosynovitis in jia; (d) assess agreement between clinical request and sites injected. this was a 10 year single-center retrospective study ( may 2006 -april 2016 in which we recruited patients with jia referred by rheumatology for us-guided tendon sheath injections. we collected patient demographics, clinical assessment information, sonographic appearance of the tendons and technical aspects of the intervention from the procedure records. we collected data from 308 visits of 244 patients (75% female, mean age 9 years 8 months) with a total of 926 injections. the ankle region was most commonly injected (85%), specifically the tendon sheaths of tibialis posterior (22%), peroneus longus (20%) and brevis (20%). 63% of the procedures were performed under general anesthesia and triamcinolone hexacetonide was used in 97% of the injections. an "out of plane" approach was used in 86% of the interventions and the 15 mhz "hockey stick" us probe was preferred for guidance (86%). we found 2 minor intra-procedure complications without sequelae. the majority of treated sites (92%) showed peritendinous fluid and sheath thickening on us. other findings were increased color-doppler signal and echogenic peritendinous fluid. a strong agreement between clinical request and sites injected was observed and most patients required one visit (78%). us-guided tendon sheath injections are used frequently to treat patients with jia. it is a safe intervention with a high technical success rate. the ankle region, specifically the medial compartment, is the area most commonly injected in this cohort of patients. the most common sonographic finding is peritendinous fluid and sheath thickening. these findings might assist radiologists and rheumatologists to characterize and more effectively manage tenosynovitis in patients with jia. to evaluate the accuracy of the software for automatic bone age (ba) estimation based on deep learning technique, and to validate the feasibility of this system in clinical practice. the software for automatic ba estimation was developed based on deep learning technique using 18,940 left hand radiographs and estimated ba of each radiograph based on greulich-pyle method. ba estimation was done for left hand radiographs of 100 consecutive patients (9 months -17 years; 42 boys and 58 girls) in three methods: (1) ai bone age (assessed by the software), (2) ai-assisted ba (assessed by two radiologists with the assistance of the software), (3) gp atlas-assisted ba (assessed by two radiologists with only gp atlas but the software). the reference ba was determined by two radiologists by consensus. the accuracy of the estimated ba by each method was assessed using concordance rate (%), pearson's correlation analysis, the root mean square error (rmse), and bland-altman plot. reading time for ba estimation by each method was evaluated. ai bone age showed 61% of concordance rate, and a significant correlation with reference ba (r2=0.986, p<0.05). the bland-altman plot of agreement between the reference ba and ai bone age showed the mean difference of -0.20 years (95% limit of agreement, ±1.22 years). rmse was 0.42 years. in reviewer 1, concordance rates were same between both gp atlasassisted ba and ai-assisted ba (72%), and rmse of ai-assisted ba (0.20) was slightly lower than that of gp atlas-assisted ba s353 (2017) 47 (suppl 2):s297-s pediatr radiol (0.23). in reviewer 2, concordance rate was slightly higher in aiassisted ba (60%) than gp atlas-assisted ba (58%), and rmse was almost the same (0.54 in ai-assisted ba, 0.55 in gp atlasassisted ba). the reading time was reduced 20.0% in reviewer 1 and 62.7% in reviewer 2. the software for automatic ba estimation based on deep learning technique showed high accuracy and may enhance work efficiency in ba estimation by allowing radiologists to save reading time and to improve accuracy. temporomandibular joint mri findings in adolescents with primary disk displacement in comparison to those in juvenile idiopathic arthritis j. bucheli, d. ettlin, c. kellenberger; zurich/ch to investigate potential differences of morphology and degree of inflammation in temporomandibular joints (tmjs) affected by primary anterior disk displacement (add) and juvenile idiopathic arthritis (jia). in 18 adolescents (15 female, age 15 ± 2 y), contrast enhanced magnetic resonance images (fig. a) of tmjs with add were retrospectively compared to those of age-and gender-matched controls with jia. morphology of articular disk and bony structures were described. osseous deformity and inflammation were qualitatively scored with progressive 4-grade scales and compared between groups with mann-whitney-u test. mandibular ramus length, measured on gradient echo minimum intensity projection images (fig. b) , was compared between groups and to normal values with independent samples t-test. in the add-group, 31/36 disks were dislocated anteriorly and showed thickening of the posterior band (27/31). in contrast, tmj disks of jia patients were mainly flattened (n=23) and/or centrally perforated (n=12) and rarely dislocated (n=1). tmjs with add showed similar overall grades of inflammation (p=0.39) and osseous deformation (p=0.53) as tmjs in the jia group. while erosions were frequent in both groups (add 25/31; jia 32/36, p=0.55), the mandibular condyle (p<0.001) and glenoid fossa (p<0.001) were less flattened in tmjs with add. in add tmjs, bone marrow oedema was less frequent (p=0.001) and grades of joint enhancement slightly lower (p=0.03), but presence of synovial thickening (p=0.43) and degree of effusion (p=0.87) were not significantly different between groups. mandibular ramus length was not significantly different (p=0.72) between groups, but in both groups clearly decreased compared to mean normal values (p<0.0001). articular disks in tmjs affected by jia are rarely dislocated. surprisingly, tmjs with primary add show considerable inflammatory change including condylar erosions. still, chronic systemic inflammation in jia joints results in considerable higher deformity of the mandibular condyle and the temporal joint surface. observation of the mostly preserved normal shape of the temporal bone may help differentiating primary add from jia. retrospective magnetic resonance imaging (mri) study of 49 consecutive jia patients (35 female, median age 14 y) with at least two consecutive tmj mri examinations ≥ 2y apart and no csi. degree of tmj inflammation was determined on t2-weighted and contrast-enhanced t1weighted fast spin echo images (fig. a) , and degree of osseous deformity on gradient echo images (fig. b) by progressive 4-grade scales (0-3). change of respective grades was assessed with wilcoxon test. mandibular growth was determined by ramus length change and compared to normal values. over a median period of 3.4 y (interquartile range, 2.4 -4.6 y), degree of tmj inflammation improved (p<0.001) with decrease in frequency of grade 3 (4.1% to 0%) and grade 2 (19.4% to 4.1%). inflammatory grades improved both in patients with (n=39, p=0.007) and without (n=10, p=0.02) systemic disease modifying medication. the degree of osseous deformation slightly improved (p=0.04), with decrease in frequency of grade 3 (5.1% to 3.1%) and grade 2 (9.2% to 6.1%), and increase of grade 0 (48% to 54.1%). overall growth rates of mandibular ramus (median, 1.3 mm/y) were not significantly different from normal growth rates (p=0.27) (fig. c) . growth rates of tmjs from patients only receiving non-steroidal anti-inflammatory drugs (median, 1.25mm/y) were not significantly different (p=0.9) compared to patients treated with systemic disease modifying drugs (median, 1.35mm/y). in patients with systemic treatment of jia, both the degree of tmj inflammation and osseous deformity as seen on mri improved at midterm follow-up. normal growth of the mandibular ramus was maintained. these results are in contrast to those from an earlier cohort treated with csi, in which on average deformities deteriorated and growth was impaired. objective: pediatric ileocolic intussusception, ici, is a common abdominal condition for which pediatric radiologists are asked to attempt emergency pneumatic reduction. because of the high success and low complication rates of pneumatic reductions, radiologists are able to make several attempts at reduction in stable patients if the initial enema attempt is unsuccessful. we have observed patients with successful reductions with rather long periods between initial symptoms of ici and performance of the air enema. we hypothesize that successful pneumatic reduction rates are independent of length of symptoms and in stable patients, repeated reduction attempts can be performed with the expectation of successful reduction. we performed an irb-approved retrospective review of all ici with a pneumatic reduction attempt between 2008-2016 at xxx. clinical, imaging and surgical data was reviewed. time to enema was defined as the time from first symptom to first air enema attempt. linear and second order polynomial statistical analysis was performed to assess the relationship between time to enema and enema outcome. results: 66 ici were identified in 61 patients. air enema was successful in 46 ici, 77%. the mean time to enema was 37.5 hours, range 4-168 hours with sd of 42.2 hours for successfully reduced ici and 35.1 hours, range 2-336 hours with sd of 53.9 hours for unsuccessfully reduced ici. surgical resection was required in 4 patients with ischemic bowel including one with an irreducible meckel's diverticulum as lead point. there was no correlation between time to enema and successful reduction, fig 1. no patient with a successful pneumatic reduction of a ici required subsequent bowel resection. conclusions: air enema for ici can be safely performed despite prolonged time to enema with the anticipation of a successful reduction. the lack of correlation of pneumatic reducibility and time to enema suggests that in surgically cleared patients with ici, the pneumatic reduction attempt may not be a true emergency and that repeated attempts at reduction are safe. additionally, though our numbers are small, they suggest that an ici is reducible or not from the beginning and do not "become irreducible" with prolongation of the time to enema. evaluation of splenic stiffness measurements for the diagnosis and the follow-up of portal stenosis after paediatric liver transplantation c. escalard 1 , a. dabadie 2 , s. chapeliere 1 , d. pariente 1 , c. adamsbaum 1 , s. franchi 1 ; 1 le kremlin-bicêtre, paris/fr, 2 la timone, marseille/fr to report our preliminary findings about the role of splenic and hepatic supersonic shear-wave elastography (sswe) in the diagnosis and followup after treatment of portal stenosis in paediatric liver graft recipients. all paediatric liver recipients with portal stenosis treated by the interventional radiology procedure, and who underwent splenic and hepatic sswe pre and post interventional procedures, were retrospectively reviewed. demographics, data about the portal stenosis (delay post transplantation, clinical presentation, initial radiological findings, hemoglobin and platelet counts), ir procedure performed, clinical and ultrasonographic follow-up and spleen stiffness pre and post ir procedure were collected. four patients were included, median age 6,5 years (range 0,9 months to 8 years) and median delay post transplantation 3,9 years (range 1 month to 4.5 years). two patients presented with anemia, associated in one case with progressive splenomegaly. one patient had liver test abnormalities, and one had decreased portal flow found on systematic doppler followup. spleen stiffness was elevated pre-procedure in all 4 patients, from 36 to 65 kpa (normal <20 kpa), and liver stiffness was normal or mildly elevated in all. portal stenosis was successfully treated by ir in 3 patients. spleen stiffness decreased rapidly, ranging from 38 to 53% (figure 1) . however, the size of the spleen remained unchanged. in the last patient, angioplasty of the portal stenosis failed leading to portal thrombosis. spleen stiffness increased on the subsequent ultrasound ( figure 2 ). mr elastography (mre) is a novel imaging technique that provides a non-invasive evaluation of liver fibrosis. the standard sequence used for this purpose on a siemens scanner has been gradient echo (gre). we also implemented echo planar imaging (epi) available as a work-in-progress (wip). our aim is to compare the liver elastogram values between gre and epi in children. after consent from both research and referred clinical subjects, a dedicated mre of the liver was performed on a 3t mr scanner (magnetom® skyra, siemens) with a pediatric mechanical driver over the right upper quadrant. an axial t2 blade with fat saturation, coronal t1 vibe dixon and axial diffusion weighted imaging (dwi) were obtained. elastograms were obtained using both standard gre and epi, in the axial plane. for the gre sequence, 5 different slices were selected and each scanned sequentially. the epi sequence incorporated 5 different slices in just one series. images were post-processed placing regions-of-interest (roi) and measuring the stiffness in kilopascals (kpa). for each sequence and each slice the mean stiffness and then the average of the means was calculated. a spleen elastogram was simultaneously generated, without changing the mechanical driver location, and the mean stiffness was also calculated. increased stiffness was defined as >2.9 kpa in the liver and >3.6 kpa in the spleen. we focused on a technical comparison between the sequences without clinical or histological correlation of findings. we included 15 subjects that had elastogram measurements of liver and 11 of them spleen stiffness on both gre and epi sequences. mean liver stiffness on gre was 2.4 (sd+/-0.71) and on epi was 2.8 (sd+/-1.04), with a pearson's correlation of r= 0.92 (p<0.001). increased liver stiffness was found in 4/15 (26.6%) of the cases in gre and 9/15 (60%) of the cases in epi. mean spleen stiffness on gre was 3.9 (sd+/-1.39) and on epi was 4.8 (sd +/-1.45) with a pearson's correlation of r=0.69 (p= 0.01). epi reported consistently higher values than gre in both liver and spleen stiffness. our preliminary data shows a moderate to high correlation between gre and epi sequences; however, the epi values were higher in both liver and spleen. in the future, larger studies are needed to validate these thresholds and patterns among different sequences. were also reviewed if done. patient's medical & surgical treatment, and clinical progress were also reviewed. active telephone follow-up 3 days after cevus was performed. results: 120 patients giving a total of 240 pelviureteric units were referred for vus study during the study period, with age ranging from 1 month to 7 years old. no contrast-related complication was encountered. except 2 cases with failed catheterization, 108 were investigations of urinary tract infection (uti), antenatal hydronephrosis and congenital anomalies etc., and remaining 10 were follow up studies of known reflux. of all cases of uti, 36 refluxing units were picked up by vus, ranging from grade i to v. of the 36 refluxing units diagnosed by cevus, 17 were missed on mcu, among which 12 were high grade refluxes (grade iii to v) requiring treatment; whereas cevus only missed one grade i refluxing unit detected by mcu. besides, one grade iv refluxing unit identified on vus was under graded by mcu to grade i. regarding patient outcomes, one patient with mcu-missed refluxing unit presented with breakthrough uti on follow up. two refluxing units that were missed on mcu but detected on cevus demonstrated scarring on dmsa. conclusion: cevus is shown to be more sensitive in detecting vesicoureteric reflux than mcu. the fact that mcu-missed refluxes detected by cevus were associated with breakthrough urinary tract infection and scarring on dmsa indicated that the extra sensitivity brought by cevus did translate to clinical significance. difficulty in visualizing low-grade reflux is a potential limitation of this technique. with favourable diagnostic performance and safety profile, cevus can be further applied in this community in the era of radiation reduction. percutaneous transbiliary needle or forceps biopsy in hepatic masses with biliary dilatation a. dabadie 1 , s. franchi 2 , d. pariente 2 ; 1 la timone, marseille/fr, 2 le kremlin-bicêtre, paris/fr hepatic masses with biliary dilatation are rare in children and mainly include rhabdomyosarcoma of the biliary ducts, but also other masses or pseudo-masses compressing the hepatic hilum. in these patients histological diagnosis of the lesion as well as temporary biliary drainage are warranted. the objective of this study is to report our experience in percutaneous transbiliary biopsy performed simultaneously and using the same access as the percutaneous biliary drainage in children with hepatic mass obstructing the biliary ducts. children presenting with a hepatic mass causing biliary obstruction, with need for biliary drainage, were considered candidates for percutaneous transbiliary biopsy of the lesion performed at the same time. the biopsy was performed under ultrasound guidance, through a sheath introduced in the dilated biliary system, using a semi-automatic 16 gauge needle or the transluminal biliary biopsy forceps set (cook medical, bloomington, usa). between 2009 and 2016, four patients were included, three females and one male, median age 5.5 years (range 2.5-11.5). all presented with jaundice and were diagnosed with a hepatic mass with secondary biliary obstruction. percutaneous transbiliary biopsy was performed in all 4 patients using the 16 gauge needle. in one patient, the biopsy did not demonstrate any tumoral cells and a second biopsy was performed using the forceps device through the same biliary access. the samples deemed adequate for analysis by the pathology department in all patients, however the samples were larger when using the needle. a retrospective -prospective study included 62 patients of both sexes (13,72 +/-3,17 y), in a two-year span. patients were divided into two groups according to the used diagnostic method (positivegroup a on us and a1 on mri, with intestine mural thickness above 3mm, and negativegroup b on us and b1 on mri, with mural thickness below 3mm). overall sensitivity and specificity of us and mri in diagnosing ibd was calculated in comparison to pathohistological (ph) findings. us examination showed an average intestinal mural thickness of 4.93 ±1.39mm and 2.7+0.18mm in group a (28 patients) and group b (34 patients) respectively. mri examination showed an average intestinal mural thickness of 6.50±1.45mm and 2,8+0,16mm in group a1 (27 patients) and group b1 (35 patients) respectively. out of 28 patients from group a, 15 (52%) had irregular mural architecture, contrary to group b in which mural architecture irregularities have not been observed. in groups a1 and b1 14 (51.9%) and 2 (5.7%) patients had irregular mural architecture respectively. average length of affected intestinal segment on us and mri was 103mm and 105mm respectively. five patients from group a and four from group a1 had signs of fibrosis. color doppler showed hyperemia in 17 and 22 patients of group a and a1 respectively. transmural signs of inflammation were found in 59% of patients on us, and 61.3% of patients on mri. average longer diameter of mesentery lymph nodes measured by us and mri was 13.29 ±3.74mm and 12.7±5.68mm, respectively. overall sensitivity of us and mri was 88.4% and 92.31% respectively. both us and mri showed a specificity of 88%. us and mri are reliable and compatible methods in diagnosing ibd, with mri being slightly more accurate. us is an extremely valuable and widely available imaging modality in every-day clinical work, both in diagnosing and follow-up of therapy effects in children with ibd. findings in percutaneous transhepatic cholecysto-cholangiography in neonates and young infants presenting with conjugated hyperbilirubinemia d.a. parra, s. peters, j. amaral; toronto/ca objective: conjugated hyperbilirubinemia is a concerning finding in neonates and young infants, biliary atresia (ba) being one of the main diagnostic considerations. ba is a rare disease characterized by fibrosis of the biliary tree. the obliteration of the biliary system leads to cholestasis and ultimately liver parenchymal injury, cirrhosis and death. an early diagnosis of ba along with a kasai portoenterostomy operation significantly improves the long-term prognosis. percutaneous transhepatic cholecysto-cholangiography (ptcc) is one of the options described in the diagnostic algorithm of ba. the aims of this study are to: (a) describe ptcc findings in patients with conjugated hyperbilirubinemia; (b) identify the abnormal patterns encountered that justify further investigations; (c) analyze technical aspects of the procedure. this is a 16 year single-center retrospective study (2000) (2001) (2002) (2003) (2004) (2005) (2006) (2007) (2008) (2009) (2010) (2011) (2012) (2013) (2014) (2015) (2016) in which we recruited patients with the diagnosis of cholestasis (less than 6 months old) referred for ptcc. we collected patient demographics, clinical information, findings in ptcc, post-procedure management and long term clinical outcome. eigthy-nine patients were referred for ptcc in the study period. the procedure was technically feasible and successfully performed in 73 patients (68% male, mean age 2.2 months). forty-one had a pre-procedure hida scan suggestive of ba. fifty-nine patients had an ultrasound-guided biopsy in conjunction with the ptcc and in all of them the cholangiography was performed through a needle placed using ultrasound guidance in the gallbladder. 53% (39) of the patients had a normal ptcc. abnormal patterns encountered were: 1) variable degrees of hypoplastic bile ducts seen in 25%; 2) atretic gallbladder without demonstration of communication with bile ducts seen in 18%; and 3) gallbladder communication with a cystic structure not communicated with the biliary ducts (cystic biliary atresia) seen in 4%. the most common diagnosis in the abnormal group was ba (71%). alagille's syndrome, alpha-1 antitrypsin deficiency and progressive familial intrahepatic cholestasis were other diagnoses in this group. no complications related to the procedure were observed. ptcc is a safe and effective option in the diagnostic algorithm of patients presenting with cholestasis early in life. visualization of the gallbladder is fundamental to perform the procedure. the majority of studies were normal in our patient population preventing further invasive investigations. three types of abnormal ptcc patters were encountered, with ba being the most common diagnosis in this group of patients. to evaluate the additive role of shear wave elastography in the sonographic distinction of biliary atresia from other causes of neonatal/ infantile cholestatic liver disease. neonates and infants with clinical and biochemical diagnosis of cholestatic jaundice were enrolled in our study after obtaining informed written consent from the parents. grey scale, doppler and shear wave elastographic findings were recorded after 4 hours of fasting using aixplorer® ultrasound system (supersonic imagine, aix en provence, france). sedation was not needed during the study. for obtaining elastographic values, linear transducer (4-15hz) was used and after image stabilization a q-box measuring 3mm was placed in the most homogenous vessel free area. the mean of three elastographic values were recorded. hida scan, liver biopsy, intra-operative cholangiogram and histopathological evaluation of resected specimens was done wherever feasible and clinically indicated. the prospectively obtained elastographic values were retrospectively evaluated. eleven of 25 patients included in our study were proven to be biliary atresia (ba) by intra operative cholangiogram and histopathological reports. the diagnosis in the remaining 14 patients included other causes of infantile cholestatic jaundice like infantile choledochal cyst, neonatal idiopathic hepatitis, progressive familial intrahepatic cholestasis, abernathy malformation, cmv hepatitis etc. the elastographic values of ba and non-ba patients were compared. six of 25 infants were younger than 60 days which included four patients with ba and their elastographic values (18.75±2.9kpa) were significantly different from that of non-biliary atresia (7±1kpa) in the same age group (p value <0.05). similarly, for patients aged >60 days also we had a significant difference (p value <0.05) in elastographic stiffness between ba (45.7±11kpa; n=7) and non-ba (19.4±3.6kpa; n=12) groups. the mean echogenic area anterior to right portal vein (earpv) was 4.45 ±0.84mm in ba and 1.47±0.36mm in non-ba group (p value <0.05). the mean gall bladder (gb) length was 1.82±0.26 mm in biliary atresia group in contrast to 3.2±0.26mm in the rest (p value <0.05). the roc plot for earpv and gb length gave a youden index cut off value of >2.7mm (sensitivity 72.7 & specificity 71.4%) and <3.32 cm (sensitivity 100 & specificity 42.9%) respectively. infants with biliary atresia have a significantly higher elastographic value when compared to age matched patients with other causes of neonatal cholestasis. we expect to validate the findings in our ongoing study with a larger sample size. to retrospectively define in a large pediatric population the association between testicular microlithiasis and testicular neoplasia. retrospective multicenter study of scrotal ultrasounds performed between january 2000 and april 2014 in subjects <18 years of age. all unique subject scrotal ultrasound reports from each institution were reviewed for mention of microlithiasis. for subjects with serial exams, the most recent exam performed was included in the analysis. all exams mentioning microlithiasis were reviewed by site-specific investigators to confirm the presence of ≥5 punctate calcifications in the testicle on a single image. the presence of testicular germ cell and stromal tumors were determined for subjects with and without microlithiasis through review of institutional pathology and imaging databases. the risk of testicular neoplasia in the context of microlithiasis was expressed in terms of odds ratios with (a-or) and without adjustment (u-or) for fixed study site (institution) effects by logistic regression. the study population included 37,863 unique subjects with confirmed microlithiasis in 1,097 (2.9%). mean subject age was 11.1±4.7 years for subjects with microlithiasis and 9.1±5.9 years for subjects without (p<0.0001). one hundred thirty-nine subjects (0. this large, multicenter study confirms that there is a significant, strong association between testicular microlithiasis and testicular neoplasia, particularly malignant germ cell tumors. children with microlithiasis have approximately 22x greater odds of having a malignant germ cell tumor than children without microlithiasis. this reinforces the need for a large prospective study assessing the risk of developing testicular neoplasia in children with incidentally identified diffuse microlithiasis. do adc-values reflect renal function or obstruction in children with uretero-pelvic-junction obstruction? p. grehten, a.c. eichenberger, c. kellenberger; zurich/ch the use of diffusion weighted imaging (dwi) in renal mri is increasing. in adults as well as in infants a positive linear correlation between adcvalues and glomerular filtration rate has been demonstrated. the aim of our study was to assess whether renal dwi can provide information on the grade of urinary tract obstruction or renal function in children with uretero-pelvic-junction (upj)-obstruction. retrospective analysis of 19 children (age 3.1+/-4.5y) with unilateral upj-obstruction who underwent pre-and postoperative mri at 1.5t and 6 normal controls (age 6.6+/-4.0y). functional mr-urography and multiple b-value dwi were part of the mr-protocol. renal adc-values were correlated to measures of obstruction and function, and compared between obstructed and non-obstructed kidneys and between pre-and postoperative studies. no correlation was found between mean parenchymal, cortical or medullary adc-values and calyceal transit time (ctt), renal transit time (rtt) and measures of differential renal function (%parenchymal s359 (2017) 47 (suppl 2):s297-s pediatr radiol volume, vdrf, pdrf). there was moderate correlation with absolute parenchymal volume and total kidney volume, and low correlation with pelvic volume. adc-values showed high correlation with age and patient's weight. adc-values normalized for age or weight showed low correlation with rtt and ctt, but no correlation with functional measures. adc-values were not significantly different between obstructed and contralateral normal kidneys (p=0.2-0.9) or between pre-and postoperative studies (p=0.3-1). renal adc is dependent on age and weight in young children and does not correlate with differential renal function. for assessing urinary tract obstruction with adc normative values need to be established. to determine the level of knowledge and awareness of medical staff, medical students and parents concerning possible risks associated with ionizing radiation. a prospective study has been conducted at children's hospital, center for adult's radiology, and medical faculty, by filling out two anonymous questionnaires (questionnaire 1medical staff and medical students, questionnaire 2parents of the children exposed to x-ray based procedures), and it included 254 participants. statistical analysis was performed using the spss 21.0. the majority of examinees assessed their knowledge about ionizing radiation as moderate. knowledge level was statistically significantly higher only in the group of medical students who passed the course of radiology, in comparison to the group of those who have not attended the course yet. only 45% of radiologists and up to 37.5% of pediatricians, pediatric surgeons and anesthesiologists are informed about "image gently" campaign. up to 80% of radiologists, and up to 22% of clinicians, both specialists and residents, are aware of alara principle. over 60% of medical doctors think that diagnostic radiology procedures are very often performed unnecessarily among children, while only 12.5% of parents share this opinion. most of the radiologists and clinicians consider it necessary to inform parents about potentially harmful effects of ionizing radiation, but even though 60-80% of clinicians claim they do inform parents in every-day clinical practice, over 70% of parents affirm that they had never been informed about effects of ionizing radiation before diagnostic procedures were performed on their children. only 26% of pediatric surgeons and pediatricians, but 72.7% of radiologist and 60% of anesthesiologists are concerned that informing parents about ionizing radiation would cause problems in every-day work. nearly 71% of parents claimed that they would not refuse to expose their child to x-ray based diagnostic procedure, after the given information about potential harmful effects. over 70% of radiologists and less than 50% of pediatric surgeons and pediatricians support the initiative to calculate the total effective dose child was exposed to during hospitalization, and place it on the discharge list. between 50% and 85% of pediatricians and pediatric surgeons greatly underestimated the effective doses in ct and fluoroscopy procedures. there are 58-100% of clinicians who are aware that ct increases the risk of carcinoma development. this study showed that general knowledge about ionizing radiation, potential risks and effective doses in pediatric population is poor, and that organized education is required. fluoroscopy in pediatric radiology -how important is an individual impact to radiation exposure of children? j. lovrenski, i. varga; novi sad/rs to determine whether there are differences between different pediatric radiologists and radiology residents in exposure of pediatric population to ionizing radiation during fluoroscopy procedures. a retrospective study has been conducted at the regional children's hospital, and included all the diagnostic fluoroscopy examinations performed within a one-year period. the fluoroscopic data along with the names of pediatric radiologists/radiology residents performing these examinations were retrieved from the evidentiary notebooks, and included: dose-area product (dap), skin dose, and fluoroscopy time. there were 4 radiologists (r1-r4), and 4 radiology residents (r5-r8) involved in fluoroscopic examinations. we found all the fluoroscopic findings in the hospital's data base, which enabled a differentiation between positive and negative findings. statistical analysis was performed using the spss 21.0. a p-value less than 0.05 was considered statistically significant. a total of 191 fluoroscopy procedures in children (mean age 4,5y, 107 males and 84 females) have been performed within a one-year period, most of which were voiding cystourethrograms (vcug) -93, and an upper gastrointestinal (gi) series -79 examinations. radiology residents and radiologists carried out 82 and 109 examinations respectively. duration of fluoroscopy procedures performed by residents (av. 32.5s) was statistically significantly shorter in comparison with duration of fluoroscopy examinations performed by radiologists (av. 53s). dap and skin dose did not show statistically significant difference between these two groups, as well as the number of positive and negative fluoroscopic findings in groups of examinations performed by radiologists and radiology residents. mean dap value ranged from 0.82μgym 2 (r2) to 7.5μgym 2 (r7) when performing vcugs, and from 1.35μgym 2 (r2) to 4.79μgym 2 (r1) for upper gi series. mean skin dose ranged from 14.33mgy (r2) to 151.48mgy (r3) for vcugs, and from 28.66mgy (r2) to 120.54mgy (r4) for upper gi series. mean fluoroscopy time ranged from 11.76s (r2) to 48.5s (r3) for vcug, and from 26.22s (r2) to 125.75s (r3) for upper gi series. statistically significant difference was shown only between radiologists r2 and r3 for dap and skin dose values in performing vcug, and for fluoroscopy time in performing an upper gi series. for all examinations dap and skin dose were statistically significantly higher in the group of positive fluoroscopic findings. this study has shown that exposure of children to ionizing radiation during fluoroscopy procedures significantly depends on radiologist/ radiology resident and the nature of fluoroscopic finding. to evaluate image quality and radiation exposure of non-contrast pediatric chest ct with automated tube voltage selection (atvs), in combination with automated tube current modulation (atcm). non-contrast chest ct scans of 160 children (91 male and 69 female; mean age, 8.7 ± 5.4 years) were analysed retrospectively with regard to radiation exposure and image quality before and after the implementation of an automated tube voltage selection. correlations of volume ct dose index (ctdi vol ) and the effective diameter (edm), before and after the implementation of atvs were compared, and confidence intervals related to the change in correlations with and without atvs were determined using fisher's z-transformation. image quality was assessed by mean signal-difference-tonoise ratios (snrs) in the aorta and in the left principal bronchus with the independent samples t-test. subjective image quality was rated by two pediatric radiologists and a general radiologist on a 10point scale. agreement between the readers was assessed using weighted kappa coefficients. a p<0.05 were considered significant. automated tube voltage selection, in combination with an automated tube current modulation, resulted in optimization of scan protocols, homogeneity of image quality, and reduction of radiation exposure for pediatric patients. advantages and disadvantages of cone beam ct for pediatric interventions l. dance, r.b. towbin, d. aria, c. schaefer, r. kaye; phoenix/us objective: illustrate the advantages and disadvantages of cone beam ct (cbct) as an alternative to conventional ct guidance and an adjunct to angiography. there is a steep learning curve to optimize utilization of cbct. we found that cbct reliably identifies high-contrast lesions. however, the lower dose and decreased penetration of cbct resulted in poorer visualization of low-contrast lesions. also cbct can be degraded by streak artifact from hardware or dense contrast. the relatively narrow field of view can be restrictive for peripherally located lesions in larger patients. however, the anatomic display is adequate for guidance in most instances. these findings are illustrated in a series of cbct-guided cases including pulmonary nodule localization, osteoid osteoma ablation, abc sclerotherapy, renal av fistula embolization, and liver lesion biopsy. the advent of cbct as an adjunct modality in the ir suite has significantly decreased the use of conventional ct guidance and significantly decreased the radiation dose in children. we have found cbct to be a practice changer. the aim of this study is to review our local drl in pediatric fluoroscopy and to compare them to values proposed by pidrl guidelines and recent international litterature. data were prospectively collected on consecutive procedures (750 total) performed from january 2016 to december 2016 on 2 different fluoroscopy units (siemens iconos r200, luminos drf). of each procedure patients data (name, weight and birth date), examination-data (kind of procedure, date, dap [cgy*cm2], total fluoroscopy time, number of images) were recorded. data from micturating-cystourethrography(mcu), barium meal/swallow(bs) and most commonly performed procedures were divided into 4 weight-groups (<10kg,10-15kg,15-30kg,30-60kg) and of each one 75th-percentile was calculated. data were compared to europeandrl and recent literature data (by age:newborn,1-,5-,10years old). weight-groups are considered a representative sample if at least 20-patients per procedure-type and per patient-group are included. our local-drl for mcu are 7(<10kg), 10(10-15kg), 24(15-30kg) and 57(30-60kg). they results to be lower than pidrls values (30, 70, 80, 75) but higher if compared to a previous local survey of 2014 (4, 9, 18, 29) . bs data are 9(<10kg), 32(10-15kg), 28(15-30kg); these data are lower than that of a previous local survey of 2014 (23, 34, 68) . the update of local-drl is helpful in daily practice to identify (and solve) critical issues such as incorrect technique or poor practice with new flat-panel equipment. pidrl guidelines: a review of local drl for pediatric head, thorax and abdomen ct in a italian referral center a. magistrelli, v. cannatà, e. genovese, m. cirillo, r. lombardi, p. toma; rome/it the aim of this study is to review our local drl in pediatric ct and to compare them to values proposed by pidrl guidelines and recent international litterature. data were prospectively collected on consecutive procedures (347 total) performed from january 2016 to june 2016 on a somatom definition flash siemens. of each procedure patients data (name, weight and birth date), examination-data (kind of procedure, clincal question, date, ctdivol16/32 and dlp16/32) were recorded. ctdivo/dlp16 from head ct were divided into 4 age-groups (<4weeks,4weeks-1y,1-6y,≥6y) and of each one 75th-percentile was calculated. ctdivol/dlp32 from thorax (chest, cardiovascular ct angiography) and abdomen+pelvis ct examination were divided into 5 weightgroups (<10kg,10-15kg,15-30kg,30-60kg,>60kg) and of each one 75th-percentile was calculated. data were compared to europeandrl and recent literature data. weight-groups are considered a representative sample if at least 20patients per procedure-type and per patient-group are included. our local drl are substantially lower than that proposed by pidrl guidelines. specifically ctdivol/dlp32 for chest ct are 1/22(<5kg), 1,52/42(5-15kg), 1,83/56(15-30kg), 2,99/113(30-60kg), 6,07/ 239(>60kg) respectively. for cardiovascular ct angiography are 0,71/ 15(<5kg), 1,01/21(5-15kg), 2,44/36(15-30kg), 2,87/90(30-60kg), 13,72/311(>60kg). while for abdomen+pelvis ct are 1,9/47(<5kg), 2,68/83(5-15kg), 3,25/131(15-30kg), 7,77/320(30-60kg), 11,21/ 532(>60kg). data for trunk sere not collected. for head ct local drl are higher in age-group 0 and 1 but lower in other age-group if compared to routine head ct pidrl ones. the update of local-drl allowed us to identify (and solve) some critical issues such as incorrect technique. drl-curve in optimization of pediatric body ct r. seuri 1 , p. laarne 2 , a. nikkola-sihto 3 , k. nygaard bolstad 4 , m.s. perhomaa 5 , a. thilander klang 6 , k. rosendahl 4 , j. ruohonen 3 , e. tyrvainen 7 ; 1 helsinki/fi, 2 tampere/fi, 3 seinäjoki/fi, 4 bergen/no, 5 oulu/fi, 6 gothenburg/se, 7 kuopio/fi objective: diagnostic reference levels (drls) in medical imaging represent valuable tools to study dose optimization in clinical practice. this is particularly important in pediatric computed tomography (ct) as the number of the examinations in many institutions is low. drls are typically given as a percentile point, usually as 75% or 3 rd quartile of the observed distribution of patient dose. in pediatric practice drls are often given for each age-or weight group separately. we present continuous drl-curve as a feasible way to compare dose levels in pediatric body ct. during 2016-2017 a selected group of nordic hospitals collected dose values (ct dose index by volume, ctdi vol , and dose-length product, dlp) from pediatric body ct examinations on children aged 5-16 years. the dose values were imported into a dynamic excel table, previously established by the radiation and nuclear safety authority in finland, stuk (fig 1) . the stuk-table includes a graphic presentation of a continuous drl-curve presented as a function of body weight, and the program automatically calculates a dose curve and compares it to the established reference level (fig 2) . the dose values were easily exported to the excel tables, and the graphic presentation and comparison with an established drl-curve was clear and readily understandable for both radiologists and radiographers. in some of the institutions included in the present study, the weight of the patient was not recorded routinely. this represents a challenge for the use of the drl-curves provided by stuk. the drl-curves provided by stuk were feasible for clinical practice. the automatic calculation of the dose curve and graphic presentation were helpful to interpret the results. the drl-curve also allows relevant comparison even with a smaller number of patients. fifty randomly selected ct chest studies performed over 10 years to assess diffuse lung disease were included in the study sample (25 females, 25 males; mean age 9.9 years + 6.6 years), comprising 9 disorders. two pediatric radiologists and a pediatric radiology fellow blinded to the results of the cts evaluated four subsets of complete chest cts (3 slices, every third slice, every other slice, and all images below the thyroid) and compared the subsets with the entire chest ct, interpreted as the control. accuracy of evaluating the primary diagnosis and determination if significant diagnoses were missed in the reduced slice ct subsets were rendered. we assume linear distribution of dose across the anatomy to estimate dose reduction on reduced slice subsets. most significant findings were present on all reduced slice ct subsets. all relevant findings were present in 100% of subthyroid, 96% of every other slice, 86% of every 3 rd slice, and 50% of 3 regional slice subsets respectively. excluded findings included small foci of ground glass opacity, consolidation, focal mosaic attenuation, and linear parenchymal bands; peribronchial thickening, dextrocardia vs dextropositioning, tree-in-bud opacities, extent of mild bronchiectasis. with the exception of consolidation in 1 of the studies, these findings were not thought to inhibit diagnostic assessment. the underlying diagnosis was correctly identified in most of the subsets: 100% subthyroid and every other slice, 90% every 3 rd slice, and 80% of 3 regional slice subsets. dose is significantly decreased by using any of these methods. while some findings are excluded with increasing gaps between slices, equivalent diagnostic information can be provided on reduced slice ct and can serve as a viable strategy to reduce lifetime radiation dose to children and young adults with diffuse lung disease imaged for routine follow-up. as findings are missed with larger gaps, this strategy should be used with caution in patients presenting with acute symptoms 3. to extrapolate the significance of early diagnosis which will compliment to treatment planning and management. case presentation: types a and b niemann-pick disease are lysosomal storage disorders that result from deficient acid sphingomyelinase activity and lead to the accumulation of sphingomyelin, primarily in tissues of the reticuloendothelial system. type b niemann-pick disease manifestations are hepatosplenomegaly, excess bleeding and bruising, growth retardation, and recurrent respiratory infections. features of hrct include thickened peribronchovascular and interlobular septal thickening, ground-glass opacities. the intermixed regions could be characterized as showing crazy paving, although this is not the predominant pattern. type b niemann-pick disease should be added to the list of clinical entities that can demonstrate crazy paving. our patient is a sevenyear old girl, presented with dry cough and fever. physical examination revealed hepato splenomegaly. radiological work up included abdominal ultrasound examination, which showed mild hepatosplenomegaly. chest radiography revealed diffuse reticulonodular infiltration in both lungs. chest hrct was done for more comprehensive evaluation which showed multilobar bilateral peribronchovascular interstitial thickening and interlobular septal thickening with ground-glass opacities and crazy paving appearance. no honeycomb pattern was seen. no sizable pulmonary nodule or sizable mediastinal lymphadenopathy was seen. no pleural effusion was seen. finding were indicating extensive pulmonary intestitial disease. a corroborative analysis along with lab tests and genetic studies revealed the diagnosis of type b niemann pick disease. 2. the spectra of hrct features including crazy paving pattern may be encountered; though not frequent. hence should be included in the differential diagnosis of crazy paving pattern. blast from the past: lemierre's syndrome in adolescents with sore throat o. kvist; stockholm/se a minor ailment such as a sore throat could prove to be a severe disorder known as lemierre's syndrome. this syndrome mostly affects previously healthy adolescents and young adults and in its classical form should meet four diagnostic criteria; primary infection of the oropharynx, septicemia, clinical-or radiographic evidence of thrombosis of the internal jugular vein (ijv) plus secondary metastatic abscesses. the infection is caused by fusobacterium necrophorum, a species of obligate anaerobe bacteria forming part of the normal human flora. the syndrome should be suspected in any patient with pharyngitis, cervicalgia and pulmonary symptoms. the incidence of lemierre's syndrome decreased dramatically after the introduction of antibiotics but has, of unknown reasons, increased over the past 15 years. we will present four patients diagnosed with lemierre's syndrome in our department during the last 8 years. the purpose of this case report is to raise awareness of this "forgotten disease". of the four patients diagnosed with lemierre's syndrome two fulfilled all 4 criteria while two fulfilled 3 out of 4. (table 1 ). the first two presented at the emergency department with one week's history of a sore throat, left sided cervical lymphadenopathy, erythematous tonsils, leukocytosis and elevated crp. in both cases the clinical condition deteriorated and they were referred to the icu. one developed ards and required initiation of ecmo. in both patients, chest ct revealed multiple pulmonary consolidations with cavitations, findings consistent with septic emboli (image 1,2 and 3). incidentally ct-neck revealed thrombosis in the left ejvand ijv (image 4). ultrasound of the neck veins confirmed the finding (image 5 and 6). blood cultures taken on admission later proved positive to f. necrophorum. the third and fourth case, with similar clinical histories but with a less aggressive development, had positive blood cultures but no thrombosis and vice versa. (table 1 and all four patients recovered and could be discharged with oral antibiotics and anticoagulants. unique teaching points: in conclusion, lemierre's syndrome is less common today thanks to antibiotics but may still occur in previously healthy adolescents and may lead to a fatal outcome. the pediatric radiologist should be aware of typical findings like septic emboli in the lungs and thrombosis in the ijv. unicameral bone cyst associated with secondary aneurysmal bone cyst of clavicle i. dasic, g.j. djuricic, s. ducic; belgrade/rs objective: aneurysmal bone cyst (abc) accounts for 2,5 % of all bone tumors. they are benign but locally destructive lesion of the bone characterized by presence of spongy or multiloculated cystic tissue filled with blood. abcs are metaphyseal, excentric, bulging, fluid-filled and multicameral, and may develop in all bones of the skeleton. most common locations include the proximal humerus, distal femur, proximal tibia, and spine. clavicle is a very rare site for aneurysmal bone cyst with only few cases reported in literature. a 10-year-old boy reported to the university children's hospital for detailed examination of swelling of right shoulder. 2-3 days before admission parents noticed tumefaction of right shoulder. there was no history of trauma or fever. physical examination revealed tumefaction of the right shoulder, in projection of acromial end of clavicle, measuring approximately 8x8cm, which was tender and fixed. the swelling was not hot to the touch, and there was no skin discoloration over that area. regional lymph nodes were not palpable. (fig. 1a) x-ray revealed osteolytic, expansible lesion in the lateral end of clavicle and there was no pathological fracture. (fig. 1b) laboratory analyzes were within normal limits. blood cultures remained sterile. chest x ray and abdominal ultrasound were normal. computed tomography (ct) revealed a thinwalled multiloculate lesion in lateral end of right clavicle. (fig. 2a) there was no extension in the soft tissues on magnetic resonance imaging (mri). mri shows the multiloculate cavities and fluid levels. (fig. 2b) . the open biopsy was done. histopathological examination confirmed the secondary aneurysmal bone cyst on the field of simple bone cyst of clavicle. the clavicle is an uncommon site for bone tumors. review of literature shows clavicle accounts for less than 1 % of all bone tumors. the patient with an aneurysmal bone cyst generally presents with pain and swelling, which may vary in duration from weeks to several years. up to 8 % of bone tumors occur in less than 20 years of age with peak incidence in second decade. radiologically, lesion is lytic and may have a soap-bubble appearance with ballooned distension of the periosteum. the differential diagnosis for aneurysmal bone cyst include giant cell tumor, chondromyxoid fibroma and telangiectatic osteosarcoma. distinction from telangiectatic osteosarcoma is difficult because the conditions have overlapping clinical and radiologic features. the differentiation is made from the histologic features. imaging of glomus tumor of liver in a child (case report) n. tewattanarat, j. srinakarind, j. wongwiwatchai, p. komvilaisak, s. areemit, p. ungarereevittaya, p. intarawichian; khonkaen/th objective: glomus tumors occur preferentially in subcutaneous tissue of fingers and toes, but extremely rare in visceral organs. most cases of the tumors are diagnosed in adults. several cases of glomus tumors in liver have been reported in adults. a literature review, no case of glomus tumor in liver in children was published. therefore, we present clinical, imaging findings of the first case of pediatric patient with glomus tumor in liver and also histopathological features. a previously healthy 11 year-old-girl was admitted with a twoweek history of progressive dyspnea on exertion and vomiting. family history was unremarkable. physical examination revealed hypertension and smooth and firm mass at epigastrium. systolic apical murmur on heart examination was noted. liver function test (2017) 47 (suppl 2):s297-s pediatr radiol showed elevated cholesterol (396 mg/dl). other laboratory tests (complete blood count, blood chemistry, renal and liver function test, coagulation test, hepatitis profiles and alpha-fetoprotein) were within normal limits. echocardiogram found mitral and tricuspid regurgitation and poor left ventricular systolic dysfunction. abdominal mri demonstrated a 12-cm well-defined exophytic hypervascular mass with intratumoral hemorrhage at segment 3/4b of the liver. there were no other suspicious lesions in other organs. the biopsy was done and revealed glomus tumor. patient underwent preoperative embolization and the liver mass revealed decreased size to 8-cm after 1-month follow up with ultrasound. after that, exploratory laparotomy with left lateral segmentectomy was performed. the pathological results showed dilated vascular channels surrounded by uniform neoplastic cells, uniform with round nuclei, fine chromatin, inconspicuous nucleoli, and pale eosinophilic cytoplasm, and well-defined cytoplasmic border. no mitotic figures and necrosis are identified. immunohistochemical (ihc) staining of tumor was positive for cd34, smooth muscle actin (sma) and h-caldesmon. others ihc including ae1/ae3, heppar1, cd31, desmin and myogenin were negative. from these findings, the tumor was finally diagnosed as glomus tumor of uncertain malignant potential due to deep location and large size. primary glomus tumor is a rare entity of liver tumor diagnosed in children. however, it should be considered in the differential diagnosis of a hypervascular liver mass. most of these tumors are benign, however tumor in liver have malignant potential due to deep seated position. therefore, tumor removal with pre-operative embolization should be considered. brain mri in a pediatric patient with linear scleroderma en coup de sabre m. mortilla, a. rosati, e. canale, c. filippi; florence/it objective: linear scleroderma "en coup de sabre" (ecds) is a rare subset of localized scleroderma. affected individuals typically have a characteristic atrophic skin lesion involving the fronto-parietal scalp. the disease usually has a benign course but rare neurologic symptoms can be seen associated: the most common described is epilepsy. intracranial mri findings described in the literature include: focal brain atrophy, calcifications and t2-hyperintense white matter lesions that may demonstrate contrast enhancement. white matter lesions and calcifications are found in the cerebral hemisphere ipsilateral to the skin abnormality. in the literature only a few pediatric cases have been described. a 4yrs. old girl was hospitalized at our institution for evaluation of a lesion of the frontal skin associated to a history of febrile seizures and mri alterations. she presented febrile seizures at the age of 2 on april 2013. on january 2014 parents noted a frontal cutaneous lesion that was defined as "linear scleroderma, port-wine stain type". on november 2014 she performed an mri at another institution showing a diffuse white matter alteration in the left emisphere with focal lesions with high susceptibility and mild contrast enhancement. she was addressed to immunosuppresive therapy with steroids and methotrexate, with steroids stopped after 6 months. a clinical cutaneous improvement was noted. on july 2016 a second mri showed a worsening of the findings. we describe a case of a little girl with ecds with no neurologic deficits or symptoms that shows extensive and progressive neuroradiologic alterations. only a few pediatric cases have been described, but it has to be known that also in absence of symptoms, patients with linear scleroderma should be screened with mri to look for cns involvement in this immune disease. brain mri can also be used to monitor the progression of the disease and the response to therapy. mals is a vascular compression syndrome which symptoms can overlap chronic functional abdominal pain. in mals the proximal part of the celiac artery is compressed by the too low located median arcuate ligament during expiration resulting in hemodynamically significant symptoms. we report two cases with mals diagnosed primarily by ultrasonography. case 1 18-year-old girl was admitted to tartu university children's clinic (tucc) due to recurrent acute epigastric pain episodes with nausea and loss of appetite during 7 years. previous analyses were normal, abdominal uss and gastroscopy did not show any abnormalities. she was referred to paediatric radiology department for doppler us (dus) which showed narrowed proximal celiac artery (ca) with turbulent flow, increased peak-systolic and end-diastolic velocities on deep inspiration and expiration, and positive ca deflexion angle on expiration. superior mesenteric artery (sma) was markedly widened, indicating possible collateral blood-supply due to severe ca stenosis. according us findings mals was suspected. abdominal mra showed proximal ca kinking, stenosis and poststenotic dilatation and confirmed diagnosis. during dsa collateral blood-supply from sma via pancreaticoduodenale arcade (pda) was seen. laparoscopic release of mal resulted in relief of patient's symptoms, she has been pain-free for two years. case 2 16-year-old girl applied to tucc due to recurrent abdominal pain episodes for 2-3 years. usually, pain occurred 2-3 times per week about 15 minutes after the start of intense cycling training or competitions, and passed about 5 minutes resting in squat position. mild mid-epigastric bruit was audible at physical examination. dus showed two-fold increase in expiratory peak-systolic and enddiastolic blood flow velocities compared to inspiratory velocities which indicated to the hemodynamically significant worsening of ca compression by mal during expiration. mra showed proximal ca compression, upward angulation and poststenotic dilatation. preoperative ct-angiography depicted collateral supply via pda. during laparoscopic surgery ca was released by transecting mal and surrounding fibrous tissue. after surgery the girl has been pain-free for one year except single pain episode during intense competition. the diagnosis of median arcuate ligament syndrome should be considered in patients with postprandial abdominal pain that does not have other clearly established etiology. colour doppler us should be the first choice imaging method. to confirm diagnosis in pediatric patients abdominal mra is preferred in our institution, but as mra may still have a tendency to movement artifacts and inadequate spatial resolution for smaller blood vessels, in these two cases mra was followed by cta or dsa. understand the unique predilection of infantile malignancies to metastasize and present as skin-based masses, most commonly lymphoma/leukemia. case presentation: an otherwise healthy 37 day old male presented to dermatology with a pedunculated, friable red glabellar mass (centered between the eyes). first noticed as a flat, bluish lesion at 10 days, its subsequent rapid growth led to an emergency department visit where dermatology diagnosed a hemangioma and initiated propranolol treatment. despite this, the mass continued to grow rapidly, encroaching upon the patient's right eye. the patient was admitted for further workup. an elevated beta hcg, anemia (7.4 mg/dl), and thrombocytopenia (92,000) suggested an alternate diagnosis. an mri and ultrasound led to a percutaneous biopsy; pathology was consistent with choriocarcinoma. pet ct found fdg-avid glabellar, liver and lung lesions. maternal and placental testing was negative for choriocarcinoma. ultrasound demonstrates a hypoechoic hypervascular mass. mri brain demonstrates cutaneous confinement of the solid avidly enhancing glabellar mass. ct shows a peripherally enhancing liver mass with a masslike area of consolidation in the right lung. initial pet/ct demonstrated fdg avid liver and lung metastases with a small focus of residual activity at the glabella consistent with incomplete resection. follow-up pet/ct showed astoundingly rapid re-growth of the glabellar mass and enlargement of the hepatic and pulmonary masses just 12 days later demonstrating the extremely aggressive nature of this cancer. 3month follow-up pet/ct showed significantly decreased size and activity of the metastases consistent with a treatment response. in a series of 208 infants with cutaneous metastases, the following diseases presented with cutaneous involvement (ordered most to least common): leukemia, langerhans cell histiocytosis, neuroblastoma, rhabdoid tumor, rhabdomyosarcoma, primitive neuroectodermal tumor, choriocarcinoma, and adrenocortical carcinoma. pathology slides (2017) 47 (suppl 2):s297-s pediatr radiol unique teaching points: considered one of the fastest growing tumors, infantile choriocarcinoma classically presents with hepatomegaly, anemia, failure to thrive, and precocious puberty between 0 days and 5 months of life. left untreated, the disease is usually fatal within 3 weeks of presentation. a solitary cutaneous metastasis can be mistaken for infantile hemangioma both clinically and radiographically. atypical mri appearance is one important clue that can suggest an alternative diagnosis. pet/ct may be useful for staging and follow-up. a rare case of ovarian juvenile granulosa cell tumor associated with ollier's disease -generalised mesodermal dysplasia p. joshi; pune/in to demonstrate a rare case of mesodermal dysplasia -association of ovarian granulosa cell tumour with enchondromatosis case presentation: two year 8 month old girl presented with precocious puberty i.e thelarche. left hand radiograph showed the radiological age corresponding to chronological age, suggestive of peripheral precious puberty. the patient subsequently underwent a sonography which revealed a pelvic mass probably arising from the right ovary ? sex cord stromal tumour. a mri of the abdomen and pelvis confirmed the pelvic mass and revealed multiple bone lesions in the right hemipelvis -on the side of the tumour she was later operated. hpe of pelvis mass revealed juvenile granulosa cell tumour. ultrasound pelvis images reveal a solid pelvic mass, probably ovarian in etiology mri pelvis also reveals multiple bone lesions unique teaching points: the aim of the poster is to create awareness about this association. the bone lesions should not be mistaken for metastasis juvenile granulosa cell tumour of the ovary (jgct) is a well-known sexcord stromal ovarian neoplasm. ollier's disease is a rare, non hereditary mesosermal dysplasia consisting of multiple enchondromas. the association of granulosa call tumour with asymmetric ipsilateral hemiskeletal distribution may indicate generalised mesodermal dysplasia as there is also association of jgct with maffucci's syndrome, other dysplastic conditions such as microcephaly, facial asymmetry,' and potter's syndrome. review of literature showed 11 previous cases of juvenile granulosa cell tumor associated with enchondromatosis, three associated with maffucci's syndrome, and the rest with ollier's disease goldbloom's syndrome is a paediatric idiopathic disease characterized by transient bone marrow oedema with recurrent crisis of bone pain, periosteal hyperostosis, fever, increased inflammatory markers and dysproteinaemia. a case series of wbmr studies in goldbloom's syndrome is reported and differential diagnosis discussed. case presentation: a 9-year-old female girl was admitted to our paediatric department because of daily crisis of bone pain of the lower limbs, associated with fever spikes, limping and nocturnal awakenings. no history of trauma was reported. laboratory tests showed mild anaemia (hb 8.2 g/dl), thrombocytosis (plt 680000/mmc), increased inflammatory markers (ers 75 mm/h, crp 7 mg/dl), high streptolysine o and dnase-b antibody levels (aso 4280 iu/ml and adn-b 6310 ui/ml, respectively). throat swab was positive for group a β-haemolytic streptococcus (gas). unusual dysproteinaemia, characterized by hypoalbuminemia (2.8 g/dl) with increased a1, a2 and g globulinaemia, was noted. x-ray examinations of both legs resulted normal. wbmri showed markedly delineated, high and homogeneous hyper-hypointensity respectively in stir/t1 of the distal tibialperoneal meta-diaphysis of both legs (fig1a,b). distal metaphysis of femur, humerus, radius-ulna and proximal tibia were also homogeneously mildly hyperintense on stir sequences bilaterally (fig1a). bone biopsy revealed signs of chronic inflammation. infectious and neoplastic diseases were ruled out and the diagnosis of gs with dysproteinaemia seemed conceivable. steroid treatment was started in association with indomethacin, leading to a prompt resolution of the clinical picture within a few days. the follow-up stir total body mri, performed after 10 months, showed the complete resolution of bone oedema. (fig2 a,b) the sock sign is a pathognomonic whole-body magnetic resonance imaging (wbmri) feature of goldbloom's syndrome (gs).it is a well marked, symmetric, homogeneous and high bone marrow hyperintensity, localized both at the distal tibial and peroneal meta-diaphysis, which looks like a pair of socks. objective: left ventricle hypoplasia is generally thought as a part of hypoplastic left ventricle syndrome or aortic hypoplasia. it is estimated that about 15-20 ml/m2 left ventricle volume is needed in order to support systemic circulation. less than that volume generally precludes biventricular repair. however conditions associated with severe preload decrease such as total anomolous pulmonary venous return (tapvr) should be considered in the differential diagnosis. tapvr presenting as hypoplastic left ventricle syndrome is presented in this study. six month old female patient admitted to emergency service with symptoms of fever, dyspnea and coughing. emergency staff started intravenous antibiotic theraphy and from medical records learned that she has been followed for partial anomolous pulmonary venous return (papvr) and atrial septal defect (asd). lung x-rays revealed pulmonary edema. echocardiography was performed and revealed very small left ventricle, papvr and 13 mm wide asd. ecg gated cardiac ct was requested with the prediagnosis of hypoplastic left ventricle syndrome. ct images revealed dilated right cavities, very small left ventricle, pulmonary edema, tapvd and peritoneal fluid plus hepatomegaly. we then retrospectively searched our archive and found she was diagnosed as papvr when she was 10 days old. all the cavities that time, were normal sized. according to these we confirmed our diagnosis as tapvr and hypoplastic appearing cavities due to reduced preload and right chamber dilatation due pulmonary overcirculation. surgical team decided to perform corrective operation and they confirmed our diagnosis unique teaching points: small left ventricle cavity in an infant need not to be due to intrinsic hypoplasia. whenever we experience such a situtation we should search for other reasons of pseudohypoplasia in order to give a chance for corrective surgery instead of palliative procesures. we present a case report of kimura disease, a rare benign chronic inflammatory disease that involves the deep subcutaneous tissues and lymph nodes of the head and neck. we report the case of a thirteen year old male who presented with a right sided facial mass which had been present for two years but had enlarged rapidly in the preceding three months. us and mr were interpreted locally as an arteriovenous malformation. review of these examinations and catheter angiography performed at this quaternary referral centre favoured a vascular tumour. subsequent percutaneous biopsy demonstrated angiolymphoid hyperplasia with eosinophilia and blood tests showed a serum eosinophilia, consistent with kimura disease. us shows a mass consisting of scattered heterogenous foci within the fat with multiple large feeding vessels. contrast enhanced mri demonstrated a solid, homogenously enhancing, mass with multiple vascular flow voids from the right external carotid artery branches. catheter angiography showed tumour blood supply from branches of the right transverse facial artery and distal right ima. the dominant supply arose superficially from the transverse facial artery. kimura disease is a rare chronic inflammatory disorder of unknown aetiology that involves the deep subcutaneous tissues and lymph nodes of the head and neck region, most common in asian men in the third decade and sporadic in the non-asian population. the histopathological and biochemical characteristics are eosinophilic lymphfolliculoid granuloma, increased eosinophils in the peripheral blood and increased ige levels. whilst ultrasound and mri are effective imaging modalities, imaging alone does not allow confident differentiation from malignant lesions and biopsy is necessitated. kimura disease has a benign indolent course with an excellent prognosis following surgical excision although local recurrence has been reported. increased naa: is it surely canavan disease? e. varga, p. barsi, g. rudas; budapest/hu leukodystrophies are a group of rare genetic, metabolic diseases that affect the central nervous system, mainly the brain. each type of them is caused by a specific gene abnormality that leads to abnormal development or destruction of the white matter of the brain. the differential diagnosis are made on the basis of clinical and neuroradiological signs. there are some diseases which show typical changes on mr spectroscopy. we present a case of a 12 year-old boy, who has been investigated due to somatomental retardation and muscle dystrophy since his six months of age. his perinatal period was normal except of a nystagmus visible from his birth. the child has muscle dystrophy, spastic quadriparesis, contractures, scoliosis, truncal hypotonia and ataxia and mental retardation. we started examinations to find out the background pathology of his idiopathic encephalo-myopathy. the brain mri showed a bilateral, symmetrical white matter signal alteration, which referred to some kind of metabolic (2017) 47 (suppl 2):s297-s pediatr radiol disease. the mr spectroscopy revealed decreased cholin and increased naa levels, which are typical of canavan disease. despite of this, the clinical aspects and the location of the involved brain areas were more typical of pelizaeus-merzbacher disease (pmd). the pmd is a genetic disorder, which is originated of the mutation of the proteolipid protein gene (plp1) located on long arm of x-chromosome (xq21-22) . this gene has an impact on growth of the myelin sheath. various types of mutations (deletion, duplication, point mutation, insertion) of plp1 gene lead to various severity of clinical picture. all form of mutations show decreased naa level on spectroscopy, except the duplication of plp1 gene. in connection with our case, we present briefly the clinical and neuroradiological differences between the two entities. magnetic resonance imaging findings in medium-chain acyl-coenzyme a dehydrogenase (mcad) deficiency l. talamanca, d. narese, m.c. rossi espagnet, l. pasquini, d. longo; rome/it we report serial brain magnetic resonance (mri) in a patient with medium-chain acyl-coenzyme a dehydrogenase (mcad) deficiency who developed acute encephalopathy. a 12-months-old girl was admitted in the emergency department of our hospital with sudden onset of acute encephalopathy with drowsiness. baseline laboratory investigations revealed severe hypoglycemia, hyperammonemia, hyperchloremic metabolic acidosis and hyperuricemia. the patient was treated with glucose solution infusion that resulted in a gradual resolution of symptoms. the first brain mri, performed within 6 hours of onset of symptoms showed bilateral symmetric restricted diffusion on diffusion-weighted imaging (dwi) in the middle cerebellar peduncle, nucleus caudatus, putamen and periventricular white matter; the adc map showed reduced diffusivity (fig 1) . the second mri, at 72 hours after the onset, revealed bilateral and symmetric hyperintensity on t2-weighted images in the middle cerebellar peduncle, nucleus caudatus, putamen and periventricular white matter. dwi showed restricted diffusion in both globus pallidus (fig 2) . a single voxel h-mrs study performed by placing a roi in the right nucleus lenticularis revealed increased values of gaba and glutamine (fig 3) . a further mri was performed 4 weeks after the first neuroimaging and indicated widespread atrophy and the appearance of a hyperintense signal in t2-wi in both globus pallidus while dwi did not reveal any remarkable signal abnormality. single-voxel mrs of the same region showed a normalization of gaba and glutamine values. brain mri showed bilateral symmetric restricted diffusion on diffusionweighted imaging (dwi) in the middle cerebellar peduncle, nucleus caudatus, putamen and periventricular white matter; the adc map showed reduced diffusivity the second mri, at 72 hours after the onset, revealed bilateral symmetric restricted diffusion on diffusion-weighted imaging (dwi) in both globus pallidus. a single voxel h-mrs study performed by placing a roi in the right nucleus lenticularis revealed increased values of gaba and glutamine. mcad is an enzyme of the mitochondrial b-oxidation of fatty acids, an essential source of energy for cells during stress. mcad deficiency is the most common genetic disorder of fatty acid oxidation. the clinical manifestation of the disorder is typically precipitated by stress due to fasting, vomiting, fever or muscular exertion and occurs in the majority of cases before the age of 2 with the onset of acute hypoketotic hypoglycemia. clinical features of this decompensated state include seizures and lethargy proceeding to coma and death in the absence of prompt treatment with intravenous dextrose infusion. mcad deficiency usually appears in an acute form and has high morbidity and mortality rates; early diagnosis is therefore extremely important in order to promptly begin treatment and obtain a complete recovery from symptoms. mr can play a significant role in the early diagnosis of the decompensated state of the disease; in our case dwi revealed the presence of lesions with a bilateral symmetric topographic distribution that strongly suggested a metabolic disease leading to acute encephalopathy. a full-term male neonate (3 days old) with external perineal anomalies was referred to our hospital. the physical perineal examination revealed a bifid scrotum containing palpable testis and a normal configured penis located at the bottom of the bifid scrotum. two soft masses of 3 and 2 cm respectively, divided from a cutaneous notch, were located below the bifid scrotum and on the right of the midline. the rear biggest mass was normal epithelized, instead the other one was a rugged pigmented mass, which resembled the scrotum (figure 1 ). there were no additional abnormalities of the external genitalia. the other peduncolar mass, located between the right scrotum and the posterior mass, had fluid content. a mild hydrocele in the right scrotum and a sliding testis on the left side were also revealed. us examination showed a hyperechoic solid tissue, corresponding to the rear biggest perineal mass. the other peduncolar mass, located between the right scrotum and the posterior mass, had fluid content (figure 2) . a mild hydrocele in the right scrotum and a sliding testis on the left side were also revealed. mri also confirmed two perineal peduncolar masses: the biggest and posterior one, was made up by homogeneous fatty matter without contrast-enhancement after intravenous gadolinium injection (figure 3 ). the patient underwent excision of perineal masses and no complications occurred in the surgery. the histopathological examination of the perineal masses revealed two areas with different histological features: the first one was characterized by the presence of smooth muscle bundles dispersed in the dermal collagen, instead the other contiguous area showed abundant mature adipose tissue in the deep dermis and hypodermis ( figure 5 ). at last the rugged swelling mass was definitively diagnosed as as without testis tissue inside, and the rear mass was diagnosed as lipoma. the physical perineal examination revealed a bifid scrotum containing palpable testis. two soft masses of 3 and 2 cm respectively, divided from a cutaneous notch, were located below the bifid scrotum. us examination showed a hyperechoic solid tissue, corresponding to the rear biggest perineal mass. the other peduncolar mass, located between the right scrotum and the posterior mass, had fluid content mri confirmed the presence of two perineal peduncolar masses: the biggest and posterior one, was made up by homogeneous fatty matter without contrast-enhancement after intravenous gadolinium injection. neonates presenting with perineal masses are uncommon. these anomalies can occur isolated or more rarely in combination with other abnormalities such as uro-genital or ano-rectal anomalies or with contiguous subcutaneous tumors. when perineal masses are found, with prenatal diagnosis or during a newborn physical examination, it is important to look for any associated congenital anomalies or subcutaneous tumors by using imaging. to describe and emphasize the significance of the "half-moon" sign in pelvic mri. a 13-year-old adolescent, karate athlete, was submitted with left hip pain, decreased range of movement and asymmetry in thigh circumference. markers for infection or inflammation were negative. frog-leg radiograph was negative for hip effusion, slipped epiphysis and equivocal for a left trochanteric abnormality. mri demonstrated a half-moon pattern of bone marrow edema at the left intertrochanteric area and at the major trochanter, surrounding an apophyseal low-intensity lesion. ap radiograph and limited ct confirmed the presence of a lytic lesion with sclerotic margins, containing calcified chondroid matrix. chondroblastoma was histologically confirmed following excision. mri, coronal stir sequence, demonstrates semilunar-shaped hyperintense area abutting the growth plate and the cortex of the femoral neck, consistent with the half-moon sign. note edema surrounding an apophyseal low-intensity lesion and soft-tissue edema. ct confirms a typical apophyseal lesion with sclerotic margins containing chondroid matrix. unique teaching points: "half-moon" sign refers to a semilunar shape of bone marrow edema at the intertrochanteric area of the hip with its base located at the cortex of the femoral neck. this distribution differs from the distribution of edema in metaphyseal and metaphyseal-equivalent osteomyelitis. "half-moon" sign has been described in patients with stress fractures and osteoid osteomas. to our knowledge, this is the first case of chondroblastoma exhibiting this sign. whenever the "half-moon" pattern of edema is identified at pelvic mri scans, a thorough search for an occult fracture line or a nidus corresponding to an osteoid osteoma or a chondroblastoma is mandatory. mr elastography (mre) is a noninvasive imaging technique that quantitatively measures liver stiffness and provides an estimate of the degree of fibrosis. our aim was to evaluate the feasibility of performing mre using both gradient echo (gre) and echo planar (epi) sequences on siemens scanners. a dedicated mre of the liver was performed on a 3t mr scanner (magnetom® skyra, siemens) with a pediatric mechanical (2017) 47 (suppl 2):s297-s pediatr radiol driver (courtesy of mayo clinic) over the right upper quadrant. an axial t2 blade with fat saturation, a coronal t1 vibe dixon and axial diffusion weighted imaging (dwi) were obtained. elastograms were obtained using both an axial standard gre and a works in-progress (wip) epi sequence. for the gre sequence, 5 different slices were selected and each scanned sequentially. the epi sequence incorporated 5 different slices in just one series. images were post-processed placing regions-of-interest (roi) and measuring the stiffness in kilopascals (kpa). for each sequence and each slice the stiffness mean was measured and then the average of the means was obtained. a spleen elastogram was simultaneously generated, without changing the mechanical driver location, and mean stiffness was also calculated. based on cutoffs in the literature, values were considered abnormal if liver stiffness >2.9 kpa and spleen stiffness >3.6 kpa. our initial experience shows that mre is feasible on siemens scanners using both gre and epi sequences. epi sequences are a promising addition to standard gre. prone versus supine ultrasound positioning for evaluation of urinary tract dilation (utd) in children c. maya 1 , y. gorfu 2 , e. dunn 1 , k. darge 1 , s. back 1 ; 1 philadelphia/us, 2 addis ababa/et objective: ultrasound (us) is used in the initial evaluation and surveillance of utd in children. utd classification systems, including the 2014 multidisciplinary consensus, assess anterior-posterior renal pelvic diameter (aprpd) and calyceal dilation. there is currently no consensus regarding optimal patient positioning-prone versus supine-during us assessment of utd. this study was performed to determine if there is a significant difference in the measurement of the aprpd, presence of calyceal dilation, or resulting utd consensus score obtained between supine and prone positions. two raters retrospectively reviewed renal bladder ultrasounds of patients with utd of one or both kidneys. technically adequate ultrasound examinations of orthotopic kidneys that were imaged in both supine and prone positions were included. those with renal anomalies or prior surgery were excluded. aprpd measurements, as well as central and peripheral calyceal dilation, were documented in both prone and supine positions. a postnatal utd consensus score was assigned to each kidney based only on these features. 146 kidneys (77 left) in 89 subjects had utd in either the supine or prone position. mean age was 0.41 years (range: 0.01 -1.97 y). female to male ratio was 1:3 (21/68). the interclass correlation (icc) of the aprpd between raters was 0.88 and 0.87 in the supine and prone positions respectively (ps<0.001). central calyceal dilation was found in 97/146 supine kidneys and 102/146 prone kidneys by rater 1 and 94/146 supine and 99/146 prone kidneys by rater 2 (kappa 0.92). peripheral calyceal dilation was found in 54/146 supine kidneys and 65/146 prone kidneys by rater 1 and 50/146 supine kidneys and 62/146 prone kidneys by rater 2 (kappa 0.89). as such the results are presented as one. the aprpd tended to be greater when prone with a strong correlation between prone and supine measurements (0.92, p<0.001). the mean difference between supine and prone aprpd was 1.1 mm (p< 2.2). in 15 kidneys, calyceal dilation was seen in the prone position and not supine while 1 kidney had central calyceal dilation only when supine. the utd score differed between supine and prone in 13/149 kidneys, with all but one higher when prone. in 10 other kidneys, the aprpd differed between positions however concurrent calyceal dilation resulted in no change in utd class. as a screening tool, performing ultrasounds in the prone position may help identify more kidneys with utd. further research is needed to determine if these differences are clinically significant. during the evaluation of magnetic resonance enterography (mre), diffusion restriction (dr) has been utilized as a marker for bowel inflammation, but in our practice we commonly see dr in otherwise normal segments of jejunum. the purpose of this article is to assess the dr in normal loops of jejunum on mre and to determine if there is a correlation between dr and luminal distention, age, magnet field strength, and bowel segment location. a retrospective analysis of subjects with a normal mre and normal clinical work up (based on available clinical history, endoscopy reports, serum white blood cell count and inflammatory markers, and stool samples) was performed. the abdomen was divided into 4 quadrants. if available, 2 loops of jejunum were randomly chosen in each quadrant. two radiologists independently evaluated these same loops of jejunum for the following: luminal distension, wall thickness, and enhancement pattern. additionally, the loops were then evaluated for the presence or absence of dr. inter-rater reliability was determined. disagreement was resolved by consensus. presence or absence of dr was correlated with luminal distension, age, magnet field strength (1.5 versus 3 tesla), and abdominal quadrant. one hundred ninety-seven loops of jejunum were evaluated in 39 patients. not all subjects had jejunal loops in all quadrants. sixteen subjects (41%) had jejunal loops with dr for a total of 29 loops. one loop had increased wall thickness and another increased enhancement but both did not demonstrate dr. no other loops demonstrate increased enhancement or wall thickening. for the presence or absence of dr, inter-rater reliability was fair (kappa=0.39). there was no correlation between the presence/ absence of dr in relation to luminal distension, age, magnet field strength, or quadrant location. of the 16 subjects who had a single loop with dr, a 2 nd loop with dr was found in 50%. 14 year old who presented with nausea. mr enterography demonstrates no bowel thickening or abnormal enhancement. a. coronal haste demonstrates the craniocaudal position of the axial diffusion sequence for reference (line). 14 year old who presented with nausea. mr enterography demonstrates no bowel thickening or abnormal enhancement. b. axial diffusion weighted seqeunce (b=800) shows diffusion restriction within loops of jejunum (arrow) within the anterior abdomen. 14 year old who presented with nausea. mr enterography demonstrates no bowel thickening or abnormal enhancement. c. corresponding adc map demonstrates low signal within the jejunal wall consistent with diffusion restriction (arrow). diffusion restriction in normal loops of jejunum on mre was present in 41% of patients. if dr is seen in an otherwise normal segment of jejunum, this can be considered non-pathologic. a patient with a loop of jejunum with dr is likely to have an additional loop of jejunum demonstrating dr. there is no correlation with dr of normal jejunum with luminal distension, magnet field strength, or patient age. our data may help reduce overestimation of disease burden when clinically applied. imaging findings in the newborn with meconium peritonitis that require surgery p. caro dominguez 1 , a. zani 2 , a. daneman 2 ; 1 cordoba/es, 2 toronto/ca objective: meconium peritonitis is a rare condition caused by an in-utero bowel perforation resulting in spillage of meconium into the peritoneal cavity and subsequent calcification. the role of prenatal and postnatal imaging is to identify infants who require surgery. the aim of this study was to evaluate the role of postnatal imaging in meconium peritonitis and to correlate the radiologic and sonographic patterns with the need for surgery. imaging studies in infants with meconium peritonitis performed between 1999 and 2014 at our institution were reviewed separately by a pediatric radiologist, a pediatric radiology fellow and a pediatric surgeon. patients were divided in a surgical and a non-surgical group. clinical, surgical and pathology reports were reviewed to validate the diagnosis. statistical analysis: comparisons between sonographic and radiographic findings and patterns in the surgical and non-surgical groups were performed using unpaired t-test and chi-square. during the study period, there were 37 infants with meconium peritonitis managed at our institution. in the 23 (62%) who needed surgery, the most frequent surgical findings were idiopathic perforation, jejunal and ileal atresia. ultrasound identified more cases with hepatic calcifications, meconium pseudocyst, ascites and pneumoperitoneum than radiography and radiography more cases of small bowel obstruction. ascites identified with ultrasound (p=0.01) [fig 1] and bowel obstruction [fig 2] diagnosed either with ultrasound (p=0.04) or radiography (p=0.01) were associated with the need for surgical intervention. one third of children with meconium pseudocysts (4/12) [fig 3] , did not require surgery. diffuse peritoneal or hepatic calcifications as an isolated postnatal finding were not associated with the need for surgery. both radiography and ultrasonography give valuable information to the surgeon to take the decision for surgery. dilatation of bowel loops and ascites detected postnatally with radiography and/or ultrasound require surgical intervention in children with meconium peritonitis. interestingly, a large proportion of infants with meconium peritonitis can be managed conservatively. 0.17 -17.4) . those included had complete fmru analysis, dti (b=0 and b=400, 20 directions), and upjo configuration in at least 1 kidney. cases with motion artifact (n=9), post-pyeloplasty (n=3) or duplex collecting systems (n=3) were excluded. pelvicalyceal dilation grade (pcd), corticomedullary differentiation (cmd), and functional parameters were included. pyeloplasty following fmru was recorded. dti tractography was reconstructed using a fractional anisotropy (fa) and an angle threshold of 0.10 and 55°, respectively (figure 1) . user-defined regions-of-interest (roi) of the renal parenchyma, excluding the collecting system, were drawn to quantify dti parameters: mean fa, apparent diffusion coefficient (adc), tract length and tract volume. the relationships between dti quantitative parameters and fmru parameters were analyzed. age and adc (roi) (p<0.01, r 2 =0.36), tract volume (p<0.01, r 2 =0.77) and tract length (p<0.01, r 2 =0.60) were positively correlated. age and fa (roi) (p<0.01, r 2 =0.46) were negatively correlated. there was a correlation between fmru parenchymal volume and tract volume (p<0.01, r 2 =0.80), but median volumes were higher on dti (tractography=98.5 cm 3 vs. fmru=60.52 cm 3 ; p<0.01). of the 16 children, 12 had pyeloplasty, 1 had nephrectomy, 2 were managed conservatively and 1 was lost to follow-up. fa was significantly lower in kidneys that went on to have pyeloplasty in comparison to those without pyeloplasty, but the 95%ci and the iqr overlapped (table 1) . the adc, tract length and tract volume were similar between these groups (table 1) . there was no difference between the adc of fa values in kidneys with and without pcd or cmd (p>0.11). linear hierarchical regressions controlling the age did not show a significant relation between adc and cortical or renal transit times (p>0.68), but lower fa values were related to a higher renal transit time (p<0.01, r 2 =0.103). table 1 . quantitative dti parameters between kidneys with and without pyeloplasty following fmru. renal adc, fa, tract volume and tract length change with age but tractography overestimates renal parenchymal volume. there was a tendency towards a lower fa in kidneys that went on to pyeloplasty. otherwise, none of the quantitative parameters evaluated in this study differentiated degrees of upjo. echo-enhanced voiding urosonography (eevus) has become an important imaging tool in urodiagnostics; however, it has been observed that during eevus the premature destruction of ultrasound contrast agent microbubbles might occur. the purpose of this study was to evaluate the possible causes of contrast vanishing during investigations and propose the protocol to avoid false negative results. eevus was performed in 163 children from april to december 2016. sonovue mixed with saline solution in a plastic bottle is applied by continuous flow through the urine catheter. the collected data according to the protocol in this prospective study was completed in 105 children, aged from 2 weeks to 10.25 years. the protocol included general patient information, indication for eevus, duration of eevus in minutes, and the presence of vesicoureteric reflux. extensive data about sonovue were recorded: charge number, expiration date, time since opening, amount of initially administered contrast (ml sonovue/ml saline solution), grading of the initial contrast opacification of the bladder, the need for immediate readministration of contrast (dose), grading of contrast opacification during examination, and the need for readministration of contrast later in the course of the examination (dose). in addition, the data regarding bladder (ratio real/predicted bladder volume, wall thickness, ureter dilatation), saline solution, the size of urine catheter (french), and the type of antibiotic prophylaxis were collected. child observation included grading of crying and muscle stiffness. normal contrast opacification of urinary tract during examination was found in 87/105 children, while in 18/105 (17.2%) the contrast opacification was insufficient. in 12/18 (72.2%) microbubble destruction occurred during the first minute, in 4 (22.2%) in 5 minutes, and in 1 in 13 minutes after the beginning of contrast administration. the reason for unsatisfactory contrast opacification at the beginning of the eevus is probably due to small urine catheter size (25% of children with fr6 catheter had insufficient opacification compared to 13.3% with fr8 in whole cohort), time since the contrast is opened (more than 3 hours in 4 children), and insufficient bladder emptying at the beginning of the procedure. the reason for microbubble destruction later in the course of the examination is bladder overfilling in combination with increased muscle stiffness and strong crying, which led to increased bladder pressure. there was no correlation between the type of antibiotics and microbubble destruction. we should be aware of possible false negative vur results during eevus caused by premature microbubble destruction. patients with fontan-type palliation of univentricular congenital heart disease have elevated central venous pressure due to their passive pulmonary flow. the altered circulation has a negative impact on several visceral organs, and these patients have chronic liver congestion. they are at risk of developing hepatic fibrosis and cirrhosis with potential malignant transformation. these changes can occur from only a few years after fontan palliation, making early detection and grading of major importance. the patchy pattern of hepatic changes makes liver biopsy an unreliable diagnostic tool. magnetic resonance imaging (mri) t1 mapping has been suggested as a technique for non-invasive assessment and quantification of hepatic fibrosis/cirrhosis. the aim of this study was to compare two different t1 mapping sequences of the liver in adolescents with fontan palliation, and in healthy controls. materials: 15 adolescents (15-17 y) with fontan circulation and 7 young healthy adults (18-24 y) were included as a part of an ongoing national population-based study. all underwent mri (1.5 tesla) pre-and post-gadolinium contrast, including two types of t1 mapping of the liver. a 3d t1 volumetric interpolated breath-hold examination (3d vibe) sequence with dual flips with b1 correction and a modified look-locker inversion recovery (molli) sequence. t1 relaxation times (ms) were measured by placing five standardized circular regions of interest (roi) in the mid-section of the liver and one in the spleen (fig 1) . statistical analysis was performed comparing measurements pre-and post-contrast, between sequences, and patients and controls. there was a significant difference in the measurements between molli and 3d vibe with increased values for the latter. within each sequence there were small, but significant regional differences in relaxation times (table 1). the same pattern was seen in pre-and post-contrast images in both groups. there were significantly increased native t1 times on both sequences in all regions in the fontan group as compared to the controls, but not post contrast. t1 relaxation times differ between the t1 mapping sequences, molli and 3d vibe, pre-and post-contrast. t1 mapping of the liver revealed significantly increased native t1 times in adolescents with fontan palliation compared to healthy slightly older controls. these findings suggest hepatic fibrosis/cirrhosis, but may also represent a component of congestion. diagnostic accuracy of ultrasound, computed tomography and wedge portography in the work-up for mesenterico-rex bypass in children with extrahepatic portal hypertension s. toso, r. breguet, m. annoshiravani, s. terraz; geneva/ch to identify the diagnostic accuracy of ultrasound (us), computed tomography (ct) scan and portography (wedge hepatic vein portography or direct portography) in the pre-operative work-up of mesenterico-rex bypass performed for extrahepatic portal hypertension in children. we conducted a retrospective analysis of pre-operative imaging for mesenterico-rex bypass in our tertiary hospital over the last 12 years. we analyzed all patients between the ages of 0-16 years, with extrahepatic portal hypertension necessitating surgical treatment that underwent us, ct and portography. three reviewers independently analysed the patency of the left portal vein, mesenteric vein, splenic vein and the presence of communication between the left and right portal vein on preoperative imaging with correlation to surgical findings. statistical analysis of diagnostic accuracy was performed. eleven patients underwent mesenterico-rex bypass for portal hypertension secondary to portal vein thrombosis. two patients had partial liver transplant. ct with ultrasound correlation was sufficient in responding to the preoperative criteria in 72% (8/11) cases. portography was useful in the 27% (3/11) cases where ct could not respond to preoperative criteria, in particular the presence of left-right communication. there was good inter-rater correlation for each modality and good correlation of findings between modalities. in the majority of cases the use of ultrasound and ct is sufficient for preoperative planning for mesentrico-rex bypass. portography is mandatory in cases with large intra-hepatic cavernoma, where the left-right communication could not be confirmed on ct. contemporaneous clinical data was reviewed where available, and a clinical decision on disease severity and activity on a likert scale made with and without imaging. fifty-three patients underwent mre and bowel us in the specified timeframe (29 male; median age 13.02 years, range 4-16 years). twenty patients had sufficient contemporaneous clinical information to be analysed. inter-observer variability for the imaging scores was assessed using bland-altman plots. where variability was beyond pre-determined limits, the studies were consensus reviewed. mean scores were used for the studies within accepted limits of variability. there was no significant difference between total mre and us scores (wilcoxon signed-rank test z=1.13, p=0.26). at the bowel segment level, there was no significant difference between the mre and us segment scores for the ileum and terminal ileum (wilcoxon-signed rank test, z=0.72, p= 0.472), but significant differences were present between the imaging scores for other bowel segments, with mre identifying more abnormalities. there is a significant positive correlation between mre and clinical consensus scores (spearman's rho=0.598, p=0.0053) and between us and clinical consensus scores (spearman's rho =0.657, p=0.0016). imaging caused a refinement to the original clinical assessment in 8 of the 20 cases, with jejunal and ileal disease the most common reason for 'upgrading' a score and absence of any detectable abnormality on us and mre the most common reason for 'downgrading' a score. we found good agreement between mre and us for total patient imaging scores, ileal and terminal ileal scores. both mre and us scores correlated well with the gold standard clinical consensus, with imaging altering the original clinical decision in 40% of cases. although us detected fewer abnormalities than mr, it correlates marginally better with the clinical consensus, suggesting it is at least equally clinically valuable. background: differentiating between acute osteomyelitis (om) and acute bone infarct (bi) in children with sickle cell disease (scd) is a challenge for clinicians and radiologists, particularly when blood cultures are negative. although bone aspiration is the gold standard test for om diagnosis, it is an invasive procedure and infrequently performed. magnetic resonance imaging (mri) has shown a potential role in differentiating between acute bi and acute om. the goal of this case series is to evaluate the utility of fluid signal on unenhanced fat-suppressed (fs) t1-weighted mr sequence in distinguishing acute bi and om in children with scd. methods: we reviewed a total of 22 children with scd admitted with long bone pain during the one -year study period 2015-2016 attributed to either an acute bi or an acute om. twelve of 22 patients with available bone aspiration, blood culture, and mri data were evaluated for fluid signal, marrow signal and other criteria. of 12 patients, nine patients were diagnosed as acute bi and two patients had acute om and one with coexisting bi and om. the diagnosis was based on the fluid signal on t1 unenhanced t1 fs mr images as compared to aspiration cytology in which eight of nine patients with bi had hyperintense fluid signal on non-contrast t1 fs mr images while one of two patients with om demonstrated hypointense fluid signal. the last patient was diagnosed as a probable coexisting lesion (om&bi) based on a giant well demarcated hypointense marrow signal with an extraosseous hyperintense fluid signal. in acute bi, an abnormal hyperintense subperiosteal or paraosteal fluid signal is frequently observed on unenhanced t1-fs weighted images. this finding was present in the majority of cases in our study population regardless of age, sex or site in the appendicular skeleton. mri fluid signal characteristic on unenhanced t1 fs shows promise as a criterion to differentiate between acute bi and om. role of mri to assess skeletal age in pediatric celiac disease s. bernardo, m. martino, a. laghi, e. tomei; rome/it objective: coeliac children are often subject to weight loss and lower somatic growth rate, compared to healthy children of the same age. the purpose of this study was to asses the feasibility of magnetic resonance imaging (mri) of the hand and the wrist to assess skeletal age and growth delay. we enrolled in our study 39 coeliac children (13 males and 26 females) affected by histological proven coeliac disease, with a chronological age ranged between 5 years and 1 month and 16 years and 4 months (mean age of 10years, +/3 years and 8 months standard deviation). a single mri sequence (t13d se, acquisition time: 1 minute 31 seconds) of the hand and wrist in coronal plane was performed of each patient to estimate the skeletal age. patients' data were compared with a population of normal subjects. the preliminary results showed a delay in skeletal age in children affected by coeliac disease in 85,7% of the simple study, with a delay of maturity of 0.83 years (+/-2,2 years of sd). only 3 children showed advance mri skeletal age when compared to normal subjects. mri of hand/wrist to assess skeletal age may be considered as a reliable indicator of somatic growth. mri, without radiation exposure, can be an used as a diagnostic tool in skeletal delay. it could play an important role in the follow up of coeliac children, after glutenfree diet. the prevalence of metaphyseal injury and its mimickers in otherwise healthy children under two years of age p. eide, å. djuve, r.e. gjøsaeter, k.f. forseth, a. nøttveit, c. brudvik, k. rosendahl; bergen/no objective: metaphyseal lesions in infants and toddlers are believed to have a high specificity for inflicted injury, however, normal metaphyseal irregularities may mimic pathology and lead to overdiagnosis. during the period 2010-2015 all children between 0 and 2 years, seen at the a&e department in bergen (bergen legevakt) due to an injury, and who had radiographs taken, were included. data on previous injury, age, sex and injury mechanism were drawn from the medical notes and pacs archive. all radiographs were reviewed by two researchers and an experienced paediatric radiologist, registering the following: number, site and type of fractures, signs of healing (yes, no), bone structure (normal, pathological) and metaphyseal appearances (shape (normal, metaphyseal collar, metaphyseal irregularity), injury). the study was approved by the institutional review board. six hundred one children (293 girls) between 2 and 24 months of age (mean 17.8 months) were included, of whom 218 (109 girls) had a total of 275 fractures. one hundred eight of the fractures (39.3%) involved the forearm, followed by leg-fractures (59/275, 21.5%) and fractures to the clavicle (37/275, 13.5%). one epiphyseal separation and one metaphyseal lesion (without a history of trauma) were seen. one thousand three hundred twenty metaphysis were analysed, of which 212 (16.1 %) were defined as either irregular (105/1320, 8.0 %) or demonstrating a metaphyseal collar (107/1320, 8.1 %). metaphyseal lesions with a history of trauma did not occur in otherwise healthy neonates and infants under 2 years of age, indicating that this type of fracture has a particular mechanism. metaphyseal irregularities are frequent, particularly around the knee, and should not be mistaken for clms to evaluate whether mri might be used for age estimation, based on greulich-pyle (gp) atlas criteria. 1.5tesla mri of the left hand was conducted in 60 adolescents, and subjectively evaluated by two blinded radiologists. for sequence optimization, coronal mri sequences (t1 tirm, t1 vibe-3d-we, and t1 se) and a left hand x-ray were compared in ten patients (eight male, two female; mean age, 13.5 years). the ages of 50 healthy volunteers (17 s375 (2017) 47 (suppl 2):s297-s pediatr radiol male, 33 female; mean age, 15 years) were assessed from coronal t1 vibe-3d-we. bland-altman plots, intraclass correlation coefficients (icc), and logistic regression models were calculated. coronal t1 vibe-3d-we achieved the best image quality. the correlation between estimated patients' ages on x-ray and mri was high. icc showed high inter-observer agreement (0.95 for x-ray, 0.97 for mri). the estimated age of the healthy volunteers tended to be older than their chronological age. the probability of overestimation was higher in girls than in boys. coronal t1 vibe-3d-we of the left hand is feasible for skeletal age estimation by gp criteria with a high readers' agreement. the likelihood of overestimation of healthy children makes it necessary to develop a new hand atlas representing changes since the 1950s. to assess the relationship between the radiographic findings of metabolic bone disease (mbd) and serum biochemical markers in preterm infants. preterm infants in our neonatal intensive care unit between january 2014 and september 2016 were included. two readers retrospectively reviewed the wrist radiography for grading according to mbd severity. we recorded the levels of alkaline phosphatase (alp) and phosphorous (p) immediately after birth, on the same day of the first wrist radiography (alp-s, p-s), the highest alp levels before the first wrist radiography (alp-hb) and during follow-up (alp-h), and the lowest p levels before the first wrist radiography (p-lb) and during follow-up (p-l). patients were subdivided into four groups according to mbd severity determined by wrist radiography for the first analysis, and were divided into two groups according to mbd presence for the second analysis. one-way analysis of variance with a tukey multiple comparison and the student's t-test were used for statistical comparisons in the two analyses, respectively. a receiver operator characteristic (roc) curve was constructed to determine the optimal cut-off values of the biochemical markers for the radiological prediction of mbd. of the 159 patients, 94, 39, 19, and 7 infants were classified into grades 0 1, 2, and 3, respectively. in the first analysis, alp-s, alp-hb, and alp-h were significantly different between grades 0-1 and 2-3 (all p<0.001). plb was significantly different between grades 0 and 2 (p=0.001) and p-l was significantly different between grades 0 and 2 or 3 (p<0.001 or p=0.001). in the second analysis, alp-s, alp-hb, alp-h, p-s, p-lb, and p-l were all significantly different between the two groups (p<0.001). the roc curve of alp-h showed the largest area under the curve values (0.752, 95% confidence interval=0.676-0.828; p=0.039) for detection of a radiographic change. the optimal cut-off value of alp-h was 473.5 u/l, and the sensitivity and specificity were 81.5% and 47.9%, respectively. the first wrist radiography was obtained at 8.3 ± 5.1 weeks after birth, and alp-h was measured at 6.9 ± 5.3 weeks after birth. the cut-off value of alp for the prediction of abnormal radiological changes in wrist radiography was determined to be was 473.5 u/l. our findings indicate that the highest alp level at around 6.9 weeks after birth could be a valuable predictor of radiological mbd in preterm infants, including those with very low and extremely low birth weights. quantitative grading of tmj synovitis in children with jia-influence of mr-coil, timing after contrast-injection and location of measurements on joint-to-muscle enhancement ratio a. hamardzumyan schmid, c. kellenberger; zurich/ch objective: assessment of signal intensity ratio between joint space and longus capitis muscle on contrast-enhanced mri has been proposed as reliable method across different mr-scanners and protocols for grading temporomandibular joint (tmj) arthritis in juvenile idiopathic arthritis (jia) with a cut-off of 1.55 for diagnosing synovitis. the aim of this study was to investigate potential influences on such enhancement ratios (er). retrospective evaluation of 14 contrast-enhanced mr-studies of 28 tmjs in 7 girls with jia (age 11.3±4.3y) obtained at two occasions with two different coils on a 1.5t scanner. joint-to-muscle er were calculated from signal intensity measurements in different joint compartments, muscles and sequences obtained with varying delay after contrast-injection, and compared with paired sample t-test. er of tmjs without synovitis (n=10) and tmjs with synovitis (n=18), determined by qualitative criteria, were compared to er reported in the literature. superior and inferior joint space to longus capitis muscle er for normal tmjs (2.2±0.9; 2.6±0.7 respectively) exceeded 1.55 in all but one case (figure) and for tmjs with synovitis (3.3±1.1, 3.8 ±1.1) were significantly higher than in 211 cases with synovitis from the literature (2.5±0.8, p≤0001). the same er were higher when obtained with dual-ring coil (3.7±1.1; 4.1±0.9) than with multichannel surface coil (2.2±0.7; 2.6±0.8; p≤0.0002). while er to longus capitis muscle were higher than those to pterygoideus muscle for both coils (p≤0.008), er to pterygoideus muscle did not differ between coils (p>0.2). not considering the timing of the scan, er to pterygoideus muscle were highest in the inferior joint space (1.65 ±0.63), followed by the anterior joint recess (1.52±0.44) and superior joint space (1.49±0.62). comparing images acquired immediately after contrast injection to later images (median delay 11min, range 5-15min), pterygoideus muscle er in the superior (1.2±0.4 to 1.8 ±0.7) and inferior (1.2±0.3 to 2.0±0.6) joint space increased substantially (p<0.0001), while er in anterior recess showed no significant increase (1.5±0.4 to 1.6±0.5, p=0.18). conclusion: joint-to-muscle er are clearly dependent on 1) the signal profile of the mr coil with muscles located further away from the coil providing higher er, 2) the time of image acquisition after contrast-injection with later obtained images providing higher er, and 3) where the joint signal intensity is measured. as these factors need to be accounted for, the described normal and pathologic ranges of joint to longus capitis muscle er cannot be generalised for every mr-system and imaging protocol. integration of 3d c-arm ct images with navigational software provides real-time fluoroscopic guidance during percutaneous interventions in the interventional radiology (ir) suite. a trajectory, drawn from skin entry point to the target lesion on the 3d c-arm ct data, is overlaid on intraprocedural fluoroscopy for real-time needle guidance. this study describes our experience with syngo iguide (siemens) needle guidance software in a range of clinical applications in the pediatric ir suite, including technical success, radiation dose and procedure time. in this irb approved study, all percutaneous interventions performed in the ir suite using syngo iguide over a 3-year period were included. cases were classified by procedure type; for each type, mean effective radiation dose (msv) was estimated using pcxmc program (v2.0.1.3, stuk) and procedure times were evaluated. forty-five patients (25 male, 20 female; mean age: 11±6 years) underwent iguide-assisted interventions including: bone biopsies -35/45 (22 pelvic, 7 lumbar, and 6 lower extremity), intra-articular steroid injections -5/45 (4 sacroiliac, and 1 temporomandibular joint), lumbar punctures -2/45, percutaneous catheter placements -2/45 (cecostomy, and chest tube placement) and bone biopsy with radiofrequency (rf) ablation -1/45. iguide was used in particular for the cecostomy procedure due to high sub-hepatic cecal pole position, and in the chest tube procedure due to the presence of loculated pneumothoraces. all procedures were technically successful. the diagnostic bone biopsy rate was 97.7%. the mean estimated dose and procedure times for each procedure type are listed in table 1 . sonography of neonatal spine (sus) is a simple, non-invasive, quick, relatively inexpensive method to evaluate lumbar spine anomalies in infants less than 4 months of age. unossified posterior neural arches allow beam penetration to obtain high-resolution images of the intra-spinal contents. sus is carried out at the bedside, does not utilize radiation & requires no sedation. linear array transducers with extended field-of-view permit diagnostic sensitivity equal to mri. factors affecting mri resolution like patient movement, pulsation & vascular flow do not affect sus. we use sus as first-line screening test in neonates with lumbosacral cutaneous stigmata & spinal dysraphism (sd) associated syndromes. this was a prospective study approved by the institutional ethics committee. thirty five children (age range of 5 to 15 years) with clinically suspected and complicated pulmonary tb were enrolled in the study. lung mri and ct scan was performed in all the patients. the sensitivity, specificity, positive predictive value (ppv), and negative predictive value (npv) of lung mri in detection of radiological findings that were considered highly suggestive or diagnostic for tb, were calculated, with ct as the standard of reference. lung mri performed equivalent to ct in detection of pleural effusion, mediastinal/hilar lymphadenopathy and lung cavitation with sensitivity and specificity of 100%. agreement between ct and mri in detection of each finding was almost perfect (k: 0.8-1). lung mri was found to be comparable to ct scan for detecting various radiological abnormalities which were highly suggestive for tuberculosis. being a radiation free imaging modality, it has the potential, particularly in children, to replace chest radiographs and ct scan in the coming years. to evaluate differences of myocardial strain assessed by feature tracking using ssfp cardiac mri sequences between pectus excavatum (pe) patients and healthy volunteers. in this prospective study, cardiac mri was performed in 10 pe patients (with a pathologic haller-index above 3.25) and 10 healthy volunteers (5 males and females, respectively; age range 13-30 years) including short-and long-axis cine-ssfp sequences on a 3t scanner. post-examination analysis included standard cardiac volumetry with measurements of the biventricular ejection fractions (ef). additionally, manual biventricular contouring by an experienced radiologist, and subsequent automated strain assessment using dedicated software (circle cvi 42 ®) was performed. longitudinal, radial, and circumferential peak systolic strain and strain rates were analyzed for both ventricles. left-ventricular ef was normal in all patients. five pe patients had a normal right-ventricular ef, in 5 pe patients rvef was slightly impaired (40-44%), all healthy volunteers had a normal rvef. compared with healthy volunteers, pe patients showed a significantly higher apical left-ventricular strain (radial: 53±16.8 vs. 26±8%, p<0.001; circumferential: -23.7±4.8 vs. -15.3±3%, p=0.001) and strain rate (radial: 3.76±1.05 vs 1.71±0.33s -1 , p<0.001; circumferential: -1.92±0.51 vs. -1.08±0.48s -1 , p=0.002). mid right-ventricular strain (radial: 14.4±6.5 vs. 8.2±2.6%, p=0.019; circumferential: -9.7±3.3 vs. -6.4±1.5%, p=0.019) and strain rate (radial: 1.07±0.45 vs. 0.63±0.24s -1 , p=0.015; circumferential: -0.79±0.27 vs. -0.5 ±0.14s -1 , p=0.011), as well as apical right-ventricular strain (radial: 25.6±8.6 vs. 16.5±8.6%, p=0.009; circumferential: -15.9±3.8 vs. -11.1±4%, p=0.019) and circumferential strain rate (-1±0.26 vs. -0.72±0.24s -1 , p=0.029) were also significantly higher in pe patients than in healthy volunteers. left-and especially right-ventricular radial and circumferential strain and strain rate increased from the bases to apices in pe patients. longitudinal strain and strain rate did not differ significantly between pe patients and healthy volunteers. myocardial strain assessed by cardiac mri differs significantly between pe patients and healthy volunteers. as the chest wall deformity usually leads to a compression of the basal parts of the ventricles, higher values of myocardial strain in the mid and apical ventricles in pe patients might indicate a compensation mechanism to enhance especially right ventricular output against sternal compression. to determine the normal range of the haller index (hi) value, and its dependence on the age, sex, and respiratory phase. evaluate the possibility of reduction of the effective dose (ed) of ionizing radiation using a single-slice ct scan technique. the retrospective-prospective study included 165 patients (av. 12y, sd 5y). it consisted of 3 parts. the prospective study included evaluation of ct scans performed by single-slice technique in 30 patients with pectus excavatum both in inspiratory and expiratory phase, without topogram. hi was measured in each patient in both respiratory phases. in retrospective study, 100 ct scans of the chest in children without pectus excavatum were analyzed to determine normal range of hi values depending on the age (0-5y, 5-10y, 10-15y, 15-18y) and gender. the retrospective study also included the analysis of another 30 ct scans in patients who were operated or diagnosed with pectus excavatum. in the latter group of patients the average value of ed of ionizing radiation was calculated, and the values were compared with the average ed obtained using low-dose ct examinations applied in the new protocol (single-slice technique). the normal value of hi was 2.23±0.32. a significant positive correlation between age and value of hi was found. older patients had higher hi (0-5y: 2.01±0.29, 15-18y: 2.35±0.33). results of mann-whitney test did not demonstrate any difference between gender in the observed group, however girls had generally higher hi in all age groups. in the group of patients who were operated/diagnosed with pectus excavatum, hi was 3.34±0.88. the average value of hi in inspirium in children with diagnosed deformity was 2.69±0.76, while in expirium it was 3.49±1.19. only 3/32 (9%) patients had hi value over 3.25 (a boundary value for surgical treatment) during inspirium, while 13/32 (41%) patients had it in expirium, which showed statistically significant difference (p=0.012). single-slice ct technique during the inspiratory and expiratory phase showed average ed of 0.02msv, which is an equivalent of 1 chest xray. it reduced ed more than 20 times in comparison with low-dose whole chest ct. the value of haller index increases with the age and in expiratory phase. we propose the single-slice ct technique without topogram in expiratory phase, as a sufficient and reliable technique in evaluation of haller index and preoperative preparation. mps iva is a lysosomal storage disorder caused by a deficiency of nacetylgalactosamine-sulfatase. main symptom is a systemic skeletal dysplasia. affection of the vascular system has not been described yet. our goal is the analysis of the vascular system in patients with mps iva, based on the example of the aorta. in a retrospective study, 32 patients with mps iva were included. the aorta in its course from 4 th thoracic vertebrae to 10 th was analyzed on the basis of 49 craniospinal mr and 4 ct examinations. to describe the course of the aorta, the area around the vertebral body was devided into 5 equal parts (fig.1) . high buckled arteries in relation to the length of the affected aortal part were indicated as aortal kinking, and a moderate twist in relation to the length of the affected aortal part as aortal tortuosity. results: twelve of 32 patients had an aortal kinking, 10 of 32 patients an aortal tortuosity, 4 of these had moderate and 3 strongly tortuous aortae. seven patients had a normal aortal course, 4 couldn't be analyzed. one patient revealed both, aortal kinking and tortuosity. this study reveals the occurrence of aortic tortuosity in patients with mps iva. we suggest that this complication could be due to glycosaminoglycane deposition in the aortic intima, which may be s379 (2017) 47 (suppl 2):s297-s pediatr radiol associated with an increased vulnerability of the vascular wall. we conclude that the examination of the vascular system should be included in regular follow-up protocols. lung ultrasound in the diagnosis and follow-up of pneumonia in children -is it really as reliable as chest x-ray? s. balj-barbir, j. lovrenski, s. petrović; novi sad/rs to investigate the role of lung ultrasound (lus) both in the diagnosis and follow-up of pneumonia in children. a prospective study was carried out in the regional children's hospital, and included 130 children (av. 2.9y, sd 2.93y) with clinically suspected pneumonia, in whom initial lus and subsequent chest x-ray (cxr) were performed within 24h. the final diagnosis of pneumonia at discharge was used as a reference test to determine the reliability of lus, cxr, clinical and laboratory findings in the diagnosis of pneumonia. children with pneumonia formed a study group, while the control group consisted of children without diagnosed pneumonia. lus finding of subpleural lung consolidation was considered a diagnostic sign for pneumonia. the children with lus signs of pneumonia were followed-up until complete resolution of the lus findings. there were from one to five follow-up lus examinations performed. a final diagnosis of pneumonia was confirmed in 105/130 (80.8%) patients, and 77/105 (73.33%) were hospitalized (av. 10.84, sd 6.19 hospital days). in diagnosis of pneumonia lus, cxr, auscultation, elevated crp, and tachypnea showed sensitivity of 94.3%, 93.3%, 79%, 80% and 32.38%, and specificity of 100%, 92%, 56%, 48% and 100% respectively. lus detected lung consolidations in 99 of 105 children with final diagnosis of pneumonia, and in 84/99 patients lus showed air-bronchogram (figures 1, 2) . lus was superior to cxr in the detection of lung consolidations smaller than 15mm. interstitial lung changes were detected by lus in 50/105 (47.62%) patients, and by cxr in 21/105 (20%). lus and cxr detected pleural effusion in 24/105 (22.86%) and 14/105 (13.33%) patients respectively. mcnemar's test showed no statistically significant difference, and cohen's kappa coefficient showed almost perfect agreement (0.864) between us diagnosis of pneumonia and final diagnosis of pneumonia. during the follow-ups, moderate to substantial agreement between lus and clinical evaluation of the course of the disease was obtained (k=0.406-0.621). in children with complete clinical and incomplete us regression of pneumonia, consolidations of less than 15mm were the most prevalent finding. the average time period until complete resolution of the lus findings was 16.3±10.24 days. children with us detected pulmonary consolidations larger than 50mm were statistically significantly longer hospitalized than others. lung ultrasound in the diagnosis of pneumonia in children is just as reliable as radiography, and should be included in the standard diagnostic protocol. the latest uk nice guidelines for childhood tb contact screening require that a chest x-ray (cxr) be requested only when mantoux or igra testing is positive or if there is a documented reason e.g. clinical concern. nice clarifies the role of cxr in determining treatment choice. we aimed to review cxr referral and treatment in the current climate of european migrant screening. retrospective review of 148 paediatric referrals to the infectious diseases clinic for tb contact screening of whom 125 had cxrs, from october 2009 to august 2015 and correlation with the medical notes. a panel of 3 paediatric radiologists independently interpreted radiographs in the clinical context of tb contact screening and a majority decision was reached. of 148 patients referred to the infectious diseases unit, 125 underwent cxr in addition to a mantoux and igra test. of those 125 cxr's, 20 were reported as having features of pulmonary tb but only 16/20 (80%) were treated as active tb. eighteen of the 105 (17%) cxr's which were reported as having no features of pulmonary tb, were treated as active tb. of those 18, only 6/18 (33.3%) had a clearly documented reason. review of the 125 radiographs (mean age 14 years) by the panel of radiologists noted that all were of readable quality, 20 radiographs were in keeping with a diagnosis of tb, 6 were inconclusive and 99 were normal. the diagnosis of tb was based on lymphadenopathy in 19 and (2017) 47 (suppl 2):s297-s pediatr radiol milliary nodules in 1. parenchymal abnormality was seen in 8 patients [one was the milliary] and effusion was seen in 3. this correlated well with the initial radiology reports of duty radiologists. of the 125 who underwent cxr, referral information was available in 120.109 (90.8%) of these had been appropriately referred because of a +ve mantoux/igra. only 8 out of 11 (72.7%) of those who had cxr despite a -ve mantoux or igra, had a documented reason. according to nice guidelines, 20% of cxr reported positive for tb were not treated for active tb. this may represent a lack of clarity regarding the definition of 'latent tb'. furthermore, only a third of the 17% of patients who received treatment despite negative radiographs had a documented reason. the current migrant crisis requires clarity of x-ray definitions of latent tb to avoid the 20% under-treatment and 17% overtreatment identified in our population. is there really no cardiac problem for performing sports ö.i̇. koska, p. bayindir, h. alper; izmir/tr objective: sudden death in young is a rare condition excluding known anomalies and sudden infant death sydrome; but its consequences are devastating because they are so unexpected. %25 of them occur in a context of sports event. everyday parents of millions of children admit hospitals in order to get permission for participating in sports events. and after physical examination and ecg, physicians are expected to decide such an important issue. however there are a number of silent reasons that may lead to child to sudden death. altough we don't perform ct scans for such indications, we have encountered several cases with abnormalities that can lead to sudden child death and while reporting an examination, awareness of these devastating conditions may be usefull. we searched our database from 01.01.2016 to 01.01.2017 in order to see how often we diagnosed such a silent reason from the ct images that are performed for some reasons. as our center is a tertiary center we have performed 452 cardiac ct examinations in that period that are mainly for excluding or defining complex cardiac anomalies. in order to prepare a pictorial review of unexpected but ct detectable sudden cardiac death reasons, we excluded congenital heart diseases (namely obstructive, shunting or complex anomalies) and ecg detectable arrhytmic diseases. the non arrhytmic, non traumatic reasons for sudden cardiac death excluding congenital heart diseases in the papers are: hypertrophic cardiomyopathy (cmp) (%36), some coronary artery path and origin anomalies (mainly abnormal left coronary artery from pulmonary artery (alcapa), and interarterial path)(%24), increased cardiac mass (%10), dilated cmp (%9), marfan disease (%6), myocarditis (%3), ischemic heart disease (%2). we detected 18 examinations according to our inclusion criteria and selected one cases of each; rca path anomaly, alcapa, dilated cmp, hypertrophic cmp, subaortic discrete membrane and increased cardiac mass for presentation although sudden cardiac death is rare in young children it is a so devastating condition that it must be taken into account for every situation. awareness of silent conditions and active search of them may protect professionals from medicolegal issues and unpleasent results. to describe the spectrum of chest ct scan findings of pulmonary involvement in childhood langerhans cell histiocytosis (lch) and propose a simple scoring system to evaluate the profusion and distribution of the main lung lesions. one hundred forty-six chest ct scans of the 48 pediatric patients with pulmonary lch enrolled in the french national database for lch until april 2016, could be retrospectively and independently reviewed by 3 pediatric radiologists. for each ct scan a semi-quantitative analysis was performed for nodular opacities and cystic abnormalities. the chest was divided in 6 fields (upper, medium and lower field of the left and the right lung) and for each field, both for the nodules and the cysts the score was 0=no lesion, 1= lesions involving up to 25% of the parenchyma, 2=25-50%, 3= 50-75% and 4=more than 75%. of 29 patients evaluated at diagnosis, 18 patients (62%) presented with nodules, 13 patients (45%) presented with cysts and 6 patients (21%) presented a combination of both nodular and cystic lesions. on the initial ct scan, median nodules total score was 1 and median cysts total score was 0. during subsequent ct scans almost the same percentage of patients with nodules (30 patients, 62 %) was found but we observed an increase number of patients with cysts (30 patients, 62 %), median nodules total score was 1 and median cysts total score was 2. the distribution of nodules and cysts was symmetric in the upper, medium and lower fields with an involvement of costo-phrenic angles in 68% of the cases. patients with pneumothorax (13 patients, 27%) had a higher cysts median score (10) than patients without pneumothorax (1). we found alveolar condensation in 12 patients (25%). none of them showed signs of infection at bal examination or any improvement after a treatment with a standard antibiotic therapy while they did show regression under the lch standard regimen of chemotherapy. we proposed a score for semiquantitative analysis of distribution and profusion of nodular and cystic lesions on chest ct scans that can be a useful tool in pediatric population to monitor lung involvement. we found a significant correlation between pneumothorax and a high cysts median score. alveolar condensation could be considered as a possible manifestation of plch in children. lung bases involvement was found in 68% of the cases, representing an important different imaging feature from adult plch. high resolution computed tomography for chronic small airway disease in hiv infected adolescents a.-m. du plessis 1 , s. andronikou 2 , h. zar 1 ; 1 cape town/za, 2 bristol/uk early treatment with antiretroviral therapy (art) and decline in infected infants due to prevention of mother-to-child transmission has resulted in an increase in the population of hiv-infected adolescents. pulmonary disease is common among them. cxr is considered insensitive and terminology inconsistent. therefore, despite concerns related to radiation dose in paediatric patients, high resolution computed tomography (hrct) is the modality of choice for the evaluation of small and large airway pathology, prominent in chronic pulmonary disease. hrct findings are used for prognosis, treatment decisions and defining anatomic extent of bronchiectasis for surgical intervention. the aim of this paper is to demonstrate the spectrum, frequency and extent of airway pathology in hiv-infected adolescents using hrct. a nested sub study was undertaken within the cape town adolescent antiretroviral cohort (ctaac); a prospective, descriptive cohort study of 520 hiv-infected adolescents on art and 120 age matched hiv-s381 (2017) 47 (suppl 2):s297-s pediatr radiol negative controls. hrct was performed on 100 patients who demonstrated abnormal lung function (defined by forced expiratory volume in 1 second (fev1) of <85% and/or low lung diffusion capacity (dlco)). single phase, contrasted multi-detector volume acquisitions were performed from the thoracic inlet to the diaphragms at full inspiration and image data postprocessed to yield thin (0,6mm) and thicker slice images (5mm). three 1mm slices at 3 cm intervals were performed in full expiration. three radiologists interpreted the c t scans independently, with strict imaging definitions, and a majority decision was generated for each finding. ages of patients ranged from between 10 to 17 years with a mean of 14,2. there were 53 females and 47 males with a ratio of 1:0,8. bronchiolitis obliterans was seen in 70% of patients and bronchiectasis was demonstrated in 39%, 12% of which was classified as severe (involving either an entire lobe or more than 50% of at least 2 lobes). there was an absence of lymphadenopathy (a sign of primary tuberculosis (tb)), lymphocytic interstitial pneumonitis (lip) and post tuberculous apical architechtural distortion. miliary tb was identified in a single patient. ground glass was seen in 10% and consolidation in 13%. the majority of hiv infected adolescents with poor lung function demonstrated bronchiolitis obliterans strongly emphasizing the use of hrct for confirming small airways disease. hrct was also useful for demonstrating extent of associated bronchiectasis in 39%. hrct allows classification of patients into those with diffuse small airways disease requiring medical management and those with local disease requiring surgery. background: chronic recurrent multifocal osteomyelitis (crmo) is an autoinflammatory paediatric non-infectious bone disease. presenting symptoms are non-specific, prolonging diagnosis, and leading to deformity, morbidity and unnecessary procedures. imaging is critical to diagnosis, with whole-body mri (wbmri) commonly used in all stages of care. in our institution, a baseline whole-body coronal stir sequence is routinely obtained. aim: to determine lesion distribution and extent on baseline wbmri via retrospective panel review of all patients clinically diagnosed with crmo, and to determine any patterns of involvement that could facilitate earlier radiological diagnosis. method: all patients diagnosed with crmo since december 2009 using published bristol criteria were identified and baseline whole body mris reviewed. the reviewing radiologists were blinded to the original report and previous investigations. each mri was reviewed for focal lesions consistent with crmo. the extent of metaphyseal and epiphyseal lesions was categorized into involvement of thirds of the width of the structure. the wbmri of forty children (28 girls, 12 boys), averaging 12 years (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) (12) (13) (14) (15) (16) (17) (18) were reviewed by the panel using a majority decision rule. three hundred three lesions were recorded, averaging 7.6 lesions (0-26). the tibia was most affected (83 lesions), most commonly the distal tibial metaphysis (25 lesions in 16 patients, 9 bilateral). rib, metatarsals and distal femoral epiphyseals lesions were common. humeral, hand and skull lesions were few. complete metaphyseal involvement, the 'smouldering physis', was most prevalent within the proximal and distal tibial metaphyses. although ranked seventh, the reportedly more common clavicular lesions were the site of the most florid lesions, demonstrating bone expansion and periosteal reactions. two clear patterns of involvement emerged. in patients with clavicular lesions, fewer overall lesions were observed (average 6.4), mainly affecting the axial skeleton and feet. patients with tibial involvement had a higher number of overall lesions (average 9.3), but few lesions outside the lower limbs. only four patients had a both clavicular and tibial lesions. twelve vertebral lesions and four cases of spodylo-discitis were identified; two at t5/6 level, one at t6/7 level, and one involving both t5/6 and t6/7. our series of 40 cases of crmo with baseline wbmri, one of the largest in the published literature, identifies the common sites that should be interrogated for involvement. this study also demonstrates potential as-yet undescribed patterns of skeletal involvement that can be used to aid radiological diagnosis and highlights a non-infective cause for spondylo-discitis. hepatic hemangiomas (hh) are the most common benign vascular tumors encountered in the pediatric population. two main types have been described congenital and infantile, which both display distinct clinical courses and biological features. hemangioendothelioma in differential diagnosis of hh is controversy. recent literature suggests that congenital hepatic hemangiomas present in a focal form, whereas infantile hepatic hemangiomas present in either a multifocal or diffuse form. the goal of this study is to evaluate the features associated with focal and multifocal hh. the records of 45 patients diagnosed with a hepatic hemangioma at a tertiary pediatric hospital from 1994 to 2015 were reviewed. we divided our series into 2 groups: focal or multifocal including diffuse form. clinical endpoints are: age of diagnosis, presence of cutaneous hemangioma, alpha-fetoprotein, thrombocytopenia, cardiac insufficiency. imaging endpoints were echogenicity on us (hypoechoic, hyperechoic or mixed), vessels density on color doppler (<2; 2-5, >5 cm 2 ). presence of calcifications, venous lakes, visible vessels and aortic tapering were assessed on us, ct-scan, mr and angio. treatment and outcome were analyzed. univariate and bivariate analysis were done. this study included 24 focal (9m, 15f) and 21 multifocal (17m, 28f) hh. antenatal diagnosis was done in 6 focal and 1 multifocal hh. focal lesions were associated with the presence of cutaneous hemangiomas (p<0.001) and calcifications (p<0.05). no other variable was significant. conservative management was decided in 12 focal and 11 multifocal hh. steroids (focal: 6, multifocal: 3), steroid-interferon (focal: 1, multifocal: 3), propranolol-steroid (focal:4, multifocal: 4) and surgery in one focal form. complete regression was observed in most lesions (focal: n=19, multifocal n=20), whereas incomplete regression <50% was observed in 4 patients (focal: n=3, multifocal: n=1) and 3 patients in the focal group with the pathology diagnosis of hemangioendothelioma. hepatic hemangiomas demonstrate a wide range of radiological features, with important overlaps in focal, multifocal or diffuse forms. focal and multifocal hh can be seen in congenital hemangioma, infantile hemangioma or hemangioendothelioma. the association of cutaneous infantile hemangioma in the focal group confirmed that the focal lesion can be seen in infantile hemangioma. however, calcifications are more frequent in focal hh which is described in congenital hemangioma or hemangioendothelioma. (2017) 47 (suppl 2):s297-s pediatr radiol symptomatic and asymptomatic meckel's diverticulum in the pediatric population -a retrospective analysis of imaging findings with histopathologic correlation n. abu ata, r. cytter-kuint, j. bar-ziv, i. hadas-halpern; jerusalem/il objective: though meckel's diverticulum (md) is a relatively common gastrointestinal anomaly, many of the symptomatic and most of the asymptomatic md's are often missed on abdominal imaging. our purpose is to describe the radiologic appearance of symptomatic and asymptomatic md in the pediatric population and to correlate the radiologic findings with histopathology. a retrospective analysis of all children diagnosed with md between 1/2004-10/2016 and had relevant imaging (n=38) was done. imaging studies-ultrasound (us), computed tomography (ct) and magnetic resonance imaging (mri) were retrospectively reviewed and evaluated for visualization of md in symptomatic and asymptomatic patients. findings were compared with the preoperative radiology report and the pathology specimen. symptomatic group (n=24): mean age 8.6±6 years, nineteen males. md presented with abdominal pain in 9 patients, small bowel obstruction (sbo) in 6 patients, gastrointestinal bleeding or anemia in 5 patients and intussusception in 2 cases. md was identified in 13 preoperative reports (54.16%) and retrospectively identified in 4 more cases (overall 17 patients, 70.1%). in 7 cases, an inflamed or perforated md were found. in 4 cases, mucosal lining resembling gastric folds was seen. inverted meckel and prominent tissue surrounding the diverticula were seen in 2 patients. in a single case md was misdiagnosed as a duplication cyst. asymptomatic group (n=14): mean age 10.9±6, eight males. md was not mentioned in any of the original reports and only 3 md's were identified retrospectively (21.4%). no mucosal abnormality or irregularity were noted. histopathology: ectopic gastric mucosa was found in 16/24 (66.67%) of the symptomatic patients vs. 2/14 (14.29%) in the asymptomatic group. all 4 patients with sonographic appearance of gastric mucosa had gastric mucosa in pathology (specificity-100%, positive predictive value-100%). md has a variety of radiologic appearances. it can be detected in most of the symptomatic patients but is almost undetectable in asymptomatic patients. heterotopic gastric mucosa is more common in the symptomatic group. inflamed gastric mucosa may have a typical appearance resembling a small stomach, a sign that was not described before and has both high specificity and high positive predictive value for gastric mucosa within a meckel diverticulum. preliminary results on dna damage from ct irradiation in pediatric patients i. dilevska, e. nagy, w. schwinger, e. sorantin; graz/at the increased radiation sensitivity in children, compared to adults, is a well-recognised fact in the pediatric radiology community. the high-dose irradiation induced dna damage has been well established, however the dosages that are clinically used in everyday ct procedures are so low, that it remains unclear how this severely affects the dna and can induce cancer in the long run. the aim of this study is to assess the effects of lowdose ionizing radiation from ct in children by establishing a standardization curve ranging from the high to the low, medically significant ctdi values. this is done by measuring the phosphorylation of the h2ax histone (γh2ax), which is considered a biomarker for quantification of radiation induced dna double-strand breaks (ddsbs). the detection of the γh2ax histone was done by two methods: immunofluorescence microscopy (im), which is an established method for detection and quantification of this histone and the new, promising flow cytometry technique (facs). for this study, 35 leucocyte samples ("buffy coats") were provided by the local transfusion department and these samples were irradiated with a clinical ct scanner (aqilionone, tmse) with values ranging from 2153,6 to 0,16 mgy ctdi. afterwards the samples were processed with both methods. for the immunofluorescence, twostep immunostaining was used with two different antibodies and the cell and foci counting were done on an olympus xc10 microscope, while the facs staining was done with a one-step antibody and the samples were measured on a navios flow cytometer (beckman coulter). comparable results were detected with both methods, with a good correlation between the facs and im, with a linear incline (r 2 >0.95) in the high and in the low dosages from 0,16 to 5.0 mgy ctdi. however, in the samples irradiated with doses below 5.0 mgy ctdi, there seems to be less phosphorylated h2ax than in the native samples. two possible explanations arise: a) low dose irradiation initiates repair that extends to ddsbs occurring naturally or b) low dose irradiation doesn´t cause phosphorylation of this histone, but affects other dna damage and repair pathways. the preliminary findings show that the facs analysis can be used as a valid replacement method for the labor-intensive if method in the higher dosages. however more analysis should be done to establish its accuracy in the lower regions since underlying mechanisms are not clear yet. a. turkaj 1 , g. cicero 2 , e. sorantin 1 , r. coroiu 3 ; 1 graz/at, 2 mesina/it, 3 cluj-napoca/ro there is only little information available regarding imaging procedures in the trauma setting of pediatric patients. such data can serve as a rational basis for running pediatric trauma units. the purpose of the paper is to investigate the number, types and distribution of imaging procedures in a tertiary pediatric trauma center serving children of about 1.2 million inhabitants with approximately 225.000 children. all trauma-caused admission to the emergency room and their imaging procedures were analyzed retrospectively occurring within a period of 15 months. a cohort of 263 patients (m:f=1.9:1) were analyzed. patients were grouped according to age into the following categories: neonates, infants, middle childhood, early adolescence, late adolescence. imaging procedures were classified into plain films, us, ct and mri. furthermore, the time of admission was noted and categorized in time slots 07:00-15:00, 15:00-20:00, 20:00-24:00 and 24:00-07:00. referral cause was divided in domestic accidents, motor-scooter-bicycle accidents, car accidents, sport injuries, falls from height and others. the average age was 9.5 ± 5.4 years, aligned in the following age-groups neonates 13 (5%), infants 68 (26%), middle childhood 42 (16%), early adolescence 58 (22%), late adolescence 82 (31%). a total of 364 imaging procedures were performed, of which 210 plain films (58%), us 81 (22%), ct 69 (19%) and mri 4 (1%). there was a statistically significant difference of imaging procedures due to age in particular in us and ct. regarding the timeslots: 07:00-15:00 ;111 patients (42%), 15:00-20:00; 118 patients (45%), 20:00-00:00; 31 patients (12%), 00:00-07:00;3 patients (1%). domestic accidents were the leading referral cause with 82 cases (31%) prevailed age groups were infants and middle childhoods corresponding for more than 75%. motorscooter/bicycle accidents accounted for 51 cases (19%) of which most were early and late adolescence (more than 85%), s383 (2017) 47 (suppl 2):s297-s pediatr radiol sport's accidents 38 (14.4%) equally shared among middle childhood, early and late adolescences. car accidents 37 (14.0%) cases and fall from height 22 (8,3%) did not show any prevalence according to the age groups. for the first time detailed data about imaging procedures at the emergency room for pediatric patients are now available. over half of the admissions (55%) occur outside regular work hours thus representing a challenge for the staff in duty and this fact should be considered in working schedules. due to strict interdisciplinary developed diagnostic pathways the number of ct examinations was reasonable low. head ct in a regional children's hospital without mri -effective doses and justification of clinical indications j. lovrenski, n. milenković; novi sad/rs to calculate effective doses (ed) for pediatric head computed tomography (ct), to determine the most common referral diagnoses, and the share of normal and pathological ct findings. a retrospectiveprospective study comprised all the children with performed ct examination (16-slice scanner) within a one-year period. pediatric ct protocols were used. the values of ed for head cts were calculated based on the two different models (shrimpton's and icrp publication 103). average ed for different age groups was expressed as the number of chest x-rays (cxrs) (1cxr 0.02msv). the most common non-traumatic referral diagnoses for head cts were determined, as well as percentage and type of pathological ct findings. a share of pathological ct findings was also determined for trauma as a referral diagnosis. head cts were represented with 649 (71%) in total number of 924 ct examinations within a one-year period. the different calculation models have shown the difference in ed values of up to 20.5%. eds for head cts were equivalent of 66 (15 years of age and older) to 140 (younger than 3 months of age) cxrs for one sequence of scanning. the most common non-traumatic referral diagnoses for head cts were: loss of consciousness, epilepsy, headache, convulsions, and vertigo. in this group of 273 patients, 86% of completely normal ct findings were found. pathological findings in this group consisted of the patients with the most common non-traumatic referral diagnoses were as follows: cortical atrophy (15 patients), arachnoid cyst (10), ischemia (6), porencephalic cyst (3), agenesis of the corpus callosum (1), chiari malformation -type i (1), open-lip schizencephaly (1), and tumor of the posterior cranial fossa (1). most common incidental, extracerebral pathology discovered included sinusitis and otomastoiditis. in patients with trauma as referral diagnosis, the share of pathological ct findings was 59.5%. it is necessary to get clinicians familiar with the extent of ionizing radiation that children are exposed to during the head ct examinations. a more careful selection of children for head cts is necessary in an every-day clinical practice, especially for patients with non-traumatic referral diagnoses. diffuse and symmetric diffusion restriction involving the white matter of the brain in patients with neonatal seizures j.-y. hwang 1 , y.j. lee 2 , y.-w. kim 2 ; 1 yangsan-si, gyeongsangnam-do/ kr, 2 yangsan-si/kr this study aimed to evaluate magnetic resonance (mr) imaging findings in patients with neonatal seizures focused on the diffuse white matter lesions on diffusion weighted image (dwi) in addition to clinical manifestations. a total of 55 neonates aged less than 1-week old underwent brain mr imaging for evaluation of neonatal seizures between november 2008 and december 2016. among them, 12 patients showed diffuse and symmetric pattern of high signal intensity on dwi. clinical, laboratory, and mr images were analyzed retrospectively. nine patients were males and three patients were females. patient age was 5.2 ± 0.8 days (range, 3-6 days). all the patients were born at full term. the most frequent month of the hospital visit was march (n=4) and january (n=3). eight patients showed generalized clonic seizure and four patients showed partial clonic seizure. stool viral test was performed in nine patients. among them, five patients were positive for the rotavirus and one patient was positive for the astrovirus. nine patients underwent cerebrospinal fluid analysis, however, all showed negative results. mr imaging was performed at 2.2 ± 1.6 days after onset of seizures. diffuse and symmetric diffusion restriction were distributed along the cerebral white matter tracts and both thalami (fig 1) accompanied with high signal intensity on either t2-weighted images or on the fluid-attenuated inversion recovery (flair) sequence. multiple foci of high signal intensity on t1-weighted images at the centrum semiovale that was affected on dwi were also observed. follow-up period was 11.3 ± 9.6 months (range, 1.8 -30.9 months) and developmental delay was encountered in three patients. six patients underwent follow-up mr imaging at the age of 8.4 ± 4.2 months (median, 8.5 months; range, 3.7-13 months). five patients showed volume loss in cerebral white matter on both sides of the brain and four patients showed high signal intensity of the periventricular white matter on either t2weighted images or flair sequences (fig 2) . myelination delay was not observed in follow-up mr images. diffuse and symmetric diffusion restriction involving the cerebral white matters can be seen in patients with neonatal seizures on mr imaging. our study shows that rotavirus is commonly encountered, but not exclusively detected in these patients. nevertheless, viral infection-associated encephalopathy should be considered when a patient is presented with characteristic clinical and mr findings. whole body mri on diagnosis and follow-up of neurofibromatosis type 1 d. grassi, v. tostes, e. caran, h.m. lederman; sao paulo/br demonstrate that whole body mri is effective on showing neurofibromatosis type 1 involvement of different regions of the body not known by the clinicians. review of 41 patients with neurofibromatosis type 1 (nf1) who underwent whole body mri throughout their follow-up with the majority of them had only brain and spine imaging studies. it was possible to demonstrate that whole body mri provides an overview of nf1 systemic manifestations and neurofibroma's extension beyond the clinic expectation. despite being rare, sarcomatous degeneration was suspected when there was any difference on the characteristics of the neurofibromas. whole body overview where its possible to see the neurofibroma's extension in right cervical region, scoliosis and multiple plexiform neurofibromas. only the biggest neurofibroma was detected by clinical exam. however it is possible to identify two others neurofibromas. whole body view of multiple plexiform neurofibromas. whole body mri is a radiation-free exam and it is useful on the diagnosis of nf1 and on patient's follow-up. it provides an overview of the systemic s385 (2017) 47 (suppl 2):s297-s pediatr radiol involvement and neurofibroma's extension beyond the clinical expectation. during patients follow up, it could also show tumor's characteristics modification, which was considered as a possible sarcomatous degeneration. accuracy of non-radiologists and lay-persons for identifying children with cerebral cortical atrophy from 'mercator map' curved reconstructions of the brain s. vedajallam 1 , a. chacko 1 , s. andronikou 2 , e. simpson 2 , j. thai 2 ; 1 east london/za, 2 bristol/uk objective: background: communication of cortical brain atrophy in children with term hypoxic ischaemic injury (hii) to parents and the legal fraternity contesting compensation rights can be very difficult using text and standard cross-sectional images. when demonstrating the cortex in hii, a single image of the brain surface, much like the way a map of the earth is derived from a globe, can be generated from curved reconstruction of coronal magnetic resonance imaging (mri) scans i.e. a mercator map. lay people's ability to identify abnormal scans from such maps without prior training requires evaluation before routine use. aim: to determine the sensitivity and specificity of lay people in detecting abnormal brain scans through review of mercator flat-earth maps of the brain, without prior training. ten mercator map images were provided to 100 participants with a distribution of 5 hii, 1 cortical dysplasia and 4 reported normal. participants were required to identify abnormal scans. sensitivity and specificity overall and for sub-groups were derived by averaging true positives and negatives; false positives and negatives. the results show a strong ability for lay-people to identify normal versus abnormal mri brain studies using mercator maps. the sensitivity and specificity in this group is 67% and 73% respectively. non-radiologist physicians and radiographers performed slightly better than lay people as expected. radiologists of course had very high sensitivity and specificity of 86% and 100%. the mercator map is therefore a viable tool in the communication of complex mr imaging to the lay-person. safety and efficacy of sphenopalatine ganglion blockade in childreninitial experience l. dance, c. schaefer, d. aria, r. kaye, r.b. towbin; phoenix/us objective: sphenopalatine ganglion (spg) blockade is known to be a safe and effective migraine headache treatment among adults. this paper will report the initial experience in the pediatric population with spg blockade. one hundred thirty-three procedures were performed in 85 patients ages 7 to 18 from february through november 2015. pre-intervention headache scores were recorded on a scale of 1 to 10. the procedure was performed supine with neck in hyperextension. anesthesia of the bilateral nares was accomplished with lidocaine spray and gel. contrast was injected using a sphenocath confirming catheter position. 4% lidocaine was injected. patients remained supine with neck in hyperextension for 10 minutes. post-intervention headache scores were recorded. mean pre-treatment score of 5.55 decreased to 3.28 post-treatment (δ2.27, 95% ci 1.34-3.20, p<0.0001). there were no complications. spg blockade is a safe and effective treatment for migraine headaches in children which results in decreased reliance on intravenous drug therapy. orbital masses represent a spectrum of benign and malignant lesions in children that can be challenging to diagnose and treat. imaging plays an important role in diagnosis, due to a potentially limited clinical examination and risks associated with biopsy. mr imaging is a powerful tool for imaging the orbit, due to the excellent tissue contrast it provides. yet conventional mri has a limitation in discriminate the benign from malignant lesions. diffusion-weighted imaging (dwi) is non-invasive rapid technique uses the water diffusibility to produce contrast among different kinds of tissues. our propose was to assess the role of dwi and calculated apparent diffusion coefficient (adc) values in characterization of the pediatric orbital masses regarding benignancy or malignancy. one hundred and thirty patients with recently diagnosed orbital masses and who underwent preoperative conventional mri and dwi were included in this study. the orbit was divided into six compartments: the eye globe, retroocular fat, optic nerve, lacrimal system, bony boundaries and extra-ocular muscles. the average adc obtained from each tumor was compared with the histopathological diagnosis determined from subsequent surgical sample. seventy girls and sixty boys with orbital masses were included in this study. their age was ranged from 1 month to 18 years. the globe is the seat of lesions in 43/130 cases, optic nerve in 27/130 case. seven cases have lesions in the lacrimal gland. forty-five of cases was diagnosed as having benign masses & 85 of cases have malignant lesions. there is a statistically significant difference between the mean adc value of the benign lesions (1.39±0.52 x10 -3 mm 2 /s) and the mean adc value of the malignant lesions (0.69±0.22 x10 -3 mm 2 /s) (p<0.001). the optimal adc cutoff value that was determined for discrimination between these lesions is: 1.075 x10 -3 mm 2 /s), with sensitivity of 97.14% and specificity of 75%. using conventional mri alone in predicting benign and malignant lesions has the sensitivity of 76% and specificity of 91% with 94% positive predictive value and 67% negative predicative value. combining dwi and conventional mri has increased accuracy, as the sensitivity and specificity were 95%, 86% respectively with 93% positive predictive value and 90% negative predicative value. (2017) 47 (suppl 2):s297-s pediatr radiol adc values provide an accurate, sensitive, fast, and non-invasive mean of characterization of pediatric orbital tumors. a priori tumor characterization is useful in timing and treatment planning for orbital tumors. utiliy of resting state fmri in children for preoperative language mapping l.-m. leiber, m. delion, a. ter minassian; angers/fr to assess if resting state fmri is able to detect language eloquent areas in childrens. six children, from 8 to 15 years old suffering from brain lesions were enrolled in this study. they underwent mri with one 3dt1 morphology session and three 10 minutes fmri sessions, including one resting state fmri and two language task induced activity fmri sessions. analysis was performed using a generalized linear model for the first one and a spatial independent component analysis approach for the two others. language maps were compared with cortical mapping obtained by intraoperative direct stimulation. language network was identified systematically by resting state session but not by task induced activity sessions. moreover, in two of the six patients, resting state fmri was able to detect eloquent areas found during intraoperative cortical mapping that were not present in task induced activity sessions. resting state fmri appears superior to task induced activity fmri in detecting language eloquent areas. is sclerotherapy an effective treatment option for ranulas or thyroglossal duct cysts in children? d. aria, l. dance, c. schaefer, r. kaye, r.b. towbin; phoenix/us to assess the utility of sclerotherapy in the treatment of ranulas and thyroglossal duct cysts materials: from 2015-2016, 8 patients varying in age from 16 months to 32 years were referred to the ir department for sclerotherapy. of the 8 patients, 6 had a diagnosis of ranula while 2 had the diagnosis of thyroglossal duct cyst by either mr, ct, or us. sclerotherapy treatments were performed with standard sclerosing agents, i.e. sotradecol 3% foam, absolute ethanol, and bleomycin. in the subset of patients with ranulas, sclerotherapy was commonly performed in accordance with salivary (submandibular and/or sublingual) gland botox injection or ethanol ablation. 22-gauge or 5f sheathed needles were used for us-guided access to the lesions, with ranula sclerotherapy being performed after placement of side-hole drainage catheters (5-10f) due to their increased viscosity. the preferred sclerosing agent was injected with dwell times ranging from 15 mins to 3 hours. salivary gland injection/ablation was performed under usguidance using a 22-gauge needle with volume injection targeted centrally within the gland or in the portion of the gland abutting the ranula. after treatment, all patients were scheduled for follow-up ultrasounds at a minimum of 8 weeks to assess lesion response or residual disease. a total of 23 sclerotherapy treatments were performed. of the 8 patients, 2 were lost to follow-up after single sessions for ranula and thyroglossal duct cyst. the other 6 patients all had follow-up ultrasounds after each of the remaining 21 sclerotherapy sessions. four of these patients showed initial improvement with either decreased size of lesion or lesion resolution while the other 2 showed no improvement with either stable or increased size on initial follow-up. the 4 patients who initially showed promising response unfortunately had recurrence on follow-up imaging and ultimately, demonstrated no favorable response to sclerotherapy after subsequent treatments regardless of whether treatment was combined with ethanol/botox salivary gland injection. in summary, all 6 patients who were successfully followed show no appreciable response to treatment for ranula or thyroglossal duct cyst. despite the emergence of clinical requests for sclerotherapy of ranulas and thyroglossal duct cysts, in our case series, sclerotherapy has not proven to be an effective treatment option using our current drug regimen. role of the susceptibility-weighted imaging (swi) in the neuroimaging of term newborns g. rudas, e. varga, p. barsi, l. kozák, ü. méder; budapest/hu objective: susceptibility-weighted imaging (swi) was introduced in the neonatal neuroimaging only a few years ago. we can find only a few publications about its advantages and disadvantages. according to our experience, swi is extremely useful not only for detecting bleedings but for the diagnosis of other diseases as well. during the last year we had 164 mri examinations on term newborns (0-14 days of life) and the swi gave additional information in 54 cases. we used a 3t philips insignia scanner. in the case of the questionable hypoxic-ischemic-encephalopathy (19 cases) and the metabolic diseases (5 cases) we could find increased signal intensity in the cortex; in the case of stroke we could find the thrombus itself in 6 cases; the avm were much clearer using the swi in 3 cases; at the pvl in 3 cases we could visualize the cysts better using swi; in the case of congenital heart disease (11 cases) and in the case of sinus thrombosis (4) we could find microbleedings and/or dilated veins; in 3 cases the position of the lateral ventricle drain or shunt was much clearer using the swi. the swi gave important additional information in 54/164 (33%). the swi is a strongly recommended new sequence at the mri examination of the term newborns' brain. a disadvantage of swi is that it requires ca. three minutes examination time (in contrast to t2* which is only 1 minute long). mechanical birth-related trauma: imaging of the "accidents of birth" a. chaturvedi, j.g. blickman; rochester/us objective: 1. to discuss definition, incidence and risk factors leading to "mechanical birth-related trauma" and compare these with existing literature. offer an organ-system based classification scheme encompassing the varied manifestations of birth-related trauma and describing the implications on care decisions. materials: the hospital imaging department database was searched for neonates who presented with history of difficult/traumatic birth at our obstetric center between january 1, 2013-june 30, 2016. search software used was primordial customised radiology solutions, san mateo, ca. the search terms used were "macrosomia", "shoulder dystocia", "instrumental delivery", "malpresentation", "cephalopelvic disproportion", "forceps" and "vacuum". initial and follow-up imaging and clinical data on these neonates was reviewed and compiled by two board-certified pediatric radiologists. the relevant literature was reviewed and findings compared. organ-system based classification scheme for birth-realted trauma. in our study, mechanical trauma of birth was seen to manifest within different organ systems, which have been listed below in the order of occurrence within our sample. injuries to the skull (sutural overlap, dents and fractures), scalp hemorrhages (subgaleal hematoma, cephalhematoma, caput). intracranial intraand extra-axial hemorrhages (subdural, subarachnoid, epidural, intraparenchymal). clavicle fractures neonatal brachial plexus injury. sternocleidomastoid hematomas. adrenal hemorrhages. cervical spinal cord contusions. schematic diagram depicting intra-and extracranial hemorrhages by location. 6-year-old with history of calvarial fracture at birth-fracture did not heal but enlarged secondary to leptomeningeal entrapment at the fracture sitean entity called "growing fracture" or "leptomeningeal cyst". multiple newborn organ systems can be injured from mechanical trauma of birth. our numbers compare favourably with the existing literature. mechanical birth-related trauma can occur simultaneously with hypoxic-ischemic birth injury. although most of these injuries spontaneously and completely resolve, long-term complications can be seen in some cases. few of these injuries are life-threatening. imaging plays a crucial role in diagnosis and follow-up, and can assist in decision making as well as in counselling the parents. ewing sarcoma of tibia in an infant girl a. seehofnerova, j. skotáková, i. červinková; brno/cz objective: ewing sarcoma (es) is the second most common primary bone malignancy in children. it histologically originates from neuroectodermal tissue and consists of small round blue cells. ewing tumour family is very close to primitive neuroectoderm tumour (pnet) family with diverse stage of differentiation, ewing sarcoma being less differentiated. approximately 50 % of the cases occur between ten and twenty years of age with slightly higher prevalence in male gender. nine-month-old caucasian girl presented to local surgery department after she had wedged her lower leg in a bed. the right lower leg was swollen and painful. she was initially diagnosed with a ligament injury and underwent standard treatment. oedema gradually disappeared, but swelling and pain increased after three weeks. she also suffered from a fever of 38.1°c (100.58 o f). at that point x-ray of her right lower leg was performed with report describing pathologically changed structure of tibia and she was referred to our university centre. (2017) 47 (suppl 2):s297-s pediatr radiol we made a second reading of the plain film, reporting sclerotic heterogeneous bone structure of the right tibial diaphysis and distal metaphysis, onion-like periosteal reaction with sunburst spiculation and cortical bone destruction. her laboratory results were: crp 7.2 mg/l, ld 6.2 μkat/l, nse 44.3 μg/l, ferritin 18 μg/l. crp has been raising for a week to 25 mg/ l, then decreased to normal level. differential diagnosis was established as a primary bone malignancy (especially es) or, less likely, an osteomyelitis. mri revealed pathological signal of bone marrow of diaphysis of the whole tibia with cortical scalloping and periosteal spiculated apposition. epiphyses were spared. dorsal cortical bone was interrupted with extraosseal spread of the process. intraosseal part enhanced heterogeneously, whereas extraosseal component enhanced almost homogeneously after contrast medium administration. total size of the tumour was assessed as 97x23.5x20 mm (22.8 ml) . adjacent muscles were oedematous with post-contrast enhancement. there were also few enlarged lymph nodes in popliteal region. results from the biopsy confirmed ews with positive ews/fli1 gene. tumour was assessed as a localized disease, enneking iib. patient underwent chemotherapy according to aews1031doc protocol and a knee-exarticulation with no traces of tumour in resection lines. nowadays she is in the first complete remission. x-ray: ap view mri: etw1_tse postcontrast, sagittal view, pre-treatment mri: etw1_tse postcontrast, sagittal view, after initial treatment unique teaching points: ewing sarcoma belongs to common primary bone tumours in children but is a very rare unit in infants. despite the age predilection it is necessary to consider this diagnosis even in children younger than one year of age. scimitar syndrome together with pulmonary sequestration and horseshoe lung: congenital pulmonary venolobar syndrome b.e. derinkuyu, h.n. özcan, y. tasci-yildiz, h g. cınar, u.a. orun; ankara/tr objective: congenital pulmonary venolobar syndrome (cpvls) comprises of a spectrum of pulmonary developmental anomalies. the main components of cpvls are hypogenetic lung partial anomalous pulmonary venous return, absence of pulmonary artery, pulmonary sequestration, systemic arterialization of lung, absence of inferior vena cava. minor components of cpvls include tracheal trifurcation, eventration and partial absence of the diaphragm, phrenic cyst, horseshoe lung, esophageal and gastric lung, anomalous superior vena cava, and absence of the pericardium. in this case presentation, we present a baby with scimitar syndrome, pulmonary sequestration, horseshoe lung and right aberran subclavian artery. a 3 month-old girl was admitted to our hospital with the suspicion of scimitar syndrome from a different hospital. she did not have any symptoms. the physical examination was unremarkable. on plain radiograph, the baby had dextrocardia. there was a doubtful tubular structure with the shape of scimitar and a nodular radioopacity behind the heart (figure 1 ). transthoracic echocardiography demonstrated the dextrocardia, atrial septal defect and the right pulmonary artery hypoplasia. afterwards, the ct angiography was done for confirmation of scimitar syndrome and other accompanying abnormalities. on the ct angiography, there was a partial anomalous pulmonary venous return to the suprahepatic inferior vena cava known as scimitar syndrome. besides this, there was a right pulmonary extralobar sequestration in the lung base. the arterial supply was arising from the celiac trunk, while the venous drainage was going directly to the inferior vena cava. therefore, the right lung was hypoplastic of which the tongue of the right pulmonary parenchyma passing between the aorta and heart, appearing confluent with the left lung in a horseshoe configuration. there was dextrocardia and right aberran s389 (2017) 47 (suppl 2):s297-s pediatr radiol subclavian artery. the patient was subjected to catheterization and angiography for treatment. on plain radiograph, the baby had dextrocardia. there was a doubtful tubular structure with the shape of scimitar and a nodular radioopacity behind the heart unique teaching points: the term cpvls is an umbrella to a group of pulmonary parenchymal and vascular anomalies that may present in combination. mdct is a helpful diagnostic tool in the preoperative evaluation for delineation of the components of this syndrome. congenital pulmonary venolobar syndrome refers to a wide spectrum of pulmonary developmental anomalies that may appear single or in combination. the main components of congenital pulmonary venolobar syndrome are hypogenetic lung (including lobar agenesis, aplasia, or hypoplasia), partial anomalous pulmonary venous return, absence of pulmonary artery, pulmonary sequestration, systemic arterialization of lung, absence of inferior vena cava, and accessory diaphragm. in this case presentation, we describe a child with scimitar syndrome, bilateral sequestration, hypogenetic lung (single lobed left lung) and right aberran subclavian artery. an 8 year-old syrian girl was admitted to our hospital with the history of heart defect. she did not have syncope or ciyanosis whereas she has easy fatigue and palpitation. on plain radiograph the anomalous draining vein was seen as a tubular structure paralleling the right heart border in the shape of a turkish sword ("scimitar") ( figure 1) . transthoracic echocardiography demonstrated the scimitar vein as well as large patent ductus arteriosus (pda), atrial septal defect and left pulmonary hypoplasia. afterwards, the ct angiography was done for confirmation of scimitar syndrome and other accompanying abnormalities. on the ct angiography, there was a partial anomalous pulmonary venous return to the suprahepatic inferior vena cava known as scimitar syndrome. besides this, there was a bilateral intralobar pulmonary sequestration in the lung bases. the arterial supply of the right side was arising from the celiac trunk, while the left side feeding artery was originating directly from the descending aorta. therefore, the left lung had a single lobe with single pulmonary vein draining to left atrium. there was a large pda and right aberran subclavian artery. the patient was subjected to catheterization and angiography for treatment. the right sided anomalous draining pulmonary vein and the feeding artery of the right sequestration were closed in the first session. the procedure was completed without any complication. afterwards, the closure of the feeding artery of the left pulmonary sequestration and the pda were planned in the next sessions. on plain radiograph the anomalous draining vein was seen as a tubular structure paralleling the right heart border in the shape of a turkish sword ("scimitar") unique teaching points: congenital pulmonary venolobar syndrome comprises a heterogeneous group of uncommon abnormalities that may occur in combination. diagnosis of congenital pulmonary venolobar syndrome can be confirmed by ct angiography that allows detailed evaluation of vascular, tracheobronchial, and pulmonary parenchymal abnormalities with a single short, noninvasive procedure. neck infection disclosing diagnosis of congenital fourth branchial arc anomaly in a girl h.n. özcan, z. aycan, b. ardıclı, m. haliloglu; ankara/tr objective: congenital branchial arc anomalies are rare entities. herein, we describe the imaging findings of acute suppurative infection of the neck caused by fourth branchial fistula in a child. case presentation: an 11-year-old girl presented to our pediatric emergency department with fever, left sided neck swelling and redness. her complaints were started five days ago. on her physical examination, there was a 4x4 cm, stiff, painful mass lesion with redness on the left side of the neck. blood count and thyroid function tests were in normal range; however, c-reactive protein level and erythrocyte sedimentation rate were elevated. neck ultrasonography revealed diffuse soft tissue swelling, a hypoechoic mass consistent with abscess in the left thyroid lobe and perithyroid tissue. the left lobe of the thyroid gland had poorly defined margin and a focus of air. contrast-enhanced neck mr imaging demonstrated an abscess in the left thyroid and perithyroid tissue ( figure 1) and enhancement of the soft tissue plane around the left pyriform fossa (figure 2 ). barium swallow revealed the sinus tract originating from the left pyriform sinus apex. the patient was operated after antibiotic treatment and sinus tract was surgically excised. the aim of this report is to describe three cases of right kidney wilms' tumor with cavoatrial tumor extension, referred to our institution between january and september 2016. case presentation: three children, two girls (3 and 7 years old) and one boy (2 years old) were admitted at the emergency service with cardiac failure symptoms; the latter had also liver failure. echocardiography showed right atrial thrombus in all three patients, as an extension of massive obstructive thrombosis of the inferior vena cava (ivc). abdominal ultrasonography revealed in all patients a right renal mass, associated to right renal vein thrombosis that extended to the ivc and to the right hepatic vein. contrast enhenced computed tomography confirmed findings. patients were treated primarily with chemotherapy before surgery, with partial regression of the thrombus in two patients and no response in one. (2017) 47 (suppl 2):s297-s pediatr radiol unique teaching points: wilms' tumor is the most common renal malignancy in children and its intravascular extension is a well-recognized event. incidence of tumor extension to inferior vena cava (ivc) is reported to be of 2-5% and intra-atrial extension of 0,2-1,2%. it occurs most commonly in tumors located in the right kidney (probably due to the shorter path of the right renal vein compared to the left one). this complication does not directly influence the prognosis of malignancy, but the degree of intravascular extension determines technical surgical strategy and increases difficulty of the surgical procedure, especially when there is intracardiac involvement, which increases morbidity. several classifications have been proposed in the adult age group, but due to the similarity of the degree of intraoperative difficulty, the same classifications are used in children. pritchett et al. (1986) described the relation between thrombus and hepatic vessels: level i -intrahepatic intravascular extension; level iiintrahepatic extension; and level iii -suprahepatic or atrial extension. staehler et al. (1987) proposed a different classification that was posteriorly modified and detailed by daum (1994) : stage i -small extension (thrombus size within ivc <5 cm); stage iilarge thrombus (> 5 cm within the ivc), but still below the hepatic vessels; stage iii -thrombus extending to the level and above the hepatic vessels; stage iv -intra-atrial thrombus. a 4 year old boy presented with a soft tissue mass in his forearm which appeared to have grown quickly in size over a period of three to four months. physical examination demonstrated a welldefined mass in the dorsal aspect of the forearm with no pulsatile bruit. intial differentials included a vascular anomaly or a sarcomatous lesion. the patient proceeded to have an ultrasound examination which revealed a very well-defined heterogenous subcutaneous mass, mostly solid in substance. the lesion measured 3.5 cm x 1.6 cm x 3.5 cm (transverse x length x depth). there was no evidence of muscle invasion. prominent internal arterial vascularisation was demonstrated and the mass was classed as inderminate in nature. subsequent mr findings demonstrated a mass with t1 signal isointense to muscle, hyperintense t2 signal and marked homogenous enhancement. small foci of intralesional t1 hyperintensity and larger areas of t2* gradient hypointensity were noted, in keeping with small areas of intralesional blood. vessels were seen to extend from the subcutaneous fat into the lesion. the mass slightly distorted the underlying extensor muscles and tendons of the forearm but there was no deep extension across the fascia. findings deemed the lesion to be more malignant in nature. the patient underwent incisional biopsy and histological findings confirmed a diagnosis of angiomatous fibrous histiocytoma. these tumours are rare soft tissue tumours which most commonly occur in children, adolescents and young adults. while it is rare, there is a potential for local recurrence and metastasis. therefore, it is essential to identify these tumours where possible or at least consider them as a differential for a soft tissue mass in a child. the surgeon commented that the imaging findings and report were essential in making the initial decision about whether to perform an incisional or excisional biopsy as the best treatment for the tumour is wide surgical excision with clearance of margins. unique teaching points: angiomatous fibrous histiocytomas are rare lesions with potential for recurrence and metastasis and therefore should be identified and managed appropriately as a malignant tumour. they are often confused as soft tissue haemangiomas or complex haematomas. it is very important to be aware of the presentation and imaging findings, remembering this form of tumour as a key differential for a soft tissue mass. nasopharyngeal anlage tumor in a neonate with the initial presentation of respiratory difficulty: correlation between imaging and clinicopathologic findings p.-s. tsai, d.-c. lin, s.-l. shih; taipei/tw the etiologies of nasal or nasopharygeal obstruction are variable in neonates. the respiratory symptoms are varied in these cases. mass lesions in nasal cavity or nasopharynx are extremely rare during the neonatal period. however, we must keep it in mind when respiratory problems occur in the neonatal period. here, we report a case presenting with sleep apnea resulting from nasal obstruction by a rare benign salivary anlage tumor in nasopharynx and discuss the imaging findings as well as clinicopathologic characteristics. the 28-day-old female infant had loud breathing sound, slow feeding and sleep apnea since birth. nasal endoscope and laryngoscope disclosed a polypoid tumor in nasopharyngeal cavity with a stalk connecting with posterior nasal septum. further magnetic resonance imaging (mri) revealed a lobulated mass about 1.6 cm in greatest diameter occupying posterior nasal cavity to the nasopharynx that was intermediate signal intensity on t1-weighted/t2-weighted images and heterogeneous gadolinium enhancement. the patient then received endoscopic resection. the tumor was shown locating in nasopharyngeal cavity and having a stalk from posterior nasal septum, partially occluding the choanae as well. resected tissue fragments displayed tan and whitish in color grossly. microscopic examination demonstrated duct-like structures and mesenchymal elements in a nodular pattern which are typical features of salivary gland anlage tumor. until now, there is no tumor recurrence for four years. unique teaching points: "salivary gland anlage tumor (sgat)" was firstly introduced in a report by dehner et al in 1994 . the tumor that has histologic resemblance to the developing salivary gland, is believed to be a hamartoma originating from minor salivary gland rather than a true neoplasm. congenital sgat displays male predilection and is a rare cause of neonatal airway obstruction. the mass is usual in the midline and attached to the posterior nasal septum or posterior nasopharygeal wall by a delicate pedicle. favorable results with simple excision are obtained. once massrelated airway obstruction is established, further examination with computed tomography (ct) or mri is helpful in anatomic evaluation, size measurement, characteristics definition and intracranial involvement. if mass induced airway obstruction is suspected in a neonate and sgat is considered based on imaging studies, invasive procedure should be careful due to the potential of tumor dislodgement from its fine pedicle resulting in complete airway obstruction. the association of intussusception with malrotation is referred to as waugh syndrome. [1] malrotation occurs in approximately 1 in 500 live births. [2] the incidence of malrotation amongchildren with intussusception is 40%. we hereby present a case report of waugh's syndrome associated with midgut volvulus. case presentation: a 5 month old male child reported to the emergency department with the clinical history of vomiting, abdominal distension, bloody mucoid stools and incessant cry. routine blood examination revealed hb: 12.9 gm%, tlc: 14500/cu mm, plt-2. 9lac/cu. mm. ultrasound (us) examination was performed and it revealed dilated fluid-filled small bowel loops with moderate amount of free fluid, right iliac fossa showed bowel within bowel appearance suggestive of target/pseudo kidney sign of bowel intussusception. no pathologic lead point was identified. transverse ultrasound image through the upper abdomen showed superior mesenteric vein noted to the left of the superior mesenteric artery hence malrotation should be considered. in view of surgical emergency non contrast enhanced ct was done and axial image showed target/sausage shaped soft tissue density mass it had alternating areas of low and high attenuation due to bowel wall and mesentry. on emergency laparotomy patient was found to have intestinal malrotation with duodenojejunal junction on the right of the midline and 180 mid gut volvulus in clockwise direction. intussusception with terminal ileum (gangrenous), caecum, appendix, whole of ascending colon, transverse colon were telescoping into descending and sigmoid colon. the volvulus was derotated and the in tussusceptum was reduced. the gangrenous terminal ileum and appendix was resected and ladd's procedure was done, a diverting ileostomy was created. the patient recovered uneventfully after which an ileo-colonic anastomosis was created transverse ultrasound shows a mass with a swirled appearance of alternating hypoechoic and hyperechoic "bowel-within-bowel" appearance (target sign) unique teaching points: on ultrasonography multiple, concentric, target like appearance of wall layers of invaginated segments (target sign) on axial scan, as well as pseudokidney sign (sandwich sign) on longitudinal scans were accepted as diagnostic criteria for intussusception. [8] it can assess the relative positions of the smv and sma which are mostly abnormal in malrotation. upper gastrointestinal contrast study is the imaging reference standard for diagnosis of malrotation with or without volvulus. abnormal position of the duodeno-jejunal junction. spiral, "corkscrew" or z-shaped course of the distal duodenum and proximal jejunum, and location of the proximal jejunum in the right abdomen. [2] a high degree of clinical suspicion and radiologist's awareness of this entity is helpful in guiding the surgeons towards diagnosis and prevention of morbidity and mortality. a rare case of epidermal naevus syndrome p. joshi; pune/in to acquaint the radiologists with the entity of epidermal nevus syndromes (enss) which are a group of rare complex disorders characterized by the presence of skin lesions known as epidermal nevi associated with additional extra-cutaneous abnormalities, most often affecting the brain, eye and skeletal systems case presentation: this one and a half year old child was referred to us for neuroimaging. he had multiple hairy naevi over his face, limbs including the palms, since birth, associated with blackish discolouration of his entire trunk. unique teaching points: epidermal nevi are overgrowths of structures and tissue of the epidermis, the outermost layer of the skin. the different types of epidermal nevi can vary in size, number, location, distribution and appearance. neurological abnormalities that can be associated with enss can include seizures, cognitive impairment, developmental delays and paralysis of one side of the body (hemiparesis). skeletal abnormalities can include abnormal curvature of the spine, the term "epidermal nevus syndrome" has generated significant controversy and confusion in the medical literature. originally, the term was used to denote a disorder that was actually several different disorders erroneously grouped together. in the recent past, the term was used to denote a specific disorder now known as schimmelpenning syndrome. however, the term epidermal nevus syndrome could be correctly applied to several different disorders. therefore, the umbrella term "epidermal nevus syndromes" now represents a group of distinct disorders that have in common the presence of one of the various types of epidermal nevi. however, there is so far no general agreement how to classify the types of this diverse group of disorders, adding to the confusion within the medical literature. these disorders are quite different from one another and are not "variants" of each other as is sometimes mistakenly stated in the medical literature. in the future, as the genetic molecular basis of these disorders is better understood, the classification may change or expand. bilateral axillary lump in a newborn diagnosed as hematoma h.n. özcan, u. aydingoz, m. haliloglu; ankara/tr objective: most birth traumas are self-limiting and have a favorable outcome. injuries to the infant that result from mechanical forces during the birth process are not uncommon. they occur most commonly on head and neck after vaginal breech delivery. however, soft tissue hematomas can be rarely seen after caesarian section (c/s). herein, we describe imaging findings of a newborn with bilateral axillary lump diagnosed as hematoma. case presentation: a 31-year-old woman was admitted to an outside hospital at 38 weeks' gestation for c/s due to prior caesarean operation. it was her fourth pregnancy (g4 p2). the pregnancy was unremarkable and she had normal ultrasounds at gestation. there was no history of trauma or fall during antenatal period. according to the c/s reports, the process of operation was uneventful any undue prolongation and without having used any other instrumentation. the weight of the female baby was 3.1kg at birth. on the 3 rd postnatal day, her mother noticed a left axillary swelling, then admitted to a tertiary children's hospital. her physical examination revealed, bilateral axillary asymmetry with a fluctuant, nontender swellings. there was no redness or discoloration of the skin. there was no clinical feature suggestive of trauma or bleeding diathesis. a superficial ultrasonography showed solid heterogeneous, hyperechogenic masses 38x35 mm in the left axillary region and 15x13 mm in the right side. doppler study did not reveal any flow in the masses. contrast enhanced mr imaging demonstrated, bilateral axillary mass lesions with fluid levels and smooth contours (figure 1 and 2) . t1w images demonstrated hyperintense component suggesting hemorrhage. after the administration of the gadolinium-based contrast material, lesions showed peripheral enhancement (figure 3) . a diagnosis of hematoma was entertained. the child was managed non-operatively. she was monitored clinically and radiologically. follow-up ultrasounds scan revealed significant regression of the swellings. unique teaching points: soft tissue hematomas can be rarely seen in newborns. the formation of axillary hematoma on the background of c/s is a rare complication, which, to the best of our knowledge, has not been previously reported. ultrasonography and mr imaging readily depicts hematoma and aids in the differential diagnosis. colorectal carcinoma (crc) is extremely rare in pediatric age, with an estimated annual incidence of approximately 1 case per million individuals. the majority of reported cases occur in adolescence, while the incidence is further lower for children under 10 years. the distribution between males and females is not equal, with higher prevalence in males (ratio of 2:1). the etiology in children is unclear as these tumors are often sporadic and not linked to a preexisting adenomatous polyp, unlike adults. predisposing factors such as familial polyposis of the colon, other polyposis syndromes, ulcerative colitis and familial multiple cancer syndromes were reported in 10 % of cases. advanced stage at diagnosis, aggressive histologic subtypes (poorly differentiated, signet ring and mucinous adenocarcinoma) and poor survival are the hallmarks of pediatric crc. case presentation: a 15-year-old male presented with a history of dyspeptic symptoms (recurrent epigastric-right flank colic pain and heartburn) for the last eight months, without evidence of irregular bowel function. after a prior diagnosis of esophagitis secondary to a gastroesophageal reflux disease, physical and laboratory examinations revealed anorexia, progressive body weight loss, microcytic iron deficiency anemia and positive fecal occult blood test. during an emergency access, abdominal ultrasound identified rounded target liver lesions and circumferential heterogeneous mural thickening of the ascending colon. contrast-enhanced computed tomography scan (cect) demonstrated a marked circumferential wall thickening of the ascending colon and cecum with a longitudinal extension of 85 mm and thickness of 22 mm; the mass contained lowdensity areas and calcifications. furthermore 5 hypovascular hepatic lesions along with lymph node metastases containing calcifications were identified. no lung metastases were found. histopathological analysis confirmed the diagnosis of metastatic colon adenocarcinoma. after chemo-and radio-therapy, only the hepatic lesions showed reduction in size and number. the patient subsequently underwent right hemicolectomy. one month after surgery he is in a rigorous follow-up through ultrasonographic evaluation of pleural effusion and ascites and cect. unique teaching points: crc, although rare, should be suspected in children presenting with unexplained persistent abdominal pain, progressive body weight loss and positive fecal occult blood test. ultrasound imaging can be appropriate in the preliminary detection of abnormal bowel wall thickening, lymph node and liver metastases; cect is mandatory to confirm the radiological diagnosis and complete the staging. to increase awareness of this rare syndrome and its varied presentation in order to facilitate its early diagnosis and treatment to prevent poor prognostic outcomes. case presentation: lemierre syndrome is a rare disease characterized by an initial infection of the head and neck leading to the development of a septic thrombophlebitis which has a propensity to spread and involve the jugular and facial veins. this progressive infection then leads to the development of metastatic septic emboli to the respiratory tract. we present the case of a 7 year old boy who attended with a 1 week history of fever and a cough. initial imaging on admission demonstrated a large left sided hydropneumothorax with multiple cavitating lesions throughout the lung parenchyma in addition to thrombosis of some of the segmental pulmonary veins. the hydropneumothorax was surgically drained and the patient was transferred to the paediatric intensive care unit after further deterioration with the development of a broncho-pleural fistula. following a short course of antibiotics there was no clinical or radiological improvement and sputum cultures grew coliform organisms which raised suspicion for a more distant source. when pus was noted to be discharging from the left ear, a contrast enhanced ct of the head and neck revealed a left mastoiditis with multiple cerebral abscesses and occlusive thrombi in the left jugular vein, transverse venous sinus, sagittal and straight sinuses. following this diagnosis antibiotic therapy was modified and targeted at anaerobes, which was vital in assisting the patients recovery and successful discharge home. unique teaching points: clasically the majority of lemierres syndrome begins in the oropharynxinvolving the palantine tonsils and peritonsillar tissue often presenting with fever, sore throat and neck pain. our case demonstrates an atypical presentation with sepsis and respiratory symptoms as a result of the septic emboli which delayed diagnosis. we have learnt from this case the importance of considering lemierres syndrome in patients presenting with signs of a respiratory infectionin particular cavitating pulmonary lesions-that have not improved with conventional therapy and to have a low threshold to investigate the head and neck as a potential source of infection. when the working hypothesis of meningitis could not help e. kovacs 1 , n. pinter 2 , g. balázs 1 , a. machovitsch 1 , a. arany 1 , z. liptai 1 , l. fonyad 1 , p. benke 1 ; 1 budapest/hu, 2 amherst/us objective: neuroinfection still represents a diagnostic challenge in the everyday practice, where clinical evaluation, imaging, laboratory and pathological workup and treatment goes hand in hand under the pressure of time. we summarized a case in which, despite the extensive multilateral collaboration the battle was lost, to bring attention to the possible causes. a two year old, previously healthy female was taken to the emergency department for altered state of consciousness and fever. she also suffered from gingivitis. the unconscious child underwent an emergency ct scan: hydrocephalus with signs of raised intraventricular pressure was detected. subsequently mri of the head and spine was performed, and showed signs of diffuse leptomeningeal enhancement with basal predominance. multiple dwi restricted parenchymal lesions with basal predominance were also found. repeated csf and blood tests did not reveal any causative organism, although the gradually increasing crp suggested infection. two weeks after the onset of symptoms a follow up mri study showed extensive cerebral and spinal swelling with no focal lesion. the child passed away three days later due to cardiac failure. autopsy and neuropathological evaluation could not reveal the cause of the disease, which was identified only weeks after the child died, by culturing sputum and csf. unique teaching points: an overview of the clinical and radiological presentation of meningitis basilaris is carried out. attention is given to the circumstances, when tuberculotic infection should be suspected, and antituberculotic treatment should be started, even before the confirmation of the presence of mycobacteria can be obtained. to describe the clinical, laboratory and mri findings of chronic nonbacterial osteomyelitis(cno) in a patient with a negative radiograph and emphasize useful imaging findings, including an unusual radial pattern of edema in both femoral heads. case presentation: a 14-year-old adolescent, was referred with progressive debilitating hip pain and inability to walk since 5 days, that was unsuccessfully treated with non-steroidal anti-inflammatory drugs. during hospitalization he developed fever up to 38 ο with normal full blood count and smear, elevated esr (95mm/h) and crp (12.8 mg/dl), positive serologic markers for streptococcus (asto) and ebv and received antibiotics with relative good response. blood cultures did not grow any pathogens, the rest of serology was negative for acute infection, tuberculin skin test was negative and immunological investigation was unremarkable. pelvic radiographs were negative. mri showed a symmetric pattern of bone marrow involvement around both triradiate cartillages, at both femoral heads and (2017) 47 (suppl 2):s297-s pediatr radiol major trochanters. complementary evaluation of tibial areas with a limited protocol disclosed asymptomatic involvement of tibial epiphyses and apophyses. a radial pattern of edema was seen at the femoral heads with alternating stripes of involved and uninvolved areas. clinical course and imaging appearances were highly suggestive of cno. rapid clinical improvement occurred during hospitalization while a repeat mri 6 months later showed complete resolution of hip findings and the patient was free of any symptoms or signs. coronal stir sequence at presentation showing the radial pattern of bone marrow edema (arrowheads) alternating with stripes of normal marrow (*) at both femoral epiphyses. note hyperinense edema (arrows) around triradial cartillages. coronal stir sequence showing the predilection of bone marrow edema symmetrically around triradial cartillages (arrows) and at major and minor trochanters (arrowheads). coronal stir sequence at 6-months follow-up shows resolution of edema. unique teaching points: cno is a not well known chronic autoinflammatory bone disorder affecting primarily children and adolescents. positive serology for streptococcus or other infectious agents has been previously reported as in our case and may be a triggering factor. striking mri findings with a negative radiograph may occur at initial stages. symmetrical distribution of non-specific bone marrow edema around epiphyses and apophyses is highly suggestive of the diagnosis in the appropriate clinical setting and following exclusion of suppurative bone infections as well as bone or hematologic malignancies. the radial pattern of edema in our patient is unusual and considered to comply with the direction of main trabecular systems in femoral heads. in 26/31 chest cts, 103 nodules (median size 2.0 mm) were detected. display mode a with 5 mm mip yielded the best interreader variability (κ=0.294) and the highest sensitivity (73.9%) compared to mode b and c (κ=0.218, sensitivity 61.2% and κ=0.238, sensitivity 59.3%, respectively). perifissural nodules were detected in all subgroups. conclusion: mip improves the detection of pulmonary nodules in chest cts of young children, but overall interreader agreement is only fair. nodules, including perifissural nodules, occur in children with and without malignancy. images were subsequently read and interpreted by board-certified radiologists and nuclear medicine physicians in communal reading. in case of identifying suspicious lesions in cect additional imaging (mri) or biopsy was performed. compared to pet/ct employing only low dose ct (ldct), the use of cect resulted in the identification of 19 additional suspicious lesions in 13 patients. furthermore the use of cect allowed us to qualify 3 lesions as benign/ physiologic which in pet/ldct were identified as suspicious and 16 lesions suspect for metastases or tumor. in those 37 patients who received combined integrated fdg pet/ct including both ldct and cect the ctdi ranged in between 1,3-15.5 mgy (n= 10.2 mgy) and the dose length product (dlp) ranged in between 82.4-2464 mgy *cm (n= 812.6 mgy *cm) specificity was significantly higher combining pet and ct compared to stand-alone ct and pet. our study showed that the acquisition of cect in combined integrated pet/ct leads to an increased specificity and thus represents an essential component of a good fdg pet/ct in pediatric oncology. in assessment of lymph nodes, inflammatory foci and liver lesions diagnostic contrast enhanced ct is essential. comparison of the detectability of ubos in neurofibromatosis type i patients with proton density-weighted and flair sequences in 3t mri l. porto, s. lescher, n. hillenbrand; frankfurt/de objective: neurofibromatosis type 1 (nf1) is an autosomal-dominant congenital disease. in nf1 patients, significant numbers of so-called unidentified bright objects (ubos) can be found in brain imaging, with predilection sites at the basal ganglia and the dentate nucleus. ubos seem to develop at a very early age, contrary to other criteria leading to diagnosis. the detection of ubos might therefore prove helpful in the early diagnosis of nf1, complementing the clinical diagnosis based on criteria of the "national institutes of health consensus development conference". the aim of the study was to investigate whether the detectability of ubos increases at 3t by comparing proton density-weighted images (pdw) with fluid-attenuated inversion recovery (flair) sequences. a total of 14 nf1 patients (7 male, 7 female, between 8 and 26 years old, mean age 15.4 years) were examined by a 3t magnetic resonance scanner. the presence of ubos was evaluated on pd-w and flair images by 4 evaluators (2 experienced neuroradiologists, 1 junior radiologist and 1 student in his final year). detectability was rated by a three-point scoring system for dedicated regions: lesions which were "well defined/detectable", "suspicious" or "detected after a second look". the wilcoxon signed-rank test was used for comparisons between the raters. the level of significance was p<0.05. significantly more lesions were marked as "well defined/detectable" in the pd-w sequence compared to flair (p<0,001 for all four evaluators together, as well as for each evaluator separately). in particular, pd-w proved to be superior for detecting ubos located in the medulla oblongata (p=0,001) dentate nucleus (p=0,002) and hippocampal region (p=0,007), regardless of the level of the raters' experience. this is the first study that compares flair and pd-w at t3 for the diagnosis of ubos in nf1. significantly more ubos are detected in the pd-w compared to flair sequences, especially for the infratentorial regions. as ubos occur at very early stages of the disease in patients with suspected nf1, pd-w might aid an early diagnosis in these patients. assessment of radiation doses from diagnostic imaging in the followup of paediatric oncology patients p. logan 1 , r. harbron 2 , k. mchugh 1 ; 1 london/uk, 2 newcastle-upon-tyne/uk objective: previous literature (1,2) has suggested paediatric oncology patients accumulate a large radiation burden as a consequence of routine diagnostic imaging examinations during therapy. we retrospectively looked at the effective doses from routine ct and nuclear medicine in three cohorts of children, namely patients with hepatoblastoma, wilms' tumours and rhabdomyosarcoma (rms). of note, in our centre we rely on repeated mris of the primary site for many tumours. effective doses (e), in millisieverts (msv), were estimated using the ncict dose estimation tool (lee et al 2015) , based on details specific to each procedure: patient age, scan region, scanner type and ct dose index (ctdi -an indicator of radiation exposure recorded at the time of each scan). doses for general radiography were estimated using pcxmc v2.0 monte carlo simulations, assuming standard exposure factors and field size. there were 59 patients in total (18 hepatoblastoma, 21 wilms', 20 rms). there were 33 boys. the mean age was 3 years 2 months (ranging from 14 days -11 years 10 months). the mean and median cumulative effective doses from ct for the whole cohort were 7.88 msv and 4.24 msv respectively. four patients in the wilms' cohort had a dmsa nuclear scintigram (0.7 -1.0 msv), no hepatoblastoma patient had any nuclear medicine imaging, and 16 patients with rms received a bone scan (3 -3.5 msv) or a pet scan (approximately 8msv). cumulative radiation doses from routine radiological investigations in paediatric oncology can be kept in a much lower range than reported in the literature (1,2). in our institution, the followup of solid intra-abdominal tumours with mri, with additional ct or nuclear medicine only when clinically justified, has resulted in a significantly low radiation exposure in these patient cohorts. mri of the primary tumour site should be implemented as a replacement for ct imaging when there is no significant detriment to the diagnostic information obtained. (2017) 47 (suppl 2):s297-s pediatr radiol mri-based evaluation of multiorgan iron overload is a predictor of adverse outcomes in pediatric patients undergoing allogeneic hematopoietic stem cell transplantation f. zennaro 1 , d. zanon 2 , r. simeone 2 , g. boz 2 , f. degrassi 2 , m. gregori 2 , g. schillani 2 , c. boyer 1 , n. maximova 2 ; 1 nice/fr, 2 trieste/it objective: iron overload is associated with poor clinical outcomes in patients undergoing allogeneic hematopoietic stem cell transplantation (hsct). although the effects of hepatic and cardiac siderosis on patient outcomes have been extensively studied, less is known about the effects of siderosis in other organs. the medical records of 44 consecutive pediatric patients who underwent allogeneic hsct in our institute from 2011 to 2015 were retrospectively reviewed. mri was used to measure iron concentrations in the liver, spleen, pancreas and bone. these patients were divided into two groups, 18 with non-elevated (<100 μmol/g; group 1) and 26 with elevated (>100 μmol/g; group 2) liver iron concentration (lic) at baseline. in group 1, only two patients had normal iron concentrations in all organs. none of the patients of group 2 presented with pathological iron concentrations in only two organs. comparisons of baseline data with results of the first follow-up mri performed 1-6 months after hsct, showed a general worsening of iron accumulation. in group 1, none of the patients showed complete absence of iron overload in a single organ. in group 2, none of the patients showed a total absence of siderosis involving fewer than three organs. this study confirms the correlations between iron overload and the risks of transplant-related complications, such as transplant related mortality, sinusoidal obstruction syndrome, infections, pancreatic insufficiency, and metabolic syndrome, in transplant recipients with systemic siderosis. another important finding of this study was the close correlations between pre-transplant bic and times to neutrophil and platelet engraftment (p<0.001 each). (15), ganglioneuromas (gn, 2) and ganglioneuroblastoma (gnb, 1), examined by 3t mri were retrospectively grouped according to tumor entity, risk factors (bone marrow metastasis, mycn amplification or 1p36 deletion) and therapeutic regime (observation versus chemotherapy). dw (b values 0, 400 and 800) and conventional mri images (t2, t1 pre and post contrast) were analyzed for tumor size, relative si-and absolute adc-values at baseline (base; no therapy), and after 3 (fu1) and 12 (fu2) months. adc values in nb were lower than in gnb and gn (0.75*10 -3 mm 2 /s versus 1.28*10 -3 mm 2 /s; p<0.05). there was a tendency towards lower adc values in tumors with risk factors (n=6) versus no risk factors (n=7) at baseline, which did not reach statistical significance (p=0.08). during follow-up shrinkage of tumor volume was noted (baseline 1206 ml, fu1 159 ml, fu2 51 ml; p<0.05 baseline vs. fu1; p=0.08 baseline vs. fu2). in the observation group, tumor adc values rose without relapse (0.89*10 -3 to 1.07 *10 -3 mm 2 /s). only in eventually relapsing tumors adc values tended to decrease further (0.95*10 -3 to 0.71*10 -3 mm 2 /s, p=0.17), despite initial reduction in tumor size. to establish inter and intra-observer variability in the radiological detection and assessment of pulmonary nodules at diagnosis in children with wilms tumours. a test set of ct thoraxes at diagnosis from 15 patients enrolled in the multicentre 'improving population outcomes of renal tumours of childhood' (import) study in the uk were assessed. five radiologists (3 chest, 2 paediatric) from 5 different centres (4 uk, 1 netherlands) completed a scoring sheet for nodule assessment on the same studies on two occasions, 6 months apart. the readers were blinded to patient respiratory symptoms, the original radiology reports and also that they were scoring identical cases. descriptive statistics, modified bland altman graph and fleiss kappa scores were used for statistical assessment. in total, 93 different pulmonary nodules across the 15 ct thoraces at both rounds were scored by at least one reader. 81 (87%) were seen by at least one reader in round 1 and 81 (87%) in round 2, 69 (85.2%) nodules were seen by at least one reader in both rounds. only 20 (21%) nodules were scored by all 5 readers in round 1, 16 (17%) by all 5 readers in round 2, and 14 (7%) nodules by all 5 readers in both rounds. of the 20 nodules seen in the first round, 11 were measured to be >5mm in at least one dimension and of these, 7 were classified as malignant by all 5 readers. the limits of agreement for mean difference in nodule size in anterior-posterior, transverse and longitudinal measurements were ±1.85mm, ±1.76mm and ±1.88mm respectively. the fleiss kappa scores ranked from poor to fair agreement for nodule border smoothness (0.03), nodule shape (0.2), solidity (0.2) and impression of malignancy (0.4). within the same readers for both rounds, nodule detection rates of agreement were between 60.7-82.9%. the average intra-reader percentage of observed agreements for nodule border smoothness, shape, solidity and impression of malignancy were 84.2%,63.9%, 90.6% and 84.8% respectively. conclusion: detection and characterisation of pulmonary nodules on ct thorax shows both intra-and inter-observer variability. this has important implications for the interpretation of metastatic disease at presentation. fever without a focus is defined as febrile illness without an initial obvious cause or localizing signs. our aim is to assess the diagnostic value of whole-body mri (wb-mri) in the diagnostic work-up of children with fever without a focus. we retrospectively searched for subjects who underwent wb-mri for fever without a focus. a total of 29 children (m=17, f=12), mean age 6.1 years (range: 0.08 -17.61) were included. 8/29 (27.6%) subjects were immunosuppressed and 6/29 (20.7%) subjects were hospitalized at onset of fever. the reference standard was based on positive cultures, biopsy or surgery. when this was not possible, a probable diagnosis was made based on clinical follow-up or serology. initially, the wb-mri images were reviewed independently by 2 pediatric radiologists blinded to all clinical information. at the end of each case the final diagnosis and the diagnostic category (5 categories: a. normal, b. infection, c. oncologic, d. rheumatologic, e. miscellaneous) was recorded. this was followed by a consensus read for comparison with the reference standard. for statistical analyses all subjects were treated as fever without a focus. results: reference standard: the diagnostic category of the reference standard was as follows: infectious 12/29 (44.8%), oncologic 1/29 (3.4%), rheumatologic 8/29 (27.6%), miscellaneous. 1/29 (3.4%). even after extensive work-up in 7/29 (20.7%) no clear cause for the fever was found table 1 . wb-mri: wb-mri diagnosed the cause of fever without a focus in 7/29 subjects (24.1%) ( table 1 ). in 2 subjects (6.8%) wb-mri results were falsely positive (1 jia and 1 myositis), and in the remaining 20 subjects no imaging findings compatible a cause of febrile disease were found. interobserver agreement was fair (kappa 0.53). in children with fever without a focus wb-mri provided the diagnosis in in almost a quarter of the cases. given the multiplicity of causes of fever without a focus, some of them not possible to visualize on mr imaging, wb-mri may be considered in routine imaging practice when evaluating pediatric patients with fever without a focus. to compare linear measurement/volume to direct volumetric measurements using 3 dimensional(3d) post-processing software. for this irb approved study initial diagnostic ct or mr exams in 100 patients(11mo-20yr) with solid tumors were reviewed by 11 radiologists and 3 technologists. radiologists recorded measurements in 3 axes in their routine method, described tumor shape (sphere, ellipse, cone) and surface texture (smooth, almost smooth, or mildly, moderately, markedly irregular). three technologists individually, and 3 radiologists by consensus, used 3d processing software (intellispace portal, philips, cleveland, oh) to directly measure tumor volume. tumor volume (v) was calculated from linear measuments using the following equations: sphere v=4/3πr 3 , ellipsoid v=8πr 2 or 16πr 2 , conicalv=2πr 2 or 4πr 2 , and cuboid v=(xyz). inter-reader variability in tumor measurement in all tumors and for tumors divided by surface characteristics was assessed amongst radiologists and technologists, and radiologist consensus using coefficient of variation (cov). tumor shape analysis was reported as 14 sphere, 84 ellipse, 2 cone, and surface texture 8 smooth, 10 almost smooth, 32 mildly irregular, 31 moderately irregular, 19 markedly irregular. inter-reader variability of as much as 1,119cc above to 383cc below the mean tumor volume was found when using radiologist determined linear measurements, with standard deviation (sd), range 0.65-413. inter-reader variability amongst technologist derived volumes was considerably less, range 102cc above to 90cc below the mean, with sd, range 0.03-97. cov analysis shows a greater degree of variation in tumor volume calculated from linear measurements [smooth(7%), almost smooth(12%), mildly(20%), moderately(18%), markedly(27%) irregular] than direct volume determination [smooth(5%), almost smooth(6%), mildly(3%), moderately(3%), markedly(5%) irregular]. variation was significant only for tumor with irregular surface texture [smooth (p=0.26), almost smooth (p=0.23), mildly (p=0.003), moderately (p=0.001), or markedly (p=0.002) irregular]. variation in linear/volume measurements in very irregular tumors. light blue=middle 50% tumor volume measurements by pediatric radiologists. whiskers mark limits of range. ▲♦ • markers =measurements by technologists. note broad degree of variation. (2017) 47 (suppl 2):s297-s pediatr radiol variation in linear/volume measurements in almost smooth tumors. light blue=middle 50% tumor volume measurements by pediatric radiologists. whiskers mark limits of range. ▲♦ • markers =measurements by technologists. note narrow degree of variation. both graphs show the same informationthe % relative variation in tumor volume measurements determined by 3 dimensional linear measurements (11 pediatric radiologists) v. volumetric processing (technologists & consensus group). radiologist generated measurements are subjective and unreliable. variation in measurement technique leads to differences in calculated tumor volume which significantly over or under estimate volume in tumors with irregular texture and is not significant in smooth tumors. quail-quantitative mri-based evaluation of pancreatic iron overload in pediatric patients undergoing allogeneic hematopoietic stem cell transplantation f. zennaro 1 , m. gregori 1 , f. degrassi 1 , e. cattaruzzi 2 , y. diascorn 3 , c. boyer 3 , n. maximova 1 ; 1 trieste/it, 2 muggia/it, 3 nice/fr objective: iron overload (io) is a relatively common but often neglected transplantrelated complication and has been associated with poor prognosis in patients undergoing allogeneic hsct for hemato-oncological disease. pancreatic io is frequent among patients with transfusion-dependent anemias, but is uncommon among patients with hematologic malignancies. the causes of pancreatic io and the potential effects of pancreas iron deposits on transplant outcomes or on the risk of developing significant late effects in long-term hsct survivors have not been yet determined. our institute routinely uses magnetic resonance imaging (mri) with various gradient-recalled-echo (gre) sequences to quantitatively measure the iron concentration in abdominal parenchymal organs in all pediatric patients before and after allogeneic hsct. this study retrospectively analyzes the correlations of pancreas io with the type of conditioning regimen and pretransplant liver iron concentration (lic) in 50 pediatric patients who underwent allogeneic hsct in our transplant unit over the last 5 years. we enrolled 50 patients, age 1-17 years. pre-transplant mean lic was 147,55 μmol/g (normal values 36 μmol/g). 3 (6%) patients had mild liver io and 25 (50%) had moderate or severe io. pretransplant mean pancreatic iron concentration (pic) was 29,59 μmol/g, whose only 4 (8%) had mild pancreatic io and none had severe io. post-transplant mean lic was 162,6 μmol/g, only one patient had mild liver io but 36 patients (72%) had moderate or severe io. post-transplant mean pic was 66,22 μmol/g, 12 (22%) patients had moderate or severe io. mean pre-transplant pancreatic volume was 33,41 cm 3 , while mean post-transplant pancreatic volume (evaluated 30 days after transplantation) was 25,41 cm 3 . 11 (91,7%, p<0,001) patients with post-transplant moderate or severe pancreatic io underwent tbi-based conditioning. mean reduction of pancreas volume in tbi group was 12,02 cm 3 (p< 0,001). no pancreatic volume reduction was observed in chemotherapy-based group. all patients with pancreatic io have had exocrine pancreatic insufficiency and 9 (83,3%) patients have had metabolic syndrome. volume reduction well correlate (mean 49,8%, p<0,0001) with pancreatic io. this study confirms that pancreatic iron overload is not so rare in patients with hematologic malignancy underwent allogeneic hsct, with increased risk of metabolic syndrome and total deficit of exocrine pancreatic activity, but not of endocrine activity. iron overload monitoring allows for chelation therapy optimization. mr is fast, reproducible and more reliable compared to serum ferritin and transfusional history and allows a multi organ evaluation. pulmonary tb is common in south africa, with many children affected. diagnosis can be challenging and chest x-ray remains fundamental for diagnosis. interpretation is difficult and shown to have wide inter-reader variability. no study however has compared cxr findings and interreader agreement between ambulatory and hospitalised patients. this study compares the frequency of cxr changes, as well as interreader agreement in ambulatory compared to hospitalised children with suspected tb. from nolungile clinic and red cross children's hospital respectively was done. each sample contained 50% proven tb and 50% negative controls. two paediatric radiologists and one paediatrician served as blinded, independent readers for the database using standardised ticksheets. our study demonstrated no significant difference in lymphadenopathy, but an increase in parenchymal change in the hospitalised group. we otherwise showed similar results to literature regarding finding frequency, but poor inter-observer agreement. if the least expert reader were removed, results were comparable with available literature. this highlights the need for development and study of explicit cxr criteria for lymphadenopathy to improve the value of cxr for paediatric tb in all settings. lung ultrasound in pediatric pneumonia -why is it necessary to use the additional trans-abdominal approach? j. lovrenski; novi sad/rs objective: to emphasize the need of lung ultrasound (lus) technique modification, which enables detection of pneumonia in children not visualized by using solely the standard trans-thoracic approach. a prospective study was carried out in the regional children's hospital, and comprised a 2-year period. the inclusion criterion was us finding of pneumonia detected by trans-abdominal, and not with trans-thoracic approach. lus examinations were performed using a combined, trans-abdominal and trans-thoracic approach. longitudinal, transversal (intercostal), and oblique sections were used. trans-abdominal examination included transhepatic and trans-splenic approach. the ultrasound probe was angulated from the most anterior to the most posterior sections while examining the lung bases by trans-abdominal approach. a pneumonia-positive lus finding included subpleural consolidation with air-bronchogram, or with an adjacent area of interstitial/ alveolar-interstitial edema. lus was always performed before the other diagnostic modalities (chest x-ray (cxr) and computed tomography (ct)), if they were indicated by pediatrician or radiologist. within a 2-year period in 14 children (mean age 3.9y, sd 2.3y) the pneumonic focus was discovered using the trans-abdominal approach, while the trans-thoracic approach showed a normal lus pattern. all the children had the clinical symptoms of pneumonia (fever and cough, with or without dyspnea/tachypnea). the auscultatory finding was positive in 4 children. cxr was performed in three children, showed a right-sided pneumonia in two, and was negative in one patient. one child had a contrastenhanced chest ct, which confirmed a left-sided pulmonary base abscess detected during lus examination by trans-splenic approach only (figures 1, 2) . apart from pulmonary symptoms, there has not been any other associated diseases found, apart from otitis media in two children. each child responded to the antibiotics treatment with resolution of infection and us signs of pneumonia. in this oral presentation we will explain and give anatomical and technical reasons for pneumonia-positive us findings within lung bases, that remained undetected by the trans-thoracic approach. left-sided abscess abutted on the spleen (s), and was detected by trans-splenic us approach. it did not contact the pleural surface approachable by trans-thoracic ultrasound (black semi-lunar mark). l-liver. conclusion: trans-abdominal (trans-hepatic and trans-splenic) approach should become an inseparable part of each lus examination, along with a standard trans-thoracic approach. this modification of technique is expected to result in a further increase of lus sensitivity in diagnosing pneumonia. is thoracic ultrasound really competitive to computed tomography in children -a two-year retrospective study j. lovrenski, k. antolović; novi sad/rs to compare diagnostic accuracy of thoracic ultrasound (us) and computed tomography (ct) in children. a retrospective study was conducted in the regional children's hospital, and comprised a 2-year period. the inclusion criteria were: chest ct performed within 24h after the us examination of thorax, and us and ct examinations in the same patient performed by different pediatric radiologists. all us examinations were performed using a combined transabdominal-transthoracic approach. ct examinations were done (2017) 47 (suppl 2):s297-s pediatr radiol according to the body mass based pediatric ct protocols. each hemithorax was analyzed separately in terms of comparison between us and ct findings. statistical analysis included the calculation of sensitivity, specificity, positive predictive value (ppv) and negative predictive value (npv) of ultrasound in diagnosis of pulmonary pathological entities. out of 176 children with chest ct, 21 of them (mean age 8,2y, sd 5,6y) fulfilled the criteria to enter the study group. lung us showed sensitivity, specificity, ppv and npv in diagnosis of pleural effusion: 100%, 96,4%, 91%, 100%; lung consolidation: 100%, 100%, 100%, 100%; lung abscess: 75%, 100%, 100%, 97%; and interstitial lung disease: 57%, 100%, 100%, 91%, respectively. within 3 hemithoraces multiseptation of pleural effusion was observed by us only. air bronchogram within lung consolidation was observed in 5 hemithoraces both by us and ct examinations. necrotic areas within pulmonary consolidations were detected by us in 4 hemithoraces, which was later confirmed by ct examination. lung abscesses were diagnosed in 3 hemithoraces by both us and ct. two small lung abscesses filled with air (1 hemithorax) and bronchiectasis (2 hemithoraces) were detected only by ct examinations. other pathological findings detected both by us and ct examinations were: congenital pulmonary airway malformation (cpam) (1 hemithorax), pulmonary sequestration (1 hemithorax), partial pneumothorax (2 hemithoraces), hidropneumotorax (1 hemithorax), inflamed pneumatocele (1 hemithorax), hydatid cyst (1 hemithorax), pericardial effusion (2 patients), soft tissue masses of thoracic wall with initial bone destruction (2 patients), and lymphomas (2 patients) (figures 1-3) . in one patient us and ct revealed cysts and an extremely dilated bronchus within lung consolidation (pathohistological finding: cpam type 2 combined with subsegmental bronchial atresia, and extensive bronchopneumonia). us examination, unlike ct, could not differentiate between eventration of the left hemidiaphragm and diaphragmatic hernia in one patient. to determine and compare the accuracy of frontal cxrs alone and 'combination frontal-lateral' set of cxrs for diagnosing lymphadenopathy in children with tb using patients with confirmed tb and controls without tb, and to compare findings in hiv-infected and hiv-uninfected children. a total of 172 children (ie: 88 children with gene xpert confirmed tb and 84 control patients admitted with lower respiratory tract infections), which were part of a larger south african study, who had both frontal and lateral cxrs, were included. three qualified radiologists read the cxrs in 2 separate sittings one month apart (one for the frontal x-ray alone and one for the 'combination frontal-lateral' cxrs) for the presence of lymphadenopathy. odds ratios and 95% confidence intervals were calculated to determine the presence of lymphadenopathy using a consensus reading on the frontal cxr and frontal-lateral cxr combination according to the final diagnosis of tb. inter reader agreement was determined using the kappa statistic. lymphadenopathy was reported in 86 (50%) patients on the frontal cxr alone and in 143 (83%) patients on the frontal-lateral cxr combination. 52 (60%) of the 86 patients with lymphadenopathy on the frontal cxr alone were gene xpert positive versus 72 (50%) of the 143 patients with lymphadenopathy on the frontal-lateral cxr combination. in all patients, the consensus reading using a frontal-lateral cxr combination resulted in a 5-fold increase (or 4,9; 95% ci 2, 4) in calling lymphadenopathy compared to using a frontal cxr only in the gene xpert positive group, the consensus reading using a frontal and lateral cxr combination resulted in a 3 fold increase (or 3,1; 95% ci 1,5-6,6) in calling lymphadenopathy compared to a frontal cxr only. overall inter reader agreement for all 3 readers when evaluating for lymphadenopathy was 'fair' on both the frontal cxr (k= 0,2088) and the frontal-lateral cxr combination (k=0,273). the addition of a lateral view to the standard frontal cxr increased the rate of calling lymphadenopathy. however, the accuracy of diagnosing lymphadenopathy on chest x-ray as a marker for tb was poor. this poor accuracy was further hampered by only 'fair' inter reader agreement for the presence of lymphadenopathy on chest x-ray. dynamic 4d ct imaging in children has significant advantages over routine ct scanning, bronchography and bronchoscopy for diagnosing trachebronchomalacia because it can be performed during free breathing without anaesthesia or invasive airwayaccess.itcanalsodemonstratevascularcausesoftracheo-bronchomalaciain the same sitting. the technique is currently performed in 1 paediatric center in the uk. we aimed to report pitfalls encountered while setting up a dynamic 4d ct imaging service for children and report the findings of studies performed. materials: dynamic 4d ctscanning was introduced after installation of a large array (320 slice) ct scanner, applications specialist training and review of the literature. imaging parameters in use by greenberg and colleagues (arkansas children's hospital, usa) were applied. referral indications, pitfalls encountered, quality of scanning and imaging findings/diagnoses were reviewed and enumerated. results: nineteen paediatric dynamic 4d ct scans (9 females, 10 males; 11 days -3 years 9 months; mean 12 months) were performed over 15 months. the first 4 studies were performed without ivi contrast due to lack of experience and 13 subsequent studies were performed with contrast ( figure 1 major pitfalls included initial failure to perform contrasted studies for simultaneous evaluation of vessels, initial failure to withdraw the endotracheal tube, patient motion under care of nurses and clinicians, failure to appreciate the value of imaging the full lung volume while trying to keep dose length product to a minimum and failure to appreciate that collapse of the airway is often in the ap plane and not appreciated on coronal slab projections -rotating 3d volume rendered images is a requirement ( figure 3 ). additional obstacles were initial clinician and radiologist lack of support after early failures and colleague concerns regarding the radiation dose. objective: diagnosis of pulmonary tuberculosis (ptb) in children relies on chest radiography, however there is wide inter-observer agreement in detecting lymphadenopathy, the hallmark of ptb. paediatric airways are pliable, thus detection of airway compression may be a more objective criterion for the presence of lymphadenopathy. thus the objctive was to assess the usefulness of airway compression on chest radiographs for diagnosis of ptb in children. chest radiographs of children admitted to red cross children's hospital with suspected ptb were read by two readers according to a standardised format and a 3 rd when there was disagreement. radiographs of children with definite ptb were compared to those with lower respiratory tract infection (lrti) from another cause. the prevalence and location of airway compression was evaluated. findings were correlated with hiv status and age. inter-observer agreement was assessed using kappa statistic. 13 .9% in older children (or 1.7; 95%ci 1.00-3.00). no association with airway compression and hiv infection was found. inter-observer agreement ranged from 0.0-0.4. eighteen-month-old male patient diagnosed with ptb; hiv negative. majority agreement of airway compression at lmb indicative of lymphadenopathy. left upper lobe opacity is in keeping with a ghon focus. there is a strong association between airway compression on chest radiographs and confirmed ptb, particularly in infants, irrespective of hiv status. however, clinical use is limited by poor inter-observer agreement. paediatric ultrasound-guided biopsies in a tertiary oncology centre: five years experience n. parvizi, m. smedley, s. chakraborty; oxford/uk objective: histological diagnosis is almost always essential to guide appropriate therapy for children diagnosed with cancer. tissue can either be obtained by surgical/open or image-guided percutaneous biopsy. the aim of this study is to assess the safety and diagnostic accuracy of ultrasound-guided biopsies in a tertiary oncology referral centre. a retrospective analysis of clinical data, imaging findings and histological diagnosis of patients aged 0 to 18 years between january 2010 and december 2015 was carried out. a total of 113 ultrasound-guided biopsies were performed in our institution on 110 patients. most of the biopsies were performed in theatre with the patient under general anesthetic and with an 18-gauge spring-loaded core biopsy needle with a minimum of two cores per patient. in 99% of lesions the needle biopsy was diagnostic. the single nondiagnostic case did not have sufficient material to make a full diagnosis and a surgical biopsy was required. eighty-two of the biopsied lesions were malignant and 31 were benign. in no cases was a repeat biopsy required. the vast majority of the biopsies were performed within one week of request with over half performed within 3 days. all biopsies were performed without complication and in the majority of cases the patients were discharged the same day or following an overnight stay. ultrasound-guided percutaneous biopsy is an accurate and safe technique in order to acquire tissue from suspected malignant lesions in children. these can be performed instead of or in addition to open biopsy and will often result in a shorter hospital admission and recovery time. the role of imaging in the diagnosis of thymoma in paediatric patients with myasthenia gravis j. adu, t. a. watson; london/uk thymomas are exceedingly rare tumours in the paediatric age group, with only very few cases having been reported in the literature. thymomas are commonly associated with myasthenia gravis (mg), with thymectomy being potentially curative. ct is the mainstay imaging modality for thymoma diagnosis in the adult population. while, chemical shift mr imaging can be helpful to distinguish thymoma from other anterior mediastinal abnormalities. currently, there is no consensus on the imaging pathway for children with mg with suspected thymoma. our aim is to review the imaging of patients who were referred to our institution for management of mg, and suggest an imaging pathway in cases where thymoma is suspected. we performed a retrospective search of the local pacs system of cases between 2000 and 2016 using the search terms "thymoma" and "myasthenia gravis" in the clinical indication for the study and the body of the final report. forty-three cases were identified using the search criteria. eight cases were excluded owing to an absence of cardiothoracic imaging. 20/35 of all cases (57%) had chest x-rays (cxr's), of these 17/20 (85%) were normal. the three remaining patients who had abnormal cxr's went on to have ct scans, which confirmed an anterior mediastinal mass (amm) in all three cases. 26/35 of all cases (74%) had cross-sectional imaging (mri 15/26 cases, ct 11/26 cases). of those, 21/26 of cases (81%) had normal studies. specifically, all 15 mri studies (100% of cases) were normal, while only 5/15 ct scans (66%) demonstrated an anterior mediastinal abnormality. 12/35 of all cases (34%) had both cxr and cross sectional studies. 9/12 of these cases (75%) had a normal ct or mri. in the remaining three cases, the amm was clearly demonstrated on both cxr and the crosssectional imaging. in our series, radiography, ct and mri studies were normal in the vast majority of cases. however, given that thymectomy is potentially s405 (2017) 47 (suppl 2):s297-s pediatr radiol curative, it is appreciated that clinicians may still be keen to radiologically investigate paediatric patients with myasthenia gravis. cxr is not an efficacious imaging modality in this context, as patients with a normal cxr may be falsely negative, and patients with an abnormal cxr may undergo cross-sectional imaging regardless. we propose that mri should be used as first line investigation for patients in this population. this approach will negate the need for ionizing radiation, maximize diagnostic yield, and facilitate surgical planning if deemed clinically appropriate. increased risk of venous thrombosis of the arm with multiple peripherally inserted central catheters insertion in paediatric patients r. gnannt 1 , n. waespe 2 , j. donnellan 2 , k. liu 2 , l. brandao 2 , b. connolly 2 ; 1 zurich/ch, 2 toronto/ca objective: peripherally inserted central catheters (piccs) are associated with superficial and deep venous thrombosis of the arm. the impact on the incidence of developing a thrombosis of the arm when inserting a subsequent picc remains unclear. the purpose of this study was to analyze the incidence of deep, upper limb thrombosis of repeated upper limb piccs in children. the study population included all patients who underwent their first successful arm picc insertion between january 2010 and december 2015. subsequent ipsilateral arm piccs were included in the analysis. patients were followed until march 2016 or until any alternative central venous line insertion (jugular, femoral, saphenous or umbilical vein lines -because of their thrombogenic effect). for each picc insertion the following data were collected: date of insertion and removal, weight of the patient, type of picc (1.9fr, 2.6fr, 3fr, 4fr, 5fr), left or right arm, and vein cannulated (basilic, brachial, cephalic). all symptomatic deep and superficial thrombosis of the arm were correlated with the picc database. four thousand one hundred thirty-eight piccs were inserted. applying inclusion and exclusion criteria, 1955 piccs remained for analysis. first, 2 nd , 3 rd , and 4 th picc insertions in the same arm were identified in 1773, 146, 30 and 6 patients, respectively. in total there were 57 upper body deep symptomatic thrombotic events diagnosed with ultrasound. a 1 st , 2 nd , 3 rd , and 4 th picc insertion was associated with 46/1773 (incidence 2.6%), 6/146 (4.1%), 4/30 (13.3%), and 1/6 (16.7%) thrombotic events, respectively. an increasing hazard ratio was seen with higher numbers of picc insertions, which was significant when comparing the 1 st with the 3 rd picc insertion in the same arm (hr 3.9, ci95%1.3-11.4, p=0.01). after excluding any confounder, double lumen piccs were associated with a significantly higher risk of thrombosis than single lumen (or 5.3, ci 1.2 -23.4, p=0.026). repetitive picc insertions in the same arm are associated with an increased risk of thrombosis. double lumen piccs are associated with a higher risk of thrombosis compared to single lumen lines. diagnostic performance of lung ultrasound for the detection of community acquired pneumonia in children j.a.m. stadler 1 , s. androunikou 2 , h. zar 3 ; 1 paarl/za, 2 bristol/uk, 3 cape town/za objective: chest radiographs (cxr) are considered the first line imaging modality when investigating cases of suspected community acquired pneumonia (cap) in children. however, cxr interpretation is limited by moderate sensitivity and specificity and poor inter-and intra-rater reliability and expose children to potentially harmful ionizing radiation. point-of-care lung ultrasound (lus) has been proposed as alternative to cxr for diagnosis of pneumonia in children and some published data suggest accuracy and reliability as good as or better than cxr. most of these studies however, were performed in in-hospital settings creating a bias for selceting more severe disease and consequently more overt radiological findings. the mean age of children in most of these studies were also well above one year, while the highest incidence and risk of complicated pneumonia occurs during the first year of life. the purpose of our study was to assess the diagnostic performance of lus for the diagnosis of pneumonia in both hospitalised and non-hospitalised children in an age group representative of the most at risk segment of the population. we performed a lus on 147 children who presented with clinical signs consistent with the who case definition for childhood pneumonia. one hundred of these patients also had chest radiographs performed as part of routine clinical care. inter-rater reliability (irr) between a general practitioner and an expert paediatric radiologist were assessed for the interpretation of lus findings consistent with pneumonia. where radiographs were available concordance between lus and cxr findings of pneumonia were also assessed. results: seventy-four hospitalised and 73 non-hospitalised clinically defined pneumonia cases were included with a median age of 10.3 years. our general practitioner reported lus findings consistent with pneumonia in 77/147 (52%) compared with 66/147 (45%) by the paediatric radiologist. substantial overall agreement between the reporters was found with an overall agreement proportion of 0.79 and kappa=0.62. agreement for the presence of lung consolidation or for a normal scan was also substantial with kappa of 0.67 and 0.68 respectively. agreement on the finding of interstitial syndrome was moderate with kappa=0.45. agreement was higher in hospitalised than in non-hospitalised cases with kappa of 0.62 and 0.56 for the respective categories. results showing concordance between lus and cxr findings are pending. conclusion: lus shows substantial irr for the diagnosis of pneumonia in children. irr are higher for the detection of consolidation or for no pathology than for interstitial syndrome. irr also appears to be lower in clinically less severe disease. 'white-out' on plain chest radiograph-a late presentation of congenital diaphragmatic hernia a. fagan 1 , c. stewart 2 , k. halliday 3 , s. rao 2 , d.t. chang kwok 2 ; 1 peterborough/uk, 2 lincoln/uk, 3 objective: awareness of the limitations of plain radiograph and computed tomography in diagnosis of late presentation of congenital diaphragmatic hernia. case presentation: a 2 year old boy presented with a 6 day history of pyrexia, vomiting and respiratory distress. he was haemodynamically stable, and had no audible air entry over his upper left thorax with occasional wheeze over the left base. he had bronchiolitis previously but did not require ventilatory support. he was otherwise well with unremarkable antenatal scans. initial chest x-ray showed a large air collection with fluid or soft tissue density within the left hemi-thorax and mediastinal shift to the right. repeat x-ray (figure 1 ) demonstrated the nasogastric tube below the diaphragm. complicated pneumonia was suspected but as the findings were atypical a non-contrast ct was performed. this was interpreted as showing a large hydropneumothorax. (figure 2) . a chest drain was inserted which drained only a small volume of fluid, and a repeat chest film showed no change. ct chest and abdomen with oral and intravenous contrast revealed a bochdalek diaphragmatic hernia (figure 3) . fortunately the chest drain had not entered the herniated stomach. the hernia was surgically corrected and the child recovered well. (2017) 47 (suppl 2):s297-s pediatr radiol bochdalek is the most common congenital diaphragmatic hernia (cdh). it is often diagnosed on prenatal ultrasound, with mri used for confirmation. cdh which is not diagnosed in the perinatal period may be asymptomatic and imaging findings can be confusing. postnatal x-ray typically shows an opacified hemi-thorax with or without gas bubbles. there can be mass effect with mediastinal shift. the position of an ng tube can be helpful in localising the stomach, but in this case the infradiaphragmatic position of the tube gave false reassurance. in neonates, the position of an umbilical venous catheter may demonstrate abnormal location of the liver. computed tomography generally demonstrates a posterolateral defect (foramen of bochdalek), which is located on the left in 80% of cases. ct is useful for excluding lung masses or bronchopulmonary foregut malformations, which may appear similar to cdh on x-ray. ct can also identify anatomical abnormalities associated with cdh. late presenting cdh is often misdiagnosed as pleural effusion or pneumothorax. there are other case reports published where chest drains were inserted before cdh was diagnosed. it is important to keep cdh in mind as a potential cause of unilateral hemithorax opacification, even in previously asymptomatic older children. ct with oral contrast can be useful in diagnosis. ovarian tuberculosis with peritoneal dissemination mimicking ovarian tumor with peritoneal seeding d. grassi, v. tostes, a. duarte, s. abib, h.m. lederman; sao paulo/br consider tuberculosis (tb) as a differential diagnosis whenever the case enrolls in an endemic region. case presentation: female, 13 years old adolescent, who presents with abdominal pain and weight loss. abdominal sonography was performed in a public family practice location and bilateral ovarian masses were detected. she was referred to an oncology pediatric facility for further investigation. abdominal mri and chest ct were performed where dissemination through the peritoneal and mesenteric lymph nodes could be detected; chest ct was normal. the patient underwent surgical intervention for diagnosis and on pathology the findings in the bilateral ovarian masses were secondary to tb involvement. sonography showing bilateral pelvic masses. t2-weighted coronal overview bilateral ovarian masses. unique teaching points: whenever a case enrolls in an endemic region of tuberculosis, it is important to consider it as a possible differential diagnosis. in this case, the initial presentation mimicked ovarian tumor with mesenteric seeding. however, only after surgical approach was possible to diagnose ovarian tuberculosis with mesenteric lymph nodes and peritoneal involvement. retrospectively, patient's uncle was discovered as having pulmonary tb. langerhans'-cell histiocytosis with thoracic involvement in infant and young child: ct findings s.-l. shih 1 , k. tsai 1 , w. huang 2 , f.-s. yang 1 ; 1 taipei/tw, 2 taitung/tw the purpose of the study was to evaluate the ct changes of thorax in the patients with langerhans'-cell histiocytosis. the 3-month-old female infant presented with generalized hemorrhagic macular rash over the skin for 2 months. the laboratory findings showed hemoglobin 7.8gm/dl (normal 11.0~16.0gm/dl). the chest radiograph showed bilateral reticulonodular infiltration. high-resolution computed tomography (hrct) of chest showed multiple cystic-like lesions (1-6mm) in the right middle and bilateral lower lobes. the pathological report was langerhans'-cell histiocytosis after skin biopsy from upper chest. then she was on scheduled chemotherapy. she was in remission after one-year treatment. the 1y10m-old girl presented with fever for 3 months. the physical examination revealed hemorrhagic-macular rash over the skin in the anterior chest wall and hepatosplenomegaly. the laboratory findings revealed albumin 2.5g/dl (normal 3.8-4.7g/dl) and hemoglobin 7.0g/dl (normal 11.0-16.0g/dl). hrct of chest showed multiple cystic-like lesions (1-6mm) in the bilateral lower lobes with left pleural effusion as well as multiple osteolytic lesions in the vertebral bodies of t7, t8, t11 and t12. the pathological report was langerhans'-cell histiocytosis after skin biopy from anterior chest wall. then she was on scheduled chemotherapy. she was doing well 10 years after treatment. the 1y6m-old girl presented with yellowish discoloration of skin for one month. the laboratory findings revealed direct/total bilirubin 4.4/7.9mg/dl (normal 0.1-0.5/0.3-1.2mg/dl), got 223iu/l (24-46iu/l) and gpt 220iu/l (12-27iu/l). the chest radiograph revealed enlargement of upper mediastinum. the ct scan of chest and upper abdomen showed punctuate calcification with heterogeneous enhancement in the upper mediastinum and several minute cysts in the lower lobes of lung (hrct) as well as dilatation of bilateral intrahepatic bile ducts in the liver. the pathological report was langerhans'-cell histiocytosis after biopsy from thymus and liver. then she was on scheduled chemotherapy and got initial response. unique teaching points: langerhans'-cell histiocytosis affecting the lungs and thymus may be in isolation or as part of a multiorgan disease. the pulmonary changes on ct scan may not have corresponding respiratory symptoms. ct scan of thorax may have multiple minute cysts (1-6mm) in the lungs, pleural effusion, calcification in the thymus and osteolytic lesions in the thoracic spine. case of fungal infection of the soft tissue in a child with acute myeloid leukemia (ultrasound aspects of diagnosis) i. begun, s. kondaurova; minsk region/by objective: early diagnosis of fungal infections of the tissues is essential for a successful and complete recovery. we describe a clinical case of fungal infection of the soft tissue in a child with acute myeloid leukemia (aml). ultrasound were made for the characteristics of the structural changes in the area of interest to perform biopsies followed by bacteriological culture studies. case presentation: patient k., 13 years old, diagnosed with aml, from which after a course of induction chemotherapy with neutropenia about 3 weeks on the skin of the foreskin appeared removable hard white coating. cultures of plaque it possible to establish the presence of fungi of the genus trichosporon spp. after 4 days, there were hyperemia, compaction and ulceration of the glans penis, which led to extensive tissue defects. with help ultrasound were determined the structural deformation of the glans penis with the pronounced around changed tissues vascularization. after 7 days in the rear surface projection of the left thigh and the lateral surface of the left calf were defined erythematous papules which progressed to ulceration with central black scab. by standard ultrasound were visualized: subcutaneous nodal education oval 1,0х0,4 sm on hip and echogenic skin thickened portion having an average degree of severity of dorsal acoustic shadow on the lower leg (weakening of the signal behind scab). in cultures of biopsies of subcutaneous foci were revealed fungi of the genus trichosporon spp too. the patient received the combination treatment (intravenous liposomal amphotericin b and surgical rehabilitation of lesions of glans and corpus cavernosum of penis). after the stabilization of patient state the treatment of the underlying disease was continued. unique teaching points: for some patients, lesions of superficial tissues may be the only sign of systemic fungal infections, and rapid recognition of these lesions may contribute to early diagnosis and treatment. ultrasound examination in such a situation naturally becomes an main imaging tool and by choice method. the scanning high-resolution of foci of the thigh of the patient k. in grayscale made possibility to determine the configuration consisting of the central echogenic focus surrounded by a hypoechoic rim (fig. 1) with peripheral changes in the type of "infiltrative" according by the active fungal infection at the exit of cytopenia. duplex and triplex ultrasound scanning were indicating to the perifocal vascularization with low level vascular resistance around of the affected area (see fig.2-3) . to increase knowledge and awareness of rare cases and diseases in order to be able to better manage and treat patients in the future. case presentation: an 3-month-old female was presented to our hospital with abdominal distention that increased in the past 3 months associated with low-grade fever, loss of weight and mild respiratory distress. abdominal ultrasonography revealed an enlarged liver with multifocal hypoechoic lesions scattered all over the liver (fig 1) . a ct scan with iv contrast (mri was not available at that time in our district) revealed severe hepatomegaly with the presence of multiple, variable in size, hepatic hypodense lesions which had peripheral (ring) enhancement after contrast injection in the arterial phase (fig 2) . progressive centripetal filling in portal phase is seen and in the delayed images many of the lesions were completely filled (fig 3) . reduction in the aortic caliber (mid-aortic syndrome) below the level of celiac branch was noted. a diagnosis of hemangioendothelioma was made although liver biopsy was not done due to fear of hemorrhage. alternative diagnosis to infantile hemangioendothelioma in this age group is hepatoblastoma, mesenchymal hamartoma and metastatic neuroblastoma. the patient was transferred to another city to a hospital with pediatric oncology department for follow up and treatment. unfortunately the lack of experience and knowledge of such rare cases led to mismanagement and delayed treatment and after less than 2 months the patient was brought back to our hospital to the pediatric icu due to deterioration of her status due to congestive heart failure. unfortunately the patient died shortly afterwards. hemangioendothelioma is twice as common in girls and can have complications due to high output chf secondary to arteriovenous shunting hemangioendotheliomas tend to involute spontaneously without therapy over a course of months to years. they are followed with sequential ultrasounds. medical therapy is reserved for severely symptomatic lesions (e.g. anemia, consumptive coagulopathy, high-output chf) and includes high-dose steroids or alpha-interferon. in cases of failed medical management, surgical resection should be performed. if partial hepatectomy is not technically achievable, transarterial embolization should be used either as definitive therapy or as a temporizing measure until liver transplantation is possible. the sad outcome of this case was mainly due to mismanagment due to lack of medical experience and knowledge of such rare cases so we suggest that such rare cases should be catalogued in a national data bank for future consultation and teaching purposes. fatal outcome of acute gastric dilatation causing acute abdomen compartment syndrome in a child: a case review c.s. yoon; seoul/kr to describe and review presumed acute abdominal compartment syndrome in a child. case presentation: a 3 years and 5months old boy was admitted to emergency room due to abdominal distention. he suffered abdominal pain and vomited since yesterday after lunch. on physical examination, his abdomen was rigid and distended. body temperature is 37.2°c. the white cell count was increased (24,140/μl). esr is 25 mm/hr and c-reactive protein was 123.4 mg/l. creatinine was increased (1.24mg/dl). amylase and lipase were increased (164 u/l and 104 u/l respectively). prothrombin time was prolonged (15.5 sec). plain abdomen radiograph shows markedly distended stomach with air-fluid level (fig.1) . first trial of nasogastric tube insertion was failed due to kinking of tube at gastroesophageal junction. contrast-enhanced abdomen ctscan shows marked distensionofstomachwithlargeamountoffoodmaterialsandintraluminalairwith prominent external compression in the duodenal 3rd-4th junction. esophageal air distention is also markedly noted with l-tube insertion. no opacification of large vessel with contrast media, without contrast enhancement of spleen, pancreas and left kidney is noted (fig.2) . prob. markedly compressed and poorly defined lower abdominal aorta with faintly visible both common iliac arteries and femoral arteries. after ctscan, nasogastric tube exchange was performed due to poor drainage of gastric fluid. about 700cc of gastric fluid was drained. however, sudden cardiac arrest of the patient was developed. although vigorous cardiopulmonary resuscitation was performed, the patient was died. (2017) 47 (suppl 2):s297-s pediatr radiol unique teaching points: acute abdomen compartment syndrome is a very serious and lifethreatening disease. as soon as possible, rapid diagnosis and adequate treatment are necessary for good prognosis. delayed diagnosis and treatment may result in fatal outcome. pleuroperitoneal fistula in a pediatric patient with primary hyperoxaluria type 1 w.p. chu; hang hau/hk to illustrate the imaging features of pleuroperitoneal fistula in a pediatric patient suffering from primary hyperoxaluria type 1 case presentation: an 11-year-old girl with the history of primary hyperoxaluria type 1 was repeatedly admitted to the hospital for recurrent right pleural effusion despite chest drain insertion. the right pleural fluid was transudative in nature and the microbiological cultures for bacteria and mycobacterial species were negative. the radiographic examination [ figure 1 ] showed moderate right pleural effusion a n d f e a t u r e s o f o x a l o s i s i n c l u d i n g b i l a t e r a l c o r t i c a l nephrocalcinosis and generalized increased in bone sclerosis. delayed planar images of the peritoneal scinitigraphy [ figure 2 ] obtained 3 and 5 hours after injection of technetium-99 m suphlur colloid found diffuse tracer activity at the right hemithorax, suggestive of pleuro-peritoneal fistula. the patient subsequently required thoracoscopy and surgical decortication at the right hemithorax and renal transplantation. primary hyperoxaluria is due to defective glyoxylate metabolism and results in increased synthesis of oxalic acid. cortical nephrocalcinosis and diffusely increased bone sclerosis are characteristic radiographic features. pleuroperitoneal fistula is unusual in patients without peritoneal dialysis. possible cause in this patient is increased intra-abdominal pressure related to portal hypertension and cirrhosis. osteosarcoma with pulmonary intra-arterial tumor embolism metastasis a. alzaher, f. alzaher; dammam/sa objective: osteosarcoma rarely invade the veins and small number of cases has been reported with venous invasion at the presentation. however, to our knowledge, no case has been reported with venous invasion and isolated distal metastasis as intra-arterial pulmonary embolisms. we are presenting a case of pediatric pelvic osteosarcoma with venous invasion and pulmonary arterial tumor embolisms as isolated distant metastasis at the presentation. the purpose of this case report is to describe the rare presentation of distant metastasis as isolated pulmonary arterial embolism that might be overlooked radiological. additionally, such tumor embolism might cause respiratory symptoms and differentiating tumor emblism from pulmonary thromboembolism is crucial to avoid the unnecessary anticoagulation. case presentation: fourteen year old boy who presented with 3 months history of right hip and lower limb pain after trauma. this was associated with lower limb swelling. the plain radiography showed right pelvic iliac bone aggressive mass, along with lobulated, soft-tissue components, extensive areas of osseous matrix, and malignant periosteal reaction. the patient could not tolerate the mri and ct scan was performed and it showed that the mass was invading the right external and internal iliac vein with imaging appearance was most consistent with osteosarcoma. patient staging was then carried on with mri under anesthesia and chest, abdomen and pelvic ct scan. the unenhanced and iv contrast enhanced chest ct scan showed multiple beaded expansion of sub segmental pulmonary arteries with soft tissue destinies and calcification suggestive of intra-arterial pulmonary tumor embolisms. there was no isolated pulmonary nodule or any other site of distant metastasis. unique teaching points: we present this case to increase the awareness of isolated intra-arterial pulmonary tumor embolisms as osteosarcoma metastasis especially with the present of venous invasion. additionally, such condition might be with respiratory symptoms and differentiating the tumor embolism from pulmonary thromboembolism is crucial to avoid the unnecessary anticoagulation. case presentation: a 14-year old boy with acute myelodysplastic syndrome presented with recurrent, acute severe anemia (hemoglobin 68 g/dl) and melena. his past history was significant for bone marrow transplant twice followed by graft-versus-host-disease of intestines, bilateral lung transplants for bronchiolitis obliterans, renal failure, scleroderma and acute pancreatitis. ct angiography performed previously did not identify active extravasation. several days before, upper gi endoscopy had demonstrated ulceration of the greater curvature of the gastric wall that was initially treated with epinephrine injection and surgical clip placement. at the time of referral, endoscopic interventions were unsuccessful leading to progressive clinical deterioration. a decision was taken to proceed to angiography to isolate the arterial source of hemorrhage, with an intention to embolize, if feasible. catheter angiography via transfemoral 4fr access revealed a left gastric artery pseudoaneurysm with active extravasation into the gastric lumen through the ulcer. after selecting the feeding pedicle of the left gastric artery with a microcatheter, the pseudoaneurysm was embolized using 40% nbca in lipiodol, resulting in complete angiographic obliteration of the bleeding source. on repeat cbc 6 hours post-procedure, the hemoglobin had increased from 80 to 115 g/dl. the patient remained hemodynamically stable in the intensive care unit. there is no evidence of bleeding recurrence 25 days later. unique teaching points: catheter angiography can define the bleeding source with greater accuracy than cta in children. there should be a low threshold to perform catheter angiography, with an intention to proceed to treatment. nbca embolization is a feasible and effective option for treatment of acute gi bleeding in children. case presentation: an infant born by cesarean section at 38 weeks of gestation, after nonreassuring cardiotocoghraphy, with meconium aspiration at birth, severe hepatocellular failure with hyperbilirubinemia, signs of hemorrhage, edema, ascites, hypoglycemia, increased ferritin values, and lactic acidosis was referred for ultrasound and magnetic resonance. both examinations showed signs of liver cirrhosis with portal hypertension; in addition, on t2-weighted images and gradient-echo images, the signal intensity of the liver and the pancreas was lower than that of the spleen and skeletal muscle, a finding consistent with abnormal iron deposition in those organs. a biopsy of the lower lip confirmed the diagnosis of neonatal hemochromatosis. unique teaching points: although the diagnosis may be suspected clinically, it must be confirmed by demonstrating the generalized iron overload affecting, among other organs, the salivary glands, liver and pancreas, with sparing of the reticuloendothelial system. the underlying cause may be associated with an an alloimmune mechanism; thus, intravenous immunoglobulin during gestation is administered in selected cases to prevent the severity of neonatal hemochromatosis. diagnosis is then crucial not only for management of the affected infant, but also for prevention in the future offspring. fishing for the answer -a rare case of paediatric exogenous lipoid pneumonia secondary to fish oil aspiration h. moodley, d. white, g.d. baker; johannesburg/za objective: lipoid pneumonia is a rare condition caused by the intrapulmonary accumulation of endogenous or exogenous fat containing substances. in the acute exogenous form secondary to aspiration of oil, it is important to make the diagnosis and remove the causative agent to prevent or arrest the progression of pulmonary fibrosis. radiopathological findings usually prompt the diagnosis, as aspiration of mineral oils is usually unnoticed due to the lack of reactive airway symptoms and patients present with vague chronic respiratory symptoms. case presentation: we present the clinical, radiological and pathological correlation of exogenous lipoid pneumonia in a 4-month-old male patient with recurrent respiratory tract infections. a ct chest demonstrated an extensive crazy paving pattern of the dependent lung segments bilaterally. the lung biopsy findings of occasional intra -alveolar macrophages with larger (2017) 47 (suppl 2):s297-s pediatr radiol foamy cytoplasmic vacuoles, raised the possibility of an exogenous lipoid pneumonia secondary to aspiration. on further history, the patient was found to have been fed fish oil by his mother, confirming the diagnosis. unique teaching points: the rare diagnosis of exogenous lipoid pneumonia can be confirmed on ct chest by measuring the hounsfield units in the most hyperdense components of consolidation (typically -150 to -30 hu). histopathological confirmation can be obtained provided that the specimens are not embedded in paraffin. the possible role of visual evaluation of dwibs in childhood renal masses based on our five cases e. varga, g. rudas; budapest/hu objective: nowadays, the diffusion-weighted mri has a great importance not only in the differential diagnosis and follow-ups of childhood renal tumors, but in the early detection of recurrence of the disease as well. the dwibs with appropriate b-values and the adc calculation can be helpful in distinguishing between benign and malignant processes. however, the adc calculation is a time consuming method and in addition, there are cases when we cannot use this technique, but we can still apply the visual evaluation of diffusion. case presentation: between 2013-2016, we had 5 cases in which the visual assessment of dwibs was the best method which helped to make the appropriate therapeutic decisions. left kidney of an infant with nephroblastomatosis was removed because of an arising wilms tumor. 2,5 years later, in the contralateral kidney, a small area of diffusion restriction appeared on the dwibs in one of the cystic residual lesions, but the anatomic sequences haven't showed any changes comparing with the previous examinations. in another patient with beckwidt-wiedemann syndrome, the follow-up ultrasound examination showed a little bulging of the surface of the left kidney. accordingly, the mri showed a barely distinguishable nodule, but the dwibs referred to a wilms tumor. in a 17-month-old child, more nodules were visible in both kidney on the dwibs than on other sequences. with the help of visual evaluation of dwibs, we were able to detect the malignant lesion easily and quickly, among a lot of cystic and solid nodules of the kidneys in a seven years old patient with sclerosis tuberosa. an 8-month-old infant was followed with a benign cystic renal disease and a new small solid nodule was found on the last ultrasound examination. instead, the visual assessment of dwibs indicated a multilocular cystic wilms' tumor. unique teaching points: the diffusion-weighted mri is suitable for differentiate benign and malignant renal lesions in children. the dwibs (with appropriate b-values) and the adc calculation are very sensitive methods in pediatric oncoradiology. the adc calculation is a long process andas our cases demonstrated -we cannot apply in every cases. the visual evaluation of dwibs is a time saving method which is spared from limitations of adc histogram-based assessment, so it may become very useful in the everyday practice. we can use it in the differential diagnosis and follow-ups of childhood renal tumors and we can detect the recurrence of the malgnancy very early and easily. mr urography in a 9-years-old female with unusual urinary dribbling m.c. terranova, c. tudisca, d. narese, g. li voti, s. salerno; palermo/it objective: congenital anomalies of kidney and urinary tract (cakut) occurs in up to 3.2% of infants, and clinically they can range from asymptomatic patients, in which anomaly is detected incidentally even in adulthood, to ante-natal or post-natal mortality due to bilateral kidney agenesis or acute renal failure. dmsa renal scintigraphy is considered gold standard, for evaluation of those cases electable for surgery, in order to assess renal function, depict and locate ectopic kidney and guide surgical management, but has the important limit of radiation exposure and may undetect poorly functional renal moieties. the advent of modern magnetic resonance technics proven to be able to assess anatomical malformations and renal function, overcoming the limits of dmsa scintigraphy, may be used as a valid alternative, especially in vulnerable pediatric population. we herein describe a case of a young girl with small left renal bud and ectopic ureter, draining in vagina, discovered by mr and undetected by previous dsma scintigraphy. case presentation: a 9 years old girl was referred for continuous urinary dribbling, after starting toilet training, with normal bladder voiding pattern, unrelated to any physical and psychological events, and no history of urinary tract infections. physical examination revealed vaginal septa and micturition training was practiced, with no symptoms improvement. abdominal us study was performed, reporting empty left renal fossa and hypertrophic right kidney; no ectopic kidney nor sign of urine stasis or other urogenital anomalies were detected, and dmsa renal scintigraphy was planned. it depicted only normal right kidney radionuclide uptake but no evidence of left renal or ectopic renal tissues activity. patient then underwent mr evaluation for suspected genito urinary malformation, that revealed a small cystic formation, with a slight cortex, at the level of the iv lumbar vertebra -that represented the left immature renal bud -supplied by a short fluid-filled tubular structure, located postero-medially to the bladder -that configured the left ectopic ureter, draining in left vaginal wall. bladder was normal, and regularly connected with the right orthotopic ureter (fig 1) . pre-surgical cystoscopy and vaginoscopy, followed by left ascending urethrogram were performed, confirmed previous mr findings, and patient underwent successfull laparoscopic left nephron-ureterectomy. unique teaching points: mr urography has proven to be a rapid, safe, radiation free, systematic diagnostic tool especially in the evaluation of poorly functioning renal systems, and of collecting system, bladder and ureteral abnormalities, overcoming the limits of conventional imaging technics agenesis of the dorsal pancreas: case report c. lanza, g. pieroni, l. amici, a. giovagnoni; ancona/it objective: agenesis of the dorsal pancreas (adp) is a rare malformation. since 1911 and until 2008, 53 cases have been reported. majority of the patients with this anomaly are asymptomatic or associated with abdominal pain, hyperglycemia, diabetes mellitus, and acute or chronic pancreatitis. case presentation: we present a case report of a 11-year-old girl with adp, diagnosed incidentally during radiological evaluation for abdominal pain. she was hospitalized in the pediatric department for recurrent abdominal pain for the past 10 months. there was no history of nausea, vomiting or trauma. biochemical investigations showed a normal random serum glucose, serum amylase levels slightly increased (149 u/l; reference value 28-100 u/l) and slightly elevated serum pancreatic lipase levels (138 u/l; reference value 22-51 u/l). the day after serum amylase levels decresed up to 80 u/l and lipase levels to 78 u/l. us revealed increased -size pancreatic head with normal contour and echotexture with no parenchymal calcification or duct dilatation. the body and the tail of the pancreas were poorly visualized. mr imaging examinations revealed only a partial visualization of the pancreas: the pancreatic head and the uncinate process were visualized with defined margins with peripancreatic fat stranding, but the distal neck, body, and tail of the pancreas were absent. on mrcp, the dorsal pancreatic duct of santorini and the minor duodenal papilla could not be visualized. the ventral pancreatic duct of wirsung and the common bile duct were normal and clearly visualized. these findings were compatible with complete adp, eliminating the need for ercp. unique teaching points: the clinical presentation of dpa varies greatly ranging from incidental detection on x-ray, surgery or autopsy through to the development of a ductal adenocarcinoma of the pancreas. abdominal pain and diabetes are the most frequent clinical manifestations reflecting exocrine and endocrine insufficiency as most of the islands of langerhans are located in the tail of the pancreas. there have also been reports of an increase in the size of the remnant pancreas and recurrent acute pancreatitis as a form of presentation. diagnosis requires confirmation of the absence of the neck, body and tail of the pancreas and duct of wirsung using endoscopic retrograde cholangiopancreatography (ercp) or mrcp. one hundred four mr images of foetal cns with a us suspicion of acc were retrospectively reviewed. foetal mri was performed at 1.5 t magnetom avanto (siemens, erlangen, germany) without motherfoetal sedation. polymicrogyria, lissencephaly, schizencephaly, subependymal heterotopias and migration disorders were evaluated. cortical findings were compared to three types of acc (complete agenesis, partial agenesis and hypoplasia). genetic tests were collected. postnatal mri or foetopsy for diagnostic confirmation were collected. on 104 foetuses, fetal mri was able to detect cortical malformations in 32 cases even in early gestational ages (<24gw). the mean gestational weeks (gw) at mr diagnosis was 26 (range: 22-36gw). mr imaging found 13/32 polymicrogyria, 7/32 lissencephaly, 5/32 schizencephaly, 4/32 subependymal heterotopias and 3/32 neuronal migration disorders. 22/32 had complete acc, 4/32 had partial acc and 6/32 had cc hypoplasia. statistically significant correlations (p<0.005) between complete acc, focal polymicrogyria and cortical dysmorphism affecting frontal lobes were found. fetal cns mri can detect cortical development malformations in complex acc, providing further information for the clinician to assess the severity of perinatal outcome. mri is a useful tool in improving obstetrical genetic prenatal counselling to predict pregnancy and foetal prognosis. clinical signs of the neonatal lymphatic flow disorder (nlfd) are a combination of the congenital chylothorax, chylous ascites and body edema. it can present as neonatal chylothorax (nc), neonatal chylous ascites, or congenital lymphatic dysplasia (cld). the prenatal appearance of lymphangiectasia has been described as nutmeg lung. the purpose of this study is to describe prenatal and postnatal imaging features and outcomes of neonates with nlfd. materials: this is a retrospective case series of neonates in our institution that had pre-and postnatal lymphatic imaging and nlfd. all patients had prenatal imaging (fetal mri and us) and underwent postnatal dynamic contrast mr lymphangiography (dcmrl) with a three-dimensional (3d) t2 space. conventional lymphangiography (cl) when performed was also reviewed. six patients with nlfd were identified (3 with nc and 3 with cld). one patient had congenital heart disease. nutmeg lung was seen in all patients on fetal mri and 4 patients on fetal us. 5/6 patients had pleural effusions, 2/6 had ascites and 1/6 had body wall edema prenatally. postnatal mri with 3d t2 space revealed soft tissue edema in the upper chest and neck (5/6 patients), mediastinal edema (5/6 patients), interstitial lung edema (6/6 patients), retroperitoneal edema (5/6 patients), and ascites (6/6 patients). dcmrl demonstrated lymphatic flow to the pleural space (5/6 patients) and to the abdominal cavity (1/6 patients) and dermal backflow (2/6 patients). cl was performed in 4 patients, all of which had collateral lymphatic flow to the lung. lymphatic intervention was performed in 3 patients, lipiodol injection for 2 patients with nc and thoracic duct embolization (tde) for 1 patient with cld. mean hospital duration in the first 4 months of life was 51 days (range 5-113) for nc and 105 days (range 75-120) for cld. all 3 patients with cld died after 4 months of age due to respiratory distress including the patient that had tde and both with findings of dermal backflow. the pleural effusions in the 2 patients with nc resolved post lipiodol injection and in the other patient with nc it resolved with conservative therapy. conclusion: nlfd is a disorder that can be recognized on prenatal and postnatal imaging. in this small series, nutmeg lung was present in all patients with nlfd and may be easier to recognize with fetal mr than us. dermal backflow on dcmrl suggests a poor prognosis. both prenatal and postnatal imaging may guide treatment and interventions in nlfd. fetal mri and postnatal ct scans of prenatally diagnosed bpms from 10 patients with available histology were analyzed retrospectively. the fetal mri and ct images were reviewed by two radiologists blinded to histological findings. specific diagnosis was assigned based on predetermined criteria. the accuracy of fetal mri was evaluated. the agreement rate in fetal mri diagnosis between two radiologists was 100 %. an overlap of 80% in fetal mri and histopathological diagnosis was reached. when comparing fetal mri and postnatal ct examinations, the agreement of the results was also 80%. the least matching histological diagnosis was bronchopulmonary sequestration (bps). fetal mri is very accurate in characterizing the bpm spectrum and provides important information on lesion type and structure when compared with histology. with relatively small number of patients high correlation between prenatal mri and postnatal ct was reached. therefore, further investigation with more patients is needed. we hypotethise that fetal mri in late pregnancy could in the future replace early (neonatal) ct examinations if fetal mri provides sufficient inforfmation for clinical management. real time virtual sonography: a new integrated approach for the evaluation of fetal cerebral pathologies? s. bernardo, a. antonelli, v. vinci, m. saldari, c. catalano, l. manganaro; rome/it objective: real-time virtual sonography (rvs) is a new technique that uses magnetic navigation and computer software for the synchronized display of real-time us and multiplanar reconstruction mri images. the purpose of this study was to evaluate the feasibility and ability of rvs to assess the main cerebral pathologies in fetuses with suspected us anomalies. materials: this is a prospective study. fusion imaging (hitachi hi vision ascendus) was offered to 35 patients undergone fetal mri for a us suspicion of cerebral pathology. the mri image dataset acquired was loaded into the fusion system using a cd support and displayed together with the us image. both sets of images were then manually synchronized and images were registered. the possibility to record the images in a video format allowed, however, the possibility to re-evaluated the examination. results: rvs was technically possible in all cases. data registration, matching and fusion imaging were performed in 25 minutes at the beginning and in less than 15-20 minutes after practice. the ability of rvs imaging to assess the main anatomical sites and fetal anomalies was evaluated and compared with standard us and mri images. the principal application of rvs was the study of midline, cerebral gyration and vascular malformations because it also allowed adding a real time doppler signal on mri images. fusion imaging helped the diagnosis in 25%. in the 25/ 35 cases of encephalic pathology, fusion imaging improved the diagnosis; in the other cases mri was superior to us even using the rvs. this is a preliminary study on the feasibility and practical use of a fetal mri-us real-time fusion imaging. both techniques are complementary but still independent and the retrospective synthesis of these exams allows optimal analysis of fetal cerebral anomalies. this technique has many advantages especially on the pedagogic plan. however, rvs is currently limited to the research area. role of foetal mri in the evaluation of ischaemic-haemorrhagic lesions of the foetal brain s. bernardo, a. antonelli, v. vinci, m. saldari, c. catalano, l. manganaro; rome/it the aim of this study was to define the role of fetal magnetic resonance imaging in the evaluation of cerebral ischaemic-haemorrhagic lesions and the extension of parenchymal injuries. from september 2010 to december 2016 we performed 271 fetal mri of cerebral region in foetuses with suspected abnormalities on ultrasound or cmv infection and toxoplasma serum conversion. fetal mri was performed with a 1.5-t magnet system without materno-fetal sedation. fetal mri detected ischaemic-haemorrhagic lesions in 14/271 fetuses, revealing a 5% pathology incidence. mri confirmed the diagnosis in 3/14 cases with us suspect of ischaemic-haemorrhagic lesions associated with ventriculomegaly. in 1/14 cases with us findings of cerebellar haemorrhage, mri confirmed and provided additional information regarding the parenchymal ischaemic injury. in 8/14 cases with us suspect of ventriculomegaly (n=3), corpus callosum agenesis (2), cerebellar vermis hypoplasia (1), holoprosencephaly (1), spina bifida (1) mri detected ischaemic and haemorrhagic lesions unidentified at us examination. in 2/14 fetuses with us suspicion of intracerebral tissue space-occupying lesion, mri modified the diagnosis to extra-axial haematoma associated with dural sinus malformation. results were compared to fetopsy or after-birth follow up. fetal mri is an additional imaging modality in the diagnosis of cerebral ischaemic-haemorrhagic lesions and it is useful in providing further information on the extension of parenchyma injury and associated abnormalities and in improving delivery management. the contribution of mid-trimester virtual autopsy with mr imaging a. d'hondt, n. d'haene, j. rommens, m. cassart, f.e. avni; brussels/be the aim of the study was to assess the potential contribution of fetal virtopsy (post-mortem mr imaging (pm-mri)) in the second trimester of pregnancy. during a one-year period, post-mortem mr imaging (pm-mri) was performed in all fetuses who died in utero or whose pregnancy was interrupted due to major malformations. the study was performed in agreement with the local ethical committee. fetuses of <26 weeks that underwent obstetrical ultrasound and pm-mr were included. mr imaging examination was performed on a 1.5 tesla magnet with a standardized protocol. the findings on pm-mri were compared to obstetrical sonographic findings (and to pathology when available). we have analyzed separately the findings in the central nervous system and those in the rest of the fetus (chest, abdomen and skeleton). the results were classified in three categories according to the diagnostic accuracy: ultrasound>pm-mri, ultrasound=pm-mri and pm-mri>ultrasound. the us and pm-mri data of ten fetuses were analyzed. their gestational age ranged from 17.6-26 weeks and their bodyweight ranged from 160-930g. for the cns malformation: pm-mri offered a better diagnostic accuracy than us in 7 cases (70%) (e.g. agenesis of the corpus callosum and holoprosencephaly). in 3 cases (30%) us offered the same information than pm-mri. there was no case where us was more accurate than pm-mri. for the rest of the body malformations: pm-mri offered a better diagnostic accuracy in 5 cases (50%) (e.g. heterotaxy anomalies or vertebral segmentation anomalies). in 3 cases (30%), us offered the same information as pm-mri. there were 2 cases (20%) where us showed major malformations that were not diagnosed on the pm-mri (two cases of cardiac malformation). post mortem mr imaging is more accurate than obstetrical ultrasound in detecting major malformations in the cns as well as in the rest of the body. the present exceptions are cardiac malformations. the examination offers an easy evaluation of the deceased fetus. it provides, in most cases, important additional information. diffusion coefficient and perfusion fraction parameters correlate with gestational age in normal human in vivo placenta: a preliminary study a. antonelli, m. guerreri, s. bernardo, s. capuani, c. catalano, l. manganaro; rome/it to investigate the potential of diffusion parameters derived from a biexponential analysis as marker to evaluate the perfusion quality of normal in vivo placenta. eighteen normal pregnancies, fulfilling the study inclusion criteria, have been analysed at 1.5 t magnetom avanto (siemens, erlangen, germany) without mother-foetal sedation. dw imaging was collected using seven b values: 0, 50, 100, 150, 400, 700, 1000 (s/mm 2 ). three regions of interest (rois) have been considered -central (c), peripheral (p) and umbilical (u) regions. a bi-exponential model was used to obtain perfusion fraction (f), pseudo-perfusion (d*) and apparent diffusion (d) coefficients. pearson test was performed to investigate correlation between diffusion parameters and gestation weeks (gw), body mass index (bmi) and basal glycaemia (bg). the average values on all rois were d=1.41±0.16•10 -3 (mm 2 /s), d*=1.81 ±1.28•10 -2 (mm 2 /s), f=3.28±0.18•10 -1 , in good agreement with the literature. in the c roi, a positive correlation (p<0.04) was observed between f and gw. after 30 gw in the p roi a positive correlation between f and gw (p<0.05) and a negative correlation between d and gw (p<0.0001) were found. no correlation was found between d, d*, f, bmi and bg. conclusion: the f increase reflects normal placenta perfusion physiology. on the other hand, the decrease of d highlights placental parenchyma maturation becoming more fibrotic during late gestational age. bi-exponential model provides more and useful information about placental morphological changes compared to mono-exponential diffusion model. to demonstrate the diagnostic value of fetal mri in the detection of fetal central nervous system (cns) impairment in prenatally echocardiographic diagnosed congenital heart diseases. we retrospectively examined 24 fetuses between 19 gestational weeks and 33 gestational weeks who performed a fetal mri in our institution after a second-line ultrasonography, between april 2010 and october 2015. fetal heart and cns studies were performed with a 1.5 tesla magnet (siemens magnetm avanto) without maternal sedation. prenatal findings were compared to fetopsy results, fetal mri after 30 gw or postnatal mri. in our sample of 24 cases, 7/24 had interatrial septal defect (iasd),intervertricular septal defect (ivsd), and atrioventricular canal defect (cavc), 6/24 had cardiac rhabdomyomas, 3/24 had hypoplastic left heart syndrome and hypoplastic aorta, 2/24 had transposition of the great vessels, 2/24 had fallot tetralogy, 2/24 had aorta coartation and 2/24 had intracardiac masses of uncertain significance. magnetic resonance imaging was able to detect cns impairment: we recognize 11/24 corpus callosum (cc) dysgenesis (4/13 cc hypoplasia, 4/13 complete cc agenesis, 3/13 partial cc agenesis), 7/24 ventriculomegalies or hydrocephalus, 3/24 subtentorial anomalies (dandy-walker, vermian hypoplasia and vermian malrotation) and 3/24 gyration anomalies. due to the high risk of cns involvement in prenatal congenital heart diseases, it is essential to suggest an mri study of the evolving fetal brain especially in complexes forms that suggest a syndromic background. fetal mri of the cns is mandatory in the study of congenital heart disease due to the high rate of encephalic anomalies associated, particularly in iasd, ivsd and cavc. first experiences and diagnostic utility of micro-ct for fetal autopsy j.c. hutchinson 1 , x. kang 2 , s.c. shelmerdine 3 , m. cannie 2 , v. segers 2 , n. sebire 3 , j. jani 2 , o.j. arthurs 3 ; 1 newcastle upon tyne/uk, 2 brussels/ be, 3 london/uk perinatal autopsy remains poorly accepted by parents, despite yielding information that affects the management of future pregnancies in around 30% of cases. microcomputed tomography (micro-ct) has shown promising results in the examination of ex-vivo fetal organs, and may provide diagnostic imaging in cases where traditional autopsy is challenging, and s416 (2017) 47 (suppl 2):s297-s pediatr radiol existing post mortem imaging techniques (ct and mri) provide insufficient diagnostic resolution. our objective was to examine whole fetuses non-invasively using micro-ct, and compare the findings with standard autopsy as the gold standard. in this ethically approved double blinded study, terminated fetuses or miscarriages underwent iodinated micro-ct examination followed by conventional autopsy. images were acquired using a nikon xth225st microfocus-ct scanner with individual specimen image optimisation. forty indices normally assessed at perinatal autopsy were evaluated for each imaging dataset by two independent reporters and a consensus report produced. autopsies were performed blinded to the imaging findings by one of two perinatal pathologists. we examined 8 fetuses, with a gestational age range of 11-16 gestational weeks. 36/320 indices were non-diagnostic (11%), but there was agreement for 271/284 diagnostic indices (overall concordance of 95.4% (95% ci 92.3, 97.3%). in seven out of eight fetuses (87.5%), the same final diagnosis was made following micro-ct examination and autopsy examination; in one case, micro-ct was non-diagnostic. ten false negatives indices included a vsd, laryngeal anomaly, ambiguous genitalia and incomplete bowel rotation, none of which changed the overall diagnosis. three apparent false positives on micro ct were a cloacal anomaly, incidental cystic neck lesion and thymic atrophy, which were not detected at autopsy. micro-ct of early gestation whole fetuses can provide highly accurate datasets with three-dimensional renderings of complex disease processes. this approach confirms the potential of this technology for non-invasive examination of small fetuses. investigation of perinatal body organ diffusion-weighted post mortem mri s.c. shelmerdine 1 , m. cheryl 2 , j.c. hutchinson 1 , n. sebire 1 , o.j. arthurs 1 ; 1 london/uk, 2 southampton/uk objective: diffusion weighted magnetic resonance imaging (dwi) uses water molecule diffusion to generate mr contrast images, and can reveal microstructural or functional changes in tissues, quantified by measuring the apparent diffusion coefficient (adc). the application of dwi to the post mortem setting is appealing as it does not require the administration of an exogenous contrast agent. a recent pilot study of 15 paediatric cases suggested that lung adc values at pm mri may be a useful marker of post mortem interval (time since death; pmi) which has forensic relevance, but other body organs have not been comprehensively evaluated. the aim of this study was therefore to evaluate the relationship between pmi and body organ adc values in a larger cohort of subjects across a wider gestational range in the setting of perinatal death. whole body perinatal postmortem mri with dwi sequences were performed at 1.5t, with b values of 0, 500, 1000 mm 2 /s. mean adc values were calculated from regions of interest (rois) placed in the lungs, myocardium, spleen, renal cortex, liver and psoas muscle. the values were measured by two independent readers, correlated against gestational age and post mortem interval (pmi) using the pearson product-moment correlation coefficient. bland-altman plots were created, and the limits of agreement used to assess the inter-observer agreement of mean adc values. results: eighty fetal deaths and stillbirths were imaged with mean gestational age 31.5 weeks (range: 20 -41 weeks). the mean pmi was 8.9 days (range 2-20 days). there was a weakly positive correlation between pmi and mean lung adc (r 2 =0.03) and spleen adc (r 2 =0.08). no correlation was found with between adc and pmi for the other body organs. there was reasonable inter-observer agreement between the two readers, with mean adc difference 11.8 mm 2 /s (+/-135.1 mm 2 /s). perinatal lung and splenic adc values show a mild increase with increasing pmi. together with other imaging parameters, this may be useful to evaluate organ-specific changes which occur in the post mortem period, particularly in a forensic setting. further research is needed to understand the organ-specific changes which occur in the post-mortem period. usefulness of combined grey-scale and color doppler ultrasonography(us) findings in the evaluation of acute pyelonephritis in children k. lee, j.h. lee; anyang/kr objective: us diagnosis of apn in children can give a valuable information to the clinicians for the early treatment. but the problem of us in the diagnosis of apn is wide range of sensitivity, which is 11-69%. the purpose of this presentation is to evaluate the usefulness of grey-scale us and color doppler us in the diagnosis of acute pyelonephritis in children. from march 2007 to february 2014, 154 children(308 kidneys), 108 boys and 46 girls, aged 2 weeks to 9 years (mean age, 7.7 months) underwent kidney us as an initial diagnostic tool for acute pyelonephritis and follow up dmsa scintigraphy within a week. criteria for acute pyelonephritis on grey-scale image were focal/diffusely increased/decreased echogenicity or loss of corticomedullary differentiation. on color doppler sonography, the criterion was decreased color flow. we classified the us diagnosis of apn into 4 categories. definite, suggestive, possible and normal. when above two grey-scale us criteria and color doppler us criterion are seen, we classified it as 'definite'. when one of greyscale us and color doppler us finding are seen, it was classified as 'suggestive' of apn. 'possible' apn was abnormal finding either on grey-scale or color doppler us. 'normal' was no abnormal findings on grey-scale and color doppler us. we compared above findings with dmsa scan, which is considered as gold standard for diagnosing apn. statistical analysis was performed on all 308 kidneys. the overall sensitivity of our study was 68%(88/129) and specificity was 72%(123/177). the positive predictive value for each definite, suggestive, possible groups were 86%, 60%, and 38% respectively. the negative predictive value for normal group was 75%, which means the false ppv was 25%. the p-value of the definite and suggestive was statistically significant, but the possible was statistically insignificant. in the diagnosis of apn in children, abnormal us finding either on greyscale or color doppler us is not optimal. abnormal us findings both grey-scale us and color doppler us showed good association with dmsa scan and statistically significant. combined grey-scale and color doppler us findings can give a more reliable information in the diagnosis of apn in children. the greater degree of gastric and/or duodenal wall thickening and increased echogenicity are helpful sonographic features in differentiating congenital duodenal anomalies from malrotation. our findings confirm the superiority of us vs ugi for evaluation of duodenal obstruction in neonates and evaluation of gastric and duodenal wall must be added to the constellation of other features to be assessed on us examinations. a measure of renal morphology as an indicator for potential renal failure a.c. eichenberger, p. grehten, c. kellenberger; zurich/ch this study introduces a measure of renal morphology, herein labelled split renal volume (srv), that should be applied as an indicator for potential renal failure and eventual surgical treatment of obstructive uropathy in children. current practice applies dynamic contrast enhanced functional renal imaging (fri) with complex post-processing methods. fri generates a measure of split renal function (srf). reduced values of srf under 45% are currently considered to be an indicator for surgical treatment. this retrospective study compares the accuracy of srv with the accuracy of srf as methods for assessing potential renal failure. materials: srv is a quotient of volumetric measurements. total renal volume is described by the sum of parenchymal volume and intra-renal collecting system volume. srv is designated in this study as the quotient of two ratios: first, the ratio of total renal volume to parenchymal volume of the left kidney; and second, the ratio of total renal volume to parenchymal volume of the right kidney. twenty-two children were studied: 16 (age 3.1±4.5y) with unilateral asymptomatic intrinsic uretero-pelvic-junction obstruction (upjo), and 6 normal controls (age 6.6±4.0y). all subjects underwent mr urography at 1.5t, which provided estimates of srf and srv for each of the 44 examined kidneys. the sensitivity and specificity of both srf and srv for predicting surgical management were determined by comparing the indicators with an expert review panel's decision to operate. the panel was blinded to values of srv. results: when a cut-off value of 45% for srf was used, the resultant sensitivity and specificity of srf for the detection of kidneys at risk were found to be 44% and 86%. the values of srv ranged between 0.3 and 3.5. it was found that a value greater than 1.1 indicated kidneys at risk. when the cut-off value of 1.1 for srv was used, the resultant sensitivity and specificity of srv for the detection of kidneys at risk were both 100%. in this small population, srv proved to be 100% accurate and is superior to srf for detecting kidneys at risk of failure due to obstruction. routine application of srv promises to simplify mr urography by obviating dynamic contrast enhanced imaging studies. further prospective studies are necessary in order to select an optimal cut-off value of srv. factors that can distort the dj flexure mimicking malrotation v. bhalla 1 , s. mohan 2 , k.a. bradshaw 2 , m. thyagarajan 2 ; 1 stoke-on-trent/uk, 2 birmingham/uk to highlight the varied radiological appearances and position of the duodenal-jejunal flexure in children and to discuss its importance in assessing for malrotation materials: retrospective analysis of the multiple fluoroscopic examinations performed in the assessment for malrotation over the past 5 years in a busy tertiary centre results: the classic position of the dj flexure is to the left of left pedicle of l1 and at the level of the duodenal bulb on frontal views and posterior (retroperitoneal) on lateral views. however variations of the normal location can appear, particularly on frontal views, in the upper gi series that can mimic malrotation which has shown to be more common in neonates. we present cases with examples to illustrate the variability in position due to various causes and its implications in the diagnosis of malrotation and volvulus. our case mix includes patients with excessively distended stomachs, large bowel obstruction, renal pelvic dilatation, repeated naso-jejunal and gastro-jejunal tube insertion and in patients post liver transplantation. malrotation and its assessment have serious management and prognostic implications. this presentation demonstrates that the imaging features can be varied, and knowledge about factors distorting the position of the dj flexure is vital in the accurate management of neonates presenting with bilious vomits. retrospective study of prospectively collected data performed at a single tertiary paediatric institution over a 16.5 year period. a total of 1000 consecutive patients, aged <18 years, were reviewed who underwent native renal biopsy. all biopsies were performed within the interventional radiology department. all patients had renal disease requiring a renal biopsy for diagnosis. outcome measures include technical success, early and late complications and the adequacy of histological samples. in addition, age, body weight, glomeruli number, histological data, number of cores, size of the biopsy needle, use of co-axial needle and the rate of tract embolisation/plugging were recorded. results: from september 1999 to april 2016, 1000 patients (mean age: 10.07 years +/-4.65; range 0.14 -18.0 years) underwent native renal biopsy. one hundred ninety-one patients were <5 years of age. nine hundred forty-six patients (94.6%) had a biopsy of the right kidney, 53 patients (5.3%) had a biopsy of the left kidney and 1 patient (0.1%) had a biopsy of a horseshoe kidney. five hundred fifteen patients were female (51.5%). seven hundred sixtynine patients (76.9%) had the procedure performed under general anaes-thetic and 227 of patients (22.7%) had the procedure performed under local anaesthetic (+/-sedation/entonox). mean number of passes of the core biopsy needle through the renal capsule was 2.7. a 16 gauge core biopsy needle was used in 100% of the patients. 81.9% of the patients had three or less passes of the biopsy needle though the renal capsule. the overall complication rate was 2.6% (n= 26). 1.2% (n= 12) of patients had a non-diagnostic biopsy. fifty-five patients underwent a post biopsy ultrasound due to clinical concerns. twenty patients developed perinephric haematoma (19 were treated conservatively; one underwent embolisation and subsequent nephrectomy). four patients developed arteriovenous fistulas. two patients developed post procedure infections (one at the skin site and one a perinephric collection). histology results were reviewed in all patients. the mean number of glomeruli obtained was 26.97 (range 2-87). glomerulonephritis was the most common histological diagnosis (n=464; 46.4%) conclusion: renal biopsy is an extremely useful diagnostic tool for renal disease. there is no published data of this size assessing the outcome of native renal biopsies in the paediatric population. jr usa 1979 a. lassrich germany 1979 j. sauvegrain france 1982 c. fauré france 1982 a. giedion switzerland 1983 e. willich germany 1984 r. astley united kingdom ringertz sweden 1994 d.g. shaw united kingdom 1996 r. lebowitz usa 1996 b. lombay hungary pena spain gold medallists london/united kingdom the dutch group of paediatric radiologists, the hague/the netherlands 1981 g. stake ringertz (espr) & d. kirks (spr) chicago/united states future espr meeting italy european courses of paediatric radiology (ecpr) genoa/italy (neuroradiology) 2000 r.fotter, graz/austria (abdomen) brussels/belgium (thorax) 2006 j-n. dacher paediatric musculoskeletal imaging) references: 1. 2014-stellungnahme-lnt-modell.pdf [internet]. [zitiert 2 an evaluation of paediatric projection radiography in ireland contrast imaging -> application -dectris background ionizing radiation and the risk of childhood cancer: a census-based nationwide cohort study best practices in digital radiography communicating radiation risks in paediatric imaging kinderradiologie-besonderheiten des strahlenschutzes diagnostic imaging and ionizing radiation -canadian nuclear safety commission epidemiology without biology: false paradigms, unfounded assumptions, and specious statistics in radiation science (with commentaries by inge schmitz-feuerhake and christopher busby and a reply by the authors) european guidelines for ap/pa chest x-rays: routinely satisfiable in a paediatric radiology division? eurosafe imaging together -for patient safety image gently campaign back to basics initiative: ten steps to help manage radiation dose in pediatric digital radiography hostens j, u. a. in-vivo dark-field and phase-contrast x-ray imaging safety commission cn. linear-non-threshold model optimisation of paediatric chest radiography optimizing digital radiography of children radiation exposure in diagnostic imaging: wisdom and prudence, but still a lot to understand radiation shielding for diagnostic radiology strahlenhygienische aspekte bei der röntgenuntersuchung des thorax the image gently pediatric digital radiography safety checklist: tools for improving pediatric radiography the standardized exposure index for digital radiography: an opportunity for optimization of radiation dose to the pediatric population gastroenterology and radiology records were searched to identify ibd patients with colonic strictures. all patients underwent an mre within 3 months of colonoscopy. the following colonic parameters were evaluated: bowel wall thickening with luminal narrowing, pre-stenotic bowel dilatation, bowel wall enhancement, and diffusion restriction (if performed). colonoscopy and operative notes were correlated. results: fourteen patients met the inclusion criteria, one with 2 colonic strictures. bowel wall thickening with luminal narrowing at the site of the reported stricture was present in all cases. pre-stenotic bowel dilatation (>3.0 cm) proximal to the reported stricture was present in 11/15 cases. using luminal narrowing and prestenotic dilatation as criteria for diagnosis of a colonic stricture, 11/15 cases were therefore positive on mre. when comparing to colonoscopy, mre diagnosed colonic strictures in 8/12 cases (67%). in the six patients who had surgery, mre accurately diagnosed colonic strictures in 5/6 cases (83%). conclusion: mre is not the primary modality for colonic evaluation, yet diagnosing colonic pathology on mre, particularly strictures, may be beneficial for the referring gastroenterologist in the assessment of these patients. potential strictures on colonoscopy did not agree with mre in all cases, but when correlating with surgery 83% of colonic strictures were accurately diagnosed in a small subset. although mre is not optimized for the evaluation of the colon, colonic strictures can be recongnized in children with crohn's disease.disorders of sexual differentiations in neonates: standardized sonographic evaluation and proposal of a reading grid h. lerisson, e. amzallag -bellenger, f.e. avni, m. cartigny; lille/fr to propose a systematic and structured sonographic approach in neonates with disorders of sexual differentiation (dsd) materials: review of the us pelvic, external genital and adrenal findings in 20 consecutive patients with clinical suspicion of dsd evaluated in the neonatal period. the us survey included: the uterus (absent or visible -with or without hormonal impregnation), the vagina (absent or present (complete or partial)), the gonads (ovaries, testis or unsetermineddysgenetic ) as well as the adrenals (normal, too small or enlarged). the us conclusions were correlated with the endocrinological and genetical work-up of each patient results: twenty cases of dsd have been included us had correctly identified the presence of a uterus in 11 patients. there was one false positive case; 6 among the 11 patients did not show the physiological hormonal impregnation. the 5 vaginal anomalies were correctly evaluated. the gonads were defined correctly as normal testis in 6 patients, normal ovaries in 4 and dysgenetic gonads in 4. they could not be visualized in 6 patients. adrenals were considered normal in 17 patients (one false negative), hypertrophied in 2 and small in one patient. to compare hepatic 2d shear wave elastography (2d swe) in children between free-breathing and breath-hold conditions, in terms of measurement agreement and time expenditure. a cohort of 57 children (12.7±4.3 years) who underwent standardized 2d swe between may and october 2015 were retrospectively evaluated. liver elastograms were obtained under free-breathing and breath-hold conditions and time expenditure was measured. median stiffness, interquartile range (iqr), and iqr/median ratio were calculated based on 12, six, and three elastograms. results were compared using pearson correlation coefficient, intraclass correlation coefficient (icc), bland-altman analysis, and student's t. median liver stiffness under free-breathing and breath-hold conditions correlated strongly (7.22±4.5kpa vs. 7.21±4.11kpa; r=0.97, p<0.001). time to acquire 12 elastograms with free-breathing was lower than that with breath-holding (79.3±32.5sec vs. 143.7±51.8sec, p<0.001). results for median liver stiffness based of 12, six, and three elastograms demonstrated very high agreement for free-breathing (icc 0.993) and for breath-hold conditions (icc 0.994). hepatic 2d swe performed with free-breathing yields results similar to the breath-hold condition. with a substantially lower time requirement, which can be further reduced by lowering the number of elastograms, the free-breathing technique may be suitable for infants and less cooperative children not capable of breath-holding. abstract: pelvi-ureteric junction obstruction (pujo), classified into intrinsic and estrinsic is one of the most frequent urological diseases affecting the pediatric population. extrinsic causes include the presence of crossing vessels, kinks or adhesions. in cases with extrinsic obstruction of puj, colour doppler ultrasound (cd-us) can detect the presence of crossing vessels. in presence of crossing vessels pyeloplasty or vascular hitch can be performed. the aim of the study is to analyze the sensitivity of cd-us and magnetic resonance urography (mru) in visualizing crossing vessels in extrinsic pediatric hydronephrosis in order to decide the correct diagnostic pathway and evaluate in the pre-operative phase which surgical technique and approach (open, laparoscopic or robotic) is the ideal to be performed. a retrospective review of medical records for patients who underwent surgical treatment for hydronephrosis from august 2006 to february 2016 was performed. a descriptive statistical analysis was performed. the presence of crossing vessels at surgery was considered the gold standard. the sensitivity was calculated for both the imaging techniques as a measure of accuracy, evaluating the ratio between the positive cases divided by the those with aberrant vessels identified at surgery. results 220 clinical charts were reviewed. crossing vessels identified at surgery were 73 (33,2% of pujo). the median age was higher in the group with crossing vessels compared to the group without crossing vessels (p< 0,0001). the sensitivity of cd-us was higher compared to mru (93,3% vs 71,7%). before the surgical time knowing which technique and approach have to be managed in hydronephrotic patients with crossing vessels could be very important. according to our preliminary datacollection cd-us has got a higher sensitivity and could be the gold standard technique. study limitations include the absence of specificity, positive and negative predictive values. in the future it could be useful to perform a double blind trial in which children with moderate-severe hydronephrosis will be subjected to both imaging techniques to evaluate not only the sensitivity, but also the specificity, the positive predictive value and the negative predictive value conclusion: conclusions in the pre-operative phase, cd-us could be sufficient for the surgeon to discern between pujo with the presence or the absence of crossing vessels, as it has a higher sensitivity and lower costs compared to mru.urosonography -nonradiant alternative for voiding cystourethrography o.m. fufezan, c.a. asavoaie, s. tatar; cluj-napoca/ro voiding cystourethrography (vcug) was considered the gold standard in the diagnosis and monitoring of vesicoureteric reflux (vur). this method is invasive due to the radiation exposure. in the present the diagnosis of vur can also be established by contrast ultrasound examination, also known as voiding urosnography (vus). the authors will present the role of vus in the diagnosis and grading of the vur and the role of patient position in the detection of vur. the infants and children with congenital anomalies of the urinary tract and/or urinary tract infection have been evaluated with vus. iatrogenic vur, neurogenic bladder and urogenital sinus anomalies were excluded. the presence and the degree of the vur were evaluated. vus has been performed using a protocol similar to the one used for vcug. in conditions of sterile urine, 0.5 ml sonovue and saline solution have been introduced into the bladder until voiding started. the patients were examined both in a supine and an upright position and the following structures have been scanned: urinary bladder, distal part of the ureters and both pelvicaliceal systems during bladder filling, during and after voiding. the visualisation of the ultrasound contrast agent in the upper urinary tract represented a positive vur diagnosis. the grading of the vur has been established based on the same criteria as in vcug. sixty five patients (130 renal units), ages between 2 weeks and 17 years were evaluated (median age ± sd: 3 years ± 4 years and 2 months) through vus. vcug was performed in 6 patients in a maximum of 48 hours after vus. vur has been identified in 35 patients (40.7% renal units). a high vur grade (iv-v) was identified in 19.2% of renal units. for the patients investigated with both methods, the results were concordant in 4 patients. in two patients vur has not been identified by vcug, but was detected during vus. the upright position (in addition to decubitus) revealed vur in 3 renal units in which the reflux was not detected in decubitus. conclusion: vus is extremely useful and reliable in diagnosing and grading vur in pediatrics. the changing of the patient position during examination can improve vur detection.new sonographic features useful in differentiating congenital duodenal anomalies from malrotation: gastric and duodenal wall thickening and hyperechogenicity p. caro dominguez 1 , s. hameed 2 , a. zani 3 , r. moineddin 3 , o.m. navarro kunstmann 3 , a. daneman 3 ; 1 cordoba/es, 2 london/uk, 3 toronto/ca the clinical and plain radiographic differentiation of congenital duodenal anomalies (atresia, web, stenosis) and intestinal malrotation is not always clear. although sonography has been documented as an important diagnostic tool to differentiate these two entities, its role is still not widely appreciated. the purpose of this study was to assess the sonographic features of the gastric and duodenal wall in a large series of neonates with congenital duodenal obstruction as these have not been reported previously. neonates who had surgically proven congenital duodenal anomalies or malrotation were identified from the surgical database in a tertiary pediatric hospital in a period of 15 years (2000) (2001) (2002) (2003) (2004) (2005) (2006) (2007) (2008) (2009) (2010) (2011) (2012) (2013) (2014) (2015) . those with an ultrasound performed within 48 hours of surgery were included in the study. imaging was retrospectively and independently reviewed by two readers in chronological order blinded to final diagnosis. a wall thickness of ≥ 2 mm of a distended loop was considered abnormal. hyperechogenicity was recorded when the wall of the stomach or duodenum was brighter than liver or splenic parenchyma. imaging findings in the group with congenital duodenal anomalies was compared to the group with malrotation using fisher's exact test. one hundred eight neonates were included in the study, 40 with a congenital duodenal anomaly, 49 with malrotation (36 with volvulus) and 19 with both. ugi was performed in 61 neonates who had us. the correct diagnosis was provided only by us in 24 of these 61 newborns (39%), only by ugi in 5 (8%), by both in 26 (43%) and by neither in 6 (10%). ugi was performed in 21 children with malrotation and volvulus, eight were diagnosed only by us, four only by ugi and nine by both. the gastric and/or duodenal wall was significantly thicker and more hyperechoic in neonates with congenital duodenal anomalies than those with malrotation (p<0.0001) [fig 1, table 1 ]. conversely an abnormal relationship between the superior mesenteric artery and vein, abnormal position of the third part of the duodenum and the whirlpool sign were found more commonly in neonates with malrotation than those with congenital anomalies (p<0.0001). key: cord-001221-due9tloa authors: nan title: ecr 2014, part a date: 2014-02-27 journal: insights imaging doi: 10.1007/s13244-014-0316-6 sha: doc_id: 1221 cord_uid: due9tloa nan percutaneous needle biopsy has been a mainstay of oncologic diagnosis for almost three decades, since the advent of ultrasound and ct. the basic principles of fine-needle aspiration and core needle biopsy can be applied to almost any site in the body, with subtle differences in technique depending on the organ being investigated and the imaging modality utilised. while excisional biopsy is still appropriate in certain cases, percutaneous needle biopsy has become the standard of care in the diagnosis of most tumors throughout the body and is also used to diagnose noncancerous conditions, such as infection. percutaneous biopsy is also beneficial in the staging of patients with cancer, particularly when another treatment method may be more appropriate than surgical resection. the advantages of percutaneous biopsy over surgical excisional biopsy include time and cost savings and reduction in morbidity. the aim of this course is to discuss the practical aspects of biopsy, needle selection, and guidance techniques and to show how to approach difficult lesions and avoid complications. imaging after treatment of breast cancer is for confirmation of lesion removal, identification of postprocedural fluid collections, detection of residual or recurrent cancer and screening for metachronous cancers. posttherapy changes -which include fluid collections, edema, skin thickening, architectural distortion, scarring and calcifications -are mainly due to surgery, axillary dissection and radiotherapy. the greatest treatment-related changes occur 6-12 months after therapy, and mammographic stability is achieved after two to three years. for mammography, pre-and all posttherapeutic images have to be compared. ultrasound is the method of choice for evaluation of fluid collections. mri is for problem solving (i.e. differentiation between scar and relapse) and should not be performed prior to 12 months after therapy to avoid false-positive diagnoses. dystrophic calcifications may develop in areas of fat necrosis mimicking malignancy. fat necrosis predominantly occurs at the treated site; however, it can develop anywhere in the ipsilateral breast. its appearance may be indistinguishable from cancer at all imaging modalities. to differentiate between fat necrosis and other common post-treatment changes from relapse, it is important to know the timeline when these changes occur and schedule follow up imaging accordingly. mammography serves as the basis for postoperative surveillance. ultrasound is helpful in the early postoperative phase, whereas mri is the method of choice, especially for differentiation of scar and relapse in the later postoperative phases. breast radiologists need to be familiar with post-treatment imaging findings in patients with breast cancer, but often patients are also imaged after a diagnosis of benign entities which are treated surgically (fibroadenomas, radial scars, papillary lesions) or after a percutaneous diagnosis of a high-risk lesion which has undergone a surgical biopsy to avoid underestimation (atypical ductal hyperplasia, lobular neoplasia or flat epithelial atypia). these procedures will leave an imprint on the breast which can be a cause of concern due to the surgical scar. furthermore, imaging findings after plastic surgery for mastopexy, reduction mastoplasties, implants or auxiliary techniques (lipofilling, hyaluronic acid) are becoming frequent in our daily practice and have their peculiarities that can overshadow breast cancers. interventional percutaneous procedures can also be a cause of tissue distortion. there are advanced systems for biopsy (bles) and for percutaneous removal of benign lesions (fibroadenomas, papillomas), which use large-gauge needles and have to be accounted for due to their trace in the breast tissue. endoscopy is currently considered the reference standard for the evaluation of colonic disease activity in patients with inflammatory bowel disease (ibd). however, it only allows evaluation of the mucosal surface and is not always complete. it cannot, therefore, help to estimate the depth of involvement of transmural inflammation and extraluminal complications, both characteristics of ibd. an evolving role for cross-sectional imaging in the evaluation of patients with ibd is increasingly recognised, especially in the setting of crohn's disease (cd) since the cross-sectional imaging has been demonstrated to have a high diagnostic accuracy not only for assessing the presence and extension of luminal disease, but also for evaluating the cd-related acute or chronic complications. available evidence suggests that ultrasound, computed tomography and magnetic resonance have similarly high diagnostic accuracy in the detection of disease activity, location, severity and complications: in particular, the penetrating and stricturing lesions which are characteristic of cd. thus, the choice of the technique for assessing cd may be influenced by local availability or expertise. in the case of ulcerative colitis, cross-sectional imaging, although less evaluated, may also be helpful in certain circumstances. there is evidence indicating that cross-sectional imaging is an alternative problem-solving tool to endoscopy whenever tissue sampling is not required and can provide valuable guidance for performing medical and surgical treatment with maximised efficacy and safety. overall, findings from crosssectional imaging accurately reflect disease activity and provide reliable information for decision-making and patient care optimisation. learning objectives: 1. to learn about optimised examination protocols for ulcerative colitis and colonic crohn's disease in the acute, subacute and chronic disease setting. 2. to become familiar with the criteria for the assessment of disease activity through ct, mri and ultrasound. 3 . to learn about an integrated approach to the use of cross-sectional imaging in colonic inflammatory bowel disease. liver transplantation is the accepted treatment of patients with irreversible liver cell failure and some metabolic disorders and in a selected group of patients with hepatocellular carcinomas. over the last decade, major transplant centres have reported improving survival rates, though during this period they have developed more complex surgical techniques, including split-liver, auxiliary and live-related transplantation, and have treated more marginal higher risk patients. this successful outcome has been dependent on appropriate recipient selection, robust surgical technique, improvements in immunosuppression and intensive care management and the prompt recognition and treatment of complications. diagnostic and interventional radiology have been core specialties in achieving the goals of improved graft and patient survival. improvement in surgical techniques has decreased the more common vascular and biliary complications, but the newer techniques present differing diagnostic and interventional challenges, particularly in paediatric recipients. developments in mr and mdct allow many of these vascular, biliary and infective complications to be diagnosed non-invasively. vascular techniques of angioplasty and stent placement may reverse the sequel of graft ischaemia or portal hypertension. mrc allows the diagnosis of biliary strictures that may be treated by dilatation or stent placement. imaging is also important in the diagnosis of recurrent disease and the acquired diseases of prolonged immunosuppression including atypical infections and the post-transplant lymphoproliferative disorders (ptld). this interactive session will present these appearances by case example and provide guidance of the appropriate diagnostic and treatment paradigm. learning objectives: 1. to understand the common imaging findings after liver transplantation. 2. to recognise significant complications following liver transplantation. a-010 16:45 b. imaging of treated liver tumours i. bargellini; pisa/it (irenebargellini@hotmail.com) imaging findings after systemic and loco-regional treatments vary greatly depending on baseline features of the treated tumour and treatment modality. conventional uni-dimensional and bi-dimensional criteria (such as recist 1.1 and who criteria) have been extensively validated in metastatic lesions treated with conventional chemotherapy. however, their prognostic value is limited in patients treated with new molecular targeted therapies and after locoregional treatments. in the setting of hepatocellular carcinoma (hcc), specific response criteria (such as easl and mrecist) have been proposed that take into account variation in the size of the viable tumour. these criteria have been extensively validated, although their interpretation could be troublesome after some specific treatments, such as molecular targeted agents and y90radioembolisation. on the other hand, there is no consensus regarding tumour response criteria for metastatic lesions after loco-regional treatments. the role of morphological criteria and several imaging biomarkers (such as those provided by diffusion and perfusion imaging, fdg activity, dual source ct) is under investigation, being able to provide additional information on tumour activity and biology. while new drugs with different mechanisms of action and new treatments are becoming available, the work of radiologists is changing and there is increasing evidence that tailored radiological response criteria are required for these new targeted and tailored treatments. learning objectives: 1. to understand the common imaging findings after chemotherapy for liver tumours. 2. to recognise common imaging findings after radiofrequency ablation of liver tumours. 3. to be aware of the common imaging findings following transarterial treatment of liver tumours. vessel size is practical, since it is related to the pathological changes as well as to the clinical and radiological presentation. the two main large vessel vasculitides are giant cell arteritis and takayasu arteritis. behcet disease may combine large and small vessel vasculitis. imaging plays an important role in primary vasculitis. chest radiographs are not especially useful in large vessel vasculitis. contrast ct and mri further detect and especially help in the characterisation of large vessel vasculitis. vessel wall changes are well detected with both techniques. contrast enhancement, distribution of vessel involvement and morphological vascular changes should be considered. today, pet/ct is the recommended imaging technique in the assessment of vessel wall inflammatory changes and in the evaluation of treatment response. although the clinical scenario differs usually between takayasu and giant cell arteritis, the radiologist should combine the imaging findings with clinical and laboratory data to suspect a specific vasculitis. therefore, this presentation will concentrate on the basic signs and associated findings in large vessel vasculitis, pathologic correlation, imaging protocols and the differential diagnosis. the term vasculitis refers to a variety of clinico-pathological entities. the most widely used chapel-hill classification divides the vasculitis syndromes into three groups based on the size of vessels primarily involved. small vessel vasculitis such as anca-associated granulomatous vasculitis (wegener's disease), churg-strauss granulomatosis and microscopic polyangitis are most often associated with pulmonary abnormalities. the spectrum of hrct findings is quite variable and differs by entity. the hrct findings will be discussed together with clinical and laboratory findings to be integrated into a multidisciplinary diagnostic approach. the typical findings in wegener's granulomatosis include solitary or multiple, often cavitary nodules or masses, or focal or diffuse consolidations, churg strauss is dominated by interlobular thickening or transient multifocal and nonsegmental consolidations frequently in subpleural distribution. all types of pulmonary vasculitis may present with focal or diffuse pulmonary haemorrhage that produces pulmonary ground glass or consolidations in various distributions. a number of collagen vascular diseases (e.g., lupus erythematosus) or other granulomatous diseases (e.g. sarcoidosis) may affect the small pulmonary vessels causing haemorrhage or pulmonary hypertension. per disease entity, the course will review typical and more rare hrct features and key features that allow for diagnosis and classification, discuss side-to-side overlapping of morphologic features important for differential diagnosis and illustrate the findings of other diseases that represent the most challenging differential diagnosis, e.g. oedema, infection or malignant diseases. learning objectives: 1. to learn when hrct is of value in investigating pulmonary vasculitis. 2. to appreciate the different appearances of pulmonary vasculitis on hrct. a-014 17:07 d. inflammation and remodeling a.a. bankier; boston, ma/us (abankier@bidmc.harvard.edu) the presentation will lay out the pathological and pathophysiological basis for the complex processes of inflammation and remodelling. the implications of these processes for imaging will be discussed and illustrated by selected pathologies. finally, the presentation will indicate how the imaging reflections of these processes could be used in the future as imaging biomarkers for the diagnosis, follow-up, and outcome evaluation of disease. at (marcus.hacker@meduniwien.ac.at) appropriate diagnosis and therapy of coronary artery disease (cad) frequently require information about both the morphological and functional status of the coronary artery tree. thus, combined imaging consisting of invasive coronary angiography (ica) plus spect myocardial perfusion imaging (mpi) is practiced in clinical routine diagnostic of patients with stable angina since many years and can therefore be accepted as the reference standard in the diagnosis of hemodynamically relevant coronary artery stenoses. both morphological and functional information are mandatory for the decision of performing an interventional therapy or initiating/maintaining medical treatment in numerous symptomatic patients. the hemodynamically relevance of coronary artery lesions is a major condition to decide whether an interventional therapy should be performed or not. a non-invasive concept providing both information could provide accurate allocation of perfusion defects to their determining coronary lesion and specific morphological and functional classification of patients with coronary artery disease. in symptomatic patients, a normal stress mpi confers a very low short-term risk for cardiac death and/or acute myocardial infarction. however, a normal mpi does not exclude the presence of underlying coronary atherosclerosis, which may be extensive although not yet flow-limiting. in this regard, ct will unmask a sizeable subgroup of patients with coronary atherosclerosis who should receive more intensive antiatherosclerotic intervention than would have been indicated by mpi results alone. knowledge regarding the presence and extent of subclinical coronary atherosclerosis in patients who do not have ischemia by mpi can be of importance in patient management. learning objectives: 1. to appreciate the scope of information a spect/ct cardiac study can deliver. 2. to become familiar with protocols of spect/ct studies. 3. to learn a structured approach to performing and reporting a spect/ct study. a-017 17:00 c. mr/pet: do we really need it? h.h. quick; erlangen/ de (harald.quick@imp.uni-erlangen.de) following pet/ct and spect/ct, mr/pet hybrid imaging is the most recent addition to the palette of hybrid imaging modalities. mr/pet synergistically combines the excellent soft tissue contrast and detailed image resolution of mr with metabolic information provided by pet. integrated mr/pet systems furthermore offer the ability to acquire hybrid imaging data simultaneously. this can be applied to mr-based motion correction of pet data. these features open up several cardiac applications, e.g. evaluation of cardiac function and viability, diagnosis of cardiac inflammatory diseases and tumorous diseases. to fully assess the diagnostic potential of mr/pet, however, several technical challenges have to be considered: attenuation correction (ac) of the patient tissues in mr/pet has to be based on mr-images and is currently hampered by a limited number of tissue classes and undercorrection of bone tissue. cardiac radiofrequency coils and ecg gating equipment are currently not considered in ac. consequently, quantification of pet data therefore might be biased. the clinical workflow is rather complex and needs to be tailored to cardiac examinations. few research groups currently explore this new hybrid imaging modality in selected cardiac applications. cardiac mr/pet: do we really need it? considering the sparse clinical experience that is available today, it is quite early to answer this question yet. however, once the remaining technical hurdles are overcome and the diagnostic potential can be fully exploited clinically, the answer is most likely positive. the majority of malignant bone tumours can be detected on plain radiography. the age of the patient, location of the tumour in a bone and history of a preexisting bone abnormality should be included in determining the likely diagnosis. careful analysis of the pattern of bone destruction, periosteal reaction and matrix mineralisation allow for characterisation of most cases of osteosarcoma, ewing's sarcoma, chondrosarcoma and adamantinoma. mri is the best imaging technique for staging by displaying 1. the extent of bone marrow involvement, including epiphyseal infiltration and skip lesions, 2. the presence and extent of extraosseous soft tissue mass, 3. involvement of the neurovascular bundle, muscle compartments and adjacent joint. this allows to find the best biopsy approach and establish the feasibility of limb salvage as opposed to amputation. longitudinal non-contrast t1 sequences are the most accurate for determining intraosseous extent. axial fat-suppressed pd or t2 sequences optimally demonstrate soft tissue extension, and dynamic contrastenhanced mri is useful for differentiation of extraosseous tumour from edema and for assessment of tumour response to chemotherapy. chest ct is the most sensitive modality for detection of pulmonary metastases, and technetium skeletal scintigraphy is still frequently used for detection of osseous metastases. the most valuable, readily available and easy-to-use techniques to assess response to radiation therapy and chemotherapy are dynamic contrast-enhanced mr imaging, diffusion mri and colour-doppler ultrasound. to evaluate local control of disease and for detection of local recurrence, mri is usually the best imaging technique. plain radiography may detect complications of prosthesis. learning objectives: 1. to consolidate knowledge on malignant primary bone tumors on plain radiography, ct and mri. 2. to understand the principles of tumour staging and monitoring chemotherapy. 3. to become familiar with imaging findings following chemotherapy and surgery. oncologic approach to malignant primary bone tumours c. dhooge; ghent/be (catharina.dhooge@ugent.be) the most common bone sarcomas are osteosarcoma (os) and ewing sarcoma. os occurs primarily in long bones, ewing sarcoma occurs also in the pelvis, spine or chest wall. localised disease confers a 65% cure rate, and initially metastatic disease 25%. a multidisciplinary approach which includes neo-adjuvant systemic chemotherapy and local control measures for primary and metastatic sites followed by adjuvant chemotherapy has become the standard of care. complete surgical excision is mandatory in os; in ewing, radiation can also be used. standard chemotherapy for os is based on a combination of cisplatin, doxorubicin and high-dose methotrexate. ifosfamide and etoposide will be further considered (euramos). systemic therapy for ewing includes vincristine, doxoribicin, cyclofosfamide, ifosfamide and etoposide. high-dose chemotherapy with autologous stem cell reinfusion is evaluated in intermediate prognosis and metastatic disease (euro-ewing). among the different prognostic factors, response to neo-adjuvant chemotherapy by measuring chemotherapy-induced necrosis is a powerful indicator of outcome in bone sarcomas. patients who achieve a good histological response to pre-operative chemotherapy, defined as < 10% viable tumour at the time of tumour resection, have a better survival than those who show poor response (>= 10% viable tumour). five-year survival for good responders is 7o-75% compared to 45-50% for poor responders. however, the outcome for malignant bone tumours has improved little in the last 25 years. large international studies exploring new drugs such as biologic agents (interferon) or mechanisms conferring drug resistance (topoisomerase inhibitors) in randomised controlled trials will hopefully lead to therapeutic innovation. learning objectives: 1. to become familiar with the principles of chemotherapy in malignant primary bone tumours. 2. to understand what the oncologist expects from the radiologist. 3 . to recognise the value and limits of chemotherapy in malignant primary bone tumours. thursday a-024 16:45 surgical approach of malignant primary bone tumours g.m.l. sys; ghent/be (gwen.sys@ugent.be) in primary malignant bone tumours, three surgical procedures are necessary: biopsy, resection and reconstruction. whether a biopsy is performed in an open or a percutaneous way is a matter of preference, but in each case it should provide sufficient and representative material for pathological investigation without compromising the following treatment. the area of interest and the trajectory should be determined preoperatively in a multidisciplinary meeting. as the biopsy tract has to be removed during the resection surgery, it should be close to the planned approach for the subsequent resection. if a biopsy is performed improperly, the diagnosis may be wrong or the following resection may be impaired because of extensive contamination of compartments, resulting in a severe functional deficit. surgery planning is based on clear imaging and a multidisciplinary discussion of tumour extension, aiming for a wide resection of the tumour with clear margins. correct perioperative measurements are based on predefined fixed bony landmarks that should preferably be visible on the same image as the tumour. an amputation is performed if a surgical limb-salvage procedure is expected to result in a non-functional limb. nowadays, several reconstruction techniques for bones (bone grafts or prostheses), tendons (artificial or human ligaments) and skin (skin flaps or grafts) are available. invasion of the soft tissues such as the neurovascular structures, muscles and skin, will determine which reconstruction technique (s) are necessary to restore the patient's function. each reconstruction technique bears inherent complications requiring a regular follow-up. we outline the current opportunities and threats in diagnostic radiology: traditional diagnostic radiology has been rapidly replaced by clinical radiology and the role of the radiologist is changing from image interpreter to clinical manager of imaging data. to care for the patient`s medical problem and not only his images is important. this contains great opportunities for radiology to develop and for the radiologist to become a central player in patient management. however, this requires not only clinical knowledge and involvement, but also visibility and sometimes even 24/7 availability. the need for " only" image reporting is declining as clinical subspecialisation easily brings image interpretation into the domain of non-radiologists. to understand the importance of identity, visibility is very important. visibility can be achieved by being part of mdt s and also in many other ways. clinical radiology is an idea which, after all these years, has not been very well embedded in current radiology and radiology training. to understand the importance of certified training, maybe the most important action we have to undertake now is to capitalise on our radiological expertise. image interpretation in a clinical context can only be done or franchised (to non-radiologist) under conditions of certification and accreditation by radiology. we should never let the primate of education and certification slip to non-radiologists. radiology certification should be a quality standard, recognised by international and national medical bodies, such as medical chambers and specialist societies. the latter should have high priority. session objectives: 1. to learn about the current opportunities and threats in diagnostic radiology. 2. to understand the importance of identity. 3. to acknowledge the importance of certified training. where are the turf battles in diagnostic imaging? g.m. bongartz; basle/ch (georg.bongartz@usb.ch) turf battles in radiology are a foreseeable development for most imaging techniques which evolve push-button methods and readily interpretable imaging results. we as radiologists must learn to accept competition. turfs should rather be seen as challenge than as threat. predominantly, nonirradiating techniques like ultrasound and mri have become progressively easier to apply (us) or to understand (mri), where the final image in some standardised areas (eg joints) can readily be interpreted by medical specialists in this field. but also x-ray diagnostics in dental medicine or orthopedic imaging is largely applied outside the radiologic department. ct today seems still relatively excluded because of its complexity. but with increasing resolution, optimal 3d reconstruction and fast accessibility, it is only a question of time when the added value of the radiologist will be under question. radiology has changed. we must become experts with respect to patho-anatomy and radiological differential diagnosis. this requires profound education, both initial training and ongoing education. radiology must be advertised internally and externally. in radiological publications, outcome studies are still underrepresented. demonstration of our dedicated skills, fostering our special expertise and offering this as support to our medical colleagues will preserve radiology for the future. cooperation with partners seems the only way out of a turf battle -we need to search for alliances and integrate our partners to create a win-win situation. a-027 16:23 beating threats in europe with radiological training a.k. dixon; cambridge/uk (akd15@radiol.cam.ac.uk) by introducing radiology to medical students, it is hoped that they will begin to appreciate how difficult it is! likewise, when teaching residents, they must come to understand the basic anatomy and principles better than their clinical colleagues; this is very much the tenet of subspecialty training. they should also appreciate that patient care is optimal when there is close collaboration between clinicians and radiologists. passing of an examination (national or edir) offers some proof that a radiologist has attained a certain standard, but the principle of testing oneself formally or informally at regular intervals again provides a measure of continuing competence. such certification can be of value in the case of litigation. radiology is one of the fastest growing specialties and the techniques that we learn during training are quickly outdated; hence, the need for life-long learning and effective continuing professional development. learning objectives: 1. to understand how to teach radiology to undergraduate medical students. 2. to become familiar with the principles of self-assessment. 3 . to appreciate the necessity for life-long learning. history of ultrasound in radiology: lessons learned l.e. derchi; genoa/ it (derchi@unige.it) the relationship between radiology and us has never been an easy love story, and still isn't. in the early 1970s this new imaging field was not readily covered by radiologists and many other colleagues established us sections within their departments. then, important fields of us (cardiology, obstetrics, gynecology) became almost exclusive domain of non-radiologists. in the 1980s, the increasing success of us initiated turf battles with other clinicians. nowadays, clinical specialists perform > 50% of us examinations wordwide. in europe, most in-hospital us examinations is still performed in radiology, but this is not the case in all countries. a strong practice in us is quite important since this is often the first approach to patients. if initial us referrals are kept, radiologists will continue to guide decisions in subsequent imaging workup. furthermore, us keeps close to patients; in europe the examination is usually done directly by radiologists or, if by sonographers, the radiologist usually checks the case with limited directed us imaging. this clearly shows our role as physicians. to maintain a key role in us radiologists need to: 1) have the best specialists in us; attention must be given to us in residency programs. 2) invest in us technology (as examples: ceus, elastography, 3d/4d). 3) invest in us research. 4) have high visibility in the us community, keeping close contact with all clinical colleagues. 5) present higher visibility of us within radiology, with leaders supporting us within the radiological community and each radiologist promoting us in his/her environment. learning objectives: 1. to understand why ultrasound has moved out of the hands of radiology in some subspecialties. 2. to learn what this means for daily radiology practice and the quality of work. 3 . to know about the threats and how we should deal with them. thursday a-029 16:59 interdisciplinary cooperation without losing identity m.f. reiser; munich/de recently, major shifts in the paradigms of patient care took place: interdisciplinary counseling and including the patient in the decision making process for diagnostic and therapeutic measures. the new concept is that the patient no longer comes to the specialist, but the specialists come jointly to the patient. this is reinforced by the competition among health care providers, political decision makers and the public. in many hospitals this general trend has resulted in the establishment of various centers and boards such as the breast cancer centers, vascular centers and tumor boards for several cancer entities to name only few. at the university hospital of munich 46 centers and boards have been implemented up to now. in almost all of them the participation of radiologists is required. this results in a major challenge in terms of personal resources. together with the regular clinical-radiological rounds the time necessary for these activities equals 2 full-time radiologist posts. the participation of radiologists has many beneficial aspects: acknowledgement of radiology as an important clinical discipline and of the radiologist as a clinical consultant; participation in and influence on the creations of sops and (internal) guidelines; opportunity to advocate appropriate radiological methods for diagnosis and interventions; increase of knowledge in clinical medicine and new concepts of therapy; close personal links with our clinical partners. in order to prevent radiologists from losing their identity as radiologists it is mandatory that they remain firmly integrated in the radiology department and to strengthen the position of radiology as the central institution for providing cost-effective imaging and interventional services. moreover it must be taken care to offer attractive career options within the field of radiology. at (michael.fuchsjaeger@medunigraz.at) ultrasound (us) is the adjunct method of choice to mammography in breast imaging. over the past two decades, us technology has undergone profound advancements and refinements. us has, therefore, become an assessment tool with a defined field of indications as well as a unique set of diagnostic descriptors for breast lesion differentiation. the acrin 6666 study has demonstrated the special benefit of us in patients at risk with dense breast tissue. the bi-rads lexicon for ultrasound, in its second edition, expanded the role of breast us. further enhancement of image quality as well as the recent advent of automated breast us has even fueled scientific discussions on the potential role of us for breast cancer screening. automated breast us, which is based on computed generation of a 3d imaging data set obtained from many parallel 2d images, offers a different approach with a variety of benefits. images are obtained by the sonographer in standardised fashion, whole breast data sets can be reviewed at any time after the examination, reducing operator dependence, and image fusion with, i.e. mri is easily possible. the basic physical background, the significance as well as important aspects of practical use of handheld and automated breast us will be explained and illustrated by the respective imaging examples. emphasis will be laid on strengths and potential weaknesses of both us technologies with regard to breast imaging. the terms "complicated cyst" and "complex-cystic lesion" are based on breast ultrasound (us) terminology. the simple cyst is a fluid-filled, clearly defined, anechoic lesion without any suspicion of a solid intracystic mass. if a simple cyst is complicated by echogenic fluid, it is called complicated cyst. this echogenic fluid can be caused, e. g., by cell debris. thin echogenic septa are common in complicated cysts. vascularisation can never be found in these echogenic components. a complicated cyst has no solid component and no thickened wall or thickened septa. the expected probability of malignancy is 2%. the us criteria of a complex-cystic lesion following berg et al. categorise it into 4 types: type 1, thick outer wall and thick internal septa (alone or in combination of both); type 2, one or more intracystic masses; type 3, mass of mixed cystic and solid components (at least 50% cystic); type 4, predominantly solid with eccentric cystic foci (at least 50% solid). complex means there is a suspicion of a tumour inside a cyst or a solid tumour with cystic components. a complicated cyst will usually be followed by us after 6 months. a complexcystic lesion needs a correlation with mammography. us-guided large core needle biopsy in combination with a us and mammography visible marker placement is useful in type 3 and in type 4 complex-cystic lesions. in type 1 and type 2 complex-cystic lesions, a preoperative hook wire placement and excision surgery is the typical procedure. learning objectives: 1. to learn about the us appearance of complicated cysts and complex-cystic lesions. 2. to consolidate knowledge on differential diagnosis for these respective lesions. 3. to understand the diagnostic algorithm for a work-up of these lesions. renal colic is the most frequent non-obstetric cause for abdominal pain and subsequent hospitalisation during pregnancy. intervention is necessary in patients who do not respond to conservative treatment. ultrasound (us) is widely used as the first-line diagnostic test in pregnant women with nephrolithiasis, despite that it is highly nonspecific and may be unable to differentiate between ureteral obstruction secondary to calculi and physiologic hydronephrosis. magnetic resonance imaging (mri) should be considered as a second-line test, when us fails to establish a diagnosis and there are continued symptoms despite conservative management. moreover, mri is able to differentiate physiologic from pathologic dilatation. in fact in the cases of obstruction secondary to calculi, there is renal enlargement and perinephric oedema, not seen with physiological dilatation. in the latter, there is smooth tapering of the middle third of the ureter because of the mass effect between the uterus and adjacent retroperitoneal musculature. when the stone is lodged in the lower ureter, a standing column of dilated ureter is seen below this physiological constriction. mri is also helpful in demonstrating complications such as pyelonephritis. in the unresolved cases, computed tomography remains a reliable technique for depicting obstructing urinary tract calculi in pregnant women, but it involves ionising radiation. nephrolithiasis during pregnancy requires a collaboration between urologists, obstetricians, and radiologists. learning objectives: 1. to list the us, mr and ct imaging findings of urolithiasis and urinary tract infections. 2. to discuss the role and the appropriate uses of us, mr and ct for imaging these suspected conditions in pregnancy. 3 . to discuss how imaging can influence the management of nephrolithiasis during pregnancy. oncology t.f. hany; zurich/ch (thomas.hany@gmail.com) in malignant tumours, pet/ct imaging using 18-fluoro-deoxyglucose (fdg) is widely used nowadays. fdg-uptake is an unspecific process and results in physiological as well as pathological malignant and non-malignant tissue uptake. to properly understand and interpret pet/ct imaging, knowledge of the mechanism and pathways of fdg in different tissue types like brain and the gastrointestinal tract is key. intrinsic as well as extrinsic factors influence uptake pattern not related to oncological disease like uptake in brown fat in patients exposed to cold ambient temperature and psychological stress or increased muscular uptake in nonfasting patient. typical treatment-related changes occur during and after treatment and must be recognised correctly so as not to overstage patient disease. a systematic analysis and knowledge of all these factors facilitate and improve the reading of oncological clinical cases. learning objectives: 1. to understand pattern of physiological fdg-uptake. 2. to learn about the pattern of non-pathological uptake in several tissue types. 3 . to understand the influence of chemotherapy and other agents on fdguptake in the body. radiologists mostly prefer to use the comparative technique while evaluating radiological images, especially when the anatomy is identical for both sides. comparative analysis mostly works if the anatomic details are not complex or the right resembles the left. however, the complex anatomy and relatively high incidence of individual variations in head and neck may hinder this way of interpretation. variable pneumatisation of paranasal sinuses and temporal bone may cause difficulty. vascular system, especially venous structures may be sources for pseudolesions. for example, asymmetrically enlarged jugular vein or venous plexuses at any location may be misinterpreted as mass of any origin. veins may also become problematic on mr imaging due to entry slice phenomenon, in-plane flow, and flow turbulence effects and can have variable enhancement. normal anatomical structures such as facial nerve may enhance and can be mistaken to be pathologic on mri. technical issues can be considered as a group that may cause pseudolesions. images of the improperly positioned patient may become problematic while evaluating tiny structures. pet and pet-ct carry their own risks for pitfalls. normal structures may confound interpretation and result in false-positive findings. the situation may become much more complicated when there is asymmetry. similarly, atrophy and unilateral absence of a structure may be misread as a mass on the contralateral side. because of the complex anatomy and relatively high incidence of individual variations, head and neck imaging demands much more attention and careful analysis. the appropriate imaging technique and detailed knowledge of anatomy are essential to recognise pseudolesions. as a general rule, detailed knowledge of the patient's clinical history is essential before any imaging study is performed, to evaluate the appropriateness of the indication, tailor the acquisition protocol and correctly interpret the study. in head and neck imaging, this rule particularly fits in the emergency setting. in certain circumstances, the swelling and enhancement of soft tissues produced by infectious lesions may mimic a neoplasm. even more so, in patients already treated with surgery or chemoradiation. in these patients, the challenge is double: to identify any abnormality in the new anatomy produced by treatment and to discriminate between inflammation, complication and relapse. these can be very difficult without knowledge, for example, of the reconstructive procedure after surgery. previous images are extremely useful, not only because they help detect abnormalities, but also because through indirect information on the growth rate of the lesion they are crucial for correct interpretation of findings. tablets in radiology represent a novelty. since the introduction of the tablets on the market, the radiological field has been probably the first medical discipline to discover the many advantages of these devices. in fact, many applications for image management have been made available on the app stores (apple and android), and allow radiologists and non-radiologists to handle dicom images on the tablet, as part of the patient's record. however, the emerging applications are driving the process from the simple dicom image viewing to the full integration of the tablet with the pacs, allowing the handling of a patient's full record and presumably the possibility to report. in view of this rapid technological development, again radiology falls in the middle of a storm and is asked to find a solution to problem: are tablets suitable to read and report dicom images? and if so, which kinds of images (ct, mri, x-ray, etc) .? how can we manage the portability of patients' data (security issues, data loss, etc).? what will be the impact on teleradiology? these issues will be addressed by the panel of experts who will speak in the refresher course. session objectives: 1. to appreciate the current state of tablet technology and its practical use in radiology. 2. to understand the pros and cons of the use of tablets. 3 . to learn about specific critical areas of utilisation (dicom images reading and teleradiology). a. tablet-computers: a technical overview j. fernandez-bayo; sabadell/es (jfernandezb@cspt.es) since their introduction in 2001, tablet pcs have evolved extensively. they have become very popular, filling the gap between laptop computers and smart mobile phones. we will review technical aspects like the processors, storage space and memory, size and weight, connectivity and networking, software, autonomy, and battery life in different devices. special focus will be on the displays and different possible uses in radiology. for diagnostic purposes, different technical aspects must be taken into consideration, like the display size, resolution, pixel size (pixel pitch or pixels per inch), luminance, and contrast. displays in radiology normally have sizes between 20" and 24" and resolutions up to 5 mpx, with luminance that ranges from 250 cd/m 2 to 600 cd/m 2 . by contrast, tablets have screen sizes between 9" and 10" and resolutions up to 3 mpx, with luminance that ranges from 370 cd/m 2 to 480 cd/m 2 . due to their screen size, tablets score better in pixel pitch, with around 250 ppi versus 150 ppi in medical displays. the two systems have similar contrast ratios. other technical aspects of display that we should take into consideration are the number of distinguishable grays that can be represented, which in tablets correlates with the number of colours that can be displayed (color gamut) and colour accuracy (delta-e). additionally, we should take into consideration that displays should be calibrated for medical diagnostic purposes and tools to calibrate tablets have recently become available. learning objectives: 1. to learn about the pc evolution: from desktops, to laptops and tablets. 2. to appreciate the versatility features of a tablet. 3 . to understand the hardware features with a specific focus on display. 4. to understand the hardware features with a specific focus on networking. a-046 16:28 b. reading dicom images on the tablet o. ratib; geneva/ch touch screen tablets are becoming widely available, providing convenient mobile solutions for physicians and health-care providers. this is particularly attractive in medicine to "nomad" physicians, who need to be able to access relevant patient data and images anywhere-anytime in their daily practice where they are rarely at a single location. while they may not always be adequate for routine diagnostic tasks, they provide a convenient mobile solution for on-call and remote consultations. there are different types of software architecture that can be implemented for such tasks. two different major designs are: (1) online web-based applications where the device serves as a "thin-client" to display images rendered and manipulated on a remote computer and (2) local applications that reside on the mobile device and can run independently after images have been downloaded on the device. the first solution requires the user to be constantly connected to the network, while the second solution can continue to function after being disconnected from the network. most pacs vendors are starting to provide web access to their imaging solutions that can be accessed from mobile devices. web access can however be slow and dependent on reliable access to wireless network. we chose to develop a stand-alone companion application to our open source imaging platform osirix. with the increasing capacity and computing power of mobile devices, users will soon be able to perform most of the processing and image manipulation functions that are today only feasible on desktop or laptop computers. learning objectives: 1. to learn which dicom readers are available for tablets. 2. to appreciate the different approaches to dicom reading (local vs remote) and the pacs/tablets integration. 3. to understand the pros and cons of dicom image reading with the tablet in regards to image quality and displays. the optimisation of clinical breast cancer care comprises the prevention of over-diagnosis, reduction of over-treatment, and avoiding unsuccessful treatments. these goals are targeted in the vph-prism project by seven european and two us partner institutions. from the prospectively collected data, we will derive optimised imaging protocols that comprehensively take a woman's history and risk factors into account. the tight integration of radiological and histopathological images enables joint assessment of quantitative tissue parameters from microscopic and macroscopic imaging. more informed therapy decisions can be taken by such enhanced multidisciplinary data, backed by a powerful case database. the reduction of overtreatment, and highly individualised diagnosis and therapy decisions are closely related. we ultimately aim at deriving predictive parameters from the multi-modal and multi-disciplinary database to select the treatment option with the best chance of enduring recurrence-free survival. prospectively collected data, personal risk factors, and corresponding imaging data fed into the database from three large cohort studies are expected to provide insights into the individual preconditions and factors affecting disease progression. to optimise therapy, the decision between therapy options is key. this will be addressed by a decision support system using the project database. for surgical excision planning, vph-prism will aim at providing better estimates of tumour size, and with visual planning aids supporting radiologists and surgeons. for chemotherapy, quantitative lesion parameters, tracked over time during therapy, may help to detect success or failure of the treatment early on, such that a chemotherapy regime can for a non-responder be switched to a different regime in due time. quantitative imaging biomarkers in dementia; the fp7 vph-dare@it project w.j. niessen; rotterdam/nl (w.niessen@erasmusmc.nl) the number of individuals suffering from dementia today is roughly 36 million. due to ageing societies, this number is predicted to increase to 115 million by 2050. worldwide annual costs are estimated to be â�¬450 billion. in 2012, the who declared dementia a global health priority, highlighting the urgent need for improvements in this area. vph-dare@it's aim is to enable more objective, earlier, predictive and individualised diagnoses and prognoses of dementias to cope with the challenge of an ageing european society. the expected impact of vph-dare@it will influence the scientific, clinical and industrial communities across europe and internationally to improve health care of dementia patients. in this presentation we will introduce the vph-dare@it project. we will then focus on the development, validation and implementation of quantitative imaging biomarkers for the early detection and differential diagnosis, which will take place as part of the project. author disclosure: w.j. niessen: advisory board; part-time detached to quantib bv as scientific director. shareholder; co-founder and shareholder of quantib bv. horizon 2020: improving diagnosis and medical interventions and support to medical imaging j.-l. sanne; brussels/be (jean-luc.sanne@ec.europa.eu) research and innovation contribute to increasing europe's competitiveness. at the same time, research and innovation help make people's lives better by improving things like healthcare. in january 2014 the european union launches horizon 2020, the biggest eu research and innovation programme ever, with a budget of â�¬ 79 billion (current prices) over seven years (2014) (2015) (2016) (2017) (2018) (2019) (2020) . eu support for research and innovation helps drive international projects across the european union and beyond, and promotes the progress of knowledge and technology. one of the three key pillars of horizon 2020 will be tackling societal challenges (priority 3) such "health, demographic change and well-being". one feature is the development of new and more effective diagnostics. relevant tools and technology innovations will be supported in view to improve disease outcomes through earlier, more accurate diagnosis and by allowing for more patient-adapted treatment. support will be provided through the work programme 2014 -2015 of societal challenge 1 "health, demographic change and wellbeing". additional opportunities are offered in the work programme 2014 -2015 of priority 2 (industrial leadership) "leit -information and communication technologies". practically, all imaging modalities have been used in space research since a long time ago. first of all, radiology is targeted in research activities, because by definition all cosmonauts and astronauts are healthy persons. the biggest volume of examinations had been performed on crew members for studies of organs and functions of the human body before and after long-term flights. health effects of zero gravity were of special interest. for example, multiple studies with involvement of both russian and international specialists were done on bone mineralisation (bone densitometry), muscle volume (mri) and metabolism (mr-spectroscopy) both in astronauts and healthy control subjects. first, ultrasound (us) examinations were conducted in space onboard russian orbital stations in 1982. complex us studies were done by the author himself during his flight as a crew member of "salut-7" orbital station in 1984. the author had found some complex changes in blood and fluid dynamics under weightlessness. teleradiology was used for data transfer to medical specialists on the earth. today, we are continuing to use radiology for research on astronauts. for example, applications of sophisticated brain mri and fmri methods are of special interest for studies of subtle brain changes in space travellers. among our targets are flights to the moon, mars and large asteroids. to be better prepared for that task, we need better diagnostic tools. new versions of mobile us systems, miniature x-ray and ct machines suitable for use inside spaceships are under development. there are several mri pitfalls that should be recognised when imaging the female pelvis. mri appearances of uterus and ovaries are dependent on the phase of menstrual cycle/use of exogenous hormone therapy. normal postsurgical and post-radiation appearances of the pelvis can sometimes mimic tumour recurrence. it is important to become familiar with these appearances to avoid potential pitfalls. one very common pitfall is differentiation of transient myometrial contraction from adenomyosis. interrogation of all imaging planes over the duration of the entire mri examination can be useful to distinguish between the two, although myometrial contractions can last up to 45 min. the choice of the correct imaging plane is crucial for the precise classification of uterine anomalies (coronal oblique) and accurate evaluation of parametrial invasion (axial oblique) in patients with cervical cancer. both dynamic contrast-enhanced mri and diffusion-weighted mri improve the accuracy of mri in the evaluation of malignant pelvic conditions. however, certain pitfalls related to each technique should be recognised to avoid misinterpretation. it is crucial to be familiar with the anatomy of the uterovesical (uv) ligament, as it is often the site of pelvic lymphoma (such as bladder or cervix lymphoma). however, some benign conditions such as endometriosis can involve the uv fold and invade both bladder and uterine wall. certain mri features can be helpful in making the correct diagnosis. learning objectives: 1. to become familiar with normal variations in mri appearances of female pelvis resulting from physiological conditions (e.g. different phases of menstrual cycle) and treatments (including exogenous hormone therapy, surgery and radiation) potentially mimicking disease. 2. to consolidate knowledge on the role of the correct mr imaging plane in avoiding potential mis-classification of uterine anomalies and parametrial invasion in patients with cervical cancer. 3 . to learn about certain pitfalls related to dynamic contrast-enhanced mri and diffusion-weighted mri. a-057 09:15 b. pitfalls in ultrasound k. kinkel; chãªne-bougeries/ch (karen.kinkel-trugli@wanadoo.fr) pitfalls of sonographic findings in the pelvis can be related to technical issues, interpretation errors or to the patient's specific condition or pathology. common problems consist of insufficient bladder filling, misinterpretation of posterior enhancement or shadowing according to the anatomical structure and pathology of a size that goes beyond the field of view of the probe. organspecific problems will be illustrated in interactive questions, particularly for the uterus and the ovaries. identification of diseases can be difficult in many areas of abdominal imaging and therefore misses are easily made, also by the more experienced radiologist. it is difficult in the mesentery and peritoneum, covering a large area but being a very thin structure where abnormalities are easily missed. therefore, knowledge of the peritoneal anatomy and pathophysiology of peritoneal diseases is not widespread and differential diagnosis can be difficult. hence, special attention should be paid to prevent misses. another difficult area is diagnosing occult gastrointestinal bleeding. here, the choice of the proper imaging method is crucial as well as understanding the pros and cons of the method. the technique used should be optimised, as otherwise sometimes subtle signs of bleeding are missed. the presence of bowel dilatation itself is often correctly diagnosed, but the extent of the obstruction, the cause of the obstruction and especially complications (ischaemia) might be misdiagnosed. ct is the preferred technique for evaluation of bowel dilatation. care should be taken to scrutinise the examination for principal findings in patients with bowel obstruction. a. mesentery and peritoneum d. akata; ankara/tr (dakata@hacettepe.edu.tr) imaging findings of neoplastic or inflammatory diseases within the peritoneal cavity and the mesentery sometimes overlap and cause difficulties in interpretation. even disease processes in the peritoneum, mesentery or omentum may not be recognised on radiological examination, causing major difficulties in the management. peritoneal anatomy and physiopathology of peritoneal diseases must be well understood for better evaluation. ct is the best modality to assess the whole cavity. mr is equally sensitive with better contrast resolution; however, both modalities have advantages and limitations. ultrasound has a complementary role in evaluating the peritoneal fluid content. the presence of lacelike mobile thin septa is highly significant for tuberculosis. for better diagnosing the pathology, systematic approach is needed such as assessing the presence or absence of fluid in the peritoneal cavity, its character and location, accompanying soft tissue densities and their location. some inflammatory or infectious causes, such as acute pancreatitis and tuberculosis, involve typically parietal peritoneum and certain peritoneal reflections. peritoneal carcinomatosis involves typically both visceral and parietal peritoneum as well as subdiaphragmatic space. contrast enhancement patterns of the peritoneal membranes and the mesentery also have a complementary role in differentiating a variety of diseases. learning objectives: 1. to learn about the imaging characteristics of peritoneal and mesenteric masses and their differentials. 2. to appreciate the potential and limitations of imaging techniques in the detection of such lesions. 3. to understand the common pitfalls in diagnosis. a-060 08:58 a. filippone; chieti/ it (a.filippone@rad.unich.it) patients with persistent, recurrent, or intermittent bleeding from the gastrointestinal tract for which no definite cause has been identified by initial oesophagogastroduodenoscopy, colonoscopy, or conventional radiologic evaluation are considered to have an occult gastrointestinal bleeding (ogib). the management of ogib is clinically challenging, since the causes of such a bleeding frequently arise in the small bowel (sb), until now considered as the ''dark continent''. conventional barium contrast studies allow only a limited evaluation of sb, whereas angiographic diagnosis is strictly related to active bleeding. the introduction of capsule endoscopy (ce) as well as of crosssectional imaging dedicated to the sb visualisation, such as multidetector-row computed tomography enteroclysis (cte) and magnetic resonance enteroclysis (mre), represents significant technological advances that have overcome the limitations of older diagnostic tests. although ce is recommended as a first-line investigation in ogib patients, cte or mre are alternative diagnostic tools when ce is contraindicated due to suspected/known obstruction or stricture. moreover, in patients in whom a tumour is suspected, cte or mre may be the preferred initial test. therefore, radiologists have to be familiar with cte and mre techniques, in terms of bowel distension, scanning parameter selection, contrast administration as well as with specific imaging findings. similarly, they have to be aware of the potential pitfalls such as suboptimal bowel distension, artefacts due to peristalsis or breathing, intraluminal food debris and previous surgery. learning objectives: 1. to understand the causes of gi bleeding and underlying pathophysiology. 2. to appreciate the strengths and limitations of the imaging techniques used in diagnosis. 3 . to learn about common pitfalls in diagnosis. dilatation. presently, ct takes a major place in this setting with a reduced role for plain films. sonography is an alternative method when ct is not recommended. the questions of mondor in 1947 were pointed before the advent of cross-sectional imaging; these are still valid and have to be answered: 1) is this a true occlusion (how to differentiate it from adynamic ileus)? 2) does the obstruction concern the small bowel or the colon (impacting on the decision to operate or not)? 3) what is the cause of the obstruction? 4) are there signs of bowel ischaemia? the key points to avoid missing imaging diagnoses in bowel dilatation are to make the distinction between true mechanical obstruction and adynamic ileus (an early sign of mesenteric infarct) and to detect signs of strangulation leading to ischaemia (such imaging findings are present despite normal blood tests). in this setting, ct is the preferred technique; if it is not available, plain films and sonography can help in an optimal medical decision. the national lung screening trial (nlst) found a 20% reduction in lung cancer mortality with three annual screens using helical ct relative to chest xray. the us preventive services task force has issued draft recommendations to provide annual ct screening to high risk individuals defined by age and smoking criteria. questions remain regarding the implementation of ct screening: the determination of risk to identify those who should be screened, the frequency and duration of screening, definitions of screen positivity based on detected nodule characteristics, diagnostic algorithms for the follow-up of positive screens, overall societal costs of screening, and methods to adequately diffuse this technology across all socioeconomic groups at risk. answers to these questions are being addressed by several groups through ongoing research and secondary analyses of trial data. several models exist to identify individuals at highest risk of lung cancer (and lung cancer mortality), which may be enhanced if validated molecular markers are included. ongoing analyses of nodule features and likelihood of lung cancer will better inform screening interpretation guidelines and diagnostic algorithms. estimates from the nlst suggest that screening as performed in the nlst will be cost effective: the base case estimates $67,000 per quality adjusted life year gained (qaly). subset analyses suggest that screening is much more cost-effective in women than men, in higher versus lower risk groups, and in current versus prior smokers. while several variables influence cost-effectiveness, major drivers of cost are the cost of ct screening exams as well as the number of follow-up ct scans per positive screen (1.26 in nlst). while the national lung screening trial (nlst) had shown a significantly reduced lung cancer-specific mortality and all-cause mortality, the current results from the various european trials do not show such positive results. the dutch-belgian nelson trial, the german lusi trial and the british ukls have not yet published their results. so far, more cancers were detected in the screening arm of published danish and italian trials, but the positive effect on cancer mortality could not yet be shown. the italian mild trial even showed higher mortality in the yearly screening arm, and no difference between 2yearly screening and the control arm. this presentation discusses the implications of these findings and the consequences on implementation on screening in clinical practice. while limited in number of participants, european trials used advanced approaches that are most likely to be used if screening will ever be implemented. this presentation will discuss issues such as growth assessment and volumetry as critical factors for nodule assessment, handling of sub-solid lesions, computer aided detection and evaluation, and use of nonradiologists for reading and standardised follow-up. the goal is to provide an insight into how the european trials have affected our idea on practical implementation of lung cancer screening. the discussion will address the following issues: 1. are there sufficient data to support the implementation of individual lung cancer screening in clinical practice? 2. if yes, how to move from efficacy to effectiveness: what are the most optimised risk profiles for screening? what is the minimum level of infrastructure support and organisation required? how should subjects be informed about screening? what are the optimal follow-up duration and screening interval? what are the technical and positive screen management requirements? 3. what about the alternatives of waiting for additional data from ongoing trials or the validation of new biomarkers of lung cancer, permitting better selection of screened population before implementing individual lung cancer screening? attendees' opinions will be collected interactively. the speakers will be asked to comment and debate. treatment of prostate cancer depends strongly on the stage of the disease at the time of detection. however, treatment is controversial, even in prostate cancers found through early detection. this presentation will be based on a careful recent literature review. early detection of prostate cancer by use of psa testing leads to a significant reduction of at least 30% of disease-related mortality in screened men. this is however at the price of 40-50% of overdiagnosis, usually resulting in overtreatment. diagnostic developments which reduce overdiagnosis and the proper identification of cases which may not require treatment are central issues of current research and will be addressed by referring to available evidence. active observation of potentially nonaggressive cancers is an option in the management of this disease until, preferably, the diagnosis of such cases can be avoided all together. radical prostatectomy and radiotherapy are the options for treating those cancers which are judged to be aggressive. treatment recommendations for prostate cancer continue to evolve and are affected by technological advances in surgery, new discoveries in tumour biology, and the development of predictive and prognostic biomarkers. with the increased complexity of treatment decision-making, the role of mri is also evolving. the more individualised and targeted the treatment approach, the greater is the role of imaging in treatment selection, planning and follow-up. mri is especially crucial for planning technologically sophisticated treatment approaches such as robotic surgery, igrt, or focal therapy and in assessing patients' eligibility for active surveillance. though needs for uniform interpretation and standardised reporting remain unresolved, the value of mri in pretreatment staging of prostate cancer, particularly for evaluating extracapsular extension and seminal vesicle invasion, has been documented. not only the tumour stage, but also its size, volume and grade (aggressiveness) are important factors that influence treatment selection. therefore, the introduction of functional mr is essential. when added to t2weighted mri, diffusion-weighted mri, dynamic-contrast-enhanced mri, and mr spectroscopy, in addition to improving tumour detection, can provide an indication of tumour aggressiveness. mri performance on all sequences is dependent on lesion size/volume and grade, and this should be considered when applying mri results to treatment selection and planning. while it has been shown that multiparametric mri is generally more accurate and informative than anatomic mri alone, evidence-based guidelines specifying which combinations of sequences are essential for specific indications in patients with prostate cancer are yet to be developed and validated in welldesigned studies with robust outcome measures. in major trauma, it is essential to immediately recognise life-threatening conditions and to initiate early treatment. the majority of these patients succumb at the site of the injury to severe injuries of the central nervous system, heart and great vessels. however, there is another peak of early deaths within the first four hours after the injury. in the majority, these patients are at risk due to haemorrhage which is basically controllable by early minimally invasive treatment. consequently, this means that the vast majority of internal injuries can be survived as long as bleeding control is achieved within the first four hours after an injury. minimally invasive interventional techniques are already in use at a very early stage of the clinical decisionmaking process. particularly, we have witnessed a major paradigm shift in the treatment of blunt aortic injuries. endovascular repair has replaced open repair in many trauma centres. in appropriately selected patients, this adoption of endovascular stent grafts has resulted in a reduction in perioperative mortality, stroke and paraplegia, as compared to open repair. this entire session will provide knowledge about indications, requirements, standard procedures, and outcome of vascular emergencies, pardon me, urgencies. a. aortic emergencies m. cejna; feldkirch/ at (manfred.cejna@lkhf.at) aortic emergencies can be classified into several categories. "acute aortic syndrome": acute aortic syndrome is an entity of changes of the aortic wall. these include aortic dissection, intramural thrombus, and penetrating atherosclerotic aortic ulcer. besides coronary malperfusion and aortic valve insufficiency (type a dissection), emergency presentation is often due to visceral/limb ischaemia. sequelae of aortic syndromes are pseudoaneurysm formation and potentially aortic rupture. endovascular treatment has been established as the treatment option in at least type b dissections and penetrating aortic ulcers. aortic aneurysm rupture: with increasing diameter, aneurysms in the thoracic, thoraco-abdominal and abdominal aorta are prone to rupture. signs of impending aortic rupture are pain and imaging signs are sometimes subtle just like blurred contours of the aorta and (blister like) vascular wall deformation. endovascular treatment is an alternative to vascular surgery. aortic trauma: in severe thoracic trauma (mostly deceleration trauma), pseudoaneurysm formation and aortic rupture occur at the level of the aortic isthmus. endovascular treatment is considered the treatment of choice. inflammation, mycotic aneurysms and aorto-enteric fistulae: with acute and chronic inflammation, aneurysm and pseudoaneurysm formation and fistulae to enteric structures can occur. endovascular treatment is more often considered as bridging to vascular surgery instead of being a definitive cure. iatrogenic aortic injuries: besides accidental aortic injury during operations or interventional procedures, transaortic valve replacement and placement of aortic balloon pumps can result in iatrogenic trauma. endovascular treatment may be a minimally invasive approach. the focus will be on systematic presentation of aortic emergencies and the role of endovascular treatment. there are a number of vascular visceral emergencies that may be traumatic or nontraumatic in origin. the degree of urgency or potential for urgency varies with each condition and the subsequent management and intervention techniques will vary accordingly. an understanding of the natural history, pathophysiology, diagnostic tests and interventional techniques for these conditions will aid the diagnostic and interventional radiologist in identifying the pathology and knowing when to refer or initiate definitive treatment. i talk about embryonal development and anatomical differentiation of cardiovascular system, with special attention to the peripheral vascular system. the goal of this part of presentation would be to understand the anatomical structure and architecture of arteries and capillaries. we will discuss the casual classification of different kinds of peripheral arterial emegencies; e.g. congenital, posttrauma, arteriosclerotic and iatrogenic. the audience will learn about different therapy approaches, interventional and non-interventional, with accent on pad (classification, pathophysiology, risk factors, statistical facts and therapy). at the end, we will review different studies about combination therapy (conventional and interventional) with different possibilities and outcomes. modern cancer research and increasing therapy are mechanism based with the development of disease-modifying therapies that target the hallmarks of cancer. modern imaging tools enable the visualisation and quantitative assessment of the expression of molecular targets, of their interaction with potential ligands, as well as of the functional consequences of interactions at a molecular, cellular, metabolic, physiological, and morphological levels in a temporo-spatially resolved manner. the ability to gather such information from the intact organism renders imaging highly attractive for biomedical research and drug development. the determination of cell proliferation with radiolabelled thymidine is a wellestablished method in various life science branches where [3h]thymidine has been used for more than 40 years and still represents the gold standard for the assessment of tumour cell proliferation. since non-invasive determination of this parameter is required in clinical studies, considerable efforts have been made in radiopharmaceutical research. the synthesis of a large series of proliferation markers resulted therefrom mostly focussing on pyrimidine nucleosides. the labels used were gamma as well as positron emitting radionuclides. here, [18 f]flt (3'-deoxy-3'-fluorothymidine) is examined and discussed with respect to its preclinical and clinical application. since apoptosis is an important mechanism of cell death in tumours responding to treatment, the non-invasive assessment of apoptosis with tracers for the detection of phosphytidyl-serine presentation and/or caspase activation could be used as surrogate marker for therapeutic efficacy. several approaches have been followed during the last years; their potential and limitations will be presented. angiogenesis is one of the hallmarks of cancer that is considerably easy to characterise with many different imaging modalities and methods. it is not only crucial for invasive and metastatic tumour growth, but is also a prerequisite for the accumulation of anticancer drugs and highly impacts the success of radiotherapy. this talk summarises our experiences in microstructural, functional, and molecular imaging of tumour angiogenesis. the microarchitecture of vessels can longitudinally be studied using high-resolution ( )ct. dce mri and hf-us are introduced as favourable tools to characterise perfusion, vessel permeability and vessel maturation during antiangiogenic treatments. using targeted probes, it is shown that "fluorescence molecular tomography (fmt)", mri and us are capable of estimating the expression of angiogenic marker molecules on tumour vessels and of matrix-associated enzymes in the interstitial space during vascular remodelling. additionally, examples are also given for epr-based nano-sized theranostics and it is shown how us can aid in better accumulating them at the target site by inducing vascular permeation. many of these novel imaging concepts and tools can relatively easily be translated into clinics. thus, one can expect them to play a major role in the clinical management of tumour treatments soon. mammography technique from the point of view of radiographic compression and positioning is no different from film screening and radiologists ignore this at our peril. we will discuss the danger areas at the edges and the back of the breast and help you to find lesions only seen on one view. with digital capture the technologist can view images immediately, but the temptation is for them to repeat exposures to obtain radiographic perfection on otherwise clinically acceptable images. however, the task of assessing quality cannot be left to them, as viewing conditions on the 'lower resolution' acquisition monitor in a bright x-ray room is not enough. there is now evidence from 2 population screening programmes that poor image quality can reduce cancer detection from between 15% in france to 24% in ontario. 'quality' can be lost at 3 keys points in the imaging chain: the x-ray beam and dose, the detector and finally display. in flanders, poor detector performance was compensated for by increasing the x-ray dose by 60% and by meticulous quality control. postprocessing is less well understood, but reader studies now show different algorithms will affect performance particularly for the detection and classification of micro-calcification. finally, it does not matter how good all the equipment is if we try and read the images with the lights on full. mammography is the most important breast imaging technique allowing the visualisation of masses and micro-calcifications. however, in conventional mammography the three-dimensional breast tissue is reduced to a twodimensional image. therefore, small lesions may be undetectable due to superimposed glandular tissue. digital breast tomosynthesis (dbt) has emerged as a new imaging modality to overcome this limitation. several lowdose mammographic projections are performed over a limited angle of up to 50 degree using a standard mammography system. the average glandular dose of a tomosynthesis scan is somewhat higher compared to one-view mammography, but lower compared to a standard mammography in two projections. based on the low-dose projections, a stack of cross-sectional images covering the entire breast is reconstructed with an interslice distance of about 1 mm. several studies have shown that tomosynthesis improves both tumour detection and the characterisation of focal masses. due to the crosssectional nature of dbt, the techniques allow on the one hand the reliable differentiation of true focal masses from summation artefacts. on the other hand, tomosynthesis improves the detailed analysis of the lesions' border to differentiate benign lesions and carcinomas. additionally, contrast-enhanced spectral tomosynthesis may allow analysing signal-intensity time curves. in conclusion, dbt adds important information to standard two-projection mammography and can replace spot compression and rolled views as problem solver for difficult cases. however, the impact of tomosynthesis on breast cancer screening has to be investigated in larger clinical trials. reading screening mammograms is not the same as reading diagnostic mammograms. the vast majority of women attending a screening programme are usually asymptomatic and do not have abnormalities associated with a malignancy. the task of a mammogram reader is to scan a mammogram and perceive any possible abnormalities that could be associated with a malignancy. in other words, we are talking about perception and not diagnosis of a finding. examples will be shown about this crucial step. in modern population-based screening programmes, we use computerised reading and recording systems. since the work flow is rather quick, we have to ensure basic steps such as identity control and see that both ris and pacs are synchronised so that decisions of screening readings are recorded in both the systems of one and the same patient. in computerised screening programmes, we use standard reports informing a woman that no signs of malignancy have been detected on her screening mammograms. in case of findings that need further assessment, there are several ways to deal with this situation. the most common way is via a phone call, but this can also be done with a letter. a screening report should be short and concise and should only inform whether we see signs of a possible abnormality that can be associated with a malignancy. extensive reports describing the contents of a breast or findings of no clinical relevance should not be part of a screening report. emergency radiology services are very much on the rise in the last decade. medical emergencies and trauma are of enormous importance and a leading cause of death in all age groups. the use of radiological imaging in emergency departments showed an exponential increase since the 1990s. the annual growth rate in ct is 5-15% per year depending on the institution. even for advanced level 3â° medical centres running an own emergency radiology unit, it is a challenge to integrate advanced radiology services in an interdisciplinary team treating patients with acute traumatic and non-traumatic emergencies. general principles: radiology and radiological imaging procedures should be integrated in an interdisciplinary team. imaging should be guided by interdisciplinary clinical algorithms or guidelines (e.g. nexus or canadian cspine rule). many clinical diagnoses relay today on a early and thorough initial radiological diagnostic workup -mostly based on mdct. emergency radiology (er) is still a relatively young subspecialty in european radiology -it deserves specific training. the lecture will cover: the development of emergency radiology and its future perspectives; the use of conventional radiography, ultrasound and mdct; logistics and management of the patient; clinical guidelines and mdct in the primary patient survey (e.g. using atls for trauma) and advanced scanning protocols for mdct. infants and children with abdominal emergencies present special diagnostic challenges because of similarities in clinical findings between various paediatric conditions. imaging is frequently a critical part of the diagnostic process, but the choice of the best imaging modality can be controversial. patient age and safety issues such as radiation exposure must be taken into consideration when planning imaging. because certain pathologies are more likely to occur in specific age groups, patient age is a primary determinant of the imaging approach. this presentation will illustrate the differences in pathology between several paediatric age groups and discuss effective imaging algorithms for congenital and developmental, inflammatory, and obstructive conditions. the optimal use of radiographs, ultrasound, ct, and mri will be discussed. pitfalls that should be avoided in ultrasound and ct will be emphasised. in diagnostic imaging, we tend to focus on radiation protection, justification and optimisation, as the primary opportunity for radiographers and radiologists to ensure the safety of patients, both adults and children; however, this ignores some other important issues. this session aims to raise awareness amongst medical imaging professionals of some key considerations in relation to a number of child protection issues. when imaging a child in case of suspected non-accidental injury, every detail of that examination from conversations with the child and their parents or guardians, technical aspects of the examination, observations during the examination and the language used following the examination need to be carefully considered. another area of medical imaging requiring attention is how we communicate any radiation risks associated with examinations or procedures with children and their parents. there is evidence that while consent processes for invasive procedures are usually in place, these often lack focus on the risks associated with a high exposure to ionising radiation. these two medico-legal areas, suspected non-accidental injury and risk communication, are commonly encountered by radiographers and radiologists and as such it is important to make sure that we operate at the highest possible professional standards and in keeping with both regulations and best practice including the production of witness statements/contemporaneous notes. on rare occasions, we may find ourselves involved in legal proceedings as a witness or expert witness and it is thus important that we are all aware of the key considerations in this regard. session objectives: 1. to appreciate the need for radiographers to focus on more than just the imaging procedure in paediatric examinations. 2. to understand the extremely vulnerable nature of paediatric patients and the need for all health professionals to pay particular attention to this. a. professional responsibilities: an international perspective m. davis; dublin/ie (michaela.davis@ucd.ie) radiographers play a vital role in imaging children with suspected nonaccidental injuries. this session will also explore the wider role that radiographers have in child protection. current legislation and its implications will be explored from a variety of countries including those outside europe. in addition, case studies will be presented focussing upon child protection issues that have arisen in the x-ray department during imaging procedures. several of the barriers to radiographers becoming involved in child protection will be explored. radiographers and their contribution to child protection will be discussed and practical examples given. learning objectives: 1. to become familiar with current legislation and guidelines which have particular relevance to radiographers from an international perspective. 2. to appreciate best practice in child protection and the need for all radiographers to be aware of this. 3. to learn about child protection case reports involving imaging, radiologists and radiographers. a-085 08:58 b. risk communication in paediatric examinations j.l. portelli; msida/ mt (jonathan.portelli@um.edu.mt) medical imaging plays a vital role in the diagnosis and treatment of numerous medical conditions for millions of patients worldwide. however since most medical imaging examinations utilise ionising radiation, the associated risks of radiation exposure also need to be acknowledged, especially since high doses of radiation are known to cause adverse biological effects. medical imaging professionals should have a good understanding of the benefits and risks associated with the imaging examinations they perform, so as to ensure a high benefit-risk ratio for all patients undergoing diagnostic imaging procedures, and to be able to appropriately communicate such information to patients, their families and other healthcare professionals. this may be particularly more important when imaging paediatric patients, who are relatively more susceptible to the effects of radiation and receive a higher effective dose per unit of radiation when compared with adults undergoing the same medical imaging examination. indeed, following worldwide media attention about radiation incidents and their adverse effects, some parents/legal guardians may be concerned and reluctant to pursue important medical imaging examinations requested for their child, as they may have a misconception of the risks involved. in this regard, this lecture will seek to enhance awareness about the radiation doses associated with common paediatric imaging examinations; highlight the importance of medical imaging professionals having an appropriate understanding of benefits and risks associated with these examinations; and encourage such professionals to improve patient care by making use of this knowledge to have better discussions with referring clinicians, patients and their families. learning objectives: 1. to appreciate the frequency and radiation dose associated with certain paediatric imaging examinations. 2. to become familiar with the current status quo in the communication of radiation dose-related risks. 3. to understand best practice and potential considerations in providing accurate information to referring clinicians, patients and their families. c. what to do if you find yourself being called to give evidence m.d. viner; london/uk radiology is a powerful tool in the investigation of cases of suspected nonaccidental injury and suspicious death in children. the evidence obtained can be pivotal in bringing successful prosecutions against suspects and protecting the child and others from further harm. it is essential that evidence is obtained, recorded and presented in accordance with applicable rules of evidence in order to be admissible in court. it is thus important that those undertaking such examinations are appropriately trained, conversant with standards of evidence and maintain continuity of evidence throughout the investigation. this presentation will review rules of evidence for cases of suspected child abuse and their application to imaging examinations. it will examine the role of the radiographer and the importance of training and familiarity with legislation and guidelines that underpin forensic practice, highlighting the pitfalls that lawyers may exploit if procedures have not been followed. drawing on examples, it will discuss best practice from the radiographer's perspective, detailing the importance of continuity of evidence and maintenance of contemporaneous notes and witness statements. it will address key considerations for radiographers and others who provide evidence or act as an expert witness. imaging professionals play a pivotal role in the investigation of suspected child abuse. it is essential that this evidence is obtained, recorded and presented with regard to the applicable standards of evidence. for those called to give evidence, the importance of appropriate imaging protocols and procedures, detailed documentation and thorough preparation cannot be understated. learning objectives: 1. to understand the importance of contemporaneous notes and witness statements if involved in any forensic or suspected non-accidental injury examination. 2. to become familiar with the importance of continuity of evidence in forensic examinations. 3. to appreciate the key considerations if you are asked to provide evidence or act as an expert witness in court. brain tumours are the second most common neoplasms in children after leukaemia. as "paediatric brain is not just a small brain", paediatric brain tumours are not the same as tumours in adults. mri is a method of choice in their diagnosis in accordance with the principle alara in the paediatric population. by the age of approximately 3 years, supratentorial tumours dominate; later (4-10 years of age), the majority of children show infratentorial neoplasms which are pilocytic astrocytomas, most often found in the hemispheres, and medulloblastomas or ependymomas -in the fourth ventricle. after the age of 10, both groups are diagnosed with equal frequency. cerebral hemispheric tumours include astrocytoma which is the most frequent, teratoma in neonates, and in older children atypical teratoid/rhabdoid tumour, ependymoma, pnet, ganglioglioma and dnet. in the midline, we deal with chiasmatic or hypothalamic glioma, craniopharyngioma and germ cell tumours of the pineal region. extraparenchymal tumours are uncommon in the paediatric population. apart from the location, imaging pattern in various sequences, and contrast enhancement of the tumour, advanced mri techniques are helpful in establishing the diagnosis. dwi helps to differentiate between tumours of high and low cellularity showing low adc values in case of medulloblastoma and high in astrocytoma. mrs, pwi and dti also add important information to the diagnosis. mri of the spinal canal is obligatory in case of these primary brain neoplasms that have a high propensity to metastasise to other parts of the central nervous system such as medulloblastomas, ependymomas, high-grade gliomas, cerebral neuroblastomas, and pineal region neoplasms. learning objectives: 1. to learn about the difference between paediatric and adult brain tumours. 2. to understand the imaging strategy for the paediatric population. 3. to become familiar with the most common paediatric brain tumours. pancreatic endocrine tumours (p-nets) include both pancreatic neuroendocrine tumours associated with a functional syndrome (functional p-nets) and those associated with no distinct clinical syndrome (non-functional p-nets). non-functional p-nets may show immunohistochemical positivity for hormones which may be produced, but not secreted, which are clinically inert and whose serum concentrations are insufficient to induce symptoms. among functional p-net, the most common are gastrinomas and insulinomas, whereas those secreting vasoactive intestinal peptide, glucagon, somatostatin and other hormones are considered together as a group called rare functional p-nets. non-functional p-nets are classified, according to the who 2010 classification, in well-differentiated neuroendocrine tumours and poorly differentiated neuroendocrine carcinomas (necs) of small or large cell type. well-differentiated neuroendocrine tumours are then divided according to a grading scheme based on mitotic count or ki67 index in nets-g1 (with a mitotic count < 2 per 10 high-power fields (hpf) and/or 2% ki67 index), and nets-g2 (with a mitotic count 2-20 per 10 hpf and/or 3-20% ki67 index). all poorly differentiated neuroendocrine carcinomas are graded g3 (with a mitotic count > 20 per 10 hpf and/or > 20% ki67 index). most pancreatic nonfunctional p-nets are well-differentiated tumours, whereas poorly differentiated neuroendocrine carcinomas are uncommon. pancreatic endocrine tumours (p-net) are divided into functional p-nets and non-functional p-nets. diagnostic imaging of these tumours includes detection, characterisation and staging. there are significant differences when dealing with functional p-nets and non-functional p-nets. in fact, in the first case the main aim of diagnostic imaging modalities is the detection of the tumour, while for non-functional p-nets the main aim is the characterisation and the differential diagnosis with other tumours of the pancreas, mainly with pancreatic adenocarcinoma. staging is also important for both tumours, but mainly for non-functional p-nets. a large number of imaging modalities are available, both "morphological" and "functional". we can arbitrarily divide the imaging modalities for the diagnosis of p-nets into three levels: the first level includes us (with contrast-enhanced us), mdct, mri and nuclear medicine techniques; the second, endoscopic us, angiography and venous sampling; the third, intra-operative us. functional p-nets are represented mainly by insulinomas and gastrinomas which are small in size in most cases. their detection is still difficult, but significant improvements have been made with us, mdct and mri, so that these tumours are detected in most cases if appropriate imaging techniques are performed. however, still, no single modality is 100% effective. non-functional p-nets can be differentiated from pancreatic adenocarcinoma, since they are hypervascular and usually large in size. since they are potentially malignant, they require accurate staging by imaging modalities, both morphological (mdct, mri) and functional (pet/ct) to plan surgery and chemotherapy. there is worldwide consensus about surgical treatment of resectable p-nets in the following clinical situations: proven malignancy, whenever it is possible to remove the primary tumour and at least 90% of liver metastases (debulking); p-nets associated with a clinical syndrome caused by hormonal hypersecretion (insulinomas and gastrinomas mainly); non-functional p-nets with a size larger than 2 cm. vice versa, there are different expert opinions about the surgical treatment of functional and non-functional p-nets in men1 syndromes and in sporadic non-functional p-nets less than 2 cm in size. in men1 all insulinomas should be resected, while for gastrinomas the extent of resection is patient tailored, deserving standard whipple for selected cases. in the most common sporadic small incidentalomas, where long-term prognosis is favourable, surgical treatment has to be weighted with co-morbidities and morbidities of the patient and the procedure planned. these tumours have a risk of node metastases at the time of diagnosis in less than 10 % of patients. whenever possible, mini-invasive approach with pancreas-sparing operations should be recommended. in elderly patients, a first period of follow-up should be preferable and surgery should be offered only if the size of the tumour demonstrates increasing trends. the "acute aortic syndrome" includes three closely related emergency entities of the thoracic aorta: aortic dissection, intramural hematoma and penetrating atherosclerotic ulcer. as these conditions present with similar symptoms, cross-sectional aortic imaging is essential for diagnosis, triage and treatment planning. initial imaging features of these pathologies including typical early complications as well as their differential diagnosis will be reviewed. as nowadays several of these patients will undergo early endovascular thoracic aortic repair, an update on its indication, the different technical options and their clinical results will follow. finally, the focus will be on repair-related late complications and progression of aortic disease. imaging follow-up protocols, features of chronic complications and their interventional repair will be discussed. a. pre-therapeutic radiological evaluation j. ferda; plzen/cz (ferda@fnplzen.cz) the acute thoracic aorta syndrome covers patients suffering from acute chest pain and those injured during high-energy trauma. despite the similar symptoms, the aortic pathologies are heterogeneous, including acute aortic injury, intramural haematoma, aortic dissection, and ruptured thoracic aortic aneurysm and mycotic aneurysms. the diagnostic approaches could include the whole pallete of the imaging modalities: chest x-ray, transesopheageal echocardiography (tee), multidetector ct angiography (mdcta), mri and pet/ct. because of some disadvantages of tee, like problems with intubation in injured patients or problems of mri with seriously ill patient monitoring, mdcta has become the most used modality due to its ability of discrimination between aortic and non-aortic pathologies, and also due to its high sensitivity, specificity, availability and especially superior geometrical resolution and potential of 3d imaging. the proper pre-therapeutic mdcta protocol is using sub-millimeter isotropic resolution covering the entire aorta with pelvic arteries. when the pathology of thoracic aorta is found during the triple rule-out triage protocol, additional mdcta of the rest of the aorta and pelvic arteries has to be completed. ecg triggering could be an important advantage in the reduction of pulsation-derived artefact. the volume of applied contrast material used should be as small as possible to plan applications during endovascular treatment. 3d reconstruction of the thoracic aorta with its side branches and advanced vessel analysis have a crucial role in the measurement of the aortic diameter, diameter profile and lengths in the selection of proper stent graft type and size. they can be accommodated even in patients with small vessels and tortuous anatomy. calcified arteries can be no longer considered absolute exclusion criteria. some devices are designed to reduce the incidence of endoleaks, improving sealing capabilities by the use of a polymer to better adjust to the variable morphology of the proximal neck or to fill the aneurysmatic sac completely. more importantly, the introduction of fenestrated devices has resolved the problem of facing difficult anatomies when the aneurismatic pathology involves renal or visceral arteries. obviously, the use of these new devices requires a learning curve. beyond an increase of cost, they permit treating those patients who in the past were considered unfit candidates for evar. the evar new frontier requires performing the procedure in an outpatient fashion. a multicentre study was conducted on 100 patients who were discharged 4/6 hours after uncomplicated stent-graft implantation. cases (4%) with access vessel complications required additional procedures and patients were hospitalised overnight. the 30-day readmission rate was 4% for access vessel stenosis or false aneurysm. from the time of the first evar procedure, significant improvements have been achieved but there is still room for further progress. the standard imaging modality after endovascular treatment for thoracic aortic pathology (tevr) is ct angiography (cta). cta enables the radiologist to assess for the patency of the endografts, the presence of any complications after tevr, and the development of any new pathology related not only to the aorta, but elsewhere above and below the diaphragm. the role of mr is reduced compared with cta, particularly in the presence of stainless steel endografts. however, good images can be obtained by mri and mra if nitinol endografts have been inserted. mr is a useful modality for follow-up in young patients who require lifelong follow-up and, therefore, limited exposure to ionising radiation. ultrasound has no practical role in the follow-up after tevr, and although plain thoracic radiographs are routinely performed by some centres post-tevr, in practice almost equivalent information can be obtained by ct. the main complications after tevr are endoleaks, type a dissection, paraplegia and stroke. the classification of endoleaks is similar to the classification for evar. type 1 and type 3 endoleaks require treatment by additional endograft coverage with or without supraaortic or visceral artery bypass. other treatment options include the use of branched, fenestrated endografts or the use of chimneys and snorkels. type 2 endoleaks are less common than post-evar. similar to the evar population, intervention is mandated for an enlarging aortic diameter and involves embolisation in most cases. interventional oncology is a discipline that uses imaging-guided procedures in the treatment of cancer patients. when the malignant disease in not curable, interventional techniques such as biliary and oesophageal stenting can provide useful palliation and improve the patient's quality of life. in patients with potentially curable tumours, thermal ablation, cryotherapy and radioembolisation provide useful alternatives to radiotherapy and surgery in carefully selected patients. interventional radiologists who treat patients with cancer should practise as clinicians, participating in multidisciplinary meetings where treatment choices can be discussed with specialists from other oncological disciplines. they should involve themselves in all stages of clinical practice, including pre-treatment consultations, ward rounds and patient follow-up. radiation oncology and interventional oncology have much in common, including the potential for curing cancer using minimally invasive techniques. interventional oncologists can usefully adopt many of the principles and methods of practice in radiation oncology, including quality assurance and the collection of robust outcome measures. an alliance between these disciplines would be beneficial to clinical practice and research in both disciplines. session objectives: 1. to understand the contribution of interventional radiology to oncology. 2. to appreciate the areas of overlap between radiation oncology and interventional oncology. 3. to understand the need for a clinical pattern of practice in interventional radiology in oncology. the current scope and future challenges j.i. bilbao; pamplona/es (jibilbao@unav.es) together with chemotherapy, surgery and radiotherapy, interventional radiology (ir) is the fourth pillar in oncology. transcutaneous and endovascular procedures, guided by imaging, constitute a fundamental knowledge essential for the multidisciplinary management of oncologic patients. the range is wide and covers most of the needs in patientâ´s care. in short: obtaining samples for making an accurate diagnosis and also to know more about its specific biology (biomarkers); ir covers any possibility needed for vascular access; percutaneous needle ablation is the best alternative in selected patients; endovascular embolisation with "vehiculisation" of therapies is an outstanding method for selective treatment, and sometimes precise ablation, of different tumors; ir is a unique way to offer palliation in a wide range of tumoral complications, such as embolisation for bleeding, stenting for vein obstructions or drainage of fluid collections. there is an obvious need of continuous technical refinement. image-guided therapy is a continuous process that implies many disciplines and that includes every step, from staging through guidance of the procedure to the evaluation of the outcomes, both immediately, during and in the follow-up. future developments in ir may be focused towards the personalisation of therapies to each patient and to a better understanding of the biological mechanisms of tumour response or progression and their image expression. finally, radiologists must be actively involved in the whole process of clinical trials, from the creation of new lines to the performance of therapy until the evaluation and diffusion of the data. radiation treatment has a fundamental role in the multidisciplinary management of people with cancer. the evidence base for radiation therapy is robust and approximately 50% of people diagnosed with cancer will benefit from radiation treatment. most of this benefit comes from an increase in cure. the technical quality of delivery of radiation treatment is of great importance in avoiding a geographic miss and also in reducing the amount of normal tissue being irradiated unnecessarily. as well as the excellent technical delivery of any treatment offered, of paramount importance is the intelligent integration of care with attention to evidence base choices for both local and systemic treatment. multidisciplinary teams are in the best position to integrate surgery, radiation treatment, interventional oncology and systemic therapy in a planned and deliberate fashion. best practice: how to organise an interventional oncology unit a. gangi, j. garnon, g. tsoumakidou; strasbourg/fr (gangi@unistra.fr) interventional oncology is a fast growing field. interventional oncology is a clinical and technical speciality. solid clinical knowledge associated with the technical skills is mandatory for a successful practice. the technical skills should be associated to the clinical part. the knowledge of all treatment modalities and the participation of a multidisciplinary team is vital for the best practice. every single patient should be seen by the interventional oncologist and followed-up. the interventional oncologist is part of a multidisciplinary team, taking care of the patient. the team includes oncologists, radiotherapists, pain specialists, psychologists, surgeons, and anesthesiologists. the interventional oncology unit should include specialised nurses, technician, anesthesiologist, anesthesiologist nurses, and the interventional radiologist. the team should be able to take care of the patient's follow-up and eventual complications. to summarise, high-quality interventional oncology services are essential for safe and effective patient care. the technical skills of the interventional oncologist should be associated with an excellent clinical knowledge of the disease. a multidisciplinary team work is mandatory for a successful interventional team. harmonisation of training and appropriate credentialing is required for clinical services of the best quality. interventional radiologists continuously improving their skills and knowledge, patient access to safe and effective minimally invasive treatment options is increasing. whereas cardiac ct and mri are routine examinations for specialised radiologists, it has been necessary to wait for the introduction of fast scanning techniques to modify the behavior of nonspecialised radiologists regarding the interpretation of cardiac cavities. the objective of this session is twofold. first, cardiac radiologists will underline the role of these imaging modalities in the assessment of congenital heart disease but also in ischaemic and nonischaemic cardiomyopathies. in the second part of this session, chest radiologists will focus on the diagnostic information accessible at the level of the right ventricle, known to be the target of numerous respiratory disorders. two practical situations will illustrate this approach: pulmonary thromboembolic and chronic respiratory diseases. accurate assessment of the right ventricle (rv) is crucial for the management of congenital heart disease. echocardiography can provide some information, but as the rv sits directly behind the sternum and as many patients have undergone multiple operations, visualisation can be difficult. furthermore, for long-term follow-up and treatment planning, accurate measurement of ventricular size and mass, and valvular flow (tricuspid and pulmonary), and assessment of anatomy in 3d and 4d are vital. this presentation will outline the role of cross-sectional mri and ct for assessing the rv, and describing the indications, imaging protocols, technical pitfalls and relevant information for treatment planning. right heart failure in ischaemic and non-ischaemic cardiomyopathies m. grothoff; leipzig/de (matthias. grothoff@herzzentrum-leipzig.de) the role of the right ventricle (rv) has been underestimated for many years. today, we know that the rv is of importance for keeping up a sufficient circulation and that right heart failure in both ischemic and non-ischemic cardiomyopathies can result in hemodynamic compromise. rv ischemia has a higher in-hospital morbidity and mortality but post-infarction chronic right heart failure is a rare finding. as the rv has a different physiology from the left ventricle (lv), also the pathophysiology of ischemia is different here. using our standard cmr tools t2 weighted imaging for detection of edema and late gadolinium enhancement imaging for detection of necrosis/scar we can find that the rate of myocardial salvage is much higher in the rv than in the lv and that rv failure in the acute phase is basically caused by reversible ischemic effects. in non-ischemic cardiomyopathies like hcm and dcm changes in the rv myocardium mostly resemble changes of the lv. in arrhythmogenic right ventricular cardiomyopathy/dysplasia (arvc/d) however, there are specific findings in the rv and the role of imaging in diagnosing arvc has been strengthened by the revised task force criteria published in 2010. cine imaging should be performed carefully for detection of rv akinesia, dyskinesia or small aneurysms as well as the planimetry of the rv. findings like the detection of fibrosis in lge imaging and the detection of fat in t1 imaging can provide additional information, but are not diagnostic for arvc. learning objectives: 1. to learn about the different ct and mri techniques for evaluating right heart morphology and function. 2. to understand the prognostic impact of right heart involvement in ischaemic heart disease. 3 . to learn about the basic morphological and functional features of different non-ischaemic cardiomyopathies. right heart and chronic respiratory diseases: can ct be used as a onestop-shop? m. remy-jardin; lille/fr (martine.remy@chru-lille.fr) over the last decade, ct technology has evolved towards fast scanning capabilities and high temporal resolution, enabling improved evaluation of the heart and surrounding structures in the course of routine thoracic ct imaging. this has progressively modified the radiologist's implication in the interpretation of chest ct examinations. firstly, it is more and more common to integrate the physiological interactions between heart and lung when analysing the ct features depicted on a given examination. secondly, it is now possible to integrate cardiac functional information into a diagnostic ct examination of the chest, providing prognostic information in the management of patients with a wide variety of chronic respiratory disorders. the purpose of this presentation is to provide non-specialised radiologists with some practical guidelines in the choice of the scanning protocols and range of functional information that can be deducted from chest ct examinations. right ventricular dysfunction and levels of pressure within the pulmonary circulation are the key points of such approaches. learning objectives: 1. to appreciate the clinical impact of a cardiothoracic evaluation from the same ct examination. 2. to learn about the scanning protocols enabling such a combined analysis. 3. to understand its compatibility with other non-invasive modalities. rv and prognosis in pulmonary thromboembolic disease n.j. screaton; cambridge/uk (nicholas.screaton@papworth.nhs.uk) right ventricular failure is the most common cause of early death following acute pulmonary embolism and in patients with chronic thromboembolic pulmonary hypertension. echocardiography is sensitive in diagnosing and quantifying rv dysfunction. ct is the reference standard for the diagnosis of acute pe diagnosis and has the potential to provide comprehensive evaluation of the pulmonary arteries, heart and lung parenchyma. ct signs of right ventricular dysfunction which have shown predictive value for adverse outcome include: flattening of the inter-ventricular septum or bowing towards the left ventricle, reflux of contrast medium into the ivc, relative rv/lv diameter ratios on transverse and 4-chamber reconstructions, and ventricular volumetry as assessed both on routine non-gated ctpa and ecg-gated ct. in patients with cteph, mri permits imaging of the pulmonary vasculature and functional evaluation of the right ventricle and pulmonary circulation, enabling both morphological assessment and prognostic evaluation. learning objectives: 1. to learn about clinical and imaging factors associated with prognosis of thromboembolic disease. 2. to understand the benefits and weaknesses of different imaging modalities in predicting prognosis in thromboembolism. 3. to discuss the merits of comprehensive imaging evaluation in the routine diagnostic workup of suspected thromboembolic disease. multimodality imaging including ultrasound has within recent years been introduced in several anatomical regions. pet, ct and mri datasets can after an initial co-registration be fused and shown either side by side or using overlay on screen while doing real-time ultrasound; thus, the pet, ct or mri dataset is reformatted in a projection to fit the real-time ultrasound images. several methods of aligning the images are available and have been shown to have a high accuracy. image fusion involving ultrasound has been tested in phantoms, animals and in patient studies, mainly in abdominal imaging. by combining several imaging modalities, it is possible to benefit from the strengths of each modality. it is useful for characterisation of and intervention on liver lesions, abscesses containing air and lesions in areas with poor overview by ultrasound. also, the method is useful for characterisation and biopsy of pet-positive lesions, especially in patients with a history of cancer. the background of the method and clinical examples, mainly from abdominal applications, will be covered. also, perspectives and future research topics will be highlighted. contrast-enhanced ultrasound (ceus) has proved to improve the detection and characterisation of pathologies compared to conventional ultrasound, ct and mri in a number of indications. ultrasound contrast agents (uca), which are purely intravascular, do not show any interstitial diffusion or glomerular filtration like iodinated complexes or gadolinium chelates. dynamic contrastenhanced ultrasound (dce-us) allows to display the enhancement of a lesion with a high frame rate after bolus or infusion administration of uca, and to compare enhancement profiles between normal and abnormal tissue. quantification of dce-us is useful to quantify tumour enhancement and to limit intra-and interobserver variability. mathematical models with several perfusion parameters can be used. dce-us has shown to be of interest after antiangiogenic therapies as it allows an earlier evaluation of tumour response than usually done with ct and mri, which remain mainly based on the recist criteria. the common perception of 3d ultrasound (us) is of surface-rendered images, especially of the foetus. the same approach, enhanced by new transducer technology and software, can be used to take ultrasonography to another level in general body imaging, providing different image presentations and working practices similar to those of ct and mr. the technology involved in a us volume acquisition was represented initially by mechanical 3d transducers, and more recently by purely electronic, matrix probes. this latest technology allows bi-plane real-time acquisitions, fast switch to volume acquisition up to 100 degrees, and 4d acquisitions with acceptable frame rates. protocols have been described for major abdominal and retroperitoneal organs, with fast optimisation of acquisition settings. the technology supports contrastenhanced ultrasound (ceus). after volume acquisition, interpretation for volume us datasets requires a post-treatment phase, including multi-planar reconstruction, multislice imaging, and volumetric analysis. virtual cystoscopy and volume ceus quantification are new options. the implementation of this new, efficient us modality in a radiology department supposes deep changes in the daily practice with delayed post-treatment reporting times. it should represent a more effective way for comparison between different examinations and a better communication tool with clinicians. the proven and potential benefits, in terms of clinical accuracy, training, workflow and overall efficiency, will be discussed. the purpose of this lecture is to emphasise some pitfalls in liver imaging. morphologic changes in the liver are usually attributed to chronic liver disease where liver cirrhosis represents the most important cause. however, noncirrhotic diseases may also induce atrophy-hypertrophic changes of the liver. the most common mechanisms are related to venous obstruction (either portal or hepatic venous) and biliary obstruction. multidetector ct and mr imaging are essential to highlight these abnormalities. when dealing with liver tumours, the most important question that has to be solved is tumour characterisation. yet, it is often difficult to assess whether a large tumour is intra-or extrahepatic. imaging findings that might be helpful will be shown. last, some liver lesions can mimic liver tumors. vascular disorders and focal fatty changes or focal fatty sparing are the most common causes. some other conditions can be also mimickers and such cases will be shown. the technique and the anatomy of the bile duct and pancreatic duct will be described. the anatomical variants of the biliary duct and the pancreatic duct system will be analysed and their possible role in generating diagnostic imaging pitfalls described. strategies to avoid pitfalls in diagnostic imaging of the bile duct and the pancreatic duct system will be illustrated, considering the possible source of pitfalls. diagnostic imaging findings of different diseases involving the biliary ducts and pancreatic duct system will be illustrated, as well as the diagnostic imaging criteria useful for the differential diagnosis. over the last two years, the number of ct and mri units has increased by 30%, and modern pet centers and leading centers for radiotherapy have been built. we can identify an approximately 20% increase in the number of radiological research projects--mainly ultrasound, ct, and mri investigations. during the last ten years the total number of vascular interventions and mr studies has increased by ten times, four times for ct, and the annual growth of us and x-ray investigations is about 10%. unfortunately, these technical innovations are not always accompanied with pacs and ris installations; this is a reason why all advantages of digital equipment are not achieved. we see rapid development of private medicine; new private hospitals and ambulances have grown by more than 10% and investment companies are looking for new projects in this field. however, the professional education of radiologists is not enough to work with new diagnostic equipment. this is a reason why in 2014 we will start a pilot project to create a new system of continuing medical education in clinical medicine, including diagnostic radiology. we hope, this pilot project will increase the efficiency of clinical practise. differential diagnosis (dd) including tumour and non-tumour brain pathologies is an integral part of neuroradiological diagnostics and in some cases is a challenge to experienced neuroradiologists. more than 5000 patients with different cns pathologies have been investigated in the department of neuroradiology, burdenko neurosurgical institute since 2002. in the vast majority of the cases, there were tumours. we used deconvolution method for bv, bf, mtt and ps maps reconstruction on commercially available software (perfusion 1.2.0, 4.0 protocols, adw, ge). ct perfusion has demonstrated high level of information in determining the degree of malignancy in glial brain tumours. a strong correlation between bv and ps and tumour degree has been demonstrated. the use of ct-pwi makes it possible to successfully carry out dd between radiation necrosis and tumour progression. some histological types of brain lesions are characterised by unique haemodynamic properties which enable using this method as non-invasive "biopsy". ct-pwi has been especially useful in dd of the skull base region, bone and extracranial pathologies. the absence of artefacts created by the skull base bones makes this method especially valuable as compared to the mri t2*-and asl-perfusions. ct-pwi makes it possible to successfully differentiate tumours and a number of non-tumour cns lesions including demyelinating diseases, infectious and non-infectious granulomas, etc. ct-pwi is a powerful method for differential diagnosis of brain pathology. t-pwi can provide unique functional information regarding tumour pathophysiology and haemodynamics, which are not available with routine ct and mri. learning objectives: 1. to become familiar with the technique of brain perfusion ct. 2. to understand the added diagnostic value of perfusion ct. 3 . to learn about input of ct perfusion for assessment of treatment. interlude: development and use of web-based teleradiology in russia o.s. pianykh; newton highlands, ma/us (opiany@gmail.com) the largest territory in the world, russia, presents a perfect teleradiology use case of extremely unevenly distributed health care, concentrated in moscow and spread thin outside over an enormous area and sparse population. this unevenness deeply affects the quality and availability of radiological services, and cries out for efficient and practical teleradiology solutions. however, the same unevenness in medical expertise, financing and it infrastructure frequently acts against the advancement of teleradiology projects, blocking their natural progress. as a result, technical, financial, educational and clinical matters, interleaved into the nascent russian teleradiology ventures, require serious and predictable solutions, based on analysis and adaptation of already developed, internationally proven strategies. currently, russian teleradiology simply takes advantage of whatever is available to make its progress better, but needs to develop itself up to the tasks it faces. tuberculosis in russia: a challenge for a national radiological service i.e. tyurin; moscow/ ru (igortyurin@gmail.com) approximately, 1.7 billion people worldwide are infected with mycobacterium tuberculosis, of which 20 million are active cases. the reasons for resurgence of tb infection include the hiv epidemic, a rise in reactivation disease in the elderly, a growing migrant population and spread of drug-resistant strains. the incidence of atypical tb infection is also on the rise, of which mycobacterium avium intracellulare is the most important human pathogen. the pathologic form of the pulmonary infection depends on the sensitivity of the infected host and is classified as primary or postprimary. primary tb pattern represents infection resulting from recent contact with the pathogen. postprimary tb pattern results from reactivation of a dormant focus within the lungs. thoracic tuberculosis produces a broad spectrum of radiographic abnormalities. the radiological patterns had been described as parenchymal, airway, vascular, mediastinal, pleural, and chest wall lesions. common causes of a missed diagnosis of thoracic tuberculosis are failure to recognise hilar and mediastinal lymphadenopathy as a manifestation of primary disease in adults, overlooking of minimal productive lesions or reporting them as inactive, and failure to recognise that an upper lobe or superior segment of lower lobe mass might be tuberculosis. in aids patients, the imaging features depend on the degree of immune suppression. a pattern of postprimary tb is also usually seen among patients with decreased immunity due to alcoholism, renal failure, diabetes mellitus, ageing, malignancy, and renal and cardiac transplantation. learning objectives: 1. to understand the scope of the problem with tuberculosis screening in the russian federation. 2. to learn about the changing imaging patterns of thoracic tuberculosis. 3. to appreciate the current role of imaging in the differential diagnosis and follow-up of this pathology. interlude: mystery of denisov's cave and paleoradiology m. mednikova; moscow/ ru (medma_pa@mail.ru) this study focuses on the anatomical identification of fossil bones from altai highland in southern siberia, their radiological description, and parallels among other hominin fossils. methods describe the small and isolated tubular bones. we used microct versaxrm-500 by xradia inc. and digital microfocus x-ray. denisova cave is the best studied paleolithic cave in north asia. archaeological data suggest that about 300 thousand years before the present, a group of humans migrated to southern siberia from the west. their descendants had lived in the altai mountains in relative isolation for 250 thousand years. the taxonomic status of the early inhabitants of southern siberia was clarified thanks to palaeogenetic studies. it was concluded that the altai hominin was genetically twice further from modern humans than were neanderthals. phylogenetic analysis suggests that this clade diverged from that ancestral to humans and neanderthals very early -about 1 billion years ago. descendants of this clade apparently survived in the altai refugium until the period 50 -40 thousand years ago. due to structural patterns of preserved pedal and manual phalanxes, humans from denisova cave could be expected to be the bearer of "archaic" traits. the extraordinarily thick walls of tubular bones in adults reflect a high level of occupational stress. radiological volumetric microscopy of the denisovan girl phalanx gave evidence for the histological estimation of the developmental age. radiological methods seem to be the perspective approach in the study of rare and fragmentary fossil human remains, differentiating between archaic and modern humans. advances in imaging of pancreatic masses g.g. karmazanovsky; moscow/ru (karmazanovsky@ixv.ru) modern diagnostic radiology allows not only to detect pancreatic tumours, but also to carry out their differential diagnosis with high accuracy. this is especially important because many benign tumours of the pancreas do not require immediate surgery. at the same time, many benign tumours may become malignant. the differential diagnosis of the pancreatic cystic lesions using endoscopic ultrasound and magnetic resonance pancreaticocholangiography has now become particularly accurate. contrast enhancement allows detecting signs of tumor invasion into the main blood vessels and adjacent organs. modern developments of radiology help to use extended operations for malignant tumours and sparing surgery with minimal removal of intact functioning pancreatic tissue in benign tumours. learning objectives: 1. to become familiar with major types of pancreatic masses and their radiological manifestations. 2. to understand approaches to the selection of diagnostic pathways in pancreatic tumours. 3. to become acquainted with new developments in diagnostic imaging of pancreatic tumours. interlude: an artistic view of ct a.l. yudin; moscow/ ru (prof_yudin@mail.ru) radiology is a specialty based largely on figurative perception of diagnostic imaging. the radiological picture of many symptoms reminds one of objects and environmental phenomena (for example, vanishing lung, draped aorta, geographic liver, porcelain gallbladder, dirty fat and others). training of creative mentation promotes lasting assimilation of educational material at the associative level. metaphorical thinking skills can also be improved by searching for amusing fragments in radiological images similar to the objects in everyday life; animals, cartoon characters, and others. the essential help in the study of the physical foundations of radiology and functional capabilities of workstations provide the execution and study of x-ray films, ct or mri of fruits and vegetables, flowers, various artifacts and other objects in the environment. eventually, it is just beautiful. ultrasound of the breast is an established imaging technique with several advantages. it has been used to differentiate solid from cystic breast lesions for a long time. it has also been increasingly used to visualise small lesions in mammographically dense breasts and is the initial imaging method of the breast in young women. the features of the lesions that need to be analysed are: shape, relation to anteroposterior to laterolateral diameter, margins, internal structure and absorption of sound (distal acoustic phenomena). color doppler enables the thorough assessment of flow within the breast lesions. elastography is established as a useful method to differentiate breast lesions on the basis of their stiffness, which can be quantified. the accurate staging of axillary disease is an important aspect in the management of patients with breast cancer. it is recognised, however, that underlying malignancy can be found in lymph nodes that appear morphologically normal. a variety of morphological features that may be seen in pathological nodes have been described (cortical thickness of > 3.5 mm and absence of a fatty hilum). the automated breast ultrasound technique has been known for a long time, but with recent improvements now may play an important role. the automated breast volume scanner (avbs) employs frequencies of 5-14 mhz. avbs has various major advantages, such as being independent of the experience of the operator as well as supplying consistent and reproducible results. additionally, for the first time it has become possible to obtain coronal images of the complete breast, which greatly assists in the planning of surgical interventions. to study the technical basics in breast ultrasound (us), a breast scanning phantom helps to understand different us settings of greyscale imaging. typically, breast us work has a linear array transducer with a minimum field of view of 3.8 cm and a high frequency of minimum 7 mhz. a broadband transducer (e.g. 6-16 mhz) with different bands is preferred. in the central axillary area, a lower frequency band offers a deeper penetration depth. high frequencies improve the tissue contrast and optimise the axial and lateral resolution. the transmitter focus is adapted to the region of interest. highly sensitive color doppler detects slow flow rates (1 cm/s and less). for frequencies and power settings used in diagnostic greyscale and color doppler studies, no safety limitations have to be considered. breast us is mainly used as a second-line imaging tool to mammography (mg). a correlation between both imaging modalities is crucial. skin markers and additional mgs may help to solve the correlation problem. in bi-rads 4 or 5 us lesions with unclear correlation in mg, a marker placement after us-guided large-core needle biopsy helps to clear the problem. the pathomorphological growth pattern of a lesion is the basis to understand different imaging aspects with different modalities. second-look us after mri is an important correlation of lesions, which were first visible with mri. understanding the complementary imaging criteria will help to reduce the number of false-positive results. a practical imaging approach to brain and neurovascular trauma will be reviewed, with an emphasis on understanding the correlation between pathophysiology and imaging signs. guidelines on when to order acute neurovascular studies will be presented. special technical considerations to help optimise ct and mr imaging protocols for suspected brain injury, cns haemorrhage, and arterial dissection will be discussed. neurological emergencies are often associated with high morbidity and mortality, and thus require prompt diagnostic and therapeutic action. nontraumatic emergencies may however have a subacute onset, and radiological signs may be subtle, which can lead to delay in diagnosis and treatment. since clinical features are often nonspecific, the radiologist may be the first to point the clinician in the direction of the correct diagnosis. it is therefore of great importance that the radiologist is aware of and familiar with the various imaging findings, on both computed tomography (ct) and magnetic resonance imaging (mri), of non-traumatic neurological emergencies. these include vascular, infectious and inflammatory diseases. commonly encountered emergencies are ischaemic and haemorrhage stroke, venous thrombosis, arterial dissection, abscess, acute disseminated encephalomyelitis (adem), and encephalitis. radiological findings in rarer diseases may mimic those in the more commonly occurring diseases, but need to be correctly interpreted as therapeutic strategies and prognosis may be entirely different. such entities include for instance posterior reversible encephalopathy syndrome (pres), reversible cerebral vasoconstriction syndrome, susac's syndrome, and status epilepticus. furthermore, initial findings of (impending) complications of brain disease, such as hydrocephalus and herniation of brain structures, may be subtle, while early recognition allows for prompt and adequate intervention. finally, diagnostic and therapeutic interventions performed in an emergency setting may interfere with the diagnosis and interpretation of clinical and imaging findings. associated limitations and pitfalls therefore need to be recognised to avoid false-negative or false-positive diagnosis, respectively. learning objectives: 1. to learn about the modalities (ct/mri) and protocols for non-traumatic neurological emergencies. 2. to learn how to diagnose the main non-traumatic neurological vascular and non-vascular emergencies. 3. to become aware of the pitfalls and limitations of clinical presentation and imaging findings in non-traumatic neurological emergencies. the current century has brought with it new challenges in radiation protection, many of which follow the development of mdct which greatly enhanced diagnostic capabilities and substantially reduced scanning time to just a single breath-hold for chest ct, making ct scanning both patient-friendly and the physician's preferred tool. ct has also been added to nuclear imaging systems to create hybrid scanners (pet/ct; spect/ct image gently 5 years later: lessons learned in radiation protection for children. the alliance for radiation safety in pediatric imaging was founded in 2007 to promote radiation protection for children worldwide through awareness, education and advocacy. comprising over 75 medical professional societies and agencies, the alliance seeks to change practice locally for improved paediatric patient safety in medical imaging. since its inception, the alliance has had 6 campaigns in ct, diagnostic and interventional radiology, nuclear medicine, digital radiography and an outreach campaign to parents and 3 educational summits. yet, there is still work to be done. there is a need for parents and patients to receive information about their imaging test prior to the performance of imaging procedures, particularly those involving ionising radiation. the paediatric medical imaging community should work tirelessly with the manufacturers of imaging equipment to tailor equipment for children to optimise the study and ensure that the users of the equipment are knowledgeable in its safe use in children. the routine display of size-specific dose estimate on ct scanners will better estimate patient dose for quality improvement within facilities and in dose registries. finally, there is a need for diagnostic reference levels in paediatric radiology. this presentation will update the audience in progress to date regarding these challenges. the image wisely programme continues to move forward, guided largely by its steering committee, composed of two representatives each from acr and rsna and one representative each from aapm and asrt. the image wisely website (www.imagewisely.org) has educational content for imaging professionals (radiologists, medical physicists, and technologists) and referring physicians. a patient tab features links to radiologyinfo.org and the image gently website. a tab for "my equipment" links visitors to radiation dose-related 'microsites' developed by ge, hitachi, philips, siemens and toshiba. as of august 29, 2013, 18,646 individuals, facilities and associations have taken the image wisely pledge. to attract traffic to its website, image wisely has recently instituted 'news' and 'top reads' sections on the splash page highlighting recent articles and announcement, highlighting breaking news coverage and journal publications on relevant topics. in 2012, content on nuclear medicine procedures was finalised, completing two of the three targeted foci of the initial action plan_ct and nuclear medicine. in october 2013, a launch meeting will initiate the process of developing content for the third target area, fluoroscopy. in 2012 and 2013, image wisely has concentrated on efforts to engage referring physician communities, with particular interest in paediatricians and emergency medicine physicians. progress has been slow, but has recently gained traction with emergency medicine in the form of radiologist participation in a 2015 symposium, diagnostic imaging in the emergency department: a research agenda to optimise utilisation, organised by the society of academic emergency medicine. learning objectives: 1. to learn about the image wisely campaign for radiation protection of adults. 2. to understand the lessons learnt while communicating messages. lessons from a national approach to patient safety in radiation protection p. cavanagh; taunton/uk (petecavanagh@gmail.com) in considering a european campaign on radiation awareness, it is useful to gain information from similar campaigns in health care. there have been a number of national patient safety campaigns based on the institute for healthcare improvement (ihi) 100,000 lives campaign initiated in the usa in 2006. following the success of this, a similar campaign was launched in england. part of this process included an analysis of the success of the programme and the key interventions and drivers that were considered essential at both the national and local level. these included strong leadership, 1. bone (pseudo)-tumours: the majority of bone tumours can be detected on plain radiography. the age of the patient, location of the tumour in a bone and history of pre-existing bone abnormality should be included in determining the likely diagnosis. careful analysis of pattern of bone destruction, periosteal reaction and matrix mineralisation allow for characterisation of most bone tumours and differentiation from pseudotumours. ct may be useful for osteoid osteoma and mri is the best imaging technique for further diagnosis and staging by displaying tumour composition and extent of bone marrow involvement, including skip lesions, presence and extent of extraosseous soft tissue mass, and involvement of neurovascular bundle, muscle compartments and adjacent joint. this allows to find the best biopsy and surgical approach. to evaluate local control of disease and for detection of local recurrence, mri is usually the best imaging technique. 2. soft tissue (pseudo)-tumours: the majority of soft tissue tumours can be detected on ultrasound. except for cysts and subcutaneous lipoma, mr will be the next imaging technique for diagnosis, local staging, and eventually to find the best biopsy and surgical approach. the age of the patient, location of the tumour and careful analysis of the signal characteristics on mri allow for characterisation of many soft tissue tumours and differentiation from pseudotumours. plain radiography and ct may be useful for detection of calcifications and myositis ossificans. to evaluate local control of disease and for detection of local recurrence, ultrasound and mri are the best imaging techniques. in this honorary lecture, i will review a number of personal impressions that may contribute to the successful performance of research projects in cardiovascular radiology. also, issues and obstacles in performing successful research in the field of radiology will be considered. key factors for success include guidance by inspiring mentor, genuine interest and motivation, some creativity and serendipity. radiology has developed tremendously with many innovative modalities over the last 25 years, providing ample opportunity to participate in clinical research. potential issues that should be addressed are subspecialisation, turf battles, competition from other clinicians/ imaging specialists and adequate training in radiology research. the field of imaging research includes traditionally more clinically oriented research by focussing on developing and testing of new modalities and applications, now becoming more basic by including molecular imaging, population imaging, outcome studies and alike. silicone-filled implants (single or double lumen) require a dedicated sequence where silicone exhibits a high signal intensity, whereas signals from fatty and fibro-glandular tissues are cancelled. diagnosis of intracapsular rupture relies on the detection of a linguine sign (direct sign) or multiple "key-hole" and/or " teardrop" images (indirect signs). extracapsular rupture is defined as the presence of silicone outside the capsule (breast, soft tissues, lymph nodes). breast reconstruction after mastectomy may involve autologous tissue flaps (skin, fatty tissue, muscle and fascia). the transferred muscle is inserted in front of the major pectoralis muscle and enhances after contrast medium injection. the most common benign findings seen in such reconstructed breasts and also after a breast-conserving treatment are oedema, seroma, haematoma, fat necrosis and fibrosis. diffuse thickening of the skin and trabeculae is usually observed the first year after completion of radiation therapy. small focal areas (less than 5 mm) of non-mass-like enhancement and thin linear or rim enhancement at the lumpectomy site can all be expected findings. these benign findings decrease progressively, but residual enhancement may be observed in 15% of women at 5 or more years. in patients who were switched from tamoxifen to aromatase inhibitors, a stronger or re-appearance of a background enhancement may be observed. before classifying such findings as benign or probably benign, clinical examination and standard imaging data must be taken into account. highly suspicious lesions in such patients are similar to bi-rads 5 lesions in the nontreated breast. prevention strategies for women at high lifetime risk of breast cancer are usually adapted to the individual woman's risk of breast cancer. women at high risk (brca mutation carriers or women with a 30% likelihood of brca-heterzygosity) are offered primary prevention, which includes chemoprevention by tamoxifen or surgery (risk-reducing mastectomy and/or salpingooopherectomy, where the latter also helps reduce the risk of subsequent breast cancer by 30%). if women opt for secondary prevention (active surveillance/screening), this has to start at 30 at the latest. mri is considered a compulsory component of all programs worldwide. due to the very limited added cancer yield of mammography in this subset of women, and because of the still unsettled issue of possibly increased radiosensitivity of brca-mutation carriers, mammographic screening is not recommended until the age of 40. there is broad agreement that (at least) an annual screening is important; especially for brca1 mutation carriers, screening every 6 months may be more appropriate. we recommend interleaved screening, with annual mri and annual ultrasound (â± mammography) phase-shifted by 6 months. there are important differences between brca1-and brca2-associated cancers in terms of age distribution and incidence rates, histologic features, but also specific imaging features which must be known by radiologists. mri screening protocols must be adjusted to the specific needs of this (usually very young) screening population. this presentation will review the current evidence with respect to screening of women at high familial risk of breast cancer and will provide information on all aspects mentioned above. chest trauma is directly responsible for 25% of all trauma deaths and is a major contributor in another 50% of all trauma mortality. blunt trauma, accounting for 90% of chest injuries, is the third most common site of injury in polytrauma patients. plain radiographs still have a role in recognition of some acute thoracic pathology that requires immediate further management, either diagnostically and/or therapeutically, such as tension pneumothorax, major transdiaphragmatic herniation, large hemothorax or obvious mediastinal hematoma. mdct of the chest is now typically included in a whole body scan with iv contrast to facilitate rapid diagnosis on polytrauma cases using less radiation than selected segmental scans. mdct is the well-proven diagnostic gold standard for chest injury evaluation. the major advantages of mdct over other modalities include identification of active bleeding, direct signs of trachea or esophageal injury, direct evidence of major arterial vascular injury, such as pseudoanurysms, pneumo and hemopericardium, location and extent of lung contusion and laceration, and assessment for thoracic spine, shoulder girdle and rib fractures. diaphragm injuries are well depicted by mdct, especially on the left by identifying both the torn diaphragm edges, herniation and constriction of abdominal contents at the level of the torn diaphragm (collar sign), and direct contact of herniated structures with the posterior chest wall (dependent viscera). tracheal injuries are suggested by diffuse and progressive pneumomediastinum, dilated tracheostomy cuff, ectopic endotracheal tube, and direct connection of mediastinal air with the trachea lumen. ct-angiography eliminates the majority of indications for diagnostic catheter angiography. pulmonary symptoms such as chest pain, shortness of breath or wheezing are common non-traumatic symptoms prompting er visits. because clinical symptoms are very non-specific, imaging plays a major role in differentiating life-threatening from less severe diseases and forming a diagnosis. the chest radiograph remains the first imaging despite its limited sensitivity for certain diseases and being prone to inter-observer variability. comprehensive cardiothoracic ct examinations using most modern ct equipment are well evaluated in their diagnostic accuracy to determine the presence of vascular life-threatening events such as aortic dissection, acute coronary disease or pulmonary embolism. protocols and literature evidence will be discussed. the main focus of the course, however, will lie on the analysis of pulmonary ct findings and its contribution to the differential diagnosis of pulmonary emergencies (e.g. pneumonia, oedema, pneumothorax, exacerbation of fibrotic or obstructive lung diseases) and how to further integrate imaging findings, laboratory findings, patient history and clinical information to tackle the differential diagnosis. imaging findings will be discussed by clinical case studies, key findings and also overlapping morphological features of other differential diagnosis will be discussed side by side, illustrating the options and also limitations of imaging findings. mentor was first introduced in greek mythology, and in its modern usage first recorded by a french writer, franã§ois fã©nelon, in 1699. since then, this concept has been widely used in the development of mentoring, mentorship and more recently of mentees, with an overarching principle based on accompanying, sowing, catalysing, showing and harvesting. this concept remains today as a fundamental one in all teaching activities and implies generally a close contact between the mentor and the mentee. however, the development of internet with concomitant e-learning capabilities, which are hugely increasing, raises the very challenging necessity to re-think this concept and to adapt it to this new era. the esr is very concerned by this endeavour in the context of the striking development of esor, on one hand, and with the launching of its e-library, on the other. n. gourtsoyiannis; athens/gr (gournick@gmail.com) the presentation "esor in action" gives an overview on all esor activities in 2013 and 2014. a detailed report on the esor courses and teaching programmes in 2013 is presented, containing statistics about the number of course participants and of scholarship and fellowship grants. additionally, all educational activities in 2014, including dates, venues, topics and local organisers, are announced. evidence-based radiology: the basics evidence-based medicine (ebm) was derived from clinical epidemiology during the last century. it "is the conscientious, explicit, and judicious use of current best evidence in making decision about the care of individual patients" (dave l. sackett, 1996) . this means integrating (1) individual clinical expertise with (2) the best available external evidence from systematic research and (3) patient's values and preferences. when considering evidence-based radiology (ebr), the needed expertise is not only clinical, but also technical, while (4) radioprotection issues assume a relevant value according to the "as low as reasonably achievable" (alara) principle. ebm (and ebr) can be practised according to the "top-down" model, when using guidelines issued by governmental, professional, or academic bodies, or the "bottom-up" model, when local physicians (1) formulate an answerable question, (2) search for the best evidence; (3) appraise critically; (4) apply findings to practice; and (5) evaluate the performance. a hierarchy of radiological studies has been established according to the investigated matter: 1. technical performance; 2. diagnostic performance; 3. diagnostic impact; 4. therapeutic impact; 5. patient outcome; 6. societal impact. different degrees of recommendations are based on different levels of evidence, with experts' opinion as the lowest level and meta-analyses of high-quality homogeneous studies and multicenter studies being the best level of evidence. to practise ebr, radiologists should be familiar at least with basic statistics and epidemiology as well as of methods for study design, thus recognising the principal types of bias which can limit the value of published studies. learning objectives: 1. to understand the historical development and general principles of evidence-based medicine (ebm) with its top-down and bottom-up approaches. 2. to learn how to apply ebm principles to radiology (evidence-based radiology, ebr) and to illustrate the main reasons for the relative delay in developing ebr, including the challenges of fast technological innovation in medical imaging. 3 . to learn about the relationship between levels of evidence and the strength of recommendations for diagnostic imaging and interventional radiology. 4. to learn how radiologists could play a stronger role in building the evidence in favour of diagnostic imaging and interventional radiology, taking the patient's interest as the primary aim of clinical practice and science. education in research: action plan j. hodler; zurich/ch a survey regarding education in research has been commissioned by the esr and published in insights imaging (2012) 3: 535-542. the results indicate that education in research, associated with career models, needs promotion. the research committee of the esr is working on possible future steps to promote research through education. several problems will have to be addressed, most notably inhomogeneity within europe, motivation issues, illdefined career paths as well as funding issues. several stakeholders will play an important role, including scientific societies, although this is the core business of academic radiology chairmen. most young professionals starting a career in academic institutions are eager to expand their professional and personal aptitudes. an effective way to support young professionals in this regard is by mentoring. mentorship is a relationship where the mentor supports a junior faculty member (mentee) in personal and professional development. the mentee benefits from early determination and initiation of career-relevant steps, greater productivity in research and publishing activity and developing techniques in networking and collaboration. moreover, the mentee gains perspectives on how his/her discipline operates academically, socially and politically, improves self-efficacy and deals more confidently with challenging intellectual work. the mentor, a knowledgeable, experienced and regarded person, benefits from fresh ideas, energy and curiosity of mentees, as well as through acceptance as a mentor an enhanced status in the department. it is a trusted relationship of dialogue, learning and challenges, based on mutual interests. however, the mentor is not automatically the best friend or the sole exclusive advisor of the mentee. more and more academic medical institutions offer facilitated mentoring programmes, which help the mentoring pairs to create an effective mentoring relationship to accomplish the desired skills. evaluation of faculty mentoring programmes in academic medical institutions demonstrates the importance of mentoring in research and academic development as well as in patient care. especially in radiology where over many years there have been challenges in recruiting and retaining talented young professionals, mentoring is considered as an essential way for preparing the next generation of scientific and intellectual leaders. pitfall: "a hidden or unexpected danger or difficulty". imaging methods can provide an extraordinary amount of useful data to specialists treating head and neck (cancer) patients. it is crucial that these data are used to full advantage of individual patients. the most important factor in this process is mutual cooperation between the physicians in charge of patient care and the diagnostic imaging specialist. pitfalls in the head and neck may present in various ways: normal variants may look like disease, incidental findings are frequently encountered and suboptimal technique may obscure important findings. moreover, many pitfalls are directly related to technical errors. the presentation aims to familiarise general radiologists, who have an interest in head and neck imaging, with common pitfalls encountered on ct and mr studies focussing on the neck. in an interactive setting, examples from daily practice will be discussed. imaging of the skull base and maxillofacial skeleton requires a meticulous imaging technique and a good knowledge of normal anatomy and possible anatomical variants. asymmetry in the pneumatisation of the paranasal sinuses, skull base or temporal bone is a common reason for misinterpretation. for example, hypoplasia of the maxillary sinus may be misinterpreted on conventional radiography as maxillary sinusitis or orbital blowout fracture, depending on the context; asymmetric pneumatisation of the petrous apex or mastoid bone may mimic, respectively, a cholesterol granuloma and fluid effusion in the non-pneumatised side on mri. vascular variants may also cause interpretation problems. for example, turbulent flow in a large jugular bulb may mimic a jugular foramen tumour on mri. variants in the vascular plexus surrounding the trigeminal or facial nerve may occur, and cause asymmetric findings on mri, possibly mimicking neuritis or perineural tumour spread. incomplete maturation or arrested development of skull base structures may also cause confusion. examples are the cochlear cleft, not to be confused with otosclerosis, or arrested pneumatisation of the sphenoid sinus, possibly mimicking a tumoural lesion in the central skull base. to avoid problems, one should keep in mind the existence of such variants, while correlating the imaging findings with the clinical problem; in some cases, an additional imaging study may be needed to exclude a pathological process more confidently. this short 5-min introduction by the session chairman will give an overview of the current state of cardiac computed tomography (ct) for diagnosis and prognosis. in addition, the introduction will provide the basis for the subsequent dedicated lectures covering low radiation dose, diagnostic accuracy, and incidental findings in cardiac ct. what are the protocols with the lowest radiation dose in clinical practice? j.-f. paul; le plessis robinson/fr (pauljf@ccml.fr) the radiation dose delivered for coronary ct angiography using retrospective gating is high, because only a small part of the total radiation delivered is used for the reconstruction of the image in the retrospective mode. on average, 20% of the radiation burden is used to reconstruct one phase of the cardiac cycle. ecg-triggered tube current modulation allows reducing the nominal dose by up to 96% in the systolic phase. another approach for reducing radiation exposure is to use prospective, sequential acquisition, with this approach being associated with 75% dose reduction compared to the spiral retrospective acquisition. exposure time may be also shortened by an increase of pitch, in particular on the dual-source ct. however, applicability to each dose-sparing technique depends on the heart rate and its regularity. dose-sparing strategies should be modified in case of high or irregular heart rate and radiation dose reduction may be less effective. for coronary ct angiography, individually weight-adapted protocols have been successfully applied, by adjusting mas to patient's weight. more recently, settings of 100 kv and even 80 kv have been successfully used for cardiac studies, especially in slim patients or children. reduction of exposure time and individual adaptation have an additive effect on dose reduction: it has thus been possible to scan down under 1 msv in selected, slim patients, using this combined approach. in many cases, using the latest technology, radiation dose may be lower than the mean radiation dose associated with conventional angiography. learning objectives: 1. to understand various protocols to lower radiation dose in cardiac ct with regard to the clinical situation and the risk of image quality impairment. 2. to learn how to tailor the radiation dose level to each patient in terms of morphology. 3. to become familiar with modulating exposure windows in regards to a patient's ecg. how accurate and prognostically valid is coronary ct angiography? f. cademartiri, e. maffei; monastier di treviso/it (filippocademartiri@gmail.com) the role of cardiac computed tomography in cardiovascular diseases is becoming increasingly important. cct is a robust and reliable investigation for the detection and exclusion of significant coronary artery disease. in addition, cct provides reliable noninvasive information concerning coronary plaque burden (severity, distribution, type), morphology and function of left and right ventricle, valves, aorta, and so forth. in the past 5 years, the prognostic role of cct has been established. the prognostic information that can be extrapolated from cct is very diverse and most of it is still under investigation. there are converging evidences that cct can stratify cardiovascular risk better than conventional clinical methods, especially in symptomatic patients. for asymptomatic individuals, the role is still controversial since coronary calcium score alone has a very important role already. several aspects of cct information seem to have importance for prognostic stratification: plaque presence, obstruction, plaque type and distribution. more recent studies have started showing the relationship between cct and pharmacological treatment. this is a very new and appealing topic, since the evidence is towards the fact that the most effective pharmacological treatment (e.g. statin) should be restricted to patients with at least some nonobstructive cad as detected by cct. this might become a revolutionary concept in cardiovascular medicine with several implications. learning objectives: 1. to learn about and integrate the prognostic information from coronary ct angiography into conventional methods. 2. to learn about coronary ct angiography and conventional methods. 3. to appreciate the prognostic impact of coronary ct angiography and conventional methods. incidental findings in cardiac ct: how to report and proceed s. leschka; st. gallen/ch (sebastian.leschka@kssg.ch) rapid advances in computed tomographic (ct) technology have facilitated the widespread use of ct for cardiac imaging worldwide, and can be considered nowadays an essential part of the clinical workup of patients with suspected coronary artery disease. albeit that the performed ct study is focussed on the cardiac structures and the coronary arteries, adjacent noncardiac structures are in the field of view whenever a patient undergoes cardiac ct to quantify coronary calcium or to perform a noninvasive coronary angiogram. in addition, the location of the heart near other anatomic regions, including the lungs, mediastinum, upper abdomen, and bones, necessitate that these structures are included when acquiring coronary ct angiographic images. several publications have demonstrated a high frequency of incidental findings on coronary ct angiography. the availability of this information is part of an ongoing clinical debate. while some radiologists believe that every image should be interpreted completely, others believe that examining noncardiac structures reveal too many incidental findings of uncertain clinical significance, which may harm because additional testing increases risk, cost, and patient anxiety. the aim of this lecture is to separate solid facts from opinions and beliefs. the diagnosis of pulmonary embolism (pe) is usually established by a combination of clinical assessment, d-dimer testing, and imaging with either pulmonary ventilation-perfusion (v/q) scintigraphy or pulmonary multidetector ct angiography (ctpa). v/q scintigraphy is a functional imaging method using isotopes for the visualisation of ventilation and perfusion distribution in the lungs. in recent years, the imaging techniques for diagnosing pe have improved. many nuclear medicine centres have adopted the single photon emission computed tomography (spect) technique as opposed to the planar technique when diagnosing pe. the introduction of 3-dimensional v/q spect technology instead of 2-dimensional planar v/q scintigraphy has resulted in fewer indeterminate results and a higher diagnostic value. the latest improvement is the addition and combination of a low-dose ct without contrast to the v/p spect (spect/ct) technique. the spect/ct in combination has been compared to ctpa, planar scintigraphy and spect alone, and one study has shown that spect/ct in combination had the highest diagnostic accuracy for pe diagnosis. spect in combination with low-dose ct without contrast enhancement is superior, especially for small subsegmental emboli; however, consensus is lacking regarding the clinical impact and treatment. spect and spect/ct may provide alternative diagnosis if pe is refuted and are feasible in almost all patients, because there are no definitive contraindications. in the present lecture, spect and spect in combination with low-dose ct are discussed in the context of diagnosing pe. over the last few years, emergency radiology (er) has been a subspeciality with growing interest. because of rapid developments in technology, ct has become the most useful tool in evaluating trauma and other emergency patients. in this lecture, the basics of planning and organising an er department are presented and discussed. besides optimising technical equipment and protocols for imaging, different logistic concepts have to be considered in planning and organising er departments. first of all, logistic concepts have to be considered for obtaining an optimal workflow: the radiology department has to be in close proximity to the emergency department and the admitting area, in particular. the whole workflow must be optimised for speed and accuracy. this also mandates having dedicated and standardised examination and viewing protocols for ct. in contrast to the usa where dedicated emergency radiology departments are well established, nonspecialised radiologists still frequently do the reading of emergency radiology cases in european countries. the radiologic staff involved has to be trained for interpretation of trauma and other emergent cases. this does not only account for residents, but also for consultants and attending radiologists. since a large number of cases will arrive during after hours and on weekends, staffing has to be adjusted to this fact, which includes attending radiologists to be available during these hours on call or, preferably, on-site. this lecture will give an overview of logistic concepts and organisation of an emergency department and will also discuss critical issues in polytrauma imaging. at least during the radiological training in hospitals, every radiologist will personally be confronted with the treatment of polytraumatised patients. it is a fact that standardised whole body mdct (wb-ct) as an independent predictor is able to save around 20% of patient lives. thus, wb-ct is the major diagnostic tool and should be performed as fast as possible. some institutions bypass the emergency room and directly start patient stabilisation in the ct cabinet. however, radiographs and focused ultrasound remain important in general settings as long as they are performed in a way which does not delay ct diagnostics. after scanning, specially trained radiologists support the whole interdisciplinary team with correct, appropriate and prioritised diagnoses. besides optimisation of parameters like logistics, patient positioning preferably 'feet first', reading and communication, 'choosing the right protocol' is a crucial factor for ideal radiological patient care. four types of protocols should be differentiated: there is a wide agreement that for patients with polytrauma, integrating whole body computed tomography (ct) scan into early trauma care significantly increases the probability of survival. therefore, ct is today considered the most important imaging technique in the diagnostic workup of polytrauma patients. the downside of whole body ct represents the relatively high radiation exposure. to overcome this handicap, the following measures can be taken: 1. positioning of the arms during whole body ct above the head results in reduction of radiation dose; 2. adaption of scan parameters, especially reduction of tube voltage to 100 kv reduces radiation dose; 3. installation of recent technical improvements like iterative reconstruction algorithm reduces noise in the image, allowing a downward adjustment in radiation dose to obtain standard diagnostic quality images; 4. installation of dose control software enables optimisation and improved dose management over time. another disadvantage of high-resolution whole body ct is the amount of acquired data. to optimise the workflow in the evaluation of a couple of thousand submillimetre images it is necessary to connect the mdct scanner with a dedicated workstation for volume image reading, which offers the possibility of quick multiplanar online evaluation. in this introduction i will define the connectome (a comprehensive map of neural connections in the brain) and related concepts such as scaling, structural and functional connectivity as well as the integration-segregation paradigm. the development of mri-based techniques such as white matter tractography and segmentation of white and gray matter has played a crucial role in the emergence of connectomics by providing tools to map in vivo the entire human structural connectivity at a macroscopic scale. i will explain these methods and how from mr imaging a human connectome can be mapped and represented as a network (set of nodes and edges). finally, i will also review the validation work related to those techniques and mention the foreseen technical advancements in the field. session objectives: 1. to learn what the human connectome is and how it is affected by brain disease. 2. to understand how the human connectome can be imaged and characterised with mri. 3. to become familiar with the network formalism and its interpretation. 4. to understand the relationship between brain function and underlying structural connectivity. 5. to understand the conceptual ideas behind connectomics. 6. to learn about the general workflow, from diffusion imaging to mapping a structural brain network. 7. to become familiar with the robustness of the technique by reviewing validation studies and getting a glimpse of the technical challenges. the economics of brain networks e. bullmore; cambridge/ uk (etb23@cam.ac.uk) we review the methods and recent results of network analysis of human neuroimaging data. human functional mri and structural mri data can be analysed using mathematical tools drawn from graph theory to quantify the complex (non-random) topological properties of brain networks. these results can be substantiated by meta-analysis of prior neuroimaging results and analysis of non-human nervous systems. brain networks consistently express complex topological features, such as small-worldness, hubs, modules and rich clubs. some of these features entail disproportionate biological cost, but may be "worth it" by supporting integrative information processing and adaptive behaviours. highly connected hub nodes are high cost/high value network components that likely also represent special points of vulnerability for diverse brain disorders. these economical principles of brain network organisation are expressed at the microscopic scale, e.g., in the nervous system of the nematode worm c. elegans, and may therefore provide a new axis for translation between macro and micro systems neuroscience. neuroimaging can be used to elucidate the economical principles of human brain network organisation in health and disease. connectomics in brain pathology m.p. van den heuvel; utrecht/nl (m.p.vandenheuvel@umcutrecht.nl) healthy brain function depends on efficient functional communication within a complex network of structural neural connections, a network known as the connectome. conversely, damage to the brain's network, disrupting local neuronal processes and/or global communication between remote functional systems may lead to brain dysfunction. in the last few years, emerging evidence from a wide variety of studies suggests that connectome abnormalities may indeed play an important role in the aetiology of several brain disorders. in my talk, i will discuss the results of recent studies suggesting an important role for affected connectome organisation in a number of neurological and psychiatric disorders. in particular, i will highlight the findings of affected functional and structural brain network in neurodegenerative disorders such as alzheimer's and als, as well as discuss how the application of network science and connectomics may aid our understanding of the biological basis of psychiatric disorders such as autism and schizophrenia. learning objectives: 1. to understand the role of connectome architecture in (cognitive) brain function and dysfunction using diffusion mri/functional mri. 2. to become familiar with connectomics as a tool for examining disease pathology in a wide range of neurological and psychiatric brain disorders. linking structure and function: the role of modeling in understanding the pathophysiology the interplay of the brain's intrinsic activity and the external world has seen a revival in the last decade, especially in neuroimaging. a long-held assumption in many of these studies has been that ongoing brain activity is sufficiently random that it averages out in statistical analysis. hence, imaging studies are termed 'activation' paradigms, where experimental manipulation results in the activation of cerebral circuits that are necessary for performing the task. nevertheless, a large amount of recent literature reports a body of observations that there are consistently distributed patterns of activity during rest. this fact has led to the suggestion that it might be possible to characterise network dynamics without needing an explicit task to drive brain activity. indeed, numerous neuroimaging experiments have evidenced the solid existence of spontaneous long-range correlations, i.e. functional connectivity (fc), by fmri, meg, and eeg techniques. the functional connectivity is defined as the statistical dependence between remote neurophysiological dynamics. the emergence of resting functional connectivity is intrinsically linked with the underlying anatomical connections between those areas, i.e. the structural connectivity. whole brain modeling can indeed establish a direct link between structure and function. furthermore, the modeling can shed light on the origin of pathological functional disfunction by making the link with the underlying anatomy explicit. we will show how, structural dti tractography, functional imaging and modelling studies can be combined for reaching this goal. traumas to the paediatric pelvis and hip include traumatic dislocations of the hip, fractures of the femoral neck, fractures of the pelvic ring, acetabular fractures and apophyseal avulsion fractures. traumatic dislocations of the hip, fractures of the femoral neck, fractures of the pelvic ring and acetabular fractures are rare in children (less than 5% of paediatric fractures), as compared to adults. these fractures are commonly the result of high-energy trauma. imaging is based on plain radiographs, but ct and mri are very useful to precisely assess bone (ct) and cartilage and soft tissue (mri) lesions. imaging enables accurate diagnosis, appropriate treatment and detection of potential complications (femoral head osteonecrosis, premature physeal closure â�¦). in contrast with the previous injuries, apophyseal avulsion fractures of the hip and pelvis are common in children and adolescents, usually associated with athletic activities. in most cases, these fractures are of good prognosis and can be treated conservatively when minimally displaced. plain radiographs confirm avulsion injuries to ossified apophyses, but mri and ultrasound are the modalities of choice to demonstrate injuries to nonossified apophyses and to assess apophyseal displacement. the elbow is a very common site for fractures in a child. the challenge for the radiologist is to differentiate normal variants of growth from possible injury and this is usually achieved by having good-quality radiographs and an understanding of normal growth. it is important to recognise those fractures which require surgical intra-operative treatment. in a small number of cases when assessing for vascular integrity, intra-articular extent and injury to cartilaginous structures, ultrasound and mr imaging have a valuable role. this lecture will give an overview of the radiographic appearance of fractures, highlight the features which require orthopaedic intervention and illustrate the use of additional imaging modalities. learning objectives: 1. to become familiar with the types of injuries seen in the paediatric elbow. 2. to understand the strengths and weaknesses of different imaging modalities. a-162 17:00 the diagnosis of c-spine injury is more complex in children than in adults. early diagnosis is crucial since delayed diagnosis results in high morbidity and mortality. leading mechanisms of pediatric c-spine trauma are motor vehicle accidents, sports and pedestrian injuries. due to their anatomy, children are prone to different types and locations of injuries. children < 10 yeas of age are more likely to injure the spinal cord itself and are prone to dislocations and high (c1-c4) bony injuries. children > 10 years of age more often sustain c-spine fractures. in children under the age of 2 years, radiographs are rarely helpful. ap and lateral radiographs are helpful in children aged between 2 and 8 years. in children aged > 8 years, additional lateral and odontoid views are obtained. anatomical variants such as pseudosubluxation of c2-c3, widening of the atlantodental interval and ossification centres may appear to be of concern on imaging, but are normal. abnormal radiographic findings require additional imaging to differentiate them further with ct on the area of concern. mri is mandatory if signs of atlantorotary subluxation and spinal cord injury without radiologic abnormality (sciwora) are present. mri identifies injuries to the spinal cord that are not apparent with other modalities, and should be used when a child presents with a neurologic deficit but normal radiographs on ct scan. nowadays, ultrasound (us) has become the first choice for performing most breast biopsies. the main advantages of this technique are non-ionising radiation, full control of the needle position in real time and widespread use of us equipments at all centres. us allows access to difficult places (such as the axilla or near the nipple), multiple lesions can be safely biopsied in one single session, the breast is not compressed, there is excellent comfort for patients and radiologists, local anaesthesia and haematoma do not hide the lesion and it is a cost-effective technique. however, the main limitation is that the lesion must be visible on us. us-guided fine-needle cytology was widely used in the past, but today its use has decreased. us-guided core-needle biopsy has proven to be a reliable technique to perform a biopsy for breast lesions, showing a sensitivity value of about 98%. furthermore, it can be safely used for performing biopsies of axillary lymph nodes. vacuum-assisted devices can be used not only for diagnostic purposes, but also for therapeutic ones, because small palpable benign lesions (such as fibroadenomas), papillomas and radial scars can be completely removed. stereotactic breast biopsy is the performance of tissue sampling under mammographic guidance. as with any imaging technique, some lesions are only seen with mammography. when these lesions are suspicious (e.g. birads 3 or higher), there are no imaging techniques that can downgrade this suspiciousness directly, although for birads 3 lesions follow-up might be a viable alternative. in mammography, most lesions that are only visible on the mammogram consist of clusters of microcalcifications. these harbour a likelihood of around 25% being malignant and should thus be classified as birads 4. this implies that tissue sampling is mandatory. different from ultrasound-guided biopsy, it is not possible to perform a real-time biopsy under mammographic guidance. rather, stereotactic biopsy uses triangulation to assess the depth of a lesion within the breast, while the lesion location in the xand y-plane is assessed on a scout view. the needle is positioned using the coordinates thus obtained. since there is no real-time feedback of the accuracy of needle positioning, it is necessary to obtain substantially more tissue than under ultrasound guidance. therefore, vacuum-assisted systems are essential. in case of calcified lesions, the biopsy result is controlled by x-ray. calcifications should be present in the sample. biopsy complications that occur under stereotactic guidance are usually limited. most common is the formation of large haematomas. scarring may also occur. breast magnetic resonance (mr) imaging is the most sensitive modality available to evaluate the breast for cancer. it can detect lesions that are occult at mammography and ultrasound. it has a limited sensitivity and the positive predictive value ranges between 15 and 40%. histopathological assessment of mr-detected lesions is therefore mandatory. some of these lesions will be visible at second-look ultrasound and can be biopsied sonographically. a significant number however will only be discernable on mr, and mr-guided biopsy is therefore the sampling technique of choice. mr biopsy has become an essential component of any breast imaging practice. several mr-biopsy techniques are available including the grid-localising, pillar and post and the freehand techniques. the technique for preparing and performing a mr-guided vacuum-assisted biopsy using the grid-localising technique is reviewed. potential complications, limitations of mr breast biopsy and actions to prevent failure are discussed. imaging-histologic correlation is essential to ensure accurate sampling. clip placement and follow-up imaging should be performed to ensure sampling, including ultrasound correlates. finally, new developments in mr-guided therapeutic interventions are discussed. abdominal injuries require a timely and reliable diagnosis to prevent potentially lethal outcomes. the armoury of clinical tools (physical examination, lab tests) does not fulfil these criteria, since they are either not fast or not reliable. imaging diagnostic modalities help the clinician to acquire the necessary amount of information to initiate focused and effective treatment. however, the selection of the appropriate imaging algorithm, modality and technique, as well as the precise detection and interpretation of essential imaging findings are frequently challenging, especially because the circumstances, under which these examinations are performed (open wounds, bandages, non-removable life-supporting equipment, lack of patient cooperation, etc)., are frequently less than optimal. knowledge of critical imaging signs, symptoms and the role they play in the evaluation of the patient's condition, as well as fast decision-making and ability to closely cooperate with the clinicians are skills of key importance for radiologist members of the trauma team. this presentation will describe the technique and important findings for ct stone studies as well as the accuracy of this study. an explanation of when iv contrast should be given to augment a ct stone study and findings of gu and non-gu diseases that can mimic symptoms of stone disease will be provided. examples and descriptions of acute mesenteric vascular abnormalities, bowel obstruction and infectious conditions will be included. ways to differentiate and categorise emphysematous infections for proper treatment will be described. lower tract emergencies will also be illustrated and described. a systematic approach to evaluating abdominal cts will be described to avoid mistakes. using cases and an audience response system, this segment of the course will go over the optimal imaging approach for patients presenting with acute abdominal pain and abdominal injuries. ct findings will be emphasised. key imaging findings of traumatic and nontraumatic causes of acute abdominal pain including gastrointestinal tract and urinary tract pathology will be explained. a systematic approach for the imaging evaluation of patients with abdominal emergencies will be illustrated and explained including proper scan protocols and analysis of imaging findings. imaging diagnosis of blunt and penetrating abdominal injuries, urinary tract obstruction, infection, bowel obstruction, and ischemia will be emphasised. transcatheter renal denervation represents a novel therapy for treating patients with treatment-resistant hypertension, leading to higher risk of major cardiovascular events. an overview of sympathetic nervous system anatomy, physiology and physiopathology will be followed by a description of the technical aspects of renal denervation. first, results in patients with therapyresistant hypertension look very promising. however, these data need to be confirmed. importantly, long-term efficacy and safety need to be assessed. as a consequence, the treatment cannot be considered, at the moment, standard therapy. future studies need to address other disease conditions characterised by sympathetic hyperactivity, including heart failure, chronic kidney failure and others. it is a general opinion that in the near future the treatment will also be applied to lesser severe hypertensive patients. future studies should also include formal cost-effectiveness analyses. renal denervation can be achieved by a number of different techniques that include radiofrequency ablation, intraluminal and high-intensity focussed ultrasound ablation, chemical ablation and radiation ablation. radiofrequency and ultrasound ablation are currently the most commonly used techniques. most of the evidence to date is derived from studies and trials based on devices that use radiofrequency ablation technology. there are a number of currently ce-marked devices available and each device differs in the catheter design, generator design and energy delivery. these device types include single-point ablation, multi-point ablation, balloon-mounted systems and irrigated technology. the indications for renal artery denervation have been formulated by various international and european societies based on the various clinical trials and studies. these indications include patients with true resistant hypertension, age 18-85 years, egfr > 45 ml/min/1.73 m 2 (mdrd formula), single renal arteries with diameter > 3-4 mm with a landing zone of 20-21 mm depending on the device, no significant renal artery stenosis > 30%, no renal artery aneurysm, no previous renal artery angioplasty or stenting and the absence of significant valvular heart disease where lowering blood pressure will be dangerous. renal denervation of the sympatic nerves around the renal arteries is a new catheter technique to treat patients with resistant hypertension. resistant hypertension is seen in about 10%-20% of all patients with hypertension. the mechanism of sympatic nerve driven resistant hypertension will be explained. the available techniques for rdn will be discussed, focusing on the pros and cons of each technique. currently, rf ablation, hifu and cryo-ablation are the techniques under investigation. the technique and physics of renal denervation with radiofrequency ablation will be explained in more detail, focusing on available devices in the market. patient selection and nonresponders will be discussed. the current evidence from the available trials will be reviewed. the future of rdn and the role of radiology and the radiologist will be illuminated. the adrenal glands are composite endocrine organs consisting of the steroid hormone-producing cortex and the catecholamine-synthesising medulla. the increased use of imaging modalities has demonstrated the presence of varying sized mass lesions in up to 5% of individuals subjected to ct studies for reasons unrelated to adrenal dysfunction. most of these incidentally discovered lesions are non-functioning benign lesions of cortical origin. however, incidentalomas may also represent functioning lesions and malignant masses. clinical diagnostic and biochemical evaluation is used to further subdivide functional and non-functional adrenal lesions. f-dopa has been found to be of high sensitivity and specificity in pet imaging of pheochromocytoma. ct and mr imaging are first choice in characterisation of adrenal lesions. techniques of dual energy ct and histogram analysis may offer additional information. pet-ct has been shown to contribute to the diagnostic power, especially in oncologic patients. knowledge of the physiologic appearance of adrenal glands in 18-fdg pet is necessary to correctly identify pathologic processes. fdg-pet also has the ability to detect metastatic lesions in non-enlarged adrenal glands. in addition, fdg-pet has the advantage of simultaneously detecting metastases at other sites. the role of mr-dwi and mr-spectroscopy in characterising adrenal masses has to be defined by further studies. differentiating benign from malignant adrenal masses using non-invasive imaging methods can reduce the need for percutaneous adrenal biopsy in patients with underlying malignant disease and the follow-up imaging of incidentally detected adrenal adenomas. renal cell carcinoma (rcc) is the most common malignant tumour of the kidney. as response rates to radiation and nonantiangiogenic chemotherapy are low, surgical excision, i.e. radical nephrectomy has been the treatment of choice. however novel treatment options have emerged, so that imaging of rcc is of increasing interest. nephron sparing partial nephrectomy has become an accepted operative option and antiangiogenic agents such as inhibitors of tyrosine kinase (tk) and mammalian target of rapamycin (mtor) have been approved for treatment of advanced rcc. thus, it has become important to perform correct local staging and identify patients suitable for partial nephrectomy using standardised scoring systems such as renal or padua. furthermore, optimal imaging strategies for monitoring of advanced and metastatic rcc are discussed, as current antiangiogenic therapy evaluation in clinical routine is based only on morphological imaging information, but changes in tumour size may lag behind functional changes. finally, common side effects, i.e. pneumonitis, of vascular disruptive agents are addressed. characterisation of renal masses can be performed using three categories with respect to the lesion size and gross architecture: the indeterminate very small masses, the cystic, and solid renal masses. lesions with diameters below 10 mm are usually difficult to classify due to partial volume effect that prevents accurate ct attenuation measurement. in the general population, these lesions are likely to be microcysts and do not require further workup. better characterisation remains needed in selected patient populations such as patients with hereditary renal tumour disease and previous history of renal carcinoma. in this case, mri combining t2w, diffusion-weighted imaging and dynamic contrast enhanced sequences or contrast-enhanced us may help differentiate very small cysts from solid neoplasms. cystic renal mass characterisation still relies on bosniak's classification with 5 categories: benign (i) and minimally complicated (ii) cysts, indeterminate cystic lesions (iif and iii) and malignant cystic masses (iv). some cystic masses remain unclassified at ct because of atypical attenuation characteristics or enhancement properties. us, contrast-enhanced us, and mri are now playing a key role by providing additional diagnostic information that help distinguish between atypical fluid filled masses and atypical solid neoplasms, especially poorly enhancing solid papillary rcc. the characterisation of small solid renal tumours starts at ct with the identification of macroscopic fat, a typical feature of angiomyolipoma. in the case of non-fatty indeterminate renal neoploasms, percutaneous-guided biopsy can be performed when accurate characterisation is needed before surgery or when renal metastases or lymphoma are suspected. drug development being a complex and costly process, there is an increasing need for imaging biomarkers to take go/no go decisions in the early clinical phases. the recist criteria based on tumour size measurements at ct are currently used for this purpose. however, additional functional and molecular biomarkers have been developed to assess the early biological effect of drugs on tumours. development of imaging biomarkers is a structured process in which new biomarkers are discovered, validated and qualified against biological processes and clinical end points. the validation not only concerns the determination of the sensitivity and specificity, but also the measurement of reproducibility. reproducibility assessments, standardisation of the acquisition and data analysis methods and quality control are crucial when imaging biomarkers are used in multi-centre trials. functional and molecular parameters obtained at perfusion imaging, diffusion-weighted mr imaging and pet are being developed and validated. the perspectives (earlier assessment of response to treatment) and limitations (limited validation and standardisation) of these imaging biomarkers in cancer drug development will be presented. more recently, pharmacodynamic imaging biomarkers such as fdg-suv and k trans have been introduced. drug developers are reluctant to use more exploratory unvalidated imaging biomarkers (i.e. cannot distinguish a true negative from a false negative). the extensive literature on biomarker validation mostly refers to biochemical biomarkers extracted as analytes from biospecimens and is unhelpful to radiologists. unlike biospecimen biomarkers, the quality and validity of imaging measurements as biomarkers depend crucially on the use of a diagnostic imaging device, in the presence of the patient, in a manner for which the device (a) was not designed, (b) has not received regulatory approval and (c) may be unfamiliar to the user in the trial site. technical validation and biological validation are orthogonal activities. ''technical validity'' is confidence that the imaging biomarker can be measured reliably anywhere in the world. ''biological validity'' is confidence that the biomarker correctly reports some underlying biology that is important to the patient's future clinical outcome. since the physician always has access to the patient's clinical status and history, the biomarker is only useful if it provides a better forecast than clinical data alone. (if the forecast is near perfect, the biomarker might be a surrogate end point). technical and biological validations are massive undertakings best achieved by consortia, and in particular publicprivate partnerships, of which the innovative medicines initiative in europe and the biomarkers the standard imaging assessment of tumour response relies on size measurements, which, with predominantly cytostatic targeted agents, may not reflect the drug effect. functional imaging biomarkers have the potential to quantify the biological characteristics of tumours and measure on-target and off-target effects that indicate early likelihood of response to a specific therapy, which can then be used to guide the optimal biological dose and drug schedule. serial, non-invasive assessments of whole tumour are possible. this is particularly important in the context of inter and intra-patient tumour heterogeneity, as different parts of the tumour and primary vs metastatic lesions may be biologically different and these characteristics may change with treatment. however, functional imaging end points suffer from variability, which can be very significant in a multicentre setting. strict quality assurance and quality control measures need to be implemented at the start of a trial and the variability across centres documented. data acquisition protocols need to take account of equipment variations. data analysis methodology needs standardisation of software, central review and preferably double reading of scans. automation may not always prove the most robust and reliable option. this presentation will focus on the factors that are crucial in determining the compatibility of data in multicentre trials with functional imaging end points. learning objectives: 1. to learn about the potential role of quantitative imaging in processes related to tumour growth such as cell metabolism, cell death, and vascular function in the assessment of tumour response. 2. to become familiar with the issues of accuracy, reproducibility and standardisation for using functional imaging biomarkers in drug development. quantitative nuclear medicine in drug development w. weber; new york, ny/us nuclear medicine techniques can detect and quantify very low concentrations of radiolabelled pharmaceuticals in the human body. this allows investigators to use nuclear imaging for various purposes during drug development. nuclear imaging can visualise drug targets that are only present in nanomolar concentrations and can thus identify patients most likely for therapies directed against these targets. a recent example is folate receptor spect imaging for the selection of patients for treatment with a folate-targeted drug conjugate. in addition, nuclear imaging and specifically pet can measure the concentration of pharmaceuticals within tumour and normal organs over time. nuclear imaging can also be used to monitor target inhibition, for example the blocking of oestrogen receptors by anti-oestrogens. finally, nuclear imaging can assess tumour response to therapy by measuring changes in tumour metabolism or proliferation, e.g. with fdg-and flt pet/ct. this allows an earlier and more sensitive detection of tumour response than morphologic techniques. since pet is a whole body imaging technology, pet imaging can also be used to study the heterogeneity of target expression, tissue pharmacokinetics, target inhibition and response. pet imaging is now widely available in many countries and has become internationally standardised. it is therefore a robust clinical technique that will increasingly be used during drug development. there are about 80.000 patients per year in europe who lose their leg. about 70% are due to diabetic ischaemic and ulcerative leg problems. in diabetic patients the prevalence of foot ulcerations is about 20% and the risk for developing foot ulcerations is increased four times. diabetic foot problems may be due to neuropathy and malperfusion or a combination of both. the neuropathic ulcer and the neuroischaemic ulcer are usually at the plantar pedis, have a punched-out appearance and are painless. bone deformities (charcot foot) may be associated. the arterial ulcer is usually at the toe, forefoot and ankle, with pale, cold skin and it may be painful. patients need a multimodality approach involving a diabetologist, vascular specialist (angiologist, vascular surgeon, interventional radiologist) and podiatrist. pain control, antibiotic and antithrombotic treatment and the treatment of cardiovascular risk factors and other co-morbid disease have to be done first. in case of ischaemic pain and ulceration imaging such as mra and cta is the next step. patients should be referred to a team of vascular specialist early in the course of their disease to plan for revascularisation options. revascularisation is the optimal treatment for patients with an ischaemic and neuroischaemic diabetic foot. a. pathophysiology of the diabetic foot v. bã©rczi; budapest/hu (berczi@hotmail.com) the incidence of diabetes mellitus, associated with both predisposing genetic and environmental factors, is increasing globally. several major clinical trials have proved that complications may occur many years following proper glycaemic control. besides peripheral arterial disease, sensory and motor neuropathy along with an altered response to infection is of crucial importance. recent studies have showed that microvascular occlusive arterial disease is not a major factor affecting the diabetic foot; infrapopliteal macrovascular disease and microvascular dysfunction (e.g. arteriovenous shunting, precapillary sphincter malfunction, capillary leakage, venous pooling) are major components of impaired perfusion of diabetic foot. there are no randomised controlled trials analysing the major outcome following endovacular or open bypass surgery. the major outcomes, however, were similar in the case series: 1-year limb salvage showed a median of 85% (interquartile range 80-90%) and 78% (interquartile range 70.5-85.5%) following open surgery and endovascular treatment, respectively. limb salvage rate, however, was considerably higher with either type of revascularisation compared to medical therapy. negative pressure wound therapy, hyperbaric oxygen therapy, effective off-loading or nonweight-bearing therapies (total contact casts rather than removable devices) have also shown promising results in recent publications. endovascular arterial revascularisation is today a solid option in the management of cli with low complication rates and limb salvage rates comparable with surgery. the restoration of adequate blood flow to the foot is crucial to facilitate wound healing, provide pain relief, and avoid whatever amputations. the angiosome concept was first introduced in 1987 by taylor and further developed by attinger for planning treatment of ischaemic lesions of the foot. they divided the foot into six distinct angiosomes, arising from tibial and peroneal arteries. planning the procedure on the basis of this concept will yield the best local results of wound healing, compared with the indirect intervention. a proper pre-procedure assessment through colour doppler us and dsa of lower limbs is mandatory for guiding the procedure through the vessels of the foot. several studies have evaluated the efficacy of pta in the btk and the reliability of the angiosome model, approaching 100 % with a limb salvage rate of up to 87% at 12 months. on the basis of these data, we can conclude that pta in diabetic patients with btk disease is a safe and effective technique. the first endovascular treatment option is related to the angiosome model, but when not feasible the indirect technique is also a valid and similarly effective procedure. to face technical failures, up to 20% in crural chronic total occlusion a decade ago, different approaches and dedicated devices and technologies have been developed in the last few years. furthermore, percutaneous revascularisations are gaining more interest, particularly in patients with critical limb ischaemia not only as first-line treatment, but also as the only possible treatment for complex lesions and high-risk patients. special techniques for crural endovascular revascularisations are by design techniques rarely used in routine practice, but could offer wide possibilities for the interventional radiologist to solve challenging situations and manage complex lesions. these techniques include options for arterial access (trans-popliteal, trans-tibial, trans-pedal), approaches for crossing chronic total occlusion (assisted endoluminal, lambda technique, re-entry technologies) and uncommon routes for angioplasty/recanalisation (trans-metatarsal loop technique, trans-collateral techniques). combined antegrade and retrograde approaches have also been developed as well as related methods for successful re-entry. deciding when the patient/lesion is a potential candidate for special techniques is also a crucial issue. the interventional radiologist should be able to convert at any time if necessary the strategy of treatment to another one. he should also be able to select the most appropriate technique for the patient in planning revascularisation. continuous medical education and training is however mandatory and for some techniques the learning curve is relatively long. pathology of the eye and orbit is rare in the radiologist's practice. however, differential diagnosis is not too difficult if the compartment model is applied. in the orbit, different anatomical structures like the optic nerve as part of the cns, muscles for moving the globe, vascular structures and glandular tissue are present in a very small space. each anatomical structure is found in a special compartment; each compartment may give rise to a different group of pathologies, and only to these pathologies: glioma in the optic nerve, rhabdomyosarcoma in the eye muscles, varix in the venous vessels (intraconal compartment) and pleomorphic adenoma in the lachrymal gland. understanding the compartments in the orbit is therefore the key to differentiating different pathological entities. this presentation explains the orbital anatomy, how the compartments are differentiated, and what changes in anatomy treatment may induce. orbital congenital lesions are uncommon. they can be diagnosed prenatally, at birth or later during childhood. several orbital components can be involved. we will focus on congenital globe lesions (such as staphyloma, coloboma, persistent hyperplastic primary vitreous, coats disease), the developmental cysts such as epidermoids and dermoids, and vascular malformations such as lymphangioma and vascular tumours, e.g. capillary haemangioma. orbital inflammatory and infectious lesions are on the other hand common. orbital pseudotumour can involve any area of orbit, being one of the great mimickers in the orbit. if located in the orbital apex and/or cavernous sinus, it will be called tolosa-hunt syndrome. other inflammatory processes in the orbit are sarcoidosis and wegener and sjogren syndrome. among infections the most common is the orbital cellulitis, mostly secondary to a sinusitis and frequent in the urgency setting. the role of the radiologist is to assess whether it is preseptal or already postseptal or complicated by a subperiosteal phlegmon or abscess. also of importance is to know and evaluate the possible intracranial complications. finally, we will focus on inflammatory and infectious lesions of some specific regions such as the globe and lachrymal gland and give some clues for their differentiation. as more than 100 pathologies can be seen in the orbit, a systematic approach is very important to come to the right diagnosis. the main and most helpful criteria of differential diagnosis of any orbital pathology is the definition of the affected orbital compartment, as some tumours may only or preferentially involve specific orbital structures. the criteria of the most frequent masses of the globe, malignant melanoma and retinoblastoma are presented as well as those of cavernoma and lymphoma, the main representatives of intraconal tumours. there are numerous extraconal neoplasms, only few arising from the nasal sinuses, and only a little number of tumours of the optic nerve. the presentation will include the most frequent as well as rare, but important tumours. the routine practice of oncologic imaging requires standardisation, which means that we need to harmonise technical protocols and agree on the meaning of selected words for the radiological report. the words "response, "progression" and "stable disease" are precisely defined according to internationally accepted thresholds and criteria. although the rules are quite simple and rather easy to apply, they are very efficient in the classification of the response to treatment, and therefore for the medical decisions. however, the role of the radiologist is not limited to measurements and calculation. the detection of new lesions may be challenging and requires experience. the differential between cancer progression and complications of the treatment might be very difficult and requires an adequate communication with the referring clinician. overall, most of the decisions taken by the clinician will be related to imaging results, stressing the importance of adequate protocols and reports. in solid as well as non-solid tumours, pet/ct imaging using 18-fluorodeoxyglucose (fdg) has demonstrated the ability to a) correctly stage disease, b) demonstrate therapy response and c) predict therapy outcome. fdg uptake can be measured objectively; however several factors in the standardisation processes of tracer application, image acquisition and post-processing are needed for reproducibility. the term standard uptake value (suv) measurement is used for compensating the influence of injected dose, decay time and body mass and represents fdg uptake in any selected pixel of the image. for therapy assessment, drop in fdg uptake represents tumour cell kill, notably a negative pet scan does not exclude viable tumour cells but overall has a better outcome. pet response criteria in solid tumours (percist 1.0) have been introduced to refine previously established pet response criteria by eortc. major changes concern the use of lean body mass-based suv (sul), sulpeak measurement in a fixed roi, use of only a single target lesion and normalization to liver uptake. metric measurements in ct component of the pet/ct as an intrinsic asset like in recist 1. 1 have not yet been introduced, but might be crucial in the future. the proposed percist 1.0 criteria are not yet standard, since several limitations hamper its general use but may improve metabolic tumour response assessment. malignant gliomas (who grade iii and iv) are the most common primary tumours of the brain. according to consensus guidelines, the standard of care of these tumours includes maximal safe surgical resection followed by combined treatment with chemoradiotherapy. radiological assessment is critical in the follow-up and should be performed at four different times: 1. within 72 hours after surgery, an early post-operative mri must be done to evaluate residual tumour and to be used as baseline for follow-up. 2. two to six weeks after completing radiotherapy, a new mri examination is recommended to evaluate the response to treatment. four possibilities are envisaged according to the rano criteria: complete response, partial response, stable disease or progressive disease. the evaluation of this first mri examination after rt is challenging and the pseudoprogression phenomenon can appear. advanced mr techniques may be of help in this respect. 3. additional follow-up should then be performed by mri every 2 to 4 months to rule out clinically silent progression. 4. in any case, an mri examination must be completed when there is a clinical suspicion of progressive disease. several options for treatment can be offered when progressive disease is detected, including antiangiogenic drugs. evaluation of response to these drugs is challenging too, and the pseudoresponse phenomenon can then appear. due its complexity, it is recommended that the management of malignant gliomas be performed in the context of multidisciplinary teams and that the radiologists are strongly involved in these teams. we are facing complex times with no parallel in human history. the worldwide economic crisis, in combination with a non-regulated process of globalisation, is pressuring countries to change their social and political model. these changes are affecting academic institutions and the health-care sector. higher education was always more internationally open than most sectors because of its immersion in knowledge, which was never worried about country juridical boundaries. it is well recognised that it was the knowledge created by universities research that contributed to the development of societies. we, as european citizens, must be able to transmit the message that having more knowledge and being capable of understanding better the world we live in will make us stronger, more successful and more competitive. european academic institutions must be prepared for this shift of paradigm and understand that they are no longer educating only for their country but for the globalised world. it is also important to bear in mind that developed health-care systems are suffering several pressures and a call for a new inter-professional collaboration concept is needed, based on each one's roles and responsibilities, towards a better and more efficient health-care delivery for the patients. in this session, the invited speakers will give us an overview about the challenges that academic institutions will face in the near future and the way they must adapt to become more attractive and at the same time guarantee that radiographers and radiologists are educated and trained according to the highest professional standards. session objectives: 1. to appreciate the challenges that academic institutions must face in order to educate graduates with the ability to work internationally and to actively contribute to the healthcare sector of the future. 2. to explore innovative approaches in education and assessment. 3. to highlight the importance of inter-professional collaboration in order to ensure that graduates are ready to meet the demands of the modern healthcare sector. challenges in undergraduate education l.j.o.c. lanca; lisbon/pt (luis.lanca@estesl.ipl.pt) radiographers operate a wide range of sophisticated equipment and perform a range of techniques in several radiological procedures. they are responsible for the radiation delivered to the patient while assuring safety and image quality at an acceptable level for an accurate diagnosis. education and training in radiography, in line with the constant technological developments, is a requirement to be fulfilled by higher education institutions (hei). this is of major importance in undergraduate education where radiographers learn to play an effective role as healthcare providers in planning, preparing and performing accurate and safe radiological procedures within the diagnostic or therapeutic field. the european qualifications framework (eqf) for radiography, in terms of the development of knowledge, skills and competences, provides a european standard for the development of radiography learning outcomes at eqf level 6. this constitutes an opportunity to develop, tune, advance and promote standards of radiographic practice, education and research throughout europe. the eqf provides guidance to increase the educational and professional recognition of radiography in europe. at a european level, the cooperation between hei in undergraduate radiography education would be an opportunity to provide discussions of mutual concern, explore new perspectives and views of different cultures, and also share learning and teaching methods. international cooperation is an opportunity to improve and provide the harmonisation of education regarding a professional group that plays an effective role in healthcare in their field of competence and expertise. there is a vast amount of evidence available from the published literature that higher education institutions continue to explore innovation in both teaching and assessment practices. this is especially true of health professional programmes as evidenced by the abundance of literature relating to medicine, nursing, radiography and other allied health professions. such higher education, health professional programmes would appear to be more innovative than many other disciplines often as a direct attempt to mirror the dynamic clinical environment in which most graduates will work. there are, however, challenges associated with any such educational innovations and novel approaches to delivery and assessment. these specific challenges must be carefully considered in parallel with the larger challenges facing higher education institutions, both nationally and internationally, along with the professions which they contribute to. through a case study approach, supported by published peer-reviewed literature, institutional reports and research, this presentation will consider international best practice in education along with the value of collaborative, inter-professional approaches to teaching and assessment. haemodialysis accesses have become the most commonly performed type of vascular surgical procedure. however, only 50% of all haemodialysis accesses remain patent at 3 years. autogenous fistulas have a higher rate of primary failure compared to prosthetic grafts (50% vs. 15%), but the long-term patency of fistulas is superior to that of grafts. autogenous fistulas fail after a median of 3 to 7 years, whereas prosthetic arteriovenous grafts fail after a median lifetime of only 12 to 18 months. the pathogenic stenoses causing access failure occur in various locations, but the most common site in prosthetic arteriovenous grafts is at the anastomosis between the graft and outflow vein, as identified in 47% (23,246) to 60% of cases, or in the outflow vein itself in autogenous arteriovenous fistulas. clinical assessment alone will detect a large number of failing fistulas. by assessment of the thrill, pulse character, palpation of the fistula itself, excessive bleeding and difficulty needling a fistula may all indicate a failing fistula. if the venous pressures during haemodialysis exceed 120 mm hg, fistula flow falls to< 500 ml/min, graft flow decreases to< 650 ml/min, or access blood flow falls by more than 25%. a fistulogram is recommended if monitoring or surveillance suggests that thrombosis is either imminent or has already occurred. duplex can be used to assess the fistula, but cannot visualise the central veins. mr and ct venography has also been used in many patients successfully. treatment of symptomatic stenosis of vascular access is essential as it can lead to thrombosis and loss of vascular access. but treatment can lead to restenosis. the treatment of stenosis remains a challenge which requires a good knowledge of different materials (guidewire, catheters, balloons and stents). though the pathophysiological mechanism of stenosis is different for native fistulas, grafts or restenosis, the treatment technique remains the same. the basic principle is the use of high inflation pressure balloon angioplasty. whatever the material used, the key is to have no residual stenosis greater than 30%. so far, no study has demonstrated the superiority of the "new" tools (cutting balloon, drug-eluting balloon, cryotherapy) regarding restenosis. except perhaps for anastomotic grafts stenosis, stents should be reserved to treat complications or failure of balloon angioplasty. the stents indications are residual elastic stenosis, wall obstructive damage, acute rupture during angioplasty, aneurysm or restenosis. complications of stenosis treatment are rare, but can lead to the loss of vascular access. the main complications are thrombosis and acute rupture. as with any treatment, there have been contraindications: infection, distal ischaemia, high flow, newly created or surgically revised access (< 6 weeks). when dealing with a vascular stenosis access, never compromise on the future, but think about the surgical alternative. so, the management of stenosis vascular access must also be multidisciplinary. percutaneous treatment of a thrombosed dialysis access can be extremely challenging. the major concern does not stem from the fact that the procedure can be complexly long, but arises rather from the management of its complications, which can be serious particularly when the access is branched onto the brachial artery. access infection is an absolute contraindication. temporary contraindications include fluid overload and severe hyperkalaemia. percutaneous thrombectomy of grafts is very well standardised and predictable: size of 6 mm, well palpable wall which is easy to needle, small average clot burden, and an underlining stenosis almost always found at the venous anastomosis. thrombectomy of avfs is subject to variations in approach and technical difficulties depending on their anatomical particularities. all techniques employed follow 2 rules: first, the removal of thrombi and, second, dilation of the stenosis responsible for the thrombosis. heparin and antibiotics must be injected. the basic principle is to place in the arterialized vein or graft 2 introducer sheaths in opposite directions to work on both the venous outflow and arterial inflow. thrombus lysis or removal can be achieved by mechanical, pharmacological and pharmaco-mechanical methods. all techniques may work in grafts given that the modest amount of thrombus (3.2 ml on average) can be simply pushed into the lungs. prosthetic grafts are thus easier to declot than native fistulas, but they are much more prone to early rethrombosis. thrombi located at the arteriovenous anastomosis form a firm and rubbery plug, frequently and notoriously resistant to thrombolysis. drug-induced lung disease is an increasingly common cause of morbidity and mortality. the diagnosis is based on clinical history and consistent radiologic findings. lung biopsy is performed in a small percentage of cases. highresolution ct may demonstrate different parenchymal patterns including diffuse alveolar damage, acute or chronic alveolar haemorrhage, nonspecific interstitial pneumonia (nsip), hypersensitivity pneumonitis, organising pneumonia, and eosinophilic pneumonia. the imaging and histologic manifestations are often nonspecific. a systematic approach to the radiological evaluation of drug-related lung diseases is essential and includes not only chest imaging pattern recognition, but also integration of available clinical information. in this interactive session, we will present and discuss several cases illustrating thoracic changes after instrumental procedures in the thorax such as surgery, radiofrequency ablation, interventional endoscopy, and intensive care. radiologists have an important role in assessing the results of these procedures as well as in depicting the complications. however, knowledge of the normal appearance after those procedures has to be presented. the initial imaging workup of polytrauma patients remains challenging. besides hardware requirements, workflow issues continue to evolve, with the current focus on the introduction of whole body ct into the early resuscitation phase of severely injured patients as a standard and basic diagnostic imaging method. this session is aimed at a thorough discussion on the requirements for advanced imaging in the early clinical situation in emergency radiology. focus is directed on the issues of radiation dose as well as on ct and contrast media protocols. a. chest and abdomen m. scaglione; castel volturno/it (mscaglione@tiscali.it) thoraco-abdominal injuries are a significant cause of death in the polytraumatised patients. early recognition and communication of lifethreatening thoraco-abdominal injuries is the major task of the radiologists involved in the emergency room. although most of these patients reach the hospital prior to dying, lethality continues to remain high. heart, thoracic great vessels, trachea, bronchus, pleura, lung, diaphragm, abdominal/retroperitoneal, vascular and solid organ injuries are potential cause of death. any appropriate surgical/interventional management approach must be carried out "around the clock", before thoraco-abdominal injuries reach the level of clinical evidence. on the other hand, non-operative management has actually become the standard of care for the most serious thoraco-abdominal injuries. these goals become feasible if a correct contrast-enhanced mdct diagnosis, in a dedicated facility in which the trauma team works effectively 24 h a day, 7 days a week, is performed. thus, in this lecture, the most serious thoraco-abdominal injuries will be illustrated, with special emphasis on vascular/injuries as well as the value of post-processing techniques, protocols, pitfalls, tips and tricks. furthermore, the importance of a rational and integrated imaging approach will be pointed out and, finally, the role of the radiologist in the emergency room will be emphasised. spinal and musculoskeletal trauma account for significant morbidity in severely traumatised patients. traumatic injuries to the spine encompass a variety of frequently occurring disorders and primarily result in stable injury. although rare, unstable disorders comprise injuries to the bone, the discs, and the ligaments. in the majority of cases, spinal cord injuries result in devastating medical and social consequences. severe musculoskeletal disorders usually are the result of high-impact accidents, such as motor vehicle accidents and falls from a height. for instance, the injured pelvic ring causes one of the most life-threatening conditions that the trauma team must handle. pelvic injuries are often associated with severe arterial, venous, and/or osseous bleeding. radiography is no longer recommended as the primary screening modality in spinal and pelvic trauma for adults. despite the radiation dose burden of ct, patients with a high risk of spine injury receive mdct imaging, as it is the method of choice. mr imaging is indicated primarily when patients present with myelopathy, and to search for spinal cord pathology. interventional radiology plays a major role in the therapy of complex traumatic pelvic disorders. extremity injuries in patients after polytrauma can be complex and are initially often difficult to be fully diagnosed. emergency radiology diagnosis is today mostly based on a standardised whole body ct (wbct), which can be extended with cta and adapted to cover extremity injuries. extremity injuries comprise: fractures of (1) long bones, (2) articular joints, (3) complex fractures of hands and feet, (4) vascular, (5) soft tissue, (6) nerve and plexus injuries and (7) amputations. imaging protocol: *mdct is indicated in all major and complex bony fractures and is carried out early or integrated with wbct. cta using mips and mprs enables a thorough workup. * the role of us and cr is limited. * the role of mr and mra (in stable patients only) is to evaluate unstable articular injuries, injuries of tendons or major ligaments and nerve and plexus injuries). * the role of dsa is mostly for intervention. clinical findings and findings from wbct determine how to proceed, "first things are done first" in a priority-oriented clinical algorithm. treatment of extremity injuries must therefore be priority oriented and carefully planned in the context of possible concurrent injuries and a possible risk of multi-organ failure (mof). systemic drugs can be used for the treatment of cns and non-cns diseases. both classes can affect the brain inadvertently. common general drugs that affect the brain in a bystander manner are steroids (~1% brain volume reduction), recreational drugs (alcohol, cocaine, heroin, xtc), metronidazole and anti-epileptic drugs (corpus callosum demyelination) and immunosuppressants like cyclosporine/tacrolimus (pres/rpls) and methotrexate. mechanisms of action include neurovascular compromise, fluid/metabolite shifts and toxic effects to myelin of other tissue components. among cns-targeted drugs, especially immunomodulating agents may cause specific side effects. cytokine-release syndromes may occur with broad-acting agents such as general t cell antibodies. specific side effects may occur in multiple sclerosis, where treatment with natalizmumab may cause reactivation of jc virus leading to progressive multifocal leukencephalopathy (pml). upon withdrawal of therapy, this may then evolve into an immune reconstitution inflammatory syndrome (iris). in alzheimer disease, novel antibodies or vaccinations against amyloid may cause amyloid related imaging abnormalities (aria), which may present with microhaemorrhage on t2* images, or with edema and effusion on flair. the objective of this session will be to review the diagnostic value of conventional sequences as well as the use of contrast in the monitoring of brain tumours, with special attention to gliomas. also, we will address the advantages and limitations of advanced techniques: perfusion, diffusion, and spectroscopy. immediately after surgery, the main objective of neuroimaging is the detection of the remaining tumour. it may also be necessary to rule out complications such as haemorrhage, ischaemia or infection. the fundamental technique is mri with contrast in the first 48 hours and also diffusion sequences. in late follow-up, the goal is to differentiate the changes secondary to treatment of those related to tumour progression or recurrence. in these cases, conventional sequences present important constraints and are useful studies of diffusion, perfusion and spectroscopy. during follow-up after chemoradiotherapy, the objective is to assess tumour response. the response according to the new rano criteria will be revised. the combination of chemotherapy and radiotherapy, as well as the use of anti-angiogenic drugs causes changes that complicate the assessment of the response to treatment, with cases of pseudoprogression and pseudoresponse. in these cases, perfusion techniques, diffusion and spectroscopy can provide relevant information, although it is necessary to standardise the quantification to make its wide use possible. the speakers in this course will update the audience on contrast media safety such as steps to be taken before contrast administration and present the newest safety guidelines. the first speaker will cover new concepts of non-renal reactions to contrast media explaining which hypersensitivity reactions are allergic and non-allergic. the audience may learn assessing symptoms according to the ring and messmer classification and understand the importance of tryptase sampling and skin testing in the follow-up. the second speaker will address nsf. the presentation will review the pathophysiology, risk factors, recent recommendations and prevention of nsf. patients with gfr less than 30 ml/min/1.73 m 2 have increased risk of developing nsf. lowstability gadolinium contrast media show the strongest association with nsf. following existing guidelines on the use of gadolinium contrast agents minimises the risk of nsf. potential long-term harm from gadolinium accumulation in the body and legal issues are discussed. the last speakers will cover contrast medium-induced nephropathy with more recently published guidelines related to that issue. the presentation will include the definition of cin and the choice of contrast medium and prophylactic measures. recent changes in esur guidelines will be explained. the risk of cin is considered significantly lower following iv. cm administration and patients referred for enhanced ct are genuinely at risk if they have an egfr < 45 ml/min/1.73 m 2 . volume expansion with isotonic saline or sodium bicarbonate may be used for preventing cin in at-risk patients. acute immediate hypersensitivity reactions occur within the hour following the administration of contrast media. they can be seen with iodinated and gadolinium-based contrast agents. over the last ten years, new concepts have emerged in the way of understanding, managing and exploring hypersensitivity reactions. the clinical appearance is best classified by the ring and messmer scoring, from grade 1 (cutaneous and subcutaneous signs) to grade 4 (cardiovascular arrest). the mechanisms involve either true ige-mediated hypersensitivity or non-allergic hypersensitivity. the differential diagnosis in favour of allergy is made on a triad: clinical signs (the more severe, the more are the chances to be allergic), elevated tryptase levels in the plasma (indicating mastocyte triggering) and positive skin tests performed one month after the reaction. these new concepts induce important consequences in managing hypersensitivity reactions: be prepared to treat the patient adequately, be prepared to draw blood after the reaction to dose tryptase levels, send the patient to a dedicated allergologist, and forget about the preventive role of premedication against severe reactions. the authorities have introduced several restrictions on the use of high-risk agents, which will be followed by every physician in the eu. the agents are contraindicated in 1) patients with severely reduced renal function including dialysis, 2) acute renal insufficiency, 3) neonates and 4) pregnant women. they may only be used with caution in patients with moderately reduced renal function and children less than 1 year old. there must be at least 7 days between 2 injections in those patients. renal function must always be determined by laboratory methods before use of high-risk agents. women should stop lactation for 24 hours. these agents should never be given at doses higher than 0.1 mmol/kg per examination in any patient. for the intermediate and low-risk agents, the restrictions are significantly less; they should only be used with caution in patients with severely reduced renal function including dialysis. if a physician does not follow these rules, he or she will have legal problems as they have been introduced into the spc by the authorities. the contrast media safety committee (cmsc) of the esur has updated its guidelines on contrast medium-induced nephropathy (cin). the acr recently updated its guidelines as well. new guidelines were produced by nephrological societies. the topics reviewed include the definition of cin, the choice of contrast medium, and the prophylactic measures used to reduce the incidence of cin. the cmsc considered it appropriate to keep the definition of cin that was agreed in 1999. however, nephrologists have recently agreed on a new definition. in the previous guideline, a number of risk factors were listed (raised s-creatinine levels, particularly secondary to diabetic nephropathy, dehydration, congestive heart failure, age over 70 years, concurrent administration of nephrotoxic drugs). the significance of these risk factors has been confirmed and new risk factors were added. the cmsc agreed that the risk of cin was significantly lower following intravenous cm administration and concluded that patients referred for enhanced ct were genuinely at risk if they had an egfr < 45 ml/min/1.73m 2 . the previous cmsc guideline suggested the use of low or iso-osmolar cm in patients with risk factors for cin and the cmsc considered that this previous guideline should not be changed. the cmsc considered that there was enough evidence to recommend that either volume expansion with isotonic saline or sodium bicarbonate may be used for preventing cin in at-risk patients, while the efficacy of nac and other drugs in reducing the incidence of cin remained unproven. guidelines produced by other societies provide very similar suggestions, thus further validating these recommendations. jia is the most common rheumatic entity in childhood and includes a subset of childhood arthritis, all of which are characterised by chronic synovitis with a potential risk of progressive joint destruction. radiological investigations in jia should ideally be able to determine the presence and degree of active inflammation, precursors of bony destructions and established erosions. however, there are many pitfalls in the interpretation of joint pathology in children. ultrasonography is often the initial tool in the assessment of arthritis and can depict joint fluid and synovitis. erosions and cartilage destruction of small joints may also be seen. the major problems are standardising the imaging technique and the lack of normal standards of anatomy in us in children. radiographs can show bone erosions and may depict cartilage loss indirectly through joint space narrowing, but are insensitive to inflammation and early joint destruction. mri is the only imaging modality that can assess all relevant anatomical structures in joint inflammation and is sensitive to early inflammation and destruction. however, large variations in the amount of joint fluid, bone marrow oedema-like lesions and changes resembling erosions are seen in children and also in healthy individuals. the differentiation between true pathology and normal findings on mri in children remains a challenge, particularly in early disease. in this lecture, the role of radiographs, ultrasound and mri and the typical radiological findings in joint pathology in jia will be presented. current knowledge on validity and reliability of the different imaging techniques in jia will be discussed. brain mri plays an important role in those criteria, as it can demonstrate the classical dissemination in time and space and helps earlier diagnosis, which is of major importance since the present recommendation in children is to start immunomodulating treatments as soon as diagnosis is established. among paediatric ms, 14% begin before the age of 6 years and 30% before the age of 10 years, frequently with an adem presentation in young children as initial manifestation of ms. however, only 20% of the adem indicate ms onset and the most predictive factors should be known, i.e. periventricular, deep white matter, corpus callosum high t2 signal lesions and black holes on t1 sequences. mri evaluation is also instrumental in differential diagnoses such as nonrelapsing adem, vasculitis, immunogenetic diseases and occasionally leukodystrophies. finally, brain mri is useful to evaluate the risk of more severe ms. the obesity epidemic represents one of the most significant european and public health challenges in the 2 1 st century with prevalence of the disease having tripled in many countries during the past 30 years. this is resulting in an ever increasing cost to healthcare systems including hospital and in particular radiology services which face unique challenges when imaging this group of patients. obesity significantly increases the patient's risk of various comorbid diseases including the incidence of cancer, diabetes, and cardiovascular and liver pathology with a multidisciplinary team approach mandatory for optimal patient care. this multidisciplinary symposium will review the implications of the epidemic with cutting edge, in-depth lectures presented by european experts addressing the epidemiology, role of imaging in the bariatric surgical patient as well as the importance of abnormal fat deposition in the liver. session objectives: 1. to learn about the impact of the obesity epidemic on european healthcare. 2. to appreciate the value of imaging techniques in the management of the post-operative bariatric patient. 3. to understand the role of radiology in fatty liver disease and the importance of imaging during subsequent patient surveillance. obesity: causes and consequences to the patient r. batterham; london/uk (r.batterham@ucl.ac.uk) obesity is one of the greatest 2 1 st century public health challenges. its prevalence has tripled in many european union (eu) countries since the 1980s. currently, 52% of eu adult population is overweight and 17% obese, and the numbers of those affected continue to rise. overweight and obesity are risk factors for numerous health problems, including hypertension, diabetes, cardiovascular diseases, respiratory problems, musculoskeletal diseases and some forms of cancer. mortality also increases sharply once the overweight threshold is crossed. because obesity is associated with higher risks of chronic illnesses, it is linked to significant additional health care costs and is already responsible for 2-8% of health costs. changes in our environment are the main driver for this increase in overweight/obese. however, a person's genetic make-up can either increase or decrease their chances of becoming overweight. the gastrointestinal tract is the body's largest endocrine organ producing hormones that regulate bodyweight. dietary modifications, such as caloric restriction, are the first-line obesity treatments. however, dieting produces only moderate weight-loss with poor weight-loss maintenance. compensatory gut hormone changes induced by dieting are thought to contribute to the failure of dieting. in contrast, bariatric surgery is an efficacious treatment modality for obesity, producing durable weight-loss, amelioration of obesity-associated co-morbidities and reduced mortality. consequently, the number of bariatric procedures undertaken within europe has doubled in the last 5 years with 112,000 procedures undertaken in 2011. there is increasing evidence that surgically-induced alterations in circulating gut hormones mediate the weight-loss and metabolic beneficial effects of bariatric surgery. learning objectives: 1. to understand the epidemiology of obesity and its impact on european healthcare provision. 2. to appreciate the aetiology of obesity and the scientific rational for surgical treatment. 3 . to learn about the effects of obesity on health. imaging of modern surgical procedures and their complications m. rengo; latina/ it (marco.rengo@gmail.com) we will illustrate the common bariatric procedures, in particular their normal appearance on different diagnostic technique as well as their early and late complications. we will illustrate the correlation between conventional barium studies and advanced imaging with mdct and mr. we will explain how to optimise mdct and mr acquisition protocol according to the clinical indication. we will explain what to evaluate before redo surgery, in particular quantitative and functional analysis. we will illustrate the role of interventional radiology in the management of early postoperative complications, in particular in the management of patients subjected to gastric banding. non-alcoholic fatty liver disease comprises a variety of pathological disorders ranging from simple steatosis to steatohepatitis. this condition is common in the western population and is typically associated with obesity and the metabolic syndrome. its incidence increases dramatically. diagnosis of fatty liver and distinction between simple steatosis and steatohepatitis are keys because the latter can lead to extensive fibrosis and cirrhosis with an increased risk of hepatocellular carcinoma (hcc). imaging plays a crucial role in diagnosing fatty liver. the two most important imaging modalities are ultrasound and mr imaging. ultrasound can exclude major steatosis but lacks accuracy to precisely quantify fat, while mr is the most accurate for quantification. the technique of reference is mr spectroscopy, but sophisticated sequences based on chemical shift principle have been shown as accurate as mr spectroscopy. unfortunately, imaging has still limitations to assess the presence of fibrosis and inflammation which are associated with steatohepatitis and functional tools could be of interest. today, imaging is combined with clinical and biological biomarkers to evaluate the risk of steatohepatitis. due to the increased risk of hcc and cirrhosis-related complications in patients with steatohepatitis, patients at risk should be enrolled in the surveillance programme. learning objectives: 1. to understand the pathophysiology of fatty liver disease and its link to cirrhosis. 2. to become familiar with the role of imaging in the detection and quantification of fat in the liver. 3 . to learn about the importance of imaging in the surveillance of patients with fatty liver disease. the concept of breast cancer units originates from the need for making available to all women in europe high-quality breast services where breast disease could be looked after by specialists working as teams. such teams have to provide all the services related to breast cancer, including genetics and prevention, treatment of the primary tumour, care of advanced disease, palliation and follow-up of previously treated women. the breast unit is made up of a group of dedicated breast cancer specialists including a radiologist, radiographer, surgeon, reconstructive surgeon, pathologist, medical oncologist, radiation oncologist and breast care nurse. the specialists involved in breast cancer units have access to all the facilities required for high-quality care and spend most of their working time dealing with breast cancer. in our hospital, we routinely work as a team and to make it possible we organise weekly meetings involving specialists from different disciplines to evaluate and plan patient care at any step of the diagnostic and therapeutic process. each year, we take care of about 1.500 newly diagnosed patients with primary breast cancer and of 10.000 patients in follow-up. about 500 are patients who undergo rt. after a short introduction from our fellows from pathology, surgery, oncology and radiation therapy, who will discuss their role in the breast unit, we will try to give a practical demonstration of the everyday work of breast units with particular emphasis on the role of the radiologist. the european society of urogenital radiology (esur) published, in 2012, the new clinical guidelines for evaluation of the multi-parametric mri of the prostate. this structured reporting/scoring system (pi-rads) is based on literary evidence and consensus of experts' opinions. the pi-rads scoring system is similar to that already employed by breast imaging (bi-rads) and reflects the probability of a prostatic lesion to be significant. each lesion can be scored in all sequences used in the multi-parametric prostate mri protocols (t2-and diffusion weighted imaging, dynamic contrast enhanced imaging and mr spectroscopy) based on defined mri criteria, which are specific for each sequence. based on the scoring in the particular sequences a final pi-rads score for each lesion can be assessed. for each lesion a five-grade scoring systems was created where, for example, the score 1 means that clinically significant disease is highly unlikely to be present and score 5 clinically significant disease is highly likely to be present. this lecture elucidates the principles of this scoring system and its impact on the target definition for the invasive diagnostics and therapy. prostate cancer screening with psa and extended systematic biopsy protocols have led to the over-detection and over-treatment of small and well differentiated cancers, considered clinically insignificant. these cancers cover up to 70% of the overall prevalence and may not be of any threat. multiparametric (mp)-mri has shown recently its value in the detection, localisation and characterisation of prostatic tumour foci larger than 0.2 cm, and may be of value to address the issue of over-detection and over-treatment. an mri-targeted biopsy strategy alone, without any additional systematic biopsies, has been suggested to decrease the detection rate of insignificant tumours while increasing that of potentially aggressive tumours. in patients with no evidence of lesion on mp-mri, the biopsy may probably be deferred. in patients with localised prostate cancer, mp-mri may also become a cornerstone in the selection, guidance and surveillance of patients managed with focal therapy. the rational for this new modality of treatment is to decrease over-treatment by destroying exclusively the index lesion detected on mp-mri. the precision of such treatments may be increased with mritransrectal ultrasound image fusion, allowing for real time navigation during the procedure. the accuracy of multiparametric mri has greatly improved the ability of localising tumour foci of prostate cancer. this property can be used to perform a trus-mr image registration, a new technological advance, which allows for an overlay of an mri onto a trus image to target a prostate biopsy towards a suspicious area. three types of registrations have been developed: cognitivebased, sensor-based and organ-based registration. cognitive registration consists of aiming at a suspicious area during biopsy with the knowledge of the lesion location identified on multiparametric mri. sensor-based registration consists of tracking in real time the trus probe with a magnetic device, achieving a global positioning system which overlays in real time prostate image on both modalities. its main limitation is that it does not take into account prostate and patient motion during biopsy two systems (artemis and uronav) have been developed to partially circumvent this drawback. organbased registration (koelis) does not aim at tracking the trus probe, but the prostate itself to compute in a 3d acquisition the trus prostate shape, allowing for a registration with the corresponding 3d mri shape. this system is not limited by prostate/patient motion and allows for a deformation of the organ during registration. the pros and cons of each technique and the rationale for a targeted-biopsy only policy are discussed. radiotherapy of the prostate typically takes the form of either external beam radiotherapy or alternatively, brachytherapy using radioactive seed implants. in both cases, the use of ultrasound has been proven to be highly useful and this presentation will give an current state of the art overview of ultrasound in external beam and radioactive seed radiotherapy. in the case of external beam radiotherapy, accurate localisation of the prostate is essential to ensure adequate target coverage with minimal damage to normal tissue. dedicated ultrasound scanners are able to provide sub millimeter localisation of the prostate superior to the imaging traditionally obtained using ct scanners. this positional information can be obtained daily. in addition, ultrasound allows the imaging of patients with metal hip implants which are normally difficult to image using ct. apart from the benefits of the technique, some pitfalls will also be highlighted. in the case of prostate brachytherapy, the use of ultrasound in the 3-d volume imaging of the prostate both prior and during treatment will be discussed. in both cases, some time will be spend discussing the quality assurance requirements for ultrasound imaging systems. image-guided radiation therapy (igrt) with onboard kilovoltage cone-beam ct (cbct) allows image guidance during radiotherapy treatments for patient setup and dose replanning. all these items will be discussed in connection with other topics: organ dose and image quality. it is compulsory to convert cbctimage's pixels from arbitrary grey scale to hounsfield unit (hu). this conversion was obtained using a catphan 600 phantom. the same phantom is used for image quality evaluation; standard ctdi head and body phantoms and a farmer chamber were used to measure the cbdi to estimate organ and effective doses by monte carlo software of different protocols of acquisition. ctdosimetry software (ver.1.0.4-impact) and pcxmc2.0 rotation software were used. to verify the dose replanning techniques by cbct, horizontal and vertical dose profiles were compared with the same obtained from ct. patient replanning was verified using cbct vs ct in terms of conformity index. image quality parameters of cbct (in comparison with ct images) are fine for spatial resolution, but are less useful for low contrast. cbdi of 5.7 mgy/100 mas was measured; 4 msv effective dose, 26 mgy prostate dose and 32 mgy bladder dose were evaluated and discussed during the presentation. replanning on cylindrical phantom shows a mean percentage difference for each profile 2% and a variation on d mean in all inserts < 3%. the mean percentage difference between parameters characterising ct and cbct-based plan values is less than 5%. the replanning showed a substantial agreement with doses evaluated on the reference ct-image; patient dose must be evaluated for all radiation sources. cranial nerves i-vi have an anteroposterior course and are best examined in the coronal plane. cranial nerves vii-xii run in an anterolateral direction and are therefore best examined in the axial plane. these two planes also allow left-right comparison which makes lesion detection easier. lesions involving the cranial nerve nuclei can be detected on axial proton-density/t2/multi-echo-ge images and diffusion-weighted images can exclude acute infarction. the cisternal segment of the cranial nerves is best detected on heavily t2-weighted images (drive/fiesta/3d-tse/ciss). at 3-tesla, 3d-sequences (e.g. b-ffe) can be used and it is often possible to cover the cisternal segments of all 12 cranial nerves. in the cavernous sinus, the cranial nerves can only be evaluated on coronal gadolinium-enhanced high-resolution t1-weighted images and similar axial images are needed to evaluate the nerves in the jugular foramen and hypoglossal canal. axial and coronal gd-enhanced highresolution t1-weighted with or without fat suppression are used to image the extracranial course of the cranial nerves. today, the tse-dixon sequences provide non-fatsat and fatsat images simultaneously, making cranial nerve imaging faster and easier. time-of-flight images can be used to study neurovascular conflicts, although these can also be detected on submillimetric gd-enhanced t1 images. of course, it is important to know the major anatomy of the cranial nerves and the most frequently occurring lesions. the abovementioned imaging techniques, the most important anatomy and the most frequently occurring lesions will be demonstrated and discussed in this lecture. mri study of the lower neck space includes the study of anatomy and pathologies of the thoracic outlet, or cervicothoracobrachial junction, extending from the cervical spine and the mediastinum to the lower border of the pectoralis minor muscle, the brachial plexus and the supraaortic vessels (carotid, subclavian arteries and veins). for this, use of a dedicated head and neck coil is fundamental to avoid frequent artefacts arising from air and the passage between different surfaces. only in case of thoracic outlet evaluation, a dynamic angio-mri study should be performed and this means the use of a surface coil. mri protocol of the lower neck should include t1-and t2weighted sequences. both fat-saturated proton density and t2 with stir sequences can be used to overcome the inhomogeneity of the magnetic field, especially with large fov. sand bags can be placed on either side of the neck and suprascapular region of the patient to improve image quality. also, flow saturation bands can be utilised to limit blood flow artefacts. also, volumetric sequences are in common use to obtain a quick examination. breath or cardiac gating can be helpful. abnormal findings of brachial plexus consist of nerve signal abnormalities with mild or marked hyperintensity on t2-weighted, being aware of magic angle effects and swelling. in case of thoracic outlet syndrome, mri protocol should define the compression of brachial plexus components arteries and or veins, both in indifferent and dynamic mri acquisition. learning objectives: 1. to learn how to overcome difficulties in performing a lower neck study. 2. to understand how to avoid the most common pitfalls. 3. to become familiar with differential diagnosis. c. ct and mri of temporal bone: user's guide f. veillon; strasbourg/fr ct and mr imaging of the temporal bone must be performed with a precise technique. in ct it is important to locate the box of the study above and not in the orbit to avoid the lenses. irradiation is divided by 10 compared with a study through the orbit. the axial sections must be parallel to the lateral semicircular canal the coronal, sagittal sections are completed by oblique coronal views through the long process of the incus and the head of the malleus to get the ossicular v. double oblique sections through the 2 componants of the v permit a view of the stapes and also the malleus and incus in 3 d (mip : 3 mm). mri must be performed parallel to the roof of the orbit permiting very good axial sections in the plane of the lateral semicircular canal (t1 and t2). the internal auditory meatus and the inner ear must be analysed with 1 mm axial sections (se) after intravenous gadolinium injection completed by a high resolution t2 (gradient echo or se) 0.3-0.4 mm, depending on the machine (3t, 1,5 t). the middle ear in chronic otitis media must be studied with t1, diffusion and high resolution t2. there is no need of contrast medium injection apart from the complication: fistula of the lateral semicircular canal, thrombosis of the sigmoid sinus. the different pathologies are then discussed: external auditory meatus and middle ear pathologies: ct first. mri is useful for postoperative cholesteatomas. inner ear malformations, otosclerosis, trauma: ct. labyrinthitis, inner ear hemorragia, schwannomas, internal auditory canal content: mri. revascularisation time windows for patients with acute ischemic stroke are generally restricted up to 4.5 hours in the anterior and up to 8 hours is the posterior perfusion area. later treatment attempts require more accurate prediction of risk and benefit, as safety and efficacy at these time strata are less well. thus, rapid and effective imaging is important for decision-making concerning intrarterial catheter based recanalisation and/or thrombolytic therapy. advanced imaging techniques identify irreversible infarction as well as tissue at risk. diffusion-weighted mri detects ischemia within minutes of onset, whereas perfusion-weighted mri and ct perfusion studies disclose the ischemic penumbra. combined, they provide information on mismatched tissue, i.e. potentially salvageable brain. in addition, non-catheter angiographic techniques like ct or mr angiography are a useful adjunct to localise arterial occlusion. as an attempt to a reliable emergency examination, the following protocol has been proven to be robust: for the anterior perfusion area, a non contrast ct may exclude cerebral bleeding and is followed by ct angiography (including supraaortic and intracranial vasculature). if technical available, ct perfusion should be performed in addition. in ischaemic strokes of the vertrebrobasilar region, cta is essential to exclude basilary stenoses or thrombotic occlusion. if the stroke onset remains unclear or might extend the above mentioned time window, mr stroke imaging (i.e. diffusion, flair and perfusion sequences) is suggested as mr offers a higher sensitivity. anyway, the best method for each emergency stroke imaging center is depending on clinical availability 24h/365 days, technical equipment and -finally -individual experience of the emergency team. some recent publications have questioned interventional treatment of stroke as an alternative to iv thrombolysis only. these papers -albeit published in highranking sources -usually do not describe the modern concepts of interventional stroke treatment. interventional radiologists, therefore, are convinced by their practical experience that the modern concept of combining iv thrombolysis with mechanical thrombectomy by stent retrievers offers a benefit to a subgroup of patients with severe stroke. this includes anatomical level of occlusion -basilar artery or single vertebral artery, proximal carotid occlusion with distal tandem occlusion, carotid t obstruction and m1 occlusion. m2 occlusions are debatable. besides location, the clinical status of the patient before stroke and time of onset, absence of early ct signs of stroke or bleeding and clinical contraindications to iv thrombolysis such as recent surgery influence the decision-making. more difficult than the description of technical success is prediction of clinical success. there are a couple of scores such as thrive available that may be used for outcome forecasting. the amount of collateral flow is frequently used as a decision tool, but is not always easy to quantify. mismatch scores and penumbra have been questioned recently. in conclusion, anatomical factors are pretty easy to identify to indicate treatment, but the clinical and functional setting still lacks quick and reliable parameters that allow a clear decision-making, particulary in borderline cases. the refresher course addresses the current state-of the-art use of different mechanical revascularisation strategies, devices and potential complications. in addition, multimodal imaging applications with a focus on patient selection for endovascular recanalisation therapies, as well as new techniques to guide endovascular therapy within the angio suite are presented. finally, some organisational aspects important for providing an interdisciplinary interventional stroke service are discussed. the ultimate goal of an acute endovascular stroke intervention is neurological recovery or improvement. recanalisation of an arterial occlusion is key in achieving this goal. clinical data suggest that endovascular stroke treatment results in higher recanalisation rates and may provide superior clinical outcomes when compared with intravenous thrombolytic therapy only. however, these higher recanalisation rates are far away in being paralleled by equally higher rates of favourable outcomes in recanalised patients. thus, patient selection remains crucial. besides the careful neurological assessment, brain imaging is here of major importance. the case presentations illustrate that imaging may help in patient selection for subsequent thrombolytic/endovascular therapies by differentiation of patients who may profit from intravenous or interventional therapy in an even extended time window from those who do not. there are a number of key areas supported by evidence-based medicine necessary for a high-level interventional stroke service. as a precondition, a neurointerventional stroke service has to be organised within a multidisciplinary acute stroke team. inside the hospital, it is all about streamlined pathways. any possible delays should be minimised at every step. sacroiliac joint pain may arise from a number of conditions including inflammatory arthritis, degeneration, fractures and tumours. studies suggest a prevalence of 10% to 60% pain arising from the joint in patients with positive clinical signs. temporary effect is provided by a mixture of local anaesthetics with steroids with a response varying between 50% and 80% in reported series. dual blocks using agents of differing duration are considered more precise, but are less often used in practice. imaging including mr and scintigraphy are of limited predictive value. injections may be into the synovial joint, around the joint or adjacent to the nerve innervation of the joint. there is evidence that para-articular sources of pain are common and injection outside the joint may be more effective. sl-joint injections are performed through a dorsal approach guided by ultrasound, fluoroscopy or low-dose ct. shortacting agents may have lasting benefit, but radiofrequency ablation has been employed in an attempt to obtain long-term response. the evidence for lasting therapeutic response to intra-articular or periarticular injection of steroids and conventional radiofrequency neurotomy is weak. there is fair evidence of longterm response to cooled radiofrequency neurotomy. facet joints account for 25-40% of all low back pain. they are affected by osteoarthritis, joint space narrowing, intra-articular vacuum phenomenon/fluid, osteophytes, synovial cyst and ligament hypertrophy. conservative therapy is initially proposed. percutaneous facet joint steroid infiltrations are minimally invasive procedures involving injection of corticosteroid with or without local anaesthetic inside the joint. they also can provide diagnostic verification of a certain facet joint acting as the pain source. the injectate usually contains a long-acting corticosteroid mixed with a local anaesthetic. sodium hyaluronate solutions or ozone were tested; however more and extensive studies are necessary. other options are either percutaneous ablation or surgical arthrodesis. fluoroscopy, computed tomography or magnetic resonance can be used for guidance. fluoroscopy has the advantage of real-time imaging. cone-beam ct can also be used. computed tomography provides better anatomy information, but has increased radiation dose for the patient. magnetic resonance has higher cost and longer duration. a recent study concluded that it is twice the cost of ct-guided infiltrations. mri can be used in combination with focal ultrasound for ablation, a technique which is still under investigation. success depends upon patient selection (59-94% immediate and 27-54% long-term relief). the level of evidence is moderate for lumbar spine concerning short-and long-term improvement. however, the most recent guidelines released (american society of pain physicians) state that it is the oldest and most commonly used technique. the success rates with its safety profile and least invasiveness seem to make it an attractive therapy. although promising for early assessment of response to treatment, these newer functional biomarkers need extensive validation and standardisation for their wide clinical use. validation includes the assessment of reproducibility and accuracy, whereas standardisation concerns image acquisition and postprocessing. the added value of the more complex functional biomarkers relative to the viability parameters should also be shown. viability and functional imaging biomarkers are evolving and emerging parameters for the early assessment of response to treatment. mri biomarkers must be able to show how tumours respond to specific treatment. they need to allow assessment of the effectiveness of new treatment more rapidly than classical clinical end points. these biomarkers must be easy to obtain to facilitate a large spread of the technique. they have to be reproducible. the longest diameter of the tumour remains the easiest biomarker that can be obtained from any kind of morphologic acquisition with no need of post-processing. additional information about the tissular organisation and cellularity can be now easily obtained using modern scanners through diffusion-weighted sequences. the ease with which those sequences are obtained for a while masked the necessity to perform a more complex postprocessing than the one initially done to get reliable biomarkers. there are numerous mri biomarkers of microcirculation, reflecting o2 consumption, blood volume, blood flow, vessel permeability and extravascular volume. to get them, we need more sophisticated acquisitions and image processing that take into account the t1 of the tissue, arterial input function, respiratory motion, etc. most of these new mri biomarkers are now used in research and in phase i studies, but have not been validated in more advanced clinical trials or in clinical practice. to use them widely and reliably, we need to perfectly understand the consequences of the choices we make during the acquisition and post-processing of these biomarkers. new targeted treatments in cancer can be effective without significantly reducing tumour size. there are already a large number of targeted treatments that are licensed to treat a range of cancers. for some of these cancers, there is currently no reliable method to tell whether the drug is effective and new response, predictive and prognostic biomarkers are required. functional imaging techniques such as diffusion-weighted mri, dynamic contrastenhanced mri and fdg-pet imaging are being developed or applied as response biomarkers. however, for these to be useful in a wider multi-centre setting, the measurements need to be precise, repeatable and reproducible. we discuss these properties in the context of emerging imaging response biomarkers. learning objectives: 1. to understand imaging biomarker precision (repeatability and reproducibility) and accuracy and how it is evaluated. 2. to learn how to interpret biomarker precision and accuracy in the context of the biomarker's intended use. coronary artery disease (cad) and its related cardiac disorders are still the number one cause of death in the usa and the western world. up to date, single photon computed tomography (spect) using traditional radiotracers like thallium-201 or tc-99m sestamibi is the most utilised imaging technique for the assessment of myocardial perfusion. however, over the past decade, there has been a growing interest in cardiac imaging with positron emission tomography (pet) and, indeed, a paradigm shift has been witnessed in the use of myocardial perfusion imaging (mpi) with pet taking advantage of the superior imaging properties of pet over spect. therefore, pet mpi is now being increasingly used for routine clinical evaluation of patients with known or suspected cad. furthermore, it is being used not only at large academic institutions, but also at community hospitals and even in private practice. several factors contribute to this shift in the use of pet mpi, including the growing availability of combined pet and computed tomography (ct) systems, mainly driven by oncological applications, radiotracer, like rubidium-82 or 18 fflurpiridaz, which can be used in clinical routine, changes in reimbursement, and the increasing clinical evidence supporting the value of pet/ct mpi. the lecture "pet for evaluation of perfusion, absolute myocardial blood flow and coronary flow reserve" will cover several aspects of the growing field of pet mpi. besides the visualisation of coronary morphology, computed tomography (ct) has shown feasibility to also assess myocardial perfusion. currently, there are two different approaches to ct-based myocardial perfusion imaging: singleshot and dynamic, sequential acquisitions over a predefined scan time. the presentation will cover basic concepts of both approaches and highlight protocol details and findings in these stress acquisitions. also, emerging scientific results with respect to diagnostic accuracy, the detection of hemodynamically relevant coronary stenosis and prognostic implications will be discussed. over the past few years, cardiovascular magnetic resonance imaging (cmr) has been increasingly established as an important method in the diagnosis of cardiovascular disease. many studies have shown the equality or even superiority of cmr compared to other imaging modalities (e.g. nuclear medicine and echocardiography). cmr offers important advantages like the absence of ionising radiation, high spatial resolution, and the combination of perfusion imaging with tissue characterisation. the main clinical applications in the assessment of coronary artery disease (cad) include ventricular function, myocardial viability and perfusion. in clinical routine, myocardial perfusion is determined by contrast-enhanced first-pass perfusion techniques during pharmacological stress using coronary vasodilators (e.g. adenosine) or ã�adrenergic agents (e.g. dobutamine). non-invasive characterisation of myocardial microcirculation is thought to reflect myocardial tissue supply much better than mere luminographic detection and quantification of epicardial coronary stenosis, and has been shown to be useful for planning of revascularisation procedures and cardiac risk stratification. in several studies on the prognostic value of cmr in cad assessment, normal stress perfusion cmr was highly predictive for a good prognosis, thus able to identify patients in whom invasive angiography can be deferred safely. the purpose of this lecture is to demonstrate how it is possible to sensitise the mr signal to water molecules diffusion in tissue and how to use calculated indices to reflect structural integrity. the concept of diffusion-weighted imaging will be introduced with particular emphasis on the pulsed gradient spin echo (pgse) sequence. methods to calculate the apparent diffusion coefficient (adc) will be described and the concept of the diffusion tensor (dt) will be explained. image processing of diffusion data includes steps like eddy current distortion correction, model fitting and potentially registration of maps to a reference space. indices that are reproducible and rotationally invariant will be described, such as fractional anisotropy (fa), mean diffusivity (md), axial diffusivity (ad) and radial diffusivity (rd). examples of when to use the adc maps or the dt indices will be given in relation to pathologies such as stroke, multiple sclerosis and neurodegenerative diseases. strategies for result presentation such as region of interest approach, histogram analysis and tractbased methods will be shown. limitations and advantages of diffusion imaging methods such as dt do not preclude the use of this technique in research and clinical radiology for investigating structural changes in disease. diffusion imaging methods have a lot of potential to be used in clinical practice. however, although diffusion-weighted imaging has been increasingly applied, clinical use of diffusion tensor imaging is limited to date. this is in part due to the lack of standardisation and the need for more complex analysis tools to evaluate the data. during this lecture, an overview will be provided of some analysis methods for diffusion-weighted and tensor imaging. i will discuss the different parameters that can be obtained as well as some advantages and limitations of the different analysis methods. it is highly recommended to include diffusion-weighted imaging (dwi) in the routine protocols for mri of the brain. dwi as well as automatically calculated apparent diffusion coefficient (adc) map is used for evaluation. the adc values of gray and white matter are identical in the adult brain. restricted diffusion (high signal on dwi and low signal on adc) is seen not only in acute stroke, but can also be present in some brain tumours, the necrotic centre of abscesses, some acute mr plaques, some contusions, encephalitis, creutzfeldt-jakob disease, metabolic diseases, etc. this finding is thus not specific, but is very helpful combined with clinical information and the signal pattern on other sequences. acute stroke has restricted diffusion during the first 7-10 days and the diffusion gradually increases to become very high in a chronic infarct. the diffusion changes in ischemic brain and spinal cord tissue are usually irreversible, but may be reversible. brain tumours with high cellularity, such as lymphoma, glioblastoma multiforme, medulloblastoma and metastases from small cell lung carcinoma, usually have restricted diffusion. the surrounding vasogenic oedema has increased diffusion. in the central necrosis of a pyogenic abscess the diffusion is restricted, while it is increased in the necrotic centre of a malignant brain tumour. reversible diffusion restriction in the cortex, the hippocampi and thalami can be seen in patients with status epilepticus. diffusion tensor imaging has so far had limited clinical use, but may be useful, e.g. for the preoperative evaluation of brain tumours. learning objectives: 1. to understand the differential diagnostic possibilities of high signal intensity lesions on diffusion weighted images (dwi) of the brain and spinal cord. 2. to become familiar with the appearance of acute, subacute and chronic stroke on dwi. 3. to learn about the appearance of cerebral tumours, infection/inflammation, neurodegenerative diseases and traumatic lesions on dwi. 4. to understand the present use of diffusion tensor imaging (dti) and diffusion tensor tractography (dtt) in clinical neuroradiology. the signal intensity in diffusion-weighted imaging (dwi) reflects the cell density in the tissue. dwi, including apparent diffusion coefficient (adc) maps, can therefore be used to differentiate highly cellular from acellular regions of tumours, distinguish cystic from solid lesions, and monitor change in tumour cellularity over time, reflecting response to therapy. in general, tumours have high signal intensities in dwi, but low corresponding adc values compared to normal/benign/reactive tissues. dwi has a wide range of clinical applications, which includes cancer imaging, imaging of infections and inflammations, evaluation of trauma and visualisation of peripheral nerves. of these, the most promising application appears to be in oncological imaging. there is, e.g. now evidence to recommend inclusion of dwi in mri protocols for lesion detection and characterisation in the liver. the advent of whole body (wb) mri including wb-dwi (from root of the neck to groin) has introduced tumour imaging with a systemic approach compared to established multi-modal diagnostic algorithms. it has been found valuable for staging, therapy evaluation and surveillance of tumours, especially in children. however, dwi is generally recommended to be incorporated into oncologic mri protocols of both wb-mri and of selected organs, because it provides additional valuable information to the conventional mr sequences. dwi of the body is frequently prone to imaging artefacts, which can obscure or mimic lesions. to minimise misinterpretations, analysis of the raw b-value images directly in conjunction with adc maps and conventional coregistered sequences is recommended. spinal surgery is most frequently performed to decompress (disc herniation, stenosis, malignant infiltration), fuse and stabilise (particularly following trauma or infiltrative destructive processes) and correct deformity. often, there may be a combination of these procedures at one operation. surgical instrumentation or bone graft is sometimes employed. patients may present themselves with symptoms early or late following the procedure. this interactive session seeks to address the variety of surgical procedures undertaken and subsequently imaged post-operatively because of symptoms. the session aims to help one to understand and become familiar with the expected post-operative imaging appearances related to the surgical procedure, learn about abnormal pathological features as a cause of symptoms in the acute and more chronic situation and explore the diagnosis and differential diagnosis. this may include post-operative fibrosis versus recurrent disc herniation versus post-operative infection. failure of fusion due to failure of instrumentation or inadequate take of bone graft can give rise to pseudoarthrosis. recurrent stenotic symptoms may relate to an inadequate decompression, recurrent disc herniation, postoperative haematoma, extension of a malignant process or ischaemic damage. joint replacement surgery for the treatment of arthritis most often offers the patient excellent results. however, there are potential complications that a radiologist should know about. it is essential to understand the importance of pre-and postoperative imaging for evaluating patients. most commonly, standard radiographs are used to assess the patients after joint replacement. however, ct, nuclear medicine methods as well as mr imaging play an increasing role in such patients. the radiologist should be aware of the most common type of prosthesis and the most common complications after joint replacement. these complications include postoperative prosthesis loosening, prosthesis fractures, periprosthetic fractures, postoperative infection, rotation failure of the prosthesis, and soft tissue abnormalities such as surrounding tendon tears. this interactive session seeks to address the variety of joint replacements which are undertaken and subsequently imaged postoperatively as a result of symptoms. the session aims to help one to understand and become familiar with the expected postoperative imaging appearances related to joint replacement, learn about abnormal pathological features as a cause of symptoms and explore the diagnosis and differential diagnosis. learning objectives: 1. to learn about changes related to surgery. 2. to understand changes related to non-surgical treatments. serbia is a beautiful country where east and west merged and often collided for centuries, and where nowadays eastern cultural heritage meets and mixes with the western heritage in a lovely and unprecedented way, with a lot of charm and with a variety of extraordinarily natural beauty and plenty of both traditional and gastronomical wonders to explore. it extends from the edges of the pannonian flatland in the north, over the danube and sava rivers to the gradually growing wonderful mountains in the south. already in 1897, the first x-ray unit was installed, and only twenty years later x-ray units are present in most state-owned and private hospitals in serbia. nowadays, slightly more than half of the thousand radiologists in serbia perform a broad variety of diagnostic imaging and interventional techniques in different radiological units, including numerous ct, mri, and few pet/ct units distributed in five university centers, a number of public clinical centers and hospitals, and also in the private sector. several centers are fully equipped with pacs and ris systems, and are capable of performing teleradiology services. there are still significant challenges in serbian radiology in the field of education and research, planning and implementation of national radiology networks, improvement of standard clinical practice and financing the new equipment. yet since radiologists' enthusiasm overwhelms most of the difficulties, radiology in serbia provides nowadays a broad variety of modern and competent diagnostic and interventional procedures, improving the management and treatment of our patients. radiology in serbia, since its beginning, has been inextricably linked to european radiology. there are written documents testifying to the fact that the first x-ray appliances in serbia had emerged and had been used for medical purposes only two years after wilhelm conrad rã¶ntgen discovered x-rays in 1895. the real beginnings of diagnostic radiology in serbia can be linked to the establishment of the general state hospital in 1908, where the first x-ray cabinet was installed. later discoveries in the field of radiological techniques, materials and contrast agents were also immediately accepted by the serbian radiology community. the first cerebral angiography was performed in 1935, which may be considered as the beginning of neuroradiology in serbia. the second half of the twentieth century is characterised by the introduction and wide application of ultrasound, ct and mr diagnostics and outbreak of vascular and nonvascular interventional radiology procedures in the areas of neuroradiology, uroradiology, and cardiovascular and gastrointestinal radiology. for years, serbian interventional radiology has successfully kept pace with achievements of the most relevant centres worldwide. nowadays, serbian radiologists monitor and enforce the most complex modern procedures in different areas of radiology. the rapid development of science and information technology has enabled the daily monitoring of all modern developments, methods and approaches and their increasingly faster introduction into practice. non-ischaemic cardiomyopathies (nicm) refer to myocardial diseases caused by mechanical and/or electrical disorder in the absence of significant coronary artery disease, valvular heart disease, hypertension, or congenital heart disease. nicm often present with genetic mutations, but no clinically apparent disease. in some cases, the presence of fibrotic tissue could cause adverse events and, therefore, the use of late enhancement (le) post-gadolinium technique is necessary in evaluating these patients. le suggestive of fibrotic tissue could be found in up to 35% of patients with nicm. in the majority of cases (up to 65%), midwall/subepicardial enhancement could be found; patchy enhancement, often at septal junctions, has been registered in 35% of patients, while the least common pattern of le was subendocardial (5%). in ischaemic cardiomyopathy (icm), subendocardial or transmural is a typical pattern of hyperenhancement and is related to coronary artery distribution. furthermore, le has the potential to provide important information for risk stratification in clinical practice. in nicm, the extent of fibrosis has been shown to be independently associated with increased rates of future adverse events including all-cause mortality, while in icm myocardium with le in more than 50% of wall thickness is unlikely to recover contractile function following coronary revascularisation. as many nicm disorders are associated with the presence of scar tissue, le in nicm is nonspecific and should be correlated with clinical presentation and history, which is critical in the evaluation of these patients. interlude: hop-on, hop-off sightseeing tour of serbia s. stojanovic; novi sad/ rs (tupsons@gmail.com) in the interlude between scientific lectures, you are most welcome to hop on a sightseeing tour around serbia during which we shall stop at a few stations where the natural and cultural heritage of our country will be shown. nota bene: some of the sights will be visible to everyone and some only to radiologists. ten thousand years of human effort and five billion years of european soil refinement will blink in front of your eyes through the window we have made with red churches' walls, azure skies and a silver sparkle of our spirit. all the time, a bit of grayscale shadow will supplement the picture as we in radiology are so used to. fragments of past and present will make a mosaic, the glance of which will hopefully light up your day. when you hop off our tour, we believe, some pictures will become part of your emotional memory and maybe will make you wish to see them in vivo. the role of prenatal mri in foetal central nervous system abnormalities: a case-based pictorial review k. koprivsek; sremska kamenica/rs (katarina.koprivsek@gmail.com) mri provides a unique opportunity for studying in vivo central nervous system development. its higher contrast resolution compared with prenatal sonography allows better visualisation of sonographically occult normal cns structures as well as structural abnormalities. in clinical praxis, prenatal mri has become a mandatory tool in evaluating: a) foetuses that have abnormalities suspected on the basis of foetal sonography; b) foetuses with increased risk for brain abnormalities even in the setting of a normal prenatal sonogram (family history of cns anomalies or a genetic/metabolic disorder); c) foetuses potentially at risk due to maternal illness; d) foetuses with congenital malformation, which are candidates for prenatal or neonatal surgical treatment; e) foetuses that could not be evaluated by sonography due to oligohydroamnion, maternal obesity, difficult position of the foetal head, or us reverberation on foetal calvaria in advanced gestational age. we will present a selection of foetal cns abnormalities detected in our institution during the last 8 years, including ventriculomegaly, abnormalities of the posterior fossa, agenesis of the corpus callosum, cerebral cortex developmental abnormalities, spine developmental abnormalities and a variety of encephaloclastic lesions. in all previously listed cases, prenatal mri could provide either crucial or additional information, which can lead to the accurate diagnosis of different cns developmental abnormalities (cortical, commissural and posterior fossa malformation), specific disorder or syndrome, further enabling adequate pregnancy management and parents' counselling. this lecture will cover the standard mammographic views required, the reporting systems for mammograms together with birads and other european systems, breast density, feature analysis, information the clinician requires in a cancer case and how to approach a b3 lesion. acr practice guidelines (2008) recommend obtaining previous mammograms as you can dismiss an abnormality that is unchanged for 5 years or that has been previously worked up and are able to detect subtle new lesions more easily, although this has not been confirmed in the screening situation. in a structured report the following information is recommended: indication, breast density, description of lesion, size, location, comparison to previous findings, overall assessment, management recommendations and a score to indicate the level of suspicion. examples of different common conditions seen on mammography will be shown including soft tissue masses, microcalcification, architectural distortion and asymmetry. breast ultrasound is one of the main imaging modalities in breast radiology, it allows us to characterise lesions and also guide interventional procedures. the bi-rads categorisation of ultrasonographic findings facilitates the diagnostic approach and also helps the radiologist to use a common language, understood not only by the rest of the radiological community, but also by other breast cancer professionals. ultrasound can be a diagnostic procedure on its own, but is mainly a modality that characterises the findings of other modalities (mammography and mri) and, as such, correlation between all these techniques is the mainstay of everyday clinical practice. this act of correlating and integrating the information of all modalities is what makes a breast radiologist a key actor in the diagnosis, staging and follow-up of breast cancer and other benign or high-risk entities. the final product of this integration will be the radiological report, the means by which we convey all the information we have gathered through all the procedures to our clinical colleagues. this report shall also follow some composition rules to be clear and concise. as with any other modalities, breast magnetic resonance imaging (mri) examinations should be reported in a structured way following the guidelines of the respective national, continental or international societies. adequate nonclinical information (i.e. patient name, date and type of examination, etc). is indispensable. any breast imaging report has to follow a stringent structure including indication, clinical history, clinical findings, brief description of technology used, assessment of parenchymal density, detailed description of significant findings, comparison with previous imaging studies and final assessment according to bi-rads. indications and contraindications of breast mri will be discussed. significant findings at breast mri include foci (small contrast-enhancing spot, nos, < 5 mm), mass lesions, "non-mass-like enhancement" (no mass lesion, partly diffuse regional contrast enhancement of various size) and associated findings. furthermore, as breast mri is a functional study, the different appearance patterns of kinetic contrast enhancement will be presented. the current status and the appropriate use of the bi-rads mri lexicon will be discussed. any breast mri report should not only follow the guidelines, but also follow a red thread, be consistent, express confidence and be comprehensible to clinicians. the overall final bi-rads assessment is based on the most worrisome finding, taking into account both breasts and all imaging methods (mammography, ultrasound, mri) evaluated. furthermore, adequate communication of the result, as well as do's and don'ts of the report wording will be discussed. the prostate is a small glandular organ, whose main function is to secrete seminal fluid. in young men it comprises of mainly the peripheral zone (70%) and a smaller central gland. however, the central gland enlarges with age to form the larger part. the main diseases of the prostate are inflammation, hyperplasia, and cancer (the most important). approximately 70% of cancers arise in the peripheral zone. the main applications of mri are for cancer detection, staging, and recurrence. mri is increasingly used for radiotherapy planning owing to its good soft-tissue contrast when compared with ct scanning. endo-rectal rf receiver coils, usually inflated with air or perfluorocarbon but sometimes of a rigid design, improve signal detection of the prostate. phased-array surface coils may also be used or (preferably) in combination. t1-weighted imaging helps to distinguish haemorrhage caused by biopsy. on t2-weighted images the peripheral zone appears brighter, owing to a larger proportion of prostatic ducts, while tumours generally appear darker. more sophisticated mr methods are increasingly used to help diagnosis. in diffusion-weighted images (dwi) tumours appear relatively bright, but dark in the corresponding calculated map of apparent diffusion coefficient (adc), owing to the more cellularly-dense nature of tumours, and hence, reduced diffusion. in dynamic contrast-enhanced mri (dce-mri) tumours appear bright owing to increased vasculature. magnetic resonance spectroscopic imaging (mrsi) of normal prostate is dominated by high levels of citrate from the prostatic ducts; in cancer this is reduced while choline is increased. prostatectomy samples allow one to verify image contrast against histology. recent studies on prostate cancer have provided a number of relevant targets for imaging and treatment purposes. today, imaging plays an important role in different aspects of the disease, but its role should grow in answering clinical questions at various phases of the disease. relevant targets for imaging include metabolites (including glucose, acetate, choline, and amino acids), antigens (including prostate-specific membrane antigen), receptors (grp receptor, cxcr4, androgen receptor), proliferation, angiogenesis, and hypoxia. in this presentation, a range of radiotracers for potential use in the imaging of prostate cancer will be discussed, as well as options to tailor nuclear imaging tracers to the various phases of the heterogeneous disease. the fusion of morphologic (ct and mri) and functional (pet, spect) imaging modalities (pet, spect) has become widely available and part of the standard diagnostic workup in cancer patients. for many years, neurosurgeons have already relied on multimodal imaging data during brain tumour surgery to identify hyper-or hypometabolic tissue. the availability of pet and spect data during percutaneous ablation procedures may also be helpful to facilitate treatment planning, probe placement, probe re-positioning, and early detection of residual disease following percutaneous image-guided ablation of cancer. however, up to now conventional us-and ct-guided thermal ablation procedures rely on morphologic information only. intraoperative implementation of multimodal data requires the application of frame-based or frameless stereotactic techniques, both relying on the establishment of an accurate relationship between the patient's preoperative image space and the intraoperative physical space. in image-guided neurosurgery, ct/mrt/spect/pet data are registered to the patient using rigid body transformation. due to respiratory motion and different patient positioning during image acquisition and the actual intervention, soft tissue deformations in the liver occur. thus, the images and the surgical presentation do not match between preoperative imaging and intervention, leading to an extensive degradation of spatial guidance. this presentation illustrates solutions for these fundamental problems that occur during 3d-navigated liver interventions, including patient immobilisation and repositioning, respiratory triggering and intraoperative imaging. r. bale: equipment support recipient; isys has supported the section of microinvasive therapy with testing equipment. patent holder; rb is a (co-) inventor of the atlas aiming device and the bodyfix immobilisation device and a (co-)shareholder in its financial returns. the goal of ultrasound-triggered, image-guided drug delivery is to increase the therapeutic index and decrease adverse effects of drugs. the bio-effects of focused ultrasound can lead to local tissue heating, cavitation, and radiation force, which can be used for 1) local drug release from nanocarriers circulating in the blood, 2) increased extravasation and cellular uptake of drugs and/or carriers, and 3) enhanced diffusivity of drugs. thermo-sensitive liposomes have been suggested for local drug release in combination with local hyperthermia more than 25 years ago. microbubbles may be designed to enhance cavitation effects. real-time imaging methods, such as magnetic resonance, as well as optical and ultrasound imaging have led to novel insights and methods for ultrasound-triggered drug delivery. image guidance of ultrasound can be used for: 1) target identification and characterisation; 2) spatio-temporal guidance of actions to release or activate the drugs and/or permeabilise membranes; 3) evaluation of biodistribution, pkpd; 4) physiological read-outs to evaluate the therapeutic efficacy. liposomes may carry both hydrophilic and hydrophobic drugs in their aqueous interior and lipid bilayer membrane, respectively. the circulation half-life may be increased by incorporating polyethylene glycol (peg)-lipids in the bilayer. recent publications have shown that ultrasound-triggered delivery is feasible. realtime imaging methods, such as magnetic resonance, optical and ultrasound imaging may lead to novel insights and methods for ultrasound-triggered drug delivery. up to now, the success of surgical tumour resection has always been limited by the surgeonâ´s vision. the human eye is not an accurate detector of small cancer cell clusters and it cannot accurately differentiate cancerous from healthy tissues due to lack of "visible" contrast. by combining a fluorescent probe targeting the folate receptor and a multi-spectral real-time fluorescence camera to observe the operating field, we found that, using fluorescence molecular imaging, 3-fold more lesions can be identified compared to conventional surgery. these first in-human results point to molecular-based clinical decision-making in surgical and endoscopic procedures as a paradigm shift over decision-making based on human vision. the talk describes current progress with instruments, methods and applications in the field of intraoperative imaging. pre-clinical and clinical results are presented and the advantages and limitations of the method as well as future directions will be discussed. the emerging field of multispectral optoacoustic tomography (msot) is also outlined. mysteries of the human brain unveiled: imaging of white matter microstructure and neuroplasticity p.m. parizel; antwerp/be (paul.parizel@uantwerpen.be) the human brain remains one of nature's great mysteries, and is considered science's final frontier. this greyish lump of tissue with a weight of 1.5 kg contains some 100 billion neurons, each of which are connected to thousands of other nerve cells in an intricate network of white matter fibers. in the previous century, the brain was perceived as a fixed three-dimensional landscape, with brain functions confined to certain locations (e.g. motor and sensory cortex, visual cortex, auditory cortex). this concept of neurolocalisationism was in line with the philosophy that there should be "a place for everything, and everything should be in its place". advanced quantitative mri techniques for acquisition and data analyis (fmri, dwi, dti, vbm), help to unravel white matter connectivity of the human brain, and are able to show that the brain can modify its structure and function in response to changing circumstances (such as learning, memory, hormones). this process, which is known as neuroplasticity, occurs at different levels and different time scales. for example, in response to injury, changes may occur at cellular level as well as on a larger scale with cortical remapping. some processes may take months or years (e.g. physical therapy and training) whereas some forms of neuroplasticity happen within hours or days (e.g. changes in brain volume and connectivity during the female menstrual cycle, which have been linked to behavioral changes). in summary, quantitative mri techniques help to unveil the mysteries of the human brain and have opened exciting new fields of active research such as white matter connectivity and neuroplasticity. there are a host of inflammatory and infective insults that can manifest focally or diffusely within the musculoskeletal system. the appearances of the underlying pathological processes in both the soft tissues and skeleton cover a very wide imaging spectrum. the appearances vary, depending on the timing and degree of inflammatory insult and the host response in the involved tissues. the approach of this lecture will cover the imaging manifestations using all modalities covering radiography, ultrasound, ct, scintigraphy and magnetic resonance imaging. the basic knowledge that is required will be displayed in 4 major musculoskeletal categories covering disorders involving the soft tissues, joints, bones and entheses. the imaging manifestations will also be linked with the evolution of the pathological processes covering acute, sub-acute and chronic stages of the inflammatory/infective disorders. by the end of the session the audience should have a clear understanding in making best use of the imaging modalities in the correct diagnosis of a wide variety of inflammatory and infective conditions that can affect the musculoskeletal system. arterial pta and stenting is firmly established as primary treatment in the management of athero-occlusive disease, particularly of peripheral limb arterial disease (pad). patients are selected on the basis of symptoms such as short distance claudication or critical limb ischaemia for lower limb disease or appropriate ischaemic symptoms in other territories in the renal and mesenteric territories and head and neck vessels. commonly used grading systems such as the fontaine or rutherford scores can be useful in patient selection. where treatment is required, noninvasive imaging is utilised to look for the site, severity and extent of arterial disease. most centers use duplex imaging as the primary imaging modality; mra or cta are often used with a higher sensitivity and specificity; and invasive angiography is reserved for problem solving or immediately prior to intervention. the tascii classification has been devised to select patients for either endovascular or surgical intervention. however, most centres will adopt an endovascular approach first. all patients should be on good medical therapy, i.e. aspirin and statins, with good blood pressure and diabetic control where appropriate. when carrying out interventions, an access sheath is used, peri-procedural heparin administered and lesions crossed using selective catheters and commonly hydrophilic guidewires. subintimal crossing of occlusions can be much simpler than trying to cross lesions luminally. balloon angioplasty and or stenting may be applied differently depending on the site and extent of the lesions. the evidence for drug-eluting technologies has also been growing with improved patency rates compared to standard balloon angioplasty. during the efrs meets russia session, radiographers have the opportunity to get information about the role and education of radiographers in the different european countries. the radiographer is a health-care team member who interacts with other professionals in the primary and secondary health-care environment to provide an optimum diagnostic or therapeutic outcome. radiographer education therefore requires that the curriculum covers a wide range of scientific, medical, pathological, sociological, ethical and technical subjects together with the development of appropriate clinical skills. the curriculum should also include the development of research and audit skills to ensure the constant improvement of service quality for the benefit of service users. the session will include a panel discussion about the role of the radiographer in image acquisition and processing. the tasks of the assistant to the radiologist are: filling of the protocol of research, survey of the patient, instructing the patient according to safety measures, positioning the patient, placement of coils of strengthening, beginning of magnetic and resonant research -the research is approved by the doctor, introduction of contrast substance (in the presence of the certificate of the procedural sister) and supervision over the patient during mr research. furthermore, the other tasks are briefing on patient safety, excluding introduction of the patient to metal objects on mr tomography, explaining the procedure of the study, informing about the duration of the study, wearing noise-cancelling headphones, warning about possible vibration and loud sounds, and providing a globular button to call the nurse. today coronary ct-angiography has become a well-established and proven diagnostic modality. quality of coronary and cardiac cta datasets has tremendous significance for correct diagnosis. a radiographer has a pivotal role in performance of coronary cta. coronary cta is one of the most challenging examinations for radiographers because even a small mistake at any stage of examination may ruin the whole study. before the scanning procedure, the radiographer performs a check for possible contraindications to contrast media injection (history of adverse reactions to contrast media and impairment of renal function are the most important ones). the radiographer checks the patient's heart rhythm and takes part in administration of betablockers for control of the heart rate. a detailed knowledge of different scanning modalities of ct-machine is a must. radiation exposure to the patient from coronary cta examinations has been one of the major public concerns. this is why the radiographer should be aware of different approaches to the performance of low-dose cta (prospective gating, tube current modulation, high-pitch scanning) according to patient body composition. the radiographer should have knowledge of when and how to use radiation dose control in an appropriate way. another big issue is injection protocols. selection of optimal bolus timing and iodine load results in highquality cta images. the radiographer has to know the basics of ct image reconstruction and interpretation in order to perform different types of reconstructions from the raw data according to the radiologist's requests and be able to recognise image artifacts. clinical examples of the radiographer's role for performance of coronary cta will be given. every country is famous for its architecture, history, literature, music, museums, etc. however, there are some distinctive features for russia. "russia is a riddle wrapped in a mystery inside an enigma." these words by the famous british statesman winston churchill aptly throws light on the pulsating art and culture of russia. the different aspects of russian art and culture find its best expression in the rich heritage. just feeling the nature and boundless expanses of the country can understand the mysterious russian soul, works of art and real masterpieces. cardiac mdct in children with congenital heart diseases v. bereznitskiy, k. serkova; moscow/ ru (vsber@mail.ru) in ct studies of children with congenital heart diseases, it is mandatory to keep the x-ray dose, amount of contrast agent and study time as low and as short as possible and simultaneously get the best diagnostic image quality. how can we reduce the x-ray dose? by minimising the volume coverage, reducing the voltage, minimising the effect of "overranging", use of x-ray protective equipment, use of tube current modulation technique, use of iterative reconstruction technique. how can we reduce the amount of contrast agent by volume? by covering of only necessary anatomic volume, minimising scanning time, use of adequate speed injection in ml/sec, which depends on catheter position and size, blood flow and anatomic structures. how can we reduce the amount of iodine concentration in the contrast agent? by lowering the voltage we may reduce the iodine concentration and get higher absorption ct values (hu). how can we reduce the time of cardiac ct studies? by preparing the study protocol ahead, preparing all necessary equipment in the ct room, warming up of the contrast agent before the study. what is the radiographer's role in cardiac ct studies? to take care along with the responsible radiologist the above-mentioned needs, to take care of adequate room and instrument temperature, to take care that only absolutely necessary people with adequate x-ray protection are in the study room, for performing the necessary image post-processing, archiving and distribution of studies. the purpose is to evaluate the quality of imaging in forced position of patients with anesthetic support. the role of laboratory technician in ct post processing. we analysed images of unconscious patients on artificial lung ventilation on 24-and 64-slice computer homographs ge and siemens and monitored them through the infusion. during investigation the patients were in forced positions, as a result they got artifacts from upper extremities on the abdominal cavity. we analysed 157 patients -hands under the butt, 135 patients -hands on the chest (abdomen), 57 patients -arms along the body. according to the images the smallest number of artifacts was identified when the patient was on the table with hands under the butt. different variations of the patient's hands position and the problem of choice of this position will be offered for researching. the reconstruction the laboratory assistant can execute and also the results of tests will be presented. by order of the doctor the laboratory technician builds 3d and 4d reconstructions of fractured ribs, pelvis, facial skeleton, sagittal and coronary reconstructions of spine in case of its fracture. gastrointestinal stromal tumours (gist) are a rare disease that metastasises in up to 85% of patients with subsequent median progression-free survival (pfs) of around 30 months. tumours are characterised by activating mutations in the kit or the pdgfra gene and treatment is mainly based on tyrosine kinase inhibitors designed to block mutated receptors. however, drug resistance is often based on mutations changing the conformity of the receptor, leaving little effective therapeutic options. to date, second line chemotherapy offers a median pfs of 6-9 months and external beam radiotherapy is limited by organs at risk close to the tumour. alternative approaches like endoradiotherapy or minimally-invasive ablation techniques are effective for local control but are inconsistently used and are not tailored to the individual patient's type of disease. to address these issues, the mitigate project proposes a closed-loop personalised treatment concept combining endoscopic-assisted tissue sampling, inline biotechnology and targeted molecular pet imaging probe development combined with minimally-invasive treatment monitored by new mr imaging techniques. a consistent value chain across european research institutes and smes will be established for mass spectrometry of tumours, linkage of radiochemical molecular imaging probes, design of new animal models and targeted therapeutic radiopharmaceuticals. this closed-loop platform will minimise fragmentation of treatment approaches by a coherent molecular-based multimodality concept, thus providing new treatment options. the mitigate platform can be expanded to further patient cohorts with oligometastatic diseases such as other sarcomas or renal cell carcinoma. gastrointestinal stromal tumours (gist) are characterised by highly specific genetic mutations. several specific targets are overexpressed in a majority of the tumours. on the other hand, secondary resistancies limit the usability of highly specific chemotherapeutics such as imatinib. instead of applying cascades of alternative tki inhibitors in order to find an efficient one, quantitative molecular imaging and targeted endoradiotherapy could be considered. for the detection of gist by imaging, 18 ffluorodeoxyglucose (fdg)-pet is widely accepted to visualise the tumour burden. however, as fdg gives no molecular information of potential targets for treatment, new radiopharmaceuticals have to be developed to visualise and quantify other target-structures expressed by gist that would be able to be addressed. this molecular information can be used both for designing a conventional treatment or an advanced strategy: i.e. targeted endoradiopharmaceuticals. compared to conventional chemotherapy this method has the great advantage that not only tumour cells expressing the targeting vector are affected but also tumour cells within the range of the radiation of the decaying radiopharmaceutical. this method is used with great success in the case of neuroendocrine tumours using labeled octreotate derivatives (a small cyclic peptide binding to the somatostatin-receptor) and non-hodgkin's lymphoma applying y-90 labeled zevalin (a monoclonal antibody binding to the cd20 antigen). the success of these methods relies on the crossfire-effect, meaning that a certain margin of tissue surrounding the cell targeted by the specifically accumulating endoradiopharmaceuticals is destroyed as well, depending on the penetration range of the emitted radiation. thus, the development of new radiopharmaceuticals for the specific diagnosis and treatment of gist would strongly improve the outcome of the tumour patient. stereotactic radiofrequency ablation of liver tumours: does improved targeting increase tumour response? r. bale, g. widmann, p. schullian, m. haidu, w.r. jaschke; innsbruck/at (werner.jaschke@i-med.ac.at) the purpose is to describe stereotactic radiofrequency ablation (srfa) and to review its inital results in the treatment of patients with primary and secondary liver tumours. one retrospective review includes 90 consecutive patients with 106 srfa sessions for the treatment of 72 hepatocellular carcinomas (hcc) and 105 metastases (1). in two other studies the outcome after srfa of intrahepatic cholangiocellular carcinomas (icc) (2) and colorectal liver metastases (crlm) (3) was evaluated. the overall technique effectiveness was 95.5% with a local recurrence at 1 year of 2.9%. technique effectiveness was not significantly different for lesions< 3 cm (95.9%) and 3-5 cm (100%). after treatment of 17 inoperable consecutive patients with 52 iccs a median overall survival of 60 months was achieved. a median os of 58 months and os rates of 92%, 66% and 48% at 1, 3 and 5 years in patients with resectable crlm were achieved. tumour size did not affect os and dfs. rfa probes can be precisely planned, positioned and distributed by means of stereotaxy. especially in large liver tumours the local recurrence rate can be greatly reduced by precise stereotactic placement of multiple radiofrequency probes. these improved local control rates result in better long-term survival rates. author disclosure: r. bale: shareholder; coshareholder atlas aiming device. other; coinventor atlas aiming device. functional and molecular imaging in tumour therapy response assessment s. aime; turin/ it (silvio.aime@unito.it) in the mitigate project further development of currently used mri and ct techniques will be tackled in order to obtain functional and metabolic information which are mandatory to detect early response to the targeted radiopharmaceutical approach. new gd-based agents are under scrutiny in order to improve dce-mri procedures and attain more precise information on the tumour microvascularity level as well on the vessel permeability and the assessment of extracellular ph and mmp activity. the x-nuclei mri ( 23 na sodium) is a non-invasive imaging technique, which enables the measurement of the tissue sodium concentration (tsc) in humans. the direct link of the tsc with the tissue integrity and viability provides a promising approach for monitoring tumour tissue, and could also help to assess cytoxicity and cell death by means of breakdown of the sodium-potassium-pump. however, 23 na mri is challenging because of the low in vivo abundance, the fast transversal relaxation rate and the low gyromagnetic ratio of the 23 na ions in human tissue. new mr measuring sequences for x-nuclei mri will be developed to establish a standardised tsc measurement method within the eu for better comparability. furthermore, the x-nuclei mr data will be reconstructed, scaled and fused with further imaging modalities. lung cancer is the leading cause of death related to cancer. most patients are inoperable as they present with advanced stage disease or even a localised tumour associated with poor general condition, limited cardiopulmonary function or a too high surgical risk. according to the stage of the disease, chemotherapy, radiotherapy and percutaneous ablation therapies are the current therapeutic options for inoperable patients. it is important that radiologists are familiar with the various response and complication imaging patterns related to each of those treatments. the timeline modifications after radiation therapy and percutaneous ablation and the diagnostic management of drug-induced lung disease will be reviewed. this presentation will summarise the current evidence and how to detect early recurrences after those treatments. learning objectives: 1. to learn about changes after radiotherapy. 2. to learn about sequela after percutaneous ablation of lung tumours. 3. to understand changes after chemotherapy of lung cancer. cardiovascular medicine owes much of its spectacular development to the parallel evolution of imaging techniques in the last thirty years. the complex contemporary techniques in interventional cardiology, electrophysiology, and cardiac surgery require advanced imaging modalities. in current times, a wide spectrum of imaging techniques -such as fluoroscopy, mri, non-contact mapping, echo techniques -is performed in organised cardiovascular labs while computed tomography and nuclear techniques are provided by the collaborative departments of radiology and nuclear medicine. it is indeed the collaborative spirit among specialists that bring about the results patients desire. cardiac magnetic resonance (cmr) is a very versatile imaging technique for the assessment of patients with left ventricular dysfunction and has become a central method for characterising the etiology of the dysfunction. indeed, wall thinning less than 6 mm and aneurysmal motion are morphological signs of transmural necrosis. furthermore, a low dosage of dobutamine (10-20 microg/min) is used to detect functional reserve in the case of viable tissue. a further option offered by cmr is late contrast enhancement (le) imaging, which allows identifying the presence of fibrotic tissue as well as necrotic infarcted myocardium. the sensitivity and specificity of late hyperintensity is, respectively, 0.86 and 0.94. similar results can be obtained with 99mtctetrofosmina g_spect. there is a relation between transmural extension of hyperenhancement and the recovery of contractile function after coronary revascularisation. the chance of recovery decreases progressively with the transmural extension of late hyperintensity, since the average value of the latter is 10â±7% in the segments that recover and 47â±14% in the segments that do not recover contractile function. cmr was also shown to be able to predict response to cardiac resynchronisation therapy differentiating between nonischemic and ischaemic cardiomyopathy le-cmr may allow to precisely delineate the presence and the location of fibrosis, avoiding the placement left ventricular leads in necrotic areas and in particular when the scar is located in the posterolateral area. at the beginning of the presentation, a short overview will be given on the relevance and prevalence of valvular heart diseases with special focus on europe and the data collected in the euroheart survey. also, the aetiologies of the various valve diseases will be briefly mentioned. in the second part, special attention will be given to aortic stenosis (as) and mitral regurgitation (mr), as these two entities are responsible for up to 60% of all valvular heart diseases. echocardiography is well accepted as the backbone examination of any valvular heart disease evaluation. echocardiographic criteria for severe as and mr are reviewed as well as their importance for the indication of valve repair or valve replacement. in the third part, we will focus on newer "cross-sectional" imaging technologies such as cardiac mr and ct. in particular, the strengths of cardiac mr in the assessment of regurgitant lesions will be demonstrated. in addition, the value of cardiac mr for the pre-interventional evaluation of congenital heart diseases will be discussed. similarly, the crucial role of cardiac ct in the workup for transaortic valve implantation (tavi) will be illustrated. finally, the yield of these novel techniques in the context of combined valvular and ischaemic heart disease will shortly be reviewed. learning objectives: 1. to better understand the role of cardiac mri in valvular heart disease. 2. to appreciate the added value of mri vs other imaging modailities. cardiac resynchronisation therapy (crt) and transcatheter valve heart (thv) interventions have been important therapeutic breakthroughs for heart failure patients and patients with valvular heart disease and contraindications for surgery. patient selection is crucial to optimise procedural outcomes and therapeutic efficacy. multimodality imaging plays a central role in patient selection and procedural strategy planning. assessment of left ventricular dyssynchrony, cardiac venous anatomy and extent and location of myocardial scar are key to identify heart failure patients who will respond to crt. stepwise use of non-invasive imaging modalities, including echocardiography, nuclear imaging, magnetic resonance imaging and multidetector row computed tomography (mdct), has been common practice to select patients for crt. recent technological advances have allowed integration or fusion of imaging modalities to create 3-dimensional models that provide relevant information. multimodality imaging is also crucial to optimise the results of thv interventions. detailed anatomical and geometrical evaluation of the mitral valve with current 3-dimensional imaging techniques has permitted better selection of patient candidates for transcatheter edge-to-edge mitral valve repair and accurate procedural guidance. for transcatheter aortic valve implantation, accurate measurement of the aortic annulus with 3-dimensional echocardiography or mdct allows us accurate selection of the prosthesis size to minimise the risk of complications, and evaluation of the procedural access (transarterial or transapical) with mdct permits accurate procedural strategy planning. the learning objectives of this session include: providing an overview of current imaging modalities to select patients for crt and thv interventions and how to use them in clinical practice. the inner layer of the anal canal consists of squamous and columnar epithelium with the transitional zone at the dentate line. the muscular component of the anal sphincter consists of an inner layer of circular smooth muscle (internal sphincter), extending downwards from the rectum, and an outer striated muscular layer extending downwards from the levator ani muscle, comprising the puborectalis muscle and the external sphincter. between these layers is the fat-containing intersphincteric space, including the continuation of smooth-muscle fibers of the longitudinal muscle of the rectum. outside the anal sphincter is the fat-containing ischioanal space. magnetic resonance imaging (mri) and endoscopic ultrasonography have become the mainstay for preoperative imaging of perianal fistulas. for complex tracts, mri seems preferable. mri can be performed using an endoluminal coil or a phased-array surface coil. a state-of-the-art imaging protocol should include t2 tse sequences in three orthogonal planes, with the axial and coronal sequences angulated at the anal canal. addition of a fat-saturated t2 tse sequence is recommended for optimal conspicuity of inflammatory changes and post-contrast t1-weighted imaging can also be helpful. intersphincteric infection is the principal feature of perianal fistulas; this is generally not found in other conditions. veins can be mistaken for fistulas, but in contrast to fistulas, veins usually are thin-walled, tortuous, symmetric structures. a pilonidal sinus may resemble a fistula, but absence of extension to the intersphincteric space helps one to discriminate between them. haemorrhoids and anal tags may resemble small submucosal fluid collections, but are easily diagnosed at clinical examination. this lecture will describe the pathogenesis of fistula-in-ano, with a focus on cryptoglandular disease, so that the radiologist can understand how the various classifications of fistulas arise. the park's classification for fistula-inano will be described with reference to cryptoglandular disease and other aetiologies. the surgical questions that need to be answered by imaging will be presented, followed by a description of what the radiologists need to include in their report for it to be clinically useful. the role of anal ultrasound and mri for preoperative fistula imaging will be described, with explanation as to why the latter is fundamental to modern management of the disease. perianal fistulising disease develops in approximately half of the adult and paediatric patients with crohn's disease (cd), with a relevant impact on their quality of life. in patients with cd, particularly those with severe fistulising ileal or colo-rectal disease, complex ramified anal fistulas associated with abscesses (parks' classification type 3-4 or s.james hospital classification type 4-5) are more frequently observed than in other patients. perianal disease thus represents a severe complication of cd, which may change disease management, by requiring specific pharmacological and/or surgical treatments. a non-responsive disease eventually may lead to total proctectomy with ileostomy. mri represents the gold standard diagnostic modality, because it provides a comprehensive staging of both enteric and perianal disease, with high accuracy and without invasiveness. moreover, mri is the ideal tool for monitoring disease response to therapy, being able to detect the inflammatory activity of perianal fistulas with high accuracy. so far, several clinical indexes have been proposed to measure fistula's activity, including the perianal disease activity index (pdai). similarly, several mri classifications of fistula's activity, based either on t2-weighted or t1-weighted contrast-enhanced imaging, have been proposed, although a widely accepted imaging severity score is not available yet. several cases of complex perianal fistulising cd of increasing severity will be shown, with anatomical and clinical correlations, staging and activity description, particularly in patient follow-up and treatment monitoring. finally, differential diagnoses with other benign conditions which may affect the anal canal, including inflammatory infective diseases, hydradenitis and pilonidal disease will be discussed. ground glass opacity (ggo) is characterised on hrct by the presence of a hazy increase in lung opacity that does not cause obscuration of underlying bronchial and vascular margins. although a very common finding, it also constitutes a very nonspecific term since it can be seen in a variety of different intraalveolar and interstitial processes with different histology including inflammatory, infectious and neoplastic diseases that have a common physiologic mechanism: partial displacement of air. ground glass opacity may even be seen in normal processes such as poor ventilation in dependant lung areas and in expiration. moreover, ggo can represent either an ongoing, active and potentially treatable disease or an irreversible process. to interpret correctly this highly nonspecific but very significant finding, it is crucial to attempt to further classify the different large main entities in which this radiological finding appears. are there specific radiological and hrct findings that can help us differentiate ggo in autoimmune inflammatory conditions from infectious and neoplastic processes? are there associated findings other than ggo, such as nodules, reticulation or focal disease, and distribution of findings that can narrow the differential diagnosis? systematic evaluation of ggo and associated findings as well as integration with clinical information (acute, subacute or chronic symptoms) is essential in defining ggo subtypes to improve the radiological diagnosis. radiologists who regularly review high resolution ct (hrct) should be aware of the range of patterns and, more importantly, their potential pathological meaning. a pattern of ground-glass opacification is one of the more common hrct findings but, to the unwary, its interpretation can be problematic. an important underlying principle is that a ground-glass pattern may be caused by any process -physiological or pathological -which partially displaces air. physiological (i.e. non-disease-related) ground-glass opacification is perhaps most commonly seen in subjects who, for whatever reason (e.g. breathlessness, obesity), are unable to maintain or achieve a satisfactory inspiratory effort during scanning. a generally increased lung density (in contrast to adults) is also a feature in infants and young children simply because there are fewer alveoli in the developing lung. finally, it is worth noting that intravenous contrast administration (presumably because of a relative but temporary increase in capillary blood volume causing partial displacement of air) can unpredictably increase lung density. disease processes which lead to partial filling of the air spaces, thickening of the interstitium, partial collapsing of alveoli, and/or increased capillary blood volume will also manifest as a pattern of ground-glass opacification. in clinical practice, the recognised causes of ground-glass opacities on hrct include pulmonary oedema (cardiogenic or otherwise), infections (e.g. pneumocystis jiroveci pneumonia) and some of the idiopathic interstitial pneumonias (e.g. non-specific interstitial pneumonia and respiratory bronchiolitis associated interstitial lung disease). the presentation will review and revise the causes of physiological and disease-related ground-glass opacification on hrct. ground-glass opacity (ggo) is defined as increased attenuation of the lung parenchyma without obscuration of the pulmonary vascular markings on ct images. ggo may be the result of a variety of interstitial and alveolar infectious and noninfectious inflammatory diseases. as an imaging finding alone, ggo does not usually allow a specific diagnosis. ggo in inflammatory disorders is often present in the company of other interstitial or alveolar findings. however, the number of diseases that cause diffuse isolated ggo or ggo as the predominant finding is relatively small and can be prioritised with clinical information. the most common cause of diffuse isolated ggo in immunocompromised hosts are a variety of diffuse, opportunistic pneumonias, e.g. pneumocystis jiroveci pneumonia (pcp), cytomegalovirus pneumonia (cmv) or herpes simplex pneumonia (hsv), which constitute the first differential. chronic onset disorders in immunocompetent patients include cellular nonspecific interstitial pneumonia (nsip), subacute hypersensitivity pneumonitis (hp), organising pneumonia, air-space sarcoid, and drug-induced lung disease. in these disorders, ancillary findings such as an associated reticular pattern with traction bronchiectasis/bronchiolectasis (nsip), mediastinal lymphadenopathy (sarcoidosis), superimposed nodularity or cysts or may help to refine the diagnosis. in patients with collagen vascular disorders, e.g. scleroderma, ggo secondary to pulmonary involvement needs to be differentiated from drug-induced lung disease. this refresher course will put ggo in the context of outpatients versus inpatients, the acuity of clinical symptoms, e.g. fever, cough and dyspnoea, signs of massive systemic inflammation, and the clinical situation such as inhalational history, pneumotoxic drug administration, immunocompromise, or bone marrow suppression. in this course, we will review the dysplastic and neoplastic conditions that are associated with persistent ggo in the lung parenchyma. we will separate these conditions into those that are responsible for localised diseases such as single nodular ggo and those responsible for more extended diseases. nodular ggo can be separated into pure or mixed or part-solid nodules. pathology-radiology correlations show that nodular ggo are related to atypical adenomatous hyperplasia (aah), adenocarcinoma (adc) in situ (ais), minimally invasive adc (mia), and invasive adc according to the new iaslc/ats/ers lung adenocarcinoma classification. differential diagnosis includes exceptional metastases of angiosarcoma and melanoma as well as infection, inflammation and localised fibrosis. diffuse ggo related to neoplastic conditions is rare and may be due to lepidic adc (former advanced adc with bac component), diffuse large b-cell non-hodgkin's lymphoma, intravascular lymphomatosis (ivl) or mucosa-associated lymphoid tissue (malt) lymphoma. these neoplastic diseases should be differentiated from infectious and inflammatory causes of diffuse ggo. we will review the value of different morphological ct criteria to differentiate benign from malignant localised ggo, such as the size, the morphology (round, oval, flat), presence of mixed vs. pure ggo, and the multiplicity of nodular shadows. discussion will also include the changes that may occur within the nodule as well as the mean doubling time. the role of pet ct and transthoracic biopsy will be discussed. finally, we will present the current recommendations regarding the management of nodular ggo. it is the purpose of this lecture to briefly discuss ankle distortion-related lesions with emphasis on failed radiographic diagnosis, discuss their significance and management implications and define the diagnostic pathways in the acute and subacute stage. significant lesions are those with no return to sports activities after 12 months; these have our major interest. in the acute setting of ankle distortion, the ottawa clinical decision rules are accepted to decide whether or not radiographic evaluation is needed; about 35% of radiographic examinations can be avoided. additional evaluation is restricted to patients with residual pain during reevaluation one week after trauma. assessment of fractures with the lauge hansen classification has a major advantage, as it defines the stability at the talocrural and distal tibiofibular joint. only in restricted cases, additional examinations may be needed to rule out instability. although radiographs easily detect displaced fractures, occult fractures may occur; also, grade ii-iii ligament lesions and peroneal tendon dislocation may go undetected. additional imaging evaluation should focus on the detection of significant lesions. significant lesions are talar fractures and complete calcaneofibular ligament tears. the latter is explained by the instability at the level of the subtalar joint with associated sinus tarsus syndrome. in case of residual local tenderness posterior and inferior to the lateral malleolus, the fibulocalcanear ligament and retinaculum peroneorum lesions are best evaluated with (dynamic) ultrasound. mri or ct is used to detect occult fractures in case of residual talocrural joint effusion with anterior talar tenderness during endorotation and plantar flexion. the ankle and foot can be affected by inflammation from a number of diseases. the main focus of this lecture will be inflammation secondary to infection and systemic inflammatory disorders. due to its function in locomotion and weightbearing, the foot is specifically susceptible to infections secondary to penetrative trauma including foreign bodies or to abnormal repetitive pressure. in addition, both seropositive and seronegative arthropathies can affect the foot. other unusual causes of inflammation include chronic recurrent multifocal osteomyelitis, osteoarthritis, mechanical disorders and sensory loss. this lecture will deal with the various patterns of inflammation in the context of pathogenesis and discuss the imaging features that aid in diagnosis. the importance of the clinical context in diagnosis will also be discussed. characterising tumours before deciding on the most appropriate treatment is a general rule in oncology. cystic tumours are now adequately graded based on bosniak's classification. however, this pre-therapeutic characterisation is not currently systematic in case of solid renal tumours, as it remains difficult in clinical practice due to the high prevalence of renal cell carcinomas (rcc) and the lack of reliable imaging criteria for recognition of benign versus malignant tumours. as a result, approximately 10% to 20% of surgically excised renal masses are actually benign. to avoid these unnecessary ablations, pretherapeutic image-guided biopsy has been proposed, but its use is still debated as it is invasive and time consuming. new validated imaging criteria, able to accurately differentiate the most common tumour types but also indolent vs more aggressive malignant lesions, would be useful to reduce the number of unnecessary biopsies or to consider the most appropriate treatment for a tumour or active surveillance. among these, mr imaging plays a major role based on chemical shift gradient echo (gre) sequences, signal intensity on t2-weighted images, dynamic contrast-enhanced sequences, diffusionweighted sequences and late contrast-enhanced images. multiparametric mr imaging is now performed in clinical practice in most primary care centres. therefore, using different combinations of two or several parameters, it is now possible to distinguish certain renal tumours. a larger validation of all these combinations is still necessary to define those having a clinical significance for routine practice. targeted therapies such as vegf mab bevacizumab, vegf tyrosine kinase inhibitors (sunitinib, pazopanib, axitinib and sorafenib) and mtor inhibitors (temsirolimus and everolimus) have been approved and included in european guidelines. pre-therapeutic imaging prerequisites are mainly based on the natural history of mrcc. this justifies imaging through a thoracoabdominal ct scan. outside clinical symptoms, there is no need for bone imaging or brain ct scan; the latter nevertheless could be done because of influencing the therapeutic strategy. pet scan should not be done due to low sensitivity. the evolution of metastatic sites by comparison from previous imaging is useful to evaluate the natural history. outside clinical trials or research imput the strategy is to use the drug in an optimal way to increase pfs. so far, monitoring has to inform about change in recist criteria for cr, pr, sd or pd, and if pd is a real pd such as recist pd or a slowing pd. in conclusion, standard ct scan and recist are adapted to real life. nevertheless, more information on the mode of action of targeted drugs should be interesting for knowledge and research purpose, without any impact on the management of patients. additional imaging could be done with additional criteria than recist on ct scan, by vascular functional imaging and pet scan. breast mri is recognised as a useful tool for a number of clinical indications, but remains relatively challenging. recognising the importance of an evidencebased approach to the development of protocols will influence the further integration of this technique into everyday clinical practice in the management of breast cancer patients. there remain concerns regarding the potential of over-diagnosis from breast mri. the aim of this integrated rc is to inform the clinical practice with regard to the establishment of breast mri in specific clinical and imaging scenarios, namely, using mri for surveillance in high-risk patients, monitoring response to neo-adjuvant chemotherapy and developing protocols for the indeterminate imaging scenario of non-mass-like enhancement. the establishment of protocols to maximise the specificity and sensitivity of the technique of breast mri in such indeterminate clinical and imaging scenarios will be discussed. non-mass like enhancement is a frequent finding in breast mri. it relates to the fact that enhancement occurs in the normal-appearing fibroglandular tissue that surpasses that of the other parts of the parenchyma. there is no associated space-occupying lesion. in pre-contrast non-fat-suppressed or fatsuppressed t1-and t2-weighted images, there is usually no correlate observable. the differential diagnosis of non-mass-like enhancement is between benign nonspecific fibrocystic disease/adenosis, hormonal stimulation, and subclinical mastitis on one hand, vs dcis or (less likely) diffusely infiltrating (usually lobular) cancer on the other. key components of differential diagnosis is configuration of the enhancement (does it follow the orientation of the milk duct or not?) and symmetry (symmetric or asymmetric). less important criteria are internal enhancement (internal architecture) and enhancement kinetics. it is important to realise that enhancement kinetics can only be used to corroborate the suspicion of dcis -but they cannot be used to alleviate the indication to biopsy a finding which, based on configuration and asymmetry, is suspicious. management depends on the different constellation of clinical, mammographic, and mri findings. it usually includes short-term follow-up (6 months) and, if stable/persistent, mr guided vacuum biopsy. assessment of the change in tumour burden is an important feature of the clinical evaluation of cancer therapeutics. tumour shrinkage and time to the development of disease progression are important end points in cancer clinical trials. however, these end points are useful only if based on widely accepted and readily applied standard criteria. criteria, known as recist, were published and are updated on a regular base. the revised recist includes a new imaging appendix and underlines the importance of moving from anatomic unidimensional assessment to either volumetric anatomical assessment or functional assessment with pet or mri. the goal of the lecture is to discuss the value of the different mr imaging techniques (e.g. mr spectroscopy, diffusion-weighted imaging, angiogenesis mapping, pet-mri), which evaluate response to treatment in breast cancer. participants will learn about particular imaging challenges of assessing response to neo-adjuvant chemotherapy. in addition, they will learn to understand clinical aspects of neo-adjuvant chemotherapy based on recist. currently, the esr has been using social media in many successful ways to improve the contacts among members and to boost our fast development as one of the most advanced scientific communities in the world. our session "the role of social media in radiology" presents the view of 4 experts, acknowledged leaders of international it projects. it seems to be important to discuss the major implications of social media for radiology, the leading clinical discipline in information technology. davide caramella will clarify the relationship of social media to professional societies and especially to the esr, including their basic features. the "social media generation" has developed from schoolkids to students and, recently, to teachers as well. alexander sachs represents the young professional expert of elearning in radiology and will reflect the current user behaviour. osman ratib will share his view on how social networks enhance the communication between radiologists, nonradiologists and patients. critical aspects of the pros and cons of large communication scenarios are followed by some ideas of future developments. jã¼rgen brandstã¤tter will indicate the patientâ´s view. most patients see social network communications with their radiologist as useful for, e.g. appointment management or other non-sensitive communication. besides communicating personal health data, a wide area of potential useful other possibilities are at hand, like anonymised health data for reviewing purposes, second opinion or education of patients. the fast development of social media may induce hopes and fears; the four speakers of this session will present them in a panel discussion. the widespread use of social networks in all professional activities has attracted a great interest in the recent years. in medical applications, the main concerns include the possible consequences in terms of patients' confidentiality protection, perceived role of the physician, patient-physician relationship, and caregivers' distraction during professional activities. there are no doubts, however, that social networks are beneficial in enhancing the information flow between scientific societies and their professional members, without any interference at the point of care. social networks have proved to be extremely effective in updating members about relevant news concerning their areas of interests and in allowing them to be informed about the educational activities promoted by their scientific societies. this presentation focuses on the social network activities promoted by the esr via facebook, youtube, twitter and other blogs. impact of social media on the training of radiologists a. sachs; vienna/ at (alexander.sachs@meduniwien.ac.at) in modern times, social media have gained more and more important value in exchanging first experiences in radiology from resident to resident. social networks such as facebook, twitter, google plus and others are used to start discussion groups about cases and share the growing knowledge with different educational concepts in each hospital. growing e-learning modalities as moocs, applications for smartphones or tabs and web-based case series or learning platforms support the training of radiologist in social media. modern elearning platforms use social media as their first choice of sharing knowledge around the whole world about certain illnesses, cases or different decisions of therapy. though sharing information seems to be easier and shows several advantages than in former times, social media can also highlight new problems. this lecture focuses on user behaviour to improve learning, the pedagogic evidence for large group learning with networks and the importance of using networks to manage time. social media networks in communication between radiologists, nonradiologists and patients o. ratib; geneva/ch while social networks have gained unprecedented popularity in our daily environment, they have only limited utilisation in medical applications. the paradigm of communication within a given community for exchange and sharing of imaging data would certainly have its place in a medical environment where there is an increasing need for multidisciplinary collaborative work. the required security and confidentiality in management of sensitive patient data have often precluded the usage of existing public social networks. professional proprietary systems have emerged in a more restricted way with much less flexibility leading to limited use. the exchange of medical images adds a level of complexity due both to the size of the data and the need for appropriate browsing and visualisation tools. traditional pacs and teleradiology system offer such features, but in a very limited way, far from the desired convenience of social networking between groups of users. a prototype of such a system aimed essentially at the community of users that need to exchange anonymised medical images and data for academic and research purposes will be presented and discussed. the project nicknamed dicom sandbox is being tested and evaluated by some users in europe under the coordination of the esr subcommittee of ehealth and informatics. developed with open source software components, it allows using existing cloud-based storage services with additional layers of secure dicom file management and visualisation. it allows the community of users to share dicom data with all social networking and notification features beyond simple peer-to-peer exchange. interactions between patients and radiologists through social media j. brandstã¤tter; wiener neudorf/ at (j.brandstaetter@codewerk.at) social networks have become integral parts of most citizen's use of the internet. especially, the younger generation uses social networks extensively; however the way those tools are used should be chosen carefully. it is one thing to use a social network for private interests, but a different one to use it as transport media for sensible data like personal health-care data. the sensitiveness of citizens regarding privacy has been increased recently by different events of misuse or fraud, especially accelerated by the recent privacy affairs caused by governmental agencies. though most patients see social network communications with their radiologist useful for, e.g. appointment management or other non-sensitive communication, personal medical reports or images shall not be shared across this media. besides communicating personal health data, a wide area of potential useful other possibilities are at hand (e.g. anonymised health data for reviewing purposes, second opinion, education of patients, â�¦). future developments shall make use of social media where useful, but always with deep respect to the patient's privacy rights. apart from the historical, but ever present clinical expectation from the neuroradiologist is the answer to the most important question if the patient has a brain tumour or not. nowadays, due to the outstanding technological advances in imaging techniques during the last decades, the stakes are growing much higher and it is the neuroradiologist on whom lies the initial responsibility of answering a large number of questions that are of utmost importance for further brain tumour patient care and treatment. having the opportunity to provide the usual and generally basic information regarding tumour morphology and exact location and to narrow the differential diagnostic possibilities, neuroradiologic expertise now opens a wide spectrum of techniques, especially those derived from mri, such as mr spectroscopy, mr perfusion, dwi, dti, swi, etc. these provide us the unique possibility of not only obtaining and comparing images, but also of exploring multiparametric brain maps, allowing us to gain insight into the internal architecture of the tumour and the functional and molecular features of the tumorous tissue. this consequently defines the actual stand of neuroradiology, indicating the uprising clinical urge not only to provide the answers regarding the tumour type, grade and possibilities of the most appropriate and patient-individualised therapy modality, whether surgical or nonsurgical, but also to accurately assess the post-treatment tumour behaviour and status, by differentiating the true tumour progression from pseudoprogression, represented by inflammatory responses to the radio-and/or chemotherapeutical treatment, and to monitor other neurooncological response assessment criteria. a. differential diagnosis and pseudo-tumoural lesions h.r. jã¤ger; london/uk (r.jager@ucl.ac.uk) conventional contrast-enhanced mr imaging gives an indication about the likely tumour type and histological grade, but advanced mr imaging methods, including perfusion-weighted (pwi) and diffusion-weighted (dwi) imaging, mr spectroscopy (mrs) and pet imaging provide additional information which helps to refine the diagnosis of intrinsic brain tumours. contrast enhancement can be a feature of low-grade (pilocytic astrocytoma and ganglioneuromas) as well as high-grade gliomas (who grade iii anaplastic gliomas and who grade iv glioblastomas). infiltrative low-grade (who grade ii) astrocytomas do not usually enhance, whereas who grade ii oligodendrogliomas can enhance. higher-grade glial tumours (who grade iii and iv) tend to have an elevated relative cerebral blood volume (rcbv) on pwi, a decreased adc on dwi and increased choline turnover on mrs and pet imaging. a raised rcbv can, however, also be seen in low-grade oligodendrogliomas, particularly in those with a 1p/19q chromosomal translocation, which is associated with a better response to chemotherapy. pwi and dwi are useful in the differentiation of glial neoplasms from cerebral lymphoma, which has an increasing incidence in the immuno-competent population. dwi and pwi are also very useful in the differentiation of enhancing pseudo-tumoural lesion such as cerebral abscesses, tumefactive demyelination, pseudoprogression and radiation necrosis. perfusion imaging plays an important role in the characterisation and management of brain tumours. low-grade brain tumours may transform into high-grade gliomas at some point, which is a transformation that is highly variable and difficult to predict in an individual patient. conventional contrastenhanced computed tomography (ct) and magnetic resonance (mr) imaging are found to be insufficient to depict this transformation and angiogenesis and therefore to detect malignancy. however, perfusion imaging provides additional information over conventional imaging in terms of tumour physiology and haemodynamics, providing important biomarkers for malignancy and prognosis. perfusion ct and mr perfusion techniques such as arteriel spin labelling and dynamic susceptibility-weighted perfusion imaging are more practical and widely used compared to nuclear medicine methods. these perfusion techniques should be considered and used in routine clinical workup of brain tumours to asses grading and prognosis. maximal safe resection, radiation therapy and temozolomide chemotherapy are the current standard of care for newly diagnosed high-grade gliomas. still, hgg have a poor survival rate. a contributing factor to the poor survival is the inability of currently available imaging techniques to accurately delineate the tumour, with the result that targeted focal treatment my not be effective. conventional imaging is not able to give an early assessment of the effectiveness of radiation and/or chemotherapy. in addition, conventional imaging has difficulties in differentiating pseudo-progression, which is a common phenomenon in conventional chemo-radiation therapy, from true progression. early identification of patients who suffer from tumour recurrence can be of great advantage: it provides the opportunity to adjust individuals more rapidly, sparing patients unnecessary morbidity and delay in the initiation of other, maybe more effective, treatment. in recent years, different functional imaging approaches such as perfusion mri, diffusion-weighted imaging and spectroscopy, have been complementarily used for imaging evaluation of treatment response. in this lecture, different advanced mr and ct imaging methods used to support differentiation between pseudo-progression and true tumour progression to assess treatment response will be discussed. in addition, a novel recently published promising technique, the parametric response mapping (prm), a novel voxel-wise analytical method of monitoring physiological and environmental changes in a tumour volume during treatment will be presented and compared to the traditional methods used. finally, the aim of the lecture is to consolidate the present knowledge and novel ideas in brain tumour imaging for assessment of pseudo-progression versus true tumour progression. learning objectives: 1. to understand the challenges and limitations of routine mri in monitoring brain tumour treatment. 2. to become familiar with the role of advanced imaging biomarkers for early assessment of treatment response. 3. to learn how to integrate routine and advance mri into clinical practice after tumour therapy. the purpose of this lecture is to describe the role of functional radiological imaging modality-ct and mr perfusion in the evaluation of head and neck tumors. conventional contrast-enhanced ct and/or mr imaging are the current standard techniques for the diagnosis and treatment evaluation of the head and neck tumors. however, this method is limited in its ability to depict the angiogenesis which is a hall-mark of tumor growth. perfusion imaging provides a rapid evaluation of tissue perfusion and can be easily implemented in every head and neck ct or mr protocol. the determination of tissue perfusion is based on examining the relationships between the arterial, tissue and potentially the venous enhancement after the introduction of a bolus of contrast material. the quantification of the perfusion values helps to outline the malignant tissue as well as to differentiate recurrent disease from nonspecific post-therapeutic changes and can be used as a therapeutic monitoring tool during and after tumor therapy. in recent years diffusion-weighted mri (dwi) gained increasing importance and also acceptance in head and neck radiology. although this functional technique is challenging due to air tissue interfaces, its ability to improve the diagnostic accuracy is widely accepted. dwi can be applied to detect lesions not only in adults, but also in children. it is helpful in lesion characterisation and has a great potential to differentiate recurrence from posttherapeutic changes. initial promising results to improve lymph node staging however are difficult to reproduce. image interpretation is performed qualitatively based on visual assessment of the high b-value images (b= 800-1000sec/mm 2 ) and the corresponding apparent diffusion coefficient (adc) map. quantitative image analysis is based on the measurement of the underlying adc value. solid tumors including recurrences are bright on the high b-value images and dark on the corresponding adc map, whereas posttherapeutic changes are bight on both the high b-value images as well as the adc map. cystic and necrotic lesions are typically dark on the high b-value image and bright on the adc map. furthermore, malignant lesions tend to have a lower adc compared to benign and cystic lesions provided that no necrosis is present. therefore, image interpretation always has to be performed together with morphological images to avoid misinterpretation of functional images. pet/ct has established itself as a robust, rapid and reliable technique in head and neck oncology. it is mainly used to stage nodal disease, to detect distant metastases and synchronous tumours, to identify unknown primary tumours in patients with metastatic neck nodes, to assess treatment response and prognosis after chemoradiotherapy and for radiotherapy planning. mri with diffusion-weighted imaging (dwi) is routinely used for the assessment of submucosal tumour spread, to stage nodal disease, to monitor treatment response and to detect recurrent disease. the information provided by pet/ct and mri is often complementary and the recent implementation of hybrid mr/pet systems in clinical settings holds promise because it can combine morphologic, functional and molecular information. this lecture focuses on clinical applications of pet/ct and mr/pet in the head and neck. current evidence about the combined use of pet/ct and mri with dwi is discussed. the principles of mr/pet data fusion are summarised as well as current knowledge regarding the diagnostic performance of mr/pet in the head and neck. typical radiologic findings of tumour manifestations are reviewed with particular emphasis on the early detection of lesions, their appearance on different imaging modalities and the added value of hybrid imaging techniques. the variable appearance of functional phenomena mimicking disease as well as the potential pitfalls of image interpretation and how to avoid them are equally addressed. major emphasis will be put on how to report the findings in a comprehensive way. multi-energy and functional imaging ct has reached a robustness allowing the use of this new technology in clinical routine for a variety of different clinical questions. this presentation will discuss the basic principles and the strengths and limitations of the techniques. implementations of multi-energy methods for material characterisation and of ct methods for functional imaging will be discussed. contrary to normal single-energy ct systems, multi-energy ct scanners allow simultaneous scanning at two peak x-ray energies. when the attenuation is measured at two energies, their values are not exactly proportional to each other, which open new diagnostic possibilities. measurements at two spectra can be achieved using multiple kvp and/or filtration or with detectors with energy discrimination. these methods have different pros and cons such as sensitivity to subject motion and dose efficiency. to be able to acquire functional data such as perfusion, images are acquired dynamically following the injection of a contrast agent and physiological models are used to convert the measured contrast agent concentration to perfusion estimates. methods that acquire multiple images have the potential to increase the radiation dose to the patient, so ct protocols need to be optimised. in computed tomography, 3d images are reconstructed from a number of x-ray radiographs that were acquired at different angles. tomographic reconstruction relates to the generation of a 3d image based on these acquired radiographs. most tomographic reconstruction methods are based on a technique called filtered back projection (fbp) in which a sharpened version of the radiographs are back projected to generate the 3d image. while it has been the standard reconstruction method, mostly due to its speed and good quality if many radiographs are available, iterative reconstruction methods are emerging. the reason for that is that fbp suffers from important disadvantages. in this talk, the basic concepts of iterative reconstruction are explained and its virtues are detailed. the flexibility of iterative reconstruction methods is demonstrated for the field of x-ray computed tomography. finally an outlook is given with respect to future research on tomographic reconstruction. interventional radiology (ir) has been increasingly applied in the management of obstetric and gynaecological haemorrhage. national reviews of maternal deaths from post-partum haemorrhage have recognised that maternal deaths may be prevented by ir and that all obstetric units should have protocols and arrangements in place to ensure appropriate and timely referral to ir. the important role that irs play in the management of fibroids has also highlighted how these techniques can be applied to other gynaecological conditions which may result in haemorrhage. this session will start by describing which gynaecological disorders may result in haemorrhage and the technical aspects of treatment followed by the published evidence for embolisation. the session will then focus on obstetric haemorrhage, with an emphasis on prophylaxis and how women deemed at high risk for haemorrhage might be managed safely. the techniques used for prophylaxis of haemorrhage will be described in detail and the published data presented. the final presentation will concentrate on the technical aspects of embolisation when haemorrhage has occurred to ensure the best results by knowing the relevant anatomy and appropriate technique of embolisation. the published evidence of the results of embolisation in pph will be presented. these presentations will be followed by a panel discussion on how irs can reduce the radiation dose whilst simultaneously ensuring successful outcomes for their therapies, an important issue in a young and fertile group of women. gynaecologic massive bleeding related to benign and malignant causes is under the scope of all radiologists because of being diagnostic and also because of its implication in interventional radiology procedures. the causes are uterine fibroids (uf) and post-partum hemorrhage (pph). however, oncologic disease, arterio-venous abnormalities, or iatrogenic injuries are less commonly known to be eligible for embolisation procedures. usually, surgical homeostasis attempts or radical hysterectomy is preferred to embolisation procedures. despite the good clinical outcome for hysterectomy and the hazardous success rate of conservative treatment, both are unsatisfactory to patients. pelvic artery embolisation (pae) could dramatically change the patients' clinical issue. the purposes of this lecture are to: revise the pelvic arterial anatomy (possible arterial anastomosis or variation); outline the aetiology of non-obstetric massive menometrorrhagia; expose the typical clinical presenting features; describe the imaging appearances of the etiologies; and discuss patient section, procedure technique, pitfalls and complications. obstetric haemorrhage occurring mainly in the postpartum period is a significant cause of maternal morbidity and death. blood loss of over 500 and 1000 ml after vaginal delivery or caesarean section, respectively, complicates 4% of deliveries. major blood loss of more than 1000 ml occurs following less than 1% of all deliveries. the causes include uterine atony, retained placenta products, placental abnormalities, uterine rupture, lower genital tract laceration, cervical ectopic pregnancy and coagulopathies. generally, treatment is based on administration of uterotonic drugs, vaginal packing, surgical ligation of uterine arteries and even hysterectomy is sometimes needed. transcatheter embolisation of uterine, pudendal, vaginal arteries and ovaries is considered to be superior and should be the first-line treatment for intractable obstetric haemorrhage where interventional radiology is available. angiography reveals extravasation of contrast agent in more than 50% of these patients. the most frequent extravasation is from vaginal artery, and then from pudendal and uterine arteries. depending on the extravasation location and haemodynamic stability of a patient, 5 f catheters or coaxial microcatheter technique is utilised for catheterisation. gelatin foam, microparticles acrylic glue and microcoils are the most frequent embolic agents. the embolisation procedure usually does not require general anaesthesia and can be repeated if bleeding continues. primary success rate in bleeding control is reported from 80 to 90 %. the most commonly reported long-term side effects after embolisation were transient buttock numbness and urinary frequency. the transcatheter pelvic artery embolisation for obstetric intractable bleeding is a fertility-preserving alternative to hysterectomy. medical imaging has nowadays integrated the diagnostic armamentarium of anosmic patients regarding not only qualitative assessment of the olfactory tract, but also quantitative evaluation of olfactory bulb volumes which are known to closely correlate to the olfactory function. many clinical studies on various pathological conditions have evidenced the value of such measurements in the workup of olfactory dysfunction for both aetiologic and prognostic purposes. imaging workup also plays a role in the medico-legal evaluation of post-traumatic anosmia together with electrophysiological and clinical olfactory tests. technical improvements in fibre tracking (ft) using diffusion-tensor imaging (dti) and appropriate designs of olfactory stimulation at bold-based functional mri (fmri) are expected to allow insights into the neurophysiological processes and circuitry of olfaction in the very near future. imaging workup of the anosmic patients will be the cornerstone of this lecture. the relevance of the different imaging techniques will be detailed. beyond the workup of anosmia, a comprehensive overview of the most common lesions of the olfactory tract seen in clinical practice will be given. additional review of lesions observed at the anterior cranial fossa in the near vicinity of the olfactory tract will be done, which comprehensively includes all commonly observed developmental, traumatic, inflammatory and neoplastic conditions not arising from the olfactory tract. their potential impact on the olfactory function or on other sensory/neurological functions will be underlined. clues to clinical/radiological differential diagnoses of the most common conditions and radiological features of the anterior cranial fossa will be highlighted. the central skull base, the floor of the middle cranial fossa, has a complex anatomy and is pierced by a variety of foramina and canals providing crossroads for spread of disease between the extra-cranial head and neck and the intracranial compartment. disease spread into the intracranial compartment indicates a dismal prognosis, as often it becomes inoperable due to involvement of vital structures including cranial nerves, carotid artery and/or brain parenchyma. imaging plays a pivotal role in the assessment of these structures which are not amenable to clinical inspection and can dramatically change the patient's management. in this complex anatomical area, ct and mr have a complementary role in providing a comprehensive roadmap for treatment planning. of major importance is the pterygopalatine fossa, the cavernous sinuses and orbital apex. the former, lying between the pterygoid plates and the maxillary sinus, is a major crossroad between the intra-and extracranial compartments and should be carefully inspected. pathologies affecting the central skull base are varied and may originate from the skull base proper, from the middle cranial fossa or from the extracranial head and neck. by looking at the centre of the lesion, its tissue characteristics and pattern of growth, it is often possible to provide a useful differential diagnosis and, most importantly, to map the lesion's extent. here, we present a radiologist-friendly approach to central skull base pathology highlighting the most important features in the differential diagnosis and treatment planning. 1. the jugular foramen: the jugular foramen is an opening in the skull base. the radiologic evaluation requires high-quality imaging with ct and mr. angiography is reserved for preoperative embolisation. it is important to recognise the "pseudo lesions". the most common tumour of the jugular foramen is the paraganglioma. the second is the schwannoma of the lower cranial nerve, and the jugular foramen meningioma is the third most common. the differential diagnosis shall be discussed. 2. the cerebellopontine angle (cpa) and the internal auditory canal (iac): the iac is a bony conduit for several nerves and a vessel, the neurovascular bundle. the cpa is a cistern of the peripheral cerebral spinal fluid, and several anatomical structures pass through this. it is also the place of some frequent disease processes. most of the lesions in the cpa are benign tumours with order of frequency: vestibular schwannoma and meningioma. the third most common lesion is a benign cystic lesion: the epidermoid cyst. in the iac, you can encounter the same benign tumoural lesion as in the cpa, but also inflammatory lesions, viral lesions and malignant lesions. why is it important in your imaging protocol of the iac and cpa region to use gadolinium? the differential diagnosis of different lesions shall be discussed. learning objectives: 1. to learn about the imaging techniques and anatomy in the posterior cranial fossa. 2. to become familiar with the imaging findings of common posterior cranial fossa pathologies. 3. to learn how to differentiate between the lesions in the posterior cranial fossa. health care is characterised by several specific features making it different from traditional markets. two of the key features are: the impossibility of patients to make choices, due to asymmetry of knowledge between them and their health-care providers; the fact that patients create an agency relationship with health-care providers, delegating to them the decision about the care delivered. due to these characteristics and to the fact that patients are fragile when they need care, there is a natural tendency for patients to rely on healthcare professionals. it is in this complex socio-technical environment that radiographers must be aware of their roles and responsibilities and ensure professional autonomy and accountability; demonstrate an ethical and knowledgeable understanding of the profession; apply professional practice in securing, maintaining or improving health and well-being; develop knowledge, skills and competences that underpin their education and training, contributing to the wellbeing of the patient; understand that professional advancement arises out of evidence-based practice and is acquired through focused research. this demands for a focus on patient care and safety, based on high professional standards. ebp is the best way to achieve this desideratum, as it combines the best research evidence with clinical knowledge and expertise, addressing the patient in a holistic way. since the radiographer is the ultimate interface between patient and technology, it is crucial to create a real teamwork concept, using guidelines for the roles and responsibilities of each team member as the pathway to minimise practice error, maximising patient and staff safety. the use of ionising radiation in medical exposures is well documented across countries. recent studies indicate that a substantial fraction (20 to 50%) of these procedures is unnecessary when taking into consideration patient clinical indication. defensive medicine, economic interest, poor patient clinical information, patient pressure and the lack of knowledge about other alternative procedures, taking into account the benefits and risks, are the principal causes of unnecessary radiological examinations. patients must be referred to a medical imaging department for an examination that should be justified according to clinically appropriate image criteria and informed of the potential benefits and risks. following justification, the optimisation of practice is essential to ensure the minimal exposure of radiation dose to the patient whilst diagnostic efficacy is maintained. the principal aim of optimisation is getting a narrower dose distribution, with lower mean and 75 th percentile values of the diagnostic reference level. optimisation processes need to consider several factors including the type of examinations, body region, clinical information, available equipment technology and image processing tools. to implement this process, a multidisciplinary teamwork is essential where radiographers, being the pivot between patient and technology, have an essential role. to understand and apply optimisation procedures, radiographers should be aware of the international guidelines, standards and directives. all medical imaging procedures must be audited to analyse if the workflow processes (referral, justification, optimisation and radiation protection principles) are according to the recommendations to create a radiation protection safety culture. although we are approaching the year 2014, a lot of clinical radiography is not based on best evidence. lot of clinical decision-making is based on, for example, traditional practices that we cannot argue as being the best possible ones. in this presentation, barriers to using research and other sources of evidence and facilitators of evidence-based (eb) radiography are described. the role radiographers have in developing eb guidelines and procedures may vary according to educational level and work description. developing eb guidelines is not the work of every radiographer, but obeying them is. the speaker gives some suggestions on what to do in a situation if there are no eb guidelines and procedures in ones' country or institution and no group that develops them. with the framework of "the new work order" and increasing implementation of new work processes, professionals are faced with new modes of collaboration requiring communicative skills as well as multiprofessional competencies between all the stakeholders across the hospital. some evidence about the consequences of ineffective communication in the field of radiography is presented. in addition to benefits associated with the procedure of clinical audit, uniform good quality protocols for examinations and uniform national/international criteria help to perform comparisons between radiology units. clinical audit also works as an educational tool and as a feedback tool for the staff on their performance. it also points out the need for corrective actions. initiatives from professional organisations are probably the most powerful engines for the construction of europe, and in many cases open the road for legal and political advances. many medical specialties felt that there was a need for the harmonisation and standardisation of medical training over europe. the esr has shared this opinion and has elaborated a unanimously appreciated training curriculum, which is constantly updated. establishing the ebr (european board of radiology), with the mission to organise a european diploma was the logical next step. today, 10 examinations have already been organised and more that 350 candidates from european countries and abroad have applied. the trainee who passes the examination proves his professional skills and has reached the objectives assigned in the curriculum. in this session, we will explain how esr organises the diploma. we will review, capitalising on our current experience, the main lessons learnt from the past editions, the keys for success and reasons for failure, as seen by the examiners. we will also learn about the "diploma adventure", from the point of view of a successful candidate. national radiology training programmes in europe differ to a large extent, regarding length of training, content, and the presence or absence of a national board examination for certification. thus, for cross-border radiologic activities, the level of training and expertise applying to radiologists is difficult to assess under these circumstances. there is an increasing number of medical subspecialties, which organise european diplomas. more than 20 subspecialties (e.g. anaesthesiology, ophthalmology, urology, etc). organise european examinations, which are well received among the respective communities. growing numbers of residents in training successfully stand this test of knowledge and practical skills. recognition of european diplomas by national authorities is an issue, which will increase the level of acceptance. the present status of the recognition process in european countries will be summarised. case material for the diploma will test knowledge in general radiology at a standard to be expected at the end of training as outlined in the esr curriculum. all ten esr-recognised subspecialty areas of the curriculum will be tested. the written exam comprises two computer-based sections, a multiple response section, and a short case section. there will be 75 multiple response questions. these questions comprise both multiple options format, a single stem with 5 answer options, and short imaging studies where candidates are asked to either annotate the image from a drop-down menu, or select the radiological features displayed or differential diagnosis from the options given. a special scoring system has been developed to prevent guessing. the short case section comprises 4 or 5 case-based questions. you may practice using the self-assessment tests on the esr website which follow the same format as the written examination. for the oral cases, you must have a systematic method and perform under pressure, which takes practice. you may rehearse with experienced radiologists who feedback on your performance. you can break a radiology report into 3 areas, observations, interpretation and conclusion. conclusions should take into account the clinical information. candidates often forget this under pressure, so ask for it to be repeated. your differential diagnosis should be logical and comprehensive. the 3 commonest causes of an abnormality is a good topic to revise. suggest if further imaging tests are indicated and give an indication of urgency. each case is marked separately. as a well-known statement in the academic world of education, "assessment drives learning". with the help of carefully prepared and performed examinations, it is possible to emphasise and instill the training curriculum. due to different reasons, training of radiology in european countries is highly varied. like in our experience in turkey, a central examination system, accompanied by a neatly prepared training charter and curriculum, is a good starting point to solve the problem. we believe that a common european assessment system like edir will contribute a great deal to the harmonisation of radiological training and establishment of quality standard in every country. the need for harmonising the training is not unique to radiology. this is why in more than 30 medical disciplines, european diploma examinations are now being organised. furthermore, in some disciplines like urology, annual and online "in-service assessment" of residents and practising urologists allows the participants to evaluate their current knowledge base against the current european standards, and also provides the trainers and directors knowledge about the teaching and learning process in education centres. although there are huge diversities among different european centres, the urgent need of harmonising radiology training and setting a standard of quality are felt by all radiologists in europe. establishing and institutionalising a common assessment system in european radiology appears to be the shortest way to reach this goal. this is why we should support "european diploma in radiology" by any means and work hard to promote its recognition throughout the continent. the majority of emergency ct studies reported by junior radiologists or general radiologists out-of-hours comprise brain scans. brain ct studies are often performed to detect acute life-threatening abnormalities, such as stroke, intraparenchymal or subarachnoid haemorrhage, cerebral edema, etc. misrecognition of these often subtle, but life-threatening abnormalities can lead to inappropriate patient management and worsen patient outcome. errors in interpretation can generally be categorised as either perceptual or cognitive in nature. perceptual errors are those in which the radiologist does not see the abnormality, resulting in a false-negative interpretation (e.g. basilar artery thrombosis, deep cerebral venous thrombosis, pres,â�¦). cognitive errors, on the other hand, are those in which an abnormality is identified but the meaning or significance of the abnormality is not recognised. cognitive errors can result in false-positive interpretation if, for example, a normal anatomic variant is mistaken for a pathologic condition. while the more common normal variants and artefacts often do not present a problem to experienced clinicians and neuroradiologists, less experienced individuals should beware of these diagnostic hazards. to reduce false-negative and false-positive reporting, a checklist of the review areas (blind spots) to be verified on any brain ct scan will be offered and the most frequent normal variants will be discussed. pitfalls in brain imaging comprise perceptual or cognitive errors of interpretation of imaging findings. errors of perception refer to a missing of a pathology that is present on an image, while cognitive errors consist of a wrong interpretation of a seen structure or pathology. interpretation may be false negative or false positive. in addition, a wrong conclusion may be drawn resulting from missing, incomplete or false clinical information, or as a consequence of a lack of knowledge of differential diagnoses. perception errors are frequently the consequence of incomplete examination protocols where lesions are missed (for instance, acute ischaemic changes without the use of diffusion-weighted imaging) or signals, for instance, flow-related phenomena are misinterpreted. asymmetric positioning of the patient`s head may also lead to misinterpretation of side differences, especially in the temporal lobe. another source of perception errors might be reduced attention (especially at night shifts) and have been proved to occur in regions that are "potential blind spots", as the sulci, cavernous sinus, meckel cave, dural sinuses, brainstem, and skull base foramina. perceptual errors may be avoided by following a checklist when reading images. all sequences should be used for comparison of signal intensities to distinguish artefacts from pathology. another very important fact to avoid misinterpretation lies in a profound knowledge of morphologic and metabolic age-related changes of the brain and of anatomical normal variants (such as, for instance, accentuated virchow robin spaces in certain locations). cystic liver lesions can be classified based on their nature as benign and malignant. in the benign category are, among others, developmental and infectious/inflammatory cysts, while neoplastic cyst can be subdivided into primary and secondary. developmental cysts originate from abnormal ductal plate malformation and consist of hepatic (bile duct) cyst, bile duct hamartomas, caroli's disease and polycystic liver disease. infectious/inflammatory cysts include, among others, abscesses (pyogenic and amoebic) and hydatid cysts. primitive neoplastic cystic lesions are cystoadenoma and cystoadenocarcinoma. secondary lesions can originate mostly from mucinous tumours such as colon and ovary. the role of crosssectional imaging in the detection and characterisation of these entities will be discussed, with an emphasis on the differential diagnosis with ct and mr imaging. benign hepatocellular neoplasms are being recognised with increased frequency using cross-sectional imaging. one of the main goals is to be able to make a clear-cut differential diagnosis between focal nodular hyperplasia (fnh) and hepatocellular adenoma (hca) since patient management is substantially different. despite the sound knowledge acquired in the last few years about the morphological features of fnh using various cross-sectional imaging techniques, new players in the field have arisen such as diffusionweighted mr imaging (dwi) and use of hepatobiliary contrast agents. these new biomarkers offer a different view over fnh and allow a more accurate characterisation even in more atypical cases. concerning hca, current knowledge implies that the sub-types of this neoplasm should be known since, again, patient management differs and these patients are no longer seen as compulsory surgical candidates. these sub-types will be further discussed and the role of imaging for risk stratification (haemorrhage and malignant transformation) will be addressed. further, illustrative cases of combined fnh/hca cases will be demonstrated along with the main imaging clues for a successful differential diagnosis. imaging in the early postoperative period is complex. it is essential for radiologists to know the new anatomic arrangement after surgery and to understand the range of normal postoperative appearances. this latter aspect can be particularly difficult, because the radiological findings are affected by the type of operation performed (open vs. laparoscopic) and the complexity of the surgery (such as the presence of adhesions or haemorrhage) as well as the underlying comorbidity of the patient. patients may be considered in 4 broad categories: haemodynamically unstable patients who may be bleeding; patients with distension or unopened bowels who may have obstruction or ileus; patients with sepsis in whom to search for an intraabdominal collection or leak; and patients who do not follow an expected recovery for which the cause is unclear. ct is the primary imaging technique, with ultrasound reserved predominantly for liver and renal transplants or assessment of perihepatic collections, and fluoroscopy for routine postoperative assessment of upper and lower gi anastomoses. ct protocols should be optimised to detect particular complications with positive luminal contrast for assessment of anastomotic leaks (8%), triple phase imaging for bleeding (without positive oral contrast) and delayed phase imaging to detect ureteric injury. since each operation has a specific range of expected complications, these should be considered when deciding on the protocol and in light of the patient's clinical status. excellent communication with the surgical team is required to make an accurate diagnosis and in particular where haemostatic compound or mesh for hernia repair was used. learning objectives: 1. to understand the best imaging options for investigating suspected postoperative complications. 2. to appreciate the normal appearances of the abdomen and pelvis after surgery, in particular with regard to free fluid, haematoma and free gas, and when to suspect complications. radiologists should be aware of the newer surgical techniques and expected post-operative alterations, to yield a correct interpretation of a post-surgery imaging examination, thus being able to differentiate a normal post-operative finding from a potential complication. in this setting, it is crucial to perform a technically adequate imaging examination, so that post-operative anatomical and functional findings may be evaluated. therefore, the aim of this lecture is to give an overview of the contribution of various imaging modalities in the diagnosis of late post-operative complications following gi tract surgery. it will include a mention of the technical issues that need to be considered to achieve better diagnostic accuracy, as well as a description and illustration of the main imaging findings of late post-operative complications. those include diseaserelated (recurrence for malignancy or inflammatory disease) and procedurerelated (anastomotic strictures, internal herniation, adhesions and intussusception, among others) complications. focus will be placed on crosssectional imaging techniques, which at present constitute the workhorse for detecting and characterising late post-operative complications after gi tract surgery. in this way, imaging has an obvious and pivotal role in planning therapy, since some late complications are usually treated in a conservative way while others require a surgical approach. lung biopsy of a suspected lung cancer remains a well-established technique for histopathologic examination in patients with suspected lung cancer. complications can nevertheless occur and therefore indication should be given after carefully balancing the benefits and drawbacks for a particular patient. the method should be clearly considered complementary to alternate methods of tissue sampling, fiberoptic endoscopic, mediastinoscopy or us-guided endoscopy, surgical biopsies and resection during a multidisciplinary discussion. several steps are needed in the preparation of the biopsy procedure, including informed consent, management of anticoagulation and anti-platelet medications, imaging assessment of the lesion and its environmental lung, and planing of the needle trajectory procedure. the choice of the guiding method and the most appropriate biopsy needle is still largely dependent on local skills and habits. ct-guided percutaneous biopsies using coaxial automated core biopsy needles offer many advantages. needle manipulation can help to reach difficult targets. participation of the patient is needed in terms of respiratory manoeuvres and breathhold. complications may occur such as pneumothoraces haemorrhage and air embolism. knowledge of the respective risk factors and the potential method of prevention or treatment by operators are essential. the therapeutic response of lung cancer can be objectively evaluated on the basis of changes in the tumoural size or depiction of metastases, such proposed in the recist criteria (response evaluation criteria in solid tumours). recent advances in cancer biology have triggered development of novel targeted therapies designed to disrupt specific biologic pathways. among them, antiangiogenic drugs represent a promising strategy for non-small cell lung carcinomas (nsclc). these agents are more cytostatic rather than cytotoxic, explaining the limitations of tumour response assessment based on morphological criteria. dynamic contrast-enhanced imaging techniques have the potential to quantify tumoural angiogenesis. in particular, dynamic contrastenhanced multidetector-row ct (dce-ct) represents a promising tool to provide non-invasive and repeatable assessment of the angiogenic process within non-small cell lung cancers (nsclc), offering the possibility to generate morphological and functional information from the same examination. dce-ct allows the calculation of regional tumour blood flow, blood volume, flowextraction product, and permeability-surface area product, over the entire tumoural volume, using mathematical models and dedicated softwares. dce-ct can depict early changes in lung cancer vascularity, before tumour shrinkage, that could help predict response to antiangiogenic drugs. becoming familiar with this technique enables the radiologist to integrate it into clinical practice and to assist the thoracic oncologist in the pre-therapeutic and follow-up evaluation of nsclc patients treated by antiangiogenic drugs. this new approach should improve patient's selection for targeted therapies. a-343 09:30 it is now accepted that pet-ct is of value in the staging of lung cancer and reduces the number of unnecessary thoracotomies. its role has been further clarified by recent publications on its value in assessing mediastinal nodal involvement, tumour aggressiveness using either standardised uptake value or total glycolytic volume, and response to neoadjuvant chemotherapy. more recently, mri has been investigated as a tool to detect distant disease using diffusion-weighted imaging, and there are a number of trials that have compared both pet-ct and dwi mri retrospectively and prospectively. this presentation will summarise the current available data and the likely benefits of either imaging modality neurological deficits in children are an urgent condition that depends significantly on imaging for a prompt and accurate diagnosis because of the significant overlap present in clinical history, presentation and neurological examination. different imaging modalities, such as ultrasound, computed tomography (ct) or magnetic resonance imaging (mri), are utilised dependent on the age of the patient and neurological symptoms. the purpose of the present lecture is to discuss the causes and imaging appearance of acute neurological conditions in childhood, broadly classified into stroke, infection, inflammatory demyelination, metabolic disorder, cerebral neoplasm or neurotoxicity. imaging also plays an outstanding role in the management of paediatric oncology patients presenting with acute neurological symptoms related to disorders of blood cell counts, immunosuppression, neurotoxicity of therapy, or progression of the primary malignancy. a review of the main indications to perform a neuroimaging procedure in these children will be undertaken as well as a differential diagnosis based on representative cases selected from the daily routine in a paediatric tertiary hospital. practical algorithms with the preferential use of either ct or mri will be developed for each section. ct continues to be the first imaging modality in these patients in many centres, despite the accompanying radiation, because of the easy availability and no requirement of sedation. however, mr imaging is nowadays better for imaging these children owing to no radiation, the more completely provided information and the useful advanced techniques that can be used, such as diffusion imaging (di), spectroscopy, arterial spin labelling (asl), and susceptibility weighted imaging (swi). learning objectives: 1. to learn about the currently limited role of ct in the non-traumatic acute setting. 2. to become familiar with radioprotection strategies and protocols adapted to children. 3. to consolidate knowledge on the role of mri as the modality of choice for acute non-traumatic neurologically ill children, with an emphasis on newer techniques. 4. to become familiar with imaging findings and the main differential diagnosis of acute neurological conditions in children. b. imaging of acute chest pain and distress in children c.e. de lange; oslo/no (clange@ous-hf.no) acute chest pain in children is a common complaint in the emergency department, but patients rarely present with significant distress or lifethreatening symptoms requiring immediate care or resuscitation. the most frequently reported cause is benign musculoskeletal pain followed by respiratory and gastrointestinal causes, while cardiac causes are less frequent. a thorough clinical history and careful physical examination will determine, in most cases, the patients in need of further investigation to establish a diagnosis. in this regard, radiology plays an important role, especially in the emergency setting in patients with more serious associated symptoms like acute breathing difficulties, swallowing problems, fever or sepsis. when choosing the appropriate technique for investigation, the consequences of radiation exposure in children must be considered. plain radiography and fluoroscopy still remain the most important and frequently used tools to gain information on various acute chest/pulmonary problems. ultrasonography is the first choice for diagnosis/treatment of pleural effusions. multidetector computed tomography and magnetic resonance imaging are mainly used for investigating pulmonary/mediastinal masses and congenital abnormalities of the great vessels and the lungs. this lecture will discuss the choice of imaging technique and the urgency of radiological management depending on the symptoms and age of the patient. the imaging characteristics of the different causes of acute chest pain and/or distress in children will be reviewed, represented by the more common conditions involving the chest wall, respiratory tract, oesophagus and the heart, as well as less frequent causes such as tumours, manifestations of congenital malformations and nonaccidental trauma. outcome data from trauma series have demonstrated improved patient survival by the prompt diagnosis of a range of injuries and the recognition of life-threatening sequels, principally that of active arterial haemorrhage. widely used trauma scoring systems are applicable in the paediatric population, although the mechanisms and combination of injuries may differ from those encountered in adults. a ct diagnosis of active haemorrhage demands early operative or non-operative intervention with embolisation or use of alternative endovascular techniques including deployment of vascular stents. this principle is applicable to blunt or penetrating liver, splenic, renal or pelvic trauma. it is also applicable in some cases to severe mediastinal and limb vascular injury. important caveats are firstly the use of ct in an overall trauma service and avoidance of any inappropriate irradiation. secondly, in paediatric interventional practice, due regard needs to be given to the delivery of implantable devices that may have adverse sequels in later life. nevertheless, the demand for immediacy in intervention may outweigh any such consideration. this presentation will summarise the importance of imaging and intervention in both the early and delayed complications of trauma with an emphasis on abdominal and thoracic trauma. brachial plexus originates from the ventral branches of the cervical nerve roots from c5 to t1. it is composed of roots, trunks, divisions, cords, and branches, topographically divided into supraclavicular (roots and trunks), retroclavicular (divisions), and infraclavicular sections (cords and branches). mri has the advantages of multiplanar imaging, high tissue contrast, and relative paucity of artefacts. the t1-weighted sequences display topographic anatomy including muscles, blood vessels, and nerves stressed by tissue fat planes. the nerves appear as elongated fibres that are isointense to the scalene muscle, posteriorly and superiorly to the curvilinear flow void of the subclavian artery. the fat-suppressed pd and t2-weighted and stir sequences detect signal alterations of the bp. general abnormal findings include: loss of fat planes around part or all bp components, nerve signal abnormalities with mild or marked hyperintensity on t2-weighted images that can be associated with swelling, focal or extensive enhancement of the nerves after gad injection on t1 fat sat images. differences in signal intensity should be judged by visual inspection, which is susceptible to a subjective point of view; the comparison of both sides of bp has a relevant role in judging the presence of signal alterations, especially when they are smooth and/or focal. the pathology of brachial plexus can be divided into nontraumatic and traumatic brachial plexopathies. among nontraumatic brachial plexopathies, we find radiation fibrosis, metastatic breast cancer and primary or metastatic lung cancer. other pathologies are tumours and inflammatory disease or thoracic outlet disease. the peripheral nerves of the upper limb are affected by a number of entrapment and compression neuropathies. these syndromes involve the brachial plexus as well the musculocutaneous, axillary, subscapular, ulnar, radial and median nerves. clinical examination and electrophysiological studies are traditionally the mainstay of diagnostic workup. however, ultrasonography and magnetic resonance imaging (mri) may provide key information about the exact anatomic location of the lesion or may help to narrow the differential diagnosis. in certain patients with the diagnosis of a peripheral neuropathy, imaging using either ultrasonography or mri may help establish the cause of the condition and provide information crucial for conservative management or surgical planning. in addition, imaging is particularly valuable in complex cases with discrepant nerve function test results. a variety of peripheral neuropathies can be encountered in the lower limb. most are entrapment syndromes affecting many nerves, such as the sciatic, gluteal, femoral, lateral femoral cutaneous, obturator and pudendal around the hip, the peroneal and its branches and the saphenous at the knee, the superficial peroneal at the lateral leg, the tibial with its plantar and calcaneal branches at the ankle, the deep peroneal and the interdigital nerves in the foot. although clinical examination and nerve conduction studies are the mainstay of the diagnostic workup of peripheral neuropathies, ultrasound (us) and magnetic resonance (mr) imaging may provide key information about the exact anatomic location of a lesion and the nature of the constricting finding or may help narrow the differential diagnosis. in patients with peripheral neuropathies of the lower extremity, us and mr imaging may provide critical information for planning an adequate treatment strategy. although us and mr imaging have followed parallel paths for nerve imaging with little comparison of the two modalities, us seems to have some advantages over mr imaging, including higher spatial resolution, time effectiveness, the ability to explore long nerve segments in a single study and to examine tissues in both static and dynamic states. advances in diagnosis of acute stroke have been achieved by brain imaging. ct or mri distinguish ischaemia from haemorrhage and may identify acute clot (dense artery sign) or vessel wall pathology by "black blood mri". dwi provides evidence of early infarction. ct and mra enable identification of large vessel pathology as potential source of embolic or haemodynamic ischaemia. supplementary techniques are ct or mr perfusion. on mri perfusion, a mismatch between the area of restricted diffusion and perfusion (pwi) is a signature of the penumbra. the tissue of pwi restriction outside of the dwi abnormality represents "tissue at risk". similarly on ct perfusion, the region of reduced cerebral blood volume presumably represents irreversible infarction and the area of reduced cbf and extended mtt visible beyond the cerebral blood volume abnormality represents potentially reversible ischaemia. morphologic imaging and advanced standardised perfusion/penumbral stroke protocols aim at identifying lesions that are amenable to acute stroke therapy and exclude pathologies that mimic stroke but do not represent vascular disease. since iv tpa has become an approved therapy from 1996, the number of acute stroke patients entitled for treatment has remained limited (~ 5) despite extension of the time frame from 3 to 4.5 h. dwi-flair mismatch and an individualised assessment of the ischaemic penumbra may serve in the identification of patients within the appropriate time frame. by selection of patients with advanced brain imaging and initiation of appropriate therapy, a further increase in good outcomes and reduction of the incidence of symptomatic haemorrhage may be achieved. in recent years, the role of imaging in the patient admitted with an acute neurologic deficit has changed significantly, due to the arrival of new treatments for acute stroke, aimed at re-establishing blood flow, reducing infarct size and protecting the brain at risk. the first goal is to differentiate haemorrhagic from ischaemic stroke and to rule out other stroke mimics. this can be achieved by performing nonenhanced ct scan of the brain. the next strategic imaging objectives include: demonstration of major blood vessel occlusion (e.g. by ct angiography) and identification of potentially salvageable brain tissue, the so-called "penumbra" (e.g. by ct perfusion). ct angiography is performed during rapid intravenous bolus injection of a high-concentration iodinated contrast agent. the fov should cover not only the intracranial arterial circulation, but also the arteries of the neck, to exclude dissection. ct perfusion is also achieved by bolus injection of contrast, followed by a series of fast images or volume acquisition. ct densities change over time and reflect the iodine concentration. perfusion images are processed to generate parametric maps, which reflect: regional cerebral blood flow (rcbf), blood volume (rcbv), mean transit time (mtt), and time to peak (ttp).the combination of ct angiography and ct perfusion provides a unique insight into the pathophysiology of the cerebral circulation. these techniques are now essential tools in the management of acute stroke and in selecting those patients who are potential candidates for advanced therapies such as thrombolysis or thrombectomy. learning objectives: 1. to become familiar with a comprehensive imaging protocol in patients with suspected stroke. 2. to understand the advantages and limitations of cta and perfusion in the initial work-up of stroke patients. 3. to recognise the different imaging patterns in stroke and their prognostic value. a-352 08:58 b. stroke mimickers and pitfalls p. vilela; lisbon/pt (ferrovilela@sapo.pt) "stroke mimic" is classically used to describe nonvascular diseases that present with acute focal neurologic deficit corresponding to a consistent vascular distribution, which may resemble or may even be indistinguishable from stoke. it is estimated that up to 15% of stroke-like presentations are due to mimickers. there are several neurological and psychiatric disorders that can have such a clinical presentation, such as seizures and/or postictal status, the most frequent one. the other classical clinical stroke mimickers include: multiple sclerosis, migraine (specially hemiplegic migraine), metabolic disturbances (more commonly hypoglycaemia/hyperglycaemia), intracranial tumours or infections and the conversion reactions. brain imaging plays a key role in the diagnosis and management of acute stroke by differentiating ischaemic from haemorrhagic lesions, identifying the vessel occluded and estimating the viable brain tissue that is at risk for stroke. imaging is also important to exclude some of the aforementioned stroke mimics. the more comprehensive stroke imaging protocols, with ct perfusion/angiography and/or with mri, have reduced significantly the misdiagnosis of stroke. mri-dwi is the most sensitive and specific imaging modality for depicting ischaemic stroke. however, it is also essential to be aware that there are some pathological processes that can mimic stroke in imaging studies. these include some disorders that may present themselves with lesions associated with restricted diffusion, like transitory postictal brain abnormalities, migraine and encephalitis. the author reviews the most common clinical and imaging stroke mimics and highlights the importance of brain imaging in depicting these mimickers and avoiding the potential adverse effects of stroke therapy in these patients. learning objectives: 1. to learn the differential diagnosis of stroke. 2. to understand the role of ct and mri in the work-up of stroke and related disorders. 3. to recognise imaging patterns that may mimic stroke clinically and radiologically. imaging plays a central role in the management of stroke, which is an important health issue according to the number of patients involved and the severity of the disease. it helps to select patients who will benefit from a revascularisation therapy (iv thrombolysis or endovascular treatment) at the acute phase of stroke. if the value of perfusion/diffusion mri mismatch in the evaluation of penumbra is still a matter of debate, other imaging factors are associated with the clinical outcome including length of clot, flair positivity, and collateral circulation. if iv thrombolysis using rtpa is still the reference treatment, endovascular treatment is emerging since several years as a feasible and efficacious alternative singularly since the appearance of stent retrievers. recent neutral randomised trials comparing iv thrombolysis and endovascular treatment have shown the critical role of appropriate imaging in the selection of patients who can benefit from acute revascularisation as well as the importance of using the most efficacious endovascular devices. prevention of stroke is partially based on the treatment of cervical and intracranial stenosis. several randomised trials comparing carotid angioplasty and carotid endarterectomy were initially negative, but a recent meta-analysis showed that below the age of 70 years both techniques were equivalent. the place and value of endovascular treatment of intracranial arterial stenosis is still controversial after the publication of the sammpris results. the management of thyroid nodules has been continuously evolving. i hope that during this session you will understand the important differences in the upto-date national and international guidelines on thyroid nodule management and understand the role of the radiologist in the multidisciplinary thyroid meetings. the features that are suggestive of benign, indeterminate and malignant nodules will be demonstrated. advances in both radiological and cytological techniques such as us elastography and braf mutation analysis that may help triage patients with thyroid nodules will be covered. the differing biopsy techniques (fine needle aspiration, non-aspiration (fna and fnnac) and trucut biopsy) and their roles will be highlighted. there will be time for an open question and answer discussion with all the speakers before the end of the session. the management of thyroid nodules and the guidelines of the various interested parties, surgeons, endocrinologists, nuclear medicine physicians, radiologists and ultrasound specialists, vary across the world, indeed between different countries within the eu, and are constantly evolving. i will discuss how the thyroid multidisciplinary meeting (mdt) works at our institution and the role of the radiologist in it. the current differing international guidelines on the management of thyroid nodules will be mentioned, highlighting their salient points and differences. the role of the differing imaging modalities used in the management of thyroid nodules will be discussed based on differing clinical scenarios. finally, the management of the common clinical scenario of the incidental thyroid nodule will also be discussed. learning objectives: 1. to understand the role of the radiologist as part of a multidisciplinary team. 2. to learn about current guidelines on the management of the thyroid nodule. 3. to understand the role of various imaging modalities in the patient with thyroid nodule. thyroid disease is ubiquitous and usually benign; therefore accurate imaging of the thyroid is a major challenge for radiology. significant advances in conventional ultrasonography allow superb visualisation and anatomic characterisation of thyroid pathology and the impact of broader bandwidths, higher frequencies, spatial compound imaging and novel signal processing techniques will be discussed in this session. the key b mode features of thyroid nodules are discussed with reference to relevant clinicoradiological guidelines, specific pitfalls and limitations. a significant number of nodules remain indeterminate after conventional assessment, and imaging advances that enable more accurate, non-invasive thyroid characterisation are highly attractive, potentially reducing unnecessary biopsy and surgery for a large number of patients. ultrasound elastography offers a potentially useful adjunct to conventional sonography in thyroid disease with a growing evidence base indicating that thyroid malignancies are typically stiffer than benign lesions and that a 'soft' cutoff value with a high negative predictive value is feasible. however, elastography studies have included a variety of different techniques, patient/nodule selection and assessment methods; therefore the current role of elastography will be discussed. fine needle biopsy of the thyroid nodule f. campoy-balbontã­n, m.c. jurado-gomez; sevilla/es (fcampoy2000@gmail.com) thyroid nodules are very common. the clinical importance of thyroid nodules rests with the need to exclude thyroid cancer, which occurs in 5-15%. ultrasound (us) has been widely attempted to differentiate benign from malignant nodules and to guide fine needle biopsy (fnb). however, considerable overlap between benign and malignant characteristics has been found. nowadays, there are a number of different guidelines for the management of thyroid nodules. at our hospital, we have adopted the guideline proposed by the society of radiologist in ultrasound (2005). the different elements necessary to perform the fnb procedure are demonstrated; the transducer probe, the needles, the slides, the syringe. the way of managing these elements is shown by figures and videos, with different skills and performances to optimise the procedure and get the best sample. uscontrol fnb can be in parallel or perpendicular, both methods are demonstrated. thyroid fnb is usually non-aspirated, but sometimes it has to be undertaken with aspiration; when and how to change from one method to another is explained. with good technique, the insufficient cytological rate can be significantly reduced, with which the need for core biopsy diminishes. although the complication rate for core biopsy is low, fnb is safer and if performed correctly has a high diagnostic yield. core biopsy should be limited to those nodules with a second insufficient fnb cytological result, with us findings suspicious for malignancy. multimodality breast imaging is emerging as radiologists have access to new technologies coinciding with the refinement of operative techniques. one of the challenges for radiologist remains the correct preoperative staging, especially the metastatic involvement of axillary lymph nodes. multimodality imaging has new accurate solutions. the imaging follow-up of patients with sophisticated oncoplastic techniques is another challenge where multimodality breast imaging is the solution. coincident with this increasing contribution to the diagnostic process is the emerging role of the breast imager as a therapeutic clinician, making use of innovative image-guided procedures. in this integrated rc, experts will present a clinical update on these newer techniques and there will be an opportunity to discuss how the evolution of such techniques is changing the nature of the modern multidisciplinary team meeting. a. conventional, functional and interventional lymph node assessment r.m. pijnappel; utrecht/nl (r.m.pijnappel@umcutrecht.nl) metastatic involvement of axillary lymph nodes has been known to be one of the most important prognostic factors for women with breast cancer. the traditional approach to staging the axilla is either lymph node sampling procedures or sentinel node biopsy. the main diagnostic features of potentially malignant involvement of the axilla are abnormal lymph node morphology (shape and cortical thickness). there has been a concerted effort in recent years to find imaging techniques that might facilitate accurate axillary staging. so far, no imaging technique alone (ct, mri, scintigraphy and ultrasound) has been capable of differentiating between positive and negative lymph nodes of the axilla in breast cancer. recent techniques like gadofosveset-enhanced magnetic resonance imaging and high spatial resolution 7-t mri imaging appear promising; however ultrasound-guided sampling of suspicious lymph nodes by core or fna remains the standard of care in assessing the axilla prior to treatment planning. ultrasound-guided axillary lymph node sampling is an effective method of assessing the axilla. a recent meta-analysis shows that ultrasound can be expected to achieve sensitivity approaching 50% for detecting abnormal nodes in those that eventually prove to be nodal metastatic disease. the false-negative rate where biopsy is performed is around 25%. it is impossible to detect the sentinel node by ultrasound alone. therefore a new promising technique was introduced, injecting an ultrasound-contrast agent around the nipple. using this method, it is possible to detect the sentinel node in 90% and therefore lower the false-negative rate of us-guided biopsy with another 15%. oncoplastic breast procedures were introduced to fill the gap between comprehensive oncologic surgical treatment of breast cancer and the achievement of cosmetic results that fulfill patient expectations in both, body imaging and psychological well-being. due to its complexity and relevance for the patient, the decision of performing these procedures must be made as part of the multidisciplinary approach of breast cancer treatment. as a consequence, the role of breast radiologists has expanded beyond the anatomic region of the breast and the usual imaging techniques. basic knowledge of the different oncoplastic techniques is mandatory to understand the spectrum of findings from a multi-modality approach. implants and/or autologous reconstruction techniques (pedicle, free or perforator flaps, as well as lipofilling techniques) are widely applied. the role of the radiologist in the multidisciplinary team is twofold: assessment during the planning stage, and imaging evaluation at follow-up. the assessment during the planning stage includes the determination of the local extent of the disease that makes the choice of the appropriate surgical technique possible, and the imaging study of the donor site in those cases where autologous reconstruction is elected. imaging evaluation at follow-up comprises the recognition of changes and potential pitfalls after reconstruction, the identification of short/mid/long-term reconstruction complications, and the detection of recurrent/second carcinomas. controversial aspects will be reviewed, such as the probability of recurrence after oncoplastic surgery, the need to establish multimodality follow-up protocols and the interrelations between the autologous tissues and the mastectomy bed or remaining breast. the use of image guidance for surgical planning has only recently been accepted. the use of intraoperative ultrasound in women undergoing lumpectomy is associated with a higher rate of negative margins. the combination of image guidance and radiological intervention techniques also harbours the possibility of tumour treatment without surgery. most techniques make use of the placement of needles within the tumour. treatment is performed by heating, freezing or extracting the tumour tissue. currently, radiofrequency ablation under ultrasound guidance is being furthest evaluated. however, in rfa even after optical complete tumour ablation, residual vital tumour tissue is still found in many cases. this is mainly dependent on tumour size with poorer results (50-60% success rates) in tumour over 2 cm, and better results (~90% success rate) in smaller tumours. adequate tumour size estimation is thus of vital importance. currently, since remaining vital cells cannot be excluded, the technique is limited to use in patients who cannot undergo surgery due to poor health state. larger series in which rfa is combined with radiotherapy have not been reported. it is therefore not clear whether it is important to actually excise residual vital tumour. similar restrictions currently hold for cryotherapy, laser ablation and hifu. large vacuum-assisted needles and the breast lesion excision system can be used to remove the tumour through a minimal incision in the skin. however, margin evaluation is difficult. nevertheless, these techniques are already optional for the removal of high-risk lesions and can potentially be combined with (focused) radiotherapy. the mã¼llerian ducts are paired embryologic structures that undergo fusion and resorption between the 6 th -11 th weeks of gestation to give rise to the uterus, fallopian tubes, cervix, and upper two-thirds of the vagina. non-development, defective vertical or lateral fusion, or resorption failure of the mã¼llerian ducts can result in formation of mã¼llerian duct anomalies (mdas), whose reported prevalence ranges between 0.4% and 8%-10%. the classification revised by the american society for reproductive medicine in 1988 is the most widely accepted. obstructive mda can occur in infants as palpable pelvic mass, at menarche with cyclic pelvic pain, or pelvic mass, and primary amenorrhea. complications include hematocolpos, hematometra, hematosalpinx, endometriosis, pelvic adhesions, and obstruction of urinary tract. mdas are commonly associated with renal and other anomalies; thus, identification of both kidneys is important. accurate diagnosis of an mda is essential because of the high associated risk of infertility, endometriosis and miscarriage, and since the management approach varies depending on the type of malformation. hysterosalpingography (hsg) is routinely used in evaluation of infertility. because a key component of mdas characterisation is the external uterine fundal contour, hsg is limited for this purpose. ultrasonography (us) is initially performed to evaluate uterine anatomy and to assess for associated renal abnormalities. mri is reserved for complex or indeterminate cases to characterise the uterine anomaly and evaluate the possibility of a vaginal abnormality, or after a seemingly normal us when clinical opinion ensures its use, or to make decisions on management strategies and preoperative planning. this refresher course will focus on the radiologist's approach to using pet-ct within the context of the gynaecologic oncology multidisciplinary meeting. the current indications for using fdg-pet/ct will be discussed for cervix, endometrial and ovarian cancer as well as the potential use of fdg-pet/ct in rare gynaecologic cancers. the value of adding fdg-pet/ct to the patient management pathway will be presented alongside the potential pitfalls in interpretation as well as controversies. future developments, including potential new tracers, will be mentioned. cystic lesions account for the vast majority of ovarian masses and are detected incidentally in 5-18%. their spectrum ranges from non-neoplastic cysts to benign tumours, e.g. cystadenomas and dermoids to the rare ovarian cancer. diagnostic criteria in us, ct and mri are based on the clinical background (age, menopausal status, medical history, and tumour markers) and the morphology of the ovarian mass. typical of a benign cystic lesion is its pure cystic structure or thin septations, fatty or haemorrhagic contents, and mild enhancement of solid components in a complex solid and cystic ovarian mass. thus, patients can be categorised into 3 different risk groups. sonography has been established as the first-line imaging modality to assess the ovaries. recently, management guidelines have been adopted for cystic ovarian lesions. in these guidelines, also cystic adnexal incidentalomas are included. mri is most useful as a complementary technique in sonographically indeterminate masses. an algorithmic approach will render a specific diagnosis in the vast majority of cases. in complex cystic lesions, integration of dwi and dynamic contrast-mri allows differentiation of rare benign complex tumours, e.g. cystadenofibroma from ovarian cancer. pitfalls of cystic ovarian tumours include cystic fibroids, peritoneal cysts, and extraperitoneal cystic tumours. compared to us, both ct and mri are superior in assessing large cystic pelvic masses. criteria to differentiate between intra-and extraperioneal origin include displacement patterns and identification of the vascular pedicle. careful analysis of imaging and clinical findings usually allows differentiation of inflammatory tumours from ovarian cancer. learning objectives: 1. to learn about specific imaging algorithms of ovarian cystic tumours. 2. to understand certain imaging features that can differentiate ovarian from non-ovarian cystic tumours in the pelvis. 3. to become familiar with the pitfalls in imaging of ovarian cystic tumours and the lessons to be learned from them. the diagnostic methods available in patients with conductive hearing loss are: personal and family history, otoscopy, audiology, imaging, surgical inspection and counseling. the most important reasons for imaging are: atypical history, suspicion of congenital hearing loss, suspected otoscopic image, asymmetric bone conduction thresholds, profound mixed hearing loss and suspected tympanometry. ct can be used to detect otosclerosis, tympanosclerosis, posttraumatic ossicular lesions, superior semicircular canal dehiscence and cholesteatoma. mri can be used to exclude schwannoma, congenital cholesteatoma and residual and recurrent cholesteatoma after prior surgery. this lecture will illustrate the value of ct and mri in the evaluation of cholesteatoma patients as well as prior to first stage surgery and prior to second look surgery. different subtypes of surgery will be highlighted and illustrated. the growing importance of mr imaging and diffusion weighted (dw) imaging in particular will be illustrated in the evaluation of cholesteatoma patients. the role of echo-planar and non-echo-planar dw imaging will be discussed as well as the eventual use of delayed gadolinium-enhanced t1weighted imaging. mr is the modality of choice in patients with congenital or acquired sensorineural hearing loss (snhl) and the complete auditory pathway from the cochlea to the auditory cortex must be studied in these patients. the labyrinth, internal auditory canal (iac) and cerebellopontine angle (cpa) are best studied using submillimetric heavily t2w images, showing the intralabyrinthine fluid and nerves. but submillimetric gd-enhanced t1w images or 3d-flair images remain more sensitive. the auditory pathway in the brainstem is best studied with a multi-echo sequence (m-ffe/medic/merge) or t2w tse sequence and the auditory cortex is best studied on t2w tse images. the clinical information provided by the otologist will direct the radiologist to a certain part of the auditory pathway or will let him use certain imaging techniques. for instance, congenital malformations in the labyrinth and iac must be excluded in case of congenital snhl, and in case of mixed hearing one will start with ct to exclude otosclerosis. the most frequent pathology in the labyrinth (labyrinthitis, intralabyrinthine schwannoma, congenital malformation, post-traumatic lesions), the iac and cpa (cochleovestibular schwannomas, meningiomas, epidermoid tumours and facial nerve neuritis) and central auditory pathway (ms, infarction, tumor and trauma) will be illustrated using clinical examples and the important "otologist-radiologist" team work will be stressed. for tumours that nearly always arise from the investing mucosa, like in the larynx and hypopharynx, it is endoscopy that directly maps the superficial extent and grades the functional impairment (arytenoid and vocal cord movement, pyriform sinus distensibility). in addition to white light, the recent use of narrow band imaging endoscopic technology, enhancing fine capillaries in the mucosal surface, enables the detection of neoangiogenesis caused by early squamous cell carcinoma. conversely, submucosal spread is the domain of cross-sectional imaging techniques. therefore, it is the integration of the two classes of data, along with the information about patient conditions, which permits the choice of the most proper treatment strategy. in early and advanced glottic cancer, treatment planning is modulated by information about deep neoplastic invasion into the paraglottic space, the cartilage or the suprasubglottis subsites. this information can be derived by discriminating the tumour tissue from intra-laryngeal muscles, fat spaces and the cortical rim of ossified cartilages. though mr shows a greater contrast resolution than ct, it is hampered by a significantly longer acquisition time. this means more artefacts caused by breathing and movement. nevertheless, mr has the potential to unravel the signals from submucosal tissues, separating tumour from oedema, muscles, fat and ossified cartilages. advanced laryngeal and hypopharyngeal cancers need to preliminary assess local (nodes) and distant (metastases) spread. ct-pet is the more accurate tool. the multidisciplinary approach to the processing of the whole frame of data is essential to offer the patient the best care. traditionally, x-ray ct scanners were equipped with a single or a few detector rows only, image reconstruction was assuming parallel slices, which was a good approximation for these fan-beam systems. about a decade ago the number of slices increased to 16 or more and the parallel slice approximation was no longer valid. the cone-beam nature of these multi-slice ct (msct) scanners had to be taken into account by specific cone-beam reconstruction algorithms. while these msct systems -today they are simultaneously acquiring up to 320 slices -are cone-beam ct systems in a general sense, the notion of cone-beam ct (cbct) is also associated with a specific kind of conebeam ct, namely those equipped with flat detectors, i.e. the non-diagnostic or non-clinical ct systems. msct, in contrast, is a cone-beam ct system for diagnostic use, i.e. a clinical ct system. this distinction between msct and cbct is useful, as there are decisive differences in application, performance, and in image reconstruction. these differences will be reviewed in the presentation, with a particular focus on why image quality in msct is so much better than in cbct. cone-beam (cb) imaging with flat detectors is performed on a variety of different imaging systems. the most important area is cb imaging using interventional c-arm systems. the minimally invasive procedures carried out on these systems benefit from the availability of high-resolution 3d images for intervention planning, guidance and outcome control. interventional cb imaging was first applied in neuroradiology using rotational angiography acquisitions. today, it is used for a variety of procedures in interventional radiology, cardiology and oncology based on angiographic and soft tissue protocols. one of the inherent advantages of this approach is the direct registration of the volume images into the interventional procedure. other application areas of cb imaging using different scanning systems are onboard imaging in radiation therapy or the integration of flat detector tomography and spect. this part of the course teaches the generation of 3d volume information from flat detector systems and its utilisation in different clinical applications. image acquisition protocols, scan modes, and system design parameters are explained. application-specific calibration and processing steps are introduced to show how cb imaging is tailored for specific clinical applications. examples are presented for angiographic and soft tissue volumetric imaging. medical applications utilising the tomographic images for diagnosis, intervention planning, guidance, or outcome control are discussed. in the last decade, three-dimensional dentomaxillofacial imaging through conebeam ct (cbct) technology has become widely available. dental cbct (digital volumetric tomography; dvt) equipment is compact and often affordable to dentists. the driver for dental cbct was implant dentistry, but its use has spread to other areas, including paediatric applications. radiation doses are variable. some systems offer a fixed, large, field of view and others fixed exposure factors, obstructing attempts at optimisation. typically, doses are at least an order of magnitude greater than for "conventional" imaging. image quality is also variable, which means that certain equipment may be unsuitable for some clinical applications. there is often scope for lower exposure factors to be used than those recommended by manufacturers. a key aspect of using cbct relates to justification. imaging in three dimensions may be perceived by dentists as inevitably superior, a view which is often implicitly encouraged by those selling equipment. the research on diagnostic efficacy is, however, limited. in 2012, the european commission published "radiation protection 172: evidence-based guidelines on cone beam ct for dental and maxillofacial radiology". this provides a comprehensive set of recommendations, including referral criteria, a quality assurance programme and optimisation strategies. priorities for future research relate to exposures to the necessary image quality requirements for specific clinical applications, along with research on the impact on clinical outcomes of cbct-based treatments. it is clear that much work remains before the place of cbct in dentistry can be established. the role of nonvascular interventional radiology of thorax for both diagnosis and treatment has significantly increased in the last 20 years. although these procedures are technically easy with highly successful results, thoracic nonvascular interventional procedures are not unfortunately routinely performed in all of the interventional units. the most commonly performed procedures generally under ct guidance are transthoracic biopsies of the lung, mediastinal lesions and pleura. the others include percutaneous drainage of thoracic collections such as pleural effusions, empyema and mediastinal collections. image-guided tumour ablation performed by either radiofrequency ablation (rfa) or microwave (mw) as a nonvascular thoracic intervention has become a serious treatment alternative in patients with lung tumours (either non-small cell lung cancer or lung metastasis) since the year 2000. interventional radiologists are expected to understand the clinical indications of these procedures at the first step. in addition, the techniques of the procedures and possible risk of complications in their management methods should be learnt by interventional radiologists as well. this refresher course will help us to discuss the main indications, techniques and complication management of these procedures. a. lung biopsy t. sabharwal; london/uk (tarun. sabharwal@gstt.sthames.nhs.uk) lung biopsy is most commonly now performed under ct guidance. it has a high technical success rate. common complications include pneumothorax, bleeding, sepsis, pain and failure. air embolism is a rare complication. pet scan is a useful tool to guide for appropriate target. ultrasound is useful for biopsying pleural-based lesions. drainage of thoracic fluid collections is a relative emergency. we will review the different thoracic fluid collections that can be drained by radiologists: pleural (parapneumonic, empyema, and malignant effusions), mediastinal, chest wall, pulmonary (lung abscesses and infected tumours) and pericardial effusions. we will answer the following questions about the main thoracic fluid collections: how to diagnose, when and how to drain, which guidance (ultrasound or ct-fluoroscopy), and procedures to perform before and after the drainage. the choice of imaging to detect thoracic fluid collections and guide drainage depends on the availability of the modalities, the imaging characteristics, location of the collection, and the comfort and expertise of the operator with the specific modalities. we will also review the main complications of percutaneous drainage of thoracic fluid collections (pneumothorax, pain, drain dislodgement and drain blockage) and compare these complications with those related to large-bore chest catheters inserted by thoracic surgeons. the incidence of lung cancers continues to increase and primary lung cancer remains the leading cause of cancer-related deaths in both women and men. therapy of lung tumours includes resection, radiation therapy, chemotherapy, thermal ablation or a combination of these treatment modalities. image-guided percutaneous thermal ablation therapies are minimally invasive techniques established in the local treatment of hepatic, renal, or osseous tumours. among these techniques, radiofrequency ablation (rfa) has now attained consideration for therapy of small pulmonal tumours. other ablation techniques that have been used for treatment of lung tumours include cryoablation, laser (litt) and more recently microwave ablation (mwa) and irreversible electroporation (ire). ablative techniques may produce a complete and irreversible tumour tissue destruction through application of either hot or cold thermal energy, or through permeabilisation of the cell membrane while using ire. ct is currently the imaging modality that is most widely used for planning, monitoring the ablation's course and for assessment of treatment response. only patients with stage i and stage ii lung cancer and those with small metastases are potential candidates for ablation. the medical history and physical examination of the patient as well as recent imaging with ct should be evaluated to determine the indication for thermal ablation. percutaneous lung rfa is considered as a safe procedure with an overall morbidity rate from 15.2% to 55.6% and mortality rate from 0% to 5.6%; it requires less costs and offers faster recovery, and reduced morbidity and mortality. sorafenib, a tyrosine kinase inhibitor, has shown clinical efficacy in patients with hepatocellular carcinoma (hcc) and is the standard of care for patients with advanced-stage hcc. nowadays, many targeted therapies are evaluated in hcc either as sole treatment or in combination with other treatments such as tumour ablation, chemo-embolisation, and surgical resection. therefore, there is a need to assess the efficacy of targeted therapy in hcc. recist is the reference method to evaluate treatment efficacy in solid tumours, but does not seem appropriate in evaluating targeted therapy as objective responses are seen in very few cases in patients treated with sorafenib or sunitinib. new criteria have been proposed to evaluate the treatment efficacy of nonsurgical treatments in patients with hcc. the most common ones are the choi criteria, the easl criteria, and the modified recist criteria. all these criteria mainly focus on internal tumour changes such as appearance of necrosis or disappearance ot tumour hypervascularity. many examples will be shown during the lecture. another approach is based on functional imaging and especially perfusion-related imaging. contrast-enhanced ultrasound, ct perfusion and dynamic contrast-enhanced mr imaging have the capability to assess perfusion changes in patients under treatment. the advantages and disadvantages of these modalities will be discussed. lastly, other functional tools that are not routinely used will be presented. the evaluation of treatment efficacy is a key issue with prognostic and patient survival implications. it is crucial to have objective and reproducible criteria for specific groups of patients. the goal of ablative therapies of hcc is to induce tumoural tissue destruction. complete response (cr) after initial chemical and thermal percutaneous ablation, defined as the absence of contrast enhancement of the treated tumour at ceus, dynamic ct or dynamic mr, has been reported to correlate to long-term survival. nevertheless, the clinical effectiveness of imaging techniques to assess initial treatment success differs according to tumour size. the success rate of rf has been demonstrated to be superior to pei in hccs > 2 cm, and depends on the ability to ablate all viable tumour tissue including an adequate tumour-free margin all around the lesion of 0.5 to 1 cm. thus, the effectiveness of rf directly depends on the tumour location and size. rf is considered an effective treatment in lesions 3 cm and its effectiveness is progressively reduced along with tumour size and it is not effective in lesions > 5 cm. ceus beyond 1 month may confirm or detect residual tumour, deserving a final ablation procedure. ct and mr are more effective in the follow-up to confirm cr and detect local recurrence, or additional hcc lesions in the liver parenchyma. the presence of transient hyperaemic inflammatory changes in the periphery of the treated area is a common finding that should be considered to avoid overestimation of the recurrence rate. one of the major characteristics of medical imaging in the twenty-first century is the dramatic influx of novel technology. this impact of new technology and techniques is experienced in all imaging modalities. the continuous development and implementation of highly sophisticated medical products and devices is key to the evolution of medical imaging leading to the improvement of patient care in terms of quality and positive outcomes. this session will analyse state-of-the-art displays (monitors, smartphones, tablets) and their applications in modern imaging. the session will provide a brief overview of displays in the current imaging chain. it will then evaluate the various specifications and parameters associated with displays. the session will evaluate current qa standards of modern displays as well as the challenges surrounding such novel technologies. image quality can be described in terms of resolution and contrast. an image displayed on a monitor consists of differences in brightness. the display monitor is at the end of the image chain in radiology, which starts at the x-ray tube. there are several factors in this chain that have influence on the contrast displayed on the monitor. diagnostic image quality can be described as observed contrast, which is not only dependent on the displayed image, but is also influenced by ambient conditions. for the primary class displays, typical characteristics of display monitors; such as resolution, homogeneity, luminance, contrast, monochrome or color, must be appropriate for the radiologist to execute a reliable diagnosis. calibration of display monitors is also important. which parameters are significant and what is the effect of variation of these parameters. there are standards like dicom gsdf and technical standard from acr-aapm-siim. both within and outside the clinical environment, the use of smartphones and tablet computers is increasing. reported applications range from teaching and education to navigation in surgical procedures. interest in the use of smartphones and tablets for viewing radiological images has been growing. however, these portable displays can differ significantly from conventional radiological displays. in order to determine where and how smartphones and tablets can be used appropriately, it is important to understand these displays and the challenges associated with them. this presentation will outline the current and potential uses of smartphones and tablet computers in radiology and compare their performance with other radiological displays and standards. the possible limitations/benefits of smartphones and tablets as display devices for radiological images will be discussed. recent research in the field will be reviewed, with emphasis on studies of diagnostic efficacy. in modern clinical environment, diagnostic monitors have replaced glowboxes and films and have become an important part of the imaging chain. the required specifications and the quality of monitors largely depend on their purpose, beginning from quite simple monitors used for the preview of radiographic images placed on modality or in control room to monitors used by high-end diagnostic workstations. decision about the kind of monitor for certain workplace is also very important from the economic standpoint as there are large differences in their prices. besides monitor specifications, also ambient conditions and ergonometry in the reading rooms are also very important issues which need to be considered to ensure optimal environment for clinical image reading. some of good and bad examples will be given in the presentation. as with other radiological equipment, also diagnostic monitors need to be controlled to ensure their optimum performance. quality control begins with monitor acceptance testing and setting up measurement parameters which are to be followed. practically all monitor vendors include some qc software within their workstations which can, together with some independent measurements, form an efficient quality control programme. in the last steps, how to deliver all information regarding image quality and possible presets on the diagnostic monitor and how not to confuse the user are important. sitting an examination is always a source of anxiety. the edir exam is no exception. this workshop is dedicated to those who want to take the edir exam, or become examiners, and would like to learn more about its format and discover some tips and tricks. the edir organisers and examiners have decided to build an interactive, friendly and enjoyable session in order to teach the essentials. some will play the role of the examiners, some the role of the candidate. in order to simulate the candidate's experience, this session will have no safety net. some senior members will expose themselves to real difficult questions in general radiology. fortunately, we hope that the attendees will be able to help the "candidates" to succeed. hopefully, you will enjoy this session and get some very useful information for your edir exam. abdominal malignancies are an important health problem in mexico. like in many other middle-income countries, there has been an epidemiological transition with an overall increase in oncologic diseases. colorectal, gastric and liver carcinomas are some of the frequent abdominal malignancies. colorectal cancer is a disease that is curable if detected early and even preventable if precursor polypoid lesions are removed. imaging plays a critical role in staging at diagnosis. additionally, virtual colonoscopy is an accepted modality in cancer screening. high-resolution magnetic resonance imaging (mri) has become a pivotal modality in the pretreatment assessment of rectal carcinoma. computed tomography (ct) is an excellent modality in the preoperative staging of gastric cancer and follow-up after treatment. positron emission tomography (pet) combined with ct (pet/ct) is particularly helpful for gastric and colonic carcinoma staging. hepatocellular carcinoma (hcc) is also common. cirrhosis related to alcohol and hepatitis c infection are by far the commonest aetiologies. ultrasound (us) in conjunction with alpha-protein is the most widely used modality for screening purposes. ct and mr are confirmatory modalities. the advent of hepatospecific gadolinium contrast agents has been very helpful in the characterisation of focal lesions in cirrhotic patients. the use of multidetector ct (mdct) in pancreatic carcinoma for the detection of vascular and adjacent organ invasion is crucial in treatment planning. over the last few decades, there has been an important improvement in imaging techniques resulting in better quality images. imaging is critical not only for the diagnosis, but also for treatment planning and follow-up. learning objectives: 1. to learn about the imaging of common oncologic gastrointestinal diseases. 2. to understand the importance of imaging in liver and colon cancer. 3. to learn how imaging supports oncologic institutions. activity, ultrasound is readily available and gives detailed local information but is limited by the restricted field of view, communication of results to clinicians and comparison of examinations on time. computed tomography (ct) is fast, readily available and gives a detailed, reproducible overview, but radiation exposure and contrast resolution are limitations. magnetic resonance imaging combines a good, reproducible overview with high contrast resolution, dynamic information and no radiation exposure and is therefore preferable in many situations, but the longer examination times than for ct, availability and costs are limiting factors. for the diagnosis of stenoses, fistulas and abscesses, either technique can be used, although the unrestricted view of ct and mri favour these techniques in many situations. in acute situations, us and ct are more accessible than mri. in that setting us can be considered, but when the examination is inconclusive or the patient has clear inflammatory signs, ct is preferable. endoscopy is currently considered the reference standard for the evaluation of colonic pathologies, including colitis. it allows direct visualisation of the mucosa and in obtaining tissue sample. however, it has major limitations including the invasiveness of the technique, incomplete endoscopy and risk of perforation. endoscopy cannot, therefore, help to estimate the depth of involvement of transmural inflammation and extraluminal complications. by contrast, an evolving role for cross-sectional imaging in the evaluation of patients with colitis has been increasingly recognised, especially in the setting of crohn's disease (cd), since cross-sectional imaging has been demonstrated to have a high diagnostic accuracy not only for assessing the presence and extension of luminal disease, but also for evaluating cd-related acute or chronic complications. establishing the ultimate cause of colitis may sometimes be challenging and histology cannot be conclusive. however, cross-sectional imaging may provide additional information that is useful in the workup of colitis. the use of cross-sectional imaging has been increasing in the evaluation of inflammatory bowel disease. following their presentations on imaging protocols and features of small bowel disease and colitis, each speaker will present a case to illustrate the learning points covered in their lectures. the session will be moderated by the chairman and the audience will have full opportunity to ask questions of all the panel. multimodality imaging is essential in a wide variety of oncology situations. anatomic imaging, whether using us, ct or mri, is mandatory for tumour localisation. moreover, the evaluation of treatment response mostly relies on size assessment, whether uni-or bi-dimensional. with the advent of new targeted bio-therapies, functional imaging has progressively been integrated in the imaging strategies whether for better tumour characterisation or for optimal evaluation of treatment response. hence, assessment of molecular targets by pet is supplemented by the recent developments of diffusion mri, reflecting tissue architecture and cellularity, tissue perfusion, reflecting angiogenesis, and magnetisation properties of tissues. hcc is a primary liver tumour where the use of multimodal anatomic, functional and metabolic imaging appears of particular interest. according to easl and aasld recommendations, noninvasive diagnosis of hcc can be performed using dynamic contrast enhanced cross sectional imaging. liver mri provides optimal sensitivity and specificity for the detection of as small as 1 cm large hcc. recent reports have suggested that the prognosis of hcc lesions could be anticipated based on the combined analysis of metabolic 18 f -fdg pet ct, as well as with diffusion weighted imaging. the objective of this lecture will be to highlight the potential of combining both metabolic and multimodal cross sectional imaging in order to improve the management of patients with hcc. the (extra)ordinary night shift at the er k. petrovic; novi sad/rs (smakap@sbb.rs) besides the accuracy, working at the er requires maximal shortening of the diagnostics time, which has a significant influence on the patient's outcome. thus, it is the radiologist's duty to be familiar with the pathophysiological mechanism of the disorders, specific protocols, possibilities and limits of certain examinations, and also to be aware of all possible pearls and pitfalls, to make the correct diagnosis. pathology encountered at the er has an extremely wide range and requires expertise in all imaging modalities from head to toe. the more the radiologist is aware of all possible situations, the more is the diagnosis accurate, and information given to the clinician is more valuable. the aim of this presentation is to point out the possibility of encountering different pathological conditions in different body regions. moreover, it is important to be reminded that in radiology there are different modalities, each of which has its own indications and limits. this lecture reviews the selected series of cases from the er department of clinical center of vojvodina, pointing out the most common possible differential diagnosis and possible diagnostic mistakes, which often occur due to the lack of experience. learning objectives: 1. to point out the in-depth knowledge and experience in all imaging modalities and all body regions required for a radiologist to perform a routine work at the er. 2. to present a series of cases that are most and less often encountered at the er, discuss the possible differential diagnosis and mistakes which could potentially be made. diagnosis and management of pancreatic cystic lesions r.j. mã©ndez; madrid/ es (ramiro.mendez@salud.madrid.org) pancreatic cystic lesions are frequently diagnosed in patients with clinically suspected pancreatic disease, but they are also increasingly detected on imaging studies performed due to other abdominal processes. the prevalence of pancreatic cysts increases with patient's age. most symptomatic cysts will be surgically resected, whereas asymptomatic lesions should be managed depending on the likelihood of causing harm to the patient. cystic lesions can be inflammatory or neoplastic. the incidence of pseudocysts is low without a history of pancreatitis. some pancreatic cystic neoplasms are malignant, but even benign lesions can become symptomatic depending on its size and location in the pancreas. the radiologist detects most of the pancreatic cystic lesions and should also play an important role in the clinical decision-making process. cyst size, morphology, calcifications, contrast enhancement, location in the pancreas, relation with pancreatic ducts, patient's age and gender are important data to classify the lesion. a specific radiological diagnosis is not possible in every patient, but in many cases this information is enough to decide on a conservative approach with imaging follow-up. if a more aggressive lesion is a concern, then endoscopic ultrasound and fluid analysis can help to better characterise some pancreatic cystic lesions. cyst puncture is only recommended if fluid analysis results will modify the patient's management. patient's age, status and preferences should also be taken into account. when follow-up is recommended, the preferred imaging technique and interval should be indicated. the chair will set the scene for the need for effective radiation protection in clinical radiology and highlight the role of clinical audit as a tool in achieving this. clinical audit is defined as a professionally led method of improving patient care through the systematic examination of systems, processes and outcomes against chosen and agreed standards. it can readily be carried out by individuals, groups or whole departments. if properly conducted, clinical audit can be an effective way of examining what we do to provide reassurance on performance, and to improve patient care. the clinical radiology audit committee (crac) of the royal college of radiologists (rcr) co-ordinates national radiology audit activity. it promotes and facilitates audit through nominated audit leads in each hospital, who act as a link between the rcr and their department. at least one national audit is carried out annually, with data collected via electronic submission and the anonymised results presented at an annual audit forum. individual departmental results are analysed using statistical process control (spc) methodology. this enables identification of departments underperforming against the national mean, and recommending corrective action, by redesigning the process being audited, or by identifying and eliminating specific root causes locally. the committee has developed a web-based tool for facilitating local audit, "auditlive", a fully searchable collection of templates which can be downloaded and adapted. fellows are also able to submit their own templates for publication hence sharing best practice. trainees are encouraged to participate in audit through audit poster competitions at national radiology scientific meetings. our experience leads us to believe that audit succeeds when relevant, locally owned and properly structured, and multi-professional, and the rcr model encourages this. models of external audit in the netherlands s. geers-van gemeren; utrecht/nl in the netherlands clinical audit is legally obligatory for healthcare professions in order to be able to practise since 2010. clinical audit is a tool designed to improve the quality of patient care, experience and outcome through formal review of systems, pathways and outcome of care against defined standards, and the implementation of change based on the results. the quality of the provision of care by professionals is assessed by peers. in the fields of radiology, nuclear medicine and radiotherapy, different models of clinical audit are used. for radiotherapy a multidisciplinary audit has been used since 2003. for nuclear medicine a multidisciplinary audit has been implemented since 2013. for radiology the clinical audit for radiologists and for radiographers are separate. implementation of the multidisciplinary audits needs requirements and adjustments of the audit system. this process is complex and needs approval of the members of all involved societies. to support the clinical audit a web based tool adas (general digital audit system) is used. the development of professional standards is a prerequisite to start clinical audit. the use of adas in multidisciplinary audits is a requirement to be able to audit different professions and focus on the content and the quality of their contribution to patient care. clinical audit is a good tool to improve the quality of patient care. important are the professional standards, the culture of learning and willing to improve by the professionals. "every defect is a treasure." learning objectives: 1. to learn about the different dutch models of external clinical audit. 2. to comprehend the importance of professional standards, the culture of learning and willingness to improve. 3. to become familiar with the use of a digital audit system to support multidisciplinary clinical audit. external regulatory audit in finland r. seuri; helsinki/fi (raija.seuri@hus.fi) directive 97/43/euratom states that the clinical audit of medical imaging should be carried out in accordance with national procedures. the finnish solution has been regulatory external audits every five years by radiological professionals with special training for audits. all radiological units have so far been audited at least twice, and the third time is performed on site in the unit. although the purpose is to audit the process of radiological practises compared to "good practise", special focuses are recommended by the finnish advisory committee for clinical audit, set by the national institute for health and welfare. at the beginning focus was on the organisation and documentation of the structure and processes of imaging practise like justification, optimisation and quality control, but also encouragement and guidance to self-assessment. later special focus has been on paediatric imaging and ct, and the third cycle will target deeper to ct practises. the auditing group includes at least a radiologist and a radiographer to audit a small unit, and a medical physicist if the unit has high-dose modalities like ct. during the audit the auditors work for an independent organisation. multi-professionality gives both insight and the possibility to contact all professionals in imaging practise. the focus of clinical audit is on quality improvement; it is a way to both give and get feed-back and education. it is not control or inspection, but encouragement and guidance to self evaluation and implementation of good practises. we often think of the scientific researcher as detached, objective, and dispassionate, nobly labouring without any expectation of reward. nothing could be further from the truth. scientists are as subject to ambition, competitiveness, envy and even guile as any person. lifting the veil on scientific discovery reveals to us the human dramas that underlie not only the coveting of recognition, but also great conflicts over priority and credit. nowhere are the stakes higher than for that pinnacle of scientific honour: the nobel prize. mri has had a notably tempestuous genesis -a cogent episode that has much to teach us. it involved an explosive clash of personalities; deceit and rampant self-interest; challenges to the basic concept of scientific behavior; legal suits and validation by the united states supreme court; and declamations of denunciation in the international press. it persisted as a 30year battle -a prize fight, a blood feud -between two protagonists: one whose seminal contribution established the biologic basis of mri, and the other whose flash of insight served as a cornerstone of diagnostic imaging. 1. metabolic disorders of the skeleton involve the mineralised components of the skeleton. they affect all bone components histologically, but involvement patterns may vary depending on the age of the patient (growing versus adult skeleton) as well as the type of bone (cortical versus trabecular bone). they can be depicted on radiographs and ct images, but remain occult on mr images because the bone marrow is spared in the vast majority of these disorders. mr imaging can help in the assessment of local complication such as fractures. 2. metabolic disorders of the bone marrow can affect either red (anemiaâ�¦) or yellow marrow as well as the balance between these 2 marrow types in the body. medical imaging plays a limited role in the assessment of these disorders, but marrow changes associated with these metabolic conditions must be recognised to avoid confusion with neoplastic conditions. in primary and secondary malignant tumours of solid organs, in most of the cases surgical resection is considered the curative treatment. however, this is possible only in about 20% of the cases with tumour-dependent recurrence rates of 60% and even more. the main components for adjuvant, neo-adjuvant and finally palliative therapy are the permanently growing number of chemoand antibody therapies. nevertheless, in many cases these therapies provide no definitive or long-lasting success, necessitating multimodality treatment concepts. in the meantime, local ablative techniques represent the main components of these concepts. three main minimally invasive tumour-ablative techniques can be differentiated: chemo-ablation (percutaneous alcohol injection, transarterial chemo-embolisation, chemotherapy, chemo-perfusion), thermo-ablation (radiofrequency-, microwave-, laser-ablation, high-intensified focused ultrasound, cryo-ablation) and radio-ablation (radio-embolisation, interstitial brachytherapy, percutaneous stereotactic radiation). these ablation techniques differ significantly among each other with respect to their mode of action and indications; nevertheless, their benefit is high tolerance and at the same time high therapeutic efficacy, which can easily be combined with other treatment modalities. the different minimally invasive techniques will be discussed together with specific short-and long-term results and complications. missed lung lesions are one of the most frequent causes of malpractice issues. chest radiography plays an important role in the detection and management of patients with lung cancer, chronic airways disease, pneumonia and interstitial lung disease. among all diagnostic tests, chest radiography is essential for confirming or excluding the diagnosis of most chest diseases. however, numerous lesions of a wide variety of disease processes affecting the thorax may be missed on a chest radiograph. the chest radiograph will also help narrow a differential diagnosis, help to direct additional diagnostic measures, and serve during follow-up. the diagnostic usefulness of the radiograph will be maximised by the integration of the radiological findings with the clinical features of the individual patient. ct has a tremendous spatial resolution that helps detect lesions in the chest and has proven to be more sensitive and specific than chest radiographs. however, missing lesions or misinterpreting lesions in ct of the chest is not uncommon. in this session, we will provide interactive cases of chest examinations (radiographs and ct) in which lesions have been missed and or misinterpreted, with a special focus on how correlation with mdct of missed lung lesions can help improve interpretation of plain chest radiographs. this session will explore the value of imaging for facilitating precision medicine, in which molecular data (including genomics, proteomics and metabolomics) is used to classify patients into subpopulations and tailor treatments to the specific molecular characteristics of their diseases. imaging already plays a limited role in precision medicine, primarily through the use of molecular imaging techniques (e.g. pet/ct, mri/pet and hyperpolarised mri) and theranostics (the combination of an imaging agent with a therapeutic entity). in the near future, the role of imaging in precision medicine will increase at a gradually accelerating pace through the development of new molecular imaging probes and theranostic agents and through progress in radiogenomics (the correlation of radiologic findings with genomic features). this session will discuss recent findings and methodologies in radiogenomics as well as the use of nanotechnology for designing novel molecular imaging probes and theranostics. in addition, as theranostics is often considered the essence of precision medicine, the session will provide an in-depth look at current and emerging theranostic strategies and their special benefits for treatment selection, assessment of dose distribution of targeted therapies, and treatment follow-up. radiogenomics and personalised (precision) medicine g.p. krestin; rotterdam/nl (g.p.krestin@erasmusmc.nl) "precision medicine" as well as related notions, such as personalised medicine, or stratification medicine, all revolve around the idea that the consideration of individual characteristics -molecular and otherwise -can improve medical research and practice. precision medicine is a multi-faceted approach to medicine that integrates molecular and clinical research with patient data and outcomes. individual assessment of the location and extent of an alteration is and always has been the basis of medical imaging, whether the 'alteration' is a disease, a malformation, or an injury. as such, medical imaging intrinsically enables "precision medicine". the addition of genomic data in the last twenty years allows new correlations to be made between cellular genomics and tissue-scale imaging. structural and functional imaging and the automated analysis of large amounts of image data have only recently reached a stage where they can be used on a large scale and in a population setting. identifying common genetic variants that contribute to explain variance in imaging phenotypes by a systematic analysis of the genome is based on genome-wide association studies (gwas). the power of gwa analyses has been recently demonstrated with the identification of susceptibility genes involved in a range of imaging phenotypes like coronary artery calcifications, intracranial volume, or size of the hippocampus. these developments highlight new etiological pathways and are expected to improve the understanding of the molecular basis of some diseases. correlation between genotype and imaging phenotypes may be relevant for further characterising the development of disease states. use of nanotechnology, imaging and therapy t. lammers; aachen/ de (tlammers@ukaachen.de) advances in nanotechnology and chemical engineering have led to the development of a significant number of novel materials for diagnosis and therapy. many different diagnostic and therapeutic nano-and micro-materials have been designed and evaluated over the years, including, e.g. gadoliniumcontaining dendrimers, uspio nanoparticles and microbubbles for functional and molecular imaging, and drug-loaded liposomes, polymers and micelles for temporally and spatially controlled drug delivery to tumors and to sites of inflammation. in the literature, such advanced nano-and micromaterials are generally claimed to be highly useful and broadly applicable. a critical reflection on their specific capabilities, however, as well as on their pharmacokinetic properties, biodegradability and toxicity is often lacking. in the present lecture, i will briefly introduce the rationale for using diagnostic and therapeutic nanomaterials. i will highlight several clinically relevant examples in which nano-and micromaterials hold potential for improving disease diagnosis and detail how combining diagnostic and therapeutic properties within a single 'nanomedicine' formulation can be used to individualise and improve (chemo-) therapeutic treatments. learning objectives: 1. to learn about the design and construction of nanoparticles for use in imaging and therapy. 2. to appreciate both the advantages and limitations of using nanoparticles as agents for both imaging and therapy. 3. to learn how nanotechnology enables multimodality imaging and therapeutic agents. theranostics w. weber; new york, ny/us precision medicine requires diagnostic tests that predict the effectiveness of specific therapeutic interventions for individual patients. this close interaction between therapeutics and diagnostics is expressed in the term "theranostics". a frequently used example for a theranostic is the staining of tumours for her2 expression prior to therapy with her2 antibodies, such as trastuzumab or pertuzumab. theranostic has also been practised since many years in nuclear medicine by using radioiodine scans to select patients for treatment with iodine-131. a more recent example is the selection of patient for peptide receptor-targeted radiotherapy (prrt) by somatostatin receptor imaging. imaging is highly attractive for theranostics, because it allows investigators to study the spatial and temporal heterogeneity of target expression, whereas in vitro assays generally analyse a small part of the tumour at one point in time. several molecular imaging probes, such 89 zr-trastuzumab or folate receptor targeting ligands, are in clinical development as in vivo companion diagnostics. imaging companion diagnostics can also be used to assess tissue pharmacokinetics and thereby help to determine the optimal dose and dose schedule of therapeutic agents. they can also identify unexpected interactions between two therapeutic agents. for example, studies with 11 c-docetaxel have shown that bevacizumab can markedly decrease the intratumoral delivery of docetaxel. finally, imaging-based companion diagnostics can assess target inhibition, as demonstrated by the inhibition of uptake of the androgen receptor ligand 18 f-fdht in metastatic prostate cancer treated with anti-androgens. imaging-based companion diagnostics are therefore expected to play an important role in establishing precision medicine. erus technique as well as the state-of-the-art mr imaging protocols tailored according to the presenting rectal tumor site, allowing trained radiologists to obtain all necessary information for appropriate treatment decision-making, will be described. normal cross-sectional appearances as well as morphological and signal changes encountered in pelvic structures/tissues that may be involved in primary rectal cancer will be illustrated. the influence of imaging findings on initial therapeutic approach and potential limitations of different imaging techniques will be discussed. the staging and categorisation of malignant lymph nodes in patients with rectal cancer is a topical issue and has resulted in some degree of confusion. much enthusiasm has been expended in determining whether mesorectal nodes are, or are not, involved in the primary disease process, as there is a perception that nodal disease is an important determinant of local recurrence. this incorrectly perceived association of nodal status and a high risk of pelvic recurrence have propagated the concept that this should be the primary indication for neoadjuvant therapy regardless of whether tme surgery is to be performed. furthermore, misinterpretation of involved local nodes results in over-treatment of patients, if firstly involved nodes alone are considered as a poor prognostic factor, and secondly the optimal treatment of involved nodes is pelvic radiotherapy plus a non-systemically acting but radiosensitising dose of chemotherapy within chemoradiotherapy (crt) schedules. in this lecture, the evidence for risk factors associated with nodal disease and validated risk factors for local recurrence will be reviewed. the evidence for both the optimal techniques and objective criteria for assessing lymph nodes with magnetic resonance imaging (mri) will be presented. the standard treatment for advanced rectal cancer is preoperative chemoradiotherapy (crt) followed by standard resection of the rectum and mesorectum. neoadjuvant crt allows downsizing and downstaging of the tumour, leading to improved resectability and local control. while the role of mri in rectal cancer treatment is recognised and mri is recommended as part of the standard staging workup, its role for restaging after preoperative treatment is more controversial. this lecture will provide an understanding of whether and how mri can assess treatment response in rectal cancer and how it may impact treatment decision. the attendees will learn about the difficulties in image interpretation and learn about potential new imaging techniques to improve its performance. primary tb typically presents with consolidation in the middle and lower lobes, and necrotic lymphadenopathy. fibrosis, tuberculomas and calcified nodes may result as sequelae. cavitation and tree-in-bud appearance involving the apical and posterior segments of the upper lobes and the superior segments of the lower lobes are the hallmarks of reactivation tb is typically seen in immunocompetent patients. in immunocompromised patients, primary tb findings are more commonly observed, as miliary or disseminated disease or atypical manifestations in case of severe immunosuppression. pleural effusion and tracheobronchial involvement may be observed. the "classical" appearance of non-tb mycobacteria (n tm ), less common and more indolent than tb, typically affects males more than 50 years old with pre-existing pulmonary disease or underlying immunologic disorder. despite a great overlap in the radiologic appearances of both infections, the presence of cavities on sites other than the upper lobes should suggest an n tm infection. the "nonclassical" form related to mac infection that predominantly affects elderly women with no pre-existing pulmonary disease mainly consists in mild bronchiectasis and centrilobular nodules predominantly located in the lingula and middle lobe. a high rate of lymphadenopathy and disseminated disease are seen in immunocompromised patients. the radiologist has to ensure the diagnosis of active tb and mention scarring before starting specific treatments; to suggest n tm infections, immune reconstitution inflammatory syndrome with paradoxical worsening in haart treated hiv-infected patients as multi-drug resistant tb; to appreciate the extent of disease and follow-up; to diagnose the complications; to propose mri or pet scans in some situations. learning objectives: 1. to appreciate the imaging features of primary and post-primary infections in tb. 2. to learn about the similarities and differences between tb and non-tb mycobacterial infections. 3. to understand the radiologist's role in diagnosis. the appropriate investigational technique, frequently targeted differential diagnosis, and the special needs of immunocompromised patients need to be understood by the referring physician as well as by the radiologist. thus, an intensive interdisciplinary co-operation on a patient basis, as well as on a department basis is essential. early detection of a focus is the major goal in febrile neutropaenic patients. as pneumonia is the most common focus, chest imaging is a special radiological task. the sensitivity of chest x-ray, especially in the supine position, is known to be low. therefore, the very sensitive thinsection multislice-ct became the gold standard in neutropenic hosts and might be cost-effective in comparison to antibiotic treatment. the infiltrate needs to be localised, so that this information can be used as guidance for invasive procedures for further microbiological workup. furthermore, the radiological characterisation of infiltrates gives a first and rapid hint to differentiate between different sorts of infectious (e.g. typical bacterial, atypical bacterial, fungal) and non-infectious aetiologies. follow-up investigations need careful interpretation according to disease, recovery, and concomitant treatment. due to a high incidence of fungal infiltrates, interpretation of the follow-up of an infiltrate must use further parameters besides the lesion size. besides the lungs, also other organs systems such as brain, liver and paranasal sinuses need attention and are to be imaged with the appropriate technique. despite advances in diagnosis and treatment, new pulmonary infections have been diagnosed. streptococcus pneumoniae remains the main aetiological agent in outpatients with community-acquired pneumonia (cap). elderly patients or those with toxic habits and various comorbidities favour the development of severe cap. in addition, the development of nucleic acid amplification techniques has emphasised the role of concomitant bacterial and viral pneumonia in the outcome of cap in elderly patients. healthcareassociated pneumonia has been recently defined as a different infectious condition by the american thoracic society/infectious diseases society of america (ats/idsa). the main concern of this new disease is the risk of having an infection due to multidrug-resistant pathogens. with the advent of haart and increased long-term survival of hiv-positive patients, the range of pulmonary manifestations has also evolved. in patients with haematological malignancies or after hsc transplant, aspergillus is a common infection. actually, aspergillus spp. isolation from lrt samples in copd may indicate an increased diagnosis possibility of ipa. new emerging viruses such as human metapneumovirus (hmpv), sars-associated coronavirus, and avian influenza caused by the h5n1 virus have been diagnosed. in 2009, an outbreak of a novel swine-origin influenza a (h1n1) virus was reported. the clinical diagnosis of new pulmonary infections as well as the presence of concomitant bacterial and viral infections has been significantly enhanced by improved laboratory methods. a systematic approach to the radiological evaluation of lung infections is essential and includes not only chest imaging pattern recognition, but also integration of available demographic, clinical and laboratory information. the paediatric central nervous system is a complex structure undergoing rapid development. as such, there is a rapid, continuous modification of what is "normal" in relation to age and the stage of development. knowledge of the normal patterns of brain development in the clinically relevant ages from 0 to 18 years is necessary to interpret neuroimaging findings correctly. knowledge of embryology and normal variants is also greatly helpful. mr imaging equipment and parameters need to be adjusted and optimised for paediatric studies. pitfalls often occur from the misunderstanding of normal conditions that are perceived as abnormal based on a comparison with the appearance of the normal brain in adults. this includes, for instance, the evaluation of the brain in the first 2-3 years of life during the course of the process of myelination. a summary of the most frequent conditions that may lead to misinterpretation of findings will be provided. a wide spectrum of anomalies of thoracic and abdominal organs may be encountered on radiologic evaluation. these anatomic variants and developmental anomalies can all pose a diagnostic challenge to the radiologist. familiarity with these anomalies, the imaging techniques available for their study, and their variable imaging manifestations is necessary for differentiating them from pathology. a basic understanding of the embryologic development and normal anatomy of thoracic and abdominal organs and vessels is also essential for identifying these anomalies. this review explores the wide variability in appearance of the normal thoracic and abdominal organs during imaging, stressing a thorough understanding of normal anatomy to recognise normal variants. the skeleton of a child is a developing system with a variety of changing normal appearances. imaging studies, especially plain films, are requested for many clinical reasons, and the radiologist is in the position to determine if an image is a normal finding or we are dealing with a lesion. the way the physis and epiphysis grow, ossify, and fuse constitutes a great source of physiologically bizarre appearances, which the radiologist must be familiar with. this talk will concentrate on the plain film diagnosis of some of the most common musculoskeletal variants. other imaging modalities will also be shown when appropriate for the case. irregularities, asymmetries, partial fusions, hypo-or hyper-dense bone areas, accessory bones, prominent normal structures, external artifacts, and potential fracture lines are the most often encountered pseudolesions. a defective radiological technique may also be potentially misleading. patient age, location of the supposed "abnormality" and lack of significant local symptoms are key factors. usually plain films, correlated with regional clinical findings, are the only imaging method that is required. however, in certain doubtful situations, ultrasound, ct, mri, bone scan, or even biopsy may be needed to reach the right diagnosis. unnecessary overuse of these imaging modalities, and the subsequent family anxiety that ensues from this overuse, should be avoided with careful analysis of the x-ray and clinical findings. the purpose of this lecture is to cover the clinical presentation, underlying pathological processes and essential mri features of relatively common conditions affecting the hip. as the hip is afflicted by different conditions according to age, this is how the various pathological entities will be presented. a simple imaging algorithm is presented showing the role of mri. the role of mr arthrography in the assessment of the dysplastic hip and femoroacetabular impingement is covered. a structured approach to mri reporting is outlined. (claudia.schueller-weidekamm@meduniwien.ac.at) mri of the hand requires high spatial resolution, perfect immobility, and homogeneous fat suppression. the hand can either be placed in the superman position, which often is uncomfortable for the patients, or both hands can be placed above the abdomen next to each other while the patient is in the supine position. standard sequences are axial pd, followed by coronal t1 tse, and t2 tse fs in the coronal and sagittal planes. additional 3d gradient echo sequences with fat saturation are recommended to assess ligaments and cartilage, as well as the triangular fibrocartilage complex (tfcc). in certain cases, mr arthrography with thin-slice t1 fs is helpful for further evaluation of the wrist ligaments. in inflammatory diseases, such as rheumatoid arthritis, static or dynamic t1 fs sequences are useful to assess tenosynovitis and synovitis. the most common injuries and inflammation of the hand and wrist are discussed with special emphasis on key findings for an accurate diagnosis. the awareness of advantages and drawbacks of other imaging modalities, such as conventional radiographs and ct, should be strengthened. the clinical impact of the radiological report is discussed to strengthen the importance of proper terminology for the description of pathological findings. the structure of the report should be clear and concise, and should allow an interaction and broad communication with clinicians. gastro-enteropancreatic neuroendocrine tumours (gep-net) are a heterogeneous group of cancers that differ in their biology and clinical presentation. diagnosis of these tumours has been improved by advances in pathology and classification and by the combined use of structural imaging and functional imaging modalities. multimodal imaging is increasingly recognised both in detecting and staging disease and also in characterising biological patterns of lesions that may be relevant to the selection and delivery of therapy. in this course, the complex nature of gep-net and the intrinsic uses and limitations of each diagnostic imaging modality will be underlined. insights to hybrid structural and molecular imaging techniques will be provided and discussed. a. tumour biology, pathogenesis and classification b. wiedenmann; berlin/ de (bertram.wiedenmann@charite.de) neuroendocrine tumour cells are characterised by the coexpression of neuronal and epithelial proteins and cellular organelles such as synaptic vesicles containing synaptophysin of neurons and intermediate filaments/cytokeratins of the epithelial cells. based on the presence of secretory vesicles and the continous, uncontrolled vesicular release of biogenic amines, neuropeptides and hormones, patients suffer in half of the cases of so called functional symptoms and syndromes. examples are the carcinoid syndrome (excessive release of serotonine) or the zollinger-ellison syndrome (excessive release of gastrin). activation or inhibition of certain g-protein coupled receptors (e.g. somatostatin receptors) or channel proteins (r-type calcium channels) can lead to the control of the hypersecretion or so called functionality of the affected patients. medical interference with signal transduction pathways involving tyrosine kinase receptors as such mtor and channel proteins can lead to an inhibition of cellular and tumour growth. these observations have led to the establishment of new therapies, especially for pancreatic nets using especially mtor and tyrosine kinase inhibitors. whereas the tumorigenesis is unknown in the case of sporadic nets, hereditary nets appear to develop via a menin mutation through the intermediate stage of hyplasia before they develop the full metastatic potential. based on the above given tumour biological and histopathological findings, a rather robust classification for nets has been developed by the european neuroendocrine tumor society (enets) using a tnm-classification together with a gradingsystem. furthermore, the formerly used terms such as apudoma, neurocrestoma, carcinoid, etc. have been largely replaced by the meanwhile generally accepted term neuroendocrine tumour. this presentation will focus on the pivotal role of nuclear medicine in the diagnosis and treatment of neuroendocrine tumours (nets). the metabolic and molecular imaging capabilities of both positron emission tomography (pet) and single photon emission tomography (spect) have made a great impact on the clinical management of patients with these tumours. a poster child of molecular imaging in oncology is scintigraphy of the somatostatin receptor (ssr). 111 in-dtpa-octreotide has a substantial value in detection, diagnosis and staging of net and more particularly in gastroenteropancreatic nets. newer ssr-binding radiopharmaceuticals have been developed for pet, mainly with gallium-68 as radiolabel, with higher affinity and more advantageous pharmacokinetics. when used with high-resolution and rapidthroughput multimodal whole body imaging of modern pet/ct cameras, these tracers provide the current state-of-the art ssr imaging. we will also discuss the clinical value of metabolic tracers, such as [ ]5-hydroxytryptophan) for amino acid metabolism imaging. the clinical merits and indications of these tracers will be explained. the continuously evolving quest to develop tracer for other receptor systems expressed on nets will be illustrated, e.g. bombesin, vip, cck and glucagon-like peptide receptor ligands. finally, the role of imaging as selection for metabolic and peptide receptor radionuclide therapy will be discussed. gastroenteropancreatic neuroendocrine tumours (gep-nets) are a heterogeneous group of neoplasms that arise from cells of the diffuse neuroendocrine system and may present with a wide spectrum of clinical presentations. their prognosis is mainly related to their biology, proliferation and differentiation. the main goals of imaging are the diagnosis and the staging of these tumours. the diagnostic challenge is very different in functional tumours where clinical presentation and laboratory parameters are of utmost importance and in nonfunctional tumours where imaging may show characteristic features such as hypervascularisation and calcifications. staging is also essential as locoregional involvement and distant metastases (such as liver metastases) may change the therapeutic approach and are major prognostic factors. multimodal workup included morphological imaging modalities with ct and mr imaging, and endoscopic ultrasound was the most useful and functional imaging. the latter includes somatostatin receptor scintigraphy, fdg pet and more recent functional tools such as pet using 68ga and 18 f-dopa. imaging may also play a role in assessing prognosis in combination with tumour differentiation and tumour proliferation, obtained from pathologic examination. last, imaging is useful in evaluating tumour response after treatment. although surgery remains the only potentially curative therapy for patients with primary gep-nets, other available treatments include chemotherapy, interferon, somatostatin analogues, and targeted therapies. imaging criteria rely not only on changes in tumour size, but also on internal tumour changes. the purpose of this session is to bring the audience up to date with a novel mri method capable of measuring brain perfusion. this method is called arterial spin labelling (asl) and provides a complete non-invasive means to quantitatively assess cerebral blood flow (cbf). as with any mri technique, asl relies on proper setting of many technical parameters to provide an adequate image quality, with minimal influence from potential artefacts. a recent position paper, co-signed by members of the perfusion study group from the international society for magnetic resonance in medicine and the european cost-funded action on 'asl in dementia', has established a series of simple guidelines to help promote this technology in clinical practice. these guidelines will be provided within this session. the created cbf maps will then be analysed, and a simple description of the main features and clinical characteristics of these physiological images will be given to the audience. in particular, a proper difference in the meaning of cbf in several diseases will be highlighted, as it can be either causative, such as e.g. in stroke and cerebrovascular diseases, where a reduced cbf leads to a breakdown in tissue homeostasis, or consequential, as in e.g. dementia, in which a reduction of cbf is the mere reflection of impaired metabolism, combined or not with an underlying brain atrophy. following this session, the radiologist or clinician should be able to better appreciate asl-based sbf maps in several neurological conditions. perfusion is an important parameter to assess the status and liability of organs and tissue. typically, exogenous contrast agents are administered to measure this quantity. arterial spin labelling (asl) is capable of estimating perfusion without the use of exogenous contrast media by labelling inflowing blood magnetically. this labelling process can happen either in a short time over an extended region or over a longer time period, but in a localised area. these techniques are called pulsed asl (pasl) or continuous asl (casl), respectively. for quantification, a critical parameter is the time the labelled blood takes to flow from the region of labelling to the imaging region. this time is typically called bolus arrival time (bat) or arterial transit time (att). it is important to either reduce the influence of this transit time on measured signal intensity or directly estimate it. applying proper bio-physical models, the perfusion-weighted data can then be converted in absolute measures of perfusion. more sophisticated methods allow measuring of the main feeding artery of each imaging voxel (vascular territory mapping) or assessing other parameters beyond perfusion, allowing more detailed assessment of tissue status and function." the use of asl in cerebrovascular disease j. hendrikse; utrecht/nl (j.hendrikse@umcutrecht.nl) obvious applications of arterial spin labelling in clinical mr protocols are cerebral blood flow measurements in patients with acute or chronic cerebrovascular disease. in patients with acute stroke, the cerebral blood flow measurements may indicate the infarct core, with severely decreased perfusion and the infarct penumbra, with decreased perfusion but still viable brain tissue. in chronic cerebrovascular disease, arterial spin labelling cbf measurements show the regionally impaired haemodynamics distal to a carotid obstruction. with adequate collateral blood flow, these areas may be relatively small and with a failure of compensatory mechanism the cerebral blood flow may fall below a critical level. in acute stroke patients, asl mri may show compensatory hyperperfusion in stroke regions after the recanalisation of an occluded artery. other applications of arterial spin labelling are clinical mr protocols in children. in addition to cbf-weighted images, asl mri has also the ability to measure timing parameters: typically, the time it takes for the magnetically labelled arterial blood to flow from the arteries in the neck to the brain tissue, which may be delayed in patients with cerebrovascular disease. furthermore, asl mri has the ability to visualise the (collateral) perfusion territories of the brain feeding arteries in many clinical applications. in patients with cerebrovascular disease, a pitfall may be the absence of label in brain regions due to delayed (collateral) flow, which also may result in high asl signals in (collateral) arteries. learning objectives: 1. to appreciate the different roles of asl in cerebrovascular diseases. 2. to become familiar with the different types of calculated images obtained from multi-time points and selective pulses asl. 3. to become familiar with the limitations and pitfalls of asl. the use of asl in non-vascular brain disease m. smits; rotterdam/nl (marion.smits@erasmusmc.nl) arterial spin labelling (asl) is a non-invasive mri technique with which cerebral blood flow (cbf) can be measured quantitatively. although the first publications of asl mri date over 10 years back, it is only now that asl is commercially available on mri systems from all major vendors and is making its way into clinical practice. the main areas of interest for current and future nonvascular clinical application of asl mri of the brain are dementia and neuro-oncology. asl is proposed as a diagnostic alternative to fluorodeoxy-dglucose (fdg)-pet in the workup of dementia patients. asl has several advantages over fdg-pet. crucially, it can easily be added to the routinely performed structural mri examination. feasibility studies show that asl provides reliable cbf maps in dementia. in patients with established alzheimer's disease and frontotemporal dementia, hypoperfusion patterns are seen that are similar to hypometabolism patterns with fdg-pet. current and future studies in this field will need to demonstrate the validity of asl in the diagnostic workup of the individual patient, early in the disease process. studies on asl in brain tumour imaging indicate a high correlation between areas of increased cbf as measured with asl, and increased cerebral blood volume as measured with dynamic susceptibility contrast-enhanced perfusion imaging. the major advantages of asl for brain tumour imaging are the fact that cbf measurements are not influenced by breakdown of the blood brain barrier, as well as its quantitative nature, facilitating multicentre and longitudinal studies. the analysis of a sinonasal tumour requires mri for differentiation between tumour and secretions or polyps, to assess the local extension and spread into adjacent compartments (skull base, intracranial, orbit, deep facial compartments) and to depict perineural spread. t2, t1 and high-resolution postcontrast series preferably in three, but at least in two different planes, are needed. ct provides additional information of bony structures and serves as a road map for surgical navigation. a fascinating benign sinonasal tumour is inverted papilloma, which has a high recurrence rate if not removed in toto and may harbour carcinoma in < 5% of patients. ct may show the attachment of the tumour as an area of increased sclerosis, which directs the surgeon to plan the operation. in patients with recurrent inverted papilloma, providing information to the radiologist about its presumed localisation is important, the more so in patients suffering from polyposis. malignant tumours are uncommon and of a large histologic variety. about 80% arise in the maxillary sinus; 70% are squamous cell carcinomas. they are often large at diagnosis, because clinical symptoms of nasal obstruction or headache are non-specific. diagnosis is by biopsy. in view of the rapid development of advanced endoscopic techniques, preoperative imaging is extremely important to assess accurately tumour extension. the skull base and dura as well as the lamina papyracea should be scrutinised for tumour locations to foresee an additional cranioendoscopic approach to a standard endonasal endoscopic approach. finally, imaging may play a role in differentiating non-nasal disease, e.g. primary bone tumours, from mucosal disease. to discuss risk/benefit considerations in medical imaging from the perspective of patients and highlight some of the pre-requisites to ensure trust and confidence. this presentation will draw on the work of the european patients' forum on patient safety, quality of care, health literacy, and patient empowerment, to explore what are the key factors to consider in radiation risk analysis, from a patient's perspective, recognising that 'one size does not fit all'. it will examine what constitutes quality information in this environment, effective dialogue between the patient and the radiologist, and the interdisciplinary team, informed consent and transparency of data. it will also highlight some of the particular challenges regarding vulnerable patients, and those requiring on-going treatment due to chronic disease (s). the justification for medical procedures is based on the assumption that the benefit outweighs the risk. this presentation looks at the radiation risk factors from recent high-profile papers (pearce et al., 2012) and publications from international bodies such as beir and icrp. at lower radiation doses (< 100 msv), quantifying, understanding and communicating radiation risk to staff, patients and referring clinicians presents a range of challenges. advances in health information systems will facilitate more precise dose risk relationships. there are a number of approaches to stochastic radiation risk assessment such as organ-/age-based assessment and effective dose equivalent assessment. at-risk groups, such as children and pregnant women, need special focus. eu directives demand special attention for high-dose interventional procedures and ct scans. these techniques, particularly if repeated, require further risk assessment regarding potential deterministic effects such as erythema, hair loss, and radiation-induced cataractogenesis. this paper looks at strategies in consenting, monitoring, and follow-up of such high-dose effects. the practical implications of the new occupational icrp eye dose limits for interventional practice are also examined. with the advent of higher field scanners in clinical practice and the construction of 'mri compatible' implanted devices, the list of the do's and don'ts while performing an mri examination changes constantly. in this presentation basic safety guidelines and rules will be explained regarding static magnetic field effects, time varying magnetic field effects, radiofrequency field effects and acoustic noise effects both with regard to the patient as well as the personnel using the equipment. due to the advances in medical technology the list of possible 'safe' and 'unsafe' items changes almost daily. therefore it is very important to have all the information about the patient's condition and implants prior to the mri procedure in order to asses possible contraindications in advance. while until a couple of years ago cardiac pacemakers and neurostimulators were contraindicated in the mri environment, the advent of 'mri compatible' pacemakers and other implanted devices introduces challenges in patient safety. in fact these devices are only safe in certain configurations and also in a lot of cases specific mri scan sequences and rf antennas are only allowed. following the european emf directive, where the mri part is derogated, the protection of staff working with em fields also became a topic of debate. what are the possible risks for staff working with mri magnets and how can one implement practical rules for the safe use of the mri equipment. the field of image-guided ablation has expended recently with new ablation techniques like micro-wave, irreversible electroporation, cryoablation. nevertheless, after each treatment, whatever the technique used, we will leave in place in the treated organ, a scar instead of the tumour. follow-up of these treated areas are done by radiologists using ct of mr or contrast enhanced ultrasound. standardisation of terms has been done in 2003 by an international committee presided by dr. goldberg. this allows reporting criteria identical from one center and from one country to another. furthermore, it allows a more homogeneous literature and evaluation of success. nevertheless, techniques are not all the same and the cellular and tissue damage in the tumour and around it in the healthy parenchyma are not identical and does not have the same evolution over time. thermal ablation is frequently used to treat liver, lung and bone tumoural lesions because of its safety, efficacy and tolerability. one issue is the lack of reliable imaging modality to assess treatment efficacy and to detect early relapse. several papers have demonstrated that 18 fdg pet/ct is a useful tool to follow-up ablated liver tumour, detecting residual disease easily and earlier than conventional imaging. few reports evaluating the usefulness of 18 fdg-pet/ct in the follow-up of ablated lung lesions are available, but prospective studies show promising results, with a high negative predictive value of this technique. very few data are available on bone lesions and further studies are needed to assess the role of 18 fdg-pet/ct in the follow-up of these lesions. in general, the in vivo typical aspect of completely ablated lesion on 18 fdg-pet/ct is a ring shape, diffuse, peripheral, homogeneous 18 fdg uptake at the treated lesion; on the other hand, the presence of heterogeneous and focal uptake is more frequently related to disease relapse. suvmax (standardised uptake value) is not a reliable indicator. it is higher in case of disease relapse than in completely ablated lesions, but also in case of important inflammatory reaction. finally, the best time point to evaluate ablation efficacy still remains to be defined, but 18 fdg-pet/ct should be performed at least 3 months after treatment to avoid dubious or inconclusive findings due to inflammatory reaction. the aim of thermal ablation treatment is to generate an area of thermocoagulation whose diameter is larger or at least equivalent to that of the tumour. this necrotic scar usually shrinks with time, but most often very slowly. therefore, the criteria of response based on size measurement cannot be applied. the pattern of thermal ablation is similar whatever the thermo-ablation technique used. on ct imaging, thermal ablation areas are well circumscribed and oval shaped. the criterion commonly used to assess the efficacy is the absence of enhancement in the thermal ablation necrosis, which corresponds to tissue devoid of viable tumour. on mr imaging, the thermo-ablation areas are typically hyperintense on unenhanced t1 due to the presence of proteinaceous material, and hypointense on t2, explained by the dehydrating effect of thermal damage. the residual tumour is typically round in shape and located at the periphery of the necrotic area or in contact with large vessels. mr imaging allows earlier detection of residual liver tumour than ct imaging. neurodegenerative diseases, cancer and heart disease perhaps summarise the major challenges to medicine in this century, a challenge in accurate diagnosis and also in treatment. recent technological advances in medical imaging technology mean that these challenges can be dealt with more efficiently. anatomy can be studied faster, safer and with higher spatial resolution and precision. in addition to anatomy, the study of function has become feasible; more sophisticated hardware and software are being used to get the required data to map out the functionality and understand how this relates to anatomy to offer a more comprehensive view of normal development and explain pathological conditions. at the same time, researchers and clinicians are urged to create a platform for reciprocal communication to facilitate translation of the research findings to a graspable clinical benefit for the patients. this translational platform will allow flagging the major clinical questions, inform current and future research experiments and at the same time help utilise recent research findings in the clinical setting. this session will review state-of-the-art mri techniques and document different approaches to translational imaging. it will also allow understanding the obstacles and remedies in implementing translational medicine. many neurological diseases are associated with progressively reduced cognitive function. recent evidence suggests that proficient cognitive function depends on an appropriate interaction between large-scale cognitive control networks in the brain. it is hypothesised that damage to white matter microstructure, as found in many neurological diseases, disrupts the integrated operation of these networks and results in impaired cognitive function. diffusion tensor imaging (dti) has been used to investigate alteration to white matter micro-structure and resting state fmri (rsfmri) has proven to be a useful technique to assess brain function in multiple cortical systems. however, the combined use of these techniques in the clinical setting has not yet taken hold. in this presentation, i will demonstrate the flexibility of these mri techniques in assessing brain structure and function and address their feasibility of use in a clinical setting. imaging in oncology is a growing field within radiology. different tomographic techniques are used either isolated or as multimodality-multivariable imaging, as there is an increasing need to combine morphological and functional information. different cutting-edge modalities, such as pet-ct, dw-mr, ce-mr and mr-spectroscopy, are standard in most clinical scenarios. new images have advantages providing excellent soft-tissue contrast and multidimensional functional, structural and morphological information. the development of new diagnostic imaging research areas, mainly in the field of oncology, cardiology and neuropsychiatry, will impact the way medicine is performed today. both clinical and experimental multimodality studies, in humans and animals, will have to demonstrate an efficient use of the imaging information provided by the modalities to affect the future of medical imaging. we will comment on the impact of continued technological developments in medical imaging on patients with cancer (diagnosis, staging and follow-up) and the challenges of imaging technologies from research into clinical reality. the recent advances and developments in measurements and biomarkers which have led to a greater understanding of cancer will be commented, together with the morphologic, metabolic and functional oncological imaging research and clinical practice. finally, the role of the radiographer in advanced oncological imaging techniques will be evaluated. when imaging the head and neck region with ct or mri, teeth are always present. we frequently encounter radiolucent or radiopaque lesions of the jaw on scans performed for other indications. familiarity with typical dental conditions is necessary to subject the patients to the right therapy. to correctly evaluate and describe those lesions, this special focus session on dental imaging gives the radiologist a tool to report dental lesions. the anatomy of panoramic and ct images will be reviewed in the first talk. technical details as well as pitfalls will be presented. in the second talk, the focus is on pre-and post-surgical imaging with ct where typical lesions of the jaw will be presented. an insight into imaging the teeth with mri will be given by the third speaker. the discussion on the impact of radiologists on dental images will complement this special focus session's theme. panoramic radiography produces a single image of the maxilla, mandible, teeth, temporomandibular joints and maxillary sinuses. during the exposure, the x-ray source and the detector rotate synchronously around the patient producing a curved surface tomography. this horseshoe-shaped zone of sharp image is called the focal trough/image layer. advantages of this technique are a good overview of lower facial hard tissues, the convenience of an extraoral examination, a low patient radiation dose, and low costs. disadvantages are limited width of the sharply imaged layer, variable magnification, and oblique projection, especially in the upper premolar region. patient positioning is most important for obtaining a detailed panoramic radiograph. in addition to patient position errors, patient movement during exposure and metal objects can cause artefacts. also, ghost images caused by structures located between the x-ray source and the rotation centre can hamper diagnostics. cbct is a radiographic imaging method that allows accurate 3d imaging of hard tissues. during a cbct scan, the scanner rotates around the patient's head (180â°-360â°) obtaining multiple sequential planar projection images by a 2d detector. the scanning software collects the data which is processed to create a volumetric data set with isotopic voxels with varying fov. disadvantages of cbct imaging are poor soft tissue contrast and artefacts. in addition to normal panoramic and cbct anatomy, after this presentation the audience will be familiar with the panoramic and cbct techniques as well as common errors and pitfalls of these techniques. pre-surgical and post-surgical imaging with mdct and cone-beam ct a. gahleitner; vienna/at (andre.gahleitner@meduniwien.ac.at) multislice-ct and more recently cone-beam-ct have become an established method for anatomic imaging of the jaws prior to dental implant placement. commonly referred to as "dental-ct", these high-resolution imaging techniques have gained importance in diagnosing dental-associated diseases of the mandible and maxilla. especially in patients with inflammations, cysts, oro-antral fistulas, odontogenous sinusitis, impacted teeth and dental fractures, new indications have emerged. unfortunately, most radiologists have had little experience in this area and many of the dental-ct findings remain undescribed. hence, we will determine the ct appearance of frequent dentalrelated diseases of the jaws and demonstrate typical pre-and postoperative findings. this presentation reflects our experiences from 18 years of performing dental-ct with 36.000 investigations, closely working together with dentists and oral surgeons. learning objectives: 1. to learn about the typical findings from pathological conditions of the jaw, which confront dentists and oral surgeons. 2. to understand these findings in cross-sectional imaging like multislice and cone-beam ct. 3. to learn about the usual treatments for these conditions in order to know how they are used in dental radiology. dental mri s. rohde; dortmund/ de (stefan.rohde@klinikumdo.de) this lecture will discuss the potential of dental mri in the field of inflammatory and neoplastic disease of the periodontal space. experimental and preliminary clinical data from high-field dental mri will be presented with a special focus on the visibility of critical anatomical structures on high-resolution sequences. the results will be compared to high-resolution cone-beam ct. based on representative cases, we will review the main causes of thoracic non-traumatic vascular emergencies (acute aortic syndrome, pulmonary thromboembolism and haemoptysis); mdct angiography has become the firstline imaging test for the diagnosis of these entities. as acute aortic disease is the most common fatal condition in patients with chest pain and prompt recognition and treatment are of paramount importance, we will review the spectrum of acute aortic pathology focusing on the distinctive findings of each entity (classic dissection, intramural haematoma and penetrating aortic ulcer) and upgrading the clues for their diagnosis. acute pulmonary embolism (pe) remains a common clinical challenge. mdct pulmonary angiography has become the first-line imaging study in the diagnosis of pe because of its speed, accuracy, low interobserver variability and ability to provide alternative diagnoses. we will review the role of mdct in the evaluation of acute thrombotic pe: findings of acute pe (including how to evaluate the severity of an episode of pe at ct pulmonary angiography) and some potential pitfalls. massive haemoptysis is a life-threatening condition that is associated with a high mortality rate. haemoptysis usually involves bleeding from the bronchial arteries or, less frequently, from nonbronchial systemic arteries. haemoptysis of pulmonary arterial origin is rare, estimated at less than 10% of haemoptysis cases. mdct angiography permits noninvasive, rapid, and accurate assessment of the cause and consequences of haemorrhage into the airways and helps guide subsequent management. acute respiratory failure can have multiple underlying causes including infection, fluid overload, immunological diseases or exacerbation of preexisting lung disease. since the clinical symptoms are nonspecific, imaging plays an important role. the first imaging method is mostly the chest radiograph, easy to access and to obtain, but non-diagnostic in many cases. (hr)ct offers more possibilities to define the differential diagnosis. the option of this interactive workshop will be to get familiar with the spectrum of diseases that can cause acute respiratory failure and learn about key findings in radiography as well as ct to reduce the differential diagnosis. the interaction between preexisting lung disease, clinical information (e.g. chemotherapy, rheumatoid arthritis, copd) and imaging findings will be discussed using clinical case studies. options and also limitations of imaging findings will be illustrated. the following scenarios will be taken into account: acute cardiac failure and various appearances of oedema; acute immunological-toxic disorders including druginduced lung disease and inhalational injuries; exacerbations of preexisting lung disease including fibrotic and obstructive lung disorders; severe infections causing respiratory failure and their complications. contrast-enhanced ultrasoud (ceus) and elastography are evolving us techniques that have already found their ways into clinical practice (ceus) or will do so in the next few years (elastography). ceus is performed with 2 nd generation us contrast media, but these contrast media are not available worldwide. in many european countries, sonovueâ® (bracco, it) is the only available contrast, consisting of micro-bubbles less than the size of red blood cells. in contrast to ct and mr contrast media, these bubbles are strictly intravascular. for us imaging, low mechanical index us techniques are used to see the resonance of sound by these bubbles. ceus is excellent for the differential diagnosis of focal liver lesions based on vascularisation and specific contrast uptake (imaging the wash-in and wash-out of us contrast over time with excellent temporal resolution) and increases us sensitivity to liver metastases in colorectal cancer patients. however, ceus is only useful when there are excellent us conditions. in pancreatic us, ceus allows to differentiate adenocarcinoma from neuroendocrine tumours based on vascularisation (us contrast uptake). whereas elastography (strain elastography or shear wave elastography) is established for the diagnosis of liver fibrosis, there are no general recommendations for using these various techniques to measure the "hardness of a focal lesion" in focal liver and pancreas lesions. diffusion-weighted mr imaging (dw-mri) provides information on tissue cellularity, extracellular space tortuosity and integrity of cell membranes by measuring the motion of water molecules in tissues modified by flows (blood vessels, glandular ducts,.). and interaction with cellular components. integrated in conventional-mr acquisition protocol, dw-mri increases sensitivity for lesion detection. the apparent diffusion coefficient (adc) can be calculated using a mono-exponential relationship between signal attenuation and b-value. this fitting is influenced by microcapillary perfusion. a more sophisticated approach (intravoxel incoherent motion, ivim) would enable estimation of parameters that separately reflect tissue diffusivity and microcapillary perfusion. using ivim-analysis, the derived quantitative parameters describe tissue diffusivity, perfusion and perfusion fraction. by providing qualitative and quantitative information, dw-mri is applied in oncology to characterise malignancy, including lesion aggressiveness, and to monitor treatment response. perfusion imaging is a useful tool to achieve information concerning tissue vasculature, microvascular permeability and interstitial space characteristics. dynamic contrast-enhanced techniques (dce-ct, dce-mr) are based on the analysis of the contrast agent (tracer) biodistribution in tissues. quantitative parameters are obtained using pharmacokinetic models, as transfer constant ktrans, extracellular-extravascular space fraction ve, vascular tissue fraction vp and the rate constant kep. quantitative dw-mr and dce-mr parameters are increasingly used as imaging biomarkers to predict tumour response and/or to monitor the effects of therapy, especially when anticancer agents with novel models of action are used (anti-angiogenic, tyrosine kinase inhibitors and several others). therefore, these new imaging biomarkers may have a pivotal role in correctly evaluating tumour response and stratify and managing cancer patients. elderly and the young can all present special problems that require a greater depth of understanding to obtain a diagnostic study. this session will help you in your quest for reliable high-quality investigations for all. a. coronary cta in patients with severe arrhythmias and high heart rate c. loewe; vienna/ at (christian.loewe@meduniwien.ac.at) besides all advances in scanner technology, heart rate remains a critical issue for coronary cta, and motion artefacts due to cardiac function represents still the most frequent reason for limited diagnostic image quality in cardiac cta. thus, the target heart rate is defined depending on the scanner system used and ranged between below 60 bpm and below 70 bpm. however, in a number of patients heart rate control is not possible or not successful (i.e. children, emergencies, heart transplant recipients), whereas a relevant proportion of ctas are performed in patients with heart rates higher than the target frequency. during this presentation, the possibilities for heart rate control by beta blocker injection and beyond will be discussed and possible workflows will be presented. furthermore, examination strategies for patients with high heart rates will be presented including reverse dose modulation, high-pitch scanning, systolic scanning and more. finally, tools for reconstruction and assessment of patients scanned at higher heart rate will be introduced. different to high heart rates and even more critical with regard to image quality is arrhythmia. due to the complexity of cardiac synchronisation, a ct suite is not the place for cardiac resynchronisation, whereas the indication to cta has to be reevaluated depending on referring diagnosis and severity of arrhythmia. since there are patients undergoing cta because of arrhythmia including patients prior to ablation treatment, strategies for examination and image reconstruction in case of arrhythmic patients have to be established and will be presented. cardiac computed tomography (ct) has become a widely available diagnostic tool used in a range of heart conditions. the commonest application of this technique is in the evaluation for coronary artery patency (coronary ct angiography) in patients with chest pain. when coronary arteries are heavily calcified, or post-coronary angioplasty with stent implantation, diagnostic problems can occur. in these circumstances, the evaluation of the coronary arteries on ct is hampered by the occurrence of high-density artefacts caused by calcifications and stent struts. these artefacts may preclude the appropriate assessment of the coronary lumen. the presence of motion artefacts in the dataset or image noise in very large patients may exacerbate the problem. in this scenario, accurate patient selection and preparation remain key to ensure that the diagnostic yield of the cardiac ct study is good. optimisation of scan parameters (kv), contrast injection protocol and use of appropriate postprocessing techniques (e.g. dedicated convolution filters) play an important role in daily clinical practice. recent technical developments include dualenergy scan techniques and gemstone spectral detector systems that acquire simultaneously high and low kilovoltage datasets. this is done to achieve tissue differentiation. in principle, by using monochromatic image reconstruction, the effect of high-density artefacts may be decreased. using a similar principle, high-density structures can be subtracted from the image. the introduction of iterative reconstruction algorithms may play a role in that these algorithms are theoretically more accurate in the modeling of physical noise and tissue geometries. lack of movement artefacts is one of the major prerequisites for good image quality in cardiac mr. it is crucial to have the minimum possible image acquisition time. it is important to make both te and tr as short as possible. data acquisition should be synchronised with patient's ecg or pulse. special attention should be paid to good quality of ecg recordings (good contact of electrodes with the skin, electrodes positioning, using of dielectric pad). in patients with arrhythmia, prospective ecg synchronisation should be used instead or a retrospective one, or special protocols may be applied for arrhythmia correction. breathing artefacts are usually not a problem for cardiac mri, because most sequences are acquired during a single breath-hold. using ssfp and parallel imaging allows obtaining a complete set of cine mr images through the whole heart in 1-8 short breath-hold periods. the technique of realtime cardiac mr is a good way to perform successful examinations even in difficult patients, especially the ones with heart failure. other systemic mrartefacts (aliasing, chemical shift, magnetic susceptibility, off-resonance) should be recognised and diminished or eliminated by the operator. these artefacts are more prominent in case of 3 t systems. late-enhancement studies with gd are very dependent on the correct selection of the ti time. phase-contrast mri requires venc calibration in cases of valve stenoses. to meet the challenges and the benefits of cardiac mri, one must balance the constraints of signal-and contrast-to-noise ratios, spatial and temporal resolution, scan time and image quality. scoliosis, a common spinal deformity in teenagers, especially girls, progresses during their growth until the end of puberty. therapeutic choices, which are either medical -with corset -or surgical, depend on this progression. follow-up is mainly clinical. however, radiographs are often indicated to give precise information: ap and lateral views of the spine in standing position remain the basis of this follow-up. obtaining a good image quality at all levels of the spine has been a technical challenge for a long time, and the question of radiation dose is also a main concern, as these radiographs require a high radiation dose. fortunately, radiographic techniques have greatly improved over the past few years: from the conventional 90 or 120 cm film to digital screens and now flat screens, we now obtain better quality images with less radiation. today, eos system using xenon chamber is the best to give good ap and lateral views. it allows 3d reconstructions with minimal radiation dose. on these radiographs, measures can be performed, essentially cobb's angle. it helps in evaluating progression of the curves and making surgical decisions. other imaging techniques are requested only in particular situations as in the presence of neurological symptoms or general disease such as neurofibromatosis, or in young children with malformative scoliosis and sometimes preoperatively. ct is best to study the vertebrae; it objectivates vertebral malformations (agenesis, hypoplasia, blocks). mr will be requested to study the cord, nervous roots, craniospinal junction and the soft tissues. collaboration between the radiologist and spinal surgeon is essential. the key elements in the diagnostic process, as for most bone lesions, are: the age of the patient, the type of bone and bone segment involved, the location within the bone, the presence of signs of aggressiveness (type of osteolysis, limits, presence and type of periosteal reaction). conventional x-rays should never be absent from the initial workup of a focal bone lesion in a child, as they provide essential features for differential diagnosis and, in most cases, eliminate the need for other more costly techniques. the need and priority for other imaging techniques, such as ct, mri and bone scintigraphy, are decided on a case-by-case basis and sometimes a combination of these techniques, which complement each other, is needed. it is the radiologist's responsibility to recommend histological analysis of a lesion via biopsy whenever the imaging aspect is not characteristic or indicates signs of possible malignancy. learning objectives: 1. to recognise the most common benign bone tumours and pseudo-tumours. 2. to understand the differences between benign bone tumours, pseudotumours and malignancies in children. 3. to understand imaging modalities that could help in the differential diagnosis of benign bone tumours and pseudo-tumours in children. a-472 17:00 a.c. offiah; sheffield/uk (amaka.offiah@nhs.net) the 2010 nosology and classification of genetic skeletal disorders subdivides 456 conditions into 40 groups defined by molecular, biochemical and/or radiographic criteria. 316 conditions are associated with mutations in at least one of 226 different genes. some of these conditions are rare or even extremely rare (occurring in fewer than 1 in 100,000 of the population). clearly, the general paediatric radiologist cannot be expected to correctly recognise and diagnose all of these conditions. the approach is to perform a set of radiographic images dependent on the patient's age/size and to develop a standard system for reviewing these images. the standard set of images for a patient over 2 to 3 years of age consists of ap and lateral skull, ap chest, ap pelvis, lateral thoracolumbar spine, ap one upper limb, ap one lower limb and dp left hand. variations on this routine dysplasia skeletal survey will be discussed and a standard system for interpreting the images will be presented using radiographs of the commoner skeletal dysplasias as examples. in the last few years, interest in body composition (bc) analysis, which is the quantification and characterisation of relative amounts of muscle, fat, bone, and other vital parts composing the human body, has grown rapidly for clinical, research and epidemiological purposes. studying body composition has gained great importance for the comprehension and decoding of a multitude of patho-physiological processes (e.g. obesity, diabetes and endocrine diseases and also gastrointestinal, renal, nervous, infectious diseases, etc). and physiological and para-physiological conditions as in athletes or growth and ageing processes. although the main imaging techniques, which include dualenergy x-ray absorptiometry (dexa), computed tomography (ct), and magnetic resonance imaging (mri), offer a differentiated and attractive analysis of bc, they still need to find a definite position in clinical practice. through 'programming' low birth weight is associated with increased rates of coronary heart disease, stroke, hypertension & non-insulin dependent diabetes. prediction of morbidity and mortality from body composition, particularly fat, stimulates the importance and application of accurate and precise methods for quantitative assessment of body composition; the gold standard for which is cadaver analysis, but other methods have to be implemented in vivo. body composition alters in many chronic diseases, starvation cases, metabolic syndromes, and senescence stages, and is a key component of health. several techniques are available which vary in simplicity and complexity of use. each make assumptions and may not measure body composition directly, but make predictions from other measurements made. skinfold thickness measurements assess regional fat and are quick and simple to perform at all ages. reproducibility is good, but less so in obesity. there is some limitation of reference data to express results as standard deviation scores (sds). body mass index (bmi; weight/height 2 ) is widely used as an index of relative weight expressed as sds for gender, age and ethnicity. waist circumference (wc) is a measure of central fat, and can also be expressed as a ratio to hip circumference. bioelectric impedance analysis (bia) measures body impedance to a small electric current, which estimates total body water (tbw) from which can be derived fat free mass (ffm). tbw can also be measured by neutron activation. air displacement plethysmography (bod pod) is a new method for body composition assessment. learning objectives: 1. to understand normal body composition in children and adults. 2. to learn how body composition can be altered by disease. 3. to appreciate the clinical relevance of assessing body composition. 4. to understand the non-imaging methods available for measuring body composition, with their advantages and limitations. computed tomography: what does it measure and how? j. damilakis; iraklion/ gr (damilaki@med.uoc.gr) ct allows measurement of total body fat and enables differentiation of subcutaneous from visceral adipose tissue. body fat can be estimated using the conventional technique of manual planimetry. using planimetry, the user delineates manually the boundaries of subcutaneous and visceral fat in each ct image. however, this method is labour intensive, time-consuming, and, therefore, not easily applicable in routine clinical practice. another ct method used for the estimation of abdominal fat is the semiautomatic measurement of adipose tissue area. abdominal fat is assessed in a ct slice by using a fixed range of hounsfield units to define the area of adipose tissue. a limitation of this method is that the attenuation range of fat may vary among individuals. the stereological volume estimation method is based on the cavalieri's principle. according to this principle, the volume of an object can be measured by cutting it into equally spaced slices and measuring the area of the object on each slice. to measure body fat using stereology, a square grid of test points is randomly superimposed on each ct section. all points lying inside the fat tissue region are selected by the user and the software automatically calculates the total number of points hitting the fat. stereology provides the possibility for efficient fat volume assessment. however, research studies are needed to optimise the stereological estimation of fat and compare stereological measurements with those from other adipose tissue measurement ct techniques. learning objectives: 1. to appreciate the role of ct imaging in body composition analysis. 2. to learn how to measure visceral and subcutaneous adipose tissue using ct. 3. to understand the advantages and limitations of ct techniques (planimetry, thresholding, stereology) in evaluating adipose tissue. mri: current and future applications d.c. karampinos; munich/ de (dimitrios.karampinos@tum.de) mri has been emerging as an ionising radiation-free imaging modality to measure fat distribution in the human body and fat content in different organs. the present talk will first introduce mri methods to measure fat distribution, including the well-established t1-weighted imaging and the emerging dixon imaging approaches. the challenges related to the data acquisition and image post-processing of the two imaging approaches in the study of fat distribution will be reviewed. examples will be shown from the current use of mri in investigating adipose tissue distribution alterations or differences in patients with metabolic disorders, including obesity and diabetes. quantitative mri methods enabling the measurement of fat content with high spatial resolution will be then presented, with a focus on water-fat separation methods. the technical challenges associated with the establishment of mri-based fat content, as an accurate and reproducible imaging biomarker will be discussed. the selection of pulse sequence parameters and image reconstruction algorithm in a state-of-the-art water-fat separation experiment will be explained. applications will be shown from the growing literature of mri-based fat quantification in abdominal organs (e.g. liver) and in skeletal muscles, aiming to show the great premise of quantitative water-fat mri in quantifying fat content with high spatial resolution in different body parts. at the end of the talk, the potential of quantitative water-fat mri will be discussed in the emerging application of measuring bone marrow fat content and its association with bone health and metabolic disorders. the key role of dual-energy x-ray absorptiometry (dxa) in the management of metabolic bone diseases is well known. the role of dxa in the study of body composition and in the clinical evaluation of disorders which directly or indirectly involve the whole metabolism as they may induce changes in body mass and fat percentage is less known or less understood. dxa has a range of clinical applications in this field, from assessing associations between adipose or lean mass and the risk of disease to understanding and measuring the effects of pathophysiological processes or therapeutic interventions, in both adult and paediatric human populations as well as in pre-clinical settings. dxa analyses body composition at the molecular level that is basically translated into a clinical model made up of fat mass, non-bone lean mass, and bone mineral content. dxa allows total and regional assessment of the three abovementioned compartments, usually by a whole body scan. since body composition is a hot topic today, manufacturers have steered the development of dxa technology and methodology towards this. new dxa machines have been designed to accommodate heavier and larger patients and to scan wider areas. new strategies, such as half-body assessment, permit accurate body scan and analysis of individuals exceeding scan field limits. although dxa is a projective imaging technique, new solutions have recently allowed the differential estimate of subcutaneous and intra-abdominal visceral fat. the transition to narrow fan-beam densitometers has led to faster scan times and better resolution; however, inter-or intra-device variation exists depending on several factors. in cancer patients, disease-free survival is a good indicator for tumour response, but for many common cancers, treatment of disseminated disease is often noncurative. the increased duration of survival is related to changes in tumour size after treatment. however, the anatomical determination of tumour response has some limitations, especially when non-cytotoxic targeted therapies are used. with these new treatments options, the lack of progression may be associated with a good improvement in outcome, even in the absence of major shrinkage of tumours. new imaging biomarkers are therefore needed to assess therapeutic response. molecular imaging is now playing a prominent role in the monitoring of cytostatic targeted therapies. pet-ct, dynamic contrast enhancement studies or diffusion-weighted imaging are the most promising ones. the aim of this session is to present the state of the art in tumour response assessment with regard to new therapeutic regimens. in early oncologic times, treatments of different malignancies were reported in different ways. c. gordon zubrod and others first articulated the model of multicentre clinical trials and argued for standards to be agreed for included and excluded subjects, the method of assigning treatment and in measuring response. nowadays, we have better knowledge of tumour biology; however, we continue using the classical response criteria (who and recist) and overall survival as a primary goal for effective treatment in most of the malignancies. in the last few years, different criteria for responses have been reported to evaluate the disease and a lot of discussions between authors have been reported. now, we can use the recist criteria v1.1, implement the percist criteria and also forget the immunotherapy criteria. furthermore in the last few years, different treatments such as vaccines, antiangiogenics and targeted therapies have increased our arsenal in the treatment of different malignancies such as kidney cancer, prostate cancer, breast cancer and so on. another problem for our patients is that those diseases have a long evolution after the first-line treatment. we have to be able to define in each disease the treatment line and type of treatment to determine which evaluation criteria are necessary and which is the objective of treatment, pfs or os. we have to be aware that if we are not able to define such topics, we may be losing active treatments. recist 1.1 are the criteria most often used in studies to evaluate response to treatment in solid tumors. on each follow-up examination, response is defined by a combination of unidimensional measurement of 'target lesions', qualitative evaluation of 'non-target' lesions, and presence/absence of 'new lesions'. ct and mri are the preferred modalities for recist evaluation, and evaluations must be performed using the same modality, in the same plane. we will review anatomic locations which should be avoided, and how to deal with intercurrent events resulting in the impossibility of measurement. cases when recist seems inadequate will be discussed, including evaluation of bone metastases, and focal therapy. finally, though these criteria were developed for drug trials, they may provide a frame for reading examinations and writing reports in routine practice. reproducible, objective and quantitative criteria help to define or in the obese patient. ct is especially helpful in those with suspected retroperitoneal pathology, in the investigation of immunocompromised patients and those with complex post-operative problems. ct guidance may be required to facilitate percutaneous abscess drainage, particularly for deep pelvic collections. in addition, ct plays a vital role as a 'problem-solver' when ultrasound has failed to fully answer the clinical question posed. this short presentation will utilise clinical studies to illustrate the benefits of ct in the investigation of the acute abdomen, both as the initial imaging modality and as a second line tool following ultrasound. learning objectives: 1. to understand the advantages of ct as a primary imaging modality for children with acute abdomen. 2. to learn about clinical scenarios in which ct is relevant. 3. to appreciate the use of ct as an adjunct to ultrasound. abdominal trauma: us is better v. miele; rome/it (vmiele@sirm.org) ultrasonography (us) is a reliable technique whose advantages are rapidity, portability and accuracy in depicting intraperitoneal fluid without interrupting resuscitation and without radiation exposure. in the haemodynamically unstable paediatric patients, it represents the first line together with the x-ray evaluation. us for trauma has become more standardised and is worldwide known with the acronym of fast (focused abdominal sonography for trauma) or e-fast (extended-fast) used in depicting also pleural and pericardial effusions and pneumothorax. nevertheless, many parenchymal injuries are not correctly visualised at baseline us and some traumatic solid organ lesions can occur without hemoperitoneum. in case of haemodynamically stable patients, who have suffered a low-energy trauma, the greater time available allows the use of specific us contrast agents, enabling a better identification of traumatic organ injuries. contrast-enhanced ultrasonography (ceus) has a greater sensibility and specificity in the identification of parenchymal traumatic lesions, both in the first evaluation and follow-up, and could avoid unnecessary radiation and iodinated contrast medium exposure. in case of haemodynamically stable paediatric patients, who have suffered a high-energy trauma, us is not recommended as first-line investigation, because ce-mdct should be performed first. only in the follow-up, ceus can be considered an alternative to ct. in conclusion, e-fast and ceus should be considered as a useful tool in the assessment and monitoring of paediatric trauma. this examination can be performed at the patient's bedside, representing a useful alternative to ct in the paediatric traumatised patients and in the follow-up of a known abdominal injury. learning objectives: 1. to understand the differences in the diagnostic paths of paediatric patients. 2. to learn about the diagnostic efficacy and limitations of ultrasonography. 3. to become familiar with the use of the contrast-enhanced ultrasonography (ceus). abdominal trauma: ct is better m. raissaki; iraklion/gr (mraissaki@yahoo.gr) ct has been considered a sensitive, specific, and accurate test in the identification and grading of injuries, especially in the severely injured child. it should be overemphasised that traumatised children differ from adults: haemodynamically stable children may actually be actively bleeding and rapidly deteriorate. conversely, children have smaller calibre vessels, stronger vasoconstriction, and stronger solid organ capsules; bleeding may stop spontaneously, organ rupture is more difficult and delayed rupture is rare. this is why few children will undergo laparotomy or trans-arterial embolisation. the goal of imaging is to clear the abdomen in multi-traumatised children, identify those that may rapidly deteriorate because of clinically silent active bleeding, increase the surgeon's confidence level and define short-and long-term medical management. due to children's increased radiosensitivity, all ct scans should be indicated based on appropriate early clinical evaluation, assessment of risk factors for abdominal injuries and evaluation of the closely monitored child. alara includes the availability of outside scans upon admission, avoiding non-contrast scans and multiple phases and applying age-and weight-dependent exposure parameters. ct should not be performed as follow-up unless there is clinical deterioration. ct has the advantage of rapidly identifying and delineating with high resolution solid organ, vascular, mesenteric, bowel injuries and pending oligaemic collapse (hypoperfusion complex or shock bowel). important fractures and thoracic injuries may be simultaneously revealed with ct. the objective documentation of intraabdominal injuries is extremely important in suspected child abuse. evaluation of mr imaging in a patient with an intramedullary lesion should focus on key features: a) the location of the lesion on the cross-sectional area of the cord, best evaluated on axial images, b) the length of the lesion evaluated on sagittal images, c) the presence of cavitation and cysts, d) signal intensity on t2-wi, e) the presence of enhancement and enhancement type, and f) associated leptomeningeal enhancement. the knowledge of the presence or absence of the brain lesions is important information for narrowing the differential diagnosis. the clinical picture and the onset of symptoms will help the differentiation between the neoplastic and inflammatory and vascular lesions. in this lecture, the imaging characteristics and typical patterns of intramedullary lesions will be presented. a diagnostic algorithm, which includes imaging, clinics and csf analysis, will be discussed. a common clinico-radiological situation is the differentiation between spinal infection, degenerative changes and osteopaenia, and spinal tumour. in most cases, conventional ct and/or mri will allow a certain differentiation, and additional biopsies are mainly used to obtain tissue for bacteriological or histopathological classification. advanced mr techniques such as dwi may sometimes help in increasing diagnostic certainty, but are seldomly used in day-to-day practice. spinal infections typically present around the intervertebral disc, but may also present as isoloated spondylitis without disc involvement, and sometimes the infection quickly spreads to the epidural space. degenerative changes my sometimes mimic infection due to strong gadolinium enhancement. the main differential diagnosis of spinal tumorous processes is osteopaenic changes (oedema), and ct may be helpful in such cases, for example to demonstrate degenerative gas in the vertebral body. rare causes of spinal abnormalities such as atypical pathogens and rare tumours may cause diagnostic problems; often the fastest road to a diagnosis is biopsy in those cases. the correct clinical diagnostic approach to spine disease is mandatory in the selection of patients to be treated. the anatomy and the relationship between different structures must be known in detail to understand the source of the pain and so to treat it percutaneously. mr, ct, dynamic x-ray and nm bone scan in selected cases can be used to understand the reason for the pain. mr with t2 stir sequence or t2 fat supp technique is mandatory to show bone marrow oedema and to decide on which metamer to perform the treatment. ct is often necessary after mr in primary and secondary spine tumours. disk disease can be seen either on ct or mr. two major treatments must be considered: discogenic pain and vertebrogenic pain, and for this reason disk treatment and vertebral treatment. disk treatment includes many mini-invasive systems to use; however, no treatment has been shown to be superior to the others, with good clinical results in 75-80% of the cases, even at long-term follow-up. vp and assisted techniques are available for the treatment of not within a few minutes following ablation, ct of the ablation zone will demonstrate an extensive area of ground glass opacity (ggo). a ggo of at least 4.5 mm peripheral to the tumour is predictive of complete ablation. as early as 24 hours post-treatment, the entire ablated region usually appeared as a well-demarcated homogeneous dense opacity on ct that corresponded to necrotic tissue and its surrounding rim of granulation tissue. this zone of ablation is the "baseline post-ablation imaging" for follow-up. then, a relatively slow involution of the ablation zone will occur with various patterns, including nodular, fibrosis, disappearance, cavitation and atelectasis. morphologic features of local tumor progression are an increase in the overall size or a change in the shape of the ablation zone (even without enhancement). it is generally considered that an ablation volume that does not increase in size on subsequent imaging after the baseline post-ablation imaging is a complete ablation. the relatively slow decrease in size of the ablation zone renders ct morphologic evaluation responsible for late discovery of local tumour progression. pet/ct is able to discover incomplete ablation earlier than ct at a stage the disease remains small. patients who have very early evaluation with pet/ct are at risk of either false-positive result due to early inflammation process, or false-negative result due to early inflammation masking active tumor foci. 3 or 6 months after ablation can be a reasonable time for pet/ct. learning objectives: 1. to consolidate knowledge on the imaging aspects of successful ablation. 2. to become familiar with the main pitfalls of post-ablation imaging. 3 . to learn about the imaging aspects of most common complications. a-503 17:00 c. follow-up imaging of thermal ablative therapies for kidney tumours d.j. breen; southampton/uk (david.breen@uhs.nhs.uk) image-guided ablation of kidney tumours has been increasingly set to become the standard of care treatment for smaller (< 5 cm) renal tumours, yet ablation remains a non-extirpative technique and is therefore paramount, in this curative setting, that imaging follow-up should reliably confirm complete tumour eradication. early on in radiofrequency ablation (rfa), control remained problematic and inadequate treatment was evidenced by residual marginal crescents of viable, enhancing disease. in the current era of more definitive ablation with multipolar techniques, cryo-and microwave ablation (mwa), this pattern of treatment failure should rarely, if ever, be encountered. typically following adequate ablation imaging should confirm a completely nonenhancing tumour and a related cortical ablation zone. whilst nonenhancement is an accepted surrogate of tumour non-viability, most practitioners look for additional collateral features such as the 'halo' sign, appearing as a soft tissue ring in the adjacent peri-renal fat, usually a sound marker of complete tumour eradication. follow-up data have shown that cryoablation (cra) can yield robust outcomes, but often incurs notable haemorrhagic change and a 'rind-like' feature around the ablation zone. cra also appears to induce faster involution of the treated tumour, whereas rfa and mwa can induce a persistent granulomatous mass which only very slowly involutes over a number of years. late local recurrence is increasingly rare at around 2-3%, but can occur as nodules of enhancing disease as late as 3-6 years after the initial treatment. subtraction mr can be useful, but to date pet and perfusion techniques still lack resolution and specificity. multiple percutaneous image-guided therapies are currently available for thermal ablation of bone tumours. thermal sources for these treatment modalities include high-intensity ultrasound, laser, microwave, radiofrequency, and cryotherapy. the predictability of thermal ablation is adequate to limit collateral damage and complications, however, is limited by biologic and anatomic variability of tissue. clinical evaluation is essential in symptomatic tumours. close imaging follow-up with ct, mri, bone scan, and pet plays a vital role in the management of the post-thermal ablation patient and detection of complications. recurrences or regrowth can be considered for repeated thermal ablation if the lesion is discovered early, before the tumour geometry, location, or distribution become unfavourable. the imaging features could vary with the different ablation method. the radiologist reporting the follow-up imaging should be familiar with different ablation methods. mri with dynamic contrast enhanced imaging and subtraction allows to detect recurrences in hypervascular tumour. contrast enhancement on t1-weighted mri imaging seems to be predictive of clinically unsuccessful ablation. on ct scan, bone reconstruction can be visualised but is a slow process, particularly in adults. pet scan is an excellent morphologic and metabolic image to follow-up the tumours. however, the inflammation produce after ablation can be misleading, particularly during the first three months. imaging follow-up plays an essential role in the management of the post-thermal ablation patient and detection of complications. interventional radiology (ir) is an evolution of radiology that treats many diseases, originally treated by traditional surgery. the clinical importance of ir has been demonstrated over the years by performing procedures that offer the benefit of therapeutic treatments, competitive from the point of view of a shorter hospitalisation time. indeed, thanks to ir, patients are treated in a less invasive manner, hospitalisation is limited and thus promotes the containment of social costs. to maintain standards clinical oversight needs to focus upon correct organisational, functional and technological appropriateness of practice. to achieve correct ir performance, it is necessary to guarantee that all the instrumental guides (fluoroscopy, ultrasound, computed tomography equipment) function optimally, the procedural equipment including guides/catheters/stents, etc. are chosen according to their technical features and their characteristics are appropriate for use, incorporating cost considerations. as the complexity and variety of interventional procedures grow, there is an increasing need to ensure the appropriate training of specialised ir staff. consideration of dedicated education and continued professional development options for radiographers working in ir is of priority. the italian association of interventional radiographers (aitri) is very important in sharing guidelines in a multidisciplinary environment to standardise and harmonise the knowledge and skills of the team in hybrid theatre and interventional suites. interventional radiology technology is rapidly expanding and, to maintain safe and efficient practice, careful consideration of current and potential future organisational needs and the training of staff within an ir suite require detailed consideration. the lecture will discuss where new and current knowledge about radiation risk and effects are coming from. a brief overview of the different sources of knowledge, including hiroshima and nagasaki life span study, will be given. the most important stakeholders involved in research and formulating guidelines for radiation protection, with special emphasis on the new main publication from the international committee on radiological protection (icrp), and the impact on radiographic practice will be discussed. new tissue weighting factors for breast glandule gives a significant higher risk for females today, especially in the pubertal age. on the other hand, they have the risk for hereditary effects significantly decreased. estimation of risk, both in general and in the individual, will be discussed. regarding staff protection, there is a new recommendation for annual dose limit for the eye lens. the previous annual dose limit was 150 msv, and this is now recommended to be decreased to 20 msv averaged over five years with no single year exceeding 50 msv. the new recommendation can be a limiting factor in interventional radiology and cardiology, if sufficient protection is not used. learning objectives: 1. to understand the importance of radiation protection in interventional radiology for patients and staff. 2. to appreciate the latest recommendations for staff radiation protection in interventional radiology. 3. to appreciate the important role of the interventional radiographer in radiation protection. a-506 17:00 the improvement of patient care and aims for the highest possible levels of service are to the forefront of the modern "interventional suite". role development experiences will be explored, considering need, effect and management of development. service demands, the need to extend those provided, the limited number of radiologists, financial constraints and the requirement for continuous professional development at state level provide much stimulus for professional radiographic role development. increased job satisfaction, reduced waiting lists and improved patient experience all provide largely positive results it appears. resistance from radiologists, multidisciplinary team members and radiographers themselves however, can provide unnecessary barriers to change. once abridged the blurring of professional lines and insecurity within multidisciplinary team members may also occur. various experiences would suggest that only by allowing ownership of change by all the clinical stakeholders involved, thus empowering them, leads to successful development. on examination clear guidelines and distinct protocols must be established, taking account of current workload, to create the ideal scenario for good multidisciplinary team ethos, where members have overlapping yet clearly defined roles. professional accountability, responsibility and an understanding of those role's are all key, but without correct training, including support and resources, no regime for role development can be achieved successfully. clinical audit not only ensures the delivery of high quality and effective care in line with best practice, whilst ensuring cost effectiveness, but also provides the confidence for all involved, especially the interventional patient. learning objectives: 1. to understand the factors influencing change in professional roles within interventional radiology. 2. to learn about the potential impact of enhanced professional roles and a multidisciplinary team approach on service delivery and patient outcomes. 3. to understand the need for clear protocols and guidelines along with appropriate training and audit of practice when implementing such changes. there have been many attempts to develop gene reporters for mri, however these give relatively modest image contrast that can be difficult to detect. i will describe in this talk a reporter that gives intense and positive contrast in mr images (up to ~8x increase in signal), which can also be used with radionuclide imaging, thus combining the sensitivity of radionuclide imaging with the spatial resolution of mri. the contrast obtained is directly related to the degree of gene expression and is readily reversible, thus allowing longitudinal studies of changes in expression. the transplantation of pancreatic islet into the liver is an excellent example of successful cell therapy. transplanted islet visualisation in vivo using a noninvasive imaging method, for example mri, is necessary to prove technical success. monitoring of transplanted islets in vivo and long-term tracking their fate using mri requires their labelling by a suitable contrast agent in vitro prior to transplantation. under encite project we successfully performed animal experiments, which proved therapy potential of labelled pancreatic islets. labelled islets implanted into the rat liver were viable and induced long-term normoglycemia in diabetic rats. mri proved their viability and even distribution in the host tissue. these results allowed performing a clinical study on a group of 12 patients, which were transplanted by iron labelled pancreatic islets from cadaver donors. the successful pilot experiment enabled introducing of transplantation of native islets into routine clinical practice. search for better alternative sites, improved immunosuppression and alternative insulinproducing cells require multimodal and multifunctional molecular probes. currently we test polymer meshes as artificial transplant sites, effect of mesenchymal stem cells as a supportive net for beta cells, and novel cellular probes combing 1h, 19 f labels and fluorescent ones. optical imaging in the clinic j. dijkstra; leiden/nl (j.dijkstra@lumc.nl) recently a lot of developments have been done in the field of optical imaging. new sensitive devices made it possible to use both visible and near infrared light as diagnostic tool and guidance tool. the advantage of near infrared is that the penetration depth in tissue is much better than for visible light, allowing to see deeper. by using techniques like augmented reality, the data from infrared, both anatomical and functional, can be presented to the operator in real-time. optical imaging is used e.g. as an evaluation tools for mammography where the optical spectral properties of the tumor cells is used to monitor the effectiveness of chemo treatment. the spectral properties of the breast are measured using a laser at different wavelengths and a camera to create tomographically a 3d volume. dedicated near infrared probes which bind to certain tissue types make it possible to look for e.g. remaining tumor tissue in resection margins during surgery. this techniques also allow to visualise structures which should be avoided during procedures like nerves. by adding multispectral imaging, the endogenous contrast can be used. different tissues have their own absorption spectrum which can be shown as additional information, for instance the ration hb/hbo2. optical imaging also allows for acquiring images at near microscopic resolution real time in-vivo by using optical coherence tomography. this modality is being tested to provide information about the presence of certain cell types very fast where otherwise histology is needed. mesenchymal stem cells constructs for image-guided cell therapy in myocardial ischemia and digestive fistulas o. clã©ment, e. blondiaux, g. rahmi, l. pidial, a. silva, f. gazeau, c. wilhelm, g. autret; paris/fr (olivier.clement@inserm.fr) regenerative medicine has recently emerged as a potential therapeutic tool. a number of preclinical and clinical trials have been conducted in many diseases ranging from diabetes to myocardial infarction and neuro-regenerative diseases that assess the feasibility and benefits of injecting stem cells. however, outcomes relating to graft survival remain generally unsatisfactory, whether the process of injection is direct, intravenous or catheter-guided. to overcome such issues, tissue engineering has potential to improve cell engraftment and therapeutic response including functional parameters. this work aimed to evaluate mesenchymal stem cell constructs for image-guided cell therapy in myocardial ischemia and digestive fistulas. we tried to options: 1. fibrin patches based on fibrinogen monomers polymerised with thrombin and seeded with cells. 2. constructs based on 3d multilayers of confluent cells sheets. tissue constructs were labelled with iron oxide particles and evaluated in a model a myocardial infarction for the fibrin patches or digestive fistula for the 3d constructs. mri at 4.7 was performed at various time points after treatments using a high resolution coil. fibrin patches could induce a therapeutic effect by increasing the left ventricular ejection fraction compared to sham. 3d constructs induced an increased number of fistula healing and enhanced micro-vasculature density compared to controls. mri of labelled stem cell constructs allowed a good evaluation of the models and showed increased therapeutic efficacy. the proposed paracrine mechanisms will be discussed. is cell imaging relevant for the clinic? lessons to be learned from preclinical research u. himmelreich; leuven/be (uwe.himmelreich@med.kuleuven.be) non-invasive imaging of therapeutic cells has become a popular field of research over the last decade. this interest was mainly based on the hope that the location, migration but also function of immune, stem and other cells can be visualised over time in individuals. the development of novel contrast agents and mechanisms for mri but also other imaging methods has resulted in exciting basic research findings. in particular, the application of relatively biotolerant iron oxide based nanoparticles has fostered the hope for direct translation into clinical research and general practice. however, pre-clinical research has also highlighted several limitations of nanoparticle based cell imaging by using mri including the generation of unspecific contrast, difficulties to quantitatively image engrafted cells, unambiguous contrast, adverse effects on cell biology, limitations for longitudinal follow-up or the lack of functional information. such shortcomings are traditionally overcome in preclinical research by combining mri with other imaging modalities like bioluminescence imaging or positron emission tomography. our research focuses on the optimisation of cell labeling strategies for robust, sensitive and potentially quantitative visualisation of stem and progenitor cells in therapy models in vivo to assess cell behavior after engraftment. the sensitivity, stability, toxicity and adverse effects on the cell biology by the labeling procedure were studied for iron oxide based particles. the potential of gdchelates and 19 f labeled compounds for cell labeling has been assessed in vitro and in vivo. based on our preclinical research finding the potential of future applications in patients will be explored. cardiac ct is becoming the imaging modality of choice for an increasing number of clinical indications, not only to rule out coronary artery disease but also to evaluate cardiac morphology and function, and to determine patient outcome after coronary artery revascularisation. however, as with any other imaging tools, appropriate interpretation of cardiac ct examinations is required to assess the clinical value of this newly established diagnostic imaging modality. this process requires performance of thorough cardiac ct acquisition protocols, detailed knowledge of standard cardiac anatomic and physiologic terminology, as well as appropriate postprocessing, reading and reporting. in particular, radiologists need to recognise and be aware of the imaging findings that may confound and lead to interpretation errors. this lecture will summarise the practical aspects of postprocessing, reading and reporting of non-invasive cardiac ct examinations. the value and limitations of every available ct postprocessing technique including two-dimensional multiplanar reformations, curved multiplanar reformats, maximum intensity projection (mip) and volume rendered images will be explained. moreover, hints for improving reading results by recognising technical causes for various artefacts in cardiac ct will be elucidated and reading approaches to diminish false positives, false negatives and inaccuracies when assessing coronary artery stenosis will be suggested. cardiac magnetic resonance (cmr) is a complex imaging technique due to the intrinsic anatomical and technical peculiarities of the exam. these include the non-orthogonal cardiac orientation within the chest cavity requiring dedicated acquisition planes and the complex respiratory and cardiac motion to which the heart is subject and requiring a combination of ecg-gated and breath-hold sequences. potential additional anatomical pitfalls also include normal structures and variants like the moderator band, papillary muscles, and the presence of prominent crista terminalis or myocardial trabeculations, whose recognition is mandatory and may mimic in some cases a pathological condition. technical issues of cmr concern the continuous intracavitary inflow of protons and the associated "slow-flow" artifacts (limiting visualisation of endomyocardial border in some cases) pitfalls related to ecg gating, like inadequate synchronisation or the t-wave swell phenomenon; and finally a series of specific artifacts intrinsically related to the use of different pulse sequences that may interfere with image quality. an additional, more complex issue to consider is also the widespread diffusion of high-field magnets which have further enhanced those aspects. knowledge of the spectrum of those cmr peculiarities is mandatory to approaching and providing a correct diagnosis according to the main clinical request. the present lecture will review the most important anatomical and technical pitfalls of cmr examination and offer, when possible, practical solutions to overcome those limitations. shoulder imaging and intervention are becoming increasingly important in clinical practice. this session considers the indications, techniques, imaging findings and relative merits of diagnostic ultrasound and mri of the shoulder. the indications, techniques and results of us-guided interventional procedures are also considered. a panel discussion will deal with controversies in shoulder imaging such as the accuracy of us and mri in assessing rotator cuff tears, tendinosis, impingement and muscle atrophy, and the efficacy of us-guided interventions. audience participation in the discussion will be welcome. the shoulder is an anatomic area that is very commonly evaluated with musculoskeletal ultrasound. ultrasonography is widely recognised as a reliable means of assessing rotator cuff disease with accuracies reaching 100% for fullthickness tears and 90-95 % for partial-thickness tears. diagnostic accuracy depends mostly on the skills and experience of the examiner. a comprehensive ultrasound (us) examination requires, first of all, sound knowledge of the anatomy. a specific scanning protocol must be adopted in every us examination in patients with shoulder disease, because focal symptoms do not correlate with the location of the disease. the greatest importance of ultrasonography in rotator cuff assessment lies in its dynamic character. several dynamic manoeuvres can reveal pathologies such as subacromial impingement. last, but not least there are several scanning pitfalls such as anisotropy. anatomy key structures as well as the us technique and scanning protocol will be presented in this lecture. dynamic manoeuvres will be described and demonstrated with videos. scanning pitfalls will be emphasised. advantages and disadvantages of the us examination compared to other imaging modalities will be discussed. guidelines concerning the mr examination technique of the rotator cuff will be presented in this session. on intermediate-weighted mr images, tendinopathy and partial and complete tears of the rotator can be differentiated with high diagnostic accuracy. indications for mr arthrography, especially for the detection of small articular sided partial tears in athletes, will be presented as well. established classification systems for the description of rotator cuff tears will be discussed. besides characterisation of rotator cuff lesions, especially in view of therapeutic decision-making, recognition of the underlying pathomechanism is necessary. therefore, the role of imaging is to detect different structural findings that are suggestive of a possibly underlying impingement syndrome. in primary impingement syndromes imaging abnormalities of the rotator cuff, the overlying bursa and the coracohumeral arch represent the centre of imaging findings. primary extrinsic impingement is caused by structural abnormalities of the coracoacromial arch, whereas secondary extrinsic impingement is related to glenohumeral instability. types of internal impingement (posterosuperior and anterosuperior impingement) are secondary to rotator cuff and/or capsular dysfunction. posterosuperior impingement can be diagnosed on mr arthrograms by identification of the socalled "kissing lesion" pattern, with corresponding lesions of the undersurface of the rotator cuff, posterosuperior labrum, greater tuberosity and superior glenoid. imaging abnormalities of this condition will be discussed. the shoulder is one of the joints in the human body that is most subject to a number of pathologic conditions, both in young and in elderly subjects, such as subacromial-subdeltoid bursitis, calcific tendinopathy, and degenerative conditions. being inexpensive, readily available, and radiation-free, ultrasound is the imaging modality of choice to guide interventional procedures around the shoulder. thanks to its high resolution and multiplanar capabilities, ultrasound can be used to guide needles precisely in the tendons of the rotator cuff or within the joint space, both gleno-humeral and acromio-clavicular. this approach can be used to perform a number of different procedures. when dealing with bursitis, a needle can be guided within the subacromial bursa to aspirate fluid and to inject anti-inflammatory drugs. in case of calcific tendinopathy, one or two needles can be used to dissolve calcium deposit and drain it, providing patients prompt relief. in selected patients with overuse tendinopathy, ultrasound can be used to guide intratendinous injection of platelet-rich plasma that has been reported to be helpful in stimulating tendon healing. although minimally invasive, these procedures should be performed in an ultrasound ward with a high degree of sterility, as risk of infection can be concrete. multi-detector computed tomography (ct) offers new opportunities in the imaging of the gastrointestinal tract. its ability to cover a large volume in a very short scan time, and in a single breath-hold with thin collimation and isotropic voxels, allows the imaging of the entire oesophagus, stomach, and the whole chest and abdomen with high-quality multiplanar reformation and threedimensional reconstruction. preparation of the patients by fasting from solid food approximately 6 hours prior the examination is important. proper distention of the oesophagus and stomach by oral administration of effervescent granules and water, and optimally timed administration of intravenous contrast material are required to detect and characterise the disease. preoperative staging of oesophageal and gastric carcinoma appears to be the main indication for mdct and may replace endoluminal ultrasound (eus) in the staging of advanced cancers. the use of various reconstruction techniques, including virtual gastroscopy (vg) using a volume-rendering (vr) technique, is promising for the detection of early gastric cancer. the application of the texture analysis technique to distinguish between the different types of gastric and esophageal tumors is still evolving. finally, the introduction of fdg pet, in combination with mdct, has resulted in further optimisation of the diagnostic workup of oesophageal cancer, as well as specific types of cases of gastric cancer. by providing morphologic and functional information in the same setting, this technique has come to be the modality of choice, when available. the diagnosis of oesophageal and gastric cancer is usually based on endoscopic findings accompanied by biopsy. however, staging is a matter for diagnostic imaging and is the major determinant of disease management. this should be discussed within a multidisciplinary forum (multidisciplinary team [mdt] meeting) in which the radiologist plays a crucial part. accurate stagingusually based on the tnm staging criteria -is essential and the radiologist's report should reflect this pivotal role. the tnm staging of oesophageal cancer and gastric cancer will be discussed in detail. the phases in staging is essentially a filtering process which seeks to initially exclude distant metastasis and/or advanced local disease, initially by optimally protocolled ct scanning, if ct shows advanced disease, treatment is palliative, but even under these circumstances imaging will help determine the method of palliation. conversely, if ct demonstrates localised disease, 18 f fdg-pet scanning for oesophageal cancer and for selected cases of gastric cancer is indicated. if this, too, shows no nodal or distant metastasis, accurate t staging with eus will help determine whether the patient proceeds directly to surgery or undergoes neo-adjuvant chemo/radiotherapy prior to surgery, or in the case of oesophageal cancer may be suitable for emr. the role of staging laparoscopy in gastric cancer will also be discussed. in summary, the radiologist and nuclear medicine physician are crucial in determining treatment. their reports are lynch pins in the mdt discussion of patient management. it is therefore essential that the imaging report should optimally inform this discussion. learning objectives: 1. to learn about the latest tmn staging in oesophageal and gastric cancer. 2. to appreciate the imaging criteria for local, nodal and metastatic disease, and understand the accuracy of imaging staging. 3. to become familiar with the structure of a perfect imaging report. a-520 09:10 c. assessment after treatment a.m. riddell; london/uk (angela. riddell@rmh.nhs.uk) it is now established that for the majority of patients with oesophageal and advanced gastric cancer, there is survival benefit from the use of neoadjuvant therapy. therefore, there is a requirement for imaging to accurately restage the tumour and to assess the response to neoadjuvant therapy, to provide prognostic information and to direct future management. restaging following therapy is challenging, as differentiating treatment-related fibrosis/oedema from viable tumour is problematic with both ct and endoscopic ultrasound. the t and n staging accuracy for both modalities falls following neoadjuvant therapy. inconsistencies in measurements due to alterations in the degree of gastric/oesophageal distension can also limit the accuracy of recist criteria to determine the response. functional imaging techniques such as pet-ct offer an improved method for assessing response. alterations in the standardised uptake value (suv) occur much earlier than changes in size; therefore a metabolic response can be detected sooner, allowing for more rapid alterations in treatment strategies. acute complications following oesophagogastrectomy generally occur within the thorax and are either related to a leak at the anastomosis/mediastinitis or respiratory complications such as pneumonia or a pleural effusion. intra-abdominal collections may develop following oesophagogastrectomy and gastrectomy. late complications following both procedures are often due to tumour recurrence: locoregional such as lymph node recurrence or at the anastomosis; metastatic spread such as haematogenous spread or via the peritoneum or pleura. currently, there is no consensus on the most appropriate timing or frequency of postoperative imaging. a. an overview of pulmonary artery hypertension n.j. screaton; cambridge/uk (nicholas.screaton@papworth.nhs.uk) pulmonary hypertension is defined by increased mean pulmonary arterial pressure > 25 mmhg at rest or > 30 mmhg during exercise. ph causes significant mortality and morbidity, but commonly presents with non-specific clinical signs and symptoms resulting in significant delay in accurate diagnosis and specific treatment. untreated ph is progressive with increased pulmonary vascular resistance leading to right ventricular failure and ultimately death. the current dana point classification of pulmonary hypertension is clinically based. it groups diseases with similar pathophysiological mechanisms and therapeutic approaches. groupings include conditions characterised by diffuse small vessel narrowing (group 1 and group 1'), ph secondary to left sided cardiac disease (group 2), chronic hypoxic pleuro-parenchymal disease (group 3), chronic thrombo-embolic pulmonary hypertension cteph (group 4), and a miscellaneous group of diseases with either unclear or multi-factorial aetiologies (group 5). in the dana point classification, small vessel diseases are subdivided into group 1 which primarily affect the pulmonary arterioles and group 1' affecting the capillary/venous pulmonary circulation (pulmonary capillary haemangiomatosis and pulmonary veno-occlusive disease). the differentiation of group 1 from group 1' diseases is important since in group 1' arteriolar dilatation treatments can cause life-threatening pulmonary oedema. group 4 is synonymous with cteph with other causes of large vessel obstruction (vasculitis and pulmonary artery tumour) being considered as group 5 disorders. recent advances include an increased understanding of molecular mechanisms underpinning pah, facilitating targeted therapy development, a rapidly expanding role of surgical pulmonary endarterectomy in proximal cteph, and recognition of imaging as a potential therapeutic end point. ct allows depicting pulmonary hypertension (ph) and helps identifying its cause, therefore playing a crucial role in the diagnostic workup. ct features of pulmonary arterial hypertension include dilatation of the pulmonary artery trunk, with a diameter greater than or equal to 29 mm, a ratio to the aortic diameter greater than 1:1 and a segmental artery-to-bronchus ratio greater than 1:1 in at least three pulmonary lobes. on ecg-gated ct, right pulmonary artery distensibility shows the best diagnostic value with 86% sensitivity and 96% specificity for a cutoff value of 16.5%. among the various causes of secondary ph, ct is especially useful for detecting signs of chronic thromboembolic pulmonary hypertension, including wall-adherent thrombi, bands, webs or chronic arterial occlusion, mosaic lung attenuation and systemic collateral supply. ct shows signs of pulmonary edema, such as thickening of the interlobular septa, centrilobular ground glass opacities, mediastinal lymph node enlargement and pleural effusion in ph caused by pulmonary veno-occlusive disease, left heart diseases or mediastinal fibrosis. signs of lung parenchyma diseases may be indentified on ct; ph is a late complication in patients with pulmonary fibrosis, sarcoidosis or chronic obstructive lung disease, but may affect systemic sclerosis patients with limited lung parenchyma involvement. congenital cardiac abnormalities with untreated right-to-left shunting resulting in eisenmenger syndrome, such as ventricular or atrial septal defect and patent ductus arteriosus are easily recognised on ct. conversely, signs of peripheral pulmonary arteriovenous shunting in portopulmonary hypertension and ph caused by hepatopulmonary syndrome are more difficult to assess. learning objectives: 1. to learn about the ct diagnosis of pulmonary artery hypertension. 2. to become familiar with the causes of pulmonary artery hypertension on ct. a-524 09:30 c. mri in pulmonary artery hypertension j. biederer; heidelberg/ de (juergen.biederer@med.uni-heidelberg.de) for the assessment of pulmonary arterial hypertension (pah), the dedicated 30 min mri protocol would comprise a free breathing and noncontrastenhanced examination, short t2-w sequences, dynamic contrast-enhanced perfusion imaging, a high-resolution angiogram, a 3d breath-hold acquisition, dynamic steady-state free precession or gradient echo sequences of the heart and a study of myocardial late enhancement. the morphologic sequences show typical features of pah: right atrial/ventricular dilatation, enlargement of the pulmonary trunk/main pulmonary arteries and peripherally attenuated pulmonary vessels. incidental infiltrates, nodules or masses of the lung, mediastinum and chest wall would be covered. the first pass contrastenhanced perfusion imaging demonstrates an increased mean transit time/decreased pulmonary blood flow, but a relatively homogeneous lung perfusion (important to differentiate from cteph, where multiple segmental perfusion defects would be expected). the cardiac part shows right ventricular mass, wall thickness and functional changes correlating with elevation of pulmonary arterial pressure: distortion of the interventricular septum, area change of the pulmonary trunk, right ventricular volume/stroke volume as well as pathologic right/left ventricular end-diastolic volume indexes. late enhancement of the right ventricular wall would correlate with myocardial fibrosis. furthermore, optional experimental velocity-encoded sequences (ideally for multidirectional flow visualisation, "4d flow") show a decreased pulmonary artery blood flow velocity, increased retrograde flow and inhomogeneous velocity profiles. in conclusion for the near future, given the availability of scanner time and appropriate experience of the team, thoracic mri is probably the most comprehensive and effective single examination for the diagnosis and follow-up of pah. in the era of organ-based radiology, the group of diseases known as multisystemic malignancies represents an obvious challenge to both radiologists and oncologists. the necessity to match the growing possibilities of different imaging modalities with widespread multisystemic pathology and clinical sufficiency resulted in upgrading well-known diagnostic algorithms. the precise knowledge of clinical staging systems and classification, and the pathologic and physiologic mechanisms of the disease pathways are important for planning imaging modalities and specific protocols. perfect imaging of multisystemic malignancies now includes not only traditional anatomic-based modalities, but also much more often different types of whole body scanning such as ct, mri, pet and their combination in spect/ct, pet/ct and now even pet/mri. new imaging modalities and growing possibilities of traditional imaging techniques obviously influence the current clinical guidelines for this disclosure: c. heussel: consultant boehringer ingelheim, grifols, novartis. a common language between radiologists and clinicians, so that the latter can make an informed treatment decision based on sound conclusions to become familiar with the conditions necessary to implement them to understand the limits of their application to learn useful lessons from these criteria for routine clinical practice chairman's introduction a. palko this requires a thorough knowledge of the relevant brain anatomy, choice of appropriate structural and molecular imaging modalities and interpretation of mri and pet/spect in the most prevalent disorders in a structured fashion the presentation has the objective of giving the audience a synthesised panorama of our country situated in north america, with more than 110 million inhabitants and a large prehispanic history based on the aztec, toltec and maya cultures, and also of interesting facts related to the three centuries of colonial existence under the spain influence and dominium until the 1810 war of independence. after 1880, mexico has never had an international war; the last was against the northern border country, the united states. also, we will give important data on how in 1910 the mexicans rebelled against a 30-year dictator, general porfirio diaz. the mexican revolution was a long and cruel war, but later opened the doors to democracy and a complex developmental era began that is still in process. some demographic and contributions to health, science and culture issues will be mentioned and also the works of mexican scientists, writers and philosophers who have been presented awards including the nobel prize. in relation to well-known mexican artists such as diego rivera and frida khalo, some facts of their works will be presented. interventional radiology in oncologic patients g. elizondo-riojas; monterrey/ mx (elizondoguillermo@hotmail.com) interventional radiology (ir) is becoming an increasingly prominent subspecialty in the care of oncologic patients. its role extends from initial diagnosis to minimally invasive treatment of the malignancy and its complications. image-guided biopsies are increasingly performed using minimally invasive techniques. also, an integral part of care of these patients is vascular access as a means of medication, chemotherapy or parenteral nutrition, and interventional radiologists can place required the devices with well-established safety and efficacy. ir also plays a substantial role in the therapy of oncologic patients, through local tumor treatments such as transarterial chemo-embolisation and locoregional control with radiofrequency/cryo ablation, as well as management of complications of malignancy such as pain, obstruction (biliary, ureteral, etc) ., venous thrombosis and drainage of thoracic and abdominal collections. in mexico, ir is a growing subspecialty, and more medical students nowadays want to be radiologists and eventually become interventional radiologists. this is a paradigm shift. more and more radiologist wants to be involved with patient management and to be more than just "observers" in the process of patient care. we have to be prepared to offer this opportunity to our residents; otherwise other specialties will "have to fill the empty space" that we have left. interventional oncology has all the advantages to fulfil this opportunity. it is our chance to contribute to the advancement of medical care. learning objectives: 1. to appreciate the role of interventional radiology in the management of oncologic patients. 2. to learn how interventional radiology changes the quality of life for patients with cancer. 3. to understand the impact of interventional radiology procedures in the outcome of some neoplastic diseases. interlude: origins and development of radiology in mexico m.e. stoopen-rometti; mexico/mx (mstoopen@clinicalomas.com.mx) mexican radiology started in 1896, just a few months after the discovery of xrays. during the last few decades, as well as in other countries, there has been a great development both in public and private sectors, which will be described in this interlude. learning objectives: 1. to learn about the history of radiology in mexico. 2. to learn about the development of radiology in mexico. 3 . to learn about the present and future of radiology in mexico. modern issues in oncologic ultrasound j. mexico/mx (jtanus59@hotmail.com) advances in ultrasound (us) technology allow confident characterisation of masses. these include harmonic imaging, compound imaging, power doppler, faster frame rates, higher resolution transducers, three-dimensional (3d) us, us contrast agents and, more recently, elastography and fusion imaging. highfrequency transducers provide superb spatial and soft-tissue resolution, permitting substantially improved differentiation of subtle lesion, margin resolution, and lesion conspicuity in the background of normal tissue. elastography features such as size ratios, shape, homogeneity, and maximum lesion stiffness complement conventional us in the analysis of lesions. ultrasound contrast agents have overcome some of the limitations of doppler ultrasound techniques with demonstration of irregular branching central or penetrating vascularity within a solid mass raising suspicion of malignant neovascularity (neoangiogenesis). ultrasound contrast agents can provide important information in the assessment of lesions to be treated by locoregional therapies, which include ablation (feeding vessels), trans-arterial chemo/radio-embolisation, detecting viable tumour persistence following this treatment; facilitation of needle positioning in cases of poor lesion delineation, and assessment of local tumour progression. it facilitates needle positioning in cases of incomplete or poor lesion delineation on unenhanced ultrasound. us contrast agents are an important key during the evaluation of the immediate treatment effect of ablation and guidance for immediate re-treatment of residual tumour. learning objectives: 1. to understand the role of ultrasound in the management of oncology patients. 2. to learn how ultrasound is used in large oncology centers. 3 . to learn about the modern concepts of ultrasound in oncology patients. the aim of this lecture is to give an overview of the techniques for imaging inflammatory bowel disease (ibd) of the small bowel and the colon with either ultrasound (us), multidetector row computed tomography (mdct) or with magnetic resonance imaging (mri) and compare the different modalities for its strength and weakness. optimal imaging of the bowel begins with the preparation phase. the small bowel has to be distended for a concise examination. this is mainly done orally, which is named enterography. a solution of 2.5% mannitol seems to be the one preparation technique mostly used for small bowel distension. another technique is the enteroclysis, application of contrast after intubation of the small bowel. the comparative advatages and disatvantages of the two preparation methods will be discussed. this intraluminal contrast gives a neutral contrast in ct and a biphasic signal in mr. the colon can be prepared in a fashion similar to colonoscopy meaning total cleansing. another possibility is the so called fecal tagging whereas the stool will be contrasted with an additive to standardised food. therefore no cleansing is needed for preparation. imaging parameters will be discussed for mr and ct. the aim of imaging for the bowel should be to establish the following: 1) presence, severity, and extent of disease; 2) activity of the disease and 3) extra-intestinal complications. us, mr and mdct have proven to be a good tool to evaluate the extent, the activity of the disease and the presence of extraluminal complications. pros and cons will be discussed when to use which technique. learning objectives: 1. to understand state-of-the-art mri, ct and us protocols for imaging ibd. 2. to appreciate the comparative advantages and disadvantages of enterography and enteroclysis protocols. 3 . to learn about protocol modifications when evaluating the colon.a-393 10:50 b. small bowel disease j. stoker; amsterdam/nl (j.stoker@amc.uva.nl) classification of small bowel crohn's disease is helpful for assessing disease activity and treatment monitoring. similar to clinically based classification, also imaging-based classification systems have been developed, of which some have been externally validated. important imaging features for determining disease activity include bowel wall thickness and vascularity/enhancement; at mri, also wall oedema plays a role. stenoses, fistulas and abscesses are important sequels. for assessment and monitoring of small bowel disease the breast imaging reporting and data system (bi-radsâ®) for mammography of the american college of radiology (acrâ®) consists of several components, a standardised lexicon of terms to be used during reporting, a 4-step coding system for the mammographic density as a surrogate parameter for the mammographic sensitivity, and a group of assessment categories ranging from 0 to 6 for structured communication regarding the recommended further management. the goal of bi-radsâ® is to improve the quality of breast imaging reporting and communication. in addition, by providing structured reports it facilitates regular quality assurance measures. the bi-radsâ® atlas for mammography is currently in its fourth edition and was released in 2003. the upcoming 5 th edition is expected soon and will be incorporated into the course as it becomes available. the breast imaging reporting and data system (bi-rads) was first developed by the american college of radiology for standardising the reporting of mammography. since its first publication in 1993, new editions have also addressed breast ultrasound (us) and mr imaging examination. the new (fifth) edition will be published soon. on the form, this new version was designed to include a web-based format. substance includes updates in lexicon descriptors, e.g. masses, calcifications, associated features (now comprising surrounding tissue with stiffness assessment), and special cases. us descriptors will be reviewed in the lecture. of note, guidance on how to link bi-rads descriptors with management recommendations has been added in the report section. a new approach to outcome assessment (audit section) is being proposed for screening us. the appropriate use of descriptors is expected to increase the accuracy of imaging interpretation. for relevant patient management, us analysis is to be integrated with other available imaging, as well as with clinical data. learning objectives: 1. to learn about the bi-rads lexicon. 2. to understand the usefulness of bi-rads system. a-434 15:00 c. mri k. pinker-domenig, p.a.t. baltzer; vienna/at (katja.pinker@meduniwien.ac.at) dynamic contrast-enhanced magnetic resonance imaging (dce-mri) of the breast is a well-established non-invasive imaging technique. it has clinical application in the screening of high-risk patients, diagnosis and staging of breast cancer, monitoring neoadjuvant chemotherapy and post-treatment follow-up. to standardise the reporting of dce-mri of the breast and minimise false-positive results without compromising sensitivity, the american college of radiology (acr) introduced the breast imaging-reporting and data system (bi-radsâ®) mri lexicon in 2003. bi-rads relies on the combined analysis of morphological appearance and lesion enhancement kinetics. it is widely used for reporting dce-mri of the breast and is applicable at any given field strength. it aims to provide an up-date report on the bi-radsâ® lexicon and instill confidence in using bi-radsâ® descriptors. the bi-radsâ® system may be placed in a broader clinical context to highlight its value for standardised reporting of dce-mri of the breast. mr-guided focused ultrasound is a new therapeutic modality which can allow selective destruction and or heating of tissues in deep body areas under close image guidance control. these talks will introduce the field and allow you to understand the areas of current work and areas of future development in this rapidly expanding field. session objectives: 1. to become familiar with mr-guided focused ultrasound. 2. to understand the advantages of focused ultrasound. 3. to learn in which areas focused ultrasound is evolving successfully. description of technique c. moonen; utrecht/nl (c.moonen@umcutrecht.nl)high-intensity focused ultrasound (hifu) is the only clinically viable technology that can be used to achieve a local temperature increase deep inside the human body in a non-invasive way. mri guidance of the procedure allows in situ target definition and identification of nearby healthy tissue to be spared. in addition, mri can be used to provide continuous temperature mapping during hifu for spatial and temporal control of the heating procedure and prediction of the final lesion based on the received thermal dose. the primary purpose of the development of mr-guided hifu was to achieve safe non-invasive tissue ablation. the technique has been tested extensively and is now accepted in the clinic for ablation of uterine fibroids. mr-guided hifu for ablation shows conceptual similarities with radiation therapy. however, thermal damage generally shows threshold-like behaviour with necrosis above the critical thermal dose and full recovery below. mr-guided hifu is being clinically evaluated in the cancer field. this presentation will cover the basic technologies for treatment of stationary tissues, and some advances towards treatment of mobile abdominal organs. for state-of-the-art mr liver and pancreatic imaging, a field strength of at least 1.5t is required. all non-blood pool gadolinium chelate-based contrast agents are suitable for dynamic liver and pancreatic mri. all gadolinium chelates should be routinely administered at a rate of 1-2 ml/s followed by a 20 ml saline flush at 1-2 ml/s using a power injector. to obtain hepatobiliary phase imaging in addition to dynamic phase imaging, the use of liver-specific contrast agents is required. gd-eob provides the highest hepatocyte enhancement, but an overlap between delayed phase and hepatocyte phase has to be considered during dynamic evaluation. the hepatocyte phase can be considered adequate when contrast is detected in the intrahepatic bile ducts. hepatobiliary phase imaging benefits from a gradient echo high flip angle, depending on magnet field strength. in the absence of liver function impairment and biliary obstruction, contrast-enhanced mr cholangiography can be obtained with gd-eob at 20-40 minutes, and with gd-bopta at 60-120 minutes. when the differential diagnosis is primarily between solid benign lesion vs. metastasis, the use of a liver-specific ca is recommended, due to the ability to diagnose fnh confidently. the combined interpretation of dynamic and hepatobiliary phase improves diagnostic accuracy of mr imaging for the detection of hcc.hemangiomas and intrahepatic ccc result in relative hypointensity in the late vascular phase after gd-eob administration. when combined with t2weighted mrcp, contrast-enhanced mrc allows morphologic and functional assessment of the biliary system. gastrointestinal stromal tumours (gist) are rare malignant tumours arising within the wall of the gut from the interstitial cells of cajal, which act as pacemaker cells controlling peristalsis. the crude annual incidence of clinically detected gists is approximately 10 cases per million in europe. the median age at diagnosis is approximately 63 years, and 80% of patients are older than 50 years. however, a small number of cases do occur in younger people and children, and these are usually syndromic gists. gists can occur at any site of the gut from the oesophagus to rectum, although they can also arise in the extra-gastrointestinal abdominal and pelvic locations, so-called e-gists. the commonest location is the stomach (55%), followed by the small intestine (35%) and rectum (5%). diagnosis is by biopsy, with spindle cell or epithelioid morphology, and immunohistochemical staining for cd117 (the protein product of the kit gene) and/or dog-1 receptors. approximately, 80% of gists have mutations in the kit gene, 10% have mutations of the pdgfra gene, and the remaining 10% have no mutation (wild-type) or rare gene mutations. early stage disease is managed by surgery, followed by 3 years of adjuvant imatinib (a tyrosine kinase inhibitor with activity against kit and pdgfra receptors) for cases at high risk of relapse. advanced metastatic disease is treated with imatinib, with a median duration of response of approximately 2 years. at disease progression, second-line treatment is with sunitinib, with a median duration of response of approximately 6 months. imaging plays a major role in the detection, characterisation and staging of gastrointestinal tumours (gists). imaging of gists depends on the mode of presentation and the local availability. endoscopic ultrasound and computed tomography (ct) are the most widely used imaging methods. gists have a spectrum of radiological appearances depending on tumour size and site of origin, but often show certain key radiological features. multiphase multidetector row ct is necessary to detect and stage gists and multiplanar imaging is important so as to define the likely organ of origin of the mass, which may be a challenging task. the clinical diagnosis of a gist is based mainly on imaging, as biopsy runs the risk of tumour rupture or seeding of the biopsy tract. in patients with an unresectable primary tumour or metastatic disease at presentation, biopsy confirmation is important before starting medical treatment. ct or/and mri are used to assess primary tumour extension, local invasion and the presence of metastases, with main sites of metastasis being the liver and the omentum. gastrointestinal stromal tumours (gists) are treated with targeted therapy regimes. these treatment strategies are based on the suppression of tumour vasculature using the tyrosine kinase inhibition pathway. drugs like imatinib and sunitinib exhibit specific changes in tumours and metastases that can be detected on cross-sectional imaging. these changes differ significantly from standard treatment effects of cytotoxic chemotherapy. while the latter leads to destruction of tumour cells and thereby to a reduction of tumour size, the former will cause a decrease in vascularity and thereby in attenuation and enhancement of lesions while the size may remain unchanged. radiologists have to be aware of these specific patterns of response to treatment. this presentation will include a review of the choi criteria which have been developed for the assessment of gist lesions under treatment. also, current imaging strategies focusing on time-resolved ct imaging (ct perfusion imaging) will be presented. the aim of this lecture is to provide a practical approach to response imaging in gist patients integrating both existing and novel strategies. radiological response evaluation using anatomical imaging was developed in the 1980s in early phase ii clinical trials. potential new anti-cancer agents were assessed by measuring tumour size before and during therapy and a predetermined reduction in size constituted response. radiological response represents an objective surrogate for patient benefit and was the primary end point in early phase ii studies. if a pre-defined percentage of patients achieved the required response, then the agent proceeded to large phase ii and iii studies where clinical time to progression or progression-free survival comprised the primary end point. between 1980 and 2000, there were extraordinary advances in cross-sectional imaging techniques which became widely available. different imaging techniques were introduced piecemeal with different co-operative groups adding different requirements, so meaningful comparisons from one trial to another could not be made. in 2000, the recist criteria were introduced requiring specific imaging stipulations and a minimum baseline tumour size to unify the different criteria and enable meaningful comparisons from one study to another. further advances continue to be made regarding anatomical and functional imaging. not all anti-cancer agents are cytocidal and many studies now use time to progression or progression-free survival defined by radiological imaging as the primary end point. certain tumour types respond in a unique manner requiring the employment of specific response criteria in these tumour types to adequately demonstrate response. some of these tumour types and their specific response criteria will be discussed. learning objectives: 1. to learn about the role of radiological response evaluation in clinical trials. 2. to understand how radiological response evaluation has evolved and continues to evolve. 3. to understand which response criteria are utilised in specific tumour types. emerging biomarkers for response assessment: pros and cons m.c. roethke; heidelberg/ de (m.roethke@dkfz.de) non-invasive response assessment of new specific anti-cancer therapies is an emerging field of oncologic imaging. in the past few years, large efforts were undertaken to develop new functional biomarkers to enable an earlier diagnosis, improved risk stratification and treatment monitoring of oncological diseases. imaging biomarkers reflect changes in tumour biology, which can be differentiated into certain categories (e.g. cell density, tumour heterogeneity, iron concentration, elastic properties, or cellular receptors). in a first step, alternative qualitative and quantitative imaging biomarkers for the different modalities (mri, ct, pet) are elucidated. for magnetic resonance imaging, new techniques with potential for treatment response monitoring such as diffusion-weighted imaging, susceptibility weighted imaging, and elastography will be assessed. then, quantification of iodine uptake of contrast-enhanced ct as an imaging biomarker will be addressed. novel pet imaging strategies for therapy monitoring will be mentioned with focus on receptor targeting tracers (e.g. psma, dotatoc). furthermore, the role of pet-ct/mri is mentioned to facilitate functional techniques in oncological imaging with imaging biomarkers. the potential clinical use of prior introduced biomarkers is demonstrated for several cancer entities (e.g. hcc, prostate cancer, malign melanoma, multiple myeloma, glioblastoma). advantages and disadvantages of the illustrated imaging biomarkers are discussed during this part of the lecture. the goal is to image the right patient, at the right time, using the right test and with the right interpretation so that patients will be advised on the right therapy. ultimately, the aim is to maximise patient outcomes at an affordable cost. this session will cover the state of the art in ebr, cer, and hta and demonstrate how the results are used in imaging decisions. the application of evidence-based medicine to medical imaging was relatively delayed in comparison to other specialties. radiologists should be aware of the necessity to justify radiological examinations and imaging-based interventional procedures on the basis of the best available evidence. diagnostic tests can be evaluated with studies exploring their value in terms of: 1. technical performance; 2. diagnostic performance; 3. diagnostic impact; 4. therapeutic impact; 5. patient outcome; 6. societal impact. notably, this is a one-way logic chain. while improvement at the upper levels implies improvement at some of the lower levels, the vice versa is not always true (e.g., a better diagnostic performance does not always imply a therapeutic impact or a better patient outcome). moreover, different degrees of recommendations are based on different levels of evidence, with experts' opinion as the lowest level of evidence and meta-analyses of high-quality homogeneous studies and multicentre studies being the best level of evidence. the quality of studies needs to be evaluated in terms of internal and external validity, the former regarding study implementation (protocol violations, reference standard, measurements, and readers' independence), the latter regarding study planning (study design, subjects selection, methods, and statistical analysis). biases influencing the internal validity limit the intrinsic value of study results, while those influencing external validity limit the generalisability of study results to clinical practice. finally, high-quality research must be planned to build the evidence in favour of radiological procedures, especially for new technologies which tend to enter the market without any preliminary demonstration of efficacy. state-of-the-art methods in ebr, cer, and hta relevant to imaging u. siebert; hall i. tirol/at more and more, clinical guideline developers and reimbursement decision makers need to base their work and decisions on solid evidence. this presentation will introduce the key concepts and principles of evidence-based medicine (ebm), comparative effectiveness research (cer), and health technology assessment (hta) and their application to the field of radiology. in particular, it will be discussed which role observational studies, clinical trials, and decision-analytic modeling play in ebr, cer, and hta and when each of these study types is needed to assess imaging technologies. specific topics include the assessment of bias, optimising cutoffs and multiple test strategies, making causal inferences, explicitly weighing benefits, risks and costs, and considering ethical, legal and social implications (elsi). the excitement generated by the discovery of x-rays led to the early adoption of this technology in many hospitals around europe. over the last three decades, the explosion of new medical imaging technologies together with the recognition by clinicians of the value of these for their patients has meant that imaging budgets have increased exponentially. evidence based radiology (ebr) is a relatively new approach designed to inform clinicians of the most appropriate technique to use in a given clinical scenario. the comparative effectiveness research (cer) is used by healthcare systems to develop a strategic approach to rationalise the availability of imaging investigations. the health technology assessment (hta) funding approach is a mechanism to assess new and emerging imaging technologies in a systematic timely manner. the uk has a nationally funded healthcare system which is designed to deliver equitable care for the population free at the point of delivery. the challenge for the uk has been to ensure the highest quality service by delivering the most appropriate technology and care for patients in a timely manner. the national institute for clinical excellence (nice) is an independent body which gives guidance on new drugs and medical devices. this body requires robust scientific evidence on which to base their decisions. to create the evidence base, the imaging studies need to be of a certain standard to be included (consort, stard, etc). an example from oncologic imaging will be used to show how ebr influences daily practice. acute abdomen and abdominal trauma are both emergencies with potential fatal sequela when under/ misdiagnosed. imaging plays a crucial role in the diagnosis and management. us is the imaging technique of choice in most cases, as it is rapid, portable, lacks radiation and there is no need for sedation in young infants. us accuracy can be enhanced by iv contrast agents administration. however, limitations may occur in obese children, in deep structures, or because of gas filled bowel loops. on the other hand, ct provides excellent visualisation without limitations by obesity, gas, or deep lesions. however, there is always the radiation exposure risk of the radiosensitive paediatric patient, while sedation is required in non co-operative young children. the aim of this session is to understand "which" is the modality of choice and "why", for the most common paediatric abdominal emergencies. the acute abdomen: ct is the answer a. paterson; belfast/uk (anniezunz@gmail.com)abdominal pain is a common symptom in children, and whilst the majority will have a self-limiting condition, in some the pain may indicate an acute medical or surgical condition that requires prompt investigation and treatment. in the paediatric setting, the primary imaging modality for those with an acute abdomen is ultrasound. however, there are certain patient groups -often older children or adolescents -in whom ct plays an important role. it is well acknowledged that ct is non-operator dependent: an important factor for children presenting to emergency departments outside children's hospitals. the speed of a ct exam is valuable in the acute setting, as is the capability to obtain images without having to touch the tender abdomen of a distressed child. ct offers a global perspective of the abdomen, and image quality is not hindered by the presence of excessive bowel gas, an abnormal body habitus only porotic fragility fractures, but also of primary and secondary spine tumours such as traumatic fractures. a wide variety of lesions in and around the orbita can impair eye movement. ct and mr imaging is frequently used to confirm or exclude lesions in and around the orbit in patients with impaired eye movement. first of all, it is very important to know the exact clinical history of the patients. ct is excellent for confirming a mass; however mri is more sensitive and arrives often at a single most likely diagnosis. characteristic imaging features may help distinguish among lesions that have overlapping clinical presentations. this review focuses on some of the common orbital masses. in this lecture common benign and malignant lesions will be discussed. vascular lesions include capillary (infantile) haemangioma, cavernous haemangioma, and lymphangioma. benign tumours include optic nerve sheath meningioma, schwannoma, and neurofibroma. malignancies that are reviewed include: lymphoma, metastasis, rhabdomyosarcoma, and optic glioma. in addition, benign and malignant lesions affecting the eye movement from outside of the orbit (e.g. from the paranasal sinuses, nasopharynx and skull base) will be discussed. trigeminal neuralgia is a unique form of facial pain, defined by the international association for the study of pain as a sudden, unilateral, brief, stabbing, recurrent pain in the distribution of one or more trigeminal nerve branches, triggered by a specific event. additional diagnostic criteria of the international headache society include paroxysmal, stereotypic pain attacks and absence of associated neurological deficits. it is due to trigeminal nerve compression at the root entry zone, a transitional zone between central and peripheral myelination, where the myelin sheath is thinner and more prone to compression and electrical stimulation. the most common cause is vascular compression, by aberrant loops of the sca, aica, pica or vertebro-basilar dolichoectasia, leading to a neurovascular conflict. small size of the prepontine and cpa cisterns has been identified as a predisposing factor. occasionally, expansile lesions of the skull base or cns compress the root entry zone and lead to atypical trigeminal neuralgia. mr imaging is the modality of choice to evaluate these patients and requires specific tailored protocols to depict its causes, including 3d heavily t2w images reconstructed in the three planes and an angiographic sequence for the depiction of neurovascular conflicts. as neurovascular contacts are quite common in the general population, strict imaging criteria for the diagnosis of nvc have emerged. the offending vessel needs to cross the nerve perpendicularly and deviate or indent its course at the rez. a pictorial review of the most common causes of trigeminal neuralgia and trigeminal neuropathy will be presented. learning objectives: 1. to understand the causes of trigeminal neuralgia and its clinical symptoms. 2. to learn about the relevant anatomy and appropriate imaging methods. 3. to become familiar with the relevant radiological images, differential diagnosis and limitations of the method. c. facing problems of the face: facial pain, tics and palsy b. verbist; leiden/nl (b.m.verbist@lumc.nl) facial impairments may be due to neuropathies of the trigeminal and facial nerve. this lecture will focus on the seventh cranial nerve. this nerve is a complex, mixed nerve with motor fibres, parasympathetic fibres, sensory fibres to the external auditory canal and special sensory (taste) fibres to the tongue. the most common presentation of facial nerve dysfunction is facial palsy. the paresis or paralysis of facial muscles may be caused by several conditions such as developmental abnormalities, infectious or inflammatory disease or tumoural lesions. other presentations of facial nerve dysfunction are facial tics or hemifacial spasm and pain. the indications for imaging, choice of imaging modality and possible imaging findings in case of facial palsy, facial tics and facial nerve-related pain will be discussed. in this presentation, the procedures used to create the standard will be reviewed and some of the most recent changes discussed. as a collaboration of professional societies and companies, integrating the healthcare enterprise (ihe, www.ihe.net) seeks to establish methods wherein health computer systems can communicate to achieve specific functional objectives. these involve development of methodologies to implement standards such as dicom, hl7, etc. in this presentation, the procedures used to create the ihe profiles will be reviewed. patient dose tracking is rapidly growing in the usa as a large number of commercial products are available in response to user demand. these products leverage the work that has gone into the development of the dicom dose structured report and the proliferation of digital imaging systems. medical physicists are crucial team members as they are most capable of performing patient dose measurements and calculations. noteworthy is that the 'toolbox' of the medical physicist is expanding. informatics with patient dose tracking tools invariably includes familiarity at some detail with dicom structure and tags, dose structured reports (sr), sr readers, ris content and orders, modality work list broker content, modality (imaging) specific content as well as pacs, archive rules for storage/retrieval and emr. patient-specific information and the highly detailed specifics of the individual dose prescription are necessary for advanced estimates of information. a dose tracking system (a qa tool outside of the normal imaging device that uses content provided by dose sr and other information systems) usually strives to elevate the quality of the dose estimate, using informatics tools such as patient and organ models, dosimetry engines, and predictive statistics. general use cases for dose tracking will be presented including advanced dose estimations for individual patient exams and qa review for both ct and fluoroscopy. examples of tracking of prescriptions by patient, protocol/procedure and operator for determination of patient dose history, 'outliers', continuous improvement (using dmaic tools) or for meeting regulatory or accrediting bodies will be included. with the introduction of digital radiology, it is possible to have automatic systems to collect and archive patient dose data individually, in addition to demographic, geometric, and other procedural parameters, as part of the dicom header or through other dicom services. these automatic systems mean significant benefits for patient dosimetry and quality control. different approaches were used, depending on the availability and level of implementation of the dicom standard, including extracting the technical information from the headers, using the radiation dose structured reports (which contain accumulated dose over several irradiation events), analysing the mpps messages sent by the modalities to the radiology information system, and implementing optical character recognition techniques on saved screen images. before issuing a formal patient dose report, the medical physicists should verify and correct all patient dose data. all these approaches allow managing more information and provide better capacity to audit the full imaging procedure and to help with the optimisation. the current level of technology allows doing so at a reasonable cost and with a great benefit for the clinical practice. automatic detection of abnormal patient doses or mistakes in the technical parameters used and their prompt correction is possible. diagnostic reference levels will be effortlessly reviewed with such systems. some examples of pitfalls and possible optimisation actions will be presented. pathology. finally, the perfect assessment of clinical course of the disease and possible outcomes, the understanding of tumor response criteria and therapyinduced changes are significant for image interpretation in patients with multisystemic malignancies. multiple myeloma is a haematologic disorder characterised by the infiltration and proliferation of monoclonal plasma cells mainly in the bone marrow. the main symptoms are hypercalcaemia, renal impairment, cytopaenia/anaemia and bone disease -summarised as crab-criteria. symptomatic multiple myeloma is consistently preceded by asymptomatic premalignant stages called monoclonal gammopathy of undetermined significance and smoldering multiple myeloma. these stages also present with detectable monoclonal protein and/or monoclonal plasma cells in bone marrow, but do not show any end organ impairment. staging of multiple myeloma is based on the measurement of the monoclonal protein in serum and urine as well as the assessment of impairment of haematopoiesis, renal function and mineralised bone. in the last decade, the development of novel therapeutic agents has led to an increase in response rates and survival time of patients with multiple myeloma, which further stresses the value of response assessment by imaging. cross-sectional imaging like mri, ct and pet-ct is currently replacing conventional radiological surveys in the initial workup and follow-up of patients with monoclonal plasma cell diseases. recent studies demonstrate the added value of mri in improving initial staging by unravelling a diffuse infiltration of bone marrow by plasma cells, a focal pattern or a combination of both. also, pet-ct can detect response to therapy earlier than conventional response criteria. furthermore, recent studies revealed that a complete remission of myeloma confirmed by mri or pet-ct goes along with a better prognosis compared to a complete response based only on serological parameters. learning objectives:1. to learn about the role of clinical staging systems and imaging in work-up and classification of plasma cell disorders with a focus on multiple myeloma and to learn about parameters of disease activity. 2. to understand the pathophysiologic mechanisms of multiple myeloma and to learn about the effects of abnormal plasma cells on bone remodeling cells.3. to become familiar with response criteria and therapy-induced changes and to compare the significance of imaging and serological markers for response evaluation in multiple myeloma. 4. to learn about recent studies on imaging based response assessment and prognostic significance.a-527 08:58over the last 40 years, there have been numerous efforts to classify lymphoid malignancies, culminating in the who classification introduced in 2008. so it is clear that malignant lymphomas require a sophisticated diagnostic approach based on clinical features, morphology, immunophenotyping and genetic analysis. it is essential that such an approach underpins the clinical management of these diseases, many of which are amenable to cure. the same situation is present in radiology staging procedures -it has a multidisciplinary approach. a wide range of staging procedures can include all radiology methods from cxr and chest and abdominopelvic computed tomograph to whole body mri, scintigraphy and pet-ct scans. lesions of the regional lymph node system. distant spread of mm is thought to transpire intra-and extravascularly (along the external vessel lattices) supported by specific mechanisms of extravasation and protection of mm cells against the local immune system. to date, many imaging methods, such as ultrasound, computed tomography (ct), magnetic resonance imaging, and positron emission tomography/ct, are used in the diagnosis of mm and its metastases, whereas lymphoscintigraphy has become an important tool for workup of the lymph node drainage patterns. radiological challenges include improved staging and re-staging of multi-systemic mm. accordingly, current imaging guidelines and the role and applications of the different imaging modalities in advanced mm (stage iii / iv) are reviewed with regard to their usefulness in patient management. however, standardised imaging protocols and integration of functional information to morphological imaging are needed in the future to allow for improved detection and guidance of treatment in patients with mm. the original atlanta classification of acute pancreatitis established in 1992 is outdated. in 2012, an international working group has modified the atlanta classification for acute pancreatitis to update the terminology and provide new morphologic classifications.the revised classification of acute pancreatitis identified two phases of the disease: early (first week) and late (after the first week). acute pancreatitis is subdivided into two types: interstitial oedematous pancreatitis and necrotising pancreatitis. if the diagnosis of acute pancreatitis is established by abdominal pain and by increases in the serum pancreatic enzyme activities, a contrast-enhanced ct is not usually required for diagnosis in the early phase. this revised classification introduces new terminology for pancreatic fluid collections. depending on the presence or absence of necrosis, acute collections in the first 4 weeks are called acute necrotic collections or acute peripancreatic fluid collections. once an enhancing capsule develops, persistent acute peripancreatic fluid collections are referred to as pseudocysts and acute necrotic collections, as walled-off necroses. all can be sterile or infected. this classification of acute pancreatitis allows a consistent, worldwide classification and should avoid confusion in the terminology of pancreatic fluid collections. the role of diagnostic imaging in chronic and inflammatory pancreatitis and ipmns is to detect structural changes of the ducts and of pancreatic parenchyma, assess the functional integrity of the gland, detect associated complications, and assist in management. these goals are generally fully achieved using mdct and mr imaging. in this lecture, the advantages and limitations of each technique will be discussed and illustrated. key features allowing differential diagnosis of both entities will be underlined. autoimmune pancreatitis (aip) was first described in 1961 and represents a rare form of immune mediated chronic pancreatitis which is characterised by a marked infiltration of lymphocytes and plasma cells into pancreatic tissue. whilst the majority of cases present with diffuse gland involvement, approximately 30% of patients demonstrate either segmental or focal involvement of the pancreas. clinical presentation is very variable with patients describing a range of symptoms; severe pain however is uncommon. imaging plays a central role in the diagnosis and management of aip and knowledge of the radiological appearances, which can vary significantly due to the various degrees of fibrosis and inflammatory infiltrate, is critical. cardinal features include focal or diffuse pancreatic enlargement with the loss of normal lobular architecture. in addition, pancreatic duct involvement as demonstrated by single or multiple focal strictures with limited more proximal dilatation is common. whilst these appearances may suggest a diagnosis of aip correlation with clinical history, serology and histopathology is mandatory to accurately diagnose atypical cases. in contrast, paraduodenal pancreatitis is a specific and rare form of segmental chronic inflammation characterised by fibrous tissue formation in the "groove" area between the duodenum, head of pancreas and lower common bile duct. the pathology was first described in 1973 and has since been subdivided into pure, segmental and non-segmental forms. whilst the radiological diagnosis of both aip and paraduodenal pancreatitis remains challenging, the presentation will emphasise relevant imaging strategies as well as provide tips and tricks for accurate diagnosis. bone scintigraphy is often used in combination with ct and clinical information for staging and therapy response evaluation of bone metastases. magnetic resonance (mr) imaging is a technique that is known to be valuable both for detection of bone metastases and for evaluation of their response to treatment. integrated positron emission tomography with computed tomography (pet/ct) combines the functional data from pet with anatomic information of ct in a single examination. 18 f-fluoride is a non-specific pet tracer that has recently shown very high sensitivity for bone metastases. for accurate response evaluation, it is important to recognise not only changes in bone metastases, but also the effects of treatment on unaffected, normal parts of the bone marrow. these latter therapy-related benign changes could otherwise be misinterpreted as disseminated disease or vice versa. despite the fact that the methods mentioned above, alone or in combination, have improved the assessment of bone metastases, they often remain non-specific. a specific diagnosis can in many cases only be achieved with a bone biopsy. this refresher course will give you an overview of the present imaging methods for detection and characterisation of bone lesions. indications for, and how to perform, ablation and cementoplasty of bone metastases will be presented. optimal algorithms for treatment follow-up of bone metastases and advantages and disadvantages with different imaging methods will be reviewed. also, future development of diagnostic and therapeutic methods will be included in the presentations, e.g. potential role of emerging pet imaging probes for assessing bone malignancies. author disclosure: h. ahlstrã¶m: research/grant support; astrazeneca. a. diagnostic approach: the role of hybrid imaging k. herrmann; wã¼rzburg/ this presentation will include a short review of the epidemiology of primary and metastatic bone disease, its classification and staging definitions. then we discuss the role of radionuclide imaging in initial and subsequent treatment strategy considerations. another aim is to provide guidelines for the appropriate use and applications of diagnostic radionuclide approaches for the assessment of bone diseases. the focus of this presentation will be on the role of radionuclide imaging in metastatic prostate, breast and lung cancer in the context of other available diagnostic imaging approaches. the ability of hybrid imaging technologies to achieve improved diagnostic accuracy will be emphasised and when appropriate the potential role of emerging pet imaging probes for assessing bone malignancies discussed. if feasible, the availability and effectiveness of radionuclide-based therapeutic approaches for malignant bone diseases will be reviewed. skeletal metastases are associated with significant morbidity and have high impact on health costs. effective palliative treatments are available, but less than 50% of patients respond in terms of tumour markers, pain or quality of life and all treatments are associated with some toxicity. it is generally accepted that the current imaging techniques are inadequate for measuring treatment response in a clinically relevant time frame such that skeletal metastases are usually considered as non-measurable disease in clinical routine and trials. there is therefore a need for non-invasive, objective methods to evaluate treatment response of skeletal metastases at earlier time points to guide clinical care. in addition to imaging structural changes in bone (e.g. x-ray, ct), it is now possible to image a number of biological characteristics of bone metastases including tumour metabolism, tumour cellularity, and osteoblast and osteoclast activity. methods currently available, or being actively investigated, include 99m tc-mdp spect/ct, 18 f-fluoride pet/ct, 18 f-fdg pet/ct, 11 c/ 18 f-choline pet/ct, rgd-spect/pet and dw-mri. some of the tracer methodologies will potentially be applicable for and complementary to pet/mri. the timing of follow-up imaging after commencing treatment is still under investigation. it is likely that tumour-specific methodologies may reflect response/non-response earlier than bone-specific methods due to a prolonged flare in reactive bone in responding metastatic sites. learning objectives: 1. to understand the techniques and quantitative parameters used for treatment response evaluation. 2. to learn the optimal timing for follow-up imaging after treatment. 3. to become familiar with common pitfalls in the interpretation of posttreatment mri and pet. panel discussion: how to differentiate between bone metastases and chronic inflammatory or treatment-induced changes 09:44 structured reporting is an opportunity and a challenge at the same time. expert speakers of this session will present and discuss their views on the subject, contributing to the clear vision of the members of audience on this complicated subject, convincing us to take this technique as an opportunity to improve and standardise the quality of our reporting activities. even though structured reporting (sr) has been appreciated as one of the effective methods of electronic reporting, there are not that many real applications to facilitate utilisation of this technique in practice. why it is so?the radiologists want a flexible tool to create clear, concise reports in a reasonably short time. like all template-based reporting systems, the application must be tailored to preferences of multiple users in a radiology department. the report templates should also be flexible in terms of length to avoid inappropriately detailed reports. the final appearance of the report is critical for acceptance by clinicians. accordingly, the technical challenges of development of sr systems may be grouped as: "user interface", "database structure", and "output file/document" problems. flexibility to comply with different user preferences will lead to both user interface design and database structure challenges. one of the major technical challenges is the transformation of structured data to a final text to be acceptable and applicable for the referring physician. also, exporting of reports to dicom format using dicom-sr concepts is still a challenge. multi-media formats are becoming more and more popular specially in sr reports. effective communication of radiology results is critical to high-quality health care. to that end, the radiological society of north america (rsna) has developed a library with more than 200 best-practice radiology reporting templates. the templates are freely available online (www.radreport.org) and have been accessed more than 750,000 times. the new ihe "management of radiology reporting templates" (mrrt) profile builds upon the web's hypertext markup language version 5 (html5) to provide an international standard for describing and exchanging reporting templates. this presentation will describe the rsna report template library, introduce the international mrrt standard for report templates, and describe opportunities for esr members and affiliated societies to participate. the broad goals of this initiative are to improve the quality of radiology reports, increase the productivity of radiologists, promote the use of practice guidelines, and advance data-driven health care.learning objectives:1. to explore a library of 'best practices' radiology reporting templates. 2. to become familiar with international standards for radiology reporting templates.3. to understand how structured reporting will promote the use of practice guidelines and will advance data-driven health-care. structured reporting in europe: the esr initiative o. ratib; geneva/chthe rsna has initiated a new initiative called radreport with the aim of helping promote standard reporting and improve reporting practices by creating a library of clear and consistent report templates (http://reportingwiki.rsna.org/). this project also supported in part by the national institute of biomedical imaging and bioengineering (nibib) has already gained the participation of numerous countries around the world, contributing with reports in different languages. these report templates are "structured" in the sense that they incorporate reusable knowledge, or meaning, to the clinical reporting process. structured interpretation and reporting for detecting significant prostate cancer is crucial, as it allows comparing inter-observer interpretation variability, reduces this variability by stimulating discussion of the individual scores, enhances communication with the clinicians in a uniform way, facilitates quality assurance plus research, and in this way improves patient outcome. in this presentation, the pi-rads scoring system will be shown and discussed, and fast effective structured reporting using computer software will be presented. in a rapidly ageing society, dementia prevalences are sharply increasing. furthermore, knowledge about disease mechanisms is constantly evolving. a more nosologic approach in the workup of dementia is required to improve prognostication, patient management as well as select appropriate treatment. a. anatomy of the limbic system t.a. yousry; london/uk (t.yousry@ucl.ac.uk)the term "limbic" has been used in many different connotations. to understand the anatomy, we have to define the term first. the clearest definition stems from broca: "le grand lobe limbic". defined as such, the limbic lobe is composed of 2 main structures: the limbic and the intralimbic gyri. 1. the limbic gyrus is composed of the subcallosoal gyrus anteriorly, followed in an arc by the cingulate gyrus, isthmus and parahippocampal gyrus. the latter is composed of 2 parts: i) a posterior narrow segment, the superior surface of which is called subiculum, and ii) a more voluminous anterior segment, also known as the piriform lobe. the latter consists of the anterior part of the uncus and the entorhinal area. 2. the intralimbic gyrus arches within the limbic gyrus. it is divided into 3 parts: i) anterior (prehippocampal rudiment); ii) superior (indusium griseum); and iii) inferior (hippocampus). the latter consists of 2 lamina rolled inside each other: the cornu ammonis and the dentate gyrus, with the cornu ammonis consisting of 4 neuronal fields (ca1-4). to understand the function, we have to understand the connections that define this function. the interplay with the insula is of particular importance. in summary, we will review the mri characteristics of the components of the limbic lobe, their connections, and their function, using 1.5 t, 3 t and 9.4 t high field imaging. at the end of this lecture, you will know definition (s) of the limbic lobe, its major subdivisions, connections and functions. structural neuroimaging is increasingly used in the diagnosis of neurodegenerative diseases. in a memory clinic setting, computed tomography (ct) and magnetic resonance imaging (mri) have become the most important paraclinical diagnostic tools. recent guidelines on the diagnosis and management of disorders associated with dementia state that neuroimaging should be performed at least once during the diagnostic workup. in the past, neuroimaging had been performed to exclude potentially treatable causes of dementia. however, this exclusionary approach of neuroimaging in the diagnosis of dementia has been replaced by an inclusionary approach driven by conclusive evidence that ct and mri can substantially support the clinical diagnosis by the demonstration of a distinct atrophy pattern and the assessment of vascular (co)morbidity. for these purposes, the use of visual rating scales allows a fast and reproducible assessment of global/regional cortical atrophy and vascular white matter pathology. more recently, new imaging markers such as cerebral microbleeds and superficial siderosis haven been identified and linked to alzheimer pathology. in addition, next to structural mri, advanced and quantitative mri methods have been introduced in the clinical setting. mri perfusion techniques such as arterial spin labelling (asl) demonstrated a diagnostic value in memory clinic patients, particularly in those showing no or inconclusive pathology on structural mri. de (horst.urbach@uniklinik-freiburg.de) cognitive decline is a clinical symptom in many neurodegenerative disorders. mri is typically performed in the initial diagnostic workup of these patients. as a structural imaging modality, mri is often unrevealing while several molecular imaging modalities show disease-associated alterations: 18 f-fdg-pet shows reduced glucose metabolism in neocortical association cortices, mainly in the posterior cingulate, precuneus and temporoparietal regions. since glucose metabolism is normally higher in the posterior cingulate and precuneus, reduced glucose metabolism must be specifically sought for or highlighted by voxel-based analysis. dynamic imaging of swallowing from the mouth to the duodenum is the only clinical test providing a fast and accurate diagnostic overview of the upper gi function. swallowing disorders are divided into those with dysphagia that means problems during eating or drinking, with suspicion of aspiration as an important subgroup and those with sensations like the globus syndrome or noncardiac retrosternal pain. oropharyngeal dysphagia in patients with neuromuscular diseases or postoperative conditions can be evaluated precisely and within the same session as oesophageal motility disorders, stenoses or postoperative problems are detected and in a complementary fashion to endoscopy, ph monitoring and manometry. the exclusive ability of dynamic imaging of swallowing is to diagnose combined disorders of the pharynx and the oesophagus, to detect and localise subtle and multiple benign stenoses of the upper gi tract and to combine visualisation of pathophysiology and bolus transport as well. radiologic evaluation concentrates on 7 functional units, which represent the visible "moving areas" of deglutition, where evident pathologic conditions can be found: 1) oral cavity and tongue, 2) soft palate, 3) epiglottis, 4) hyoid and larynx, 5) pharyngeal constrictors, 6) pharyngoesophageal segment, 7) oesophagus and stomach. this lecture intends to explain the common causes of dysphagia, the approach to a tailored examination and the use of an advanced imaging technique. further, the basics of taking the swallowing history and the structure of reporting swallowing disorders along the seven functional units will be provided. hoarseness is defined as a rough or noisy quality of voice. the possible causes of hoarseness are manifold, ranging from benign diseases such as the common cold to malignant tumours. therefore, hoarseness as a symptom should always be taken seriously. evaluation of a patient with hoarseness by a head and neck specialist will always starts with a history and a physical examination including laryngoscopy. after these examinations, a diagnosis can be established in most patients without additional imaging. the aetiologies of hoarseness are: 1) inflammation/infection, 2) trauma, 3) neoplasms, 4) others (including medical conditions, e.g. hypothyroidism) and 5) vocal cord paralysis. this presentation will focus on imaging of vocal cord paralysis. vocal cord paralysis should not be considered a diagnosis, but as a symptom of (possible) underlying disease. when vocal cord palsy is discovered, this is frequently a reason to perform cross-sectional imaging. the radiological workup needs to include the full course of the vagus nerve. moreover, reporting radiologists need to be able to recognise the radiological signs of vocal cord palsy in the absence of hoarseness, since many patients with cord palsy are asymptomatic (up to 30%). the anatomy of the vagus nerve and its laryngeal branches that innervate the intrinsic muscles of the larynx will be discussed. then the (expected) course of the vagus nerve and recurrent laryngeal nerve will be shown. finally, radiological signs of vocal cord palsy will be discussed using examples from daily practice. in contemporary medicine, endovascular techniques often replace conventional methods of treatment, including surgery, in the management of an increasing range of diseases. this requires development of specific methods assessing the effectiveness of treatment and able to detect complications that may be much different from those occurring in conventional therapy. this is first of all seen in the endovascular treatment of patients suffering from vascular lesions and neoplastic diseases. commonly, there is a high initial technical success of endovascular treatment, but the durability is not always satisfactory and needs to be further examined. endovascular treatment is bound to the risk of specific complications, often without clinical symptoms. therefore, there is a need to use imaging follow-up of these patients.interventional radiologists are aware of the importance of those issues and should play an important role in developing and deciding about the follow-up scheme and choice of the best imaging methods for these patients. besides indepth knowledge of the treatment, radiologists are also familiar with the possible complications and can offer an optimal, minimally invasive and cost effective diagnosis and treatment. the potential imaging methods for follow-up after angioplasty (pta) and/or stenting include doppler ultrasound, cta and mra. although excellent images can be obtained by cta and mra, the drawbacks of these studies for routine follow-up are obvious. (access to ct and mr equipment, cost, contrast medium, ionising radiation, etc). in the uk, the most common imaging method is duplex ultrasound. there is no established role for the use of ultrasound contrast agents. ultrasound is freely available in the majority of centres, is inexpensive and complication free. follow-up by ultrasound may be undertaken by radiologists, although more usually by technologists in vascular laboratories. in practice, few patients are followed up by any imaging study at all unless they develop symptoms. the main category of patients who undergo some form of imaging follow-up after pta/stenting are patients with surgical bypass grafts, who are usually routinely followed up whether they have undergone angioplasty/stenting or not. in view of the fact that this is a lecture on follow-up after intervention, procedural complications are excluded from the discussion. the complications of angioplasty and stenting are similar. the main early complications are restenosis or reocclusion. other early complications are related to the arterial puncture site and include haematoma, dissection, occlusion and pseudoaneurysms. the main late complications are restenosis and reocclusion. treatment of restenosis and reocclusion usually involves additional angioplasty or stents using conventional or drug-eluting balloons or stents. cutting balloons, atherectomy and cryotherapy have a controversial role based on limited evidence. imaging follow-up of oncologic patients after embolisation procedures j.i. bilbao; pamplona/es (jibilbao@unav.es)the term "embolisation" groups different procedures in which imaging guidance is fundamental for both performing the procedure and for the early detection of complications. it has been demonstrated by several studies that "tumoural response" is tightly associated with survival, thus it is of major interest to measure accurately how the tumour is modified by the treatment. the "world health organisation" -who -first published the objective criteria for the evaluation of response. these criteria were slightly modified in 2000 and named as "response evaluation criteria for solid tumors"-recist. accordingly, "complete response" (cr) corresponds to the disappearance of the tumour, "partial response" (pr) is defined when there is a decrease in the tumour size equal to or higher than 30% and "progressive disease" (pd) is applied when there is an increase equal to or higher than 20%. "stabilisation of the disease" (sd) corresponds to measurements in between > 30% (pr) and < 20% (pd). tumours (until five nodules in the same viscera), no matter if necrotic or viable, were evaluated with one measure (its largest diameter). a new version ("1.1 recist) has introduced modifications, among which is the number of nodules (2 instead of 5) that needs to be evaluated. in some circumstances, when morphologic criteria (recist and who) fail to predict the outcome, then new functional criteria have been recently established. "mrecist" (which only measures the tumour that uptakes contrast) is an accurate classification for hcc. new methods "beyond recist" have been established for some specific treatments such as targeted therapies. in this session, the audience will have a comprehensive overview of the elastography, its principles and current state-of-the-art clinical applications. the session will deliver an overview of currently available methods of both ultrasound elastography (use) and magnetic resonance elastography (mre), their physical principles, technical and equipment requirements as well as the influence of various factors for obtained results. following this session, the audience will have insight into clinical applications of elastography in liver, prostate and brain diagnostics. the strengths and weaknesses of elastographic modalities will be compared and discussed under consideration of more established imaging modalities. the session will present potential developments of use and mre and possible future clinical applications. panel discussion will aim at defining the place of elastography in current and future diagnostic algorithms. the well-known sensitivity of the palpating hand for detecting lesions is related to the incredibly wide range of values of the shear modulus in the body, spanning over eight orders of magnitude. elastography was invented to exploit this high variability of constants by introducing the shear modulus into the image contrast of medical ultrasound or magnetic resonance imaging. today, both ultrasound elastography (use) and magnetic resonance elastography (mre) are in clinical use, predominantly for staging liver fibrosis or discriminating tumours in the breast, liver, and prostate. the talk reviews the physical principles, technical requirements and current methods of both use and mre. furthermore, the strengths and weaknesses of elastographic modalities are compared and discussed under consideration of more established imaging modalities. an outlook of elastography is given, highlighting the real-time feasibility of use and the sensitivity of mre to tissue pressure. suspicion of prostate cancer (pca) exists in the case of elevated psa serum values and/or suspicious findings on digital rectal examination (dre). systematic biopsy (sb) will be done to confirm or rule out pca. unfortunately, an elevation of psa serum values often is caused by benign changes, e.g. prostatitis or adenomyomatosis and not every cancer is palpable on dre. furthermore, sb may miss clinically significant disease in up to 35%. therefore, a more targeted approach would be desirable and imaging of pca is currently under strong effort. one possibility for visualisation of pca is the representation of tissue elasticity. usually, cancers have higher cell and vessel density than the normal surrounding tissue and therefore are associated with increased stiffness. in contrast to dre, where only the posterior parts of the prostate can be reached, rte does not have this problem, since all anatomical regions can be evaluated. furthermore, this noninvasive technique is time-and cost-effective and targeted biopsy or focal therapy of the prostate can be done under real-time conditions. another important issue is that rte can be performed by both urologists and radiologists. nevertheless, rte is of limited value in the detection of small cancer lesions and there may be problems in visualising pca with predominantly gleason pattern 3. the lack of data about inter-and intraobserver variability and of multicentre studies (now in process) are probably the reasons why rte has not been included in the guidelines of urological societies so far. cerebral tissue structure is altered in many neurodegenerative diseases, but also during physiological processes like maturation or ageing. structural changes directly affect the mechanical tissue properties. magnetic resonance elastography (mre) is an imaging technique capable of assessing biomechanical brain parenchymal properties non-invasively. viscoelasticity can be quantified by analysing the propagation of mechanically elicited shear waves in the investigated tissue. thus, mre could be a helpful tool to detect physiological or pathological processes influencing the cerebral tissue integrity. learning objectives: 1. to appreciate the advantages and limitations of a virtual palpation of the brain. 2. to become familiar with mechanical wave induction and detection in cerebral measurements. 3 . to learn about current and potential clinical applications. 4 . to learn about the relationship between microscopic and macroscopic, as well as focal and globally diffuse biomechanical brain parenchymal alterations. are based on the generation of shear waves inside the liver tissue with specific mr liver drivers and ultrasound probes. subsequently, phase images revealing the displacement of the waves will be investigated for healthy and pathological (alcoholic fibrosis) livers. moreover, the development of phantoms mimicking the stiffness of biological soft tissues (liver, muscle, â�¦) will be also presented. the viscoelastic (elasticity and viscosity) properties of healthy and fibrotic livers were measured, and the relevance of these parameters, used as a liver diagnostic marker, was analysed. in parallel, an increase of the wavelength as a function of the stiffness was obtained for the developed set of phantoms. the characterisation of the elastic properties is an excellent marker to differentiate minor and major fibrosis. a summary of the advantages and disadvantages of us and mr elastography techniques will be presented. a-558 09:00 the breast lesion excision system (bles) has evolved as a breast radiological technology over the last decade and is now in widespread use in europe and across the world. it was designed as a large biopsy device, but more recently due to its unique capability to obtain a single large breast tissue specimen in only a few seconds by utilising a radiofrequency cutting and cauterising wave, it has increasingly been explored in the therapeutic setting. it is easy to use under ultrasound or mammographic guidance with procedures taking a similar length of time to that of a vacuum biopsy, and with patient preparation and anaesthetic essentially identical. the technical aspects of performing these procedures will be detailed as well as its use specifically to perform excisional biopsies. this is limited by patient and lesional factors, all of which will be discussed in more detail. following a bles, the post-procedure appearances need to be considered so that follow-up imaging can be interpreted accurately. the risks and complications of this procedure are outlined as well as a discussion made of the latest papers in this field that may suggest future applications and developments. learning objectives: 1. to understand the mechanism of the bles technique. 2. to become familiar with the post-bles aspects of various types of imaging. during the past few years, it has been shown that there is not a single disease entity called "breast cancer". there are different subtypes that entail diverse recurrence risks. this is the first issue to take into account, and patients will be stratified accordingly before any follow-up is planned. imaging findings in a patient treated for breast cancer will depend on the type of treatment: breast conserving therapy (bct), mastectomy (and all the reconstructive techniques), radiotherapy and minimally invasive techniques. to differentiate between fat necrosis and other common post-treatment changes from relapse, it is important to know the timeline when all these changes take place and also schedule the follow-up imaging procedures accordingly. other important issues to take into account are the limitations and indications of the different modalities (mammography, ultrasound and mri). although ultrasound and mammography have traditionally been used in the follow-up of these patients, mri is being used more and more often due to its superior multiplanar capabilities and the functional information not supplied by the other techniques. blood clot formation in the veins is referred to as venous thrombosis (vt). vt is most common in the deep veins of the legs and pelvis. if the thrombus dislocates to the pulmonary arteries this is referred to as pulmonary embolism (pe). the combination of deep vein thrombosis (dvt) and pe is referred to as venous thromboembolism (vte). the diagnosis of dvt and vte is essential, as vte is potentially fatal. furthermore, undiagnosed, non-fatal dvt may result in negative long-term pathologies (e.g. post-thrombotic syndrome). major risk factors for the development of vte are thrombophilia, history of dvt, age > 60, surgery, obesity, long travel, cancer, immobility and pregnancy. in addition, underlying congenital abnormalities or compression syndromes (may-thurner syndrome) are also important to diagnose. diagnosis of vte is not always easy. primary diagnosis includes clinical (wells score) and lab testing (d-dimer). first line imaging testing is done by leg ultrasound (us). if pe is suspected ct is indicated immediately. ct of the pulmonary arteries (ctpa) may be combined with indirect ct venography (ctv). the question of when to combine ctpa and ctv still remains. a favourable approach is to add ctv in a negative ctpa. recently mr venography (mrv) is emerging as comprehensive imaging tool especially in patients with chronic dvt to assess the extent and underlying causes. in this respect imaging without radiation dose with high spatial delineation of vascular abnormalities facilitates intervention for thrombolysis or interventional therapy including recanalisation and stenting. alternatively, intravenous unfractionated heparin is used in situations when a quick reversal is necessary. b) non-medication: early mobilisation has been widely adopted to activate the muscle pump. if early mobilisation is not possible, compression stockings and/or pneumatic compression boots are applied to better empty the veins. 3. treatment: a) anticoagulation: the main goal of anticoagulation is to prevent progression and recurrence of dvt. typically, anticoagulation is started with lmh, followed by vitamin k antagonists (coumadin). the first dvt is generally treated for 3-6 months; recurrent dvt for 12 months. b) compression therapy: compression stockings ameliorate pain and leg swelling of acute dvt. in addition, the development of a post-thrombotic syndrome (pts) should be reduced. c) thrombolysis: the main goal of thrombus removal is prevention of pts. in addition, thrombolysis is used for severe ilio-femoral dvt, especially with phlegmasia coerulea dolens. there are different ways of thrombolysis: systemic thrombolysis was abandoned because of high bleeding complications. catheter-based thrombolysis has shown to reduce the bleeding risk, but it is quite time and resource consuming. the latest development is pharmaco-mechanical catheter thrombus removal which combines thrombolytic drugs with a mechanical maceration. recent studies (cavent,torpedo) have shown a reduction of pts compared to anticoagulation. the use of inferior vena cava filters (ivcfs) is a controversial method for the prevention of pulmonary emboli. there are large variations in their usage; often with ten to one hundredfold differences in placement between different countries. ideally, ivcf usage is based on sensible protocols derived from clinical experience and trials. in practice, this is less frequently the case. indications, contraindications and questionable indications (mainly during venous thrombolysis) will be discussed. familiarity with ultrasound guidance will be stressed. the key technical steps in the insertion and removal of ivcfs will be discussed. the question that this refresher course is aimed to answer is whether novel it tools may actually help in improving quality and workflow efficiency in daily radiological practice. in fact, since the early installations of pacs, it tools have often been considered as mere productivity tools rather than enabling technologies for fostering quality in medical care. the three distinguished lecturers in this course will address the following topics: improving quality and efficiency of computerised order entry through decision support, improving quality and efficiency of reporting through structure and templates, and improving quality and efficiency of dose management through exchange between modalities and registries. they will cover all aspects of the radiological workflow: from the selection of the most appropriate diagnostic procedure, to the efficient reporting of diagnostic and non-diagnostic data (such as radiation dose information and contrast media information). they will demonstrate how newly adapted it tools may provide assistance throughout the radiological workflow, with potentially enormous gains in terms of patients' safety and total quality management. session objectives: 1. to appreciate the need for it tools to ensure quality control. 2. to understand how to collect data concerning radiation dose. a. improving the quality and efficiency of computerised order entry through decision support p. mildenberger; mainz/ de (peter.mildenberger@unimedizin-mainz.de) electronic communication of requests for radiological procedures is a logical and relevant extension to integrated information systems in health care. this communication of orders and the entry (oe) into ris improve the workflows. but, quality improvements require additional efforts to link order-entry-solutions with health knowledge for ordering the appropriate imaging procedure. these clinical decision support (cds) tools should be based on generally accepted and implemented criteria, e.g. evidence-based medicine. it is known that the acceptance of such systems, if successful and efficient implementations are given, is very good. it concepts for cds are well known and standards for classifications are available, but semantic interoperability is still a developing area. actually, clinical information systems provide different levels of integration of oe and cds. further developments could be an implementation of interoperability profiles and the representation of cds knowledge in webbased services of non-commercial organisations. b. improving quality and efficiency of reporting through structure and templates e. neri; pisa/it (emanueleneri1@gmail.com)the report represents the final stage of the diagnostic imaging process, for which the radiologist is responsible. this process is driven by an accurate selection of the diagnostic tests, based on the clinical question. therefore, the report should be an expression of this path, depending on the question asked by the clinician. the structure of a radiology report for the same clinical problem and the same method of investigation varies from country to country and between different radiologists. this diversity can be a problem in the global world where a patient can have imaging tests from different places with different reporting languages, or when patient data is transmitted and shared between different centres. there is, therefore, the need to standardise the report as much as possible; finalising its structure and contents to a specific clinical problem, and possibly using a standard terminology. an attempt to solve this problem is in progress with the joint initiative on structured report esr-rsna (http://www.rsna.org/reporting_initiative.aspx), aimed at improving reporting practises by creating a library of clear and consistent report templates. the main expected benefits of structured reporting templates are report uniformity and improvement of communication between referring physicians. literature evidences that structured reporting can also quicken report turnaround, and reduce costs and lexical errors; thereby improving the quality and safety of radiological practise. the european directive on medical exposures requires the assessment and evaluation of patient doses, especially in procedures involving high doses to the patient. in the current draft of the new directive on basic safety standards, some requirements on patient dosimetry in diagnostic and interventional radiology have been reinforced: x-ray systems should provide dosimetric information with the capability of being transferred to the examination report (for all ct and interventional systems). diagnostic reference levels (drls) shall be reviewed regularly. these requirements will push the industry and the users to develop better strategies to evaluate patient doses, transfer these values to patient reports (contributing to the patient exposure tracking system) and also use available software to process these dosimetric data and perform some automatic analysis. this analysis should: a) include periodic calibration factors for patient dose quantities, b) include automatic detection of high dose values (especially relevant for interventional procedures), c) include statistical analysis to update drls and compare with the existing ones and d) suggest corrective actions to fulfil the quality assurance programmes and the clinical audit requirements. dicom radiation dose structured reports represent a significant advantage, but more efforts will be necessary for the automatic process of the relevant data contained in the report to verify that the radiological risk is acceptable and to suggest, if appropriate, corrective actions to improve clinical practice. without these last steps, patient dosimetry efforts and european regulations for radiation safety could only have a moderate impact. gastrointestinal tumors include a variety of lesions, with the most frequent being adenocarcinoma of the small and large intestine, small bowel lymphoma, neuroendocrine tumours (nets) and gastrointestinal stromal tumours (gists). according to histology, location and initial imaging staging, those lesions may require completely different therapies: surgery alone, adjuvant chemotherapy (cht), neoadjuvant cht followed by surgery or a combination of neoadjuvant chemoradiotherapy (crt) followed by surgery. after treatment, imaging follow-up is mandatory. the most common post-operative findings after small bowel or colonic resections will be presented, together with clues for early detection of recurrence. in those cases which underwent adjuvant cht, imaging findings and diagnostic criteria related to the use of either cytotoxic or cytostatic drugs will be shown, to facilitate the interpretation of radiologists in assessing response to therapy. finally, tissue changes following neoadjuvant crt will be discussed, particularly in rectal cancer. the possibilities of different imaging modalities in assessing either complete or partial response to therapy will be presented, with a critical analysis of different imaging findings. unlike infectious enteritis, in patients with crohn's disease (cd) the changes in clinical activity have poor correlation with changes in inflammatory lesions after medical treatment. mucosal healing (mh) and improvement in patient's symptomatology are usually considered the main objectives of medical treatment. however, improvement in clinical symptoms is not always associated with mucosal healing and the persistence of severe inflammatory lesions augurs a more aggressive disease course in terms of flare-ups, hospitalisation requirements and the need for surgery. endoscopy is the gold standard for the assessment of luminal lesions in cd, but given the good correlation shown between endoscopy and cross-sectional imaging in assessing the activity and severity, imaging is increasingly introduced as a tool to monitor medical treatment. there is some evidence indicating that crosssectional imaging can be considered a responsive and reliable tool as it detects meaningful changes in patients' status over time after therapeutic interventions. besides this, cross-sectional imaging is capable of monitoring the colon and the small bowel and penetrating lesions that cannot always be assessed by endoscopy. becoming familiar with the radiological changes during and after treatment will be key in the decision-making process. degeneration is routinely defined as a morbid change of cells, tissues and even organs. in the msk system degeneration occurs in bones, joints (synarthrosis and diarthrosis), muscles and tendons. primary degeneration implies ageing as well as overuse, based on mircrotrauma. the latter may be related to constitutional, professional or sports-related factors. a distinction between ageing and overuse is not possible with the use of histology and imaging. only the intensity of the changes, which may be inadequate in relation to the age of the patient, may give a hint. on the contrary, the term "secondary degeneration" should be used for clearly defined events or diseases, which finally will result in the degeneration of tissues. the causes are inflammation (ra, infection), metabolic disease (e.g. cppd) or trauma. other ways to classify degeneration of the msk system are related to the anatomy. accordingly, degeneration of the particular parts of the peripheral or axial skeleton, muscles and tendons has to be discussed. one has to have in mind that bones, cartilage, muscles and tendons form a complex unit. the single elements of these complex units jointly undergo degenerative deterioration, e.g. bone, cartilage, fibrocartilage and capsule are jointly involved in case of oa of the knee joint. the same holds true for the synchondroses of the spine. at the rotator cuff not only the tendons, but also the underlying bone and the muscle tissue are changed. (o.m.vandelden@amc.uva.nl) there are many different types of embolisation, but all share many basic principles. the specific approach, technique, materials and equipment used may differ depending upon many variables such as the type of vascular territory involved (venous, arterial, small vessels, large vessels), clinical setting (elective or emergent procedure), and type of underlying disease to be treated (e.g. tumor embolisation, acute haemorrhage, vascular malformation, arteriovenous fistula, etc). pre-procedural imaging and planning are essential for most embolisation procedures and intra-procedural navigation can be done with fluoroscopy, dsa, and new 3d-techniques. with proper imaging workup prior to embolisation procedure time, radiation dose and contrast load can be significantly reduced. embolisation materials can be roughly divided into liquid agents (alcohol, glue, polymers), particulate agents (pva, calibrate microspheres, drug-eluting beads) and coils (detachable, non-detachable) and plugs (amplatzerâ®-plugs). plugs and coils are deployed at the exact site of destination and usually easy and safe to use. particles and liquid agents reach their site of destination by flow guidance and can be more difficult and unpredictable in their use. complications include puncture-site complications (thrombosis, dissection, haematoma), systemic complications (contrastinduced nephropathy, allergic reactions) and specific embolisation-related complications (non-target organ embolisation, end-organ ischaemia, postembolisation syndrome). when used with expertise and proper experience, most types of embolisation have good results with acceptable complication rates. although there has been advancement in imaging techniques, several pitfalls in the assessment of diseases of the pancreas, small bowel and rectum remain. the differentiation and the correct characterisation of tumours and inflammatory disease in some cases may be difficult. also, atypical presentation of common tumours or uncommon tumours persists and is a challenge. problematic situations are constantly represented as intestinal bleeding and unexpected findings. in this session, we point out the procedure of the best imaging modality and protocols of challenging cases. a. pancreas c. triantopoulou; athens/gr (ctriantopoulou@gmail.com)pancreatic imaging and interpretation of focal lesions remains a challenging issue. despite the advances in imaging techniques and the dedicated protocols that are now in use, a possibility for pitfalls remains. these pitfalls are related either to the inability of the early recognition of a lesion, or to the wrong characterisation of a "mass". both pitfalls are of great importance, taking into account the lethal pancreatic cancer and the possible complications that may follow an unnecessary pancreatic surgery. there are many variants of the pancreatic parenchyma, the ducts or even vessels, and deep knowledge of the pancreatic anatomy and embryology is needed, to be able to recognise these variations in imaging. a pancreatic variant may not only be misinterpreted as a severe pancreatic disease (e.g. ectopic spleen vs neuroendocrine tumour), but may also be the underlying cause of pancreatic inflammatory lesions (e.g. ectopic pancreas on the duodenal wall causing groove pancreatitis). other pitfalls are related to the atypical presentation of a common lesion (e.g. isoattenuating pancreatic adenocarcinoma), the presence of uncommon tumours, diffuse or multifocal diseases, the co-existence of two different entities and the heterogeneous or overlapping appearance of cystic lesions. in any challenging case, a focused methodology should be applied and the diagnostic procedure based on predefined imaging parameters, taking also into consideration the clinical and laboratory findings. excluding pancreatic cancer should be the first goal and every attempt should be made to differentiate between surgical and non-surgical cases. endoscopy is the gold standard in small bowel diseases, but it is a challenging technique: the pillcam is a commonly used tool and multidetector ct is a diffuse investigation technique. ct enteroclysis/enterography is a worldwide tool in intestinal exploration. throughout the investigation of the small bowel, morphologic anomalies or embryonal development defects may be present (meckel's diverticulum, duplications of intestinal tracts). artefacts may be determined and there may be misunderstanding. mdct is the first tool in emergency diagnosis; imaging pitfalls are possible. unsuspected diseases may be revealed: we will see a case of gist in a patient affected by intestinal bleeding of an obscure origin. ct enteroclysis may find unknown or unsuspected diseases: correct technical parameters have to be respected, as artefacts may be derived from an improper acquisition technique, such as a limited distension or poor intravenous enhancement. in follow-up, mr is preferred to investigate the intestine, mainly in the young population. unexpected findings may be due to rare pathology: we met a case of endometriosis, with ambiguous presentations; patients affected by autoimmune pathologies (pyoderma gangrenosum or lupus erythematosus), with unknown inflammatory intestinal chronic diseases. in oncology, pet-ct imaging is the main diagnostic tool, but there are abdominal pitfalls that limit its effectiveness (intestinal hot spots, artefacts from peristalsis): the small bowel may frequently obstruct an easy diagnosis. in case of emergency, if the radiological diagnosis is not clear, the surgeon determines the management of the patient. in case of a defective study technique, a correct examination may be repeated. endoscopy or pillcam may help to detect mucosal lesions invisible at ct. mri plays a key role in the assessment of disease of the rectum and in particular for the staging (and restaging) of rectal cancer. in this session, the relevant mr anatomy of the rectum will be discussed. furthermore, the strengths and weaknesses of mri in the assessment of rectal cancer during primary staging and restaging after chemoradiotherapy will be highlighted using various rectal cancer cases. finally, we will discuss some rare tumours of the rectum (including gist and carcinoid). optimisation of ct and mr techniques has provided new challenges for imaging in the assessment of airway and lung diseases. phenotypic abnormalities which can be recognised on visual and quantitative evaluation of ct images in copd patients may improve the diagnostic accuracy, help optimise treatment and provide a framework for clinical trials. although expiratory ct helps assess air trapping due to small airway obstruction and excessive dynamic collapse of large airways, potential tricks in technique and interpretation of ct images must be known. owing to multiple and successive improvements over years, functional and morphologic evaluation of the lung using mri has become reality for clinical practice. already regarded as a favoured cross-sectional imaging in paediatric chest radiology, mri of the lung is gaining new indications also in lung diseases occurring in adults. the potential for high-resolution computed tomography (hrct) to uncover several morphological subtypes that come under the umbrella term chronic obstructive pulmonary disease (copd) is now more familiar to both radiologists and specialist respiratory physicians. a complete approach to the classification of copd would ideally assimilate several parameters through a combined visual-quantitative hrct analysis. the insight that some subjects given the label of copd have "pure" airways diseases or emphysema can be readily provided by a simple visual evaluation. the subtypes -centrilobular, panlobular, and paraseptal emphysema -can be reliably distinguished on hrct images. the visual assessment of bronchial abnormalities and accompanying smoking-related interstitial lung disease may also complete the phenotypic classification of copd. furthermore, it is now possible to objectively quantify the global extent of emphysema, gas-trapping, and bronchial metrics by two types of softwares which are now increasingly available on latest ct workstations. learning objectives:1. to learn about the classification of copd. 2. to appreciate the role of hrct in the classification of copd. a-578 16:28 this presentation will examine the role of expiratory ct in the diagnosis of small and large airways diseases. small airways disease or air trapping may be a feature of asthma, copd and hypersensitivity pneumonitis, and is typically characterised by a mosaic attenuation pattern on ct. tracheobronchomalacia and excessive dynamic airway collapse (edac) are large airways conditions that may be recognised by tracheal narrowing on inspiratory and/or expiratory ct. the typical clinical and ct manifestations of these diseases will be reviewed. additionally, a number of important caveats with regard to ct in small and large airways disease will be discussed: 1) the comparative strengths and limitations of ct, bronchoscopy and lung function testing in making the diagnosis; 2) the overlap in appearances that exists between diseased and healthy individuals; 3) the variability in definitions of conditions such as tracheobronchomalacia. the optimal ct technique for imaging of airways disease, including the role of dynamic expiratory ct, will also be reviewed. for routine clinical applications, a standardised mri protocol has been widely implemented. it addresses the major challenges of mri of the lung, i.e. low proton density, susceptibility artefacts as well as respiratory and cardiac motion. beyond visualisation of lung morphology, which is done in an inspiratory breath-hold, functional imaging has become an integral part of the routine protocols: perfusion, blood flow, ventilation, respiratory motion, diffusion. for perfusion imaging, inspiratory or expiratory scans can be used, blood flow measurement should be performed during shallow breathing, and ventilation and diffusion are mainly assessed in inspiration. respiratory motion is best assessed by dynamic image acquisitions. continuous breathing can also be combined with triggering or navigators to improve image quality or derive functional maps. mri is recommended as the first-line cross-sectional imaging modality in paediatric chest radiology, including cystic fibrosis, complicated pneumonia, any pulmonary or cardiovascular anomaly, as well as the assessment of mediastinal masses in children and adults. mri is also challenging pet/ct in the staging of lung cancer (tnm) as well as ct and echocardiography in the assessment of pulmonary arterial hypertension. mrieven without contrast -is an alternative in the diagnosis of acute pulmonary embolism if iodinated contrast medium is contraindicated or in pregnant women. mri should also be used in complicated pneumonia, e.g. in immunocompromised patients as well as for the functional assessment of chronic obstructive pulmonary disease (copd) or severe asthma. the role of mri in interstitial lung disease stills needs to be determined. unlike the simple forms of cranisynostosis whose modalities and timing of surgical correction are well established, the management of faciocraniosynostoses requires a multispecialistic and repeated evaluation of the single patients. their evolution, in fact, depends on the specific genetic anomalies but also on the phenotype, which can vary in time, of their clinical expression which may lead to different degrees in severity of the associated functional disturbances (csf dynamics impairment, visual deficits, respiratory anomalies, etc). consequently these conditions may require several surgical steps the timing of which are dictated by the exact clinical diagnosis and the evaluation of the functional status at different ages. current management of faciocraniostenoses is thus based not only on the radiological studies but also on the functional assessment of the brain function (e.g. mri imaging studies, metabolic and cerebral blood circulation investigations, respiratory pathways volume evaluation, sleep recording). today's surgical multidisciplinary management may benefit a large variety of techniques which extend from free bone cranioplasty with intraoperative active fixed expansion to more dynamic and less invasive methods which exploit the physiological brain expansion in infants or the gradual cranial vault expansion mechanically stimulated by springs or distractors. in the present report, we will review the decision making process and the rationale on which, at the necker-enfants malades, we base the use of the currently available techniques for skull expansion and correction of cranial malformations according to the accurate dynamic radiological and functional evaluation at different stages of the disease. learning objectives: 1. to learn about the imaging patterns of faciocraniosynostoses. 2. to learn how and when to image. 3. to become familiar with associated brain anomalies. b. all about the paediatric pituitary gland m.i. argyropoulou; ioannina/ gr (margyrop@cc.uoi.gr) mr is the imaging modality of choice for the assessment of the pituitary gland (pg) and the hypothalamus. the normal adenohypophysis is bright during the first two months of life and appears isosignal to the brain parenchyma afterwards. the neurohypophysis is bright, provided that the child is well hydrated. the pg height decreases during the first year of life and then increases until puberty. adenohypophyseal deficiency has been associated with a small pituitary size, an ectopic neurohypophysis, a hypoplastic or absent pituitary stalk, hypothalamic gliomas, craniopharyngiomas and iron overload states. precocious puberty may be idiopathic, but it has also has been associated with hypothalamic hamartomas, craniopharyngiomas and hydrocephalus. diabetes insipidus may be secondary to histiocytosis x, germinomas and trauma causing pituitary stalk interruption. the hypothalamopituitary axis is evaluated by using sagittal and coronal t1-weighted images without and with contrast administration. dynamic contrast enhancement may be useful in the evaluation of disorders responsible of diabetes insipidus. magnetisation transfer imaging may be useful in the evaluation of pituitary deficiencies or precocious puberty. familiarity with orbital and ocular anatomy is crucial to the understanding of disease processes of the orbit. lesions of the orbit may be divided into those which are intraocular and those which are extraocular. the underlying aetiology and geneses of many different lesions that can occur in the orbits vary depending on the location of the lesions and sometimes on additional nonorbital conditions. ct and mri play crucial roles in the evaluation of orbital pathology where often mri still is a complement to ct examination in the evaluation of orbital lesions familiarity with the radiologic appearance of common orbital lesions is important, as many of these lesions will not be seen on physical examination. after a very brief anatomic overview, most of this lecture will focus on the more common benign and malignant lesions as well as differential diagnosis involving the orbit and lachrymal gland in both the paediatric and adult population. the lecture will also present suggested imaging protocol and standard of care with respect to imaging. learning objectives: 1. to understand the embryology and imaging findings of the most common malformations.2. to learn about space-occupying lesions and the differential diagnosis of tumours and inflammatory conditions. 3. to be aware of the role of conventional and advanced mr sequences in the diagnostic approach to lesions in the orbit. room e1 the hand and wrist injury to the wrist and hand is an important clinical problem. first, such injury is relatively common. second, the spectrum of abnormalities is complicated. the purpose of this presentation will be to learn more about the imaging appearances of soft tissue and osteoarticular injury of the wrist and hand using multiple imaging techniques. emphasis will be placed upon pathomechanics and characterisation of greater and lesser arc injury patterns of the wrist. the various posttraumatic instability patterns of the wrist will be also discussed. rheumatoid arthritis (ra), psoriatic arthritis (psa) and other inflammatory disease can be diagnosed and sometimes differentiated in the early stages of the disease on the basis of mri and/or pdus features of the hand and wrist. rheumatoid arthritis (ra) activity is closely correlated with inflammation. the synovial membrane is the principal site of inflammation in which the inflammatory process enhances capillary perfusion and permeability. doppler ultrasonography (dus), using the amount of colour pixels in the region of interest, and dynamic magnetic resonance imaging (de-mri) are both able to detect this inflammation in the wrist and hand. although these techniques are both capable of monitoring synovium inflammation modifications after ra treatment, pdus has become an essential tool for ra joint monitoring in routine practice in view of its sensitivity in the detection of synovitis, feasibility in outpatient clinics, and low cost. (ellopis@hospital-ribera.com) radiological study of the wrist and hand is challenging due to its complex anatomy with many small structures and the number of normal bone and soft tissue variants that might mimic injuries. moreover, many findings can be asymptomatic. their knowledge is important to avoid misdiagnosis. during this lecture we will also review the role of the different imaging modalities, such as plain films for wrist alignment and bone structures as well as the important role of us and mr in differentiating tumour from tumour-like conditions. we will become familiar with some specific radiological findings that allow us to make accurate diagnoses of soft tissue and bone lesions. learning objectives: 1. to learn more about the spectrum of intra and para-articular soft tissue tumours, and soft tissue tumour-like lesions. 2. to become familiar with us and mri findings of specific soft tissue lesions. room e2oncologic imaging chairman's introduction c. pfannenberg; tã¼bingen/ de (christina.pfannenberg@med.uni-tuebingen.de) with recent advances in cross-sectional imaging, the frequency of detecting "incidental findings" has markedly increased. incidental findings (=incidentaloma) are defined as unexpected, asymptomatic abnormalities detected by imaging performed for an unrelated reason. these incidentalomas have created a management dilemma for both radiologists and clinicians, particularly in the cancer patient in whom any mass warrants further evaluation. discovery of incidental findings often leads to a cascade of additional tests that is costly, provokes anxiety and exposes patients to the risk of unnecessary radiation and intervention. the workup of incidentalomas varies widely by physicians, and strategies for optimising patient management are only beginning to emerge. in this course, guidelines concerning a rational approach to some of the more common incidental abnormalities in cancer patients are presented. basic principles and tools for interpretation of incidental findings, common pitfalls and protocol issues regarding the differentiation of benign and malignant lesions as well as treatment-induced abnormalities will be addressed with a focus on the liver, lung and skeletal system. at the end of the session, the speakers will discuss the role of functional imaging techniques for characterisation of incidental lesions. session objectives: 1. to become familiar with basic principles and common pitfalls in interpretation of incidental findings in the lung, abdomen and skeletal system. 2. to learn how functional imaging (dwi, pet/ct, bs) can help in lesion characterisation.3. to provide attendees with clear and practical messages for the management of the most common incidental findings in cancer patients. a. abdomen: common pitfalls and protocol issues a. ba-ssalamah; vienna/ at (ahmed.ba-ssalamah@meduniwien.ac.at) an incidentaloma is quite a frequent diagnosis in medicine, in general, and in radiology, in particular. by definition, an incidentaloma is an abnormality or a tumour found by coincidence without clinical symptoms or suspicion. these incidental findings have long posed challenges to physicians, and particularly to radiologists as well as health-care providers due to the resulting high costs. the scope and scale of these challenges have increased with the introduction of new technologies, in particular cross-sectional imaging, such as mdct and mri using sub-millimetre thin slices. incidentalomas still cause a management dilemma for clinicians, radiologists and even for the patients themselves. this dilemma is particularly pertinent to oncology patients. therefore, a precise knowledge of the broad spectrum of incidental findings is crucial. based on this knowledge, we can choose the appropriate radiologic examination that will provide a confident diagnosis. this way, needless uncertainty, for both the patient and the physician in charge, is avoided. furthermore, invasive procedures, such as biopsies, with the potential for complications, as well as cost-intensive follow-up examinations, can be reduced. furthermore, mri is usually used to detect the side effects of chemotherapy of the liver. simple steatosis is usually reversible, unless the liver receives a 'second hit' of damage from other causes leading to other manifestations, including chemotherapy-associated steatosis, sinusoidal obstructive syndrome, nodular regenerative hyperplasia, veno-occlusive disease, peliosis, pseudo-cirrhosis, and sclerosing cholangitis largely due to microvascular injury. finally, the effects of chemotherapy on peritoneal and mesenteric structures after performing intraperitoneal chemotherapy will be discussed. this presentation will discuss the complex topic of incidental findings in thoracic imaging of oncological patients. incidental findings will be presented with respect to their respective organs and anatomical regions. the presentation will emphasise the clinical relevancy of the findings as well as the specific of risk estimation in oncological patients. finally, the presentation will discuss the usefulness (or lack thereof) of current management guidelines for incidental findings, as designed for the general population. illustrative clinical scenarios will be discussed. radiographs and ct often detect incidental observations in bones, corresponding either to normal variants or benign conditions, which require additional imaging to rule out malignant conditions. mri most often provides nonambiguous explanation for these observations. beside this, mri, targeting either the whole body or only the axial skeleton, often including diffusionweighted (dwi) sequences, is increasingly used for bone tumour detection in many "osteophilic" cancers and haematologic malignancies, without need for contrast material injection and without irradiation, with unparallelled sensitivity to bone lesions. an important advantage and also a challenge for musculoskeletal radiologists are the all organ screening capabilities of dwi, demanding careful study of the huge information provided and knowledge extending far beyond bones in terms of organs and metastatic spread of different cancers. a second major advantage is its ability to detect lesion changes under therapy. however, benign lesions and non-neoplastic conditions, as well as artefacts may also lead to confusing observations on mri, and particularly on dwi. anatomical mr sequences as well as other imaging modalities are of utmost help to recognise these pitfalls. whole body mri including dwi sequences has to position itself among other diagnostic tools, bone scan, spect, and especially pet with its variety of tracers, in the currently evolving strategy of bone screening techniques, which will most likely vary according to the primary cancer. learning objectives: 1. to present most frequent x-ray and ct pseudo lesions and benign conditions and show how mri often enables straightforward interpretation of these abormalities. 2. to highlight the strengths of mri with diffusion weighted imaging (dwi) for malignant lesion detection and characterisation within bones, but also beyond bones. 3. to highlight the typical appearance of malignant lesions on projectional and cross-sectional imaging. 4. to learn to differentiate these lesions from normal marrow variations, stress lesions, bony pseudo-lesions and other benign conditions, and to become familiar with treatment induced changes within lesions and their environment. 5. to situate mri amongst other functional imaging techniques (pet, spect, ). colorectal cancer is the 3 rd most commonly diagnosed cancer in the world with 60% of cases diagnosed in the developed world. with an estimated 1.3 million new cases clinically diagnosed and over 600,000 people killed worldwide by this disease on an annual basis, colorectal cancer is a true public health concern. survival of colorectal cancer is directly related to the extent of disease and specifically presence of liver metastases. imaging plays a key role in the initial staging of colorectal cancer and is the gold standard in evaluating extra colonic disease, primarily liver metastases. imaging is also widely used for therapy monitoring and staging. ct, mri, pet/ct and pet/mri are the key imaging modalities. in addition, tumour response therapy assessed with morphological and functional biomarkers is increasingly used by advanced gastrointestinal oncologic programs. furthermore, image-guided therapy is widely used for patients with unresectable lesions. liver colorectal metastases were the first liver metastases to be treated with image-guided ablation techniques. a gamut of ablative techniques exists ranging from transarterial embolisation, radiofrequency ablation, highly intensified focused ultrasound, brachitherapy etc. in short, diagnosing, characterising and finally assessing tumour response after neoadjuvant and image-guided therapy are all functions where imaging plays a pivotal role. this course is divided into three logical segments dealing with current treatment options, morphological and finally functional biomarkers and it is followed by a panel discussion which includes audience participation. a. current treatment options t.k. helmberger; munich/de (thomas.helmberger@klinikum-muenchen.de) hepatic metastases in colorectal cancer may occur in 20% to 80% of the cases. considering the general oncological (isolated hepatic tumour load; prognostic benefit), and technical (size, number, location of hepatic metastases; expected hepatic functional reserve) framework, surgical resection is still considered to be the method of choice -even if this statement never had been verified by rtcs. nevertheless, in clinical reality only 20-30% of patients with liver metastases may qualify for resection. in consequence, the majority of patients need other or at least modified therapeutical pathways including adjuvant or neoadjuvant chemotherapy and more and more image-guided local ablative therapies. the latter encompass chemo-(transarterial chemoperfusion/-embolisation), thermo-(radiofrequency-, laser-, microwave ablation, high intensified focused ultrasound), and radio-ablative (radio embolisation, interstitial brachytherapy, etc). techniques. particularly, thermalablative techniques gained wide acceptance over the last years, since ample evidence could be presented showing that this method can be applied as primary and also complementary therapies in resectable and non-resectable metastatic disease. furthermore, recent data confirm that in multimodality therapy concepts, progression free survival and overall survival in patients with primarily unresectable and with unfavourable prognosis is comparable to surgery with 5-year survival rates more than 50%. minimally invasive, imageguided therapies will not replace surgical resection; however, these therapy modalities are eligible in a large number of cases and should be implemented consequently in multimodality treatment regimens according to the interdisciplinary consensus of oncologists, interventional radiologists, and surgeons. colorectal liver metastases are typically identified as low attenuation lesions on portal venous phase ct. planning of optimal therapy depends on accurate localisation and characterisation of all focal liver lesions and this is best achieved with mri, which should include diffusion-weighted imaging and use of hepatocyte-specific contrast medium. the typical mri signature of colorectal metastases includes low signal on t1w, moderately increased signal on t2w, irregular peripheral arterial phase enhancement with low signal on portal venous phase, restricted diffusion and absent hepatocytes. morphological tumour response can be assessed with either modality. size-based systems for assessing tumour response are widely applied, with recist 1.1 the most widely used at present. recist 1.1 includes several modifications that make it more user friendly than recist 1.1. more advanced morphological criteria have been described for new targeted and molecular therapies, including overall attenuation, the tumour-liver interface and the appearance of the peripheral rim of enhancement. as hepatic surgeons become more aggressive in their approach to resection in patients with liver metastases, it is important to understand that disappearance or calcification of liver metastases after treatment does not necessarily equate to a complete pathological response. the timing of imaging is therefore critical in assisting the surgeon to remove all previously affected hepatic segments after chemotherapy. learning objectives: 1. to learn about the algorithm for detecting and characterising liver metastases. 2. to understand conventional imaging criteria for assessing tumour response. 3 . to learn about the rationale for monitoring patients after radical and palliative treatments. conventional size measurement criteria remain the most widely used method to determine the response of colorectal liver metastases to treatment. however, tumour size reduction is assessed relatively late (e.g. 12 weeks after treatment) and new targeted treatment may be effective without reducing tumour size. new functional imaging techniques can be applied to quantify different aspects of tumour biology and to develop response, and predictive and prognostic biomarkers. we discuss the use of diffusion-weighted mr imaging, dynamic contrast-enhanced mr imaging and fdg-pet imaging in the evaluation of treatment response in patients with colorectal liver metastases. digital breast tomosynthesis (dbt) is a promising technique for breast imaging based on a full-field digital mammography (ffdm) platform. the x-ray tube moves through a proscribed arc, and several low-dose projection images are acquired. images are reconstructed into a stack of 1 mm slices. the radiation dose is about the same or slightly higher than for ffdm. the most important advantage of dbt is the elimination of superimposed tissue, which improves detection of lesions otherwise hidden by dense breast parenchyma and reduces the interpretation problems caused by overlapping tissue. dbt is suggested to improve sensitivity as well as specificity in women with dense breast. dbt is superior to ffdm in tumour size assessment and for mass visibility and cancer conspicuity. dbt is comparable to ffdm for evaluation of microcalcifications. dbt is superior for the detection of spiculated masses and architectural distortion. the potential to improve sensitivity and specificity is of interest for screening. an open question is whether dbt should be applied in one or two views. two-view dbt would mean a doubling of radiation dose, but a solution is the implementation of synthetic 2d images reconstructed from the 3d dataset of dbt. the synthesised images are created by summing and filtering the stack of reconstructed dbt slices. using synthetic 2d allows "combo mode" to be implemented in screening with the same radiation dose as for conventional 2d. results using dbt in breast cancer screening are very promising. different study design of published studies may explain the variations of results. magnetic resonance imaging of the breast provides a multitude of techniques for detection of breast cancer and differentiation of benign from malignant lesions. in the last few years, significant improvements of scanner hardware and equipment in terms of coils as well as sequence software have been achieved. to date, multiparametric quantitative measurement of perfusion, diffusion and tissue chemistry is possible at field strengths up to 7 tesla. although higher field strengths and improved sequence protocols provide higher signal and allow faster imaging, specific technical issues have to be considered to avoid artefacts and pitfalls. this talk aims to demonstrate the possibilities and limitations of multiparametric and (ultra-)/high-field mri. furthermore, these new techniques are put into the broader clinical context to determine the potential value for breast lesion detection and differentiation. positron emission mammography is a recently developed imaging device using positron emission technology. after injection of a positron-emitting radiotracer, the radiation is detected by a dedicated high-resolution camera, providing high spatial resolution. commercially available systems include cameras where the breast is compressed and which display a 2d image similar in its layout to a mammogram and hanging breast devices where a 3d image similar in its layout to mri is produced. these devices have been compared to pet/ct and have shown higher spatial resolution, accuracy and sensitivity in detecting malignant breast lesions. the most widely studied tracer in pet/ct and in pem is fluorodeoxyglucose (fdg). fdg is a glucose analogue and has had a major impact on oncology imaging with pet/ct. breast carcinomas demonstrate increased glucose consumption and the intensity of the uptake has been correlated with prognosis, hormonal receptor and her2 status, ki67 and nodal involvement. current potential indications for pem are detection and characterisation of breast lesions, local staging in patients with known breast cancer and baseline assessment prior to neoadjuvant chemotherapy. future developments of pem will involve new tracers and fusion with other breast imaging modalities. fluorothymidine is a proliferation tracer that seems promising in early assessment of response to chemotherapy. fluoroestradiol has the potential to image oestrogen receptor status in vivo. the possibility of pem-guided biopsy is a very exciting development and has the potential to select lesions with the highest intensity of uptake. fusion with mri, us and mammography will increase the diagnostic accuracy. the presentation will focus on two frequent findings on mri with increasing incidence during ageing, notably "unspecific" hyperintense lesions on t2/flair and cerebral mircobleeds (cmbs) on t2* or swi images. clinicoradiologic studies suggest that these t2/flair lesions are associated with increased risk of cognitive decline, stroke and death. the clinical relevance of these lesions probably depends on periventricular versus deep white matter location. radiologic-histopathologic studies correspondingly indicate that the degree of histopathologically confirmed demyelination also depends on the location of these t2/flair lesions. cerebral mircobleeds (cmbs) are punctate hypointense lesions on t2* or swi images. while multiple cmbs are associated with diseases such as cerebral amyloid angiopathy (caa), clinicoradiologic studies demonstrate increased incidence of sporadic cmbs in mild cognitive impairment (mci) and alzheimer dementia, indicating a degrading effect of cmbs on cognition. on the other hand, radiologic-histopathologic studies show that not all black spots on t2* or swi correspond to cmbs. cmb mimics include micro-calcifications. the presentation will demonstrate typical manifestations of these "unspecific" t2/flair lesions and cmbs during ageing and provide tips for the interpretation of these lesions during daily clinical routine. with the increasing use of mri, it has become more common to discover incidental brain findings. these findings may be non-specific or have some morphological characteristics and geographical distribution highly suggestive of a demyelinating disease. the term "radiologically isolated syndrome" (ris) was introduced by okuda in 2009 to describe those asymptomatic patients with radiographic abnormalities highly suggestive of multiple sclerosis (ms). sometimes, these lesions may even meet the mri criteria for dissemination in space, which are currently used to predict future development or conversion to ms in patients presenting a clinically isolated syndrome (cis). however, we must not forget that these radiological criteria should be applied only when the patient had experienced any clinical manifestations suggestive of a demyelinating disease. therefore, what happens in those patients in whom we found highly suggestive lesions but have never had symptoms? due to lack of knowledge about the natural history or evolution of this new syndrome, clinical and therapeutic management of these patients is not well established, nor is the risk of conversion to ms. recent data, however, indicate that the presence of gadolinium-enhancing cervical cord and cortical lesions significantly increases the risk of conversion to cis or ms. all these data have improved the characterisation of ris subjects and in our understanding of risk factors for initial symptom development. incidental findings on brain imaging are defined as previously undetected abnormalities of potential clinical relevance that are unexpectedly discovered and unrelated to the purpose of the imaging. incidental findings are increasingly detected in clinical practice, with screening, and in the research setting. data on the prevalence of these abnormalities are scarce, the clinical course of the findings is often unknown, and the management of such lesions is not clear. the prevalence of incidental findings can be expected to vary depending on the purpose of the imaging exams. with improvements in imaging technology (higher field scanners, new pulse sequences), the number of detected incidental findings will increase dramatically. another important point is the advent of imaging biomarkers. advanced techniques for postprocessing and analysis, such as automated segmentation of brain structures or voxel based morphometry, will lead to the discovery of imaging biomarkers. once the predictive value of these markers has been established, most mri studies of the brain, both in the clinical and research setting, will reveal information that might be relevant for the well-being of patients or participants. although still incidental, these findings can unfortunately no longer be considered unexpected. we will soon face large medical, ethical, and practical problems as a result of technical improvements. in this lecture, the most important incidental findings and their prevalence will be reported. the management of incidental findings in the clinical and research setting will be discussed. finally, recommendations for follow-up will be provided. the primary assessment of laryngeal cancer is provided by endoscopy, which is accurate in delineating both the superficial extent and functional impairment. imaging techniques are recommended to grade submucosal invasion, local and distant spread. in the last few decades, open and endolaryngeal surgical procedures as well highly sophisticated rt techniques have been developed to treat the tumour while preserving critical laryngeal functions. for example, early glottic tumours (tis-t2) can be treated by endoscopic laser excision or rt. the integration of information acquired by endoscopy and imaging is essential for proper treatment planning. the radiologist has to know that the site of origin (supraglottis vs glottis or subglottis) and local extent (superficial and submucosal) are the key tumour-related factors in planning the type of treatment. submucosal invasion has a variable impact depending on the location of the primary tumour. the 5 key issues in glottic cancers include the invasion of: the posterior paraglottic space, crico-arytenoid joint, and anterior commissure and contralateral true vocal cord, and vertical spread towards supra and/or subglottis, thyroid or cricoid cartilage. the 5 key issues in supraglottic cancers encompass the invasion of: base of the tongue, preepiglottic space, piriform sinus, vertical spread into glottis and subsequent cartilage invasion (observed exclusively in transglottic cancers). functionsparing surgical techniques -as supracricoid laryngectomies -can be applied in advanced cancers when sparing of the posterior commissure, the ipsilateral crico-arytenoid joint, the mucosa investing the upper cricoid and the outer perichondrium of the thyroid cartilage is demonstrated by endoscopic and imaging mapping. the detection of recurrent laryngeal carcinoma is often challenging. to better appraise the expected findings after initial surgery of laryngeal cancer, the classical partial laryngectomy and laser laryngeal surgery are briefly presented.(chemo)radiotherapy has become an important treatment modality for laryngeal carcinoma. the recurrence rate in t2-t4 laryngeal carcinoma is reported to be between 25% and 50%. the difficulty in differentiation between radiation reaction (such as oedema, fibrosis and soft tissue and cartilage necrosis) and recurrent disease is discussed. a histologic study on wholeorgan sections of 29 recurrent glottic carcinomas is also presented: recurrent disease presents with different tumour spread than does a primary carcinoma, resulting in difficulties in estimating the extent of tumour recurrence. currently, selected recurrences of early glottic carcinoma are, whenever possible, treated by larynx-preserving salvage surgery. in those cases, a precise evaluation of the recurrent tumour extent is mandatory for planning larynx-preserving salvage surgery. this is especially true in critical regions such as the preepiglottic space, infiltration into cartilage, contralateral tumour spread and subglottic tumour extension. the accuracy of crt-classification is relatively low: many patients with signs and symptoms suggesting tumour recurrence present with post-radiotherapy changes; small tumor foci, often localised in the subglottic region, are undetectable by imaging studies. tissue changes in the neck treated by surgery and/or radiotherapy (rt) make the detection of residual or recurrent tumour more difficult. clinical evaluation of the neck is also hampered by these changes. rt-induced fibrosis and postsurgical scar tissue make palpation of the neck very difficult. endoscopy is hampered by endolaryngeal oedema which can persist for many months post-rt. therefore, any (non-invasive) method helping in the detection of recurrence is welcome. patients at risk for local failure after rt can be successfully identified by a post-rt ct (or mr) study between 1 to 6 months after rt. the optimal time point to perform such a 'baseline study' seems to be about 3 to 4 months post-rt. patients with indeterminate findings are candidates for 'imaging surveillance'; i.e. follow-up imaging every 3 to 4 months up to a period of 2 years after rt. however, ongoing studies suggest that metabolic imaging (fdg-pet) may detect local recurrences with a higher accuracy than 'conventional' anatomically based imaging techniques, such as ct and mr. ct and/or mr-findings in the treated neck are frequently inconclusive. at present, new techniques are available to detect recurrent cancer. pet-ct is widely applied in the post-treatment setting. also, advanced mr-techniques such as diffusion weighted imaging (dwi) and dynamic contrast-enhanced mr (dce-mr) can be applied. focusing on the larynx, the advantages of these techniques as well as the limitations will be shown using imaging examples from daily practice. during the last 10 years, several hundred new radiotracers for pet imaging of cancer have been developed and tested preclinically. these tracers are based on proteins (e.g. antibodies and antibody fragments), peptides (e.g. g proteincoupled receptor ligands) or small molecules (e.g. radiolabelled protein kinase inhibitors or metabolic substrates). using these radiotracers, the expression and function of a variety of proteins can be studied in patients, including for example glutamine/glutamate metabolism, neutral amino acid transport, psma, grpr, sstr, cxcr4, folate and alpha-v beta-3 integrin expression. some of these radiopharmaceuticals are potential companion diagnostics and may allow selection of patients for treatment with radiopharmaceuticals or targeted drug conjugates. preclinical and initial clinical data are promising for several new radiotracers, but the key challenge is the clinical validation and dissemination of these compounds. validation and dissemination have been hampered so far by regulatory hurdles as well as by the lack of standardised trial designs for the validation of imaging agents and the lack of accepted and appropriate end points to prove clinical utility. addressing these issues will be critical for the future clinical use of pet and other molecular imaging technologies. imaging targets in cancer range from simple size measurements to more specific biomarkers on functional, cellular, metabolic and molecular levels. as our understanding of basic tumour biology has advanced, techniques have been developed to exploit this information to produce increasingly specific molecular imaging tools. the biodistribution of these molecular imaging probes should be more specific in diagnosing and assessing cancer than the morphological information acquired using anatomical imaging alone. this lecture will discuss current and emerging functional and molecular imaging techniques using mri and their applications in oncology. functional measures of tumour blood flow and vascular permeability can be made using dynamic contrast-enhanced mri. diffusion-weighted imaging is a surrogate for the cellular content of the tumour and emerging methods can be used to probe features of the extracellular space such as tumour ph and stromal content. on the molecular level, cell surface expression of specific proteins and enzyme activity within the cell can be imaged; labelled probes have been developed which bind to these proteins and a new mr technique is being developed for assessing tumour glucose in a similar way to pet. hyperpolarisation methods are emerging to overcome the major limitation of mr: low sensitivity. one such approach is dynamic nuclear polarisation, which can probe carbon metabolism non-invasively in patients with cancer. functional and molecular imaging techniques with mri will increasingly be used in radiology in conjunction with anatomical imaging methods to improve diagnosis and prognosis, target biopsies, as well as predict and detect response to treatment. with mr-spectroscopy, diffusion-weighted imaging, pet-and spect-ct, as well as pet-mri, molecular imaging has already become part of clinical routine diagnosis. also, some contrast agents such as spio for mps-labelling and scavenger-receptor binding gadolinium chelates are clinically applied for liver and lymph node imaging. however, there are still a number of highly promising novel tools that are expected to emerge clinically in the near future. in this context, the first part of the talk will give an overview on how optical imaging basically works and which future clinical applications can be expected. in this context, raman spectroscopy, fluorescence optical reflectance imaging, fluorescence mediated tomography, photoacoustic imaging and cerenkov luminescence imaging will be addressed. the second part of the talk introduces molecular ultrasound imaging as a safe and preclinically wellevaluated method. besides the diagnostic use of molecular ultrasound contrast agents, which have been already evaluated in clinical trials, the potential of this method also for theranostic purposes will be highlighted. the assessment of the amount of arterial calcification with computed tomography is a standard method in the risk stratification of coronary heart disease. coronary calcium detection by ct has been shown to identify atherosclerotic plaque and to quantitatively assess coronary calcium. many studies have demonstrated the association between the degree of coronary calcium, the burden of atherosclerosis, and the risk for cardiovascular events associated with coronary calcium. the cac scoring can provide individual risk assessment and reclassify the low and particularly intermediate framingham risk cohort into lower-and higher-risk strata. the absence of cac is associated with a very low risk of future cardiovascular events, with modest incremental value of other diagnostic tests in this very low-risk group. the role of cac in the workup of symptomatic patients is under discussion and there is evidence that the absence of cac has a high negative predictive value for ruling out acute coronary syndrome. although cac measurement is highly standardised, some technical aspects have to be considered and all possibilities of dose reductions utilised. this presentation will show the technical and epidemiological fundamentals of cac scoring and discuss the clinical applications of the method. coronary cta has gained an important role in the evaluation of patients with chest pain, suspected of coronary artery disease (cad). in comparison to invasive coronary angiography, coronary cta with 64-multidetector ct has an excellent sensitivity for coronary stenosis. specificity for stenosis is less excellent, but has improved with newer ct generations. the strongest impact of coronary cta has been on the exclusion of stenosis in symptomatic patients at low-intermediate pre-test probability. in contrast to invasive angiography, coronary cta yields more information than just the severity of stenosis. coronary cta also allows determination of plaque types (calcified, non-calcified, partly calcified) and quantification of the atherosclerotic plaque burden. also, new developments point to the possibility to assess the haemodynamic significance of stenosis based on ct density measurements in the coronary arteries, or evaluation of myocardial perfusion. thus, coronary cta yields quantitative imaging biomarkers that could be used for risk stratification in the future. recent studies have shown that whether or not a patient has stenosis and plaque, as well as the type and burden of plaque, affects the risk of myocardial infarction and mortality. therefore, the impact of coronary cta imaging biomarkers reaches beyond the mere assessment of stenosis for symptomatic treatment and could potentially alter medical management of patients for improvement of long-term prognosis. a-608 17:00 c. added value of carotid and peripheral artery imaging for risk assessment l. natale; rome/ it (lnatale@rm.unicatt.it) technical protocols optimisation of mra and cta of carotid and peripheral arteries is crucial for image quality and to complete the analysis of both lumen and vessel wall. furthermore, mra protocol needs to be integrated with dedicated pulse sequences in order to obtain vessel wall imaging that is already included in cta datasets. new ct and mr scanners allow this optimisation in terms of radiation exposure, contrast media dose reduction and spatial resolution. all these parameters will be discussed for both techniques. according to international guidelines, non-invasive imaging indications will be discussed, with particular attention to high risk population (e.g.: diabetic patients). some possible imaging biomarkers of plaque composition will be discussed. learning objectives: 1. to become familiar with optimal technical considerations for performing cta and mra of the carotid and peripheral arteries. 2. to understand clinical indications for carotid and peripheral cta and mra. 3. to discuss the role of cta and mra parameters including plaque imaging as biomarkers of cardiovascular disease. key: cord-014687-0am4l5ms authors: nan title: spr 2012 date: 2012-03-29 journal: pediatr radiol doi: 10.1007/s00247-012-2356-8 sha: doc_id: 14687 cord_uid: 0am4l5ms nan dear colleagues, i confess i haven't read many "welcome letters" at the beginning of the spr program book over the years. perhaps the only defensible benefit of this is that there is no preconception about the content of this message…or the length. i will be brief. this meeting is about building bridges…bridges from our past to the future and bridges between all of us who believe fundamentally in maintaining or improving the health of our children. the content, which is detailed on subsequent pages, speaks for itself. this material will be presented during the sessions with an appreciative look back at past accomplishments-the legacy of our subspecialty-with a vision to the future of pediatric imaging. we can only measure how broad and deep our successes have been by connecting with these beginnings. looking beyond the titles (and the speakers), i think you will see that the material is not only about techniques and tactics but about ideas, insights, energy, all conspiring in the creative process … an aggregate for excellence in pediatric imaging. the content is also punctuated by a strong presence of our clinical colleagues. again, this builds bridges. how can we maintain and expand these relationships? moreover, the connections between science and clinical practice are evident in the structured blending of scientific papers and topical presentations by both imaging and clinical experts. this blending is also "fraternal" in that there will sometimes be disagreement and critical commentary, but this is essential in the advancement of medicine. support and criticism make a stronger mortar. in the end, this gathering is about fostering a connected community, including technologists, nurses, physicists and other allied health experts including industry experts. finally, the emblem of pediatric radiology has always been embossed by cooperation, passion, commitment, and humanistic care. i believe the program content, the presenters and you, the participants, all embrace this. i hope that you will feel the spirit and the passion of the meeting and all of us will in many ways be better able to care for children because of this-even if you never read this message! donald p. frush the gold medal of the society for pediatric radiology is our most distinguished honor. the spr medal is awarded to pediatric radiologists who have contributed greatly to the spr and our subspecialty of pediatric radiology as a scientist, teacher, personal mentor and leader. marilyn goske has always wanted to make a differenceand what a difference she has made! her role as an educator, and her lifelong commitment to improving training for residents, fellows, faculty, medical staff and radiologic technologists has resulted in many wonderful initiatives that have benefited all in pediatric radiology. the work she is most proud of-the cleveland clinic web based curriculum, working with the leadership of spr's philanthropic campaign for children, launching the image gently campaign and the pediatric research component within the american college of radiology's dose index registry share a common theme: educating others in providing the best care possible for children. born in berea, ohio, marilyn's father, george, was a chemical engineer. her mother, cornelia aka "corky", loved writing as one of the first women journalists for the associated press and later teaching, passions she passed on to her daughter. while marilyn was blessed with a strong female role model in her mother, it was her brother, james, who was her cheerleader, always pushing her to dream big. he encouraged her to follow in his footsteps first at ohio university, then on to the ohio state college of medicine to pursue an md degree during an era when nursing would have been a more conventional goal. marilyn met her husband rick on a double date in college-unfortunately, they were with different dates! luckily, they were able to get together for an actual date with each other 18 months later. they quickly became engaged and married within a year of that first true date. when rick started his residency in internal medicine, marilyn transferred to the university of connecticut school of medicine in farmington. it was here that she met her first pediatric radiologist-and what a giant-mike ozonoff! when rick moved on to a neurology residency in rochester, new york, marilyn followed and met another pediatric radiology giant: beverly wood, at strong memorial hospital. beverly proved to be a wonderful teacher, mentor, co-researcher and lifelong friend. marilyn describes beverly as inspirational and "fearless" in trying new technologies. it was during her time in rochester that marilyn went to her first spr meeting and, not surprisingly, won the 1984 caffey award for her work on "experimental neonatal intraventricular hemorrhage: clinical, radiographic and pathologic features." by then marilyn had two young children and moved on to the private sector, practicing part-time for several years first in rochester, then in cleveland, ohio. her years in private practice were particularly helpful in learning the importance of patient oriented service-and paved the way for her intuitive public relations strategies when designing the image gently campaign in later years. dr. goske was asked to join the cleveland clinic in 1990, as the first full-time section head of pediatric radiology. it was here that she built a new section and spearheaded the web based education program for pediatric radiology residents with co-founder janet reid. this important free web site with 65 modules is used widely by over 200 radiology residencies nationally and internationally. her passion for education continued, inspiring her to complete a medical education fellowship focused on professionalism within the cleveland clinic lerner college of medicine. her work towards this fellowship has led to many creative educational initiatives including yearly educational summits at the spr. she was named chair of the professionalism committee of the rsna where she along with her committee have sponsored interactive workshops on this topic dear to her heart. dr. goske's energy and effective leadership skills brought her to become involved in the society for pediatric radiology, first as the coordinator for spr's first video-taped course in 1994. mentors diane babcock and carol rumack proposed her for the nominating committee. this was followed by chair of the membership committee, where she organized the first formal survey of the society, then as a board member, then as secretary, and finally as president and chair of the board of directors, completing 12 years on the spr board. working together with stuart royal, she successfully energized the campaign for children raising funds for the research and education foundation of the spr and expanded the work of prior presidents in further organizing the corporate support committee. marilyn's years as president and chairman of the board of the spr were highly successful with many unique strategic goals. she was instrumental in the founding of the junior spr. she led the wonderful 2007 spr national meeting in miami which included the first educational summit to enhance knowledge in adult learning and resident competencies. most people would rest after completing their arduous year as president but as chairman of the board, marilyn was just beginning! she moved to cincinnati children's hospital, joining the radiology department and was named the dr. corning benton endowed chair for radiology education where she got to work with dr. janet strife, another influential mentor and friend. acknowledging spr's long focus on reducing radiation doses in the imaging of children but concerned about the lack of change in practice by a majority of radiologists despite increasing reports of possible side effects, marilyn developed a public relations and awareness campaign. her goal was to inspire all to work towards decreasing radiation exposure to children when possible. with the help of many, she founded the alliance for radiation safety in pediatric imaging and the image gently campaign, initially focusing on ct. her ability to encourage numerous experts and societies to work together and get involved in "child sizing the amount of radiation used" has resulted in a groundswell of research and activity in this area. currently 69 organizations with over 800,000 members have joined the alliance including 24 international societies. the web site, www.imagegently.org, has been immensely successful filled with free information pamphlets in over 12 languages, pqi projects, and modules for parents, physicians, and technologists. the image gently campaign has received several awards including the associations advance america honor roll, rt image magazine group with the "most influence in radiology" and the most effective philanthropy program from aunt minnie. image gently has spawned the creation of the adult-focused image wisely campaign. the alliance has been named by the joint commission, u.s. food and drug administration, and the american medical association in their influential statements on radiation dose as providing much needed guidance and information. marilyn's exceptional talent is inspiring and coordinating experts in multiple fields to work together towards common goals. she continues to work hard on the image gently campaign with more safety and quality messages planned for the coming years. she is also proud of her work with the acr dose index registry and quality improvement registry in ct scans in children in working toward developing diagnostic reference levels with a talented consortium of pediatric radiologists, medical physicists and technologists. she has acted as a national and international expert in her work with the international atomic energy agency, the world health organization and the national council on radiation protection in medicine and the fda. dr. goske's multiple committee appointments are taken seriously, and her work is always meticulous, well thought out, and brought to successful completion. she has been an active member of numerous national and international societies including the john caffey honorary society, acr, rsna, espr, aawr, and scorch. it is important to remember that dr. goske is also a successful researcher with numerous grants obtained through the spr ref including the thorne griscom education award and the rsna scholar grant. she has published over 80 peer-reviewed articles, 19 electronic publications, 7 chapters, and presented 26 scientific exhibits as well as given numerous scientific presentations. an articulate and engaging speaker, she has been invited to give over 130 lectures locally, nationally and internationally. while marilyn has been very focused on her work with the spr, she believes that it is her amazing family and their love that really fuels her life. her husband rick is an internationally known neurologist and researcher in multiple sclerosis. her adult children jamie and brian, both in manhattan, remain close, and spending quality time together as a family remains the joy of her life. whether it is relaxing together in florida cooking or fishing, or taking an exotic vacation to india, being with rick, jamie and brian makes her the happiest. marilyn's genius is partly refusing to take "no" as an answer. along the way, at every turn there were those who believed that what she wanted to do couldn't be done. her approach was to draft the nay-sayers to the team and charge ahead with their willing and enthusiastic help. daniel burnham might have been talking about marilyn and not about his plan for the city of chicago when he said: make no little plans; they have no magic to stir men's blood and probably themselves will not be realized. make big plans; aim high in hope and work, remembering that a noble, logical diagram once recorded will not die, but long after we are gone be a living thing, asserting itself with evergrowing insistence. as an amazing change agent, inspirational leader, and wonderful role model, the spr is proud to honor marilyn goske with the 2012 gold medal. she made big plans! dorothy i. bulas, md pioneer honorees were first acknowledged in 1990 as a means to honor certain physicians who made special contributions to the early development of our specialty. it is time to reevaluate the meaning of the pioneer honoree. the subspecialty of pediatric radiology has been in existence now for more than 50 years. we are beyond "the early development"; we must recognize other pioneering paths and should consider contributions to the subspecialty beyond the bounds of a modality, a technique, an observation or a change in practice. whatever this advancement is, it must be forged with vision, innovative ideas, and the ability to enable and sustain science and application. george s. bisset, iii, m.d. why george bisset? has he been part of the pediatric radiology landscape these last ten years? been part of the dialogue that has been increasingly influential across all of radiology, a conversation steeped in a deep tradition of excellence in diagnosis and treatment, and the safety and welfare of our children? been a leader in science and application? part of the landscape? no. but he has been beyond that and has worked tirelessly within the horizon, surveying…a step before, but guiding us on towards our destiny. a conversant? part of the dialogue? maybe. but he has been defining thought and concept upon which such conversation is born and nurtured. part of the science and application? yes, as much as anyone who promotes, who facilitates and sustains discovery, then here we are. horizons, innovation, and the gift of en-abling…what else is needed to define a true pioneer? how was this done? simply stated, george bisset has devoted at least the last decade to the advancement of our specialty in truly novel ways through his leadership, especially in rsna and the abr. in the rsna, as the scientific program committee chair several years ago he was instrumental in the conception, development and implementation of the integration of scientific papers and refresher course topics. this has been a resounding success, is currently used in other categories during rsna and is a model for other meetings, including the annual meeting for the society for pediatric radiology over the past few years. pediatric radiology was first in this effort. george continued to endorse topics that were marquees for pediatric radiology over the year in his education role on the rsna board of directors. he endorsed and implemented the pediatric campus concept at the 2011 rsna. early returns are that this was an extremely successful model to consolidate experts in pediatric radiology (and those interested in this subspecialty), pertinent science, education and administration. george is now the president of rsna, perhaps the most widely respected scientific and educational organization for our profession across the globe…and i would argue, with more promise for our future success in pediatric radiology than has ever existed. and george bisset, who through two terms as the pediatric trustee for the board of trustees for the abr, again, was on the horizon of a critical, sometimes perilous, and complete transformation of our certification examination process, always mindful of his constituency and colleagues, his duty as a physician, and the public and patients. this required delicate diplomacy, forward thinking, professionalism, and enlistment of a cadre of experts from within our subspecialty to assure excellence in pediatric radiology through abr certification. he was also a leader in the development, validation and implementation of the imagerich computer based examination model (the pediatric caq) now the standard for the new abr examinations. with these successes in mind, who better to embody the concept of bridging horizons that is the theme for this entire meeting? if you were looking for more numbers and accolades, i apologize. here are some: more than 225 contributions to medical and scientific literature, advancing care through pediatric body ct and mr imaging research, a litany of presentations and invited lectures, vice chairs, chairs, chiefs, boards of directors, committee member and committee leader, clinical excellence including as a pediatric cardiologist and interventional radiologist, a superb speaker and author.… all are on his cv but i believe serve really as signposts for his gifts, some of those mentioned above, that a cv simply cannot convey. he could have played it safe with all of these successes on his cv. but pioneers don't play it safe. they are on the horizon, too busy defining thought and enabling (our) advancement-building bridges. i believe it is time to reevaluate the meaning of the pioneer honoree and i have the greatest honor and pleasure of introducing george s. bisset, iii for the pioneer award for 2012. linked with past awardees, he continues an exceptional legacy and i don't believe his explorations and discoveries are finished… donald p. frush, md the society bestows presidential recognition awards on members or other individuals whose energy and creativity have made a significant impact on the work of the society and its service to its members. in 1999, david kushner was recognized by the spr with its first presidential recognition award for his vision and foresight in working with both the american college of radiology (acr) and the society for pediatric radiology (spr) in developing an important new relationship and for his service to the spr. in summarizing his considerable efforts for that award, i noted that he "contributed substantively to the increased visibility of the spr within the acr. his tenure as our treasurer placed our organization on a firm financial foundation." with the current award, the society recognizes his indefatigable continuing efforts on our behalf including: his work with the acr: 1. establishing a pediatric radiology caucus at the annual acr meeting, 2. convincing the acr of the value of managing specialty societies by making the spr its first successful new model for imaging society management, 3. advocating tirelessly for pediatrics and children's health within the acr by serving on the council steering committee and then as acr council vice speaker and speaker, 4. helping establish the first pediatric commission, assuring that pediatric issues will receive support of the college and its resources while serving on the board of chancellors of the acr for the past five years. the spr's "image gently" campaign was a beneficiary of this pediatric commission of the board of chancellors, 5. continuing to shepherd and contribute to the pediatric component of the acr practice guideline process. his work with the spr: since his earlier award, david has served as: foundation from 2000 to 2003, including the launch of the formal fundraising effort, "the campaign for children," 2. spr president 2003 -2004 , organizing and running a very successful meeting in savannah, 3. chair of the board of directors of the spr from 2004 to 2005, including leading a strategic planning process that resulted in a new, more focused division of labor amongst board members and defined board responsibilities. david was born in fargo, north dakota, received a ba from the university of minnesota, and received his medical education at the university of pennsylvania. this was followed by two years of training in pediatrics at children's hospital, boston. he then did a two-year fellowship at the national institute of health in bethesda, performing research in embryology and teratology. he returned to massachusetts general hospital for training in diagnostic radiology. this was followed by a year of residency in pediatric radiology at children's hospital boston, followed by a one-year fellowship. he then became director of the pediatric radiology section at massachusetts general hospital, a position he held from 1979 to 1988. from 1988 to 2005, david was chief of the division of diagnostic imaging and radiology at children's national medical center in washington, dc attracting a strong faculty, training many fellows and promoting research. during that time, he served as a volunteer radiologist and pediatrician to inner city healthcare systems aiding the indigent and homeless, and developing telemedicine capabilities linking free clinics with radiology experts. in 2005, our man inside the beltway moved a bit outside by accepting the medical directorship of radiology at the children's hospital of the king's daughters in norfolk, virginia, and professor of radiology and pediatrics at the eastern virginia medical school. he assures me that life there is good, being a bit more "laid back" with fishing and sailing just outside the door. he also finds time for italian cooking and practicing jazz on his several guitars. fortunately for all of us in the spr, david is close enough to our central office and the acr that he will be able to continue work on our behalf for many years to come. the society bestows presidential recognition awards on members or other individuals whose energy and creativity have made a significant impact on the work of the society and its service to its members. the 2012 spr presidential award is given in recognition of stuart's numerous significant and outstanding contributions to the spr over many years of service. the awardee is selected by the honors committee, a committee comprised of the three most recent past presidents of the society. dr. royal is a proud native of birmingham, alabama. he is a second generation physician who came naturally to his desire to care for children as the son of a pediatrician, arnold royal, who took care of children in the birmingham community until he was 79 years old. dr. royal attended rice university in houston, texas followed by md and ms degrees from the university of alabama at birmingham. he subsequently moved to san francisco, where he completed a pediatric internship followed by a diagnostic radiology residency at the university of california, san francisco. dr. royal credits dr. charles gooding at ucsf for influencing his decision to pursue a career in pediatric radiology. during his internship stuart observed dr. gooding make a plain film diagnosis of tapvr, type 3 on a severely ill and perplexing newborn, and he was immediately hooked into radiology. while at ucsf dr. royal was also appointed as a national institute of health research fellow in the department of radiology. following residency, stuart completed a fellowship in pediatric radiology at the children's hospital medical center in boston. from boston, stuart returned to his roots in birmingham, alabama in 1980, where he was appointed as a pediatric radiologist at the university of alabama and subsequently the children's hospital in birmingham. in recognition of his outstanding leadership skills and accomplishments at the children's hospital, dr. royal was appointed as the radiologist-in-chief in 1987 , and subsequently the harry m. burns endowed chair of pediatric radiology. he also holds appointments as clinical professor of radiology and pediatrics at the university of alabama at birmingham and serves on the children's hospital board of trustees. at alabama dr. royal has earned the high esteem of his colleagues, referring physicians, and staff for his outstanding clinical acumen as a diagnostic radiologist and for his undaunting commitment to excellent care of children. colleagues describe stuart as one who fosters a strong work ethic, high commitment to teaching, and sincere compassion for children. in 2006, stuart was the recipient of the children's advocate award by childcare resources for improving the quality of care and access to radiological services for underserved children in birmingham. stuart has been married to the love of his life, barbara royal, for the past 40 years. stuart and barbara are the proud parents of two very accomplished children, jeremy a budding radiologist in training at the university of alabama, and rachael, who has an mba and works as a vice president for moody's in new york. stuart and barbara are also the proud grandparents of three grandchildren. in conversation, stuart is quick to pull out his iphone and share the latest pictures of family members while recounting their latest activities and milestones. throughout his professional career, dr. royal has worked tirelessly to advance the mission of the society for pediatric radiology. he is past president and chairman of the board of the spr and has served on numerous spr committees. he ran a highly successful spr meeting in new orleans in 2005. those in attendance will recall the jubilant parade stuart led through the streets of new orleans to culminate the meeting. as president and then chair of the spr board, stuart played a critical and instrumental role in bringing the spr management contract under the umbrella of the acr. the synergy achieved by the spr-acr relationship has yielded results well beyond a simple management contract. pediatric radiology and spr now have a voice at the "radiology table." stuart has also been a strong advocate for supporting translational research to advance the care of children via imaging. to help achieve this goal, he has worked aggressively to secure increased funding for the society of pediatric radiology research and education foundation. following the launch of the ref's campaign for children in 2000, stuart made it his personal mission to work with the leadership of the society, both past and present, to discuss major gifts to the foundation. through stuart's personal effort, the foundation received pledges for many significant leadership gifts, including from spr pioneers drs. hooshang taybi and ed singleton and from himself and barbara. the spr is highly fortunate to have benefited from stuart's numerous contributions and dedication to the care of children. the society is very proud to bestow the 2012 president's award on dr. stuart a. royal. the society extends honorary membership to individuals outside of pediatric radiology who have made outstanding contributions to the care of children. this evening, dr. harvey l. neiman, whose leadership of the american college of radiology is resoundingly praised, is the recipient of the 2012 honorary member award. for 2012, as in 2007 when his contributions were similarly recognized, dr. neiman's selection by the society for pediatric radiology honors committee was made in appreciation for the strength of his efforts to further the spr's philosophy, goals, and programs for responsible diagnosis and treatment of the young patient as embodied in the acr and spr's "image gently" campaign. image gently has succeeded not only in raising awareness of the great diagnostic benefits we can offer to pediatric patients but also directs us to acknowledge the downside of overzealous diagnostic efforts where excessive radiation becomes a risk. importantly, the "image gently" campaign, an upbeat, positive program rather than a punitive one, a smile rather than a frown, makes pediatric and all radiologists aware that their best practice reflects balanced, educated, up-to-date utilization of state-of-the art technology with exercise of responsible leadership in protecting the pediatric patient. for adults, awareness of the need for patient protection is communicated in image wisely. dr. neiman's vision and successful achievements are evident on every page of his curriculum vitae. a consummate strategist in assembling teams to make forward-looking goals a reality, harvey now stands at the top of our specialty as the first physician executive director of the american college of radiology. at this time in big-business medicine, as we see the physician, leader of the patient care team, being diminished to one of many "providers," it is so important for our patients' well-being for us to recognize the obligations commanded by our training, clinical experience and commitment. dr. neiman's recognition of the need for physicians' leadership in improving the quality of patient services and his development of programs in all areas of the college's activities have been just short of miraculous-image wisely for adults, quality and safety including the performance guidelines and accreditations, education, government relations, economics, imaging metrix, acrin, and the new radiology leadership institute-to name only a few. all have contributed significantly to the care of our patients and the stature of our specialty. dr. neiman was born in detroit and attended mumford high school. from wayne state university, he received his b.s. in 1964 and his md in 1968. harvey's postgraduate training was at the university of michigan, where he was a resident in radiology (1969 -1972 ), chief resident (1971 , and a 1972-73 fellow in angiography (cardiovascular radiology), receiving abr certification in 1973 and a caq in vascular and interventional radiology in february 1995. dr. neiman often expresses his gratitude to and profound respect for his mentor and beloved chief at the university of michigan, dr. william martel. dr. neiman was chief of cardiovascular radiology at walter reed army hospital and a lecturer in cardiovascular radiology at the afip from 1973 -1975 . in 1975 , he joined the northwestern radiology faculty, rising to professor in 1981, and for ten years he headed up the section of angiography and sectional imaging, advancing its technology and honing the skills of northwestern's radiology residents. harvey also offered a highly sought-after fellowship in interventional radiology, us, and ct. in 1985, dr. neiman left northwestern to assume the chair in medical imaging at the western pennsylvania in pittsburgh. i was the first woman to have completed his fellowship in us, ct, and interventional radiology at northwestern and accompanied him to pittsburgh. his tenure at west penn attests to his talent in making his visions a reality: the department became a highly respected, successful academic private practice notable in many areas including ultrasound, breast and women's imaging, and interventional radiology. harvey instituted an excellent radiology residency program in 1988 as well as fellowship programs in 1986 in the areas of excellence noted above. during the 40 years since harvey received his md, he has been awarded honors from many national, international, and specialty societies, has been an invited lecturer over 181 times on ultrasound, interventional radiologic, radiologic educational, management, turf issues, disruptive and new technology topics to name just a few. dr. neiman, who was a founder of the sru (society of radiologists in ultrasound), has to his credit 122 peer-reviewed articles, 69 scientific presentations and 20 exhibits, a text co-authored with dr. james yao, angiography of vascular disease (1984) , and 26 book chapters. he has received many honors including fellowship in the american college of radiology, american institute of ultrasound in medicine, society of radiologists in ultrasound and the society of cardiovascular and interventional radiology (now sir). as part of his strong commitment to the future leaders of radiology, for diagnostic radiology he has served as a member of the residency review committee of the accreditation council for graduate medical education. he has been a member of the american college of radiology and its committees and commissions for many years including the commissions on education, ultrasound, and economics. he also served as chair of the commissions on ultrasound and economics. from 1994 to 2002 , he was a member on the acr board of chancellors, serving as its chairman 2000-2002. he was president of the radiology advocacy alliance from 1998 to 2000. in 2003, nine years ago, dr. neiman became the acr's executive director. he currently serves in this position, where his excellent business skills, knowledge of health policy and economic issues, and strong administrative background have furthered our specialty. his goal, to ensure that the acr's resources benefit all radiologists and patients across all economic strata, is evident in his actions at the college. harvey has a devoted, wonderful family that often included me and my youngest daughter on many pittsburgh occasions. his beautiful, elegant wife of many years, ellie neiman, is here tonight to celebrate with him the spr's recognition of his many achievements. dr. neiman has two accomplished, lovely daughters, jennifer, extremely successful in her marketing career, and hilary, an attorney. jennie's husband, dr. seth kligerman, one of many young radiologists whom harvey has mentored, is on the radiology staff at the university of maryland. how harvey has had time between, through, and among all of these achievements to have become mentor, colleague, and friend to me and to so many others who have been inspired by his ability to see into the future and to shape it in a positive way is remarkable. now that dr. neiman has taken all of radiology under his wing, not just its component parts, the future of our specialty, one of the best, can be assured but also recognized for its centrality to all of medicine. it is my honor and privilege to introduce to you harvey l. neiman md, facr as this year's society for pediatric radiology honorary member. the singleton-taybi award is given in honor of edward singleton and hooshang taybi, in recognition of their personal commitment to the educational goals of the spr. initiated in 2006, the award is presented annually to a senior member of the spr whose professional lifetime dedication to the education of medical students, residents, fellows, and colleagues has brought honor to him/her and to the discipline of pediatric radiology. it comes as no surprise to those who know him that dr. daneman, "dr. d" as some of us call him, has been named the 2012 recipient of the singleton-taybi award in recognition of his many years of dedication to the education of residents, fellows, and colleagues. born in south africa in 1947, he received his medical degree at the university of the witwatersrand, johannesburg, receiving the harwood-nash award for the most successful student in surgery. initially, dr. d thought he would become a pediatric surgeon; but after passing the part i examination offered by the royal australasian college of surgeons, he changed his mind and began his training in diagnostic radiology. he chose a radiology residency at the royal prince alfred hospital, in sydney, australia. this included a year in pediatric radiology at the royal alexandra hospital for children in sydney where his interest and love of pediatric radiology began. dr. d then had the foresight to pursue pediatric radiology fellowship training at the hospital for sick children in toronto, canada. after completing the fellowship, he was immediately offered a position as staff radiologist at "sick kids." he became director of body imaging in 1984 and radiologist-in-chief in 1988 serving in that capacity for 7 years. his management style was simple but effective. he chose staff that were young, but smart and innovative. he nurtured them and provided them with all the tools they needed to become successful professionals, like him. but contributing to his own department was not enough for him. he also found the time and strength to contribute, teach, train, and help pediatric radiologists in the most remote portions of the globe in every continent, which resulted in recognition from prestigious organizations in places such as south america, israel, europe, taiwan and australia: he is an honorary member of the european society for pediatric radiology and the sociedad latinoamericana de radiologia pediatrica as well as other national societies. dr. d is an "institution" inside the great institution that is sick kids. his teaching is unique and praiseworthy in being enthusiastic, provocative, and fun at the same time. his lectures have been regarded as both instructive and practical by his students and trainees due to his special gift of making the most complicated things look as simple as possible. in sharing his diagnostic knowledge and know-how, he passes his own, innate teaching spirit on to his apprentices. he has earned several awards for this, including the outstanding teacher award granted by the university of toronto fellows at sick kids for the past 5 consecutive years. dr. d receives numerous invitations to present at national and international meetings and symposia and has been invited as a visiting professor to more than a hundred institutions across the globe. he does not only teach us the ins and outs of pediatric radiology, but he makes sure that we learn to love it and understand the importance not only of good practice but also the imperative to pass knowledge on by teaching and publishing. dr. d is someone who inspires us to reach beyond our limits, someone we want to emulate. he shares his knowledge, his wisdom, and his advice freely. he shares with us the most incredible secrets of his own career, so we understand from his personal experience. dr. d never tells you what to do, he suggests to you, in an incredible articulate fashion, what you want to do yourself. dr. d has been and is for many of us, more than an educator, more than a mentor, he is our "coach." well before this concept was introduced into medicine by a. gawande 1 , dr. d intuitively had the vision to "coach" his trainees, trying to get the best out of them, without pressure, but with love and passion, and especially emphasizing the importance of achieving a worklife balance in order to prevent the now so common "stress and burnout" affecting the radiology community 2 . he warned us that many high achievers reach their goals only at the expense of their personal lives, but dr. d has been as successful personally as he is professionally. his wonderful wife of 40 years, louise, his two daughters and his recently newborn granddaughter serve as sources of strength and pride. he is a truthful and generous friend to many, both in and out of radiology. it is not uncommon for many of us, who came through sick kids, to come back and visit and be invited to his house to share a wonderful dinner with other invitees, who may be radiologists from north america or from other parts of the globe visiting sick kids to learn from him. dr. daneman's research has widely influenced the field of pediatric radiology. examples include the work of dr. daneman and his colleagues on intussusception, which has promulgated the use of ultrasound for diagnosis, and the use of air enema for reduction. this approach has been adopted as standard practice at many institutions in north america and across the globe. to share his research with others in the field, dr. daneman has authored or co-authored more than 200 publications, including peer reviewed articles and book chapters on a wide range of topics related to the imaging of children. dr. d is one of those rare people who are irreplaceable. he is a superb teacher, a gifted academician, a capable administrator, and a person called "friend" by so many of us. we are thrilled and proud to present our society's singleton-taybi award to dr alan daneman in recognition of his lifelong accomplishments and personal commitment to the educational goals of the spr. we cannot imagine anyone more deserving of this award than dr. d. thank you "coach"! monica epelman, md and oscar navarro, md john caffey, md 1895 -1978 dr. caffey was regarded throughout the world as the father of pediatric radiology. his classic textbook, pediatric x-ray diagnosis, which was first published in 1945, has become the recognized bible and authority in its field. the seventh edition of this book was completed several months before his death in 1978. it has been among the most successful books of its kind in the medical field. dr. caffey was born in castle gate, utah on march 30, 1895 . it is interesting that he was born in the same year that roentgen discovered the x-ray. dr. caffey was graduated from university of michigan medical school in 1919, following which he served an internship in internal medicine at barnes hospital in st. louis. he spent three years in eastern europe with the american red cross and the american relief administration, and returned to the united states for additional training in medicine and in pediatrics at the universities of michigan and columbia, respectively. while in the private practice of pediatrics in new york city at the old babies hospital of columbia university college of physicians and surgeons, he become interested in radiology and was charged with developing a department of pediatric radiology in 1929. he frequently expressed appreciation and admiration for the late ross golden, chairman of radiology at columbia presbyterian hospital, who allowed him to develop a separate department of diagnostic radiology without undue interference, and who was always available to help and advise him. dr. caffey's keen intelligence and inquiring mind quickly established him as the leader in the fields of pediatric x-ray diagnosis, which recognition became worldwide almost instantaneously with the publication of his book in 1945. dr. caffey received many awards in recognition of his achievements. outstanding among these were the mackenzie davidson medical of the british institute of radiology in 1956, the distinguished service award of the columbia presbyterian medical center in 1962, the outstanding achievement award of the university of michigan in 1965, the howland award of the american pediatric society in 1967, the jacobi award of the american medical association in 1972, and the gold medal award of the american college of radiology in 1975. he had been a member of the american journal of roentgenology. he was a counselor of the society for pediatric radiology and was an honorary member of the european society of pediatric radiology. dr. caffey's contributions to the pediatric radiologic literature were many. he was instrumental in directing attention to the fact that a prominent thymic shadow was a sign of good health and not of disease, an observation that literally spelled the end to the practice of thymic irradiation in infancy. infantile cortical hyperostosis was described by him and is called "caffey's disease." dr. caffey in 1946 first recognized the telltale radiographic changes that characterize the battered child, and his students helped disseminate his teachings about these findings. it was dr. caffey who first recognized and descried the characteristic bony changes in vitamin a poisoning. he recognized and described the findings associated with prenatal bowing of the skeleton. in 1963, three years after his retirement from babies hospital, he joined the staff of the children's hospital of pittsburgh as associate radiologist and as visiting professor of radiology and pediatrics at the university of pittsburgh school of medicine. although dr. caffey came to children's hospital and the university of pittsburgh in an emeritus position, he worked daily and on weekends throughout the years he was there. in pittsburgh, he made four major new contributions to the medical literature. he described the entity, "idiopathic familial hyperphosphatasemia." he recognized and described the earliest radiological changes in perthes' disease. he called attention to the potentially serious effects of shaking children, and used this as a subject of his jacobi award lecture. he described, with the late dr. kenny, a hitherto unrecognized form of dwarfism that is now known as the caffey-kenny dwarf. the john caffey society, which includes as its members pediatric radiologists who have been intimately associated with dr. caffey, or who have been trained by his students, was established in 1961. this society is now among the most prestigious in the field of radiology. his book and the society named in his honor will live on as important memorials to this great man. his greatness was obvious to all who worked with him. he was warm, kind, stimulating, argumentative, and above all, honest in his approach to medicine and to x-ray diagnoses. his dedication to the truth was expressed in his abiding interest in the limitations of x-ray signs in pediatric diagnosis and in his interest in normal variation in the growing skeleton. he was concerned with the written and spoken word and was a skilled semanticist. his book and his articles are masterpieces of language and construction. he stimulated and was stimulated and loved by all who had the privilege of working with him. radiology and pediatrics have lost a great man, but they shall ever have been enriched by his presence. interstitial lung disease, which is more common in infants than older children, is defined as a rare heterogeneous group of parenchymal lung conditions primarily due to underlying developmental or genetic disorders. affected infants typically present with clinical syndromes characterized by dyspnea, tachypnea, crackles, and hypoxemia. mainly due to a lack of evidence based information regarding underlying pathogenesis, natural history, imaging findings, and histopathologic features of interstitial lung disease, the understanding of interstitial lung disease in infants has been limited in the past. however, in recent years, the understanding of interstitial lung disease in infants has been substantially improved primarily due to: 1) advances in imaging technology for better detection; 2) improvement of thoracoscopic techniques for lung biopsy; 3) established pathologic criteria for consistent diagnosis; and 4) development of new classification system based on underlying etiology of the interstitial lung disease. in fact, several forms of interstitial lung disease in infants that exhibit distinct clinical, radiological, and pathological patterns are currently emerging. the overarching goal of this article is to review a new classification system, imaging findings, and pathological correlation of interstitial lung disease in infants. improved understanding of this often challenging disorder can aid in early and accurate diagnosis, which in turn, will result in improved patient care. large airway disease in pediatric patients: impact of advanced post-processing techniques catherine m. owens, bsc mbbs mrcp frcr the introduction of multidetector row computed tomography (mdct) scanners has altered the approach to imaging the pediatric thorax. in an environment where the rapid acquisition of ct data allows general hospitals to image children instead of referring them to specialist pediatric centers, it is vital that general radiologists have access to protocols appropriate for pediatric applications. this lecture will focus on the main principles of volumetric ct imaging that apply generically to all mdct scanners and in particular we describe the reconstruction techniques for imaging the pediatric thorax and the low-dose protocols used in our institution on a 64-slice dual source ct scanner. examples of important clinical applications with the impact and added value of post processing are also given. neoplasms, by definition, comprise an abnormal uncoordinated proliferation of cells that persists even after the inciting stimulus as ceased. the resulting mass may be benign or malignant and arise from any tissue that is normally found in the location where the mass develops. thus, tumors of the chest may arise from bone, lung, pleura, lymphatics, muscle, etc. whether benign or malignant, chest masses may be incidental findings on imaging obtained for other reasons. this presentation will focus on malignant tumors of the chest, address the imaging characteristics and staging of the most common chest malignancies and discuss characteristics that may aid in distinguishing these lesions from their corresponding benign or infectious counterparts. included in this presentation will be the most common chest wall malignancies (ewing family of tumors and rhabdomyosarcoma), mediastinal malignancies (lymphoma, germ cell tumors, and neurogenic malignancies) and pulmonary primary malignancies (pleuropulmonary blastoma and carcinoid). the changing appearance of selected tumors in patients treated with new targeted therapies will be introduced. lung disease is the most common chronic disease of childhood, but young children cannot perform the breathing maneuvers required for the most commonly used method for assessing lung function, spirometry. ct provides exquisite structure information about the lung but concerns regarding the long-term consequences of the relatively high radiation dose limit its use particularly in the pediatric population. magnetic resonance imaging (mri) has the potential to provide regional information about the lung without the use of ionizing radiation. while conventional proton mri has found widespread clinical application in most organs of the body, mri of the lung lags behind because the lung is intrinsically difficult to image with mri. the strength of the mr signal depends on the physical density of protons in the tissue being imaged and the local environment of the protons. the lung has a low physical density and thus a low proton density so little mr signal is generated by the lung. furthermore, the magnetic susceptibility effects from its many air-tissue interfaces cause what little signal is generated to rapidly decay so that the lung typically appears dark on conventional proton mr images. a variety of strategies have been developed to overcome the inherent difficulties of mri of the lung, resulting in recent substantial improvements in image quality. additionally by administering an inhaled gaseous contrast agent, such as the hyperpolarized noble gases helium-3 or xenon-129, direct visualization of lung airspaces in an mr image is possible. a number of unique strategies for evaluating the structure and function of the human lung using hyperpolarized gas mri have been developed. although the level of structure detail possible with lung mri may never equal that of ct, mri may nonetheless has the potential to provide clinically useful information and be a sensitive, effort independent test of pediatric lung disease. for a matter of time, we will focus in this presentation only on the following: intestinal malrotation a normal visceral situs can be inferred sonographically in relation to the right-sidedness of the superior mesenteric vein, to the retromesenteric location of d3 and to the right iliac position of the ileocecal valve. conversely, intestinal malrotation is likely when the 3 aforementioned features are reversed. in addition, cdu can display the whirlpool pattern in case of midgut volvulus or internal hernia, alleviating the need for preoperative opacification. the reliability of us in diagnosing intussusception is well documented since the early 1990s. the value of us in predicting the success or failure of pneumatic reduction and/or bowel necrosis is more debatable, based upon a coexisting bowel occlusion, the presence of interloop fluid, bowel wall changes (intramural air, dilated mural vascular channels), absent blood flow at cdu. the continuous down-grading of us in comparison to ct, and the opposite conclusions of various series regarding imaging of pediatric appendicitis are based upon different prerequisites and definitions. historically and in most usa institutions, sonography reports are either negative (entire normal appendix), positive (abnormal inflamed appendix), or equivocal (non-visualization or partial visualization of appendix). the equivocal group is then logically investigated by a subsequent abdominal ct. in europe, some usa centers, and in our practice, us reporting include 4 groups and take into account ancillary findings: 1. normal appendix (blind-ended, lamellated, compressible, <6 mm in diameter, without peristalsis; 2. appendix not depicted, no secondary signs; 3. appendix not depicted, with one of the following: hyperchoic mesenteric fat, fluid collection, local dilated small bowel loop; 4. appendix inflamed. group 3 represents most cases of perforated appendicitis, groups 1 and 2 the negative sonogram. ct is then indicated only in obese patients and to assess the feasibility of percutaneous interventions. inflammatory bowel disease in the recent literature, mr enterography is often preferred to ct enterography. small bowel series look prehistoric and us is rarely mentioned. sonography however is very valuable both for screening children presenting with abdominal pain, diarrhea, weight loss, or gi bleeding and for following the course of the disease and searching for complication. hypervascularization has been proved to parallel the disease activity. initially mentioned by dr. rita teele, the interest of us for differentiating high-intermediate/low varieties of imperforated anus has been re-emphasized more recently. a perineal rectal cul de sac distance of 15 mm is quoted as the significant cut-off value. us can also display rectourinary fistulae outlined by air. update on mdct and mri of hepatobiliary disease in children: what's new lisa h. lowe, md a variety of disorders may affect the pediatric liver. recent advances in histopathological knowledge and imaging techniques have led to important changes that radiologists must be aware of in order to allow for an accurate limited differential, and in some cases, specific, diagnosis. this presentation will focus on recent developments that have lead to a better understanding of the embryopathogenesis for fibropolycystic liver diseases (including choledochal cysts and caroli disease), histopathological findings that have led to new classification systems for of pediatric vascular anomalies, technological advances and contrast agents in magnetic resonance imaging that are useful to characterize and limit the differential diagnosis of hepatic masses. diagnostic errors in pediatric abdominal imaging: diagnostic pearls and pitfalls george a. taylor, md this presentation reviews the types of diagnostic errors in abdominal imaging occurring over a 13-year period in an academic pediatric radiology practice. radiologists engage in two interrelated processes when interpreting imaging studies: perception and analysis. failures in perception (failure to identify an important finding) are a common source of diagnostic error in pediatric imaging, while failures in the analytic portion of the process (over-or faulty interpretation of a finding) are not as common. under-interpretation of findings can be related to a number of perceptual and visual phenomena including visual isolation where attention is selectively focused on a main area of the image while less or no attention is given to secondary areas, and satisfaction of search which occurs when additional lesions remain undetected after detection of an initial lesion. many analytic errors are the result of commonly used heuristics or shortcuts in reasoning. these include the availability heuristic in which likelihoods are based on memory of a similar case, the framing effect in which a different diagnosis is reached based on how the information is presented, and the anchoring heuristic in which the initial impression is difficult to change, despite conflicting new information. another recognized pitfall is blind obedience, in which a diagnostician stops thinking when confronted by authority. this authority can be human or technical (reliance on a laboratory value). finally, diagnostic errors can result from an attitude of overconfidence. examples of these heuristics and strategies to minimize cognitive errors will be discussed. marta hernanz-schulman, md, faap, facr this session will consider abdominal masses that present in the neonatal period, spanning developmental, inflammatory and neoplastic conditions. time constraints do not allow an exhaustive list or description, but the more important or frequent lesions are discussed. the presentation is subdivided by systems. the renal section discusses various conditions presenting with hydronephrosis, such as ureteropelvic junction obstruction and duplication anomalies, followed by autosomal recessive polycystic kidney disease and multicystic dysplastic kidney, cystic entities commonly presenting in the perinatal period. neoplastic renal entities include lesions with benign behavior, such as ossifying renal tumor of infancy, with the discussion extending to entities with very poor prognosis such as clear cell sarcoma and rhabdoid tumor, while discussing the congenital mesoblastic nephroma, its histologic subtypes and the differences in their presentation, imaging findings and clinical behavior. suprarenal lesions include the adrenal hemorrhage, congenital neuroblastoma and subdiaphragmatic sequestration. hepatic lesions include developmental anomalies that present as mass lesions, such as choledochal cysts, vascular lesions such as congenital and infantile hemangiomas, and neoplastic lesions such as the mesenchymal hamartoma and hepatoblastoma. differences in clinical presentation, imaging characteristics and behavior of the lesions are discussed. the section on pancreatic lesions discusses pancreatic cysts and pancreaticoblastoma. gi tract and mesenteric lesions include duplication cysts, lymphangioma, and meconium pseudocyst, and their relationship to bowel obstruction and persistent perforation. ovarian cysts can present as large masses in neonatal girls, and should be high in the differential diagnosis of large masses encountered in female infants; the imaging characteristics of simple and complicated cysts are described, as well as their course and potential complications. pediatric procedures: from imaging to intervention the spectrum of vascular anomalies in pediatric patients: multimodality imaging evaluation and current treatment patricia e. burrows, md vascular anomalies are categorized into two main groups, vascular tumors and vascular malformations. genetic and molecular regulation of vascular genesis of angiogenesis, and mutations responsible for some of the vascular malformations, have been delineated. in order to implement future targeted treatment of vascular lesions, accurate diagnosis is important. imaging modalities that are effective in distinguishing the various types of vascular anomalies and demonstrating the extent include ultrasonography with doppler interrogation, mri and various forms of mr vascular flow imaging, conventional angiography and venography. techniques used to image lymphatic channel anomalies, conventional lymphangiography, lymphoscintigraphy and infrared fluorescent lymphangiography. in this presentation, common forms of vascular anomalies will be described and rare or recently recognized anomalies will be mentioned. current treatment of the different forms of vascular anomalies will also be discussed, including pharmacotherapy using beta blockers, angiogenesis inhibitors and mtor inhibitors. endovascular techniques used in treating vascular malformations, including embolization and sclerotherapy will be presented. pediatric vascular disease is extremely varied, with a wide range of conditions requiring diagnostic or therapeutic intervention. technological improvements in non-invasive imaging modalities such as mri and ct have reduced the need for diagnostic angiography; however, with advances in interventional techniques, arteriography in the pediatric patient is now often performed for therapeutic reasons. pediatric arteriography presents unique issues and challenges. tremendous variability in patient size and physical maturity limits the ability to standardize technical aspects of performing arteriography. in addition, radiation protection, sedation/anesthetic support, monitoring of fluid balance, and maintaining patient warmth must be considered. a regimented protocol for assessment of the pediatric patient must be followed, with review of the indications for the study requested, and review of patient-specific issues such as coagulation profile, concurrent medical disease, patient weight, and anesthetic concerns. appropriate patient monitoring is imperative to ensure patient safety. vascular access can be quite challenging. ultrasound and micropuncture access techniques have tremendously improved successful access while reducing associated complications. the smallest catheter that can accomplish procedure objectives should be used. for most diagnostic cases, 4 french systems can be used for children>10 kilograms, while 3 french catheters are preferred in those <10 kg. intraprocedural heparinization (75-100 iu/kg) is also more often used, especially in children weighing less than 10-15 kg. rates and volumes of contrast injected for pediatric arteriography are not standardized, as in adult patients. in general, contrast dose should be limited to 6-8 ml/kg, and 4-5 ml/kg in premature infants and neonates. all these new technique are less invasive, improve patients' outcomes and reduce morbidity. they are also cost-effective as patients are discharged home earlier and recover faster from the intervention. the future holds promising new technologies such as high-intensity focused ultrasound (non-invasive method of thermal ablation) and nanoparticles for drug delivery. pediatric interventional radiology will continue to be an essential part of these minimally invasive therapies. musculoskeletal imaging: from planning to performance kirsten ecklund, md the purpose of this talk is to review advanced mr imaging techniques currently being used in the evaluation of pediatric musculoskeletal tumors. the goals of these techniques include improved image resolution and quality, lesion tissue characterization, and increased acquisition speed. diffusionweighted (dw) and perfusion imaging will be emphasized; however, whole body, metallic artifact mitigation, and volumetric sequences will also be discussed. dw mri is based upon the brownian motion of water within extra and intra-cellular spaces which depends upon tissue cellularity. dwi can aid in the differentiation of benign from malignant lesions, which generally have restricted diffusion. there is even greater potential for dwi in the assessment of tumor response to therapy. the apparent diffusion coefficient (adc) maps are critical to accurate interpretation of diffusion sequences. adc maps distinguish between restricted diffusion and t2 effect, both of which appear bright on dwi. both qualitative and quantitative tissue assessments can be made with dwi. challenges for dwi in the pediatric musculoskeleton include susceptibility artifacts from bone, motion vulnerability, and geometric distortion at larger fields of view. our current protocols and parameters for dwi will be presented. contrast-enhanced (dce) mr using one of a variety of vendor specific sequences. qualitative and quantitative assessments of inflow and distribution of contrast have been shown to help differentiate between benign and malignant lesions and to evaluate drug efficacy during therapy. this technique is especially promising in those patients undergoing antivascular and antiangiogenic therapy. tal laor, md congenital abnormalities of the musculoskeletal system can result in alterations of limb size, configuration, and/or segmentation. these disorders often affect both the osteocartilaginous skeleton as well as the surrounding soft tissues and can be localized or diffuse. in this session, we will focus on the imaging features of several congenital abnormalities that result in a small or short limb, in altered configuration of a limb, or in abnormal segmentation. deformities of both upper and lower limbs will be examined. like congenital abnormalities, developmental disorders of the pediatric musculoskeletal system can be limited to a single area or can affect numerous sites within the body. for example, neonatal brachial plexopathy is a localized disorder that produces characteristic musculoskeletal alterations about the shoulder girdle and elbow of affected children. the alterations of morphology and function of the shoulder develop over time with growth of the child and change in response to a variety of therapies. we will review the features of developmental anomalies of the pediatric musculoskeletal system and evaluate the role that imaging plays in the initial evaluation and in the subsequent assessment of these children during treatment. multimodality imaging of skeletal trauma in children: using all of the tools peter j. strouse, md skeletal trauma is a common indication for imaging throughout the pediatric age range. newborns may suffer birth trauma. infants and toddlers may be subject to abusive injury. children of all ages may suffer accidental injury. older children and adolescents are increasing hurt in sporting activity and vehicular accidents. fracture patterns vary with maturation of the child. interference with normal growth is a potential complication. imaging of skeletal trauma begins with radiography. proper anatomic and age specific radiographic technique assures optimal diagnostic yield. radiography suffices in most cases to diagnose fracture or confirm normalcy. "clinical correlation" aids in diagnosis. ultrasound, ct, mri and nuclear medicine may play a role in specific instances where plain radiographs are non-diagnostic or to better delineate certain fractures. arthrography and conventional tomography have occasionally been used in the past and tomosynthesis may prove useful. follow-up radiographs may be useful for diagnosis or confirmation of some fractures. this presentation will focus on the imaging of acute skeletal injury. technique and approach for plain radiography will be emphasized. specific indications and roles for ancillary imaging techniques will be defined and illustrated with representative cases. although classically thought of as a disease of adulthood, stroke is much more common in the pediatric population than was once appreciated. this may be due to many factors, not the least of which is increased awareness due to the presence of subspecialty stroke teams now fairly commonplace in many children's hospitals, and the fairly recent advent of more advanced imaging technique such as diffusion-weighted imaging (dwi) and its routine use in imaging the central nervous system (cns) in the child and adolescent. causes of stroke in children can be protean, and range from idiopathic on one end of the spectrum, to traumatic on the other, with many causes in between, many of which may not be intuitive to the clinician without further research. moyamoya disease and its many causes, such as sickle cell disease (scd), trisomy 21 and neurofibromatosis type i (nf i) can all lead to stroke in children, as can congenital clotting deficiencies such as factor v leiden deficiency and congenital cardiac lesions with their resultant shunting of blood between the left and right cardiac circulations. although usually arterial in nature, strokes may arise from the venous system in clinical scenario of venous thrombosis with resultant venous infarctions. factors contributing to venous thrombosis in children and adolescents can be due to dehydration (especially in the very young), severe iron deficiency anemia, inflammatory bowel disease and exogenous hormone ingestion such as is seen with oral contraceptives (ocp) in young women. advanced imaging techniques for neuroimaging in pediatric patients: where are we now? blaise v. jones, md the past decade has seen a large number of advanced imaging techniques introduced to the clinical armamentarium of the pediatric radiologist. from the development of multidetector ct scanners that can obtain whole head diagnostic studies in less than 2 s to the routine use of 3 t mr imaging, technical advances have dramatically changed our ability to diagnose and manage neurological disorders in children. however, all of these advances are not of equal clinical utility, and it is imperative that the pediatric radiologist be well versed in their judicious and appropriate application. this presentation will discuss the effective use of volume ct scanning, cta, swi, asl, fmr, pmr, and other advanced imaging techniques in the diagnosis of neurological disorders presenting in childhood. at the conclusion of the presentation the attendee will have a better understanding of how to ideally apply these technologies in practice. a spectrum of abnormality in pediatric neck: practical imaging choices and interpretation caroline d. robson, mbchb learning objectives: 1. become familiar with an optimized imaging approach for head and neck infections 2. recognize the complications of head and neck infections 3. recognize the utility and interpretation of imaging for neck masses this talk will cover the imaging approach and interpretation of findings in head and neck infection and neck masses. infection includes acute complicated sinusitis, coalescent mastoiditis, neck infection and local and intracranial complications. optimized imaging protocols and image interpretation for neck masses will also be discussed and illustrated. acute complicated sinusitis is diagnosed when acute sinusitis is accompanied by orbital symptoms (e.g. proptosis) and/or mental status changes, seizures or other neurological findings. coalescent mastoiditis is diagnosed when otomastoiditis is accompanied by tenderness and/or swelling over the mastoid process. ct and mr provide complementary information. ct is obtained with contrast. mr sequences include fatsuppressed t2, t1, diffusion, and fat-suppressed contrastenhanced t1 weighted images with mr venography. intracranial complications include epidural abscess, subdural empyema, meningitis, cerebritis, brain abscess, venous thrombosis and venous infarction. the limitations and usefulness of ct in the diagnosis of neck abscess will be illustrated. the imaging approach to masses depends on patient age, and the size and location of the mass. us, ct, mr, and nuclear medicine studies provide complementary information. as for infection, optimized imaging approaches and key imaging features for various masses will be discussed. embryology and diagnostic approach in spinal dysraphism l. santiago medina, md, mph and esperanza pacheco-jacome, md congenital anomalies of the spine are malformations that can be confusing due to the complexity of their embryology, and to the sometimes unclear classifications and terminology. the purpose of this review is to give a clear and basic understanding of the different stages of the embryological development of the spinal cord, starting with the bilaminar disc in the first week of gestation. during the second week, the formation of a trilaminar disc (gastrulation), the notochord, and the formation of the neural tube or neurulation. also, a review of the development of the distal cord: conus medullaris, filum terminale, ventriculus terminalis, by a different mechanism, canalization and retrogressive differentiation. beside the embryological review, a case correlation will be presented using mr imaging to demonstrate these malformations. open spina bifida entities include meningocele and myelomeningicele. closed or occult spinal dysraphism (osd) is characterized by a spinal anomaly covered with skin and hence with no exposed neural tissue. osd spectrum includes dorsal dermal sinus, thickened filum terminale, diastematomyelia, caudal regression syndrome, intradural lipoma, lipomyelocele, lipomyelomeningocele, anterior spinal meningocele and other forms of myelodysplasia. several studies have shown that mri and ultrasound have better overall diagnostic performances (i.e., sensitivity and specificity) than plain radiographs for detection of occult spinal dysraphism. for h1n1, most patients had mild illness but a small percentage required mechanical ventilation and icu admission. the high risk groups include children <5 years old and those with chronic medical conditions in particular neurodevelopmental impairment. pediatric mortality was 7.5% of all deaths associated with the pandemic reported in the u.s. in both conditions, the most prominent radiographic and ct features were airspace disease including ground glass opacities (ggo) and consolidation, commonly with multi-focal and bilateral involvement. pleural effusion, adenopathy and cavities were absent. in some patients with viral infection, respiratory symptoms may be mild but are complicated by neurological manifestations. a brief review of mri features in h1n1 related encephalopathy including acute necrotizing encephalopathy (ane) will be given. bernard f. laya, do tuberculosis (tb) is a worldwide major public health problem with one-third of the world's population being infected. it is a leading cause of death and disability from infection worldwide. children are amongst the most vulnerable group because of their immature immune status. a child usually gets tb infection after being exposed to a sputum-positive adult. depending on many factors, the infection can lead to latency or tb disease. it can affect virtually any organ in the body and can be devastating if left untreated. tb in children remains a diagnostic challenge. in addition to history of tb exposure, signs and symptoms, laboratory and microbiologic tests, medical imaging remains a valuable tool in its diagnosis. although findings are nonspecific, the radiograph is the most commonly ordered initial imaging tool for screening and diagnosis of pulmonary and musculoskeletal involvement. computed tomography and magnetic resonance imaging offer more detailed assessment especially in cranial and abdominal involvement. medical imaging is also utilized to follow up patients during or after anti-tb treatment. knowledge of the common imaging patterns, pitfalls and dilemma are very important in establishing the diagnosis of tb in children. the pathophysiology of pediatric tb will be discussed as it correlates with imaging findings. the wide spectrum of imaging manifestations in various modalities will be presented. imaging updates along with pitfalls and dilemma in the interpretation will also be discussed. tb can affect almost every organ system but the author will present cases that are more commonly encountered. and concurrent ct/ pet-ct (k00.33) panels. there were more indeterminate nodule predictions by pet-ct (n038 of 75; 51%) and concurrent ct/pet-ct (n 023; 31%) than by ct alone (n012; 16%). the overall accuracy of ct alone was 71%, pet-ct alone 45% and concurrent review 60%. worst case sensitivity and specificity were 85% and 44% for ct alone, 60% and 19% for pet-ct alone, and 67% and 48% for concurrent ct/pet-ct. conclusions: pet-ct assessment of pulmonary nodules in children is feasible but limited by non-diagnostic quality ct images and atelectasis caused by sedation. subjective assessment of nodules by pet-ct does not appear to improve the ability to distinguish benign from malignant histology in children with solid malignancies. semi-quantitative nodule assessment using the standardized uptake value may improve the performance of pet-ct in this setting and will be investigated in the future. purpose or case report: nec is the most common lifethreatening medical/surgical emergency of the gastrointestinal (gi) system in neonates, with an incidence up to 10% in infants weighing <1500 g. with advances in treatment of nec, increased survival rates result in rise in post-nec gi complications such as feeding intolerance. development of post-nec bowel strictures results from healing of involved bowel and can result in bowel obstruction. it has been routine to study the bowel of infants after medical treatment for nec by contrast enema and small bowel follow-through prior to initiating feeding. however, in order to "image gently" we are attempting to decrease the radiation exposure to these patients. we postulate that in patients with no abnormal bowel dilation prior to initiation of feeds, the incidence of colonic stricture would be so low that routine enemas would be unnecessary and could be eliminated from the workup. recorded as present or absent in 6 anatomic abdominal regions defined as: 1 and 2-from the dome of the diaphragm to top of l2 to the right and left of midline, respectively; 3 and 4-from top of l2 to the iliac crest to the right and left of midline, respectively; 5-from the iliac crest to the top of the sacrosciatic notch; 6-below the top of the sacrosciatic notch. we assessed the frequency of findings in each region and how often findings in regions 5 and 6 were associated with findings in regions 1-4. 95% confidence intervals were calculated. results: the fewest pertinent findings were present in region 6 in 10.2% (51/501) (95% ci: 7.7-13.1%) of radiographs. findings included: abnormal bowel 6% (n031), bowel gas paucity 1.4% (n07), pneumatosis 0.4% (n02), inguinal hernia 0.8% (n04) and osseous abnormalities 1.2% (n06). pertinent findings were present in region 5 in 67.7% (339/501) (95% ci: 63.4-71.8%). findings included: abnormal bowel 43.7% (n0 219), bowel gas paucity gas 19.6% (n098), pneumatosis 1.6% (n08), free air 0.2% (n01), and abnormal bowel with pneumatosis 2.6% (n013). among 51 patients with an abnormality in region 6, 49 (96.1%) also had an abnormality within at least one of regions 1 through 4. among the 342 patients with an abnormality in region 5 or 6, 338 (98.3%) also had an abnormality within at least one of regions 1 through 4. catheter/tube tips were located in region 5 in 6.8% (n034) and region 6 in 1.4% (n07) of radiographs, respectively. pneumatosis was present most frequently in regions 3 (5.8%), 4 (4.0%), and 5 (4.2%). free air was present most frequently in regions 1 (1.6%), regions 2 and 3 (0.6% each). conclusions: our preliminary data suggest that pertinent findings on neonatal portable abdominal radiographs are rarely isolated to the pelvis, implying that gonadal shielding of regions 5 and 6 should not compromise diagnostic accuracy. purpose or case report: the purpose of this study was to determine the sensitivity, specificity, and positive and negative predictive value of ultrasound in diagnosing appendicitis when the appendix is visualized, using three diagnostic categories: positive, negative, and equivocal. the 3-category diagnostic accuracies for appendiceal diameter and radiologist impression were compared. methods & materials: a retrospective study was performed evaluating all right lower quadrant ultrasound reports dictated over a 5-month period. included studies were interpreted as positive, negative, or equivocal for appendicitis. report impressions that did not specify one of these categories and studies where the appendix was not seen were excluded. the pathologic diagnosis of appendicitis was considered the gold standard for a positive diagnosis. because virtually all pediatric surgical cases in the region are referred to our hospital, it was assumed that the patient did not have appendicitis if surgery was not performed. logistic modeling using appendiceal diameter as the independent variable established cutoff diameters of ≤6 mm0negative, >8 mm0positive, and 6<x≤ 8 mm0equivocal. sensitivity, specificity, and positive and negative predictive values were calculated for both methods. results: of the 571 patients imaged during the study period, 255 (45%) met the inclusion criteria; 34 (6%) reports did not categorize the impression and in 282 (49%) studies the appendix was not seen. surgery was performed on 122 (48%) subjects, of which 101 (83%) had a pathologic diagnosis of acute appendicitis. using the radiologist impression, there were 68 true positives (tp), 2 false positives (fp), 8 false negatives (fn), and 150 true negatives (tn), for a sensitivity of 97% (95% ci090-100%), specificity of 95% (ci090-98%), ppv of 89% (ci080-95%), and npv of 99% (ci095-100%). there were 27 (11%) cases reported as equivocal; of these, 7 (26%) had a pathologic diagnosis of appendicitis. using appendiceal diameter, there were 46 tp, 6 fp, 2 fn, and 161 tn, for a sensitivity of 88% (ci077-96%), specificity of 99% (ci096-100%), ppv of 96% (ci0 86-99%), and npv of 96% (ci092-99%). there were 41 (16%) cases categorized as equivocal; of these, 25 (61%) had a pathologic diagnosis of appendicitis. conclusions: the use of diagnostic categories enables high ppv and npv with a relatively low number of equivocal cases. using appendiceal diameter alone results in higher ppv than that of the radiologist impression, but also yields a higher number of equivocal cases. purpose or case report: intussusception is an obstructive condition that a segment of the bowel invaginates into adjacent bowel and is an urgency that needs to be reduced as soon as possible to prevent bowel ischemia or necrosis. when it occurs in the infants and young child, it usually develops idiopathically and reduced by the technique such as air enema under the fluoroscopic guidance or saline enema under the ultrasound guidance. the success rate of the non-surgical reduction has reported over 95%. the pneumatic reduction is to introduce air into the patients' rectum via a ballooned foley catheter by hand pump. a mercury manometer connecting with the foley catheter calibrates the pressure of insufflation, and the recommended maximum pressure is 120 mmhg. the hydrostatic reduction is to drip saline from a bag at the height of 3 ft that may be different according to the institute's guidelines. until recently, in both techniques, the precise measurement of the intraluminal pressure was not possible. with the purpose of intraluminal pressure monitoring, we introduced a specific digital pressure gauge that can measure both pneumatic and hydrostatic pressure in various units and can give the collected data to our workstation. with the data, we purpose to make the curve of intraluminal pressure during the procedure and to compare the pattern and difference in both techniques of reduction, which permits suggesting the better technique for reducing the intussusception. from february 2011, we performed the intraluminal pressure monitoring in 8 children; 4 cases of pneumatic reduction and 4 cases hydrostatic reduction. the results indicated that the curves were similar in both techniques. however, the hydrostatic reduction tended to need longer time and higher pressure difference than the pneumatic reduction. we assumed that a higher flow rate and more fluctuating introduction of pressure in the pneumatic reduction made the difference between both methods. purpose or case report: anecdotal evidence suggests that some pediatric brain tumors, particularly pilocytic astrocytomas, demonstrate greater enhancement on delayed post-contrast t1 weighted mr imaging compared to early post-contrast imaging. our goal was to compare immediate post-contrast imaging with delayed post-contrast imaging in pediatric brain tumors. methods & materials: the research protocol was granted exempt status by the institutional review board (comirb# 10-1354). between november 2010 and march 2011, all patients for whom an mri of the brain was ordered to follow-up known brain tumor or to evaluate new brain tumor underwent a modified protocol that included both immediate and 10 min delay post-gadolinium images. the modified protocol sequence order was dwi, t1 mprage, contrast injection, immediate post-contrast t1 mprage, t2, flair, 10 min delayed post-contrast t1 mprage. this sequence allowed both immediate and delayed post-contrast imaging to be performed without scanner downtime. a total of 67 unique patients met inclusion criteria of an enhancing primary brain tumor with the delayed imaging performed within a window of 6-19 min. these studies were evaluated independently by 2 pediatric neuroradiologists (ns and lf) and a radiology resident (jm) to compare the degree of lesion conspicuity and edge discrimination, and to determine an overall preference. in cases of discrepancy between reviewers, final grading was determined by group consensus. results: delayed post-contrast images were preferred in 55/67 tumors (82%), immediate post-contrast images were not preferred in any case, and 12/67 cases were graded as equivalent (18%). notably, delayed imaging was preferred for 19/20 pilocytic astrocytomas (95%). in 9/67 cases (13%), the improvement in conspicuity and edge discrimination on delayed imaging was felt to have a potential impact on clinical management, e.g. by extending resectable or treatable tumor margin. conclusions: delayed post-contrast imaging can be performed easily by reordering existing mri protocols, and no scanner downtime is required for this protocol change. our results indicate that pediatric brain tumors (particularly pilocytic astrocytomas) often enhance more conspicuously on delayed imaging, that no diagnostic confidence is lost on delayed imaging, and that clinical management may be more accurately guided. 3-directions) were retrospectively reviewed, after irb approval. both sporadic (n07) and nf-1 associated optic gliomas (n06) were included. tumors confined to intraconal optic nerve were excluded due to technical limitation of epi dwi within the bony orbit. apparent diffusion coefficient (adc) of the solid portions of the tumor was measured using the region of interest method both at baseline and on follow-up mri. results: for the 13 patients, 7 required treatment (surgery and/or chemotherapy) for symptomatic tumor progression (5 sporadic opg and 2 cases of nf-1). median follow-up interval was 3.1 years (range: 7 months to 10.5 years, sd 2.7 years). there was no difference in adc values between sporadic and nf-1 associated opg. opg that required therapy had significantly higher baseline mean adc (1589 x 10-6 mm2/s, sd 0.22), whereas opg with low mean adc (1255 x 10-6 mm2/s, sd 0.18) remained clinically asymptomatic or stable (stratified mann-whitney test, p00.0002). an increase in mean adc of 100 x 10-6 mm2/s doubled the odds the patient will require treatment (or02.16, 95% ci: 1.51-3.10, p<0.0001). enhancement patterns did not predict tumor behavior or nf-1 status (fisher's exact test, p00.192). conclusions: significantly higher mean adc was seen in opg that required therapy for tumor progression. mri may be a useful prognostic tool in further defining a subset clinically significant sporadic or nf-1 associated opg. purpose or case report: fast brain mri imaging has recently been introduced for assessing brain ventricles in patients with ventriculo-peritoneal shunts (vps). however, there is minimal literature on how this method could be beneficial for other indications. compared to ct, this method reduces lifetime cumulative radiation dose and has multiplanar capabilities. it is much faster than full brain mri, reducing exam costs and potentially reducing the need for sedation. however, fast brain mri has lower resolution than a standard brain mri and cannot detect hemorrhage. the goal of our study is to retrospectively assess additional clinical applications for fast brain mri. methods & materials: patients who had undergone fast brain mri were found in xenobase, a database which references deidentified electronic medical records at our institution. xenobase was then used to identify subgroups by diagnosis. one of the most common diagnoses was arachnoid cyst. after irb approval, patients with fast brain mri and arachnoid cyst were identified so that their fast brain mri could be compared to any full brain mri and to clinical outcomes. fast brain mri findings were excluded if there was not a full brain mri within 1 year. agreement with full brain mri, and documented effect on clinical management were coded for statistical review. results: between 2008 and 2011, there were 14 arachnoid cyst patients with 16 fast brain mri exams. in 12 members of this group, fast brain mri was used alone or in comparison with a full brain mri in the decision to follow or discharge the patient. 2 exams failed to report a pituitary cyst and mass effect which were reported on prior exams. 6 patients had no complications in the year following their fast brain mri. the most common complication was headache (4 cases). conclusions: fast brain mri reduces radiation exposure, time, cost, and the need for sedation in vps patients. these benefits may cautiously be extended to other patient groups also requiring routine imaging, such as those with arachnoid cysts. disclosure: the authors disclose that they will discuss or describe, in the educational content, a use of a medical device or pharmaceutical that is classified by the food and drug administration (fda) as investigational for intended use. purpose or case report: susceptibility-weighted imaging (swi) is a new technique that exploits susceptibility differences in different tissues, to provide a different type of tissue contrast. swi is a gradient echo sequence utilizing both phase and magnitude data to achieve exquisite sensitivity to tissue magnetic susceptibility effects. it is extremely sensitive to even minute amounts of paramagnetic substances and therefore for detection of blood products (hemosiderin, ferritin), deoxygenated blood, calcium, iron, and small vein depiction. it is particularly suited for vascular imaging, especially in cerebral ischemia. swi has been shown to be more sensitive in detecting cerebral microbleeds than is conventional t2*-weighted gradient-recalled echo imaging (gre) partly because of its inherent sensitivity, increased spatial resolution and the thinner slices acquired. recent studies have shown that swi detected more microbleeds in more patients, irrespective of their location and that swi may be more sensitive in detecting traumatic lesions than ct or mri. methods & materials: between january 2011 and october 2011 we have performed swi on 75 pediatric patients (from 1 day to 15 yrs old) affected with different pathologies. mri was performed using either a 3-or 1.5-t magnet (achieva ; philips healthcare, best, the netherlands). among these patients 62 also received a classic gre sequence. results: our experience confirms a greater sensibility of swi than gre in detecting microbleedings and larger bleedings. swi is much more helpful in patients younger than 1 year since it can distinguish hemorrhagic and non hemorrhagic punctuate white matter lesions detected as hyperintensities on t1-w images. it is more accurate in distinguishing petechial hemorrhages and ischemic foci in patients with germinal matrix hemorrhages. swi can provide important diagnostic information not only in vascular pathologies but also in tumors showing the altered tumor microvascularity, the degree of intratumoral necrosis and the presence of subtle defects of the bbb within the surrounding parenchymal tissue. the technique also allows the detection of possible bleedings in infectious lesions. conclusions: swi is a valuable technique in the evaluation of a wide variety of intracranial pathologies in the pediatric population and its use is advisable on a routine basis. purpose or case report: a common problem with pediatric mr imaging is motion. diffusion-weighted imaging (dwi) is highly sensitive to the effects of both rigid-body motion and brain pulsation. the resulting motion artifacts can manifest in several ways, and include blurring (motion between volumes), slice 'drop-outs' (motion during the diffusion encoding), and aliasing (motion during the parallel imaging/ghost calibration scan). in order to improve image quality in pediatric dwi and avoid the potential for repeat scans, we have implemented our grappa-accelerated diffusion tensor (dt)-epi sequence on over 1,600 pediatric patients at our institution, and have developed tailored reconstruction software to correct for large motion and reduce the need for general anesthesia (ga). methods & materials: grappa-accelerated epi dti data was collected on 100 patients at 1.5 t and 1,500 patients at 3 t between the ages of 1 month and 18 years old. with these data, we investigate the use of a method to select the best grappa and ghost calibration weights; 3d rigid-body realignment with importance weighting; a new volume rejection criterion for large motion; together with other procedures to lower image noise and reduce phase artifacts. all image reconstruction was performed using compiled threaded matlab code on the vendor's (ge) multiprocessor reconstruction hardware. results: using the maximum motion detected from the 3d realignment procedure on the 1,600 dti exams, 51% of patients did not move (either through co-operation or ga, denoted here by <1 mm of motion); 28% of patients moved between 1-3 mm; 13% between 3-5 mm; 6% between 5-10 mm; and 2% between 10-18 mm. except for 3 patients in total, the motion correction steps employed here were extremely robust in correcting for motion. in addition, the motion correction steps employed here do not blur or negatively affect the data on non-moving patients. conclusions: our proposed integrated reconstruction scheme suggests that correcting for different types of motion at different stages of the dti acquisition is critical to provide scans of diagnostic quality. apart from the very rare instance (0.2%) where the patient moved continuously an extensively throughout the scan, our motion correction procedures employed here are extremely robust. using this scheme, we show that highly diagnostic motion-corrected dti data can routinely be read on our patient database within 10 min. . participating sites followed mutually agreed upon vendor-specific dti protocols used for neonates in clinical practice: ss-epi; b 0700;~2 mm3 voxel; 30-32 directions; te~84 msec; 1 acquisition; parallel imaging; multi-channel (8-32) head coil. tensor data was analyzed at one site using internally developed software in idl. b0 and eddy current distortion were assessed by analyzing grid line distortion on acr slice 5 ; deviations from linearity were measured in the phase encoding direction. acr slice 7 was used to assess snr of the center and periphery of the b00 image, and fractional anisotropy (fa) of the phantom, which should approach 0. deviations from specified sequence parameters were recorded. results: both siemens scanners had some image degradation due to vibration susequently corrected by the vendor. nonlinear gridline distortion was highest on the ge followed by philips but was corrected with the use of 2nd order shimming. eddy current distortion was consistently smaller than acquisition voxel size after image registration. te varied from 74-92 msec; acquisition bandwidth range was 1563-2928 hz/pixel. the 2 mm slice thickness was problematic on clinical ge scanners resulting in non-isotropic voxels. across vendors, snr was consistently higher in the image periphery than center by a factor of 1. 30-0.45 ). the greatest difference was showed in patients with fhc. no association was found between the value of ldl-c and imt. the 62.5% received drug treatment at the time of evaluation. in dbt-1 a no association was found between the imt and the levels of hba1c and lipids. and in the ob group found no association between imt and bmi z score. fhc 31%, 8% of dbt-1 and 6% of ob showed atherosclerotic plaques and intima irregularities. conclusions: the imt ultrasonography was able to demonstrate that patients with chronic diseases, with increased cardiovascular risk in adulthood, showed early alterations of carotid intima media in children. this allows clinical applications of preventive and therapeutic guidance. a benchmark for precision of flow assessment was determined from differences between aortic and pulmonary arterial flows, which should agree. the precision of flow when utilizing a slow flow structure (vein) and a fast flow structure (artery) was then determined, serving as an indicator of the precision of slow flow measurements. this was done in pairs for the upper body (svc flow vs difference between ascending and descending aortic flow), lower body (ivc flow vs descending aortic flow) & total body (svc flow+ivc flow vs ascending aortic flow). paired t-tests were used to identify significant differences in the respective arterial and venous flow rates. with an f-test, the relative precision of the arterial flow (determined from aortic and pulmonary arterial flow) was compared against the precision of agreement between upper, lower, and total body flows, each of which has a slow flow venous component, thus assessing precision of venous flow measurement. results: arterial & venous flow measurements were strongly correlated for the upper body (r00.89), lower body (r00.96) and total body flow (r00.97); net aortic and net pulmonary trunk flow rates were also tightly correlated (r00.97). moreover, there was no significant difference in the precision of arterial & venous flow measurements (t-test, p00.31). lower venc (200 cm/s or lower) improves the accuracy and precision associated with low velocity venous flow, a finding that tended to but it did not reach statistical significance. conclusions: with 4-d pc mri, the accuracy and precision of venous flow quantification are comparable to arterial flow quantification, though venc settings may improve venous flow assessment. disclosure: dr. tariq has indicated that he will discuss or describe, in the educational content, a use of a medical device or pharmaceutical that is classified by the food and drug administration (fda) as investigational for intended use. the spatial resolution requirements for imaging tiny target vessels in neonates have so far precluded its use of cemra in this patient population. the purpose of our study, therefore, was to explore the potential of high resolution cemra at 3.0 t in neonates with suspected congenital vascular anomalies methods & materials: 16 neonates (mean age 9.4 days, range 1-28 days; mean weight 2.7 kg, range 1.5 kg-4.2 kg) underwent cemra at 3.0 t. cemra was performed under controlled apnea on a 32-channel 3.0 t system using either a 12-channel head-neck coil (9 pts) or a 15-channel adult knee coil (7 pts). gd contrast delivery was calculated based on a total dose of 0.2 mmol /kg. parallel imaging factors of 4-6 were used, generating 0.7 x 0.5 x 0.6 mm voxels in an acquisition time of 17-22 s. images were scored for quality and the presence of artifacts independently by two observers. the cemra series were evaluated to identify pulmonary arterial and venous anatomy. extra-pulmonary vascular anatomy was divided into 12 sections for image quality assessment on mpr. results: the mra data sets had high mean image quality and low mean artifact grading scores. no significant difference was evident between the two observers for scoring image quality and artifact (p00.9), and there was good interobserver agreement (k00.66, 95% ci: 0.26-0.81). the pulmonary arteries were confidently visualized to at least the 2nd order branches in all 16 patients, at least the 3 rd order branches in 15 (93%). out of 176 evaluated segments, 164 (93%) were graded as the vessel "very well visualized with excellent definition of vessel" pa abnormalities were diagnosed in 10 patients and pv anomalies in 6 patients. correlation was made with open surgical findings in 12 cases, confirming the cemra diagnoses with no discrepancy between the operative and imaging conclusions. the results of our study suggest that high resolution cemra at 3.0 t is extremely promising in neonatal cchd and, in combination with echocardiography, may often provide comprehensive information for treatment planning. with appropriate use of physiological motion compensation, parallel imaging and coil configuration, voxel volumes less than 0.5 mm3 are routinely achievable. purpose or case report: it is not well understood whether transfusion-dependent children (mainly those who have hereditary anemias subject to excessive iron levels from regular blood transfusions) with no or mild cardiac iron overload and without signs of heart failure exhibit early changes in cardiac dysfunction. this study aims to evaluate intramyocardial deformation and subsequent cardiac dysfunction in such patients using the cardiovascular magnetic resonance technique of myocardial tagging as well as assess iron overload by another cardiovascular magnetic resonance technique of t2 star (t2*). we hypothesize that transfusion dependent children undergoing chelation therapy will be at high-risk for cardiomyopathy despite normal or slightly elevated iron levels and no signs of heart failure due to progressive myocardial deformation as assessed by myocardial tagging; that is, we expect abnormal mechanical parameters to exist despite t2* values which correspond to normal or slightly elevated myocardial iron levels. methods & materials: 8 patients (mean age 15 yrs) requiring regular blood transfusions for various reasons (e.g. thalassemia, sickle cell disease, other anemias) were investigated using harmonic phase magnetic resonance tagging and t2* imaging. various myocardial mechanical parameters were quantified and correlated to cardiac iron levels as measured by t2*. results: 2 children with no overt signs of heart failure (as measured by ejection fraction and volume indices) exhibited normal t2* iron levels in combination with global circumferential abnormal myocardial strain and 4 children exhibited regional strain. conclusions: this preliminary data suggests that transfusiondependent children without overt signs of heart failure exhibit early signs of cardiac dysfunction (an effect of strain as assessed by myocardial tagging) in direct relation to normal or slightly elevated myocardial iron levels (as measured by t2*). a larger sample size of children could support the idea of abnormal myocardial mechanics being a diagnostic imaging marker for the development of myocardial iron overload and eventual iron-mediated cardiomyopathy. the choice of coil and field of view varied according to the age and size of the patient. imaging was performed on a 1.5 t magnet (philips mri system). after the cine gradient echo time of flight sequences were acquired, the dynamic keyhole mr angiographic sequence was applied in the coronal orientation. this sequence commenced 2-5 s after initiation of the first bolus administration of 2-10 ml of undiluted gadopentetate dimeglumine (0.5 mmol/ml, magnevist) at a rate of 2-3 ml/sec followed by 10-20 ml of saline at a rate of 2 ml/sec. image acquisition was repeated multiple times without delay for 60 s during shallow breathing. contrast material was administered through a peripheral or central venous line, and sometimes via simultaneous bilateral extremity injections. rarely manual hand injection was performed. the parameters were as follows: centra k-space filling, acquired voxel size 1-1.2 x 1-1.2 x 2-3, reconstructed voxel size 0.4-1 x 0.4-1 x 1-1.5, number of dynamics 8-20, keyhole percentage 25-38%, sense (parallel imaging) factor 2x1-2x2, dynamic times 1-3.6 s, and injection rate 1-3 cc/second. image analysis was based on original contrast-enhanced data sets, mip and volume rendering. the quality of the mrv was graded by a subjective scale from 1-5 (10excellent, no limitations; 50nondiagnostic). comparison with unenhanced mr venographic sequences and doppler ultrasound were available in all cases. results: 4d mrv provided diagnostic information on patency of venous segments in all cases, including the presence of venous occlusion or stenosis, the segments involved, and collateral venous pathways. conclusions: 4d mr venography using the method outlined is a reliable means of estimating central venous thrombosis in children, using short dynamic scan times with high spatial and temporal resolution, creating an effect similar to conventional venography. paper #: pa-033 analysis of optimal phase interval for prospective ekg-triggered cardiac ct in children prakash masand, md, texas children's hospital, savivek bogale, lorna browne, rajesh krishnamurthy purpose or case report: evaluate high temporal resolution cine mri of the heart in children to determine relationship of heart rate to the optimal motion free interval during the cardiac cycle, and to derive a chart depicting optimal reconstruction intervals across a range of heart rates which could be applied for prospective ekg triggered ct imaging of the heart. methods & materials: pediatric patients who had high temporal resolution cine steady state free precession sequence (50 frames acquired across a single cardiac cycle) performed as part of a mri/mra of the heart from 2005-2011 were included. a single reader analyzed the high temporal resolution cine data to determine the location and duration of the motion-free phase interval in systole and diastole for heart rates ranging from 60-140 bpm. the following information was collected: age, heart rate, duration of systole and diastole, ekg phase and phase percentage of motion-free interval, and duration of motion-free interval. heart rates were grouped in ranges of 10 (61-70, 71-80, 81-90 etc.), with at least 25 patients in each group. wilcoxon sum rank test was performed to compare the static durations of systolic and diastolic phases for each heart rate group. two-tailed p-values<0.05 were considered to indicate statistical significance. a chart matching heart rate range to the optimal phase of image acquisition and reconstruction was created. results: optimal reconstruction intervals for motion-free imaging of the heart in systole and diastole, and single best phase for a given heart rate are as follows: (please see table 1 ) mean duration of the motionless phase in systole and diastole for a given heart rate is as follows: (please see table 2 ) conclusions: this is the first time that variability in location of the motion-free interval within the cardiac cycle with respect to heart rate in children has been studied in rigorous fashion. this chart will have immediate application in the so-called 'target scan', which uses prospective ekg triggered acquisition of data in combination with half-scan reconstruction to minimize radiation dose with respect to retrospective ekg gated imaging. results: a total of 10 patients were found to have aberrant pda by ccta. nine patients had a pda emanating from the brachiocephalic artery to the pulmonary arteries and one patient had pda emanating from the carotid or the subclavian artery according to the operative report. all ten patients had echocardiography in addition to ccta. nine of the ten patients underwent surgery. one patient was lost to follow up. comparison between ccta and echocardiography to operative report showed the following: 3 out of the 10 echocardiograms agreed completely with ccta and operative report. 7 out of the 10 echocardiograms did not report aberrant pdas which were seen on ccta and confirmed during surgery. in one patient, the echocardiogram reported a double aortic arch which was found to be an aberrant pda from the left brachiocephalic artery; a finding that changed the surgical management and pre-surgical planning. the results were statistically significant with a p value of <0.05. conclusions: diagnostic accuracy of ductus arteriosus anatomy is important in pre-surgical planning and management of patients with ductal dependent pulmonary circulation. cardiac ct angiography is more accurate as compared to echocardiography in diagnosis of aberrant patent ductus arteriosus. ) in patients younger than 1 year of age. the prospective ecg-gated protocol scanned 50% of the cardiac cycle with 10 msec padding in patients with heart rates greater than 100 bpm. two experienced radiologists evaluated the image quality and course of the coronary arteries. image quality was assessed based on the degree of homogeneity of vascular enhancement, presence of stair-step artifacts, image signal and noise as well as the overall subjective image quality based on a 4 point scale. the course of the left and right coronary arteries was also evaluated based on a 4 point scale, focusing on how well the evaluator was able to visually follow the coronary artery from its origin to its termination. radiation dose was recorded and compared. results: the mean score of the homogeneity of vascular enhancement, stair step artifacts, image noise and signal, overall image quality, and score given to visualization of the course of the coronary arteries showed no significant difference (p>0.35) in the retrospective and prospective ecg gated groups. the mean estimated effective dose was significantly lower for the prospective ecg gated group compared to the retrospective group, (0.83 msv vs 2.39 msv) respectively (p<0.0005). conclusions: prospective ecg-gated cardiac mdct provides comparable assessment of coronary anatomy, image quality with significantly less radiation dose when compared to the retrospective ecg-gated mdct. prospective ecg gated cardiac mdct is a powerful adjunct to the treatment and surgical planning of pediatric patients with congenital heart disease less than 1 yr of age with lower radiation dose. methods & materials: 3 pediatric neuroradiology lectures were recorded and made available to 29 radiology residents at a university program through on-line streaming video viewed through an internet link. topics included brain tumors, phakomatosis, and congenital brain malformations. one lecture per week was recommended prior to case conferences that reviewed the same topic. pre-and post-tests and a feedback survey were administered. nonparametric paired sign test and analysis of covariance were used to evaluate changes in test scores overall and according to feedback responses. spearman's partial rank correlation coefficient was used to evaluate the relationship between the number of viewed videos and test scores. results: twenty-nine residents completed the pre-test and 28 the post-test. the means (sd) scores were 59.3% (12.0%) and 64.8% (14.2%) respectively. there was a significant improvement in test scores (p 00.019). residents that agreed/strongly agreed that the streaming technology lectures were convenient had greater improvement than those who did not (14.0 vs. -3.2%, p00.001). similarly, those who agreed/strongly agreed that being able to replay a lecture was helpful had greater improvement than those who did not (10.9 vs. -6.7%, p 00.001). finally, those who agreed/ strongly agreed that the streaming technology lecture format was a better teaching tool had greater improvement than those who did not (10.8 vs. -4.7%, p00.003). significant positive correlation between number of videos watched postconference and improvement was present (spearman's rho0 0.48, p00.013). conclusions: on-line streaming video with live case conferences enhances radiology resident learning of pediatric neuroradiology. step (mpps) software provided an accurate measurement of scan time. visual charting made gaps in utilization apparent. technologists and nursing notes correlated to gaps identified barriers and opportunities for improvement. nursing and anesthesiology reduced redundancies. standardized protocols lead to more consistent scan times. appointment access for sedated mri was measured by the third available appointment. results: manually entered data points were time consuming, inconsistent and unreliable. the process improvement was most effective when fewer more reliable data points were used to evaluate the effect of change. the program resulted in a reduction of appointment access for sedated mri from 30 days to 2 days with no change in the hours of operation. magnet utilization was increased from 58% to 73%. induction outside the scan room provided the most efficient process tested. we ranked first in utilization in a children's healthcare cooperation of america (chca) survey as measured by exams per scanner. patient preference for a.m. scheduling was shown by survey and corroborated by scheduling data. consistent scan times were achieved by protocol standardization augmented by indication driven decision support. conclusions: a consise definition of mr utilization established a metric that was used in the process cycle of analyze-optimize-measure. anesthesia induction outside the magnet was the most efficient practice but required collaboration between nursing, mr technologists and anesthesiology. protocol standardization were valuable aspects of process improvement essential to optimizing parallel sedation. these adjustments reduced appointment access from 30 days to 2 days, increased utilization from 58% to 73% and produced a number one rank in utilization by chca survey. we exploited the synonym option in epic order entry to translate indications into procedures mapped to specific protocols for mri neuroimaging. the order screen allows the provider to enter an indication. that indication is linked through a synonym option to a specific exam and protocol. the recommendation is based upon institutionally created clinical care guidelines, and can be accepted with a single click to complete the order. the requesting provider retains the option to override the recommendation. an step in process development utilized an order queue established within the epic inbasket. a pediatric radiologist monitored the queue and communicated with referring providers to obtain additional history and educate toward best imaging practice. these interactions facilitated development of a robust index of clinical indications used to create the synonym pool. results: mri neuroimaging indications were expanded into a robust data set linked to specific mri exams aligned with specific protocols. the synonym option within epic created the opportunity for the requesting provider to simply enter an indication which drives the procedure and recommended protocol. provider satisfaction has been high and concurrence with recommendations nearly universal. conclusions: indication driven order entry was achieved through the synonym option in order entry within the epic emr. imaging recommendations are based upon institutional clinical care guidelines developed through consensus. a robust compilation of pediatric mri neuroimaging indications has been created and linked to specific exams and protocols. compliance with the indication driven recommendation has been high. modifications of the current system are currently under development for all cross sectional modalities and organ systems. paper #: pa-039 cost-effectiveness of routine neonatal renal ultrasound in non-syndromic complex congenital heart disease elfrides traipe, tch, extraipe@texaschildrens.org; jill v. hunter, marthe munden purpose or case report: to assess the prevalence of abnormal renal ultrasound in non-syndromic complex congenital heart disease (cchd) and assess the cost-effectiveness of routine renal ultrasound in this population. we restrospectively reviewed the initial neonatal renal ultrasound and any subsequent renal imaging in 97 patients with non-syndromic cchd. etiologies included hypoplastic left heart syndrome (hlhs), transposition of the great vessels (tga), coarctation of the aorta (coa), truncus arteriosos (ta), double outlet right ventricle (dorv) with or without patent ductus arteriosus. patients were recruited consecutively as part of a prospective trial for pre-and post-operative magnetic resonance imaging of the brain. results: the neonatal pre-operative renal ultrasounds were analyzed in 41 female and 56 male patients. only 1 of the 97 patients showed any congenital renal anomaly. this patient was born with hypospadias, that would have routinely stimulated neonatal follow up. conclusions: knowledge of embryology would not lead us to anticipate a high co-incidence of congenital renal and cardiac pathology. based on this statement and our findings, our recommendation to improve cost-effectiveness is not to perform routine neonatal renal ultrasound in non-syndromic cchd, but only if otherwise clinically indicated. purpose or case report: to conduct a meta-analysis of the diagnostic performance of contrast enhanced voiding urosonography (cevus) in comparison to voiding cystourethrography (vcug) or direct radionuclide cystography (drnc). a literature search was conducted for studies published on cevus in the pediatric age group. studies were included if the ultrasound contrast agents (usca) levovist® (bayer-schering pharma, germany) or sonovue® (bracco, italy) were used and enough data was available to extract 2x2 tables. if the cevus was compared to both vcug and drnc in the same patients the results for each were analyzed separately. a bivariate hierarchical model that takes into account the heterogeneity in cevus sensitivity and specificity in different studies was used for the assessment of the summary diagnostic metrics. the summary roc curve was derived and presented graphically from the parameters of the model. additionally, the 95% confidence intervals (ci) and the positive (lr+) and negative (lr-) likelihood ratios were calculated. results: out of 127 publications only 30 comparative studies fulfilled the inclusion criteria. these encompassed 26 cevus studies in comparison with vcug and 4 with drnc with regards to detection of vesicoureteric reflux. in 26 studies the usca levovist® and in 4 sonovue® were used. a total of 2549 children with 5078 pelvi-ureteral-units (puus) were included in the meta-analysis. cevus compared to vcug and drnc had a sensitivity of 90% (ci: 85-93) and a specificity of 92% (ci: 89-94) with lr+and lr-of 11.7 and 0.11, respectively. the performance of cevus was better when compared to drnc than to vcug (sensitivity 94%, specificity 95% versus 90% and 92%, respectively. the meta-analysis of the diagnostic performance of cevus regarding the urethra included 880 patients (682 boys). excellent imaging of urethral anatomy was reported in over 97% of the patients. however, currently there is only one comparative study with 146 patients available. in this study 100% sensitivity and 100% specificity were reported. conclusions: sufficient evidence is available clearly demonstrating the high diagnostic performance of cevus compared to vcug or drnc regarding the detection or exclusion of vur in children. these findings combined with the absence of radiation should be convincing reasons for promoting the widespread use of cevus in children. disclosure: dr. darge has indicated that he will discuss or describe, in the educational content, a use of a medical device or pharmaceutical that is classified by the food and drug administration (fda) as investigational for intended use. purpose or case report: prenatal ultrasound (us) has increased identification of infants with asymptomatic renal pelvic dilatation. society for fetal urology (sfu) grading is used in the sonographic evaluation of pediatric hydronephrosis. based on us findings, a nuclear medicine diuretic renogram may assess renal function, which could result in operative intervention. standardized protocols for diuresis renography, the "welltempered renogram," already exist; however, no current study has assessed effect of intravenous hydration (iv) status with us in the evaluation of childhood hydronephrosis. our study assesses the effect of hydration on sfu grading. in this prospective irb approved study, pediatric patients diagnosed with pelvicaliectasis requiring a diuretic renogram were recruited to undergo pre and post hydration renal us. a urinary catheter was placed followed by renal us pre and post iv hydration (10 ml/kg normal saline bolus). imaging was performed by the same sonographer on the same us machine. a well-tempered renogram was then performed. all images were reviewed by two blinded radiologists, one pediatric radiologist who assigned sfu grades to each kidney. results: data were collected from 34 studies, with ages ranging from 6 weeks-16 years, with an average age of 22 months. there were 28 unique patients. of these, 23 underwent a single renogram, 4 underwent two renograms, and 1 underwent 3 renograms. one patient had a solitary kidney due to mcdk. thus, there were 33 usable paired sonograms (67 kidneys) for analysis. sfu grades were compared in the pre-and post-hydration us for each kidney. two-sided statistical tests were done to assess whether sfu grades changed significantly after hydration (sign test). 52 of 67 (78%) kidneys remained the same grade post hydration. when there was a difference, most demonstrated an increase (13 of 15 kidneys and p<0.01). no change in sfu grade pre-and post-hydration differed by more than 1. only 1 kidney went from grade 2 to grade 3. sfu above grade 2 is considered clinically significant. no kidney that was grade 3-4 pre-hydration became grade 0-2 post-hydration. when sfu is dichotomized grade 0-2 vs. 3-4, there was no significant change in grade from pre to post hydration (p01). conclusions: hydration does not appear to have a clinically significant effect on sfu grade. therefore, performance of a "well-tempered" us is unnecessary. disclosure: dr. lee has indicated that she will discuss or describe, in the educational content, a use of a medical device or pharmaceutical that is classified by the food and drug administration (fda) as investigational for intended use. study type was significantly associated with both total and weighted score (both p < 0.0001). rus was better and mag3 was worse than vcug, rnc, and dmsa, which did not differ from each other. other factors associated with worse total scores included patient age 1-3 years (p<0.001) and non-white race (p00.04). gender, prior testing history, wait time, and parent education were not associated with total scores. in the multivariate model, rus remained the best, mag3 the worst, and dmsa, vcug, and rnc in the middle (p<0.0001). compared directly, dmsa and vcug total score did not differ (p00.59). conclusions: this study documents significant differences among gui studies with respect to the patient and family experience, but there was no overall difference between dmsa and vcug. these findings may be useful to aid decision-making when considering gui for pediatric patients. we retrospectively reviewed the imaging findings of 29 consecutive patients with histologic diagnosis of cd (17 males, 12 females; mean age 14.6 years; age range 5-24 years) who underwent mre between 1/21/ 2011 and 10/10/2011. the mre was performed in a siemens avanto 1.5 tesla scanner. standard departmental volume of polyethylene glycol and fluid were administered for bowel distention. the imaging protocol included dwi with eight b values ranging between 0 sec/mm2 and 800 sec/ mm2 and gadolinium enhanced dynamic 3d vibe (volume interpolated breath hold exam) in the coronal plane. the studies were qualitatively evaluated in a blinded fashion by two board certified radiologists. disease activity was defined as bowel wall thickening and enhancement in the gadolinium enhanced images. dwi abnormality was defined as bowel thickening, increase signal on dwi images and decrease signal on adc maps of the ileum. intra voxel incoherent motion (ivim) dwi parameters were used as quantitative biomarkers for the analysis of slow diffusion (d) and fast diffusion fraction (f). results: gadolinium enhanced vibe images identified abnormal thickening and enhancement of the ileum in 11/29 (38%) patients. dwi identified abnormal signal in 11/29 (38%) patients. the sensitivity and specificity of the qualitative dwi for identifying ileitis, as shown by gadolinium enhanced imaging, were 82% and 89%, respectively. quantitative analysis showed statistically significant difference in ivim maximal values for f (fast diffusion fraction) between abnormal (mean00.67, std00.17) and normal (mean00.8, std00.14) ileum segments (p00.012). there was statistically significant difference in ivim maximal values for d (slow diffusion) between abnormal (mean 02.2 μm2/ms, std 0 0.7 μm2/ms) and normal (mean 02.7 μm2/ms, std 0 0.6 μm2/ms) ileum segments (p00.0084). abnormal loops of bowel had decreased slow and fast diffusion parameters. conclusions: diffusion weighted imaging has excellent sensitivity and specificity for the detection of active ileitis in pediatric cd. furthermore, quantitative ivim model parameters provide effective biomarkers for this condition. ivim dwi has the potential to assess bowel inflammation without intravenous contrast enhancement and further increase our understanding of cd. methods & materials: forty pediatric patients (median age 13.8 years, range 10.0-17.7) with suspected (n035) or confirmed ibd (n05) were included and underwent gastroileocolonoscopy with biopsies followed by mre (median interval 20 days, range 6-55). the mre results were compared with macroscopic and microscopic assessment of the ileum. the clinical importance of the mre results was registered. results: crohn disease (cd) was diagnosed in 25 cases, ulcerative colitis (uc) in 12, and ibd unclassified (ibdu) in three. macroscopic ileitis was detected in 15/25 (60%) of cd cases and in 2/12 (17%) of uc (backwash ileitis). microscopic inflammation was found in another four cd cases and one ibdu patient. in total, discrepancy between macroscopic and microscopic inflammation was found in 9 cd, 2 uc and one ibdu patients. the sensitivity of mri was 64% (against macroscopy and/or microscopy) to 71% (against macroscopy alone), while the specificity was 100% and 92%, respectivley. mre findings was decisive for diagnosis in 4/40 (10%) and led to treatment adjustments in 11/40 (28%) in the following six months. conclusions: mre is a reliable method for imaging of intestinal inflammation in pediatric ibd, and can be supportive or essential for clinical treatment decisions. results: of 15 children with ec, 7 had ct imaging of the abdomen and pelvis. these 7 children ranged in age from 15 months to 16 years (mean 10.2 years +/− 6.3) with a male predominance (n04, 57%). the most common presenting symptoms were abdominal pain (n06), bloody diarrhea (n03), and rectal bleeding (n03). ec was characterized as a dense and predominant eosinophilic inflammatory infiltrate in the lamina propria and/or epithelium without granulomas. ct scans were abnormal in 6 (86%). no colonic luminal contrast was present in 2 patients, and in one of these, the colon appeared normal. abnormal ct findings included cecal wall thickening (n05, 71%), mucosal enhancement without colonic wall thickening, (n01, 14%), mesenteric lymph node enlargement (n02, 29%), terminal ileal thickening (n02, 29%), jejunal and ileal thickening (n01, 14%), and pneumatosis (n01, 14%). of the 5 patients with cecal involvement, 4 primarily involved the cecum with less severe or no ileal or downstream colonic involvement. pneumatosis extended along the length of the colon with rectal predominance. conclusions: the predominant ct finding in our ec series was wall thickening, most severe in the cecum with variable extent downstream with mild or no involvement of the terminal ileum. although there is overlap, these findings are different from the most common patterns encountered with ulcerative colitis or crohn disease and should raise the possibility of ec in children presenting with abdominal pain and bloody diarrhea. purpose or case report: timely identification of childhood arterial ischemic stroke (ais) is critical to development of acute treatment strategies. we present our experience prior to and following development of a pediatric stroke alert system (sas). through multi-disciplinary collaboration in a tertiary care setting, a pediatric sas was established in 2008. we describe the system, imaging protocol evolution, and impact upon the time between admission and mri initiation (time-to-mri) in patients with childhood ais. of 74 patients in our stroke database (comirb #05-0339), 27% met inclusion criteria for stroke alert initiation (acute focal neurological deficit within 12 h). eleven pre-2008 and nine post-2008 patients met criteria. we compared the time-to-mri between these two groups, utilizing a two-tailed t-test. results: the pediatric sas has two phases: i-neurological evaluation and ii-imaging and treatment consideration. phase i stroke alert is initiated when a child presents with an acute focal neurologic deficit. if neurology confirms stroke symptoms and ct head is negative for an alternative etiology, a stroke alert is called prompting an emergent brain mri. if mri confirms an acute stroke, hyperacute therapies are considered. initial mri protocol included dwi, t2, flair, 3d tof cow mra, 2d tof neck mra and fat saturated t1 neck imaging. after internal quality review, t1 mprage brain and contrast enhanced 3d neck mra were added. the sequence order was also altered so diagnostic sequences were scanned first (dwi and cow mra). there was a trend towards decreased time-to-mri in the post-2008 group (mean0152 min, sd +/− 120) as compared to the pre-2008 group (mean 340 min, sd0+/−304; p00.10). conclusions: institution of a pediatric sas improved urgent neurologic evaluation and demonstrated a trend towards shorter time-to-mri. ongoing quality review has enhanced imaging quality and decreased time-to-mri. continued refinement of pediatric sas's will be critical to the success of recently funded phase i clinical trials in the evaluation of hyperacute therapies. results: there were 6 female and 3 male infants. the mean post-gestational age at presentation was 20 days (range 0-90 days), while the corrected age was less than 30 days for all patients. 7 patients presented with seizures and signs of infection; 1 presented with lethargy and later proved to have protein c deficiency. mri was performed 0-12 days from presentation in these 8 patients. another patient with known protein c deficiency underwent mri at 3d for followup of screening us abnormalities. there were a total of 27 deep cerebral white matter lesions: 21 frontal, 4 parietal, 2 temporal lobe. lesions were fluid signal cavities with restricted diffusion. larger lesions had dependent debris. all lesions had associated hemorrhage and most lesions had evidence of adjacent small vessel venous thrombosis. lesions imaged after gad showed peripheral enhancement. three lesions were seen to increase in size on follow-up imaging. three patients, 2 with meningitis confirmed via microbiology and 1 with presumed meningitis by csf counts, underwent surgical aspiration of a total of 6 lesions. all specimens were sent for pathology and culture and were negative for microorganisms. conclusions: recognizing the mr appearance of necrosis and liquefaction after deep white matter cerebral venous infarction in neonates can distinguish this entity from cerebral abscess and potentially avoid an unnecessary neurosurgical aspiration procedure. all four children were initially treated with aspirin but experienced recurrent events on therapy. all four were subsequently anticoagulated. two children have remained on warfarin for 6-7 years without recurrent events, while the other two had recurrent events despite adequate anticoagulation. these two children underwent uncomplicated coil embolization of the affected vertebral artery segment, and they have remained symptom-free for five and 20 months since then. conclusions: dava was diagnosed by ca in 3/4 patients. all four children with dava in our series suffered recurrent strokes despite aspirin therapy. two of the four experienced further strokes on anticoagulation, necessitating endovascular therapy. these findings suggest that dava in children may require ca to diagnose, and that it may be refractory to standard adult therapies. ongoing multicenter efforts in childhood ais should further evaluate the diagnostic approach and recurrence risk of childhood dava. ) and cerebral gray matter abnormalities were present in 6 (1%). posterior fossa lesions were seen on us in 1.6% , but mastoid views were included in only 50% of the centrally read us. conclusions: in the largest extreme preterm cohort to date with near-term mri and serial us, 19% had mod-severe wma on brain mri, similar to previous reports. cerebellar abnormalities were detected more frequently by mri than by us. neurodevelopmental outcomes at 18-22 months and school age will assess the relative and combined values of mri and us as outcome predictors. , an analysis technique based on task-free resting state fmri recording, can be useful in assessing disruption of connectivity in certain disease states, including epilepsy. in healthy control subjects, functional connectivity reveals strong bilateral interhemispheric connectivity in such system as sensory-motor, visual, auditory as well as dorsal attention and default mode networks. in patients with epilepsy associated with unilateral diffuse hemispheric disease such data is limited. differences in the pattern of activation would suggest alteration in connectivity in these entities. this finding would impact the typical interpretation of this data that is becoming routinely collected for epilepsy pre-surgical evaluation. methods & materials: siemens (erlangen, germany) system, 3-tesla (trio) scanner was used for imaging (epibold sequence, te030 ms, flip angle090°). resting state fmri scan were performed in both awake and anesthetized patient. awake patients were instructed to relax and rest while keeping their eyes open. analysis was performed using 1000 functional connectomes project scripts based on afni and fsl software packages. resting state data were analyzed for connectivity with the following seeds: somatomotor, visual, auditory, and default mode (posterior cingulated cortex (pcc)). results: we applied this technique to evaluate 12 patients with hemispheric seizure disorders, including rasmussen's, neonatal infarct and migration disorders. all the subjects demonstrated some deviation from typical interhemispheric connectivity with a spectrum of findings. the figure below shows connectivity patterns in a patient with cortical dysplasia. while some interhemispheric connectivity remained in somatomotor (sm) and auditory (a1) systems, it was disrupted in visual (v1) and default mode (pcc) networks. variable patterns were found across the cases that corresponded to lesion side, supportive of disruption in interhemispheric connectivity as measured by fmri. conclusions: resting state functional connectivity patterns are well documented in healthy subjects. these results suggest that interhemispheric connectivity disruption is a typical feature of unilateral diffuse hemispheric disease though variable in presentation, either being limited to select systems or demonstrating broad disconnect between the two hemispheres. these results should be carefully considered when evaluating data for pre-surgical epilepsy evaluation. purpose or case report: premature birth is associated with white matter injury leading to a wide ventricular system. however,normative standards for ventricular size are lacking for this particular group.aims: we aimed to, in a controlled, population based norwegian cohort of ex-prematures without major handicaps, and for men and women separately,to 1) create standards for radiological indices of ventricular dilatation, 2)investigate associations of these measurements with subjectively assessed ventricular size,3) examine differences in ventricular size between ex-prematures and healthy controls methods & materials: the initial birth cohort included 217 neonates, birth weight below 2000 g (low birth weight)born within hordaland county, norway, between april 1st 1986 and august 8th 1988. 113 of 174 eligible survivors (without major handicaps)underwent mr examination during the period january 2006 to may 2007. 103 of these were expremature (born before gestational age 37 weeks) and were included in this sub-study. based on t2 weighted images, the ventricular size was subjectively judged as being normal, mildly, moderately or severely dilated by an experienced paediatric neuroradiologist, while objective measurements were performed in a blinded fashion, by a second observer (sma) using an imaging software program (nordic ice®). results: the normative standards for the ventricular system in ex-premature young adults showed wide variations, in particular for the occipital horns. the agreement between subjective and objective assessment of ventricular size was good. ex-prematures had smaller heads than those born term (control group). there was no difference in ventricular size between the two groups, even after adjusting for head size. ex-premature males had larger ventricles than females; however, the difference disappeared after adjusting for head size. conclusions: young adults born prematurely with a birth weight below 2000 g do not have larger lateral ventricles than healthy controls born term, even after correcting for a smaller head size. paper #: pa-057 best practice for reproducibility when measuring t2*: implications for liver and cardiac iron assessment mark ferguson, md, radiology, seattle children's hospital, markferg@uw.edu; randolph otto, seth d. friedman purpose or case report: patients with red blood cell transfusion-dependent conditions receive high amounts of iron that can lead to abnormal iron accumulation in tissues resulting in organ damage. while the liver is the dominant excess iron storage organ, iron related cardiotoxicity is a leading cause of morbidity and mortality in patients with transfusion-dependent thalassemia. therefore, accurate determination and tracking of tissue iron levels in both the liver and the myocardium is important for patient prognostication as well as monitoring treatment changes. while multi-echo gradient echo mri (t2*) is widely used and validated method employed for iron assessment, less attention has been given to derived metrics. specifically, the literature almost exclusively reports and uses the mean value for t2* from a pixel-wise (pw) map. infrequently used is the median. the median is a potentially superior metric than the mean because it is insensitive to outliers. outliers will always occur in data because of either noise or imperfect vessel exclusion. to compare mean versus median on reproducibility of t2* measurement, 23 subjects who had paired heart/liver measurements were examined. the entire liver (excluding vessels) and the interventricular septum myocardium were traced on representative images from each series. mean and median t2* values were generated from the pixel maps. r2* (1000/ t2*) and coefficient of variation (cv) were computed on a patient-by-patient basis. these measures were then summarized for the group. results: markedly higher r2* values were observed in both heart and liver using median summary measures (liver: t0−2.79, p0.01, heart: t0−2.8, p0.01). these findings were accompanied by lower cv's (better reproducibility) for the median approach (liver: t01.89, p0.07; heart: t01.91, p0.07). conclusions: the consistent difference in derived t2* values between the methods (median>mean) should be considered when comparing derived r2* values to established normal ranges. cv data support that using the median as the final summary metric will always outperform mean metrics for measuring change in r2*. this finding has immediate implications for the scientific literature and for guiding therapeutic management over time. results: twelve children (age 5mo-13yo; m:f 6:6) with gsds (7 abca mutations, 4 sp-c mutations, 1 undefined mutation) and 16 children (age 2wk-18yo; m:f 10:6) with other dlds (including pulmonary interstitial glycogenosis, neuroendocrine cell hyperplasia of infancy, lymphocytic interstitial pneumonia, lipoid pneumonia, diffuse alveolar damage, granulomatous infection, capillaritis and other pulmonary hemorrhage syndromes) were identified. ct findings with highest sensitivity for gsds were ground glass attenuation (83%), parenchymal cysts (67%), and interstitial thickening (58%). parenchymal cysts, honeycombing, and pectus excavatum were more specific for gsds compared to other dlds (p<0.05). the combination of either parenchymal cysts and honeycombing or ground glass attenuation and pectus excavatum provided the highest specificity (100%) but low sensitivity (25%). the combination of parenchymal cysts and ground glass attenuation provided good specificity (81%) and modest sensitivity (50%). no combination of findings provided both high sensitivity and specificity. conclusions: ground glass attenuation is the most sensitive finding for gsds, while parenchymal cysts, honeycombing, and pectus excavatum are more specific findings for gsds than other chronic dlds of childhood. however, no single finding or combination of findings on chest ct is both highly sensitive and specific for gsds, and chest ct cannot substitute for genetic testing or lung biopsy for the differentiation of gsds from other dlds. pes were observed in 33 scans of patients without a history of congenital heart disease (chd), and 26 pes in 12 scans of patients with a history of chd. z-axis scan lengths for the chest ct exams ranged from 10.1-33.3 cm. a z-axis scan length of 14 cm centered 3.5 cm below the carina captured all pes in all patients, and a length of 12 cm centered 3.5-4 cm below the carina in patients with chd. a z-axis scan length of 8 cm centered 5 cm below the carina was sufficient to capture at least one pe in all patients, and a length of 8 cm centered 4-5 cm below the carina in patients with chd. the radiation effective dose of the chest ctpa exams ranged from 3-10 msv. limiting the z-axis scan length on ctpa exams to 14 cm or 8 cm would have resulted in a 20% or 40% decrease in z-axis coverage, respectively, and estimated radiation effective dose reduction of 21-42% due to less radiation exposure to the intrathoracic structures, thyroid gland and upper abdominal viscera. conclusions: limiting the z-axis scan length coverage for ctpa exams based on a model of the typical anatomic distribution of pes relative to the reference level of the carina permits a substantial reduction of radiation dose in children without reducing the sensitivity for detection of pulmonary emboli. purpose or case report: to determine whether the addition of multiplanar reformation mdct images affects reader performance parameters and provides added diagnostic value compared to the use of axial ct mdct images alone for diagnosing pe in children. this was an institutional review board-approved retrospective study of 60 consecutive pediatric patients who underwent ctpa for clinically suspected pe. two faculty pediatric radiologists and two radiology residents independently reviewed each study initially using only axial mdct images and later using mpr mdct images in any x-, y-, or z-axis for detecting pe. diagnostic accuracy, confidence level, and interpretation time of mpr mdct images were compared to axial mdct images using mcnemar's test and paired t-tests. the kappa coefficient was calculated to assess interobserver agreement. diagnostic accuracy was compared between faculty pediatric radiologists and radiology residents by logistic regression whereas confidence level, interpretation time, and added diagnostic value were evaluated with analysis of variance (anova). results: the final study cohort consisted of 60 ctpa studies from 60 children (28 m/32 f; mean age 14.7 years). nine (15%) of 60 ctpa studies were found to have pe. diagnostic accuracy in correctly detecting pe ranged from 91.7 to 100% (mean096.7%), with no significant differences between the use of axial and mpr mdct images. logistic regression indicated no significant difference in diagnostic accuracy of detecting pe between faculty pediatric radiologists and radiology residents for axial mdct images (p0.48) or mpr mdct images (p0.24). confidence level and interobserver agreement were significantly higher and average interpretation time was longer in evaluating pe with mpr mdct images compared to axial mdct images for all reviewers (p<.001). compared to faculty pediatric radiologists, significantly greater increases in confidence level, interobserver agreement, interpretation time, and added diagnostic value using mpr mdct images compared to axial mdct images to diagnose pe were found for radiology residents (p<0.001). conclusions: use of mpr mdct images in diagnosing pe on ctpa in children significantly increases confidence, interobserver agreement, and interpretation time among faculty pediatric radiologists and radiology residents. because mpr mdct images provide significantly greater improvements in reading parameters for residents than for faculty members, their routine use should be encouraged for trainees. paper #: pa-062 chest ct in children, anesthesia and atelectasis beverley newman, md, radiology, stanford university, bev.newman@stanford.edu; elliot krane, terry e. robinson purpose or case report: in spite of advances in ct equipment and speed, sedation/ anesthesia is required in many young children for optimal quality ct for detailed parenchymal evaluation; resultant atelectasis is a common and important quality issue. our purpose was to evaluate the safety and effectiveness of a standardized lung recruitment technique. methods & materials: with irb approval and parental informed consent, 49 controlled ventilation, low dose, chest ct's (cooperative effort between anesthesia, pulmonology and radiology) were performed in 38 children (7 had 2-4 cts) (21 f, 16 m; ages .02-5.13 yrs, mean 2.5 yrs). indications included cystic fibrosis 8; ciliary dyskinesia 4; chronic or interstitial lung disease 16; evaluate pulmonary metastases 10. ct parameters were 80-100kvp, 25-80mas, iv contrast 11. various prior methods employed by the pediatric anesthesiologists to maintain lung inflation had unpredictable results (a brief survey showed 5/9 nonintubated anesthetized cases had problematic atelectasis). a standardized intubation technique was therefore adopted: 1.use of a tight fitting face mask during induction and iv placement, inspiratory pressures of 20-25 and peep of 5. 2. introduction as early as possible using an appropriately sized cuffed endotracheal tube. 3. alveolar recruitment maneuvers-10-12 3 s breaths to 40 cm h2o/5 (32-35 in 1st 6 cases). 4. three breaths at 25/5, inspiratory breathold followed by 25-30 cm on 4th breath for scout and inspiratory scan, and complete ventilator disconnection for expiratory scan. recruitment breaths repeated before each scan. two experienced readers reviewed and scored the images on a 5 point scale for overall quality and atelectasis. results: all studies were completed safely with no procedural complications. one child had propofol-related postoperative emergence delirium. all ct scans were diagnostically good to excellent with small subsegmental atelectasis in 8 (6/8 were the initial cases with lower recruitment pressures) and segmental atelectasis in 2. 13 cases had prior cts, without this technique, that were suboptimal due to moderate procedural atelectasis, in spite of tracheal intubation in the majority of cases. conclusions: an intubation lung recruitment technique can be performed safely and consistently by different individuals using a standardized protocol. procedural atelectasis that affects quality is reliably absent and repeat sequences are not needed. obtaining a high-quality dynamic airway imaging study is critical for accurate interpretation and subsequent medical decision-making. the ideal mri sleep study is one that allows successful completion while maintaining spontaneous breathing without artificial airway, which can be an anesthesia challenge. dexmedetomidine has been shown to have sedative properties paralleling natural sleep with minimal respiratory depression. we hypothesized that dexmedetomidine compared to propofol would have less effect on upper airway tone and airway collapsibility and provide favorable conditions with less airway interventions required during dynamic mri airway imaging in children with osa. in this prospective study, we examined the requirement for airway intervention for propofol (100-200 mcg/kg/m) and dexmedetomidine(1-3 mcg/kg/h) in children and adolescents with osa. severity of osa was analyzed by overnight polysomnography. for children with history of mild osa there was no intervention unless oxygen saturation decreases below 90%; while for children with history of moderate/severe osa, an artificial airway was placed when oxygen saturation decreased below 85%. results: demographics and osa severity by polysomnography were comparable. requirement for artificial airway by severity of osa as documented by polysomnography will be shown. mri sleep studies required airway intervention in 3/26(12%) children in the dexmedetomidine group versus 7/ 29 (24%) children in the propofol group. mri sleep studies were successfully completed without the use of artificial airways in 23 children (88%) in the dexmedetomidine group versus 22 children (76%) in the propofol group. conclusions: safe and effective anesthetic management is a key factor in obtaining good quality mr images of the airway. although there was no statistical significant difference in the need for airway intervention between drugs, dexmedetomidine provided acceptable sedation for mri sleep studies with less airway intervention in children with osa. dexmedetomidine may be the preferred agent for sedation during mri sleep studies in children, and may offer benefits to children with sleep disordered breathing requiring anesthesia or sedation for other diagnostic imaging studies. an open mouth and administration of cpap resulted in smaller ap diameter of the retroglossal airway compared to images without cpap due to cpap pressure pushing the tongue posteriorly. in patient 1 volume of oral cavity anterior to the tongue increased from 7.41 ml to 11.74 ml. meanwhile, the ap diameter of the retroglossal airway decreased from 4.8 to 1.4 mm (71% decrease). in patient 2 the mouth was initially closed but parted when the pressure of cpap was added with the oral volume increasing from 3.69 ml to 15.80 ml. the ap measure of the retroglossal airway decreased from 8.3 mm to 2.8 mm (66% decrease). in patient 2 the mouth was then closed and cpap reapplied resulting in an ap measurement of 11.0 mm (33% increase). the ap diameter difference between cpap and no cpap were tested with paired t-test, but were not statistically significant (p00.1475). conclusions: positive airway pressure on a patient by full facemask and an open mouth can have an adverse effect on the retroglossal airway. this adverse effect is an important consideration in the use of positive airway pressure to support airways for osa, or during emergency resuscitation when a full facemask is used. paper #: pa-065 the purpose or case report: a nanoparticle blood pool iodinated contrast agent (nctx) has been designed and tested in preclinical animal models. we report data in animal models exemplifying its advantages over conventional contrast in the setting of ct pulmonary angiography methods & materials: nctx blood pool nanoparticles of 125 nm diameter with an encapsulated total iodine concentration of~125mgi/ml were administered by intravenous injection to mice, rabbits, dogs, pigs and sheep. (these studies were actually conducted for other purposes and a review of the data revealed the similarities that motivated this paper.) total injected volumes were~5 ml/kg in large animals, and as high as 10 ml/kg in small animals to provide satisfactory vessel enhancement. iohexol or iopamidol was administered for comparative studies with conventional contrast. in a subset of pigs, iatrogenic pulmonary arterial emboli were introduced prior to contrast administration. toxicity studies were conducted in mice and monkeys. results: the visualization of pulmonary vessels using nctx blood pool nanoparticles was generally at least equivalent to using conventional contrast, and superior in several cases, particularly in small veins and when bolus timing of the conventional contrast was suboptimal. in all cases, satisfactory vessel enhancement was achieved for a duration of several hours following a single infusion of nctx blood pool nanoparticles. there was no evidence of renal toxicity, and only transient elevation of hepatic enzymes at relevant dose levels. conclusions: nctx nanoparticle blood pool agents demonstrate several advantages over conventional glomerularfiltered iodinated contrast agents for ct pulmonary angiography in animal models, including no nephrotoxicity, no dependence on bolus injection technique, superior depiction of small veins, and capability of re-imaging for follow-up studies without needing contrast re-injection. potential applications in human pediatric subjects include the diagnostic and post-therapeutic evaluation of cardiopulmonary anomalies and pulmonary embolism, especially in patients with renal insufficiency or tenuous vascular access. disclosure: dr. annapragada has indicated that he is a stock holder and consultant for marval biosciences inc. paper #: pa-067 cardiovascular image quality using a nanoparticle ct contrast agent: preliminary studies in a pig model rajesh krishnamurthy, radiology, texas children's hospital, rxkrishn@texaschildrens.org; ketan ghaghada, prakash masand, abhay divekar, eric hoffman, ananth annapragada purpose or case report: image quality in a separate study using a long circulating, liposomal-based nanoscale blood pool iodinated contrast agent (nctx) suggests clinical utility in pediatrics, potentially reducing difficulties in contrast-ct of children with congenital heart disease (chd) including the size of intravenous cannula, need for accurate timing, inability to simultaneously opacify multiple targets of interest (requiring repeated contrast administration and/or repeated imaging). methods & materials: six pigs (average weight 30 kg) were imaged after slow intravenous infusion of nctx (105 mg i/ml) at an iodine dose of approximately 900 mg i/ kg (8.5 ml/kg). retrospective ekg gated ct imaging was performed 3 h later using a 128-slice dual-source ct scanner at 80 and 120 kvp. two radiologists analyzed and graded (on a 5-point scale with 1: unreadable, 5: excellent) images aimed at anatomic structures relevant to chd. quality of images obtained at 80 and 120 kvp were compared. uniformity of contrast opacification was measured using a roi-based ctnumber method at various intracardiac and extracardiac sites and mean non-uniformity was calculated. results: there was excellent agreement between the two readers on all counts at 120 kvp. 80 kvp images received lower scores for coronary morphology (4/5), and aortic valve visualization (3.5/5), but were comparable in other aspects. pulmonary artery and pulmonary vein branch visualization extended up to the 5th generation in all cases. visualization of coronary artery branches was possible up to the second generation, with good arteriovenous separation. subtle morphologic features including crista terminalis, thebesian valve, foramen ovale, membranous septum, and chordae of the mitral valve were demonstrated in all cases. automated functional analysis and myocardial mass quantitation was feasible in all cases. there was no significant difference in blood pool attenuation between the atria, ventricles, and extracardiac vasculature on quantitative assessment. no image artifacts were visible on the reconstructed images. conclusions: these findings suggest that nctx promises to be superior to conventional contrast agents for ct imaging of complex congenital heart disease, due to the absence of nephrotoxicity, avoidance of repeated contrast administration, and reduced number of scans performed. avoiding the need for accurately timed scans precludes the need for large bore intravenous access. these attributes make it a promising agent that warrants further studies. disclosure: dr. annapragada has indicated that he is a stock holder and consultant for marval biosciences inc. paper #: pa-068 theoretical cost and x-ray dose reduction in pediatric congenital heart disease imaging by the use of a nanoparticle contrast agent robert bell, the university of texas-houston; rajesh krishnamurthy, gabriela espinosa, christopher petit, ananth annapragada purpose or case report: the purpose of this study is to determine the effective, population averaged reduction in costs and radiation dose that can be achieved in the diagnosis of congenital heart disease by use of a nanoparticle long circulating blood pool contrast agent. methods & materials: a markov model of the decision tree followed at the texas children's hospital in the image based diagnosis of congenital heart disease was constructed in treeage software. the model included ct angiography, mr angiography, cardiac catheterization, and echocardiography diagnostic modalities. patient records, accumulated between 2003 and 2011 were examined to inform the model. the radiation dose and cost for each step were encoded as penalty functions. markov simulations were run for two decision trees: (1) utilizing ct angiography and (2) replacing conventional ct angiography with blood-pool agent based ct angiography. the overall population x-ray dose and accrued cost was calculated for each pass through the model. results: x-ray dose distributions for the example populations showed substantial reductions per ct study, as much as 50%. averaged over the population, since a sizeable fraction of patients are diagnosed without ever being exposed to any x-ray based modality, reductions were more modest, but still substantial. costs per ct study were slightly higher when the blood pool contrast agent was used. when the diagnostic probability using the blood pool agent increased, it led to an automatic overall cost reduction. conversely when the diagnostic probability remained unchanged, costs rose, commensurate with the increased cost of the contrast agent. conclusions: the use of a blood pool contrast agent for ct angiography leads to substantial reduction in radiation dose in the setting of congenital heart disease. cost reductions are more modest, and are driven almost completely by the reduction in the number of mr and invasive angiography procedures resulting from increased diagnostic success using blood pool based ct angiography. the model as constructed does not account for potential workflow changes that might result from the use of a new contrast agent. actual reductions realized may therefore be higher. disclosure: dr. annapragada has indicated that he is a stock holder and consultant for marval biosciences inc. paper #: pa-069 frequencies and patterns of situs discordance in chest and abdomen justin boe, stanford, justinj.boe@gmail.com; beverley newman, shreyas vasanawala, frandics chan purpose or case report: incidence of situs anomalies, including heterotaxy and situs inversus, is estimated at 0.02% of population. as the first step in the segmental analysis of structural heart disease, the determination situs position is of fundamental importance. abdominal situs, as defined by splenic position and morphology, and cardiac situs, as defined by atrial morphology, are usually but not always in agreement. echocardiographers also employ the relative position of the great arteries and vein at the hiatus to determine cardiac situs. we evaluate the frequencies of discordances among abdominal, hiatal and cardiac situses. methods & materials: with retrospective irb approval, imaging records from 2001 to 2011 were reviewed for the diagnosis of cardiac situs inversus and heterotaxy. patients who had cardiac ct or mri were included. images were evaluated on a 3d-processing station by a cardiac radiologist. cardiac situs was determined by the morphology of the atrial appendages. when an atrial appendage was not adequately visualized, cardiac situs was assessed by the relative position of the main pulmonary artery and bronchi. hiatal situs was determined by the relative position of the aorta and the systemic venous return, and abdominal situs by the position and morphology of the spleen. results: thirty-five cases were identified, with 23 cardiac ct and 12 mri. patients' age ranged from 1 day to 35 years old. in the abdomen, the numbers of situs inversus, asplenia, and polysplenia were 11 (32%), 12 (34%), and 12 (34%). for the heart, the numbers of situs solitus, inversus, rightisomerism, and left-isomerism were 2 (6%), 13 (37%), 11 (31%) and 9 (26%). the abdominal and cardiac situses were discordant in 5 (14%) cases. polysplenia had the highest number of discordance with the heart. hiatal situs was discordant with the abdomen in 5 cases (16%) and with the heart in 8 (25%) cases. conclusions: situs disagreement between the abdomen and the heart is not uncommon and they should be documented separately in radiology reports. hiatal situs, as used by echocardiographer, disagrees with the cardiac situs in a quarter of the cases. it should be used with caution in the segmental analysis. paper #: pa-070 diminished asl intracranial perfusion in children with neurofibromatosis type 1 kristen yeom, md, stanford university, kyeom@stanford. edu; cynthia campen, patrick barnes purpose or case report: neurofibromatosis type 1 (nf1), a neuro-cutaneous syndrome affecting 1/3500 children is associated with moyamoya syndrome (mms). however, no comparisons of cerebral perfusion in patients with nf1 and nf1-associated mms to healthy controls exist. we hypothesize cerebral blood flow (cbf), as measured by magnetic resonance imaging (mri) arterial-spin-labeled (asl), is diminished in children with nf1 compared to healthy controls, with the lowest levels seen in patients with nf1-associated mms. methods & materials: twenty children aged 2-18 years with nf1, four with mms, and 26 age-matched controls underwent asl cbf on a 3 t magnet. pseudocontinuousspin-echo-asl technique was used. measurements were taken bilaterally in cerebral cortical-subcortical regions, and the deep gray nuclei. trends in measurements as a function of disease severity were tested with the jonckheere-terpstra test for ordered alternatives. a bonferroni-adjusted p-value less than 0.0013 was considered significant. results: we identified 6/12 areas with significantly diminished asl cbf (ml/100 g/min) in patients with nf1 (midrange), and nf1-associated mms (lowest) compared to healthy controls (highest). these included the: thalami (left: p00.0002, right: p00.0004); superior/middle temporal lobes (left: p 00.0012, right: p 00.0009); temporooccipital lobes (left: p00.0006, right: p00.0003); occipital poles (left: p 00.0008, right: p 00.0001); centrum semiovale (left: p00.0022, right: p00.0005); and left parietal lobe (p00.0012). conclusions: cerebral perfusion diminishes in a graded fashion in children with nf1 and nf1-associated mms, particularly in the posterior circulation and the mca-pca posterior watershed zones. future studies may demonstrate an important role for asl in the presymptomatic diagnosis of cerebral vasculopathy, and the definition of nf1-related vasculopathy patterns. paper #: pa-071 cingulate gyrus mri sign in pediatric nf1 patients: a novel imaging marker nadja kadom, md, radiology, children's national medical center, nkadom@childrensnational.org; nabila hai, rhea udyavar , amir noor, gilbert l. vezina, maria t. acosta purpose or case report: we observed a magnetic resonance imaging (mri) signal abnormality in the anterior cingulate gyrus of pediatric patients with neurofibromatosis type 1 (nf1). the cingulate gyrus could play a role in cognitive deficits of nf1 patients. the first objective here is to document inter-rater reliability scores for visual detection of this sign. the second objective is comparing adc values of the cingulate gyrus in areas of visually abnormal mri signal in nf1 patients to matched normal mris to confirm a pathophysiological basis of the visual mri sign. methods & materials: retrospective analysis, irb approved, 61 nf1 patients and 38 matched controls. in the visual assessment part, two blinded neuroradiologists rated presence or absence of mri signal abnormality in the cingulate gyrus in three different age groups of nf1 patients mixed with normal controls. cohen's kappa inter-rater reliability coefficients were calculated. the same blinded neuroradiologists evaluated the cohort one year later, this time by agreement at the workstation. in the adc measurements part, two researchers, one blinded, manually placed roi's in the anterior and posterior cingulate regions of 26 nf1 patients and their matched controls, and student t-test was used to assess for significance of differences in measured values. results: cohen's kappa for the three age groups showed very good agreement (kappa coefficients were either 0.9 or 1.0). rater agreement at the workstation was 100%. all subjects with a positive finding also had nf1 and the sign was not seen in any of the normal controls. the prevalence of the sign was 43%. adc measurements showed significantly higher adc values in the anterior cingulate gyrus of nf1 patients when compared to normal controls and also when compared to the posterior cingulate gyrus in nf1 patients. conclusions: our results show that visual t2/flair mri abnormalities in the anterior cingulate gyrus are present in 43% of patients with nf1 from ages 2 to 19 years. adc measurements confirm a pathophysiological basis for this finding. future correlation with clinical manifestations, such as learning and behavioral manifestations in patients with nf1, are under way to further evaluate the clinical importance of this finding. tract-based spatial statistical analysis of diffusion tensor imaging in pediatric patients with mitochondrial disease seth friedman, phd, seattle children's, seth.friedman@ seattlechildrens.org; andrew v. poliakov, sandra l. poliachik, dennis w. shaw purpose or case report: often diagnosed at birth or in early childhood, mitochondrial disease presents with a variety of clinical symptoms, particularly in organs and tissues that require high energetic demand such as brain, heart, liver, and skeletal muscles. in a group of pediatric patients identified to have complex i or i/iii deficits, but with white matter tissue appearing qualitatively normal for age, we hypothesized that quantitative dti analyses might unmask deficits in microstructural integrity. methods & materials: dti and structural mr brain imaging data were collected in 10 pediatric patients with confirmed mitochondrial disease and 10 clinical control subjects matched for age, gender, scanning parameters, and date of exam. paired tract-based spatial statistics (tbss) were performed to evaluate differences in fractional anisotropy (fa) and mean diffusivity (md). results: in patients with mitochondrial disease, significant widespread reductions in fa values were shown in white matter tracts. md values were significantly increased in patients, having a sparser distribution of affected regions compared to fa. results of tbss statistical analysis will be shown. to be shown in green is the mean fa skeleton which represents the centers of main white matter tracts. all results p<.05. red and yellow represent a significant increase, blue and light blue represent a significant decrease. conclusions: despite qualitatively normal appearing white matter tissues, patients with confirmed mitochondrial disease have widespread microstructural changes measurable with quantitative dti. this supports the evaluation of such metrics in other populations where gross imaging features may be normal. to extend our studies to patients with other plp1 mutations, we analyzed the brains of 52 male pmd patients (ranging in age from 2 to 45) and 9 female carriers for whom the plp1 genotype had been determined and analyzed by mri. for each patient we measured, white matter volume (wmv) and the intercaudate distance (icd). the mri data were correlated with functional disability scores (fds) using a system we developed for clinical evaluation of pmd patients and which was validated by assessments of 22 pmd patients. brain volume and segmentation were measured using nih image 1.62. the average number of coronal slices analyzed from each patients mri was 60 slices. when graywhite contrast was not adequate, then the intercaudate distance (icd) and intercaudate ratio were measured as described in caon et. al., (2003) . results: comparison of the mr measurements and the fds demonstrated that white matter volume inversely correlates with functional disability, suggesting that the initial disability does correlate with the extent of myelination. the intercaudate distance also correlated with the fds, and may usefully substitute when gray-white matter segmentation is not possible. conclusions: pmd is a clinically and genetically heterogeneous disease caused by mutations in the gene encoding the major cns myelin protein, proteolipid protein (plp). myelin is a major target of disease pathogenesis in most cases of pmd, but how the various mutations cause clinical disability is not fully understood. our data demonstrate that the extent of brain white matter atrophy, measured directly by volumetric fractionation, or indirectly by analyzing the intercaudate ratio, is significantly correlated with the patient's functional disability. white matter atrophy is thus the main cause of clinical disability in patients with pmd of all ages and mutation type. paper #: pa-074 maturational effects on language localization in children demonstrated by fmri susan palasis, md, children's healthcare of atlanta at scottish rite, spalasis@yahoo.com; binjian sun, laura l. hayes, richard a. jones purpose or case report: language localization is of paramount importance when contemplating surgery in children with intractable epilepsy or brain tumors. the potential risk of injury to language centers in the developing pediatric brain needs to be weighed against the potential benefits of surgery. in the past, language localization was crudely and invasively determined using the wada test. most institutions are now transitioning to non invasive localization using functional mri (fmri). the purpose of our study was to analyze language localization relative to age in children using age appropriate language paradigms and fmri. methods & materials: forty three healthy, english speaking, right handed children underwent fmri evaluation for language localization. the studies were performed on a 3 t system. three novel age appropriate language block paradigms were utilized, targeted both to expressive and receptive language processing. these paradigms were the auditory category decision task (audcat), the auditory description decision task (addt), and the listening task. the spatial statistical maps generated by the fmri data were fused to the 3d anatomical mri dataset. language areas were localized and statistical analysis was performed with age as the variable in a general linear model. results: our results demonstrate a distinct trend in language localization and lateralization with brain maturation. in the young age groups (less than 12 years) the localization tended to be less focused and bilateral in the frontal and temporal regions of the brain. in the older age groups (greater than 12 years), language became more localized and lateralized to the expected left sided pattern. the findings were more robustly demonstrated with the addt task and were statistically significant (p<0.05). conclusions: our study clearly demonstrates the plasticity of language centers in the maturing pediatric brain. this observation is significant for neurosurgical planning and rehabilitation in the pediatric population. (3) no slc26a4 mutations were found in 16, 12 and 47 subjects, respectively. significantly higher association with slc26a4 mutations was found in bilateral eva+v/c dysplasia (16/18). double mutations of slc26a4 is more often associated with combined eva+ v/c dysplasia, while a single mutation with eva only. cochlear aplasia without eva (0/2) and snhl with normal imaging (3/21) are less likely associated with slc26a4 mutation. conclusions: slc26a4 mutation is highly associated with eva and v/c dysplasia. once eva with or without v/c dysplasia are found at imaging, genetic investigation is recommended for slc26a4 mutation because of possible thyroid involvement. moderate-severe hie who were randomized to cooling (33.5°c for 72 h). there were 73 in the hypothermia group and 63 in the control group. all mris were reviewed by a cental reader masked to the clinical findings, groupings, and outcomes. the mri findings were scored according to pattern and extent of injury, including involvement of the cerebral hemispheres, basal ganglia, thalami, internal capsules, and other structures. brain injury scores were correlated with death or disability at 18 months postnatal age. results: no mri abnormalities were observed in 38 of 73 infants (52%) in the hypothermia group and in 22 of 63 infants (35%) in the control group (p00.08). infants in the hypothermia group had fewer areas of injury (12%) as compared with the control group (22%, p0 0.02). there were 51 of the 136 infants with death or disability at 18 months. the brain injury score correlated with outcome of death or disability (p00.001) and disability among survivors (p00.0001). conclusions: fewer areas of brain injury on mri were observed following whole-body hypothermia. the mri brain injury score is a marker of death or disability at 18 months following hypothermia for term hie. . presence or absence of the "red dot" on fa color maps was correlated to clinical (ataxia, oculomotor abnormalities etc.) and morphological data, and to fa and md measurements. results: the "red dot" was absent in js and hgpps (genetic cross wiring impairment diseases) and present in coma and wvs (no reported gene abnormalities so far) as in normal controls. js and coma presented on mri molar tooth appearance. hgpps presented "split pons" appearance. js and coma patients presented oculomotor apraxia, wvs and hgpps palsy of the horizontal gaze. mirror movements were found in 2 js and in wvs. ipsilateral responses are present in hgpps. wvs presented multiple cranial nerves impairment. in js, fa and md values of scp, pt and pc were significantly lower than in normal controls (p >0.01). in hgpps high fa and low md were found in pc and pt (p >0.01) and normal in scp. conclusions: the "red dot" absence is unrelated to morphological or clinical abnormalities. absence of the "red dot" is associated to abnormal measurements of fa and md in pc and pt( low in js and high in hgpps). these findings indicate a pivotal role for the pc in the physiopathology of these diseases. the "red dot" absence seems to be a marker of genetic cross wiring diseases. in this view, coma and wvs should not be considered as part of these diseases. sonographic predictors of intermittant testicular torsion in the pediatric patient jennifer williams, md, pediatric radiology, texas children's hospital, jlwilli1@texaschildrens.org; marthe munden purpose or case report: intermittent testicular torsion (itt), defined as sudden onset unilateral scrotal pain with spontaneous resolution, is difficult to confirm both clinically and sonographically. the purpose of this study was to determine if sonographic predictors exist for diagnosing itt in the pediatric patient. methods & materials: a search of the pacs data system for patients presenting with suspected intermittent testicular torsion was performed. fifteen patients with a total of 20 episodes presenting over a 2 year period were found. a retrospective review of the medical records for clinical presentation, surgical outcome, and comorbidities was performed. scrotal ultrasound images and reports were reviewed for testicular size and echotexture, testicular flow, epididymal appearance, vascular bundle appearance, and presence of hydrocele. results: an abnormal appearance of the vascular bundle was found in 85% of episodes (17/20). initial absence of testicular flow followed by reperfusion during the scan was seen in 30% of episodes (6/20); 45% had increased flow (9/ 20), 10% had decreased flow (2/20), and 15% had normal flow (3/20) . nine of the 15 patients had surgery; of these 8 were found to have evidence of itt and 1 was found to have acute testicular torsion. of patients with itt, 88% (7/8) had an abnormal vascular bundle. testicular flow was not initially visualized but returned during the exam in 50% of patients (4/8), was increased in 38% of patients (3/7) and was decreased in 13% patients (1/8). conclusions: itt is a difficult diagnosis. the most reliable sonographic indicator is an abnormal spermatic cord, found in 85% of episodes and 88% of surgically proven itt. dedicated views of the spermatic cord must be obtained in order to differentiate an abnormal epididymis from an engorged vascular bundle (the so-called pseudomass). attention to testicular flow is of particular importance. while visualization of a transition from no or decreased testicular flow to normal flow during the sonogram is certainly diagnostic of itt, increased testicular flow should not lead to false reassurance. purpose or case report: testicular torsion is a common acute condition in boys requiring prompt and accurate diagnosis. the objective was to evaluate ultrasound accuracy and findings, and clinical predictors in testicular torsion in boys presenting to the stollery pediatric emergency department (ed) with acute scrotal pain. methods & materials: retrospective review of us, surgical and ed records for boys aged 1 month to 17 years, presenting with acute scrotum from 2008 to 2011, was performed. age, demographics, clinical symptoms, physical findings, us and surgical techniques, findings and diagnoses were recorded. surgical results and follow-up were used as the gold standard as all pediatric urology in our region is performed at our centre. results: 343 patients presented to ed with acute scrotum with the following diagnoses: 35 testicular torsion, 11 possible torsion-detorsion, 3 torsion of appendix testes, 135 epididymo-orchitis, and 159 other. of 266 us performed, 29 boys had torsion confirmed by surgery. there were 8 inconclusive us reports, none of which had torsion at surgery or follow-up. the false positive rate of us was 1.5% (4 patients), and there were no false negatives. six torsion patients had no us. median time from ed to us and surgery for torsion patients was 159 and 303 min. six patients had non-salvageable testes. diagnostic accuracy of us compared to surgery was 96% for torsion and 67% for other. sonographic heterogeneity was seen in 80% of patients with testes that the surgeon felt were non-viable at surgery and 72% of patients with viable testes (p00.35). sudden-onset scrotal pain (92%), abnormal position (86%) and absent cremasteric reflex (91%,) were most prevalent in torsion patients. conclusions: color doppler us is accurate and sensitive for diagnosis of torsion in the setting of acute scrotum. despite heterogeneity on pre-operative us, many testes were felt to be salvageable at surgery. rate of salvage of torsion was high. common symptoms and findings of torsion were sudden onset of pain, abnormal testicular position and absent cremasteric reflex. paper #: pa-080 diagnostic twists of tubal torsion srikala narayanan, md, children's national medical center, snarayan@childrensnational.org; anjum n. bandarkar, dorothy bulas purpose or case report: fallopian tube torsion is a rare cause of acute pelvic pain in a young female and requires prompt diagnosis for immediate surgical intervention. our purpose is to review varied imaging findings of surgically proven cases of tubal torsion. methods & materials: retrospective review of our data base from 2007 to 2011 revealed 7 cases of surgically proven fallopian tube torsion. ages ranged from 9 to 15 years of age. all had pelvic ultrasound performed, 3 cases had additional ct performed for acute pelvic pain. results: us findings included thickened dilated tubular hypoechoic structure (5), cystic mass (4); adnexal (3), midline (1). five cases had normal ovaries bilaterally (2 with paratubal cysts). ct imaging findings include dilated, fluid filled, thickwalled tube with internal hyperdensity (40hu) likely debris/ hemorrhage in 1 case. additional findings included cystic adnexal mass (3 cases), beak sign (1 case) and increased vascularity (1 case). secondary signs included free fluid (5), peritubular fat stranding (1), vascular congestion and thickening of the broad ligament (1) and enlarged draining vein (1). laparoscopic salphingectomy was performed in 3 cases (including 2 cases with isolated tubal torsion). laparoscopic detorsion was performed in a total of 4 cases. in addition, laparoscopic cyst drainage was performed in 2 out of these 4 cases. detorsion with paratubal cystectomy and hemorrhagic ovarian cystectomy was performed in 1 of the 4 cases. conclusions: imaging diagnosis of tubal torsion can be difficult. it can occur in isolation with a dilated thickened tubular structure adjacent to a normal ovary or potentially mimic appendicitis, pyosalpinx, complex adnexal cyst or cystic adnexal neoplasm. presence of normal ovaries, beaked tapered tubular structure with intratubal fluid level and hemorrhage may help in making the diagnosis. it is important to recognize this entity in a patient with acute pelvic pain to facilitate prompt tubal sparing surgery. paper #: pa-081 adjusted renal length in pediatric bone marrow transplant recipients nicholas bodmer, md, university of washington, nbodmer@gmail.com; teresa chapman, sangeeta hingorani, marguerite parisi purpose or case report: bilateral nephromegaly has been observed in the bone marrow transplant (bmt) patients at our institution. this study aims to quantify this observation, thereby providing radiologists with an adjusted baseline agedetermined renal growth curve for bmt patients. methods & materials: a retrospective clinical chart and imaging review was performed on 185 patients who underwent bmt between 2006 and 2010 and who had abdominal imaging including the kidneys. ultrasound, ct, and mri exams were used for renal length measurement. renal lengths were assessed for each age group, first as an average length of all the patients within that age group overall, and subsequently as an average renal length by age group divided into the following time frames after transplantation: 0-30 days, 31-90 days, 91-180 days, and 181+ days. clinic chart information collected included bun, creatinine, weight, and medication use. results: renal length was measured using 278 imaging cases, distributed across each age group as follows: 6-12 months, n 011; 13 months-2.5 years, n 030; 2.6-4.5 years, n033; 4.6-7.5 years, n038; 7.6-11.5 years, n0 51; 11.6 years and higher, n0115. renal lengths were greater, on average, within every age group, compared with previously established normative age-related renal lengths (rosenbaum et al.) . the augmented renal lengths universally were observed in the 0-30 day post-transplantation timeframe. return to normal renal lengths typically occurred by 6 months post transplant. clinic chart review revealed that the majority (87%) of patients received nephrotoxic medication within two weeks of imaging. conclusions: pediatric bmt patients have larger kidneys in the absence of known renal disease than age-matched peers. a revised, age-based renal length chart for post-bmt patients has been generated which should help prevent the misdiagnosis of nephromegaly in this population, eliminating unnecessary diagnostic evaluations. multiple etiologies to explain renal enlargement in these patients are possible, including fluid overload, nephrotoxic medication, or direct effect of the transplant. purpose or case report: mr urography can be a comprehensive exam for anatomical and functional pediatric renal evaluation. quantification of renal function may benefit when dynamic contrast enhanced images can be obtained at high spatiotemporal resolution and with minimal respiratory motion artifacts. though respiratory triggering may decrease motion artifacts, it results in loss of temporal resolution by a factor of about three. a two-echo gradient echo sequence with segmented outer k-space sampling and view-sharing/dixon image reconstruction (disco, differential subsampling with cartesian ordering) was chosen as a starting point due to its high temporal resolution. it was then modified to enable respiratory triggering while maintaining temporal resolution of one temporal frame every one to two respirations, with segments of k-space only acquired in the expiratory phase of respiration. imaging parameters were: 12°flip angle, ± 167 khz bandwidth, tr~3.56, matrix 256x200, fov 28-34 cm, slice thickness 4 mm, and 2x2 spatial acceleration. with irb approval and informed patient consent 9 consecutive patients referred for mri renal function evaluation were recruited (age range; 0.5 to 9.6 years, mean±sd: 3.99±3.6 years; males 78% females 22%), and scanned on a ge 3 t mr using a 32-channel torso array with the respiratory-triggered high spatiotemporal resolution technique to extract regional gfr maps. two readers by consensus assessed image qualitative snr, motion artifacts and volumetric fat-water suppression performance. results: data acquisition was obtained to completion in all subjects without triggering failure. temporal resolution was approximately 12 s for two respiratory cycles. no case had major fat suppression failure, whereas minor fat suppression failure was seen in 11% (95% c.i. 0 to 37%). all cases had diagnostically acceptable snr. no motion artifacts were noted in 7/9 cases, while some artifacts with ghosting in 2/9 cases. regional gfr maps could be successfully extracted for each patient without the need for image registration. attached figure shows image quality. conclusions: view-sharing offsets loss of temporal resolution from respiratory triggering. thus, high spatiotemporal resolution renal dynamic contrast enhanced respiratory triggered images can be obtained with minimal motion artifacts in a pediatric clinical setting to evaluate renal function. disclosure: dr. chowdhury has indicated that he will discuss or describe, in the educational content, a use of a medical device or pharmaceutical that is classified by the food and drug administration (fda) as investigational for intended use. methods & materials: the study cohort was selected from the irb approved children's oncology group aren03b2 study. cases are evaluated for pre-operative wt rupture based on central review of surgical/pathology findings. 70 wt cases with rupture were matched to 70 wt controls by age and tumor weight (within 6 months and 50 g). ct scans were independently reviewed by 2 blinded radiologists, for presence/absence of rupture and the following ct signs: poorly circumscribed mass, perinephric fat stranding, peritumoral fat planes obscured, retroperitoneal fluid, ascites beyond cul-de-sac, peritoneal implants, ipsilateral pleural effusion, intratumor hemorrhage. sensitivity, specificity of ct for assessing pre-operative wt rupture was determined. the relationship between ct signs and rupture was assessed by mcnemar's test, and the most predictive ct signs determined by backward selection multivariate logistic regression. results: sensitivity, specificity for detecting wt rupture were: reviewer 1-53.7%, 88.4%, reviewer 2-70.2%, 88.4%. kappa coefficient for interobserver agreement was substantial: 0.76 (p<0.0001). all ct signs tested, except peritoneal implants and intratumoral hemorrhage, had significant association with tumor rupture (p<0.01). for reviewer 1, ascites and fat stranding around tumor were most predictive (odds ratio 18.359 and 10.554, p<0.01). for reviewer 2, ascites and retroperitoneal fluid were most predictive (or 8.345 and 4.916, p<0.01). conclusions: ct has high specificity but relatively low sensitivity for detecting preoperative wt rupture. the presence of ascites beyond cul-de-sac is the best indicator of preoperative rupture, followed by fat stranding and retroperitoneal fluid. paper #: pa-084 the failed pyeloplasty: evaluation with mr urography damien grattan-smith, children's healthcare of atlanta, damien.grattansmith@mac.com; ricahrd jones, stephen little, wolfgang cerwinka, hal scherz, andrew kirsch purpose or case report: to identify imaging characteristics associated with failed pyeloplasty seen with mr urography. we have performed mr urography in 142 children following pyeloplasty. from this group, 16 children had follow-up surgical intervention with repeat pyeloplasty or balloon dilatation of the upj. imaging features reviewed included degree of hydronephrosis, calyceal transit times, renal transit times, signal intensity versus time curves, as well as functional analysis based on volumetric and patlak differential function and change in the asymmetry index. results: all children who underwent a second surgical procedure had delayed calyceal transit times. the degree of hydronephrosis and renal transit times were either stable or worse when compared to pre-operative evaluation. functional derangement could show stability, slight improvement or deterioration. the asymmetry index estimated the severity of the obstruction. conclusions: mr urography is valuable in the evaluation of children who have undergone pyeloplasty. the calyceal transit time appears to be the most reliable discriminator when comparing successful and failed pyeloplasty. calyceal transit times may be prolonged before the hydronephrosis becomes progressive. disclosure: dr. grattan-smith has indicated that he will discuss or describe, in the educational content, a use of a medical device or pharmaceutical that is classified by the food and drug administration (fda) as investigational for intended use. purpose or case report: initial attempts at interpreting functional mr urography (fmru) can be challenging. a time intensive navigation through a multitude of both subjective and objective functional results is necessary to render a useful interpretation. this is a guided review of fmru, noting the important functional findings in high-grade unilateral pelvicalyceal dilatation (pcd), in the absence of ureterectasis, with a contralateral normal kidney allowing for an optimal functional comparison. methods & materials: a retrospective functional evaluation of 16 cases with unilateral pelvicalyceal dilatation (pcd), without prior pyeloplasty, was conducted. the fmru studies were carried out according to a standard protocol and post-processing using the chop-fmru software. this included iv hydration, bladder catheterization and iv furosemide administration. fifteen minutes after diuretic administration, a dynamic coronal 3d fat saturated t1 sequence was performed in a supine position over 15 min. a sagittal 3d t1 and delayed single coronal t1, both fat saturated, followed in a supine and/or prone position. the following functional features were evaluated: visualization of the ureter, the presence of a contrast-urine level and swirling of contrast in the dilated renal pelvis. the functional results included in the analysis were calyceal transit time (ctt), renal transit time (rtt), time-to-peak (ttp), parenchymal volume (pv), differential renal functions (volumetric-vdrf, patlak-pdrf and volumetric patlak-vpdrf) and the difference between vdrf and pdrf. results: 16 patients were comprised of 8 males and 8 females with an age range of 0.1-17.0 years (median 0.8 yrs). of the kidneys with pcd, the ureter was visualized in 10, 3 during the dynamic sequence, 4/9 during supine delay and 3/7 only in prone position. a contrast-urine level was present in 14 of the dilated systems, and swirling in 6. the ureter was visualized during dynamic sequence in all contralateral normal kidneys and at no time was swirling or a contrast-urine level identified. the average functional parameters are seen in table 1 . a statistically significant (p<0.05) difference between the normal and dilated pelvicalyceal systems was achieved in ttp, pdrf and vpdrf for this small sample size. conclusions: awareness of multiple functional features and the range of calculated results may aid in subsequent combined interpretation of the fmru with the morphologic analysis. disclosure: dr. lecompte has indicated that she will discuss or describe, in the educational content, a use of a medical device or pharmaceutical that is classified by the food and drug administration (fda) as investigational for intended use. 2007 and 2011. demographics, clinical presentation , diagnostic studies and treatment outcomes were evaluated. post-procedure imaging was evaluated for clot burden reduction (patency) and residual venous stenosis by two-reader consensus. results: ten patients (5 male; 5 female, mean age 16 years, range 15-18) presenting with acute upper extremity swelling and pre-procedure imaging revealing 100% occlusion of the axillary and subclavian veins received successful endovascular therapy. all 10 patients underwent infusion catheter placement for thrombolysis with tissue plasminogen activator or urokinase. 6 patients received additional pharmacomechanical treatment. angioplasty was also performed in all patients. the mean treatment duration was 33 h (range 16-62). post-procedural imaging revealed that 9 of 10 patients achieved 75-100% patency (clot burden reduction) and 1 patient achieved 50-75% patency. the residual venous stenosis was graded: 5 patients had 0-25% stenosis, 2 patients had 25-50% stenosis and 3 patients had 75-100% stenosis. all patients were discharged on full anticoagulation therapy with low molecular weight heparin. 9 patients had surgical rib resection postthrombolysis with an average length of time from thrombolytic therapy to surgery being 32 days (range 14-73). 3 patients had re-thrombosis events during the follow-up period (mean 10 months; range 1-34), with one re-thrombosis event occurring within one week of thrombolytic therapy, prior to surgery and the other two occurring 3-5 weeks post-rib resection. there were no procedure related complications. one patient was lost to follow-up after initial successful catheter directed therapy. conclusions: percutaneous endovascular techniques such as pharmacomechanical thrombolysis and angioplasty appear to be feasible and safe options for paget schroetter syndrome in otherwise healthy adolescent patients. in attempt to prevent rethrombosis and chronic symptoms, we refer all patients for adjunctive surgical decompression. future larger studies are needed to address optimal strategies for these patients. combined 3d fluoroscopy image guided percutaneous intervention with real-time optical sensing at the tip of a needle for tissue characterization rami nachabe, philips, rami.nachabe@philips.com; john m. racadio, drazenko babic, ross schierling, jasmine hales, benno hendriks purpose or case report: to investigate the feasibility and potential of real-time tissue characterization at the tip of a needle with diffuse optical spectroscopy (dos) sensing capabilities during 3d fluoroscopy guidance using cone beam ct and dedicated needle path planning software. methods & materials: a c-arm x-ray system that combines fluoroscopy and 3d imaging from a cone beam ct was used to image a woodchuck with hepatocellular carcinoma (hcc). the imaging system enabled needle path planning, which was used to perform insertion and navigation of a needle toward the liver tumor. the needle was integrated with optical fibers for real-time tissue spectral sensing at its tip. optical spectra measurements were obtained continuously as the needle passed through healthy liver tissue and then into the tumor. from the diffuse optical spectra measurements, the following clinical parameters were extracted for tissue characterization: blood volume fraction, blood oxygenation, lipid volume fraction and tissue light scattering (related to tissue density). the tissue parameters were compared for healthy liver and tumor using the kruskal-wallis test. results: the tissue density of the healthy liver was lower than that of the tumor. higher blood and lipid volume fractions as well as oxygenation levels were observed in the healthy liver as compared to the tumor. all differences were statistically significant (p<0.01). additionally, a much wider heterogeneity in tissue density was observed in the tumor as opposed to the healthy liver. conclusions: differences in tissue properties between tumor and healthy liver enable discrimination between these two types of tissues. adding real-time optical sensing at the tip of a needle to 3d fluoroscopy image guidance is a feasible technique that complements the imaging information with relevant physiological parameters; it facilitates more precise definition of tumor boundaries despite any target motion during needle insertion. disclosure: dr. racadio has disclosed that he is a consultant for philips healthcare and receives travel reimbursement. rami nachabe, drazenko babic and benno hendriks are employees of philips healthcare. methods & materials: two children aged 6 months and 3 months were treated at this institution for liver failure resulting from urea cycle disorders, with a hepatocyte transplant procedure. the recipient liver was irradiated prior to transplant to facilitate engraftment. the procedure involves the injection of prepared hepatocytes from a suitably screened, compatible donor, via a main portal vein branch into the recipient liver. in both procedures access to the umbilical vein was achieved by the surgery service and a 4 french arterial sheath was placed. a 4 french angled catheter was used for diagnostic runs and to access the right and left main portal vein. a 3 french fogarty catheter (edwards lifesciences, irvine, ca) was placed to isolate each portal vein branch in turn and hepatocytes injected using hand injections. pressures in the main, right and left portal veins were measured and hand injections of contrast made at regular intervals. careful attention must be paid for evidence of pruning of portal branches, indicating occlusion of small portal branches, or portal to hepatic vein shunting. if shunting is seen, infusion must be stopped as embolism of hepatocytes into pulmonary arteries may result with serious clinical sequelae results: in both patients, the desired number of hepatocytes were successfully delivered into the recipient liver. in both cases, mild pruning of the portal vein branches was evident at the end of the procedure. portal vein presssures remained steady. there was no venographic or clinical evidence of pulmonary arterial embolization. conclusions: the interventional radiologist plays a central role in the hepatocyte transplant procedure. familiarity with catheterizing portal branches from an umbilical vein approach, measuring venous pressures, using small occlusion catheters and recognizing venographic end points such as portal vein pruning and portal to hepatic vein shunting are necessary to the safe and successful completion of this new technique. purpose or case report: the aim of the study was to evaluate the trends in term of type of tube placed, number of procedures per year, number and age of the patients as well as the number of procedures per patient and the interval of time between two placements, and finally the irradiation burden borne by the patients. methods & materials: after reb approval the radiologic files of the patients who underwent naso-duodenal-jejunal (ndj) or gastro-jejunal (gj) or jejunal (j) tube placement under fluoroscopy over the past five years (2006 to 2010) were extracted from the ris and reviewed. the results were tabulated as a single batch and stratified by year. results: eighty-nine patients representing 234 procedures (155 ndj, 77, gj, 2 j) were included. only 38 patients underwent a single procedure. the average number of procedures per patient was 2.6 with a maximum of 12 during the study period. the average patient's age was 55.3 months (sd074.88, median0 11.43). the average fluoro time per procedure was 7.2 min (sd08.3, median05.0). the average interval between two procedures was 58 days (sd0108,44, median018). the average fluoroscopy time per patient combining those having a single procedure and those having multiple ones, was 19.57 min (range 0.3 to 151.7, sd024.36, median012.45). conclusions: fluoroscopic placement of enteric tubes delivers a significant amount of irradiation. our data led to two interventions with respect to insertion and management of the tubes. on one hand, when the attempt pursued by a radiologist is not successful after 10 min of fluoroscopy other strategies should be considered including another operator or an alternative technique for tube positioning. on the other hand, information will be distributed toward the clinicians and nurses in order to improve the management of these tubes and avoid fortuitous displacement which was responsible of a significant amount of repeated procedures leading to undue irradiation. purpose or case report: to evaluate drug elution pharmacodynamics of doxycycline in an albumin-based solution, as used in percutaneous imaging-directed therapy of aneurysmal bone cyst (abc) and microcystic lymphatic malformation (lm) methods & materials: doxycycline mixed with 25% human serum albumin (hsa), and doxycycline mixed with saline solution (both 20 mg/ml) were evaluated using a fluid diffusion chamber system over 8 h, recording ph and doxycycline concentration. static ph and doxycycline concentrations were recorded every 5 min for the first 180 min, then every 30 min for a total of 8 h, averaged over 3 trials in each of the hsa and saline systems. statistical analysis evaluated standard deviation and rate of change for the 3 trials in each system. drug elution dynamics data were correlated with clinical experience in the doxycycline/albumin treatment of 49 patients (233 treatments) with aneurysmal bone cyst (abc) and 63 patients with 1263 lymphatic malformation microcysts. results: drug elution was linear in both the hsa and saline systems, with statistically significant (p<.001) slower elution drug release from the albumin system as compared with the doxycycline and saline solution, both over 3 and 8 h. purpose or case report: to describe a successful interventional radiologic approach to the management of paget schroetter syndrome presenting as acute arm swelling in adolecent athletes. methods & materials: institutional review board approval was obtained for this retrospective study. five patients aged 14 to 18 years (mean 16.5 years) were treated at this institution over a 2 year period all presenting with acute arm swelling (july 2009 -july 2011). ultrasound confirmed subclavian vein thrombosis in all cases. all were treated with placement of an infusion catheter (ev3, plymouth, mn), infusion of tissue plasminogen activator (tpa) at a rate of 1 mg/hour overnight and aspiration of remaining clot with a "trellis" (bacchus vascular, santa clara, ca, usa) thrombectomy device. results: clot was successfully removed in all five patients. complete clearance of clot was confirmed by contrarst venography in all cases. in four patients balloon angioplasty of a narrrowing at the junction of the subclavian and brachiocephalic veins was carried out. in one, the thrombus recurred within 6 h. the patient was retreated the next day with aspiration of clot using the "trellis" device and an infusion catheter placed with low dose (0.5mgs/hour) tpa commenced until surgical review; this patient was operated on within 48 h of final thrombolysis. all patients were seen by a vascular surgeon with an interest in this condition. all underwent surgical decompression; at end of the study period all patients were asymptomatic. conclusions: interventional radiologic management of acute axillo-subclavian thrombosis due to paget schroetter syndrome is safe and highly successful in the adolescent population. early recurrence of thrombus is not uncommon and prompt surgical consultation with a view to early surgical decompression is recommended. purpose or case report: diagnostic reference levels (drl) or target radiation dose ranges for pediatric ct scans are needed in the u.s. the first u.s. pediatric ct dose index registry (quircc) within the american college of radiology recorded estimates of patient radiation dose using a new method (ssde) based on body width(bw) for the purpose of developing diagnostic reference levels (drl). in addition to developing drl at the 75th percentile, the purpose of this study was to determine the ssdes associated with the lower range of acceptable image quality through subjective image quality evaluation. methods & materials: six children's hospitals participated in a retrospective review of abdominal ct with iv contrast on patients <18 yrs of age. from 939 exams, each site submitted de-identified images for selected cases based on ssde and patient width. a total of 106 cases were selected from the lowest, first quartile and median ssde. six investigators reviewed 3 images from each case under identical viewing conditions and rated them for subjective quality according to a score sheet and reference scale of images with known quantum mottle. cases were considered non-diagnostic if at least 3 of 6 reviewers ranked them as such. results: first, second, and third quartile ssde and ctdi-vol32 values from 6 sites for each bw will be shown. 6/ 106 cases were ranked non-diagnostic by the reviewers. 4/6 non-diagnostic cases were below the 10th percentile based on ssde. 5/6 of "non-diagnostic" cases had ssde less than the 25th percentile. the unacceptable case with ssde above the 25th percentile (16 cm, ssde 8.2 mgy) was due to subcutaneous metal implant with artifact. the quircc 75th percentile using ctdivol 32 for a 5 yr old is 7.1 mgy which is 30% lower than the acr ct accreditation data's published 75th percentile. conclusions: this consortium developed target dose ranges (drls) for ct of the abdomen with iv contrast for routine exam indications based on evaluation of image quality that establish lower and upper ranges (25-75 percentile) of patient dose(using ssde) associated with clinically acceptable images. this study demonstrates that pediatric radiologists in this consortium are comfortable interpreting images at or above the 25 percentile ssde and judged all but one image within this target range as diagnostically acceptable. table 1 ). with the exception of neonate chest, most used age-based techniques; only two centers reported using thickness. no survey used grids for wrist images, while 2/3 of the surveys used grids for chest and abdomen exams in 5-year-olds. at the most common sid there was up to a 60 kvp variation (5year-old chest ap) and up to 8-fold variation in mas (13 year old scoli lat). only two surveys used equipment that displayed the new iec exposure index. conclusions: participants report variability in the techniques and methods used to acquire common radiographic studies, reflecting differences between detector types and users. radiologists, technologists, medical physicists, manufacturers, and the fda have an opportunity to work together to standardize the techniques based on detector type to optimize radiation exposure for pediatric radiographic exams. disclosure: dr. don has indicated that he performs contract research for carestream and that he is on the speaker's bureau for siemens and receives an honoraria. purpose or case report: this study assesses community adoption of ct radiation dose guidelines after a 10-year international initiative to reduce medical radiation exposure in children. size-specific dose estimates (ssde) from community pediatric body ct scans are compared to ssde from matched scans obtained at a children's hospital that adheres to image gently campaign principles. we reviewed 112 pediatric ct scans (14 chest (c), 80 abdomen/pelvis (ap),18 chest/abdomen/ pelvis (cap)) transferred from 32 community imaging centers to our university children's hospital between july 2010 and february 2011. community scans were acquired with variable parameters and reconstructed with traditional filtered back projection (fbp). comparison was made to 432 children's hospital ct scans, performed in accordance with principles of the image gently campaign. because iterative reconstruction (ir) software was added to our scanner during the study, enabling us to reduce ctdivol by 60%, children's hospital scans were divided into two groups: a) 213 scans obtained with standard weightbased pediatric protocols and fbp (october 2009-october 2010; 58 c, 110 ap, 45 cap) and b) 219 scans obtained with reduced-dose weight-based pediatric protocols and blended ir/ fbp (october 2010-april 2011; 85 c, 104 ap, 30 cap). ctdivol and greatest lateral dimension were recorded from each scan and were used to calculate ssde. mean ssde from community scans was compared to mean ssde from children's hospital groups a and b. statistical analysis was performed with student's t-test. results: patient age range was 0-17 years in both community and children's hospital groups. mean ssde for community c, ap, and cap scans was 1.7, 1.3, and 1.6 times higher than mean ssde for matched scans in control group a (p<0.001) and 5.0, 2.8, and 3.7 times higher than mean ssde for matched scans in control group b (p<0.0001). conclusions: ssde was significantly higher for community pediatric body ct scans than for matched scans performed at a children's hospital that adheres to image gently campaign principles. results suggest that more community outreach and education are required in implementation of low-dose ct protocols outside of children's hospitals. concurrent use of ir provides a means of achieving even greater ssde reduction than is possible with fbp alone and should be encouraged. paper #: pa-095 optimization of tube voltage and current in size-based pediatric ct imaging: a phantom study boaz karmazyn, md, radiology, riley hospital for children, bkarmazy@iupui.edu; yun liang, keith kaser, peter johnson, mervyn cohen purpose or case report: determine the change in ct dose index (ctdivol) required to maintain the same quantum mottle noise when using lower tube voltages (80 and 100 kvp) relative to 120 kvp in different sized cylinder water phantoms (cwp) representing a wide range of pediatric body sizes. we performed 256 mdct scans of 10, 20, 25, and 35 cm cwp. thirty scans were performed for each phantom. the tube currents ranged from 50 to 500 mas with increments of 50 mas, and the tube voltage levels were 80, 100, and 120 kvp. the noise (standard deviation in hu) was measured using center region of interest (roi) that was 80% of phantom's area. two other rois (each 2% of the area) were placed at the center and periphery of the phantom images to measure noise gradient. results: in the smallest (10 cm) cwp, approximately the same noise level was maintained with all three tube voltages without a significant change in ctdivol. for the 20, 25, and 35 cm phantoms, the average ctdivol needed to be increased by 2%, 4%, and 19%, respectively, to maintain same noise level when the voltage was decreased from 120 to 100 kvp. the average ctdivol needed to be increased by 15%, 22% and 52% to maintain the same noise level in the 20, 25, and 35 cm cwp when the tube voltage was decreased from 120 to 80 kvp. the difference between central and peripheral noise increased on average by 11.1%, 19.6%, 23.7%, and 28.0% in the cwp of 10, 20, 25, and 35 cm, respectively. in each cwp, the central to peripheral noise difference was more pronounced (up to 3.7% more) with decrease in kvp from 120 to 100 or 80. conclusions: noise measurements in the water phantom model indicate that tube voltage could be decreased from 120 to 80 in cwp of 10 cm without significant change in ctdivol. it is also possible to decrease the voltage from 120 to 100 kvp with a minimal (< average 5%) increase in dose in cwps of 10, 20, and 25 cm. the noise gradient increases with larger cwp and smaller kvp. paper #: pa-096 comparison of radiation dose estimates, image noise, and scan duration in pediatric body imaging using 320-row and 64-row ct jennifer johnston, md, radiology, cincinnati children's hospital medical center, jhtai@yahoo.com; daniel j. podberesky, erin angels, terry t. yoshizumi, greta toncheva, donald p. frush purpose or case report: to compare effective dose (ed) estimates, image noise, and scan duration for pediatric chest, abdomen and pelvis protocols using 320-row and 64-row ct scanners in various acquisition modes. methods & materials: organ doses were measured using 20 mosfet dosimeters. dose, scan duration, and noise measurements were made in a 5-year-old anthropomorphic phantom for conventional helical, 160-detector helical and volume acquisition modes for chest, abdomen and pelvis protocols on a 320-row ct, and for helical mode on a 64row ct (aquilion one and aquilion 64, toshiba medical systems, otawara, japan) using similar scan parameters representing currently used clinical protocols. mean organ doses from three runs for each protocol, in combination with icrp 103 tissue weighting factors, were used to obtain ed for each protocol. noise was measured as the standard deviation of hounsfield units in 3 equivalent locations at 4 levels for each protocol with an roi tool. ed and noise were compared with a paired t-test or sign test. results: compared to helical acquisitions on the 64-row ct, ed of all tested acquisition modes on the 320-row volume ct were significantly lower for chest, abdomen/pelvis (ap) and chest/abdomen/pelvis (cap) protocols (table) . scan durations were lower across the board on the 320-row volume ct. compared to acquisitions on the 64-row ct, noise was in general similar to those on 320-row ct protocols, but some acquisition protocols on the 320-row ct produced greater noise (table) , specifically volume acquisition for chest ct and 160-detector helical and volume modes for ap and cap protocols. conclusions: dose savings can be achieved for chest, ap and cap ct examinations on a 320-row ct scanner compared to helical acquisition on a 64-row ct, with shorter scan durations. image noise was in general comparable between protocols. although noise differences between some modes did reach statistical significance, the impact on overall image quality will need to be studied further. paper #: pa-097 the observed to expected total fetal lung volume as a predictor of short-and long-term morbidity in surviving infants with congenital diaphragmatic hernia emily stenhouse, the royal hospital for sick children, emilysten@doctors.org.uk; neil patel, judith simpson, watt andrew, gregor walker, carl davis purpose or case report: observed-to-expected total fetal lung volume (o:e tflv) is a validated mr measure which we have previously demonstrated to be significantly reduced in non-surviving infants with congenital diaphragmatic hernia (cdh). our aim was to investigate the relationship between o:e tflv and short-and long-term morbidity outcomes in surviving infants with cdh. methods & materials: a retrospective analysis of cases of isolated left-side cdh referred to our institution for fetal mr evaluation between 24-35 weeks. mr imaging studies were performed on a 1.5 t philips system using a phased array body coil. the observed tflv was calculated by multiplying the summed area of the region of interest by the section thickness. the expected tflv was calculated with a formula previously described in the literature using the gestational age of the fetus. the observed tflv was expressed as a percentage of the expected tflv at a given gestation. morbidity outcome data was obtained from the case records of all surviving infants. specific measures of illness severity relating to short-term intensive care management and long-term outpatient management were recorded. differences in o:e tflv between outcome groups were assessed by t-test. results: 18 liveborn infants with isolated left-side cdh and antenatal mr scans were identified. scans were performed at 24-35 weeks gestation. 12 infants survived to discharge; gestation 38.5 (36.0 -39) weeks, birth weight 3.17 (2.03-3.66) kg. median length of admission was 38 (23-103) days, median duration of follow-up was 3.1 (0.7-5.4) years. o:e tflv was significantly lower in non-surviving infants; 23 vs. 37%, p0 0.005. o:e tflv was significantly lower in infants who received high frequency oscillation ventilation (hfov) versus those who were conventionally ventilated (29% vs 41%, p00.05). o:e tflv was also significantly lower in those infants who had a length of admission greater than the median of 38 days (29% vs. 43%, p00.02). o:e tflv trended lower with other measures of increased morbidity; inhaled nitric oxide use, patch repair of diaphragm, rehospitalisation within 1 year, supplemental feeding at discharge, gastro-oesophageal reflux, and developmental delay. conclusions: as well as predicting survival, lung volume measurement by o:e tflv is a promising predictor of outcome and morbidity in surviving infants with cdh. further studies in larger populations are required to provide quantitative predictive risk data. characterization of the inherent acoustic noise of a dedicated nicu mri system jean tkach, phd, cincinnati children's hospital medical center, jean.tkach@cchmc.org; yu li, ron g. pratt, christopher villa, beth m. kline-fath, charles dumoulin purpose or case report: we have developed a small foot print 1.5 t mri scanner specifically for neonatal imaging that can be easily installed in a neonatal intensive care unit (nicu). the scanner has a maximum patient bore diameter of 21.8 cm (without rf coil), and roughly twice the gradient performance of the best conventional adult whole-body 1.5 t mr systems. it is known that sensory stimulation such as acoustic noise can elicit autonomic instability in both term and preterm neonates. the inherent noise properties of the nicu mri system were measured as part of the initial safety evaluation of the system and compared against that of a conventional 1.5 t mri system. to evaluate the inherent acoustic noise characteristics of the nicu mri scanner, sound pressure level (spl) measurements were performed on it and on a conventional adult sized whole body 1.5 t hdx ge mri system (ge healthcare, waukesha, wi). a brüel & kjaer model 2250 sound level meter (brüel & kjaer sound & vibration measurement a/s, denmark) was used to perform the spl measurements for 6 several different mr acquisitions (spin echo, gradient echo, fast rf spoiled gradient echo, fully balanced steady state free precession, gradient echo echo planar, and diffusion weighted) using acquisition parameters consistent with clinical protocols. the mr sequences, acquisition parameters, noise measurement equipment and methodology were identical for the two mr systems. the maximum spl in units of a weighted decibels (dba) was recorded for each of the mr acquisition/mr system combinations evaluated. results: the maximum spl values measured during each of the 6 mr acquisitions were lower for all sequences (average 11.33dba (range05-18dba)) for the nicu mri unit as compared to the conventional mri scanner ( table 1 ). the average measured maximum spl value, reported in dba, across all 6 acquisitions was 86.2±2.6 for the nicu scanner, and 97.5±2.9 for the conventional mri scanner. the highest spl values were measured for the diffusion-weighted sequence: 85 and 103dba, for the nicu and conventional mri scanner respectively. conclusions: because of the smaller dimensions of the gradient coils in the nicu mri system, acoustic noise is less than that of conventional mri scanners despite the superior gradient performance of the smaller coils. the lower inherent acoustic noise level of the nicu system provides improved safety for the neonate, and facilitates siting of the unit in the nicu. disclosure: dr. tkach has indicated that she will discuss or describe, in the educational content, a use of a medical device or pharmaceutical that is classified by the food and drug administration (fda) as investigational for intended use. paper #: pa-099 late neurologic events in extremely premature infants carlos guevara, md, radiology, duke university, cjg7@duke.edu; brett bartz, caroline l. hollingsworth, caroline w. carrico, michael c. cotten, charles m. maxfield purpose or case report: germinal matrix hemorrhage (gmh) is a major complication of prematurity. persistence of germinal matrix and immature neurovascular autonomic regulation in the premature neonate is thought to predispose to gmh. most gmh in premature population occurs during the first 4 days of life, and yet the persistence of the germinal matrix to 32 weeks gestation may allow for post-natal gmh outside of the immediate perinatal period. to our knowledge, this is the first systematic review of late gmh (after the first week of life) in a large population of extremely preterm neonates (less than 28 weeks of gestation). this irb approved retrospective review included patients weighing less than 750 g or born at less than 28 weeks of gestation from 2008 through 2010. the study population included 150 infants who had a head ultrasound (hus) within the first week of life and at least one follow hus after the first week of life. all hus were reviewed by three experienced pediatric radiologists for the presence and grade of ich or late developing hemorrhagelike lesions (hll). infants with and without hll were evaluated for several clinical variables, including neurodevelopmental outcomes (bayley scales). results: average gestational age of study population was 25.1 weeks. the incidence of gmh in the first week of life was 34% grade 1, 38.6% grade 2, 4.9% grade 3/ 4, and 2.2% posterior fossa. new echogenic foci (hll) at the caudothalamic groove were seen in 13.3% after the first week of life. 70% of these lesions were bilateral. a four-fold increase in incidence of hll was seen in infants <750 g compared to those> 750 g. higher grade hemorrhages were not seen in this patient population, although 6% of infants had late posterior fossa hemorrhages. the clinical course of infants with hll trended towards a higher incidence of stressors, but this was not statistically significant. the psychomotor development index scores were lower than those infants without hemorrhage. conclusions: small hll at the caudothalamic groove are common in extremely preterm infants after the first week of life. higher grade (2-4) hemorrhages were not seen. there were no cases of intraventricular extension and no direct complications. if isolated, this finding necessitates no follow-up imaging, but may be associated with poor neurodevelopmental outcome. disclosure: dr. guevara has indicated that he will discuss or describe, in the educational content, a use of a medical device or pharmaceutical that is classified by the food and drug administration (fda) as investigational for intended use. purpose or case report: tof/apv is a rare congenital heart lesion in which pulmonary arteries may become aneurysmally dilated and compress adjacent airways. pulmonary arterioplasty is often required to relieve tracheobronchial compression in addition to intracardiac repair. the purpose of this study was to review pre and postnatal imaging findings and their impact on patient management and clinical course. methods & materials: a retrospective database search identified 9 infants with tof/apv between 2005-2011 (4 fetal diagnosed cases and 5 diagnosed postnatally). for fdc, prenatal ultrasound (us) and fetal mri were correlated with postnatal ct for the size of the central pulmonary arteries, airway compression, and presence / distribution of air trapping/atelectasis. for all cases postnatal ct findings (between 3-9 days of age) were correlated with clinical management and outcome. results: prenatal diagnosis of tof/apv was suggested sonographically, based on dilated central pas, between 21-28 weeks gestational age (ga). fetal mri, performed between 32-37 weeks ga confirmed the diagnosis and aneurysmal central pas and demonstrated air trapping &/or atelectasis in 3/4 with normal appearing lungs in 1 fetus. size of the pas (4/4) and presence and distribution of lung abnormality (3/4) correlated closely between fetal mri and postnatal ct, although detailed visualization of the central airway/ vascular relationships were better defined on ct. fetal mri identified an unexpected diaphragmatic hernia (dh) not seen on us. for the pnd cases, ct showed aneurysmal pas and airway compression with air trapping &/or atelectasis in 4/5 infants. seven infants with airway obstruction on ct required pulmonary arterioplasty; 1 infant with no air trapping did not have arterioplasty. 7/8 operative patients survived, one with concomitant dh died at age 22 days due to hemorrhagic shock. one fdc was inoperable due to poor cardiac function and died at age 7 days. conclusions: prenatal mri correlates well with postnatal ct for assessing pulmonary artery size and location and severity of lung abnormality in patients with tof/apv, this allows for appropriate management planning and may negate the need for an immediate postnatal ct. ct accurately depicts the location and extent of airway compression and resultant air trapping or atelectasis, serving to guide the need for and extent of the arterioplasty procedure. paper #: pa-101 craniosynostosis syndromes: prenatal findings by us and mri eva rubio, md, cnmc, rubioeva@yahoo.com; anna blask, alexia egloff, dorothy bulas purpose or case report: craniosynostosis with associated malformations is a feature of several related syndromes resulting from a fgfr or twist genetic mutation. syndromes include apert, crouzon, pfeiffer, and carpenter syndromes. our purpose was to review imaging findings which aid in suggesting the diagnosis prenatally. we retrospectively reviewed prenatal us and mri findings in 6 cases with prenatal (5 with postnatal/molecular) diagnosis of a craniosynostosis syndrome: 3 cases of apert, 1 case of carpenter, and 2 cases of pfeiffer syndrome. results: 5/6 cases were correctly diagnosed prenatally. in the second trimester findings may be subtle, with mild calvarial changes; digit abnormalities, in particular, may elude the imager in unsuspected cases. although the diagnosis could be made with either modality, the full spectrum of abnormalities was best appreciated using a combined imaging approach of mri and us. by us many salient features were depicted: turribrachycephaly/trigonocephaly/cloverleaf (6/6); syndactyly (4/4); polydactyly (1/1). agenesis of the corpus callosum was identified by us in (2/2) cases. conversely, mri, performed in all cases, contributed additional observations not well seen by us: the fetal airway was well delineated in all cases (6/6); a low lying spinal cord was noted (1/1), midface hypoplasia (6/6) and migrational/sulcation abnormality (1/1). additional findings of absent ductus venosus with biliary atresia (1/1), abdominal wall defect (1/1) and renal anomalies (1/1) were seen with both modalities. reimaging in later pregnancy depicted important changes (2/2), including worsening hydrocephalus and resolution of suspected airway occlusion. conclusions: us and mri are complementary modalities in evaluating fetuses with craniosynostosis. airway patency, midface hypoplasia, spinal cord abnormalities and intracranial abnormalities are often better seen with mri. fetal activity, digits, bone detail, and cardiac anomalies are better appreciated by us. findings may be subtle in the second trimester. repeat imaging in later pregnancy may reveal specific information affecting delivery planning. paper #: pa-102 pcpra best paper 2011 hyperpolarized carbon-13 mrsi for pediatric disease john mackenzie, md, department of radiology and biomedical imaging, ucsf, john.mackenzie@ucsf.edu; yi-fen yen, linda nguyen, jeffrey gu, john kurhanewicz purpose or case report: to study the potential of carbon-13 mr spectroscopic imaging (13 c-mrsi)-a radiation free molecular imaging strategy-for the detection and treatment monitoring of pediatric disease. methods & materials: the potential of 13 c-mrsi to detect pediatric disease was tested in rodent models of pediatric arthritis. animals were induced with arthritis and subsequently given intravenous hyperpolarized 13 c-pyruvate, and imaged. the amount of 13 c-lactate produced from pyruvate in normal and arthritic joints was measured both at single points in time and dynamically at either 3 or 14 tesla. the 13 c-mrsi data were compared with clinical measures of arthritis, cell stimulation studies, and joint changes on conventional anatomic mri and histology. results: alterations in lactate production as measured by 13 c-mrsi appear to depict sites of arthritis and correlate with other more established but potentially less reliable or more invasive measures of disease status. imaging robust mouse models of pediatric disease may be feasible at 14 telsa. this method may also be translated from high-field to clinical equipment with reasonable hardware and software modifications that allow detection of hyperpolarized 13 c compounds. 13 c-mrsi depicts increased lactate production at specific regions of inflammation within arthritic joints and is confirmed by histological inspection and anatomic mri. on average, lactate production is increased by 60% in areas affected by inflammation. conclusions: the intravenous injection of hyperpolarized carbon-13 compounds and subsequent imaging with 13 c-mrsi provides a unique molecular imaging strategy to noninvasively monitor pediatric disease. this non-invasive imaging strategy may eventually provide clinical utility for several pediatric diseases involving inflammation, infection and tumor. disclosure: dr. mackenzie has indicated that he will discuss or describe, in the educational content, a use of a medical device or pharmaceutical that is classified by the food and drug administration (fda) as investigational for intended use. methods & materials: using the hemangioma-vascular malformation clinic registry at cincinnati children's hospital, we searched for patients diagnosed with khe whose evaluation included mri. twenty such patients were found, although three of the patients had no pre-therapy mris. the imaging studies were reviewed by the authors with assessment of the following characteristics: location, margin definition, soft tissue involvement, and pre and post contrast signal intensity. results: location: lesion location was as follows: trunk (9), extremity (3), extremity plus trunk (3), and head/neck (2). signal: all lesions were dark on t1 weighted sequences with diffuse enhancement after contrast administration. the majority of the lesions were bright on t2 weighted sequences, but there were 3 cases that had heterogenous to low t2 signal (with all involving the retroperitoneum). of the 17 cases, only one had both high arterial and venous flow by mri. margin definition: four of the lesions had well defined borders (greater than 50% well circumscribed) with minimal to no adjacent infiltration/edema. two of those four cases were exophytic masses. the remaining 13 cases were poorly defined lesions with adjacent infiltrative fluid signal intensity and enhancement. tissue/organ involvement: tissue/organ involvement was counted if abnormal fluid-signal intensity or enhancement was identified at that site. review of these cases showed fifteen patients with muscular involvement. dermal and subcutaneous involvement was observed in all but 4 cases, with the uninvolved lesions being isolated and deep. additional sites of suspected involvement included bone (3), pleura (1), penis (1), and pancreas (2). conclusions: khe is a rare neoplasm of infancy with a spectrum of features by mri. poorly defined lesions are much more frequent than well-circumscribed masses. however, pathologic correlation of such infiltrative margins is usually not available as treatments after biopsy are primarily medical rather than surgical. common additional mri features include predominant involvement of muscle, subcutaneous fat, and skin over viscera and bone with lesions generally showing increased t2 signal and enhancement. is dedicated chest ct needed in addition to pet ct for evaluation of pediatric oncology patients? ibrahim tuna, montefiore medical center, dristuna@yahoo. com; jeffrey levsky, jeremy rosenblum, rosanna ricafort, benjamin taragin purpose or case report: to evaluate the diagnostic accuracy of low dose ct performed during pet-ct as compared to dedicated chest ct in the assessment of pulmonary findings in children with malignancy. the institutional review board approved this hipaa compliant research. pediatric oncology patients, ages between 0-21, with known solid malignant tumors who were referred to pet-ct and standard chest ct within 30 days for staging or assessment of treatment response between 01-2008 and 01-2011 were eligible for this retrospective study. radiology reports were reviewed for potential discrepancies. two radiologists re-evaluated the standard chest ct and low dose chest ct portion of the pet ct of the discordant cases, while comparing with the most recent prior studies. studies were scored for pulmonary nodules, bony metastasis, adenopathy, and pleural effusions. true discrepancies were assessed by a panel of pediatric oncologists to judge whether the differences in reports might lead to a significant change in management. results: 120 (57 female, 63 male) patients were identified. 31 radiologic reports of 16 different patients (8 female, 8 male) had potential discrepancies based on review of the reports. the primary tumors were rhabdomyosarcoma (n0 6), hodgkin's lymphoma (n 03) and others (n 07). reevaluation of the original images showed true discrepancies in 3.3% (4/ total 120). in 2 studies, the discrepancy had no clinical significance. in 2 studies, a pulmonary nodule was identified on standard chest ct which was not described on the pet-ct. both of these patients had rhabdomyosarcoma. one of these patients had findings that pediatric oncologists considered significant enough to alter patient management. conclusions: we found a low false negative rate for clinically significant findings on the low dose portion of pet-ct as compared to standard chest ct. in the future, improvements in acquisition technique and post processing of the ct portion of the pet-ct may further improve its diagnostic utility, obviating the need for a routine separate diagnostic ct, thereby minimizing radiation exposure in these young patients. methods & materials: 98 low-dose cta examinations were performed in pediatric patients over a three year period to evaluate suspected vascular traumatic injury with some patients receiving scans of more than one area of the body. areas scanned in this include the head and/or neck (n054), chest (n017), abdomen and/or pelvis (n013), upper extremity (n08) and lower extremity (n017). in 80 of these patients, suspected vascular injury was due to a history of either blunt (n 041) or penetrating (n 039) trauma. 64 patients were referred directly from the emergency department, while 27 were inpatients and the remaining 7 were referred from an outpatient setting. patients (32 f:66 m) ranged in age from 0 to 23 years old (mean age 11). studies were performed on a 64-channel mdct scanner with 80 or 100 kv, 40 to 200mas, 1.0 to 1.5 mm section thickness, reconstructed with 50% overlap, and 0.8 to 1.5 pitch. contrast medium was power-injected using weight-based protocols to optimize iodine delivery. exams were interpreted on a workstation using advanced imaging techniques. patient radiation dose was calculated in all cases. clinical outcome was assessed through a 6 month follow-up when possible. results: all studies were technically adequate. 76.5% (n078) of studies revealed no vascular injury, while 23.5% (n023) revealed acute vascular pathology. vascular injuries included vascular occlusion (n012), vasospasm (n03), narrowing/dissection (n04), pseudoaneurysm (n02), and transection (n0 1). extravascular traumatic findings were demonstrated in 51.0% (n050), including fractures, lung injury, soft tissue hematomas, and a ruptured baker's cyst. of the patients with acute vascular findings, 43.4% (n010) underwent surgical management (including 6 for vascular injury), while 52.1% (n012) were managed conservatively. one patient with active extravasation was managed with angiographically-guided embolization. in no case was catheter angiography required to confirm cta findings. conclusions: low dose cta is a reliable means to screen pediatric patients emergently for acute vascular injury. vascular and non-vascular pathology can be diagnosed noninvasively for efficient patient management. paper #: pa-106 elasticity measurement by acoustic radiation force impulse (arfi) technique of normal liver, kidney and spleen in healthy children mi-jung lee, radiology, severance children's hospital, mjl1213@yumc.yonsei.ac.kr; myung-joon kim purpose or case report: there are many previous studies about using acoustic radiation foce impulse (arfi) value to measure the elasticity of tissue, mainly the liver in adult patients. however, there was limited study about arfi measurement in the children. the purpose of this study is to evaluate the arfi value in the normal liver, kidney and spleen in healthy children and to evaluate the effect of sex, age, and body mass index (bmi). the study prospectively enrolled healthy pediatric volunteers who are under 18 years old, and underwent abdominal ultrasonography and arfi between july 2011 and august 2011. arfi velocity measuring was performed by 4-9 mhz linear probe for children under 5 years old and 1-4 mhz convex probe for older children. arfi velocity was measured three times at each organ. however this measurement was stopped if the child cannot tolerate. results: two hundred two children (m:f092:110; mean age, 8±4.7 years) were enrolled. and arfi measurement was performed only two time for some organs in three children. the mean arfi value was 1.12±0.20 m/s in liver, 2.20±0.49 m/s in right kidney, 2.33±0.53 m/s in left kidney, and 2.25 ± 0.41 m/s in spleen. arfi velocity was not different between boys and girls. however, arfi velocity was different between right and left kidneys (p00.001). the arfi value of right kidney, left kidney and spleen was correlated with age, height, weight and bmi (p<0.001). however, the arfi value of liver was not correlated with these parameters. conclusions: arfi measurement is feasible in children with only three times acquisition for each abdominal organ. the mean arfi velocity was increased according to the age, height, weight and bmi in kidney and spleen, but it was constant in liver. disclosure: dr. lee has indicated that she will discuss or describe, in the educational content, a use of a medical device or pharmaceutical that is classified by the food and drug administration (fda) as investigational for intended use. purpose or case report: diagnostic image quality can be achieved over a wide range of radiation exposure in digital radiography. "exposure factor creep" or "dose creep'" in which technologists tend to increase dose to avoid the appearance of noise has been well described. using the alara principle, acceptable images can be achieved while minimizing dose. at our institution "dose creep" has been observed in bedside pediatric chest radiography. to address this we coupled a data mining tool with a continuous quality improvement (cqi) initiative which educates individual technologists on appropriate technique. methods & materials: radiation dose in digital radiography is estimated from an exposure index, a proprietary format that varies among manufacturers. our institution uses a fuji computed radiography system which calculates an s, or sensitivity value, that provides an approximation of the radiation dose to the imaging plate, using an inverse scale. overexposed bedside chest radiographs were defined by a s value less than 150. a data-mining program was developed to extract from the dicom header the s value and other relevant information, on a monthly basis. these data were used to provide training and feedback on a one-on-one-basis. results: with ad hoc feedback and group training initiatives prior to implementation of this new system, approximately 16.7% (344/2057) of bedside chest radiographs were overexposed over a four month period. after one-on-one intervention with the technologists, preliminary findings reveal a trend towards fewer overexposed radiographs with approximately 9.2% (40/435) with s<150. conclusions: our tool provides a simple method for systematically identifying overexposed radiographs and the corresponding responsible technologists. we anticipate that this personalized educational program will continue to reduce the proportion of overexposed radiographs and thus the radiation dose to our pediatric patients. purpose or case report: ensuring radiation protection for children undergoing ct scans is challenging due to rapidly changing technology, differences in ct equipment and potential lack of understanding of unique aspects of scanning children. the joint commission has named technologists' training as an "action" item. we developed 8 online training modules to fill potential gaps in ct technologists' education. methods & materials: four modules were created by pediatric radiologists, radiologic technologists and medical physicists; 4 were developed by education/training experts from major ct vendors (ge, philips, toshiba, siemens) through the medical imaging technology alliance. 4 modules were created as microsoft word documents containing de-identified images and edited by education specialists at the american society of radiologic technologists and the alliance for radiation safety in pediatric imaging. they were converted to audio/video format using question/answer narration.4 vendor modules were created in microsoft powerpoint format and edited. all 8 modules were converted into adobe captivate learning program to achieve uniformity of appearance. modules are hosted on the asrt server and linked to the image gently website. a certificate may be printed as documentation of completion. results: all 8 modules are available at www.imagegently.org. two introductory modules discuss basics of ct equipment and medical physics related to radiation dose in children. the third and fourth modules discuss dose-saving strategies for neu-roct and body ct. four vendor-produced modules address unique aspects of equipment design such as automatic exposure control and dose saving strategies for children. conclusions: through collaborative efforts with medical imaging professionals and vendors, we have developed 8 free online modules addressing radiation protection for children. ct technologist training in specific dose saving strategies for children is variable and limited. these modules have the potential to improve ct technologists' understanding of equipment. end confusion which focused attention on improving communication with patients and families. there is little research regarding health literacy (hl) in radiology. the purpose of our study was to determine if an educational intervention (brochure) improves hl for parents whose child will undergo a fluoroscopic study. methods & materials: an education exemption was obtained from the irb. a multidisciplinary team developed brochures for 5 fluoroscopic procedures. participants were randomly selected and asked to complete a survey to assess their knowledge of the procedure and use of radiation both before and after reading a brochure. a final survey to rate and gain feedback about the brochure was completed. results: median age of children whose parents participated (n0120) was 4 years. vcug was most commonly performed (46%). prior to the brochure, 92% of participants knew the name of the test their child was having. after the brochure, 99% knew the name (p < .0001). prior to the brochure, 81% felt informed about the test, whereas 99% felt informed after (p<.0001). test scores showed an improvement in parent knowledge about the procedure with a median increase of 20 points after the brochure (scale of 1-70; p<.0001). even after reading the brochure, 23% of parents wanted more information. prior to the brochure, 68% of parents knew the test involved radiation compared to 100% afterwards (p<.0001). parents improved their understanding of the relative amount of radiation compared to background from 25% before to 79% after the brochure (p<.0001). overall, 99% rated the brochure >2 on a 3-point scale with 92% rating the brochure 3 (p<.0001). written feedback was uniformly excellent. conclusions: improving hl for parents is part of the mission of radiology medical professionals. our study demonstrates that there is room for improvement in communicating with parents about fluoroscopy. straightforward information for parents provided as a brochure improves their understanding of radiologic fluoroscopic procedures. paper #: pa-110 compendium of resources for radiation safety in medical imaging anum minhas, duke university, anum.minhas@duke.edu; donald frush purpose or case report: diagnostic imaging, including ionizing radiation modalities, maintains a foremost role in evaluation of medical disorders. there is increasing awareness and need for information across varied sectors about low level radiation and potential risks. many medical/scientific organizations have resources discussing radiation risk and management. however, there is no one resource compiling the same available information. methods & materials: websites, including those of national and international medical organizations (e.g., acr, "image gently" alliance, iaea) were reviewed for information on radiation dose, risk, justification, optimization, guidelines (which included general information about improvement in quality and dose reduction without specific mention of optimization techniques), appropriateness criteria, and general principles of radiation safety for radiography, fluoroscopy/angiography, and ct. this information was divided by modalities and separated into adult and pediatric populations. information from organizations that were not arbitrarily considered to be national (e.g., subspecialty society, regional organization, individual institution/practice) was not reviewed. the resources were then organized into 8 tables, organized by modality. websites with training modules were noted as well. results: 29 websites were explored. overall, less information is available about medical radiation safety in children compared to adults. across both, most information is available on ct, then fluoroscopy, and finally radiography. across all groups and modalities, there is no information available for patients/parents on optimization, appropriateness, or guidelines, with the exception of adult radiography where there were some guidelines. conclusions: this compendium on medical imaging radiation serves as a collective resource for communities including the public and regulatory organizations. additionally, the compendium can be used to determine redundant or deficient areas, providing opportunities for more comprehensive and efficient efforts in medical radiation protection for patients. inappropriate and cloned histories in children: how big a problem is it? leann linam, md, radiology, uams/ach, llinam@uams. edu; chetan c. shah, s bruce greenberg purpose or case report: acr standards require appropriate clinical history for obtaining imaging examinations. cloning clinical histories is a federal violation. our purpose is to determine the frequency of inappropriate histories (ih) and/or cloning histories (ch) at a tertiary children's hospital. methods & materials: three pediatric moc radiologists reviewed clinical histories for radiographs obtained at a tertiary children's hospital on 3 randomly selected dates (2 weekdays and 1weekend day) for appropriateness and cloning. appropriate histories have associated icd-9 codes. cloning is defined by identical clinical histories occurring on 3 consecutive days and could be clinically appropriate or inappropriate. only the first patient radiograph on a day was included. χ2 testing was performed to determine significant differences. results: 14% (54/388) of exams had ih. ih were significantly more common in inpatients than outpatients (p< 0.0001). nicu examinations accounted for 52% of all ih and were significantly more frequent than other inpatient locations (p0.006). the cvicu examinations accounted for 11% of all ih and was the second most common patient location for ih, but not significantly different from other inpatient locations (p00.09). the increased frequency in ih on the weekend reflects a change in patient mix with fewer outpatient examinations performed than on weekdays and was not significant (p00.07). the most common ih included: evaluate ett or evaluate lungs (15 each). cloning only occurs in inpatients and was combined with ih in 48% of patients with ch. the nicu accounted 63% of ch which was significantly greater than other inpatient locations (p00.026). conclusions: 1 in 7 radiographs had ih which can lead to misdiagnoses or nonpayment by insurance companies. inpatients, especially the nicu were the most common patient locations. cloning was also a common problem and was frequently combined with ih. identifying the extent of ih allows for corrective educational measures to be instituted which should improve compliance with existing medical and legal standards for ordering radiographs. paper #: in vivo validation of size-specific dose estimates (ssde) through breast entrance skin dosimetry (esd) during pediatric chest ct angiography sjirk westra, md, radiology, massachusetts general hospital, swestra@partners.org; xinhua li, mannudeep kalra, bob liu, suhny abbara purpose or case report: ssde is a new ct dose measure that corrects scanner console ct dose index (ctdi) for cross-sectional body diameter, being a better estimate of absorbed dose in individual patients of varying body size. ssde has been developed through phantom studies and computer simulations of ct dose, but has not yet been validated in vivo. the purpose of our study was to determine correlation between ssde and measured breast entrance skin dose (esd) for pediatric chest cta across a variety of scanning techniques, scanner models and patient sizes. methods & materials: our study was irb-approved, with waiver of written informed consent. during 42 consecutive chest cta exams done on 4 different scanners over a period of 7 years, we measured mid-sternal esd as an approximation of breast dose with skin dosimeters, which was also expressed as mammogram equivalents. for each scan, we recorded patient age, weight, effective ma, kvp, console ctdivol-32 cm and dlp-32 cm (from which we calculated age-adjusted effective dose (ed)). we measured effective chest diameter ø to convert ctdi to ssde, and we correlated ssde with measured breast esd, using linear regression. we evaluated image quality with regard to answering the clinical question. (table) , due to systematic introduction of automatic exposure control, low kv and high pitch scanning techniques. all studies were of diagnostic image quality to address the clinical question. conclusions: ssde is a valid measure of ct dose in pediatric patients undergoing chest cta over a wide range of scanner platforms, techniques, and patient sizes, and may be used to model breast and other organ dose, and to document results of dose reduction strategies over time. purpose or case report: the purpose of this project was to create an automated system capable of quantifying slice-byslice ct image quality and radiation dose data based on patient size. the information generated from this system should enable size-specific optimization of ct scan parameters in order to obtain images of diagnostic quality at the lowest possible radiation doses. methods & materials: a mathematical model was developed to predict ct image noise based on kvp, effective mas, and water-equivalent diameter of the patient. a conical water phantom was used to calibrate the model on multiple scanners and accounting for different operational modes and scan parameters, including tube voltage (kvp), tube current (effective mas), bowtie filter, and focal spot size. a software application was created to process image data from the scout topogram and incorporate dicom metadata from the axial images. a database and data viewing application were developed to display individual and aggregate study data. all of these systems were integrated and automated to enable real-time monitoring of image quality and radiation dose as a function of patient size. results: since the completion of the automated system, 565 ct exams have been processed. a search application allows the user to find an individual study or a collection of studies based on parameters such as body part imaged or study protocol. the viewing application displays slice-by-slice patient diameter, radiation dose, and image quality for each study. radiation dose estimates are adjusted for patient size, yielding size-specific dose estimates. the application also graphs individual study data compared to those of comparative studies that are included in the search. conclusions: we have successfully developed an automated system that monitors ct image quality and radiation dose data based on patient size. the system enables simultaneous real-time monitoring of all studies performed on all ct scanners at our institution. specifically, the system enables size-specific radiation dose estimates at every scan level. this system will be used to guide protocol adjustments in order to optimize ct image quality and thus optimize radiation dose. disclosure: dr. larson has disclosed that he has a patent application in process through cchmc for ct radiation dose reduction. purpose or case report: at many institutions, ct scan parameters for children are determined by patient age or weight. aapm task group 204 recommends cross sectional body dimension, such as patient width to determine size specific dose estimates. the purpose of our study was to develop prediction models of body width based on patient age and weight and compare these models with actual measured body widths for children undergoing body ct. methods & materials: 6 children's hospitals participated in a 3-month retrospective review of abdominal ct scans on patients <18 years of age after local irb approval. recorded values included patient width(cm) from an axial image at the level of the splenic vein, patient age (yrs) and patient weight (lbs). a regression model for predicting patient width as a function of age and weight was determined. results: 939 exams, 472 had all 3 measurements. both age and weight were significant predictors of patient width (p<.0001). there was also a significant interaction between weight and age (p<.0001), indicating that the relationship between patient width and weight depended on the age of the patient. the r2 for the regression model for predicting patient width from age and weight individually were 0.65 and 0.83 respectively. the r2 for the model including both age and weight and their interaction was 0.86 leaving 14% of the variation unexplained. the regression equation for this model is: patient width 014.1 + 0.34 x age(yrs)+ 0.12 x weight(lbs)-0.003 x age x weight. despite the r2 of 0.86 for the model using both age and weight, the average error (rmse) for predicting patient width compared to a direct measurement of width was 1.9 cm. the plot of observed minus predicted values (residuals) versus predicted values indicates that the best model (combination of weight and age) results in measurable errors of predicted patient width relative to direct measurement. conclusions: a combination of both patient age and weight results in a more accurate patient width prediction than using age or weight alone. while age and weight can be used to predict body width, this is not sufficiently accurate for generating ct protocols. therefore, direct measurement of body width form either physical measurement on the patient or from the scout view or an axial image is preferred to select appropriate scan parameters for pediatric abdominal ct. paper #: pa-115 automated size-adjusted dose monitoring for pediatric ct dosimetry olav christianson, clinical imaging physics group, olav. christianson@duke.edu; ehsan samei, donald frush purpose or case report: the potential health risks associated with low levels of ionizing radiation have created a movement in the radiology community to minimize radiation dose during ct imaging; this is especially important for pediatric patients due to their increased sensitivity to radiation. it is thus essential to accurately assess the risks to pediatric patients undergoing ct imaging. current efforts to monitor radiation dose, however, are limited because they do not account for differences in risk from ionizing radiation due to variability in patient size, age, and gender. in this context, we developed an automated size-adjusted dose monitoring program capable of performing patient-specific risk estimation to facilitate protocol optimization. methods & materials: dicom routing software was used to send dose reports and scout images to an image repository on a dosimetry server. optical character recognition was used to extract dose-relevant data from dose reports; patient size was determined from corresponding scout images. based on anatomical location, risk estimation conversion coefficients (qfactors) were determined for each series in the dose reports. the q-factors were adjusted according to patient size, age, and gender and then multiplied by the dlp to estimate the risk to each patient. this process was applied to the cohort of pediatric patients undergoing ct examination at our institution. to evaluate the impact of including patient size, age, and gender, risk estimates were obtained excluding and including the dependencies on size, age, and gender. the results were computed in units of cancer incidence per 1000 cases exposed (cpt). results: the average patient-generic risk estimate for a pilot group of patients undergoing body ct was 0.15±0.14 cpt. by including patient size, the risk estimate was increased to 0.26 cpt±0.27 cpt. by including patient age and gender, the average risk estimate was further increased to 1.0 cpt±0.72 cpt. conclusions: we developed a new size-adjusted dose monitoring program for pediatric ct dosimetry. comparisons between patient-generic and our new patient-specific risk estimates show that failure to consider patient size, age, and gender resulted in risk estimates that were too low by a factor of seven. additionally, the increase in standard deviation we observed demonstrates that our method of including patient size, age, and gender is sensitive to the inherent variability in the patient population. disclosure: dr. christianson has indicated that he will discuss or describe, in the educational content, a use of a medical device or pharmaceutical that is classified by the food and drug administration (fda) as investigational for intended use. purpose or case report: treatment of prenatally diagnosed lung masses is controversial, with many specialists recommending elective surgical removal in the first year of life because of a reported or perceived increased risk of infection and malignancy, while other centers recommend a conservative approach to management. the natural history of unresected lung masses is not clear. in our center, our standard recommendation is prophylactic resection of asymptomatic lesions, although not all families choose this option. we asked whether respiratory morbidity increased during the time prior to elective resection of prenatally diagnosed lung masses. methods & materials: ninety-eight pregnant women carrying fetuses with chest masses were imaged by ultrasound (us) and magnetic resonance imaging (mri). medical records of the liveborn infants were retrospectively reviewed. results: fetal diagnosis of a lung mass was made at a mean of 27 weeks gestation (range 17-32 wks). intrauterine fetal demise was documented in 4 pregnancies. there was one elective termination of pregnancy. three infants were lost to follow up. thus, outcomes were available for 90 children (59% m, 41% f) with prenatally diagnosed lung masses. significant respiratory morbidity (rm) was defined as the occurrence of pneumonia, asthma, chronic coughing or wheezing, or respiratory symptoms severe enough to require an emergency room visit or hospitalization. of the 76 children who had surgical removal of their lung mass, 34 (45%) had rm prior to surgery. fifteen out of 90 children did not have surgery but have been followed expectantly, and 3 of 14 (21%) developed some form of rm. fifteen of 76 (20%) infants had immediate and significant rm (tachypnea, grunting, increased work of breathing, increased oxygen requirements or need for intubation) in the newborn period leading to urgent surgery (range of age at surgery: 1-10 d; mean 2.5 d). of the 61 initially asymptomatic infants, 17 (28%) developed rm prior to elective removal of the mass (range 6-96 weeks, mean 17 weeks). of the lesions removed, histology revealed: cystic adenomatoid malformation (ccam) 59%, ccam + sequestration 21%, sequestration 8%, congenital lobar emphysema (cle) 7%, ccam+cle 1%, other 3%. conclusions: the risk of respiratory morbidity appears to be increased during the time prior to elective resection of prenatally diagnosed lung masses, which may be important for parents and pediatric specialists to consider when deciding whether to remove an initially asymptomatic lung mass. purpose or case report: it is now accepted that fetal mri with its superior tissue resolution can be very helpful in clarifying anomalies detected during obstetrical ultrasound. this is particularly the case with intracranial abnormalities, although indications are expanding. the current english medical literature, though, appears to be focused on evolving mri techniques and how mri compares to ultrasound with regards to image quality and detection of additional findings which may alter the diagnosis. however, we found no study specifically evaluating the clinical relevance and impact of the information obtained by fetal mri to the specialists who counsel and treat these patients. a "satisfaction and clinical impact" survey was created and sent to all the members of our fetal diagnosis and treatment group, asking specifically how the clinicians rated their satisfaction with this type of imaging, its influence on their counseling and on various clinical decisions, both prenatal and postnatal. results: we received responses from 37 specialists in 10 different clinical disciplines. the greatest number of respondents came from our obstetricians (28%), many of whom perform their own ultrasounds, and from members of our medical geneticists/genetic counselors (27%), although 46% of respondents were from various other clinical disciplines, both medical and surgical. there was a surprisingly high degree of satisfaction overall with the quality of the images and with the type and amount of information provided. most respondents indicated they felt fetal mri was "moderately" or "extremely" useful for their particular clinical decisions, and most respondents agreed that fetal mri impacted "moderately" or "significantly" on counseling and management of these pregnancies. impact appeared greatest on the counseling of the parents and their decision to terminate/pursue the pregnancy, and the least impact was on issues around delivery. conclusions: fetal mri, in addition to providing images of better quality, particularly in certain conditions, has clinical value in that it directly impacts on the counseling of parents and on clinical decisions. 2006-2011. ultrasound reports were reviewed to determine sonographic diagnoses. selected patients from this cohort underwent mri using ge 1.5 tesla magnet without contrast (sequences included ssfse, fiesta, fgre or dual echo in 3 planes). the images were reviewed and multiple characteristics were assessed for specifiying the area of obstruction. the features included: presence of normal fluid-filled bowel, small rectum for gestational age, signal of meconium in the rectum, and meconium filled dilated bowel. results: 46 cases of sonographically suspected bowel obstruction were identified during the study period; 27 of these underwent fetal mri. of these 27 cases, 4 had normal mri and postnatal outcomes, 2 cases did not have postnatal findings available, and 2 had postnatal meconium peritonitis but no obstruction. one case of congenital chloride diarrhea was diagnosed by fetal mri. a variety of bowel abnormalities were observed amongst the remaining 18 cases. proximal obstruction was diagnosed in 8 cases: jejunal atresia (n07) and multiple atresia (n01). distal obstruction was diagnosed in 10 cases: ileal atresia (n03), meconium plugging (n04), closed gastroschisis (n01), enteral duplication cyst (n01), and imperforate anus (n01). characteristic patterns of features were identified amongst these 18 cases that specified the location of obstruction. these patterns of findings allowed accurate localization of the level of obstruction in all cases when compared to postnatal findings. distal obstruction was characterized by normal fluid-filled small bowel and high t1 signal in distended loops. jejunal atresia was characterized by multiple loops of dilated bowel with high t2 signal primarily in the left upper quadrant. small rectum for gestational age was not consistently associated with proximal or distal atresia. conclusions: evaluation of fetal mri with attention to specific features allows localization of bowel obstruction. this may aid in counseling and postnatal management, including the need and type of postnatal imaging study. early diagnosis and treatment of ph may prevent clinical deterioration. pvt may produce a spectrum of imaging appearances, which has not been fully recorded in the literature. the goal of this paper is to review the spectrum of imaging appearances of neonates and survivors of neonatal pvt with special emphasis on the role of us and to correlate these findings with the clinical findings including outcome. methods & materials: a retrospective review of 133 consecutive neonates admitted between 1999-2003 and diagnosed with pvt was conducted. diagnosis was established by us at a mean age of 9 days (range: 1-40). health records, initial and follow-up (f/u) imaging were reviewed. findings were classified as non occlusive, single branch, pvt (grade 1); occlusive pvt (grade 2) and pvt with extensive parenchymal ischemia (grade 3). results: pvt was diagnosed in 133 patients, 70 of whom were followed up to for 2 years or longer. twelve patients were excluded due to liver disease, 22 expired and 29 were lost to f/u. of the 70 in whom f/u was available, at the time of initial diagnosis, grade 1 pvt was present in 27, all were on the left. grade 2 pvt was diagnosed in 28 and grade 3 pvt in 15. on f/u physical exam, findings were unremarkable in 68/70 patients. liver function tests (lft) and thrombophilia assessment were available in 25 children, mild lft abnormalities were noted in 9 and 6 children had evidence of thrombophilia. us exams were available in 37/70 children. among the 37 survivors of neonatal pvt, us was regarded as normal in only 14 children; 16 showed left lobar atrophy (lla), 5 had slowly progressive splenomegaly without other signs of ph, and 2 developed clinically significant ph requiring shunting. conclusions: pvt has a wide spectrum of imaging appearances, it is possibly underdiagnosed and clinically unsuspected. varying degrees of lla are likely a sequela of clinically silent left pvt. us is a sensitive method for the detection of disease and assessment of progression. paper #: pa-120 fetal mri in arthrogryposis hedieh eslamy, md, radiology, lucile packard children's hospital, hkeslamy@gmail.com; erika rubesova, louanne hudgins, britton rink, richard a. barth purpose or case report: to present the fetal mri findings in fetuses with a prenatal diagnosis of arthrogryposis and correlate with postnatal outcome or autopsy results. arthrogryposis refers to contractures involving more than one joint which often represent deformational changes secondary to decreased or absent fetal movement. prognosis varies widely dependent on diagnosis, ranging from isolated contractures in amyoplasia to lethality in some cases. we hypothesized that fetal mri may demonstrate central nervous system (cns) pathology and muscle abnormalities which are important for predicting postnatal outcome. methods & materials: we identified 6 fetuses with a diagnosis of arthrogryposis between january 2010 and october 2011. all had fetal mri which was performed on a ge 1.5 tesla magnet, with ssfse, fiesta and fgre sequences in 3 planes. the fetal mri's were evaluated for cns and muscle abnormalities. the extremities were evaluated for: muscle mass, increase in subcutaneous fat (indicative of muscle atrophy), and extremity joint positioning. these findings were subsequently correlated with the clinical exam of the neonates, pathology in the abortus and karyotype when available. results: results of fetal us, amniocentesis, fetal mri and post-natal or post-termination outcomes will be summarized. five fetuses had ≥2 limb joint contractures. a sixth case had neck hyperextension and lateral flexion associated with akinesia and hydrops. on mri, no structural brain or spine abnormalities were identified. the abnormalities detected in the extremities were: severe decrease in muscle mass associated with increased subcutaneous fat (3 cases); normal muscle mass (2 cases); moderate decreased muscle mass associated with increased subcutaneous fat (1 case). in the 3 cases that delivered, the diagnoses were amyoplasia (2) and distal arthrogryposis (1). in a fourth case that underwent elective termination, autopsy was consistent with amyoplasia. two cases are pending delivery. conclusions: while fetal mri can be useful to rule out cns anomalies, it may also provide important information on decreased muscle mass as an important prognostic sign in a fetus with arthrogryposis. in our series, severely decreased muscle mass was predictive of amyoplasia, and joint contractures limited to hands and feet with preserved proximal muscle mass was predictive of distal arthrogryposis. both diagnoses are associated with relatively good prognosis and usually normal intelligence. purpose or case report: the purpose of this study is to assess the effects of iterative reconstruction technique (irt) on image quality metrics measured in child-sized anthropomorphic phantoms as kvp is changed. methods & materials: ct scans were performed on anthropomorphic phantoms with sizes of 1, 5 & 10 years (atom phantoms, cirs, norfolk virginia) using low dose pediatric chest protocols (1.6, 3 & 6 msv) to determine baseline noise and dose levels. subsequently three voltage levels (120, 100 & 80 kvp) were used while adjusting mas to maintain baseline ctdivol and without mas adjustment which allowed varied ctdivol. images were reconstructed using 100% filtered back projection (fbp) and blends fbp: ir (80:20, 60:40, & 40:60) . parameters including ctdivol, dose length product, scan length, kvp, and mas, were recorded for each scan. image noise, contrast:noise (cnr), and signal:noise (snr) data were recorded from rois in phantoms and dilute iodine contrast filled syringes (5, 3, 1.5%). results: as kv is lowered from 120 to 80, image noise is doubled if mas is not increased to maintain ctdivol, and cnr is increased but snr is decreased due to the increased image noise. as kvp is lowered from 120 to 80, image noise is increased nominally (8-21%) if mas is increased to maintain ctdivol; therefore the increase in cnr and decrease in snr is negligible. ctdivol is reduced >300% in all phantom scans as kv is reduced from 120 to 80. irt reduces image noise by up to 36% [range 10-41%] in all phantom sizes and in clinical images. as ctdivol is maintained in patient scans, image noise, cnr, and snr are reduced in patients (p<0.05), resulting in improved image quality. conclusions: when lowering kvp, compensation with increases in mas is necessary to maintain ctdivol. however, lower target ctdivol can be achieved when adding irt as image noise can be decreased. for these phantoms, cnr and snr improved using all [selected] levels of ir, even when kv was reduced, resulting in lower ctdivol in phantoms. at all kvp settings when irt is applied, image noise is reduced, resulting in improved cnr and snr for all phantoms. disclosure: dr. bardo has indicated she is in the speaker's bureau and receives an honorarium from koninklijke philips. paper #: pa-122 adaptive iterative dose reduction in evaluation of the pediatric abdomen with ultra-helical 320-channel mdct jeffrey hellinger, md, stony brook university, jeffrey. hellinger@yahoo.com; bernice hoppel, richard mather, monica epelman purpose or case report: radiation reduction is paramount for pediatric patients. ultra-helical 320-channel mdct allows for rapid acquisitions at low dose. we evaluated the ability of a new adaptive iterative dose reduction algorithm (aidr) to reduce noise in low-dose ultra-helical pediatric abdominal ct scans. aidr is an iterative algorithm that adaptively reduces noise in the raw and image domains while preserving image structure. the raw data from 14 consecutive low-dose pediatric abdomen exams was gathered. a dose simulation tool which adds noise to raw projection data was employed to simulate tube current at 1/4 of baseline ma. data were reconstructed with both standard filtered back projection and with aidr. regions of interest were drawn in the liver and lumbar musculature to determine the signalto-noise (snr), contrast-to-noise (cnr) and overall diagnostic quality of each data set. statistical significance was determined using a student's t-test. subjective image quality was evaluated by two reader blind review using a five point scale (50excellent, 10unacceptable). results: the snr and cnr were significantly lower for the 75% dose reduction datasets compared to the original filtered back projection reconstructions (snr: 3.59 vs 2.20, p<0.001; cnr: 1.24 vs 0.75, p00.01). when aidr was applied to the 75% dose reduction data, the snr and cnr improved to be superior to the native case (snr: 3.59 vs 5.48, p<0.001; cnr: 1.24 vs 1.95, p00.02). the average image quality score for the low dose datasets with aidr was 4.2 compared to 3.4 with standard filtered back projection at the baseline ma conclusions: aidr significantly improves the image quality of pediatric abdominal ct images. with a simulated 75% reduction in dose, aidr produces images with significantly greater snr and cnr. the subjective image quality scores for aidr showed dramatic improvement over standard filtered back projection. aidr processing algorithms with ultra-helical 320 mdct will allow 75% reduction in radiation exposure while achieving the same diagnostic quality as compared to routine pediatric abdomen mdct radiation protocols with filtered back projection processing algorithms. purpose or case report: to explore incorporating asir into pediatric head ct protocols, to reduce patient radiation dose while maintaining image quality. methods & materials: an alderson rando head phantom was estimated to approximate the size of a 7-year-old child's head, and was scanned at decreasing 10% ma intervals (100 to 50%, 150 to 75 ma) relative to this institution's age-based head ct protocols. each of these studies was then was reconstructed at 10% asir intervals (0% to 100%), and a 100 mm2 roi was obtained in a consistent location behind the frontal bone to estimate noise (sd). using this phantom data, our ventriculoperitoneal (vp) shunt follow-up ct protocol was modified, and patients were scanned at 20% asir with approximately 20% ma reductions relative to our normal age-based mas. these asir studies were then anonymously compared to older non-asir head ct studies from the same patients (with identical kvp/slice thickness) by two blinded attending pediatric neuroradiologists. all studies were evaluated subjectively for diagnostic utility (1-4), sharpness (1-5), noise (1-4), and artifacts (1-4). 50-100 mm2 rois were drawn in consistent locations to estimate noise in air, bone, csf, and white matter (wm). results: the phantom study suggested similar same noise levels at 100% ma/0% asir (3.9) and 80% ma/20% asir (3.7). 12 patients (average09, range01 to 17 years) were then scanned at approximately 20% ma reductions, with an average of 349 days (range027 to 871 days) between the asir study and prior non-asir study. the average ctdivol and dlp values of the 20% asir studies were 22.4 mgy and 338.4 mgy-cm, and for the non-asir studies were 28.8 mgy and 444.5 mgy-cm, representing statistically significant decreases in the ctdivol (22.1%, p00.00007) and dlp (23.9%, p00.0005) values. there were no significant differences between the asir studies and non-asir studies in respect to diagnostic acceptability (p00.33), sharpness (p0 0.45), or noise (p00.84). there was a non-significant trend that the asir studies had a lower artifact score (1.8 vs 2.1, p0 0.06). there was good to perfect (kappa00.5 to 1.0) agreement. the asir studies had statistically significant decreased csf noise (3.0 vs 4.4, p00.0000008), but no noise differences were seen in air (p00.46), bone (p00.26), or wm (p00.22). conclusions: our findings suggest that asir can provide dose reductions in pediatric head ct without affecting image quality. purpose or case report: to validate the t2 map as a noninvasive quantitative biomarker of fatty infiltration of muscles and to determine whether the t2 map can differentiate between boys with dmd and healthy boys. methods & materials: two groups of boys with similar ages (range 5-15 years) were evaluated: 42 boys with dmd (mean age 10.4 years) and 29 healthy boys (mean age 11.7 years). mr images were performed at 3 t. fatty infiltration of the pelvic and thigh muscles on t1-weighted images (wi) was graded from 0 to 4. on t2 maps with and without fat suppression, the muscle with the greatest fatty infiltration on t1-wi was selected, and a region of interest was placed to obtain t2 values. t2 values from t2 maps with fat suppression were subtracted from values of t2 maps without fat suppression and designated as the "t2 fat value." t2 fat values were obtained from the same muscles in all boys. comparison was made between the t2 fat values of the two groups. the upper reference limit of the reference interval (ri) of t2 fat values was obtained from the control group to establish the normal range and applied to both groups to determine the accuracy of the t2 map. results: the gluteus maximus muscle had the greatest fatty infiltration on t1-wi. median t2 fat value was 73.0 msec for dmd (95% ri 193.8, range 29.2-175.6) and 7.5 msec for the control group (95% ri 19.2, range 1.4-21.6). when applied to the two groups, the upper reference limit of the ri for control patients yielded 100% sensitivity, 93% specificity, 95% positive predictive value, and 100% negative predictive value. conclusions: utilization of t2 maps for the quantitative measurement of fatty infiltration of muscles can clearly differentiate between dmd and normal control boys with a high degree of accuracy and precision. this advanced noninvasive technique may potentially replace invasive muscle biopsies currently used for diagnosis. purpose or case report: prior work has shown that the gluteus maximus muscle has the greatest t2 relaxation time on mr imaging using t2 mapping in boys with duchenne muscular dystrophy (dmd). however, an increased t2 value on t2 relaxation time mapping may reflect both fatty infiltration and inflammation of the muscle. fatty infiltration characteristically follows inflammation in this disease process. therefore, the purpose of this study was to determine the contribution of each component (fat and inflammation) within gluteus maximus muscles and to correlate each component to clinical assessments. methods & materials: forty-six boys with dmd (ages: 5-15 years) were recruited. mr imaging of the pelvis using t2 maps with and without fat suppression were performed. the t2 map "fat values" (t2 value calculated from the t2 map without fat suppression [fs] minus t2 map with fs) and the t2 map "inflammation value" (t2 value from the t2 map with fs) were obtained. clinical assessments typically used to evaluate dmd patients (including clinical functional score, 30 ft run, gower score, and 4 step-up time) were also performed. spearman correlation coefficients between fat and inflammation values and the clinical assessments were calculated. results: there was a statistically significant correlation between the fat value of the gluteus maximus muscle and each clinical assessment test (p<0.05). however, the inflammation value of the gluteus maximus muscle did not correlate with any clinical assessment. conclusions: in dmd, the amount of fatty infiltration of the gluteus maximus muscle has excellent correlation with clinical assessment. the amount of inflammation of the gluteus maximus muscle, however, does not correlate with clinical function. therefore, further study is needed to determine whether components (fatty infiltration or muscle inflammation) of the single most involved muscle reflect the components of all the muscles of the pelvis and thighs and whether the cumulative muscle involvement of each component represents clinical disease severity. utility of contrast-enhanced mr imaging in children with osteonecrosis: does gadolinium help? lamya atweh, md, radiology, texas children's hospital, laatweh@texaschildrens.org; robert c. orth, wei zhang, r. paul guillerman, herman kan purpose or case report: at our institution, gadolinium contrast-enhanced mr sequences are often obtained to assess epiphyseal and non-epiphyseal osteonecrosis in children. several studies have shown that dynamic contrast-enhanced sequences may provide prognostic information about long-term complications and healing of osteonecrosis. to our knowledge, no studies have determined the added value of routine post-contrast mr imaging in assessing acute complications related to chronic osteonecrosis. the purpose of this study was to evaluate the utility of intravenous gadolinium contrast in the mri identification of complications in children with an established diagnosis of osteonecrosis. methods & materials: 64 patients were restrospectively identified (age range: 1.75 years to 25.75 year; m:f 0 59:80) with an imaging diagnosis of chronic osteonecrosis who underwent 139 contrast-enhanced mr studies between 1/2000 and 9/2011. the pre-and post-contrast mr images were consensus reviewed by two caq pediatric radiologists. pre-and post-contrast images were reviewed at separate times. the pre-contrast images were available during the review of post contrast images. studies were assessed for: osteonecrosis location (epiphyseal, non-epiphyseal osteonecrosis, or both), joint effusion, marrow edema, and epiphyseal collapse. 95% confidence interval (ci) and cohen's kappa coefficient(κ) was calculated to assess observed agreement. results: the diagnosis of osteonecrosis without complicating features was made in 49.6% (ci: 41.3-58.0%) (69/139) of pre-contrast studies and 53.2% (ci: 45.0%-61.5%) (74/ 139) of post-contrast studies. when chronic osteonecrosis with complicating features was identified,pre-and postcontrast images idenfied joint effusion in 44.9% (57/127) and 51.2% (65/127) (κ00.686, p<0.001); marrow edema in 50.4% (70/139) and 46.8% (65/139) (κ00.727, p<0.001); and epiphyseal collapse in 51.2% (65/127) and 42.5% (54/ 127) (κ00.796, p<0.001), respectively. myositis or muscle strain was incidentally diagnosed in 12.2% (17/139) pre-contrast and 10.1% (14/139) post-contrast (κ 0 0.674, p <0.001) studies. conclusions: the high observed agreement between the pre-and post-contrast mr images shows that the addition of intravenous gadolinium may not be necessary in the majority of children with chronic osteonecrosis. paper #: pa-127 systematic protocol for assessment of the validity of bold mri in a rabbit model of inflammatory arthritis at 1.5 tesla michael chan, bhsc, university of toronto, mw.chan@ utoronto.ca; afsaneh amirabadi, anguo zhong, antonella kis, rahim moineddin, andrea s. doria purpose or case report: blood oxygen level-dependent (bold) mri has the potential to identify regions of early hypoxic and vascular joint changes in inflammatory arthritis. at this point, there is no standard protocol for data analysis of bold mri measurements in musculoskeletal disorders. standardization of the technique is paramount to compare results between studies and assess the validity of this technique in tissues outside the blood-brain barrier. our objective is to optimize bold mri reading parameters in a rabbit model of inflammatory arthritis by determining the diagnostic accuracy of (1) statistical threshold values (r>0.01 vs r>0.2), (2) summary measures of bold mri contrast [ the mean of the % bold signal differences within the region of interest (roi) (diff_on_off) and the percentage of suprathreshold voxels within the roi (pt%)], and (3) voxel activation algorithm (positive, negative, and positive_negative). methods & materials: using bold mri protocols with a carbogen stimulus on a 1.5 t magnet, we imaged injected and contralateral knee joints of 21 juvenile rabbits at baseline, and days 1, 14 and 28 after a unilateral intra-articular injection of carrageenin. nine non-injected rabbits served as controls. receiver operating characteristic (roc) curves were plotted to determine the diagnostic accuracy of the reading parameters. the bold measures from [(injected knee-control knees)/control knees] were counted as positive cases, while the bold measures from [(contralateral knees-control knees)/control knees] were regarded as negative cases. areas under the curve (aucs) were calculated to determine the most accurate parameters. results: using diff_on_off and positive_negative activations as constants, r>0.01 was found to be more accurate than r>0.2 (p00.03 at day 28). comparison of diff_on_off and pt% yielded no statistically significant difference (p> 0.05). finally, positive_negative activations for diff_on_off and negative activations for pt% using r>0.01 were the most diagnostically accurate (auc00.78, p<0.01 at day 28, and auc00.90, p<0.01). conclusions: from the results of this study, the most diagnostically accurate and clinically relevant reading parameters included the use of a more lenient threshold of r>0.01, a diff_on_off measure of bold contrast, and a positive_negative voxel activation algorithm. pt% may used as an ancillary measure of bold contrast. quantitative versus semi-quantitative mr imaging of cartilage in blood-induced arthritic ankles andrea doria, md, phd, diagnostic imaging, the hospital for sick children, andrea.doria@sickkids.ca; ningning zhang, carina man, pamela hilliard, ann marie stain, victor blanchette purpose or case report: to cross-sectionally compare the ability of a scoring system (semi-quantitative method) with a manual segmentation technique (quantitative method) to evaluate the status of the articular cartilage of growing ankles of children with blood-induced arthritis. methods & materials: 12 boys, 11 with hemophilia (a, n09; b, n02) and 1 with von willebrand disease, median age 13 (range, 6-17) underwent a high resolution mri protocol at 1.5 tesla, x-rays, and physical examination using the hemophilia joint health score (hjhs) system. two blinded radiologists scored the mri examinations for cartilage items (horizontal component: surface erosions, scores 0-2 and vertical component: cartilage degradation, scores 0-4) according to the semiquantitative method (international prophylaxis study group mri scale). an experienced operator applied a validated quantitative 3d-mri method (horizontal components: ac, vc, vctab, thctab; vertical component: thccab) to corresponding high resolution mr images of ankles. results: internal correlation of the semi-quantitative method components was substantial (r00.72, p<0.0001, tibia) to high (r00.91, p<0.0001, talus) in any site of investigation, but it was site-specific with the quantitative method, being significant only in the talar trochlea (r00.86, p<0.0001). external correlation of corresponding components of the semiquantitative and quantitative methods was moderate (r00.55, p00.005) to poor (r00.39, p00.05) for horizontal components, and non-existent for vertical components. components of the semi-quantitative method highly correlated with lifetime number of previous ankle bleeds (r00.74-0.84, p<0.0001), pettersson x-ray (r00.87-0.94, p<0.0001), and hjhs scores (r00.91, p<0.0001). this correlation was poor (r00.42, p0 0.04) to moderate (r0−0.56, p00.004) for horizontal components of the quantitative method. conclusions: the biologic concepts of the semi-quantitative and quantitative mri methods are distinct for assessment of ankles. the semi-quantitative method is valid for assessing cartilage changes in cross-sectional studies of blood-induced arthropathy, however the quantitative method is suboptimal or less powerful for this purpose. paper #: pa-129 shoulder mr arthrography in skeletally immature patients nancy chauvin, md, department of radiology, the children's hospital of philadelphia, chauvinn@email. chop.edu; camilo jaimes, victor ho-fung, diego jaramillo purpose or case report: there has been a well documented increase in sports participation in children which has lead to an increase in sports-related injuries. to date, there are no studies describing the value of shoulder mr arthrography compared with the gold standard, arthroscopy. we retrospectively reviewed 80 mr shoulder arthrograms obtained in pediatric patients between 2004 and 2010 who underwent subsequent shoulder arthroscopy. interpretation of the images was performed by three pediatric radiologists who were blinded to the arthroscopy findings. images were evaluated in consensus and independently. assessment included evaluation of the osseous structures, labral-ligamentous complex, joint space and the rotator cuff interval. the mr results were compared with reported surgical findings. sensitivity and specificity were calculated. results: nine patients were excluded due to technical reasons. of the remaining 71 patients, 48 were boys (9.7-18.5 years, mean 15.7 years) and 23 were girls (12.7-19.3 years, mean 15.6 years). at arthroscopy, 53 patients (74%) had injury to the anterior inferior glenoid labrum. mr sensitivity was 92% for depiction of bankart-type injuries with a specificity of 94%. 37 patients (52%) had hill sach lesions and mr had sensitivity of 86% with specificity of 88%. 24 superior labrum anterior posterior (slap) tears (33%) were identified at arthroscopy with mr sensitivity of 67% and specificity of 89%. overall, mr arthrography had a positive predictive value of 96% for identification of a surgical lesion. agreement between the observers was high. interobserver reliability was calculated with an intraclass correlation coefficient (icc)of 0.638 with a cronbach's alpha of 0.841. conclusions: mr shoulder arthrography can accurately depict labral and osseous injury and provides pertinent preoperative information. a novel multi-channel mr coil for improved pediatric elbow coil imaging suraj serai, phd, cchmc, suraj.serai@cchmc.org; randy giaquinto, kathleen emery, charles dumoulin purpose or case report: single flex coils or adult size coils are currently used for imaging the pediatric elbow. this frequently results in uncomfortable patient positioning, motion, poor fat suppression, low snr and there is currently lack of a dedicated pediatric elbow coil in the commercial market. our goal was to explore the usefulness of a new coil array dedicated for pediatric elbow imaging and to compare quantitative & qualitative imaging findings to commercially available coils. methods & materials: an eight channel elbow coil was designed. the coil frame was designed to be rigid and lightweight. seven identical loop coils were built into a polycarbonate frame and an eighth coil built into a paddle that fits into the top frame. the coil elements were constructed with heavy copper to provide a high q-factor and increased snr. the complete coil including electronics & covering, weighs only 1.4 kg. mr imaging under irb approval was performed on a ge 1.5 t scanner using a routine clinical elbow protocol including t1w, pdw, t2w, fat-sat, non-fat-sat, 2d & 3d sequences. subjects were positioned feet-first with the elbow on the side & were subjectively assessed for comfort level. images obtained from the new coil & from the current commercial coils were compared for snr. results: scan positioning was reported to be comfortable. snr was between 20-25% higher as compared to the routine coils. fat saturation was uniform, indicating that the magnetic susceptibility of the coil is well-matched to human anatomy. anatomical detail depiction was subjectively better for anatomic features such as trochlea. detection & diagnostic confidence of elbow disorders were improved with the new coil & greatly decreased motion artifacts were observed. conclusions: the new pediatric elbow coil provided excellent image quality, patient acceptance and clinical performance improvements over existing coils. the open coil design also allows for imaging of the elbow in a partially flexed position or in a cast. the advantages provided by the new coil are expected to include shortened image acquisition times (via parallel imaging) & increased snr. disclosure: dr. serai has indicated that he will discuss or describe, in the educational content, a use of a medical device or pharmaceutical that is classified by the food and drug administration (fda) as investigational for intended use. incremental value of knee radiography in the interpretation of pediatric knee mri yen-ying wu, texas children's hospital, yxwu@ texaschildrens.org; robert c. orth, wei zhang, r. p. guillerman, herman kan purpose or case report: the acr appropriateness criteria recommendation for the imaging work-up of knee pain is radiography followed by mri. in many cases, mri is performed prior to review of radiographs or the referring subspecialist does not feel radiographs add value, particularly when ligamentous injury is suspected. the purpose of this study is to determine if radiography adds incremental value in the interpretation of knee mr studies electively referred by pediatric sports medicine and orthopedic subspecialists. knee mri studies referred from pediatric sports medicine physicians or pediatric orthopedic surgeons between 9/2008 and 9/2011 (n0194, ages 4-18 years, m:f087:107) with accompanying radiographs were identified. patients were separated into 3 groups based on mri findings: normal, ligamentous injury, or osteochondral injury (osteochondral lesions, bone contusions/fracture, and avulsion injury). knee radiographs were consensus reviewed by two caq pediatric radiologists blinded to mri findings and categorized into the same groups. radiograph and mri findings were compared and categorized into 3 groups: neutral if radiograph and mri findings were the same, misleading if findings were discordant, or helpful if radiographs improved mr interpretation. the latter group was analyzed for impact on mr diagnosis. results: for 194 knee radiographs, 166 were normal, 2 showed ligamentous injuries, and 26 showed osteochondral injuries. when radiographs were interpreted as normal (n0 166), by mr 44% were normal, 33% had ligamentous injury, 10% had osteochondral injury, and 13% had both ligamentous and osteochondral injury. when radiographs were interpreted as ligamentous injury (n02), by mr 50% were normal and 50% had ligamentous injury. when radiographs were interpreted as osteochondral injuries, by mr 8% had ligamentous injury, 38% had osteochondral injury, and 54% had both ligamentous and osteochondral injury. subset analysis of true positive radiographs (n025) found 56% to be helpful and 44% to be neutral in mr diagnosis. for radiographs considered helpful, 0% resulted in a change in mr diagnosis. in regards to the influence of radiographs on mr interpretation, 37% (72/194) were misleading, 56% (108/194) were neutral, and 7% (14/194) were helpful. conclusions: a minority of pediatric knee radiographs aided mr diagnosis, and none resulted in a change in diagnosis. pediatric knee mri and interpretation should not be predicated on radiologist review of knee radiographs in this subset of patients. paper #: pa-132 sonographic evaluation of pediatric skeletal lesions: is it worthwhile? henrietta rosenberg, md, radiology, the mt. sinai medical school, henrietta.rosenberg@mountsinai.org; amish patel, neil lester purpose or case report: the purpose of this paper is to demonstrate how ultrasound(us) may serve as a readily available, cost-effective, non-invasive, non-ionizing, practical tool for the evaluation of a variety of skeletal abnormalities in the pediatric age range. we reviewed the clinical and imaging findings in 31 patients seen during the past 2 years in whom us demonstrated abnormalities related to the skeletal system, excluding patients with hip joint effusions or ddh. results: us proved useful in the following situations: evaluation hard superficial immobile mass (osteoma shin) (1), absent medial end clavicle on x-ray in region of neck mass (us showed abc medial end clavicle)(1), to determine if soft tissue mass involves adjacent bone nodular fasciitis surrounding clavicular head (1), for diagnosis and followup fracture (displaced/non-displaced) in infants (4), diagnosis osteomyelitis in patients with cellulitis (4), question of fracture underlying cephalohematoma or subgaleal hematoma (4), rib mass (osteochondroma) (1) or mass costochondral junctions (contour deformities costochondral cartilage) (6), firm posterior knee mass (baker's cyst) (1), firm anterior knee mass (septated cystic mass suprapatella region due to rheumatoid disease) (1), immobile hard scalp mass due to epidermoid cranial vault (1), painful mass occipital bone with soft tissue components extending through the skull externally and internally due to langerhan's histiocytosis (1), indeterminate mass clavicle clinically thought to be post-traumatic sequellae, resolved on follow-up (1), assessment craniosynostosis (3), for differentiation of pathological entity from normal anatomic structure (lump on back of slender baby proved to be normal posterior spinous process) (1). conclusions: us is worthwhile for evaluation of wide range of pediatric skeletal abnormalities and helps to determine if the a lesion is one that is "touch" or "don't touch". to maximize diagnostic accuracy, the imager should have thorough knowledge of the clinical history, physical findings, laboratory and other imaging findings. in equivocal cases or in those patients in whom the field of view (fov) is insufficient for complete visualization of an obvious lesion or if malignancy is suspected, us serves to triage those patients in whom further imaging is necessary. high incidence of vertebral fractures in children with acute lymphoblastic leukemia 12 months after the initiation of therapy mary ann matzinger, md frcp(c), university of ottawa, matzinger@cheo.on.ca; nazih shenouda , brian lentle, josée dubois, helen r. nadel purpose or case report: vertebral fractures due to osteoporosis are a potential complication of childhood acute lymphoblastic leukemia (all). to date, the incidence of vertebral fractures during all treatment has not been reported methods & materials: we prospectively evaluated 155 children with all during the first 12 months of leukemia therapy. lateral thoracolumbar spine radiographs were obtained at diagnosis and 12 months. vertebral bodies were assessed for incident vertebral fractures using the genant semi-quantitative method, and relevant clinical indices such as spine bone mineral density (bmd), back pain and the presence of vertebral fractures at diagnosis were analyzed for association with incident vertebral fractures. results: of the 155 children, 25 (16%, 95% confidence interval [ci] 11% to 23%) had a total of 61 incident vertebral fractures, of which 32 (52%) were moderate or severe. thirteen of the 25 children with incident vertebral fractures (52%) also had fractures at the time of diagnosis. vertebral fractures at diagnosis increased the odds of an incident fracture at 12 months by an odds ratio of 7.3 (95% ci 2.3 to 23.1, p00.001). in addition, for every 1.0 standard deviation reduction in spine bmd z-score at diagnosis, there was 1.8-fold increased odds for incident vertebral fracture at 12 months (95% ci 1.2 to 2.7%, p00.006). conclusions: children with all have a high incidence of vertebral fractures 12 months after diagnosis, and the presence of vertebral fractures and reductions in spine bmd zscores at diagnosis are highly associated clinical features. purpose or case report: to provide objective measures of acetabular morphology utilizing volume-rendered ct and to better characterize normal acetabular development in adolescents. implications for the diagnosis of femoroacetabular impingement (fai) will be discussed. methods & materials: 146 hips in 73 consecutive patients (36 female, 37 male; ages 13-20 years) who underwent abdominal and pelvic ct for non-hip related complaints were retrospectively examined. examinations were performed for a variety of complaints, including abdominal pain, nephrolithiasis, vomiting etc. patients with obvious hip pathology were excluded. pelvic rotation was eliminated, and pelvic inclination was measured and corrected to 60°u tilizing a volume rendered ct model. measurements of femoral head diameter (fhd), anterior femoral head coverage (fhca), and posterior femoral head coverage (fhcp) were obtained. femoral head area (fha) was defined as π(fhd/2)2. percent anterior femoral head coverage (%fhca) was defined as (fhca/fha)*100. percent posterior femoral head coverage (%fhcp) was defined as (fhcp/fha)*100. acetabular version by volume-rendered ct (avvr) was defined as (fhcp/fhca). results: average pelvic inclination angle (sd) was 70.9 (5.6) for females and 64.8 (6.3) for males. average (sd) %fhca was 22.7 (4.9) for males and 18.6 (5.6) for females. average (sd) avvr was 2.39 (0.57) for males and 3.42 (1.19) for females. among males, average avvr decreased with subject age. on the other hand, there was little change in average avvr with age among females. conclusions: average avvr is greater for females than males, and this difference becomes more striking with increasing subject age. this represents an unexpected finding given the reported increased incidence of "pincer" type fai among females. characterization of acetabular morphology among adolescents with clinical fai should consider subject age and gender. in this regard, volumerendered ct is capable of providing an objective measure of acetabular morphology. mistakes in musculoskeletal plain film interpretation james crowe, pediatric radiology, texas children's hospital, jecrowe@texaschildrens.org; george s. bisset purpose or case report: to evaluate the mistakes made by trained pediatric radiologists when interpreting radiographs of the extremities obtained for the evaluation of outpatient acute pain (mostly post-traumatic). we retrospectively evaluated all radiographs and associated interpretations obtained during a 6 month period from april 15, 2011, to october 15, 2011, of the elbows, wrists, knees and ankles in pediatric outpatients who presented with acute pain in the affected area. all radiographs were previously interpreted by a caq-certified pediatric radiologist varying in experience from 1 year to 57 years. 745 abnormals were identified, including 305 elbows, 168 wrists, 175 knees and 97 ankles. all radiographs were determined to be "as dictated", missed significant finding, or overcall. attention was focused on the missed findings and overcalls. results: findings were as follows: elbow radiographs-14 missed findings and 10 overcalls, wrist radiographs-12 missed findings and 5 overcalls, knee radiographs-9 missed findings and 0 overcalls, ankle radiographs-14 missed findings and 10 overcalls. this resulted in a total of 49 missed findings (6.6% of abnormals) and 25 overcalls (3.4% of abnormals). of the 49 misses, 49% were fractures. the highest mistake percentage occured in the ankles where the combined misses and overcalls approached 25%. this was also the location where we found the highest percentage of missed fractures (9.0%) conclusions: when just abnormal cases were considered, fully trained pediatric radiologists have a mistake rate of approximately 9.8%, if misses and overcalls are included. from a quality improvement perspective, we will review all of the types of misses and overcalls to expose common themes. longitudinal assessment of osteoporosis in a blood-induced hemophilia rabbit model using quantitative ultrasound kuan-chieh wang, university of toronto, kc.wang@ utoronto.ca; afsaneh amirabadi, anguo zhong, christopher tomlinson, andrea s. doria purpose or case report: the reduction of physical activities in hemophilic patients may lead to bone demineralization and consequent osteoporosis. quantitative ultrasound (qus) is free of ionizing-radiation, relatively inexpensive, and easy to use that making this technique suitable for follow-up of hemophilic children with clinical suspicion of osteoporosis. to our knowledge, no previous study has investigated the value of qus for longitudinal assessment of growing bones in an animal model which is paramount for clinical translation of the technique once change in measurements could relate to either the baseline pathology or physiologic bone growth variability. the objective of this study is to investigate the intra-and inter-operator reliability of qus over time, and its ability to discriminate bone loss in pathologic vs control knees of a rabbit model of blood induced arthritis. methods & materials: sixteen juvenile white new zealand rabbits distributed into two groups: 8 received 8 intraarticular blood injections over 17 weeks (n 0 8 pathologic and 8 contralateral knees), and 8 noninjected rabbits were used as controls (n 016 knees). midshaft tibia speed-of-sound (sos) was measured at baseline, and weeks 8 and 17 of the experiment. two operators scanned each site twice at each time point. qus measurements were compared to microct (reference standard) on week 17 to validate the study results. results: the sos measured in the control group increased significantly (p<0.001) over the 17 week period. there was not such an increase in the arthritis sos value (p>0.05). in both groups the overall intra-operator coefficient of variation of sos measurements was 6% at baseline and decreased to 2% at week 17 likely due to increased tibia size. the inter-operator reliability was 6% at baseline and 3% at week 17. with regard to the effect of bone growth on qus measurements for the control group (n 016), sos values increased by 419.13 m/s, whereas for the pathologic group (n08), they only increased by 195 m/s. statistically significant differences in ratios of sos between final/baseline results were noted (p 00.016) between the pathologic and control groups. conclusions: the longitudinal use of qus has an acceptable intra-and inter-operator reliability. even accounting for the significant impact that bone growth has on qus measurements over time, qus can differentiate pathologic from control knees in the proposed animal model and holds potential for clinical use in the assessment of osteoporosis in hemophilic children. methods & materials: the study was approved by the institutional review board. 68 pediatric patients with 73 abdominal tumors (34 malignant and 39 benign lesions) underwent diffusion-weighted mr imaging (dwi) on clinical 1.5 t (n039) and 3 t (n029) mri scanners. adc maps were generated from b0500 dwi and adc values were retrospectively and independently measured by two radiologists. adc values of benign and malignant tumors were compared with the welch two sample t-test. a p value of 0.05 was considered to indicate statistical significant differences. in addition, a receiver operating curve analysis (roc) was performed to determine the optimal cut-off adc value for differentiating benign and malignant tumors. results: the mean adc value (mm2/sec) of benign tumors was 1.681 x 10-3 for the first reader and 1.679 x 10-3 for the second reader. the mean adc value (mm2/sec) of malignant abdominal tumors was 1.018 x 10-3 for the first reader and 1.113 x 10-3 for the second reader. the differences between benign and malignant tumors were statistically significant (p<0.001 for both readers). roc analysis revealed an optimal cut-off adc value for differentiating malignant and solid tumors as 1.1 x 10-3 mm2/sec. conclusions: diffusion-weighted imaging with adc maps can be used to differentiate between benign and malignant pediatric abdominal tumors. creation of a database to evaluate imaging findings in long-term survivors of pediatric malignancy alexander towbin, md, radiology, cincinnati children's hospital medical center, alexander.towbin@cchmc.org; seth hall purpose or case report: over the past 20 years, there have been significant improvements in the treatment of pediatric malignancies. improved therapy has led to an increase in the number of long-term survivors. many of these survivors are now experiencing late effects as a result of the original disease process or its treatment. these late effects are frequently identified on imaging. the purpose of this study is to create a database of the imaging findings of long-term survivors of pediatric malignancy in an attempt to begin to classify the findings and identify associations. methods & materials: after irb approval, the institutional cancer registry was searched to identify all patients younger than 20 years of age who were diagnosed with a solid tumor between 1980 and 2005. patients were included in the database if they survived for more than 2 years from the date of their initial diagnosis. the electronic medical record system was then used to obtain demographic and treatment information for each included patient. the dictated reports from all cross-sectional imaging studies evaluating the chest, abdomen, or pelvis performed more than two years from the date of diagnosis were then reviewed. each positive imaging finding was classified by the involved organ. results: after querying the institutional cancer registry, 909 patients were identified who met the inclusion criteria for this database. the most common neoplasms were neuroblastoma, wilms tumor, and astrocytoma. of the included subjects, 420 had imaging of the chest, abdomen, or pelvis. overall, 2851 reports were evaluated and classified. findings were most commonly identified in the lungs, musculoskeletal system, kidneys, liver, and lymph nodes. conclusions: a database examining the late effects in longterm survivors of pediatric malignancies was created. this database has the potential to help identify the radiologic manifestations of the complications of cancer therapy and thus help guide rationally determined long-term risk-benefit ratios in the treatment of pediatric malignancies. imaging followup of lymphoma in pediatric patients: is pelvic ct necessary? javier lopez bueno, md, children's hospital of eastern ontario, jlopezbueno@cheo.on.ca; nishard abdeen purpose or case report: pelvic ct is often included in the imaging followup of patient with lymphoma before, during and after treatment to assess response to treatment and monitoring for relapses. while such followup is expected to improve detection of relapse, there is little objective evidence of its effectiveness in lymphoma. anecdotally, there are few pelvic relapses in pediatric patients with lymphoma regardless of primary site. we hypothesize that pelvic ct could be avoided as part of the followup without adverse impact on survival or in the detection rate of relapses, and with subsequent significant reduction in the radiation dose, particularly to the gonads. methods & materials: research ethics board approval was obtained. patients diagnosed with lymphoma and with at least one year of followup at our tertiary care pediatric hospital were included. sex, age, type of lymphoma, stage, primary site, site of relapse if any as well as the number of ct scans of the head, neck, chest, abdomen and pelvis were recorded. results: a total of 29 patients met study criteria. there were 21 males and 8 females, with an average age of 11.9 years (range 3-17 years). eighteen patients had hodgkin disease (62%) and eleven had non-hodgkin lymphoma (38%). mean length of followup was 3.8 years (range 1-12 years). an average of 4.5 pelvic scans per patient were performed for surveillance (range 0-12). three relapses were detected. of these only one was in the pelvis, in a patient whose initial t cell non-hodgkin lymphoma was extensive and involved the neck, chest, abdomen and pelvis. conclusions: this study suggests a low incidence of pelvic relapse in pediatric patients with lymphoma. the routine use of pelvic ct in surveillance protocols may therefore be of little benefit while imposing a significant radiation burden. our study is limited by small sample size and short length of followup. further large scale studies are required. (esft) is performed by measuring the size of the tumors before and after chemotherapy. the proposed method of measuring tumor size, however, differs amongst recist 1.1 (response evaluation criteria in solid tumors), who (world health organization) and cog (children's oncology group) response criteria. in our project, we assessed whether response classification differs between the three different methods. methods & materials: after irb approval, we retrospectively analyzed mri studies of 55 patients with ewing sarcoma who were treated at stanford and ucsf medical centers. tumor size was assessed before and after therapy. tumor measurements were obtained using recist 1.1 (longest single diameter), who (longest diameter and perpendicular diameter), and cog criteria (three measurements to calculate tumor volume). tumor response was assessed by the differences in sizes of the tumors before and after treatment using four response categories: progressive disease (pd), stable disease (sd), partial response (pr), and complete response (cr). concordance between the three response classification systems was assessed using cohen's kappa (k) coefficient and percentage of disagreement per response category. results: the k statistic for concordance in cog/who, cog/ recist and recist/who were 0.663, 0.210 and 0.166 respectively. disagreement rates for recist/who, cog/ who, and cog/recist were 12.73, 34.55, and 47.27% respectively. using tumor volume, twenty-six patients were reclassified: twenty-four cases of stable disease coded by recist were reclassified as progressive disease by cog and two cases of partial response coded by recist were reclassified as complete response by cog. conclusions: this study demonstrates poor agreement between the recist 1.1 and cog response criteria in esft. given the degree of discordance between response criteria in esft, evaluation of the prognostic impact of each of these classification systems may guide selection of the optimal system for future use in this disease. imaging recognition of chylous ascites following surgery for abdominal neuroblastoma zeyad metwalli, md, baylor college of medicine, metwalli@bcm.edu; r. p. guillerman, heidi v. russell, eugene s. kim purpose or case report: surgical resection is a standard part of multimodality treatment of neuroblastoma, the most common abdominal malignancy of infancy and early childhood. chylous ascites is a rarely reported complication of surgery for abdominal neuroblastoma, and is likely underrecognized, posing the risk of nutritional deterioration and sepsis. to facilitate early diagnosis and institution of appropriate therapy, we present the salient imaging findings of the largest known series of chylous ascites following surgery for abdominal neuroblastoma. methods & materials: all patients with abdominal neuroblastoma complicated by post-operative chylous ascites over a five-year period at a large children's hospital were identified by a database search. a retrospective review of the imaging studies and clinical charts was conducted. results: chylous ascites developed following surgical resection of abdominal neuroblastoma in 5 of 36 patients, with the diagnosis made between postoperative days 20 and 33. four cases were high-risk neuroblastoma and one was intermediaterisk neuroblastoma. all 5 cases involved resection of an adrenal mass and dissection around the abdominal great vessels. all 5 cases manifested with abdominal distention on physical exam, and ascites was suspected clinically in 3 cases. computed tomography (ct) in all 5 cases revealed a large volume of ascites of near-water attenuation (range of −3 to 16.5 hounsfield units). the 3 cases imaged with ultrasound (us) showed hypoechoic or anechoic ascites without septations. the chylous ascites resolved after 1-4 months of treatment with dietary fat restriction, medium chain triglycerides, intravenous octreotide, or peritoneal catheter drainage. conclusions: chylous ascites is an under-recognized complication of surgical resection for abdominal neuroblastoma, occurring in 14% of patients in this series. the diagnosis is supported by the demonstration on ct or us of a large volume of ascites causing abdominal distention 3-5 weeks post-operatively. the ascites is typically near-water in attenuation rather than fatty in attenuation and should not be misattributed to peritonitis, hemorrhage, bowel leak, or early tumor recurrence. cervical spine injuries in patients with suspected physical abuse nadja kadom, md, radiology, children's national medical center, nkadom@childrensnational.org; zarir p. khademian, tanya hinds, katherine deye, allison m. jackson, eglal shalaby-rana purpose or case report: to evaluate the incidence and nature of cervical spine injuries and relationship to posterior fossa abnormalities in children who underwent brain and cervical spine mri as part of the clinical workup for suspected physical abuse. methods & materials: authors retrospectively analyzed records of eighty-five children less than three years of age who were documented by the child protective services at a level one pediatric trauma center over a period of four years (2006) (2007) (2008) (2009) (2010) . only patients who underwent both mri imaging of the cervical spines (c-spine) in addition to brain imaging as part of the clinical workup were included. cspine and posterior fossa of brain mris were independently reviewed by two pediatric neuroradiologists, both blinded to clinical details. c-spine abnormalities (bone marrow edema, cord edema, intrathecal blood, disc pathology, soft tissue/ ligamentous injury, vascular injury) were documented and correlated with abnormalities seen in the posterior fossa (blood, brainstem edema, cerebellar edema). results: at this time, 40/82 patients have been reviewed. twenty patients (50%) had both cervical spine injuries and posterior fossa abnormalities. there were no patients with isolated cervical spine injuries without posterior fossa abnormalities, but there were five patients (12.5%) that had posterior fossa abnormalities in the absence of c-spine injuries. fifteen patients (37.5%) did not have any spinal or posterior fossa imaging abnormality. none of the patients had bone marrow edema, disc pathology, or intrathecal blood. one patient had vascular neck injury and cord edema. conclusions: our results show that the incidence of cervical spine injury in children under investigation for abusive head trauma is as high as 50%. our data show further that cervical spine injury predicted posterior fossa injury in all patients, while presence of posterior fossa injury predicted concomitant c-spine injury in only 75%. the incidence of c-spine trauma we found in these patients is higher than reported elsewhere in the literature and may impact whether or not routine c-spine mri will be included in national imaging guidelines for children under investigation of abusive head trauma. pediatric skull fracture andre loyd, phd, biomedical engineering, duke university, aml6@duke.edu purpose or case report: skull fractures are often seen in the setting of non accidental trauma (abuse) abuse, and are usually attributed to falls from heights above 1 m. part of the difficulty in assessing height is due to uncertainties in actual distance. objective: to determine what types of skull fractures can occur in pediatric and adult post-mortem human specimens during controlled impacts on hard surfaces from various heights. methods & materials: skull fracture patterns in postmortem human specimens from a unique bank of pediatric specimens (30-week gestation to 16-years-old, n013) were subjected to controlled drops from both arbitrarily low heights (15 and 30 cm) and high heights (2 m) onto an aluminum platen. the specimens were dissected from the neck at the occipital condyles and intracranial were sealed inside the head using pmma. the heads were dropped on to five different impact locations. fractures were identified using palpation and high resolution mdct. results: no specimens between 33-weeks-gestation and 24days-old sustained fractures from the 15-30 cm drops. three out of four (75%) specimens ages between 5-and 22-months old fractured due to the 15 or 30 cm drops. the 9-and 16-year-old specimens and all adult specimens survived the 15-30 cm drops. all specimens subjected to the 2 m drop fractured. the specimen between 11-months and 22-months sustained either a linear fractures or diastatic fractures from the 15 cm and 30 cm drops. the results indicate that some aged infants and young children can sustain skull fractures by being dropped or falling from relatively low heights. drops, as low as 15 cm, can cause linear and diastatic fractures in pediatric skulls. the presences of compliant sutures and fontanelles in neonatal heads allow the head to deform during impact. these data add very important information to mechanisms of skull fractures across ages, including ages in which child abuse is a consideration. evaluation of a new classification system for temporal bone fractures in children aimed at increasing prognostic value badriya al-qassabi, md, mcgill university, albahlania1@ yahoo.com; lucia carpineta, rania ywakim, bahar torabi, andrew m. zakhari, lily h p. nguyen purpose or case report: to compare a new classification of temporal bone fractures which specifically evaluates involvement of the otic capsule against the traditional classification system (transverse versus oblique versus longitudinal), to evaluate whether this new classification is able to better identify patients at risk of adverse otologic outcome and neurologic complications in the pediatric population. methods & materials: a retrospective hospital chart review was performed by ent colleagues searching for all patients with temporal bone fractures seen at our center over the past 10 years. this was followed by a blinded review of the ct heads by a resident and a trained pediatric radiologist with neuro expertise. these cts were evaluated for petrous involvement, otic capsule involvement and any associated intracranial lesions. this information was then correlated with clinical outcome measures including post-traumatic hearing deficit, facial nerve palsy, persisting csf leak and global neurologic sequelae. the new classification was compared to the traditional one, and specifically analysed for the ability to better predict the clinical outcomes. results: expectedly, pediatric temporal bone fractures were infrequent and otic involvement even more rare. fractures with involvement of the otic capsule (versus otic sparing) were found more frequently in boys. they were also more likely to be associated with immediate otologic signs and neurologic findings on presentation. these fractures also had the highest association with conductive hearing deficit (>60%) and were twice as likely as otic sparing fractures to be associated with immediate facial nerve palsy and with more important concomitant intracranial injuries such as midline shift. conclusions: while our numbers are small, our results suggest a trend that when temporal bone fractures show involvement of the otic capsule, there is higher risk of adverse otologic outcome and neurologic complications even in the pediatric population. absence of a causal relationship between mr detected subdural hematomas (sdh) in neonates with hypoxic-ischemic encephalopathy (hie) deniz altinok, children's hospital of michigan; jay shah, harut haroyan, gulcin altinok, nitin chouthai purpose or case report: the existing controversy regarding subdural hemorrhages noted in patients with hie is an important discussion in the medical, legal and child-welfare realms. it is our goal to provide additional information to this critical debate through mr findings on patients with clinically diagnosed hie. methods & materials: all patients born with clinically diagnosed hie, and treated at children's hospital of michigan in the past 8 years were examined; those with head mri taken within 19 days of life were selected. in total, 41 patients fit the criteria, this included: 22 males and 19 females, and an age range of 2-19 days at scan (average age of 10 days at scan). all traumatic births, coagulopathies, and other pertinent clinical findings were noted. mr imaging was reviewed and reported by a blinded pediatric neuroradiologist, these reports were then compared to the "original read". results: all 41 patients were confirmed radiologically to have hie. the causes of hie in all cases examined were either intrauterine/delivery asphyxia, aspiration, or congenital disease. of these 41 cases, the findings were: 6 sdh, 11 parenchymal hemorrhages, 4 intraventricular hemorrhages, 4 cephalohematomas, 3 subarachnoids, 1 large subcutaneous hemorrhage and 1 instance of mca stroke. all 6 patients with mr detectable sdh had 1 or more confounding factors (1 meningitis, 3 coagulopathies, 4 chest compressions, 1 cardiac malformation, 1 pph, 1 severe pulmonary hemorrhage requiring transfusion of plasma and prbc). conclusions: it has been hypothesized that sdh is often found incidentally in children diagnosed with hie, this is however a dubious conclusion considering our results. in fact, the presence of sdh and hie concomitantly is low even when including a population with traumatic births such as ours. sports-related concussion in children: an mri and mrs study kim cecil, phd, cincinnati children's hospital medical center, kim.cecil@cchmc.org; todd a. maugans, james l. leach, mekibib altaye purpose or case report: the pathophysiology of sportsrelated concussion (src) is poorly understood, especially for children. following src and mild traumatic brain injury in adults, a few mri and proton mrs studies have identified axonal injury with declines in the neurometabolite n-acetyl aspartate (naa). we wanted to examine a src adolescent population with proton mrs, diffusion tensor imaging (dti) and other mri methods within 72 h of concussion and with short term followup to determine if there were differences in imaging metrics with age and sex matched healthy control participants. methods & materials: twelve children, ages 11-15 years, who experienced src were evaluated with impact neurocognitive testing, t1-weighted mri, susceptibility weighted imaging (swi), dti, proton mrs, and phase contrast angiography (pca) at less than 72 h, 14 days and 30 days or greater post-concussion. healthy, age and sex matched controls for each src participant were recruited and evaluated at a single time point. quantitative imaging metrics included fractional anisotropy, metabolite concentrations, and global cerebral blood flow (cbf). group comparisons were examined by paired t-test or wilcoxon signed rank test. correlational data employed spearman rank correlation. results: impact results revealed significant differences in initial total symptom score (tss), and reaction time (rt) for the src group compared with the control group, with tss resolving by a mean of 14 days and rt at 30 days. no evidence of structural injury was observed qualitatively for either group. analyses between groups or over time within the src group found no decreases in naa or elevation of lactic acid upon mrs, and no changes in fractional anisotropy upon dti. within the src group, significant changes in the global cbf were observed. improvement towards control values occurred by 14 days for 27% and by 30 days for 64% of src group participants. conclusions: pediatric src affects global cbf without evidence of structural or metabolic injury. predictive value of high resolution mr imaging of brain and sella in children with clinical optic nerve hypoplasia for hypopituitarism charles glasier, radiology, arkansas childrens hospital, glasiercharlesm@uams.edu; raghu h. ramakrishnaiah, julie shelton, chetan c. shah, paul h. philips purpose or case report: to review the spectrum of cns abnormalities and their incidence in children with optic nerve hypoplasia and to calculate the sensitivity and specificity of magnetic resonance imaging in predicting endocrine abnormalities. methods & materials: this is an irb approved retrospective study of 44 children with clinical optic nerve hypoplasia who underwent mri of the brain and orbits as part of the clinical workup in a tertiary care pediatric hospital. high resolution mri studies were performed on 1.5 tesla scanners. mri studies were reviewed for optic nerve hypoplasia, absent or ectopic posterior pituitary, absent pituitary infundibulum, absent septum pellucidum, migration anomalies and hemispheric injury.radiologists were blinded to patients endocrinologic status.all patients had clinical evaluation by a pediatric neuro-ophtalmologist and endocrinologist. a standardized panel of serologic testing that included serum cortisol, acth, tsh, and free t4 levels were performed on all patients. statistical analysis was performed to determine the sensitivity and specificity of mr findings in predicting endocrinologic deficiency. results: study included 44 children(26 males and 18 females) who had clinical optic nerve hypoplasia. the mean age of the study population was 3 yr (sd:4.7 yr).15 children had unilateral and 29 children had bilateral optic nerve hypoplasia by mri.6 children had absent posterior pituitary bright spot and 9 had ectopic posterior pituitary,7 had absent infundibulum,1 had complete callosal agenesis,3 partial callosal agenesis and 16 had callosal thinning. 9 had absent septum pellucidum. 2 had hypopituitarism. of the 12 patients with hypopituitarism 8 had abnormal abnormal pituitary on mri, 3 had absent septum pellucidum, and 1 child had migration abnormality. none had corpus callosal abnormality. the sensitivity and specificity of mri in predicting hypopituitarism by demonstration of abnormal pituitary is 75% and 81% respectively. the positive predictive value and the negative predictive value is 60% and 90% respectively. among the 32 patients with normal endocrinologic function, none had pituitary abnormalities on mri. conclusions: pituitary abnormalities are the most common intracranial abnormality in patients with optic nerve hypoplasia followed by absent septum pellucidum. detection of pituitary abnormalities by the mri has high specificity and high negative predictive value for endocrine abnormality. paper #: pa-148 ct imaging pearls for shunted pediatric brains srikala narayanan, md, children's national medical center, snarayan@childrensnational.org; nadja kadom purpose or case report: shunted pediatric patients frequently present emergently with symptoms that could indicate shunt malfunction, such as headache and vomiting. here, we present imaging pearls on non-contrast head ct in shunted children. methods & materials: illustration of each of the following: 1. shunt tip and volume averaging-consider location of side holes and use of multiplanar reformatted images. 2. shunt at burr hole-consider radiolucent shunt parts. 3. shunt rupture in the neck-remember to investigate the lower extracranial shunt parts. 4. shunt in cyst/subdural shunt (vs dislocation)-consider primary shunt location in a cyst rather than shunt dislocation. 5. enlarged temporal horns-look for it. in infants occipital horns may dilate first. 6. enlarged 3 rd ventricle-look for bulging of lateral walls. 7. sulcal effacement-use the "three shades of gray" rule. 8. small cisterns-detecting shape distortion can help. 9. periventricular edema-easily overlooked because of similar low density compared to ventricular fluid. 10. slit-ventricle -requires cautious reporting. conclusions: careful evaluation of ct images in shunted pediatric patients can reveal important clues for making an accurate diagnosis, even when prior images are not available. successful treatment of mice with creatine transporter deficiency kim cecil, phd, cincinnati children's hospital medical center, kim.cecil@cchmc.org; diana m. lindquist, matthew r. skelton, gail j. pyne-geithman, joseph f. clark purpose or case report: creatine transporter deficiency (ctd) is an untreatable x-linked mental retardation syndrome with severe cognitive and speech impairment. patients are identified by an absence of creatine in the brain on mr spectroscopy (mrs) and distinguished from two creatine synthesis deficiency syndromes with genetic testing. for ctd, the absence of the transporter (slc6a8) prevents creatine from crossing the blood brain barrier and entering brain cells. a brain specific ctd knockout mouse was developed replicating key features of the human disease and establishing an animal model for treatment of ctd. we report the successful treatment of the ctd knockout mouse and present confirmation by mrs. methods & materials: brain specific knockout and littermate control mice were randomly assigned and treated with on one of three supplements: agentx (confidential), creatine or maltodextrine as placebo. 1h and 31p mrs data were collected on a 7 t mr system (bruker). mice (n016) were studied with mrs after 9 weeks of supplementation. single voxel 1h data were acquired on a 144 ul voxel covering the cerebrum using a double spin echo sequence. 31p data were acquired with an isis sequence from the same voxel. metabolite quantification was performed with jmrui and compared between groups and over time with statistical tests for significance (t-tests, anova). results: creatine and phosphocreatine levels in the brain were all significantly higher after 9 weeks supplementation of agentx in knockout mice, compared to creatine and placebo fed knockout mice (phosphorus mrs [144 ul brain voxel] with phosphocreatine (pcr) (0 ppm) observed only in agentx treated knockout mice. adenosine triphospate (atp) gamma (−2.5 ppm), alpha (−7.5 ppm) and beta (−17 ppm) peaks are noted in all three knockouts. conclusions: successful treatment was achieved in a slc6a8 brain specific knockout mouse for the second largest known cause of x-linked mental retardation in humans, ctd. disclosure: dr. cecil has indicated that she will discuss or describe, in the educational content, a use of a medical device or pharmaceutical that is classified by the food and drug administration (fda) as investigational for intended use. prevalence of abusive injuries in siblings and contacts of abused children kenneth feldman, md, general pediatrics/children's protection program, university of washington/seattle children's, kfeldman@u.washington.edu purpose or case report: siblings and children who share a home with a physically abused child are thought to be at high risk for abuse. however, rates of injury in these children are unknown. disagreements between medical and cps professionals are common and screening is highly variable. our objective was to measure the rates of occult abusive injuries detected in contacts of abused children using a common screening protocol. this was a multi-center, observational cohort study of 20 child abuse teams who shared a common screening protocol. data were collected for all children <10 years undergoing evaluation for physical abuse and their contacts. for contacts of abused children, the protocol recommended physical examination for all children <5 years, skeletal survey and physical exam for children <24 months, and physical exam, skeletal survey and neuroimaging for children <6 months old. results: among 2,825 children evaluated for abuse, 618 met criteria as "physically abused" and these had 477 contacts. for each screening modality, screening was completed as recommended by the protocol in approximately 75% of cases. of 133 contacts who met criteria for skeletal survey, new injuries were identified in 16 (12.0%). none of these fractures had associated findings on physical examination. physical examination identified new injuries in 6.2% of 257 eligible, examined contacts. neuroimaging failed to identify new injuries among 19 imaged, eligible contacts less than 6 months old. twins were at significantly increased risk of fracture relative to other non-twin contacts (56.3% vs 11.9%, or 19.9). conclusions: these results support physical examinations and skeletal survey, regardless of physical examination results, for contacts of abused children <24 months of age. too few children had cranial imaging to change recommendations to image contact children less than 6 months old. even for children where no injuries are identified, these results demonstrate that abuse is common among children who share a home with an abused child. they support including contacts in evaluations and interventions (foster care, safety planning, social support) designed to protect physically abused children. the project was supported by the health resources and services administration/maternal shown that pediatric rib fractures may be a marker for significant intrathoracic injury. this information has been used to suggest that children with rib fractures and no underlying intrathoracic injury may have sustained them due to insufficient bony mineralization and minor trauma rather than inflicted injury. methods & materials: irb approval was obtained for a retrospective review of all children under 3 years of age with imaging diagnosis of rib fracture over a 6-year period at two university hospitals. children with prior thoracotomy, previously recognized metabolic bone disease, and prematurity <36 weeks were excluded. medical records were reviewed and children with documented abuse or accidental trauma were evaluated. children with indeterminate injury mechanisms were excluded. sixty-six patients with rib fractures were included in analysis, 47 due to abusive injury and 19 due to accidental trauma. children were analyzed for associated intrathoracic, abdominal or intracranial injury, additional fractures and retinal hemorrhage. results: abused children were younger (4.7+/−6.1 months) than accidentally injured children (18.9+/−11.1 months, p< 0.001). children with rib fractures due to accidental trauma had a higher incidence of intrathoracic injury compared to those due to abusive injury (53% vs 13%,p<0.001). there was no difference in the incidence of abdominal or intracranial injury between groups. mortality and icu admission rates were similar. abused children had a higher total number of rib fractures (mean 5.5 vs 3.0, p<0.009) and were more likely to sustain additional fractures outside of the thoracic cavity (77% vs 63%, p<0.001). conclusions: abuse is a more common cause of rib fractures in young children than accidents. children with rib fractures due to abusive trauma are less likely to have intrathoracic injury compared to those sustaining rib fractures due to accidental trauma. this suggests differences in mechanism of injury between groups. pediatric elbow fractures: a different angle on an old topic shannon zingula, md, pediatric radiology, cincinnati children's hospital medical center; kathleen emery, christopher g. anton purpose or case report: the 3 most common elbow fractures classically reported in pediatric orthopedic texts are supracondylar (sc) (50-70%), lateral condylar (lc) (20%), and medial epicondylar (me) fractures (10%) with fractures of the proximal radius (including but not limited to fractures of the radial neck) being relatively uncommon (5-10%). our experience at a large children's hospital suggests a different distribution. purpose: 1) to describe the frequency of different elbow fracture types in a large pediatric population, and 2) to determine the fracture types that were occult on initial radiographs but detected on follow-up. methods & materials: review of medical records identified 468 children, median age 6 years and interquartile range for age of 4-8 years (range, 0.8-18 years) diagnosed with elbow fractures at our institution from october 2010 through july 2011. initial and follow-up radiographs were reviewed in blinded fashion independently by two experienced pediatric musculoskeletal radiologists to identify fracture type(s) on initial and follow up radiographs. note was made of fractures identified on follow up only. results: the most common fractures included sc (n0254, 54%), radial neck (rn) (n080, 17%), and lc fractures (n066, 14%). as compared to classically referenced incidences, rn fractures were seen significantly more (p<0.0001) and me fractures (n025, 5%) significantly less (p0.0008) than would be predicted. in 26 patients without fracture seen on initial films, occult fractures were seen on follow up; sc (n012, 46%) and rn fractures (n08, 31%) were most common. the frequency of rn fractures compared to the overall group (31% vs. 17%) approached but did not reach statistical significance (p00.06). 34 patients with one fracture had additional fractures seen on follow-up not seen initially with olecranon fractures most frequent (n018, 53%.) this was significantly more common than the number identified on initial radiographs (n033, 7%) (p<0.0001). conclusions: sc fractures are the most frequent elbow fracture seen initially and in follow up followed by rn and lc fractures in a distribution different than classically described. the relatively high frequency of rn and olecranon fractures detected on follow up speaks to their potentially occult nature. careful attention to these areas is warranted in patients with initially normal radiographs. purpose or case report: previous studies have found that fractures involving the spine, hands and feet are rare on skeletal surveys for suspected child abuse, leading some authors to suggest eliminating views of these regions from the initial skeletal survey protocol. the purpose of this study was to assess this recommendation by performing a historical review of these injuries in a population undergoing screen-film based skeletal surveys for suspected abuse. this cross-sectional, retrospective irb approved study reviewed the reports of the initial skeletal surveys of all children <2 years of age with suspected abuse imaged between april, 1988 and december, 2001 . infants underwent skeletal surveys according to acr standards acquired on a mammographic type screen-film imaging system with at least 13 line pairs per millimeter resolution. studies in toddlers were performed using a par speed screenfilm system. results: 62% (225/365) of all skeletal surveys demonstrated positive findings, and 44% (98/225) had >1 fracture. 5.5% (20/365) of all studies had fractures involving the spine, hands or feet. of all positive skeletal surveys, 8.9% (20/ 225) had fractures involving the spine, hands or feet, and 20.4% (20/98) of all patients with >1 fracture on skeletal survey had fractures involving these regions. conclusions: these data, acquired in the screen-film era, suggest that fractures of the spine, hands and feet may not be rare in infants and toddlers in cases of suspected child abuse. the benefits of eliminating views of these regions from the initial skeletal survey should be carefully weighed against the cost of missing these potentially important injuries in at-risk pediatric populations. purpose or case report: dating fractures is critical in cases of suspected infant abuse, but there are little scientific data to guide radiologists, and dating is generally based on personal experience and conventional wisdom. we previously reported a scientific scheme for dating fractures in infants based on an analysis of subperiosteal new bone and callus formation in birth-related clavicular fractures. we hypothesize that when used as a guide this system can significantly improve the ability of radiologists to accurately date fractures in young infants. methods & materials: 103 radiographs of presumed birthrelated clavicular fractures in infants 0-3 months were reviewed by 2 pediatric radiologists with 2 (reader a) and 15 (reader b) years experience in two reading sessions separated by one year. for the first read, no guidelines were provided. training was carried out prior to the second session, and readers were given the dating scheme as a guide during fracture analysis. readers were asked to provide an estimate of the minimum and maximum fracture age in both sessions. the primary outcome was whether or not the reader's estimated range for fracture age included the actual fracture age. a secondary outcome was the width of the estimate of fracture age. these outcomes were compared across the two reading sessions. results: the rate of correct response significantly increased after training for each reader (reader a: 66% to 89%, p<.0001; reader b: 76% to 86%, p0.041). the width of estimated fracture age after training was significantly smaller for each reader (reader a: mean width 17 days to 13 days, p<.0001; reader b: 25 days to 15 days, p0.001). conclusions: our results suggest that the ability of a radiologist to accurately date fractures can improve significantly when provided with a scientifically based system outlining patterns of fracture healing. this scheme can be applied in radiologic practice and may prove particularly useful in cases of suspected abuse, where fracture dating often has forensic implications. purpose or case report: to demonstrate the acute and subacute features of proximal femoral physeal fractures in the abused child. also to demonstrate how to recognize this injury in patients with unossified femoral heads. the database of patients with suspected non-accidental trauma, accumulated over 12 years, was reviewed. 254 out of a total of 599 patients (43%) were proven to be cases of non-accidental trauma, as determined by the child abuse pediatrician. from these 254 patients, the cases of proximal femur growth plate fractures were identified. results: 7 patients with proximal femur growth plate fractures were identified for a prevalence of 2.8%. one patient had bilateral proximal femoral fractures, for a total of 8 fractures in 7 patients. 5 were boys, 2 were girls with ages ranging from 2.5 mos to 2 yrs 2mos. in 4 patients, the fracture was revealed on imaging performed because of refusal to bear weight; in the other 3 patients, the fracture was found during imaging for the skeletal survey. the fracture was on the left side in 7 cases and on the right side in 1 (the patient with bilateral fractures). in all of the fractures, there was lateral displacement of the femoral shaft. in 3 fractures, the femoral head was not yet ossified simulating the appearance of a dislocation. location of the femoral head in the hip joint was verified by ultrasound or ct (ct abdomen had already been done in 1 patient) thus delineating the presence of a physeal fracture. 6/8 fractures were salter-harris i and the other 2 were salter-harris ii fractures. the fracture was acute in 2 cases and subacute in 6 cases. in these 6 subacute cases, periosteal reaction and/or calcifying subperiosteal hemorrhage was present in 3, and irregularity and scalloping of the metaphysis was present in the other 3. conclusions: proximal femoral growth plate fractures are quite uncommon in non-accidental trauma. the injuries are typically salter-harris i or ii fractures, seen more often in the healing phase. in the presence of an unossified femoral head, the laterally displaced femoral shaft can simulate hip dislocation; this can be clarified with hip sonogram. purpose or case report: in recent years, metal stents have been used to overcome airway obstruction in children for whom no better surgical option is available. these devices are not designed for use in the airway, however, and may cause significant complications. bioabsorbable airway stents may avoid some of the problems associated with metal stents. methods & materials: this is a retrospective review of all endoluminal insertions of bioabsorbable airway stents at a single institution from april 2010 to september 2011. custom-made polydioxanone stents of various sizes (ella dv, ella, czech republic) were used. results: twelve stents were inserted in the airways of seven children. indications were: recurrent obstruction after slide tracheoplasty (2), persistent airway compression after correction of a congenital cardiac lesion (2), collapse of stem cell supported tracheal homograft, tracheomegaly following fetal balloon insertion, and syndromic tracheobronchomalacia (tbm). eleven stents (diameters 6 to 12 mm) were placed in the trachea and one in the left main bronchus. two stents had to be removed and replaced for technical reasons (one was too long and the other too narrow). the child with syndromic tbm died when treatment was withdrawn because she could not be weaned from the ventilator. the remaining children are alive at a median follow-up of nine months (range 1 to 17 months). the granulation tissue response was similar to that seen after placement of metal stents. the stents were observed to absorb gradually over a period of approximately three months, requiring serial stenting in two children. conclusions: bioabsorbable airway stents are more difficult to insert than metal stents. they cause similar early complications, especially granulation tissue formation, but appear to avoid potential long-term complications of metal stents, including vascular erosion and growth limitation. disclosure: dr. mcclaren has indicated that she will discuss or describe, in the educational content, a use of a medical device or pharmaceutical that is classified by the food and drug administration (fda) as investigational for intended use. purpose or case report: renal angiomyolipomas (amls) in tuberous sclerosis complex (tsc) grow at a faster rate, exhibit a wider and more problematic range of symptoms, and hemorrhage more frequently than sporadic amls. we examined the efficacy of prophylactic embolization of renal amls in tsc in decreasing tumor size, alleviating symptoms, and preventing hemorrhage while preserving renal function. we retrospectively reviewed the charts and imaging studies of 47 consecutive patients who underwent transarterial, transcatheter embolization of 52 amls. tumor volume was measured from available ct or mri imaging before and after embolization. pre-and postembolization symptoms and creatinine levels were documented. results: 37 patients had available follow-up imaging at a mean of 63 months post-embolization. the mean preembolization tumor volume was 581 ml and postembolization was 284 ml; median decrease in volume was 76%. using the schwartz method, the mean glomerular filtration rate before embolization was calculated to be 95.75 ml/min/1.73 m2. after embolization the mean value was statistically unchanged at 101.97 ml/min/1.73 m2. none of the patients experienced renal hemorrhage or symptom recurrence during the follow-up period. conclusions: selective embolization of renal amls in patients with tsc decreases tumor volume, relieves symptoms and reduces the risk of future hemorrhage while preserving renal function. etoh was injected percutaneously with 25 g needle; transductal ablation performed through a 4 f micropuncture sheath. drug volumes, technical difficulties, percentage reduction in saliva production, family reported clinical significance, and complications were recorded. results: salivary gland ablation (sga) included bilateral smg and slg ablation without parotid gland ablation in 20 cases, and with unilateral parotid gland ablation in 4 cases. one case of bilateral parotid gland ablation following surgical resection of bilateral smgs. mean etoh dose for smg04.2 ml, and 3.1 ml for slg. one case of focal skin necrosis was noted; no other complications. patient families reported response to sga in 24/25 cases (96%) with mean saliva production of 66%. greatest health and family impact was reported with elimination of hospitalizations for recurring aspiration pneumonia (2 cases), elimination of choking in bed (3 cases) , and improved patient sense of self-hygiene in 8 cases. one complication occurred with temporary marginal mandibular nerve paralysis (resolution in 6 months). conclusions: percutaneous and transductal sga is feasible, safe, and effective in this small patient series, offering an alternative to surgical salivary gland resection, or treatment option following failed surgical intervention. paper #: pa-159 mr-guided procedures in children: initial experience joao amaral, md, diagnostic imaging, the hospital for sick children, joao.amaral@sickkids.ca; michael temple, dimitri parra, philip john, bairbre connolly purpose or case report: the primary purpose of this study was to review our initial experience with mr-guided procedures in children. our secondary objective was to share some aspects on how to start an mr-guided program in a tertiary pediatric center. patients with lesions identified only on magnetic resonance (mr) imaging were selected to undergo an mr-guided procedure. patients' demographic data, primary diagnosis, referring team's clinical suspicion, lesion's anatomical location, tissue adequacy for pathology, final diagnosis and clinical follow up were reviewed. aspects of starting a program of mr-guided procedures, safety concerns, imaging and technical challenges, and mr compatible materials were also addressed. results: to date, 7 procedures (5 bone biopsies, 1 soft tissue biopsy and 1 pre-surgical needle localization) were performed in 6 patients during 9 months. there were 4 girls and 2 boys with a mean age of 10.2 years (3y5mo-17 yrs). one patient had a nasopharyngeal carcinoma, 1 cardiofacial syndrome, 1 wilm's tumor and 3 had no previous medical issues. the clinical suspicion for 2 procedures in 2 patients was metastatic disease and for 5 procedures in 4 patients was primary malignancy or infection. lesions were located in the tibia (2-metaphysis and diaphysis), femur (2 -metaphysis and epiphysis), thigh (1-soft tissues), sacrum (1) and retroperitoneum (1). all biopsies provided adequate tissue for diagnosis. needle localization and hook deployment was also accurate. malignancy was excluded in all patients. final diagnosis included 1 chronic recurrent multifocal osteomyelitis (crmo), 3 osteomyelytis, 1 fibrous tissue, 1 osteoid osteoma, and 1 scar tissue. mean follow up was 6.6 months. no patient required a second procedure to confirm the diagnosis. conclusions: mr with its unique soft tissue resolution and lack of ionizing radiation is an excellent method to guide interventions in children. one of the greatest advantages of this method is the precise target localization especially in lesions located in the bone marrow or lesions better identified on mr. special safety measures, specific mr compatible material (needles, surgical instruments), dedicated imaging techniques to reduce or increase material/needle artifact and careful technique are paramount. 2006-2011. 11 m, 15 f; 2 .5-59 months, mean 8.3 months, median 5 months, mode 5 months. sonographic approach expanded as our experience grew over 71 months. 25 studies performed by a single pediatric radiologist. bilateral sonography included: interscalene and supraclavicular neck, nerve roots at neural foramina, cervical spinal canal, diaphragm during spontaneous respiration, rhomboid muscle, serratus anterior muscle, posterior shoulder, all performed and interpreted blind to other imaging. results: interscalene and supraclavicular neck evaluated in all patients. all exhibited echogenic interscalene portion of brachial plexus.size and extent of traction neuroma varied. nerve roots at foramina noted in axial and coronal planes. in 11 cases enlarged root(s)noted. cervical spinal canal studied in 19 patients: cord oscillated normally, no syrinx, cord concentric in canal. intracanalicular traction pseudomeningoceles on concurrent ct myelography or mri were not apparent on us. in 2 cases a "clumped" retracted nerve root on the cervical cord was later found to correspond to a pseudo-meningocele on ct myelogram. otherwise, cervical spinal canal us was unremarkable in 24 cases. diaphragm motion was evaluated in 23 patients during spontaneous respiration; no phrenic nerve palsy. rhomboid muscle was evaluated for atrophy in 16 patients; 4 had atrophy. the rhomboids are innervated by the dorsal scapular nerve which arises solely from c5, prior to c5 joining the brachial plexus. intact rhomboid indicates that the central c5 root is intact. serratus anterior muscle, innervated by the long thoracic nerve (c5,c6,c7), was evaluated for atrophy in 12 patients; 6 had atrophy. dynamic evaluation of the posterior shoulder looking for posterior laxity was evaluated in 10 patients; 4 had laxity. posterior shoulder dislocation or subluxation is a known sequela of brachioplexopathy which sometimes requires muscle transfer when the child is older. conclusions: comprehensive us evaluation of perinatal brachioplexopathy detects: extent of traction neuromafibroma from the interscalene region peripherally toward clavicles (important for neurosurgeon), thick nerve roots, phrenic nerve diaphragm palsy, muscle atrophy from denervation, and posterior shoulder subluxation. us misses: intracanalicular traction pseudomeningoceles. paper #: alt-001 impact of the image gently campaigns in adult-focused hospitals: a survey of practice leaders brett bartz, duke university medical center; donald frush, kimberly applegate, michael callahan, laura coombs, marilyn goske purpose or case report: the alliance for radiation safety in pediatric imaging is an organization that uses social marketing to promote radiation protection for children and effect change across radiology practices. the impact of the alliance's image gently campaigns on practice patterns in radiology practices has yet to be assessed, especially outside of freestanding children's hospitals. the purpose of this investigation was to assess the impact of the image gently campaigns on academic and private practices/institutions that treat children but primarily serve adults. a web-based survey was emailed to leaders in radiology practices (n01186) who do not practice at freestanding children's hospitals utilizing the acr's pred database. the survey consisted of 18 questions designed to measure the recognition and impact of the image gently campaigns, including the impact on practice patterns. results: a total of 186 practice leaders in 41 u.s. states and territories responded for a response rate of 15.7%. the majority (94%) of sites image pediatric patients in their practices. respondents consisted of department chairs (60%), group presidents/ceos (33%), and division chiefs (13%). the majority (52%) of respondents described their practice as a hospital-based private practice without a dedicated pediatric radiology division. the vast majority (95%) of respondents was familiar with the image gently campaigns; 55% of respondents reported that image gently had effected a change on how they imaged children. specifically, respondents (%) reported that the campaign caused a modification to lower dose protocols for head ct (57%), chest ct (66%), and abdominal/pelvic ct (69%). slightly more than half of respondents (55%), however, estimated that the image gently campaign resulted in no modification of pediatric fluoroscopy exposure. conclusions: to our knowledge, this is the first survey evaluating the impact of the image gently campaigns. there is near universal recognition of the campaigns, which have impacted practice patterns beyond the freestanding children's hospital in ct, but not in fluoroscopy. reliability of shear-wave velocity using different frequencies in acoustic radiation force impulse (arfi) elastography mi-jung lee, radiology, severance children's hospital, mjl1213@yumc.yonsei.ac.kr; suyon chang, myung-joon kim purpose or case report: although there are many studies about acoustic radiation force impulse (arfi) measurement, standard protocol has not been established. and a new probe with high frequency has been developed which can be applied for pediatric patients. the purpose of this study was to assess the reliability of shear-wave velocity (swv) at various depths using different frequencies to suggest standard measurement in arfi elastography. methods & materials: arfi elastography of both the elasticity phantom and normal liver was performed at different depths (2-5 cm) with convex (1-4 mhz) and linear (4-9 mhz) probes. ten valid swv measurements at each depth were performed. it was repeated ten times with the phantom and it was done in 8 healthy volunteers (m:f03:5, age 20-34 years; mean 25.5). the mean value and standard deviation of swv were calculated. results: in both the elasticity phantom and the liver, variability of swv was different between the depths in both probes. the depth with lower variability in the phantom was 4 and 5 cm with the convex probe and 2 cm with the linear probe. in the liver, the depth with lower variability was 4 cm with the convex probe and 3 and 4 cm with the linear probe. in comparison of two probes, the linear probe showed lower variability at 2 and 3 cm depth in the phantom and at 3 cm depth in the liver whereas the convex probe showed it at 4 cm depth in both the phantom and the liver. conclusions: in arfi elastography, measurement of depth shows different variability in both low and high frequency probes. to obtain the most reliable measurement of swv, using high frequency probe is recommended for 2-3 cm depth and using low frequency probe is recommended for 4-5 cm depth. disclosure: dr. lee has indicated that she will discuss or describe, in the educational content, a use of a medical device or pharmaceutical that is classified by the food and drug administration (fda) as investigational for intended use. imaging 100-year-old fetuses sabah servaes, children's hospital of philadelphia; teresa victoria, ann johnson, sandra kramer, richard markowitz, diego jaramillo purpose or case report: to demonstrate normal anatomy and pathology of medical museum specimens without disturbing the specimens. methods & materials: nine fetal specimens from a medical museum were imaged with ct and mri (1.5 t and 3.0 t) when possible with the specimens in their preserving fluid and containers. results: the 9 fetal specimens are estimated to be approximately 100 years old. one specimen is from the first trimester, seven are from the second trimester, and one is from the third trimester. normal anatomical structures at various stages of development including the brain (and varied sulcation pattern), lungs (lobar anatomy), and skeletal structures (several developmental features such as the ossification centers, perichondrial structures, and marrow cavitation) can be evaluated using imaging without causing harm to the specimens. pathologic entities including anencephaly and sirenomelia are also evaluated demonstrating features of these entities. conclusions: imaging historical fetal specimens provide an opportunity to evaluate normal developmental changes and pathological entities and also to gain a better understanding of the museum pieces without damaging the museum specimens. pediatric ct interpretations: does a tertiary care radiologist make a difference? wendy d. ellis, monroe carell jr. children's hospital at vanderbilt university; sumit pruthi, david johnson, christopher eakins, chang yu, marta hernanz-schulman purpose or case report: to determine whether a substantive difference exists between the pediatric imaging reports of community radiologists and reinterpretations by tertiary care radiologists at a free-standing children's hospital; and how those interpretations were related to the final diagnosis. methods & materials: this retrospective review examined the computed tomography (ct) reports of all pediatric patients referred to our tertiary care children's hospital over a 17 month period (1/1/2009-5/31/2010). the outside reports and the requested second interpretation reports were compared and their content categorized as "agreement" vs. "disagreement: major or minor". a representative sample of 92 major disagreements in which there was reliable followup information was correlated with the final diagnosis to determine if there was added value provided by the reinterpretation. results: ct scans from 732 patients were submitted for reinterpretation. disagreements were found in 301/732 cases (41.1%); with 50.5% (152/301) classified as major disagreements. among the 427 neurologic cases, major disagreements occurred in 53 patients (12.4%) and minor disagreements in 92 patients (21.5%). among the 305 body scans, major disagreements occurred in 99 cases (32.5%) and minor disagreements in 57 cases (18.7%). in the cohort of cases reviewed for final diagnosis, the second read interpretation was more accurate in 90.2% of cases with a p-value of <0.0001 (neurologic 84.4%, p0<0.0001; body 95.7%, p0<0.0001). conclusions: in our review, discrepancy rates between community and tertiary care radiologists in interpretation of pediatric ct scans were substantial, with discrepancies occurring in more than 40% of cases. further review of the cases for final diagnosis, showed that a significant number of the tertiary care interpretations were more accurate. possibilities that may account for this discrepancy include subspecialty training and elapsed time since performance of the study, which might provide additional clinical data in some cases. diagnostic ct scans performed at outside institutions should not be repeated considering added radiation burden to the child and additional expense. our data indicates there is added value to the reinterpretation which impacts the accuracy of the report (as assessed by the final diagnosis), and should be recognized by payors as integral to optimal patient care. ionizing radiation exposure from radiography in the neonatal intensive care unit-per-patient cumulative effective doses amaya basta, radiology and biomedical imaging, ucsf; jesse courtier, john mackenzie purpose or case report: to better understand the levels of exposure to ionizing radiation for infants in the neonatal intensive care unit (nicu). we retrospectively collected the number and types of radiographs performed per infant in our nicu by searching our radiology information system database over a five-year period. we focused on the most common examinations (98% of all radiographs) and assigned each an estimated equivalent dose based on published literature: chest and abdomen021.3 micro sieverts (μsv), one-view chest013.3 μsv, abdomen013.5 μsv, twoview chest026.6 μsv, two-view abdomen027 μsv. we then calculated a cumulative equivalent dose (ced) for each infant based on the number of each type of examination they received. descriptive statistics were generated to depict the distribution of number of examinations and ced. results: over five years, 2,626 infants cared for in our nicu received at least one radiograph of the chest and/or abdomen. the number of examinations obtained on these infants was 9.6, 4, 1, 137 (mean, median, minimum, maximum). the 1st quartile was 1 and the 3 rd quartile was 11 examinations. the cumulative equivalent dose these infants received was 157.9, 61.2, 13.3, 2, 092.2 μsv (mean, median, minimum, maximum) . the 1st quartile was 21.3 and the 3 rd quartile was 61.2 μsv. two hundred infants (7.6% of the study population) received a ced of over 500 μsv. conclusions: descriptive statistics provide a valuable assessment for the broad range of radiation that infants receive in the nicu. although the distribution is skewed towards a low level of exposure, a subset of patients (7.6%) received a ced of over 500 μsv. identification of factors that cause infants to enter this group will be important for future dose reduction strategies. poster #: cr-001 congenital cardiac fibroma: a case report earic bonner, meharry medical college, ebonner07@email. mmc.edu; seth crapp, david parra purpose or case report: a 5-week-old male presented to his pediatrician with a ii/vi systolic ejection murmur along the left sternal border. he had mild tachypnea without cyanosis. his oral intake was adequate with no evidence of failure to thrive. he was referred to a pediatric cardiologist who performed an ecg and a transthoracic echocardiogram. the ecg showed normal sinus rhythm at 135 beats per minute with no abnormalities. the transthoracic echocardiogram showed a 25 x 25 x 14 mm homogeneous mass originating from the anterior free wall of the right ventricle, and mild dilation of the right ventricle. mild dynamic subpulmonary stenosis and a secundum atrial septal defect were also noted. although the murmur was significantly louder at one month follow-up, a repeat echocardiogram did not reveal any increase in the size of the mass. at 2 months of age, a cardiovascular magnetic resonance imaging (cmri) study under general anesthesia was performed. cmri revealed a 16 x 21 x 22 mm cardiac tumor that was causing narrowing of the right ventricular outflow tract. the tumor was hypointense on t2-weighted imaging and hyperintense on t1weighted imaging, with positive delayed enhancement. these findings, along with the size and location of the mass, are consistent with a diagnosis of a cardiac fibroma. chest mra, that was also performed, showed normal extracardiac vascular anatomy with no evidence of peripheral branch pulmonary stenosis. cardiac fibromas do not usually increase in size; however, the concern is the child's risk of arrhythmias. frequent holter monitoring was recommended for this patient. considerations were also made for an electrophysiology study in the next 1-2 years to determine the risk of ventricular ectopy. at that point, the patient can be assessed for the possibility of resection of the fibroma. purpose or case report: treatment of pulmonary atresia is complex and demands intricate solutions. one solution is the creation of a conduit between the right ventricle and the main pulmonary artery. the lifespan of these conduits is limited by progressive occlusion over time, which can be treated with endovascular stent placement in lieu of surgical re-intervention. however, these stents are at high (40%) risk for fracture, typically at the stent waist. the radiologist should be aware of this complication, as they may be the first to identify it on chest radiograph. the purpose of this electronic poster is to familiarize radiologists with this entity by presenting 3 cases of stent fracture and migration. methods & materials: over a 6 month period, we identified three children with rv-pa stent fractures and associated stent migrations on chest radiography. imaging analysis was focused on the appearances of these fractured stents. patient management and outcomes were reviewed. results: three children, 2 males, 1 female (ages 4, 3, and 3 years) were found to have asymptomatic rv-pa conduit stent fractures with fragment migration. one chest xray was performed in the er for fever and cough; one was pre-op for gi surgery; one was done to confirm abnormal findings seen on a routine cardiac echo. the time between stent placement and fracture detection ranged from 1 to 22 months. two patients had stent fractures and embolizations to the right ventricle that required open surgery to remove stent fragments. the third patient had embolization to both pulmonary arteries, but did not require treatment. all patients did well. conclusions: stent fractures and migrations are a relatively common complication of rv-pa conduit stent placement. pediatric radiologists need to be aware of this complication in order to provide value-added interpretations. purpose or case report: we describe the case of a 23 week stillborn fetus with a 5.5 cm diameter craniopharyngioma detected by ultrasonography. a g1p0 woman in her third decade had ultrasonographic examination showing hydrocephalus, polyhydramnios and an intracerebral mass. the nature of the mass was uncertain and intracerebral hemorrhage was considered. the pregnancy was terminated at 23 weeks gestation. at postmortem examination the decedent was a 650 g male fetus with a head circumference of 24.5 cm and a crown-rump length of 21.8 cm. anterior and posterior fontanelles appeared large. no other external abnormality was found. the placenta was unremarkable and cytogenetics on placental tissue showed a normal male karyotype. examination of fetal viscera was remarkable for mildly underweight adrenal glands (0.75 g, expected 1.5 g) and hepatomegaly (66.4 g, expected 21.7 g). intracranial csf was increased in volume. there was a suprasellar 5.5 cm diameter somewhat gritty, but smooth-surfaced tumor. the brain and tumor together weighed 135 g. the floor of the cranium and sella turcica were grossly normal. histologic examination of the tumor showed an adamantinomatous type craniopharyngioma with characteristic epithelium, stellate reticulum, focal keratinizing squamous epithelium and calcification. pre-and postnatal mri of caudal regression syndrome claire b. beaumont, md, university of arkansas for medical sciences, cbbeaumont@uams.edu; nafisa k. dajani, leann e. linam purpose or case report: caudal regression syndrome is a rare form of caudal dysplasia characterized by a spectrum of findings including agenesis of the lumbosacral vertebra, multiple orthopedic deformities in the lower limbs, as well as anomalies of the gastrointestinal and genitourinary tracts. the mechansim of caudal regression syndrome is not completely understood but is believed to be secondary to a defect in the induction of caudal elements. mri is a valuable tool for identifying the specific anomalies involved with caudal regression syndrome on a case-by-case basis. the following is a case from our institution which includes both pre-and postnatal mri. unsuspecting tuberous sclerosis diagnosed on neonatal cranial ultrasound vikas menghani, md, pediatric radiology, women's and children's hospital, drvikasmenghani@gmail.com; puneet gupta, richard thomas, vaseem iqbal, jan najdzionek. purpose or case report: tuberous sclerosis (ts) is a rare autosomal dominant genetic disorder causing hamartomatous proliferation in number of organ systems. because the classical triad of epilepsy, mental retardation and adenoma sebaceum is not commonly seen on clinical examination, imaging plays a central role in the diagnosis and treatment of tuberous sclerosis. central nervous system features of ts include subependymal nodules, cortical tubers, subependymal giant cell astrocytoma, white matter bands and cysts. in patients with ts, cerebral involvement in the form of subependymal nodules is seen in 95% to 100% and white matter abnormalities are noted in 40% to 90% of cases. knowledge of expected radiological features is thus important in making the correct diagnosis. recent studies have indicated that earlier appearance of brain lesions indicate a greater risk of mental retardation and a more severe clinical course. we present a case of a 23-day-old neonate who was referred to us with concerns for hydrocephalus. the cranial ultrasound demonstrated multiple echogenic subependymal nodules of varying sizes and mild asymmetry of the ventricles. the differential diagnosis included ts, torch infections, and x-linked subependymal heterotropia. areas of increased echogenicity were noted within the white matter of the left frontal lobe, which favored ts. subsequently, an mri was performed to validate these findings and assess for additional white matter lesions. the mri showed classic manifestations of ts that included periventricular lesions and streaky, linear, wedge-shaped hyperintensities on flair imaging. a noncontrast ct scan was also performed which revealed classic calcified subependymal nodules. cardiac rhabdomyoma and renal angiomyolipoma are the other recognized manifestations of ts and were respectively excluded by subsequent echocardiogram and renal ultrasound. pyloric atresia with epidermolysis bullosa: fetal mri diagnosis with postnatal correlation arnold c. merrow, md, radiology, cincinnati children's hospital medical center, carl.merrow@cchmc.org; jason s. frischer, anne w. lucky purpose or case report: pyloric atresia (pa) is an uncommon disorder, accounting for 1% of congenital gastrointestinal atresias. up to 55% of cases have associated anomalies, the most common of which is epidermolysis bullosa (eb). prenatal findings have been reported sonographically for each of these anomalies, both in isolation and in the rare case of association. a case of isolated pa has been reported by fetal mri. we present the first reported case of pa with eb diagnosed by fetal mri with corroborative postnatal imaging and surgical findings. the mother of this child was initially referred to the fetal care center of cincinnati at 21 weeks gestation for a possible myelomeningocele diagnosed by prenatal ultrasound at an outside facility. these ultrasound images were not available for review at the time of our workup. a fetal mri was the first study to be obtained at our institution. the mri showed no myelomeningocele or brain anomalies. the stomach was moderately enlarged throughout the exam and did not empty. subjective polyhydramnios was also noted. no duodenal dilation was seen, and there was minimal fluid in the distal bowel loops. this constellation of findings raised concern for pyloric atresia, resulting in a careful search for any sign of epidermolysis bullosa due to a known association of these disorders. prominent debris was seen layering dependently in the amniotic fluid and in the dilated fetal stomach, and the external ears were abnormally small and misshapen. the pa-eb association was proposed as the underlying diagnosis based on our mri findings. it was also postulated that skin blistering over the lumbosacral spine at the time of the prior outside ultrasound could have mimicked a myelomeningocele, thus prompting the referral to our center. at delivery, the baby had numerous skin defects, and the ears were malformed. an abdominal radiograph obtained after nasogastric tube placement and air injection showed no gas beyond the stomach. a pyloric ultrasound showed a distended stomach without a patent pyloric channel to the duodenal bulb, consistent with pyloric atresia. a skin biopsy confirmed epidermolysis bullosa, and the patient underwent a resection of the pa with gastroduodenostomy. the baby subsequently expired less than two weeks later, most likely due to sepsis based on wound cultures and autopsy results. our case demonstrates the ability of fetal mri to diagnose this rare condition and highlights the key imaging manifestations of the pa-eb association. disclosure: dr. merrow has indicated that he is an author for amirsys and receives a royalty accordingly. purpose or case report: we demonstrate a case where the changing position of the contrast filled appendix lead to the diagnosis of malrotation, with review of the embriology of intestinal rotation. a newborn preterm female presented with a golf ball sized umbilical mass, that reduced by itself, thought to represent an umbilical hernia vs omphalocele. she was unstable to undergo an upper gi exam under fluoroscopy, therefore a limited contrast study was performed at bedside and was inconclusive for malrotation. subsequent nicu radiographs showed changing position of the appendix filled with residual contrast, visiting all quadrants of the abdomen in a random pattern over a few days period. this confirmed our suspicion for malrotation. it is well know that in malrotation the position of the cecum can be variable, most commonly located in the right upper quadrant or left lower quadrant. to our knowledge it has not been described yet that the changing position of the appendix can lead to the diagnosis of malrotation. through this case we display the embriology of the intestinal rotation and the radiologic signs of malrotation. poster #: cr-008 mr imaging patters of liver transplant complications in the pediatric population edward richer, md, emory university, richerej@gmail. com; adina alazraki, jonathan loewen purpose or case report: pediatric liver transplantation is a relatively common surgery, with more than 500 transplants in the united status annually. the spectrum of post transplant complications has been previously described, primarily utilizing ultrasound. as mri has become a more widely used technique in pediatric imaging, and ultrasound findings may be non-specific, knowledge of mr imaging patterns is an important adjunct in the post-transplant evaluation. we present a spectrum of complications, including vascular, biliary, hepatic parenchymal, and systemic complications. methods & materials: using an electronic record system, we identified pediatric patients with prior liver transplantation who subsequently underwent abdominal mri at our institution and were found to have a post transplant complication. patient management and outcomes were reviewed. results: our review of a subset of the available patients shows vascular complications to be the most commonly encountered abnormality at our institution, including hepatic artery stenosis/thrombosis, and portal vein stenosis/ thrombosis, cavernous transformation of the portal vein. biliary complications were relatively common, including bilary stenoses and bilomas. hepatic parenchymal and systemic complications, such as ptld, were less common. we demonstrate the mr imaging patterns of these complications. conclusions: pediatric liver transplantation is a relatively common surgery, and the mri appeance of post transplant complications warrants illustration as abdominal mri becomes more widely used in pediatric imaging. we present a pictorial review of common patterns of complication. imaging of progressive familial intrahepatic cholestasis (pfic) matthew d. dobbs, md , radiology, vanderbilt university medical center, matthew.dobbs@vanderbilt.edu; sumit pruthi, stephanie e. spottswood purpose or case report: progressive familial intrahepatic cholestasis (pfic) is a relatively rare pediatric liver disease due to a genetic mutation (abcb11 gene on chromosome 2q24-31) in a bile salt export protein causing cholestasis leading to chronic inflammation within the biliary system. the diagnosis is made clinically with detection of a low ggt in the face of an elevated bilirubin and alkaline phosphatase. genetic testing confirms the diagnosis. one of the 3 subtypes, type 2, was shown in 2006 to be highly related to the development of hepatocellular carcinoma. the vast majority in children in this study developed hcc at less than 2 years of age. radiological contribution to the management of these chronic liver disease patients is to perform surveillance imaging to detect hcc. due to the rarity of this condition, almost no reports exist in the radiological literature describing the imaging features or management of this condition. our presentation will review the imaging findings in our small population of pfic type 2 patients on us, ct, and mri. we will also review suggested surveillance imaging techniques and imaging algorithms. renal rhabdoid mimics wilms tumor vikas menghani, md, pediatric radiology, women's and children's hospital, drvikasmenghani@gmail.com; paul montgomery, jan najdzionek, vaseem iqbal purpose or case report: in the past most pediatric renal tumors have been classified together under the umbrella of wilms tumor. however, over the last decade with advancement in imaging, several distinctive imaging features specific to renal tumors have been recognized which aid in their classification as being distinct pathologically. we present a case of rhabdoid tumor where in the primary tumor arose from the kidney. it had classical imaging features of wilms tumor. we want to highlight that even with the most sophisticated imaging techniques, specific renal tumors cannot always be diagnosed with preoperative imaging and how this alters the management and prognosis for child with a renal mass. in our case, the postoperative findings, pathology and immunohistochemical techniques confirmed a rhabdoid tumor. differentiation of these two tumors is essential since in patients with rhabdoid tumor survival is poor with 4-year overall survival rates of 42% for stages i and ii and 16% for stages iii, iv, and v. on imaging, there are several features that suggest the diagnosis of rhaboid tumor. these include subcapsular fluid collections, linear calcifications outlining tumor lobules, and vascular invasion. also, a pertinent feature of rhabdoid tumor due to its aggressive nature is the presence of lung metastasis (83%) and synchronous malignant brain lesions (15%). these findings were not present on our case, which led us in formulating a diagnosis of wilms. our patient is unusual in the fact that the local renal findings and absence of metastasis, synchronous malignant lesions, and vascular invasion led us to an incorrect diagnosis of wilms tumor. in conclusion, we would like to stress that diagnosis of rhabdoid tumor of the kidney on imaging presents a challenge because of its imaging similarity to wilms tumor. ectopic ureters in young infants: mru findings shin-lin shih, md, department of radiology, mackay memorial hospital; yi-fang chen, chun-chao huang, fei-shih yang purpose or case report: to localize the terminations of ectopic ureters by mri methods & materials: mr urography (mru) was conducted in four female patients with hydroureter and a suspected ectopic orifice. mr imaging was performed with a 3 t mr scanner (achieva; philips). the imaging protocol mainly consisted of a single-shot t2-weighted turbo spin echo sequence with a slice thickness of 4 mm and multiplanar reformations. the ages of the four patients were 1 day, 3 days and 2 months (for two). the latter two patients presented with urinary tract infection. the newborn patients presented with abnormal prenatal examination. the pertinent findings and descriptions of a variety of renal anomalies were described. results: the locations of the ectopic ureters were two in the vagina, one in the uterus and one in the bladder neck. the associated renal anomalies were a right duplex kidney in four, a left duplex kidney in one, a left ectopic dysplastic kidney in one and vesicoureteral reflux in one (confirmed by vcug). conclusions: mru may demonstrate the exact point of termination of an ectopic ureter and also the associated renal anomalies. poster #: cr-012 acquired polycystic kidneys in neuroblastoma survivors richard bellah, , radiology, the children's hospital of philadelphia, bellah@email.chop.edu; bernard kaplan, camilo jaimes, yael p. mosse, jill p. ginsberg, kevin e. meyers purpose or case report: neuroblastoma (nbl) is the most common extracranial solid malignancy of childhood. with current therapy, the prognosis and long term survival of patients affected by this condition has dramatically improved. nevertheless, the treatment for nbl may account for some complications further in life. in patients with neuroblastoma, acute renal failure can occur usually as a result of a thrombotic microangiopathy associated with bone marrow transplantation. in addition, end-stage renal disease has been reported in long-term survivors of nbl. this exhibit describes and illustrates the first case series of five patients with treated nbl in whom the imaging features of polycystic kidney disease (pkd) developed over time, and in some cases, as progressive renal failure ensued. methods & materials: medical and imaging records were reviewed (irb approved) of patients with treated nbl in whom pkd became apparent during the course of followup imaging. results: five patients displayed findings of pkd on us and/or ct. three of the five patients (where images were available) had normal renal imaging at time of nbl diagnosis. the mean age at nbl diagnosis was 2.4 years (range 1.3-3.3 yr). the mean age at time pkd was detected was 14.6 years (range 8-18 yrs). none of the patients had a family history of pkd, or had previously undergone dialysis. all patients received chemotherapy and total body irradiation prior to bone marrow transplantation. four patients survived nbl therapy but eventually developed end-stage renal disease. conclusions: an association between acquired pkd and nbl has not been previously reported. the etiology of this observation is still unclear, but a toxic insult is likely to account for the renal changes. further research is needed to establish the epidemiology, prognosis, and etiology of this association. abnormal migration of the retention anchor suture in a case following gastrostomy tube insertion surendra narayanam, mbbs, dmrd, dnb, division of image guided therapy, department of diagnostic imaging, the hospital for sick children, nrssbabu@gmail.com; joao amaral, luke toh, bairbre connolly, vicente deoliveira, dimitri parra purpose or case report: during percutaneous gastrostomy tube placement, retention anchor suture(s) are deployed into the stomach to tack the anterior gastric wall to the abdominal wall. in our practice the thread of the retention anchor suture is cut at 14 days and the metallic portion passes pre rectum. we report an interesting and very rare migration of the metallic portion of the retention anchor suture in post-primary gastrostomy tube insertion. an 8-month-old girl, with a mitochondrial disease and severe hypotonia underwent percutaneous gastrostomy placement. during the procedure the retention anchor suture thread snapped and the metallic portion of the suture remained within the stomach. day1 post procedure, the child became uncomfortable, so a gastrostomy tube check was performed. the suture was not visible in the abdomen on abdominal x-ray or fluoroscopically. on close review of the images, the suture was found projected over the distal esophagus. initial impression was the anchor suture had refluxed into the esopahgeal lumen. careful attempts were made to remove it along with the nasogastric tube, from above under fluoroscopic control. however on withdrawal of the nastogastric tube, the retention anchor suture moved enbloc with the nasogastric tube. once removed the retention anchor suture was confirmed to be within the nasogastric tube. this case illustrates the importance of examining the chest x-ray carefully before assuming a retention anchor suture has passed. to understand the appropriate post procedural radiographic workup and its technique for timely diagnosis. 3. to learn the potential complications of delayed diagnosis. pediatric retroperitoneal synovial sarcoma ahmad aouthmany, university of toledo medical center, ahmad.aouthmany@utoledo.edu; asif abdullah purpose or case report: pediatric synovial sarcoma most commonly affects the extremities, especially the lower thigh and knee region; other primary sites such as the retroperitoneum have been only infrequently reported. we report an extremely rare case of a retroperitoneal synovial sarcoma masquerading as retroperitoneal hematoma in a 16-year-old white female with non-traumatic back pain and non-contrast enhanced ct findings of right quadratus lumborum and psoas region presumed hematoma. coagulation studies revealed factor xi deficiency also known as hemophilia c. however, on follow-up imaging, the presumed retroperitoneal bleed persisted and a subsequent mr examination revealed a solid enhancing mass. ct, mr, and fdg-pet findings as well as a brief histopathology are discussed. our case is rare in the regards that the tumor occurred in an uncommon retroperitoneal location in a pediatric patient and was mimicking a retroperitoneal hematoma which posed a significant diagnostic challenge. despite a rare entity, synovial sarcoma among other sarcomatous lesions maybe considered in the differential consideration of a spontaneous retroperitoneal hematoma even in hemophiliac patients. longitudinal bracket epiphysis michael jubang, geisinger, mjjubang@geisinger.edu; farzad sedaghat, william j. malone, george wu, william mirenda purpose or case report: longitudinal bracket epiphysis is a rare anomaly with multiple synonyms such as delta bone, triangular bone, and congenital angular deformity. the purpose of this case report poster is to discuss an 11-month-old male born with an adducted right great toe with a broad nail and a notch in the center of the distal phalanx. the review will discuss radiographic findings, the natural progression of the disease, the treatment options, the mri findings used for pre-surgical planning, and associated pathology. whole body mri in pediatric non oncologic diseases: pictorial review ramy el jalbout, md, radiology, chu sainte justine, ramy.jalbout@yahoo.com; vijay moorjani purpose or case report: with the advances in scanning techniques and the scanning sequences, the role of wbmri is expanding. mri has a great role in the pediatric population owing to its inherent advantages namely lack of radiation, high tissue specificity, and high diagnostic yield at the level of the entire body under a single sedation. unlike the application of wbmri in the assessment of metastasis and bone marrow involvement in leukemia, its role in systemic diseases is yet to be further investigated. certain diseases such as crmo are very often multifocal. the extent of osteonecrosis in patients on steroids, dermatomyositis and the lesions related to child abuse are very often wide spread in the skeleton. we intend to present some of the findings of these pediatric systemic and multifocal diseases on wbmri. chronic relapsing multifocal osteomyelitis (crmo): crmo can be acute or chronic and is multifocal. the abnormality manifests as high signal intensity. wbmri can guide for the best site for biopsy and provides monitoring for response to treatment. osteonecrosis: only few small studies evaluated the usefulness of wbmri in the diagnosis of both the symptomatic and asymptomatic sites of osteonecrosis in all patients on steroid therapy. wbmri is more sensitive than conventional radiographs. the abnormalities are typically geographical areas of high stir signal intensity. myopathies: wbmri has also the role of detecting the extent of idiopathic inflammatory myopathies such as dermatomyositis in the entire skeleton. child abuse: wbmri has a low sensitivity for the highly specific fractures that are pathognomonic for child abuse. conclusions: wbmri is a useful examination in the pediatric patient that is radiation free, quick and allows imaging of the entire body. it is an adjunct to dedicated mris to look for multifocality and extent of systemic diseases such as crmo, osteonecrosis in patients on steroids and dermatomyositis. it has a great potential as a screening examination but at the same time can detect both the symptomatic and the asymptomatic lesions in the bone marrow and muscles that are otherwise not seen on conventional radiography. it also allows guidance for biopsy and monitors response to treatment. mobile "cerebroliths" in hemihydranencephaly: a case report usha d. nagaraj, md, the ohio state university medial center, usha.nagaraj@osumc.edu; brent adler purpose or case report: hydranencephaly is a congenital central nervous system disorder manifested by the replacement of the cerebral hemispheres with a thin membranous sac filled with cerebrospinal fluid and necrotic debris. hemihydranencephaly is an extremely rare brain condition in which the vascular anomaly is unilateral, with fewer than 10 cases previously reported in the literature. this is a case of a 4-month-old male who presented to the ophthalmologist for evaluation of possible leukocoria of the right eye. the patient had a history of a difficult vaginal delivery that required forceps delivery with possible associated trauma to the right eye. dilated fundoscopic exam revealed retinal calcifications. this caused a clinical concern for retinoblastoma and ct and mri of the orbits were obtained. ct demonstrated profound dilatation of the left lateral ventricle with only a thin rim of cortex surrounding it. there was some midline shift to the right with mild dilatation of the right lateral ventricle. the thalami and brainstem were spared. there were multiple soft tissue bodies that layered in the dependent portion of the left lateral ventricle, which were isodense to grey matter. mri revealed similar findings consistent with hemihydranencephaly involving the left cerebral hemisphere. there were multiple round soft tissue masses that measured up to 1 cm in size that layered posteriorly in the left lateral ventricle. these masses were isointense to grey matter on t2 and hyperintense on t1. when the patient was placed with his head turned to the left, these masses moved to the dependent portion of the left lateral ventricle. the orbits were normal on both ct and mr. these soft tissue collections are presumed to be mobile collections of infarcted brain tissue. this unusual appearance has not been described in the radiology literature. we review the ct and mr findings and review the relevant literature. purpose or case report: citrullinemia type i is a rare inborn error of urea cycle metabolism resulting in hyperammonemia. in the classic form, the newborn presents with poor feeding, vomiting, progressive lethargy and signs of increasing intracranial pressure 3-7 days after birth, rapidly progressing to apnea, coma and death if left untreated. we present a case of a term infant who presented to the hospital on the 5th day of life with a typical history of poor feeding and profound hypotonia. upon admission he had multiple episodes of apnea and hemodynamic instability prompting intubation and intensive support. laboratory evaluation revealed multiple abnormalities, most notably, hyperammonemia (910umol/l) and elevated citrulline (>800umol/l). mri of the brain performed on the 7th day of life showed findings consistent with term hypoxic ischemic encephalopathy with restricted diffusion in bilateral rolandic cortex and subcortical white matter, bilateral caudate heads and lenticular nuclei, bilateral insular cortex, and bilateral cerebral peduncles. the genu of the corpus callosum, bilateral deep frontal white matter, and the left parietal white matter also demonstrated restricted diffusion suggesting infarction secondary to thrombosis of deep intramedullary veins. an area of restricted diffusion in the right parietal cortex was suspicious for superficial venous infarct. review of the literature reveals that this case of neonatal citrillunemia has unique mri findings. while our patient had diffusion changes with some shared similarities to the previous two cases in the literature, there are also findings consistent with deep intramedullary venous thrombosis and infarction. poster #: cr-020 duplicated internal auditory canal: a rare anomaly of the temporal bone ahmad aouthmany, university of toledo medical center, ahmad.aouthmany@utoledo.edu; asif abdullah purpose or case report: duplicated internal auditory canal (iac) is a rare anomaly of the temporal bone, which is usually associated with sensorineural hearing loss. only a few cases have been previously described in literature. we describe an extremely rare case of duplicated right internal auditory canal in a six month-old patient with a history of down syndrome. a six month-old male with trisomy 21 presented with profound bilateral sensorineural hearing loss. the patient failed the newborn hearing screening tests. past medical history was unremarkable for recurrent ear infections. on focused physical examination, the auricles were normal appearing. external auditory canals were patent bilaterally revealing clear and translucent tympanic membranes. patient did not reveal a facial palsy. subsequently, a high resolution computed tomography (hrct) of the temporal bone was performed. duplicated appearance of the right internal auditory canal with separation of facial and vestibulocochlear segments was noted. the facial nerve canal demonstrated normal caliber while there was significant narrowing of the cochlear canal near the fundus. significant stenosis of the vestibulocochlear segment of the duplicated iac was identified at the porus acousticus. dehiscent right posterior semicircular canal was also seen. an enlarged right vestibule was also noted. a single iac was identified on the contralateral side with significant stenosis at the porus acousticus. high-resolution magnetic resonance imaging of iac was recommended which revealed normal appearance of the bilateral cochlear and vestibular nerves. duplication of the iac is an extremely rare anomaly involving a redundant osseous canal extending from the cerebellopontine angle through the otic capsule bone toward the labyrinth or cochlea. a duplicated iac may or may not be associated with congenital sensorineural hearing loss secondary to aplasia or hypoplasia of the vestibulocochlear nerve. to evaluate for structural abnormalities that may preclude cochlear implantation, it is important to evaluate pediatric patients with sensorineural hearing loss radiologically. although hrct is the best imaging modality for evaluation of osseous iac, the iac contents are best viewed on mri in oblique sagittal planes of the iac using a 3-d volumetric steady state sequence. neuroimaging in hemiplegic migraine: cases and review of the literature nicholas v. stence, md, children's hospital colorado-radiology, nicholas.stence@childrenscolorado.org; sita kedia, john a. maloney, jennifer armstrong-wells, timothy bernard purpose or case report: hemiplegic migraine (hm) is a rare variant of migraine with aura. it is characterized by a motor deficit lasting up to 24 h that is fully reversible. little neuroimaging data for hm exists in the literature. we report our experience with two pediatric cases of hemiplegic migraine. we also review published cases of pediatric hm with abnormal findings on neuroimaging. methods & materials: cases 1 and 2 presented to our institution with severe headache (ha), acute right-side weakness, aphasia, and altered mental status (ams), which did not resolve after 24 h. magnetic resonance imaging (mri) and genetic testing are reviewed for these cases. the literature was reviewed for pediatric cases with neuroimaging changes during hm attacks. results: initial mri, including diffusion-weighted imaging (dwi), was negative in both patients within 24 h of onset. repeat mris at 93 h (case 1) and 75 h (case 2) were both positive for mild hyperintensity on trace diffusion images, and corresponding reduced diffusion on adc maps, involving regions of the cortex and juxtacortical white matter in left middle cerebral artery distributions. these findings completely resolved at 3 months in both cases. mr angiograms (mra) were negative in both cases. case 1 had a family history of migraines and was found to have an unreported mutation in atp1a2 gene at a highly conserved location in vertebrates. case 2 had a family history of hm and was found to have an indeterminant mutation in the cacna1a gene. infectious, metabolic and hypercoagubility work up was negative. case 1 required inpatient rehabilitation and at 1 year follow up was requiring speech therapy. case 2 resolved completely. in the literature, 6 cases of hemiplegic migraine with neuroimaging changes were reported. all cases had prolonged hemiplegic migraines (symptoms>24 h) and showed cerebral edema with or without restricted diffusion. conclusions: all eight hm cases in the literature with abnormal findings on neuroimaging had prolonged attacks. mris for our two cases and two cases reported in the literature were initially normal at admission. mild swelling and restricted diffusion developed in our two cases after 24 h, and resolved on follow up mris. subtle findings on diffusion and t2 imaging may lag behind the clinical picture in hm, therefore serial neuroimaging may be useful in individuals with prolonged symptoms. most cases eventually show resolution clinically and on mri. correlation of neurosonographic anatomy with matching mr scan planes denise castro, hospital for sick children, denisecastro22@ gmail.com; pam rasalingham, omar islam, don soboleski purpose or case report: new high-resolution mr sequences have allowed for exquisive anatomic detail and enables reconstruction of images in any scan plane desired. this ability allows for precise matching of mr image planes with the standard oblique coronal, sagittal and axial images obtained during routine neurosonography. the purpose of this poster is to correlate the morphology demonstrated on neurosonography with the mr image, utilizing this ability in order to enhance our understanding of the neuroanatomy distinguishable on sonographic imaging. we believe this will allow a better appreciation of the subtle differences in echotexture of neuroanatomic structures which are often ignored or overlooked on neurosonography and help improve our detection of subtle sonographic abnormalies. ectopic cerebellum in the posterior cranial fossa: report of a case and review of the literature usha d. nagaraj, md, the ohio state university medical center, usha.nagaraj@osumc.edu; daniel boue, lisa martin purpose or case report: cerebellar heterotopia is a common congenital anomaly frequently encountered in the form of cell rests around the fourth ventricle. however, isolated well-differentiated cerebellar ectopia is extremely rare. of the 8 previously reported cases in the literature, only 4 have presented as a discrete, extraaxial mass and none have been described in the posterior cranial fossa. we present a case of a 5-year-old male who initially presented with persistent daily headaches. physical exam including a detailed neurologic exam was within normal limits. non-contrast computed tomography (ct) of the brain was initially performed, demonstrating no abnormalities. further work-up with magnetic resonance imaging (mri) was performed, which revealed a well-defined, extra-axial mass superior to the cerebellum and inferior to the tentorium, immediately beneath the vein of galen. the mass was isointense to grey matter on t1 and t2 sequences and there was no significant enhancement on post-contrast images. there was mass effect on the vermis and the cerebellar tonsils were displaced 3 mm below the foramen magnum. neurosurgery was consulted and the mass was removed for diagnosis and treatment of the patient's symptoms. the mass was easily identified intra-operatively and gross total resection was accomplished successfully. pathologic analysis of the mass revealed well-formed cerebellar tissue without evidence of neoplasia. to the best of our knowledge this is the only case of ectopic cerebellum presenting as a discrete extra-axial mass in the posterior cranial fossa. our case shows that an extra-axial mass that parallels grey matter on all sequences can be a presentation of ectopic cerebellum. we describe the ct and mri findings, surgical and histopatholgical results and review the relevant literature. pediatric isodense acute subdural hemorrhage jeffrey s. kao, md, msee, university of kansas-wichita, run4boston@gmail.com; debbie desilet-dobbs purpose or case report: the density (attenuation coefficient) of subdural hemorrhage (sdh) in computed tomography (ct) is important in assessing the acuity of sdhs. an acute sdh is traditionally described as hyperdense and then becoming isodense in approximately 3 weeks when entering the subacute phase. in this report, we document the case of a pediatric patient with the new appearance of an acute sdh within 40 h of the prior ct that was isodense. greater than 95% of the collection was isodense, with a small focus of hyperdensity. acute sdhs are known to be isodense to gray matter in patients with anemia (wp smith, am j neurorad 1981). however, the hemoglobin and hematocrit was within normal limits. in addition, acute sdhs that are only a few hours old can have a mixed hyperdense and hypodense appearance because of uncoagulated blood before clotting takes place (j provenzale, ajr 2007) . thus, an acute sdh can have an isodense appearance in a non-anemic patient. radiologists should consider the possibility of an acute sdh with an isodense appearance, especially in case of possible non-accidental trauma where timing of an injury is important. undifferentiated sarcoma of the esophagus in an 11year-old male: case report and radiologic/pathologic correlation michael e. daniel, md, ut southwestern / children's medical center dallas, michael.daniel@utsouthwestern. edu; lisa sutton, sandy cope-yokoyama, neil j. fernandes purpose or case report: mesenchymal neoplasms of the gastrointestinal (gi) tract occur infrequently in the adult and are extremely rare in the pediatric population. the occurrence of these lesions in the esophagus is limited to a collection of case reports in the available literature. most esophageal mesenchymal tumors in the pediatric gi tract are benign leiomyomas. the vast majority of malignant mesenchymal tumors in children are categorized as either sarcomas or gastrointestinal stromal tumors (gist). we report a case of a high grade undifferentiated sarcoma of the distal esophagus in an 11year-old male. while this tumor most closely resembles a gist, the immunohistochemical profile of the lesion is not typical of any distinct mesenchymal neoplasm. a review of the literature demonstrates a single case report of a likely benign undifferentiated mesenchymal neoplasm of the distal esophagus in an adolescent. to our knowledge, this is the first reported case of an undifferentiated esophageal sarcoma in a pediatric patient. we provide radiologic and pathologic features of the above lesion, and review the typical imaging and pathologic characteristics of mesenchymal gi neoplasms. potential airway management issues in sedated children kimberly fagen, md, ms, children's national medical center, kfagen@childrensnational.org; nadja kadom, ira cohen purpose or case report: many pediatric imaging studies require sedation. it has been shown that a variety of health care professionals other than anethesiologists may provide sedation, including advanced practice registered nurses, nurse practitioners, physician assistants, fellow level trainees, emergency medicine physicians, intensivists, pediatricians and, last but not least, radiologists. moderate sedation, also called "conscious sedation", does generally not require an anesthesiologist as there is usually adequate spontaneous ventilation and no airway intervention required. however, in case of a complication during the imaging study intubation may become necessary. for patients with certain congenital or acquired conditions emergent intubation may be very difficult and should be brought to the attention of an anesthesiologist prior to inducing moderate sedation. the four "d's" is a quick way to assess potentially difficult airways that necessitate consultation with anesthesia prior to moderate sedation: dentition (incisor/tooth size, dental alignment, and macroglossia), distortion (swelling from infection, tumor, or trauma), disproportion (hyoid-chin ratio, such as with micrognathia), and dysmobility (jaw or cervical spine movement issues, i.e. trauma or atlanto-occipital instability). presence of some of these features may be an indication to consider general anesthesia for sedation; at the very least, anesthesiologist's awareness of a potentially difficult intubation adds to patient safety during moderate sedation. purpose or case report: lymphangiomatosis describes the presence of multiple lymphangiomas often with multiorgan involvement; typically bones, spleen, mediastinum and lungs. although lymphangiomatosis has been described in patients ranging from birth up to 80 years, it most frequently presents in childhood. the lesions can occur in any tissue in which lymphatics are normally found, with a predilection for neck and chest involvement. the clinical presentation is variable including pleural or pericardial effusion, hemoptysis, protein wasting enteropathy, peripheral edema, hemihypertrophy and disseminated intravascular coagulopathy. the coexistence of lytic bone lesions and chylothorax serves as an important diagnostic clue. we describe typical radiographic, ct and mri findings in the appropritate clinical setting that narrow the differential diagnosis and raise concern for this rare entity as the etiology for the patient's symptoms. we report a 12-year-old girl and 2year-old boy with pulmonary lymphangiomatosis with typical presentation and imaging findings. results: bilateral interstitial infiltrates, pericardial and pleural effusions are evident on chest radiograph. sampling of the pleural fluid demonstrates chylous effusion. ct scans of the thorax reveal diffuse smooth thickening of interlobular septa and bronchovascular bundles with extensive infiltrative involvement of mediastinal fat. osseous and splenic lesions are demonstrated both on ct and mr. differential diagnosis includes interstitial edema, lymphoma and sarcoidosis. conclusions: the natural history of pulmonary lymphangiomatosis is characterized by progressive growth and compression of adjacent structures. therapy should aim to decrease the compressive effects, to control chylous effusions, and to maintain cosmesis. the success of surgical resection is limited by inability to separate lymph collections from normal structures. characteristic clinical and radiographic presentation, chylothorax, and extrathoracic lymphatic dysfunction should prompt a consideration of lymphangiomatosis and prevent delay in diagnosis. aortic arch congenital anomalies: what the radiologist needs to know luana stanescu, radiology, seattle children's hospital, stanescu@u.washington.edu; stephen done purpose or case report: 1. review classic imaging findings in congenital aortic arch anomalies which can improve detection on radiographs and barium esophagogram 2. describe pertinent embryologic basis of the radiologic findings 3. describe correlative imaging findings on ct and/or mri in dedicated cases 4. describe common diagnostic pitfalls methods & materials: after obtaining institutional irb approval we reviewed various patients presentations with this condition and analyzed images to characterize this particular entity and it's manifestations for better definition of diagnostic criteria. results: radiographs and barium esophagogram: algorithmic approach in reviewing chest radiographs in order to improve detection of aortic arch anomalies; classic findings and common pitfalls. cross-sectional imaging (ct and mri): what the surgeons need to know before surgical repair; detection of associated cardiac anomalies. sample cases: double aortic arch, double aortic arch with complete or partial atresia of one of the arches. conclusions: major teaching points of this exhibit are: 1. review of classic features of congenital aortic anomalies on radiographs, esophagogram, ct and mri with pertinent embryologic basis 2. describe the utility of various imaging modalities in congenital aortic anomalies, emphasizing common pitfalls. cardiovascular and mediastinal imaging in children with unexpected clinical presentation shunsuke nosaka, md, radiology, national center for child health and development, nosaka-s@ncchd.go.jp purpose or case report: children with cardiovascular and mediastinal diseases can be congenital or acquired in etiology. they usually present with straightforward clinical course. in certain situation, however, some of the children show unexpected clinical presentation predominantly with those of neighboring organs such as respiratory tract, hepatobiliary system, and gastrointestinal tract. these unexpected presentations can be the cause of delay in proper diagnosis and treatment. the purpose of this exhibit is demonstrate a variety of imaging findings of cardiovascular and mediastinal diseases in children with unexpected clinical presentation. this exhibit is case based presentation of cardiovascular and mediastinal imaging in children including tips, pitfalls and lessons learned among patients presented with unexpected clinical presentation. diagnostic imaging modalities for cardiovascular disease usually consist of various combinations of plain radiography, ultrasound, ct, mr imaging, fluoroscopy, nuclear medicine, and angiography. the general concept of alara-as low as reasonably achievable-should always be utilized when radiation-producing modalities are indicated in children. the diseases included will be double aortic arch found during workup for the cause of aspiration pneumonia, unilateral pulmonary vein atresia presented with recurrent episodes of pneumonia, severe mitral regurgitation secondary to chordal rupture mimicking fluminant hepatic failure, myocarditis initially present as acute abdomen, cardiomyopathy as unusual initial presentation of neuroblastoma, and thymolipoma mimicking gradual development of cardiomegaly. conclusions: it is important for radiologist to be familiar with imaging findings of cardiovascular and mediastinal diseases in children with unexpected clinical presentation. cardiac embryology made easy: a novel teaching approach using claymation andrew phelps, children's hospital boston, aphelpsmd@ gmail.com; purpose or case report: congenital heart disease can be an intimidating subject for radiology residents, and cardiac embryology is key to its understanding. however, this can be an equally intimidating topic to teach! various diagrams and animations are available in textbooks and online, but much like advanced origami, many of these resources suffer from being visually too complex for the first-time learner. to overcome this teaching obstacle, i created my own cardiac embryology animations using modeling clay and incorporated them into a comprehensive didactic lecture on congenital heart disease. methods & materials: cardiac embryology animations were created using modeling clay, a digital camera, and microsoft powerpoint. surface and cross-sectional views were generated, depicting the key events in cardiac embryology: heart tube formation, cardiac looping, chamber division, truncus arteriosus division, and pulmonary venous connection. example models are shown in figure 1 . results: in this lecture, the animations are presented alongside actual embryonic heart photographs. the lecture then uses the embryology knowledge as a basis to explain the common congenital heart diseases and their mri appearances. examples of septal defects, ventricular hypoplasia, and transposition of the great arteries are presented, among others. conclusions: understanding cardiac embryology is required in order to approach congenital heart disease in a logical fashion. modeling clay animations are a cheap and easy way to simplify this complex topic. arterial tortuosity syndrome: an introduction to the clinical and radiologic manifestations in the pediatric population neal desai, umkc som, neal540@gmail.com; suchit patel, ayushi gupta, marius hubbel, doug rivard purpose or case report: 1. to describe the clinical findings of arterial tortuosity syndrome and give a brief discussion of the disease process. 2. to describe the radiologic manifestations of arterial tortuosity syndrome. 3. to give a brief discussion of loeys-dietz syndrome-a disease with similar arterial findings, but with unique molecular characteristics from arterial tortuosity syndrome. 4. to use this knowledge to help establish the diagnosis and reduce mortality. methods & materials: arterial tortuosity syndrome overview • epidemiology • molecular basis • pathophysiology • review of signs, symptoms and presentation • brief discussion of treatment differential diagnosis of arterial tortuosity syndrome • loeys-dietz syndrome-similarities and differences radiologic findings and discussion • chest radiograph • computed tomographic angiography • magnetic resonance angiography-neck • magnetic resonance angiography-head • conventional angiography making a diagnosis • sample case report • review questions conclusions: arterial tortuosity syndrome is a rare disease whose chief manifestation is severe cardiovascular connective tissue defects. due to the nature of these defects and the significance of rapid intervention, it is important to be aware of and recognize the radiologic manifestations associated with arterial tortuosity syndrome in the presence of appropriate clinical history to help offer a better prognosis to the patient. dynamic pulmonary computed tomography for evaluation of cardiopulmonary disease shilpa v. hegde, md, arkansas childrens hospital, university of arkansas, shilpavhegde@gmail.com; s. bruce greenberg purpose or case report: dynamic pulmonary computed tomography (dpct) is a wide-detector ct technique that allows for continuous chest imaging during respiration. when combined with intravenous contrast, the technique is a unique tool for evaluation of cardiopulmonary abnormalities in children with cardiopulmonary abnormalities. the purpose of this poster is to illustrate the technique of dpct for evaluation of cardiopulmonary disease in children with congenital heart disease and persistent respiratory distress. methods & materials: methods and materials: 8 dpct exams with intravenous contrast were performed on 5 infants with a history of congenital heart disease and palliative surgery. four continuous 350 msec gantry rotations were obtained with respiratory rates set at 40/minute. the imaging was accomplished during the time of a single respiratory cycle. 80 kvp and low ma resulted in effective dose of≈1.5 msv. eight respiratory phases were reconstructed to create 3d and mpr cine loops for evaluation of cardiopulmonary abnormalities. results: cardiopulmonary abnormalities were detected in all patients. patency of sano shunt, blalock tausig shunt or patent ductus arteriosus stent was established. intimal thickening was identified in one sano shunt. hypoplastic branch pulmonary arteries were present in 3 infants and pulmonary vein thrombosis in 1 infant. left bronchomalacia was identified in four of five infants and best or only identified on the expiratory phase of respiration. left lung air trapping was present in two patients. conclusions: dpct with intravenous contrast is the ideal study for evaluation of the post-operative infant with congenital heart disease and persistent respiratory distress. the role of low-dose ct angiography in the evaluation of renovascular hypertension in children jessica kurian, md, chop, kurianj@email.chop.edu; monica epelman, kassa darge, els nijs, jeffrey hellinger purpose or case report: historically, the evaluation of renovascular hypertension has been accomplished via us and conventional angiography. based on the reported adult experience we introduced renal ct angiography (cta) for the evaluation of renovascular hypertension in mid-2006. our institution has a robust, well-established protocol, which results in reproducible, high quality images. we aim to present our imaging strategies for the evaluation of these patients and to discuss and illustrate the role of low-dose cta with 3-d imaging as a noninvasive alternative in the evaluation of pediatric renovascular hypertension. methods & materials: we used our department information system to identify pediatric patients (< 18 years of age) who had documented renovascular hypertension confirmed either by conventional angiography and/or surgery during a 5-year period. we present our protocol and discuss the indications, limitations and benefits of renal cta. ct thin slice data, obtained employing dose reduction strategies, was reviewed and reconstructed in 2d and 3d renderings. pertinent us and mr studies as well as demographic and clinical data were reviewed and recorded. several causes for renovascular hypertension were documented and relevant ct angiographic findings were selected for presentation. results: radiation dose ranged 0.58-4 msv. fibromuscular dysplasia was the most common diagnosis followed by neurofibromatosis type 1. vascular pathology included stenoses, beading, occlusions, and aneurysms. disease was noted in the extraparenchymal renal arteries in approximately 70% of the cases. the choice of the imaging modality for the investigation of renovascular hypertension in pediatric patients remains controversial. in the authors' experience, cta with 3-d imaging is a valuable, non-invasive diagnostic tool for the evaluation of pediatric renovascular hypertension. low dose protocols can reduce the radiation exposure associated with ct. this method can spare patients the complications associated with conventional angiography. fetal mri: brain, head and neck malformations-a pictorial essay sumit singh, md, children's hospital of wisconsin, sumitsingh78@yahoo.com; mohit maheshwari, teresa c. gross kelly, tushar chandra, ibrahim s. tuna, craig johnson purpose or case report: the purpose of the exhibit is to illustrate various brain, head and neck massses/vascular anomalies on fetal mri. we will also briefly discuss the normal fetal brain anatomy as seen on fetal mri. methods & materials: major indications for fetal mri include evaluation of inconclusive sonographic findings in cases of cns malformations. in our institute patients are scanned on 1.5 t mr scanner. a body surface six channel phased array coil is used to maximize signal to noise. all the scans are checked by a neuroradiologist to make sure adequate 3 plane imaging of the brain or other lesion in question were performed. 3 plane scanning of the fetal body is also performed for the laterality determination of the lesion and also screen for other congenital anomalies. results: prenatal usg is frequently inconclusive for evaluation of complex fetal brain and head and neck anomalies. most studies suggest that mri after first trimester is safe. in addition, advent of rapid mri sequences like single shot fast spin echo (ssfse) have helped in reducing scan time and motion artifacts leading to availability of diagnostic quality images. these have led to increasing use of mri as supplemental tool to further investigate inconclusive fetal sonographic findings. mri provides better anatomical delineation of these complex abnormalities. it helps in making appropriate diagnosis with high confidence and aids in appropriate obstetric and prenatal/neonatal surgical planning or intervention. this educational exhibit will illustrate few common fetal anomalies. these will include agenesis of corpus callosum, malformation of cortical development, posterior fossa malformations, ventriculomegaly, in-utero stroke, orbital abnormalities and some fetal neck masses/ vascular malformation. correlation and confirmation with the postnatal mri will also be provided for some cases. conclusions: technical and therapeutic advances have driven the development of fetal mri. it is an important adjunctive tool for prenatal imaging in those instances in which a complex anomaly is suspected by sonography, when fetal surgery is contemplated, or when a definitive diagnosis cannot be determined. it has prognostic implications and may help in optimal and timely obstetric and neonatal management. purpose or case report: this educational report will provide a review of the imaging appearance of intradiaphragmatic and subdiaphragmatic pulmonary sequestrations on fetal mri. the proposed pathophysiology, review of sequestration subtypes, and surgical management options will also be described. case examples will be provided to illustrate the fetal mr imaging findings of these variants of pulmonary sequestration that help support the diagnosis. specifically a "triangle sign" of t2 hyperintense tissue directed toward the diaphragm will be demonstrated. illustrative case examples will be placed in the context of a differential diagnosis for subdiaphragmatic masses seen on prenatal imaging. imaging signs that help make a diagnosis of these pulmonary sequestration variants and separate this entity from other lesions will be emphasized. poster #: edu-009 mri of the fetal head and neck masses alok jaju, md, mallinckrodt institute of radiology, alokjaju@gmail.com; joshua shimony, per amundson purpose or case report: fetal magnetic resonance imaging (mri) is a useful problem solving tool for abnormalities detected by prenatal ultrasound (us). masses of the head and neck region can vary from benign incidental lesions to devastating neurological lesions and life threatening tumors. we share our experience in characterizing these lesions by prenatal mri, that can have a bearing on follow up imaging, perinatal management and overall prognosis. we did a retrospective review of all fetal mri studies performed at our tertiary care children's hospital between 11/2002 and 06/2011, to identify fetuses with head and neck masses. we reviewed the maternal demographic and clinical data, prenatal ultrasound, fetal outcomes and post natal imaging (when available). results: out of the 351 fetal mri studies, 20 had dominant head and neck masses. majority were encephaloceles (9 occipital, 1 parietal). the remaining included variety of masses such as nasal glioma, teratoma (3), epidermoid cyst, hemangioma and lymphatic malformation (3) . mri played a useful role in distinguishing encephaloceles from other masses based on underlying bone defect and intracranial extension. it also helped in characterizing other masses based on location and signal characteristics. the presence and degree of airway compromise was determined. intracranial anomalies associated with encephaloceles including callosal dysgenesis, cerebral and cerebellar hypoplasias, migrational disorders and spinal anomalies were also correctly identified. conclusions: we present the prenatal mr imaging findings of a spectrum of head and neck lesions, correlating with prenatal ultrasound, postnatal imaging and clinical or pathological outcomes. purpose or case report: the immaturity of the cns in neonatal infants makes neurologic assessment difficult. neuroimaging plays an essential role in the assessment of brain injury by helping to indentify the injury and expected neurologic outcome. cranial ultrasound (us) is usually the first neuroimaging modality used since the technique is portable, does not involve radiation and can be used sequentially. magnetic resonance imaging (mri), however, is the most sensitive imaging modality for the detection of hypoxic brain injury. the goal of this presentation is to compare the us and mri performed within a 24-hour interval, and evaluate these findings to improve the interpretation of the us which is usually the first methodology used to evaluated these patients. we performed a retrospective review of the neonatal imaging studies with us and mri performed within 24-hour interval on 72 preterm and term newborns with clinical history of hypoxia-ischemia. the imaging findings of the two modalities, mri and us, were correlated with the pattern and severity of the injury and brain maturity. results: diffuse white matter abnormalities were observed in 60% of the patients by us or mri. the ultrasound identified diffuse increased echogenicity which did not show correlation with mri in 30% of patients. focal white matter abnormalities were better identified by mri on non-cavitary leukomalacia which is the most common pvl observed in premature neonates with low birth weight and the most difficult to identified using us. cavitary leukomalacia showed strong agreement in both methodologies. the mri identified 6% more cases of intraventricular hemorrhage, however, the corresponding increase in hemorrhage was of minimal clinical significance. in most cases extra axial hemorrhage was better identified by mri. conclusions: after viewing this exhibit, the viewer will gain a better appreciation and understanding of the neuroimaging characteristics of hypoxia-ischemia in us and mri, and thus improving the interpretation of the us which is usually the first imaging modality used to evaluate this patient population. purpose or case report: the most common thoracic lesions found on prenatal imaging, congenital pulmonary airway malformation (cpam), bronchopulmonary sequestration (bps), and congenital diaphragmatic hernia (cdh), usually have characteristic imaging findings previously described in detail. however, common entities presenting with atypical findings and rarer thoracic entities do occur and can be characterized by fetal magnetic resonance (mr) imaging. the purpose of this educational exhibit is to show examples of atypical presentations of common thoracic lesions and more unusual thoracic entities on fetal mr. when applicable, prenatal mr is compared with prenatal ultrasound, postnatal imaging, operative findings, or pathology. methods & materials: using a radiology information system database, the reports of all fetal mr exams at our institution from january 2005 through january 2011 were reviewed. when unusual thoracic findings were described in the report, all prenatal and postnatal images (when available) were evaluated. in the cases selected, medical charts were reviewed for operative findings and pathologic reports. results: the cases to be described, both pulmonary and extrapulmonary in location, include: hybrid lesion in a horseshoe lung, cpam extending across the midline, bilateral bps, bps located within the mediastinum, bps located within the leaves of the diaphragm, ectopia cordis and cdh as components in pentalogy of cantrell, cdh with herniation of liver into the pericardium, elongated esophageal duplication cyst, chest wall lymphatic malformation, and tight double aortic arch causing congenital high airway obstruction syndrome (chaos). conclusions: after studying this educational exhibit, the reader will be acquainted with a variety of unusual fetal pulmonary and extrapulmonary lesions, with emphasis on fetal mr. prenatal and postnatal imaging findings in megacystis-microcolon-intestinal hypoperistalsis syndrome (mmihs) mary kitazono, chop, mkitazono@gmail.com; richard bellah purpose or case report: to review the classic constellation of findings seen in prenatal and postnatal imaging of megacystis-microcolon-intestinal-hypoperistalsis syndrome (mmihs), as well as to illustrate additional imaging features that are variably seen in this syndrome. the imaging database at our children's hospital was searched for all cases of mmihs diagnosed since 2002. all available prenatal and postnatal imaging studies were reviewed in patients with a diagnosis of mmihs, and representative images are provided with a description of the findings. results: since 2002, 6 patients (5 girls, 1 boy) have been diagnosed with mmihs at our institution, including 4 on prenatal mri and us. the characteristic prenatal imaging findings include marked urinary bladder distension, bilateral pelvicaliectasis, and dilated, tortuous ureters, as well as a diminutive colon containing no or minimal t1w-hyperintense meconium on mri. postnatal imaging studies also characteristically demonstrate a massively distended urinary bladder (with no apparent mechanical cause of obstruction) as well as a small, unused colon with dilated, hypoperistaltic small bowel seen proximal to the microcolon. additional findings which are variably seen include intestinal malrotation, stomach and esophageal hypoperistalsis or aperistalsis, gastroesophageal reflux, and biliary stasis. conclusions: although a rare syndrome, the constellation of imaging findings in mmihs is pathognomonic, and recognition of the classic pattern of findings can allow the radiologist to make a diagnosis of mmihs in both the in-utero and postnatal setting. early diagnosis is essential for allowing prenatal counseling regarding this generally fatal disorder, as well as to optimize early management options. purpose or case report: gastric mass lesion are uncommon. this presentation is an educational review of pediatric gastric mass lesions including gastro-intestinal stromal tumor (gist), inflammatory myofibroblastic tumor (pseudotumor). burkitt's lymphoma, squamous cell carcinoma, gastric teratoma, gastric varices, gastric hamartoma, gastric polyp and hypertrophic pyloric stenosis (hps). clinical presentation is varied with upper gi bleeding, feeding intolerance, pain, weight loss and fatigue manifesting. the imaging work-up might initially have been endoscopy or ultrasound. cross section imaging (ct mr) can be invaluable. the role and impact of fdg pet on the management, staging and follow up of the oncologic pathology will be emphasized. imaging findings in megacystic microcolon intestinal hypoperistalsis syndrome, a rare disease kiery braithwaite, pediatric radiology, emory-egleston, kieryb@yahoo.com; kiery braithwaite, paula dickson, marianne m. ballisty purpose or case report: megacystis microcolon intestinal hypoperistalsis (mmih) syndrome is a rare congenital form of severe functional intestinal obstruction which is more commonly found in females. the presenting clinical and imaging features of this disease can often mimic other causes of proximal bowel obstruction in the neonate. in combination with its common association with intestinal malrotation, the clinical picture of mmih syndrome may be confusing at times. awareness of additional imaging features characteristic of mmih syndrome may help the radiologist suggest this diagnosis. the purpose of this study is to enhance the ability of the pediatric radiologist to suggest this rare diagnosis by recognizing this unusual constellation of imaging features. we retrospectively reviewed the clinical data and imaging studies of four patients with mmih syndrome at our institution. imaging studies included plain radiography, ultrasonography, fluoroscopy, and cross sectional imaging. the initial presentation and clinical outcome was also reviewed. results: the clinical presentations of our patients, who were all female, were somewhat varied but typically included symptoms of intestinal obstruction. the diagnosis of mmih syndrome was made in our patients from the first few weeks of life through early childhood. the four patients demonstrated imaging features characteristic of this disease including a very large dilated bladder, severe bilateral hydroureteronephrosis, gaseous distention of the stomach and proximal small bowel, intestinal hypoperistalsis, and a very small colon. the clinical course of these patients that we observed was also quite variable, with some patients dying in neonatal period while another patient continues to do reasonably well at 14 years old after a multi-organ transplant. conclusions: mmih syndrome is a rare and frequently lethal disease. the ability of the pediatric radiologist to recognize this constellation of imaging findings can help the clinical team arrive at a diagnosis of mmih syndrome. more prompt diagnosis can aid in the development of a long term management plan for the patient and in counseling the family regarding the prognostic implications of this disorder. pathologies of omphalomesenteric duct remnant: radiologic-surgical correlation swapnil bagade, md, pediatric radiology, mallinckrodt institute of radiology, bagades@mir.wustl.edu; geetika khanna, rebecca hulett purpose or case report: 1. to facilitate understanding of embryology of the omphalomesenteric(vitelline) duct and normal anatomy of the umbilicus. 2. review the spectrum of omphalomesenteric duct malformations and diversity of clinical presentations of these remnants. 3. illustrate the imaging findings of omphalomesenteric remnants, from the common such as meckel's diverticulum to the uncommon such as the omphalomesenteric duct cyst, with surgical correlation. methods & materials: cases with complications of persistent omphalomesenteric duct were collected from the joint surgery/radiology conferences at a tertiary level children's hospital. imaging features were correlated with intraoperative findings. conclusions: preoperative diagnosis of complications related to the omphalomesenteric duct remnants can be challenging because clinical and imaging features overlap with other etiologies of acute abdomen. knowledge of the embryologic, clinical, radiologic, and surgical characteristics of omphalomesenteric duct remnants will aid in early and accurate diagnosis. neonatal bowel obstruction-a pictorial essay tanmay patel, university of kentucky; harigovinda challa purpose or case report: bowel obstruction is the most common abdominal emergency in the newborn period and in most cases is secondary to a congenital anomaly requiring early surgical intervention. however not every case of abdominal distension or dilated bowel is secondary to mechanical bowel obstruction or underlying surgical condition. radiologic imaging forms a central role in the work up of newborns with suspected intestinal obstruction. the role of the radiologist is to identify whether or not mechanical obstruction is present; if obstruction is identified on initial radiographs, to determine the level of obstruction, and finally to identify the etiology of obstruction. initial plain radiographic evaluation also helps to determine the subsequent diagnostic or therapeutic approach. methods & materials: a retrospective review of multiple radiographic and fluroscopic examinations in patients with diagnosis of neonatal bowel obstruction was performed at kentucky children's hospital. multiple examples of classical imaging findings were compiled and placed into a pictorial review. results: neonatal intestinal obstruction generally presents with nonspecific symptoms such as abdominal distention, vomiting, or failure to pass meconium depending on the level of obstruction and time of occurrence of underlying congenital lesion/atresia in the intrauterine life. initial plain radiographs of the abdomen reveal dilated bowel loops when obstruction is present. high intestinal obstruction is suspected when only few dilated loops are identified, while multiple dilated bowel loops are seen in low obstruction. most cases of high obstruction may not need another diagnostic imaging test. all cases of distal intestinal obstruction require water soluble enema to identify the etiology of obstruction. in conditions like functional immaturity of the colon, and meconium ileus water soluble enema is therapeutic and thus surgery can be avoided in most cases. the objective of this presentation is to present an educational exhibit of classical imaging findings of various types of neonatal bowel obstructions, and how to differentiate between them. conclusions: bowel obstruction is the most common abdominal emergency in the new born period. most cases are secondary to a congenital surgical condition and early diagnosis and treatment significantly reduces mortality and morbidity. radiographic evaluation plays a central role in the diagnosis and treatment of these conditions. poster #: edu-017 3d t2-weighted mrcp in the pediatric population-a pictorial review nathan egbert, mbbs mph, university of michigan, nathaneg@med.umich.edu; jonathan r. dillman, peter j. strouse purpose or case report: to demonstrate the utility of 3d t2-weighted magnetic resonance cholangiopancreatography (mrcp) in the pediatric population, and to illustrate the mrcp findings of various conditions affecting in the pediatric pancreaticobiliary system. we identified all mrcp exams performed on pediatric patients (< 18 years of age) from january 1, 2000 through august 1, 2011 by searching institutional electronic medical records. we then identified representative 3d t2-weighted mrcp images of various conditions affecting the pediatric pancreaticobiliary system. results: representative 3d t2-weighted mrcp images (including source, maximum intensity projection, and volume rendered images) from the following conditions will be presented: abnormal biliary narrowing/stricture (including sclerosing cholangitis, anastomotic strictures following kasai procedure & liver transplantation, and "pseudostricture"), biliary atresia, choledochal cyst (including various subtypes, based on todani classification), choledocholithiasis & cholelithiasis, congenital anomalies of the pancreaticobiliary system (including pancreas divisum and anomalous pancreaticobiliary junction), pancreatobiliary system trauma (including main pancreatic duct transection), and other rare conditions affecting the pancreaticobiliary system (including rhabdomyosarcoma of the biliary tree). conclusions: 3d t2-weighted mrcp has become an extremely useful tool in the evaluation of children with suspected disorders of the pancreaticobiliary system. since mrcp has distinct advantages over alternative diagnostic techniques, such as endoscopic retrograde cholangiopancreatography (ercp) or percutaneous cholangiography, including lack of ionizing radiation and noninvasiveness, mrcp is a much preferred initial study for pediatric pancreaticobiliary imaging. this pictorial review is intended to highlight the 3d t2weighted mrcp appearances of various pancreaticobiliary conditions occurring in the pediatric population. purpose or case report: magnetic resonance enterography (mre) is rapidly emerging as an important imaging tool for the diagnosis and follow-up of inflammatory bowel disease (ibd). its lack of ionizing radiation makes this imaging modality especially vital to the pediatric population. using a casebased approach, we will demonstrate the usefulness of diffusion-weighted imaging (dwi) as part of a comprehensive mre protocol for the assessment of ibd in children. the basics of dwi will be discussed with particular attention to abdominopelvic techniques. the role of mre dwi for the evaluation of pediatric crohn disease (cd) and ulcerative colitis (uc) will be reviewed using a case-based approach. key images from pertinent imaging studies will be identified by searching institutional electronic medical records and presented with relevant clinical data. results: a review of pediatric mre examinations suggests dwi can be used to detect the following: 1) small and large bowel segments affected by ibd (both cd and uc) 2) abdominopelvic abscesses (including within the mesentery, body wall, iliopsoas muscle, and liver) 3) abnormal lymph nodes 4) sacroiliitis 5) perianal disease (including abscesses and other penetrating complications). conclusions: dwi has the potential to play a very important role in the diagnosis and follow-up of pediatric ibd. this mre technique is particularly useful for detecting a variety of disease-related complications. as the exact meaning of bowel wall restricted diffusion is poorly understood to date, continued investigation will be necessary to determine the clinical and histologic significance of this finding. cases of cf involving the gi tract were collected from clinical workflow encounters of the authors and from the main hospital medical records database. relevant imaging studies were reviewed for known gi manifestations of cf. these imaging studies were correlated with clinical histories and available intraoperative and pathologic findings. results: cf involvement of the gi tract presents over a wide range of ages, organs involved, and associated symptoms. these manifestations can generally be divided anatomically into those involving the alimentary tract, hepatobiliary system, and pancreas. alimentary tract manifestations consist of meconium ileus in uncomplicated and complicated forms (with the latter including secondary intestinal atresia, volvulus, and perforation with meconium peritonitisdistal intestinal obstruction syndrome, constipation, rectal prolapse, duodenal fold thickening, and appendiceal dilation. hepatobiliary disorders secondary to cf include microgallbladder, cholelithiasis, biliary ductal abnormalities, neonatal hepatitis, and cirrhosis (including complications such as portal vein thrombosis and ascites). pancreatic expressions of cf include fatty infiltration, calcifications, and cysts/ cystosis, frequently in the setting of malnutrition and/or stooling abnormalities. this exhibit will demonstrate the spectrum of clinical and radiologic gi findings in this disease from the fetal and neonatal period through adolescence across a range of imaging modalities. conclusions: gastrointestinal manifestations of cystic fibrosis occur frequently in the pediatric population and may be the earliest clinical expression of the disease. familiarity with the variety of gastrointestinal imaging findings of cystic fibrosis can expedite appropriate diagnosis and therapy, particularly in those children in whom the primary disease is not clinically suspected. beyond acute appendicitis: imaging of additional pathologies of the pediatric appendix kelly dietz, md, cincinnati children's hospital; arnold c. merrow, daniel j. podberesky, alexander j. towbin purpose or case report: primary acute appendicitis (or appendiceal inflammation caused by a superimposed bacterial infection in the setting of appendiceal obstruction) is by far the most common pathology of the appendix, and imaging evaluations to exclude this diagnosis occur daily in the pediatric radiology setting. the clinical and imaging differential diagnosis in a patient with right lower quadrant pain and suspected appendicitis is a broad but well-recognized list that predominantly involves structures adjacent to the appendix including the ovaries, small and large bowel, and ureters. there are, however, less common pathologies primarily involving the appendix which can create an imaging diagnostic dilemma in the setting of right lower quadrant symptoms. our goal is to review the imaging and clinical manifestations of these less commonly encountered appendiceal abnormalities. methods & materials: cases of appendices that were abnormal by imaging but ultimately determined not to be due to primary acute appendicitis were collected from clinical encounters by the authors as well as through a search of the radiology and pathology report databases. clinical course, surgical findings, and pathology reports (if available) were subsequently reviewed through the main hospital medical records system. results: the collected cases demonstrate a wide range of additional pathologies of the appendix outside of primary acute appendicitis. a variety of imaging modalities were employed in the workup of these cases. examples reviewed in this exhibit include crohn's disease, ulcerative colitis, cystic fibrosis, carcinoid tumor, inguinal hernia with incarceration, retained foreign body, pinworm infestation, and ileocolic intussusception. conclusions: despite the frequency of primary acute appendicitis, there is a differential diagnosis when an abnormal appendix is found by imaging. familiarity with these alternative diagnoses may be particularly helpful in guiding management of the patient whose clinical presentation is not typical for primary acute appendicitis. methods & materials: a hospital pacs database search from the past 10 years for patients with bws. selected cases, with multimodality imaging, were cross-referenced with pathology reports from patient records database. results: intricate abdominal pathologies are depicted utilizing multimodality imaging, such as plain films, us, ct, mri and pet/ct, and with pathologic correlation. cases with highlight the following: liver: hepatoblastoma, nonspecific hepatobiliary cysts, multiple hemangiomas mimicking metastatic disease; adrenal: dysplastic organomegaly mimicking neoplasm; pancreas: diffuse and focal hyperplasia in the setting of hyperinsulinism, organomegaly; renal: neprocalcinosis, including medullary sponge kidney, nephroblastomatosis, organomegaly; adnexal: ectopic paraovarian adrenal tissue mimicking metastatic lymph node; urinary bladder: benign fibro-uroepithelial polyp. conclusions: diagnosis of bws can be difficult when the classic clinical and radiological findings are not present. these few cases highlight the unusual abdominal pathologies, so when detected, a radiologist can aid in the appropriate diagnosis and help guide therapy for these young patients. this poster will discuss pharmaceuticals the fda considers investigational for their intended use. disclosure: dr. lecompte has indicated that she will discuss or describe, in the educational content, a use of a medical device or pharmaceutical that is classified by the food and drug administration (fda) as investigational for intended use. radiologic-pathologic review of pancreatic masses encountered at a tertiary pediatric hospital over a 10-year period no kwak, md, radiology, long island jewish medical center, kwak_nb@yahoo.com; karen naar, jeanne choi-rosen, lee collins, sukhjinder singh, anna thomas purpose or case report: review of pathologically proven pancreatic masses in pediatric patients encountered at a tertiary pediatric hospital over a 10-year period. describe the key morphologic features and other pertinent findings using various imaging modalities. correlate pathologic and radiologic findings. methods & materials: illustrate the various imaging characteristics of pathologically proven pancreatic masses including pseudocyst, pancreatoblastoma, solid pseudopapillary tumor, acinar cell carcinoma, ductal adenocarcinoma, lymphoma, pancreatic neuroblastoma, and inflammatory myofibroblastic tumor. correlate pathologic and radiologic findings. identify the key imaging features that allow narrower differential diagnosis. results: pancreatoblastoma and solid pseudopapillary tumor are the more commonly encountered pediatric primary pancreatic tumors. both are bulky and heterogeneously enhancing tumors with solid and cystic elements. pancreatoblastoma occurs more commonly in young children. internal hemorrhage and fibrous capsule favor solid pseudopapillary tumor which more commonly occurs in adolescent girls. ductal adenocarcinoma, acinar cell carcinoma and an inflammatory myofibroblastic tumor, which were pathologically proven in our pediatric patients, are exceedingly rare entities. the imaging findings of these cases and their pathology when available will be presented, as well as a quick literature review of these rare tumors. illustration and correlation of the pathologic and radiologic findings. conclusions: pancreatic masses in children are rare but in general have a better prognosis than in adults. salient imaging findings for the various tumors encountered at a tertiary care center with pathologic and radiologic correlation. evaluation of hepatoblastoma with gadoxetate disodium-typical, atypical, pre and post treatment evaluation arthur b. meyers, radiology, cincinnati children's hospital, arthurbmeyers@yahoo.com; alexander j. towbin, daniel j. podberesky purpose or case report: gadoxetate disodium (gd-eob-dtpa) is a hepatobilliary mri contrast agent that is widely used in adults for characterization of liver tumors and is being increasingly used in pediatric patients. hepatoblastoma is the most common primary hepatic malignancy of childhood. the purpose of this presentation is to describe our experience with the use of this agent in the mri evaluation both before and after initiating therapy in patients with hepatoblastoma. methods & materials: the radiology report system at our institution was queried for all patients with pathology proven hepatoblastomas who underwent a liver mr with administration of gadoxetate disodium between 8/1/10 and 2/28/ 2011. the mr imaging characteristics of the patient's primary hepatoblastoma pre-and post-therapy (when available) and post treatment findings (when available) were reviewed. results: 22 mri studies in 9 different patients were reviewed. the patients ranged in age from 4 months to 12 years. 6 patients had pre and post treatment evaluation with gd-eob-dtpa enhanced mri, 1 patient had only pretreatment evaluation and 2 patients had only post treatment evaluation. 6 of the hepatoblastomas did not take up gd-eob-dtpa during the hepatocyte phase and were therefore low signal intensity during the hepatocyte phase of imaging. this was useful in the pretreatment evaluation of hepatoblastoma, particularly in defining the relationship of the tumor to hepatic and portal veins. post treatment gd-eob-dtpa imaging allowed characterization of the biliary anatomy and demonstrated the communication of a postoperative fluid collection with the biliary tree, consistent with biloma. 1 atypical hepatoblastoma showed uptake of gd-eob-dtpa on hepatocyte phase imaging, similar to what has been described in adults with atypical hepatocellular carcinoma. conclusions: gadoxetate disodium enhanced mri is useful in the imaging evaluation of hepatoblastoma, particularly in defining the relationship of tumor to vascular and biliary anatomy and in characterizing post-treatment complications. disclosure: dr. meyers has indicated that he will discuss or describe, in the educational content, a use of a medical device or pharmaceutical that is classified by the food and drug administration (fda) as investigational for intended use. imaging of the gallbladder and biliary tree in pediatric age group ihsan mamoun, md, cleveland clinic, ihsanmamoun@ yahoo.com; s. pinar karakas, unni udayasankar, neil vachhani, ellen park purpose or case report: interactive educational exhibit to illustrate the embryology, anatomical variants as well as congenital and acquired diseases of the bile ducts and gallbladder in pediatric patients. methods & materials: a)the embryology of the gallbladder and biliary tree will be demonstrated with diagrams. b) imaging techniques for gallbladder and biliary tree including us, ct, mri, ercp and intraoperative cholangiogram will be discussed. c)imaging findings of various lesions with special emphasis on key findings that can lead to accurate diagnosis will be discussed. d)an appropriate list of differential diagnosis will be provided. e)an algorithm for the assessment of suspected biliary pathology will be presented. f)the exhibit will be interactive and the reader will answer questions about the discussed entity, related imaging algorithm and management. results: a)discuss congenital anomalies including duplicated and septated gallbladder, choledochal cyst, caroli disease, situs abnormalities and biliary atresia. b)discuss infectious and inflammatory conditions including cholecystitis, kawasaki's disease, sclerosing cholangitis and hepatitis. c)discuss iatrogenic complications including post transplant biliary stricture and leak. d)discuss benign and malignant neoplasms invoving the gallbladder including polyps, ptld and rhabdomyosarcoma. conclusions: this exhibit will demonstrate a logical approach to imaging of the congenital and acquired diseases of the gallbladder and biliary tree based on the embryology and underlying pathology. postnatal work up of congenital uronephropathies-a pictorial essay harigovinda r. challa, radiology, university of kentucky, hch229@uky.edu purpose or case report: the use of obstetric ultrasound routinely in the prenatal care has lead to the discovery of many fetal anomalies. uronephropathies in the newborn represent one of the largest groups of anomalies amenable to neonatal management. since these uropathies are detected mostly in asymptomatic patients the treatment is mainly preventive. the pediatric radiologist has a key role in the post natal work up and management of these patients with prenatally diagnosed neprhouropathies and familiarity with the congenital urinary tract abnormalities is necessary. methods & materials: a retrospective review of multiple radiographic, sonographic and fluroscopic examinations performed in the newborn babies and infants with prenatal diagnosis of urinary tract abnormalities was performed at kentucky children's hospital. multiple examples of classical imaging findings were compiled and placed into a pictorial review. results: numerous anomalies can be detected in utero, including anomalies of renal number, position, morphology, collecting system dilation and bladder, urethral abnormalities. of these postnatal work of congenital hydronephrosis is the most common routinely encountered clinical entity. renal ultrasound is the initial examination in the evaluation in all cases of prenatal hydronephrosis, which is best performed around postnatal day 5. if collecting system dilatation persists on postnatal ultrasound, further imaging work up with vcug, radionuclide imaging may be required depending on degree of dilatation. conclusions: uroneprhopathies are increasingly detected in the prenatal life with increasing use of obstetric ultrasound. the objective of this presentation is to demonstrate in a pictorial essay of different neprhouropathies and their workup in newborns. isolated fallopian tubal torsion: causes, imaging findings, and how to suggest the diagnosis jesse courtier, md, ucsf dept of radiology, jesse. courtier@ucsf.edu; amaya m. basta, rebecca maine, pierre-alain cohen, shinjiro hirose, john d. mackenzie purpose or case report: the purpose of this educational report is to describe the rare entity of isolated fallopian tubal torsion in the pediatric population and depict the cross sectional imaging findings that help make a diagnosis and guide management. the proposed pathophysiology, predisposing factors, and surgical management will be described. an illustrative case example of 12-year-old female patient will be provided with surgical correlation. the exhibit will review imaging findings on us, ct and mri that help support the diagnosis including, dilated tubular structure in the pelvis, normal ovaries, and corkscrewing and beaking of the proximal fallopian tube. isolated fallopian tubal torsion will be placed in the context of a differential diagnosis for girls presenting with pelvic pain and the imaging signs that help make a diagnosis of isolated tubal torsion and separate this entity from other causes of pediatric pelvic pain will be emphasized. multimodality imaging characteristics of genitourinary rhabdomyosarcoma rhea udyavar, md, george washington university medical center, rudyavar@gwmail.gwu.edu; amir noor, pranav k. vyas purpose or case report: in this pictorial essay, we will demonstrate salient imaging features of mr, us, and ct modalities for the diagnosis of genitourinary rhabdomyosarcoma in male (n04) and female (n04) children ages 2-14 years, evaluated at our institution over the past 6 years. background information, including tumor biology, staging, and treatment will also be discussed. the swollen scrotum: ultrasound technique and differential diagnosis kelli r. schmitz, md, oregon health & science university, schmitzk@ohsu.edu; roya sohaey purpose or case report: to review the ultrasound protocol for the performance of scrotal ultrasound and illustrate the ultrasound appearance of conditions resulting in scrotal swelling in pediatric patients. a retrospective review of the imaging database at a tertiary pediatric referral center was performed to identify pediatric patients who presented with scrotal swelling and underwent diagnostic ultrasound. when available, surgical/pathologic correlation was obtained. results: a variety of pathologic processes result in scrotal swelling. causes illustrated include: testicular torsion, epididymitis/orchitis, hydrocele, varicocele, inguinal hernia, trauma, adrenal rest, and testicular or paratesticular neoplasm. conclusions: the causes of scrotal swelling are myriad, including infectious/inflammatory, developmental, traumatic, and neoplastic etiologies. in children, the clinical presentation of a swollen scrotum is nonspecific, and ultrasound plays a key role in making the correct diagnosis. experiences of starting a functional mr urography program at a university hospital: trials and tribulations steven l. blumer, bsc, montefiore medical center/albert einstein college of medicine, sblumer@montefiore.org; ibrahim tuna, amanda north, benjamin taragin, netta blitman, terry l. levin purpose or case report: starting a functional mru program can be challenging as there are numerous potential hurdles to overcome. this presentation describes the process of starting a functional mr urography (fmru) program at a university hospital and discusses the difficulties encountered starting such a program. selecting a sufficient patient referral base, resolving common and uncommon technological issues, and education of clinicians, patients and technical staff are some of the challenges that will be discussed. conclusions: awareness of the common pitfalls in fmru imaging and close partnering with referring physicians can make establishing a functional mru program easier. despite many potential obstacles, the benefit of exquisite anatomical and functional information provided by fmru in children, without exposure to ionizing radiation, greatly outweighs any challenges. disclosure: dr. blumer has indicated that he will discuss or describe, in the educational content, a use of a medical device or pharmaceutical that is classified by the food and drug administration (fda) as investigational for intended use. pictorial review of ultrasound findings in boys presenting to emergency department/urology with acute scrotum teresa liang, faculty of medicine, university of british columbia, teresaliang86@gmail.com; peter metcalfe, william sevcik, michelle noga purpose or case report: testicular torsion is a common acute condition in adolescent boys. rapid and accurate diagnosis is critical. diagnosis is currently based on history, physical findings, and ultrasound (u/s) with doppler. the objective of this poster is to demonstrate ultrasound findings from a retrospective review of acute scrotum over 3 years, and to demonstrate some pitfalls of the technique with regard to testicular torsion diagnosis. we reviewed the u/s, surgical and ed records at the stollery children's hospital for boys aged 1 month to 17 years, presenting with acute scrotum from july 1, 2008 to 2011. age, demographics, clinical symptoms, and physical findings, u/s and surgical techniques, findings, diagnoses and follow-up were also recorded. results: 343 patients presented to uah stollery ed with acute scrotum: 35 were diagnosed with testicular torsion (2 inguinal torsion), 11 were suspected of a torsion-detorsion, 3 torsion of appendix testes, 135 epididymitis/orchitis, and 159 other diagnoses including hydroceles, varicoceles, epididymal cysts, abscesses, cellulitis and hematomas. for the 266 patients who had ultrasound,100% sensitivity and 88% specificity for testicular torsion. the ultrasound findings including size, vascularity and echogenicity associated with both salvageable and necrotic testicles including use of color and pulse doppler will be reviewed. the sonographic findings and pictorial examples associated with the more common acute scrotum etiologies will be presented. sonographic findings from problematic cases (those with inconclusive ultrasound reports or false positive reports) will also be addressed. conclusions: ultrasound imaging problem case examples and characteristic findings of common acute scrotum presentations at stollery hospital at the university of alberta are reviewed in this poster. primary and secondary amenorrhea in pediatric patients: from the beginning to the end cesar cortes, md, miami children's hospital, n4c03@ hotmail.com; yanerys ramos, ricardo restrepo, alejandro diaz, lorena sequeira, edward lee purpose or case report: to describe the role of imaging in evaluating patients with primary and secondary amenorrhea and to illustrate the normal imaging findings of the reproductive organs in the pediatric population as well as the imaging findings of the different etiologies causing amenorrhea. a search of the literature is done to determine the different etiologies of amenorrhea and the role of imaging in their evaluation. first, we will focus on the normal physiologic hormonal influence and changes of the girl's reproductive organs since birth until adolescence on ultrasound and mri. images of the normal appearance of the female reproductive organs as well as imaging findings of the different common and uncommon etiologies of amenorrhea will be shown. then, specific reference will be made to crucial related concepts such as minipuberty of infancy, latest criteria for polycystic ovarian disease and ovarian failure syndrome among others. finally, the treatment, either medical or surgical will be briefly discussed. results: causes of amenorrhea in children range from disorders affecting the hypothalamus, pituitary gland, adrenal glands, and ovaries, as well as uterine and vaginal structural abnormalities. even though history and clinical exam are essential in evaluating a patient with amenorrhea, the pediatric radiologist plays a pivotal role helping guide the area to be imaged and thus the modality that should be used. mri and ultrasound are the main modalities in the evaluation of amenorrhea. conclusions: ultrasound and mri are the main imaging modalities used in the evaluation of amenorrhea in children and are usually part of the work up. amenorrhea in children can have implications in girl's fertility allowing pediatric radiologists to play an important role in helping not only the patient but also their offspring. imaging of mullerian duct anomalies in children kelly k. horst, md, radiology, university of michigan, khorst@med.umich.edu; maryam ghadimi mahani, deepa pai, jonathan r. dillman, peter j. strouse purpose or case report: the purpose of this educational exhibit is to provide an up-to-date appraisal of mullerian duct anomalies presenting in the pediatric population. the appearances of anatomic variants on ultrasound and mri will be used to illustrate the strengths and potential pitfalls of these imaging modalities. methods & materials: patients who have previously undergone ultrasound and/or mri in the course of their clinical workup within the university of michigan health system (umhs) were identified using electronic medical records. imaging reports were reviewed by a single author in order to identify relevant imaging findings (interesting anatomic variations, associated anomalies, etc.). pertinent images from these imaging examinations were de-identified and saved to a secure hard drive. the medical record was accessed by a single researcher to obtain relevant information regarding the patients' clinical presentations. in cases of corrective surgery, pathology reports were reviewed, if available, for correlation with the imaging findings. results: cases of mullerian duct anomalies were reviewed within the pediatric population. clinical manifestations were correlated with imaging appearances. conclusions: mullerian duct anomalies represent a range of developmental variants. although functioning ovaries and age-appropriate external genitalia are characteristic, there may be anomalies ranging from uterine and vaginal agenesis, to duplication of the uterus and vagina, to minor uterine cavity abnormalities. müllerian malformations are frequently associated with abnormalities of the renal and axial skeletal systems, and pediatric patients in particular may present with these associated anomalies. menstrual abnormalities may represent a more typical presentation in the adolescent age group. this is in contrast to the adult population, which may be more likely to present with infertility. the variation in clinical presentations make mullerian duct anomalies difficult to diagnose and, because surgical techniques for correction and treatment depend on the underlying anatomy, understanding these variants in the context of imaging studies is important to their diagnosis and management. patient 2 had radiographs which showed an irregular left humeral metaphysis with an associated fracture. patient 3 had a 3 phase bone scan that showed slightly increased uptake on the angiographic and blood pool phases and increased activity on the delayed phase in the right femur. radiographs showed a moth eaten appearance of the right femur with soft tissue swelling. patient 4 had radiographs that showed periosteal reaction in the right tibia with an associated fracture. patient 5, in addition to radiographs, had an mri that showed osteomyelitis of the left humerus and scapula with an associated subperiosteal abscess. patient 6 had multi focal osteomyelitis that was demonstrated on radiographs by irregular cortices and periosteal reaction involving the upper and lower extremities. conclusions: neonatal osteomyelitis is an uncommon entity that can have severe complications if not diagnosis and treated promptly. it is important to review cases and to review the appearance of neonatal osteomyelitis on multiple modalities. radiographs will usually demonstrate periosteal reaction and possibly soft tissue swelling. additional studies may be obtained to evaluate for complications, such as abscesses or involvement of the joint space. purpose or case report: review the epidemiology of ddh. describe the critical diagnostic imaging findings of ddh. understand the role of imaging accompanying treatment. methods & materials: images including radiographs, ultrasound, ct and mri will be used to demonstrate the current and historical role of imaging in caring for patients with ddh. discussion of the importance of reducing radiation exposure when choosing imaging studies will be included. results: radiographs and ultrasound are used primarily in making the diagnosis of ddh. ultrasound and mri are most often used during the course of treatment to assess its effectiveness. mri is increasingly utilized without sedation for patients in spica cast. conclusions: imaging is critical in the care of patients with ddh. pediatric musculoskeletal ultrasound of the proximal lower extremity (pelvis to thigh) julia rissmiller, md, dept of radiology, children's hospital boston, julia.rissmiller@childrens.harvard.edu; howard christianson, michael j. callahan purpose or case report: to review indications for ultrasound of the proximal lower extremity (pelvis, hip and thigh), and to illustrate the practical use of ultrasound in evaluation of the proximal lower extremity, emphasizing the sonographic appearance of various musculoskeletal disorders. ultrasound is a well-established modality for the evaluation of painful hip, developmental hip dysplasia, soft tissue infection, palpable masses, and foreign bodies in children. in general, ultrasound has a more limited role for the primary evaluation of other pediatric musculoskeletal disorders including trauma, articular and periarticular diseases and tumors or tumor-like processes. advantages of ultrasound, a relatively non-invasive technique, include excellent spatial resolution, low cost, lack of ionizing radiation, lack of need for sedation, and the ability to image the patient in real-time. the major disadvantage of ultrasound is operator dependency, which is particularly evident in musculoskeletal applications. we present ultrasound examples of pathology involving the proximal lower extremity (pelvis, hip and thigh). cases include developmental hip dysplasia, hip effusion, osseous metastasis to the iliac bone, osteomyelitis of the hip, femoral acetabular impingement, rectus femoris hernia, vascular malformation, ewing's sarcoma and myositis ossificans. results: a range of images from pediatric diagnostic ultrasounds performed of the proximal lower extremity (pelvis to thigh) will be presented emphasizing the sonographic appearance of various musculoskeletal disorders. conclusions: ultrasound is an excellent modality for evaluating the proximal lower extremity in children, beyond the current indications of painful hip, developmental hip dysplasia, soft tissue infection, palpable masses, and foreign bodies in children. a multi-modality pictorial review of lesions of the epiphysis in infants and children ernesto i. blanco, md, st. christopher's hospital for children, eiblanco74@gmail.com; jacqueline urbine, evan geller, peter pizzutillo purpose or case report: to review the imaging spectrum of epiphyseal lesions in infants and children. a retrospective review of our imaging database was performed to identify studies with either primary lesions of the epiphysis or processes that affect the epiphysis. results: multiple epiphyseal lesions were elucidated primarily by radiography, with cross-sectional imaging included where clinically necessary. congenital lesions include the epiphyseal dysplasias represented here by chondrodysplasia punctata. epiphyseal infarction may due to multiple etiologies including slipped capitol femoral epiphysis, developmental dysplasia of the hip, sickle cell disease, or idiopathic reasons. neoplasms may occur in the epiphysis, including chondroblastoma and histiocytosis. traumatic lesions include fracture and avulsion. osteomyelitis can occur in the epiphysis as well. pseudolesions that mimic pathology will also be reviewed. other pathologies that can affect the epiphysis include juvenile idiopathic arthritis and hemophilia. conclusions: a wide spectrum of congenital and acquired pathologies may affect the epiphysis in the infant and child. plain radiography, computed tomography, and magnetic resonance imaging all contribute to the diagnosis of these varied lesions. purpose or case report: we aim to present the spectrum of common and uncommon hip disorders in pediatric population. we will formulate a systematic approach and present a flowchart to workup and characterize hip diseases. methods & materials: relevant imaging appearances of normal as well as pathological hip will be presented. normal hip anatomy will be discussed through anatomic drawings and radiological images (plain radiographs, ct, usg, and mri). we will illustrate the various anatomic landmarks, measurements and lines on plain radiographs and ultrasound of hip. results: evaluation of limp and hip pain in the pediatric population has undergone rapid evolution. surgical treatment for these disorders continues to be refined, and our ability to identify patients along the spectrum of disease continues to improve. yet, despite our advances, obtaining an accurate diagnosis can remain challenging, especially in the setting of mild structural abnormalities. many imaging studies can be used to evaluate the bones and soft tissues, but conventional radiography is the primary imaging modality for most clinical conditions. plain radiographs usually are obtained first because they are sensitive and specific for a wide range of bone pathology. more sophisticated imaging modalities including radionuclide scintigraphy (bone scan), ultrasonography (usg), computed tomography (ct) and magnetic resonance imaging (mri) are reserved for specific clinical situations. each of these imaging modalities has specific advantages and disadvantages. it is the aim of this review to guide in selecting and interpreting the appropriate imaging modality for a variety of common disorders. this exhibit will illustrate imaging features of developmental dysplasia of hip, perthes disease, slipped capital femoral epiphyses, hip malformations in syndromes, femoral acetabural impingement, labral disorders, septic arthrits and other disorders. the role of various imaging modalities in evaluation of these disorders will be discussed, along with common imaging pearls and pitfalls. conclusions: a systematic approach is necessary for evaluation of pediatric hip disorders. familiarity with normal appearances, pitfalls and specific imaging of these entities is essential for proper diagnosis and management. osteoid osteomas: a pain in the "night" diagnosis nancy k. laurence, md, the children's hospital of philadelphia, nkang26@gmail.com; monica epelman, richard markowitz, camilo jaimes, diego jaramillo, nancy chauvin purpose or case report: a common benign bone-forming lesion, osteoid osteoma comprises approximately 12% of all benign bone tumors. the tumor is composed of a nidus of vascular osteoid tissue and woven bone lined by osteoblasts, frequently with considerable surrounding inflammation. the radiolucent nidus surrounded by variable degrees of reactive sclerosis usually leads to a straightforward diagnosis; however, sometimes the diagnosis of osteoid osteoma can be challenging, as it may have a non-specific and misleading appearance on different imaging modalities, particularly on mri. the purpose of this exhibit is to review the typical and atypical features of osteoid osteomas on different imaging modalities. we present diagnostic dilemmas of osteoid osteomas from our institution and how imaging characteristics can aid in diagnosis. we performed a retrospective review of our imaging database to identify cases of typical and atypical osteoid osteomas, with special emphasis on cases which posed a diagnostic dilemma on imaging. results: when osteoid osteomas occur in atypical locations the diagnosis can be elusive. when located in the intraarticular space there is often minimal or absent cortical thickening and there may be a joint effusion with synovial hypertrophy. phalangeal lesions may cause extensive bone marrow edema and surrounding soft tissue swelling. both of these types of osteoid osteomas can be mistaken for infection. the recently described "ct vessel" or "vascular groove" sign, a low density vascular groove adjacent to the nidus, is highly specific for osteoid osteoma. in the authors' experience, a rim of sclerosis surrounding the nidus may aid in diagnosis on mri and can be identified as an outer hypointense halo on all sequences. we illustrate the findings in cases of atypical osteoid osteomas which may be difficult to diagnose including intraarticular, phalangeal, and vertebral osteoid osteomas. we also show examples of the newly described sign which has high specificity for osteoid osteoma. conclusions: imaging findings in osteoid osteomas can be misleading and cause misdiagnosis, especially in atypical cases. knowledge of their appearance in atypical locations and specific findings can aid in the correct diagnosis. ultrasound of normal entheses in the growing skeleton nancy chauvin, md, department of radiology, the children's hospital of philadelphia, chauvinn@email.chop. edu; pamela f. weiss, monica epelman, diego jaramillo purpose or case report: ultrasound is an underutilized modality in the evaluation of the pediatric musculoskeletal system. evaluation of tendon insertions about the elbow, knee and foot can be easily performed with ultrasonography. a good knowledge of the age dependent normal ultrasound appearance of the entheses is crucial in order to evaluate for pathology, such as trauma or ethesitis-related arthritis. this exhibit will serve to provide the reader with a practical approach to imaging when assessing tendon insertions. optimal patient positioning and transducer selection will be discussed. in addition, important anatomic landmarks will be described to allow for reproducibility and avoiding pitfalls. methods & materials: transverse and longitudinal ultrasound images of 12 entheseal insertion sites were performed on 20 healthy girls and boys between the ages of 5 and 17 years. ultrasound of the elbow was performed while in full extension and the insertions of the common flexor and common extensor tendons were evaluated. the quadriceps and patellar insertions were imaged with patients in the supine position, with the knees flexed at 30 degrees. the achilles tendon and plantar fascia insertion were evaluated with the patient prone, with the feet hanging off the edge of the table. results: tendons demonstrated the expected fibrillar pattern with parallel echogenic lines. the appearance of the entheses changed as the insertion matured from sonolucent cartilage to echogenic bone. conclusions: using a systematic approach and knowledge of the normal anatomy, sonography of the tendons of the elbow, knee and foot can easily be performed in children. pediatric musculoskeletal ultrasound of the distal lower extremity (knee to ankle) howard christianson, md, radiology, children's hospital boston, howard.christianson@childrens.harvard.edu; julia rissmiller, michael j. callahan purpose or case report: ultrasound is a well-established technique in children for evaluation of the painful hip, developmental dysplasia of the hip, soft tissue infection, palpable masses and foreign bodies. in general, ultrasound has a somewhat more limited role for the primary evaluation of several other pediatric musculoskeletal disorders in the setting of trauma, articular and periarticular diseases and tumors and tumor-like conditions. inherent advantages of ultrasound include excellent spatial resolution, a lack of ionizing radiation, a relatively non-invasive technique and lack of a need for sedation. real-time imaging allows problem solving not available with other modalities which is well suited for musculoskeletal applications, particularly in the setting of trauma. the major disadvantage of ultrasound is operator dependency, which is particularly evident in musculoskeletal applications. the purpose of this study is to illustrate the practical use of ultrasound in the evaluation of the distal lower extremity (knee to ankle) emphasizing the sonographic appearance of various musculoskeletal disorders. examples include: 1) cystic lesions around the joints: baker's cyst, synovial cyst, ganglion cyst and suprapatellar bursitis; 2) infectious processes: pretibial, subperiosteal and intramuscular abscess; 3) tumor and tumor like lesions: nerve sheath tumor, tumoral calcinosis; 4) trauma related injuries: sinding larsen johansson, tibialis anterior muscle herniation, hematoma. methods & materials: cases selected for presentation from a series of diagnostic musculoskeletal ultrasounds performed at our institution. results: a range of images from diagnostic ultrasounds performed of the distal lower extremity (knee to ankle) will be presented emphasizing the sonographic appearance of various musculoskeletal disorders. conclusions: selected musculoskeletal ultrasounds of the distal lower extremity are presented to familiarize the audience with the sonographic appearance of various musculoskeletal disorders and to highlight the tremendous potential of ultrasound in evaluating musculoskeletal disease in children and adolescents. role of conventional and dynamic contrast enhanced magnetic resonance imaging in diagnosis of hemihypertrophy syndromes in children shrey k. thawait, md, phd , radiology, yale university-bridgeport hospital, sthawai2@jhmi.edu; gaurav k. thawait, sally e. mitchell, laura m. fayad, john a. carrino, kate puttgen purpose or case report: hemihypertrophy syndromes in children are complex and there is some overlap among these conditions. hence, establishing a diagnosis can be challenging. identification of the correct vascular anomaly associated with these overgrowth disorders helps to correctly classify the disease into one of the several syndromes, which in turn guides management. in this educational poster, we will review the definition, clinical presentation, conventional magnetic resonance imaging (mri) and contrast enhanced magnetic resonance angiography and venography (mra / mrv) features of hemihypertrophy syndromes in children. methods & materials: 1. learn the diagnostic criteria for overgrowth syndromes in children such as klippel-trenaunay syndrome (kts) and parkes weber syndrome (pws) with special emphasis on associated vascular anomalies. 2. gain knowledge of high resolution mri technique for evaluation of vascular anomalies associated with the hemihypertrophy syndromes. 3. understand the additional value of dynamic contrast enhanced mra / mrv in the differentiation of the hemihypertrophy syndromes in the pediatric age group. results: 1. mri technique for a dedicated "vascular anomaly protocol" consisting of fat saturated t2 weighted, pre contrast axial t1 weighted, and post contrast triplanar t1 weighted fat saturated imaging will be described. 2. special emphasis will be provided on dynamic contrast enhanced mra/mrv. 3. conventional and dynamic mri features of clinically proven cases of hemihypertrophy syndromes will be demonstrated. conclusions: systematic mri interpretation utilizing a dedicated vascular anomaly protocol enables the radiologist to correctly identify the hemihypertrophy syndrome, and provide detailed extent of disease. correlative ultrasound, mri imaging and physical examination of elbows in hemophilic children andrea s. doria, md, the hospital for sick children-diagnostic imaging, andrea.doria@sickkids.ca; frederico xavier, arun mohanta, carina man, ningning zhang, pamela hilliard purpose or case report: 1.to report a systematic ultrasound (us) protocol for assessment of hemophilic elbows. 2. to discuss advantages and disadvantages of us and mri for evaluating hemophilic elbows in comparison with physical examination. 3.to illustrate us and mri findings and associated pitfalls in hemophilic joints. background: the value of physical examination for assessment of early arthropathic changes in hemophilic joints is unknown. us does not require sedation in young children, but involves operator training and standardized technique. mri is the reference standard imaging modality for assessment of pathology in hemophilic joints. standardization of a systematic protocol for data acquisition and interpretation of us findings and understanding of the correlation of findings between physical examination, us and mri in hemophilic elbows is essential for the use us as an outcome measure both in clinical practice and research. so far such information is not available for growing elbow joints. methods & materials: eight hemophilic boys (age range/ median, 7-17/13 years) with a history of prior elbow bleeds underwent us and mr imaging, and physical examination on the same day. corresponding images on us and mri were highlighted to illustrate abnormalities and pitfalls. soft tissues (effusion/hemarthrosis,synovial hypertrophy,hemosiderin deposition) changes were characterized as small, moderate, or large. erosions, cartilage and subchondral abnormalities were graded based on depth or extent of articular changes. results: 1. us is helpful for discriminating synovial hypertrophy, joint effusion/hemarthrosis, and large hemosiderin deposition which otherwise generates susceptibility artifacts on gradient-echo mri obscuring adjacent tissues. 2. us can visualize erosions, cartilage and subchondral abnormalities at the joint periphery. however,differentiation between subchondral cysts and erosions is usually unfeasible by us. 3. prior knowledge of the degree of joint maturation is essential for an accurate evaluation of cartilage loss by us. 4. physical examination has limitations for assessment of early joint changes in contrast to us. conclusions: us can be useful for assessing hemophilic elbows, with advantages over mri in the evaluation of soft tissues. further development of an us-mri atlas on normal cartilage in growing joints is needed for definition of the value of us in the assessment of minimal osteochondral abnormalities. digital atlas of skeletal surveys of common skeletal dysplasias shawn parnell, mbbs, md, dnb, radiology, seattle children's hospital, shawn.parnell@seattlechildrens.org; corey wall, edward weinberger purpose or case report: skeletal dysplasias are conditions of abnormal bone and cartilage growth which result in short stature. developing expertise in the radiographic evaluation of skeletal dysplasias can be difficult, as more than 250 dysplasias exist. exhaustive description of individual dysplasias can be found in hard copy textbooks, without the ability to compare individual dysplasias side by side. by providing radiographic images and descriptive text of thirteen common skeletal dysplasias and two comparative normal skeletal surveys, we aim to facilitate understanding of the terminology and highlight the differences in imaging appearances one may commonly encounter in interpreting skeletal dysplasias. methods & materials: initial skeletal surveys and/or follow up radiographs obtained for evaluation of skeletal dysplasias at our institution from 2005 to 2011 were compiled and reviewed for best quality images. selected images for each case were labeled according to body part and view, to include ap and lateral views of the spine and skull and ap views of the extremities and pelvis. for neonates, ap and lateral babygram images were used. the software program used for viewing the atlas, written in c#, may be freely downloaded. it permits linked scrolling and resizing of the images, and simultaneous comparison of different cases is available. cases may be viewed as unknowns or in a selfteaching mode. results: radiographic images for thirteen common skeletal dysplasias and two comparative normal skeletons (neonate and child) are provided within an interactive digital atlas. cases include achondroplasia, pseudoachondroplasia, cleidocranial dysplasia, thanatophoric dysplasia, diaphyseal dysplasia, multiple epiphyseal dysplasia, osteopetrosis, osteogenesis imperfecta, multiple hereditary exostoses, dysostosis multiplex, fibrous dysplasia, asphyxiating thoracic dysplasia (jeune syndrome), and spondyloepiphyseal dysplasia. conclusions: by displaying radiographic images of several common skeletal dysplasias in an interactive and comparative format with descriptive text, understanding of basic radiographic terminology and appearances will be facilitated. purpose or case report: 1. to classify various pediatric msk soft tissue masses 2. to describe pathogenesis, imaging appearances and differential diagnosis of these lesions methods & materials: radiology and clinical medical records were reviewed and pediatric patients with musculoskeletal soft tissue masses were identified. representative images were collected as examples of each lesion. the lesions were then classified into different groups based on the similar pathology and etiology. brief discussion is done for each of these masses with their multimodality imaging appearances. results: the search yielded pediatric soft tissue masses of multiple different etiologies, including post-traumatic (hematoma, fat necrosis, fibromatosis coli, myositis ossificans), inflammatory or infectious (cellulitis, abscess, granuloma annulare, retained foreign bodies), pseudotumors (synovial cysts, ganglion cysts, vascular malformations) and neoplastic lesions (fatty, vascular, neural, fibrous, muscular). multiple different imaging modalities were used to evaluate these masses, including ultrasound, ct and mri. representative examples of different lesions and their appearances on different imaging modalities will be presented and an organized approach to the diagnosis of these lesions will be discussed. conclusions: musculoskeletal soft tissue masses are relatively common in children. majority of these are benign; however, up to 6% of these lesions can be malignant "sarcomas". multiple different imaging modalities often provide complimentary information in the work-up of these lesions. despite multimodality imaging approach, tissue diagnosis or short interval follow-up is still often required when the mass does not show typical features of a benign etiology. pediatric radiologists should be familiar with various pediatric msk soft tissue masses and their imaging appearances, and should be able to guide appropriate management. results: 199 elbow mri examinations were reviewed on children aged 4 months to 18 years with 28 (14%) of these investigating clinical instability in 25 children. mechanism of injuries included congenital dislocation 10 (36%), traumatic dislocation 13 (46%), fracture or avulsion 2 (7%) and other injuries 3 (11%). the patient's with congenital elbow dislocations most commonly presented with radial head dislocation and associated dysplasia or flattening, effusion and less frequently dysplasia of the olecranon or capitellum. patient's with traumatic dislocations were frequently associated with ligamentous or capsular disruption, bone oedema and epicondylar avulsion with effusion, loose osseous bodies and fractures less often. the epicondylar avulsions and ligamentous or tendon injuries occurred equally often in those few patients with unspecified injury mechanism. conclusions: a number of the bony, ligamentous, articular and developmental anomalies evident on elbow mri have been illustrated highlighting the importance of careful and systematic review of all elbow structures when presented with a child with elbow instability. accurate identification of these abnormalities is vital to facilitate their appropriate management. methods & materials: from our computerized radiology information system, we retrieved all patients that have foot ultrasound for evaluation of vertical or oblique talus deformities in the last 6 years (10/2005-10/2011). the us was performed by a pediatric radiologist using a high resolution linear and tight convex curve probes with foot in neutral, plantar flexion and dorsiflexion. all medical charts, ultrasound scans and foot radiographs were reviewed by a pediatric radiologist. results: we identified nine patients' with foot deformities who were suspected of vertical or oblique talus and were evaluated by ultrasound. seven patients are male; two of them had initial foot radiographs that were not diagnostic. two female patients had unilateral oblique talus deformity. there were 7 patients with vertical talus deformity; three of them had bilateral deformities. conclusions: us can directly visualize the unossified navicular, the talar cartilage and their alignment. dynamic us can. ultrasound evaluation of costal chrondral pathologies in children presented as anterior chest wall mass or pain nucharin supakul, md, radiology, riley hospital for children, tanyasupakul@yahoo.com; boaz karmazyn purpose or case report: to summarize our experience with the use of ultrasonography (us) for evaluation of costal cartilage pathology presented as anterior chest wall mass. methods & materials: from our computerized radiology information system, we retrieved all patients that have chest wall ultrasound for evaluation of a mass in the last 4.5 years (4/2007-8/2011) . the us was performed by a pediatric radiologist using a localized scan with high resolution linear probe. all medical charts, pathology results, ultrasound scans and other imaging studies were reviewed by a pediatric radiologist. results: ten patients were found with costal chrondral pathologies. nine patients presented with anterior chest wall mass and one with chest wall pain. eight patients had angular deformity of a single costal cartilage and one patient had biopsy proven osteochrondroma, presented with anterior chest wall mass. one patient had a non-union fracture after motor vehicle accident, presented with anterior chest wall pain. in patients with rib deformity, the mass was non-tender. nine patients had prior imaging study including chest x-rays (n08), ct scan (n0 2), breast mr (n01). all these studies were negative. conclusions: us optimally demonstrated costal cartilage abnormities. chest radiographs and cross sectional studies were negative. we therefore recommend using high resolution chest wall us in children with negative chest radiograph and anterior hard chest wall mass. challenges in pediatric marrow imaging-boning up on current mr techniques srikala narayanan, md, division of radiology, children's national medical center, snarayan@childrensnational.org; neha kwatra, nabile safdar purpose or case report: a wide range of pathologies demonstrate similar findings when imaged using conventional mr sequences. however, pediatric musculoskeletal imagers are increasingly leveraging newer techniques to add specificity to their diagnoses when abnormal marrow signal is detected. the purpose of this educational exhibit is to review the application of current mr techniques to pediatric marrow imaging across the spectrum of normal, variant, and pathologic processes. methods & materials: cases with potentially overlapping imaging appearances on conventional mr sequences, including hematopoetic marrow, sickle cell disease, osteomyelitis, chronic recurrent multifocal osteomyelitis, and infiltrative neoplasms, will be presented. the basis of various mr techniques including chemical shift imaging, "whole body" marrow imaging, diffusion weighted imaging, and fat-water separation techniques such as dixon or ideal (ge) will be reviewed. the strengths and weaknesses of such techniques in differentiating between infection, neoplasm, and normal variation will be emphasized through the case examples. challenges and pitfalls in the imaging of these pathologies using such techniques will be discussed. results: current mr imaging techniques add specificity to diagnoses of marrow pathology which are otherwise difficult to differentiate using traditional sequences alone. the use of opposed phase imaging can be helpful in differentiate hematopoietic marrow or infection from infiltrative and neoplastic conditions. "whole body" marrow imaging may serve as an alternative to other modalities which involve significant radiation exposure. the use of diffusion weighted imaging is a promising, but developing, technique being applied to marrow pathology. conclusions: pediatric bone marrow mr imaging is a challenging area for a vast majority of the radiologists. understanding normal developmental bone marrow changes and being aware of the pitfalls is crucial to render accurate diagnosis. current techniques such as ideal, chemical shift imaging, and "whole body" mri have a potentially important role in further characterization of marrow abnormalities. radiologists beware: unusual imaging manifestations in child abuse eglal shalaby-rana, mbbs (hons), children's national medical center, erana@childrensnational.org; allison m. jackson, tanya hinds, katherine deye purpose or case report: to present less common imaging manifestations of injuries in child abuse that may not be readily recognized as possibly abusive injury. methods & materials: through bi-monthly review of cases with the child protection team over a period of 12 years, the imaging studies of patients with suspected non-accidental trauma were recorded. of the 654 pts with suspected nonaccidental trauma, outcomes were available in 599 patients. the child protection team concluded 254 (43%) were cases of non-accidental trauma with reasonable medical certainty. this data base was reviewed for less common injuries that were found in these medically confirmed cases of child abuse. results: less common manifestations of abuse identified by radiographs included salter-harris injuries in the proximal humerus, and proximal femur. pelvic fractures were rare and when present were associated with sexual abuse. severe chest wall injury, with associated rib fractures, causing complete or near-complete white-out of the chest was occasionally encountered. soft tissue injures, such as hematomas were found in various locations in the body including the buttocks and anterior abdominal wall, were imaged on ultrasound and ct. paraor prevertebral injuries, with or without associated bone injury were identified; one infant presented with retropharyngeal soft tissue swelling. mri identified cervical spine injuries which included ligamentous injury and intrathecal hematomas. conclusions: while classic metaphyseal lesions and rib fractures are the most common, specific injuries documented by radiologic work up of suspected non-accidental trauma, less common injuries to the soft tissue and skeletal system may occur as a result of child abuse. the ability of the radiologist to recognize these uncommon manifestations of demonstrated in axial, coronal, and sagittal planes. the ligament of interest will be denoted by arrows. at the conclusion of the anatomy section, there will be a self assessment exam. the participants then will be asked to identify the ligament. if answered correctly, a summary slide will be displayed and, if common, images of the relevant pathology will be demonstrated. if an incorrect answer is indicated, a slide will appear denoting the incorrect answer with explanation. conclusions: hopefully, with review of this educational exhibit, the participant will have a better understanding of the relevant ligamentous anatomy of the ankle and hindfoot. purpose or case report: the purpose of this educational exhibit is to demonstrate the pathologic sonographic findings, one might encounter in the pediatric ankle. a systematic methodological approach including patient positioning, transducer orientation and sonographic technique are vital for ideal sonographic assessment of the pediatric ankle. using a data search program from a large academic institution, pediatric ankle ultrasounds performed in the last 10 years were reviewed. pathologies include trauma, inflammation/infection, masses and congenital abnormalities. examples of normal anatomy will be included particularly when demonstrating ligament and tendon pathology. the normal side was often assessed for comparison purposes. results: ankle sonography is a useful modality to evaluate commonly encountered pathologies in the pediatric ankle. radiographically occult fractures may be discovered. ligament and tendon pathology, such as tears of the anterior talofibular ligament, high ankle sprain and peroneus longus tendon tears, can be easily detected. signs of infection that can be radiographically occult such as subtle periosteal reaction or fluid collections can be identified. finally, "lumps and bumps" can be characterized. for example, one of the most commonly encountered masses in the pediatric ankle is a ganglion cyst which can be well characterized sonographically. awareness of imaging pitfalls is also critical to avoid misdiagnosis and to guide appropriate management. conclusions: with basic ultrasound skills and knowledge of normal anatomy, sonography of the pediatric ankle is a useful modality to evaluate soft tissue structures and other pathologies. it is comparable to mri and allows for dynamic evaluation without need for anesthesia. resonance angiography (mra) using time resolved imaging is a relatively new technique that has become increasingly utilized in the diagnosis of vascular anomalies. we will describe the technique used at our institution, time resolved imaging of contrast kinetics (tricks, ge healthcare, milwaukee, wi), and the parameters that can be adjusted to optimize the exam. we will review key imaging features of hemangiomas and vascular malformations in various modalities, with a special emphasis on the tricks appearance. we performed a retrospective review of all the tricks studies performed at our institution for suspected vascular anomalies. in addition to the mr imaging features, we specifically analyzed the t1 weighted with fat saturation post tricks enhancement and the temporal tricks enhancement pattern. we reviewed all additional imaging including plain film, ultrasound, and ct and correlated the radiographic imaging with the available clinical and histopathologic features. results: we present illustrative cases of hemangiomas, kaposiform hemangioendothelioma, venous malformations, arteriovenous malformations, lymphatic malformations, and other pitfall lesions. we propose a diagnostic algorithm that relies heavily on the post contrast t1 weighted with fat saturation post tricks enhancement pattern and the temporal tricks enhancement pattern. conclusions: time resolved contrast-enhanced mra has become an increasingly important adjunct in the diagnosis of vascular anomalies. optimization of the exam technique and familiarity of the tricks imaging appearance is essential and can often assist in accurate lesion characterization. purpose or case report: vertical expandable prosthetic titanium rib (veptr) is increasingly used in the treatment of thoracic insufficiency, scoliosis, and chest wall defects in children. in contrast to spinal fusion surgery, veptr allows for growth while stabilizing the deformity. we review the indications, pre-operative imaging, normal radiographic appearance, and complications of this device. methods & materials: on review of the literature, the indications for veptr have expanded in the past several years to include thoracic insufficiency, idiopathic and neuromuscular scoliosis, and chest wall defects. we illustrate the normal radiographic appearance of the three common configurations of veptr (cradle-to-cradle assembly, cradle with lumbar extension assembly; cradle-to-ala hook assembly). we discuss the potential complications of veptr, including infection, rib fracture, dislodged hardware, and neurological injury, with an emphasis on imaging diagnosis. results: there is a relatively high rate of reported complications with veptr in the literature. therefore, awareness of the growing number of indications, as well as the expected and unexpected appearance of this device, aids in radiographic diagnosis of complications. conclusions: vertical expandable prosthetic titanium rib (veptr) is gaining acceptance in the treatment of thoracic insufficiency, scoliosis, and chest wall defects in children. recognition of the indications, normal radiographic appearance, and complications of this device will facilitate timely and accurate diagnosis. disclosure: dr. philips has indicated that she will discuss or describe, in the educational content, a use of a medical device or pharmaceutical that is classified by the food and drug administration (fda) as investigational for intended use. spectrum of pediatric spinal neoplasms: an interactive tutorial benjamin t. haverkamp, md, radiology, university of missouri-kansas city, haverkampbt@umkc.edu; salvador f. iloreta, maha jarmakani, lisa lowe, seth gibson purpose or case report: the objective of this educational electronic exhibit is to provide the radiologist with an approach to pediatric spinal neoplasms. emphasis will be placed on narrowing the differential diagnosis using a combination of lesion location, characteristic imaging findings, relevant history, and associations. the exhibit format will include a casebased review of various pediatric spinal neoplasms, radiologicpathologic correlation, and a brief discussion of imaging findings useful in guiding surgical management. an interactive selfassessment exam will be presented at the end of the exhibit. results: a review of the specific etiologies will be presented with classification as intra-and extra-medullary and extradural lesions. radiologic images will be related to gross and microscopic pathology. conclusions: after viewing this exhibit, the learner will be able to: 1. recognize the clinical, imaging, and pathologic characteristics of pediatric spinal neoplasms. 2. understand relevant imaging findings useful in surgical management. 3. test their understanding of the presented material through an interactive exam. poster #: edu-057 craniosynostosis jason tsai, mbchb, children's hospital boston, jason. tsai@childrens.harvard.edu; diana p. rodriguez purpose or case report: to review the normal developmental appearance of the cranial sutures with computed tomography (ct) and to describe ct findings of the various forms of craniosynostoses. in this irb-approved retrospective study we reviewed ct images of subjects diagnosed with craniosynostosis between 2006 and september 2011. we included patients with single-suture synostosis, isolated bilateral coronal synostosis, pansynostosis, and combined craniosynotoses. additionally, we identified individuals with normal appearing sutures from 0 to 5 years of age imaged with head ct to describe the pattern of normal development of the cranial sutures. results: a description of the normal developmental ct appearance of the cranial sutures using computed tomography has been provided. of the group of patients with craniosynostosis the following variables were recorded: age at presentation, the pattern of sutural fusion, skull shape, presence of hydrocephalus, genetic testing, and types of surgical correction. conclusions: we have demonstrated the normal developmental ct appearance of the cranial sutures and the ct patterns of the various forms of craniosynostoses, with clinical, genetic and surgical correlation. posterior fossa tumours: a pictorial review sam byott, md, manchester children's hospital, sambyott@ hotmail.com; neville wright, vivian tang, abdu shabani, stavros stivaros purpose or case report: posterior fossa tumours account for 54-70% of childhood brain tumours. the most common differentials include pilocytic astrocytoma, medulloblastoma and ependymoma. mr imaging is crucial to diagnosis, staging and identification of complications such as hydrocephalus and haemorrhage. soft tissue characteristics alongside tumour location, invasion and clinical history facilitate radiological discrimination prior to surgery. however, there is significant clinical equipoise with regards to the imaging appearances in a significant proportion of cases making definite diagnosis difficult. the aim of this study is to evaluate the radiological findings and correlate with histological data. this will allow identification of the key morphological features that discriminate different tumours. these can then be presented to educate fellow radiologists. methods & materials: radiology pacs and patient notes were used to collate radiological, histological and clinical data. results: there were 27 patients presenting at our institution with posterior fossa tumours. 12 had pilocytic astrocytomas, 8 had medulloblastomas and 7 had ependymomas. one patient had an atypical teratoid rhabdoid tumour (atrt). traditional features alongside more advanced mr characteristics were correlated with histology, and the features allowing for discrimination of tumour types are presented in this pictorial review. conclusions: posterior fossa tumours have a highly variable radiological appearance. we present a range of appearances and describe the important morphological features that allow radiological discrimination of tumour type. poster #: edu-059 3dt1 imaging of the pediatric spine teresa c. gross kelly, children's hospital of wisconsin, tkelly@chw.org; ibrahim s. tuna, mia s. kelly, tushar chandra, sumit singh, mohit maheshwari, hervey d. segall purpose or case report: some abnormalities of the pediatric spine can be challenging. we have discovered that in many such cases, diagnosis of spinal lesions can be faciliated by using the 3dt1 weighted sequence. the purpose of this educational poster is to demonstrate the remarkable usefulness of 3dt1 weighted images for delineating pathology of the pediatric spine. methods & materials: lesions of the spine that will be reivewed in this educational exhibit will be categorized as: (1) vascular (2) due to infection/inflammation (3) neoplastic/ neurogenic (4) congenital (5) traumatic/iatrogenic (6) endocrine/metabolic. the imaging characteristics of lesions found in the pediatric spine will be described and the utility of 3d t1-weighted mr sequences for the evaluation of these lesions will be discussed. finally the role of imaging in the treatment planning of abnormalities of the pediatric spine will be addressed. results: this educational exhibit will provide numerous examples of how 3d t1-weighted imaging can elucidate diagnosis of lesions involving the spine. examples include enhancement of the cauda equina in guillain barre syndrome, lipomatous malformations, spondylolysis in children with low back pain, thecal cysts, filar cysts, metastasis, hydromyelia and ventriculus terminalis. conclusions: 3d t1-weighted images of the spine performed in the sagittal plane with coronal and axial reformations, as well sagittal oblique reformations (scotty dog reformations) for evaluation of spondylolysis, can facilitate the evaluation of lesions involving the pediatric spine. the normal pediatric spine: a pictorial review of mr anatomy and development in the infant, child and adolescent ibrahim s. tuna, md, radiology, children's hospital of wisconsin, dristuna@yahoo.com; teresa c. gross kelly, tushar chandra, mohit maheshwari, sumit singh, hervey d. segall purpose or case report: radiological evaluation of the pediatric spine can be more challenging in child than in the adult patient due to the wide range of normal anatomic variants and synchondroses, combined with the unique effects of trauma in children. mri is an excellent imaging modality for the evaluation of the pediatric spine. however, in order to provide an accurate interpretation of acute posttraumatic changes in the pediatric spine, particularly in the setting of abusive head trauma, a fundamental knowledge of normal anatomy, variants and pathology of the pediatric spine is required. the aim of this educational exhibit is to illustrate normal mri anatomy of the spine in the infant, child and adolescent. methods & materials: this exhibit will first describe basic spinal embryology and development of the vertebra and spinal cord, followed by mri depiction of the developmental anatomy of the spine from infancy through adolescence. the changing appearance of the spinal canal, spinal cord and vertebral bodies with age will be illustrated using normal cases from the radiology database. sagittal and transverse diameter of vertebral bodies, thickness of the dural thecal sac, dimensions of the spinal canal, normal bone marrow signal changes, vertebral body heights, level of conus medullaris, prevertebral and paraspinous soft tissues and epidural fat thickness will be described and changes according to age will be pointed out. results: in early life, the spinal cord extends to the inferior aspect of the bony spinal column. because the vertebral bodies grow longitudinally faster than the spinal cord does, the conus medullaris may change. ossification of the vertebral bodies and posterior elements is nearly complete by age 10, with a resultant decrease in the spinal canal diameter. the nucleus pulposus becomes smaller after 10 years and spans approximately half the disk space in the sagittal plane. the spinal cord is elliptical in cross section in the cervical spine and demonstrates a difference in signal between the normal gray and white matter of the spinal cord which should not be mistaken for intramedullary pathology. conclusions: a solid understanding of normal spine anatomy and embryological development is essential in evaluation of pediatric spine, mainly in the setting of trauma. familiarity with normal anatomic variants is essential to provide an accurate interpretation of pathology in the pediatric spine. spectrum of intracranial cystic lesions in infants and children ernesto i. blanco, md, st. christopher's hospital for children, eiblanco74@gmail.com; eric faerber purpose or case report: to review the imaging spectrum of intracranial cystic lesions in the pediatric population. methods & materials: a retrospective review of our imaging database was performed to identify studies obtained in which the findings included intracranial cystic lesions. results: multiple cystic lesions were elucidated primarily by computed tomography or magnetic resonance imaging. these lesions can be divided into nonneoplastic and nonneoplastic tumor-associated cysts. the nonneoplastic cysts, which is the largest group, include: cavum septi pellucidi and cavum veli interpositi, choroid plexus cyst, enlarged peri-vascular spaces, pineal cyst, the large spectrum of arachnoid cysts, colloid cyst, epidermoid cyst, rathke cleft cyst, and porencephalic cyst. nonneoplastic tumor-associated cysts include: craniopharyngioma, optic glioma, pilocytic astrocytoma, hemangioblastoma, and ganglioglioma. conclusions: intracranial cystic lesions are relatively common entities in the pediatric population. a wide spectrum of nonneoplastic and nonneoplastic tumor associated pathologies are presented using both computed tomography and magnetic resonance imaging. kelly, sumit singh, ibrahim s. tuna, hervey d. segall purpose or case report: the aim of this educational exhibit is to provide a comprehensive review of imaging features, classification and management of pediatric spinal cord tumors. we also aim to elicit the differences between pediatric spinal cord tumors and their adult counterparts. we will summarize the differences between the individual tumors based on histological cell types and the pertinent implications on management and outcome methods & materials: this exhibit will provide an overview of the common as well as uncommon tumors of the pediatric spinal cord. various classification systems for these tumors-anatomical as well as histological will be discussed. we will illustrate the relevant imaging findings that can help in differentiating these tumors. results: pediatric spinal cord tumors account for 1% to 10% of all pediatric central nervous system tumors. mri is the mainstay for the initial diagnosis as well as the post surgical evaluation and surveillance of these tumors. pediatric and adult spinal cord tumours differ both in terms of anatomical location as well as histology. the disease and treatment related morbidities are also different in children as compared to adults. astrocytomas, ependymomas, glioneural tumors and csf metastasis represent the vast majority of cord neoplasms in the pediatric age group. some of cord tumors may also be associated with inherited syndromes (like neurofibromatosis type 2) or may have genetic predisposition. these would also be discussed. we will also illustrate and discuss common non neoplastic spinal masses that may mimic tumors. conclusions: pediatric spinal cord tumors have varied clinical presentations, imaging appearance and outcome. this review would improve the understanding of these tumors thereby helping in diagnosis, management and follow up of these uncommon neoplasms. multi-modality imaging of pediatric head and neck lesions jason au, md, oklahoma university health sciences center, jasonmau@gmail.com; anthony alleman, mahmoud elkaissi, roy jacob purpose or case report: the purpose of this study is to present a side by side comparison of the multi-modality imaging features of pediatric masses. using cases that have been imaged with multiple modalities, the exhibit will delineate the sonographic, mr, and ct appearance of congenital, infectious, and neoplastic head and neck lesions in the pediatric population. methods & materials: a restrospective search of pacs was performed on studies completed at the oklahoma university medical center on the oklahoma university health science center campus from january 2008 to the present. ultrasound, ct, and mr examinations were selected that depicted relevant pediatric head and neck pathology. all studies were de-identified prior to image export. results: over twenty representative cases of pediatric infections, fibrous tumors, cystic neoplasms, vascular malformation, bony tumors, developmental anomalies, and other neoplasms were selected for inclusion. results: pictorial review of cases including the following representative cases: myelonmeningocele associated with arnold chiari malformation, lipomyelomeningocele, tethered cord with spinal lipoma/fibrofatty filum, tethered cord and dermal sinus tract, and chiari i with syringohydromyelia. several unique cases including the following will be presented as well: thoracic meningocele with arnold chiari malformation, terminal myelocystocele, diastematomyelia, and myelomeningocele without arnold chiari malformation. while mri demonstrates the cranio-cervical junction and the cervicothoracic spinal cord better than ultrasound, ultrasound often allows for improved resolution of the distal spinal cord, lumbosacral spinal canal, and spinal dysraphism structures near the skin surface in the neonate. conclusions: congenital spinal malformations are complex and variable in imaging appearance. it is important to understand the classification in order to determine the appropriate management and prognosis. in the neonatal period imaging should be performed with ultrasound and mri studies, as they may provide different and complementary information. conclusions: hypoxic ischemic injury is a common condition resulting in a wide spectrum of severe neurological defects. while in the past treatment only consisted of supportive care for hii, recent advances have yielded promising treatment options if initiated within a limited time window. thus due to the severity of the disease and the need for rapid intervention, it is important to recognize radiological manifestations of hii along with its clinical signs and symptoms to offer a better prognosis to the patient. craniosynostosis: looking beyond the sutures tushar chandra, md, children's hospital of wisconsin, drtusharchandra@gmail.com; teresa c. gross kelly, mohit maheshwari, sumit singh, ibrahim s. tuna, hervey d. segall purpose or case report: the aim of this educational exhibit is to provide a framework upon which the diagnosis of the various types of craniosynostosis can be facilitated. our goal is to provide an efficient way to evaluate craniosynostosis for the radiologist in clinical practice. we plan to accomplish this goal by providing a succinct review of the sutures, an overview of the various classification schemes for craniosynostosis and potential complications associated with premature sutural closure. the role of imaging in the evaluation of craniosynostosis will be described and the features of craniosynostosis that are most important to the craniofacial surgeon will be elucidated. finally, surgical strategies for the repair of craniosynostosis and postoperative findings will be described. results: some of the forms of craniosynostosis may have a genetic basis, but many are spontaneous in nature. untreated progressive craniosynostosis can lead to inhibition of brain growth, and an increase in intracranial pressure. mdct with mip and 3d surface reformations is the preferred modality for diagnostic evaluation of craniosynostosis. it is also a robust modality for post operative assessment and long-term follow up. mri is a useful adjunct for assessment of associated intracranial anomalies and complications. timely and appropriate imaging is essential to assess for potential complications of craniosynostosis which may include intracranial hypertension, anomalies of external and middle ear, hydrocephalus, chronic tonsillar herniation, cranial base deformity, impaired venous drainage, enlarged emissary foramina and veins and optic atrophy. on the other hand, positional plagiocephaly should not be misinterpreted as craniosynostosis. surgical management is typical for nonsyndromic craniosynostosis, which involves correction of craniosynostosis between three to six months of age. conservative management is the mainstay for syndromic craniosynostosis. postoperative follow up imaging for surveillance for ventricular size and signs of raised intracranial pressure are necessary. conclusions: craniosynostosis is a challenging area of pediatric neuroimaging. knowledge of the sutural anatomy, an understanding of the potential intracranial complications caused by premature sutural closure, as well as the role that imaging plays in presurgical planning, can provide a practical way for the radiologist to evaluate craniosynostosis in a fast-paced clinical setting. poster #: edu-067 the perinatal brain and spinal cord-imaging across a life border: a case-based approach anand dorai raju, md, radiology university of tennessee, araju@uthsc.edu; harris l. cohen, matthew whitehead, asim choudhri purpose or case report: to review normal and abnormal perinatal ultrasound (us) and magnetic resonance (mr) imaging findings and note their significance for the analysis of the fetal and neonatal brain as well as spinal cord and vertebral column using a case based approach. to highlight us and mr capabilities in allowing correct perinatal diagnosis of congenital and acquired central nervous system abnormalities. methods & materials: cases will be shown of normal and abnormal anatomic findings in fetal and neonatal brain and spinal cord imaging. key teaching points necessary for the diagnosis of such brain abnormalities as ventriculomegaly, chiari malformations, holoprosencephaly, and agenesis of the corpus callosum as well as dandy walker malformations and avms will be discussed. intraventricular hemorrhage, periventricular leukomalacia, anoxic injuries and infectious abnormalities will be reviewed. abnormal anatomic findings in fetal and neonatal spine evaluations for congenital and acquired abnormalities and key teaching points necessary for the accurate diagnosis of tethered cord, myelomeninocele, caudal regression syndrome, hydromyelia, diastomatomyelia and sacrococcygeal teratoma will be reviewed. some diagnostic difficulties and controversies will be addressed. conclusions: ultrasound aided by mri can provide ready diagnosis to many central nervous system abnormalities involving fetuses and neonates. ever improving perinatal imaging experience and technique allow for better prenatal as well as postnatal diagnosis. cases showing such imaging and key points helping such imaging diagnoses will be reviewed. overview of imaging of pediatric extraocular orbital tumors srikala narayanan, md, division of radiology, children's national medical center, snarayan@childrensnational.org; nadja kadom, gilbert l. vezina purpose or case report: to show the spectrum of benign and malignant extraocular orbital tumors in children. methods & materials: we reviewed the cross-sectional imaging of orbit (ct and mr) done in the last 5 years. specific imaging signs of extraocular tumors including benign and malignant tumors such as hemangiomas, lymphangiomas, optic nerve glioma, optic nerve sheath meningioma, pseudotumors, rhabdomyosarcoma, orbital myofibroma, eosinophilic granuloma and neuroblastoma metastases will be shown. important imaging features that should be considered when formulating a differential diagnosis will be described. conclusions: the spectrum of diseases affecting pediatric orbit is substantially different from what we see in the adults. it is not easy always to differentiate between different tumors. important imaging characteristics will help us towards better differential diagnosis. in this exhibit, we will illustrate ultrasound anatomy of the neonatal spinal cord. discussion of the normal anatomic variants and pathological conditions of the spinal cord will be provided. representative images of a variety of common and uncommon pathological conditions of the spine will be presented to illustrate teaching points. in abnormal cases, follow up mri images will also be illustrated for comparison. results: ultrasound is a robust screening modality for evaluation of the lumbosacral spine in neonates. it is cheaper, readily available, safer first line imaging modality in neonates suspected to have spinal malformations. under able and well trained operator, diagnostic accuracy of spinal ultrasound approaches mri. however, mri remains the gold standard for imaging evaluation of spine. normal variants that simulate disease processes like ventriculus terminalis, prominent filum terminale and central echo complex will be presented. congenital malformations of the cord such as tethered cord, hydromyelia, lipoma, diastematomyelia, myelomeningocele, lateral meningocele and presacral masses will also be discussed. conclusions: ultrasound is a very useful screening technique for evaluation of pathological conditions of lumbosacral spine in neonates. this review would improve the understanding of utility and limitations of ultrasound in evaluation of neonatal spinal malformations. purpose or case report: although mri is the standard for detecting epilepsy and brain tumor abnormalities, pet-ct is performed to ascertain metabolism related to epileptogenic regions or characterize tumor metabolic activity. asymmetric metabolism often correlates to structural abnormalities like cortical dysplasia. metabolic activity often correlates with tumor aggressiveness or grade. fdg pet is commonly used to assess seizure and tumor metabolism. the lesser utilized amino acid pet tracers (c11 methionine, fdopa) show increasing value with lower grade tumors due to high tumor to normal tissue contrast. literature is accumulating regarding c11 methionine (cmet) in the detection of lesions like cortical dysplasia and its ability to delineate low grade seizure related tumor lesions. despite the established fdg and accumulating cmet literature, little information exists about the imaging seen with both in pediatrics. as these studies are increasingly viewed as part of fusion mri images, there is more scrutiny of focal metabolism correlating with mri findings and less interpretative reliance on abnormality based solely on asymmetry. methods & materials: review of 110 patients who underwent cmet and fdg brain pet-ct was performed. each was imaged on a philips scanner and had prior mri. studies demonstrating a variety of tumors, postoperative findings of residual or recurrent tumor, and pseudoprogression were selected. epilepsy cases with structural cortical abnormalities or seizure-associated tumors were also selected. cmet and fdg studies were analyzed by 3 pediatric neuroradiologists and the imaging findings correlated with prior mri and any pathology or follow-up imaging. pictorial galleries of the cmet and fdg imaging patterns were created. results: pathologically proven low-grade glial tumors showed increased cmet uptake and no hypermetabolism on fdg. high-grade tumors showed increased uptake on cmet and hypermetabolism on fdg. patients with residual or recurrent tumors showed uptake similar to their original tumor. granulation tissue and pseudoprogression changes showed increased uptake on cmet and no hypermetabolism on fdg. epilepsy surgery patients with cortical dysplasia or low grade glial tumors showed increased uptake on cmet and fdg hypometabolism. conclusions: this study illustrates the variety of findings on cmet and fdg pet-ct in pediatric patients clinically evaluated for brain tumor and epilepsy. this atlas provides readers with a guide to the appearance of these findings on an emerging imaging technique. pediatric head and neck neoplasms: a multimodality pictorial review alok jaju, md, mallinckrodt institute of radiology, alokjaju@gmail.com; marilyn j. siegel purpose or case report: neck masses are common in children and most occur in the suprahyoid region. knowledge of the fascial spaces involved in conjunction with imaging features can help in diagnosis. in this pictorial review, we present a multimodality imaging approach based on anatomy of the suprahyoid fascial spaces for evaluation of pediatric neck tumors. methods & materials: radiology information system (ris) at our tertiary care children's hospital was queried to identify patients with suprahyoid neck masses who had imaging performed between july 2004 and present. a variety of conditions having congenital, inflammatory, neoplastic, or vascular origin were identified and the anatomic location in the neck as well as imaging and clinical findings were retrospectively reviewed. results: the imaging evaluation included ultrasound, ct and mri. lesions arose within the following fascial spaces of the suprahyoid neck: superficial, carotid, masticator, submandibular, sublingual, parotid, parapharyngeal, visceral, retropharyngeal and prevertebral. key imaging features important in diagnosis included lesion vascularity, calcification, necrosis and bone invasion. we discuss and illustrate these imaging findings and relate them to specific suprahyoid fascial spaces. specific lesions include vascular and lymphatic malformations, teratoma, nerve sheath tumors, thyroglossal duct and branchial cleft cysts, pleomorphic adenoma, dermoid cyst, ranula, lymphadenopathy, abscess, lymphoma, rhabdomyosarcoma, neuroblastoma and nasopharyngeal carcinoma. conclusions: knowledge of fascial spaces of the suprahyoid compartment and key imaging features on multiple modalities can aid in the diagnosis of pediatric neck masses. pediatric sinusitis: spectrum of imaging findings with clinicopathologic correlation roy jacob, md, university of oklahoma, drjacobr@gmail. com; paul digoy, robert s. glade, anthony alleman purpose or case report: the clinical spectrum of sinusitis in children can range from uncomplicated bacterial sinusitis to invasive fungal sinusitis. most cases respond favorably to medical management. however, complications occasionally occur due to the spread to adjacent structures. imaging plays an important role in characterizing the disease and guiding the clinical and surgical planning and treatment. this electronic presentation outlines the following-1. review radiologic anatomy and unique characteristics of pediatric sinuses. 2. review the clinical features, pathophysiology, and microbiology of sinusitis. 3. review of ct and mri imaging characteristics of sinusitis with representative cases such as complicated sinusitis and invasive fungal sinusitis. 4. review the treatment approaches of sinusitis. methods & materials: a retrospective search of pacs was performed on studies completed at the ou children's hospital in oklahoma city for the last three years. ct and mr examinations were selected that depicted relevant disease processes. corresponding nasal endoscopic pictures were obtained from cases which required surgical management. all studies were de-identified prior to image export. results: over fifteen representative cases of the clinical spectrum of sinusitis and its complications were selected for inclusion. conclusions: this educational exhibit provides a concise review of imaging, clinical features, and treatment of pediatric sinusitis. findings will be richly illustrated with radiological and clinical images. microcephaly or hydrocephalus. knowing the embryology of the cerebellum and 4th ventricle is important to perceive the development of posterior fossa malformations and to further understand the imaging findings. several classifications schemes have been proposed from a pure embryologic to an imaging-based approach using some essential findings such as the size of the posterior fossa, the presence of csf collection or expansion of csf space, and the size and morphology of the cerebellum. mr is the gold-standard for adequately access and characterize the posterior fossa structures. this pictorial essay will review the mr findings of some of the most common posterior fossa malformations including dandy-walker malformation, persistent blakes pouch, mega cisterna magna, arachnoid cyst, paleocerebellar hypoplasia, cerebellar agenesis, cerebellar and pontocerebellar hypoplasia, cerebelar cortical malformations, isolated brainstem hypoplasia/dysplasia and chiari malformations. we will provide a practical approach to the mr findings of posterior fossa malformations in children. conclusions: mr plays a crucial role in identifying and characterizing malformations of the posterior fossa structures. it should give a logical approach to these complex malformations thus guiding the refereeing physician into the clinical approach and in determining further investigations. results: neuroimaging features of abnormal thalami as encountered in the pediatric population were detailed, and wherever applicable, the relevance of additional mr imaging sequences and techniques to determine etiology was described. while there was considerable overlap in imaging appearances, making a precise diagnosis was found to be challenging in difficult cases, and by and large, a stepwise approach was successfully formulated and used to: 1. diagnose the more emergent conditions and to 2. devise a management algorithm for the less acute abnormalities. conclusions: bilateral thalamic lesions are occasionally encountered in pediatric neuroimaging and have a limited differential; a good knowledge base and adequate technique are imperative to tease out the precise diagnosis and institute appropriate management. cortical developmental abnormalities in pediatric seizure patients ibrahim s. tuna, md, radiology, children's hospital of wisconsin, dristuna@yahoo.com; mohit maheshwari, teresa c. gross kelly, sumit singh, tushar chandra, hervey d. segall purpose or case report: to describe various cortical malformations with illustrative examples. we will also briefly discuss the embryology, genetic basis, classification schemes and characteristic imaging findings . methods & materials: this exhibit will illustrate three main categories of cortical malformations: neuronal proliferation, migration and organization. understanding of this complex topic would be facilitated by brief discussion on the embryological basis and proposed genetic causes of some of these cortical malformations. classification schemes on embryology and imaging will be discussed. characteristic imaging findings of these malformations will be discussed and examples from the authors database will be shown. results: neuroimaging in pediatric seizures is challenging. mri is considered the imaging modality of choice because of superior soft tissue contrast and better ability to characterize the pathologic process. we will also discuss the dedicated seizure protocol which is used in our institute. pet-ct imaging can also provides additional information in cases where mri is negative, inconclusive or does not correlate with eeg/clinical findings. brief discussion on advanced imaging techniques will also be presented. malformations are frequently detected in infancy. however, if the initial mri scan performed in infancy is negative, a repeat scan after 2 years of age may be helpful. conclusions: evaluation of cortical malformation in seizure patients still remains a challenging area of pediatric neuroimaging. reviewing of the embryological basis, classification schemes and characteristic imaging findings would improve the understanding the cortical malformations and interpreting the images. poster #: edu-079 sprs best poster 2011 cystic neonatal lesions associated with the spinal cord: discussion and differential diagnosis for these uncommon lesions jacob pirkle, md, jpirkle@mc.utmck.edu, james boyd, brian dupree purpose or case report: to review intradural cystic neonatal spine lesions and discuss the various causes and appearance of these lesions. this poster presentation provides a brief review of neonatal cystic spine lesions, including their etiologies, and presents the targeted audience (radiology resdients, fellows, and practicing radiologists) a helpful differential diagnosis of these lesions based upon their imaging appearance. methods & materials: a brief overview of neonatal cystic spine lesions, their etiology, and imaging appearance is presented in poster format utilizing both literature search and printed reference material. images from several cases of cystic neonatal spine lesions are presented. results: a brief overview of neonatal cystic spine lesions, their etiology, and imaging appearance is presented in poster format utilizing both literature search and printed reference material. images from several cases of cystic neonatal spine lesions are presented. conclusions: neonatal spine ultrasound is often performed to evaluate for abnormalities related to the presence of sacral dimples, cutaneous stigmata, skin tags, hairy tufts, during the evaluation of other congenital anomalies, or when prenatal ultrasound/mri demonstrates an abnormality warranting postnatal follow-up. the identification of cystic spinal cord lesions is relatively rare in the neonate. however, the etiology of these lesions can often be deduced or surmised based upon the location and the imaging appearance of the lesion. the most common cause of a cystic intramedullary spinal lesion is ventriculus terminalis, with a reported incidence of 2.6%. additional lesions include transient dilatation of the central canal, filar cyst, syringohydromyelia, intramedullary arachnoid cyst, and myelomalacia related to in utero/birth trauma. extremely rare etiologies in the neonate include epidermoid/dermoid, cavernous malformation, intranatal cystic infections etiologies, neuroepithelial cysts, and cystic neoplasms. mimics include diastematamyelia, spinal lipomas, and intramedullary hematomas. numerous imaging examples of these lesions are provided in the accompanying poster. brain mri in peroxisomal disorders: a pictorial essay bruno p. soares, md, radiology and biomedical imaging, university of california at san francisco, bruno.soares@ucsf. edu; leonardo vedolin, guido gonzalez purpose or case report: our presentation aims to illustrate the brain mri patterns in peroxisomal disorders. peroxisomes are intracellular organelles involved in important cellular processes including beta-oxidation of very-longchain fatty acids and plasmalogen production. peroxisomal disorders can be categorized into disorders of peroxisomal biogenesis, in which the peroxisomes are abnormally formed and several peroxisomal functions are deficient, and in defects involving a single peroxisomal function, in which the structure of the peroxisome is intact. disorders of peroxisomal biogenesis include zellweger syndrome, neonatal adrenoleukodystrophy, infantile refsum disease and rhizomelic chondrodysplasia punctata. numerous disorders are caused by loss of a single peroxisomal function including x-linked adrenoleukodystrophy and acyl-coa oxidase deficiency. clinical findings in peroxisomal disorders include dysmorphic features, hepatic dysfunction, neurodevelopmental delay, retinopathy and hearing impairment. methods & materials: pictorial essay illustrating brain mri patterns in peroxisomal disorders, including disorders of peroxisomal biogenesis and disorders with loss of a single peroxisomal function. results: brain abnormalities in peroxisomal disorders have a wide spectrum of patterns. neuronal migration disorders with abnormal myelination are typically seen in zellweger disease and neonatal adrenoleukodystrophy. specifically, the association of abnormal myelination with germinolytic cysts is suggestive of zellweger syndrome. classic x-linked adrenoleukodystrophy typically shows posterior central white matter involvement and symmetric demyelination also involving the corticospinal tracts and corpus callosum. a similar pattern of white matter involvement is seen in acyl-coa oxidase deficiency and infantile refsum disease. conclusions: brain mri helps narrow the differential diagnosis and guides subsequent evaluation in infants presenting with clinical features concerning for peroxisomal disorders. therefore, knowledge of the brain mri patterns in peroxisomal disorders is important for the radiologist interpreting neuroimaging studies. clots in tots: role of imaging in diagnosis of acute stroke and its causes in children asif abdullah, c.s. mott children's hospital of the university of michigan, asifa@med.umich.edu; ellen hoeffner, augusto elias purpose or case report: stroke is a major cause of morbidity and mortality in children. long-term neurologic deficits occur in 50% to 85% of infants and children after arterial ischemic stroke. limited awareness regarding pediatric stroke among physicians and in general community is a major concern. imaging plays crucial role in the diagnosis of pediatric stroke. the goal of this presentation is to provide awareness to the reader about the role of imaging in childhood stroke and its myriad causes in children. we will provide a case based approach to imaging diagnosis of acute pediatric stroke based on three categories: (1) arterial ischemic stroke, (2) cerebral venous thrombosis, and (3) hemorrhagic. arterial ischemic stroke (ais) is classified according to the pediatric stroke classification (psc). psc includes eight subtypes of ais: (1) sickle cell disease, (2) cardioembolic disease, (3) moyamoya syndrome, (4) cervical arterial dissection, (5) stenoocclusive cerebral arteriopathy, (6) other determined etiology, (7) multiple probable etiologies, and (8) undetermined etiology. we will describe the role of computed tomography (ct) and magnetic resonance imaging including angiography (mri/mra) in identifying these causes in relation to available clinical data. the etiologies of cerebral venous thrombosis related infarction would be discussed from an imaging perspective with a case-based approach with emphasis on mrv and swi techniques. finally, we will focus on hemorrhagic causes of childhood stroke such as vascular malformation, aneurysm, neurocutaneous disorders, coagulopathy, and a variety of other causes from an imaging standpoint. perfusion imaging in pediatric stroke demonstrates flow within the brain and can detect areas that are at risk of ischemia; however, further studies in the pediatric population need to be validated for the role of this technique in pediatric stroke. results: the most important factors in the diagnosis of childhood stroke are causal investigation, appropriate laboratory tests, and imaging studies. imaging is frequently the first step in the evaluation of an acutely ill child. conclusions: pediatric stroke is a debilitating disease that requires urgent multidisciplinary approach for diagnosis and treatment. in cases of both ischemic and hemorrhagic origin, the radiological approach to be obtained in emergency setting leads to the initial screening and the first therapeutic possibility. methods & materials: this exhibit will illustrate the characteristic imaging findings of vascular anomalies in the head and neck region. vascular anomalies are divided into vascular tumors and vascular malformations which include slow flow malformations (capillary malformations, venous malformations, lymphatic malformations and their combinations) and high flow malformations (arteriovenous fistula and arteriovenous malformations). complex malformations are also seen in several syndromes including klippel-trenaunay syndrome, phace syndrome, etc. cases from author's database will be used for illustration. results: a review of clinical manifestations, characteristic imaging findings and interventional treatment strategies in cases of head and neck vascular anomalies will be presented with pre and post treatment imaging features. ultrasonography and mri are the mainstay in diagnosis of these malformations. ct scan and catheter angiography may occasionally be needed for diagnosis and treatment planning. various imaging findings and main treatment options will be listed. conclusions: head and neck vascular malformations are common in pediatric population. understanding the characteristic imaging findings and clinical presentation is essential in evaluating the vascular malformations. interventional procedures are generally the preferred treatment modality, either alone or in association with surgery in majority of these cases. isolated cortical diffusion restriction in pediatric brain mri ihsan mamoun, md, cleveland clinic, ihsanmamoun@ yahoo.com; sarah stock, s. pinar karakas, unni udayasankar, janet r. reid purpose or case report: diffusion-weighted imaging continues to emerge as a powerful neuroimaging tool. isolated cortical restricted diffusion is a particularly striking pattern with specific differential in the pediatric population. we aim to review this specific imaging pattern supplemented by case examples and key physiologic and imaging concepts. methods & materials: review the concept of diffusion restriction a) pathophysiology b) specific imaging appearances pictorial review of pediatric conditions that lead to cortical restricted diffusion: a) post ictal change b) infection-i. meningoencephaliitis ii. herpes c) hypoxic ischemic injury d) infarct: venous and arterial e) posterior reversible leukoencephalopathy f) mitrochondrial cytopathy g) metabolic: hypoglycemia. discuss certain artifacts. summary table and differential clues conclusions: the pattern of isolated cortical restricted diffusion has specific differential diagnosis in the pediatric population. the radiologist should be aware of this as use of dwi continues to grow. this exhibit with familiarize the reader with common conditions that specifically affect the cortex and produces true restricted diffusion. methods & materials: high resolution ct scan and mri are mainstay of diagnosis and assessment in patients with sensorineural hearing loss. in this exhibit we will present a pictorial review of ct scan and mri images of various causes of sensorineural hearing loss (snhl) that are seen on imaging. reviewing the embryologic basis of these anomalies would enable better understanding of this complex subject. results: the new system classifies these malformations according to descending order of severity into complete labyrinthine aplasia, cochlear aplasia, common cavity, cystic cochleovestibular malformation or incomplete partition-i (ip-i), cochleovestibular hypoplasia, and incomplete partition-ii (ip-ii). there is a lot of confusion in literature pertaining to mondini deformity. the new classification divides incomplete partition into ip-i representing cystic cochleovestibular malformation and ip-ii representing the classic mondini deformity with three components (cystic cochlear apex, dilated vestibule, and large vestibular aqeduct). recently a subclassification of ip-i and ip-ii has been proposed (subdividing into typical and atypical subtypes)[2]. this will be discussed briefly. isolated large vestibular aqueduct without associated cochlear abnormalities will also be discussed. we will discuss the relevant embryology with correlations of malformations to the timing of embryologic insult. conclusions: the new classification system provides precision in description of inner ear malformation. this also helps in providing a uniform scale for comparison of effectiveness of cochlear implant for different malformations. purpose or case report: congenital cranial nerve anomalies often present as sensory and/or motor deficits of unknown etiology in the pediatric age group. the early recognition of a definitive cranial nerve abnormality using high-resolution imaging can focus further clinical investigation and shorten the time to diagnosis. methods & materials: to promote appropriate recognition of cranial nerve anomalies, we present the imaging findings of the most commonly affected cranial nerves and provide correlation with clinical presentation. all studies were performed on a 1.5 t magnet with dedicated high resolution imaging of cranial nerve exit zones. results: ours is a tertiary care pediatric hospital with an extensive neuroimaging database. we intend to review all known cases of cranial nerve anomalies from the prior 5 years and present interesting and representative images including optic nerve hypoplasia as part of septo-optic dysplasia, kallman syndrome, duane retraction syndrome, and mobius syndrome. conclusions: congenital cranial nerve anomalies present with varied symptomatology including anosmia, impaired vision, occulomotor deficits, and hearing loss. additionally, clinical manifestations of cranial nerve anomalies can be difficult to recognize in the pediatric age group. effective imaging and prompt diagnosis is crucial to initiate appropriate clinical management. purpose or case report: mr is the standard for evaluation of tumors or epilepsy. pet-ct imaging is often performed to ascertain metabolic asymmetries related to epileptogenic regions or to better characterize the metabolic activity of tumors. a baseline for normals with pet-ct fdg-18 and c11 methionine does not exist. methods & materials: retrospective review was performed of the 110 pediatric patients who underwent pet-ct with c11 methionine and fdg. representative studies were selected for patients imaged during infancy (<1 yr), early childhood (1-4), childhood (4-7), late childhood (7-12), teenage (13-18). c11 methionine and fdg studies were analyzed for normal patterns of uptake and any trends identified across the stratified age groups. representative pictorial image galleries of the c11 methionine and fdg imaging patterns through development were created. results: the pattern of radiotracer uptake on c11 methionine differed from that of fdg. the c11 uptake remained low level throughout development compared to fdg uptake, which was robust in much of the cortex. the cortical fdg uptake within the frontal lobes progressively increased with age. the c11 uptake within the brainstem and thalamus was equal to cortex throughout development. the fdg uptake within the basal ganglia was equal to cortex while the brainstem and thalamic uptake was generally less than cortex. several anatomic structures showed robust c11 uptake not seen on fdg. these included the lacrimal, submandibular and parotid glands. incidentally, the pituitary gland and hippocampus consistently showed c11 uptake equal to cortex contrary to their appearance on fdg. our institutional protocol regarding the performance of combination c11 methionine and fdg brain pet-ct studies is presented. conclusions: this study illustrated the normal appearance of brain pet-ct imaging performed with c11 methionine and fdg in a representative cohort of the pediatric patients through development. normal variance imaging patterns and developmental trends seen with each radiotracer was demonstrated. the pediatric cerebellum: a pictorial review of normal anatomy using mri and diffusion tensor imaging ibrahim s. tuna, md, radiology, children's hospital of wisconsin, dristuna@yahoo.com; sumit singh, teresa c. gross kelly, mohit maheshwari, tushar chandra, hervey d. segall purpose or case report: the aim of this educational exhibit is to illustrate normal anatomical and functional anatomy of the cerebellum in the pediatric patient. the cerebellum receives sensory input from the brain and spinal cord and integrates this information to coordinate motor control. in addition, the cerebellum also plays a role in some cognitive functions such as attention and language. the first step toward understanding how cerebellar abnormalities can lead to neurological dysfunction, is to provide a solid understanding of the neuroanatomy and functional pathways of the cerebellum. we will describe basic cerebellar embryology, the various cell types and gross anatomy using mr images as well as dti fiber tractography. methods & materials: this exhibit will describe the microstructure, gross anatomy and functional pathways of the cerebellum through illustrations, mr images, diffusion tensor imaging (dti) and pathological correlation. first embryology of the cerebellum will be described, followed by mri depiction of the developmental anatomy of the cerebellum from infancy through adolescence. finally dti tractography images will be used to delineate functional pathways to and from, as well as within, the cerebellum. pathological specimens will be photographed to further illustrate gross anatomy. results: afferent white matter pathways travel mainly via the inferior and middle cerebellar peduncles. the main efferent cerebellar white matter pathway is through the superior cerebellar peduncle. transverse fiber tracts are present in the vermis. there are mainly two main systems of cerebellar white matter fibers which are easily visualized with dti color mapping; however more anterior components of dti tracts are intermixed with afferent white matter projections following the middle cerebellar peduncle. conclusions: knowledge of the precise neuroanatomy and white matter tracts of cerebellum may elucidate our ability to comprehend the clinical manifestations of cerebellar diseases in children. a solid understanding of normal cerebellar anatomy, development and functional fiber tracts in the pediatric patient can provide a baseline that may help predict the clinical outcome of various diseases or interventional procedures. gastroesophageal reflux scintigraphy: a low radiation alternative to gerd evaluation in children vikas menghani, md, pediatric radiology, women's and children's hospital, drvikasmenghani@gmail.com; feraas jabi, jan najdzionek, vaseem iqbal purpose or case report: gastroesophageal reflux disease (gerd) is among the common causes for failure to thrive, recurrent cough and aspiration in children. early diagnosis of gerd is essential in avoiding long-term sequelae such as growth delay, chronic lung disease, esophageal stricture, and esophagitis. gastroesophageal reflux scintigraphy, a noninvasive imaging modality, has been applied for detection of gerd and gastric emptying in children over the past few decades. the radiation burden is considerably small given that a very low dose of radioactivity via a short half-life radioisotope like technetium-99 m tagged to oral sulfur colloid is administered to a patient. this feature makes reflux scintigraphy especially attractive as the patient can be scanned for prolonged and delayed periods without increasing radiation dose permitting not only identification but also assessment of severity of gerd. characterizing gerd severity is essential in determining how aggressive the pediatrician should be with therapy. gastroesophageal reflux scintigraphy also allows a child to be fed their regular meal tagged to radiopharmaceutical without altering food taste. qualitative and quantitative parameters like gastrointestinal transit and gastric emptying time can be measured, respectively. scintigraphy is highly sensitive to low grade reflux making it very desirable for monitoring response to therapy. while scintigraphy like all other imaging modalities,has limitations, it continues to be an excellent technique for gerd identification and characterization as well as in monitoring response to gerd therapy. the pediatric kidney-a review of common and uncommon renal anomalies ruby lukse, staten island university hospital, drjosemorey@gmail.com; josé morey, jeremy neuman, arnold brenner, oren herman, adam bernheim purpose or case report: renal parenchymal imaging in nuclear medicine has long been performed with 99mtcdimercaptosuccinic acid (dmsa) due to its sufficient binding to the renal tubules to permit renal cortical imaging. dmsa is of particular value when high-resolution images of the renal cortex are needed. this poster will be a pictorial review of common and uncommon congenital anomalies evaluated on dmsa imaging, such as horseshoe kidney, pelvic kidney, sshaped kidney and crossed-fused ectopia. the poster will also correlate planar imaging findingss with appropriate additional imaging including computed tomography (ct), magnetic resonance imaging (mri), fluoroscopic imaging and plain film radiographs when clinically warranted and in keeping with the as low as reasonably achievable (alara) principle set forth by the american college of radiology (acr). purpose or case report: in this poster we will review the differential diagnoses of congenital anomalies that give the appearance of hydronephrosis on renal imaging of the pediatric patient. we will show a pictorial review of both common and uncommon congenital anomalies such as congenital megaureter, ureterocele, uretero-pelvic junction (upj) obstruction, uretero-vesicular junction (uvj) obstruction and posterior urethral valves (puv). we will also review common mimickers of hydronephrosis such as multicystic dysplastic kidney (mcdk) and pseudo-obstruction secondary to bladder overdistention. the poster will also correlate planar imaging finds with appropriate additional imaging including computed tomography (ct), magnetic resonance imaging (mri), fluoroscopic imaging and plain film radiographs when clinically warranted and in keeping with the as low as reasonably achievable (alara) principle set forth by the american college of radiology (acr). the pediatric bone scan-a review of neoplastic pathology shrita smith, staten island university hospital, drjosemorey @gmail.com; josé morey, jeremy neuman, arnold brenner, daniel klein, purpose or case report: bone imaging continues to be the second greatest-volume of nuclear imaging procedure performed today, offering the advantage of total body examination, low cost, and high sensitivity. the diagnostic utility, sensitivity, specificity and predictive value of 99 m-tc bone imaging of malignant conditions have long been established. in fact, more than 3,450,000 bone scans were performed in the united states in 2005. in this poster we will review the current indications for planar bone imaging for the evaluation of malignant and benign neoplasms in the pediatric population, such as osteoid osteoma, langerhan cell histiocytosis (lch), osteoblastoma, ewing's sarcoma, lymphoma, osteosarcoma and osseous/hepatic metastatic disease from neuroblastoma. the poster will also correlate planar and single-photon emission computed tomography (spect) imaging findings with appropriate additional imaging including computed tomography (ct), magnetic resonance imaging (mri), positron emission tomography (pet), and plain film radiographs when clinically warranted and in keeping with the as low as reasonably achievable (alara) principle set forth by the american college of radiology (acr). the many faces of duplex kidneys on dmsa scans-a pictorial essay neha kwatra, children's national medical center, nskwatra@childrensnational.org; massoud majd purpose or case report: renal duplication is the most common malformation of the urinary tract and is often seen in children with urinary tract infections (uti). the purpose of this study is to learn to recognize duplex kidneys on dimercaptosuccinic acid (dmsa) scintigraphy, review their entire spectrum of findings and correlate with other imaging modalities. methods & materials: dmsa scintigraphy is routinely performed in the nuclear medicine department with a single-head gamma camera (siemens e.cam, schaumberg, illinois). about 1.5 h after injection of dmsa, posterior and posterior oblique images are obtained using parallel and pin hole collimators. differential renal function is also calculated. dmsa scan reports containing the words "duplex" or "duplicated" from 2006-2011 were populated using a radiology search engine (montage health care solutions inc.). the images were then reviewed in pacs and representative examples were selected for the poster. the scans were evaluated for renal position, size, contour, any evidence of duplication and parenchymal damage. results: patterns of duplication included non complicated duplex kidney recognized by asymmetric renal size and a prominent cortical bar separating the two moieties, complicated duplex systems with hydronephrosis, scarring or pyelonephritis of one or both moieties. a small nonfunctioning upper moiety was sometimes evidenced by just an indentation along the superomedial aspect of the larger lower moiety. cases with bilateral duplex kidneys were also seen. illustrative examples of each will be provided. correlating findings on other imaging modalities will also be included. conclusions: establishing the diagnosis of duplex kidney on a dmsa scan requires a careful systematic review of the images. the findings can be subtle and it is important for the radiologist to recognize them. correlation with other modalities such as ultrasound or voiding cystogram can be complementary. the assessment of parenchymal function of the upper and lower moieties separately on dmsa scintigraphy can be of immense value in patient management and in choosing surgical options. poster #: edu-094 18 f-fdg pet/ct imaging of pediatric brain tumors, neurofibromatosis 1(nf1) and non-lymphomatous head and neck tumors. lisa states, md, radiology, chop, states@email.chop.edu; purpose or case report: this educational poster will review the current literature and summarize the value of 18 f-fdg pet/ct in standard clinical practice in the evaluation of pediatric brain tumors, nf1 plexiform neurofibromas and malignant peripheral nerve sheath tumors, and nonlymphomatous head and neck tumors. normal variants and pitfalls will be reviewed. comparison with other pet tracers will be briefly discussed. case examples will be used to illustrate the value of 18 f-fdg pet/ct in grading, staging, assessment of therapeutic response and detection of residual or recurrent disease in various pathologic entities. results: examples of cases will include: benign brain tumor, residual brain tumor in the post-operative bed, brain metastasis, malignant peripheral nerve sheath tumor in nf1, head and neck rhabdomyosarcoma, mandibular osteosarcoma, and infection. conclusions: an understanding of the value of pet molecular imaging is essential to the success of the next phase of hybrid imaging with pet/mri which has the potential to play an important role in the development of new diagnostic and therapeutic approaches for the treatment of pediatric brain tumors, nf1, and pediatric head and neck tumors. disclosure: dr. states has indicated that she will discuss or describe, in the educational content, a use of a medical device or pharmaceutical that is classified by the food and drug administration (fda) as investigational for intended use. the pediatric bone scan-a review of non-malignant pathology josé morey, staten island university hospital, drjosemorey@ gmail.com; jeremy neuman, arnold brenner, vinh phan, cheryl lin purpose or case report: bone imaging continues to be the second most performed nuclear imaging procedure, offering the advantage of total body examination, low cost, and high sensitivity. the diagnostic utility, sensitivity, specificity and predictive value of 99 m-tc bone imaging of benign conditions have long been established. in fact, more than 3,450,000 bone scans were performed in the united states in 2005. in this poster we will review the current indications for planar bone imaging for the evaluation of non-malignant diseases in the pediatric population, such as acute osteomyelitis secondary to salmonella enterobacteriaceae and tubercle bacillus (tb), chronic osteomyelitis, reflex sympathetic dystrophy, spondylolysis, bone infarcts in the setting of sickle cell disease, fractures (occult/stress), ankylosing spondylitis, dermatomyositis and non-accidental trauma. the poster will also correlate planar and single-photon emission computed tomography (spect) imaging findings with appropriate additional imaging including computed tomography (ct), magnetic resonance imaging (mri), positron emission tomography (pet), and plain film radiographs when clinically warranted and in keeping with the as low as reasonably achievable (alara) principle set forth by the american college of radiology (acr). purpose or case report: we review the radiologic features of pathologic conditions linked to diesel exposure. the hydraulic fracturing ("fracking") technique is increasingly used in many areas of the country to extract natural gas from rock formations. diesel fuel, or fluids containing diesel, are one component of fracking fluid and create a potential for ground water contamination and risk to air quality. the toxic effects of diesel exhaust are described in the literature, and include asthma, hydrocarbon pneumonitis, and leukemia. there are no scientific data currently available on the effects of chronic diesel ingestion. methods & materials: multi-modality examples of pathology were obtained from a radiology database at a tertiary care pediatric hospital. the specific cases displayed are not known to have diesel exposure, but are intended to serve as representative examples of the type of pathology that may be encountered in the setting of chronic diesel exposure. results: imaging findings of asthma include hyperexpansion, atelectasis, peribronchial thickening, and air-trapping. hydrocarbon pneumonitis may demonstrate low attenuation consolidation and subsequent pneumoatocoeles with ct. leukemia may present on plain radiographs with lucent metaphyseal bands and with marrow infiltration on mri. conclusions: in conjunction with other symptoms not necessarily evaluated in the radiology department, including rhinitis, laryngitis, acute coronary syndrome, and dementia, the radiologist may suggest the diagnosis of diesel toxicity, particularly in populations that may be at high risk of exposure. pediatric radiology in the philadelphia region: a historical review* richard markowitz, md, children's hospital of philadelphia, markowitz@email.chop.edu purpose or case report: the specialty of pediatric radiology in the philadelphia region has grown and evolved over the past eight decades originating from early "visiting" radiologists to drs. hope and kirkpatrick, the "giants" of the 1950s and '60s, to over fifty practicing pediatric radiologists today. clinical excellence, commitment to teaching, and advancement of knowledge through research remain the goals and ideals, much as they were many years ago. philadelphia has been a fertile home and environment for this evolution, mostly because of outstanding leaders and role models who have trained and influenced generations of pediatric radiologists. developments and leadership at the children's hospital of philadelphia, st. christopher's hospital for children, and a.i. dupont institute are highlighted. the purpose of this poster is to tell the story of the growth and development of pediatric radiology in this area and to explore the intellectual origins, professional "genealogy," and legacies left by those who created and those who have carried on this tradition. *note: this material is based on a previously published article: pediatric radiology (2009) 39:969-981 and "addendum" (pediatric radiology 2010: 1454-1455), but never presented at spr. superficial lumps and bumps henrietta k. rosenberg, md, radiology, the mt. sinai medical school, henrietta.rosenberg@mountsinai.org; diane belvin, neil lester purpose or case report: superficial soft tissue masses in the pediatric age range can be quite challenging to the pediatrician and the imager. the purpose of this presentation is to demonstrate the efficacy of duplex/color doppler ultrasound for the diagnosis and follow up of a large gamut of superficial lumps and bumps. methods & materials: we reviewed our experience during the past 6 years using ultrasound to evaluate superficial soft tissue masses that had been encountered in many parts of the body, from the skull to the soles of the feet, in a large group of patients ranging in age from newborn to 21 years. all sonograms were performed after obtaining pertinent clinical information as well information regarding the clinical characteristics of each of the masses, e.g. location, consistency (firm [solid], compressible [cystic]), fixed or easily movable, smooth or irregular surface, tenderness. the masses were palpated by the imaging team and duplex/color doppler ultrasound was performed. comparison sonographic views of the opposite side were obtained as needed. clinical followup and surgical/pathological correlation was obtained in most of the patients. results: most of the masses were benign and included a wide variety of etiologies. most often, us was sufficient for assessment of soft tissue masses if the entire mass was included in the field of view. if the lesion was too large for the field of view or malignancy was suspected, ct/mri were required preoperatively. nuclear medicine studies are reserved for midline masses likely due to ectopic thyroid and pet was used for more complete evaluation of a lesion that was likely malignant. conclusions: duplex/color doppler ultrasound (us) is the modality of choice for evaluation of superficial lumps and bumps! this modality allows for rapid acquisition of information without the use of ionizing radiation, intravenous contrast material, or sedation/anesthesia. reliable information can be rapidly acquired regarding the size, shape, borders, location, internal consistency, vascularity, vascular encasement/displacement. correlation of the ultrasound and clinical findings helps narrow differential diagnosis. sonography helps to determine what is the next best step: watchful waiting (clinical observation, follow-up us), surgical resection, or us guided interventional procedure. present day imaging of down syndrome rupa radhakrishnan, md, radiology, university of cincinnati college of medicine, radhakrp@ucmail.uc.edu; alexander j. towbin purpose or case report: down syndrome is a common genetic condition characterized by unique physical traits and multisystem anomalies. the purpose of this exhibit is to portray the imaging findings of down syndrome and discuss with illustrative examples, the use of imaging in multidisciplinary management. methods & materials: published literature was reviewed to identify the multisystem imaging findings in down syndrome. the electronic medical record system was then searched to find illustrative case examples from our institution. results: in patients with down syndrome, abnormalities can be found in the musculoskeletal, cardiovascular, respiratory, gastrointestinal, and central nervous systems. abnormalities can range from emergent, life threatening conditions such as malrotation with midgut volvulus to chronic conditions such as scoliosis. examples of abnormalities from each organ system and the modalities used for diagnosis and management are described. cardiovascular system: echocardiogram and cardiac mri and ct are useful in evaluating congenital heart disease associated with down syndrome. respiratory system: micrognathia with macroglossia and hypotonia predisposes patients to sleep apnea which can be evaluated with dynamic mri. chest ct demonstrates subpleural cysts which are characteristic of this syndrome. gastrointestinal system: fluoroscopy and/or radiographs are the mainstay in diagnosing many gastrointestinal disorders including duodenal atresia, malrotation, annular pancreas, imperforate anus, and hirschsprung disease. central nervous system: choroid plexus cysts may be identified on prenatal ultrasound in a fetus with down syndrome. imaging is used in the evaluation of epilepsy, hearing loss and alzheimer disease that is more common in these individuals. musculoskeletal system: multiple skeletal anomalies can be present in patients with down syndrome. radiographs are often used as the method of identifying and, if needed, following the anomalies. prenatal imaging: increased nuchal translucency is the earliest imaging finding. other features of down syndrome can be identified on prenatal ultrasound or mri. prenatal imaging is helpful in determining the prognosis of the fetus and in guiding management. conclusions: modern day multidisciplinary management has improved quality of life and survival in individuals with down syndrome. imaging plays a critical role in guiding management in these individuals. imaging the spectrum of lymphatic malformations in the pediatric patient andrew schapiro, md, radiology, university of wisconsin, aschapiro@uwhealth.org; kara gill, bradley maxfield purpose or case report: lymphatic malformations (lm) occur as a result of abnormal development of the lymphatic system during embryogenesis. as 90% of lm present by 2 years of age, these lesions represent an important pediatric entity. lm can often be suspected clinically in an infant with the classic presentation of an asymptomatic, soft mass in the head, neck, or axilla. however, myriad presentations are possible as lm occur in numerous other anatomic locations, can be multiple, and can be a component of mixed vascular malformations. in addition, the true extent of lm is often not apparent clinically. given these considerations and the implications for proper management, imaging plays an important role in the assessment of lm. the purpose of this exhibit is to review the spectrum of radiographic, ct, sonographic, and mr imaging findings of a variety of lm presentations. methods & materials: cases of lymphatic malformation in pediatric patients identified at a single institution over the past ten years with available imaging were reviewed utilizing pacs. results: images of lm involving the head and neck, chest, abdomen, retroperitoneum, extremities, and skeletal system were identified. in addition, cases of lymphangiomatosis and mixed venolymphatic malformation were identified. various imaging modalities including radiography, ct, sonography, and mr were represented. conclusions: adequate knowledge of the imaging characteristics of lm across multiple modalities enables proper diagnosis, assessment of disease extent, and guidance of appropriate therapy in pediatric patients. results: ct and mr imaging findings in nine cases will be presented. they include 1) congenital absence of the inferior vena cava with thrombosis of the external iliac vein secondary to venous stasis 2) pyelophlebitis complicating ruptured appendicitis 3) left iliac vein thrombosis in a patient with may-thurner syndrome 4) splenic vein thrombosis complicating pancreatitis 5) splenic vein thrombosis following splenectomy 6) renal vein thrombosis in an infant of a diabetic mother 7) adrenal vein thrombosis as the presenting sign of antiphospholipid syndrome 8) budd-chiari syndrome associated with underlying myeloproliferative disease 9) iliac vein thrombosis as a manifestation of behcet's syndrome (hughes-stovin syndrome, a variant of behcet's syndrome, which presents with systemic venous thrombosis and pulmonary artery aneurysms will also be discussed). conclusions: thrombosis of large abdominal and pelvic veins in children and adolescents is uncommon. certain conditions, both congenital and acquired, predispose to the development of venous thrombosis. ct/mr imaging defines the extent of thrombosis, and demonstrates additional findings that may elucidate the nature of the underlying condition leading to clot formation. purpose or case report: because abnormal gait in a young child has a wide range of causes, imaging plays a critical role in establishing the definitive diagnosis. the purpose of this exhibit is to review the clinical clues (age, duration, laboratory markers) and imaging findings of the causes of abnormal gait in a toddler and to assess the strengths and limitations of radiographs, ultrasound, magnetic resonance imaging (mri), and computed tomography (ct). methods & materials: cases, from a single institution experience with various causes for abnormal gait in a toddler, are reviewed and categorized into congenital, traumatic, inflammatory, neoplastic, or neuromuscular etiologies. results: there are various causes of abnormal gait in a toddler. the congenital causes include spinal dysraphism, proximal and distal skeletal deformities and dysplasias. the traumatic causes include non-accidental trauma, toddler's fracture, foreign body, and soft tissue injuries. the inflammatory causes include juvenile idiopathic arthritis, transient synovitis, and infection, including osteomyelitis, septic arthritis, discitis, cellulitis, and abscess. the neoplastic causes include various neurogenic, bone, and soft tissue tumors. the neuromuscular causes include cerebral palsy and spinal bifida. the combination of clinical presentation, supporting laboratory findings, and classic imaging findings help to distinguish the possibilities and often allows confident diagnosis. conclusions: knowledge of imaging findings and clinical factors can demystify the diagnosis of abnormal gait in a toddler. familiarity with the clinical presentation can ensure the performance of the appropriate diagnostic studies, timely diagnosis, and effective treatment. nonaccidental causes should never be overlooked. ultrasonography has become an important tool in the radiologist's armamentarium, augmenting radiography, mri, and ct. approximately 20 different contrast agents for mri and ct are now commercially available for use. although most of them are fda approved in adults, information on usage and safety in children is not readily available. the most important reason is lack of controlled studies in children, especially for the age of 0-2 years. however, the lack of fda approval has not limited the use of these promising agents in children. in fact, there is widespread off-label use of these agents in most major pediatric hospitals in the country. based on a review of relevant literature in children, and based on a survey of radiology faculty at major pediatric hospitals, this poster will address the gap between approved use and reality in the setting of pediatrics. results: using a tabular format, this poster will provide a list of mr and ct contrast agents that are available for clinical use, their relevant clinical properties (ionic or nonionic, viscosity, linear or macrocyclic, degree of relaxivity for mri, iodine concentration for ct, cost, dosage, halftime, incidence of allergic reactions, nephrogenic systemic fibrosis and other adverse reactions), fda approval status (for ages 0-30 days, 30 days-2 years, and 2-17 years), common pediatric applications, and contrast injection protocols for common applications. conclusions: to enlighten imaging personnel about usage and safety of contrast agents in children. disclosure: dr. krishnamurthy has indicated that he will discuss or describe, in the educational content, a use of a medical device or pharmaceutical that is classified by the food and drug administration (fda) as investigational for intended use. a pictorial essay and literature review of the spleen in sickle cell disease david hindson, md, boston medical center, david. hindson@bmc.org; heather imsande, philippa sprinz, ilse castro-aragon purpose or case report: the morbidity and mortality of sickle cell disease (scd) results from acute and chronic infarction events that affect almost every organ. repeated infarction has some of its greatest visual and physiologic impact within the spleen. continuous hemolysis, sequestration and vaso-occlusion within the spleen result in loss of splenic function early in life and frequently autosplenectomy thereafter. by 2 years of age, approximately 90% of children with hemoglobin ss disease will have diminished splenic function, putting them at increased risk for infections. treatments for scd have evolved over the last 20 years, and among others include penicillin prophylaxis and immunizations, hydroxyurea and transfusion therapy (or hypertransfusion program). imaging findings are a reflection of the different treatments and their efficacy. methods & materials: our institution cares for a large group of patients with sickle cell disease, from birth to adulthood. this offers an unprecedented opportunity to document the imaging findings of the spleen with different treatment regimens, and over many years. the splenic size and morphology can be followed, by ultrasound, in a very straightforward way. we have compiled a pictorial essay of the various imaging characteristics of spleens from infants to adults. we also performed a literature review to compare and supplement the findings of our images. results: there is a spectrum of imaging findings in the spleen of patients with scd that changes from birth to childhood. the findings range from the normal appearance of a spleen to a calcified spleen, and include regenerative nodules, fibrosis, altered parenchymal echotexture, increased echogenicity, and changes in size, including enlargement secondary to sequestration. the ultrasound characteristics not only change with advancing age, but also appear to depend on whether or not the patient has received specific treatments, and at what age treatment was initiated. conclusions: the ultrasound appearance of the spleen in patients with scd is variable. treatments such as blood transfusions and hydroxyurea, patient compliance with therapy and type and severity of the disease are some of the factors that affect imaging characteristics. cystic fibrosis: not just for children cindy miller, md, radiology, yale-new haven hospital, cindy.miller@yale.edu purpose or case report: cystic fibrosis has been recognized for hundreds of years with the first descriptions of it including such anecdotes as mothers licking the foreheads of their children and knowing that if it tasted salty, an early death could be predicted. it was not until 1939 that the disease was first named by dr. dorothy andersen, and for the following 50 years, treatment was largely supportive, and imaging was essentially done with plain films alone. in 1989 with the elucidation of the cftr gene, there was an explosion of knowledge which included the range of increased awareness and understanding of the suspected etiology, imaging findings and significance of the ductus bump. the contribution of 3d imaging for evaluation of the pediatric central airways jessica kurian, md, the children's hospital of philadelphia, kurianj@email.chop.edu; monica epelman, david a. mong purpose or case report: evaluation of the central airways in children has historically been accomplished by flexible bronchoscopy, an invasive technique associated with inherent risks and complications. multidetector ct (mdct) with volume rendering offers a noninvasive alternative for airway evaluation. in this educational exhibit, we will review imaging techniques and clinical applications of mdct for the assessment of large airway maladies in children. methods & materials: mdct imaging in children with a variety of tracheobronchial disorders is reviewed. for each entity, the characteristic clinical features are described, and key imaging features are illustrated. emphasis is placed on the contribution of 3d techniques for characterizing complex airway anomalies. dose reduction strategies are also highlighted. results: the entities reviewed in this exhibit include, but are not limited to, congenital anomalies of tracheobronchial branching, airway malformations associated with situs, and congenital or acquired airway compression and/or obstruction. conclusions: mdct with volume visualization is a useful adjunct for evaluation of the pediatric central airways in a variety of pathologies. as a noninvasive technique, it avoids sedation risks and spare patients from complications associated with conventional flexible bronchoscopy. low dose protocols should be used to minimize radiation exposure. bronchopulmonary foregut malformation that result from abnormal budding of the primitive foregut. currently, many such anomalies are initially detected by prenatal ultrasound and are further delineated by fetal magnetic resonance imaging (mri), while others may be incidentally detected on postnatal radiologic examinations or later in life in the setting recurrent pulmonary infection. imaging plays a very important role in the diagnosis and characterization of these lesions and assists surgical planning. the purpose of our educational exhibit is to illustrate the common and uncommon radiologic appearances of cpams using various imaging modalities, including radiography, computed tomography, prenatal and postnatal ultrasound, and prenatal and postnatal mri. methods & materials: all pediatric and adult cpam (including both sequestration and ccam) patients were identified using electronic medical records. pertinent imaging reports (including radiography, prenatal and postnatal ultrasound, ct, and prenatal and postnatal mri) were reviewed by a single author in order to identify relevant imaging findings. relevant images from these imaging examinations were de-identified and saved to a secure hard drive. medical records were accessed by a single researcher to obtain relevant demographic information as well as data regarding the patients' clinical presentations. in cases of corrective surgery, operative and pathology reports were reviewed, if available, for correlation with the imaging findings. results: cases of pediatric and adult cpam were identified and presented in a variety of clinical contexts. their appearances were reviewed through multiple imaging modalities. conclusions: congenital pulmonary airway malformations are varied in their clinical presentation and imaging appearance. the purpose of this pictorial essay is to enhance understanding of their diagnosis and to use a multidisciplinary approach in order to highlight imaging aspects that may alter clinical management. disclosure: dr. horst has indicated that she will discuss or describe, in the educational content, a use of a medical device or pharmaceutical that is classified by the food and drug administration (fda) as investigational for intended use. the imaging evaluation of cystic lung disease in children: an evidence-based approach jordan caplan, md, pediatric radiology, lucile packard children's hospital, stanford university, caplan@stanford. edu; beverley newman purpose or case report: the goal of the poster is to provide a framework for use when confronted with cystic lung disease in a child. methods & materials: the differential diagnosis for the types and causes of cystic lung disease in children will be presented using an evidence-based, age appropriate approach. categories of disease discussed and illustrated with case examples will include: a. congenital cystic bronchopulmonary malformations b. infectious cysts c. autoimmune/inflammatory/vasculitic disease with cavitating lesions d. neoplastic conditions e. collagen/soft tissue abnormalities f. mimics of cystic lung disease results: the pathophysiology, imaging appearance, and demographics of the above entities will be reviewed with attention to relevant recent literature. important educational points include the differentiation of bronchopulmonary malformations from neoplasm, notably pleuropulmonary blastoma (ppb), the relationship between lung cysts and ppb, and the management and surveillance of lung cysts in children. conclusions: an evidence-based approach to the broad spectrum of causes of cystic lung disease in children is a useful starting point in forming a concise and pertinent differential diagnosis. an understanding of the pathophysiology, imaging appearance, and demographics of these entities is essential in guiding patient management. pediatric interstitial lung disease (ild): a pictorial review with radiologic and pathologic correlation hollie west, md, diagnostic radiology, vanderbilt university, hollie.c.west@vanderbilt.edu; melissa a. hilmes, sudha p. singh, jennifer soares, lisa young purpose or case report: while adult interstitial lung disease is a well-described and fairly well understood group of disease processes, pediatric interstitial lung disease (ild) remains a subject of uncertainty and misunderstanding for many clinicians and radiologists. confusion surrounding the phenomenon of pediatric ild stems not only from the rarity of the disease, but also from the extensive list of disease entities that can produce ild, the existence of certain patterns that are restricted to infants and children and the fact that patterns of ild manifest differently in a child's developing lung than in an already developed adult lung. imaging plays an important role in diagnostic work-up of this disease and can guide lung biopsy in specific patient populations. methods & materials: the irb approved retrospective study will show patients at our institution over a 10 year period diagnosed with various types of ild, including pulmonary insterstitial glycogenolysis (pig), diffuse neuroendocrine cell hyperplasia (nehi), surfactant deficiency diseases, and lung diseases associated with other systemic processes such as downs syndrome and inflammatory bowel disease. we will include patients with biopsy proven ild and will provide examples of the major ilds, including clinical, radiologic and pathologic correlation. our pictorial review will describe the radiologic patterns associated with the different forms of ild, emphasizing what the radiologist needs to know and how to be helpful to a multidisciplinary team in the diagnosis and treatment of these diseases. results: the study will report the frequency of ild at our institution, including a breakdown of the various subtypes of ild. we will show examples of the subtypes with correlative chest radiography, computed tomography, and pathology. we plan to highlight specific differentiating factors between the different diseases and demonstrate how a radiologist can be helpful in collborating with clinicians in diagnosing and treating these diseases. conclusions: pediatric ild can be a confusing topic for radiologists. increasing knowledge and awareness of these diseases, their clinincal presentation, work up, and treatment is important for pediatric radiologists who work as part of of a multidiciplinary team. poster #: sci-001 ct radiation dose delivered by community hospitals and imaging centers stephen little, children's healthcare of atlanta, stephen. little@choa.org; damien grattan-smith, bonnie johnson purpose or case report: to evaluate and compare ct radiation dose for pediatric abdominal and cranial ct examinations performed by community hospitals and imaging centers. methods & materials: 148 consecutive ct examinations (49 cranial, 99 abdominal) from 41 community hospitals and imaging centers were reviewed following transfer of care. the examinations were performed between january and july 2011. 433 consecutive ct examinations (241 cranial, 192 abdominal) performed at our own institution were also reviewed. ctdivol and dlp were obtained from the dose report for each examination (32 cm-phantom for abdominal exams, 16 cm-phantom for cranial exams). patient age and weight were obtained from the medical record. results: average ctdivol for abdominal ct performed by local community hospitals and imaging centers was 8.7 mgy, while average ctdivol was 4.3 mgy for abdominal ct performed at choa. there was a wide variation in ct radiation dose delivered. while some sites delivered a ct radiation dose comparable to our own, others delivered a substantially greater dose. in fact, 23% of pediatric abdominal ct exams performed by local community hospitals and imaging centers exceeded the notification value recommended by the aapm (10 mgy using the 32cm phantom). low kvp technique for imaging small children was infrequent. multi-phase examinations were more often performed, resulting in additional elevation in ct radiation dose when dlp is considered. average ctdivol delivered by local community hospitals and imaging centers for cranial ct was 44 mgy compared to a ctdivol of 30 mgy for cranial ct performed at choa. 8% of pediatric cranial ct exams performed by local community hospitals and imaging centers exceeded the notification value recommended by the aapm (60 mgy for 2-5 years, 80 mgy for >5 years). conclusions: despite ongoing efforts at education, there is wide variation in ct radiation dose delivered for pediatric abdominal and cranial ct examinations performed by local community hospitals and imaging centers. appropriate use of dose check software on newer scanners may help reduce the number of children subjected to excessive ct radiation dose. ultimately, each site performing pediatric ct must take responsibility for minimizing radiation dose while producing diagnostic quality exams. the impact of adaptive statistical iterative reconstruction on ct image quality parameters -a phantom study karen thomas, md, radiology, hospital for sick children, karen.thomas@sickkids.ca; nancy ford, angjelina protik, paul babyn purpose or case report: to quantify the effect of adaptive statistical iterative reconstruction (asir) on ct image quality parameters. methods & materials: phantom (catphan 600) studies were performed on a ge hd750 64-slice scanner to investigate the impact of a) 50% asir compared to routine filtered back projection using variable kvp (80-140) and mas (5-200), and b) incremental asir % (0, 30, 50, 70, 100%), scanning at 75mas and variable kvp (80-120). pitch, acquisition fov and detector width were kept constant. image noise, spatial and contrast resolution, contrast noise ratio (cnr) and wiener spectrum analysis were performed on 0.625 mm ax, 5 mm ax mpr and 2 mm cor mpr series. results: 50% asir resulted in a mean decrease in noise of 30% (0.625 mm ax), 26% (ax mpr) and 28% (cor mpr) and improvement in cnr of 38-49%. incremental advantage was seen with stepwise increase in asir %. however, application of asir was associated with a small reduction in spatial resolution (2-8% at 50% asir). low contrast detectability (lcd) improved except at the smallest target lesion size. image quality effects at very low mas and at high asir % will be presented. conclusions: image noise reduction and improvements in cnr and lcd with asir hold considerable potential for dose reduction in pediatric ct. this study provides quantitative data that may be used to design asir-enhanced protocols with consideration of diagnostic task, balancing image quality benefits and potential pitfalls. pictorial essay on cardiac mr for congenital heart disease on 3 t mr scanner with rf multi-transmit technology (tx) taylor chung, md, diagnostic imaging, children's hospital & research center oakland, taylorchung12@gmail.com purpose or case report: this is a pictorial essay (e-poster) to show artifacts on cine ssfp images pre-tx and post-tx upgrade on congenital heart disease cardiac mr; to illustrate methods prior to tx-upgrade to minimize artifacts. disclosure: dr. chung has indicated that he will discuss or describe, in the educational content, a use of a medical device or pharmaceutical that is classified by the food and drug administration (fda) as investigational for intended use. revisiting the relationship between anthropometric parameters and left ventricular mass abdullahi adamu, md, phd, ahmadu bello university, scorpion68kd@yahoo.com purpose or case report: the purpose of this study was to find the correlation between anthropometric parameters and left ventricular mass in normal adolescents and young adults. methods & materials: 147 healthy individuals in the age range 17 to 23 years (73 males and 74 females) were included in this study. anthropometry was performed with standard anthropometry kit and measurements of height, weight, body surface area (bsa), upper arm circumference and upper hip circumference were taken. echocardiography was performed and the american society of echocardiography (ase)-recommended method was employed for calculation of left ventricular mass (lvm). statistical analysis was performed using statistica 6.0 (stat soft, usa). results: the mean value of lvm for all our subjects was found to be 124.53±2.79 g. there was significant correlation between lvm and height (r00.52, p<0.0001), weight (r00.63, p<0.00001) and bsa (r00.64, p<0.00001). correlation with upper arm circumference was moderate (r0 0.46, p<0.0001), while it was found to be weak with upper hip circumference (r00.23, p<0.01). diagnostic. both field strengths can be used successfully for cardiac and vascular imaging. the decision as to which to use is weighted by local availability and the relative requirement for detailed vascular vs intra-cardiac imaging. disclosure: dr. nguyen has indicated that she will discuss or describe, in the educational content, a use of a medical device or pharmaceutical that is classified by the food and drug administration (fda) as investigational for intended use. poster #: sci-006 color coded 3d cardiac cta of congenital heart disease: a five year experience nhi huynh, md, radiology, st. joseph hospital and medical center, e.nhihuynh@gmail.com; randy richardson purpose or case report: post-processing of cardiac computed tomography angiograms can be performed on a commercially available workstation to create color coded 3d volume rendered images of the segmented heart and great vessel anatomy in patients with congenital heart disease. these studies optimally demonstrate complex anatomy, streamlining communication between members of the healthcare team and providing a tool for communicating complex anatomy and treatment options with families. these studies have been ordered with more frequency over the past five years. we retrospectively reviewed the types of congenital heart disease demonstrated by cardiac 3d cta over the past five years at a congenital heart center. methods & materials: color coded cardiac cta postprocessing was performed from ecg gated prospective and retrospective cta data on a commercially available workstation for 333/395 patients over the past three years. the anatomy was initially segmented and colored into individual parts of the anatomy of the heart and great vessels as follows rv 0 purple, lv 0 light red, aorta 0 red, pulmonary arteries 0 blue, systemic veins and right atrium 0 aqua, pulmonary veins and left atrium 0 pink, pda or collaterals 0 green, airway 0 yellow, coronary arteries 0 neutral. the anatomy was then reassembled and images obtained every 3°in a 360°rotation for display. results: 3d color coded cta images were used in the treatment and care of congenital heart patients for the following types of congenital heart diseases: 124 cases of complex anatomy (tga, truncus arteriosus, hlhs, tricuspid atresia, tof…), 67 coronary artery anomalies, 68 cases of pulmonary atresia or stenosis, 44 cases of systemic and venous anomalies, 40 cases of coarctation or interruption of the aortic arch, and 56 tracheobronchial tree anomalies. conclusions: color coded cardiac cta post-processing is an effective and viable method for demonstrating anatomy in complex congenital heart patients. it is an excellent tool for demonstrating anatomy which is difficult to see by echocardiography such as: coronary artery anomalies, pulmonic atresia, aortic arch coarctation or interruption, and tracheobronchial anomalies and/or stenosis. neuroimaging in the evaluation of hie in term neonates post hypothermia therapy julio m. araque, md, radiology, medical college of georgia, jaraque@georgiahealth.edu; jatinder bhatia, leann vanlandingham purpose or case report: to illustrate and review the potential utility of brain mri, ct and ultrasound in hypoxic ischemic encephalopathy in newborns treated with hypothermia. neuroimaging studies including brain ultrasound, ct and mri of fifteen term newborns treated in our institution with therapeutic hypothermia, since april 2010 were evaluated retrospectively. more relevant lesions are depicted and the diagnostic and prognostic value of the findings is discussed and compared with a review of the literature. results: recent studies showed that patients treated with cooling had a more favorable prognosis than was suggested by the clinical grade of encephalopathy compared with infants treated with standard care. our institutional protocol includes the performance of mri, and ultrasound. ct is performed when is a clinical impossibility of perform mri. brain ultrasound was performed in all the 15 patients. mri scans were obtained in 11 neonates. ct was obtained in 3 patients. all mri studies included dwi. the utility of dwi and adc maps as an aid in diagnosis of non-ischemic lesions is becoming increasingly established. mri evidence of brain injury was visible on basal ganglia in 8 cases with negative ultrasound. abnormal signal intensity in the posterior limb of the internal capsule coexists with lesions in the basal ganglia and thalami have been associated with abnormal motor outcome. the remaining 3 newborns did not develop significant mri evidence of brain injury. it has been suggested that the ability of mri to predict subsequent neurological impairment is unaltered by therapeutic hypothermia. further research is needed for defining the relation between mri findings and cooling. it is possible that imaging findings might be delayed in cooled infants. conclusions: mri offers the highest sensitivity in detecting anoxic injury of the neonatal brain. mr biomarkers in combination with clinical markers may identify patients with adverse outcome with therapeutic implications. disclosure: dr. araque has indicated that he will discuss or describe, in the educational content, a use of a medical device or pharmaceutical that is classified by the food and drug administration (fda) as investigational for intended use. purpose or case report: to correlate bowel wall diffusionweighted imaging (dwi) apparent diffusion coefficient (adc) values with multiple mr enterography (mre) and clinical findings in pediatric small bowel crohn disease. methods & materials: 54 pediatric crohn disease patients with mre exams containing diffusion-weighted imaging and demonstrating terminal ileitis were identified. minimum bowel wall adc values were tested for correlation/association with other mri findings and clinical parameters (including laboratory values). results: there is negative correlation between adc value and degree of bowel wall thickening (r0(−)0.27; p00.048). lower adc values were significantly associated with striated pattern of arterial phase postcontrast enhancement (p0 0.007), greater degree of arterial phase postcontrast enhancement (p00.006), and presence of stricture (p00.005). adc values were not associated with diseased bowel length, degree/pattern of delayed postcontrast enhancement, degree of mesenteric inflammation or fibrofatty proliferation, or clinical markers of inflammation. conclusions: restricted diffusion in pediatric small bowel crohn disease is associated with other mri findings of that are suggestive of active disease, including degree of bowel wall thickening and degree and pattern of arterial phase postcontrast enhancement. our data also suggests that dwi may be useful when attempting to characterize small bowel strictures as either predominantly inflammatory or fibrotic, although further investigation is needed. quantification of blood flow into and out of the liver with 4 d phase contrast mri in the pediatric patient binh huynh, md, radiology, stanford, bhuynh@stanford. edu; shreyas vasanawala, albert hsiao purpose or case report: the ability to probe blood flow dynamics in the liver may aid management of children with liver disease, including shunt fractions in portal hypertension and arterial flow fraction in diffuse liver disease. the purpose of this study is to evaluate the ability to measure blood flow into and out of the liver with time resolved volumetric (4d) phase contrast mri in the pediatric patient. methods & materials: nineteen consecutive patients were retrospectively identified who underwent 4d flow imaging through the level of the hepatic vessels on 1.5 t and 3 t magnets. a software enabling 4d flow program was utilized to first assess for the feasibility of measurement of flow in the hepatic artery (ha), portal vein (pv), splenic vein (spv), superior mesenteric vein (smv), supra (sivc) and infrahepatic (iivc) inferior vena cava. if measurable, calculations were performed to evaluate for internal consistency by comparing the sum of smv and spv flow to pv flow. calculations were then performed to compare hepatic inflow (pv+ha) to hepatic outflow (sivc-iivc) and for the percentage of pv and ha contribution to hepatic inflow. results: of the nineteen patients, all of the above mentioned six vessels were visualized and measurable in two patients, both of which were imaged on the 1.5 t magnet. in the remaining patients, flow measurements were limited by respiratory motion artifacts obscuring the smaller vessels, and severe eddy currents, particularly in patients imaged with the 3 t magnet. the evaluation for internal consistency demonstrated an average of 1.2% (0.06% & -1.5%) difference between smv+spv and pv flow. hepatic inflow was found to closely match the measured hepatic outflow with an average difference of 11.1% (19.1% & 3.1%). the portal vein was found to contribute 82.9% and 87.3% to hepatic inflow, while the hepatic artery contributed 17.1% and 12.7%. conclusions: measurement of hepatic flow with phase contrast mri is more challenging than assessment of thoracic flow. when respiratory artifacts are minimal, vessels can be identified and measurements have internal consistency and good agreement between hepatic inflow and outflow at 1.5 t. conversely, flow measurements were limited at 3 t by eddy currents. thus, ongoing efforts are aimed at mitigating respiratory motion artifacts at 1.5 t. poster #: sci-011 mri findings in post-fontan hepatopathy adina alazraki, md, radiology, emory university/children's healthcare of atlanta, adina.alazraki@choa.org; pinar bulut, kiery braithwaite, miriam vos, rene romero, nitika a. gupta purpose or case report: as advances in congenital heart disease continue to improve both mortality and quality of life, associated complications are becoming more prevalent. amongst patients who have had fontan repair for hypoplastic left heart syndrome, tricuspic atresia, or other right heart dysfunction, it is well known that liver disease is a complication. we describe the mri findings in post-fontan patients and propose mri as a useful tool to the hepatologist's evaluation of these patients. methods & materials: irb approval was obtained for a retrospective review of 29 patients who underwent fontan repair and were subsequently referred for hepatology evaluation between 2010-2011. all but one patient was scanned on a siemenstriotrim 3 t magnet; one patient was scanned on a ge twinspeed 1.5 t magnet with an equivalent protocol due to orthodontics. a standardized departmental protocol was utilized. mri findings were correlated with age at surgery and years since surgery. mr images were reviewed independently by 2 pediatric radiologists and compared with the dictated report in the patients record. results: 17 patients underwent mri of the abdomen. 4 patients had mri incompatible hardware and 8 patients were not scanned secondary to insurance denial. patients were divided into 4 groups based on elapsed time since surgery: less than 5 years, 5-10 years, 10-15 years, and greater than 15 years.(table 1) mr images were evaluated for the presence of fibrosis, congestion and any other hepatic abnormalities. fibrosis was determined based on a specific pattern of delayed reticular enhancement in combination with liver morphology. congestion was deemed present if there was increased t2 signal in the liver parenchyma or periportal regions in combination with cloud-like enhancement on dynamic post-contrast images. all patients demonstrated morphologic changes in the liver with varying degrees of hepatic fibrosis and hepatic congestion. fibrotic changes were often non-uniform, and thus could be underdiagnosed by biopsy. interestingly, 4 patients, 24%, had focal arterially enhancing lesions speculated to represent vascular proliferative lesions, however, none warranted biopsy. conclusions: it is established that patients who undergo fontan develop hepatic abnormalities. mri is a reliable, non invasive technique that accurately demonstrates these findings. mri may be a more sensitive method to evaluate the etiology and full extent of hepatic disease. poster #: sci-012 complications within the interventional radiology division of a tertiary care children's hospital: initiatives for ongoing quality and practice improvement brian dillon, children's hospital boston, brian. dillon@childrens.harvard.edu; pamela sanborn, yolanda milliman-richard, darren orbach, stephan voss purpose or case report: between 2004 and 2010, procedure-related complications occurring within the division of interventional radiology at our institution were recorded and classified according to level of severity. the goals of this study were to determine rates of procedurebased complications based on severity, to establish thresholds for complications, and to determine whether measurable trends in complications over time were evident. methods & materials: between 2004 and 2010, 14,042 interventional procedures were performed within the division of interventional radiology at our institution. adverse events were characterized both according to level of severity (using an institutional 5 point severity scale), and with brief descriptions of individual events. adverse events were reviewed monthly at the division's morbidity and mortality conference, with respect to procedure type and operator. based on review of our interventional radiology data and benchmarks rates used for diagnostic errors, threshold complication rates were established by consensus between the department quality improvement committee and the division of interventional radiology. for severe events (level 4 and 5) there is no allowable threshold; all such events were subjected to both internal and institutional review. results: the overall complication rate was less than 1% for all procedures performed. the complication rates for the respective severity levels were: level 1 (0.235), level 2 (0.3), level 3 (0.1), level 4 (0.249), and level 5 (0.028). the severity of a given complication was not associated with procedural complexity. no operator-specific trends were identified. conclusions: since 2003, the society of interventional radiology has offered guidelines and strategies for improving safety and quality in interventional radiology. however, no specific benchmark data or procedural recommendations are available for pediatric interventional procedures. our results demonstrate rates of complications well below published overall complication rates for interventional radiologic procedures. this database of procedure-based complications serves as a foundation for a quality improvement program that allows review of complications with respect to specific procedure types, individual operators, and procedural complexity, in an effort to institute an ongoing and continuous process of quality improvement within interventional radiology. purpose or case report: dysosteosclerosis (dss), an extremely rare dense bone disease, features short stature and fractures and sometimes optic atrophy, cranial nerve palsy, developmental delay, and failure of tooth eruption in infancy or early childhood consistent with osteopetrosis (opt). bone histology during childhood shows unresorbed primary spongiosa from deficient osteoclast action. additionally, there is remarkable progressive flattening of all vertebrae mimic ppi blocking mineralization. during ehdp treatment for gaci, in our patient prolonged high dose ehdp resulted in severe skeletal deformity resembling hypophosphatasia which was reversable with drug stoppage. methods & materials: a 7-year-old boy with gaci referred for profound, acquired, progressive skeletal deformity. he was receiving 200 mg/day of ehdp and was wheelchair bound. we studied him and his response to stopping ehdp. results: skeletal radiographic findings resembled pediatric hypophosphatasia with pancranial synostosis, widened physes with metaphyseal osteosclerosis, "tongues" of radiolucency, along with cupping and fraying, and long-bone bowing. in addition there were large intra and extraarticular calcifications. radiographic features of bp-induced opt included femoral erlenmeyer flask deformity and osteosclerosis (lumbar sine dxa z-score +5.7). biochemical parameters of mineral homeostasis were essentially normal although serum osteocalcin was low and he had markedly elevated serum levels of creatine kinase and trap-5b consistent with osteopetrosis (opt). after stopping ehdp, he improved quickly with remarkable healing of his rachitic appearing skeleton and decreased joint calcifications. conclusions: our patient with gaci had profound skeletal deformities from high-dose ehdp therapy that significatly improved with drug stoppage. magnetic resonance imaging in the evaluation of infants with hypoxic ischemic encephalopathy julio m. araque, md, radiology, medical college of georgia, jaraque@georgiahealth.edu purpose or case report: to illustrate and review a spectrum of brain abnormalities of infants with hie. defining the most useful approaches and mri sequences, to facilitate identification and early diagnosis of lesions with the potential to predict outcome and abnormal neurodevelopment. methods & materials: reviewed available evidence on mri strategies for evaluating infants with hypoxic ischemic encephalopathy. different cases illustrating lesions are presented and discussed for proper diagnosis correlating physiopathology and imaging appearance. more relevant findings are depicted with didactic illustrations. identifying studies where new techniques such as dwi, adc, dti, swi, or mrs adds significant diagnostic value to the overall interpretation. results: mri is routinely performed as a very sensitive method for detection of hie lesions. advanced mr techniques, such as dti, dwi, adc, mrs, swi offer the possibility of detecting injuries at a time when intervention is theoretically possible. the understanding of the physiopathology allows for prediction of the location and extent of lesions, facilitating identification and appropriate classification. the identification of infants with potentially abnormal neurodevelopment, offers the opportunity to provide therapeutic neurodevelopmental interventions in early childhood. mrs is the best mr biomarker to predict neurodevelopmental outcome in asphyxiated full-term neonates. brain metabolite ratios and regional adc values may vary between mr systems and coils. development of normal values for each institution is required, and support of physicists is mandatory. conclusions: mri continues to evolve as a valuable adjunctive tool routinely obtained in nearly all cases of hie. advanced mri techniques increase sensitivity of conventional t1 and t2-w images and outperform computer tomography and ultrasound for confirming the diagnosis of hypoxic-ischemic brain injury or providing prognostic information for the care of patient with hie. disclosure: dr. araque has indicated that he will discuss or describe, in the educational content, a use of a medical device or pharmaceutical that is classified by the food and drug administration (fda) as investigational for intended use. posterior fossa abnormalities in children amit gupta, mbbs, radiodiagnosis, r.n.t. medical college, udaipur, rajasthan, india, amitsensation@yahoo.co.in purpose or case report: the aim of this exhibit is to demonstrate various conditions involving the posterior fossa in children with emphasis on importance of embryologic development of cerebellum in reaching a correct diagnosis. methods & materials: this pictographic presentation displays the imaging features of cases encountered in our clinical practice on 1.5 tesla magnetic resonance (mr) imaging. results: with the advent of mr imaging, there has been a revolution in identification and characterization of malformations of the brain this is especially true in posterior fossa, where the sensitivity and specificity of mr imaging with its multidimensional imaging capability are far superior to those of computed tomography (ct) in the detection of subtle morphologic abnormalities. however, there is still a great deal of confusion regarding their classification, terminology, and spectrum of expression and this is where neuroembryology is of great help. this exhibit demonstrates : 1) review of embryology and normal anatomy of cerebellum. 2) mr appearance of spectrum of conditions involving posterior fossa in children which includes developmental abnormalities (dandy-walker complex, arnold chiari malformations, cerebellar dysplasia/ hypoplasia, joubert's syndrome, etc.), cysts (arachnoid cyst, giant cisterna magna etc.), tumours (medulloblastoma, ependymoma, hemangioblastoma etc.) and miscellaneous conditions. significantly reduces dose (1/3 of other gadolinium based contrast agents), and doesn't require trigger imaging. conventional mri provides important information regarding the anatomical extent, size, and relation to critical anatomical structures thus when combined with twist, mri provides the best information without use of radiation in children. functional connectivity mri in pediatric brain tumor patients with and without epilepsy andrew v. poliakov, phd, radiology, seattle children's hospital; david bauer, edward novotny, seth d. friedman, dennis shaw, jeff ojemann purpose or case report: functional connectivity mri (fcmri) is a way to evaluate cortical networks across different modalities such as motor, sensory, vision, and the default mode network using functional magnetic resonance imaging. fcmri relies on correlation in fmri image intensity that occurs between functionally connected regions. this effect can be seen in awake as well as anesthetized patients. we evaluated these pathways in pediatric patients with brain tumors. methods & materials: patients were randomly selected from our tumor database. inclusion criteria included age less than 18, history of brain tumor resection, and complete fcmri data. imaging was performed on a 3 t siemens trio system. functional mri data were acquired as part of a clinical imaging protocol over 6.5 -8 min using a gradient echo, echo-planar sequence. preprocessing of fmri data followed by independent component analysis (ica) was performed using fsl software. functional connectivity analysis was performed using software provided by 1000 functional connectomes project, based on afni and fsl software packages. correlation maps were produced by extracting the bold time course from a seed region, computing the correlation coefficient between that time course and the time course from all other brain voxels, correcting for multiple sampling and degrees of freedom and thresholded at a z value of 3.0. results: fourteen patients were included in the study, eight female and six male. tumor types include ganglioglioma (5), pleomorphic xanthoastrocytoma (2), juvenile pilocytic astrocytoma (2), ependymoma (1), anaplastic astrocytoma (1), glioblastoma multiforme (2), and primitive neuroectodermal tumor (1). seven patients had tumor-associated epilepsy, and seven patients did not. the figure shows connectivity patterns in the motor network in patients without (a) and with (b) epilepsy. in the patients without epilepsy, functional connectivity was often displaced but not decreased or absent. in the patients with epilepsy, we observed decreased or absent functional connectivity. similar results were found for default mode network: connectivity was diminished or absent in the patients affected by epilepsy. conclusions: fcmri is a novel technique that may prove useful for evaluation and presurgical planning by giving us insight into how tumors disrupt function. functional connectivity was often displaced but relatively preserved in the patients without epilepsy. it was disrupted or absent in the patients with epilepsy. poster #: sci-022 corpus callosum dti measurements in neurofibromatosis type 1 and normal controls nadja kadom, md, radiology, children's national medical center, nkadom@childrensnational.org; amir noor, rhea udyavar, marine bouyssi-kobar, iordanis evangelou, maria t. acosta purpose or case report: many patients with neurofibromatosis type 1 (nf1) have corpus callosum enlargement; pathogenesis and underlying pathophysiology are unclear. the goal of our study is to investigate the pathophysiological basis of corpus callosum enlargement in nf1 patients through mri diffusion tensor (dti) measurements. methods & materials: retrospective study, irb approved. patients consecutively selected from institutional data base; inclusion criteria: established diagnosis of nf1, brain imaging with dti sequence, abnormally high corpus callosum to skull ratio; excluded were patients with complications of nf1 that could affect size of the corpus callosum. age and gender matched normal controls were randomly selected from the radiology data base. roi were placed manually over the corpus callosum for dti measurements using dti-studio by two independent researchers, one blinded to diagnosis. results: fifteen nf1 patients and matched controls were analyzed. the corpus callosum to skull ratio was found to be significantly different between the experimental and control group (p00.0001). for nf1 patients we found: a trend to lower apparent diffusion coefficient (adc, p00.067), significantly higher radial diffusivity (p00.023), significantly lower axial diffusivity (p00.0002), and significantly lower fractional anisotropy (fa, p00.0012). conclusions: the significantly lower axial diffusivity in nf1 can indicate that there are more crossing fibers in the corpus callosum of nf1 patients than in normal controls. further studies using comparative dti tractography may be helpful in further investigating this stipulation. the significant increase in radial diffusivity can be explained by a variety of factors, including thinner myelin sheaths, increased interstitial fluid, smaller axons, or a combination thereof. the trend of lower adc may indicate low axonal diameter, as adc has been shown to more strongly correlate with axonal diameter without the myelin sheath. in future studies we will correlate abnormal corpus callosum dti markers with cognitive functions in nf1 patients to see if relationships exist that can be used as predictors of cognitive deficits in nf1 patients. screening for vitamin d deficiency in children with suspected non-accidental fracture conor kain, md, tripler army medical center; veronica rooks, laura keller, jordan pinsker, allyson cordoni, sarah frioux purpose or case report: determine if routine screening of vitamin d levels after suspected non-accidental fracture detects vitamin d deficiency and changes clinical outcomes. methods & materials: after irb approval we reviewed all skeletal surveys performed at tripler army medical center (tamc) in the last 10 years and selected the children who were evaluated for suspected non-accidental fracture. we determined if 25-hydroxyvitamin d [25(oh)d] level was requested for these patients and characterized the provider's clinical suspicion of vitamin d deficiency as high or low. per the 2010 institute of medicine report and 2011 endocrine society guidelines we defined vitamin d deficiency as a 25 (oh)d level of less than 20 ng/ml. we calculated the prevalence of children with low 25(oh)d levels whose providers had low clinical suspicion for vitamin d deficiency. results: 396 skeletal surveys were done at tamc from november 2000 to july 2011. 99 were performed after identifying a suspected non-accidental fracture. of these patients 11 children from ages 1 to 7 months had 25(oh)d levels requested. for children whose providers had a low pre-test suspicion for vitamin d deficiency, the prevalence of vitamin d deficiency was 12.5% (95% binomial ci 0.003-0.524, 1 of 8 cases. these results indicate that at least one out of every three hundred children evaluated for nonaccidental fracture could have vitamin d deficiency despite a low clinical suspicion by their provider, although the actual rate is likely much higher given that we found one in eight cases. the child we identified with a low vitamin d level whose provider had no suspicion for rickets was treated with ergocalciferol and continued to be evaluated for abuse. conclusions: routine vitamin d level screening after nonaccidental fracture may detect vitamin d deficiency in children for whom there is low clinical suspicion. as our population resides at a low latitude and receives greater than average sun exposure, the rate of deficiency in children with suspected non-accidental fracture may be much greater in other areas. comet tails and dirty shadows: the secrets behind artifacts in pediatric ultrasound adam edelstein, pediatric radiology, massachusetts general hospital; anuradha shenoy-bhangle, katherine nimkin purpose or case report: to review common ultrasonographic artifacts, explain what causes them, and show how they can be used to aid in diagnosis in a variety of pediatric conditions, including less common entities. methods & materials: ultrasonographic images in patients less than 18 years of age were reviewed. cases were selected that showed classic artifacts which helped with the diagnosis of a variety of entities. results: ultrasound artifacts include comet tail, reverberation, ring down and "dirty" shadowing. these can be used to help characterize a variety of pediatric conditions including gossypiboma, bezoar, subcutaneous foreign body, complications of nec, and staghorn calculus. artifacts can also be used to confirm the presence of stool or bowel gas. conclusions: familiarity with ultrasonographic artifacts is critical for tissue characterization and can help narrow the differential diagnosis in difficult pediatric cases. cardiac cta: non-vascular ring tracheobronchial compression secondary to enlarged patent ductus arteriosus in infants with congenital heart disease. nhi huynh, md, radiology, st. joseph hospital and medical center, e.nhihuynh@gmail.com; todd chapman, randy richardson purpose or case report: tracheobronchial compression or narrowing secondary to a vascular ring has been well documented. the purpose of this study is to describe the frequency of airway compression secondary to an enlarged patent ductus arteriosus detected by ccta without the presence of a vascular ring. methods & materials: a retrospective study of 282 ccta exams in infants was performed over the period between 03/ 28/2007 and 09/28/2011. ccta was performed with a 64-slice mdct, with ekg gating, followed by three-dimensional reformations. results: of the 282 congenital heart disease infant patients, there are 49 patients with tracheobronchial compression or narrowing. of these 49 patients, 20 patients reported to have patent ductus arteriosus as the primary cause of tracheobronchial compression or narrowing. approximately 41% of patients with airway compression in patients with congenital heart disease are secondary to an enlarged and/or tortuous patent ductus arteriosus. none of these cases were due to a vascular ring. of these 20 patients, 10, 6, and 4 patients demonstrated to have mild, moderate, and severe airway compression respectively. conclusions: tracheobronchial compression or narrowing secondary to vascular ring with a patent ductus arteriosus has been well documented. in this study, we demonstrate that a significant percentage of airway compression in patients with congenital heart disease without a vascular ring is due to a tortuous enlarged patent ductus arteriosus. cardiac cta is uniquely equipped to evaluate airway compression due to an enlarged patent ductus arteriosus and can help improve patient care in congenital heart disease patients with respiratory symptomatology. pediatric liver mr elastography: a primer suraj serai, phd, cchmc, suraj.serai@cchmc.org; daniel j. podberesky, alexander j. towbin purpose or case report: a wide variety of pediatric liver disorders may be complicated by the development of liver fibrosis and ultimately cirrhosis. with early interventions, the progression to hepatic fibrosis can be slowed, halted, and in some cases reversed. liver biopsy has long been considered the gold standard for assessing the presence and degree of liver fibrosis. however, liver biopsy has disadvantages, due to its potential sampling error, risk of complications, relatively high cost, intra-and inter-observer variability, and, in general, poor acceptance by pediatric patients and their parents. mr elastography (mre) is a relatively new, non-invasive technique that provides a safe, rapid and cost-effective method for objectively evaluating of a wide variety of hepatic diseases by quantitative stiffness evaluation of the liver-parenchyma. the purpose of this exhibit is to review our clinical experience with this technique and illustrate the application of liver mre in the pediatric population at our medical center. methods & materials: a review of pathogenesis and staging of liver fibrosis in children and current methods available for assessing liver fibrosis will be provided. a review of mre physics and technique, including the specific liver mre protocol used at our institution will be illustrated. we will review widely-used and emerging clinical indications for liver mre, as well as benefits and limitations to the technique, supported by brief literature review. results: in addition to sharing our liver mre technique, we will illustrate clinical case examples from our institution of a variety of liver disorders including non-alcoholic fatty liver disease, non-alcoholic steatohepatitis, storage disorders, cardiac disease, and idiopathic elevated liver enzymes. conclusions: this educational exhibit will review our experience with liver mre, a safe, newly available technique which will play an increasingly important role in the noninvasive evaluation of pediatric liver disease. poster #: sci-027 spectrum of tuberculosis in children amit gupta, mbbs, radiodiagnosis, r.n.t. medical college, udaipur, rajasthan, india, amitsensation@yahoo.co.in purpose or case report: the aim of this exhibit is to present a spectrum of tuberculosis (tb) in the human body which commonly involves pulmonary, nervous, musculoskeletal, gastrointestinal and genitourinary systems. this pictographic presentation displays the imaging features of tb cases encountered in our clinical practice with reference to plain x-rays, ct and mri as appropriate. results: with the advent of the newer modalities, the utility of the plain skaigram has been largely limited a initial screening tool only. whereas ct scores over mri in pulmonary tb (parenchymal disease, lymphadenopathy, pleural effusion, empyema, miliary disease) and abdominal tb (spectrum from mesenteric lymphadenitis to visceral involvement), the magnetic resonance (mr) imaging is much better in diagnosing cns tb (tuberculoma, abscess, meningitis, subdural empyema and myelitis). in musculoskeletal and genitourinary tb, ct and mr imaging may be preferred based on the stage of disease and the character of the lesion. cardiac involvement (pericarditis) is among the less common affections of tb. conclusions: tuberculosis is a multisystem disease that can affect virtually any part of the body from head to toe. tb demonstrates a variety of clinical and radiologic findings and has a known propensity for dissemination from its primary site and therefore can mimic numerous other disease entities. hence it is imperative for radiologists to understand the typical disease distribution, patterns and imaging manifestations of tb. 2010 janet l. strife, md 2011 carol m. rumack md 1987 ole a. eklof, md 1987 clement c. faure, md 1987 andres giedion, md 1987 denis lallemand, md 1987 arnold lassrich md 1992 donald r. kirks, md 1992 beverly p. wood, md 1993 hooshang taybi md 2008 marta hernanz-schulman, md, facr 2009 m. ines boechat, md, facr 2010 neil d. johnson, mbbs 2011 dorothy i. bulas, md *deceased singleton-taybi award investigator award this award is given to the author of the best paper presented by a resident or fellow at the spr meeting md 2002 ricardo faingold, md 2003 andrea doria, md 2004 nina m. menezes, phd anthropometric parameters are a strong determinant of lvm in healthy individuals kiyarash mohajer, pierangelo renella, paul j. finn purpose or case report: despite theoretical advantages of higher field strength ssfp cine imaging, time-resolved magnetic resonance angiography (tr-mra), and high resolution contrast-enhanced mra (ce-mra) were performed. two readers independently evaluated the data for image quality, vessel and cardiac chamber definition, and presence of artifacts. snr and cnr were calculated. results: 95% of ssfp cine images at 3 t were rated as good or excellent quality with 73% having mild and 24% having moderate artifacts (k00.07) 100% of arterial and venous phase ce-mra images were considered good or excellent cardiac chamber definition was considered good or excellent in 95% of arterial and venous phase ce-mra images (k00.08). 100% ce-mra images showed good or excellent definition of the thoraco-abdominal vessels on average, both readers scored cine ssfp images higher at 1.5 t and cemra images higher at 3.0 t. overall diagnostic performance was high at both field strengths. conclusions: mri of pediatric patients with chd and vascular abnormalities at 3.0 t is feasible. relative to 1.5 t, snr and cnr are both improved at higher field strength and higher resolution cemra is achievable t are more prevalent, they rarely render cine imaging non-poster # exclusion criteria were lack of correlating us or follow up information. two pediatric radiologists blinded to us findings reviewed the mr images and analyzed the contents of abdominal wall defect, organ location and attachment; spine anomalies; umbilical cord and limb anomalies. results: our search yielded 16 patients. all fetuses had ventral wall defects, small thorax and eviscerated liver and bowel. in two cases kidneys were in extracorporeal location. in 12/16 there was no membrane covering extruded organs. in five mr showed organs attached to the placenta or uterine wall (mainly bowel and liver) mahmoud al-hawary and, by adolescence, paradoxical metaphyseal osteopenia with thin cortical bone. reports of consanguinity indicate autosomal recessive inheritance our studies, spanning ages 11-44 mo, showed weight 50%, but length diminishing from~30% to −2.3 sd. head circumference was +4 sd. she had frontal bossing, blue sclera, normal teeth, genu valgum, and unremarkable joints. radiographs showed orbital and facial sclerosis, basilar thickening, "bone-in-bone" appearance in the pelvis, sclerotic long bone ends, and fractures of ribs and extremities. progressive metaphyseal widening occurred as vertebrae changed from ovoid to flattened and became beaked anteriorly. consistent with opt, serum pth concentrations reflected dietary calcium levels. serum bone alkaline phosphatase, osteocalcin, and trap5b were sub-normal. iliac crest contained excessive primary spongiosa and no osteoclasts. splice sites and exons were intact for the genes encoding cholride channel 7, t-cell immune regulator 1, opt-associated transmembrane protein 1 the hallmarks include stippled epiphyses, nasal hypoplasia, and hypoplastic distal phalanges and developmental delay. punctate calcifications are seen not only in the epiphyses but also in the paravertebral regions. paravertebral puncta are commonly associated with defective ossifications in the cervical spine. the malformation of the cervical spine causes spinal canal stenosis and instability, which occasionally necessitate surgical intervention none of the cases had brain infarction. conclusions: tortuousity and luminal narrowing of the cervical arteries is a common finding in cdp-bt. this previously unknown malformation is an important factor to discriminate patients at increased risk of cerebral ischemia, particularly in patients undergoing surgical intervention. disclosure: dr. okabe has indicated that she will discuss or describe severe skeletal toxicity from protracted etidronate therapy for generalized arterial calcification of infancy william h. mcalister, md, mallinckrodt institute of radiology campbell sheen purpose or case report: generalized arterial calcification of infancy (gaci) is an autosomal recessive disorder caused by deactivating mutations within the gene for ectonucleotide pyrophosphatase phosphodiesterase-1 (enpp1). enpp1 on osteoblasts, chondrocytes, and vascular smooth muscle cells hydrolyzes nucleotide triphosphates to nucleotide monophosphates and inorganic pyrophosphate (ppi) can time-resolved contrast-enhanced mra (twist) classify soft tissue vascular anomalies in the head and neck in children accurately? aylin tekes, md 28 children from 0-17 years of age were enrolled. twist and conventional mri was performed (triplanar t2-weighted [t2-w] imaging with fat saturation, pre-contrast axial t1-weighted [t1-w] imaging, and post contrast triplanar fat-suppressed t1-w imaging). twist was performed in coronal plane using blood-pool mr contrast agent (ablavar-lantheus) to enhance image quality and spatial resolution of mra. two pediatric neuroradiologists evaluated all patients in two different sessions, 15 days apart: one session conventional mri with contrast was evaluated, in the second session twist was evaluated. clinical evaluation and/or percutaneous venogram/lymphogram data were the gold standard. results: our patients had diagnosis of infantile hemangioma (n04), venous malformation (n012), and lymphatic malformation (n012). twist alone could accurately classify 26/ 28, conventional mri with contrast could accurately classify 22/28. conventional mri with contrast combined with twist could accurately classify all cases. conclusions: twist offers high temporal resolution in the order of seconds, and provides functional data about the dynamics of contrast enhancement comprising the arterial, venous and delayed venous phases kiery cr-2, sci-11 edu-91, edu-92 edu-35, edu-40, pa-045 edu-86, pa-036 a-092, pa-093, pa-108, pa-109, pa-113 edu-7, edu-59, edu-60, edu-62, edu-66, edu-69, edu-78 edu-59, edu-60, edu-62, edu-66, edu-69, edu-78 suraj sci-26, pa-124, pa-125 edu-98 pa-147, edu-86, pa-036 the society for pediatric radiology gratefully acknowledges the support of the following companies in presenting the 55th annual meeting and postgraduate course: cme committee reviewers for this activity have disclosed any relevant financial relationships. no conflicts of interest exist.abuse and offer potential mechanisms of injury may help make the diagnosis of child abuse. the pediatric elbow-mri findings with multimodality correlation michael guandalini, md, royal children's hospital; murray bartlett purpose or case report: to describe and illustrate elbow abnormalities identified by mri performed in a cohort of pediatric patients with multimodality correlation. methods & materials: retrospective review of mri elbow studies performed at the royal children's hospital, melbourne between 2003 and . the studies were reviewed by a pediatric musculoskeletal radiologist and pediatric radiology fellow with patient demographics, clinical indication, findings and selected images recorded. results: 199 elbow mri examinations were reviewed on children aged 4 months to 18 years (123 boys, 76 girls) with equal numbers of left and right sides examined. clinical indications included previous trauma in 147 cases (74%) and nontraumatic conditions in 52 (26%). the most common traumatic indication was suspected or confirmed fractures or avulsions (21%) followed by osteochondral or cartilage injuries (18%), growth arrest (16%), loose bodies (14%) and ligament injuries (10%). hemophilia (38%) was the most frequent nontraumatic indication followed by neoplasm (17%). mild to severe arthropathy, fractures, physeal growth arrest, subluxations, osteochondral lesions and loose bodies were the most frequently demonstrated abnormalities. ligament strains and tears, bone oedema, neuromuscular abnormalities, infections and several neoplasms including lipomas, vascular/lymphatic malformations and bone tumors also featured. conclusions: this pictorial review illustrates the broad range of abnormalities one might expect to encounter on pediatric elbow mri studies, highlighting the major features and corresponding appearances on ct and plain x-ray. spectrum of patellar tendon avulsive injury on mri in children: differentiation between acute and chronic avulsive injuries of the inferior patellar pole and tibial tuberosity zeyad metwalli, md, baylor college of medicine, metwalli@ bcm.edu; herman kan, scott rosenfeld, r. p. guillerman purpose or case report: the extensor mechanism of the knee is an intricate component of the joint and is frequently injured in pediatric athletes. due to the strength of the patella tendon, trauma to the anterior knee is often manifested by avulsive injuries, which may occur on an acute or chronic repetitive basis. purpose: this pictorial review will illustrate differentiating radiographic and mri features of acute and chronic avulsive injuries of the pediatric knee. outline: 1. anatomy and physiology a. discuss the anatomic differences of the pediatric and adult knee extensor mechanism b. pathophysiology and biomechanical basis for chondro-osseous avulsion injuries versus tendon tears in the skeletally immature. purpose or case report: the purpose of this educational exhibit is to demonstrate the magnetic resonance imaging (mri) appearance of the ankle and hindfoot ligaments using an interactive approach. methods & materials: a 3 tesla siemens mri scanner with a multichannel ankle coil was utilized in the acquisition of images of ankle and hindfoot. three dimensional volume acquisition proton density images will be used to demonstrate the ligamentous anatomy of the ankle and hindfoot in axial, axial oblique, coronal, and sagittal planes. results: the exhibit will begin with an interactive review of the ankle and hindfoot ligamentous anatomy with each ligament poster #: edu-073 cns imaging findings in hemophagocytic lymphohistiocytic syndrome rupa radhakrishnan, mbbs, md, dnb, radiology, university of cincinnati college of medicine, radhakrp@ucmail. uc.edu; marcia k. kukreja, alexandra filipovich, alexander j. towbin purpose or case report: hemophagocytic lymphohistiocytosis (hlh) is a rare, life threatening condition caused by an uncontrolled proliferation of activated lymphocytes and histiocytes with high levels of inflammatory cytokines. the organs most commonly involved in this disorder include the liver, spleen, lymph nodes, bone marrow and central nervous system (cns). the purpose of this exhibit is to review the cns imaging findings associated with hlh, its complications, and its management. the published literature was reviewed to identify the potential imaging findings hlh. the electronic medical record system was then searched to find illustrative case examples from our institution. cases demonstrating the primary imaging findings as well cases highlighting complications of the disease or its therapy were selected. results: cns involvement is common in hlh with approximately 75% of patients demonstrating neurological symptoms. ct findings of cns involvement include diffuse parenchymal atrophy, low attenuation lesions in the white matter and calcifications. mr findings include diffuse leptomeningeal and perivascular enhancement, t2 hyperintense lesions with nodular or rim enhancement as well as confluent white matter lesions, and diffuse parenchymal volume loss of the cerebrum and cerebellum. restricted diffusion has been demonstrated in some lesions. ring enhancing parenchymal lesions have been described representing active demyelination. intracranial hemorrhage may occur as a result of thrombocytopenia and coagulation abnormalities. sepsis with opportunistic organisms can involve the cns and produce intracranial findings such as parenchymal abscesses. cns changes, such as posterior reversible encephalopathy syndrome, are also seen with the commonly used immunomodulatory regimen used in the treatment of hlh. conclusions: this exhibit will aid the viewer in identifying the cns imaging findings of hlh as well as the complications of the disease and its therapy. while the cns imaging findings are not specific, they may help the radiologist formulate a diagnosis in association with the other clinical and imaging findings; furthermore, imaging can help the clinical team in managing the disease and its complications. methods & materials: medical records of our pediatric patients with palpable head masses over the last 5 years, were reviewed and images were collected. correlation of us of these lesions with other imaging modalities and/or pathologic diagnosis was done. results: us appearances of various head masses including congenital/developmental (encephalocele, meningocele, dermoid, occipital protuberance), traumatic (cephalhematoma, subgaleal hematoma, calvarial fracture), inflammatory/infectious (sebaceous cyst, histiocytosis, dermatitis), vascular (malformations, pseudoaneurysm) and neoplastic (benign and malignant lesions including metastases) etiologies, will be illustrated with case based approach. mri and/or ct or tissue diagnosis can be problem solving. role of ultrasound guidance for percutaneous procedures (biopsy, sclerotherapy) will also be described. conclusions: ultrasound can play an important role in the delineation, diagnosis and guiding further management of pediatric palpable head masses. us can differentiate various scalp lesions and suggest the underlying calvarial defect or involvement to some extent, helping to narrow the differential diagnosis for such lesions. color doppler us can be useful to detect vascularity within the lesion or vascular lesions. given that us is often requested for the evaluation of palpable head masses, pediatric radiologists should be familiar with their sonographic features. posterior fossa malformations-a pictorial review rui santos, md, bc children's hospital, ruiradiologia@gmail. com; khalid khashoggi, angela t. byrne purpose or case report: posterior fossa malformations are a group of central nervous system anomalies that may be detected during pregnancy or present early infancy with features that include hypotonia, developmental delay, mutations responsible for the disease and proposals as to mechanism of action of the mutation with respect to disease manifestations. this preceded the development of hypotheses regarding the relationship between genotype and phenotype and the attempt to utilize imaging modalities that could better assess disease activity as it related to functional status. the purpose of this exhibit is to briefly review the history pre-1989 and to focus on the numerous ways in which the understanding has improved since that time. conclusions: 1. there are over 1000 different mutations of the cftr gene responsible for cystic fibrosis with varying prevalence throughout the world. 2. the class of mutation often dictates its particular mechanism of action. 3. there is some relationship between genotype and phenotype-particularly with respect to pancreatic involvement. 4. newer imaging modalities including ct and mri with or without hyperpolarized helium are better predictors of disease severity than is plain film. imaging pulmonary tuberculosis in infants: what are the most useful diagnostic radiological findings? handan cakmakci, pediatric radiology, dokuz eylul university hospital, handancakmakci@gmail.com; nevin uzuner, filiz tetik purpose or case report: early diagnosis and treatment are very important for infants with tuberculosis. infantile pulmonary tuberculosis is more symptomatic, and the risk of severe and life-threatening complications such as tuberculous meningitis or miliary tuberculosis is higher. bacteriologic confirmation of the disease in children is difficult and in younger infants (<3 months), the tuberculin skin test is frequently negative. therefore, radiological findings play important role in diagnosing tuberculosis in infants. the purposes of this study are to identify chest x-ray and lung ct findings in pulmonary tuberculosis of infants and consider the most useful diagnostic findings of these age group patients.methods & materials: chest radiographs and chest ct images of 7 infants who were diagnosed in our hospital from 2005 to 2011 were retrospectively reviewed. the study group included 2 boys and 5 girls ranging in age from 2 to 12 months (mean age, 6 months). chest x-ray and computed tomography images were analyzed considering air space consolidation, nodular lesions, cavitating lesions, mediastinal enlargement, hyperinflation, bronchial narrowing, atelectasis pleural effusion on plain radiography and additional mediastinal calcific or caseating lymph nodes on ct images.results: air space consolidation was seen on 5 out of 7 chest x-ray and computed tomography images. nodular lesions were seen 2 out of 7 chest x-ray and computed tomography images. cavitating lesion was seen on 1 out of 7 chest x-ray and computed tomography images. mediastinal enlargement suggesting lymph node was seen 5 out of 7 chest x-ray and computed tomography images. hyperinflation, bronchial narrowing was seen 2 out of 7 chest x-ray and computed tomography images. atelectasis, pleural effusion was seen 1 out of 7 chest x-ray and 2 out of 7 computed tomography images. mediastinal caseating lymph nodes, mediastinal calcific lymph nodes were seen 3 out of 7 computed tomography images. conclusions: frequent and the most useful diagnostic radiological findings of pulmonary tuberculosis in infants are mediastinal or hilar lymphadenopathy with central necrosis and air space consolidations. disseminated nodules including miliary lesions and airway complications are also detected in this age group. ct can show detailed parenchymal lesions and tuberculous lymphnodes especially calcified ones. the ductus bump: radiographic findings of this normal variant and differential diagnoses anusuya mokashi, staten island university hospital, anusuya.mokashi@gmail.com; jeremy neuman, cheryl lin purpose or case report: the ductus bump: review of radiographic findings, differential diagnoses and current controversies. the ductus bump was first described in 1965 by berdon et al as a transient physiologic mass in the chest in newborn infants. some controversy remains as to the exact etiology and clinical significance. although initially thought to represent a dilated ductus arteriosus, recently it has been suggested that it actually represents a ductus arteriosus aneurysm that spontaneously resolves. others contend it represents dilation of the infundibulum of the closing ductus. regardless of etiology, the time of discovery, location, and rapid resolution are characteristic of this entity. in this presentation we will review the radiographic and echocardiogram findings of the ductus bump, as well as discuss the differential diagnosis. the frontal radiographic findings are a round mass to the left of the vertebral spine projecting from the mediastinum near the aortic arch. this mass does not indent the esophagus and it cannot be seen on the lateral view. it is classically said to resolve within the first few days of life. the controversy regarding the etiology has also led to some disagreement involving the clinical significance and appropriate follow up, which will also be discussed. after reviewing this educational poster, the reader will have conclusions: abnormalities of the posterior fossa are often difficult to differentiate solely on the basis of their radiologic appearances alone. however, an accurate diagnosis is essential for proper treatment planning and genetic counselling. therefore it is imperative for radiologists to be well versed with the normal anatomy and development of cerebellum so as to correctly diagnose the various posterior fossa abnormalities.poster #: sci-019imaging of oculoauriculofrontonasal syndrome with low-dose 3-dimensional computed tomography paritosh c. khanna, md, radiology, seattle children's hospital, pkhanna@uw.edu; kelly evans, gisele ishak, joseph gruss, michael cunningham, anne hing purpose or case report: oculoauriculofrontonasal syndrome (oafns) combines elements of abnormal morphology of the frontonasal and maxillary processes of the face. the aim of our exhibit is to demonstrate the low-dose computed tomography (ct) features of this syndrome, in seven patients who have been followed at seattle children's hospital (sch) over 18 years. we underscore the imaging features of this condition, and describe additional features including bony nasal abnormalities not previously described in the literature, to improve imaging recognition of this spectrum. we present 3d ct imaging features of a series of eight patients with oafns. in keeping with the alara (as low as reasonably achievable) concept and the image gently recommendations (www.imagegently. org), ct head and face studies were obtained on six of eight patients at sch, while two had prior exams at outside institutions. using a 64-slice multidetector ct scanner (ge lightspeed vct, waukesha wi), low-dose ct (120 kv, 150 mas or lower depending on age) of the head and face was obtained. planar bone window and 3d surface rendered images were analyzed. results: our series of patients demonstrated bifid nasal bones, uni-or bilateral mandibular hypoplasia, temporomandibular and zygomatic dysplasia and bony external auditory canal abnormalities. one patient had an interfrontal bone with a frontal bony defect that was contiguous with the metopic suture. we describe additional previously unidentified ct anomalies of the nasal bones, anterior nasal spine and nasal septum. these structures are involved in all patients who had ct imaging available, although unique features are present in each case. conclusions: ct is the mainstay of imaging of craniofacial anomalies in the post-natal period, both pre-and postoperatively. in addition to our low-dose ct imaging findings of oafns, novel nasal bone anomalies identified by our group serve to identify a new subset of patients with this syndrome and may help refine the phenotype of the oafns spectrum. key: cord-005105-twsy61oq authors: nan title: siu 2015 abstracts date: 2015-09-21 journal: world j urol doi: 10.1007/s00345-015-1684-3 sha: doc_id: 5105 cord_uid: twsy61oq nan introduction and objective: th e bladder is generally considered an organ for voiding and storage of urine, with the urothelium serving as an impermeable barrier. recent discovery of aquaporins in the bladder urothelium in rodents and later on also in human challenges this notion of impermeability. upregulation of aquaporins in response to dehydration or bladder outlet obstruction and downregulation following transitional cell carcinoma has been shown. th is emphasize the need to better understand the function and distribution of aquaporins, as well as their role in bladder diseases. th e present study aims at establishing basic knowledge about the expression of aquaporin 3 (aqp3) in the porcine bladder, related to gender and gestational age. th ree pregnant sows at 60, 80 or 100 days of gestation were sacrifi ced. fetuses were removed and necropsied. th e bladder was rapidly removed and whole wall tissue samples from the bladder dome was snap frozen in liquid nitrogen and stored at -800c. genetic gender determination was performed and fetuses with uncertain gender determination were excluded. aquaporin 3 mrna expression was analyzed using qpcr and β-actin was used as the reference housekeeping gene. results were compared using two-way anova. results: a total of 41 samples were analyzed. gestational age was either 60 (n=11), 80 (n=14) or 100 days (n=16). aquaporin 3 was expressed in all samples. aqp3 mrna expression was increased in the fetal porcine bladder with increasing gestational age (p<0.001). however, there was no signifi cant diff erence in aqp3 mrna expression between genders (p=0.71). conclusion: expression of aqp3 in fetal porcine bladder is demonstrated with increasing expression during gestation. to our knowledge aquaporins in the porcine bladder tissue have not previously been studied. th is exciting new discovery contributes to the ongoing discussion on reviewing the dogma that the lower urinary tract has an impermeable barrier function. improved contractility of the long term bladder outlet obstruction induced bladder underactivity using growth factor expressing mesenchymal stem cells introduction and objective: as the underactive bladder is diffi cult to manage, a new method of increasing bladder contractility in patients with underactive bladder is desired. mesenchymal stem cells (mscs) can serve as vehicles for the gene, proliferate and differentiate into bladder smooth muscle cells to repopulate damaged bladder. th e other is that the exogenous hepatocyte growth factor (hgf) gene can provide complementary functions as angiogenesis and inhibition of fi brosis. th is study was performed to examine the recovery of the decreased bladder contractility in the long term bladder outlet obstruction (boo) models of rats using transplantation of hgf expressing human mscs (hgf-hmscs) into the bladder wall. introduction and objective: suddenly dropping to low environmental temperature, cold stress exacerbates lower urinary tract symptoms (luts) such as urinary frequency and urgency. th is study determined if transient receptor potential ankyrin 1 (trpa1) channels could mediate the cold-stress induced detrusor overactivity in rats. materials and methods: twenty-four female 10-weeks sprague dawley (sd) rats were used. th is 35th congress of the société internationale d'urologie -siu 2015 abstract book study used hc030031 (tocris bioscience) as trpa1 channel antagonist. th ree days prior to cystometric investigations, polyethylene catheters were inserted into the bladder and abdominal cavity. cystometric investigations of the unanesthetized rats were performed at room temperature (rt, 27±2°c) for 20 min. following, the rats were intraperitoneally injected with vehicle, 1.0-(low dose), or 10.0-(high dose) mg/kg hc030031 (n=8, in each). aft er 20 min, the treated rats were exposed to low temperature (lt, 4±2°c) for 20 min. during the cystometric investigations, the micturition parameters were recorded. introduction and objective: hypoxia-inducible factors (hif1, hif2 and hif3) play a critical role in cellular and systemic responses to hypoxia by inducing a range of diverse genes involved in cell survival, they have also been implicated in development of renal cell carcinoma. we aimed to assess the eff ect of zinc and cobalt on hypoxia-inducible factor expression in immortalized human kidney cells. 1 to 5 cells in 1 mcl). esr at the observed patient aft er the seventh transfusion decreased from initial 6 mm/ hour to 3 mm/hour. aft er the fourth transfusion of mononuclear fraction of peripheral blood at the patient the increase in the content of the total testosterone that allowed to reduce a dose of 1% of dermal gel of testosterone from 1.6 ml per day to 0.5 ml per day was observed. aft er the seventh transfusion of mononuclear fraction of peripheral blood because of normalization of production of testosterone the restored number of own leydig's cells an androgen -replacement therapy was cancelled. introduction and objective: ketamine use as a recreational drug is on a rapid increase in young people. many reports have shown that long-term ketamine abuse is liable to lead to lower urinary tract symptoms that resemble interstitial cystitis (ic). ic is a disease characterised by severe and chronic pelvic pain with frequency, urinary urgency, and nocturia in the absence of bacterial infection or other diseases. th is study evaluated the therapeutic eff ect of human umbilical cord blood derived mesenchymal stem cells (ucb-mscs) in a ketamine induced cystitis (kc) rat model. for kc rat models 10-weekold, female sprague-dawley rats were used. sham treatment (n=5) rats were assigned to the control group. th e rats in the kc group (n=10) and kc+m-scs group (n=9) were intravenously injected with ketamine at a dose of 25 mg/kg for 5 days a week over a duration of 2 weeks. aft er one week, 1 x 106 ucb-mscs were directly injected into the submucosal layer of the anterior wall and dome of the bladder in kc+mscs group. th e cystometric parameters and immunohistochemical results (toluidine-blue, masson trichrome, tunel staining) were measured at one week following the intervention. results: most rats in the kc group exhibited irregular voiding frequency and decreased inter-contraction interval in comparison with the control group (118.8 ± 34.3 vs. 306 .5 ± 138.5 seconds, respectively; p< 0.05). th e kc+mscs group demonstrated improvement in most voiding parameters to normal levels within 1 week. a single injection of ucb-mscs signifi cantly increased the inter-contraction interval (339.0 ± 131.2, p<0.05) ( figure 1 ). in immunohistochemical analysis, the bladders in kc group were characterized by mast cell infi ltration in toluidine-blue staining, fibrosis in masson trichrome staining and apoptosis in tunel staining which were signifi cantly ameliorated in the bladders in the kc+mscs group ( figure 2 ). conclusion: th e injection of ucb-mscs restored the damaged bladder and associated pathologies including mast cell infi ltration, fi brosis and apoptosis in the kc rat model. stem cell therapy could be valuable treatment option for painful bladder conditions such as ketamine induced interstitial cystitis. mp-01.12, figure 1 . introduction and objective: currently no markers are available to predict intravesical bacillus calmette-guerin (bcg) response. among the various markers under study survivin has good sensitivity in detecting bladder cancer cases and there has been very limited number of studies regarding survivin as a prognostic marker and predictive marker. prospective evaluation of urinary survivin levels as a potential prognostic and predictive biomarker in non-muscle invasive bladder cancer cases on intravesical bcg therapy was planned in this study. from august 2013 to august 2014 a total 30 intermediate and high risk group patients of nmibc age ranging from 32 to70 yrs (mean 56) planned for intravesical bcg instillation were enrolled. recurrence and progression score were calculated by using eortc genitourinary scoring system and risk table. patient's urinary samples were taken, pre and post [6 (t1), 12 (t2) and 24 weeks (t3)], intravesical bcg instillation. urinary survivin expression was studied by elisa technique. results: out of 30 patients, 25 (83.30 %) had complete remission at 6 months th e mean survivin levels in remission group (group i) was 0.41+/-0.49 which was signifi cantly less than those in recurrence group (group ii) mean 1.92+/-0.19. pre and post bcg, there was a signifi cant decrease in the urinary survivin levels in group i when compared to group ii where there was a signifi cant rise in pre and post bcg urinary survivin levels (p value<0.01). conclusion: low pre bcg urinary survivin level can be used as a useful predictive marker for achieving complete remission in nmibc patients with on intravesical bcg immunotherapy. also pre and post bcg urinary survivin levels act as a useful prognostic marker and can be used as an adjunct to cystoscopy. introduction and objective: th e natural resistance-associated macrophage protein 1 (nramp1) gene modulates macrophage activation in a myriad of infectious and autoimmune diseases. its single nucleotide polymorphisms (snps) have been identifi ed to infl uence susceptibility to tuberculosis and response to bcg therapy in murine models. in this study, we evaluate the predictive role of nramp1 snps in the oncological outcomes of asian patients receiving intravesical regimes of bcg for nmibc. a total of 139 nmibc patients who underwent post-transurethral resection intravesical regimes of bcg (81mg or 27mg) or bcg (27mg) with interferon alfa from 1995 to 2013 and deemed intermediate to high risk by the european organisation for research and treatment of cancer risk tables, were prospectively recruited. from these patients and a group of 148 healthy controls, peripheral blood samples were stored and genomic dna purifi ed. a total of 15 nramp1 snps were evaluated using high resolution melt analysis. th e corresponding results were verifi ed by dna sequence analysis. kaplan-meier and cox regression methods were used to analyze the data. introduction and objective: microscopic hematuria can indicate presence of underlying urological conditions. aua guidelines recommend evaluation algorithms for microscopic hematuria. population-based studies have focused on risk pools such as heavy smokers and elderly men. we evaluated whether men interested in self-managing their lower urinary tract symptoms (luts) with an over-the-counter (otc) product should be screened for microscopic hematuria to detect undiagnosed signifi cant conditions (including urothelial malignancy) causing hematuria. materials and methods: urine dipstick testing was conducted in men who preferred to self-manage luts using an otc product. urologic assessment was conducted by a urologist to determine conditions causing/contributing to the urinary symptoms for: men <45 years; and men ≥45 years who had traces of glucose, leukocyte, and/or blood in urine; or had an aua symptom index score ≥20. men experiencing complete urinary retention, dysuria, extreme thirst, gross hematuria, or urethral discharge ("do not use" symptoms in this study) were also assessed. men ≥45 years of age who did not meet any of these criteria did not undergo urologic assessment. introduction and objective: th is fi rst experience, pilot study, was aimed to evaluate the outcome of en-bloc bladder tumor resection using the plasma-button electrode in cases of papillary non-muscle invasive bladder tumors (nmibt) from the perspectives of surgical safety and effi cacy, perioperative morbidity, histological assessment and short-term oncologic outcome. a total of 55 patients previously diagnosed by abdominal ultrasound, contrast ct and fl exible cystoscopy with papillary bladder tumors over 1 cm in diameter were included in the trial. th e exclusion criteria consisted in solid sessile tumors, lesions located in bladder neck area and tumors involving the ureteral orifi ce. en-bloc tumor resection using the plasma-button approach was applied in all enrolled cases. th e tumor base was subsequently biopsied by standard single-wire loop resection and followed by plasma-button coagulation. th e fi rst follow-up cystoscopy was completed at 3 months. results: all procedures were successfully performed leading to visually complete tumor ablation. th e mean tumor diameter was 1.8 cm (range between 1 and 4 cm). no obturator nerve refl ex adverse events or cases of bladder wall perforation were encountered. no signifi cant postoperative hematuria and re-intervention requirements were encountered in this series. th e mean catheterization period was 1.6 days (range 1 to 2.5 days) and the mean hospital stay was 2.1 days (range 1 to 3 days). th e pathological analysis confi rmed the presence of detrusor muscle in the resected biopsy specimens for all enrolled patients, thus enabling for a reliable tumor staging to be established (all nmibt histology diagnosed patients). a single case of other site residual lesion was found during the fi rst evaluation cystoscopy, while no orthotopic recurrences were described. to reduce the overdiagnosis and overtreatment of insignifi cant tumors there is an urgent need for a specifi c test to detect clinically signifi cant prostate cancer (pca). using gene expression profi ling specifi c pca-biomarkers were identifi ed. eight promising biomarkers were selected and the diagnostic accuracy was tested in urine of an intent-to-treat cohort. th e aim of this study was to clinically validate the four-gene biomarker panel (hoxc6, dlx1, tdrd1 and hoxc4) using an independent prospective multicenter study cohort. in two independent prospective, multicenter studies (cohort 1: n=490 en cohort 2: n=371) urine was collected aft er digital rectal examination (dre) from men undergoing prostate biopsies based on an elevated serum psa level (≥3.0 ng/ ml) and/or suspicious dre. klk3, hoxc4, hoxc6, tdrd1 and dlx1 mrna levels were measured using rt-qpcr. th e assay was validated according to miqe criteria, hence the test is a standardized laboratory developed test (ldt). results from cohort 1 were used to develop models with (combinations of) the four genes based on the comparative ct method. th e chosen model was validated in cohort 2, i.e. a fully independent validation cohort. results: pca was identifi ed in 41% (202/490) and 47% (174/371) of men from the studies respectively. th e model with the combination of hoxc6/dlx1 resulted in the highest average auc (0.76) and specifi city (36%) at ≈90% sensitivity, based on cohort 1. furthermore, hoxc6 and dlx1 were signifi cant in the logistic regression, in 96% and 94% respectively. th is model was independently validated for the diagnosis of pca with gleason score ≥7 in prostate biopsies. using roc curve analysis hoxc6/dlx1 outperformed pca3 in both cohorts (cohort 1 auc=0.75 vs. 0.64; cohort 2 auc=0.73 vs. 0.62). adding serum psa to the hoxc6/dlx1 model resulted in an auc of 0.81 and 0.80, respectively. th is study showed the promising results of a new urine test for the early diagnosis of clini-cally signifi cant pca using a model which combines hoxc6 with dlx1. th ese results demonstrate that this model could be used to assess the risk of pca with gleason score ≥7 and therefore could reduce the amount of unnecessary prostate biopsies. introduction and objective: curcumin contains mul-introduction and objective: a family history of prostate cancer is a well-recognized high risk factor for this disease. various models for an inherited risk for prostate cancer have been described, but to date traditional linkage and association studies have only identifi ed a small number of rare tumor suppressor genes and snps involved in prostate cancer risk and development. we performed whole exome sequencing on multiple participants (n=5) with prostate cancer from 3 families with a signifi cant history of prostate cancer to potentially identify new prostate cancer susceptibility variants. exome variants were fi ltered against a range of parameters with a subset of variants chosen for validation by sanger sequencing and segregation analysis within their respective families. each prostate cancer participant met the following criteria for inclusion if: (i) they had a verifi ed diagnosis of prostate cancer, (ii) there were multiple cases of prostate cancers in the family, iii) pathology, diagnostic and treatment notes were available, and (iv) they were classifi ed as brcax mutation status. results: essential splice site, missense and stop lost variants were fi ltered against a recently published candidate gene list, leaving 19 shared truncating variants and 17 shared missense variants to be genotyped through all prostate aff ected (n=13) and unaff ected male participants (n=8). th ree missense variants demonstrated complete segregation and one missense variant demonstrated partial segregation with the prostate cancers. th ree truncating variants demonstrated complete segregation and three truncation mutations demonstrated partial segregation with prostate cancer. no segregating variants between the three families were shared. conclusion: ten truncating or missense variants showed either complete or partial segregation in our three familial prostate cancer families. of interest, we detected a cyp3a43 and parp variant in our multicase prostate cancer families. th ese two variants have previously been reported to occur in other familial associated prostate cancer families, thereby, potentially adding to the evidence that these two variants may have a role in the risk and development of prostate cancer. another eight novel variants were detected that segregated with disease and warrants further investigation. 35th congress of the société internationale d'urologie -siu 2015 abstract book were recorded. patients with diabetes, hypertension or known cardiovascular disease were excluded. introduction and objective: traditional methods of prostate cancer diagnosis in males with an elevated or rising psa have relied on outpatient trus biopsy using local anaesthetic and taking between 6-18 biopsies. trus biopsy is painful, associated with rectal bleeding in 10%, uti in 40% and urosepsis in up to 5% of patients. it is also has a poor sensitivity (<30%) low accuracy rates of <25% and a poor specifi city of <30%. from 2010 we changed to template guided prostatic biopsy (tgpb) carried out transperineally under a general anaesthetic. to date we have carried out tgpb in 344 patients with a positive biopsy rate of 60% (accuracy of 81%; and specifi city of 87%). th e procedure is painless, utis occurred in 5%, no sepsis and no rectal bleeding. because of the large numbers of biopsies taken 15% of patients had transient retention. in patients who had a previous -ve trus biopsy 48% had a subsequent +ve tgbp and patients having tgbp on the fi rst occasion for an elevated psa (2.5-10) 58% had a positive biopsy. results: with the advent of 3tesla mri and mri fusion technology we have now progressed to mri fusion biopsy using real time ultrasound imaging and fusing the abnormal mri image to perform the biopsy (biojet fusion, global prostate solutions) . th is allows for even greater accuracy of the biopsy without taking large numbers of samples. to date we have achieved a +ve biopsy rate of 75% with an accuracy of >90% (in 32 patients). to date there have been no cases of uti, sepsis or retention. to determine the suitability of circulating tumour cells (ctcs) as prognosticating indicator and biomarker for delivery of precision medicine. patients were recruited and screened (n=20) as a part of admet (androgen deprivation th erapy and adjuvant metformin) trial. five millilitres of whole blood was collected from patients for ctc enrichment, enumeration and propagation. enrichment was performed using cd45 negative selection kit (rosettesep™). ctcs were identifi ed using immunofl uorescence imaging with antibodies against prostate specifi c antigen, cytokeratin, cd45 and nucleus. cells were propagated in customized stem cell solution with hypoxic conditions. results: at screening, 18 of 20 patients demonstrated circulating tumour cells with the mean number of 574 (range 1-1763, ±613) . in all of the enriched samples, cells could be propagated temporarily with the peak population being reached at 3.5 weeks. cells were cultured in both 2d and 3d conditions and temporary organoids could be developed from 5 of 18 patients. polymerase chain reaction and immunofl uorescence imaging at 4 weeks aft er culturing demonstrated characteristics consistent with prostate cancer cells. conclusions: circulating tumour cell technology remains a viable option as a means of providing biomarker information and tumour activity indicator in delivering precision medicine. firstly, enumeration can be used to help determine the response to a treatment. secondly, temporary culture and progression into development of organoids may be used to allow for downstream analysis and therapeutic decision. transcriptionally-targeted retroviral replicating vectors: a novel strategy for gene therapy of prostate cancer introduction and objective: while hematospermia is mainly associated with genitourinary infl ammatory disorders, there are very few studies for prostatitis associated hematospermia (pah) via robust prostatitis evaluation methods. for this reason, we evaluated the incidence of pah with systematic evaluation methods for prostatitis. we evaluated 37 hematospermia patients from a single hospital over fi ve years. we classifi ed the patients into pah versus he-matospermia without evidences of prostatitis (hwp) by using a nih-cpsi (chronic prostatitis symptom index) questionnaire and expressed prostatic secretion studies. 35th congress of the société internationale d'urologie -siu 2015 abstract book cant diff erence in patient's the quality of life impact (table 2) . introduction and objective: chronic prostatitis/ chronic pelvic pain syndrome is a chronic pain disease with high prevalence rates and substantial health care costs. chronic prostatitis syndrome is a common urological condition that many clinicians fi nd diffi cult to diagnose and treat eff ectively. th e signifi cance and diagnostic value of semen analysis in bacterial prostatitis has been extensively debated and remains controversial. our objective was to investigate the diagnostic accuracy of semen and urine culture in the diagnosis and treatment outcome of bacterial prostatitis. th e present study is based on a retrospective analysis of a database of over 600 patients (age range 17-57 years) who met the consensus criteria for bacterial prostatitis, 75% of whom had dysuria, 35% perineal discomfort, 60% had obstructive luts, 37% infertility of unknown etiology, 10% erectile dysfunction and 25% recurrent infection of the partner. segmented urine cultures and semen culture, were performed in all patients. treatment were started as per the culture report and culture negative patients were treated empirically with quinolones group of antibiotics. patients were followed-up for 1 year to rule out disease recurrence. results: of the 600 patients, 425 had positive semen culture and 45 had positive urine culture; 130 had negative culture for both semen and urine. of the positive cultures 75% of the bacteria was gram-negative microorganisms (escherichia coli was the commonest specimen isolated) and 25% had signifi cant positive cultures for gram-positive microorganisms. patients with positive semen culture had 100% response to antibiotics and full recovery was noted from the symptoms prospective aft er the full course of the antibiotic and recurrence of the disease were noted in 25% of the patient aft er 1year follow-up. patients with urine positive cultures, 45% had response to antibiotic, but 75% recurrence were noted in 1 year. patients with negative cultures, 10% had symptomatic relieve but all of them had recurrence in 1 year follow-up. conclusions: th e diagnosis of chronic prostatitis is diffi cult due to the absence of typical clinical symptoms and specifi c ultrasonographic signs. our data support the usefulness of semen analysis in the diagnostic work-up of prostatitis patients. semen culture positive patient responded well to medications and recurrence rate was very minimal compared to urine positive and culture negative patients. in our clinical work-up, semenculture are considered the only tests necessary to diagnose bacterial prostatitis and also guide us through the treatment. (rc) has been shown to be a predictor of poor outcomes in patients with bladder cancer. change in muscle volume during neoadjuvant chemotherapy (nac) administration has not been well studied. our objective was to assess for psoas muscle volume (pmv) change during the period of nac therapy and to assess if such a change was a predictor of pathologic response or survival. mp-05.03, figure 1 . introduction and objective: alternative approach to the radical cystectomy for muscle-invasive bladder cancer is radical transurethral resection (tur), followed by chemotherapy/ radiotherapy. objectives: primary end points of the study were os (overall survival) and dss (disease-specifi c survival). secondary endpoint -oos survival aft er salvage cystectomy. materials and methods: sixty eight patients with t2 bladder cancer were treated by 'complete' tur fol-lowed by chemotherapy / radiotherapy. th e follow-up ended in june 2014. all patients were subjected to "safety" resection. patients who had no tumor (t0), or had non-muscle-invasive (t1) tumor were given the option of follow-up with cystoscopy and adjuvant therapy or immediate cystectomy. mostly elder patients are candidates for bladder sparing. th ose with invasive tumor on the safety resection were subjected to cystectomy-65 patients (control group). we used spss 17: xi-square and kaplan-meier for statistical processing. results: five years overall survival (os) in the bladder spared group was 53% (n-36), and 70 % of the cystectomy group (n-46) -p= 0.015. th e disease specifi c survival (dss) was 72% and 79% for the bladder spared and cystectomy group respectively (p=0.04). th irty four percent (23 patients) with preserved bladder developed recurrent tumors. a repeated tur was conducted. fift een percent (4) of them were with invasive tumor and the action taken was cystectomy. fift y percent (2) of the salvage cystectomy group and 70% of the immediate cystectomy group survived 5 years. of the preserved bladder patients, 7 (10%) necessitated dj stenting and 5 (7%) pns. pns in the cystectomy group were 2 (3%). haematuria occurred in 12 patients with preserved bladder and in 4 of the cystectomy group. th e statistical diff erence between both groups according to complications is p =0.001. infl ammatory conditions were more common in the bladder sparing technique-4 orchiepididymitis, 1 urosepsis, 3 pyelonephritis, compared to 3 urosepsis and 3 pyelonephritis in the cystectomy group. conclusion: bladder conservation and radical cystectomy for muscle-invasive bladder cancer appear comparable regarding the dss until the 5th year. cystectomy continues to be standard of care. radical tur is successful bladder-sparing strategy in selected patients with no residual tumor on retur and lower life expectancy. introduction and objective: bladder cancer occurs commonly in the elderly patients. in some circumstance, uremic patients developed bladder cancer. we considered patients who are aged more than 75 years old, end stage renal disease (esrd) or poor performance status (eastern cooperative oncology group, ecog >=2) as fragile patients for operation. we conducted this study to assess radical cystectomy (rc) outcomes and chemotherapy use including neoadjuvant and/or adjuvant chemotherapy in the fragile patients in routine practice. all patients undergoing rc for bladder urothelial cancer in china medical university hospital from 2008 to 2014 were enrolled. patients' basic characters, surgical and pathology reports and treatment records were retrospectively collected. patients were stratifi ed into fragile and non-fragile group. pearson's chi-square test and student t-test were used to assess parameters of these two groups. results: we identifi ed 93 patients. th ere were 18 patients aged more than 75 years old, 11 patient are uremic status and 8 patients were performance ecog:2. total 32 patients were stratifi ed into fragile group. th e sex and pathological staging were no diff erence in these two groups. major perioperative complications defi ned as clavien-dino grade 3 or more were 31.5% in fragile group and only 4.9% in non-fragile group (p=0.009). chemotherapy use rate was 53.1% and 75.4% in fragile and non-fragile groups (p=0.029). th e 30-day morbidity rate of non-fragile and fragile group was 26.2% and 34.4%, respectively. th e 90day morbidity was no signifi cant between these two groups (35.7% of non-fragile and 37.5% of fragile groups). in fragile group, 30-day mortality rate was 9.4% and 90-day mortality rate was 12.5%. th ere was no 90-day mortality in non-fragile group. half the patients died within 21 months in fragile patients and fi ft y percent of patients lived aft er 5 years in non-fragile patients. conclusions: fragile patients received radical cystectomy had higher perioperative major complications rate and higher 90-day mortality rate. we off ered complications and morbidity rate in these patients who received radical cystectomy. in elderly, esrd or ecog>=2 patients, we need more cautious care to decrease complication and morbidity rate. introduction and objective: primary management of muscle invasive bladder cancer (mibc) is cystectomy (cx). all traumas, including major surgery like cx, induce a stress response (sr), which plays an important role controlling the human immune system. a widely used parameter for systemic surgical sr is measurement of serum levels of c-reactive protein (crp). th is prospective study aims to compare the introduction and objective: several prognostic models predicting survival of patients with metastatic urothelial carcinoma (uc) have been developed, however, of them, the fi rst model by bajorin in 1999 is still the most representative and widely-used. th e aim of this study was to validate three major prognostic models constructed based on phase 2 and 3 trials, by using a cohort of real-world patients. we reviewed 200 patients with metastatic uc who received fi rst-line chemotherapy at our fi ve affi liate institutions between 2003 and 2011. using this multi-institutional cohort, we validated the following models: the "bajorin model", a model consisting of visceral metastasis and performance status (j clin oncol 1999; 17:3173) ; the "apolo model", a nomogram including visceral metastasis, performance status, albumin and hemoglobin (j natl cancer inst 2013; 105:499) ; and the "galsky model", a nomogram including leukocyte count, number of sites of visceral metastases, site of primary tumor, performance status and lymph node metastasis (cancer 2013; 119:3012) . cox proportional hazards regression model was used for multivariate analysis. harrell's c-index was calculated for each model. conclusion: all models were demonstrated to have high external validities in real-world patients, and of them, the "apolo model" achieved the highest c-index in the present population. further studies with larger populations are needed for establishment of the next standard model. the impact of female gender on bladder cancer specifi c death risk after radical cystectomy: a meta-analysis of 27912 patients liu s, yang t, na r, jiang h, ding q introduction and objective: bladder cancer was one of the most commonly diagnosed cancers in the world. up till now, there has been no study summarizing current studies on gender disparity and bladder cancer outcomes aft er radical cystectomy. to perform a fi rst meta-analysis on the association between female gender and cancer-specifi c death risk aft er radical cystectomy. a comprehensive literature search of the medline and embase databases was conducted for relevant studies published till november, 11th 2014 . th e primary goal of our study was to investigate the impact of gender disparity on cancer-specifi c death risk aft er radical cystectomy in urothelial bladder carcinoma population. th e meta-analysis was performed by estimating the odds ratios (or) and confi dence intervals (ci) through a random eff ect approach. results: a total of 17 studies were included in the meta-analysis with a total population of 27912 patients. th e baseline characteristics of the 17 studies were described in table 1 . female gender was associated with a worse survival (pooled or: 1.20, 95% confi dence interval 1.09-1.32) compared with male gender aft er radical cystectomy. signifi cant (q=40.59, p=0.001) statistical between-study heterogeneity was present, with 60.6% of variance secondary to between-study diff erences (i2: 60.6%). sub-group analysis found the correlation was signifi cant in north american, european studies (or: 1.17, 95% ci 1.02-1.32 and or: 1.34, 95% ci 1.19-1.51, respectively) and studies from larger size of samples (or: 1.24, 95% ci 1.11-1.38). we also found studies adjusted for the key elements (t stage, n stage and grade) obtained positive correlation (or: 1.21, 95% ci 1.09-1.35). introduction and objective: pathologic response after neoadjuvant chemotherapy for muscle invasive bladder cancer is used widely as a surrogate endpoint for overall survival. controversy persists, however, whether the absence of residual cancer (pt0) or the presence of only non-muscle invasive residual cancer (pt1, ptis, pta) is the optimal surrogate endpoint. we aimed to assess survival dependent on these pathologic responses in a large multicenter patient cohort. we retrospectively reviewed records of patients with urothelial cancer who received neoadjuvant chemotherapy and underwent cystectomy at 19 contributing institutions from 2000-2013. patients with ct2-4an0m0 and eventual pn0 disease were selected for this analysis. estimated os was compared between pt0 and pt1/pta/ptis patients. a multivariable cox proportional hazards regression model for overall mortality was generated to evaluate hazard ratios (hrs) for variables of interest (age, gender, number of cycles and type of chemotherapy regimen, surgical margin, and pt0 vs. pt1/pta/ptis). conclusions: pt1/pta/ptisn0 and pt0n0 stage on the fi nal cystectomy specimen are strong predictors of survival in patients receiving nac and rc. we did not discern a statistically signifi cant diff erence in os when comparing these two endpoints. signifi cance of computer materials and methods: fift y patients were included in our study, 39 of them presented with haematuria and a recent diagnosis of bladder carcinoma, and 11 patients with a history of previous transurethral resection of superfi cial bladder cancer in their follow up period. th ey ranged in age 42 years to 75 years with a mean of 58.5; while male to female ratio was 5.25:1. th e main steps to perform virtual cyctoscopy incorporate proper bladder distention with air aft er draining the residual urine through foley's catheter and scanning the patient in both supine and prone positions. an excellent overview of the bladder masses was obtained in all cases and the results of virtual cyctoscopy and conventional one were comparable with excellent sensitivity rates of virtual cyctoscopy in detection, localization and morphology description of the bladder lesions at variable sizes. results: for detection of all lesions (n=62), virtual cyctoscopy alone showed sensitivity: 98.4%, specifi ty: 81.81% with two false positive and one false negative in comparison to conventional cyctoscopy which detected 61 lesion while in axial ct alone the sensitivity: 73.8%, specifi ty: 100% with 7 false negative fi ndings. conclusion: ct virtual cystoscopy is a promising technique for use in bladder tumor detection of lesions larger than 5 mm. optimal evaluation requires adequate bladder distention with the patient in both supine and prone positions and interpretation of both transverse and virtual images. is an evolving technique aiming to improve upon the diagnostic sensitivity of prostate biopsy for the diagnosis and local staging of prostate cancer (pca). diff erences in interpretation, expertise and application of mpmri may be responsible for the range of reported results. th is retrospective study aims to evaluate the diagnostic accuracy of mpmri in a cohort of patients from melbourne, australia, as compared to the gold standard of radical prostatectomy (rp). th is retrospective study was conducted in 2015 through the electronic patient records of a tertiary hospital and several private urology practices in melbourne, australia. patients having undergone rp had their records assessed for the presence of a pre-operative mri performed aft er 1st january 2013 which was then evaluated against the reference standard of a radical prostatectomy wholemount specimen. mri sequences typically included t2 weighted imaging, diff usion weighted imaging and dynamic contrast enhancement at 3t. mri reports were evaluated using the prostate imaging-reporting and data system (pi-rads) system. in our cohort the sensitivity and specifi city of mpmri for prostate cancer (pca) detection was found to be approximately 70-80% and 40-50% respectively. th e area under the curve for determining local stage was approximately 0.5. conclusion: mpmri may have a useful role as an adjunct for prostate cancer diagnosis and directing management toward improving patient outcomes. staging information may be less reliable. a randomized prospective trial to assess the outcomes of mri/trus-guided prostate biopsy and traditional 12-core trus-guided prostate biopsy baco e 1 , rud e 2 , eri l 1 , moen g 1 , vlatkovic l 3 , svindland a 3 , eggesbø h 4 , ukimura o 5 introduction and objective: th e outcomes of magnetic resonance imaging (mri) and 3-dimensional transrectal ultrasound (3d-trus)-image-fusion-guided prostate targeted biopsy (mri-group) has not yet been compared with traditional 12-core trus-guided prostate biopsy (control-group) in a randomized control trial (rct) . th e aim of this study was to compare the prostate cancer (pca) detection rates (cdrs) and histopathological outcomes in the two groups. th is prospective rct included 175 prostate biopsy (pb) naïve patients with suspicion for pca, where 85 were randomized to mri-group and 89 to control-group from 09/2011 to 06/2013. in the mri-group, two tb of mri suspicious regions was followed by 12-core systematic random biopsy (rb). in the control-group, two tb towards palpable and/or trus-visible suspicious regions and 12-core systematic rb were performed. clinically signifi cant pca (cspca) on biopsy was defi ned as maximum cancer core length (mccl) ≥5mm of gleason score (gs) 6 or any mccl of gs ≥7 according to start criteria. cdr of all pca and cspca, and histopathological fi ndings were compared between the two groups. results: in the mri-and control-group cdrs were 51/86 (59%) and 47/89 (53%), (p=0.573). cspca were detected in 37/86 (43%) in and 44/89 (49%) in control-group, (p=0.484). tb (median 2 cores/ patient) detected cspca in 32/38 (84%) in mri-and 16/44 (36%) in control-group (p=0.012), respectively. concordance of gs on biopsy and radical prostatectomy specimen was 16/22 (73%, k = 0.518) in mri-and 14/25 (56%, k = 0.386) in the control-group (p<0.001). upgrading of gs biopsy vs. gs-rp specimen was 20% in mri-group and 49% in control-group (p<0.001). since the present study had a restricted cohort size, this may limit the generalizability of the results. no signifi cant diff erence in cdrs was found between the two groups. pca diagnosis can be achieved with few mri/trus-fusion guided prostate biopsy. gleason score on targeted biopsy was more accurate in the mri-group. introduction and objective: infection is a complication of trus prostate biopsy, despite the use of antibiotic prophylaxis. worryingly the rate of infectious complications following trus biopsy has been shown to be increasing. we aimed to determine the rate, severity, risk factors and microbiology resistance patterns associated with trus biopsy sepsis. as well the standard patterns of care surrounding trus prostate biopsy. a retrospective case-control study was conducted. using electronic coding all patients who presented to cabrini hospital with sepsis following a trus biopsy from 2009 to 2013 were identifi ed. validated cases were matched to controls in a ratio of 1:3. eligible controls were required to have undergone a trus biopsy at the same surgical institution as the case and in the closest period of time. demographic, procedural and patient related data-points were recorded for all patients using hospital and urologist records. univariate logistic regression models were constructed and used to determine risk factors associated with infection. results: seventy-one cases developed sepsis following trus biopsy and were matched to 213 controls. th e average rate of sepsis over the 5-year study period was 1.5%. a sofa score ≥2 was identifi ed in 28% of cases. we found a high prevalence of antibiotic resistant e. coli, with 61% of blood culture isolates classifi ed as multidrug resistant organisms. eight diff erent prophylactic antibiotic regimens were identifi ed. statistically signifi cant risk factors included previous antibiotic use and prior international travel within the six months prior to biopsy. th e addition of a penicillin antibiotic to standard fl uoroquinolone antibiotic prophylaxis was protective. conclusions: trus biopsy is an elective procedure and as such needs to be associated with minimal morbidity. th e patterns of care surrounding periprocedural variables for trus biopsies were non-uniform and diverse. a wide variety of diff erent prophylaxis regimens and bowel preparation routines were recorded. patients with risk factors for sepsis may represent a better target population for intervention with alternative preventative strategies. alternative preventative options include augmented prophylaxis, tailored prophylaxis or the tp biopsy approach either as a fi rst line biopsy modality or based on epidemiological risk factors. psa level) and pathological data was collected for all patients undergoing fi rst-time prostate biopsy with at least 7 months follow-up, at 32 music practices. from this overall cohort we identifi ed all patients whose pathology revealed multi-focal hgpin and/or asap (pre-malignant pathology) . for this subgroup, we examined the frequency of repeat biopsy across music practices and cancer detection outcomes. introduction and objective: nowadays overtreatment is recognisable challenge in pca management. overdiagnosis is possible reason for further overtreat-ment. we hypothesised that repeated prostate biopsies could not only help to cure but also harm patients with pca. consecutive 282 patients who underwent biopsy for suspicious pca following at least one rebiopsy at single tertiary medical centre in 2004-2015 were included. age, initial and subsequent psa, drv, histology and biopsy features were recorded along with characteristics of subsequently diagnosed pca and chosen treatment approach. descriptive statistical methods were used for further analysis. results: basic characteristics were (mean±sd or frequency): age at initial biopsy (62.9±6.9 years), time between initial/fi nal biopsy (33.1±26.1 months), initial/ fi nal psa (10.77±9.52 and 15.07±17.90 ng/ml), drv (normal/suspicious 80.5%/19.5%), and number of initial/fi nal biopsy cores (8.1±1.8 and 10.0±2.7). initial/ fi nal histology was bph in 67 (23.8%)/44 (15.6%), infl ammation in 114 (40.4%)/85 (30.1%) and premalignant lesions in 101 (35.8%)/45 (16.0%) cases. finally, 108 (38.3%) pca were diagnosed (99 by biopsy, 9 by turp) performing 712 biopsies aft er all. mean number of biopsies per patient was 2.52 in total and 2.70 to reach cancer positive histology; turp was performed in 61 (21.6%) patients. in 51 (51.6%) patients ≤2 biopsy cores were cancer positive and in 60 (60.6%) patients gleason score was ≤ 6. gleason score ≥ 8 was found in 18 (18.2%) cases. treatment with curative intention was held in 39 cases (rrp 35, external radiotherapy 4), no treatment (as/ww) in 6 and hormonal therapy in 237 patients. fourteen patients with minimal low grade cancer (≤2 positive cores, gleason score ≤ 6) underwent rrp (40% of all surgery cases). conclusion: repeated biopsy is important approach in pca diagnosis. however, based on our results we cannot exclude the risk of overdiagnosis and subsequent overtreatment with signifi cant impact on patients' quality of life, including radical surgery for low risk disease and early hormonal therapy in non-metastatic low-intermediate risk disease. th e study is retrospective, but potential bias became the advantage, since we could exclude prospective "self-control" within treatment decision making process. (siemens, munich, germany) and images were interpreted visually to evaluate uptake in biopsy districts of prostate gland. th e lesions suspicious for pca were submitted to additional targeted biopsies. introduction and objective: multiparametric mri (mpmri) and mri/trus-fusion-guided biopsy (tb) are advocated to detect index lesions and signifi cant prostate cancer (pc) within the prostate more exactly than systematic biopsies (sb) . th e aim of this study was to evaluate the detection accuracy of tumor foci by mp-mri and tb on radical prostatectomy (rp) specimen. we selected 120 consecutive patients who were treated with rp for localized pc diagnosed by tb and/or transperineal saturation sb. on mpmri, all lesions were scored according to pirads. all lesions with pirads≥2 underwent tb. on rp specimen, index lesion was defi ned as highest gleason score (gs) or highest tumor volume (tv). gs=3+3 and tv≥1.2ml or gs≥3+4 and tv≥0.7ml were considered signifi cant. we performed spearmans correlation coeffi cient between mpmri and rp specimen and fisher's test between mpmri, tb and sb. introduction and objective: prostate biopsy is evolving to pre-biopsy multi-parametric mri (mp-mri), followed by systematic biopsy (sb) ± targeted biopsy (tb). mp-mri combined with trus-guided tb may increase detection rates of prostate cancer (pca), especially clinically signifi cant pca (cspca). however, few studies compare the detection rate of sb versus tb in the same cohort of men, as recommended by the standards of reporting for mri-targeted biopsy studies (start) consensus panel. th is study compares the diagnostic yield of sb and tb in a single cohort. th irty-three patients had a pre-biopsy mp-mri that identifi ed a target lesion. each patient then had a trus-guided sb and tb. th e cognitive fusion technique was used to perform the tb. results: among the 33 patients, mean age was 68 years; mean psa was 9.4 ng/ml. th e positivity rate for pca was 64% (n=21) for both sb and tb. th e positivity rate for cspca was 55% (n=18) for sb and 42% (n=14) for tb (p=0.46). sb underdiagnosed 2 cases (6%) of cspca that were detected through tb; tb underdiagnosed 5 cases (15%) of cspca (p=0.43) . th e positivity rate for sb and tb combined was 61% (n=20) for cspca (p=0.35). conclusion: detection rates for pca using sb and tb were equal, but sb had a higher detection rate for cspca. combining tb with sb increased the rate of detection for cspca by 6%. tb alone was 9% more introduction and objective: active surveillance (as) has gained popularity with the intention of avoiding or postponing interventions in subjects with pca of low biological potential. unfortunately, several inclusion criteria have been proposed but many doubts still persist about their performance in predicting favorable disease. we aimed to assess the added value of biopsy factors, like maximum cancer length in a core (mcl), cumulative cancer length (ccl), cumulative length of positive cores (clpc), and percentage of cancer involvement in positive cores (cipc), to the prias criteria in patients who underwent radical prostatectomy (rp) but eligible for active surveillance (as). from january 2002 to december 2007, 750 consecutive subjects underwent rp. we identifi ed 147 (19.05%) patients who were eligible for as based on prias criteria: clinical stage t1c or t2, psa level of ≤10 ng/ml, gleason score ≤6, psa-d of <0.2 ng/ml2 and one or two positive biopsy cores. we calculated the diagnostic accuracy of biopsy factors in determining pathological confi rmed unfavorable disease. decision curve analysis (dca) were performed. explored, we examine the feasibility of monitoring low volume gleason sum (gs) 3+4 disease compared to gs 3+3 disease. introduction and objective: th e selection of prostate cancer patients for active surveillance (as) is based on the criteria for low risk according to protocols such as the national comprehensive cancer network (nccn) or european association of urology (eau) guidelines. we aim to compare pathological upgrading and upstaging rates between prostate cancer patients who met the above guidelines but underwent radical prostatectomy. we also aim to refi ne the selection criteria for our local population. a total of 317 men were treated with rp at our tertiary center from 2000 to 2013. seventy-three patients met the nccn criteria for active surveillance: ct1-t2a, prostate-specifi c antigen (psa) less than 10ng/ml, and biopsy gleason sum 2 to 6. th irty-fi ve met the eau guidelines, which had additional criteria of: 2 or less biopsy cores positive and 50% or less ca detected per core. results: of the 73 patients who met the nccn criteria, 27 (40.0%) showed pathological upgrading (gleason > 7) while 7 (9.6%) were upstaged (pt3). upgrading and upstaging fi gures for the 35 patients meeting the eau guidelines were 10 (28.6%) and 3 (8.6%) respectively. analyzing the patients who met the nccn criteria, those who had 25% or more of the number of biopsy cores positive for prostate cancer had a far greater upgrading rate of 70.6%, which was more than the 28.6% (p = 0.025) seen in the other patients. psa density or percentage of individual core did not show any statistical diff erence in upgrading or upstaging. conclusion: a lower percentage of upgrading was seen in patients meeting the eau. upstaging fi gures were relatively the same. when counseling patients for active surveillance using the nccn criteria for low risk, we should exercise strong caution in patients with 25% or more of the number of biopsy cores positive for prostate cancer. biochemical recurrence rates in active surveillance candidates and the role of improving gleason grading introduction and objective: to evaluate prospectively the role of prostate-specifi c antigen (psa) density to predict gleason score upgrade in prostate cancer patients eligible for active surveillance (t1/t2, biopsy gleason score ≤6 and psa ≤10ng/ml and ≤2 positive biopsy cores). between january 2010 and november 2013, among the patients who underwent more than 10 core trans-rectal ultrasound guided biopsy, 60 patients eligible for active surveillance under-went radical prostatectomy. using the modifi ed gleason criteria, tumor grade of the surgical specimens was examined and compared to the biopsy results. results: a tumor upgrade was noticed in 24 (40.0%) patients. extra-capsular disease and positive surgical margin was found in 6 (10.0%) and 8 (17.3%) patients, respectively. a statistical signifi cant correlation between the psa density and postoperative upgrade was found (p=0.03); this is in contrast to the other studied parameters which failed to reach signifi cance, including psa, prostate volume, number of biopsy cores and number of positive cores. tumor upgrade was also highly associated with extra-capsular cancer extension (p=0.00). th e estimated optimal cutoff value of psa density was 0.13 ng/ml2, obtained by roc analysis (area under the curve 0.66, p=0.02, 95% ci 0.53-0.78). conclusions: psa density represents a strong predictor for gleason score upgrade aft er radical prostatectomy in patients eligible for active surveillance. since tumor upgrade increases the potential for postoperative pathological adverse fi ndings and prognosis, psa density should be considered when treating and consulting patients eligible for active surveillance. surgical outcomes of south australian patients who have discontinued active surveillance plagakis s 1 , o'callaghan m 1,2,3 , moretti k 2,4 , foreman d 1, 5 introduction and objective: active surveillance (as) is a recognized management pathway for patients with low risk prostate cancer (pca). diff ering protocols exist to identify suitable patients and manage their follow up. our study compares surgical pathology outcomes between patients who were initiated on, but discontinued, as and underwent radical prostatectomy (rp) with patients who received surgery immediately at the time of diagnosis. we also explore predictors of as discontinuation. our cohort comprised men diagnosed with pca from the south australian prostate cancer clinical outcomes collaborative database between 2005-2012, aged 50-75 years, gleason score ≤6 and psa ≤10. patients were stratifi ed into an immediate treatment group and an as group. to assess if as derivation rules aff ected outcomes, patients were sub-categorised according to enrolment criteria of university of toronto, prias and royal marsden protocols (with psa and gleason adjustment accordingly). all patients had a minimum of two years follow up. chi squared, logistic regression and cox proportional hazards modelling were used to compare outcomes between groups. results: forty-three (17%) patients in the as group underwent rp, compared with 260 in the immediate treatment group. extra capsular extension and upgrading of histology at rp were more common in those managed by as compared to those receiving im-mediate surgery. th ese associations were supported by sensitivity analysis using prias and toronto criteria but not royal marsden selection criteria. as trended to being associated with unfavourable surgical pathology in multi-variable analysis, but this was only statistically signifi cant for prias ), p=0.02). in all patients managed by as, sensitivity analysis suggested that the percentage of core positive at diagnosis is a signifi cant predictor of as discontinuation in those meeting the university of toronto selection criteria (hr 1.29 (1.10-1.51), p=0.001). to determine if prias has increased rates of active surveillance (as) for patients with low-risk prostate cancer (pca). secondly, to determine whether urologists are operating on greater proportions of high-grade pca as a result of increasing as and what eff ect this has on surgical practice. prospective data was collected on patients from 2008-2013 (cohorts 2008-2010, 2011-2013) who underwent trus biopsy by a urologist in geelong (n=537). positive trus biopsies (n=288) in both the pre and post prias cohorts were assessed to see if they met prias eligibility and whether they received as or active treatment (at). at patients were risk stratifi ed by gleason score and d' amico risk. data on post-prostatectomy staging, margin status and nerve-sparing techniques were collected. chi-squared test were used to calculate statistical signifi cance between cohorts. results: as increased between cohorts (12%, 25%, p=0.006). before prias 29% (13/45) of patients eligible for as by prias criteria opted to undergo as compared with 55% (17/31) aft er the introduction of prias (p=<0.0001). th e relative proportion of high-grade pca (gleason score ≥ 8 and d' amico high-risk) undergoing at increased from 5 to 12% (p=0.16) and 9 to 15% (p=0.27 introduction and objective: renal trauma is predominantly managed conservatively. trauma nephrectomy is reserved for patients who fail conservative or alternative management options. nephron sparing surgery is the cornerstone of renal preservation. our objective was to review the management of renal trauma at three tertiary facilities in queensland over a 10year period and compare these outcomes with current literature. a retrospective analysis was performed to fi nd the total number of renal traumas presenting to the princess alexandra hospital, royal brisbane and women's hospital and gold coast hospital, in queensland, australia. renal trauma patients were identifi ed using icd-10 codes (s37.00-02) and operative databases. patients requiring angioembolisation were obtained from radiological databases. we accessed the number of conservatively managed patients, trauma nephrectomies and angioembolisations for renal trauma. results: a total of 668 renal traumas were identifi ed from june 2002 to june 2012. six hundred and sixteen injuries were managed conservatively. th irty-three patients warranted acute exploration due to haemodynamic instability and resulted in nephrectomy in all cases. a trauma or general surgeon was the primary operator. fift een patients underwent angioembolisation for blunt renal trauma and 4 patients for penetrating injuries. two patients proceeded to delayed nephrectomy for ongoing bleeding and for a ureteric stricture requiring nephrectomy aft er failed auto transplantation. th ese were performed by an urologist. th ere were 2 further devascularised atrophic kidneys. seventeen of 19 renal units were spared and 15 of 19 patients remained with functioning kidneys. all treated patients with angioembolisation were followed up with either mag 3 renogram or ct triple phase and had functional kidneys at 2.5 years. conclusion: renal trauma is managed conservatively in most cases, consistent with the current literature. angioembolisation is an eff ective management option in selected patients with renal trauma. th is may prevent the need for trauma nephrectomy. in our cohort, patients requiring a trauma nephrectomy had predominantly grade iv and v injuries. general or trauma surgeons performed trauma nephrectomies in the acute setting of haemodynamic instability with rapid transfer to theatre. delayed nephrectomies were performed primarily by urologists in this cohort. introduction and objective: to review the contemporary management of traumatic extra-peritoneal bladder ruptures at an australian level one trauma centre. patients presenting with bladder injuries from july 2001 through to june 2013 were identifi ed using the traumanet database. th is was cross-linked with medical records and only patients with extra-peritoneal bladder rupture were included in the study. clinico-pathological data were collected from the database, medical records and health information services coding data. results: over the twelve-year study period, 41 multi-trauma patients sustained an extra-peritoneal bladder rupture. of these patients, 95.1% had a concurrent pelvic fracture and 56.1% had co-existing intra-abdominal injury. a total of 23 patients underwent operative repair for the bladder rupture and 18 patients were managed conservatively with catheter drainage. of the patients managed operatively, 83% of cases were done at the time of another general surgical or orthopaedic operation and only two cases were done as a stand-alone repair. conclusion: extra-peritoneal bladder ruptures can be managed both conservatively and with operative repair. if operative repair is performed, it is usually done at the time of another operation for concomitant injury. management outcomes of major renal injuries following blunt trauma: changing concepts over years results: a total of 35/56 (62.5%) of group i, and 52/59 (88.1%) of group ii were treated non-operatively. diagnosis and grading in group i depended mainly on u/s, ivp and in some cases ct scan, while u/s and enhanced ct scan were mainly used for most of the group ii cases. in the total cohort, grade iii, iv and v renal injury were seen in 35 (30.4%), 48 (41.7%) and 32 (27.8%) patients respectively. open exploration was followed in 21 (37.5%) and 7 (11.9%) patients of group i and ii, with an overall exploration rate in 25/80 (31.3%) of grade iv and v injury. th e incidence of nephrectomy have decreased from 8 cases (14.3%) in group i to 3 cases (5%) only in group ii (2/3 kidneys were pathologic). double-j stenting and percutaneous drainage of urinoma was done in 3 and 2 cases, and chest-tube drainage to one patient with traumatic urinothorax in the conservatively managed group. outcomes were excellent, however in the non-operatively managed (grade iv-v) cases, 4/55 (7.3%) normotensive patients had a non-functioning kidney within one year of follow up. conclusion: non-surgical management of high grade blunt renal injury can be safely undertaken and also recommended unless the patient is haemodynamically unstable. accurate grading is sometimes imprecise in multi-trauma patients, where instability is not always due to renal injury. drainage of extravasation is necessary to reduce morbidity. abdominal exploration does not mandate concomitant renal exploration, which is indicated in selected instances, otherwise it is an aggressive decision with a triple incidence nephrectomy rate. management of grade iv renal trauma: a revision of the aast renal injury grading scale is mandatory chiron p 1 , hornez e 2,3 , boddaert g 2 , dusaud m 1 , bayoud y 1 , molimard b 1 , desfemmes f 1 , durand x 1 introduction and objective: th e aast (american association for the surgery of trauma) injury grading scale for renal trauma is currently the most important variable predicting the need for kidney repair or removal, for morbidity and mortality aft er blunt or penetrating injuries of the kidney. th e 2011 revision included the renal pelvis, the uretero pelvic junction and the segmental vascular injuries as grade iv, limiting grade v to severe hilar injuries. however, this revision does not permit the identifi cation of the group of patients who will require surgery because of hemodynamic instability due to grade iv renal injuries. th is study aims to propose an add-on for the grade iv of aast renal injury scale, in order to improve the management of these patients. we searched the following electronic databases: medline and scopus database. searches were not restricted by date, language or publication status. searches were last conducted in september 2014. paediatric studies were excluded. results: seventy-one articles were found, 57 were pertinent, including 6 directly related to the topic. th ree risk factors were identifi ed to be associated with surgery for hemodynamic instability: peri-renal hematoma >3.5cm, intravascular contrast extravasation, medial renal laceration. presence of two or more of these criteria has been validated by 2 others studies to predict the need for intervention. patients with >25% devascularized fragments also present a poor prognosis and should be treated more aggressively. conclusion: th ese data should be incorporated into a future reassessment of the classifi cation, in order to better determine the need and time for surgery in grade iv renal traumas, generally leading to a nephrectomy. single panurethral reconstruction can be a surgical challenge. techniques include staged urethroplasty, augmented anastomosis with buccal mucosa graft (bmg) onlay via penile and/or transperineal, skin fl aps, or combinations of these. we report our experience of single stage modifi ed transperineal urethroplasty using a dorsal bmg in treatment of panurethral stricture. aft er obtaining irb approval, we performed a retrospective review of our urethral stricture database and identifi ed patients having undergone single stage transperineal urethroplasty using dorsal bmg as treatment of pan-anterior urethral stricture. patient characteristics, operative, and post-operative outcomes were studied. failure was defi ned as a need to any intervention during the follow-up period. results: th irteen patients underwent complete anterior urethra dorsal urethrotomy with dorsal bmg onlay between september 2011 and january 2015. mean age was 47.9 years (sd: +/-8.4). urethral stricture etiology was lichen sclerosis in 5 patients (38.5%), idiopathic in 5 (38.5%), hypospadias in 2 (15.4%) and infection in 1 (7.7%). previous treatments of dilatation and dviu were noted in 12 patients (92.3%) and previous urethroplasty in 2 (15.4%). mean operative time was 258.7 minutes (sd: +/-68.5). mean estimated blood loss was 280.8 cc (sd: +/-154.8). th ere were no intraoperative complications. early postoperative complications were buccal donor site bleed in 2 patients (15.4%) one treated with digital compression and other with hemostatic stitch, one patient (7.7%) presented a perineal abscess and secondary urethroperineal fi stula. late complications was observed in 3 patients who had postoperatory dribbling (23%). at mean follow up of 20.6 +/-14.6 months, 3 had recurrence (23.7%) requiring dviu without new recurrence aft er a mean follow-up of 7.8 months (range 3-10) and one had meatal stenosis treated with dilatation (7.7%) without recurrence aft er 24.9 month of follow-up. conclusion: in this small cohort, reconstruction of panurethral strictures may be safely and eff ective-introduction and objective: we present a novel technique for reconstruction of bulbo-membranous urethral strictures aft er surgery for bph with external sphincter sparing to preserve continence. anatomical studies have shown that the rhabdosphincter is separated from the membranous urethra by a sheath of connective tissue. by meticulous dissection of this sheath we separated the muscle from the urethral wall preserving the sphincteric function. patients with bulbo-membranous strictures aft er turp or open prostatectomy (op) who failed dilation and/or internal urethrotomy were reconstructed with a bulbo-prostatic anastomosis with preservation of the fi bers of the external sphincter. th e bulbo-membranous junction is approached dorsally, the inter-crural space is opened on the midline and the bulb is mobilized only from one side, without detachment from the perineal body. th e bulbo-membranous junction and membranous urethra are exposed and secured with vessel loops. th e membranous urethra sheath is opened circumferentially, carefully refl ecting the circular muscle fibers until exposure of the urethral wall. gentle blunt proximal dissection allows separating the muscle away from the urethra up to the prostatic apex, where healthy urethra is found to perform the anastomosis. results: from january 2010 to march 2015 we operated 16 patients (9 aft er turp and 7 aft er op). all had membranous or bulbo-membranous strictures; bladder neck contractions were excluded. mean age was 68 years (57 -81). fourteen patients have been treated with either dilation and/or dviu; seven were with a suprapubic tube. mean length of stricture was 3 cm (1 -4.5) , mean time from surgery to reconstruction was 30 months (2 -153) and mean follow-up was 28 months (1 -63) . two patients were not evaluable due to insuffi cient follow up. of the remaining 14, twelve were completely dry or using one security pad (85.7% success). th ere were two clavien 1 complications (both scrotal hematomas) and no stricture recurrence. conclusion: excision and bulbo-prostatic anastomosis with sphincter sparing for strictures aft er surgery for bph is feasible and safe. our technique allows preserving continence in most patients. to our knowledge this technique has not been described before. a larger series and reproduction in other centers will help to validate its therapeutic role. introduction and objective: panurethral strictures are complex and extensive strictures that involve the penile and bulbar urethra. management of these patients is challenging. in the last two decades, oral mucosal graft s have gained widespread popularity as the most versatile substitute tissue for urethral reconstruction. th e aim of this paper to present the shortterm outcome of our experience in the use of oral mucosal graft s in one-stage urethroplasty in patients with panurethral strictures. materials and methods: between april 2012 and october 2014, 32 men were evaluated and had one-stage oral mucosa urethroplasty for panurethral strictures. results: th ere were 32 patients age range of 39-75 years with a mean of 53.16 years. aetiological factors identifi ed were poorly treated urethritis 23 (71.9%), post-urethral catheterization 8 (25%) and lichen sclerosis 1 (3.1%). th e commonest cause of catheter-associated panurethral strictures was part of intra-operative patient monitoring in 4 (50%), following spinal cord injury 2 (25%). preliminary suprapubic cystostomy was done in 27 patients (84.4%). graft length ranged from 4-20cm with a mean of 10.7cm. oral mucosa donor sites were buccal in 17 (53.1%), labial 1 (3.1%), combined buccal and labial 12 (37.5%) and 1 (3.1%) for combined buccal/lingual and buccal/labial/penile skin fl ap respectively. twenty eight patients (87.5%) had satisfactory voiding on removal of the urethral catheter and subsequent follow-up whereas 4 patients (12.5%) experienced diffi culty. of these 4, one patient had bladder outlet obstruction due to benign prostatic hyperplasia which was the reason for previous repeated urethral catheterization that had resulted in the stricture. oral mucosa donor site complications were present in 4 patients (12.5%) and consisted mainly pain and numbness in the mouth. duration of follow-up ranged from 1-29 months and there was no mortality among the patients. conclusion: panurethral strictures are common in our practice mainly resulting as complication of prolonged urethral catheterization. urethral reconstruction by one-stage oral mucosa graft urethroplasty is feasible, has good outcome though it may be associated with minor donor site complications. larger number of patients and longer-term follow-up are needed to assess durability of the procedure. missed and delayed ureteral injuries in hasan sadikin hospital, bandung, indonesia introduction and objective: to review our experience with delayed and missed traumatic ureteral injuries. materials and methods: genitourinary trauma database was retrospectively reviewed from 2012-2014. variables such as time to diagnosis, imaging modalitites, location of missed or delay injuries, management, duration of operation, length of stay and complications were noted. introduction and objective: traumatic urethral stricture as the result of straddle injury or pelvic fracture urethral injury (pfui) is associated with long term morbidity and reduce the quality of life. most patients will end with long life urethral dilatation even aft er endoscopic treatment. anastomotic urethroplasty at present is the answer of defi nitive treatment. general principles of urethroplasty are to defi ne healthy urethra above and below the site of surrounding fi brosis and to perform a spatulated end-to-end anastomosis. prior to the year of 2013, most urethral stricture cases including traumatic anterior and posterior urethral stricture was managed mostly with direct vision internal urethrotomy (dviu) in our institution. we present our experience with transperineal anastomotic urethroplasty. to our knowledge this is the fi rst indonesian local centre report of the changing defi nitive treatment of traumatic urethral stricture in a series of patients. we retrospectively reviewed traumatic urethral stricture due to straddle injury and pfui that had been treated with urethral reconstructive surgery by transperineal anastomotic urethroplasty approach. th e data cases from january -december 2013 were analyzed; which were the age of patients, location, length of gap, previous operations, and treatments. th e clinical outcome was evaluated with urofl owmetry aft er 1, 3, 6, 9 and 12 months aft er the surgery. results: a total of 30 patients came with traumatic urethral stricture to hasan sadikin hospital during 2013, which consist of 25 patients with pfui and 5 patients with traumatic anterior urethral stricture due to straddle injury. th e median age was 38.5 and 45.6 for pfui and straddle injury, respectively. twenty four percent of pfui patients had distraction length >2 cm and 76% had distraction length <2 cm. meanwhile, 80% of straddle injuries had stricture length <2 cm and 20% had distraction length >2 cm. in order to achieve tension free of anastomotic urethroplasty, 83% of pfui patients underwent crural separation, 20% patients underwent inferior pubectomy and only one patient for supracrural re-routing. sixteen percent of patient of pfui are redo case urethroplasty. success rate aft er transperineal anastomotic urethroplasty of pfui cases was 87%, 75% for redo case pfui and 100% for straddle injury cases. mean q max rates at 1, 3, 6, 9 and 12 months aft er catheter removal of pfui patients was 19, 20, 21, 19 and 19 ml/s whereas for straddle injury patients was 19, 18, 15, 18 and 18. conclusions: in short term follow up, transperineal anastomotic urethroplasty achieved a signifi cant good result for traumatic urethral stricture treatment at our institution. recurrence after urethroplasty in a tertiary care centre in sub-saharan africa: an analysis of preoperative factors introduction and objective: urethral strictures disease remains very common in sub-saharan africa but despite this, there are no available reconstructive urology trainings / fellowships outside the formal urology residency programmes of the region. we reviewed the outcomes of urethroplasties at a tertiary urology centre in nigeria, sub-saharan africa which typically off ers general urology service. preoperative independent predictors of recurrence post-urethroplasty were determined. th e records of a total of 39 men who had urethroplasty for proven anterior urethral stricture disease between february 2012 and january 2014 were retrospectively analyzed. age, social status, aetiology of strictures, stricture location, length of strictures and type of urethroplasty were assessed. appropriate inferential statistics were performed to determine independent predictors of stricture recurrence. results: mean patient age was 48 years (range 25 to 90) and majority of the patients were of low income status 30 (76.9%). iatrogenic strictures due to urethral instrumentations and catheterization 24 (61.5%) and post infl ammatory strictures 12 (30.8%) were more common. isolated penile and long segment peno-bulbar strictures accounted for over two-thirds of all patients 27 (69.2%). mean stricture length was 5.2cm (range 2 to 16cm). most patients had quartey's urethroplasty 17 (43.6%), others had buccal mucosal graft 10 (25.6%), orandi 6 (15.4%) and anastomotic bulbar urethroplasty 6 (15.4%). for a mean follow up of 10.8±12 months, the overall recurrence rate was 53.8% with mean time to recurrence of 10.3 months. of the evaluated preoperative factors (age, p=0.482; social status, p=0.446; aetiology, p=0.296; stricture location, p=0.218; type of urethroplasty, p=0.057; stric-ture length, p=0.019), only stricture length (p=0.019) was a signifi cant predictor of recurrence. roc analysis was done and stricture length >5cm signifi cantly predicted recurrence (auc of 0.857, p=0.032). conclusion: stricture length >5cm are a signifi cant cause of recurrence following urethroplasty in the setting of prevalent general urology practice in sub-saharan africa. th e introduction of formal reconstructive urology fellowship or training may help improve skills and outcomes. introduction and objective: males with hypospadias are likely at increased risk for future urologic complications as adults. however, it is unclear how childhood surgery modifi es this risk. th e purpose of this study is to describe the spectrum of adult presentations with hypospadias-related complications and examine the eff ect of childhood surgery on these complications. a retrospective chart review over a 10 year period, from august 2004 -december 2014, demonstrated 93 adult patients who presented to an adult reconstructive urologist with urologic complications related to hypospadias. patients were divided into two groups: those with no prior hypospadias surgery (group 1, n=19) and those who underwent surgical correction as a child (group 2, n=74). charts were reviewed for age at presentation, initial complaints, history of repair, and surgical intervention required. results: overall, the mean age at presentation was 34.6 years old. meatal location was not statistically diff erent between groups 1 and 2, respectively: glans (26.3% vs. 44.6%), subcoronal (1.6% vs. 29 .7%), coronal (10.5% vs. 1.4%), distal penile (15.8% vs. 9.5%), midshaft (10.5% vs. 5.4%), and penoscrotal (5.2% vs. 4.1%). overall, luts (49.5%) was the most common presenting complaint, followed by spraying (23.7%), urethrocutaneous fi stula (18.3%), recurrent uti's (15.1%), and chordee (14%). comparison demonstrated group 2 patients were more likely to present with luts (55.4% vs. 26.3%, p=0.04) and recurrent uti's (18.9% vs. 0%, p=0.05). contrastingly, group 1 patients presented more commonly with cosmetic dissatisfaction (15.8% vs. 4.1%, p=0.04). urethral stricture disease was demonstrated in more patients who had previous hypospadias repair, than those who had not (47.3% vs. 10.5% p=0.004). of these, strictures were signifi cantly longer in the previous surgery group (5.5 cm vs. 3.0 cm, p=0.02). surgical intervention was required in 31.6% of group 1 and 56.8% of group 2 (p=0.07). conclusion: correction of hypospadias as a child likely increases the future risk of urethral stricture, recurrent uti's, and subsequent luts, but improves patient satisfaction with cosmesis. follow-up of hypospadias repair patients should extend into adulthood, as a signifi cant portion of adult presentations ultimately require surgical intervention. introduction and objective: during male to female gender confi rming surgery with vaginoplasty, a space is created for the neovagina within the potential space between the prostate anteriorly, and denonvillier's fascia and rectum posteriorly. entry to this plane is challenging, and to date, the only surgical approaches to this space describe blunt and sharp dissection along the ventral surface of the urethra. th e likely trauma to perirectal vasculature muscle-laden connective associated with this approach may account for the observed recto-vaginal fi stula rate associated with vaginoplasty. we describe an alternative, never before published approach using a male urethral sound upon the apex of the prostate to enter this plane with sharp dissection in a reliable and effi cient fashion. we describe our surgical technique, wherein we use a male urethral sound during the dissection to help expose denonvillier's fascia over the apex of the prostate. we dissected a block of tissue containing prostate, denonvillier's fascia and rectum from human cadavers, to describe (using ihc) the location and relative abundance of blood vessels (factor viii ab.), nerves (nf & s-100 ab.), and connective tissue (h&e and masson's trichrome), to support the sharp surgical approach we describe over the traditional approach to this plane. we describe clinical outcomes and the recto-neovaginal fi stula rate utilizing this approach in our institutions. results: immunohistochemistry results showed that the sharp dissection we describe is associated with incision through signifi cantly fewer blood vessels and sensory-motor nerves as compared to the traditional surgical approach. use of the sharp dissection we describe resulted in, at our institutions, a signifi cant decrease in recto-neovaginal fi stula in the peri-operative period. conclusion: th e surgical technique we describe for dissection of the plane between prostate and denonvillier's fascia during vaginoplasty is well supported by the anatomic studies we performed, and, is associated with lower morbidity. th is surgical approach and technique is also likely useful for gaining access to this same plane for repair of recto-vesical and recto-urethral fi stulas. introduction and objective: mitrofi noff procedure is commonly employed as bladder draining tool in patients who are unable to do clean intermittent self-catheterization through native urethera. it preserves renal function in small capacity and high pressure bladders and to improve quality of life. here we want to share our single centre experience of patients undergoing mitroffi noff procedure. a retrospective study of 38 patients who underwent mitrofi noff procedure from january 2009 till december 2014 with a median age of 23 (range =5 to 76). twenty eight patients were males while 10 female. indications for catheterizable stoma formation included neurogenic bladder in 22 patients, small bladder in 12, bladder tumor in 2, uretheral stricture in one and interstitial cystitis in one patient. median follow-up was 1 month to 5 years. stoma was made from appendix in 32 cases, from tapered ileum in 4 cases and from ureter in 2 cases. stoma location was lower right quadrant in 30 cases, left lower quadrant in 4 cases and at umbilicus in 4 cases. augmentation accompanied by mitrofanoff was done in 22 patients while mitrofanoff alone was done in 16 patients. augmentation was done by using ileum in 20 patients and cecum in one and illeocecum in one patient. data was entered from chart review and analyzed on spss. sixteen patients were analyzed in terms of complications and stoma revision. results: post-operative complications included uti in 10 (26.3%) patients, stones formed in 2 (5.26%), fistula was seen in 1 (2.63%) patient (augmentation cystoplasty + mitrofanoff ), stoma stenosis seen in 3 (7.89%), stoma revision done in 2 (5.26%). one female (2.6%) patient had dribbling urine through urethera (incontinence), she underwent bladder neck closure. metabolic complications were not seen based on serum electrolytes follow-up records. we concluded that aft er mitrofanoff procedure renal function was preserved in most of the patients while no metabolic complications were seen in patients aft er undergoing mitrofanoff +bladder augmentation. stone risk was 5.26% which was not very high. quality of patients was improved aft er mitrofanoff procedure. results: sesfm has higher porosity and larger pore size compared with bam (p< 0.05). at 2 weeks, the presence of vesical calculus was evident in 7/10 rabbits. histological analysis showed that sesfm and bam promoted similar degree of urothelium regeneration (p>0.05), and sesfm promoted a higher degree of smooth muscle and vessel regeneration compared to bam at each time point (p< 0.05 ). in addition, muscle strips supported by sesfm displayed higher contractile responses to carbachol, kcl, and phenylephrine compared with bam. at 8 weeks, both matrices elicited similar mild acute and chronic infl ammatory reactions. conclusion: our results demonstrated that sesfm has greater ability to promote bladder tissue regeneration with structural and functional properties compared to bam, and with similar biocompatibility. introduction and objective: ureteral access sheaths (uas) can aid ureteroscopy by facilitating multiple passes of the ureteroscope, maximizing irrigation drainage, and reducing intra-renal pressures. however insertion of the access sheath may induce ureteral ischemia, cause iatrogenic ureteric injury, and could ultimately lead to ureteric stricture. in this study, we aim to evaluate the stricture rate following ureteroscopy both with and without the use of uas. we performed a retrospective chart review of consecutive ureteroscopies performed at our center (a tertiary referral center for endourology) between april 2012 and april 2014 to treat ureteric and renal calculi. th e primary outcome was the development of new hydronephrosis three months following successful ureteroscopy, not due to an obstructing stone. patients without follow-up renal ultrasound (us) or ct scan 3 months post-ureteroscopy were excluded. data on age, sex, size of the stone, location of the stone, stone density, stone-free rate (sfr), time of the procedure, pre-op stenting, postop stenting, use of the uas, size of the uas, length of the uas, stone analysis, and imaging details were recorded. baseline and outcome variables were compared with anova and chi-square analysis where appropriate using spss statistical soft ware. results: a total of 203 patients were eligible. a uas was used in 121 (59.6%) patients; 103 (85.1%) for renal stones and 18 for proximal ureteric stones. th ere was no signifi cant diff erence in baseline or demographic data. none of the patients developed new hydronephrosis or developed a ureteric stricture, and none required endoureterotomy. conclusions: uas use during ureteroscopy for renal and ureteric stones is both safe and eff ective. even with routine use of 11.5f and 14f uas, ureteric stricture rates are very low (zero in this series), suggesting that signifi cant ureteric injury is rare with proper technique and case selection. to evaluate the value of fl exible ureteroscopy for the treatment of the upper urinary tract calculi in children. a total of 32 children, 17 males and 15 females, were identifi ed in this study. th e median age was 6.9 years, range 8 months to 16 years. among them, 18 patients had the upper ureteral calculi (15 with calculi in situ, 3 with middle/fi stal ureteral calculi shift ing to upper ureteral aft er rigid ureteroscopic lithotripsy) and 14 had renal calculi. ipsilateral mild to moderate hydronephrosis was found in all of the cases. four children had melamine-induced stones (3 with upper ureteral calculi and 1 with renal calculi). th e calculi were found on left side in 17 cases, on right side in 11, and on both sides in 4 (upper ureteral calculi). th e median stone size was 1.0 (range 0.6 to 1.5) cm. retrograde fl exible ureteroscopy and anterograde fl exible ureteroscopy in mini-percutaneous nephrolithotomy was performed. results: twenty eight cases were performed retrograde fl exible ureteroscopic procedure. one case was conversed to mini-percutaneous nephrolithotomy because the fl exible ureteroscope could not be inserted into the upper ureter. th e fl exible ureteral access sheath was failed to insert into the upper ureter in 3 cases, and the fl exible ureteroscope was inserted into ureter directly. th e successful rate of stone search was 100% in 31 cases. th irty cases were successfully performed in one stage. th e stones were successfully fragmented aft er two stages in two cases. th e success rate of stone fragmentation was 90.6% with the holmium laser lithotripsy in one stage. th ree anterograde fl exible ureteroscopy with mini-percutaneous nephrolithotomy were successfully performed, and the stones were successfully found and fragmented aft er a single holmium laser lithotripsy. th e median operative time was 35 (range 20 to 70) mins. th ere was no major perioperative complication. th e patients were discharged from hospital aft er a median of 4.5 days (range 3 to 7). double-j stent was removed aft er 2 to 4 weeks when no residual stones more than 2.0 mm in size were found. no recurred stones, no urethra stricture, no ureter stricture, no urinary incontinence and no vesicoureteral refl ux were found during the 2 to 72-months follow-up. conclusion: flexible ureteroscopy is a safe and feasible method for the treatment of the upper urinary tract calculi in children. it is suitable for the stones in the pelvis and calyceal where the rigid ureteroscopy could not reach. introduction and objective: laparoscopic ureterolithotomy is an alternative to open ureterolithotomy for the primary treatment of large, impacted, proximal or mid ureteral stone. transperitoneal and retroperitoneal approaches are the 2 basic techniques and each has its own advantages and disadvantages. th e aim of this study is to compare retroperitoneal versus transperitoneal laparoscopic ureterolithotomy in eff ectivity, pain scale and early complications. in this prospective comparison study from january 2013 to december 2014, 36 patients with proximal and mid ureteral stones underwent retroperitoneal laparoscopic ureterolithotomy or transperitoneal laparoscopic ureterolithotomy. th e randomization occurred on consecutive sampling on a 1:1 basis. groups 1 and 2 consisted of patients who underwent retroperitoneal laparoscopic ureterolithotomy and transperitoneal laparoscopic ureterolithotomy, respectively. demographic and clinical variable, operative time, length of stay, ureteral suturing, pain scale according to visual analog scale (vas) and early complications data were collected and analyzed. statistical analysis was performed with spss® version 17.0 using student t-test and mann-whitney u tests with p value<0.05 considered statistically signifi cant. results: vas on day 1 between the 2 groups was statistically signifi cant, and was higher in group 2 (p<0.05). according to the clavien-dindo classification of surgical complication all the patients were in grade 1 classifi cation. th e diff erences in operative time, length of stay, ureteral suturing, visual pain analog score on day 3, and early complications between the 2 groups were not statistically signifi cant. ionising radiation is commonly used in urological practice in the form of fl ouroscopy. to date there is a relative dearth of information regarding patient exposure during the urological procedures and the subsequent risk of development of a lethal malignancy due to the radiation exposure. objectives: to determine the radiation exposure for a patient for the most commonly performed urological procedures and determine the lifetime additional risk of fatal cancer per procedure. data was collected prospectively in two institutions on endoscopic urological operations. procedures were classifi ed as retro-graphic, semi-rigid ureteroscopic (urs) and fl exible ureterorenscopic (furs). data collected included procure type and diffi culty, dose are product [dap (gy*cm2)]). th e eff ective dose (ed) as measured in millisievert was determined from the dap by using the monte carlo calculation. results: a total of 395 consecutive operations from two institutions were assessed. th e mean ed for all procedures in this study was 0.3948 msev, irq (0.1184 -0.7583). th e maximum ed was 5.938 msev. th e radiation exposure for all procedures was relatively small, for diagnostic retrographic procedures the median ed was 0.1121 msev. for retrograde procedures that involved a stent insertion the median ed was 0.4389 msev. th e median ed for all ureteroscopic surgeries was 0.2957msev, and the median ed for all furs procedures is 0.4914. th e fi ndings of this study are reassuring. endoscopic urological procedures appear to expose patients to relatively small radiation compared to other procedures requiring fl uoroscopy and a very low lifetime additional risk of fatal cancer per procedure. five during the follow no local recurrence was noted and two patients presented with distant metastasis. th e actual 5-year overall and cancer specifi c survival was 91.8% and 98.2%, respectively. on multivariable cox regression analysis, acci was the only factor associated with increased risk of overall mortality (hr 1.51; 95% ci (1.10 -2.07)). conclusion: rpn achieves excellent long-term oncological outcomes. age and comorbidities are associated with increased risk of overall mortality. to our knowledge, this is the fi rst series of long-term follow up aft er rpn reported to date. introduction and objective: partial nephrectomy provides equivalent oncologic and superior functional outcome compared with radical nephrectomy over the short and long term. with the development of laparoscopic techniques and increasing laparoscopic surgical experiences, laparoscopic partial nephrectomy (lpn) has become an acceptable alternative to radical nephrectomy for expert laparoscopic urologists to treat small renal mass. it was reported that using barbed suture can reduce warm ischemia time during lpn. we designed a single blind randomized controlled trial to fi nd whether the barbed suture can materials and methods: from july 2014 to march 2015, forty-six patients with renal score less than 10 were enrolled for this study. patients were randomized into two groups: control and v-loc group. all patients were evaluated before surgery including performance status, asa score, liver and renal function, abdominal ct, lung function, and cardiac function etc. during the surgeries, standard 4 ports were placed. aft er the renal artery was clamped by bulldog, tumor resection was performed using a cold scissor. th en the inner layer deep vessels and collecting system, and outer layer were sutured with v-loctm 180 respectively in v-loc group. in control group, inner layer was sutured with 2-0 absorbable sutures, and the outer layer renal parenchyma was sutured with 0 absorbable sutures. operative characteristics and complications were compared between groups. results: laparoscopic partial nephrectomy was successfully completed in all forty-six patients without open conversion. control and v-loc groups were equivalent in demographic and tumor characteristics. no signifi cant diff erence was seen between control and v-loc groups in operative time (137 vs. 132 min, p = 0.47), estimated blood loss (121 vs. 123, p = 0.33), warm ischemia time (23 vs. 21 min, p = 0.25), and complication rate (18% vs. 19.1%, p = 0.87). conclusion: lpn with v-loc sutures for renorrhaphy is safe and feasible. however, using v-loc suture for renorrhaphy doesn't show any superiority in patients with low and moderate complexity renal tumors in our randomized control trial. small th e local recurrence free survival was signifi cantly better in the combined us/ct-guided group than in the us-guided group (p= 0.016). recurrences were found in 2% with us/ct-group and in 20% in usgroup. th e overall complication rate was similar (us/ ct 13% versus us 17%) in both groups. th e mean percentage decrease in the estimated glomerular fi ltration rate (egfr) aft er the treatment was 1.1±18.3% with us/ct, compared to 5.0±11.7% mean decrease in egfr aft er treatment in the us-guided group (p= 0.27). conclusion: th e use of combined us/ct-guidance when performing renal rfa resulted in superior primary and short term outcome compared to the use of us-guidance alone in patients treated at the same institution. increased experience with rfa treatment probably also contributed to the results. introduction and objective: to present our initial experience in 10 female patients undergoing transvaginal notes-assisted laparoscopic partial nephrectomy (pn). between august 2013 and january 2015, a prospective analysis of the initial ten patients who underwent transvaginal notes-assisted pn was entered into an institutional review board (irb)-approved database. th e procedure was performed using two umbilical trocars and one trocar through the vaginal wall. th e main renal artery clamping, segmental renal artery clamping and unclamped pn were performed depending on the circumstances of the tumour. some perioperative parameters including operative time, warm ischemic time, blood loss, and perioperative complications were recorded. sexual function was assessed with the female sexual function index (fsfi) questionnaire before and aft er surgery. th e cosmetic results were investigated by administering patient scar assessment questionnaire and scoring system (psaq). results: nine transvaginal notes-assisted pns were completed successfully. one patient with a right anterior upper-pole tumor was converted to radical nephrectomy because of persistent bleeding from the parenchymal defect. th e median (range) operating time was 120 (110-190) mins and the median (range) estimated blood loss was 140 (50-400) ml. th e median (range) warm ischaemia time (wit) was 25 (20-40) mins. th e median (range) postoperative hospital stay was 5 (4-10) days. all surgical margins were negative. eight patients completed the fsfi questionnaire, and analysis did not show diff erences in fsfi scores before and aft er surgery. th e better cosmesis results were confi rmed by the psaq score. transvaginal notes-assisted pn is a safe and feasible surgical procedure in the treatment of small renal mass with excellent cosmesis results. more prospective studies with long follow-up are needed to investigate the oncologic safety. introduction and objective: to analyze the complications of urologic transvaginal natural orifi ce transluminal endoscopic surgery (tv-notes), and to explore eff ective measures for its prevention and management. materials and methods: from may 2010 to february 2015, a total of 245 cases underwent tv-notes in our institute. intraoperative and postoperative complications were graded according to satava and clavien-dindo grade classifi cations system. th e major complications and their treatments were most importantly analyzed. results: among the 245 tv-notes procedures, 5 case conversion to open surgery and one case conversion to suprapubic-assisted laparoendoscopic single-site surgery (sa-less). th irty-one (12.65%) patients had intraoperative complications, the minor and major was 13 (5.3%) and 18 (7.35%), respectively. th e intraoperative complications include 5 cases of pneumoderm, 4 cases of skin ecchymosis, 2 cases of pleural damage, 3 cases of liver injury, 1 case of adrenal central vein injury, 4 cases of spleen injury, 3 cases of inferior vena cava injury, 3 cases of renal veins injury, 1 case of right iliac vein injury, 1 case of bladder injury, 1 case of renal collecting system injury, 2 cases of colon injury, 1 case of rectum injury. th e proportion of patients incurring minor and major postoperative complications undergoing tv-notes was 8.16% (n = 20) and 1.2% (n = 3), respectively. th e postoperative complications include 1 case of adrenal crisis, 5 cases of incision infection, 10 cases of postoperative fever, 5 cases of postoperative bleeding, 1 case of the right external iliac artery thrombosis and 1 case of urinary leakage. no intraoperative and postoperative deaths occurred. conclusion: tv-notes operation is safe and feasible surgical technique in urology, and does not increase the incidence of complications. but there is a potential risk of major complications occurring, which should be paid more attention to prevent. introduction and objective: knotless barbed suture, a relatively innovative type of suture, can eliminate knot tying, speed the placement of the sutures, and create the possibility of improved scar cosmoses. th e minimally invasive radical prostatectomy (mirp), as one of the earliest surgeries that adopted this advanced technique, was reported about diverse eff ects on the patients and the surgeons. our objective is to present the available evidence about the effi cacy and safety of barbed sutures in minimally invasive radical prostatectomy. we searched pubmed, em-base, and cochrane library for published studies and clinicaltrials.gov for additional information to identify randomized controlled trials (rcts) and cohort studies addressing the application of barbed and conventional sutures in mirp (until feb. 2015) . quality assessment was performed according to cochrane recommendations. th e data were analyzed using review manager (version 5.3), and sensitivity analysis was performed by sequentially omitting each study. hemi-pelvises, 80.0% had the periprostatic plexus (ppp) as the largest vein of the dvc. th is was followed by the obturator vein (ov) (12.2%), which originates from the lateral part of the plexus and runs laterally. next was the internal pudendal vein (ipv) (7.8%), which originates lateral to the posterior part and runs postero-laterally. in the rp group, the dvc bunching stump was an average of 11.8 mm from the origin of the cavernous vein. no complications occurred while performing examinations. conclusion: 3d-ct pelvic venography depicted the dvc and its related veins in all 110 cases. venous systems making up the dvc diff ered among patients. in 80.0 %, the main venous system was the ppp, which can be controlled by conventional dvc ligation technique. however, in the remaining 20% of hemi-pelvises, the ipv and the ov were the main venous systems. th ese will need wider ligation because of existing outside and to the back of pathways. we believe that a better understanding of dvc will lead to refi ned rp. introduction and objective: bladder pheochromocytoma and carcinoid tumors are rare neuroendocrine tumors of the bladder. presenting a series of 3 cases of these rare bladder tumors which were managed laparoscopically. materials and methods: case 1 was a 51 years lady who presented with symptom of giddiness following micturition. ultrasound revealed a 1.3 cm bladder mass at the bladder base. twenty four hour urinary biochemical evaluation and mibg scan did not reveal any abnormalities. cystoscopy revealed a submucosal sessile mass above the trigone. on cystoscopic bladder distension a spike in blood pressure (180/100) was noticed which fell rapidly on emptying. patient underwent laparoscopic partial cystectomy aft er 2 weeks of alpha blockade with phenoxybenzamine. case 2 was a 33 years old gentleman who presented with episodes of severe headache following micturition. despite 5 antihypertensives his blood pressures were not under control. ultrasound revealed a 5 cm bladder mass in the left lateral wall encroaching close to the left ureteric orifi ce. twenty four hour urinary biochemistry and mibg scan was suggestive of bladder pheochromocytoma. aft er 2 weeks of alpha blockade he underwent cystoscopy followed by laparoscopic partial cystectomy with left ureteric reimplantation. case 3 was a 45 years old gentleman a hypertensive who underwent an attempted turbt and subsequent hypertensive crisis and bleeding for a bladder mass in a peripheral hospital. he was stabilized and referred to our center for further management. ultrasound revealed a 4 cm anterior wall mass. twenty four hour urinary biochemistry and mibg scan was suggestive of bladder pheochromocytoma. aft er 2 weeks of alpha blockade he underwent laparoscopic partial cystectomy. mri has shown to be accurate in diagnosing index tumours in prostate cancer. a variety of focal therapies has been explored in treating these lesions. th is study aims to compare the detection rate, grade and location of non-index lesions found in radical prostatectomy specimens with their initial mpmri. a prospective database of all men undergoing mpmri for suspicion of prostate cancer in our group practice was kept. ethics approval was obtained from epworth healthcare. of these men, all who had a 3-d summary diagram including pirads score for each mpmri and who then underwent radical prostatectomy were assessed. volumetric studies were performed for all prostatectomy specimens and compared to each corresponding mpmri 3-d summary diagram. analysis of non-index lesions was performed. conclusion: a signifi cant amount of patients who underwent radical prostatectomy in treatment for prostate cancer were identifi ed to have non-index tumours in their volumetric analysis. in our cohort of patients, the majority of low grade disease was undiagnosed on mpmri. however, a signifi cant amount of moderate grade non-index tumours were also missed on initial mpmri. th is questions the safety and appropriateness of focal therapy. ongoing research is warranted and we will continue to report our prospective mp-mri database as our experience with this modality grows. eligibility for active surveillance of prostate cancer and functional outcomes after prostatectomy shepherd a 1, 2 , o'callaghan m 2, 3, 4 introduction and objective: we aimed to compare the outcomes following radical prostatectomy (rp) of active surveillance (as) and non-as candidates. we hypothesised that as eligibility at diagnosis would be associated with favourable pathological, surgical and also functional outcomes. using a prospectively maintained database, all patients with a primary treatment of rp conducted prior to 2013 were identifi ed, including those who were initially eligible for as. men defi ned as eligible for as were those: diagnosed between 50 and 75 years of age; with gleason score ≤6; psa ≤10; clinical stage ≤2a; and with percentage of positive cores ≤50%. we compared the histopathological and functional outcomes of the two groups. results: of 2663 patients with a primary treatment of rp, 400 met the criteria for as. pre-operative tumour characteristics of the patients meeting criteria for as were favourable compared with those ineligible (lower psas and less cancer in the biopsies; p<0.001). functionally, the groups had similar pre-operative continence (95% vs. 98%) and potency rates (84% vs. 80%). histologic characteristics of the prostate specimen in patients qualifying for as were more favourable, with lower rates of positive surgical margins and extracapsular extension observed in this group (p<0.05). following rp, at 6-, 12-and 24-month follow-up, there were no signifi cant diff erences in the proportion of men who were continent between as and non-as candidate groups (6 months: 96% vs. 93%; 12 months: 96% vs. 96%; 24 months: 83% vs. 94%; p>0.05). similarly, no signifi cant diff erences between groups were observed in the proportion of men who were potent at 6-and 24-month follow-up (6 months: 52% vs. 43%; 24 months: 75% vs. 52%; p>0.05). aft er 12-month follow-up, however, potency appeared to be higher for the as candidates (71% vs. 52%; p=0.034). were assessed pre-implant as well as at 1, 3, and 6 months aft er seed implantation, and every 6 months thereaft er. we evaluated clinical factors, including prostate volume (pv), neoadjuvant combined androgen blockade (cad), radiation dose to 90% of the prostate volume (d90), and to 30% of the urethral volume (ud30) to predict urinary disorders aft er brachytherapy using multivariate analysis. results: th e mean pre-implant ipss was 8.1, with the greatest mean score of 16.7 at 1 month aft er seed implantation. at 3, 6, 12, 24, 36 and 60 months, the mean ipss had decreased to 16.6, 13.3, 9.8, 9.5, 8.5 and, 8.5 respectively. th e mean pre-implant prostate volume (pv) was 27.1 g, followed by 20.8 g at 12 months and 19.5 g at 24 months aft er brachytherapy. in cases with pv more than 30 g, d90 more than 160 gy, and ud30 more than 240 gy, ipss levels were signifi cantly high-er even 2 years aft er treatment. on multivariate analysis, d90 more than 160 gy (p<0.0001) and ud30 more than 240 gy (p=0.0226) were independent predictors for ipss increases of more than 5 points at 2 years aft er brachytherapy. only d90 was an independent predictor at 3 (p<0.0001) and 5 years (p=0.0002) aft er brachytherapy. introduction and objective: metformin has been shown to be protective in prostate cancer (pc). we aimed to assess the eff ects of metformin on pc outcomes in men treated with external beam radiotherapy (ebrt) and/or androgen deprivation th erapy (adt). we also aimed to investigate the eff ects of metformin on the above outcome measures in type 2 diabetic men with pc. th e outcome measures of time to biochemical failure (bf), metastasis, pc specifi c mortality and overall mortality were analysed in men on metformin using a competing risk model and a cox proportional regression model. a total of 2055 eligible cases, of whom 116 were on metformin, were identifi ed with a median follow-up of 95.7 months. th ere were no diff erences in age, initial psa, gleason scores, t stage, d' amico risk or duration of adt between men who were on metformin and those not on metformin. treatment with metformin did not result in any apparent improvement in time to bf, time to metastases or overall survival but there was an increase of 1.5 fold in pc-specifi c deaths (p<0.05) in men on metformin and adt when adjusted for cancer risk and co-morbidities. on a subgroup analysis of the 247 men with type 2 diabetes, similar fi ndings were seen with metformin being associated with a 2.7 fold increase in pc-specifi c deaths (p <0.05). th ese adverse eff ects were lost in men on metformin and statins. conclusions: th e use of metformin did not improve time to metastases, time to bf or overall survival in men undergoing ebrt +/-adt for pc with curative intent. however, in type 2 diabetic men on high doses of metformin there was an increased risk of pc-specifi c mortality. further studies are needed to investigate these fi ndings. th e objective of this study is to assess ire eff ects in prostate tissue and to correlate ire treatment planning with the 3d-histopathology of radical prostatectomy (rp) specimens that essential structures will be spared. sixteen patients, scheduled for rp, ire procedures were performed 4 weeks before rp. ablation was performed according to two protocols: focal or extended ablation. th e electrode probes were inserted transperineally under ultrasound guidance. th e locations of the electrodes were used as input for the plannings soft ware. following rp, the specimens were processed into whole-mount sections, were histopathologically (pa) assessed and ablation zones were delineated. th e volumes of tissue alteration were determined by adding the delineated areas. th e planned and pa ablation volumes were compared using the pearson correlation coeffi cient. results: th e 3d volumes of the ablation zones follow the planned lesions volumes with a pearson correlation index r=0.72 with a slope of 1.34 ( figure 1 ). th e focally planned ablations results in a volumetric smaller histopathological ablation zone than predicted whereas the extended ablations result in volumetric larger ablation. pa showed sharply demarcated fi brotic and necrotic areas with mild infl ammation. th e urethra was aff ected by the ire treatment in nine mp-09.08, figure 1 . correlation of ablation volumes t2-weighted mri and ceus with h&e pathology (pa) mp-09.09, figure 1 . scatterplot of planned ablation zone volumes compared with volumes in histopathology patients were observed throughout the neurovascular bundle in thirteen prostates and extended beyond the prostatic capsule in twelve cases. conclusion: 1) ire in prostates results in sharply demarcated lesions with fi brotic and necrotic features, but may damage essential structures as urethra, capsule and nerves. 2) th e actual ablation zones on 3d-histopathology follow reasonably the planned ablation zones. 3) focal ablation protocols lead to a smaller ablation zone than extended ablation protocols. therapeutic all patients treated at our institution with primary pca t3-4, n0, m0 were included provided they did not present with a long history of adt. patients were stratifi ed into 3 groups according to their psa nadir occurring between 6-30 weeks following hifu. group a (n=96: nadir <0.2 ng/ml), group b (n=59: nadir >0.21-2ng/ml ng/ml), group c (n=29: nadir >2 ng/ml). th e primary endpoint of our analysis was the onset of any salvage therapy other than hifu. repeat hifu can be performed without undue additional morbidity and is standardly not considered as salvage therapy but rather an adjuvant to the index hifu. multivariate analysis was performed to determine what predicts onset of salvage therapy. results: at inclusion: 91.5% of patients were t3 and 8.5% were t4. outcomes are summarized in table 1 . conclusion: group a (nadir <0.2) showed 77% salvage treatment free survival without adt; preoperative high gleason, high initial psa and "no turp" were negative predictive factors for outcome; 25% of the patients had 2nd hifu treatments in follow-up; in case of salvage therapy most patients opted for adt. metastasis-free survival of 93% at 5 and 87% at 10 years excludes turp in pca as potential metastasis-inducing factor. combined "turp and hifu" showed its oncological effi cacy, postponing / avoiding classical salvage therapies (rad/adt) and their potential side eff ects. laparoscopic radical prostatectomy (lrp): changing trends in practice introduction and objective: we audited our lrp outcomes in order to evaluate outcomes and how our practice has evolved over the years. we evaluate pathological and margin status outcomes and determine whether there has been a shift towards treatment of higher risk disease and the impact of this practice on margin status. a total of 339 patients underwent lrp performed by one surgeon at our institution from june 2004 to september 2014. we divided the cohort into early period from 2004-2008 (group 1, n=114) and 2009-2014 (group 2, n=225). results: mean age was 64 yrs. mean preoperative psa (9.1) and gleason score (gs, 6) did not diff er between groups. however, preoperative stage ≥t2c increased from 8 (7%) to 42 (19%) for groups 1 and 2 respectively. postoperatively, diagnosis of gs ≥7 increased from 18 (16%) in group 1 to 118 (52%) in group 2. similarly, 38% of group 2 was staged as pt3 compared to 24% of group 1. th ere were more extracapsular extension in group 2 (31%) compared to group 1 (25%). overall positive surgical margin (psm) rate was 16% (group 1, 10% vs. group 2, 19%). when stratifi ed according to pathological stage, psm was identifi ed in more men with pt3 (9%) compared to pt2 (7%). th e commonest site of psm was at the apex. seminal vesicle invasion rate was similar (3%). results: mean operation time and length of hospital stay for rarp and lrp were 145.5±43.6 min and 118.1±39.1 min, and 6.4±0.9 days and 6.6±1.1 days, respectively (p = 0.003 and p = 0.721). aft er 17 cases, the mean operation time for rarp was similar to lrp (less than 2 h). positive surgical margins in localized cancer were seen in 11.1% and 8.9% of cases in rarp an lrp, respectively (p = 0.578). at postoperative 3 months, sexual intercourse was reported in 14% and 12%, and pad-free continence in 96% and 81% in patients with rarp and lrp, respectively (p = 0.796 and p = 0.012). conclusion: previous large-volume experience of lrps may shorten the learning curve for rarp in terms of oncological outcome. additionally, previous experience with laparoscopy may improve the functional outcomes of rarp. introduction and objective: signifi cant prostate cancer is increasingly diagnosed in younger men. th is patient group has high expectations regarding oncological and functional outcomes at robotic radical prostatectomy (rarp). we reviewed a prospective database (1500 rarps) at a single tertiary referral centre and obtained erectile dysfunction rates/treatment and continence pre-and post-operatively, positive margins, metastases and death. median follow-up was 4 years. male sprague-dawley rat aged 9 weeks were used. a total of 20 rats were divided into two groups. one group was used as a control and other group received intramuscular injections of testosterone propionate (3 mg/kg) plus 17β-estradiol (0.03 mg/kg) for 12 weeks to induce bph. th e prostate and genitourinary organ weights, histopathologic change and serum hormones were evaluated. we compared the eff ects of ldd175 (10 mg/kg) with tamsulosin (10 μg/kg) in intraurethral pressure responses induced by es of the hypogastric nerves. we performed western blotting for alpha 1a and 1d receptor of adrenergic nerve. results: bph-induced rats showed signifi cantly increased absolute prostate weight and prostatic index (prostate weight/body weight x 100), increased testosterone, free testosterone and estradiol levels in the serum. histomorphology also showed that epithelial cell layers in the prostates of bph-induced rats were larger than control groups. ldd175 and tamsulosin signifi cantly inhibited the intraurethral pressure elevation induced by es of the hypogastric nerves. alpha 1d and alpha 1a adrenergic receptors in bph rat model were expressed more than control. ldd decreased expression of alpha 1d adrenergic receptor than control. conclusions: th is study suggested that ldd175 could be an alternative medicine to treat bph inducing lower urinary tract symptoms. does according to recent studies, atherosclerosis has a key role in the pathogenesis of bph. th erefore, we evaluate the correlation between prostate volume and intima-media thickness (imt) of carotid artery in diabetic bph. from january 2010 to august 2014, 111 patients with dm were analyzed, retrospectively. baseline characteristics and diabetic profi le were collected. mean intima-media thicknesses (imt) were collected using carotid doppler ultrasound. and prostate volume (pv) was measured by transrectal ultrasound. two groups were analyzed using lineal regression analysis. results: th e patients were classifi ed into group 1 (n=67, 60.3%) and into group 2 (n=44, 39.7%) based on the presence of bph. th ere were statistically signifi cant diff erences on bmi, waist circumference and hba1c between the two groups (table 1) . th ere is a signifi cant correlations between imt and pv and imt and transition zone (tz) (p=0.027, p=0.008, figure 1 ). porting symptoms listed on the otc label as reasons for not using the product; traces of glucose, leukocyte, and/or blood in their urine; or an aua-si score ≥20. conclusion: pvp has demonstrated acceptable complication rates compared to traditional turp in treating bph in a cohort of men having a greater frequency of comorbidities and in those having to remain on oral anticoagulation. th is makes pvp an attractive alternative to turp in such men particularly if symptomatic relief and re-treatment rate in the longer term is demonstrated to be equivalent. prospective study of high-risk patients undergoing photovaporisation of prostate (pvp) without cessation of oral anticoagulants ow d 1 , papa n 1 , sengupta s 1,2 , lawrentschuk n 1,2,3 , bolton d 1 introduction and objective: greenlight laser photovaporisation of the prostate (pvp) is suggested to be safe to perform on high risk patients requiring surgical intervention in the management of benign prostatic hyperplasia (bph), where cessation of oral anticoagulation is not possible due to medical comorbidities. we prospectively evaluated the outcomes of patients who underwent pvp with ongoing oral anticoagulant therapy. materials and methods: between january 2011 and december 2013, 62 patients with ongoing oral anticoagulant therapy were treated with pvp. types of oral anticoagulants were recorded and perioperative outcomes were collected. th ese metrics included transfusion rate, duration of hospital stay and laser treatment variables. ninety-day readmissions also were recorded as were complications of treatment. results: sixty-two patients were treated by greenlight laser pvp while taking oral anticoagulants. out of this total, 27 patients (43.5%) were on warfarin while 26 (41.9%) had ongoing clopidogrel. th e remaining 9 were either taking one or a combination of other (non-asprin) oral anticoagulants. nine out of 62 (14.5%) patients required readmission post pvp, and all of these readmissions were for management of complications related to haematuria. five of this group of 9 patients (18.5% of total cohort) had undergone pvp without cessation of warfarin, while 4 of 9 patients (15.4% of total cohort) had undergone treatment without cessation of clopidogrel. th ree patients (4.8%) required blood transfusion. conclusions: despite continuation of oral anticoagulants in these high risk patients, the readmission rate is low and transfusion rate is similar to what has previously been reported for conventional turp in patients without anticoagulation. greenlight laser pvp is a viable option for surgical management of bph in patients for whom cessation of oral anticoagulant therapy is contraindicated. introduction and objective: cystinuria is a rare, chronic condition characterised by recurrent urolithiasis. th e condition is due to a variety of genetic mutations in an amino acid transporter and accounts for between 0.5-2 percent of urinary tract stones. cystine urolithiasis may be treated by preventative medical therapy or therapeutic urological intervention. it is the authors' experience that patients tend to shy away from long-term medical treatment, possibly due to a perceived lack of effi cacy or poorly tolerated side-eff ects. as with all chronic conditions, quality of life for cystinuric patients is expected to be diminished. sub-optimal medical therapy and the need for repeated urological intervention is expected to have a further impact on quality of life. th e authors seek to describe the natural history and quality of life in patients with cystine urolithiasis. th is in turn allows further improvements to the standard-of-care off ered to such patients. a cohort study was carried out involving participants recruited from a single surgeon's case mix. participants suff ering from cystinuria and related urolithiasis were invited to complete a questionnaire involving demographic information, use of medical treatment, surgical interventions and the sf-36 quality of life survey. attitudes towards the use of current and potential future medical treatments were also explored. results: fourteen participants completed the survey. th e sf-36 survey showed lower quality of life than the general public in 7 of 8 domains. th e mean interventional rate in patients with cystinuria was 10.6 procedures per patient. most patients reported previ-ous use of d-penicillamine and urinary alkalinisation medications, with most ceasing due to side-eff ects or lack of perceived effi cacy. conclusion: cystinuria is associated with a high rate of surgical intervention and lower quality of life than the general public. individuals with this condition report that medical management is either ineff ective or poorly tolerated. th ere is a need for further improvements in medical management of cystinuria, to reduce the rate of operative intervention. recommendations to guide clinical practice, based on patients' experience of cystinuria management can be made. dipstick results: a total 600 patients were retrospectively reviewed for the ph results. th e mean diff erence in ph between spot urine value and the 24-hr collection values was 0.52± 0.45 ph. higher ph was associated with lower accuracy (p < 0.001). th e accuracy of spot urine samples to predict 24-hour ph values of <5.5 was 68.9%, 68.2% for 5.5 to 6.5 and 35% for >6.5. samples taken more than 75 days apart had only 49% the accuracy of more recent samples (p < 0.002). th e overall accuracy is lower than 80% (p < 0.001). infl uence of diurnal variation was not signifi cant (p = 0.588). conclusions: spot urine ph by dipstick is not an accurate method for evaluation of the patients with urolithiasis. patients with alkaline urine are more prone to error with reliance on spot urine ph. relationship is the fi rst lithotripter on the market with a unique design that allows for a dual focus system with the option of either a narrow or wide focal zone. ex vivo data on the slk-f2 lithotripter shows that the disintegration capacity and the renal vascular injury are independent of the focal diameter of the sw generator at the same peak positive pressure and disintegration power. th e objective of this study is to compare the single-treatment success rates of narrow and wide focal zones for the shock wave lithotripsy of renal stones. a total of 182 patients with previously untreated radio-opaque solitary stone located within the renal collecting system, measuring at least 5mm, were randomized to receive narrow or wide focus lithotripsy while maintaining a constant overall energy level. patients were followed with kub x-rays and renal ultrasound at 2 and 12 weeks post lithotripsy to assess stone area and stone free status. urinary markers indicating the degree of renal cellular damage (microalbulin and beta 2 microglobulin) were measured pre and post swl, 24 hours post swl and 7 days post-treatment. primary outcome was success rate, defi ned as stone-free or adequate fragmentation (sand and asymptomatic fragments <=4mm) at 3 months post-treatment. mp-11.03, figure 1 . introduction and objective: despite being uncommon, infantile kidney stone remains a major health problem due to its higher recurrence rate and morbidity. th e parents usually notice that their infants have recurrent fever and failure to thrive of unknown origin. th ose patients comprise a big challenge for the urologist in management. th erefore, this study aimed to evaluate the outcome of shockwave lithotripsy (swl) in management of renal stones in infants. a retrospective analysis of prospectively collected data performed between january 2009 and december 2012 for infants underwent swl for single radio-opaque renal stones ≤15 mm at a single stone center. swl was performed with dorneir s lithotripter with a maximum of 1500 shocks per session. a single session was indicated for each infant, but a second session was performed when satisfactory disintegration was not achieved. follow-up based on urinalysis, urine culture and sensitivity, plain x-ray kidney ureter bladder (kub) and abdominal ultrasonography (us) was carried out 2 weeks post swl and monthly for 3 successive months. multislice computed tomography (msct) was performed 3-months post-swl to confi rm the stone-free status. results: a total of 87 infants, less than 24 months of age were enrolled in this research. swl success was defi ned as absence of any residual fragments on msct 3 months aft er the last session. stone free rate was 93.1% aft er the fi rst swl session and reached 100% aft er the second session. rate of retreatment with second session of swl was 6.9%. urinary tract infection (uti) was detected in 10.3%, transient renal obstruction with low grade fever in 4.6% of infants and no major complication had been recorded. conclusion: th e new generation of swl technology with a precise focal area seems to be safe and eff ective in management of kidney calculi in infants. stone introduction and objective: th e incidence of abdominal discomfort is frequent during pregnancy, but renal colic is infrequent. one of the main causes of renal colic during pregnancy is urolithiasis. managements of urolithiasis during pregnancy are hydration, antibiotics, ureteral stent insertion, percutaneous nephrostomy, and ureteroscopic stone removal. in this study, we assessed the reliability and stability of ureteral stent insertion to pregnant patients with renal colic. results: th e overall mean patient age (54 years), male to female ratio (1.8:1) and mean asa score (2.0) did not vary signifi cantly between years. admissions for elective renal stone procedures, adjusted for population, increased 45% over the study period. th is growth was entirely in the last 5 years, corresponding with a 20-fold increase in the use of pyeloscopy (from 38 to 759 cases per year). from the fi rst to last year, there was a 6% reduction in eswl (from 832 to 781 cases per year) and a 28% increase in pcnl (from 170 to 218 cases per year). nephrolithotomy ranged from 11 to 20 cases per year. th ere has been an increase in the proportion of associated ureteric stent insertions from 5% to 38%. th e proportion of day-only admissions has decreased from 80% to 62%. th e average government assigned cost per admission has increased 115%. conclusion: victorian public hospitals have seen a rapid expansion in the use of pyeloscopy and laser for treatment of renal stones. th is corresponds with a signifi cant increase in admissions for elective renal stone treatment, relatively fewer day-case admissions, higher treatment costs and more associated stent isertions. introduction and objective: th is retrospective study assessed the semirigid ureteroscopy approach coupled with ballistic or ho:yag laser lithotripsy for the treatment of proximal ureteral stones. patients with a single lower calyceal stone with an evidence of a ct diameter between 1 and 2 cm were enrolled in this multicentric study. exclusion criteria were the presence of coagulation impairments, age less than 18 or more than 75, presence of acute infection, presence of cardiovascular or pulmonary comorbidities. patients were randomized into three groups: group a: patients treated with swl; group b: patients treated with rirs; group c: patients treated with pcnl. patients were controlled with abdomen x-ray and ct scan aft er 3 months. a negative x-ray or an asymptomatic patient with stone fragments less than 3 mm big and a negative urinary colture were the criteria to assess the stone-free status. a statistical analysis was carried out to assess patients' data, success and complications rates, re-treatment rate and need for auxiliary treatment. radiotherapy is an eff ective and common treatment for the prostate cancer. however, there is still an historic deep rooted fear of its use due to the existence of late genitourinary toxicities such as the radiation cystitis. nowadays these toxicities may pose less of a threat due to the use of newer radiotherapy techniques and the reduction of radiation doses applied to the tissues adjacent to the tumor. th e objective of our study is to fi nd predictive factors and determine the cumulative incidence of overall and severe radiation cystitis. conclusion: radiation cystitis is a feared complication of the use of radiation therapy in prostate cancer which occurs infrequently, and the severe cases requiring hospitalization are very rare. th e characteristics of the tumor, purpose of radiotherapy used or radiation dose applied do not seem to infl uence the incidence of radiation cystitis. introduction and objective: th e aim of the study was to assess prognostic factors of biochemical and radiological disease progression (dp) in subgroup of lymph node (ln) positive prostate cancer (pc) pts. evaluation of detection rate of 68ga-psma pet/ct for biochemical recurrence after radical prostatectomy introduction and objective: prostate specifi c membrane antigen (psma) is overexpressed in more than 90% of all prostate cancers (pca). since the introduction of pet-imaging with 68gallium-labelled psma, this method is regarded as a signifi cant step forward in the diagnosis for recurrent pca. from the 216 patients that were scanned for detection of recurrent pca aft er radical prostatectomy between august and december 2014, 185 were evaluable for retrospective analysis. patients underwent pet/ct aft er injection with the 68ga-hbed-psma. th e potential infl uence of psa-level, primary gleason score (gsc) and psa-doubling time (psa-dt) on the detection rate were evaluated. results: a total of 129 (70%) patients had pathological fi ndings on the 68ga-psma pet/ct, with an average psa-level of 6.44 ng/ml (range 0.06-126 ng/ ml). detection rates were 27%, 66%, 79% and 91% for psa-levels <0.5, 0.5-1, >1-2.5 and >2.5 respectively. if recurrent pca was detected, oligometastatic disease (5 metastasis or less) was most commonly seen (68%). th e detection effi cacy was signifi cantly infl uenced (p<0.05) by higher gsc (59% and 80%, for gsc ≤7 and ≥8 respectively). for the 99 patients that were evaluated for the infl uence of psa-dt on detection rate, no signifi cant diff erence was found (p=0.122) for psa-dt <4 months and ≥4 months (detection rate 85% and 75% respectively). conclusion: 68ga-psma pet/ct has a high detection rate compared to prior studies of conventional imaging modalities, especially in lower range psa-levels. further research is needed to determine to assess whether localization of small volume disease on 68ga-psma pet/ct can improve diagnostic algorithms and outcomes in patients with recurrent pca. introduction and objective: to assess long-term results of salvage pelvic lymph node dissection (plnd) in prostate cancer (pc) patients (pts) with biochemical recurrence aft er primary local treatment and confi rmed solitary lymph node (ln) metastases. results: a total of 9,356 abstracts were screened, 298 full-text papers were considered, and 26 articles were included (1 rct, 8 comparative studies, and 17 case series). th is abstract focuses on the comparative studies. primary therapy was prostatectomy in 3, radiation therapy in 4, and 2 studies included both therapies. diff erent defi nitions of recurrence were applied among mostly retrospective studies and the adt strategy oft en not specifi ed. factors associated with unfavorable outcomes (overall, pc-specifi c, or metastasis-free survival) included higher age, higher psa nadir, higher gleason score, higher psa-dt, and early start of adt at recurrence. contradictory results were reported on the role of the length of adt aft er ebrt, partly explained by a selection of high risk cases. most patients with disease relapse aft er primary therapy seem not to benefi t from adt while side eff ects are known to be harmful. selected highrisk patients (short psa doubling time, high gleason score) however may have benefi t, and early start of adt may be preferable in this group. an intermittent adt strategy in this setting may be feasible. a rct is indicated, although diffi cult to perform. a personalized approach is warranted, taking disease characteristics, side eff ects, and quality of life into account. adt may only be given in patients with pc recurrence who have high risk characteristics. introduction and objective: locally radio-recurrent prostate cancer (rr-pca) can off er a chance of cure albeit with potential morbidities. current salvage treatment options include radical surgery and minimally-invasive ablative modalities such as hifu and cryosurgery (s-cryo). current data suggests that s-cryo can achieve disease-free survival (dfs) rates up to 60% at 5 years. however, the majority of data is based on retrospective analysis with mid-term follow-up and there is still paucity of data on longterm outcomes. th e aim of this study was to analyze morbidity and oncological outcomes, with median follow-up 10 years, of s-cryo on rr-pca patients at an academic center. figure 2 ). adverse events were similar between the treatment arms. figure 1 . th ese analyses demonstrates that, during the fi rst year of treatment, men treated with degarelix had a reduced risk of disease-related adverse events. th ere was also a lower risk of death, likely due to the higher incidence of cv events in lhrh agonist patients. introduction and objective: androgen-deprivation therapy (adt) appears to increase cardiovascular (cv) morbidity and mortality in men with prostate cancer, particularly in those with a history of cv disease (cvd). however, the risk is lower with the gonadotropin-releasing hormone (gnrh) antagonist, degarelix, compared with lhrh agonists. here we evaluate regional diff erences in baseline cv status in men with prostate cancer treated with degarelix or lhrh agonists and their subsequent risk of cv events. th is was a pooled analysis of data from three phase 3 studies with a duration >6 months. individual patient level data on baseline cv status and subsequent cv events over 1 year were summarized by geographic region (usa/canada vs. europe). cv event data were compared using cumulative incidence functions (with all-cause mortality as the competing risk) and cox regression analyses. canada had more severe disease and a higher cv risk (p<0.05) ( table 1 ). in men with baseline cvd, cumulative incidence (95% ci) of a cv event was 9.4 (6.0-14.6) in usa/canada vs. 3.6 (2.0-6.2) in europe (p=0.007). at baseline, cv status was similar in the degarelix and lhrh agonist groups (table 1) . however, in those with baseline cvd, degarelix was associated with a lower risk of subsequent cv events vs. lhrh agonists in both regions (hazard ratio [95% ci]: 0.42 [0.20-0.87]; p=0.02). conclusions: men in the usa/canada with prostate cancer and cvd and who were treated with adt were more likely to experience a cv event than their counterparts in europe. th is likely refl ects the greater severity of baseline cvd and higher cv risk in these patients. degarelix reduced the risk of cv events compared with lhrh agonists in both regions. introduction and objective: androgendeprivation therapy (adt) decreases bone mineral density and may increase skeletal complications in metastatic prostate cancer. however, lhrh agonists and gnrh antagonists have diff erential eff ects on follicle-stimulating hormone (fsh), which regulates bone resorption. th e current analysis compared the eff ect of lhrh agonists and the gnrh antagonist, degarelix, on serum alkaline phosphatase (salp), a marker of bone turnover, and the incidence of skeletal adverse events (aes). conclusions: degarelix suppressed s-alp more quickly and for longer than lhrh agonists. it also reduced bone pain and was associated with a lower incidence of fractures. collectively, these data indicate that degarelix provides better control of skeletal disease in men with metastatic prostate cancer, an eff ect that may be mediated by its diff erential eff ect on fsh. prognostic introduction and objective: testosterone (t) regulates nitric oxide synthase and is necessary to achieve an optimum response to pde5 inhibitors for erectile dysfunction. recently, tadalafi l was found to be eff ective for treating lower urinary tract symptoms (luts) secondary to benign prostatic hyperplasia (bph). we studied the relative importance of the t level in patients with luts and determined whether the t level predicts the response to tadalafi l 5 mg once daily for luts/bph. aft er a 4-week washout period, 122 men older than 45 years without (n=62, t level ≥300 ng/dl) and with (n=60, t level <300 ng/dl) hypogonadism were given tadalafi l 5 mg once daily for 12 weeks. we assessed its impact and the severity of luts/bph using the international prostate symptom score (ipss) and bph impact index (bii) and ipss quality-of-life (ipss-qol) subscores. safety was assessed using treatment-emergent adverse events. introduction and objective: diabetes has been reported as a major cause in patients who complain of erectile dysfunction and is frequent in the comorbidity of severe erectile dysfunction. also, patients with diabetes are oft en poor response to treatment for erectile dysfunction. in such patients, according to the mirodenafi l (mvix ) use of the odf (oral decomposition fi lm) 50mg and 100mg was to compare the therapeutic eff ects of the treatment period. of the patients with erectile dysfunction were enrolled in a patient with diabetes. and the patients were classifi ed into two groups by randomized double blind controlled trial. th e fi rst group was to take the mirodenafi l odf 50mg once a daily and the second group was to take a 100mg at least twice one week, depending on the need to have sexual intercourse. international index of erectile function-5(iief-5), international prostate symptom score(ipss) were examined for each time of initial visit, 4 weeks, 8 weeks, 12 weeks. th e questionnaire items of two groups were analyzed at each time point. total of 39 patients were included in the study. th e patients who were taking once a daily were 18 and the patients taking when needed were 16. th ere was no signifi cant diff erence between age, iief-5 score, and ipss of each groups on initial visit. ipss score and quality of life score was lowered gradually all aspects in the two groups. iief-5 score was a tendency to increase in all categories. in comparing the two groups at 4 weeks, once a day group showed a signifi cantly higher score than the group taking when needed for the questionnaire of erection confi dence, erection times, iief-5 total score(p<0.05). th ere was no diff erence between two groups at 8 weeks, 12 weeks. in addition, this study showed the similar therapeutic eff ect between the two groups at end point of continued treatment during the 12 weeks. conclusion: aft er daily dose method 8 weeks, at least twice weekly dosing method and daily dose method is determined to exhibit the same eff ect. th erefore, we think that it is possible to change the intermittent dosing from daily regimen aft er two months. introduction introduction and objective: phosphodiesterase 5 inhibitors (pde5i) are the established fi rst line therapy for most cases of erectile dysfunction(ed). it is estimated that 20-30% of ed patients may drop out and discontinue the usage of these drugs. th is study aims to evaluate the patient perspective of discontinuation of on-demand tadalafi l 20 mgm and switching to daily tadalafi l 5mgm for ed. th e study comprises 72 men with median age 56 years suff ering from ed of average 1.6 years duration. co-morbidities included: hypertension (46%), diabetes (38%), dyslipidemia (32%) and smoking (28%). th e primary indication for usage of on-demand tadalafi l 20 mgm was ed. all the patients had used 20mgm tadalafi l on demand on more than 8 occasions over the last 3 months. results: th irty-eight out of 72 men opted to discontinue on-demand 20mgm tadalafi l and switch to daily dose 5mgm tadalafi l. a detailed interview was conducted to identify the reasons for this switch over. th e salient factors were: 1) unsatisfactory clinical response to on-demand dose (42%), 2) adverse eff ects with on-demand dose (22%), 3) concomitant improvement in luts (44%), 4) economic factors-daily dose therapy is cheaper than on-demand (14%), 5) freedom of spontaneous sexual activity with daily dose (36%), 6) patient perception of daily dose as a long-term cure for ed (26%), 7) combination of above factors (78%). overall 76% of patients planned to continue daily dose tadalafi l 5 mgm. conclusion: daily dose tadalafi l 5mgm appears to be preferred by patients over on-demand 20 mgm tadalafi l for ed treatment. and plateaued aft er two years. in 56% of men, iief-ef improved by 1 category, in 22% by 2 and in 6% by 3 categories. five men remained within the same category despite slight improvements in score, 1 man's score dropped from 26 to 25 changing from "no ed" to "mild ed". fift y six percent men achieved normal erectile function. conclusions: improvements in erectile function were clinically meaningful and signifi cant during the fi rst 2 to 3 years of t therapy and sustained during the full treatment duration. th ey were independent of obesity class. it may be necessary to continue t therapy for 2 to 3 years before an optimal response is achieved. hypogonadal conclusion: all changes were clinically meaningful and sustained for the full observation period, despite the fact that patients' age increased by 7 years. t therapy seems to be highly eff ective in hypogonadal men with t2dm, improving both erectile function and glycemic control. needle-free delivery of intracavernosal injections: proof of concept introduction and objective: intracavernosal injection is a well-established second line therapy for the treatment of erectile dysfunction (ed) and has shown very high success rates. despite this, intracavernosal injection is not a therapy suited to all patients for a number of reasons including needle phobia (trypanophobia), pain, and anxiety with self-needling. th e development of needle-free injectable devices has been heralded as a promising advance in the administration of certain vaccines and parenteral medications. initial research into the use of these devices in the delivery of intracavernosal injections however showed inferiority to needle-tipped injectors in terms of efficacy and pain scores. th e use of needle-free injection devices is not currently recognised for the administration of intracavernosal injections. it was the aim of our study to investigate the ability of contemporary needle-free injection devices to successfully deliver intracavernosal injections. two diff erent needle-free injection devices were used to inject 0.5mls of methylene-blue solution into the corporal bodies of a number of australian brangus bullock penises; the bioject®ze-tajet™(spring-loaded fi ring system) and biojector®2000 (pressurized co2 fi ring system) were used. both products are produced by bioject medical technologies inc., california, usa. all the available syringe depths were used for each device, and compared with the injection of the same volume of methylene-blue with an insulin syringe as a control. following injection, a cross-section of the penis was taken, and the depth of penetration observed macroscopically. results: despite the comparatively thicker and denser tunica albuginia of the bullock penis, the pressurized co2 device successfully delivered the solution into the corporal body, through the tunica. none of the syringes from the spring-loaded device penetrated the tunica. we have shown that contemporary needle-free injectable devices can in theory be used to administer intracavernosal injections successfully. th e bullock penis model may not be the ideal model for the human penis but we are currently in the process of performing human cadaveric experiments with these devices. needle-free injection devices may be very useful in the administration of intracavernosal injections in the future and extend the use of these therapies to a wider population of patients. penile linear shock wave therapy for poor responders to prior erectile dysfunction therapy (19), ici with alprostadil (4), vcd (2) and muse (1) . all these patients opted to discontinue these regimen due to unsatisfactory erectile improvement or side eff ects. th ese patients were treated with lswt by renova device with four weekly outpatient sessions without any analgesia or preparation. lswt was applied to four anatomical sites (right, left crura, and right, left corpus cavernosum) at 300 shocks per minute, total 5000 shocks per session. patients were followed up at 1 and 3 months aft er the last session. results: at one month follow up statistically significant improvement in iief was recorded in 19 patients (73%) from mean score of 13.6 at baseline to 19.2.th e improvement was maintained at 3 months .no side eff ect was noted. overall 92% patients expressed satisfaction with lswt irrespective of the clinical outcome. conclusion: lswt appears to be a safe and eff ective noninvasive, offi ce based therapy in the management of diffi cult to treat poor responders to prior treatment of ed. introduction and objective: hypogonadism and sexual dysfunction are common clinical presentation in male liver transplant candidate. th e aim of the study was to evaluate the eff ects of living donor liver transplantation (ldlt) on testosterone, sex hormone-binding globulin (shbg), free androgen index (fai) and erectile function in ldlt recipient. introduction and objective: penile size has been a source of major concern and anxiety to the male population since several years. diff erent methods for increasing penile size have been described in the literature, such as, pubopelvic liposuction, lipectomy, suspensory ligament dissection, z-plasty, v-yplasty and injections. combining some of these techniques may be more eff ective to improve the length of the penis. in this study, patients were underwent the combination of z-plasty and suprapubic lipectomy for increasing penile size. between 2004 and 2014, 29 patients who complained decreased penile size were underwent surgery. z plasty and suprapubic lipectomy were performed to each patient. informed consent was provided by all participants. th e outcomes were assessed based on the preoperative and postoperative penile length in the fl accid state at maximal stretch and patient-partner satisfaction. th e paired student t test was used for statistical analysis. results: median age of the patients was 32.1 (20-72) years. th e etiologies were congenital micropenis in 3 (10%), concealed penis in 16 (55%), previous penile surgery in 9 (30%) and epispadias in 1 (5%) patient. mean preoperative and postoperative penile lengths were 8.1cm (6-11cm) and 10.9cm (7.3-14cm) respectively. th e mean increase in stretched penile length was 2.8±0.6cm (minimum 1.3cm, maximum 4cm) (p<0.05). th e patient and partner satisfaction rates were 82.7% (24/29) and 48.2% (14/29) respectively. only one postoperative complication was detected. th is was a wound infection at suprapubic incision site. conclusions: based on our results, the combining of the penoscrotal z-plasty and suprapubic lipectomy is a safety, eff ective and satisfactory procedure for lengthening of the penis in selected cases. corporal lengthening with infl atable penile implants 79: 1310-5 (2012) ). recently, we have developed a new technique that combines key aspects of these 2 approaches to create a minimally invasive, no-touch ("mint") technique for penile prosthesis insertion. we theorized that the mint technique would take advantage of the benefi ts that each of these established approaches off ered and therefore our aims were to assess feasibility, safety, post-operative hematoma and infection rate and percentage of patients cycling the prosthesis by 4 weeks. th e principles of the mint technique involve a small infrapubic incision approach combined with a no-touch technique facilitated by using 2 standard surgical drapes (1 x clear non-adhesive drape and 1x ioban® drape) and an alexis® wound retractor. we present results for our fi rst 50 consecutive patients undergoing primary prosthesis implantation from may 2012 -july 2013 with at least 3 months follow-up. patients having revision surgery, or with complex surgery necessitating >1 incision were excluded. data was collected using a prospective database. results: average age (±sd) was 59.8 (±11.3) years. median follow-up was 11.7 months. patients had one or more of the following etiologies for erectile dysfunction: vascular disease (n=22), post-radical prostatectomy (n=16), diabetes (n=8), peyronies disease (n=8), venous leak (n=4) and priapism fi brosis (n=1). seventy percent had used intracavernosal injections. implant used: coloplast titan (n=47), american medical systems (lgx; n =2), (cx; n =1). th e average (±sd) cylinder and rear tip extender length was 18.7 (±1.6) and 0.9 (±0.8) cms respectively. all operations were completed successfully and there were no peri-operative complications necessitating intervention or re-operation. th ere were 2 post-operative hematomas (treated conservatively). sixty-fi ve percent could cycle prosthesis by 4 weeks. th ere were no post-operative infections. conclusion: th e mint technique for penile implant surgery is a safe and feasible procedure with a zero infection rate in our fi rst 50 patients. effi cacy and safety of botulinum th e initial number of patients to be recruited were twenty-six, but actual patient enrolment was eleven (six control and fi ve botulinum toxin a). all of the patients had a history of vulvar pain for more than six months despite proper medical treatments. patients were randomly assigned to two groups: control -saline injection, toxin -botulinum toxin a (meditoxin® injection, meditox, inc., korea). in both groups, areas of pain were mapped on the vestibule and injections were performed at fi ve sites to cover the entire painful area. th e dosage of each injection was 1-2ml with a maximum cumulative total of 10ml. at baseline, two, four, and eight weeks aft er the injection, visual analogue scale (vas) and sf-32 questionnaires were scored. data was analyzed and p value was considered to be signifi cant at <0.05 according to the mann-whitney test. results: th e mean age of patients was 43.2 (37-52) years old in the control group and 44.8 (26-56) years old in the toxin group. aft er breaking of the blinding, two of the toxin group had 50iu of botulinum injection, and the others had 100iu injections. two patients from the control group dropped out because of aggravated pain. th eir vas were 7 and 6 respectively at their drop-out point (baseline 3 and 4, respectively). at week eight, vas was signifi cantly decreased in toxin group when compared with baseline (table 1) . th ere were no drug related adverse reactions. introduction and objective: congenital anomalies of uro-genital system have increased globally as a consequence of higher maternal age at pregnancy and developments in assisted reproductive techniques in the last few decades. aim of the study was to determine the incidence of apparent congenital uro-genital anomalies in north indian newborns and factors associated with them. a prospective study was conducted to collect data of all newborns delivered at our institute between september 2012 and august 2014. th e predetermined format included newborn's birth weight and gestational age, maternal age, parity and infertility treatment if any. newborns weighing less than 1000gm or born before 32 weeks of gestation were excluded from the study. results: th ere were 20,432 deliveries with 10,952 males and 9480 females. a total of 799 apparent uro-genital congenital anomalies were recorded with an incidence of 39.1 per 1000 newborns. th e most common anomaly was cryptorchidism found in 678 newborns, amongst others hypospadias was noted in 61, ambiguous genitalia in 34, congenital hernia/hydrocele in 20, exstrophy-epispadias complex in 5 and prune belly syndrome in 1newborn. newborns weighing less than 2,500 grams had a higher proportion of anomalies (9.64%) in comparison to those weighing over 2,500 grams having 1.99% (p = 0.0001). maternal age (>30yrs), parity (>2) and infertility treatment were recorded in 5.40%, 4.93 % and 9.80% respectively and all were independently associated with increased risk of uro-genital anomalies (p=0.0001). conclusions: incidence of apparent congenital uro-genital anomalies was 3.91%. infertility treatment, parity (>2) and maternal age (>30years) were independently associated with increased risk of congenital uro-genital anomalies. comparison conclusions: double-breasting spongioplasty is very good method to decrease complications in hypospadias repair, so it is recommended an as interposing tissue in tipu. advantages of the double breasting spongioplasty are that avoiding of suture line and adding two layers of spongiosum over neourethra decreases the chances of urethral fi stula and gives cylindrical shape to neo-urethra. use stretched penile length (spl) is the standard measurement used in reconstructive penile surgery (rps), but is associated with high inter-rater variability, and is seldom reported. furthermore, ruler-based measurements require that all measurements be made intraoperatively; post-hoc measurements are diffi cult to impossible. we used a novel smartphone application to assess the correlation of post-op digital-photo based length measurements to intra-operative ruler measurements. 35th congress of the société internationale d'urologie -siu 2015 abstract book materials and methods: intra-operative spl was measured in a consecutive series of pediatric patients undergoing rps who agreed to participate in this study. spl was measured intra-operatively (spl-io), and a picture was taken, with the ruler and from a true lateral view, as proof. a second digital picture was taken at the same time, with a reference object (obj) (object whose dimensions are known and constant). post-op, spl was later measured using the medmeasure! app for iphone and ios android, using the picture with obj, by two diff erent surgeons blinded to intra-op measurements. th e three diff erent measurements (intra-op spl (spl-io), and post-op using the app (spl-s1 -spl-s2) were then compared to assess overall correlation and correlation to ruler measurements using spss 20.0 statistical soft ware package. results: twenty consecutive patients underwent surgery for hypospadias (n=15), buried penis (n=1), epispadias (n=3) and circumcision accident (n=1). median age at surgery was 18 months [6-301]. median penile spl-io was 3.8 cm [2.4 -8.9 ]. when ruler-based measurements (spl-io) and app-photo based measurements were treated as independent measurements (students t test), there was no statistical diff erence between any of the three groups (p 0.51-0.81). even with spl-io measurements were treated as the gold standard, by bland-altman limits of agreement analysis, the correlation factor of spl-ip to spl-s1 & spl-s2 was >99%. conclusions: when compared with intraoperative measurements, digital measurements using medmeasure! are reliable and precise, provided that the picture is taken from a true anterior-posterior or lateral view. because measurements are made based on captured images, a limitless number of length measurements (within the same plane as the reference object) can be made post-hoc. use of digital photography and this smartphone app has the potential to aid in surgical planning, improve documentation, and, facilitate clinical research. aseel's technique for distal penile and coronal hypospadius repair (simple, easy with less complications) introduction and objective: th is technique is modification of the old operation of arab that makes it very simple, easy to learn and even in cases of failure there will be no problem of redoing it or other operation because of the minimal tissue dissection. th is technique was applied in 43 patients. first a transverse ventral incision is done parallel to the circumcision incision and 1cm proximal to the urethral meatus, figure ( 1) . th en proximal and distal skin dissection is done, figure ( 2). a longitudinal incision across the urethra plate extending through the meatus is done, figure ( 2) and closed transversely that leads to urethral advancement, figure ( 3). th en aided by 2 skin hooks the distal skin edge is pulled downwards to create a roof for the advanced urethra, figure (4) followed by closure of the skin incision, no catheter or stent is left , figure ( 5). th is is a 10-minute operation and the patient is discharged as a day case. results: th irty-eight patients passed without complications and 5 had loss of the skin stitches either partial in 3 cases or complete in 2 cases that were repaired by reapplication of the stitches, no meatal stenosis or fi stula were reported. th is is a very easy technique that can be applied as an outpatient or day case, and done in 10 minutes, with no catheter or stent per urethra left or complications such as urethral meatus stenosis or fi stula formation. th e remained boys (261) underwent transinguinal laparoscopy during ipsilateral herniorrhaphy. all data were collected prospectively. results: th e incidence of cppv confi rmed by transinguinal laparoscopy was 27.5% (72/261). th e width of hernia sac and mother's age at birth were signifi cant risk factors in the univariate analysis. however, in the multivariate analysis the width of hernia (>1cm) sac was only an independent risk factor for cppv (odds ratio 2.335; p=0.03). th e laterality, type of hernia, age, preterm, low birth weight, twin, blood type, father's and mother's age at birth, and the type of delivery were insignifi cant. in this study the width of hernia sac was the independent risk factor for cppv. th is result suggests that the transinguinal laparoscopic examination is benefi cial for the detection of cppv in boys with this risk factor. however, it should be considered in the clinical practice that the one-third of boys with cppv has a narrowed width of hernia sac (<1cm). low introduction and objective: traditionally bladder exstrophy complex is managed by staged repair, however now there is trend towards single stage repair. to achieve a satisfactory level of continence, secure abdominal wall closure and preservation of renal functions in patients with bladder exstrophy remains an elusive goal. objective of the study was to assess continence and functional outcome of single stage repair pediatric and adults. materials and methods: th irteen patients, 11 boys and 2 girls with classic bladder exstrophy were treated from 2009 to 2013. aft er proper evaluation patients under went complete primary repair of exstrophy repair (ureteric re-implantation, bladder closure with or without cystoplasty, iliac osteotomy, neck reconstruction and epispadias repair). bladder and urethral plate was mobilized as single unit and bladder closure was done to create an adequate capacity bladder. epispadias repair was done by separating the two corpora; tubularization of urethral plate and ventral transposition of neo-urethra to create an orthotopic neomeatus. th en bilateral anterior iliac osteotomies were performed and external fi xators were applied to approximate the pubic symphysis which helps in sphincteroplasty. bladder neck was reconstructed using young dees technique and placed deep within the pelvis; sphincteroplasty was done followed by abdominal wall closure. voiding cysto-urethrography was obtained at 3 months and at one year. continence was defi ned as dry intervals of 3 hours or more. patients were followed-up at 1, 3, 6, 12 months and annually. results: age of patients varied from 5 days to 21 years (mean 11.2 years). pre-operative symphyseal gap varied between 4 -8 cm and post operatively the average diastasis was 2.5 cm with the range of 2 cm to 4 cm. in a follow-up period was 6 months to 3 years, 10 patients had good results (2 girl and 8 boys) minor supra-pubic leak was present in 4 patients which was managed conservatively, all being able to hold urine for 3-4 hours with no leaking at night. colo-cystoplasty was needed in 4 cases with small bladder plate. overall continence rate was 76.9% in single stage. two male incontinent patients were continent aft er second surgery. conclusions: single stage complete bladder exstrophy repair is safe and viable option for both pediatric and adult cases. augmentation enterocystoplasty is required in small bladder capacity cases. anterior iliac osteotomy with approximation of pubic symphysis improves continence and allows tension free closure of abdominal wall and sphincter. long wilms tumor (wt) represents approximately six to seven percent of all pediatric cancers and accounts for more than 95 percent of all tumors of the kidney in the pediatric age group. recently some centers have explored the role of nephron sparing procedures in children with unilateral wilms tumors because of the concern about late occurrence of renal dysfunction aft er unilateral nephrectomy. we assessed the long-term renal functional outcome aft er parenchymal-sparing procedure for non-syndromic unilateral wilms tumor at our center. we retrospectively reviewed the records of all children with unilateral wilms tumor who had undergone nephron sparing surgery at our center. patient's long-term renal function, tumor recurrence, and survival, were determined from a review of each patient's medical record. results: a total of eight patients underwent partial nephrectomy (pn) and the remaining three with polar tumors underwent hemi-nephrectomy (hn) following chemotherapy. smaller tumor volumes were associated with not only preservation of renal function but also increase in egfr during the follow-up period. th e median preoperative egfr was 106 ±10.78 and median egfr at the last follow-up was 131.0 ±3.52. in properly selected children with non-syndromic unilateral wilms tumor, nephron sparing surgery provides excellent renal function preservation. introduction introduction and objective: hyperbaric oxygen (hbo) therapy, which increases the amount of oxygen dissolved in the blood and that carried to tissues, is used in the treatment of several disorders. hbo therapy may be a useful adjunctive treatment in the management of some of challenging conditions encountered in pediatric urology practice. in this paper, we report our experience on the use of hbo therapy in children with urologic problems. we reviewed our department's records to identify pediatric patients who received hbo therapy between 2011 and 2014. all patients were evaluated at the department of underwater and hyperbaric medicine and informed consent was obtained from the patient or his parents. total number of hbo sessions was determined based on patient's clinical response to hbo therapy. results: eleven patients received hbo therapy during the study period. all of them were male. th e mean age was 8.63 ± 5.53 (1-17 years) . indications of hbo therapy were necrosis aft er hypospadias and epispadias repair, penile glans necrosis, circumcision caused penile skin necrosis, sickle cell crisis induced priapism, and testicular torsion. th e average number of hbo sessions was 6.72 ± 2.53 (4-11). nine patients (81%) healed aft er hbo therapy, but 2 (19%) patients did not (table 1) . . th e essential parameters of kegel exercise are duration of contraction and active relaxation, and, frequency of exercises. to date, exercise duration times could only be captured during in-clinic biofeedback. we hypothesized that a smartphone-based app that provides users biofeedback -and reports mean duration of contraction and relaxation, could help return to continence aft er rp. we designed/made a working prototype of such an app, and validated it. our novel app (ios) was programmed to allow users to record the duration of kegel active pfm contraction and relaxation. it also allows users to record urinary frequency, urgency, voiding, and leakage events, and number of pads used-on a daily basis. it contains a 12-q visual analog scale questionnaire that queries satisfaction (urinary, sexual, erectile), pain control, depression, sleep quality, and quality of life. data from the app can be "pushed" automatically by the user to a queryable custom database on a hipaa-secure server (ucsf). we provided the app to 10 non-medical colleagues (5 women/5 men age 40-70) for evaluation. all completed 10 mock kegel exercises using the app to measure contraction/relaxation duration, which were timed using a stopwatch. measured times were compared to duration times recorded in our database for each user. a 10-point likert scale was used to query the following 3 items: 1) user reported ease of use; 2) privacy related anxiety related to use of such an app to submit study data wirelessly; and 3) perceived usefulness of the app to improve kegel performance. results: th e pfm contraction and relaxation times recorded by the app within the wireless database disagreed with stop-watch measured duration times by mean +/-<1 second for all 10 subjects. mean likert scores: 1. "overall ease of use" score =9.4 (sd 0.5), "privacy related anxiety" score = 9.1 (sd 0.7), and "usefulness"=9.8 (sd 0.3). conclusions: our novel smartphone app appears to allow users to accurately record key kegel exercise parameters: duration and progress. th e platform also allows collection of key patient data during daily life. a randomized controlled clinical study is warranted to further assess clinical utility, and, possible means to further enhance utility and research. safety and effi cacy of reduced dose of botulinum toxin-a for patients with detrusor overactivity place j, vyas l, watcyn-jones t, lupton b, miah s, darrad j, kumar v introduction and objective: th is prospective study was carried out to look at the response of a lower dose of botulinum toxin-a for treatment of symptoms of oab, its tolerability and side-eff ects. materials and methods: following due counselling and consenting, all newly diagnosed patients with confi rmed detrusor overactivity on uds (n=49, with a mean age of 62.2 years (range=35-88)) were given 100 iu of trigone-sparing, intra-detrusor botulinum toxin-a. of the total of 49 patients, 7 (14.2%) were males and 42 (85.8%) were females. of this cohort, 57.1% stopped anticholinergic medications because of lack of benefi t. th e rest (42.9%) could not tolerate the side eff ects. th e procedure was performed in outpatient department using a fl exible cystoscope under local anaesthetic. th ese patients fi lled up a pre-treatment iciq-sf for oab as well as ui and follow-up scores at week 1, 6 and 16. th e per-procedural pain score and follow-up urinary residual volumes were recorded. results: two (4.1%) patients did not respond to the treatment at all. in the responders, average scores from the iciq-sf questionnaire fell from the pre-treatment level of 35.2 (21-40) to 13.92 (0-39) at week 1, 11.6 (0-25) at week 6 and 12.84 (0-22) at week 16 (p<0.001). th e urgency incontinence scores fell from an average pre-treatment level of 17.2 (8-20) to 4.35 (0-18) at week 16 follow-up. th e average daytime urinary frequency scores fell from 2.4 to 0.84 and nocturia scores fell from 3.13 to 2.1. five patients went into urinary retention following intra-detrusor botulinum toxin-a injections. in the rest of the cohort, post void residuals remained largely unchanged with pre-procedure fi gure of 70.5 mls (0-224) to 74.8 mls (0-159) (p=ns). average pain score was 3.75 (0-8) on a scale of 1 to 10. no symptomatic uti was found in post procedural patients. conclusions: th ese results albeit with a small number of cases, have suggested a signifi cant clinical response in over 95% patients with proven detrusor overactivity with a reduced dose of intra-detrusor botulinum toxin-a injections, thereby maintaining the clinical eff ectiveness of the drug and at the same time reducing the cost of delivery with possibly reduced incidence of urinary retention. prior to the initiation of intravesical onabotulinumtoxina treatment, all patients had an assessment of mid-stream urine for culture and sensitivity, renal tract ultrasound scan, subjective and objective assessments of symptoms (including iciq-ui and iciq-oab questionnaires) and conventional urodynamic study. all patients had proven overactive bladder. onabotulinumtoxina effi cacy and durability was assessed by subjective and objective assessments of symptoms. results: duration of effi cacy of onabotulinumtoxi-na injections is well maintained in the idoa group in comparison with noab group. th ese trends are shown in figure 1 . four injections out of 55 administered in total to the idoa group were unsuccessful (7.2%) and brought no relief of symptoms to the patient. th ere were no unsuccessful treatments in the ndoa group (0/30 total injections administered). results: from the general practitioner's records, none of the non-traceable patients were on botulinum toxin-a treatment elsewhere. of the total number of traceable patients (n=28), 10 (36%) stayed on mirabegron alone. of these 90% were satisfi ed (9/10). as a whole 32.1% (9/28) were satisfi ed and continued with mirabegron only. one patient moved to combined mirabegron with an anticholinergic. of the 10 patients on mirabegron iciq-sf scores fell from 13.36 (8-21) to 7.7 (0-20) at 18 months. eighteen of 28 (64%) patients progressed requiring botulinum toxin a treatment. side-eff ects included-palpitations (2), vomiting (1), rashes (1), lethargy (1) and yellow urine (1) . th is study showed that 36% of patient with refractory oab symptoms awaiting fi rst or subsequent treatment with intra-detrusor botulinum toxin a injections will respond to mirabegron and 80% of these responders (32.1% of total) are able to come off botulinum toxin a at 18 months, reducing the burden of the waiting list; with a cost reduction mirabegron= £352 vs cost of botulinum toxin a= £525/year/patient. th is is a small study but provides a medium-term option for patients on long waiting list for botulinum toxin a thereby helping to limit use of botulinum toxin-a for patients with detrusor overactivity. introduction and objective: patients that fail to achieve symptom improvements with sacral neuromodulation (snm) may benefi t from increased aff erent stimulation via tined lead placement at the pudendal nerve. we evaluated 2−year outcomes of chronic pudendal neuromodulation (cpn) in patients that had failed sacral neuromodulation (snm). adults enrolled in our prospective observational neuromodulation study that had a pudendal lead placed were evaluated. medical records were reviewed. outcomes were measured at 3, 6, 12 and 24 months with interstitial cystitis symptom/problem indices (icsi−pi), overactive bladder questionnaire (oabq) symptom severity (ss) and quality of life (qol), voiding diaries, and global response assessments (gra analysis of voiding dysfunction after transobturator tape procedure for stress urinary incontinence introduction and objective: voiding dysfunction is common complication of midurethral sling surgery (mus) for stress urinary incontinence. however, the defi nition of post-mus voiding dysfunction is inconsistent in the literature. subjective feeling of slow stream, signifi cant postvoid residual (pvr), additional procedure for bladder emptying, or objective fl ow rates can be a yardstick of voiding dysfunction. in this study we retrospectively investigated the risk factors for post transobturator tape procedure (tot) voiding dysfunction applying various defi nitions in one cohort. four hundred fi ft een patients were evaluated who underwent tot. preoperative urodynamic study were performed and urofl owmetry and international prostate symptom score questionnaire were investigated pre and post-operatively. several postoperatively parameters representing voiding dysfunction were adopted for analysis. acute urinary retention requiring catheterization (aur), subjective feeling of voiding diffi culty during follow-up (vd), and signifi cant postoperative pvr greater than 100 ml or more than 50% of voided volume (pvr) were adopted for categorization of the defi nition of voiding dysfunction. results: sixteen patients (3.9%) required catheterization, 45 (11.0%) experienced post-operative voiding diffi culty, 65 (17.7%) and 27 (7.4%) showed low fl ow rate and signifi cant pvr. in the aur and vd category, concomitant co-operation and general anesthesia were signifi cant parameters, especially anteroposterior repair of vagina. older and menopaused patients complained subjective voiding diffi culty. th e patients in vd category showed lower fl ow rates and larger pvrs. patients in pvr category had old age and low preoperative fl ow rates. th e patients with vd tend to be prescribed alpha blocker during postoperative follow-up period. th ere were no signifi cant urodynamic parameters attributing for various voiding dysfunction categories. with logistic regression analysis aur, vd and pvr category had concomitant co-operation and preoperative retention history as risk factors. conclusion: several factors including preoperative voiding symptoms and intraoperative parameters such as co-operation may aff ect postoperative voiding dysfunction. th e diversity in clinical presentation underscores the importance of a high clinical suspicion with an appropriate diagnostic evaluation. subjective and objective voiding dysfunction should be evaluated aft er midurethral sling operation. introduction and objective: some have hypothesized that patients with lower functional bladder capacity (fbc) experience less improvement in symptoms after staged neuromodulation procedures. th erefore, we evaluated the impact of baseline fbc on generator implant rate and symptom changes. adults enrolled in our prospective observational neuromodulation study were evaluated. functional bladder capacity (fbc) was defi ned as average volume per void on 3 day voiding diary. data were collected from medical records, and validated interstitial cystitis symptom/problem indices (icsi−pi) and overactive bladder questionnaire (oabq) symptom severity and health related quality of life (hrqol) domains, and examined with descriptive statistics, wilcoxon rank sum tests, logistic regression, and spearman correlation coeffi cients. results: of 242 patients (mean age 59.1 ± 16.8 years; 84% female), most had urinary urgency/frequency with or without urge incontinence (62%) and a sacral lead placed (81%); 19% had the lead placed at the pudendal nerve. mean fbc at baseline was 156.5 ± 96.6 ml. among the 242, 223 (92%) had ≥50% improvement in overall symptoms aft er lead placement with subsequent generator implant. baseline fbc was similar between implanted/not implanted patients (p=0.25), however implanted patients had a median 20.7% increase in fbc aft er lead placement compared to explanted patients whose fbc decreased by median 2.7% (p=0.005). logistic regression identifi ed a strong relationship between percent change in fbc aft er lead placement and generator implant (p=0.0058) but there was no relationship between baseline fbc (ml) and subsequent generator implant. at 3 months, a lower pre-implant fbc weakly predicted a greater improvement in oab-q hrqol from baseline (p=0.035; r = -0.23). fbc (ml) at baseline, or percent change in fbc aft er lead placement, had no relationship with achieving at least 50% improvement in icsi−pi or oab−q symptom severity scores at 3 months. conclusions: lower baseline fbc should not be a contraindication to neuromodulation since there was no impact on outcomes. improved fbc aft er lead placement may have contributed to overall improvements in symptoms leading to generator implant. improvement in fbc was equal to or greater than that seen in medical treatment trials for oab. introduction and objective: to present our preliminary experience with the sars (sacral anterior root stimulator) in spinal cord-injury patients with hyperactive bladder at our center. th e sars is an implantable electronic device that allows patients with spinal cord injury to assume voluntary control of micturition, defecation and erectile function. it involves a s2-s4 dorsal (sensitive) rhizotomy and placement of electrodes around those roots, which are connected to a subcutaneous receiver antenna. by transcutaneous radiofrequency stimulation of that antenna the patient can selectively use 3 stimulation programs to activate the diff erent functions: program 1 for micturition, program 2 for defecation and program 3 for erection. results: between january 2013 and november 2014 nine sars implants (eight men and one woman) were performed in patients with spinal cord injury-related overactive bladder refractory to standard conservative treatment. average age was 42 years and mean follow-up was 22 months (range 3-25). bladder function: eight of the nine patients exhibit an increase of the bladder capacity and use the device 4-5 times daily, voiding 250 -300 cc with ≤50cc residual urine. one of these 8 patients showed de-novo postoperative stress incontinence due to sphincter incompetence that was solved with placement of a suburethral sling. th e ninth case had a poor compliance and low capacity bladder; despite sars, he failed to increase capacity and persisted incontinent so aft er 15 months he underwent a continent urinary reservoir. voiding objectives were therefore achieved in 8/9 patients (89% success). defecation: all patients use the device once a day. erectile function: of the eight male patients, seven achieved erection with sars. however, this erection was not always reliable for intercourse; 4 patients associate sildenafi l and eventually 2 requested a penile prosthesis implantation. complications: th ere were no postoperative complications or failure of the internal components. one patient showed a transient s3 neurapraxia, which resolved spontaneously aft er 12 months. conclusion: in selected spinal cord injury patients, sars is an excellent option for urinary and defecatory control, being also useful for erectile function in some of them. how to determine the complication rate of urolastic (vinyl dimethyl polydimethylsiloxane, pdms), a bulking agent for female stress urinary incontinence. twenty-eight females with stress urinary incontinence were treated with pdms. th e group mainly consisted of secondary patients (n=25), with extensive comorbidity. six patients had one previous surgical procedure for sui; nine underwent two procedures and ten received three or more interventions. an amount of 3.2-4.4 ml of pdms was injected at 3-4 positions paraurethrally at the midurethra. procedures were performed on the outpatient department, with local anaesthesia. th e clavien dindo score was determined aft er 6 months, to assess the severity of the complications encountered. results: aft er six months, 29% (8/28) of the patients reported a 100% improvement, 14% (4/28) a 90-95% improvement and 14% (4/28) a 75-80% improvement, 11% (3/28) reported 50% improvement and 7% (2/28) was 20% improved. six patients (21%) had no improvement aft er six months, four of which had also not shown initial improvement. in one patient the implants were removed during surgery, so no follow-up was available. of twenty-eight patients treated, 43% (12/28) had no complications. in 57% (16/28) complications were seen, which were classifi ed following the clavien dindo-classifi cation. a score of i was appointed to 21% (6/28) of the patients. reasons were: implant-exposure, minor pain, anti-emetics use or de novo retention. th ree patients had a score of ii, because of more severe complaints of pain or urge. th ey were treated pharmacologically. in 25% (7/28) one or more implants were removed, mostly due to exposure, erosion or pain. removal under local anaesthesia was performed in 14% (4/28) of the patients and this resulted in a iiia-score. th ree patients (11%) had a iiib-score, which meant the implant(s) were removed under general anaesthesia. in the fi rst twenty-eight diffi cult to treat patients receiving pdms, in ten cases a clavien dindo grade ii-iiib is scored, mainly because of surgical removal of implants. in spite of the seemingly high complication rate, this remains a useful therapeutical option for female stress urinary incontinence. magnetic stimulation for stress urinary incontinence: a randomized, double-blind, sham-controlled trial introduction and objective: we conducted a multicenter, randomized, double-blind, sham-controlled trial to evaluate the effi cacy of magnetic stimulation (ms) for stress urinary incontinence (sui). a total of 120 sui subjects were randomized 1:1 to active or sham ms for eight weeks (twice weekly). th e primary criterion for response was a reduction of 5 points or more in the international consultation on incontinence questionnaire for urinary incontinence-short form (iciq-ui sf). th e secondary outcomes included objective (leakage of less than 1 gram on 1-hour pad test) and subjective cure (a 'never' response to 'how oft en do you leak urine?), incontinence diary, pelvic fl oor muscle strength, urofl owmetry, patient global impression of improvement (pgi-i) and international consultation on incontinence questionnaire-lower urinary tract symptoms quality of life (iciq-lutsqol). results: using the primary criterion, 45 (75.0%) of 60 subjects were treatment responders in the active group compared to 13 (21.7%) of 60 subjects in the sham group (relative risk (rr) 3.46, 95% ci 2.09-5.72, p<0.001). based on objective cure, 25 (41.7%) subjects in the active group were dry versus 4 (6.7%) subjects in the sham group (rr 6.25, 95% ci 2.32-16.87, p<0.001). nineteen (31.7%) in the active group and 3 (5%) subjects in the sham group perceived themselves as dry (rr 6.33, 95% ci 1.98-20.28, p<0.001). th e active group had greater reductions (p<0.05) in incontinence frequency than the sham group. changes in pelvic fl oor muscle strength and urofl owmetry parameters were not statistically signifi cant between groups (p>0.05). th irty-nine (65%) subjects in the active group reported signifi cant benefi ts (much/very much better) for pgi-i rating compared to 11 (18.3%) subjects in the sham group (p<0.001). all item scores in iciq-lutsqol were not statistically diff erent (p>0.05) except 'eff ect on friends' , 'smell' , feeling of embarrassment' and 'overall impact' in the active group. of all evaluable subjects, 3 (5.3%) of 57 subjects in the active group and 5 (8.6%) of 58 subjects in the sham group experienced adverse events (p=0.72). conclusions: modifi ed tvt abbrevo is a simple, safe and eff ective procedure with comparable short-midterm cure rates to standard tvt abbrevo. th e modifi cations of avoiding the tunnelling device and groin exit helped to minimize the groin pain and analgesic requirements. evaluation of standard practice for artifi cial urinary sphincter implantation auckland dhb, auckland, new zealand; 2 ucd medical center, sacramento, usa introduction and objective: th e artifi cial urinary sphincter (aus) has been available since 1972 and over this time it has established itself as the gold standard in management of post prostatectomy incontinence. th e successes, failures and diffi culties are well documented, however little is published regarding the standard implantation practice of the aus. our objective was to review the standard practice for implantation of the aus within a group of high volume implanters. aft er obtaining institutional review board ethical approval a web-based questionnaire was designed using survey monkey soft ware. an email was sent to the current members of the society of genitourinary reconstructive surgeons (gurs) explaining the aims of the confi dential questionnaire with a web link to the aforementioned questionnaire. all results were collected via survey monkey and were then analyzed. results: one hundred and twenty gurs members were contacted by email, 70 members replied. th is group averaged 18 aus placements a year (range 5 to 53). pre-operative assessment utilized routinely included pad weights in 32.1%, pad numbers in 84.9% and urodynamic studies in 55% of participants. additionally 93% of participants surveyed would routinely perform a cystoscopy in the pre-operative assessment ninety four percent of those surveyed used greater than one pre-operative antibiotic; most commonly gentamicin with either vancomycin or cefazolin. th e antibiotic most commonly utilized alone was levofl oxacin. post-operatively 87% continue antibiotics anywhere between 24 hours and 1 month, with 5% continuing intravenous antibiotics for a minimum of 5 days. intra-operatively 74% have aus componentry prepared on a separate set up stand. th e single cuff aus, size 4.0 and 4.5 cm cuff were the most commonly placed cuff s, with the 61 -70cm reservoirs. radio-opaque contrast is used by 33% of participants in the aus reservoir. only 60% of participants would recommend a medical alert bracelet in the post-operative period, and 63% encourage pump traction. conclusion: despite a uniform technique recommended for the implantation of the aus by american medical systems in order to improve success and decrease complications, there is great heterogeneity in pre-operative assessment, surgical placement and post-operative management of the aus in a cohort of high volume implanters. patients presenting to a multi-disciplinary stone clinic were administered a survey. th ey were asked to elect a treatment modality from shock wave lithotripsy (swl), ureteroscopy (urs) or percutaneous nephrolithotomy (pcnl) for a hypothetical 15mm kidney stone. th e success rates (50% swl, 75% urs and 95% pcnl), morbidity and the risks associated with each treatment options were explained. patients were also to elect whether personal or doctors' decision of treatment is most preferred and the most important variable in deciding a choice of treatment modality. results: of the 106 respondents with mean age 55.9±13.4, female/male ratio was 1:1 ( figure 1 ). majority of the subjects (57%) elected urs as their treatment choice (table 1) . previous experience with urs (p=0.002) and pcnl (p=0.044) impacted the choice of urs. th e respondents were equally distributed in their primary concern being success rate (47%) versus risks (43%) associated with the procedure of choice (p=0.001). age and gender has no infl uence on treatment choice (p=0.37 and p=0.22) and on whether the primary concern is success or risk (p=0.68 and p=0.67 respectively). majority (86%) of the surveyed population would prefer the physician recommend the appropriate treatment. conclusion: th ough patients prefer the physician to recommend the appropriate treatment for a medium-sized renal stone, it is important for the physician to consider the patient's priorities of minimizing risk versus maximizing success. as such, majority of patients selected ureteroscopy as a procedure with a balance of moderate risk and moderate success. solo introduction and objective: sonography has been brought in percutaneous nephrolithotripsy (pcnl) as an adjunct to x-ray to restrict radiation exposure. th is study was designed to respond this question that "is sonography proper enough to supersede x-ray in pcnl under spinal anesthesia?" moreover, we investigated possible predictors of success. tract infection were excluded from study. th e intraand post-operative surgical outcomes were evaluated. results: th e mean age of the patients was 41.0 ± 12.4 years. mean stone size was 3.9 ± 1.2 cm. mean access and operative time were 12.1 ± 3.1 and 75 ± 12.2 minutes respectively. superior calyx was selected for access in 47% of patients. th e patients were categorized in following groups; history of more than one section previously open stone surgery (40%), horseshoe kidney (8%), major lumbosacral deformity (18%), failed standard pcnl (18%), children under 10 years old (10%), pregnancy (6%). th e primary complete stone free rate was 68%, and aft er ancillary procedures (urs, swl), raised to 84%. th e mean hemoglobin drop was 2.1 ± 1.0 gr/dl. transfusion needs in 6 patients. signifi cant prolonged or delay hemorrhage was not shown in any cases. pneumothorax was detected in one patient that managed with chest tube insertion. visceral or solid abdominal organ injury was not occurred. conclusion: with some attention, the outcomes of ultrasonography-guided pcnl for challenging renal stones are comparable with standard fl uoroscopic approach, and in some situation, fl ank position contain benefi ts rather than standard prone position. study of ten cases of p.c.n.l in "previously operated kidney stone with incisional hernia" conclusions: p.c.n.l in incision hernia patient is a safe procedure with excellent results. c.t. urogram is necessary tool for puncture.1st puncture in virgin fi eld (out of incisional hernia site) and avoiding colonic gas shadow on fl uoroscopy is key point. bowel injury is the concern -which should be taken care during puncture. daycare pcnl: now a reality! introduction and objective: pcnl as a therapy for renal stones is an established modality. th e use of holmium laser has led to miniaturisation of instruments and sheaths and has thus made the procedure less morbid. a stage has come for the patient to now leave hospital on the same day of the procedure. materials and methods: all cases were done under spinal anaesthesia and prone position. aft er placing a retrograde ureteric catheter, pcs was accessed through the appropriate calyx, and a 15 french sheath with suction capability was used. holmium laser was the energy used. aft er fragmentation, clearance was achieved by a combination of suction and retrograde wash and confi rmed radiologically and visually. clots were fl ushed out through the sheath which was then removed having retained the guide wire. finger pressure on the puncture site achieved haemostasis. th e guide wire and the retrograde catheter were fi nally removed. no urethral catheter was kept. a total tubeless procedure in the real sense. all patients were counselled about haematuria and pain. results: from january 2014 to march 2015, a total of 32 cases are included comprising 27 renal and 5 upper ureteric stones. stone size ranged from 1.0 to 2.8 cms. age ranged from 22 to 68 yrs. th e m/f ratio was 4:1. operative time ranged from 18 to 72 mins. th ere was no signifi cant blood loss. all patients received 1 dose of a parenteral analgesic 2 hrs post procedure, were ambulant 6 hours postopt and were allowed oral liquids. 1 patient had leak at puncture site lasting for 24 hours .all had haematuria which cleared completely within 12 to 36 hours. all were off ered discharge on the same day without any major event. one patient had clot retention on the 5th po day requiring clot evacuation. conclusion: pcnl as a day care procedure has been achieved by the above described method. patient acceptance is fair though most showed apprehension of going home the same day aft er a major procedure. whether it can be accepted universally remains to be seen. initial experience in ultraminiperc we have reviewed our initial experience of ultra-miniperc-ump in 100 patients. between june 2014 and march 2015, total 100 patients underwent ultra-miniperc. puncture and dilatation were done under fl uoroscopy in prone position. we used 11 and 13 fr ump amplatz. stones were fragmented by holmium laser and removed by whirlpool eff ect. post-operative stone-free status was confi rmed by ultrasonography and x-ray aft er 1 week. results: mean patient age was 38 years (11 to 75 years) and male to female ratio was 1.2:1. in 15% the procedure was bilateral simultaneous and in 4% in solitary kidney. stone locations were lower calyx (48%); upper calyx (5%), middle calyx (3%), renal pelvis (9%), upper ureter (11%) and rest were at multiple sites. calyx punctures were lower (81%), upper (9%), middle (5%) and multiple in rest. eight punctures were supracostal. mean operative time from puncture to amplatz removal was 32 minutes (range 20 to 75 minutes). signifi cant bleeding (hb drop more than 1.5 gm/dl) was in 5 %. all were managed conservatively without transfusion. dj stents were kept in 16 patients. nephrostomy-tube was not kept in any patient. eleven percent of patients had minor complications like pleural eff usion (2%), uti-fever (4%), and mild hematuria (5%). all were managed conservatively. one patient required conversion to miniperc-18 fr track due to intraoperative poor vision. mean hospital stay was 2 days (1-4 days). th ree patients required readmission for fever or clot colic. stone-free rate was 92%. eight percent had small fragments that were treated by oral hydrotherapy. two patients were treated by eswl. introduction and objective: a prospective randomized controlled study was executed to compare minipercutaneous nephrolithotomy (miniperc) and retrograde intrarenal surgery (rirs) in the management of renal stones larger than 10mm in a single session. between june 2014 and february 2015, 70 patients presenting with renal stones >10mm were randomized to a miniperc or a rirs group in a ratio of 1:1. randomization was performed by a biostatistician and opened to the surgeon at the time of the patient's admission on the day before surgery. patient and stone characteristics, perioperative outcomes, and complications were compared between the two groups. th e primary end point was "stonefree", which was defi ned as no residual stone or stones <2 mm on computed tomography within 3 months postoperatively. results: th irty-fi ve patients (miniperc) and 33 (rirs) were included in the fi nal analysis. th ere were no statistically signifi cant diff erences in stone size (39.1 ± 30.7 versus 28.9 ± 17.5 mm, p=0.102) and stone number (4.71 ± 6.29 versus 2.54 ± 2.56, p=0.067) between the miniperc and rirs groups. laterality, mean hounsfi eld units, stone location, presence of staghorn stone, and stone composition were similar between the both groups (p>0.05). miniperc and rirs had stone free rates of 85.7% and 97.0%, respectively (p=0.199). operation time (76.1 ± 70.6 versus 99.6 ± 60.8 minutes, p=0.148), hemoglobin drop (0.69 ± 0.98 versus 0.38 ± 0.97 g/dl, p=0.323), and hospital stay (1.6 ± 1.1 versus 1.5 ± 0.9 days, p=0.728) were similar between the two groups. pain visual analogue score at 1 hour postoperatively (4.2 ± 2.6 versus 5.7 ± 3.0, p=0.029) and analgesic requirement (31.4% versus 57.6%, p=0.050) were lower in the miniperc group. two patients in the miniperc group and 1 in the rirs group had minor pelvic or ureter perforation. one patient in each of both groups had hypertension and urinary tract infection. miniperc and rirs are safe and feasible surgical options for managing renal stones larger than 10mm. rirs had a little higher stone free rates, but more immediate postoperative pain and higher analgesic requirement compared with miniperc. colonic perforation during percutaneous nephrolithotomy darabi mahboub m, aslzare m, shakiba b introduction and objective: percutaneous nephrolithotomy (pcnl) is the treatment of choice for large, extracorporeal lithotripsy failure stones and those in the inferior calyx. despite the development of new techniques and the increasing experience in recent decades, complications may still occur. colonic perforation is one of the most dangerous and rare complications of pcnl, which may lead to peritonitis and sepsis. we present our 18-year experience on the diagnosis and management of colonic perforation during pcnl. we retrospectively reviewed the data of 5260 pcnl procedures performed between may1995 and august 2013. preoperative and operative factors, such as age, sex, history of previous ipsilateral stone intervention, stone side, stone location, site of skin puncture and punctured calyx, were reviewed in patients with colonic injury. results: colonic perforation was found in 11 patients (5 males and 6 females) and the mean age was 40.4 ± 22.2 years (range: 4 to 71). all injuries were retroperitoneal. th e left side was aff ected in 5 patients and the right side was injured in 6 cases. conservative management was the treatment planned for all patients. it included withdrawal of the nephrostomy tube outside the kidney to the colon as a percutaneous colostomy, insertion of a double-j ureteral stent, intravenous broad-spectrum antibiotics, bowel rest and total parenteral nutrition. under this conservative management, complete healing of the colon was achieved in all patients. early diagnosis and conservative management of colonic perforation can minimize patient morbidity and mortality and result in excellent healing of the fi stulous tract without any serious complications. colon materials and methods: during ten years, 6480 pnl procedures performed in our center. extraperitoneal colonic perforation complicated 11 procedures. all cases were managed without any tube in the colon. we took a retroperitoneal drain through pnl tract and a double-j stent inserted in all cases. we reported the results of our 11 cases that managed without colostomy tube. results: male to female ratio was 9/2. th e diagnosis was established aft er nephrostomy tract dilation and nephroscope insertion before lithotripsy in two cases and in 9 other cases, at the end of nephrolithotomy during amplatz sheath removal. conservative treatment was successful in all cases. mean hospital stay was 5/7 days. th ere wasn't any fever or other major complication. conclusions: it seems that management of retroperitoneal colonic perforation when diagnosed intraoperatively during tubeless pnl without colostomy tube is safe and eff ective. does intercostals nerve block and peritubal nerve block with bupivacaine reduce post-operative pain after percutaneous nephrolithomy? introduction and objective: to fi nd the most eff ective post-operative analgesia method aft er percutaneous nephrolithotomy (pcnl). in a prospective, 18-months duration study all patients undergoing pcnl (tubeless or with 24-f nephrostomy) were divided into 3 groups. group 1 (pcnl in fi rst-6-months) had no intervention; group 2 (pcnl between 7 and 12 months) received intercostal block (icb) with 0.25% bupivacaine; group 3 (pcnl in last 6-months of study) had peritubal track infi ltration (pti) with 0.25% bupivacaine at end of procedure. visual analog pain scores and rescue analgesia requirements at 3,6,12 and 24 hours in the 3 arms were compared. results: see table 1 . conclusions: peritubular tract infi ltration with bupivacaine established its superiority over both intercostal block and standard pcnl for post-operative analgesia and rescue analgesic requirements. the post-operative fever was defi ned as body temperature above 38.5 within hospital stay. relationship between clinical factors and sirs or post-operation fever was assessed using logistic regression analysis. results: a total of 110 male (67.1%) and 54 female (32.9%) were enrolled in our study (table 1) . forty-fi ve cases (27.4%) developed sirs and fever was observed in 20 cases (12.2%). shock was observed in 9 (5.5%) cases. in univariate analysis, stone size (p = 0.012) and urine wbc (p = 0.001) were found to be the predictors of sirs. in multivariate logistic analysis, stone size (or=1.48, p=0.009) and urine wbc (or=1.00, p=0.007) were signifi cantly related to the development of sirs (table 2 ). in univariate analysis, post-operative fever was found to be associated with the location of stones (p=0.012), stone size (p=0.016), urine wbc (p<0.001) and albumin (p=0.018). by multivariate logistic regression analysis, only stone size (or=1.62, p=0.024), urine wbc (or=1.00, p=0.002) and serum albumin (or=0.79, p=0.009) were associated with post-operative fever (table 2) . conclusion: patients with larger stone size and urinary tract infection before surgery might have higher risk of developing sirs and fever, while a normal serum albumin was found to be the protective factors of fever development. introduction and objective: perioperative hemorrhage owing to high vascularity in bph is the fearsome complication of turp that leads to clot retention, reoperation and oft en requiring blood transfusion. finasteride, a type 2 5α-reductase inhibitor, by interacting with vascular endothelial growth factor (vegf), reduces prostatic angiogenesis. microvessel density (mvd) is a histological measurement of angiogenesis and thus a marker of bleeding. we aim to determine the eff ect of two weeks preoperative fi nasteride therapy in reducing prostate vascularity in terms of mean microvessel density (mvd) and expression of vegf in prostate urothelium among patients of bph by comparing with controls. trial has been conducted in department of urology at shifa international hospital islamabad from jan 2013 to jan 2014. total 80 patients of benign prostatic hyperplasia (bph) planned for transurethral resection of prostate (turp) having prostate sized of more than 40 grams on trans-abdominal ultrasonography were randomized into two groups each group having 40 patients. th e finasteride group (group a) was prescribed oral 5mg of fi nasteride daily for 2 weeks before surgery. th e control group (group b) didn't receive any drug. aft er 2 weeks, turp was performed and prostate chips were sent for histopathological determination of mvd and expression of vegf. results: mean age 66.21±10.08 years, ranging from minimum of 48 years to 86 years. th e mean prostate gland size was comparable in both groups (55±10.7 grams vs. 58.1±10.8 grams). mean mvd in fi nasteride group was 20.25±10.3 whereas in control group mean mvd was 48.9 ±22.6. when compared the mean mvd in both group, the mean mvd was signifi cantly low in fi nasteride group as compared to control group with a p= <0.0001. similarly mean expression of vegf was 30% in fi nasteride group compared to 65% in control group. th is expression of vegf was also signifi cantly lower in fi nasteride group as compared to control group (p= 0.0017). also mean mvd was clearly correlated with size of prostate gland and the correlation was found statistically signifi cant on pearson correlation test (2-tailed) with p= 0.04. conclusion: finasteride reduces microvessel density and hence prostate vascularity with only 2 week therapy and the mean mvd is clearly correlated with size of prostate. characteristics 5-alpha reductase inhibitor induced prostate volume reductions yun j 1 , yang h 2 , kim d 2 , jeon y 2 , lee c 2 introduction and objective: benign prostatic hyperplasia develops in the transition zone of the prostate and 5α-reductase inhibitors (5-aris) reduce prostate volume. we investigated whether oral treatment with the 5-aris dutasteride and fi nasteride more significantly aff ected volume reduction in the transition zone or in the entire prostate. total prostate and transition zone volumes (tpv and tzv) were measured at baseline using a transrectal ultrasound (trus) and then at 1 yr aft er the commencement of dutasteride (0.5 mg) or fi nasteride (5.0 mg). th e ratio of tpv to tzv was used to determine the transition zone index (tzi). volume reduction (%) was calculated as the ratio of volume reduction to baseline prostate volume. additionally, serum prostate specifi c antigen (psa) concentrations were measured at baseline and then at 1 yr aft er the 5-ari were commenced. results: all of the 43 patients (mean age, 68.5 yr ± 7.2; range, 53-82 yr) with clinical lower urinary tract symptoms suggestive of benign prostatic hyperplasia and who were 5-ari naïve were prescribed dutasteride (0.5 mg, 74.4 %, 32/43) or fi nasteride (5.0 mg, 25.6 %, 11/43) for more than 1 yr (13.5 ± 4.2 mos). at baseline, the mean tpv, tzv, and tzi values were 58.0 ± 25.6 cm 3 , 30.8 ± 16.6 cm 3 , and 0.52 ± 0.13, respectively. at 1 yr aft er the commencement of the 5-ari, the mean tpv, tzv, and tzi were 48.0 ± 23.5 cm 3 , 28.1 ± 19.0 cm 3 , and 0.55 ± 0.13, respectively. th e tzi value is not signifi cantly diff erent at 1 yr compared with baseline (p > 0.05), while the tpv and tzv reductions are 22.7 ± 15.2 % and 27.2 ± 16.8 %, respectively; there is no signifi cant diff erence between the tpv and tzv volume reductions (p>0.05). conclusion: th ese results show that prostate volume reduction induced by 5-aris occurs in the entire prostate universally, rather than in the transition zone specifi cally. russo g, favilla v, privitera s, castelli t, fragalà e, cimino s, morgia g introduction and objective: combination therapy with of 5-alpha reductase inhibitors (5-ari) and alpha-blockers (ab) is the gold standard for the treatment of moderate-severe secondary to benign prostatic hyperplasia (bph). several clinical trials have already analyzed the overall impact of the medical treatment of luts/bph on sexual sphere, but any one investigated the overall impact on erectile dysfunction (ed) and libido alterations (la). th e aim of this this systematic review and meta-analysis was to evaluate the impact of combination therapy on ed and la from randomized clinical trial (rct). we performed a search of the cochrane central register of controlled trials, pubmed, embase, cochrane database of systematic review, and web of science, until december 2014. we conducted a meta-analysis to determine the impact of combination therapy (5ari + ab) in determining the onset of ed or la. a p value <0.10 was used to denote the presence of heterogeneity. of the 103 studies reviewed, only fi ve rct were included, involving 6131 participants. th e overall prevalence of erectile dysfunction was of 7.93%, 4.66% and 6.47% in patients treated with combination therapy, 5ari and ab respectively. th e overall prevalence of altered libido was of 3.69%, 3.37% and 2.37% in patients treated with combination therapy, 5ari and ab respectively. combination therapy 5ari + ab was found to be associated with increased risk of ed (or = 1.81; p <0.00001) and la (or = 1:58; p = 0.03) compared to monotherapy with ab. th e combination therapy was found to increase the risk of ed (or = 1.25; p = 0.04) compared to monotherapy with 5ari, but not the risk of la (or = 1:03; p = 0.84). analyzing the individual monotherapies, therapy with alpha-blockers signifi cantly reduces the risk of ed (or = 0.70; p <0.01) and la (or = 0.67; p = 0.01) compared to treatment with 5ari. conclusions: combination therapy 5ari + ab is associated with a higher risk of ed. in addition, 5ari monotherapy has the same risk of the combination of having la. th ese results could be taken into account during the counseling therapy in patients with luts/ bph. mladenov b, mariyanovski v introduction and objective: bph bleeding is one of the common causes of gross hematuria in older men. 5-alpha reductase inhibitor (5ari) treatment has been showed to reduce prostate tissue microvascularity and to prevent bph-associated hematuria. alpha-blockers are oft en prescribed, where their eff ect on hematuria is not well evaluated. th e aim of this study was to investigate the impact and effi cacy of the current used drugs for bph for treatment and prevention of bph-caused hematuria. a total of 119 men with median age of 69 were enrolled for a period of 2 years. all were presented with bph-caused macrospopic hematuria, diagnosed according to an adopted investigation protocol. detailed history was obtained, including usage of alpha-blockers and/or 5-ari prior to the hematuria episode. patients were released or immediately hospitalized and catheterized according to their status. all patients were followed up for 1 year for recurrent bleeding and were divided into 3 groups -with an alpha-blocker, 5-ari, or without therapy. in this study 82 patients were sent home and treated conservatively, other 37 with severe bleeding and/or clot retention necessitated catheterization and hospitalization. from 119 patients 22 (18%) were taking alpha-blockers, 9 (8%) 5-ari, and 88 (74%) had no medications for the bph prior to the hematuria. patients were followed up for recurrent bleeding for 1 year in 3 medication groups. 39 were given alpha-blockers, 38 -5-ari and 42 were released without medication for the bph. within 1 year bph-bleeding occur respectively in 11, 5, and 14 cases. th ere was a statistically signifi cant diff erence between the group with 5-ari therapy and the group without therapy (p=0.001). no statistically signifi cant diff erence (p=0.075) was found between the groups with an alpha-blocker and without therapy. in all cases with medication the hematuria episodes were lighter according to blood loss and/or hospital stay (in days) than the initial one. conclusions: according to our study, bph-associated hematuria can be eff ectively controlled and reduced with 5 ari. although as per our data alpha-blockers have a positive eff ect on the intensity of the recurrent hematuria, much more signifi cant results in treating and controlling bph-bleeding are shown with 5-ari. effi overactive bladder syndrome (oab) is a common condition with a negative impact on quality of life. botulinum toxin is commonly used. despite the favorable outcomes seen using botulinum toxin a, the method of injection and side eff ects still need to be solved. our aim is to use botulinium toxin with simple method and check its safety and effi cacy. a total of 82 patients with refractory oab were included in this study. inclusion criteria was refractory non neurogenic oab not responding to conservative management for at least 3 months. aft er written consent, patients were randomly divided into two groups. group a (45 patients) received botulinium toxin a 100 unit intravesical instillation diluted in 50 cc normal saline, group b (37 patients) received placebo in the form of 50 cc normal saline by the same method. patients were evaluated initially by history, physical examination, overactive bladder symptom score (oabss), quality of life symptom score (qolss), urine analysis, routine laboratory investigations, kub, pelviabdominal ultrasound and urodynamics. patients were followed up at one, and two month post instillation for effi cacy and safety by oabss, qol score, side eff ects and postvoid residual urine. introduction and objective: th e authors evaluate the safety and effi cacy of the prostatic urethral lift when performed in conjunction with a second procedure. in this retrospective study, 19 patients underwent the prostatic urethral lift between january 2014 and november 2014. sixteen patients received the prostatic urethral lift as a single procedure and the mean patient age for this group was 65 years (range 39 to 86). in the remaining 3 patients, a second procedure was performed in conjunction with the prostatic urethral lift . th ese 3 procedures were: th ulium laser enucleation of the middle lobe, optical urethrotomy and bladder neck incision. results: in patients who were treated with the prostatic urethral lift as a single procedure the mean international prostate symptom score was 18.4 (range 14 to 26) and mean maximum urine fl ow rate was 10.9mls-1 (range 5 to 19). th e average prostate volume was 47cc (range 26 to 79) and mean quality of life rating was 3.9 points (range 3 to 5). at 6 months aft er the procedure, the mean international prostate symptom score improved by 7.2 points (40%), mean maximum urine fl ow rate by 5.6mls-1 (51%) and mean quality of life rating by 1.9 (49%). th e improvements achieved in the 3 combined procedures were greater than the patients who underwent the prostatic urethral lift as a single procedure. th ere was one case (5%) of postoperative moderate pelvic pain which was managed conservatively with a nonsteroidal anti-infl ammatory drug. a urinary tract infection occurred in one case (5%) and resolved aft er treatment with an antibiotic. th ere were no complications in the combined procedure cases. no patients reported any decline in erectile function, retrograde ejaculation or dysejaculation. conclusion: th e prostatic urethral lift is a safe and eff ective treatment for lower urinary tract symptoms secondary to benign prostatic hyperplasia while preserving sexual function. in carefully selected patients, the performing the prostatic urethral lift in conjunction with a second procedure may achieve superior results with no major complications. evaluation . we sought to evaluate the effi cien-cy, safety and outcome parameters between green-light pvp and vit. data of 955 xps cases were retrospectively collected from 5 experienced surgeons at high volume greenlight xps centers. preoperative, operative and post-operative parameters were collected and compared between groups. pvp was defi ned as pure vaporization only while vit included techniques to incise into adenoma and allow tissue resection and removal. results: as summarized in table 1 , men undergoing vit (n=283) had larger prostate size, higher ipss∕qol and retention preoperatively than those undergoing pvp (n=672). while vit allowed greater delivery of energy (4.9 vs. 3.5 kj∕g), operative time was longer and had greater need for >2fi bres. th ere were no diff erences in intra and post-operative adverse events. while no diff erences were observed in ipss∕qol at 6 months post-operatively, more favorable qmax and pvr were observed at 6months, along with greater psa reduction, in the vit group. preoperative patient characteristics introduction and objective: to prospectively evaluate at two years, the quality of life (qol) and satisfaction of subjects randomized to either gl-xps or turp for luts/bpo. a total of 291 patients at 29 sites in 9 european countries who were candidates for surgical relief of bpo were randomised 1:1 to undergo gl-xps or turp. subjects had ipss scores >12 and prostate volumes <100mls. multiple self-administered patient questionnaires were assessed from baseline to 2 years via: 1) a general health status eq-5d-3l questionnaire (index score and visual scale); 2) physical and mental health (sf-36 physical health and sf-36 mental health scores); 3) erectile function and ejaculatory status (iief-5 questionnaire); 4) urinary continence via oabq-sf symptoms, oabq-sf health and iciq-ui sf; 5) overall satisfaction: willingness to undergo the procedure gain or 6) recommend to a friend. table 1 and subject satisfaction at 2 years is shown in figure 1 . conclusions: th ere is a statistically similar improvement in qol with gl-xps and turp at 2 years. erectile function is not aff ected by gl-xps or turp and both result in a 70% risk of retrograde ejaculation at 2 years. functional introduction and objective: technology for photoselective vaporisation of the prostate (pvp) has evolved in recent years. we report our early experience of pvp with the greenlight™ 180-w xps and assess our institutional learning curve for this technique. we performed a retrospectively analysis of our fi rst 150 patients undergoing pvp using the greenlight™ 180-w xps over a twoyear period. data was collected on demographics, prostate volume, length of stay, time to trial of void, and complications. complications were graded according to the clavien classifi cation system. th e operative learning curve was analysed via various intra-operative lasering variables including the total delivered energy, total vapourisation time (vt), and vapourisation time/operation time (vt/ot). th e study population was divided into three consecutive equal groups and the three groups were compared. results: mean age was 68. mean length of stay was 1.6 days. mean prostate volume was 65cc. twenty-fi ve percent were on some form of anticoagulation. twenty-one percent were in-dwelling catheter-dependent preoperatively. th e median duration to removal of in-dwelling catheter was 1 day. seventy-six percent had a successful trial of void on day 1. th e overall complication rate was 15%, the vast majority of which were clavien grade i or ii. th ere were no statistically signifi cant diff erences between the groups in terms of age or prostate size. over time, there was a statistically signifi cant decrease in ot and increase in vt/ot but no diff erences in complication rates, time to trial of void or length of stay as experience increased. conclusion: greenlight laser pvp using the 180-w xps is a safe and effi cient treatment option for benign prostatic hyperplasia, with minimal bleeding and low complication rates. our data suggests that a learning curve exists for this procedure in terms of intra-operative lasering variables with no statistically signifi cant increase in post-operative complications or length of hospital stay during this period. tillou x, le gal s, chahwan c, oitchayomi a, doerfl er a introduction and objective: to compare results of pvp (photoselective vaporisation of the prostate) in elderly patients to those observed in younger male patients taking into account the presence of an indwelling bladder catheter. we performed a review of our prospectively maintained database between december 2012 and march 2015. a total of 123 patients were operated for luts related to hbp. th ree groups were fi rst established to compare results of pvp in elderly male patients. we then analyzed the impact of an indwelling bladder catheter by comparing two groups of patients under and above 70 year-old. results: th ere were no diff erences between groups for bmi, neurological disorder or hypertension history, aspirin treatment, ipss, qol and preoperative pvr (post void residual). patients above 75 years old had statistically more heart diseases (p=0.0001) and had more anticoagulant treatments (p=0.05). prostate volume increased with aging (p=0.047), which resulted in an increased procedure time (p=0.05) and an increased amount of energy delivered (p=0.04). for postoperative outcomes, there were no diff erences between groups for bladder catheter removal time, ipss, qol, pvr, and surgical complications. postoperative qmax was statistically lower for patients above 75 years old (p=0.04) but with a decreased diff erence compared to preoperative measurements (p= 0.0001). in the group without an indwelling catheter, postoperative catheter time was signifi cantly longer in patients over 70 years (p=0.016) with a greater pvr (p=0.03). urofl owmetry and ipss voiding were signifi cantly improved in both groups without diff erences. th ere was no diff erence for early or late postoperative complications. for patients with an indwelling catheter, for all parameters studied, no statistically signifi cant diff erences were found except higher post-operative pvr in patients older than 70 year-old. conclusions: pvp is an effi cient and safe procedure in elderly male patients despite more heart diseases and anticoagulant treatments. with or without a previous indwelling bladder catheter, functional outcomes were identical whatever age. introduction and objective: th e procedure of holep has steep learning curve and more than 30 cases are needed for overcoming the curve. th e objective of our study is for identifying the detailed steps in improving skills during learning curve. total 90 patients who underwent holep in single center were included in the study. th e operation was performed by 3 surgeons who were experienced tur-p more than 200 cases. patients were divided into 3 groups. groups were initial 10 cases (group 1), mid 10 cases (group 2), and later 10 cases (group 3) in each surgeons. th e enucleation time, morcellation time, the amount of energy use, diff erential count of hemoglobin between pre-and post-operation, post-operative urofl owmetry parameter were compared between each group. especially, enucleation time was divided into 2 diff erent steps, which was action time that was actual use of laser energy or dissecting prostate tissue using cystoscopy and identifi cation time was time for identifying anatomical structure without any procedure. results: mean ages was 70.31 years old and mean bmi was 23.90kg/m2. mean psa was 5.89ng/ml and mean prostate volume was 68.97cc. th ere were no signifi cant diff erences in baseline characteristics in preoperative data. aft er 10 cases (group 2), there was less use of laser energy, less time consuming for morcellation and identifi cation compared to group 1. identifi cation time was signifi cantly improved than group 1 and more shortening feature as cases added but had no signifi cant diff erence. aft er 20 cases (in groups 3), there was more signifi cant diff erence in all operative parameter. especially morcellation time was signifi cantly improved aft er 20 cases. th ere was no signifi cant diff erence in post-operative urofl owmetric parameters. conclusion: in initial experience, it seemed to be overcoming one step about identifying surgical anatomy in learning curve aft er 10 cases. especially, 20 cases were optimal cases for overcoming learning curve for morcellation. aft er 20 cases, we did not overcome the learning curve but all operative parameter was improved. transrectal ultrasound as an intraoperative tool in the identifi cation of the plane of dissection during holep procedure introduction and objective: holmium laser enuclation of the prostate (holep) has been named since 2013 as the potential gold standard of treatment for bladder outlet obstruction as a consequence of benign prostatic hiperplasia. one of the most important steps during procedure is to identify the plane of dissection between the adenoma and periferic zone. in this study we demonstrated the utility of transrectal ultrasound in the identifi cation of this surgical plane during ho-lep for novel surgeons. materials and methods: previews informed concerned, we preform transrectal ultrasound during holep of 5 patients, using the 8880 proved of the 800 flex focus ultrasound system of bk medical, obtaining images of the prostate as a method to simplify the identifi cation of the surgical plane. we preformed holep as a standard method with storz endoscopic instruments using 26fr resectoscope with a kunts element and with the 100 watts holium laser power suite from lumenis, we obtained images of the fi ve patients in real time with axial and sagital planes simultaneously, clearly helping the surgeon to identify the surgical dissection plane between the adenoma and the peripherical zone. conclusions: transrectal ultrasound could be a useful tool during the training of novel surgeons in holep technique. introduction and objective: th e aristolochia family of herbaceous plants has been used worldwide for traditional medicinal purposes for more than two centuries. th ese plants contain aristolochic acid (aa), a powerful nephrotoxin and human carcinogen, which, in susceptible individuals, causes chronic kidney disease and/or upper urinary tract urothelial carcinoma (utuc). bioactivation of aa yields a reactive intermediate that binds covalently with dna to form aristolactam (al)-dna adducts. in the urothelium, these adducts give rise to a unique mutational signature. as there are several reports of renal dysfunction in japan associated with the use of aa-containing chinese herbs, we hypothesize that a fraction of utuc cases in this country may result from past use of aristolochia herbs. patients with histologically confi rmed utuc who underwent nephroureterectomy in kyushu university aft er august 2011 were eligible for this study. informed consent was provided by each participant prior to surgery. surgical specimens of tumor and renal cortex were snap-frozen following nephroureterectomy. dna was isolated from renal cortex and analyzed for the presence of al-dna adducts using either mass spectrometry or a 32p-postlabelling method. dna isolated from matched tumor samples was subjected to mutational analysis of the tumor suppressor gene tp53. results: th irty three utuc patients were enrolled in this study between august 2011 and march 2014, 22 males and 11 females, with a mean age of 73 years. al-dna adducts were detected in 2 of 33 renal cortex samples (6.1%) analyzed; adduct levels were 0.26 and 1.0 per 108 deoxynucelotides. sequencing analysis of tp53 in tumor dna revealed the absence of the unique mutational signature associated with aa. conclusion: aa exposure was confi rmed in two utuc patients; however, in these two cases, the mutational profi le of tp53 in tumor dna was not consistent with aa-induced carcinogenesis. further accrual and analysis of utuc cases are needed to estimate the prevalence of aa exposure in japan, to evaluate the role of aa exposure to utuc in this country, and to confi rm the public health implications of these fi ndings. preoperative introduction and objective: our aims are to assess the association between upper urinary tract urothelial carcinoma (uutuc) development and the polymorphisms in the aurora kinase a (aurka) phe31ile (rs2273535) and survivin rs1042489c>t genes. a total of 186 patients with uutuc and 187 hospital controls with bladder stones were recruited in this study. clinical records, demographic data, and possible confounding factors were collected using a standardized questionnaire. genotyping was determined using a real-time polymerase chain reaction using taqman probe. results: signifi cantly more controls than patients with uutuc drank alcohol and tea, but there were no diff erences in the frequencies of cigarette smokers and coff ee drinkers. aurka phe31ile gene polymorphisms, but not survivin rs1042489c>t gene polymorphisms, were associated with uutuc development (χ2 test and multivariate logistic regression) (χ2=3.88, p=0.048; crude or=2.06, 95% ci=1.01-4.40; adjusted or=2.67, 95% ci = 1.07-6.94). stratifi cation analysis and multivariate logistic regression analysis showed that only the association between aurka phe31ile gene polymorphisms and uutuc development were diff erentiated between those with and without the habits of smoking, tea drinking, or coff ee drinking. conclusion: our major fi ndings supported that aur-ka phe31ile gene polymorphisms, but not survivin rs1042489c>t gene polymorphisms, increase genetic susceptibility to uutuc. metastatic and has thereaft er stabilized around 50%. th ere was a regional variation in the proportion of patients who underwent cn between 42% and 59%. th e relative survival at fi ve years was 24% aft er cn compared to 4% in patients who did not undergo cn (p<0.05). th e median age of the m1 patients who underwent cn was 66 years compared to 71 years in patients who did not undergo cn. tumor recurrence, aft er initial treatment with curative intention in primary m0 patients, was 20% aft er fi ve years. th e location of the metastases were: lung 56%, bone 21%, lymph nodes 21%, liver 16%, adrenal 7% and brain metastases in 5% of the patients. th irteen percent of the patients suff ered local recurrence in the renal fossa aft er nephrectomy. th e most common treatment for patients with a recurrence was oncological medical treatment (49%). metastasectomy was performed in 17% of the patients with recurrence and in 63% of the patients the surgery had a curative intention. conclusions: th e incidence of metastases in renal cell carcinoma in sweden is decreasing and is lower than in historical materials. th e patients with synchronous metastases who undergo cn have a signifi cantly better survival than patients who do not undergo cn, but constitute a highly selected group. recurrence after initial treatment with curative intention is treated surgically in 17% and oncologically in 49%. immediate introduction and objective: pretreatment characterization of renal masses (rm) remain suboptimal with overtreatment being a signifi cant concern. we examined the ability of preoperative clinical characteristics to predict histological features of rms. in the global renal mass study conducted by the clinical research offi ce of endourology society (croes), data were collected for consecutive patients with renal masses who underwent surgery for clinical stage i renal mass between 2010-2011. based on surgical histology, tumors were categorized as benign, low aggressiveness cancer, and high aggressiveness cancer. we assessed the ability of clinical (patient gender, age, smoking history, bmi), laboratory (preoperative hemoglobin and c-reactive protein) and radiographic (tumor diameter, location, exophytic rate and enhancement) characteristics to discriminate between benign and cancer (low + high aggressiveness) and between highly aggressive tumors and others (benign + low aggressiveness cancer). multivariate logistic regression was used to estimate the probability of the histological group by clinical and radiographic features in the entire cohort and a sub group of ct1a tumor. th e performance of the models was consequently studied by calibration, nagelkerke's r2, and discrimination (roc area under the curve). results: th e study cohort included 2224 patients with clinical stage i renal mass of which 1367 (61%) had ct1a mass. benign lesions were found in 369 (16.6%), low aggressiveness tumors in 1156 (52%) and high aggressiveness tumors in 699 (31.4%). male gender, smoking history, increased tumor size, and lower exophytic rate were associated with malignancy and high aggressiveness features (all p-values <0.05). models developed based on these characteristics had the ability to discriminate benign from malignant (bootstrap corrected c-index of 0.64) and high aggressiveness tumors from benign and low aggressiveness tumors (bootstrap corrected c-index of 0.66). similar results were achieved in the ct1a subgroup. th e c-index of tumor diameter as a single predictor of malignancy and high aggressiveness tumors in the entire cohort was 0.6 and 0.63, respectively. conclusions: although older age, male gender, smoking history, increased tumor diameter and reduced exophytic rate are associated with malignancy and high aggressiveness of renal mass, models incorporating these characteristics have modest discriminating power, slightly better than the predictive ability of tumor size alone in clinical stage i tumors. could surgery be prevented in the management of small renal masses? introduction and objective: th e diagnosis, characterization and management of small renal masses (srms) remains an important clinical issue. a proportion of srms may be benign or have low malignant potential. th ese lesions could arguably be managed non-operatively. strategies such as renal mass biopsy may be valuable in reducing the rate of unnecessary surgery. we evaluated a large contemporary surgical series of resected srms in a tertiary center with a very low biopsy rate to determine the number of procedures that could have been prevented for benign and low malignant potential lesions. conclusion: sbrt is a safe and effi cacious modality and appears to be well-tolerated at the dose fractionation we have used, and its use correlates with improved survival in this cohort of patients with rcc. cyberknife can deliver complex treatment plans to multiple lesions while minimizing irradiation to the surrounding healthy tissue, thereby decreasing the risk of complications. cyberknife has the potential to be an excellent treatment modality for renal cancer patients with renal cell carcinomas or patients with bilateral renal cell carcinoma who refuse surgery or are medically inoperable. introduction and objective: th e introduction of the robotic surgical systems has changed the way both surgeons and patients view urological surgical procedures. we tested the same theoretical and tangible benefi ts for partial nephrectomy with tele-lap alf-x system. we review our technique of robot-assisted laparoscopic partial nephrectomy performed using a new robotic telesurgical device (alf-x) on swine large white/landrace model. we set up an operating theatre to test alf-x on partial nephrectomy procedure to be performed on swine large white/landrace in total anesthesia. th e console incorporates the following main components: an ergonomic seat, the laparoscopic teleoperation master (ltm) with haptic handles, a 3d-hd monitor, an eye-tracking system (ets), a keyboard and a touchpad, and one foot pedal. th e ets is an infrared-based eye tracking system that detects which point the surgeon is looking at. th ere was one surgeon placed at computer-console and one surgeon placed at the surgical table. a random decision on the kidney to be tested is performed before the operation. once the trocars are placed and the kidney isolated a period of warm ischemia is due to perform the partial nephrectomy on the lower or upper pole (random choice). th e haptic sensation can be used for palpation, pushing or pulling to estimate elasticity and consistency of tissues and controlling the tensility of the sutures when tying. low-cost disposable or reusable instruments were used. results: to date, we performed 7 partial nephrectomy with alf-x robot on swine large white/landrace (pigs) models. th ree robot's arms were used. five partial nephrectomies were on the right kidney, while 2 were on the left one. th e mean surgical time was 32.4 minutes (range 45-18 min). th e mean warm ischemia time was 9.4 min (range 7.4-12 min). th e mean blood loss was 48.6 ml (range 20-90 ml). conclusions: according to these experimental experiences on pig models, we may assume that robot-assisted laparoscopic partial nephrectomy, using tele-lap alf-x system, is safe, feasible and reproducible procedure. moreover it off ers a good perception when instruments touch each other avoiding collision between robotic arms. we believe that robot-assisted tele surgery approach could be reasonable an innovative contribution in the near future also in humans. it also off ers a reduction of costs per intervention. preoperative chronic kidney disease to reduce the eff ects of selection bias and potential confounding factors, 600 patients in non-ckd group were selected by propensity score matching. results: th e median age of all patients was 57.3 years (range, 20-94 years) and the median follow-up was 35.0 months (range, 1-154 months). comparisons of the propensity score-matched cohorts showed that t and n stages were more advanced and the tumor size was larger in the ckd than in the non-ckd group (p < 0.05 each). kaplan-meier analyses showed that recurrence-free survival (rfs), cancer-specifi c survival (css), and overall survival (os) were signifi cantly lower in the ckd group (p < 0.01 each). multivariate regression analysis showed that preoperative ckd status was an independent predictor of css and os in patients with rcc (p < 0.05 each). conclusion: preoperative ckd may be associated with more aggressive features and poorer prognosis in patients with rcc. rcc patients with preoperative ckd should be followed up frequently and carefully aft er nephrectomy. .0014) were independent prognostic factors. bone-modifying agents (zoledronic acid and denosumab) were not associated with os. th e median os of patients receiving molecular-targeted therapy aft er diagnosis of bone metastasis was signifi cantly better than that of those who did not receive targeted therapy (16.0 vs. 9.0 months, p=0.0118). our study suggests that molecular-targeted therapy prolongs survival of rcc patients with bone metastasis. th us, molecular-targeted therapy, nephrectomy and surgery for bone metastasis should be considered for these patients. introduction and objective: ureteric stenting for urinary tract obstruction secondary to malignancy may off er a survival benefi t and buy time for oncological management. since the introduction of the ureteral stent symptom questionnaire (ussq), studies have revealed that up to 80% of patients with ureteric stents for benign conditions experience stent related symptoms that interfere with daily activities and reduce quality of life. our aim was to evaluate stent symptoms in patients with malignant obstruction and their impact on health related quality of life. patients with indwelling ureteric stents for malignant obstruction were identifi ed from the departmental stent register during a march to june 2014. telephone interviews and face to face interviews at the time of stent change were conducted using the validated ussq. results were analysed according to the questionnaire scoring system. results: twenty patients with a mean age of 73 years completed the ussq. of these patients 55-65% reported bothersome urinary symptoms that included storage symptoms, incontinence and haematuria. fifty percent of patients experienced stent related pain in the fl ank (6/10), suprapubic (4/10) and groin area (4/10). fift y percent of these patients required regular analgesia and 50-70% experienced pain interfered with activities and daily life. seventy percent of patients experienced diffi culty in performing physical activities, with a negative impact on social life. one out of 20 patients reported sexual dysfunction. eighty fi ve percent experienced urinary tract infection (uti) with 25% having a uti most or all of the time and 45% requiring admission to hospital. mortality within one year of stent insertion was 30%. conclusion: ureteric stents are associated with signifi cant debilitating symptoms and reduced quality of life in patients with malignant obstruction. th is has signifi cant implications for management of cancer patients and patient counselling. ureteric stenting can prevent death from malignant obstruction, but may result in prolonged suff ering due to stent symptoms without benefi t in overall survival. introduction and objective: management pheochromocytoma laparoscopic was initially controversial because of the possibility of adrenergic discharge with the generation of the pneumoperitoneum. th e work of a proper medical preparation and anesthetic precise control obvious that circumstance and allows more precise surgery and a better image as it gives the laparoscopy to get with much less aggressive surgical removal. our goal is to present the preparation and the key points in its approach. we present 66-year-old male with recent diagnosis prostate cancer and high pressure treated with 2 drugs. discovery of left adrenal mass of 5 cm. in ct and mri and scintography with mibg suggestive focus of pheochromocytoma in the adrenal gland. twenty-four-hours urine: total catecholamines: 164.5 ug/24 (14-110) adrenaline: 94.7 ug/24 hours (2d-23); normetanephrines 2442 ug/24 (120-650), metanephrines: 6631 ug/24 (50-350). vanilvandelico 11.7 ug/24 (1-10). preparing medical / anaesthetic consisted: entry 3 days before surgery and control alpha-blockers with doxazosin every 12 hours. treatment with beta-blockers with propranolol. expansion of intravascular volume with intravenous fl uid therapy 12 hours before surgery. and control of blood glucose levels. intraoperatively crisis were treated with nitroprusiate. results: aft er adrenalectomy laparoscopic left with a length of 110 minutes and adequate control pressure intraoperative the pathology diagnosis was of pheochromocytoma. postoperative attended without incident (clavien i) and went out hospital to the 48 hours. th e presence a pheochromocytoma should not be a contraindication to laparoscopic approach of the adrenal gland in services experienced laparoscopic, and must be an exhaustive control of anesthetic, as well as a careful dissection of the gland trying to avoid excessive manipulation of the same. robotic assisted "davinci" adrenalectomy al-ansari a, younes n, al-rumaihi k, al-jalham k, gul t, badawi a, kamkoum h introduction and objective: adrenal mass could be challenging, especially when it is large in size or cystic, adrenal had short and variable vasculature, in addition to functional adenoma, adrenal surgery require minimal handling. robotic assisted adrenalectomy (ra) had been proven to be safe and eff ective. objectives: to describe robotic adrenalectomy (ra), to ensure a safe and eff ective removal of complex adrenal mass. we reviewed the record of 10 consecutive patients who underwent ra performed by a single surgeon, between january 2012 and january 2015, fi ve were right and fi ve were left , 6 were solid and 4 were cystic, none were functional adenoma patients position and port placement were similar to renal surgery, aft er control of the renal vein the gland was dissected, small arteries were clipped and the gland were removed. results: patients were 6 females and 5 males, age range between 23 to 66 years mean tumor size was 7.5 cm range (3.5-10 cm), mean hospital stay was 4 days, no perioperative complications, all masses were intact, one postoperative addisonian crisis pathology was benign 3 cyst, 2 adenoma, 2 ganglionuroma, 1 neuroendocine, 1 adrenal hyperplasia, 1 adrenocortical neoplasm of low malignant potential. conclusion: robotic adrenalectomy is safe and feasible in the management of complex adrenal mass. robotic materials and methods: th e girl was in a good general health and came walking to our out-patients department. she was admitted and her investigations reviewed. she had a right renal mass with cavo-atrial extension with an isolated embolus in the pulmonary artery. she was planned for a complete excision under cardio-pulmonary bypass with deep hypothermic circulatory arrest. under general anaesthesia, aft er establishing complete monitoring, she was opened by long midline laparotomy and mid-sternotomy. mid-sternotomy extension was done up-front in-view of the pulmonary embolus. an incision was made in the posterior peritoneum medial to the inferior mesenteric vein. th e right renal artery was dissected posterior to the left renal vein, ligated and divided. suddenly her end tidal carbon-di-oxide fell. th e video demonstrates the trans-esophageal echo-cardiography confi rming fragmentation of the cavo-atrial thrombus and its migration into the right ventricle and main pulmonary artery. th e patient was immediately put on cardio-pulmonary bypass. initially the venous return was low. she was rapidly cooled to 18 degrees centigrade and aorta cross clamped just above the diaphragm. arterial infl ow was reduced to 1 litre per minute to main blood fl ow to the brain. th e video demonstrates opening, clearing and repairing of the right atrium, right ventricle and main pulmonary artery in a step by step approach. th e branches of the pulmonary artery were cleared with fogarty's catheter. right radical nephrectomy was completed and ivc cleared and repaired. th e total circulatory arrest time was 32 minutes. she was slowly re-warmed and taken off cardio-pulmonary bypass. results: her post-op recovery was uneventful. th e fi nal histo-pathology report showed a primitive neuro-ectodermal tumor. she received adjuvant chemotherapy for 16 cycles and is well at 15 months of follow-up. in an appropriate case pulmonary artery embolectomy along with excision of cavo-atrial tumor thrombus is acceptable in experienced centers. an up-front mid-sternotomy should be contemplated in patients where the risk of embolisation of tumor thrombus is high. a total of 29 consecutive patients who underwent a turbts were identifi ed from january 2010 to february 2015 by a single surgeon at our institution. we excluded 10 patients as they had a known history of bladder cancer that previously underwent treatment. via rigid cystoscopy, tumors were resected en bloc using a polypectomy snare with electro-cautery and retrieved transurethrally. following turbts, the base of the tumor was either biopsied and fulgurize or a formal turbt was performed. results: nineteen consecutive patients (median age 70, range 43-97) underwent an initial turbts for the initial staging and management of bladder tumor. median number of tumors found was 1 (range 1-8). median tumor size was 3cm (range 2cm-5cm). median follow-up was 26 months (range 1-51months). tumors sites were: 7 posterior wall, 2 trigone, 8 lateral wall, 2 anterior wall. immediate aft er snaring of the tumor, 6 patients underwent biopsy and fulguration while 7 underwent a turbt in the same operative setting. 1 patient from the turbt group experienced an obturator refl ex. muscle was visualized on 8 of 13 pathology specimens. 2 patients required subsequent redo procedure to obtain muscle for tissue diagnosis and staging. recurrence occurred in 5 patients (median 6.5months, range 1.5-43 months). conclusion: turbts is a feasible technique for pedunculated bladder tumors. it provides a bloodless fi eld with maximal visibility for the surgeon and may be an adjunct in turbt. dilep-diode laser (980 nm technical aspects for overcoming the holep learning curve omori y, matsumoto s, matsumoto s introduction and objective: holep is an excellent surgical procedure and alternative to turp and open prostatectomy for bladder outlet obstruction due to benign prostatic hyperplasia. it has been widely accepted and performed, for its safety and eff ectiveness. however, it may not be considered an option for the majority of worldwide urologists, because of its steep learning curve. our objective is to help beginners and operators who are interested in learning holep to get familiarized with it, and feel confi dent about opting for this procedure. in this video we demonstrate a case of holep using 100 watt holmium laser in a 74-year-old male with 65ml prostate. th e operative fl ow is described as follow: 1) downward dissection of the left lobe and longitudinal incision; 2) downward dissection of the right lobe and longitudinal incision; 3) enucleation of the medium lobe; 4) lateral side dissection of the both lobes; 5) 12 o' clock incision and bladder neck ablation at between 2 and 10 o' clock 6) diagonal longitudinal incision of apical lobes; 7) enucleation of the both lobes; 8) hemostasis; 9) morcellation. results: in this video operative time was 55min (enucleation time: 30 min) and resected tissue weight was 38g. our procedure has some modifi cations compared to the surgical technique from original procedure of gilling, separating 3 lobes and dissecting in a retrograde fashion. conclusion: holep is a safe and eff ective surgical procedure. we hope our procedure will become the reference for beginners and urologists who are wishing to master it, but are worried about methods and complications. and also we hope holep will become the new gold standard for the treatment of benign prostatic hyperplasia. to obliterate the circular fi bers of bladder neck to the level of proximal urethra, carefully avoiding the external striated sphincter. laser power is reduced to 40w to prior to vaporization of any pseudomembranous trigonitis, which is commonly found in pbno or recurrent cystitis cases. results: laser vaporization is successful in relieving voiding diffi culties. th is procedure opens the bladder neck and allows for optimal post-operative urine fl ow. th e patient had improvement in both objective and subjective voiding functions immediately aft er treatment. during 3-months follow-up urofl owmetry, the maximum fl ow rate increased from 6 to 17 ml/s. th e postvoid residual urine decreased from 95ml to less than 20 ml. conclusion: primary bladder neck obstruction in female can be eff ectively and safely treated with laser photoselective vaporization of the bladder neck. bilateral retroperitoneal laparoscopic nephrectomy using 3mm instruments introduction and objective: laparoscopy has become the standard nephrectomy approach. it has been shown that th e retroperitoneal approach is comparable to the transperitoneal approach when it comes to safety and results, even more, it can present advantages in selected patients, as in patients with prior abdominal surgery. th e use of 3mm instruments is gaining acceptance as a safe way to improve aesthetic results and minimize abdominal wall trauma while maintaining the principles of standard laparoscopy. we present the case of a 61-year-old woman with a history of radical hysterectomy and radiotherapy, aft er which she presents: 1) bilateral ureteral obstruction that produces terminal renal insuffi ciency, and, 2) vesico-vaginal fi stula, refractory to conservative treatment. th e decision is made to perform a bilateral retroperitoneal laparoscopic radical nephrectomy as a defi nitive treatment of the vaginal fi stula and as preparation for the kidney transplant. results: th e right nephrectomy is performed fi rst. classic retroperitoneal technique is used, using 3mm trocars (with an 11mm trocar to create the retroperitoneal space). on the left side, a previously produced nephrostomy catheter tract is used to insert a 5mm trocar. no relevant intraoperatory complications were observed. preoperative haemoglobin was 85 g/l and the postoperative was 88 g/l aft er transfusion of one bag of packed red blood cells. th e only postoperative complication was the infection of the 5mm left side trocar tract (where the previous nephrostomy catheter was placed). th e total hospital stay was 6 days. th e pathological anatomy for both kidneys was: chronic pyelonephritis with extended interstitial fi brosis and tubular atrophy. conclusions: retroperitoneal laparoscopic nephrectomy is an effi cient and safe approach, comparable to transperitoneal laparoscopic nephrectomy, and even superior to this one in patients with previous abdominal surgery. th e use of 3mm instruments (in this case in a combined fashion), allows performing the surgery in a safe way, with superior aesthetic results. pure aft er complete mobilization of the renal artery three hem-o-lok clips were applied and the artery was transected. th e ivc was isolated upwards as far as possible, and intraoperative laparoscopic ultrasound was employed to identify the extent of the thrombus. aft er the inferior vena cava ivc was blocked using tourniquet loops above and below the thrombus and the contralateral renal vein was blocked, the ivc was opened and the tumor thrombus was extracted entirely. th e ivc was stitched with a running 4-0 polypropylene suture. th e specimen was extracted in an endoscopic extraction bag through a gibson incision. results: from february 2012 to june 2014, fi ve patients underwent pure conventional retroperitoneal laparoscopic nephrectomy and tumor thrombectomy. th e mean patient age was 57 yr (43-71 yr). th e mean operative time was 241 min (180-300 min), and the mean estimated blood loss was 290 ml (50-1000ml). th e mean length of tumor thrombus was 5.5 cm (4-10 cm). with a mean follow-up of 11.5 mo (5-30 mo), one patient was identifi ed lung metastasis four months postoperatively. introduction and objective: partial nephrectomy provides equivalent oncologic and superior functional outcome compared with radical nephrectomy over the short-and long-term. with the development of laparoscopic techniques and increasing laparoscopic surgical experiences, laparoscopic partial nephrectomy has become an acceptable alternative to radical nephrectomy for expert laparoscopic urologists to treat small renal mass. however, higher complexity tumors are associated with more resection of normal tissue, a longer warm ischemia time, and postoperative morbidity, especially entirely endophytic hilar tumor. in order to reduce normal tissue resected during laparoscopic partial nephrectomy for entirely endophytic hilar tumor, we develop a novel technique to deal with the higher complexity tumors. subject is a 43-year-old female with t1a clear cell carcinoma with a diameter of 2.6 cm. th e tumor is entirely endophytic hilar tumor. renal nephrometry score is 10. she underwent laparoscopic partial nephrectomy in retroperitoneal approach. standard 4 ports were placed. th e surgeon opened gerota's fascia and dissects along the renal capsule mobilizing the kidney from within gerota's fascia. th e resection line was marked using the laparoscopic ultrasound probe. aft er the renal artery was clamped by bulldog, tumor enucleation was performed using a cold scissor. one incision above the tumor was made, and careful dissection was performed to approach the tumor. th e tumor was completely mobilized outside its margin. th en the inner layer renal parenchyma and collecting system was sutured with 2-0 absorbable sutures and the outer layer renal parenchyma was sutured with 0 absorbable suture. results: th e procedure was successfully accomplished without open conversion and transfusion. th e operative time was 120min, and the estimated blood loss was 50ml. th e warm ischemia time was 30min. histology revealed that the tumor was chromophobe renal cell carcinoma, and the surgical margin was negative. conclusion: laparoscopic partial nephrectomy for entirely endophytic tumor is challenging. tumor enucleation with one resection line can reserve more normal renal tissue during the procedure. more cases are needed to evaluate the effi ciency of the technique. introduction and objective: laparoscopic adrenalectomy by posterior approach carries high recovery and shorter operative time. children with metastatic high risk neuroblastoma arising from the suprarenal gland should undergo local surgical excision of the primary tumor before further intensifi cation of chemotherapy and possible bone marrow transplantation. herein, we report a video of left laparoscopic adrenalectomy showing the diff erent steps of the procedure. 35th congress of the société internationale d'urologie -siu 2015 abstract book materials and methods: a 3.8-year-old boy with left metastatic suprarenal neuroblastoma, received chemotherapy according to high risk european protocol. child positioned in prone position, fi rst trocar at the tip of the last rib by open introduction, two 5mm trocars one in costovertebral angle and the other is lateral. balloon development of the space, gerota fascia opened, the upper pole of kidney identifi ed, mass dissected, suprarenal vein is clipped during dissection, extraction in bag. results: oral feeding is begun aft er 6 hours, discharge from hospital in the second day postoperatively, rapid convalescence, rapid resumption of chemotherapy. conclusion: laparoscopic adrenalectomy using posterior approach gives direct access to the adrenal gland, no peritoneal violation, rapid intestinal movement recovery, short hospital stay and rapid recovery. all advantages that might facilitate the early start of adjuvant chemotherapy in children with neuroblastoma, however, oncological outcome should be proven by long-term follow-up, larger number of patients, and good selection of small tumor facilitates surgical extirpation. introduction and objective: robotic multiplex partial nephrectomy (rmxpnx) is minimally invasive partial nephrectomy for three or more tumors in a single kidney. rmxpnx has been previously shown feasible with excellent preservation of renal function. we present our technique of off -clamp robotic transperitoneal multiplex partial nephrectomy in the treatment of multifocal and hereditary renal tumors. a prospectively maintained database was retrospectively queried to identify all patients who underwent rmxpnx from 2007 to 2013. rmxpnx is defi ned a resection of 3 or more masses from a single kidney. patients underwent rmxpnx when the largest tumor reached 3 cm in size. tumors were excised using enucleation techniques. from the data of 54 eligible patients, a representative patient was identifi ed and surgical video was edited to demonstrate the important aspects of the surgical technique. results: th e patient is a 20-year-old white male with von hippel lindau diagnosed with bilateral multifocal renal tumors with several tumors >3cm in size. he underwent bilateral robotic multiplex partial nephrectomy separated by 6 weeks with no operative complications. th irty fi ve tumors were excised from the right kidney. fift y two lesions were then resected from the left kidney. his preoperative creatinine was 0.88 and at 1 year postop from bilateral multiplex partial nephrectomies his creatinine is 1.07. in the hands of an experienced surgeon, off -clamp robotic transperitoneal multiplex partial nephrectomy is feasible, safe and eff ective in the treatment of multifocal and hereditary renal tumors. th is technique provides exceptional renal functional preservation and decreases technical diffi culty of reoperation. louie-johnsun m introduction and objective: th e advantages of minimally invasive laparoscopic surgery are well documented. as there are few urological emergencies suitable for a laparoscopic approach, the increased use of robotic surgery for elective procedures that can be performed equally as well laparoscopically threatens the acquisition of skills that can be transferred from these elective procedures (e.g. laparoscopic radical prostatectomy, pyeloplasty and partial nephrectomy) to emergency cases. in emergency situations, a robotic approach may not be feasible or practical. we highlight this with three recent cases. materials and methods/results: a video presentation of three of our recent urological emergency cases managed successfully laparoscopically which includes: (1) a 17-year-old girl with neurogenic bladder presenting with urinary peritonitis aft er spontaneous rupture of an augmentation cystoplasty: laparoscopic adhesolysis and repair of perforated augmented bladder. (2) an 80-year-old woman with intraoperative mid ureteric injury during laparoscopic right hemicolectomy: laparoscopic ureteroureterostomy and insertion of ureteric stent. (3) a 40-year-old woman with ureterovaginal fi stula post laparoscopic hysterectomy: laparoscopic ureteric reimplantation with psoas hitch and insertion of stent. conclusion: despite the increasing use of robotic surgery in urology we encourage the continued training and dissemination of advanced laparoscopic skills in the elective setting to allow for the advantages of laparoscopy to be transferred to the less common urological emergency setting. robotic ureteric catheter placement; 2) 4 port placement with patient in lateral position; 3) bowel mobilization; 4) localization of lower calyx by intra-operative ultra sound probe; 5) lower segmental nephrectomy; 6) anastomosis (ureterocalicostomy) with 3-0 v-lock sutures over a pre placed 5f ureteric catheter and drain placement; 7) changing of ureteric catheter to dj-stent on 3rd day post-operatively. results: th e procedure was completed successfully without any intra operative complications in all the cases. mean operative time was 160±23 minutes and analgesic requirement of 192±40 milligram of tramadol. none of the patients required blood transfusion. urethral catheter was removed on 5th and drain on 6th post-operative day and stent aft er 6 weeks. one patient had clavien grade 1 (pyrexia) complication. conclusions: robot-assisted laparoscopic ureterocalicostomy for secondary upjo is safe and feasible in expert hands. apart from the short recovery times, early mobilization, decreased analgesic requirements; robotic approach provides the added advantage of technical ease and precision of suturing. laparoscopic dismembered pyeloplasty for upjo in pelvic ectopic kidney apollo bgs hospital, mysore, india introduction and objective: renal ectopia is a rare anomaly and may be associated with pelvic ureteric junction obstruction (pujo). we report such a case with an ectopic pelvic kidney (l-type) with pujo and its successful laparoscopic management. th rough this report we emphasize the importance of adequate preoperative imaging and intraoperative details to avoid mishaps. a 35-year-old male was admitted with complaints of right-side lower abdominal pain of a dull aching type lasting 6 months. ultrasonography revealed left pelvic kidney. th ese fi ndings were confi rmed with an intravenous pyelogram, which showed the left kidney low lying in the pelvic region with features of hydronephrosis and upjo. ct angiography revealed no crossing vessel as the cause of pujo. results: th e patient was taken up for transperitoneal laparoscopic pyeloplasty under general anesthesia. aft er creation of the pneumoperitoneum and with the ports in place, dissection was started and the dilated pelvis could be visualized through the peritoneal window. th e peritoneum was incised and the dilated pelvis on the left side was reached. aft er further dissection, the classic anderson-hynes dismembered laparoscopic pyeloplasty was done by using 4-0 vicryl. minimal excision of the redundant pelvis was required and because the kidney was not mobilized, nephropexy was not required. care was taken to avoid injury to the right ureter, which was coursing in close proximity to the left renal pelvis. preoperatively placed stent was retained and repositioned during the pyeloplasty. estimated blood loss during the procedure was around 50 ml, and the procedure was completed in 120 minutes without any intraoperative complications. th e patient could tolerate oral feeding on the evening of the same day. conclusion: th e upjo in ectopic pelvic kidneys presents a large spectrum of presentation. th e laparoscopic approach provides good surgical exposure, and operative times are compared to those of laparoscopic procedure in anatomically normal kidneys. laparoscopic we present laparoscopic radical cystectomy (lrc) and intracorporeal orthotopic ileal neobladder with two isoperistaltic aff erent limbs. a 71-year-old male patient with recurrent urothelial bladder carcinoma. ct demonstrates bulky bladder tumor in right lateral wall. lrc and intracorporeal urinary diversion were performed. six trocars were used in the procedure. aft er lrc and extended pelvic lymph node dissection were accomplished, a 60cm ileal segment 15cm proximal to the ileocecum was harvested, of which a 10cm proximal ileal segment was moved to anastomose with the end of the harvested segment which was right isoperistaltic aff erent limb. th en 40cm ileal segment was detubularisated leaving 10cm intact proximal ileum for left isoperistaltic aff erent limb. th e harvested ileal segment was symmetrically folded with identical limb lengths. th e posterior wall of the neobladder was sutured, and ileoureteral stents were delivered into the two isoperistaltic limbs and passed up the ureter and coiled into the renal pelvis, and one foley catheter was delivered into the neobladder at the same time. bilateral ureteroileal anastomoses were performed in a continuous manner respectively. th e anterior wall of the neobladder was closed and the posterior urethra was anastomosed with the neobladder. we have performed 10 cases with this technique. all procedures were completed without open conversion. th e mean operative time was 415min with a blood loss of 150ml. th e construction time of the neobladder was 180min. th e time to orally allow was postoperative day 5 in all. th e mean hospital stay was 12d. foley catheter and dj stents were removed on postoperative day 21. no major complication was occurred. conclusion: laparoscopic radical cystectomy and intracorporeal orthotopic ileal neobladder with two isoperistaltic limbs were a safe and feasible for experienced laparoscopic surgeons. however, more cases and long follow-up were required to evaluate the function of the novel neobladder. all in this video, we wanted to share our robotics augmentation ileosistoplasty experience in 11-year-old male patient with a diagnosis of neurogenic bladder. an 11-year-old male patient treated with clean intermittent catheterization and anti-cholinergic therapy for neurogenic bladder. bladder capacity was detected 180cc, the irregularities in the bladder contour and left grade 1 vur was detected in control video urodynamics. so we decided to implement robotic augmentation ileocystoplasty to the patients. results: th e transperitoneal approach is performed by using veress needle to access the peritoneal cavity. th e abdomen was insuffl ated using co2 and trocars placed under direct vision (1 of camera port (12 mm), 3 of da vinci ports (8 mm) was placed and 1 of 5 mm and 1 of 10 mm assistant ports were placed). a 30 cm segment of ileum with mesentery was incised with about 30 cm proximal from the ileocecal valve and this segment was suspended. intestinal anastomosis was performed with 4-0 vicril and 4-0 monocril sutures and created a u-shaped ileal pouch. th e bladder was released from the surrounding tissue. about 8 cm, longitudinal incision was made to the bladder. a single-j catheters were placed to the left ureter and bladder for the left ureteral catheter and cystostomy. th e bowel prepared for bladder augmentation and it was sutured with 4.0 pds with wate tight anastomosis. operation was terminated by placing the drainage catheter. introduction and objective: although their numerous indications make double-j stents frequently preferred in the armamentarium of the urological practice, serious complications can arise, if they are not used correctly. in endourological surgeries, due to type and stuff of material the breakage or fracture risk of the equipment is more. th ere are various types of surgical procedures for the removal of the foreign bodies. shock wave lithotomy (swl) and ureteroscopy (urs) are the fi rst step in the removal encrusted ureteral stent. th is report presents a case of successful forgotten ureteral stent removal by means of fl exible ureterorenoscope (furs) and fl uoroscopic imaging. a 32-year-old male patient was admitted to our clinic with the complaint of recurrent urinary tract infection. in his medical history he said that he had an open kidney stone surgery in 2013 and aft er 4 months d-j catheter removal had been performed. aft er radiologic imaging it is determined that there are two d-j catheter pieces in the right kidney collecting system. furs and removal of foreign body was performed successfully. postoperative fi rst day patient discharged with no complication. results: various materials and coatings have been developed to avoid ureteral stent complications such as encrustation and infections. th e incidence of encrustation increases with the duration that the stent remains in place. th ere are numerous types of removal techniques for foreign body removal, however furs seems to be the better one with the minimal postoperative rates. our technique was performed easily and in a short surgery time. conclusion: flexible urs modifi ed with fl uoroscopy has particular advantages for treating encrusted ureteral stents. th is procedure is least invasive and is thus considered to be most suitable surgery for encrusted ureteral stents or foreign body materials in the kidney. results: we outline strategies to prevent diffi culties with urethro-ileal anastomosis during rarc iucd neobladder formation. furthermore we off er some key technical points that can be benefi cial in overcoming challenging urethro-ileal anastomosis. conclusions: due to the technically complex nature of rarc icud neobladder formation, the awareness of potential pitfalls during each step of the process is essential. issues and solutions discussed in this video provide a valuable resource for clinicians performing this procedure. robotic in this video we present a patient presenting with concomitant renal neoplasm and a large calculus in the renal pelvis that what was managed with robotic pyelolithotomy at the time of partial nephrectomy. results: aft er exposure of kidney the ureter was identifi ed. th e renal pelvis was exposed and pyelolithotomy was performed. aft er this hilum was clamped and partial nephrectomy and renorrhaphy followed. th e warm ischemia time was 21 minutes. th e procedure was completed without any complications. patient was discharged on the second postoperative day. conclusions: although uncommon, the presence of concomitant stone and renal neoplasm can make the decision of optimal patient care more challenging. using robotic platform simultaneous management of both conditions can be accomplished in appropriately selected cases. single introduction and objective: female epispadias is a rare congenital anomaly and is classifi ed, into vestibular, subsymphyseal, and retro-symphyseal. historically treatment consists of staged repairs with urethral and vulvar reconstruction in fi rst stage followed by bladder neck reconstruction at a later age. in addition, staged procedures require multiple sessions of surgery and anesthesia, and are associated with relatively higher morbidity. recently single stage perineal urethroplasty has been used for epispadias repair. objective of the study is to evaluate the results of single-stage perineal urethroplasty with double breasting of the urethra and bladder neck and sphincteroplasty in female epispadias. we treated 5 patients with severe female epispadias since 2007 to 2014. age varied from 5 to 25 years (mean 10years). perineal urethroplasty with double breasting, sphincteroplasty, and genitoplasty was done in cases. th e urethral plate and bladder neck was mobilized from the surrounding tissue till bladder neck. a urethral mucosal strip of about 5 to 10 mm was denuded from the bladder neck to the end of urethral plate on one lateral edge, and tubularized over a 12f catheter. urethroplasty was done with double breasting of the urethral muscle margins starting from inside the bladder neck downward to the neo-meatus with corporoplasty, sphincteroplasty, and genital reconstruction. results: all patients were satisfi ed and happy about cosmesis. of the 5 patients, 4 were fully continent with a dry interval of 4 to 5 hours, one of them had occasional night wetting was put on anticholinergic. one was partially continent with dry interval of 3 hours required anticholinergic. conclusions: perineal urethroplasty with double breasting of urethra, from inside the bladder neck to the neomeatus, resulted in continence in most cases because it increased the urethral and bladder neck resistance, as well as bladder capacity, all were important factors in continence. we advocate this procedure as a fi rst choice in all patients with female epispadias, because it is simple, safe, and eff ective for continence. single we had partial penile disassembly to have the advantage of both technique. so objective of the study was to evaluate the functional and cosmetic outcome of single stage partial penile disassembly repair in isolated male epispadias. a retrospective analysis of 43 cases of primary epispadias repair, performed during july 1998 to july 2013 at our institution. patients were classifi ed on the basis of type of epispadias, urinary incontinence, presence/degree of chordee and penile rotation. exstrophy epispadias complex and secondary repair were excluded. surgical technique: penile de-gloving with mobilization of urethral plate from ventral to dorsal aspect with preservation of blood supply at both ends, distally up to the level of midglans and proximally up to pubic symphysis with division of penopubic ligament to lengthen the penis and position the urethra ventrally. tubularization of urethral plate followed by spongioplasty, corporoplasty with medial rotation of corporeal bodies (without any corporotomy) and glanuloplasty with meatoplasty to bring the meatus ventrally. skin cover with rotation of ventral fl aps and z-plasty when required. results: age of the patients varied from 6 months to 26 years with a mean of 9 years. forty patients (93%) had excellent cosmetic outcome while three patients (7%) had minimal residual chordee/torque but didn't require any surgery in a follow-up to 2-10 years. all seven partially incontinent patients in the study group achieved continence aft er surgery. none of the patients developed complications like fi stula or stricture. all the 12 patients in the post pubertal group reported normal erections and successful ejaculations aft er the surgery. post-operative follow-up ranged from 2-10 years with a mean of 4 years. conclusions: th e technique incorporates all the benefi ts of cantwell ransley repair, needs less extensive dissection than total penile disassembly. both functional and cosmetic results are good with low complication rate. spongioplasty reconstructs near normal urethra and corporoplasty with spongioplasty also helps in prevention of urethral fi stula. introduction and objective: to introduce a unique technique, single port laparoscopic assisted extraperitoneal closure of patent processus vaginalis using j shaped bended spinal needle. materials and methods: a 2.7-mm 30-degree laparoscope was inserted through an umbilical incision. th e scope could view both inguinal ring. j shaped bended 18g spinal needle was inserted just 5mm lateral to the internal inguinal ring. th e needle was introduced to the extraperitoneal space over the vas deferens and spermatic vessels, injecting of saline for the preperitoneal hydrodilation. a 3-0 polyester suture was threaded through an 18g spinal needle. same 3-0 polyester suture was threaded through a 20g spinal needle from the tip. along the guidance of the suture and 18g needle, j shaped bended 20g spinal needle was reintroduced to extraperitoneal space. 20g spinal needle traveled through the upper margin of internal ring, 20g needle tip was pulled out of the initial 18g needle punctured opening. 3-0 polyester suture was pulled outside from the 20g needle tip and then 20g needle is also withdrawn. aft er all these procedure, internal inguinal ring was completely encircled and tied extracorporeally. th e knot was buried in the subcutaneous area within the punctured needle hole. results: sixteen children underwent laparoscopic transcutaneous extraperitoneal (lte) repair of hydrocele by using j shaped bended spinal needle. all patients were discharged on the same day aft er surgery without any complication. during a mean follow-up period of 6 months (range 1-12mo), no recurrence has been observed except fi rst 2 cases. th is lte technique is simple, fast, safe and cosmetic procedure for pediatric hydrocele. robot assisted laparoscopic ureteral reimplantation for girl and boy patients: differences and similarities introduction and objective: nowadays robot assisted laparoscopic extravesical ureteral reimplantation is getting famous and in the literature is being an alternative for gold standard open surgery. in our clinic we have performed 8 ralur procedures in our clinic for vesicoureteral refl ux and ureterovesical stricture and with this video-abstract we would like to share our experience on ralur in girl and boy patients; diff erences and similarities of procedure. we have performed 8 ral-ur cases in our clinic between july 2014-april 2015 for pediatric and adult patients. technique: all procedures have been performed under general anesthesia. nasogastric tube and urethral catheter placed to all patients. for all procedures 4-port confi guration is used: two robotic 8 mm trocar, one 12 mm camera trocar and one 10 mm (including 5 mm cover) assistant trocar. following docking robotic working arms of robot is placed. in all procedures one monopolar curved scissors, one needle holder and one maryland bipolar forceps is used as the working arms. all procedures performed transperitoneally and extravesically. in the working area of the procedure girls have more structures compared to boys. uterus, fallopian tubes and ovaries are the risky structures for girls while the vas deferens in boys. as seen in the video fallopian tubes, uterus and vas deferens are extraperitoneal organs, but ovary is intraperitoneal organ. we create a peritoneal window to reach the retroperioneal space and to dissect the ureter. dissecting the ureter we have been very careful not to harm vas deferens in boys and fallopian tubes in girls. protecting this structures we open one peritoneal window in boys and two windows in girls to fi nd and to work with the distal part of the ureter. vessel tape is used to hang the ureters. th e bladder is elevated with a 3-0 straight needle vicryl suture through the abdominal wall. aft er that the ureter was clipped with a hemoloc clip and sutured with a 3-0 vicryl suture in watertight fashion (if necessary). aft er suturing the distal ureter tailoring for the dilated distal rest ureter is performed (if necessary). following detrusorotomy, mucosa is cut for the anastomosis (if necessary). before the ureterovesical anastomosis 6 f nelaton or a dj catheter was placed inside the ureter (if necessary). ureterovesical anastomosis is made with a 4-0 monocryl suture (if necessary). in the cases that ureter and mucosa are not cut, realignment suture is used. detrusorraphy is performed by a 3-0 barbed suture. following detrusorraphy we repaired the parietal peritoneum to close the peritoneal window one line and two lines in boys and girls, respectively. results: ralur procedure has been used successfully in girls and boys by considering the anatomical differences. bleeding was minimal in all patients. all patients discharged at the 2nd or 3rd postoperative days. conclusion: while using ralur procedures in pediatric patients, surgeon must be aware of the anatomy. mistakes during the procedure may damage the reproductive system components. performing this procedure in children, compared in adult patients, there are diffi culties due to the small size of the abdominal cavity. with the appropriate trocar placement this problem can be solved. robot assisted laparoscopic left ureteral reimplantation for ureterovesical stricture introduction and objective: extravesical robot-assisted laparoscopic ureteral reimplantation (ralur) for vesicoureteral refl ux (vur), ureterovesical strictures (uvs) and ureteral pathologies are alternative to the gold standard open repair in the literature. with this video presentation we want to share our initial experience with robot-assisted laparoscopic extravesical ureteral reimplantation using the ureteral advancement technique for a 5-year-old boy patient who is the youngest patient received this intervention in turkey. we have performed 8 ral-ur procedure for adult and pediatric patients in our clinic. th is patient explained in the video was a 5-yearold boy who has had recurrent infections due to this condition. when the patient applied to our clinic he had already grade 4 left ureterohydronephrosis. we performed left sided ralur procedure for this patient. technique: th e davinci si system was used via a transperitoneal approach. we used a 4 port confi guration for the procedure; one 12-mm trochar for optic, two 8-mm trochars for robotic working arms and one 10-mm trochar for assistance. th e patient was placed in a modifi ed trendelenburg (approximately 10°) position. aft er docking the robotic arms, the ureter is identifi ed closed to the vas deferens. th e ureter is dissected distal to the vas and tented up with a tape. th e bladder is elevated with a 3-0 straight needle vicryl suture through the abdominal wall. a 4 cm detrusorotomy is performed". aft er that left ureter was clipped with a hemoloc clip and sutured with a 3-0 vicryl suture in watertight fashion. aft er suturing the distal ureter tailoring for the dilated distal rest ureter is performed. before the ureterovesical anastomosis 6 f nelaton catheter is placed thorough urethra and bladder inside the left tailored ureter. following this application nelaton catheter is binded to the urethral catheter. ureterovesical anastomosis is made with a 4-0 monocryl suture. detrusorraphy is performed by a 3-0 barbed suture. following detrusorraphy we repaired the parietal peritoneum and fi nished the procedure. foley catheter, nelaton catheter and drain are left at the end of the procedure. rectourethral fi stula is a morbid complication that can occur post trauma, radical prostatectomy, radiation, or pelvic surgery. th e management of these cases can be challenging and might require multiple procedures to achieve cure. th e use of omentum fl ap between the rectum and the urethra is recommended for its potential benefi ts in prevention of fi stula recurrence. we aim to illustrate the feasibility and safety of a new laparoscopic surgical technique for interposition of omentum in patients with complex pelvic fractures urethral injury (pfui) and rectourethral fi stula (ruf). we performed prospective case series of 3 patients with pfui and ruf from september 2014 till october 2014. th e initial approach is perineal with continued dissection until urethral transaction. laparoscopic team mobilises omentum and enters retroperitoneum lateral to bladder. a tvt needle is passed from perineum hugging the posterior wall of pubic symphysis and enters peritoneal cavity. th is tract is dilated and omentum transposed in to perineum. th is omentum is used as interposition between urethral anastomosis and rectum. th e clinical outcome was considered a failure when any instrumentation was needed or the recurrence of ruf. 35th congress of the société internationale d'urologie -siu 2015 abstract book results: median age is 30 years (range 28-33). all 3 patients had complex pfui with ruf. th ey all had an attempt of perineal anastomotic urethroplasty with ruf repair that failed outside our center and were referred to us subsequently. all the patients had supra pubic catheters and 2 of the three patients were passing urine through the rectum and the urethral meatus. one of the patients had a loop colostomy that was closed during the fi rst failed surgery. no intra-operative or post-operative complications occurred. patients were discharged home on post-operative day 3. all 3 patients had the urethral catheter removed aft er 6 weeks. th ree-month follow-up shows no fi stula recurrence with good urine fl ow. conclusion: using our new technique of laparoscopic omentoplasty for interposition of omentum in patients with ruf post pfui is a viable and safe option. th is allows us to perform a perineal surgery with the benefi t of omental interposition using a minimally invasive technique. further studies with larger number of patients as well as longer follow-up would be needed. introduction and objective: to test the hypothesis that a new surgical technique using elaborated perineal anastomotic urethroplasty combined with laparoscopic omentoplasty for patients with complex and prior failed pelvic fracture urethral defect repair was feasible, safe, and eff ective. we performed a prospective, observational, stage 2a study to observe treatment outcomes of combined perineal and laparoscopic approach for urethroplasty in patients with pelvic fracture urethral defect at a single center in pune, india, between january 2012 and february 2013. complex and redo patients with pelvic fracture urethral defect occurring aft er pelvic fracture urethral injury were included in the study. anterior urethral strictures were excluded. th e primary study outcome was the success rate of the surgical technique, and the secondary outcome was to evaluate feasibility and safety of the procedure. th e clinical outcome was considered a failure when any postoperative instrumentation was needed. results: fift een male patients with a median age of 19 years were included in the study. seven patients were adolescents (12-18 years) and 8 patients (53.3%) were adults (19-49 years). th e mean number of prior urethroplasties was 1.8 (range, 1-3). all patients underwent elaborated bulbomembranous anastomosis using a perineal approach with inferior pubectomy combined with laparoscopic mobilization of the omentum into the perineum to envelope the anastomosis and to fi ll the perineal dead space. of 15 patients, 14 (93.3%) were successful and 1 (6.6%) failed. one adolescent boy 14 years old developed a recurrent stricture 2 months aft er the procedure and was managed using internal urethrotomy. median follow-up was 18 months (range, 13-24months). conclusion: combining a laparoscopic omentoplasty to a membranobulbar anastomosis for complex and redo pelvic fracture urethral injury is successful, feasible, safe, and with minimal additional morbidity to the patient. th e technique has the advantage of a perineal incision and the ability to use the omentum to support the anastomosis. dorsal results: buccal mucosal graft urethroplasty was done in all the patients with the graft being harvested from the buccal mucosa of the oral cavity. postoperative evaluation was done with voiding cystourethrogram at the time of catheter removal during the 4th postoperative week. mean peak urinary fl ow rate increased from 6.8 ml/sec to 30.8ml/sec with normal fl ow curve stabilised at 3 months to a mean of 24.4 ml/sec. patients were followed at 3, 6, 9 and 12 months in the fi rst year and then 6 monthly thereaft er with urofl owmetry and ultrasonogram. mean follow-up period is around 18 months. two patients required urethral dilatation for recurrence of symptoms. none of the patients developed stress urinary incontinence during follow-up. conclusions: female urethral stricture disease is under diagnosed and bmg urethroplasty is underutilised. our study adds to the limited evidence base, that bmg urethroplasty can be done safely with good results in females. a introduction and objective: ureteral fi stula's treatment oft en includes long and complex surgical and endoscopic therapies and represent a challenge for the urologist oft en with disappointing results. uventa® stent placement could represent a new option of conservative treatment for ureteral fi stulas. materials and methods: uventa® self-expanding ureteral stent are able to restore urinary fl ow in ureteral stenosis and to facilitate the closure of ureteral fi stulas thanks to its triple layer structure made of two layers of metal mesh with interposed a ptfe membrane. uventa® stents are available in diff erent lengths and diameters, and allow the coaxial overlap of the ends of multiple stents, providing a lumen of large caliber able to ensure the proper urinary fl ow and the possibility of further endoscopic procedures. we show the case of 65-year-old man that in september 2014, undergone to pelvic surgery for an adenocarcinoma of the sigma in advanced stage. th e postoperative period revealed a urinary leakage, dealt initially in conservative way by the general surgeon. due to unsatisfactory results, the patient was then evaluated by the urologist and subjected to bilateral ascending pyelography highlighting the presence of a high fl ow left ureteral fi stula in pelvic tract; he case was managed immediately with bilateral ureteral stenting prior to placement of a uventa® stent. th e subsequent step was a retrograde pyelography through the left stent, used to identify the site of the ureteral fi stula. aft er hydrophilic guidewire positioning and mono-j stent removal, the delivery system of the uventa® stent is advanced coaxially to the guidewire under radiologia control. once reached the desired position the stent is released from its delivery system whit pull-back technique playing a uventa® stent 9fr x 20 cm allowing its simultaneous self-expansion. th e next ureteroscopic control has shown the need to placement of an additional uventa® stent to complete fi stula's coverage. following the insertion of a hydrophilic nitinol guidewire a new uventa® stent 9fr x 12 cm has been positioned further in order that the ends of the two stent's overlap for a length of at least 3 cm. results: intraoperative retrograde pyelography showed that the stent have eff ectively excluded the fi stula. th e absence of contrast medium leakage was also documented by retrograde cystography performed after 7 days from stents positioning. conclusions: in our experience, the application of uventa® stent has proven to be an eff ective option in the conservative treatment of minimally invasive ureteral fi stulas. robotic we performed fi ve robotic ureteroplasties using a buccal mucosal onlay between september 2014 and march 2015. th e graft was procured by our otolaryngology colleague (jcl). th e graft onlay was performed using 5-0 pds suture and stent was placed robotically. stent was left in place for 4-6 weeks, and imaging repeated aft er removal. results: table 1 describes each case and the outcomes observed. th e three patients who have undergone stent removal and reimaging had complete success and resolution of obstruction. th ere were 3 post-operative complications, and none were higher than grade iii (table 1) . table 2 shows the demographic and perioperative variables of the 5 patients undergoing this procedure. conclusion: our technique of robotic buccal mucosal ureteroplasty is safe and eff ective. we believe this is a relatively simple technique which is easily replicated. long-term data will be important to prove the validity of this procedure. primary endoscopic realignment of rupture urethra introduction and objective: pelvic fracture urethral injury (pfui) is more common in india and subcontinent. th ere is no consensus on the initial management of this injury. th ere are two schools of thoughts in all cases of suspected or confi rmed urethral rupture: a) initial supra-pubic catheterization (spc) followed by urethral reconstruction of inevitable stricture; and b) realignment of urethra. we demonstrate method of primary endoscopic realignment of rupture urethra and review the literature comparing these two procedures. a 45/m-presented with retention of urine and bleeding per urethra. he had sustained pelvic trauma when he was crushed between a tank and a wall. aft er initial resuscitation he had x ray pelvis, ct abdomen, rgu. he then underwent spc under ultrasound guidance. on 17th day aft er spc he underwent primary endoscopic realignment of the rupture urethra. we have shown a technique and reviewed the relevant literature emphasizing advantages of realignment. results: we used a two endoscopes technique one each from the spc route and per-urethral route. intra-operative contrast study was done to see extent of injury and also to see possible patency and continuity of the urethra. additionally methylene blue study was also done. a ptfe guide wire (gw) was passed from below. at the fi rst site of the gw from above it was apparent that further manoeuvers such as "going for light" would not be required. th e gw was carefully pulled in suprapubically. a silicon foley catheter (14 f) was gently passed perurethrally over it. th e position of catheter was confi rmed suprapubically. patient had no major or minor complication. catheter was placed in for 6 weeks and removed. post catheter removal patient voided well. th ese results correlated well with other studies in the literature. conclusion: 1) technically not a challenging procedure. 2) low risk and low complication rate. 3) one failure of procedure does not preclude further attempts. 4) adequate experience and instrumentation are essential. 5) level 3 evidence in favor of this approach over spc alone and further urethroplasty. neourethra with penile skin flap after total amputation of the penis kulkarni s, joshi p, batra v, sharour w, hunter c, surana s, kulkarni j introduction and objective: urethral carcinoma is a rare oncological entity. th e standard treatment for invasive urethral squamous cell carcinoma is radical penectomy, prostatectomy, cystectomy and ileal conduit. in our technique, we describe a palliative surgery that avoids the ileal diversion and perineal urethrostomy through the use of dorsal penile skin tubularization. th is video represents a detailed, step-by-step technique for retro auricular graft harvesting that we have found facilitates resident and general urologist teaching. ears were prepped and draped. th e grafted was areas were marked bilaterally. diluted lidocaine with epinephrine was injected subcutaneously. th e graft was harvested using sharp scissors. donor site was closed in two layers with minimal aesthetic changes. conclusions: our technique to harvest retroauricular graft is a simple and reproducible. it is useful in patients with lack of bmg. th is step-by-step video could be a useful resource for residents and general urologist who wish to learn an alternative graft . hand combined antegrade and retrograde intraureteric surgery in re-implanted ureter introduction and objective: we review a case of re-implanted ureter complicated with stricture and stone impaction. a 43-year-old gentleman was following the urology department at hmc. between the year 1991 until 2014 he was managed by the same urology team for his multiple urological complaints. diff erent open and endourological approaches were conducted. at the year of 2013, this gentleman was complaining of colicky pain due to a 1 cm impacted stone in the left lower ureter, 4 sessions of eswl failed to break it. ivu showed left ureteric stricture, cystoscopy with trial of ureteroscopy was unsuccessful because the left ureteric orifi ce couldn't be identifi ed, so left percutaneous nephrostomy access inserted and followed by antegrade fl exible ureteroscopy, small opening found at the lower part of mid ureter and opened widely by laser, then followed by antegrade double j stenting. retrograde rigid ureteroscopy 7 french identifi ed the stone at mid ureter in a later session and fragmented by laser. a double j stent was reinserted and removed later with smooth recovery. results: management of stones, in the male urethra, is a challenge, more so in a reconstructed urethra. th e dilemma always is whether it is worth incising an otherwise normal or reconstructed urethra, to extract a calculus, especially in this minimally invasive era. th e point to note is the 'painting' technique used to powder the stone, rather than fragmenting the stone into large fragments, which are then diffi cult to remove. high frequency and low energy laser setting is the order of the day. conclusion: laser lithotripsy using a high frequency low energy setting, is a good option for urethral calculi in a reconstructed urethra. retrograd introduction and objective: uretery duplication is a most common congenital anomaly of upper urinary system. th e incidence of it, in autopsy and intravenous pyelography (ivp) series, is 0.7% and 2-4% respectively. it is two-fold more frequent in women than men. retrograde intrarenal surgery (rirs) is a new technology in stone surgery with the fl exibility and most eff ective visualing. in patients who suff er from kidney or uretery with ureter duplication, rirs become the best surgery choice with its advantages. in this case, we present a patient who have the symptoms of kidney stone and ureter duplication. a 46-year-old male patient applied our clinic with the left fl ank pain. in his intravenous pyelography (ivp) and computerized tomography, it was clearly seen left ureter duplication of which both ureteropelvic junction and duplicated ureters obstructed by two kidney stones. other laboratory tests were normal. rirs surgery was performed the patient successfully. postoperative fi rst day patient was discharged without any complication. results: ureter duplication is a rare congenital anomaly of upper urinary system but the rarest thing is that the obstruction of both duplicated ureters with upj by kidney stones. in our case this kind of case successfully treated by rirs. in this surgery a new technique of access sheet entering for rirs was applied. to our knowledge it is the fi rst case in literature. surgical procedures in patients with urinary tract abnormalities are more diffi cult than the normal anatomy. th e development of new technologies is changing approach to such cases. rirs fi eld of use is gradually increasing in urologic practice. rirs in is a preferable method in duplicated ureter with stone formation. a introduction and objective: nephron-sparing surgery is now the standard of management of small renal mass and is increasingly performed for larger and more challenging lesions. th e aim of this study is to report our experience with robotic partial nephrectomy (rpn) and lapascopic partial nephrectomy (lpn) in 37 patient's surgical outcome (blood loss, wit los renal function, complication). (2)) aml (rpn (6) lpn (8)), oncocytoma (rpn (2) lpn (0)) and simple cyst (lpn (1)). th e positive surgical margin rate were both 0% in rpn and lpn group. th e decline in glomerular fi ltration rate at the last available follow-up was similar in both groups. laparoscopy training at home guijarro a, ascencios j, morales s, huertas j, fernández b, navarro f, paniagua p introduction and objective: th e increasing use of laparoscopic surgery makes training fundamental to acquisition of the basics techniques of endourology. unfortunately, laparoscopic fi eld requires high ability and a long learning curve so it's needed simulators to practice. traditional pelvitrainers improve the laparoscopic skills of a trainee but don't simulate the real conditions of the human body. we present a homemade training surgical model that may help to achieve the skills needed and simulates the abdominal space. it is called simulated environment for laparoscopic training (selt). we have developed a laparoscopic training system based in a simulated environment. we modifi ed a dummy who represents a human trunk, this model it easy to fi nd in hardware stores. th en, we performed several orifi ces in order to place traditional laparoscopic ports in pelvic surgery disposition and two additional for our camera. inside the dummy we placed three screws and developed another hole for attaching a cork panel. also, we used a wardrobe fl ashlight as lighting system. as optical system we have used a 9 inch tablet or a photographic camera linked to the tv. finally, for reproducing a vesicourethral model we use two balloons in order to create an anastomosis between them. final price for the selt model, excluding optical system and disposables (we used discarded ports) was 20 euros, what is signifi cantly lower than the commercial pelvitrainers. time needed for installing all the devices is about 60 minutes. results: th e level of simulation is high, it is more realistic, being harder and diffi cult than "traditional" pelvitrainers. th e degree of movements is limited by the real placement of the ports, distance until exercise is similar and we have to be able to work without results: nine patients underwent tmc left pyeloplasty. th ere were 5 female and 4 male patients with age ranging from 21-28 years .operating time ranged from 120-150 minutes with mean of 132 minutes. per-operative blood loss was minimal ranging from 10-20 ml. return of bowel movement was within 1-2 days. all patients were discharged within 2 days and drain removed with 2-3 days. two patients were discharged on 2nd day but drain was removed on 3rd day in outdoor. follow-up of 8 patients showed improvement in their pain status and ivu showed no re-stricture or stenosis. our last patient is yet to come for the fi rst follow-up. conclusion: tranmesocolic approach for left puj obstruction is feasible and seems to have low morbidity with shorter hospital stay. comparison with colon-refl ecting pyeloplasty and larger number of cases are needed for better statistical evaluation. transperitoneal conclusion: th e overall cdr (67%) for our cohort was comparable to results from mri in-gantry biopsy. in volumes >40 cm3, the cdr was 57% which was signifi cantly higher than that achieved by historical trus controls. th is study reinforces the benefi t of fusion biopsy in prostates in all volumes, but this utility is further enhanced in large volume glands without the potential toxicity associated with increased number of biopsies. fusion mim-transperineal fusion biopsy has the greatest impact in the biopsy naive population results: during the above mentioned period 246 patients underwent radical prostatectomy. in 99 (40.2%) cases erp was preceded by mpmri and psm was detected in 16 of them (16.2%). in the majority of patients (11/16; 68.7%) with positive margins pca was locally advanced or gleason score was greater than 6. th e margin was focal in 6 (37.5%) cases. th e most frequent location of psm was the prostate apex. it occurred in 10 patients (62.5%) and in 7 of them the right side was involved. in 9 (56.2%) patients psm was detected in a location in which mpmri did not reveal the presence of pca. in 5 of them, cancer invaded periprostatic tissues. macroscopic evaluation of the specimen performed directly aft er the erp indicated the possibility of psm presence only in 2 patients but in both cases histological evaluation of the prostate specimen revealed extensive psm. the peri-prostate fat seen on mri. prostate volume was calculated using (height x width x length x π)/6. peri-prostatic fat density was then calculated using peri-prostatic fat volume/ (peri-prostatic fat volume + prostate volume). peri-prostatic fat ratio was calculated using (peri-prostatic fat volume / prostate volume). intervention includes cryoablation, brachytherapy, prostatectomy, external beam radiation with or without androgen deprivation therapy. results: a higher periprostatic fat density is signifi cantly associated with a higher gleason score, p=0.026, odds ratio 32.0. a higher periprostatic fat ratio is also associated with a higher gleason score, p=0.004 odds ratio 3.25.patients with a higher prostate fat density (p=0.003, odds ratio 91.95) and higher peri-prostatic fat ratio (p=0.004, odds ratio 2.87) was also more likely to undergo intervention for prostate cancer (table 1 ). psa has no correlation between periprostatic fat and periprostatic fat ratio. a higher prostate fat density and fat ratio is signifi cantly associated with a higher gleason score and a higher likelihood of patient undergoing an intervention for prostate cancer. peri-prostatic fat density and fat ratio may be an important risk factor in diagnosing patients higher grade prostate cancer. laparoscopic . th e mean urinary ph among the diabetics was 5.61 ± 0.36 and among the non-diabetics was 6.87 ± 0.32, which was signifi cantly lower (p<0.000044). conclusions: th ere is a strong association between type 2 diabetes and uric acid stone formation. th ere is also a strong association between diabetes mellitus, bmi, and also with lower urinary ph. the most patients 39 (80%) were discharged on good condition while one patient died post-operatively. majority of patients 39 (80%) stayed in the ward more than 7 days post operation, the long-term post-operative outcome is yet to be assessed. conclusion: usd in our local setting seem to aff ect people of low social economic status whose daily activities in the fi elds, livestock keeping etc. mean survival; therefore longer stay in the hospital has a detrimental economic impact. outdated diagnostic, treatment equipment and technology lead to prolonged hospital stay. th ere is a need therefore for administrators and urologists in tanzania to improve quality of management of usd by acquiring aff ordable equipment and technologies. percutaneous nephrolithotomy in an ambulatory setting introduction and objective: percutaneous nephrolithotomy (pcnl) is the gold standard for the surgical management of large renal stones. various modifi cations have been done over a period of time to bring down the morbidity of this procedure. ambulatory pcnl (a-pcnl) aims at short hospital stay which is less than 24 hours with faster recovery aft er pcnl. th is study aimed at exploring the feasibility and safety of short stay ambulatory pcnl. : th e number of pcnl procedure done at our institute annually ranges between 750-900. hence, carefully selected patients with single renal calculus, size<2cm, bmi <35kg/m2, favorable anatomy, no medical co-morbidities and moreover patients staying within a radius of 15km to the hospital with a supportive well informed family were given the option of a-pcnl. a total of 12 patients underwent a-pcnl from april 2014 to june 2014. all patients underwent totally tubeless pcnl with single puncture, amplatz size <26f, minimal saline irrigation and puncture site infi ltration with 0.25% bupivacaine. postoperatively narcotic analgesics were given; catheter was removed in the post-operative ward and patient was discharged within 24 hrs. patients were explained regarding the complications of the procedure and need for homecare management. results: ten out of 12 patients had insignifi cant post-operative period. one patient returned aft er 48hrs with loin pain which was evaluated and managed with injectable nsaid. another patient had hematuria which resolved aft er 72 hours with conservative management. introduction and objective: chronic kidney disease (ckd) is associated with increased cardiovascular (cv) disease, independent of other risk factors. it is unclear whether anaemia develops in the setting of nephrectomy induced ckd, and whether it leads to an increased risk of cv morbidity. we assessed the impact nephrectomy has on renal function and evaluated our cohort for the presence of anaemia in relation to ckd stage and cardiac specifi c morbidity. pre-operative, post-operative, and yearly creatinine, hb and hct (up to 5 years) was collected from 91 nephrectomy patients between 2006 and 2009. th e cohort was stratifi ed by cardiac risk factors and the prevalence of anaemia was stratifi ed by each ckd stage. we collected all-cause mortality and cv morbidity and mortality data. statistical tests were two-sided. where data was non-normally distributed median values and non-parametric tests were used. results: th e eff ect of nephrectomy on renal function is immediate (pre-operative vs. post-operative cr: p=0.00) but not progressive (post-operative vs. 5-year cr: p=0.935). elderly patients, patients with ≥2 risk factors, bmi≥30 or hypertension had signifi cantly higher post-operative cr (p=0.00; p=0.003; p=0.046; p=0.041). advanced age and mild ckd were important risk factors for ckd stage progression. th e prevalence of anaemia increased as ckd stage increased. at one year, the prevalence of anaemia was highest in ckd-4 patients (66.7%), compared to ckd-3 (28.6%) and ckd-2 (15.4%) patients. fift een percent of patients experienced a new cv event; 62% of these patients were anaemic. conclusion: nephrectomy leads to immediate renal function deterioration but with no progression over time. th e clinical impact of nephrectomy is especially important in elderly patients and in patients with mild pre-operative renal impairment. th e prevalence of anaemia is more common in patients who have a higher ckd stage aft er nephrectomy, and may be a key risk factor for cv morbidity in nephrectomy patients. we believe that it is important to be able to predict who will progress to clinically signifi cant ckd, in order to optimise comorbidities and aggressively treat complications of ckd, such as anaemia. renal results: urological complication were observed in 27.06% of all transplants. in an early phase we found that 1.76% of patients showed problems related to the ureterovesical suture (loosening of the suture or attaching the double-j stent in the suture). suspicion of leakage with the formation of a urinoma was noted in 1.76% of cases. more frequent were the late urological complications: hydronephrosis was seen in 9.41% of cases. when further analyzing this group we discovered a distal ureteral stenosis in 3.53% of all transplants. persistent hydronephrosis was resolved by reimplantation (3.53%), permanent nephrostomy (1.18%) or placement of a double-j stent (0.59%). a large group of late complications consisted of infectious pathology. th us 8.82% suff ered from complicated urinary tract infections which slightly more than a quarter of this population presenting with hydronephrosis. recurrent urinary tract infections without complications were found in 9.41% of transplanted patients. conclusion: currently, the urological team mainly plays a role in the pre-and post-operative phase of renal transplantation. given the signifi cant compli-cations associated with the ureterimplantation performed during kidney transplantation, we advocate a place for the urologist in the perioperative phase as well. since the majority of the complications could be related to refl ux pathology, we propose a ureterimplantation with anti-refl ux mechanism. and october 2012, 46 patients were prospectively randomised into two groups. all patients presented with a simple renal cyst underwent ultrasonographic aspiration and injection of a sclerosing agent. in group 1, 25 patients had the cyst injected with eo, and in group 2, 21 were treated with ae. one injection was used in cysts of <200 ml and two injections were used in larger cysts. complete and partial success were defi ned as complete cyst ablation or a >50% reduction in cyst volume with symptomatic relief, respectively. patients were followed up using semi-annual ultrasonography and computed tomography for 2 years. results: sclerotherapy was technically successful in all patients. th ere was no signifi cant diff erence in cyst volume between the groups. aft er 2 years of follow-up there was complete symptomatic relief in both groups, and the overall radiological success rate was 100% of both groups, at 79% complete and 21% partial in group 1, and 83% complete and 17% partial in group 2. th e frequency of transient complications in the form of microscopic haematuria was 7% and 13%, and of low-grade fever was 4% and 10% in groups 1 and 2, respectively. a composite outcome parameter, known as "trifecta", has been recently proposed as measure of the surgical quality for partial nephrectomy (pn) procedures. we aim to validate the value of "trifecta" as a predictor of operated kidney functional preservation in a multi-institutional cohort of patients undergoing minimally invasive pn. we retrospectively reviewed records of consecutive cases of minimally invasive (laparoscopic and robotic) pn performed for ct1 renal masses in 4 centres from usa and europe from 2009 to 2013. inclusion criteria consisted of availability of a renal scan obtained within two weeks prior to surgery and follow-up renal scan 3-6 months aft er the surgery. trifecta was defi ned as a combination of negative surgical margin, zero perioperative complications and warm ischemia of less than 25 minutes. th e primary endpoint of the study was to compare the degree of ipsilateral renal function preservation in relation to achievement of trifecta. renal function preservation was defi ned as a proportion of post-operative to pre-operative split renal function assessed by mag3 renal scan. a multivariable linear regression model was used to determine the independent value of several factors (surgical modality, charlson comorbidity score, achievement of trifecta, r.e.n.a.l score) to predict ipsilateral split function preservation. th e logic was that pnet is chemo-responsive and remaining are not. results: a total of 26 patients were identifi ed. th e various histo-pathologies are shown in table 1 . group 1 had 20 and group 2 had 6 patients. mean age in group 1 was 60.7 yrs (34-88 yrs) with 17 (85%) males and 3 (15%) females. tumor was right-sided in 15 (75%) and left -sided in 5 (25%) cases. th e mean tumor size was 9.55 (5-18) cm. necrosis was noted in 4 (20%). level of thrombus was level i in 1, level ii in 10, level iii in 4 and level iv in 5. mean age in group 2 was 25.8 yrs (14-35 yrs) with 3 (50%) males and 3 (50%) females. tumor was right-sided in 5 (83.3%) and left -sided in 1 (16.6%) cases. th e mean tumor size was 11.8 (7-16) cm. necrosis was noted in 2 (33%). level of thrombus was level i in 0, level ii in 5, level iii in 0 and level iv in 1. one of these was diagnosed pre-operatively by a biopsy and had received chemotherapy with partial tumor shrinkage. remaining 5 received adjuvant chemotherapy. of relevance is that the youngest patient in group 1 was 34 years whereas the oldest patient in group 2 was 35 years. in patients with renal tumors and venous thrombus who are younger than 35 years, pre-operative biopsy should be contemplated. in patients with a diagnosis of pnet, neo-adjuvant chemotherapy can be studied. introduction and objective: th e use of nephrectomy in emergency is increasingly rare due to the improved critical care urinary sepsis and development of radio-embolization. few series have been reported on this subject. th e aim of our study was to evaluate current indications, morbidity and mortality and results of nephrectomies performed in our hospital in emergency. a single-center retrospective study was conducted from january 2007 to december 2013. twenty patients were operated in emergency from total nephrectomy. results: nine women and 11 men with a mean age 51.7 (46.6 to 85.2) were treated for 9 sepsis on emphysematous pyelonephritis or renal abscess, 4 trauma with haemorrhagic shock, 7 acute bleeding on renal tumours with haemorrhagic shock. one patient required critical care for multiple organ failure. th e time between the initial care and surgery was 2.7 days (0.5-8). ten patients were referred to the emergency room by their physician and 10 by a peripheral hospital. all these nephrectomies concerned native kidneys (14 left kidneys). surgical approach was a lumbotomy for 14 patients and a median laparotomy for 6 patients. one patient died of multiple organ failure following urinary sepsis. one patient required dialysis following nephrectomy. th e mean follow-up aft er surgery was 17.7 months (0.1 to 48.7). conclusion: th e nephrectomy in emergency remains anecdotal. uncontrolled urinary sepsis were the main indications. th e identifi cation of populations at risk of progression to septic shock is essential for faster and reduced mortality in sepsis care. experiences of adrenalectomy for the incidentally discovered adrenal masses introduction and objective: a diagnosis of urinary tract obstruction (upjo) results in a functionally signifi cant impairment of the urinary transport from the renal pelvis to the ureter. options for the surgical management of upjo include ureteral stent placement, balloon dilation (antegrade, retrograde or cutting balloon), endopyelotomy, and open or laparoscopic pyeloplasty. however, in some cases, surgery is not eff ective, or too invasive for a particular patient. we herein report ten cases of treatment using bethanecol chloride. we retrospectively reviewed the record of 10 patients, 3 men and 7 women, aged 24 -84 years (mean 50.1) whose diagnosis was upjo (7 cases of hydronephrosis on the left , 3 on the right). th e chief complaints were back pain (5 cases) and urinary tract infection (3 cases). one patient had no complaint. all patients took 10mg of bethanecol chloride 3 times a day for two weeks. aft er two weeks, kidney condition was evaluated using ultrasonography. results: five cases of hydronephrosis decreased or disappeared. five cases showed no improvement. among the latter, one had pyelonephritis, two had received laparoscopic pyeloplasty (one of whom had a non-functioning kidney and a pyelonephritis), and another had a non-functioning kidney. guzman martinez-valls p, sanchez rodriguez c, doñate iñiguez g, maluff torres a, honrubia vilchez b introduction and objective: we present man 63-yearold, hypertensive, diagnosed incidentally of intrathoracic renal ectopia during a constitutional syndrome study. intrathoracic renal ectopia is a very rare fi nd, with an incidence of less than 1 of every 10,000, which mainly aff ects left kidney since the liver protects the right diaphragm from pressure changes. a literature review of incidence, source, clinic, diagnostic and treatment of this type of renal ectopia occurs and we present the case diagnosed in our service. : chest x-ray shows a mass back in mediastinum so it was decided to ask for tomography computer (ct) that shows a hernia left postero-lateral difragmatic with promotion to the thoracic cavity of upper pole and half of the left kidney. since the patient is asymptomatic and the hernia is extrapleural does not need repairing surgical treatment. annual checks will be. intrathoracic renal ectopia is a very uncommon, usually asymptomatic, fi nding oft en diagnosed incidentally and which does not usually require treatment. surgical (53), non-clamp zero ischemia (7). th e average blood loss was 553ml (range 50ml -3200ml) and 8 patients (12%) required blood transfusion. postoperatively 10 patients (15%) had surgical complications: severe haemorrhage requiring emergency completion nephrectomy (2), post-operative urinoma formation requiring ureteric stenting (7), pneumothorax requiring tube thoracostomy (1) . early 30 day mortality occurred in one patient with pre-existing stage 5 chronic kidney disease who died of acute on chronic renal failure. th e r.e.n.a.l. score of those with and without surgical complications was 7.1 and 8.1 respectively. th e complication rate of low (score 4 -6), intermediate (score 7-9), and high (score 10-12) r.e.n.a.l. category was 11.8%, 20.8% and 50% respectively. statistically, blood loss, transfusion rate and surgical complication rate were not signifi cantly associated with medical co-morbidity, r.e.n.a.l. score or mode of ischemia, although more complex mass apparently resulted in more surgical complications. our study suggested that partial nephrectomy is a safe operation with acceptable bleeding risk and low complication rate. further larger scale study is needed to analyze the correlation of complications with renal mass complexity. introduction and objective: th e sound of running water has been eff ectively used for toilet training during the toddler period. however the eff ect of the sound of running water (srw) on voiding function for adult male with lower urinary tract symptoms (luts) has not been evaluated yet. to determine the eff ect of the srw on urination of male patients with luts, multiple voiding parameters of urofl owmetry with postvoid residual urine (pvr) were assessed according to the presence of the srw played by mobile application. a statistically pre-calculated numbers of 18 consecutive male patients with luts were prospectively enrolled between march and april 2014, excluding patients with hearing impairment, disability for movement, neurologic disease, urology deformity, and recent history of urinary tract infection or urethral stricture. urofl owmetry with pvr measured by bladder scan were randomly performed once a week for two consecutive weeks with and without srw in a completely sealed room away from exterior noise aft er pre-checking bladder volume scanned to be more than 150cc. th e srw was played with river water sound among relax melodies recorded in the smart-mobile application. results: th e mean age of enrolled patients and their mean ipss were 58.9 ± 7.7 years (range: 46-70) and 13.1 ± 5.9. all patients have not been prescribed any medications including alpha-blocker or anti-muscarinic agents in the last three months. a signifi cant increase in mean peak fl ow rate (pfr) with srw was detected in comparison with pfr without srw (15.7 ml/s vs. 12.3 ml/s, p = 0.0125). however, there were no diff erences in other urofl owmetric parameters including pvr. materials and methods: over a two-year period, 214 men underwent lumbar spinal fusion by a single neurosurgeon. we excluded men with previous prostate or urethral surgery, a history of urinary retention, men taking alpha-blockers or fi ve alpha-reductase inhibitors, and men with prolonged hospital stay, leaving 148 men evaluable. all men left the operating room with a foley catheter in place and were given a void trial on the day of anticipated discharge. twenty-three men were unable to void aft er eight hours and had their foley catheters replaced; they were discharged next day with an appointment for urologic follow-up. th ese men were compared to successful voiders with respect to comorbid medical conditions, age, surgical placement of hardware, operative time, lumbar level, multiple level fusion, and surgical approach. results: using multivariable analysis, successful postoperative voiders were compared with men who failed the initial voiding trial. only insulin-dependent diabetes mellitus (p-value less than 0.01) and multiple lumbar level surgery (p-value less than 0.01) were predictive of initial postoperative failure of voiding trial. conclusion: men scheduled to undergo lumbar fusion who have insulin-dependent diabetes or who will require multiple level intervention may benefi t from preoperative initiation of alpha blockade at the time of scheduling, as well as an inpatient postoperative urologic consultation. introduction and objective: heart rate variability (hrv) is a tool to measure autonomic nervous function, however there is no evidence that it is able to defi ne sympathetic hyperactivity in men with luts. we suppose that luts is diff erent between sympathetic hyperactive and hypoactive patients. th erefore we measured their hrv, divided luts patients into two groups, sympathetic hyperactive group and sympathetic hypoactive group according to the lf/hf ratio, and then compared their clinical situations. a total of 39 symptomatic luts patients (ipss>8) and 48 healthy volunteers were enrolled. all subjects had no disease which can aff ect autonomic nervous system, such as diabetes, hypertension and so on. electrocardiographic signals were obtained from subjects in resting state and calculated the hrv indices with spectral analyses. we divided luts patients into two groups by lf/hf ratio 1.8 which was mean value in healthy volunteer and compared the diff erence of clinical characteristics, ipss, psa and trus results. th e parameters were compared by independent sample t-test using spss version 12. results: th ere was no diff erence in age, serum psa and volume of prostate. th e comparative results of pa-rameters of hrv between groups (mean ± standard error) are in the table 1 . conclusions: as most investigators believe that lf and hf represent sympathetic and parasympathetic nervous system activity, respectively, our results may suggest that luts patients with relatively sympathetic hypoactivity suff er from nocturia more than those with sympathetic hyperactivity. we suggest that the imbalance of the autonomic nervous system activity may be a factor that evokes varieties of symptoms in men with luts. introduction and objective: women presenting with urogenital pain oft en have lower urinary tract symptoms (luts). pelvic fl oor dysfunction and hypertonicity is thought to contribute to these symptoms. physical therapy and myofascial release are eff ective for both conditions, suggesting a common underlying pathophysiology. we aim to investigate the association among pelvic fl oor tone, luts, and pelvic organ distress. th ere was a tendency of lower hemoblobin decrease in 5ari group, however, this results was not statistically signifi cant. th ere were also no significant diff erences in improvement of ipss, qol and urodynamic fi ndings between the two groups. conclusion: preoperative use of 5ari does not compromise, but rather increase the effi ciency of surgery. th e use of 5ari is not a contraindication to th ulium laser vapoenucleation. age-specifi c relationships between lower urinary tract symptoms and late-onset hypogonadism symptoms in the japanese general population introduction and objective: aging is known to aff ect sexual, psychological and physiological functions including lower urinary tract symptoms (luts). recent data suggested that severity of luts was associated with that of late-onset hypogonadism (loh) in elderly men. however, information on the association in young adults is limited. in this study, we evaluated the relationship between luts and loh symptoms in young and middle-aged adults. results: th e mean ages of the patient and control groups were 40.50±5.12 years and 38.17±2.12 years, respectively (p=0.09). th e mean ifsf-total and all of the ifsf sub scales (except pain) in the patient group were signifi cantly lower than those of the control group. th e mean udi-6 score of the patients was signifi cantly higher than the controls (p=0.001). th e mean iiq-7 scores of the patients was higher than controls, however this increase was not statistically signifi cant (p=0.11). introduction and objective: sav1 is one of the core components of hippo pathway, and this pathway plays a role for cell proliferation, apoptosis and migration through regulation of yes-associated protein 1 (yap1). yap1 is known as an oncogenic protein in many human cancers, but only a few studies demonstrated that yap1 acts as an oncogene in renal cell carcinoma (rcc). in our previous study, we identifi ed sav1 was downregulated in high grade clear cell renal cell carcinoma (ccrcc) cases compared with low grade ccrcc cases and re-expression of sav1 inhibited rcc cell proliferation in vitro. to evaluate a role of sav1 in vivo, we created a murine xenograft model of human rcc. a total of 786-o cells with stable sav1 re-expression (sav1-1) and control cells (control) were subcutaneously injected into the fl anks of mice, respectively. th ese two cell lines were also injected into subrenal capsule. tumor size, histological appearance and proliferation rate were evaluated. furthermore, transcriptome analysis was performed using a whole-genome microarray, in order to identify functional pathway by ingenuity pathway analysis (ipa) soft ware. to explore whether the identifi ed pathway was involved in hippo signaling pathway, western blotting was performed using antibodies against downstream proteins. in addition, the luciferase reporter assay was performed to explore whether the promoter activity is regulated by hippo signaling. results: tumors injected with sav1-1 showed a decrease of tumor size and growth rate, compared with those of control. by immunohistochemical analysis, it was shown that re-expression of sav1 caused yap1 to localize in the cytoplasm. pathway analysis revealed that tgfβ signaling was found to be inhibited in tumors with sav1-1. in sav1 re-expression cells, protein levels of tgfβ were lower than those in control cells. when yap1 and tead were introduced, reporter activity of tgfβ promoter was increased. attached to a linear motion stage with a stepper motor. shaft buckling was determined by measuring the peak force to compress a 12 cm section of the shaft a distance of 5 cm. lubricity was measured by extracting each wire through simulated tissue at a constant speed, measuring average force over a 5 second period. tip fl exibility was determined by isolating the distal 5 cm portion of each guidewire and measuring the peak force required to compress a distance 2.5 cm while securing the tip in a small hole in a wooden block. perforation force was evaluated by stabilizing each wire in the dilator of a ureteral access sheath and measuring peak force required to perforate aluminum foil. up.023, table 3 . th e results showed that kh-204 protected tm3 cells against h2o2-induced oxdidative stress in a dose-dependent manner. it improved signifi cantly both the decline of semen parameters and decrease of testicular weight of androgen-defi cient rats at a dose of 400 mg/kg. also it inhibited the activities of aromatase with and then increase the serum testosterone levels. conclusion: th ese results suggested that the aromatase inhibitory activity of kh-204 may contribute to the improvement of serum testosterone levels in androgen-defi cient male rats. introduction and objective: although several theories have been suggested, the pathophysiology of interstitial cystitis/bladder pain syndrome (ic/bps) is unclear. disruption of the bladder epithelial barrier is an important pathophysiologic theory of ic/bps, and uroplakin is known to have an important role in the bladder epithelial barrier. th e change in expression of uroplakin subtypes in the bladder could be related to ic/bps. we investigated the change in expression of uroplakin ib and iii in the bladders of patients with ulcerative ic/bps. bladder tissue samples were obtained from patients with ulcerative ic/bps who were treated with augmentation ileocystoplasty. samples for the control were obtained from normal bladder tissue apart from the malignant lesions of 5 patients with bladder cancer who needed radical cystectomy. a voiding diary, the pain visual analogue scale (vas), and the o'leary-sant interstitial cystitis symptom index (icsi), and problem index (icpi) were used to assess patients with ic/bps before operation. expressions of uroplakin ib and iii were compared between the ulcerative ic/bps and control groups by immunofl uorescence staining and western blotting. results: in total, 19 patients with ic/bps (mean age 56.8 ± 11.6 years, 16 women and 3 men) were evaluated. th e mean symptom duration was 4.2 ± 2.2 years. preoperative voiding frequency, nocturia, and functional bladder capacity documented in the voiding diary were 21.1 ± 12.8, 5.9 ± 4.2, and 151.1 ± 62.7 ml (mean ± sd), respectively. pain vas score, icsi, and icpi were 8.4 ± 1.3, 17.7 ± 2.2, and 14.7 ± 1.8 (mean ± sd), respectively. th e mean anesthetic bladder capacity was 518.8 ± 201.9 ml. immunofl uorescence staining showed that uroplakin ib and iii were localized in the urothelium. in western blot analysis, immunoreactive bands indicating expression of uroplakin iii were signifi cantly increased in the ic/bps group compared with the control group. however, uroplakin ib expression was not diff erent between the ic/bps and control groups. green fl uorescence protein cassette, and the infectivity of kshv was assessed using fl ow cytometry. to investigate viral replication, the levels of expression of representative kshv latent and lytic proteins were analyzed by immunofl uorescence assay. in addition, cell cycle and proliferation following kshv infection was analyzed. finally, cdna microarray was performed to identify gene changes by infection of kshv in bc. results: four bc cell lines, except rt4, showed levels of infection similar to or higher than those of hu-vecs. infectivity of kshv in tccsup and huvec cells was similar, but t24, 5637, and ht-1376 cells showed signifi cantly higher infectivity than huvec. our tested kshv-infected bc cells were latently infected by kshv. interestingly, a subset of kshv-infected bc cells showed higher brdu incorporation and proliferation rate than non-infected cells. furthermore, in soft agar colony formation assay, the numbers and sizes of colonies of kshv-infected cells were signifi cantly greater and larger, respectively, than non-infected cells. cdna microarray analysis showed that many proliferation and cancer development-related genes were simultaneously up-regulated in kshv-infected cells. introduction and objective: bladder cancer (bca) is the second common genitourinary tumor, and especially muscle-invasive bca (mibc) is poor prognosis. th erefore, it is important to clarify the mechanism of invasion in mibc is useful for the strategy of appropriate treatment. previously, we have showed hgf-met signaling is correlated with invasion in bca cells. here, we investigate the eff ects of met inhibitor, cabozantinib (xl184), in bca cells to investigate the significance of met upregulation in rt4, 5637, j82, t24, um-uc-3 cells, we conducted western blot analysis. next, we examined eff ect of cabozantinib on proliferation and invasion abilities using mtt and matrigel invasion assays. invasion assays were performed by the xcelligence system. moreover, to investigate biological function of hgf-met signaling, we analyzed gene expression profi le and real time pcr of 5637 cells which cultivated with or without hgf stimulation. . th e mechanical properties of scaff olds were measured to compare tensile strength between two types. for in vitro cell study, scaff olds were seeded with human fi broblast cell at 5 x 105 cells and were cultured for up to 2 weeks. th e ability of these scaffolds to support fi broblast cell growth was also investigated in vitro. results: 3d strand-deposited scaff olds were characterized by sem images and porosity measurement. sem images showed the surface morphology of pcl scaff olds. th e young's modulus of 90°pcl was 20.7±4.8 mpa, and 45°pcl was 12.5±4.0 mpa, respectively. human fi broblast cells covered well the surface of the scaff olds. immunofl uorescent staining of α-er-tr7on fi broblast cells/scaff olds confi rmed that the cells remained viable and proliferated throughout the time course of the culture. th is is a preliminary study to investigate the possibility of using 3d bioprinting technique for tissue engineered tunica albuginea. introduction and objective: aft er 35-40 years at people the decrease in a pool of pluripotent stem cells resulting in insuffi ciency of replenishment of cellular structure of cambial zones and, as a result, to incomplete replacement of the perishing old cells is observed. in reply surrounding epithelial and endothelial cells, and also the macrophages, attracted with death of old cells, stimulate cells division of growth zones by the cellular growth factors (pechersky a.v. et al., 2008) . to 11 patients aged from 52 till 76 years with a cancer of a kidney, bladder, prostate gland of a stage of t2-t4 the chemotherapy or target therapy was carried out. to 4 patients of 60 -82 years for restoration of regeneration it was carried out from 4 to 7 transfusions of mononuclear fraction of peripheral blood, same-gender and blood types with recipients. results: in 1 month aft er carrying out chemotherapy or target therapy aft er development of a leukopenia in 11 patients the level of the basic fi broblast growth factor (bfgf) increased on average by 1.74 times, at 4 patients from them the increase in level of the human vascular-endothelial growth factor (human vegf-a) on average by 1.25 times was observed, the 3rd of them had an increase in the human epidermal growth factor (human egf) on average by 1.13 times. in 3-6 months aft er the last transfusion of mononuclear fraction of peripheral blood the maintenance of hemopoietic cells predecessors of cd34+ in peripheral blood increased on average by 3.25 times (at 4 patients with 1 to 2-5 cells in 1 mcl). at 4 patients the level of the basic fi broblast growth factor (bfgf) decreased on average by 1.78 times, at 2 patients from them reduction of level of the human vascular-endothelial growth factor (human vegf-a) on average by 1.48 times was observed, the 3rd of them had a reduction an human epidermal growth factor (human egf) on average by 4.12 times. decrease in levels of cellular growth factors naturally brought at all 4 patients in a buccal epithelium to decrease in an expression of p53 on average by 6.02 times, at the 3rd of them to decrease in an expression of bcl-2 on average by 60.0 times. excess stimulation of mitotic activity at people 40 years are more senior it is possible to lower to normal level by means of restoration of number of a pool of pluripotent stem cells by transfusion of mononuclear fraction of the peripheral blood from young donors of 18-23 years of one with the recipient blood types and a sex. mashhadi r to compare the expression rate of sex steroid hormone receptors of estrogen (er), progesterone (pr) and androgen (ar) in normal urothelium and urothelial bladder cancer (ubc) and to evaluate the possible associations of these receptors expression with cancer progression and patient's survival. we evaluated the clinical data and tumor specimens of 120 patients with patho-logically confi rmed primary ubc with 132 normal healthy controls. both patients and controls selected from list of subjects who have been referred to sina urology clinic, and had a minimum of one year follow-up duration. data collected from medical cords. for evaluation of expression, immunohistochemistry was performed on paraffi n-embedded tissue sections using a monoclonal antibody for androgen, estrogen and progesterone receptors. presence of at least 10% positive cells defi ned as positive expression. results: none of the control subjects showed ar expression, while 22% of the patients were ar-positive. er/pr expressions were observed in 4.2%/ and 2.5% of the cases and in 2.3% and 1.5% of the controls, respectively. a statistically signifi cant correlation was found between ar expression and tumor stage and grade (p < .001). ar-positive patients showed a signifi cantly poorer prognosis than ar-negative cases (log-rank test, p = .02, hazard ratio = 2.12; 95% confidence interval: 1.36-4.65). conclusion: ar expression was signifi cantly associated with higher grade and poorly diff erentiated tumors with unfavorable outcome. ar expression test might be useful as a diagnostic tool for determining the malignancy and outcome of ubc patients. park s, park w, yoon s introduction and objective: previous researchers consider interaction roles of ampk and ros as a regulator of cancer cell apoptosis and cancer invasiveness in hypoxia and oxidative stress. th e aim of this study was to fi nd out the other aspect of invasion and cell death mechanisms as a new treatment option in urothelial cancer. we performed western blot analysis to determine association between ampk regulator (compound c, aicar) and ros scavenger (nac and tempol) as cytotoxic eff ectors. using gelatin zymography to measure mmp-2, 9 activity, we evaluated the cancer invasion. pathway activation analysis was also determined by western blot. cell survival was investigated by mtt analysis. results: ros scavenger like nac and tempol treated cells showed no change of expressions of phospho-ampk. aicar, compound c and tempol treated cells showed no change of mmp-2 and mmp-9 expressions. however, nac treated cells showed decreased expressions of mmp-2 and mmp-9. ai-car and compound c treated cells with or without added nac and tempol showed no change of mtor and phospho-mtor expressions. aicar treated cells only showed decreased expression of phospho-p70s6k. compound c and tempol treated cells did not showed statistically any change in cell counts. however, aicar and nac treated with or without added compound c and tempol showed increased cell death signifi cantly. conclusions: activator of ampk and ros scavenger like nac decrease t24 invasion activity and increase t24 cell death. so, we demonstrate that the cytotoxic mechanism of bladder cancer remains to be further investigated. epigenetic bladder cancer is still one of common human malignancies which some environmental agents play important role in the process of carcinogenesis, such as aromatic amines or chronic arsenism, and easy to be recurrent and progressive despite of therapy. it is continuing to search some novel genetic or epigenetic biomarkers and to investigate their signifi cance in bladder urothelial carcinoma. doc-2/dab2 (diff erentially expressed in ovarian carcinoma-2/disabled-2) interacting protein (dab2ip), a novel family of ras gtpase-activating protein family, is a potent tumor suppressor gene. th e objectives of this study are to explore the prognostic values of dab2ip expression and the possible regulatory mechanism in superfi cial bladder cancer. with irb consent and patient permit, eight human urothelial cancer cell lines and 64 superfi cial bladder cancer tissues were available for exploring dab2ip expression using western blotting and immunohistochemical staining, respectively. th e prognostic signifi cance of dab2ip expression in term of recurrence and progression were analyzed with log-rank test. aft er treated with demethylizing agents trichostatin a (tsa) and 5-aza 2' deoxycytidine (aza) separately and together, 8 urothelial carcinoma cell lines were then tested with dab2ip mrna expression using quantitative rtpcr. data mining was also done using published mrna diff erential array (dataset gse 18423). th irty patients with non-muscle invasive bladder cancer and 30 agematched healthy controls were included in the study. peripheral blood samples were obtained from the patients before transurethral resection of bladder tumor (turbt), twenty days aft er the operation (fi rst control) and at the end of intravesical immunotherapy (second control). vegf-2, mmp-2, es and tsp-1 were measured by enzyme-linked immunosorbent assay (elisa). th e mean marker levels of the patients and controls were statistically compared. th e mean marker levels of the patients before turbt, in the fi rst and second control were also compared. results: th e mean age of the patients (6 females and 24 males) and controls (6 females and 24 males) were found to be 67.27±8.44 and 65.74±7.22, respectively (p=0.54). although the mean vegf and mmp levels in the patients before turbt were signifi cantly higher than the controls (p<0.001 and p<0.05, respectively), there were no diff erences between the mean es and tps-1 levels (p=0.53 and p=0.67, respectively). th e wegf-2 and mmp-2 levels signifi cantly decreased aft er turbt (p<0.001 and p<0.05, respectively). th ese reductions continued aft er intravesical immunotherapy, but these diff erences between fi rst and second control were statistically insignifi cant. th is study showed that elevated angionenic factors in the patients with bladder cancer decreased aft er the treatment. we think that vegf and mmp may be used for the follow-up and therapy of non-muscle invasive bladder cancer. prognostic results: nitrose oxide level and bfgf expression were signifi cally elevated in patients with urothelial carcinoma associated with chronic bladder infection, normal urothelium showed low levels of no and low expression of bfgf. conclusion: th e association of elevated levels of nitrose oxide and over-expression of bfgf indicated that the angiogenic peptide bfgf had been modulated by nitrose oxide. th ese results would indicate an anti-angiogenisis target therapy in urothelial carcinoma associated with chronic bladder infection. the relationships between increase of serum creatinine and recurrence of nonmuscle invasive bladder cancer after transurethral resection of bladder tumor introduction and objective: while impaired renal function had a negative impact on the prognosis of invasive bladder cancer by infl uencing stage of tumor and selection of treatment modality, the relationships between the change of renal function and prognosis of non-muscle invasive bladder cancer (nmibc) have not yet been studied. preliminarily, we investigated the impact of increased serum creatinine and recurrence of nmibc. a total of 74 patients who underwent transurethral resection of bladder tumor (turbt) with minimum follow-up of 40 months were divided into two groups based on with (n=41) or without recurrence (n=33). th e changes of serum creatinine from the preoperative baseline to the time of recurrence were evaluated (δ creatinine). for subjects without recurrence, serum creatinine was measured at 36 months aft er turbt. th e impact of variables including characteristics of host (age, sex, past medical history, bmi, and smoking history), tumor (location, size, and grade), and laboratory data on recurrence of nmibc were then analyzed. tsai y 1 , jou y 2 , tsai y 1 , liu b 3 , lin h 4 , wei c 3 , chen s 5 , tsai h 1 , tzai t 1 introduction and objective: bladder cancer is a common human malignancy and exhibits a life-long risk of disease recurrence and progression. it is continuing to search some simple, innovative biomarker to monitor the disease status in order to diminish the suff ering during cystoscopic follow-up. th e metabolite of tryptophan aft er indoleamine 2,3-dioxygenase (ido) digestion, 3-hydroxyanthranilic acid (3-haa) is conventionally thought to be a potential biomarker for bladder cancer occurrence. th e aim to study is to investigate the diagnostic potential of an integrated a 3-haa-based biosensor for urothelial carcinoma of the upper tract and urinary bladder. human urothelial cancer cell lines and human urothelial carcinoma tissues as well as adjacent benign tissues were available for exploring ido expression, including western blotting and immunohistochemical staining. patients who received urological surgery were enrolled for urine 3-haa testing using an integrating biosensor for 3-haa. some of urine specimens were investigated with high performance liquid chromatography (hplc) assay. results: from western blotting assays, eight human urothelial carcinoma cell lines exhibited more ido expression than the immortalized cell sv-huc. both of urothelial carcinoma of urinary bladder and upper urinary tract exhibited more ido immunoreactivity than those of the adjacent benign bladder, ureteral or cortical tissues (chi-square test, p=0.0073). th ere is a moderate correlation for urine 3-haa measurement based on between hplc and the biosensor assays (r2=0.47, p=0.0033). besides, the 3-haa content within the cultured media of tccsup and bftc905 measured with biosensors signifi cantly increased with incubation time (p <0.0001). finally, patients with urothelial carcinoma of bladder and upper tract have higher urine 3-haa levels than those without recurrence or benign urological disease, such as bph, or hernia (unpaired t-test, p=0.028), except for urolithiasis. conclusion: th e integrated biosensor exhibited a modest accuracy in urine 3-haa detection. both of urothelial carcinoma of urinary bladder and upper tract exhibited higher ido expression and its metabolite 3-haa in urine. how a cancer spreads: public awareness of genitourinary cancer introduction and objective: patients' perceptions of disease can aff ect the diagnosis and treatment of the disease. it is diffi cult to give a defi nite answer to the questions; "can genitourinary cancers be spread around during coitus or in public bathtub?". doctors know that there is no evidence that cancers can be spread in this way, however many people don't know that. th e objective of this study was to investigate the public awareness of genitourinary cancer. one hundred and forty nine patients who have visited outpatient department of urology completed a self-administered questionnaire from june 2013 to july 2013. th e questionnaires included epidemiologic information about age, gender, residential area, level of education and yearly income and the questions whether prostate cancer and bladder tumor could spread out during coitus or bathing. returned responses to 11 questions were analyzed. results: a total of 149 of 160 (93%) patients completed the questionnaires. mean age was 65 years, and 87 (58%) men and 62 (42%) women were included. th e residential area were metropolitan in 117 (79%), urban in 18 (12%), and suburban in 13 (9%), respectively. th e level of education were middle school graduates in 43 (29%), high school graduates in 54 (36%), and college graduates in 52 (35%), respectively. th e yearly incomes were under 30,000 dollars in 79 (53%), 30,000~50,000 in 54 (36%), and over 50,000 in 16 (11%), respectively. seventeen (11%) and 7 (5%) patients answered that they thought that bladder tumor could spread during coitus and bathing, respectively. likewise 18 (12%) and 3 (2%) patients answered that they believed that prostate cancer could spread during coitus and bathing, respectively. moreover, young patients (<40 years) reported that they have the opinions that coitus spreads prostate cancer (25%) and bladder tumor (21%). of college graduates, 17% and 15% reported that they thought coitus spreads prostate cancer and bladder tumor, respectively. conclusion: a signifi cant proportion of patients believed that prostate cancer and bladder tumor could spread during coitus. furthermore, even young and highly educated people also tended to have this misbelief. protoporphyrin we evaluated the feasibility of photodynamic diagnosis of bladder cancer by spectrophotometric analysis of voided urine samples aft er extracorporeal treatment with 5-aminolevulinic acid (ala). further, we investigate the protein that plays a key role in increased accumulation of protoporphyrin ix in bladder cancer cells. sixty-one patients with bladder cancer, confi rmed histologically aft er the transurethral resection of a bladder tumor, were recruited as the bladder cancer group, and 50 outpatients without history of urothelial carcinoma were recruited as the control group. half of the voided urine sample was incubated with ala, and the rest was incubated without treatment. intensity of the samples at the excitation wavelength of 405 nm was measured using a spectrophotometer. th e diff erence between the intensity of the ala-treated and ala-untreated samples at 635 nm was calculated for photodynamic diagnosis of bladder cancer. immunohistochemistry was used to estimate the expression of peptide transporter 1, hydroxymethylbilane synthase, ferrochelatase, atp-binding cassette 2, and heme oxygenase-1 in samples from 75 patients who underwent transurethral resection of bladder tumors. th e correlation between the expression of each protein in cells from resected bladder specimens and accumulated protoporphyrin ix in bladder cancer cells in voided urine was evaluated using pearson's correlation analysis. results: th e area under the curve was 0.84. sensitivity and specifi city of the method were 82% and 80% respectively. th e expression of peptide transporter 1 (p < 0.01, r = 0.39), heme oxygenase-1 (p < 0.01, r = 0.33), and ferrochelatase (p < 0.01, r = 0.75) was correlated with the accumulation of protoporphyrin ix in bladder cancer cells in voided urine. we demonstrated that protoporphyrin ix levels in urinary cells treated with ala could be quantitatively detected by spectrophotometer in patients with bladder cancer. th e expression of ferrochelatase plays a key role in the accumulation of protoporphyrin ix in photodynamic diagnosis of bladder cancer. assessment of visual inspection as a tool to determine pelvic drain fluid type following radical cystectomy crozier j, papa n, lawrentschuk n introduction and objective: following radical cystectomy, patients generally spend a period of days under observation on a urology ward. during that time, staff closely monitor pelvic drain output to assess for the possibility of a urine leak. we aim to investigate the ability of medical and nursing staff to correctly identify pelvic drain fl uid type using visual inspection alone. investigators collected a series of de-identifi ed images showing pelvic drain fl uid in patients post radical cystectomy. th e fl uid type in each image was confi rmed by measuring creatinine level. investigators then attended a victorian public hospital urology meeting and a victorian gp conference. attendees were invited to participate in a study. present staff included consultant urologists, urology registrars, urology residents, urology nurses, medical oncologists, radiation oncologists, general practitioners and medical students. participants were then provided with a survey. th ey were asked to indicate their level of experience working on a urology ward, the number of years since graduation from their primary medical or nursing degree. participants were then shown the series of pelvic drain fl uid images on a project. th ey were asked to correctly identifying the fl uid type in each image. using the survey, participants had the option of choosing either urine or peritoneal fl uid. results: all groups poorly identifi ed fl uid type. no individual staff group was signifi cantly better at identifying fl uid type. level of experience on a urology ward and years since graduation do not infl uence ability to determine fl uid type. conclusion: visual inspection of pelvic drain fl uid is a poor determinant of fl uid type. chang y, hsiao p, chen g, lee s, huang c, wu h, yang c, chang c introduction and objective: muscle invasive bladder urothelial cell carcinoma occasionally mixed with squamous diff erentiation. we conducted this study to investigate the incidence and treatment outcome of bladder urothelial cell carcinoma with squamous component. we enrolled 93 patients muscle invasion bladder cancer who received radical cystectomy with bilateral pelvic lymph node dissection during 2008 to 2014. patients' characteristics, chemotherapy record, and pathological report were retrospectively reviewed. th e following endpoints were assessed: overall survival (os) and recurrence-free survival (rfs). response of neoadjuvant chemotherapy subgroup was also analyzed. all survival data were analyzed by the kaplan-meier method using a log-rank test and multivariate analysis was carried out using a cox proportional hazards regression model. results: it was very clear that more than one third of these cases coming from the south of saudi arabia (34.65%). th e bilharzia infestation found in (25.07%) of the cases most of them are the southern patients. th e t staging turn to be high in most of our cases (30.14% are t3b). squamous cells carcinomas was also a striking feature of our result and found in (23.66%). lymph node involvement found in one fourth of these cases (25.63%). a total of (26.76%) had local or lymph node recurrence and (28.17 %) got distant metastasis. around 94% (337 cases) of our result showing that these cases having high grade and around 40% (292 cases) had a hydronephrosis upon presentation. bladder cancer as a cause of death because of its advancement or recurrence account for (76.13%) of deaths happened in these cases. th e survival of these cases severely aff ected by the fact that 110 cases (30.99%) could not know there survival status because they stop to show up in our institute for follow-up in spite the fact that there are some of them followed for more than 5 years. arabia showing that the bilharzia infestation is quit high especially in the south and the squamous cell cancer is not as low as we expected. finding of hydronephrosis, lymph node involvement, high t and high recurrence in high percentage of our cases indicating that the bladder cancer aggressiveness behavior is not changing over 35 years. introduction and objective: th is is an observational retrospective study utilising long-term patient follow-up for 15 years (ys). to determine the survival and quality of life in women with age range 20-54 years, who had been treated for carcinoma of the bladder with radical cystectomy with preservation of genital organs. materials and methods: study included 13 women patients with invasive urothelial carcinoma of the bladder treated with genital sparring radical cystectomy during the period from 1995 to 2006. th ey had orthotopic ileal neobladder. follow-up included recurrence-free survival, metastases-free survival, overall survival, continence, and sexual function. results: overall survival up to 10-15 ys was in 8/13 women (61.53%). survivors up to15 ys were in 4/13 (30.77%). survival from 5 to 9 ys was in 5/13 patients (38.46%). tumours stage of t1 were 4/13 patients, t2 were 5/13 patients, and t3a were 3/13 patients. tumour grade was g1 in 3/13, g2 in 9/13, and g3 in 1/13. age range of 20-37 ys were 7 patients, range of 38-45 ys was 3 patients, range of 46-54 ys was 3 patients. continence was good in10/13 patients; three patients 3/13 needed cic. sexual function tested by fsfi over<20-30 was (84.61%). conclusion: th e study provide evidence of safety and effi cacy of radical cystectomy with sparing of genital organs in women aged 20 to 54 with low grade, low stage invasive urothelial carcinoma of the bladder. oncological outcome for 5-15 years was good; continence and sexual function were very good. th is procedure should be considered when surgical approach appears to be feasible. tan w, sherer b, nehra a, deane l introduction and objective: radical cystectomy for bladder cancer has been the surgical gold standard for decades. increasingly, experience with robotic assisted techniques has become more common in select centers. in the majority of instances, the urinary diversion has been performed extracorporeally and with the use of stents. herein, we report our center's initial experience with robotic radical cystectomy and stentless totally intracorporeal urinary diversion. a retrospective review of the medical records of all patients undergoing robotic cystectomy and intracorporeal diversion was conducted at rumc from 2013-2014. specifi cally, attention was focused on perioperative parameters. results: a total of 5 patients were identifi ed (male=3, female=2) in the sample. four patients underwent intracorporeal ileal conduit reconstruction and one patient underwent totally intracorporeal ileal neobladder reconstruction. no patients received a pre op bowel preparation, post op pca or epidural and all were allowed oral intake early. no patient received a transfusion for operative blood loss. one patient was readmitted for dehydration. see table 1 for details. conclusion: robotic assisted radical cystectomy with stentless intracorporeal diversion is safe and feasible. eliminating bowel preparation, pca and epidural, and incorporating early refeeding and ambulation may result in a shortened length of stay. a rigorous post-operative plan to optimize return of bowel function, permit rapid reintroduction of diet without restrictions and facilitate early ambulation is critical in improving outcomes for this patient population. computed up.055, table 1 . and hypermethylation of these two gene promoters. in order to investigate clinical usefulness for noninvasive bladder cancer detection, we further analyzed the methylation status in urine samples of bladder cancer patients. methylation of the tested genes in urine sediment dna was detected in the majority of cases that were hypermethylated in tumor samples (93.7%) and the frequencies were 79.3% 70.8% and 96.3% for apc, rarβ and survivin, respectively. our results indicate that methylation of apc, rarβ and survivin gene promoters is a common fi nding in patients with bladder carcinoma. th e ability to detect methylation not only in bladder tissue, but also in urine sediments, suggests that methylation markers are promising tools for noninvasive detection of bladder cancer. usefulness of the all cases were followed for over 1 year. th e procedure is 1) point marking; 2) circular incision; 3) level incision; and 4) specimen retrieval using a needle electrode in accordance with the ukai's method. we investigated pathological fi ndings (margin situation), operation time, complications and recurrence. results: it is possible to diagnose the precise pathological fi ndings by turbo. we judged the width and depth ew in sequential section. th ere were few complications during and aft er the operation. operation time of turbo (28-171 min) was longer than conventional turbt. urethral catheter holding period and hospitalization period aft er turbo was the same as turbt. turbo is a relatively safe procedure even for beginners. twenty cases had a recurrence in 50 cases. eleven cases had a recurrence in under 1 year, but the same place recurrence was 4 cases. th ere were few cases of same place recurrence in under 1 year among margin-negative cases. th erefore we judged that ew-negative cases had no residual cancers. conclusion: turbo is a safe and useful procedure that provides precise pathological fi ndings with minimal complications. second tur is not necessary for turbo. turbo has a possibility to be gold standard of the treatment for non-muscle invasive bladder cancer (nmibc). the risks of bladder-preserving bacillus calmette-guérin therapy in high-grade non-muscle-invasive bladder cancer continuous physical activity has many eff ects on human body. it doesn't only strengthen the skeleton or muscles; it also affects cardiovascular system, nervous system and etc. in this research we wanted to fi gure out if continuous physical activity (cpa) eff ects the lower urinary tract symptoms in retired military offi cers or not. th is is a retrospective study. retired offi cers attending to urology clinic for annual prostate control and not using any drugs for prostate were enrolled in this study. aft er the patients' permission were taken for the study they were asked for cpa or not and their international prostate symptom scale (ipss) answers were compared. results: th ere were 22 patients in cpa group and 17 patients in non-cpa group. th e mean age is 59 (45-71) in cpa group and 58.94 (47-71) in non-cpa group. answers of questions in ipss: incomplete emptying (p=0.001), frequency (p=0.001), urgency (p=0.001), and straining (p=0.000) were detected statistically rare in cpa group (table 1) . although they were not statistically signifi cant, intermittency (p=0.1), weak stream (p=0.06) and nocturia (p=0.5) were rare in cpa group too (table 1) . in order to maintain a better lower urinary tract function, elderly men should continue their physical activity aft er retirement. conclusions: th e number of nocturia episodes was signifi cantly and linearly correlated with ipss total score, voiding, storage, qol and nih-cpsi voiding scores. however, other risk factors, including bmi, body fat percentage, blood pressure, bun, creatinine, lipid panel, ck, t3, free t4, prostate-specifi c antigen, serum testosterone levels, urine fl ow (assessed using urofl owmetry) and prostate size (assessed using transrectal ultrasound and digital rectal examinations) were not associated with the number of nocturia episodes, despite an a priori assumption that they all infl uence nocturia risk. risk results: symptom prevalence increased to 13.1%, and the mean international prostate symptom score increased by 2.6 points during 3 years. aft er adjusting for confounders, smoking history of ≥50 pack-years was an independent risk factor for symptom deterioration and storage sub-symptoms, compared with non-smokers (3.1 and 5.1 odds, respectively). physical activity had a protective eff ect for voiding sub-symptoms. high daily protein intake exacerbated the storage symptoms. however, alcohol intake was not associated with symptom deterioration. conclusions: th e symptom prevalence among elderly men living in a suburban area increased to 13.1%, and the international prostate symptom score increased by 2.6 points during 3 years. smoking history, physical activity, and protein intake were associated with symptom deterioration. however, there was no signifi cant association with alcohol intake and symptom deterioration. russo g, castelli t, urzì d, privitera s, fragalà e, favilla v, cimino s, morgia g introduction and objective: a signifi cant amount of epidemiological evidences have underlined an emerging link between mets, benign prostatic enlargement (bpe) secondary to benign prostatic hyperplasia (bph) and related lower urinary tract symptoms (luts). we aimed to assess the connections between lower urinary tract symptoms (luts) related to benign prostatic enlargement (bpe) and metabolic syndrome (mets) with its components. is increased prostatic urethral angle related to lower urinary symptoms in male without prostatic obstruction? introduction and objective: th e prostatic urethra is a bent tube, and the clinical signifi cance of the prostatic urethral angle (pua) was recently reported. we investigated the statistical signifi cance of an increased pua on the international prostate symptom score (ipss), with luts/bph. a prospective analysis was made of 74 patients (64.50±7.95 years) with luts and/or bph. patient underwent an evaluation including the ipss, psa, transrectal ultrasonography, urofl owmetry, and measurement of post-void residual. pua were measured by cystourethroscopy ( figure 1 ). in order to minimize the eff ect of prostate, patients with prostatic obstruction under cystourethroscopy were excluded. th e minimum pua degree of symptoms change was constructed as a predictor of the eff ect of medication. all patients received tamsulosin 0.2mg during the fi rst 2 weeks and 0.4mg during the next 4 weeks. results: th e psa, prostate volume and pua were 1.26±1.13ng/ml, 26.58±8.76ml and 26.32±6.77°, respectively. th e area under the roc curve was 0.542 at the 23 degrees with a sensitivity of 40.0% and a specifi city of 80.0%. comparing a higher pua (over 23 degree, group a) with a lower pua (under 23 degree, group b), patient with a higher pua had a longer luts period (p=0.026), an improvement of symptoms aft er medication (p=0.0374) and an increase of average fl ow rate (p=0.032). however, there was no signifi cant diff erence in age, psa, post-voided volume between the two groups. conclusion: pua showed signifi cantly correlated with the improvement of ipss, the eff ect of medication, and urofl owmetry. our fi ndings suggest that pua under cystourethroscopy may be one method to assess the presence of luts in men and help in the treatment of individuals by better predicting their likely classifi cation from ipss, urofl owmetry, and prostate volume. however, further studies are needed to explore the mechanisms and the eff ects of pua under cystourethroscopy. introduction and objective: th e prevalence of lower urinary tract symptoms increased with age. it is known that irritable bladder symptoms such as urinary frequency, urgency, nocturia increased with age in many studies. recently it was reported that vascular calcifi cation was one of the cause of lower urinary tract symptoms. we studied to evaluate the association between lower urinary tract symptoms of vascular calcifi cation in the abdominal ct using by agar score. th e records were obtained from a retrospective database who underwent abdominal ct due abdominal pain, hematuria. sex, age, height, weight, prostatic size, calcifi cation of aorta and internal iliac artery, amount of subcutaneous fat and visceral fat in the umbilicus level, international prostate symptom score, overactive symptoms score and urofl owmetry were assessed. calcifi cation of aorta was estimated from renal artery bifurcation to iliac artery bifurcation level. and internal iliac artery calcifi cation was calculated from bifurcation of iliac artery to bladder. we scanned each subject of 0.5cm interval on the ct scan. th e calcifi cation of blood vessels was measured as agar score using abdominal ct aft er our explaining about each contents of nih-cp-si and iief-5, the paper was checked by volunteers in person, and then we collected it. th e subjects were limited to 40-50s korean male. we analyzed the collected questionnaires, and considered men who have perineal and/or ejaculatory pain or discomfort and a total nih-cpsi pain score of ≥4 as having prostatitis-like symptoms, and categorized to four groups by iief-5 score, mild (17-21), mild-moderate (12-16), moderate (8-11), severe (5-7). results: an average age of 1032 volunteers was 50 years old (42-59). th e iief-5 category was divided to fi ve groups. among total volunteers, 72 persons were chronic prostatitis like symptom patients (6.9%), and whose nih-cpsi average of pain score, voiding score, quality of life score and total score were 7.6±3.1, 4.3±2.5, 5.8±2.3, and 17.8±6.7, respective-up.064, figure 1 . ly. th ere were a little correlations among pain score, voiding score, quality life score, but not signifi cant. an average of total iief-5 scores in chronic prostatitis like symptom patients was 14.0±6.8, it was signifi cantly lower than absent group. th ere were all negative correlations of between iief-5 and pain score (t=-6.199, r2= 0.036, p=0.000), voiding score (t=-0.157, r2 = 0.025, p=0.000), qol score (t=-7.845, r2= 0.056, p=0.000), and total score (t=-9.366, r2 = 0.078, p=0.000). conclusion: th e higher total nih-cpsi score, especially pain score plays a larger role, adversely aff ects erectile function of chronic prostatitis like symptom patients in 40-50s korean male. a antimuscarinic agent is the mainstay of treatment, but it have side eff ects such as dry mouth, constipation. th ese eff ects resulted in cessation of medication in many cases. th e authors therefore assessed the impact of side eff ects on health-related quality of life (hr-qol) through an analysis of questionnaires. th is study was designed to investigate the patients' satisfaction by quality weight (utility weight) of health status as aff ected by the side eff ects of oab medications in 4 tertiary hospitals in korea. patients who had oab symptoms lasting longer than 3 months and side eff ects aft er any antimuscarinic treatment fi lled in the eq-5d. th e questionnaire and vas score for two diff erent health statuses, presence or absence of side eff ects, were analyzed. quality weight was calculated using the score of ed-5d health status. results: one hundred patients were enrolled. th e most prevalent side eff ect was dry mouth (61%), followed by constipation (4%). twenty-eight percent of the patients had dry mouth and constipation concurrently. most of the patients with side eff ects tried to overcome these side eff ects (79%), but 10% desired a change in medication, and 6% stopped medication altogether. fift y-fi ve patients replied that they consider side eff ects to be an important factor in deciding on the continuation of medication. th e quality weight of eq-5d without side eff ects was 0.863, while the quality weight with side eff ects was 0.666 (p=0.00000014). th e vas score was 79 in patient without side eff ects and 57 in those with side eff ects, supporting the results of quality weight assessment. th e same trend was observed when stratifi ed according to age and sex. as for the overall distribution of ed-5d, the patients with side eff ects were less healthy in terms of daily life, pain/discomfort, and anxiety/depression. introduction and objective: treatment of men with large prostates is challenging with greater risk of complication and retreatment. while photo-vaporization (pvp) has been well described for greenlight 180w-xps, vapor resection techniques have been described to help improve tissue resection, including vapour-incision techniques (vit). we sought to evaluate the effi ciency, safety and outcome parameters between greenlight pvp and vit specifi cally for men with prostate volumes >80. among 955 xps cases retrospectively collected from 5 experienced surgeons at high-volume greenlight xps centers, 271 had large prostates. preoperative, operative and post-operative parameters were collected and compared between groups. results: as summarized in table 1 , men undergoing vit (n=100) had comparable preoperative parameters to those undergoing pvp (n=171). while vit allowed greater delivery of energy (4.2vs3.2 kj/g), operative time was longer and there was greater need for >2fi bres. th ere were no diff erences in intra-and 90day post-operative adverse events. both vit and pvp demonstrated comparable marked improvements in ipss/qol at 6 months post-operatively. however, despite greater urinary retention and pvr preoperatively, men with vit demonstrated signifi cantly lower post-operative pvr and greater qmax at 6 moths. no signifi cant diff erence in retreatment rates was noted between vit and pvp follow-up. conclusions: both greenlight pvp and vit techniques can be safely used to treat men with large prostates. both techniques off er signifi cant and durable relief of symptom relief with comparable complication rates at 3 years. longer follow-up is necessary to assess durability. open within two years, one-hundred patients were prospectively randomized into two equal groups. all patients underwent tvp whereas rb was used in group-2. rb is a balloon fi xed to 3-way foley catheter tip by blaster strip making it air tight. we placed it in the rectum opposing prostate and infl ate (pressure controlled) for 15 min. hemoglobin (hg) levels have been assessed pre-and postoperation. blood transfusion, amount of saline for irrigation, catheter duration, hospital stay, and rectal complain were recorded. follow-up was 1 and 3-mo, postoperatively. results: enucleated adenoma weight was 102 gm in g-1 and 106 gm in g-2. th ere is signifi cant diff erence between both group for hg-loss within fi rst 24h post-operative and total hg-loss 0.9 gm in g-1 and 0.2 gm in g-2 (p, 0.008) and 1.9 gm vs. 1 gm (p, 0.001) respectively. also there is signifi cant diff erence between both group in relation to the saline/l for irrigation (11.4 vs. 2.5 l), catheter duration (5.7 vs. 4.3 day), and hospital stay (6.2 vs. 5.1 day), with favorable results to the rb group. blood transfusion was 4 in g-1 and one in g-2. th ere is no rectal complain. conclusion: rb infl ation post-tvp is simple and safe procedure without operative technique, reduces post-operative blood loss, blood transfusion incidence, saline for irrigation, and shortens the catheterization period and hospital stay, without rectal complication. conclusion: th ough this was not a head-to-head study and there were a number of dissimilarities in the study design, we demonstrated a non-inferiority of our study and a signifi cantly shorter median length of catheterization, time until stable health, and hospitalization relative to the goliath study. introduction and objective: th ulium laser enucleation of the prostate (th ulep) has been introduced as a minimally invasive treatment for benign prostatic obstruction (bpo). th e aim of the study is to assess what are the intraoperative key points and possible complications of the morcellation procedure aft er th ulep. to assess whether this events have any eff ect on hospitalization length. a cooperation between the university of milan and moscow was settled. prospective study that analyzes events that prolonged the morcellation process aft er completing thullium laser enucleation procedure in a group of 337 consecutive patients was performed. events related to the morcellation procedure were recorded. patients' hospitalization length were evaluated aft er discharge only considering patients that were not re-admitted because of a surgical related issue. statistical analysis was performed by the student t and chi-square test and logistic regression analysis. for all statistical comparisons signifi cance was considered at p<0.05. results: mean age was 67.8 years. five groups of reasons for prolonged morcellation were recorded. bladder suction with wall damage, bleeding due to "ex vacuo" fast empting, suction problem, morcellation impairment and prolonged morcellation time due to enlarged prostate. each group of issues was related to a signifi cant prolonged operative time (p<0.05). th e table 1 shows the key points rate and their correlation with a prolonged hospital stay. a statistical significance between the event and the prolonged hospital stay found only for bladder suction. conclusions: issues related to the morcellation procedure aft er laser enucleation of the prostate (th ulep) causes prolonged hospitalization length only in the case of bladder suction. other events, even if related to a slower operative time, do not mean a prolonged hospitalization. suprapubic cystostomy makes turp more effective and safer introduction and objective: a recent survey found turp the commonest performed procedure in bph, despite the rising popularity of laser prostatectomy. th e reasons for popularity in laser are ease of performance, lesser complications, and good results. it is the complications factor that makes it look attractive. th e onus is therefore to make turp safer. th is is more applicable in india, where the cost of laser excludes 80-90% of patients. numerous innovative procedures have been tried to make turp safer. continuous outfl ow has been described as innovation, the means to achieve it not described. introduction and objective: prophylactic peri-vesical drain placement during suprapubic prostatectomy remains a widespread surgical practice. however the surgical technique of suprapubic prostatectomy has signifi cantly improved and as such the contemporary role of prophylactic surgical drains needs reevaluation. it has been traditionally assumed that prophylactic drains helps prevent fl uid collection (blood, serum, urine) which if not drained can lead to surgical wound complications. th is paper investigates the incidence of surgical wound complications aft er a series of suprapubic prostatectomy done without placement of surgical drains but in the context of modifi cations to the surgical technique. prostatic hyperplasia (bph) were operated upon between 2009 and 2015 -all using a modifi ed suprapubic prostatectomy technique that includes meticulous dissection, hemostatic suturing that covers the main areas of anatomic distribution of the urethral arterial branches of the inferior vesical artery, non-placement of drains and suprapubic catheter, and also routine irrigation of the surgical wound with normal saline among other modifi cations. pre-and post-operative blood hemoglobin levels, prostate specimen weights and presence of surgical wound complications if any were recorded. th e main outcome measure was to determine the presence of early surgical wound complication defi ned as clinical evidence of hematoma/ seroma, infection, drainage or wound dehiscence. results: th e mean age of the patients was 68.7 (range of 54 to 84 years). th e mean prostate weight was 93.5gm-(range of 56 to 238gm). th e mean hemoglobin diff erence was 1.13 mg/dl (range of 0.4mg/dl to 2.6mg/dl). on a minimum 30 days observation of the surgical wounds, there was only one case of superficial wound infection (0.9%) that healed with wound dressing. th ere was no mortality and none of the patients received blood transfusion. in the context of an improved surgical technique, suprapubic prostatectomy for bph can be safely performed without the placement of prophylactic peri-vesical drain. non-placement of prophylactic surgical drains in this series was not associated with increased wound complication rate. effects of detrusor underactivity conclusions: according to detrusor activity, there were not diff erent in diff erences between preoperative or postoperative ipss. abnormal detrusor contractility (esp. dua) cannot be a contraindication for tur-p, and turp should be a defi nite therapeutic option in abnormal detrusor activity. geavlete p, dragutescu m, multescu r, georgescu d, geavlete p introduction and objective: th is long-term retrospective study aimed to analyze the re-intervention necessities aft er bipolar plasma vaporization of the prostate (bpvp) in patients with medium sized benign prostatic hyperplasia (bph). materials and methods: th ere were followed 328 patients who underwent bpvp for prostates sized between 30 and 80 ml. th e re-intervention rates were analyzed during a follow-up period of at least 12 months. results: additional interventions consisted of immediate reoperation for secondary hematuria, endoscopic re-intervention for urethral stricture or blad-der neck sclerosis and transurethral resection of the prostate (turp) for residual bph bulk. endoscopic hemostasis during hospitalization was required in 2 cases (0.6%) and in discharged patients in other 2 cases (0.6%). during the follow-up period, 3 patients (0.9%) with bladder neck sclerosis underwent the plasma vaporization approach. urethral stricture was diagnosed in 24 patients (7.3%), 21 of them receiving internal optical urethrotomy while urethroplasty was performed in 3 cases. residual adenoma was present in 2 patients (0.6%), thus requiring and secondary turp. conclusion: bpvp is a valuable endoscopic treatment alternative for medium size bph cases with higher effi ciency and a satisfactory rate of reoperation. diode laser 980nm for the treatment of bph: long-term comparison of the enucleation vs. vaporization introduction and objective: to report 5-years follow-up results of clinical trial comparing diode laser enucleation of the prostate (dilep) with diode laser vaporisation of the prostate (dlvap). a total of 151 consecutive patients were included in the prospective study who had received laser treatment for bph. patients were assigned to two groups based on the type of procedure: 106 to dilep group and 45 to dlvap group. patients with a history of neurogenic bladder dysfunction, chronic prostatitis or bladder cancer were excluded from evaluation. standard follow-up examinations were performed in both study groups in predefi ned time points (in the perioperative period, at month 1 and month 3, and month 6, and then every year). primary endpoints included: lower urinary tract symptoms (luts) as measured by the international prostate symptom score (ipss), urinary fl ow rates and post-void residual urinary volume. complications were assessed. an additional endpoint was to review video records to precisely determine the timeframes for individual surgical procedures and to plot the learning curve. results: all the remaining 151 patients had undergone the 4-year follow-up assessment. measurements were performed at 1, 3, 6, 12, 24, 36, 48 and 60 months. th ere were no statistically signifi cant differences in baseline characteristics between the two groups. no signifi cant intraoperative and early postoperative bleeding was observed. hospital stay aft er surgical intervention covered 1 day that was equal to average time of urethral catheter indwelling. th e improvement rates, calculated based on the ipss scores at 5 years aft er surgery, were 78.9% and 60.5% in the dilep and dlvap group, respectively. th e results indicate signifi cant decrease in severity of luts. th e sustained treatment eff ect was in favor of dilep intervention group. also treatment effi cacy was better in the dilep group compared to the dvlap group, as regards the maximum urinary fl ow rate (qmax). th e diff erence was statistically signifi cant. conclusions: diode laser enucleation and vaporisation of the prostate are low-risk minimally-invasive treatment option of treatment of patients with bph. both methods may be safely performed even in high risk and patients on ongoing oral anticoagulation. treatment eff ects are better and more sustained with laser enucleation than with laser vaporization of the prostate. dilep is a true endourological alternative to turp. changes in urination according to the sound of running water using a mobile phone application introduction and objective: th e sound of running water (srw) has been eff ectively used for toilet training during toddlerhood. however, the eff ect of srw on voiding functions in adult males with lower urinary tract symptoms (luts) has not been evaluated. to determine the eff ect of srw on urination in male patients with luts, multiple voiding parameters of urofl owmetry with postvoid residual urine (pvr) were assessed according to the presence of srw played by a mobile application. eighteen consecutive male patients with luts were prospectively enrolled between march and april 2014. urofl owmetry with pvr measured by a bladder scan was randomly performed once weekly for two consecutive weeks with and without srw in a completely sealed room aft er pre-checked bladder volume was scanned to be more than 150 cc. srw was played with river water sounds amongst relaxed melodies from a smartphone mobile application. results: th e mean age of enrolled patients and their mean international prostate symptom score (ipss) were 58.9 ± 7.7 years (range: 46-70) and 13.1 ± 5.9, respectively. all patients had not been prescribed any medications, including alpha-blockers or anti-muscarinic agents, in the last 3 months. th ere was a signifi cant increase in mean peak fl ow rate (pfr) with srw in comparison to without srw (15.7 ml/s vs. 12.3 ml/s, respectively, p = 0.0125). however, there were no diff erences in other urofl owmetric parameters, including pvr. th e study showed that srw from a mobile phone application may be helpful in facilitating voiding functions by increasing pfr in male luts patients. th is study aims to analyse how bladder outlet obstruction index (booi) and bladder contractility index (bci) aff ect surgical outcome for bph patients who were treated homium laser enucleation of the prostate (holep). we classifi ed the 166 patients, who were treated holep and observed more than 6 months, into group i (booi≥40 and bci≥100, n=45), group ii (booi≥40 and bci<100, n=24), group iii (20<booi<40 and bci≥100, n=18) and group iv (20<booi<40 and bci<100, n=79) based on urodynamic study result. patient's characteristics including volume of prostate, psa, ipss, maximum urinary fl ow rate and residual urine volume compared in each group. and we also compared ipss, maximum urinary fl ow rate, residual urine volume before and 6 months aft er surgery. results: th ere was no signifi cant diff erence comparing age, psa, ipss, maximum urinary fl ow rate and residual urine volume among each group. th e prostate volume, ranked in ascending order of group, are as follows: 71.9±37.1ml, 61.5±21.9ml, 41.2±13.7ml and 40.9±14.9ml, it had signifi cantly disparity between group i and iii (p=0.004), group i and iv (p=0.000), and group ii and iv 9p=0.018). using repeated measure anova, we found that ipss, maximum urinary fl ow rate and residual urine volume were signifi cantly improved within group in each group aft er surgery except ipss storage subscore between group ii and group iii and residual urine volume. and the degree of improvement among each group was not diff erent (table 1) . th e incidence of aur (6.5%) and bph-related surgery (2.6%) were low in ct group. in comparison of baseline age, psa, and pv according to switch of medical therapy, baseline pv was signifi cant diff erence in both groups, respectively (p=0.007, p=0.004). conclusion: th ere was more mt than ct in initial treatment. however, there was more switch of medical treatment type in initial mt in real-world clinical practice over 10-year follow-up. th e incidence of bph progression events was high in initial mt group. th e initial use of ct is recommended in patients with luts and bph. relationship between bladder wall thickness and lower urinary board the antarctic research vessel "shirase" on their way home and approximately two months aft er returning to japan. we analyzed the data of 12 members of the winter party who had responded to the questionnaires more than 3 times before departure and during their stays in antarctica. results: compared to before departure, the mean scores for all of the questionnaires decreased during their stays in antarctica, from 3.42 to 2.31 points for ipss, from 1.25 to 0.986 points for oabss, and from 4.58 to 3.78 points for psqi, but the mean volume voided per micturition increased from 213 to 233 ml. in regard to the amount of change in ipss scores over the same period, a signifi cant diff erence was noted between 7 members with a pre-departure score ≥ 3 points and 5 members with a pre-departure score < 3 points (-2.22 vs. 0.448, p = 0.0416). th is study is the fi rst to report the urinary status of people in a polar environment investigated with questionnaires and voiding logs. we initiated this study under the assumption that one's urinary status would deteriorate in a polar environment, but our fi ndings indicated that urination and sleep tend to improve in antarctica. management of male luts: a southeast asia regional survey on practice patterns and perspectives results: responses were obtained from 100 urologists from 54 centres with size ranging from 50 to 500 patients per week. referral patterns diff er across the region -in hong kong, singapore and malaysia, patients prefer or are required to consult a general practitioner before seeking urologist care. common investigations that respondents proposed included urofl owmetry ± post-void residual volume measurement (75%), psa (63%), urinalysis (52%), voiding diary (45%), physical examination (38%) and trus-biopsy (33%). however, only urinalysis and symptom scores are essential investigations recommended consistently in major international guidelines. whether urofl owmetry should become an essential investigation in sea remains debatable. luts secondary to bph/bpo (94%) and oab (71%) were the two most common diagnoses for the case scenario, and correspondingly, alpha-blocker (97%) and antimuscarinics (55%) were the two predominant treatments suggested by respondents. nocturnal polyuria is a common cause of nocturia especially amongst elderly, yet relatively few urologists (32%) considered this condition as a main diagnosis. respondents felt that there was a paucity of large-scale epidemiology studies on luts in sea, and on the natural history of the disease. more education on the proper evaluation and diagnosis of luts is needed for both gps and urologists in the region. results from this sea survey revealed variations in urologists' practice patterns and guideline recommendations, and pointed to the needs for further research and education in luts. female urethral prolapse: bhalla v 1 , attri a 1 , bhalla s 2 introduction and objective: urethral prolapse means the protrusion of the distal urethra through the external urethral meatus. female urethral prolapse is a rare condition that has bimodal distribution aff ecting postmenopausal women and prepubertal girls. female urethra has two layers of smooth muscles inner longitudinal layer and outer circular which remain adherent to each other by strong connective tissue. separation of these two layers with episodic increase in intra-abdominal pressure leads to complete urethral prolapse. birth trauma during prolonged vaginal delivery, perineal tears, debility, malnutrition and periurethral bulking agent injections have been implicated in postmenopausal group. we present two postmenopausal female patients of urethral prolapse having similar clinical presentation aged 49 years and 52 years respectively. th ey presented with symptoms of blood spotting of undergarments and voiding diffi culty with dysuria of acute onset. on physical examination a doughnut-shaped erythematous infl amed mass was seen protruding from external urethral opening. th e evaluated parameters included pop-q grade, international prostatic symptom score (ipss), overactive bladder questionnaire (oab-q), international consultation on incontinence questionnaires short form (iciq-sf), maximum fl ow rate (q-max), and residual urine volume (ru). we evaluated them before and 1, 3, 5 year aft er surgery. results: pop-q grade before surgery tended to be high in elderly group without signifi cance. anatomical cure at 5 year aft er surgery (%) of non-elderly and elderly was 90 and 89%, respectively. a tendency to having poor scores was observed in elderly group concerning preoperative ipss, iciq-sf and oabss; however they did not attain signifi cance. th ese three parameters improved in both groups aft er surgery; however, the percent improvement was signifi cantly poor in elderly group. th e maximum fl ow rate before surgery was signifi cantly low in elderly group and was still low aft er surgery. th e residual urine volume did not show signifi cant diff erence in each group before and aft er surgery. in the observation period of 5 year, de novo oab and mesh extrusion were observed in elderly group with a signifi cant frequency. conclusions: th ough the anatomical cure was not age specifi c, age apparently aff ected on the outcome of tvm especially in the percent improvement of luts. autologous materials and methods: ten women with sever and complicated stress urinary incontinence secondary to the bladder neck and urethral trauma or congenital epispadias (with or without extrophy) underwent transurethral injection of autologous muscle derived cells. a second injection was performed according to the assessment of patients, 6 months aft er the fi rst treatment session. all patients were followed at one week, 1, 6 and 12 months aft er injection by physical examination (cough stress tests), one hour pad test and iiq-7 score. multi-channel urodynamic study and maximal urethral closure profi lometry (mucp) was performed before and 12 months aft er the last treatment session. cough stress test, one hour pad test and urofl owmetry were repeated at 36 months aft er the last injection. in each visit the severity and incidence of complications was recorded. results: all patients completed the study and were followed for 36 months. th ree patients were cured; four and three of patients were improved and failed to the treatment respectively. th ere were no major adverse events related to the treatment. conclusions: according to our clinical results, in a limited number of female patients, muscle derived cell therapy is a minimally invasive and safe procedure in the treatment of patients with severe and complicated sui. th e cure rate is not high, though it may be considered as an option beside other treatment modality. are we evaluated the eff ect of patient position and bladder fi lling status on the q-tip angle for urethral hypermobility. we measured the q-tip angle in the supine position and at a 45° angle in a reclining position in patients during bladder emptying and then repeated the measurements while fi lling the bladder, usually 200-300 ml. we defi ned urethral hypermobility as the urethral angle straining or coughing minus that at rest > 30°. results: all 63 female patients (mean age, 62 ± 11 years; range, 36-81) who complained of urinary incontinence were assessed using the q-tip angle. th e pelvic organ prolapse quantifi cation stages of all patients were ≤ stage 1. mean q-tip angle with an empty bladder was 14.1 ± 9.1° in the supine position and 16.4 ± 11.1° in the 45° reclining position (p = 0.001). mean q-tip angle during the fi lling bladder state was 15.4 ± 9.7° in the supine position and 15.9 ± 11.0° in the 45° reclining position (p = 0.771). th e urethral hypermobility rate during the bladder emptying state was 11.1% (7/63) in the supine position and 19.1% (12/63) in the 45° reclining position. th e relative positive ratio of the reclining to the supine position is 1.71. th e urethral hypermobility rate during the bladder fi lling state was 15.0% (9/60) in the supine position and 15.3% (9/59) in the 45° reclining position. th e positive rate was higher in the 45° reclining position during bladder emptying than that in the other position during bladder fi lling. conclusion: th e outcome of the q-tip angle measurement and the rate of urethral hypermobility changed in relation to patient position. th e reclining position during bladder emptying increased the q-tip angle, resulting in positive urethral hypermobility. rotational th ere was no mortality from the surgical procedure, whereas pain and catheter blockage was main complication. all patients were followed at 2, 4, 24 and 48 weeks respectively. our success rate was 100%. vesicovaginal fi stula is the most common urogenital fi stula. obstructed labor and its complications are still the leading cause of its development, whereas iatrogenic fi stula is also up-coming warning for all health care professional. the effi cacy of combination therapy of alpha blocker with anticholinergic in adult women with overactive bladder introduction and objective: overactive bladder (oab) is associated with symptoms including urgency, with or without urge incontinence, usually with frequency and nocturia. anticholinergics are mainly used for the treatment of patients with oab, especially women. other than anticholinergics, alpha blockers have been shown in several clinical reports to be useful in treating detrusor overactivity caused by neurological diseases. th e aim of the study is to evaluate the effi cacy of alpha blocker in combination with anticholinergics to treat women suff ering from oab. th is prospective study enrolled 70 female patients with oab. patients have been randomised into two groups. th e interventions for the 24-week treatment period included solifenacin daily for the group 1 and combination of both solifenacin and tamsulosin daily for the group 2. at baseline and 24 weeks aft er treatment, patients completed a 3-day bladder diary, international prostate symptom score (ipss), quality of life (qol) index, overactive bladder symptom score (oabss), maximum fl ow rate (qmax) and postvoid residual urine volume (pvr). results: a total of 70 women were randomised and 54 completed this study (group 1; 29, group 2; 25). statistically signifi cant improvements in terms of urgency and frequency were observed in both groups at 24 weeks aft er treatment as compared with baseline (p<0.03 and <0.02), while no inter-group diff erence was observed between the two groups. although group 2 showed improvement of ipss voiding subscore, qol and qmax than group 1 but not statistically signifi cant (p=0.15, p=0.15, p=0.07) . no signifi cant diff erence was observed in terms of toxic events between the two groups. conclusion: th e combination of alpha blocker and anticholinergic for 24 weeks was noninferior to anticholinergic alone in effi cacy, and there was no evidence of benefi t of alpha blocker in treating female oab. further studies are needed to assess the role of combined therapy of alpha blocker and anticholinergic in the treatment of female oab. conclusion: advancement of cystoscopy will continue undoubtedly. th is report emphasizes the key people whom contributions will always be a corner stone in the fi eld of urology. "gleason" in a nutshell unusual urogenital disorders introduction and objective: to present some aspects of unusual urogenital disorders, congenital malformations, and syndromes, sometimes occurring in eminent personalities or having been described by famous scientists. th e review of historical sources and biographies of famous suff erers and the study of modern medical literature about all these rare urogenital diseases. results: penile deformities such as hypospadias (the most known representative was henry ii of france 1519-1559, suff ering also from chordee) and the rare epispadias (respectively the most known was the byzantine emperor heraclius, 575-641) were recorded by historians because of the infertility consequences or the bizarre urination habits (heraclius needed protective measures to avoid getting wet). historians also were attracted by spectacular and dramatic urological emergencies, such as fournier gangrene, known by the case of the prominent suff erer herod. referring to famous researchers, françois gigot de la peyronie (1678-1747), founder of the royal academy of surgery of france, described the homonymous disorder (1743), consisting of penile deformity due to induration of the corpora cavernosa of the penis. th e above disease, called also induratio penis plastica (ipp) is one of the extraordinary urogenital problems together with the strongly psychologically and non-physically induced syndromes koro (genital retraction syndrome) and castration anxiety (the latter described by freud). belief that genitals have disappear and fear of damage or loss of the penis characterize them both. much of the research has been done on the two above topics, although still relevant today. conclusions: unusual urological disorders are broadly known when happening on famous personalities or when described by famous physicians or when attract the common opinion as extraordinary events (called mirabilia by historians). koutsiaris e 1 , drettas p 1 , oikonomou a 2 , poulakou-rebelakou e 2 , rempelakos a 3 introduction and objective: th e loss of a testis represents a psychologically traumatic experience in males of any age. testicular loss is commonly the result of torsion, trauma, infection or malignancy. th e patients who experience orchiectomy request the implantation of an artifi cial testis for psychological or cosmetic reasons. testicular prostheses are one of the most commonly implanted devices and we present the evolution of these devices. review of the medical literature regarding the history of testicular prostheses and the various materials that have been used during the decades. results: th e fi rst testicular prosthesis was an alloy of molybdenium, cobalt and chromium and was used in 1941. during the 1950s, other materials were used such as plexiglass and polyethylene without much success. it was then suggested by the scientifi c community that the ideal testicular prosthesis should not produce any infl ammatory reaction and that should be also made by a proven non carcinogen material. it was also suggested that the material of the prosthesis should also resist mechanical press and take and hold the desired form. as a result, solid silicone rubber prostheses were introduced and used in the 1960s. th e demand for more natural feeling implants lead to gel fi lled silicone devices appearing in 1972. in 1988, fi rmer silicone coated prosthesis became the "gold" standard. in the us in 1992, the food and drug administration (fda) halted the use of gel fi lled breast implants due to the risks of autoimmune disorders and the possibility of tumor development. as a consequence, in 1995 there was a voluntary withdrawal of silicone gel fi lled testicular prostheses and replacement with saline fi lled prostheses. nowadays both silicone and saline fi lled testicular implants are used worldwide which are safe and eff ective. conclusions: testicular prostheses reduce the psychological impact that results from loss or absence of a testicle and should be off ered to male patients of any age. introduction and objective: we investigated population-based management trends of urinary stone disease in the use of extracorporeal shock wave lithotripsy, ureteroscopy and percutaneous nephrolithotomy during the recent 5 years in a korean population. we conducted this retrospective study by reviewing the medical records of patients diagnosed with acute ureteric colic in the emergency room and in the urology outpatient from january 2009 to december 2013. nine hundred patients were diagnosed with ureteric stone and all of them underwent ultrasound as the primary imaging modality. sensitivity, specifi city, positive and negative predictive value in determining the size, position of the stone in the ureter by ultrasound has been documented. results: out of 900 patients, there were 800 males (90 %) and 100 females (10%). age range was 13-65 years. our study found that color doppler ultrasound with twinkling sign, diagnosis was made with confi dence in 835 cases (92.7%). sixty-fi ve patients who failed the ultrasound, the stones were confi rmed by helical ct, failure to detect the stone was mainly due to poor visualization (due to bowel gases and obesity) and smaller size of stone. right side stones were seen in 338 (37.6%) patients while left side stones were seen in 562 (62.4%). stones were detected bilaterally in 4 cases (0.4%). th e range of stones size was 3-1.5mm. th ere were 190 (21.1%), 77 (8.5%) and 633 (70.5%) upper, middle and lower ureteral stones. conclusion: th ere is no doubt that spiral ct is superior in the demonstrating of ureteral calculi. th e present study emphasized that utilization of color doppler ultrasound with twinkling in trained hands can provide an excellent alternative modality with high sensitivity and specifi city in diagnosis of acute ureteric colic and with confi dence can be used as fi rst imaging modality, hence we could avoid high cost, higher radiation dose and high workload. contemporary imaging practice patterns following ureteroscopy for stone disease cleveland clinic, cleveland, usa introduction and objective: routine imaging following ureteroscopy for treatment of renal/ureteral calculi continues to be a topic of debate. however, with the increasing focus on healthcare costs and quality, judicious use of diagnostic imaging to optimize outcomes while minimizing resource utilization is a priority. we sought to identify post-ureteroscopy imaging practices amongst experienced urologists. a redcap questionnaire was sent to urologists in north america. th e questionnaire surveyed demographic data, clinical volume, and imaging preferences post-ureteroscopy. additionally, we surveyed the extent to which stone, anatomic, and procedure-related factors infl uenced these preferences. th e likelihood of altering clinical practice and the desire for specifi c imaging guidelines were also assessed. th e interquartile range (iqr) was utilized as a measure of median consensus, with a lower iqr denoting increased agreement. results: th ree hundred twenty two urologists completed the questionnaire. th e mean number of years in practice was 18±10; 82% of respondents performed more than 5 ureteroscopic stone procedures monthly. routine postoperative imaging was obtained by 48% of participants as follows: us (47%), kub (17%), ct (4%), ivp (2%), and kub + us (30%). urologists who did not routinely image patients were more concerned about cost (55% vs. 25%, p= <0.0001), radiation exposure (69% vs. 44%, p= <0.0001), and diagnostic inaccuracy of us (57% vs. 44%, p= <0.02). th ese urologists were also less likely to have completed an endourology fellowship (7% vs. 23%, p= <0.0001). th e most compelling predictors of obtaining postoperative imaging were post-op pain and fever (median 5, iqr 1), residual stones (median 5, iqr 1), ureteral perforation (median 5, iqr 2), and presence of a solitary kidney (median 4.5, iqr 2). conclusions: currently, about 50% of urologists who regularly perform ureteroscopic stone procedures obtain post-op imaging. imaging preferences were guided by the presence of residual fragments, ureteral perforation, solitary kidney, and postoperative pain or fever. introduction and objective: ct scans expose patients to ionizing radiation which is associated with risks of secondary malignancy. we sought to evaluate the performance of reduced dose ct scans in patients evaluated for renal colic in the emergency room. up.107, figure 1 . introduction and objective: intraoperative exposure to ionizing radiation is a growing concern for the safety of both patient and or staff . eff orts to reduce the amount of radiation during ureteroscopic procedures oft en result in decreased image quality. lessray™ is a device used to digitally enhance images obtained from a c-arm using a low-dose pulse setting allowing for reduction in radiation dose while maintaining image quality. a randomized prospective trial of 23 patients was performed comparing ureteroscopic cases for unilateral obstructing ureteral stones using standard fl uoroscopy compared to lessray™. patient demographics, stone parameters, and operative characteristics were recorded in addition to total radiation dose, total fl uoroscopy time and images obtained ( (table 2) . a statistically signifi cant reduction in radiation exposure to the surgeon was also noted (p = 0.03). image quality was not compromised and no conversion from less-ray™ to standard fl uoroscopy was needed in any case. a nearly threefold reduction in patient radiation exposure was achieved using the lessray™ digital enhancement device compared to standard fl uoroscopy. th is novel technology has not previously been used in urologic surgery and off ers a promising alternative to standard fl uoroscopy while ameliorating risks to both the patient and surgeon. bilateral results: in the 10 cases of cn patients, 3 accepted retroperitoneal laparoscopic cyst unroofi ng, 5 accepted retroperitoneal laparoscopic partial nephrectomy, 1 patient with a preoperative diagnosis of cystic renal cell carcinoma, the maximum diameter of 8cm and located in the center of the kidney got retroperitoneal laparoscopic radical nephrectomy. one patient recurred 7 yrs later aft er retroperitoneal laparoscopic cyst unroofi ng, and underwent open partial nephrectomy at last. six mestk patients underwent retroperitoneal laparoscopic radical nephrectomy and 1 accepted retroperitoneal laparoscopic partial nephrectomy. twelve cases were followed up for 6 months to 11 years, no recurrence. conclusion: cn and mestk are rare benign tumors of the kidney. preoperative misdiagnosis is high. multi-cystic lesions with no mural nodules should take cn/mestk into consideration, especially when the lesions convex to the pelvis, should be highly suspected for cn diagnosis, and to assess the possibility of partial nephrectomy. cyst unroofi ng for cn has recurrence risk. the value of 3-t multiparametric mri for detecting prostate cancer of t3 stage introduction and objective: th e objective of this study was to prospectively determine the value of 3-t multiparametric (mp) mri with pelvic -phased array coil for prostate cancer of t3 stage. december 2014, 114 patients underwent 3-t mpm-ri with pelvic -phased array coil, transrectal ultrasound-guided biopsy and radical prostatectomy for adenocarcinoma. mr images were evaluated by three experienced radiologists with regard to extracapsular extension and seminal vesicle involvement and compared with whole-mount histopathological sections as a gold standard. we estimated the sensitivity, specifi city, positive, and negative predictive value and overall accuracy of mpmri for t3 disease. introduction and objective: prostate cancer (pca) imaging has undergone a revolution in the past fi ve years with the rise of multiparametric magnetic resonance imaging (mri) for cancer detection and the evolution of positron emission tomography-computed tomography (pet-ct) for staging. initially, choline pet-ct was considered the new standard for detecting metastatic disease where biochemical recurrence (bcr) occurs aft er primary treatment, but a newer agent based on prostate-specifi c membrane antigen (psma) has emerged. despite the reported promising results with this novel imaging modality few reports correlating psma pet-ct with pca histology have been documented. we present the case of a fi t 76 year old gentleman, where psma pet-ct was used to accurately detect pca pelvic lymph node (ln) metastasis in the setting of bcr following primary radiation treatment. results: th e positive psma pet result was confi rmed with histological examination of the involved pelvic lns following robotic-assisted laparoscopic pelvic ln dissection (plnd). larger studies are required to document accurately the role of psma pet-ct but it is likely it will usher in a new era of surgical and even radiation treatment of oligometastatic disease, aiming for cure or prolonged deferring of systemic treatment. introduction and objective: imaged guided radiotherapy has been shown to improve the outcome of pelvic radiotherapy, notably with prostate gold seed fi ducials. lipiodol has been utilized for radiotherapy bladder fi ducials, but can be technically diffi cult to inject as discrete fi ducial markers, particularly in the post-prostatectomy setting. th e objective is to investigate contrast agent/tissue glue mixtures as radiotherapy bladder fi ducials with respect to deliverability and visualisation for radiotherapy verifi cation. two radiopaque contrast agents, lipiodol and urograffi n were investigated. th ese were mixed with a three tissue glues: histoac-ryl™, tisseel™ and glubran™. to simulate the clinical procedure, the mixtures were injected ex-vivo into the submucosa of fl uid fi lled pigs' bladders using a cystoscope and williams needle. th e aim was to produce a small, medium and large fi ducial. th e bladders were transferred to a pigs' pelvis to provide realistic tissue densities for radiotherapy imaging. visualisation of the pelvis was performed in accordance with radiotherapy procedures. th e initial imaging was done on a radiotherapy ct simulator. radiotherapy verifi cation was performed by radiation therapists using widely accepted protocols including cone beam ct (cbct) and kilovoltage (kv) & megavoltage (mv) 2d planar images. results: delivery: urograffi n glue mixtures were diffi cult to deliver as it polymerized rapidly in the catheter. consequently it was only possible to produce a single fi ducial. th e lipiodol glue combinations were all deliverable. visibility: th e urograffi n glue combinations were only able to produce a single fi ducial that was visible on ct and cbct but were not visible with kv or mv verifi cation. all of the lipiodol glue combinations produced multiple fi ducials that could be satisfactorily visualised on ct and cbct. lipiodol with either hystoacryl or glubran produced visible fi ducials on kv imaging, however the lipiodol tisseel combinations could not be seen. no combination produced suffi cient contrast with mv planar imaging. introduction and objective: th e fl exible urethrocystoscopy is a procedure that is performed routinely in urology for monitoring bladder tumors and diagnosis in patients with lower urinary tract symptoms and hematuria. th e aim of this study is to analyze whether the use or not of antibiotic prophylaxis is indicated in this outpatient procedure. prospective nonrandomized observational study in which 100 patients were divided into two groups: -group 1: 48 patients with prophylaxis with ciprofl oxacin 500 mg 1 h before urethrocystoscopy; -group 2: 52 patients without antibiotic prophylaxis. prior to inclusion in the study absence of urinary tract infection is checked by urine culture obtained three days before the procedure. indication of cystoscopy, cystoscopy results, presence of comorbidities, urine culture aft er 7 days, urinary symptoms over the next seven days were analyzed. statistical analysis with spss 20.0 with signifi cance diff erences p≤0.05. results: th e mean age of patients in group 1 was 66.7 ± 12.4 years versus 65.6 ± 10.8 years in group 2 (p=0.6). no diff erences in the percentage of men / women included among the groups. fourteen percent of patients in group 1 had bacteriuria compared with 12% in group 2, no signifi cant diff erence. in the multivariate analysis, it appears that neither age, diabetes, smoking, lower urinary tract symptoms or immunosuppression were associated with the onset of bacteriuria between groups. conclusion: th e use of ciprofl oxacin prophylaxis in fl exible cystoscopy is not indicated in our health area, because does not diminish the presence of urinary tract infection or bacteriuria. minimal inhibitory concentrations for a novel anti-bacterial peptide eluting urethral catheter introduction and objective: catheter associated urinary tract infection is a serious prevalent medical problem. several strategies have been developed to suppress the seemingly inevitable ascent of foreign pathogens through the urethra. th e primary strategy has been to coat the surface of the catheter with repellant agents, such as silver alloy hydrogels or anti-biotics. anti-bacterial peptides, such as human beta defensing 3 (hbd-3) or cathelicidine are naturally produced peptides from the urothelium, acting to inhibit bacterial attachment and infi ltration as part of the innate immunity of the host. we have recently been able to engineer anti-bacterial peptide elution through gelatin coated catheters. th is study investigates the effi cacy of this strategy in deterring common uti pathogens. materials and methods: e. coli and p. aeruginosa, bacteria commonly associated with uti, were inoculated in tryptic soy broth, and then were aliquoted into each well of plates. anti-bacterial peptides, either recombinant hbd-3 or cathelicidine, were diluted and added to each well at increasing concentrations, where microorganisms were exposed for 24 hours or for the indicated times following antimicrobial challenge and determination of the planktonic mics. bacteria were then enumerated by serial dilution plating. time-kill studies were performed. bactericidal activities of the antimicrobial agents were defi ned as a 3 log decrease in the cfu/ml over 24 hours relative to cell counts in the starting inoculum. results: th e standard inoculant of e. coli and p. aeruginosa commonly required an mic of 40μg/ml hbd-3, and 20μg/ml for cathelicidine. time kill studies estimated bactericidal eff ect for hbd-3 on e. coli and p. aeruginosa both at 5 hours, while for cathelicidine it was 16 and 20 hours, respectively. conclusion: th e current study demonstrates the efficacy and feasibility of a controlled release elution of anti-bacterial peptides, hbd-3 and cathelicidine, in inhibiting growth of common uti pathogens. the conclusion: co-infections of ng with ct appear less frequently. and mpcr method is rapid and accurate for identifi cation of stp. th e mpcr should be conducted in advance prior to antibiotic treatment as well as it will be better to give suitable antibiotics rather than empirical combination antibiotics for ng with ct in patient with urethritis. introduction and objective: th e prevalence of multi-drug resistant extended-spectrum beta-lactamase-producing (esbl) bacteria in normal gut fl ora in the australian community is increasing. current prophylactic antibiotic regimes for trans-rectal ultrasound (trus) prostate biopsies do not have activity against esbl organisms leaving some men at risk of esbl sepsis. our objective is to determine the prevalence of esbl in gut fl ora in northern tasmanian men and to identify risk factors for colonisation. patients were recruited into two groups. group 1 were volunteers from the urology pre-operative clinic or the general community. group 2 were men undergoing trus prostate biopsies. all patients were assessed via an enrolment questionnaire for the presence of known esbl risk factors. further procedural data were collected for those who had trus biopsies. all patients were assessed for esbl via a faecal culture, prior to any antibiotic prophylaxis. fisher's two-tailed test was used for comparative analysis. patients with ic/pbs were assessed with the o'leary-sant interstitial cystitis index score and global response assessment questionnaire prior to commencing treatment. assessment with these questionnaires was performed aft er 6 treatments (10 weeks) and again aft er 10 treatments (24 weeks). assessment end points were pain, urgency, symptom score and problem score. results: data was collected on 10 patients, 9 female and 1 male. six patients had failed rimso-50 dimethyl sulphoxide (dmso) 50% w/w treatment prior. at baseline the mean pain score was 6.6, urgency score 7.00, symptom score 13.5 and problem score 12.5. aft er 24 weeks the mean pain score fell to 2.0, urgency score to 1.80, symptom score to 6.89 and problem score to 5.67. at 10 weeks the global response to treatment was 100%. nocturia was the fi rst symptom to improve with urgency and pain following. no side eff ects were noted no was reported during instillation and all patients tolerated the treatments. conclusion: ic is a diffi cult disease to treat. it requires a multimodal approach. we found that intravesical chondroitin sulphate reduced pain, urgency and o'leary-sant symptom and problem scores in patients with ic/pbs. all patients tolerated the treatment and no side eff ects were reported. introduction and objective: extended spectrum beta-lactamase (esbl) producing enterobacteriaceae are an increasing concern in an era of antibiotic resistance as they cause infections ranging from community acquired urinary tract infection (uti) to life threatening sepsis. we retrospectively reviewed the incidence and antibiotic susceptibility profi le of all esbl producing enterobacteriaceae at a university hospital in the united kingdom. patient gender, age and catheter specimen were assessed as risk factors. patient age, gender and specimen type were recorded in the database. urine samples received from outside our institution (including community isolates) were excluded from the analysis. urine was processed by calibrated loop sampling on to chromogenic clear media (oxoid ltd, basingstoke, uk). a positive culture was defi ned as ≥ 105 cfu/ml except for samples from children and pregnant women where a cut-off value of >103 cfu/ml was used. susceptibility testing was performed by bsac (british society of antimicrobial chemotherapy) disc diff usion testing and reported for ampicillin, co-amoxiclav, piperacillin-tazobactam, carbapenems (ertapenem, meropenem), nitrofurantoin, pivmecillinam, trimethoprim, cephalexin, fosfomycin, third generation cephalosporins (ceft riaxone, ceft azidime) quinolones (norfl oxacin or ciprofl oxacin), aminoglycosides (gentamicin, amikacin) and others. cultures of more than two organisms (heavy mixed growth) were considered contamination and excluded. other exclusion criteria included missing data such as gender, age or susceptibility results, age < 16 years old or an unusual specimen type such as an ileal conduit, nephrostomy, prostatic secretion, bag specimen or a suprapubic aspirate. results: our initial database included 44,395 samples which was reduced to 37,538 samples from 28,604 unique patients aft er exclusion criteria were applied. causative organisms were found to predominantly be e. coli, enterococcus, klebsiella, pseudomonas and proteus species. th e proportion of causative organisms was largely stable across the ten year period. antibiotic resistance was demonstrated to have increased, particularly across fi rst line agents. male gender and catheter use were associated with multi-resistance. in the modern era of antibiotic resistance we demonstrate that antibiotic resistance in hospital urinary tract infections is increasing. our results may be used to guide empirical treatment of hospital urinary tract infection. chronic pyelonephritis is a risk factor for renal dysfunction after urinary diversion in bladder cancer uehara s 1,2 , murao w 2 , otsuki h 2 , shimizu t 2 , yoshioka t 1,2 , fujio k 2 1 okayama university, okayama, japan; 2 abiko toho hospital, abiko, japan introduction and objective: several reports showed that acute pyelonephritis is a risk factor for renal dysfunction in bladder cancer aft er urinary diversion, but the impact of chronic pyelonephritis fer renal dysfunction was unclear. materials and methods: from 1990 to 2008, 140 patients underwent radical cystectomy in our institute. among those patients, 68 who showed hydronephrosis (more than grade2) or did not have enough data were excluded in this retrospective study. finally 72 patients were enrolled. th e urinary diversions were divided into 4 types: ileal neobladder (ib), ileal conduit (ic), ureterocutaneostomy without stent (uc) and ureterocutaneostomy with stent (ucws). ureteral stents were indwelled because of the ureteral stenosis aft er ureterocutaneostomy. because the cases of ucws generally showed pyuria and bacteriuria, ucws was determined as the chronic pyelonephritis model, and the estimated serum creatinine-based glomerular fi ltration rate (egfr) was calculated and compared with other urinary diversion. results: median follow-up period was 48.0 months (range 24-108 months) and median egfr was 62.1ml/ min/1.73m2 before surgery and 54.8ml/min/1.73m2 at the last follow-up. th e median decrease of egfr during the period between pre-surgery and the last follow-up in ib, ic, uc and ucws was 10.7, 6.1, 2.5 and 17.7ml/min/1.73m2 respectively. renal function was signifi cantly impaired in ucws cases than other urinay diversion. conclusion: chronic pyelonephritis may be a risk factor for renal dysfunction aft er urinary diversion. to avoid the renal dysfunction, ureteral stents should not be indwelled permanently. comparison of antibiotic susceptibility of escherichia coli between community-acquired and post-biopsy acute prostatitis introduction and objective: th e etiology of acute prostatitis aft er transrectal-ultrasound-guided-prostate-biopsy (pbx-ap) seems to be diff erent from that of community-acquired acute prostatitis (ca-ap). recent studies suggested that pbx-ap should be considered a separate category of prostatitis, distinct from spontaneous acute prostatitis. th us, we aimed to compare antibiotic susceptibility of escherichia coli between ca-ap and pbx-ap. of 4,383 patients who underwent transrectal-ultrasound-guided-prostate-biopsy, a total of 34 patients had pbx-ap. in 22 among these, escherichia coli was isolated on urine or blood culture. in 91 of the 209 patients with ca-ap, escherichia coli was identifi ed on urine or blood culture test. th us, a total of 113 patients with ca-ap (n = 91) or pbx-ap (n = 22) caused by escherichia coli were included in this retrospective study. we compared demographic variables, data on clinical laboratory tests or transrectal ultrasound and antibiotic sensitivity data between the two types of prostatitis. results: in comparison to the ca-ap group, the pbx-ap group showed signifi cantly higher incidence of bacteremia and lower count of white blood cell. th ere was no signifi cant diff erence between the two, regarding to other clinical or laboratory parameters including age, body mass index, serum psa, prostate volume and percentage of patients with ebsl-positive escherichia coli. th e percentages of patients with quinolone-resistant escherichia coli in the ca-ap and pbx-ap groups were 12.1% and 72.7%, respectively, while those with 2nd or 3rd cephalosporin-resistant escherichia coli were 7.7% -9.3% and 18.2% -20.0%, respectively (table 1 ). in both groups, the percentage of patients with amikacin-resistant escherichia coli were 0.0%. our data suggest that a combination therapy of cephalosporin and amikacin can be recommended for treatment of pbx-ap while quinolone alone may be a feasible treatment option for ca-ap. the effectiveness of prostatic massage in treating chronic prostatitis (cp) tanabalan c, panah a, kabir m, masood j, pati j, nargund v introduction and objective: we review the eff ectiveness of prostatic massage under general anaesthesia (ga) for persistent symptoms aft er failure of antibiotic therapy. th e mainstay of treating cp is empirical antibacterial therapy with varying results. prostatic massage has been used to treat cp with mixed results. retrospective study of patients that were seen in urology outpatient clinics from june 2010 to july 2014 with symptoms of chronic prostatitis. all patients had a full clinical evaluation and urinary samples were sent for culture/microscopy on their visit. patients were treated initially with a course of 5-aminoquinolone and doxycycline in combination with lifestyle advice. if initial antibiotic therapy failed and no abnormal results detected in the work-up, a prostatic massage was off ered. th is involved a rigid cystoscopy followed by a 5-minute prostatic massage under anaesthesia. post-operatively patients received a further course of antibiotics. patients were followed up aft er the procedure and were assessed for improvement in symptoms. a total of 64 patients (82%) commented on an improvement in some or all of their cp symptoms for a mean length of time of 11.9 (range 2.1 to 21.7 weeks). mean psa was 2.16 (range 0.266 to 58.8). one bladder tumour and one urethral stricture were detected on cystoscopy with one prostate cancer following prostate biopsies. if voiding urinary symptoms present men were given an alpha-blocker, there was no signifi cant improvement in pain symptoms post-operatively between the two groups (p= 0.758). th ere were no adverse eff ects from having the procedure with no complications noted. prostatic massage under ga is a safe and eff ective therapy in the treatment of refractory cp in select patients. th e issues of long-term surveillance and assessment of response to treatment remains a challenge. th ere seems little role for alpha-blockers, psa testing and mri prostate in the management of cp. oral antibiotic therapy and lifestyle modifi cations should remain as a fi rst-line treatment option. th e eff ect of stress, lifestyle and ethnicity has not been demonstrated in this study and further research will need to be undertaken. intravesical hyaluronic acid and chondroitin sulfate therapy for interstitial cystitis and painful bladder syndrome shin b, hwang e, chung h, kim s, jung s, kang t, park k, kwon d introduction and objective: damage to the urothelial glycosaminoglycan (gag) barrier layer may underlie the pathogenesis of several chronic bladder pathologies, including interstitial cystitis/painful bladder syndrome (ic/pbs). th is study evaluated the eff ect of intravesical hyaluronic acid (ha) in ic/pbs. twenty patients received intravesical ha 800 mg and chondroitin sulfate (cs) 1 g (ialuril®) in 50 ml saline solutions once weekly for 4 weeks, once every 2 weeks for the next 1 month, then once every month for the next 4 months. results: a signifi cant improvement in urinary symptoms was evident on voiding diaries (number of voids and mean void volume; p=0.003 and 0.007, respectively). th e interstitial cystitis symptom index and interstitial cystitis problem index resulted in a significant improvement in both scores (p=0.007 and 0.005, respectively). th e storage symptom score (ipps) decreased from 7.95 to 7.2 (p=0.012). th e quality of life to urinary symptom reduced from 5.15 to 4.45 (p=0.002). th ere was no statistical signifi cant change in the voiding symptom score of ipps aft er ialuril instillation (p=0.741). conclusions: th is promising experience seems to offer an additional therapeutic option in patients with refractory ic/pbs. prevention of surgical site infection: new approach alexander e 1,2 , hulda t 1 , edna d 1 introduction and objective: until the middle of the 19th century, when ignaz semmelweis and joseph lister became the pioneers of infection control by introducing antiseptic surgery, most wounds became infected. in cases of deep or extensive infection this resulted in a mortality rate of 70-80%. most surgical site infections (ssi) are superfi cial, but even so they contribute greatly to the morbidity and mortality associated with surgery. th e aim of this study is to fi nd out rate of surgical site infection by single change of wound dressing. th e study is prospective in two hospitals (ba regional hospital, tophill hospital in kumasi). surgically clean cases are selected for operation. wounds are not opened till the seventh day or when soaked. window is left for wound inspection. results: results are shown in table 1 . table 1 , 30 patients with diff erent surgical conditions were operated. average post-surgery change of dressing was 7 days. ssi=1/30 (3.3%). single post-surgery change of dressing is eff ective ssi prevention method. effects of semen cuscutae on the fertilization ability in varicocele-induced rat introduction and objective: th ere is no specifi c medication to improve the sperm motility and count yet. th is study aimed to evaluate the favorable eff ects of purifi ed fl avonoid, semen cuscutae extract (sce) against oxidative stress injuries and other homeostatic imbalances in reproductive organs in adolescent rat with varicocele and to develop the new herbal medication to treat the male fertility. materials and methods: seventy-two rats were divided into 6 groups: control (ctr) + hydroxypropyl-methyl cellulose (hpmc) (ctr + hpmc), ctr + 100 mg/kg sce and ctr + 200 mg/kg sce, varicocele (vc) + hpmc, vc +100 mg/kg sce and vc + 200 mg/kg sce. in ctr group, they were started with medication for 28 days from 4 weeks aft er environmental stabilization. for the vc groups, they were given medications for 28 days aft er 4 weeks of operation. blood was collected before sacrifi ce for the testosterone test. sperm motility, daily sperm production (dsp), sperm count, and sperm transit time were calculated. th e seminiferous tubules were graded according to johnsen scoring. th e mrna expression of glutathione peroxidase (gpx1) and .54 nmol/mg protein, respectively) than vc group (54.84 ± 12.76 u/mg protein and 37.7 ± 8.29 nmol/mg protein, respectively). also, the testosterone, johnsen score were signifi cantly increased in the dose of 200 mg/kg sce group than other groups. th ese results suggest that purifi ed fl avonoid semen cuscutae extract could be an alternative medicine for the infertility patients by inhibition of oxidative stress by favorable mechanisms. the relationship between pregnancy rate and semen quality improvement after varicocelectomy varicocele is the most common cause of male infertility and is generally correctable via surgery. in some reports, pregnancy rates were improved aft er varicocelectomy in male patients with poor semen quality. th e aim of this study was to determine the relationship between semen improvement and pregnancy rate. patients who underwent microsurgical varicocelectomy from jan. 2010 to jun. 2012 were enrolled. all patients had history of infertility (>1 year) and confi rmed varicocele on physical examination. th e abnormality of semen analysis results was based on 1997 who guidelines. varicocelectomy was performed in patients with poor semen quality in a series of two semen analysis where the female partner was normal in spontaneous pregnancy, as evaluated gynecologically. microsurgical varicocelectomy was performed by single surgeon. follow-up semen analysis was performed 4 months aft er operation. improvement in semen quality was defi ned as >20% improvement in total motile sperm compared with pre-operation semen analysis. pregnancy rate, method of pregnancy, and time to pregnancy were investigated. results: a total of 98 male patients were included in this study, 69 (70.4%) in the improvement group (ig) and 29 (29.6%) in the non-improvement (nig). th e pregnancy rate was 81% (56/69) in the ig group and 76% (22/29) in the nig group; there was no significant diff erence between groups. pregnancy methods between the two groups were similar (table 1) . introduction and objective: to review the learning curve, complications and outcomes of the fi rst 80 cases of microsurgical vasectomy reversal performed in a developing country. th e fi rst dedicated service in male infertility microsurgery in south africa was established in 2012. between january 2012 and december 2014, a total of 80 patients underwent microsurgical vasectomy reversal by a single surgeon (amir d zarrabi). mean patient age was 45 years (range 29 to 66), mean age at vasectomy 33 years (range 19 to 56), mean number of children for the male partner 2.4 and mean age of the female partner 33 years (range 20 to 45). th e mean time interval between vasectomy and reversal was 11.3 years (range 0.5 to 29.5). five patients had previous failed vasectomy reversals and in 3 patients the indication for reversal was post-vasectomy pain syndrome. a total of 26% of patients travelled from other countries for their surgery. results: mean surgical time per testicular unit was 80.2 minutes (range 37 to 115) and total operative time 157 minutes (range 95 to 200). sperm motility (intra-operative light microscopy) was good in 23.5%, average in 8.4% and poor in 68.1%. vasovasostomy was required in 45.8% of testicular units and vaso-epididymostomy in 42.2%. in 6 patients sperm was harvested at the time of reversal for cryopreservation. complications occurred in 21% of patients and were managed conservatively in all but 3, who required an additional surgical procedure. for patients with adequate follow-up the overall surgical success rate was 81%. mean post-operative sperm count was 73.3 million. nine pregnancies and 3 live births have been recorded during the limited follow-up. comparing the fi rst 40 cases with the last 40 cases revealed no signifi cant diff erences in surgical time, complications or patency rates. th e mean post-operative sperm count was 10% higher for the last 40 cases. although microsurgical vasectomy reversal is technically demanding and requires specialized equipment and instruments, it can be successfully implemented in a developing country. infl uence of unilateral iatrogenic torsin on contralateral testis in rat, prepubertal and postpubertal introduction and objective: th e present study was conducted to investigate the infl uence of hemicastration and age at hemicastration on the subsequent contralateral testis. sixty-four wistar-derived male rats divided randomly in 4 groups. group 1 named immature intervention, group 2 immature control, group 3 mature intervention and group 4 mature control. in group 1, rats hemicastrated at 30 days of age (prepubertal). in group 2, sham surgery (midscrotal incision) was done at same age. in group 3, rats hemicastrated at 70 days of age (postpubertal) and in group 3 sham surgery was done at same age. twenty days aft er fi rst surgery, in intervention groups contralateral orchiectomy was done and in control groups random orchiectomy (left or right) was done. blood sampling for evaluation of serum testosterone was performed just before second surgery. results: testis weight and the mean testicular weight per 100 g of body weight was greater in hemicastrated rats. th ese parameters was greater in prepubertal group than postpubertal hemicastrated rats. th ere was no appreciable diff erence in serum testosterone levels in 4 groups. our research demonstrated that hemicastration resulted in compensatory hypertrophy of the remaining testis and it decreased as the animals aged. hemicastration does not lead to reduction in serum testosterone levels and remaining testis can retrieve a normal serum testosterone level. role of antibiotic in the treatment of semen hyperviscosity: a single institution study introduction and objective: th e prevalence of semen hyperviscosity is estimated to be between 12-29% and can lead to male factor infertility both in vivo and in vitro. semen is composed of fl uids secreted by the male accessory glands, which contain proteins essential to the coagulation and liquefaction of semen. hypofunction of the prostate or seminal vesicles causes' abnormal viscosity of seminal fl uid. hyperviscosity can impair normal sperm movement in the female reproductive tract, and can lead to decreased sperm count. multiple factors have been predicated which result in the development of semen hyperviscosity, of this infection is considered to be one of the main contributor. aim of the study was to predict the eff ect of antibiotic in the treatment of hyperviscosity. th is is a single institution study, 80 patients (age range 21-41 years) were recruited who were diagnosed with semen hyperviscosity (failure to liquefy aft er 30 min). medical, sexual, and family history were documented. all the patients semen were kept for culture and they all got levofl oxacin for 14 days and patient who had positive culture were changed to appropriate antibiotics. all the patients underwent repeat semen analysis aft er 3 weeks. results: seventy seven percent patient had previous history of prostatitis, 12% patient had past history of sexual transmitted diseases. seventy fi ve percent patient are suff ering from infertility, of this 7% patient had a family history. th irty seven percent patients had positive culture and of this only 10% patient had liquefaction post treatment. culture negative patients, 40% patient had liquefaction post treatment. conclusions: semen hyperviscosity is associated with infertility and exact cause is considered to be multifactorial, of this infection is considered to be the main factor. in our study we did found that most of the patients has infection but antibiotic treatment even for culture positive patients showed minimal eff ect. treatment with antibiotic along to treat hyperviscosity cannot be considered curative since in our study the eff ect was only 30%. further research is needed to better understand the contributors to semen hyperviscosity and the treatments that can be used for infertile males with hyperviscous semen. modifi ed microsurgical subinguinal varicocelectomy: bundle ligation technique hong y, lee s, choi k, park d, hong j introduction and objective: microsurgical varicocelectomy has become the gold standard because of low recurrence and postoperative complication rate. during the procedure, isvs should be carefully dissected, cut and suture-ligated one by one. however, it is not easy to divide all isvs in a horizontal line, which can result in some uncertainty whether every single isv was divided or the same vein was unnecessarily divided multiple times. th erefore, we have developed a modifi ed technique, so called bundle ligation technique (blt), to make the procedure more reliable and simpler. a total of 89 cases of microsurgical subinguinal varicocelectomy performed from 2008 to 2013 were grouped as conventional varicocelectomy (cv, n=44, age: 20±7.4) and blt (n=45, age: 21±6.7). mean follow-up time was 12.2±5.9 months. blt is a simpler procedure because isvs are ligated as a whole, however, it is possible only aft er dissecting and securing the testicular artery fi rst. we compared operation time, resolution of palpable varicocele or pain, recurrence rate and complications. results: mean operation time was 72.5±16.5 in cv group and 60.1±20.8 in blt group (p=0.03). resolution rates 3 months aft er surgery were 93.18% (cv) and 93.33% (blt) in each group. recurrence aft er surgery during the mean follow-up time was 7.31% (cv) and 4.76% (blt). th e aim of the study is to evaluate the eff ect of hbo on the level of sperm dnaf and on the content of reactive oxygen species (ros) in semen. th e study included 90 men with idiopathic infertility, the level of sperm dnaf was above 15% and the content of ros in the sperm was above 0.64 mv/sec. in the main group (n=60) 10 sessions of hbo were performed and in vitro fertilization (ivf) was carried out 3 months later. in the control group (n=30) ivf was performed without preceding hbo. th e age of patients ranged from 25 to 37 years (median -30.5 years). sperm dnaf was determined by tunel, the level of ros in semen was studied by chemiluminescence. th e assessment was made at the time of entry into the study and aft er 3 months (in the main group -3 months aft er hbo). in the main group, average sperm dnaf aft er hbo decreased from 33.2±7.5% to 11.9±5.9% (p<0.05), the median level of ros in semen decreased from 0.89 mv/sec to 0.39 mv/sec (p<0.05), whereas in the control group of patients these fi gures have remained almost at the same level -31.2±6.1% and 31.7±6.3% (p>0.05), 0.86 mv/sec and 0.88 mv/sec (p>0.05). pregnancy resulting from ivf occurred in 63.3% (38/60) of the cases in the study group and in 36.7% (11/30) -in the control group (p<0.05). conclusion: hbo is an eff ective method to reduce the number of sperm with dnaf, which can potentially lead to an increased fertility in patients with idiopathic male infertility. to evaluate the natural history and growth kinetics between sporadic clear cell renal cell carcinoma (ccrcc) and ccrcc in von hippel-lindau disease (vhl). we reviewed 60 patients with 61 sporadic ccrccs and 15 patients with 30 vhl ccrccs all confi rmed by delayed surgery aft er at least 12 months active surveillance. th e growth rate was calculated. th e growth kinetics between sporadic and vhl ccrcc were compared. th e initial tumor diameter and pathological grade were reviewed, and their correlation with the growth rate were analyzed. results: th e mean growth rate of sporadic ccrcc was 0.86 cm/yr (range, 0-4.74 cm/yr). th e mean growth rate of vhl ccrcc was 0.49 cm/yr (range, 0.04-1.89 cm/yr). th e growth rate of vhl ccrcc was lower than that of sporadic ccrcc (p=0.024). for vhl ccrcc, the initial tumor diameter aff ect the growth rate (r=0.804, p<0.001), while the pathological grade not (p=0.317). for sporadic ccrcc, the pathological grade aff ect the growth rate (p<0.001), while the initial tumor diameter not (r=-0.207, p=0.110). conclusion: th e growth kinetics of vhl ccrcc is more indolent than that of sporadic ccrcc. for ccrcc with aggressive growth kinetics, its growth rate might correlates with the pathological grade, for those with slow growth kinetics, the growth rate might correlates with the initial tumor diameter. effects of trpm7 silencing on the proliferation, migration, and invasiveness of renal cell carcinoma (rcc) cells proliferation, migration, and invasiveness of human rcc following trpm7 knockdown. we constructed sirna sequences targeting the trpm7 gene and then transfected them into rcc cells mediated by liposome. th e potency of 100 nm trpm7 sirnas was detected trpm7 mrna measurement by rt-pcr. th e eff ect of trpm7 sirna on cell viability was determined by wst-1 assay. cell motility and invasiveness were evaluated by wound healing assays and a matrigel migration and invasion assay. transfected rcc cells were cultured in eagle's minimum essential media supplemented with 10% fetal bovine serum. all measurements were done 24 hours aft er trpm7 blocking. results: trpm7 sirna weakly inhibited the gene transcription of trpm7. it was for nothing in the proliferation of human rcc cells. compared with vehicle control, the migration and invasion of human rcc cells were suppressed signifi cantly by trpm7 sirna until aft er 48 hours. in addition, although protein levels of mmp-9 were not changed signifi cantly, we found that the protein levels of matrix metalloproteinase (mmp)-2 were diminished markedly by trpm7 sirna. th ese results suggest that trpm7 may have a role in the rcc progression including migration and invasion through upregulation of mmp2. role of tnf-and cd44 in resistance to sunitinib treatment in clear cell renal cell carcinomas introduction and objective: tumor necrosis factor-α (tnf-α) was originally reported as a cytokine to induce apoptotic cell death and cachexia. recent studies have indicated that tnf-α also enhances tumor progression by inducing epithelial-mesenchymal transition (emt). tnf-α is also known as a modulator of cd44 expression, which belongs to cancer stem cell marker in several cancers. in this study we clarifi ed the signifi cance of tnf-α as well as cd44 in clear cell renal cell carcinomas (ccrccs). protein expression of tnf-α and cd44 was examined by immunohistochemistry in primary ccrccs, untreated metastatic ccrccs, and metastatic ccrccs treated with sunitinib, and its association with the clinicopathological parameters and prognosis was analyzed. involvement of tnf-α in emt and induction of cd44 was analyzed by comparing expression of emt-related genes and cd44, and migration and invasion in cultured ccrcc cell lines. results: tnf-α and cd44 were predominantly expressed in carcinoma cells of high-grade ccrccs with positive correlations with primary tumor stage and distant metastasis. th ere was a positive correlation between tnf-α and cd44 expression, and elevated expression of tnf-α and cd44 was a poor predictor of prognosis. tnf-α enhanced migration and invasion of ccrcc cells together with down-regulation of e-cadherin expression and up-regulation of matrix metalloproteinase 9 and cd44 expression. tnf-α also up-regulated the expression of tnf-α itself in ccrcc cells. twenty-fi ve patients were treated with sunitinib for metastasis, and the patients with cd44-high tumors showed a shorter time to treatment failure compared to those with cd44-low tumors. furthermore, residual carcinoma cells in the sunitinib-treated metastatic ccrccs were strongly positive for cd44, and the cd44 expression was signifi cantly higher in tumors from the sunitinib-treated patients than in those from untreated ones. conclusions: tnf-α seemed to play an important role in progression of ccrccs by inducing emt, and suggested that tnf-α-induced cd44 might be involved in the resistance to sunitinib treatment. although further experimental studies on the relations between cd44 expression and cancer stem cells in ccrccs are needed, our data suggest that therapy targeting tnf-α and/or cd44 may provide a clue for improving the prognosis of patients with sunitinib-resistant ccrcc. introduction and objective: th e aim of this study was to investigate the relationship between the immunohistochemical expression of hypoxia-inducible factor-1α (hif-1α) with histological parameters such as tumor size; presence of tumor necrosis and hemorrhage; nuclear grade and pathological stage in patients with clear cell renal cell carcinoma (ccrcc). specimens from 40 cases of rcc patients treated with radical prostatectomy were formalin-fi xed, paraffi n embedded, and stained with h&e. additional sections from each case were stained for hif-1α. hif-1α immunohistochemical expression was estimated as negative (0), weak positive (+1), moderate positive (+2), and intense positive (+3). th e statistical package "in stat 3" was used for data processing. results: immunohistochemical expression of hif-1α in crcc was signifi cantly higher than in normal kidney tissue at statistically signifi cant level (hif-1α: x2-test = 8.76, p=0.012). a positive non-signifi cant correlation was found between hif-1α and the tumor nuclear grade (r=0.181, p=0.262); between hif-1α and presence of hemorrhage (r=0.08, p=0.589); whereas, a negative non-signifi cant correlation of a very weak scale was observed comparing hif-1α and tumor size (r = -0.264, p=0.09); hif-1α and pathological stage (r=-0.05, p=0.754), as well as hif-1α and tumor necrosis (r=-0.164, p=0.309). conclusion: our data showed heterogeneity in angiogenic activity, which might have an impact on biological behavior and anti-angiogenic, anti-vegf therapy of ccrcc patients. th is study suggests that there should be taken more than one tissue biomarkers into the consideration in predicting the biological behavior of ccrcc. introduction and objective: clear cell renal carcinoma (ccrcc) is the most frequent rcc subtype and is characterized by high mortality of 40%, due to late diagnosis and distant metastases found in 30% of rcc patients. although the involvement of vhl (von hippel-lindau), hif1a (hypoxia-inducible factor 1-alpha) and vegf-a (vascular endothelial growth factor a) genes in development and progression of ccrcc is widely analyzed, our objective was to perform the common study of those factors in clinical samples of matched tumor-normal kidney biopsies of ccrcc cases. materials and methods: vhl, hif1a and vegf-a mrna levels in samples were assessed by quantitative polymerase chain reaction (qpcr); rna was extracted from matched tumor-normal (t, c) kidney samples of 86 ccrcc patients (mean age 62.1 ± 11.2, median age 62); 41 ccrcc cases were characterized by local or distant metastasis; sunitinib was administrated to 30 patients. vhl, hif1α and vegf-a proteins were localized in matched tumor-kidney tissue of 6 patients with the use of immunohistochemistry (ihc). molecular data was statistically calculated with clinical and follow-up data. introduction and objective: to identify tissue biomarker that are predictive of the therapeutic eff ect of sunitinib in treatment of metastatic clear cell renal cell carcinoma (mcrcc). our study included 39 patients with mcrcc; these were selected from 119 patients who received sunitinib in our hospital between the years 2005 -2012 according to inclusion criteria of the study. patients were stratifi ed into two groups based on their response to sunitinib treatment; non-responders (progression), and responders (stable disease, regression). th e eff ect of treatment was measured by comparing imaging studies performed before the initiation of treatment with those done between 3rd and 7th months of treatment. histological samples of tumour tissue and healthy renal parenchyma, acquired during surgery of the primary tumour, were examined with immunohistochemistry to detect tissue biomarkers (mtor, p53, vegf, hif1, hif2, caix). th e comparison between the two groups of patients was based on comparing the average levels of biomarker expression in both tumour tissue, as well as in healthy renal parenchyma. results were evaluated using student's t-test. results: when considering the results of the group of responders, statistically signifi cant diff erences in marker expression in tumour tissue versus healthy parenchyma were found for mtor (4%/16.7%;p=0.01031), p53 (4%/12.7%;p=0.042019), vegf (62.7%/45%;p=0.019836) and caix (45%/15.33%;p=0.001624). as for the group without response (non-responders), a statistically signifi cant diff erence was also evident in p53 a vegf expression in tumour versus healthy tissue (3%/21.3%;p=0.02824 resp. 36.3%/12%;p=0.011921). in the responders, a further signifi cant diff erence was found in the frequency of high expression (more than 60%) between tumour tissue and healthy parenchyma in vegf (65%/35%;p=0.026487) and caix (42%/8%;p=0.003328). caix shows high levels of expression in the tumour tissue, in both of the evaluated groups. when comparing the expression levels in the same type of tissue, between the group of responders and non-responders, no signifi cant diff erence in any biomarker was found. conclusion: a signifi cantly higher expression of vegf in crcc in comparison to healthy parenchyma, can predict a better response to sunitinib. on the other hand, the high expression of vegf in healthy renal parenchyma can predict worse response to treatment. the impact of preoperative retrograde pyelography before radical nephroureterectomy for upper urinary tract urothelial carcinoma on intravesical tumor recurrence song p 1 , ko y 1 , choi j 1 , moon k 1 , jung h 1 , kim t 2 introduction and objective: despite its diagnostic role in identifi cation of upper urinary tract urothelial carcinoma (uut-uc), approach to ipsilateral ureteral potentially aggravates spread of tumor, as reported in preoperative ureteroscopy before nephroureterectomy. we thus assessed the impact of preoperative retrograde pyelography (rgp) on intravesical recurrence aft er radical nephroureterectomy for uut-uc. of a total of 114 patients who underwent nephroureterectomy for uut-uc from january 2000 to june 2012 in our institution, 72 patients who did not undergo preoperative ureteroscopy were selectively enrolled. computed tomography and urine cytology as a basic diagnostic modality were performed in all subjects. th e impact of preoperative rgp and the other variables (age, sex, operating time, clinicopathological factors, and hematological factors) on intravesical recurrence were analyzed by multivariate cox regression model. during a mean follow-up period of 61.2 months, 32 (44.4%) patients had intravesical recurrence aft er rnu, and 41 subjects (56.16%) underwent preoperative rgp. th e mean duration from preoperative rgp to rnu was 14.2±19.4 days and mean interval of intravesical recurrence was 22.0±23.1 months. multivariable analysis showed that rgp and pathologic stage over t2 were independent factors for intravesical tumor recurrence (p=0.012 and p=0.036, respectively, table 1 ). regarding the duration from preoperative rgp to rnu, no signifi cant diff erence was observed between the recurrence group and the non-recurrence group (p>0.05). as with preoperative ureteroscopy, our data demonstrated that preoperative rgp is an independent factor associated with intravesical recurrence of uut-uc aft er rnu. introduction and objective: axitinib which is tyrosine kinase inhibitor is standard 2nd-line treatment for metastatic renal cell carcinoma (mrcc). th e neutrophil-to-lymphocyte ratio (nlr), an index of systemic infl ammation, is associated with outcome in several cancer types. to assess the relation of pretreatment nlr with progression-free survival (pfs) and overall survival (os) of patients treated with axitinib. twenty-two patients with mrcc were treated with axitinib between october 2012 and january 2015. patients were stratifi ed in two groups with nlr >3 (group a: n=12) vs. <3 (group b: n=10). pfs and os were estimated using kaplan-meier method. results: median os and pfs were 11.8 and 8.3 months, respectively. median os was 8.0 and 21.2 months in group a and group b, respectively (p= 0.011). median pfs was 5.6 and 15.4 months in group a and group b, respectively (p<0.001). multivariate analysis showed that nlr >3 was an independent predictor of os (hr .4.405; p=0.018). in patients with mrcc treated with axitinib, pretreatment nlr might be an independent predictor for the outcome. th e aim of this study was to evaluate whether preoperative neutrophil-to-lymphocyte ratio (nlr) predict the prognosis in patients with upper urinary tract urothelial carcinoma (uu-tuc). a cohort of 147 patients diagnosed with uutuc from 1994 to 2010 at tokyo metropolitan tama medical center was enrolled in this retrospective study. log-rank test and cox proportional hazards regression models were used for univariate and multivariate analyses. results: on univariate analysis, pathologic t stage, grade, lymphovascular invasion, c-reactive protein (crp) level, and nlr were signifi cantly associated with recurrence-free survival (rfs) and cancer-specifi c survival (css). th e rfs rates for an nlr < 2.5 and for one ≥ 2.5 at 5 years were 80.9% and 27.8%, respectively. th e css rates for an nlr < 2.5 and for one ≥ 2.5 at 5 years were 74.2% and 29.4%, respectively. th e multivariate cox proportional hazards regression models showed that the nlr could be an independent predictor for rfs and css. based on the results of multivariate analysis, the scoring model was developed. rfs and css rates at 5 years were as follows: 0 risk factor, 97.0% and 97.0%, respectively; 1 risk factor, 91.3% and 91.3%, respectively; 2 risk factors, 56.1% and 37.8%, respectively; 3 risk factors, 25.8% and 23.4%, respectively; and 4 risk factors, 5.0% and 5.0%, respectively. conclusion: th e preoperative nlr is an independent prognostic predictor. th e model based on the nlr and pathologic factors can be useful in clinical practice. clinicopathological outcome of small cell carcinoma of upper urinary tract: one starting point, diverging paths lu k, wang h, lin v, yu t introduction and objective: primary small cell carcinoma of upper urinary tract (uut-scc) is an extremely rare disease entity with distinct histological and biological behavior, representing less than 0.5% of urinary tract tumor. th e rarity of these neoplasms poses a diagnostic and therapeutic challenge. little is known about uut-scc and the current knowledge of this disease is based on case reports or small series. our aim of study was to characterize the patients with uut-scc and to evaluate patient outcomes with the available treatment modalities. th is was a single-institute retrospective observational cohort study of patients with small cell carcinoma of upper urinary tract followed at e-da hospital, kaohsiung city, taiwan be-tween january 1, 2008 and october 1, 2014. patient and tumor data were analyzed using descriptive statistical methods. results: six patients with primary uut-scc were identifi ed, consisting of 2 arising from renal pelvis and 4 from upper ureter. th e median age at diagnosis was 71 years with male-to-female ration of 2:4. th e most common presenting symptoms were painless gross hematuria, followed by fl ank pain. th e morphological appearance of the tumor cells and their immunohistochemical reactivity for neuroendocrine markers and cytokeratin helped establish the diagnosis. in 3 of 6 cases, scc coexisted with urothelial carcinoma. surgery was standard treatment given to all patients. of all cases, 5 of 6 patients received chemotherapy, including one receiving neoadjuvant chemotherapy and 4 administering adjuvant chemotherapy. overall median survival was 12 months. conclusion: primary small cell carcinoma of the upper urinary tract is characterized by an aggressive clinical course with early metastatic spread and relatively short overall survival. although high response rate to cytotoxic chemotherapy, its duration of response is limited and the prognosis remains dismal. as there is no standard of care for patients with uut-scc, further eff orts should be directed at its early detection and made to develop more eff ective therapeutic approach for this high-risk lethal disease. prognostic introduction and objective: th e aim of this study was to evaluate the impact of body mass index (bmi) on survival in patients with non-metastatic renal cell carcinoma (rcc) treated with radical or partial nephrectomy. between june 1994 and july 2012, 469 patients with rcc underwent radical or partial nephrectomy at two hospitals. among these patients, 21 patients with lymph node or distant metastasis were excluded. th us, the medical records of the remaining 448 patients (302 men and 146 women, mean age of 55.9 years) were retrospectively reviewed. th e median follow-up duration was 44 months (range 4 to 215 months). th e patients were classifi ed into 3 groups according to their bmi based on the asia-pacifi c criteria for obesity: normal (18.5 to <23 kg/m2), overweight (23 to <25 kg/m2), and obese (≥25 kg/ m2). th e prognostic signifi cance of various clinicopathological variables including bmi was analyzed using univariate and multivariate analysis. results: of the total 448 patients, 168 patients (37.5%) were categorized as normal, 112 (25.0%) as overweight, and 168 (37.5%) as obese. forty-six patients (10.3%) developed local recurrence or distant metastasis and 20 patients (4.5%) died of disease during the follow-up period. in the univariate analysis, bmi, tumor size, t stage, fuhrman's nuclear grade, coag-ulative tumor necrosis, and lymphovascular invasion were signifi cant predictors of recurrence-free survival. also, bmi, tumor size, t stage, fuhrman's nuclear grade, and lymphovascular invasion were signifi cant predictors of cancer-specifi c survival. in the multivariate analysis, bmi (p=0.010), tumor size (p=0.009), t stage (p<0.001), fuhrman's nuclear grade (p=0.006), and lymphovascular invasion (p=0.001) were independent predictors of recurrence-free survival. also, bmi (p=0.012), tumor size (p=0.004), t stage (p=0.028), and lymphovascular invasion (p=0.013) were independent predictors of cancer-specifi c survival. our results suggest that bmi is an independent prognostic factor for recurrence-free and cancer-specifi c survival in patients with non-metastatic rcc treated with radical or partial nephrectomy. th ese fi ndings indicate that bmi could be an eff ective tool for predicting recurrence or survival in patients undergoing nephrectomy for non-metastatic rcc. phase i/ii study of multipeptide-based cancer vaccine ima901 after single-dose cyclophosphamide in japanese patients with advanced renal cell cancer hongo f 1 , ueda t 1 , nakamura t 1 , naya y 1 , okihara k 1 , tamada s 2 , schoor o 3 , singh-jasuja h 3 , nakatani t 2 , miki t 1 introduction and objective: ima901 is the fi rst therapeutic vaccine for renal cell cancer (rcc) consisting of multiple tumor-associated peptides (tumaps) confi rmed to be naturally presented in human cancer tissue. objective was to assess the safety and tolerability of ima901 vaccination. in this phase i/ii study in japan, we treated a total of 10 japanese patients with advanced rcc with human leukocyte antigen a (hla-a)*02 + subjects in 2011-2012. each of the vaccinations consisted of an i.d. injection of gm-csf (75 μg) followed within 15-30 minutes by an i.d. injection of ima901 (413 μg of each peptide). th e vaccine therapy was a monotherapy, i.e. no other anti-tumor therapies were concomitantly administered during the study course. no treatment with either anti-cancer agents or immunosuppressants was allowed within 4 weeks before entering the trial. patients were to receive 7 vaccinations in the fi rst 5 weeks of treatment (induction period) followed by 10 further vaccinations at 3 weeks intervals for up to 30 weeks (maintenance period). th e primary endpoint was safety and tolerability. th e secondary endpoints were pfs, os, immunogenicity. results: no treatment-related serious adverse events (saes) or deaths were observed during the study period. at follow-up at 4 months, all cases were assessed for treatment response. ten percent of patients had partial response (pr), 50% with stable disease (sd), 40% of patients had progressive disease (pd). median pfs was 5.5 months and median os was 17.5 months. among all patients analyzed for t-cell response, fi ve showed vaccine-induced (vi) t-cell responses against at least one hla class i-restricted tumap and two patients with responses to multiple tumaps. interestingly, two of the immune responders were of hla-a*0206 phenotype, a hla suballele rarely occurring in europe and us but common in japan. we evaluate the patients who underwent robot-assisted laparoscopic partial nephrectomy (ralpn), laparoscopic partial nephrectomy (lapn), or open partial nephrectomy (opn) in terms of perioperative outcomes. all 95 patients with ct1a renal masses who underwent ralpn (n=10), lapn (n=56), or opn (n=29) between november 2005 and may 2014 at our institute were compared in terms of perioperative outcomes, including the mean operative time, ischemia time, estimated blood loss, change in the estimated glomerular fi ltration rate (egfr), surgical margins, and complications. intraoperative and early postoperative data were collected retrospectively. conclusion: ralpn was signifi cantly associated with shorter ischemia time. any methods of partial nephrectomy preserved renal function at three months postoperatively and showed good oncological outcomes. laparoscopic nephrectomy: does patient obesity affect outcome? introduction and objective: th e prevalence of obesity worldwide is increasing, up to 28% of men and 29% of women are now obese. th ere are various means to assess obesity, waist circumference (wc) has emerged as a superior determinant of obesity and then body mass index (bmi). th is study evaluates wc on the outcome of laparoscopic nephrectomy. data was obtained on 144 consecutive patients. a wc of >80 cm for women and >95 cm for men is considered obese. data collected includes age, gender, asa score, wc, anaesthetic duration, operative approach, surgery duration, blood loss, renal function, complication rate and duration of hospital stay. overall, 144 patients underwent laparoscopic nephrectomy, 86 were male and 58 female. seventy three (50.7%) patients had wc above normal for their gender. mean anaesthetic duration was longer in obese patients 208.1 minutes vs. 184.2 minutes, (p=0.0199). operative duration in obese patients was also longer, 149.6 minutes vs. 134.9 minutes, (p=0.0856). th ere was no diff erence between groups for conversion, number of ports, intra-operative complications, blood loss, or post-operative complications. however, obese patients had a longer in-patient stay; 10.6 days versus 6.3 days. conclusion: laparoscopic nephrectomy is safe in obese patients. however, obese patients should be warned that their obesity may be associated with increased anaesthetic and surgical ties and prolonged recovery. the long-term oncologic results of radiofrequency ablation for small renal tumors sung g 1 , bae y 2 , kim s 1 introduction and objective: th e aim of this study was to retrospectively evaluate the long-term oncologic results of radiofrequency ablation (rfa) of small renal masses (srms). : th e patients who had been followed over 5 years aft er percutaneous or laparoscopic rfa for small renal mass were included in this study. a total of 47 patients and 48 renal tumors were included. th e follow-up study included physical examination, chest radiography, creatinine, and contrast-enhanced ct or mri. recurrence was defi ned as contrast enhancement aft er 3 months or lesion growth at subsequent imaging or viable cancer cells on follow-up biopsy. results: th e mean tumor size was 2.3 cm and the mean follow-up period was 93.3 months. technical success was achieved in 43/48 renal tumors (89.6%). repeated rfa was necessary in 5 tumors due to incomplete ablation. th e overall complication (oc) occurred in 35.8% of which the low-grade complications accounted for 96.2% of oc. a relevant deterioration of renal function aft er rfa was very rare. th e 5-year local recurrence-free survival rates, cancer-specific survival rates, and overall survival rates are 91%, 95.7%, and 89.3% respectively. conclusion: rfa is considered useful treatment for selected patients with srms and also for nephron-sparing. our long-term follow-up results suggest excellent therapeutic outcome with rfa, while achieving eff ective local tumor control. introduction and objective: endoscopic approach of the terminal ureter was proposed as a complementary fi rst step in nephroureterectomy with perimetal cystectomy in order to obviate the low abdominal incision. we aimed to establish the value of a novel method of endoscopic distal ureteral management: pluck technique using bipolar plasma vaporization. during the last 4 years, we performed nephroureterectomy involving plasma-button uretreal desinsertion by bipolar vaporization in 62 upper urinary tract transitional cell carcinoma (uuttcc) cases (pta -23 cases; pt1 -18 cases; pt2 -12 cases; pt3 -9 cases). th e tumor was pyelocaliceal in 42 cases, ureteral in 16 cases and both ureteral and pyelocaliceal in 4 cases. th e follow-up protocol included cystoscopy with urinary cytology, abdominal ultrasound and ct. th e mean follow-up period was 18 months (range 3 to 42 months). results: all procedures were successfully completed. th e mean duration of the endoscopic procedure was 12 minutes. in 2 cases, aft er the completion of the nephroureterectomy, endoscopic haemostasis of the desinsetion area and margins was necessary. th e postoperative complications' rate was 4.8%: 3 cases of hematuria, one imposing endoscopic approach and another treated conservatively. during the follow-up period, 9 patients presented bladder recurrences, 1 had renal fossa tumor and 4 had secondary lymphnode invasion. th e disease-specifi c mortality rate was 8%. conclusion: th e endoscopic detachment of the terminal ureter using bipolar plasma vaporization as part of one-step nephroureterectomy is a safe and eff ective method. mid-term evaluation demonstrated good oncologic outcomes. 35th congress of the société internationale d'urologie -siu 2015 abstract book introduction and objective: we thought that combining open and laparoscopic surgery for partial nephrectomy would be less invasive than open method, easier and expend shorter time to clamp renal artery than pure laparoscopic approach. and combining approach would lead to introduce pure laparoscopic approach safely from open method. we reviewed the records of patients with renal mass treated with partial nephrectomy from 2009 to 2014 at our hospital. a total of 125 patients underwent partial nephrectomy. of these, 50 patients underwent pure laparoscopic procedures. seventy-seven patients underwent combining method, and two patients of these with solitary kidney and one patient with chronic nephritis were excluded. we compared these two groups in terms of perioperative outcomes, including the mean operative time, ischemic time, change in the glomerulofi ltration rate (egfr), and adverse events. conclusion: th is nonrandomized, comparative study suggests that pure laparoscopic approach had longer cold ischemic time but lower postoperative egfr change. complication rates were almost equivalent for both approaches. th erefore, we might shift safely to pure laparoscopic approach through the combined approach in the way of partial nephrectomy. nephron th irty-four (15.2%) had bilateral suspected malignant tumors and were used as material for this study. twenty-fi ve were men and 9 were women. results: eighteen patients (53%) had the same type of tumor in both kidneys. ten of them had clear cell carcinoma and 4 had papillary renal cell cancer. four patients had bilateral oncocytomas. in 12 patients (35%) the lesions diff ered between the kidneys (table 1). in all patients only one kidney was operated on one occasion. in two patients treated with radical nephrectomy (rn) over 20 years ago for renal cancer the subtype of the fi rst tumor was unknown. ten patients were treated with nss -nss, 12 with rn -nss, 7 with nss -rn, 4 with nss -observation and 1 with nss -radiofrequency ablation. two of the patients had von hippel-lindaus disease and one had birt-hogg-dubé syndrome. conclusion: bilateral renal masses were found in 15% of the patients in a material of patients treated with nss. over 50% of them had the same type of tumor on both sides but 22% of these were benign. th e combination of diff erent malignant and benign lesions occurred in 35%. th ese fi ndings are strong arguments for tumor biopsy before surgery is decided. preoperative oita red cross hospital, oita, japan introduction and objective: approximately 15% to 50% of patients who underwent total nephroureterectomy for upper urinary tract (uut) urothelial carcinoma (uc) developed recurrence in the bladder during the follow-up period. last year, we presented a risk factor for intravesical recurrence aft er laparoscopic radical nephroureterectomy (lrnu) in patients with uut-uc in siu congress. th is time, we will report the result of analysis of a multi-center study. a total of 126 patients with uut-uc received lrnu between january 2002 and december 2013 in oita university hospital and 3 affi liated institutions that were enrolled in this study. patients with concomitant bladder cancer or a history of bladder cancer were excluded from this study. postoperative cystoscopy and urine cytology were performed every 3 months for 2 to 5 years, and postoperative intravesical recurrence was evaluated pathologically. th e signifi cance of each variable was analyzed univariately by log-rank test. multivariate analyses by cox proportion hazards regression model was used to estimate simultaneous eff ects of multiple risk factors. statistical signifi cance was defi ned as a p value of <0.05. results: median follow-up aft er lrnu was 28 months (range 2-142). of the patients, postoperative intravesical recurrences were shown in 48/126 (38%). average time to fi rst intravesical recurrence was 7.01 months. in univariate analysis, there were two signifi cant risk factors of intravesical recurrences. one was for patients who did not receive postoperative adjuvant chemotherapy (p=0.018). th e other was for patients with preoperative positive urine cytology indicating class iv and v (p=0.041). multivarite analysis revealed that preoperative positive urine cytology indicating class iv and class v was a signifi cant risk factor for intravesical recurrence (hr2.23 95% ci 1.20 -4.15 p=0.011). in this multi-center retrospective study, preoperative positive urine cytology was a significant risk factor for intravesical recurrence. th erefore, adjuvant chemotherapy such as intravesical instillation therapy can be eff ective to prevent intravesical recurrence in patients with preoperative positive urine cytology. retroperitoneal laparoscopic nephron-sparing surgery for complicated renal cysts introduction and objective: to evaluate the feasibility, effi cacy and safety of laparoscopic partial nephrectomy for complex renal cystic lesions. a retrospective cohort study on clinical data of 27 patients with complex renal cystic lesions treated by laparoscopic partial nephrectomy from may 2008 to april 2011 in peking university th ird hospital. according to the bosniak classifi cation, 7 cases were lesions of grade iif, 11 were grade iii, and 9 were grade iv. th e mean diameter of cystic lesions was (3.58±0.75) cm, and 4 lesions were larger than 4.0 cm. results: all procedures were performed through retroperitoneal approach and successful. th e mean operative time was (123.1±16.8) min, ranged from 100 min to 160 min, and the mean renal warm ischemia time was (29.7±3.5) min, ranged from 25 min to 40 min. blood loss in operations was from 50 ml to 110 ml, and the mean was (75.5±21.8) ml. th e postoperative hospital stay was 4~6 days, and the mean was (5.11±0.85) day. postoperative pathological results included 10 simple renal cysts (37.0%), 2 cases of adult cystic nephroma (7.4%), 1 mixed epithelial and stromal tumor (3.7%), 13 cases of renal cell carcinoma with cystic change (48.1%), and 1 multilocular cystic renal cell carcinoma (3.7%). th e results showed 14.3% of cystic lesions of grade iif, 45.5% of grade iii and 88.9% of grade iv were malignant. in the follow-up ranged from 12 to 48 months (median 24 months), there was no case of recurrence. conclusion: th e diff erentiation between benign and malignant renal cystic lesions before surgery remains diffi cult. according to the bosniak classifi cation, radiological diagnostic fi ndings are standard but still limit to the accuracy to determine the dignity of pathological entity. laparoscopic partial nephrectomy is feasible to treat complex renal cystic lesions, and is a safe and eff ective minimally invasive option. introduction and objective: th e aim of the study was to evaluate the value of metastasectomy in patients with metastatic renal cell carcinoma (mrcc) in the targeted therapy era. we reviewed the medical records of 323 patients who presented with mrcc and received no systemic therapy before enrollment. of them, 13 underwent complete metastasectomy followed by targeted therapy (complete metastasectomy group), 48 underwent partial metastasectomy followed by targeted therapy (partial metastasectomy group), and 262 treated with targeted therapy alone (non-metastasectomy group). we estimated progression-free and overall survival using kaplan-meier curves. a cox proportional hazards regression model was used to estimate the prognostic signifi cance of metastasectomy. results: clinicopathological variables did not diff er among the 3 groups except for history of nephrectomy, bone metastasis, number of metastatic sites, and time from diagnosis to treatment. th e median progression-free survival was 17.1, 16.2, and 11.4 months in the complete, partial, and non-metastasectomy groups (p = 0.030). karnofsky performance status (hr 3.21, p < 0.001), cell type (hr 1.84, p = 0.027), sarcomatoid or rhabdoid features (hr 2.21, p < 0.001), retroperitoneal lymphadenopathy (hr 1.86, p < 0.001), number of metastatic sites (hr 1.40, p = 0.030), lactate dehydrogenase (hr 1.75, p = 0.006), and time from diagnosis to treatment (hr 1.54, p = 0.009) were independent predictors of progression-free survival. th e median overall survival was 70.9, 29.9, and 19.4 months in the complete, partial, and non-metastasectomy groups (p < 0.001). complete metastasectomy (hr 0.3, p = 0.028) was an independent predictor of overall survival, along with age (hr 1.02, p = 0.005), karnofsky performance status (hr 3.90, p < 0.001), sarcomatoid or rhabdoid features (hr 1.93, p = 0.001), bone metastasis (hr 1.67, p = 0.003), retroperitoneal lymphadenopathy (hr 1.82, p < 0.001), number of metastatic sites (hr 1.69, p = 0.001), hemoglobin (hr 1.47, p = 0.017), neutrophil (hr 1.78, p = 0.033), corrected calcium (hr 1.96, p = 0.022), and time from diagnosis to treatment (hr 1.68, p = 0.005). conclusion: complete metastasectomy performed before targeted therapy signifi cantly increased overall survival in patients with mrcc. if surgically resectable, aggressive metastasectomy should be considered. guideline results: prominent international guidelines and strategies varied signifi cantly in relation to follow-up practice. th e mode and frequency of radiological imaging was signifi cantly diff erent across the guidelines for low and intermediate risk disease. although there is currently no consensus within the literature regarding surveillance protocols, various guidelines and strategies have been developed using both patient and tumour characteristics. th is information raises questions regarding the follow-up practice in australia due to both the lack of guidelines and the fi nancial. introduction and objective: nephrectomy is the cornerstone therapy for renal cell carcinoma (rcc) and its continued refi nement through research may enhance patient outcomes. medical registries are used domestically and internationally to aid research, assess trends and help guide future practice of many medical disciplines. th ere is currently no national australian nephrectomy registry. th is review aimed to explore possible defi ciencies within the australian rcc nephrectomy fi eld and through assessment of literature from established registries, determine if a national nephrectomy registry is appropriate and justifi ed to address these issues. a pubmed search identifi ed records pertaining to rcc nephrectomy in australia. a similar search identifi ed records relating to established nephrectomy registries internationally as well as other surgical registries of clinical importance. th ese records were reviewed to address the stated aims of this article. results: australian rcc nephrectomy fi eld lacks population-based data: resulting key issues identifi ed 1) diffi culty benchmarking individual and institutional outcomes; 2) small sample sizes and reduced power of studies; 3) assessment of regional and nationwide outcome trends: diffi cult to achieve and oft en done years in retrospect with no ongoing monitoring; 4) care centralisation debate: can small volume centres provide comparable outcomes to high volume centres? 5) best practice guidelines: patterns of adherence to existing protocols is uncertain; and 6) limited platform for large scale prospective studies -restricting potential research. review of established international registries demonstrated the registry model can eff ectively address issues comparable to those identifi ed in the australian literature. a centrally held, de-identifi ed national nephrectomy registry could provide a means of ad-dressing defi ciencies identifi ed in the australian rcc nephrectomy fi eld. th e model is supported by evidence from comparable international examples and will provide population-based data needed for studies at the institutional, regional and national level. th e development of a confi dential and non-threatening escalation policy to be implemented should trends in the data emerge is a future possibility. scope exists for possible integration with current or future registries/ databases to develop a more encompassing urological, cancer or surgical registry. need remains for continued exploration of the feasibility and practicalities of initiating such a registry. new technologies of identifi cation of renal artery in retroperitoneal laparoscopic renal surgery hao y, xiao c, liu y, ma l introduction and objective: th e objective of this study was to evaluate the feasibility of a new method to identify renal vessels during retroperitoneal laparoscopic nephrectomy. a total of 90 patients underwent transperitoneal radical laparoscopic nephrectomies from january 2010 to august 2012. in the fi rst consecutive 30 patients (group 1) we located renal artery with the standard technique; in the last consecutive 60 patients (group 2) the medial arcuate ligament (mal)-psoas muscle fat complex was used as an anatomic landmark to identify renal vessels. comparative analysis was carried out between the two groups, including mean hilar exposure time, mean blood loss, duration of hospital stay, conversion rate and complication rate. no diff erences were noted in gender, age, mean body mass index, tumor side and size of the lesions in the two groups (p>0.05). mean hilar exposure times were 10.3 ± 3.1 minutes in group 1 versus 6.1 ± 1.7 minutes in group 2 (p<0.001). mean blood loss was 153.3 ± 39.8 ml in group 1 versus 110.8 ± 28.1 ml in group 2 (p<0.001). no signifi cant diff erences were detected regarding duration of hospital stay, complication rate and conversion rate between the two groups (p >0.05). no complications and no recurrence of disease at ct evaluation were recorded neither in group 1 nor in group 2. conclusion: radical laparoscopic nephrectomy in use of the mal-psoas muscle fat complex as an anatomic landmark is technically feasible and safe. in conclusion, the mal-psoas muscle fat complex can serve as an objective and belt-and-braces anatomic landmark for the identifi cation of the renal vessels in retroperitoneal laparoscopies. kalpinskiy a, alekseev b, kaprin a, nyushko k, vorobyev n, vokach d introduction and objective: th e aim of our study is to evaluate the results of percutaneous radiofrequency ablation (rfa) of renal tumors in elderly patients with severe comorbidities and a high risk of surgical intervention. th e aim of this study was to evaluate the expression of cd31 and microvessel density (mvd) in clear cell renal cell carcinoma (ccrcc) as well as the relationship between mvd and possible prognostic markers like tumor size, degree of tumor necrosis and degree of tumor hemorrhage. expression of cd31 was detected in 40 patients with ccrcc and 20 cases with benign kidney tissue using immunohistochemical staining. th e mvd was studied by weidner's method. results: th e expression of cd31 in the clear cell renal cell carcinoma (ccrcc) (109.5 (ds±76.5), varied from 5 to 292.) were signifi cantly higher than the expression of cd31 in the benign kidney tissue, as the control group, was 23.2 (ds±22.5) (u=699, p<0.0001). th e mvd values marked by cd31 were negatively correlated with degree of tumor necrosis (r=-0.304, p=0.055), tumor size (r=-0.09, p=0.578), but no association was found between mvd values and degree of tumor hemorrhage (r=-0.01, p=0.93) in crcc. our results show that mvd in crcc were signifi cantly higher than mvd in the benign kidney tissue. th ere was a negative non signifi cant correlation between the mvd and presence of tumor necrosis as well as between mvd and tumor size. on the other hand, there was no correlation between mvd and degree of tumor hemorrhage in ccrcc. conclusion: expression of hif-1α and vegf in crcc was signifi cantly higher than in normal kidney tissue. th e expression of hif-1α and vegf may be responsible for angiogenesis in ccrcc, however these angiogenic factors play an important role in the prognosis of ccrcc patients. transvaginal hybrid notes nephrectomy in a low resource setting firaza p, lorenzo e, bardelosa j, reyes e, patron n introduction and objective: hybrid notes decreases the invasiveness of conventional laparoscopic surgery and overcomes the limitation of pure notes especially in the absence of angulated instruments. th e patients are 66, 69 and 32-year-old females with complaints of recurrent fl ank pain and urinary tract infection due to an obstructed non-functioning kidney. materials and methods: materials used include standard laparoscopic instrumentations and a 300 endoscope. under general anesthesia the patient was placed in a lithotomy position with the aff ected side up at 45 degrees. veress needle was initially inserted thru the umbilicus and was later replaced with a 10mm laparoscopic port with additional 5mm port also inserted at the aff ected lower quadrant site. pa-tient was then positioned in a steep trendelenberg and 10mm port was inserted thru the posterior vaginal wall under direct vision from the abdominal cavity that was later used for the endoscope. nephrectomy proceeded despite noted severe adhesions and the kidney was placed in the specimen retrieval bag. th e vaginal port site was enlarged to 3cm for extraction of the specimen. th e vaginal wound was repaired using running 2-0 absorbable sutures. results: th ree cases of transvaginal hybrid notes nephrectomy were successfully completed. th e median operative time was 310 minutes (range: 280-335). th e mean estimated blood loss was 300 ml for the three cases. median renal dimensions (cm) were as follows: craniocaudal 10.2 (range: 10.6-9), laterolateral 6.5 (range: 7-5.3), and anteroposterior 4.8 (range: 6.5-3.9). th e patient resumed regular diet as early as day 1 post operatively. drain was removed prior to discharge. th e mean date of discharge was 3rd day post-operatively. th ere were no noted surgical complications according to clavien-dindo grading system. conclusion: hybrid notes transvaginal nephrectomy is a feasible and reproducible procedure in selected patients regardless of laterality for better cosmesis, reduced post-operative pain and early recovery. however, the view was challenging because it was from the pelvis. th e left side procedure proved to be more diffi cult due to the gonadal vein obstructing the view, which is usually larger in young females. introduction and objective: to summarize our clinical experiences of laparoendoscopic single-site surgery (less) in urology. results: all procedure underwent successfully using single trocar x cone (storz) without any major complications. early recovery with minimal scar is the hallmark of less surgery. duration of time (30-145 mns), blood loss (5-40ml), mobilization (24-48 hrs), hospital stay (2-6days). no intraoperative complication without any conversion to other surgery (multi port laparoscopic surgery) and uneventful post-operative period was the fi nal outcome. introduction and objective: th e use of fl exible cystoscopy to study bladder is usually perform in urology departments using diff erent types of lubricant to reduce pain. th e objective is to compare the use of lubricant gel with lidocaine versus lubricant gel without anesthetic in fl exible cystoscopy in terms of pain and tolerability. materials and methods: seventy two patients are divided in two groups in this observational not randomized study. group 1: 38 patients with lidocaine gel 2% and group 2: 34 patients with lubricant gel without anesthetic. th e main variables analyzed are score in visual analogue scale (vas) and score in spanish pain questionnaire (spq). t-student test and chi-square test are used to compare diff erences using spss program and signifi cant statistical diff erences is considered p≤0.05. results: mean age of patients in group 1 is 64.50 ± 12.39 years and 67.79 ± 10.87 years in group 2 (p=0.23). th e distribution according to sex was 29 men:9 women in group 1 and 25 men:9 women in group 2 (p=0.78). th e main pain score in vas was 2.21 ± 2.05 in group 1 versus 1.59 ± 1.61 in group 2 (p=0.16). in the spq, the current intensity value was 1.82 ± 0.86 in group 1 versus 1.53 ± 0.74 in group 2 (p=0.14), and the total intensity value was 1.92 ± 1.86 in group 1 versus 1.03 ± 1.75 in group 2 (p=0.04). th e cost of gel with lidocaine is 1.25 euro and gel without anaesthetic 0.22 euro. conclusion: th e use of lidocaine gel do not produce benefi t in the fl exible cystoscopy and expensive the procedure. new laparoscopic surgery using water filled laparo-endoscopic surgery systems introduction and objective: urologist usual operated under water fi lled condition, such as transurethral surgery, percutaneous renal surgery. however, laparoscopic surgery was done under co2. water fi lled condition has several merits. water pressure is suppressing venous bleeding and prevent from co2 embolism in venous injury condition. to keep water temperature as same as body temperature was useful to avoid low body temperature. simultaneous observation of ultrasound image from the surface of the body and laparoscopic view is possible during surgery. th us we conduct to develop the water fi lled laparo-endoscopic surgery systems (wafles). first problem is dispersion of blood aft er bleeding. it interrupts the laparoscopic view. we solved this problem to control the fl ow of irrigation, aff ording the continuous observation of bleeding point and it is easy to control the bleeding by vessel sealing system or coagulation. second problem is managing fl oating organs such as intestine or nets. th ese are disturbed the operating view and space. to keep the operating space, we use sheath and single port devices. however, obtaining wide view was still hard in the water because fl oating organs disturb the fi eld. to solve this problem, we use 3-d tracking navigation system. results: using young male pig, we performed partial nephrectomy and radical cystectomy using this new system. wafles is now developing. we will be present the update of this research soon. comparison of safety, effi cacy and cosmetic outcomes between standard laparoscopic live donor nephrectomy and mini-laparoscopic donor nephrectomy: a randomized clinical trial introduction and objective: th is study was conducted to compare safety, effi cacy and cosmetic outcome between standard laparoscopic live donor nephrectomy (sldn) and mini-laparoscopic donor nephrectomy (mldn) in a randomized clinical trial. from march 2012 to june 2013, 100 consecutive kidney donors were randomly assigned to two equal groups for laparoscopic donor nephrectomy. from march 2012 to june 2013, 100 consecutive kidney donors were randomly assigned to two equal groups for laparoscopic donor nephrectomy. mldn: six to eight centimeters pfannenstiel incision was made slightly above pubis symphysis and 11 millimeters trocar was fi xed through exposed fascia using open technique. five mm port was placed under direct vision at the umbilicus for camera insertion and two 3.5 mm ports were placed in subxiphoid and paraumbilical area. sldn: ten mm port was placed at umbilicus using open access technique for camera insertion. five mm trocar for grasping and 11 mm trocar for vascular clipping were placed at subxiphoid and paraumbilical areas under direct vision, respectively. th e second 5 mm trocar was placed in suprapubic area. cosmetic appearance was assessed three months aft er surgery by using the modifi ed patient scar assessment questionnaire (psaq). conclusion: our experience in this study revealed that peri and postoperative fi ndings were comparable between sldn and mldn but mldn has signifi cant better cosmetic appearance than standard laparoscopic approach. qiu m, ma l, lu j introduction and objective: to report our experience and outcomes with retroperitoneal laparoscopic anderson-hynes dismembered pyeloplasty for the repair of ureteropelvic junction obstruction (upjo). we performed 47 retroperitoneal laparoscopic anderson-hynes dismembered pyeloplasty between june 2003 and december 2011. ureter was found in the lower pole of the kidney psoas front, then ureteropelvic junction stenosis was dissociated. ureter was cut at about 1 cm distal ureter beyond the part of stenosis, then stenosis was resected. posterior wall was continuous sutured, and double j tube was antegrade placed. at last, anterior wall was continuous sutured. patient characteristics and perioperative outcomes were analyzed. perioperative parameters including operative time, estimated blood loss, postoperative length of hospital stay, and complication. results: th e procedure was successfully accomplished in all patients, and no patient required conversion to open surgery. th e mean operation time was 157.7min (80-317min), mean estimated blood loss was 69ml (10-400ml), mean postoperative length of hospital stay was 7.5d (4-28d), and mean time of keep drainage tube was 5.7d (1-26d) . patients were followed up for 18 ~ 120 months (average 53.6 months). eighteen cases were followed up in 5 years, and anrenal cyst (12) other 11 patients were followed up for 5-10 years. th e total remission rate was 86.2%. conclusion: retroperitoneal laparoscopic dismembered pyeloplasty is a safe and effi cacious procedure for upjo in a long time follow-up. positioning-related complications of robot-assisted radical prostatectomy (rarp) in a steep trendelenberg position with physique fixation appliance by the negative pressure takeda h, nakano y, narita h introduction and objective: because of recent advances in minimally invasive surgical techniques, robot-assisted radical prostatectomy (rarp) has become the primary treatment option in prostate cancer. rarp, however, necessitates patients to be placed in a steep trendelenberg position, which presents multiple opportunities for complications relating to the positioning of the patient. our study aims to study the prevalence and demographic predictors of these positioning complications. we included patients who underwent rp from 2012 to 2015 using data extracted from our hospital database. all patients (n=103) had trendelenberg position with physique fi xation appliance by the negative pressure, hug-u-vac and film dressings. positioning complications (skin, eye, nerve, compartment syndrome/rhabdomyolysis) were identifi ed using patient-level diagnosis and procedural international classifi cation of disease, 9th edition, clinical modifi cation codes. we analyzed body pressure by portable interface pressure sensor. results: positioning complications occurred in 1.2% of cases with shoulder complications contributing the most to this frequency. rubefaction occurred in 4 cases, without bedsore. having positioning complications not increased a patient's odds of having increased age, bmi, operation time, body pressure, insignifi cantly. conclusion: th e steep trendelenberg position used in rarp was not shown to be associated with patient positioning-related complications in this sample. physique fi xation appliance by the negative pressure is safety and useful. evaluation of nasogastric tube (ngt) suction for evacuation of large bladder blood clot introduction and objective: blood clot formation in the urinary bladder can be caused by many etiologies such as postoperative bleeding, tumor bleeding, radiation cystitis and etc. acute urinary retention may disclose and a large three way catheter with irrigation is placed conventionally to prevent further formation of blood clot and manually remove the blood clot. when this failed an endoscopic procedure takes place to con-trol the bleeding and to relief the bladder. urologists may fi nd it diffi cult to remove a large, thick and bulky clot using ellik evacuator. here we introduce using nasogastric tube as an alternative to procure a safe and effi cient way to remove these bothersome clots. aim: to introduce a novel method to successfully remove large, troublesome blood clots during cystoscopy. we prospectively perform blood clot evacuation on 21 patients within 6 month (september 2014 -february 2015) in hasan sadikin hospital. th e patient, preoperatively have at least ½ of bladder volume with blood clot using ultrasonography. a 16 fr ngt inserted into the bladder through the resectoscope sheath 24 fr and connected to suction unit with a 300 mmhg negative pressure. a calibration of the ngt tip does not exceed more than 2 cm from the cystoscopy beak was made. backward and forward movement was set in motion during the procedure to facilitate blood clot removal. cystoscopy evaluation was performed in the end of the procedure to evaluate any complication. a total cystoscopy time, ngt suction time, and the volume of blood clot were documented. results: a total 21 patients was all successfully managed with this method without any complications such as bladder laceration/perforation. th e mean age was 52 years old with male predominance. most common etiologies of blood clots retention were postoperative bleeding (57 %). th e average time for clot removal time was 20 (5 -70) minutes. th e average volume of blood clots removed was 483 grams. conclusion: evacuation using ngt suction is eff ective, safe and an effi cient way to remove of large bothersome clot. learning curve assessment of robot-assisted radical prostatectomy in the oncological and functional outcomes takeda h, nakano y, narita h introduction and objective: th is study aims to compare the oncological, safety and functional outcomes between fi rst-step rarp and second-step rarp. th e study was conducted on a total of 100 patients having undergone robot-assisted radical prostatectomy from 2012 to 2015. th e fi rst 50 patients (group 1) were compared with the second 50 (group 2) to evaluate the learning curve eff ects. results: both groups were similar with respect to age, prostate-specifi c antigen level, body mass index, gleason score, and distribution of the clinical stage. th e operative time was 192 minutes for group 1, and 172 minutes for group 2 (p=0.01). individual times of various stages of the procedure (dissection of the seminal vesicles, entering the extraperitoneal space and dissection of the endopelvic fascia, incision of the bladder neck, division of the prostatic pedicles and preservation of the neurovascular bundle, and urethrovesical anastomosis) decreased signifi cantly over time. estimated blood loss was 241ml for group 1, 189 ml for group 2. th e length of stay was 9.3 days for group 1, 9.1 days for group 2. positive surgical margin rates were 31% for group 1, 27% for group 2. while one patient in group 1 had biochemical recur-rence, no patient in group 2 had biochemical recurrence. continence rates at 12 months were 90.1%, and 92.5% in groups 1 and 2. conclusion: surgical, oncologic, and functional outcomes of rarp improve with increasing experience. outcomes similar to the published series by high-volume centers could be achieved aft er 80 to 120 rarp cases. possibility of 3d modeling and intraoperative navigation during procedures in the retroperitoneal space introduction and objective: application of 3d modeling allows you to get more information about the spatial imaging of the disease. intraoperative navigation in the retroperitoneal space is an innovative minimally invasive procedure, the surgeon improves orientation in retroperitoneal space. we present the method of intraoperative navigation based on virtual simulation during videoendoscopic partial nephrectomy for kidney's tumors. special computer program has been developed, that created three-dimensional image of operative space on the basis of preoperational tomographic data of a concrete patient. we used hardware-soft ware complex (hsc) for virtual modeling of the surgery zone. th e complex consists of a pc, original soft ware and mechanical 3d digitizer. th e hsc allowing to form virtual 3d model of a patient according to the results of tomography examination. th e original method of matching the system of coordinates of a virtual model with the patient was off ered. th e procedure was conducted under the conditions warm ischemia, aft er mobilization of the kidney, partial nephrectomy was performed by observing the image of 3d organ model agreed with the video image of the kidney tumor. th e method was originally performed for the 12 patients with small renal tumors, who needed in surgical treatment, their average age was 42.5 (in the range from 36 to 54) years, men -5 (41.7%), women -7 (58.3%). size of the tumors were 3.2 (2.0 -4.0) cm, they were located in the lower poles of the kidneys. average time of an operation performed with the use of the computerized choice of the surgical approach was 95.5 (80-155) minutes. warm ischemia time was 20.5 (18 -28 min). th ere were no complications during the operation and in the post-operative period. th ere were no cases of positive surgical margins. conclusions: usage of the introduced computer program allows the surgeon to determine compliance with the contours of the 3d models of the body shown in the video monitor. th e technique provides additional possibilities for the surgeon in selecting borders in partial nephrectomy. th is method is particularly perspective for teaching beginner surgeons, it can help them acquire skills in minimally invasive surgery. possible impact of continuous drainage after minimally invasive partial nephrectomy introduction and objective: postoperative management of partial nephrectomy without drain placement is common, but the specifi c eff ects on patients are unclear. we investigated the impact of no drain placement aft er minimally invasive partial nephrectomy (mipn). we retrospectively studied 194 consecutive patients who underwent laparoscopic and robotic partial nephrectomy at a single academic center. th e study group included 46 evaluable patients without drain placement. th e quantity of postoperative fl uid collection in the perirenal space was calculated using computed tomography. th e pre-and postoperative serum concentrations of total protein and albumin, in addition to neutrophils, lymphocytes, monocytes numbers and c-reactive protein (crp) levels in the blood were compared. results: drain was placed in 148 (76.3%) patients who underwent mipn. th e remaining 46 (23.7%) patients were not provided with drain placement. although the average total quantity of fl uid discharged from the drain was 214 ml, the average fl uid remaining in the perirenal space was not signifi cantly diff erent with or without drain placement (20.3 ml vs. 16.8 ml, p=0.64). decrease in serum total protein and albumin with drain placement was signifi cantly greater than without drain placement (total protein; 18.9% vs. 12.2% p<0.001 and albumin; 24.7% vs. 22% p=0.038). no drain placement also caused markedly greater decreases in lymphocytes and monocytes than drain placement, while neutrophils and crp were not different. a mipn population was necessary by design, which may limit the ability to generalize these results. conclusion: analysis of the quantity of fl uid collection showed little need for routine drain placement. no drain aft er mipn prevents serum protein loss and might aff ect wound-healing immune responses. initial experiences of laparoscopic radical cystectomy introduction and objective: simultaneous treatment of bilateral lesions is an interesting application of laparoscopy. our goal was to present our experience with simultaneous bilateral laparoscopic pyeloplasty using three midline ports in two adult patients. two adult patients (one male and one female) underwent bilateral laparoscopic dismembered pyeloplasty in one session. one of the patients had horseshoe kidneys. a 12-mm trocar was placed through the umbilicus, and two 5-mm trocars were placed midline 10-12 cm superior and inferior to the umbilicus. results: intra-and postoperative periods were uneventful. operation time was 245 and 280 minutes in the fi rst and second patient, respectively. obstruction was relieved in both patients bilaterally on a 6-month follow-up. conclusions: simultaneous bilateral laparoscopic pyeloplasty using three midline ports is safe and feasible in adult patients with bilateral ureteropelvic junction obstruction. introduction and objective: radical cystectomy is considered to be the most eff ective treatment for patients with muscle-invasive bladder cancer. most urinary diversions are performed extracorporeally because of complex procedure time consuming. however, with the development of minimally invasive radical cystectomy techniques, increasing attention has been focused on intracorporeal urinary diversions, including both ileal conduit and orthotopic neobladder. we reviewed cases of laparoscopic radical cystectomy with intracorporeal ileal conduit in our medical center. ten patients with bladder cancer who underwent laparoscopic radical cystectomy and intracorporeal ileal conduit were retrospectively reviewed. with the cystoprostatectomy and lymphadenectomy completed, a 15-20cm segment of ileum was identifi ed 15cm from the ileocecal junction. division of the isolated segment of bowel and the mesentery was performed using the endo-gia stapler. ileo-ileal continuity was reestablished by creating a generous side-to-side anastomosis with endo-gia stapler. th e left ureter was passed to the right side of the abdomen. aft er placement of single-j stent, the ureters were spatulated and the ureteroileal anastomis was performed with a running suture. results: laparoscopic radical cystectomy and intracorporeal ileal conduit were performed successfully in all ten patients from jan 2014 to dec 2014. th e mean operating time was 330min (300 -450 min), and the mean ileal conduit construction time was 110min (95 -130min). th e mean blood loss was 170 ml (60 -350 ml), and no patient received transfusion. th e time to orally allow was postoperative day 5 (4-7). th e mean hospital stay was 10d. no major complication occurred. results: all the procedures were successfully completed without additional trocars except for one patient who was immediately converted to suprapubic-assisted laparoendoscopic single-site surgery (sa-less) nephrectomy for rectal injury during the placement of the zou-port. in our initial 3 cases, tri-port was used. in the subsequent 20 procedures, zou-port was used. th ere were no other intraoperative complications occurred. postoperative complications included a right external iliac artery thrombosis in one patient who underwent pure transvaginal notes simple nephrectomy. th e mean operative time was 80 (range 60 to 90) mins and the mean estimated blood loss was 25 (range 20 to 50) ml for pure transvaginal notes renal cyst decortication. th e mean operative time was 186 (range 160 to 280) mins and the mean estimated blood loss was 110 (range 160 to 280) ml for pure transvaginal notes nephrectomy. th e mean visual analog scale (vas) pain score was 3.1 (range 2-5) on postoperative day 1. th e mean time for ambulation was 1.6 (range 1-2) d. th e mean time for oral feeding was 2.2 (range 2~3) d. th e mean postoperative hospitalization stay was 5.2 (range 3~8) d. during the 3 to 51-month follow-up period, all the patients were in good condition. th e posterior colpotomy incision healed well. th ere was no scar on the abdominal wall. th ere was no retrograde infection of pelvic and abdominal cavity, umbilical hernia, or uterine prolapse. conclusion: th e application of zou-port in pure notes transvaginal eff ectively reduces the diffi culty of operation and avoids the abdominal and pelvic organ injury, which is worthy of clinical application. lower ureter stricture. all the cases presented only one abdominal scar before surgery, including 13 cases with the history of caesarean section, 10 cases with the history of birth control surgery, 6 cases with the history of appendectomy, 3 cases with the history of inguinal hernia repair, 3 cases with the history of ureterolithotomy, one case with the history of bladder lithotomy, and 6 cases with the history of laparotomy surgery. th e mean length of scar is 7.2 (1.5 to 18.5) cm. under general anesthesia, the patients were positioned in lithotomy with aff ected side elevated at 70°. two trocars (5mm or 10mm) were introduced into abdominal cavity from the incisions at the right and left medial margin of umbilicus. a 10-or 5-mm trocar was inserted into the abdominal cavity through the abdominal scar under the direct vision. our technique for the transabdominal scar-assisted u-less is similar to that of standard laparoscopy, using conventional operating apparatus placed in the umbilical trocars, under direct vision achieved by a fl exible-tip 0° laparoscope placed through the trocar at the abdominal scar. th e specimen was placed inside a homemade bag and removed under direct vision through an extended incision at the abdominal scar. to explore the application of three-dimensional (3d) laparoscopic technique in hybrid transvaginal notes nephrectomy. a total of 8 female patients underwent hybrid transvaginal notes nephrectomy using 3d laparoscopy system. th ose included 4 cases of hydronephrosis, 3 cases of renal empyema, and 1 cases of renal atrophy. th e median age was 39 (range 33 to 55) years, and body mass index was 23.7 (19.8~28.5) kg/m2. all patients were with unilateral disease and normal contralateral kidney. th e perioperative data including operative time, estimated blood loss, and surgical outcome were analyzed. results: th e procedures were successfully completed. th e median operative time was 100 (85 to 150) mins. th e median estimated blood loss was 120 (80 to 450) ml. th e patients were recover ambulation on postoperative day 1 to 2, and tolerated diet on postoperative day 2 to 3. th e patients were discharged on postoperative day 7 to 8. th ere were no intraoperative or postoperative complications. during the 6-to 10-month follow-up period, all the patients were in good condition. th e posterior colpotomy incision healed up well. th ere were two hidden umbilicus scars. and p=0.961, respectively). mean incision length was shorter (5.2 vs. 7.1 cm, p<0.001) and the scar satisfaction score was higher (8.6 vs. 7.7, p=0.001) in ldn with fl ank incision group. th e postoperative pain scores were higher (p=0.025) in ldn with fl ank incision group but analgesic requirements were similar in both groups (p=0.565). conclusion: ldn with fl ank incision had cosmetic satisfaction and comparable graft function, although challenging to the surgeon with longer warm ischemia time and higher postoperative pain. the effect of caudal block on postoperative analgesia in robotic assisted laparoscopic prostatectomy: a prospective study in a national referral centre introduction and objective: caudal block is widely used in paediatric surgery. it provides satisfactory postoperative pain relief in lower abdominal operations with minimal complications. th is pilot study explores its eff ect on postoperative pain control and its safety in patients who underwent robotic assisted laparoscopic prostatectomy (ralp). from 2013 to 2014, 40 consecutive patients were randomised into 2 groups of 20 patients. th e intervention group received caudal block using ropivacaine immediately aft er operation, while the control group only received analgesia consisting of paracetamol, nsaids, and opioids. both groups were assessed using verbalised pain scores in recovery room, and 6, 12, 24, 48, 72 hours aft er the operation. additional analgesic requirements were recorded in the intervention group. opioid-related adverse events and the time to passage of fl atus were also recorded. introduction and objective: th e dorsal venous complex (dvc) ligation and vesicourethral anastomosis (vua) are the most challenging parts during laparoscopic radical prostatectomy (lrp). th is study will introduce a unique technique without any knots for the dvc ligation and vua using the unidirectional single running self-retaining suture. th is study is to examine the eff ectiveness of our knotless laparoscopic radical prostatectomy compared with the conventional technique. materials and methods: from december 2013 to december 2014, 45 lrp were separated into 2 groups: group 1 of 20 knotless lrp and group 2 of 25 conventional single-knot lrp. during knotless lrp, the dvc is sutured using a 1-0 1/2 circle self-retaining suture with 3 bites at the same place, and the vua is performed with a 23-cm 3-0 5/8 circle barbed self-retaining suture with one needle driver. retroperitonoscopic pyeloplasty is a feasible approach in the management of pelviureteric junction obstruction with a crossing vessel. anterior transposition using the posterior approach demands a good experience. herein, we present a case with complex vascular anatomy representing a real surgical challenge for a retroperitonoscopic approach. in the period from 2006-2015, 21 cases with a crossing vessel were operated by a single surgeon using both transperitoneal and retroperitoneal approaches. we report here a 5 y old girl with left sided pelviureteric junction obstruction presenting with recurrent loin pain. lateral retroperitoneal laparoscopic approach was used with 3 trocars; 5mm optic trocar and two 3 mm working trocars. th e pelviureteric junction was tightly pushed anteriorly and close proximity to complex crossing vessels. dissection from the crossing vessels was performed followed by anterior transposition of the pelviureteric junction and a diffi cult anastomosis was performed with antegrade dj insertion. smooth postoperative recovery, no leakage, dj is removed aft er 1.5 month; follow-up ultrasound revealed decompression of the pelvis with no recurrence of the symptoms during the follow-up period. conclusion: retroperitonoscopic lateral approach is feasible for the management of pelviureteric junction obstruction with crossing vessel even in the most diffi cult cases in well trained hands. robotic assisted laparoscopic reimplantation for iatrogenic ureteral injury franklin a, jones c, pokala n, cummings j introduction and objective: ureteral injuries are a source of morbidity in pelvic surgery. robotic approaches to these injuries have been proposed. we reviewed our experience with this approach to examine the outcomes in patients undergoing robotic assisted laparoscopic reimplantation (ralr) for iatrogenic ureteral injury. oncological outcomes of robotic prostatectomy in the victorian public sector basto m 1,2 , sathianathen n 3 , te marvelde l 4 , landau a 1,5 , graves r 1,5 , everaerts w 1,5 , birch e 1 , lawrentchuk n 1 , goad j 1 , moon d 1 , murphy d 1, 2, 5, 6, 7 introduction and objective: following the installation of the davinci s at peter maccallum cancer centre in 2010, we aim to report medium-term oncological outcomes of patients undergoing robot-assisted radical prostatectomy (rarp) and to identify factors that act as predictors for biochemical recurrence (bcr) and oncological failure (of). a prospective cohort of 257 consecutive men who underwent rarp in a single victorian public hospital were followed up for a median time of 12.6 and 12.9 months for bcr and of respectively. of was defi ned as bcr (psa≥0.2ng/ml) or the start of adjuvant therapy. however, longer-term data is still required to better evaluate oncological success. functional outcomes of robotic prostatectomy: the victorian public sector experience basto m 1,2 , sathianathen n 3 , te marvelde l 4 , landau a 1,5 , graves r 1,5 , everaerts w 1,5 , birch e 1 , lawrentchuk n 1 , goad j 1 , moon d 1 , declan murphy d 1, 2, 5, 6, 7 introduction and objective: to report medium-term functional outcomes of men aft er undergoing robotic assisted radical prostatectomy (rarp). furthermore, the impact of the procedure on quality of life will also be analysed. a cohort of 258 consecutive men who underwent rarp in a single victorian public institution was assessed post-operatively for continence and potency status. a 'prostate cancer research survey' that was distributed pre-operatively and at 3, 6, 12, 24 and 36 months post-rarp, in combination with hospital medical records were utilized to collect data. th e following validated questionnaires were included in the survey: expanded prostate cancer index composite for clinical practice (epic-cp), sexual health inventory for men (shim) and prostate cancer related quality of life scale (pcar-qols). th e latter primarily evaluated the impact of surgery on quality of life. results: utilising hospital medical records, of the 178 (70%) men that had follow-up post-operatively, 79% (101/128) were fully continent at 12 months using a zero pad defi nition and 93% (119/128) were continent using a zero or security pad defi nition. of those who completed the epic-cp questionnaire, preoperatively (n=113 responders), 95.6% and 98.2% were continent using a zero and security pad defi nition respectively. at 12-months (n=59 responders), 81.4% of patients were fully continent using zero pads per day and 94.9% of patients were continent using none or security pad per day. regarding erectile function, shim scores were available for 106 men pre-rarp, of which 58% were considered to be potent. of this subset of men, only 11%, 10% and 11% are considered post-operatively potent at 3, 6 and 12-months. none of the patients that were pre-operatively impotent regained their erectile function at 12 months. sexual confi dence was the facet of life that was most impacted by rarp. other quality of life subdomains showed no signifi cant diff erences aft er robotic prostatectomy. conclusion: th ere has been satisfactory recovery of continence post-rarp, however, erectile dysfunction still remains an important adverse sequela of surgery. overall, robotic prostatectomy has been successfully implemented in the victorian public sector with satis-introduction and objective: to compare patterns of care and perioperative outcomes of robotic prostatectomy to other surgical approaches, and create an economic model to assess the viability of robotic prostatectomy in the case-mix public health funding system. we retrospectively reviewed all radical prostatectomies (rp) performed for localised prostate cancer in victoria, australia, between july 2010 and april 2013 from the victorian admitted episode dataset (vaed), a large administrative database that records all hospital inpatient episodes in victoria, australia's second most populous state. patterns of care, length of hospital stay (los) and blood transfusion rates (btr) were compared by surgical approach. we then created an economic model to evaluate the incremental cost of robotic assisted radical prostatectomy (rarp) over open radical prostatectomy (orp) and laparoscopic radical prostatectomy (lrp) incorporating the cost off set from diff erences in length of hospital stay and blood transfusion rates. th e economic model constructs estimates of the diagnosis related group (drg) costs of orp and lrp, adds the gross cost of the surgical robot (capital, consumables, maintenance and repairs), and manipulates these drg costs to obtain a drg cost per day which can be used to estimate the cost off set associated with rarp in comparison with orp and lrp. economic modelling was performed around a base-case scenario, assuming a 7-year robot lifespan and 124 robotic cases performed per fi nancial year, and one and twoway sensitivity analyses performed for the 4-arm da vinci shd, si and si dual surgical systems (intuitive surgical ltd, sunnyvale, ca, usa). both situations present a challenge to the surgeon contemplating a radical prostatectomy for prostate cancer, due to surgical access and anomalous vascular and ureteric anatomy. open radical prostatectomy has been reported in transplant recipients, but very little has been described using a robot-assisted laparoscopic approach. a case series will be described, illustrating the challenges and techniques required to successfully perform transperitoneal robot-assisted radical prostatectomy in patients with a congenital pelvic kidney or renal transplant within the pelvis. operations were performed using the da-vinci surgical system. we will describe a series of patients between 2007 and 2015 who underwent transperitoneal ro-bot-assisted radical prostatectomy, including patients with a congenital pelvic kidney and a redo renal transplant within the pelvis. prostatectomy was performed using a partial nerve spare in all cases, and pelvic lymph node dissection was not performed. th ere was a mean console time of 117 minutes with a mean estimated blood loss of 175 ml. histopathology confi rmed gleason sum 6-7 disease confi ned to the prostate with no extraprostatic extension or seminal vesicle invasion (pt2c), and surgical margins were free of tumour in all cases. th e tumour volume ranged from 4.7 to 6.5 cubic centimetres. th e psa became undetectable postoperatively and remained undetectable without further therapy. careful perioperative review of imaging and placement of ports under direct vision was essential in avoiding complications. stay suture is applied at glans. circumcision incision is applied leaving at least 5mm tissue of inner mucosal collar. penile skin is denuded down to the penoscrotal junction. minor degree of chordee is corrected by this procedure. a 6 fr feeding tube in the urethra adds to identify the distal urethra which is just underneath the skin in these case, which removed at the end of procedure. mucosa is defi cient ventrally and is replaced by a triangular patch of skin. th is skin patch is excised and mucosal edges are approximated in the midline. th is simple maneuver gives glans penis an upward tilt and meatus appears almost on the tip of glans. redundant preputial skin is excised and mucocutaneous approximation is done with 6/0 pds. no dressing is required. we operated 18 cases of glanular hypospadias between december 2009 and january 2015. mean age of children was 3.53±2.88 years. all cases were day cases. th ere was no need for catheterization and dressing. we used temporary dressing for mild bleeding immediate post op in 4 cases only which were removed in recovery room. th ere was no immediate post-operative complication like urinary retention, severe pain, fever or urinary tract infection. th ere was no complication of meatal stenosis in follow-up (2-12 month follow-up). urine stream was good and cosmesis was satisfactory to parents. we had low complications in our set up and success of glanular hypospadias by our technique was good in terms of good urine stream and cosmesis. conclusions: th e goal of modern hypospadias surgery is a functional neourethra that appears to be normally circumcised penis. tubularized incised plate urethroplasty is a widely applicable technique for distal hypospadias repair. but our current series shows that modifi ed tubularized incised plate technique has low complication rate and excellent cosmetic results superior to tubularized incised plate urethroplasty for primary distal hypospadias repair. however, these results must be further evaluated by comparison study of large series. the impact (catalona, 1988) was performed in 5 patients. occult metastatic disease was found in two patients (3 groins) at the time of diagnosis and subsequently developed in 4 patients during follow-up. th erefore, a total of 9 (36%) of the patients developed metastatic disease. conclusions: current management protocols place moderately diff erentiated t1 penile scc without vascular invasion in a low risk group for lymph node metastases. for this reason a primary option for these patients expectant approach is currently recommended. our experience has shown that patients in this group are really at higher risk for metastatic disease, and we suggest early modifi ed groin dissection instead of expectant observation. introduction and objective: penile cancers are rare. in ghana, they account for less than 2% of all genitourinary cancers. data on penile cancers in ghana is scanty. we report on 13 cases of penile cancers seen over the last 5 years at the komfo anokye teaching hospital (kath). th e aim of the study was to describe the clinicopathological presentation and the mode of treatment of penile cancers in our setting. th is was a retrospective study of histologically confi rmed cases of penile cancers seen at kath from january 2009 to december 2014. information gathered included age, the clinicopathological features and mode of treatment using a structured proforma. results: th ere were 13 cases of histologically confi rmed penile cancers over the period. th e age range was from 32 -91 years with a median age of 62 years. eight were uncircumcised and 10 were married. in only one did the lesion not originate from the glans penis rather aff ecting the base and upper part of the left of hemi-scrotum. in 4 patients, the lesion was restricted to the glans penis, it had involved the distal penis in 3, midshaft in 2, proximal penile in 1 and base of penis in 2 one of whom had auto amputation. all were squamous cell carcinoma with majority being moderately well diff erentiated (80%). seven had ulcerative lesions and 6 were caulifl ower-like. majority were advanced (t4) involving the corpora (69%). only one patient reported with a t1 lesion. eleven patients (84.6%) had lymph node involvement and two had distant metastasis at presentation. only one patient had a penile sparing surgery with 10 of them having partial penectomy at various levels with ure-throstomy at the stump ends. one had total penectomy with suprapubic urinary diversion whiles the one with auto amputation had radiotherapy as the primary treatment. eleven of the patients had lymph node dissection. four had adjuvant radiotherapy. conclusion: most patients present with advanced disease making any hope of achieving a functional and cosmetically acceptable penis aft er treatment impossible. further education is needed to ensure early detection and treatment. how does partial penectomy due to penile cancer affect the sexual life? even though the high incidence of penile cancer in brazil, the sexual life of its patients, as well as their partners, has never been evaluated before. th e aim of this study is to evaluate erectile function in patients who underwent partial penectomy due to penile cancer, describe the socio-demographic and clinical data as well as to assess the patient's partners' sexual function. we performed a prospective analysis in 40 patients between 2008 and 2014 at pernambuco state cancer hospital in brazil. th e sample consisted of patients who were submitted to partial penectomy for the treatment of penile cancer. control group included volunteer couples from the general population with similar socio-demographic features. th e assessment of erectile function and female sexual dysfunction were evaluated with iief-5 and fsfi respectively. results: th e prevalence of erectile dysfunction (ed) in the group of individuals subjected to partial penectomy was 62.5%, including severe ed in 25%, moderate ed in 10%, mild-to-moderate in 20%, mild ed in 7.5%, and no ed in 37.5% of the participants. th e prevalence of ed in men of the control group was 26.3% and was typically characterized as mild ed (p < 0.001). between partners of partial penectomy and control groups, 70% and 63% reported sexual dysfunction, respectively (p = 0.336). a comparative analysis of the risk factors for the ed showed that there were not diff erences between both groups (body mass index (bmi); tabagism; diabetes; hypertension; dyslipidemia and hypogonadism). conclusion: th e actual incidence of erectile dysfunction in patients submitted to partial penectomy for penile cancer is 62.5%. comparative analysis between patients who underwent partial penectomy and general population showed a higher dysfunction rate in addition to more severe ed. in despite of that, their partner's sexual function was similar between the analysed groups. the introduction and objective: androgens are essential for the development and growth of the genitalia. th ey regulate the erectile physiology by multiple mechanisms. several studies have examined associations among sex hormones' serum levels, erectile function and sex drive. we sought to identify a protocol for using testosterone in men with erectile dysfunction and late-onset hypogonadism (loh). during a 16-month period, men with erectile dysfunction who presented to the andrology clinic were selected. th ey underwent a complete physical examination and fi lled out the international index of erectile function-5 questionnaire. serum luteinizing hormone (lh) and testosterone levels were evaluated. patients received a single intramuscular injection of 250 mg testosterone. th ereaft er, serum levels of lh and testosterone were measured 3 weeks later. results: th e mean age was 53 years old. aft er treating patients with testosterone, 45 (94%) showed improvement in loh symptoms including libido, loss of energy, irritability and quality of life. th e mean international index of erectile function was 9 and 13.1, prior to and aft er treatment respectively. mean serum testosterone levels before and aft er treatment were 4.2 and 4.1 ng ml_1 respectively (p = 0.849). mean serum lh revealed a signifi cant decrease aft er the study (p = 0.004) (6.12 and 5.1 ng ml_1, before and aft er the study respectively). our fi ndings suggested that testosterone replacement therapy improves libido and loh symptoms in individuals with almost normal or lower limit normal value of serum testosterone levels. does l-carnitine therapy add any extra benefi t to standard inguinal varicocelectomy in terms of deoxyribonucleic acid damage or sperm quality factor indices: a randomized study to evaluate if addition of l-carnitine therapy to standard varicocelectomy adds any extra benefi t in terms of improvement in semen parameters or deoxyribonucleic acid (dna) damage. one hundred patients enrolled in this study and were randomly divided into 2 groups (50 patients in each group). in group 1, standard inguinal varicocelectomy and, in group 2, standard inguinal varicocelectomy plus oral antioxidant therapy (oral l-carnitine, 250 mg 3 times a day) were performed for 6 months. for all patients, routine semen analysis and dna damage test of spermatozoa (by 2 methods of terminal deoxynucleotidyl transferase dutp nick end labeling and protamine damage assay) were performed at baseline and at 3 and 6 months postoperatively. results: in both groups, the improvement in semen analysis parameters and dna damage was observed, but there was not any statistically signifi cant diff erence between the 2 groups in these parameters, although the slope of improvement in dna damage was slightly better in group 2 (that was not statistically signifi cant). we observed that addition of 750 mg of l-carnitine orally daily to standard inguinal varicocelectomy does not add any extra benefi t in terms of improvement in semen analysis parameters or dna damage. serum uric acid as a risk predictor for erectile dysfunction introduction and objective: testicular torsion is one of the few urological emergencies that require prompt diagnosis and treatment, since its delay leads to testicular ischemia inevitably leads to testicular necrosis and atrophy. we aimed to determine the pattern of presentation and early outcome of patients with testicular torsion managed at kcmc. th is was a hospital based descriptive retrospective and prospective study involving 106 patients who were managed for testicular torsion between january 2006 and january 2015. eighty three (78%) were at the age of 13 years with a mean 16.92 and a standard deviation of 6.01. results: left side was more aff ected by 64.9%. th irty two (29.7%) patients arrived at kcmc within six hours from the onset of symptoms. scrotal pain was the main complaint. seventy two (68%) patients were misdiagnosed at the peripheral health facilities and treated empirically with antibiotics. ninety six point nine percent of those with more than 360 degrees of rotation and duration of arrival to kcmc beyond six hours were found with missed torsion compared to 52.4% of those with a degree of rotation less than 360 and less than six hours on arrival to kcmc (p-value 0.000). orchiectomy of the aff ected testis and fi xation of the viable was the mostly adopted treatment option by 55.4%. eighty four percent of our clients had fi rm and smooth testis at follow-up of three months with 16% having atrophic testis at three months in both groups (retrospective and prospective arms). conclusion: testicular torsion aff ects more young adolescent males. all patients with testicular torsion presented with scrotal pain. most patients arrived to kcmc hospital beyond six hours majority of them being treated empirically with antibiotics at the peripheral health facilities. missed torsion is a common sequel to our patients outcome at three months is promising by having viable testis. ho:yag laser ablation for ulcerative interstitial cystitis tokyo women's medical university aoyama hospital, tokyo, japan introduction and objective: in cases of ulcerative interstitial cystitis are usually treated by tur or by electrocautery, resulting in improvement of pain. efficacy of electrocautery using laser remains unclear because of a very few number of case reports. we treated this time ulcers of interstitial cystitis by cautery using ho:yag laser to evaluate its effi cacy as well as safety. materials and methods: eight cases with hunner's ulcers whose pains were hardly controlled aft er drug therapy and/or hydrodistention were treated with ho:yag laser. patients were evaluated with interstitial cystitis symptom index (icsi), interstitial cystitis problem index (icpi), international prostate symptom score (ipss), quality of life (qol) index and a visual analog pain scale (vas) at base line, one, three and six months post operatively. statistical analysis was performed using the paired t test, in which p<0.05 was considered statistically signifi cant. results: patients were all females aged 56 to 84 years. half of them were treated more than two times. scores obtained by the questionnaire survey were improved aft er the laser therapy. scores of icsi, icpi, ipss, qol index and vas were statistically signifi cantly decreased at one and three months. only vas was statistically signifi cantly decreased at six months. th ere was no severe complication associated by the therapy. conclusion: ho:yag laser therapy for ulcerative interstitial cystitis is effi cacious at least for three months. also this treatment is safe for aged patients. introduction and objective: th e use of methylene blue (mb) to highlight anatomic structures in urology is a well-established practice. a narrow urethral plate can be diffi cult to properly locate intraoperatively, particularly in panurethral strictures. our objective is to assess the value of intraurethral injection of mb during urethroplasty. th ere is 5 cc of mb (10mg/ ml) diluted in 10 cc of normal saline. th e mb is gently injected retrograde into the urethra. a penile clamp is applied for 5 minutes to increase the contact time of the mb with the urethra. th e urethroplasty commenced and the urethra was opened. th e impact of the mb on the anatomy of the urethra was by subjective assessment of a single surgeon (s.b.k.). results: a total of 492 consecutive cases were prospectively evaluated from 2010-2014. precise staining of the narrow lumen was successfully observed in 464 (94%). in these 464 cases, the diseased urethral strictured portion of the urethra was subjectively stained blue with mb. th e grossly normal appearing urothelium remained pink and did not take up signifi cant mb stain. in 28 (6%) cases minimal or no staining was observed. extravasation in to the spongiosa was seen in 8 (2%) cases. in 22 (4%) cases there was dense staining distal to the narrow lumen. th ere were no known allergic complications. conclusion: normal urothelium does not appear to be stained by mb. mb readily stains diseased and strictured urotheilum. intraurethral injection of mb is a useful tool in urethroplasty. it helps in delineation of stricture and identifying lumen. it guides us to the exact area of urethra to be augmented. it is a simple, non-costly and non-invasive tool. in our high volume tertiary referral unit, it is now standard to inject methylene blue in urethra immediately prior to urethroplasty. demography, preoperative imaging and surgical outcome in penile fracture results: condition was occurred in 73.8% of patients during an abnormal sex such as masturbation, aggressive sex and also taghaandan. all patients except one that refused intervention were treated surgically. only four cases involved bilateral corporal injury. two involved unilateral corporal injury with an associated urethral injury, and one involved bilateral corporal injury with an associated urethral injury that all were repaired primary. urine analysis was performed for 69.2% of patients. gross hematuria was seen in one and microscopic in two patients of urethral injury and did not see in others. retrograde urethrogram were not taken of patients with urethral injuries. diagnostic cavernosography or magnetic resonance imaging was not used in any of the patients. cystoscopy was performed in case of gross hematuria with complete urethral transection. no complications occurred in the patients in early follow-up. we are interested in that report entire result of this study such as longterm surgical outcome at congress. conclusion: based on islam promotion for early and inexpensive marriage, avoiding from abnormal sex can signifi cantly decrease penile fracture. in addition, we recommended immediate surgical exploration and repair of tunica albuginea without any preoperative diagnostic imaging. introduction and objective: cowper's glands are two exocrine glands, which are located in the perineal pouch between the fascia layers of the urogenital diaphragm. th ey excrete pre-ejaculate into the urethra to lubricate it and neutralize acid to enable sperm to pass through the urethra. th e glands form two ducts that are 2.5 to 3 cm long. although anatomic variations exist, the majority of ducts combine to make one confl uent passage that opens at the posterior part of the bulbar urethra. cowper's gland collecting ducts dilatation is called syringocele, an uncommon and under-diagnosed anomaly in adults. in pediatric patients there are 1.5% and 2.3% found on autopsy studies. we are presenting case of an adult 20-year-old male, whose symptoms were unrecognized by many physicians, even experienced urologists. th e patient had diff erent treatments with antibiotics and other diff erent medications without success. results: th e patient's chief complaint was dribbling aft er voiding few drops of urine when smiling, coughing, sneezing, crouching and any kind of eff ort. he received treatment as an outpatient by family physician and dermatologist. a bulging on the perineum was found by palpation, hard to elastic consistency, walnut size formation in the corpus spongiosum, easily movable from the perineal skin. urethroscopy was performed and the fi nding in the bulbar urethra was a cystic formation, gray to white color with very thin blood vessels. it fi lled the lumen of the bulbar urethra, but with pressure very easily passed the urethra and verumontanum to the bladder. voiding and retrograde urethrography showed fi lling defects in the bulbar urethra. th is cystic formation was fi xed to the fl oor of the urethra. an incision and deroofi ng of the cystic wall by resection was done. th e patient aft er this procedure was without dribbling aft er voiding. introduction and objective: th e use of methylene blue (mb) to highlight anatomic structures in urology is a well-established practice. th ere are diff ering opinions regarding the management of short atraumatic bulbar strictures. some favor augmentation with buccal mucosal graft (bmg) while others favor excision and primary anastamosis (epa). th e divergence of opinion is unifi ed toward epa in the face of signifi cant spongiofi brosis. our objective is to determine if mb can be used to assess the degree of spongiofi brosis in short atraumatic bulbar strictures. we term the procedure methylene blue spongiography. five cc of methylene blue (10mg/ml) is diluted in 10 cc of normal saline. th e dissection for the urethroplasty continues until the bulbar urethra is exposed. th e location of the stricture is identifi ed. insulin needles are inserted in three locations. one needle is placed in the sponge proximal to the stricture. another needle is placed in the sponge at level of stricture. th e third needle is placed in the sponge distal to the stricture. large atraumatic clamp is place at the most proximal extent of the bulb to limit the confounding blood fl ow from the bulbar artery. methylene blue is gently injected via distal needle. th e two remaining needles are then observed for mb effl ux. presence of mb effl ux in needle proximal to stricture implies a defi ciency of signifi cant spongiofi brosis and urethral transection with epa is not performed. absence of effl ux of methylene blue in proximal needle implies signifi cant spongiofibrosis and epa is performed. we performed mb spongiosography in 22 short bulbar idiopathic strictures. mean length of the stricture was 1.2 (range 1 to 1.5). in 18 (82%) cases methylene blue was seen across the stricture and transecting urethra was avoided. in 4 (18%) cases where no mb went across primary excision and anastomosis was performed. no patients had adverse reaction or complication of methylene blue. conclusions: methylene blue spongiography can be performed to guide the method of urethroplasty performed. it is a simple, cost eff ective, and time effi cient method to further evaluate the degree of spongiofibrosis. effi . th e allium bulbar urethral stent is a fully covered, self-expandable, large caliber metal stent, specially designed for the treatment of bulbar urethral strictures. th e indwelling time for the stents was planned to be 12 months. all men underwent an internal uretrotomy procedure followed by an endoscopic stent placement. progressive decreasing of the urinary peak fl ow rate, recurrent urinary infection and stent migration were the early removal criteria. th e success criteria aft er the stent removal were: no evidence of stricture on urethrogram or endoscopy, urinary peak fl ow greater than 15ml/sec and no recurrent urinary tract infection. results: five stents were replaced since very early migration not more than one month period. none of the patients reported discomfort at the stent site. five patients complained of mild urinary incontinence which was resolved aft er stent explantation. all stents were removed very easily without any complication 3 to16 months (mean 9.4 months) aft er implantation. follow-up period was meanly 24 months (9 to 36) after stent explantation. clinical success was achieved in 78 patients (78%). conclusion: based on our results, temporary placement of allium bulbar urethral stent, for management of the recurrent urethral strictures, is noninvasive, safe and eff ective procedure. the impact of testicular loss on the psychopathology we also compared the results of long-term treatment group and short-term treatment group. th is study showed that 14 cases of long-term continuous administration of doc consisting of 11 or more cycles among 51 patients of castration-resistant prostate cancer (crpc) treated with doc from october 2008 to september 2013 at our institution, retrospectively. nineteen patients who had treated with doc 10 or less cycles were defi ned as short-term dose group, and both groups were compared. doc was administered every 3 to 4 weeks at 60 to 70 mg/m2, and was treated with prednisolone at 10 mg/day as a general. results: th e median number of treatment cycles was 15 (range 11 to 27), and the median age of patients was 70 (range 60 to 80) years old. th e median psa levels at start of doc based chemotherapy was 4.4 (range 2.2 to 171.7) ng/ml. th irteen cases (93%) showed a decrease in psa levels and 10 cases (71%) showed a decrease in psa levels of 50% or more, the 1-year survival rate of long-term dose and short-term dose group were 100% and 16%. adverse eff ects of grade 3 or lower consisted of leukocytopenia in 85% and thrombocytopenia in 28%, stomatitis and general fatigue in some cases, however, grade 4 or higher were not observed in long-term dose group. in multivariable analysis of parameters, long-term treatment was related to psa levels at start of treatment and alp levels. pattern of use of androgen deprivation therapy in prostate cancer: an italian multicenter cross-sectional analysis introduction and objective: androgen deprivation therapy (adt) for prostate cancer (pca) is widely used with diff erent indications, however, some discrepancies exist between clinical practice and the recommendations of the international guidelines. th e aim of this cross-sectional study was to evaluate patterns of use of adt in patients with pca in italy. we also aimed to measure the adherence of adt prescriptions to the recommendations of the eau guidelines. materials and methods: th e choice study was an italian multicenter cross-sectional studying conducted from december 2010 to january 2012 on 1380 patients treated with adt for pca (fi rst prescription or renewal of therapy). th e project involved 9 radiotherapy departments and 21 urology centers. inclusion criteria were: age ≥18 years, previous diagnosis of pca and current adt. at baseline all the following information were included: charlson comorbidity index (cci), clinical stage, psa level at the time of the diagnosis, total prostate volume and gleason score; gleason score and pathological stage from radical prostatectomy (rp) when available. we subdivided the cohort into three risk categories for each treatment group, based on d' amico classifi cation. patients were categorized according to primary treatment into rp, radiotherapy (rt), rp + rt and adt only. radiotherapy comprised external beam therapy and brachytherapy. adt included bilateral orchiectomy, gnrh agonists or anti-androgens. th ree geographical areas were considered: northern, central and southern italy. adt change (adt-c) was defi ned as any modifi cation of therapy between previous adt and treatment prescribed aft er enrolment. the prevalence and outcomes of pt0 disease after neoadjuvant hormonal therapy plus radical prostatectomy in high-risk prostate cancer introduction and objective: to identify the prevalence and clinical outcomes of pt0 disease following neoadjuvant hormonal therapy (nht) and radical prostatectomy (rp) in high-risk prostate cancer. we retrospectively included 111 patients who had received nht and rp for the treatment of high-risk prostate cancer. we classifi ed the patients into two groups, the pt0 group and the non-pt0 group depending on whether a residual tumor was observed or not. we identifi ed 6 cases (5.4%) with pt0 disease aft er reviewing all slides of the patients. th ere was no recurrence of disease in the pt0 group during a median follow-up of 59 months. among the 105 patients in the non-pt0 group, biochemical recurrence (bcr) developed in 60 patients (57.1%), with the median time to bcr being 14 months. conclusions: among the 111 patients with high-risk prostate cancer, we found 6 cases that showed a pathologic complete response aft er nht and no recurrence of disease during the follow-up, which means that the androgen-deprivation therapy could potentially eradicate high-risk prostate cancer. th is is one of the largest studies demonstrating the prevalence of pt0 disease and its outcomes aft er nht among patients with high-risk prostate cancer. introduction and objective: in metastatic castration-resistant prostate cancer (mcrpc), data are limited regarding optimal combinatorial or sequential use of available treatments. p12-2 (stride; nct01981122) is an ongoing, randomized, open-label, phase 2 study evaluating concurrent vs. sequential administration of the androgen receptor inhibitor enzalutamide (enz) with the autologous cellular immunotherapy sipuleucel (sip-t). fift y-two patients (pts) with asymptomatic or minimally symptomatic mcrpc were randomized 1:1 to receive 3 sip-t infusions with enz starting 2 weeks before (n=25, concurrent arm a) or 10 weeks aft er (n=27, sequential arm b) sip-t initiation. th e primary endpoint is peripheral t cell proliferation response to pa2024, the sip-t immunizing antigen. secondary endpoints include interferon (ifn)-γ elispot and humoral immune responses to pa2024 and prostatic acid phosphatase (pap), product release parameters (total nucleated cell count, cd54+ cell counts, and antigen presenting cell activation [as measured by cd54 upregulation]), cytokine production, and adverse events (aes). results through week 26 are described. results: pa2024-specifi c t cell proliferative response was signifi cantly elevated at all post-baseline time points (p<0.001) and was sustained through week 26, including a >10-fold increase at week 20 in both arms. th is pa2024-specifi c response was observed in nearly all pts, 95.8% in arm a vs. 92.6% in arm b. both arms showed a signifi cant and sustained increase in humoral responses to pa2024 and pap as well as ifn-γ elispot response to pa2024. sip-t product parameters were similar between arms. cytokines indicative of immune activation (such as ifn-γ, interleukin-2, and tumor necrosis factor-α) were also elevated in both arms. aes were observed in 88% (arm a) and 100% (arm b) of pts. th e incidence of grade ≥3 aes was similar between arms. materials and methods: tur specimens without hormonal use (4 cases), specimens aft er three weeks of chlormadinone acetate (cma) (9 cases), specimens aft er average six months of dutasteride (3 cases), and specimens two weeks aft er initial use of degarelix (3 cases) were studied using he and immunohistochemical staining with prostate specifi c antigen (psa), prostatic stem cell markers such as cd44, cd117, and vimentin. results: specimens treated with cma showed acinar dilatation and atrophy of glandular cells. specimens treated with dutasteride showed marked decrease of gland and increase of fi bromuscular tissue. specimens treated with degarelix showed prominent decrease of gland and glandular cells. psa was stained all of the prostatic glandular cells in all specimens. cd44 was stained at basal cells in normal prostatic tissue without hormones, however in hormone treated specimens, basal cells elongate and some glandular cells were also stained by cd44, especially in cma treated specimens. cd117 was stained in many glandular cells without special patterns. vimentin was stained in all mesenchymal interstitial cells and a part of basal cells, and not stained in glandular cells. conclusion: elongation of basal cells and increased sensitivity to cd44 in glandular cells, especially treated with cma, were thought to the result of emt of prostatic glandular cells. th ree weeks use of cma might be a good model to observe emt of prostatic cells among these three hormone models, presumably because six months use of dutasteride is long enough to alter the structure of prostatic tissue, and degarelix has strong apoptotic activity to prostate cells in a short period. aryl plays an important role in normal physiologic responses such as development, cell cycle regulation, and immune function in various tissues. th e strong nuclear ahr expression was observed in the invasive phenotype and an elevated nuclear ahr expression was associated with a poor prognosis of human prostate. on the other hand, the ahr defi ciency results in a smaller volume and in increased susceptibility to prostate tumors in mouse model. in the present study, we investigated ahr expression and its role in the growth and invasiveness of human prostate cancer cells. we checked ahr proteins expression in prostate cancer cell lines and in human prostate cancer specimens by immunoblotting and immunohistochemistry respectively. we used a small interfering rna targeting ahr, constitutive active ahr expression vector, and ahr agonist and antagonist were used to moderate its expression and signaling to examine growth and invasion in prostate cancer cells. introduction and objective: androgen deprivation therapy (adt) has been increasingly used in patient with prostate cancer (pca). it has been considered that adt is associated with greater risk of incident cardiovascular disease (cvd). th e one of the reason is that hyperlipidemia was caused by adt may contribute to greater cvd risk. but the evidence remains inconclusive and sometimes contradictory. in our present study, we investigated an eff ect of adt on arterial atherosclerotic changes assessed by cardio-ankle vascular index (cavi) in pca patients. th e present study was participated in 53 patients with prostate cancer before initiate adt. we recorded and statistically analyzed the data of the patients before adt and at 1 months, 3 months, and 6 months aft er adt. and the patients' arterial atherosclerotic changes was evaluated by cavi at baseline. correlation between the degree of infl ammation and gleason score in prostate cancer patients alexandrescu e, geavlete p, georgescu d, geavlete b introduction and objective: hypothesis regarding the involvement of infl ammatory processes in prostate cancer has been the subject of several recent studies. chronic infl ammation generates the appearance of morphological changes of atrophic type, lesions located predominantly in the periphery of the gland, as well as prostate cancer (pca). th e aim of the study was to assess the possible infl uence of associated infl ammation on the gleason score in pca patients. results: th e gleason score 5-6 was detected in 66 patients (50.76%), score 7-8 in 58 patients (44.62%) and score 9-10 in 6 patients (4.61%). cases of aggressive disease (gleason score 7 -10) were detected by prostate biopsy, while high-grade infl ammation has been mostly associated with pca cases incidentally detected by turp. no signifi cant correlations were found between the presence and degree of histologically proved infl ammation and the gleason score or the presence of pca. identifi cation of n6-methyladenosine methylated mrnas in prostate cancer pang k 1,2 , cumberbatch m 2,3 , catto j 1,2 introduction and objective: rna methylation is a common epigenetic event in oncogenesis, and the most common form is the methylation of n6-adenosine (m6a). th e recent identifi cation of >12,000 m6a-methylated human mrnas from >7000 human genes point towards novel epigenetic mechanisms. however, the distribution of m6a in the prostate transcriptome is unknown. we aimed to predict the mrnas susceptible to m6a-methyation in primary prostate cancer (pca) and castrate-resistant pca (crpc), and identify the functions of these mrnas. th e aim of this study was to assess the contribution of multiparametric mri and pca3 in pre-decision of initial biopsy in patients with serum psa level 3-10 ng/ml and normal digital rectal examination. th e study is planned as prospective and single-centered. patients whose serum psa level 3-10 ng/ml with normal digital rectal examination scheduled for initial prostate biopsy were included in the study between february 2013 and march 2014. each patient underwent multiparametric mri (diff usion, spectroscopy, dynamic-contrast, t2) one week prior to biopsy. th e lesion seen at least in two mri was accepted as multiparametric mri lesion. twenty to thirty ml initial urine samples were taken aft er 3 minutes prostate massage for pca3 examination before biopsy. pca3 score over 35 was considered as signifi cant. guided biopsies were taken according to lesions seen in multiparametric mri. patients with high psa levels were separated into two groups as high pca3 scores and normal pca3 scores. each group, then, was separated into two groups due to mri results as lesion positive and negative. tumor incidence and positive predictive values were calculated in patients with high psa and pca3 scores with positive multiparametric mri lesion. tumor incidence and negative predictive value were also calculated in patients with high psa level but low pca3 score with negative multiparametric mri lesion. up.248, figure 1 . a biopsy-induced hemorrhage was defi ned as a case in which a subject complained of bleeding from the rectum and excretion of blood clots was confi rmed. we categorized signifi cant rectal bleeding into two grades for hemostasis management, including mild and severe. when the bleeding was classifi ed as mild, we inserted the gelatin sponge into the participants in either group b or reinserted it into those participants in group a. if the bleeding could not be stopped by this approach, we additionally used index fi nger pressure for ten minutes or more to promote hemostasis. in the severe cases, an endoscopic clipping was performed to control the bleeding because arterial bleeding was suspected. a blood test and a questionnaire survey, and pain related to biopsy was performed before and aft er biopsy. th e diff erence in background factors between groups a and b was assessed. to identify the independent predictive factors for rectal bleeding for all participants, background factors, including insertion of a gelatin sponge into the rectum were analyzed by logistic regression analysis. results: signifi cantly fewer patients in group a required hemostasis aft er biopsy compared to group b (3 (2.0%) vs. 11 (8.5%), p=0.029). th e results of blood tests performed before and aft er biopsy and the results from the questionnaire did not diff er signifi cantly between the two groups. in multivariate analysis, only "insertion of a gelatin sponge into the rectum" emerged as a signifi cant predictor of hemostasis. our results suggest that the tissue elastic modulus of prostate cancer may increase with an increase in the gleason score and that the diff erence in the stiff ness between low-grade lesions and prostate hyperplasia may be slight. th ese basic fi ndings will contribute to the development of quantitative elastography technique. the results: th e median ipss was 12, the mean psa was 6.1 ng/ml; the mean size of prostate was 41.4cc. of the total subjects, prostate cancer was detected in 707 (21.6%) patients. among 8 subscores refl ecting specific luts, the nocturia was only symptom score predict the cancer detection. th e detection rate of patient with nocturia more than 5 time a day was 60.2%, but the cancer detection rate of patient without nocturia was only 12.4%. at multivariate analysis adjusting infl uence of covariate of age, psa, prostate size and transitional zone size, frequency and nocturia scores were the two only factor predicting cancer detection. at the roc curve analysis measuring the benefi t of the additional consideration of the severity of nocturia and frequency, the additional consideration induced 2.9% prediction accuracy elevation (from 0.834 to 0.863). conclusions: men with frequency or nocturia have lesser chance of prostate cancer detection rate than the men without luts. however, the infl uence of these storage symptoms seems not strong enough to change current consensus of indication to biopsy the prostate. routine in the discontinuing group were 0%, 0%, -0.36%, -0.36% and -0.32%, respectively (p=0.5640). th e median δegfr at baseline, 1, 3, 6 and 12 months in the continuing group were 0%, 0%, -0.31%, -0.42% and -0.42%, respectively (p=0.6851). th e continuing group decreased 6 months later. however, the renal function in the discontinuing group had a tendency to improve at 12 months aft er treatment insignifi cantly. th ere was not statistical signifi cant diff erence in various factors between discontinuing group and continuing group. conclusions: it was possible that the recovery of testosterone was associated with the improvement of the renal function. it has been reported that the discontinuation of adt recovered the level of testosterone. namely, the discontinuation of adt for prostate cancer might revive the renal function. th erefore, it was suggested that intermittent adt might recover the renal function. introduction and objective: as more and more patients are getting diagnosed as carcinoma of prostate (cap), we would like to look into how prostate cancers are presented at the early age of forties and how they were treated. as cap is more popularised in the media, more and more people are asking gps for psa measurements. introduction and objective: irreversible electroporation (ire) is a novel ablative therapy for prostate cancer, with reported advantages of sparing surrounding essential structures. th ese properties could potentially help to reduce or avoid side eff ects. th e objective is to determine quality of life outcomes (qol) and side-eff ects of ire treatment. sixteen patients planned for radical prostatectomy (rp), were asked to participate in the study. all patients underwent an ire treatment one month before rp, using a focal or extended ablation protocol. th e safety was measured by the number of adverse events graded by the common terminology criteria for adverse events (ctcae). to determine qol validated questionnaires (expanded prostate cancer index composite (epic), the fi ve-item version of the international index of erectile function (iief-5) and international prostate symptom score (ipss)) were used. results: five developed a urinary retention (ctcae grade 2) solved by an indwelling catheter or self-catheterisation. two patients developed a urinary tract infection (ctcae grade 2), one progressed to urosepsis (ctcae grade 3), both resolved without sequelae. mild haematuria (ctcae grade 1) was noted in ten patients, spontaneously resolved within 27 days. five patients experienced temporary incontinence with duration of 15-31 days, three suff ered from total incontinence and needed pads and pelvic fl oor training (ctcae grade 2). two patients reported mild hematospermia, lasting one and thirty days. ipss showed no signifi cant diff erence between baseline (average of (avg) 11±8) and four weeks postoperatively (avg 12±7). iief showed no signifi cant diff erence between baseline (avg 17±7) and four weeks postoperatively (avg 17±8). epic outcomes, shown in figure 1 , were not signifi cantly diff erent at baseline, one and four weeks aft er ire, regardless of the used ablation protocol. conclusion: ire treatment for prostate cancer is safe and shows only adverse events that lie within the range of what was expected and shows promising rates of genito-urinary functional preservation. introduction and objective: mri-guided transurethral ultrasound ablation (tulsa) is a novel minimally-invasive technology for treatment of prostate cancer aiming to provide local disease control with low morbidity. th e ultrasound device generates conformal volume of thermal ablation, shaped precisely to the prostate using real-time mri thermometry feedback control. aim of this prospective, multi-national phase i study is to determine safety and feasibility of mri-guided tulsa. biochemical recurrence (bcr) was defi ned using phoenix criteria (psa nadir + 2ng/dl) and positive biopsy in the treated area was considered recurrence. we compared the perioperative and oncologic outcomes following fc in patients with gs 6 vs. gs 7 (3+4) at initial trus biopsy. th e complications were reported using the clavien-dindo classifi cation. we found 82 patients with gs 6 and 21 with gs 7 (3+4). clinical and operative characteristics were similar (table 1) . th e mean follow-up was 26.7 (±16.9) months. th ere was no signifi cant diff erence noted between gs 6 vs. gs 7 in the biopsy recurrence (24% vs. 38%, p=0.3) and bcr rates. th ere were 20 complications in 14 (13.5%) patients. all were low grade, except two patients who had iii b complications (table 2) . conclusion: th e perioperative and oncologic outcomes of fc -hemiablation for unilateral, organ confi ned pca appears to similar between gs 6 and gs 7 (3+4) disease. pentafecta in the evaluation of surgical results after open radical prostatectomy de la rosa h, rios s, martinez n introduction and objective: "pentafecta" has been used to evaluate the oncological and functional results in patients with prostate cancer treated with minimal invasive radical surgical techniques. in this study we evaluate, with this quality tool, the outcomes in a group of patients undergoing open radical prostatectomy. we analyzed retrospectively the database of surgeries performed at the urology department of the military hospital of guadalajara and the clinical fi les of patients with localized prostate cancer treated with radical prostatectomy. we describe the patients' characteristics including the charlson comorbidity index (cci) and identify the parameters that conform pentafecta as well as the variables that can infl uence the oncological and functional results using the fisher´s exact test. results: fift y four patients were treated with radical prostatectomy between 2009 and 2014, fi nding in their fi les a minimum of 12 months of follow-up. seven patients were discarded of the study because they undergo laparoscopic radical prostatectomy, and 4 more because missing information at their fi les. th e average age was 64 (44-78) and the cci average was 6.31 (0.9-11.5). mean operative time was 257min (90-420) and intraoperative bleeding 650cc (100-2500). th e presence of potency, continence, biochemical recurrence-free survival, negative surgical margins and no perioperative complications were 26%, 70%, 67%, 33% and 49% respectively. seven (16%) patients achieved pentafecta, and 36 patients (84%) failed to achieve. statistical analysis confi rmed the surgeon's experience as the only factor associated with achieving pentafecta. conclusions: th e fi rst cause of failure to achieve pentafecta in our study group was impotence, second were positive surgical margins and third surgical complications mainly intraoperative bleeding. pentafecta is a useful tool for objective assessment of oncological and functional outcomes of patients treated with open radical prostatectomy. plasma introduction and objective: hepatocyte growth factor (hgf) is a well-known multifunctional growth factor, the amount of evidence has accumulated suggesting that the hgf/met (hgf receptor) signaling axis is involved in cancer progression. macrophage stimulating protein (msp) is also known as a growth factor which activates not only macrophages but also cancer cells and osteoclasts through the activation of the specifi c receptor d' origine nantais (ron). hgf and msp are secreted as an inactive single-chain precursor (pro-hgf, pro-msp), which lacks biological activity and, therefore, requires proteolytic activation for conversion to an active two-chain form by hgf activator (hgfa). although, there have been reported a lot of study for hgf/met signaling with castration-resistant (cr) pc and bone metastasis, the report for examination of plasma protein is rare. in addition, msp/ron signaling axis is not well evaluated in pc. here, we analyzed the associations between pc progression and plasma levels of hgf and a closely related molecule, msp. conclusion: dehydroepiandrosterone (dhea) concentrations in blood were examined by newly developed ultra-sensitive quantifying method, lc-ms/ms. we confi rmed that low serum dhea levels in men with prostate were related to high gleason score and advanced clinical stage. th ese results suggest that serum dhea level may be useful as a prognostic factor in men with prostate cancer. introduction and objective: androgen/androgen receptor (ar) signal is known as a powerful driver of prostate cancer (pca) progression. previously we reported the limitation of prostate-specifi c antigen (psa), which is an ar-regulated protein, at diagnosis as a prognostic biomarker of pca. paradoxically pca patients with low psa < 3.5 ng/ml had a more advanced stage of cancer compared with those with psa between 3.5 and 10 ng/ml. although serum total testosterone (tt) has also been reported as a pca prognostic biomarker, its usability is still controversial. we examine the potential and the character of tt as a biomarker, comparing to psa. serum tt level of patients who underwent prostate biopsy at kanazawa university hospital between 2007 and 2013 were measured and pca-specifi c survival (pcass), overall survival (os), and the correlation between tnm stage and tt level were analyzed. results: of total 379 biopsied patients, 255 were diagnosed with pca. median tt was 4.6 ng/ml (range: 1.4-11.7). when patients were divided into 5 groups according to their tt at diagnosis, patients with tt < 2 and ≥8 ng/ml had worse pcass than those with 2 ≤ tt <4, 4 ≤ tt < 6, and 6 ≤ tt < 8 ng/ml. os in patients with tt 2 < and ≥ 8 ng/ml also was worse than that in other groups. moreover, tt 2 < and ≥ 8 ng/ml showed worse pcass even in patients with advanced stage (t4 or n1 or m1). higher tnm stage was observed in patients with tt 2 < and ≥ 8 ng/ml than those with 2 ≤ tt <8 ng/ml. low tt level has been reported as a predictive biomarker indicating worse outcomes in pca patients. th is study showed not only low but also high tt level may indicate poor prognosis. th ese data are consistent with our previous studies showing low psa (< 3.5 ng/ml) also might indicate poor prognosis as well as high psa. although poor prognosis of high tt and high psa strongly depends on androgen/ar signal, poor prognosis of low tt and low psa patients may be due to other signals than androgen/ar. usefulness of psa as a marker of prostate cancer in men treated with dutasteride takeda h, nakano y, narita h introduction and objective: to analyse whether the use of treatment-specifi c criteria for repeat biopsy maintains the usefulness of prostate-specifi c antigen (psa) level for detecting prostate cancers. th is study was a retrospective investigation to assess the eff ects of dutasteride on psa in asymptomatic men aft er negative 1st biopsy and on repeat prostate biopsy decision. th e usefulness of psa was evaluated using biopsy thresholds defi ned by three times consecutive rises and 0.4ng/ml up in psa from nadir (the lowest psa level achieved while in the study) in the dutasteride group. prostate cancer pathological characteristics were compared. results: of 115 men, 23 (dutasteride) underwent at least one prostate biopsy during the study and were included in the analysis. mean follow-up (month) was 26.3, ipsa was 10.73 ng/ml, mean prostate volume(cc) was 38.15, psad was 0.28ng/ml/cc. nine of 23 (39%) were detected prostate cancer, 11% (1/9) of gleason 7 and 11% (1/9) of gleason 8-10 cancers were detected in the dutasteride group. in the study, the incidence of gleason 7 and gleason 8-10 cancers generally increased with greater rises in psa. sensitivity of psa kinetics with dutasteride was high as usual. conclusion: using treatment-specifi c biopsy thresholds, the present study shows that the ability of psa kinetics to detect prostate cancer is maintained with dutasteride in men with a previous negative biopsy. biopsy decisions based on three times consecutive increased and 0.4ng/ml psa measurement from nadir in the dutasteride group are useful, indicating the importance of confi rmation of psa measurements. our goal was to develop a fi t-for-purpose assay that could be performed on rna from diagnostic needle biopsies, and provide improved risk stratifi cation in early-stage pca. to date, development and validation studies have included >1,500 patients from four academic centers. in these studies, archival tissues were assayed following prospectively designed protocols with pre-specifi ed methods and statistical analysis plans. results: feasibility and development studies confi rmed gene expression and identifi ed genes whose expression was predictive of clinical recurrence, biochemical recurrence (bcr), prostate cancer death, and adverse pathology (ap) at surgery in the face of tumor heterogeneity and multifocality. analytic validation studies showed that the assay provided robust, reproducible results over a wide range of rna inputs, diff erent operators, instruments, and reagent lots. th e fi rst clinical validation study established gps as an independent predictor of ap in men with nccn verylow to intermediate-risk pca. exploratory analyses showed that gps is a robust predictor of ap despite inter-observer diff erences in pathologic grade and stage assessment. a second clinical validation study in a racially diverse population confi rmed the assay as a predictor of ap and validated the assay as a strong predictor of bcr (hr/20 gps units=2.9; p<0.001). gps was also signifi cantly associated with metastatic disease (hr/20 units=3.8; p=0.032). other exploratory analyses showed that the assay can predict 1) likelihood of clinical recurrence aft er bcr, regardless of salvage therapy, and 2) tumor aggressiveness when assessed in adjacent normal-appearing tissue. all four gene groups contribute to the predictive value of the assay. conclusions: th e development program for the assay addressed challenges of small sample size, tumor heterogeneity, multifocality, and biopsy under-sampling. validation in two large contemporary cohorts of men with pca in two prospectively designed studies provides level ib clinical evidence for gps as a predictor of ap. clinical and therapeutic implications of neuroendocrine prostate cancer: a long winding road to cure lu k, wang h, lin v, yu t introduction and objective: primary neuroendocrine cancer of prostate is an extremely rare variant of prostate cancer, comprising 0.5% to 2% of prostate malignancies. th is entity encompasses various clinical contexts, ranging from the de novo small cell carcinoma (scc) to a treatment-emergent transformed phenotype that arising from typical adenocarcinoma (ad) of the prostate. th e rarity of these neoplasms poses a diagnostic and therapeutic challenge. little is known about neuroendocrine prostate cancer and the current knowledge of this disease is based on case reports or small series. our purpose was to characterize the cases treated at a tertiary academic center and to evaluate patient outcomes with the available treatment modalities. th is was a single-institute retrospective observational cohort study of patients with neuroendocrine prostate cancer followed at e-da hospital, kaohsiung city, taiwan between january 1, 2008 and october 1, 2013. patient and tumor data were analyzed using descriptive statistical methods. results: among 826 prostate cancers, six patients were identifi ed with primary neuroendocrine prostate cancer, comprising 3 from de novo mixed variety (scc and ad) and 3 from transformed phenotype (pure scc). th e median age at diagnosis was 73.5 years. th e most common presenting symptoms were obstructive symptoms (weak stream, incomplete empty and urine retention). th e morphological appearance of the tumor cells and their immunohistochemical reactivity for neuroendocrine markers, and prostate specifi c antigen (psa) helped establish the diagnosis. overall median survival was 12 months from diagnosis of neuroendocrine prostate cancer/ prostate small cell carcinoma. conclusion: primary neuroendocrine prostate cancer is characterized by an aggressive clinical course with relatively short lifespan. although high response rate to cytotoxic chemotherapy, overall prognosis is poor. as there is no standard of care for patients with neuroendocrine prostate cancer, further eff orts should be directed at its early detection and made to develop more eff ective therapeutic strategy. association th e mean duration for the side eff ect to occur was 11 months (range 6-18 months), the mean duration between the onset of side eff ect and beginning of hbo therapy was 12 months (range 5-18months). th e patient with both hemorrhagic proctitis and cystitis completely recovered, and the remaining 5 patients had improvement of side-eff ects. conclusion: hbo therapy can be a choice of treatment for radiation induced side-eff ects. a treatment trend of the prostate cancer in japanese provincial hospital introduction and objective: th e prostate cancer patients can choose various treatment options for cancer. however, the choice is limited by a diff erence in the scale and/or the location of each medical institution. we examined a treatment trend of the prostate cancer in our japanese provincial hospital. we evaluated 147 patients who had a diagnosis of prostate cancer between 2007 and 2013. th ey were classifi ed four groups, 11 cases of the middle-aged generation (range -64 years old), 31 cases of the early advanced-aged generation (range 65-74), 74 cases of the middle advanced-aged generation (range 75-84) and 31 cases of the latter advanced-aged generation (range 85-). we sorted each groups using the d' amico risk classifi cation system. in the middle-aged generation, 8 patients, except for metastatic 3 cases, underwent radical prostatectomy or radiotherapy. in the early advanced-aged generation, 15 of 27 low-very high risk group patients (56%) chose radical prostatectomy or radiotherapy. on the other hand, in the same generation, 6 of 10 intermediate risk group cases (60%) were treated with hormonal therapy. in the middle advanced-aged generation, only 12 of 65 low-very high risk group patients (18%) underwent radical prostatectomy or radiotherapy, which was fewer compared with the early advanced-aged generation. th at means, they oft en chose hormonal therapy. in the latter advanced-aged generation, all patients, except for 3 cases, were treated with hormonal therapy. th e 3 cases belong to the low-intermediate risk group, chose watchful waiting (psa monitoring). introduction and objective: robot-assisted radical prostatectomy (rarp) has emerged as an excellent treatment option for men with localised prostate cancer. as with other surgical treatment options, urinary incontinence remains a signifi cant side eff ect of the procedure and has been associated with weak pelvic fl oor muscle (pfm) strength. we aimed to assess pfm strength preand post-rarp, its relevance to incontinence and relevant predictors of poor outcomes post-op. we conducted a retrospective analysis of a prospectively collected database of 118 men undergoing rarp by 2 urologists over a 30-month period. each man had a pelvic fl oor strength assessment pre-operatively and at 1 week and 4 weeks post-operatively. pfm strength was recorded as strong (grade 1), moderate (grade 2) or weak (grade 3). continence rates were recorded at 4 weeks post-op, with continence defi ned as no requirement for pads or continence aids. basic demographic data and histological data were also collected. introduction and objective: urethral trauma is reported to occur in 0.3% of patients undergoing catheterisation but, in practice, seems to be more common than this. we have investigated its incidence retrospectively and prospectively and have evaluated a new approach to catheterisation to reduce the incidence of catheter-related trauma and its consequences, which has led to the development of a novel urethral catheterisation device (ucd) produced by urethrotech™. a total of 150 patients being catheterised for cardiac surgery were reviewed retrospectively and 74 studied prospectively to determine the incidence of urethral trauma due to urethral catheterisation. one hundred similar patients were then studied prospectively to trial a ucd to see if it reduced the incidence of trauma. (10) lavh (9) myomectomy (1) lap. ovarian cyst excision (1) (4) nephrectomy (1) ileal ureter substitution (1) ureterolithotomy (1) angioembolization (1) urs c d-j stent (6) ureteroneocystostomy (8) ureteroureterostomy (7) 0.170 hospitalization ( notes. none had documented consent and none had been counselled about potential complications. one hundred and forty-six were successfully catheterised. four (2.7%) required a suprapubic catheter for traumatic and unsuccessful urethral catheterisation. no other adverse events were recorded. seventy-four consecutive patients were studied prospectively aft er counselling and consenting. th e incidence of urethral trauma was 7 out of 74 (9.5%). five had urethral or perineal pain and urethral bleeding (6.8%) and 2 (2.7%) additionally required a suprapubic catheter. having developed a practice of passing a urethral catheter over a guide wire in patients undergoing reconstructive urethral surgery in our unit we subsequently trialled the urethrotech™ ucd for routine urethral catheterisation. th is ucd was used for catheterisation in 100 consecutive patients without complications. we conclude that urethral catheterisation has a signifi cant risk of trauma -ten times the reported incidence -and to reduce that risk the catheter should be passed over a guide wire, as with the ure-throtech™ ucd, as is the practice for passing catheters and similar tubes into other anatomical structures. th is should particularly apply in high risk patients, such as those being catheterised for cardiac surgery who are about to be heparinised, and in higher risk circumstances such as when catheterisation is being performed by junior medical or nursing staff . results: mean age at the time of transplantation was 12.9 ± 3.6 years with male to female ratio of 1.9:1. etiology of esrd included renal parenchymal diseases (54%), 1o vesicoureteric refl ux (17%) and 2o vesicoureteric refl ux due to posterior urethral valve (14%), urolithiasis (8%) and neurogenic bladder (6%). pre-transplant bilateral nephroureterectomies were performed in 14 patients, augmentation ileocystoplasty with mitrofanoff conduit in 5 patients while posterior urethral valve fulguration in 5 patients. mean serum creatinine post-transplantation was 0.6mg/dl and 0.8mg/dl at 1 week and 12 months respectively. surgical complications occurred only in two patients; one developed lymphocele while other presented with febrile uti due to ureteric refl ux in the early postoperative period and was managed by doing a new ureteral reimplantation. th e mean graft and patient survival rates at one year were 97% and 100% respectively. one patient lost her graft at 3 months which was turned out case of hyperoxaluria. acute rejection was seen in 6 (17%) patients. all of these were successfully reversed with pulse therapy. none of the patients developed cytomegalovirus (cmv) infections or lympho-proliferative disease. symptomatic urinary tract infections aft er transplantation occurred in 12 (34%) patients including pyelonephritis in 3 (8.5%) patients. two of these 3 patients with pyelonephritis had prior bladder augmentation. ureteric stenosis is a well recognised major urological complication of renal transplantation. following initial antegrade decompression, defi nitive treatment options include long-term ureteric stenting, endoscopic stricture dilatation/division or ureteric re-implantation. th ere is minimal current data in the literature to help guide patient choice. we aimed to characterise the outcomes following management of ureteric stenosis at a large european regional transplant centre. a retrospective cohort study was performed for all patients following renal transplantation who required treatment for ureteric stenosis between august 2008 and august 2013. case identifi cation was via a prospectively maintained database on all renal transplant patients and international classifi cation of disease procedure codes. results: of 629 renal transplants performed during the study time period, 21 patients developed ureteric stenosis requiring intervention (3.3%). eleven patients underwent initial open ureteric re-implantation, 3 had endoscopic management and 7 had longterm ureteric stents. mean length of time between elective stent changes was 4.2 months (range 1-12 months). one patient opted for open re-implantation aft er a period of stenting with a good outcome. one experienced graft failure due to non-compliance with immunosuppression, otherwise renal function was preserved. of the 12 patients having open re-implantation only one experienced re-stenosis -managed with long-term ureteric stenting and 91.7% had satisfactory renal function at follow-up. two patients received successful balloon dilatation and 1 patient had upper tract stenosis managed with pyeloureteroplasty. all 3 patients have experienced no decline in graft function since. endoscopic, open reconstruction and long-term stenting can all provide satisfactory outcomes for the majority of renal transplant patients aff ected by this problem. medium-term graft function was well preserved. in recent years approximately half of patients have proceeded to open re-implantation. surgical and clinical factors impact the choice of treatment. however, patient choice also plays a significant role. th is study has provided up to date information to aid counselling patients. further prospective study is warranted to assess what variables infl uence patient choice and cost effi ciency of open re-implantation versus long-term ureteric stenting. the angiogenic mechanisms of endothelial progenitor cells in kidney transplantation patients introduction and objective: th e blood fl ow blocking during kidney transplantation oft en results in renal ischemic injury. in this process, endothelial cells and endothelial progenitor cells (epcs) are activated to participate in angiogenesis. epcs and endothelial cells participate in angiogenesis and tissue repair through diff erent signaling pathway. prostaglandin e2 (pge2) is a kind of metabolites of arachidonic acid, and is a mediator of infl ammation and ischemia. pge2 took part in angiogenesis and epcs diff erentiation according to our previous study. in this study we will demonstrate the angiogenic function of epcs of kidney transplantation patients and reveal the molecular mechanisms of angiogenesis. materials and methods: epcs from peripheral blood aft er kidney transplantation were isolated by density-gradient centrifugation. facs was used to identify the epcs. th e aa metabolites pge2 in epcs cultured medium was measured by liquid chromatography-tandem mass spectrometry (lc-ms/ms). q-pcr and wb were used to detect the expression of endothelial markers in human umbilical vein endothelial cells (huvecs) cultured with epcs conditional medium. tube formation assay was performed to elucidate the angiogenic ability of huvecs. results: epcs from kidney transplantation expressed c-kit and cd31 by facs analysis. multiple types of aa metabolites was detected in the conditional medium by lc-ms/ms and pge2 was increased to more than 2-fold aft er kidney transplantation. huvecs cultured with conditional medium highly expressed cd31 and ve-cadherin and also formed more tubes compared with control. huvecs given pge2 had the same biological characteristics like the conditional culture. conclusion: pge2 paracrine of epcs from kidney transplantation enhanced the capacity of angiogenesis in huvecs. graft survival, proteinuria and kidney growth: challenges between pediatric and adult deceased kidney donation basiri a 1,2,3 , zare s 4 introduction and objective: th e presence of widening discrepancy between supply and demand of donor and recipient in the fi eld of renal transplantation, has led us to compare the graft and patient survivals, post transplantation complications, rate and severity of proteinuria secondary to hyperfi ltration injury and the kidney growth of recipients who underwent transplantation from pediatric (group 1) and adult deceased donors (group 2). each groups contains 36 patients. outcome measures included, patient and graft survivals, quality of graft function as assessed by serum creatinine (scr) and estimated gfr (egfr), surgical complications, proteinuria that was detected by routine urinalysis and then confi rmed by a 24-h urine protein >250 mg, and kidney length that measured by early and following ultrasonography. results: th e mean donor age in groups 1 and 2 were 8.5 (range 2.5 to 15 y/o) and 36 (15 to 65 y/o) respectively. th e nine kidneys (25%) from pediatric donors (group 1) were off ered en-block. mean follow-up was 21 month (range 6 to 72). th ere were no statistical differences in the incidence of dgf between two groups (21% versus 19%) (p=0.62). group 1 had a slightly higher incidence of acute rejection than group 2 (12 versus 8%), but the diff erence was not statistically signifi cant (p=0.57). one year's graft survival were similar between two groups (86% and 88%). serum cre-atinine (scr) and estimated gfr (egfr) th ere were no statistically diff erences between two groups (1.28 versus 1.31 mg/dl and 87 versus 88 cc/min respectively) (p=0.20). th e incidences of surgical complications that required surgical intervention (urinary leakage, ureteral stenosis, lymphocele, vascular thrombosis) were similar in both groups (16 versus 14%) (p=0.42). development of proteinuria was not diff erent between two groups (11% versus 9%) (p=0.12). early kidney length within one week was signifi cantly lower in group 1 than in group 2 (75 ± 12 mm versus 112 ± 14 mm) (p<0.001), but the rate of increase of kidney length in group 1 was signifi cantly greater than group 2 (92 ± 15 mm versus 118 ± 16 mm) (p<0.001) under follow-up period. conclusion: although in this study, median-term outcomes and complications of single and en-block kidney transplantation from pediatric donors are acceptable and same as those from older donors. but assessment of functional and hemodynamic adaptation of small pediatric kidneys in adult recipients and subsequent hyperfi ltration eff ects requires the study with more cases and greater follow-up periods. george a, singh c, devasia a introduction and objective: th e need for vascular access for hemodialysis (hd) increases with the increasing number of patients with end stage renal disease (esrd) requiring hd, with increasing life span, and with more available facilities especially in developing countries. when the usual accesses (radiocephalic and brachiocephalic) have been utilised or failed, a ptfe graft is usually considered. we present here a 'bridging' option of a basilic vein transposition, as a doable, cost eff ective procedure before av graft ing. patients with end stage renal disease were included. th ey all either had poor cephalic veins at the wrist and cubital fossa, or had previously used and failed fi stulae. anasthesia: regional block (local anaesthetic). technique: th e basilic vein was exposed using three small incisions: 1cm above cubital fossa, mid arm (medial aspect), and upper arm (medial aspect up to axilla). th e vein was completely freed off surrounding structures, tributaries tied, distal end ligated, patency ensured and vein delivered out of the uppermost incision. using a tunneller, the vein was rerouted subcutaneously, anteriorly to reach the cubital fossa incision. th e brachial artery was identifi ed and looped. arteriovenous anastomosis was done using 7'o' prolene, continuous sutures. (images in the poster). results: out of a total of 230 venous access surgeries done during the study period, seven basilic vein transpositions were done. all had pre-operative doppler evaluation to assess size and patency of veins. all fi stulae created were functional at the time of discharge. th e fi stula is used for hemodialysis at 4-6 weeks, when the fi stula matures (arterialization of the vein implying good/suffi cient fl ow for dialysis). one patient needed exploration for a venous thrombus, 24 hours later, which was removed with a venotomy and 35th congress of the société internationale d'urologie -siu 2015 abstract book using a fogarty catheter. subsequently with anticoagulation for 48 hours, the fi stula continued to function and is being used for access. th e second patient had exploration on the 6th post-operative day for evacuating a subcutaneous hematoma. th e fi stula is patent and will be used once it has matured. five of the seven done were uneventful and are being used for hemodialysis access. conclusion: basilic vein transposition, is the preferred option of vascular access over a ptfe graft , as it is cost eff ective, autologous and doable under regional anaesthesia. retrospective results: a total of 160 renal transplants have been performed since 1996. th e transplants were performed via an extraperitoneal approach with a modifi ed lich-gregoir ureteric anastamosis in most cases. jj-stents were not routinely used. th irty two urological complications were noted in 29 transplants (18%). th ere were 20 boys and 9 girls with ages ranging from 2.5 to 18.4 yrs (mean 9.4). th e most common complication was vesico-ureteric refl ux (vur) occurring in 17 patients (59%). all those with vur presented with recurrent urinary tract infections and bladder dysfunction was present in 41% (none were augmented). vur was managed successfully with reimplant in six and submucosal injection of defl ux in three; eight patients were managed conservatively. post-operative urine leaks occurred in 6 patients (21%) and were managed with reimplant in two, uretero-ureterostomy in one, jj-stent in one and conservatively in two. ureteric stenoses presented in 6 patients (21%) with hydronephrosis and worsening renal function and were managed initially with either percutaneous nephrostomy or jj-stent placement. surgical management was performed in four patients (three reimplants and one uretero-ureterostomy); two patients were managed conservatively with transient jj-stent placement. th ree patients (10%) developed unexplained hydronephrosis -one with worsening renal function due to chronic rejection and two with stable renal function. loss of graft occurred in 3 patients (10%) as a direct result of their urological complication. th ere were 3 deaths -two due to chronic rejection and one due to overwhelming sepsis immediately post uretero-ureterostomy for ureteric stenosis. conclusion: urological complications following paediatric renal transplantation are common and can cause signifi cant morbidity and even mortality. vur was the most frequently observed and, if presenting with recurrent utis, can be managed successfully with surgery. other urological complications observed included urine leaks, ureteric stenoses and unexplained hydronephrosis. kidney transplantation in abnormal bladder: analysis of outcome kumar a, gulia a, chauhan u, sharma a, yadav r, dassi v introduction and objective: kidney transplantation in abnormal bladder is a challenging situation and associated with poor outcome. we have analyzed outcome of our data of last 8 years. materials and methods: from 2006 to 2014, 14 patients who had abnormal bladder had undergone kidney tx. average age at the time of transplant was 17 years. average age at bladder reconstruction was 8 years. four patients had neurogenic bladder who were practicing cic, 3 using native urethra and one had appendix as a mirofenof procedure. two patients had bilateral nephrectomy for grade 5 vur and their lower ureters were used for augmentation and other two had ileocystoplasty. four patients of grade 5 vur refl ux had subsequent transplant in the bladder. four patients with puv had bladder augmentation and mitrofenof procedure due to poor compliance. one child with puv had augmentation by stomach patch when he was 5 year old. one patient had cystectomy in the past and ileal conduit reconstruction where transplant ureter was implanted. all patients had very trabeculated and thick bladder during ureteric reimplantations. all patients had extravesical ureteroneocystostomy with stents. urethral catheter was kept on average of 7 days. no patients had any ureteric leak or stricture in postoperative period. all four patients with cic through native urethra had recurrent uti in the postoperative period and required long-term chemoprophylaxis. one patient who had ileocystoplasty before transplant, died due to sepsis just before his transplant. incidence of uti was 46% in this group. six patients also had pyelonephritis, which was controlled by injectable antibiotic. rejection rate was 22% in this group in fi rst 6 month which was higher than our normal bladder group. average serum creatinine was 1.7 mg% at 3 months and 1.9 mg% at 1 year which was high than normal bladder population. average follow-up is 2.8 years where serum creatine was 2.3 mg%. mean hospital admission was 4.5 times. conclusion: kidney transplant in abnormal bladder is a good option but long-term results are inferior. recurrent uti and pyelonephritis are still a troublesome problem. various techniques and procedures are required to overcome these diffi cult situations. analysis of results: th e mean operative time, warm ischemia time and blood loos were 146 minutes, 5.2 minutes. 220 ml respectively. th ere were 26 major complications including hemorrhage and injury to organs like bowel, spleen and pancreas. fourteen of these patients required exploration to control bleeding or repair. two patients were explored for adhesive obstruction. th ere were 74 minor complications which were managed conservatively. one patient died in immediate postoperative period due to slippage of a single hemolock clip. all patients have adequate vascular and ureteric length. th ere were 260 cases of multiple vessels. th ere were two urinary fi stulae and one ureteric obstruction. mild atn was noticed in 36 patients. no graft was lost. hospital stay was 4.26 days. operative time has also come down to 110 from 150 minutes. th e average cost of the laparoscopic donor nephrectomy is us$ 1000. conclusion: lap donor nephrectomy is a safe and minimally invasive procedure. it is a cost eff ective procedures even for the developing country. prostate carcinoma in solid organ transplant recipients tillou x 1 , guleryuz k 1 , bouvier n 2 , belin a 3 , chiche l 4 , bensadoun h 5 , doerfl er a 1 introduction and objective: improvements in immunosuppression and anti-infection drugs in solid organ transplantation have led to a signifi cant survival increase for patients and graft s. prostate cancer (pc), being the most common tumor in men and given the increasing number of old male recipients, should show an increasing incidence in solid organ transplant recipients (sotr). th e aim of this study was to analyze retrospectively our liver (ltr), kidney (ktr) and cardiac transplant recipients (ctr) treated for a pc. between january 1993 and december 2014, we found 43 pc in 1407 male sotr (3%): 13 pc in ltr, 28 in ktr and 2 in ctr. a ge at diagnosis was 64.5±6.1 (51.7-77.6) years old and the interval from transplantation to diagnosis was 85.5±60.7 (9.1-241.5) months. mean psa level was 11.2±11.3 (0.5-53) ng/ml. clinical stages were t1, t2 and t3 in respectively 25, 14 and 4 patients. diagnosis was suspected during screening, because of prostatitis or bone pain in respectively 38, 1 and 1 patients. th ree pc were discovered aft er prostate transurethral resection. results: th irty-one patients (21 ktr and 10 ltr) with a localized disease underwent radical prostatectomy (rp). histological fi ndings were 21 pt2c and 9 pt3 tumors, with 5 positive surgical margins. gleason score (gs) was 5 in 1 case, 6 in 22 cases, 7 in 6 cases and 9 in 1 case. one patient with positive pelvic lymph nodes was given hormonotherapy. another had a biochemical recurrence at 10 months and was treated with salvage radiotherapy. with a mean follow-up of 63.4±42.3 (0.6-199.1) months, two ktr died from kp, 3 and 11 years aft er hormonotherapy and rp respectively. conclusions: prevalence of pc in sotr remains controversial, even though a signifi cant increase can be expected in the coming decades. it is therefore recommended to systematically screen male transplant recipients aft er 50 years of age because outcome is much better if pc is diagnosed and treated early. radical prostatectomy is feasible in ktr as well as in ltr. conservative introduction and objective: conservative surgery results in the transplanted population remain unknown because they are only presented in small series or case reports. our objective was to study renal conservative surgery for kidney graft renal cell carcinomas (rcc) in a multicenter cohort. nephron sparing surgery (nss), radiofrequency ablation (rf) and cryoablation (ca) were studied. iiib) . none of the patients treated by radiofrequency ablation or cryoablation had complications. th e mean time of follow-up was 42.9 months (0.6-137). fift y-nine (95.1%) patients had a functional kidney graft , without dialysis and no long-term complications. specifi c survival was 100% at the last time of follow-up. conclusion: nss has proven its effi ciency for treatment of small tumors of transplanted kidneys with good long-term functional and oncological outcomes, which prevent patients from returning to dialysis. cryoablation and radiofrequency ablation seem to be alternative therapies that can be chosen with good results, in selected patients. ureteric implantation into introduction and objective: conventional technique recommends ureteric anastomosis to the bladder during kidney transplantation in patients with bladder augmentation. we report our experience of kidney transplantation in augmented bladders with the transplant ureter implanted into the bowel portion of the cystoplasty. a total of 6 patients (mean age, 28.2 years (range 22-55 years), 2 female, 5 deceased donors) with augmented cystoplasty and subsequent kidney transplantation by a single surgeon between 2011 and 2014 was reviewed. following standard arterial and venous anastomosis and reperfusion of the transplanted kidney, ureteric implantation involved continuous pds 5/0 anastomosis between the spatulated ureter and full thickness bowel portion of the cystoplasty over a size 6fr dj stent. a second layer of bowel plication was performed around the anastomosis to prevent refl ux using interrupted 3/0 vicryl sutures. chart review was performed to evaluate the short-term urological and kidney function outcomes. results: th e cause of renal failure was bilateral vesicoureteric refl ux in 2 patients, posterior urethral valve with refl ux nephropathy in 2 patients, tuberculosis of the urinary tract with infl ammatory ureteric stricture in 1 patient, and lumbosacral agenesis with neurogenic bladder in 1 patient. bladder reconstruction was performed at a median duration of 73 months (6-157 months) before transplantation. gastrocystoplasty was performed in 2 patients, while the colon and/or ileum were used in the remaining patients. all reconstructed bladders except 1 had a mitrofanoff created for clean intermittent self-catheter drainage aft er transplantation between 5 to 8 x / day. aft er surgery, th e dose fi nding study, toxicokinetics of human bone marrow-derived mesenchymal stem cells, and study deciding timing and number of cell injection were conducted in order. results: from the dose fi nding study, 1×106 was selected as dose per an injection of human bone marrow-derived mesenchymal stem cells. from the toxicokinetics of human bone marrow-derived mesenchymal stem cells, 14 days was selected as interval between repeat treatments. in the third study, the ratio of maximal intracavernous pressure to mean arterial pressure was signifi cantly lower in the control group than in the sham group (23.4% vs. 55.1%, p<0.001). immediate single injection of human bone marrow-derived mesenchymal stem cells (39.8%, p=0.035) signifi cantly improved erectile function compared to that in the control group, whereas delayed single injection (38.1%, p=0.079) showed marginally signifi cant improvement. all histomorphometric changes were signifi cantly improved in the up.319, figure 1 . immediate or delayed single injection groups than in the control group. repeat treatments did not provide any incremental eff ect on recovery of erectile function and histomorphometric changes. conclusion: intracavernous injection of 1×106 human bone marrow-derived mesenchymal stem cells results in recovery of penile erection along with histomorphometric changes in a rat model of cavernous nerve injury, even when treatment was delayed by 4 weeks following cavernous nerve injury. any incremental eff ect aff orded by repeat treatments remains to be undefi ned. relationship between metabolic syndrome, erectile dysfunction and hypogonadism abou farha m, el-abd s, el-gharbawy m, abou farha o introduction and objective: a strong association between erectile dysfunction (ed) and metabolic syndrome (ms) and hypogonadism was determined. aim of the work: to investigate the relationship between (ms), (ed) and the incidence of hypogonadism. th e correlation between hypogonadism and the metabolic risk factors was also determined. a total of 227 patients with ed were included in the study, patients meet the criteria of ms were estimated. ed was classifi ed based on iief-5 domain score and the relation between severity of symptoms and the number of metabolic risk factors was determined. th e incidence of hypogonadism in ms patients was determined and the correlation between hypogonadism and metabolic risk factors was identifi ed. introduction and objective: peyronie's disease (pd) is a fi brotic disorder aff ecting the tunica albuginea of the corpora cavernosa. erectile dysfunction (ed) due to pd may be secondary to the penile deformity and the resultant changes in the hemodynamic parameters. th e aim of this study is to defi ne color doppler duplex ultrasound (cddu) characteristics in pd, with specifi c attention to describing the presence and etiology of ed in these patients. introduction and objective: th e cause of peyronie's disease (pd) is unknown. th e most accepted causative theory is trauma to tunica albuginea. because prevalence varies (0.4-9%), the potential for contributory cofactors have been proposed. we hypothesized that metabolic syndrome and other comorbidities may be found at higher rates in pd. retrospective chart review of 1833 patients presenting to a men's health clinic with a variety of complaints: erectile dysfunction (ed), premature ejaculation (pe), premarital checkup, small penis, decreased libido, lower urinary tract symptoms (luts) were screened for pd. variables collected: presence/absence of diabetes mellitus (dm), hypertension(htn), dyslipidemia (dl), body mass index (bmi), total testosterone (t), penile peak systolic velocity (psv) and end diastolic volume (edv), smoking, and glycosolated hemoglobin level (a1c) in patients with dm. results: a total of 1833 patients, with a mean age of 41 years (range 19-86) were analyzed. pd incidence ranged widely within individual clinics (7-51%, average 17%). hypertension, bmi, t level, total number of comorbidities, low psv, abnormal edv, and mean a1c were not associated with the presence of pd. 35th congress of the société internationale d'urologie -siu 2015 abstract book diabetes was associated with pd (p=0.005) and dm patients had a 7% higher incidence. patients with the highest a1c levels (>8.5) had an increased incidence of pd [or 1.6 (p=0.025, ci 1.061-2.459)]. increased age was correlated with pd (p=0.025); for each year of life, the likelihood increases by an or of 1.019 (~2% per year) (p=0.001, ci 1.004-1.027). dyslipidemia (p=0.006) and smoking (p=0.041) were associated with 5-7% lower incidences of pd. conclusion: peyronies disease is found in about 17% of patients seen for other complaints. diabetes, particularly poorly controlled diabetes, is associated with an increased incidence. several other clinical factors appeared noncontributory. a decreased incidence of pd in smokers and patients with dyslipidemia is seen, but does not necessarily refl ect a protective role, but likely increased levels of erectile dysfunction in these groups--patients with inability to achieve erection are unlikely to complain of peyronies' disease. further research into the interaction of pd and dm are warranted. kim j, park j, chae j, oh m, park h, kim j, moon d introduction and objective: limited data are available concerning sexual behavior of korean men. th is study aimed to perform the national sex survey and to collect the basic data for establishment of the prevention strategies of sexually transmitted infections (stis) and hiv/aids. th is is a national survey performed on a sample of 2,500 individuals (1,273 men and 1,227 women) aged 18-69 years old. th e online surveys were carried out on a national scale in south korea. subjects were randomly selected from resident registration. a structured questionnaire was developed which elicited information concerning: demographic information, information on their sexual behavior, sexual identity, prostitution, experience of stis, and experience of sex education. results: th e majority of the subjects were either married or living with a partner. mean number of sexual intercourse is 3.0±3.3 times a month. mean sexual satisfaction score using visual analog scale is 63.2±24.6. eighty-four percent had a fi xed sex partner; 13.1% (22.6% of men; 2.5% of women) had experience through a speed dating or prostitution; 0.9% of men and 1.1% of women were sexually attracted to the same gender only, 1.5% of men and 2.0% of women were sexually attracted to both gender; 1.8% of participants had the experience of the stis. only 10.4% of the respondents had received sex education in the past year. we performed the national sex survey according to the nationwide distribution of population. it would be useful for establishment of the prevention strategies of stis and hiv/aids. to control stis and hiv/aids, powerful policies containing sex education and medical services will be needed. the introduction and objective: erectile function evaluated by international index of erectile function-5 (iief-5) tends to decrease in aging, obesity and hypogonadism, but the importance of body composition is unclear. in the present study, we evaluated associations between iief-5, body composition and testosterone level (tt) in middle-aged men. design was a population-based cross-sectional study in middle-aged men. between march and september 2013, 1910 police officers aged 40-59 years who had participated in a health examination were included. total 1,845 men underwent a detailed clinical evaluation using the validated international index of erectile function-5 (iief-5) questionnaires and body composition (measured by bioelectrical impedance analysis). weight, body mass index (bmi), waist-hip ratio (whr), and serum testosterone level were also established. results: data from 1899 men were analyzed. th e median age was 53.0 years, and median value of iief-5 score was 18. th e iief-5 score was inversely associated with age, whr, and body fat percentage (bfp) (r=-0.238; p<0.001, r=-0.106; p<0.001, r=-0.081; p=0.001, respectively), and positively associated with body muscle percentage (bmp) and body skeletal muscle percentage (bsp) (r=-0.080; p=0.001, r=-0.064; p=0.006, respectively). testosterone level had no correlation with iief-5 score (p=0.147). using logistic regression analyses, age, whr, bfp, and bsp predict moderate to severe erectile dysfunction (ed) in univariate analysis. age, whr, and bfp were independent predictive factors for moderate to severe ed in multivariate analysis (p<0.001, or 1.136, 95% ci 1.100-1.174; p=0.028, or 0.876, 95% ci 0.778-0.986; p=0.024, or 0.986, 95% ci 0.954-1.020, respectively). our data showed that erectile function in middle-aged men was closely associated with whr and bfp than with testosterone level and body muscle percentage. however, whr was identifi ed as a negative predictive factor for ed. further studies for the unique form of obesity pattern in korean men will be needed. in order to estimate the magnitude and outline the main components of adult male genital organs "dysmorphophobia" in greece, we surveyed the beliefs of men about parameters potentially aff ecting their sexual performance and activity as they relate with self-perceptions regarding adequacy of their external genitalia image. herein, we present preliminary results of this questionnaire based cross-sectional study. a specially designed self-administered questionnaire, consisting of 15 demographic characteristics and 10 main outcome measure questions aiming at defi ning whether and how beliefs regarding men's sexual image adequacy aff ect their sexual confi dence and function (answers scored 0-5), was fi lled in by 70 males (aged 19-85) who consulted a single urology clinical setting, for symptoms unrelated to genital area pathology. statistical analysis was performed using spss-22, p<0.05. results: th e majority of subjects (86.4%) were highly satisfi ed of their sex organs image, while only one in seven (13.6%) reported moderate to low levels of satisfaction. small penile size in the fl accid state was the most frequent (51.1%) complaint followed by small erect penis dimensions (20%). in one out of two men (49.3%), sex image inadequacy impression was based on self-assessment, in 27.5% on sexual partner comments and in only 5.8% on expert medical examination. nine out of ten men (89.4%) considered external genitalia appearance the most signifi cant determinant of a man's sexual confi dence with 75.7% believing they strongly fulfi l this requirement, while most of them (71.3%) were highly satisfi ed with their whole body image. in only one in ten men (12.1%) the impression of the sexual partner regarding sex image aff ects signifi cantly his sexual performance. most men (68.2%) argued against resorting to surgical techniques to improve their sex image, 6% considered this option imperative for their well-being, while one in four (25.8%) would consider surgery if a spectacular cosmetic result was guaranteed. various statistically signifi cant correlations between demographic and main outcome measures variables were recorded. conclusions: symptoms of genital organs dysmorphophobia, are expressed by one in seven men of the general population, in most cases complaints focus mainly at small penile size, while most frequently impression of inadequate sex image originates from self-assessment and negative sexual partner's comments. th e majority of men consider genital image a strong determining factor for sexual performance, while very few experience sexual relationships difficulties due to feelings of genital inadequacy. only a small minority of men would be strongly willing to undergo external genitalia surgery, which they consider imperative treatment for sexual image inadequacy. abou farha m, el-abd s, el-gharbawy m, abou farha o introduction and objective: metabolic syndrome is a public health problem associated with increased incidence of erectile dysfunction (ed). erectile dysfunction in patients with metabolic syndrome is diffi cult introduction and objective: erectile dysfunction (ed) and lower urinary tract symptom/ benign prostatic hyperplasia (luts/bph) has common pathophysiology. and phosphodiesterase type 5 inhibitor (pde5-i) partially reverses the prostatic tissue contraction, and increases cyclic guanosine monophosphate to show antiproliferative eff ects in the prostatic smooth muscle cells and consequently, voiding symptoms were suggested to be improved. however, there was no defi nite mechanism of the eff ectiveness of pde5-i on luts/bph. some previous study has reported the hypothesis which is pde5-i improve the blood fl ow rate of prostate and it may improve the luts. in present study, by transrectal ultrasonography (trus), evaluated the change of blood fl ow rate of prostate aft er pde5-i administration. materials and methods: total 16 patients were included in this study. among enrolled patients, 9 patients had once daily administrated mirodenafi l (mvix®, sk chemical, korea) 50mg for 1 week, other 9 patients had administrated placebo daily. peak systolic velocity (psv) and end diastolic velocity (edv) were estimated by trus at before medication and a day aft er last administration. results: baseline characteristics were no signifi cant diff erence between two groups. in mirodenafi l group showed 4.82 cm/sec increase of psv and placebo group showed 0.29 cm/sec increase of psv (p=0.029). moreover, mirodenafi l group showed 0.38 cm/sec increase of edv and placebo group showed 0.19 cm/sec decrease of edv (p=0.543). once daily administration of mirodenafi l 50mg showed improvement of blood fl ow rate of prostate. factors predicting outcomes of penile rehabilitation with udenafi l 50mg following radical prostatectomy introduction and objective: udenafi l is a selective phosphodiesterase type 5 inhibitor (pde5i) made available in recent years for the treatment of erectile dysfunction (ed). penile rehabilitation using pde5is following radical prostatectomy (rp) has been advocated; however, there are no previous reports on the role of udenafi l for potency recovery aft er rp. herein, we evaluated independent predictors of potency recovery in rp patients who underwent penile rehabilitation with udenafi l 50mg. between january 2011 and december 2013, a total of 305 patients underwent rp at a single institute. among them, 143 men were enrolled in a penile rehabilitation program using udenafi l 50 mg every other day. uni-and multivariable cox regression analyses were used to determine independent predictive factors for potency recovery. results: th e overall potency rate was 41.3% during the mean follow-up of 20.4 months. on the multivariate cox analyses, preoperative international index of erectile function (iief)-5 scores (hazard ratio [hr], 1.049; p = 0.040), alcohol consumption (hr, 2.043; p = 0.020), and gleason biopsy score (hr, 0.368; p = 0.024) were independent preoperative predictors for potency recovery. among post-rp variables, the use of robotic procedures (hr, 2.287; p = 0.030) and pathologic stage (hr, 0.506; p = 0.038) were significantly associated with potency recovery. conclusion: th is study identifi ed predictive factors for the recovery of potency in patients undergoing penile rehabilitation with udenafi l following rp. our results provide physicians with useful information for counseling rp patients and selecting optimal candidates for penile rehabilitation. introduction and objective: androgen replacement therapy (art) effi cacy on late-onset hypogonadism (loh) has been widely investigated in western countries; however, it remains controversial whether art can improve health and prolong active lifestyles. we prospectively assessed long-term art eff ects on the physical and mental statuses of aging men with loh in japan. of 1637 volunteers eligible 334 patients > 40 years with loh were randomly assigned to either the art (n=169) or the control groups (n=165). art was conducted with intramuscular injection of testosterone enanthate 250 mg each time every four weeks up to 12 times. th e primary endpoint was health-related quality of life assessed by questionnaires. secondary endpoints included glycemic control, lipid parameters, blood pressure, waist circumference, body mass index (bmi), body composition, muscular strength, bone mineral density (bmd), international prostate symptom scores (ipss), international index of erectile function (iief)-5 scores, and serum prostate-specifi c antigen levels. th e safety and tolerability of long-term art were also examined in these populations. results: fift y-two weeks aft er the initial treatment, art signifi cantly aff ected the role physical subdomain of the short form-36 health survey (sf-36) scale (p = 0.032). art was also associated with signifi cant decreases in waist circumstance (p = 0.002) and serum triglyceride (tg) (p = 0.013) and with signifi cant increases in whole-body and leg muscle mass volumes (p = 0.071 and 0.011, respectively), serum hemoglobin (p < 0.001), ipss voiding subscore (p = 0.042), and the second question on iief-5 (p = 0.005). th ere was no signifi cant deference between the groups in terms of bmi, bmd, isometric handgrip strength, serum fasting blood sugar and hemoglobin a1c, serum psa, and the incidence of sever adverse events. conclusion: long-term art for patients with loh have the benefi cial eff ects on role physical subdomain of the sf-36 scale, serum tg, waist circumstance, muscle mass volume, voiding subscore of ipss, and the second question of iief-5. we hope our study will contribute to the future development of this area. introduction and objective: hyperoxaluria is characterised by a high urinary oxalate level. super-saturation of urine with oxalate will lead to nucleation, aggregation and the formation of calcium oxalate crystals leading to renal calculi. patients with hyperoxaluria are at increased risk of recurrent urolithiasis. objectives: to analysis the interventions and outcomes of new patients with enteric and dietary hyperoxaluria referred to a metabolic stone clinic. an analysis of patients with hyperoxaluria was performed. data examined included; age, sex, metabolic abnormalities, malabsorptive syndromes, previous treatments, stone composition, medical and life style interventions. all patients had 2 or more 24hr collections of urine performed at median of 6 months apart. twenty-four-month follow-up was performed to assess need of further stone treatment. results: a total of 37 patients were identifi ed for study. twenty-fi ve were male, 12 were female. th e median age is 50 years, iqr (22 -73). first median urinary oxalate level is 0.45 mm, iqr (0.3800 -0.5500). patients that reduced their oxalate intake and increased their fl uid intake were signifi cantly less likely to need further long-term stone treatment. th e arr of increased urinary output and decreased urinary oxalate on the need for further stone surgery is 35th congress of the société internationale d'urologie -siu 2015 abstract book 26.3%, ci (-1.534 -54.098) . th e rrr for the need of stone surgery is 63.1%, ci (-43.8 -90.5) . th e nnt to prevent one patient needed further stone treatment is 3.805, ci (1.848 --65.187) . conclusion: hyperoxaluria is important cause of recurrent stone formation that requires management in a dedicated metabolic stone clinic. compliance with fl uid, dietary and medical management is limited. in compliant patients, urine parameters and stone recurrence rates can be altered. clinical using specifi c diagnosis codes from billing data, patients were identifi ed that met criteria for urosepsis secondary to an obstructive ureteral calculi. data was analyzed in the following areas: demographics, admitting hospital of origin, duration of admission before transfer, need for higher level of care, need for invasive procedures, and length of hospital stay. results: using the screening criteria 88 patients were identifi ed. th e average age was 55; 71% were female versus 29% male. patients transferred from an outside hospital made up 40% of the patients and overall hospital admission lasted 8.6 days. of the patients transferred 31% went to the icu for an average duration of 2.51 days. of the transferred patients 29% needed vasopressor/ionotropic therapy, and 20% required intubation. overall, over 90% needed urologic intervention; 57% had ureteral stent placement and 34% underwent nephrostomy tube placement. patients admitted from the ed made up 60% of the patients and had an average admission of 6.74 days. of these patients 30% went to the icu for an average of 1.38 days. only 11% and 15% needed vasopressor/ionotropic therapy and intubation respectively. also, 77% had ureteral stent placement and only 6% had a nephrostomy tube placed. conclusion: urospesis in the setting of an obstructive ureteral stone is a medical emergency that merits urgent relief of the obstruction. once this condition is identifi ed, any facility without the resources for prompt intervention should transfer these patients immediately to a center with these capabilities. th is is supported by our data, as transferred patients on average had a longer icu and hospital stay, and needed more aggressive interventions. clinical signifi cance of ureteral wall thickness adjacent to the stone in abdomen-pelvis ct in the patients treated with extracorporeal shock wave lithotripsy park m, yeo j, cho d introduction and objective: although, ivp was standard diagnostic tool for years, the use of abdomen-pelvis ct (apct) without contrast, particularly in an acute setting, is becoming increasingly common. th is study was planned to know the clinical signifi cance of ureteral wall thickness adjacent to the stone in apct in the patients treated with extracorporeal shock wave lithotripsy (eswl). : th e data of 174 patients who took ap-ct to diagnose ureter stone and were treated with eswl was reviewed. aft er maximum zoom of the ap-ct image showing the longest diameter of stone, the ureteral wall thickness adjacent to the stone was measured by same physician. th e baseline characteristics of patients, the parameters related to ureter stone and effi cacy of eswl were investigated. th e correlation between ureteral wall thickness and those parameters was statistically analyzed. th en, the patients were divided into two groups by the median value of ureteral wall thickness and the diff erence of those parameters between two groups was also investigated. additionally, cut-off value of ureteral wall thickness contributing to the diff erence in the effi cacy of eswl was determined. in simple correlation analysis, bmi, stone length at kub, stone diameter in ct, number of eswl, and time to stone removal showed signifi cant positive correlation with ureteral wall thickness. th e median value of ureteral wall thickness was 2.30mm and the patients were divided into two groups. in comparison of baseline characteristics between two groups, group ii showed more incidence of pyuria than group i and stone burden at kub and ct also showed statistical diff erence between two groups. in comparison of effi cacy of eswl, group ii showed more number of eswl and longer time to stone removal than group i. th e cut off value of ureteral wall thickness contributing to the diff erence in the effi cacy of eswl was 2.095mm. conclusions: in addition to actual size of stone, ureteral wall thickness of ct also aff ects the treatment effi cacy of eswl. especially, the ureteral wall thickness greater than 2.095mm has an impact on the results of the eswl. the introduction and objective: th e treatment of large volume bladder stones by current equipment continues to be a management problem in both developing and developed countries. ah-1 stone removal system (srs) invented by us is primarily used to crush and retrieve bladder stones. th is study evaluated the safety and effi ciency of transurethral cystolitholapaxy with srs to treat the large volume bladder stone. materials and methods: srs, which was invented by aihua li in 2007, composed by endoscope, continuous-fl ow component, a jaw for stone handling and retrieving, lithotripsy tube, handle, inner sheath and outer sheath. a total of 126 patients with bladder stones were performed by transurethral cystolitholapaxy with srs since 2008. th ese patients were divided into four groups by the stone size. fift y nine patients with stone size <2cm were in group a, 40 patients with stone size from 2 to 2.9cm were in group b, 16 patients with stone size from 3 to 3.9cm were in group c, and 11 patients with stone size ≥4cm were in group d and the largest stone was 6.4cm. results: characteristics of patients and stone removal time in variable size were evaluated. to patients with single stone, stone size was 1.35±0.37cm and the operating time was 5.50±3.92min in group a. stone introduction and objective: eswl has emerged as a primary modality of treatment for solitary renal calculi in modern era. th e size of calculus is a major factor for consideration before subjecting a patient to eswl procedure. stone size less than two centimetre is considered ideal for eswl. other factors like obesity, position of calculus, renal infundibular anatomy and stone composition etc. also determine clearance rates. given a choice patients in india still prefer one time clearance by pcnl than multiple eswl sittings for similar sized calculus. our study reiterates the benefi ts of eswl in developing world with multivariate data supporting it. th e objective of this study was to evaluate the feasibility and safety of minimally invasive percutaneous nephrolithotomy combined with fl exible ureteroscopy for upper urethral calculus aft er radical cystectomy urinary diversion. a total of 6 patients underwent minimally invasive percutaneous nephrolithotomy combined with fl exible ureteroscopy from january 2013 to august 2014. th ere were 4 cases that were diagnosed urinary stones aft er bricker urinary diversion of radical cystectomy, 1 case of studer orthotopic ileal neobladder, and 1 case of cutaneous ureterostomy. th ere were 4 cases with left side calculi and 2 cases with right side ones, including renal calculus, ureteral calculus and ureterointestinal anastomotic calculus. th e upper urethral calculi were identifi ed by urinary tract ultrasound and the multiplanar ct. all of 6 cases underwent minimally invasive percutaneous nephrolithotomy combined with fl exible ureteroscopy. th e ureteral stent was indwelled for 4 weeks routinely. th e kidney ureter and bladder x-ray or a ct scan was examined 4 weeks aft er the procedure to evaluate the clinical outcomes. any residual calculus larger than 4 mm was taken as signifi cant. results: th e combined lithotripsy was carried out successfully in all the 6 cases. th e mean operative time was (53±8.9) min. th e nephrostomic catheter was removed 3 days aft er the surgery. th e average blood loss was less than 50ml. no residual calculus was found during the 4 weeks' follow-up. th e average follow-up was 11 months. one case had recurrent calculus 13 months aft er the fi rst procedure, which was successfully managed by the fl exible ureteroscopy again. minimally invasive percutaneous nephrolithotomy combined with fl exible ureteroscopy for upper urethral calculus secondary to urinary diversion aft er radical cystectomy is technically feasible introduction and objective: th e main goal of any intervention for urolithiasis is complete stone removal in order to achieve a stone free status. complete stone removal assures resolution of the immediate adverse outcomes of the stone disease, and prevents possible long-term complications such as pain, obstruction and stone growth. percutaneous nephrolithotomy is an eff ective procedure which is being considered as the gold standard in the treatment of large/complex renal calculi. reported stone free rates are up to 90%, probably refl ecting the level of experience, stone properties and equipment employed in the procedure. it is well established that higher incidence of residual fragments increases the complication rates and needs further interventions. th e main reason for failure of complete radiolucent stone clearance is inability to visualize the residual stones either by nephroscope or by fl uoroscopy. th e use of intraoperative ultrasound for assessment of residual radiolucent stones during percutaneous nephrolithotomy, will help to increase stone free rate. materials and methods: between sept. 2010 and sept. 2014 intraoperative ultrasound was used in 74 cases of large complex radiolucent renal stones. results: it showed stone free rate 100% in 68 patients, false negative in 4 patients (5%) and there was diffi cult scanning in 2 patients (3%). conclusions: th e use of intraoperative ultrasound for assessment of residual radiolucent stones during percutaneous nephrolithotomy, it will help to increase stone free rate. intravenous acetaminophen decreases sedation requirements during extracorporeal shockwave lithotripsy conclusion: th ere is benefi t in pre-operative administration of intravenous acetaminophen in reducing the dose requirements of sedative analgesic for satisfactory pain control during the procedure of swl under conscious sedation. introduction and objective: while most of the bleeding associated with pcnl can be managed conservatively, few need angioembolisation. th ere are diff erent technical methods of embolisation with risk of varying degree of parenchymal damage. we present case of ultrasonography guided embolisation. materials and methods: right lower calyx pcnl was performed successfully in 17 year female with 21 mm renal stone in solitary kidney. she came back on 15th postoperative day with gross hematuria, with 7 cm by 5 cm clot in renal pelvis and 11 mm arterio-venous fi stula at pcnl puncture site. patient was managed with iv higher antibiotics, strict bed rest, blood transfusion and iv tranexamic acid. but her renal function deteriorated (creatinine-6.5 mg/dl). one haemodialysis was done and patient was explored by sub costal approach, with idea of removal of blood clots and suture ligation of av fi stula. renal pelvis was opened and clots were removed. during operation av fi stula was located with doppler usg and deep suture by 2-0 vicryl was attempted to close av fi stula, but due to oedematous kidney suture closure was not possible. so under usg guidance 22 gauze lumber puncture needle was inserted into av fi stula, its position was confi rmed by saline jet on real time usg and 1 cc histoacryl tissue adhesive (monomeric n-butyl-2-cyanoacrylate) was injected into av fi stula. intraoperative embolisation of av fi stula was confi rmed by colour doppler. results: renal functions became normal in 48 hours and patient was discharged on 5th postoperative day. aft er 21 days ivp was done which demonstrated normally excreting whole kidney, showing successful superselective embolisation in solitary kidney. conclusions: usg guided procedure avoids the side eff ects of contrast media in case of acute renal failure. it avoids hazards of radiation and complications of angiographic catheterisation. th e main importance of this procedure is preserving maximum renal tissue, especially in case of renal insuffi ciency and in solitary kidney. th is procedure gives a new vision to do percutaneous usg guided embolisation by thin 22 gauze needle without need of angiography, iv contrast, radiation and minimum morbidity. ultrasound th ree pregnant women in the 16th, 20th and 28th week of pregnancy presented with a symptomatic large renal stone in the fi rst and multiple renal stones in the second and third which were unresponsive to conventional medical therapy. th ey required defi nitive stone treatment. th e operations were done in nov 2012, jun 2014 and feb 2015. data was gathered prospectively. all steps of gaining access to the pyelocalyceal system including needle insertion, tract dilation, and amplatz sheath placement were performed under ultrasonography guidance. tract was dilated with single shot technique. th e fi rst two procedures were performed in supine position and the third procedure was performed in lateral fl ank position. results: two patients were stone-free postoperatively and one patient had only an asymptomatic 4 mm residual stone. th ey were discharged on the 2nd postoperative day and had an uneventful postoperative course. no fever, bleeding or renal colic was noticed during postoperative hospitalization. th e fi rst two patients delivered their fetuses at term without any abnormality reported by the examining pediatric specialist aft er their birth. th e third patient was followed until 33 week of pregnancy without any obstetric complication. conclusion: ultrasonography can be used as an imaging modality guiding all steps of obtaining percutaneous access in pregnant women. supine or fl ank ultrasound guided percutaneous nephrolithotomy can be off ered to pregnant women in whom conservative measures fail to the patient's well-being. introduction and objective: acute ureteral obstruction in pregnancy may result in severe pain, hematuria and serious complications like upper urinary track infection with consecutive sepsis. th e ureteral stenting has been usual in recent years. we evaluated the usefulness of ureteral stenting for ureteral obstruction with symptoms in pregnancy. fift y-three pregnant women participated in this study. abdominal ultrasonography, serum creatinine levels, white blood cell (wbc) counts, urinalysis and urine culture were done in all patients. of these 53 pregnant women, 18 women were treated by ureteral stenting because of not improving with conservative management (positioning, analgesia, antibiotics, etc.). th ey were completely followed-up to removal of ureteral stent. results: of these 53 pregnant women, 18 women who were treated by ureteral stenting, experienced signifi cant relief of pain at least for 2 days. in abdominal ultrasound, 16 patients (88%) had resolution of hydronephrosis. twelve of 18 patients (66%) continued to have problems post-therapeutically irritative voiding symptoms with dysuria, urgency, frequency, and hematuria, but 11 patients experienced relief of symptoms for 10 days. a patient was taken remove of stent due to continuous complaint irritative voiding symptoms. aft er delivery, 17 patients were taken ivp. of 17 patients, 13 were normal fi nding with ivp. four patients were diagnosed ureter stone (upper 2, mid 1, lower 1). th ree patients were treated by extracoporeal shock-wave lithotripsy for the stone in upper and lower urinary tract. a patient was treated ureteroscopic lithotripsy. conclusions: since the ureteral stents were usually placed without any major problems and well tolerated with only minor and short post-therapeutic discomfort. we concluded that the ureteral stenting was a simple, safe and eff ective method of internal upper tract drainage in case of symptomatic ureteral obstruction during pregnancy. safety introduction and objective: to evaluate objective and subjective outcomes of retrograde intrarenal surgery (rirs) for the treatment of radiopaque 10 -20 mm renal calculi. a retrospective analysis was performed for 34 patients who underwent rirs to treat renal calculi sized with 10 -20 mm between april 2013 and december 2013. operative and postoperative data were collected for each patient such as stone burden, stone location, number of sessions, and auxiliary procedures. th e term of follow-up was one year at least. surgery was usually performed under general anaesthesia. flexible ureteroscopy with ureteral access sheath and holmium-yag laser were employed. patients were evaluated with simple radiography, abdominal ultrasonography, or ct without contrast. surgery success was determined as stone free rate (sfr) at three months aft er last session. re-treatment rates were also calculated. results: mean age was 55.2 ± 13.6 years old. th e highest-frequency location was pelvis (50%). single stones were described in 74% of patients although multiple urolithiasis were detected in the 26%, mainly located in the lower calyceal. average surgery time was 52.2 ± 17.7 min. th e auxiliary procedure rate and the re-treatment rate were 2.9% and 8.8%, respectively. th e overall sfr and sfr aft er a single session were 91.1% and 88.2%, respectively. although no serious complications were noted in all of patients (above clavien-dindo classifi cation level iii), clavien level i to ii complications were identifi ed in two-patients (5.8%). all these patients were successfully treated conservatively. conclusion: our fi nding suggest that rirs represents a valuable treatment option of 10 -20 mm radiopaque renal calculi for selected patients. rirs would be also a good therapeutic alternative to extracorporeal shock wave lithotripsy (eswl) and percutaneous nephrolithotomy (pnl). rirs should be considered as fi rst line treatment. prospective analysis is required to be corroborated these fi ndings. ureteroscopic lithotripsy for extremely old patients yoshioka t 1 , uehara s 2 , otsuki h 2 , shimizu t 2 , murao w 2 , fujio k 2 , kikuchi h 3 , fujio k 1 , wada k 1 , araki m 1 , ebara s 1 , watanabe t 1 , nasu y 1 introduction and objective: one of the biggest problems in 21st century is an aging society. in 2013, the number of old people (≥65 years old) in japan was 31,900,000. th at is about 25% of all japanese population. japanese society is becoming not an "aging" society, but an "aged" society, and we have to prepare for this society. on the other hand, upper urinary stone is a common disease, and oft en occurs not only young people but also aged people. however, there are no standard treatments for aged patients of upper urinary stones, especially extremely old patients who are more than 85 years old. in this study, we investigate the safety and effi cacy of ureteroscopic lithotripsy of upper urinary calculi for these patients. between january 2012 and october 2014, 254 ureteroscopic lithotripsy (urs) underwent in abiko toho hospital. of these cases, 5 cases are for the extremely old patients (≥90 years old). we retrospectively reviewed gender, age, body mass index (bmi), american society of anesthesiology (asa) physical score, stone size, reasons for operation (whether symptomatic or not), operative duration, and stone free rate (sfr) of all cases. all data were reviewed by one urologist, and asa physical scores were evaluated by one anesthesiologist. results: all cases were bedridden female. mean age was 91.75 (range 90 to 95), bmi was 19.4 kg/ m^2 (range 17.8 to 21.0), asa physical score was 2.5 (range 2 to 3). 4 cases had preoperative complicated pyelonephritis, and 3 out of these 4 cases were indwelled preoperative unilateral ureteral catheters. mean stone size was 6.68mm (range 4.4 to 9.6), and operative duration was 56.2 minutes (range 36 to 81). postoperative complication was 1 pyelonephritis (clavien grade 4), and sfr was 40% (2/5 cases). in all cases, postoperative unilateral ureteral catheters were indwelled, and were withdrawn 2 weeks later. th ere have been no recurrent stones and/or pyelonephritis (median observation time: 10.5 months). conclusion: although sfr was low, urs for extremely old patients can prevent recurrent complicated pyelonephritis even on infected stones. th ere were 82.9% of patients who had a single urinary stone and 17.1% (n = 14) had 2 or more. one hundred and nine stones were treated. sixty-three percent of stones were intrarenal. th ere were 5 (6.5%) postoperative complications: two stage 2 clavien classifi cation infections (prostatitis at day 13 and two pyelonephritis 48 hours aft er the procedure); three stage 3b complications (two renal colics requiring ureteral stenting 48 hours aft er discharge and 1 symptomatic perirenal urinoma 48 hours aft er discharge). th ere was one intraoperative complication (1.9%): a ureteral wound with contrast leakage. th e rate of transfer to conventional hospitalization was 2.2%. stone size infl uenced the stone-free status and the need for more than one sessions (p <0.0001). th ere was a signifi cant correlation between operative time and stone size above 10 mm (p=0.0002). conclusions: flexible and rigid ureteroscopy are safe and effi cient procedures for upper urinary tract stones, and can easily be carried out in an outpatient introduction and objective: renal stone disease is one of commonest urological disorders. pakistan is located in stone belt region with high incidence of urolithiasis. th ere have been innovations and improvement in stone treatment modalities. eswl is one of them. here we share experience of single centre in terms of stone free rate and effi cacy in adults. a retrospective study in which we included adults (age above 18 years old) who underwent eswl from january 2013 to december 2014. eswl was done by standard technique. we used modulith sl x lithotripter 4th generation storz medical. number of shocks per session 3500 for kidney and 4000 for ureter. energy level for kidney is set at 7 and for ureter at 9. rate of shock wave delivery is 90 shocks/minute. we followed patients for 3 to 6 months aft er last eswl session done. stone free status was defi ned as residual stone not more than 4 mm in size. we reviewed data charts of patients for diff erent variables mentioned in results. introduction and objective: yolk-sac tumor (yst) is formed almost 65% germ cell tumors of infant and children. yst is the most common type of testis tumors in prepubertal period, but adult pure yst is extremely rare. in this case we aim to share our surgical experience with an adult pure yst in the right testis. a 47 year-old man was referred to our clinic from cardiovascular surgery department for right testicular mass which is detected during the evaluation of his deep vein thrombosis. th e patient stated having a slowly progressive increase in size of his right gonad. th ere is no history about testicular trauma or epididymoorchitis. physical examination revealed a painful right testis which was uniformly increased in size and presented a smooth surface. usg showed a volumetric increase in the right testis. mass size was detected as 9.5 x 10.5 x 10 cm, which was characterized by cystic components in heterogeneous echogenicity. serum chemistry revealed a marked increase in afp while β-hcg and ldh levels were within the normal limits. results: a right radical inguinal orchiectomy was performed. during the orchiectomy, because of the invasion to scrotum skin, scrotum skin was removed. th e surgical specimen was rigid, its surface was smooth and necrotic areas were observed ( figure 1 ). pathologic examination revealed a pure yst with positive spermatic cord, tunica albugea, tunica vaginalis and scrotum skin invasion and in light microscopy tumor cells with large hyperchromatic nuclei arranging concentrically around a small vessel were seen (schiller-duval or glomeruloid body). metastasis of lung adenocarcinoma to the testis is an extremely rare occurrence and very few cases have been reported to date. th e authors aim to review the current literature in regard to incidence, clinical manifestation, sources of primary tumour and mechanism of metastasis, in addition to retrospective ten year review of testicular pathology at a single institution. we report an unusual case of a 33-year-old non-smoking australian gentleman who presented with a six month history of cough and dyspnoea. a physical examination, complete laboratory and radiological work up was performed. a palpable left testicular mass was identifi ed, ct scan revealed multiple bilateral lung nodules and mediastinal lymphadenopathy, however testicular tumour markers were negative. th e patient underwent a radical left inguinal orchidectomy and endobronchial hilar lymph node biopsy with bronchial washings. medical records and pathology results for patients undergoing radical orchidectomy over the past ten years at our institution were obtained and analysed. results: histopathological examination of the left testis and lung biopsy revealed features of a moderately to poorly diff erentiated adenocarcinoma, with morphological and immunohistochemical appearances consistent with lung origin. th e prognosis is extremely poor. a total of 130 patients underwent radical orchidectomy at our institution between january 2004 and february 2014. th e mean patient age was 32 (18-66). histopathology is summarised in table 1 . cur-up.373, figure 1 . 35th congress of the société internationale d'urologie -siu 2015 abstract book rent literature review confi rms testicular metastases are rare and may be discovered incidentally at autopsy or following diagnostic orchidectomy. autopsy series revealed testicular metastases in 0.02 to 2.5% of specimens. th e most common primaries, excluding lymphoma and leukaemia, include prostate, melanoma, sarcoma, gastrointestinal tract, kidney and lung, with most testicular metastases being a fi nal manifestation of widespread tumours. conclusions: testicular metastases from lung adenocarcinoma origin are scarcely encountered in clinical practice and may create a diagnostic dilemma by mimicking primary testicular neoplasms. extensive pathologic evaluation and specifi c immunohistochemical staining is essential. in patients presenting with a testicular mass, the diff erential diagnosis must include metastatic carcinoma. by 24.7 on average compared to only 8.6 by non-users (p=0.024). many of these fi ndings were only present with recent vge; heavy users from high school and middle school did not show similar trends (table 1 ; figure 1 ). conclusion: th is study shows that subjects with heavy vge perform better on the da vinci skills simulator than subjects who report no vge. th e improvements seen with recent vge are not apparent if stratifying for frequency of use during high school and middle school. th ese fi ndings may have important implications for the future of surgical training. 'virtual urology clinic': a feasibility study in a busy uk teaching hospital introduction and objective: urology is an advancing surgical specialty with a parallel increase in demands from health service commissioners to meet national targets and patients' needs. th is has been refl ected on the outpatient urology service with a rising burden and delays in patients' outpatients' assessments. in our busy tertiary unit, we estimated a total of 1281 overdue outpatient appointment (by 6 months or more). th us we designed this virtual clinic feasibility study aiming to: prioritise patients according to their clinical needs, enhance their care and decrease the burden by assigning patients to our novel computer based follow-up models. we used the hospital information system to identify one urologist overdue appointments (by 6 months or more). all included cases had thorough review of their medical notes, investigations and treatment before being stratifi ed according to their diagnosis then assigned one of 3 outcomes: urology, cancer nurse specialist (cns) and gp follow-up. results: a total of 191 cases were reviewed in this virtual clinic over a period equivalent to 5 full working days. even though they were all waiting to see one urology cancer surgeon, only 27% had a primary diagnosis of cancer with the rest being diagnosed with a benign urological condition. th e clinical investigator recommended for only 45% of all patients to have a urology follow-up with 33% and 22% discharged to the gp and computer based follow-up respectively. all patients received a letter explaining the procedure of this clinic along with a tailored management plan. th ere was an evident gap between the dynamic changes in service provision with new available tools and our current practice. th is virtual clinic allowed bridging this gap by categorising the urological priorities and utilising existing resources such as our novel computer based follow-up models. over the last year more than 1000 patients' visits have been registered on our computer based clinic which is potentially a cost eff ective model. patients' perspectives of accessibility introduction and objective: patients undergoing major lower abdo/pelvic operations are oft en catheterised (idc) at the start of the procedure to monitor urine output and decompress the bladder to avoid bladder injury. early removal of urinary catheters aft er surgery has been associated with a decrease in urinary tract infections though increasing failure of trial of void (tov), thus being discharged with idc or prolonged admissions. th e aim of this study is to determine the optimal time for tov. th is is a retrospective study looking at patients undergoing abdominal or pelvic procedures due to colorectal/pelvic pathology in the townsville base hospital surgical unit from jan 2008 -dec 2012. pre-procedure idc and the deceased were excluded. data was collected from the operating theatre database (ormis). results: out of the 306 total, 142 were female while 164 male, 94 abdominal and 212 pelvic procedures. sixteen male patients had documented prostatic history which include bph, prostate cancer and prostatitis post radiation. four were discharged with an idc failing tov. fift y-seven percent of the patients had their catheters removed on day 2 post-op; 5.6% on day 1, 13% on day 3, 4.9% on day 4 and 11% >4 days. th ree patients developed a urinary tract infec-tion (uti) (0.98%). patients with good pre morbid function and female tend to pass their trial of void on day 1 post op for pelvic procedures. th e majority of patients had comorbidities and failed tov on day 1. th ere was no signifi cant diff erence between day 1 and day 2 in uti rates (increasing day 3 onwards). conclusions: idc's should be removed in a timely manner to reduce complications, balanced with monitoring fl uid balance. we proposed that patients should have tov on day 2, due to increased rates of failed tov day 1 in patients with comorbidities and no diff erence in uti rates between days 1 and 2. th e limitation of this study is the lack of documentation of preoperative urinary function. to further this study, we can analyse the data to state diff erences between bladder dysfunction as well as tov in groups with various comorbidities. international urology journal club on twitter: a growing educational forum introduction and objective: urologists use urinary and thoracostomy drainage collection systems regularly. pleural and urine fl uid pools at the bottom of dependent loops of both thoracostomy and urinary drainage tubing systems, respectively. we hypothesized that fl uid pooled in a dependent loop 1) diminishes the expected negative pressure-head delivered to the pleural space by a chest-tube, and 2) obstructs antegrade catheterized urine drainage. we created an ex-vivo thocacostomy tube model, and, performed two separate clinical trials to test our hypothesis. a pleur-evac chest drainage system was connected to -20 cmh2o wall-suction. a digital pressure transducer was connected to the drainage tubing close to the insertion of connection to a chest-tube. model: to simulate dependent loops observed in hospital patients, we created 21, 35, and 58cm-high dependent loops (distance between the bottom of loop and the highest-point en-route to the drainage box). th e pressure close to the (blind-ending) chest-tube was measured as the drainage tube was fi lled in 5ml. increments. fitted linear regression of pressure and loop-height was performed. clinical trials #1. pressure within the drainage tube was measured in six icu patients with thoracostomy tubes in place following cabg surgery. clinical trial #2: we performed early-morning hospital icu bedside bladder-scan us on 20 patients with an indwelling urinary catheter and clear urine, to assess for un-drained residual urine. results: with an empty dependent loop, thoracostomy tube pressure equaled the suction pressure (-20cm h2o). pooled of fl uid within the dependent loop diminished proximal negative pressure (p<0.0001) in a volume (i.e. loop-height) dependent fashion. th e net range of proximal drainage tube pressure ranged from -20 to +35cmh2o. in icu patients, an identical relationship between loops and chest-tube pressure was observed. bladder scan of catheterized ward patients revealed high urine residuals (mean 142 ml) with a dependent loop present, and ~zero residual when no loop present. conclusions: th oracostomy-tube negative-pressure is steadily diminished as a dependent loop fi lls with fl uid. th e resulting air-lock opposes antegrade drainage. th e weight of the fl uid column accounts for positive thoracic pressures, and could account for why many patients fail water seal trials. similarly, urinary tubing dependent-loops result in air-locks that prevent gravity dependent drainage. th oracostomy and urinary drainage tubing should always be positioned without dependent loops. single incision mid-urethral sling (miniarctm) and tension-free vaginal tape (tvt) procedure in women with stress urinary incontinence (sui) at 12 months. a total 187 women with sui were randomized to receive miniarc and tvt. th e primary outcomes were objective and subjective cure rates at a 12-month follow-up visit. objective and subjective cure of sui were defi ned as a negative cough stress test and absence of self-reported sui symptoms. cure rates of the two groups were compared at 12-month follow-up. results: a total of 158 (85%) of 187 women originally included in the study (miniarc: 87, tvt: 71) were evaluated at 12-month follow-up. th ere were no signifi cant diff erences found in demographic and clinical preoperative parameters. objective cure rates for miniarc and tvt groups were 90% and 94% while subjective cure rates were 84% and 89%. th ere was no statistically signifi cant diff erence between groups (p>0.05). conclusions: our 12-month randomized clinical trial showed that miniarc single incision sling is not inferior to tvt procedure with respect to objective and subjective cures at 12-month follow-up. introduction and objective: male sui is a debilitating and challenging problem to manage. insertion of transobturator sling off ers less invasive treatment than aus insertion. published data demonstrate cure rates of 75% but are limited by short follow-up. th e aim of our study was to report long-term outcomes for male transobturator slings for sui with a mean 4 year (minimum 2 year) follow-up. a single-centre retrospective audit of outcomes in 39 male patients who underwent transobturator sling insertion for sui. follow-up was conducted via telephone or in outpatient clinic. incontinence was classifi ed as mild (≤2 pads/day), moderate (3-4 pads/day) or severe (≥5 pads/day). classifications post-surgery were: cured -dry; improved -≤2 pads/day and ≥50% less pad use; failure -no change or worsened. results: in patients with mild/moderate incontinence, 20/31 patients (= 64.5%) were cured/improved with tot. success rates were poor in severely incontinent patients, regardless of radiotherapy history (25%; n=2). of 22 'cured'/'improved' patients, 18 (81.8%) maintained that degree of continence for the duration of follow-up. one patient was lost to follow-up. th ree patients reported a later decline in continence; 2 patients had had previous pelvic radiotherapy. one patient had progression of underlying prostate cancer. conclusion: durable success rates of 64.5% are achievable in men with mild/moderate sui who have not had pelvic radiotherapy. pelvic radiotherapy may play a role in delayed failure of tots with 25% of patients with mild/moderate sui who were initially cured/improved declining in the second or third year aft er surgery. the mesh wallstent (urolume) in the treatment of detrusor external sphincter dyssynergia in men with spinal cord injury dept. of surgery, div. of urology, king saud university faculty of medicine, riyadh, saudi arabia introduction and objective: to evaluate the longterm effi cacy and safety of the urolume stent for the treatment of detrusor sphincter dyssynergia (dsd) in spinal cord injured (sci) patients. twenty-four spinal cord injured patients with neurogenic bladder and dsd associated with high detrusor pressures and incomplete emptying on pre-operative video-cystometrograms (vcmg) were retrospectively reviewed. twenty-one patients had cervical level injury whilst 3 had a thoracic injury. eleven patients were on clean intermittent catheterization (cic) and 13 with indwelling foley's catheter. all patients underwent urolume stent insertion according to standardized protocol. follow-up assessment included blood chemistry, ultrasound scan (upper tracts and residual urine) at one and three months aft er insertion, and a follow-up vcmg at six months. residual urine volume, autonomic dysrefl exia, catheter need, and presence of bladder stones and hydronephrosis were compared before and aft er treatment. post-operative patient and physician satisfaction, complications and re-obstruction rates were also analyzed. paired t-test is used and p value <0.05 was taken as signifi cant. results: th e twenty-four patients had a mean (range) follow-up of 4.1 (2.5-11) years. th e mean age was 46 introduction and objective: at present, sacral neuromodulation (snm) with interstim® therapy is indicated for non obstructive urinary retention and overactive bladder, including urinary urge incontinence and signifi cant symptoms of urgency-frequency alone or in combination, in subjects who have failed or could not tolerate more conservative treatments and do not have any neurological disorder. th ere are also reports of the use of interstim® in the treatment of chronic pelvic pain and other conditions. we report our experience with the use of this device in patients with post-traumatic brain injury damage without anatomical anomalies and with severe urinary voiding dysfunction who had failed intensive medical and behavioral therapies. materials and methods: from november 2013 to november 2014, 13 patients underwent interstim® placement (9 male and 4 female). all had severe voiding dysfunction secondary to post-traumatic brain injury damage; ten of them had also defecatory disturbances (8 a chronic constipation and 2 fecal incontinence). th e main goal was to evaluate the improvement of the urinary symptoms and the second goal the improvement of the intestinal symptoms. success was defi ned as a ≥50% improvement in any of the two variables evaluated. results: with a mean follow-up of 10 months, 11/13 patients reported ≥50% improvement in their urinary voiding symptoms (85%), in these patients urinary frequency decreased from 17 to 6 episodes per day, mean voided volume increased from 159cc to 364cc, incontinence disappeared in 5 of 6 patients and urgency disappeared in all 11 patients. of 10 patients with intestinal disturbances, 8 showed a signifi cant improvement (80%). one patient showed a clavien iii complication (seroma and partial dehiscence of the surgical wound managed with conservative surgical treatment). conclusion: snm in post-traumatic brain injury patients is an eff ective and safe option for urinary and defecatory dysfunction when other conservative therapies have failed. to our knowledge the use of inters-tim® in this scenario has not been reported previously. a larger series and a longer follow-up are needed to validate this indication. introduction and objective: th ere were some reports that in the patients who have stress incontinence (sui) with detrusor underactivity, voiding symptoms aggravated aft er mid-urethral sling operation (mus). we report our experiences of mus cases on the patients who have sui with detrusor underactivity. conclusion: urethral sphincter and bladder function worsen immediately aft er rarp and recover over time. th e bladder storage function aft er rarp returns to almost the same level before rarp, the voiding function improves compared with the condition inserted into the rabbit bladder through the urethra and saline solution is infused using a disposable syringe into the bladder through the end cap. conventional cystometry was performed and the intravesical pressure was measured by prototype intravesical pressure sensor at the same time. we also evaluated the biocompatibility of ecofl ex® by checking changes in the levels of macrophages, macrophage migratory inhibitory factor, and infl ammatory cytokines in the bladder tissue and urine. cape town, south africa 35th congress of the société internationale d'urologie -siu 2015 abstract book and urgency incontinence are signifi cantly detected luts in children with vur the 17-gene genomic prostate score assay: initial commercial experience of 4,000 patients 35th congress of the société internationale d'urologie -siu 2015 abstract book 35th congress of the société internationale d'urologie -siu 2015 abstract book pelvic strength physiotherapy percutaneous treatment of bladder stones in children: 10-year experience; is blind access safe? extirpative treatment of upper urinary tract urothelial carcinoma: an 18-year comprehensive review paik l th e overall complication rate was 54%. no hydronephrosis were seen thought the follow-up period. stricture rate was low, only one patient (4%) at one year, and none at 5 years had urethral stricture. 8 patients (33%) required re-stenting due to stent migration (7 patients, 29%), or stricture (1 patient, 4%), all of which happened during the fi rst year of surgery. 7 patients (29%) required alpha-blockers to control bladder neck dyssynergia post operatively. 2 stents (8%) were removed due to exacerbation of autonomic dysrefl exia symptoms (n =1); encrustation and stone formation (n =1). overall, 88% of patients and 80% of physicians felt there was improvement in urination at 1 year. conclusions: th e treatment of detrusor sphincter dyssynergia in spinal cord injured patients with urolome stent is safe and eff ective sacral neuromodulation with interstim® therapy for urinary voiding dysfunctions in post-traumatic brain injury patients: a new therapeutic indication? hospital pablo tobon uribe, medellin, colombia 35th congress of the société internationale d'urologie -siu 2015 abstract book between pre-and post-operative qmax abstract book before rarp; however, the urethral sphincter func male 6 (46.15%) 6 (60%) 0.68** introduction and objective: we evaluated the clinical eff ect of alternative fl utamide therapy for metastatic prostate cancer that relapsed aft er initial maximum androgen blockade (mab), and investigated the relationship between the eff ectiveness of alternative fl utamide therapy and the eff ectiveness of initial mab. and december 2012, 87patients with metastatic prostate cancer that relapsed aft er initial surgical or medical castration along with bicalutamide for mab were treated with fl utamide therapy (375 mg daily). importantly, patients who had discontinued bicalutamide because of adverse events were excluded.results: of the 87 patients treated with alternative fl utamide therapy, prostate-specifi c antigen (psa) levels decreased by >90% (group a) in 18 patients (21%), by 50-90% (group b) in 15 patients (17%), and by 0-50% (group c) in 18 patients (21%), but increased by >0% in 36 patients (41%). th e median duration of response was 22.5, 8.5, and 3.5 months for groups a, b and c, respectively. th e duration of response for 15 patients (17%) was more than 12 months. aft er alternative fl utamide therapy, decreased psa levels of >50% were achieved in 11 of 25 patients (44%) with mab nadir psa levels of <0.2 ng/ ml, in 14 of 37 patients (38%) with mab nadir psa levels of 0.2 to 4 ng/ml, and in 8 of 25 patients (32%) with mab nadir psa levels of >4 ng/ml. during the observation period there were no severe side eff ects.conclusion: approximately 60% of patients with metastatic prostate cancer who relapsed aft er mab with bicalutamide achieved a decrease in their psa level with no severe side eff ects. th e nadir psa level during mab, however, was not a predictor for the eff ectiveness of alternative fl utamide therapy. th us, alternative fl utamide therapy is a reasonable treatment option for metastatic castration resistant prostate cancer. nevertheless, changing to another therapy should be considered in patients who achieve decreases in psa levels of <50% with alternative fl utamide therapy, as the duration of response was relatively short in these patients. association of renal function and androgen deprivation therapy with prostate cancermasuda h, kanesaka m, sugiura m, hou k, araki k, kojima s, naya y introduction and objective: we evaluated the change of renal function by androgen deprivation therapy (adt) and examined the association of the occurrence of renal dysfunction and concomitant diseases. between january 2009 and april 2013, 106 patients who could measure estimated glomerular fi ltration rate (egfr) at pretreatment, 1, 3 and 6 months were evaluated retrospectively. all of them were diagnosed prostate cancer by prostate biopsy pathologically and had taken adt for at least 6 months. we assessed the renal function of 106 prostate cancer patients by using the egfr and investigated the time-independent change rate of the egfr (δegfr) aft er adt. th e δegfr was calculated by (post treatment egfr-pretreatment egfr)/pretreatment egfr ×100). univariate and multivariate logistic analyses were carried out to identify clinical covariates signifi cantly associated with the risk factors for renal dysfunction at 6 months later.results: th e incidence of the renal dysfunction at 6 months was 63% (67/106). th e mean δegfr at 1, 3, 6 months were -0.9%, -3.3% and -2.2%, respectively (p=0.0678). th e incidence of the renal dysfunction at 6 months was signifi cantly associated with the renal dysfunction at 1 month (p<0.0001), at 3 months (p<0.0001), hypertension (p=0.0017) and dyslipidemia (p=0.0288). th e renal dysfunction at pretreatment with adt did not aff ect the renal function 6 months later (p=0.3577). th e renal dysfunction at 1 months (odds ratio [or] 7.05, p=0.0004), renal dysfunction at 3 months ([or] 6.71, p=0.0001), hypertension ([or] 3.49, p=0.0151) and hyperlipidemia ([or] 5.85, p=0.0246) were independent predictors of the renal dysfunction at 6 months in the multivariate analysis.conclusions: it was suggested that the renal dysfunction with adt occurred relatively early. th e earlier renal dysfunction may cause the renal dysfunction at 6 months later. so, when the treatment of adt began, it was thought that an examination of periodical renal function was necessary. th e present results suggested that it was necessary to control the blood pressure and lipid for receiving adt with prostate cancer. immune (pc) and isolated lymph node metastases aft er curative therapy are usually treated with an anti-androgen therapy. th e choline pet-ct is the method of choice in diagnostic of the recurrent psa. controver-sial in the latest debate is the oncological eff ectiveness of the local salvage therapy of isolated lymph node metastases. th e aim of this study is to compare the oncologic outcome of the salvage lymphadenectomy (la) alone versus the la in combination with adjuvant radiotherapy (ar) and androgen deprivation therapy (adt).materials and methods: th erefore we randomized 86 patients with biochemical recurrence of a pc (psa: ≥0,2ng/ml) aft er curative local therapy and detection of at least one lymph node metastasis. we applied two treatment arms. a (n=46): single la; b (n=40): la plus ar/adt (bicalutamide) over 2 years. we determined the biochemical recurrence-free survival (bfs) and the time-to-treat (ttt) until complete androgen blockade. conclusion: compared for both treatment arms, the combination of la plus adt/ar is superior to la alone. however, both methods are to be seen as individual decisions in highly selected patients. th e oncological long-term eff ectiveness is questionable. stem cell transformation of prostatic cells after hormonal therapy we reviewed 16 consecutive patients who underwent transperineal mri-trus fusion target biopsy followed by conventional transrectal systematic 12 core biopsy between july 2014 and mar 2015 in our institution. in all patients, t2 low region was detected by prostate mri image and target biopsy was conducted for region of interest (roi) of the mri image utilizing biojet system. baseline characteristics and pathological outcome were analyzed.results: in analyzed cohort, mean age was 68.4±9.1 years, median initial psa was 7.6 ng/ml (range, 4.2-18.6), median prostate volume (pv) was 33.2 ml (range, 17.5-92.2) , and median volume of roi was 1.11 ml (range 0.16-2.41). of 16 patients, prostate cancer was detected in 9 (56%) patients by target biopsy and 8 (50%) patients by systematic biopsy. patients with positive biopsy was likely to be higher psa than men with negative biopsy (p= 0.039). median roi/pv was not signifi cant between them (2.35 vs. 2.51: positive vs. negative, p=0.491). cancer detection rates per core between target and systematic biopsy were 49.9 and 22.2 %, respectively (p=0.012).regarding pathological results, mean gleason score of target biopsy was 2.8 compared with 2.1 of systematic biopsy, although which is not statistically signifi cant (p=0.158).conclusion: mri-trus fusion target biopsy is gradually spreading in japan, since its higher cancer detection rate compared with conventional systematic biopsy. in our institution, substantial detection ability of prostate cancer by mri-trus fusion target biopsy was confi rmed, which encouraged future clinical trial for prostate focal therapy. multiparametric introduction and objective: sepsis has always been a concern in the traditional transrectal ultrasound (trus) guided biopsy of the prostate. however, rates of sepsis following trus biopsy have shown to be increasing around the world in addition to the emergence of multiresistant organisms found in rec-tal fl ora. as a result, our practice of seven urologists has switched to transperineal (tp) biopsy. we aim to determine the rate of hospital re-admission in our patients undergoing tp biopsy. an ethics approved prospective database of all men undergoing tp biopsy at our practice has been kept including antibiotics used as well as re-admission for infection. introduction and objective: robot-assisted radical prostatectomy (rarp) has become one of standard treatments for localized prostate cancer. however, a feasibility of rarp in elderly patients has not been clear yet. we performed a comparative analysis of peri-surgical / oncological outcomes for younger and elder patients underwent rarp. we reviewed and compared our initial 280 consecutive patients who underwent rarp from 9/2012 to 3/2015 for peri-surgical outcomes, including surgical times, blood loss, complications, pathological fi ndings, continence recovery, and oncological outcomes stratifi ed by age less than 70 and over 70 years.results: in our cohort, 173 men were age less than 70 and 107 men were ≥70. preoperative parameters (age, psa, gleason score) were similar in both younger and elder groups. operative time (mean: 167 vs. 171 minutes) and estimated blood loss were similar in both groups. one of elder patients (0.9%) needed transfusion. peri/post-operative complications in both groups appeared to be minimal with no cases of intra-operative open conversion. one of younger patients needed a surgical settlement for port site herniation. surgical positive margin rates in organ-confi ned (pt2) disease were also similar (7.6%, younger vs. 9.0%, elder). continence at 3 months was 80% in elder patients as opposed to 87% in younger patients. biochemical recurrences in short follow-up period (median 14 vs. 13 months) were observed 5.6% in elder patients as opposed 6.4% in younger patients.conclusions: in our study, although urinary continence recovery in elderly patients might show a short delay, rarp in elderly patients was relatively safe and yielded good oncologic results. rarp is feasible eve in elderly patients. quality in the fi rst study, community-based urologists ordering at least 4 assays from 5/2013 to 1/2014 participated. clinicopathologic data, the gps and treatment were abstracted from medical records of gps patients and a clinically similar baseline group. th e proportion of men recommended and pursuing active surveillance (as) before and aft er the availability of the gps were computed. in the second prospective study, urologists at 3 centers (academic and community) recorded tr on pre-and post-gps questionnaires, including changes in treatment intensity.results: fift een urologists completed the chart review study on 211 men (124 gps; 87 baseline). th e relative increase in tr for as was 22%, (51% baseline, 61% gps; absolute diff erence of 10%). gps pts chose as more than baseline pts (67% gps; 43% baseline, absolute increase of 24%, relative increase of 56%). of men recommended as, 96% of gps and 80% of baseline pts chose it. in 158 men in the prospective study, the relative increase in recommendation for as was 24% and absolute tr increase for as was also 10% (41% to 51%). 18% of tr changed post-gps and tr modality and/or intensity occurred in 26% of men (25 decreased; 14 increased; 2 equivocal).conclusions: both studies, conducted with diff erent methodologies, demonstrate that use of gps provides meaningful change in tr and decisions in men with newly diagnosed pca and results in a net increase in recommendation and/or adoption of as. in the chart review study, tr changes appear to underestimate changes in actual treatment received and more gps patients than baseline patients were assigned to as supporting the clinical utility of gps in the initial assessment and management of men with low risk pca. comparison we prospectively evaluated in patients with clinically localized prostate cancer, the possible association between hce (≥5.0mmol/l) and aggressive prostate cancer. pre-operative serum cholesterol levels (ch), triglycerides (tr), were prospectively assessed in 767 men treated consecutively with radical prostatectomy from feb. 2011 to oct. 2014. th e results were related to patient specifi c and clinico-pathologic data.results: patients with hce (n=287) had a more aggressive grade gleason score (gs) ≥7b, p<0.001)), a locally more advanced stage (≥pt3a, p<0.001), and lymph node metastasis (n+, p<0.001). hce was also associated more frequent with a positive surgical resection margin (r1, p<0.001). in multivariate regression analysis hce is associated with a high-risk pc (hr 13.26, 95% ci 8.23 to 21.37, p < 0.001) -adjusted for psa, dre, age and poor biopsy score (gs ≥8).conclusion: th e results indicate that hca is associated with high-grade and metastatic disease in men diagnosed with clinically localized pc. our fi ndings suggest that ch can be used as an additional predictive marker in therapy. conclusion: th e incidence of bs-positive tumours is low in men being staged for radical treatment except in high-risk disease. pelvic/prostate mpmri alone cannot be relied upon to exclude bone metastases in this group. hyperbaric oxygen therapy for radiation induced side-effects introduction and objective: to evaluate the effi cacy of hyperbaric oxygen (hbo) th erapy for prostate conclusions: in our japanese provincial hospital, the comparatively young patients chose a treatment according to treatment algorithm. however, according to aging, the patients tended to choose hormonal therapy regardless of algorithm. as for one of the reasons, it is thought as follows: even if the patients chose operation or radiotherapy, it may be diffi cult to visit the institutions that have such a treatment because public transport does not develop in our prefecture. nurse-led telephone follow-up for prostate cancer surveillanceturner b, tanabalan c, nargund v, pati j, wells p introduction and objective: we review the patients' experience of a nurse-led, telephone follow-up service for men with 'stable' prostate cancer, to measure satisfaction and quality. th e telephone follow-up service is based on the premise that psa measurement can be used as a surrogate for outpatient attendance. telephone follow-up service serves to reduce the number of patients attending hospital appointments. th is has led to increased clinic capacity and reduced waiting times, ensuring urgent care is available for patients who need it. a nurse-led, protocol based telephone follow-up service was set up for patients deemed to have 'stable' disease. questionnaires were sent to all patients. survey was voluntary and anonymous. we addressed a variety of aspects of the service, including time, duration and content of the telephone appointments, patients' preference for type of follow-up (telephone vs. hospital follow-up) and overall satisfaction with the service.results: response rate of 73%. reported high satisfaction with telephone follow-up (90% were either satisfi ed or very satisfi ed). majority of patients found the length of the conversations to be 'just right' (93%) with a lesser majority expressing that the calls were always at times convenient to them (78%) and that they were always called when they were told they would be called (74%). patients felt that the information given to them over the phone was always easy enough to understand (89%) and the majority felt that they always had the opportunity to ask questions during the conversations (81%). when asked whether they would prefer telephone follow-up or hospital follow-up, 79% of respondents reported that they would prefer telephone follow-up, citing convenience, time and privacy as the reasons for their preference. twenty-one percent of patients would prefer hospital follow-up, reporting ease of understanding, not liking the telephone and preference for face to face contact.conclusions: telephone follow-up relieves pressure on the outpatient department, increases capacity, reduces waiting times and brings care closer to home. patients perceive the service as a valuable addition to their care and report high levels of satisfaction with the service. prostate ' th e target sample sizes of australasian trials 'currently recruiting' ranged from 18 to 5000 men (median=380), the majority of trials investigating medical and radiation oncological interventions. five of the trials 'currently recruiting' were recorded as single-centre studies in new south wales, victoria and queensland. of the remaining 11 trials, 82% (n=9) were recorded as international, industry sponsored, multi-centre studies with australian and/ or new zealand recruitment sites.conclusion: australasian prostate cancer clinical trial activity (though likely under-recognised in this study, due to trial registration limitations) represents a relatively small fraction of international eff ort. continued investment will ensure that the talented and world-leading scientists and medical professionals across both nations can tackle the big challenges in prostate cancer through working collaboratively. assessment modifi ed laparoscopic intravesical nonrefl uxing ureteral reimplantation with psoas hitch using a submucosal tunneling introduction and objective: we aimed to study the safety and effi cacy of the cystoscopy-assisted nonrefl uxing ureteral reimplantation technique using sub-mucosal tunneling during laparoscopic ureteroneocystostomy (unc) with a psoas hitch in patients with distal ureter stricture aft er gynecologic surgery. we reviewed six female patients who underwent gynecological surgeries. all patients showed persistent postoperative distal ureter stricture or obstruction. th ese patients underwent laparoscopic nonrefl uxing unc with a psoas hitch using a submucosal tunneling technique combined with cystoscopy at our institute.results: th ey had corrective surgery at an average of 13.3 weeks aft er ureteral injury. th e short-term success was confi rmed either by voiding cystourethrography (vcu) or by diuretic isotope renal scan (mag-3) conducted 3 months aft er the operation. none of the patients showed evidence of postoperative stricture at the reimplanted site and refl ux on either mag-3 renal scan or vcu. none of the patients showed major or minor complications during follow-up. it is safe and feasible to perform the laparoscopic nonrefl uxing unc with a psoas hitch using a submucosal tunneling technique combined with cystoscopy for ureteral stricture. upper ureteral injuries were more frequent in the urological surgery group than in the non-urological surgery group (50% vs. 9.5%). complications or serious injuries were more frequent in the urological surgery group. th ere were no signifi cant diff erences in the mean durations of hospitalization and indwelling times between the groups. conclusion: th e occurrence of a ureteral injury during urological surgery is an infrequent but serious complication may occur. urologists should pay attention to the potential for ureteral injury, especially during a ureteroscopic ureterolithotomy for the treatment of an upper ureter stone. reducing the risks of trauma due to urethral catheterisation mundy a, yim i, tamini a, roberts n conclusion: isolated ureteric trauma can be managed successfully using minimally invasive endoscopic and radiological approach. a pcn initially helps in minimizing extravasation and ureteral wall edema subsequently facilitating stent placement. medium-and longuniversity of sydney, sydney, australia introduction and objective: urethral stricture is a common urological presentation for obstructive lower urinary tract symptoms. th e treatment of choice for a durable outcome is usually substitution urethroplasty using buccal mucosal graft . graft failure is not uncommonly encountered. we present the mediumand long-term outcomes of ventral buccal mucosal graft urethroplasty using spongio fl ap technique. a retrospective review of a single surgeons experience was reviewed for a period of 17 years. data was collected from medical records, surgeon's notes and operation reports. inclusion criteria included reconstruction of anterior urethral stricture using bm graft positioned ventrally and graft support using spongio fl ap technique. patients who were lost to follow-up were excluded from analysis. graft patency was defi ned as having a lumen greater than 17 fr. th is was assessed via cystoscopic examinations at 3, 9 and 18 months intervals post procedure.results: a total of 296 male patients identifi ed with age ranging from 15 to 79 years and mean age of 46 years. average length of bm graft used was 4.4cm. total of 271(92%) achieved long-term successful outcome. of these 262 (88.5%) patients had successful outcomes with no further interventions, and 9 (3.5%) required gentle urethral dilatation at fi rst cystoscopy and subsequently achieved long-term patency. sixteen (5.5%) of this cohort formed recurrent stricture at initial cystoscopy, and 9 (3.5%) of patients formed urethral stricture formed delayed stricture, despite the initial cystoscopic examination and urethral dilatation.conclusion: ventral buccal mucosal graft urethroplasty using spongio fl ap technique has very good short-term and long-term graft patency outcomes. outcome of paediatric kidney transplantation: single center experience nawaz g, jamil i, athar khawaja m, muhammad s, shohab d, ur rehman a, ali khan i, khan a, hussain i, akhter s introduction and objective: renal transplantation is the treatment of choice for children with end-stage renal disease (esrd) because in addition to making them off dialysis it also improves growth and development of the child. about 15-25% of children have a lower urinary tract dysfunction due to congenital or acquired genitourinary anomaly as the etiology of esrd and they need a diversion or augmentation procedure prior to transplantation. we aim to deter-mine the outcome of paediatric renal transplant at 1 year in term of graft survival and complications. we retrospectively reviewed the record of 35 consecutive children underwent living related renal transplant between jan 2002 to jan 2014. all were primary renal transplants and had living related renal donors. patient characteristics, causes of esrd and pre transplant surgical procedure were recorded. patients with lower tract abnormalities as cause of renal failure underwent reconstructive procedure prior to transplant. induction immunosuppression consisted of triple therapy with antithymocytic globulin (atg), prednisone and mycophenolate mofetil (mmf). cyclosporine was introduced when creatinine came down to >50% of normal. all patients were treated as cmv positive with either acyclovir or ganciclovir and received daily dose of trimethoprim-sulfamethoxazole as prophylaxis for pneumocystis carnii pneumonia aft er transplantation. post transplant surgical and medical complication, graft and patient survival were recorded.conclusion: ureteric implantation into the bowel portion of augmented bladders appears safe in this population of patients with previously reported increased risk of ureteric complications and urinary tract infections aft er transplantation. transition of cavernous function after radical prostatectomy materials and methods: study subjects were 33 ed patients with a history of rp (median age: 67). intervals between rp and examination diff ered among patients (range: 1 to 92 months). we also performed doppler penile ultrasound examination using intracavernous injection of 20 micrograms of prostaglandin e1. we adopted an infusion rate of less than 20 ml/min at 90 mmhg of intracavernous pressure as the normal cavernous function limit for dicc.results: arterial velocity in ultrasonic examinations showed a tendency to decrease. cavernous function aft er rp clearly diff erentiated according to phospho-diesterase 5 inhibitors (pde5is) response ( figure 1 ). in the pde5is responder patient group (7 cases), the rate of normal cavernous function was 0% at 1 month, 4 months, and 6 months, but the rate increased to 50% at 9 months, and 100% at 12 months. a diff erent transition was seen in the pde5is non-responder patient group (26 cases). in this group, the rate of normal cavernous function was also 0% at 1 month. however, from here, the rate increased to 67% at 6 months, and then aft er this point, it decreased to 17% at 12 months. sixteen 12-week-old sprague-dawley rats were induced diabetes by a onetime intraperitoneal injection of streptozocin (50 mg/ kg). one week later, the diabetic rats were randomly divided into 4 groups including a normal control, dm control and two uu treated group (100, and 500 mg/kg/d). th e latter 8 rats were fed uu by intragastric administration for 8 weeks. aft er 8 weeks, penile hemodynamic function was evaluated by measuring the intracavernosal pressure aft er electrostimulating cavernous nerve. we measured nitric oxide (no) and cyclic guanosine monophosphate (cgmp) activity. endothelial nitric oxide synthase (enos) and neuronal nos (nnos) protein expression was determined by western blot. masson's trichrome staining was also assessed.results: serum glucose level in dm +uu group was signifi cant lower than in that of the dm control groups. maximum intracavernosal pressure in dm control rats decreased signifi cantly compared to normal control rats and increased signifi cantly compared to untreated dm rats aft er uu supplementation. dm + uu500 group had signifi cantly increased no and cgmp level compared with the dm control group. decreased activity and expression enos and nnos were found in the dm groups compare with normal control group. decreased enos and nnos in diabetic rats were improved by uu administration. decreased the cavernous smooth muscle to collagen ratio was improved in dm + uu groups in the masson's trichrome staining.conclusions: uu eff ectively ameliorated erectile function in a streptozocin induced diabetic rat model of erectile dysfunction. you d 1 , jung s 1 , jang m 2 , kim b 1 , lee c 1 , song g 1 , choi k 3 , shin h 3 , suh n 4 , kim y 3 , ahn t 1 , kim c 1 the etiology and management of erectile dysfunction (ed) in patients with metabolic syndrome (ms). eighty-six patients suff ering from erectile dysfunction and metabolic syndrome were included in the study, patients were classifi ed based on iief-5 domain into three groups: mild ed (n= 21), moderate ed (n=46) and severe ed (n=19). th ese patients were treated using upgraded regimen protocol (changing of the life style for 3 months, on demand use of pde-5 inhibitors for 4 months, chronic dosing with long acting pde-5 inhibitors for 4 months and combination therapy of pde-5 inhibitors and intracavernosal injection for 4 months) re-evaluation of the patients was done at the end of each stage by (iief-ef, waist circumference and laboratory investigations).results: aft er 3 months of lifestyle modifi cation there was increase in the iief-ef but this change was not signifi cant the overall improvement was (30%), aft er on demand pde-5 inhibitors for 4 months(76.4%) of patients with mild ed were improved, (60%) with moderate ed and (46.1%) with severe ed were improved. non-improved patients in each group aft er on demand pde-5 inhibitors received pde-5 inhibitors chronic dosing for another 4 months then re-evaluated (55.5%) of patients with mild ed were improved, (38.8%) with moderate ed and (28.5%) with severe ed were improved, combination therapy in the form of tadalafi l 10 mg daily and pge1 10μg on demand were off ered to patient whom reported failure of pde-5 inhibitors chronic dosing patients with mild symptoms reported the maximum improvement (50%), patients with moderate symptoms reported fair improvement (18.2%); however patient with severe symptoms reported no improvement at all.conclusion: pde5 inhibitors should be considered as the fi rst line phamaco-therapy in treatment of ed in metabolic syndrome patients. non-responders to pde5 inhibitors may have a benefi t from daily dosing of long acting pde-5 inhibitors. combination therapy of pde-5 inhibitors chronic dosing associated with intracavernosal injection of pge1 may play a role as a salvage therapy aft er failure of monotherapy. following this upgraded regimen case with ms and ed can have overall successful results in 78.7%. comorbidity of premature ejaculation and erectile dysfunction: are they inseparable in chinese adult men?tang y, yang j, jiang x introduction and objective: premature ejaculation (pe) and erectile dysfunction (ed) are usually regarded as a symbol of incompetence. but in china for the inconsistent defi nitions of pe, some of them cannot correctly distinguish pe from ed. th erefore, to fi nd out the real relationship between pe and ed, a detailed investigation was implemented. were enrolled. all the subjects were evaluated by the face-to-face questionnaires of premature ejaculation diagnostic tool (pedt) and the international index of erectile function (iief-5). a professional urologist was invited to measure their lengths of penis and volumes of testes. all the data were analyzed by spss version 13.0 soft ware.results: a total of 1782 men aged from 18 to 70 years (30.99 ± 6.60) were categorized into lifelong pe (lpe) (244 men), acquired premature ejaculation (ape) (440 men), variable pe (vpe) (727 men) and subjective pe (spe) (371 men), respectively. th ere was no signifi cant diff erence among the four pe subtypes except for the ielts and the iief-5. th e self-estimated ielt of spe was signifi cant longer than that of other subtypes, and the similar case could be seen in iief-5. th e highest percentage was found in ape (55.68%) for chronic prostatitis (cp) and in lpe (96.72%) for ed.conclusion: vpe was the most common subtype, next ape, thirdly spe and the least one is lpe. consistent with the previous reports, we found that the incidence of cp in ape was the highest among all the four subtypes of pe, and cp was a signifi cant risk factor of ape but not for other subtypes. th ere has always been controversial about the relationship between pe and ed. th e results from our multinomial logistic regression analysis showed that ed was not only associated with pe, but also could be regarded as a risk factor of pe. introduction and objective: depression oft en overlapped with late-onset hypogonadism (loh) syndrome. clinically, many loh patients who have depressive symptom were treated with testosterone replacement therapy (trt). however, treatment efficacy of trt for these patients is unclear. in this study, we aimed to identify characteristics of loh patients on trt who had medical history of ongoing mental health treatment for depression syndrome. we reviewed 190 consecutive patients who visited men's health clinic and underwent trt in our institution during june 2007 and december 2012. prior to trt, patients received a physical examination and full hormonal evaluation including free testosterone (ft), lutenzing hormone (lh), and follicle-stimulating hormone (fsh). th e aging males' symptoms (ams) score was also evaluated. trt was conducted by 125mg monthly testosterone injection. effi cacy of trt was noted when diff erential of ams score between pre-and post-treatment was more than 10 points. in the entire cohort of 190 patients, the mean age was 56.6 ±10.6 years and pre-trt ams score was 49.5±13.7. pre-trt ft, lh, and fsh were 6.5 ± 2.1 ng/ml, 6.3 ± 5.9miu/ml, and 11.9 ± 14.7miu/ml, respectively. of total 190 patients, 68 cases (35.8%) had diagnosis of depression by psychiatrist and ongoing mental health treatment. patients with positive medical history of mental health treatment were found to be younger (53.8 vs. 58.1 years, p = 0.007), higher pre-trt ams score (56.8 vs. 44.9, p < 0.001), lower lh (5.1 vs. 7.0%, p = 0.022), and lower fsh (9.4 vs. 13.4%, p = 0.006) compared to patients with negative medical history of mental health treatment. effi cacy of trt was greater in men who have mental treatment history (66.7 vs. 38.2%, p = 0.002) based on ams improvements. while, there were no signifi cant diff erence in ft (6.75 vs. 6.40 ng/ml, p = 0.328), trt duration (498 vs. 557 days, p = 0.571), and trt discontinuation rate (80.9 vs. 73.8%, p = 0.269) between two groups.conclusion: even though, loh patients who had diagnosis of depression and underwent medical treatment such as antidepressant, trt can be feasible approach for those patients. majority of those loh patients underwent mental health treatment at the same moment with trt, which may not harm treatment effi cacy of trt. the effect on blood flow rate of prostate in daily administration of mirodenafi l 50mg for benign prostatic hyperplasia patients: randomized paroxetine is the most eff ective ssris. in few studies, tramadol has been used to treat pe. considering the high incidence of pe in men and lack of consensus on its treatment, we decided to compare the therapeutic eff ects of tramadol, paroxetine and placebo in the treatment of primary pe. in this randomized, double-blind, placebo-controlled clinical trial, 150 patients were randomly divided into 3 groups. one group was treated with tramadol 50 mg, the other group took paroxetine 20 mg and the third group was treated with placebo. before starting treatment and aft er 12 weeks, patients were asked to measure their average intravaginal ejaculation latency time (ielt) and fi ll the pep (premature ejaculation profi le) questionnaire. aft er collecting the data, they were recorded in spss version 19 and were analyzed.results: patients in the 3 groups in baseline characteristics, including mean age, ielt and pep were similar at the beginning of the study and there was no clinically signifi cant diff erence in the 3 groups (p>0.05). a total of 126 patients completed the study period. at the end of the 12th week, the mean ielt and average of pep scores increased in all 3 groups. th ese changes in tramadol group were signifi cantly higher than the paroxetine and placebo groups (p<0.0001). th ere were no signifi cant diff erences in terms of side eff ects between the 3 groups. th e results showed that despite an increase in mean ielt and pep scores in all 3 groups, the rate of improvement in tramadol group was considerably more than the other groups. th us, tramadol may be considered as an appropriate alternative therapeutic for long-life pe. the effi cacy and safety of tadalafi l 5mg once daily for the treatment of erectile dysfunction related to the vascular causes after robot-assisted radical prostatectomy: 2-year follow-updong-a university hospital, busan, south korea; 2 jeil hospital, ulsan, south korea introduction and objective: to evaluate the effi cacy and safety of tadalafi l 5 mg once daily use in the treatment of erectile dysfunction (ed) based on the vascular cause aft er robot-assisted radical prostatectomy (rarp). th e study retrospectively evaluated 92 patients who underwent rarp and had a penile rehabilitation by tadalafi l 5mg once daily use at our medical center. th e patients were surveyed based on the abridged fi ve-item version of the international index of erectile function (iief-5) questionnaire, which was self-administered before the surgery, and at 6 months, 1 year and 2 years aft er the surgery. th e 92 patients were classifi ed into the tadalafi l group (n=47) and the non-tadalafi l group (n=45). each group was then classifi ed depending on the nerve-sparing (ns) procedure: bilateral ns and unilateral ns. additionally, patients who underwent a penile color-duplex u/s study to evaluate the cause of erectile dysfunction were also analysed.results: at 6 months, 1 year, and 2 years, the total iief score of the tadalafi l group and that of the non-tadalafi l group were 10.0±3.4 vs. 7.0±4.0, 13.2±5.6 vs. 7.7±4.8, and 13.8±4.7 vs. 8.1±4.2, respectively. statistically signifi cant improvements (p<0.05) were observed in the tadalafi l group for all 5 domains of iief-5 score, while in the non-tadalafi l group there was no signifi cant improvement in any of the domains at 1 and 2 years. fift y three patients had a penile color-duplex u/s study. arteriogenic and venogenic ed was seen in 31 patients (58.5%) and 7 patients (13.2%). fift een patients (28.3%) showed unremarkable fi ndings. venogenic ed patients had little response compared to arteriogeinc ed patients by tadalafi l 5mg once daily use (0% vs. 22.5%). th e overall side eff ects were hot fl ushing in 8.5%, headache in 4.3%, and dizziness in 2.1%. in ed patients aft er ns ralp, a once daily dosage of tadalafi l 5 mg was well tolerated and signifi cantly improved ef compared with the non-tadalafi l group until two years. but in the venogenic ed patients, response to a once daily dosage of tadalafi l 5 mg was relatively limited compared to the arteriogenic ed patients. effects of long-term androgen replacement therapy on the physical and mental statuses of aging males with late-onset hypogonadism (earth): a randomized phase 3 trial in japan introduction and objective: to determine the role of stone density and skin-to-stone distance (ssd) by non-contrast computed tomography of the kidneys, ureters and bladder (ct-kub) in predicting the success of extracorporeal shock wave lithotripsy (eswl). we evaluated 267 patients who received eswl for renal and upper ureteric calculi measuring 5-20mm, over a 50 month period. mean stone density in hounsfi eld units (hu) and mean ssd in millimeters (mm) was determined on pre-treatment ct-kub at the ct workstation. eswl was successful if post-treatment residual stone fragments were ≤ 3 mm.results: e5wl success was observed in 63.5% of the patients. mean stone densities were 513 ± 163 and 795 ± 101 hu in e5wl successful and failure groups, respectively; this was statistically signifi cant (p < 0.001, student's t-test). mean ssd were 11.2 ± 1.8 and 12.4 ± 2.2cm in eswl successful and failure groups, respectively, this was not statistically signifi cant.conclusions: th is study shows that stone density can help in predicting the out-come of eswl. we propose that stone densities <500 hu are highly likely to result in successful eswl. conversely, stone densities >800 hu are less likely to do 50. th is should be accounted for when considering eswl. assessment th is prospective study was conducted upon 20 children with mean age 4.47 ± 2.17 years. patients underwent retrograde intrarenal surgery (rirs) under general anesthesia as monotherapy. th e procedure was initially started by the semi-rigid ureteroscope (storz 7.5 f) and holmium laser and was completed by the fl exible ureterorenoscope (fl ex x2) for other parts of the stone which were not accessible by the semi-rigid ureteroscope. ureteral access sheath was not used and only hydrodilation was performed. patients were evaluated preoperatively by ultrasound and plain x-ray of the abdomen and pelvis. pre-intervention sterilization of urine was performed in all patients using culture guided antibiotics. follow-up lasted for 3 months.results: stone-free rate aft er a single session treatment was 80% and 95% aft er second session. mean operative time was 52.0 ± 16.50 minutes. th e mean fl uoroscopy exposure time was 16.0 ± 6.20 seconds. mean hospital stay was 1.25 ± 0.64 days. all patients had jj stent inserted. no major complications (clavien iii-v) occurred. none of the children received blood transfusion. th ree patients needed a second session of rirs, 1 patient required a pnl session.conclusions: retrograde intra renal surgery using combined semi-rigid and fl exible ureteroscope off ers eff ective and safe option for treatment of medium sized renal stones children with comparable results to shock wave lithotripsy (swl) and percutaneous nephrolithotomy (pnl). introduction and objective: calcium stones are associated with osteoporosis and manifested mainly by elevated fasting urinary calcium/creatinine ratio. th e objective of this study is to demonstrate the presence of abnormal metabolism of calcium and calciuria in women with osteoporotic fracture with no previous-ly known renal lithiasis compared to women without osteoporosis and without renal lithiasis. eighty-seven women were included in the study and divided into two groups: group 1: 55 postmenopausal women with osteoporotic fracture and without renal lithiasis; group 2: 32 postmenopausal women without osteoporosis and without history of renal lithiasis. th e following parameters of phospho-calcium metabolism were analyzed: calciuria 24 h, oxaluria 24 h, uricosuria 24 h and citraturia 24 h. th e presence of hypercalciuria, hyperoxaluria, hyperuricosuria and hypocitraturia was compared between the two groups. statistical signifi cance was determined as p≤0.05. results: th e mean age was 70.1 ± 13.8 years in group 1 and 56.7 ± 6.4 years in group 2 (p = 0.0001). women in group 1 had higher levels of serum alkaline phosphatise (p<0.05) and fasting urinary calcium/ creatinine ratio (p<0.05) than women in group 2. th e percentage of women with hypercalciuria in group 1 (40%) was higher compared to women in group 2 (18.8%) and statistically signifi cant (p = 0.04). th ere were no statistically signifi cant diff erences in the percentage of hyperoxaluria, hyperuricosuria and hypocitraturia between the two groups. th is paper has the limitations of cross sectional study in a unique center and with a low number of patients. dept. of urology, ulster hospital, dundonald, uk introduction and objective: bladder stones are more common found in children from developing countries. open cystolithotomy or transurethral cystolithalopaxy are the traditional treatment but a percutaneous approach has been advocated. we present our experience with percutaneous cystolithotomy in children with bladder stones without any ultrasonic or fl uoroscopic guidance. from april 2001 to october 2011, a total of 147 children (135 boys and 12 girls) with a mean (range) age of 4.07 (1-12.5) years underwent percutaneous cystolithotripsy (pccl). th e mean (range) stone diameter was 2.74 (0.8-5) cm. one hundred thirty-eight children (94%) had a solitary stone while nine (6%) had more than one stone. th e main component of the stones were calcium oxalate in 70 patients (48.6%).results: all children were stone-free aft er one pccl; no recurrent stones developed. th e mean (range) pccl procedure time was 29.6 (12 to 48) min and intraoperative blood loss was scant. perioperative complications were few. th e mean (range) hospital stay was1.2 (1-3) days.conclusions: blind access pccl (without any ultrasonic or fl uoroscopic guidance) is a facile and safe approach for removing stones in the pediatric bladder stones. advantages include the lack of ionizing radiation, no need for opacifi cation by iodine contrast media and low relative cost. we recommend this minimally invasive technique for management of large bladder stones (larger than 1cm) in children. to our knowledge, this is the largest single center series re-ported on percutaneous cystolithotripsy of endemic bladder stones in children. retrograde intrarenal surgery (rirs) in an unusual kidney (21), polycystic kidney (10)]; who underwent rirs for stone management was evaluated. stone size was less than 20mm in all the cases. bleeding being the commonest complication, hemoglobin drop was measured to fi nd out the blood loss. all patients were assessed by x-ray and usg on the fi rst postoperative day and 1 month follow-up. th e other parameter of focus was operative time, hospital stay, stone free rate and the auxiliary procedure. th e auxiliary procedure was divided as (staged, follow-up (1month) or other-pcnl/swl) so that stone free was the main target for the patients. conclusion: urolithiasis occurs in an abnormal kidney, indeed challenging, but rirs can also be performed successfully. proper handling of instrument can increase the longevity of the instrument for cost eff ectiveness. although complete stone clearance cannot be achieved, but meritorious achievement is less morbidity, early recovery, minimal bleeding with less complication. th us, rirs can be performed effi ciently, effi caciously and successfully in an unusual kidney with prior exposure of rirs. value of intraoperative ultrasound in decreasing of the risk of residual radiolucent stone post-pcnl al shareef j, aboelmagd m introduction and objective: hemorrhage is the most concerning complication aft er tubeless percutaneous nephrolithotomy (pcnl). we compressed the access tract of the kidney with oxidized regenerated cellulose (surgicele) aft er pcnl to facilitate homeostasis for tubeless pcnl. since april 2013 to september 2014, 162 pcnl was performed at our hospital. all patients received one stage procedure with metal dilator. aft er the end of stone extraction, the access tract was cauterized and an 8 f foley catheter was inserted to the renal pelvis through the working sheath then infl ated and gently retracted. th e working sheath was withdrawn to the renal capsule and the access tract of the renal parenchyma was packed with surgicele and compressed with small sized dilators through the working sheath for 5 minutes. a bloodless tract usually could be obtained in nearly every patient and all patients underwent tubeless modifi cation. th e results of these patients were analyzed with retrospective chart review.results: th e age of these 162 patients ranged from 26 to 82 (mean 56.1) years old. th e average stone size was 3.7 (0.9-10.5) cm and the average operation time was 80.1 (30-200) minutes. th e target stones had been removed in all patients and the overall stone free rate was 69.1%. th e postoperative blood transfusion rate was 3.1% with no patient underwent angiographic intervention or other management for severe hemorrhage. postoperative fever was noted in 14.2 % patients and sepsis was noted in 1.2% patients. th is study was designed to evaluate the adverse eff ects of swl on the metal devices for spine fi xation and the hemoclips for hemostasis. a total of 7 cases who underwent swl for treatment of upper ureteral and renal stones were investigated. th eir ages were from 56~71years (mean 63.4±5.8838). male patient was one and female patients were 6. th e piezolith 3000 (wolf, germany) was used as the lithotripter. th e metal devices were hemoclips for cholecystectomy in one, and pedicle screw in fi ve patients and bone cement (polymethylmethacrylate) in one patient for spinal fi xation through l1 to s1. th e locations of the stones were the kidneys in 3 and the upper ureter in 4 patients and their sizes were from 0.6cm to 1.2cm (mean, 0.95±0.2572) . th e numbers of the swl were 2.0~17.0 times (median, 2) . th e distances between the stones and metal devices were 3.0~5.5cm (mean, 4.5±0.9962). th ey were followed-up for 0.0~15.0 months (5.4±6.5219). th e complications were investigated in terms of pain, fever, damage of the devices (change of morphology and location in simple x-ray fi lm and their function). no patient showed fever and pain in sites of the devices requiring medication, injection or other management during or aft er swl. one patient was admitted for acute colick fl ank pain with tenderness in costovertebral angle caused by acute ureteral obstruction by a crumbled small piece of the stone. th ere was no complication concerning with the eff ect of the swl on metal devices. even though swl is one of the safe treatment modality in various clinical fi elds, it can't be said that swl is always safe without complication. however, it can be said that it would be safe when it being done following the instruction. a prospective study to identify risk factors of pleural injury during percutaneous nephrolithotomy a total of 332 patients with renal/upper ureteric stones, undergoing pcnl between january 2013 and june 2014 were evaluated for pleural injury. an erect chest x-ray antero-posterior view on inspiration was done within 6-hours of pcnl. th e patients were divided into groups a and b depending on whether they developed or did not develop pleural injury. patient-, stone-, renal-and procedure-related factors were compared between the two groups. patients with any known disease of lungs or pleura, patients undergoing simultaneous bilateral pcnl, relook nephroscopy, concomitant other procedures such as endo-pyelotomy or retrograde ureterorenoscopy were excluded from study. tract dilatation up to 28-f was done using alken metal dilators and an amplatz sheath was placed into system. nephroscopy was done with rigid nephroscope and stones were fragmented with pneumatic lithoclast.results: pleural complications occurred in 10 patients (3%). out of 332 patients, 141 had supra-costal puncture and 6 (4.2%) developed pleural injury; 191 patients had infra-costal puncture and pleural injury occurred in 4 (2% on multivariate analysis, only low bmi and mean age <27-years was associated with higher risk of pleural injury. th e limitation is the small number of patients (as pleural injury is not common a very large number is needed to show signifi cance).conclusions: higher incidence of pleural injury was noted in patients with low bmi and younger age. large multicenter study can provide a true picture. flexible and rigid ureteroscopy in th e success rate was defi ned as radiopacities less than 2 mm on plain fi lm at one month follow-up aft er the fl exible ureteronoscopic procedure. our tips included: tip 1, moving technique, refers to move the lower pole stones to the upper pole or middle pole depending on the convenient site for fragmenting the stones with the escape basket. if the stones were large or the lower pole orifi ce is narrow, we fragmented the stones into two or more pieces, trapped and moved the stones into the convenient pole. tip 2, holding technique, refers to hold the stones in the renal pelvis and insert a laser fi ber through the escape to fragment the stones. tip 3, sheath technique, refers to extract the large stones and pull the stones to the sheath distal side, the stone was too large to pull out, a laser fi ber was inserted though the escape, fragmented the stones. all the videos were recorded.results: overall success rate was 95.1%. th e success rate in the renal pelvis stone, upper pole, middle pole and lower pole was 100%, 97.3%, 93.3%, 93.1% respectively. th e operating time was 113.6 minutes on the average. th ree patients had fever over 38°c aft er the procedures. no urosepsis occurred.conclusion: our tips are feasible in the treatment of kidney stones with fl exible ureteronoscopy. satisfactory success rate, shortening operating time, less fl exible ureteronoscopy consuming and less complication were obtained in the procedures of fl exible ureteronoscopy with escape. ureteroscopic introduction and objective: patients with underlying diseases, especially in old-aged, the urinary tract obstruction with the ureter stone would progress to the severe condition like renal failure or sepsis. prompt urinary diversion like percutaneous nephrostomy or removal of the stone via ureteroscope is necessary for these patients. however, most of them have poor general conditions to endure regional or general an-esthesia. so, we tried to implement the ureteroscopic removal of stone (urs) without anesthesia for the patients with ureter stone who were in septic conditions or severe urinary tract infections (uti). fift een patients (2 males and 13 females) included this study and all of them had serious problems like sepsis, heart problems or lung problems which were diffi cult to endure anesthesia. most of them were inserted pre-operative percutaneous nephrostomy catheter (pcn) due to impending septic shock. all of the stones were impacted in the ureter and urs were successfully performed with painkiller like pethidine 25mg iv. success rate of stone removal, pain perception during operation using a visual analog pain scale were done. results: th e mean age of the patients was 71.8 (±10.84). th e position of the stones was as follows; 6 upper ureter, 1 mid-ureter and 8 lower ureter stones. and there was no patient that had to stop the operation because of intolerable pain. th e mean of vas (visual analogue pain scale) was 3.2(±0.86). overall success rate was 100%. however, 20% of cases were unable to fi nd the impacted calculi but stone debris and blood clots. th e general condition of the patients except one was improved quickly aft er operation and discharged aft er 5.4 (±5.75) days.conclusion: most obstructive uropathy due to calculi was in serious conditions to need immediate procedures and urs were safely and successfully performed under intravenous analgesics. in some of female patients, urs is well-tolerated even without analgesics. prompt urs procedure with intravenous analgesics can recover these conditions with minimal morbidity. geavlete p, georgescu d, multescu r, geavlete b introduction and objective: percutaneous nephrolithotomy (pcnl) is nowadays a widely practiced procedure. despite the good stone-free rates, it still has a specifi c morbidity. our goal was to describe the complications of this method on a signifi cant series of patients. between january 2001 and january 2015, 3248 patients (age between 18 and 82 years) underwent pcnl (3546 procedures). we used 24f rigid nephroscopes and 15f fl exible ones (214 procedures). th e mean follow-up period was 92 months (range 2 to 148 months).results: intraoperative incidents were encountered during 122 procedures (3.4%): losing the percutaneous traject (63 cases), poor visibility due to bleeding and imposing the termination of the procedure (41 cases) and descendant stone fragments' migration imposing antegrade ureteroscopic removal (26 cases). th e overall complications' rate was 18% (638 cases): signifi cant bleeding requiring blood transfusions (83 cases), emobolisation (7 cases) nephrectomy (4 cases) or open surgical hemostasis (3 cases), sepsis (7 cases), fever (121 cases), pyelocaliceal perforations (38 cases), hemoperitoneum (1 case), persistent lumbar uri-nary fi stulae requiring retrograde jj ureteral stenting (371 cases) and extra-renal stone fragments migration (3 cases). however, the majority of these complications were minor. th e mortality rate related to pcnl procedures was 0%.conclusion: according to our experience, pcnl is a safe and eff ective technique. most of the intraoperative incidents or complications are minor and easy to solve. however, an adequate training is imperative in order to reduce the associated morbidity. is spinal anesthesia adequate for percutaneous nephrolithotomy? introduction and objective: to evaluate the adequacy of spinal anesthesia in terms of patient and surgeon satisfaction and convenience during percutaneous nephrolithotomy. patients who were candidates for percutaneous nephrolithotomy and operated by two endourology fellows during july -september 2014 were enrolled. spinal anesthesia was performed using an injection of 0.25 mg/kg bupivacaine 0.5% in the intrathecal space; no opium (fentanyl) agent was used. all procedures were performed with the patient in the prone position. access was achieved by fl uoroscopic guidance, and the tract was dilated using a single-stage technique. anestheisa duration was defi ned from injection of anesthetic medication to fi xation of nephrostomy tube. operation duration was defi ned from start of cystoscopy to fi xation of nephrostomy tube. patient pain and satisfaction during operation and surgeon satisfaction was measured by an ordinal likert-type scale and collected by an examiner blinded to the study objectives.results: a total of 50 patients (mean±sd age, 48.1±12.2 years; 29 male) were enrolled during the study period. th e mean±sd of anesthesia and operation duration were 83.4±21.5 and 52.7±23.0 minutes respectively. severe pain causing signifi cant discomfort to the patient and surgeon was observed in 6 patients (12%). in three patients the operation was prematurely terminated because of excessive pain and/ or agitation of the patient. mild-moderate pain was observed in eight patients (16%). vomiting and headache was observed in another two patients. the african 300: our experience of stenting ureters in outpatients without screening or ga introduction and objective: to review 301 ureteric catheters/dj stents placed under local anaesthetic, with antibiotic coverage, without the use of screening, at groote schuur hospital (gsh) over the last 8 years. a prospectively collected database exists from july 2007 until present. all patients signed informed consent and received pre-procedural oral antibiotics. a post-procedural abdominal kub radiograph was obtained to ensure correct placement. demographic data and variables (stent/catheter, indication, side, success/failure -including reasons for failure) were collected. patients were asked to subjectively rate the level of pain at the end of the procedure.th e data has been collected and tabulated into an ex-cel® worksheet.results: a total of 301 procedures (average 37.6 per year) were performed with age range from 14 to 94 years (average: 47.8 years). th e average time taken was 15 minutes (median: 10 minutes). th e shortest procedure recorded was 3 minutes, and longest was 60 minutes (with a failure). th e failure rate totals 14.3% and further inspection shows that 9.3% of failures were with bilateral stents, 46.5% right sided and 41.9% left sided. stated diff erently, 19% (4/21) of bilateral stents failed, 16.1% (20/124) of right sided stents failed, and 12.2% (18/148) left sided stents failed. th ere was a success rate of 85.7% with stenting under local anaesthetic. th e average subjective pain score was 3.9, which is tolerable. sivalingam et al (2013, urology 81: 498-502) showed the average cost for stenting under general anaesthetic was almost 4 times more expensive than under local. th eir local group had a failure rate of 8.7%, which was lower than our 14.3%, but we had a larger group (300 in 8 years vs. 46 in 4 years).conclusion: flexible cystoscopy and stenting under local anaesthetic without screening is useful and feasible, with minimal morbidity, discomfort and failures. it can be practiced as a cost eff ective, offi ce-based procedure and is suitable for the third world environment. introduction and objective: urolithiasis is an ancient disease with global distribution and is an important health problem all over the world. th ere are diff erent results for stone clearance rate in diff erent renal and ureteric locations aft er eswl. here we share our experience of the comparison of stone free rates and complications in diff erent renal locations. a retrospective study in which we included adults (age above 18 years old) who underwent eswl from january 2013 to december 2014. eswl was done by standard technique. we used modulith sl x lithotripter 4th generation storz medical. we followed patients for 3 to 6 months aft er last eswl session done. stone free status was defi ned as residual stone not more than 4 mm in size. we reviewed data charts of patients for diff erent variables mentioned in results. introduction and objective: tubeless percutaneous nephrolithotomy (pcnl) for staghorn calculi has been reported to be safe and eff ective in select patients. although outpatient pcnl has been recently been shown to be safe and eff ective in a series of 50 patients, it requires further study before urologists embrace same day discharge following pcnl. th e objective of this study is to report our early experience in treating staghorn calculi with pcnl on a completely outpatient basis, assessing its safety and effi cacy. a review of all outpatient tubeless pcnl cases between march 2007 and may 2014 at two canadian centres was performed, including collection of preoperative, intraoperative and postoperative data. strict preoperative, intraoperative and postoperative criteria were used in the selection of candidates for outpatient pcnl: no intraoperative complications including signifi cant bleeding or collecting system perforation; postoperative hemodynamic stability; adequate pain control; reliable patient with supportive family.results: fift y patients underwent ambulatory pcnl during the study period. staghorn calculi were treated in 9 patients including 2 cases of bilateral staghorn calculi, resulting in a total of 11 staghorn renal units treated by ambulatory pcnl. all 9 patients were discharged home uneventfully 2-6 hours postoperatively. th ere were no major postoperative complications, emergency room visits, hospital readmissions or deaths. th e stone-free rate was 64%, with 7 of the 11 renal units being stone-free at follow-up.conclusion: th is small series represents the largest series of ambulatory pcnl for staghorn calculi to date. in very carefully selected patients, pcnl for staghorn calculi on a completely outpatient basis appears safe and may be feasible. further research on ambulatory pcnl for staghorn calculi is required prior to widespread adoption by urologists. introduction and objective: th e most diffi cult aspect of percutaneous nephrolithotomy (pcnl) is frequently the renal puncture. most are performed under fl uoroscopic control. parallax, the assessment of the displacement of an object when viewed along two lines of sight, is the concept which allows the surgeon to gauge the 3d relationship of the needle to the kidney from a 2d fl uoroscopic image. whilst most urologists appreciate successful access correlates with both kidney and stone images moving in unison on rotation of the c arm (or "reverse parallax"), confusion oft en arises with unsuccessful attempts in relating how to amend the puncture with the radiological fi ndings. we create a model to describe visual observation of parallax. by way of a short video we outline how it can be implemented seamlessly into routine pcnl.results: visualization of the theory followed by its application in theatre clearly demonstrates a failsafe technique to allow operators to reliably detect when their puncture needle is deep or superfi cial to the stone.conclusions: parallax, as an adjunct to routine fl uoroscopy during pcnl, allows the operating urologist to rapidly gauge depth of needle in relation to the collecting system in diffi cult access scenarios. familiarity with this technique is important to minimize radiation exposure, ensure satisfactory access to the collecting system and improve operating times. the signifi cance of non-enhanced compute tomography for renal colic has been overestimated in absence of pyuria kim t 1 , ahn s 2 , kang j 3 , kim j 1 , myung s 1 , moon y 1 , kim k 1 , chang i 1 1 introduction and objective: th e study was undertaken to compare clinical utility in patients undergoing non-enhanced computed tomography (nect) and intravenous urography (ivu) in patient with classic symptoms of renal colic without evidence of urine infection and to determine the clinical importance. th is was a retrospective observational analysis of all adult patients between 2005 and 2013. all nect and ivu were reviewed and categorized as the cause of symptoms. non-urolithiasis cause were further categorized as "acutely important", "follow-up recommended", and "other unimportant cause". full record review blinding to imaging fi nding was underwent including demographics, diagnosis, and management. we compared stone characteristics on imaging study, and demographic, exact diagnosis, and management methods between nect and ivu groups.results: a total of 2,218 patients were available inclusion criteria and 1525 (68.8%) patients were underwent ivu and 693 patients were nect. th e incidence of nect was 1.25% at 2005, but 94.9% at 2013. nect group was older (45.5±15.0 vs. 42.4±13.7 years old, p<0.01), less hematuria in urine analysis (87.2 vs. 90.2%, p<0.05) and more admit (18.6 vs. 12.0%, p<0.01) than ivu group. urinary stones were detected 1413 (63.7%) patients. nect group showed higher proportion of renal stone, mid ureteral stone and multiple stones (20.9 vs. 13.8%, p<0.001, 5.5 vs. 2.7%, p<0.01, 14.6 vs. 6.5%, p<0.001, respectively), and smaller stone (3.62±3.23 vs. 4.15±2.36 mm, p<0.001), and more radiolucent stone (25.7 vs. 13.2%, p<0.001) comparing to ivu group. th e incidence of urolithiasis more than 4mm were no diff erence between nect and ivu groups (20.5 vs. 20.0%, p=0.79 on radiologic fi nding, and 20.2 vs. 20.5%, p=0.87 on full chart record). moreover, the incidence of "acutely important" among non-urolithiasis cause was similar between nect and ivu groups on full record review (1.3 vs. 0.9%, p=0.14) . th e incidence of the active management including surgery and extracorporal shock wave therapy (eswl) were not diff erence between nect and ivu group (35.4 vs. 39.9%, p=0.67).conclusions: nect is a rapid and accurate diagnosis test for suspected renal colic, and nowadays almost renal colic patients in our hospital underwent nect in ed. however, it did not show better advantage for the detection of clinically signifi cant urolithiasis and acutely signifi cant cause of renal colic in patient with renal colic and absence of pyuria. from january 2007 to july 2014 we reviewed the scrotal ultrasound images of all patients diagnosed with leydig cell tumor and treated with conservative surgery (group a). we considered only patients that were fi rst diagnosed at one of the participating centers. we create a random homogenous control group of patients (group b), in term of age and presentation, diff erent from the group a just for the defi nitive malignant histology. all the images were collected and we analyzed ultrasound features of the lesions classifi ed in terms of length, us lesion homogeneity, shape, presence of hypervascularization. th e collected data were analysed by an online regression (student's t-test, chi-square test, and logistic regression analysis).results: th irty fi ve patients with leydig cell tumor underwent conservative surgery at our centers. a random group b of 35 patients was also considered. pa-tient mean age was 35.11 years (range 28 to 45) for the fi rst group and 33.89 years for the second one (range 22 to 41). patients presented either with a palpable testicular nodule (12 patients group a, 34.28% -29 patients 82.86% group b) or a nodule diagnosed by ultrasound (23 patients group a, 65.72% -6 patients 17.14% group b). mean ultrasound size was 0.96 cm and 1.57 cm for the two groups respectively (range 0.25 to 1.8 cm and 0.8 to 3 cm). both groups had hypervascularization of the lesions with no signifi cant diff erences. patients presenting with lct (group a) had an homogenous ultrasound intralesional aspect and the shape is defi ned with an elliptic or spheroid mold while patients from group b had dis-homogenous intralesional aspect and non-defi ned margins (p>0.05).conclusion: although most focal lesions will be malignant and require an orchiectomy, recognition of the benign entity may be challenging. in a small lesion mainly not palpable the presence of a well-defi ned shape with an homogenous intralesional ultrasound aspect do correlate with a lct. adult testicular pure yolk-sac tumor the association of torsion with testicular cancer: a retrospective study introduction and objective: testicular torsion is a medical emergency that usually requires surgical exploration of scrotum to allow reperfusion of the aff ected testis. nonetheless, such surgeries can be frequently resulted in orchiectomy due to tissue ischemia and necrosis. however, testicular malignancy has been anecdotally reported with the association of torsion in the surgical specimens and the literature remains scant on the association of torsion with testicular tumors. th is retrospective study was set to explore the association of torsion with testicular cancer in cases of testicular torsion undergoing orchiectomy during scrotal exploration. a chart review was performed for patients who admitted to our clinic and had a diagnosis of testicular torsion between january 2003 and february 2015. data of patients' characteristics, the laterality of the torsion, time and type of intervention and pathological examination were recorded. results: overall, 32 patients with a diagnosis of testicular torsion were identifi ed. th e mean age was 21.1 years (ranges from 7 to 39 years). all the patients had unilateral intravaginal testicular torsion aff ecting the left side in 17 cases (53.1%) and on the right side in 15 cases (46.8%). manual detorsion was successful in 6 patients (18.7%) all of whom underwent bilateral testicular fi xation surgery within 24 hours via scrotal incision. twenty-six (81.2%) patients underwent emergency surgery with a testicular detorsion and fi xation surgery in 6 (18.7%) cases (bilaterally in 5 and right-sided in 1) and orchiectomy in 20 (62.5%) cases (8 in right side and 12 in left side). th e type of incision was scrotal in 6 cases, inguinal in 10 cases and unspecifi ed in 4 surgeries. pathological examination of specimens revealed ischemia and necrosis in 18 cases, while 2 patients underwent testicular removal via inguinal incision had malignancy including seminoma and malign mixed germ cell tumor.conclusion: our retrospective study, as the largest case series in the current literature, showed the association of intravaginal torsion with testicular cancer to be 6.4%. further high-level evidences are needed to establish the optimal incision type in testicular torsion cases with surgical exploration to avoid scrotal violation resulted from suboptimal approaches. wong l 1,2 , dickson b 2 , catton c 2 , yap s 2,3 , alkasab t 2 , van der kwast t 2 , hamilton r 2 , jewett m 2 1 st vincent 's hospital, melbourne, australia; 2 princess margaret hospital, toronto, canada; 3 university of california davis, davis, usa introduction and objective: paratesticular sarcoma (pts) is an uncommon disease and the literature is mostly confi ned to small case series with short follow-up. herein we present an update on our institution's experience in the management of patients with pts. fift y-one men with pts at princess margaret cancer center, between 1990 and 2012 were identifi ed from retrospective chart review. important relevant clinical pathological variables were collected with study endpoints being local recurrence, metastasis and overall survival. univariate analysis of variables associated with survival end points was performed with cox proportional hazards regression.results: median follow-up of our cohort was 11.0 years (iqr 4.3-18.2) with a median overall survival of 13.9 years. at presentation 92.2% (n=47) of men had localized disease. interval completion hemiscrotectomy (performed aft er initial unplanned diagnostic surgery) was done in 25 men, in which 25% (n=5) had residual disease present. local recurrence (lr) occurred in 12 patients (23.5%). median time from diagnosis to lr was 15months. univariate analysis showed presence of positive margins at diagnostic surgery (hr 4.81, p=0 .047) and upfront/ completion hemiscrotectomy (hr 0.21, p=0 .02) to be signifi cant variables. at last follow-up, 7/12 men (58.3%) with lr were alive and disease free, 4 developed metastatic disease with 3 pts-related mortalities, and 1 deceased of other cancer type. metastasis was present in 13 men (25.5%), with median time to metastasis 18mo, and median to from metastasis to death 11.4mo. at last follow-up, 21.6% (n=11) of the patients were deceased with 7 cases attributable to pts. on univariate analysis, there were no significant variables for metastatic disease, and age (hr 1.04, ci 1.00-1.08, p=0.02) and non-localized disease at presentation (hr 5.17, p=0 .02) were signifi cant for overall survival.conclusion: in our cohort of pts patients with median 11 years follow-up, aggressive treatment of local recurrence (23.5%) resulted in good disease free survival for 7 of 12 men. completion hemiscrotectomy, particularly for positive margin disease, may decrease local recurrence. a rare case of testicular metastasis from primary lung adenocarcinoma: case report and ten-year review of testicular pathology at a single institution demkiw s 1 , jackett l 2 , goad j 1 , wong l 1 introduction and objective: health care websites provide a valuable resource of health information to online consumers, especially patients. offi cial surgical and medical society websites should be a reliable fi rst point of contact. th e primary aim of this study was to quantitatively assess medical and surgical society websites for content and highlight the essential features required for a high-quality, user-friendly society website. twenty specialty association websites from each of the regions, australia, uk, canada, europe, and the usa were selected for a total of 100 websites. medical and surgical specialities were consistent across each region. each website was systematically and critically analysed for content and usability.results: th e average points scored per website was 3.2 out of 10. of the total (n=100) websites, 12 scored at least 7 out of 10 points and 2 scored 9 out of 10. as well, 35% (35.0/100) of the websites had an infor-mation tab for patients on their respective homepages while 38% (38.0/100) had download access to patient information. a minority of the websites included different forms of multimedia such as pictures and diagrams (24.0/100, 24%) and videos (18.0/100, 18%). we found that most society websites did not meet an adequate standard for delivery of information. half of the websites were not patient accessible, with the primary focus being for health professionals. as well, most required logins for information access. specialty health care societies should create patient-friendly websites that would be benefi cial to all online consumers. application materials and methods: students were selected by sampling in pbl group (n =56) and pbl-ebm group (n =51), and the two groups received clinical teaching of urology by pbl and pbl-ebm model respectively. at the end of the study, each student received objective and subjective evaluation.results: th ere was no signifi cant diff erence in results of the baseline on evidence-based medicine between two groups (p>0.05), but the percentage of high-recommended-level research evidence obtained by the students in the pbl-ebm group was signifi cantly higher than that in pbl group (p<0.05). and questionnaire showed more students in pbl-ebm group believed that this teaching model improved their ability of comprehensive analysis and application of medical evidence, and developed their skills in solving problem and obtaining information on various subjects (p<0.05).conclusions: th e model of problem-based learning combined with evidence-based medicine is feasible and eff ective in clinical teaching of urology and optimize the outcomes from pbl education. by the pbl-ebm model teaching, students improve the ability to advantage in managing evidence from medical studies, analyzing and solving problem, obtaining and applying medical information. incidence (dvt) or pulmonary embolism (pe), is recognized as one of the most serious complications of surgery. in urologic surgery, this has not been well reported thus the objective of this study is to access the risk factors for the development of vte among patients undergoing major pelvic surgery for prostate and bladder cancer in an australian tertiary referral center. consecutive patients undergoing major pelvic uro-oncologic surgery, namely radical cystectomy and radical prostatectomy over a fi ve-year period (2009-2013) were identifi ed. patient variables, types of surgery, types of thromboprophylaxis (pharmacological and/or mechanical) used in this patient cohort were collected for analyses as predictive factors.results: an overall incidence of vte was 1.8%. patients undergoing radical cystectomy were more likely to suff er a vte event compared to patients having radical prostatectomy. in this cohort, the risk factors for vte include, prolonged operative time of greater than 4 hours, lymph node dissection (lnd) and patients requiring blood transfusions.conclusion: patient undergoing major pelvic uro-oncologic surgery have a 2% risk of developing vte. risk factors identifi ed in this study should be used to guide the use of early and prolonged thromboprophylaxis. optimal trial of void after idc insertion for pelvic surgery th am c 1 , ho p 2 introduction and objective: in 2012, we pioneered the fi rst international twitter-based journal club (#urojc) to discuss urology articles on a monthly basis with diverse global participation. since that time, this model of an international twitter-based journal club has been adopted by several other medical specialties including general surgery, respiratory medicine and nephrology. th e objective of this study is to examine the development of the urology journal club into an innovative and thriving forum for exchange of ideas, information and opinions since its conception two years ago. monthly twitter analyses such as number of users, tweets and impressions for the journal club were obtained via a third-party service called symplur using the hashtag #urojc. qualitative analysis was also performed of each individual tweet to assess for relevance to the discussion. comparisons were made between data from the fi rst and second year of operation of the journal club, including the number and geographic location of participants, as well as the quantity and quality of tweets.results: see table 1 for summary statistics. th e total number of unique users of #urojc almost doubled from year one to year two. th e mean number of total participants increased by seven per month, and mean number of total countries represented increased by three per month. while the number of tweets per month also increased from year one to year two, the proportion of content-relevant tweets remained stably high at approximately 60%. meanwhile, there was a greater degree of participation from authors of the study being discussed over time. journal club continues to draw robust participation from a global audience, and serves as a benchmark for twitter-based journal clubs in other specialties. th e majority of tweets are relevant to the content of the article, providing a novel forum to discuss new research fi ndings with a global audience. prognostic impact of perinephric fat stranding on computed tomography in ureteral urothelial carcinoma introduction and objective: ureteral urothelial carcinoma causes gradual ureteral obstruction. perinephric fat stranding is defi ned as linear areas of soft tissue attenuation in the perinephric space, which can result from any acute process or injury to the kidney. we analyzed the prognostic impact of perinephric fat standing as well as secondary signs of upper urinary obstruction on the oncologic outcomes of patients with ureteral urothleial carcinoma. a total of 86 patients who were evaluated by abdominal-pelvic computed tomography (ct) preoperatively and were diagnosed with ureteral urothelial carcinoma aft er nephroureterectomy conducted between january 2001 and december 2010 were enrolled in this retrospective study. we analyzed the association between oncologic outcomes and clinical-pathologic fi ndings, including secondary signs of upper urinary obstruction on preoperative ct such as hydronephrosis grade, perinephric fat stranding, renal enlargement, kidney density diff erence, renal cortical thinning, periureteral fat stranding.results: preoperatively 46 patients (53.5%) had perinephric fat stranding on preoperative ct. multivariate analysis showed that perinephric fat stranding, higher pt stage (≥ t3), lymph node involvement of cancer, and positive surgical margin were independent prognostic factors of cancer-specifi c survival (p = 0.030, p = 0.007, p < 0.001 and p = 0.029, respec-tively). and perinephric fat stranding, higher pt stage (≥ t3), lymphovascular invasion, and lymph node involvement of cancer were identifi ed as independent prognostic factors of recurrence-free survival in ureteral urothelial carcinoma (p = 0.018, p = 0.021, p = 0.010 and p = 0.001, respectively).conclusion: perinephric fat stranding on preoperative ct in ureteral urothelial carcinoma was found to be an independent prognostic factor of disease recurrence and cancer-specifi c mortality. our fi ndings indicate that immediate radical surgery and adjuvant therapy should be considered in patients with perinephric fat stranding preoperatively. lower increased urinary tract malignancy in end-stage renal disease (esrd) has been reported. however, little is known in chronic kidney disease (ckd). th is study is designed to explore the association between ckd and upper urinary tract urothelial carcinoma (uut-uc). health insurance database, we included ckd patients between january 2000 and december 2011. th e non-ckd controls were selected with the ratio 4:1 and frequency matched with gender, age group and index date. chi-square test and t-test were used to inspect sociodemographic information and comorbidities. logistic regression analysis was used to calculate hazard ratio (hr) and 95% confi dence interval (ci). a 74 year-old man with a strong family history of various cancers presented with haematuria and was subsequently found to have a mass in the right pelviureteric junction suggestive of urothelial carcinoma. work-up confi rmed the diagnosis without evidence of metastatic disease and the patient went on to have an open transperitoneal nephroureterectomy. laparoscopic approach was initially attempted but abandoned due to dense adhesions thought secondary to previous open bowel resection for colorectal cancer. a fl ank incision was used; there were no specifi c operative complications and the specimen was easily retrieved without manipulation or rupture. post-operative recovery was unremarkable and histological analysis of the tumour revealed a non-invasive high-grade papillary urothelial carcinoma at the right pelviureteric junction with clear resection margins. approximately 9 months post-operatively the patient re-presented with a rapidly enlarging mass at the fl ank incision. imaging demonstrated a circumscribed hypodense mass within the muscle layers at the site of the scar and biopsy revealed poorly diff erentiated carcinoma. surgery to excise the mass was subsequently performed and immunohistochemical analysis revealed a lack of staining for msh6.results: abdominal wall metastasis following open nephroureterectomy for upper tract urothelial carcinoma is rare, with only one case reported previously. given patient's previous history of colorectal cancer, strong family history and immunohistochemical fi ndings are highly suggestive of lynch syndrome. incisional site tumour recurrence following surgery for urological malignancy is a very rare complication, with only a handful of case reports existing, mostly relating to port-site metastasis following laparoscopic surgery. wound recurrence following open surgery is an extremely uncommon but recognised event, more frequent in certain gynaecological and general surgical malignancies. ls involves inherited defects in the dna mismatch repair system, resulting in predisposition to a number of malignancies. urologists should consider the possibility of lynch syndrome in any patient with de-novo upper tract urothelial carcinoma, and strongly recommend genetic testing where patients meet the amsterdam ii criteria or are diagnosed under the age of 60. prognostic ) developed recurrent bladder cancer within 2 years aft er nephroureterectomy, and the median interval between surgery and intravesical recurrence was 15.5 months (range 6 to 48 months). multifocal tumors, native aristolochic acid nephropathy and distal ureter invasion were determined as risk factors for intravesical recurrence by univariate analysis. however, by multivariate analyses, multifocality (hazard ratio = 2.603, 95% ci = 1.529 -8.906, p = 0.019) and native aristolochic acid nephropathy (hazard ratio = 2.179, 95% ci = 1.085 -8.093, p = 0.038) were identifi ed as independent predictors for the development of recurrent bladder cancer aft er surgery for uut-uc in renal transplant recipients.conclusions: th e incidence of intravesical recurrence aft er laparoscopic nephroureterectomy for uut-uc in renal transplant recipients is high, and most subsequent bladder cancers recur within 2 years aft er surgery. tumor multifocality and native aristolochic acid nephropathy are signifi cant independent risk factors in developing initial intravesical recurrence aft er laparoscopic surgery for primary upper urinary tract urothelial carcinoma aft er renal transplantation.introduction and objective: transient urinary incontinence may occur in up to 44% of patients aft er holmium laser enucleation of the prostate (holep). however, there are few published data concerning the factors associated with de novo urinary incontinence (ui). th e aim of this study was to investigate the associated factors of de novo ui aft er holep. our study included 141 patients who underwent holep. enrolled patients were divided into two groups according to the presence of ui. independent t test was used to compare between two groups. logistic regression was performed to analyze a correlation between de novo ui and other factors such as age, prostate volume, retrieved tissue weight, operative time, and the fi rst post-void residual (pvr) urine volume immediately aft er removing postoperative urethral catheter. urethral catheter was removed aft er bladder instillation with a 200 ml normal saline via urethral catheter, and pvr urine volume was estimated immediately aft er the fi rst postoperative self-voiding. all defi nitions of ui corresponded to recommendations of the international continence society.results: aft er holep, 44 patients (31.2%) had de novo ui, most of which resolved within 1-6 months; 34 had stress ui, 6 had urgency ui, and 4 had mixed ui. age and pvr urine volume were signifi cantly higher in ui group than non-ui group (75.09 ± 6.82 vs. 72.01 ± 8.04 years; p = 0.029, 81.88 ± 67.13 vs. 30.15 ± 23.56 ml, p < 0.001). in a logistic linear regression analysis, only pvr urine volume was an independent predictor of de novo ui aft er holep. th e most optimal cut-off value of pvr urine volume for predicting de novo ui was defi ned as 39.5 ml in the receiver operating characteristics curve analysis (sensitivity, 75.0%; specifi city, 74.2%; auc, 0.815; p < 0.001).conclusion: about one-third of patients might undergo de novo ui following holep, and most of them might have been resolved within 1-6 months. high pvr urine volume aft er removal of postoperative urethral catheter is associated with de novo ui aft er holep, and could be used a practical tool to predict postoperative de novo ui. concomitant transurethral and introduction and objective: stress urinary incontinence is a common medical problem among women. th e urethral closure complex and/or the support mechanisms are responsible for incontinence in the majority of patients. several surgical procedures with diff erent degrees of invasiveness and outcomes have been reported to treat the problem. although many are reasonably eff ective, a general trend towards study of natural and biocompatible tissues is emerging over popular synthetic materials. here we report our experience with injection of autologous adipose-derived stem cells to the periurethral region as a new method of stress urinary incontinence treatment. ten women with symptoms of stress urinary incontinence were treated by injections of autologous adipose-derived stem cells into the periurethral region via transurethral and transvaginal approach under urethroscopic observation. th is report presents the short-term outcome of the patients. th e outcome measured by pad test results, iciq-sf scores and qmax.results: th e mean age of the participants was 45.8 ± 8.7 years. urinary incontinence signifi cantly decreased through the fi rst two, 6 and 24 weeks aft er the injection therapy. th e diff erence was signifi cant in pad test results (p<0.001) and iciq-sf scores (p<0.001), especially comparing results between 2 and 6 weeks and among 6 and 24 weeks, but not for 2 and 6 weeks compared to each other. surprisingly, qmax showed improvement aft er the study period (means 32.6 vs. 35.7; p=0.002). th is study showed that injection of the autologous adipose-derived stem cells to periurethral region is a safe, yet shot-term eff ective treatment option for stress urinary incontinence. further studies with longer follow-up are needed to confi rm its longterm effi cacy. sparc sling system for treatment of female stress and mixed urinary incontinence in the elderly sung l, noh c, chung j, yoo j introduction and objective: th e aim of this study was to investigate the safety and effi cacy of the suprapubic arch (sparc) sling procedure for the management of urinary incontinence in elderly versus younger women. a total of 299 women underwent the sparc procedure for female urinary incontinence. of these patients, 258 were classifi ed younger women (sui, 214. mui, 44) and 41 (sui, 32. mui, 9) were elderly (more than 65 year). th e preoperative evaluations included a complete medical history, a female bladder questionnaires, urogynecological examination and urodynamic test with valsalva leak point pressure (vlpp). th e main outcome measures were perioperative morbidity, postoperative sui, persistent or de novo urge incontinence, postoperative complication and voiding dysfunction. th e objective and subjective success rate were evaluated by visual analogue score and global patient impression questionnaire at 1, 3, 6 months. th e mean follow-up period was 36±14 mo (range, 12-90 mo).results: th e incidence of sparc related morbidity was similar in both groups. for the operation outcome results, in younger group (258 patients) there were 232 cases of cure (89.9%), 20 cases of improvement (7.8%), and 6 cases of fail (2.3%) and in elderly group (41 patients) there were 36 cases of cure (87.8%), 4 cases of improvement (9.8%), a case of fail (2.4%) (p>0.05). th e operation satisfaction rate of patients was 93.7% in the younger group and 90.2% in the elderly group (p>0.05). a total of 279 patients (93.3%) would like to recommend the sparc procedure to others. th e objective success rate and operation satisfaction rate of the younger group did not diff er from elderly group. no severe intraoperative or postoperative complications occurred in both groups.conclusions: th e sparc procedure is eff ective and off ers a satisfactory cure rate without signifi cant morbidity in elderly women. validity introduction and objective: urinary incontinence secondary to surgery or trauma is a debilitating condition for the patient, and for the urologist a diffi cult situation to manage. because of the complexity of reconstructive surgical techniques and the cost of the prosthetic devices used, there is a need for a simple procedure. aims: we here in report our experience in managing urinary incontinence secondary to sphincteric incompetence in 7 patients using a modifi ed bulbar urethral sling procedure over a period of 5 years. results: all patients were continent postoperatively, with only mild stress leakage in the erect posture in two patients, during a mean follow-up of 30.5 months (range 3-58 months) and required one or some time two pads per day to remain continent during the daytime. one patient required clean intermittent catheterization for a short period postoperatively. conclusions: th e male bulbourethral sling procedure using a polypropilene mesh is economical and safe but further experience is needed to establish this procedure as an alternative for the treatment of male urinary incontinence. investigation of a teikyo university, tokyo, japan; 2 juntendou university, tokyo, japan introduction and objective: th is study compares the safety and benefi ts of administering anticholinergic agent propiverine hydrochloride in combination with adrenergic alpha-1 receptor antagonist silodosin (sp group) as therapy for patients diagnosed with benign prostatic hyperplasia with overactive bladder, as opposed to administering silodosin alone (s group). th is study included 41 male patients aged 50 or above who had an international prostate symptom score (i-pss) of 8 or more, an overactive bladder, a qol index of 2 or greater, an overactive bladder syndrome score (oabss) of 3 or more along with an oabss urgency score of 2 or greater, and a maximum urinary fl ow rate of <15ml/s. at random, 19 patients were assigned to the sp group, and 22 to the s group. th e sp group was administered 8 mg/day of silodosin along with 20mg/day of propiverine hydrochloride and the s group 8mg/day of silodosin only, for 12 weeks respectively. i-pss, qol index, oabss urofl owmetry results, and residual urine were evaluated prior to therapy and 4, 8, and 12 weeks post-therapy.results: th ere were no statistically signifi cant diff erences in patient background between the two groups. statistically signifi cant improvements were seen in i-pss total score, qol index, and oabss 4 weeks post-therapy, but there were no statistically signifi cant diff erences between the two groups. both groups refl ected statistically signifi cant improvements in i-pss storage symptom scores and voiding symptom scores, but there were no diff erences between the two groups. analyzing by prostate volume, among those with lower prostate volume (average 23.6 ± 6.4mm3), the sp group showed a statistically signifi cant improvement in i-pss total score and oabss as compared to the s "monotherapy" group. no serious side eff ects were shown in either group.conclusion: among benign prostatic hyperplasia patients with overactive bladder, those treated with silodosin alone showed statistically signifi cant improvements in both storage and voiding symptoms, as did those additionally treated with propiverine hydrochloride. results were even more benefi cial when both silodosin and propiverine hydrochloride treatment were used for patients with lower prostate volumes. the effi cacy and safety of fesoterodine in vulnerable elderly patients with overactive bladder takeda h, nakano y, narita h introduction and objective: we evaluated the efficacy and safety of fesoterodine in medically complex vulnerable elderly patients with overactive bladder. in this 12-week, patients were community dwelling men and women 65 years old or older. patients with oab had scores of less 3 or more on the ves-13 by nccn (vulnerable elders survey). we evaluated the changes of each parameter before and 4 to 12 weeks aft er the administration of fesoterodine 4 mg per day. th e overactive bladder symptoms score (oabss), ipss were used as a subjective questionnaire for overactive bladder symptoms. we compare between vulnerable elderly group and no-vulnerable elderly groups. statistical comparisons before and aft er the administration were made using the wilcoxon signed-rank test. to examine the relation between oabss and ipss, spearman's testing was used for correlations between independent variables and p<0.05 was considered statistically significant. safety evaluations included self-reported symptoms and post-void residual volume.results: a total of 47 patients were enrolled (mean age71.8 years, 53.4% age 75 years or greater). th e vulnerable elderly patients had high rates of comorbidities, polypharmacy and functional impairment. at week 12 both group had insignifi cantly greater improvements in oabss (p=0.34) and ipss (p=0.18). adverse eff ects were generally similar.conclusions: fesoterodine improved overactive bladder symptoms not only in no-vulnerable elderly patients, but also in vulnerable elderly patients. the effectiveness and tolerability of fesoterodine 8mg in "real world" outpatient clinical settings the benefi cial effect of a combination of solifenacin and mirabegron on oab patients persu c, paraianu b, nita g, geavlete p introduction and objective: th e development of a new drug class intended for the treatment of oab patients opened a new and promising era for our patients. th e current study aims to evaluate the eff ects of a combination therapy using an antimuscarinic and mirabegron. we designed a prospective study including oab patients with or without wet episodes. treatment was started with two months of solifenacin 10 mg, then mirabegron 25 mg was added for the next two months. th e patients were evaluated using a bladder diary for three consecutive days at the end of each treatment period. we compared the total number of voidings, the number of urgency episodes and the number of urge incontinence episodes. th e statistical analysis included only the patients who fi nished the whole four month period. a total of fourteen female sprague-dawley® rats weighing 175-200g were used, which were randomly divided into two groups. both the experimental group and the control group, fourteen rats were inserted intrathecal catheter in the spinal l6-s1 segment. seven days later, all rats were catheterized through the bladder dome for saline-fi lling cystometry. in experimental group, seven rats were given intrathecal diff erent concentration ketanserin (0.01-0.1mg/kg) dose-response curves for ketanserin were followed by doi (0.1mg/kg) test.in control group, seven rats were given intrathecal normal saline. all rats were intravascularly perfused with 4% paraformaldehyde aft er the completion of the urodynamic recordings. th e l6-s1 spinal cord were removed and pathological sections and immunohistochemical staining were made. meanwhile, we observed and recorded the distribution of 5-ht2a receptors in the spinal motor neuron. results: th irty-four patients were included in the study. twenty-four of them completed the follow-up. twenty-one were female and 13 were male with an average age of 9.48 years (5-31 years). detrusor sphincter dyssynegia was the most common abnormal urodynamic fi ndings in these patients. th ere was an improvement in bladder capacity, detrusor and sphincter action following de-tethering surgery.conclusion: urodynamics should be considered as a part of preoperative evaluation in all patients with primary tethered cord syndrome to decide the urological aspect of management. urinary bladder reinnervation with creation of a "somato-autonomic" refl ex pathway in rabbits -s1) and detrusor muscle (recipient, s1-s2) were located. aft er their resection, intradural anastomosis of donor root to the recipient distal root stub was performed. th ose roots whose stimulation elicited the largest response were always selected. aft er 8-16 months (mean 12 months), the artifi cial refl ex arc's function was examined (to date in 11 rabbits). under general anaesthesia, skin segments l5-s1 were peripherally stimulated and then the spinal root above the anastomosis was stimulated. detrusor response was measured using an emg strip electrode and intravesical pressure (pves) monitoring and sphincter response using an emg needle electrode. a root sample from under the anastomosis was resected for histology.results: electromyography confi rmed detrusor response to peripheral skin stimulation in 7 (64%) animals and sphincter response in 8 (73%). five (45%) animals displayed elevated intravesical pressure (pves) up to 15 cm h2o. root stimulation induced detrusor and sphincter emg response in 7 (64%) and 9 (82%) rabbits, respectively, and 4 (36%) animals displayed increased pves up to 24 cm h2o. micturition was not induced in any animals. with confi rmed detrusor contraction (emg, elevated pves), external sphincter activity was never inhibited. somatic-to-autonomic anastomosis creation was histologically confi rmed in all samples. hind limb paresis occurred in 2 (18%) animals and spinal lesion in 3 (27%).conclusion: lumbar-to-sacral-nerve rerouting is a technically manageable method with donor root fibres verifi ably joining recipient roots. only in a limited percentage of cases, however, can the method achieve positive functional results, i.e. demonstrable detrusor contractions and elevated intravesical pressure. physiological micturition without detrusorsphincter dyssynergia as described in the literature did not occur in our experiment. development in this study, we evaluate the effi cacy of the prototype intravesical pressure sensor integrated into a catheter-like tube and in the rabbit and biocompatibility of ecofl ex® as a packing materials in the rats. th e catheter type wireless pressure sensor is manufactured by direct inserting the prototype sensor into the port split from the feeding tube between the sensor and the port so the tube could hold the bladder pressure. th e tip of the tube is results: th e measured resonance frequencies and the pressure data converted from those signals were compared to the reference pressure data obtained from a conventional cystometry. th e scale factor of the sensor to correlate the prototype sensor resonance frequencies to the reference pressure data is -2.1 kpa/ mhz (=-0.476 mhz/kpa), comparable to the result of its in-vitro measurement, a pressure responsivity of -0.418 mhz/kpa. increased macrophage activity and mif in the bladder were revealed in the early phase aft er implantation of ecofl ex®. however, decreased macrophage activity and mif in the bladder were observed in the later aft er implantation. furthermore, decreased infl ammatory cytokines were also observed at that time. in this study, we demonstrated the feasibility of the catheter type which is non-invasive method and easy to apply to patients in actual examination. further investigation to overcome the limitation of the prototype intravesical pressure sensor is necessary for the application to the real life practice. in addition, ecofl ex is biocompatible materials for the implanted medical devices in the bladder. introduction and objective: urethral pressure profi le (upp) is a primary method for evaluating urethral continence function in human beings. however, upp recording in female rat, a widely used animal model, has been challenging because of the animal's small body size. th is study reports a novel method for recording upp in female rats. seventeen anesthetized female rats were studied. leak-point pressure (lpp) data of 14 rats were included; the other 3 rats were excluded due to animal die or abnormal urogenital organ. upp curves were recorded using a modifi ed method of water-perfusion catheter system, with the lateral hole facing 3-, 6-, 9-, 12-o' clock positions respectively in a randomized sequence. lpp, functional urethral length (ful), and maximum urethral close pressure (mucp) were the analysis parameters. in the era of aging society, an easy-to-use screening tool for voiding dysfunction refl ecting to activity of daily life is much-needed. bladder diary (frequency volume chart) is gold standard to check urine storage status, but diffi cult for elderly to measure and record all the time. urofl owmetry is useful to check voiding status, but limited to clinics or hospitals. we developed a portable device, p-urofl owdiary®, which records every urine fl ow with bladder diary at home. we elucidate the feasibility and the usefulness of this device. materials and methods: p-urofl owdiary® records voiding time and date, length of voiding, voided volume, fl ow rate and self-evaluation of every urination for a couple of days with gravimetric determination method. th e device consists of a disposable urine cup, a load cell and the circuit board on which microcomputer, clock, acceleration sensor, audio guidance, bluetooth and sd card mounted. self-evaluation of every urination is recorded by pushing one of the four buttons on the body-side, which represent "very good", "good", "bad" and "very bad". th e data in sd card are analyzed using the dedicated soft ware. accuracy of the measurement has been approved in a comparative study of the device and an existing urofl owmeter. th e infl uences of hand shaking are canceled by acceleration sensor and are smoothed by the soft ware.results: th e feasibility study were done under the approval of irb of nara medical university. first semester study in 230 healthy volunteers focused on user-friendliness. th e results were almost acceptable except for female volunteers, especially in elderly. th e urine volume and peak fl ow rate as well as self-evaluation were linearly related in volunteers who measured multiple sessions. a clinical trial in patients with voiding dysfunction is in operation in seven institutions, and summarized data will be reported.conclusion: p-urofl owdiary® is light and small and easy-to-use at home even in elderly. although its practical usefulness as voiding diary have been proved, the usefulness as urofl owmetry and self-evaluation of every urination is not clarifi ed yet. however, p-urofl owdiary® seems to be a useful tool for screening of voiding dysfunction as well as assessment of therapeutic performance. to determine the continence position and the contributory factors in the female canine urethra. materials and methods: by using 12 adult female dogs, we determined the continence function of each 5 mm intervals of the urethra when we excluded these segments by progressively inserting a 12fr catheter and recording the abdominal leak-point pressure (alpp). th e urethral pressure profi le (upp) and alpp were determined before and 1min aft er occlusion of the abdominal aorta. each urethra specimen was split into 16 segments averagely and the histological components were determined. th e relationship between the histological components and the urodynamic parameters were analyzed.results: th e striated muscle confi ned to the distal 1/3 urethra. th e anatomic structure of the proximal 2/3 urethra was found to be quite homogenous, which surrounded by circular smooth muscle. th e connective tissue constituted with abundant collagen fi bers and vascular plexus was most voluminous in the distal 1/3 urethra, and relatively richer near the bladder neck. upp had 2 pressure zones: high pressure zone corresponding to the distal 1/3 urethra and low pressure zone corresponding to the proximal 2/3 urethra. alpp decreased sharply when exclusion progressed over the distal 1/3 urethra. alpp and mucp decreased about 24% and 40% aft er occlusion of aorta, respectively. th e distribution of the urethral pressure or pressure change is in accordance with the location of the striated muscle sphincter; there is no linear correlation with any other particular tissue component in the diff erent urethral segments.conclusion: th e strongest continence function locates at the distal 1/3 urethra with striated muscle layer; the remaining 2/3 proximal urethra lacking striated muscle has only weak continence function. striated muscle is the predominant contributory factor to continence and the other components like vascular sinusoids, smooth muscle, collagen fi bers are minor contributory factors. urodynamics in children: a 10-year experience persu c, mirciulescu v, geavlete p introduction and objective: urodynamics, in the modern defi nition of the term, developed rapidly from a state of the art gadget into an extremely useful tool in the armamentarium of the modern practitioner, who is no longer accepting the clinical exam as the mainstay of the diagnosis, but requires more and more in-depth data from paraclinical investigations.our study aims to review the particular aspects of the urodynamic examination in children. we retrospectively reviewed the data from our archive in patients aged less than 16 years old, examined in our department in the last 10 years. for analysis purposes, patients were divided into two groups, less than 10 years old and more than 10 years old, considering that compliance during the examination improves greatly with age. a total of 43 children were evaluated, 21 in the fi rst group and 22 in the second. we noticed changes in the procedure over time, due to the lack of standardization.results: th e main conditions behind the urinary symptoms were spina bifi da, myelomeningocele, cerebral palsy, spinal cord injury, frontal dementia. children with chronic conditions showed a signifi cantly better compliance during the examination, providing "cleaner" traces and shorter examination times. in 5 cases (11%), the results of the exam were considered unreliable. in the fi rst group, sensations are recorded in only 4 cases (19%), the other traces are marked as pain or crying. in the second group, the sensations are reported by 20 children (91%). in six cases (15%), more than one examination was available, and the intra-individual variability was higher than in adult patients. urodynamics in children is a challenging, yet useful investigation, which requires both a state-of-the-art equipment and dedicated and highly professional staff . th e main question when thinking about urodynamic testing in children is not whether it can be done, but if it is really needed for the management of the patient, keeping in mind not only the benefi ts but also the potential harm that it can do. the underactive bladder syndrome: a single center experience persu c, geavlete p introduction and objective: detrusor underactivity (uab syndrome) is defi ned as a contraction of reduced strength or duration, leading to obstructive symptoms of the lower urinary tract. our study aims to review our clinical experience with such cases. we reviewed the electronic fi les of the patients diagnosed with uab aft er urodynamics in the past 5 years. our review focused on the referral diagnosis and other associated conditions, as well as on the symptoms reported by the patient during history taking or the examination itself. we tried to correlate symptoms with the parameters obtained during urodynamics. th e initial treatment offered was also recorded.results: a total of 67 patients (41 males, 36 females) were analyzed. th e most common referral diagnosis was bladder outlet obstruction (40 pts -60%), followed by oab syndrome (20 pts -30%) and other conditions (7 pts -10%). most patients reported signifi cant dysuria (57 pts -85%), sensation of incomplete voiding (40 pts -60%) and the need for straining in order to void (30pts -45%). other reported symptoms include recurrent utis (24 pts -36%), urgency (20 pts -30%), frequency (20 pts -30%) and urinary incontinence (10 pts -15%). th e initial treatment consisted of self-catheterization (33 pts -49%), α blockers (20 pts -30%), suprapubic cystostomy (6 pts -9%), double voiding (6 pts -9%) and neurostimulation (2 pts -3%).conclusion: th e most common causes for uab include neurogenic conditions and obstructive symptoms associated with aging. th ere are no specifi c symptoms to support this diagnosis but some might suggest it stronger than others. urodynamic evaluation is mandatory to assess the parameters of this condition. underactive bladder: clinical features, urodynamic parameters, and treatmenthoag n, gani j introduction and objective: underactive bladder is a complex clinical condition that remains poorly defi ned in the available literature. we aim to determine its prevalence among those with voiding dysfunction, presenting symptoms, risk factors, urodynamic fi ndings, and treatment undertaken. a retrospective chart review was conducted on consecutive urodynamic studies performed for voiding dysfunction between 2012 and 2014, to identify patients with detrusor underactivity. underactive bladder was defi ned as bladder contractility index less than 100. charts and urodynamic tracing were examined for patient demographics, suspected risk factors, presenting symptoms, urodynamic parameters, and treatment undertaken.results: th e prevalence of underactive bladder in this series was 23% (79/343). average age was 59.2 (range 19-90). women represented 68.4% (54/79) of patients. th e most common reported symptoms were: urinary urgency (63.3%), weak stream (61.0%), straining (57.0%), nocturia (48.1%), and urinary frequency (46.8%). prior pelvic surgery and prior back surgery was noted in 40.5% and 19.0%, respectively. most common management was intermittent self-catheterization at 54.4%, followed by observation/conservative treatment at 25.3%, and sacral neuromodulation at 12.7%.conclusion: underactive bladder is common, yet precise diagnosis and treatment remains nebulous. th ere exists signifi cant overlap in symptoms compared to other bladder disorders, and urodynamic evaluation is useful in determining those patients with impaired detrusor contractility. th is will help prevent mismanagement of these patients with surgery or medical therapy that may worsen their condition. th ere remains much work to be done to better understand this condition, and establish optimal management for patients. what is the relationship between the size of a patient's medical notes and their fitness?birring a, jelski j, burns-cox n introduction and objective: assessment of patients' co-morbidities is necessary when considering treatment options. comorbidity tools exist but aren't always used outside of studies. clinicians may infer a patient's fi tness from the size of their notes. th is is particularly apparent in multidisciplinary meetings when the patient, and sometimes the referring clinician, is absent. we aim to establish if any correlation exists between the thickness and weight of medical notes and patient comorbidity. th ickness and weight of medical notes was measured for 100 consecutive patients admitted to a urology/surgical ward. comorbidity was assessed using the charlston comorbidity index (cci).results: mean (and range): age 63 (19-93) years; thickness 4.2 (0.3-36.4) cm; weight 1770 (157-16874) g; cci 1.6 (0-8). male to female ratio 1:1. pearson's correlation (r) between thickness and cci was 0.27 (p=0.01). th e correlation between weight and cci was 0.25 (p=0.01). regression analysis showed, an 8.5cm increase in thickness gives in a 1-point increase in cci (p=0.01); and a 5000g increase in weight gives a 1-point increase in cci (p=0.01).conclusion: th ere is a statistically signifi cant relationship between the thickness and weight of a patient's notes and their cci (p=0.01), but the strength of this relationship is extremely weak (r=0.25 and 0.27). on average, an 8.5cm or 5kg diff erence in size has only a 1-point diff erence in cci. th is change may reduce the 10-year survival of a patient by as little as 5%. size of notes is a highly misleading indicator of fi tness. patients should have a formal comorbidity assessment before deciding treatment options.did you know? siu academy... the endorsed event programme allows approved webcasts from high-quality meetings around the world to be presented and shared on the portal.off ers a wide range of content eligible for selflearning cme credits non-accredited content is eligible for self-learning credits. contact your national accreditation body to fi nd out how. navigate the portal to its full potential by using the top and bottom panels. this allows you to narrow down your search by selecting the type of content, topic, sub-topics and labels to fi nd exactly what you are looking for. what's trendingthe what's trending page gives you an overview of featured content and the most recent material at a glance. the "rate & comment" feature allows you to share your feedback on every piece of material available on the portal. share exciting new content with colleagues through facebook and twitter at the click of a button.www.siu-urology.orgregister today! siu academy reaches over 43,000 users.are you one of them?siu members span over 100 countries and represent the full spectrum of clinicians and investigators from all the urological subspecialties, including established academic and non-academic urologists, as well as physicians undergoing full-time training in urology.siu membership gives you an equal voice in this influential organization. we believe that each member can contribute the knowledge and experience needed to forge valuable links between urologists, and between developed and developing nations. by working together, our members carry on the tradition of creating positive change in a changing world. as a new member, you will be a partner in the one urological association dedicated to creating sustainable educational projects and providing and improving urological resources worldwide.members are able to vote for siu leadership, organize siu-endorsed educational activities, become involved in the congress scientific programme, as well as contribute to various siu academy programmes. we strive to make each member feel valued, respected, and supported.the siu network, both virtual and live, is an unparalleled pool of global contacts. siu brings urologists together. key: cord-006870-f5w6fw6q authors: nan title: abstracts presented at the neurocritical care society (ncs) 15th annual meeting date: 2017-09-19 journal: neurocrit care doi: 10.1007/s12028-017-0465-9 sha: doc_id: 6870 cord_uid: f5w6fw6q nan external ventricular drain (evd) management after subarachnoid hemorrhage (sah) is thought to influence patient outcomes and complications. evidence from single center randomized controlled trials suggest that an early clamp trial is safe and associated with shorter icu stay and fewer evd complications. however, a recent survey revealed that most neuro icu's across the us still adopt a gradual wean and continuously draining evd strategy. therefore, we sought to determine the optimal approach at our institution. we reviewed 200 consecutive patients admitted to our institution from 2012 to 2017 with nontraumatic sah requiring an evd. in 2015, our neurocritical care unit revised our internal evd management guideline from a gradual wean to an early clamp trial approach. we performed a retrospective multivariate analysis to compare outcomes before and after our guideline change. patients that were gradually weaned after institution of the new guideline were also included in the early clamp trial group. we observed a significant reduction in ventriculoperitoneal shunt (vps) rates after changing to an early clamp trial approach (13% early clamp vs 35% gradual wean, p=0.002, or=0.208 on multivariateanalysis). there was no increase in delayed vps placement at 3 months (8.6% vs 9.3%, p=0.41). an early clamp trial approach was also associated with a shorter mean evd duration (10.2 vs 15.6 days, p<0.001), shorter icu length of stay (14.2 vs 16.9 days, p=0.001), shorter hospital length of stay (18.2 vs 23.7 days, p<0.001), lower rates of non-functioning evd (15% vs 30%, p=0.025), and fewer ventriculostomyassociated infections (1.3% vs 8.8%, p=0.039). we found no difference in symptomatic vasospasm rates between the groups (20.2% vs 24.6%, p=0.52). an early clamp trial approach is associated with fewer complications and shorter length of stay compared to a gradual evd wean. prospective multicenter studies are needed to provide further insight into the best strategy. autoimmune encephalitis refers to rare sometimes paraneoplastic conditions in which the immune system attacks the brain, leading to altered function. delayed diagnosis and treatment potentially leads to permanent neurological injury or death. the primary objective of this study was to analyze the admission and discharge modified rankin scale (mrs) assessments among patients diagnosed with autoimmune encephalitis, and to identify any effectiveness of immunosuppressive therapy on a subset of these patients. through retrospective chart review we identified patients that met currently accepted clinical and serological criterion for autoimmune encephalitis. clinical data was obtained on these cases and a modified rankin score mrs was assessed on both hospital admission and discharge or subsequent 'best clinical' visit. assessment of "improvement" from initial therapy was based on any decrease in mrs score and clinical neurological functional improvement in accordance with physician and patient affirmation by the time of discharge. seventy-seven patients met criterion for clinical or serological autoimmune encephalitis. of these patients, 11 had cancer and 66 did not have known cancer. fifty-seven (74%) patients underwent immunosuppressive therapy with corticosteroids, ivig, and/or plasma exchange and 30 patients experienced a decrease in mrs score. improvement from initial treatment was 21%, 71%, 58%, and 80% for admitting mrs scores or 2 through 5 respectively. the p-values for improvement from initial immune therapy based on an mrs of 3, 4, or 5 compared to an mrs of 2 were 0.0014, 0.035, and 0.013 respectively. immunosuppressive therapies for patients with an initial mrs score of 3, 4 or 5 may have a higher yield than for those with an mrs of 2. these therapies are generally reserved for those with an mrs of 2 or greater. further study is needed to assess functional improvement in those with autoimmune mediated encephalitis treated with immunosuppressive therapies. many patient, family and hospital factors have been associated with obtaining consent for organ donation after brain death (bd). we evaluated potential factors that played a role in the consent rate in a large tertiary hospital over a period of 11.5 years. we evaluated all declarations in our hospital's bd registry between january 2006 and june 2017 regarding consent for donation. we cross-matched the hospital electronic medical records with the records of the local organ procurement organization to identify this population. 254 patients were included in the registry (59. 5% african american) and 213 were approached for donation. there was a 71.8% consent rate for organ donation. there was no significant relationship between sex, admission diagnosis, icu (neuro vs. medical vs. surgical), physician specialty (neurology vs. other), time from event to bd declaration or religion and decision to donate. families were more likely to consent to donation if the patient was non-aa (88% vs 62% for aa, p<0.001), was younger (46.5 vs 52.4, p=0.026), had a lower creatinine at the time of death (1.7 ± 1.9 vs 2.4 ± 2.3 mg/dl, p=0.015), and had an apnea test completed (74% vs 50%, p=0.017). in a logistic regression model, only aa race and pao2 independently predicted refusal of donation (odds, 95%ci, 5.3, p<0.001 and 0.84, p= 0.017, respectively) . although the majority of bd patients in this large series were aa, their families were 5 times less likely to consent for organ donation than non-aa families. there is an urgent need to explore the reasons for low donation rates in this population. post-anoxic myoclonus is seen in up to 20% of patients who remain comatose, and historically was felt to be a poor prognostic sign. little distinction has been made in the literature between epileptic (cortical) vs subcortical myoclonus. from 604 consecutive cardiac arrest patients that did not return to baseline (may 2007-may 2016) we identified 18% (n=111) patients with clinical myoclonus. basic demographics and characteristics of their arrest were collected and eeg reports were reviewed. raw eeg including video was reviewed by two epilepsy-trained neurologists, whenever available. myoclonus was subcategorized into subcortical and cortical based on the presence of a preceding eeg correlate. jerk-locked eeg back-averaging was performed on two representative patients. the average age of patients with myoclonus was 63+/-17 years, and 29% (n=32) survived to discharge. cortical myoclonus was twice as likely as subcortical myoclonus (59% vs 23%, respectively). compared with 493 patients without myoclonus, patients with myoclonus were more likely to have longer, more severe arrests. patients with subcortical myoclonus were at risk for electrographic seizures, although at a lower rate than those with cortical myoclonus (8% vs 43%, respectively). mortality rates did not differ between patients with cortical and subcortical myoclonus (74% vs 76%). patients with cortical myoclonus were more likely to be discharged in a vegetative state compared to those with subcortical myoclonus (82% vs 33%, respectively (or 9.3; 95%ci 1.1-76.7). amongst survivors, good functional outcome at discharge did not differ between cortical vs subcortical myoclonus (12 vs 16%, respectively). jerk-locked eeg back-averaging was useful in distinguishing subcortical from cortical myoclonus. myoclonus is seen in every sixth patient with cardiac arrest. cortical and subcortical myoclonus cannot be distinguished using clinical criteria. both may have good outcomes when managed with targeted temperature management and an aggressive antiepileptic regimen. intoxication by central nervous system (cns) depressant drugs can lead to anoxic brain injury by cardiac or respiratory arrest. we tested the hypothesis whether intoxication by these drugs contributes to mortality in acute anoxic brain injury we utilized healthcare cost and utilization project databases (nationwide inpatient sample and kids' inpatient database) to obtain patients admitted with diagnosis of anoxic brain injury. patients with drug intoxication (opioid, alcohol, sedative/hypnotic drugs) were identified. regression analysis was used to assess relationship between drug intoxication status to in-hospital mortality. the regression model was adjusted for age, gender, chronic medical comorbidities, presence of cardiac arrest and hospital characteristics. we analyzed a total of 12,319 patients with anoxic brain injury out of which 197 (1.6%) had drug intoxication and 35% were reported to have cardiac arrest. median age was 58 years and 54% patients were males. in-hospital mortality was 57%. among the survivors, 20% underwent feeding tube placement and 15% had tracheostomy. drug intoxication was a significant positive predictor of inhospital mortality with adjusted odds ratio 1.5 (1.1 -2.1), p=0.01. cns depressant drug intoxication is associated with higher in-hospital mortality in patients with acute anoxic brain injury. cardiac arrest affects approximately 600,000 individuals every year and is the third most common cause of mortality in the us. currently, there is no way of reliably risk stratifying survivors of cardiac arrest. identifying early predictors of outcome is vital for triaging and clinical trial enrollment. we proposed to identify key clinical and laboratory parameters that can reliably predict long-term outcomes among comatose survivors of cardiac arrest. this was a retrospective chart review of comatose survivors of cardiac arrest. we gathered data regarding several clinical (age, pre-arrest mrs, gcs on admission, 24 and 48 hours, presence/absence of shock and respiratory failure) and laboratory parameters (troponins, lactate, creatinine, and alt at admission, and peak values within the first 24 and 48 hours) as well as characteristics of the cardiac arrest (duration, arrest rhythm, location, and bystander cpr). we used a dichotomized gos (1-3 vs 4-5) at 6 months as the primary outcome. we performed univariate and multivariable analysis to identify predictors of poor outcome. a total of 98 patients were enrolled. on univariate analysis, higher age, higher pre-arrest mrs, lower gcs at 48 hours, non vf/vt arrest rhythm, in-hospital arrest location, absence of bystander cpr, and shock were statistically significant (p <0.05) for poor outcome. in multivariable analysis, only higher prearrest mrs and lower gcs at 48 hours were independent predictors of poor outcome; no bystander cpr demonstrated a trend for being an independent predictor. none of the early laboratory data achieved statistical significance for predicting poor outcome. we identified several clinical predictors of poor outcome in our small cohort of comatose survivors of cardiac arrest. the above variables need to be analyzed among a larger cohort that includes all survivors of cardiac arrest in order to develop an injury severity score that can help risk stratify cardiac arrest survivors. after cardiac arrest, somatosensory evoked potentials (sseps), eeg characteristics, and mri are routinely used to evaluate comatose patients. the relationship between structural hypoxic injury, absent cortical potentials and the generation of background reactivity or epileptogenic potentials is unclear. here we evaluate a consecutive series of patients with cardiac arrest that were studied with sseps and evaluate clinical, eeg, and mri measures to study the dissociation between hypoxia-induced thalamic disconnection and spontaneous cortical activity. in this retrospective cohort study, all comatose patients post-cardiac arrest who received sseps were identified and reports were reviewed. 71 patients were found; one patient with a high cervical cord injury was excluded. we recorded presence of cortical (n20) and subcortical evoked responses (p14), whenever available. based on the closest available eeg (maximum 2 days from ssep recording) we determined reactivity, background characteristics (diffuse suppression or burst-suppression versus all other backgrounds), and presence of generalized periodic discharges (gpds) or seizures. diffusion weighted or t2 flair abnormalities in the thalamus were evaluated based on available mris. chi-square and fisher's exact test were applied as applicable. of 70 patients with ssep, 33 (47%) had absent n20s, and 29% of those (n=9) had absent p14. eeg reactivity was possible, albeit less common, in patients with absent n20s (10% vs 51%, p<0.001), but none of the patients with absent p14s had a reactive eeg. those with absent n20s were more likely to have diffusely suppressed or burst-suppressed background (94% vs 51%, p=0.03) and to have abnormal thalamic signal on mri (50% vs 12%, p=0.008). gpds, stimulus-induced gpds, and seizures were equally common in those with and without n20s. the integrity of the somatosensory thalamo-cortical pathway does not appear to be necessary for presence of reactivity or generation of periodic epileptiform discharges. all families of patients who have become brain dead (bd) should be offered the choice of donation. this does not always happen and the factors that lead to approaching them or not are not known. our objective was to evaluate which factors influence the donation coordinators (dc) working for an organ procurement organization approach families after brain death we evaluated all declarations in our hospital's bd registry between january 2006 and june 2017 regarding consent for donation and cross-matched the hospital electronic medical records with the records of the local organ procurement organization. in order to refine neurologic prognosis in cardiac arrest patients we sought to incorporate heart rate variability into a multimodal prediction model. heart rate variability has been shown in animal studies to be preserved in survivors of cardiac arrest. in our preliminary study, we retrospectively analyzed patients admitted to the university of virginia who had undergone a cooling protocol following cardiac arrest. analysis of heart rate variability for each patient was done in the frequency domain using the fast fourier spectral transform with spectral bands at 0.150-0.400 hz for high frequency (hf) and low frequency (lf) power within the frequency band 0.040-0.150 hz. the unit-less lf/hf ratio was considered a measure of balance between sympathetic and parasympathetic tone. over a 3-year period, a total of 167 patients were cooled. 45 patients (27%) had ceeg, 13 (8%) had routine eegs and 17(10%) had sseps performed. numerous patients (42, 25% of all arrests or 72% of all eegs performed) had malignant patterns, defined as burst suppression, severe suppression, or generalized periodic discharges. of the 17 sseps, 10 had an absent n20 (none survived to discharge) and 7 had an n20 that was present (3 survived to discharge). 2 patients with absent n20s and malignant eegs had lower lf/hf ratios when compared to 2 survivors with present n20s (0.78 vs. 1.46). the trend towards parasympathetic dominance following a severe neurologic injury and loss of normal sympathetic tone in those patients with absent n20s and malignant eegs and may serve as an additional marker of poor prognosis following cardiac arrest. physicians often struggle with the intricacies of brain death determination and communication about end-of-life care. in an effort to remedy this situation, we introduced an educational initiative at our medical school to improve student comprehension and comfort dealing with brain death. beginning in july 2017, students at our medical school were required to attend a 90-minute brain death didactic and simulation session during their neurology clerkship. students completed a test immediately before and after participating in the initiative. of the 145 students who participated in this educational initiative between july 2016 and june 2017, 124 (86%) consented to have their data used for research purposes. students correctly answered a median of 53% of questions (iqr 47-58%) on the pretest and 86% of questions (iqr 78-89%) on the posttest (p<0.001). comfort with both performing a brain death evaluation and talking to a family about brain death improved significantly after this initiative (18% of students were comfortable performing a brain death evaluation before the initiative and 86% were comfortable doing so after the initiative, p<0.001; 18% were comfortable talking to a family about brain death before the initiative and 76% were comfortable doing so after the initiative, p<0.001). incorporation of simulation in undergraduate medical education is high-yield. at our medical school, knowledge about brain death and comfort performing a brain death exam or talking to a family about brain death was poor prior to development of this initiative, but awareness and comfort dealing with brain death improved significantly after this initiative. this initiative was clearly a success and can serve as a model for brain death education at other medical schools. early withdrawal of life support (ewls) is a major factor in deaths following hypoxic ischemic injury after cardiac arrest (ca) in patients receiving targeted temperature management (ttm). appropriate timing of prognostication, and subsequent withdrawal of life support is recommended in recent guidelines, but is not always followed in clinical practice. we describe the impact of ewls in a multicenter registry database. using data from the international cardiac arrest registry (intcar), we defined ewls as withdrawal in the first three days of hospitalization. among all patients treated with targeted temperature management, we developed a logistic regression model to predict ewls. we then performed a propensity score and evaluated the incidence of good outcome between deciles of risk for ewls. 1311 patients entered into intcar from 2012-2016 from 16 different hospitals were included. mean age was 62 (±16) years, mean cpr duration was 28 (± 21) minutes, 689 (53%) had a shockable rhythm, and 812 (62%) received bystander cpr. support was withdrawn in 609, with 336 (55%) events classified as ewls. (26% of total cohort). among patients with support withdrawal, older age (p=0.002), nonshockable rhythm (p=0.003), increased ischemic time (p=0.03), and shock on admission (p<0.001) were associated with ewls. among propensity matched patients grouped into deciles of probability for ewls, survival with good functional outcome occurred in 18% (6th decile), 30% (7th), 10% (8th), 6% (9th), and 12% (10th decile). early withdrawal of life support after cardiac arrest occurs frequently, and is associated with age, duration of cpr, a non-shockable rhythm, and shock at the time of admission. a cohort of patients propensity-matched to those with ewls had 6-30% survival with favorable neurologic outcomes. these data support that in most patients receiving ttm, conservative and delayed prognostication after cardiac arrest is appropriate. brain herniation (bh) is a deadly event that requires immediate central venous access for infusion of hyperosmotic agents, especially 23.4% nacl. traditional venous catheters, whether peripheral or central, takes several minutes to place, and requires skill for successful placement, thus delaying critical treatment. intraosseous (io) cannulation has been shown, at least during cardiac arrest, to be a secure and rapid means of central vascular access that requires limited training. however, limited data exists on the use of io in bh for administering 23.4%. the aim of study of this study is to measure changes in serum sodium and bh reversal after administering 23.4% via io. retrospective chart review of patients with acute neurologic injury requiring 23.4% and io placement due to a lack of central access. demographics, diagnosis, gcs, sodium (na+), and pupillary reactivity, and immediate and delayed complications were collected. results 9 patients included: 4 males, age range 33-84 yo. diagnosis include intracerebral hemorrhage ( n=7), extra-axial hematoma (n=1) and sah (n=1). gcs ranged 3 to 8. all patients were intubated. most patients were co-treated with hyperventilation, nabicarb, mannitol, and propofol. io was placed in tibia (1) or humerus (8); all placed correctly on first attempt. comparing 1 hr post-23.4% nacl treatment to pretreatment: na+ level increased in 6 of 9; gcs improvement in 4 of 9; and returned pupillary reactivity in 4 of 7. no adverse events reported, such as shock, cardiac arrest, tissue or limb injury. preliminary data suggest that during bh, io cannulation results in safe and timely 23.4% administration in patients with no central access. additional safety data is needed, particularly with regards to the potential for myonecrosis. however, if safe, io cannulation should replace central line placement as the initial route of central venous access during bh. the pupillary light reflex is associated with outcome after cardiac arrest as a dichotomous variable (present/absent) at various time points following resuscitation (rosc). infrared pupillometry provides quantitative measures including pupil diameter (pd), and neurological pupil index (npi) which ranges from 0 (nonreactive) to 5 (brisk) and reflects velocity and degree of pupil constriction in response to a standardized light stimulus. these measures may provide early prognostic information to guide therapy. comatose adult survivors of cardiac arrest treated with targeted temperature management were monitored with the neuroptics npi-200 pupillometer. outcomes were defined as good (go) if discharge cerebral performance category score was 1-2, and poor (po) if 3-5. data are presented as median (iqr). groups were compared using non-parametric statistical tests. fifty-one patients were enrolled; the median age was 57 (48.5-68.5), and 33 (65%) were male. initial rhythm was vt/vf in 55%, asystole in 23%, and pea in 20%. outcome was good in 16 (31%) patients. the initial pd did not differ between outcome groups [3.1 (2-4.7) po vs 3.0 (2-4.2) go]. the initial npi was lower in poor outcome patients [3.3 (1.5-4) vs 3.9 (2.4-4.2) go, p=0.005] measured 4.5 (3.4-6.3) hours after rosc. npi dropped below 3 in more poor outcome patients [27(77%) vs 6(37.5%) go, p=0 .015], and to zero in 18(51%) poor vs 1(6%) good outcome patients (p=0.005). receiver operator characteristic curves confirmed that initial npi predicted poor outcome better than pupil diameter (auc 0.78 vs 0.61, p=0.016). a low neurological pupil index predicted poor outcome 4-6 hours after resuscitation from cardiac arrest, and dropped to abnormal levels (<3) and to zero (reflecting a non-reactive pupil) more often in patients with poor outcomes. additional research is needed to define potential confounders, optimal timing, and thresholds for different levels of neurological risk with pupillometry. prediction of death in a timely manner after withdrawal of life support (wls) is essential during organ donation after cardiac death (dcd). we aimed to develop a modified version of the recently develop dcd-n score to improve the specificity of prediction and test it in a specific group of patients with catastrophic brain injuries referred for dcd. we analyzed prospectively collected data by our local organ procurement agency on all consecutive adults with severe neurological injury evaluated for dcd across 18 centers in the usa from march 2015 to may 2017. we analyzed three variables used in the dcd-n score (corneal reflex, cough reflex and oxygenation index) and substituted the fourth variable for vasopressor support. a total of 278 patients, mean age 50 (sd±13) years were included in the final analysis. anoxic brain injury was the most common cause of death (55%) followed by stroke (27%). in multivariate logistic regression analysis adjusted for age and cause of death, absent corneal reflex (or 3.2, 95% ci 1.6 to 6.0, p = 0.0005, 2 points), absent cough reflex (or 2.2, 95% ci 1.1 to 4.2, p = 0.02, 1 point), vasopressor support at high doses (or 4.9, 95% ci 2.3 to 10.5, p < 0.0001, 2 points) and o2 ind ci 1.6 to 5.5, p = 0.0005, 2 points) were associated with the likelihood of death within 60 minutes of specificity 83% and auc 0.81. the modified dcd-n score has a greater specificity in predicting death within 60 minutes of wls and is developed specifically from a cohort of patients evaluated for dcd. future prospective studies are needed for further validation of this scoring system. significant number of the patients with anoxic brain injury have poor neurological recovery. this created a significant anxiety in families who often request early prognostication. this study was conducted to evaluate possible ultra-early prediction of good neurological recovery in patients undergoing hypothermic protocol for anoxic brain injury retrospective chart review of the patients with anoxic brain injury was conducted. all patient underwent standard evaluation and management in the early stages of icu care, including initiating of hypothermic protocol with intravenous cooling device. all patients underwent evaluations with eeg and ssep within first day after admission during hypothermia phase and mri brain after re-warming. total of 65 charts were reviewed. 9 patient had normal ssep and normal mri. all patients had good neurological recovery, except for one patient who died secondary to severe cardiac failure eeg did not have any predictive value for the good neurological outcome when it was done during hypothermic protocol. normal ssep may a reliable predictor for good neurological recovery. apnea test is the essential component to confirm brain death by stimulation of respiratory center in brainstem. guidelines recommend that apnea testing should meet the criteria of disconnection from mechanical ventilator, and oxygen supplying by catheter. however, during the apnea test under this technique, disconnection from ventilator may induce hypoxia due to abrupt decruitment of alveoli and pulmonary barotrauma such as pneumothorax. there are some studies that suggest continuous positive airway pressure can be effective for patients with hemodynamically instability and respiratory impairment. we suggest a novel method of apnea test by using ambu bag with positive end-expiratory pressure (peep) valve to avoid abrupt change of peep during the apnea test. apnea testing was performed by using ambu bag with peep valve to 26 adult brain death patients. ambu bag was not bagging during the testing and just connected to endotracheal tube with 10 l/min of 100% oxygen. peep valve was applied the same peep of previous mechanical ventilator. on the apnea testing, vital signs and ekg were monitored. arterial blood gas analysis were measured 2 and 4 minutes after disconnection from mechanical ventilator. there were no significant differences in mean pao2 between before and after apnea test (275 ± 181 and 260 ± 178, p=0.7). mean arterial blood pressure were 90 ± 17 mmhg and 90 ± 22 mmhg before and after the test, respectively. during the intervention and following observation, arrhythmia or pulmonary complications had not occurred. we suggest a novel method of apnea testing which is a simple and easy technique by using ambu bag with peep valve to minimize decruitment of alveoli. this method shows vital signs and respiratory oxygenation of the patients remained stable during the test. declaration of brain death based on clinical exam has been plagued with challenges. as a result, ancillary testing such as nuclear scintigraphy cerebral blood flow (cbf) studies have been recommended. we present a case in which the apnea test could not be completed due to hemodynamic instability and where the nuclear scintigraphy cbf study resulted in a false declaration of brain death. a 59 y/o male was admitted with bilateral hearing loss and confusion. on day two, the patient developed blurred vision, and an mri confirmed bilateral cerebellar and pontine infarctions. by day four, he had developed diffuse cerebral edema in the cerebellum, brainstem, and bilateral occipital lobes, and we proceeded with the clinical exam for brain death. all cranial reflexes were absent; however the apnea exam could not be completed due to blood pressure instability. a nuclear scintigraphy cbf study revealed the complete absence of radiotracer activity, and the patient was pronounced dead. two hours later, the patient regained a gag reflex. on the following day, the clinical exam, with the exception of apnea testing, was again consistent with brain death. a cerebral angiogram was performed and demonstrated normal blood flow to the anterior circulation. the patient was ultimately pronounced dead on day eight after two separate complete clinical brain death exams, including apnea testing, were performed. cerebral angiography showed essentially normal blood flow where nuclear scintigraphy showed no blood flow. nuclear scintigraphy cbf studies are commonly recommended when apnea testing cannot be completed. given the dramatic differences in the results observed between these modalities, a reevaluation of this practice should be considered. patients' perceptions of recovery moderate outcomes, however studies exploring the specific cognitive, functional, and psychological domains associated with subjective perceptions of recovery at hospital discharge after cardiac arrest (ca) are lacking. this is a prospective, observational cohort of patients admitted to columbia university medical center after ca, and survived to hospital discharge between 9/2015-5/2017. patients with sufficient mental status to perform a neuropsychological exam and a questionnaire at discharge were included. subjective perceptions of recovery were assessed via responses to the forced-choice dichotomized question, "do you feel that you have made a complete recovery from the arrest?"objective outcome measures of recovery included: repeatable battery for neuropsychological status (rbans), modified lawton physical self-maintenance scale (l-adl), barthel index (bi), cerebral performance category scale (cpc), center for epidemiological studies-depression scale (ces-d), and post traumatic stress disorder-checklist (ptsd-c). chi-square, wilcoxon-rank sum, and logistic regression were used to compare the respondents, and determine factors associated with subjective perceptions of recovery. 64 patients were included with mean age of 52±17 years; 58% were men and 48% were white. 67% responded not having made a complete recovery. no significant differences were found between respondents in terms of demographics, charlson comorbidity index, arrest-related variables, rbans, l-adl, bi, pre-or post-arrest cpc scores. those responding that they had not made a full recovery had higher rates of ptsd-c (45% vs 0%, p<0.001), and depression (51% vs 25%, p=0.05). moreover, everyone that screened for ptsd (n=19) reported not having made a complete recovery. patients with higher ptsd scores were more likely to report not having made a complete recovery (or 1.25; p< 0.003) after adjusting for age, gender and depression scores. presence of post traumatic stress disorder symptomatology at discharge, and not neurocognitive or functional status, is highly associated with post-cardiac arrest patients' subjective perceptions of recovery. early eeg background reactivity is a strong predictor of neurological recovery after hypoxic-ischemic brain injury despite hypothermia and sedation. unfortunately, expert interrater-agreement on visual scoring of eeg background reactivity ranges from 24-50%. recent studies indicate that machine-learning approaches using quantitative eeg (qeeg) might yield equivalent or superior performance to current eeg reactivity assessment practices, however its ability to predict outcomes has not been tested. we hypothesized that a qeeg reactivity method can predict long-term functional outcome in hypoxic ischemic brain injury. we retrospectively reviewed clinical and eeg data of cardiac arrest patients managed with hypothermia at two university hospitals. eeg reactivity was tested daily using a structured exam consisting of auditory, tactile, and visual stimulation. our quantitative eeg method evaluated changes in eeg spectra, entropy, and frequency features during 30 seconds before and after each stimulation-step (30 qeeg features used). only the first eeg reactivity assessment for each subject was used in the final analysis. good outcome was defined as cerebral performance category of 1-2 at six months. a penalized multinomial logistic regression was utilized for feature selection and a random-forest classifier was employed in the training and validation sets. model performance evaluation metric was the area under roc curve (auc). outcome and eeg data was available for a total 77 subjects, and 30 cases were excluded due to presence of burst-suppression, periodic epileptiform discharges, or eeg artifact. forty-seven subjects were included in the final analysis. mean age was 57.8 (standard deviation 17.9) years and 29.8% had good outcome. the combination of four features provided best outcome prediction performance with an auc of 0.87 (kolmogorov-smirnov test, skewness, two-group test, and renyi entropy). early qeeg reactivity is predictive of good outcome at six months. a quantitative approach to eeg reactivity analysis might facilitate accurate and individualized prognostication in hypoxic-ischemic brain injury. hypoxic-ischemic brain injury is the leading cause of morbidity and mortality following cardiac arrest, and the ability to predict neurologic recovery in comatose cardiac arrest survivors is limited. functional mri measures brain network connectivity and resting-state network connectivity can be measured in comatose patients. the default mode network (dmn) is one resting state network that has been correlated with consciousness. we hypothesized the degree of connectivity in the dmn and other resting-state networks would correlate with consciousness recovery in post-cardiac arrest coma. consecutive patients with hypoxic-ischemic coma were enrolled. functional mri was obtained on all patients on post-arrest day 2-5 on an inpatient 3 tesla mri. the connectivity in multiple resting-state networks was analyzed using pearson's correlations between 30 component maps for each subject and 14 previously defined standard network maps. connectivity in the default mode network and in additional resting-state networks was correlated with outcome. good outcome was defined as consciousness recovery at any point in the acute hospitalization. 15 patients were included in this study. the mean age was 57±14 years (22-79) and 9 were male. 6 patients survived with good outcome. the primary arrest rhythm and the duration of cardiac arrest did not differ between groups (primary rhythm as vt/vf: 50% vs 44%, good vs poor, p= 0.8; cardiac arrest duration: 20.2±11.7 minutes vs 20.2±12.1 minutes, good vs poor, p=0.99). patients with good outcome had significantly higher mean network connectivity (0.13±0.06 vs 0.07±0.04, good vs poor, p=0.03). dmn connectivity showed a trend towards significance (0.14±0.04 vs 0.09±0.06, good vs poor, p=0.1). in comatose patients following cardiac arrest higher fmri measured resting state connectivity correlated with consciousness recovery. functional connectivity may be developed as a prognostic biomarker. sedative and analgesic infusions and neuromuscular blockade agents (nmba) are commonly used for comfort, suppression of shivering, and reduction of metabolic activity during targeted temperature management (ttm) after cardiac arrest. the optimal sedation and analgesia regimens are unknown. we sought to describe variability in sedation and shivering management practices at us and european cardiac arrest receiving centers. international cardiac arrest registry (intcar) centers were surveyed regarding sedation protocols for ttm after cardiac arrest. the survey was administered via redcap with a response rate of 48%. ten united states and 28 european centers completed the survey. shivering is measured at 35 (92%) of centers and recorded at 14 (37%) centers. ten centers use nmb to control shivering prophylactically, 12 centers use nmb only if shivering occurs, and 16 centers increase opioids or sedatives when shivering occurs, but do not use nmb. the most common sedative was propofol (31/38 centers), followed by midazolam (24/36) and the most common analgesic was fentanyl (25/38) followed by remifentanyl (17/25). 0, 18, and 21 centers report having a sedation target of light, moderate, or deep respectively. a sedation scale is used at 25 (66%) centers, targeted to patient comfort at 8 (21%) centers. daily sedation lightening is protocolized when rewarming starts at 6 (16%) centers, when normothermia is reached at 28 (72%) and not specified in the remainder of groups. of patients who awaken, centers report that they expect this to occur at 24 (17 centers), 48 (12 centers) and 72 (6 centers) hours respectively. among cardiac arrest receiving centers internationally, there is significant variability in ttm sedation and shivering management strategy. our hospital policy allows an optional sbd (with an apnea and a cerebral blood flow test) or a dbd (with an apnea test). we have evaluated the adoption of and reason for performing a single brain death exam (sbd) vs two (dual) brain death exams (dbd) and their impact on organ function and consent for organ donation. we evaluated our hospital's bd registry between january 2006 and june 2017 regarding sbd or dbd. we also cross-matched our electronic medical records with the records of the local organ procurement organization. of 251 bd declarations, 115 (46%) were sbd and 136 (54%) dbd. during the 1st five years, 43% of all bd exams were sbd and during the second 57%. patients with sbd were older (50.6±16.5 for sbd vs 46.5±17.1 years for dbd, p= 0.057), had a primary neurologic diagnosis (96% vs 47%, p< 0.001) and were admitted to the neuro-icu (74% vs 27%, p< 0.001). during the 2nd exam, 76.7% patients were on equal or higher dose of pressors. sbd patients had lower k+, bun, creatinine and heart rate, but higher peak na+ and apnea pao2 (for all p<0.05), although apnea ph and paco2 were similar. the time between injury to bd pronouncement was shorter in sbd by 29.4 hours. there was no difference in consent rate between sbd and dbd (74% vs 70%, p=0.47). at our institution, bd declaration was more often done by dbd exams, although the primary diagnosis and the unit of admission influenced the decision. an increased adoption of sbd exams was noted after the 2010 aan bd guidelines, supporting sbd exam, were published. although the number of exams did not affect rate of consent for donation, surrogate markers indicated better function of organs after sbd, while dbd patients stayed in the icus over a day longer. there are no data supporting better numbers or function of organs in donors after brain death (bd), if there is a shorter waiting period (as expected with single brain death exam [sbd] ) from the time that bd is declared to the time the patient arrives at the operating room (or). our goal was to find if the number of brain death exams, either sbd or dual (dbd), had any impact on the number of organs recovered and transplanted we evaluated our hospital's bd registry between january 2006 and june 2017 regarding sbd or dbd and cross-matched our electronic medical records with the records of the local organ procurement organization out of 251 bd declarations, 150 led to consent, of which 74 (49.3%) after sbd and 76 (50.7%) after dbd. there was a trend for longer consent to or time for dbd (41.7 ± 20.1 hours vs 36.4 ± 13.7 for sbd, p=0.07). there was no difference in the number of organs recovered or transplanted based on the number of exams (4.0 ± 1.8 vs 3.7 ± 1.8 organs/patient recovered and 3.2 ± 2.0 vs 2.8 ± 1.9 transplanted for sbd vs dbd, respectively, p>0.05). there was a trend for more lungs to be transplanted after sbd exam (62% vs 44%, p=0.06), but this was not found with kidneys, heart, liver, pancreas or intestines. in multiple logistic regression models, adjusting for variables pertinent to each individual organ function (for example, bun or creatinine level for kidneys, blood gases for lungs etc), the number of exams was not an independent predictor for successful transplantation conclusions sbd exam led to similar numbers of organs transplanted compared to dbd exam in this single center registry analysis. more rapid brain death declaration, as with sbd, is not a factor that influences organ transplantation the glasgow coma scale (gcs) is a standardized and commonly used way of assessing important aspects of neurological condition for critically ill patients. while it is a validated tool for prognostication, it is unclear whether serial measurements add value to this prognosis. we used a large set of serially collected gcs measurements to assess the impact of gcs score on the trajectory of neurological recovery as well as factors affecting score variance. gcs total and subscores (483,041 time points from 5,456 patients) recorded hourly by registered nurses in the neurosurgical intensive care unit (nsicu) between january, 2012 and may, 2016 were analyzed retrospectively. k-means clustering provided groups with similar progression characteristics during nsicu stay. k-means clustering provided groups with similar progression characteristics during nsicu stay. descriptive features for each cluster were binned into histograms and evaluated for similarity using 2 and kruskal-wallis tests. linear correlations of the sub-scores were very high (eye-verbal: 0.583, eye-motor: 0.686, verbal-motor: 0.583), while compositional variance was low for aggregate scores. hour-to-hour variance in gcs correlates to significant nsicu activities such as nursing shift changes. among patients with similar minimum gcs scores during their stay, those that recovered were significantly less likely to have deteriorated in the hospital ( 2, p<<0.0001). for patients with a minimum gcs<=8, those that arrived at their minimum score (i.e., did not deteriorate in nsicu) were 18.6% more likely to recover than those who deteriorated in-hospital (kw, p<<0.0001) . patients that experienced recovery show significantly greater improvement as early as 2 hours after their minimum score (kw, p<<0.0001). the gcs is unnecessarily complex for most nsicu patients and can be represented by fewer variables. serial gcs measurements do provide value for prognosis and may be able to distinguish patients with potential to recover early in their hospital course. stroke is a major cause of death and disability, and common admission to neurological intensive care units. preferences for cardiopulmonary resuscitation (cpr) are often discussed, but there is limited understanding of cpr outcomes among stroke patients. systematic review and meta-analysis of published literature from 1990 to 2016 among stroke patients undergoing in-hospital cpr. preferred reporting items for systematic reviews and meta-analysis, metaanalysis of observational studies in epidemiology, and utstein guidelines were used to construct standardized reporting templates. detailed searches of pubmed and cochrane libraries were supplemented with hand-searched bibliographies. primary data from studies meeting inclusion criteria at two levels were extracted, i) survival to hospital discharge after cpr, and stroke as a primary admitting diagnosis, and the less restrictive, ii) survival to hospital discharge after cpr with stroke listed as a comorbidity, were meta-analyzed to generate weighted, pooled estimates of survival to hospital discharge. of 818 articles screened, there were 176 articles (22%) that underwent full review. three articles met primary inclusion criteria, specifically identifying patients with stroke as a primary admitting diagnosis. twenty additional articles met secondary inclusion criteria, listing stroke as a comorbidity. there was an 8% (95% confidence interval (ci) 0.01, 0.14) rate of survival to hospital discharge rate from a combined sample of 561 patients that received in-hospital cpr. among the more heterogenous population of inpatients with stroke listed as a comorbidity, there was 16% (95% ci 0.14, 0.19) rate of survival to hospital discharge. adherence to utstein reporting guidelines was poor, and neurological outcomes were measured in 6 (26%) of studies. survival to hospital discharge among stroke patients is lower relative to general hospital populations. these preliminary findings highlight the need for improving the quality of evidence to inform patient and provider discussions of cpr among stroke patients. there is often a tendency to treat patients with traumatic brain injury (tbi) and a glasgow coma scale (gcs) score of 3 on presentation less aggressively because of low expectations for a good outcome. based on the crash trial database, a prognosis calculator has been developed for the prediction of outcome in tbi patients. our aim was to investigate whether the crash calculator can be used for prognostication in patients with tbi and gcs of 3 on presentation. we performed a retrospective review of patients with tbi and a gcs score of 3 from 1/12 to 9/16. the crash calculator has been validated to estimate mortality at 14 days and death and severe disability at six months (glasgow outcome scale-gos 1-3). the calculator uses country of origin (usa in our dataset), age, gcs, pupils reactivity to light, presence of major extracranial injury, and findings on ct scan of brain (petechial hemorrhages, obliteration of the third ventricle or basal cisterns, subarachnoid bleeding, midline shift, and non-evacuated hematoma). the individual prognosis for mortality at 14 days and unfavourable outcome at 6 months was calculated and compared with the actual outcomes. a total of 62 patients were included. a tend toward underestimation of the risk of mortality at 14 days was found (estimated mortality was 66 % compared to actual mortality of 81%; difference of 15%, p = 0.05). however, the estimation of outcome at 6 months was accurate (estimated gos 1-3 was 85.5 % compared to actual of 85.5 %, p = 1.0). the crash prognosis calculator underestimated the risk of mortality, but accurately predicted unfavourable 6 month outcome in patients with tbi and gcs of 3 on presentation. pending larger studies to validate our findings, we believe that crash calculator can only support -not replace -clinical judgment. there are no nationally enforced standards regarding brain death. few data exist on how brain death is determined across the u.s. we used claims data from 2012-2015 from a nationally representative 5% sample of medicare defined as icd-9-cm code 348.82. the primary outcomes were evaluation by a neurologist or neurosurgeon, defined as a physician evaluation-and-management claim associated with the medicare provider specialty codes for neurology or neurosurgery, during the dates of the hospitalization. cpt codes were used to ascertain ancillary testing: brain radionuclide imaging, transcranial doppler ultrasound, or electroencephalography for brain death determination. exact binomial confidence intervals (cis) were used to report proportions. we identified 312 patients with a brain death diagnosis. common associated neurological diagnoses were stroke (122 patients; 39.1%), cardiac arrest (120; 38.5%), and traumatic brain injury (tbi) (45; 14.4%). head ct or brain mri was performed in 79.8%; this was true of 91.6% of cases of stroke or tbi versus 68.3% of cardiac arrests. neurologists were involved in the care of 137 patients (43.9%; 95% ci, 38.3-49.6%). they were more commonly involved in the care of stroke (50.8%) or cardiac arrest (55.0%) than tbi (6.7%) or other conditions (24.0%). neurosurgeons were involved in 98 cases (31.4%; 95% ci, 26.3-36.9%), mostly after tbi or stroke. two hundred patients (64.1%; 95% ci, 58.5-69.4%) were seen by a neurologist or neurosurgeon. twenty-nine patients (9.3%; 95% ci, 6.3-13.1%) underwent any ancillary testing. two hundred and nine patients (67.0%; 95% ci, 61.5-72.2%) were seen by a neurologist or neurosurgeon or underwent ancillary testing. in a nationally representative cohort of elderly patients, one-third of patients with a brain death diagnosis were not evaluated by a neurologist or neurosurgeon or by using ancillary tests. traumatic brain injury (tbi) is a major cause of death and disability in the us. recent advances in 3d illustration (3di) can precisely quantify intracranial pathology on computed tomography (ct). the current standard of measurement, abc/2, demonstrates variability in precision with bleed phenotype. the aim of this project is to assess accuracy automated 3di and compare it to standard abc/2 measurements. baseline ct scans collected during the protectiii multicenter clinical trial (n=881) were retrospectively reviewed by a central neuroradiologist. subdural and epidural hematomas were identified (n260). the radiologist calculated abc/2 score using osirix (mac) and radiant (pc) workstations. in a blinded fashion, research assistants concurrently generated 3di using the following methods: dicom data were resampled to 1.5 mm thickness slices and symmetrized using image analysis software (aquarius terarecon inc, 2012) . lesions were then compiled into single volumetric regions of interest (3d slicer v4.5, 2015) . hemorrhages were divided into two groups for analysis: group 1. volume of hemorrhage bland-altman analysis. this study was irb approved. there is a significant difference between the results of the 3di and abc/2 methods. in group 1. the estimated relative bias between the two measurements (after transformation) is 0.17 (sd 1.16; pvalue 0.044; 95% ci 0.005, 0.333). in group 2, the relative bias is -0.712, sd 1.22, pvalue <0.0001, 95% ci (-1.013, -0.410). the 3di method calculates detailed surface area measurements in large and small volume hemorrhages, while abc/2 averages cross-sectional area. the abc/2 estimates vary by bleed phenotype and offer less topographical precision than 3di. this is particularly true in extra-axial hemorrhages, which are numerous studies have shown a significant association between hypotension and poor outcome in patients with head injuries. prior investigations have demonstrated that generation of negative intrathoracic pressure (itp) in ventilated patients with brain injury improves mean arterial pressure (map) and lowers intracranial pressure (icp). we hypothesized that augmentation of negative itp by breathing through an impedance threshold device (itd) with 7 cmh2o of inspiratory resistance would improve mean arterial pressure in a porcine model of intracranial hypertension. six spontaneously breathing female pigs (42.2 ± 3.7 kg), anesthetized with propofol, were subjected to focal brain injury through inflation of an 8 french foley catheter placed in the epidural space. once a stable injury was obtained, baseline data were collected for 20 minutes followed by 20 minutes of itd use. results are reported as mean ± sd. the itp without the itd during inspiration was -1.0 ± 0.4 mmhg, compared to -9.0 ± 0.8 mmhg with the itd, p<0.001. following brain injury, map (mmhg) was significantly higher during itd use (95 ± 11 vs. 89 ± 11; p<0.001). cerebral perfusion pressure (mmhg) was also significantly higher during itd use (75 ± 11 vs. 69 ± 10; p<0.05). icp (mmhg) was not significantly different between groups (20.1 ± 3.4 vs. 19.9 ± 3.3; p=0.19) although end tidal carbon dioxide levels (mmhg) were significantly higher during itd use (26 ± 3 vs. 20 ± 1; p<0.005) presumably due to lower respiratory rates during itd use (29 ± 5 vs. 35 ± 7; p=0.21). contralateral cerebral blood flow (ml/100gm/min) was similar between groups (34 ± 18 vs. 34 ± 17). in this porcine model of intracranial hypertension, spontaneous respirations through an itd significantly improved map and cpp. this approach could be utilized to prevent hypotensive episodes in the setting of brain injury. the impact of applying nanotechnology and biomedical engineering to improve the management of patients with spinal cord injuries (sci) is still not accurately described, nor understood. a systematic review of the literature was conducted, according to prisma criteria, to identify publications revolving around "sci+nanotechnology" and "sci+biomedical engineering" indexed on pubmed in the period 2007-2017. furthermore, the database of clinicaltrials.gov was searched to highlight the stage of translation of this research into clinical practice through randomized clinical trials (rct). finally the uspto database was interrogated to identify the number of pertinent patents filed in northamerica in the same timeframe. the literature on bioengineering and nanotechnology contributions to sci is exponentially growing, with almost 50% of articles published between 2015 and 2016. its quality and the interest of the scientific community are high, as confirmed by the average impact factor (14.9) and the average number of citations (5) of articles published in the last two years. this field still represents a niche of sci research: the 56 articles reviewed represent only 1.2% of all articles on sci published in the same decade. this trend is confirmed on clinicaltrials.gov: out of 886 rct on sci only few focus on the application of those technologies, furthermore 34 out of 40 articles spurring from the rct identified were published after 2010, and 25% after 2016. interestingly, with 119 patents registered by the uspto, the interest in the commercial application of this research seems vivid. currently, the most promising areas of research are: nanofabrication/nanoscaffolding for structural repair, nanodrugs for regeneration, and design of neural interfaces for functional therapies. this review showed that both universities and independent research institutions (mostly from usa, china and european union) are driving this research race; the figures provided above suggest its potential to become a successful example of translational medicine. there are no neuroprotective and neuroregenerative treatments available for traumatic brain injury (tbi). clinical trials investigating potential treatments such as therapeutic hypothermia and progesterone have failed. pre-clinical studies indicate there may be a role of stem-cells in promoting neuroprotection/neuroregeneration in-vivo in animal models of tbi. we aim to provide a pre-clinical literature review into stem-cells as a potential therapeutic option in tbi-animal models. a literature search was conducted on pubmed and google scholar using the terms "traumatic brain injury", "stem-cell", "preclinical", and "animal studies". studies were included if there was an in-vivo animal model of tbi with either intravenous or intra-cortical stem-cell transplantation, along-with a control group, and investigated either motor or behavioral outcomes, or a combination. twenty-seven studies (n=1184 animals) satisfied the criteria. 774/1184 (65.4%) animals were investigated for outcomes. 17 studies harvested stem-cells from human-source, whereas 10 harvested stem-cells from animal-source. bone-marrow stromal-cells (bmsc) were used in 17 studies, neural stemcells (nsc) in 7, and miscellaneous in 3. 450/774 (58.1%) animals received any stem-cell transplantation, whereas 324 were controls. of animals receiving stem-cell transplantation (450), 339 (75.3%) showed significantly better outcomes relative to control animals in each individual study, with exception of one study. amongst transplanted animals, functional outcomes did not differ significantly when grouped by stem-cell type (p=0.553), transplantation route (p=0.054), and source (p=0.784). animals were followedup until 1 week (n=5 studies), 2 weeks (n=10), 4 weeks (n=5), or >4-weeks (n=7). this pre-clinical data demonstrates that stem-cell transplantation may have treatment potential in tbi as shown by improvement in functional outcome in as many as three-quarters of all animals that were treated with stem-cells. this data provides a foundation for the design of clinical translational studies. age of trauma patients including those with asdh is increasing as stated by national trauma registers. we were especially interested if age > 65 years significantly influences outcome compared to younger patients and if other factors like initial gcs have an influence too. methods midline shift, if asdh was surgically removed, additional contusions, comorbidities and intake of anticoagulants. outcome was analyzed using the glasgow outcome scale (gos) at hospital discharge (gos 1) and if possible 6 months after discharge (gos 2). uni-and multivariate analysis (cox regression model) was performed using the sigma stat softwar 0.05. adverse outcome p=0.014. in addition, all patients > 65 years with an initial gcs 3 died whereas only 44% of younger patients with initial gcs 3 died (p<0.005). this was the only significant result in the multivariate analysis the monovariate analysis of our data showed a significantly higher risk for adverse outcome after asdh whe it should be considered if it is reasonable to transfer them from local hospitals to a specialized neurosurgical clinic, especially in times of limited resources. reported incidence of pulmonary edema in isolated head injury varies from 50-85%. lung sonography is a potentially useful non invasive technique to detect extravascular lung water(evlw). this study aimed to identify the presence of evlw using lung ultrasound (b lines >3 per lung field) in chead injured patients admitted to icu . secondary objectives were to compare diagnostic accuracy and time to identification of evlw using chest x ray versus lung ultrasound. association of evlw with duration of mechanical ventilation (mv)and icu stay were observed after ethical clearance (iec no. int/iec/2015/372), 120 patients with head injury requiring mv and critical care were enrolled in the study. daily routine chest x ray and bedside lung ultrasound were done from the day of icu admission until the patient was on mechanical ventilator support. four inter costal spaces (ics) were scanned in semi recumbent position; third and sixth ics on either side of sternum till mid clavicular line. evlw was reprted as > 3 b lines per lung field scan sonographically. details of mv and icu management were noted . evidence of evlw at the time of admission using sonography and cxr was recorded in 32 and 6 patients respectively. during icu stay 61.7% patients showed evlw using lung usg (vs 43 patients on cxr). mean delay in detection of evlw on cxr after detection on ultrasound was 1.42±0.767 days. patients with low gcs, s. albumin, pao2/fio2 ratio and greater apache ii and saps ii had significantly higher incidence of evlw. duration of weaning, mechanical ventilation and icu stay was significantly longer in patients with presence of evlw (p <0.05) conclusions: lung ultrasound appears promising in detecting evlw earlier than chest x ray and may aid to minimize the duration of mechanical ventilation, weaning and icu stay . antiepileptic drugs (aeds) are recommended by guidelines for prophylaxis of early post-traumatic seizures (pts) associated with traumatic brain injury (tbi). there has been an increased use of both phenytoin and levetiracetam for this indication. the purpose of this study is to determine the incremental cost-effectiveness of phenytoin compared with levetiracetam for early pts prophylaxis in tbi patients. a cost-effectiveness study was conducted comparing phenytoin and levetiracetam for early pts prophylaxis during the 7 days post-tbi. patients were included if they were 18 years or older, received a study drug, and had a diagnosis of tbi. patients were excluded if they had a history of epilepsy, did not sustain a recent tbi, were initiated on both study drugs concurrently, or were switched to pentobarbital for elevated intracranial pressure. data was collected via retrospective chart review using electronic medical records and publically reported costs. effectiveness was measured as having a successful seizure prophylaxis regimen (sspr), which was defined as 1) no clinical or electrographic seizure, 2) no discontinuation of study aed, 3) no cross-over of study aed to different aed, or 4) no addition of aed during the 7 days of therapy. the costs included costs of the study drugs, phenytoin level, and eeg. the data was used to calculate the primary endpoint, the incremental cost for the incremental change in sspr or the incremental cost effectiveness ratio (icer). the phenytoin regimen (n=136) cost $371.76 and had an sspr of 81.6%. the levetiracetam regimen (n=237) cost $628.85 and had an sspr of 86.1%. the icer was $57 for each 1% increase in sspr with levetiracetam. the sspr of phenytoin and levetiracetam were similar. because patients who received phenytoin may differ from those who received levetiracetam, further analysis is needed prior to drawing any conclusions about the cost-effectiveness of levetiracetam relative to phenytoin. augmented renal clearance (arc) has been reported in up 85% of critically ill tbi patients and may impact therapeutic drug concentrations. improved predictors of arc are needed. serum cysc, a validated marker of glomerular filtration, has not been examined as a marker for arc in critically ill tbi patients. this pilot study tested the hypothesis that serum cysc concentrations are lower than reference values following tbi. adult tbi patients enrolled in the ukccts-unctracs prospective study of arc effects on drug clearance, were eligible. cysc serum concentrations (elisa -r & d cysc) were measured daily for up to 7 days and compared to reference values. descriptive statistics and student t-test for continuous measures (patient vs. reference lower range cysc) were calculated. the first ten patients [7m/3f, mean age= 41.5years (18-59 y/o), median gcs=6 (iqr3-7)] provided a total of 49 serum cysc for analysis. each patient provided at least 4 samples (range 4-7) for up to seven days. measured serum cysc concentrations were below the reference range in 24 of 49 samples. the overall mean cysc concentration was 0.589 + 0.132 mg/l vs expected mean of 0.621 + 0.05. (ns) measured values fell below the lower reference range in 5 patients (2m/3f) for the first 4 study days (mean = 0.483 + 0.101 vs 0.622 + 0.067 p<0.05). the mean difference between measured concentration and reference value was 0.139 + 0.07 mg/l. after 4 days, four patients (2m/2f) remained below reference values with a mean difference of 0.14 + 0.06 mg/dl. preliminary results show cysc was not consistently below reference ranges in all tbi subjects. a subset of subjects showed significantly lower cysc within seven days of injury. the relationship between cysc and arc needs to be further examined as analysis continues. functional connectivity of the default mode network (dmn) is believed to be necessary for recovery of consciousness after coma. however, dmn connectivity has not been comprehensively studied in patients with acute severe tbi. we hypothesized that dmn connectivity in patients with acute severe tbi is associated with level of consciousness. we prospectively enrolled patients admitted to the intensive care unit for acute severe tbi and performed resting-state functional mri (rs-fmri) as soon as safely possible. dmn functional connectivity was assessed by rs-fmri analysis of the blood-oxygen level dependent (bold) signal using a seed-based approach. pearson's correlation coefficients were calculated between the mean bold time series within dmn nodes and all other regions in the brain. level of consciousness was assessed at the time of the scan using the coma recovery scale-revised (crs-r). two-sample t-tests were performed to identify brain regions with connectivity differences between conscious and unconscious subjects. we then tested for associations between level of consciousness and dmn connectivity within these regions. we enrolled 16 patients (12 male, mean+/-sd age 30+/-8 years) and 16 matched controls (11 male, age 28+/-8 years). rs-fmri was performed 9.6+/-4.5 days post-injury. at the time of rs-fmri, patients' levels of consciousness were coma (n=1), vegetative state (vs; n=4), minimally conscious state (mcs; n=7), and post-traumatic confusional state (ptcs; n=4). connectivity within the medial prefrontal cortex and posterior cingulate was selectively reduced in unconscious patients (coma and vs) compared to conscious patients (mcs and ptcs; false discovery rate-corrected p < 0.05). when these regions were further interrogated, connectivity correlated with crs-conclusions dmn functional connectivity correlates with level of consciousness after acute severe tbi. traumatic brain injury (tbi) is a substantial source of death, disability, and healthcare utilization. many older tbi patients present to community hospitals and are transferred to trauma centers for further care; however, little is known about the provision of care and patient outcomes at the final receiving hospital. we described trauma center care among geriatric transfer patients with tbi. we conducted a secondary analysis on a sub-cohort from a prospective multi-center study focusing on ambulance and emergency department (ed) care of injured older adults transported via ambulance. the current analysis focused on tbi patients transferred to the region's level i trauma center from another hospital. transfer paperwork from the originating hospital was reviewed and we conducted a detailed medical record abstraction, including computed tomography (ct) findings, procedures, length of stay (los), and ed disposition. data were collected on 205 transfer patients. thirty had confirmed abnormalities on head ct (14.6%). the mean age was 78 years (range: 55-91), 57% female, and the most frequent mechanism of injury was falls (93%). average los was 13.5 days (range: 0-230, median los 4.5), with 8 patients staying one day or less. ct findings included subdural hematoma (60%), subarachnoid hemorrhage (50%), and intraparenchymal hemorrhage (36.7%). five patients required neurosurgical intervention (17%), eight required icu admission (27%), two were discharged from the ed (7%), and two transitioned to inpatient hospice (7%). tbi is a frequent cause of transfers to trauma centers. in our sample, admission occurred in the majority of patients, but neurosurgical intervention was less common. however, for appropriately selected patients, strategies such as telemedicine may reduce transfers thus saving resources and improving continuity of care for patients and their families. this is an area in which future research is warranted. the prospects and timing of decannulation may affect surrogate decision making regarding tracheostomy for traumatic brain injury (tbi) patients, yet predictors of decannulation are unknown. methods tracheostomy admitted to an affiliated acute rehabilitation hospital between january 2014 and december 2014. patients who had life-sustaining measures withdrawn were excluded. admission data, including injury characteristics and presence of lung injury on initial chest x-ray, and inpatient complications were compared. patients were followed throughout rehab and to the point of decannulation. patients lost to follow up were eliminated from analysis. time of decannulation was verified by inpatient physician notes. a cox proportional hazards model was created to determine factors associated with the time to decannulation and reported as hazard ratios (hr). there were 209 tbi patients admitted to the icu during study period and 94 (79% men, mean 46 yearsold, median gcs 7) underwent tracheostomy after 10 ± 6 days of intubation, of which 79 were followed throughout rehabilitation. overall cannulation time was 37 (29-65) days. 55 (70%) patients had their trach removed prior to discharge from rehab after 35 (27-49) days of cannulation. in a cox proportional model adjusting for sex, reintubation, aspiration pneumonitis, and presence of lung injury on admission chest x-ray; a higher hospital discharge gcs was associated with a shorter time to decannulation (hr, 1.147; 95% ci, 1.023-1.286; p =.019) while patients who required inpatient dialysis had a longer time to decannulation (hr: 0.281; 95% ci, 0.098-0.803; p = .018). the majority of tbi patients that require tracheostomy will be decannulated prior to discharge from rehab. longer durations of tracheostomy cannulatio hospital discharge and those that receive inpatient dialysis. goal directed therapy (gdt) is thought to be associated with outcome after traumatic brain injury (tbi). our team applied gdt to standardize care in patients with moderate to severe tbi, who were enrolled in a large multicenter clinical trial. physiologic goals were defined a priori in order to standardize care across 42 sites participating in the protect iii trial. data were collected hourly for all randomized subjects (n=882). hours where gdt were not achieved were classified as "transgressions". these included: map1.4; platelets180mg/dl; and sbp180mmhg. the proportion of hours spent in transgression was calculated for each parameter and grouped by quartile. poor outcome was defined via stratified dichotomy of the gos-e. data were adjudicated electronically and via expert review. for each parameter, the association between outcome and either (1) occurrence of transgression or (2) cumulative duration of transgression was estimated via logistic regression model, and backward selection was used to identify the physiologic parameters associated with outcome. subgroup analyses were performed in subjects with intracranial monitoring (ticp, n=480) . parameters significant at alpha 0.01 are reported. prolonged duration of transgression was associated with poor outcome when: glucose>180mg/dl (p=0.0001); hgb180mg/dl (p=0.0098) and inversely associated with map180 mg/dl (p=0.0015) or and was inversely associated with map<65mmhg (p=0.0055). the protect iii clinical trial rigorously monitored compliance with gdt after tbi. multiple significant associations between physiologic transgressions and patient outcome were found. the data suggest that reducing physiologic transgressions is important to minimizing patient morbidity after tbi. the measurement and management of intracranial pressure (icp) is a key component in the care of severe head injury. extracranial ventricular drains (evd) have remained the standard due to the ability to lower icp with the drainage of cerebrospinal fluid (csf). placement of an evd is a more invasive procedure than intraparenchymal icp monitors (ipm) and it is unclear if the use of an evd improves outcomes. we hypothesized that early placement of an evd, in adult patients with severe head injury, would not affect outcomes. utilizing data from the citicoline brain injury treatment (cobrit) trial, a prospective multicenter study, we identified 224 patients who met the inclusion criteria; 1) placement of an icp monitoring device, 2) glasgow coma score (gcs) less than 9, 3) evd placement prior to arrival or within 6 hours of arrival at the study institution. primary outcome was glasgow outcome score-extended (gose) at 180 days post injury. secondary outcomes included neuropsychological evaluations at 180 days post injury, mortality, and length of icu stay. logistic regression with forward-stepwise predictor adjustment and propensity score adjustment was performed to assess the independent association between evd placement and outcomes. patients who received an evd prior to or within 6 hours of arrival at the study institution had worse gose at 180 days (3.8 ± 2.2 vs 4.9 ± 2.2, p=0.007), higher in hospital mortality (23% vs 10%, p =0.021), and did worse on 4 out of 8 neuropsychological measures at 180 days. there was no difference in icu length of stay (16.5 ± 9.0 vs 13.9 ± 10.8, p=0.289). early placement of evds in severe adult head injury is independently associated with worse outcomes and higher in hospital mortality. goal directed therapy (gdt) is thought to be associated with outcome after traumatic brain injury (tbi). our team applied gdt to standardize care in patients with moderate to severe tbi, who were enrolled in a large multicenter clinical trial. physiologic goals were defined a priori in order to standardize care across 42 sites participating in the protect iii trial. data were collected hourly for all randomized subjects (n=882). hours where gdt were not achieved were classified as "transgressions". these included: map1.4; platelets180mg/dl; and sbp180mmhg. the proportion of hours spent in transgression was calculated for each parameter and grouped by quartile. data were adjudicated electronically and via expert review. for each parameter, the association between outcome and either (1) occurrence of transgression or (2) cumulative duration of transgression was estimated via logistic regression model, and backward selection was used to identify the physiologic parameters associated with mortality. subgroup analyses were performed in subjects with intracranial monitoring (ticp, n=480). parameters significant at alpha 0.01 are reported. mortality was 17.2% and 23.2% in the full and ticp cohorts. prolonged duration of transgression was associated with increased mortality for: hgb1.4 (p180mg/dl (p180mg/dl (p=0.0093), and sbp1.4 (p1.4 (p=0.0005). covariates inversely related to mortality included single occurrence of map180mmhg (p<0.0032). the protect iii clinical trial rigorously monitored compliance with gdt after tbi. multiple associations between physiologic transgressions and mortality were observed. the data suggest that maintaining physiologic measures within gdt guidelines may be important in preventing deaths. current outcome models in moderate-severe traumatic brain injury (mstbi) include only admission characteristics. yet, mstbi patients commonly have prolonged intensive-care-unit(icu)-stays with high risks to develop icu complications, lending to the hypothesis that these may be additionally associated with outcomes. the objective of this study was to examine the incidence rates of pre-specified medical and neurological icu complications, and their impact on post-traumatic in-hospital mortality and 12month functional outcomes. we analyzed 431 mstbi patients consecutively enrolled in the prospective observational optimismstudy at a level-1 trauma center between 11/2009-1/2017. poor outcome was defined as glasgow outcome scale 1-3. multivariable logistic regression was employed to adjust for admission characteristics and icu-length-of-stay. the mean age was 52±22 years, 73% were men, and median motor glasgow-coma-scale and injury-severity-scores were 4 (iqr 1;5) and 27 (iqr 25;38), respectively. the three most common medical and neurological icu complications were: hyperglycemia (83%), systemic inflammatory response syndrome (69%) and fever (66%); intracranial pressure crisis (icp; [56% of n=162 with icp-monitor]), brain edema requiring osmotherapy (46%), herniation (45%). multivariable models were adjusted for age, marshall-ct-classification, motor glasgow-coma-scale, pre-admission hypotension, icu-length-of-stay and injury-severity-score. after adjustment, in-hospital mortality was significantly associated with in-icu-cardiacarrest (or 23;95%ci 3.5-152. recent studies suggest benefits for early tracheostomy in patients with traumatic brain injury (tbi), yet data regarding who will require tracheostomy is lacking. ad lifesustaining measures withdrawn were excluded. admission and inpatient variables were compared. multivariable logistic regression analyses were used to assess admission and inpatient factors associated with receiving a tracheostomy and to develop models predictive of tracheostomy. there were 209 patients (78% men, mean 48 years-old, median gcs 8) meeting study criteria with tracheostomy performed in 94 (45%). admission predictors of tracheostomy included gcs, marshall score, injury mechanism, pao2/fio2 ratio, and number of quadrants on chest x-ray with consolidation. inpatient factors associated with tracheostomy included the requirement for an external ventricular drain (evd), number of operations, pneumothorax, inpatient dialysis, aspiration, reintubation, and the presence of hospital acquired infections. multiple logistic regression analysis demonstrated that the development of hospital acquired infection (adjusted odds ratio [aor], 4.78; 95% confidence interval [ci], 2.18-10.48; p < .001), number of operations (aor, 1.47; 95% ci, 1.2-1.78; p < .001), pneumothorax (aor, 2.64; 95% ci, 1.08-6.48; p = .034), reintubation (aor, 7.18; 95% ci, 2.50-20.54; < .001), penetrating tbi (aor, 0.14; 95% ci, 0.03-0.60; p=0.008) and placement of evd (aor, 6.73; 95% ci, 3.03-14.95; < .001) were independently associated with patients undergoing tracheostomy. a model of inpatient variables only was more strongly associated with tracheostomy than one with admission variables only (roc auc 0.90 vs. 0.72, p<0.001) and did not benefit from addition of admission variables (roc auc 0.91 vs 0.90, p=0.76). potentially modifiable inpatient factors have a stronger association with tracheostomy than do admission characteristics. existing traumatic brain injury (tbi) guidelines are designed primarily for the evaluation and management of tbi in tertiary care centers with advanced neuroscience capabilities. military special operations medical providers, however, are often required to treat and sustain patients in austere environments with limited resources for up to 72 hours. tbi management guidelines directed specifically toward the care of these patients are needed. a review of recent operational experiences involving tbi and a survey of military special operations medics prompted a multidisciplinary expert panel to develop draft clinical practice guidelines/recommendations for prolonged field management of tbi. the panel conducted an in-depth review of literature on tbi and related topics and adapted existing and emerging therapies to address the unique challenges encountered in prolonged field care. tbi management while optimal management of pbto2 is not fully established. the objective of this -coeur arterial blood gas was drawn (icp, cpp, hemoglobin, temperature, pco2 and pao2). probes were localized in normal appearing white matter. we used a was calculated. a total of 1006 data sets were collected from 38 patients (mean age 44.5±20.0, median gcs 4, mortality range from 94 to 400). mean pao2 for the group as a whole was 178 mmhg (± 88) and mean cpp was 72 mmhg (± 12). mean duration of pbto2 monitoring was 6.5 days (± 3.7). taking into account all determinants of pbto2 and using a protocolized approach to correct pbto2, the mmhg for a few days. high pao2 values are possibly required due to the fact that oxygen delivery to the brain is rate-limited by diffusion and impaired by oedema or microvascular ischemia. it should be noted that pulse oximetry is not sensitive to detect pao2 below this level. traumatic brain injury (tbi) and stroke are extremely common causes of acute brain injury (abi), which cause long term disability and permanent neurological impairment. coma and stupor are common manifestations of abi, due to interruptions of the ascending reticular activating system (aras). neuro stimulants can improve functioning of the aras. despite decades of research there is a paucity of prospective high-level evidence utilizing neuro stimulants to help with earlier awakening from coma and stupor in abi. we reviewed the literature using the grade level of evidence (loe) methodology. we performed a preliminary literature search of the national library of medicine (nlm) using search terms abi and stimulants. within the literature we searched for timing of stimulant use among abi studies and included all forms of abi such as tbi, stroke, and anoxic injury. we retrieved 508 total results, of which we excluded 474 since they did not meet grade high loe criteria or were "n of 1" studies or aggregates. only 34 high loe randomized studies or meta-analyses were found. among these various stimulants were investigated including methamphetamines such as methylphenidate and lisdexamfetamine, caffeine, armodafinil, galantamine, and amantadine. methylphenidate had 10 randomized trials and a meta-analysis in subacute tbi but reported only attention as a main outcome. we were unable to draw broad-level recommendations about optimal timing, best stimulant, and patient centered outcomes from this data. there is insufficient data to recommend optimal stimulant, timing, and dosing among heterogeneous abi disease models. we propose conducting future homogenous abi neuro stimulant trials in for safety, tolerability, dose-finding, optimal timing, and outcomes based efficacy. neuro stimulants could play a role in earlier awakening and extubation in abi which could improve outcomes similar to sedation/vacation bundles in icu's currently if studied adequately. tbi remains the leading cause of death and disability in young adults in the us and europe. thus far, pharmacological and non-pharmacological intervention studies did not confirm benefits on functional outcomes. the inducible enzyme nitric oxide synthase (inos) is upregulated in response to brain injury, causing excessive production of no, a key driver of secondary injury after tbi. the antipterin vas203 is a structural analogue of the endogenous nos cofactor and a potent in-vivo selective inhibitor of inos. a randomized, placebo-controlled phase 2 study examined 3 dose levels of vas203 in 32 patients with acute moderate or severe tbi. cerebral microdialysis showed pharmacologically relevant drug concentrations close to the injury and a tendency for vas203 to increase the arginine/citrulline ratio, an indirect marker of nos inhibition (stover et al., j neurotrauma 2014). vas203 conferred a significant benefit on the extended glasgow outcome scale interview (egos-i) at 6 and 12 months after injury. no changes in systemic blood pressure or partial brain oxygen pressure were noted. a recent pharmacokinetics and pharmacodynamics study further corroborated the selective inos inhibition by vas203. the confirmatory nostra phase 3 trial (eudract no. 2013-003368-29; clinicaltrials.gov identifier nct02794168) was initiated in 2016. adult patients with a nonrequiring intracranial pressure monitoring, are randomized 1:1 to vas203 or placebo, administered in addition to standard of care, as intravenous continuous infusion for 48 hours, starting between 6 and 18 hours post tbi. the primary efficacy endpoint is egos-i at 6 months post injury. additional endpoints include the daily therapy intensity level and tbi-specific quality of life measures. continuous safety monitoring is performed by an independent committee. nostra iii, the only ongoing registration study in acute moderate and severe tbi, is sponsored by vasopharm gmbh, and plans to recruit 232 patients by q3 2018. a glasgow coma scale (gcs) score of 3 on presentation in patients with traumatic brain injury (tbi) portends a poor prognosis. consequently, there is often a tendency to treat these patients less aggressively because of low expectations for a good outcome. we performed a retrospective review of patients with tbi and a gcs score of 3. demographics, apache iv scores , pupillary reactivity to light, intracranial pressure (icp), icp burden (the number of days with an icp spike >25 mm hg as a percentage of the total number of days monitored), and outcome (mortality and glasgow outcome scale-gos at 6 months, with good outcome defined as gos of 4-5). patients were divided into 2 groups: group 1 (gos = 1-3) and group 2 (gos = 4-5). a total of 62 patients were included. the overall mortality rate was 80.6 %. at 6-month, 9 patients (14.5 %) achieved a gos 4-5. compared to group 2 (n = 9), group 1(n = 53) had higher average apache iv score (104 ± 19 vs 89 ± 27, p = 0.04), more patients with bilateral fixed pupils (59 % vs 22 %, p = 0.04), and higher icp burden ( 50 ± 34 vs 0 ± 0, p = 0.0001). gos score 4-5 was achieved in 41% of patients presenting with bilateral reactive pupils versus 6.9 % of patients presenting with bilateral fixed pupils (p = 0.005). 14.5 % of patients with tbi and a gcs of 3 at presentation achieved a good outcome at 6 months. apache iv scores, icp burden, and pupillary reactivity were significant predictors of outcome. we believe that patients with severe tbi who present with a gcs of 3 should still be treated aggressively initially since a good outcome can be obtained in a significant proportion of patients. elevated circulating catecholamine levels are independently associated with functional outcome and mortality after isolated traumatic brain injury (tbi). we assessed the ability of peripheral catecholamine levels to improve the prognostic performance of the crash and impact-tbi models. prospective, observational, multicenter cohort study, conducted at three level 1 trauma centers in canada and usa. epinephrine (epi) and norepinephrine (ne) concentrations were measured in the peripheral blood at admission (baseline), 6, 12 and 24h after trauma. outcome was assessed at 6 months and dichotomized into favorable [extended glasgow outcome scale (go -tbi models, which identified core prognostic markers of severe tbi. the baseline model (m1) included age, gcs and pupillary size/reactivity. the model 2 (m2) included m1 + hypoxia, hypotension and marshall ct classification. model 3 and 4 included m1 + epi levels, and m1 + ne levels, respectively. the risk models performance was assessed by comparing receiver operating characteristic (roc) curves, and by the use of integrated discrimination improvement (idi) index. m3 had significantly higher roc and idi than the baseline model (m1), to predict mortality. m3 had a roc = 0.930 (0.891 -0.968, p = 0.012) and idi = 0.14 (p = 0.0001). the prediction of mortality was not improved by including ne [m4 = roc = 0.896 (0.848 -0.943, p = 0.245) and idi = 0.02 (p=0.124)]. the integrated discrimination improvement index indicated the prediction of unfavourable outcome by the baseline model was improved by including epi (idi = 0.04, p=0.024), and ne (idi = 0.08, p=0.0002) in the models. catecholamine levels improved risk models performance to predict mortality and unfavorable outcome after traumatic brain injury. following traumatic brain injury (tbi), depression is common and may influence recovery. small trials demonstrated that various drugs are beneficial in managing depression following tbi, but no large, definitive study has been conducted. we performed a meta-analysis to estimate the potential benefit of anti-depressant medications following tbi. multiple databases were searched using the terms "anti-depressant tbi," and "depression treatment tbi" to find prospective pharmacologic treatment studies of depression following tbi. studies were excluded if they did not measure depression as an outcome. effect sizes for anti-depressant medications in post-tbi patients were calculated for within-subjects designs that examined change from baseline after receiving medical treatment and treatment-placebo designs that examined the differences between anti-depressants and placebo groups. a random effects model was used for both analyses. of 923 titles screened, 10 studies were included, with 288 total patients. medications evaluated included selective serotonin reuptake inhibitors, monoamine oxidase inhibitors, and tricyclic antidepressants. pooled estimates showed significant reduction in depression scores for individuals after pharmacotherapy (mean change [mc] -11.7, 95% confidence interval [ci]: -15.5 to -8.0) and significant difference in reduction of depression scores between medications and placebo in the pooled estimate (standardized mean difference of four trials [smd] -0.4, 95% ci: -0.7 to -0.1); however only one of the four treatment-placebo studies found medications significantly reduce depression scores more than placebo. this meta-analysis found a significant benefit of pharmacotherapy for treatment of depression in patients with tbi. however, there was a high degree of bias and heterogeneity regarding tbi severity, time since injury, depression severity, and demographics. larger prospective studies on the impact of anti-depressants on post-tbi depression are warranted to better understand treatment effects and the relationship of post-tbi depression and outcome more broadly. pleural effusion (pe) has been reported in 62% of medical icu. there is little published data on the prevalence and clinical significance of pe in mechanically ventilated patients with traumatic brain injury. head injury patients admitted to icu for mechanical ventilation (mv) within 48-72 hours and gcs > 5 were assessed for eligibility. presence of pe was assessed by serial cxr on daily basis and volume of effusion was estimated and recorded. in case there was no evidence of pe on cxr, a bedside sonography in semi recumbent position was done within 72 h of icu admission. pleural fluid volume was estimated based on 4-point classifications on sonography. details of mechanical ventilation and icu management were recorded. successful weaning was defined as ability to breath spontaneously for 48 h. primary aim was to observe prevalence of pe in mv head injured patients. as secondary measure; impact of pe on duration of mv, weaning and length of icu stay were compared. study enrolled 90 patients. three baseline cxr showed pe. total of 27(30%) patients developed pe in icu. 9 patients had evidence of pe on both cxr and usg. 18 patients had only sonographic evidence of pe, which were not detected on cxr. significantly more minimal effusions were detected on sonography (10/27, p=0.03). duration of mechanical ventilation and duration of icu stay were significantly more in patients with pe. (p= 0.009, mann whitney rank sum test) there was no significance difference in duration of weaning in patients with and without effusion (2.9±2.2, 2.1±1.3, p=0.084). chest ultrasonography increased the detection rate of pleural fluid. patients with pe had longer duration of mechanical ventilation. early detection may be associated with shorter period of mechanical ventilation and icu stay spine surgery can trigger a systemic inflammatory response syndrome and lead to hypotension requiring vasopressors. as sepsis is a major differential diagnosis in the post-operative period, the objective of this study is to understand the prevalence of a true systemic infection in this setting. retrospective review of all consecutive adults with post-operative shock requiring vasopressors following spine surgery in an academic tertiary medical center. a total of 43 patients, median age 69 years (iqr 57-74), were included in the final analysis. comorbidities included a median bmi of 28 (iqr 23-33), coronary artery disease (28%) and diabetes mellitus (16%). median estimated blood loss was 1200 cc (iqr 450 to 2150 cc). circulatory volume was adequately replaced in a total of 72% patients within 6 hours post-op. all patients received crystalloids, and an additional 42% received multiple (>4) units of prbcs transfusion. adequate urine output was confirmed in 42 (98%) of the patients. the maximum median rate and duration of each vasopressor infusion was as follows: phenylephrine 100 mcg/min (iqr 60-150, n = 39), 21 hours (iqr 12-46), norepinephrine 40 mcg/min (iqr 20-95, n = 13), 16 hours (iqr 8-62), epinephrine 10 mcg/min (iqr 10-50, n = 3), 12 hours (iqr 8-16) and vasopressin 0.04 units/min, 23 hours (4-31, n = 3). of the 43 patients, 34 (79%) met at least 2 sirs criteria. infection was confirmed in a total of 10 patients; positive respiratory or blood cultures in 7 (16%) patients and positive urinalysis or urine culture in 5 (12%). two patients (5%) were diagnosed with myocardial infarction. no patients had pulmonary embolism. our study suggests that the risk of infection and sepsis in patients with persistent shock following spine surgery is small but not negligible. larger multicenter studies are needed to confirm our findings and to identify the predictive factors. ischemic and hyperemic injuries may occur unnoticed after severe traumatic brain injury (tbi) and contribute to additional brain damage. maintaining an adequate cerebral perfusion is considered crucial in preventing such injuries, as deviations from autoregulation-guided optimal cerebral perfusion pressure (cppopt) are associated with greater mortality and disability. this makes reliable estimation of cppopt an interesting diagnostic and treatment tool for monitoring. cppopt is defined as the cerebral perfusion pressure (cpp) at which the pressure reactivity index (prx) is minimal. the leading method for estimating cppopt automatically, by aries et al. (2012) , fits a parabola to pairs of prx and cpp data. the method uses preset heuristics to reject the fit as unreliable, namely when the parabola is too "shallow" or does not cover a certain cpp range. as a result, the 2012 cppopt estimates could be generated only about 50-60% of the time. moreover, the manually set heuristics potentially restrict the generality of the model. here, we propose an alternative method based on bayesian inference. treating prx at each time as a function of cpp corrupted by noise serves as a "forward model" that can be inverted to yield, for a given data set, a temporally evolving posterior probability distribution over cppopt. the mean of this distribution is a bayesian estimate of cppopt; we find that these estimates are generally consistent with those obtained from the classic method. importantly, the width of the distribution at a given time serves as a metric of uncertainty about cppopt estimation. we find that this uncertainty tends to be large at time points where the classic method with preset heuristics rejects the fitted parabola. our method makes manually setting rejection criteria unnecessary. bayesian estimation of cppopt holds promise as a tool for providing additional decision support in the care of individual tbi patients. quantitative parameters derived from continuous eeg (ceeg) have been useful to understand evolution of traumatic brain injury (tbi) and the impact on regional networks. these parameters are often interrogated at a global level rather than region-specific. the regional evaluation of quantitative eeg parameters may provide an objective assessment of regional network function, and be of predictive value for prognostication continuous eeg was performed in 54 patients with tbi, and mri imaging was obtained during acute and chronic time points post injury (within 30 days and 6 months, respectively). the extended glasgow outcome scale (gose) assessed clinical recovery at 6 months, with good recovery defined as gose score 5-8 and poor as gose score 1-4. volumetric measurements of selected brain regions, both cortical and subcortical, were obtained at acute and chronic time points. quantitative parameters derived from ceeg, such as percent alpha variability (pav) and hemispheric symmetry, were calculated continuously and anatomically (frontal, temporal, occipital) through the acute hospitalization course. we hypothesized that persistent regional variation in alpha power post injury would lead to brain regionspecific atrophy and may predict outcome at 6 months acute pav within the first 48 hours post injury was poor in patients with poor outcome. in addition, patients with poor outcome had significantly more atrophy in the thalamus, hippocampus, and temporal and occipital lobes. asymmetry of the hemisphere pav values correlated with both brain atrophy and clinical outcome regional asymmetry of pav within the first 48 hours post injury correlates with chronic brain atrophy and clinical outcome after tbi after moderate and severe traumatic brain injuries (tbis), individuals are often admitted to an intensive care unit (icu), and later require intensive rehabilitation. many neuro-icus engage therapists and physiatrists for rehabilitation and therapy during a patient's icu admission. however, the optimal timing, intensity, and components of rehabilitation needed while in the icu are not known and practice patterns are highly variable. the goal of this study is to describe the rehabilitation practices to identify whether there is consensus on best practices. an electronic survey asking participants to describe tbi rehabilitation practices in their icu was distributed via redcap through the neurocritical care society (ncs) and american congress of rehabilitation medicine (acrm) websites. potential respondents were first asked if they cared for patients with tbi in the icu, and if they answered "yes," they were invited to complete the survey. two email reminders were sent to each group for completion. after 51 weeks, the data were extracted and analysis completed. there were 47 respondents who reported that they cared for patients with tbi in the icu (17 attending physicians, 6 advanced care practitioners, 15 therapists, 4 nurses, 4 fellows, and 1 other). of these, 96% recommended early rehabilitative care. the most common reasons to wait for the initiation of physical therapy and occupational therapy were normalization of intracranial pressure (icp) (86% and 89% respectively) and hemodynamic stability (66% and 69% respectively). speech therapy was typically recommended after extubation (65%) and normalization of icp (58%). the majority of clinicians caring for patients with tbi in the icu support early rehabilitation efforts, typically after a patient is extubated, intracranial pressure has normalized and the patient is hemodynamically stable. prospective studies evaluating the merits of these self-reported rehabilitation initiation criteria are warranted. high-dose methylprednisolone (hdmp) has been studied as a potential therapeutic option for acute sci, with mixed results regarding efficacy and consistent suggestion of complications. we conducted a retrospective cohort study of acute sci patients extracted from the medical information mart for intensive care iii (mimic-iii) database to evaluate the hypothesis that steroid-related adverse drug events (ades) occur less often than in published clinical trials using hdmp. three groups of patients coded for acute sci were identified from mimic-iii from june 2001 to october 2012: hdmp recipients per nascis ii/iii protocols (hdmp, n = 55), patients who received some steroids but not per nascis ii/iii protocols (non-hdmp, n = 47), and patients who did not receive steroids (no steroids, n = 198) . demographics and data on complications of steroid therapy were extracted. one-way anova or student's t test were used to evaluate continuous variables; chi-squared or fisher's exact test were used for nominal or categorical variables. there were no differences in steroid-related ades between the three groups. there were higher average blood glucose readings in recipients of any steroids compared with the no steroids group, and more variation in blood glucose readings in hdmp recipients compared with the other two groups. there was a higher icu los and ventilator time in the hdmp group compared with the other two groups. compared with three other trials examining similar use of hdmp in acute sci, there were higher rates of pneumonias overall, though lower rates of urinary tract infections, skin & soft tissue infections, pressure ulcers, and superficial thromboemboli/thrombophlebitis. the results of this study are consistent with previous works related to the potential for harm regarding the use of hdmp or any steroids in acute sci. changes in selected adverse event profiles may be due to standardization of icu supportive care over time. cervical spinal immobilization and clearance protocols are important steps in the minimization of secondary spinal cord injury. patients with primary neurologic diseases are frequently found down and placed in rigid cervical collars despite sustaining minimal-to-no cervical injury. in these patients, neurologic dysfunction can complicate and delay cervical clearance. decreasing time spent in cervical spinal immobilization could improve patient care by allowing greater access to / range-of-motion of the neck, increasing patient comfort, and decreasing skin breakdown. through retrospective chart review over a 28-month period, we collected the following: the rationale behind each mri, any mri evidence of cervical instability, the result of any ct imaging, and the basic mechanism of any trauma. for patients that were simply found down, any evidence of trauma either by history or physical exam was recorded. during the study period, there were 306 instances where an mri of the cervical spine was performed. of those mris, 176 (58%), were performed for cervical spinal clearance. sixty-one (35%) of mris were ordered without any ct imaging first. of the patients with a normal ct, six (3.4%) were found to have mri evidence of cervical instability. notably, of the 62 patients who were found down, there was only one instance where the mri demonstrated instability. that patient had extensive facial injuries suggestive of an unwitnessed fall. in the 40 patients that were found down with no history or evidence on physical exam of trauma, there was no mri instability. for patients that are found down without any history or evidence on physical exam of trauma, a ct of the cervical spine is likely sufficient for cervical spinal clearance. acute subdural hematoma (asdh) represents a major clinical entity in severe traumatic brain (stbi), approximately 60% are accompanied by various extents of asdh. stbi has been reported to cause cerebral circulatory disturbances at an acute stage and had the worst circulatory disturbance among stbi. in this study, we focused on the cerebral circulation of asdh, evaluated the absolute left-right difference between cerebral hemispheres and compared the cerebral circulation between the favorable outcome group and the unfavorable group. we retrospectively reviewed 31 patients with asdh. they were admitted to our hospital from 2002 to2011. in these patients, we simultaneously performed xenon-computed tomography (xe-ct) and perfusion ct to evaluate the cerebral circulation on post-injury days 1-3. we measured cbf using xe-ct and mean transit time using perfusion ct and calculated the cerebral blood volume (cbv). a significant absolute difference in cerebral circulation between the hemispheres among different types of tbi was observed in mtt. there was no significant difference in these parameters between left-right hemispheres with asdh among the favorable outcome group and unfavorable group. although there was no significant difference in age, gcs at the onset of treatment, cbf and cbv, there was significant difference only in mtt between the favorable outcome group and unfavorable group. the circulatory disturbance in patients with asdh occurs diffusely despite the focal injury. additionally, in unfavorable patients, the circulatory disturbance is worse than in favorable patients. because asdh suffered ischemia more than other types of stbi, we had to perform not only removal of the occupying lesions, but also neurointensive care, including whole-body management and hypothermia therapy for the ischemic brain after surgery. we have to adopt a treatment strategy appropriate to the pathophysiology of the different tbi types. kcentra is 4-factor prothrombin complex concentrate that is fda approved for reversal of warfarin. there is limited research describing the use of kcentra for coagulopathy in the setting of traumatic intracranial hemorrhage. here, we show the largest ever retrospective review for the use of kcentra in the setting of traumatic intracranial hemorrhage. retrospective chart review was performed from 2013-2016 for patients with intracranial hemorrhage who presented to the r adams cowley shock trauma center. patients who received kcentra were identified. basic clinical information was obtained including cardiac/stroke history, blood pressure, glasgow coma score, medication history, and categorization of hemorrhage. pre and post inr level was assessed. hemorrhagic expansion was assessed with ct scan up to up to 24 hours. disposition and thromboembolic events were recorded. forty-four patients were identified as receiving kcentra in the setting of traumatic intracranial hemorrhage. pre and post kcentra dosing inr was found to be significantly different (p<0.001) across the two groups assessed (warfarin and tbi/noac coagulopathy). seventeen patients (38.6%) had hemorrhagic expansion as determined on ct scan. disposition (home vs rehab vs death) was found to have three significant variables: history of stroke, hemorrhagic expansion, and admission glasgow coma score. eight patients (18.2%) were found to have thromboembolic events. here, we show the largest retrospective review describing the clinical use of kcentra for coagulopathy reversal in the setting of intracranial hemorrhage. overall, kcentra is shown to be a safe and effective drug for the reversal inr. importantly, our reported hemorrhagic rate of 38.6% is lower than established rates reported in the literature for warfarin/coagulopathic patients with intracerebral hemorrhage (50-60%). the prognostic importance of hemorrhagic expansion was highlighted in the disposition analysis which showed that zero patients were discharge home if there was recorded expansion. despite the impact of post-traumatic amnesia (pta) duration on long-term functional outcome after traumatic brain injury (tbi), radiologic predictors of pta duration are lacking. we hypothesized that the number of traumatic microbleeds (tmbs) detected by gradient recalled echo (gre) magnetic resonance imaging (mri) in neuroanatomic regions that mediate memory correlates more strongly with pta duration than does the number of global tmbs. using a prospective outcome database of patients treated for mild-to-severe tbi at an inpatient rehabilitation hospital, we retrospectively identified 65 patients who underwent acute mri with gre. pta duration was determined by the galveston orientation and amnesia test, orientation log or chart review. a rater blinded to pta duration identified tmbs on the gre datasets globally and in neuroanatomic regions that mediate memory, including the hippocampus, fornix, corpus callosum, thalamus, and the temporal lobe. associations between global and regional tmbs (in the 5 mentioned locations) and pta duration were tested using spearman rank correlation coefficients. the cohort was comprised of 25% ( hippocampus and corpus callosum tmbs are associated with pta duration, and thus may have greater utility for predicting functional outcomes than global tmb number. validation of these findings in larger prospective studies is indicated. using a large two-center cohort of 413 penetrating traumatic brain injury (ptbi) patients, we previously developed the survival after acute civilian penetrating brain injuries (spin) score, a logistic regressionbased parsimonious risk stratification scale for estimating survival after civilian ptbi. the objective of the present study was to externally validate the spin-score. our multicenter validation cohort comprised 362 ptbi patients retrospectively identified from three u.s. level-1 trauma center registries. the spin score variables (motor gcs [mgcs], sex, pupillary reactivity, self-inflicted ptbi, transfer status, injury severity score [iss] and inr) were collected from the trauma registries supplemented by chart review. using the spin-score multivariable logistic regression model from the original study, receiver-operating-characteristic area-under-the-curve (roc-auc) analysis and hosmer-lemeshow goodness-of-fit testing was performed. the mean age was 32±15 years, and patients were predominantly male (85%), with 41% white and 28% black. in-hospital mortality was 52%, and 6-month mortality of discharge survivors was 3. in this multicenter external validation study, the full spin-model predicts in-hospital survival after ptbi with excellent discrimination and calibration. after removing inr from the model, discrimination remained excellent, but model calibration diminished. the full spin-score may provide important information to guide families and physicians after civilian ptbi. limited data has described alterations in vancomycin pharmacokinetic (pk) parameters in traumatic brain injury (tbi) patients that have resulted in sub-therapeutic concentrations. the primary objective of this study is to evaluate the pk parameters of vancomycin in tbi patients to determine if using the common clinical practice of capping creatinine clearance (crcl) to 120 ml/min in determining dosing impacts achievement of therapeutic concentrations. this was a single-center, retrospective study of patients at least 18 years of age with tbi who received vancomycin and one reported steady-state vancomycin serum level from april 2014 to december 2015. predicted pk parameters based on population data using actual and capped creatinine clearance (crcl) at 120ml/min were compared with calculated pk parameters based on serum trough concentrations at steady state. the difference was assessed using a two-sample wilcoxon rank-sum test where p < 0.05 was considered statistically significant. when using actual crcl [median 167 ml/min patients with tbi experienced crcl that were greater than predicted. based on the results of this study, actual crcl is more accurate at predicting vancomycin pk than the common practice of capping crcl at 120ml/min. therefore, actual crcl should be used when determining vancomycin dosing regimens in patients with tbi to achieve desired therapeutic concentrations. neurocritical care is traditionally provided within institutions in urban centers while access in rural communities has been limited. transport to urban centers is not always favorable for a variety of reasons including critical patient condition, family wishes, weather, and geography. our hypothesis is that tele-neurocritical (tele-ncc) can extend access to this service with meaningful impact on icu outcomes. a tele-ncc pilot study was initiated within intermountain healthcare. starting 5/1/17, the study included all ischemic stroke patients admitted to the icu of one primary stroke center in utah. tele-ncc consultations were provided by ncc physicians at our flagship hospital located three hundred miles from the spoke site. tele-ncc consultations occurred via an existing telehealth platform developed inhouse. primary outcomes for this pilot study were icu and hospital lengths of stay (los). secondary outcomes include stroke complication rates and results on a provider satisfaction questionnaire. to date,12 tele-ncc consultations have been performed with median hospital los = 3 days (iqr 2.8 -4.3) and icu los = 1.6 days (iqr 1 -2). in the 12 months prior to the pilot, there were 109 admissions to the icu for ischemic stroke with median los = 4 days (iqr 2.8 -5.8) and icu los = 1.8 (iqr 1 -2.6). for this small sample size, the p-values for comparison of hospital and icu lengths of stay before and after tele-ncc are 0.39 and 0.78 respectively. tele-ncc care can have significant impact on icu outcomes by expanding access to critical support from neurocritical care specialists. tele-ncc expands access to not only consultation on critical neurological emergencies, but also on when to de-escalate from the icu or in end of life discussions with which general icu teams may not be comfortable. these impacts could be measured as important decreases in hospital and icu los. hospital readmissions increase health care costs, increase patient exposure to nosocomial disease, and imply patients were not stable for discharge. because readmissions are a target for hospitals and payers, several centers have developed predictive readmission scores in order to identify high-risk patients. we contend that these general readmission scores are not suitable for neurocritically ill patients and that specific predictive score must be developed to identify high-risk patients. we conducted a retrospective chart review of 340 consecutive patients admitted to our neuroscience critical care unit. we recorded the readmission scores, reason for admission, length of stay,and if they were readmitted. we then compared the median readmission scores between the two groups. after removing patients without readmission scores or died at the end of the original admission,we analyzed the records of 279 patients. patients were more likely to be readmitted if they were initially emergently hospitalized or had malignancy. readmitted patients had a longer original hospital length of stay. we found no difference median readmission score between those who were readmitted, and those who were not. most readmitted patients (65.8%) had an original "low-risk" readmission score. we found that our center's score was poor in predicting readmission for neurocritical care patients and that several components of the score do not apply to our patient population. we propose that to accurately predict readmission,centers should create their own unique readmission scores for more homogeneous admission populations. clinical evaluation of the level of consciousness in non-communicative patients can be very challenging. in this study, we aimed to evaluate the nurses and nursing assistants' (nas) perception of the consciousness on patients suffering from disorder of consciousness (doc). through their activities, nurses and nas have an extended observation time of patient's behavior, and make repeated implicit assessments of patients' clinical state of consciousness. we hypothesized that even in the absence of a structured and explicit evaluation of consciousness (in contrast for instance with the coma recovery scale revised -crs-r), nursing expertise could be a valuable measure to improve assessment of state of consciousness in doc patients. this was a prospective observational single-center study. our primary objective was to correlate the nurses and na's assessment of doc-patients' consciousness quantified through an analogic visual scale (the "doc-feeling score") with the results of the standard methods (including crs-r, fmri, electrophysiology). the secondary objective was to identify elements which correlate with this assessment and/or with the expert's diagnosis (such as visual pursuit, patient's participation to nursing, motor responses to verbal command or adapted reactions to painful care). . linear regression reveals a good correlation between the "doc-feeling score" and the crs-r gold standard (r2 = 0.37, p-value <0.0002, figure 2 ). global assessment of the level of consciousness by all the caregivers interacting with the patient using the "doc-feeling score" is reliable and can improve assessment of state of consciousness in doc patients. investigating causes of deterioration in neurological patients is important to anticipate these complications and improve outcomes. this is a prospective observational study performed at an academic tertiary care trauma, stroke and neurorehabilitation center. data was collected over a year from rapid response system activations (rrsa). in one year, our center had 5388 admissions. 169 rrsa were performed on 140 patients. most common admission diagnosis was ischemic stroke 45 (32%). most common rrsa organ system involvement was respiratory system (n=59, 34.8%). the only predictors of death or new limitation of care in those patients who had rrsa were age (67 years vs 58 years, p <0.01) and history of cancer 8 (26%) vs 11 (19%) p=0.02. 62.1% (n=105) of rrsa happened during day shift and 37.9% (n=64) during night shift. 20.7% (n=35) of rrsa happened around shift change and were more likely to result in an unplanned icu admission. 37.7% (n=63) of rrsa happened within 24 hours of admission and were more likely to result in unplanned icu admissions. the most common reasons for in hospital decompensation in neurological inpatients are nonneurological. most common organ system involvement responsible for rrsa is respiratory system. the only predictors of death or new limitation of care were history of cancer and age 67 and older. rrsa activations were more frequent during day shift. however, there was no different in the outcomes we evaluated between day and night shifts. rrsa happening around shift change wew more likely to result in unplanned icu admission. rrsa within 24 hours of admission showed an increased risk of unplanned icu admission when compared to rrsa happening after 24 hours of admission. neurocritical care is a growing field with an increasing number of dedicated neuroscience intensive care units. in this dynamic context, it is unclear which types of physicians provide neurocritical care across the united states. we performed a retrospective cohort study using claims data from a nationally representative 5% within analyzed critical care procedures . the primary outcome was physician specialty, defined by medicare provider specialty codes. in a sensitivity analysis, we excluded claims for services on the day of admission and claims associated with a diagnosis of cardiac arrest, since these activities may often occur outside of neuroscience intensive care units. we identified between 2009 and 2014, neurologists were responsible for approximately one-quarter of neurocritical care services among a nationally representative cohort of elderly patients. critically-ill patients on mechanical ventilation (mv) cannot verbally communicate. research suggests several phenomena occur in patients during mv because of impaired communication including anxiety, loss of control, loneliness, and compromised interaction (schou and egerod, 2008) . for neurocritical care patients, this can be especially profound when coupled with cognitive and motor/sensory deficits. currently, the blom® speaking valve (sv) is the only approved product available that allows phonation in ventilator-dependent patients with tracheostomy. sv trials are known to facilitate vent-weaning. the current standard of care (passy-muir speaking valve, 30 minute trials), is contra-indicated in patients who cannot tolerate cuff deflation. as such, the blom® sv was evaluated for clinical and quality efficacy. we retrospectively evaluated clinical outcomes associated with blom® sv on mv during a trial in a neuroicu of a large tertiary center between 6/1/2014 and 5/31/2016. baseline demographics, diagnoses, physiologic, sedation, delirium, mobility and swallowing parameters, length of stay, ventilator modes and settings, ventilator days, work of breathing and presence of pneumonia were abstracted along with patient, family and interdisciplinary staff satisfaction survey results. 28 patients were recommended for blom® tracheostomy. 22 patients received sv trials. of the 185 trials were performed, 28% (52) were optimal/completed (30+ minutes); 36% (68) were suboptimal/completed trials (0-29 minutes); 14% (27) unable to complete. satisfaction results from patients/families were positive compared to the interdisciplinary team survey results. remaining parameters currently in analysis with results pending, to be completed by end of august, 2017. impaired communication during mv is suboptimal for neurocritical care patients. our clinical experiences with blom® sv showed positive and negative outcomes. positive benefits were enhanced patient/family engagement and family satisfaction. unanticipated obstacles included significant increase in patient fatigue during sv trials, often delaying ventilator weaning. further study is needed to determine efficacy in this population. patients with clinical signs of cerebral herniation require immediate intervention known as a "brain code". in our neurosciences critical care unit (nccu), a rapid response program is in place to ensure the safety of 23.4% hypertonic saline's use (high risk medication) and to expedite its delivery to the bedside given the emergent need for this medication when ordered. our institution, however, is lacking a more holistic and structured approach to cerebral herniation syndrome that include components of tiers zero to three emergency neurological life support elevated icp or herniation protocol. the neurocritical care communication council consists of bedside staff nurses, nursing leadership, advanced practice providers (nurse practitioners and clinical nurse specialist), pharmacists, respiratory therapists and physicians. the council identified processes during neurological brain codes that could be improved as a result of using a bedside debriefing tool. the unit leadership council of the nccu reviewed literature on hospital debriefing tools and referenced this organizations current resuscitation debriefing tool. from these sources, a brain code debriefing form was constructed. a clinical tool was developed with the expectation of standardizing the brain code process in this nccu. the brain code debriefing form will be piloted to determine unit and system wide value. pre-and postimplementation data will be collected to discover areas of improvement for optimized patient care. through the development of this debriefing tool, it was ascertained that a clinical practice guideline for impending cerebral herniation would be beneficial to further guide and direct evidence-based care. thus, a preliminary algorithm for identification and emergency treatment is in process. the americas medical center is a 212-bed tertiary hospital complex, located in the city of rio de janeiro. the center was elected by the international and the brazilian olympic committees as the referral hospital for the olympic family (of), comprised of athletes and their crews, support and technical personnel, credentialed media and credentialed governmental representatives from the participating countries. the neurology and neurocritical care teams were selected to head a comprehensive program of acute emergency neurology, including a 10-bed neurocritical care unit (nicu), and 24-7 emergency neurology service. we hereby describe our experience during the 2016 olympic games in rio de janeiro, brazil results 63 neurological assessments were conducted in patients from the of, 22 of these involving athletes from 19 countries. the most common reason among athletes were traumatic brain injuries (tbi), with 6 politraumas (all involving cycling), 7 mild tbi (3 of boxing, 2 of field hockey, 1 of rowing and 1 of cycling) and 2 moderate tbi (cycling and water polo). three patients were admitted to the nicu: 2 ischemic strokes and 3 politraumas with tbi. motor vehicle accidents with associated tbi involving the of were surprisingly frequent, with 10 assessments, none requiring admissions. finally, 39 ct scans of head, 22 ct scans of the cervical spine and 14 mri scans (3 brain and 11 spine mri) were performed to assess the patients. of note, cases of seizures, functional deficits, multiple sclerosis flare and psychiatric complaints were observed affecting the of. not only that multiple sports-related injuries were observed, cases of diverse acute neurological issues were reported involving members of the of. olympic games are complex events mobilizing thousands of people, and a comprehensive and detailed plan for neurological emergencies is of extreme importance the term "handoff" has been defined as the "transfer and acceptance of responsibility for patient care that is achieved through effective communication, passing patient-specific information from one caregiver or team of caregivers to another to ensure the continuity and safety of the patient's care" (patterson and wears, 2010) . the joint commission reported that two-thirds of sentinel events occur at the time of patient handoff, which led to a national patient safety goal, requiring standardized process for handoffs (the joint commission on accreditation of healthcare organizations, 2006) . to support this npsg, a nccu specific handoff tool and timeout process were created to support the transition from or to nccu. nccu postoperative handoffs were identified as an area to enhance staff satisfaction and patient safety. baseline data to evaluate the frequency of neurosurgery report was performed in may 2017. using a qualtrics survey in june 2017, staff satisfaction with current ns or report was obtained from nccu rns, nps, and fellows evaluating whether they felt they received: accurate medical history, accurate information about performed procedure, sufficient handoff for patient care, specific patient goals, recent pharmacological intervention, anticipated concerns regarding diagnosis/procedure, estimated blood loss, blood/fluid intake, airway concerns, complications and overall satisfaction with handoff. a taskforce of rns, nps, neurointensivists, and neurosurgeons was established, ending with the creation of a handoff tool and timeout process. the new tool and process were initiated and two months later, a repeat survey was sent to evaluate staff satisfaction and perceived effectiveness of the new process and handoff tool. currently being tabulated at time of submission. using standardized, open communication techniques including handoff tools and a timeout throughout the perioperative period is crucial to positive outcomes and can improve perioperative care in the nccu patient and increase satisfaction and collaboration of all team member during or handoff. in the age of the healthcare reform and rising costs, it is important for strategic service lines to explore cost saving and care efficiency strategies. beginning in september 2016, physician and administrative leadership within the duke neurosciences intensive care unit (neuroicu) began investigating per patient cost to explore opportunities to decrease direct cost to the neuroicu, cost to the patient, and reduce redundancy of care. with assistance from health system finance, the team assessed the following data points within each cost group and compared these values to that of our peers within the us news and world report top honor roll: · number of units · direct cost per unit · total direct cost our performance according to our peers in the following cost areas was: 1.pharmacy-ranked 8th out of 15 2.laboratories-ranked 12th out of 15 3.radiology-ranked 14th out of 15 4.cardiovascular-ranked 14th out of 15. based on these performance metrics, neuroscience administrative and medical leadership developed a project grid of prospective initiatives and identified the following for each cost area: ·stakeholder-led teams inclusive of providers, nursing, and administration ·duration or impact of each initiative: short, medium, or long ·activity phases based on duration the stakeholder-led groups would propose and validate projects based on scope and duration. at each group's meeting, members reviewed charge level financial data by activity code for the group's respective cost area to develop applicable initiatives. multiple initiatives are currently underway including those within the cost areas of pharmacy, laboratories, and radiology. included among these initiatives is a change in routine resistant organism screening and cervical spine clearance. other initiatives will be target intravenous anti-hypertensive treatment and laboratory frequency. the total cost savings from these initiatives can only be estimated at this point but will likely be in excess of $50,000 for the calendar year. it is uncertain whether dedicated neurocritical care units are associated with improved outcomes for critically ill neurologically injured patients in the era of collaborative protocol-driven care. we examined the association between dedicated neurocritical care units and mortality, and the effects of standardized management protocols for severe traumatic brain injury. we surveyed trauma medical directors from centers participating in the american college of surgeons trauma quality improvement program (tqip) to obtain information about icu structure and processes of care. survey data were then linked to the tqip registry, and random-intercept hierarchical multivariable modeling was used to evaluate the association between dedicated neurocritical care (ncc) units, the presence of standardized management protocols and mortality. we performed three sensitivity analyses reclassifying ncc units by restricting to closed units, under ucns director leadership, and exclusion of neurotrauma units. data was analyzed from 9,773 adult patients with isolated severe traumatic brain injury admitted to 134 tqip centers between 2011 to 2013. fifty icus were dedicated neurocritical care units, whereas 84 were general icus. rates of standardized management protocols were similar comparing dedicated neurocritical care units and general icus. care in a dedicated neurocritical care unit was not associated with improved risk-adjusted in-hospital survival (or 0.97; (95% ci 0.80-1.19; p= 0.79). the results from the model were robust in our sensitivity analyses. the presence of a standardized management protocol for these patients was associated with lower risk-adjusted in-hospital mortality (or 0.77; 95% ci 0.63-0.93; p=0.009). compared to dedicated ncc models, standardized management protocols for severe traumatic brain injured patients are low-cost process-targeted intervention strategies that may improve clinical outcomes. understanding the differences in processes of care within the context of icu structure is necessary to better understand mortality differences observed between centers, and may help in the design of future trials for severe tbi patients. complex multidisciplinary care of patients in the neurocritical care unit requires reliable and effective communication to minimize medical errors. we implemented a structured rounding process that incorporates ahrq-endorsed team strategies and tools to enhance performance and patient safety (team stepps) to improve interprofessional collaboration between team members. we convened a project team of physicians, advanced practice providers (apps), nurses, respiratory therapists, and pharmacists in a 16-bed nicu. we defined structured rounding processes and implemented team stepps strategies to promote closed-loop communication between team members during daily rounds. the assessment of interprofessional team collaboration scale (aitcs-ii) was administered to team members at baseline and 16 months post-intervention. impact on overall team collaboration and subscale domains of team partnership, cooperation and coordination was assessed. the possible range of the overall collaboration score is 23 to 115; higher scores indicate better collaboration. the survey was completed by 61 (85%) staff at baseline, and 54 (77%) staff post-intervention. overall team collaboration scores improved significantly pre and post-intervention (78.0 ± 18 vs 89.7 ± 15, p < .001), as did subdomain scores of team partnership (27.9 ±6.9 vs 31.9 ± 5.2, p < .001), collaboration (28.1 ± 6.3 vs 32.1 ± 5.7), and coordination (22.1 ±6.6 vs 25.7 ± 5.7., p < .001). perceived shared understanding of patient daily goals between nurses and providers (physicians/apps) increased from 58% to 91% (chi-square 15.7; p < .001). 68% of staff reported that the intervention shortened or did not affect the duration of rounds. of those who reported longer duration of rounds, 100% responded that the intervention was worthwhile. interprofessional team collaboration can be enhanced by structured rounding and communication workflows. by promoting closed-loop communication during daily rounds, shared understanding of patient daily goals between team members is increased, and may optimize quality and safety of patient care. advanced practice providers (apps) are increasingly utilized to provide clinical care within neurocritical care units (nsicu) . despite the complex issues in this patient population, the specific educational and orientation needs of these providers have not been established. to meet the demands for rapidly and effectively training apps to provide advanced neurocritical care (ncc), a structured educational curriculum was developed and integrated within the standard orientation and on-boarding process for newly-hired app within our nsicu. this curriculum was designed with measurable learning goals, objective assessments of goal achievement, and opportunities for additional education and remediation at multiple steps within the program. the curriculum has three phases with distinct goals and assessments. phase i covers basic triage and resuscitation issues for the acutely-decompensating patient. phase ii covers general critical care principles in significantly greater depth. phase iii provides detailed experience and exposure to specific ncc issues. each phase incorporates relevant reading assignments with a tailored study guide, as well as a multiple-choice question post-test to demonstrate knowledge acquisition. phases ii and iii also include an oral exam incorporating hypothetical patient scenarios to allow the app to demonstrate comprehension and application of the goals for each phase. each phase lasts approximately 4 to 8 weeks with the expectation that the entire orientation curriculum will be completed within six months of employment. in addition to the educational curriculum, phases i and ii include working alongside a more senior app preceptor and providing bedside care for a progressively increasing number of patients. apps not meeting minimum established standards on any aspect of the curriculum are provided additional remediation and instruction by the preceptor and ncc faculty based on an individualized learning plan. a standardized educational curriculum provides a structured learning environment for new apps in the field of neurocritical care. reimbursement changes from the centers for medicare and medicaid services and value based purchasing systems have made quality improvement linked to clinical outcomes more crucial than ever. in one neuroscience icu, providers and nurses collaborate to address key infection parameters that impact patient outcomes. quality metric data in one neuroscience icu was collected over a period of 3 fiscal years. outcome measures, consisting of glycemic and temperature control, and ventilator weaning strategies, were obtained after certain parameters were enforced over two years and then compared to the initial year. the urinary catheter utilization has decreased by over 10%, with catheter associated urinary tract infections decreased by 80% in 3 years (p-value <0.0001). central line utilization decreased by 5%, with a 60% decrease in central line associated blood stream infections in 3 years (p-value 0.45). new ventilator weaning strategies were put into place utilizing adaptive support ventilation mode, which decreased total ventilator days by 1000 days/year . successful weaning and extubations resulted in no recorded ventilator-associated pneumonia in the last 3 years. this neuroscience icu maintains glucose below 180mg/dl more than 85% of the time. regarding temperature control data, a normothermia protocol was implemented that utilizes aggressive temperature control coupled with bromocriptine administration. as a result, 95% of patients had a temperature less than 38°c. all of the quality initiatives that have been implemented have improved the observed/expected mortality ratio by 4.4%. this study shows that by optimizing infection control, temperature management, glycemic control and ventilation strategies, there is an overall positive impact on the patient's morbidity and mortality. as evidenced by these results, this institution is now a top performer when compared in a national clinical database. this presentation will share the pragmatic strategies to create a culture of quality improvement in any neurocritical care unit or patient care organization. health care records are not accessible universally at point of care delivery. in developing countries like thailand a large proportion of health care records are still paper based. patients may not able to convey relevant information about their own medical problems and medications during patient-physician encounters or in the event of emergency. our purpose was to create a simple platform for recording relevant basic healthcare information through a system that can be securely accessed even in countries like thailand. our vision is to improve healthcare communications and leverage social media in thailand and other developing countries, particularly for patients with lower levels of education or socioeconomic status. we created a cloud-based personal healthcare information platform 'meid' that uses a qr code scanned from wristbands and other products like stickers to access patient information. conventional methods require a treating team to request medical records from a patients' prior hospital visits including visits at different medical facilities. time lost during this process can potentially cause delay in treatment decisions. we also aim to improve health literacy in thailand. application name 'meidth' is available in both apple store and google play. we launched meid in thailand in april of 2017. we have more than 1,000 active users and have sold more than 3000 wristbands. the meid thailand facebook page has received 20,367 likes. there are at least two patients that have already benefited from this product: one of these patients received intravenous tissue plasminogen and had a good outcome. timely access to his past medical history and medications via meid was a key in this case. our cloud based personal healthcare information platform using qr codes from wristbands and stickers can help increase health literacy, decrease times to appropriate treatment, improve patient safety and decrease healthcare costs. clinical pharmacists have become an integral part of multidisciplinary medical teams. expanding the role of pharmacists in the neurocritical care units has the potential to positively impact the quality of patient care and provide costs savings. this study examines these potential benefits at one neurocritical care unit. we reviewed patient medication profiles and had formal rounds with a pharmacist four times per week. for the purposes of this study, the focus was on minimization of a select number of high expense drugs. nine months of baseline data was compared to three months of post intervention data. interventions were performed at the time of rounding, which involved timely conversion to enteral formulas, changes to alternative medications or discontinuation of medications. we then performed a cost-benefit analysis to assess the net amount of money saved by reducing inappropriate pharmacy drug use following the interventions. average cost of nicardipine was $34,122 pre-intervention, compared to $23, 871 post-intervention (pvalue 0.0229). the cost of iv levetiracetam usage on average was $4,719 pre-intervention and $3,612 post-intervention (p-value 0.102), while the cost of iv dexmedetomidine was $2355 pre-intervention compared to $1800 post-intervention (p-value 0.5226). average expense per month was reduced by approximately $11,900 per month compared to the average expense per month from the previous 9 months (p-value 0.0128). appropriate use of stress ulcer prophylaxis was also positively impacted; patient days/month on famotidine was reduced by approximately 30% from baseline, 222 patient days (pre-intervention) vs 150 days post-intervention. pharmacist interventions within a neurocritical care unit are known to be beneficial clinically for patients, however this study also shows that their interventions offer substantial cost benefits and should justify creating collaborations between pharmacists and neurointensivists. multi-disciplinary rounds have been shown to improve patient outcomes. the objective of this study is to observe the effect on patient care, team dynamic, and nursing satisfaction before and after the implementation of a nursing-led rounding model in the neurological icu. prior to the implementation of the nursing-led rounds quality initiative, nurses in the neurointensive care unit (nicu) were asked to answer a brief survey on basic demographics and perceptions of team dynamics and satisfaction in the nicu. a multidisciplinary systems-based rounding sheet inclusive of the abcdef bundle and previous nicu checklist was created and revised with extensive bedside and senior nursing educator input. while rounding, nurses presented and clinicians were to in real-time come up with an assessment and plan and relay these to the nurse and other team members. any questions, educational pearls or concerns by the clinician team or the bedside nurse were encouraged during these rounds. nurses completed a 6 month post-implementation survey. 42 of the full-time nicu nurses (71%) responded to both the pre-implementation and postimplementation surveys. a bimodal distribution of nursing experience was noted with 41% new nurses (<1 year) and 31% experienced nurses (5 years+). more than half of the nurses (68%) reported doing both night and day shifts as opposed to being exclusive to only day or night. there was an increase in the nursing perceptions of participation during rounds as well as education during rounds. nurses felt significantly more involved with patient decision making and felt that they were able to give input into the patients care. the implementation of a nursing-led rounding structure may be beneficial to communication, education and overall patient care. as the project continues, we hope to further examine common icu objective measures as well as other subjective measures such as patient satisfaction scores and communication perceptions. with increased elective and non-elective volume, directing the flow of admissions has become essential to the efficient operation of inpatient strategic service lines. this is especially true in the neurosciences where widespread acute ischemic stroke intervention has placed an especially high demand on comprehensive stroke centers. as a result, an important collaboration was formed at duke between the health system, transfer center and neurosciences to create an algorithm-driven multi-hospital triage and pre-hospital care system called phast (pre-hospital acute services team). in this abstract, we present the formation and current state of this service. this effort was formally begun in the spring of 2015 with an initial focus on centralizing the admission process into the duke neurosciences intensive care unit (neuroicu) by an icu physician. after some initial success, it was clear that the service line would benefit from a more formalized process. as a result, a successful multidisciplinary collaboration with a core group of physicians and administrators was formed to develop algorithms and to overcome multiple administrative and legal hurdles. over a period of 24 months, multiple algorithms were developed to systematize neuroscience admissions including acute ischemic stroke and vascular and non-vascular neuroscience emergencies. in an effort to decrease door-to-intervention times as well as effectively mitigate the impact of limited bed-space availability, this system now serves 3 hospitals including 2 with acute neurointerventional services and the 3rd with a burgeoning neurohospitalist program and incorporated rehabilitation services. in addition to systematizing the transfer and admission process, quality assurance, improvement, and educational processes are in a place. the current state of phast is that of a young but maturing and now essential service for duke neurosciences. extubation involves removal of an endotracheal tube (ett) and is a common intensive care unit (icu) procedure. extubation failure occurs in 8-20% of icu patients and can be difficult to predict accurately. we hypothesized that a multivariate re-intubation scale calculation (risc) model could predict extubation failure better than a single variable like rapid shallow breathing index (rsbi). after irb approval, we conducted a retrospective review of data on mechanically ventilated icu patients above 18 years of age who were not receiving mechanical ventilation through a tracheostomy tube from january 1, 2006, through december 31, 2015 at mayo clinic rochester. various data points were gathered on these patients via electronic medical records search, and reintubations within 72 hours of extubation were identified. univariate and multivariate logistic regression models were used to predict reintubation after extubation and construct a risc estimate. we included a total of 6161 patients which were randomly divided into a derivation set (n=3080) and validation set (n=3081). in the derivation set, patients had a mean age of 62±17 years, and 59% were men. three hundred and ninety three extubation failures occurred within 72 hours. predictors of extubation failure included underweight status, gcs score>=10, mean airway pressure at 1 minute=1500ml and total mechanical ventilation days>=5 in the final multivariable model. risc score was calculated using the validation set and ranged from 0 to 8. logistic model result shows that, as risc increased by 1, the odds of having extubation failure was 1.6 fold higher (c-index=0.72). roc analysis shows that the best cut off for risc was >=4 vs. <4, which demonstrated a sensitivity of 0.80, specificity of 0.54 and auc=0.67. the current risc model warrants further exploration in a prospective study to help critical care providers to decide when extubation can be done more safely. this report presents results of the 2nd nationwide survey concerning neurocritical care units (ncus) in china. this is an observational cross-sectional survey and close-ended self-reported questions were used. the questionnaire was sent to 31 different provinces (autonomous regions and municipalities) across china from october 1st, 2015 to january 1st, 2016. basic information, equipment and device information, and staffing and organization information were investigated. in total, 101 questionnaires from 101 ncus at 92 hospitals in 28 regions were received. most of the hospitals with ncus were large-scale (average hospital beds: 2150), teaching (84.8%), and tertiary hospitals (97.8%). the average number of ncu beds was 14, occupying 11.2% of the total number of beds in their department. most of the equipment and devices (37/50) were available in over 80% of the 101 ncus. however, some devices were centralized by hospital and operated with assistance from other departments. a total of 1250 full-time doctors and 1978 full-time nurses were employed at the ncus. a few of the ncus achieved a doctor-to-bed ratio of 0.5:1 (40.6%) and a nurse-to-bed ratio of 1:1 (37.6%). and respiratory therapists, clinical dieticians, clinical pharmacists, and physiotherapists were present in 5.9%, 32.7%, 36.6% and 49.5% of the 101 ncus. the number of ncus increased, the availability of ncu equipment became more sufficient, and the staffing of ncus improved. however, we should pay attention to the management of specialized ncu equipment, the shortage of ncu staff, and the need of ncu training. automated devices collecting quantitative measurements of pupil size and reactivity are increasingly used for critically ill patients with neurologic disease. however, there is limited data on the effect of ambient light conditions on pupil metrics. to address this issue, we we tested the range of pupil reactivity in healthy volunteers in both light and dark conditions. we measured quantitative pupil size and reactivity in seven healthy volunteers with the neuroptics-200 pupillometer in both bright and dark ambient lighting conditions. bright conditions were created by overhead led lighting in a room with ample natural light. dark conditions consisted of a windowless room with no overhead light source. the primary outcome was the neurologic pupil index (npi), a composite metric ranging from 0-5 in which >3 is considered normal. secondary outcomes included resting and constricted pupil size, change in pupil size, constriction velocity, dilation velocity and latency. results were analyzed with multi-level linear regression to account for both inter and intra-subject variability. seven subjects underwent ten pupil-readings in bright and dark conditions, yielding 140 total measurements. mean resting pupil sizes were 3.56 v. [13.8-16.4 ], p<0.001). all additional secondary outcomes except latency were also significantly different between conditions. we found that ambient light levels impact pupil parameters in healthy subjects. however, changes in npi are small and more consistent in varying lighting conditions than other metrics. further testing of patients with poor pupil reactivity is necessary to determine if ambient light conditions could influence clinical assessment in the critically ill. practitioners should standardize lighting conditions to maximize the reliability of their measurements. neural stem cells (nscs) are known to have anti-inflammatory effect in strokes in previous studies. however, the mechanism of anti-inflammatory effect in direct co-culture with nscs in hemorrhagic stroke remains unclear. the aim of this study was to investigate whether direct co-culture with nscs modulates hemolysate-induced inflammation in raw 264.7 cells. we stimulated raw 264.7 cells with hemolysate to induce hemorrhagic inflammation in vitro. hemolysate-activated raw 264.7 cells were co-cultured with hb1.f3 directly for 4 hours. following direct co-culture, the production of cycloxygenase-2 (cox-2), interleukin-signal regulated kinase (erk) were assessed by western blotting, and tumor necrosis factor (tnfevaluated by enzyme-linked immunosorbent assay (elisa). hemolysate generates an activation of inflammatory response in raw 264.7 cells. direct co-culture with hb1.f3 significantly suppressed the phosphorylation of erk 1/2 in hemolysate-activated raw 264.7 cells. the expression of inflammatory mediators such as cox-2, il-by direct co-culture with hb1. f3 cell. in addition, the expression of cox-2, il-attenuated by erk inhibitor (u0126). our results demonstrated that direct co-culture with hb1.f3 cells reduced the inflammatory responses in hemolysate-activated inflammation via suppressing erk1/2 pathway. this suggests that nscs treatment can suppress the inflammatory response in hemorrhagic stroke. no pharmacological intervention improves outcomes after primary intracerebral hemorrhage (ich). we developed a novel therapeutic approach based on known biological function of endogenous apolipoprotein e (apoe). apoe is a key mediator of neuroinflammatory responses and modifies recovery from a variety of acute and chronic brain injuries. unfortunately, intact apoe holoprotein does not cross the blood brain barrier (bbb) and cannot be administered as a neurotherapeutic. we created apoemimetic peptides that cross the bbb and down-regulate neuroinflammatory responses in vitro and in vivo. cn-105, our lead candidate, is a 5-amino acid apoe-mimetic peptide derived from apoe's receptorregion. cn-105 retains anti-inflammatory and neuroprotective effects of intact apoe, was well-tolerated in preclinical studies, readily crosses the bbb, and demonstrates excellent pharmacokinetic, safety, and tolerability profiles in phase 1 studies. this is a multicenter, open-label phase 2a trial of cn-105 in patients with acute primary supratentorial ich. a total of 60 participants between the ages 30 and 80 years across 4 study centers, with a confirmed radiographic diagnosis of spontaneous, primary supratentorial ich. patients will be evaluated for eligibility within 12 hours of symptom onset. eligible participants will receive cn-105 intravenously over 30--minute infusion every 6 hours up to 3 day maximum. participants will be monitored daily throughout the treatment phase and receive standard-of-care treatment for the duration of the study. primary: to assess safety of cn-105 administration in primary ich. secondary: to evaluate effects of cn-105 administration on 30--day mortality and functional outcomes. exploratory: to investigate feasibility of radiographic surrogates of clinical outcomes using perihematomal edema measurements on serial brain ct and mri, and investigate feasibility of serial biochemical markers of neuroinflammation as surrogate measure of perihematomal edema and clinical outcome. cn-105 represents a first-in-class agent now entering phase 2 clinical trials in patients with acute ich. novel oral anticoagulant (noac) associated intracranial hemorrhage is a life-threatening condition for which activated prothrombin complex concentrate factor eight inhibitor bypassing activity (feiba) may be used for reversal. few studies report its use in spontaneous or traumatic intracranial hemorrhage. our institutional protocol is reversal with feiba 25 units/kg and escalating doses as needed. the safety and efficacy of this protocol was assessed. we performed a retrospective review of adult patients presenting to a level 1 trauma center between 2014-2016 with spontaneous or traumatic intracranial hemorrhage while on a noac . we evaluated the medication they presented on, indication for anticoagulation, location and size of the hemorrhage, presentation gcs, dosage of feiba recieved, change in size of hemorrhage on serial imaging as well as time between serial images, complications from reversal, and need for blood product transfusion. we identified 19 patients with an acute intracranial hemorrhage while on noacs. patients underwent a baseline head ct documenting acute intracranial blood, were reversed with feiba (25 u/kg), and underwent repeat imaging 6 hours later per protocol. ten (59%, 10/17) patients had no increase in hematoma volume on repeat imaging. two underwent neurosurgical procedures (aneurysm coiling, sub-occipital craniectomy) without intra-operative bleeding complications. five (29% 5/17) patients had clinically insignificant increase in size of hemorrhage. of those, one underwent a subsequent neurosurgical procedure, which was already anticipated. two (12%, 2/17) patients had clinically significant hematoma enlargement. of those, one underwent urgent craniectomy (indicated based on initial presentation) and one required a ventriculostomy for hydrocephalus. two patients had no repeat imaging. adjusted dose feiba (25 units/kg) may be an effective alternative to standard dose (50 unit/kg) for reversal of noacs in acute intracranial hemorrhage. our experience showed clinically significant hematoma expansion in 12% of patients and no increase in unplanned neurosurgical procedures after reversal with feiba. here we sought to determine if there is an association between recanalization success and rate of hemorrhagic transformation amongst patients who have undergone intra-arterial thrombectomy for ischemic stroke secondary to anterior circulation large vessel occlusion (lvo), many treated at extended time from last seen well (lsw) after mri assessment. stroke patients with anterior circulation lvo treated with thrombectomy between april, 2011 to june, 2017 were studied. group-wise comparisons were made between patients with post thrombectomy hemorrhage (as confirmed by a single, blinded neuro-radiologist reviewer) and patients without hemorrhage. failed or incomplete recanalization was defined as mtici < 2b. symptomatic intracranial hemorrhage (sich) was defined as validated hemorrhagic conversion or parenchymal hematoma plus 4 point decrease in nihsss. pertinent baseline characteristics were recorded and analyzed. sich was more prevalent amongst patients with tici<2b recanalization (or 2.76 [95ci 1.33 -5.71]). interestingly there was a low rate of sich amongst patients with tici=0 recanalization (2/12 [16.7%]). although many patients were treated at advanced time lsw no excess rate of sich was observed. baseline characteristics including age, presentation nihss, and presentation aspects were similar among the two groups. rates of sich are low after successful mri seleted thrombectomy regardless ot time lsw. patients with poor recanalization show increased rates of sich in keeping with past literature. our data suggest that thrombectomy after mri selection may be safe and effective for patients at extended time lsw of tor patients with unknown lsw. cta spot sign is associated with hematoma growth, a common complication of intracerebral hemorrhage (ich) that portends worse outcomes. magnesium and calcium are cofactors in the clotting cascade and for platelet aggregation. we tested the hypothesis that magnesium and calcium levels are associated with the presence of the cta spot sign. patients with spontaneous ich presenting to northwestern memorial hospital were identified from a prospective observational registry. inclusion criteria included cta obtained within 24 hours of symptoms onset and admission magnesium and calcium levels. cta spot sign (active contrast extravasation on ct angiography) was identified by a board-certified neurointensivist or neuroradiologist. variables suggesting association with spot sign at p<0.1 were assessed for inclusion in a logistic regression model, and a parsimonious predictive model for ct spot sign was developed using backward stepwise variable selection. 146 patients (age 63 ± 14.5 years, 47% male, median ich score 1 [iqr 1-3]) were included. seventeen (11.6%) patients with cta spot sign were identified. admission magnesium was 1.96 +/-0.27 and calcium was 9.27 +/-0.56. lower magnesium (or 0.074, 95% ci 0.007-0.746, p 0.027), lower calcium (or 0.390, 95% ci 0.156-0.973, p 0.044), and higher ich score (or 1.98, 95% ci 1.28-3.07, p 0.002) were independently associated with ct spot sign. magnesium and calcium level on admission are associated with the presence of a cta spot sign in patients with ich. magnesium and calcium supplementation may be attractive therapeutic targets for preventing harm from hematoma growth. cerebellar intraparenchymal hemorrhage (iph) is a rare and likely underreported complication of subdural hematoma (sdh) evacuation. we present two cases of post-operative iph and review the literature. case 1. an 83-year-old man underwent craniotomy for evacuation of a chronic right frontoparietal sdh. post-op ct showed pneumocephalus. the patient was extubated and clinically improved. three days post-operatively, he became lethargic and a ct brain revealed a 4cc right cerebellar iph. he was unable to safely swallow, declined a feeding tube and died under hospice care nine days later. case 2. a 72year-old man underwent craniotomy for evacuation for a left convexity sdh. routine post-op ct revealed an incidental left cerebellar iph. he returned to baseline one month later. only four such cases have been reported in the literature (1-4). two cases led to death within one week and two recovered, one with significant deficits. five more occurred following burr hole drainage of sdh and two others following drainage of subdural hygromas (2, 5-10). the incidence of cerebellar iph following supratentorial craniotomy has been reported in up to 0.29% of cases with significant morbidity or mortality (3). it occurs irrespective of age, pre-existing coagulopathy or arteriovenous malformations. size of insult and amount of csf loss do not correlate to iph, despite the fact that cerebral blood flow imaging shows over-drainage of cerebrospinal fluid (csf), causes intracranial hypotension and subsequent damage to dural veins (3,11). iph also occurs independently of operating room position, even though having the head turned is thought to compress venous drainage in the neck and cause congestion (3). cerebellar vasculature may be more sensitive to changes in intracranial pressure, though why this does not lead to complications more routinely is not clear. cerebellar iph should be considered in cases of neurological decline after sdh evacuation. intracerebral hemorrhage (ich) location predicts outcome, but most studies have examined differences between deep, lobar, and infratentorial locations. this study aims to characterize specific deep ich locations in a diverse cohort. the ethnic/racial variations of intracerebral hemorrhage (erich) study is a multi-center, prospective, u.s.-based study. 1345 subjects with supratentorial deep ich, known ich volume, and three-month follow-up data were included. logistic regression was used to evaluate the association between location and poor outcome (mrs > 3). receiver operating curve (roc) analysis was performed to identify ich volumes specific for poor outcome by location. 671 thalamic, 581 putaminal, and 83 caudate ichs were included. median ich volume was largest in putamen (15 ml), followed by thalamus (9 ml) and caudate (4 ml, p<.001). intraventricular hemorrhage (ivh) was most prevalent in caudate (94%), followed by thalamus (65%) and putamen (23%, p < 0.001). subjects with thalamic ich were older (62 vs 57 vs 58 years, p < 0.001) and more likely hypertensive (91% vs 85% vs 82%, p= 0.002) than those with putaminal and caudate ich, respectively. compared to thalamic, putaminal ich had more ich expansion (23% vs 15%, p < 0.001) and surgery (20% vs 14% p = 0.004) but fewer external ventricular drains (15% vs 27%, p < 0.001). thalamic location predicted poor outcome (or 2.25, 95% ci 1.35-3.73) at 90 days after adjustment for age, sex, premorbid disability, ich volume, ich expansion, ivh, and admission gcs. roc analysis identified 10 ml for thalamic and 29 ml for putaminal ich without ivh as having 95% specificity for poor outcome. there are significant differences in characteristics and outcomes within deep ich. specificity estimates for the identified ich volume thresholds require external validation. these findings may have implications for prognostication and clinical trial design. racial differences in outcome after intracerebral hemorrhage (ich) among asians, native hawaiians and other pacific islanders (nhopi) have been inadequately studied since these racial groups have been historically aggregated into a single racial category. a multiracial prospective cohort study of ich patients was conducted from 2011 to 2016 at a tertiary center in honolulu, hi to assess racial disparities in come after ich. favorable outcome was defined as 3month modified rankin scale (mrs) score £ 2. patients with no available 3-month functional outcome, race other than asians and nhopi, and baseline mrs >0 were excluded. multivariable analyses using logistic regression were performed to assess the impact of race on favorable outcome after adjusting for the ich score, early do-not-resuscitate (dnr) order and dementia/cognitive impairment. a total of 220 patients (161 asians, 59 nhopi) were studied. overall, 65 (29.5%) achieved favorable outcome at 3 months. nhopi were younger than asians (51.8±15.3 vs. 63.9±16.7 years respectively, p<0.0001), and had higher prevalence of diabetes (39.0% vs. 21.1% respectively, p=0.007), obesity (58.9% vs. 23.1 respectively, p<0.0001), and lower prevalence of early dnr order (3.4% vs. 24.2% respectively, p=0.0004) and advance directive presence (6.8% vs. 29.2% respectively, p=0.0005). nhopi race was a predictor of favorable outcome in the unadjusted model (or 2.47, 95% ci: 1.32, 4.62) and after adjusting for the ich score (or 2.30, 95% ci: 1.06, 4.97) but not in the final model (or 2.04, 95% ci: 0.94, 4.42) . in the final model, the ich score remained as the only independent negative predictor of outcome (or 0.26, 95% ci: 0.17, 0.41 per point). nhopi are more likely to achieve favorable functional outcome after ich compared to asians even after controlling for ich severity. however, this association was attenuated after adjusting for dnr status and baseline cognitive factors. intracerebral hemorrhage (ich) patients often require continuous antihypertensive infusions. we sought to identify clinical and care process predictors of anti-hypertensive infusion duration, and tested whether infusion duration independently predicts intensive care unit length of stay (icu los) after adjusting for validated measures of ich illness severity. we identified spontaneous ich patients admitted 12/2013-9/2015 to a tertiary center, excluding those transitioned to comfort care within 24 hours. we abstracted demographic and clinical variables from the medical record. we calculated the total duration each patient received continuous infusion of an antihypertensive medication. we categorized glasgow coma scale score as 14-15; 8-13; or < 8. two reviewers independently classified ich location and etiology. we determined univariate associations of clinical variables to anti-hypertensive infusion and performed regression analysis to determine the effect of continuous infusion on icu los. we identified 495 spontaneous ich patients and excluded 50 for early comfort care. in the remaining 445, mean age was 70 [69-71] years, 45% were female, median ich score was 1 [1-2], and 44% had lobar hemorrhages. continuous infusion included nicardipine, clevidipine, labetalol and diltiazem. a total of 127 (28%) patients received anti-hypertensive infusions, mean 13 hours. mean time to enteral antihypertensive administration medication was 32.5 hours, and mean icu length of stay was 3.4 days [3.0 -3.8]. predictors of longer antihypertensive infusion duration were male gender (p=0.003), non-lobar ich (p=0.0002), non-caucasian race (p<0.001), younger age (p<0.0001), higher initial systolic (p=0.03) and diastolic bp (p=0.01), worse gcs category (p<0.001), and longer time to first enteral medication (p<0.0001). anti-hypertensive infusion duration independently predicted icu los (p<0.0001) after adjusting for age, race, gcs category, time to enteral antihypertensives, and ich score. worse gcs category, younger age, non-lobar ich location, and race are significant independent predictors continuous iv antihypertensive infusion duration, which is significantly associated with longer icu stay. patients with sich have a high risk of vte. pharmacological prophylaxis such as unfractionated heparin(ufh) has been demonstrated to reduce vte. however, published datasets exclude patients with recent ich out of concern for hematoma enlargement. aha/asa guidelines recommend ufh 1-4 days after hematoma stabilization while the eso has no recommendations on timing of ufh. there are few data for patients who received ufh before 48 hours. our institutional practice is to begin ufh following sich after 24 hours of clinical and radiographic stability. we examine the impact of this practice on risk of hematoma expansion. we performed a retrospective cohort analysis of 87 sich patients admitted in 2012-2013 to a single us university hospital. demographic and clinical characteristics were abstracted. ich was measured via 3d volumetrics for an admission ct, a 24 hour follow-up, and a follow-up prior to discharge. percent hematoma growth between 24-hour ct and discharge ct was calculated. risk factors for expansion >5%, including early heparin use, were analyzed via oneway t-test and chi-squared tests. results 87 sich patients analyzed had a median ich score of 2(iqr1-3) and median admission gcs of 10(iqr6-13). 39%(34/87) patients received early ufh. 18%(16/87) suffered hematoma expansion >5%. overall mean hematoma growth was higher with early ufh (ufh24hr -15%,p=0.0007). in multivariate analysis, ich score, gcs and initial hematoma size did not predict >5% hematoma expansion. early vte prophylaxis at 24 hours from sich had a statistically significant increase in hematoma size, but this increase is clinically insignificant. in this cohort, early ufh did not increase risk of significant hematoma expansion. further prospective trials are warranted, given the high risk of vte in this population. antiplatelet therapy at the time of spontaneous intracerebral hemorrhage (sich) may increase the risk of hemorrhage expansion and mortality. current guidelines recommend consideration of a single dose of desmopressin in sich associated with cyclooxygenase-1 inhibitors or adenosine diphosphate receptor inhibitors. this study sought to compare outcomes in patients that received desmopressin for antiplatelet reversal in the setting of sich to similar patients that did not receive desmopressin. this retrospective chart review of the electronic medical record included adult patients admitted for sich that were on antiplatelet agents at the time of diagnosis. patients that received desmopressin were compared to similar patients that did not receive desmopressin. exclusion criteria included traumatic brain injury, active coagulopathy and thrombocytopenia. the primary outcome was the incidence of hematoma expansion. additional outcomes included average increase in hematoma volume, in-hospital mortality and functional outcome at hospital discharge. overall, 73 patients (36 received desmopressin, 37 did not receive desmopressin) were included for analysis. incidence of hematoma expansion was not different between groups (36% with desmopressin vs 22% without desmopressin, p=0.17). average largest increase in hematoma volume on follow-up imaging from baseline was not different (10.5±16.7 ml with desmopressin vs 10.2±26.7 ml without desmopressin, p=0.96. in-hospital mortality was significantly higher in the desmopressin group (20% vs 8% without desmopressin, p=0.016) as well as the incidence of a modified rankin score of 4-6 at discharge (39% vs 28% without desmopressin, p=0.029). administration of desmopressin for antiplatelet reversal in sich does not appear to reduce the incidence of hematoma expansion. further studies assessing temporal relation of desmopressin administration and hematoma expansion are needed to confirm the results of this single-center retrospective study. clinical outcome after intracerebral hemorrhage (ich) remains poor. definitive phase-3 trials in ich have failed to demonstrate improved outcomes with intensive systolic blood pressure (bp) lowering.we sought to determine whether other bp parameters-diastolic bp, pulse pressure (pp), and mean arterial pressure (map)-showed an association with clinical outcome in ich. we retrospectively analyzed a prospective cohort of 672 patients with spontaneous ich and documented demographic characteristics, stroke severity, and neuroimaging parameters. consecutive hourlybp recordings allowed for computation of systolic bp, diastolic bp, pp, and map. threshold bp values that transitioned patients from survival to death were determined from roc curves. using inhospital mortality as outcome, bp parameters were evaluated with multivariable logistic regression analysis. patients who died during hospitalization had higher mean pp compared to survivors (68.5 ±16.4mmhg vs. 65.4 ±12.4 mmhg; p=0.032). the following admission variables were associated with significantly higher in-hospital mortality (p < 0.001): poorer admission clinical condition, intraventricular hemorrhage, and increased admission normalized hematoma volume. roc analysis showed that mean pp dichotomized at 72.17 mmhg, provided a transition point that maximized sensitivity and specific for mortality. the association of this increased dichotomized pp with higher in-hospital mortality was maintained in multivariable logistic regression analysis (or 3.0; 95%ci 1.7-5.3; p < 0.001) adjusting for potential confounders. widened pp may be an independent predictor for higher mortality in ich. this association requires further study. a national confidential enquiry into patient outcome and death (ncepod) report concerning management of aneurysmal subarachnoid haemorrhages in the uk suggested up to half of patients received suboptimal consideration for organ donation. as demand for organs continues to increase, so does the need to pursue all potential sources of donor organs. subarachnoid haemorrhages have an estimated mortality of 50% and can potentially provide younger donor organs with less chronic pathology. this is a comprehensive picture of donation rates within a tertiary centre. retrospective data regarding all deceased patients on the neuro-intensive care unit during 2016 with aneurysmal subarachnoid haemorrhage as the cause of death was obtained from the nhs blood and transfusion team. the local audit committee provided ethical approval. data regarding organ donation was extracted and compared to national data, then analysed using fisher's exact test. referral rates were 100%. this is greater than the national average of 57.7% (p=0.001), yet only 30.8% of referred patients proceeded to organ donation. consent was withheld in 52.8% of potential donors. nationally 37.9% of donors are lost due to non-consent (p=0.235). 32.1% of consented patients were unable to donate organs, similar to national figures (p=1.00). referral rates within this centre are excellent; consent remains the main obstacle. consent rates can be improved using a long contact model where specialist nurses in organ donation establish relationships with relatives prior to any discussion of donation. the ideal discussion is a pre-planned collaboration involving a senior doctor and a specialist nurse. early brain stem testing may facilitate earlier acceptance of death by relatives whilst reducing the duration of the multi-systemic effects of the associated hyperresponsive cascade on donor organs. neurosurgeons should be encouraged to suggest organ donation when declining referrals. further work is needed to assess the barriers to instituting these measures and inspiring change. spontaneous brainstem hemorrhage has been historically associated with high mortality. however, updated data on the frequency and outcome of spontaneous brainstem hemorrhage is scarce vis-a-vis advances in neuro-critical care. the purpose of this study was to investigate the frequency and outcome of spontaneous brainstem hemorrhage. records of consecutive intracerebral hemorrhage (ich) patients presenting to an urban academic medical center from january 2010 though december 2015 were reviewed. cases with brainstem hematomas were isolated for analysis. data on demographics and outcomes were collected and analyzed. sub-group analysis was also done to look at outcomes based on location of hemorrhage in the brainstem. of 181 consecutive spontaneous ich patients, 13 (7.18%) presented with brainstem hemorrhage; 7 (53.8%) were pontine, 2 (15.4%) mesencephalic, and 4 (30.8%) were located in both the pons and the midbrain. the average age was 52.92 years and (38.46%) were men. median glasgow coma scale on presentation was 6.5. thirty-day mortality rate was 62.5%, with 6 in-hospital deaths and 2 deaths post discharge. two and 3 patients were discharged home or a rehabilitation facility, respectively. in subgroup analysis, thirty-day mortality for midbrain, pons and combined pons/midbrain hemorrhage was 0%, 57% and 100%, respectively. spontaneous brainstem hemorrhage remains an uncommon but highly fatal clinical entity. more than one-half die within 30 days. only a minority are discharged to rehabilitation or home. in sub-group analysis, location of brainstem hemorrhage was shown to influence outcome, with 100% mortality in case of combined pons/midbrain hemorrhage, and more than 50% mortality with pontine hemorrhage. midbrain hemorrhage was associated with good outcome with 100% survival. patients with intracerebral hemorrhage (ich) frequently present with hypertension. it is unclear whether this is due to preexisting hypertension (prhtn) causing the bleed, an effect of the bleed, or both. we retrospectively analyzed a single-institution cohort of ich patients presenting between 2013 and 2016. data included home antihypertensive use; asbp; tte, and ekg and imaging results; and nicardipine administration. the primary objective was to assess the relationship between prhtn and asbp, while the secondary objectives were to assess the relationship between prhtn, imaging and acute antihypertensive requirements. 112 ich patients met inclusion criteria. in our assessment for prhtn, we found that 46% of patients were on antihypertensives, 16% had lvh on ekg, and 15% had lvh on tte. there was a significant relationship between lvh on tte and lvh on ekg (p<0.001), but not between home antihypertensive use and presence of lvh using either modality. asbp was higher for all patients with markers of phtn, but this was only significant for patients with lvh on tte (181mmhg, iqr 153-214 vs. 152mmhg, iqr 137-169, p < 0.001) and patients with lvh on ekg (195 mm hg, iqr 155-216 vs. 147 mm hg, iqr 129-163, p<0.001). all patients with markers of prhtn were more likely to require nicardipine, but this was only significant for patients with lvh on tte (94% vs. 64%, p=0.016) and patients with lvh on ekg (83% vs. 52%, p=0.018). all patients with markers of prhtn were more likely to have deep bleeds (p=0.017 for patients with lvh on ekg vs. those without lvh on ekg). there was no relationship between any markers of prhtn and the presence of a spot sign. in patients with ich, prhtn is related to higher asbp, deep bleed location, and increased acute antihypertensive requirements. all spontaneous intracerebral hemorrhage (sich) patients, including those with low severity are uniformly admitted to the intensive care unit (icu) at our institution. many may not benefit from this high-intensity observation and leave the icu within 24 hours without experiencing any complications. identifying low-risk characteristics could aid in triaging such patients to stroke units instead. retrospective data collection of all sich patients admitted to our institution from june 1, 2013-june 30, 2016 included ich score, need for surgical interventions, medical complications, and icu/hospital los. we analyzed variables predicting short (< 24 hour) icu los among low severity (ls-ich) patients (defined as those with ich score 0-1). 163 (52%) of 313 sich patients had ich scores of 0-1, of which just under half (78) had icu los 24 hr. they also spent significantly fewer days in hospital (4 vs 9.7, p<0.001). we could not identify a clear ich score cutoff that was sensitive enough to predict short icu los. however, requirement for antihypertensive infusion and early clinical deterioration correlated strongly with longer icu los p<0.001. there appears to be a subset of mild ich patients (ich score 0-1) who do not require icu observation. a risk assessment score incorporating gcs and ich volume may be able to delineate this low-risk population who could instead be admitted to a stroke unit, with the potential for significant cost saving and hospital efficiency. obesity has been linked with relative longevity in several disease conditions. this relationship has been termed the "obesity paradox." in this study we sought to evaluate the impact of obesity on short-term outcomes in patients with intracerebral hemorrhage (ich). patients admitted with a diagnosis of ich were selected from the 2003-2014 nationwide inpatient sample (nis) database, using icd-9 codes. patients with ich were dichotomized based on the presence of obesity as a coexisting diagnosis based on icd-9 codes and diagnosis related groups. the primary outcome measure was in-hospital mortality. length of stay and total charges were also examined as resource utilization measures. of obesity is a major health care burden as evidenced by higher resources utilization. counterintuitively, obesity appears to be associated with lower in-hospital mortality in ich patients. one possible physiological basis for this could be that the higher ldl levels on presentation result in a lower likelihood of hematoma expansion. recent short-term outcome analysis indicates association of spontaneous intraventricular hemorrhage (ivh) related hydrocephalus with incontinence and gait dysfunction. we explore the association of hydrocephalus scores, intraventricular alteplase and clinical variables with these outcomes at long term follow up in survivors from the clear iii trial. clear iii, a randomized, multi-center, double-blinded, placebo-controlled trial was conducted to determine if pragmatically employed external ventricular drainage (evd) plus intraventricular alteplase improved outcome, in comparison to evd plus saline in patients with ivh causing obstructive hydrocephalus. we assessed hydrocephalus scores on survivors at diagnosis, days 30 and 365. incontinence and dysmobility were defined using 12-month barthel index subscores (<10 for bladder and <15 for mobility, respectively). outcome measures were predictors of incontinence and gait dysmobility at 1 year after ich. this prospective observational study analyzed consecutive ich-patients (n=246) treated at the neurological and neurosurgical departments of the university-hospital erlangen, germany over a 21month inclusion period (05/2013-01/2015). we analyzed the influence of patient characteristics, inhospital measures and functional status on treatment recommendations and on oac initiation during 12-month follow-up. clear treatment recommendations by attending stroke physicians seem necessary to ensure oac initiation after ich. oac showed beneficial associations; however data here suggests the presence of an indication bias introduced by treatment recommendations and outpatient care during follow-up. therefore, observed association with age and functional status might affect unadjusted analyses. although recently, non-vitamin k antagonist oral anticoagulants (noacs) therapy in patients with non valvular atrial fibrillation have half the incidence of intracerebral hemorrhage (ich) compared to warfarin. however, it would be still controversial subject that outcome of noac-associated ich (nich) might be worse or better than warfarin-associated ich (wich). in this study, we investigated clinical outcome and radiological finding of ich between two different anticoagulation treatments. retrospective review of medical records was performed for 1,197 patients who admitted with ich from 2003 to 2016 in seoul national university bundang hospital. clinical characteristics, functional outcome, location and volume of ich, and all-cause mortality within 90 days were analyzed. among those patients, 47 patients with wich and 8 patients with nich were included. lesion location was common in supratentorial deep area (50.0%, 44.7%), lobar area (37.5%, 31.9%) and brainstem and cerebellum (12.5%, 23.4%) in the nich and wich group, respectively. no significant difference found in initial nihss (15.5 vs 10), discharge nihss (16.5 vs 8), mrs (0 to 2) at discharge (14.9% vs 25.0%), mrs (0 to 3) at discharge (36.2% vs 25.0), mrs (0 to 2) at 90 days (25.5% vs 12.5) and mrs (0 to 3) at 90 days (25.5% vs 12.5) in nich and wich group. we did not find any difference between nich and wich for allcause mortality at discharge (17% vs 0%), 90 days (27.7% vs 0%), and 1year (34% vs 25%). median baseline ich volume was not significant difference in two groups (3676.2 vs 1542.24). in our study, functional outcome, mortality, and baseline ich volume were similar following nich and wich. because of low statistical power due to small sample size in our study, further studies with prospective larger patient cohorts will need to be conducted. novel oral anticoagulants (noac) are increasingly used as an alternative to vitamin-k antagonists (vka) such as warfarin for anticoagulation and have shown lower rates of intracranial hemorrhage in several randomized clinical trials. it has been suggested that noac-iphs might be particularly dangerous, yet the literature regarding hematoma characteristics and outcomes between noac-iphs and vka-iphs is inconclusive. given the lack of standardized reversal strategies and lack of information on outcomes following noac-associated iph, the aim of this meta-analysis was to compare 1) mortality; 2) hematoma volume, and 3) risk of hematoma expansion in patients who developed an iph on noacs versus vka. a meta-analysis of the literature through december 2016 was conducted using pubmed, embase and cochrane databases in accordance with prisma guidelines. pooled risk ratios (rr) were calculated for mortality and hematoma expansion and pooled mean difference (md) was calculated for hematoma volume (ml) using random-effect (re) and fixed-effect (fe) models. noac-iph was not associated with increased mortality (re and fe: rr: 1.07; 95%-ci: 0.89;1.28, i2=0.00%, p-heterogeneity=0.29; 7 studies) and hematoma expansion (re and fe: rr: 0.97; 95%-ci: 0.77;1.21, i2=0.00%, p-heterogeneity=0.48; 4 studies) compared to vka-iph. the hematoma volume of noac-iph was smaller than vka-iph (re: md: -8.83ml; 95%-ci: -17.00; -0.67, fe: md: -6.48ml; 95%-ci: -9.85; -3.10; 5 studies), but with considerable heterogeneity that could not be alleviated (i2=79.1%, p-heterogeneity0.05). noac-iph was not associated with increased mortality or hematoma expansion compared to vka-iph and may be associated with a smaller hematoma volume. controversy exists regarding blood pressure (bp) reduction and perihematomal ischemia (phi). we investigated the association of acute bp reduction and presence of qualitative and quantitative phi in a large prospective cohort of intracerebral hemorrhage (ich). consecutive patients from the prospective nih funded dash1 study (> 18 years, primary spontaneous ich) were included. phe volume was outlined on t2/flair and ich volume on gre; these and adc were co-registered. tissue characteristics was defined as: ce = adc 1200 x 10-6 mm2/sec. the association of clinical, radiographic factors and bp at baseline and 24 hours with qualitative perihematomal and/or remote ischemia (i.e. dwi bright adc dark) and quantitative ce on adc were determined. 164 patients (50% female) with mean age 64 ± 15, and nihss 8 (iqr 3, 17) were included. mri time was 34.6 hours (iqr 21, 60). 37% had lobar ich. ich volume was 12 cc (iqr 5, 33). 44% had perihematomal (33%) or remote ischemia (21%). 99% of patients had areas of perihematomal adc 1 cc) was associated with higher absolute (52±30 mm hg, p=0.05) and relative (38% ± 16% vs 33% ± 15%, p=0.058) map reduction, younger age (p=0.03), h/o tia/stroke (p=0.04) and larger ich volumes (32 vs 7 cc) (p<0.001). in multivariate analysis, map reduction was not significantly associated with ce whereas ich volume was (p=0.00). perihematomal and remote ischemia is frequently seen after ich, but the severity of phi is small and of unclear significance. bp reduction may be associated with phi but this was not an independent predictor. introduction: patients with left ventricular assist devices (lvads) receive anticoagulation and antiplatelet therapy to prevent pump thrombosis. consequently, neurological events including intracranial hemorrhage (ich) are one of the most feared causes of morbidity and mortality in these patients. there is little evidence to guide initiation of anticoagulation after such ich events. methods: this is a retrospective, single academic center analysis of lvad patients from 2014-2017. the electronic medical record was reviewed after irb approval for the physiologic, laboratory, and radiographic data of these patients as well as survival or cause of death by 30 days or by discharge. results: during the analysis, 51 patients were reviewed, 7 of which (13.7%) had intracranial hemorrhage. one patient was excluded from analysis after care was transitioned to hospice, thus follow-up scans were not obtained. the remaining 6 patients were receiving both aspirin (81-325mg daily) and warfarin (2-8mg daily) with an inr of 1.5-3.3 (mean=2.8) at the time of ich. aspirin (81-325mg daily) was resumed within 1-2 (mean=1.1) days post ich. warfarin was resumed 1-20 (mean=6.6) days post ich at 2-8mg (mean=4mg) with goal inr (1.7-2)-(2-3) depending on device. there was 1 death due to withdrawal of life support in setting of multiple comorbidities, though follow-up scan 7 days post warfarin resumption revealed no evidence of rebleed. the remaining 5 patients showed no evidence of rebleed on ct scans at 2 months post warfarin resumption and were subsequently discharged to rehab facilities or home with modified rankin scores 0-4 (mean=2.8). conclusion: in this review of 51 lvad patients, about 13% suffered ich, and of those 6 survivors aspirin was safely resumed within 2 days and warfarin was safely resumed as early as 7 days post-event. further studies are needed in order to establish safe practice guidelines and risk factors to prevent ich. intracerebral hemorrhage (ich) remains a devastating form of stroke, and perihematomal edema worsen outcomes after ich. recent studies have demonstrated the safety of minimally invasive surgery (mis) for hematoma removal, but the efficacy of mis in the treatment of ich is controversial. this study aimed to evaluate the effect of mis compared with medical treatment for basal ganglia ich. we retrospectively analyzed the clinical outcomes of prospectively collected data from two stroke centers. the treatment strategies of the two stroke centers for basal ganglia ich are different; one stroke center underwent mis and the other stroke center medically treated according to the current guidelines. we hypothesized that mis could reduce perihematomal edema and improve functional outcomes compared to medical treatment. primary outcome of this study was a modified rankin scale (mrs) at 3 months after ich occurrence. a total of 155 patients with basal ganglia ich were treated with different treatment strategies; 86 patients underwent mis and 69 patients received medical treatment. no statistically significant differences were found in age, sex, hematoma volume, and glasgow coma scale scores between the groups. a better functional recovery (mrs < 3) at 3 months was found in the medical treatment group than the mis group (46.4% vs 14.0%, p <0.05). no significant differences were observed between groups in terms of mortality. our findings suggest that the best medical treatment improves functional recovery after basal ganglia ich compared to mis. these results are contrary to other studies of ich, and further randomized trials are required. perihematomal edema (phe) after intracerebral hemorrhage (ich) is thought to be predominantly vasogenic. the presence and extent of cytotoxic edema (ce) is controversial. we investigated phe diffusivity (phed) and factors associated with ce. consecutive patients from the prospective nih funded dash1 study (> 18 years, primary spontaneous ich) were included. phe volume was outlined on t2/flair and ich volume on gre; these and adc were co-registered. tissue characteristics was defined as: ce = adc 1200 x 10-6 mm2/sec. clinical and radiographic factors associated with ce were determined. cytotoxic edema is detected in the perihematomal area, early after ich and is associated with younger age, larger ich and prior h/o tia/stroke. its clinical significance needs to be studied further. hemorrhagic stroke carries a high mortality rate and determining prognostic factors during initial presentation can aid redirecting intensive care unit (icu) management. we described the physiological profile and clinical outcomes of hemorrhagic stroke patients in a colombian icu. we retrospectively reviewed all hemorrhagic stroke patients admitted to our icu from 2014-2017. clinical characteristics, outcomes, available laboratory values and hourly vital signs from the first 48 hours in the icu were retrieved and analyzed. our primary stroke center admitted 395 patients, 72 (18%) were hemorrhagic. out of these, 47 required icu management, representing 1 % of the total 4687 icu admissions during this time frame. intracerebral hemorrhage (ich) was present in 32 patients while subarachnoid hemorrhage (sah) was seen in 15. the latter had a median fisher score of 4. for all patients, the most common risk factors were hypertension (61.7%), dyslipidemia (29.8%) and smoking (17.0%). icu mortality was 25.5% (53.3% with ich and 12.5% with sah). mean sequential organ failure assessment (sofa) score was significantly greater in patients who died (8.8 vs. 1.8, p<0.05) and mean glasgow coma scale was significantly lower (8.1 vs. 13.2, p<0.05). vasopressors were required in 18 patients (38.3%), mechanical ventilation in 22 (46.8%), and half of the patients requiring either support therapy died. only 5 patients (10.6%) had fever in the first 48 hours and all died. mean coefficient of variation for systolic, diastolic and mean blood pressure was significantly lower in patients who survived. mortality cases were more likely to have hypokalemia and hypomagnesemia than surviving patients (50.0% vs. 25.7% and 58.33% vs. 40%, respectively). icu-admitted hemorrhagic stroke patients have a poor prognosis. sofa and gcs are accurate predictors of mortality. certain electrolyte disturbances, fever and a higher variation of blood pressure during the first 48 hours were associated with a worse outcome. the association between worsening cerebral edema and unfavorable outcome in ich patients has been described in rcts. the objective of this analysis was to compare hospitalized spontaneous ich patients with and without perihematomal edema (phe) expansion and to evaluate relationships between hypertonic saline (hts) use, peak serum na, phe expansion, and short-term outcomes. we conducted a cross-sectional study of consecutive spontaneous ich patients admitted to a single center from 11/2014-11/2015. head cts during the first week of admission, use of hts, and phe (using abc/2 method) were evaluated. phe expansion of 10% or more was considered worsening edema. outcomes of interest included time to peak na, poor disposition (not home or inpatient rehabilitation), discharge mrs 4-6, and in-hospital death. of 180 ich patients, 43% experienced worsening phe. there was no difference in age, race, sex, arrival bp arrival, or vascular risk factors in patients with or without worsening phe. however, for each mm of midline shift (mls) present on initial head ct, odds of phe expansion was decreased by 16% (or 0.84, 95%ci 0.73-0.97, p=0.014). mls on initial head ct was the best discriminator of phe expansion (auc 0.811 (95%ci 0.663-0.958). although hampered by small sample size, our data indicates that finding that ich patients with degree of mls on initial head ct is the best radiographic predictor of had lower odds of phe expansion. those without mls at presentation may be at risk of phe expansion, and counterintuitively may be those most in need of aggressive medical management. may suggest a role for intensive osmotherapy in patients with favorable imaging at presentation. intracerebral hemorrhage (ich) is a devastating stroke with high mortality rates. previous studies have shown a potential role of immune cells as a prognostication method. a high neutrophil to lymphocyte ratio was associated with poor outcomes after ich. we sought to determine whether absolute lymphocyte count(alc) at admission was predictive of outcomes in patients with ich. we performed a retrospective chart review of all patients admitted to our hospital with a diagnosis of ich from january 2012 to december 2016.we collected baseline demographic characteristics, medical history, ich scores, differential leucocyte, platelet and total leucocyte(tlc) counts at admission. the functional outcomes after ich were measured using modified rankin scale (mrs) at discharge. mrs of 5 and 6 were considered poor outcomes. statistical analysis was done after grouping lab values into higher and lower groups with respect to the normal reference ranges a total of 257 patients with ich were admitted to our center during the study period. 111 patients were included in the study and the rest were excluded due to lack of differential leucocyte counts at admission. 34% (38 of 111) had poor outcomes. univariate analysis using fisher's exact test showed significant association between low alc levels (10.5) were also found to be significantly associated with worse outcomes (p = 0.0036, 0.0001, 0.0022, respectively). however, after multivariate analysis, only low absolute lymphocyte counts retained significant association (p =0.0268). intracerebral hemorrhage patients with low absolute lymphocyte counts at admission have a higher probability of poor outcomes at discharge. further studies are required to confirm our results. intraventricular hemorrhage (ivh) is a significant predictor of poor outcome after intracerebral hemorrhage (ich), and may differentially predict hydrocephalus and mortality among blacks vs. nonblacks. we aimed to confirm these findings in a separate cohort of spontaneous ich patients with severe ivh. the cleariii-ivh trial was a randomized, multi-center placebo controlled trial examining the effect of intraventricular alteplase versus saline, on outcomes in patients with spontaneous ivh. we retrospectively analyzed data on all 500 patients, including self-reported race/ethnicity, medical comorbidities, presentation characteristics and functional outcomes. represented race/ethnic groups with >5 subjects per group were 252(50.4%) white/non-hispanic (wnh), 53(10.6%) white/hispanic (wh), 168(33.6%) black/african american/non-hispanic (bnh), and 14(2.8%) asian. bnh were significantly younger than rest of the cohort with median age [interquartile range] 55 [46,60] years, had more hypertension(97%, p=0.056), and significantly higher rates of antihypertensive medication non-compliance (70.8%, p=0.048). wnh had more frequent coronary artery disease (14.7%, p<0.001), use of vitamin k antagonists (10.7%, p=0.002) and elevated inr on presentation (9.1%, p=0.002). bnh had significantly more frequent hydrocephalus on presentation (23.8%, p=0.003), and a higher rate of ventriculoperitoneal shunt placement (25%, p=0.015). neither ich nor ivh volume at enrollment, nor ivh remaining at end of treatment differed significantly between race/ethnic groups. however, bnh patients were more likely to have greater than 80% ivh reduction, a recognized endpoint for better functional outcomes in cleariii (26.8% vs. 25%-wh; 17.1%-wnh; 7.1%-asian; p=0.019), and this difference persisted in those who received intraventricular alteplase (p=0.04) and after adjustment for diagnostic ivh volume (p=0.03). race/ethnicity was not an independent predictor of mortality or poor outcome at 30 or 180 days on multivariable logistic regression. although functional outcomes did not differ significantly among race/ethnic groups, differences in risk factors, hydrocephalus/shunting post ivh and response to thrombolytic therapy warrant further exploration. investigators from the randomized trial of unruptured brain arteriovenous malformations (avm) trial (aruba) reported in 2013 that interventions to obliterate unruptured avms resulted in greater morbidity and mortality compared to medical management. we investigated whether patterns of avm treatment changed after aruba's publication. we used inpatient and outpatient claims data from 2009-2015 from a nationally representative 5% sample of medicare beneficiaries. unruptured brain avms were identified using icd-9-cm code 747.81. the date of first avm diagnosis was coded as occurring before or on november 20, 2013 (online publication of aruba) versus after. outcomes were referral to a neurologist or neurosurgeon, and interventional treatment. interventional treatments were identified using cpt codes 61680-61692, 61623-61624, 61796, 61798, or 77371-77372. the likelihood of outcomes after versus before aruba was compared using survival analysis with log-rank tests and cox proportional hazards models adjusted for age, sex, race, and the charlson comorbidity index. we censored patients at diagnosis of intracranial hemorrhage. we identified 1,444 patients with a mean 2.8 (±2.0) years of follow-up after diagnosis of unruptured brain avm. diagnosis was most often by neurologists (20.6%), neurosurgeons (14.4%), and internal medicine specialists (11.3%). after aruba publication, there were no changes in 1-year cumulative rates of referral to a neurosurgeon (26.9% after, 26.8% before; p = 0.99) or neurologist (46.8% after, 47.7% before; p = 0.97), but there was an increase in avm treatment (7.0% after, 3.5% before; p = 0.0096). after adjustment for demographics and comorbidities, there was an increased likelihood of interventional management (hr 1.9; 95% ci, 1.1-3.2) after aruba's publication. in a nationally representative cohort of elderly patients, we found an increase in interventional avm management after publication of aruba. this is notable given that our data pertain to older patients who are generally seen as less suitable surgical candidates. elderly patients with severe intracerebral hemorrhage (ich) are often projected to have future functional dependence but unclear degree of cognitive recovery. surrogates for such patients frequently weigh multiple concerns when facing the difficult decision of whether to prolong life with tracheostomy and gastrostomy tube insertion versus pursue comfort care. we aimed to characterize distinct groups of surrogates in these situations, based solely on how they prioritize their concerns. subjects recruited from a probability-based us population sample completed an online best-worst survey that presented the above scenario and asked the respondent to prioritize concerns as the patient's surrogate. clusters were identified with latent class analysis after weighting data to match the us census demographic distribution. class solutions were replicated 20 times from random starting seeds, with the solution chosen after factoring in akaike's information criterion. we identified 4 distinct decisional groups among 792 respondents (response rate = 44.6%). all groups reported multiple concerns as important, but group 1 (34.4%) was more concerned than any other that the patient was too old to live with disability. group 2 (26.4%) focused on ensuring agreement among other family members. group 3 (20.7%) was concerned that the patient might suffer if tube feeding and iv fluids were stopped and that the prognosis could be incorrect. group 4 (18.6%) had numerous considerations that were comparably important but prioritized paying for long-term care. groups varied in whether they would actually request prolonging care for the patient (group 1 = 5.20%, g2 = 9.46%, g3 = 31.13%, g4 = 23.12%, p<0.0001). in a multivariate model, religious affiliation and frequency of attending religious services were the only variables independently predicting group membership. we identified 4 distinct profiles of decisional patterns for surrogates of severe ich patients with uncertain prognosis. these data will inform development of strategically tailored decision aids. cerebral venous sinus thrombosis (cvst) represents an important cause of both ischemic and hemorrhagic strokes in young people. while recent guidelines recommend management in a stroke unit, the impact of neurocritical care in this condition has not been studied. we aimed to assess whether the introduction of a neurocritical care program influenced clinical outcomes in cvst patients. we retrospectively reviewed electronic medical records of adult patients admitted to yale new haven hospital's neuroscience icu (nicu) between 2011 and 2017 with a diagnosis of cvst. demographics, vascular risk factors, comorbidities, length of stay and discharge modified rankin scale (mrs) were collected. patients were excluded for age 24 hours of presentation. we compared two time periods, before (epoch 1, 2010-2012) and after (epoch 2, 2013-2017) the introduction of continuous staffing of cvst cases by neurointensivists in the nicu. univariable and multivariable logistic regression were utilized to model the odds of poor outcome (dichotomized mrs 0-2 vs 3-6). fifty-three patients with cvst met the inclusion criteria during the study period (mean age 39 (+/-17) years, 51 % female). 20 patients were identified for epoch 1 and 33 patients for epoch 2. overall, 40 patients (76%) had a good (mrs 0-2) outcome. for epochs 1 and 2, good outcomes were observed in 12 (60%) and 28 (85%) patients, respectively (p=0.04). in both univariable and multivariable regression analysis (adjusted for age and sex), admission during epoch 2 was associated with a significantly reduced odds of a poor outcome (or 0.27, ci 0.07 -0.98; p =0.048) and (or 0.27, ci 0.07-1; p=0.05), respectively. in this small, single-center cohort of patients with cvst, most patients experienced a good outcome. the institution of continuous neurointensivist coverage was independently associated with better outcomes. further validation in prospective, multicenter cohort studies is needed. thrombelastography (teg) provides a dynamic assessment of clot formation, strength, and stability. we examined relationships between teg parameters and outcomes from intracerebral hemorrhage (ich). we prospectively enrolled patients with spontaneous ich between 2009 to 2017. teg was performed at the time of admission. we divided patients into two groups based on the presence or absence of hematoma expansion (he). clinical characteristics, baseline teg values, and outcomes were compared between the two groups. multivariable regression analysis was conducted to compare the differences of teg components between the two groups after adjusting for potential confounding effects. we included 275 patients, 67 (24%) with he and 210 (76%) without he. patients with he were more often male and had higher rates of aspirin use, lower incidence of intraventricular hemorrhage, and larger baseline hematoma volumes. after controlling for potential confounders, mean r time was independently associated with he (5.3 ± 0.4 vs. 4.8 ± 0.2 mi significantly higher risk of he with or 2.63 (95% ci: 1.49, 4.65), p=<0.001. patients with hematoma expansion were more likely to have poor neurological outcome (mrs 4-6) at discharge (91% vs. 73%, p=0.002) and had higher mortality rates (28% vs. 14%, p=0.005). overall, 47 patients (17%) died in the hospital. following multivariable analysis, patients who died had significantly lower mean delta (0.4 ± 0.2 vs. 0.6 ± 0.2 mins.; p=0.04) and smaller angle (69.9 ± 3.1 vs. 66.1 ± 1.9 degrees; p=0.01) than those who lived. hematoma expansion and mortality from ich are independently associated with slower clot formation on teg. baseline teg identifies significant coagulation disturbances which may predict poor outcome and represent potential targets for therapeutic intervention. intracerebral hemorrhage (ich) patients often present with acute hypertension requiring intravenous and enteral antihypertensive medications. we performed a cohort study to determine clinical predictors of time to enteral antihypertensive medication and its effect on icu length of stay (icu los). we identified consecutive spontaneous ich patients admitted from 12/2013 to 9/2015 to a tertiary center, and excluded those transitioned to comfort care (cmo) within 24 hours of admission. we calculated time from hospital admission to first enteral (oral or feeding tube) antihypertensive. we abstracted demographic and clinical variables. two reviewers examined medical records and classified ich location and etiology. we determined univariate and adjusted associations of clinical variables to time to enteral antihypertensive medication and performed regression analysis to determine effect on icu los. we identified 495 patients and excluded 50 for early transition to cmo. endotracheal intubation (p=0.03), higher ich score (p<0.001), no outpatient antihypertensive use (p=0.001), and non-lobar ich location (p=0.005) predicted longer time to starting enteral antihypertensive in adjusted analysis. presenting systolic or diastolic bp, time of icu admission (day vs. night), sex, and race were not significant predictors of time to enteral antihypertensive. time to enteral anti-hypertensive is the strongest predictor of icu los (p<0.0001) after adjustment for age, gcs, ich score, sex, race, and duration of iv antihypertensive infusion. patients with higher ich scores, intubation, no prior antihypertensive use, and non-lobar ich are at risk for increased time to enteral antihypertensive administration. timely enteral antihypertensive administration is an important and potentially modifiable predictor of icu los in acute ich. overall mortality from intracerebral hemorrhage (ich) represents a combination mortality from a potentially fatal disease as well as practice variation around treatment withdrawal of care. early do-not-resuscitate (dnr) rates are independently associated with in-hospital mortality and may serve as a proxy for withholding aggressive care. the 2007 american heart association (aha) guidelines recommended that dnr orders should not be applied before 24 hours out of a concern that less aggressive care would lead to a self-fulfilling prophecy and excess mortality. we performed a retrospective analysis of temporal trends among primary ich patients presenting to all nonfederal emergency departments in california from 1999 to 2014 using data from the office of statewide health planning and development (oshpd). demographic information, clinical covariates (such as mechanical ventilation, craniotomy), and early dnr status within 24 hours were collected and analyzed using segmented regression to evaluate for differences in linear trends from 1999-2006 compared with 2007-2014. over a use of early dnr orders for ich patients has steadily decreased over the last 15 years, even after adjusting for age and disease severity. the pace of this downward trend did not significantly change around the time when recommendations on early dnr use for ich in aha guidelines were revised in 2007. spontaneous intracerebral hemorrhage (ich) is a common form of stroke that often results in severe morbidity or death. for most ich, there are no proven therapies for acute management. evidence suggests minimally invasive surgical evacuation of ich may result in improved patient outcomes. the enrich clinical trial is designed to determine the efficacy and economic impact of early ich evacuation using minimally invasive, transulcal, parafascicular surgery (mips) compared to standard guideline-based management. in this abstract we present the trial design and rationale at the foundation of the enrich clinical trial. enrich is an adaptive, prospective, multi-center clinical trial designed to enroll up to 300 patients with acute ich. patients are block-randomized based on hemorrhage location (lobar vs basal ganglia) 1:1 to mips or standard management. included patients are 18 -80 years, gcs 5-14, baseline mrs 7, presenting within 24 hours from last known well and found to have a spontaneous, cta-negative, supratentorial ich (30-80 ml). primary efficacy will be determined by demonstrating significant improvement in the mean utility-weighted mrs at 180 days after enrollment. economic effect of mips will be determined by quantifying the cost per quality-adjusted life-years gained at pre-determined time points. the rationale for early intervention is to interrupt the time-dependent ich related pathophysiology caused by mechanical pressures and the pro-inflammatory secondary cascade that leads to worsened cellular injury and edema formation. the planned enrichment strategy acknowledges that hemorrhages in varied locations may have a differential response to mips. study adaptation, in the form of enrichment, may occur if pre-determined futility rules are met for the primary outcome in either of the two locations. enrich is designed to establish the clinical and economic value of early mips in the treatment of ich. enrollment was initiated in december 2016. early seizures (< 30 days) after intracerebral hemorrhage (ich) may be associated with the presence and degree of perihematomal cytotoxic injury. we explored the association between perihematomal diffusivity (phd) and early seizures after ich. consecutive patients from the prospective nih funded dash study (> 18 years, spontaneous ich) were included. all patients had multimodal mri within 2 weeks. perihematomal edema (phe) volume was outlined on t2/flair and ich volume on gre; these and adc were coregistered to analyze phd. eeg monitoring was performed for clinical suspicion of seizure. mean adc values of phe and the percentage of phe volume were compared between the seizure and no-seizure groups, with adc values 1200 as vasogenic edema. results 26 (11%) of a total of 229 patients had early seizures at a median of day 2 post ich. mean adc in the phe region was higher in the seizure group (mean: 1169 +/-127 vs 1066 +/-154, p=0.001). ich, absolute, and relative phe volumes were not different between groups. the phe of the seizure group had a lower percentage of cytotoxic edema (5% vs 8%, p=0.007) and a higher percentage of vasogenic edema (43% vs 30%, p 1300 was the most predictive of seizure with auc = 0.73, though adc thresholds between 1200-1400 had largely similar auc's. phe volume of >24% (of adc > 1300) identified patients with seizure with sensitivity of 0.81, specificity of 0.63, and remained significant in multivariable analysis. patients with early post-ich seizures have higher mean perihematomal adc and a larger percentage of vasogenic edema in the perihematomal region. vasogenic edema due to bbb breakdown and perihematomal inflammation rather than cytotoxic injury is associated with early post ich seizures. novel neuroprotective treatments hold the promise to improve patient outcomes by broadening time windows of intervention and reducing hypoperfusion and reperfusion injury in the era of mechanical thrombectomy for acute ischemic stroke. hibernating species, such as arctic ground squirrels (ags), demonstrate remarkable resilience to ischemic and reperfusion injuries. bioinformatic analyses of genomes of hibernating species reveals signatures of convergent evolution in genes regulating stability and formation of mitochondrial respirasomes. hypoxia pre-conditioning (hpc) also leads to improved survival upon subsequent exposure to hypoxia, and is associated with increased stabilization of respirasomes. the respirasome is a macromolecule consisting of oligomers of complex i, iii, and iv. cox7a2l is a key mediator of respirasome stability via interactions with complex i and iii. in this study, we explored the role of cox7a2l in mediating respirasome stabilization in ags neural stem and progenitor cells (nsc/npcs) as well as mouse nsc/npcs exposed to hpc. respirasome stability was assessed using blue native gel electrophoresis and mitochondrial metabolism assessed by measuring oxygen consumption in vitro (seahorse metabolic analyzer). exposure to mild hypoxia and induction of hif leads to stabilization of respirasomes, upregulation of hif, and modulation of mitochondrial metabolism. interestingly, overexpression of the ags isoform of cox7a2l, which has amino acid substitutions in residues mediating respirasome stability, recapitulates the effects of hypoxia on respirasome stability and mitochondrial metabolism without altering hif expression. targeting respirasome stability by modulating cox7a2l is a potentially novel neuroprotective target for treatment of ischemic injuries. testing of these hypotheses in pre-clinical models of stroke is on-going. acute stroke symptoms need timely diagnostics in order to ensure best outcomes. as a non-academic, community-based center located in rural western nc, where we are the regions only comprehensive stroke center, we developed a process to intake stroke patients quickly directly from ct to interventional radiology when applicable. a smooth transition reduces the quantity of time from imaging to interventional suite, ultimately reducing the time it takes to prepare to actively treat a patient. interventional radiology value stream mapping started in june 2016. multidisciplinary team worked in multiple work groups to design and create "code ir stroke now". flow chart created to show multiple moving parts simultaneously, to streamline transition from er (sometimes this includes triage from the region also) to ir. an ir "ready" criteria was made, er and ir checklists, followed by post procedure debrief and treatment plans/order set to standardize care and documentation. first mock code ir was done 3/28/17, this was critiqued/perfected. "go live" date: 4/3/17. we continue process improvement today. in first three months, 13 patients have gone through this process. average compliance for goal door to puncture <90min went from 78.6% to 100%. door to groin times reduced from 72 minutes to 62minutes. our performance is 26 minutes quicker than other comprehensive stroke centers (88m avg gwtg database). saved an average of 19 million neurons per patient. total of 247 million neurons saved on average since 4/3/17! door to groin times can be reduced with streamline approach to care. multidisciplinary team approach, including house supervisors, anesthesia, switch-board in addition to the bedside staff and providers can make a smooth transition from the time a large vessel occlusion is identified to getting the patient to the interventional suite. activation of "code ir stroke now" page activates this team 24/7. it is unknown whether antithrombotics for secondary stroke prevention in patients with acute ischemic stroke (ais) due to infective endocarditis (ie) reduce the rate of secondary ais or increase major bleeding. we conducted a multi-center, retrospective cohort study from 2007-2015 of patients with ais secondary to left-sided ie, separated into two groups (antithrombotic vs no antithrombotic). antithrombotics included antiplatelets and/or therapeutic anticoagulation. the primary outcome was a composite of recurrent ais and major bleeding. secondary outcomes included ais and major bleeding individually. a binary logistic regression model adjusted for age and native vs prosthetic valve involvement was used for outcome evaluation. the final analysis included 123 patients (91 antithrombotic vs 32 no antithrombotic). median age was 61 years and 25 (20%) patients had prosthetic valve infections. infecting organisms were mostly methicillin sensitive s. aureus (29%) or streptococcus spp. (26%). valve repair/replacement occurred in 34 (28%) patients. aspirin with or without another antithrombotic (85%) was the most common antithrombotic treatment. the primary outcome occurred in 25.3% vs 15.6% of patients with antithrombotics vs no antithrombotics, respectively (or 2.2; 95% ci 0.7 to 6.9). ais (6.6% vs 2.9%; or 2.2; 95% ci 0.2 to 20) and major bleeding (18.7% vs 12.5%; or 2.3; 95% ci 0.7 to 8.1) were similar between groups. a subgroup analysis of aspirin monotherapy vs no antithrombotic yielded similar results for the primary outcome (28.6% vs 15.6%; or 3.1; 95% ci 0.9 to 11.1) and ais (7.1% vs 3.1%; or 2.3; 95% ci 0.2 to 25.0). major bleeding was increased, however (26.2% vs 12.5%; or 4.1; 95% ci 1.01 to 16.7; p=0.048). antithrombotics after ais secondary to ie were not associated with a decrease in recurrent ais or an increase in major bleeding. aspirin monotherapy was associated with an increase in major bleeding without any reduction in ais. malignant hemispheric stroke (mhs) represents between 2-8% of all hospitalized ischemic stroke in the united states. pooled analysis of 3 european studies has demonstrated that decompressive hemicraniectomy (dchc) for mhs reduces mortality compared with conservative medical management and may also improve functional outcomes. these trials however, excluded patients with major medical comorbidities that might confound clinical outcomes. apache ii and sofa scores are validated icu scoring systems to help characterize disease severity and estimated hospital mortality. this study aims to evaluate apache ii and sofa scores in predicting outcomes for patients undergoing dchc for mhs. this is a single center retrospective analysis of patients who underwent early dchc for mhs between may 2010 through january 2017 at unc chapel hill. apache ii and sofa scores were calculated for the date of admission or date of first presentation to neurologic care. outcomes included mortality at discharge, mortality at 30 day, and functional outcome at last follow up, up to one year. multivariate analysis included timing of surgery, age, laterality, presence of midline shift, hemorrhage or multiple territory infarction. we identified 44 patients who met inclusion and exclusion criteria. the median age was 58 (25 to 78), -nine percent of patients received surgery by hospital day 2. full statistical analysis is pending. our hypothesis is a positive correlation between icu severity scores and mortality. given apache ii and sofa scores capture the effects of acute and chronic disease that would affect patient recovery, we hope to provide a more comprehensive prognostication of outcomes following surgery to help guide physicians and family members of these patients in their decision-making process. we conducted this study to investigate the effects of decompressive craniectomy (dc) combined with hypothermia on mortality and neurological outcomes in patients with large hemispheric infarction. within 48 hours of symptom onset, patients were randomized to one of the following three groups: dc group, dc plus head-surface cooling (dcsc) group and dc plus endovascular hypothermia (dceh) group. we combined the data of the dcsc and dceh group to dch group during analysis. the primary endpoints were mortality and modified rankin scale (mrs) score at 6 months. there were 9 patients in the dc group, 14 patients in the dcsc group and 11 patients in the dceh group. for all patients, the mortality at discharge and after 6 months was 8.8% (3/34) and 35.3% (12/34), respectively. the dch group had lower mortality, but the difference was not statistically significant (at discharge, 4.0% vs. 22.2%, p=0.098; 6 months, 32.0% vs. 44.4%, p=0.449). after 6 months, 22 patients survived, and 54.5% of the surviving patients had good neurological outcomes (mrs score of 1-3). the dch group had better neurological outcomes, but this difference was also not statistically significant (10/17, 58.8% vs. 2/5, 40.0%; p=0.457). the total number of patients experiencing complications in the dc group and the dch group was 15 (7.2%) and 59 (10.3%), respectively. treatment with hypothermia led to decreased mortality and improved neurological outcomes in lhi patients who received dc. a multi-center rct is needed to confirm these results. destiny ii investigated hemicraniectomy in patients 61-years and older for the treatment of malignant cerebral edema. we sought to describe the treatment effect of early hemicraniectomy in destiny ii, using number needed to treat to benefit (nntb) and benefit per hundred (bph) treated at 6 and 12months. as an mrs of 5 is generally undesirable, we also present nntb and bph excluding this outcome. for all possible dichotomizations of the mrs, net nntb was derived by taking the inverse of absolute risk difference, and net bph by multiplying absolute risk difference by 100. for benefits simultaneously across all disability transitions on the mrs, nntb, and bph, estimates were derived using joint outcome tables: 1) algorithmic minimum and maximum and 2) four independent experts. the expert data is presented as geometric mean. the algorithmic nntb was 2.34 (range 1.89-2.78) at 6-months and 2.71 (2.38-3.03) at 12-months, while bph was 44.5 (36-53) and 37.5 (33-42). the expert nntb was 2.25 (2.08-2.56) at 6-months and 2.78 (2.63-2.94) at 12-months, and the bph was 44.4 (39-48), and 35.9 (34-38) respectively. excluding mrs 5 the algorithmic nntb was 4.38 (range 4-4.76) at 6-months and 4.44 (3.35-4.55) at 12-months, while bph was 23 (21-25) and 22.5 (22-23). the expert nntb was 4.36 (4.0-4.76) at 6-months, and 4.4 (4.35-4.54) at 12-months, and bph was 22.9 (21-25) and 22.7 (22-23) respectively. early systematic hemicraniectomy improves outcome (including mrs 5) for every 2-3 patients treated. excluding patients with mrs 5, hemicraniectomy improves outcome for every 4.4 patients treated. the algorithmic range provides bounds to the data, while the expert geometric mean provides the most accurate point estimate. these data provide a powerful tool to describe the potential treatment outcomes to families during the first day following a malignant middle cerebral artery infarction. background cerebral bypass surgery is performed to restore, or revascularize blood flow to the brain. previous studies have not shown whether emergency surgical reperfusion therapy may be effective in acute ischemic stroke patients with large artery occlusion and hemodynamic deterioration. objective to evaluate the effect of emergency sta-mca bypass surgery on the outcome of hemodynamic compromised patients who had progressive or fluctuating stroke despite best medical treatments. we retrospectively reviewed the clinical and radiological data of 57 consecutive patients treated by both emergency bypass surgery (31 cases, 54.4%) and elective bypass surgery (26 cases, 45.6%) due to large artery occlusion at a single center. the effect of surgical therapy was measured with the modified rankin scale (mrs) at 3 months. clinical severity was evaluated by the national institutes of health stroke scale (nihss) between pre-and post-operative state. major perioperative complications were defined as any hemorrhagic stroke, myocardial infarction and death. results occlusive sites were the cervical internal carotid artery in 32 (56.1%) patients and the middle patients in emergency surgery group and 24 (92.3%) patients in elective surgery group. emergency bypass surgery improved nihss (preoperatively, 9 [4-16] ; 2 weeks postoperatively, 6 [2-11]). major perioperative complications in 30 days were happened in three patients (9.7%) after emergency bypass surgery, and four patients (15.4%) after elective bypass surgery. emergency revascularization surgery may be effective alternative treatment for acute ischemic stroke patients with hemodynamic deterioration refractory to maximal medical treatments without significant complications. larger randomized clinical study is needed to evaluate the effect of emergency revascularization surgery in acute hemodynamic deterioration. multiple studies have reported lower mortality rates in obese patients with various cardiovascular disorders, a phenomenon called as the 'obesity paradox'. such relationship has been largely unreported in patients with neurological pathologies especially stroke. this study reports the effect of obesity on prognosis in patients with ischemic stroke. analysis of national inpatient sample data (2003-2013) showed a total of 1,168,847 patients discharged with primary diagnosis of is, icd-9 code 433.xx and 434.xx. patients with obesity were identified using agency of healthcare research and quality (ahrq) criteria. we used binary regression to compare inhospital mortality between obese and non-obese patients with ischemic stroke. from 2003-2013, 1,168,847 patients with ischemic stroke were identified of which 8.7% were found to be obese. obese patients with ischemic stroke were more often younger, female, and african american as compared to caucasian. after risk adjustment for demographics, and baseline comorbidities, obese patients with ischemic stroke had lower observed in hospital mortality as compared with non-obese patients with ischemic stroke (2.5% vs 4%, or: 0.717 ci=0.681-0.756 p<0.001). from an eleven year nationwide cohort of patients with ischemic strokes, we observed a significant protective effect of obesity and better prognosis including a lower mortality rate. more prospective studies are warranted to further analyze this counter-intuitive trend. very early mobilization of critical care patients improves outcome, length of stay, and patient satisfaction. data for efficacy of very early mobilization for stroke patients have been mixed, and there is limited outcomes data for patients mobilized within 24 hours of receiving intravenous alteplase (iv tpa). the objective of this retrospective observational study was to determine if patients receiving iv tpa who were mobilized earlier were more likely to discharge home. medical records of ischemic stroke patients who received iv tpa between 2012 and 2016 at two urban facilities were reviewed for mobility protocol activities. patients who received endovascular treatment, were placed on comfort care day zero or one, mobilized after the first 24 hours, and transferred out or left against medical advice were excluded. multinomial regression was used to determine if there were significant differences in patients' discharge status by time first mobilized, adjusting for stroke severity using the national institutes of health stroke scale (nihss), age and gender. of the 268 patients included, 46.6 % (n=125) were female, mean age was 68.6 (±14.8), and the median admit nihss was 5.0 [iqr: 3.0, 10.0]. the median time first mobilized was 9.0 hours [iqr: 4.3, 15.0], 71.3% (n=191) of patients were discharged to home, 12.3% (n=33), a skilled nursing facility (snf), 13.8% (n=37), an inpatient rehab facility (irf), and 2.6% (n=7) hospice or expired. there was suggestive, but inconclusive evidence for a relationship between time first mobilized and discharged to snf versus home (p=.071). for every one hour increase in time mobilized, patients were 1.07 (95% ci= 1.00 -1.15) times more likely to be discharged to snf than home. this study reveals very early mobility is potentially efficacious after iv tpa. longer time to first mobility was associated with discharge to skilled nursing facility, although this was not statistically significant. medical management of cerebral edema after large volume stroke varies greatly across institutions. hypertonic saline has emerged as a common treatment strategy to attempt to reduce edema and theoretically prevent the need for decompressive hemicraniectomy. there is no established protocol for hypertonic saline administration and there have been concerns regarding safety. in a single-center, retrospective analysis we identified patients who received hypertonic saline for malignant edema after an ischemic stroke involving the entire hemisphere or diffuse middle cerebral artery (mca) territory. we compared patients who received continuous infusions of 2% or 3% hypertonic saline to those who received continuous infusions with boluses of 23.4%. the primary endpoint was time to goal sodium (150). secondary endpoints included the need for surgical decompression and adverse events. we included 28 patients who received only continuous infusions of hypertonic saline and 20 patients who received a combination of continuous infusions and bolus doses. we found no significant difference between number of patients who reached goal sodium (14 vs 14 respectively, p=0.17) or time to goal sodium (20 hours vs 23.5 hours, p=0.68). there was a significant difference in the number of patients who underwent surgical decompression (4 vs 8, p=0.04). there was not a significant difference in the rate of acute kidney injury or development of acidosis between groups (5 vs. 5, p=0.55). both hypertonic strategies appear to be safe. bolus dosing, on review, was more often instituted during clinical deterioration, accounting for the higher rate of surgical intervention. we feel we can safely be more aggressive earlier in the clinical course to potentially avoid surgical decompression. furthermore, we may need to look more closely at our target sodium, evaluating whether it should be based on the patient's baseline sodium or a universal value. even though recanalization is strongly associated with improved functional outcomes and reduced mortality, clinical benefit from thrombolysis is reduced as stroke onset to treatment time increases. in the recent study, endovascular treatment(evt) has been demonstrated to improve functional outcome in patients with acute ischemic stroke (ais) within the time window of onset to 6 or 8 hours. however, beyond usual thrombolysis time window, early neurologic deterioration(end) related with proximal artery occlusion is not uncommon in ais. with this, we report ais case series treated with evt because of end related proximal artery occlusion. from january 2012 through march 2017, all 261 patients underwent iat for ais with anterior circulation stroke. among them, twenty-four patients underwent evt due to end. at admission, all twenty-four patients showed near to complete occlusion of a proximal artery and had diffusion-perfusion mismatch. mean age was 68. initial median initial national institutes of health stroke scale (nihss) was 5 and nihss after end was 12. all patients had diffusion-perfusion mismatch over 200%. seven patients treated with iv-tpa before evt. good recanalization (tici 2b/3) was achieved in 91.7%. the hemorrhagic complication was seen in the follow-up computed tomography scan in 4 of 24 cases: three were hemorrhagic transformation, another was the subarachnoid hemorrhage. the thromboembolic mortality case. in our report, evt in ais with end achieved safe and successful recanalization. and successful recanalization was associated with good clinical outcome. we think evt could be a useful method in case of end in ais patients with proximal artery near to complete occlusion, even beyond usual 6 to 8 hours time window for evt. jugular bulb venous monitoring can provide information about cerebral hemodynamics and metabolism. we investigated the feasibility and clinical application of jugular bulb venous monitoring in acute ischemic stroke patients at neurocritical care unit. from march 2015 to june 2017, we conducted jugular bulb venous monitoring in 33 patients in a tertiary referral hospital. five patients were excluded; 3 without ventilator care and 2 other diseases than stroke. jugular venous catheters were placed in internal jugular vein by ultrasound-guided method. lactate, venous oxygen saturation (sjvo2), and arteriovenous oxygen saturation differnece (avdo2) were monitored every 4 hours. metabolic derangement was defined when lactate level was more than 2.0 mmol/l. patients were divided according to presence of clinical deterioration. for long-term prognosis, modified rankin scale 5-6 at 3 months were defined as poor outcome. twelve patients (42.9%) showed metabolic derangement and they experienced more frequent clinical deteriorations compared to patients without metabolic derangement (n=9, 64.3% vs. n=3, 21.4%, p=0.022). clinical deterioration was noted in 14 patients, and lactate level was significantly higher in the presence of clinical deterioration group (1.44±0.48 vs. 1.04±0.20mmol/l, p=0.009). adjusting other potential variables (age, baseline stroke severity, sjvo2, and avdo2), metabolic derangement was an independent factor associated with clinical deterioration (or 6.60, 95% ci 1.23-35.44, p=0.028). meanwhile, poor outcome group (n=12) showed no difference on lactate level, but avdo2 were higher in poor outcome group (29.54±5.51 v. 24.95±5.65, p=0.041). avdo2 remained an independent factor for poor outcome after multivariable logistic regression analysis (or 3.68, 95% ci 1.08-12.55, p=0.038). this study showed that lactate was associated with clinical deterioration during neurocritical care, whereas venous desaturation contributed to long-term prognosis. jugular bulb venous monitoring is a feasible tool in patients with acute ischemic stroke at neurocritical care unit. swift recognition of stroke symptoms, immediate access to testing and timely treatment plays a vital role in functional outcomes (middleton et al., 2015) . delays can postpone treatment and complicate recovery. delays at this facility included registration, order entry times, and imaging. pi included evaluating and eliminating interruptions, with a goal of reducing the time to treatment. process improvement (pi) utilized an evidence-based algorithm to improve performance metrics and treatment of acute strokes. setting was a suburban, ancc magnet recognized primary stroke center with 16 beds in the ed that experiences 24,010 ed visits and 6,619 admissions per year. patients included in the acute stroke protocol presented with signs and symptoms of stroke and last known well within 12 hours of symptom onset. participation included ed staff, and staff working in areas impacted by stroke care. code stroke was initiated for patients who fit the criteria. an overhead page was implemented notifying the team throughout the hospital. radiology would prioritize ct and call the ed as soon as ct was ready. in the meantime, ed team continued assessments. with ct resulted, the physician would determine whether the patient was eligible for tpa. the acute stroke protocol included a list of inclusion/exclusion criteria for tpa administration. other treatment requirements included reminders for frequency of vital signs, neuro checks and assessments. implementation began in may 2016 and the team began to see a significant decrease in ct times and better compliance of dysphagia screening and nih assessments. ct tat completed within 45 minutes increased from 62% to 83%. nih stroke scale completion rose from 79% to 100%. compliance with completing dysphasia screening increased from 86% to 93%. results stem from a commitment to excellence from the entire team. pi continues to further improve care for stroke patients. induced hypertensive therapy (iht) has used to enhance cerebral perfusion pressure in subarachnoid hemorrhage and stroke, but there is no established indication for iht in ischemic stroke. we report the usage of iht in acute ischemic patients with hemodynamic instability caused by steno-occlusive disease of a main cerebral artery. we reviewed acute ischemic stroke patients with cerebral perfusion deficit due to intracranial and extracranial steno-occlusive disease. iht was applied for early neurological deterioration and maintained until hemodynamic instability was stabilized over 24 hours or neurointervention including angioplasty and extracranial intracranial arterial bypass surgery were performed. 52 patients were analyzed. territories of stroke were 31 of anterior circulation of intracranial vessels, 11 of posterior vessels, and 10 of extracranial vessels. mean duration of ih therapy was 4176.04 minutes. pre and post nihss score of ih therapy was 8.19 and 7.35, respectively. 30 patients (57.7%) were showed improvement and 13 patients (25%) were stabilized without further aggravation. 16 patients revealed bradycardia. there was no fatal complication of therapy. 15 patients were performed further treatment include bypass surgery, angioplasty, and stenting after ih therapy. at 3 months follow up, 34 patients showed good outcomes (modified rankin scale 0, 1, and 2). iht may be safe and effective for the neurologic deterioration or progression of acute ischemic stroke with hemodynamic instability due to severe steno-occlusive disease of major cerebral artery. large randomized trials are needed to confirm this result. most patients with progressive stroke have a poor prognosis. the aim of our study was investigate the factors related with progressive neurologic deficit (pnd) in the patients receiving recanalization therapy for acute ischemic stroke. -month period, were enrolled. blood pressures (bps) at 0, 12, and 24 hours after admission and bp variation (bpv) for the first 24 hours were collected. variables associated with pnd were analyzed. among 216 enrolled patients, 68 patients showed pnd. the patients with pnd had higher systolic bps at 0, 12, and 24 hours after admission and higher bpv than the others (p <0.05). posterior circulation stroke was more prevalent in the patients with pnd (p <0.01). in logistic regression analysis, pnd was independently associated with posterior circulation stroke [odds ratio (or) = 3.35, p <0.001] and systolic bp at 24 hours after admission (or = 1.02, p = 0.03). pnd may be associated with elevated systolic bp for the first 24 hours after admission in the patients receiving recanalization therapy for acute ischemic stroke. telestroke has revolutionized stroke care delivery in the modern era. massachusetts general hospital (mgh) uses the most common model, the hub and spoke. the demonstration of superiority of endovascular therapy (et) with intravenous tpa over tpa alone for acute stroke patients with large vessel occlusions prompts a thorough assessment of telestroke's role in the delivery of et, particularly in terms of transferring patients to hubs capable of et. our primary objective was to examine associations between transfer time and clinical outcomes. patients were selected from the get with the guidelines-stroke registry who were transferred to mgh from jan 2011 to oct 2015 who had nihss>6 and last known well<12h on mgh arrival (n=618). we excluded patients for whom we could not calculate the primary predictor, transfer time (defined as the mgh arrival time minus the telestroke consult answered time, n=384). several clinical outcomes were explored by linear and logistic regression to determine association with transfer time. of the 234 patients in the study, 120 (51%) were transferred by ambulance, 114 (49%) by helicopter, and 63 (27%) underwent et at mgh. median transfer time was 132 min, and median aspects decrease was 2 during transfer. longer transfer time was associated with decreased likelihood of undergoing et (p=0.003). however, transfer time was not significantly associated with aspects decrease during transfer. for those patients undergoing et, transfer times bore no association to 90 day mrs. this study identifies an association between longer transfer time and decreased likelihood of undergoing et. reasons are varied, and are not clearly related to imaging progression alone. only 27% of transferred patients underwent et. more efficient spoke triage and transfer may improve the ratio of patients treated with et. these data provide an important perspective during this period of stroke triage evolution. intra-arterial thrombectomy (iat) has been approved for acute treatment of ischemic strokes (is). with the advent of several new devices for iat, this procedure has become more widely utilized with better outcomes. we performed this analysis to evaluate trends and predictors of utilization of iat over an 8 year period. analysis of nationwide inpatient sample data (2006 to 2013) showed a total of 850,997 patients discharged with a primary diagnosis of is, icd-9 code 433.xx, and 434.xx. iat was ascertained by icd-9 procedure code 39.74. independent predictors of iat were studied using binary logistic regression. the predictors included in the model were age, sex, race, teaching status, and insurance type. results 4903 or 0.6% of is patients received iat. mean age of patients receiving thrombolysis was 71.01 years. percentage of is patients receiving iat has consistently increased from 0.037% in 2006 to 1% in 2013. we also observed significant year to year decrease in mortality among patients receiving iat. in 2006, 26.2% of iat patients died as compared to 15.8% in 2013. using binary logistic regression, the statistically significant independent predictors of iat utilization were age (or= 0.978, p=0.000), female gender (or=1.120, p=0.019), insurance type as compared to medicare (private insurance or=1.199 p=0.006, and self-pay or=0.778 p=0.05). as compared to caucasians, african americans were less likely to receive treatment (or=0.531 p=0.000). also, a teaching hospital was found to be more likely to administer iat as compared to a non-teaching hospital (or = 5.941, p=0.000). is patients with younger age, female gender, private insurance and patients admitted to teaching hospitals are more likely and african americans are less likely to receive iat. this study showed that iat utilization has increased significantly since 2006 with a steep decline in the in-hospital mortality. this may point to improved iat devices and better patients' selection. telestroke plays an integral role in stroke care. nationally the most common model is the hub and spoke, which is used at our institution. understanding telestroke's role in the transfer of candidate patients for endovascular therapy (et) is critical to minimizing delays. our primary objective was to evaluate predictors of transfer delay. patients were selected from the get with the guidelines-stroke registry who were transferred to mgh from jan 2011 to oct 2015 with nihss>6 and last known well<12h on mgh arrival (n=618). we excluded patients for whom we could not calculate transfer time (the mgh arrival time minus the telestroke consult answered time, n=384). ideal time was calculated using google maps incorporating date/time information for ground transfers and straight line distance at 130mph for helicopter transfers. ideal time was subtracted from actual time to calculate delay, accounting for distance, mode of transport, weather, and traffic. analysis of covariance was used to explore 3 possible predictors of delay (night vs. day, weekend vs. weekday, tpa delivery at spoke). of the 234 patients in the study, 120 (51%) were transferred by ambulance, 114 (49%) by helicopter, and 63 underwent et. a significant proportion of the variation in delay was explained by the predictors (f=6.43, p<0.0005). nocturnal transfer (1800-0600hrs) was associated with significantly longer delay (20.53 additional minutes relative to daytime transfers, p<0.0005). weekend vs. weekday transfer and tpa delivery at spoke hospital did not contribute significantly to model variance. our findings highlight the importance of refining protocol approaches. nocturnal transfers were associated with substantial delay relative to daytime transfers. in contrast, delivery of tpa was not associated with delays, underscoring the impact of effective protocols that are in place. metrics and protocols for transfer, especially at night, may have a positive impact on transfer times. the use of anticoagulant therapy in the acute stage of ischemic stroke is controversial. novel oral anticoagulant (noac) is effective in preventing recurrent embolism in patients with non-valvular atrial fibrillation (nvaf), but the risk of hemorrhagic transformation is the major concern for its early use in ischemic stroke. we aimed to study the use of noac in patients with acute ischemic stroke and nvaf. patients with acute ischemic stroke and nvaf, who were admitted to our acute stroke unit from 2014 to 2016, were recruited in this single-centre cohort study. the timing of initiation of noac is at the discretion of the treating physician based on the stroke severity and infarct size. nvaf attributed to 32.5% (214/ 659) of all ischemic stroke cases. the early recurrent embolism rates were 1.4%, 3.3% and 4.7% at one week, two weeks and one month respectively. noacs were prescribed in 105 patients. noacs were initiated within one week in 47 patients (44.8%). the median time to noac initiation were five days (iqr 1.8 -18.0), nine days (iqr 6.3 -25.3) and 20 days (iqr 12.0 -37.0) for patients with no/small-sized infarct, moderate-sized infarct, and large-sized infarct respectively. at one month, two patients had recurrent ischemic stroke despite treated with noac. only one patient, who had a large-sized infarct, developed symptomatic hemorrhagic transformation. early use of noac in ischemic stroke appears to be safe. further large prospective studies are required to evaluate the risk and benefit of noac use in acute ischemic stroke. osmotherapy (hypertonic saline or mannitol) is the mainstay of available therapy to counter cerebral edema that can develop after large hemispheric infarction. in a post-hoc analysis of the games-rp trial, we hypothesized that patients with large infarction, treated with intravenous glyburide, might require less osmotherapy than placebo treated patients. games-rp was a multi-center prospective, double blind, randomized, placebo controlled study which enrolled 84 patients with large anterior circulation infarction. patients were randomized to iv glyburide administration (biib093; n=44) or placebo (n=40) with target time from symptom onset to drug infusion decompressive craniectomy (dc), or both. total bolus osmotherapy dosing was quantified by an "osmolar load" (volume in l * osmolarity in mosm/l). of the 84 subjects, the percentage of patients who received bolus osmotherapy did not differ between the glyburide and placebo treated subjects (51% v. 53%; p=0.89). there was no difference in mean total osmolar load received (mosm) or hours from drug bolus to osmotherapy administration. overall, 40 subjects received osmotherapy. the baseline dwi lesion volume (ml) was significantly larger in the osmotherapy treated group (170.2 ±53.3 v. 147.4 ±45.5; p=0.047). the presence of adjudicated malignant edema on imaging was more common in the osmotherapy group (63% v. 30%, p=0.004), as was dc (45% v. 8%; p<0.0001). among patients with adjudicated clinical neurologic deterioration from edema, 31% (n=11) did not receive osmotherapy. treatment with iv glyburide was not associated with less osmotherapy, possibly due to a ceiling effect resulting from the large infarct volumes. however, osmotherapy use was associated with larger infarct volumes, malignant edema, and higher incidence of dc. use of osmotherapy did not always follow the appearance of clinical or radiographic malignant edema. acute ischemic stroke patients receiving intravenous alteplase (iv-tpa) are placed on bedrest for 24 hours or longer due to provider fear of worsening stroke symptoms from decreased cerebral perfusion. this is based on medical uncertainty and lack of robust studies, despite american stroke association (asa) recommendations for mobilization when hemodynamically stable. this retrospective observational study evaluates very early mobility in acute ischemic stroke patients post iv-tpa while evaluating for change in nihss. medical records of ischemic stroke patients who received iv-tpa between 2012 and 2016 at two urban hospitals were reviewed for mobility protocol activities. patients who were given endovascular treatment, placed on comfort care on day zero or one, mobilized after the first 24 hours, transferred out or left against medical advice were excluded from the analysis. multiple linear regression was used to determine if those patients mobilized earlier saw a greater change between nihss at admit and 24 hours post iv-tpa administration, adjusting for age and gender. of the 268 patients included in the final analysis, 46.6% (n=125) were female, mean age was 68. the multiple linear regression results showed no significant relationship between change in nihss from admit to 24 hours post iv-tpa and earlier mobilization, after adjusting for age and gender (ß= -0.065 change in nihss points per hour; p=0.181). this study reveals early mobility does not worsen stroke symptoms or severity based on nihss. this suggests that very early mobility of patients after iv-tpa is safe as recommended by asa. interhospital transfers to a stroke center following iv-tpa administration are increasingly common. however, no studies have evaluated icu needs in these transfer patients and such understanding may have a significant impact on resource utilization. the aim of this study is to compare the frequency, timing, and nature of icu-level needs in post-iv-tpa patients that were transferred versus those who present directly to the admitting hospital. retrospective chart review of consecutive, tpa-treated ischemic stroke patients admitted to the icu at a comprehensive stroke center servicing a large telestroke referral network from 11/2013 to 7/2015 was performed. we evaluated patient demographics, stroke characteristics, and icu needs between transfer and non-transfer patients before and after icu admission. results 331 patients were admitted to the icu post-tpa. 237 patients (71.6%) were transferred from an outside hospital, of which 123 patients had icu needs (51.9%). this frequency of icu needs was no different when compared to the non-transfer patients (47/94, 50.0%, p = 0.81). similar icu needs were observed for each specific icu intervention between transfer and non-transfer patients (iv antihypertensive, vasopressor requirement, iv rate control, respiratory support, ia therapy, icp monitoring, hypertonic therapy, and neurosurgical intervention, all p > 0 association with icu needs (or 11.9 in transfer patients, or 9.7 in non-transfer; both p < 0.0001). transferring post-iv-tpa patients is not associated with increased icu needs. about one-half of post-tpa patients do not have icu needs, and these patients typically have milder stroke severity. our data supports the safety of transferring post-tpa patients, and to potentially monitor a subgroup of these patients in a non-icu setting. the ability to appropriately triage post-tpa patients may lead to more efficient and cost-effective stroke care. stroke patients requiring decompressive craniectomy remain at high risk of prolonged mechanical ventilation as well as ventilator associated pneumonia (vap). early tracheostomy placement may provide a reduction in the duration of mechanical ventilation however prediction of those who ultimately require a tracheostomy remains a clinical challenge. a preoperative assessment of tracheostomy dependence may help to guide decision making. the authors compare key outcome data after early versus late tracheostomy and develop a preoperative decision-making tool to predict postoperative tracheostomy dependence. a subsequent validation utilizing a decision tree analysis applied prospectively is ongoing and will be presented. we performed a retrospective analysis of prospectively collected registry data and developed a propensity weighted decision tree analysis to predict tracheostomy requirement utilizing factors present prior to surgical decompression. outcomes include probability functions for icu los, hospital los, and mortality based on data for early (10 day) tracheostomy. a subsequent validation of the decision tree is being applied prospectively to evaluate its predictive value. a total of 168 surgical decompressions were performed on patients with acute ischemic or spontaneous hemorrhagic stroke between 2010-2015. forty eight patients (28.5%) required a tracheostomy, whereas 35 (20.8%) developed vap, and 126 (75%) survived hospitalization. mean icu and hospital los were 15.1 and 25.8 days respectively. utilizing gcs, sofa score and hydrocephalus presence, our decision tree analysis provided a 63% sensitivity and 84% specificity for tracheostomy prediction. early tracheostomy conferred significantly fewer ventilator days (p<0.001) and shorter hospital los (p=0.014) with similar vap and mortality rates between groups. early tracheostomy shortens duration of mechanical ventilation and length of stay following surgical decompression for stroke, however without a demonstrable impact in mortality or vap rates. a preoperative decision tree awards a practical tool that may provide insight to guide preoperative decision-making with patient families. patients suspected acute stroke are critical in time delay of endovascular or intravenous thrombolytic therapy. prehospital notification from emergency medical services (ems) may shorten the door to recanalization time. the 'brain saver', web-based prehospital notification system could reduce the time interval from symptom onset to recanalization. beginning in march 2016, stroke team consisted of stroke specialized doctors, nurses and radiologists of multi departments received direct alarms via smart phone application from paramedics of ems about transport information of patients with suspected stroke. we compared baseline characteristics and prehospital/ in-hospital delay time in stroke patients treated with intravenous thrombolysis or endovascular treatment for 12 months with and without ems use brain saver protocol. 167 patients (69 patients with protocol and 98 patients without protocol) were enrolled in this program. the patients who used brain saver had shorter median onset-to-arrival times (63 minutes versus 142 minutes, p < .001) and in in-hospital delay time (35 minutes versus 52 minutes, p<.001). prehospital notification by brain saver was associated with shorter median door-to-imaging time (5 minutes versus 12 minutes, p<.001), door-to-needle time (20 minutes versus 31 minutes, p <.05), door to puncture time (55 minutes versus 137 minutes, p < .001) we found that prehospital notification was associated with faster door-to-imaging time, door-to-needle time and door-to-puncture time in patients presenting within 6 hours of symptom onset. close collaboration between stroke team in hospitals and the ems system gives stroke suspected patients an in-time emergency care system. infection is a common complication in the acute phase after ischemic stroke. furthermore, malnutrition is associated with unfavorable outcome in patients with stroke. therefore, we investigated that premorbid undernutrition identified by objective and quantitative method, nutritional risk index (nri) was related to the risk of infection after ischemic stroke. a consecutive 852 patients who were admitted within 7 days after ischemic stroke onset between october 2010 and october 2015 were included. we assessed initial nutritional status using nri, and nri formula as follows: nri = (1.519 × serum albumin, g/dl) + {41.7 × present weight (kg)/ideal body weight (kg)}. the patients were categorized into three groups on the basis of nri [no risk (nri >97.5), moderate risk (nri 83.5-97.5), and severe risk (nri <83.5)]. we compared the clinical characteristics and nri according to the presence of infection. among the included patients (mean age, 67.7 years, male, 60.6%), 85 (10.0%) patients experienced infection during hospitalization. the rate of pneumonia was 81.2% (n=69), and the rate of urinary tract infection was 11.8% (n=10) among total infection. the proportion of lower nri patients (moderate risk and severe risk) was significantly greater in the infection group (45.9% vs. 17.9% and 10.6% vs. 2.7%, p <0.001). moreover, higher nri patients were less likely to be admitted to the intensive care unit (1.4% vs. 5.1% vs. 6.7%, p = 0.004). a multivariate analysis revealed that lower nri groups had a higher risk of infection [odds ratio (95% confidence interval); moderate risk 3.98 (1.95 -8.13); severe risk 4.21 (1.10 -16.14), p for trend = 0.001]. our study demonstrated that the lower nris predicted infection complications and severe infections after ischemic stroke. this suggests that assessment of nutrition depletion could be a useful predictor and a modifiable risk factor for infection following stroke. cyp2c19 plays a major role in the metabolism of the clop[idogrel. cyp2c19 generates an active oxidized metabolite of clopidogrel that exerts antipl;atelet activity by inhibiting p2y12 reeceptor. the major alleles of the cyp2c19 gene are *1, *2, *3 and *17 and approximately 30% of caucasians and 55% of asians have one or more loss of function alleles in this study, patients with at least two *2 or *3 allels were classified as poor metabolizer(pm), those with one *2 or *3 allele were classified as intermediate metabolizer(im), and those without a *2, *3 or *17 alleles were classified as extensive metabolizer. in addition. those with (*2/*17 or *3/*17) were classified as unknown metabolizer. 784 stroke patients were enrolled for this trial. the mean age was 61 years, and 32% were women. 61% had a history of hypertension, 29% of dm and 28% of dyslipidemia. of the participants, 37% were classifies as em, 1% as um, 45% as im, 16% as pm and 1% as unknown metabolizer. 38% had good genotype for clopidogrel metabolism and 62% had poor genotype. there were no significant diffirences in the demographic and clinical findings between the good and poor genotype groups the prevalence of cyp2c19 polymorphisms is different according to the ethnicity. the racial difference in platelet function may lead to diffrerences in the treatment as well as new targets for antiplatelet therapy the social brain hypothesis is an evolutionary theory proposing that the number of contacts in a primate's social network is proportional to neocortical volume. we tested the hypothesis in a patient population with social network data before and after vascular events. we studied whether social network indices would decrease after stroke, but not after myocardial infarction (mi), as anticipated by the theory. we examined trajectories of the lubben social network scale score (range 0-50, higher values indicating larger network) before and after vascular events in participants from the cardiovascular health study. we used a repeated measures design with linear mixed models to compare the change in social network score before and after events in 382 persons with ischemic stroke and 395 with mi. over a mean of 11.1 years of follow-up for stroke and 12.4 years for mi, we examined an average of 4 social network scores for each participant. we controlled for socio-demographics, baseline cognitive function, and comorbidities. social network scores declined significantly after stroke (an additional -0.14 points every year, 95% ci -0.27, -0.01, p=0.04), but not after mi (-0.06, 95% ci -0.16, 0.04, p=0.24) compared to the baseline slope in fully adjusted models. social network score declined more steeply after stroke than after mi, even after adjusting for potential confounders. these findings support the social brain hypothesis but do not address mechanism. shrinkage of the social networks may be a specific target for interventions to optimize recovery in vascular diseases, particularly stroke. emergency neurological life support (enls) protocols are an essential component to assessment and management of patients within the first hours of the neurological emergency. with increasing focus on emergent endovascular treatment for large vessel occlusion (lvo) in acute ischemic stroke our institution incorporated stroke van assessment as part of the enls acute stroke initial assessment protocol. stroke van screening tool was taught to all nurses in the emergency department (ed) who triage stroke. all patients who presented to the ed with suspected stroke had a van assessment completed prior to ed physician evaluation and ct imaging. patients with weakness in addition to visual changes, aphasia, or neglect were considered van + and triaged immediately to ct angiogram head/neck with immediate notification to the neurointerventionalist. a sample of 76 patients presenting to the ed as a stroke alert over an 8 month time period were utilized. using the stroke van assessment tool was found to improve time to identification of lvo by reducing time from arrival to cta for van positive patients from 77 minutes pre-intervention (n=31) to 27 minutes post-intervention (n=35). this was a significant decrease in time to identification of patients presenting with lvo (p<0.05), improving time to endovascular treatment. incorporating stroke van as part of the acute stroke assessment protocol improved identification of patients presenting with lvo, decreased time to cta imaging and improved time to endovascular treatment which is well documented with improved neurological prognosis. time is essential in neurological emergencies. the van assessment is quick and easy to perform, requires no scoring or calculations, and is the only lvo screening tool tested in the ed by ed nurse and physicians. we suggest incorporating stroke van to the enls acute stroke protocol as a way to improve identification of lvo and improve time to endovascular treatment. elevated blood pressure (bp) is known to be related to hemorrhagic transformation (ht) after ischemic stroke. however, the effect of bp variation on the ht remains unclear, especially in patients with successful recanalization after mechanical thrombectomy. therefore, we investigated the relationship between bp and ht after mechanical thrombectomy following ischemic stroke. a consecutive 141 patients with acute ischemic stroke and successful recanalization (tici 2b or tici 3) were included for the analysis between january 2013 and november 2016. the information on bp was obtained over the first 24 hours using various parameters including mean, maximum (max), minimum (cv), and successive variations (sv) for systolic, diastolic bp, and mean bp. we defined major ht as a parenchymal hematoma type 2 (ph2). among the included patients (age, 66.3; and male, 55.2%), 16 patients (11.3%) developed major ht over the first 24 hours after successful recanalization. systolic bp max-min was significantly increased in patients with major ht compared to those without major ht (61.2 mmhg vs. 44.2 mmhg, p = 0.034) while other bp parameters were not. in addition, systolic bp max-min was significantly associated with symptomatic ht (n=11, 7.8%, p = 0.007). after adjusting for confounders, systolic bp max-min was independently associated with major ht (odds ratio, 1.028; 95% confidence interval, 1.004-1.051). our results demonstrated that absolute change of systemic bp over the first 24 hours was associated with major and symptomatic ht after successful mechanical thrombectomy after acute ischemic stroke. this suggests that maintaining stable systolic bp is an important factor in possibly preventing major ht after successful recanalization. the benefits of intravenous tissue-plasminogen activator in acute ischemic stroke are highly timedependent. however, there are so many cross-departmental tasks to eligible patent that many stroke centers have difficulty achieving the guideline recommended 1-hour door-to-needle (dtn) time. we have developed web based visual task management system called "task calc. stroke" (tcs) by using information and communication technology. herein, we performed a trial installation and preliminary evaluation of tcs. the application software of tcs was designed to run on the google cloud platform. tcs alerts the relevant hospital staff to the patient's arrival condition and time, and displayed tasks to be performed and its treatment status by changing color in real time on networked wall-mounted smart devices in the several relevant departments. we started a trial installation of tcs during the daytime from august 2015. we compared lead times before (august 2014 to july 2015) and after (august 2015 to july 2016) trial installation of tcs. trial installation of tcs in our hospital showed successful information sharing. a total of 33 patients included (pre: 13, post: 20) . after the installation, significant reductions occurred in the median time from door to complete blood count time [26.6 vs. 17.5 min, p < 0.001] and a trend toward a reduction from door to needle time [36.0 vs. 30.0 min, p = 0.175]. tcs may be useful tool to reduce the lead times of acute stroke patients. tcs is a new approach that has the potential to promote efficiency for acute stroke care. prior history of intracranial hemorrhage (ich) has been considered a contraindication to administration of intravenous recombinant tissue plasminogen activator in acute ischemic stroke, per the original activase fda label and 2013 aha/asa guidelines. however, limited data are available on the risks of lysis in patients with prior ich. we performed a cross-sectional study of adult patients who received thrombolysis, using administrative claims data on admissions to acute care hospitals in california between 2005-2011. diagnosis codes were used to identify patients who received thrombolysis, and to ascertain (1) a prior diagnosis of ich, including intraparenchymal hemorrhage (iph), subarachnoid hemorrhage (sah), subdural hematoma (sdh), or epidural hematoma (edh); and (2) relevant comorbidities, including hypertension, smoking, diabetes, heart failure, atrial fibrillation, renal disease, malignancy, and demographic data. we used univariable and multivariable logistic regression to model the odds of in-hospital mortality as a function of prior ich, after adjusting for potential confounders. 60,142 patients received thrombolysis during the study period (mean age 65 [sd 15], female count 26,613 [44%]). of these, 824 patients (1.4%) had a documented diagnosis of prior ich on admission. inhospital mortality was 7% overall, 6.9% for patients without prior ich, and 33.1% for patients with prior ich. in multivariable analysis, all prior ich subtypes remained independently associated with in-hospital mortality, including iph (or 5.9, ci 4.9-7.1, p <2e-16); sah (or 6.5, ci 4.8-8.8, p <2e-16); and sdh (or 3.8, ci 1.8-7.5, p=0.0002). only 4 patients had edh and testing was not possible. 1.4% of patients who received thrombolysis during the study period had prior diagnosis of ich. prior ich was found to be significantly associated with in-hospital mortality regardless of ich subtype. we evaluated the association between early neurological improvement (eni) after ert and time spent from symptom onset to recanalization, according to the degree of collateral circulation measured using multiphase cta. patients with anterior circulation occlusion who underwent ert based on a non-contrast brain ct and multiphase cta were evaluated. collateral status was evaluated using a pial arterial filling score, which was developed into a six-point scale. eni was defined as equal to more than 50%, or as an 8-point decrement in nihss from baseline. neurological statuses at day 1 and at day 7 (or discharge) were determined by a certified neurologist using nihss. the collateral circulation degree measured by multiphase cta was inversely correlated with baseline stroke severity (p=0.02). the proportion of eni at day 1 was significantly lower in patients with poor collateral status (score 0~4) according to the time from symptom onset to recanalization (0-180, 50.0%; 180-360, 14.8%; > 360, 14.3%; p=0.02). however, the proportion was similar in patients with a good -180, 57.1%; 180-360, 50.0%; 360-480, 50.0%; >480, 50.0%; p=0.97, day 7 or discharge; 0-180, 81.0%; 180-360, 71.4%; 360-480, 100.0%; >480, 66.7%; p=0.68). collateral status was the best predictor for eni after ert. eni was achieved in only 5 (14.3%) patients with poor collateral status, and their time from symptom onset to recanalization was more than 180 minutes. the time window for ert might differ according to baseline collateral status measured by multiphase cta. the current time window for ert within 6 hours from symptom onset to groin puncture could be atrial fibrillation (af) is the most common cardiac arrhythmia among adults. despite of the proven advantage in primary and secondary stroke prevention in patients with af, antithrombotic therapy has been reported to be still underused in many countries. however, there is a little data about the incidence of af and any changing pattern of antithrombotic therapy among patients with af over the past decade in korea. data source for this study were obtained from the nationwide sample cohort comprising 1,025,340 individuals (2% of entire population in korea) which were established by nationwide health insurance system. during a 10-year follow-up period, there was 16, 273 developed af (1.58%). the incidence of patients with af remained relatively constant during study period (8.23% in 2004 vs 8.24% in 2013). the proportion of patients with antithrombotic therapy increased from 18.5% in 2004 to 36.5% in 2013 significantly (p for trends < 0.001). however, the proportion of patients with antiplatelet agents was higher than with oral anticoagulation. af steadily increased over recent 10 years in korea. however, only 36.5% of af patients were receiving antithrombotic therapy. our study demonstrated that there was huge gap between the clinical practice and treatment guideline in antithrombotic medication for af patients in korea over the past decade. ohiohealth (oh) possesses one of the nation's largest neuroscience programs and is the leading volume provider of stroke care in ohio. oh is comprised of 12 hospital-based sites, 4 primary stroke centers, 1 comprehensive stroke center, and a virtual health (vh) stroke network that serves 24 hospitals throughout the state. in august 2016, stroke services at ohiohealth were restructured to enable dedicated clinical time for vh providers, require expertise, training, and quality review participation for stroke responders, streamline activation algorithms to limit hand-offs, and eliminate identified barriers to vh consultation. a 6 month interim analysis was planned to assess the impact of these changes (termed "stroke 2.0"). comparative analyses were performed between the first 6 months of stroke 2.0 and the similar time period of the year prior to restructuring. pre-defined metrics included consultation volume, vh response time, iv-tpa time to treatment, research enrollment volume, endovascular referral rate and time to treatment, ischemic stroke (is) observed : expected (o:e) mortality data, and patient retention rate at associate vh sites. during the first 6 months of stroke 2.0, 2007 encounters were seen (historical 700) with a mean activation to vh log in of 4.3 minutes. both volume of patients treated with iv-tpa (154 vs. 96, p< 0.05) and mean treatment times (63 vs. 86 minutes; p< 0.005) were significantly reduced. mean time to endovascular intervention was less during stroke 2.0 (98 vs. 140 minutes, p <0.05). system-wide o: e mortality was reduced after restructuring (0.513 vs. 0.704, p< 0.05), accounting for 21 additional lives saved. acute stroke research enrollment doubled (77 vs. 38) during this same period. transfer rates to vh hub were unchanged (59 vs. 59 %, p = 1.0). strategic changes in staffing, expertise, vh structure, and access can have profound and positive changes on a well-functioning stroke system. strokes due to cns fungal infections (scfi) are often misdiagnosed. retrospective study of electronically-extracted records in patients with strokes & positive fungal studies, from cerebrospinal fluid (csf) or brain biopsy. other stroke etiologies were excluded. thirteen patients had scfi by a priori exclusion & inclusion criteria. nine were males. mean age was 53+17 years. symptoms were mild [nihss 6 (2, 9.5) (median and iqr)]. focal deficits & headaches (both 76.9%) were common. seventy-percent were immuno-compromised (medications, malignancy, transplant recipients). clinical course was indolent in 30.7%. seventy-percent had poor outcome (2-ltac, 4-snf, 2-dead). ninety-two percent had csf pleocytosis (range:27-471) while 61% had csf glucose less than 40mg/dl (range: 2-37). seventy-five percent had lymphocytic predominance. seven strokes were from yeasts (4-cryptococcus, 1-coccidiomycosis, 1-histoplasma, 1-candida) and 6 from molds (4-zygomycetes, 2-aspergillus). sixty-two percent had posterior circulation involvement (71.4% yeast vs 50% molds). there was lepto-meningeal enhancement in 83% of yeast vs. 0% of molds infections (p= 0.01). the basal ganglia (bg) was involved in 75% of intravenous-drug users (ivdu) vs. 0% of non-ivdu (p=0.01). one had abnormal cns vessel imaging directly attributed to the ischemic lesions. in this series, patients were young, immunocompromised or ivdu. stroke sizes & clinical deficits were modest with no angiographic evidence of vasculitis. majority had csf pleocytosis & hypoglycorrhachia. posterior circulation involvement was typical. lepto-meningeal meningitis was only seen in yeast infections. the bg was spared in non-ivdu but common in ivdu. mechanism of stroke in yeast infections is probably from meningitis & secondary involvement of small perforating branches. mechanism in mold infections in immuno-competent ivdu is probably direct angio-invasiveness in small vessels of the bg. outcomes are poor in spite of therapy. scfi should be considered in selected cases of cryptogenic (recurrent or progressive) strokes with clinical, csf and mri features described. life-threatening bleeding requires prompt reversal of factor xa (fxa) inhibitors. their anticoagulant effects can be reversed with the antidote andexanet alfa. the efficacy of andexanet to reverse bleeding in an apixaban anticoagulated porcine trauma model was investigated. after ethical approval, male pigs (n=15) were given apixaban for 3 days (20 mg daily); the sham group (n=5) received placebo. standardized polytrauma by blunt liver injury and bilateral femur fractures were inflicted. 12 minutes post-trauma, animals were randomized (n=5 per group) to a single andexanet bolus (1,000 mg), a bolus (1,000 mg) + infusion (1,200 mg over 2 hours) regimen, or vehicle (control). blood loss (bl) and hemodynamics were monitored over 6 hours or until death and analyzed by anova (mean±sem). apixaban anti-fxa levels were 183±26 ng/ml with no differences between anticoagulated groups prior to injury. bl in the sham animals was 494 ± 24 ml 12 minutes after injury (total bl 651±39 ml at "x" hours; 100% survival). anticoagulation with apixaban significantly increased bl 12 minutes after injury (873±25 ml; p<0.01). controls exhibited a total bl of 3,913±235 ml with 100% mortality (mean survival time = 165 minutes). treatment with a bolus or bolus+infusion of andexanet was associated with a significant reduction in bl versus sham (p<0.05) and 100% survival. two hours after injury, apixaban anti-fxa levels in bolus animals were 99±45 ng/ml, whereas the bolus+infusion regimen resulted in levels of 17±6 ng/ml (p<0.05). hemodynamic parameters (e.g., cardiac output) and markers of shock (e.g., lactate) recovered to pre-trauma levels in andexanet-treated groups. clinically and macroscopically, no adverse events were observed. in this study, andexanet effectively and safely reversed apixaban anticoagulation and reduced bl induced by severe trauma under anticoagulation. the bolus alone had a similar impact on survival and bl as the bolus+infusion regimen in this lethal porcine model. current guidelines for management of pain, agitation, and delirium in mechanically ventilated patients in the intensive care unit (icu) recommend an analgesia-first approach to sedation management. however, these guidelines are derived from non-neurologic patient populations leaving uncertainty in their generalization to this population. the purpose of this study was to evaluate implementation of an analgesia-first sedation clinical pathway in the neuroscience icu. a single-center cohort study was performed within the neuroscience icu including patients mechanically ventilated for greater than 48 hours over a time period of three months before and after clinical pathway implementation. providers were educated on the pathway with emphasis on frequent assessment of richmond agitation-sedation scales (rass), critical care pain observation tool (cpot), and confusion assessment method-icu (cam-icu) scores and systematic de-escalation of sedatives through adequate pain and delirium management. outcome measures included frequency and magnitude of rass, cpot, and cam-icu scores, analgesic and sedative medication prescription/administration per day of mechanical ventilation (mv). a total of 107 patients met inclusion criteria (67 pre-pathway and 40 post-pathway). there was no statistically significant difference in the median frequency of rass (4.8 vs. 4.1) and cpot (6.7 vs. 6.4) assessments per day of mv or in median rass (-3 vs. -3) and cpot (0 vs. 0) scores. mean acetaminophen usage increased from 85.1% to 100% (p< 0.001) post-pathway implementation. there was no statistically significant difference in mean opioid or propofol usage, however a trend toward increased morphine and decreased propofol usage was observed post-pathway. analgesia-first sedation pathway implementation trended towards increased opioid analgesic and decreased sedative use, however only increased acetaminophen usage was significant. this highlights challenges in changing unit-based practices and future directions include focus on the frequency and reliability of pain, agitation and delirium assessment. interdisciplinary coordination and communication remains necessary for effective unit-based practice changes. andexanet alfa (andexanet), a modified, recombinant human factor xa (fxa) molecule, binds and sequesters fxa inhibitors. in a phase 2 study of apixaban, rivaroxaban, edoxaban, and enoxaparin in healthy volunteers, andexanet rapidly reversed pharmacodynamic markers of anticoagulation. here, the ability of andexanet to reverse the anticoagulant activity of betrixaban was investigated. in a randomized, double-blind, phase 2 study in healthy subjects, andexanet (n=12) or placebo (n=6) was administered intravenously following 80mg po qd betrixaban to steady state (7 days). in cohort 1 (andexanet bolus only), subjects (n=6) received a 800-mg andexanet bolus 3 hours after the last betrixaban dose (day 7) or placebo (n=3). in cohort 2 (andexanet bolus plus 2-hour infusion), subjects (n=6) received a 800 mg andexanet bolus 4 hours after the last betrixaban dose, followed by a 2-hour infusion of andexanet (8mg/min) or placebo (n=3). endpoints included safety and pharmacodynamic markers of anticoagulation reversal. following treatment with betrixaban in cohort 1, andexanet rapidly decreased anti-fxa activity from 29.9±11.6 to 6.5±4.5ng/ml, while the anti-fxa levels following placebo were largely unchanged (45.2±44.8 to 43.6±37.7ng/ml). unbound betrixaban plasma concentration decreased from 12.3±5.6 to 3.6±2.7ng/ml with andexanet, but remained constant following placebo administration (18.3±17.9 to 19.3±18.1ng/ml). similar results were observed in cohort 2 following andexanet bolus (2 minutes after bolus), and the effects were maintained during the 2-hour infusion of andexanet. for cohort 1, thrombin generation was restored in 6/6 (100%) and 1/3 (33.3%) of andexanet-administered and placebo subjects, respectively. for cohort 2, thrombin generation was restored in 5/6 (83.3%) of andexanet subjects versus 1/3 (33.3%) of placebo subjects. andexanet was well tolerated; there were no thrombotic events or serious/severe adverse events. andexanet was well tolerated and rapidly reversed anticoagulation effects of betrixaban in healthy subjects. these and other studies indicate that andexanet could be a universal antidote for fxa inhibitors. andexanet alfa (anxa), a recombinant human fxa molecule, reverses the anticoagulant activity of fxa inhibitors. in studies of healthy volunteers, anxa showed dose-dependent reversal of direct and indirect fxa inhibitors in tissue factor (tf)-initiated thrombin generation (tg). we compared rivaroxabaninduced inhibition of tg initiated via the extrinsic pathway (tf) versus intrinsic pathway (non-tf). tf-initiated tg was measured using a calibrated automated thrombogram (cat) and ppp-reagent. non-tf-initiated tg was measured using cat and actin fs. anti-fxa activity was measured using an anti-fxa chromogenic assay. pooled plasma was spiked with rivaroxaban or rivaroxaban+anxa; tg, anti-fxa activity, and clot formation were measured. for low tf-initiated clot formation, thromboelastography profiles were measured. anxa alone had minimal effect on endogenous thrombin potential (etp). anxa fully reversed rivaroxaban-induced anticoagulation in the actin fs assay, independent of anxa-tfpi interaction. modulation of tf activity was assessed by correlating etp versus anti-fxa activity with rivaroxaban or rivaroxaban+anxa. rivaroxaban dose-dependently inhibited tf-initiated tg as anti-fxa activity increased. at similar anti-fxa levels, rivaroxaban+anxa had higher etp than rivaroxaban alone, but not in the actin fs assay. clot formation was studied in plasma using thromboelastography without rivaroxaban. anxa did not affect thromboelastography parameters, with/without recombinant tissue plasminogen activator (rtpa). when low tf initiated clot formation without rtpa, anxa reduced the thromboelastography-r parameter, but not maximum amplitude. the fibrin clot was lysed at low rtpa, resulting in well-segregated coagulation and fibrinolysis. with the optimal rtpa, fibrin clots formed at each tf concentration were compensated by the fibrinolytic activity of rtpa. without a fxa inhibitor, anxa had minimal effect on tf or actin fs-initiated tg with no direct effect on rtpa function. anxa dose-dependently and completely reversed rivaroxaban-induced inhibition of tg initiated by intrinsic or extrinsic pathways, but had different effects on etp due to the anxa-tfpi interaction. there is a growing body of evidence relating poor outcomes to off-hour management. studies investigating the effect of overnight extubation (oe) have produced mixed results, and limited data is available for brain-injured patients. there may also be tendency to limit oe due to decreased staffing levels at night. we sought to determine the safety of oe and risk factor profiles associated with extubation failure (ef) in this cohort. we conducted a retrospective review of mechanically ventilated patients admitted to a single-center in-house database. exclusion criteria included limitations in care, tracheostomy placement, selfextubation, and death prior to extubation. the primary outcome was ef defined as non-elective endotracheal intubation within 72 hours. ef rates were compared between daytime (6am -5:59pm) and overnight (6pm -5:59am) extubation cohorts. in-hospital mortality served as a secondary outcome. amongst 997 identified patients, 783 (78.5%) underwent daytime extubation (de) and 214 (21.5%) oe. ef was indifferent between de and oe (10.1% and 8.4% respectively; p=0.46). however, multivariable adjustment for clinical severity indicators suggests higher ef for oe (or: 1.16, ci: 0.65-2.06; p=0.61). compared to de, oe was more likely performed in elective post-operative patients (29.9% vs 21.1%; p=0.006) with lower apache-ii scores (median 11 vs 13; p=0.002), and shorter durations of mv (median 0.3 vs 1.4 days; <0.001). higher apache-ii score, longer duration of mv, and admission diagnoses of acute vascular injury or neuromuscular disease were associated with ef. there was no difference in mortality (p=0.91). in our cohort, oe was not associated with increased ef or mortality. our results suggest that oe can be performed safely if standard extubation criteria are met in low-risk patients. these data provide a basis for subsequent more robust studies. case series have reported reversible left ventricular dysfunction, also known as stress cardiomyopathy or takotsubo cardiomyopathy, in the setting of acute neurological diseases such as subarachnoid hemorrhage. the nature of the association between various neurological diseases and takotsubo remains incompletely understood. we performed a cross-sectional study of all adults in the national inpatient sample, a nationally representative sample of u.s. hospitalizations, from 2006-2013. our exposures of interest were primary diagnoses of acute neurological disease, defined by icd-9-cm diagnosis codes. our outcome was a diagnosis of takotsubo cardiomyopathy. binary logistic regression models were used to examine the associations between our prespecified neurological diagnoses and takotsubo cardiomyopathy after adjustment for demographics. we identified 18,321,298 adults with a primary acute neurological diagnosis and 231,416,640 patients admitted to the hospital without a primary acute neurological diagnosis. among neurological diagnoses, subarachnoid hemorrhage (odds ratio [or], 9.20; 95%ci, , status epilepticus (or, 6.31; 95% ci, 5.21-7.63), transient global amnesia (or, 2.71; 95% ci, 1.66-4.43), and meningoencephalitis (or, 2.36; 95% ci, 1.91-2.92) were most strongly associated with takotsubo cardiomyopathy. weaker associations were present for ischemic stroke (or, 1.18; 95% ci, 1.08-1.30) and migraine headache (or, 1.44; 95% ci, 1.31-1.59). intracerebral hemorrhage and guillaine-barre syndrome were not significantly associated with takotsubo cardiomyopathy. in our multivariable model, female sex was significantly associated with takotsubo (or, 5.09; 95% ci, 4.85-5.35). we found associations with takotsubo cardiomyopathy for several acute neurological diseases besides subarachnoid hemorrhage. gram-negative meningoventriculitis (gnmv) causes significant morbidity and mortality. in addition to intravenous antibiotics, intra-thecal (it) or intraventricular (iv) antibiotics may be used to treat central nervous system (cns) gram-negative infections, including multi-drug resistant gnmv. there are limited studies on the effect of direct cns administration on cerebrospinal fluid (csf) cultures, csf routine parameters and other clinical outcomes. we conducted a retrospective chart review of all patients who received it or iv antibiotics for gnmv since 2009. demographics, source of illness, severity of illness (sofa), intravenous and it/iv antibiotic choice and csf microbiological, drug level and routine analysis were collected. time to pathogen clearance from csf culture was also measured. there were 32 inpatient encounters where iv/it antibiotics were given for gnmv during our study period, of which 24 were cared for in a neurosciences intensive care unit. antibiotics utilized were: gentamicin (20), colistimethate sodium (7), amikacin (4), and tobramycin (1). the most common pathogens were p. aeruginosa (8), k. pneumoniae (8), enterobacter sp. (7) and e. coli (5). prior to dosing, median csf white blood cell (wbc) count, protein and glucose was 2804/ul, 201 mg/dl and 25 mg/dl, respectively. it/iv antibiotics were dosed a median of 4 times per patient and clearance of csf culture occurred in a median of 5 days. there were significant changes in csf wbc (p< .001), protein (p<.001) and glucose (p<.001) between the first and last dose of iv/it antibiotics. twenty-five (78.1%) patients survived to discharge, 20 (62.5%) were confirmed alive at 6 months. patients who survived to discharge went to rehabilitation (5), home (5), long-term acute-care (9) and skilled nursing facility (6). it and iv antibiotics significantly improve csf wbc, protein and glucose profiles and clear csf cultures in patients with gnmv. it and iv administration may provide additional benefit to systemic therapy. gram-positive organisms are the most common cause of meningo-ventriculitis. systemic antimicrobial therapy may fail to achieve adequate cerebrospinal fluid (csf) concentrations, particularly against organisms with higher minimum inhibitory concentrations, such as mrsa and vre. direct intraventricular (iv) or intra-thecal (it) administration may be beneficial as they can facilitate high csf levels at the site of infection. there are limited studies on the effect of direct central nervous system (cns) administration of antibiotics on csf cultures, csf routine parameters and other clinical outcomes. we conducted a retrospective chart review of all patients who received it/iv antibiotics for grampositive meningo-ventriculitis since 2009. demographics, source of illness, severity of illness (sofa), intravenous and it/iv antibiotic choice and csf microbiological, drug level and routine analysis were collected. time to pathogen clearance from csf culture was also measured. there were 30 inpatient encounters where iv/it antibiotics were given for gram-positive meningoventriculitis during our study period, of which 23 were cared for in a neurosciences intensive care unit. antibiotics utilized were: vancomycin (28) and daptomycin (2). the most common pathogens were staphylococcus sp. (15), enterococcus sp (5), and streptococcus sp (8). prior to dosing, median csf white blood cell (wbc) count, protein and glucose was 430/ul, 117mg/dl and 47mg/dl, respectively. it/iv antibiotics were dosed a median of 4 times per patient and clearance of csf culture occurred in a median of 3 days. there were significant changes in csf wbc (p< .001), protein (p<.001) and glucose (p=.045) between the first and last dose of iv/it antibiotics. twenty-nine (96.7%) patients survived to discharge, 19 (63.3%) were confirmed alive at 6 months. it and iv antibiotics significantly improve csf wbc, protein and glucose profiles and clear csf cultures in patients with gram-positive meningo-ventriculitis. it and iv administration may provide additional benefit to systemic therapy. use of prothrombin complex concentrate (pcc) for urgent reversal of anticoagulant associated coagulopathy is increasing, and at the university of illinois hospital (uih), an anti-thrombotic reversal guideline was developed in may 2016 in order to assist licensed practitioners in choosing the appropriate reversal agent, optimal dosing, and improve timely administration pcc. the current study examined the safety and efficacy of pcc used for the urgent reversal of anticoagulant associated coagulopathy before and after the development of the anti-thrombotic reversal guideline. this was a retrospective chart review of adult patients who received pcc as the only hemostatic agent at the uih from jan 2008 to april 2017. the primary endpoint was hemostasis and secondary endpoints included thromboembolic events and time to pcc administration. there were 21 and 17 patients who received pcc before and after the anti-thrombotic reversal guideline, respectively. frequent cause of coagulopathy was warfarin (81% and 76%, respectively), and frequent indication for pcc was acute intracranial hemorrhage (81% and 76%, respectively). 3-factor pcc was more frequently used before the guideline and 4-factor pcc was more frequently used after the guideline. in patients presenting with warfarin induced major bleeding, target inr <1.4 was achieved in 71% and 62% of these patients before and after the guideline, respectively. clinical assessment of bleeding cessation from direct oral anticoagulant (doac) therapy was difficult to assess. thromboembolic event was observed in 38% and 6% of the patients, respectively. median time to pcc administration from its initial order was 107 minutes and 80 minutes, respectively. hemostasis was similarly observed in the warfarin group before and after the development of reversal guideline, but more thromboembolic events were observed before the reversal guideline. in order to further reduce the pcc administration time, a change in workflow has been made to administer pcc in timely manner. dexmedetomidine, a selective alpha-2 adrenoreceptor agonist inhibiting sympathetic neuronal activity, is a mild sedation agent. two recent case reports showed reduced norepinephrine (ne) requirement in septic shock with clonidine, a less selective alpha-2 agonist. increased vasopressor responsiveness (vr) was also observed with dexmedetomidine in cardiovascular surgical settings. sympatholytic effects of the alpha-2 agonists reverse vascular desensitization due to high levels of sympathetic activity in sepsis. depletion of intra-neuronal catecholamines with reserpine has shown to increase vr. in septic sheep infused with escherichia coli, clonidine reduced renal sympathetic tone and restored vr. additionally, alpha-2 agonists have shown to decrease pro-inflammatory cytokines and reduce mortality, improve capillary perfusion deficit, and lower arterial lactate in animal sepsis models. a prospective trial in human septic shock is in the pipeline. we report decreases in vasopressor requirement with initiation of dexmedetomidine in two patients with brain injury. a 51-year-old woman presented with a high-grade subarachnoid hemorrhage and concomitant reverse takatsubo cardiomyopathy. her clinical course was complicated by septic shock secondary to aspiration pneumonia at admission. when dexmedetomidine was started after 36 hours of ne infusion, a steady decrease in ne dosage was observed until its discontinuation. increased vr was also observed in a 33year-old man being treated for new onset refractory status epilepticus. on hospital day 10, the patient continued to have stimulus-induced seizures on ketamine, midazolam and pentobarbital infusions and required ne to maintain an adequate mean arterial pressure. when dexmedetomidine was added, a decrease in ne infusion was observed within an hour and continued for six hours until the patient no longer required vasopressor therapy. these findings are consistent with aforementioned reports of restored vr by alpha-2 agonists in septic shock, and warrant further investigation of possible beneficial effects of attenuated hyperadrenergic state conferred by alpha-2 agonists in various neurocritical care settings. decreasing the amount of time a patient remains intubated has been shown to reduce multiple negative outcomes. by extubating these patients earlier, risk of infection, prolonged immobility, and delirium are reduced. in early 2016, this nsicu was chosen to participate in the society of critical care medicine's icu liberation collaborative. the collaborative was focused on implementation of the abcdef bundle or icu liberation. the successful implementation of the bundle led to a decrease in the amount of time neurocritically ill patients were intubated. the bundle elements began to be rolled out in june 2016 (end of 1st quarter). included in the bundle's roll out was the creation of a respiratory clinical specialist role to help the interprofessional team with the respiratory components of the bundle. this role was a full time respiratory care practitioner who was dedicated to the nsicu and helped to ensure standards were being met. additionally, as a part of the bundle's implementation, a spontaneous awakening trial and spontaneous breathing trial algorithm was developed and initiated. this algorithm relied on interprofessional collaboration between nursing and respiratory therapy with communication to the provider and was rolled out in september 2016 (end of 3rd quarter). ventilator o/e for 2016: 1st quarter-0.953, 2nd quarter-0.989, 3rd quarter-0.827, 4th quarter-0.798 ventilator o/e for 2017: 1st quarter-0.844, 2nd quarter-0.700 the bulk of the research conducted that proved the benefits of the bundle elements has been completed in medical and/surgical patient populations. the neurocritical care patient population is very specialized and has several nuances that may impact the way the various elements need to be implemented. through this process, we have found that the techniques suggested within each element can positively impact the neurocritical care patient population. the cognitive reserve hypothesis refers to inter-individual differences in the ability of patients to cope with brain pathology. cognitive reserve can be measured by surrogate markers such as education and occupation and has shown to be an important predictor of outcomes in alzheimer disease, multiple sclerosis and traumatic brain injury. in this prospective longitudinal cohort study we determined whether cognitive reserve measured as number of years of education and employment status predicted 3-month functional outcome of ncc patients. demographic and clinical data, including number of years of education and occupational status, were collected. at three months after discharge, glasgow outcome scales (gos) were collected via telephone from patients or surrogate respondents. gos scores were categorized into 'good' or 'poor' outcome (gos 1-3). from march 2016 to july 2016, 35/83 patients with 3-month follow-up data were included. mean age was 56 ± 19 years, 12 (34%) were male, with stroke as the predominant admitting diagnosis.the two groups with good vs poor outcomes did not differ in age, gender or race in univariate analysis although employment status was statistically different in the two groups. in multivariate logistic regression neither employment nor education was a significant predictor of good vs poor outcome (p = 0.34, p = 0.88). prognostication in neurocritical care patients is difficult. the effect of cognitive reserve needs to be studied further. our current sample size is small and as enrollment continues, we will determine the relationship between cognitive reserve and 3-month functional outcome. fever commonly occurs in patients with spontaneous intracerebral hemorrhage (sich). however, it is non-infectious in the majority of cases. blood cultures (bcx) are often obtained as part of a fever workup, yet their utility may be limited and false-positive results may potentially compromise patient care. we hypothesized blood cultures in the first 48 hours would more likely be false-positive. we performed a retrospective chart review of patients admitted to a tertiary medical center with a diagnosis of spontaneous intracerebral hemorrhage. patients with secondary causes of ich as well as institution of comfort measures only were excluded. data obtained included demographics, clinical parameters of ich and blood culture results. blood culture results and charts were reviewed for adjudication of false-positive and true-positive cultures. of 654 included patients with sich, 226 patients (34%) had 1065 blood cultures obtained. 52 cultures were positive, of which 23 were classified as false-positive and 29 as true positive. false positive results were more common in the first 2 days (17 vs. 6), while true positive results were more common after the first 48 hours (12 vs. 17) (p= 0.018). early blood cultures in patients with sich are more commonly non-infectious. in line with prior published data, our results demonstrate the high cost and limited yield for blood cultures within the first 48 hours. predictive energy expenditure (pee) equations are commonly used in lieu of indirect calorimetry (ic) due to cost and limited resources; however, these equations may not be as accurate as ic in estimating resting energy expenditure (ree) in critically ill patients. the purpose of this study is to compare pee and measured energy expenditure (mee) in critically ill adults with acute brain injury. this was a retrospective review of adult patients admitted with acute brain injury between may 1st, 2014 and april 1st, 2016 who had ic performed. three predictive equations (pe), harris benedict (hbe), penn state university, and mifflin st jeor (msj), were used in comparison to ic results. subgroup analyses included a modified aspen weight-based equation, stratifying patients based on bmi and type of acute brain injury. 144 patients met inclusion criteria. comparing the pee estimated by the three predictive equations to the mee from ic found no significant difference. high degrees of interpatient variability were discovered in each anova analysis, with standard deviations ranging from 17 -29%. despite no difference found among pee and mee, pearson's correlations indicated weak associations when hbe, penn state, and msj were individually compared to mee (r-values = 0.372, 0.409, and 0.372, respectively). in patients with a bmi < 30 kg/m2, a significant difference was found (p-value=0.0006) with pee underestimating the ree. additionally, in aneurysmal subarachnoid hemorrhage a significant difference was observed between pee and mee( p-value=0.005). the results of this study highlight the importance of using ic whenever feasible due to the interpatient variability of the ree of critically ill patients with acute brain injury. although predicative equations appear to have similar estimations as ic, interpatient variability warrants more accurate measurement with ic to optimize nutrition in patients with acute brain injury. introduction 4-factor prothrombin complex concentrate (pcc) should be administered as soon as possible for reversal of anticoagulation in the setting of life-threatening bleeding or urgent procedures. limited information is available on the safety, efficacy, and time to administration of pcc when administered at high infusion rates. on march 21, 2017 grady health system implemented a rapid pcc administration strategy while attempting to reduce times from order entry to administration as a quality improvement initiative. this irb-approved, retrospective evaluation includes pcc administrations 90 days pre-and post-protocol implementation. after protocol implementation, pcc doses were prepared in up to four, 60-ml syringes, dependent on the ordered dose. each syringe was administered over 2 minutes, not exceeding a rate of 750 iu/minute. the primary objective of this study is to evaluate the safety of a rapid administration strategy for pcc. secondary objectives include turn-around times and effectiveness of inr reversal in patients previously on warfarin. results 52 unique pcc administrations were identified: 29 administrations in the pre-cohort and 23 in the postimplementation cohort. most pcc administrations were in the setting of spontaneous or traumatic intracranial hemorrhage. there were no infusion-related adverse events documented with the exception of a possible pcc infiltration post-implementation which resolved with supportive care only. the median order entry to administration time was higher in the post-implementation group (52 vs. 42 minutes). 18 administrations in the pre-cohort and 11 administrations in the post-cohort were for warfarin reversal. a greater percent of patients previously on warfarin reversed to an inr < 1.4 in the post-cohort compared to the pre-cohort, 81.8% vs 72.2%, respectively. this retrospective evaluation suggests that rapid intravenous push administration of 4-factor pcc is safe and effective. time to administration was longer after implementation of rapid pcc administration and may have been due to operational limitations. icu readmission is defined as a return to the icu during the same hospital admission. there are multiple studies related to medical and general surgical recidivism, however there is limited data on icu readmissions following spine surgery. the aim of this study was to evaluate factors associated with icu readmissions following spine surgery. patients requiring icu admission following spine surgery from june 2013 to june 2017 were studied. variables included age, gender, icu and hospital disposition, icu and hospital length of stay, bmi, comorbidities, surgical location, number of previous surgeries and vertebra manipulated, estimated blood loss, post op blood transfusions, and cause of readmission. a 1:1 matched control group based on age, bmi and location of surgery was identified. thirty-two patients required readmission following spine surgery during the study period. there was a higher prevalence of preoperative atrial fibrillation in the readmission group (20% vs. 5%, p=0.04). ebl (1041 vs 1214 ml, p=0.9) and lowest maps (60 vs 59.2 mmhg, p=0.7) were not significantly different in the two groups. we found a higher mortality rate (22% vs 0%, p=0.01), longer icu (60.7 vs 39.5 hours, p=0.06) and hospital los (17.28 vs 7.87 days, p= 0.001) in the readmission group. respiratory distress (25%) was the most common reason for readmission followed by cardiovascular instability (13%). discharge rates to inpatient rehabilitation and nursing facilities were similar for both groups; however 42% of the control group went directly home as opposed to 19% of the readmission group. complex spine patients who experience icu recidivism have a longer hospital stay and incidence of death within 5 years of their index procedure. they are less likely to be discharged home. preoperative a-fib correlates with increased incidence of readmission to icu post-operatively. further studies are needed looking at post operative fluid and pain management. to demonstrate the feasibility of exenatide infusion for hyperglycemia following acute brain injury. adult patients with acute brain injury and having two blood glucose concentrations >150 mg/dl and was administered within 48 hours of admission and continued per protocol for a maximum duration of 48 hours. the primary endpoint was feasibility (<25% of subjects experiencing severe hypoglycemia (<40 -180 mg/dl). descriptive endpoints were also collected. data is presented as medians [interquartile range] or percentages. a total of eight patients received exenatide (age 64.0 years [58.8, 67.8], 87.5% male, 50.0% caucasian, 50.0% history of diabetes, a1c 6.5% [5.5,7.3]). admitting diagnoses were intracerebral hemorrhage (n=3), acute ischemic stroke (n=3), subarachnoid hemorrhage (n=1), and subdural hematoma (n=1). glascow coma score was 10.5 [7.0, 14.0] and sequential organ failure assessment was 2.0 [1.0, 4.0]. based upon predefined criteria, feasibility was met with 0% of subjects experiencing severe hypoglycemia, 87.5% achieving the blood glucose goal, and 0% experiencing nausea requiring discontinuation. blood glucose was controlled during the 48-hour exenatide infusion ( intravenous exenatide infusion is feasible for the treatment of hyperglycemia following acute brain injury. extubation failure remains a common complication in critical care patients, and is associated with increased intensive care unit and hospital length of stays, hospital costs, morbidity and mortality. the most common cause of reintubation is laryngeal edema, often identified by the presence of a high pitched inspiratory whistling sound known as post-extubation stridor (pes). providers in the neurocritical care unit (nccu) at a large urban academic medical center noted higher than normal rates of pes. to reduce the rates of pes and reintubation without delaying extubation, a clinical pathway was created by an interdisciplinary team. the purpose of the pathway was to aid in the identification of patients expected to develop pes and guide prophylactic treatment. prior to project implementation, all providers in the nccu completed hands on training with practice in completing the pathway in the form of a checklist. during the 12 week implementation phase, checklists were completed on all intubated patients daily during rounds. during the 12 week trial, there were a total of 606 ventilator days. there were 531 completed checklists, yielding an 87.62% compliance rate for utilization of the clinical pathway. of the 56 patients who were extubated during the trial, 54 had a checklist completed, generating 96.43% compliance on the day of extubation. a chi-square analysis was performed to evaluate outcomes following all non-palliative extubations during the 12 week pre-implementation (n = 43) and post-implementation (n = 56) periods. implementation of the pathway was associated with a statistically significant reduction in rates of pes (1, n = 99) = 6.16, p<0.02, reintubation (1, n = 99) = 5.54, p<0.02 and reintubation due to pes, (1, n = 99) = 8.32, p<0.005. the clinical pathway implemented in our nccu was safe and effective in reducing rates of pes, reintubation and reintubation due to pes. agency for healthcare research and quality (ahrq) identified postoperative deep vein thrombosis (dvt) or pulmonary embolism (pe), also commonly referred to as venous thromboembolism (vte), as one of the complications acquired in the hospital and thus developed a mechanism to report its rate using administrative data. postoperative vte rate reduction became top priority for the university of illinois (uih) due to its high yearly rate, especially among patients in the neurosciences intensive care unit (nsicu). therefore, a quality improvement team in the nsicu implemented vte bundle and analyzed its effect on the vte rate. the vte bundle was initiated on all neurosurgery and neurology patients admitted to the nsicu since march 2016. vte bundle included lower extremity doppler ultrasound within 24 hours of admission, vte education provided to patient or family member within 48 hours of admission, and daily surveillance on proper use of mechanical sleeves and the mechanical device, low-dose heparin initiation and maintenance therapy, and documentation of activity status. the nursing staff were encouraged to follow the early mobilization protocol. mean vte rate was 52.9 per 1000 cases approximately 1-year before and 33.6 per 1000 cases approximately 1-year after the implementation of vte bundle. the rate of compliance was high on all aspects of vte bundle, especially on correct placement of ipc sleeve >85%; functioning ipc device >90%; low-dose heparin >90%; documentation of activity status >94%. no adverse effects were noted (i.e., skin breakdown, major bleeding) during the study period. this was the first time in 3 years at uih, the postoperative vte rate was reduced among nsicu patients based on the ahrq reports. the reduction may partly be attributed to the implementation of vte bundle; however further evaluation need to be performed to determine the effect size of vte bundle. increasing evidence suggests that large volume infusions of 0.9% sodium chloride (nacl) for resuscitation are associated with hyperchloremic metabolic acidosis and renal vasoconstriction leading to an increased risk of acute kidney injury (aki). in patients with neurologic injury, hypertonic (1.5% or 3%) nacl or sodium acetate (naacetate) may be required for therapeutic hypernatremia, treatment of cerebral salt wasting or elevated intracranial pressure. the primary aim of this study was to determine the incidence of aki in neurologically injured patients receiving intravenous hypertonic nacl and in those who were switched to hypertonic naacetate based on provider preference. this single-center, retrospective study compared patients that received only hypertonic nacl to patients that were switched to naacetate. data was collected to assess renal function, hyperchloremia, and metabolic acidosis. a total of 301 patients were screened and of those 142 were included. the patients who were switched from nacl to naacetate (n=45) had a greater incidence of aki (27% vs. 6%, p<0.001) and hyperchloremia (56% vs. 29%, p = 0.01) compared to patients who received only nacl (n=97). the incidence of metabolic acidosis was increased but not statistically significant (15% vs. 11%, p = 0.791). on average, hypertonic nacl was switched to hypertonic naacetate on day 3 of treatment with a mean chloride of 115.7 meq/l at the time of the switch. there was no statistical difference in the administration of nephrotoxic antibiotics, mannitol, vasopressors, or contrast dye between the two groups. the receiver operating characteristic (roc) analysis demonstrated that if a patient received greater than 2055 meq of chloride over 7 days they were more likely to develop aki (sensitivity 72%, specificity 70%, p=0.002, auc 0.70). neurologically injured patients receiving hypertonic sodium therapy requiring a switch to hypertonic naacetate had an increased incidence of hyperchloremia and aki. in-hospital complications following acute neurological injury has been a topic of extensive research to help reduce the morbidity and mortality among the patients. however, the incidence and prevalence of in-hospital infections following an acute neurological injury at the national level has never been studied. the aim of our study is to determine the frequency and prevalence of in-hospital complications among different patient groups admitted following acute neurological injury. we identified patients with primary diagnosis of ischemic stroke (is), subarachnoid stroke (sah), intracerebral hemorrhage (ich), status epilepticus (se), meningitis, encephalitis and traumatic brain injury (tbi) from nationwide inpatient database (2011-2014) through using the respective icd-9 codes. common in-hospital complications among the above-mentioned diagnoses through using their respective icd-9 codes patients with primary diagnoses of is (n=1855297), sah (n=101576), ich (n=254758), se (n=190701), meningitis (n=46067), encephalitis (n=23839), tbi (n=1142155) were identified. in-hospital events such as myocardial infarction (mi), sepsis, pneumonia, deep venous thrombosis (dvt), pulmonary embolism (pe), urinary tract infections (uti), and gi bleed were identified and compared among different patient groups. patients with se were noted to experience higher systemic complications, mi (3.6%), sepsis (11.2%), pneumonia (8.6%), dvt (1.7%), uti (16.2%), gi bleed (0.41%). patients admitted with meningitis had a higher incidence of sepsis (20.5%), pneumonia (9.0%), dvt (2.2%), pe (1.5%) and uti (12.7%) compared to the other groups. uti was the most common in-hospital complication observed. based on our analysis, we report a higher incidence of urinary tract infections among all patients admitted following acute neurological injuries. patients with primary diagnosis of status epilepticus experienced more systemic complications compared to the other diagnoses. macroglossia is a phenomenon that has been documented in association with prolonged neurosurgical procedures, brainstem injury, phenobarbital administration, and venous/lymphatic congestion of the tongue. however, exact causation of this condition in the neurocritical care population remains unclear. patients with macroglossia face significant risk for airway compromise. no interdisciplinary patient safety and management protocol exists. patients admitted to two neuro icu's within a single health system between 2012-2017 were reviewed. twenty-five patients with macroglossia were identified. an interdisciplinary patient management protocol was created, instituting airway safety standards, oral care directives, and interventions to promote symptom resolution. early consultation to oral and maxillofacial surgery and consideration of early tracheostomy was recommended. seventeen patients (68%) were women. age ranged from 20-81 years. the majority (16/25) of patients were african american. primary diagnoses included status epilepticus (12/25) and stroke (1 sah, 4 ais, 6 ich). nineteen patients received antiepileptic medications before diagnosis. average gcs at symptom onset was 5.8 [3] [4] [5] [6] [7] [8] [9] [10] [11] and at time of discharge was 8.9 [3] [4] [5] [6] [7] [8] [9] [10] [11] [12] [13] [14] [15] . median symptom onset was hospital day 5 [0-39]. twenty patients (80%) required tracheostomy. nine (36%) experienced symptom resolution by hospital discharge. two patients received botulinum toxin injection; both experienced symptom resolution. lingual massage was performed in two patients; in both patients, tongue swelling resolved. tongue lacerations occurred in 10/25 patients (40%), although most were observed following macroglossia onset, ruling out trauma as an inciting event. chlorhexidine oral rinse was discontinued for all except five patients due to concern for angioedema. endotracheal tube was dislodged in two patients, complicating reintubation, although successful. no trend in pre-existing allergies or antibiotic regimen was apparent. macroglossia is a relatively uncommon but high-risk condition in the neuro icu that warrants further study. care of patients with macroglossia should be standardized in order to ensure airway safety. an interdisciplinary approach is recommended. one of the biggest challenges of magnetic resonance imaging (mri) examination is the acquisition of high-quality diagnostic images, as it requires the neurological intensive care unit (nicu) patients to keep still for a significant time. in situations with poor patient cooperation, unplanned sedation is inevitable, which can lead to complications such as desaturation and hypotension. we investigated the incidence and factors related to complicated mri examinations (mri-c) in patients admitted to the nicu. we designed a retrospective study to review the data of 218 patients who had an attempt to undergo brain mri during stay in the nicu between july 2014 and august 2016. the mri-c group was defined when a patient met one of following criteria: 1) required sedation for mri examination due to irritability 40 mmhg or required inotropic agents, 4) developed cardiac or respiratory arrest. of 218 patients, 66 (30.3%) developed mri-c. the most common cause of mri-c was unexpected irritability at the mri room. among patients with mri-c, 62 (93.9%) patients required unplanned sedation; 9, desaturation; 6, hypotension; none, cardiac or respiratory arrest. higher apache ii scores (p = 0.031) and lower gcs scores (p = 0.047) on admission and use of sedative agents during critical care in the nicu were associated with mri-c (p < 0.01). in addition, patients with mri-c had longer mri scan time than those without mri-c (p = 0.004). many of neuro-critically ill patients undergo unsafe mri scans. our findings suggest that severity of illness and use of sedative agents during management in the nicu were factors related to mri-c. introduction: fulminant hepatic encephalopathy (fhe) with diffuse cerebral edema has dismal prognosis if transplantation is not performed. novel therapeutic interventions may change this outcome. we reviewed all cases with fhe admitted to our hospital since 2008. in 2010, we developed a multidisciplinary management protocol, mandating transfer of patients entering grade 3 from other icus to the neurosciences-icu (nicu) for intracranial pressure (icp) management. multiple interventions were utilized including coagulopathy reversal with factor vii and prothrombin complex concentrate (pcc, kcentra), icp device placement, osmotherapy, aggressive ammonia lowering regimen with lactulose and rifaximin, early renal replacement therapy, mild hypothermia for refractory icp, in conjunction with liver transplantation candidacy investigation. results: twenty-four patients (19 women, mean age of all patients 40 years) were admitted; seven were managed in the micu/sicu and 17 in the nicu. the etiology of fhe was acetaminophen toxicity in 72% of patients. the model for end-stage liver disease (meld) admission scores and liver enzymes between the micu/sicu and the nicu were not different (mann-whitney test). although the nicu admission ammonia level was higher than the micu/sicu (168.75 vs 99.50, p = 0.00), the lowest achieved ammonia was lower in the nicu (41.31 vs 78.13, p = 0.022, mann-whitney). patients received icp monitoring (all in the nicu plus 2 in the sicu) and the highest icp recorded was 120 mm hg. the preand post-coagulation reversal inr were 3.37 and 1.3, p=0.031, wilcoxon test). seven patients in the nicu received hypothermic treatment. mortality in the micu/sicu was 85.7% (6/7) and in the nicu 41.1% (7/17), p = 0.13 (chi square test). conclusion: a multidisciplinary approach centered around anti-cerebral edema protocol-driven management based on novel interventions may improve the outcome of patients with fhe. catheter-associated urinary tract infections (cauti) are among the most common health-care associated infections (hcais), (gould, 2016) . neurological patients in the critical care setting are particularly at risk for cauti due to cognitive, motor, and sensory deficits. in the neuro intensive care unit, despite following recommended cauti reduction bundle guidelines, cauti rates continued to rise over the last five years with rates reaching 6.45 per 1000 catheter days. in january of 2017, the unit implemented a cauti taskforce to perform a literature review of best practices and subsequent 1:1 peer training and education targeting cauti reduction. in an analysis of organisms causing the infections, e. coli and enterococcus bacteria accounted for more than 50% of cautis on the unit. the taskforce (comprised of 13 staff nurses) focused on fecal management, proper cleaning technique, and proper indications of indwelling urinary catheter necessity. using training videos, indwelling urinary catheter care checklists, and real-time feedback on technique, the taskforce performed 1:1 training with bedside staff over four weeks. to ensure undivided attention, the taskforce worked in pairs enabling one trainer to teach and observe the staff member receiving training while the second trainer provided the necessary clinical duties for the trainee's patients. after implementation, the cauti rate decreased to 3.43 for january-march 2017 and 2.83 for april-june 2017, lowering total cauti events to 23 for fy17 compared to 32 for fy16. implementing a 1:1 training program focused on fecal management, cleaning techniques, and appropriately timed catheter removal can reduce cauti rates in the neuro critical care setting. brain aneurysms can be treated with coil embolization or flow-diverting devices. thromboembolism is a major complication of aneurysmal coil embolization, with an incidence as high as 28% . new flowdiverting devices have been designed to have a mesh with high coverage area and high flexibility to facilitate the redirection of blood flow. these features can induce blood stagnation and thrombosis. to reduce the risk of thrombosis, the common but unproven practice of dual antiplatelet therapy with aspirin and clopidogrel has been implemented from the cardiac literature. despite some favorable outcomes, clopidogrel, "non-responsiveness" has been reported to be present in as low as 5% to as high as 56% making this agent not optimal. this will leave practitioners with other oral p2y12 alternatives such as prasugrel and ticagrelor that have not been studied widely in this setting. it is therefore likely that controversy exists among practitioners regarding the use of optimal antiplatelet agents in neurointerventional procedures. we hypothesized that practices in regards with the use of oral antiplatelets in neurointerventional procedures are likely heterogeneous and different from state to state. by using an electronic survey, we would like to identify different practices surrounding the use of oral anti-platelets in neuro-endovascular centers in the united states. an electronic survey will be distributed via the web using survey monkey (seattle, wa). the survey will be posted on the neuro-critical care society (ncs) web page. all practicing neuro icu or stroke physicians, pharmacists, physician assistants, or nurse practitioners are eligible to respond to this survey. this survey is approved by the johns hopkins hospital irb and the ncs research committee. 8 centers have completed the survey at this point. the results will be analyzed after the closing date of survey (9/4/2017). to be completed myasthenia gravis (mg) crisis and guillain-barre syndrome (gbs) are immune mediated diseases that may require mechanical ventilation as part of their management if severe. comparative analysis of outcomes in terms of length of stay, disability, and mortality between these two disease entities at national level is not reported mechanically ventilated patients with primary diagnosis of guillain-barre syndrome and myasthenia gravis were identified from the nationwide in-patient sample (nis) database for the years 2012 to 2014 mechanically ventilated mg patients (n=2330, mean= 62+/-19.5 years) were older compared to gbs patients (n=2060, mean= 55.9 +/-20.0 years, p=0.001). medical co-morbidities were significantly higher in mg patients (diabetes mellitus, congestive heart failure, coagulopathy, chronic lung disease and dyslipidemia) whereas significantly higher nicotine dependence and alcohol abuse were noted in gbs. significantly higher in hospital complications of pneumonia and urinary tract infection were noted in gbs. disease severity measured by apdrg severity index and rate of treatment with intravenous immunoglobulin and plasma exchange was comparable. length of stay (25.3 ± 18.2 days , p < 0.0001 ); hospital charges ( $353361.2 ± 293863.2 vs 232160.12 ± 222881.3 p = 0.001) ; moderate to severe disability ( 86.6% vs 46.2% p < 0.001) were significantly higher for gbs patient compared to mg. inhospital mortality was comparable ( 8.7% gbs vs 8.6 % mg, p =0.93). in multivariate analysis after adjusting for confounders including treatment, myasthenia gravis patients had significantly less disability (or 0.06 (95% ci 0.03-0.10) and shorter length of stay (or 0.32, 95% ci 0.16-0.61). mechanically ventilated gbs patients have higher in-hospital complications, length-of-stay, and disability compared to mg. this may reflect a delay in diagnosis of gbs at admission and poor response to immunotherapy in certain gbs variants. betrixaban is an inhibitor of factor xa (fxa) for prophylaxis of venous thromboembolism (vte) in at-risk patients hospitalized for acute medical illness. a phase 3 trial (apex) compared extended-duration anticoagulation with betrixaban to enoxaparin in acute medically ill patients; the effect of patient characteristics on population pharmacokinetics and exposure-response relationships is analyzed here. patients received betrixaban (35-42 days; n=3,759) or enoxaparin (10±4 days; n=3,754). the primary efficacy and safety endpoints were composite occurrence of vte events and incidence of major bleeding, respectively. betrixaban dose was 80mg po qd (40mg po qd for patients with severe renal insufficiency/requiring concomitant p-glycoprotein inhibitor). pharmacokinetic samples were collected -5 hours or 10-30 hours after the most recent dose of study medication. patient characteristics included age, sex, race, region, body weight, crcl category, and specific p-glycoprotein inhibitor. 3,146 pharmacokinetic samples were analyzed. at 80mg, the projected concentration was 18.8ng/ml at 2 hours post-dose and 16.1ng/ml at 20 hours post-dose, showing a stable daily concentration. coadministration of 2 p-glycoprotein inhibitors on the day of sampling more than doubled betrixaban concentration to ~35ng/ml at 20 hours post-dose. at 40mg, the projected concentration was 7.2ng/ml at 20 hours post-dose, indicating a greater-than-dose-proportional exposure relationship. patient age, sex, weight, crcl category, p-glycoprotein inhibitors, and region were significant covariates affecting betrixaban pharmacokinetics. the exposure-response relationship for the primary efficacy endpoint was not significant, but the relationship between betrixaban concentration and major/clinically relevant nonmajor bleeding was significant in multivariate testing (p=0.011). the betrixaban pharmacokinetic profile exhibited stable serum concentrations with qd dosing. several covariates had a 15%-20% effect on betrixaban concentration, but no effect on efficacy/safety. betrixaban dose should be adjusted to 40mg for patients taking amiodarone or clarithromycin, but not other p-glycoprotein inhibitors. andexanet alfa is being investigated for reversal of anticoagulation by factor xa (fxa) inhibitors. a pharmacokinetic/pharmacodynamics model, developed in healthy subjects, predicted the andexanet regimen required to reverse anticoagulation by fxa inhibitors. the current analysis validated the pharmacokinetic/pharmacodynamic model using interim data from the annexa-4 study in patients with acute major bleeding. in annexa-4, an ongoing prospective, open-label study, bleeding anticoagulated patients received iv andexanet bolus (400 or 800 mg) followed by 120-minute infusion (4 or 8 mg/min). anti-fxa activity was measured before andexanet administration (baseline), at end of bolus (eob), at end of infusion, and at 4, 8, and 12 hours after infusion. the relationship between baseline anti-fxa activity and reversal in healthy subjects was derived from the pharmacokinetic/pharmacodynamic model and used to predict percent reversal for patients with acute major bleeding. from the first interim analysis of annexa-4, 73 patients (apixaban, n=39; rivaroxaban, n=34) had plasma levels available for model qualification, although 7 did not meet criteria for inclusion into safety and 27 did not meet criteria for efficacy analysis. the mean observed percent reversal of anti-fxa activity for rivaroxaban and apixaban was well predicted by the healthy subject pharmacokinetic/pharmacodynamic model; the point estimates fell within the 90% confidence intervals of predicted values. the percent reversal at eob for rivaroxaban and apixaban were 74.4 [58.3-90.7] and 83.9 [75.3-92.5], compared with 76.3 and 84.1 predicted by the model. the predicted reversal closely fit the observed confidence intervals through the first 4 hours for rivaroxaban and apixaban, and extended through all evaluated time points for rivaroxaban and slightly outside of post-4-hour time points for apixaban, possibly due to higher baseline anti-fxa activity levels for apixaban. the pharmacokinetic/pharmacodynamic model in healthy subjects closely predicted the extent of reversal of anti-fxa activity for apixaban and rivaroxaban in patients with major bleeding. risk factors and methods to predict extubation failure are well established for patients in medical icus and surgical icus. literature on patients who fail extubations in neurological icus is limited. the intention of this study was to collect descriptive information from patients with neurological injuries who failed liberation from mechanical ventilation. retrospective review of all patients with acute neurological injury who were admitted to our neuro icu and who required reintubation within 72 hours of discontinuation of mechanical ventilation between january 2012 -february 2017. we identified 60 patients intubated primarily due to neurological pathology who required reintubation within 72 hours after initial extubation over a 5-year study period. the majority of reintubated patients (n=43; 71.7%,) had a positive fluid balance prior to failed extubation. twenty-six of the reintubated patients had a concurrent underlying chronic cardiac and/or pulmonary disease. five patients were placed on noninvasive ventilation post extubation. low glascow coma scale and absence of basic brainstem functions (gag and cough reflexes) was only minimally predictive of extubation failure. most of our reintubated patients did not have significant supratentorial midline shift nor an insult to the posterior circulation or dominant hemisphere. in patients with primary brain injury who required reintubation, a positive fluid balance prior to extubation may confer a lower rate of successful extubation. lesion location and supratentorial midline shift may not be tightly associated with extubation success. overall, our reintubation rate is quite low. early tracheostomy may play a small but significant role in the low rate of reintubation. further studies may be useful in creating a scoring system to identify the likelihood of extubation success in patients with neurological injury. surgical prophylaxis guidelines for evd insertion recommend peri-procedural antibiotics rather than prolonged antibiotic administration for the duration of evd placement. several small studies have shown that prolonged systemic antibiotic use does not reduce the incidence of catheter related ventriculitis. prolonged use is also associated with a higher rate of multi-drug resistant (mdr) infections. this study aims to show that prolonged antibiotic administration following evd insertion is potentially harmful. this is a single center, retrospective, chart review. all 100 patients admitted to our hospital who had an evd placed from january 2000 to march 2017 were identified. patients with preceding infections, incomplete data or uncertain infection diagnosis were excluded. sixty-nine patients were analyzed. documented variables included demographics, comorbidities, indications for evd, duration of antibiotic therapy, infections and organisms' sensitivities. eight patients (12%) did not receive any antibiotic therapy; the rest received cefazolin following evd insertion. infections occurred in 22 of 69 (32%) patients; 13 of 22 (59%) were mdr bacteria. ventriculitis occurred in 4 (6%) patients, and 2 of these were resistant to cefazolin (mdr). ventriculitis was not associated with the use or duration of antibiotic therapy. graphical analysis showed that the probability of any infection decreased during the first 3 days of antibiotic prophylaxis. after 3 days, the longer patients remained on prophylactic cefazolin, the higher the probability of infection (spearman rank correlati patients who received antibiotics for > 3 days were 2.5 times as likely to develop mdr infections (95% ci,0.60 to 10.3; p=0.3). cefazolin may prevent infections for the first 3 days after evd insertion. however, prolonged administration increased the risk of mdr bacterial infections. a randomized study comparing periprocedural (72hrs) antibiotic use is needed to resolve this controversy. each year more than 13,000 deaths are associated with urinary tract infections. eighty percent of all utis are associated with an indwelling catheter. neuroscience intensive care (neuro-icu) units have the highest rates of catheter associated urinary tract infections. catheter associated urinary tract infection (cauti) increases morbidity rates, length of stay, and costs among hospitalized patients. at an urban academic medical center, our neuro-icu had the highest cauti cases among our icus. the purpose of this project was to reduce our cauti cases by 50%. this quality improvement project used several strategies: (1) formed a multidisciplinary cauti task force that included nurses, physicians, infection control, management and supply chain personnel; (2) developed an action plan to update standard of practice by conducting a review of the literature and pilot testing new products; and, (3) educated staff using huddles, a bedside guide, and email blasts with cauti facts starting in august 2016. additionally, cauti prevention was discussed during patient handoffs among nurses and physicians. data were collected for all neuro-icu patients from fiscal year (fy) 2016-2017. cauti cases are determined by utilizing cdc's national healthcare safety network. analysis included evaluation of trends across time. we reduced our number of cauti cases from 5 in fy 2016 to 1 in fy 2017. as of the beginning of fy 2018, we have not had a cauti for 365 days. a comprehensive approach with a strong commitment by clinicians is critical for sustaining a reduction in cauti. we reduced our cases and exceeded our goal. our efforts to provide evidence-based care are ongoing as we continue to monitor the research and upcoming supplies aimed at making hospitalacquired cauti a never event. isophane insulin (nph) is a commonly prescribed basal insulin to manage hyperglycemia in critically ill patients on continuous tube feeding due to its intermediate duration of action. however, the incidence of hypoglycemia may be higher given the duration of nph can last between 14-24 hours and because of the potential for unexpected interruption in feeding. using scheduled regular insulin (ri) instead of nph may reduce this risk given its shorter duration of action. it may also improve glycemic control due to more frequent titration. this was a single-center, retrospective, observational, cohort study from december 2016 to may 2017. patients on continuous tube feeding who were prescribed scheduled ri were compared to those prescribed nph. all patients continued to receive an insulin sliding scale. choice of agent was determined by the bedside team. the primary endpoint was incidence of hypoglycemia while secondary endpoint assessed efficacy. in our patient population, a higher incidence of hypoglycemia was seen in those that received nph. hypertonic saline bolus (hsb) is a proven intervention for neurological emergencies arising from cerebral edema and increased intracranial pressure. safety of hsb administered via central venous catheters is well established. however, infusion of hsb through peripheral intravenous access raises concern for complications related to caustic nature of the solution. we aim to assess the safety of peripherally administered boluses of hypertonic saline (3% sodium chloride) at a regional level 1 trauma and comprehensive stroke center. we performed retrospective chart review of patients who received hsbs from january 1, 2014 to january 1, 2015 as part of a quality improvement project. we identified 167 instances of hsb administration. the cases were individually reviewed for iv gauge, location of the iv, whether central access was present at the time of administration, documentation of iv removal, and volume of boluses. patients were excluded if there was concurrent central venous access catheter present at the time of hsb administration or unrelated death within 12 hours after administration of hsb. adverse events were defined as line infiltration, erythema, or swelling at the site of hsb administration. 111 charts were excluded from the study because of presumed administration of hsb through central venous access, not peripheral iv. two patients had adverse events (3.5%). none of the patients progressed toward limb threatening complications. the majority of patients (54/56) did not experience erythema or infiltration of the iv. hsb administered through peripheral intravenous access does not pose significant risk of severe complications and may be safely used in emergency situations in the absence of central line access. routine screening of high risk asymptomatic trauma or surgical patients for venous thromboembolism(vte) is controversial. studies suggest against screening while others recognize that some patients at high risk may benefit. the purpose of this pilot study is to evaluate the outcome of routine screening in patients who underwent neuro-surgical interventions. all adult patients admitted to a neuro-intensive care unit with a primary diagnosis of brain injury requiring surgical interventions were included. data from april-june, 2017 were retrospectively collected on all subjects who had either spine or cranial surgery. data collected include: incidence of vte, number of times duplex ultrasonography and computed tomography of the chest was performed. on july 1st, prospective data collection began by screening for presence of deep vein thrombosis(dvt) on day 1, 7 and 14 from admission or surgery day. all patients received pharmacologic and mechanical vte prophylaxis within 36-48 hours post-operatively. a total of 101 (pre-pilot, n=91 and post-pilot, n=10) subjects were included in the study. in the pre-pilot group, the ages ranged from 18-70 and most were male. majority, 73/91(80%) had either craniotomy/craniectomy while 18/91(20%) had spine surgery. about 30/91(33%) were admitted with primary diagnosis of traumatic brain injury. of the 91 subjects, 35 had duplex screening for dvt and 8 had screening for pulmonary embolism(pe). the incidence of vte was confirmed in 11/91(12%); (dvt-8% and pe-4%). median hospital length of stay was 9 (iqr 4-15) days. 38/91(42%) were discharged home and 2/91(2%) death rate was attributed to pe. in the post-pilot group, one incidence of pe was identified on day 1 post surgery screening. the rest of the results are still pending. in this preliminary report, post surgical patients have a higher incidence of vte. routine screening might benefit to lower the incidence of mortality caused by pe. epsilon aminocaproic acid (eaca) is an antifibrinolytic agent that crosses the blood-brain barrier and has shown benefit in decreasing bleeding in patients acutely. its use in intracranial hemorrhage has uncertain benefit. we aimed to describe the administration and impact of eaca in a single-center neurosciences intensive care unit (neuroicu) over one year. we performed a single-center retrospective study of neuroicu patients undergoing intravenous eaca administration over a one-year time period. inclusion criteria included eaca administration over 24 hours for a diagnosis of acute traumatic hematoma. the dose and duration of eaca infusion was collected. we additionally collected and compared pre-administration and post-administration prolonged thromboplastin time (ptt) hematology assays and neuroimaging. clinical outcomes were reviewed for survival at hospital discharge. over a 13-month period (april 2016-may 2017), 24 patients each received a 24-hour infusion of eaca. the most common indication for eaca was to prevent worsening of intracranial hemorrhage in patients in traumatic coma (gcs <8). 68% of patients underwent neurosurgical management. ptt assay values showed a significant difference before and after eaca administration. (ptt 30.3+/-sd vs. 28.6+/-sd; student's t test p<0.05, n=21). stability of the intracranial hematoma burden was evident following eaca in 63% of patients. 29% of patients who received eaca survived to discharge. patients receiving eaca showed a significant reduction in ptt assay values 24 hours after completing their dose. ct neuroimaging demonstrated stable intracranial hemorrhage burden in most patients receiving eaca despite a high prevalence of acute operative neurosurgical management. however, only a modest number of patients receiving eaca survived to discharge. these results suggest that eaca may acutely reverse hematologic abnormalities and enable emergent neurosurgical management in patients with severe, acute traumatic hemorrhage, despite a limited role in affecting survival outcomes in these patients. prognostication is difficult for patients admitted to a neurocritical care unit (nccu). can serum biomarkers obtained as part of routine admission lab work help predict outcomes among patients in this prospective cohort study, the following biomarkers were measured at admission: c-reactive protein (crp), arterial lactate, neuron specific enolase (nse), lactate dehydrogenase (ldh), albumin, and brain natriuretic peptide (bnp). we collected information about demographics, comorbidities, hospital procedures and complications and 30-day mortality. we compared these serological biomarkers in patients who were alive versus those who had died at 30 days. a total of 112 patients were enrolled over 4 months from june to september 2016, 11 of which whom (9.8%) died within 30 days of admission. there were no statistically significant differences in age or gender between the two groups. the 30-day mortality group had a higher mean charlson comorbidity index (cci) (3.0 vs 1.6, p=0.027) as well as mean nse (39.1 vs 13.9 ug/l, p=0.008) and bnp levels (590.2 vs 177.3 pg/ml, p=0.003). mean crp, lactate, and ldh were also higher in the 30-day mortality group (79.5 vs 51.8 mg/l, 2.3 vs 1.9 mmol/l, and 307.2 vs 274.2 u/l) while mean albumin was lower (3.0 vs 3.3 g/dl), although these differences were not statistically significant (p<0.35). cci and serological biomarkers may have utility in predicting 30-day mortality among patients admitted to the nccu. as we continue enrollment, we plan to develop a predictive model for 30-day mortality on admission for patients admitted to the nccu using serological biomarkers, cci and admission characteristics. among hospitalized acutely ill medical patients, the risk for venous thromboembolism (vte) is high. the goal was to examine vte prophylaxis of at-risk patients and vte risk during hospitalization and in the outpatient continuum of care. acutely ill medical patients were identified from the marketscan commercial and medicare databases from 1/1/2012 to 6/30/2015. inclusion criteria were hospitalization for heart failure, respiratory diseases, ischemic stroke, cancer, infectious diseases, and rheumatic diseases; 6 months of continuous insurance coverage prior to (baseline period) and after (follow-up period) the index hospitalization. outcomes included the proportions of patients receiving inpatient and/or outpatient vte prophylaxis, and the risk for vte events. years, and 55.4% were female. patients were hospitalized for infectious diseases (40.6%), respiratory diseases (31.0%), cancer (10.7%), heart failure (10.4%), ischemic stroke (6.4%), and rheumatic diseases (0.9%). mean hospital length of stay was 4.8 days. in total, 59.1% (n=10,581) of patients did not receive any vte prophylaxis, and 7.1% (n=1,267) received both inpatient and outpatient vte prophylaxis. during hospitalization, 38.2% (n=6,843) received vte prophylaxis (enoxaparin, 76.7%; warfarin, 15.2%; enoxaparin and warfarin, 5.3%; a direct oral anticoagulant (doac), ~2%). following discharge, 9.7% (n=1,738) received outpatient vte prophylaxis (warfarin, 43.8%; doac, 13.7%; enoxaparin, 10.1%; enoxaparin and warfarin, 7.6%). among the entire study population, the vte event risk remained elevated up to 30-40 days after hospital admission. among hospitalized acutely ill medical patients, the risk for vte was present in both the inpatient and outpatient settings, with significant vte risk extending into the post-hospitalization period. only a small portion of at-risk patients (7.1%) received vte prophylaxis in both the inpatient and outpatient continuum of care, suggesting an unmet medical need for vte prophylaxis in the post-hospitalization. brain edema is a good research target in various forms of neurologic injury. a real time measurement of brain edema is possible using thermal conductivity methods. however, this technique might be hard to apply in small rodents, which are commonly used as experimental brain edema models. we developed a new approach method for applying thermal conductivity methods in rodent brain edema model. a 10-week-old spraque-dawley rats were used for brain edema model. qflow 500 probe was inserted through a suboccipital burr hole, located 3mm left from the midline, then was advanced anteriorly 10mm from the occipital bone margin until probe place assistance value indicates valid values (ranging from 0 to 2.0). probe was fixated using adhesive glues and tagging suture. in vivo brain water content was continuously calculated using thermal conductivity values. for validation, calculated brain edema was compared with standard methods (dry/wet brain weight ratio) in water intoxication models (intraperitoneal injection of distilled water, 20% of body weight) and drying effect of mannitol was validated in streptokinase induced intracerebral hemorrhage (ich) models. calculated brain water content was 78.6±0.6% in thermal conductivity method and 78.4±0.5% using dry/wet weight ratio methods (p=0.43). in water intoxication model, brain water content started to increase 30 minutes after injection and reached up to 81.5±0.7% at 6 hours post injection. on wet/dry weight method, edema was measured as 81.0±0.8% (p=0.80). in ich model, brain water content started to drop 30 minutes after administration of mannitol (0.5mg/kg) and drifted back 4 hours after injection of mannitol. thermal conductivity method in assessing brain edema is applicable in rodents using suboccipital approach through burr hole. this method may better reflect dynamic changes of brain edema. in patients with critical brain injury, alterations of brain physiology with dialysis initiation are poorly understood. from a consecutive series of brain-injured patients undergoing invasive multimodality monitoring between 2008 and 2016, 13 patients that underwent continuous veno-venous hemodialysis (cvvh-d) and 4 patients that underwent intermittent hemodialysis (ihd) were identified. changes in mean arterial pressure (map), intracranial pressure (icp), and brain tissue oxygenation (pbto2), and microdialysis lactate-pyruvate ratio (lpr) were compared six hours prior to and twelve hours following dialysis initiation. high-resolution data was collected every 5 seconds, with the exception of lpr collected hourly. data were normalized to patient maximum values, analyzed by fitted segmented regression, and checked for slope change-points by davies' test. values prior to dialysis initiation were averaged as a baseline for comparison. median values for patients undergoing cvvh-d were map 85 +/-12.77, icp 9.8+/-9.61, pbto2 21.7 +/-6.023 mmhg (n=5), and lpr 21.6 +/-22.13 (n=4). normalized median values for patients undergoing ihd were map 94 +/-13.73, icp 19 +/-5.32. for the cvvh patient segmented regressions with normalized data, there was no change in map (slope 0.0004) during the twelve hours. however, we found a change-point in icp at 4.78 hours (ci 3.76-5.79, slope change 0.006 to 0.0006) and pbto2 at 4.99 hours , slope change 0.006 to -0.023). lpr increased through cvvh (slope 0.036 +/-0.0097). median values for patients undergoing ihd were map 94 +/-13.73, icp 19 +/-5.315. there was no identified change-points in map or icp in ihd patients, further parameters were limited by small sample size. initiation of cvvh in patients with neurologic multimodality monitoring showed change-points in icp and pbto2 in setting of stable map, with slight decrease in icp and pbto2. initiation of hd in showed no change-points in icp. data on the cerebral effects of antihypertensive agents are limited but potentially important in patients requiring blood pressure reduction in neurological emergencies. our objective was to measure the effect of rapid-acting antihypertensive agents on cerebral blood flow (cbf) in patients with acute hypertension we conducted a prospective, quasi-experimental study of patients with a sbp > 180 mmhg and planned rapid-acting antihypertensive treatment in the emergency department. patients < 18 years or pregnant were excluded. non-invasive hemodynamic and transcranial doppler measurements of the middle cerebral artery mean flow velocity (mfv) were obtained prior to and post treatment. analysis included descriptive statistics and generalized linear modeling to test the effect of four categories of antihypertensive agents on mfv. categories included clonidine, iv labetalol, iv hydralazine and combination therapy. we enrolled 35 patients (37% female) with a mean age of 49 ± 13 years. eight (23%) patients received clonidine, 6 (17%) iv labetalol, 5 (14%) iv hydralazine and 16 (46%) combined therapy. the mean baseline sbp was 214 ± 24 mmhg and mfv 49 ± 13 cm/sec. the mean percentage fall in sbp by medication was: clonidine -12 ±7%, labetalol -13 ±12%, hydralazine -23 ±11%, and combination -23 ±16%. the overall change in mfv was -9 ±15%, and by medication was: clonidine -10% (95%ci -2 to -21%), labetalol -11% (95%ci -5 to -27%), hydralazine +1% (95%ci -18 to +21%), and combination -11% (95%ci -2 to -19%). adjusting for baseline bp, hydralazine caused less change in mfv compared to other medications (difference between means +12%, 95%ci -3 to +26%, p=0.1). in this study with modest bp reductions, rapid-acting antihypertensive medications had comparable effects on cerebral blood flow. these results hint that cerebral blood flow may be more stable with hydralazine administration, but further testing of hydralazine and infusions such as nicardipine is required. studies exploring correlations between non-invasive (oscillometric) blood pressure (nibp) and intraarterial blood pressure (abp) have excluded neurocritically ill patients with continuous infusion of vasoactive medications. compared to abp, nibp monitors generally tend to over-read at low values and under-read at high values. this study examines the relationship between simultaneously measured nibp and abp recordings in these patients. following informed consent, prospective observation of patients (n=70) admitted to a neurosciences icu, with simultaneous abp and nibp monitoring and continuous vasopressor (n=21) or antihypertensive (n=49) infusion. paired nibp/abp observations along with covariate and demographic data were abstracted via chart audit. analysis was performed using sas v9.4. 2,177 paired nibp/abp observations from 70 subjects (49% male, 63% white, mean age 59 years) receiving vasopressors (n=21) or antihypertensive agents (n=49). t-tests show significant difference between paired readings: ([sbp: m=137 vs 140mmhg respectively; p<.0001], [dbp: m=70 vs 68mmhg respectively, p<.0001], [map: m=86 vs m=90mmhg respectively, p<.0001]). the paired differences for specific medications were tabulated, with 50-70% of the differences <10mmhg, and 75-90% of the values with <20mmhg difference. bland-altman plots for map, sbp, and dbp demonstrate good intermethod agreement between paired measures (excluding outliers) and demonstrated marked nibp-abp sbp differences at higher blood pressures. pearson correlation coefficients for paired measurements show strong positive correlation for map (+0.82), sbp (+0.84), and dbp (+0.73). despite a statistically significant difference between nibp and abp readings for patients on vasoactive medications, there may be no clinical significance. the relatively positive and linear correlation between paired values guide providers towards not being forced to use one over the other. the final manuscript will aim to detail whether there is a clinical significance in particular vasoactive medications. pathological activity in continuous electroencephalogram (ceeg) data of icu patients is conventionally categorized into a small number of named rhythmic and periodic patterns. we aimed to develop a valid method to automatically discover a small number of homogeneous pattern clusters, to facilitate efficient interactive labeling by ceeg experts. we extracted 576 time and frequency domain features from 12+ hour ceeg recordings from 10 different icu patients. after removing artifacts, we applied principal component analysis (90% variance retained), then separated the data into 9 clusters (k-means). from each cluster we took 9 random samples plus the most central one, rendering 900 samples in total. three expert electroencephalographers independently categorized all samples into one of 6 standard pattern categories (seizures, gpds, lpds, lrda, grda, burst suppression, other). we compared two methods for labeling clusters: (1) "labor intensive labeling" (lil): assign the most frequent of 30 expert-provided labels; (2) "labor efficient labeling " (lel): assign the most frequent of the 3 expert labels for the central sample. we compared interrater agreement (ira) among experts vs. between each expert and consensus labels using lil vs. lel. finally, we used laplacian eigenmaps (le) to visualize the data. this research suggests that large ceeg datasets can be automatically clustered into a small number of patterns described by standard icu eeg pattern labels. we demonstrated efficient cluster labeling by inspecting only the central-most representative of each cluster. furthermore, le visualizations support the hypothesis of an interictal-ictal continuum. real time measurement of cerebral oxyhemoglobin (oxyhb) and deoxyhemoglobin (deoxyhb) using near infrared spectroscopy (nirs) may help us better understand the status of cerebral oxygenation and possibly cerebral blood flow (cbf) in patients with acute brain injury. we developed 48 multichannel functional nirs (fnirs) system and evaluated its role in patients with acute brain injury. a 48 channel fnirs system (nirsittm) was used for measuring cerebral oxyhb and deoxyhb in patients with brain injury. measurement protocols were as follows; baseline measurement for 5 minutes with activation stimuli (nipple pinching for 5 seconds). patients groups were categorized as follows; 1) global cerebral ischemia with profound cerebral injury (n=40), 2) large ischemic stroke or decrease in cbf in the frontal lobe due to severe stenosis in the middle cerebral artery (mca) or internal carotid artery (ica) (n=74), 3) high grade subarachnoid hemorrhage with a risk of vasospasm (n=14), control groups did not have either cerebral lesion or cbf abnormality (n=22). global ischemia with good functional outcome group had better oxyhb level (rso2) compared to those with poor outcome (67.4% vs. 59.5%, respectively, p = 0.003). patients with poor perfusion in the mca territory had low oxyhb level compared to mirror lead in the contralateral hemisphere. oxyhb level in patients with decreased vasomotor reactivity on diamox spect had improved after carotid stenting. three patients who underwent superficial temporal artery-middle cerebral artery bypass surgery had transient hyperperfusion syndrome. oxyhb and total hb were elevated in the affected area. patients with sah and vasospasm had blunted oscillation pattern of oxyhb compared to those without vasospasm. bedside multichannel measurement of oxyhb and deoxyhb using fnirs might be useful in understanding hemodynamic changes occurring in patients with acute brain damage at the real time. multimodality monitoring (mmm), brain tissue oxygenation (pbto2) and microdialysis (md) in sah may be important to the treatment of delayed cerebral ischemia (dci). our hypothesis was that concordance between pbto2 and md occurs in the tissue bed displaying angiographic vasospasm. this retrospective observational study includes 10 patients with sah. the extent of angiographic vasospasm for each vessel was graded on angiography by the on call neuro-interventionalist and quantified as 0 (no spasm) to 6 (severe spasm). pbto2 and md probes were placed in the frontal lobe white matter. the severity of vasospasm was estimated by the weighted average of (1x aca + 2 x mca + 3 x ica) / 6. cases with score of 2 or more were considered to have clinically relevant vasospasm. using a within-subjects design, epochs of baseline mmm were compared with during spasm using daily mean for pbto2, lpr, glucose, icp and cpp. given the limited number of observations the simplifying assumption was made that the observations from all epochs are independent. the measurements from all patients were divided in the two groups with and without spasm and were compared using a twotailed non-paired student t-test. sixteen sets of baseline and vasospasm epochs were evaluated for pbto2 and 18 for md. compared with baseline values, the average pbto2 was significantly lower (15.1 vs 24.6mmhg, p=0.003), lpr was non-significantly higher (38.3 vs 28.4, p=0.07), and glucose was similar (0.9 vs 1.2 mmol/l, p= 0.5) during vasospasm epochs. there was no difference in icp (9.7 vs 9.7mmhg, p=0.98). these differences were unaffected by induced hypertension, when cpp was augmented for treatment of dci (120.4 vs 101.3 mmhg, p=0.07). mmm during angiographic vasospasm after sah suggests discordant changes in brain oxygenation and metabolism. these data suggests that dci may be related to metabolic factors other than tissue oxygenation. multimodal monitoring including brain tissue oxygenation (pbto2) is increasingly used for the management of acute tbi patients. the optimal management of pbto2 is not fully established. increasing fio2 is efficacious to correct pbto2 but may mask other oxygen delivery mechanisms which may be deficient. the objective of this study was to explore the clinical utility of a pbto2/pao2 ratio to detect overtreatment by fio2. retrospective cohort stud were collected simultaneously whenever an arterial blood gas was drawn (icp, cpp, hemoglobin, temperature, pco2 and pao2). causes of cerebral hypoxia (pbto2 < 20mmhg) were noted. pbto2/pao2 ratio <0.15 was considered abnormal and plotted over time for each patient individually. 1006 data sets were collected from 38 patients (mean age 44.5±20.0, median gcs 4, mortality 45%). 33.0% of the time and associated with a mean pao2 of 250 mmhg. measures within the low pbto2-low ratio category had significantly lower cpp (64 vs 72 mmhg), higher pao2 (242 vs 130 mmhg) than patients with normal pbto2 or normal ratio respectively. various causes of hypoxic pbto2 were reported when the ratio was abnormal: hypocapnia, low cpp, low cardiac index, long equilibration time... four patterns of evolution of the ratio over time were identified and associated with different mortality rate: 28.5%, 33.3%, 46.7% and 60%. conclusions associated with increased pao2 and decreased cpp. this suggests clinicians often used fio2 to compensate for deficient cerebral oxygen delivery. indeed, various causes of hypoxia besides low pao2 were identified and corrected. pattern of temporal evolution of the ratio seems to correlate with mortality. pupillary light response (plr) evaluates cranial nerves ii, iii, and midbrain function. bedside quantitative infrared pupillometry provides reproducible assessment of the plr, reported as the neurological pupillary index (npi). increased intracranial pressure results in decreases in npi. intracranial hypotension (ih) can also cause brainstem distortion. we therefore hypothesized that similar changes in npi could be seen with ih. here, we describe sequential changes in npi in ih before and after treatment. we identified four patients monitored with pupillometry for clinical care during ih diagnosis and treatment. ih was diagnosed with a compatible history, exam, and characteristic neuroimaging findings. patients' npi at baseline, during symptomatic ih, and after treatment were compared using related samples friedman's two-way anova and wilcoxon signed ranks tests. two patients were male; causes of ih were csf leak following lumbar instrumentation (n=3) and basilar skull fracture (n=1). mean baseline npi was normal (defined as >3) and declined in one or both eyes concurrent with clinical deterioration in the 24-48 hours preceding definitive diagnosis. all patients underwent treatment for csf leak with epidural blood patch or fracture repair, with return of npi > 3 within 5 hours of treatment. the baseline, symptomatic and post treatment npi's differed significantly (3.55±0.35 vs 0.80±0.59 vs 3.65±0.24, mean +/-sd, pre-treatment vs nadir vs post-treatment, p=0.05). both baseline and post treatment npi's differed from the npi nadir (p=0.068) but there was no difference between baseline and post-treatment npi (p = 0.71). impairment of the plr, as measured by npi, occurred during symptomatic ih and resolved after treatment. because management of intracranial hyper-and hypotension differ markedly, our results emphasize the importance of evaluating the clinical context before attributing pupillary/npi changes to increased icp. automated pupillometry provides a non-invasive, bedside tool for monitoring progression and treatment of intracranial hypotension the correlation of optic nerve sheath diameter (onsd) as seen on ultrasonography (us) and directly measured intracranial pressure (icp) has been well described. nevertheless, differences in ethnicity and type of icp monitor used are obstacles to the interpretation. therefore, we investigated the direct correlation between onsd and ventricular icp and defined an optimal cut-off point for identifying increased icp (iicp) in korean adults with brain lesions. this prospective study included patients who required an external ventricular drainage (evd) catheter for icp control. iicp was defined as an opening pressure over 20 mmhg. onsd was measured using a 13 mhz us probe before the procedure. linear regression analysis and receiver operator characteristic (roc) curve were used to assess the association between onsd and icp. optimal cut-off value for identifying iicp was defined. a total of 62 patients who underwent onsd measurement with simultaneous evd catheter placement were enrolled in this study. thirty-two patients (51.6%) were found to have iicp. onsd in patients with iicp (5.95 ± 0.25 mm) was significantly higher than in those without iicp (5.17 ± 0.57 mm) (p 5.6 mm disclosed a sensitivity of 93.75% and a specificity of 86.67% for identifying iicp. onsd as seen on bedside us correlated well with directly measured icp in korean adults with brain lesions. the optimal cut-off point of onsd for detecting iicp was 5.6 mm. impaired cerebral autoregulation following neurological insult has been established as a strong predictor of clinical outcome. hypothermia may offer autoregulatory protection in these patients, although the effect of body temperature on autoregulatory status is unclear. retrospective analysis of data from an ongoing prospective study to evaluate multimodal monitoring using near infrared spectroscopy (nirs) for bedside measurement of autoregulation. ninety-one comatose patients (gcs <8) were continuously monitored for up to three days. nirs derived cerebral oximetry index (cox) was used as a marker of autoregulation. cox was calculated as a moving, linear correlation coefficient between regional cerebral oxygenation saturation and map. autoregulation improves as cox values approach 0, and is impaired as values approach 1. patients were grouped by trend in temperature seen over the monitoring period: no change (<1oc temperature change, n=12), increase (n=6), decrease (n=7), increase followed by decrease (n=7), decrease followed by increase (n=6), and fluctuating (n=53). we performed multivariable logistic regression analysis to assess the association between temperature and outcomes. the association between hourly temperature and cox was assessed using mixed random effects models with random intercept. in patients showing a sustained increase or decrease in temperature, a linear relationship between temperature and cox was seen; for every 1oc increase or decrease in temperature, cox changed by 0.045±0.010 (p<0.001) and -0.020±0.018 (p=0.15), respectively, after adjusting for pco2, haemoglobin, map and temperature probe location. mean temperature changes over the monitoring period for these groups were 2.52±1.07oc and -1.77±1.13oc, respectively. cox did not change significantly in other groups. there was no significant difference in mortality or poor outcome (mrs 4-6) at discharge and 3, 6, or 12 months between patients in each group. in acute coma patients in the neurocritical care unit, increasing body temperature is associated with worsening cerebral autoregulation as measured by cox. the historical tradition of examining the pupillary light reflex (plr) required the examiner to score the size and reactivity of the pupil. a change in the plr from brisk to sluggish or fixed may be a marker of a pathological process and a need for intervention. the plr has been difficult to quantify and has poor inter-rater reliability. handheld pupillometry provides several novel measures, such as the neurological pupillary index™ (npi) and constriction velocity (cv) that may be more quantifiable than the plr. the purpose of this analysis is to examine the relationship between cv and npi in neurologically injured patients. the end-panic registry is a prospective registry of pupillometer values and variables associated with intracranial dynamics (e.g., icp). this analysis from 946 adult (over 18 years) patients from 2 hospitals includes 42,568 pupillometer readings; left eye (20,943), and right eye (21,625). subjects had a mean age of 57.9 yrs and 48.1% were male. the primary admission diagnosis included neoplasm (241), ischemic stroke (169), sah (82), ich (81), tbi (9), and other (364). the left eye mean/s.d. cv (1.6/0.9) npi (4.1/0.9) and size (3.5/1.2) were similar to the right eye cv (1.6/0.9) npi (4.1/0.9) and size (3.5/1.2); statistically significant difference related to large sample size. the correlation between left eye cv and npi (r2=0.068, p<0.001) was significantly improved after controlling for size (r2=0.67, p<0.001). the correlation between right eye cv and npi (r2=0.048, p<0.001) was significantly improved after controlling for size (r2=0.67, p<0.001). constriction velocity is highly dependent on size of the pupil. further studies need to be undertaken to determine the sensitivity and specificity of abnormal npi and cv in detecting pathological processes such as midline shift or 3rd nerve compression that effect pupillary reactivity. cerebral injury is increasingly described in adult recipients of extracorporeal membrane oxygenation (ecmo) therapy. we describe the association between regional brain tissue oxygenation (rso2) measured by near infrared spectroscopy (nirs), survival, and cerebral injury on neuroimaging. a single-center retrospective chart review was conducted of adult patients who underwent veno-arterial (va) ecmo from april 2016 to october 2016. all patients had received nirs monitoring during ecmo therapy. baseline demographics, in-hospital complications, and mortality were recorded. desaturations of rso2, defined as decline >25% below baseline or absolute value <40, were recorded and analyzed. desaturation burden was calculated by area under the curve analysis and measured by rso2*seconds. eighteen va ecmo patients (9 females) underwent nirs monitoring during the study period. eleven patients experienced desaturations, while 7 did not. patients with desaturations tended to be younger (50.2 vs. 64.7 years old), more likely female (8 vs. 1), had lower ejection fraction (28.6% vs. 46.4%) and experienced liver dysfunction (7 patients vs. 1). patients with desaturations were more likely to have abnormalities on ct scan (6 vs. 0). eleven of the 18 patients survived to discharge. survivors tended to be younger (50.2 vs. 64.6 years old) and had lower initial ecmo sweep (4.1 vs. 6.7). survivors had lower baseline rso2 values at the beginning of nirs monitoring (right -57 vs. 65, left -57 vs. 68), fewer desaturation events (7 vs. 14), lower desaturation burden, and spent less overall time desaturating (1:21 vs. 3:09 hours). desaturation on nirs may be correlated with cerebral injury in the adult va ecmo population and may have utility in triggering clinical investigation or determining prognosis. further studies in larger patient populations are needed to determine its reliability and accuracy. pressure reactivity index (prx) is the most validated index to measure cerebrovascular reactivity in patients after traumatic brain injury. the aim of this study is to identify the natural history of cerebral autoregulation measured by prx in various forms of brain injury to monitor restoration or not of cerebral vasomotor reactivity in the acute phase. retrospective analysis of data from ongoing prospective study to evaluate multimodal monitoring using prx for the measurement of cerebral autoregulation at the bedside. thirty comatose patients (glasgow coma scal used as a marker of autoregulation. prx was calculated as a moving, linear correlation coefficient between icp and map. impaired cerebral autoregulation has been pre standard maximal medical therapy was implemented to treat elevated icp, cerebral edema, etc. patients with withdrawal of care in the first 48 hours or brain death on neurological exam were excluded. thirty comatose patients from acute brain injuries (16 intracerebral hemorrhage, 6 tbi, 5 aneurysmal subarachnoid hemorrhage, 2 intraventricular hemorrhage, 1 hypoxic ischemic encephalopathy) were studied. the average prx upon starting neuromonitoring using prx was 0.3 ± 0.35 (impaired), whereas the average prx at the end of day 3 of neuromonitoring was 0 ± 0.10 (restored). one third of the patients had icp crisis during monitoring. the average opening icp=8.3, average highest recorded icp=26.9. impaired cerebral autoregulation has been implicated as a predictor of clinical outcome. aggressive medical therapy instituted by the neurocritical care team (icp and cerebral edema management, blood pressure control, etc.) may result in restoration of cerebral vasomotor reactivity measured by prx by intensive care day 3-5. restoration of cerebral vascular reactivity may be a necessary but not sufficient for favorable outcome. elevated intracranial pressure (icp) is an important cause of death following acute liver failure (alf). while invasive icp monitoring (iicpm) remains the gold standard, the presence of coagulopathy increases the risk of bleeding in alf. measurement of optic nerve sheath diameter (onsd) using optic nerve ultrasound (onus) may accurately detect elevated icp. our goal was to study the ability of onus to detect sustained intracranial hypertension following alf, and to predict death and therapeutic intensity level (til), a quantitative measure of the intensity of treatment required to control icp. consecutive patients with alf admitted to our institution in a 6-year period underwent onus. blinded measurement of onsd was performed from deidentified onus videos. patients underwent iicpm on the basis of an institutional protocol for selection of appropriate candidates, coagulopathy reversal and insertion of an intraparenchymal monitor. the til-basic for management of icp during the icu stay was recorded. the ability of highest onsd to predict concurrent icp>20mmhg at the time of measurement, sustained icp elevation >20mmhg at any time and til-basic>2 was assessed in patients who underwent iicpm, while prediction of death was assessed in all patients. receiver operating characteristic (roc) curves were constructed for the outcomes of interest. thirty-nine patients with alf were admitted during the study period, 29/39(74%) underwent onus, 25/39(64%) underwent iicpm and 19(49%) died. of 25 patients who underwent iicpm, 13(52%) developed sustained icp elevation and 7(28%) had a til-basic>2. the roc area under the curve (auc) of onsd for prediction of concurrent icp>20mmhg was 0.63(95% confidence-interval 0.39-0.82, p=0.42 for null hypothesis of auc=0.5), sustained icp elevation at any time was 0.51(0.28-0.73,p=0.97), death was 0.56(0.36-0.74,p=0.59) and til>2 was 0.61(0.42-0.79,p=0.33). in patients with alf, onsd measurement performed poorly for detection of icp elevation, and was a poor predictor of til and death. limited literature exists regarding the neurochemical and physiologic events that occur as brain death develops. using intracranial multi-modality monitoring, we identify physiological changes that signal the onset of brain death. we measured intracranial pressure (icp), brain partial oxygen tension (pbto2), cerebral blood flow (cbf), and biochemical correlates of cerebral metabolism in 4 patients with diffuse hypoxic ischemic brain injury after cardiac arrest during the development of brain death. monitoring probes were inserted into cerebral white matter through a burr hole using a ct compatible multi-lumen bolt. brain tissue energy-related metabolites (lactate, pyruvate, glutamate, glucose, glycerol) were measured using a bedside microdialysis analyzer. pbto2 and temperature were measured via a licox catheter. cerebral perfusion was measured with a hemedex bowman perfusion monitor. brain death was confirmed in accordance with institutional guidelines. a characteristic pattern of physiologic and neurochemical findings emerged as brain death occurred. absolute loss of cerebral autoregulation, with a near perfect correlation between icp and map was followed by equalization of map and icp resulting in progressive drop in cpp to zero, followed by a progressive decline in pbto2 that became unresponsive to a 100% fio2 challenge. cerebral perfusion decreased in tandem with pbto2. lactate/pyruvate ratio (lpr), glutamate, and glycerol all increased precipitously, with lpr consistently >1000. brain temperature decreased despite maintenance of a normal core temperature. finally, intracranial compliance, while initially very low (evidenced by marked increase in the p2 component of the icp waveform), appeared to paradoxically re-normalize as the recording continued. continuous neuromonitoring reveals a characteristic pattern of cerebrovascular physiologic changes that accompany brain death. these changes are consistent with a progressive cessation of cerebral perfusion caused by diffuse cerebral edema. although not currently a part of the formal brain death determination process, such monitoring could be helpful to identify when brain death has truly occurred. automated devices that collect objective quantitative data on pupil size and reactivity are increasingly used for critically ill patients with neurologic disease. however, there is limited data on the normative range of pupillary reactivity in the critically ill, and the relationship between reactivity and traditional monitoring metrics. to determine pupil characteristics in this population, we prospectively collected quantitative pupillometry data in patients admitted to the neuro icu with an expected stay of at least 24 hours. trained nursing staff measured pupillary reactivity with the neuroptics-200 pupillometer device every 2-hours. measurements included the neurologic pupil index, (npi) a composite metric ranging from 0-5 in which >3 is considered normal, resting and constricted pupil size, constriction velocity, dilation velocity and latency. these recordings were compared with averaged intracranial pressure (icp) and glasgow coma scale (gcs) assessments within the same hour. we used univariate and spearman's rank tests to explore associations between pupil characteristics and clinical variables, followed by multi-level linear regression to account for intra-and inter-subject variability. one-hundred patients underwent 4200 paired observations. fifty-five patients had at least one recorded episode of anisocoria, 27 had low npis in more than 10% of recordings, and 29 had normal pupil reactivity. average and minimum npi was correlated with average and minimum recorded hourly glasgow coma score (gcs) (p values <0.001). increased asymmetry in both pupil size (p=0.002) and dilation velocity (p=0.02) was associated with increased intracranial pressure (icp). anisocoria was associated with hyperosmolar therapy (p=0.002). the presence of low npis in more than 10% of total pupil measurements was associated with death at discharge (p=0.02). the range of pupillary metrics varies among critically ill neurologic patients and correlates with gcs and icp. further study is needed to establish whether change in pupil metrics predict specific clinical events. near infrared spectroscopy (nirs) provides a non-invasive measurement of regional cerebral oxygen saturation (rso2) that may be able to detect seizure activity. in this study, we explored the hypothesis that rso2 is lower ipsilateral to seizures or epileptiform activity compared to the contralateral side in comatose patients. five patients (2 men and 3 women; mean age 69) underwent continuous electroencephalography (ceeg) monitoring and nirs recording. ceeg data were classified as baseline, epileptiform activity or seizure, slowing, or burst suppression at hourly intervals over the course of the recoding period (mean duration 34.1 hours, range 24 to 85 hours). three patients had idiopathic status epilepticus, two had intracranial hemorrhage, and one had a temporal meningioma. the relationship between rso2 and epileptiform discharges was explored using scatterplots. the association was assessed using mixed random effects models with a random intercept. an independent within-subject residual structure was used. there were 127 measurements with ceeg and nirs from 5 patients. one patient was excluded as the nirs sensors were potentially reversed. epileptiform activity or seizures were observed in a median of 37% of the measurements (iqr 23-62%). rso2 was significantly lower on the side ipsilateral to seizures -5.19, p <0.001) after adjusting for map. all patients only had partial seizures with no generalization. partial seizures and/or epileptiform discharges were not associated with impaired autoregulation. we found a significant lower cerebral oxygen saturation ipsilateral to seizures and/or epileptiform activity. the association was observed in patients with various etiologies of coma, and with either convulsive and non-convulsive seizures. decreases of regional cerebral oxygen saturation at the bedside may alert the clinician of ipsilateral seizures. elevated intracranial pressure (icp) and cerebral edema are common causes of mortality in neurocritical-care patients. key monitoring techniques for icp-elevation include neuroimaging and invasive icp-measurement. examination of the pupils is routinely performed to determine disturbances within cerebral physiology but shows high inter-rater variability. portable infrared pupillometry is increasingly used for accurate measurements. the benefit of these technique remains to be established in patients with elevated icp. aim of this study was identify pupillary parameters associated with icpcrisis in neurocritical-care patients. we prospectively enrolled 31 critically-ill patients (subarachnoid hemorrhage/intracerebral hemorrhage/stroke/bacterial meningitis) admitted to our neurointensive care unit(07/2016-07/2017) who required placement of external ventricular drains. we recorded serial pupillometer readings [i.e. maximum/minimum apertures(mm), constriction/dilation velocities(mm/sec.), latency period(sec.)] and corresponding icp values every 3 hours after admission. neurological pupil index(npi), an algorithm that compares above mentioned pupillary parameters to a normative model of pupil reaction to light, grades pupil-function on a scale of 0(nonreactive) to 5(normal). receiver operating characteristic(roc) curve analysis was performed to investigate associations between pupillary parameters and presence of icpcrisis(icp>20mmhg). in 31 our data suggest a relationship between non-invasively detected changes in npi, cv or mcv and icpcrisis. yet, clinical benefit of these parameters is subject to future studies. lung injury is frequently observed in patients with severe, acute brain injury. while these patients often require mechanical ventilation, a lung protective ventilation strategy has not been extensively studied. this may be due, in part, to concerns that elevated positive end-expiratory pressure (peep) could adversely affect intracranial pressure (icp) or cerebral perfusion pressure (cpp). we were interested in exploring this relationship as a first step towards understanding whether mechanical ventilation resulted in a transmission of pressure to the brain. 8) and received both mechanical ventilation and icp monitoring were enrolled in this pilot study. an esophageal balloon was inserted to measure their transpulmonary pressure (ptp). fluid responsiveness was assessed prior to the intervention. subjects underwent a step-wise increase in peep (increments of five) from 5 to 15 cmh2o. airway pressure, ptp and icp were measured at each peep interval. of the planned twenty, three patients have been enrolled to date. primary diagnoses included aneurysmal subarachnoid hemorrhage and intraparenchymal hemorrhage with a median gcs of 7. patients were ventilated using either volume control or pressure support ventilation; median fio2 was 0.35. two patients were on vasopressors and the same two patients were determined to be fluid responsive. at baseline (peep 5), mean icp, cpp, and ptp were 6mmhg, 85mmhg, and -3.18cmh2o, respectively. when peep was increased to 10 cmh2o, the average change from baseline in icp and cpp was -3.7% and -2.2%, respectively. when increased to 15 cmh2o the change from baseline in icp and cpp was 3.0% and 0.5%. during the intervention icp did not exceed 20 mmhg, nor did any patient experience hypotension. preliminary data suggests that intrathoracic pressure is not directly transmitted to the intracranial compartment. continued enrollment is needed to confirm these findings. neurocritical care after severe traumatic brain injury (stbi) is focused on detecting and preventing secondary brain injuries. in addition to intracranial pressure (icp), measures of brain tissue oxygen (pbto2), regional cerebral blood flow (rcbf), and electrocorticography (deeg) may provide critical clinical data. few studies have assessed the safety of such an approach and the reliability of data that is gathered. we describe here the placement, complications, and reliability of multimodality monitoring (mmm) data from a novel, single burr hole approach using a four-lumen bolt at our institution. we included consecutive adult stbi patients admitted to the neuroscience intensive care unit at the university of cincinnati from april 2015 to march 2017 who underwent mmm as part of standard clinical management per institutional protocol. data was obtained regarding device placement and complications. all data was visually inspected for errors and gaps in data. 40 patients were included. the mean age was 43+/-17 and 85% were men. bolts were placed a median of 17.7 (iqr 8.3-16.9) hours from injury. no clinically significant complications occurred, although 37.5% had minor complications (e.g. small tract hemorrhage or pneumocephalus). suboptimal placement of probes was noted in 13%. we monitored patients a median 103.5 (iqr 48.8-133.6) hours. icp data was the most reliable, with data available 94.8% of the total monitoring time and only 1.2% error time. pbto2 and deeg data were reliable for > 90% of total monitoring time with < 2% error time. rcbf provided data for 77% of total monitoring time and had 17.9% error time. mmm in stbi may be carried out via a single burr hole without significant clinical complications and reliably yields continuous data to facilitate clinical decision making. this supports the feasibility of our approach as an alternative to icp monitoring alone. intracranial hemorrhage patients with non-compliant ventricles may have high intracranial pressure (icp) despite normal ventricle size. we aimed to assess the incidence of elevated icp among those with no radiographic evidence of intracranial hypertension. prospectively enrolled primary intracranial hemorrhage patients (sah, sdh and iph) admitted to two tertiary-care centers between 4/2008-5/2016 were retrospectively reviewed. among patients with external ventricular drainage (evd), admission head ct (hct) scans within 72h prior to evd placement were reviewed for evidence of elevated intracranial pressure (icp) including: ventricle size (bicaudate index, temporal horn size), basal cistern effacement, midline shift and global cerebral edema. when all of these features were absent, patients were classified as having normal-icp hct. the incidence of elevated icp (>20mmhg) at the time of evd placement and during hospital stay were recorded. of 741 intracranial hemorrhage patients enrolled, 253 (34%) had evd. 23/253 (9%) had a normal-icp hct. of these, 11/23 (48%) had elevated opening pressure at the time of evd placement, and 13/23 (57%) had elevated icp during their hospital stay. among normal-icp hct patients with icp>20mmhg, 92% had sah, and the median gcs and hunt-hess scores were 14 (range 3-15) and 3 (range 2-5). the positive and negative predictive values of normal-re 52% 62%, respectively (auc 0.471, p=0.648) the only radiographic feature that was associated with elevated icp was global cerebral edema (or 5.4, 95% ci 3.5-8.4, p<0.001). approximately half of intracranial hemorrhage patients without radiographic features of elevated icp had icp>20mmhg at the time of evd placement and additional patients had elevated icp during their hospital stay. radiographic findings should not be relied upon to exclude the possibility of elevated icp. the measurement of intracranial pressure (icp) is a cornerstone of intensive care management following severe traumatic brain injury (stbi). it has been only recently that the time integral of icp has been quantified in relation to outcome; the time integral of brain tissue oxygen (pbto2) has not been studied. we gathered time-locked intracranial monitoring data on s tbi patients at the university of cincinnati over 2 years. clinical management of all patients followed national standards. raumedic pto probe was used to measure icp and pbto2; accuracy was verified by visual inspection with automated data cleaning. normalized data was mapped based on correlation with glasgow outcome scale scores at 3-6 months. we studied 43 patients aged 42+/-18 years (mean+/-sd); 84% were male. initial post-resuscitation glasgow coma scale score was median 6 (interquartile range: 4.5-7). 13/43 underwent craniectomy prior to monitoring. among those with good (gos4-5) and poor (gos1-3) outcome, the average icp was 13.2+/-5.6mmhg and 18.4+/-8.6mmhg (p=0.09); the average pbto2 was 25.7+/-10.0mmhg and 31.1+/-21.5mmhg (both n.s.). the correlation with outcome was dependent on both icp and time: an icp > 27mmhg for > 5 minutes was associated with poor outcome, whereas an icp < 23mmhg was associated with poor outcome only after 4 hours. in contrast, the pbto2 level, but not the duration, correlated with poor outcome in those without craniectomy at a pbto2 < 30mmhg, and particularly below 12mmhg. pbto2 burden was less reliable in those following craniectomy. we replicated the effects of icp/time in a cohort of patients with severe tbi, both with and without craniectomy and subsequently demonstrated the burden of brain tissue hypoxia in those without craniectomy. the time integral of multimodality monitoring data may provide more accurate measures of secondary insult burden with implications for clinical care and prognosis. neurologists who work in neurocritical care (ncc) as neurointensivists may have critical care (cc) charges rejected for payment unless they are classified per centers for medicare services (cms) taxonomy codes in their systems as critical care providers. the neurocritical care society and cms created a new ncc code 2084a2900x to fix this issue. we polled the aan ccen section members for awareness of this problem. we conducted a six question google forms survey using the aan ccen synapse community website to assess knowledge of the ncc taxonomy code: we received 20 anonymous responses by the time we closed the poll on 7/13/17. question (q1) and (answers, a1): are you a neurology or neurosurgery back grounded intensivist who does neurocritical care at your hospital? y/n (yes/no). a1: 95% reported being neurologists. q2: were you aware of the new cms neurocritical care taxonomy code 2084a2900x ? y/n a2: 55% were aware of the taxonomy code. q3: are you aware why the ncc taxonomy code was created? y/n a3: 55% of respondents were unaware why this code was created. q4: what is your primary department for revenue collection? a4: 85% reported neurology, 15% neurosurgery, 15% critical care, and 15% blend. q5: are you aware that medicare can reject critical care charges (99291 and 99292) can be rejected unless you are listed as a cms 'critical care provider' or as a neurocritical care provider? a5: 20% reported rejected charges at their centers. q6: are you aware of rejection of critical care charges happening at your own institution due to this misclassification? y/n a6: 20% of respondents reported rejected charges at their center. although limited in sample size, this survey revealed almost half of the respondents were unaware of the ncc code. we believe a larger study is warranted. arterial subdural hemorrhage (sdh) is a rare but potentially devastating neurologic entity. it has been associated with ruptured aneurysms. we report a case-series of five patients with arterial sdh and their outcomes. a retrospective chart review of our institute's vascular database was conducted using a pre-defined search strategy including the terms "aneurysm", "arterio-venous malformation", "subdural hemorrhage", and "dural arterio-venous fistula" (dural-avf). amongst 200 patients in the database, five cases were identified with ages ranging from 43 to 78 (four females). four had sdh due to aneurysm (two internal-carotid, one middle-cerebral, and one posteriorcerebral artery; one had parieto-occipital dural av-fistula. no patient had preceding head-trauma or anticoagulation. of aneurysmal patients, one had no sah. on admission ct-head imaging, the mean-sdh size was 10.88mm (sd 3.24; range 7.4-15mm), and mean midline-shift (mls) was 12.64mm (sd 2.49; range 9-15mm). the mean ratio between sdh-size and mls was 1.16 (sd 0.25). in a historic cohort of acute subdural hemorrhage of non-arterial etiology ; the mean size of sdh was 8.0 mm and the mean mls was 4.6 mm. ratio of mls: sdh size was 0.56. in our series, three patients with aneurysms had decompressive-craniectomy, one had mini-craniotomy for sdh evacuation; the patient with dural-avf had coiling and mini-craniotomy for sdh evacuation. four patients had died during hospitalization, whereas patient with dural-avf recovered to baseline functional-status at 6-month follow-up. arterial sdh is a rare entity and may present without subarachnoid hemorrhage and any preceding head-trauma. the degree of midline-shift is usually out of proportion to sdh size. there should be a low threshold to obtain vessel imaging in cases of sdh with no clear trauma history. mls: sdh ratio may be a useful screening tool for possibility of arterial sdh especially in absence of trauma and may reflect rate of bleeding. neurostimulant medications (amantadine and modafinil) are sometimes prescribed after acute nontraumatic brain injury to facilitate wakening and rehabilitation participation; the safety and effectiveness of this practice is unknown. following a retrospective evaluation of our experiences, we characterized anticipated challenges to designing a prospective randomized trial of neurostimulant medications to promote rehabilitation participation after acute non-traumatic brain injury. retrospective chart review of patients over with subarachnoid hemorrhage (n=17), intracerebral hemorrhage (n=41) and ischemic stroke (n=30) who received neurostimulant medications over a period of 43 months. data regarding clinical course and potential confounders to assessing response were collected. continuous data are reported as median and interquartile range. neurostimulant medications were initiated in 88 patients at a median of 7 (5-13) days after hospital admission, for hypersomnolence 68 (77%), not following commands 28 (32%), lack of eye opening 25 (28%), and/or low gcs 15 (17%). thirty-nine (44%) patients were receiving sedatives or opioids at the time of neurostimulant(s) initiation. twenty-two (25%) patients received newly prescribed sedatives or opioids after neurostimulant(s) initiation. potentially sedating antiepileptic medications were prescribed to 14 (16%) of patients. twenty-two (25%) patients were intubated at the time of neurostimulant initiation confounding the gcs-v. potentially confounding clinical factors included hydrocephalus 37 (42%), vasospasm 7 (8%), and seizures 4 (5%). twenty-eight (32%) of patients had temporary cerebrospinal fluid diversion in place at the time of neurostimulant initiation. initiation and titration of neurostimulant medications after acute non-traumatic brain injury was common, but timing and indications varied widely. confounders to assessing effectiveness included concomitant sedating medications, variable pathophysiology related to the type and location of the stroke, and clinical factors like seizures, vasospasm, and hydrocephalus. these confounders are likely to make prospective evaluation of neurostimulant medication effectiveness difficult in the period of initial therapy following acute non-traumatic brain injury. brain small vessel disease can cause cognitive impairment via ischemic or hemorrhagic mechanisms. current imaging modalities, specifically magnetic resonance imaging allow for easier detection of different intracranial pathological processes including cerebral microhemorrhages (cms). research demonstrated that the number and location of cms correlate with the type of cognitive impairment (memory, processing speed, executive function, and motor speed). a retrospective analysis of 50 patients (age 44 to 87) seen at our neurology outpatient clinic from 2010 to 2017 who were identified by linguamatics software to have "microhemorrhage" in their radiology mri report. additional information included age, sex, cognitive examination, presence of cardiovascular risk factors, mri, and the number and location of cms. cognitive function was determined by mini mental state examination (mmse) score and diagnosis by a cognitive neurologist. patients were grouped by presence of 1 cm or greater (2 to 10) and regression was used to determine a relationship with mmse and vascular risk factors. the number of microhemorrhages per patient were 1(17 patients), 2 (5 patients), 3 (8 patients), 4 (12 patients), 5 (3 patients), 6 (3 patients) and 10 (2 patients). vascular risk factors included hypertension (16 patients), diabetes mellitus (25 patients) and smoking history (26 patients). regression analyses indicated that the presence of more than 1 cm correctly predicted mmse lower than 26 at 83% (p=0.003). age was the only factor that influences this finding and increased this prediction to 90%. this study provides novel evidence that the presence of multiple cms on brain images predicts the presence of cognitive impairment. this study raises the need for more investigations. point-of-care ultrasound is a valuable tool in critical care, allowing timely and frequent beside assessment of clinical questions. neurocritical care has long utilized transcranial doppler but is still early in the adoption of other critical care ultrasounds. this study looked at the comfort level and competency of the participants at the point-of-care ultrasound workshop at the 2016 neurocritical care society annual meeting. the workshop comprised of didactics and hands-on small group practice using live models. topics covered included ultrasound physics, lung, cardiac, optic nerve sheath ultrasounds, as well as case studies in neurocritical care. participants were asked to complete an anonymous pre-and postworkshop assessment on a volunteer basis. a total 41 pre-workshop and 33 post-workshop assessments were completed. the mean age of the participants was 40.7 ± 9.2 years. there were 21 (51.2%) attending physicians, 8 (19.5%) advance practice practitioners, 7 (17.0%) fellows, 4 (9.7%) residents, and 1 (2.4%) research scientist. participants had limited ultrasound experience prior to the workshop, with 12 (29.2%) reported none, 16 (39.0%) reported < 1 year, and 10 (24.3%) reported 1 to 3 years. on a 1-5 scale on comfort using ultrasound with 1 being very uncomfortable and 5 being very comfortable, participants reported a median score of 2 (iqr 2-3) pre-workshop with an improvement to 4 (iqr 3-4) post-workshop. for 15 matched pre-and post-tests, all 15 participants had an improvement in their ultrasound knowledge. while the majority of the participants at this workshop had prior ultrasound experience, many are still uncomfortable with their ultrasound competency. the format of didactics and hands-on small group practice improved the comfort level as well as overall ultrasound knowledge of these participants. additional opportunities for point-of-care ultrasound training should be considered in neurocritical care fellowships and meetings. event related potentials (erps) allow assessment of cognitive processing in unconscious brain-injured patients. here we explored the diagnostic and prognostic value of erps obtained shortly after brain injury. we prospectively collected a comprehensive erp paradigm labeled "local global paradigm" from a consecutive series of unconscious patients with acute brain injury. this auditory paradigm allows the assessment of: 1) cortical responses, 2) unconscious cognitive processing, 3) unconscious focusing of attention, and 4) conscious processing of sounds. levels of consciousness assessed with the coma recovery scale-revised (crs-r) at the time of recording were correlated with the presence/absence of each erps component and functional connectivity/complexity measures. we tested the prognostic value of each measure for recovery of consciousness prior to discharge. we analyzed 32 recordings from 15 patients (median recordings per patients 2[iqr 1,3]). recordings were made 6 [iqr 4.25,10.75] days after brain injury and all patients were unconscious at the time of the initial recording. underlying etiologies included ich(n=6), sah(n=4), tbi(2) and other (n=3). there were trends for higher crs-r scores in patients with preserved erp components. crs-r scores correlated with the functional connectivity indexed (rho=0.44; p=0.01) but not with complexity measures. five (33%) patients regained consciousness (within 6 to 42 days from brain injury). one of these patients had to be excluded due to poor quality recording. all the 4(100%) remaining patients had the three type of non-conscious responses preserved on at least one recording in comparison to only 3(30%) among patient who did not recover consciousness (fischer p-value = 0.07). similarly, connectivity was greater in patients who regained consciousness (0.0855 vs 0.0797; p=0.05) but the complexity was similar. simple bedside erp responses indexing cognitive processing during the local global paradigm obtained shortly after brain injury correlate with the level of consciousness but, more importantly, the probability to recover consciousness. over a decade ago, the institute of medicine introduced family-centered care (fcc) as a vital aspect of quality health care by strongly recommending that family members of intensive care unit (icu) patients be actively involved in decision-making. while there are many resources to help icu staff conduct meetings and provide information to families, the latest society of critical care medicine guidelines for fcc recommend the implementation of communication and decision support tools for family members to use. electronic decision support tools such as my icu guide have been effective in pilot studies at allowing family members to customize information delivery and communicate their preferences to icu staff. we sought to integrate a decision support and communication tool for families into an electronic patient portal. we developed an electronic patient and family engagement checklist for the neurointensive care unit (nicu) using doctella (patient doctor technologies, sunnyvale, ca), an existing patient engagement application. checklist components included: identifying a spokesperson, developing an advance directive, understanding diagnosis and prognosis, access to helpful resources, and a family meeting guide and planner. we presented the checklist to our hospital's patient and family engagement steering committee for the icus and received useful feedback. the checklist will also be vetted by the hospital's patient and family advisory council. usability testing will also be conducted. a family engagement checklist using an electronic patient portal is a novel strategy to enhance communication in the nicu. further validation of the tool is needed. applying painful stimuli to brain injured patients is a time-honored practice assumed to provide valuable clinical information for diagnosis, prognosis, and potential guidance for therapeutic interventions. however, there is limited literature that has evaluated and discussed the benefits and potential adverse effects related to repeated painful stimulation during bedside neurological examinations. though providers intend to do no harm, the practice of repetitive painful stimulation can unintentionally damage patient's skin, muscle, and bone, as well as inflict emotional duress. in conjunction with basic ethical principles used to justify painful stimulation during patient examinations, we propose a revisiting of the practice of routine repetitive painful stimulation in neurologic bedside assessments. 1. discuss the current literature regarding the use of painful stimulation and its beneficial and damaging effects, 2. describe alternative strategies for neurologic assessments, 3. propose guidelines to optimize accurate neurologic assessments while avoiding unnecessary repeated painful stimulation, 4. propose the development of a graded methodology for delivering painful stimulation when necessary for neurologic assessments. a summary of the literature will be outlined and discussed focusing on the ethical considerations and justification for the use of painful stimulation in the neurologic patient and the perception of pain in coma and minimally unconscious patients, 2. alternative strategies will be presented to minimize bodily and emotional injury, 3. a proposed outline with a companion flow diagram "easing the pain guidelines" implemented in a tertiary care neurocritical care unit will be presented. there has been little attention paid to the burden of painful stimulation inflicted on patients in the neurocritical care unit. the guiding principle of nonmaleficence (do no harm) morally obligates clinicians to evaluate current practice standards using repetitive painful stimulation in routine neurologic assessments. implementing standardized guidelines will limit unintended harm to patients without compromising accurate neurologic assessments. plasmapheresis is utilized in anti-n-methyl-d-aspartate receptor (nmdar) encephalitis to remove autoantibodies. antiepileptic drugs (aed), such as valproate, are often used to control seizures which may complicate anti-nmdar encephalitis. it is important to prevent rapid reductions of aed levels to ensure proper seizure management in this setting. we obtained total and free (active drug, unbound to plasma proteins) valproate levels intermittently throughout two 5-day courses of daily plasmapheresis. during the first course, trough levels were obtained. during the second course, levels were obtained before, during, and after plasmapheresis. the patient was a 26 year old female, weighing 79 kg. albumin was 2.6 g/dl. her valproate regimen ranged from 1250 mg to 2250 mg every 8 hours (47 to 85 mg/kg/day), given intravenously or enterally. prior to the first plasmapheresis, valproate dose was 1250 mg every 8 hours, resulting in a total level of 25 mcg/ml (reference range: 50-125 mcg/ml). free valproate was 21 mcg/ml (reference range: 7-23 mcg/ml); free fraction was 86% (reference range: 5-18%). four days later, prior to the 5th plasmapheresis, the total valproate level was 35.3 mcg/ml. two days after the 5th plasmapheresis the total level was unchanged at 34 mcg/ml; free valproate was 8 mcg/ml and free fraction was 24%. during the second course of plasmapheresis, valproate total levels, free levels, and free fractions were 49 mcg/ml, 18 mcg/ml, and 36% before, 105 mcg/ml, 24 mcg/ml, and 23% during (valproate dose given upon initiation of plasmapheresis), and 59 mcg/ml, 24 mcg/ml, and 41% after plasmapheresis, respectively. valproate serum levels were not markedly influenced by plasmapheresis. free valproate levels and the free fraction were highly elevated throughout the patient's hospital course, however. future studies should evaluate critically ill patients' clinical response and toxicity correlations as the free fraction of valproate appears to be elevated in this setting. the purpose of this study is to assess knowledge retention of emergency neurological life support (enls) after participation in the course via a prospective observational study. study subjects seeking enls certification consented for study participation (enls-vs) from the ncs website then took a closed-book, 70 multiple-choice question pre-test within 72 hours of enls course participation. after completion of the enls course, participants took the same closed-book, 70 multiplechoice question test (post-test). these tests consisted of novel questions from material presented in the course. questions were not repeated from the enls certification exams. thirty participants enrolled in the study with 11 completing both the pre-test and immediate post-test. all 11 participants' scores improved on the post-test as compared to the pre-test. the mean percent correct on the pre-test was 63.5% with a median of 64.3% (range 34.5-85.7%). of the participants who have completed both pre-and immediate post-test, the mean pre-test score was 72.4% with a median of 72.9% (range 61.4%-72.9%). the mean post-test score was 86.7% with a median of 88.6% (range 77.1%-94.3%). the improvement of scores was statistically significant on the post-test compared to the pre-test (86.7% vs. 72.4 % %, p< 0.005). all participants in the emergency neurological life support course showed improved test scores immediately after participation in the standard enls course. this study will assess knowledge retention at 6-months following training, and is actively enrolling new participants. augmented renal clearance (arc, defined as a creatinine clearance of > 150ml/min) has been demonstrated in neurocritical care disease states such as traumatic brain injury, intracranial hemorrhage, and subarachnoid hemorrhage. arc may result in increased elimination of renallyeliminated medications, thereby reducing drug exposure with standard doses. the overall prevalence of arc is not well described. the purpose of this study was to estimate the overall prevalence of arc in a neurocritical care population. this was a retrospective cohort study of adults > 18 years of age admitted to the intensive care unit on the neurosurgery service. demographic and pertinent laboratory data were collected for patients admitted from january 1, 2016 thru december 31, 2016. an arctic score was calculated for each patient (6 or greater suggests arc). parametric data was compared using one-sample student's t-test, nominal data was compared using fisher's exact test (alpha = 0.05). statistical analysis was conducted using ibm spss version 24. present in a total of 37.24% of patients. a broad spectrum of neurocritical care diagnoses was present. the mean age in years was significantly lower in patients with arc [47.8 (14sd)] than without arc [54 (17sd), p = 0.026], as was the serum creatinine [with arc 0.55mg/dl (0.1sd) vs without arc 1mg/dl (0.6sd), p < 0.001]. mean hospital length of stay was greater in patients with arc than without [10.1 (10sd) vs 6.5 (10sd), p < 0.001]. arc occurs commonly in neurocritical care patients and likely merits proactive screening or direct measurement of creatinine clearance in select patients. pharmacokinetic studies of commonly used renally-eliminated medications may be needed to establish population parameters in the neurocritical care population. education surveys demonstrate gaps in resident neurocritical care education and training. we assessed junior residents' baseline knowledge of neurologic emergencies, procedural competency, knowledge of available resources, and the impact of pre-rotation orientations. junior residents (neurosurgery pgy1s and neurology pgy2s) who had not previously rotated in the neuroicu were surveyed. a three-part survey was administered: part i, knowledge of icu structure and personnel; part ii, procedural competency; part iii, comfort with common neurocritical care emergencies. the survey was comprised of selection responses. after the survey but prior to starting the rotation, each resident was oriented to the unit by a neuroicu attending and nursing director. this orientation reviewed rotation goals, icu structure, personnel and rounding expectations. a survey was repeated to evaluate the orientation. of 15 residents who had not rotated in the icu, 10 (66.7%) responded. none of the residents understood their specific role within the icu team. 80% did not understand the role of the resource nurse and were unaware of where to find procedure equipment. 60% of residents were not comfortable placing an a-line; 30% were not comfortable performing a lumbar puncture. over half of respondents said they "didn't know and could not easily find" the indications for hemicraniectomy after malignant mca ischemia, the indications for icp monitoring, or the initial workup of autoimmune encephalitis. 14 residents responded to post orientation surveys. 76% felt the orientation was helpful in explaining the roles of team members. 61% felt it was at least "somewhat helpful" in understanding the role of the resource nurse. 46% felt the orientation was "helpful" and 38% felt it was "somewhat helpful" in identifying the goals of the rotation. these baseline measures underscore the importance of structured interventions, both before and during the neuroicu rotation, to improve junior resident comfort and preparedness in managing neurologic emergencies. physician-staffed helicopter emergency medical services (hems) are a well-established component of prehospital care in japan. however, there has been no report on hems and neurocritical care patients. we studied characteristics of neurocritical care patients who were transported by hems. we retrospectively evaluated neurocritical care patients who were brought to our emergency and critical care medical center (eccmc) by hems between january, 2010 and march, 2017. we excluded patients in whom the outcome was unknown, those who were transported to other hospitals or between facilities. of 4216 the most important role of hems is rapid transportation of a flight medical team to the scene to provide immediate, lifesaving medical treatment. we found that half of patients admitted to our hospital by hems were neurocritical care patients. as proposed in the enls of neurocritical care society, hems is considered useful to allow neuro-emergency patients to receive the best care in the first hour. optic nerve sheath diameter (onsd) measurement using ocular ultrasound has been shown to accurately detect elevated intracranial pressure (icp), but does require specialized training. variations in the optimal onsd threshold for detection of elevated icp in the literature limits clinical utility, and may reflect heterogeneity in manual measurement techniques. our objective was to develop, and validate against expert measurement, an image-analysis algorithm for onsd measurement to facilitate standardization and ease of use of this technique. consecutive patients with acute brain injury admitted to the neurointensive care unit underwent ocular ultrasound with a multipurpose point-of-care ultrasound machine. a 6-second video was recorded from each eye in the axial plane and downloaded in dicom format. the onsd measurement algorithm was as follows. an average of images was calculated using non-overlapped segments of the image sequence. a line integral was performed to estimate the border of the region of interest (roi), the globe. the roi orientation and globe point of the segmented region were established, then a point 3mm posterior to the globe point identified. the onsd was measured at this point. manual onsd measurement was performed separately from the dicom videos by an expert blinded to the algorithm measurement. an intraclass coefficient (icc) was calculated for absolute agreement between highest onsd measured by the algorithm and expert manual measurement. a total of 27 patients with acute brain injury underwent ocular ultrasound. the icc for absolute agreement between algorithm (median 0.66, interquartile range 0.61-0.71) and manual expert (median 0.63, 0.61-0.71) highest onsd measurement was 0.68 (95% confidence interval 0.31-0.85). an algorithm for automated measurement of onsd was developed and demonstrated good inter-rater agreement with expert measurement, although further refinement is required. automated measurement may help standardize and simplify a promising noninvasive bedside tool for the detection of elevated icp. after transition to electronic health record (ehr), transition to inpatient hospice required a separate encounter to account for change in insurance payer in our neuroicu. this negatively affected completed transitions and hence patient-centered care. the focus of this quality improvement project was to define the new process, improve outcomes, and identify further opportunities. the quality improvement method "plan-do-study-act" was employed for this work within a 30-bed neuro-icu at a large academic medical center. we assessed the current state (not enabling transition to inpatient hospice) and the desired state (enrollment in hospice during inpatient stay). a new process was created using an ehr discharge navigator, coordinating all relevant stakeholder groups (patient/caregiver, nurse, pharmacist, bed control, physician,). in addition, standard methodology for unit-based education, in-service, just-in-time training, and booster education was employed to identify process, outcome, and improvement opportunities. after rollout of the new discharge navigator, 90% of all patient-facing staff successfully completed the inpatient hospice training. process improvements lead to increase in palliative care consults by 500% (16 to 96 annually) and inpatient hospice discharges up to 30% (68 to 88 annually). furthermore, there was a statistically significant improvement in the vizient mortality index r2 = .11, f(1,51 ) = 22.64, p < .05 and length of stay index r2 = .10, f(1,51) = 12.64, p < .05 within the study population and period. ability to transfer patients to inpatient hospice is often limited and complicated. this study shows how employing standard quality improvement as well as education and implementation methods can result in improved process and outcome measures with sustainable success. opportunities remain in further analyzing and optimizing 'time to palliative care consult', 'time to admission to hospice and withdrawal of artificial support'. arnp and pa's are a rapidly growing part of the critical care workforce. proper selection among a pool of app candidates for the job is necessary to ensure the "right fit" and optimize patient safety. conventional interview techniques may not be adequate when selecting critical care app's. we hypothesized that use of a simulation center could be used to help select app candidates based on their critical thinking skills in conjunction with contemporary interviewing skills. from 2010 to 2013, we performed conventional interviews for app's to staff critical care and neurocritical care patients. in 2014 we changed to an interview process consisting of the conventional interaction with the interviewee followed by simulation. after narrowing down the initial candidate pool, each was taken to the simulation center where they participated in a simulation of a decompensating patient. proctors were able to view the simulation in a separate room and direct the simulation mannequin. during this time proctors were able to evaluate the interviewee's patient interaction, assessment and interventions. an evaluation tool was to grade app candidates for their decision making skills, communication and thought. from 2014 to 2017, we screened 40 candidates before selecting 21 for interviews and finally 10 of those for simulation. over this timeframe, our center hired 6 app's. comparing the ratio of screen applicants to employment was 6.6 and ratio of interviewed to hired candidates was 3.5. these ratios show the competitive process and potential use of simulation in selecting apps. compared to the time period of applicants prior to simulation to after, retention went from 75 to 92%, and disciplinary action for practice deficiencies went from 16% to 0%. the use of simulation based interviews for critical care app's in our institution improved retention and decreased the number of disciplinary actions compared to conventional interview methods. the contraindications for lumbar puncture (lp) in the setting of cerebral mass effect remain debatable. limited retrospective data advocate its potential safety. yet, high-quality guidelines specifically addressing this topic are not available. specific patient populations (post-instrumentation & immunosuppressed) may benefit from csf studies. we reviewed 1072 consecutive patients who underwent lp and cerebral imaging a week before or after lp from 2007-2014. all individuals with evidence of brain herniation, a component of midline shift, or mass effect were included. all subjects received a low volume lp (5-10 cc of csf). there were 132 patients with radiological increased icp. midline shift (average = 4 mm) was present in 39 patients. we also observed herniation: uncal (n=16), subfalcine (n=15), and a combination of both (n=10) , ventricular effacement (n=67) and cisternal compression with partial occlusion: quadrigeminal cistern (n=3), cerebellar-pontine-angle cistern (n= 14), ambient cistern (n=24), crural cistern (n=14), prepontine cistern (n=7), suprasellar cistern (n=12), basal cistern (n= 2), suprachiasmatic cistern (n= 4), cisterna magna (n=3), interpeduncular cistern (n=3), medullary cistern (n=4). all patients tolerated the lp without complications. most survived a week after the procedure (n=128, 97%). notably, four individuals deteriorated for reasons unrelated to the lp and expired within a week because of withdrawal of care. as brain compliance cannot yet be accurately determined radiologically, we believe anatomical involvement should drive decision-making regarding lp safety. our data suggest that a low volume lp (5-10 cc) might be safe in individuals with subfalcine herniation, midline mass effect < 4 mm at foramen of monro level, and partial cisternal effacement. we believe that while lps might be safer in patients with supratentorial mass effect, individuals with posterior fossa involvement may tolerate it as well. these promising findings need further verification in larger sample populations. the importance of neurocritical care has recently been recognized in japan. however, to date, there has been no neurocritical care training program. we developed the neurocritical care hands-on seminar as a proposed training module, and here we report the satisfaction of participants. we prepared a post-course questionnaire about participants' degree of satisfaction. the main concept of our seminar was "how to maintain cerebral oxygen demand and supply balance." beginning with a short lecture about this concept, participants joined four hands-on scenarios: post-cardiac arrest syndrome (pcas), subarachnoid hemorrhage (sah), traumatic brain injury (tbi), and states epilepticus (se). in the pcas scenario, participants learned how to trouble shoot regarding targeted temperature management, especially in regard to the management of shivering. in the sah scenario, they learned about perioperative management, including delayed cerebral ischemia. in the tbi scenario, starting with actual insertion of an intracranial pressure (icp) monitor in the simulator, they learned about icp management through a scenario-based simulation. in the se scenario, they learned about se management, with actual continuous electroencephalogram monitoring. this seminar was held twice in 2017. most participants were middle-aged intensivists; 11% were in their twenties (6/54), 64.8% were in their thirties (35/54), 18.5% were in their forties (10/54), and 5.6% were in their fifties (3/54). most of the participating physicians were specialists in emergency or intensive care medicine (74.1%; 40/54); nurses (13.0%; 7/54) and a clinical engineer (1.9%: 1/54) also participated. most participants (81.5%; 44/54) were satisfied with the seminar, and almost all (98.1%; 53/54) improved their self-confidence in the ability to carry out clinical practice in neurocritical care. we received positive, satisfied reactions from the japanese intensivists who participated in our seminar. for further improvement, we need to collect objective data to assess the utility of our neurocritical care hands-on seminar. lumbar puncture in the presence of mass effect? ciro ramos-estebanez uhcmc, case western reserve university/neurology, cleveland, ohio, usa introduction 1) we propose an international consortium that would prospectively confirm the safety of low volume lumbar puncture (lp) in the presence of mass effect in selected scenarios. 2) welcome peers and advisors to join the effort. lp may be clinically necessary in the presence of cerebral mass effect. while empirical antibiotic therapy is generally successful, specific groups such as post-instrumentation patients and immunosuppressed individuals may benefit from cerebrospinal fluid (csf) studies. in the absence of high-quality clinical recommendations, uncontrolled retrospective literature suggests that a small volume lp (5-10 cc) might be without complications in specific situations. nevertheless, the ethical principle of non-maleficence and the liability risk prevent clinicians from performing lps. in this scenario, an extended length of stay, poor outcomes, or a higher cost of care are legitimate concerns. synthesize an external peer reviewed methodology to maintain rigour and transparency. 6. seek appraisal, approval and endorsement of national and international quality improvement committees. 7. generate and assimilate the most current clinical evidence through: a. systematic review and meta-analysis. b. prospective randomized controlled clinical trial. 8. construct a protocol to inform decision making amongst healthcare and non-healthcare personnel. 9. dissemination and implementation. 10. schedule updates and/or revision. 15 centers across the globe (north america = 5, south america=4, europe=2, and asia=5) have agreed to establish an lp consortium so far. retrospective analyses suggest low-volume lp's relative safety in the presence of increased icp. thereby, an expert consortium trusted with prospective verification would potentially benefit specific patient populations. patient centered decision making in the nccu requires family members understanding of their loved one's preferences and values as well as the complexities of their medical condition and treatments. family-centered care (fcc) is essential so that family members are actively involved in decision-making. stakeholders have reported their preference to receive prognostic information in smaller packets and recapitulated in different venues including rounds, bedside and care conferences. we examine implementation of a multimodal communication strategy on clinician utilization, family engagement and satisfaction in the nccu. an interdisciplinary team convened to develop a plan implementing a multimodal communication strategy. pre-implementation survey of clinicians (mds, nps, rns, etc.) and patient families was completed to determine the level of family engagement already in place in the nccu. four interventions were implemented: family communication boards were installed in patient rooms; family engagement pamphlets developed; a script and schedule for family care rounds was developed; nursing and provider staff were educated on inviting families to participate in patient care team rounds. family involvement on patient care rounds and family conferences was compared before and after the implementation of the 4 best practice initiatives. additionally, pre and post implementation patient satisfaction survey results were also compared to evaluate the project's success. pre-implementation data was collected from october -november 2016. sixty-one clinician surveys and forty family surveys found that family more consistently participated on daily rounds. baseline and postimplementation surveys demonstrated families feeling supported during the decision-making process. the implementation of a multimodal communication framework to achieve consistent family engagement and communication has led to an appreciable change in utilization by clinicians. its use is supported by consistent positive family attitudes towards communication and availability of information in the nccu. neurocritical care society undertook initiatives to integrate social media in member engagement activities and initiated a twitter journal club (#ncstjc) in 2015 with the first journal club conducted in february 2015. articles were chosen by a subgroup of the communications committee in consultation with dr. eelco wijdicks, chief editor, neurocritical care journal. these articles were chosen based on their overall importance and the interest bound to generate amongst the journal club attendees. the journal club occurs bimonthy over an hour and is unique in the participation of the authors. the journal club is registered with healthcare hashtag project. each article chosen for #ncstjc is made available free to download 2 weeks before and after the scheduled date for the journal club courts springer. analytics data on usage on article discussed in #ncstjc was obtained from sean beppler, editor, clinical medicine. between feb 2015 and apr 2017, 12 sessions were held with data available from 11. the ncc articles discussed had higher than average altmetric scores (measuring social media activity). these articles represented 5% of all ncc articles discussed on twitter since feb 2015 but 15.3% of all tweets. total usage (number of times an article html page is accessed, or a pdf is downloaded ) was 12, 989 ( mean 1082, n=11) representing 24.6% usage of all neurocritical care articles, a total of 39 citations and 3191 downloads ( mean 290) . the upper bound of the audience as assessed by the publisher was total of 111, 524 for all 1 articles (mean 9,294 per article) twitter is becoming an emerging platform for dissemination of information in medical education and academic activities. while the exact impact of the initiative on member engagement or outreach in enhancing journal impact or citations is hard to determine, we saw trends in enhanced engagement. neurostimulant medications have been studied in patients with traumatic brain injury, but few studies describe their use in patients with acute non-traumatic brain injury. our objective was to describe neurostimulant medication prescribing patterns, clinical response, and potential adverse effects in this patient population. retrospective database review of patients with acute ischemic stroke, intracerebral hemorrhage, or subarachnoid hemorrhage who received amantadine or modafinil from december 2012 through june 2016. neurostimulant selection, dosing regimen, and indication were recorded. patients were classified as responders if they met two of the following three criteria within 7 days of neurostimulant initiation: 1) increase in average daily gcs of greater than 3 points, 2) neurological improvement documented in provider progress notes, or 3) increased participation in rehabilitation therapies documented in physical or occupational therapist progress notes. safety data included need for a new anxiolytic or sleep aid or seizure. continuous data are reported as median with interquartile range. eighty-eight patients received neurostimulants: intracerebral hemorrhage (n=41), ischemic stroke (n=30), subarachnoid hemorrhage (n=17). median age was 66 (55-73) years and 57 (65%) were male. amantadine (n=71), modafinil (n=13), or both (n=4) were initiated a median of 7 (5-13) days after hospital admission. the median initial daily dose of amantadine and modafinil were 200 mg and 100 mg, respectively. reasons for initiation included somnolence (77%), not following commands (31%), lack of eye opening (28%), and low gcs (17%). forty (45%) patients were responders, occurring at a median of 3 (2-5) days after neurostimulant initiation. twenty-three (26%) patients required new prescription of an anxiolytic or sleep aid. four (5%) patients developed seizure. neurostimulant medications may increase wakefulness and participation in rehabilitation therapies in patients with acute non-traumatic brain injury, with tolerable adverse effects. the role of neurostimulants in this population should be defined in prospective studies. difficulty in obtaining peripheral intravenous (piv) access often necessitates central venous access placement in many critically ill patients. central line placement exposes patients to potential complications such as pneumothorax, hemorrhage, catheter-related infection or deep venous thrombosis. ultrasound-guided piv placement has become common practice in emergency departments, but there is no systematic program to train and support routine use of ultrasound-guided piv access in icus. we have developed a systematic program to train and support icu nurses in becoming experts and clinical leaders in ultrasound-guided piv placement. we hypothesize that implementation of this program will increase nurse confidence and chances of successful piv placement subsequently decrease central line-related complications in 30-bed neurocritical care icus. we have developed a video didactic training program for the neurocritical care nursing staff. the program discusses use and maintenance of the ultrasound machine and guided-technique for piv placement including the short-and long-axis approaches. the training video is followed by a hands-on simulation session using mannequins. standardized-surveys are administered to nurses before training and then at 3 and 6 months post training. we are prospectively collecting data on nurse comfort level with ultrasound-guided piv placement, total iv attempts, patient central line associated bacteremia (clab) rates and total number of patient central line days. we will compare this data for 6 months pre-and post program implementation. comparisons will be made using t-test and chi-square analyses or non-parametric equivalents depending on data distribution. central-line related complications are an important clinical problem in all icus. we have developed and implemented a systematic training program to support nursing-led ultrasound-guided piv placement. we will determine if this program reduces the overall number of central lines placed, duration of indwelling central lines, and clab rates in a neurocritical care, and subsequently expand to additional icus and beyond. ultrasound measurement of optic nerve sheath diameter (onsd) is a sensitive and specific non-invasive ultrasonographers. despite clinical applications in the icu, er and outpatient settings, neurology residents lack experience and training. the aim of our project was to provide neurology residents with foundational skills in ocular ultrasound and onsd measurement. we designed a two-part workshop for neurology residents covering ultrasound basics, measurement of onsd, and ultrasound appearance of papilledema. workshop 1 was a 30 minute lecture and demonstration followed by 90 minutes of hands-on practice. two weeks later, workshop 2 included 60 additional minutes of practice to consolidate learning. the practical portions were facilitated by emergency medicine attendings and residents with experience in performing ocular ultrasounds. neurology residents tracked the number of practice ultrasounds performed. they also completed anonymous pre-and posttests to assess their knowledge of ocular ultrasound and their comfort level and likelihood to perform future procedures using a 6-point likert scale. prior to the workshop, the majority (14/19) of neurology trainees had never performed an ocular ultrasound. one (1/19) was able to answer two basic questions about the procedure correctly, which increased to 100% on the posttest (n=16). trainees performed an average of 5 ultrasounds total during the workshops. resident self-assessment of comfort performing the procedure increased from a median of "very uncomfortable" to "moderately comfortable" on the 6-point likert scale (p=0.001). resident likelihood to perform the procedure in the future increased from a median of "very unlikely" to "moderately likely" on the 6-point likert scale (p=0.002). this session successfully increased basic knowledge, comfort, and likelihood to perform ocular ultrasound among neurology residents. future directions include follow-up to gauge magnitude of practice changes and accuracy of procedural skills. reaching patients by telephone is a common method of assessing functional outcome, cognitive function, and quality of life after hospital discharge. however, when patients do not answer the phone, missing data creates bias and warrants strategies to increase follow-up rates. we hypothesized that we would have less follow up with patients discharged to long-term care facilities and sought to examine other potential sources of lost data. between 1/2016 and 3/2017, we identified all patients admitted to the university of cincinnati neuroscience intensive care unit (nsicu). we excluded those with recurrent admissions, boarders, and those admitted < 24 hours or for uncomplicated post-op care. telephone follow-up was attempted for each patient. univariate analysis was used to identify associations with patients who did not answer the phone. 1103 critically-ill patients were included. average age was 59.7+/-17.6 and 53% were men. the average hospital length-of-stay was 9.4+/-8.9 days. major diagnoses were: ischemic stroke (25%), intracerebral hemorrhage (19%), traumatic brain injury (15%), seizures/status epilepticus (10%) and subarachnoid hemorrhage (9%). 271 (25%) died in the hospital; 130 (12%) died by follow-up. 702 survivors were assessed 133.2+/-25.6 days following admission. 462 calls were answered, 231 were not. there were no associations between rate of answered calls and age, gender, race, hospital length-of-stay, diagnosis, or hospital disposition. there were no differences in between morning vs. afternoon calls. only the number of attempts differed: the probability of an answered call was 90% on the first attempt but declined to 14% by the third attempt (or 0.13; p<0.01). our outcome assessment strategy captured data on 78% of neurocritically ill patients. those who answer the phone are most likely to answer with the first call; the probability of a patient answering after a second phone call may not justify resources needed to continue calling these patients. posterior reversible encephalopathy syndrome (pres) typically presents with vasogenic edema on neuroimaging. a subset of patient, however, can have "atypical findings" including restricted diffusion and intracranial hemorrhage. these atypical findings all suggest acute vascular injury, and may mark a distinct pathophysiological subtype of pres. however, it is unknown whether atypical imaging findings are associated with differences in precipitating factors or outcome. patients with evidence of restricted diffusion, frank hematoma, microhemorrhage, or subarachnoid hemorrhage were classified as having atypical imaging findings. the demographics, risk factors, clinical outcomes, and degree of vasogenic edema for patients with typical (n = 109) vs atypical pres findings of vascular injury (n = 75) were analyzed. patients with atypical pres had a longer hospital stay (22.8 vs 15.4 days; p = 0.039) and were less likely to be discharged home (54.7% vs 69.7%; p = 0.036). severity of vasogenic edema (graded using a standardized radiologic scale) was also higher in patients with atypical imaging findings (severe edema: 41.3% vs 21.1%; p = 0.003). restricted diffusion and hemorrhage are features of acute vascular injury that may mark a unique pathophysiological subtype of pres. pres patients with these atypical imaging features had longer hospital stays, greater degree of vasogenic edema, and were less likely to be discharged home. this may be due to the fact that bleeding and infarction lead to irreversible brain injury, prolonging hospital stay and contributing to overall disability. in 2016, 16 deaths occurred in the neuro-oncologic critical care unit (nccu). the impact of this event is significant for patients, families, and the staff that care for them. brain and spinal pathology can be incredibly debilitating causing a rapid and impromptu decline of the patient's status. in order to better support patients, family, and staff throughout the dying process, the nccu staff created formalized endof-life care interventions. these interventions include educational pieces and supportive approaches to aid all involved through the dying process. several interventions were created to help transition the family members during the dying process. these include the creation of: dnr-cc closet, homemade blankets, condolence cards, hygiene bags, educational packets, word clouds, and aromatherapies and massage items. once the patient's code status is changed to comfort care, a blanket is given to the patient. family members are provided with a bag of toiletries for those that remain at bedside. education on the dying process are given to family members. multidisciplinary resources are provided, such as religious support focused on patient/family beliefs, palliative care for symptom management, and dietary provision of light snacks to the family. education for the physicians, nurse practitioners, nurses, and patient care associates was provided for those who wished to attend to further understand this end of life care program. a 29 item tool was created to collect before and after data on staff satisfaction and comfort with the end of life process. results from this process are currently in process. creating specific end-of-life care interventions for the nccu have enabled staff to better care for patients and families. through the creation of the interventions and utilization of the dnr-cc closet, this unit has been able to better provide comprehensive education and supportive pieces to patients and family members during such a difficult time. delirium is a neuropsychiatric syndrome, characterized by disturbance in awareness, with reduced ability to sustain attention, impaired cognition, perception, tends to fluctuate in severity during the day; in critical care is associated with longer stay and increase mortality. this study aimed to determine the incidence, prevalence, predictors, risk factors and outcomes of delirium in critically ill adult. a historical cohort study was conducted in adult patients hospitalized in a polyvalent icu from january 2016 until december 2016. delirium was diagnosed using cam-icu. a bivariate and multivariable risk were analyzed and presented as odds ratio (or) and 95 % confidence interval (ci). a total of 1133 patients were enroll. delirium developed in 276 patients.the incidence was 24.3%. three independent predictors for delirium were identified, sedation (or 6 (95% ci, p < 0,001); alcohol dependence (or 4,4; 95%ci, p < 0,001) and glasgow coma scale < 8 (or 2,2; 95% ci, p < 0,001). delirious patients had a significantly apache ii (15 (11-21) vs 13 (8-19), p < 0.001), higher sofa, (6 (3-8) vs 4 (2-7), p< 0.001) and higher saps iii (56 (48-65) vs 50 (41-60), p< 0.001). other risk factors were hyperlactatemia ( p<0.002), and hypotension (map<65mmhg),(p< 0.035). patients required prolonged mechanical ventilation, p< 0.001), and prolonged icu-hospital stay. the incidence of delirium in the period from january 1 to december 31, 2016 was 24.3% in a polyvalent intensive care unit. exposure to sedative medications, alcohol dependence, and decrease glasgow coma scale minor 8 are independent predictors for the development of delirium. similarly, the icu stay was longer in the group that developed delirium; however, mortality was not affected by the presence of this condition. it has been previously reported that the course of hsv-2 in the cns is significantly more benign that hsv-1, and that it rarely causes encephalitis or significant morbidity in immunocompetent adults. the aim of our study was to investigate the claim that hsv-2 cns infections are typically benign, and to assess for predictors of poor outcome in those patients who do suffer significant morbidity from hsv-2 cns infections. restrospective chart reviews were completed on patients with a positive hsv pcr at our institution from july 2008 until july 2016. patients with a hsv pcr positive for hsv-2 were selected in our analysis. multiple clinical variables were evaluated in these patients and we assessed outcome in the patient population, dichotomizing outcome into two categories at the time of discharge: good outcome defined as home or inpatient rehabilitation versus those with poor outcome defined as death, hospice, or placement in a long term acute care facility. 21 patients with hsv-2 positive pcrs were identified. their charts were evaluated for demographics, laboratory values (serum and csf), imaging results, and outcome. there were 3 patients with poor outcomes. it was noted that they were all female, their mean age was 59.6 (vs 47.2 in the good outcome group) and two of the three were immunocompromised (67% vs 44% in the good outcome group). statistical analysis was performed however due to the small sample size no statistical significance was found. however, age, sex, clinical presentation consistent with encephalitis and immune status seemed to have a trend towards poor outcome in this pilot study. future study with larger sample size is warrented to further assess this trend, as hsv-2 may not be as benign as previously reported. there is a high prevalence of non-traumatic illness in patients presenting to emergency departments as trauma team activations (tta). we sought to determine the prevalence of neurologic emergencies within a population of patients receiving a tta. this was a retrospective review of prospectively-collected registry data capturing all ttas in a highvolume, urban, academic level i trauma center. records from june 2011 through june 2016 were reviewed to identify patients found to have a diagnosis of ischemic stroke, intracerebral hemorrhage (ich), subarachnoid hemorrhage (sah) or status epilepticus. further demographic, clinical, and outcomes data was then abstracted from the electronic medical record. a proportion of abstracted charts were reviewed by an independent reviewer to ensure data quality. there were 18,859 trauma activations in the registry during the study period. 120 patients (0.6%) were found to have a nontraumatic neurologic emergency and were included in the analysis. of these patients, there were 55 ischemic stroke (46%), 40 ich (33%), 15 sah (13%), and 10 status epilepticus (8%) patients. the mean age was 67, and 70 patients (58%) were male. the mean gcs on presentation was 10. about half of these patients (43%) were intubated in the emergency department. all patients received a head ct scan. 20 patients (16%) received intravenous thrombolysis. neurologic emergencies such as ischemic stroke, ich, sah or status epilepticus were common diagnoses in this population of trauma activation patients. clinicians caring for patients in these settings must maintain a high index of suspicion for non-traumatic illnesses, and act quickly to mobilize appropriate resources when a diagnosis is made to avoid delays in care. further research is needed to examine ways to improve both time to diagnosis and quality of care in this patient population. formalized communication strategies decrease post-traumatic stress disorder (ptsd) symptoms in caregivers in the intensive care unit (icu). in one study, only 2% of family meetings met all shared decision-making criteria. however, much of the research has focused on family meetings, ignoring less formalized communication. the decision maker (patient or caregiver) was interviewed for all patients admitted to the medical (micu), neurosciences (nsicu), surgical (sicu), and cardiothoracic icu (cticu) for greater than 72 hours. subjects who stated significant decisions had been made were asked to report on 10 aspects of shared decision making on a 5-point scale. they identified the lead provider, who was subsequently approached to complete the same questionnaire. overall, 121 eligible decision makers were identified, 47 (39%) in the micu, 31 (26%) in the nsicu, 25 (21%) in the sicu, and 18 (15%) in the cticu. of these, 63 (52%) were unable to be contacted, 7 (6%) had insufficient english, and 13 (11%) reported no decisions made, with 38 (31%) enrolled. nineteen (50%) provider interviews were completed. topics most reported covered "well" or "thoroughly" by caregivers were assessment of understanding (36, 95%) and the nature of the decision (35, 92%), while those least covered were need for input from others (23, 61%) and the context of the decision (25, 66%). topics reported most covered by providers were the nature of the decision (18, 95%) and opinions about the treatment decision (17, 89%), while those least covered were patient's values and preferences (12, 63%) and their preferred role in decision making (10, 53%). eighteen (47%) caregivers and 5 (26%) providers described all topics covered "well" or "thoroughly." these results demonstrate differences in perception of shared decision making by decision makers and providers. further qualitative investigation is underway to elucidate the nature of these inconsistencies. organ donation is a life-saving medical intervention. the effect of race, insurance and economic status on organ donation and recipients has not been studied at a national level. in our study, we analyzed nationwide in-patient (nis) database of years 2011-14 to select donors and recipients. baseline demographics (i.e., age, gender, race), insurance status and socio-economic status was compared between two groups. we identified donors (n=26821) and recipients (n=108953) from 2011-14. recipients were significantly older (mean age ± sd, 50.3±16.3 vs 41.5±13.5, p<0.001). donors had higher (57.1% vs 38.3%, p<0.001) proportion of women compared to recipients. both groups had a higher proportion of whites compared to other races (67% and 57.9% respectively). insured patients were largely represented in both groups with private insurance predominating in donors (67%) and medicare in recipients (50.2%). interestingly, self pay represented 15.5% of donors but only 0.8% of recipients. race, insurance and socioeconomic status seem to be evenly similarly represented in donors and recipients. interestingly self pay insurance has a higher distribution among donors than recipients. central line-associated bloodstream infections (clabsis) are a common health care associated infection accounting for 30,100 infections annually in the intensive care and acute care areas (cdc,2014). according to the center for disease control, clabsis result in thousands of deaths yearly and upwards of billions of health care dollars spent on preventable hospital acquired infections. intensive care patients, especially the neurocritical care population, have an increased need for centrally placed catheters related to inadequacy of peripheral access, need for caustic iv medications, and fluid resuscitation. our neuroicu's goal was to decrease utilization and subsequently reduce number of clabsis. in february 2016, we initiated a patient-centered quality improvement effort with this goal in mind. the neuroicu clinical nurse leaders conducted rounds daily to evaluate the necessity and management of central lines. the neurocritical care team and clinical nurse leaders collaborated in exploring alternatives if central lines were present. in addition to daily rounding, clabsi bundles based on cdc guidelines for clabsi prevention were initiated. our neuroicu developed checklist "buster cards" in september of 2016, prompting staff to the bundle interventions. the intent of the cards was to enhance nurse to nurse dialogue of bundle elements. the cards were evaluated monthly for trends in care. from august 2015-june 2017, there was a 15% reduction in neuroicu utilization of central lines. in addition, the mean number of clabsis per month decreased from 0.67 to 0.22. trending of unit buster cards did not show care variances during this time period. implementing daily clinical nurse leader rounds with enhanced team communication significantly reduced the neuroicu's utilization of central lines and thereby decreased the rate of clabsis. percutaneous dilatational tracheostomy (pdt) is one of the most commonly performed procedures on critically ill patients. many studies showed the safety and feasibility of pdt, but there is limited data of pdt in neurocritical care units. we have described our experience of pdt performed by neurointensivist. pdts were performed by neurointensivists at bedside using the griggs guide wire dilating forceps technique. to confirm a secure puncture site, pdt was done under fiberoptic bronchoscopic guidance. from september 2015 to may 2017, procedural data were prospectively collected. the patients' demographic and clinical characteristics were retrospectively reviewed. we analyzed immediate complications of pdt as the primary outcome. pdts were performed for 46 patients; the mean age was 65.9 years, 26 (56.5%) were male, and mean acute physiology and chronic health evaluation ii score was 20.5 ± 7.0. overall, the procedural success rate was 100% and the mean procedural time was 19.7 ± 9.3 min. periprocedural complications occurred in 13 patients; 10 had minor bleeding and 3 had tracheal ring fracture. there were no serious periprocedural complications of pdt. from our experience, pdt performed by neurointensivist was safe and feasible and was implemented without serious complications. the neurocritical care unit (nccu) is a fast paced setting with a multitude of providers and team members requiring optimal communication. it is also a high cost/high utilization environment, dictating the need for patients to be moved thru appropriate levels of care efficiently. all of this must be accomplished while providing support and opportunity for collaboration and decision making on the part of the patient/ family unit. there is great discussion in the case management world about the benefits of a unit based verses service based case management model. we looked at outcomes following the implementation of a unit based case manager in the nccu. a dedicated case manager (cm) was implemented in the nccu to maximize assessment, advocacy, communication, education, identification of resources, and facilitation of services. processes to support maximal contributions were created.interventions included use of a discharge planning worksheet, implementation of a morning huddle, and space for the case manager to be physically available on the unit. los of patients discharged from nccu decreased from 7.2 to 5.1. alos for patients that passed thru the nccu during their hospitalization decreased from 10.7 days to 9.2. there was a 38% increase in discharges from nccu from 2015 to 2016. average time from admission to cm assessment decreased from 51 hours to 32.2 hours. progress notes indicating intervention and/or communication of the plan increased from 211 to 630. staff questionnaire indicated increased awareness of los and dc plan needs. in this midwestern, academic medical center, integrating a dedicated, unit based cm resulted in improved los, increased discharges and improved staff awareness of dc plans. high throughput genotyping technologies and large collaborative consortia have revolutionized the field of medical genetics. open data access is the final barrier to be overcome to capitalize fully on the opportunities currently available in stroke genetics research. the international stroke genetics consortium (isgc) has created the cerebrovascular disease knowledge portal (cdkp), a comprehensive web-based resource to explore and freely access genetic data related to cerebrovascular diseases. funded by the nih, the cdkp has been jointly developed by the isgc and the american heart association (aha) institute for precision cardiovascular medicine. the cdkp seeks to democratize access to genomic data and potentiate stroke genomics research by providing open access to genetic, phenotypic and imaging data on stroke. within the cdkp, data are aggregated, integrated, and harmonized according to a pre-specified standardized pipeline. any institution or investigator working with stroke genomic data is welcome to deposit their data or use available data. the cdkp houses two types of data, each meeting different regulatory and analytical needs: summary level data and individual level data. the cdkp offers three main features: (1) a web-based graphical user interphase that allows the exploration of stroke genomics information through a wide menu of integrated tools for analysis and data visualization; (2) a repository of full sets of genome-wide summary statistics produced by published landmark studies in the field, available with a single mouse click ; and (3) a repository of individual level data, accessible through a secure cloud working space provided by the aha platform for precision medicine. the cdkp can be accessed at www.cerebrovascularportal.org. the cdkp advances the isgc's goal of liberal data sharing in stroke genomics and other areas of cardiovascular research that may benefit from genomic analyses. in the future, phenotypic datasets can be added to further enrich sharing of non-genetic data as well. hyperosmolar therapy using hypertonic saline is common in patients admitted to the neurocritical care unit (nccu) for the management of different type of cytogenic cerebral edema or increased intracranial pressure (icp). vancomycin is commonly prescribed in nccu as empiric antimicrobial therapy. the purpose of the study is to evaluate the effects of hypertonic saline therapy on the pharmacokinetic parameters of vancomycin in critically ill patients with generalized or compartmental icp. this was a retrospective, observational study of adult patient consecutively admitted in the nccu between february 2012 and february 2017 who received hypertonic saline (3% sodium chloride) and vancomycin dosing protocol managed by the pharmacist. patients with serum creatinine > 1.4 mg/dl were excluded from the study. the estimation of vancomycin trough levels was done by using published pharmacokinetic equations and then compared to the measured trough levels with the paired t test. the study protocol was approved by our institutional review board. of forty-four patients who met the inclusion criteria, twenty-one patients (47.7%) were diagnosed with intracerebral hemorrhage, nine (20.5%) ischemic stroke, seven (15.5%) subarachnoid hemorrhage, four (9%) subdural hemorrhage, two with brain tumors, and one patient with chiari malformation. the mean dosing regimen was 13.8 ± 3.4 mg/kg every 12 (8 -24) h. the mean measured trough level was lower than the predicted trough level (9 ± 3.3 vs. 18.9 ± 6.2 mcg/ml; p < 0.0001). the mean serum sodium level was 147 ± 8 meq/l and the mean serum osmolality was 317 ± 18 mosm/kg. critically ill patients with cerebral edema or high icp who were treated with hypertonic saline achieved a subtherapeutic vancomycin level that may lead to lower through level and possibly poor clinical response. further research is warranted to evaluate the clinical response of vancomycin in this patient population. unnecessary telestroke activations are costly to emergency departments (ed), telestroke providers, and patients. therefore it is important that ed nurses are well trained to effectively recognize stroke symptoms, and decrease the rate of false-positive stroke code activations. the nursing-driven acute stroke care (nas-care) study aims to determine if implementing a standardized ed stroke program decreases door-to-needle times in emergency departments utilizing telemedicine. the nas-care intervention consists of ed nursing education including mock codes, nihss certification, and implementation of a standardized flow sheet. in this interim analysis from the first 4 (of 7) nas-care study hospitals, we examined ed admission and discharge diagnoses at each site for 3 months of blinded baseline data collection ("control") and 6 months after standardized training ("intervention"). false-positive encounters were defined as stroke code activations for which the patient diagnosis on leaving the ed was not stroke. although hospitals trended toward a reduction in false-positive stroke code activations after implementation of the standardized stroke education, mock stroke codes, and flow sheet, none of the values were statistically significant. further research is needed to determine whether intensive ed nursing education can improve telestroke resource utilization. pharmacist-driven intravenous (iv) to oral (po) conversion protocols result in greater compliance, improved cost-savings, and better patient outcomes related to length of stay, re-admission, and duration of intravenous therapy. this study aims to determine the cost-savings and patient impacts of such a conversion protocol for anti-epileptic drugs (aeds) including lacosamide, levetiracetam, phenytoin, and valproic acid. a retrospective, observational phase was conducted to determine usual practice patterns concerning conversion to oral therapy between 11/1/2016 and 11/30/2016. the conversion protocol was approved in december 2016 and implemented in january 2017. a second retrospective phase observed conversion practices beginning 02/01/2017 and ending 03/02/2017. length of intravenous and oral therapy, date eligible for conversion, and date of conversion were recorded. hospital acquisition costs were utilized for medication expenditure calculations. this information was used to determine financial impact of the protocol and is presented as descriptive endpoints. adverse drug events were collected via an institutional incident reporting system. a total of 408 encounters were identified, resulting in 147 encounters in the pre-cohort and 121 postcohort encounters. looking at the pre and post cohorts respectively, both cohorts had similar median lengths of stay (11 days vs. 9 days), 30-day readmission rates (6.8% vs 9.9%), and rates of conversion from oral back to intravenous therapy (6.8% vs 6.6%). the median length of intravenous therapy was 5 days prior to protocol implementation and decreased to 3 days in the post-cohort. the average cost per day of aed therapy was $10.36 in the pre-cohort but decreased to $4.46 in the post-cohort. median missed opportunity costs, defined as the cost savings if conversion occurred at the earliest possible date, also decreased between the cohorts from $3.87 to $1.24. pharmacist involvement in aed conversion had a positive financial impact without compromising patient care. the national institute of neurological disorders and stroke (ninds) established the nih strokenet to facilitate the rapid initiation and efficient implementation of multi-center exploratory and confirmatory clinical trials focused on promising interventions in stroke prevention, treatment, and recovery. strokenet was initiated in the fall 2013, and involves over 350 hospitals across the us. the network is anchored by 25 regional coordinating centers (rccs), along with the national coordinating center (ncc) at the university of cincinnati and national data management center (ndmc) at the medical university of south carolina, as well as active participation by the ninds. one of the primary goals of the strokenet is to serve as the primary infrastructure for conducting stroke clinical trials and pipeline for new potential treatments. to maximize the impact of nih strokenet, it is important for the larger community of stroke researchers and clinicians, including the neurocritical care specialists, to know its structure and the process and timeline by which stroke trials are developed and implemented. since the inception of the network, 49* proposal concepts have been submitted to the strokenet and are in different development stages. among those evaluated to obtain ninds permission to submit a grant application, 16 have submitted and 3 are in the process. every application has been prepared and submitted for peer review within 3 months of the ninds permission. two* funded strokenet trials are now underway with brisk enrollment rates, and another is awaiting study initiation. (*as of abstract submission date) the nih strokenet has become a stable infrastructure and offers several distinct advantages to developing competitive clinical trial proposals, including scientific input from the strokenet working groups, comprehensive feasibility assessments (including site enthusiasm and patient availability), assistance with grant budgeting, and other requirements for grant submission that are likely to help refine and improve the application. the modified early warning score (mews) is a physiological scoring system, validated in adult medicalsought to determine the value of mews to identify clinical deterioration or occurrence of sepsis in neuroicu patients. we retrospectively reviewed all patients admitted to the neurological intermediate care unit (imc) or neuroicu of a large tertiary care center from 7/2015presentation/during admission. baseline characteristics, diagnoses, physiologic parameters, infections, treatment with antibiotics, neurological worsening and mortality were abstracted from the electronic medical record. outcomes were defined as escalation of care and discovery of a new infection or sepsis. of 2556 p were male. 62% were intubated, and in-hospital mortality was 22% (versus 9% for all admissions). 182 (40%) were already treated with antibiotics for a known infec diagnosed in 19%. in reaction to the elevated mews score, antibiotics were added or broadened in 22%, and level of care was escalated in 2.7% from imc to icu. in 18.2%, there was neurological worsening, most frequently associated with increasing cerebral edema (34%) and midline shift/herniation (18%). the mews score is not a valuable screening tool in the neuroicu population. it preferentially was triggered in known high acuity patients with ongoing or present infections with no change of management in the majority of patients. while associated with high mortality, its ability to indicate new infections or sepsis was poor. in 1 out of 5 patients, the mews score was associated with neurological worsening known at that time of the score. other screening tools should be explored for early warning in the neuroicu. introduction: it is challenging to maintain neurosciences critical care nursing expertise in an environment of a rapidly expanding knowledge, changing evidence-based practices and technological advancements. to address the needs for neuroscience nursing expertise in a mixed critical care unit, our institution developed a core group of nurses, known as "neuro champions", who have additional training and expertise in neurocritical care. methods: nursing participation was voluntary and recruitment was via unit-wide announcements. the goal was to improve patient care by developing a core group of nurses who serve as resources and educators for all things neurosciences related. to develop content expertise, the nurses initially completed a set curriculum including: neuro anatomy and pathophysiology, cerebral hemodynamics and multimodal monitoring, pupillometry, eeg interpretation, temperature management, evds, and quality indicators. bi-monthly meetings continued ongoing education, with content including clinical case studies and review of processes and protocols. additionally, 6 beds staffed by neuro champions were designated as critical neurological care unit ("cncu") beds to co-localize the highest acuity neurosciences patients. the neuro champions are responsible for educating and sharing neuro related practices with the entire icu nursing staff. results: as a result of the implementation of the neuro champion role, our icu has benefited from: 1) dedicated co-localized beds for the highest acuity neuro patients; 2) increased number of enls certified nurses; 3) improved collaboration between the medical team and nurses; 4) promoting care uniformity to maintain comprehensive stroke center certification; 5) integration of multimodal monitoring advancements, all of which supports advances in patient care and research. conclusions: the neuro champion role has provided a platform for neurosciences-specific nursing expertise in a mixed critical care unit and has facilitated education dissemination to the entire staff via a core group of nurses. this expanded knowledge has improved the care of the neurologically critically ill patients. the rate of cerebrovascular complications in patients treated with extracorporeal membrane oxygenation (ecmo) is about 7%. transcranial doppler (tcd) can be used to noninvasively monitor cerebral blood flow velocities (cbfvs) in patients undergoing ecmo. the aim of this study is to describe tcd-cbfv patterns in patients undergoing venovenous (vv) and venoarterial (va) ecmo. a neuro-surveillance protocol among ecmo patients was initiated as part of a quality improvement project at our institution. daily neurological exam, daily tcd, brain-ct on days one and three and 24-hr continuous eeg were performed in all patients undergoing vv and va-ecmo. demographics, clinical and imaging data were collected for the duration of ecmo support. cbfvs, lindegaard ratios (lr), pulsatility index (pi) and resistance index (ri) on tcd were collected. total of 11 patients were included in the study [6 female (55%); 9 caucasians (82%)]. mean age was 62 years. 8 (73%) patients received va-ecmo; 1 (9%) vv-ecmo; 2 (18.2%) received both va and vv-ecmo. median days on ecmo was 7 days. median number of tcd studies performed was 2 (mean, 3.45 we observed an overall pattern of low-normal flow cbfvs and reduced pulsatility in patients on va-ecmo. nurse practitioner (np) and physician assistant (pa) roles continue to expand in the critical care setting. single and multisite studies have examined various aspects of app practice, but none have focused on role implementation within the neurologic critical care unit (nccu). the purpose of this study was to obtain foundational knowledge about how nccu apps are implementing the role nationally this was a voluntary, cross-sectional, descriptive study of nurse practitioners (np) and physician assistant (pa) practicing in the us. apps were invited to participate in this voluntary, 70 item survey. distribution occurred initially through email inquiry via multidisciplinary, professional organization listservs (ncs, aacn, aann) followed by snowball effect circulation. enrollment occurred from march to june 2016. data was collected in redcap and analyzed using spss with descriptive statistics for demographic, institutional, practice, role characteristics of the sample and for each survey data element 172 app participants completed the survey: 78% np, 12% pa, 10% other. the majority of respondents were master's prepared (82.9%) acute care trained, (68.9%) and hospital employed (81.4%). participants were either early in their career (38.7% 1-5 years as app) or experienced (28.7% > 9 years). 81% work in a direct care role with 77% providing total care for their patients with an average daily caseload of 7.6 + 3.4 patients. 63% of providers believed 3-6 patients was a reasonable caseload for total care. in addition to the nccu, 28% of participants care for patients in step-down or emergency department (36%) with 49% routinely bilingl for their work. this study is the first to provide information regarding how ncc apps are implementing the role in the united states. this study provides benchmarking data which may guide future research with this population as well as serve as a template for evaluation of other app specialty roles. despite advances in treatment, the median survival for high grade gliomas (hgg) remains poor. there is a growing body of research showing that palliative care improves quality of life and survival in patients with advanced malignancies. we sought to examine our own practices in the neurologic intensive care unit (nicu) regarding palliative care consultation in this population. we hypothesized that the incidence of palliative care consultation is low and associated with a clarification of patient's wishes, measured by a change in code status. we conducted a retrospective cohort review of patients with previously diagnosed hgg admitted to the nicu from 2011-2016 with a length of stay (los) greater than 48 hours. the primary outcome was the incidence of patients with an advanced directive or inpatient palliative care consult (pcc). secondary outcomes included intensive care unit los, change in code status and location of death. 90 patients were identified with hgg. the mean age was 59.5 years (19-86years), 64% were male, 81% were white. zero patients were admitted with an advanced directive on admission. pcc was obtained in 16 patients (18%). pcc was associated with increased nicu stay (254 hrs vs 63 hrs p=0.01), a change in code status to do not resuscitate (69% vs 11% p=0.00001), and an increased likelihood to not die in the hospital (92% vs 58% p=0.08). at our large academic tertiary care facility intensivists underutilize palliative care services for hgg patients. patients with fatal brain tumors are not having end of life discussions prior to admission, indicating a need for early palliative care intervention. patients are six times more likely to change their code status and there is a trend towards dying outside of the hospital if they receive a palliative care consult. hypertonic saline (hts), a hyperosmolar solution, is typically administered using a central venous catheter (cvc) due to concerns of extravasation, but a cvc is rarely readily available. in emergent situations, intraosseous (io) access is used when peripheral intravenous access is not available. existing literature does not address the administration of hypertonic saline using io access for adult patients with brain injury. the administration of hts is often delayed due to the time taken to obtain a central venous access. insertion of an io needle is typically much faster than a cvc. we report the safety and tolerability of hts using io route. a prospective pilot study on the safety and tolerability of 3% hts via io is currently underway. data on local complications at the site of injection, pain during insertion and during infusion, and serial serum sodium levels were collected. additionally, we report a case of successful administration of 23.4% hts using the io route. preliminary data demonstrated that 3% hts was well-tolerated, with no reports of severe pain, infections, extravasation, soft tissue injury or local infectious complications in our sample of patients with brain injury. indications for use of hypertonic saline included patients with cerebral edema and mass effect from intracerebral hemorrhage. an appropriate rise of serum sodium levels by approximately 1 mmol/l/hr in was observed. in the case where 30 ml of 23.4% hts, no local complications were observed and serum sodium levels rose appropriately. administration of hts using io route appears to be safe and feasible. utilizing io access for urgent administration of hts may reduce the lag time to administration of the initial bolus, reduce the need for emergent placement or eliminate the placement of cvc in certain cases. optic nerve sheath diameter (onsd) measurement is an emerging bedside tool to assess intracranial pressure (icp) non-invasively in brain injury patients. multiple studies demonstrate onsd width from 4.5mm to 5.8mm correspond to an external ventricular device (evd)-measured icp >20mmhg. we sought to create a low cost, 3-d constructed, re-usable osnd teaching model to train neurology, neurosurgery, and critical care advanced practice providers and physicians. we searched the national library of medicine using terms "optic nerve sheath diameter ultrasound" with combinations of "simulation" and "model." the literature was used in conjunction with a human non-contrast head ct head model to make an eye ball model which was then tested in our simulation center and compared to a live human model. we identified 253 articles, of which 15 were associated with models and two with simulation. one gelatin model was reported, upon which we based our initial design. we could not validate the visual findings of this model. however, following construction of multiple beta models, the design most representative of human eye anatomy was a globe made of ballistics gel with either a 3mm, 5mm or 7mm 3-d printed "optic nerve" attached to a platform composed of ballistics gel and psyllium powder with a hollowed out core for ultrasound gel the globe rests upon. this model was taught to learners at a continuing medical education event prior to teaching osnd on a live human model. a 3-d printed skull from ct head data is being created to incorporate this model. a simple 3-d ballistic onsd model allows learners to learn proper hand placement, basic landmarks, onsd measurement, and practice proper pressure on human eyes. this model can be replicated and utilized in a sustainable fashion given that the globe and platform are composed of ballistics gel. pressure measurements using pressure guide wires is an invaluable diagnostic tool in the management of many endovascular revascularization therapies. its role is well established in coronary artery disease management such as use of fractional flow reserve (ffr) as a standard diagnostic tool to determine need for stenting, angioplasty or bypass. renal fractional flow reserve remains an integral physiologic parameter used in endovascular revascularization therapy of renal artery stenosis. despite the wide spread use of pressure wires in endovascular therapies, its application in the management of cerebral venous diseases remains vastly unexplored. we sought to evaluate the safety and applicability of pressure guide wires in several cerebral venous diseases. patients undergoing diagnostic angiography for possible venous outflow obstruction had pressures measured by pressure guide wires (volcano verrata® or prestige primewire®) across the following vessels: superior sagittal sinus, torcula, right and left transverse sinus, right and left sigmoid sinus, and right and left internal jugular vein. venous pressures were also collected from patients undergoing venous thrombectomy, stenting, or an arteriovenous malformation embolization (avm). five patients who underwent diagnostic angiography for pseudotumor cerebri showed no major variability in their pressures across the cerebral venous architecture which was confirmed by lack of stenosis or thrombi on intravascular ultrasound (ivus). four patients had a pressure difference above 10 which was suggestive of a stenosis and later confirmed by ivus. patients undergoing pressure measurements that had evidence of stenosis or thrombosis by ivus showed improvement in pressure gradients post stenting or thrombectomy. no variability in pressure gradients were noted in a patient that underwent avm embolization. pressure measurements using pressure guide wires can improve diagnostic accuracy and guide management of several diseases of the cerebral venous system. further studies are necessary to understand the applicability of this approach in the management of venous disease. monitoring metrics is imperative for quality assurance and ongoing improvement in a developing clinical unit. a new neurocritical care unit (nccu), specializing in the treatment of critically ill, neurologicallyinjured patients opened in july 2013. this study examined quality metrics that correlate with the development and growth of a neurocritical care program. data from patients with principle diagnoses of ischemic stroke (isc), subarachnoid (sah) or intracerebral (ich) hemorrhage, seizure, or brain tumor, admitted to nccu in 2014 and 2016 were used in the analyses. quality metrics included overall and individual complication rates per 1,000 patient days of pneumonia, venous thromboembolism, pulmonary embolism, sepsis, septic shock, pulmonary edema, gastrointestinal bleeding, and catheter associated urinary tract infection, as well as hospital mortality and length of stay (los). chi-squared and mann-whitney tests and poisson regression were used to compare metrics between 2014 and 2016. patient volumes increased by 17.0% (439 to 515) from 2014 to 2016. the overall complication rate declined significantly from 3.94 to 2.33 per 1,000 patient days (p=0.031). the highest complication rate in 2014 and 2016 was pneumonia (1.45 and 0.85 per 1,000 patient days, respectively). the proportion of patients who expired decreased from 11.6% (n=51) in 2014 to 10.5% (n=54) in 2016, though not significantly (p=0.65). there were no significant differences in los among patients with isc, brain tumor or seizure. however, those with sah or ich had significantly shorter stays in 2014 (median [interquartile range] =3.0 [2.0, 9.5]) versus 2016 (7.0 [2.0, 14.0]) (p=0.032). data suggest that over the initial 3-year period, complication rates among patients in the nccu improved. los did increase for hemorrhage patients; however, this may be related to greater severity of illness in the patient population over time. further analyses will be conducted to account for severity and other factors. delirium is a frequently seen but underestimated problem in critical care settings. delirium screening is considered time consuming, which is one of the factors leading to under diagnosis. the cam-icu screening tool for delirium has been validated in medical and surgical icus. among neurological patients, it has been validated in stroke patients but not in general neurocritical care population. this study was designed to validate cam-icu flow sheet in neurointensive care unit. a prospective cohort study was conducted in a 16 bed neurointensive care unit of a university hospital. patients meeting the inclusion criteria (all nicu patients) and exclusion criteria (comatosed, aphasic, psychotic, prior diagnosis of neurocognitive disease, persistently vegetative state, sedated) were screened for delirium by (1) a nurse practitioner using confusion assessment method (cam-icu) and (2) a physician reference rator using delirium screening criteria in diagnostic and statistical manual of mental disorders-5. assessments were done daily monday through friday for the icu stay. paired assessments were done less than 4 hours apart. the study enrolled 50 patients (19 male, 31 female). 159 daily assessments were done. mean age of the patients was 63.5 and mean sap score was 23. admitting diagnoses were ich (8), sah (10), ischemic stroke (5), tumor (9), spinal surgery(4), neurological infections(4), seizures(3),elective angiograms(4), hydrocephalus(1), transverse myelitis(1) and av dural fistula(1). using dsm-5 criteria, the reference rator identified delirium in 8 out of 50 (16%) patients during the icu stay. 27 out of 159 assessments were positive for delirium according to dsm-5 and 29 according to cam-icu. cam-icu flow sheet had sensitivity of 96.43% (95%ci 81.65% -99.91%) and specificity of 98.51% (95%ci 94.71%-99.82%). cam-icu has high sensitivity and specificity for diagnosing delirium in critically ill neurological population. it is a valid tool for diagnosing delirium. a value stream mapping event (vsm) for general neurology inpatients, revealed multiple barriers related to videofluoroscopy swallow studies. there was a high volume of patients requiring instrumental swallow assessments, a limited number of radiology appointments, and transportation delays that were delaying feeding plans, discharge recommendations and goals of care discussions. an operations engineer involved in the vsm event started the process by collecting observational data regariing timing. after meeting with the chief operating officer, director of patient transport, director of radiology, speech pathology manager, neuro intensive care unit manager and the operations engineer, a pilot program was agreed upon. the results for the three week pilot program were successful, and resulted in a permanent change in procedure. the pilot data showed a decrease in test time by 5 minutes, a decrease in transport delays by 13 minutes, and a decrease in length of stay by 0.6 days. the number of patients waiting for the study dropped from 1.6 to 0.3 per week. by annualizing this data, the change has created 238 new available bed days, 38 additional patient encounters and an incremental annual contribution margin of $381, 425. with the appointment time consistent, the nurse is able to plan patient care around the study, and ensure the patient is prepared and not delayed for the study. it has also allowed, if deemed safe for the patient to swallow, medications to be changed from the intravenous route to the oral route earlier, and earlier determination of safe feeding and diet restrictions. we previously reported outcome for children with refractory and super-refractory status epilepticus in a cohort of 40 patients. mortality was 30%. 25% of survivors required new tracheostomy and/or gastrostomy tubes. the majority of surviving patients experienced some degree of disability at discharge as determined by the pediatric cerebral performance category scale (pcpc). here, we aimed to identify patient factors in this cohort that were associated with a decline in functional neurologic outcome at discharge. retrospective chart review of children age 0-19 years who received pentobarbital infusion for status epilepticus in the pediatric intensive care unit of a large tertiary children's hospital from 2004-2015. outcome was defined using pcpc at admission and discharge. potential factors associated with outcome were evaluated using fisher's exact test and wilcoxon rank sum test. 40 children were included. pcpc score at admission (p=0.0006), etiology of status epilepticus (p=0.015), new tracheostomy (p=0.012), and new gastrostomy tube (p=0.012) were all significantly associated with children were more likely to have normal baseline neurologic function and more likely to have febrile encephalitis, stroke/trauma, or hypoxic ischemic encephalopathy as the etiology of status epilepticus. duration of pentobarbital infusion (median = 8days vs. 3days) (p=0.005) and duration of hospital admission (median = 1.48months vs. 0.49months) (p=0.005) were both longer in patients who had an admission pcpc score, etiology of status epilepticus, new tracheostomy and gastrostomy tube as well as longer duration of pentobarbital infusion and longer hospital stay were significantly associated with a decline in functional neurologic outcome at hospital discharge in children with refractory and superrefractory status epilepticus. status epilepticus (se) is the most common pediatric neurological, and super-refractory se is a lifethreatening form of se that continues or recurs for more than 24 hours despite multiple therapeutic interventions. this population-based study investigated pediatric se and srse admissions in germany. pediatric (age 0-18 years) admissions between 2008-2015 were identified in the arvato health analytics database. se, epilepsy, and febrile seizure cases were identified using a modification of a previouslypublished algorithm based on icd-10 diagnosis codes (g40, g41, and r56) and coding for ventilator and intensive care unit use. based on primary diagnosis, prior epilepsy status, and ventilation se was subclassified as non-refractory, refractory (rse), and super-refractory (srse). inpatient mortality, costs, length-of-stay (los), and discharge disposition were assessed overall and for rse and srse. the algorithm identified 11,693 seizure-related admissions and classified 4% as se, of which 22.9% were rse and 13.1% were srse. the rse frequency was highest among ages 1-6. the incidence of cases classified as srse peaked among newborns (age<1 year), decreasing between ages 1-7 years. cases classified as se accounted for 23.0% of total costs associated with seizure-related hospitalizations. srse exhibited the highest per case cost (mean €77,316), amounting to 58.0% of all se costs, and these costs correlated with the highest los (median 44.5 days). srse was associated with greater mortality (11.7%) cases classified as srse accounted for 14.2% of all pediatric seizure-related costs, despite representing only 0.5% of admissions. srse was associated with the highest los and mortality rate. these results highlight the burden of illness associated with srse and suggest that optimization of srse management has the potential to improve outcomes and reduce costs. despite its more routine use and the recognition that mri provides superior detection of traumatic brain injuries, there has been little written about how mri might affect the acute management of trauma patients. we sought to describe mri findings in a cohort of children admitted to the picu with tbi and to extend comparisons between ct and mri in acute trauma. a secondary aim was to quantify in what ways mri findings influenced clinical management in this cohort. we retrospectively identified 101 patients admitted to the picu with an acute head injury between september 2010 and may 2016 who underwent head mri within the first 96hrs. we compared mri with ct findings, using the nih common data elements definitions of injury type. we determined by chart review the indication for mri and if there was documentation that mri led to a change in management, defined as either an escalation or a de-escalation of care. seven patients had mri only, and mri identified additional lesions in 60 of the 94 patients who had first undergone head ct. of these, 49 patients had new intra-parenchymal lesions, 22 had new extra-axial lesions, and 11 had both a new intra-parenchymal and a new extra-parenchymal lesion identified. the most frequent new lesions were contusions and traumatic or diffuse axonal injury. acute management was influenced by mri in a majority of patients, leading to an escalation of medical or surgical management in nearly one third and a de-escalation of care in half. early mri may have a beneficial role in the acute management of pediatric traumatic brain injury. mri frequently identified clinically important lesions not appreciated on ct, and findings influenced management decisions. future studies will assess whether early mri improves patient outcomes or provides cost/benefit by reducing length of stay. while adverse outcomes of decompressive hemicraniectomy (dh) including infection, disturbances of the csf compartment, and sunken flap syndrome are well documented, there is a dearth of literature assessing outcomes related to the timing of cranioplasty. while adverse outcomes of decompressive hemicraniectomy (dh) including infection, disturbances of the csf compartment, and sunken flap syndrome are well documented, there is a dearth of literature assessing outcomes related to the timing of cranioplasty. we identified 143 patients who received dh, 60 of whom underwent reconstructive cranioplasty at our institution. the post-cranioplasty complication rate was 20%, which was due in part to hemorrhage, infectious complications, or csf compartment disturbances. patients receiving early cranioplasty developed an increased rate of hemorrhagic complication (19% vs 0%; p = 0.01), increased median hospital length of stay (los) (10 vs 4 days; p = 0.002) and increased median icu los (3 vs 1 days; p = 0.01). of the patients who received dh surgery related to malignant cerebral edema from an acute ischemic stroke, total complication rates trended down for early compared to late cranioplasty surgery (8% vs 18%; p = 0.68). patients receiving dh surgery for any cause who underwent early reconstructive cranioplasty, experienced higher rates of hemorrhagic complications and increased hospital and icu los. however, among those patients receiving dh surgery for the specific indication of malignant cerebral edema from acute ischemic stroke, significant differences did not exist between the early and late cranioplasty groups. the total complication rates in these patients trended lower in the early group. another important and mainly unpublished finding is that a majority of dh patients are lost to surgical follow up and may therefore impact the complication rate of this not so benign surgery. postoperative antibiotics (pa) are often administered to patients after instrumented spinal surgery until all drains are removed to prevent surgical site infections (ssi). this practice is discouraged by numerous medical society guidelines, so our institutional neurosurgery quality improvement committee decided to discontinue use of pa for this population. we retrospectively reviewed data for patients who had instrumented spinal surgery at our institution for seven months before and after this policy change and compared the frequency of ssi and development of antibiotic related complications in patients who received pa to those who did not (non-pa). we identified 188 pa patients and 158 non-pa patients. discontinuation of pa did not result in an increase in frequency of ssi (2% of pa patients vs. 0.6% of non-pa patients, p=0.4). growth of resistant bacteria was not significantly reduced in the non-pa period in comparison to the pa period (2% vs. 1%, p=1). the cost of antibiotics for pa patients was $5,499.62, whereas the cost of antibiotics for the non-pa patients was $0. on a per patient basis, the cost associated with antibiotics and resistant infections was significantly greater for patients who received pa than for those who did not (median of $26.32 with iqr $9.87-$46.06 vs. median of $0 with iqr $0-$0; p<0.0001). after discontinuing pa for patients who had instrumented spinal procedures, we did not observe an increase in the frequency of ssi. we did, however, note that there was a non-significant decrease in the frequency of growth of resistant organisms. these findings suggest that patients in this population do not need pa, and complications can be reduced if pa are withheld. the development of flow-diverting stents has allowed for new treatment options for giant vertebrobasilar aneurysms. however, the expertise required to perform these procedures safely and concerns about complications continue to limit their use. we sought to identify common complications of this treatment that can be anticipated by neurointensivists, to optimize management in the postoperative period. we retrospectively reviewed our hospital database of treated aneurysms to identify those with giant vertebrobasilar aneurysms. medical and neurological complications were recorded. six patients (5 male, 1 female) underwent treatment of giant vertebrobasilar aneurysms with pipeline embolization devices. five received adjunctive coiling. frequently reported pre-procedure symptoms were dysphagia (n=4), diplopia (n=3), dysarthria (n=3), facial weakness (n=3), hemiparesis (n=2), gaze palsy (n=2), and nystagmus (n=2). five patients ambulated normally. due to concerns about necessary procedures after stenting when on antiplatelet therapy, three patients received prophylactic ventriculoperitoneal shunts, two underwent gastrostomy, and two underwent tracheostomy. angiography confirmed successful aneurysm embolization in all patients. postoperatively, all patients developed new or worsened symptoms attributed to brainstem edema, including hemiparesis (n=4), facial weakness (n=4), dysphagia (n=4), diplopia (n=4), nystagmus (n=3), gaze palsy (n=3), and dysarthria (n=3). neurological symptoms were treated with steroids, with most symptoms subsiding by discharge. five patients had medical complications, including pneumonia (n=2), respiratory failure (n=2), gastrointestinal bleeding (n=2), arrhythmia (n=2), urinary tract infection (n=1), and myocardial infarction (n=1). two patients were re-intubated, three underwent gastrostomy, and one underwent tracheostomy. functional status at 3-months was available for five patients. three achieved modified rankin scale scores between 0-2, one regressed to a 5, and one died. the treatment of giant vertebrobasilar aneurysms presents significant challenges. practitioners should anticipate temporary postoperative neurological worsening and various medical complications. prophylactic shunt placement, gastrostomy, and/or tracheostomy should be considered in patients anticipated to likely need these procedures after treatment. ventriculostomy-related infection (vri) remains a major complication of external ventricular drain (evd) placement. historically, prophylactic antimicrobials are utilized to decrease the incidence of vri after evd placement. recent guidelines for the insertion and management of evds recommend a single preoperative dose prior to evd insertion and urges against the use of duration antibiotic prophylaxis. prior to the publication of this guideline, we hypothesized that significant variations existed among institutions with respect to antibiotic prophylaxis practices in this setting. the purpose of this practice survey was to determine trends in antimicrobial prophylactic strategies utilized by various healthcare institutions for evd placement prior to publication of the 2016 neurocritical care society (ncs) evidence-based guidelines for the insertion and management of evds. a seven-question practice survey on antimicrobial prophylaxis for evd placement was distributed to active pharmacist members of the ncs by email and open for response from 12/22/15 to 1/25/2016. the following information was collected: antimicrobial prophylaxis regimen utilized, pharmacologic class, utilization of impregnated catheters, and institution guidance. survey results were analyzed for trends in antimicrobial prophylaxis in the setting of evd placement. respondents (43/105, 41% response rate) from 43 institutions completed a seven-question evd management survey. most institutions initiate a single dose of antibiotics prior to evd insertion (31/43, 72%). periprocedural antimicrobial therapy is the most common prophylactic strategy utilized by respondents (18/43, 42%). of respondents who do not continue antimicrobial prophylaxis for the duration of evd placement, 59% (10/17) utilize antimicrobial-impregnated catheters to reduce incidence of vri. the importance of antimicrobial prophylaxis to prevent infectious complications associated with evd placement is widely accepted. prophylactic strategies vary between institutions. periprocedural antimicrobial therapy is the most common prophylactic strategy utilized by survey respondents. antimicrobial-impregnated catheters are commonly utilized in institutions using periprocedural antimicrobial prophylaxis. the postoperative course seen in critically ill neurosurgical patients is known to vary depending on the timing of the surgical procedure. this study seeks to compare the clinical characteristics, complications, and outcomes between elective or urgent surgery patients admitted to the intensive care unit (icu). retrospective review of a two-year neurosurgical patients' cohort. the pre and postoperative conditions and outcomes were compared between elective (group a) and emergency (group b) surgery patients. a total of 416 patients were evaluated, 262 in group a and 154 in group b. the most common diagnosis was intracranial tumor. the mean american society of anesthesiology (asa) score was significantly higher in group b than in group a (3.35 vs. 2.79, p<0.05). mean sequential organ failure assessment (sofa) score on admission was higher in group b (2.47 vs. 0.83, p<0.001). these patients were more likely to require mechanical ventilation (or 14.75, p<0 .001) and vasopressors (or 5.76, p<0.001) . group b had a higher probability of rebleeding (or 5.29, p<0 .001), intracranial hypertension (or 11.9, p<0.001), hydrocephalus (or 6.45, p<0.001), and reintervention (or 1.91, p=0.043). post-operative nausea and vomiting were less likely in group b (1.9% vs. 9.9% and 0 vs. 3.4%, respectively). mean hospital and icu los were shorter in group a than in group b (9.1 vs. 15.4 and 2.8 vs. 5.7, p<0.001 respectively). mortality rate during icu stay was higher in group b (9.74% vs. 1.52%; or 6.96, p<0.001). the preoperative glasgow coma scale (gcs) in patients who died, was below 8 in only a minority of them (14.28% in group b; 0% in group a). in this cohort of neurosurgical patients, emergency, compared to elective operations, were associated with higher post-operative complications and mortality rates. emergency surgery was associated with a higher severity of illness measured by the sofa and asa scores. intraprocedure rupture (ipr) is a rare but potentially serious complication of endovascular coiling of intracranial aneurysms. potential complications include hemorrhage, ischemic stroke, vasospasm and hydrocephalus which can lead to increased morbidity and mortality. the clinical course for these patients is not well studied and characterized. we performed a retrospective review of prospectively collected data for all unruptured aneurysms treated with endovascular coil embolization between july 2003 and march 2017 at a large universitybased hospital. out of 998 cases of all unruptured aneurysms coil embolizations, 10 (1.002%) patients had ipr. we reviewed baseline data, procedure notes, clinical course, and outcomes at discharge and at 3, 6 and 12 months. among the ten patients, the location of the aneurysms included: 4 basilar apex, 3 internal carotid artery 1 anterior communicating artery, 1 posterior cerebral artery, and 1 posterior communicating artery aneurysm. patients were monitored in the icu for variable lengths of time and daily transcranial doppler ultrasound detected no significant sonographic vasospasm. the large majority of the patients (8/10) were discharged to home at their baseline functional status assessed by modified rankin scale. one patient was discharged to inpatient rehabilitation for cognitive deficits from ipr of a basilar apex aneurysm. they were subsequently discharged home with supervision. there was a single mortality in a patient receiving retreatment of a proximal ica aneurysm with prior stenting and coil embolization who developed massive subarachnoid hemorrhage with diffuse intraventricular hemorrhage with external ventricular drain placement. the incidence of ipr is very low and potentially serious complications occur rarely in these patients. the location and factors associated with ipr are highly variable and without clear associations. outcomes of such complications are overall favorable. a short observation period in the hospital is likely warranted with a benign clinical course the most likely outcome. the standard treatment of cerebral venous-sinus thrombosis (cvst) is anticoagulation. however some patients clinically deteriorate secondary to mass-effect from infarct or intracerebral-hemorrhage (ich). the role of decompressive-craniectomy (dc) in this patient population is unknown. we elucidate the baseline characteristics of patients treated with dc, and report their outcomes. a retrospective chart review of our institutional database identified patients with cvst who were treated with dc. demographic and clinical data were collected. imaging variables collected from ct-head or mri-brain immediately before dc were intracerebral-hemorrhage volume (ich-v), combined volume of mass-effect from infarct/ich and peri-lesional edema (me-v), midline-shift at level of pinealgland (mds-p), midline-shift at cranial-most portion of corpus-callosum (mds-cc), and herniation-type. favorable outcome was defined as glasgow-outcomes scale of 4-5 upon last-known follow-up. a total of 15 patients (females=10) treated with dc were identified with mean-age 46.7 (+/-17.4), mean glasgow-coma scale (gcs) before surgery 8 (+/-3.9), mean-ich-v 42.2 ml (+/-44.0), mean-me-v 100.7 ml (+/-51.6), mean-mds-p 6.1mm (+/-3.9), and mean-mds-cc 7.4mm (+/-6.5). transverse-sinus was most commonly involved (n=10). 14/15 patients had any herniation, most commonly cingulate (n=10). meanchange in gcs from admission to before-surgery was -4.8 (+/-4.2). ten patients were anticoagulated before surgery. on last-known follow-up, 9/15 patients had a favorable outcome. four had died. on chisquare analysis, superior-sagittal sinus thrombosis was associated with unfavorable outcomes (p=0.025), and mortality (p=0.039). on univariate binary-logistic regression, there was a non-significant trend towards unfavorable outcomes (p=0.082) and mortality (p=0.079) with every-point decrease in mean-gcs before surgery. the predictive-value of other factors towards outcomes is unknown given limited sample-size. decompressive-craniectomy might improve outcomes even in patients with cvst who have developed coma, cerebral herniation, have failed treatment with anticoagulation, and have large-volume masslesions causing midline-shifts of >5mm. a prospective multi-institutional observational-cohort would poster presentations better delineate outcomes in comparison to matched-patients who are not treated with decompressivecraniectomy. meningiomas are often benign and mostly asymptomatic, and the treatment approaches may include open surgical resection, radiosurgery, and/or watchful waiting. reported morbidity and mortality rates for elderly patients undergoing meningioma resection vary widely. we sought to investigate mortality rates for elderly patients undergoing craniotomy for meningioma resection using the nationwide inpatient sample (nis). the nis datasets from 2003 to 2013 were used to identify patient admissions for meningioma resection based on the icd-9-cm code 01.51. age categories were defined as 70 years of age. primary outcomes were in-hospital mortality, poor outcomes (defined as death or discharge to a facility other than home), cost and length of hospitalization. a total of 24,953 patients were identified who underwent meningioma resection during 2003-2013 of which 20.4% were elderly (>70 years). each of the primary outcomes was heavily influenced by the advancing age. in-hospital mortality was higher in the elderly as compared to the younger patients (3.5% vs 1% p<0.001), as was the rate of a poor outcome (64.8% vs 28.1%, p<0.001). elderly patients also had a higher cost ($104425 vs $96012, p=0.013) and increased length of hospitalization (8.9 vs 6.8 days, p<0.001). in our study, age > 70 was strongly associated with adverse outcomes after meningioma resection. this increased risk should be taken into account when considering surgical intervention in this subgroup. based on this study, closer perioperative monitoring may be warranted in the elderly patient subgroup. treatment with anticoagulation improves outcomes in cerebral venous-sinus thrombosis (cvst). however patients who develop extensive infarcts and/or intracerebral-hemorrhage with mass-effect resulting in comatose-state are at risk of poor outcomes, and may benefit from decompressive craniectomy (dc). we evaluated the role of dc in the management of malignant cvst and its impact on outcomes. literature-search was conducted on pubmed and google-scholar using terms "craniectomy", and "cerebral venous-sinus thrombosis". we included studies that described any number of patients with cvst who underwent dc after clinical deterioration and reported their outcomes. a similar search strategy identified patients from our institute. outcomes were reported as modified-rankin scale (mrs) or glasgow-outcomes scale (gos) and were classified as favorable (mrs 0-3; gos 4-5), or unfavorable (mrs 4-6; gos 1-3). a total of 296 patients (females=164; males=74; unknown=58) who underwent dc for malignant-cvst were identified from 29 studies (n=281) and our institute (n=15). age and gcs (before-surgery) were only available from 125 patients, with mean-age 36.74 (+/-13.52) and mean-gcs 7.58 (+/-3.03). 199 patients (67.2%) had favorable-outcomes, while 63 patients (21.3%) died. in the multi-variate binarylogistic regression-model, every point-drop in gcs decreased the odds of favorable-outcomes by 0.57times (p<0.001; 95%ci=0.423-0.775), and survival by 0.58-times (p=0.002; 95%ci=0.414-0.821). thrombosis in internal-jugular vein (ijv) (or=10.39; 95%ci=1.36-79.30; p=0.024) and deep-cerebral veins (dcv) (or=8.94; 95%ci=1.33-60.17; p=0.024) predicted unfavorable-outcomes. ijv-thrombosis (or=10.67; 95%ci=1.07-106.86; p=0.044) and dcv-thrombosis (or=13.5; 95%ci=1.57-115.82; p=0.018) also predicted mortality. interestingly, cortical-vein thrombosis was associated with lower odds of unfavorable outcomes (or=0.217; 95%ci=0.051-0.921; p=0.038). data regarding anticoagulation and long-term follow-up were not uniformly available. for patients with malignant-cvst, craniectomy could potentially improve outcomes. factors such as gcs before-surgery and cvst location can help predict outcome following dc and aid the decision-making process. a multi-institutional observational cohort should be designed to prospectively evaluate predictors for, timing of, and outcomes after craniectomy in cvst. the external ventricular drain (evd) is commonly used in the neurocritical care unit to help monitor intracranial pressure (icp) with the added advantage of therapeutically treating elevated icp by diverting cerebrospinal fluid (csf). placement of an evd can be complicated by hemorrhage surrounding the catheter insertion tract, which in some cases may prove to be fatal. this retrospective study was designed to look at the rate of tract hemorrhages after evd placement that were performed at our institution as well as associated outcomes. we conducted a retrospective review of all patients who underwent evd placement during a 3 year period using our institutional database. postinsertion computerized tomography (ct) scans of the head were analyzed independently by 2 physicians to identifying tract hemorrhages. data on primary diagnosis, age, sex, length of icu stay and mortality were collected and analyzed. a total of 115 patients were identified as having had an evd placed during their hospital course. 15 patients were excluded as there were no images of evds present in their records. 100 patients were analyzed, of which 43% were male. mean age was 59.4 years. 50% of patients had a diagnosis of subarachnoid hemorrhage, 45% with intraparenchymal hemorrhage and 16% with ischemic stroke. mortality was 15% among all evd patients. the rate of tract hemorrhages among all patients with evd images was 21%. asymptomatic tract hemorrhages occurred in 19 patients (95.23%) with 1 patient (4.77%) dying due to the tract hemorrhage itself. among patients with tract hemorrhages mortality was 14.3%. the rate of tract hemorrhages was noted to be 21% with the majority being asymptomatic. there was no difference in mortality among patients with evds who developed tract hemorrhages compared to patients with no tract hemorrhages. verapamil is a phenylalkylamine calcium channel blocker that blocks the calcium ion influx through slow channels into conductile and contractile myocardial cells and vascular smooth muscle cells resulting in vascular relaxation and vasodilatation. symptomatic hypotension and/or extreme bradycardia/asystole are often seen with intravenous verapamil administration requiring pharmacologic treatment. in neuroendovascular field verapamil is mainly being used as a vasodilator agent. current lack of pharmacokinetic/pharmacodynamics data of intra-arterial verapamil often makes very challenging to neurointerventionalists during endovascular procedures. the purpose of this study is to observe acute hemodynamic effects of intra-arterial verapamil administration as well as the safety of higher dose of the medication during endovascular treatment. ten patients who underwent endovascular treatment for acute ischemic stroke were evaluated pre and post procedure with vital signs. the dosage of intra-arterial verapamil was documented and tabulated along with the pre and post heart rate and systolic blood pressure. the dose of intra-arterial verapamil varied from 1 to 5 mg in each internal carotid or vertebral artery, total dose per patient per procedure varied from 2.5 to 10. the average dose of intra-arterial verapamil administered was 4.95 ± 2.0 mg or 59.7 ± 30.8 mcg/kg that were infused over 5 to 10 minutes. at the baseline before administration of intra-arterial verapamil, the mean systolic blood pressure (sbp) was 157.8 ± 24.4 mm hg and the mean heart rate (hr) was 71.6 ± 16.2 bpm. after administration of intraarterial verapamil, sbp decreased by mean of 16.7 ± 0.8 mm hg but we observed no symptomatic hypotension requiring any pharmacologic treatment. hr changed only by mean of 0.1 ± 5.4 bpm post intra-arterial verapamil. we observed no acute significant changes in hemodynamic parameters with administration of verapamil in carotid or vertebral arteries. this may represent its safe use during neuro-endovascular therapy. growing evidence suggests inflammation is critical in epileptogenesis. endogenous brain apolipoprotein e protein (apoe) modulates neuroinflammatory responses to injury through downregulation of glial activation and secondary neuronal injury. we created a 5 amino acid peptide (cn-105) mimicking the binding face of apoe. cn-105 downregulates the inflammatory response in vitro and in vivo and improved histologic and clinical outcomes across several injury models in mice. we hypothesized that downregulation of inflammation by administration of cn-105 will reduce the development of epilepsy after pilocarpine induced status epilepticus in mice. c57bl/6 mice were intraperitoneally injected with pilocarpine to induce status epilepticus. following induction of status, animals were randomized to receive two doses of cn-105 or vehicle at 45 minutes and 6 hours. status was terminated by injection of benzodiazepine at 55 minutes. epidural eeg leads were surgically placed at 3 weeks and continuous video-eeg (cveeg) monitoring was performed for several days in a row at 4-6 weeks post status to determine spontaneous seizure development and frequency. at 4-6 weeks following induction of status epilepticus, administration of 0.2 or 0.5mg/kg cn-105 reduced the development of epilepsy by approximately 50% compared to vehicle treated animals. further, cn-105 treated animals that did develop seizures had significantly fewer seizures than vehicle mice. similar results were seen with 7 daily doses of 1mg/kg starting at 45 minutes. importantly, cn-105 is not an anticonvulsant as cveeg monitoring during status induction clearly demonstrated that seizures were not stopped or reduced by injection of cn-105. these results are consistent with the hypothesis that inflammation plays an important role in the development of epilepsy after injury and demonstrates treatments that target inflammation, like cn-105, can prevent and/or reduce the development of epilepsy. this represents the first therapy to prevent the development of epilepsy that has entered into clinical trials. to determine the speed of brain entrance of the antiepileptic drugs (aeds) brivaracetam (brv) and levetiracetam (lev) after single intravenous dosing in humans. brv and lev both bind to synaptic vesicle protein 2a (sv2a), but brv has more rapid brain entry than lev in mice and monkeys [1] . sv2a can be quantified in the living human brain using pet imaging with [11c]ucb-j[2]. pet scans (n=13) were performed with [11c]ucb-j administered by a bolus-infusion protocol in healthy volunteers (n=9). therapeutic dosages of brv (50mg, n=1; 100mg, n=4; or 200mg, n=2) or lev (1500mg, n=6) were administered as 5-minute intravenous infusions 60 minutes after the start of the first pet scan. tracer displacement half-times were determined by subtracting the radioligand clearance halftime from the radioligand displacement half-times estimated by exponential fitting of the post-aed drop in distribution volumes (vt). data were also analyzed using an advanced mathematical model that described the relationship between brain [11c]ucb-j pet data and time-varying aed plasma curves to directly estimate brain entrance (k1) of both aeds and [11c]ucb-j, free fraction of [11c]ucb-j in the brain, and vt values. the radioligand clearance half-time was 8 minutes. tracer displacement half-times were 1.7 and 2.1 minutes for brv 200mg, and 20 ±6 minutes for lev 1500mg. lower brv doses had longer half-times, but values were misleading as they assumed 100% sv2a occupancy. the advanced compartment model described well -dose scans. using the advanced model, the brv uptake rate (~50 ul/min/cm3) was found to be at least 8-fold higher than that of lev (~6 ul/min/cm3). the results demonstrate that brv enters the human brain faster than lev. the potential therapeutic benefit of this has yet to be determined. while intravenous anesthetic therapy (ivat) represents the gold-standard for treatment of refractory status epilepticus (rse), the optimal depth and duration of therapy is not known. the goal of this retrospective observational study was to describe the relationship between the depth of burst suppression and the ability to successfully wean ivat during rse treatment. fifty patients were identified with rse who underwent continuous electroencephalography. using persyst, the suppression ratio (sr) was calculated up to 72 hours prior to weaning ivat. the type and duration of ivat was recorded, as well as complications. we compared these variables between successful and unsuccessful weans. the mean sr for all patients was 19.0±26.3%, with a mean treatment duration of 63.3±42.1 hours. there was no difference in treatment duration between successful and unsuccessful weans(p=0.54), but sr was significantly lower in successful weans (10.0±15.2% vs 27.9±33.4%, p=0.01). the receiver operating curve (roc) for the sensitivity and specificity of the mean sr to predict a successful weaning attempt did not identify a threshold to predict weaning success. the use of pentobarbital was associated with a significantly higher sr when compared to midazolam (69.1±18.9% vs 6.9±8.2%, p <0.001). patients failed ivat weaning a mean 24.5±22.6 hours after initiating the ivat wean, which occurred after a mean decrease in the midazolam infusion rate of 68 ± 33%. depth of sr was not associated with infection risk (p=0.74), but was associated with the need for tracheostomy (27.6±32.7% versus 10.2±17.2%, p=0.01). vasopressors were required in 87.5% of patients while on ivat. unsuccessful weaning of ivat was associated with a higher depth of sr, which is likely a marker of disease severity. depth of sedation was not associated with increased risk of infection, but was associated with the need for tracheostomy. vasopressor requirements are common. the primary objective of this study was to determine the sensitivity and specificity of real-time neuro icu nurse interpretation of quantitative eeg (qeeg) trends in the identification of recurrent nonconvulsive electrographic seizures in adult patients admitted to the neuro icu. thirteen adult patients admitted to the neuro icu that had nonconvulsive seizures on continuous eeg (ceeg) monitoring were included in the study. neuro icu nurses consented for their participation and underwent a brief, standardized qeeg training session. a 1-hour qeeg panel (rhythmicity spectrogram, left/right and amplitude-integrated eeg, left/right) printout containing the marked sentinel seizure(s) was displayed next to the bedside ceeg/qeeg monitor. at one-hour intervals, the nurses logged the number of seizures seen in the past hour based on their qeeg interpretation for the duration of their shift. their answers were compared with the gold standard of neurophysiologist interpretation of seizure occurrence on raw eeg. a total of 120 hours of qeeg data was reviewed for 13 patients. average length of data collection was 9.5 hours. for the neuro icu nurses' ability to detect the presence of seizures on real-time qeeg the sensitivity was 70.0% (95% ci, 34.8-93.3%) and specificity was 90.0% (95% ci, 82.8-94.9%). the positive predictive value for seizure detection was 38.9% (95% ci, 24.2-56.0%) and the negative predictive value was 97.1% (95% ci, 92.7-98.8%). the false-positive rate was 0.075/hr. a simplified panel of qeeg trends can be used by neuro icu nurses to screen for recurrent electrographic seizures in critically ill patients with a reasonable sensitivity, an excellent specificity and a very low false-positive rate. this may facilitate earlier identification of recurrent electrographic seizures by notifying the neurophysiologist who is not present in the icu and not able to perform real-time ceeg interpretation. nonconvulsive status epilepticus (ncse) is an indicator of poor outcomes in neurocritical care settings. however, because of unfamiliarity with continuous electroencephalography monitoring (ceeg), the diagnosis and treatment of ncse remains challenging, and its clinical impact and prognostic factors have not been sufficiently reported in japan. we performed ceeg for 188 adult patients in our neurocritical care unit with coma or unexplained altered mental status from april 2013 to september 2015. we reviewed all ceeg records according to the american clinical neurophysiology society's terminology (2012 version), and diagnosed patients with ncse when the ceeg revealed spatiotemporally evolving or fluctuating periodic or rhythmic discharges and after considering clinical information based on the modified salzburg consensus criteria. patients with ncse were aggressively treated with benzodiazepines, fosphenytoin, and levetiracetam. they were divided into a generalized convulsive status epilepticus (gcse) group and a non-gcse group. we compared mortality and outcomes between the two groups after 3 months using fischer's exact test. outcomes were defined as poor when the glasgow outcome scale score was worse at the 3-month follow-up than at admission. we excluded 15 cases undergoing supportive care or lacking of follow-up. of 173 cases in the study, 61 cases were diagnosed with ncse, including 18 cases with accompanying gcse and 43 cases without. mortality rates at the 3-month follow-up were significantly higher in the non-gcse group than the gcse group (19% vs. 0%, respectively; p = 0.0492). the rate of poor outcomes was significantly higher in the non-gcse group than in the gcse group (26% vs. 0%, respectively; p = 0.0138). this study suggests that the absence of gcse is associated with increased mortality and poor outcomes among ncse patients. limitations of this study include its retrospective design and small number of ncse patients. further studies are necessary to identify additional prognostic factors. super-refractory status epilepticus (srse) is a life-threatening condition in which status epilepticus recurs or continues for over 24 hours despite first-, second-, and anesthetic third-line agent (tla) medications. no treatments are currently approved for srse. a randomized, double-blind, multi-center, placebo-controlled phase 3 trial evaluated brexanolone (usan; formerly sage-547 injection), a synaptic and extrasynaptic gabaa receptor positive allosteric modulator as adjunctive therapy for srse (nct02477618; "status trial"). enrolled subjects underwent a qualifying tla wean after at least 24 hours of seizure-or burstsuppression. srse subjects failing the qualifying wean were randomized 1:1 to a blinded infusion of brexanolone or placebo as adjunctive therapy following resumption of one or more tla infusions. subjects were administered the blinded infusion for 6 days, during which attempts were made to wean off tla infusions. clinical standardization guidelines (csgs) facilitated standardization across sites by outlining eeg patterns for which tla weaning should be continued, paused, or discontinued. an on-call clinical standardization team provided real-time support. safety was assessed via adverse events, laboratory testing, vital signs, and ecg parameters. the primary endpoint was defined as successfully super-refractory status epilepticus (srse) is a life-threatening neurological condition characterized by status epilepticus persisting over 24 hours despite treatment with first-, second-, and third-line agents (tlas) or upon the weaning of tlas. currently, there is no consensus around treatment protocols for srse. this study aims to describe srse treatment patterns and related outcomes in a us population. we retrospectively identified srse cases in cerner healthfacts®, a large, de-identified, us electronic health record database, using records from 2000-2015. cases were classified as srse using a modified version of a previously published algorithm using icd-9 and procedure coding for status epilepticus (345.00, 345.01, 345.1x, 345.3, 345.41, 345.51, and 345.81) , ventilator support, pharmacotherapies. descriptive and univariate statistics were used to evaluate anesthetic treatment, anti-epileptic medications, and the association between glasgow coma score (gcs) and mortality. using our algorithm, 1153 srse cases (1137 patients) were classified. multiple tlas were received in 89% of cases, and in 37%, >2 concurrent tlas were received. the first post-admission tlas were propofol, lorazepam and midazolam, respectively, in 38%, 38% and 18% of cases. median anesthetic duration was 9.5 days. mortality was higher in -8 (3.1 vs. 1.6 days; p<0.001). srse patients identified in our analysis underwent variable treatment patterns, reflecting lack of co days of tla treatment. nonconvulsive seizures (ncs) and nonconvulsive status epilepticus (ncse) occur in approximately 20% of neurologically critically ill patients. the most effective antiepileptic drug (aed) regimen to treat ncs and ncse is unknown. this study was designed to determine the efficacy of add-on clobazam, a unique 1,5-benzodiazepine with favorable pharmacokinetic properties, in the treatment of ncs and ncse. a retrospective chart review was performed on 17 adult patients who were admitted to the neurological intensive care unit between january 1, 2013 and june 1, 2017, were diagnosed with ncs or ncse by continuous eeg monitoring and received clobazam as add-on therapy. the primary efficacy endpoint was defined as clobazam being the last aed added before ncs/ncse cessation, regardless of latency between dosing and ncs/ncse cessation. of the 17 patients included in this study, 7 (41%) had ncs vs. 10 (59%) with ncse. the most common etiologies were autoimmune (n=6) and cns tumor (n=5), with 7 patients (41%) having pre-existing epilepsy. clobazam was the last aed added before cessation of ncs/ncse in 12 of 17 (71%) subjects. clobazam was chosen as the 3rd to 6th line agent. clobazam was started at a median of 2 days from the onset ncs/ncse (range 1-55 days). the median total daily dose of clobazam was 20 mg (range 10-60 mg). this study suggests that clobazam may be effective at various time points in the treatment of ncs/nsce and may prevent the need for addition of intravenous anesthetic drugs to control seizures. however, a prospective study is warranted to determine efficacy and optimal dosing. continuous electroencephalography monitoring(ceegm) with international 10-20 system is essential for detect nonconvulsive status epilepticus (ncse). in japan, both ceegm systems and human resources are lacking, and few facilities are able to conduct such advanced monitoring. the ceegm headset, described in this report, is a novel and easy-to-use technology. we attempted to validate the novel ceegm headset by comparing it with a conventional, international 10-20 ceegm system (conventional ceegm). we completed this study at a single center, eight-bed neurocritical care unit, between january 2017 and june 2017. the new, ceegm headset features eight electrodes (f, c, t, o), and is capable of simultaneously transmitting eeg data by bluetooth. patients with disturbed consciousness, of unknown etiology, underwent ceegm headset followed by conventional ceegm. we verified the concordance rate of the two systems for detecting eeg morphologies (e.g. periodic discharges, rhythmic delta activity, spikes and waves), and diagnosing ncse. eeg morphologies were appreciated according to "american clinical neurophysiology society's standardized critical care eeg terminology: 2012 version" and diagnosis of ncse were done according to modified salzburg consensus criteria. among this period, we enrolled thirty patients. three patients were excluded because of not satisfying protocol. final analyses included verified data from 27 patients. the mean age was 66 years old (range: 20-86), 59% were male, mean acute physiology and chronic health evaluation (apache) ii score was 15 (range: 5-27), and mean full outline of unresponsiveness (four) score was 10 (range: 6-16). we appreciated concordant eeg morphologies, and ncse, in 78% (21/27), and 74% (20/27) of patients, respectively. this easy novel ceegm headset may be useful in settings with limited resources or access to conventional ceegm technology. further study is needed to validate the actual diagnostic ability of this novel headset. the traditional approach to interpreting eeg requires physicians with formal training to visually assess the waveforms. this approach is less practical in critical settings when a trained eeg specialist is not readily available to diagnose subclinical seizures, such as non-convulsive status epilepticus, in patients with altered mental status. we have recently invented an algorithm for sonifying eeg, and in the current study, we explored whether individuals without eeg training can detect ongoing seizures by simply listening to one channel of sonified eeg. we sonified 84 eeg samples (15-second long) that represented various conditions commonly seen in the icu (7 seizures; 25 lpd, gpd, or burst suppression, and 52 normal or slowing). 34 medical students and 30 nurses were asked to indicate each audio sample as "seizure" or "non-seizure". we then compared their performance with that of eeg experts [epilepsy attendings with >10 years of experience (n=2) and epilepsy fellows (n=7)] and some of the medical students (n=29) who also diagnosed the same eegs on visual display. non-experts listening to single-channel sonified eegs detected seizures with remarkable sensitivity (students: 98±5%; nurses: 95±14%) compared to experts or non-experts reviewing the same eegs on visual display (attendings: 100%; fellows: 90±11%; students: 76±19%). if the eegs contained seizures or seizure-like activity, non-experts listening to sonified eegs rated them as seizures with high specificity (students: 85±9%; nurses: 82±12%) compared to experts or non-experts viewing the eegs visually (attendings: 95±1%; fellows: 91±7%; students: 65±20%). our study confirms that individuals without eeg training can detect ongoing seizures or seizure-like rhythmic periodic activity by merely listening to short duration of sonified eeg. while sonification of eeg cannot replace the traditional approaches to eeg interpretation, it provides a meaningful triage tool for fast assessment of patients with suspected subclinical seizures. super-refractory status epilepticus (srse) is a life-threatening form of status epilepticus (se) that continues despite, or recurs after, 24 hours of therapeutic interventions, including continuous intravenous anesthetic third-line agents (tlas). no therapies are approved for srse, leading to substantial variation in both management and determination of treatment response. for the phase 3 trial of brexanolone as adjunctive therapy for srse involving up to 180 international sites, we developed and implemented clinical standardization guidelines (csgs) for real-time support of tla administration, weaning, and outcome assessment under eeg neuromonitoring. a clinical standardization team (cst), including investigators and se experts, developed consensus csgs defining acceptable eeg patterns for continuation, termination, or pausing the weaning of tlas. csg implementation was facilitated by training and cst call centers staffed internationally by physicians with critical care eeg expertise. in cases of disagreement, the local site retained final decision-making authority. a "traffic light" system defined: 1)"green" tolerated eeg patterns (improving background, 3 seizures within 3 hours, discharges >3 hz, or discharges 1-2.9 hz with evolution and no improvement over 6 hours), and 3)"amber" eeg patterns not meeting the above, for which tla weaning should be paused while optimizing anti-epileptic medications and monitoring for transitions to green/red eeg patterns. the initial 125 cst consultations yielded 97% csg compliance; 83% of eegs underwent cst review. few cst consultations lasted >60 minutes (7%); most lasted <30 minutes (67%). this phase 3 trial demonstrates the feasibility of applying neuromonitoring csgs for tla weaning in srse patients, to ensure better consistency of clinical care and reliability of the primary outcome measure in clinical trials. csgs were well accepted by investigators and may serve as a framework for future clinical trials or clinical therapies in srse. severe brain trauma is a leading cause of death and disability worldwide. post-traumatic epilepsy (pte) is a chronic complication that occurs in up to 40% of cases (frey, 2003; najafi et al., 2015) . drugs and other interventions to prevent epileptogenesis would likely be most effective early after traumatic brain injury (tbi), but cannot be given indiscriminately. there is a critical need for tools that quantify those at high risk for pte. abnormal neural activity, in the form of ictal-interictal continuum abnormalities(iicas) are increased acute brain injuries, and appear to differentiate patients at risk for secondary brain injury (e.g. kim et al., 2017) . we hypothesized that iicas acutely following tbi may be a marker of posttraumatic epilepsy risk. we evaluated continuous eeg data from moderate to severe tbi patients who did and did not develop pte, (any seizure 2-12 months post-tbi; n=50). seizures <1month post-tbi were classified as symptomatic, not pte. conventional 10-20 scalp electrode placement was used and eegs were reviewed by standard visual analysis, by the mgh neurophysiology service. daily eeg reports were scored for the presence of iicas and seizures. demographic data including gender, age, tbi severity and type of brain injury were recorded. univariate and multivariate regression analyses were performed to determine which iica and demographic features correlated with pte. gcs (p=0.02) and tbi severity (p=0.02) were significantly associated with pte, as expected. seizures (p=0.002), epileptiform discharges (p=0.0003), generalized periodic discharges (0.0003) and lateralized rhythmic delta activity (p=0.04) independently predicted risk for post-traumatic epilepsy. epileptiform discharges, in particular, were more prevalent acutely post-tbi in pte patients. increased iica prevalence is significantly associated with pte and may be a predictive marker for identifying patients who may benefit from anti-epileptogenesis trials. rapidly obtaining eeg signals in the ed and icu for at-risk patients can enhance diagnosis accuracy and speed, while cutting down time until treatment. ceribell inc has developed a portable eeg data recorder and electrode headset with rapid setup (~ 5 min) technology without any eeg technician required to overcome the inaccessibility of eeg in urgent situations when seizures are suspected. the purpose of this study is to evaluate the signal quality and performance of the ceribell system compared to a reputable clinical eeg system. we collected eeg samples in the laboratory and at stanford university medical center. laboratory collections on healthy volunteers included simultaneous collection of eeg using ceribell and nihon kohden systems, and a split-signal that recorded eeg to both data recorders from the same electrodes. in the icu, eeg was recorded with the ceribell system on 25 patients and subsequently with the clinical eeg system. data was filtered and spectral densities, mean frequency (mf), spectral entropy (se), and 75% spectral edge frequency (sef75) were computed. in the split-signal test, the waveforms consistently appeared similar by visual inspection. the analysis of ceribell data revealed (mf = 22.46 hz, se= 8.51, sef75 = 21.56) similar to the commercial system (mf = 22.86 hz, se = 8.52, sef75 = 21.58). in the simultaneous test, the ceribell system produced (mf = 14.3 hz, se = 8.4, sef75 = 17.36) similar to the commercial system (mf = 15.5 hz, se = 8.58, sef75 = 18.84). in the clinical setting, the ceribell system showed spectral density distributions comparable with the commercial system. our results indicate that the signal quality of the ceribell system is similar to a commercially available eeg used widely in the clinical setting, while requiring less setup time and allowing more portability. status epilepticus (se) is a life-threatening condition characterized by prolonged seizures without regaining consciousness between seizure events. when se continues or recurs 24 hours or more after treatment with third line anesthetic agents, it is considered super-refractory se (srse). there are few population-based studies on the descriptive epidemiology of srse at a national level. the objective was to estimate the incidence of srse in canada in 2010-2012. we analyzed standardized national administrative record-level data covering all provinces across canada as provided by the canadian institute for health information. srse episodes were classified from two databases for acute care admissions (discharge abstract database) and emergency visits (national ambulatory care reporting system) over 3 fiscal years (2010/2011 to 2012/2013). cases were identified as srse using a modification of a previously published algorithm using icd-10-ca diagnostic codes for epilepsy (g40), status epilepticus (g41), or convulsions (r56) plus an intensive care unit stay of 2 days or more with mechanical invasive ventilation. using our algorithm, from 2010-2012, the mean annual number of cases classified as srse was 3,427 (9.98/100,000 persons per year). the annual incidence was higher in males (11.78/100,000 per year) than females (8.21/100,000 per year). the highest rates were in the age group 70-79 years: 20.7 and 32.9 per 100,000 per year for females and males, respectively. the mean age of srse patients was 52 years (sd=22 years), with 58% males. the most common comorbidities for srse included metabolic disturbances (39%), sepsis (32%), toxic withdrawal state (31%), cardiovascular disease (22%), and head trauma (13%). in-hospital mortality for srse was 21%. this is the first study reporting estimates of srse incidence in canada. these results suggest that srse is associated with a substantial disease burden. interventions that improve patient outcomes and reduce mortality are required. new-onset refractory status epilepticus (norse) is a condition characterized by prolonged pharmacoresistant seizures in a previously healthy individual with no identifiable etiology during initial evaluation. typical magnetic resonance imaging (mri) findings include bilateral limbic and neocortical t2-weighted hyperintense lesions. fluorodeoxyglucose (fdg)-positron emission tomography (pet) findings have not been previously reported. this study sought to describe fdg-pet and mri characteristics in patients with norse. methods 12 patients were retrospectively identified amongst a database of autoimmune-mediated encephalitis from 2008-2017, meeting diagnostic criteria for norse and having undergone mri and pet over the course of their illness. imaging findings were confirmed with a board-certified neuroradiologist. nine patients were autoantibody positive: three n-methyl-d-aspartic acid (nmda) receptor, two glutamic acid decarboxylase (gad), three voltage-gated potassium channel (vgkc)-complex with two having leucine-rich glioma-inactivated protein 1 igg positivity, and one gamma-aminobutyric acid (gaba) b receptor. all patients had identifiable abnormalities on fdg-pet. hypometabolism was most common, with 11 of 12 patients having diffuse, bilateral, or unilateral frontal, parietal, or occipital cortical hypometabolism. nine patients also had bilateral (7) or unilateral (2) mesial temporal hypermetabolism. two patients had multifocal hypermetabolism with bilateral or unilateral frontal abnormalities in addition to mesial temporal findings. of the nine patients with fdg-pet hypermetabolism, concurrent mri scans failed to show corresponding t2-weighted hyperintense lesions in the mesial temporal and medial frontal regions in two patients. fdg-pet findings in norse include bilateral or unilateral mesial temporal or mesial frontal hypermetabolism with diffuse, bilateral, or focal cortical hypometabolism. hypermetabolism may reflect regions predominantly involved in acute epileptogenesis. fdg-pet may improve sensitivity when compared to mri alone. while seizures are uncommon but reported in primary intraventricular hemorrhage (ivh), little evidence is available on the prevalence of hyperexcitable patterns on long term eeg monitoring. we sought to determine the prevalence of hyperexcitable patterns and seizures in patients with primary ivh who were extracted from a cohort consisting of patients with spontaneous intracerebral hemorrhage (sich) who underwent continuous electroencephalogram (ceeg) monitoring between january 2013 and december 2016 at yale-new haven hospital. indications for ceeg monitoring included fluctuation of or depressed mental status, abnormal movements and a limited clinical exam. we recorded demographics, radiologic hydrocephalus, duration of eeg recording and eeg findings. hyperexcitable patterns comprised generalized, bilateral independent or lateralized periodic discharges (pds), lateralized rhythmic delta activity (rda), brief potentially ictal rhythmic discharges (b(i)rds), and spike-and-wave discharges (sw). of 196 adults with sich who had ceeg performed, 13 patients had primary ivh. hydrocephalus was present in 9 patients (69%). patients were monitored for a mean duration of 22.4 (± 14.7) hours. 9 patients had hyperexcitable patterns and/or electrographic seizures (70%): electrographic seizures and co-existent hyperexcitable patterns were captured in 2 of 13 patients (16%) and hyperexcitable patterns without seizures in 7 of 13 patients (54%). hyperexcitable patterns included periodic discharges (pds) (4) (generalized, lateralized and bilateral independent, with and without rhythmicity), rhythmic delta activity (rda) (5) (both lateralized and generalized, with and without sharps), brief potentially ictal rhythmic discharges(b(i)rds) (1) and spike-and-wave discharges (sw) (1). there was no significant difference between patients with and without hydrocephalus and hyperexcitability or electrographic seizures (p= 0.76). both electrographic seizures and/or patterns of hyperexcitability on eeg are common in our selected cohort of primary ivh patients. this underscores the importance of continuous eeg monitoring in this patient population, since the detection of non-convulsive seizures may offer an opportunity for therapeutic intervention. patients with aneurysmal sah (asah) frequently have ictal-interictal continuum (iic) eeg patterns. while seizure burden can worsen outcomes, less is known about iic burden. we investigated the impact of iic burden and anti-epileptic drug (aed) treatment on asah outcomes. we included patients with asah undergoing continuous eeg (ceeg) from 2011-2016. patients with nonaneurysmal sah or 90%, 50-89%, 10-49%, 1-9%, <1%. age gender, admission gcs, apache ii score, fisher and hunt and hess (hh) scores, aed dosing and discharge gos were ascertained by chart review. presence of iic patterns in asah independently predicts worse neurologic outcome, although maximum burden does not. although nearly half of these patients receive aed treatment, our data suggest that aed treatment may not influence outcome. prospective studies may further delineate the clinical risks and benefits of aed treatment. refractory status epilepticus (rse) is defined by failure to control epileptic activity after the administration of 1st and 2nd line antiepileptic agents. mortality associated with rse has been estimated to be around 23-61% at hospital discharge. we conducted this study to analyze trends in the frequency and management of rse. we conducted a cross-consortium (uhc) database from 2009 to 2016. this is a database from 120 academic medical centers and their 299 affiliated hospitals in the united states and consists of a sample of 12,366,264 patients. data including age, sex, antiepileptics (aed) and length of stay was collected. total mean age was 52.4 years and females were 48.83%. there was an increasing trend of using lorazepam as the first line aed (58.5% in 2009 to 60.5% in 2016) and a decreasing trend was noted of using midazolam as the first line aed (62.9% in 2009 aed (62.9% in to 55.4% in 2016 . leviteracetam was the most common second line aed used throughout all years which was followed by propofol followed by phenytoin/fosphenytoin. mean length of hospital stay was 10.8 days. between 2009 to 2016, the proportion of hospitalized patients in the united states diagnosed with rse has increased. lorazepam and leviteracetam have been the most common aeds used. mean length of hospital stay has not changed. status epilepticus is associated with high risk of multi-organ dysfunction. ketamine for the treatment of super refractory status epilepticus (srse) has the benefit of a different mechanism and lack of cardiac depression when compared with other anesthetic agents. this study evaluated the improvement in sequential organ failure assessment (sofa) score in patients treated with ketamine for srse. this is a retrospective study of patients with srse from 2011 to 2016. the timing and dosage of anesthetic agents used in their treatment were abstracted. sofa scores at admission and for the first 6 days after initiation of ketamine were calculated. the presence of shock prior to initiation of ketamine included septic shock and cardiogenic shock. outcomes including mortality, organ failure, and hospital associated infections (hais) were also recorded. a total of 47 patients were treated with ketamine after failure of seizure control using other anesthetic agents. seventeen (36.2%) had an improvement of their sofa score while 30 (63.8%) did not. the median sofa score on admission was 5 (iqr 4-6) for those who had an improvement and 6 (iqr 6-8) for those who did not (p=0.11). cardiac arrest was the etiology of srse for 6 (37.5%) patients who improved vs. 10 (62.5%) patients who did not (p=0.89). patients required 0 to 3 vasopressors for hemodynamic support, with less needed for those who had an improvement (p=0.02). there was a higher rate of hais in patient who did not have an improvement of their sofa score (p=0.04). there is a subset of patients treated with ketamine for srse who have an improvement in their sofa score, require less vasopressor support, and have a lower rate of hais. further studies are needed to better understand which patient population may most benefit from the use of ketamine for treatment of srse. the ceribell eeg system (ces) is a novel 8 channel eeg device with instant sonification and visual display capability that can be set up quickly without an eeg technician. we hypothesized that by using ces, we can decrease time to eeg acquisition and improve diagnosis and treatment decisions in suspected nonconvulsive seizures (ncs). adult icu patients (gcs < 12) who had continuous eeg (ceeg) as part of clinical care were enrolled. once ceeg was ordered, consent was obtained and ces was placed by the treating physician (n=7) who listened to the left/right hemisphere signals for 30 seconds each. suspicion for seizure (1=low, 5=high) and decision to treat (yes/no/not sure) were rated pre-and post-sonification. three blinded epileptologists compared accuracy of sonification with visual ces eeg. outcomes were difference in time to eeg acquisition, change in suspicion for seizure and decision to treat, and ease of use (1=challenging; 5=easy). 35 patients (mean age 61 +/-18, median gcs of 6 (iqr 4-8.5) were enrolled from 7:00 am to 5:00 pm. start of eeg acquisition was significantly faster for ces (23 minutes (iqr 14-46) vs 145 minutes (iqr 93-237) p<0.001), median difference 86 minutes (iqr 60-152). one patient had ncs during sonification and this was accurately identified and treated. low suspicion for seizure (1) was more likely postsonification (63% vs 37%, p=0.029). treatment decision changed in 40% after sonification, and this was in the correct direction 86% of the time. inappropriate decision to treat decreased from 26% to 9% (p=0.07). negative predictive value was 100% (95% ci 85-100%). ces was consistently rated easy to use. the ceribell eeg system is easy to use, speeds eeg acquisition, accurately identifies ncs, and enables appropriate treatment decisions. it has the potential to greatly enhance timely diagnosis and treatment of ncs in critically ill patients. the aim of the study was to understand the efficacy of ketamine in refractory status epilepticus and identify the underlying factors affecting the effectiveness of ketamine. moreover, we also studied the rate of complications in patients who underwent continuous midazolam ketamine dual therapy for treatment of refractory status epilepticus. this is retrospective cohort study evaluating the efficacy of ketamine in patient with refractory status epilepticus in total of 52 patients admitted to university of maryland medical center in either neuro intensive care unit /micu during the last five years between (2011-2016). we established a standardized algorithm for managing refractory status epilepticus. electrographic and clinical control of seizures was classified into four groups: likely response, possible response, permanent response and no response reviewed by a team of epileptologist and neuro intensivist. the effective doses of ketamine to abort rse were studied. complications intensive care unit stay while on therapy were reviewed. of the 52 patients, 29 were male, 23 were female. 22% of the patients had cardiac arrest as an etiology of seizures. median loading dose was 1.5 mg/kg, median maintenance dosage was 4 mg/kg/hr. 25 % of the patients had no response to ketamine. 75% were responsive to ketamine of which, 12 patients had likely response to ketamine, 28 patients had possible response.38.5% of the patients had permanent response to ketamine. 67% patients had hospital acquired infections, 34 % patient had metabolic acidosis, 25% had ards. this is one of the largest single center study illustrating the efficacy of ketamine in aborting rse. further study should address the difference in incidence of complications in patients with usage of ketamine versus groups alternative therapies. this study also demonstrates the etiology of seizures and its influence on efficacy of ketamine in aborting rse. acute cardiopulmonary complications are frequently observed in convulsive status epilepticus but mechanism is poorly understood. complications include tachy-arrhythmias, myocardial ischemia, takotsubo cardiomyopathy and neurogenic pulmonary edema. herein, we mapped evolution of cardiac dysautonomia as function of 5 sequential electrographic stages of se in four subjects admitted to icu. we hypothesize pathological co-activation of both arms of autonomic system contributes to cardiac complications. heart rate variability (hrv) is considered a proxy for ans tone on heart. we analyzed hrv in time and frequency domain, complexity measure (lempel ziv-lz) during se and mapped changes as function of stages of se as determined by scalp eeg. conventional scalp eeg recording and lead i-ekg (sampled at 256 hz) were analyzed using kubios hrv software 2.1. cardiac vagal index (cvi) and cardiac sympathetic index (csi) were calculated using geometric lorenz-plot method. parasympathetic activity is expressed in rmssd, pnn, cvi, and hf power four adults (range 22-59; m=3) were admitted to icu following convulsive se. ictal hrv changes initially reflected high sympathetic system activation (high csi) and reduced vagal tone (low hf, rmssd) as reported previously with convulsive seizure. earlier stages of se (stage i and ii) were marked by dual activation of the ans with sympathetic predominance (lower cvi/csi ratio). later stages of se (stage iv and v), demonstrated progressive increase in parasympathetic activity (hf power, rmssd, cvi, cvi/csi ratio). hf power and rmssd at stage v se was three times higher than during discrete seizure. lz complexity measure downtrended with the loss of fluctuations in late stages of se. in one subject se terminated with asystole this case series highlights dynamic changes in sympatho-vagal imbalances with progressive se. dual activation of sympatho-parasympathetic system and loss of complexity measures are associated with increased cardiac complications. therapies directed towards stabilization of cardiac dysautonomia might minimize complications super-refractory status epilepticus (srse) is a life-threatening neurological condition that is characterized by status epilepticus that persists for 24 hours despite treatment with first-, second-, and third-line agents (tlas) or upon the weaning of tlas. srse is associated with limited treatment options, and high morbidity and mortality. this study aims to describe and quantify inpatient srse treatment and its associated outcomes in the us. srse cases were classified retrospectively using a modified version of a previously published algorithm applied to a large, de-identified, us electronic health record database (cerner health facts®) covering >600 hospitals (2000) (2001) (2002) (2003) (2004) (2005) (2006) (2007) (2008) (2009) (2010) (2011) (2012) (2013) (2014) (2015) . cases were classified utilizing icd-9 and procedure coding for status epilepticus (345.00, 345.01, 345.1x, 345.3, 345.41, 345.51 and 345.81) , ventilator support or with los>180 days or missing age were excluded. univariate statistics were used to describe mortality, hospital los, icu los, and discharge disposition. our algorithm classified 1153 cases as srse (1137 patients). most cases (61%) were to large (300+ beds) and/or teaching hospitals (86%). mean hospital los was 24.4 days, and icu los was 15.1 days. both los and icu los were significa average mortality rate was 23.5%. mortality rates increased with number of tlas used (1-2 tla=21.5%; 3-rged home (6% with tracheostomy), while 32% (n=285) were discharged to another facility. treatment of srse requires acute, intensive management in the hospital setting. los and mortality rates were high and increased with increasing use of tlas. while good outcomes remain possible even after srse, additional interventions are needed that enable seizure control, liberation from anesthetic and ventilator management, and improved mortality. refractory status epilepticus (se) carries an exceedingly high mortality and morbidity, often warranting an aggressive therapeutic approach. initially used in childhood epilepsies, ketogenic diet (kd) has also accumulated supporting evidence in the treatment of pediatric se. recently, the implementation of kd in adults with refractory and super-refractory se has been shown to be feasible and effective. we describe our recent experience with a new onset refractory status epilepticus (norse) patient and the unexpected challenge of achieving and maintaining a ketotic target. practical advice, a comprehensive review of offenders jeopardizing ketosis commonly used in the neurocritical care unit and alternatives is provided. a previously healthy 29-year-old woman was admitted with cryptogenic norse following a febrile illness with a course complicated by prolonged super-refractory se. a comprehensive work-up was notable only for mild cerebral spinal fluid (csf) pleocytosis, elevated non-specific inflammatory serum markers, and edematous hippocampi with associated diffusion restriction on magnetic resonance imaging (mri). repeat csf testing was normal and serial mris demonstrated resolution of edema and diffusion restriction with gradually progressive hippocampal and diffuse atrophy. she required an aggressive approach including high anesthetic infusion rates, 16 anti-seizure drug trials (in various combinations), empiric partial bilateral oophorectomy, and immunosuppression. enteral ketogenic formula was started on hospital day 27, however, sustained beta-hydroxybutyrate levels > 2mmol/l were only achieved 37 days later following a careful comprehensive adjustment of the care plan. notably, a significant response to kd was only achieved with beta-hydroxybutyrate levels > 3.5 mmol/l. there are hidden carbohydrates in commonly administered medications for se, antibiotics, and even electrolyte repletion formulations and solutions used for oral care -all challenging the use of kd in this setting. tailoring comprehensive care and being aware of possible complications of kd are important for the successful implementation and maintenance of ketosis. early seizures are estimated to occur in 18-33% of patients with moderate to severe traumatic brain injury (tbi) (herman 2015, vespa 1999). continuous eeg (ceeg) is essential for detection of nonconvulsive seizures (claassen 2004) the university of california davis protocol for tbi includes ceeg on a case by case basis, which we reviewed. a retrospective review of patients admitted to icu for tbi from 9/23/2016-3/13/2017 was performed for demographics, icu length of stay (los), and ceeg. patients with ceeg were assessed for demographics, tbi severity, gcs, ceeg indication and findings. 100 patients were identified. twenty-one were monitored on eeg. median age was 36, 24% were female. indications for ceeg included seizure prior to admission (n=4), altered mental status (ams) (n=13), ams with paroxysmal events (n=4). seizures were recorded in 2 patients. median duration of ceeg was 26.8, 296.36, and 146.25 hours among the groups. those with seizures prior to hospitalization were connected to ceeg earliest (median 14 .65 hours) but had the longest median icu los (623.27 hours), followed by ams (40.28 and 424.92 hours) and ams with paroxysmal events (78.83 and 377.88 hours). median gcs was 3, 6, and 5 respectively. median los for patients without seizures or interictal epileptiform activity (iea) was 380.63 hours, 483. 47 for those with iea only, and 580.58 for those with seizures. median gcs was 4.5, 6, and 4 among the eeg groupings. our data suggests seizures prior to hospitalization, ceeg recorded seizures, and iea predict longer icu los. associated lower gcs likely indicates more severe injuries. tbi patients with ams may have delay to seizure detection and treatment. our rate of seizure detection is lower than expected. a more consistent protocol for ceeg will likely improve seizure detection. prospective studies are needed to determine if ceeg can predict and influence outcomes. status epilepticus is a serious neurologic emergency. although many studies have been published on incident status epilepticus, there are few data on the risk of recurrent status epilepticus. we performed a retrospective cohort study using administrative claims data to identify all patients hospitalized with status epilepticus in california, new york, and florida between 2005-2013. our primary outcome was a recurrent hospitalization for status epilepticus. survival statistics were used to calculate the cumulative rate of recurrence at 30 days, 1 year, and 5 years. in subgroup analyses, we compared rates of recurrence according to age, gender, race, and etiology (stroke, traumatic brain injury, acute and chronic central nervous system (cns) infections, brain tumors, dementia, autoimmune cns disease, or unspecified etiology). we identified 37,418 patients with status epilepticus. during a mean follow-up of 2.9 (±2.0) years, 4,755 (12.7%; 95% ci, 12.4-13.0%) developed recurrent status epilepticus. the cumulative rate of recurrence was 2.7% (95% ci, 2.5-2.9%) at 30 days, 10.9% (95% ci, 10.5-11.3%) at 1 year, and 20.8% (95% ci, 20.2-21.5%) at 5 years. the 5-year cumulative rate of recurrence was 19.8% (95% ci, 18.9-20.6%) in women versus 21.9% (95% ci, 21.0-22.8%) in men, 16.8% (95% ci, 16.0-23.2% (95% ci, 22.4-24.0%) in patients <60, and 19.1% (95% ci, 18.4-19.9%) in white patients versus 23.0% (95% ci, 22.1%-24.0%) in non-white patients. the 5-year cumulative rate of recurrence was highest for status epilepticus associated with autoimmune cns disease (30.3%; 95% ci, 25.4-35.9%) and chronic cns infection (24.1%; 95% ci, 19.6-29.4%). approximately 1 in 5 patients with status epilepticus experienced a recurrent episode within 5 years. recurrence was most often seen in younger patients, non-white patients, and patients with underlying autoimmune cns disease or chronic cns infection. super-refractory status epilepticus (srse) is a rare, life-threatening form of status epilepticus (se) refractory to multiple therapies including anesthetic third-line agents (tlas). enrollment in a srse clinical trial is challenging because patients may present urgently before srse is confirmed or may dynamically improve before randomization. pivotal clinical trials in srse require patient selection criteria accurately identifying srse at randomization. in this phase 3 trial of brexanolone as adjunctive therapy for confirmed srse, the enrollment scheme enabled operationally confirming srse prior to randomization during a qualifying wean (qw) under real-time eeg neuromonitoring. informed consent was obtained for all subjects 1) admitted in se having failed first-and second-line therapies; 2) transferred on tlas in seizure-or burst-suppression; or 3) transferred without seizure-or burst-suppression or not receiving tlas. subjects were required to achieve seizure-or burst-suppression for 24 hours through continuous administration of one or more tlas, followed by a post-enrollment qw of tlas. enrolled subjects failing the qw were randomized to concomitant brexanolone or placebo following reinstitution of one or more tlas. subjects not randomized after a successful qw underwent a 3-week follow-up. the qw protocol and criteria for qw failure were developed and implemented utilizing eeg neuromonitoring to confirm srse after enrollment using the definition of shorvon and colleagues. a qw was performed on over 100 evaluable subjects across 180 international sites to enable enrollment of patients with confirmed srse. subjects with a successful qws who were not randomized provided insight into outcomes associated with se and avoided the randomization of patients who did not meet srse criteria following enrollment. the use of neuromonitoring-guided diagnosis during a structured qw helped confirm srse, facilitating the enrollment of appropriate patients into this phase 3 trial in a rare, critically ill, and dynamic srse patient population. autoantibodies to the 65 kda isoform of gulutamic acid decarboxylase (gad65 ab), commonly found in t1dm patients, have been associated with drug resistant epilepsy. ketosis prone diabetes is a heterogenous syndrome encompassing various forms of beta cell dysfunction culminating in diabetic ketoacidosis. rates of epilepsy in patients with ketosis prone diabetes are not known. we compared the prevalence of epilepsy in patients with ketosis prone diabetes in a multi-ethnic population with the prevalence of epilepsy in the type 1 diabetes population as well as the general population in a metropolitan medical center. our study design is prospective review of retrospectively collected sera of 500 patients admitted for diabetic ketoacidosis (defined as ph < 7.3, bicarb < 17, with ketonemia or ketonuria) for the presence of gad65 ab. all these sera were assessed separately for autoantibody presence or absence at dr hampe's lab in washington, seattle. we also reviewed patients medical records for neurological diagnoses. this done in a blinded fashion by two separate reviewers. out of our 500 patients with ketosis prone diabetes, 4.3% also had epilepsy. this is higher than the published rate in type 1 diabetics (1.35%) and the general population in the surrounding area (<0.05%). antibody testing revealed 21% of patients with ketosis prone diabetes were gad65 ab positive with a rate of epilepsy of 1%. a two-tailed t test between the gad65 ab + group and gad65 ab -group showed no statistically significant difference in prevalence of epilepsy in these two groups. while prevalence of epilepsy is higher in the ketosis prone diabetes population than the general population of houston, the difference is not related to titers of gad65 ab, and must be due to some other unknown factor in these patients management of refractory status epilepticus commonly involves the induction of seizure-or burstsuppression using anesthetic agents. however, the duration and endpoints of these therapies are not well defined. specifically, weaning anesthetic agents is complicated by the emergence of eeg patterns on the ictal-interictal continuum (iic), which have uncertain significance, given that iic patterns may worsen cerebral metabolism and oxygenation, have a dissociation between scalp and depth eeg recordings, and indicate a late stage of status epilepticus itself. determining the significance of iic patterns in the unique context of anesthetic weaning is important to prevent the potential for unnecessarily prolonging anesthetic coma. we identified a series of patients who underwent over 48 hours of burst-suppression therapy, multiple weaning attempts, and continued weaning despite the initial emergence of iic patterns. patients who experienced anoxic brain injury were excluded from the series. we report 5 cases of patients who underwent successful weaning despite initial emergence of iic patterns. eeg patterns following anesthetic weaning (including lateralized periodic discharges approaching 3 hz frequency and lateralized rhythmic delta activity) as well as terminal eeg patterns are described in detail. in these 5 patients, continuing weaning of anesthetic agents despite the emergence of iic patterns did not result in relapse to status epilepticus. while the metabolic impact of these patterns on brain activity is uncertain, weaning strategies that treat iic as a surrogate of recurrent status epilepticus risk further prolonging anesthetic management and its known toxicity. we speculate that iic patterns are transitional and may have a context-specific association with status epilepticus relapse, with less risk conferred when these patterns are observed during the weaning of anesthetic agents after prolonged burst-suppression therapy. other electrographic features aside from this clinical context may discriminate the risk of status epilepticus relapse, such as eeg background activity. brivaracetam (brv) is approved as adjunctive therapy for focal (partialyears) with epilepsy. brv is available as oral tablets, oral solution, and an intravenous (iv) formulation. the formulations are interchangeable. this abstract reports the safety and tolerability of iv brv. during clinical development, 177 participants received iv brv. we report pooled safety findings from 153 participants receiving brv 25-150 mg doses. the therapeutic range of brv is 25-100 mg twice daily. in n01256, 24 healthy volunteers received iv brv as a 15-minute infusion or 50 mg/min bolus (25, 50, 100, or 150 mg single doses; n=6 in all groups). in ep0007 (nct01796899), 25 healthy volunteers received iv brv 100 mg as a single 2-minute bolus injection or oral tablets. in n01258 (nct01405508), 104 patients received 7 days of brv oral tablets 100 mg twice daily or placebo, and then 4.5 days of iv brv 100 mg twice daily either as a 2-minute bolus or 15-minute infusion for nine doses in total. treatment-emergent adverse event (teae) data were pooled. data reported are for iv brv 25-150 mg (n=153). most frequent teaes were somnolence 30.1%, dizziness 15.7%, fatigue 15.0%, headache 7.2%, dysgeusia 6.5%, euphoric mood 3.9%, feeling drunk 3.9%, and infusion-site pain 3.3%. infusion-site pain was specific to administration route. most teaes were mild or moderate and occurred mostly in healthy volunteers. iv brv was well tolerated, with an ae profile consistent with oral administration except for routespecific injection-site aes, dysgeusia, euphoric mood and feeling drunk. the interpretation of these data was complicated by the difficulty of pooling disparate studies involving healthy volunteers and epilepsy patients with heterogeneous medical histories and concomitant antiepileptic drug use. further clinical trials or real-world experience are needed to understand potential clinical impact. ucb pharma funded refractory status epilepticus (rse) is a challenging condition that requires multiple antiepileptic drugs (aed) to treat. during rse, the brain is under excessive excitation, which results in an increase in glutamate receptors such as alpha-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid (ampa) and nmethyl-daspartate (nmda).. perampanel (per), a novel, noncompetitive ampa-receptor antagonist, may have a role in the treatment of rse and there are positive results in different animal models with rse. we identified 8 adults patients over a 6 month period who were treated with per for different forms of rse. one was excluded as the etiology of rse was anoxic brain injury and care was transitioned to comfort only within 24 hours of initiating per. three patients had a definite response to per, which we defined as resolution of ictal patterns on electroencephalogram (eeg) within 48 hours of per without adding a new aed. one had a possible response with significant improvement in eeg findings; however, there was some eeg improvement predating the initiation of per. in observed several treatment factors that may have increased response to per. those who responded had it used earlier in the treatment cascade (sixth or seventh vs. ninth or tenthaed ), higher initial dose (8 mg vs 4mg), and were escalated to maximum dosage within 48 hours. they were also more likely be receiving continuous ketamine and midazolam, suggesting a possible synergy with per. there were no documented adverse effects in any patient prior to discharge. one patient did experience a decline in phenytoin levels, which could be related to per as there are reports of enzyme-inducing properties. we observed efficacy of per in several patients with focal and generalized rse without a significant adverse effect profile. further studies are needed to clarify the dosing, timing and appropriate indications in rse treatment. topiramate is a potent broad-spectrum anti-epileptic drug (aed) with several mechanisms of action including blockage of the inotropic glutamatergic ampa receptor, voltage-gated sodium channels, antagonism of non-nmda glutamate receptors and enhancement of gaba mediated chloride conductance. we hypothesize that topiramate is an effective adjunctive therapy in rse and srse due to multiple mechanisms of action. we performed a retrospective analysis of 11 patients admitted to the intensive care unit with status epilepticus (se) at a tertiary referral center from 2013-2016. we reviewed demographics, age, seizure type, etiology, prior aed/topiramate exposure, time to response to treatment, eeg reports and neuroimaging results. rse was defined as failure of benzodiazepine and another conventional second line aed to stop se. srse was defined as se that continues or recurs 24 hours after being treated with an anesthetic agent. 6 (55%) were male, 6 (55%) had a history of seizures; mean age of patients with se was 62.5 years. of 11 treated patients, 6 (55%) had focal non-convulsive se (ncse), 1 (9%) had myoclonic se, 1 had myoclonic, followed by generalized ncse,1 (9%) had generalized ncse, and 1 (9%) had focal and generalized nonconvulsive se, prior to administration of topiramate. 3 (27%) patients were treated with 2 aeds, 8 (72%) patients with 3 aeds prior to topiramate. electrographic seizures improved in 10 (91%) patients after receiving topiramate. resolution of electrographic seizures occurred within 12 hours in 2 (18%) patients, 24 hours in 4 (36%) patients, 48 hours in 2 (18%) patients and 72 hours in 2 (18%) patients. our findings suggest that topiramate could be an effective adjunctive treatment in rse and srse. however, prospective studies, including larger number of patients are needed to confirm these findings. patients with refractory status epilepticus (se) require multiple antiepileptic drugs (aeds) to abort seizures, and often barbiturates. there is a paucity of data on how to wean aeds safely once seizures are controlled while minimizing medication side-effects or withdrawal symptoms. a retrospective review of 160 patients admitted to mayo clinic in rochester, minnesota for se between 2006 and 2016 was performed. patient demographics, se type (focal versus generalized, convulsive, and refractoriness), seizure etiology, aeds in admission and at outpatient follow-up, aed side effects from use and withdrawal, and functional outcomes in terms of modified rankin scale were recorded. 44 of 160 (27.5%) patients had refractory se, 24 (15.0%) patients had refractory non-convulsive status epilepticus (ncse), 62 (38.8%) patients had convulsive se, 18 (11.2%) patients had ncse, and 12 (7.5%) patients had epilepsia partialis continua. of the 122 patients with outpatient follow-up (ranging 1 to 50 weeks following hospital discharge with 68.0% patients following-up within one month), 120 patients were on an aed regardless of etiology. patients were on a median of 1 aed in both refractory and nonrefractory se at follow-up. 9 (5.6%) patients had withdrawal seizures after aeds were weaned (3 had a prior stroke, 1 traumatic brain injury, 2 idiopathic, 2 multifactorial). none of the 13 patients completely weaned off a barbiturate had seizure recurrence at follow-up. 6-month mortality in refractory se was 22/68 (32.4%) and 23/92 (25.0%) in non-refractory cases. favorable functional outcome at follow-up was achieved in 17/68 (25.0%) patients with refractory se versus 29/92 (31.5%) in non-refractory se. we found a low rate of late seizure recurrence after weaning aeds in refractory and non-refractory se, particularly in the case of barbiturates. spreading depolarizations (sd) are strongly associated with secondary brain injury after aneurysmal subarachnoid hemorrhage (sah). however, studies to understand whether sds play a causal role in secondary injury are hindered by existing sd induction methods which are invasive, cumbersome, and cause primary tissue injury. we developed a method to study the role of sds after experimental sah using commercially available transgenic optogenetic mice which express channelrhodopsin (chr2) in cortical neurons. we used in vivo laser speckle and doppler flowmetry, intrinsic signal imaging, and local field potential (lfp) and extracellular potassium shifts to detect sds. we optogenetically induced sds with light through intact and unaltered skull in multiple regions without causing primary brain injury. we found regional differences in thresholds for optogenetically-induced sds (from lowest to highest threshold): (1) whisker barrel, (2) motor, (3) sensory, and (4) visual cortex. lower thresholds were associated with higher chr2 tissue expression. changes in lfp and increased extracellular potassium concentrations at the site of stimulation preceded precipitation of an sd. finally, we induced and detected sds in the setting of sah over several days through chronically implanted glass coverslips non-invasive optogenetic light stimulation can reliably induce sds in the setting of sah. longitudinal optogenetic induction of sds in chr2 transgenic mice is a potentially useful tool to study the role of sds in the pathogenesis of secondary brain injury after sah. aneurysmal subarachnoid hemorrhage is a devastating neurologic injury with significantly prolonged hospital courses and high morbidity and mortality. when aneurysms are detected, they often require securement either via surgical clipping or endovascular techniques. a subset of intracranial aneurysms, given location, poor surgical approach, and wide neck are amenable to flow diversion which promotes thrombosis through redirecting of blood flow within an aneurysm leading to slow obliteration. approximately 10% of treated aneurysms with flow diversion do not obliterate after 12 months, but currently there is no validated way to predict treatment failure. computational models of blood flow of flow diverted aneurysms predict a significant difference in the hemodynamic energy loss across aneurysms between cases that resolve and those that do not. energy loss could be estimated clinically during angiography, however, this hypothesis needs to be validated experimentally because computer models often over estimate hemodynamic parameters, poorly predict flow through stents, and may not have the resolution to fully describe intra-aneurysmal blood flow. in this pilot study, four cases of giant fusiform intracranial aneurysms will be selected --two with resolution following flow diversion treatment, and two without resolution. models of each vessel geometry will be fabricated using additive manufacturing techniques. under fluoroscopy, within the model vessel, flow diverting stents will be placed within the aneurysm in the same configuration that was achieved clinically. model blood, containing tracer particles will be pumped through model aneurysms and using particle image velocimetry, energy loss will be calculating within model vessels following treatment. energy loss between aneurysms successfully and unsuccessfully treated with flow diversion will be compared experimentally. hemodynamic energy loss may be a clinically measurable value which could predict treatment failure after flow diversion. additive manufacturing techniques can be used to test patient specific hemodynamics to improve understanding of flow-diversion treatment success or failure. the national institute of neurological disorders and stroke (ninds) and the national library of medicine (nlm) initiated development of unruptured cerebral aneurysms and subarachnoid hemorrhage (sah)specific common data elements (cdes) in 2015 as part of a joint project to develop data standards for funded neuroscience clinical research. through the development of these data standards, the ninds and nlm sah joint cde initiative strives to improve sah data collection by increasing efficiency, improving data quality, reducing study start-up time, facilitating data sharing/meta-analyses and helping educate new clinical investigators. the sah cde working group (wg) consisted of 83 international members with varied fields of sahrelated expertise and was divided into domains such as subject characteristics and assessments and exams. the wg developed a set of sah-specific cde recommendations by selecting among, refining and adding to existing field-tested data elements, especially established stroke cdes. wg cde recommendations were drafted into the nih cde repository. following an internal review of recommendations, the sah cdes were vetted during a public review on the ninds website for 6 weeks and later posted on nlm and ninds websites. version 1.0 of the sah cdes was available on the ninds cde website in april 2017. these new sah cdes and recommendations include those developed for unruptured intracranial aneurysms and long-term therapies. the website provides uniform names and structures for each data element, as well as guidance documents and template case report forms using the cdes. the ninds encourages the use of cdes by the clinical research community in order to standardize the collection of research data across studies. the ninds cdes are a continually evolving resource, requiring updates as research advancements indicate. these newly developed sah cdes will serve to be a valuable starting point for researchers and facilitate streamlining and sharing data. subarachnoid hemorrhage (sah) represents 5% of stroke admissions in the us. aneurysmal hemorrhage represents the most dangerous etiology, however 10-15% of sah have negative digital subtraction angiography (dsa). there is variation in practice with regards to repeat diagnostic studies and timing of such studies. it is not uncommon to repeat dsa in 7-10 days of the initial assessments. this study aims to describe the costs associated with prolonged icu stay and repeat diagnostic studies this patient cohort. retrospective review of all patients admitted for spontaneous sah between january 2011 and april 2017 at our single institution. patients with at least one negative initial angiogram for suspected spontaneous sah were included. patients were categorized into diffuse patterns of sah and nondiffuse. cost estimates were based on standard costs as provided by our financial department and cdc estimates for costs of hospital acquired infections. one hundred fifty-four patients were identified with initial negative dsa. second angiograms were performed in 81% of patients, and potentially positive causal findings in 18/125 (14.4%). icu los for angiogram negative diffuse sah and non-diffuse were 10.1 and 6.5 days respectively. other indications for icu stay included vasospasm (8.5%), evd placement (30.8%), and intubation (22%). the excess cost estimates per patient for angiogram negative diffuse and non-diffuse sah were $71,567 and $52,843 respectively. hospital acquired complications were an additional total $57,422 for the cohort. this is the first study to our knowledge attempting a cost analysis of the diagnosis and management of patients with angiogram negative sah. we had a high frequency of patients requiring icu admission for other indications, which should continue to dictate the level of care. however, there may be a cohort of lower risk patients in which de-escalation would not harm, and be of benefit in the reduction of morbidity and cost. purpose: to evaluate the feasibility and potential role of bedside optical coherence tomography (oct) as a diagnostic protocol in terson's syndrome (ts) in patients with acute subarachnoid hemorrhage (asah). background: 10% of sah patients become permanently legally blind. the average cost of lifetime support and unpaid taxes for each blind person is approximately $900,000. ts presents as ocular bleeding commonly associated with asah. it can be diagnosed by fundoscopy, yet retinal haemorrhages, detachments and macular holes may be undetected. early ts identification is critical since untreated it may lead to legal blindness, limit rehabilitation and impair quality of life. pilot study: 31 sah patients were screened for ts with dilated fundoscopy and then with oct. mood assessments (phq-9, hds), quality of life measures (nih-promis) and subjective visual function scales (vfq-25) were performed. there was a 22.6% (n=7) incidence of ts. dilated retinal fundoscopy significantly failed to detect ts (n=4, 57.1% missed cases). ivh was significantly more in ts (85.7% vs. 25%). no participants experienced any complications from oct examinations. neither decreased quality of life visual scores nor a depressed mood correlated with objective oct pathological findings at 6 weeks follow-up after discharge. there were no significant mood differences between ts cases and controls. oct is the gold-standard in retinal disease diagnosis. this pilot study showcases its bedside feasibility in asah. in our series, oct was a safe procedure that enhanced ts detection by decreasing false negative/ inconclusive fundoscopic examinations. it allows early diagnosis of macular holes and severe retinal detachments, which require acute surgical therapy to prevent legal blindness. besides, oct aids ruling out potential false positive visual deficits in individuals with a depressed mood at follow up. a comprehensive study is underway to understand the impact oct might exert on blindness prevention and quality of life. fever is common in patients with aneurysmal subarachnoid hemorrhage (asah), and blood cultures are commonly sent to diagnose etiology. several studies have shown a low incidence of positive blood cultures, but no studies have assessed blood cultures in patients with asah. we performed a retrospective analysis of patients admitted with asah between january 2013 to december 2015. blood cultures were adjudicated as true positive (tp) or false positive (fp) based on speciation, time to positivity, number of cultures positive, and repeat culture results. tp patients were compared to all other patients. age, gender, hunt hess, modified fisher, aneurysm treatment, incidence of delayed cerebral ischemia (dci), length of stay (los), and neurological outcomes were analyzed. 324 patients with asah were included. blood cultures were sent on 195 (60%). sixteen were positive. eleven were adjudicated tp and 5 fp. thus, 3.4% (11/324) of patients had true bacteremia, and blood culture yield for true infection was 5.6% (11/195). fp rate was 2.6% (5/195). eight tps were gram negative (73%), and all contaminants were staphylococcus non-aureus. median post-bleed day for tp results was 23. only 3 patients were tp within the first week of admission (0.9%). tp patients had higher admission wfns (p=.015) and ivh score (p=.006), but age, gender, aneurysm treatment, and fisher score did not differ. tp patients had longer icu and hospital los and higher incidence of dci (56% vs 27%, p=.026). mortality did not differ in the two groups either. the yield of blood cultures in asah patients is low. even with a contamination rate under 3%, 31% of positive blood cultures are fp. future studies should evaluate factors to identify patients at higher risk of bacteremia to reduce costs and improve care. intra-arterial verapamil therapy reduces cerebral vasospasm after aneurysmal subarachnoid hemorrhage (sah). there is little literature that quantitatively describes its safety, required dosing, or efficacy. as a result, therapeutic outcomes need to be subjectively analyzed by experienced radiologists during the intervention and clinically correlated by cerebral perfusion pressure, intracranial pressures and transcranial dopplers. we present a novel imaging analysis to quantify cerebral perfusion in realtime and apply this technology to patients undergoing therapy for vasospasm. we developed software to evaluate changes in contrast flow dynamics for digital subtraction angiography (dsa) scans performed pre-and post-intra-arterial therapy for vasospasm. performing signal intensity curve deconvolution on a voxel by voxel basis provides quantitative 2d perfusion parameters including: time to peak, time to drain, area under the curve, root mean transit time, arrival time, tissue concentration, arterial input functions and cerebral blood flow at each voxel. after aligning perfusion studies, our software then displays and automatically creates regions of interests for changes in perfusion to visualize the effects of interventions. our software quantitatively measures perfusion from dsas and can normalize two dsas accounting for differences in volume and speed of contrast administration. two applications of this technology are demonstrated. the first subtracts perfusion from pre-and post intra-arterial interventions quantifying exact changes in perfusion at each voxel. the second compares two dsa studies of the same patient at different dates to contour the territories susceptible to delayed cerebral ischemia. we compare this analysis to mri imaging when applicable demonstrating ischemic changes aligning to the susceptible territories outlined by our analysis. dsa based perfusion is an effective study to quantify the need for and the precise effects of endovascular interventions. quantitative thresholds and analysis based on dsa perfusion may assist with real-time assessment of treatment efficacy for patients undergoing intra-arterial verapamil therapy. we aim to characterize the clinical predictors of ventriculoperitoneal shunt (vps) placement in aneurysmal subarachnoid hemorrhage (asah) patients. there has been no clear consensus as to effective measures of predicting vps placement in these patients. we reviewed the clinical data of patients with aneurysmal subarachnoid hemorrhage (asah) who were treated at our institution between 2011-2014. we eliminated patients who died or had withdrawal of care during admission. we recorded patient demographics and clinical predictors including admission/discharge glasgow coma scale (gcs), hunt hess score, aneurysm size/location, modified fischer score, modified rankin scale (mrs), intracranial pressure (icp) values during evd clamp trial, and incidence of vasospasm requiring intra-arterial therapy. there were 112 patients included in this study and 36% of patients required vps (n=42/112). vps patients had significantly worse mrs functional scores at discharge (2.7 vs 3.4; p=0.029), but this began to balance at 1 year (2.5 vs 3.3; p=0.08). aneurysms were significantly larger in vps patients (7.4cm vs 5.5cm; ci: 0.57 to 3.38; p=0.006). a greater percentage of vps patients had posterior fossa aneurysms, but this was not found to be statistically significant (37% vs 52%; p=0.12). vps patients had significantly lower gcs scores at admission (12.9 vs 14.1; p=0.02), and discharge (11.7 vs 9.4; p=0.01). there was no difference in modified fischer score (p=0.36) or hunt hess (p=0.06), but both variables were higher in the vps cohort. there was no difference in the frequency of vasospasm in the vps cohort (p=1.0), or icp values (p=0.15). patients presenting with large aneurysms and poor gcs scores had a significantly higher likelihood of requiring vps during admission. these patients had significantly poorer mrs scores at discharge but not at 1 year. subarachnoid hemorrhage (sah) affects a young population and results in death or disability in the majority of those who experience it. this epidemiology is very different from other forms of stroke. consequently, patients with sah and their families may have different priorities for recovery. involving patient perspectives is encouraged in research and is often accomplished using patient-reported outcome measures (proms). however, whether proms reflect patient and family priorities is unclear given that (a) proms are often developed without their input; and (b) generic proms may not apply to specific conditions. we aimed to systematically review the sah literature that has: a) involved patient, family or caregivers in evaluating existing outcome measures, b) developed novel outcome measures by incorporating their perspectives (including co-development), or c) described outcomes important to patients, families, or caregivers. we searched embase and ovid medline from inception to december 19, 2016. study eligibility and data extraction was performed independently and in duplicate. for each eligible citation, we abstracted the following: study population, design, type of patient involvement, and outcome measure(s), as applicable. we planned a qualitative summary of all included studies. our search yielded 4275 unique citations. only four articles have met our eligibility criteria. in each, patients (n=235) self-report impairments resulting from sah and their impact on their lives (aim c). none involve the evaluation of prom applicability. additionally, we found 8 articles that, although they did not meet our a priori eligibility criteria, discuss collecting proms (n=2), using proms to predict health outcomes (n=4), and comparing prom applicability without patient perspectives (n=2) in sah populations. based on our findings, there is alack of patient, family, or caregiver involvement in selecting or identifying outcomes after sah with direct relevance to them. sah research may be overlooking outcomes that are important to patients. early brain injury (ebi) after aneurysmal subarachnoid hemorrhage (asah) is defined as brain injury occurring within 72 hours of aneurysmal rupture. although ebi is the most significant predictor of outcomes after asah, its underlying pathophysiology is not well understood. we hypothesize that ebi after asah is associated with an increase in peripheral inflammation measured by cytokine expression levels and changes associations between cytokines. methods asah patients were enrolled into a prospective observational study and were assessed for markers of ebi: global cerebral edema (gce), subarachnoid hemorrhage early brain edema score (sebes), and huntassays to determine levels of 13 pro-and anti-inflammatory cytokines. pairwise correlation coefficients between cytokines were represented as networks. cytokines levels and differences in correlation networks were compared between ebi groups. of the 71 patients enrolled in t associated with high grade sebes. correlation network analysis suggests higher systematic inflammation conclusions ebi after sah is associated with increased levels of specific cytokines. peripheral levels of il10, il6 and ession levels of individual cytokines may offer deeper insight into the underlying mechanisms related to ebi. few recent studies have evaluated health resource utilization and patient outcomes in aneurysmal subarachnoid hemorrhage (asah) in the united states. empirical evidence implicates asah as one of the highest cost diseases treated in the hospital. we identified asah patients to determine hospital charge, length of stay (los) and patient disposition associated with care in u.s. hospitals using claims data from the 2013 national inpatient sample (nis). patients within the international classification of disease, 9th revision (icd-9) 430 diagnosis code were identified; a secondary analysis of the nis (2013) was conducted utilizing icd-9 clinical modification codes excluding patients with traumatic and non-aneurysmal sah. population size, patient outcome, average charge and average los were calculated using subgroups including: aneurysmal clipping or endovascular coiling (n=5,925), aneurysmal clipping or coiling with external ventricular drain (evd) (n=4,660), use of evd only (n=2,355), other surgical procedures (n=880) and medically managed (n=1,545). analyses were survey-weighted and adjusted for patient and hospital characteristics. in 2013, asah resulted in an average per patient hospital charge of $308,139, an average los of 17 days, an average mortality of 20% and total, annual hospital charges of $4.7 billion. the highest average charge per patient ($417,042) and hospital los (22 days) were attributed to clipped or coiled patients with evd, and highest mortality (47%) found in medically managed patients. these data support the conclusion that asah is a high cost illness managed in u.s. hospitals, and help raise awareness to the potential economic benefits resulting from developing safer, more effective therapies. additional analyses with updated datasets including lifetime burden of asah (e.g. physician fees, long term medical and care costs, hospital re-admission impact, quality of life, productivity loss, caregiver burden) should be explored to understand the full economic burden of asah and the potential cost effectiveness of new therapies. external ventricular drain (evd) placement is a mainstay of treatment for patients with aneurysmal subarachnoid hemorrhage with hydrocephalus or elevated intracranial pressures, but the optimal strategy for evd management is still unclear. the goal of this study was to compare the impact of evd clamping at three different levels on the duration of drain placement and the intensive care unit (icu) length of stay. we performed a retrospective analysis of patients admitted with aneurysmal subarachnoid hemorrhage to the neurological icu from december 2015 to january 2017 and included all patients who had an evd placed. patients who died were excluded from the study. patients were divided into three groups: patients whose evd was clamped at 10 mmhg, patients whose evd was clamped at 15 mmhg, and patients whose evd was clamped at 20 mmhg. duration of drain placement in days and icu length of stay in days was compared among the 3 groups using an analysis of variance (anova). outcomes were adjusted for presenting hunt-hess score, modified fisher grade, gender, and age. there were 10 patients who had their evd clamped at 10 mmhg, 23 who had their evd clamped at 15 mmhg, and 25 who had their evd clamped at 20 mmhg. there was no difference in duration of evd placement among the three groups (adjusted p-value 0.36, unadjusted p-value 0.6) nor in icu length of stay (adjusted p-value 0.18, unadjusted p-value 0.43). evd clamping at three different levels did not affect drain duration nor length of stay in icu. this study was limited by the small number of patients enrolled. further studies are need to clarify optimal strategies for evd management in the icu. headache is a presenting complaint in majority of patients with asah and is known to persist long after initial icu care. various medications have been used for control of headache with major emphasis on opiate use. history of a prescription for an opioid pain medication increases the risk for overdose and opioid use disorder. we looked at prevalence of opiate use at discharge and its associated factors. chart review of all patients admitted in a tertiary care center between jan 2014 and march 2016 was carried out. along with baseline demographic data, information about use of pain scores, csf diversion, use of opiates, average morphine equivalent doses, use of opiates at discharge and destination at discharge was collected. analysis was carried out using microsoft excel. the study was approved by hospital irb. 52 patients were admitted with asah in above period (70% female, average age: 57 yrs). 45 (62% home, 25% snf) survived to discharge. among survivors, 40% required csf diversion for hydrocephalus. all people complained of pain on presentation and were prescribed opiates during hospital stay. average oral morphine equivalent doses used was 86 mg per day. 25 (56%) patients were prescribed opiates on discharge. alternative regimens included (2 patients: tricyclic antidepressant (tca), 2 opiate + tca, 1 acetaminophen, 1 dexamethasone, tca and opiates). most common prescribed form of opiate was oxycodone. there was no significant association between opiate use/morphine dosing and age, gender, final disposition and csf diversion, opiate prescription at discharge is common in patients with asah. no clinical characteristic seem to predict analgesic need at discharge. little data exists about better alternatives leading to variety of treatment approaches. further controlled trials are needed to decrease opiate use and prevent adverse effects delayed cerebral ischemia (dci) in sah has been associated with vasospasm-dependent and vasospasmindependent phenomena. for more than 40 years isolated hemostasis disorders have been reported in these patients. the objective of this systematic review is to describe the natural history of hemostasis in sah. we systematically reviewed the medline, embase, cochrane and lilacs databases using controlled language and the prisma statement and included studies on spontaneous sah analyzing any hemostasis parameter. we screened 1794 titles, of which 57 observational were included. evidence was evaluated following the strobe statement. no meta-analysis was attempted because of the methodological nature and heterogeneity of the studies. hemostasis is profoundly altered during the first hours after bleeding, with several alterations noted including a hypercoagulable state concomitant with increased fibrinolysis activation and reduced clot stability. direct and indirect coagulation markers show a trend towards normalization of hemostasis in the first 2 to 3 days. platelet count decreases with a nadir 4 to 6 days after bleeding and a recovery in the following weeks. a later nadir is associated with dci. platelet aggregability is consistently decreased in the first few days, regaining its normal function around the second week after bleeding. in addition, the persistence of these alterations or the presence of a second peak in pro-coagulatory activity is associated consistently with dci and worse functional outcomes. the hyperacute phase of sah is characterized by a profound activation in hemostasis with reduced clot stability, probably due to an increase in the fibrinolytic pathways. on the second day post-bleeding, a slow trend towards normalization takes place, except in patients evolving towards dci. further research on the pharmacologic manipulation of hemostasis in sah might be warranted to decrease dci and improve outcomes in this population. hypertonic saline(hts) is a treatment for sah-related cerebral edema, administered to improve cerebral perfusion and reduce brain injury. hts a supra-physiological chloride concentration that can contribute to acute kidney injury which can lead to a poor outcome. in a previously published single-center cohort of 1,267l sah patients, 16.7% developed acute kidney injury (aki). hyperchloremia, but not hypernatremia, was correlated with an increased risk to develop aki (o.r. 7.39 ). aki was correlated with increased mortality. a secondary analysis of the aforementioned sah patient cohort (2009) (2010) (2011) (2012) (2013) (2014) , was analyzed. trends of acute kidney injury were evaluated in relation to the burden of exposure to intravenous chloride, as well as serum levels of sodium and chloride. the proportion of patients developing aki with a maximal serum chloride concentration of 108 (p 109, will be randomized into one of two treatment groups: standard hypertonic saline solution (nacl 23.4%) versus a solution of nacl/na-acetate. we hypothesize that by reducing the iv chloride burden(baseline compared to post randomization exposure), the delta serum chloride level will decrease, and will subsequently reduce aki occurrence (acetate trial, clinicaltrials.gov nct03204955). aki is common in sah patient population, and associated with worse outcomes. serum chloride concentrations are a significant risk factor for the development of aki. a prospective randomized clinical trial now underway examining the relationship between the hypertonic solution composition and serum chloride concentration, and to the development of acute kidney injury in aneurysmal sah. spontaneous spinal subarachnoid hemorrhage (ssah) is a rare but serious condition that can lead to a variety of medical complications. literature to this point primarily includes isolated case reports, and none have looked at hyponatremia as a complication. patients were identified from the electronic medical record database at the mayo clinic in rochester, minnesota. the advanced cohort explorer tool was used, searching from january 2000 to december 2015. inclusion criteria were spinal subarachnoid blood products due to hemorrhage into the spinal subarachnoid space not due to (1) redistribution of blood from intracranial subarachnoid hemorrhage, (2) trauma, (3) medical procedures, or 4) predominant hematomyelia who experienced symptoms and received treatment at our facility. eight patients (median age 70 years, range 51-87) were identified as meeting the study criteria. five of these eight patients experienced hyponatremia during hospitalization with a median value of 125 meq/l. all of these patients were treated with free water restriction and one patient briefly received 1.5% sodium chloride solution; in all cases the hyponatremia improved after free water restriction. in all cases the hyponatremia improved with fluid restriction, and there was no documentation of increased urine output, suggesting that it was likely due to siadh. cord compression and hyponatremia were present together in two patients, and in these cases treatment of the hyponatremia was particularly useful to avoid worsening edema. to our knowledge this is the first compilation of cases of spontaneous ssah highlighting hyponatremia as a complication. there is significant morbidity and mortality associated with aneurysmal subarachnoid hemorrhage (sah) and only about 20% of patients survive and resume their previous lifestyle after 3-6 months. many randomized clinical trials (rcts) have been conducted yet no treatment definitively improves outcome from sah. outcome is strongly related to baseline factors, yet imbalances are common in early trials. we developed a technique to identify promising treatments at early phase using a pooled control arm model (ppredicts: kent, shah, mandava neurology 2015) that compares early studies at their own baselines. we applied this method to sah to develop a multi-dimensional model (ppredicts-sah). models for functional outcome and mortality (dependent variables) were developed based on baseline variables (eg: wfns grade 4-5 % and age) using methodology developed for ischemic stroke (mandava, kent, stroke 2009 ). the outcome model is a 3-dimensional surface bounded on either side by +/-0.1 prediction interval surfaces. these prediction interval surfaces incorporate statistical variability to assess whether a treatment differs from expected outcome. treatment arms from rcts and single arm trials, of various treatments of sah were compared against the pooled controlled arm. the best model fit was for good outcome (modified rankin score 0-2 equivalents) based on % patients with wfns 4-5 and age (r2=0.54; p<0.001). seven trials of known negative drug tirilazad were superimposed on the model and fall within the +/-0.1 prediction interval surfaces confirming futility. three trials were neutral and within the prediction interval surfaces while case series using implanted prolonged release nicardipine and a low dose heparin study were above the +p=0.1 surface showing promise. models were also developed for mortality (r2=0.23, p=.02). outcome models based on percentage of high grade wfns and age were successfully developed. this approach may be useful to prioritize treatments worthy of further study. oral nimodipine is recommended to improve outcome in treatment of aneurysmal subarachnoid hemorrhage (asah). fda approved nimodipine liquid oral solution (nos) in 2013 to reduce complications associated with administering nimodipine capsules (nc) to patients with impaired swallow. experience with nos at our center has been complicated by increased liquid bowel movements (lbm) prompting unnecessary testing for infectious diarrhea and exposure to invasive fecal management devices. study approved by local qualtiy improvement review committee. data was collected prospectively in consecutive patients diagnosed with asah during intensive care unit (icu) course. formulations of nimodipine available were generic nc (heritage pharmaceutical) and nos (arbor pharmaceuticals). we examined total icu days exposed to nos, icu days with lbm, infectious diarrhea investigations, and fecal management device use. all statistical tests were performed using minitab. 27 patients were studied from 3/6/2017 to 6/23/2017; 17 patients exposed to nos for 143 icu days, 71 icu days with lbm, 7 infectious diarrhea investigations, and 5 required fecal management devices. 17 patients exposed to nc for 154 icu days, 9 icu days with lbm (all cases were also received nos), no infectious diarrhea investigations, and no fecal management device requirements. odds ratio for lbm with exposure to nos was 15.9 (95% ci 7.5 to 33.5, p < 0.0001). the high incidence of lbm with nos resulted in more infectious diarrhea testing and fecal management device use. uncontrolled diarrhea may increase risk for dehydration and delayed cerebral ischemia, although this is not explored in the current study. nos can mitigate risks associated with needle aspiration of nc, however these issues coupled with higher cost may limit benefit of its use. possible solutions may include compounding nc into a liquid formulation by pharmacists or pharmacy technicians. possible safety and cost benefits require further investigation. headache (ha) management after subarachnoid hemorrhage (sah) is challenging and lacks standardization. we hypothesized that inadequate inpatient ha pain management leads to the development of chronic ha (cha) after sah. prospective, observational study of non-traumatic hunt and hess (hh) grades i-iii sah patients admitted from 2/2014 to 12/2014. after informed consent we recorded demographics, clinical and radiographic features, analgesic and steroid doses, hospital course and inpatient pain scores using numeric rating scale (nrs, 0-10) before (nrs-pre) and after each analgesic administration over post-bleed days 0-14. a phone survey administered 12-24 months after admission evaluated cha burden. inpatient ha control effectiveness was evaluated by percent pain resolution from initial pain score, using nrs-pre. the percentage of administrations yielding full pain resolution was compared between those with and without cha. chi-square and t-tests were used for statistical analyses. 29 patients, 69% female, mean age 54.8 ±11.4 years with hh grade i (6/29), ii (16/29), and iii (7/29) sah were enrolled with 7 lost to follow-up. at follow-up, 27.3% patients (6/22) reported daily ha, 13.6% (3/22) occasional ha, and 59% (13/22) no ha. full pain resolution after analgesic administration was associated with less cha (57 [17.4%] vs. 80 [24.3%], p=0.029). mean daily inpatient opioid dose (morphine equivalents) for patients with and without cha was 14.9 mg and 8.9 mg, respectively (p=0.28). mean nrs-pre were 4.94 vs 4.12 for patients with vs without cha, respectively (p=0.05). inpatient analgesia for sah-related ha is inadequate and may be associated with the development of chronic ha. patients with cha had higher mean inpatient pain score and fewer analgesic administrations resulting in complete pain resolution. inpatient opioid dose per day was higher in cha group, although not statistically significant. additional research is needed to characterize the relationship between inpatient headache management and chronic headache after sah. subarachnoid hemorrhage (sah) remains a significant cause of neurological morbidity and mortality with few interventions to prevent delayed cerebral ischemia. hypocapnia has been associated with worse outcomes in brain injury. sah patients may be particularly susceptible to hypocapnia induced vasoconstriction. this study aims to describe the incidence of iatrogenic and spontaneous hyperventilation in sah patients. a descriptive analysis was performed on a retrospective cohort of adult sah patients admitted to beth israel deaconess medical center icus between 2008 and 2015 with gcs <9 who were treated with mechanical ventilation and an extraventricular drain, and had at least one abg. patients on chronic ventilator support were excluded. the lowest paco2 per icu day was analyzed. 125 patients were included with 959 days with at least one documented paco2. mean gcs on admission was 5.0 (sd 1.7). 70.3% of patients survived to hospital discharge. 61.6% of patients were exposed to severe hypocapnia (paco2 30mmhg, those with severe hypocapnia had similar pao2 and pao2/fio2 ratios, but mildly increased leukocytosis (13.1 vs 12.3). 40.9% of paco2s <30mmhg occurred during spontaneous ventilation or over-breathing. prior studies have shown that hypocapnia causes decreased brain tissue perfusion and is associated with worse outcomes in sah patients. these recent data demonstrate that severe hypocapnia is common in patients with sah severe enough to warrant intubation, and is associated with both iatrogenic and spontaneous hyperventilation. hypocapnia is not primarily compensatory or hypoxia driven, as suggested by mean ph and pao2. confirmation of this association and potential future interventions require further study. although delirium is associated with higher rates of hospital complications among critical care patients, limited data exist on risk factors for delirium in aneurysmal subarachnoid hemorrhage (sah). a previous study identified older age, high hunt hess grade, intraventricular hemorrhage (ivh), and hydrocephalus as risk factors for delirium. we sought to identify risk factors for delirium during admission after sah. retrospective review was performed of prospectively collected data for consecutive sah patients enrolled into the university of maryland recovery after cerebral hemorrhage (reach) study. baseline data and clinical complications during each admission, including delirium, were recorded. statistical analysis was performed using univariate and multivariate logistical regression. 103 sah patients from july 2014 to january 2016 were reviewed. while age was not singly associated with delirium during icu admission, higher hunt hess grade, ivh, hydrocephalus, hospital-acquired infection, elevated troponin, and intubation were significantly associated with delirium on univariate analyses. upon stepwise multivariate logistic regression, ivh (or 9.6, p=0.04) and intubation (or 6.4, p=0.01) remained significantly associated with delirium. ivh and intubation predicts delirium during icu admission for sah. further analyses are needed to determine if the relationship between ivh and delirium is primarily explained by risk of hydrocephalus, risk of fever, medication exposure, or through independent mechanisms. stroke triage scales are very important in order to expedite acute evaluation, assure quick door to neuroimaging time and decrease door to needle time in patients with ischemic stroke eligible to intravenous thrombolysis. subarachnoid hemorrhage (sah) is associated with a high mortality in the acute phase due to a particular risk of early and devastating re-bleeding. therefore patients with sah also need urgent assessment. the performance of classic triage stroke scales in the identification of patients with sah was not previously evaluated. the objective of our work was to evaluate the performance of the los angeles prehospital stroke screen (lapss) in identifying patients with sah admitted to a tertiary hospital. we evaluated consecutive patients admitted to a tertiary hospital with sah from january 2009 to may 2016. at hospital admission, lapss was applied by trained nurse personnel to all noncomatose patients with complaints suggestive of neurological disease. a total of 139 with sah patients were evaluated (mean age 55.9 +/-15.6), 59.7% females). lapss was applied to 94 patients. lapss was positive in only 45 patients (32.4%). patients with a positive lapss had higher nihss stroke score at admission ( 4, [2,23] versus 0, p<0.01), lower glasgow coma scores (14 [8, 15] versus 15, p<0.01) and a significant shorter door to neuroimaging time (p<0.01). in patients with sah and mild symptoms, lapss was not a sensitive screening tool in our series. hospital and pre hospital services using lapss for triage of patients with stroke should be aware of this limitation and include in triage flowcharts specific questions evaluating sah specific symptoms. spontaneous subarachnoid hemorrhage (sah) is a neurological emergency, which despite current advances in management strategies and advent of institutional protocols, remains with significant rates of mortality due to poorly understood causes. our objectives were to characterize in-hospital mortality by evaluating the primary cause of death and externally validate the hair score, a clinical score that prognosticates mortality. in this retrospective cohort study, we reviewed all sah patients admitted to our neuro-icu between april 1, 2010 and march 31, 2016. univariate and multivariate logistic regressions were performed to identify predictors of in-hospital mortality, our primary outcome. to validate the hair score, the model's predictors were hunt and hess score at treatment decision, age, intraventricular hemorrhage, and re-bleeding within 24 hours. discrimination was assessed by visualizing the receiver-operating curve and calculating the area under the curve (auc). among 434 sah patients with a median age of 56 years (interquartile range, 48 -65), 63.6% females, inhospital mortality was 14.1% (n=61). of those, 54 (88.5%) had a neurological cause for death or withdrawal of care and 7 (11.5%) had a cardiac death. median time from sah to death was 6 days. the main causes of death were the primary effects of the initial hemorrhage, re-bleeding and refractory edema. factors significantly associated with in-hospital mortality in the multivariate analysis were age, hunt and hess score, and intra-cerebral hemorrhage. maximum lumen size was also a significant risk factor among aneurysmal sah patients. the hair score had a satisfactory discriminative ability, with an auc of 0.89. our in-hospital mortality is lower than previous reports, attesting to the continuing improvement of our protocolized subarachnoid hemorrhage care. the major causes are the same as previous reports. the hair score showed good discrimination and could be a useful tool for predicting mortality. so far, scientific and therapeutic efforts mainly focused on the prevention of rebleeding and ischemic complications(dci) in patients with subarachnoid hemorrhage(sah). however, data regarding the impact of parenchymatous hemorrhage(ph) on longterm outcome in these patients is limited. all consecutive patients with atraumatic sah admitted to our hospital over a 5-year-period(2008-2012) were retrospectively analyzed. extent of sah as well as presence, localization and volume of ph were evaluated. functional and health outcome were assessed after 12 months using the modified rankin scale (unfavorable:3-6) and the eq-5d. propensity-score(ps)-matching was performed to minimize potential bias due to confounding variables between sah-patients with and without ph. of overall 494 patients with atraumatic sah, 85(17.2%) patients had ph on initial imaging. ph-patients had a worse clinical condition on admission (wfns: ph 4(3-5) vs. øph 2(1-4);p<0.001) and a greater extent of sah (modified fisher: ph 3(2-4) vs. øph 2(1-3);p=0.001). median ph-volume was 11.0(5.4-31.8)ml with largest volumes in patients with ruptured )ml). after successful ps-matching (parameters: age, wfns, modified fisher and graeb score) patients with ph had worse functional and health outcome after 12 months compared to those without ph (mrs 3-6: ph 56/82(68.3%) vs. øph 33/78(42.3%);p=0.001; eq-5d: ph 50(30-70) vs. øph 80(65-95); p<0.001). in multivariate analysis presence of ph was the strongest independent predictor of unfavorable outcome after 12 months followed by the occurrence of dci (risk-ratio(95%ci): ph 4.5(2.0-10.0); p<0.001). parenchymatous hemorrhage is frequent and associated with functional and subjective impairments in patients with atraumatic sah. aneurysmal subarachnoid hemorrhage (asah) is associated with early and delayed brain injury. insulin growth factor (igf1) is a potent cellular growth-promoting factor with demonstrated independent neuroprotective actions in stroke and neurologic disease but has not been well characterized after asah. this study sought to examine the relationship between plasma igf1 levels and outcomes after asah. this cohort of 128 asah patients was 50.6 years (sd 10.03) and female (66%) with a mean hh 3 (45%), wfns 1 (41%) and fisher 3 (48%). initial and peak plasma igf1 concentrations were measured in 268 plasma samples from a banked biorepository using a commercial sandwich solid-phase elisa kit. delayed neurological deterioration (dnd) and delayed cerebral ischemia (dci) were determined using radiologic and clinical information. igf1 levels were log transformed due to non-normality. anova, t-tests, pearson correlations and logistic regression analyses were completed using spss and sas. older age was significantly associated with lower initial and peak plasma igf1 levels (r=.37, p<.001; r=.41, p<.001). men had higher initial and peak plasma igf1 levels than women (p<.01; p=.002), and premenopausal women had higher initial and peak plasma igf1 levels than post-menopausal women (p=.003; p=.004). lower peak plasma igf1 levels were associated with increased clinical severity by wfns (p=.02) and fisher grade (p=.03) as well as the development of dnd (p=.04; p=.003). lower peak igf1 levels were associated with the presence of dci (p=.009). controlling for age and fisher grade, log peak plasma igf1 levels remained significantly associated with the presence of dnd (p=.01; or 0.27; ci: 0.1-.74) and dci (p=.007; or 0.29; ci: 0.12-0.7). igf1 levels have not been well characterized after asah. these results suggest lower plasma igf1 are associated with clinical severity and outcomes after asah and provide impetus for future work to further examine these relationships. induced hypertension (ih) is the mainstay of medical management for delayed cerebral ischemia (dci) after subarachnoid hemorrhage. however, using vasopressors to raise systemic blood pressure well above normal levels may be associated with systemic and neurological complications, of which posterior reversible encephalopathy syndrome (pres) has been increasingly recognized. however, the frequency and risk factors for ih-induced pres have never been systemically evaluated we identified 68 patients treated with ih from 345 sah patients admitted over a three-year period. pres was diagnosed based on clinical suspicion (i.e. unexplained deterioration), confirmed by imaging. we conducted retrospective extraction of data on ih therapy, including baseline and highest target mean arterial pressure (map) and vasopressor dose/duration. we compared those with pres to ihtreated controls and also described the clinical features and sequelae of all pres cases. five sah patients were diagnosed with pres, with median time from initiation of vasopressors to diagnosis of 6.6 days (range 1-8 days). baseline map did not differ between pres and ih controls, but highest target map was greater (140 vs. 120 mm hg, p=0.006). magnitude of ih was similarly greater (54 vs. 34 mm hg above baseline, p=0.004). all cases presented with lethargy, three had new focal deficits, and one had a seizure. one died from cardiac complications but the other four patients had complete resolution with ih discontinuation, without infarction or residual disability. pres was diagnosed in 7% of patients undergoing ih therapy and was most likely when map was raised well above baseline to levels exceeding the traditional limits of autoregulation (130-140 mm hg). high clinical suspicion for this reversible disorder appears warranted when aggressive ih targets are maintained for several days or in the presence of unexplained neurological deterioration. other interventions may be preferable for refractory dci when moderate degrees of ih have been attempted. patients with aneurysmal subarachnoid hemorrhage (asah) may receive significant exposure to potentially harmful ionizing radiation exposure (phire) from diagnostic tests and therapeutic procedures during their initial hospitalization. we hypothesized that risk factors to detect excessive phire are present at the time of admission. following irb approval, all patients admitted to our institution with documented asah over a 4-year period were retrospectively evaluated for inclusion and exclusion criteria. patients were excluded if they died prior to discharge. all study data, including sah-specific and patient-specific risk factors, were obtained from the electronic medical record. the total effective dose of ionizing radiation (tedir) per patient was calculated from previously published radiation exposure data. phire was considered to have occurred if tedir was greater than 50 msv, the annual phire limit for radiation workers. logistic regression models were then fit to the dataset to evaluate clinical variables that significantly the risk of phire in these patients. data were collected from 108 patients (58.4% of all asah patients evaluated). the mean tedir in these patients was 47.8 msv. forty-two (38.9%) of patients met criteria for phire. in multivariate logistic regression modeling, male gender (or=3.2, ci=1.1-11.8), posterior circulation aneurysms (or=3.7, ci=1.2-11.5) and ventriculostomy (or=24.8, ci=3.7-164.7) were significantly associated with an increased risk of phire. in this study, approximately 40% of asah patients received phire. male gender, posterior circulation aneurysms and ventriculostomy were significantly associated with increased risk of phire. these factors may serve as important predictors of patients who require additional or complex care necessitating repeated diagnostic or therapeutic procedures during their hospitalization. alternative diagnostic or therapeutic modalities should be considered for patients with these risk factors to limit the risk of phire. future research should also evaluate the effect of phire on neurologic outcomes in these patients. it remains unclear whether patients with unruptured intracranial aneurysms (ica) should be treated. vessel wall enhancement (vwe) in high-resolution magnetic resonance vessel wall imaging constitutes a promising marker of aneurysm instability in this population. to find risk factors for aneurysm instability, we sought to identify predictors of vwe in patients with unruptured icas. we conducted a retrospective analysis of prospectively collected data on patients with unruptured ica evaluated by a single provider. all patients were evaluated using a previously validated algorithm to ascertain vwe using high-resolution magnetic resonance vessel wall imaging. two different raters, blinded to the study data, categorized all observed aneurysms as vwe-positive or vwe-negative. kappa statistics were used to evaluate the reproducibility of this approach. univariable and multivariate logistic regression modelling was utilized to identify factors associated with vwe after adjusting for potential confounders. 94 patients with unruptured ica were included in the analysis (mean age 59 [sd 14] , female sex 77 [82%]). of these, 34 (36%) were vwe-positive and 60 (64%) were vwe-negative. inter-rater reliability for vwe ascertainment was excellent (kappa 0.86, 95%ci 0.75, 0.97). 9 out of 10 (90%) patients presenting with cranial nerve palsy were vwe-positive. in univariable analysis, age (p=0.03), headache on presentation (p=0.004), and size (p<0.001, per additional millimeter) were associated with vwe-positive status. in multivariable analysis, headache on presentation (p=0.007) and size (p=0.003) remained independently associated with vwe. cranial nerve palsy is an established clinical marker of aneurysm instability; consequently, our results confirm the role of vwe as a marker of aneurysm instability. headache on presentation and aneurysm size are independently associated with vwe; these risk factors for aneurysm instability could be used to select patients with unruptured icas that may benefit from vessel wall imaging. prognostication in subarachnoid hemorrhage (sah) patients presenting in coma is crucial for surgical decision making. indications for aggressive aneurysmal treatment are unlikely for those not demonstrating signs of neurological improvement chronologically or after ventricular drainage. early neurological evaluation is, however, challenging in critically ill sah patients requiring anesthesia and intubation for airway protection. in this single-center retrospective study, we applied continuous amplitude-integrated eeg (aeeg) monitoring using a subhairline montage for wfns grade v patients who did not undergo emergency aneurysm treatment. monitoring was initiated soon after admission to the icu. patterns of aeeg findings were classified according to rundgren, et al. as follows: flat (f); suppression-burst (sb); electrographic status epilepticus (ese); and continuous (c). based on the aeeg findings, indications for aneurysm treatment were reevaluated. outcome was assessed at six months using the glasgow outcome scale. twenty-three patients, 8 men and 15 women, aged 68.3 ± 14.1 years (mean ± sd), were eligible since december 2012. all patients underwent prophylactic intravenous sedation. the population represented 28 % of all grade v patients including those resuscitated after cardiac (n=9) or respiratory (n=2) arrest. the glasgow coma scale scores were 3 (n= 21), 4 (n=1), and 5 (n=1), respectively. aneurysms were located in the posterior fossa in 9 patients (39%). aeeg monitoring was initiated 11.8 ± 12.2 hours median 8.4, 1.03-41.7 hours after arrival. all patients showing early f (n=12) or sb patterns (n=3) died. one patient demonstrated ese remained in a persistent vegetative state. five out of 7 patients with a c pattern underwent aneurysm treatment; 4 clippings and 1 coil embolization. moderate disability was attained in 3 and severe disability in 2. two patients undergoing conservative therapy died. continuous aeeg provided useful prognostic information for identifying salvageable sah patients undergoing sedation in the early phase. delayed cerebral ischemia (dci) may result in focal neurological deficits and cerebral infarction after subarachnoid hemorrhage. while global cerebral blood flow (cbf) may be variably reduced, dci is more likely related to regional impairments in cbf below critical perfusion thresholds. we applied volumetric methods to assess the proportion of brain exhibiting hypoperfusion (pbh) in those with clinical dci and in the symptomatic hemisphere of those with focal deficits. methods 61 patients with aneurysmal sah underwent 15o-pet and ct imaging during period of risk for dci (median 8 days after sah, iqr 7-10). we measured pbh as proportion of voxels with cbf < 25 ml/100g/min, after excluding regions of infarction/hematoma on ct. we compared pbh in patients with vs. without dci at time of pet and, in those with focal deficits, we compared hypoperfusion between affected and unaffected hemispheres. pbh was greater in the 23 (38%) with dci compared to those without dci (20%, (9) (10) (11) (12) (13) (14) (15) (16) p=0 .006) despite higher mean arterial pressure (map) and most being on active hemodynamic therapies. global cbf was also lower in those with dci (36.0 vs. 44.4 ml/100g/min, p=0.01) but did not differ between those remaining symptomatic and those whose deficits had resolved. while mean hemispheric cbf was not lower in the affected hemispheres of 13 with lateralizing deficits (40.2 vs. 41.1 ml/100g/min, p=0.15), there was greater pbh in the symptomatic hemisphere (21% vs. 18%, p=0.049). sah patients with dci have a greater proportion of brain with hypoperfusion despite active hemodynamic therapy and higher map. there was also larger proportion of the symptomatic hemisphere with hypoperfusion despite no asymmetry of hemispheric cbf. such measurements of hypoperfusion may better reflect the regional pathophysiology of dci than global averaged measures of cbf. further studies should determine whether burden of hypoperfusion correlates with tissue and patient outcomes. patients who survive aneurysmal subarachnoid hemorrhage (asah) are often burdened with lasting cognitive impairment due to a combination of sequelae including neuro-cardiac injury. the impact of neurocardiac injury after asah is poorly understood. this study sought to examine if neurocardiac injury detected by global longitudinal strain (gls) is associated with poor performance in neuropsychological np memory impairment after asah. we studied 135 asah patients at 3 months and 112 at 12 months (sahmii study r01nr04221) after hemorrhage. speckle tracking gls from 3 apical views were assessed days 0-5 from bleed from transthoracic echocardiograms. neuropsychological (np) outcomes covering 7 domains were completed at 3 and 12 months after hemorrhage by trained personnel. memory tests included controlled oral word association (cowa), wechsler memory scale (wms) and rey auditory (r-aud) and complex figure (reyc). anova and kruskal-wallis, pearson and spearman correlations and logistic regression were completed using spss and sas. there were 30 (22%) patients with abnormal gls (defined as >-17%) and 27 (24%) in the 3 and 12 months groups respectively. gls groups had similar age, gender and fisher grade. abnormal gls was associated with higher hh at 3 (p=.05) and 12 (p=.002) months. abnormal gls was significantly associated with decreased performance in r-aud memory domains at 3 months (p=.013) and 12 months (p=.027) after asah and even when controlling for age and hh at 3 months (p=.010). gls<-17 was associated with poor memory performance 12 months after asah in cowa (p=.008) and the wms (p=.02) even after adjusting for age and hh, cowa (p=.008) and wms (.018). neuro-cardiac injury detected by gls was associated with decreased performance in memory domains of np function at 3 and 12 months after asah. while these relationships require further examination, neurocardiac injury may contribute to long term np impairment after asah. delayed cerebral infarction (dci) is a frequent complication following high-grade aneurysmal subarachnoid hemorrhage (asah). management of dci includes maintaining hypertension, which is challenging in heavily sedate patients. ketamine is a hemodynamically stable, analgesic sedative not studied in this population. we hypothesize that ketamine infusion (k), as compared to traditional sedatives (control), will safely improve the hemodynamic profile in high grade ventilated asah patients retrospective review of asah patients admitted 1/2015 to 2/2017 requiring mechanical delayed cerebral infarction (dci) is a frequent complication following high-grade aneurysmal subarachnoid hemorrhage (asah). management of dci includes maintaining hypertension, which is challenging in heavily sedate patients. ketamine is a hemodynamically stable, analgesic sedative not studied in this population. ventilation >72 hrs, and without dnr within 48 hrs from admission. we assessed demographics, hemodynamics, pressor, dci at 2 weeks, ventilator and icu los, and mortality. fisher exact, wilcoxon, and paired t-test applied. comparing k (n=16) vs control (n=19), median (q1, q3) results for: age 59 (48, 67) vs 59 (48, 72); hunt and hess 4 (3, 5) vs. 4 (3, 4); mpm-3 30 day estimated mortality 27. 8% vs. 28.5%; and gcs 7 (6, 9) vs 7 (5, 8) . ketamine initiated on day 4 (2, 5); icu los 20 (17, 24) vs. 15 (7, 22); and vent los 17 (12, 29) vs. 11 (8, 28) . mean (sd +/-) for 8 hours before and after ketamine: map 93 (11) vs 99 (15), p 0.05, except where noted. ketamine infusion, as a second line sedative, had no effect on mortality or icp, and improved map. however, there was a nonsignificant increase in dci as well as vent los, without a greater rate of tracheostomy. prospective studies are needed to study the effect on dci and long term outcomes. seizures are a well-known complication of aneurysmal subarachnoid hemorrhage(asah) and occur most commonly in the immediate post-hemorrhagic period. most commonly used antiepileptic drugs (aeds) for seizure prophylaxis in asah include phenytoin and levetiracetam. there is no reliable data available on the safety and efficacy of restricting aed prophylaxis only till the aneurysm is secured. we retrospectively chart reviewed patients admitted to our neurosciences intensive-care-unit with asah during the last two years. seizure incidence was studied in patients treated with phenytoin versus levetiracetam and in patients treated for 3 to 7 days versus those where aed was discontinued immediately after aneurysm was secured. in 28 patients aed prophylaxis was discontinued immediately after the aneurysm was secured, and in 21 patients it was continued for 3 to 7 days. of th phenytoin was used in 20 patients and levetiracetam was used in 8 patients. in patients receiving aed prophylaxis for 3 to 7 days, phenytoin was used in 8 cases and levetiracetam was used in 13 cases. none of these patients had seizures reported during hospitalization or at three month follow-up. stopping the aed prophylaxis immediately after aneurysm coiling is not associated with increased risk of seizures. seizures at presentation in patients with asah are not associated with development of epilepsy at 3 months. both phenytoin and levetiracetam are well tolerated in patients with asah when limited to the immediate post-hemorrhagic period. the main preceding factor of delayed cerebral ischemia (dci) in asah is cerebral vasospasm (cvs). anticipating dci can have major impact on patient outcomes. studies have attempted to predict dci in patients with asah by using various imaging modalities that measure cvs, ranging from transcranial doppler ultrasonography, ctp, and mr perfusion. few compare these imaging modalities to the accepted gold standard of dsa. we propose that mri using asl imaging can be used as a sensitive and specific measure of cvs and can be used as a marker to identify patients with asah who are at risk for developing dci. to support our hypothesis, we compare asl results in patients with documented cvs on dsa who developed dci. 165 patients in the academic years 2013 to 2016 with the diagnosis of asah were admitted to our nicu. the inclusion criteria for the patient population was the presence of asah confirmed by dsa, diagnosis of dci by a neurointensivist, mri with asl, and a repeated dsa during the hospitalization after dci was suspected. all patients underwent mra with asl on day 8 in an attempt to capture the peak time of cvs. nine patients were included in this study. all cases with perfusion defects on asl sequences had confirmed cvs on dsa except for one. the outlier in our cohort developed dci with asymmetry on asl that was not demonstrated on dsa. to our knowledge, no studies have compared the specificity of asl with dsa in detecting cvs. this study highlights the utility of asl in detecting cvs in patients with asah. our limited data suggests asl can be utilized for detection of dci and cvs with greater confidence than the conventional modalities. we also suggest that asl approaches the utility of dsa in the detection of cvs. blood glucose dysregulation following aneurysmal subarachnoid hemorrhage is associated with serious complications and poor clinical outcome. an influence of hyperglycemia on the occurrence of delayed cerebral ischemia (dci) is assumed, nevertheless the exact mechanism remains unclear. the goal of the present study aims to investigate the influence of systemic blood glucose level on cerebral perfusion measured by dynamic perfusion computed tomography (pct) and outcome. daily serial blood glucose levels and pct data sets of 206 patients treated at our neurointensive care unit after asah were retrospectively analyzed. serial pcts were performed between six hours and 21 days after aneurysm repair. mean average of mean transit times (mtts) was calculated for each perfusion scan. the maximum mean transit time (maxmtt) and outcome assessed with glasgow outcome scale were correlated with defined blood glucose ranges as followed 1.) >180mg/dl (hyperglycemia) 2.) 140-180mg/dl (elevated glucose level) 3.) 110-140mg/dl (strict glucose control) and <110mg/dl (low glucose level). hyperglycemia (>180 mg/dl) was associated with prolonged maxmtt (p< .05, rs = .13) and was linked to an increased risk of infarction (p < .001) whereas strict glucose control (110-140 mg/dl) correlated significantly negative with maxmtt (p < .05, rs = -.17). strict glucose control was also associated with a lower occurrence of cerebral infarction and good outcome (p < .001, rs = .47). in contrast, elevated blood glucose levels (140-180 mg/dl) and hyperglycemia showed a negative correlation with good outcome (p < .001, rs = -.26, rs = -.35). the present analysis supports for the first time the assumption that dysregulation of blood glucose balance influences cerebral perfusion and thus may contribute to the occurrence of dci and poor outcome. therefore careful monitoring and prompt treatment of blood glucose levels after asah should be highly valued to avoid cerebral perfusion deficits correlated with poor outcome. the aim of this study was to determine the correlation between transcranial doppler (tcd) velocities and angiographic vasospasm after subarachnoid hemorrhage (sah). methods 221 patients with sah were evaluated with spencer technologies tcd power m mode from 2-14 days, following the sah. both the temporal windows were insonnated to determine flow velocities in the middle (mca) and anterior cerebral arteries (aca) and the suboccipital widow was used to determine flow velocities in the vertebral (va) and basilar arteries (ba). the middle cerebral artery/ipsilateral extracranial internal carotid artery velocity ratio (lindegaard ratio) was also correlated with vasospasm ct angiography and conventional cerebral angiography was used to confirm tcd findings suggestive of vasospasm. the sensitivity, specificity, likelihood ratios for positive and negative tcd results, positive there was 131 males and 90 females and with mean age 42.72+-7.6 years. 88 % were aneurysmal sah. delayed ischemic neurological deficits (dind) developed in 48/221 patients (21.70 %). interobserver ue of cm/s were useful (likelihood ratio for negative result = 0.15, likelihood ratio for positive result = 14.89). lindegaard ratios correlated well with vasospasm. tcd diagnosis of vasospasm was more often present in the mca, followed by aca and basilar arteries. tcd is a good non invasive method to detect vasospasm and predict the occurrence of dind. very high angiographic vasospasm. tcd is also useful to follow up patients with angiographically proved vasospasm. aneurysmal subarachnoid hemorrhage (asah) is a significant cause of morbidity and mortality. the mortality rate approaches 50%. nearly half of the survivors remain unable to care for themselves . dci occurs in 29% of these patients . when present, it doubles the risk of poor outcome. -several methods have been used to treat cerebral vasospasm and dci, which is a major cause of morbidity and mortality in patients with aneurysmal subarachnoid hemorrhage (sah). milrinone safe and, potentially, effective treatment of dci as reported in low level of evidence literature . however, the efficacy not compared in a randomized way to placebo. we will examine the effectiveness and safety of intra-venous injection of milrinone for the treatment of dci following aneurysmal sub-arachnoid haemorrhage. our intension is to study the outcome of using milrinone as an addition to current therapies such as hypertensive therapy are not effective enough, yet can not be replaced as it is standard of care. as intravenous milrinone was not yet shown to have an affect in dci in a randomized controlled trial. this pilot trial is a step towards that study. the study is a pilot trial of a randomized placebo-controlled double blind trial testing the potential beneficial effect of milrinone, a phosphodiesterase inhibitor, on clinical neurological outcome in patients with dci after aneurysmal subarachnoid hemorrhage. the study drug will be given along with the standard therapy when dci occurs. the administration of milrinone increases cerebral blood flow most likely as a result of cerebral vasodilation. as intravenous milrinone was not yet shown to have an affect in dci in a randomized controlled trial. this pilot trial is a step towards that study. milirinone promising treatment for delayed cerebral ischemia following aneurysmal sub-arachnoid haemorrhage .particulary by using standardized protocol as a finding suggestive of good prognosis fever in the neurocritical care population is very common and is strongly associated with increased mortality and poor outcome. fever is aggressively treated in the icu due to its deleterious effects. yet despite best efforts with standard antipyretic agents and even with aggressive cooling measures with endovascular cooling catheters some patients may still have refractory fevers. celecoxib, a cyclooxygenase-2 (cox-2) inhibitor, has been used as an adjunctive antipyretic agent. this is a retrospective analysis to evaluate the effectiveness of celecoxib in lowering temperatures in patients with refractory fevers. this is a retrospective chart review of patients admitted to a neurointensive care unit at a single institution with fevers (>38.3c) that do not respond to convention treatment with acetaminophen, endovascular cooling catheters and ibuprofen. 83 patients with severe traumatic brain injury, subarachnoid hemorrhages and intracerebral hemorrhages were included. patient temperature recordings were obtained in the period of 24 hours before and 48 hours after administration to the first dose of celecoxib. the mean temperature of the before and after periods were compared and temperature difference was calculated. 83 patient records were included. the average of the mean temperatures in the before periods and after periods were 37.79 c (+/-sem 0.0659) and 37.37 c (+/-sem 0.062 respectively. there was a significant difference on mann-whitney-wilcoxon rank sum test (p<0.000003). one average there was a drop of 0.41(+/-sem 0.069) degree celsius of the mean temperature after the start of treatment. in neurocritically ill patients with fevers that are refractory to conventional treatments adding celecoxib, a cox-2 inhibitor seems to be effective at lowering the core body temperature. further study is warranted to evaluate for adverse effects such as risk of cardiovascular events. achieving and maintaining normothermia (nt) after subarachnoid hemorrhage (sah) or intracerebral hemorrhage (ich) often requires temperature modulating devices (tmd). shivering is a common adverse effect of tmd's that can lead to further costs and complications. we evaluated a new esophageal tmd, the ensoetm (attune medical: chicago, il), to compare nt performance, shiver burden, and cost of shivering interventions with existing tmd's. patients with sah or ich and refractory fever were treated with the ensoetm. patient demographics, temperature data, shiver severity, and amount and costs of medication used for shiver management were prospectively collected. control patients who received other tmds were matched for age, gender, and body surface area (bsa) to ensoetm recipients and similar retrospective data was collected. all patients were mechanically-ventilated. fever burden was calculated as areas of curves of time spent above 37.5 or 38c. demographics, temperature data, and costs of ensoetm recipients were compared to recipients of other tmd's. eight ensoetm recipients and 24 controls between october 2015 and november 2016 were analyzed. there were no differences between the two groups in demographics or patient characteristics. no difference was found in temperature at initiation (p = 0.4) and fever burden above 38°c (p = 0.47). ensoetm recipients showed a non-significant trend in taking longer to achieve nt than other tmd's (p = 0.07). ensoetm recipients required fewer shiver interventions than controls (p = 0.03). ensoetm recipients incurred fewer costs than controls per day (p = 0.04). the ensoetm achieved and maintained nt in sah and ich patients and was associated with less shivering and lower pharmaceutical costs than other tmd's. further studies in larger populations are needed to determine the ensoetm's efficacy in comparison to other tmd's. targeted temperature management is an important aspect of care in neurologically impaired patients. however, achieving optimum temperature for a specific patient can be challenging; a patient's size, body composition, metabolism, and hypothalamic function contribute to his or her response to a given temperature management modality. the purpose of this study is to evaluate patient response to esophageal temperature management when continuously applied for at least 72h. deidentified core temperature data for 18 patients (a total of 1237 measurements) were obtained from three hospital sites where esophageal temperature management was used for at least 72h (range 72-452h). indications for active temperature management included: cardiac arrest (7), refractory fever (4), subarachnoid hemorrhage (4), intracranial hemorrhage (2), and traumatic brain injury (1). goal temperatures ranged from 33-38°c and initial patient temperatures ranged from 35-40°c. deviation from goal was calculated by subtracting target temperature from actual temperature for each measurement which allowed the calculation of the mean and standard deviation for each time point across all temperature management protocols. across 129 time points, representing an average treatment time of 137.7h, 95.3% of mean deviations from goal were within ±1°c and 68.5% were within ±0.5°c. in interpreting these results, several limitations must be considered. this dataset reflects a wide range of temperature management protocols and clinical scenarios. for example, a larger than average deviation in measurements recorded in the 24-36h period was related to rewarming in cardiac arrest patients who rewarmed slowly. also, the later time points were dominated by sah, ich, and refractory fever patients who often experience more pronounced fever spikes. this analysis indicates that esophageal temperature management is a feasible option for patients who require active temperature management for 72 or more hours. the role of therapeutic temperature management (ttm) in neurocritical care is uncertain. one question that has been inadequately addressed is the diversity of practice across multiple neurocritical care units (nccu) throughout the world. a barrier to understanding this practice variance is a data collection method that would provide adequate understanding of how ttm is implemented in various nccus. the purpose of this pilot study is to test the efficacy of a data collection method that would provide unitlevel data on ttm practice. the design of this study was prospective, observational, and cross-sectional study using quality assurance methodology. the study received institutional review board approval. to reduce the risk of loss of confidentiality and promote privacy, individual patients were not consented. data on temperature management was collected each day for 90 consecutive days. completed data was available for 90 days. mean daily census of 15 patients included the following mean number of patients with sah (2), ich (1), ischemic stroke (2) and other (9). of those, ttm was provided to at least one patient during 40 of 90 days (44.4%). the most common ttm method (tylenol) was used on 112 patient days; surface cooling was used on 53 patient days. ttm was initiated for fever management (109 patient days) and normothermia (11 patient days). the most common associated complication was hypocalcemia (19) and hypokalemia (5). the data collection form was easily and quickly filled completed on a daily basis, but provides limited data. although the form captured a significant number of events surrounding the use of ttm, the primary limitation noted is the inability to link specific events (e.g., hypokalemia) to specific patients or diagnoses. this pilot study demonstrates the efficacy of data capture and provides insight towards refining a prospective observational study to describe ttm practice. brainstem tumors are exceedingly dangerous due to its proximity to the structures responsible for basic human survival in the neurocritical care setting. these lesions may cause autonomic dysregulation. we report on a rare case of a female with a past surgical history of ventriculoperitoneal shunt with a brainstem mass of müllerian type epithelial tissue. methods 38 year old caucasian female presented to our hospital status-post fall after episodes of lightheadedness, as well as, episodes of decreased respirations in her sleep. mri showed a medullary contrast enhancing mass with calcifications measuring 2.8 x 2.7 x 1.5 cm and a small calcified lesion in the right lateral ventricle. suboccipital craniectomy for biopsy and decompression was performed. intraoperatively, the heart rate and blood pressure dropped transiently due to the mass being firmly adhered with calcification to the medulla. the neuropathologist diagnosed the tissue as mullerian type epithelium with estrogen receptors. post-operatively, our patient encountered several instances of cardiac pauses on monitoring that required the need for cardiology to place a permanent pacemaker. the above is a rare case of a calcified heterogeneously contrast enhancing brainstem mass that underwent neurosurgical biopsy. histopathology results indicated müllerian type epithelial tissue which is tissue that gives rise to female reproductive organs. the origin of a brainstem lesion from an embryologically gynecological site could be speculated to have traveled retrograde via the ventriculoperitoneal shunt catheter. patient required postoperative cardiac management and intervention with a pacemaker for encroachment or mechanical conflict of the mass onto the rostral ventrolateral medulla. oncology recommended pet ct scan and further consideration for tamoxifen chemotherapeutic regimen. this case is a reaffirmation of the importance of brain tumor location and tissue diagnosis for the purpose of adjuvant treatment of neurosurgical lesions in the neurocritical care setting. tranexamic acid (txa) has been used off label in cardiovascular and orthopedic surgery, as well as in trauma resuscitation. the use of txa has increased since the publication of crash-2 (2010) and matters (2012), demonstrating its efficacy in trauma patients to reduce bleeding. there remains concern about the thrombotic risk as well the reduction in the seizure threshold after txa administration. case description: we present a case of a 25-year-old female admitted to the surgical icu after a motor vehicle accident with multiple traumatic pelvic and extremity fractures and soft tissue injury. she subsequently developed extensive arterial and venous thromboses with bilateral acute ischemic strokes with superimposed posterior reversible encephalopathy syndrome after txa administration. a second case involved a 50-year-old female who had a fall from standing and given txa in the field by ems. shewas admitted to the neurocritical care unit with status epilepticus and suffered a complicated course with cardiogenic shock due to stress induced cardiomyopathy. discussion: the risk-benefit balance of txa administration is generally considered acceptable in severe bleeding. the cases presented here suggest the neurological risks of txa administration may be poorly understood and demonstrate the need for better patient selection and heightened awareness for early identification and management of complications given the possible severity of neurologic sequelae. conclusion: txa is an anti-plasmin drug that is increasingly used in the areas of trauma and postoperative bleeding. we aim to educate clinicians in the potential neurological complications that can arise with its use. cryptococcus neoformans is normally an opportunistic infection known to cause meningoencephalitis and can present with stroke like symptoms. in imaging, cns vasculitis can be identified, which can lead to cerebral infarcts. when involved, these cerebral vessels are small sized leading to lacunar infarcts. we present a case that involved a large vessel territory leading to patient mortality. initial treatment with glucocorticoids, though beneficial in other meningoencephalitidies, may actually be harmful in fungal cns infections. case: a 57 year old male with a presents with 2 weeks slurred speech and worsening headache. an enhancing lesion on brain mri in left temporal lobe was concerning for vasculitis. patient was treated with glucocorticoids, with a negative rheumatologic workup and discharged home. patient subsequently presented 2 days later with worsening symptoms, with ct imaging showing completed infarcts. blood cultures were positive for cryptococcus neoformans; patient died due to diffuse right mca territory edema and brain herniation syndrome. discussion: it is important to consider cns infection even in immunocompetent patients who present with any of the following: fever, nuchal rigidity, mental status change, and headache. cns vasculitis in association with infection is caused by basilar meningeal exudates. these cause traversing vessels to become inflamed, leading to distal inflammation and subsequent thrombus and infarction. we present a right mca territory infarct , presumed to be based on the aforementioned vasculitic process. when acute infarcts are associated with opportunistic cns infections, they are usually not associated with large vessel infarction. we also examine the adjunctive use of glucocorticoid therapy for treatment of fungal cns infections. this is an infrequent case of cryptococcus neoformans causing a cns infection in an hiv-seronegative patient not on chronic immunosuppressive medications. this case presents a unique complication of cryptococcal infections, a cns vasculitis leading to infarction in a large vessel territory. we describe the baseline characteristics, continuous intravenous midazolam doses, seizure control, hospital course and outcomes in patients who received high dose continuous midazolam infusion for refractory status epilepticus in this retrospective case series study, we evaluated adult patients with refractory status epilepticus treated with high continuous intravenous midazolam doses in an academic neurocritical care unit between august 2016 and june 2017. four patients were identified. the maximum midazolam dose for each patient was: withdrawal seizures (occurring within 48 hours of discontinuation of continuous iv midazolam) occurred in patient b. "ultimate continuous iv midazolam failure" (patient requiring change to a different continuous intravenous antiepileptic drug despite maximum optimized dose) was not observed in any of the four patients. hospital complications occurred in patient a and b due to infections. hypotension related to continuous infusion midazolam occurred in patient a. three out of four patients discharged alive to a skilled nursing facility; after a goals of care discussion with the family, the fourth patient had withdrawal of care due to the severity of his brain injury. in this case series, we report the use of high dose continuous iv midazolam for treatment of refractory status epilepticus. there were no midazolam-related deaths. neurologic complications in infective endocarditis (ie) occur up to 35 % and are independent predictors of mortality. infectious intracranial aneurysms known as "mycotic aneurysm" (ma) are rare constituting 2-5 %. hemorrhaging rate is 50%. mortality is 80% with rupture. ruptured ma poses significant management conundrum due to lack of available solid prospective data guiding the order (cardiac vs neurosurgical) or timing (early vs delayed) of surgery. a 34y/o male iv drug abuser presented with acute hypoxemic respiratory failure secondary to pneumonia and suspected meningitis. gsc 6 intubated on iv antibiotic. hemodynamic instability prompted tee showing large aortic valve vegetation. blood cultures positive mssa fulfilled criteria for ie. tests showed kidneys infarctions. ct brain showed r mca territory infarct with sah.cta head revealed small ma along the distal r mca m4 branch confirmed with cerebral angiogram. acute heart failure and arrhythmia led discussion on cardiothoracic surgery for valve replacement. due to ruptured ma, decision to secure it was made prior to cardiac surgery. after failed endovascular intervention, patient underwent surgical clipping. post operative mri brain showed new infarcts suggesting recurrent embolization. due to risk of intracranial bleeding, cardiac surgery was postponed for at least 2 weeks initially then to 6 weeks. patient underwent avr after completed 6 weeks of antimicrobial therapy with st jude mechanical valve and discharged on anticoagulation with a modified rankin scale of 1. this case reflects on how urgent surgical intervention should take place.safety period between neurological event and cardiac surgery is largely debated because of lack of controlled studies. there has been no consensus on how to approach those cases as paucity of robust evidence. given their rarity the best management modality remains unclear. this case stress the importance of multimodal therapy in achieving good outcome although the timing of surgery remains a matter of debate. we present a patient with vertebral cerebral artery embolism (cae) following blunt trauma. case presentation: a 49 year-old male was admitted with a right vertebral artery dissection and occlusion with intraluminal air, widespread pneumocephalus, bilateral pneumothoraces, a pulmonary laceration, and multiple fractures including ribs, c3 transverse foramen (with normal alignment), and femur following a motor vehicle collision. his pupils were initially nonreactive, and he experienced one hour of witnessed generalized seizure activity on arrival despite aggressive treatment. management: midazolam infusion, levetiracetam, and fosphenytoin were initiated for seizure control. targeted temperature management to 36 celsius was initiated on arrival out of concern for hypoxic brain injury. computed tomography at 12 hours demonstrated resolution of vertebral and intracerebral air, diffuse edema, and diffuse loss of gray-white matter differentiation, thus a hypertonic saline infusion was initiated. the following day, an mri demonstrated diffusion restriction in the areas adjacent to the air, including c3-4 and diffusely throughout bilateral cerebral hemispheres. prognosis was thought to be poor. however, the following day, the patient awoke. by day four he followed commands. he was discharged to skilled nursing on day 17. at three months he had only minimal residual right hip weakness. discussion: there are only three case reports of cae following blunt trauma, and only one involving the vertebral artery. air migrates to the arterial circulation due to a positive gradient from low central venous pressure or high airway pressure. pulmonary venous air then embolizes to cerebral vasculature. as little as 2ml of arterial air emboli can be fatal with the major cause of death being circulatory obstruction and arrest from air trapped in the right ventricular outflow tract. conclusion: this patient developed pneumocephalus and cae due to a pulmonary laceration. as the cerebral air reabsorbed, his seizures resolved and his exam improved. petrous ica aneurysms are extremely rare1-2 and difficult to treat surgically, due to the inherent challenges of microsurgical access to the carotid canal of the petrous bone3-4. endovascular approaches may also prove challenging, typically as the consequence of therapeutically-unamenable morphology, but occasionally due to size considerations as well.5 a 23-year-old male presented with headache and vertigo for the past 3 weeks. the patient was hivpositive with medication noncompliance and denied any history of trauma or head injury. head ct identified a 3.9 x 2.3 cm heterogeneous soft tissue density lesion in the right petrous bone. ct angiography revealed a 3.0 x 1.8 x 2.8 cm lobulated giant aneurysm of the right petrous ica. mri/mra was performed to rule out thrombosis and showed giant partially thrombosed right petrous ica aneurysm. the decision was made to treat using flow diversion. the patient underwent catheter angiography, confirming a giant 3 x 3.5 cm right internal carotid artery petrous segment aneurysm. we proceeded with flow diversion pipeline endovascular device, placement of two pipeline endovascular devices (flex 5 x 30 and 5 x 25) successfully. final angiographic runs showed significant stasis within the aneurysm and demonstrated the flow-diverter construct was well placed both proximal and distal to the aneurysm neck with no sign of endovascular leak. the patient was discharged home well. we suggest that flow diversion is an ideal treatment for petrous ica aneurysms, specifically un-ruptured lesions of complex morphology. other options for treating petrous ica aneurysms challenging, not possible, less effective, and/or carry substantial risks. second, several of the disadvantages of pedocclusion of side vessel branches and preclusion of future coil embolization, do not apply to the petrous segment of the ica. lastly, use of ped in petrous ica aneurysms has proven effective in the vast majority of reports. the spot sign is a focus of enhancement within the hematoma on ct angiogram (cta) with unique characteristics. it has a spot-like appearance within the margin of a parenchymal hematoma without connection to an outside vessel. it should measure greater than 1.5 mm in diameter in at least one dimension. its contrast density (hounsfield units, hu) is at least double that of the background hematoma. finally, there should be no hyperdensity at the corresponding location on non-contrast ct. it is a strong predictor of hematoma expansion and poor prognosis in intra-parenchymal hemorrhage. the pathogenesis of spot sign remains unclear. some studies showed an association with faster rates of contrast leakage which indicates continued bleeding. a spot sign has not been reported with isolated intraventricular hemorrhage (ivh) before. a case report of a 59-year-old man with a past medical history of hypertension who got admitted to the er with acute encephalopathy and right-sided weakness. head ct-scan (hct) revealed isolated ivh. cta was notable for a spot sign. it measures 2.8 mm in diameter and 175 hu in density (surrounding hematoma measures 80 hu). it lies within the hematoma without connections to any adjacent vessel. a follow-up hct after four hours showed expansion of the ivh. although seems uncommon, looking for a spot sign in isolated ivh can also anticipate expansion of the hemorrhage. a further study is needed to validate this observation and calculate the prevalence of the spot sign in isolated ivh. west nile neuroinvasive disease may present with nonspecific physical exam and imaging findings. to our knowledge, this is the first report of wnnd involving the temporal lobe in adults with neuroimaging suggestive of limbic encephalitis. our patient presented in winter and developed autonomic instability and sensory deficits, which are all rare findings in wnnd. 73-year-old texan with dm presented with acute confusion and seizure in november. patient complained of headache, fever, diarrhea and lower extremity weakness after a fishing trip. patient was febrile with mosquito bites on his arms. neurological exam was significant for comatose state, absent brainstem and deep tendon reflexes, and flaccid paraparesis. he developed autonomic instability with labile blood pressures. lp revealed 13 wbc/mm3 (monocyte predominance), 23 rbc/mm3, glucose 99 mg/dl, elevated protein of 82 mg/dl, and a positive west nile virus (wnv) igm antibody; gram stain, hcv pcr, and the paraneoplastic and autoimmune panels were negative. eeg showed severe diffuse brain slowing. mri brain had t2 flair and dwi changes in right hippocampus and posterior limb of internal capsule. emg described severe subacute sensorimotor axonal polyneuropathy without prolonged distal latencies and normal conduction velocities. he received 5 days of ivig without improvement and was terminally extubated. our patient presented with both clinical entities of west nile: wn fever and wnnd (present in less than 1% of cases). our patient had axonal polyneuropathy with paralysis which is due to inflammatory changes in the white matter tracts affecting spinal sensory pathways. sympathetic ganglia involvement caused the autonomic instability, another very rare manifestation of wnnd. november presentation was due to warmer texas winter. recognize that west nile fever and west nile neuroinvasive disease may present together in winter. recognize that west nile neuroinvasive disease can present with rare temporal lobe neuroimaging, sensory involvement, and autonomic instability. intracerebral hemorrhage (ich) is a common pathology seen in the neurocritical care setting that can be associated with significant morbidity and mortality. the use of sympathomimetic agents containing phenylpropanolamine (ppa) have been associated with ich in the past which lead to the drugs' removal by the fda as an over the counter medication in 2005. we report a case in which ppa was the etiology for a spontaneous ich in a patient who was taking an appetite suppressant. case report and review of the literature we report a case of a 40 year old female with no prior medical history, who presented with sudden onset left sided hemiparesis and hemianesthesia found to be due to a right striatocapsular intraparenchymal hematoma. systolic blood pressures at presentation and throughout the hospital course were normal. extensive work up including multiple ct scans of the head, mri brain, ct angiography, mr angiography and digital subtraction angiography were performed with no evidence of any vessel abnormality. etiology of the ich was attributed to the use of ppa. in young patients with no known comorbidities, ppa use should be considered a primary etiology of ich when no intracranial vessel abnormality can be detected. seizures have been known to cause sudden death, but reports in the literature of only cardiopulmonary failure in cases of sudden unexpected death in epilepsy (sudep). we present the case of a patient who presented post-seizure and developed sudden progressive and fatal cerebral edema within 14 hours after a second seizure. a 22 year old female with a history of down syndrome and epilepsy presented to the emergency department after a prolonged convulsive seizure. she received 2 doses of 2mg lorazepam and levatiracetam 6.7 mg/kg with cessation of seizure activity and return to baseline neurologic status within 5 hours of the initial event. head ct showed lack of sulci throughout the cerebral hemispheres and basilar cistern effacement despite being at her baseline neurologic status. 8 hours after presentation the patient had another seizure, vomited, was intubated and an additional 15 mg/kg of levatiracetam given. 14 hours after presentation, the patient was admitted to the neuroicu with absent brainstem reflexes and repeat head ct with worsened cerebral edema and tonsillar herniation. formal brain death testing was performed approximately 24 hours after the patient's initial presentation. seizures are known to cause a hypermetabolic state in the brain. uncontrolled neuronal firing leads to hyperemia, failure of na+/k+ atp pump, increased levels of neuronal chloride, and inability for cells to maintain homeostasis. in this case, the patient's initial head ct showed cerebral edema, likely from prolonged seizure activity. once the second convulsive seizure occurred, a period of pre-intubation hypoxemia coupled with post-intubation hypotension allowed for progression of cerebral edema in an already compromised brain; similar to what is seen in post-cardiac arrest and traumatic brain injury. this case illustrates the importance of controlling for factors that can contribute to secondary brain injury in seizure patients. posterior reversible encephalopathy syndrome (pres) is a clinico-radiographic syndrome characterized by seizure, headache, encephalopathy and neuroimaging findings of symmetric white matter edema in the posterior cerebral hemispheres. cerebellar and brainstem involvement occurs rarely. here, we report a patient who presented with severe pres complicated by diffuse cerebellar edema and obstructive hydrocephalus requiring decompression with ventriculostomy placement. this is a case report from a tertiary medical center. a 23-year-old woman with a history of migraine presented to the emergency room with 2-day history of fever, right upper quadrant abdominal pain, nausea and vomiting. on day two of hospitalization, the patient developed worsening headache, dizziness and lethargy and her blood pressure was elevated to 188/93 mmhg. ct of the brain showed cerebellar edema and bilateral occipital lobes with effacement of the fourth ventricles and associated hydrocephalus involving the lateral and third ventricle. mri obtained post-operatively revealed t2-weighted/flair diffuse hyperintensities in the parietal, occipital lobes and cerebellum. there was no mass lesion or restricted diffusion in diffusion weighted images (dwi) suggestive of acute infarction. cerebellar edema with compression of the fourth ventricles with hydrocephalus was slightly improved status post interval ventricular drain placement. ventriculostomy was weaned off over the course of seven days. follow up mri showed improvement of the hydrocephalus with decreased in t2-weighted hyperintensities in posterior parietal and occipital lobes as well as within the cerebellum. severe cerebellar edema with obstructive hydrocephalus is an exceedingly rare complication of pres; however, prompt recognition and surgical decompression in addition to usual medical management is critical to achieve a favorable outcome. while obstructive hydrocephalus may be successfully treated with medical management and blood pressure reduction, this case emphasizes that clinical evidence of brain herniation should prompt immediate consideration for emergent ventriculostomy placement or surgical decompression to redirect cerebrospinal fluid and reduce intracranial pressure. one of the biggest uses of qeeg is the alpha delta ratio (adr). adr drops of 20% from baseline are associated with vasospasm (vsp/dind). we describe a case in which subtle qeeg adr change occurred in a poor grade sah patient over a number of days, making it challenging to detect an acute adr drop. this is a case report and literature review. this study also compared hemispheric adr values against the mca values by tcd, dsa, cta and clinical exam. a 67 year old female with hunt hess iii, wfns iv, came in comatose with a ruptured ica aneurysm. over six days, she developed refractory vsp/dind. the patient's adr was gradually declining but their increased icp required propofol sedation, which itself lowers adr. re-analysis over multiple days had to be performed, and that re-analysis showed a gradual adr decline preceding the vsp/dind. when looking at our cases, we found a sensitivity and specificity of (40,75%) when using the adr nadir compared to cta/dsa. recent publications have shown the adr method has less than ideal sensitivity and specificity of (65,43%). qeeg adr is a useful multimodal monitoring parameter in neuroicu patients with relatively good baseline adr. however, its ability to detect vsp and dind in poor grade sah patients who have adr values that are already low (< 0.5) is challenging, particularly given the confounders in this population, such as eeg artifact which artificially raise adr values, and sedation (e.g., propofol) which suppress adr values. based on this information, we would suggest neuroicu centers carefully use continuous eeg monitoring for other indications such as nonconvulsive seizures, unless they have sophisticated bedside protocols about sedation vacation (baseline daily adr that is not) and eeg department resources (technicians who can fix eeg electrode artifacts). hypoxic-ischemic brain injury is a severe consequence of global cerebral hypoperfusion following cardiac arrest. brain ct findings may include diffuse sulcal effacement, loss of cisternal spaces, poor differentiation of grey/white matter, and decreased densities in the basal ganglia and watershed territories. the connection between aggressive resuscitation, as seen with in-hospital cardiac arrest, and cerebral edema is unclear. here we present the case of a hemodynamically unstable patient who developed transient reversible cerebral edema believed secondary to aggressive resuscitative efforts and pressor therapies. a 55 year old female with a past medical history significant for diabetes and hypertension presented to the emergency department with headache and non-bilious vomiting. workup revealed isolated ventricular hemorrhage secondary to a ruptured left posterior inferior cerebellar artery (pica) aneurysm and cerebellar arteriovenous malformation, which underwent subsequent embolization. during her early hospital course she remained intubated due to pulmonary factors, but awake and alert with a non-focal neurologic examination. her course was subsequently complicated by a severe metabolic acidosis requiring several doses of bicarbonate boluses and continuous infusion, cvvhd, intravenous crystalloids, hydrocortisone and multiple pressors to maintain stability. over a 24 hour period she received 10 liters of volume while maintaining a mean arterial pressure above 60mm hg and o2 saturations above 88%, without requiring cpr. subsequent progressive encephalopathy developed, with a ct brain revealing diffuse sulcal effacement prompting hyperosmolar therapy. gradually her encephalopathy began to improve, with repeat imaging showing improvement of cerebral edema and return of grey/white matter differentiation. this case highlights a potential etiology of reversible cerebral edema that may confound early prognostication in patients with hemodynamic instability such as multi-organ failure and in-hospital cardiac arrest. further investigations are warranted. langerhans cell histiocytosis (lch) is a rare disease with an incidence of 0.2-2.0 cases per 1000,000 children under 15 years of age. frequency in adults is unknown. the hypothalamic-pituitary manifestations of lch (commonly diabetes insipidus) and hypernatremia are well known complications. here we present a case where a patient presented with poor mental status and the etiology remained unknown initially despite extensive testing. electronic medical record was reviewed regarding hospital course, sodium trends, and radiology images. this patient is a 66 year old female with history of langerhans' cell histiocytosis with biopsy-confirmed suprasellar metastases (complicated by pan-hypopituitarism) who was transferred to our institution for hypernatremia and hydrocephalus. she had undergone two cycles of chemotherapy, most recently one week prior to presentation, and five rounds of radiation completed three months earlier. her presentation to the community hospital from a nursing facility was with unresponsiveness and she was intubated on arrival. her sodium was 174 at that time; and had been 137 three days prior. sodium was corrected from 174 to 139 over the course of four days with a drop from 174 to 157 within the first ten hours. her mental status improved to the point where she was awake and following commands; however still remained intubated. when she presented to our institution her sodium was 139 and subsequently became unresponsive with a poor neurological exam limited to cranial nerve function only. she was evaluated with eeg monitoring and mri brain; however both were unrevealing for a cause. she had an external ventricular drain placed for concern for hydrocephalus that did not change her exam. one week later repeat mri brain revealed extrapontine myelinolysis. this case highlights the complications associated with intracranial lch and the need for repeat imaging in patients with rapid sodium correction to identify effects of osmotic demyelination. cangrelor is a rapid-acting, intravenous p2y12 platelet receptor inhibitor with a plasma half-life of 3-6 minutes and full platelet recovery achieved within one hour after discontinuation. because it is rapidly reversible, cangrelor is commonly used to bridge patients with recent coronary stents to cabg surgery. oral p2y12 inhibitors, such as clopidogrel, have a delayed onset and offset with platelet recovery occurring over 5-7 days, making their use challenging perioperatively or in the setting of an acute bleed. safety and efficacy data of cangrelor in noncoronary stents are lacking. we present two patients in whom cangrelor was used to maintain internal carotid artery (ica) stent patency acutely. both patients presented with an ischemic stroke secondary to acute occlusions of the left ica and left middle cerebral artery (mca) and were taken emergently to the neurointerventional suite for carotid artery stenting (cas) and mechanical embolectomy of the mca clot. heparin and eptifibatide were administered intraoperatively. post-procedure dynact demonstrated intracranial hemorrhage complications. dual antiplatelet therapy (dapt) with clopidogrel and aspirin, typically initiated following cas, was deferred given the difficulty of reversing their antiplatelet effect in hemorrhage expansion. instead, cangrelor was initiated to maintain carotid stent patency at 0.75 mcg/kg/min in one patient and 0.5 mcg/kg/min in the other patient and infused for 5.5 and 25 hours, respectively. platelet reactivity was trended with the verifynow® assay and used to adjust cangrelor dosing. serial imaging was obtained to monitor hemorrhage expansion. one patient was transitioned to oral dapt and discharged while the other patient deteriorated neurologically from malignant cerebral edema and expired. cangrelor may be useful following cas complicated by intracranial hemorrhage when the need to maintain stent patency must be balanced with the risk of hemorrhage expansion. further research is warranted to determine its safety and efficacy in noncoronary stents. cerebral amyloid angiopathy (caa) although has been described in the literature, the different categories of this entity and its recognition and subsequent treatment are still elusive. it is important for neuro intensivists to recognize its variable presentation . we describe a single case report and perform a systemic review. caa depending on pathology can be categorized as inflammatory-caa where perivasculitis is seen on biopsy. this causes a non-destructive perivascular inflammatory infiltration and amyloid deposition pattern. on the other hand, amyloid beta related angitis (abra) results in a vasculitis and there is predominantly granulomatous angio-destructive inflammatory mediated disease affecting leptomeningeal and cortical vessels characterized by meningeal lymphocytosis and abundant amyloid-beta deposition within the vessel walls. caa on the other hand results in no inflammation of vessels but rather just deposition of amyloid deposition in the walls of vessels. we report a case of a 82 year old man with an extensive cardiac history, who presented with syncope. initial computed tomography (ct) of head was negative. during admission, he acutely started having trouble answering questions including his name, and was unable to communicate his needs. repeat ct head showed hypodensity in left frontal region which was attributed to a stroke. he than developed complex partial seizures requiring intubation and seizure management. lumbar puncture showed mild pleocytosis. mri brain showed edematous changes of the left subcortical and deep white matter frontal lobe region which on repeat imaging subsequently worsened. biopsy was eventually performed which confirmed inflammatory cerebral amyloid angiopathy. he was treated with steroids and immunosuppression with gradual improvement. 3 month follow up in clinic with continued improvement to independence. recognize the various subtypes of caa in their pathology, presentation and potential treatment. in acute emergency situations, intraosseous vascular access represents an alternative route of vascular access when peripheral vein insertion is difficult. we present the first documented case of intraosseous alteplase (tpa) administration in a patient with acute ischemic stroke symptoms. methods 57 year old male with past medical history of hypertension, end stage renal disease, and diabetes mellitus presented to the hospital with sudden onset expressive aphasia and right sided numbness 36 minutes prior to ed arrival. nihss was 3 and code stroke was activated. patient blood pressure was 207/102. ct head did not show any acute intracranial hemorrhage. it was decided to proceed with thrombolytic therapy. one peripheral venous access was obtained through which nicardipine drip was started to lower the blood pressure however second peripheral venous access was attempted multiple times but was unable to be obtained. tpa is more effective the faster it is administrated, and there was no known contraindications to administering tpa via intraosseous access (io). we report the first known case of successful and safe administration of fibrinolytic therapy through the intraosseous route in a patient with acute ischemic stroke symptoms. intraosseous access has been considered to be more invasive than intravenous (iv) and carries theoretical risk of bleeding however we were able to demonstrate tpa administration through io without any local or systemic complications. the bioavailability of alteplase through io access has not been studied however it is considered to be close to iv infusion in case of morphine and vasopressors. no studies negate or support the use of intraosseous access in stroke patients. contraindications are few and complications are uncommon. the findings of our case report suggest that intraosseous cannulation may be safely used for fibrinolysis in acute ischemic stroke patients with difficult peripheral venous access in in-hospital or out-of-hospital setting. tufts medical center, boston, massachusetts, usa we report a case of a pregnant patient with bilateral ovarian teratomas who presented with treatment refractory nmda receptor encephalitis despite removal of bilateral teratomas, successfully treated with rituximab. case report and discussion of treatment and outcome. 25 year old 22 weeks pregnant female with known ovarian cysts who presented with one week of confusion and subsequent status epilepticus. she was started on empiric treatment with ivig while undergoing workup. nmda receptor antibody was confirmed. left oophorectomy and right ovarian cystectomy were performed, both of which confirmed ovarian teratoma. she was given high dose steroids. her worsening condition prompted consideration of additional agents. plasma exchange and rituximab were initiated and then she was continued on rituximab alone. she improved dramatically over six weeks and delivered at full term via spontaneous vaginal delivery. at one year follow up, the child was healthy and meeting appropriate milestones. we report the use of rituximab for safe and successful treatment of nmda receptor encephalitis in a gravid female. neovascular glaucoma (nvg) is a known complication of carotid endarterectomy in patients with carotid stenosis. there are no previous reports of acute nvg refractory to medical treatment following carotid artery stenting (cas). we report a patient who needed surgical treatment for acute exacerbation of nvg following cas. a 56-year-old man with hypertension, diabetes, and hypercholesterolemia presented with recurrent transient weakness in his right hand. fifteen days before presentation, he had experienced acute loss of vision on the left side because of central retinal artery occlusion. magnetic resonance imaging of the brain was unremarkable. conventional angiography showed an occlusion of the left proximal internal carotid artery. ophthalmological evaluation before cas showed neovascularization of the iris and a normal intraocular pressure (iop) of 14 mm hg in the left eye. cas was uneventful, but the following morning, the patient developed pain in the left eyeball with an iop of 49 mm hg. anterior chamber paracentesis followed by intraocular injection of bevacizumab, panretinal photocoagulation, and medical treatment failed to reduce the iop below 32-36 mm hg. eighteen days following cas, an ahmed glaucoma valve was implanted in the left eye to treat the refractory nvg. iop decreased to 6 mmhg and his ocular pain resolved completely post implantation. although nvg is a rare complication of cas, it should be suspected in patients who develop acute ocular pain following cas. nvg may respond to anterior chamber paracentesis, panretinal photocoagulation, and bevacizumab, but surgical treatment, such as implantation of an ahmed glaucoma valve, should be considered in cases with refractory nvg. background: cerebral amyloid angiopathy is a common cause of spontaneous lobar intracerebral hemorrhage. convexal subarachnoid hemorrhage can be a manifestation of cerebral amyloid angiopathy. whether focal amyloid burden predicts future hemorrhage is unclear. case: an 82-year-old man presented with transient left arm weakness and paresthesias in the setting of previous cognitive decline. mri showed a convexal subarachnoid hemorrhage of the right central sulcus, as well as susceptibility weighted imaging findings consistent with superficial siderosis. lumbar puncture revealed normal cell count with a mildly elevated protein. he had spontaneous resolution of his symptoms after several hours. one year later he presented with sudden onset confusion and imaging again showed a convexal subarachnoid hemorrhage over the posterior right frontal lobe. susceptibility weighted mri revealed hemosiderin over the right posterior frontal and anterior parietal lobes. an amyloid-pet, obtained one year prior to his first spell as a research participant, demonstrated asymmetric amyloid deposition in the right temporo-parietal region. 6 years after his initial episode he presented again with confusion, headache, and decreased level of alertness. a ct scan demonstrated a right-sided temporo-parietal intracerebral hemorrhage in the area of asymmetric amyloid deposition on pet. his family opted for comfort measures only, and he was discharged to hospice. autopsy revealed severe amyloid angiopathy, as well as alzheimer disease, braak stage vi. discussion: this case illustrates the clinical course of a patient with amyloid angiopathy, including recurrent convexal subarachnoid hemorrhages, and superficial siderosis. of importance, the amyloid pet scan predicted the location of his intracerebral hemorrhage 7 years later. the case of a 23-year-old man, presenting with a past medical history of migraine headaches, dipola, vertigo, with symptoms later progressing to lethargy and confusion for 10 days. brain mri revealed a peripherally enhancing mass within the left thalamus with central restricted diffusion, which is consistent with a cerebral abscess. case report of congenital heart disease when discovered in adulthood is an interesting entity, especially when it is the source of brain abscesses. detailed history taking, physical examination and appropriate imaging can usually reveal the anomaly. the diagnosis of brain abscess should promote the clinician to consider right to left shunts as a possible predisposing condition for brain abscess management of acute cerebral embolism in patients with implanted ventricular assist devices (vads) is particularly challenging, since chronic anticoagulation often precludes the use of intravenous tissue plasminogen activator (iv-tpa). we describe a vad patient who suffered cerebral embolization, and was successfully treated with thrombectomy, emphasizing the nuances particular to this clinical scenario in the context of limited historical experience. a 54 year-old man with heart failure (ejection fraction 10%) and heartware ii vad implantation about 15 months prior, was found at the scene of a car accident with expressive aphasia, right homonymous hemianopia, extinction and right hemiplegia, with a national institutes of health stroke scale (nihss) score of 12. upon arrival, his ct was unremarkable, but cta revealed occlusion of the left middle cerebral artery (m1 segment). since his inr was 2.1, he underwent emergent thrombectomy with the solitaire device, resulting in complete revascularization (tici = 3) 120 minutes from onset, with rapid deficit resolution (nihss = 0). the procedural and clinical success was accompanied by lack of evidence of infarction in subsequent ct studies, and a modified rankin score of 0 upon discharge. the removed thrombus displayed early organization, suggesting unexpected firmness, and underscoring the potential importance of mechanical removal rather than chemical lysis in vad patients. our case has attributes that set it apart from those previously reported: 1) the use of a hybrid (i.e. retrieval plus aspiration) endovascular retrieval technique, 2) the lack of concurrent use of thrombolytic drugs, and 3) the rapid, sustained and optimal clinical improvement. the utilization of vads continues to grow, yet the literature regarding endovascular techniques for managing these types of patients remain scarce. however, the increasing availability of centers capable of delivering this type of treatment, suggests that thrombectomy should be strongly considered in vad patients with acute cerebral embolism. extreme cerebral oxygen changes has not been reported via monitoring of partial brain tissue oxygen levels. here we present an asah patient with brain tissue oxygen (pbto2) monitoring, who developed cerebral hypoxia due to cerebral vasospasm, then went on to develop cerebral hyperoxia with associated cerebral infarction. methods 54 yo female with hh5fg4 sah with initial gcs of 3t underwent coiling of a ruptured basilar tip aneurysm. a pbto2 monitor was inserted to guide therapy. this patient had multiple episodes of low pbto2 (80 mmhg). this corresponded to infarction on follow up head ct and mri with preservation of local arterial vessels on mra, consistent with diagnosis of dci. in the present case, high pbto2 is more likely resulted from a combined effect of 1) increased cbf from co-administration of ketamine at the time of milrinone infusion; 2) decreased cerebral metabolic demands in already infarcted left frontal lobe, resulting in reduced oxygen uptake; 3) accelerated reperfusion and thus hyperemia with milrinone. restoration of flow with milrinone may have been too late to reverse the prolonged period of vasospasm induced ischemia, resulting in perfusion of infarcted tissue, or luxury perfusion. clinicians utilizing pbto2 monitoring for dci management should be cautious of high pbto2 values, as it may herald cerebral infarction. further studies are needed to better elucidate the mechanism of reperfusion injury and potential treatments. patients with acute brain injury, especially those with intracranial hemorrhages are at a higher risk for hemorrhage while on therapeutic anticoagulation. unfractionated heparin (ufh) is frequently used as it is easily reversible and has a short half-life. activated partial thromboplastin time (aptt) is traditionally used to monitor its effect. several disadvantages with aptt monitoring include inability to reach therapeutic goal, over-or under-dosing and its associated complications. anti-xa level is reported to have better correlation with actual degree of anticoagulation using ufh. retrospective chart review of 3 patients with acute brain injury who required initiation of early therapeutic anticoagulation and monitored with anti-xa level. case 1 -30 year-old-man with intracerebral hemorrhage (ich) developed lower extremity deep vein thrombosis (dvt) and required therapeutic anticoagulation. patient became therapeutic within six hours of titrating infusion based of anti-xa levels and remained therapeutic. asymptomatic rectal bleeding associated with fecal management system was noted. case 2 -26 year-old-man with cerebral venous sinus thrombosis presented required therapeutic anticoagulation. ufh infusion was initially monitored using aptt levels which had widely varied lab results, thus monitoring was switched to anti-xa levels which provided a more consistent therapeutic range. however, patient developed thrombocytopenia in the setting of inflammatory bowel disease. therefore, ufh infusion was changed to argatroban infusion. case 3 -22 year-old-man with lower medullary acute ischemic stroke due vertebral artery dissection required therapeutic anticoagulation to prevent recurrence. patient became therapeutic within 27 hours of titrating based of anti-xa levels. to monitor therapeutic anticoagulation, anti-xa level appears to achieve target anticoagulation level faster and without serial variation as compared to aptt. however, anti-xa level estimation is costlier as compared to aptt and not widely available. by restricting it to special populations like those with acute brain injury might justify its use and underscore cost-effectiveness. neurological admissions presenting to the icu benefit from a dedicated neurocritical care team but many community hospitals lack this subspecialty expertise. with an aging population and a neurointensivist shortage, more patients are transferred to designated neurocritical care units which increases healthcare spending and resource utilization. recognizing this obstacle, we describe the management of a patient in status epilepticus via our novel "eneuro-icu" consult program in which a 'sub-hub' of the northwell health tele-icu was set up at the only hospital out of 19 in our health system that is staffed 24/7 by neurointensivists. a 56-year-old man with history of a left frontal meningioma presented with multiple seizures to a hospital within our healthcare system. he received 6 mg of lorazepam and levetiracitam in the emergency department and was admitted to the icu for further monitoring. there he was witnessed to have recurrence of clinical activity concerning for ongoing seizure. levetiracitam was increased and phenytoin was added. neither immediate neurological consult nor continuous eeg was available, thus an "eneuro-icu" consult was obtained. in this model, the bedside provider contacts the tele-icu that facilitates a conference call with the neurointensivist. av technology was used to provide consultations and follow ups. the neurointensivist determined the patient was rapidly returning to baseline and recommended a head ct, lab studies and continuation of the anti-epileptic drugs. the eicu team monitored the patient overnight. by leveraging the infrastructure in place for management of critically ill patients remotely, an additional level of subspecialty care was offered in a timely manner and allowed the patient to remain at their local facility. based on the success of the initial program we are currently in the process of extending the virtual consult service to various community hospitals' eds/icus to improve outcomes for patients who would benefit from neurocritical care services. hypoglycemic encephalopathy is a potentially life-threatening manifestation of hypoglycemia, it is usually caused by metabolic change, hypoglycemic agents, and malignancy. here, we report a patient with hypoglycemic encephalopathy caused by sleeve gastrectomy a 34-year-old woman was admitted due to unconsciousness of acute onset. she showed normal corneal and vestibulo-ocular reflex but sluggish pupil light reflex and decerebrated posture by painful stimulation. she has taken severe medications for weight control including orthosiphon powder and hydrochlorothiazide after bariatric surgery. laboratory studies showed significantly low blood glucose level (13mg/dl) with normal liver enzyme and creatinine. there was no evidence of adrenal insufficiency. electroencephalography showed no epileptiform discharge. initial and follow-up brain magnetic resonance imaging revealed diffuse high signal intensity on white matter expanded to cortex, corpus callosum and posterior limb of the left internal capsule, suggesting hypoglycemic encephalopathy. in abdomen-pelvic ct, there is no mass lesion like carcinomas or insulinoma. the clinical diagnosis of hypoglycemic encephalopathy followed by sleeve gastrectomy was made by given history of bariatric surgery and the lack of evidence of hypoglycemic agent overdose, adrenal insufficiency, endogenous hyperinsulinism or malignancy. there are several hypotheses that sleeve gastrectomy can encourage hypertrophy of beta cells, hypersecretion of glucagon-like peptide, glucagon abnormality and increased insulin sensitivity, that may induce hypoglycemia. we suggest that clinicians should consider sleeve gastrectomy itself as a possible cause of profound hypoglycemia pulmonary embolism (pe) is a fatal complication in neurological conditions with plegic extremities. clinical presentations and supportive testing can be variable. we present a case of pe which presented with st segment elevations 2 weeks after spontaneous intracerebral hemorrhage (sich). case report and review of the literature we present a case of a 68 year old female with a history of a recent sich with resultant left hemiplegia who presented with a syncopal episode and chest pain. on physical examination, she was noted to be tachypneic and tachycardic with an unchanged neurological exam. pulmonary embolism can present with a variety of ekg abnormalities including st elevations after sich and the treating physician should be aware of these idiosyncrasies. anticoagulation should be cautiously initiated in such cases. infectious intracranial aneurysms (iia) are rare neurovascular lesions associated with infective endocarditis. we present a case of a large iia which developed within 24 hours of a negative ct angiogram and ruptured despite 4 weeks of appropriate antibiotic treatment. a 66 year-old woman presented with fevers and malaise. her initial workup revealed an aortic valve mass and blood cultures grew out streptococcus. three days after intravenous penicillin therapy was initiated for bacterial endocarditis, she developed a new headache and right hemianopsia. a head ct demonstrated a left occipital lobe stroke with hemorrhagic transformation. further workup with ct angiography revealed a 5 mm outpouching along of the distal branch of the left pca, consistent with an infectious intracranial aneurysm. on repeat imaging, this aneurysm demonstrated growth despite medical treatment, and required coil embolization/occlusion. aortic valve replacement was planned after 4 weeks of antibiotic therapy because of continued severe aortic insufficiency and persistent valve vegetation. on the day of surgery, she developed acute word-finding difficulty followed by a rapid neurologic deterioration resulting in coma. a head ct demonstrated a new left frontal intraparenchymal and subarachnoid hemorrhage associated with the rupture of an 11mm x 11mm irregularly shaped aneurysm in the region of the left mca bifurcation, which had been absent on a prior surveillance ct angiography just 23 hours prior. she underwent emergent coil embolization, extraventricular drain placement, and decompressive hemicraniectomy. despite these measures, her exam did not improve. she was transitioned to comfort measures and life-sustaining therapies were withdrawn. the development of iia can occur despite appropriate medical treatment. these aneurysms may rapidly expand and rupture within hours, as shown by our case. even with prior exonerating imaging, clinicians should have a high suspicion for iia development in all infective endocarditis patients. the corneomandibular reflex, also known as wartenburg reflex or von solder phenomenon, is a rare pathological reflex signifying severe supranuclear trigeminal injury. it presents as contralateral jaw deviation to corneal stimulation. etiologies include upper brainstem lesions, large hemispheric lesions with brainstem compression, as well as advanced amyotrophic lateral sclerosis and multiple sclerosis when corticobulbar pathways are affected. this clinical finding is useful in differentiating structural and metabolic causes of coma, as this examination finding would not be present in metabolic phenomena. a middle aged man presents with a hypertensive right thalamic hemorrhage and a four score of e0m0b0r1. the patient's cornea was stimulated with a cotton swab. the cornea was tested bilaterally to determine any lateralizing features. recording on video was performed with patient's family written consent as patient was comatose. upon stimulation of the patient's cornea a contralateral jaw jerk was appreciated. this was replicated contralaterally. this case describes a common patient with a rare physical examination finding. there is utility in recognizing this finding as it will aid in determination of the underlying cause of a comatose state. the corneomandibular reflex present at presentation rules out a metabolic cause. a structural cause was validated by imaging studies (shown). the reflex arc was researched and has been independently artistically rendered (shown), which demonstrates the pathway beginning with the afferent limb of the corneal stimulus (v1) which travels to the main trigeminal sensory nucleus via the trigeminal ganglion. severe supranuclear trigeminal lesions will inhibit inhibitory interneurons within the mesencephalic nucleus, leading to activation of the motor nucleus of the trigeminal nerve. this causes activation of the ipsilateral external pterygoid muscle which produces a contralateral jaw jerk. overall this patient fared poorly and expired several days after admission. pneumocephalus is when air enters and is contained inside the intracranial compartment. when intracranial pressure increases causing neurological decline, patients can experience nausea, vomiting, seizures, dizziness, and altered mental status. here we present three cases of postoperative pneumocephalus which resolved quickly with humidified oxygen delivery via high-flow nasal cannula. we follow the cases with a review of the mechanisms and pathophysiology of pneumocephalus and its treatment, as well as future directions in management. case series of 3 patients with post-operative pneumocephalus who were treated with high-flow nasal cannula. case 1 describes a 78-year-old woman who underwent hemicraniotomy for removal of meningiomas, with focal postoperative neurological signs and 8mm of midline shift on head ct due to pneumocephalus. case 2 describes a 57-year-old woman who underwent right anterior temporal lobectomy for seizures, who developed postoperative focal prefrontal lobe signs and mount fuji sign on head ct. case 3 describes a 58-year-old man with bilateral subdural hematomas, status post bilateral burr hole evacuation. he was excessively somnalent postoperatively with bilateral pneumocephalus. with high-flow nasal cannula, they all returned to clinical, and near radiographic baseline within 8, 12, and 20 hours, respectively. recognizing the limitations of a small case series, we believe these cases support use of high-flow nasal cannula when treating patients with symptomatic pneumocephalus. thsee patients showed more rapid clinical and radiographic improvement after implementation of hfnc oxygen therapy than previously described using other methods. high-flow nasal cannula may help washout nitrogen from the lungs, allowing a downward gradient from the nitrogen in the intracranial air bubble out the lungs. in addition, high-flow nasal cannula is more comfortable for the patient, allowing for more consistent treatment. randomized studies are needed to confirm our findings. the neurotoxin produced by clostridium botulinum is the most lethal toxin known by weight. early recognition and treatment of botulism are crucial for full recovery. we present a case of progressive paralysis secondary to botulism toxemia following a gunshot wound (gsw). a 27-year-old man suffered a gsw to the right lower extremity. he was treated in the emergency department where the wound was irrigated and closed. some bullet fragments could not be retrieved due to close proximity to popliteal vessels and surrounding nerves. he returned ten days later with diplopia and nausea. he denied consumption of canned foods or illicit substances and had no preceding upper respiratory or gastrointestinal illnesses. on examination, he exhibited ptosis and symmetric bilateral motor weakness with diminished deep tendon reflexes. the gsw showed no signs of infection. progressive respiratory insufficiency resulted in intubation and mechanical ventilation. a lumbar puncture revealed normal opening pressures and cerebrospinal fluid analysis was unremarkable. titers for acetylcholine receptor and anti-muscle specific kinase antibodies were negative, as was a tensilon test. blood toxicology analysis showed no evidence of illicit substances or heavy metal poisoning. a high suspicion for wound botulism led to consultation with the regional poison center and cdc. blood and anaerobic wound samples were obtained for toxin bioassay and culture. empiric intravenous penicillin g therapy was started. equine heptavalent antitoxin (h-bat) was obtained and administered on hospital day 2. serum toxin bioassay tested positive for botulinum neurotoxin type a. the patient required a gastrostomy tube due to persistent dysphagia. after one month of hospitalization, he was discharged home and continues outpatient physical therapy. wound botulism from traumatic injury is exceedingly rare with only one to two cases reported annually. our case is the first reported incidence of wound botulism from a single gunshot wound. hyperammonemic cerebral edema (hce) with brain herniation carries a dismal prognosis historically despite aggressive treatment. however, we report a case where a patient with severe hce and herniation returned to her neurological baseline after aggressive medical management. a 62-year-old woman became acutely comatose with a blown left pupil and required intubation several days after admission for encephalopathy. head ct demonstrated diffuse cerebral edema with central and bilateral uncal herniation. profound hyperammonemia (238ug/dl) was implicated, though hepatic function was normal. her intracranial hypertension was ultimately controlled using hyperventilation, sedation, and osmotherapy, resulting normalization of her brainstem reflexes and improvement in her coma and imaging. continuous veno-venous hemodialysis (cvvhd) normalized her ammonia and encephalopathy that was initially refractory. multiple porto-hepatic shunts were identified on hepatic ct angiogram as the cause of her hyperammonemia, and were embolized. she was eventually weaned off cvvhd and extubated, without residual neurological deficits. our case demonstrates that, with contemporary management, clinical and radiographic reversal of hce and herniation is possible and prognosis is not uniformly poor. therefore, neurological prognostication in these patients should only be performed after assessing the clinical trajectory following cerebral resuscitation and ammonia reduction. furthermore, our case provides an example of how cvvhd can be used to reduce refractory hyperammonemia quickly until the cause of the hyperammonemia can be ascertained and addressed. finally, this is the first case reported of hce secondary to primary portosystemic shunt in absence of hepatic disorder; vascular imaging of the liver should be considered in the work-up of patients with hyperammonemia. a good neurological prognosis is possible for patients with hce and cerebral herniation with aggressive management that includes reduction of icp and ammonia. ccvhd is a useful adjunct to treat refractory hyperammonemia. a porto-systemic shunt should be considered as an etiology for hyperammonemia. cerebral venous sinus thrombosis (cvst) often presents with intracerebral hemorrhage and seizures. extensive involvement of the cerebral sinuses can lead to comatose state due to cerebral edema and associated intracranial hypertension. if not reversed with early therapeutic anticoagulation, then mechanical thrombectomy and decompressive hemicraniectomy (dhc) may be necessary as life-saving measures. however, etiological diagnosis of associated hypercoagulable state is needed for successful long-term treatment. case report of a patient presenting with cvst requiring anticoagulation, dhc and total colectomy (to treat underlying ulcerative colitis) as treatment with full anticoagulation was associated with lifethreatening hematochezia. twenty-five year old man with one week history of diarrhea presented with left sided weakness. imaging studies confirmed extensive cvst with minimal venous drainage through bilateral cavernous sinuses as well as right hemiparesis secondary to left post cingulate intracranial hemorrhage. patient subsequently developed loss of vision and became encephalopathic, despite initiation of anticoagulation with heparin. hence, mechanical thrombectomy was attempted but was unsuccessful. he also developed consumptive thrombocytopenia for which his anticoagulation was switched to argatroban. progressive neurologic deterioration necessitated dhc. his neurological examination progressively improved upon re-initiation of anticoagulation resulting in restoration of vision and resolution of left hemiparesis. later in the disease course, he developed symptomatic hematochezia associated with his primary disease, ulcerative colitis and required total colectomy. subsequently he was transitioned to oral anticoagulation and transferred to inpatient rehabilitation facility due to deconditioning from prolonged hospitalization. cvst can be life-threatening unless early treatment is initiated. appropriate and timely treatment including etiological diagnosis can lead to favorable patient outcomes. adverse effects of intrathecal non-ionic contrast during myelography are rare but can include seizures and encephalopathy. to our knowledge, cerebral edema has only been reported in the literature in two previous cases. we report a case of malignant cerebral edema following intrathecal administration of non-ionic contrast who developed seizure like activity with radiographic evidence on a head computerized tomography (ct) scan of acute diffuse cerebral edema. an 80 year-old male underwent an elective spinal ct myelogram using 20mm of isovue m 200 non-ionic contrast to evaluate chronic lumbar pain related to spinal stenosis. no complications were reported intra-procedurally and the patient was discharged home. the patient began to complain of progressive worsening headaches. the following morning he started complaining of nausea/vomiting, lost consciousness with posturing vs seizure like activity. a head ct revealed extensive brain edema and swelling with crowding of the brainstem and herniation ( fig. 1 ). this patient was intubated and given an iv mannitol, 23.4% hypertonic saline followed by an infusion of 3% hypertonic saline infusion. serial cts revealed complete resolution of his cerebral edema 48 hours after admission ( fig. 2 and 3) . the patient's mental status improved, was extubated, and then was discharged home 5 days after admission. while significant adverse effects of non-ionic contrast following spinal myelography are rare, the potential life threatening severity of these incidents warrants further patient education following this routine outpatient procedure. we recommend close neurological monitoring after intrathecal administration of contrast media. patients should be provided with detailed instructions about the potential side effects of non-ionic contrast and how to seek medical attention if symptoms of cerebral edema are noted post procedurally. a large acute traumatic subdural hematoma with brain compression and midline shift is typically considered a neurological emergency necessitation surgery. spontaneous resolution of a large subdural hematoma is considered a rare phenomenon with a few case reported in the literature. to our knowledge, we present the first case of spontaneous resolution of a traumatic acute subdural hematoma with brain compression and midline shift on dual antiplatelet therapy. a 71 year-old patient initially presented after being found down and unresponsive in his home. the patient was on aspirin and clopidigrel. he was found to have altered mental status, wasn't following commands, and had a glascow come scale score of < 8. the patient's initial head ct revealed a large left acute subdural hematoma (sdh) measuring 1.8cm in diameter. neurosurgery was consulted upon arrival for possible emergent evacuation. the patient's repeat head ct showed a decreased sdh to 1.1cm in diameter. given the rapidly resolving sdh, surgery was postponed. another repeat head ct the following day revealed a decrease in size of the sdh to 10mm in diameter. several theories have been proposed for the rapid resolution of an acute sdh including csf leaking into the sdh through a tear in the arachnoid membrane with rapid reabsorption, redistribution of the hematoma in the subdural space, and acute fluctuations in icp driving the spontaneous resolution of the sdh. close neurological and repeat imaging may be helpful in managing these patients. as seen in our patient and others, a low density band in the subdural hematoma may indicate csf and be a predictor for spontaneous resolution of an acute sdh. the features of this atypical case offer points of discussion regarding the surgical or non-surgical approach of these patients. early post-hypoxic myoclonus -or myoclonic status epilepticus -develops within 48 hours of the initial anoxic injury and is associated with poor outcomes per current aan practice guidelines. late posthypoxic myoclonus -or lance-adams syndrome -develops >48 hours after the anoxic injury, consciousness is regained, and is associated with relatively good outcomes. the patient is a 46 yo man with a history of alcohol and cannabis use disorder, bipolar disorder, pnes who presented after attempted hanging for up to 15 minutes. intial rhythm was pea; he had 3 rounds of cpr, received 1mg epinephrine, and was intubated prior to rosc. myoclonic jerks were noted within 24 hours post arrest. hypothermia protocol was initiated as gcs was 3t. ct head showed subtle loss of grey-white differentiation. eeg initially showed that his generalized myoclonic jerks correlated with cortical activity. he was started on versed gtt, keppra, vpa with improvement in the frequency of jerks. on post-arrest day 3, mri brain showed mild cerebellar edema. mri c-spine was negative for significant myelopathy, arguing against myoclonus as a spinal reflex. mentation gradually improved; on post-arrest day 7 he opened his eyes to command. eeg evolved to show gpeds and sirpids and oxc and tpm were added. on post-arrest day 11 a paralytic challenge resolved electrographic spikes, suggesting subcortical origin of myoclonus. he continued to improve cognitively, but despite clonazepam, vpa, home oxc he continues to have severe intention myoclonus. despite the presumed poor prognosis, the patient's family pursued aggressive measures and his mentation gradually improved. early post-hypoxic myoclonus carries a poor prognosis, however, in this case, the patient survived with a good cognitive outcome likely owing to his age and relatively few comorbidities. further studies are needed to differentiate early-onset lance-adams from myoclonic status since prognosis differs greatly. posterior reversible encephalopathy syndrome (pres) can occur from multiple etiologies and often presents with rapid-onset headache, altered consciousness, seizures and/or visual disturbances. vasogenic edema involving predominantly cerebral white matter is a key finding on imaging studies. although seizures are a frequent presenting symptom of pres, refractory status epilepticus (rse) requiring multiple antiepileptic medications is very rare. a case report of a patient presenting with pres and clinical course complicated with rse necessitating use of intravenous anesthesia, ketamine, and newly-available brivaracetam. 65-year-old woman with history of congestive heart failure, chronic iron deficiency anemia and uncontrolled hypertension was admitted for severe encephalopathy and convulsive status epilepticus (cse) for longer than 30 minutes necessitating propofol and midazolam infusions. her admission systolic blood pressures were in the 280s, and mri brain revealed bilateral parieto-occipital t2/flair hyperintensities consistent with pres. despite adequate control of hypertension following admission, patient remained encephalopathic and continuous electroencephalography (eeg) demonstrated nonconvulsive status epilepticus (ncse). the patient's ncse continued despite use of maintenance antiepileptics (fosphenytoin, lacosamide, levetiracetam) and high-dose infusions of midazolam and propofol. ketamine infusion was started to maximize nmda receptor blocking properties, and burstsuppression pattern on eeg was easily achieved with bolus infusions followed by continuous infusion. addition of brivaracetam was used to replace levetiracetam and allowed patient to remain seizure-free when iv anesthetics were weaned off. patient required prolonged hospitalization with gastrostomy tube placement and tracheostomy, which was later decannulated prior to patient's discharge to home with family. high index of suspicion is necessary to identify patients in ncse with prolonged encephalopathy that have pres. early use of ketamine along with a benzodiazepine may result in rapid achievement of burstsuppression to treat se. brivaracetam may be a useful agent to treat rse. diagnosis of diabetes insipidus(di) includes polyuria, hypernatremia and low urine specific gravity. we present two patients, receiving hyperosmolar therapy for intracranial hypertension (iht), in whom using low urine specific gravity to diagnose di lead to delayed treatment. this is a retrospective case series. criteria used to diagnose di at our institution include polyuria, sodium <300mosm/kg and urine to plasma osmolality ratio <2. case 1: 23-year-old male with subdural hematoma, iht on hyperosmolar therapy, developed polyuria. sodium rose from 141 to 172meq/l. urine specific gravity was 1.020 excluding di. eventually, sodium rose to 184meq/l. specific gravity remained 1.009 but urine osmolality was 162mosm/kg and urine/plasma osmolality ratio was 0.42, consistent with di. vasopressin was initiated, however the patient had already developed lactic acidosis and renal failure due to hypovolemia. case 2: 49-year-old female with intracerebral hemorrhage and iht on hyperosmolar therapy, developed polyuria. sodium rose to 176meq/l, specific gravity remained >1.005 but urine osmolality was 187mosm/kg and urine/plasma osmolality ratio was 0.49 consistent with di. vasopressin was initiated. hyperosmolar therapy increases urine osmoles and raises urine specific gravity. this interferes with diagnosis of di which requires low urine specific gravity. while specific gravity measures the weight of particles, osmolality measures particles independent of their weight and thus accurately measures urine tonicity in the presence of heavy particles like mannitol. moreover, urine/plasma osmolality ratio is able to demonstrate relative hyposmolarity of urine when compared to serum assisting with diagnosis of di even when urine specific gravity is elevated. we conclude that urine specific gravity does not reliably detect di in patients receiving hyperosmolar therapy. urine osmolality and urine/plasma osmolality ratio may detect di earlier and prevent dehydration and kidney injury. these findings should be validated prospectively. endovascular intervention in the treatment of cvt(cerebral venous thrombosis) is an alternative strategy when cases deteriorate despite best medical management or develop refractory intracranialhypertension. we present a patient with cvt due to heparin-induced thrombocytopenia(hit), with intraparenchymal hemorrhage(iph) and refractory intracranial-hypertension, who was managed with systemic anticoagulation, continuous intra-sinus infusion of rtpa and mechanical thrombectomy(mt) resulting in excellent outcome. case report: a 50-year-old woman with left parafalcine meningioma s/p cyberknife was started on subcutaneous heparin for radiation necrosis 5 days prior to admission. she presented to the hospital with new onset headaches and nausea. ct head showed increased edema with mid-line shift around the meningioma, for which steroids were started. within 2 days her headaches worsened and repeat imaging demonstrated right temporal iph. emergent hematoma evacuation was performed. mri brain showed right cerebellar infarct and mra head showed extensive cavernous sinus thromboses, from right internal jugular vein and into sigmoid and transverse venous sinuses. she tested positive for hit and was switched to argatroban drip. patient however continued to deteriorate due to refractory intracranial-hypertension. intra-cavernous rtpa injection and mt was done but the thrombosis was noted to recur on repeat angiogram 24hrs later. an intra-sinus catheter was left in place for continuous infusion of rtpa at 1 mg/hr. for 12hrs was done while argatroban drip was continued. the patient's intracranial pressure returned to normal. repeat venogram showed resolution of cvt. patient tolerated the therapies well, without any further hemorrhagic complications. modified rankin score at 6 month follow-up was 1. this case features successful aggressive endovascular interventions including in-situ rtpa infusion, mt and concomitant systemic anticoagulation for cvt due to hit, complicated by intracranial hemorrhage and refractory intracranial hypertension. the paucity of high quality evidence related to safety, efficacy and modality of endovascular treatment lead to making therapeutic decision on individual basis. acute brain injury may be followed by encephalopathy marked by electroencephalographic features along the ictal-interictal continuum (iic). the use of perfusion imaging to co-localize radiographic features of known malignant eeg patterns may add an important context to guide treatment escalation or de-escalation. this is only the second report in which widely available ct or mr perfusion techniques were favored for this application over more cumbersome metabolic imaging such as pet. retrospective analysis was performed on records for patients admitted to a neurosciences icu, exhibiting encephalopathy, with eeg features on the iic, who underwent perfusion imaging. studies included ct perfusion, mr perfusion, arterial spin labeling, or spect. these studies were obtained for unrelated purposes. escalation or de-escalation of anti-convulsant and sedative medication, hospital course, and patient outcomes were extracted. perfusion imaging data was juxtaposed with eeg patterns along the iic, and patient outcomes are described in narrative form. seven cases were identified. four cases occurred in the context of intraparenchymal hemorrhage, of which one was secondary to meningioma resection. two cases occurred after treatment for subdural hematoma, and one case was related to ischemic stroke. anti-convulsant and sedative management was escalated or de-escalated relative to the presence or absence of radiographic co-localization of hyperperfusion in all but one case. emerging data indicates that some iic eeg patterns may merit aggressive treatment. metabolic signatures of secondary brain injury as measured by cerebro-oximetry or microdialysis have associated these patterns with unfavorable outcomes. we report case studies in which information gleaned from basic perfusion imaging may suffice to distinguish between benign iic patterns and those that should be regarded as near-ictal. the cases hint at novel ways to conceptualize treatment of encephalopathy following acute brain injury and suggest a dimensional shift in thinking towards electroperfusive status epilepticus. sudep has classically been a diagnosis of exclusion. recent studies have shown, however, that similar genes -and even genes within the same family -are associated with sudep and brugada. this suggests that perhaps the cardiac irritability of brugada syndrome exists on a spectrum with epileptic sudden death. a 25 yo man with a history of presumed seizure disorder presented as a transfer from another hospital after being found to have anoxic brain injury following cardiac arrest. he had been shopping with his wife when he was thought to have one of his typical seizures. he was non-responsive for about 20 minutes. on arrival ems found him pulseless. cpr was started en route and continued for 30 minutes in the ed where he was defibrillated three times before achieving rosc. he completed the therapeutic hypothermia protocol. cardiac catheterization was clean. eeg showed diffuse slowing with no epileptiform discharges. imaging showed diffuse anoxic brain injury. after nearly two weeks without clinical improvement he was made comfort care. . of note, previous seizure workup failed to identify epileptiform activity. he was given an aed prescription which he never filled. further chart review showed that he had previously presented to the ed after a "seizure" episode which lasted 45 minutes. his neuroexam was non-focal. ct head was negative. review of his ekg at that time showed type 1 brugada syndrome pattern with an elevated jpoint and t-wave inversions in v1 and v2. his sudden cardiac arrest is most likely a result of symptomatic brugada symptomatic brugada is important to identify early since deaths such as the one discussed above may be prevented by an implanted defibrillator. this case highlights the need for heightened awareness and more effective testing for brugada in the setting of seizure or pseudoseizure. patients with cerebral air embolism (cae) often exhibit more severe symptoms than those typically associated with the number of air emboli and size of infarcts on brain images. however, this discrepancy between symptoms and imaging findings has not been sufficiently explained. we report a case of cae in which disruption of the blood-brain barrier (bbb) and perfusion defects were identified via brain magnetic resonance imaging (mri). a 79-year old man with a lung mass was admitted to our hospital. percutaneous needle aspiration of the mass was performed in the left lower lobe of the lung. the patient developed sudden confusion and irritability after the procedure. during neurological examination, he could follow only simple commands and exhibited symptoms of left-sided weakness and neglect (medical research council grade 2). noncontrast computed tomography (ct) of the brain revealed a few small air emboli in the right frontal subcortical area. multimodal mri of the brain was performed 50 minutes after the onset of symptoms. t2-weighted gradient-echo imaging revealed only a few small air emboli in the right frontal area, and diffusion-weighted imaging findings were unremarkable. in contrast, time-to-peak imaging revealed widely distributed perfusion defects in the right hemisphere, while contrast-enhanced t1-weighted imaging revealed prominent leptomeningeal enhancement, suggestive of bbb disruption in the right hemisphere. magnetic resonance angiography revealed no steno-occlusive lesions. the patient was treated with 100% oxygen via a high-flow nasal cannula. his weakness subsided the next day, although his confusion persisted for 18 days. follow-up mri performed five days after the onset of symptoms revealed resolution of the abnormal findings. our findings suggest that disruption of bbb and perfusion defects may develop in patients with cae. extensive impairments of the bbb and perfusion may explain the mismatch between severe neurological symptoms and small air emboli/infarcts. co-existence of cerebral salt wasting and diabetes insipidus is an extremely rare entity that has only been described in 2 adult case series and a paediatric series. due to the complex nature of diagnosing this entity, mistreatment may ensue and lead to high morbidity and mortality rates. we report a case of a patient who was admitted to the neurosurgical intensive care unit after sustaining a subarachnoid haemorrhage secondary to a ruptured anterior communicating artery aneurysm. a 67-year old lady presented with sudden onset of severe headache and nausea. gcs was 12 (e3v4m5) with no focal neurological deficits. she underwent endovascular coiling and embolisation of the aneurysm under general anaesthesia and had a left external ventricular drain inserted. in the immediate postoperative period, she was found to be polyuric, with the initial workup suggestive of diabetes insipidus. desmopressin was administered with initial good effect. however, her polyuria recurred and persisted despite desmopressin. the repeat workup revealed the presence of concomitant cerebral saltwasting. she was then treated with fludrocortisone and sodium chloride supplementation. careful monitoring of her serum sodium levels and overall fluid balance allowed close titration of the desmopressin, fludrocortisone and sodium chloride supplementation. she was eventually weaned off treatment and discharged well with normal sodium levels and with no neurological deficits. this case highlights the difficulty encountered in managing concomitant cerebral salt wasting and diabetes insipidus in critically ill neurosurgical patients and the need to for a high index of clinical suspicion, early intervention and close monitoring. levetiracetam is a commonly used antiepileptic drug (aed) used to treat epilepsy. this agent was approved by the fda in 1999, is available in oral and intravenous formulations, and offers advantageous pharmacokinetics, minimal drug interactions, and a favorable side effect profile. the purpose of this case report is to describe a case of severe, asymptomatic rhabdomyolysis exacerbated by levetiracetam administration. the medical record was reviewed and data was collected to describe a case with a pertinent review of the literature. a 43-year-old african-american male with a history of hypertension presented to the emergency department following a tonic-clonic seizure. baseline labs were drawn and revealed a ck level of 1,226 iu/l, negative urine myoglobin and normal renal function. levetiracetam therapy was initiated and no further seizures were noted. the patient's ck continued to trend up throughout his stay despite aggressive fluid resuscitation with a positive myoglobin on hospital day 2. the ck reached a peak of 41,463 iu/l on hospital day 4. after a literature review and evaluation of his medication list, six casereports were identified linking elevated ck and rhabdomyolysis to levetiracetam administration. at that time levetiracetam was discontinued and the ck rapidly declined to 6,426 iu/l on hospital day 6. the patient never had muscle pain or kidney injury and was discharged on hospital day 6. this case-report describes rhabdomyolysis associated with levetiracetam administration with a naranjo probability scale score of 6 indicating a probable adverse drug reaction. the adverse effects of generalized pain and neck pain are described in the package insert with an incidence of 2-8%; however, it is not reported that ck levels were monitored. due to the frequent use of this aed and given the rare yet serious adverse effect of rhabdomyolysis, ck levels should be monitored upon initiation. acute toxic leukoencephalopathy (atl) is a potentially reversible disturbance to white matter caused by exposure to toxins. we report the first case of a patient with atl in the setting of a fentanyl overdose and reviewed the literature. a 28 year-old man with a history of opiate abuse was found unconscious, last seen well nine hours prior. he was known to have purchased 10mg of fentanyl that day. he was intubated and briefly required blood pressure support. he was initially hypoglycemic and suffered fulminant liver damage, acute kidney injury, rhabdomyolysis, and stunned myocardium. comprehensive toxicology screen was positive for cannabis and fentanyl. mri of the brain showed pronounced bilateral restricted diffusion in the high frontoparietal subcortical white matter with radiographic stability five days later. he remained intubated and neurologic exam poor with fluctuating brainstem reflexes and posturing despite improvement in end-organ function. atl has been reported in a 19-month-old girl and an 85-year-old man with exposure to transdermal fentanyl, both of whom had favorable outcomes (2,3). one case has been reported following oral oxycodone ingestion (11). of 27 cases of atl secondary to inhaled heroin, 48% were fatal (5). preferential white matter injury has been seen in cases of hypoxic ischemic encephalopathy (hie) (7,10). it was initially thought to be secondary to wallerian degeneration following grey matter damage, but post-mortem pathology has shown direct insult to axons (6). atl has been reported in one case of hypoglycemic coma (8) and one case of uremia (9). it has never been reported in isolated hepatic encephalopathy, secondary to seizure, or with cannabis use alone. based on our review of the literature, the most likely causes of this patient's atl are fentanyl or hie. fentanyl should remain on the differential as a previously unreported cause of atl. autonomic dysregulation is a common complication of acute spinal cord injury (sci). subsequent hypotension may worsen central nervous system injury as well as neurologic and mortality outcomes. to help mitigate this occurrence, consensus guidelines recommend maintaining patients' mean arterial pressure (map) >85 mmhg within the first seven days based on evidence from limited clinical trials. limited data exists describing the use of midodrine, an alpha-1 agonist and the previously only available enteral vasopressor, for blood pressure (bp) augmentation in this setting. the use of midodrine is limited by cardiovascular side effects such as bradycardia. droxidopa, a novel enteral precursor of norepinephrine that works independently of the central nervous system, may serve a role in sustaining map in acute sci. we describe a novel case of droxidopa use in a 64-year old male who sustained a spinal cord contusion secondary to severe stenosis at the fourth cervical vertebrae following a ten-foot fall. droxidopa was used to facilitate vasopressor wean in the setting of neurogenic shock as a complication of acute spinal cord injury. to sustain adequate cns perfusion (map goal >65-85 mmhg) and facilitate patient transfer to a lower level of care, droxidopa 100 mg three times daily was initiated after five days of continuous infusion of intravenous norepinephrine. daily assessments of hemodynamic parameters were performed, including blood pressure, heart rate, map, and an electrocardiogram. successful wean of norepinephrine was achieved within 24 hours of droxidopa initiation, with an average map sustained above 65 mmhg. the patient was transferred to a lower level of care within 72 hours of droxidopa initiation. no cardiovascular side effects were observed. droxidopa was well tolerated and facilitated transition from norepinephrine infusion to an enteral option. droxidopa may be a viable option in stable neurocritical care patients who require vasopressors to sustain adequate cns perfusion. traumatic brain injury is acute and sometimes rapidly aggravated during or after surgical treatment. imaging study is most important and computed tomography (ct) is the golden standard in tbi. however the patient should be transfer to ct room or relatively high cost mobile ct scanner may be used. ultrasound is not expensive and also does not produce radiation exposure. we studied the effectiveness and advantages of intra-operative ultrasound examination in traumatic brain injury patients intra-operative ultrasound was used after decompression of injured brain from june 2016 to april 2017. the ultrasound device was the affiniti 50 (philips ultrasound inc, usa) and 2.5 mhz transducer was used. the transducer was covered by thin transparent sterilized vinyl with ultrasonic gel with aseptic manner. to protect brain injury by the ultrasonic probe, a saline soaked gauze was applied on the cerebral cortex. the axial images were captured and then stored in pacs system promptly. ultrasound images were compared to postoperative ct scan. there were 13 male and 2 female patients were examined by ultrasound during there surgery. ipsilateral hemisphere, especially cortical layer was slightly distorted to identification. brain stem area was visible in most cases. contralateral hemisphere was seen in unilateral craniotomy and craniectomy cases. in bilateral craniectomy cases, both hemispheres were observed well. parenchymal hemorrhage was also identified and confirmed for removal using ultrasound. in severe brain swelling cases, arachnoid space was seen increased echogenicity. ultrasound image was compared to postoperative ct scan. intra-operative ultrasound is effective in real time inspection of brain during surgery and may helpful detect opposite or parenchymal hemorrhage before closure and leaving operation room. to describe a rare case of a varicella zoster virus (vzv) meningitis with progressive multiple cranial nerve deficits in the absence of cutaneous zoster rash. a young woman with idiopathic thrombocytopenic pupura on steroids presents with horizontal diplopia in the setting of seven days of intractable headache. she had no meningeal signs, fever, leukocytosis or cutaneous rash. within three days into hospitalization, she developed bilateral cn vi, cn iii, right cn v and right cn vii palsies in a progressive fashion. csf analysis revealed cell count of 1,146/mm3, a protein of 202 mg/dl and glucose 8 mg/dl. cytology, tuberculosis, bacterial and fungal cultures, ace and hiv testing were negative. vzv-dna was detected in csf in high titers vzv quant: 3.9million. contrasted brain mri revealed mild diffuse leptomeningeal enhancement in the basilar region. she recovered almost all cranial nerve function within 10 days of treatment with acyclovir and high dose steroids. a diagnosis of polyneuritis cranialis with zoster sine herpete (zsh) was made given pcr positive vzv-dna in csf. vzv reactivation with a wide array of neurological deficits can present without rash making diagnosis challenging. zsh should be in the differential for acute cranial nerve deficits as prompt treatment with acyclovir can lead to rapid recovery. stress-induced cardiomyopathy or neurogenic stunned myocardium is a well-documented cardiac complication following aneurysmal subarachnoid hemorrhage (sah). onset is usually immediate, within hours after aneurysm rupture, and is characterized by left ventricular dysfunction with pulmonary edema and elevation in cardiac biomarkers. this can often be mistaken for an acute myocardial infarction or ischemia. the pathogenesis appears to be the result of elevated catecholamine levels following injury leading to myocardial contraction band necrosis and cardiac dysfunction. this syndrome occurs more commonly in patients with severe or "high-grade" sah. we review a case of delayed cardiac dysfunction coinciding with the onset of vasospasm. a 52-year-old female presented with a h&h3, mf4 sah. she appeared to have lost consciousness prior to arrival and was reporting worst headache of life. she had an evd placed upon arrival with opening pressure at 27. she underwent endovascular coiling of a ruptured aneurysm of her anterior communicating artery aneurysm. initial echocardiogram demonstrated normal wall motion with ef of 63%, and minimal troponin i elevation at 0.04 ng/ml. on post-bleed day 10 the patient became more somnolent and developed chest pain with an ecg demonstrating st-elevation in all anterolateral leads concerning for acs. she was taken for cardiac catheterization where she had non-obstructive vessels with no vasospasm seen. her ef was reported at 25-35% with apical ballooning present. her repeat echocardiogram also demonstrated a new apical akinesis with ef 45%, and troponin peaked to 16 ng/ml. her tcds at the time were suggestive of vasospasm with bilateral lr >3, but no focal deficit present. it appears that regardless of timeline, stress-induced cardiomyopathy or neurogenic stunned myocardium occurs after sympathetic or catecholamine surge and may occur after the onset of vasospasm in patients with aneurysmal sah. the rapid neurological assessment of critically ill patients with neurologic disease is paramount when determining a course of action. neuromuscular blockade is often used during critical care transport and in the emergency department. unfortunately, this can delay examination and assessment leading to unnecessary testing and procedures. historically, neuromuscular blockade reversal was accomplished using a combination of neostigmine and glycopyrrolate. however, this can lead to incomplete reversal and unwanted side effects from these medications. sugammadex is a cyclodextran injectable compound that has been fda approved in the united states since 2015 for rapid reversal of rocuronium induced neuromuscular blockade. sugammadex works by forming a complex with rocuronium and rendering it unable to bind to nicotinic cholinergic receptors at the neuromuscular junction. sugammadex can reverse neuromuscular blockade without the unwanted side effects of cholinesterase inhibitors. this is a case report of the successful use of sugammadex to reverse the effects of neuromuscular blockade in an intracerebral hemorrhage patient. a 77 year old male with a history of atrial fibrillation and a supratherapeutic inr presented via aeromedical ambulance with a 63 ml left frontal intracerebral hermorrhage causing a 10mm midline shift. he received a 100 mg bolus of rocuronium prior to arrival and had a gcs of 3 upon presenting to the neurosciences icu. a train-of-four revealed 0/4 twitches. he was given 4 mg/kg of sugammadex with a return of 4/4 twitches within 30 seconds. a more accurate neurological examination was then obtained demonstrating that his brainstem reflexes were intact, he could open his eyes spontaneously and reacted purposefully to painful stimulation. this allowed a non-operative course to be taken. sugammadex can reliably and quickly reverse neuromuscular blockade allowing for the immediate assessment of the neurocritical care patient. it is a useful tool with minimal side effects. piperacillin-tazobactam is commonly deployed as empiric antibiotic therapy. piperacillin-induced hematologic laboratory test abnormalities were rare in pre-marketing studies, and whether these alterations are of clinical significance has been studied little. aberrations in platelet function have not been implicated. in the present case, we discuss a patient presenting with hypertensive intracerebral hemorrhage (ich) who sustained two additional hemorrhages in distinct locations after routine removal of intracranial monitors and an external ventricular drain (evd). these significant bleeding events occurred exclusively during piperacillin-tazobactam therapy and were correlated with new abnormalities in the patient's platelet function assay (pfa) results. a 55-year old vietnamese male with hypertension presented for treatment of a left basal ganglia ich. epinephrine/collagen and adenosine diphosphate/collagen pfas at the time of evd and quad-lumen bolt placement were normal, and imaging showed no hemorrhage after placement. hospital course was complicated by aspiration pneumonia requiring empiric piperacillin-tazobactam administration. after removal of the quad-lumen bolt and evd on separate days, both follow-up ct scans showed new hematomas in the devices' tracts, with significant intraventricular hemorrhage. repeat pfas were abnormally prolonged, representing a distinct change from baseline. a trend toward normalization of pfas was observed after discontinuation of piperacillin-tazobactam with progression toward baseline thereafter. the present case is unique in that the significant bleeding that occurred was attributable to objectively confirmed platelet dysfunction rather than thrombocytopenia. other possible innate causes of bleeding were less likely as the patient demonstrated normal platelet count, von willebrand multimers, platelet morphology, and clotting factors. this is the first reported case of intracranial (periprocedural) hemorrhage potentially related to piperacillin-tazobactam; further research into this drug's impact upon qualitative platelet function is needed. the life-saving potential of extracorporeal membrane oxygenation (ecmo) has been well recognized since the 1960s. modern advancements of research and technology have allowed ecmo to be accepted as a dependable intervention for patients with severe pulmonary or cardiac failure. however, with increased use, associated complications that detract from the benefit of ecmo are surfacing as well. this case report describes a case of diffuse intracerebral hemorrhage (ich) after prolonged ecmo resulting in cerebral edema, mass effect, and eventual brain herniation. the patient is a previously healthy 19 year old female who presented with fever, chills, and myalgia. when evaluated at urgent care, she was noted to be hypoxic and was sent to an outside hospital where her monospot test was positive. upon arrival, the patient was placed on venovenous ecmo (vv-ecmo) due to severe hypoxia. she was also in acute renal failure requiring continuous renal replacement therapy (crrt). she had an episode of hypotension with bradycardia. subsequently, her pupils were noted to be fixed and dilated. a stat ct head then showed diffuse bilateral hemorrhages at the graywhite junction as well as diffuse edema. labs showed thrombocytopenia likely due to disseminated intravascular coagulation (dic). her exam was consistent with brain death. it has been estimated that up to 90% of patients who were placed on ecmo as a last resort for respiratory failure have neurological complications including ich. there is no stereotypical pattern of bleeding but diffuse hemorrhage has been seen, which is consistent with the pattern seen in our patient. notably, those with ich have significantly higher rates of mortality. thrombocytopenia, dic, and platelet dysfunction that develop as a result of ecmo are thought to play a role in the development of ich. to present a case report of syndrome of the trepheined (sot) and paradoxical herniation without craniectomy. sot is reported when a constellation of positional neurological symptoms arise following large craniectomy, resolving in a delayed fashion following cranioplasty. paradoxical herniation may occur in extreme cases.the pathophysiology is incompletely understood however proposed mechanisms include compression of underlying brain by the flaccid skin flap due to the gradient between atmospheric and intracranial pressure exacerbated by upright pressure, changes in cerebral blood flow, and csf fluid. a middle aged woman with a history of mood changes eight months preceding admission presents with worsening left hemiplegia over one week. mri revealed a 78 x 44 mm right frontal cystic mass. hyperosmolar therapy and steroids were initiated for midline shift and brainstem compression. her immediate post operative course after tumour excision was uncomplicated. on post-operative day two, she developed uncontrolled hypertension, worsening anisocoria, and decerebrate posturing requiring urgent intubation. head ct revealed uncal and subfalcine herniation despite a large resection cavity. an external ventricular drain was placed and removed due to lack of drainage. within 12 hours of trendelenburg positioning, she improved both clinically and radiographically. she did not undergo an intraoperative csf reduction and no preadmission history (back pain, orthostatic headache, trauma) to support an occult csf leak. she had a recurrence of symptoms on post-operative day eight which also resolved upon lying flat for 48 hours. she was ultimately discharged to acute rehab and tumor pathology returned as glioblastoma (who grade 4). this novel case of sot in the absence of craniectomy demonstrates the complex and poorly understood consequences of slow growing massive tumors, csf dynamics and exertional force on static cns structures. this case also illustrates the benefits of a collaborative, multidisciplinary approach to patient care in the neuroicu. to present a lesser known leukoencephalopathy that occurs when patients overdose on inhaled heroin vapor 'chasing the dragon" is a method of inhaled heroin vapor that is different from smoking or snorting heroin. heroin powder is placed on aluminum foil, which is heated by placing a flame underneath. the white powder turns into a reddish-brown gelatinous substance that releases a thick, white smoke, which resembles a dragon's tail. the fumes are "chased" or inhaled through a straw or small tube. currently the us is facing a growing epidemic of heroin use making this leukoencephalopathy more pronounced. a 34-year-old female with history of drug abuse presented to the emergency department with altered mental status. the boyfriend informed staff that she likely smoked heroin. on arrival, she was drowsy but easily arousable. her brainstem reflexes were intact but she was grossly dysmetric. urine drug screen was positive for opiates only. initial ct of the brain demonstrated extensive loss of gray-white differentiation within the cerebellar hemispheres and bilateral lucency in the globus pallidus and developing hydrocephalus. patient was placed in the neurointensive care unit to monitor and was managed medically with hypertonic therapy to combat her cerebral edema. an mri was done which demonstrated a distinctive pattern of symmetrical white matter t2 hyperintensities in the cerebellum, hippocampus and internal capsule bilaterally characteristically known as "chasing the dragon" sign. the patient gradually improved with supportive treatment, but continued to have mild ataxia upon discharge. we present a case of leukoencephalopathy that was generally rare to see, but now that heroin use is now at a 20 year high within the us, this phenomenon may become more prominent. heroin inhalation leukoencephalopathy should be suspected in all patients with a history of chasing the dragon when they present with neurological abnormalities. the use of intra-venous (iv) thrombolysis for the treatment of acute ischemic stroke is now the standard of care. this is typically followed by endovascular thrombectomy if patient is eligible does not improve . we present a rare acute ischemic posterior circulation stroke that had progression of the stroke despite receiving both intra-venous thrombolysis and endovascular thrombectomy. case report: a 38 years old african-american gentleman with past history of obesity, sleep apnea and prostatic hyperplasia, presented with acute onset left hemiparesis, with limb ataxia, who then progressed to altered sensorium in the emergency room needing endotracheal intubation. his initial nihss was 10. he was given iv thrombolysis, with subsequent vascular imaging that showed a top of the basilar clot, that was removed via endovascular intervention. a sister and one of the aunts reported a history of 'clots' when asked about family history. despite initial improvement, the patient deteriorated clinically after about 14 hours from symptom onset, and was found to have extension of stroke into the brainstem, with simultaneous acute loss of brainstem reflexes . the patient was started on palliative withdrawal of care by the family about 2 days from the initial onset of symptoms. his thrombophilia work-up revealed later that he was homozygous for methylenetetrahydrofolate reductase (mthfr) gene mutation, 677c >t. this case with a poor outcome due to extension of the ischemic stroke despite receiving the standard of care therapy, highlights the need for considering the use of anticoagulation within 24 hours postthrombolysis and thrombectomy in cases with underlying thrombophilia. the current guidelines do not support this aggressive approach. there is a dire need for randomized controlled trial about such cases to provide evidence based care to avoid a repetition of a similar poor outcome. barbiturate therapy has shown benefit in reducing intracranial pressure (icp) in patients who are refractory to other treatment modalities. however, severe adverse drug effects can accompany barbiturate use when used at the high doses required for icp management, such as hypotension, hepatic/renal dysfunction, and infection, among other deleterious consequences. dyskalemia has been reported infrequently in the literature with most of the cases involving patients on thiopental. there remains little guidance for management of this adverse effect. we present a case of severe dyskalemia induced by high-dose pentobarbital therapy and experience with management of this rare but life threatening effect. the patient was a 26-year-old male with traumatic brain injury and subdural hematomas complicated by refractory icp elevations. after hyperosmolar therapy, sedation, and csf drainage failed to control icp, and he was deemed to not be a candidate for surgical decompression, high-dose pentobarbital was started. after initiation of pentobarbital, his initial potassium of 4.0 mmol/l decreased to a nadir of 1.9 mmol/l over the next 24 hours despite aggressive repletion with a total of 600 meq of oral and intravenous potassium chloride. upon down-titration and discontinuation of pentobarbital, the serum potassium rapidly rebounded to 8.3 mmol/l with st-segment elevations on ekg. pentobarbital was restarted in an attempt to stabilize escalating icps and elevated serum potassium. subsequently a slow taper was utilized to mitigate dyskalemia during barbiturate discontinuation. dyskalemia associated with high-dose barbiturate therapy presents a significant dilemma to practitioners as both severe hypo-and hyperkalemia can be life threatening. published literature provides little guidance on how to safely manage patients who experience this adverse effect. patients receiving barbiturate therapy should have frequent potassium monitoring especially in the initiation and discontinuation phases. potassium repletion should be approached with caution, especially preceding discontinuation of barbiturate therapy. diffuse astrocytoma (formerly known as 'gliomatosis cerebri') may present with seizures or symptomatic raised intra-cranial pressure. this is typically followed by a few months of relatively stable phase (with treatment) and then possible subsequent development of glioblastoma multiforme. we present a rare case of a previously healthy caucasian lady who had new onset seizures, that showed glioblastoma multiforme already present on a background of diffuse astrocytoma. case report: a 65 years old caucasian lady with no significant past medical history was admitted with new onset focal seizures with secondary generalization, needing intubation and propofol for airway protection. brain imaging showed left frontal ring-enhancing mass, with a smaller satellite lesion in the left insular cortex, on a background of diffuse infiltrative lesion involving left fronto-temporal lobe and a smaller area of right parafalcine frontal lobe. biopsy of the left frontal mass revealed it to be glioblastoma multiforme. this is a rare situation when a previously healthy patient presents with new onset seizures and already has glioblastoma multiforme on a background of diffuse astrocytoma (or 'gliomatosis cerebri'). her post operative imaging revealed disease progression with increase in the size of the left insular cortical lesion. she was discharged home with plan for radiotherapy and chemotherapy. diffuse astrocytoma with glioblastoma multiforme within can remain asymptomatic till late in the disease course. diffuse astrocytoma (or 'gliomatosis cerebri') is a rare disease and even more rare is to have this remain asymptomatic till the development of glioblastoma multiforme within. this particular case highlights the need for vigilance about such a possibility, as this aggressive brain tumor carries a grave prognosis, especially when it develops on background of a diffuse astrocytoma. subdural hygromas (sdg) are cerebral spinal fluid collections in the subdural space that may occur following trauma. decompressive craniotomy may increase the risk for acute sdg or other forms of external hydrocephalus along the surgical plane. while these are traditionally benign and resolve spontaneously, they may in rare cases cause clinical deterioration. we report three cases. cases 1 and 2 were alcoholic men aged 54 and 69, respectively, who suffered severe traumatic brain injury (tbi) following falls while intoxicated. they had early clinical deterioration prompting emergent hemicraniectomy for left-sided sdh with midline shift (mls). case 1 clinically worsened on postoperative day (pod) 6 with posturing, decreased pupillary responses, and new-onset seizures. new bilateral, extensive subdural hygromas were noted, enlarging over serial ct scans up to 1-cm with progressive mass effect. uncal herniation and downward brainstem displacement occurred by pod8 despite external ventricular drainage. case 2 deteriorated on pod4 with fluctuating exam and newonset seizures. imaging revealed new subgaleal fluid collection measuring 1.8-cm and a contralateral sdg. on pod8, hemicraniectomy was performed for new mls from enlarging fluid and hemorrhage in extradural component. both died shortly after withdrawal-of-care. case 3 was a 68 year-old man with dural arteriovenous fistula who presented with spontaneous left-sided sdh and underwent left hemicraniectomy. on pod3, he had new-onset seizures and new bilateral sdg measuring 1.5-cm on the left and 0.5-cm on the right without mass effect. two days later; the right sdg grew to 2.8-cm causing significant mass effect. he recovered after burr-hole evacuation and temporary subdural drain placement. sdg following sdh evacuation can have a malignant course, causing clinical deterioration without prompt recognition and csf diversion. all patients had large volume sdh and two were alcoholic; larger prospective cohorts are required to identify risk factors. seizures may be an early clinical sign. moyamoya disease is an intracranial vasculopathy that results in stenosis of bilateral internal carotid arteries with subsequent development of extensive collateralization. the diagnostic criteria for moyamoya disease are well established and generally accepted, yet reaching the diagnosis can be challenging in some cases. herein, we present an unusual case of progressive cerebral vasospasm triggered by pituitary apoplexy that led to a delay in the underlying diagnosis of moyamoya disease. case report. a 53-year-old female with hyperlipidemia presented to the emergency department with a bifrontal headache, right-sided weakness, and dysarthria. ct angiogram showed extensive multifocal narrowing of the bilateral supraclinoid icas, proximal aca/mcas, and posterior circulation. mri brain revealed a left insular stroke as well as a sellar mass with a central hemorrhagic component. mr perfusion demonstrated decreased perfusion in the right hemisphere. lumbar puncture and extensive vasculitic workup was unremarkable. endocrine studies were notable for elevated prolactin with low fsh and lh levels. despite protracted blood pressure augmentation strategies, the patient continued to experience progressive infarcts in the left mca/aca territory. repeat ct angiogram showed progression of vasculopathy, and transcranial doppler studies demonstrated worsening vasospasm of the right mca and left pca arteries. the patient received corticosteroids given concern for apoplexy, and was maintained on aspirin and verapamil. given the aggressive nature of her vasculopathy, the patient underwent conventional angiography two weeks later, which revealed bilateral suzuki grade iii moyamoya. following this diagnosis, she received bilateral sta-mca bypass surgeries. it is important to revisit the differential diagnosis of cerebral vasospasm when the clinical course does not conform to expectations. this case highlights moyamoya as the causative agent in progressive vasculopathy likely masqueraded by pituitary apoplexy and concomitant vasospasm. moyamoya is an important diagnosis to consider in patients with a fulminant vasculopathy refractory to traditional treatment of vasospasm. visualization of intracranial structures by ultrasound in adults is limited by the presence of skull, though ultrasound imaging can occur through temporal windows. point of care ultrasound allows assessment of midline shift, brainstem, and ventricles. doppler allows visualization of cerebral perfusion patterns. patients with a hemicraniectomy have better temporal windows available since a portion of their skull has been removed. in such patients, ultrasound can provide a non-invasive method to serially assess midline shift, intracranial hematomas, and focal ischemia at the bedside. we present images of a cranial ultrasound that shows remarkable anatomical details that correlate well with computed tomography (ct) head. a 74 year-old male presented with right-sided weakness and confusion and was found to have a left parietal intraparenchymal hemorrhage with cerebral edema and left-to-right midline shift on ct head. increase in cerebral edema and expansion of the hematoma caused clinical neurological decline necessitating a left-sided hemicraniectomy with clot evacuation. a cranial ultrasound was performed two days after surgery to assess for progression of cerebral edema and intracranial hemorrhage. a transtemporal approach in axial plane was used to visualize intracranial structures through the craniectomy window. physiological structures like the falx cerebri, lateral ventricles, midbrain, mammillary bodies, choroid plexus, splenium of corpus callosum, thalami, and circle of willis were visualized with incredible anatomical detail. pathology such as intracranial hemorrhage, focal ischemic areas, vasogenic edema as well as encephalomalacia were identified with close correlation to the noncontrast head ct. the patient is currently recovering in the neurocritical care unit with supportive care. cranial ultrasound has potential applications in point of care assessment of intracranial pathology in neurocritical care patients. this application has promising use in directing therapy in patients who are otherwise unstable for transport or are unable to undergo neuroimaging secondary to positioning needed for management of cerebral edema. cerebral mucormycosis is a rare infection caused by fungi found in soil and decaying vegetation. the rhino-orbital-cerebral type is classically associated with aids, diabetes, malignancy and immunosuppression. we observed a series of young immunocompetent patients who presented with a fulminant form of isolated cerebral mucor associated with severe meningoencephalitis, parenchymal necrosis and symptomatic cerebral edema. six patients with histopathological diagnosis of cns mucormycosis admitted to the university of cincinnati neurocritical care unit between 2008 and 2017 are presented. patient ages ranged from 22-45 (median 27). none had diabetes or hiv. drug use (intravenous and intranasal) was confirmed in 4 patients. they presented with altered mental status (2) and focal neurologic deficits (4). four patients presented with fever and leukocytosis. mri revealed lesions in the basal ganglia (5) or cerebellum (1) which were characterized by t2 hyperintensities with patchy restriction and susceptibility signal. contrast enhancement was present in 5 patients. mass effect (6) and midline shift (4) were prominent. mechanical ventilation was required in four patients. all but one patient received amphotericin b. three died from intractable intracranial pressure (icp). one patient eventually gained functional independence, one still requires high level of care, and one was lost to follow-up. csf analysis was negative for mucor in all cases. fulminant cerebral mucormycosis should be considered in every young patient presenting with rapid onset meningo-encephalitis and necrotized cerebral lesions, especially if located in the basal ganglia. history of ivdu should raise further suspicion. these patients should be monitored in intensive care settings as they can rapidly develop malignant cerebral edema and increased icp. antifungal therapy should be initiated upon presentation as it has been shown to improve morbidity and mortality. the incidence of acute ischemic stroke in the immediate post-partum period ranges between 4-18% and is considered a serious cause of morbidity and mortality. pregnant or postpartum women are less likely to receive iv tissue plasminogen activator (tpa) primarily because of pregnancy, ongoing peripartum bleeding and/or recent delivery. the fda classifies tpa as a category c drug and current recommendations consider pregnancy a relative contraindication for receiving tpa. we present two cases of peripartum ischemic strokes with varying ischemic stroke time windows requiring aggressive revascularization therapy (endovascular and pharmacologic). a 32y g2p2 presented to an outside hospital 12 days post-partum with new onset of facial droop and left upper extremity weakness (nihss 6). imaging showed right m1 cutoff and occlusion of several m2 branches. the patient was not a candidate for tpa given ongoing vaginal bleeding. the decision was made to proceed with mechanical thrombectomy when her exam worsened to nihss 12. the thrombectomy was successful with tici 2c reperfusion. she was discharged home 4 days later with a nihss of zero. a 30y g1p1 presented 4 days post-partum with new onset of left facial droop and slurred speech (nihss 2). imaging showed right m1 cutoff with reconstitution, but with significant associated penumbra. acute worsening of exam post tpa triggered a push for mechanical thrombectomy achieving a tici 3 recanalization. post procedure the patient's only symptom was decreased sensation in left fingertips. at 30-day follow up the patient had returned to her baseline with a nihss of zero. endovascular and pharmacologic revascularization therapy should be considered on an individual basis in the peripartum population. current literature is limited to case reports /case series. larger multicenter trials are warranted and anticipated in the near future. while the optimal duration of burst suppression for status epilepticus (se) has not been established, burst suppression poses significant morbidity that may be dependent on the amount of time spent in burst suppression. herein, we report a case of se that resolved after ultra-short burst suppression. case report. a 74 year-old female was admitted to the neuro-intensive care unit after experiencing several brief tonic-clonic seizures characterized by right-sided shaking and left-sided head turn. despite lorazepam and levetiracetam administration, the patient did not return to baseline and was transferred to our unit. on presentation, her workup revealed a leukocytosis and a glucose level > 300 mg/dl. lumbar puncture showed a mild pleocytosis for which broad spectrum antibiotics were initiated. on initial examination, she was unresponsive and was not following commands. electroencephalogram (eeg) demonstrated frequent sharp and slow discharges in the right posterior quadrant with generalization (~20 seizures/hour) with minimal improvement following levetiracetam and phenytoin administration. given the refractory nature of seizures, the patient was intubated and treated with general anesthetics. using propofol, burst suppression was achieved (consisting of 1-2 s bursts with intermixed suppressions) and was continued for < 2 hours. following weaning, the patient had no further evidence of seizures, and eeg showed lateralized periodic discharges in the right occipital lobe. mri did not demonstrate an occipital focus, but did reveal cortical diffusion restriction in the bilateral posterior hemispheres. the patient was extubated the following morning, and was transferred to the neurology floor two days later. this case provides evidence that in certain situations, relatively brief periods of burst suppression in se can serve as a "reset switch", allowing for resolution of seizures while minimizing toxicities associated with prolonged burst suppression. further studies to determine which patients may benefit from ultrashort burst suppression are warranted. there are two systems of facial control, voluntary and emotional; these are independent up to the level of the facial nucleus. we described a case of a patient who presented with isolated emotional facial palsy after intracerebral hemorrhage (ich). retrospective review of a case admitted to the neurocritical care unit (nccu) of the johns hopkins hospital. a 29 year-old woman with history of migraines who presented to the emergency room after a colleague noticed she was not moving the left lower side of her face when she smiled. head ct showed a large right frontal ich involving the medial frontal lobes and anterior thalami. on review of an old mri done, an underlying developmental venous anomaly with an associated cavernoma was seen. her exam was notable for a flattened emotional affect, no facial palsy when asked to activate on command, but a facial droop that occurred in the context of her smiling to jokes and other humor. her nccu course was complicated with significant brain edema requiring osmotherapy up to 3 weeks out from the initial insult with self-limited episodes of brain herniation characterized by extensor posturing, dilated pupils, hypertension, hyperventilation and tachycardia. these were initially dismissed as sympathetic storming vs seizures as she will come out of those to her baseline (awake with mild left sided weakness) many times without therapy. she eventually required a hemicraniectomy two weeks after presentation. conclusions solated emotional facial palsy can be the presenting sign after ich when the hemorrhage involves the contralateral thalamus, of the striato-capsular region or the medial frontal lobes. in this case, transient icp elevations were leading to dilated pupils, tachycardia and hypertension -highlighting that heart rate changes can be variable with elevated icps and that in young patients, brain herniation episodes can be self-resolved with hyperventilation. 18 yo female with no pmh developed fever, headache, and neck pain. she presented to outside hospital day 2 after ct head was negative, patient was discharged. symptoms did not improve and she went to her pcp on day 4 and was instructed to go to the ed. she presented to osh and underwent a lp that was indicative of viral meningitis with wbc 357 cells/mm3 and protein 215 mg/dl. patient admitted and treated with acyclovir. on day 6, she developed generalized body aches. on day 8, she was trying to stand with assistance and she became rigid. parents report a total of 4 seizures and was intubated for airway protection. she underwent another lp on day 8 with an opening pressure of 55 cm h2o. csf was sent for paraneoplastic panel. csf analyses and blood cultures were negative. evd placed for icp pressures of 30-34 cm h2o. history obtained from mother and father who reported the patient had been hiking 2 weeks prior. results mri brain showed meningeal enhancement scattered throughout the supratentorial and infratentorial brain and most compatible with inflammatory sequela of meningitis. patient continued on keppra, high dose steroids, antibiotic, antiviral, antifungal therapy until cultures resulted. additional treatments included ivig therapy followed by plasmapheresis, and finally rituximab. continued workup with brain biopsy showed demyelinating process and possible necrotizing encephalitis. mri four weeks after initial presentation showed white matter demyelination and deep gray nuclei lesions consistent with adem. four score of 0 on admission improved to 11 (e3, m0, b4, r4) 5 weeks after patient presented from osh. diagnosis of adem vs ms variant made based on the above data. case provides information for the clinician diagnosing and treating adem. potential for further studies with treatments described above and their effect on meaningful neurological outcomes. dengue is a flaviviruses transmitted via mosquitos and prevalent in south east asia. neurological complications are rare but can involve encephalitis, myelitis, neuromuscular dysfunction and neuroophthalmological problems. we describe an interesting case of dengue encephalomyelitis. retrospective review of a case admitted to the neurocritical care unit (nccu) of the johns hopkins hospital a 54 year-old ship filipino captain with no significant past medical history but an extensive exposure to heavy metals, travel throughout the pacific, who presented with progressively worsening fevers, encephalopathy, urinary retention and tremors. he was transporting iron ore and other metals in a cargo ship from russia through south-east asia through to bermuda. while passing through the pacific, he began to experience malaise, myalgia, and fever. he was treated with amoxicillin but became worse, developing urinary retention, periods of confusion, and word finding difficulties. he was initially hospitalized in bermuda and then transferred to our hospital for further workup. given his rapid deterioration, he was initially in the nccu. his exam was notable for mild expressive aphasia, paratonias, right-sided weakness with hyper-reflexia, and a low amplitude tremor. his csf was notable for lymphocytic pleocytosis, elevated protein, low glucose. mri brain showed flair hyper-intensities in the frontal lobes, and diffusion restrictions in the bilateral basal ganglia and thalami. mri spine showed extensive flair hyper-intensity lesions. an extensive workup evaluated for heavy metal toxicities, autoimmune disorders and infectious workup. csf analysis came back positive for dengue igg and igm, leading to a diagnosis of acute dengue fever and encephalomyelitis. with supportive care in the nccu, he improved considerably over 2-3 weeks and was discharged home to the philippines. dengue encephalomyelitis is a rare infection but should be considered in patients living in endemic areas. treatment includes supportive care with fluid resuscitation, neurological monitoring and monitoring for hemorrhage. posterior reversible encephalopathy syndrome (pres) is known to cause altered mental status and leukoencephalopathy in the setting hypertensive emergency. we present a novel case of severely asymmetric pres due to a concurrent right transverse sinus dural arteriovenous fistula (davf). a 53 year-old woman with hypertension, non-compliant on medication, had fatigue and 2 weeks of intermittent left sided weakness when she presented to an outside hospital for evaluation. initially upon arrival her glascow coma scale (gcs) was 14. her mental status deteriorated over 6 hours, eventually requiring intubation. her peak blood pressure was 269/147. outside ct demonstrated scattered intracerebral hemorrhage (ich) and she was transferred for higher level of care. on admission her gcs was 4. review of her outside ct was remarkable for extreme right-sided white matter hypodensity, moderate left white matter hypodensity, and small scattered ich. workup including infectious, inflammatory, and neoplastic processes were excluded through serum, csf studies, and mri. conventional angiogram demonstrated a right transverse sinus davf with reflux into cortical veins, which was subsequently embolized. her white matter t2-weighted hyperintensities improved on follow-up mri, and her gcs was 11 at the time of discharge. our case highlights the possibility of asymmetric pres due to abnormal venous congestion due to the right-sided davf. venous hypertension likely caused the patient's intermittent left sided symptoms in the weeks prior to admission. few cases of unilateral or asymmetric pres have been reported following induced hypertension for treatment of subarachnoid hemorrhage or in the setting of vascular malformation. to our knowledge, this is the only case of severely asymmetric pres and preceding stroke like symptoms due to a davf. the most common pathology associated with an intraluminal carotid thrombus is underlying atherosclerosis. in rare cases it may be associated to thrombocytosis. currently there are no clear recommendations for the treatment of ischemic stroke associated with thrombocytosis. our case describes the use of plateletpheresis for the acute management of thrombocytosis complicated by an internal carotid artery thrombus resulting in a right mca stroke. a 55-year-old female with past medical history of menorrhagia who presented complaining of left face, arm and leg weakness with associated shortness of breath. upon arrival her nihss was 1 and the initial head ct was unremarkable. laboratory results revealed a hemoglobin 8.2 mg/dl, hematocrit 30 mg/dl, and platelet count of 1014 x 103/ml. she was not a candidate for thrombolytic therapy due to the time window. soon after admission she had acute worsening of symptoms with an nihss of 17. a cta of the head and neck showed acute ischemic infarction involving the right mca territory with non-occlusive intraluminal thrombus within the right carotid bulb. asa 325 mg and heparin infusion were initiated promptly. after a thorough work-up for thrombocytosis, reactive thrombocytosis secondary to iron deficiency anemia was diagnosed. plateletpheresis as well as oral ferrous sulfate were started. after one plateletpheresis cycle the platelet count stabilized at 400x103/ml. complete thrombus resolution was confirmed on follow-up cta on day 10 of admission without need for surgical revascularization. the role for plateletpheresis is not well established in secondary thrombocytosis. in cases with extreme thrombocytosis immediate surgical thrombectomy may be contraindicated due to high risk of rethrombosis. urgent cytoreduction with correction of the putative mechanism for thromboyctosis should be undertaken for optimal management. plateletpheresis is safe and efficient in reducing the platelet count to decrease the risk of clot progression or further clot formations which could worsen patient outcome. hyperpyrexia is an elevated core body temperature secondary to an elevated hypothalamic set temperature. hyperthermia is an elevated core body temperature beyond the normal hypothalamic set temperature. intracranial hypotension can present with a wide variety of symptoms ranging from orthostatic headache up to coma. it has never been reported to present with fever, namely hyperpyrexia. a case report of a 55 year old female patient with a history of depression, diabetes mellitus, hypertension, and angiogram negative subarachnoid hemorrhage status post ventriculo-peritoneal (vp) shunt placement six years ago who was complaining of worsening headaches and slurred speech for the past three months but acutely decompensated one morning. she suddenly became confused and agitated but became obtunded. initially, she was given haldol. she was found to be febrile (rectal temperature of 104.8 f). she was given dantrolene and bromocriptine for suspected malignant neuroleptic syndrome with no effect. creatine phospho-kinase was not elevated. she underwent infectious work up which later came negative. cooling measures like external cooling, peripheral iv cooling, tylenol and nsaids were also not helpful. fever responded to central intravascular cooling but encephalopathy did not. several expert attempts of lp and shunt tapping failed to obtain csf. brain imaging showed bilateral chronic symmetrical hygromas, diffuse pachy-meningeal thickening and enhancement, slit-like ventricles and slumping of the midbrain with closure of the mammillary pontine distance. following shunt setting adjustment, the encephalopathy markedly improved and the fever did not recur after stopping the cooling measures and antimicrobials. intracranial hypotension might present with hyperpyrexia, likely secondary to hypothalamic dysfunction. in our case, hyperpyrexia was reversible as the intracranial hypotension was emergently treated. nevertheless, spontaneous intracranial hypotension might be difficult to diagnose especially if it presented with non-classical symptoms like fever. complex emotions about critical illness can affect families in the icu. rightfully, we put focus on how they are impacted, but we also need to pay attention to how it can affect providers and our decision making. a poignant case from my training was a 15-year-old girl struggling with lupus. she had now developed lupus cerebritis and had massive intracranial hemorrhages. despite aggressive efforts to manage cerebral edema, she repeatedly herniated brain matter out of old craniotomy scars with incredible force. it was the most horrifying thing i've ever seen. other organs were also failing, with four consulting services working to salvage them unsuccessfully, prompting numerous procedures. this went on for a month. the therapies that we can offer have limits from a physiological standpoint which we must recognize and respect. we struggle with reconciling the interventions we feel compelled to implement versus what is realistic. i remembered the most valuable advice that i once received: "only do something to someone if it does the complexity of the neuro icu is amplified by the nature of intracranial catastrophes and poor recovery (in contrast to pure medical illness). providers cling to what is technically indicated while families cling to hope, but neither is enough and concurrently too much. we lose our autonomy to grieving families telling us to "do everything" losing sight of the bigger picture. we lose our autonomy to one another by pushing onwards, which can unintentionally push each other into the territory of doing more harm than good. something for them". all services began to share this view, thus slowly dialysis, steroids and immunosuppression stopped. eventually, her heart stopped. my experiences have reiterated a simple paradigm: to do no harm. through this, i can empower myself to take control of each situation by first taking control of myself. we report a case of an hiv positive patient who presented with cryptococcus gattii meningitis who then developed acute respiratory distress syndrome (ards) secondary to pneumocystis jirovecii pneumonia (pjp) that required ecmo support. ards in immunocompromised hiv positive patients is associated with extremely high mortality. ecmo can improve oxygenation in patients without increasing alveolar pressure and therefore avoid mechanical lung damage with ventilation. we present a patient with newly diagnosed aids with cryptococcus gattii meningitis and course complicated by pjp that progressed to severe acute respiratory distress syndrome (ards) for which veno-venous ecmo was initiated. patient is a 27year old male who presented to the emergency department with new onset seizures. lumbar puncture in the ed overflowed the manometer and demonstrated wbc 62, rbc 610, protein 41, glucose 51, positive yeast gram stain positive for yeast with pcr and ag positive. his cultures later grew out cryptoccoccus gattii. he was admitted to the nsicu and we placed a lumbar drain and an intraparenchymal ipc monitor that demonstrated elevated icps to the 60-80mmh20 but improved with drainage. the day of admission he acutely desaturated and required emergent endotracheal intubation. chest x-ray demonstrated bilateral infiltrates. bal was positive for pj. five days following presentation and respiratory failure he was started on veno-venous ecmo. two days following initiation of pjp treatment with bactrim his chest x-rays and lung compliance began to improve. he remained on ecmo for a total of 10 days before decannulation. he underwent induction chemotherapy for four weeks for meningitis. this case report demonstrates the use of ecmo in a complicated and critically ill patient with aids, pjp, and cryptoccous gattii meningitis. to our knowledge, few cases of ards secondary to pjp are reported and none are reported with concurrent cryptococcus gattii infection. sympathetic storming occurs during the acute care of patients following severe brain injury. cannabinoid cb1 receptors (cb1r) mediate the effects of delta(9)-tetrahydrocannabinol (thc), the psychoactive component in marijuana. expression of cb1r is widespread in the central nervous system and includes the hypothalamus, which is thought to mediate the hypothermic inducing effects of cannabinoids. dronabinol is a synthetic analogue of thc we present a novel therapeutic use of cannabinoids in a case of super-refractory sympathetic storming following coccidioidal meningitis and extensive bilateral subcortical stroke a 26-year-old previously healthy man was transferred from an outside hospital for treatment of meningitis, vasculitis, and hydrocephalus requiring placement of a ventriculostomy. workup subsequently revealed coccidioidal meningitis. during hospitalization the patient had severe vasospasm, elevated intracranial pressure, diabetes insipidus, cerebral salt wasting, and severe sympathetic storming. intermittent storming episodes with high fever persisted for over 8 weeks despite treatment with bromocriptine, dantrolene, tylenol, ibuprofen, phenobarbital, and sinemet. due to its mechanism of action, a trial of dronabinol 10mg divided twice daily was tried. the storming episodes ceased and within 6 hours the average temperature decreased by about 2.5 degree centigrade. temperature over the next several days was better controlled with a substantial reduction in use of anti-pyretics, surface cooling measures, and other storming medications our case highlights a novel therapeutic use of cannabinoids in super-refractory sympathetic storming related to brain injury. dronabinol may be an alternative pharmacotherapy with unique mechanism of action in difficult to control sympathetic storming patients with poor grade subarachnoid hemorrhage(sah) commonly present with significant mental status changes that preclude reliance on neurologic exam for screening for neurologic deterioration. jugular venous oximetry monitoring has been suggested for use in guidance of hyperventilation therapy, barbiturate coma, and vasospasm monitoring. no studies are found in literature validating its use in sah. milrinone has been using for the treatment of vasospasm in sah in an established protocol in the montreal neurological hospital. this study was performed using multiple methods of monitoring, but not jugular bulb oximetry. we report one case with high grade subarachnoid hemorrhage complicated by vasospasm treated with milrinone using jugular bulb monitoring for dose titration. methods 71 years old female presented with thunderclap headache and subsequently became comatose. noncontrast head computer tomography showed posterior fossa subarachnoid blood. she was intubated, external ventricular drain (evd) was placed and she was admitted to neurosurgical intensive care unit (nsicu). angiogram showed left posterior inferior cerebellar artery aneurysm and was successfully coiled. her hospital course was complicated by refractory symptomatic vasospasm. angiogram showed basilar artery vasospasm treated with intra-arterial verapamil. post procedure patient was not able to tolerate norepinephrine due to tachycardia and could not maintain hypertension on phenylephrine. milrinone was then started. jugular bulb catheter was place because the area at risk was not amenable to invasive multimodality monitoring. oximetry was monitored and her milrinone rate was titrated to goal of venous oximetry in the range of 50-70%. on day 20, angiogram showed no more evidence of vasospasm. her exam was back to her prior poor baseline. subsequently, she was discharged to long term care facility. our case demonstrates the benefit of using jugular venous oximetry monitoring guidance for milrinone dose titration. further, it may be an effective tool is research studying treatments of cerebral vasospasm repetitive transcranial magnetic stimulation (rtms) is increasingly used in treatment of various conditions including depression, chronic pain, and movement disorders. the use of rtms for chronic management of medically refractory epilepsy has grown substantially in the last 15 years. however, little literature exists on use of rtms for acute status epilepticus. the exact antiepileptic mechanism of rtms remains unclear, but may be secondary to inhibition of cortical excitability. we report promising response to rtms in a case of super-refractory focal status epilepticus. the study is a case report. a daily dose of 1800 pulses of 1hz rtms was applied to the left occipital lobe. treatment course was divided into 3 periods of 3-5 consecutive days each for a total of 13 days of treatment over 18 days. a 63-year-old woman with recent hemiarthroplasty complicated by wound infection presented with acute unresponsiveness and right gaze deviation, evolving into fluctuating encephalopathy, word finding difficulty, and right hemineglect. eeg revealed persistent left posterior quadrant lateralized periodic discharges (lpds), at times evolving into electrographic seizures, and positron emission tomography demonstrated a co-localized hypermetabolic focus. mri revealed subtle bilateral occipital t2 hyperintensity without diffusion restriction, which later resolved; cerebrospinal fluid was noninflammatory. seizures continued despite treatment with multiple aeds, burst suppression, and empiric trial of high dose corticosteroids. the patient demonstrated abrupt electrographic and clinical improvement after rtms initiation. previously unseen brief periods of lpd resolution were observed within 30 minutes after first tms session with further improvement in eeg background correlating with improvement in encephalopathy and clinical findings over subsequent days. given excellent safety profile, rtms may be useful transitional therapy in management of some cases of status epilepticus. durability of efficacy, patient selection, and optimal treatment schedules remain important unresolved questions. further study is required. central pontine myelinolysis (cpm) occurs due to rapid osmotic shifts causing demyelination in white matter, typically due to rapid correction of hyponatremia mostly in setting of alcoholism, malnutrition, and/or liver/renal dysfunction. sequelae may include cranial neuropathies, quadriparesis, seizures, and encephalopathy. no specific treatment exists; literature reports indicate favorable outcomes in only 50-67% of patients. our patient is a 50 year old male with hypertension, tobacco and alcohol abuse, admitted with severe aortic stenosis, complicated by alcohol withdrawal, pneumonia, and acute kidney injury. he was treated with benzodiazepines, broad spectrum antibiotics, and fluid resuscitation. on hospital day (hd) 10, he had to be intubated for airway protection due to acute confusion and quadriparesis. his blood work was notable for wide fluctuations in serum sodium, from 131 on admission to 155 on hd7 to 146 on hd10. otherwise, laboratory evaluation was remarkable only for mildly elevated ast and serum creatinine. mri brain 2 days after symptom onset (hd12) showed dwi and flair hyperintensities around central pons bilaterally crossing midline. eeg showed severe generalized slowing. diagnosis of cpm was made and intravenous immunoglobulin (ivig) (0.4 g/kg/day for 5 days) was initiated within 4 days of symptom onset, on hd 14. after initiation of ivig, patient showed rapid improvement, first noted in the bilateral upper extremities. by hd 20 i.e., 6 days after initiation of ivig, he was able to be successfully extubated; and he had regained 3-4/5 strength in all extremities. neuropsychology testing at 1 month demonstrated intact cognition. we describe a case of rapid clinical improvement in cpm following treatment with ivig. in addition to ours, about 5 similar cases have been reported, in which beneficial outcomes were demonstrated following prompt initiation of ivig. one proposed theory would be through reduction of myelinotoxic antibodies, thus promoting remyelination. few cases have reported central neuronal hyperventilation (cnh) secondary to infiltrative malignancy or autoimmune disease. the lesion is usually located at the pontine tegmentum and interrupts the fibers between the respiratory centers in the pons and those in the medulla. we report a case of a 57 year old female with multiple comorbidities who was admitted to the neurocritical-care unit after intra-operative rupture of a 4mm distal basilar aneurysm while being electively coiled. an external ventricular drain (evd) was placed due to early signs of ventriculomegaly. the postoperative exam showed progressive encephalopathy, left > right hemiplegia progressive tachypnea (rate and depth) despite being on assisted mode ventilation leading to severe hypocapnia (12.8 mmhg) and compensatory renal acidosis (bicarbonate = 8.5 mmol/l) to maintain normal ph. attempt to sedate the patient led to severe metabolic acidosis. intraventricular nicardipine was started and the patient ventilator settings were changed to bi-level pressure control. transcranial doppler (tcd) showed markedly improved vasospasms. the patient respiratory rate and, to a lesser extent, the tidal volumes improved after several days. sedation was weaned off successfully. evd was successfully weaned off and removed. tcd and ct angiogram showed severed basilar artery vasospasm while mri done later showed bilateral tegmental midbrain ischemia. one case has reported acute central neuronal hyperventilation following left thalamic bleed while another reported chronic neuronal hyperventilation that was attributed to old bilateral lacunar thalamic strokes by exclusion. our case is the first to report central neuronal hyperventilation following aneurysmal subacrachnoid hemorrhage that got complicated by bilateral tegmental midbrain strokes. while respiratory centers are known to exist in the medulla and the pons, more recent articles have described networks that regulate breathing extending to the midbrain peri-acquiductal grey and possibly the thalami. our unique case supports this hypothesis. serotonergic and atypical antipsychotic drugs are often used in the critically ill in the treatment of posttraumatic depression and anxiety disorders. hyperactive delirium may mask serotonin syndrome, which carries high morbidity and mortality if left untreated. we describe a case of serotonin syndrome in a critically ill patient in the setting of surgical and neurocritical intensive care unit. a 56-year-old male with remote trauma presented with left upper abdominal pain. a ct-scan of abdomen showed left diaphragmatic hernia. he underwent left thoracotomy and repair of diaphragmatic hernia. his postoperative course was complicated by sepsis, ileus, and aspiration pneumonitis. he was started on sertraline and quetiapine for stress-induced anxiety disorder, depression and agitation. despite increasing doses of sertraline, patient became agitated, tremulous, and confused. physical examination included fever, tachycardia, hypertension, diaphoresis, dilated pupils, hyperactivity, and clonus. initially considered to be due to hyperactive delirium, these manifestations did not improve with haloperidol. neurocritical care was consulted. due to presence of hyperactivity, fever and clonus, serotonin syndrome was strongly suspected. sertraline and quetiapine was discontinued and cyproheptadine added. within 24-hours his symptoms improved and cyproheptadine was tapered over 10 days. serotonin syndrome, a potentially life-threatening syndrome, is manifested by triad of mental status changes, neuromuscular and autonomic hyperactivity. a multitude of drug combinations can result in serotonin syndrome. serotonin syndrome is a diagnosis of exclusion, based on history and neurological examination in a patient taking serotonergic drug. 5ht-2a receptors are most commonly incriminated along with high levels of norepinephrine.the keys to management include discontinuation of all serotonergic agents, supportive care, and cyproheptadine. cyproheptadine, a potent 5ht-2a antagonist, is effective in ameliorating symptoms. a high suspicion for diagnosis is important for reducing morbidity and mortality associated with this neurologic syndrome in the critically ill. ruptured cerebral mycotic aneurysm as consequence of infective endocarditis (ie): a management qeeg adr in poor grade sah: is it really useful? recognize the various subtypes of cerebral amyloid angiopathy bilal butt baylor college of medicine 24-hour development of a giant infectious intracranial aneurysm: a case report catherine albin intra-operative ultrasound in traumatic brain injury patients namkyu you syndrome of the trepheined (sot) and paradoxical herniation without craniectomy elysia james spectrum health neurosciences -icu division stephen a. trevick 1 , andrew naidech 2 , leah tatebe 2672 patients were included. median age was 54 years. 66% were female, 26% smokers, 54% hypertensive and 12% diabetic. 8% had a history of cad or mi and 14% had hyperlipidemia. in the multivariable analysis, the odds ratio for unfavorable outcome, defined as mrs score of 3-6, was 5.7(95%c.i: 4.6-7.0) and 66.0(95%ci: 44.0-99.1) for the intermediate-grade(iii) and high-grade(iv and v) hh groups respectively, when compared to the low-grade(i and ii) hh group. age, hypertension and diabetes were found to be negatively associated with mrs, while hyperlipidemia was positively associated. gender, race, smoking and history of cad/mi were not significantly related to mrs. a positive trend for better mrs outcome was observed across years (p=0.008). this trend was not related to hh grade on admission, (p=0.18 for interaction between hh grade and year). hh scale on admission is associated with the mrs outcome upon discharge for patients with nontraumatic sah. models predicting the probability of a good mrs outcome could be created based on the hh grade on admission, age, hypertension, diabetes and hyperlipidemia status. the data suggest a trend toward improvement in medical and surgical care for this patient population across years. ciro poor-grade subarachnoid hemorrhage (sah) is associated with high mortality rates. although death rates have decreased in the last three decades, the exact mechanisms of demise are still to be determined in this patient population. a retrospective study of consecutive poor-grade sah patients (world federation of neurosurgical societies grades iv and v) aggressively treated in two academic high-volume centers, one in the netherlands (amc) and one in canada (smh). the primary outcome was in-hospital mortality. the main reasons of death were evaluated. a total of 357 poor-grade sah patients were admitted between 2009 and 2013, 178 to amc and 179 to smh. 152 (43%) patients died, and 85 (24%) of those patients died before having the culprit aneurysm treated. the median interval between hospital admission and death was three days (iqr 1-12).withdrawal of life support was the main reason of death in both centers (total of 107 deaths -71%), cardiopulmonary causes, aneurysm rebleeding, refractory intracranial hypertension, and other extracranial causes), represented less than 15%. extensive review of patients chart for all the data collection including literature search for similar cases if reported before. although rare, there are multiple case reports and series of nkh and clinical findings of hemichorea-hemiballism (hc-hb). there are few case reports of nkh with unilateral signal changes in the caudate and putamen. our patient presented with acute right basal ganglia ich. despite the typical imaging findings of nkh, work-up and management of ich took precedence over control of bg. mri findings were different in our patient given presence of positive gre and dwi/adc in areas other than t1 hyperintensity, which is known to be associated with nkh. we hypothesize an association between ischemia and hemosiderin deposition with hyperglycemia. the selective vulnerability of unilateral involvement of basal ganglia and caudate is unclear and needs more research. identification of neuroimaging findings in nkh in absence of focal neurological deficits (hc-hb) is important, especially for a first responder. early recognition can prevent icu admission, provide efficient patient care and allocation of resources. although most metabolic diseases affect basal ganglia bilaterally; nkh is associated with specific unilateral neuroimaging findings even in absence of movement disorders or focal neurological deficits. a 32 year old male with a history of seizure disorder due to mesial temporal lobe sclerosis, presented with altered mental status after a lamotrigine overdose. he had consumed 9.6 gm of the drug. he was awake and alert at presentation. urine toxicology was negative. initial creatine kinase (ck) was 1478 iu/l and peaked at 5974 iu/l; his creatinine was 1.3 mg/dl. lamotrigine level went from 14 mcg/ml to 38.6 mcg/ml after 18 hours. four days after admission it was 31 mcg/ml. a head ct at admission was negative. despite initial alertness, he developed profound encephalopathy with agitation and rigidity, requiring heavy sedation, induced paralysis, and intubation. this in turn lead to hemodynamic instability, which along with persistently elevated lamotrigine levels, prompted initiation of continuous veno-venous hemodia-filtration (cvvhdf) on hospital day 5. the lamotrigine level declined to 13.3 mcg/ml within 24 hours, the encephalopathy and rigidity resolved, and he was extubated. to our knowledge, this is the first reported case of lamotrigine toxicity managed with cvvhdf. overdoses up to 15 g have been reported and can even result in death. while cleared hepatically, the half-life of lamotrigine is approximately twice as long when patients have chronic renal failure. in a small series of 6 patients with renal failure, approximately 20% of lamotrigine was reported to be removed by hemodialysis. we applied this principal to our patient. our experience suggests that augmenting drug clearance with dialysis may help reduce the time on mechanical ventilation, need for higher doses of sedatives, and improve time to discharge. cvvhdf should be considered a supplemental treatment option for lamotrigine toxicity. traumatic brain injury (tbi) complicated by percutaneous coronary intervention (pci) remains a significant clinical dilemma. dual anti-platelet therapy (dapt) is standard after pci, but may contribute to progression of tbi. novel antiplatelet drugs with ultra-short half-lives, such as the p2y12-adenosine receptor antagonist, cangrelor, may provide added clinical flexibility in avoiding tbi-associated hematoma progression, particularly in the absence of reversibility options. case report. we report a 53 year-old female who presented to the ed after a syncopal episode with a fall down a flight of stairs. an ekg was obtained demonstrating inferior wall stemi. signs of head trauma included facial and scalp contusions, and bloody otorrhea. initial gcs was 14. a non-contrast head ct demonstrated tsah and contusions of bilateral frontal lobes and left temporal lobe, and a non-displaced fracture of the left temporal bone. neurosurgery, interventional cardiology and critical care were consulted. the patient developed signs of cardiogenic shock related to stemi and was taken emergently to cath lab. successful revascularization of proximal rca occlusion was achieved. heparin was given per protocol, and aspirin and cangrelor administered post-pci. cath lab was complicated by tonic-clonic seizures requiring intubation. repeat head ct demonstrated blossoming of bifrontal contusions, trace subdural hematoma development and increased tsah conspicuity. dapt infusion was continued, and subsequent imaging was stable, allowing transition to asa and clopidogrel. she survived with only minor disability. newer generation p2y12 inhibitors can be administered intravenously with reliable platelet inhibition similar to older p2y12 receptor inhibitors. with rapid reversibility upon discontinuation, their utilization should be considered any time pci complicates tbi. cerebral air embolism (cae) is a rare but potentially fatal entity with high morbidity and mortality, commonly seen secondary to iatrogenic causes like neurosurgical procedures, vascular surgeries, etc. as also deep sea diving. cae after esophagogastroduodenoscopy (egd) is extremely uncommon. we present a rare case of cae post egd resulting in diffuse cortical infarction. an 80 year old man underwent an elective (egd) for esophageal stricture with biopsy and balloon dilatation. patient did not wake up after procedure. on initial exam, patient was comatose, glasgow coma scale 4t with decerebrate posturing. computed tomography (ct) revealed multiple foci of cerebral air embolism. ct angiogram of the brain was negative. diffusion weighted imaging and apparent diffusion coefficient imaging sequences in magnetic resonance imaging (mri) showed diffuse, global bi-hemispheric cortical infarction. ct chest showed pneumomediastinum. only 21 cases of cae from egd have been reported in literature prior to this case. 5 received hyperbaric oxygen therapy(hbo). 12 patients had a documented patent foramen ovale (pfo) or some form of arteriovenous (av) shunt. presence of av shunts/ pfo, therapeutic endoscopic procedures providing vascular communication as well as providing pressure gradient are all factors facilitating air embolism associated with egd. hbo therapy has been shown to improve outcomes in cae patients, initiating therapy >6 hours after insult and early and significant ischemic changes seen on ct/ mri prior to starting therapy were strong predictors of poor outcomes. our patient did not have a documented echocardiogram with a shunt study prior to the egd. cae after egd causing global cerebral bi-hemispheric ischemia as seen in our case is extremely rare. hbo has been shown to improve outcomes. time to treatment > 6hours and early ct/ mri changes suggest poor outcomes. studies do not recommend benefit of screening for pfo or av shunts prior to every egd. key: cord-000977-ka4261wc authors: nan title: ecr 2013 book of abstracts b scientific sessions date: 2013-03-07 journal: insights imaging doi: 10.1007/s13244-013-0228-x sha: doc_id: 977 cord_uid: ka4261wc nan analysis of breast mri a dedicated cad software was used (computer-aided analysis). it enables semi-automatic analysis of enhancement characteristics of the whole tumour (3d analysis of early vs. delayed phase) and the "hot-spot" (i.e. voxel with highest washin/washout ratio). potential of breast mri characteristics vs. classical prognostic factors to predict disease-related death was investigated separately and in combination using cox regression. to identify significant and independent predictors for disease-related death, backward feature selection was applied (p entry /removal: < 0.05 /> 0.01). results: two-hundred and twenty-three patients were included (disease-related death: n=24/10.8%; censored: n=187/83.9%; loss to follow-up: n=12/5.4%). mean follow-up was 4.7years. if tested separately, cr analysis identified significant potential both for breast mri and classical prognostic factors to predict diseaserelated death (p < 0.001). if breast mri characteristics and classical prognostic factors were used in combination, predictive performance could be further increased significantly (p < 0.05): after feature selection five classical prognostic factors (tnm stage, tumour typing, her2neu score) and six breast mri characteristics (hot-spot: time to peak enhancement, washout ratio; 3d analysis: tumour volume; tumour voxels showing washout plus weak/intermediate washin and tumour voxels showing plateau and weak washin) remained in this final model as significant and independent coefficients (p < 0.05). conclusion: breast mri has a significant potential to predict disease-related death in breast-cancer patients. it not only can be used as a stand-alone tool for this task but also adds significant predictive value to classical prognostic factors to stratify this endpoint. s169 a c d e f g b thursday metabolic syndrome, diabetes and cardiovascular disease. there is a need to find a biomarker which proves to be reliable, non-invasive and easy to perform in clinical practice. methods and materials: our aim was to know whether serum alanine aminotransferase (alt) is a reliable biomarker of liver fat content in nafld, and to determine if the current threshold of normality for alt is appropriate to assess the presence of liver fat. this is a cross-sectional, randomised, prospective, population-based study. we studied 120 healthy subjects with alcohol consumption less than 50 g/ week. quantification of liver fat content was by spectroscopy 1h mr 3 t. 5% of liver fat content as the upper limit of normal for the diagnosis of hepatic steatosis. results: there was an excellent positive correlation between liver fat content and serum levels of alt (r = 0.73, p < 0.0001). results of the backward step-wise regression analysis showed that serum alt was the most important predictor of hepatic steatosis (ß coefficient=3.25). all subjects with alt values > 37 u/l had hepatic steatosis (ppv:100%) and none of the subjects with alt < 20 u/l had steatosis (npv: 100%). roc curves were created; the best cut-off value for the diagnosis of nafld was alt: 23 u/l (sensitivity: 94.67%, specificity 73.91%, ppv: 85.84%, npv: 89.47%). conclusion: serum alt levels could be a reliable biomarker of nafld if the upper limit of normal for alt is set at 23 u/l. absolute quantification of phosphorus compounds in the liver on a clinical 3 t scanner purpose: hepatic energy metabolism plays an important role in insulin resistance and liver diseases. the aim was to establish a robust and fast method to detect and to quantify liver atp content in molar concentrations for use in a clinical setting, i.e. large cohort studies. methods and materials: healthy volunteers (n=86; 58 ± 12 years; bmi: 25.6 ± 3.1 kg/m²) consented to the approved protocol. all experiments were performed on a 3-tesla mri scanner (philips achieva 3.0 t x-series, the netherlands). 31 p spectra were acquired using a 14-cm diameter 31 p surface coil, with the built-in 1 h body coil used for noe enhancement and decoupling (tr: 4 sec; acquisition time: 13 minutes). localisation in the liver was achieved using isis. separately, intra-and interday variability were measured on 6 volunteers. the absolute quantification was established using matching phantoms and an external reference (mpa). results: all peaks were well resolved with the mean snr (γ-atp) of 16. the concentrations were found to be 1.97 ± 0.61 mmol/l (phosphomonoester), 7.80 ± 2.11 mmol/l (phosphodiester), 1.97 ± 0.52 mmol/l (inorganic phosphate) and 2.70 ± 0.59 mmol/l (γ-atp). the intra-and interday reproducibility was 4.5%, respectively, 1% (pme) 9%, respectively, 10% (pde), 11%, respectively, 2% (pi) and 9%, respectively, 3% (γ-atp). conclusion: the absolute quantification for large cohort studies has been successfully established on a clinical scanner. the obtained concentrations from this study agree with the concentrations from previous studies. thus, the current method can reliably detect concentration changes above 10% in phosphorus compounds in human liver. differential portal venous flow response to terlipressin in normal and cirrhotic rats: non-invasive assessment using phase-contrast mri m. chouhan, a. bainbridge, n. davies, r. mookerjee, r. jalan, s. walker-samuel, m. lythgoe, s. punwani, s.a. taylor; london/uk (manil.chouhan@gmail.com) purpose: portal venous flow (pvf) measurement using phase-contrast mri (pc-mri) is technically feasible at 9.4t. the purpose of this study was to assess the sensitivity of pc-mri to expected changes in portal flow after terlipressin administration and study the functional response in normal and cirrhotic rats. methods and materials: eight sprague-dawley rats were randomised to bile duct ligation (bdl) procedure (n=4) or sham laparotomy (n=4). after 4 weeks, pvf was measured using respiratory-gated 2d pc-mri (2 mm slice thickness, 10° flip angle and 22 cm/s velocity encoding) with a 9.4t agilent system. terlipressin (known to reduce pvf) was administered intravenously at a dose of 10mcg/100 g and pc-mri measurements repeated sequentially for 30-40 minutes post-administration. bulk pvf was normalised to explanted liver weight, obtained after termination of the experiment. data were analysed using paired and unpaired student t-tests. results: baseline liver weight normalised mean pvf in sham (143.53±14.42 ml/ min/100 g) vs bdl (79.51±44.74 ml/min/100 g) rats was not statistically significant (p=0.059). the reduction in pvf post-terlipressin was significant in sham (mean reduction of 63.48±14.28 ml/min/100 g; p < 0.05), but not in bdl (mean reduction of 55.44±35.71 ml/min/100 g; p=0.053) rats. significant differences in post-terlipressin nadir pvf in sham (80.05±20.18 ml/min/100 g) vs bdl (24.07±14.66 ml/min/100 g) rats were, however, demonstrated (p < 0.05). conclusion: expected reductions in pvf were detected non-invasively using pc-mri in both normal and cirrhotic rats. data are suggestive of a lower baseline pvf in cirrhotics, which go on to demonstrate a different, more labile haemodynamic response to terlipressin compared with normal rats. the incidence of biological effects from 3.0 tesla (t) mri compared to 1.5 t: an observational study in 911 consecutive outpatients f. alghamdi, p. bertrand, l. barantin, m.a. lauvin, x. cazals, f. domengie, r. bibi, d. herbreteau, j.-p. cottier; tours/fr (faisal.gh.30@gmail.com) purpose: to compare the acute biological effects of a 3.0 tesla (t) magnetic resonance imaging (mri) to 1.5 t mri methods and materials: after mri examination, 911 patients (449 with 3.0 t mri and 462 with 1.5 t mri) were presented with a verbal rating scale questionnaire consisting of 11 symptoms related to mri examination. chi-square tests were used to assess the relationship between the strength of the magnetic field (mf) and the incidence of the symptoms. a p value of <.05 was considered significant. results: there was no statistically significant relationship between the strength of the mf and the incidence of the symptoms related to static mf exposure, such as vertigo (p =.13), nausea (p =.35), headache (p =.21), and a metallic taste (p =.64). a warm feeling induced by radiofrequency (rf) was significantly higher in the 3.0 t mri (p <.0001) with a significant correlation between the mean specific energy absorption rate (sar) and a warm feeling in the 3.0 t mri (p <.0001). numbness/ tingling related to the gradient mf was significantly higher in the 3.0 t mri (p =.027). conclusion: the thermal effect induced by the rf and the numbness/tingling induced by the gradient field were significantly higher in the 3.0 t mri than in the 1.5 t mri. there was no statistically significant difference between the symptoms related to static mf exposure from the 3.0 t mri and 1.5 t mri. double echo sequences both effects can be separated one from the other. we present an extension of this concept to multi-echo measurements. methods and materials: brain perfusion measurements were performed in 10 patients as part of an ongoing study investigating the reproducibility of perfusion parameters on a 3 tesla mr scanner (siemens magnetom verio). three slices were recorded with a temporal resolution of 2 s by means of a four echo flash sequence (tr = 52 ms, te = 1.2/5/10/15 ms, alpha = 30 ¼ 70°). evaluations of contrast to noise ratios (cnr) during the bolus passage of omniscan (ge healthcare) through different tissues were done with an inhouse software written in idl (exelis vis). results: the cnr is improved by a factor of about 1.8 calculating delta-r2 * from four echoes compared to calculations based on two echos. signal intensity estimations for te = 0 do not significantly benefit by the increased number of echoes. conclusion: multi-echo measurements allow for a larger dynamic range of t2 * shortening compared to single or double echo sequences, at the same time giving more signal. by extending the concept to keyhole and/or epi sequences, covering of entire tumours could be achieved. we select patients with uni-or bi-lateral endoprostheses from 100 consecutive referrals for whole body (wb) pet/mr imaging (mmr, siemens healthcare). simultaneous wb-pet/mr scanning was performed at 120 min p.i. of 300 mbq [18 f ]-fdg: 4 min/bed including dixon water fat segmentation (dwfs)). mr-ac was performed using a) original mr-images (dwfs), b) as a) with implant-induced air-pockets filled with soft-tissue, c) as b) superimposed with co-registered endoprostheses from ct and d) as a) with implant-induced airpockets filled with metal. pet reconstruction after mr-ac (a-d) used aw-osem (3iterations, 21subsets, 2 mm gaussian) on 344-matrices. mean/max standardised uptake value (suvbw) was calculated from interest volumes with 40% isocontour levels over the hips, pelvic muscle and bladder. results: in 100 patients we found 1 and 2 uni-and bi-lateral endoprosthesis, respectively. associated mr artefacts were much larger than the implants: 20.9% versus 2.5% of the attenuating voxels in (a) of the central hip region. mr-ac using (b) and (c) recovered fdg-distribution pattern compared to uncorrected pet (noac) images and (a), while (d) resulted in severe overestimation (> 470% suvmax). the relative changes in suvmax/mean in the reference regions (bladder, pelvic muscle) from (b-d) compared to (a) were insignificantly small. conclusion: endoprostheses cause pet/mr artefacts and bias pet quantification. artefacts and bias can be corrected by automated inpainting with a single softtissue composition prior to mr-ac, thus restoring quantitative activity distribution. author disclosures: t. beyer: founder; cmi-experts gmbh. in vitro comparison of ultrasound-based elastography techniques s. franchi-abella 1 , j.-m. correas 2 , c. elie 2 ; 1 le kremlin-bicêtre/fr, 2 paris/fr (stephanie.franchi@bct.aphp.fr) purpose: ultrasound elastography techniques are based on two different physical principal: strain and shear wave velocity (swv). the purpose of this study was to assess the performance of these two techniques in vitro on a calibrated elasticity phantom using five ultrasound diagnostic imaging system to improve clinical comprehension and use of elastography. an operator performed all acquisitions on a tissuemimicking phantom developed for elastography calibration (cirs 049 a) containing spherical inclusions embedded in an homogeneous background (bg) of known elasticity (30 ± 5 kpa). two inclusions were harder than the bg and two were softer (44±6 kpa, 75 ± 10 kpa, 12 ± 3 kpa and 18±4 kpa). protocol was performed using high-frequency linear transducer on four different inclusions. qualitative assessment was done on elastograms. semiquantitative measurements were based on the ratio of strain or elasticities between the bg and each inclusion and were compared with theoretical ratio. quantitative evaluation was performed with swv techniques. results: all techniques are adequate when assessing whether or not an inclusion is harder or softer than the bg. semi-quantitative ratio of stiffness between two structures is not reproducible and strongly depends on the manufacturer. it is more accurate for swv techniques. direct quantitative evaluation of stiffness using swv exhibits biases for soft targets but can still be used to precisely measure stiffness if bias is taken into account. conclusion: limitations and advantages of the different elastography techniques must be known while performing an elastography acquisition in clinical practice. static magnetic fields in 1.5 and 3 t mr scanners do not influence perception of pain and touch compared with placebo exposition a. pomschar, k. kamm, r. ruscheweyh, r. laubender, m.f. reiser, a. straube, b. ertl-wagner; munich/ de (andreas.pomschar@med.uni-muenchen.de) purpose: potential biological effects of static magnetic fields have been in the focus of public debate with the european physical agents (electromagnetic fields) directive 2004/40/ec having the potential to seriously limit mr imaging in europe. data on potential effects are still very scarce. we aimed to investigate the influence of homogeneous static magnetic fields in 1.5 and 3 tesla mr scanners on pain and touch perception compared with placebo exposition. methods and materials: 18 healthy volunteers (age: 23 ± 1.8 years, 9 females) underwent three experimental sessions on separate days in randomised order, using field strengths of 0t (placebo scanner), 1.5 t and 3 t. participants were blinded to field strength. no imaging sequences were acquired. in each session, a quantitative sensory and pain testing programme was performed before and after a 10-min exposure to the static magnetic field. it included thresholds for mechanical detection, mechanical pain, pressure pain, heat pain and phasic heat pain intensity ratings. a linear mixed-effects model was used for statistical analysis. results: for 1.5 and 3 t compared with the placebo control, statistical analysis revealed no significant effect of the magnetic field for all tested qualities, thresholds for mechanical detection (p=0.82/0.09), mechanical pain (p=0.83/0.53), pressure pain (p=0.97/0.28), heat pain (p=0.53/0.38) and phasic heat pain intensity ratings (p=0.56/0.75). conclusion: short exposure to static magnetic fields in clinical 1.5 t and 3 t mri scanners had no significant effect on pain and touch perception compared with a placebo exposure. plaque has formed correlating with cardiovascular risk factors. the present study aims at investigating whether there are differences in the carotid wall thickness and echogenicity between patients with ibd and well-matched healthy controls by high-resolution ultrasonography of the carotid arteries. methods and materials: 31 ibd patients (19 male, mean age: 36.9 yrs, crohn/ ulcerative colitis: 19/12, 17 smokers) and 29 healthy controls (15 male, mean age: 36.1 yrs, 16 smokers) underwent high-resolution ultrasonography of the carotid arteries. the following variables were recorded in bilateral common carotid arteries: 1) imt at 5, 10 and 15 mm from the carotid bulb, 2) emt (the distance between the common carotid wall and the internal jugular vein) and 3) ec. results: common carotid artery imt (0.000 < p < 0.01, t-test) and emt (p < 0.001, t-test) were significantly higher in ibd patients compared with controls. no difference in ec was found between ibd patients and controls. no difference in imt, emt and ec was found between crohn's and ulcerative colitis patients. smokers ibd patients had significantly higher imt and emt values than smokers controls (0.002 < p < 0.022, t-test). conclusion: ibd appears to be a risk factor for development of early atherosclerosis as showed by greater values of carotid imt and emt in ibd patients compared with healthy controls irrespective of smoking history and type of ibd disease. purpose: to evaluate the accuracy of the preliminary ct interpretation made by the radiology residents in the emergency department. during four periods of 20 consecutive days, attending radiologists prospectively recorded any disparity between their own ct interpretation (reference standard) and the preliminary interpretation delivered by the emergency radiology residents. disparities were recorded during both regular hours and on-call time. a misinterpretation was considered major when potentially life-threatening within hours after admission. the total number of ct performed during the survey was recorded and further classified into neuroradiological and body examinations. a rate of disparities was calculated for all ct examinations and also for body and neuroradiological cases. results: a total of 3044 emergency ct examinations were performed during the survey: 1568 (51%) were body ct and 1476 (49%) neuroradiological cases. disparities were reported in 145 (4.8%) of all ct examinations: 0.8% (25/3044) were major misinterpretations (17 body, 8 neuro). there were 100/1568 (6.3%) disparities reported in body ct versus 45/1476 (3%) in neuroradiological examinations (p=0.001). no significant difference was found when comparing disparities recorded during regular working hours (47/1083 (4.3%)) versus on-call period (98/1961 (5%)), p=0.47. our results show that disparities occur most frequently in emergency body ct examinations, but major disparities represent a small proportion of all misinterpretations. the detailed analysis of our data allows comparison and purpose: detection of abdominal injury is a very important component in trauma management, so an accelerated assessment of liver and spleen injuries including their degree of severity is necessary. there is a good case to believe that in stress situations this subjective performance results in diagnostic mistakes. structured objective scores as the organ injury scale (ois) drawn up by the aast are a valuable guidance for objective trauma assessment. aim of our study was to evaluate retrospectively whether a structured approach using the ois differs to real-time-diagnosis. methods and materials: the ois was applied by an experienced radiologist on ct data of 53 patients which underwent ct laparotomy after abdominal trauma. these results were correlated with the original text of the initial ct findings. finally, we compared both with the intraoperative findings gathered from the surgery report. results: regarding the original ct report we found a mean divergence of 0.68 ± 0.8 to the ois found in the surgery report for liver injuries (0.69 ± 1.17 for spleen injuries). in comparison with the structured approach, where we detected a divergence of 0.8 ± 0.68 (0.47 ± 0.77 for spleen injuries). there was no significant difference, but we detected a lower rate of over-diagnoses in both approaches. conclusion: a structured approach to abdominal trauma using an imaging checklist does not lead to a significantly higher detection rate, but reduces the rate of overdiagnoses and may be more precise in grading the severity grade plus streamlines the emergeny-ct-procedure. comparison of efficacy and safety between distal embolisation and augmented embolisation techniques for treating blunt splenic injuries with active haemorrhage within a two-year period, 26 consecutive patients of bsi in whom haemodynamics was stable but ct showed contrast extravasation were included in this prospectively study. we randomised them into distal embolisation group and augmented embolisation group. they were followed up twice by ct at 1 week and 3 months after embolisation. we compared their demographics, injury grades, clinical parameters, hemograms, successful rates and splenic infarct volumes between the two groups. embolisation failure was defined as persistent hypotension that required surgery or detection of splenic contrast extravasation on follow-up ct. complication was defined as post-embolisation splenic infarct or splenic abscess. results: all underwent first follow-up ct, 24 underwent second follow-up ct. of 26 patients, 17 received distal embolisation, 9 received augmented embolisation. their basic demographics, ct injury grades, clinical parameters and hemograms did not differ. their mean systolic blood pressure was significantly elevated after embolisation. two (2/17, 12%) of the distal embolisation group failed and required a second augmented embolisation. none of the augmented group failed but the difference did not reach statistical significance. the mean splenic infarct volume purpose: to evaluate whether radiographers' experience in breast imaging helps in reducing significant artefacts when acquiring dynamic breast-mri. methods and materials: one experienced radiologist prospectively evaluated a total of 270 breast-mri examinations performed by three different radiographers (r1, r2 and r3) over the period september 2011-june 2012 (90 examinations each). r1 had a 5-year experience in breast-mri and 15 years of experience in breast imaging; r2 and r3 had no specific training in breast imaging, and 5-(r2) and 2-year (r3) experience in breast mri. for each examination the radiologist, who was blinded to radiographer's experience, was asked to assess the presence or absence of significant artefacts, defined as motion artefacts affecting image quality and/or diagnostic evaluation. the prevalence of significant artefacts in r1, r2 and r3 examinations was tested with the chi-square test. results: significant artefacts were found in 45/270 examinations (16.6%;ci95%=12.7-21.6%). in particular, significant artefacts affected 6/90 examinations (6.6%;ci95%=3.1-13.8%) performed by r1, 22/90 examinations (24.4%;ci95%=16.7-34.2%) performed by r2 and 17/90 (18.8%, ci95%=12.1-28.2%) performed by r3, with a significant difference between r1 and r2 (p < 0.05). conclusion: artefacts potentially affecting image quality and diagnostic evaluation are less frequent in breast-mri examinations performed by those radiographers who combine experience in breast imaging with specific experience in breast-mri. a possible explanation is a better understanding of disease specific problems and of the importance of empathise with the patient. accuracy of ultrasonographic diagnosis of acute appendicitis in pregnant women n. kokhanovsky, a.-r. zeina, n. reindorp, a. levit-kantor, y. glick, a. nachtigal; hadera/il (nataliakoh@hotmail.com) purpose: to assess the reliability and value of the sonographic examinations in the diagnosis of acute appendicitis in pregnant women. we obtained sonographic examinations performed on 68 pregnant women with suspected acute appendicitis retrospectively for 16 months (sep. 2008 -feb. 2010 . the average age of study subjects was 27.3 years, with an average gestational age of 26 weeks. sonography was the first imaging modality employed. surgery or clinical follow-up was the gold standard for the evaluation of sonographic performance. all examinations were performed using grey-scale graded compression in the left lateral decubitus position. the sonographic criteria for acute appendicitis were detection of a noncompressible, blind-ended, tubular, structure measuring greater than 6 mm in maximal diameter. results: 4 patients had positive sonographic findings of acute appendicitis (5.9%). sonographic findings were correlated with surgical findings and clinical follow-up. the diagnosis was confirmed in all 4 patients (100%). in the 64 patients with negative sonographic findings of acute appendicitis, the result for 1 patient (1.6%) proved false-negative, whereas the remaining 63 (98.4%) improved on clinical follow-up. accordingly, sensitivity was 80.0%, specificity was 100% and overall accuracy was 98.5%. moreover, in 4 out of the 64 patients with negative sonographic findings for acute appendicitis, a different pathologic finding such as acute pyelonephritis was identified. conclusion: our experience suggests that ultrasonographic examination with the optimal study protocol is a highly accurate method for the diagnosis of acute appendicitis in pregnant women and should be performed as the first imaging test. purpose: to exploit the ever increasing quantity of routinely acquired imaging data generated in clinical practice for research, we propose an infrastructure for the automated anonymization, extraction and processing of image data stored in clinical data repositories. methods and materials: as proof of principle, we used this infrastructure to implement a pipeline for measuring brain volumes in clinical mri. this fully automated system consists of four steps: subject selection using pacs query, anonymization of privacy sensitive information and removal of facial features, quality assurance on dicom header and image information, and biomarker extraction. 1114 examinations were selected based on mri protocol: dementia (246), multiple sclerosis (446) and a general healthy elderly population study (422) . we evaluated the effectiveness of the infrastructure in accessing and successfully extracting biomarkers from routinely acquired clinical imaging data. to prove the validity, we compared brain volumes from dementia and multiple sclerosis patients with the healthy population. results: success rates of 82.5%, 82.3% and 100% are achieved for the three protocol groups, respectively, indicating large amounts of routinely acquired clinical imaging data can be used for research purposes. in line with the literature, tive statistics, t-student tests for comparing groups, and mann-whitney tests for verifying hypothesis and item relations. results: most radiographers completely agree (37.5%) or partially agree (40%) that evidence-based radiology makes part of their job requirements, but only 32.5% consider it absolutely useful for developing their skills. most research projects and papers (72.5%) are done by radiographers during their degree to develop their knowledge and quality of services rendered. age and academic degree do not have statistical significance (p < 0.05) for evidence-based radiology; however, there is a slight increase for radiographers with higher academic degrees and for those who have greater access to research papers and literature. conclusion: evidence-based practice is not applied by most radiographers as a work method; however, the underlying knowledge on this thematic suggests it would be well received and developed to enhance skill, knowledge and the department general quality. radiographers quality assurance work: resistance and cooperation r. gullien, j.g. andersen, a.e. haakull; oslo/no (uxraul@ous-hf.no) purpose: explaining the radiographer-chosen improvement initiatives in quality assurance work (qaw), adjustment and progression of these initiatives and changing possible resistance to cooperation. methods and materials: different implementation strategies and improvement initiatives were used in the qaw to prevent a feeling of insecurity, threatening, uneasiness, less valuable, to avoid conflicts and to enable education, training, self-assessment, improve oneself. manager implements measurements, strategies and improvement initiatives. the employees came up with suggestions of actions, brainstorm. voting was performed and top three were selected. combination of suggested and specific initiatives over time: continuous individual feedback over time (baseline, after implementation, follow-up), individual assessment measured by experience in mammography, theoretical and practical training, lectures, examples, individual positioning training, reading guidelines and articles, individual feedback on positioning technique, tailored training for new employees, different checklist for employees (new/"old", inexperienced/experienced), checklist for updating knowledge, self-study, workshops, training in self-evaluation, new internal guidelines, frequent feedback if necessary, practical training with supervisor, temporarily get another kind of work, meetings and discussions, inform about qaw when job interview. results: positive changes in cognition, self-knowledge, personal skills, confidence in the situation, comfortable, demystified, attitude change; related to knowledge and awareness. teamwork manager and employee with focus on improvement work and differentiate between work and employee. conclusion: using various strategies are beneficial, different methods to meet different needs. top-down, bottom-up, threat-relaxation, tentative-participation, resistance-cooperation. dialogue and cooperation between staff and management; between the radiographers are essential for success. radiographers' knowledge about adverse reactions to iodinated contrast media a. santos, l. capitolina, i. silva, a. saraiva; coimbra/pt (adelinosantos@estescoimbra.pt) purpose: eudravigilance-pharmacovigilance is a data processing network and management system for reporting and evaluating suspected adverse reactions of medicinal products in the european economic area. the main purpose of this paper is to assess the level of knowledge of radiographers relatively adverse reactions of iodinated contrast media (icm). methods and materials: an original electronic survey was used, which is composed of four dimensions of study to gauge radiographers' knowledge regarding the chemistry of icm (i), potential adverse reactions (ii), possible procedures to be taken in emergency situations (iii) and actions to be taken under the national pharmacovigilance system (iv), in a first phase. and throughout various european countries (northern, central and mediterranean), in a second stage. results: only 11.5% of respondents were able to correctly answer the four questions on chemistry of icm. however, a significant relationship between those who know the classification of adr and who has knowledge of chemistry icm still exists. concerning the procedures to be taken in case of adr, we found that only 13.3% of subjects were able to correctly identify usual emergency procedures in this type of situation and, regrettably, only 3% of the sample proved able to correctly identify all adverse reactions suggested by the questionnaire. the only method that enables epidemiological continuing surveillance safety of all drugs is the spontaneous reporting of adverse events. this pioneer b-0147 11:24 fast search for radiology cases in hospital systems via contentbased image retrieval g. langs 1 , r. donner 1 , m. holzer 1 , d. markonis 2 , h. mueller 2 , e. birngruber 1 ; 1 vienna/at, 2 sierre/ch (georg.langs@meduniwien.ac.at) purpose: efficient and quick access to comparable cases and corresponding radiology reports is crucial during radiological assessment and increases quality. currently, in most cases search queries within a pacs are limited to meta data. brain volumes (expressed as percentages of intracranial volume) were found to be significantly smaller in patients scanned under dementia (79.7%) and multiple sclerosis (81.4%) protocols, when compared with healthy controls (82.8%). conclusion: this demonstrates that quantitative image biomarkers can be reliably extracted from routinely acquired clinical imaging data. this enables secondary use of clinical images for quantitative biomarker discovery at a hitherto unprecedented scale. interactive methods improve radiology long-term learning j.c. pueyo, j. etxano, p. slon, r. zalazar, j. ros, l. garcía del barrio, g. bastarrika, a. villanueva; pamplona/es (jetxano@unav.es) purpose: personal remote response systems (clickers) have shown to be an interesting tool to encourage participation. the aim of this study is to evaluate whether the use of clickers improves learning and retention of radiology within a group of medical students. methods and materials: 175 medical students attended 17 radiology lessons. each lesson was about 145 radiological images. at the beginning of each lesson, students have a pdf with all the images corresponding to that day. at the end of each lesson, there were five interactive questions of those images using clickers. three months later, there was an examination with multiple-choice questions. half of the questions were images that had already been interactively worked with clickers. the other half were images of the pdfs not worked with clickers. incorrect answer value was -0.25. to evaluate the difference in the degree of learning achieved between both methods, we analysed the index of correct and false answers of each group. results: the averages of the correct answers were significantly higher in the group of interactive teaching than in the passive education group (63 vs 53%, p < 0.005). the percentage of incorrect answers of the interactive teaching group was significantly lower than in the other (23.4 vs. 27.4 p < 0.05). the percentage of unanswered questions was significantly lower in the interactive group (13% vs 19.5% p < 0.005). conclusion: interactive learning with remote response devices (clickers) is an effective method in teaching radiology, because it significantly improves learning and retention of knowledge. purpose: to evaluate diffusion-weighted (dwi) and dynamic contrast-enhanced (dce) magnetic resonance imaging (mri) for diagnosis of recurrent papillary thyroid cancer (ptc) in comparison to ultrasound and peroperative and histopathological findings. methods and materials: twenty-eight patients with suspicion for recurrent ptc underwent 3 t mri, including dwi (b=0-50-100-500-750-1000 sec/mm 2 ) and dce-mri (25 runs; 6 seconds each; pre-, during and post-contrast). interpretation criteria were: b1000-dwi for detection of soft tissue lesions and lymph nodes (ln); characterisation with apparent diffusion coefficient (adc) calculated from all (adcavg), low (adclow) and high b-values (adchigh); characterisation by dce-mri with arterial slope (as), area under the curve (auc) and c-peak. the adc and dce-parameters of tumoural and benign lesions were compared with a mann-witney u test. receiver-under-the-operator-curve analysis determined a threshold from which the accuracy of functional mr-imaging was compared to ultrasound in correlation to histopathology. results: only adchigh and as showed statistical difference between recurrent tumour and benign lesions (adchigh: p=0.002; as: p < 0.0001). per-neck region, b1000-dwi combined with as yielded highest sensitivity of 93% with 98% specificity. ultrasound showed a sensitivity of 72% and specificity of 98%. per patient, functional mri corrected ultrasound in only 4 patients for diagnosing tumour recurrence. however, functional mri findings correctly changed treatment planning in 13 of 28 patients [excluding tumour recurrence (n=2), mediastinal metastatic ln (n=5), laryngeal metastasis (n=2), ipsilateral nodal skip metastasis to level ii (n=2), contralateral nodal metastases (n=2)]. conclusion: combining b1000-dwi with dce-mri may show additional value to ultrasound for diagnosing and planning treatment in recurrent ptc. diagnostic evaluation of patients with squamous cell cancer of the head and neck after free flap reconstructions -the usefulness of functional imaging techniques m. członkowski, a. trojanowska, p. trojanowski, j. klatka, a. drop; lublin/pl (m.czlonkowski@interia.pl) purpose: to evaluate patients operated on head and neck squamous cell cancer and reconstructed using free tissue transfer flaps methods and materials: we evaluated 34 patients with t4 tumours of oral cavity, oropharynx, hypopharynx and larynx. all patients underwent surgical resection of the tumour and reconstruction with free tissue transfer flap: musculocutaneous, fasciocutaneous, osseous and osseocutaneous. patients underwent post-operative radiotherapy. in the whole group we performed ct and/or mr study 3, 6 and 12 months after the completion of therapy. in patients suspected for recurrence based on ct/mr findings, mr diffusion-weighted imaging and ct perfusion were additionally performed. in case of positive findings these patients were qualified for surgery. results: in 11 out of 35 patients imaging study was suggestive for recurrence (4 nodal and 7 local). in this group additional functional imaging was performed. mr dwi and ct perfusion findings were indicative of nodal recurrence in two cases and patients were operated on. recurrence was not proven on histology in either case. in 7 patients with suspected local recurrence additional functional imaging was performed in 5 cases and the recurrence has been proven histologically in 3 cases. conclusion: we have to be aware that functional imaging may be of little value in patients reconstructed with free flaps. although diagnostic imaging plays a prime role in post-treatment follow-up, positive findings must be evaluated with caution. careful reading together with ent surgeon is vital. purpose: chronic bronchitis (cb) is usually caused by smoking and characterised by chronic inflammation and remodelling of the airway wall, commonly in large airways. the study purpose is to determine differences in airway wall thickness (awt) and wall area percentage (wa%) between subjects with and without cb symptoms. methods and materials: 50 heavy smokers with cb symptoms (cough, mucus, dyspnoea and wheezing) and 50 heavy smokers without cb symptoms were randomly selected from 1,413 participants in a lung cancer screening trial. airway walls were measured on images in thin-slice low-dose ct with a dedicated software tool, for airways with a luminal diameter ³5 mm in 5 selected bronchi (rb1, rb4, rb10, lb1+2 and lb10). differences in measurements between the groups were assessed by t-test. the association between cb symptoms and awt and wa% was analysed using multiple linear regression adjusted for age, body mass index, smoking habit, amount of emphysema, and lung function. results: mean awt measured at 5 bronchi was 1.55±0.44 mm and 1.42±0.40 mm in subjects with and without cb symptoms, respectively (p < 0.001). wa% was 47±12% and 43±11%, respectively (p < 0.001). with adjustment for confounders, a significant positive association between both airway wall measurements (awt and wa%) and cb symptoms was found for airways with a luminal diameter from 5 to 10 mm (p < 0.01). in airways with a luminal diameter ³10 mm, no significant association was found (p> 0.05). conclusion: patients with chronic bronchitis symptoms have thicker airway walls of airways between 5 and 10 mm diameter, not in larger diameter. value of inspiratory and expiratory lung volume und lung density for detection of bronchiolitis obliterans syndrome ( ). there was a significant lower variation between the different kernels using ir when compared to fbp. image noise was reduced by 27% when compared to fbp. conclusion: variation of quantitative emphysema chest ct parameters between different reconstruction kernels is significantly reduced with ir when compared to fbp and may increase the robustness for therapy planning. assessing pulmonary perfusion in emphysema: automated quantification of perfused blood volume in dual-energy ctpa f.g. meinel, a. graef, s.f. thieme, f. bamberg, c. neurohr, m.f. reiser, t.r.c. johnson; munich/ de (felix.meinel@med.uni-muenchen.de) purpose: to determine whether automated quantification of lung perfused blood volume (pbv) in dual-energy computed tomography pulmonary angiography (de-ctpa) can be used to assess the severity and regional distribution of pulmonary hypoperfusion in emphysema. we retrospectively analysed 40 consecutive patients (mean age 67 ± 13 years) with pulmonary emphysema, no cardiopulmonary comorbidities and a de-ctpa negative for pulmonary embolism. automated quantification of global and regional pulmonary pbv was performed using the syngo dual-energy application (siemens healthcare). we further quantified the global and regional percentage of voxels with a ct density <-900 hu. emphysema severity was rated visually and pulmonary function tests were obtained by chart review. results: global pulmonary pbv showed a moderate but highly significant negative correlation with residual volume (rv) in % of predicted rv (r=-0.62, p=0.002, n=23) and a positive correlation with forced expiratory volume in 1 second (fev1) in % of predicted fev1 (r=0.67, p < 0.001, n=23). global pbv values strongly correlated with diffusing lung capacity for carbon monoxide (dlco, r=0.80, p < 0.001, n=15). pulmonary pbv values decreased with visual emphysema severity (r=-0.46, p=0.003, n=40). moderate negative correlations were found between global pbv values and parenchymal hypodensity in a per-patient (r=-0.63, p < 0.001, n=40) and per-region analyses (r=-0.62, p < 0.001, n=40). conclusion: de-ctpa allows simultaneous assessment of lung morphology, parenchymal density and pulmonary pbv. in patients with pulmonary emphysema, automated quantification of pulmonary pbv in de-ctpa can be used for a quick, reader-independent estimation of global and regional pulmonary perfusion, which correlates with pulmonary function tests. author disclosures: t.r.c. johnson: equipment support recipient; siemens healthcare. research/ grant support; bayer healthcare. purpose: brain death has adverse effects on lung perfusion and ventilation with possible damage of lung parenchyma pre-transplantation. we wanted to assess brain dead subjects treated with a new drug regime with hrct as a pre-transplant work-up. methods and materials: eleven pigs were decapitated (dc) assuring brain death, attached to ventilator and treated with a new drug regime optimising circulation thereby preventing lung edema. thirteen non-decapitated pigs (n-dc) attached to ventilator, supported with conventional treatment served as controls. all were monitored 24h and thereafter examined with chest hrct. images were analysed by two radiologists using a pre-defined questionnaire assessing parenchymal and airway changes. in consensus, an overall conclusion inferred presence of edema, infection/atelectasis or airway pathology. severity was estimated with a subjective scale. results: after 24h there were no significant differences between the groups regarding mean arterial pressure (map), arterial oxygen/fraction of inspired oxygen (pao2/fio2), amount of infused fluid, urine production or clinical signs of edema. out bos. lung volume (vol), mean lung density (mld), 10 th , 20 th , 30 th , 40 th , 50 th percentile (p10-p50), peak, full width half maximum (fwhm), percentage of high (>-300 hu, hav) and of low attenuation values lav) were assessed with dedicated software (mevis pulmo). measurements of patients with/without bos and patients without bos with normal (fev1> 90% of baseline, bos0)/slightly reduced values for fev1 (fev1 81-90% of baseline, bos0-p) were compared with independent t-test. results: vol, mld, p10, p20, p40, p50, peak, and fwhm (p²0.005) in expiration scan as well as difference in volume between inspiration and expiration (p < 0.001) were significantly different in patients with/without bos. in inspiration, p10 (p=0.017), fwhm (p=0.036) and lav (p=0.026) showed significant differences at higher levels. comparing patients with bos0 and bos0-p, p10 might be used for distinction (p=0.029). conclusion: expiratory lung volume and density showed significant differences in patients with/without bos. p10 value might be used as an imaging biomarker for early detection of bos. author purpose: the aim of this study was to prospectively evaluate the diagnostic value of density mappings for detection of bos following lung transplantation. methods and materials: 132 ct examinations were carried out in lung transplant patients in full inspiration / expiration using a 64-row mdct (120 kvp, rotation time 0.8 s, pitch 0.984, collimation 1.25 mm, reconstruction increment 1 mm, standard reconstruction kernel). 27 / 105 examinations were performed in patients with / without bos (bos 0: 80, bos 0p: 25, bos 1: 11, bos 2: 5, bos 3: 11). the assessment of at was performed using both, a threshold-based method in expiration (hu range: -910 hu to -850 hu) and density mappings of hu values in inspiration and expiration after registration applying a threshold of -910 hu to -750 hu and hu differences ² 70 hu between expiration and inspiration. with both methods, measurements of patients with / without bos were compared with independent t-test. results: at quantified with density mappings was significantly different in patients with / without bos. mean at was 28% in patients with bos and 18% in patients without bos. comparing patients with and without bos at might be used for distinction (p=0.002). at quantified with the standard threshold-based method also showed differences between both groups, but with a lower significance (p=0.019). conclusion: measurement of at with density mappings of hu-values showed a significantly better distinction between patients with / without bos than the standard threshold-based method. non-invasive focal therapy of organ confined prostate cancer: phase i study using magnetic resonance guided focused ultrasound technology and excision pathology for efficacy assessment a. napoli, v. panebianco, m. anzidei, f. boni, v. noce, l. bertaccini, g. cartocci, f. ciolina, c. catalano; rome/ it (alessandro.napoli@uniroma1.it) purpose: to assess safety and initial effectiveness of non-invasive high-intensity 3 t mr-guided focused ultrasound (mrgfus) treatment of localised prostate cancer in a phase i, treat and resection designed exploratory study. methods and materials: on the basis of a power analysis, 11 patients with biopsyproven focal t2 prostate cancer (low-to-intermediate risk: gleason max 3+4), confirmed on a previous multiparametric mr exam, including dynamic contrast enhanced (dce) imaging, underwent mrgfus. all patients were scheduled to laparoscopic prostatectomy; mrgfus treatment was carried out on mr identifiable lesions (max 2) using a patient-specific energy and real-time mr thermometry monitor for correct location. non-perfused volume (vpv) in the post-ablative mri was than compared with excision pathology for necrosis assessment. results: no significant complications were observed in all subjects during or immediately after the procedure. procedure was validated by pathologist that demonstrated extensive coagulative necrosis at the site of sonication surrounded by normal prostatic tissue with inflammatory changes; these features positively compared with immediate post-ablative mri scan and npv. at histology 10 patients were free of residual viable tumour within the treated area; in the remaining patient, 10% of residual tumour was observed within the npv. there was a variable amount of isolated cancer tissue within non-treated parenchyma that was identifiable neither at mri nor at biopsy. to determine the impact of axial traction during mr imaging of the ankle cartilage at 3.0 t in volunteers with respect to motion artefacts, image quality and cartilage surface delineation. methods and materials: optimised coronal and sagittal t1-weighted (w) turbo spin echo (tse) sequences with a drive pulse (in-plane spatial resolution 0.21 mm), a sagittal fat-saturated intermediate-weighted (imfs) tse sequence and a 3d gradient echo sequence were acquired at 3.0 t in 8 volunteers with and without axial traction of 6 kg. joint space width was measured at four locations in the tibiotalar joint. motion artefacts, general image quality, delineation of the cartilage surface, cartilage matrix and the confidence of diagnosing cartilage pathology were evaluated independently by two radiologists. differences were assessed using a wilcoxon test. results: with axial traction, joint space width increased significantly (1.7±0.5 mm vs. 0.3±0.2 mm). consequently, delineation of the cartilage surface was rated superior in 7/8 volunteers (p < 0.05). no differences were found in motion artefacts, general image quality, and artefacts within the cartilage matrix (p> 0.1). comparing the different sequences, cartilage surface and matrix was best visualised by the t1-w tse sequences with a drive pulse (surface average of all regions and readers in sag t1-drive vs. imfs on a four-point scale 1.3±0.6 vs. 3.0±1.0, p < 0.05). conclusion: axial traction of 6 kg increases the joint space width at the tibiotalar joint, and thus better visualises the articular cartilage surface. highest spatial resolution and visualisation of both cartilage surface and matrix were achieved by a t1-w tse sequence with a drive pulse. s188 c a d e f g b results: all affected subjects were women between 14 and 52 years old (mean age: 40). ischiofemoral space was significantly narrower in patients with ischiofemoral impingement when compared with control subjects (13.1 ± 4.06 mm vs 24.9 ± 4.55 mm, respectively; p < 0.01). quadratus femoris space was also significantly narrower in affected subjects (9.4 ± 2.97 mm vs 16.4 ± 1.08 mm; p < 0.01). inclination angle was not statistically different (p> 0.05). the degree of oedema and fatty infiltration was inversely proportional to values of ischiofemoral and quadratus femoris space. the interobserver agreement (ĸ) was 0.8 for ischiofemoral space, 0.63 for quadratus femoris space and 0.53 for inclination angle. conclusion: ischiofemoral impingement can be accurately diagnosed following anatomic and imaging mr criteria. us-guided viscosupplementation of the hip: therapeutic efficacy in patients affected by femoro-acetabular impingment c. martini 1 , f. lacelli 2 , e. fabbro 1 , g. ferrero 1 , g. serafini 2 ; 1 genoa/it, 2 pietra ligure/ it (chiarapio@libero.it) purpose: us-guided viscosupplementation is a safe and effective therapy for symptomatic osteoarthritis (oa) of the hip and it allows to replace nsaids therapy and to delay prosthetic intervention. femoro-acetabular impingement (fai) is a cause of oa. the purpose of this work is to evaluate the efficacy of viscosupplementation as therapy of oa in patients affected by femoro-acetabular impingement. methods and materials: 352 patients selected by orthopaedists for hip pain and plain films signs of oa (degrees ii-iv of k-l) underwent viscosupplementation (4 ml of intermediate weight hyaluronic acid for three times every 30days). each patient was evaluated before the treatment and 1, 3, 6 and 12 months after the treatment by means of vas and oxford score. hence, these patients were divided into responsive (increase oxford score=/> 10 and/or reduction vas0/> 3) and non-responsive (increase oxford score< 10 and/or reduction vas0< 3). then we retrospectively evaluated the plain films of the hip these patients had done before the therapy, in order to find the signs of fai. results: 281/352 (79.8%) patients were included into the "responsive" group; 71/352 (20.2%) in the "non-responsive" one. in the "responsive" group we found signs of fai on the plain films of 37/281 patients (11.4%); in the "non-responsive" in 43/71 (60.5%). conclusion: despite viscosupplementation is an effective therapy of oa, there is an high prevalence of non-responsive among patients affected by fai. a new way to measure lower limb length and alignment using 3d models based on biplanar linear radiography: a comparison with measurements on supine ct scans and upright full-length radiographs r. guggenberger, c.w. pfirrmann, p. koch, f. buck; zurich/ch (romanguggenberger@yahoo.de) purpose: to compare lower limb length and alignment angle on supine computed tomography (ct), upright full-length radiography (ufr) and 3d models based on upright biplanar radiography (blr). methods and materials: irb-approved study involving 51 consecutive patients (22 male, 29 female; mean age 68.8years; range 43-92years) scheduled for total knee replacement. lower limb length and alignment angles were measured on ct, ufr and 3d models based on blr using standard and extended length measurements by two independent readers. measurements of different modalities were compared by paired t-tests, pearson correlation coefficients and bland-altman analyses. results: mean limb lengths were 783 mm (sd±56.1 mm, range 639-927 mm), 785 mm (sd±53.0 mm, 655-924 mm), 780 mm (sd±55.4 mm, 633-921 mm) and 783 mm (sd±55.9 mm, 636-924 mm) for ct, ufr and 3d models using standard and extended measurements, respectively. mean alignment angles were 2.3° (sd±5.5°, range -12°-20°), 2.5° (sd±6.7°, -17°-18°), 3.4° (sd±6.6°, -14°-18°), respectively. length and angle measurements differed significantly when comparing standard 3d models to ct and ufr, respectively (p < 0.001). pearson correlation coefficients were 0.992, 0.993, 0.995 and 0.998 for limb length and 0.968, 0.983 and 0.984 for angle measurements in ct, ufr and 3d models, respectively. bland-altman analyses for ct and ufr compared to 3d models showed a small positive mean difference in length using standard measurements (2.7 mm, sd±5.5; 5.4 mm, sd±13.1) and a small negative mean difference in angle measurements (-1.1°, sd±2.5; -0.9°, sd±3.1). no bias for length measurements was seen using extended measurements. conclusion: upright 3d models allow for lower limb length and alignment angle measurements comparable supine ct scans and ufr. stable or unstable tear of the medial meniscus of the knee: can weight-bearing mri solve the problem? a. la marra, s. mariani, e. costantini, a. conchiglia, a. barile, c. masciocchi; l'aquila/ it (alicelm@hotmail.it) purpose: to assess the role of 1.5 t, dedicated low-field standard and upright-mri in the evaluation of stable or unstable tears of medial meniscus in comparison with arthroscopy. we retrospectively reviewed and analysed 20 mri exams (group a) of normal knee and 77 mri exams (group b) of knee with clinical evidence of tears of the medial meniscus. in the same session, after conventional 1.5 t and "dedicated" 0.27t supine mri exam, the patients underwent upright weight-bearing examination with the same dedicated mri unit. in all cases sagittal and coronal se t1-w were used. all patients underwent arthroscopy within 21 days from mri exam. results: in group a, no statistically significant anatomical modifications of shape, intensity and position of the medial meniscus between standard 1.5 t, dedicated supine and upright mri were observed. in group b, the images acquired in the supine position (dedicated and 1.5 t mri) documented in 31 cases a traumatic tear (group b1) and in 46 cases a degenerative tear (group b2). in group b1, weightbearing mri showed presence of unstable tear only in 19 out 31 cases. in group b2, weight-bearing mri showed a degenerative unstable meniscal tear only in 29 out of 46 cases. arthroscopy confirmed weight-bearing mri diagnosis in all cases. conclusion: our preliminary results show that upright weight-bearing mri has wide potentials for the study of dynamic modifications in case of meniscal stable or unstable tear. periosteal high volume image-guided injection of recalcitrant medial collateral ligament injuries: a retrospective case series analysis o. drumm, o. chan, p. malliaras, d. morrissey, n. maffulli; london/uk (odrumm@yahoo.co.uk) purpose: we evaluate a novel injection method, periosteal high volume imageguided injection, in the management of recalcitrant medial collateral ligament (mcl) injury of the knee. the injection, comprising 10 ml of local anaesthetic with 25-50 mg of hydrocortisone, is directed at the periosteal attachment of the mcl. 28 patients in total received the intervention between june 2009 and november 2011 at a london hospital. each was asked to complete a study-specific questionnaire including a visual analogue scale (vas) and the international knee documentation committee (ikdc) subjective knee form (to describe symptoms pre-injection and at follow-up). results: 68% of patients responded (n=19). three patients were omitted according to the exclusion criteria. 31.3% of patients (n=5) were professional athletes. mean duration of symptoms was 5.4 (sd=6.6) months. patients reported a mean improvement on the vas of 75.4% (sd=23.7). there was a significant improvement in ikdc scores (mean difference of 42%, sd=14.2) pre-and post-injection (p=0.01). 62.5% of patients (n=10) had returned to their previous level of sport at follow-up including all the professional athletes. knee symptoms returned to normal in 50% (n=8), and improved substantially in a further 37.5% (n=6). the remaining 12.5% (n=2) experienced an initial improvement but symptoms recurred. conclusion: periosteal high volume image-guided injection is a useful treatment for recalcitrant mcl injury, a common sports injury that can result in lengthy periods of missed training and competition. results are encouraging, particularly amongst the professional athletes studied. ischiofemoral impingement, do you want to believe? r. prada, r. oca, a. rocha, l. fernández, m. costas, g. tardáguila; vigo/es (roqueoca@hotmail.com) purpose: to find out if there are anatomic and imaging mr criteria to diagnose ischiofemoral impingement. methods and materials: 290 mris of the hip were retrospectively reviewed from august 2011 to september 2012. a total of 9 ischiofemoral impingement were diagnosed and 20 normal patients were included as control. ischiofemoral space, quadratus femoris space and femoral inclination angle were measured independently by two blinded musculoskeletal radiologists. the degree of oedema and fatty infiltration in the quadratus femoris muscle were also assessed visually. differences in ischiofemoral space, quadratus femoris space and femoral inclination angle were studied between pathological and control cases. the interobserver reliability was obtained for quantitative variables. purpose: to assess the value of oral effervescent powder administration for ct evaluation of the oesophagus, quantitatively and qualitatively. methods and materials: 42 patients (27m/15f, mean age 57y) referred for thoracoabdominal staging ct were included in this prospective irb-approved study. contrast-enhanced imaging was performed on a 64-slice ct-scanner after oral administration of 3 g effervescent powder immediately before image acquisition. oesophageal distension was assessed at three levels (proximal/middle/distal) by volumetry of the inner (id) and outer diameter (od). two blinded readers separately evaluated oesophageal distension in the corresponding segments on a three-point scale. at an interval of two weeks, both readers in consensus decided on the number of diagnostic oesophageal segments in each patient in terms of the possibility to decide upon a potentially underlying pathology. findings were compared with results from a matched control group. quantitative and qualitative results were compared (t-test, mann-whitney u test). inter-observer variability was calculated (weighted-cohen-κ). results: id and od were significantly larger in all oesophageal segments after effervescent powder administration as compared to the control group (p < 0.05; mean id: 1.13 vs. 0.14, mean od: 2.17 vs. 1.26). further, oesophageal distension was rated significantly better, with a good inter-observer variability (mean weighted κ=0.75). at consensus evaluation, 93 oesophageal segments (74%) were rated as diagnostic in the effervescent group, versus 49 segments (38%) in the control group (p < 0.0001). conclusion: correctly timed oral administration of effervescent powder results in good distension of the oesophagus, allowing readily assessment of the wall at contrast-enhanced ct as compared to studies without effervescent powder. 15 de (marcandre.weber@med.uni-heidelberg.de) purpose: to prospectively evaluate whether dynamic contrast-enhanced (dce) mri can assess vascularity within pseudarthrotic clefts and predicts clinical outcome better than the clinical non-union scoring system (nuss). methods and materials: sixty-four patients (mean age, 49.3 years) with nonunion of an extremity fracture in computed-tomography received 3-tesla mri including dce (coronal t1-weighted fat-saturated vibe, tr/te=3.76/1.35 ms, 17 measurements, 2 mm slice thickness) after 0.1 mmol/kg body-weight of gadoterat. we assessed vascularity within the pseudarthrotic cleft using a region-of-interest analysis. signal intensity curves were subdivided into those with more intense contrast-agent uptake in the pseudarthrotic cleft than in normal adjacent muscle tissue (vascularised non-union) and those with similar or less uptake. the pharmacokinetic parameters of the tofts model (ktrans, kep, iauc, ve) were correlated to the clinical outcome at one-year follow-up (n=37). results: despite inserted osteosynthesis material, dce parameters could be evaluated in n=60 at first visit. sensitivity/specificity of vascularised non-unions as indicator of good clinical outcome was 77.3%/46.7% compared to 95.5%/26.7% using nuss. logistic regression revealed non-significant impact of nuss on clinical outcome (p=0.27, odds ratio=0.97). at first examination, median iauc (initial area under the enhancement curve) was 24.13 in patients with good outcome compared with 10.96 in non-responders (p=0.032), while ktrans, kep, and ve were not significantly different. using a receiver operating characteristic analysis, sensitivity/specificity of iauc at the optimal cut-off value of 17.5 to predict outcome was 68.2%/76.9%. all pharmacokinetic parameters did not change significantly at the one-year control (n=18). purpose: imaging-guided thermal ablation has become the therapy of choice among the different treatment strategies of symptomatic osteoid osteoma lesions. in this descriptive, prospective study, our objective was to evaluate typical post-procedural mr-imaging characteristics following mr-guided laser ablation of osteoid osteoma. methods and materials: 35 patients with osteoid osteoma treated with mr-guided laser ablation underwent follow-up mr-imaging immediately after the procedure as well as after 3, 6, 12, 24, 36 and 48 months. imaging protocol included fatsaturated t2w spir tse, non-contrast and contrast-enhanced t1w tse images and subtraction images. mr images were jointly reviewed by two radiologists, regarding the appearance of treated areas, nidal enhancement and presence of side effects such as bone oedema and soft tissue enhancement. imaging was correlated to clinical status. results: mean follow-up time was 13.9 months. 28 patients showed a postprocedural target-sign appearance with subsequent "positive inward fusion" of the different zonal compartments. post-procedural mr-imaging can support evaluation of therapeutic success. characteristic mr findings correlated well with the clinical status. conclusion: interpretation of post-procedural follow-up mr-imaging after laser ablation of osteoid osteoma may contribute to understanding of histopathological post-therapeutic changes and cornerstones of therapeutic success. s190 c a d e f g b results: the mean value of dmax obtained by surgical specimen was 57.45 mm (range 10-250) versus 70.73 mm (range 16-195. 3) of dmax measured through mdct. if the dmax values were stratified into three groups (group 1 smaller than 45 mm, group 2 between 45 and 80 mm, group 3 bigger than 80 mm), a correlation with mdct results of 62.22, 65.90 and 100%, respectively, was found. conclusion: mdct is an accurate technique to obtain an appropriate preoperative definition of dmax, within the limits of tumour bigger than 45 mm. the revaluation of each case with dmax smaller than 45 mm will supply additional information about the discrepancy (retraction of the stomach following immersion into formalin, diffusion in the submucosal layer). percutaneous endoscopic gastrostomy (peg) and jejunostomy (pej) placement guided by ct fluoroscopy with or without simultaneous endoscopy in otherwise untreatable patients c. de (christoph.trumm@med.uni-muenchen.de) purpose: percutaneous endoscopic gastrostomy (peg) or jejunostomy (pej) is substantial for patients with swallowing disorders to maintain enteral nutrition or to palliatively decompress intractable small bowel obstruction. endoscopic placement can be impossible due to previous (gastric) operation, obesity, hepato-splenomegaly, peritoneal carcinosis, inadequate transillumination or obstructed passage. computed tomography (ct) fluoroscopic guidance with or without endoscopy can enable the placement of a peg/pej if endoscopically guided placement fails. methods and materials: 101 consecutive patients were referred to our department for feeding support (n=87) or decompression (n=14). reasons were: ent tumour (n=51), oesophageal cancer (n=19), mediastinal mass (n=2), and neurological disorders (n=15). decompression tubes were placed because of cancer (n=13) or crohn's disease (n=1). the following approaches were chosen: i. ct fluoroscopy and simultaneous gastroscopy (n=61), ii. ct fluoroscopy and inflation of the stomach via nasogastric tube (n=29), and iii. direct puncture under ct fluoroscopic guidance (n=11). results: ct fluoroscopy-guided peg/pej was feasible in 89 of 101 patients. no procedure-related mortality was observed. one tube was misplaced into the colon in a patient with a history of gastrectomy. no complication was seen after removal. minor complications were dislodgement (n=17), peristomal leakage (n=7), wound infection (n=1), superficial skin infection (n=6) and tube obstruction (n=2). conclusion: ct fluoroscopy-guided peg/pej is feasible and safe, and provides adequate feeding support or decompression. it offers the benefits of minimally invasive therapy even in patients with contraindications to established endoscopic methods, combining the advantages of both techniques. long-term complications -mainly tube-related problems -are easily treated. ct assessment of post-resection arterial stumps for right-sided colorectal cancer: a potential marker of quality of resection? t.l. kaye, d.g. jayne, n.p. west, d.j.m. tolan; leeds/uk (thomas.kaye@leedsth.nhs.uk) purpose: there is evidence that the quality and extent of colonic resection affects tumour recurrence rates and patient survival. this is currently evaluated by pathological analysis of the resected specimen. analysis of post-resection arterial stumps via routine follow-up ct could act an alternative in vivo marker. methods and materials: staging and follow-up ct scans from 156 patients with right-sided colorectal tumours were analysed. pre-operative arterial anatomy and post-operative arterial stumps were demonstrated using multi-planar reformats and volume rendering techniques. methods of stump identification, stump length and stump orientation were recorded. results: ileocolic (98.7%), middle colic (94.2%) and right colic artery (23.7%) identification was comparable with catheter angiogram studies. mean time interval between staging and analysed follow-up ct was 25 months. post-resection ileocolic stumps were consistently identified (88.4% of cases). in the vast majority of cases this was via a thrombosed vessel (97%). there was a wide variation in ileocolic stump length (2.5 -74.3 mm, mean 27.6 mm, standard deviation 13.5 mm). conclusion: to the best of our knowledge this is the largest study to date demonstrating arterial stumps post colonic cancer resection. it is the first to consistently identify stumps years after colonic resection using routine surveillance (portal venous) ct. ct-based stump length analysis may therefore have potential as an in vivo marker of extent and quality of surgical resection. prospective study of using balloon duodenography catheters in ct enteroclysis for small bowel diseases k.c.h. lau, l.m.f. tee; hong kong/hk purpose: to determine the usefulness of using balloon duodenography catheters (bdc) for ct enteroclysis (cte), with a comparison of small bowel distension in using bdc and nasogastric catheters (nc). one of the limitations of cte is the suboptimal distension of the bowels, especially the distal ileum. using bdc, there is less reflux of contrast into the stomach and should have more contrast in the distal small bowel. the study protocol was approved by the ha kwc research and ethics committee and all patients gave written informed consent for the examination and this study. from may 2011 to july 2012, cte was performed in 60 consecutive patients with random allocation of 27 patients using bdc and 33 patients using nc. all catheter insertions and cte examinations were performed according to department protocol. small bowel distension was differentiated into four regions (proximal jejunum, distal jejunum, proximal ileum and distal ileum) and given a score from 1 to 3 (1 -< 20 mm, 2 -20-30 mm, 3 -> 30 mm). results: distension of proximal and distal ileum was better with bdc than nc (p < 0.05: statistically significant difference). no significant difference was present for others sites (p> 0.05). conclusion: our study shows statistically significant better distension of the proximal and distal ileum, with the use of bdc when compared with nc. this is of particular use, as the distal ileum is a common site of small bowel diseases. with better bowel distension, this would suggest that using bdc would help to further improve the accuracy of cte. role of preoperative imaging with multidetector computed tomography (mdct) in the management of patients with gastroesophageal reflux disease (gerd) symptoms, candidate to sleeve surgical revision m. rengo, d. caruso, f. vecchietti, m.m. maceroni, g. silecchia, a. laghi; latina/ it (marco.rengo@gmail.com) purpose: to evaluate if multidetector computed tomography (mdct) can be helpful and useful in the decision-making process in sleeve patients with gastroesophageal reflux disease (gerd) symptoms and to demonstrate the reproducibility and accuracy of the technique. methods and materials: twenty-three patients submitted to lsg, complaining upper gi symptoms and/or weight regain and scheduled for a sleeve surgical revision were investigated. all patients underwent mdct scan, upper gi barium swallow study and endoscopy. mdct was compared with barium and endoscopy features as concern: oesophageal dilatation, neo-fundus development and volume, hiatal hernia, sleeve size in toto and atrum dilatation. all patients underwent laparoscopic sleeve revision. surgical findings were considered "as gold standard". results: a total of 21 patients with hiatal hernia, neo-fundus or sleeve dilatation underwent surgical correction. all findings identified at mdct were confirmed by intraoperative findings. the presence of hiatal hernia was significantly underestimated by both barium and endoscopy with a sensitivity of 57.1% and 50%, respectively (p=0.04, p=0.02). conclusion: mdct is an accurate method for the detection of hiatal hernias and quantification of gastric volumes and can be considered as non invasive method to guide surgery. purpose: the maximum tumour diameter (dmax) is a prognostic factor in patients with gastric cancer, considering its dependence on the depth of invasion. the aim of our work has been to evaluate the accuracy of mdct in the preoperative definition of dmax in patients with gastric cancer, assuming surgical specimen measurements as gold standard, in order to obtain a pre-surgery prognostic evaluation. methods and materials: pre-surgery ct examinations of 104 patients (mean age 68.81, range 25-90) with diagnosis of gastric cancer were evaluated retrospectively and in a blind fashion by a radiologist with expertise in the oncologic field. the dmax measured was obtained through 2d multiplanar curved reconstruction (adw 4.6 ge healthcare). the results were compared with macroscopic data after surgery. s191 a c d e f g b thursday b-0199 15:21 pilot study to assess the diagnostic performance of mri in the identification of adhesions between the abdominal wall and small bowel loops, using a time-efficient protocol a. gupta, a. hansmann, p.f.c. lung, r. tandon, r. ilangovan, m. marshall; purpose: abdominal adhesions following surgery are the commonest cause of small bowel obstruction and may complicate subsequent surgery. accurate identification of adhesions has been reported using mr fluoroscopy sequences. we report our results utilising a time-efficient protocol. methods and materials: 10 patients scheduled for open colorectal surgery and who had undergone previous abdominal surgery were recruited over 4 months (mean age 44, range 29-59). the abdomen was divided into 9 segments prior to mr and surgery enabling accurate correlation. using a 1.5 t scanner (siemensavanto), t2 sagittal, axial, sagittal true-fisp 30s cine sequences were obtained (slice thickness 1 cm), in inspiration, expiration and abdominal strain. scanning time was 8 min. adhesions were identified by finding angulation, fixation or altered peristalsis. 4 readers analysed the images independently, providing a consensus opinion on the number and location of adhesions. laparotomy was the gold standard. results: 90 abdominal segments were evaluated with adhesions identified in 44% at laparotomy and 34% on consensus mr. 31 segments demonstrated adhesions on mr; 74% correlated at surgery, whilst the remainder were found in adjacent segments (26%). using a 2x2 table, sensitivity was 60%, specificity 86%, with positive and negative predictive values of 77% and 73%, respectively. overall accuracy was 74%. conclusion: our results suggest utilisation of a time-efficient mr protocol in identifying adhesions between the bowel and anterior abdominal wall is feasible in a busy unit, and may represent a non-invasive application in the research of adhesion-preventative techniques. reader performance rose during our study and further improvements may be realised in a larger trial. 14:00 -15:30 room f1 oncologic imaging new biomarkers for tumour quantification purpose: patients with lung cancer often suffer additional chronic lung diseases, and often these patients present with fdg avid mediastinal lymph nodes due to inflammatory reasons rather than malignancy. fdg-pet is the leading imaging modality for n-staging in lung cancer patients; however, in patients with doubtful fdg-pet status, 3d ct histogram analysis might give an additional value to diagnostic imaging. in this investigation 3d ct histogram analysis was used to identify metastatic lymph node involvement in lung cancer patients in correlation to fdg-pet/ct. methods and materials: 38 lymph nodes from 32 patients aged 43-76 years diagnosed with lung cancer were investigated. fdg-pet/ct was performed prior to surgery/biopsy according to clinical schedule. lymph node assessments were acquired using fdg-uptake and 3d ct histogram analysis on the basis of non-enhanced ct scans. for computing the histograms, the lymph nodes were segmented by a semi-automatic algorithm; the segmentation result was corrected manually if required in certain cases. both imaging findings were correlated with the results from the histological gold standard study. results: 21 positive and 17 negative histologically proven lymph nodes were successfully analysed by 3d ct histogram. the histological positive lymph nodes presented a median ct hu value of 34.5 while histological negative lymph nodes presented a median ct hu value of 7.6. findings were independent of the fdguptake value. conclusion: 3d histogram analysis seems to be a very promising and valuable imaging surrogate for n-staging stratification in patients with lung cancer with doubtful glucose uptake in fdg-pet. evaluation of crohn's disease recurrence in patients with ileocolic anastomosis: value of computed tomography enterography with water enema f. paparo, m. revelli, c. puppo, i. garello, l. bacigalupo, l. rollandi, r. piccazzo, a. garlaschi, g.a. rollandi; genoa/ it (francesco.paparo@galliera.it) purpose: to investigate the value of computed tomography enterography with water enema (cte-we) in the assessment of the status of the anastomotic site in patients with crohn's disease (cd) who had previously undergone ileocolic resection. were retrieved from our institutional radiology database, and reviewed in consensus by two gastrointestinal radiologists. the presence of cd anastomotic recurrence and its phenotype (inflammatory, stricturing, penetrating) , and the presence of inflammatory lesions involving other bowel segments beside the anastomotic site were recorded. endoscopy and medical records were used as reference standards. results: ct signs of cd recurrence were detected in 45 patients, including: 32 (71.12%) isolated anastomotic recurrences, 11 (24.44%) anastomotic recurrences + synchronous inflammatory lesions (sils), 2 (4.44%) inflammatory lesions not involving the anastomotic site. phenotypes of the 43 cd anastomotic recurrences were: 22 (51.1%) inflammatory (non-stricturing non-penetrating), 16 (37.2%) stricturing, 4 (9.3%) penetrating. no relation was found between the phenotype of cd recurrence and the type of the anastomosis (ll, tl, tt) (p = 0.1252; chi-square test). conclusion: cte-we allowed a complete characterisation of the anastomotic site and the detection of sils, which had a relatively high prevalence in our study cohort (24.44%). crohn's disease activity: correlation of inflammatory mediators with overall small-bowel motility s. bickelhaupt 1 , s. pazahr 1 , j.m. froehlich 1 , r. cattin 2 , h. bouquet 3 , g. rogler 1 , p. frei 1 , a. boss 1 , m. patak 1 ; 1 zurich/ch, 2 biel/ch, 3 berne/ch purpose: active crohn's disease (cd) increases the level of inflammatory markers of which c-reactive protein (crp) and calprotectin are commonly used to monitor disease activity. the aim was to evaluate the correlation between crp and calprotectin levels and overall small bowel motility in patients with crohn's disease assessed with mri. methods and materials: 13 patients with crohn's disease (4f/9m, mean 42y) were included in this irb-approved prospective study. mri (1.5-t, philips achieva) was performed after a 1-h preparation of 1000 ml mannitol-solution (3%). cine t2w-2d-ssfp motility acquisitions (tr 2.47/te 1.23/250 ms slice repetition time) were performed in free breathing over 69-84sec. randomly chosen small-bowel segments were analysed in two abdominal quadrants using dedicated mr-motility assessment software (motasso). contraction frequency, amplitude, luminal diameter and amplitude diameter ratio (occlusion ratio, adr) were evaluated as well as crp (ngl/ul) and calprotectin (ug/g) levels. pearson's correlation was calculated. results: calprotectin was determined in mean 12 days (sem±10.09) before, crp 15 days (sd±28.80) before mri. a significant inverse linear correlation was found between the contraction frequency and both the level of crp (r=-0.701, p=0.008) and calprotectin (r=-0.805, p=0.001). expansion of the mean small bowel diameter significantly correlated with calprotectin levels (r=0.857, p=< 0.001) but not with crp (r=0.447, p=0.126). the absolute amplitude of the contractions did not correlate neither with the level of crp (r=-0.527, p=0.064) nor with calprotectin (r=-0.612, p=0.026). the ratio describing relative luminal occlusion during contraction (adr) significantly correlated with calprotectin (r=0.736, p=0.004) and with crp (r=0.577, p=0.039). alterations of overall small bowel motility during active phases of cd significantly correlate with the level of calprotectin and crp. author disclosures: h. bouquet: employee; fromer employee of sohard ag. s192 c a d e f g b measured on fdg-pet. treatment response was evaluated after three cycles of platinum-based chemotherapy, according to recist. the predictive value of texture and pet parameters have been investigated by multivariate analysis. results: fourteen out of 25 patients were non-responders (4 progressors, 10 stable disease). combining heterogeneity and suv in a unique parameter (heterogeneity*suv), the latter was significantly higher in responders than in non-responders (medians 192.7 vs 92.8, respectively; p0< 0.0001) and showed a high predictive value: odds ratio (probability of response) of third vs first tertile was 49 (p0.003). responses in first tertile were 1/8, in the second 3/9, in the third 7/8 (p0.007, p for trend 0.003). tumour heterogeneity alone showed a significantly weaker predictive value, while suv alone was not predictive of treatment response. conclusion: the combination of texture features of tumour heterogeneity on cect and the metabolic information provided by fdg-pet has the potential to be an independent predictor of response to first-line chemotherapy in advanced nsclc. in particular, tumour suv combined with heterogeneity provides an additional value compared with tumor heterogeneity alone. purpose: to assess whether tumour heterogeneity, quantified by texture analysis on contrast-enhanced ct (cect), can predict the response to chemotherapy in advanced non-small cell lung cancer (nsclc). fifty-three pre-treatment cect studies of patients with advanced nsclc who had undergone first-line chemotherapy were retrospectively reviewed and analysed. treatment response was evaluated after three cycles of platinum-based chemotherapy, according to recist. tumour uniformity on ct images has been assessed by a three-step method: image thresholding; multiscale filtering by laplacian-of-gaussian filter; quantification of texture features on filtered images using first-order statistics. the predictive and prognostic values of resulting texture parameters have been investigated by multivariate analysis. results: thirty-one out of 53 patients were non-responders (7 progressors, 24 with stable disease). average overall survival was 13 months (4-35), minimum follow-up was 12 months. in the adenocarcinoma group (n=31), the tumour uniformity multiplied by the grey-level of unfiltered images (gl*uni index) has been shown to be the unique independent variable predictive of treatment response. dividing the gl*uni index (8.5-46.6) into tertiles, lesions in the second and the third tertiles had a 8-fold higher probability of treatment response compared to those in the first (p0.02). tnm stage, sex, age and performance status did not show predictive value. no association between texture features and response to treatment was observed in the non-adenocarcinoma group. gl*uni index was not prognostic. conclusion: texture features of tumour heterogeneity on cect images in advanced lung adenocarcinoma has the potential to be a predictive indicator of response to platinum-based chemotherapy. textural analysis of lymphoma on unenhanced computed tomography: initial evidence for a relationship with tumour glucose metabolism, stage, end of treatment status and survival s. babikir, b. ganeshan, a.m. groves, i. kayani; london/uk (b.ganeshan@ucl.ac.uk) purpose: to provide initial evidence in lymphoma for a relationship between tumour heterogeneity, as assessed by ct texture analysis (ctta), and tumour glucose metabolism, stage, end of treatment status (eots) and survival. methods and materials: this retrospective, pilot study comprised 50 consenting lymphoma patients with consecutive routine 18 f-fluorodeoxyglucose (fdg) pet-ct scans. texture analysis using texrad, (a commercially available texture analysis software), of non-contrast-enhanced ct images with lesions involved: 1) image filtration extracting fine, medium and coarse texture-scales, and 2) texture quantification using proportion positive pixels (ppp), standard-deviation (sd), and kurtosis (k). corresponding tumour fdg uptake (standardised uptake value (suvavg and suvmax)), clinical-stage and eots from pet-ct and clinical reports were collected. survival was assessed by optimised kaplan-meier analysis. results: 7, 19, 9 and 15 patients had stages i, ii, iii and iv, respectively. fine to coarse textures correlated with suvavg (baseline-scan: sd at coarse-scale, rs=0.362 p=0.011; interim-scan: ppp at medium-scale, rs=-0.766 p=0.0001) and clinical-stage (baseline-scan: k at fine-scale, rs=0.424 p=0.002). baseline coarse textures predicted eots (ppp at coarse-scale, p=0.006; k at coarse scale, p= tumour vascularization imaging without contrast agents: the potential of ivim-mri m. iima 1 , o. reynaud 2 , t. tsurugizawa 2 , l. ciobanu 2 , j.-r. li 2 , f. geffroy 2 , b. djemai 2 , d. le bihan 2 ; 1 kyoto/jp, 2 gif-sur-yvette/ fr (mamiiima1@gmail.com) purpose: to investigate the potential of ivim mri to evaluate perfusion and diffusion in a 9l glioma rat brain tumour model using a 17.2t mri scanner. methods and materials: 14 fischer rats were studied. ivim mri images were acquired with 72 b values (25 b values; 2 to 160 s/mm², 35 b values; 172.5 to 935 s/mm², and 12 b values; 1150 to 3025 s/mm²). the signal attenuation curve was first fitted using a biexponential diffusion model to estimate slow and fast components fraction (fslow, dfast and dslow) of the pure diffusion part of the signal (for b> 500s/mm²). then, the diffusion component was removed from the signal and the remaining signal was fitted using the ivim model for b< 200 s/mm² to get estimates of perfusion fraction, f, and pseudo-diffusion, d*. fitting was performed on a roi basis and on a pixel-by-pixel basis to generate diffusion and perfusion maps. all rats were killed and histology (cd31) was obtained for comparison with ivim parameters. results: ivim maps clearly highlighted areas with high and low fraction perfusion within tumours which were generally heterogeneous, as confirmed by histology. interestingly, we found a negative correlation between the ivim perfusion fraction and fslow, suggesting that cell density in high perfused areas is less than in other tumour parts and normal brain tissue. conclusion: this study confirms that ivim mri can delineate high perfusion areas in tumours and provide information on tissue structure from diffusion parameters. intravoxel incoherent motion (ivim) diffusion-weighted mri for monitoring the therapeutic efficacy of a vascular disrupting agent (ckd-516) in rabbit vx2 liver tumours i. joo, j. lee, j. han, b. choi; seoul/kr purpose: to evaluate the diagnostic value of intravoxel incoherent motion (ivim) diffusion-weighted imaging (dwi) in the quantitative assessment of therapeutic efficacy of a vascular disrupting agent (vda) (ckd-516) in rabbit vx2 liver tumours. in 29 vx2 liver tumour-bearing rabbits (23 in the treated group and 6 in the control group), ivim-dwis were performed at a 3 t scanner using 12 b values before and 4 hours, 24 hours, 3 days, and 7 days after ckd-516 administration. apparent diffusion coefficient (adc) and true diffusion coefficient (d), pseudo-diffusion coefficient (d*), and perfusion fraction (f) of tumours were compared between the control and treated groups and among time points. correlation between change in tumour size and ivim-dwi parameters was analysed to determine which ivim-dwi parameters can be predictors for tumour response. the treated group showed a significantly larger increase in adc at 24 hours, a decrease of d* at 4 hours, and a decrease of f at 4 hours and 24 hours, than did the control group (p < 0.05). in the treated group, compared to baseline values, d* and f significantly decreased at 4 hours and then recovered at 24 hours and d significantly increased at 24 hours (p < 0.005). in addition, the greater decrease in f at 4 hours correlated with the smaller increase in tumour size during the 7 days (rho=0.53, p=0.04). conclusion: the therapeutic effect induced by vda could be effectively evaluated using ivim-dwi, and f could be an early predictive indicator for tumour response. texture analysis on contrast-enhanced computed tomography combined with fdg-pet in predicting the response to chemotherapy of advanced non-small cell lung cancer m. ravanelli, f. ferraroni, d. farina, m. morassi, p. tessitore, p. rossini, r. maroldi; brescia/ it (marcoravanelli@hotmail.it) purpose: to assess whether tumour heterogeneity, quantified by texture analysis on contrast-enhanced ct (cect), combined with fdg uptake at pet-ct can predict the response to chemotherapy in advanced non-small cell lung cancer (nsclc). pre-treatment cect studies and fdg-pet studies of twenty-six patients with advanced nsclc who had undergone first-line chemotherapy were retrospectively reviewed and analysed. tumour heterogeneity was measured by texture analysis on cect images; mean suv from each patient was s193 a c d e f g b thursday b-0208 15:12 scatter amplitude is a good landmark for tumour localisation and treatment assessment in time-domain diffuse optical tomography during neo-adjuvant chemotherapy in breast cancer m. van purpose: neo-adjuvant chemotherapy response may be monitored in a noninvasive way using multi-spectral diffuse optical tomography (dot). a clinically feasible measurement method in these 3d volumes is proposed and compared with previously published whole breast measurements. methods and materials: twelve breast cancer patients were included, which received neo-adjuvant chemotherapy. four dot scans were obtained: before therapy, after 3 and 9 weeks and pre-operative (18 weeks) . deoxyhaemoglobin (hb), oxyhaemoglobin (hbo2) and percentages water and lipids were measured in volumes as measured in dce-mri scans before therapy, centred on areas of high scattering amplitude and approximate location in pre-treatment dce-mri and/ or x-ray mammography. patients were divided in responders and poor responders based on post-operative pathological assessment. results: responders (r) and poor responders (pr) showed statistically significant (p < 0.05) different development of hb values at 3, 9 and 18 weeks within measurement volumes relative to the first dot scan: 0.66/1.08 (r/pr, 3 weeks), 0.56/1.07 (9 weeks), 0.55/1.48 (18 weeks) . for hbo2 results were similar, but only significant for 9 and 18 weeks: 0.71/1.03 (3 weeks), 0.53/0.89 (9 weeks), 0.56/1.06 (18 weeks) . percentages water and lipids were not significantly different. whole breast measurements did not show statistically significant differences for hb and hbo2 between responders and poor responders. conclusion: using the scatter amplitude to determine the tumour location in dot volumes enables the measurement of hb and hbo2 such that these parameters differ significantly between responders and poor responders. this potentially allows effectiveness assessment of neo-adjuvant treatment in breast cancer patients already at 3 weeks. software validation of metastatic sarcoma lesion assessment using ct volumetric density tumour trajectory l.r. purpose: recent studies suggest that tumour assessment methods accounting for both tumour density and volume (sact, mass, choi) add value beyond assessing axial dimensions (recist) or selective regions of interest (roi). we have developed a comprehensive tumour response method termed total volume of viable tumour (tvvt) that assesses rate of change in hounsfield unit (hu) density over treatment course (tumour trajectory), thereby quantifying viable tumour burden as a volume of interest (voi). steeper trajectories may translate to earlier determination of response versus progression. we evaluated the efficacy of experimental volume/hu (tvvt) software and criteria within our picture archiving and communication system (carestream health, rochester, ny) to circumscribe, segment and characterise volumetric density distribution throughout all parts of measurable lesions on ct. comparison of response and tumour trajectory assessment between recist criteria and tvvt was performed in a test set of 10 patients with various sarcomas under radiologist supervision. histograms depicting range and absolute hu for whole tumor volumes were analysed on a subset of patients. results: preliminary investigation shows feasibility of semi-automatic segmentation to outline and quantify density distribution in whole tumour volumes. initial assessment of our set of metastatic lesions suggests that hypervascular sarcomas are a worthwhile study cohort. histogram shifts appear to correlate with qualitative visual estimates of tumor necrosis whereas recist diameters demonstrate little or no differences. conclusion: comprehensive tumour analysis using volumetric density algorithms such as tvvt should more accurately reflect tumour burden and trajectory over selective linear or roi measurements, leading to improved image-based tumour staging and response assessment. semi-automated quantification of whole tumour burden should decrease inter-observer measurement variability, enabling more convenient, reliable imaging results for multiple contiguous vascular metastases. 0.032). median (range) overall and disease-free survival was 34 (8-52) and 31 (3-56) months, respectively. medium texture-scale predicted overall (baseline-scan: k, p=0.0002, interim-scan: k, p=0.0008) and disease-free survival (baseline-scan: k, p=0.0031, interim-scan: k, p=0.046). suvmax predicted disease-free survival (baseline-scan: p=0.024). clinical-stage did not predict eots and survival. conclusion: evidence provided suggests that ctta offers an objective measurement of lymphoma severity on ct. the potential risk stratification and prognostic assessment implications may allow optimal selection of pet-ct candidates in lymphoma. author disclosures: b. ganeshan: shareholder; shareholder and director of texrad ltd, an imaging software company that is developing and commercialising the texture analysis software considered in this study. improvement in both sensitivity and specificity of readers with next generation of mammography cad v. nikitin, i. lossev, a. filatov, n. bagotskaya; longmont, co/us (vadim.nikitin@parascript.com) purpose: the purpose of the study was to compare radiologist performance for screening mammography with and without parascript® accudetect® computeraided detection (cad) software. each of 240 mammography cases (including 120 cancer cases and 120 normal cases) was reviewed by 12 radiologists without and with cad (accudetect, version 6.1). the mammography cases were obtained with ge senographe essential and philips microdose mammography l30 full-field digital mammography systems. each radiologist initially interpreted a case without cad noted the findings and assigned bi-rads category 0, 1 or 2 to the case. for each radiologist, the unassisted interpretation was "locked" before the radiologist turned on the cad marks. after turning on the cad marks, the radiologist could add, remove or adjust the findings noted on the unassisted interpretation as well as change the bi-rads score for the case. sensitivity and specificity calculations for unassisted and cad-assisted interpretations were based on the bi-rads category assignment dichotomization: (bi-rads = 0) versus (bi-rads = 1 or 2). results: average increase in sensitivity due to assistance of cad is 1.5%, which translates into 18.8% of those initially missed cancers that were recognised with cad assistance. average increase in specificity due to assistance of cad is 4.9%. both increases in sensitivity and specificity are statistically significant. the study demonstrates that both sensitivity and specificity of radiologists increased with assistance of accudetect cad system. assessing the contribution of hypoxia to r2* differences between cancerous and normal prostate tissue a. johnson, a. latifoltojar, v. hamy, h. fitzke, k. shmueli, s. punwani; london/ uk (aj372@cam.ac.uk) purpose: r2* bold mri is proposed as a potential tool for mapping tumour hypoxia in prostate cancer. however, r2* has a complex relationship with tissue oxygenation that remains unexplored in prostate cancer. r2* is the sum of r2 (primarily reflecting tissue structure) and r2' (highly sensitive to static magnetic field inhomogeneities, e.g. from deoxyhaemoglobin). whilst r2* changes are observed for prostate cancer, they may reflect tissue structure or oxygenation differences. this study aimed to clarify the nature of r2* change by quantifying and comparing r2* and its components (r2 and r2') for cancerous and normal prostate tissue. methods and materials: twenty patients underwent 1.5 t multi-parametric (mp) prostate mri (dwi, dce and t2-weighted), supplemented by dual echo-time t2* and t2 quantitation and followed by biopsy. tumour and healthy regions of interest (identified on mp-mri and confirmed by biopsy) were contoured in consensus by two experienced observers on matched t2-and t2*-weighted images. mean r2*, r2 and r2' were calculated and compared between cancerous and normal tissue using the student's t-test. results: r2* and r2 were significantly greater for cancer than normal tissue (r2*: 18 ± 5 s-1 [mean ± sd] vs. 13 ± 7 s-1 respectively, p = 0.0130; r2: 11 ± 2 s-1 vs. 6 ± 2 s-1 respectively, p < 0.0001). no significant difference was found in r2' (7 ± 4 s-1 vs. 7 ± 7 s-1 respectively, p = 0.5597). conclusion: prostate tumour r2* values predominantly reflect differences in r2 (tissue structure) and not r2' (tissue hypoxia). s194 c a d e f g b men for diagnosis, especially when receptors have to be studied in defining the origin of axillary lymph node metastases. purpose: aim of this study was to determine the diagnostic performance of gadofosveset-enhanced mri for axillary lymph node staging in breast cancer patients. methods and materials: ten women diagnosed with invasive breast cancer underwent both non-enhanced and gadofosveset-enhanced 3dt1-weighted mri. a radiologist, blinded for clinical data, evaluated all lymph nodes with regard to size, morphologic features and gadofosveset uptake. lymph nodes depicted on mri were matched with nodes removed during surgery. nodal status was investigated by a blinded pathologist. sensitivity, specificity, ppv, and npv values were calculated. results: a total of 152 lymph nodes were extracted during sentinel lymph node biopsy or axillary lymph node dissection of which 116 were matched with lymph nodes depicted on mri. histopathological examination resulted in 21 macro-metastases and 8 micro-metastases. with contrast-enhanced mri, 20 lymph nodes were rated as true positive, 83 as true-negative, 4 as false positive, and 9 as false negative. this resulted in an overall node-by-node sensitivity, specificity, ppv and npv of, respectively, 67% (95% ci 49-80), 95% (95% ci 89-98), 83% (95% ci 64-93) and 89% (95% ci 81-94). if ignoring micro-metastases, mri showed a sensitivity of 87% (95% ci 68-96) and a specificity of 96% (95% ci 89-98). calculated ppv and npv were 83% (95% ci 64-93) and 97% (95% ci 90-99), respectively. conclusion: this feasibility study concerning gadofosveset-enhanced mri of axillary lymph nodes showed promising initial results. these results warrant larger studies to confirm these promising results. to assess sensitivity and specificity of prone breast 18 fdg-pet-ct for detection of lymph node metastases and to compare it with 3 t ce-mri of the breast. methods and materials: 74 patients with breast cancer were included in this irb-approved prospective study. all patients underwent 3 t ce-mri and 18 fdg-pet-ct of the breast in the prone position. patients were injected with ca. 300 mbq 18 f-fdg. ct data were only used for attenuation correction. in mri lymph nodes were considered positive for malignancy if there was enlargement > 1 cm, thickened cortex, loss of fatty hilum, matted nodes or an irregular node contour. in pet-ct a lymph node was classified as positive when 18 fdg-uptake was greater than blood-pool activity. the evaluation of nodes was performed on a patient-bypatient basis. all nodes were histopathologically verified. results: 18 fdg-pet-ct achieved a sensitivity of 79% and a specificity of 98%. ppv was 0.95 (ci 0.76-0.99), and npv was 0.91 (ci 0.8-0.96). diagnostic accuracy was 0.92. ce-mri had a sensitivity of 74% and a specificity of 84%. ppv was 0.68 (ci 0.48-0.83) and npv was 0.88 (ci 0.76-0.94). diagnostic accuracy was 0.81. 24 nodes were positive and 50 nodes were negative for malignancy. the mean suvmax of lymph node metastases was 5.52 (range 1.14 -12.75). conclusion: 18 fdg-pet-ct improves identification of lymph node metastases as compared with 3 t ce-mri. in patients with lymph nodes classified as malignant by 18 fdg-pet-ct of the breast a sentinel lymph node biopsy can be omitted and surgeons can proceed immediately to alnd. purpose: to evaluate accuracy of us and us-guided-fnab for diagnosing axillary metastasis in breast carcinoma patients and to determine applicability of the bi-rads categorisation. we retrospectively reviewed data on 858 patients who underwent preoperative or prechemotherapy axillary us for axillary staging from january 2009 to december 2011. us-guided fnab was performed if lymph nodes showed any suspicious findings according to the bi-rads categorisation: even cortical thickening with preserved hilum, category 4a (c4a); even cortical thickening with compressed hilum or uneven cortical thickening with preserved hilum, c4b; uneven cortical thickening with compressed hilum, c4c; hypoechoic mass with loss of hilum, c5. us and fnab findings were compared using sentinel lymph node biopsy (slnb) and axillary lymph node dissection (alnd) data. results: of 858 patients, 212 (24.7%) showed suspicious nodes on us and underwent us-guided fnab. of these 212 patients, 91 (42.9%) showed positive, 112 (52.8%) showed negative, and 9 showed insufficient findings on fnab. of 858 patients, 767 patients either with normal axillary us (n = 646) or without positive findings on fnab (n = 121) underwent slnb. of these patients, 169 (22%) had metastatic lymph node. of 91 patients with positive fnab findings, 57 underwent neoadjuvant chemotherapy and 34 underwent alnd. the sensitivity, specificity, ppv and npv of us were 47.6%, 86%, 60.4% and 79.7%, respectively. the ppv of us was 26.3% in c4a, 67.4% in c4b, 46.4% in c4c, 93 .3% in c5. the sensitivity, specificity, ppv and npv of us-guided-fnab were 71.7%, 100%, 100% and 70.2%, respectively. conclusion: axillary us showed high specificity and npv. a categorisation similar to bi-rads could be applicable for assessing axillary metastasis in breast cancer patients. improving diagnostic yield in axillary lymphadenopathy sampling: core biopsy and vacuum-assisted core biopsy r. salvador, x. salvador, i. miranda, o. dominguez, l. romero; barcelona/es (rafasalvador@telefonica.net) purpose: to analyse and compare the tolerance of the method and the results obtained by sampling axillary lymph nodes with two different devices: large-needle (cb) and vacuum-assisted core biopsy (vacb), directed to patients where previous fine needle aspiration (fnab) has failed to obtain material, or those with different cancers to determine the origin of the metastasic node. methods and materials: 22 consecutive patients, suspicious or proved to have breast cancer were included, all of them with enlarged lymph nodes and signed the informed consent. the two groups were alternatively sampled by large needle (14g) core biopsy and vacuum-assisted needle (14g) biopsy to obtain 2 cylinders in each procedure. eleven patients in each group. the size of the sample (weight), as well as the time of the procedure from the injection of anaesthetic to the final collection of the 2 samples was recorded. discomfort, as well as the acceptance of the method was also recorded and scored in a 4-grade scale. results: the size of the samples obtained by vacuum-assisted method was bigger than that by core-needle (between twice and three times bigger). but the time for both procedures was similar (always 4-5 minutes). no differences were found in pain or any discomfort and tolerance of the method. conclusion: vacuum-assisted axillary lymph node biopsy is a procedure to obtain samples at least as safely as with core-needle biopsy and deserves bigger speci-s195 a c d e f g b thursday methods and materials: 567 breast cancer patients between 2009 and 2011 underwent preoperative axus. suspicious nodes as per protocol were biopsied, negative axillae proceeded to sentinel lymph node biopsy (slnb). patients were stratified based on number of abnormal nodes identified on axus (1, 2, > 2 nodes) and the number on final histology was noted. sensitivity, specificity, positive predictive and negative predictive values for axus-fnac/core biopsy were calculated. results: 266 (46.9%) patients had positive axillary nodes on final histology with 169 detected by axus-fnac (sensitivity 86.2%, specificity 100%, ppv 100%, npv 68.6%). patients with nodal metastases identified by axus-fnac had a mean nodal burden of 7.1 nodes on histology (sem=0.6, 95% ci=5.9-8.3; 1 node identified on axus=4.8 nodes on final histology, 2 nodes on axus=9.9 nodes, > 2 nodes=9.6 nodes) with correlation between axus and histology node numbers (r=0.39, 95% ci=0.24-0.51, p-value< 0.0001). axus-fnac detected 63.5% of node positive patients. mean nodal burden of patients diagnosed on slnb with negative axus or fnac was 2.4 nodes. the z011 trial questioned the role of axus in preoperative axillary staging of breast cancer in cases with ²2 positive sln. in this study, a single fnac positive node correlated with 4.8 nodes on final histology suggesting that axus continues to be essential in guiding appropriate management of the axilla in breast cancer. would have undergone mastectomy due to ci, while mri determined 18 additional mastectomies, increasing mastectomy rate from 38% to 52% (p < 0.021). in the ci group, 9 patients had multifocal, multicentric, synchronous or bilateral cancers, 9 (100%) at mammography and 8 (89%) at ultrasound; 2 mastectomies were due to false positives at both conventional tests (2/124, 1.6%). in the ci and mri group, 30 patients had multifocal, multicentric, or synchronous bilateral cancers, 5 (17%) at mammography, 15 (50%) at ultrasound, and 29 (97%) at mri (3 only mri-detected synchronous bilateral cancers) (p < 0.002); 2 mastectomies were due to mri false positives (rate 2/122, 1.6%, not significantly different from ci group, p=0.987). conclusion: mri was more sensitive than ci for multifocal, multicentric, or synchronous bilateral cancers. the additional mastectomy rate due to mri was 14%. adding mri, the percentage of young patients conservatively treated remained near to 50%. by using solely ci or using ci and mri, the inappropriate mastectomy rate was equal or lower than 2%. imaging features in mammography and breast ultrasound are related to her-2 receptor over-expression of primary invasive breast cancer a. adams 1 , k.g.a. gilhuijs 1 , k.e. pengel 2 , c.e. loo 2 , w.p.t.m. mali 1 , s.g. elias 1 ; 1 utrecht/nl, 2 amsterdam/nl (a.adams@umcutrecht.nl) to investigate what mammography and ultrasound imaging features are related to over-expression of the her-2 receptor in invasive breast cancer. these features could give insight in molecular basis of imaging phenotype, facilitate prebiopsy patient recruitment for early-phase her-2 targeting molecular imaging trials, and ultimately aid in predicting therapy response and prognosis. methods and materials: mammography and breast ultrasound imaging features of 598 early invasive breast cancers were scored according to the 4 th edition of the bi-rads lexicon, her-2 status was determined on surgical specimens. relevant imaging features to predict her-2 over-expression were first identified by conducting a systematic review and meta analysis, and then applied in multivariable logistic regression models. results: her-2 over-expression was found in 80 cancers (13%). on multivariable analysis, the presence of microcalcifications (or 3.5, 95% ci 2.1-5.8) on mammography, and posterior mass attenuation (or 0.5, 95% ci 0.3-0.9) on ultrasound were strong, independent predictors. less strong predictors were breast density category 3/4 (or 0.9, 95% ci 0.5-1.6) and mass presence (or 0.8, 95% ci 0.4-1.4) on mammography, and circumscribed mass margin (or 0.8, 95% ci 0.3-2.1) imaging of axillary lymph nodes in breast cancer patients: how do enhancement kinetics of contrast-enhanced lymph nodes apparent on dynamic mr-mammography correlate with standardised uptake value of 18 f-fdg pet/ct? j. krammer, c.g. kaiser, a. schnitzer, s.o. schönberg, k. wasser; mannheim/ de (julia.krammer@umm.de) purpose: focusing on contrast-enhanced lymph nodes (ln) apparent on dynamic mr-mammography (dmrm) we intended to answer the following questions: 1) is there a correlation between the maximum standardised uptake value (suvmax) of 18 f-fdg pet/ct and maximum signal-intensity increase as well as type of signal-intensity curve (1-3) on dmrm? 2) do contrast-enhanced ln negative on 18 f-fdg pet/ct have a significantly lesser signal-intensity increase and/or lower curve grading on dmrm compared to 18 f-fdg pet/ct positive ln? methods and materials: 25 breast cancer patients who underwent both 18 f-fdg pet/ct and dmrm were analysed. the mean study interval between the examinations was 7 days. the signal-intensity increase and curve type of axillary ln ³ 0.5 cm in short-axis and with predominant contrast enhancement on dmrm were analysed and correlated with the suvmax on 18 f-fdg pet/ct. results: 30 ln in 21 patients were 18 f-fdg pet/ct positive. there was no correlation between the maximum signal-intensity increase and suvmax of these ln (r=0.04, p=0.05). 14 ln in 9 patients did not show an appropriate correlate on 18 f-fdg pet/ct (not visible or suvmax²blood pool). these ln did not reveal a significantly lower curve grading or lesser signal-intensity increase compared to ln positive on 18 f-fdg pet/ct. there is no association between the uptake of 18 f-fdg and the vascularisation of axillary ln on contrast-enhanced dmrm as signal-intensity increase and curve type do not correlate with suvmax. unspecific contrast-enhanced ln on dmrm negative on 18 f-fdg pet/ct can frequently show enhancement kinetics equivalent to those rated positive on 18 f-fdg pet/ct. ultrasound elastography in the diagnostic assessment of axillary lymph nodes in women presenting to a breast imaging centre l. sim, l. leong; singapore/sg (gdrssj@sgh.com.sg) purpose: to evaluate the performance of elastography in distinguishing benign and metastatic axillary lymph nodes. methods and materials: 67 women with 72 sonographically visible axillary lymph nodes undergoing biopsy at our breast imaging centre were evaluated independently with conventional ultrasound, elastography and combined ultrasound and elastography (ceus). the elastogram was classified as benign or malignant, based on the strain pattern, the length and area ratios of the lesion seen on elastography versus ultrasound. validation of radiological diagnosis was by histopathology. the sensitivity, specificity, ppv, npv and accuracy of each test were compared individually and with ceus. to obtain a parameter for diagnostic performance, roc curves were plotted. results: of the 72 axillary lymph nodes biopsied, 33 had metastases and 39 were benign. the sensitivity, specificity and accuracy of conventional ultrasound were 93.9%, 30.8% and 59.7%, respectively. the sensitivity, specificity and accuracy of elastography were 93.9%, 97.4% and 95.8%, respectively, and that of combined ultrasound and elastography were 97%, 92.3% and 94.4%, respectively. the sensitivities of all 3 tests were similar but the specificity and accuracy obtained by elastography and ceus were significantly better than conventional ultrasound (p < 0.0005). elastography correctly diagnosed 96% of histologically benign lymph nodes which were deemed malignant on ultrasound. conclusion: the use of elastography alone or combined with ultrasound has a higher specificity and accuracy than conventional ultrasound in evaluating axillary lymph nodes. given the high specificity of elastography, biopsy could have been avoided in 96% of cases classified as malignant on ultrasound but benign on elastography. the z011 respiratory syncytial virus-related encephalitis: brain mr study with diffusion imaging a. pak, s. suh, g. son, y. lee, h. seo, k. kim, b. eun, n. lee, h. seol; seoul/kr (suppy@korea.ac.kr) purpose: respiratory syncytial virus (rsv) is a common pathogen of acute respiratory infection causing significant morbidity and mortality in childhood. among the major complications, encephalitis has been sporadically reported. we describe the incidence, clinical and mri imaging findings of rsv-related encephalitis in this report. we retrospectively reviewed the medical records and imaging findings of patients with rsv-positive enzyme assay, admitted at the paediatric department in three urban tertiary-care hospitals of our medical centre for 7 years. there were 3856 cases with a diagnosis of rsv-bronchiolitis. among them, 28 (28/3856, 0.73%) had taken brain mri due to neurologic symptoms. 8 of 28 (28.6%) showed positive imaging findings. 5 of 8 positive mr imaging cases revealed non-rsv related pathology such as sdh, diffuse brain atrophy due to status epilepticus, periventricular leukomalacia, pre-existed ventriculomegaly, hypoxic brain injury. results: there were three rsv-related encephalitis. the incidence of this entity is 0.08% (3/3856) for rsv positive enzyme assay, 10.7% (3/28) for brain mri examination, and 37.5% (3/8) for abnormal mri findings. the imaging findings of rsv-related encephalitis are as following: rhombenmesencephalitis pattern, rhombenmesencephalitis with acute disseminated encephalitis pattern, and limbic encephalitis pattern. conclusion: encephalitis rarely occurs with rsv bronchiolitis. however, when brain mr is needed in suspicion of neurologic involvement, rsv encephalitis is not uncommon among abnormal mr cases and mimics other viral and limbic encephalitis on imaging study. physicians should be aware of this entity for proper diagnosis and neurologic care of rsv-positive patients. cortical-juxtacortical lesions in clinically isolated syndromes: distribution and diagnostic value j.p. salazar, c. auger, d. pareto, r. mitjana, m. tintore, j. corral; barcelona/es purpose: to evaluate presence and spatial distribution of cortical-juxtacortical lesions in patients with a clinical isolated syndrome (cis) by using mri-based lesion probability maps and to determine its impact to demonstrate lesion dissemination in space (dis) according to the 2010 mcdonald criteria for multiple sclerosis (ms). methods and materials: 65 cis patients aged between 20 and 50 years old (mean 35.9 years) who underwent brain and spinal cord 3 t mri within the first five months after symptoms onset. the following sequences were obtained: 1) pd and t2-weighted; 2) t2-fast flair; 3) un-enhanced and contrast-enhanced t1-weigthed; and 4) 3d double inversion-recovery. cortical-juxtacortical lesions in each patient were identified, manually outlined and segmented into a binarized mask. a cortical-juxtacortical mri-based lesion probability map was obtained. the 2010 mcdonald criteria for dis were assessed in each patient. results: cortical-juxtacortical lesions were identified in 24 patients (60%). frontal lobe was the most affected area with an incidence of 37% of the lesions. temporal and parietal lobes had also a significant incidence (20% and 23% purpose: the aim of this study is to explore whether cns hemodynamic disturbances, detected in patients with clinically isolated syndrome (cis), correlate with executive function. methods and materials: thirty cis patients and forty-three healthy subjects matched for age, gender, education level, fsiq, and place of residence were administered computerized tests of visuomotor learning and set-shifting ability. regional cerebral blood volume (cbv), cerebral blood flow (cbf), and mean transit time (mtt) values were estimated using the dynamic susceptibility contrast-and irregular mass shape (or 1.3, 95% ci 0.8-2.1) on ultrasound. the area under the roc curve was 0.69 (95% ci 0.63-0.75, p < 0.001), and 0.67 after adjustment for over-optimism. post-test probabilities of her-2 over-expression were 23-37% for cancers with calcifications, without posterior mass attenuation, and 5-10% for cancers without calcifications, with posterior mass attenuation. conclusion: microcalcifications on mammography, and posterior acoustic attenuation of masses on ultrasound were predictors of her-2/neu over-expression, indicating that imaging characteristics reflect molecular expression patterns in breast cancer. purpose: to study regional changes in brain metabolites during early hiv infection compared with later stage hiv infection and hiv-seronegative controls. enhanced t2*-weighted mri (dsc-mri) technique in 20 regions of interest in normal appearing white matter (nawm) and normal deep grey matter (ndgm) structures bilaterally, that serve as integral components of brain circuits responsible for visuomotor learning and executive functions. results: cis patients showed significantly elevated reaction time (rt) on both tasks, while their cbv values were globally increased. significant, positive correlation coefficients were found between error rates on the inhibition condition of the visuomotor learning task and cbv values in both thalami and occipital, and periventricular nawm, bilaterally. on the set shifting condition of the respective task significant positive associations were found between cbv values in the semioval centre and periventricular nawm bilaterally and error rates, between cbf values in both thalami and error rates, and between cbf values in the left parietal nawm and right caudate and rt. conclusion: impaired executive function in cis patients, including inhibition and set shifting abilities, correlated positively with elevated regional cbv values thought to reflect active widespread brain inflammatory processes. the "central vein sign": is there a place for susceptibility-weighted imaging in possible multiple sclerosis? t. kau, m. taschwer, m. schönfelder, j.r. weber, k.a. hausegger; klagenfurt/ at (t.kau@gmx.at) purpose: susceptibility-weighted imaging (swi) may have the potential to depict the perivenous extent of white matter lesions (wmls) in multiple sclerosis (ms). we aimed to assess the discriminatory value of the "central vein sign" (cvs). in a lesion-based 3 t mri study, 28 wmls in 14 patients were prospectively included applying the following criteria: 1) at least one circumscribed lesion > 5 mm, 2) not more than eight non-confluent lesions > 3 mm. flair images served as gold standard for the identification of wmls which were classified as periventricular, subcortical, or infratentorial. only defined wmls with a maximum diameter of > 5 mm were correlated with their swi equivalent for cvs evaluation. results: five patients fulfilled the revised mcdonald criteria for ms and nine patients were given an alternative diagnosis with non-ms-wmls most probably representing focal gliosis. a total of 28 lesions > 5 mm (19 ms-wmls and 9 non-ms-wmls) were detected. consensus reading found a central vein in 16 out of 19 ms-wmls (84%) and in one out of nine non-wmls (11%), respectively. the cvs proved to be a highly significant discriminator (p < 0.001) between ms-wmls and non-ms-wmls with a sensitivity, specificity, positive and negative predictive values, and accuracy of 84%, 89%, 94%, 73%, and 86%, respectively. the frequency of cvs positive lesions was highest in the periventricular zone (7/10), even more markedly in ms-wmls alone (6/7). inter-rater agreement was good (kappa=0.77). conclusion: even though the cvs is not exclusively found in ms-wmls, swi may be a useful adjunct in patients with possible ms. single-and multi-voxel proton spectroscopy in patients with pyogenic brain abscess p. the study was primarily designed to find the optimal dose range of br14 to detect malignant focal liver lesions. secondary objectives were the evaluation of the safety profile and comparison with contrast-enhanced mri (ce mri). methods and materials: 25 patients (9f, 16m, mean age: 66y) with known hcc or liver metastases were examined in three centres during a time period of three months. each patient underwent a baseline and at least three contrast-enhanced us (ceus) with ascending dose levels (0.25 ml, 1.0 ml, 4.0 ml) of br14. ce mri was done 4 weeks prior or post-study examination. lesions were recorded in on a liver map, with respect to localisation, size and suggested lesion type. examination quality was documented and safety parameters were assessed. results: the number of lesions detected with br14 ceus increased with dose, while the number of missed lesions and the lesion size decreased. despite the increasing contrast enhancement no other image quality parameter showed a substantial difference. no significant changes were found for the analysed safety parameters and no serious adverse events were reported. conclusion: we finally conclude that the recommended dose level of br14 is between 1.0 ml and 4.0 ml for which the lesion detection was comparable to the ce mri. in addition, we found a higher number of especially small lesions with higher doses of br14 which might be due to a higher sensitivity of ceus for the detection of liver metastases. however, this is an interesting and debatable finding. histopathological characteristics of the primary hcc and recurrence were obtained by a review of the pathologic reports. the association between the variations in histopathological and imaging characteristics of primary and recurrent hcc was estimated using linear regression analysis. the initial recurrence was extrahepatic in 14 (58.3%, lung, bone, lymph nodes, brain, spleen, adrenal), intrahepatic in 7 (29.2%) and both intrahepatic and extrahepatic (peritoneum, lung, bone, lymph nodes) in 3 (12.5%) patients. of 14 patients with initial or late intrahepatic recurrence, 2 (14.3%) showed a variation in imaging characteristics between the primary hcc (hypervascular) and the recurrence (hypovascular), 1 (7.1%) showed a variation in histopathological charduring 2005-2011 588 patients with 1-3 hccs were treated with radiofrequency ablation (alone or combined with ethanol injection) . patients had complete ablated tumours at 1 mo. ct was followed-up serially, using alternated ceus (one sulphur hexafluoride-based microbubbles injection per lobe) and ct every 3 months. the following patterns of recurrence were considered: a, enhancing tissue within the lesion; b, enhancing tissue adherent to the lesion; c, enhancing tissue within the same liver segment of the treated nodule; d, enhancing tissue within a different segment (progression heidelberg/de (gregor.pahn@med.uni-heidelberg.de) purpose: quantitative assessment of image quality and radiation exposure reduction potential of a next-generation solid-state mdct detector with fully integrated readout electronics in comparison with its predecessor. methods and materials: using standard ct image quality phantoms and an automated quantitative image quality analysis software developed in-house, image quality and radiation exposure (re) of an mdct system (somatom definition flash, siemens) either equipped with ufc™ or new "stellar" detectors has been assessed for different combinations of acquisition and reconstruction parameters. subsequently, measurements and analysis were repeated for "stellar" detectors without altering parameters apart from noise-weighted reduction of tube currenttime product resulting in image noise levels equal to those achieved when using their predecessor. results: image noise of both detectors was comparable for small absorption crosssections (øwater=24 cm) while being 18-35% lower for large ones (øwater=40 cm) when using "stellar" detectors. ct number stability and uniformity declined with increasing subject cross-section, particularly at 80 kvp, though not as much for "stellar" detectors. when noise of "stellar" acquisitions was increased to ufc™ levels, re reduction of 28-54% was achieved. for the "stellar" detector cnr was slightly higher (same re) or slightly lower (reduced re), while spatial resolution was always equal for both detectors (up to 20 lp/cm at mtf10%). conclusion: overall image quality improves when a next-generation mdct detector is employed instead of using its predecessor. for acquisition settings intrinsically acteristics (from moderate to poor differentiation), but no association was found between imaging and histopathological variations. the most common pattern of recurrence was extrahepatic location, followed by intrahepatic recurrence and both intrahepatic and extrahepatic diffusion. variations in dynamic-imaging characteristics of intrahepatic recurrence were not associated with variations in histopathological characteristics. films strips were scanned before and after irradiation with the epson perfection v500 photo scanner in reflective mode. the reference dosimetry system was calibrated in terms of air kerma in air. the measured reflectance change is converted into air kerma using a calibration curve. air kerma was converted into absorbed dose using the appropriate ratio of mass-energy absorption coefficients water-to-air for a given beam quality, defined by half-value layer following the aapm tg-61 protocol. results: dose values for each of the five ctdi phantom film positions were obtained by averaging dose profiles from each film piece over the length of 10 cm, and were used to calculate weighted ctdivol. the average difference for six scanners between calculated and listed ctdivol was 3.9% with a maximum observed difference of 6.9%. conclusion: in contrast to ionisation chamber measurement, the proposed method requires only a single exposure, does not need stem effect correction, and provides an acceptable accuracy in comparison to ct scanner listed ctdi values. measured dose profiles allow for measurements of dlp and peak doses at the same time. associated with high image noise the new detector exhibits much lower noise levels, offering great potential for radiation exposure reduction without adversely affecting overall image quality. munich/de (zsuzsanna.deak@med.uni-muenchen.de) purpose: to evaluate the dose reduction potential of hir and ir in comparison with fbp. methods and materials: an anthropomorphic cardiac phantom (qrm corp., germany) was scanned using a 64-row mdct scanner (ct 750hd; ge-healthcare, usa). the phantom's calcification insert was replaced with a model simulating a stented aortic aneurysm with endoleak and intraluminal thrombus. images were obtained at tube voltages of 120 kv, 100 kv and 80 kv using automated tube current modulation with incrementally increasing noise indices (ni=16, 25, 34, 43, 52, 61, 70) adjusted to a primary reconstruction slice thickness of 2.5 mm. after acquisition, images of 0.625 mm slice thickness were secondarily re-reconstructed with fbp, hir (asir® with 50% blending, ge-healthcare) and ir (veo®, ge-healthcare). twenty-one radiologists blinded to image reconstruction methods independently analysed the detectability of simulated vascular pathologies (endoleaks < 1 cm² and intraluminal thrombus < 3 mm). contrast-to-noise ratio was measured for the stented aorta. a two-by-two purpose: to compare two low-dose scanning protocols, and to estimate effects on the signal, noise, effective radiation dose (ed), quality of acquired data. methods and materials: 90 patients were divided into three groups. the scanning protocol was 120 kvp 200 mas in first group, 80 kvp 200 mas in second group, and 120 kv 50 mas in third group, special reconstruction algorithms have not been used. for quantitative and qualitative evaluation we used visual scores (1-3), mean arterial attenuation, noise, contrast-to-noise ratio (cnr) in three arterial segments and ed. results: the bmi ranged from 21 to 38 kg/m2 and were not significantly different between groups (p=0.07, 0.614, 0.297, respectively). the mean intraarterial attenuation in 1, 2, 3 groups was 315±6 hu, 448±76 hu, 334±33 hu, respectively, but significantly higher in second group (p=0.0003). noise in second group (64±20 hu) was significantly higher than that in third group (45±14 hu, p=0.0002), and first group (29±8.5 hu, p=0.0002). the cnr in second (6.64±2.3) and third (6.36±2.1) groups was significantly lower than that in first group (11.7, p=0.0001). image quality was comparable between three techniques, except aorto-iliac segment in second group. effective dose was 27.1±5.9mzv, 8.1±1.8mzv and 6.4±1.02mzv, respectively, differences were significant (p=0.0001). conclusion: average radiation dose reduction up to 77% was achieved using "80 kv" and "50 mas" protocol providing sufficient image quality. application of the 80 kv protocol in people with bmi> 30 is limited, especially in evaluation of aorto-iliac segment due to higher noise and attenuation levels. while at 50 mas protocol such limitation is not observed. this allows to recommend it as the preferred protocol for low-dose runoff cta in case of special reconstruction algorithms. purpose: to assess the quality of ct images reconstructed with sinogram affirmed iterative reconstructions (safire) and comparing their performances with iterative reconstructions in image space (iris) and standard filtered back projection (fbp) algorithms on a siemens somatom definition flash. results were used to optimise a dual energy (de) abdominal protocol. methods and materials: fbp, iris and the 5 strength levels in safire (s1-s5) reconstructions were characterised in contrast, noise and spatial resolution for medium-smooth filters using a tungsten wire in air, water and catphan phantoms. standard deviation (sd), contrast-to-noise ratios (cnr), noise power spectra (nps), modulation transfer function (mtf), and the non-prewhitening matched filter signal-to-noise ratio (snrnpw), a quasi-ideal observer metric in the frequency domain assumed to be the most reliable image quality reference, were calculated for all kernels and used for dose saving evaluations. results: the highest cnr in de protocol resulted with a composition factor of 0.6. compared to fbp, the average sd reductions were 51±2% with safire s5 and 30±2% with iris kernels. a shift towards low frequencies in the nps was found for all iterative filters, giving to images a different texture. differences between mtf values were within 5% in all fbp-iterative coupled filter comparisons. the optimal kernels, from snrnpw analysis of abdominal protocol, resulted i31-s5 for safire and i-44 for iris with a potential dose reduction of 42% and 30%, respectively. conclusion: iterative reconstructions and de acquisition strongly improve image quality reducing the noise and improving the contrast without affecting the spatial resolution. the impact of tube voltage, scan direction and beam collimation on the performance of automatic tube current modulation systems in paediatric and adult ct n. buls 1 , j. schoenaers 2 , g. van gompel 1 , k. nieboer 1 , j. purpose: to reduce the radiation dose exposure and contrast medium volume using low-kv ct angiography protocol (100 kv; 40 ml) in the evaluation of abdominal aorta, maintaining high diagnostic performance. a total of 60 patients with abdominal vascular disease were prospectively enrolled. all patients underwent 256mdct scan examination of abdominal aorta (brilliance ict, philips). 30 patients were scanned using lowdose radiation protocol (100 kv; automated tube current modulation) and ultralow-contrast volume (40 ml; 4 ml/s; 350 mgi/ml) and a control group of 30 patients underwent standard ct-angiography protocol (120 kv; automated tube current modulation) and standard contrast volume (120 ml). density measurements were performed on abdominal aorta, renal arteries and common iliac arteries. the radiation dose exposure (dose length product, dlp), the intravessels density and the signal-to-noise ratio (snr) were calculated, compared and statistically analysed. results: all exams were considered diagnostic, allowing the correct visualisation of main aortic branch and vascular wall. higher density measurements were obtained in low-kv protocol: mean attenuation value of abdominal aorta 343 hu, renal arteries 331 hu and common iliac arteries; in comparison to control group: mean value of abdominal aorta 319 hu, renal arteries 294 hu and common iliac arteries 323 hu. a reduction of 65% (p < 0.05) of radiation dose exposure in low-kv protocol (335 dlp; 5.8 ctdivol) was obtained among control group (973 dlp; 19.4 ctdivol). conclusion: low kv protocol and ultra-low contrast medium volume (40 ml) reduce the radiation exposure (over 65%) and the renal damage, allowing a relevant reduction of contrast material volume, enabling to evaluate more easily young patients or patients with renal failure. an international multi-centre comparison of the non-contrast mr angiography technique time-spatial labelling inversion pulse (time-slip) against contrast-enhanced ct angiography for assessing renal artery stenosis: the renal artery contrast-free trial ( (t.vogl@em.uni-frankfurt.de) purpose: to compare contrast-enhanced magnetic resonance angiography (mra) with conventional digital subtraction angiography (dsa) for detecting stenoses and planning of therapy in patients with peripheral artery occlusion disease (paod). in this retrospective study, 71 patients (20 women/51 men; mean: 68 years) with established paod underwent both imaging modalities in a maximum interval of 40 days. dsa was the standard of reference. the pelvic and leg arteries were divided into 31 anatomic segments, which were graded on a scale from 1 to 4 (1=no stenosis, 2=stenoses < 70%, 3=stenoses ³70%, 4=occlusion). the pelvic and leg vessel systems were categorised with the tasc ii-score into five grades (none, tasc-a, tasc-b, tasc-c and tasc-d) for detecting whether the therapeutic consequences would be the same for both imaging modalities. iodine load reduction in ct aorta angiography with gemstone spectral imaging: comparison with standard ct aorta angiography x. luo, j. wu, j. sun, m. chen; yangzhou/ cn (luoxianfu@gmail.com) purpose: to compare quantitative and subjective image quality between computed tomographic aorta angiography (ctaa) with a gemstone spectral imaging (gsi) technique with reduced iodine load and standard ctaa. methods and materials: 86 patients underwent ct scanning on hdct (discovery ct750 hd, ge healthcare). all cases were randomised into two groups: standard ctaa (100-120 kvp) with 500 mg/kg per body weight of iodine (n=46) and gsi scanning ctaa (image reconstruction at 50 kev) with the same injection volume as in the standard protocol but composed of contrast medium and saline in a 1:1.5 fashion (n=40). signal intensity and noise of aorta were measured; signal-to-noise ratio (snr) and contrast-to-noise ratio (cnr) were calculated. a five-point scale was used to subjectively evaluate vascular enhancement and image noise. results: compared with standard ctaa, gsi ctaa demonstrated higher signal intensity in all aorta arteries (all p < 0.05), inferior noise only in segmental arteries (p < 0.05), higher snr and cnr (both p < 0.05), and compatible effective dose (p > 0.05). the five-point score was higher in the standard ctaa protocol (p < 0.05). the inter-reader agreement regarding the dichotomized diagnostic versus nondiagnostic scale was similar (p > 0.05) between two groups. conclusion: gsi ctaa with image reconstruction at 50 kev allows a significant reduction of 60% iodine load while improving intravascular signal intensity, maintaining snr and with comparable radiation dose. >/=70% and cta </=50%). on average measured stenotic severity (n=27 arteries) was similar between nc-mra (63 ± 17%) and cta (60 ± 17%) (p=0.41). purpose: we aim to assess the expansile differences between the ishimaru zones of the aortic arch throughout the cardiac cycle. this study further focuses on the implications of this variation in diameters of the aorta for sizing endovascular procedures. cardiac gated ct examinations of atherosclerotic ascending, arch and descending aorta, performed for a number of reasons, were evaluated. presence of calcified and non calcified plaques in the arch was used as markers for atherosclerosis. patients with acute aortic syndromes, connective tissue syndromes and aortitis were excluded. the best systolic and diastolic images were interrogated and true transverse slices were obtained using a 3d workstation. differences between the systolic and diastolic images for the short axis, long axis and an average of the two were calculated. results: a total of 135 zones were evaluated in 27 patients. the average variation between diastole and systole diameters was 1. zone 0 -0.17 mm; 2. zone 1 -0.0 mm; 3. zone 2 -0.38 mm; 5. zone 4 -0.58 mm. conclusion: while the average variations were well under 1 mm for all zones the maximum was noted in zone 4 (0.58) and the least in zone 1 (0.0). the study shows limited variations in atherosclerotic aortas supporting the theory of reduced expansibility in them secondary to the disease process. this in turn suggest that we need not undertake gated examinations of the aorta prior to endovascular procedures thus avoiding the hazards of radiation. purpose: to compare low-pitch retrospectively ecg-gated (gated) and high-pitch non-ecg-triggered (non-gated) multidetector ct (mdct) protocols in terms of measurements of the aortic root and the aortic valve and consequently prosthesis sizing in transcatheter aortic valve implantation (tavi). methods and materials: 46 consecutive tavi candidates underwent mdct examination with retrospectively gated helical scanning of the aortic valve region followed by a non-gated whole aorta ct angiography. eleven anatomical structures within the aortic root and the aortic valve which are deemed to be crucial for tavi planning were measured throughout the cardiac cycle and compared with measurements from non-ecg-gated scans. differences in annular dimensions measured in both types of scans were tested in terms of relevance for prosthesis sizing. results: substantial differences in measurements were found for the aortic root at the right coronary ostium level (p < 0.05), the sinotubular junction and the aortic sinuses diameter (p < 0.001). the maximal annular dimensions occur in early systole. measurements of diameters in high-pitch scans agree only to diastolic images. however, measurements of annular perimeter in non-ecg-triggered highpitch scans agree to systolic images. the highest agreement in prosthesis sizing according to measures from both ct protocols in systole and diastole was noted if annular perimeter was followed. conclusion: even though the results of annular perimeter are comparable at first glance, only a dedicated gated cta protocol offers the full potential to perform all measurements at the optimal time point and should be recommended for prosthesis sizing in tavi. purpose: to examine possible relationships between severity of aortic valve calcification, the degree of aortic-valve-regurgitation (avr) and occurrence of mace events after transcatheter-aortic-valve-implantation (tavi). methods and materials: 58 patients (25 men, 83.3±6.1 years) with symptomatic aortic stenosis were included in this study. 15 patients received a corevalve® aortic valve prosthesis and in 43 patients an edwards sapien™ prosthesis was implanted. prior to tavi, all patients underwent a thoracic-pelvine ecg-gated-ctangiography for therapy planning. the aortic-valve calcification score (as) and aortic-valve calcium volume (av) was measured and compared to post-procedural avr measured by echocardiography and to the 30-day incidence of major-adversecardiac-events (mace). the overall incidence of mace after tavi was 29.3%. there was no significant correlation between the amount of as and av and mace after tavi (both p> 0.05). post-interventional avr did not correlate with pre-procedural measured as and av (both p> 0.05). patients with post-procedural avr showed no significant differences in as and av than patients without evidence of avr after tavi ( thursday target noise sd12.5 and fbp reconstruction) and referred to follow-up chest ct within two months were enrolled. aec (sd25) integrated with aidr3d was used in follow-up chest ct protocol (group b), the raw data of which were reconstructed again with fbp (group c). the max/min mas of each subject and their correlation with bmi were investigated to validate whether system could personalise tailor tube current. the chest images were divided into upper, middle and lower parts which were evaluated separately by two radiologists with 3-point scale (3-good, 2-acceptable, 1-poor). image noise was measured in these parts with 8-mm diameter roi placed on specific anatomic structures. effective dose (ed) was compared. . mpr and 3d reconstruction images were created, and reviewed by two experienced radiologists with blinded, who measured the tracheal lumen to determine the presence of central airways narrowing. the 3d reconstruction of confidence was graded on a 4-point scale from 0 (no confidence) to 3 (highest of confidence. the mpr noise was assessed by measuring the sd of the pre-sternal soft tissue. the dlp was used to compare radiation doses. results: the mpr image noise was ranked higher for ct images of 80 kv protocol than 100 kv protocol. there was no significant difference in confidence between 80kv and 100 kv protocol (p > 0.05). excessive central airway collapse (reduction > 30%) was seen in 3 patients with tracheomalacia and remaining 13 subjects had centre airway stenosis. dlp of 80kv protocol was 244.9 mgy.cm and 100kv protocol was 539.8 mgy.cm. the 640-slice dynamic volume ct is a promising method for diagnosing central airway narrowing. the 80kv protocol performs as well as the 100kv protocol for the 4d dynamic imaging in small bmi objects. purpose: the purpose of this study was to examine the influence of different arm positioning on automatic tube current modulation of multi-slice ct on chest image quality and radiation dosage. methods and materials: sixty patients underwent scanning by using care dose 4d thorax ct protocol in which both arms were raised above the shoulder region using standard-position (group 1) and postural manoeuver (group 2), respectively. objective and subjective image quality was assessed. individual recorded the ctdiv values and the tube current-time product per exposed section. effective radiation dose was calculated. results: compared with the image quality in the standard-position group, the image quality in the postural manoeuver group was decreased on subjective image quality but within acceptable diagnostic limits. the average effective dose in the postural manoeuver group was 3.37 msv; the dose in the standard-position was 17% lower than this. conclusion: both arms were raised above the shoulder region scanning using care dose 4d thorax ct protocol can reduce the overall dosage to patients and the image quality without adverse influences, and may be more feasible in clinical practice. the effectiveness of lead apron for radiation protection in ct n. weber, p. monnin, c. elandoy, s. ding; lausanne/ch (nicolas.weber@hesav.ch) purpose: to determine the effectiveness of lead shielding for radiation protection in ct. methods and materials: three 32-cm diameter ctdi (pmma) phantoms, of 15 cm long, placed side by side, were scanned over a length of 28 cm with a ge 64 ct scanner. absorbed dose was estimated with thermoluminescent dosimeters positioned in the middle, and at two levels in periphery of the phantom (1 cm inside): top and bottom. additionally, the dose was measured on the surface of the phantom ("skin dose"). tld were placed over a length of 28.5 cm, with 14.5 cm in the scatter field. three acquisitions were performed: 1) without lead apron, 2) with a lead apron at 0 cm from the edge of the primary field and 3) with a lead apron at 2.5 cm. results: in scattered radiation, no significant difference of dose was found between without shielding and with the apron at 0 cm, in the middle of the phantom. however, in the presence of the apron the dose is lowered by as much as 12% at the bottom of the phantom, whereas the skin dose is increased by 10% (tunnel effect). this indicates that the scanner a retrospective study was conducted in two radiology departments from public hospitals using a sample of 535 patients under 15 years submitted to head ct examinations between 2008 and 2011, performed with different equipments: somatom emotion 2 (n=100), somatom emotion 6 (n=250) and somatom emotion 16 (n=185). the influence of patient age and cephalic perimeter were considered. multiple data analysis was used in order to assess radiation dose levels and the concordance of these with diagnostic reference levels. the results were obtained for four different paediatric groups, divided according to patient age: less than 1 year; 1 to 5 years; 6 to 10 years and 11 to 15 years. the mean values obtained of dose length-product from some groups are lower than the diagnostic reference levels (720 mgy.cm from 6 to 10 years and 807 mgy.cm from 11 to 15 years). however, until 5 years the values are higher than the recommendations (569 mgy.cm for less than 1 year and 590 mgy.cm from 1 to 5 years). conclusion: this work identifies possible gaps and all possible methods should be applied to reduce the radiation dose provided without deteriorating image quality. a set of recommendations are needed to optimise the radiation dose since the children have a superior radiosensitivity. dose values in eye lens in paediatric brain computed tomography: influence of different protocols c. carriço 1 , m. inácio 1 , a. kristiansen 2 , m. larsen 2 , j. santos 1 , s. holm 2 , g. paulo 1 ; 1 coimbra/pt, 2 odense/dk (catarina.carrico@hotmail.com) purpose: the number of head computed tomography (ct) examinations in paediatrics had an exponential increase. taking into account the highest radiosensitive of children tissues and organs, radiology departments should permanently optimise ct protocols in order to minimize exposure, especially to more radiosensitive thursday body mask is classified into 4 classes (fat, water, air, and outliers) by a multivariate gaussian intensity model, regularized by a markov random field. to increase robustness to image variability, the statistical model parameters are automatically updated with the em algorithm. the air voxels are rejected from the mask and the adipose tissue segmentation is refined using a new 3-class gaussian intensity model. to separate sat from vat, an intra-abdominal mask is created by calculating the convex hull around the water tissue (water fraction of at least 50%). the adipose tissue quantification is, even under heavy motion, visually satisfactory. it is, moreover, highly consistent over the two datasets of each subject, as demonstrated by the high icc (r=0.997) and the small difference in fat, sat, and vat percentage of total body volume of 0.26%, 0.14%, and 0.12%, respectively. conclusion: an automatic adipose tissue quantification method based on spatially regularized multivariate gaussian mixture models is demonstrated to provide consistent measurements for sat and vat. computational texture analysis in interstitial lung disease: comparison of descriptors and classification accuracy j. ofner 1 , c. purpose: to evaluate and compare sequential ct to spiral ct examinations of the brain in terms of radiation dose and image quality. the study was carried out prospectively on 40 patients referred for brain ct. radiation dose and image quality data were gathered from an equal number of ct examinations performed with either sequential (n=20) or spiral (n=20) techniques. radiation dose data in terms of ctdivol and dlp were recorded by the scanning radiographers at the end of each examination. a ct brain image evaluation set was compiled which was evaluated by four radiologists. the radiologists evaluated the quality of the images by visually grading the reproduction of anatomical structures as outlined in eur 16262: european guidelines on quality criteria for ct. results: mean ctdivol and dlp readings were significantly higher (p < 0.05) for sequential scans over spiral scans (ctdivol: 22.06 mgy vs. 14.94 mgy and dlp: 304.60 mgycm vs. 229.10 mgycm). the mean image quality grading scores for all criteria for the sequential technique were significantly (p < 0.05) higher than those obtained by the spiral technique. conclusion: spiral acquired ct brain images have lower radiation doses. the quality of the images produced using this technique, however, produces images of a lower quality to those obtained using the sequential technique. further research is recommended investigating whether the level of image quality produced by the spiral technique is sufficient for diagnosis in order for patients to benefit from associated radiation dose reductions. termined the number of alerts triggered, based on the currently used, exclusively study description-based threshold method. the default setting of this threshold is twice the median for each separate descriptor. then, logical combinations of study description and protocol were made and linked by a rsna radlex elements, for a total of 62% of all examinations. the mapped data sets were then used to determine the number of alerts triggered when using a threshold method based on a combination of study description and acquisition protocol. the impact of both strategies on relevant dose information was assessed. results: considering only the relevantly mapped scans, we found a 51% decrease, from 959 to 466 alerts, using the radlex-based alert triggering. of these, 23 (5%) were not previously reported by the old method. the new alerts could all be attributed to patient or examination-related factors. of the 470 alerts (49%) that were no longer reported, none were found to have any clinical relevance. the combination of study description and acquisition protocol in the threshold method for ct dose measurements helps to decrease the number of alerts, while maintaining patient safety. purpose: to optimise ct protocols and parameter settings, by comparing the radiation dose between 2 different ct scanners of the same type. methods and materials: using dedicated software (dosewatch®), dose information from ct examinations performed on two 64-slice lightspeed vct scanners over an 7-month period was prospectively evaluated. we compared the administered radiation doses for 61 equivalent acquisition protocols on the 2 machines, and identified acquisition protocols in which there was a significant dose variation. for these protocols, we performed a rigorous imaging parameter check, including comparison of the number of examinations, acquisition types, number of irradiation events, ma, kvp, scanning length, exposure time and pitch factor. these data were then linked to the protocol setup. results: we found significant parameter variations in 5 out of 61 ct acquisition protocols. in 4 cases, the variations could not be attributed to a difference in the acquisition protocol set-up, and a thorough inspection did not lead to any improvement. for 1 acquisition protocol (helical skull), we found that the noise index was erroneously configured on one of the ct machines. after correction of this parameter, the median dose length product (dlp) on this machine was reduced from 771 mgy.cm to 446 mgy.cm (42% decrease), based on measurements during 2 months prior to correction (148 cases) and 5 months after correction (364 cases). the use of a patient dose managing system for ct can identify suboptimal parameter settings, and helps to significantly reduce the radiation dose without loss of relevant diagnostic information. it (marco.moschetta@gmail.com) purpose: to assess the reliability of 3d analysis ct software in determining urinary stones volume and density. methods and materials: ct images of 140 patients for a total of 219 urinary stones (116 calyceal, 22 pelvic, 81 ureteral) were evaluated. all exams were performed using a 320 mdct with a low dose protocol and without injection of contrast material. ct scans were independently evaluated by two expert radiologists. for each stone, volumetric [sv (stone volume) = l (length) x w (width) x t (thickness) x π x 0.52 ] and densitometric [selecting a roi on axial plane] measurements were calculated. the obtained data were then compared with the measurements performed by the 3d analysis ct software (vitrea fx 2.1). differences between the two systems were evaluated by the analysis of variance (anova) test. the interobserver agreement was calculated using the cohen's kappa (k) test. the volumetric and densitometric measurements of urinary stones obtained without 3d analysis software showed a lower interobserver agreement (k = 0.54) than that resulting from the use of the software (k = 0.98). statistical significant differences were found between volumetric and densitometric measurements as performed with and without the 3d software for each urinary stone (p < 0.05). conclusion: volumetric and densitometric evaluation of the urinary stones provided by 3d analysis software is reliable and reproducible and could significantly influence the therapeutic choices. the 3dslicer open-source platform for segmentation, registration, quantitative imaging and 3d visualisation of biomedical image data s. pujol 1 , s. pieper 2 , r. . overall image quality, identifiability of vessels and homogeneity of liver parenchyma were graded by two experienced radiologists in consensus using a 5-point rating scale with a true non-contrast ct (tnc) scan as standard of reference (1=no difference; 2=minimal, non-relevant difference; 3=visible but diagnostically irrelevant difference; 4=relevant difference; 5=obvious difference). image noise was measured in liver parenchyma, retroperitoneal fat and aortic lumen. wilcoxon signed-rank non-parametric test was used to assess statistical significance. the nvnc was superior compared to the standard vnc regarding overall image quality and identifiability of vessels (2.4 vs. 3.2/p < 0.001 and 1.4 vs. 1.9/p < 0.001), whereas no significant difference was observed concerning the homogeneity of the liver parenchyma (nvnc: 2.5/svnc 2.4). there was no significant difference regarding image noise with an average value of 7.5 hu (nvnc) and 7.4 hu (svnc), respectively, compared to 9.8 hu (tnc). the new algorithm provides a better image quality and an improved assessment of vessels and small structures. the nvnc images represent adequate substitutes for tnc images, rendering an omission of non-contrast acquisitions feasible, corresponding to a substantial dose reduction. image quality of monoenergetic low-kev datasets for lower extremity dual-energy ct angiography s. sudarski, d. schneider, p. apfaltrer, s.o. schönberg, t. henzler; mannheim/ de (sonja_sudarski@gmx.de) purpose: to compare image quality of conventional 120-kev polyenergetic images (peis) and monoenergetic images (meis) for dual-energy ct angiography (de-cta) datasets of the lower extremity. we retrospectively evaluated de-cta datasets obtained from 18 patients (13 men, 67±10 years). meis were calculated in 10-kev intervals from 120 to 40 kev using the 80-and 140-kev image data. attenuation and image noise were measured in the external iliac, femoral, popliteal and one lower leg artery. contrast-to-noise ratio (cnr) and signal-to-noise ratio (snr) were calculated for each vessel. differences in these parameters were compared between the different monoenergetic datasets. the two best meis were compared to 120-kev-peis. results: snr and cnr of 70-and 60-kev meis were highest when compared to other low-kev meis. in 70-kev meis, cnr in external iliac, femoral and popliteal arteries was higher compared to peis (+29%, +19% and +12%; p < 0.05), while cnr did not change in lower leg arteries (p> 0.05). snr in external iliac and lower leg arteries was equal in 70-kev meis and peis, while in femoral and popliteal arteries it was lower (-9%, -10%; p < 0.05). 60-kev meis showed a higher cnr in lower leg arteries compared to peis (+17%; p < 0.05), while snr did not differ (p> 0.05). in the other three arteries, 60-kev meis showed significantly not only higher cnr but also lower snr. purpose: persistent sub-centimetre ggo are pre-malignant. hrct improves detection of small nodules and low dose ct (ldct) reduces patient exposure but both decrease cnr essential for characterisation of small ggo. we investigate the use of adaptive iterative dose reduction (aidr) in low dose hrct (ld-hrct) for diagnosis of small ggo. methods and materials: ldct (120 kv, 25 mas, 64 x 0.5 mm) was used in 3 stages: 1) computer-simulated lung nodules 5, 8 and 10 mm spheres each of ct# 100, -630 and -800 hu; 2) identical synthetic nodules, placed in an anthropomorphic chest phantom and 3) 22 in vivo pulmonary nodules (13 ggo, 9 solid); 5.1 mm diameter (4.0-6.9), mean ct# -327 hu (8 to -738). raw data reconstructions are as follows (slice thickness/overlap mm): 0.5/0.5, 1/1, 2/1, 2/2, 3/1, 4/2, 4/4, 5/2.5 and 5/5 with fbp. in vivo images were also reconstructed with aidr. ct# and cnr were determined for each protocol. results: ct# accuracy decreases with increased slice thickness for all nodules: 5/5 reconstructions decrease ct# > -400 hu for 5 mm solid (+100 hu) nodules and ~ -130 hu for 5 mm ggo (-630 hu and -800 hu), spearman's coefficient = -1.0, p < 0.005. hrct (< 3.0/1.5 mm) has accurate nodule ct# (error< 10% purpose: to investigate whether optimisation of volume-doubling time (vdt) cutoff for fast-growing nodules in a lung cancer screening trial can improve accuracy of lung cancer diagnosis. methods and materials: all subjects underwent at least two low-dose computed tomography (ct) scans during the baseline-round screening and regular secondround screening in year 2 of the nelson lung cancer screening study and were referred to a pulmonologist because of a solid nodule with volume ³50 mm 3 and vdt < 400 days. histology was the reference for diagnosis, or, to confirm benignity, stability of the nodule volume on subsequent ct scans for at least two years after referral to a pulmonologist. nodule volume and vdt were semi-automatically calculated by software. reduction of false-positive rate was evaluated at maintained sensitivity for lung cancer diagnosis with the vdt cut-off of 400 days as reference. results: 68 fast-growing nodules were included (61 individuals), of which 27 nodules (40%) were malignant. mean follow-up of non-resected benign nodules was 4.4 (range 2.7-5.7) years. the optimal vdt cut-off for the 3-month follow-up ct in the baseline round was 232 days. using this cut-off, false-positive referrals reduced by 33% (20 versus 30 false-positive referrals). for the regular secondround screening, vdts varied more among malignant nodules, precluding lowering of the vdt cut-off of 400 days. conclusion: lowering the vdt cut-off of the 3-month follow-up ct in baseline lung cancer screening from 400 to 232 days may reduce false-positive referrals, without apparent loss in sensitivity. mia, invasive adenocarcinoma, and the extents of invasive carcinoma component were quantified. association between imaging parameters and pathologic classification was examined. results: 177 patients (98%) were pathologic stage 1 a, and 2 were 1b and the other one was 2 a. of all 190 tumours, 38 were ais (20%), 56 were mia (29%), and 96 were invasive adenocarcinoma (51%). based on univariate analysis, tumour size in lung setting, uniformity, and entropy were able to significantly separate tumours according to pathologic classification, whereas tdr, volume, mass, or suvmax were not. on multivariate analysis, uniformity and entropy were remained as independent factors to stratify the pathologic subgroups of patients (odds ratio [or] = 0.001, p =.007, and or = 2.4, p =.01, respectively). conclusion: texture parameters on ct imaging metrics, reflecting tumour heterogeneity, appear to help stratify pure ggn lung adenocarcinoma. non-solid, part-solid or solid? classification of pulmonary nodules in thoracic ct by radiologists and a computer-aided diagnosis system c. purpose: classifying pulmonary nodules into solid, part-solid and non-solid is crucial for patient management. a computer algorithm is compared to a radiologist on a large data set obtained from a multi-center lung cancer screening trial. methods and materials: low-dose chest ct scans (16x0.75 mm, 120-140 kvp, 30 mas) with part-solid, non-solid, and solid nodules with a diameter between 7 and 30 mm were randomly selected from two sites participating in the dutch-belgian nelson lung cancer screening trial. the set contained 137 scans, including 50 part-solid, 50 non-solid and 52 solid nodules. the nodule-type recorded in the screening database was used as a reference standard. an automated classification system for characterisation of nodules was designed using morphometric features. the accuracy of the computer algorithm was evaluated in three ways: classifying nodules (1) as solid or subsolid, (2) as solid, part-solid or non-solid, and, (3) for the subsolid lesions only, as part-solid or non-solid. an experienced thoracic radiologist independently performed the same classification. the accuracy of the automated system to differentiate between solid and subsolid nodules was 0.88, compared to 0.95 for the radiologist. the computer classified the nodules as solid, part-solid or non-solid with an accuracy of 0.72 versus 0.80 for the radiologist. the software reached an accuracy of 0.71 in differentiating part-solid from non-solid nodules, where the radiologist had an accuracy of 0.77. conclusion: a novel automated characterisation tool for pulmonary nodules shows promising performance and could aid radiologists in selecting the appropriate workup for pulmonary nodules. (19), additional to bled aneurysm (9) and additional coiling (21). aneurysms ranged in maximal size between 2 and 30 mm (mean/median 9 mm). aneurysms were located in the cavernous sinus (n=14), supraclinoid internal carotid artery (n=33), anterior communicating artery (n=3), middle cerebral artery (n=2), pericallosal artery (n=2) and posterior circulation (n=17). patients were preloaded with aspirin and clopidogrel (multiplate test control). clinical and angiographic follow-up was done at 3-to 12-month intervals after treatment. results: single stents were placed in 49 cases, 2 stents in 12 and flow-diverter stents in 10. in 14 cases no additional coil aneurysm occlusion was performed. seventeen procedural complications occurred (24%): 3 thrombo-embolic, 5 in-stent thrombosis, 3 haemorrhages, 3 side-branch occlusions and 3 technical device problems. most had no clinical sequel, but 2 patients died (3%) and 5 patients had permanent neurological deficit (7%). five aneurysms (7%) needed second additional stenting during follow-up. mean follow-up was 9 months (range 0-39 months). conclusion: endovascular intracranial aneurysm occlusion with stent assistance is a delicate procedure with a higher complication rate compared to regular coil occlusion. however, this technique is useful in complex otherwise difficult or untreatable intracranial aneurysms. in-stent restenosis occurred in 9/683 cases (1.3%) and solved with angioplasty in 2/9 cases (22%) or re-stenting in 7/9 (78%). primary patency rate was 98.7%; secondary patency rate 100%. neurological events occurred in 3.2% of cases. results were analysed correlating neurological complications with the operator's experience, plaque morphology and patient's age. neurological disorders were 1.9 % in asymptomatic patients and 4.5% in symptomatic ones (p=0.001) and they proved to be higher in older patients (> 80y) 6.4% vs 2.7% of patients < 80 years (p < 0.05). the overall neurological adverse events were 6.1% in the presence of complex plaque morphology and 1.0% in case of stable plaques (p < 0.001). friday within 3 months after the procedure. a total of 91 high signal lesions on dwi were serially numbered and the signal change on conventional mri in the follow-up was evaluated. the quantitative parameters on dwi (location, volume and value of apparent diffusion coefficient: adc) for each lesion were measured. we used fisher exact test and the mann-whitney u test to compare differences between two groups; statistical significance was assigned when p < 0.05. results: there was statistically significant difference in the presence of dwi lesions (multiple: 65% versus single: 100%, p=0.03). in each lesion, the volume was significantly small (0.074±0.019 cm 3 versus 0.149±0.113 cm 3 , p=0.009) and the permanent signal change was less observed in multiple antiplatelets use (5.2% versus 24.5%, p=0.02). there was negative correlation between the volume and the value of adc (r=-0.48, p <.0001). conclusion: periprocedural use of multiple antiplatelet agents is expected to reduce the volume of thromboembolism and permanent signal change in the follow-up. purpose: the treatment of vertebral split fractures remains controversial, consisting of either corset or internal fixation. the aim of this study was to evaluate ct-and fluoroscopy-guided percutaneous vertebroplasty in the management of vertebral split fractures. methods and materials: institutional review board approval and informed consent were obtained for this study. sixty-two consecutive adult patients who had posttraumatic vertebral split fractures (a2 according to the ao classification) without neurological symptoms were prospectively treated by percutaneous vertebroplasty. all these procedures were performed by an interventional radiologist under computed tomography (ct) and fluoroscopy guidance using only local anaesthesia. postoperative outcome was assessed using the visual analogue scale (vas) and oswestry disability index (odi) scores. results: vertebroplasty was performed on thoracic and lumbar vertebrae. the filling of the vertebral body was satisfactory in 100% of the patients, with seven discal cement leakages (14%). the mean vas measurements ± standard deviation (sd) significantly decreased from 7.9 ± 1.5 preoperatively to 3.3 ± 2.1 at 1 day, 2.2 ± 2.0 at 1 month, and 1.8 ± 1.4 at 6 months (p < 0.001). the mean odi scores ± sd had also a significant improvement: 62.3 ± 17.2 preoperatively and 15.1 ± 6.0 at the 6-month follow-up (p < 0.001). radiological union was observed within the 6 months following vertebroplasty in all the cases. the results of our study showed that type a2 vertebral fractures could be successfully treated by ct-and fluoroscopy-guided percutaneous vertebroplasty with an excellent functional recovery. long-term results of microsurgical and endovascular therapy of intracranial aneurysms in patients following subarachnoid haemorrhage k. bojanowski 1 , j. baron 2 , b. kostkiewicz 1 , m. zawadzki 1 , j. walecki 1 ; 1 warsaw/pl, 2 katowice/pl (jerzy.walecki@cskmswia.pl) purpose: the aim of this paper was to evaluate long-term clinical outcomes and radiologic findings in patients following microsurgical treatment and endovascular embolisation of intracranial aneurysms. methods and materials: a total of 66 subjects aged 20 -75 (42 women and 24 men) were evaluated. patients were divided into two groups according to the type of procedure they underwent: 36 patients had open surgery and 30 patients had undergone endovascular embolisation. the assessment was performed from 6 months to 4 years after treatment. all patients underwent a follow-up cerebral arteriography and clinical evaluation. results: a total occlusion or a neck remnant was discovered in a majority of patients following microsurgical procedures and endovascular treatment (94% and 3% in contrast to 87% and 7%, respectively). no recurrent aneurysms were revealed. the mann-whitney u test did not reveal any statistical significance in long-term treatment results regarding self-reliance (p-value=0.2). the amount of blood extravasated following the rupture of an aneurysm was a significant independent factor influencing the clinical outcome and determined the long-term results in both groups (p-value< 0.05). a correlation between a patient's age and the clinical outcome following a microsurgical procedure was proved. the outcome was better in younger patients (p-value< 0.05). this was not observed in patients after endovascular treatment. conclusion: microsurgical and endovascular therapy are comparable methods for treating cerebral aneurysms; however, embolisation is correlated with a higher rate of complications in elderly patients. the final clinical outcome depends on the amount of extravasated blood following a subarachnoid haemorrhage. embolisation of cerebral aneurysms with hydrogel-coated coils: systematic review and meta-analysis a. pałys, z. serafin, w. lasek; bydgoszcz/pl (serafin@cm.umk.pl) purpose: hydrogel-coated coils for endovascular treatment of cerebral aneurysms were developed to reduce the risk of aneurysm recurrence and the rate of retreatment. the aim of this review was to verify the efficacy and safety of hydrogel-coated coils. methods and materials: a literature search was performed by two independent researches for papers published up to august 2012 on follow-up results of intracranial aneurysm embolisation with hydrogel-coated coils. analysis included aneurysm presentation at follow-up compared to initial treatment result, the rate of rebleeding and retreatment, and specific complications. pooled rates of major recurrences and total recurrences were calculated. results: of 41 articles on the use of hydrogel-coated coils for embolisation of cerebral aneurysms, 13 (1575 aneurysms) were included. significant heterogeneity was found regarding patients populations, methods of aneurysm coiling, follow-up schedules, and recurrence definitions. a cumulative follow-up rate was 76% (95% ci, 74-78%, range 51-100%). pooled major recurrence rate was 13% (95% ci, 11-15%, range 2-27%) and pooled total recurrence rate was 17% (95% ci, 15-19%, range 3-29%). control groups consisting of aneurysms treated with bare platinum coils were analysed in only in four articles (436 aneurysms). pooled major recurrence rate for bare platinum coils was 33% (95% ci, 28-38%) and was significantly higher than this for hydrogel-coated coils. conclusion: embolisation of cerebral aneurysms with hydrogel-coated coils results in lower rate of major recurrence, than with bare platinum coils. more high-quality standardised prospective studies are needed to define specific indications for the use of hydrogel-coated coils. effect of antiplatelet therapy on radiographic outcome of positivity on diffusion-weighted imaging in elective endovascular coiling of unruptured cerebral aneurysm t. . 12 males (n=11) were followed retrospectively over 9 months; 8 males (n=8) were followed prospectively over 12 weeks. the diagnosis of pt was confirmed with ultrasound and power doppler (average thickness of prospective subjects 10.3 mm, average neovascularisation 3.8 on modified ohberg scale). all subjects were injected under real-time ultrasound guidance with 10 ml of 0.5% marcaine mixed with 25 mg hydrocortisone followed by a mean of 30 ml normal saline at the interface between the pt and hoffa's body, adjacent to the area of neovascularisation. the same supervised rehabilitation programme was followed by all patients. the visa-p questionnaire was administered for pre-injection severity and at follow-up. results: there was instant resolution of neovascularisation in all subjects. the visa-p score statistically significantly improved from a mean of 45.5 to 64.0 for (p < 0.01), which is likely to be clinically significant. the retrospective data increased by 19.9 points compared to 16.4 in the prospective subjects followed over a shorter time period. over 60% of the prospective subjects agreed/strongly agreed that their symptoms/strength had improved, with over 33% returning to their required level of sport within 12 weeks. purpose: our aim was to investigate the potential impact of visceral fat assessment by dxa in the clinical management of patients submitted to different therapeutic programs for obesity. we prospectively recruited 169 patients affected by obesity and submitted to medical and/or surgical treatment. body mass index (bmi) and body composition were analyzed with anthropometric and whole-body dxa evaluations simultaneously performed at baseline and after one year. a new software available to estimate android visceral fat was applied to last-generation dxa equipment. results: ninety-one patients ruled out the study. among patients ending the follow-up period (28-males, 50-females, 53.4±13.0-year-old, 40.5±9.1-kg/m2) bmi decreased in 69/78-88.5% controls, while regained in 9/78-11.5%. an opposite trend between bmi and total fat mass/non-bone lean mass (tfm/tlm), android ratio (afm/alm), and android visceral/subcutaneous fat (v/s) was found in 7/78-9.0%, 11/78-14.1% and 31/78-39.7%, respectively. bmi was significantly correlated with tfm/tlm and afm/alm (r=0.717 and 0.713 respectively), while it was far from a statistically significant connection with v/s (r=0.011, p=0.896). although slightly better correlations were demonstrated between tfm/tlm (and afm/alm) and v/s, these were extremely low (r=0.146, p=0.061 purpose: to prospectively evaluate dual gradient-echo mri with dixon-based generation of fat-/water-images (mridixon) for quantification of the muscle-fat content (mfc) in-vitro and in patients with achillodynia compared to asymptomatic volunteers. methods and materials: mridixon was used to measure the mfc of 15 phantoms containing titrated mixtures of organic muscle/fat from 0-100% as well as of the gastrocnemius (dixongastro) and tibialis anterior (dixontibialis) muscles in 30 patients (13 women; mean age, 57±15 years) with achillodynia and in 20 matched asymptomatic volunteers (10 women; mean age, 30±14 years) at 1.5 t. accuracy of mridixon in quantification of mfc was assessed in-vitro as well as in-vivo using single-voxel mr-spectroscopy (mrs) as the standard of reference. dixongastro and dixontibialis were related to visual grading of the mfc (grades 0-4) in both muscles (visualgastro and visualtibialis). results: correlation of mfc derived from mridixon, phantoms and mrs was excellent with correlation coefficient (r 2 ) ranging from 0.93 to 0.99 and mean measurement bias ranging from -0.1 to +0.8%. mean dixongastro/dixontibialis was 7.0±4.7/4.9±2.3 in patients and 3.6±0.7/3.6±0.5 in volunteers. visualgastro/ visualtibialis ranged from 0 to 2/0 to 3 and 0 to 1/0 to 1, respectively. no significant difference was seen for dixontibialis between patients and volunteers (p=.07), whereas dixongastro was significantly higher in patients (p <.01). both, visual-gastro and visualtibialis did not differ in patients and volunteers (all, p>.05). conclusion: mridixon allows for accurate quantification of mfc and demonstrates a significantly higher fat content in the gastrocnemius muscle in patients suffering of achillodynia than in asymptomatic volunteers, outer performing visual assessment of mfc. and disappeared after more than 12 months. the unloading-findings were more severe at the patella and femur than at the tibia (p < 0.001). high scores of severity were associated with confluent and patchy patterns (scr=0.923, p < 0.01 and kt= 0.877 p < 0.01). conclusion: bone marrow changes at the knee related to disuse are most prominent 2-6 months following unloading when both patchy and confluent hyperintense patterns are present. manifestations of unloading are most prevalent within the patella and the femur and associated with increased vascularity. methods and materials: from whole body 18 f-fdg pet/ct datasets including a dedicated head and neck investigation protocol of 40 consecutive patients (mean age: 61 ± 9 years) with histopathologically proven pharyngeal and laryngeal malignancies virtual 3d 18 f-fdg pet/ct panendoscopies were reconstructed using an investigational software application. the feasibility to completely assess specific spaces of the upper airways by a virtual "fly-through" and to detect primary tumours was tested; the time for an automated segmentation of the virtual 18 f-fdg pet/ct panendoscopies was measured. the nasopharynx, oropharynx, laryngopharynx, epiglottis, subglottis and the tracheobronchial tree were accessible in all 40, the laryngopharynx, aryepiglottical folds, piriform sinus, glottis, and oral cavity in 37, 37, 37, 33 and 16 patients, respectively. in all 12 patients with restricted fiberoptical evaluation due to a primarily intubation the subglottical space was entirely accessible via virtual panendoscopy. the primary tumour was depicted in 36/40 patients (90%). the mean processing time for virtual 18 f-fdg pet/ct panendoscopies was 145 ± 98s. conclusion: virtual 18 f-fdg pet/ct panendoscopy of the upper airways is technically feasible and can detect pharyngeal and laryngeal malignancies. the tool allows for a complete evaluation of the subglottical space when optical panendoscopy is incomplete due to intubation. it may be used for planning endoscopy-guided biopsies and surgery in the future. centrations were determined dynamically before and after exercise using a whole body mri-system (achieva, 3 t, philips healthcare). point-resolved spectroscopy (press) was used to acquire spectra from a voxel in the m. vastus lateralis. the total creatine (t-cr) peak was used as internal reference. post-exercise acquisition of spectra started approximately 15 minutes after cycling. results: exercise-induced elevations of acetylcarnitine levels were similar in both groups (δpost-pre 3.1±1.9 mmol/kg wet weight (ww)). however, post-exercise acetylcarnitine kinetics were significantly different (p < 0.05). in sedentary subjects, the concentration continued to increase during recovery towards a plateau at 40 minutes (8.5±0.3 mmol/kgww). in contrast, the acetylcarnitine concentration started to decrease from 5.8±0.5 mmol/kgww at 20 minutes after exercise in the trained subjects towards 4.4±1.0 mmol/kgww at 40 minutes. conclusion: we demonstrate the dynamic character of acetylcarnitine in a situation of changing substrate demand/supply. the current protocol can differentiate between two metabolically different groups, which opens a window towards investigation of acetylcarnitine in relation to metabolic flexibility and insulin resistance. in vivo differentiation of muscle precursor cells using mr relaxometry n.c. chuck, f. azzabi zouraq, d. eberli, a. boss; zurich/ch (natalie.chuck@usz.ch) purpose: to assess the differentiation process of muscle precursor cells (mpcs) applying magnetic-resonance-imaging (mri) relaxometry and diffusion measurements in a mouse model in correlation with histology, immunohistochemistry and organ bath. methods and materials: human mpcs were isolated from biopsies of the m.rectus abdominis. the mpcs were mixed with a collagen carrier and injected subcutaneously in nude mice. animals with collagen-only-injections served as controls. mri was conducted on a 4.7t small-animal-scanner (bruker biospec) at 5 time points between day 3 and 21 post-injection. relaxometry measurements comprised t1 and t2 measurements using multi-echo-spin-echo (te 11-99 ms) and saturationrecovery-sequences (recovery time 118-4000 ms) and t2* quantification with a multi-echo-gradient-echo-sequence (te1 = 4.5 ms, δte = 7 ms, 12 echoes). diffusion imaging was performed with a spin-echo-sequence including diffusion gradients with b=0.400 and 800s/mm 2 . relaxation times and adc values were measured in the skeletal muscles. evaluations were performed with custom-made matlab scripts. animals were harvested after 28 days and the engineered muscle tissue was assessed by histology, organ-bath and immunofluorescence. results: relaxation and diffusion properties of the engineered tissue could reliably be measured at all time points. relaxometry measurements revealed a decrease of t1, t2 and t2* relaxation-time during differentiation (initial measurement: t1 2242.6 ms±116, t2:224.3 ms±66, t2*:33.5 ms±4; final measurement: t1:1386.64 ms±88, t2:31.9 ms±4, t2*:10.8 ms±0.8), thereby approaching the physiological relaxation properties of muscular tissue. adc showed a decrease from 2.24 mm 2 / s±0.26 to 1.51 mm 2 /s±0.05. cell differentiation and myofibre formation was confirmed by histology, immunohistochemistry and contractility confirmed by organ bath. conclusion: we demonstrated that mri relaxometry measurements are able to describe the differentiation of muscle precursor cells. this method might offer the possibility to non-invasively assess the effectiveness of cellular therapies for muscular disorders in near future. purpose: to evaluate diagnostic accuracy of diffusion-weighted magnetic resonance imaging (dwi) in predicting response to neo-adjuvant chemo-radiotherapy (ncrt) in patients with locally advanced cervical carcinoma using apparent diffusion coefficient (adc). cervical lesions adc were correlated with post-surgical histopathology. methods and materials: 24 women (figo>ib bulky) underwent mri and dwi prior to, after 2 weeks and at the end of ncrt, using 1.5 t scanner. cervical lesion volume and adc were measured at each assessment. radical hysterectomy was performed 4 weeks after mri. treatment response was determined based on histopathology and was classified as complete response (cr), residual (rd) or stable disease (sd). mean adcs (madc), adc increase and volume reduction (vr) rates were compared using histopathology as reference standard results: according to histology, 13/24 (54%) had cr, 11/24 (46%) had rd < 1 cm. 2 patients presented sd. before therapy, in the study population madc was 0.96±0.06x10-³ mm²/s but it was lower in sd (0.76±0.1x10-³ mm²/s). after 2 weeks of ncrt, madc correlated with tumour response: a) in cr with 23% percent change (1.20±0.02x10-³ mm²/s vs 0.98±0.06x10-³ mm²/s; p < 0.001); b) in rd with 10% percent change (1.05±0.02x10-³ mm²/s vs 0.93±0.06x10-³ mm²/s; p < 0.001). tumour volume decreased in cr and rd with reduction rate of 48% and 46%, respectively. at the end of crt, no significant differences on adc between for comparison of quality data, chi-square and odds ratio were used. results: in 80 subjects (67%), 114 benign (63.5%) and 6 malign (3.5%) lesions were detected. six subjects underwent operation (5%) for adrenal carcinoma, renal carcinoma, pancreatic mucinous cystadenoma, intradural schwannoma (2), and enchondroma of the femur. in one subject, tuberculosis pneumonia was detected and medical treatment was given. in 3 subjects focal nodular hyperplasia of the liver, and in one an unclassified solid mass in spleen were encountered and they are in follow-up. the most common incidental lesions were liver cyst (12), liver haemangioma (9), renal cyst (13), and thyroid nodule (6). no significant difference was observed for the incidence of benign and malign lesions between subjects aged ³40 years and < 40 years (p=0.209 and p=0.898, respectively). conclusion: 7% of the population screened by wb-mri underwent further surgical and medical treatment. wb-mri is a useful and non-invasive tool for the detection of incidental lesions in asymptomatic subjects. purpose: to assess the value of elasticity parameters on breast sonoelastography by influence of menopause factor. methods and materials: 286 female patients (premenopausal vs postmenopausal: 192 vs 108) with 300 breast lesions were conducted routine ultrasound and elastographic ultrasound preoperatively. the elastic parameters of strain ratio (sr, sr1 was calculated using the same-level and normal-appearing breast region as reference; sr2 was calculated using the subcutaneous fat as reference) were then obtained, with the pathologic diagnosis served as golden standard. the sensitivity, specificity, and area under the curve were analysed by receiver operating characteristic (roc) curve with or without the influence of menopause factor. purpose: to assess if stiffness as measured by shear-wave elastography (swe), could be an early biomarker of response to chemotherapy in a breast cancer model. a human invasive ductal carcinoma was implanted subcutaneously in 10 athymic female mice. after 8 weeks of growth, 2 tumours were removed for baseline pathological analysis and 8 were treated by oral chemotherapy during 5 weeks. ultrasound was performed every week before and during treatment, using a superficial 8-mhz probe. maximum diameter and mean elasticity value of the tumor were measured. kinetics of changes in diameter and elasticity before and under treatment were calculated as the slope of diameter or elasticity over time. at the end of the treatment, tumours were removed for pathological analysis. results: before treatment, we observed a progressive stiffness increase along tumour growth (slope: 8.8 kpa/week). under chemotherapy, we observed an early stabilisation of tumour stiffness (slope: -0.8 kpa per week). furthermore, a significant decrease of elasticity values was seen after four weeks of treatment (p=0.03). we also observed an early progressive decrease of diameter showing that there was a good response to treatment. after five weeks of treatment, we observed modifications of the pathological features of the tumor, i.e. mainly a decrease of cellular density. conclusion: in our model, we observed an early stabilisation of tumour elasticity with an inversion of elasticity slope under treatment showing that swe could be an interesting tool to assess early tumor response to chemotherapy. purpose: shear wave elastography (swe) can differentiate benign from malignant solid breast masses. small, low-grade cancers can have benign (low) mean stiffness values but often show a ring of slightly stiffer tissue around the lesion. we aimed to establish whether taking the presence of a ring sign to indicate malignancy improves the discriminatory performance of swe in screen detected solid breast masses. the ring sign was defined as the presence of stiffer borders on at least 2 aspects of the lesion. the presence or the absence of the ring sign was independently assessed by two breast radiologists, blinded to pathology outcomes, in a consecutive series of 145 screen-detected solid masses. a third radiologist arbitrated in discordant cases. the discriminatory performance of swe using a threshold mean stiffness value of 50 kilopascals (kpa) was compared with taking either a threshold mean stiffness of 50 kpa or a ring sign as positive. results: of 145 masses, 42 were benign and 103 were malignant. in 122 (84%), the ring sign findings of two radiologists were concordant. for mean stiffness threshold of 50 kpa, sensitivity was 83% and specificity was 55%. when either mean stiffness over 50 kpa or a ring sign was counted as positive, sensitivity was 91% and specificity was 45%. the increase in sensitivity was statistically significant (fisher's exact test, p=0.048). the drop in specificity was not (p=0.25). the ring sign can improve the sensitivity of shear wave elastography in differentiating benign from malignant screen-detected solid breast masses. purpose: the purpose of our study was to investigate arterial spin labelling (asl) mri for functional assessment of transplanted kidneys at 1.5 t and 3 t. methods and materials: 105 renal allograft recipients (mean age 50.8 ± 14.7 years) were included in this study. asl mri was performed at 1.5 t (n=71) and 3 t (n=34) using a single-slice paracoronal fair truefisp sequence (30 averages, inversion time 1200 ms, slice thickness 8 mm, matrix 128 x 128). for quantification of asl perfusion, t1 relaxation times were determined at 1.5 t and 3 t using the variable flip angle approach. rois were drawn by a single reviewer on asl parameter maps for quantification of cortical perfusion. asl perfusion was correlated with allograft function as determined by the estimated glomerular filtration rate (egfr) and compared between patients with good or moderate allograft function (group a; egfr > 30 ml/min/1.73 m²) and patients with heavily impaired allograft function (group b; egfr ² 30 ml/min/1.73 m²). results: asl perfusion and egfr were comparable at 1.5 t (36.1 ± 22.6 ml/ min/1.73 m² and 237 ± 101 ml/100 g/min) and 3 t (42.3 ± 22.2 ml/min/1.73 m² and 248 ± 66 ml/100 g/min). asl perfusion was significantly higher in group a (283.9 ± 59.4 ml/100 g/min) as compared to group b (195.6 ± 62.0 ml/100 g/min) (p < 0.0001). asl perfusion values exhibited a significant correlation with egfr (r=0.59, p < 0.0001). a total of 151 patients were enrolled at 5 centers in japan. all patients provided written informed consent before entering the studies. unenhanced ultrasound, contrast-enhanced ultrasound, and contrast-enhanced mr images were independently assessed by three blinded reviewers, who viewed the different images in a randomised sequence and were also blinded to subject characteristics. the observation period for safety assessment was 3 days after the contrast agent administration. results: among 140 patients included in the diagnostic analysis, the accuracy of contrast-enhanced ultrasound (86.7%) was significantly higher than that of unenhanced ultrasound (66.9%) and contrast-enhanced mri (69.5%) (both p < 0.001). sensitivity and specificity of contrast-enhanced ultrasound (92.9%, 84.0%) were also superior to unenhanced ultrasound (86.5%, 58.5%) and contrast-enhanced mri (86.5%, 62.2%) (sensitivity: p=0.177 and p=0.160) (specificity: both p < 0.001). the incidence of adverse events was 9.9%, with adverse drug reactions in 3.3% (all mild). conclusion: compared with unenhanced ultrasound and contrast-enhanced mri, contrast-enhanced ultrasound with sonazoid ® (perflubutane) microbubbles achieved significantly better diagnostic accuracy and specificity for breast lesions without causing serious adverse reactions. methods and materials: in a retrospective study, 21 patients with non-tumorous increased signal intensity of the kidneys on dwi sequences (b=800s/mm2) and corresponding adc-decrease was identified. as a control group served 60 patients without clinical signs of renal infection. all patients underwent routine mri-protocol of the abdomen including epi-sequence for the dwi (b.0/400/800), t2w haste, t1w vibe post-contrast (dotarem). confirmation of renal infection was established on the basis of clinical criteria. t1w-and t2w-images were assessed and compared to dwi for the presence of altered signal and the degree of the visibility of pathology was graded on an three-point scale. in all 21 patients with positive dwi-findings, a renal infection could be confirmed while none of the patients in the control group showed a suspicious signal pattern on dwi. t2w-imaging and contrast-enhanced t1w-imaging displayed obvious pathologic signal in 3/21 (14%) and 11/19 (58%) patients, slightly pathologic signal in 17/21 (81%) and 7/19 (37%), respectively. no pathologic change was seen in 1/21 (4%) and 1/19 (5%). the median visibility score of 2 for the dwi-imaging and the t1w-images was significantly higher than the median visibility score of 1 for the t2w-imaging (p=0.0001 (dwi vs. t2w) and p=0.078 (t1w vs. t2w). no significant differences were found between the visibility scores of t1w imaging and dwi. conclusion: dwi of the kidneys seems to be highly sensitive for the detection of infections within the kidney. purpose: to investigate feasibility dynamic-contrast-enhanced (dce)-mri assessment of kidney function and renal masses on a single slice compared with investigation of the whole organ or tumour. methods and materials: fourteen patients with renal tumours (11 renal cell carcinomas, 2 angiomyolipoma, 1 oncocytoma) before and after partial nephrectomy underwent dce-mri at 3 t (magnetom verio, siemens healthcare sector) with a time-resolved angiography with stochastic trajectories (twist)-sequence (voxelsize 2.6x2.6x2.6 mm 3 , temporal resolution 2.5 mm) with half-dose gadobutrol (bayer healthcare pharmaceuticals). 28 kidney datasets and 14 tumour datasets were assessed using in-house built idl-software pmi 0.4. using 2-compartment-models with semi-automated segmentation, renal perfusion and filtration as well as tumour perfusion and permeability were calculated for a single central region-of-interest on a single slice or the whole organ or tumour. statistical analysis was performed with paired t-tests and pearson´s correlation coefficient. results: there were no significant differences between single slice / whole kidney (plasma-flow 275.8±105.6 vs. 234±96.7 ml/100 ml/min, plasma-volume 28.2±8.9 vs. 25.0±9.0 ml/100 ml, glomerular-filtration-rate 16.9±9.2 vs. 15.9±8.0 ml/100 ml/ min) as well as between single slice/ whole tumour (plasma-flow 122.5±85.6 vs. 120.5±95.2 ml/100 ml/min, plasma-volume 18.9 vs. 13.0 ml/100 ml and permeabilitysurface-product 5.4±7.9 vs. 5.4±8.3 ml/100 ml/min). correlations between single slice and whole organ/ tumour was were excellent and significant for all parameters (r = 0.95 to 0.99, p < 0.01). conclusion: single slice assessment of kidney function and renal masses with dce-mri does not show significant differences to the more time-consuming analysis of the whole organ/ tumour. incorporation of single slice analysis of dce-mri data in future studies appears feasible and justifiable. in vivo sodium ( purpose: renal allograft rejection is associated with chemokine ligand 2 (ccl2)dependent glomerular and interstitial macrophage recruitment. ccl2 blockade with the oligonucleotide/spiegelmer mnox-e36-3'peg inhibits leucocyte recruitment. the purpose of this study was to evaluate mr renography and diffusion-weighted imaging (dwi) for assessment of this novel chemokine-directed therapy in an experimental murine animal model. methods and materials: an orthotopic renal transplant mouse-model with acute allograft rejection (balb/c into c57/bl6) was used. 5 animals were treated with low-dose cyclosporin a in combination with mnox. 7 animals did not receive treatment. 3 syngenic controls (c57/bl6 into c57/bl6) were performed. imaging was conducted at 3 t with a dedicated mouse coil. diffusion-weighted imaging was performed with b values ranging 0 to 800 s/mm2. mr renography was performed with a twist-sequence with a temporal resolution of 1.5 seconds following a bolus of 10µl gadobutrol in 100µl nacl. significance between subgroups was assessed with wilcoxon´s rank-sum test. results: syngenic allograft showed substantially higher plasma flow (53.2±17.2 ml/100 ml/min) and significantly lower (p < 0.05) adc (1.20±0.02 mm2/s) than native kidneys (44.1±7.1 ml/100 ml/min and 1.29±0.09 mm2/s). allograft-adc of treated animals (0.98±0.14 mm2/s) was substantially higher than of untreated animals (0.76±0.17 mm2/s). cortical plasma flow (24.5±5.5 ml/100 ml/min) was significantly lower (p < 0.05) for untreated animals compared to treated animals (37.4±7.6 ml/100 ml/min). volume of distribution and mean transit time did not show significant differences between the subgroups. conclusion: chemokine-directed treatment ameliorates acute renal allograft rejection. functional mri is able to non-invasively assess these therapy effects in this experimental model and holds high potential to become an alternative to invasive organ biopsy. assesment cisplatin-induced interstitial nephropathy using diffusion-weighted mri r. del vescovo, f. giurazza, r.l. cazzato, c.l. piccolo, r.f. grasso, b. beomonte zobel; rome/it (r.delvescovo@unicampus.it) purpose: to assess the potential of noninvasive diffusion-weighted magnetic resonance imaging (dw-mri) to depict interstitial kidney changes in patients (pts) under cisplatin-based chemotherapy. we analysed adc maps of 34 oncologic patient (5 woman and 29 men; mean age 56 years; 50% affected by advanced lung cancer) treated with cisplatin-based chemotherapy comparing with age-and sex-matched control group's adc maps. the creatinine clearance (crcl) used to determinate renal function was based on the formula of crockfort (normal value > 60 ml/min). the adc values were calculated using a roi positionated manually on the cortex of each pole in axial and coronal images. for statistical analysis t-test was used. a p value of less than 0.05 was considered significant. results: there was no anatomical difference visible with conventional mr imaging of the cortex and medulla relationship. in pts treated with cisplatin there was a reduction of adc values in the cortex, but no significant changes in medulla. the adc values of healthy volunteer were significantly higher comparing with patients treated with cisplatin (p < 0.04). there was no significant difference between the adc values of left and right kidney in each patient except in one who present a unilateral ureteral obstruction. no significant correlation was found between the creatinine clearance and adc values obtained in both groups. conclusion: dw-mri may allow a noninvasive detection of changes in kidneys in pts with interstitial nephropathy during and after chemotherapy treatment. purpose: to investigate the feasibility of reconstructing anatomic connectivity of sacral plexus using 3 t-mr diffusion tensor imaging (mr-dti) with three-dimensional (3d) tractography approach. 3 t-mr-dti was performed on 10 women volunteers. the sequence was acquired on oblique axial plane parallel to the sacrum, from the level of the l4 nerve to the coccyges. main diffusion directions reflecting the fibre orientation were determined using a sense-ssepi with diffusion-sensitised gradients (b600 mm2s-1) along 16 directions. a deterministic bre-tracking algorithm was used to show fibre architecture, compared with anatomic atlas. three rois were placed at different levels of the spinal cord nerves: one in the middle of each tract-of-interest, accompanied by "and" selection rois at both ends of the nerve tract roi. diffusion-weighted ssh-epi images are processed on a dedicated workstation for data pre-processing with medinria deterministic software. results: tractography of the sacral plexus was feasible for all 10 volunteers, giving 3d insight into the general anatomy and organisation of the nerves l4 to s4. main artefacts in fibre reconstruction, caused by bladder over-distension, by presence of air in rectum and by constant small movements due to breathing and/or spontaneous contractions of pelvic organs, never invalidate the feasibility of tractography. fibres were reconstructed from medulla to the pelvic course of main branches of sacral-plexus nerves. emerging branches of pudendal nerve were found in 6 volunteers. conclusion: 3 t-mr-dti allows a precise anatomic reconstruction of lumbar-sacral plexus. these findings are encouraging for using dti as a mean to investigate sacral-plexus, especially in female pelvis. te=2.64 ms to 60.42 ms; tr=75 ms; 24 averages; measurement time=46:50 min). all hr images were corrected for inhomogeneous sensitivity of coil. the 23 na-snr values are given on a pixel-by-pixel basis for 20 mm from the renal cortex in the direction of the medullary pyramid. the t2* maps were calculated by fitting the 23 na signal decay mono-exponentially on a pixel-by-pixel basis using least squares fitting routine written in idl. results: the mean cortico-medullary 23 na-snr for all 16 healthy kidneys increased from the renal cortex (34.1 ± 10.2) towards the renal medullary pyramid (88.8 ± 20.9). the cortico-medullary increase ranged inter-individually from 50.8 to 65.7%. the mean 23 na-t2* of all volunteers was 19.9 ± 1.8 ms. the feasibility of ultra-high field, hr 23 na-mri of healthy human kidneys was demonstrated. moreover, high 23 na-snr provided by 7.0t allowed the in vivo measurements of 23 na-t2* times in human kidneys for the first time. arterial spin labelling for the prostate: initial experience at 3 t mri s. takahashi 1 , n. aoyama 1 , t. kimura 2 , k. kitajima 1 , y. ueno 1 , s. sato 3 , k. sugimura 1 ; 1 kobe/jp, 2 otawara/jp, 3 osaka/jp (staka@med.kobe-u.ac.jp) purpose: to assess the value of asl-perfusion mri for the prostate using dynamic contrast-enhanced (dce) study findings as the reference standard. methods and materials: 22 male patients (mean age 69.2 ± 7.6 years) with suspected prostate cancer were prospectively included in this study. single-slice 2d-pulsed asl images were acquired during our routine prostate screening protocol on a 3 t mri unit, including the dce study. first, roi was drawn for the obturator muscle on a control image of asl sequence (scont.ref). then, rois were drawn for the femoral artery, the obturator muscle, the normal pz and the regions where dce showed early enhancement on the tagged asl image. these values were divided with scont.ref, yielding an asl ratio (aslr). analysis of the variance was performed to assess differences in aslr for each tissue or region. a radiologist scored the degree of enhancement on dce and compare to the contrast ratio of aslr and the visual assessment of asl signals. results: a mean aslr of the femoral artery was 15.8±6.9%, where those of the normal pz and the obturator muscle were 0.6±0.5%, and 0.6±0.5%, respectively. on the other hand, the enhanced regions on dce showed a mean aslr of 0.98±1.0%. visual assessment of the asl image detected 7 out of 12 well-enhanced regions. contrast ratio of aslr demonstrated significant positive correlation to the degree of enhancement on dce (spearman; r=0.54, p=.007). conclusion: asl may allow detecting the region of the higher tissue blood flow in the prostate without contrast materials. purpose: aim of this study was to investigate the feasibility of contrast-enhanced 7 tesla mri of the female pelvis. methods and materials: 10 healthy female volunteers were examined on a 7t whole body mr system (magnetom 7t, siemens) utilising an 8-channel transmit/ receive radiofrequency body coil. the examination protocol included 1) t1w fs 2d flash, 2) dynamic t1w fs 3d flash, 3) t2w tse sequences. for qualitative image analysis of t1w mri, the delineation of pelvic anatomy, pelvis vasculature, tissue contrast and overall image quality was assessed and for t2w mri the zonal anatomy of the uterus and the conspicuity of the ovaries were evaluated (fivepoint-scale analysis: 5 = excellent to 1 = non-diagnostic). image impairment due to various artefacts was assessed. contrast ratios between junctional zone and myometrium were obtained via roi analysis for t2w mri. results: of all three sequences, 2d flash mri offered best overall image quality (mean contrast-enhanced 4.75) and highest tissue contrast (mean contrastenhanced 4.92). for the t1w sequences, 2d flash imaging was rated with higher scores for all assessed structures than 3d flash mri. t2w tse imaging provided a moderate to high conspicuity of the zonal anatomy of the uterus with mean scores ranging from 3.5 for endometrium to 4.67 for myometrium. overall image impairment was rated strongest for t2w mri (2.95) and least for 2d flash mri (mean 4.24). our results indicate the successful transformation of the associated high snr into high spatiotemporal resolution t1w pelvis mri at 7 t and valuable non-contrast diagnostics of pelvis vasculature. de (david.schneider@stud.uni-heidelberg.de) purpose: high vessel attenuation as well as a high contrast-to-noise (cnr) ratio is a prerequisite for highly diagnostic cervical and cerebral ct-angiographic examinations. the purpose of this study was to evaluate the value of calculated low-kv-monoenergetic dual-energy ct (dect) angiographic datasets. methods and materials: 41 patients (21 men, mean age 58 ±14) that underwent dect-angiography of the cervical (n=7) or cerebral vessels (n=34) were retrospectively included in this study. 80 and 140-kv dect data were used to calculate low-kv monoenergetic image datasets from 120 to 40 kev (10-kev intervals). vessel and soft tissue attenuation and image noise were measured in various regions of interest and the cnr was subsequently calculated. differences in image attenuation and cnr were compared between the different monoenergetic datasets. vessel attenuation and cnr of the best monoenergetic datasets were then compared to conventional 120-kv polyenergetic datasets. results: in comparison to conventional polyenergetic 120-kv datasets, above all, 60-kev monoenergetic cervical datasets yielded to a significant increase in vessel attenuation and cnr (+40%, +18%; all p < 0.01). for cerebral vessel assessment, in particular 70-kev monoenergetic datasets improved vessel attenuation and cnr (+3%, +10%; all p < 0.01) when compared to conventional 120-kv datasets. conclusion: calculated 60-kev monoenergetic image data significantly improves vessel attenuation as well as the cnr of cervical dect-angiographic studies, whereas 70-kv monoenergetic datasets are favourable to improve vessel attenuation and the cnr of cerebral dect-angiographic studies. thus, lowering the amount of iodinated contrast-material might become feasible using monoenergetic-low-kv images, which is particularly important for combined perfusion and angiography protocols. purpose: single case reports suggest that black blood mri (t1-weighted fat and blood suppressed sequences with and without contrast injection; bb-mri) may visualise intracranial vessel wall contrast enhancement in primary angiitis of the central nervous system (pacns). in this single-centre observational pilot study we prospectively investigated the value of bb-mri in the diagnosis of large artery pacns. methods and materials: in this prospective, mono-centric study 12 patients with suspected large artery pacns received a standardised diagnostic programme including bb-mri. 10 patients without any evidence of pacns and without intracranial stenosis served as control group. vessel wall contrast enhancement was graded (grade 0-2) by two experienced readers blinded to clinical data and correlated to the final diagnosis. results: four of 12 included patients received a final diagnosis of pacns. all of them showed moderate (grade 1) to strong (grade 2) vessel wall contrast enhancement at the sites of stenosis. a moderate (grade 1) vessel wall ce grade was also observed in 6 of the remaining 8 patients in whom alternative diagnoses were made: arteriosclerotic disease (n=4), intracranial dissection (n=1), and moyamoya disease (n=1). none of the patients in the control group had vessel wall contrast enhancement. conclusion: our pilot study demonstrates that vessel wall contrast enhancement is a frequent finding in pacns and its mimics, but it is absent in patients without evidence of intracranial vascular disease. larger trials will be necessary to evaluate the utility of bb-mri in the diagnostic workup of pacns. purpose: the availability of endovascular services is increasing, but still not available in the majority of tpa centres. the aim of this study was to describe the relations between nihss and large vessel occlusions in patients with hyper-acute ischaemic stroke. a prospective single hospital registry based on consecutive patients admitted for tpa work up with routine cta was started on july 1, 2009; this analysis is based on patients admitted before december 2011. bispebjerg university hospital has a tpa-service with a catchment area of app. 1.7 mio. inhabitants on even dates. ct scans are performed using 64-section mdct (brilliance-64, philips healthcare) with cta from the aortic arch to the vertex. all images were systematically reviewed by a blinded neuroradiologist; sensitivity, specificity, positive predictive value and negative predictive value were calculated at all levels of nihss. results: five-hundred and seventy-three patients with acute ischaemic stroke were entered into the registry. at a nihss score equal to or larger than 10, the sensitivity was equal to 43.8%, the specificity was 89.6% the positive predictive value was 63.2% and the negative predictive value was 89.6% in predicting an acute occlusion. conclusion: if the cut off is set at nihss 10, there is a 10% risk of missing an occlusion and a 37% risk of transporting a patient with a tpa drip for no reason. the relation is between occurrence of large vessel occlusions and nihss is a continuum. contribution of the temporal maximum intensity projection ( purpose: the goal of retrospective study was to compare possibilities to measure the extent of mca occlusion (thrombus length) in patients with acute stroke and predictive value for recanalization and clinical outcome after systemic therapy. we analysed 63 patients with mca occlusions (25 males, average age 72.3 years, range 23-91 years) detected with multimodal ct examination (non-contrast ct, perfusion ct and conventional cta). conventional cta (slice 0.6 mm) and temporal maximum intensity projection (tmip) datasets (slice 1.5 mm) reconstructed over the full time span from volume ct perfusion were used for thrombus length measurement. results of used techniques were compared and correlated with results of systemic thrombolytic therapy (24 hours recanalization and 3-month clinical outcome). results: there was no statistically significant difference in measurement results using conventional cta and tmip, but in 23 subjects (36%) measurement of thrombus was not possible using conventional cta due to unclear peripheral border of thrombus. we proved statistically significant correlation of whole extent of thrombus and recanalization success (p=0.0241). the involvement of m2 section was main negative factor for recanalization (p=0.0068). the strong significant correlation of thrombus length and 3-month clinical outcome was proved (p=0.0079) with cut-off value of 11 mm. conclusion: our results confirm the benefits of detailed evaluation of cerebral arteries using tmip datasets, which enable to measure thrombus length in all subjects in comparison to conventional cta. the thrombus length was established as negative factor for recanalization and clinical outcome after systemic thrombolytic therapy. that with an optimised mr-protocol, mural inflammatory changes of superficial extracranial and intradural arteries can be detected in patients with gca. methods and materials: 10 patients with suspected gca underwent 3.0 tesla mri, including fat saturated (fs) t1w scans pre-and post-contrast, optimised for assessment of intradural vwe, and high-resolution fst1w scans to evaluate superficial extracranial vessels. temporal artery biopsies were available in 4 cases. vwe of intradural and extracranial vessels was evaluated by two observers results: in 5 patients, gca was diagnosed clinically, in 4 biopsy proven. a clear vwe of superficial extracranial vessels was detected in 8 cases. clear vwe of the intradural internal carotid artery (ica) was detected in 6 cases, 5 with corresponding vessel wall thickening. slight enhancement of the right medial cerebral artery was seen in 1 case. in one patient with gca, no vwe of intradural or extracranial vessels was detected. one patient who did not receive a temporal artery biopsy presented with vwe of intradural and extracranial arteries, but the final clinical diagnosis was connective tissue disease. conclusion: vwe of extracranial vessels is a frequent finding in gca. additionally, vwe of intradural arteries, mainly the ica, can be found. therefore, high-resolution mri seems to be a feasible technique to visualise vasculitic involvement of the extra-and intracranial arteries in gca. purpose: to measure cerebrovascular reserve using fmri (cvr fmri) in patients with severe stenosis of the middle cerebral artery (mca) to identify those at risk of haemodynamical stroke. methods and materials: among 16 patients with severe intracranial arterial stenosis, 7 patients (4 females; 61.9±18.5years) had a stenosis of the right (n=4) or left (n=3) mca only. cvr fmri was performed using bold contrast with a block-design hypercapnic challenge (co2 7%) at 3 t. averaged end-tidal co2 pressure (etco2) was used as regressor for statistical analyses. we measured %bold/mmhg etco2 on segmented grey matter of mca territories. we calculated a laterality index with limca =(left_cvr-right_ cvr)/(left_ cvr+right_ cvr). li were compared to those obtained in 100 volunteers that provided a 99% confidence interval for | limca |< 0.08. basal perfusion was measured using dynamic susceptibility contrast. results: basal perfusion measurements were symmetrical in all patients. no adverse reaction to hypercapnia was detected. cvr values ranged from 0.13 to 0.37 with m±sd=0.25±0.07. among these 7 patients, three patients had a normal |limca|< 0.08 ranging from 0.02 to 0.05 (0.04±0.01), and four patients had an abnormal |limca|> 0.08 ranging from 0.13 to 0.17 (0.16±0.02). all abnormal li values identified the mca territory ipsilateral to the stenosis. conclusion: these preliminary results show that among patients with severe stenosis of mca, several patients have abnormal |limca| in the territory ipsilateral to the stenotic artery, suggesting significant cvr impairment that might be at risk of haemodynamic stroke. cvr fmri should be considered to better define treatment strategy, including intravascular stenting. purpose: in this study, we aimed to evaluate the endothelial functions in patients with nonalcoholic fatty liver disease (nafld). in this observational case-control study, a total of 51 patients with nafld and age and sex-matched 21 healthy controls were enrolled. in both patients and controls, levels of asymmetric dimethylarginine (adma), systemic endothelial function (brachial artery flow-mediated dilation) (fmd) and carotid artery intima-media thickness (c-imt, mm) were measured. endothelial functions of the brachial and carotid arteries were evaluated by vascular ultrasound. results: carotid intima media thickness was significantly higher in patients with nafld than controls (0.67±0.09 versus 0.52±0.11 mm, p < 0.001). the average c-imt measurements were found in groups of control, simple steatosis and nafld with (borderline and definitive) nash as 0.52±0.11, 0.63±0.07 and 0.68±0.1 mm, respectively. the differences between groups were significant (p < 0.001). measurement of brachial artery fmd was significantly lower in patients with nafld compared to controls (7.3±4.8 versus 16.5±7.1%, p < 0.001). fmd measurements in groups of control, the simple steatosis and nafld with nash as 16.5±7.1, 9.64±6.63 and 7.03±4.57%, respectively, and the differences were statistically significant (p < 0.001). the increase in c-imt and decrease in fmd were independent of metabolic syndrome and it was also more evident in patients with simple steatosis and nash compared to controls. conclusion: our data suggested that nafld is associated with endothelial dysfunction and increased early atherosclerosis compared to healthy subjects. purpose: this study aimed to assess image quality and radiation dose of ct angiography (cta) in kidney donors obtained with automated kvp selection and sinogram-affirmed iterative reconstruction (safire), using scans with fixed kvp and filtered back projection reconstruction algorithm as the comparison. methods and materials: mean attenuation, contrast-to-noise ratio (cnr) and signal-to-noise ratio (snr) at abdominal aorta, right renal artery (rra) and left renal artery (lra) were measured in 24 kidney donors who had undergone cta with tube current modulation, 120 kvp, filtered back projection reconstruction algorithm (group a) and were compared with 24 bmi-matched kidney donors who had undergone cta with automated kvp selection and safire (group b purpose: cerebral small vessel disease (svd) is a common cause of cognitive impairment. white matter hyperintensities (wmh) and lacunar infarcts are the commonest magnetic resonance imaging (mri) parameters observed in clinical practice. the relationship between these findings on mri and cognitive impairment remains unclear. the aim of our study was to determine the relationship between lacune count, total lacune volume and location of lacunes with cognition. methods and materials: patients with lacunar stroke and wmhs were recruited to the prospective scans study. baseline data (n=121) was used for this analysis. multimodal mri and neuropsychological testing were performed. lacunes were identified and counted by a neuroradiologist on a t1 image, then mapped using an automated region growing technique. lacunar volume was calculated from the resulting masks, and lacunar location automatically determined by projection onto standard atlases. t2 wmh volume and brain volume were also measured. results: in multiple regression controlling for wmh volume and brain volume, both the lacune number and the total volume were related to a significant decrease in executive function (number: beta=-0.21, p < 0.006; volume: beta=-0.16, p < 0.04) and processing speed (number: beta=-0.26, p < 0.001; volume: beta=-0.24, p < 0.004). lacunes in the thalamus were associated with impaired processing speed performance (p < 0.002). one can infer a number of things relating to cognitive impairment when looking at an mri scan of a patient with cerebral small vessel disease. 1) the number of lacunes are a better predictor of cognitive status than diffuse wmh and 2) thalamic lacunes, in particular, are associated with impaired processing speed. purpose: to perform qualitative and quantitative analysis of altered haemodynamics of liver cirrhosis patients after tips-stent-graft implantation and volunteers using time-resolved flow-sensitive 4d mri at 3 t. our study group consisted of 5 liver cirrhosis patients including an examination before and after stent-graft implantation as well as 10 volunteers. 3d liver flow characteristics in the arteries and portal vein were evaluated using flow-sensitive 4d mri at 3 t mri with a spatial resolution of 1.6x2.1x2.4 mm³ and temporal resolution of 62.4 ms. hepatic flow visualisation was performed using 3d streamlines and time-resolved particle traces. quantitative evaluation included retrospective extraction of regional maximum and mean velocities, flow volume, vessel area as well as pulsatility and resistance indices. results: 3d streamlines and particle traces visualisation in the arterial and portal venous system could successfully be performed for almost all patients and volunteers. quantitative results reveal maximum and mean velocities tend to be lower in mri compared to doppler ultrasound, area showed significant lower values for us (p < 0.01). comparing the changes after tips-stent-graft implantation the data results demonstrated an increase of velocities and flow volume in the venous system as well as hepatic artery. conclusion: flow-sensitive 4d mri enabled a qualitative and quantitative evaluation of arterial and portal venous haemodynamics of liver cirrhosis patients before and after tips-stent-graft implantation including a volunteer group. flow-sensitive 4d mri may be a standardised method with complete volumetric and functional coverage of the blood flow haemodynamics providing additional information in patients after tips-stent-graft implantation. on a 5-point-scale. signal-to-noise ratio (snr) and contrast-to-noise ratio (cnr) was calculated with roi measurements. results: snr of the common carotid artery and middle cerebral artery was 53.6±22.7 and 43.3±15.3 (group a) versus 54.1±20.5 and 46.2±14.6 (group b). cnr was 40.0±19.3 and 29.7±12.0 (group a) compared to 40.7±16.8 and 32.9±10.9 (group b). subjective iq was excellent in both groups (mean score 4.4±0.7 versus 4.4±0.6). differences between the two groups were not significant. the osdr algorithm xcare™ does not compromise iq of head and neck cta. its application can be recommended for cta in clinical routine to protect the thyroid gland and ocular lenses from unnecessary high radiation. precision of pulmonary vein diameter measurements assessed by ce-mra and steady-state-free precession imaging f. henes, p. bannas, m. regier, j. buhk, k. müllerleile, g. adam, m. groth; purpose: to evaluate inter-and intraobserver reliability of pulmonary vein (pv) diameter measurements by contrast-enhanced magnetic resonance angiography (ce-mra) and ecg-gated 2d unenhanced steady-state-free precession sequences (ssfp). methods and materials: ce-mra and ssfp of 60 pv in 17 patients were evaluated. pv diameters were measured in transverse and coronal orientation at predefined levels by two independent readers. intraclass correlation coefficient (icc) and bland-altman analysis (ba) were used to assess inter-and intraobserver reliability and variances. f-test was performed for comparison of intra-and interobserver variances. pearson´s correlation coefficient and ba were used to compare ce-mra and ssfp. a t-test was used to determine possible significant differences between the measurements. results: there was moderate correlation (r = 0.68, transverse; r = 0.66, coronal) without significant difference in diameter measurements between ce-mra and ssfp (p = 0.15, transverse; p = 0.25, coronal). intraobserver limits of agreement (lag) ranged between ±0.50 cm (transverse) and ±0.86 cm (coronal) for ce-mra versus ±0.40 cm (transverse) and ±0.67 cm (coronal) for ssfp. interobserver agreement showed lag ranging between ±0.59 cm (transverse) and ±0.83 cm (coronal) for ce-mra versus ±0.34 cm (transverse) and ± 0.75 cm (coronal) for ssfp. only transverse ssfp measurements revealed icc > 0.75. intra-and interobserver variances did not reveal significant differences between ce-mra and ssfp in any orientation (all p-values > 0.05). conclusion: ssfp and ce-mra enable comparable precision of pv diameter measurements. however both methods revealed a wide range of intra-and interobserver agreement, which has to be thoroughly considered in the clinical use. the application of ct angiography with whole brain perfusion imaging in the evaluation of patients with transient ischaemic attack h. shi, f. yang, x. ma, w. guo, s. dong, m. qiao; beijing/cn (shihuiping@yahoo.com) purpose: to investigate the 320-row low-dose volume ct perfusion imaging combined with ct angiography in the evaluation of cerebral microcirculation changes of transient ischaemic attack (tia). sixteen cases of tia patients (male 11, female 5) underwent 320 row of dynamic volume ct perfusion imaging combined with ct angiography during 40 ml 370 mgi/ml contrast agent injection and acquired the blood flow perfusion parameters such as regional cerebral flow (rcbf), regional cerebral volume (rcbv), mean transit time (mtt), time to peak (ttp) and delay time (dly) and dynamic 4d-cta images. the measured region including the ischaemia side local lesions and the corresponding healthy side brain tissue perfusion parameters. the dynamic 4d-cta images were reconstructed to show vascular stenosis site and vascular collateral circulations. the stenosis of one side middle cerebral artery in 13 cases, one side posterior cerebral artery in 3 cases. the cbf, cbv, mtt, ttp and dly in stenosis and healthy side had statistically significant difference (p < 0.05) and the parameters were 33.9 ± 6.4 and 35.7± 6.9 ml/ (100 g •min), 2.03±0.15 and 2.11±0.18 ml/100 g, 3.88±0.66 and 3.69±0.72s, 14.43±4.20 and 13.68±4.08s, 2.09±0.85s and 1.51±0.58s. the one-stop ctp/cta imaging technique significantly improves the accuracy and efficiency in the evaluation of cerebral arteries stenosis, infarct localisation and abnormal blood perfusion and is a perfect imaging tool for the tia diagnosis. comparison of high pitch (3) and standard pitch (0.6) ct angiography using 128-slice dual-source ct in patients with peripheral arterial disease k. choo, j. park, j. kim, j. roh; busan/kr (speedsmile@hanmail.net) we investigated the effect of high-pitch (3) ct angiography with good image quality on qualitative and quantitative parameters and reduced the radiation dose in patients with peripheral arterial disease. methods and materials: eighty patients were divided into two groups; the protocol was high pitch in 40 patients group and standard pitch in the other 40 patients group. for quantitative analysis we calculated the mean arterial attenuation, the mean difference between maximum and minimum attenuation values, contrast-tonoise ratio (cnr) and figure of merit (fom). in addition, visual scores were used for qualitative evaluation. results: there were no significant intergroup differences in mean arterial attenuation (high pitch vs. standard pitch: 428.6 ± 85.6 vs. 434.3 ± 86.9 hu) and in the mean difference between maximum and minimum attenuation (high pitch vs. standard pitch: 240.1 ± 90.0 vs. 220.1 ± 98.4 hu). both the mean cnr and the mean fom were not significantly different (high pitch vs. standard pitch: 27.0 ± 10.8 vs. 28.0 ± 8.6, 2.2 ± 1.96 vs. 1.5±0.8, respectively), and there was no significant intergroup difference in visual scores. the mean dose-length product was significantly lower at high pitch than at standard pitch (408.4 ± 43.4 vs. 619.8 ± 188.4.7 mgy·cm). the high-pitch protocol ct angiography with 128-slice dual-source ct allows for reduction of the radiation dose by approximately 34% versus standard pitch protocol ct angiography with 128-slice dual-source ct without deterioration of vascular enhancement and image quality. differential diagnosis of cervical artery dissection and intra-arterial thrombosis using mri and mra m. dreval, m. krotenkova, l. kalashnikova, l. dobryinina, r. konovalov; purpose: this study aimed at exploring mri and 3d-tof mra in differential diagnosis of intra-arterial thrombosis and cervical artery dissection (internal carotid artery and vertebral artery) in different periods of disease using the contrast index. a total of 40 patients with extracranial artery dissection manifested by ischaemic stroke or isolated headache (20 men, 20 woman, mean age 37.3±6.1 years) and 8 patients (5 men, 3 woman, mean age 52.4±8.8) with ischaemic stroke due to intra-arterial thrombosis were studied. scanning protocol included 3d-tof mra sequence for extracranial internal and vertebral arteries and t1 fat suppression (f/s) sequence for neck in axial plane. mrt/mra were carried in dynamics and obtained data were analysed in 6 time intervals: 1-3 days, 4-7 days, 8-14 days, 15-21 days, 22-60 days and 61-90 days. intramural haematoma (imh), intra artery thrombus (iat) and m. sternocleidomastoid signal intensity was measured and contrast index calculated. results: after statistical analysis of the data with the use of non-parametric statistical methods (mann-whitney u test) it was revealed that value of the contrast index of imh was higher than that of iat within 2-5 time interval (4 to 60 days) (p < 0.05). the contrast index did not differ significantly within first 3 days and during 3 months. the subjective visual analysis showed the same results. conclusion: mri sequences as t1 f/s and 3d-tof mra could be useful for differential diagnosis of imh and iat within the interval of 4 days to 2 months of the disease. impact of organ-specific dose reduction on image quality of head and neck ct-angiography r.s. lanzman, l. schimmöller, p. purpose: assessment of coronaries on patients with high heart rate (hr) using present generation ct is challenging due to an increase of vessel motion. the purpose of this study was to evaluate the performance of a novel coronary motion compensation algorithm on patients with a hr > 60 bpm. prospective or retrospective ccta scans on 15 patients with minimum hr of 60 (mean: 72) where acquired using a discovery ct750 hd (ge healthcare, waukesha, wi) and reconstructed using conventional ccta reconstruction algorithm (std) and novel coronary motion compensation algorithm, snapshot freeze (ssf). two senior cardiovascular radiologists evaluated diagnostic image quality of 13 coronary segments in a blinded manner using a 4-grade scale (1 non-diagnostic, 4 excellent). 186 coronary segments were assessed. results: overall number of diagnostic segments was higher using ssf compared with std (95% vs. 85%). overall average score of ssf reconstructed segments was significantly higher compared with std reconstruction ( purpose: to evaluate the feasibility and imaging quality of double prospectively ecg-triggered high-pitch spiral acquisition mode for coronary computed tomography angiography (ctca) in patients with atrial fibrillation (af). methods and materials: 47 patients (11 women, 36 men; mean age 64.5±12.1 years) were enrolled for ctca examinations using a dual-source ct with 2×128 × 0.6 mm collimation, 0.28 s rotation time and a pitch of 3.4. double high-pitch mode was prospectively triggered first at 60% and later at 30% of the r-r interval within two cardiac cycles. image quality was evaluated using a four-point scale (1 = excellent, 4 = non-assessable). results: from 672 coronary artery segments, 77.5% (521/672) was rated as score of 1, 20.8% (140/672) as score of 2, 1.2% (8/672) as score of 3 and 0.4% (3/672) was rated as 'non-assessable'. the average image quality score was 1.25±0.38 on a per segment basis. mean dose-length product (dlp) for ctca was 92.6±28.2 mgy·cm, the effective dose was 1.30±0.39 msv (0.64-1.97 msv). in patients with af, double prospectively ecg-triggered high-pitch spiral acquisition could be a feasible and valuable scan mode for ctca with a consistent dose below 2 msv as well as diagnostic imaging quality. coronary artery calcium scoring from dual-source chest ct: purpose: to assess the concordance between ungated, high-pitch (thoracic) and ecg-gated (cardiac) examinations in the assessment of coronary artery calcium (cac) score. methods and materials: 185 smokers (mean heart rate: 71.9 bpm) underwent dual-source ct examinations with acquisition of two sets of images during the same session: (a) an ungated, high-pitch scan over the entire thorax (pitch: 3.0, temporal resolution: 75 ms) (group 1); (b) a prospectively ecg-gated scan over the cardiac cavities (group 2). two operators independently analysed the cac load on both examinations and categorised the population according to the agatston score. results: the interobserver reproducibility was good for both techniques (group 1: kappa=0.90, group 2: kappa=0.89). the mean absolute values of the agatston score did not significantly differ between groups (p=0.18). there was good reproducibility between the two techniques in classifying the population according to the commonly used cutoffs (kappa: 0.90). the ungated technique adequately categorised 172 out of the 185 patients (93); in the 13 discordant cases (13/185; 7), the ungated studies yielded lower scores than gated studies, with no more than one score category misplaced by the ungated studies. bmi and heart rates did not significantly differ between concordant and discordant scores (p=0.81, p=0.21, respectively). differences in cac scores between techniques were correlated to differences in the cac scores at the level of the right coronary artery (r=0.98; p=.0001). conclusion: despite the mean heart rate of the studied population, a good concordance in assessing the cac scores was found between ungated, high-pitch and ecg-gated examinations. diagnostic accuracy of free-breathing coronary cta using dualsource ct high-pitch acquisition: comparison of single and double scans with conventional angiography m.c. so 1 , w.l. chin 2 , c.m. wong 1 , c.w. tai 1 , m.w. leung 1 ; 1 hong kong/hk, 2 singapore/sg (ninamc_so@yahoo.com.hk) purpose: to retrospectively investigate whether two subsequent prospectively ecg-gated high-pitch ct acquisitions can increase the diagnostic accuracy of coronary ct angiography (ccta) for free-breathing patients compared with a single acquisition and conventional angiography. methods and materials: twenty-one patients (8 male, 13 female, mean age 77.2 years) with heart rates < 60 bpm unable to hold their breath underwent two immediately subsequent free-breathing ccta scans in dual-source ct prospectively ecg-triggered high-pitch mode, followed by conventional angiography within 1 month. ccta data and conventional angiograms were evaluated by segment by two different observers. ccta image quality was rated on a four-point scale (1 = excellent to 4 = unevaluable) with ³50% diameter stenosis considered significant. purpose: radiation exposure reduction in cardiac cta using a novel iterative reconstruction algorithm (aidr3d) with automatic exposure control (aec). methods and materials: 60 patients were examined on a 320-row detector ct (aquilionone, toshiba medical systems) using 100 kv, 8-12 cm z-axis, 350 ms acquisition time, 0.5 mm slice thickness and 320 mm fov. contrast medium injection was performed using a standardised protocol with 0.66 mg iodine per kg body weight. group 1 (g1) consisted of 30 patients (bmi=25.7±3.6 kg/m2, hf=54.9±7.4 bpm) examined using bmi adapted tube current (140-580 ma) and a fbp reconstruction algorithm in combination with advanced noise reduction filters. in group 2 (g2) 30 patients (bmi=25.7±3.7 kg/m2, hf=58.3±7.8 bpm) were examined using the novel reconstruction algorithm aidr3d. for aec a target noise of 33 hu was predetermined. analysis was performed using circular regions of interests placed into the descending aorta (da), left ventricular lumen (lv) and myocardial wall (mw). signal-and contrast-to-noise-ratio (snr, cnr) were calculated. doselength-products (dlp) were recorded and effective doses were estimated. results in g1 and g2 were compared using an unpaired t-test. results: both snr and cnr differed significantly in both groups: snr in g1 and g2 were 19.5±6.6 and 23.0±5.3, respectively, in da (p=0.025) and 12.7±4.4 and 20.4±4.5, respectively, in lv (p < 0.001). cnr in g1 and g2 were 9.3±3.7 and 19.3±5.0, respectively (p < 0.001). effective dose was in g2 (0.88±0.34msv) 24% less than in g1 (1.15±0.46msv; p < 0.011). conclusion: aidr3d with aec allows for significant radiation dose reduction compared with advanced fbp reconstruction with bmi-adapted exposure. image quality parameters in the aidr3d group were superior to the reference group indicating further dose reduction potential. purpose: the verbal interaction between the child and the radiographer in the radiographic examination is an unexplored, but important area of clinical practice. the aim of this study was to investigate the nature of that interaction between child and radiographer and the extent to which it varied as a function of the child's age. the participants in the study were 20 female radiographers and 32 children (3-15 years) examined for acute injuries. the verbal interactions of child and radiographer during the examination were videotaped and analysed using the roter interaction analysis system (rias). descriptive and non-parametric statistics were used to analyse the interaction data. the results revealed that 80% of the verbal interaction was carried out by the radiographer either to the child or to an escorting parent, while 17% was carried out by the child and 3% by the parent. of the radiographers' communication directed to children, 78% was categorised as task-focused exchange and 22% as socio-emotional exchange. of children's utterances, 34% was categorised as a task-focused exchange and 66% involved socio-emotional exchange. the distribution of task-focused and socio-emotional utterances varied with regard to children's age. more frequent utterances and more frequent socio-emotional exchange were found for interactions involving younger children. conclusion: these findings reinforce the need for radiographers to be flexible and sensitive in their interactions with children and to recognise the child's individual and developmental capabilities when engaging them in radiographic procedures. requesting x-rays at the right time to utilise the capacity of the radiology department: an everyday challenge m. mowinckel-nilsen; os/no (milh@helse-bergen.no) purpose: historic data shows that delayed ordering of x-rays makes it difficult to optimally utilise the capacity of the radiology department in a small orthopaedic hospital. what could be done to improve this? methods and materials: a method called patient-focused redesign (developed by leicester royal infirmary, adapted to norwegian conditions by ringerike hospital hf) was used as a tool to find a better workflow in ordering x-rays. a multidisciplinary team was assembled, and a project outline was made with a process demarcation. the team prepared a communication plan, mapped the current workflow, had a creative phase redesigning a new workflow, and measured the situation before the new workflow was tested in the hospital. an analysis of the old and new workflow was made. evaluation was done after the new workflow had been in place for 1.5 years; new measurements were done to see the effects of the changes in the workflow. results: numbers of steps in the workflow were halved, saving time for several professions. x-ray examinations not ordered on time were reduced by 76.5%. examinations ordered a week or more before the images were taken, which is within the desired timeframe, were increased by 64.1%. conclusion: patient-focused redesign is a good method for finding better and more efficient workflows; it can save time, increase the exploitation ratio of the equipment, and ultimately increase the quality of the radiographic service. discrepancies between ct and conventional angiogram results were resolved by consensus together with a third observer. sensitivity, specificity and accuracy of single and double high-pitch scans were calculated on a per segment basis. estimated effective radiation doses were calculated using dose length product x 0.014. results: ccta images were diagnostic for 86% (243/283) and 97% (276/283) of segments for single and double scans, respectively, and sensitivity, specificity and accuracy were 100%, 88%, 90% and 98%, 95%, 95%, respectively. the mean estimated effective radiation dose was 1.3msv and 2.5msv, respectively. in patients with heart rates ²60 bpm, free-breathing ccta using dual source ct double scans in high-pitch acquisition mode was associated with high diagnostic accuracy for the assessment of coronary artery stenosis at a very low effective radiation dose. author disclosures: w.l. chin: employee; siemens medical solutions. one beat coronary ct angiography using 640 slices multidetector ct scanner in patients with atrial fibrillation to evaluate image quality and ionising radiation doses of ct coronary angiography using 640-slices multidetector ct in patients with atrial fibrillation (af). methods and materials: 28 patients that have persistent af with median heart rate of 75 bpm underwent coronary ct angiography using 640-slices multidetector ct with adaptive iterative dose reduction system. all ct examinations were performed using a one-beat prospective gating; in patients, that presented heart rate > 65 bpm, was used a broad phase window width (30-85% of r-r). the effective dose was assessed for every patient. coronary arteries were subdivided into 15 segments using the american heart association's (aha) model. image quality was evaluated by two expert radiologists on a workstation (vitrea, toshiba) using a 4-score grading system: score 1 (absence of motion artefacts), score 2 (presence of mild artefacts), score 3 (presence of moderate artefacts) and score 4 (presence of severe artefacts). median score of both radiologist and inter-rater reliability (k coefficient) were assessed. results: image quality was judged excellent (score 1) in 65.4% of coronary artery segments (275/420), good (score 2) in 22.7% (95/420), fair (score 3) in 7.1% (30/420) and low (grade 4) in 4.8% (20/420). mean effective dose was 3.35msv (range between 1.3 and 7.9 msv). inter-rater reliability was excellent (k=0.85). conclusion: high image quality and low ionising radiations effective doses demonstrate that the newest generation of ct scanner overcome the limitation at coronary ct angiography that atrial fibrillation poses so far. influence of aidr on accuracy of plaque characterisation and lumen assessment during ct coronary angiography a. ursani, h. mehrez, h. kashani, n. paul; toronto, on/ca (ali.ursani@uhn.ca) purpose: to determine the impact of adaptive iterative dose reduction (aidr) on accurate lumen assessment in a custom-built arterial plaque phantom. methods and materials: custom-built 10 cm coronary artery phantom with 6 x 3.5 mm (g1) and 6 x 5 mm (g2) vessels, lumen stenosis 0, 30, 50, 70, 90 and 100% due to 400 hu and 800 hu plaque; and 3 x3.5 mm (g3) and 3 x 5 mm (g4) vessels with lumen stenosis 30, 50, 70% due to -60 hu and 60 hu plaque. the lumen measured +400 hu. volume ct (vct) was performed; spatial resolution 350 μm with low-and high-resolution kernels (fc04, fc30, fc90), 120 kvp and 150 ma. 0.5/0.35 mm axial images were reconstructed ± aidr. in-line histography mapped average plaque ct# (hu) and average lumen ct# (hu) and vessel profile. in was measured and image contrast (c) calculated. results: lumen stenosis contrast data for soft filter kernel fc04 and calcified plaque 800 hu: without aidr: g1:30%=894/705; 50%=910/602; 7 0 % = 7 8 4 / 5 5 0 ; 9 0 % = 6 0 0 / 4 0 0 ; g 2 : 3 0 % = 9 1 9 / 5 5 0 ; 5 0 % = 9 1 5 / 5 0 0 ; 70%=864/400;90%=413/360. with aidr: g1: 30%=870/602; 50%=890/530; 70%=770/490; 90%=580/345. g2: 30%=900/620; 50%=898/544; 70%=856/562; 90%=400/330 aidr improved mean contrast ~10% for calcified plaque and 15% for non-calcified plaque for all reconstructions with 30-70% luminal stenosis (paired t-test, p²0.001). aidr improved accurate representation of 90% lumen stenosis in 3.5 mm vessels. conclusion: aidr improves plaque image contrast by 10-15% and visualisation of high-grade stenosis in 3.5 mm coronaries. this promises superior performance for accurate coronary plaque characterisation and lumen assessment. results: analysis of the results for the area under the curve (auc) demonstrated statistically significant differences in the accuracy of fracture identification between groups (p value < 0.032), when categorised with respect to post-graduation clinical experience. radiographers with greater and less than 3 years clinical experience scored mean az scores of 0.737 and 0.716, respectively. a trend in increased performance and increased clinical experience was also demonstrated with a mean increase of 9.2% and 8.8% in terms of sensitivity and specificity, respectively. conclusion: radiographers with increased clinical experience performed the most accurately with respect to auc, sensitivity and specificity findings. hospital category did not influence the radiographer's performance in this investigation: university teaching centre versus large regional centre. the acceptable standard following post-graduate image interpretation training is 80-95% in terms of accuracy of skeletal fracture identification. graduate training programmes/cpd modules in clinical decision making are recommended as is a survey on a national scale to incorporate a larger sample size. purpose: to accurately measure the workload of radiographers and sonographers for the first time in the uk and compare them with that of consultant radiologists in a dgh. reporting data for sonographers, radiologists and reporting radiographers at a large dgh was taken from electronic records. these were converted into an rvu score using an adapted version of the pitman-jones rvu system. reporting workload was calculated by dividing the total rvu scores by the number of pa spent reporting images by members of each group. results: there were 9 sonographers working 80.5 pa/week, 2 reporting radiographers worked 10 pa/week, and 14 consultant radiologists working 158.21 pa/ week during the period april 2010 -march 2011. sonographer workload amounted to 1,955.9 rvu per pa per year (rvu/pa/year). radiographer workload was to 4,277 rvu/pa/year. crude consultant radiologist workload was 4,106 rvu/pa/ year, but they spend 42.49% of their time on non-reporting activities, giving a net score of 7,140 rvu/pa/year. the reporting radiographers and sonographers make a valuable and significant contribution dealing with the increasing radiology workload. however, radiologists are more productive per pa. differences in pay grades makes costeffectiveness between the groups more equal. radiographer's expectations for role development: a national survey in view of radiography students in final year of graduation c.m. mendes, a.f.c.l. abrantes, r.p.p. almeida, l.p.v. ribeiro, s.i. rodrigues; purpose: to investigate the role development expectations of graduate radiographers with a view to predicting the potential impact of a misalignment of these expectations on quality of the service delivery and staff retention. a self-applied questionnaire development by williamson and mundy (2009) in uk was validated for the portuguese language by the backtranslation method with permission of the authors and assigned to radiography students in final year of graduation in the portuguese health schools. a total of 84 valid questionnaires, in the likert scale format, utilised 20 attitude questions in relation to main themes of research (expectation, valence and knowledge) and were interpreted and statistically analyzed through descriptive statistics and spearman's rho correlation. the radiography students stated an expectation for role development opportunities with 66.7% indicating that these expectations would be realized within 2 (50.0%) and 5 (29.8%) years of graduation. a significant and strong positive correlation (r=0.791, p=0.000) between job satisfaction and expectation for role development in 5 years after graduation was seen. farther, there were no significant differences between the health schools for the expectation, valence and knowledge. conclusion: there is an expectation and value assigned for role development opportunities. expectation is seen to be intrinsically linked with job satisfaction suggesting that misalignment of this would have a potentially negative impact on motivation and retention of the future radiography workforce. however, there is risk management in computed tomography using an incident reporting system m. antoniutti, s. doratiotto; treviso/it (sdoratiotto@alice.it) purpose: improving the management of patient safety by adopting best management practices for the governance of the system and the corporate network. methods and materials: analysis of the critical situation in the diagnostic computed tomography (ct) performed in 2009-2011 with incident reporting system (ir) using the instrument of audit and definition of improvement actions. results: improving actions have been taken together with a method of monitoring the most critical issues with greater severity or frequency of occurrence in the ct process. critical areas: high number of booking errors from the radiological studies of central booking, inappropriate requests by general practitioners (gps). improvement action (ia): organization of the audit with gps, the final shared document has been spread through the internet site. high number of patients not adequately prepared for the examination (non-hydrated, non-fasting, incomplete clinical information, and incomplete filling of the informed consent form examination). ia: a letter from the chief of radiology was sent to all departments to alert that requests for ct must be sent in. radiology correctly completed and audit with gps. errors found in pacs. ia: correction of pacs errors and permanent organization of audit. conclusion: this project helped the development of effective interventions closely related to the understanding of the organization's critical work in the ct process with the need to streamline the planning ct scan of the list to avoid an incongruous workload and to give each patient the right welcome. internal audits and permanent working groups have been proposed to actuate effective remedial actions. is a radiographer-led immediate reporting service for emergency department referrals a cost-effective initiative? m. hardy 1 , b. snaith 2 ; 1 bradford/uk, 2 wakefield/uk (m.l. hardy1@bradford.ac.uk) purpose: demand for both emergency department (ed) and radiology services continues to increase across the uk while simultaneously, healthcare organisations are being asked to evaluate the quality of care provided and constrain service costs. national guidance on radiograph reporting times recommends ed radiographs are reported on day of patient attendance but in practice, delays in reporting persist. this study considers whether a radiographer-led immediate reporting service for ed referrals could provide a cost-effective service improvement solution. a pragmatic multi-centre randomised controlled trial was undertaken. 1502 patients were recruited and randomly assigned to an immediate or delayed reporting arm and treated according to group assignment. patient health gain was measured in terms of change in utilities derived from eq-5d responses at baseline and 8-week follow-up. resources used and the costs of an immediate reporting service were analysed at the patient level and compared to standard reporting practices. results: 1688 radiographic examinations were performed (1502 patients). 79 discordant radiographic interpretations were identified (n=79/1688; 4.7%). interpretive errors were significantly reduced within immediate reporting arm. no significant difference was noted in the relative improvement in patient perceived health status between the 2 arms of the study. the average cost saving per patient in the immediate reporting arm £23.40. conclusion: radiographer-led immediate reporting of ed radiographs is a cost-effective service development and its universal introduction could make a significant contribution to the current drive to increase service productivity within current budget constraints. an investigation into the ability of irish radiographers: in the identification of wrist and scaphoid fractures a.p. tyrrell 1 , l. rainford 2 ; 1 kilkenny/ie, 2 dublin/ie (louise.rainford@ucd.ie) purpose: to investigate the ability of irish radiographers in identifying and locating wrist/scaphoid fractures, to add to the evidence base for role expansion. in total, 25 radiographers across two university teaching and two large regional hospitals in ireland participated. the computer application ziltron demonstrated 71 plain film wrist radiographs in a free-response operating characteristic (froc) study. the data set contained 35 abnormal images (fracture (s) present) and 36 normal (non-fracture). "truth" was determined by the radiology report. fracture were categorised: obvious to subtle. statistical analysis was performed by jafroc application. friday provides insight into the influence of technology on the professional development and practice in this field. in august 2011, a postal questionnaire was distributed to 521 hospital sites across the uk operating both a radiography and trauma service. information was sought relating to: the type of trauma and radiography service operated; details of the rads operated, including education and audit to support radiographer participation; the mandatory/voluntary status of the rads; and the imaging technology operating within the organization. results: a total of 328 (n=328/521; 63.0%) responses were received within the defined timeframe. analysis of the data is ongoing but will include a descriptive summary of current practice across the uk with regard to "red dot", commenting and reporting by radiographers and assessment of the impact on the implementation of digital imaging technology across the uk on service levels compared to an earlier survey undertaken in 2007. conclusion: radiographer contribution to the interpretation of trauma images is an expectation of uk radiographer practice. whether the profession has moved forward in its readiness to progress beyond "red dot" and embrace commenting is yet to be seen and this presentation will provide an insight into practice boundaries and variations that exist. 14:00 purpose: diagnostic value of dynamic contrast-enhanced perfusion mri in detection and characterisation of endometrial cancer, correlated with tumour grading, being the histopathological analysis as the standard of reference. a total of 80 patients with histologically proven endometrial carcinoma underwent a dedicated pelvic mri examination (1.5 t system, achieva, philips), using high-resolution pelvic phased array multicoil. each patient scan a lack of social recognition of the radiographer, suggesting the need to promote measures to increase the profession recognition. job satisfaction among radiographers in switzerland: a national survey n. richli meystre, p. lehmann, n. mamboury; lausanne/ch (nicole.richli@hesav.ch) purpose: the technological improvements in radiology over the past decade have resulted in an important rise in demands for radiological examinations and treatments. an increasing number of well qualified radiographers are needed and healthcare authorities are worried about the growing shortage of radiographers. job (in)satisfaction has been highlighted as a contributing factor to turnover, respectively, to long-time retention. the aim of this survey was to appreciate workplace conditions and job satisfaction among radiographers. methods and materials: all radiographers working in switzerland were invited to participate with an online questionnaire. different factors contributing to job satisfaction were scored from -2 (very unsatisfied) up to +2 (very satisfied). results: 753 radiographers completed the questionnaire. the response rate is estimated at 26%. 62% are working in diagnostic, 23 % in nuclear medicine and 15% in radiooncology. 37% are working for more than 10 years in the same place. the overall job satisfaction level was scored at 0.66. the highest levels were reached for the diversity of job activities (+1.19), the quality of radiology facilities (+ 1.16), teamworking (+1.03) and autonomy (+1.03). the lowest levels were reached for collaboration with radiologists (+0.23), salary (+ 0.17) and career opportunities (0). conclusion: radiographers in switzerland are rather satisfied about their job and the workplace conditions. in order to avoid shortage, efforts should be taken to increase the number of radiographer students and in supporting returnees. jobenrichment measures are seen as a necessity for retention in a profession with low career opportunities. progression of quality improvement works in radiography by radiographers r. gullien, j.g. andersen, a.e. haakull; oslo/no (uxraul@ous-hf.no) purpose: to visualise the ongoing progression over years in quality improvement work in radiography by radiographers and share our experiences. methods and materials: 1) as a basis through the entire improvement work, the national quality assurance manual (qam) that specifies how to measure the quality assurance work was used. 2) practiced the method in the department as basic measurement individual and overall measurements (static/snapshot). 3) individual and overall measurements recorded several times over a period to see changes (dynamics/moving range) (local). 4) implemented targeted improvements. 5) measured inter-variability among the quality control (qc) radiographers. 6) training the qc radiographers to avoid differences between them. 7) national meeting with representatives from all counties (national). 8) comparison across the counties and input to the audit of the qam. 9) cooperation with hospital outside norway, benchmarking the system, comparison across countries (international). results: radiographers were trained by self-assessment: their knowledge was updated, their skills were developed, their attitude to regular audit was changed and improved, their own performances against international and national standard and objectives were reviewed. targeted initiatives against unacceptable variances in performance are necessary. time set aside to allow radiographic quality assurance work, analysing, evaluating and act accordingly. qc radiographers have the responsibility of ensuring the essential quality improvement and assurance work. conclusion: progression is from snapshot/static to dynamics/moving range, from general to focused measures, from local to national, from national to international. quality improvements became more and more complex over time. advancements and developments are important in addition to the continuous implementation of basic training and instructions. radiographer contribution to the interpretation of trauma radiographs: a survey of uk practice b. snaith 1 , m. hardy 2 , e. lewis 1 ; 1 wakefield/uk, 2 bradford/uk (bev.snaith@midyorks.nhs.uk) purpose: radiographer abnormality detection schemes (rads) were introduced in the uk in the mid-1980s with the development of the "red dot scheme". this presentation reports the findings of a new survey and establishes the current position of rads (including "red dot", commenting and reporting) across the uk and was with the obturator in 12 cases and with the internal pudendal in one case. the angle of origin of the uterine artery on the right side showed a mean of 53.2° (sd: 25.23, range: 0°-98°). on the left side the angle showed a mean value of 54.8° (sd: 17.72, range: 19°-91°). the uterine artery arises typically directly from the iia anterior division. atypical origins like origin from the iia main stem or from the iia posterior division should be searched for when the artery could not be found in its typical location. fibre tracking evaluation of sacral nervous pathways 3d architecture in women affected by endometriosis m. sergi, v. vinci, s. bernardo, p. sollazzo, m. saldari, l. manganaro; rome/it (mariaeleonora.sergi@gmail.com) purpose: to evaluate feasibility of tractography to study sacral nerves in women affected by pelvic endometriosis. we enrolled 2 groups of patient: 25 women with us diagnosis of endometriosis and a control-group of 10 women. with 3 t mri, we reconstructed nervous pathway postprocessing dti images. we analysed 2 main parameters: 3d architecture of nervous pathways and fractional anisotropy values (fa). we analysed fibres length and branches morphology, thereafter we assigned to each a range of values obtaining 3 main classes of pathways: 1 st class (normality, 3-4), 2 nd class (mild alteration, 5-6) and 3 rd class (severe alteration, 7-8). results: analysing 3d nervous pathways, we obtained a homogeneous distribution of the control group (10pt) in the first class (normal pathways). all cases of endometriosis of the posterior compartments (18/25 patients) presented an abnormal pathway (3 rd class), while remaining cases with anterior-medial localisation were equally distributed in 1 st and 2 nd class. we obtained low fa values in both groups; however, in case-control group range values were included between 0.47 and 0.34 while in patient groups fa values were lower between 0.36 and 0.24. conclusion: fibre tracking allowed a complete evaluation of the female pelvis defining the global situation of the patient and leastly formulating a potential explanation to symptoms. fibrotic reaction, adhesions and nerves growth stimulation factors may explain both of the altered branch morphology and the lower fa values. we suggest tractography as a complementary tool for the female pelvis study, representing the only non-invasive way to study nervous pathways. purpose: to verify whether mri accuracy in diagnosing deep infiltrating colorectal endometriosis (dice) can be improved using an association of two selected findings. laparoscopy or histopathology was taken as the gold standard. methods and materials: imaging database of our institute was retrospectively reviewed. t2-weighted mr images were evaluated by two experienced radiologists using two criteria. first, not thickened or thickened intestinal wall surrounded by fat-plane interface represents a normal result; nodules/hypointense plaque-like lesions in the adjacent fat-plane joint to thickened intestinal wall are considered an abnormal result. second, not thickened or thickened intestinal wall surrounded or not by fat-plane interface represents a normal result; nodules/hypointense plaque-like lesions in the adjacent fat-plane joint to thickened intestinal wall showing "radiating retracting shape" are considered an abnormal result. a third radiologist looked in medical history for laparoscopy and histopathology. mri results were compared with laparoscopy or histopathology findings by 2 x 2 tables and were statistically analysed (k statistics). .30 years) with clear symptoms attributable to pelvic floor dysfunction. all patients were given a questionnaire designed to obtain physiological data (age, gender, bmi) and pathological (diabetes, comorbidities, previous pelvic surgery). the mri provided a morphological study with t2-weighted sequences in the axial sagittal and coronal plane and an cinematic fiesta (fast imaging employing steady-state acquisition) in the sagittal plane at rest and during the phase of maximum straining, to measure the line pubo-coccygeal (pcl), the line h (pelvis diastasis) and the m (lower pelvis). results: bmi correlated significantly with h (p = 0.037) and pcl (p = 0.026), while age correlated with h (p = 0.009) and m (p = 0.004). the parity but not the number of children causes a significant increase in pelvic lowering (p = 0.038) as well as previous pelvic surgery (p = 0.038). the pathophysiological changes are predictive of morphometric parameters obtained with mri. because of its fast acquisition a cinematic sequence could be advisable in all study protocols of female pelvis. origin of the uterine artery in females using three-dimensional reconstructed contrast-enhanced mr angiography before uterine purpose: to describe the patterns of origin of the uterine artery from the internal iliac artery (iia) before uterine artery embolisation (uae) using three-dimensional (3d) reconstructed contrast-enhanced mr angiography (ce-mra). the study was retrospectively performed on 84 females (mean age 45.5 year). pre-embolisation ce-mra was performed before uae. 3d images were reconstructed using syngo-vesselview application. for each uterine artery the point of origin was identified and the angle which the artery makes with its main stem of origin was calculated. the uterine artery was detected in 165 (98.2%) of the 168 (84 patients) arteries. the artery originated directly from the iia anterior division in 141 arteries of the detected arteries (85.5%), from the iia bifurcation point in 7 arteries (4.2%), from the iia main stem in 3 arteries (1.8%) and 1 uterine artery (0.6%) originated from the iia posterior division. the uterine artery originated indirectly from the anterior division with a common segment in 13 arteries (7.9%). the common origin friday measured on the mr console and compared among positions. the obstetric conjugate and the sagittal inlet and outlet were both assessed in the midsagittal plane. results: mr pelvimetry in the different positions proved feasible in all subjects, yielding diagnostic quality images in every volunteer and pregnant woman, although the hand-to-knee positions were found difficult to maintain. in the hand-to-knee position, pelvic inlet reduced from 13.3 cm to 13.0 cm and obstetric conjugate from 12.6 cm to 12.3 cm. in contrast, sagittal midpelvic diameter enlarged from 13.3 cm to 13.6 cm, pelvic outlet anteroposterior diameter from 11.5 to 12.0 cm and sagittal pelvic outlet diameter from 8.7 cm to 9.1 cm. our results showed that a hand-to-knee birthing position expands sagittal midpelvic diameter, pelvic outlet anteroposterior diameter and sagittal pelvic outlet diameter, suggesting facilitation of labour and delivery. retrospective analysis of elements that can predict short-and longterm outcome in patients affected by uterine leiomyomas and treated with mrgfus purpose: to retrospectively evaluate predictive factors to obtain an optimal treatment of uterine fibroids treated using magnetic resonance guided focused ultrasound (mrgfus). methods and materials: 68 fibroids (52±18 mm) in 55 symptomatic women (age average 40±5) were treated using mrgfus (exablate 2100) combined with a 3 t mr unit (ge). t2 si and t1 si of fibroids were measured on pre-treatment examination before and after administration of gadolinium (gd-bopta, bracco); also the distance between centre of myoma and skin, skin thickness, maximum diameter and volume of fibroids were recorded. the day of treatment the non-perfused volume (npv) was recorded at the end of the treatment. it was considered treatment time in terms of energy (j) used and duration of single sonication. all parameters were related to final npv and volume shrinkage at 12 months to established short-and long-term results of treatment. results: difference between t1 si of the fibroids and healthy myometrium significantly correlates with volume shrinkage (45%) and npv (60%, r=0.85). t2 si on pre-treatment studies, distance between skin surface and centre of myoma (53±19 mm) and skin thickness (13±7 mm) show a mild correlation with volume reduction at 12 months (36+18 mm, respectively r=-72.5 p=0.047 and r=69.7 p=0.03).moreover, there was positive correlation between measured parameters, sonication duration and energy necessary to obtain a > 50% npv (70±15%, r= 62.8, p=0.021). conclusion: si ratio on t1w of uterine fibroids and myometrium on screening mri should be considered as predictor of positive outcome for mrgfus treatment. 14:00 purpose: we evaluated feasibility of 3 t system in the detection of endometriosis implants in the douglas pouch, in order to offer a precise preoperative diagnosis of deep infiltrative endometriosis involving this particular region. methods and materials: from october 2010 and april 2011, we enrolled 19 women coming with either ultrasound or anamnestic suspect of endometriosis. pelvic mri examination was performed on 3 t system. we theoretically divided female pelvis in three compartments and concentrated on the posterior one, evaluating, in particular, the uterosacral ligaments and the specific signs of posterior cul-de-sac obliteration. results: mri diagnosed posterior cul-de-sac obliteration in 15/19 patients. we detected in 5/15 cases nodular endometriosis implants in pcs; signs of fibrotic plaque on the uterine serosal surface were identified in 4/15 cases; 3/15 cases showed a tethered appearance of the rectum, 6/15 cases presented an elevation of the posterior vaginal fornix. in 3/15 cases strands between uterus and intestine was clearly depictable, at last, involvement of utero-sacral ligaments (usls) and signs of utero-sacral ligaments involvement were identified in 6/15 cases. moreover, glandular-like collection localised behind uterus was identified in 7/15 cases. mri findings were compared with laparoscopy, thus obtaining a sensitivity value of 93%, and specificity value of 75% conclusion: precise preoperative mapping of posterior cul-de-sac region is essential for a preoperative planning. in our work 3 t mri revealed excellent in the evaluation of posterior cul-de-sac obliteration associated with an optimal evaluation of the utero-sacral ligaments, due to the higher contrast spatial resolution. diffusion-weighted magnetic resonance imaging of the female pelvis: do apparent diffusion coefficient values of the fat tissue change over the menstrual phases? purpose: to establish whether the apparent diffusion coefficient (adc) measured with dwi in the pelvic fat tissue of healthy reproductive-age women significantly varies from the proliferative to the periovulatory phase of the menstrual cycle. methods and materials: 27 women (18-40 years) , not assuming oral contraceptives nor referring any vaginal discharge or abnormalities of their menstrual cycles, underwent pelvic dwi (1.5 t, 8-channel coil, sagittal scans, b values: 0 and 800 mm/sec2) both at the 5 th day after the beginning of the menstruation and repeatedly every day in the periovulatory phase; among these latter examinations, the one corresponding to the 14 th day before the subsequent cycle was retrospectively selected. an adc value resulting from the average of three measurements obtained at slightly different position was calculated for each examination within a circularshaped, 4-mm diameter region of interest totally included in the adipose tissue of the ischiorectal fossa. the statistical significance of the differences between the adc values measured in the two menstrual phases was determined using the student's t-test per paired data. the adc values measured in the pelvic adipose tissue in the proliferative phase of the menstrual cycle (mean: 0.765 mm2/sec, range: 0.26-1.26) were higher than those obtained in the periovulatory phase (mean: 0.558 mm2/sec, range: 0.24-0.89). the difference was highly significant at statistical analysis (p < 0.001). the adc values measured with dwi in the pelvic adipose tissue of healthy reproductive-age women are significantly higher during the proliferative than in the periovulatory phase of the menstrual cycle. purpose: to evaluate alzheimer's disease premature diagnosis based on spectroscopy mri. we carried out a prospective study on 178 patients (116 women and 62 men) whose ages ranged 27 to 68 years (mean age 65 ± 12). every patient presented mild or moderate cognitive impairment according to reisberg score (3-4 grade). standard brain mr and spectroscopy brain mr were performed using a 3 t intensity mri device (archieva tx, philips healthcare, best, the netherlands). spectroscopy mr was focused in posterior parietal and frontal lobes gray substance using a unique volume (20 x 20 x 15 mm) and two different echotimes, te (32 and 136). morphology and volume of temporal lobes were evaluated through flair coronal images which were used to quantify temporal horn width and so classify patients in four groups. jmrui (java magnetic resonance user interface) was used to calculate quantitative parameters in mr spectroscopy. mr was used to measure: calculation of naa (n-acetyl aspartate), cr (creatinine), cho (choline) and mi (myo-inositol) metabolites ratios. we used analysis of variance to compare metabolite ratios between the different patient groups previously defined. results: we found significant differences (p ² 0.05) between groups in naa/cho concentration (p=0.022), both in long and in short eco times and frontal and parietal anatomical regions. no other significant differences between groups were found. conclusion: mr spectroscopy could increase efficiency in alzheimer's disease premature diagnosis as well as turning out to be a useful additional tool for the clinician next to clinical history. differentiating multiple system atrophy and parkinson's disease on 3 t mri: a novel use of decision tree s. rajandran nair, l.k. tan, n. ramli, s.y. lim, k. rahmat, h. mohd nor; kuala lumpur/my purpose: differentiation of multiple system atrophy (msa) and parkinson's disease (pd) remains a clinical challenge. the purpose of this study was to develop a decision tree using parameters obtained from standard mri and diffusion tensor imaging (dti) to distinguish these clinical entities. we performed standard mri brain and dti at 3.0 t on 26 pd and 13 msa patients. linear, volumetry and dti (fractional anisotropy, fa and mean diffusivity, md) of putamen, substantia nigra, pons, middle cerebellar peduncles (mcp) and cerebellum were measured. a three-node decision tree was developed, with the aim of 100% specificity at node 1, 100% sensitivity at node 2 and highest combined sensitivity and specificity at node 3. results: mean mcp width, anteroposterior diameter of pons and mean fa mcp with cut-off values of 14.6 mm, 21.8 mm and 0.55 respectively, were selected for the decision tree from nine parameters (mean width, fa and md of mcp; anteroposterior diameter of pons; cerebellar fa and volume; pons and mean putamen volume; mean fa substantia nigra compacta-rostral) that showed statistically significant (p < 0.05) differences between msa and pd. the decision tree accurately classified 12 out of 13 msa patients with an overall 92% sensitivity, 96% specificity, 92% ppv and 96% npv. the decision tree could be used as a diagnostic algorithm in the differentiation of msa and pd. subthalamic nuclei 3 tesla t2-relaxometry correlated to updrs scores in pre-deep brain stimulation ( purpose: degeneration within the subthalamic nucleus (stn) in parkinson's disease (pd) is a potential marker for targeting dbs. we aimed to investigate whether pre-and postoperative unified parkinson's disease rating scale (updrs) scores are related to t2 relaxation (t2r) of the stn and whether there is a correlation of laterality between clinical assessment and t2r. methods and materials: 12 patients and 14 controls were examined at 3 tesla by a multicontrast spinecho sequence. stn and control volumes relaxation times were analysed updrs scores were determined during "on" and "off" pre-and postoperatively. follow-up checks (median 3 years) 15 subjects had stable disease (sd), 20 had progression of disease (pd) and 16 developed ad. baseline metabolic ratios (1h mrs) between the 3 groups of patients indicated significant differences in the left frontal lobe in mi/h20 ratio, between patients with sd (0.27) and dp (0.22) (p = 0.03). in groups of patients with dp and ad there was a significant difference in naa/cr (1.77 vs. 1.43), (p = 0.02). conclusion: mi and naa seem to be very sensitive biomarkers for conversion from mci to ad. the significance of our metabolic ratio results needs further study. purpose: uric acid has been associated with focal vascular brain disease such as lacunar infarcts and white matter lesions. however, it is unknown whether uric acid also relates to global brain changes such as brain atrophy. we therefore studied the relation of uric acid with brain atrophy and whether this is coupled with worse cognitive function. in 814 persons of the population-based rotterdam study (mean age 62.0 years), we studied the relation of uric acid levels with brain tissue atrophy and cognition, using linear regression models, adjusted for age, sex and putative confounders. brain atrophy was assessed using automated processing of mri. cognition was assessed using a validated neuropsychological test-battery and we computed compound scores of cognitive domains. results: higher uric acid levels were associated with white matter atrophy (difference in z-score of white matter volume per standard deviation increase in uric acid: -0.07 (95% confidence interval: -0.12; -0.01)). this was particularly marked when comparing hyperuricaemic to normo-uricaemic persons (z-score difference: -0.27 (-0.43; -0.11)). worse cognition was primarily found in persons with hyperuricaemia (-0.28 (-0.48; -0.08)). conclusion: hyperuricaemia is related to white matter atrophy and worse cognition. the neural correlates of anomia in the conversion from mild cognitive impairment to alzheimer's disease e. pravata' 1 , j. tavernier purpose: language impairment is frequently observed in patients with alzheimer's disease (ad; in this study, we investigated the extent and distribution of brain atrophy in subjects with conversion from mild cognitive impairment (mci) to ad with and without naming difficulties. methods and materials: this study was approved by the institutional review board and was hipaa compliant. all subjects or their legal representatives gave informed consent for participation. ninety-one subjects from the alzheimer's disease neuroimaging initiative (adni) with (n=51) and without (n=40) naming impairment as per the boston naming test (bnt) underwent brain magnetic resonance (mr) imaging 12 months before and at ad diagnosis. structural mr images were processed using voxel-based morphometry. longitudinal and cross-sectional comparisons between groups were performed to assess differences in gray matter (gm) loss patterns. results: during the 12-month prior to diagnosis, ad patients with naming difficulties showed distinct areas of greater gm loss in the temporal lobes, cingulate gyri, and precunei than patients without naming difficulties. gm volume in the left fusiform gyrus (brodmann area 20) was greater in patients without naming impairment. this study provided evidence of distinct patterns and dynamics of brain atrophy in ad patients with naming difficulties when compared with those with intact language, as early as 12 months prior to ad diagnosis. language deficits and their neuroanatomical correlates should be taken into account in the design of a structural imaging biomarker for the early detection of ad. gender differences in grey matter atrophy patterns in the mild cognitive and early alzheimer's disease m. spampinato 1 , e. pravata' 1 , b. langdon 1 , k. patrick 1 , r. parker 2 ; 1 charleston, sc/us, 2 gainesville, fl/us (emanuele.pravata@gmail.com) purpose: to investigate gender-specific differences in grey matter (gm) volume loss patterns in amnestic mild cognitive impairment (amci) patients with and without progression to alzheimer's disease (ad) using mr voxel-based morphometry (vbm). we included 186 amci patients (128 males, 58 females; age 77±7 years), with (n = 91) and without (n = 95) conversion to ad, from the alzheimer's disease neuroimaging initiative (adni) cohort. three-dimensional mprage brain scans obtained one year before conversion from amci to ad and at ad diagnosis were available. the general linear model was performed to evaluate for differences over time in cognitive decline from the clinical dementia rating (cdr) scale. optimised vbm with spm8 was used to assess gm volume differences by performing cross-sectional and longitudinal group comparisons with two-sample and paired t-tests. results: both male and female ad converters showed significant cognitive decline at cdr (p < 0.001). total gm volumes significantly differed between all groups of males and females (p < 0.01). compared to stable amci, male ad converters showed atrophy progression one year prior to ad diagnosis in the limbic, temporal, parietal, frontal, insular lobes and deep gray nuclei, while female ad converters showed only one area of significant gm loss in the right uncus (p < 0.05 fwe-corrected). the extent and distribution of regional gm volume loss in amci to ad converters is strongly influenced by the gender. this finding has potential implications for therapeutic approaches in ad and should be taken into account in clinical trials. purpose: excessive daytime sleepiness (eds) is an important non-motor symptom of parkinson's disease (pd). the underlying neuropathological mechanism accounting for eds is not well understood. the purpose of the present study was to determine regional grey matter (gm) volume changes in pd patients with eds. scale ess ³ 12) (eds-pd), 17 age and disease duration-matched pd patients (epworth sleepiness scale ess ² 6) and 17 age-matched healthy controls were enrolled in the study. the χ 2 and student's t tests were used to test for differences in demographic and clinical characteristics between groups. differences in gm volume between groups were evaluated by applying the voxel-based morphometry (vbm) method. results: total calculated levodopa equivalent dose was higher in eds-pd when compared to pd patients (p < 0.05). comparison of eds-pd with pd patients and controls showed increased gm volume bilaterally in the hippocampus, the parahippocampal gyrus, the fusiform gyrus and in cortical areas in the temporal, frontal and parietal lobes (p < 0.001). conclusion: eds-pd patients present increased regional gm volume in the mesolimbic/mesocortical dopamine pathway, which is activated during sleep. drug-induced gm volume increase through a process of neuronal plasticity may represent the underlying mechanism. purpose: olfactory dysfunction is the second most frequent feature of pd, occurring in 70-90% of patients. recent studies suggest that the olfactory system is among the earliest brain regions involved in pd. diffusion-weighted imaging (dwi) and diffusion tensor imaging (dti) consent quantitative measures of the microstructural integrity of nuclei and fibre tracts. our aim was to assess fractional anisotropy (fa) changes of the olfactory tract in early pd patients (hoehn ed yahr stage 1-2.5) and to correlate fa values with the clinical score of the olfactory deficits methods and materials: a case control study was conducted on 15 pd patients responding to uk pd society brain bank for probable pd and 13 healthy controls that underwent mri (1.5t, avanto, siemens, erlangen, germany). we performed t1 weighted mprage, t2 and pd weighted tse and epi (on 12 non-collinear directions at b0 and 1000s/mm2 to assess dti) sequences. fa was computed with standard formulas. all subjects underwent upsit (university of pennsylvania smell identification test) results: we found a significant difference between fa values of the gyrum rectum subcortical white matter of pd patients and healthy controls (0.27± vs. 0.39±; p < 0.05). a significant difference was also found in upsit values between the two groups (p < 0.05). our results suggest that early olfactory dysfunction in patients with pd may be a primary consequence of damage to the olfactory tract. diffusion tensor imaging reaches the diagnostic sensitivity to assess early olfactory dysfunction in pd patients quantitative evaluation of myocardial perfusion reserve at 3 and 1.5 tesla in comparison to invasive measurement of fractional flow reserve for detection of coronary artery disease t. walcher, k. ikuye, w. rottbauer, j. woehrle, p. bernhardt; ulm/ de (peter.bernhardt@uniklinik-ulm.de) purpose: fractional flow reserve (ffr) is considered as the standard invasive diagnostic tool to determine haemodynamic significance of coronary artery disease (cad). adenosine-perfusion cardiac magnetic resonance imaging (cmr) at 1.5 and 3 tesla has been proven to be capable to noninvasively determine myocardial perfusion reserve, but has not been compared against each other and validated against ffr as standard reference. methods and materials: 34 patients (62.0 ± 10.9 years) with suspected cad were included into the study. all patients were scanned at both field strengths, 1.5 and 3 tesla, including adenosine and rest perfusion imaging. coronary x-ray angiography including ffr measurement in the left anterior descending (lad), circumflex (cx) and right coronary artery (rca) was then performed in all patients. myocardial perfusion reserve was calculated in 544 myocardial segments for each field strength and compared to the ffr measurement of the supplying coronary artery. ffr ²0.8 was regarded as relevantly reduced. in 38 coronary arteries (19 lad, 8 cx, 11 rca) a ffr ²0.8 was found. receiver operator curve analysis yielded higher area under the curve for 3 t in comparison to 1.5 t cmr (0.963 vs. 0.645, p < 0.001) resulting in higher sensitivity (0.91 vs. 0.62) and specificity (1.0 vs. 0.77). conclusion: quantitative evaluation of myocardial perfusion reserve at 3 and 1.5 tesla is capable to detect haemodynamic significance of coronary artery stenosis. in our cohort, the diagnostic accuracy at 3 t seems to be superior to 1.5 t. dynamic stress computed tomography perfusion imaging for the detection of functionally significant coronary lesions purpose: to evaluate the performance of hyperaemic myocardial blood flow (mbf) derived from stress computed tomography perfusion (ctp) imaging in the detection of functionally significant coronary lesions defined by fractional flow reserve (ffr) ²0.75 in a prospective cohort of patients with stable chest pain. coronary computed tomography angiography (ctca) and ctp were performed in 50 patients (35 males/15 females; mean age 58±9 years) referred to invasive angiography. a second-generation dual-source ct scanner (somatom definition flash, siemens) with a dynamic ecg-triggered axial shuttle mode was used. this technique provides an arterial input function and myocardial time-attenuation curves fitted to a 2-compartment model to give mbf. hyperaemia was induced by infusion of adenosine (140µg/kg body weight). three to 4 minutes into the infusion, 60 ml of contrast were injected. gantry rotation time was 285 ms, collimation 64x0.6 mm, tube voltage 100 kv and the tube current-time product was 300 mas/rotation. purpose: the use of ct-scans in assessment of coronary artery disease is rapidly growing. more selective referral of stable angina patients with intermediate probability of coronary artery disease (cad) to ct coronary angiography (ctca) may temper the health care spending on cardiac ct-scans. the value of updated algorithms using "in-office-evaluation" and calcium score (casc) is investigated. we evaluated retrospectively 2042 symptomatic stable angina patients who underwent "in-office-evaluation", unenhanced ct-scan for calculation of casc and ctca. outcome of our study was non-invasive diagnosis of obstructive cad (³50% lumen diameter narrowing) by ctca. two algorithms were developed. first algorithm used "in-office-evaluation" consisting of chest pain typicality, sex, age, risk factors and ecg. the second algorithm used both "in-office-evaluation" and casc. discrimination of both models was tested using the area under the roc curves (auc). patients were classified to low (< 10%), intermediate (10-90%) and high pre-test probability (³90%) of obstructive cad. testing with casc or ctca was deemed appropriate in patients intermediate probability of cad. net reclassification improvement (nri) of algorithm 2 was calculated in patients with intermediate probability of cad according to algorithm 1. results: discrimination of cad was significantly higher using algorithm 2 compared with algorithm 1 (auc: 0.90 vs. 0.80, respectively). the "in-office-evaluation" algorithm reduced both unenhanced ct-scan and ctca by 12%. an additional 32% of ctca-scan was reduced using algorithm 2 subsequently with nri of 66%. conclusion: updated algorithms using both "in-office-evaluation" and casc may reduce referral of stable angina patients to ctca by 44%. dynamic ct perfusion imaging for the detection of myocardial ischaemia: a first experience with a 3d semi-automated evaluation software u. ebersberger 1 , r.p. marcus 2 , u.j. schoepf 1 , p. blanke 1 , y. wang 3 , l. geyer 1 , a. purpose: to evaluate the performance of a 3d semi-automated evaluation software for its accuracy and time saving potential for ct perfusion myocardial blood flow (mbf) and blood volume (mbv) assessments compared to manual evaluation as well as to spect. methods and materials: 37 dynamic, time-resolved myocardial perfusion ct datasets acquired using a dual-source ct system (somatom definition flash, siemens healthcare, forchheim, germany) were assessed both manually and by use of the semi-automated prototype for mbf and mbv, based on the aha 16-segment model. time required for each assessment was recorded. results were compared to spect as the standard of reference. results: 592 segments were evaluated. 19 (3.21%) were excluded due to insufficient coverage. a comparison of mbf and mbv measurements using the prototype versus manual assessment showed high correlation (spearman's rank correlation coefficient = 0.85/0.83, p < 0.0001). mean evaluation time for mbf and mbv analysis was 49.1 ±11.2 minutes with manual assessment and 16.5 ± 3.7 minutes with the use of the prototype (p < 0.001). conclusion: 3d semi-automated assessment of dynamic myocardial perfusion ct highly correlates with manual assessment. significantly decreased assessment time appears promising for the integration of myocardial perfusion ct in clinical workflows. friday protocol (adp): clinical examination, mdct-ca; the positive cases were recovered and underwent ca. if mdct-ca was negative for significant cad the patient was dismissed from the ed and taken under follow-up for 2 years. the costs of every protocol and the amount of costs for individual methods were calculated. based on the results, the two diagnostic paths were compared about cost/effectiveness ratio. results: at timi score only 30% of the patients resulted with high risk, whereas mdct-ca was judged positive in 40% of the cases. mdct-ca compared to ca revealed an accuracy of 97.8%, ppv and npv were 99% and 100%. the adp revealed lower costs than the protocol with only hospitalization (11645€ against 5322€), and showed better cost/effectiveness ratio. at 2-year follow-up 99.3% of the patients resulted well being. the adp can help better than timi score to rule out patients with undifferentiated chest pain. moreover, cost analysis demonstrated a better cost effectiveness ratio in comparison to the hospitalization, also confirmed with a long-term follow-up. purpose: transient ischaemic dilation (tid) in the setting of abnormal spect myocardial perfusion imaging (mpi) has been linked with increased cardiovascular risk. however, the significance of tid in the setting of an otherwise normal mpi study has not been clearly established. coronary computed tomography angiography (ccta) was utilised to evaluate the prevalence of atherosclerotic lesions and the severity of coronary stenosis in patients with tid with or without associated myocardial perfusion defects on spect-mpi. the study population consisted of 1553 patients who had undergone both ccta and stress/rest cardiac spect. in patients with tid coronary cta was used to evaluate each coronary segment for the presence and composition of atherosclerotic plaque and the degree of coronary stenosis. findings were compared with a 2:1 matched-pair control cohort without tid. results: tid was identified in a total of 30 patients from a screening population of 1553 consecutively imaged patients. findings demonstrated that compared to tid negative risk-factor matched controls (n=60), tid positive patients had no significant differences in the presence and extent of atherosclerosis or the degree of coronary artery stenosis as evaluated by ccta. similarly, there were no significant differences in ccta measures of coronary artery disease (cad) in tid positive patients with normal perfusion compared to tid negative patient with a normal perfusion study (n=48). these results suggest that the presence of tid with an otherwise normal spect study does not reliably predict an increased risk for or the extent and severity of coronary artery disease. -89] ) underwent wb-cta (64x0.6 mm) with an adapted contrast injection protocol (iomeprol-400, 400 mgi/ml; 70+50 ml@4 ml/s). coronary arteries were divided into 15 segments and the extra-coronary arteries into 32 segments, detected stenoses were graded using a 5-point scale. an atherosclerosis burden score (abs) was generated for each individual and correlated to traditional cv (framingham risk index; fri). abs and fri were compared using kaplan-meier analysis, roc analysis and stepwise multivariable cox regression models. results: at baseline mean abs was 19.5±20.1 and mean fri was 12±10.7; 64.5±11.3m after wb-cta all patients received an interview to determine health status. according to kaplan-meier curves, mean event-free time was of 62.3±2.4m for abs< 10, 57.6±1.9m for 10<abs20, with a statistically significant difference between the three groups (p=0.012). mean event-free time was 57±5.6m for fri mild-risk group and 52.5±4.2m for high-risk group without significant differences between the two groups (p=0.072). for the prediction of cv events, in the highrisk group abs showed an accuracy of 0.89, meanwhile fri of 0.69 (p=0.007). multivariable analysis showed that only age (p=0.011), abs score (p=0.000) and therapy (p=0.001) were independent predictors of hard cv events. conclusion: wbcta-derived abs reflects real atherosclerotic burden and provides superior risk stratification and event prediction with respect to fri; hard event prediction was significantly associated with age, abs and therapy. purpose: detection of patients with "high-risk-cad" consisting of left main (lm) and/or three-vessel cad (3vd) is important because optimal medical treatment combined with revascularisation has shown to improve prognosis in these patients. diagnostic performance of ct coronary angiography (ctca) to detect or exclude "high-risk-cad" is assessed. the discrimination of "high-risk-cad" by ctca is compared with duke risk score and calcium score. methods and materials: we evaluated retrospectively 1136 symptomatic patients with stable angina without prior revascularisation (61±11 years, 31% women) who underwent invasive coronary angiography (ica) and ctca between 2004 and 2011. vessels were considered obstructive in the presence of ³50% lumen diameter stenosis. results: "high-risk-cad" determined by ica was present in 17% (196/1136). sensitivity of ctca to detect "high-risk-cad" was 95% (95% ci: 91%-97%), specificity was 83% (81%-86%), positive predictive value was 54% (49%-59%) and negative predictive value was 99% (98%-99%). the "high-risk-cad" discrimination by ctca was significantly (auc: 0.90) higher compared with duke risk score (auc: 0.69, p < 0.0001) and calcium score (auc: 0.73, p < 0.0001). conclusion: ctca accurately rules out "high-risk-cad" in patients with stable angina. ctca provides incremental value in the discrimination of "high-risk-cad" compared with the duke risk score and calcium score. results: 85% of the total radiation dose was applied during the pre-and postinterventional ct-series leaving only 15% to being applied by the ct-guided intervention itself. single slice acquisition was associated with lower doses compared to continuous ct-fluoroscopy (37 mgy*cm vs. 153 mgy*cm, p < 0.001). overall, the use of 80 kv during the interventions led to significantly lower radiation doses compared with 120 kv (mean: 86 mgy*cm vs. 215 mgy*cm, p < 0.001). third quartile of radiation doses varied considerably for different interventions depending on complexity. conclusion: to our knowledge, these data represent the largest sample of ctguided interventional procedures. therefore, we suggest preliminary reference levels for each subgroup based on the third quartiles of our analysis. the radiation dose applied can be reduced using 80 kv instead of 120 kv for the intervention and by preferring single-slice acquisition over ct-fluoroscopy whenever possible. (57 tumours) presenting local recurrences of sts of the trunk or limbs were selected from our institutional database. two radiologists visually assessed possibility of cryotherapy according to common inclusion criteria: maximal diameter size of the tumour ²10 cm, distance to skin > 5 mm, distance to neurovascular structures at least 3 mm, potential access, absence of articular involvement and planned cryoablation covering the entire lesion volume. characteristics of patients eligible for cryoablation were comparing with not selected patients. results: mean tumour size was 64 mm (10-178). most frequent histological subtypes were unclassified sarcomas (n=16), liposarcomas (n=15), or myxofibrosarcomas (n=7). surgical treatment consisted in wide excision (n=16), or combined treatment (n=24). after surgery, the severe complications rate was 47.5%. since relapse, mean follow-up was 42.8 months with a median overall survival of 57.6 months and median recurrence-free survival of 39.5 months. a subgroup of 13 patients was identified and comparison with other patients showed that trunk, shoulder and pelvic girdle locations (p =0.002), locally aggressive (p=0.016) and deep (p=0.002) tumours, ²5 cm (p=0.044), and liposarcoma and myxofibrosarcoma subtypes (p=0.007) were indicative of eligibility for cryoablation. conclusion: eligibility criteria as defined are useful for plan cryoablation as a technically feasible alternative to surgery for treatment of local relapse of sts. robot-assisted radiofrequency ablation of liver tumours: early experience b.j.j. abdullah, c.h. yeong, k.l. goh, b.k. yoong, g.f. ho, c. yim; kuala lumpur/my (basrij@ummc.edu.my) we report our preliminary experience of rfa of the liver tumours using a robotic-assisted guidance system. methods and materials: 6 patients with 8 lesions were treated using the robio ex (perfint healthcare, ma, usa) robotic positioning system. all the lesions were smaller than 2.5 cm diameter. all the procedures were performed under general anaesthesia. following baseline ct scans, the lesions were identified. the puncture site and trajectory were then determined on robio ex workstation. the angulation of the needle, depth of lesion, the fluoroscopic dose as well as the accuracy of placements was determined. the performance level of procedures was documented for each biopsy on a five-point scale (5-1: excellent-poor). results: all the tumours were targeted successfully. one lesion in 2 patients required minor readjustment. 4 patients (5 lesions) had needle placement with no cranio-caudal angulation, whereas 2 patients (3 lesions) had cranio-caudal angulation of up to 200. the orbital angulation ranged from 60 to 1180. the depth of needle ranged from 12.2 to 4.7 cm from skin surface. performance levels were all 5 except in one patient (4). the fluoroscopic (dlp) and total dose (ctdivol) for the entire procedure were 316±92 mgy.cm and 260.83±70.02 mgy, respectively. post-rfa ct scans showed successful ablation of the targeted lesions. no immediate complications were noted. conclusion: robotic-assisted planning and needle placement appear to be technically easier, it requires fewer number of needle passes, fewer check scans using logistic regression, ccs more than 100 was the predictor of presence of oms (odds ratio 7.484, 2.459-22.776 in 95% confidence interval). the prevalence of oms was significantly higher in patients with more than 50% stenosis and in patients with mixed and non-calcified plaques. the prevalence of oms on de-mri and significant coronary disease on ctca are not uncommon even in asymptomatic patients with type 2 diabetes. ccs more than 100 is the only predictor of oms. author epicardial fat volume and coronary artery disease at ct: racial differences in african american and white patients with acute chest pain p. apfaltrer 1 , a. schindler 2 , u.j. schoepf 2 , j. nance 2 , u. ebersberger 2 , r. vliegenthart 2 ; 1 mannheim/de, 2 charleston, sc/us (paul.apfaltrer@umm.de) purpose: thoracic adipose tissue likely promotes coronary artery disease (cad). possibly, differences in cad risk between races are influenced by racial differences in thoracic adipose tissue. we compared ct-derived measures of thoracic fat and potential correlations with cad between african american and white patients. methods and materials: 372 age-and-gender-matched black and white patients (186 black: mean age 54±11 yrs, 50% men; 186 white: mean age 54±11 yrs, 50% men) who underwent thoracic dual-source ct for chest pain evaluation were retrospectively included. epicardial adipose tissue (eat) volume and mediastinal adipose tissue (mat) volume were quantified using an automated analysis algorithm. peri-coronary fat thickness (pft) was measured on reconstructed sections orthogonal to the right coronary artery centreline. non-calcified and calcified plaque volume was quantified by applying a threshold-based automated algorithm. cad was defined as 50% or greater coronary artery stenosis. patients with cad showed significantly higher eat than those without cad (97.9±52.6 cm 3 vs. 77.4±43.5 cm 3 , p < 0.05). significant correlations were observed between eat measurements and calcium volume (r=0.221; p < 0.05). the relationship between race and extent of adipose tissue remained significant after adjustment for cardiovascular risk factors. conclusion: measures of thoracic fat were generally higher for symptomatic white than for black patients suggesting a differential relationship between thoracic adipose tissue and cad pathophysiology by race. purpose: the imactis navigation system with electromagnetic needle holder tracking was developed to allow interactive display of the needle trajectory in a 3d volumetric ct volume, allowing the radiologist to choose optimal entry point and track to the target during ct-guided percutaneous interventions. the ctnav trial compares the accuracy of the needle placement using standard ct procedure (ct group) and using the navigation system procedure (nav group). methods and materials: prospective, randomised, comparative, open, controlled study conducted between june 2010 and january 2012 in grenoble university hospital on 120 patients who had to undergo a percutaneous ct procedure. patients were randomised to have normal procedure (ct group) or navigation system assisted procedure (nav group). the main outcome was the distance between the planned trajectory and the effective needle trajectory after the first placement attempt. significance was set at 0. friday dynamic contrast-enhanced mri (dce-mri) and histology, we assessed the impact of this therapeutic approach on the tumour vasculature. methods and materials: rats bearing breast cancer bone metastases were imaged using vct and dce-mri prior to and 25 days after the onset of therapy; untreated (n=12) and treated (integrin inhibitor monotherapy; n=12) or together with antiresorptive agent (combination therapy; n=11) to assess osteolysis and functional mri parameters, respectively. mean vessel diameter and sma and collagen-iv-positive vessel area fraction were assessed histologically. results: compared to the control group, bone defect healing at the osteolytic site occurred in rats receiving monotherapy and even more frequent after combination therapy as shown by vct. in addition, we observed a profound effect of mono-and combination therapy on the tumour vasculature determined by dce-mri parameters amplitude and exchange rate constant. both therapy regimens induced elevated vessel permeability/perfusion in bone metastases, but opposite to monotherapy, combination of agents additionally elevated the blood volume. immunofluorescence analysis of osteolytic lesions revealed more tumour blood vessels after combination therapy and equally immature vasculature as compared to monotherapy. conclusion: upon treatment with integrin inhibitor monotherapy or in combination with an antiresorptive agent, vessel remodelling could be assessed by dce-mri. interestingly, the degree of vessel remodelling could be correlated with bone defect healing, so we conclude the existence of a strong interaction between tumour angiogenesis and bone turnover in lytic osseous lesions. purpose: islet transplantation is a less invasive/safer/repeatable option than surgical pancreas transplantation for type 1 diabetic patients; it can be performed after kidney transplantation (iak), alone (ita) in patients without chronic renal insufficiency, or as an autotransplantation (iat) after pancreatectomy (immunosuppression unnecessary). steatosis is a consequence of islet engraftment: its meaning is controversial. our longitudinal study aimed to assess steatosis incidence at ultrasound after islet auto-and allo-transplantation, and to identify any relationship with graft function. ultrasound was performed at baseline/6/12/24 months in 108 islet-transplanted patients (33 iak/50 ita/25 iat). steatosis first detection/ prevalence/duration/distribution were recorded. steatosic (s) and non-steatosic patients (ns) were compared for the following parameters at baseline/6/12/24 months: insulin independence rate, ß-score, c-peptide, glycated-haemoglobin, exogenous insulin requirement, fasting plasma glucose, infused islet mass. results: steatosis was found in 21/108 patients, 24% (20/83) allo-transplanted, 4% (1/25) auto-transplanted (better outcome), with first detection at 6 months, highest prevalence at 1 year (18 cases). s-patients had a significantly higher infused islet mass (ie/kg: s=10.822; ns=6.138) and worse basal metabolic conditions (ß-score: s=1.7±1.6; ns=2.8±2.8), but better islet function at the time of steatosis first detection (ß-score: s=3.9±2.0; ns=2.9±2.3), after which a progressive islet exhaustion, along with steatosis disappearance, was observed. conversely, in ns patients these parameters remained more stable in time. conclusion: steatosis at ultrasound is significantly less detectable in auto-transplanted-patients with better clinical outcome. it seems to be related to stressed islets' overworking activity (higher ß-score values when steatosis appears), and a higher infused islet mass. steatosis presence precedes metabolic alterations and (structural insight) was adapted in order to allow calibrated bone density and bone structure analyses of the vertebral bodies, using an underlying light weight calibration phantom with design for coronary calcium scoring (image analysis phantom® purpose: to validate a magnitude-based method, transposable on any imaging system and for all current clinical fields (1.5 and 3.0 t) for liver fat volume fraction (fvf) quantification without dominant component ambiguity problems. methods and materials: mr imaging was performed at 1.5 and 3.0 t using a multiple-angle multiple-gradient echo acquisition. a quantification algorithm correcting for relaxation time effects using a disjointed estimation of t1 and t2 * of fat and water and accounting for the nmr spectrum of fat was developed. validations were performed in a prospective comparative study with histology on 28 patients with chronic liver diseases. results: mr-estimated fvf and histological results were strongly correlated (ρ=0.96). roc analysis showed that fvf allowed the diagnosis of a mild (cut-off = 5.5%) and a moderate steatosis (cut-off=15.2%) with a sensitivity/specificity of 100%. water relaxation times (t1 and t2*) were found significantly reduced in patients with iron deposition (p < 0.01), whereas water t1 was found significantly increased in patients with cirrhosis (p < 0.01). conclusion: this method that can be performed at 1.5 and 3.0 t on all imaging systems provide an accurate quantification of the fvf in patients with chronic liver disease. fvf could be a relevant biomarker for the clinical follow-up of patients with nafld as well as to quantify steatosis in the full spectrum of chronic liver diseases. interestingly, thanks to the separated estimation of fat and water relaxation times, detection of cofactors such as iron deposition or cirrhosis in patients with nafld could be achieved. combination of liver intravoxel incoherent motion imaging with mr fat quantification at 3.0 t to distinguish between pure steatosis and nash purpose: to evaluate the combination of liver intra-voxel incoherent motion imaging (ivim) and a mri fat quantification method at 3.0 t to make the distinction between nash and pure steatosis. a multi-angle multi-gradient echo acquisition combined with a dedicated algorithm was used to quantify liver fat volume fraction (fvf), corrected for water and fat relaxation times and accounting for the nmr spectrum of fat. ivim was performed using a single-shot se-epi sequence, in free breathing, with 11 b-values (0-20-40-60-80-100-200-300-400-600-800s.mm -2 ) and a weighted signal averaging procedure. three orthogonal diffusion gradients were sequentially applied. a 2000 ms tr, 54 ms minimum te; 21 axial slices of 8 mm thick; 400×300 mm² fov; 128×96 matrix were used. ivim parameters (pure molecular diffusion coefficient (dslow), perfusion-related diffusion coefficient (dfast) and perfusion fraction (f)) were estimated. mr imaging was performed on a healthy volunteers group (n=33), and on patients with histologically confirmed pure steatosis (n=16) or nash (n=4). results: wilcoxon test showed that dslow was significantly lower when fat is present (fvf > 5.5%) (p < 0.01). dslow and dfast were found significantly reduced between subjects with pure steatosis (brunt=0) and nash (brunt> 0) (p < 0.05). conclusion: fat vesicles in pure steatosis restrict molecular diffusion without modification of micro-perfusion. in nash, fibrosis still increase the restriction of molecular diffusion compared to patients with pure steatosis and decrease the microperfusion as illustrated by the decrease of perfusion-related diffusion coefficient. these preliminary results suggest that combining mri fat quantification and ivim could be a none invasive mean to distinguish between pure steatosis and nash. quantification of steatosis hepatitis and liver iron overload in a population-based study using magnetic resonance imaging j.p. kühn 1 , d. purpose: to describe hepatic biochemistry in biopsy-proven nafld states using 31 p-mrs and to evaluate its diagnostic performance for distinguishing non-alcoholic steatohepatitis (nash). methods and materials: the cohort consisted of healthy controls (n=19), and 132 nafld patients with liver biopsy, as follows: simple steatosis (ss, n=37), nash with non-significant fibrosis (nash-nsf, n=49) and nash with significant fibrosis (nash-sf, n=46). 31 p-mrs was performed on a 3 t mri to obtain signal intensities for phosphomonoesters (pme), phosphodiesters (pde) and component glycerophosphocholine (gpc), total adenosine triphosphate (atp) and component α-atp, and inorganic phosphate (pi). these were expressed as percentages relative to total phosphate and compared using one-way anova with post hoc bonferroni test. receiver operating curve (roc) analysis was performed to determine cut-off values with highest youden index. statistical significance was declared at α< 0.05. results: compared with controls, all nafld groups had higher pde (p < 0.049). ss and nash-nsf had decreased pme (p=0.001-0.015), increased gpc (p < 0.001), normal total atp (p=0.067-1.000) and decreased pi (p=0.018-0.021). nash-sf had normal pme (p=0.764) normal gpc (p=0.727), decreased total atp (p=0.035) and normal pi (p=0.443). α-atp was significantly decreased in both nash groups and identified as a potential diagnostic marker. the computed area under the roc was 0.705, and an α-atp threshold of < 13.13% gave a 65% sensitivity and 73% specificity for the identification of nash. conclusion: 31 p-mrs shows observable spectroscopic patterns within the nafld spectrum. α-atp is a potential diagnostic marker for distinguishing nash from ss. clinical implications of fatty liver on hepatic diffusion-weighted imaging studied in healthy subjects h. dijkstra, a. handayani, p. kappert, m. oudkerk, p.e. sijens; groningen/nl (h.dijkstra01@umcg.nl) purpose: to evaluate the diagnostic implications of fatty liver on dwi by assessing the hepatic fat fraction (hff) and t2* of healthy subjects in eight liver segments in order to eliminate patient-related confounding factors such as cirrhosis and fibrosis. methods and materials: eleven healthy volunteers were examined with dwi (seven b-values) and two series of in-and out-of-phase dual-echo spoiled gradient echo sequences (spgr) to obtain the hff (dixon's method). a third spgr series was acquired to calculate t2 * relaxation. dwi data were analyzed using the ivim model: molecular diffusion (dslow), microperfusion (dfast) and the respective fractions (fslow/fast). for each subject, four circular regions-of-interest (ø22.3 mm) were drawn in each segment according to the couinaud-bismuth classification. data with low snr< 5 were excluded. ivim parameters were compared between groups of low (²2.5%), intermediate (2.5²hhf< 10%) and high hhf (> 10%). linear correlations between hhf, dwi parameters, and t2 * were assessed. results: in each segment, dslow decreased with increasing hff. dslow averaged over all segments differed significantly (p < 0.001) between low (0.99×10 -3 mm 2 /s), intermediate (0.74×10 -3 mm 2 /s) and high hff (0.32×10 -3 mm 2 /s). both dslow and t2* decreased with hff (r 2 =0.89; r 2 =0.72). dfast and fslow/fast showed small intergroup differences (p < 0.04). conclusion: increasing hepatic fat fractions caused significant reduction of the molecular diffusion and shortening of t2*. this implies that hepatic dwi hindered by fat leads to apparent fluctuations of the molecular diffusion and hypointensity on dwi images; this may induce false diagnoses such as fibrosis or cirrhosis. (p < 0.001/p < 0.001), whereas there was no significant correlation between bat volume and the amount of subcutaneous adipose tissue (p=0.70). bat activity was an independent, negatively influencing variable for liver fat content (p=0.027). conclusion: bat significantly correlates with body fat composition, especially visceral fat mass considered relevant for the development of metabolic syndrome, and seems to be an independent regulator of hepatic steatosis. in-phase/opposed-phase mri and mr spectroscopic measurements for the quantification of liver fat content in morbidly obese patients h. agreement for the three individual liver segments (ii, iv and vii) had upper/lower limits of +5.0/-11.9%, +1.9/-9.6% and +4.8/ -12.0% and insignificant biases of 3.4% (p=0.14), -3.9% (p=0.25) and -3.6% (p= 0.27), respectively. conclusion: ip/op imaging and mrs are reliable methods for the assessment of lfc. ip/op imaging is superior in terms of processing time and liver coverage and provides information for cases with larger regional fat differences and is helpful for lipid assessment in the left liver lobe where mrs is impractical. purpose: pancreatic islets transplantation (islets-tx) is a promising treatment for patients with type-1 diabetes. neoangiogenesis of transplanted islets is a crucial phenomenon for engraftment and was investigated with dce-mri in mice. the aim was to use dce-mri in clinical islets-tx to evaluate the relationship between early vascular changes, islets loss and long-term clinical outcome. methods and materials: 6 diabetic pts were enrolled. dce-mri was performed at baseline and 7 days after islet-tx with a 3d-t1w-tfe dynamic sequence (temporal resolution: 4sec; 45 dynamics) acquired during gadolinium bolus injection. k-trans was assessed by dce-mri datasets. three patients received ferucarbotran labelled islets and were monitored with t2*sequences (before islets-tx, 7 days and each month after). unlabelled islets were infused in the remaining three patients. glycated haemoglobin, blood glucose, daily insulin request and stimulated c-peptide were monthly assessed in order to calculate beta-score (0-8) purpose: brown adipose tissue (bat) mass and activity is considered a significant factor for the development of adiposity and metabolic syndrome in humans, and represents a natural target for the modulation of energy expenditure. we evaluated the correlation of bat activity and active volume as detectable on fdg-pet/ct scans with abdominal body fat composition and liver fat estimation. methods and materials: 4852 fdg-pet/ct examinations in 3680 individual patients were screened for bat, resulting in 601 patients and controls for subsequent analysis, matched for exam date and therefore ambient temperature, age, and gender. in addition to bat volume and activity, an automated segmentation was used to determine visceral fat and subcutaneous fat as well as lean tissue in the abdomen. liver fat was estimated in 430 patients with non-contrast-enhanced ct. spearman rank correlation between parameters and a multi-variate model for liver fat excluding influencing parameters was calculated. results: bat volume and activity showed a significant inverse correlation with total adipose tissue (activity p < 0.001/volume p=0.022) and visceral adipose tissue in 15 studies, which were mainly underpowered and of heterogeneous study design, 31 different parameters were studied. most frequently studied parameters were tumour diameter or volume, ktrans, kep, ve, and apparent diffusion coefficient (adc). other parameters were analysed in only two or less studies. tumour diameter, volume, and kinetic parameters did not show any pretreatment differences between responders and non-responders. in two studies, pretreatment differences in adc were observed between study groups. at early response monitoring significant and non-significant changes for all parameters were observed for most of the imaging parameters. conclusion: evidence on distinguishing responders and non-responders to neoadjuvant chemotherapy using pretreatment mri, as well as using mri for early response monitoring, is weak and based on underpowered study results and heterogeneous study design. thus, the value of breast mri for response evaluation has not yet been established. s249 a c d e f g bfriday the role of magnetic resonance imaging in assessing residual disease and pathologic complete response in breast cancer patients receiving neoadjuvant chemotherapy: a systematic review r. prevos 1 , m. smidt 1 , v. gadovist®) was injected intravenously at a dose of 0.1 mmol/kg bw and six dynamic t1w gre sequences (vibe) were collected. the contrast kinetics of all malignant lesions were analysed quantitatively on a pixel by pixel basis using a computer-aided detection system (icad). the signal enhancement pattern was coded by three colour intensities and three colour hues. pharmacokinetic changes were analysed based on the tofts model including vascular permeability and extracellular volume fraction. results: in comparison to the baseline mri, follow-up examinations showed a significant tumour size reduction of 57% on average. a decrease of colour hues and colour intensities demonstrated significant changes in contrast kinetics. vascular permeability revealed a statistically significant decrease (p < 0.05). however, extracellular volume fraction changes revealed only a slight decrease under chemotherapy (mean decline of 16%). the cad analysis provides a reliable evaluation of tumour size, contrast kinetics, vascular permeability and extracellular volume fraction within a reasonable time. this form of cad analysis provides a fast and reliable assessment of early treatment response, enabling a fast modulation of therapy for non-responders. purpose: to assess the use of recist, mrecist and volumetric measurements in patients with invasive ductal carcinoma (idc) with initially marked necrosis on neoadjuvant chemotherapy (nact). in prospective analysis of 71 patients, 14 patients were selected based on marked intralesional necrosis and examined 3 times on mri: before the beginning, after the 2 nd cycle and upon completion of nact (anthracycline/taxane-based regimen). the lesions were measured in axial plane according to recist and mrecist. the volumes of the entire lesion and of the viable tissue were computed. results: the longest diameters measured according to recist and mrecist and the appropriate volumes were significantly different initially, after the 2 nd cycle and upon the completion of nact (p < 0.001 for all). the size of the lesions was significantly different with/without the necrotic areas. differences in tumour diameter and volume change (delta; %) between recist and mrecist were not significant after the 2 nd cycle and upon completion of nact (p> 0.01 for both). according to either recist or mrecist, including the volume measurements, the same number of patients were classified in the same response category, i.e., early response -pr (21.4%); late response -pr (50.0%). conclusion: to our knowledge, this is the first trial testing the use of mrecist in extrahepatic setting. there was no significant difference in changes of diameters or the corresponding volumes according to recist vs. mrecist. further research in larger groups needs to assess the use of the tools in the follow-up of new nact protocols. purpose: to assess the potential value of fibrosis quantification using t1 mapping in hypertrophic cardiomyopathy (hcm) in comparison to late contrast enhancement imaging, circumferential strain and lv thickness. methods and materials: seventeen patients with hcm, and 11 controls subjects were prospectively included. all patients underwent cardiac mr with the following sequences: 1) cine sequence, 2) tagging sequence cspamm tr/te=37.1 ms/1.4 ms; matrix 256, fov 340, temporal resolution 37.1 ms, distance between tag: 6 mm, short axis. 3) molli sequence (tr/te=3.0 ms/1.5 ms; matrix 144-150, thickness:7 mm) acquired before and 5, 7, 9 min after gadolinium injection (dotarem, 0.2 mmol/kg). 4) late gadolinium enhanced sequence 10 min after injection. t1 values were assessed in blood and in the 6 segments of the mid-lv slice. statistical analysis were performed for patients and for segments with (+) and without (-) enhancement on lge. r1, δr1, δr1 ratio were calculated (partition coefficient of gd, λ). results: in hcm, λ was significantly different between patient with (0.54±0.08) and without (0.45±0.05) enhancement on lge (p < 0.0001). no significant difference was measured in λ value between control and hcm without delayed enhancement (p=0.1). we did not found any correlation between lambda and circumferential strain (r=0.11; ci (-0.12;0.34); p=0.3). on the other hand, we found a significant correlation between lv wall thickness and circumferential strain (0.40; ci (0.20;0.56); p < 0.0001). in hcm, fibrosis is a focal process. in our study, there were no correlation between the presence of fibrosis and circumferential strain, but we found a significant correlation between lv wall thickness and circumferential strain. purpose: there is no consensus on surveillance strategies of reconstructed breasts after breast cancer, and it is routinely based on clinical examination alone. this study aims to assess the incidence and radiological presentation of breast cancer recurrences after deep inferior epigastric perforator (diep) flap reconstruction for women with a history of breast cancer. methods and materials: 265 consecutive women who underwent diep flap reconstruction after breast cancer from 1997 to 2009 were included in this retrospective study. all had annual screening for recurrence and we reviewed their follow-up records in our institution. the date and site of recurrences -ipsilateral or controlateral to the reconstructed breast, regional and metastatic disease -were retrieved. clinical and radiological presentations -on mammography, ultrasound, and mri -were further analysed. results: 31 of 265 patients presented 34 relapses, with a mean delay of 4.7 years (sd=2.9) after diep reconstruction; 14 (41%) were ipsilateral, while 6 (18%) were controlateral and 14 (41%) metastatic. ipsilateral recurrences had a tendency to occur earlier (3.8 years, sd=2.4, p=0.11) and 12 presented at a clinically patent stage. purpose: to assess the potential value of segmental quantification of myocardial fibrosis using t1 mapping in dilated cardiomyopathy (dcm) in comparison to late contrast enhancement imaging and circumferential strain. methods and materials: seventeen patients with dcm, and 11 controls subjects were prospectively included. all patients underwent cardiac mr with the following sequences (parameters set according to recommendation of the scmr): 1) cine sequence, 2) tagging sequence cspamm tr/te=37.1 ms/1.4 ms; matrix 256, fov 340, temporal resolution 37.1 ms, distance between tag: 6 mm, short axis. 3) molli sequence (tr/te=3.0 ms/1.5 ms; matrix 144-150, thickness: 7 mm) acquired before and 5, 7, 9 min after gadolinium injection (dotarem, 0.2 mmol/kg). 4) late gadolinium enhanced sequence 10 min after injection. t1 values were assessed in blood and in the 6 segments of the mid-lv slice. statistical analysis were performed for patients and for segments with (+) and without (-) enhancement on lge. r1, δr1, δr1 ratio were calculated (partition coefficient of gd, λ). results: in dcm, λ was not significantly different between patient without (0.50±0.05) and with at least one segment showing enhancement on lge (0.52±0.06; p=0.06). in all dcm, λ was significantly higher compared with the value obtained in control subject (p < 0.0001). we found a significant correlation λ and circumferential strain in each segment (r=0.55; ci (0.39;0.68); p < 0.0001), and between λ and lvef (r= -0.56; ci (-0.82;-0.11); p < 0.01). conclusion: in dcm, fibrosis was a diffuse process involving all the myocardium. there was a correlation between the quantity of fibrosis, circumferential strain and lvef. .051). the correlation between us and cmr end-dyastolic and stroke volume indexes was significant but with a very low coefficient, while the correlation for the ejection fraction was acceptable. the icc was unsatisfactory for all volumes and good for the ejection fraction. the widest bland altman plot range was found for the end-diastolic volume index. in conclusion, metrics of lv volume index and function showed significant systematic inter-modality differences. in particular, the us volumes were systematically underestimated. this suggests that serial measurements of volumes and function in ti should be performed using the same method and, if available, the more reproducible cmr technique. author disclosures: c. tudisca: research/grant support; the miot project receives "no-profit support" from industrial sponsorships (chiesi farmaceutici s.p.a., apopharma inc. and bayer-shering). this study was also supported by: "ministero della salute". . obtained 15 min after injection of 0.2 mmol/kg of gadolinium. lge was quantified automatically and defined as area of myocardium with signal intensity 6sd above the mean signal of remote myocardium. indexed end-diastolic left ventricular mass (iedlv mass) was assessed and lge extension was defined as percentage of total iedlv myocardium mass. patients were followed prospectively for a mean of 40.2±11.1 months, during which period occurrence of vt and icds were recorded. purpose: noncompaction of the left ventricle myocardium (lvnc) is a rare cardiomyopathy characterised by multiple and excessive trabeculations, deep intertrabecular recesses and thickened ventricular myocardium. this condition is considered mostly congenital but acquired forms have also been described. aim of the present study is to assess lvnc prevalence in β-thalassaemia patients and its potential association with cardiac siderosis methods and materials: 229 transfusion-dependent patients with β-thalassaemia (160 major and 69 intermedia, mean age 37.8 ± 12.8 years, mean bsa 1.64 ± 0.24 kg/m 2 ) presenting for cardiac and abdominal iron assessment by mri (1.5t scanner, avanto, siemens-germany) were studied. cardiac iron overload was assessed by t2* black-blood gradient-multiecho sequences; cardiac functional and morphological characteristics were evaluated using ssfp acquisitions. risk factors for lvnc were noted and none of the patients had neuromuscular or congenital heart disease. results: 69 patients (30%) fulfilled the preassigned strict criteria for lvnc on cardiac mri. there were no statistically significant differences between patients with and without lvnc with respect to demographics, haemoglobin levels, splenectomy status, systemic, hepatic, and cardiac iron overload indices, iron chelation therapy. patients with lvnc showed a significant lower cardiac functional performance (ejection fraction; volumes impairment). conclusion: patients with β-thalassaemia have a higher prevalence of lvnc than normal individuals suggesting an underlying iron deposition mechanism to explain this condition in absence of conventional risk factors. these data seem to be crucial regarding an entity with adverse cardiac outcomes, especially in patients with β-thalassaemia where cardiac disease remains a primary cause of mortality. ranged from 2.3 mm to 34.3 mm (mean = 11.3 mm). involvement of internal carotid artery (n = 9, 64%) was more common than external carotid artery (n = 5, 36%). petrous segment of ica was the most commonly involved segment (n = 5, 36%), followed by cervical segment of ica (n = 4, 29%) and maxillary artery (n = 3, 21%). conclusion: carotid blowout syndrome following rt were more common in our study subjects with advanced t and n stage of npc, local recurrence and repeated rts. pseudoaneurysms were identified in most patients. ica involvement was more common and petrous segment of ica was the most commonly involved segment. of the 6 patients with involvement of pns, one presented with orbital extension. nasopharyngeal and oropharyngeal involvement was seen in two cases. in 20 cases (77%), the primary tumours seen as diffuse enhancing mucosal thickening. in five cases (19%), the primary tumours seen as an enhancing mass lesion. in one case (4%), the primary tumour was undetectable. bone destruction was noted only in 3 cases (12%). conclusion: nasal-type nk/t-cell lymphomas of the sinonasal regions often presents with diffuse mucosal thickening rather than mass lesion. and they can mimic inflammatory disease such as sinusitis. radiologists should be familiar with these findings indicative of the possibility of nktl, and should perform a histopathologic confirmation to establish a diagnosis. results: a significant relationship between symptoms and morphological manifestations was found (disk displacement (p < 0.001), osteoarthritis (p < 0.001) and effusion (p = 0.001)). in the group without reduction there were significant increases in the risk of experiencing symptoms (p = 0.002) in the group with reduction the risk was marginal (p = 0.071). significant correlation between age and osteoarthritis (p = 0.001) and age and effusion (p = 0.022) was found. there was no correlation between sex and morphological manifestations. significant increases in the risk of experiencing symptoms were found in the group with morphological manifestations (disk displacement (p = 0.006), osteoarthritis (p < 0.001) and effusion (p < 0.001)). statistically marginal results were verified with multivariate analysis. conclusion: mri morphological manifestations of the tmj correlate with the presence of symptoms, therefore mri has a crucial role in the diagnosis of treatment of tmj dysfunction. purpose: to compare image quality of fbp, asir and veo reconstructed ct images of the neck in tumour patients with a contrast-enhanced scan. methods and materials: consecutive regular contrast-enhanced tumour staging ct-scans (discovery hd750, ge; helical, 0.8s, 120 kv, 50-400 ma mod., ni 33) of the neck were reconstructed using fbp, asir and veo; n=27. image quality at three defined heights (lymph node levels=lnl 2, 3, 7) were independently rated by 2 radiologists blinded to the reconstruction algorithm. readers rated image quality including artefacts, contrast and noise using a semi-quantitative scale of 0 to 10 (lower than 5 was defined as non-diagnostic) yielding a summary score for each height. wilcoxon´s test was used for statistical testing. icc was calculated. purpose: maxillary sinus pyocele is a true chronic abscess found in drugrefractory sinusitis. the purpose of this study is to define this new entity and its mri-characteristics. we retrospectively reviewed mri datasets for 23 patients with "pseudotumoral sinusitis" on ct (including 2 bilateral cases). the mri datasets were scored by two radiologists for morphological features, t1 and t2-weighted signal intensities, contrast enhancement and the degree of impact on the sinus mucosa and the retromaxillary fat. these features were compared with per-operative findings. results: we observed a content presenting t1 low signal (92%), heterogeneous t2 low signal (92%), a capsule with contrast enhancement (100%) containing microabscesses (52%), a mass effect on the lateral nasal wall (100%) and retromaxillary fat stranding (88%). eighteen pyoceles were treated endoscopically, with confirmation of a maxillary sinus abscess in all cases. furthermore, we suggest a staging system for maxillary sinus pyocele. conclusion: maxillary sinus pyocele presents specific mri characteristics. this entity must be suspected on sinus ct scan and recognised on mri. surgical endoscopic sinus surgery is needed. these findings therefore merit further investigation. purpose: to compare mr imaging at 1.5-and 3.0-t in the same individuals for performance in the diagnosis of cartilage lesions of the knee. this prospective study was approved by our institutional review board, and informed consent was obtained from all patients. from december 2010 to february 2012, mr examinations of the knee at both 1.5-and 3.0-t were performed in 100 symptomatic patients (71 men, mean age 45y, range 17-75y) who underwent subsequent knee arthroscopy. three blinded independent readers graded all articular surfaces seen at mr using the noyes classification system. with arthroscopy as the reference standard, the sensitivity and specificity of the 1.5-and 3.0-t mr protocols for detecting cartilage lesions were calculated. differences between the 1.5-and 3.0-t exams were compared using bootstrapping statistics (p < 0.05). results: for all readers and grades of cartilage lesions combined, the respective sensitivity, specificity, and accuracy of mr for detecting cartilage lesions (n=144) were 60%, 96%, and 87%, respectively, at 1.5-t and 69%, 96%, and 90%, respectively, at 3.0-t. for detecting and correct grading of cartilage lesions, the readers performed significantly better with 3.0-t than with 1.5-t (p=0.001). conclusion: a comprehensive mr protocol at 3.0-t significantly improves diagnostic performance for evaluating the articular cartilage of the knee in symptomatic patients, when compared with a similar protocol performed at 1.5-t. purpose: the purpose of this study is evaluation of correlation between relative signal intensity of mr images in retrodiscal tissue, superior and inferior heads of pterygoid muscle in tmd patients with types of anterior disc displacement and condylar flattening. in this cross-sectional study, 31 mr images of patients who had anterior disc displacement were evaluated. after relative signal intensity measurement for retrodiscal tissue, superior and inferior head of lateral pterygoid muscle, the correlation between relative signal intensity and types of anterior disc displacement and also condylar flattening was evaluated. results: the correlation between relative signal intensity of mr images and type of anterior disc displacement in retrodiscal tissue (p-value=0.10), superior head of lateral pterygoid muscle (p-value=0.68) and inferior head of lateral pterygoid muscle (p-value=0.40) was not significant. there was also no statistically significant correlation between relative signal intensity of mr images and flattening of condylar head in retrodiscal tissue (p-value=0.75), superior head of lateral pterygoid muscle (p-value=0.49) and inferior head of lateral pterygoid muscle (p-value=0.60). we found that although mri is a non-invasive procedure in the diagnosis of tmd, probably relative signal intensity of mr images in retrodiscal tissue, superior and inferior head of pterygoid muscle is not a good predictor for type of anterior disc displacement and flattening of condylar head. it seems that this cannot be used as a diagnostic marker for tmd progression. high resolution 3d mr imaging of the temporomandibular joint: feasibility and comparison with 2d sequences u. navarro, m. ravanelli, d. farina, e. botturi, r. maroldi; brescia/it (navarrougo@gmail.com) purpose: to assess the feasibility of high-resolution 3d mr imaging of the temporomandibular joint (tmj) and to compare 3d and standard 2d techniques. methods and materials: ten volunteers underwent a tmj mr study with surface coils including a proton density (pd) fat-saturated 3d sequence "space" and 2d pd fat-saturated sequences acquired on parasagittal and paracoronal planes. twenty tmj were imaged and analysed. the contrast between articular disk (ad) and bilaminar zone signals was measured on parasagittal images and normalised by the ad signal. capability of 3d sequences to depict eight small anatomical structures of the tmj (4 on parasagittal and 4 on paracoronal plane) was assessed and compared to that of standard 2d sequences. results: contrast between bilaminar zone and ad in 3d and 2d sequences was 2.93 and 2.61, respectively (p 0.34). fifty-eight out of 80 structures assessed in parasagittal plane were detectable on 2d sequences, 67/80 on 3d sequences (p 0.03). among the 80 structures assessed on paracoronal images, 40 were recognised on 2d sequences, 67 on 3d sequences (p 0.0001). conclusion: high resolution 3d mr imaging of tmj is feasible with 3d pd fatsaturated space sequences. the detectability of anatomical structures, potentially key for joint functionality (ligaments) is enhanced in comparison to standard 2d sequences, especially on paracoronal plane. results: aea was identifiable in 106/106 on the axial plane, 106/106 on coronal and 105/106 on sagittal. in 43% of patients, the aea canal run inside the skull base (condition #1), in 57% of cases a pneumatised cell was interposed between the canal and the skull base (condition#2), 52% of the pneumatised cells above the aea canal were supraorbital cells, 35% supra-bullar recesses and 13% frontal sinuses. in these cases, the average distance between the aea canal and the skull base was 2.2 mm (range 1. in 20 patients with kl grade 1-2 knee oa, dgemric was acquired at 3 t using a 3d-spgr sequence before and 3 months after ha treatment. to evaluate patient symptoms, the knee injury and osteoarthritis outcome score (koos) questionnaire was recorded at baseline and follow-up. we analysed 8 matching anatomical rois in the medial and lateral knee compartment in both examinations, using the t1 relaxation times as a measure of cartilage quality. outcomes of dgemric and koos at baseline and follow-up were compared using paired testing to evaluate the symptomatic and potential structural effects of ha. results: outcomes of dgemric at follow-up (pooled median t1 504 ms) did not improve significantly compared to baseline (pooled median t1 490 ms) in any of the analysed anatomical cartilage rois. patient complaints improved significantly in koos subscales: pain, daily-, and sports activities. conclusion: using dgemric, no improvement in articular cartilage quality can be detected 3 months after ha. however, patient complaints decreased significantly after ha. therefore, the results of this study suggest that the working mechanism of ha is not acting through an improvement of sgag content in the cartilage. purpose: to analyse the spatial resolution of different reconstruction kernels and acquisition protocols including a prototypic high-resolution protocol in flat-panel (fp) and multi-detector (md) ct to evaluate contrast and cartilage depiction quality of fpct and mdct arthrography. a cone-beam image quality phantom was used to compare resolution and different reconstruction kernels of standard mdct (120 and 80 kv), standard binned (2x2) and prototype high-resolution unbinned (1x1) fpct protocols (5s and 20s runs each). with the resulting fpct kernel best matching the standard mdct kernel (u90u), joint phantoms with differently sized cartilage defects were scanned. ct numbers and noise in iodine contrast and phantom cartilage tissue were measured, and contrast-to-noise ratios (cnr) were calculated. depiction quality of cartilage defects was qualitatively rated by two independent radiologists. results: a sharp reconstruction kernel for all fpct protocols best matched the resolution of the standard mdct kernel. high-resolution 20s 1x1 binning fpct showed superior resolution in higher frequencies than 1.6 lp/mm. the cnr were highest in 20s fpct, followed by 5s fpct binned and mdct protocols. interreader agreement for depiction quality of cartilage defects was substantial and high in joint phantoms (0.74 and 0.8, respectively; p < 0.001). the best ratings of cartilage defect depiction quality were seen in fpct 20s, followed by fpct 5s and mdct acquisitions. conclusion: fpct arthrography offers superior cnr and cartilage defect depiction quality to mdct, and spatial resolution for small structures is higher when applying high-resolution acquisition protocols. subjects with risk factors for oa (incidence cohort) and 40 subjects from the control cohort. right knee 3 t mris were analysed at baseline and 48 months. coronal flash sequence was used to measure cartilage volume at baseline, multi-echo spinecho sequence to generate t2 maps at baseline and 48 months. regression models were adjusted for age, gender and bmi and were applied to 4 compartments (medial femur, lateral femur, medial tibia and lateral tibia). results: global t2 measurements increased in all cohorts over 48 months. baseline t2 were significantly greater in the progression cohort compared to incidence and control cohort (p < 0.001), whereas 48-month follow-up data showed significantly greater measurements in the incidence cohort (p < 0.003). most pronounced t2 changes over time were observed in the incidence cohort (p < 0.023), changes in the progression cohort were not significant. mean volume did not significantly differ between the cohorts, but progression cohort subjects showed the highest volumes in all compartments. purpose: the goal of the study was to demonstrate the benefits of t2 mapping to the assessment of lumbar disc repair after the adct. methods and materials: 50 patients, male and female, age range 18-40, with a single-level degenerative disc disease (ddd) were studied. all patients had a standard lumbar microdiscetomy performed and 4-6 weeks after the surgery underwent the adct. prior to the surgery, one month later and 3, 6 and 12 months after the adct each patient had a mr examination on the 1.5 t mr scanner. 20 patients completed a 12-month long follow-up protocol. t2 mapping revealed the level of ddd and the adjacent levels. the evaluation of signal intensity was carried out using pixel value software. results: each patient during the 12-month long follow-up reported a significant relief of pain: vas score ranged 0-3, odi score 0-20%. in the mr examination held after the adct, changes in signal intensity seen on t2-weighted mr images were reported. t2 mapping showed signs of the disc repair regardless of the lack of changes in disc dimensions. mild increase of t2 with improved homogeneity of the structural morphology of the nucleus pulposus was observed on t2 after the adct. conclusion: t2 mapping may be used for evaluating the changes of the molecular composition and structural integrity of the intervertebral disc after the adct and other novel restorative therapies. it has also the potential to be valuable in the detection of the early degeneration in the intervertebral disc. purpose: to evaluate the feasibility of t2* and t1gd mapping to assess glenohumeral cartilage, and to establish baseline values of healthy glenohumeral cartilage at 3 t. methods and materials: forty asymptomatic volunteers (mean age: 24.8 ± 2.2 years) without shoulder abnormality were included. the mri protocol comprised a three-dimensional (3d) double-echo steady-state (dess) sequence for morphological cartilage evaluation, a 3d gradient-echo (gre) multiecho sequence for t2* assessment, and a dual-flip-angle 3d gre sequence for t1gd mapping. statistical assessment involved descriptive statistics establishing mean t2* and t1gd values ± standard deviation and the one-way analysis of variance (anova) to identify any significant differences between the t2* and t1gd values of various regions of the glenohumeral joint. intra-class correlation (icc) analysis comparing repetitive t2* and t1gd measures of ten randomly selected individuals was used to assess intra-and inter-observer reliability. purpose: to evaluate the efficacy of the treatment of uterine adenomyosis using magnetic resonance imaging-guided focused ultrasounds (mrgfus) with a new specific technical plan. twenty-four patients aged between 28 and 47 years (mean age 37.5), with symptomatic adenomyosis and uterine fibroids were treated with mrgfus in our department, from october 2011 to july 2012. this study evaluates the findings on 6 patients affected by adenomyosis alone. symptomatology was assessed through the symptom severity score questionnaire. one single treatment was performed with an average energy delivered to each patient equal to 2840 j (with a minimum value of 1300 j and maximum of 4800 j). the longest treatment duration was 120 minutes. the plan employed was characterised by high density and reduced size of the spot length (ranging from 4 to 6 mm) with the shortest cooling time between the sonifications. results: the evaluation of the non-perfused volume on the c.e. t1-weighed sequences performed 6 weeks after treatment, measuring each single slice, showed a maximum retraction of the necrotic area of 73% and a minimum of 52% with a mean value of 66.5%. after six weeks, the symptomatic score showed a reduction of about 80% if compared to the pre-treatment one. the treatment with mrgfus allows a resolution of the symptoms and a reduction of the treated area, maintaining the integrity of the uterus, in a pathology which, up to now, has limited therapeutic perspectives. is uterine artery embolisation in large sized myoma as efficient as in normal sized myoma: a retrospective comparative study in 263 patients h. choi 1 , g. jeon 1 , m. kim 2 , j. lee 1 , j. yoon 1 , s. hwang 1 ; 1 seongnam/kr, 2 seoul/kr (piscean84@hanmail.net) purpose: the purpose of this study was to evaluate the effectiveness, safety and complications of uterine fibroid embolisation (ufe) when applied to myomas of large volume. a total of retrospectively collected 323 patients who underwent ufe for symptomatic uterine fibroids without adenomyosis between january 2005 and february 2011 were included in this study. patients were divided into two groups: 63 patients were selected with large fibroid burden group, defined as a dominant fibroid with a longest axis ³10 cm or a uterine volume of ³700 cm 3 and remaining 260 patients with control group. fibroid infarction and volume reduction with mri, complications and patients' satisfaction score were evaluated. results: the large fibroid group consisted of 63 (mean age 37.10 ± 5.62) women and 260 (mean age 37.33 ± 5.62) women included in control group. there were no statistical difference in average % volume reductions of dominant fibroid as 46% in large group and 41.19% in control group, the mean satisfaction score at immediate follow-up (average 2.94 months) and mid-term follow-up (average 32.63 months) and procedure related complications or major surgery following ufe. conclusion: uterine fibroid embolisation is a safe and effective treatment method which can be utilised in the treatment of myomas of large volume. the size of myoma is not a definite contraindication or poor prognosis factor for embolisation. : 76 leiomyomas in 60 women (average age 39.3 years) were treated with mri-guided focused ultrasound (mrgfus). the treatment is carried out using the ablative properties of the hifu system under 3 t mri guide. symptoms were scored using severity score (ss) and quality of life was determined using the ufs-qol score. pre-treatment measurements of leiomyoma volume were obtained by mr images. after treatment, non-perfused volume (npv) was calculated from t1-w contrast-enhanced mr sequences. the average volume of treated fibroids was 90.27 ± 90.4 mm3. follow-up images were obtained 3, 6 and 12 months after treatment and served to determine leiomyoma shrinkage. qualitative and quantitative relations between fibroid volume, npv ratio at treatment, and 12-month shrinkage were measured. results: mrgfus treated patients demonstrated a significant change in usf-qol score: mean ss score values were 48.6 ± 13.4 (pre-treatment), 25.1 ± 8.9 (threemonths follow-up), 22.1± 7.5 (six-months follow-up) and 19.3± 6.8 (twelve-months follow-up). fibroids volume changed from 90.27±90.4 mm3 (before treatment) to 54 ± 66.1 mm3 (at 12 months follow-up). we encountered a statistically significant difference between the two values (p = 0.001). mean post-treatment vnp was 57.65±52.9 mm3, about 63% of total fibroid volume (p=0.001). conclusion: mrgfus therapy of leyomioma results in a significant relief of symptoms and greater than 50% total fibroid ablation. the procedure is carried out in a totally non-invasive manner and features a high-safety profile. results: mri-guided focused ultrasound treatment was technically successful in 115 of 123 patients (93.5%). in 8 patients treatment was not possible due to bowel loops in the beam pathway that could not be mitigated (n=6), patient movement (n=1) and system malfunction (n=1). average non-perfused volume ratio was 88±15% (range, 38 to 100). mean applied energy level was 5400±1200j, and mean number of sonications was 74±27. no major complications occurred. two cases of first degree skin burn resolved within one week after the intervention. of the baseline characteristics analysed, only the planned treatment volume had a statistically significant impact on the non-perfused volume ratio. purpose: placenta percreta (pp) is a recognised cause of severe postpartum haemorrhage, with high risk of blood transfusions and emergency hysterectomy with maternal morbility and mortality. our purpose is to evaluate the role of bilateral occlusion balloon catheter insertion in to both internal iliac arteries (iia) before elective caesarean to prevent haemorrhage and to preserve the uterus. this is one of the longest cohort of women treated with prophylactic balloon occlusion and prevents caesarean hysterectomy in abnormal placentation. methods and materials: twenty-two pregnant women who were identified as having a pp by us were treated prophylactically with bilateral occlusion balloon catheters placed in the anterior trunk of both iia prior to elective caesarean. the balloons were inflated immediately after the baby delivery and deflated four hours later. patients with peri-operative bleeding were treated with uterine artery embolisation (uae), blood transfusion or hysterectomy. for each patient, estimated volume of blood lost and transfusion required was recorded. results: abnormal placentation was confirmed histologically as percreta (13), acreta (7) and increta (2). estimated median blood lost during the delivery was noted 1.8l (range 0.5-12l). postpartum haemorrhage occurred in nine patients, six had successful embolisation and three required hysterectomy. no foetal or mother death occurred. conclusion: prophylactic occlusion balloon catheter insertion in both iia prior to elective caesarean deliveries in patients with abnormal placenta contributes to successful treatment, reduced blood lost and preserved the uterus in this high risk group of women. results: a total of 11 transcatheter embolisation procedures of bilateral uterine arteries with or without extra-uterine feeding arteries were performed as the firstline treatment, and with a technical success rate of 82% (9/11). embolisation was incomplete in two patients who had an extra-uterine blood supply or a dominant draining vein; the former recovered from menorrhagia during our close observation, while the latter underwent a successful second embolisation procedure. clinical success was achieved in the remaining eight patients after a single procedure and there was no recurrence of bleeding. only one minor complication occurred: rupture of the proximal ua. recovery to their normal menstrual cycle was seen in all eight of the clinically successful patients, one of whom subsequently had an uneventful intrauterine pregnancy carried to term. .9 years ± 9.9 years) underwent a pre-therapeutic fdg-pet/ct scan and a fdg-pet/ct after the second cycle of nact. histopathology served as the reference standard. suvmax of cancer lesions before and after the second cycle of nact were measured. two evaluation algorithms were used: (a) pcr: sinn score 3 and 4, npcr: sinn score 0-2; (b) pcr: sinn score 4, npcr: sinn score 0-3. the absolute and relative decline of the suvmax (δsuvmax, δsuvmax (%))was calculated. differences of the suvmax and of the suvmax decline between pcr and npcr lesions were tested for statistical significance (p <.05). to identify the optimal cut-off value of δsuvmax (%) to differentiate between pcr lesions and npcr lesions a receiver operating curve (roc) analysis was performed. results: using evaluation algorithm a the δsuvmax was 13.5 (pcr group) and 3.9 (npcr group) (p = 0.006); the δsuvmax (%) was 79% and 47%, respectively (p = 0.001). on roc analysis an optimal cut-off δsuvmax (%) of 66% was found. using evaluation algorithm b the δsuvmax was 17.5 (pcr group) and 4.9 (npcr group) (p = 0.013); the δsuvmax (%) was 89% and 51%, respectively (p = 0.003). on roc analysis an optimal cut-off δsuvmax (%) of 88% was found. conclusion: fdg-pet/ct early differentiates between pcr and npcr after two cycles of nact. in our study we prospectively enrolled 23 consecutive patients (m:f=20:3, mean age 70years) affected by hcc: 6 patients at presentation and 17 at restaging. in all cases we performed a whole body cho-pet and compared findings with referring ct (n=20) and/or mri scanning (n=11), for a total of 25 paired scans. the reference standard for validating imaging results was either histology (5 patients), or a multidisciplinary work-up. for every modality we determined diagnostic accuracy on a scan-based and on a site-based analysis. results: on a scan-based analysis cho-pet and ct/mri demonstrated an accuracy of 86.4% and 88%, respectively, whereas on a site-based analysis the two modalities demonstrated a sensitivity and accuracy, respectively, of 67.6% and 65.9% for pet, and 71.7% and 69% for ct/mri. in both analyses, no statistically significant difference was found on t-test. in 7/23 patients, hcc showed either loco-regional involvement (n=3) or distant metastases (n=6). all extra-hepatic lesions were properly detected by cho-pet (accuracy 100%), whereas ct/mri missed a large part of them (accuracy 58.8%) and this most likely due to the limited field of view during acquisition. in 7 cases (30.4%), pet information determined a change in treatment planning. conclusion: according to our findings, cho-pet has a comparable accuracy with ct/mri in hcc. the principle advantage of the modality appears its ability to detect extra-hepatic lesions, which can lead to treatment modification. furthermore, in-/opposed-phase sequence (dixon) used for attenuation correction in mr/pet were evaluated. in all images, the diagnostic confidence in identification of nodules was rated on a 4-point scale (1=certain; 4=uncertain). additionally, the involvement of each lung lobe (primary/metastatic) was assessed. ct scan in inspiration served as reference. the diagnostic performance of each modality was compared in a lesion-and lobe-based analysis. the diagnostic confidence was compared using wilcoxon test. results: 48 lung nodules were evaluated. in the lesion-based analysis, sensitivity (false negative rate) of ctex, vibein, vibeex and dixon was 77% (23%), 52% (48%), 48% (52%) and 25% (75%). in the lobe-based analysis reflecting the clinical assessment, sensitivity (false negative rate) was 94% (6%), 89% (11%), 89% (11%) and 53% (47%), respectively. in ct and mri diagnostic confidence was rated higher in inspiration (mean score ctin/ctex 1. purpose: to evaluate the relationship between quantitative ct-perfusion parameters and tumour volume with glucose metabolism parameters, in staging of lung cancer patients with 18 fdg pet/ct whole body study. methods and materials: thirty-one patients with biopsy-proven lung cancer, referred for cepet/ct staging, were prospectively enrolled in our study. ctp was performed with following parameters: 120 kv; 80 mas; scan 30, during intravenous injection of 50 ml of contrast-agent, flow rate: 5 ml/sec. ctp and cepet/ct data were used to calculate a range of tumour vascularity parameters (blood flow, blood volume and mean transit time) and tumour glucose uptake (suvmax), and finally correlated with tumour volume using a commercially available software. four patients were excluded due to the advanced stage of the tumour. ct perfusion parameters were then statistically analysed and compared with those of fdg-pet. results: perfusion parameters were calculated with a dedicated software (perfusion 3.0; advantage; ge) and a quantitative map of arterial perfusion was generated. patients were divided into two groups according to tumour volume, with a cut-off of 14 cm3. linear regression was performed among two groups and statistically significant correlations (p < 0.05) were found between bf and suvmax (negative correlation) and between mtt and suvmax (positive correlation) for tumours with volume > 14 cm3. these findings may be due to the inadequate blood inflow typical of larger tumours, with a significant increase of anaerobic metabolism and glucose consumption. conclusion: cepet/ct perfusion is a feasible technique that offers informations related to the biological tumour behaviour that can be used for planning treatment and for an accurate evaluation of tumour response after therapy. retention as pib positive (pib+) or pib negative (pib-). data of the unidirectional influx k_1 from a subset of 7 ad patients and 3 controls were used for correlative analysis. data were analysed using regions of interest (roi) analysis. results: we found a strong, positive correlation across brain regions between k_1 and epib (r=0.70; p < 0.001). epib values were significantly lower in posterior cingulate (p < 0.001) and parietal cortices (p=0.002) in pib+ subjects compared with pib-although the group difference were stronger for rcmrglc in cortical areas (p < 0.001). strong positive correlations between epib and rcmrglc were observed in all cortical regions analysed, especially posterior cingulate and parietal cortices (p < 0.001). this study suggests that a single dynamic pib-pet scan may provide clinical estimates of pathological (amyloidosis) and functional changes (impaired blood flow) in ad. this dual information might be valuable both in early diagnosis of ad and evaluation of treatment strategies, but our results emphasise the need for further research. purpose: to assess the diagnostic accuracy of diffusion kurtosis imaging (dki), dynamic susceptibility-weighted imaging (dsc) and short echo time chemical shift imaging (csi) for grading gliomas, as separate techniques and in a multimodal approach in order to determine the best discriminative parameter (s). methods and materials: 35 patients with cerebral gliomas (12 f/23m; age range: 22-78, median age: 55) underwent dki, dsc and csi on a 3 t mr scanner. diffusion parameters: mean diffusivity (md), fractional anisotropy (fa), mean kurtosis (mk); perfusion parameters: mean relative regional cerebral blood volume (mean rrcbv), mean relative regional cerebral blood flow (mean rrcbf), mean transit time (mtt) and relative decrease ratio (rdr), and twelve csi metabolite ratios were compared between 22 high-grade gliomas and 14 low-grade gliomas (mann-whitey-u, p < 0.05 significance, bonferroni corrected). sensitivity, specificity, diagnostic accuracy and optimal thresholds were determined for the techniques separately and combined. results: mk, md, mean rrcbv, mean rrcbf, rdr, lips/cho, lips/cre, myo/sum and cre/sum showed statistically significant differences among tumour grades, with mean rrcbf as the best discriminative parameter. the combination of mean rrcbf, mk and myo/sum to grade gliomas showed diagnostic accuracy, sensitivity and specificity of 100%, whereas combining mean rrcbv, md and lips/cho gave a diagnostic accuracy, sensitivity and specificity of 91%, 93% and 82%, respectively. conclusion: combining the parameters mean rrcbf, mk and myo/sum to determine the glioma grade was pathognomonic in this study. the best performing parameters, when used individually, were found to be mk and mean rrcbf. additive value of arterial spin labeling in differentiating primary central nervous system lymphoma from glioblastoma multiforme: an observer performance study k. yamashita, t. yoshiura, a. hiwatashi, o. togao, k. kikuchi, k. yoshimoto, h. honda; fukuoka/jp (yamakou@radiol.med.kyushu-u.ac.jp) purpose: to determine whether asl has an additive diagnostic value to the conventional mr images in differentiating primary central nervous system lymphomas (pcnsls) from glioblastoma multiformes (gbms). methods and materials: mr images of 48 patients including 12 with pcnsl and 36 with gbm were retrospectively studied. two independent neuroradiologists took part in 2 reading sessions. in the first session, the observers read only conventional mr images (t1-weighted image, t2-weighted images, post-contrast images, and dwi with apparent diffusion coefficient maps). in the second session, they read asl cerebral blood flow (cbf) maps along with the conventional images. the confidence level for the diagnosis (pcnsl versus gbm) was graded on a 5-point scale. interobserver agreement as well as sensitivity, specificity, accuracy, positive predictive value (ppv), and negative predictive value (npv) were assessed for the two readers. purpose: organ-based tube-current modulation (obtcm) is a technique developed to lower ct radiation dose to anterior dose-sensitive organs. this irb-approved observational study aimed to establish the location of breast tissue in a female patient in supine position with arms raised over their shoulders. a secondary purpose was to look for possible thresholds of chest diameter and woman's age below or above which the breasts lie in a central location with subsequent possible benefit from obtcm. methods and materials: informed consent was obtained in 200 consecutive women included. from standard chest ct acquisitions, one 5/5 mm image set with fov of 500 mm and x and y coordinates at 0 were obtained. from the gantry rotation centre (x=y=0), the outer and inner angles limiting the breast tissue were measured and compared to the angles (60°), where obtcm delivers lowered and increased dose to the organs. results: outer angles of breast tissue were < 60° for one breast in only two patients. inner breast angles were > 60° in 14/200 patients for at least one breast. no threshold of chest diameter or age was found to predict a central enough location of the breast for obtcm to be beneficial. conclusion: our data show that the angular position of breast tissue is higher than the limit where reduced versus increased radiation dose is delivered in obtcm. this system should therefore not be applied to ct chest examinations in adult women lying supine. purpose: to evaluate the effect of an organ-based tube-current modulation (obtcm) and bismuth shielding on image quality and breast radiation dose in women undergoing low-dose chest ct. methods and materials: low-dose chest ct was obtained from 80 women, who were randomly assigned to a control, obtcm, breast shield, or breast shield plus obtcm group. axial slice images from aortic arch, carina, and inferior pulmonary vein were used to analyse image quality. three radiologists scored the image quality in terms of artefact and noise, and then designated the overall image quality as optimal (does not affect the diagnostic accuracy) or suboptimal (affects the diagnostic accuracy). noise levels were measured in the anterior and posterior lung in each image. a phantom dose study was conducted to measure the radiation dose. results: images with artefacts or noise were more frequently obtained in the breast shielded groups. the overall image quality was not significantly different among the four groups. measured noise levels in the anterior lung were significantly higher in the breast shielded groups than the control group; however, no statistical significance was found among the four groups in the posterior lung. in the phantom dose study, a 16-37.5% dose reduction in the breast was achieved using the breast shield and/or obtcm protocol. the radiation dose in the female breast may be reduced using the breast shield or obtcm during low-dose chest ct with acceptable image quality. the obtcm reduced the radiation dose in the breast without inducing image quality deterioration. the solid parts of gliomas and compared between high-and low-grade gliomas. all the parameters were also normalised to the corresponding values in contralateral normal appearing white matter (nawm) and compared between high-and lowgrade gliomas. a receiver operating characteristic (roc) analysis was performed for statistical analysis. results: there were significant differences in adcfast and adcslow values between high-and low-grade gliomas (p < 0.05). the α value was significantly lower in high-grade gliomas than that in low-grade gliomas (p < 0.001). in addition, the adcfast, adcslow and α values that were normalised to the values in the contralateral nawm were all significantly different between high-grade and low-grade gliomas (p < 0.05). conclusion: ivim imaging with biexponential and stretched-exponential model is a useful tool in grading cerebral gliomas. the α value may be the best parameter for distinguishing high-from low-grade cerebral gliomas. purpose: this study aimed to determine which combination of acquisition and iterative reconstruction parameters for low-dose mdct at low tube voltages yields image quality and diagnostic confidence equivalent to current clinical standards in thoracic imaging. methods and materials: thoracic images of eight sedated and mechanically ventilated pigs were acquired with mdct during mid-inspiratory breath hold using standard (120 kvp, 180 mas) and low-dose protocols at low tube voltages (100/80 kvp) and current-time products (120/60/30 mas). using lung and soft-tissue kernels, images of all acquisitions were reconstructed with filtered backprojection (fbp); low-dose acquisitions were also reconstructed iteratively (levels 2 and 5, idose, philips healthcare). three independent blinded readers sorted the resulting 19 image data sets per animal according to diagnostic image quality (best to worst), and sorted images were statistically clustered. additionally, ct numbers and noise have been determined in lung parenchyma, liver, muscle and aorta of all image data sets. results: interreader-agreement was moderate-high (κ=0.56-0.66). for any fixed set of acquisition parameters fbp-images were ranked lowest while those reconstructed iteratively (idose5) were ranked highest independent of reconstruction kernel. the 19 image series could be clustered into 3 homogeneous clusters of equivalent diagnostic quality: iteratively reconstructed images acquired at 100 kvp/120 mas (idose2/5), 100 kvp/60 mas (idose5) or 80 kvp/120 mas (idose5) were ranked equivalent to fbp-images acquired using standard protocol. iterative reconstruction did only affect ct numbers at very low dose (80 kvp/30 mas) while image noise could be reduced by up to ~60%. conclusion: using low-kvp and low-mas protocols combined with iterative image reconstruction, radiation exposure of thoracic mdct could be reduced by 50-75%. purpose: to determine utility of adaptive iterative dose reduction using threedimensional processing (aidr 3d) for pulmonary nodule identification on low-dose 320-detector-row ct using different scanning methods in phantom study. a chest ct phantom including simulated pulmonary nodule was scanned on a 320-detector-row ct using non-helical wide volume scan (wvs) and helical scans as 64-detector-row ct (64hs) and 160-detector-row ct (160hs) at nine different tube currents. all data sets were reconstructed using aidr 3d and filter back projection (fbp). to determine the capability of overall identification, two chest radiologists independently evaluated lesion conspicuities by five-point scoring system. at the each scanning method, gold standard was defined as the data set of standard tube current (270 ma) reconstructed by fbp. interobserver agreements of detection and the capability for radiation dose reduction on each scan method were assessed by kappa statistics and roc analyses. results: interobserver agreements were almost perfect or substantial at all data sets (κ> 0.60). when applied aidr 3d, area under the curves of data sets equal to or higher than 30 ma on wvs, 40 ma on 64hs, and 40 ma on 160hs had no significant difference with standard data sets (p> 0.05). on the other hand, when applied fbp, radiation dose reduction was limited in comparison with the data sets applied aidr 3d at all scanning methods. conclusion: aidr 3d was more useful for low-dose chest ct examination for nodule screening than fbp, and wvs can reduce more radiation dose than 64hs and 160hs on 320-detector-row ct. methods and materials: 50 ctpa studies planned with frontal topogram only (protocol 1) were compared with 50 ctpa studies planned with frontal and lateral topograms (protocol 2).optimal scan length was defined from lung apex to lung base. excess scan length beyond these landmarks was measured. mean organ doses to thyroid, liver and stomach were estimated using standard conversion factors. results: the mean excess scan length was significantly lower in protocol 2 compared with protocol 1 (19.5 ± 5.3 mm vs 39.1 ± 5.3 mm,p < 0.0001). the mean excess scan length below lung bases was significantly lower in protocol 2 cohort compared with protocol 1 (7.5 ± 4.2 mm vs 23.0 ± 4.2 mm,p < 0.0001), as were the mean organ doses to stomach (4.24 ± 0.26 mgy vs 5.22 ± 0.26 mgy,p < 0.0001) and liver (5.60 ± 0.21 mgy vs 6.38 ± 0.21 mgy,p < 0.0001).a trend towards reduced over-scanning above the apices in protocol 2 was observed compared with protocol 1 (12.0 ± 3.2 mm vs 16.2 ± 3.2 mm,p= 0.07), with a trend towards lower mean thyroid organ dose in ( purpose: volumetric measurement of a nodule is more sensitive in the detection of tumour growth than axial diameter measurement. the purpose of this study was to assess the accuracy of lung nodule volumetry using adaptive iterative dose reduction (aidr) 3d in comparison with filtered back-projection (fbp) in an anthropomorphic thoracic phantom on 320-detector row ct. conclusion: pulmonary haemorrhage during fine-needle lung biopsy is a frequent event. it protects against pneumothorax in patients with pre-existing comorbidities, especially for long needle trajectory, for bleeding greater than 6 mm developing along the needle track. feasibility and safety of ct-guided percutaneous radiofrequency, microwave or cryoablation of the pulmonary and mediastinal unresectable tumours adjacent to the heart and large vessels c. pusceddu, l. melis, g. meloni; cagliari/it (clapusceddu@gmail.com) purpose: to verify the feasibility and safety of radiofrequency ablation (rfa), microwave ablation (mwa) and cryoablation (cra) under ct guidance in the treatment of cancer adjacent to the heart and large vessels. methods and materials: 27 patients (mean age of 64 years) with unresectable primary and secondary pulmonary and mediastinal tumours (12 nsclc, 1 invasive thymoma, 1 mesothelial sarcoma and 13 metastases) were treated by ct-guided rfa (14 cases), mwa (7 cases) and cra (6 cases). all the tumours were in contact or distant from the large vessel wall or the pericardium less than 1 cm. all ablations were performed under conscious sedation and local anaesthesia. vital signs of the patients were non-invasively monitored continuously. the therapeutic outcomes were evaluated by contrast-enhanced ct after 1 month. in two patients, an electrode is penetrated in the pericardium without any consequences. results: in all cases, the procedure was technically successful. no intraprocedural arrhythmia occurred. morbidity consisted of 7 cases of pneumothorax, 3 cases of pleural effusion and 1 case of asymptomatic thickening of the pericardium. in the ct control after 1 month, there was a complete necrosis in 22 cases and a partial (from 70 to 90%) necrosis in the remaining 5 cases. conclusion: indifferently from the energy source used to obtain the tumour necrosis, the treatment of the pulmonary and mediastinal unresectable tumours adjacent to the heart and large vessels is feasible and safe because the blood flow cause a "heat-sink" effect adjacent to such structures that prevent undesired thermal damage. factors influencing local tumour control in patients with neoplastic pulmonary nodules treated with microwave ablation ( were placed in lateral position with the biopsy side down (group b). statistical analysis was performed comparing pneumothorax rate between the two groups. the rate of pneumothorax requiring intervention was also assessed. the effect of other variables (patients demographic characteristics, lesion characteristics, lesion distance from the skin and biopsy technique) was evaluated in both groups. results: 27 pneumothorax occurred in group a (15.61%) versus 1 (2.44%) in group b (p= 0.025). pneumothorax requiring treatment was noticed in 10 cases (5.78%) in group a, versus 0 (0%) in group b. emphysema and lesion size were independent risk factors for pneumothorax in group a. emphysema was also independent risk factor for pneumothorax necessitating a drainage catheter insertion in group a. no independent risk factor was recognised for pneumothorax or pneumothorax requiring intervention in group. purpose: the aim of this study was to evaluate the feasibility of percutaneous transthoracic needle biopsy of pulmonary nodules under xperguide cbct navigation guidance. between february 2010 to july 2011, we evaluated 70 patients with a pulmonary lesion. all patients had a diagnostic conventional chest ct and after underwent percutaneous transthoracic needle biopsies of pulmonary nodules under xperguide cbct navigation guidance.the mean size of the lesion was on average 5.5 cm. immediately after fnab an additional cbct was performed to evaluate any complications; moreover, a follow-up expiratory chest radiograph was obtained. calculation of radiation dose of the procedure and statistical analysis were performed. results: technical success rate was achieved in 100% of cases. forty-six lesions were diagnosed as malignant, 20 were benign, and 4 were indeterminate. all malignancies diagnosed by fnab were confirmed by history and imaging. the overall accuracy, sensitivity, specificity, positive predictive value and negative predictive value were 94.2%, 92%, 100%, 100% and 92%, respectively. in the 34 patients with a lesion equal or less to 3 cm undergoing xperct-guided lung biopsy the average effective dose was 11.14 msv (range 1. purpose: this study aimed at reviewing the results and the safety of embolisation in patients affected by haemoptysis of pulmonary arterial (pa) origin. all consecutively patients treated for haemoptysis of pa origin during 12 years (1999 to 2011) were reviewed. age, underlying disease, and haemoptysis volume were recorded. ct-scan and pulmonary angiography of each patient were reviewed for the description of the pa lesion (aneurysm, false aneurysm, irregularity of the pa or abrupt interruption) and the material of embolisation used for the treatment. results: forty-three patients (10 women, 33 men; mean age: 53 years) were treated during this period. aetiologies were tuberculosis (n=13), lung cancer (n=8), necrotizing pneumonitis (n=8), aspergillosis (n=5), behcet disease (n=5) and others (n= 4). five abnormalities of pa were found: pseudo aneurysm of the pa (papa) (n=28), aneurysm of the pa (apa) (n=5), irregularity of pa (n=4), early interruption of pa (n=3), one pavm, and no abnormalities in 2 patients. materials used for embolisation were coils (n=25), onyx (n=14) and covered stent (n=2). two early recurrences, 5 short-term recurrences, and one long term recurrence after embolisation were recorded. they were treated by surgery (n=4) percutaneous microwave ablation of lung tumours c. pusceddu, l. melis, g. meloni; cagliari/ it (clapusceddu@gmail.com) purpose: to assess the feasibility and safety of percutaneous ct-guided lung tumour microwave ablation. methods and materials: 28 consecutive patients (18 men, 10 women, mean age 62 years) underwent ct-guided percutaneous microwave ablation (mwa) of unresectable lung tumours (11 primary nsclc and 17 metastases) mean size 3.2 cm (2.5-8 cm). the study cohort was selected according to the following criteria: 1) maximum tumour size less than 9 cm in diameter, 2) less than 5 metastatic tumors, 3) patients with a normal coagulation status and 4) provision of written informed consent. all procedures were performed with ct guidance under conscious sedation and local anesthesia. one or two straight microwave antenna (14 or 16-gauge) were placed directly into the tumour for 8-12 minutes. follow-up included contrast-enhanced ct at 1, 3, 6 months and then at 6-month intervals; stable or reduction size and the absence of tumour enhancement ct images were considered indicative of complete tumour necrosis. results: in all cases, the procedural was technically successful. morbidity consisted of 8 cases of partial pneumothorax (28.6%) which were resolved spontaneously within 7 days. at a mean follow-up of 8 months (range 2-15), we recorded a 67.8% of complete response (tumour necrosis = 100%) and a 32.2% of partial response (tumour necrosis range 65%-92%). our preliminary results show that percutaneous ct-guided microwave ablation is feasible and safe for the treatment of primary and secondary lung tumour. further follow-up and a prospective controlled trial is necessary to validate the procedure. 1week before the ablation and at 24hours, 3, 6, 9 and 12 months post ablation. thin section ct volumetric measurement of the lesions was performed at the same time periods as a second parameter for comparison. the lesion mri enhancement intensity in each study was estimated, and the ratio to the paraspinal muscle enhancement intensity at the same level was measured (lesion muscle signal (lms ratio). the correlations between post ablation follow-up ct volume of tumours and ce-mri lms ratio at the follow-up periods were assessed. results: the preablation tumour volumes ranged between 0.30 and 6.1 cm (mean: 1.5 cm³, sd:1.3). lms ratio 1 was noted in preablation due to high contrast enhancement of the tumour and in 24-h post ablation due to the inflammatory response associated with the thermal ablation and due to tumour residue or progress. weak correlation was detected between the lms-ratios and ct-volumetric changes in 24-h post ablation. strong correlation between the lms ratios was estimated between the follow-up periods of 3 months (spearmanr:0.62,p=0.0021), 6 months (spearmanr:0.66,p=0.001), 9 months (spearmanr:0.61,p < 0.001) and 12 months (spearman r:0.7, p < 0.00001). conclusion: ce-mri follow-up of the mw ablated lung tumours can be used effectively to assess the tumour response to ablation using lms ratio as a parameter of assessment. purpose: to compare image quality between standard-dose filtered back-projection (fbp) and low-dose iterative reconstruction (ir) protocols in computed tomography (ct) of the cervical spine. methods and materials: forty patients investigated by ct of the cervical spine for chronic neck pain and/or cervical radiculopathy were prospectively randomised into two groups: standard-dose ct (120 kvp, 275 mas) with fbp, or low-dose ct (120 kvp, 150 mas) with ir. image noise, signal-to-noise (snr) and contrast-tonoise (cnr) ratios were measured. two radiologists, blinded to ct parameters, independently assessed the following anatomical structures at c3-c4 and c6-c7 levels, using a four-point scale: intervertebral disc, content of neural foramina and dural sac, ligaments, soft tissues and vertebra. they subsequently rated overall image quality using a ten-point scale. volume ct dose index (ctdivol) and doselength product (dlp) were recorded. imaging quality of reduced radiation dose lumbar spine ct with iterative reconstruction c.-j. lin, s. hung, w. guo, t. wu; taipei/tw (bcjlin@gmail.com) purpose: the purpose of our study was to investigate the diagnostic accuracy of ct scans of the lumbar spine (ctls) acquired with lower mas and kilovoltage reconstructed with an ir algorithm. we prospectively recruited 120 patients for ctls. patients were classified into three groups. the radiation dose reduction was set to 50% of the original estimated dose with alternative tube currents and 120 kv in group a, and 100 kv in group b. images were reconstructed with idose 4 level 4 reconstruction algorithm. for group c, the standard mas and 120kv with filtered back projection (fbp) algorithm was employed. the snr of the intervertebral disc (ivd), dural sac (ds) and psoas muscle (pm), and the cnr of the ivd and ds were compared across groups. two radiologists independently rated the quality of each reduced-dose image as either equivalent ('1') or inferior ('0') to the rater's subjective 'standard' ctls. results: there were decreased snrs of all rois in group a but only ds showed statistical significance. there were significant decreased snrs in ivd, ds, and ps in group b. there was a weak correlation between snr and bmi in all 3 groups. the cnrs for groups a, b and c were 0.08+0.05, 0.15+0.09 and 0.12+0.06, respectively. the mean image quality scores for groups a, b and c were 0.63, 0.83, and 0.87, respectively. conclusion: with the aid of the ir algorithm, it is feasible to provide diagnostic ctsl imaging with a 50% radiation reduction using lower mas. multidetector computed tomography of the cervical spine: optimisation of iterative reconstruction strength levels purpose: it was reported previously that trabecular bone structure parameters could add significant information for predicting bone strength beyond bone mineral density. in the past, trabecular bone structure analysis was limited by the spatial resolution of clinically available mdct scanners. recent technical improvements have made it possible to determine trabecular bone structure parameters of the spine using clinical mdct. therefore, the purpose of this study was to assess trabecular bone structure parameters obtained from clinical mdct as well as xtreme-ct (hr-pqct) as standard of reference and to investigate whether clinical mdct can predict vertebral bone strength. methods and materials: fourteen thoracic vertebral bodies were harvested from formalin-fixed human cadavers (11 women and 3 men; age: 84±10 years). all specimens were examined using xtreme-ct (isotropic voxel size of 41 μm³) and a clinical whole body mdct (interpolated voxel size: 146x146x300 μm³, spatial resolution: 250x250x600 μm³). trabecular bone structure analyses (histomorphometric and texture measures) were performed in the xtreme-ct as well as mdct images. vertebral failure load was determined in an uniaxial biomechanical test. results: xtreme-ct and mdct-derived trabecular bone structure parameters showed correlations ranging from r=0.60 to r=0.90 (p < 0.001). correlations between trabecular bone structure parameters and failure load amounted up to r=0.86 (p < 0.001) using the xtreme-ct images, and up to r=0.79 (p < 0.001) using the mdct images. correlation coefficients obtained with xtreme-ct and mdct were not significantly different (p> 0.05). the spatial resolution of clinically available whole body mdct scanners is suitable for trabecular bone structure analysis of the spine and to predict vertebral bone strength. contrast-to-noise (cnr) ratios were measured. two radiologists independently and blindly evaluated the following anatomical structures at both c3-c4 and c6-c7 levels, using a four-point scale: intervertebral discs, content of neural foramina and dural sac, ligaments, soft tissues and vertebrae. they ultimately rated the overall diagnostic image quality using a ten-point scale. as the strength level of irs increased, the image noise decreased linearly, while the snr and cnr both increased linearly (all p²0.001). for the intervertebral discs, the content of neural foramina and dural sac, and for the ligaments, the subjective image quality scores increased linearly with increasing ir strength levels (all p²0.03). in contrast, for the soft tissues and vertebrae, the image quality scores decreased linearly with increasing strength level of irs (all p < 0.001). finally, the overall diagnostic image quality scores increased linearly with increasing ir strength levels (both p < 0.001). the optimal strength level of irs in cervical spine mdct depends on the anatomical structure to be analysed. for the intervertebral discs and the content of neural foramina, high ir strength levels are recommended. relationship among facet joint fluid ( years) affected with low back pain underwent mri of lumbar spine using sagittal t1-and t2-weighted fast spin-echo and axial t2*-weighted gradient-echo sequences. for each level from l3 to s1, disk degeneration was graded using the thompson scale (1-5), while the fjf was graded as 0 (absent), 1 (monolateral), or 2 (bilateral): per-patient disk degeneration and fjf were calculated summing the scores of the 3 spine levels. spearman correlation coefficient, multivariate regression analysis, friedman mcnemar tests were used. data were reported as median and interquartile interval (ii). the degeneration of l3/l4 (median 3; ii 2-3) was lower than that of both l4/l5 (median 3; ii 2-3; p=0.017) and l5/s1 (median 3; ii 3-4; p=0.002). the fjf of l5/s1 (median 0; ii 0-1) was lower than that of both l3/l4 (median 1; ii 0-2; p=0.002) and l4/l5 (median 1; ii 0-2; p=0.019 near-perfect correlations of suv values were found for the myocardium (suvmax/ mean: r = 0.98/0.98); good correlations were found for the liver (r = 0.6/0.7), subcutaneous fat (r = 0.6/0.8), bone marrow (r = 0.6/0.5), psoas muscle (r = 0.6/0.5) and the suvmax of the blood-pool (r = 0.6). correlations between mrac and ctac were non-significant for suvmax and suvmean of the lung and the suvmean of the blood-pool. the mean suvmax and suvmean in mrac-pet compared to the respective ctac values was significantly lower in all organs (p < 0.05) but in the myocardium (suvmax) and the psoas muscle (suvmax/mean). results: sixty-three patients were referred for a pre-treatment fdg pet-ct; age range was 21-78 years (mean age 47 years). pet-ct had a major impact on patient management in 32%, a minor impact in 8% and no impact in 60%. in patients with a major impact; 12 had unsuspected nodal involvement, 5 had occult metastases, 2 had synchronous tumours and 1 had negative nodes on pet-ct. these findings either altered radiotherapy treatment planning or treatment intent. during the follow-up period until august 2012, 25% developed disease recurrence following completion of therapy (11% isolated local relapse and 14% distant (± local) disease). conclusion: fdg pet-ct can have a major impact on patient management in locally advanced cervical carcinoma, by detecting occult disease or characterising indeterminate findings on mri, resulting in an alteration in radiotherapy treatment planning and/or treatment intent in up to one-third of patients. is there a role for standard uptake value in the prognostic evaluation of lung nodules? purpose: we report about our approach in imaging patients with cervical cancer using an integrated simultaneous pet/mri device. goals were the introduction of a stable and effective protocol for whole body and dedicated pelvic examination and rating of image quality. methods and materials: ten patients with primary (n=4) cervical carcinoma or tumour recurrence (n=6) were included. patients underwent a simultaneous pet/ mr, pet/ct and conventional mr examination. mr and pet image quality were rated on a likert score system (0-4) by three radiologists and a nuclear physician. pet data were simultaneously visually compared by two nuclear physicians and a radiologist. purpose: brca1 and bra2 mutation carriers may be more susceptible to radiationinduced cancer because of their role of tumour suppressor genes in radio-induced dna damage repair and signalling. heterozygous mutations of a tm , a major kinase initiating the response to radio-induced dna double-strand breaks, is likely to be involved in lymphoma as well as in breast cancer in high-risk patient (hrp) treated for a hodgkin disease. thus the standard two-view mammographic screening annually recommended with mri in hrp must be adapted. recent literature data were analysed. individual radiosensitivity was assessed by radiobiological effects and epidemiological studies. radiophysical and radiological mammographic data about calcifications detection and reduction of exposures were also taken into account. high-resolution diffusion-weighted imaging of pancreatic ductal adenocarcinoma using 2d reduced field of view single-shot echo planar imaging at 3.0 tesla c. ma, y. li, h. wang, s. chen, j. lu; shanghai/cn (mengqihi@gmail.com) purpose: to demonstrate the feasibility of high-resolution dwi of pancreas using 2d reduced field of view (rfov) single-shot echo-planar sequence in the evaluation of pancreatic ductal adenocarcinoma. methods and materials: 50 normal volunteers and 50 patients with histopathologically proven pancreatic ductal adenocarcinoma by surgery were included in the study. high-resolution dwi of pancreas was obtained using a multi-section 2d rfov single-shot echo-planar sequence on the axial plane (fov 16×8 cm 2 , matrix 128×64). adc of the normal pancreas in control group and pancreatic ductal adenocarcinoma group were measured. mann-whitney u-test has been used to compare adc values between tumoral tissues and normal pancreatic tissues of the volunteers. results: on the high-resolution dw images, all pancreatic ductal adenocarcinoma demonstrated high signal intensity relative to the surrounding pancreatic parenchyma. the mean and standard deviations of the adc values (×10 -3 mm2/s) were as follows: pancreatic ductal adenocarcinoma (n = 50), 1.53 ± 0.26 (1.02 -2.23), and normal pancreas in normal volunteers (n = 50), 1.98 ± 0.25 (1.60 -2.73). adc of the pancreatic ductal adenocarcinoma were significantly higher compared with those of normal pancreas (u = 230.000, p = 0.000). conclusion: rfov dwi shows advantages in higher resolution (1.25×1.25 mm 2 ) and blurring reduction compared to full fov dwi of the pancreas. it makes a statistically significant difference on the adc measurements of the pancreatic ductal adenocarcinoma when comparing to the control group. this approach is promising to benefit the early diagnosis of pancreatic cancers. purpose: to prospectively evaluate the application of arfi implemented with virtual touch tissue quantification in the study of pancreatic cystic lesions, using different analysis methods, compared with the final diagnosis (pathological or by mri/eus findings). methods and materials: 38 patients with pancreatic cystic focal lesion (diameter > 3 cm and located at a depth < 5.5 cm) were included in the study and underwent conventional us. for every patient 5 measurements with virtual touch quantification roi were performed. in order to distinguish mucinous (potentially malignant) from serous cystic lesions (mainly benign) the result "xxxx/0" was considered meaning simple liquids (reportable to water), and the accuracy of virtual touch tissue quantification in differentiating cystic-pancreatic lesions was calculated. to consider the lesion as containing complex fluids (potentially mucinous), two different reading methods have been applied: at least two numerical values when performing five measurements; prevalence of numerical values irrespective of the number of measurements. sensitivity, specificity, positive and negative predictive values and accuracy were calculated for the differential diagnosis between mucinous versus non-mucinous cystic lesions. results: sensitivity, specificity, ppv, npv and accuracy in the group of cystic lesions using the first reading method were, respectively, 68.8%, 77.3%, 68.8%, 77.3%, 73.7%. sensitivity, specificity, ppv, npv and accuracy in the group of cystic lesions using the second reading method were, respectively, 37.5%, 100%, 100%, 68.8%, 73.3%. conclusion: arfi with virtual tissue touch quantification can have a role in noninvasive characterisation of pancreatic cystic lesion during the conventional us examination. purpose: to evaluate the efficacy of ct perfusion for detection of malignancy in pancreatic masses. methods and materials: 27 patients (pts) who presented with a mass in the pancreas were enrolled in this institute review board-approved prospective study after informed consent and underwent biphasic cect with perfusion ct of the pancreas. pts were followed up and results of cytopathological diagnosis obtained. final diagnosis consisted of malignancy (adenocarcinoma) in 11, various benign masses in 13 and neuroendocrine tumour in 3 pts. control group consisted of 15 pts who were referred for ct for an indication other than pancreatic pathology. 11 perfusion parameters were calculated using software mistar 3.2 (apollo imaging software). ct perfusion parameters were compared between the control and study groups as well as results of cytopathological diagnosis using anova and dunnett 2-sided t-test for statistical analysis. results: all perfusion parameters except extraction (e) were significantly different between adenocarcinoma and benign groups. all perfusion parameters except permeability (ps) were also statistically significantly different between adenocarcinoma group and controls. blood flow (bf), blood volume (bv), extraction fraction product (efp), ps and peak enhancement intensity (pei) showed decreasing trend in values, whereas rest of the parameters showed an increasing trend from normal to benign to adenocarcinoma. neuroendocrine tumours had different perfusion values with significantly elevated bf, bv, pei and earlier time to peak (ttp). one patient with pancreatic tuberculosis had perfusion values paralleling adenocarcinoma but with relatively earlier ttp. conclusion: perfusion ct seems to be a useful tool for differentiating between malignant and benign pancreatic masses. comparison after the acquisition of axial t1w and t2w sequences and coronal mrcp, diffusionweighted mr imaging was performed using an axial respiratory-triggered spin-echo echo-planar sequence with multiple b values (150, 500, 1000, 1500 sec/mm²) in all diffusion directions. adc value was calculated by using a dedicated software fitting the curve obtained from the corresponding adc for each b value. fitted adc values were calculated by two observers in conference for each cystic pancreatic lesion and for normal pancreatic parenchyma. imaging results were correlated with surgery, ercp, and/or imaging follow-up. results: final diagnoses included intraductal papillary mucinous tumour (ipmt) (n=58), serous cystoadenoma (n=18), and mucinous cystoadenoma (n=10). fitted adc value was 1.33x10-3 mm2/sec for normal pancreatic parenchyma, 3.10x10-3 mm2/sec for ipmt, 2.57x10-3 mm2/sec for serous cystoadenoma, 2.93x10-3 mm2/ sec for mucinous cystoadenoma. fitted adc values were significantly higher in mucinous neoplasms than in serous cystoadenomas (p < 0.05). our results suggest that diffusion-weighted 3 t mr imaging with b-multiple se-epi may be helpful to differentiate mucinous from serous cystic pancreatic lesions. further investigations in larger series of patients are necessary to confirm our data. purpose: cardiac magnetic resonance imaging (cmr) using a comprehensive approach consisting of adenosine perfusion and late gadolinium enhancement (lge) at 1.5 tesla has established for detection of relevant coronary artery disease (cad). little is known about the potential advantages of 3 tesla cmr to detect relevant cad. aim of our prospective study was to compare a clinical routine cmr protocol performed at both 1.5 and 3 tesla in patients with suspected cad undergoing coronary x-ray angiography. methods and materials: 52 patients (62.3±10.2 years) with suspected cad were included into the study. all patients were scanned at both 1.5 and 3 tesla including functional imaging, adenosine stress and rest perfusion, and lge. cmr images were analysed by two blinded readers in consensus. x-ray angiography served as the reference method. results: diagnostic accuracy of the combined analysis of perfusion and lge imaging yielded better values at 1.5 and 3 tesla than the analysis of perfusion images alone. sensitivity and specificity at 3 tesla were superior to 1. purpose: the purpose of this study was to evaluate the prevalence of pathological cardiac mri findings in subjects with mild coronary calcifications. methods and materials: 101 asymptomatic volunteers were selected from a large population-based screening study in accordance with their agatston calcium score (group 1: agatston score: 0, n = 51, age 60.10 +-6.41; group 2: agatston score: 1 -100, n = 50, age 63.9 +-6.33). all subjects underwent cardiac mri at 1.5 t. the mri protocol included a) functional assessment of the left ventricle, b) assessment of adenosine stress-/rest perfusion and c) quantification of late gadolinium enhancement (lge). results: a stress-induced perfusion deficit was present in 1/101 subjects (1.0%), whereas lge was seen in 17/101 subjects (16.8%). group 1 (agatston score: 0): in this group none of the subjects showed a perfusion deficit, whereas in seven subjects lge was observed (13.7%). two of the seven subjects showed an ischaemic-type pattern of lge (3.9%) indicating chronic infarction. group 2: median agatston score of group 2 was 19 (q1, 11; q3, 43). in this group a perfusion deficit could be observed in one subject (2.0%), whereas lge was observed in ten subjects (20.0%). however, all of these lge patterns were assessed as non-ischaemic. the prevalence of stress-induced myocardial ischaemia in subjects with mild coronary calcifications score is low, whereas the frequency of non-ischaemic lge is relatively high. long-term follow-up will clarify whether these cardiac mri findings contribute to cardiovascular risk stratification in asymptomatic subjects. purpose: to determine the feasibility of ct-based myocardial perfusion imaging to differentiate ischaemic and infarcted myocardium as compared to magnetic resonance imaging (mri). we prospectively enrolled subjects with suspected coronary artery disease, who underwent adenosine-mediated stress myocardial perfusion imaging by dynamic dual-source ct (100 kv, 320 mas/rot) and 3 t-mri. myocardial blood flow and volume (mbf and mbv, respectively) were derived from ct images, using a model-based parametric deconvolution method for 16 myocardial segments. these were related to perfusion defects visually assessed during rest/stress and delayed mri acquisitions. conventional measures of diagnostic accuracy and differences in mbf/mbv were determined in a blinded fashion. results: among 41 enrolled subjects, 31 (mean age 70 ± 9 years, 74% men) completed the protocol. the prevalence of ischaemic and infarcted segments detected by mri was moderately high (11.6% and 12.4%, respectively purpose: patients with extra-cardiac arterial disease (ecad) are at high risk of coronary heart disease. we examined the prevalence of silent, significant coronary artery disease in patients with stenotic or aneurysmatic ecad. methods and materials: cardiac asymptomatic ecad patients without contraindications for computed tomography (ct) and magnetic resonance imaging (mri) underwent coronary ct angiography (ccta) and adenosine perfusion mri (apmr). calcium scoring was performed based on non-contrast ct. ccta was positive when ³50% lumen diameter stenosis in a coronary artery was found. patients were referred to a cardiologist when ccta showed a stenosis in the left main coronary artery (or equivalent), or when apmr showed inducible myocardial ischaemia. results: in total, 115 patients (mean age 65 yrs; 76% male) were included. patients were divided into 2 categories: stenotic (n=87) and aneurysmatic ecad (n=28). ccta was positive in 38% in stenotic and 29% in aneurysmatic ecad. no ccta was performed in 20% due to excessive calcium. two patients, 1 stenotic and 1 aneurysmatic ecad had left main stenosis. apmr was positive in 12% in stenotic and 11% in aneurysmatic ecad. eighteen percent of stenotic and 21% in aneurysmatic ecad have been referred to the cardiologist. a cardiac intervention was performed in 43% of stenotic and 33% in aneurysmatic ecad. significant stenosis or high calcium score was found in 58% in stenotic, compared to 50% in aneurysmatic ecad. none of these outcomes were statistically significant. conclusion: silent, significant coronary artery disease is highly prevalent in patients with ecad, either stenotic or aneurysmatic. purpose: to evaluate non-linear image blending in comparison with linear image blending in late phase dual-energy computed tomography (dect) for the visualisation of delayed myocardial contrast enhancement in acute myocardial infarction (mi) and to identify optimal parameters for non-linear image blending. methods and materials: acute reperfused mi was induced in seven pigs by temporary occlusion of the left anterior descending or left circumflex artery. two hours after reperfusion contrast-enhanced late phase dect (80 kv/140 kv) was performed. dect data were post-processed with linear and non-linear image blending techniques. contrast and percentage signal difference between healthy and infarcted myocardium as well as the blood pool of the left ventricle were computed for the linear and non-linear techniques including the low and high kv images. data were compared using repeated measures anova and post hoc t-tests. results: non-linear blending showed the highest signal differences for all contrasts and analyses. repeated measure anovas confirmed these differences to be statistically significant for the different post-processing techniques (p-value ranging from < 0.001 to 0.003). paired-samples post hoc t-tests proved the significance of these results (p-value ranging from < 0.001 to 0.037). the ideal settings for nonlinear image blending can be deduced from the ct values of the regions of interest in the linearly blended images with the weighting factor 0.3. conclusion: non-linear image blending improves the visualisation of acute mi in dect. non-linear image blending in late phase dect of acute mi is superior to linearly blended images as well as source images obtained at 80 kv or 140 kv. purpose: to assess feasibility and reliability of the juvenile arthritis mri scoring system (jamris) for the wrist to evaluate early-stage disease activity, and to compare reliability of jamris for the wrist for early-stage disease with the validated paediatric-targeted mri scoring system (ptmris) for children with more progressive stage of disease. methods and materials: mri datasets from 20 juvenile idiopathic arthritis (jia) patients with wrist involvement were evaluated independently by three readers using jamris and ptmris. assessment of early-stage disease activity in jamris was achieved through extending soft tissue scoring items (synovial hypertrophy, tenosynovitis) and specifying the grading of bone scoring items affecting < 25% of the bone (bone marrow changes, bone erosions). intraclass correlation coefficient (icc) or cohen's kappa was used to assess inter-and intrareader reliability. icc of each jamris scoring item was compared with the icc of its equivalent in ptmris. results: three jamris scoring items (synovial hypertrophy, bone marrow changes and bone erosions) showed moderate to good reliability: icc varied from 0.62 to 0.89 for interreader reliability and 0.28-0.95 (reader 1) and 0.88-0.97 (reader 2) for intrareader reliability. reliability of tenosynovitis was moderate to poor with cohen's kappa varying from 0.24 to 0.48 (interreader) and 0.41 to 0.64 (intrareader). jamris and ptmris showed similar results of interreader reliability. conclusion: early jia disease activity in the wrist can be reliably evaluated with three-out-of-four features of the simple and accurate jamris scoring system. correlating clinical disease assessment and responsiveness to change will be needed to validate jamris for the wrist as outcome measure and disease monitoring tool. showing equivocal findings or a bone injury outwith the clavicle. in those found to have clavicle fractures, 32 follow-up radiographs were performed in 26 individuals (4%). orthopaedic fixation was not performed in any of the identified cases. conclusion: despite a high pick-up rate of fractures, clavicle radiographs do not appear to substantially alter clinical management. in our centre, immobilization is the usual management for suspected traumatic clavicle injury, regardless of radiographic appearance. we suggest that, in the context of an experienced paediatric emergency department team, radiographs are reserved for patients causing concern at follow-up and are not required routinely at presentation. (an) is an eating disorder characterised by alteration of bone metabolism (osteopenia) and of body composition (reduction and abnormal distribution of fat mass-fm and lean mass-lm), due to oestrogen deficiency and self starvation. the aim of our study was to address bone metabolism and body changes in a cohort of patients with an by using dual-energy x-ray-absorptiometry (dxa). prospective study on 75 patients with an, submitted to dxa at baseline-t0 and after 12months-t12. we evaluated total and regional fm and lm percentages, as well as lumbar bone mineral density-bmd and z-score, linking them to clinical variables: menarche/amenorrhea/hormonal therapy and physical activity. results: among the 46/79-58.2% patients that completed the study the t0 clinical condition was as follows: bmi=16.4±1.4 kg/m2, low levels of fm percentage (21.7±5.7%), osteopenia (z-score:-1.21±1.27sd, with higher values related to physical activity-p=0.001). at t12: significant increase in bmi-p=0.001, with lm reduction and fm increase (more evident in the trunk-p < 0.001); regarding bone, no significant changes were observed, though a tendency in terms of improvement associated with resumption of menses was manifested. after one year, significant conclusions on bone metabolic condition could not be reached. by contrast, weight recovery was associated with the increase of fm and a distortion of its distribution, more evident in trunk region (potential and adjunctive risk factor for the relapse of the psychiatric condition). the complexity of these clinical findings suggested that dxa, a low-dose and low-cost technique, could have a key role in long-term monitoring of an patients. replacing conventional spine radiographs with dual-energy x-ray absorptiometry (dxa) in children with suspected reduction in bone density e. adiotomre, l. summers, p. broadley, i. lang, g. morrison, a. offiah; purpose: children have greater lifetime risks of radiation-induced complications compared to adults. in children with osteogenesis imperfecta conventional radiographs are obtained to assess spine morphometry, while dxa assesses bone density. in adults dxa is used for both. we aim to establish whether idxa can replace spine radiographs in assessment of paediatric vertebral morphometry. methods and materials: an 18-month prospective study of 200 consented children (5 to 15 years old) with and 50 without suspected reduction in bone density, who had lateral spine radiographs and lateral dxa scans on the same day, was conducted. three observers will independently assess all images (blinded to corresponding results of radiographs and dxa) using a modified abq technique. 100 random images will be interpreted twice. diagnostic accuracy and inter-and intraobserver reliability of dxa will be compared to the gold standard of radiography. patient/carer experience, dxa radiation dose compared to radiographs and health economics will be assessed. results: interim analysis of the first 50 recruited patients showed 26 had 1 or more vertebral fractures. the fracture detection sensitivity for dxa was 62.7% and specificity 87.8%. the overall accuracy for vertebral fracture detection with dxa was 83.5%. the overall agreement between radiographs and dxa was 68.7%. the modified abq technique has limitations in children and a more reliable scoring system is required. compared to radiography dxa does not appear to be worse for morphometry and given the reduced dose and comparable image quality, dxa should be recommended for morphometry in children pending more robust analyses. (n=221) had ddh necessitating 3 or more ultrasound examinations, of which 23% (n=50) required treatment. there was one case of missed hip dislocation, representing 0.0001% of unexamined patients. no patients with iic hips at presentation with conservative management represented with a dislocated hip. radiographs in the treated group demonstrated a satisfactory outcome in 94%. one patient represented with a dislocated hip following erroneous cessation of harness treatment and went on to develop early avascular necrosis. two patients were lost to follow-up. conclusion: a delayed approach to managing ddh in infancy allows those patients with ultrasonographically immature hips the opportunity to develop normally without invasive treatment and identifies patients which would most benefit from treatment. this reduces the demand on resources that a ddh screening programme which treated patients more promptly would incur. within the same financial constraints, this allows more patients to be selected for screening. a delayed approach results in a satisfactory outcome with no subsequent late dislocation in those treated appropriately. purpose: in cases of hip complaints in the paediatric population it is common practice to acquire both ap and frog-leg lateral (fl) radiographs. the combination of these views has a diagnostic yield, but also doubles the radiation exposure. in our observation, the fl view alone is often diagnostic. we therefore investigated the diagnostic accuracy of obtaining a solitary fl view as compared to a combination of the ap and fl views. methods and materials: children aged 2-15 years who were sent in for hip radiographs between september 2007 and january 2011 were included in the study. cases of related trauma or a history of hip pathology were excluded. radiographs were retrospectively assessed by two independent radiologists. radiologists were blinded for the ap radiograph while assessing the fl radiograph and vice versa and radiographs were presented in a random order. we used the kappa test to calculate interobserver agreement and agreement between the assessment of both views and the solitary fl view. results: 524 children (mean age 8.1 yrs) met the study criteria and were included for analysis. 477 children had a normal exam and 47 were considered abnormal. calculated interobserver agreement using the kappa test was 0.96. agreement between the solitary fl view and the combination of the ap/fl view was 0.989. the diagnostic accuracy of the fl radiograph in case of hip complaints in children is as high as the current standard of both ap and fl views. and healthcare centres. statistical analysis was made using descriptive statistics, mann-whitney and kruskal-wallis tests in order to verify correlation between items. results: radiographers consider that it is essential the implementation of a quality control program in the radiology department, but there is lack of information in this field, and 53.2% do not know what a quality control program is. 96% of radiographers claim their institutions do not have quality control programmes or accreditation. however, 25.5% had received education on quality and 85% make regular personnel radiation measures. also, despite there is no lack of radiological protection equipment in most departments, 77.4% claim they are in poor condition. conclusion: quality control programs are essential to the radiology department and radiation safety guidelines must be implemented. despite that some radiology departments have radiological protection equipment often applied by radiographers, their effectiveness and condition must be checked regularly. purpose: applying control charts to demonstrate the importance of implementing a radiological imaging quality control system. research conducted in a public hospital comprising a total of 1110 randomly selected exams (640 chest studies, 340 abdominal studies and 130 foot studies) grouped in 37 samples, each one with 30 exams. the conformities and non-conformities found were used to establish three types of quality control charts based on the evidence collected, namely the proportion of conformities and non-conformities (p), the total number of non-conformity exams (np) and the total number of non-conformities in each sample (c) in order to suggest corrective actions for improvement. results: considering all exams, 57% are non-conformities and 43% are within conformities. of 640 chest studies, 40% were within conformities and 60% were non-conformities; of 340 abdominal studies, 46% were within conformities and 54% were non-conformities. foot studies had an almost even distribution of conformities and non-conformities with 51 and 49%, respectively. conclusion: this research allowed the identification of different types of nonconformities found in radiological images which have impact on imaging quality. therefore, the existence of adequate quality control of radiographic imaging is essential. a review of diagnostic imaging frequency to aid research exploring the issue of consent for higher dose paediatric examinations j.l. portelli 1 , j. mcnulty 2 , s. mohan 2 , p. bezzina 1 , l. rainford 2 ; 1 msida/mt, 2 dublin/ie (jonathan.portelli@um.edu.mt) purpose: concerns have grown in recent years in relation to potential radiationrelated risks associated with diagnostic imaging examinations performed on paediatrics (< 18 years). this retrospective cohort study aims to provide an insight into the use of potentially higher dose computed tomography (ct) and fluoroscopyguided examinations in paediatrics, in two national clinical centres of comparable catchment areas in malta and ireland. methods and materials: retrospective data, of higher dose diagnostic imaging examinations performed in paediatrics in 2011, was collected from departmental logbooks and radiology information system (ris) databases of the participating centres. this data included details pertaining to patient's age, type of examination and relevant examination kv, mas, dap, fluoroscopy time, ctdi and dlp (if available). data were categorised according to age and examination type, and effective dose estimates for ct were calculated. results: in 2011 alone, at least 2,093 ct examinations, 1,532 fluoroscopy-guided procedures and 438 cardiac catheterisation interventions were performed on paediatrics across both centres. particular complex fluoroscopy-guided interventions had an associated dap exceeding 10,000cgy.cm2, while effective dose estimates for ct examinations indicated that some paediatric patients may receive a moderate (> 3-20msv) or high radiation dose (> 20-50msv). conclusion: paediatric patients may undergo examinations that potentially involve a high dose of ionising radiation. further research to explore the debated issue of benefit-risk communication and consent in paediatric imaging is therefore justified and encouraged, particularly as the study's findings also indicate that repeat or multiple imaging examinations of different anatomical areas are commonly performed in ct. purpose: to estimate the lifetime attributable risk (lar) of cancer incidence for individual organs following radiation exposure during pci in the context of two opposite sides of angiographic spectrum of coronary occlusive disease: st-elevation myocardial infarction (stemi) and chronic coronary total occlusion (cto). we identified all consecutive patients treated with pci for stemi (n=555) and for cto (n=543) in a tertiary care centre in 6 years. the lars of cancer incidence for six organs (colon, liver, lung, red bone marrow, stomach and thyroid) were estimated using the biological effects of ionising radiation (beir) vii model. the estimated lars of cancer incidence for individual organs was found to markedly increase as the age of the patient decreases and was significantly higher for the lung (additional risk up to 18/100.000 person's lifetime exposure in cto and 9/100.000 in stemi patients, respectively, p < 0.0001) and for the red bone marrow (up to 3.5/100.000 and 1.5/100.000, respectively, p < 0.0001). in both the groups, the estimated lar of cancer incidence for stomach, colon, liver and thyroid was similar and very low. conclusion: in pci procedures, the lung was the organ with the highest radiation absorbed. according to beir-vii model, the number of additional cancer cases for individual organs was on average two times higher in patients treated with pci for cto and the highest lars were for lung and red bone marrow cancers. project retake: quality assurance of radiation hygiene by maintaining image quality purpose: to reduce the extent of retake while maintaining image quality. the research was conducted in two digital x-ray labs, data for six months were analysed by quantitative method. patient data: id, information of retakes was stored at modality, post-examination. 750 random patients, undergoing standard x-ray examinations, were selected each month. a standard examination contains two or three exposures, front oblique and/or lateral. radiographers were encouraged to choose a cause for retake. analysis contained: type of examination, number of projections, number of exposures and retake reason per patient. the causes are systemised in the modality, ready to select if there is a retake. reject options were radiographer, patient or student failure. there was an average of 234 retaken images out of 750 examinations. that is to say, 30% margin of error. 28% of the standard examinations were retakes; the reject option was radiographer failure. rest 2% was patient or student failure. as a result of this a pgmi test is established for the digital labs to test quality assurance. results after this quality assurance give a reduction of 110 retakes per month. a reduction of 50% retakes due to radiographer failure. conclusion: environment, method, monitoring and feedback, influence radiographer result and radiation dose to patients. radiographers using digital x-ray need quality assurance as in mammography. pgmi usage will give feedback to maintain image quality and reduce radiation dose. implementation purpose: to evaluate the importance that radiographers give to quality control programs, radiological protection and the verification of radiological protection criteria. a 30-item quality control assessment and radiological protection questionnaire was applied to radiographers working on public hospitals s285 a c d e f g b saturday viability was tested by performing two tests on the lateral position of the lumbar spine, with a phantom. the results obtained using the aluminum filter resulted in a reduced variation in relative dose rate (9%) compared to not using the filter as well as a 32% reduction in dose to the entrance surface of the skin. regarding the image quality, it has been found that the use of filter presents significant reasons the optimisation of this parameter. these results indicate that the use of the filter should be considered as a good practice in the lumbar spine radiography to achieve dose reductions. antero-posterior (ap) pelvic radiography: collimator errors and their effects on radiation dose h. brookfield 1 , a.s. manning-stanley 2 , a. england 1 ; 1 liverpool/uk, 2 salford/uk (aengland@liverpool.ac.uk) purpose: to investigate the range of collimator errors in x-ray rooms and to calculate their possible effects on the radiation dose for ap pelvis examinations. a collimator test tool was suspended at three heights (14, 21 and 28 cm) above the table bucky in nine x-ray rooms. heights corresponded to the patient thickness (mean, ±2sd) in 100 patients. the x-ray beam was visually collimated to the inner boundary of the test tool and exposed to radiation. differences between the visualised field size and the resultant x-ray field size (corrected for magnification) would indicate any collimator errors. on the pelvic phantom minimum textbook collimation was set and then changed in order to simulate a range of possible collimator errors. phantom examinations used a standard technique with exposure termination using outer aec chambers. dose-area-product (dap) was recorded. results: out of nine x-ray rooms all but one produced a smaller irradiated area than was visually set. errors ranged from a 16% reduction in irradiated field size to a slight over irradiation by 0.4%. with the possibility that these errors could be larger in other institutions a range of (-27% to +18%) errors were simulated. increasing the field size by 1 cm (superior/inferiorly) increased the dap by 5%. laterally, a 1 cm increase caused a 4% rise. increases of 1 cm in both planes raised dap by 4%. in this study collimator errors were minimal and favoured under irradiation. small errors can affect dap and are more dose significant in the superior/inferior plane. breast shielding significantly reduces breast dose during lumbar spine radiography n. mekiš, d. žontar, d. škrk; ljubljana/si (nejc.mekis@zf.uni-lj.si) purpose: as use of protective shielding for the patient in conventional radiography varies widely in practice, the study aimed at providing objective answer about the effect of lead rubber sheet shielding for a specific case of breast dose during the lumbar spine radiography. influence of the body mass index on the breast dose was also investigated. the study was conducted both on an anthropomorphic phantom and on a cohort of 100 female patients, randomly divided into two equal groups. in both cases lumbar spine imaging was conducted in ap and lateral projection with and without the lead shield (in case of the patient study the shielding was used in one group only). the dose was measured by thermoluminescent dosimeters (tld) placed at the centre of the breast. results: using the lead shielding dose to the right breast was reduced from 0.45±0.25 mgy to 0.09±0.07 mgy (p < 0.001) and the dose to the left breast from 0.26±0.14 mgy to 0.06±0.04 mgy (p < 0.001), compared to the unshielded breast. on average, the breast dose was reduced by approximately 80%. no correlation between the body mass index (bmi) and the breast dose was found. conclusion: based on the results, we can conclude that the use of breast shielding is recommended in lumbar spine radiography. despite the low-dose exposure even without shielding, the dose can be further reduced. moreover, the quality of the x-ray image is not affected by the use of the lead shield. an approach for portuguese diagnostic reference levels for bedside chest radiography a. sousa, s. serém, j. santos, g. paulo; coimbra/pt (sarajoanacs@hotmail.com) purpose: bedside chest radiography represents the most commonly performed examination. taking into account the different protocols and equipments it is important to develop diagnostic reference levels, in order to promote a patient safety culture and consequently health care best practice. this research was carried out in two imaging department centres from the same geographic region (hospital a and hospital b). in phase one, the exposure parameters and entrance skin dose (esd) value of 40 bedside standard patients' chest radiography were collected. to optimise the obtained dose values in hospital b more 15 bedside standard patients' chest radiography were collected on phase two, using parameters of hospital a, that had already went through an optimisation process. results: in phase one hospital a esd value was statistically lower (16.45 μsv) in comparison to hospital b (21.94 μsv). in phase two hospital b decreased significantly the esd value (17 μsv) in comparison with the phase one, but with no significant differences with hospital a. conclusion: patients in hospital b at phase one were 25% more exposed to ionising radiation than patients from hospital a for the same procedure. the implementation of optimised protocols at phase two reduced the dose levels in 29.1% in the hospital b. the regional drl for bedside chest radiography was set at 17 μsv. an investigation into the relationship between the exposure index value and image quality m.-l. butler, l. rainford; dublin/ie (marielouise.butler@ucd.ie) purpose: 'exposure creep' is a documented phenomenon in computed radiography (cr) where radiation dose is given unnecessarily to patients due to cr's processing capabilities. manufacturers have responded by developing an exposure index (ei), which is a measurement of detector dose and hence relates to noise in the image. this study aimed to identify how the ei value relates to image quality in clinical practice. methods and materials: three imaging suites and five radiographic examinations were included: ankle and wrist series (antero-posterior (ap) and lateral); ap and lateral lumbar spine; ap pelvis and postero-anterior (pa) chest projections. in total, 306 examinations were documented with a minimum of 10 patients for each projection. twelve patient images representative of each projection were selected according to their agfa lgm value; 3 low, median and high lgm values and images recording 3 lgm values closest to the manufacturers' guidelines. three observers, experienced radiographers (minimum of 6 years working clinically), reviewed the images for noise and overall exposure of the image. in addition the observers indicated what ei value they judged appropriate to image presentation. results: no significant difference in image quality was noted across the categories of lgm when considering noise (chi-square (12)=19.265, p=0.082) or exposure (chi-square (12)=18.012, p=0.115). lgm values judged by observers as representative of image quality were lower than those recorded clinically. no correlation with lgm and clinical image quality was identified in this study. further research is recommended to include additional manufacturers and radiographic examinations. attenuation of anode heel effect with an aluminum filter and their influence on patient dose in lumbar spine radiography j. soares, r. dores, p. sousa, s.i. rodrigues, l.p.v. ribeiro, a.f.c.l. abrantes, r.p.p. almeida; faro/pt (joana.soares.8@hotmail.com) purpose: study the attenuation of anode heel effect with an aluminum filter, thereby optimising the image quality, without increasing the patient dose exposure. this study was performed in a radiology department with a conventional radiology equipment. the filter construction was based on the radiographic study of the lumbar spine in a lateral position, and used the following technical parameters: 80 kv, 10 ma, 100 ms and 90.2 cm of sid. experiments were performed to study the behaviour of anode effect along the longitudinal anodecathode axis. measurements of dose rate using the detetor unfors xi rf was carried out. this detector also allowed performing the equipment quality control. in order to standardise the variation in beam intensity of x-ray filters were used with different thicknesses of aluminum to reduce the value of the dose rate and to determine the thickness of the filter construction. after construction of the filter, the stereological approach enables the quick estimation of rv parameters with high accuracy and reproducibility from mr images. automated computerized software for diameter and volume measurements of pulmonary metastatic disease: preliminary evaluation e. lotan, d. aharoni, s. raskin, b. boursi, r. berger, e. konen; ramamt gan/il purpose: serial ct scans of metastatic tumours are vital in assessing the efficacy of cancer treatment. we evaluated the performance of a novel automated computerized software system that integrates registration, segmentation and tumour measurement into a single process to expedite recist measurement with the addition of volume measurement. methods and materials: measurements of long and short-axis of 50 lung metastatic lesions in 18 sequential patients with metastatic renal cell carcinoma were manually obtained twice by 3 radiologists. those measurements were compared with automated software measurements (carestream health, rochester, ny). in addition, the software automatically identified the lesions' contours and volumes; the readers could accept the automated measurement or correct it manually. intraobserver correlation was assessed by intraclass correlation coefficient (icc), and interobserver reliability by the concordance correlation coefficient (ccc) and bland-altman limits of agreement. purpose: clinical guidelines for follow-up of pulmonary nodules depend on nodule type and therefore accurate characterisation of nodules is important. a novel computer-aided diagnosis (cad) system to distinguish solid, part-solid and nonsolid nodules is presented and evaluated on a large data set from a lung cancer screening trial. methods and materials: the automated characterisation system is based on a previously published nodule segmentation algorithm. four different parameter settings were used to extract the solid part, non-solid part and solid core of the lesion. for each segmentation, volume, mass, average density, 5 th percentile and 95 th percentile of densities inside the segmentation were used as features. a k-nearestneighbour classifier was used to classify nodules. the accuracy of the system to differentiate between solid and subsolid nodules, between solid, part-solid and non-solid nodules and between part-solid and non-solid nodules was evaluated. a data set consisting of 137 low-dose chest ct scans (16x0.75 mm, 120-140 kvp, 30 mas) with 52 solid, 50 part-solid and 50 non-solid nodules was collected from a screening trial. the nodule type recorded in the screening database was used as the reference standard. experiments were performed in leave-one-nodule-out cross-validation. the accuracy of cad to differentiate between solid and subsolid nodules was 0.88. differentiation into solid, part-solid and non-solid nodules gave an accuracy of 0.72. cad had an accuracy of 0.71 in differentiating part-solid from non-solid nodules. automated characterisation of pulmonary nodules shows good performance. this can aid radiologists to decide on appropriate workup in clinical practice. author purpose: right ventricular (rv) volume and ejection fraction (ef) assessment is of clinical value. this procedure, based on manual delineation of the endocardial contours on mr images, is time-consuming due to ventricle's complex shape. we introduce a stereological method for estimating rv parameters from mri data without the need for image segmentation. methods and materials: twenty-two consecutive patients with coronary artery disease underwent cardiac mri. stereological estimations involved the automatic placement of a systematic grid of test points with random orientation over shortaxis images. all points hitting the rv were counted using the semiautomatic point selection process. the optimum point spacing of the grid was defined. the software automatically provided the rv volumes and ef. two independent observers evaluated the measurement reproducibility. stereological estimations were compared with those determined by manually tracing rv contours. results: acceptable estimations of rv parameters with a mean coefficient of error of 6.9±1.3% were obtained by counting an average of only 12 points per image. the mean time of stereological analysis was 3.7±0.4 min, whereas the intraobserver and interobserver variability was 3.2-5.2% and 4.6-7.8%, respectively. the mean differences between stereology and manual tracing for estimating the end-diastolic volume, end-systolic volume and ef were small and equal to 4.1±8.0 ml, 2.1±4.6 ml and -0.4±3.5%, respectively. the parameters obtained by the two methods were not significantly different (p> 0.05), and they were strongly correlated (r> 0.88). performed after standardised preparation. 2d-motility-acquisitions (dynamic-2d-t2-fiesta; tr 247.07/te 1.23/fov500/15 mm) covering the entire small bowel were performed in free breathing over 75sec. image analysis for the assessment of small bowel motility was performed both manually and with the software. the time consumption and reproducibility were compared using coefficient of variance and paired student`s t-test. results: 25 single regions of interest were analysed two times by hand and two times using motasso with a dedicated displacement provider. mean small bowel contraction frequency was 5.25 contractions per minute (sd+-2.74) for manual and 4.86 (sd+-2.48) for motasso analyses; the mean luminal diameter was 17.88 mm (manual, sd+-9.31) and 18.00 mm (motasso, sd+-9.13), respectively. the variability of repetitive measurements (coefficient of variation) was 9.77% (sd+-11.08) for manual and significantly lower (p < 0.01) for motasso-assisted measurements (3.90%, sd+-5.69). the mean duration needed for a single small-bowel motility assessment was 17.48 min for manual (sd+-1.75 min, range 14-22 min) and high significant lower (p < 0.001) for motasso-assisted measurements (4.52 min, sd+-1.58, range 2-8 min). the use of motasso proves highly reliable and fast measurements of small bowel motility in free breathing mri. reproducibility was significantly higher for motasso-assisted than for manual measurements, while the time needed for the single measurement could be tremendously reduced using motasso. purpose: plaque treatments carry considerable risk, and hence, adjunct techniques are necessary to help doctors in making a confident decision about the necessity of such procedures for a patient. mostly, symptomatic patients face a greater risk of cardiovascular diseases, and hence, classification of the plaque into symptomatic and asymptomatic is necessary. therefore, we have developed a non-invasive computer-aided diagnostic technique for the same. methods and materials: carotid artery images were acquired using multi-detector row ct angiography (mdcta). the region of interest (roi) was segmented manually from the images, and the rois were used to extract texture-based and discrete wavelet transform-based features. significant features were used to train and test support vector machine (svm) classifiers of various kernel configurations. the svm classifier with a polynomial kernel of order 3 presented the highest accuracy of 90%, sensitivity of 95.6%, and specificity of 84.4%. we formulated a riskscore, which is a combination of all the features, in order to monitor the variations in features, and also to more objectively classify the two classes. conclusion: a technique that uses the ct images to identify symptomatic and asymptomatic plaques would add more value to this modality in the area of atherosclerosis management. we have proposed and demonstrated the efficiency of one such technique in this work. the classification accuracy is high, and the technique is non-invasive, fast, highly objective, cost-effective and user-friendly. therefore, it can serve as a valuable adjunct tool that can be used by clinicians in deciding treatment options for patients. automated labelling framework applied on full and partial spine ct scans d. major, j. hladuvka, f. schulze, k. bühler; vienna/at (david.major@vrvis.at) purpose: the spine is often a frame of reference for diagnosis. for this purpose its parts have to be labelled in upper body ct scans which is a time-consuming task. an automated framework is introduced for detecting intervertebral disk and vertebra centre points and its labels in ct data containing the spine fully or partly considering clinical resource constraints. the framework uses a machine learning-based classification approach for detecting spinal canal centre point candidates as a first step. intervertebral disk-, rib-and sacrum centre point candidates are extracted next to the spinal canal by the same classification approach. intevertebral disk centre point labelling is started relative to either ribs or sacrum depending on detection certainty. the labelling run is done iteratively along the spine by obtaining best matches of trained local appearance models to detected three intervertebral disk and spinal canal centre point candidate clusters. vertebra centres/labels are derived from the intervertebral disk ones. the framework has been trained on 16 and tested on 36 solutions. accordingly, dedicated software was developed. we evaluated its clinical performance in a series of brain tumours imaged with state-of-the-art 3 t-mri. methods and materials: seventeen enhancing brain tumours were investigated (magnetom trio/3 t; dynamic t1-weighted-sequence/twist: temporal-resolution: 1.77s, in-plane-resolution: 1.2*1.1*1.1 mm 3 , 10 ml dotarem@2 ml/s; anatomicsequence/mprage: in-plane-resolution: 1.0 mm 3 ). post-processing was performed to test a dedicated commercially available cad-tool. amongst other pre-processing features it implements [1] elastic 3d-motion-correction (dynamic-contrastenhanced scans), [2] co-registration of dce-and anatomic-scans (3d and 4d), [3] identification of regions-of-interest (3d-roi), [4] identification of appropriate arterial-input-function (aif). output data include quantitative pharmacokineticparameters (two-compartment tofts-model: k trans , k ep , ve, etc). and fitted/unfitted enhancement-curves ([mmolgd/l]). all 4 pre-preprocessing features and the quality of fitted curve-data were evaluated by an experienced neuroradiologist and scored on confidence-scales (0=not appropriate to 10=excellent). pharmacokineticparameters were correlated with final diagnosis (benign/malignant: roc-analysis). results: motion-correction was technically successful in all cases. co-registration in 3d (mean-score[ms]:9.4) and 4d (ms=9.3) as well as identification of the aif (ms: 9.6) reached excellent ratings. placement of 3d-rois was difficult in one lesion (score=6). yet, in total it was performed appropriately (ms=9.0). overall quality of fitted curve-data reached good scores (ms=9), resulting into a high diagnosticaccuracy for the differentiation of benign vs. malignant tumors (auc=89% [k ep ]). the software showed an excellent clinical performance. this should help to further promote quantitative pharmacokinetic-analyses and might broaden its application in clinical practice in the future. rapid semi-automated volumetry of pleural effusion in mdct m.p.f. botelho, f.d. gonzalez-guindalini, h. chalian, v. yaghmai; purpose: to evaluate precision and reproducibility of volumetric semi-automated quantification of pleural effusions in mdct. this study was irb approved. we evaluated 29 consecutive pleural effusions in 20 adult patients undergoing contrast-enhanced mdct of the chest. two independent blinded readers used a semi-automated segmentation software for estimation of volume and recorded quantification time. manual volumetry was obtained as the reference. we evaluated the volumetry for precision, time for assessment and inter-rater agreement, as well as percentage of over-and under-segmentation. statistical analysis encompassed paired t-test, bland-altman plot and lin's concordance correlation coefficient. the mean semi-automated and manual volumes were 1040.3 ml (sd 964.6 ml) and 1033.1 ml (sd 979.0 ml), respectively (p=0.379). semi-automated volumetry showed significant inter-rater agreement, with bland-altman precision of 8.2% (upper and lower limits of 18.5% and -13.7%, respectively). the mean semi-automated volumetry was accurate when compared to manual volumetry, with bland-altman precision of 5.0% (upper and lower limits of 12.1% and -7.7%, respectively), and lin's concordance correlation coefficient (ρc) = 0.998. there was a mean of 2.3% over-segmentation using the semi-automated software. the average user time for semi-automated volumetry was 105.3 sec/case, whereas those for manual volumetry were 336 sec/case (p < 0.001). conclusion: rapid and accurate semi-automated volumetry of pleural effusions in mdct is feasible and reproducible. purpose: to present a paradigm shift in computer-assisted image interpretation and to assess its application in ct colonography. a novel segmentation-free scheme has been developed with the hypothesis that accurate colon segmentation is neither necessary nor an end clinical objective for delivering efficient support such as colon centreline, electronic colon cleansing (ecc) and computer-aided detection of lesions (cad). methods and materials: thick regions are expanded until they encompass statistically significant representations of the colon wall and its surroundings (air, tag, soft/hard tissue). from these regions, a coarse colon centreline is inferred through topological analysis guided by anatomic constraints; ecc is obtained by determining a transposing function depicting the distribution of voxels in a given air-region, and applying said function to tag-regions depicting statistically similar colon wall surroundings; unlike surface shape analysis, a cad identifies local hyper-density concentrations from implicit surfaces flux, at a given depth related to the targeted lesion size. the complete schemes were retrospectively tested on 111 and 135 patients datasets for {centreline; electronic cleansing} and cad, respectively. results: colon centreline extraction was accurate in 85% of combined cathartic and tagged datasets. cad performance was similar to that in the literature, specifically a sensitivity of 80% [70] [71] [72] [73] [74] [75] [76] [77] [78] [79] [80] [81] [82] [83] [84] [85] for lesions at least 7 mm featuring a false-positive rate less than 5 per-patient. the presented novel paradigm in computer-assisted image interpretation prevents traditional limitations arising from "accurately segmenting" a specific organ for further processing. to our best knowledge, this is the first attempt to design and validate such a paradigm shift in ct colonography. purpose: the role of mesorectal vasculature in rectal cancer is poorly understood. aim of our study was to determine impact of tumour growth as well as neoadjuvant chemoradiotherapy on mesorectal vasculature. methods and materials: ten patients with locally advanced rectal cancer underwent (re)staging mri. dynamic contrast-enhanced mri with blood pool contrast agent (gadofosveset) was performed. maximal intensity projections (mips) were used to assess macrovascular structure. number, diameter and length of vascular branches were determined in mesorectum surrounding tumour and normal rectal wall. same parameters were used to compare pre-and post-chemoradiotherapy mips. the mesorectal microvascular function was studied using relative enhancement-time curves, and expressed as area under the initial 2 minutes of the enhancement curve (auc). results: a significantly higher number of vessel branches was found in tumourneighbouring mesorectum compared to mesorectum around normal rectal wall (p=0.001). furthermore, vessel diameter in tumour surroundings was 0.2 mm larger (p=0.025). the average auc in tumour-neighbouring mesorectum was also higher (6.35 and 0.58, respectively (p=0.01)). comparison of pre-and post-crt mips revealed 40% lower vessel branching after crt (p=0.002). moreover, the vascular diameter of 1.7 ± 0.2 mm at the primary staging was significantly decreased to 1.3 ± 0.2 mm after crt (p=0.007). in contrast, crt resulted in significantly increased auc values. conclusion: there is a significantly enhanced vascular structure and function in the tumour-surrounding mesorectum, which may have an important prognostic value for rectal cancer patients. furthermore, chemoradiotherapy induces remodelling of the mesorectal vasculature. value of 3d fse cube sequence at 3 t mri in preoperative local staging of rectal cancer r. scandiffio, p. vagli, p. bemi, a. mantarro, l. faggioni, r. balestri, p. buccianti, e. neri, c. bartolozzi; pisa/it (rossellascandiffio@libero.it) purpose: to compare a standard t2w imaging, based on 2d acquisitions, with 3d fse cube sequence in the local staging of rectal cancer at 3 t mri. methods and materials: 32 patients with rectal cancer were prospectively evaluated at 3 t mri before and after neoadjuvant chemotherapy. sagittal, coronal, axial and oblique 2d t2w fse images and an additional 3d t2 fse cube sequence were obtained. each 3d dataset was processed with multiplanar and curved planar reconstructions along the rectal centreline. two experienced radiologists, using, respectively, 2d or 3d sequences evaluated t and n parameters, with specific attention to measurement of the distance lesion-puborectal muscle and mesorectal fascia, and lesion extension. all t and n parameters were evaluated independently and grouped for statistical analysis. linear cohen k values were calculated to quantify agreement between mri and histopathological data. image quality was evaluated using a linear qualitative scale. results: global sensitivities for t parameters were 67% and 62% for 2d and 3d images, while n category lesion accuracy values were 70% and 68%, respectively. accuracy in measuring the distance from pubo-rectal muscle to lesion border was 60% and 98% for 2d and 3d, respectively. image quality was considered very good on 2d images, and good on 3d images. conclusion: no significant differences between 2d and 3d images were observed for t and n staging. t2w fse cube demonstrated higher accuracy than 2d in determining the distance between lesion and pubo-rectal muscle, which represents a key factor in planning surgical resection. purpose: spatial vascular heterogeneity decreases from periphery towards tumour core in solid tumours and is related to cancer viability. this pattern is not present in rectal tumours. the aim of this study was to determine whether rectal tumour spread into layers of rectum, affects tumour vascular function compared to that of normal rectal wall. tumours were segmented into luminal, mural and extramural regions. normal tissue counterparts were defined (mucosa, muscularis propria and mesorectal fat). initial slope (slopei) and area under the first 120s of enhancement curve (auc120) were determined from relative signal enhancement-time curves. pixel parameter values and mean parameter values were compared per patient and for entire patient group. the correlation between kinetic parameters of tumour segments and of corresponding normal tissues was determined. results: for each patient, both the slopei and auc120 were significantly higher for luminal tumour pixels compared to mural and extramural tumour pixels (p < 0.05). mural pixel parameter values were significantly higher than the extramural pixels (p < 0.05). for the patient group the mean auc120 for the luminal, mural and extramural tumour region was 240±46, 178±20 and 129±18, respectively. there was a strong and significant correlation between the parameters of tumour segments and those of corresponding normal tissues (pearson's correlation coef-ficient=0.84, p=0.0001). purpose: patients with complete response (cr) after crt might be considered for less aggressive treatment like a wait-and-see strategy. few studies investigated the value of dwi-mri for predicting cr after crt, but none included lymph nodes in the analysis (ypt0n0). the aim of the present study was to retrospectively determine the additional value of dwi-mri to conventional (t2-weighted) mri for predicting cr after crt. methods and materials: eighty locally advanced rectal cancer patients underwent crt followed by restaging mri and operation. mri consisted of conventional sequences and dwi. two readers with different levels of experience independently scored conventional images for cr and, in a second reading, combined conventional and dwi-mri images. a 5-point confidence level score was used to generate roc curves. differences in performance were calculated by comparing areas under the roc curves (auc). interobserver agreement, sensitivity, specificity and positive predictive values (ppv) were calculated. histology served as reference standard. results: ten of 80 patients (13%) had a pathologic complete response (ypt0n0). comparison of the roc curves showed significant improvement of the auc only for the experienced reader 1 from 0.77 to 0.88 (p=0.009). sensitivity improved from 20-30% to 40-70%. specificity and ppv improved only for reader 1 from 87 to 93%, resp., 25 to 58%. interobserver agreement improved from 0.14 to 0.27. conclusion: adding dwi to conventional mri improves diagnostic performance of experienced readers and increases interobserver agreement for identification of cr. sensitivity and ppv remain low, with a considerable risk of over-and undertreatment. purpose: transanal endoscopic microsurgery (tem) is a minimal invasive technique for local resection of t1 and selected t2 tumours and is also an emerging option for good-responders after chemoradiation. in most centres follow-up includes regular mri. this study aimed to describe the mr morphology of the rectal wall during follow-up in patients that received tem. methods and materials: forty-nine patients underwent a post-tem mri in our centre. for 21 patients only one post-operative mri was available. for 28 patients > 1 mris were available. the mr morphology of the tem-site was studied on the consecutive mr examinations. 32 patients were primary treated with tem, 17 patients underwent chemoradiation followed by tem. results: we identified three morphological patterns: (1) rectal wall thickening with or without fibrosis, (2) a notch at the tem-location, and (3) irregular delineation of the rectal wall. multiple patterns could occur within one patient. 32 patients (65%) had rectal wall thickening, 17 patients (35%) a notch, and 28 patients (57%) irregular delineation of the rectal wall. in addition to these patterns, oedema (due to chemoradiation) persisted in post-chemoradiation tem-patients. ten patients had dehiscence after tem post-chemoradiation (n=58%). six luminal recurrences occurred; 3 had rectal wall thickening, 3 a notch, and 5 an irregular rectal wall. sinogram-affirmed iterative reconstructed simulated ecg-gated ultra high pitch ct pulmonary angiography in the acute setting: effect on dose and image quality s.j. co 1 , s. nicolaou 1 , j. mayo 1 , t. liang 1 , d. hou 1 , k. krzymyk 2 ; 1 vancouver, bc/ca, 2 topanga, ca/us (co.steve@gmail.com) purpose: to evaluate the effect of a simulated ecg-gated computed tomographic pulmonary angiography (ctpa) at 100 kv on image quality and radiation dose. retrospective study includes 100 patients referred for ctpa with pitch 3.2. 50 patients were scanned with a standard 100 kv protocol and 50 patients were scanned with a simulated ecg-gated 100 kv protocol that introduces a specialized cardiac bowtie filter. all other scanning parameters were kept constant. images were reconstructed with filtered back projection and iterative reconstruction (safire, siemens). central pulmonary vessel attenuation and background noise were quantitatively measured and signal-to-noise (snr) and contrast-to-noise (cnr) were calculated. two radiologists performed qualitative assessment grading visualisation of the pulmonary vasculature and noise level (likert scale). volume ct dose index and dose length product were recorded and effective dose was calculated. purpose: to evaluate the impact of iterative reconstructions on the diagnosis of acute pe on low-dose ct angiograms. methods and materials: 53 patients were prospectively enrolled in a study designed to compare low-dose and full-dose images simultaneously available from the same dataset. the examinations were acquired with (a) both tubes set at similar energy (120 kvp) and (b) the total reference mas (i.e., 110 mas) split up in a way that 40% was applied to tube a while 60% was applied to tube b. three series of images were generated: (a) full-dose images (generated from both tubes), reconstructed with fbp (group 1), used as the standard of reference, (b) low-dose images (generated from tube a; 60% dose reduction) reconstructed with fbp (group 2), then with an iterative reconstruction algorithm (safire) (group 3). results: all 81 patients showed significant decrease of qs (mean 17.4 to 9.8, p <.001), rlr and aopa between initial and f/u ct-pa. in 10/81 patients complete pe lysis was found. there was good correlation between reduction of qs and regression of rlr (r=-.506; p <.001) and aopa (r=-.458; p <.001), respectively. rlr and aopa changes (r=.330; p=.003) correlated poorly. patients with initial qs > 20 showed higher reduction of qs at f/u, but no significant difference was found concerning the reduction of rlr between patients with initial qs > 20 and ²20 (p=.921). the time interval between initial and f/u ct-pa differed between patients with and without complete lysis (3.5 vs. 2.14 weeks, p=.016). conclusion: clot resolution is associated with improvements of rlr and aopa, but the time to complete resolution is variable and not predictable. rlv and aopa are independent markers of right heart burden in patients with pe, but they correlate poorly with each other. clinical significance of high density thrombi on non-enhanced ct scan in patients with pulmonary thromboembolism k.s. beck, b. lee, h. kim, d. han; seoul/ kr (sallahbar@gmail.com) purpose: to evaluate the incidence and significance of occasionally detected high density thrombi of pulmonary embolism (pe) on non-enhanced chest ct scans. we retrospectively evaluated the non-enhanced and enhanced ct findings of 76 patients with pulmonary embolism, and the incidence of high density thrombi was calculated. then in both iso-density thrombi (group 1) and high-density thrombi (group 2) groups, embolic burden score, ventricular septal bowing, and diameter of right ventricle (rv) and left ventricle (lv) were evaluated and compared using independent sample t tests. purpose: to investigate the general applicability of a 70 kv protocol for routine ct pulmonary angiography (ctpa) in unselected patients. methods and materials: thirteen patients suspected of having pulmonary embolism underwent ctpa with a novel 70 kv protocol (208 mas, pitch 1.2) on a 64-slice ct device. ten patients who were investigated with the standard protocol (100 kv, 120 mas, pitch 1.2) served as the control group. images were reconstructed with sinogram affirmed iterative reconstruction with medium regulation strength in both groups. 75 ml of contrast material (350 mgi/ml) was injected at 4 ml/s. ctdivol, dlp, signal intensity in the pulmonary trunk and segmental arteries and corresponding snr values were compared. images were assessed for diagnostic quality and artefacts. results: chest diameter was not significantly (p> 0.05) different between the groups. ctdivol (2.3 vs. 6.6 mgy) and dlp (71 vs. 193 mgycm) were by 65% and 63% lower at 70 kv (p < 0.05); iodine attenuation was significantly higher (e.g. segmental arteries 554 vs. 313 hu), but so was image noise, resulting in no significant differences in snr. photon starvation artefacts from dense contrast material in the venous system and high image noise in bigger patients were the main drawbacks at 70 kv. conclusion: 70 kv ctpa seems feasible in clinical routine and results in a dose reduction of more than 60% compared to a 100 kv protocol at equal snr; however, patient selection is advisable. artefacts from inflowing contrast material will require dedicated injection protocols or the use of low-iodine contrast material. purpose: pulmonary hypertension (ph) is a disease characterised by an elevated pulmonary arterial pressure (pap) and is diagnosed invasively via right heart catheterization (rhc). we explored whether timing measures from dynamic contrast-enhanced computed tomography (ct) can be used as a non-invasive method to determine ph. methods and materials: 20 patients (15 with and 5 without ph) were examined with a novel dynamic contrast-enhanced ct sequence following their diagnostic or follow-up rhc. x-ray attenuation over time curves were recorded for several regions of interest (rois) in the main pulmonary artery and in the ascending aorta and subsequently fitted with a spline fit. time differences between the contrastmaterial bolus peaks were measured. distances between the rois were measured in a simultaneously acquired thorax ct to calculate the bolus propagation speeds. we compared our results to haemodynamic parameters acquired during rhc. results: time differences between peaks showed good correlation (spearman correlation coefficients ³ 0.65) with mean pap, pulmonary vascular resistance and gas exchange parameters. discrimination between patients with and without ph was achieved by evaluating time differences (sensitivity/specificity 100%/80%, 95% confidence intervals: 72-100% and 28-99%, respectively) and bolus speeds (sensitivity/specificity 100%, 95% confidence intervals: 72-100% and 48-100%, respectively). ) . lesions located in the vertebral body were excluded, while lesions in proximity to joints or neurovascular bundles were included. treatment success was determined at clinical and imaging follow-up at 1, 3, and 6 months post-treatment. a visual analog pain score (vas) was used to assess changes in symptoms. results: treatment was carried out using a variable number of sonications (mean 4±1.8) with a mean energy deposition of 866±211 j. there were no treatment-or anaesthesia-related complications. a statistically significant (p=0.001) difference was noted between the overall pre-and post-treatment mean vas scores (8.3±1.6 and 0.6±1.5, respectively). six of the 7 treatments were conducted on patients with typical osteoid osteoma and all were completely clinically successful. the patient with giant osteoma had pain recurrence after 2 weeks, requiring surgery. at imaging, oedema and hyperemia associated with typical osteoid osteoma gradually disappeared in all lesions. no apparent relationship between nidus vascular extinction and successful outcome was found. conclusion: mrgfus ablation represents an effective and totally non-invasive therapeutic option for osteoid osteoma management, without treatment-related adverse events. purpose: radiographic damage was recently identified as a feature of poor prognosis in polyarticular juvenile idiopathic arthritis (pjia). however, most radiographic studies did not differentiate pjia from other subtypes of jia and little is known in pjia persisting into adulthood. we set out, therefore, to describe radiological peripheral involvement in young adults with pjia as compared to rheumatoid arthritis (ra) patients. methods and materials: all consecutive pjia patients followed in a transition program were included. age, sex, disease duration, and treatment information were collected. laboratory tests and standard radiographs of the hands and wrists, feet and hips were then analysed by two independent radiologists blinded to the diagnosis. a ra control group (< 55years), matched for sex and disease duration, was recruited. düsseldorf/de (rotem.lanzman@med.uni-duesseldorf.de) purpose: the purpose of our study was to investigate changes in kidney perfusion following renal denervation using arterial spin labelling (asl) mri at 1.5 t. methods and materials: 7 patients (mean age 58 ± 13 years) undergoing interventional renal denervation were included in this study. in each patient, between 6 and 8 ablations were performed per renal artery. asl mri was performed at 1.5 t using a single-slice fair truefisp sequence in the coronal plane (30 averages of label and control pairs, inversion time 1200 ms, slice thickness 8 mm, matrix 128x128) prior to and within 24 hours following renal denervation. patients refrained from fluid intake for at least 2 hours prior to the examination. following post-processing, rois were drawn by a single reviewer on asl parameter maps for quantification of cortical perfusion. both kidneys of each patient were used for statistical analysis. results: image acquisition was completed successfully in all patients and perfusion was determined for 14 kidneys in 7 patients. in 6 patients, asl perfusion increased by at least 10% following denervation, while in one patient asl perfusion decreased following intervention. mean asl perfusion following renal denervation (245.8 ± 43.3 ml/100 g/min) was significantly higher than prior to denervation ( purpose: to evaluate trochlear morphology as a potential risk factor for patellofemoral osteoarthritis, determined by morphological and quantitative measurements of cartilage degeneration using 3 t magnetic resonance imaging (mri) of the knee. methods and materials: mr images of right knees of 304 randomly selected subjects, aged 45-60 years, from the osteoarthritis initiative (oai) progression cohort were screened for trochlear dysplasia, defined by a pathological trochlear depth. out of 304 subjects, n=85 demonstrated a shallow trochlea (depth ²3 mm; 28%). in these, and also in a random sample of controls with normal trochlear depth (n=50), we calculated the facetal ratio and assessed knee structural abnormalities using a modified whole-organ-mr-imaging score (worms). cartilage segmentation was also performed and t2 relaxation times and patellar cartilage volume were determined. anova and multivariate regression models were used for statistical analysis of the association of mri structural measures and trochlear morphology. results: knees with a shallow trochlea showed higher patellofemoral degeneration (worms mean ± standard deviation, 11.2±4.6 versus 5.7±4.2; multivariate regression, p < 0.001) and lower patellar cartilage volume than controls (900±664 mm3 versus 1671±671 mm3, p < 0.001). knees with a pathological facetal ratio showed increased patellofemoral worms scores (8.3±4.6 versus 2.3±6.3, p < 0.001). t2 values at the patella were significantly lower in the dysplasia group. however, significance was lost after adjustment for cartilage volume (multivariate regression, p=0.673). conclusion: trochlear dysplasia, defined by a shallow trochlea, is associated with higher worms scores and lower cartilage volume, indicating more advanced osteoarthritis at the patellofemoral joint. reliability of tomosynthesis for semiquantitative assessment of knee osteoarthritis features by radiologists with different levels of expertise purpose: to describe early x-ray findings in the hands and evaluate progression of destruction after five years correlated to clinical parameters in early psoriatic arthritis (psa). in 31 men and 46 women with psa fulfilling the caspar criteria hand x-rays were available from the 5-year follow-up and either inclusion or the 2-year visit. x-rays were scored by the wassenberg scoring system. results: median symptom duration at inclusion was 12 months. 58% had polyarticular and 38% mono/oligoarticular psa. at the first evaluation 60% had wassenberg score zero. at the 5-year visit median score was 2. in 34 patients (44%) the score was still 0, in 28 between 1 and 5, in 5 between 6 and 10, in 6 between 11 and 15, and 1 patient each had a score of 19, 22, 39, and 42. at baseline women had significantly higher disease activity than men, but similar x-ray score. at 5 years men had improved considerably in function and disease activity score, but had greater x-ray progression (58% vs 28%, p=0.009). male gender was a significant predictor of x-ray progression. longer symptom duration at entry predicted x-ray progression (p=0.038) and prevented minimal disease activity (p < 0.001). conclusion: after 5 years of psa, most patients still have no or very little hand joint destruction. symptom duration at inclusion and male gender were the main predictors of x-ray progression, preserved function at baseline was protective. despite worse clinical outcome with higher disease activity scores, women had less x-ray progression than men. purpose: cortical thickness mapping is a technique that uses clinical computed tomography (ct) imaging to plot the distribution of cortical bone thickness in 3d. given our understanding of their relationships with bone mineral density, we performed a study to investigate the effects of age, weight, and osteophytes on cortical bone distribution in the proximal femur. we analysed ct imaging data from a cohort of 230 women aged 66±17 years, selecting one hip from each randomly according to side. a dicom analysis tool (stradwin) was used to contour each hip semi-automatically and create a 3d surface mapped with individual cortical thickness values. statistical parametric mapping was then performed to investigate model effects of age, weight and osteophytes on cortical thickness. results: cortical thickness was generally thinner with advancing age, but was preserved in characteristic load-bearing regions at the medial femoral neck and lateral subtrochanteric cortex. greater weight was also associated with significantly thicker cortex per kilogram at these same sites. including osteophytes in the model showed that increasing severity was detected as increasingly thick cortical bone around the articular margin at the femoral head-neck junction. conclusion: these results demonstrate, for the first time, the effects of age, weight and osteophytes on cortical bone thickness in the proximal femur. it will be essential for future analysis of bone in this region to take these effects into account. conclusion: raw-data-based iterative reconstruction significantly improved image quality in very-low-dose prospectively ecg-triggered coronary dsct angiography when compared to standard reconstruction using fbp. along with substantial reduction of radiation exposure, iterative reconstruction also shows a trend towards higher accuracy in coronary stenosis detection compared to fbp. methods and materials: 12 patients underwent evaluation of the rv function on 1.5 t employing a 32-element coil. acquisition was performed using a real-time radial ssfp sequence (16 projections) in a multislice breath-hold and free-breathing setting with a spatial resolution of 2x2 mm 2 (matrix 128; slice 6 mm) and a temporal resolution of 46 ms (tr 2.9 ms). through-time radial grappa reconstruction was performed off-line (matlab) incorporating fully sampled (128 projections) calibration data acquired prior to the undersampled datasets. segmented cartesian cine ssfp was acquired at identical slice positions in multiple consecutive breath-holds with a spatial resolution of 1.3-1.5x1.3-1.5 mm, 6 mm slices and 35 ms temporal resolution (tr 3 ms). free-breathing and breath-hold real-time datasets were evaluated for rv size and function and compared with segmented cine ssfp. this hipaa-compliant study was approved by the institutional review board and patients gave informed consent. 20 patients underwent delayed phase cardiac ct on a second-generation dect scanner. late iodine enhancement data were compared with late gadolinium enhancement images from 3 t cardiac mri. dect greyscale images were reconstructed as 100 kv, 140 kv and weighted-average (wa; linear blending) images from low and high kv data incorporating 80%, 60% or 30% of 100 kv data. in addition, a colour-coded map of myocardial iodine distribution was calculated from dect data. two independent blinded radiologists reviewed all images for late enhancement areas in standard cardiac views and rated subjective image quality. results: dect data from 100 kv, wa-80% and wa-60% showed identical results for the correct identification of myocardial scarring (89% sensitivity, 98% specificity and 96% accuracy). however, wa-60% received the best subjective image quality rating and average measured infarct size correlated best with mri. colour-coded iodine distribution maps were prone to artefacts (52% sensitivity, 88% specificity, 81% accuracy), overestimating quantity of scars while underestimating lesion size by 55% compared to mri. conclusion: linear blending of delayed phase cardiac dect data improves image quality for the detection of myocardial scar tissue compared to mri. colour-coded myocardial iodine distribution maps were prone to artefacts and showed inferior diagnostic performance. influence of iterative reconstruction on coronary calcium score in cardiac computed tomography k. jaspers 1 , j.a.c. van osch 2 , j.m. groen 1 , m.j.w. greuter 1 ; 1 groningen/nl, 2 zwolle/nl (m.j.w.greuter@umcg.nl) purpose: to investigate the relation between the percentage of iterative reconstruction (ir) and coronary calcium score in cardiac computed tomography (ct). a phantom containing 100 cylindrical calcifications with varying size and density was inserted into a thorax phantom (qrm thorax, qrm, germany) with artificial lungs and spine. the phantom was scanned with a clinical acquisition protocol on a 64-slice ct (lightspeed vct xt, ge). each scan was repeated five times. the images were reconstructed with filtered backprojection (fbp) and increasing percentages of ir of 20-100%. the amount of calcium was determined as an agatston score. the influence of percentage ir on both total agatston score (tas) of the phantom as well as the individual calcium score (ias) for each calcification was investigated. purpose: to demonstrate that diffusion-weighted imaging (dwi) is able to pick up intracranial recurrences of medulloblastoma (mb) with higher sensitivity than contrast-enhanced (ce) series. methods and materials: all mri examinations of 22 children with histologically proven mb were retrospectively evaluated. routine follow-up examinations were performed initially 3 months after operation and thereafter, every 6 months for the next 2 years. then, controls were done yearly. concomitant cranial and spinal mri included t1, t2, and flair in the axial plane, followed by t1 after gadolinium (gd) in 3 orthogonal planes for the brain. additional dwi was performed. subsequent spinal imaging included sagittal t1-en t2-weighted images. results: eleven recurrences were observed in 10 patients. in 5 patients recurrent disease was observed at the resection site in 2 of which subarachnoid spread was also observed, with recurrence in loco only in 3 patients. five patients had recurrent disease away from the resection cavity, 2 of them in the frontal areas and 4 intraventricular recurrences at the supratentorial level. in 2 patients ce-series scored better than dwi; in 3 patients results on dwi and ce-series were equivocal. in 5 patients, recurrences were better demonstrated on dwi; some of them were only observed in retrospect. the results of our retrospective study demonstrate that dwi is a powerful technique allowing for early diagnosis of recurrent disease in mb patients. dwi especially demonstrates non-enhancing metastatic lesions earlier than celesions. dwi should therefore be included in surveillance imaging protocols of mb patients, especially in the group of high-risk patients. radiation-induced telangiectasia in the long-term survivors of intracranial germ cell tumours: whole-ventricle vs whole-brain radiation l. li, s. mugikura, t. murata, t. kumabe, k. jingu, t. fujii, e. mori, s. takahashi; sendai/jp (liliyanzhen05@gmail.com) purpose: telangiectasia on mr images were reported to be seen in patients who received intracranial radiation. to determine the relationship between the radiation field/dose and the prevalence of telangiectasia on mr images, we compared whole-ventricle alone (wv) and whole-ventricle plus whole-brain (wb) radiation groups in the long term survivors (more than 10 years) of intracranial germ cell tumours (gct). we compared the number of telangiectasia on t2*weighted mr images (t2*wi) between wv (n=12) and wb (n=11) groups. total dose of radiation between two groups was not significantly different (54. evaluation of diffusivity in pituitary adenoma in the sella turcica with 3d turbo field echo with diffusion-sensitized driven-equilibrium preparation: initial experience a. hiwatashi 1 , t. yoshiura 1 , o. togao 1 , k. yamashita 1 , k. kikuchi 1 , h. honda 1 , m. obara 2 ; 1 fukuoka/jp, 2 tokyo/jp purpose: to evaluate the feasibility of 3d turbo field echo (tfe) with diffusionsensitized driven-equilibrium (dsde) preparation, which is a novel non-epi technique for diffusion-weighted imaging, for pituitary adenoma in sella turcica. methods and materials: this prospective study included thirteen patients (9 females and 4 males, age 19-82 years) with pituitary adenomas were imaged with 3d tfe with dsde preparation. among them four were prolactin-producing (prl), three were growth hormone-producing (gh) and six were non-functioning tumours (non). motion probing gradients were conducted at one direction (a-p) with b values of 0 and 500 s/mm 2 . the imaging voxel size was 1.5x1.5x1.5 mm 3 . the apparent diffusion coefficients (adcs) were measured in the pituitary adenoma and the normal pituitary gland. results: in each patient, a pituitary adenoma was clearly visualised on 3d tfe with dsde preparation and adc maps without obvious geometrical distortion. adc of the pituitary adenoma ranged from 0.57 to 2.90 x10 -3 mm 2 /s (mean ± standard deviation, 1.37±0.72 x 10 -3 mm 2 /s), and was higher than that of the normal pituitary gland (1.34±0.23 x 10 -3 mm 2 /s) without statistically significant difference (p > 0.05). adc in prl (2.07±0.92 x 10 -3 mm 2 /s) was significantly higher than that in gh (0.86±0.31 x 10 -3 mm 2 /s) and in non (1.17±0.32 x 10 -3 mm 2 /s) (p < 0.05). conclusion: with its insensitivity to field inhomogeneity and high spatial resolution, 3d tfe with dsde preparation was feasible to evaluate the diffusivity in the pituitary gland. adc measurement using this new technique may help characterise hormone activity of pituitary adenomas. author disclosures: m. obara: employee; makoto obara. and 51.3 gy in wb groups). in the wb group, axial sections of the ventricular level were considered to have received significantly higher dose of radiation (51.3 gy, high-dose field) than the other upper and lower levels (24.0 gy, low-dose fields). in the wb group, we compared the number of telangiectasia on t2*wi between ventricular level and the other upper and lower levels. results: telangiectasias were observed in 22 (96%) patients. the number of telangiectasia in the wb group was significantly higher than the wv group (average 8.5 in wb and 3.6 in wv, p = 0.019). in wb group, the number of telangiectasia was significantly higher in the ventricular level than the other upper and lower levels (p < 0.01). conclusion: radiation-induced telangiectasia appears to occur in at least 96% of patients who undergo cranial irradiation. larger radiation exposure and higher radiation dose were associated with higher number of telangiectasia lesions. preoperative classification of cerebral tumours by applying whole brain vpct: which parameter to use in order to achieve the highest prognostic value? results: typical features of fibroadenomas were "lobulated shape" (or=8.6), "sharp margin" (or=14.0), "internal septations" (or=17.1), "hyperintense signal in t2w" (or=17.6) and "persistent curve-type" (or=16.2; all: p < 0.001). diagnostic accuracy increased significantly (p < 0.001), if features were assessed in combination. highest values were then observed, if the following feature combinations were present: "sharp margin and persistent curve type" (or=140.3), "plateau and internal septations" (or=18.1). overall accuracy of breast mri for the differential diagnosis of fibroadenomas vs. breast cancers revealed excellent auc (0.95, cross-validated sample). conclusion: in breast mri fibroadenomas show typical morphologic and dynamic characteristics. particularly, if multiple breast mri characteristics are assessed in combination, differential diagnosis vs. breast cancer is possible with excellent accuracy. purpose: to compare lesion detection and characterisation by the combination of one-view breast tomosynthesis (dbt) and one-view digital mammography with two-view digital mammography (mx). the study included 250 consenting women with breast lesions classified as suspicious at mammography and/or ultrasound. a clinical performance study comparing two-view (cc, mlo) mammography, and the combination of dbt in mlo view and mx in cc-view (dbt+mxcc) was conducted with six breast radiologists. data were analysed per-lesion, using lesion localisation fraction -llf (the percentage of lesions correctly localised). lesion detection was determined by calculating the total number of lesions rated above bi-rads 1. lesion characterisation was evaluated by counting malignant lesions rated above bi-rads 3 and benign lesions scored bi-rads 2 or 3. lesion detection and characterisation for all lesions, and stratified for malignant and benign lesions, were compared between dbt+mxcc and mx using analysis of variance (anova). p-values < 0.05 were considered statistically significant. the non-inferiority margin was set at 5%. results: overall, dbt+mxcc was superior to mx alone in terms of number of lesions correctly detected and characterised (llf difference: +6.85%, -95% ci: +4.02%; p-value = 0.0007). dbt+mxcc superiority was confirmed for benign lesions (llf difference: +7.93%, -95% ci: +5.71%; p-value < 0.0001), while noninferiority was achieved for malignant lesions (llf difference: +3.03%, -95% ci: -4.59%; p-value < 0.369). purpose: to estimate the inter-reader reproducibility of dbt added to 2d-dm in comparison to that of 2d-dm alone. a series of 65 breasts (65 women, aged 58±9 years) underwent dbt (giotto, ims, italy) as an adjunct to 2d-dm. after an agreement on how to report 2d-dm and dbt, 3 independent readers (r1, r2, r3) with > 6 years of experience in 2d-dm and > 1 year of experience in dbt evaluated all studies. each reader evaluated the breast density and assigned a bi-rads score using only 2d-dm. after 30 days, they repeated the evaluation adding dbt to 2d-dm. the inter-reader reproducibility was estimated using the quadratically weighted cohen's kappa. the breast density reported at 2d-dm by the most experienced reader was: 75% in 1 (1%). considering the b1, b2, b3, b4, and b5 bi-rads scores, the same reader assigned the followings: 25, 0, 10, 20, and 10 using 2d-dm; 31, 1, 7, 13, and 13 using 2d-dm plus dbt. for each pair of readers, 2d-dm plus dbt resulted in a higher inter-reader reproducibility than that of 2d-dm alone: kappa value for 2d-dm ranged from 0.418 to 0.566 while that for 2d-dm plus dbt ranged from 0.656 to 0.758. purpose: based on a novel approach, digital breast tomosynthesis (dbt) may simultaneously acquire 2d and 3d images of the breast. variable dose geometry is used to give a sufficient dose in the central projection for that image to be a 2d mammogram (2d-cp). we investigated whether 2d central projection (2d-cp) obtained with dbt is equivalent to digital mammography (dm) in terms of image quality. we retrospectively evaluated 45 asymptomatic patients who underwent dm and dbt with 2d-cp for screening. two experienced radiologists in consensus reviewed the dm and 2d-cp images in separate sessions. readers were asked to subjectively score image quality on a 1-5 scale in terms of a) artefacts (1=absent to 5=significant artefacts), b) noise (1=absent to 5=very high noise) and c) fibro-glandular-breast-tissue-to-fat-contrast (1=poor to 5=excellent). the comparison between 2d-cp and dm scores was performed with a wilcoxon signed-rank-test on a per-breast basis. results: there was no significant difference between dm and 2d-cp in terms of artefacts, with median scores of 2.0 for both techniques (p> 0.05). a significant difference (p < 0.05) was found between dm and 2d-cp concerning noise and contrast (median were 2 vs 4 and 5 vs 4, respectively). conclusion: although dm is superior to 2d-cp in terms of image noise and contrast, both techniques showed a reduced incidence of artefacts. clinical studies should be performed to assess whether this qualitative difference has clinical relevance. the role of additional ultrasound and tomosynthesis after normal digital mammography: comparison between both techniques p. slon, j. etxano, i. purpose: to increase the diagnostic accuracy of mri in the detection and local staging of bladder tumours by using fluid-attenuated inversion recovery (flair) sequences. methods and materials: 32 patients with bladder tumours detected by us underwent mri using 1.5 t superconductive magnet. we performed tse t1-weighted and t2-weighted and flair sequences on axial scans. the contrast to lesion ratio was always evaluated. all the patients underwent cystoscopy with transurethral biopsy and 14 had subsequent cystectomy. in comparison with other sequences, flair sequence was more sensitive in the detection of bladder neoplasms. this sequence demonstrates the hyperintense signal of bladder neoplasms from the filled bladder lumen with no signal. the sensitivity in the identification of bladder neoplasms was 100% with flair sequences, 89.6% with tse t2-weighted sequences and 86.2% with tse t1-weighted sequences. that was due to the higher signal-to-lesion ratio of flair sequences in comparison with the others. in fact, on flair sequences the mean value of contrast to lesion ratio of bladder neoplasm was 33.1 while on se t1-weighted sequences and tse t2-weighted sequences was, respectively, 15.2 and 29.2. flair sequences allowed the detection of small papillomas (< 2 mm). tse t2-weighted sequences were more sensitive than other sequences in the study of bladder wall infiltration. conclusion: flair sequences were more sensitive in the detection of bladder neoplasms, thanks to their higher contrast-to-lesion ratio and were helpful in the visualisation of small papillomas, especially when multifocal. while the inter-reader reproducibility of 2d-dm resulted only moderate, the adjunction of dbt allowed to reach a substantial reproducibility. the use of dbt added to 2d-dm can reduce inter-reader variability and allow for more reliable readings from different radiologists. the oblique coronal scans were parallel to the plane of the bladder neck. 15 patients underwent also voiding mr-cystourethrography performed with t1-weighted spoiled 3d gradient-echo acquisitions on sagittal plane performed after the filling of bladder lumen with contrast-material-enhanced urine. the entire mr examination lasted no longer than 10 minutes. we detected 18patients with abnormality of smooth muscular structures of the bladder neck and 3 with bladder neck cyst. mri allowed a perfect evaluation of the different smooth detrusor muscles of the bladder neck. in patients with urinary bladder neck dysfunction, we detected hypertrophy of posterior smooth muscular structures of bladder neck and kyphosis of prostatic urethra. 6 patients were able to perform voiding mr-cystourethrography that showed the characteristic radiological features. conclusion: mri with voiding mr-cystourethrography could be performed in male patients with bladder outlet obstruction in order to visualise the aspect of the b-0692 10:57 purpose: the non-invasive investigation of urinary bladder carcinoma by magnetic resonance (mr) virtual cystoscopy was evaluated by us and compared with conventional cystoscopy. methods and materials: thirty consecutive patients, presenting with gross haematuria and trans abdominal ultrasound suggestive of mass in the bladder were taken up for study. all patients underwent conventional cystoscopy and ciss 3d mr imaging and the images reconstructed for virtual cystoscopy using volume rendering technique. lesions were detected and the number, size, location and morphologic features of lesions were noted. subsequently, patients underwent conventional cystoscopy, and the findings were noted. the final diagnosis of the cases was established by histopathology. results: sixty-five lesions were seen in mr virtual cystoscopy and 69 in conventional cystoscopy. the smallest lesion identified on mr virtual cystoscopy was 3 mm. overall sensitivity and specificity of mr virtual cystoscopy for lesion detection were 94.2 and 100%, respectively. for lesions greater than 5 mm, the detection rate was 98%.pearsons correlation test showed a good between virtual and conventional cystoscopy for maximum and minimum diameters of the lesion (0.98 and 0.92, respectively). location of the lesions and their morphological characteristics were found to correspond by both methods. conclusion: mr virtual cystoscopy is an effective tool in the detection of urinary bladder tumours, especially those larger than 5 mm. when bladder lesion is less than 5 mm a sessile conventional cystoscopy is better than mr virtual cystoscopy. purpose: to evaluate the diagnostic accuracy of a diagnostic imaging technique called voiding mr cystourethrography. methods and materials: 10 normal volunteers and 86 male patients with bladder outlet obstruction (evaluated with urine-flow velocity recording) underwent voiding mr cystourethrography. the mr examination was performed with 1.5 t superconductive magnet. the filling of the urinary bladder with paramagnetic contrast agent was obtained by the i.v. administration of furosemide followed by ¾ of the normal dose of a paramagnetic contrast agent. during the micturition two consecutive t1-weighted spoiled 3d gradient-echo acquisitions on sagittal plane were performed. 3d row images were post-processed with mip algorithm. 25 patients performed retrograde and micturating conventional cystourethrography in the month preceding mri. results: homogeneous opacification of the bladder lumen was always obtained. 10 patients were unable to perform the mr examination. in all the volunteers and in all the patients studied (76 pts), a perfect evaluation of the male urethra with mri was obtained and its visualisation with mip reconstructed images was considered comparable to that obtained with conventional cystourethrography. site, length and number of urethral strictures were accurately determined. the analysis of 3d sagittal scans allowed a better evaluation of the morphology of the urethral strictures in comparison with conventional cystourethrography. conclusion: voiding mr cystourethrography demonstrates the morphology of the bladder neck and urethra during the micturition and can substitute standard cystourethrogram, avoiding radiation exposure to the gonads and urinary catheterization. image quality on liver ct based on sinogram-affirmed iterative reconstruction algorithm b. schulz, b. bodelle, p. siebenhandl, m. beeres, f. al-butmeh, c. frellesen, t.j. vogl; frankfurt a. main/de (mail@borisschulz.com) purpose: to evaluate efficiency of sinogram-affirmed iterative reconstruction technique, regarding noise and image quality on contrast-enhanced computed tomography (ct) of the liver. methods and materials: ct examinations were performed upon 32 patients (128 slice ct, 120 kv, 180 mas, activated tube current modulation, 0.6 mm collimation). each examination was reconstructed at standard filtered back projection (fbp) and 5 different safire strengths in 5 mm images in transversal direction with soft tissue kernel. image noise was defined as standard deviation (sd) of hounsfield units (hu) in air, and signal-to-noise ratio (snr) of the liver was defined as mean liver hu per liver sd. subjective image quality was evaluated by three raters using a 5-point scale (1=non-diagnostic image quality, 5=excellent image quality). results: average image noise was 6.2 hu (fbp), vs. 5.7 hu (safire 1), vs. 5.0 (safire 2) 4.4 hu (safire 3), 3.8 hu (safire 4), 3.1 hu (safire 5). snr of the liver consecutively increased when using the iterative reconstruction algorithms from 8.4 (fbp) to 9.3 (safire 1) to 10.4 (safire 2) to 12.2 (safire 3) to 15.1 (safire 4) to 17.5 (safire 5). the differences in image noise and snr of each safire-strength to fbp was statistically significant (p < 0.05). subjective image quality was voted 3.9 (fbp) vs. 4.3 (safire 1) vs. 3.7 (safire 2) vs. 2.8 (safire 3) vs. 1.8 (safire 2) vs. 1.2 (safire 5). conclusion: sinogram-affirmed-based iterative reconstruction technique significantly reduces image noise and increases snr for examinations of the liver. however, subjective image quality decreases with strong iterative strengths. bladder neck. these anatomical information are useful to determine the causes of voiding obstruction and diagnose urinary bladder dysfunction. mri findings of radiation-induced changes in the urethra and periurethral tissues in patients with prostate cancer c. marigliano 1 , o.f. donati 2 , o. akin 2 , d. goldman 2 , j. eastham 2 ; 1 rome/it, 2 new york, ny/us purpose: the aim of this study was to assess radiotherapy (rt)-induced changes in the urethra and periurethral tissues in patients with prostate cancer (pca). this retrospective study included 108 men (median age, 65y; range, 43-87y) who underwent external-beam radiotherapy (ebrt) and/or brachytherapy for pca. on endorectal-coil mris of the prostate obtained within 180d before rt and 2-63 months (median, 20 months) after rt, two readers independently measured the urethral length (ul) and graded the margin definition (md) and signal intensities (sis) of the urethral wall, the levator ani and obturator internus muscles and the muscles of the genitourinary diaphragm on 4-point scales. results: mean ul decreased significantly from pre-to post-rt mri for both readers (from 15.2 to 12.6 mm and 14.4 to 12.9 mm, [p < 0.0001, both]). inter-reader agreement for ul was excellent for pre-and post-rt mri (icc= 0.89 and 0.90, respectively). both readers found significantly decreased md and increased si in the urethral wall and pelvic muscles on post-rt mri (p?0.008). inter-reader agreement was fair for md (?=0.31, pre-and post-rt) and si of the urethral wall (?=0.33, pre-and post-rt) and ranged from slight to moderate for si of the pelvic muscles (?=0.11-0.56, pre-rt and?=0.11-0.46, post-rt). si changes in the obturator internus muscle were greater after ebrt (p=0.0003-0.01), while si changes in the levator ani muscle were greater after brachytherapy (p=0.03). conclusion: after rt of the prostate, mri shows urethral shortening, decreased urethral margin definition and increased si of the urethral wall and pelvic muscles. mri anatomic evaluation in patients with persistent urinary incontinence after advance male sling: a work in progress study with a 3 t system v. zampa, d. pistolesi, s. ortori, l. faggioni, m. marletta, c. bartolozzi; pisa/it (virnazampa@hotmail.com) purpose: retrourethral transobturator sling is a new functional treatment of stress urinary incontinence after prostatectomy consisting in repositioning the urethral sphincter into the pelvis. overall success rate is 54-80%; however, a failure rate of 20-45% is reported. the aim of this study was to retrospectively analyse morphologic changes visible on mri after sling procedure in incontinent patients and compare with the continent ones, in order to detect possible factors explaining the different clinical outcome. methods and materials: 16 patients treated with advance sling were enrolled: 8/16 had clinical recovery while 8/16 had persistent incontinence. mr protocol performed with a 3 t system included 3d t2w sequence (cube) and a high temporal resolution fiesta for dynamic mri. on the t2w sequence, the length of the bulbus posterior to the sling and the distance of the sling from a line parallel to the symphysis pubis (lsp), were measured. mann-whitney test was used to analyse the results. results: in the 8 incontinent patients the length of the bulbus posterior to the sling was < 8 mm (range 4-8 mm) while in the continent ones was > 12 mm (12-23 mm) (p < 0.001). the sling position was located posterior to the lsp in 7/8 incontinent patients (4-12 mm) and almost coincident in 6/8 continent patients (p=0.04). conclusion: based on our results, the length of the bulbus posterior to the sling seems to strongly correlate with continence. although our results must be confirmed in a larger series, surgeons should consider this element in planning the proper position of the device. of the patient and type of examination semiautomatically. in addition, 40 abdominal ct examinations were performed with a standard tube potential of 120 kvp. radiation doses (ctdivol) were noted for all examinations. signal-to-noise ratio (snr) was determined in the contrast-enhanced lumen of the abdominal aorta (a), liver (l) and spleen (s). subjective iq (lesion detectability, diagnostic confidence) was rated on a 4-point scale (1_non diagnostic; 4_excellent) by two readers. results: whereas noise level was slightly elevated when using tps algorithm compared to the standard protocol (10.2 vs. 8.0 hu, p < 0.01), no significant differences in snr (15.2±5.4 vs. 16.5±5.2 [a], 10.5±3.3 vs. 11.7± 3.9 [l], 10.8±3.8 vs. 12.0±3.9 [s]) were observed between the two protocols. subjective iq (mean score of 3.9 versus 3.8, respectively) was good to excellent in all examinations. tps lowered the ctdivol significantly as compared to standard abdominal ct (6.1±1.7 mgy vs. 11.0±3.9 mgy, p < 0.01). conclusion: attenuation-based tps lowers the dose of abdominal ct in clinical routine by up to 45% while maintaining high subjective and objective image quality. second generation dual-energy ct of the abdomen: radiation dose comparison with 64-and 128-row single energy acquisition c.n. de cecco, a. darnell, n. macias, g. muscogiuri, c. ayuso, a. laghi; rome/it (g.muscogiuri@gmail.com) purpose: this study was designed to compare the radiation dose in abdominal dual-energy (de) and single energy (se) acquisitions obtained with a dual-energy ct (dect) and a 64-row ct (sect). a total of 130 patients divided into two groups underwent precontrast and portal abdominal 128-row ct examination. in group a, de portal acquisition was performed; group b underwent se portal acquisition. group c was compound of 32 subjects from group a studied with 64-row sect. in each group, the portal phase dose length product (dlp) and radiation dose (msv) were calculated. results: a significant radiation dose increment (p < 0.05) was observed in group a 10.2±2.3 msv in comparison to group b 8.9±2.4 and group c 8.8±1.9 msv. no significant difference (p> 0.05) was reported between se 64-and 128-row acquisitions. a significant positive correlation between radiation dose and bmi was observed in each group (group a, r2=0.59, p < 0.0001; group b, r2=0.35 p < 0.0001; group c, r2=0.20, p=0.0098). in clinical practice, abdominal de modality delivers a significant higher radiation dose to the patient compared to 64-and 128-row se acquisition. the radiation increment can be justified if a real advantage in patient diagnosis is obtained using de information. can iterative reconstructions improve the detection of small hypervascular liver nodules with dual-energy ct? l. facchetti 1 , l. berta 2 , l. mascaro 1 , f. pittiani 1 , l. romanini 1 , r. maroldi 1 ; 1 brescia/it, 2 milan/it (facchettil@gmail.com) purpose: to optimise dual-energy ct (dect) protocols with sinogram iterative reconstruction (safire) algorithms for improving small hepatocellular carcinoma (hcc) detection. a dect arterial acquisition of a cirrhotic patient was reconstructed using the standard filtered back projection (fbp-b20f) and 3 iterative reconstructions both for the whole dose protocol (de composition 0.5) and for 80-kv acquisitions. each one of the iterative medium-smooth filter (i26-i30-i31) was reconstructed at 3 different strengths (s3-s4-s5) for a total of 20 image series. for each series, 8 virtual spherical lesions were simulated in random positions on the liver. a lesion-to-liver contrast (llc) of +20 hu was selected for de-composition 0.5 and +30 hu for 80 kv, according to a preliminary study on 20 hccs acquired with dect. four expert radiologists performed a detectability test and rated the overall quality, noise and sharpness (5-point scale) in all images. results: 2/32 lesions were detected with fbp-b20f. in all the iterative reconstructions, the strength-5 kernels led to detect 23±1.2/32 lesions. the highest image quality ratings were 3.3±1.3 (b20f), 3.5±0.7 (i30-s3 de-composition 0.5) and 3.1±1.2 for i30-s5 de-composition 0.5, without a statistical difference (anova test). all subjective ratings in the 80 kv series were defined as suboptimal (2.3±0.3). conclusion: iterative reconstructions increase the sensitivity of the detection of sub-centimetric low-contrast lesions, even in the 80-kv series delivering half dose. the i30-s5 reconstruction was considered the best for the routine protocol. efficacy of a liver detection algorithm for noise reduction in abdominal ct n. ardley 1 , k. buchan 2 , k. lau 1 ; 1 clayton/au, 2 melbourne/au (nicholas.ardley@southernhealth.org.au) purpose: the liver, an inherently low contrast structure, appears 'noisy' on routine ct of abdomen. this may impede liver lesion detection. the development of a specific ct liver detection algorithm delivers higher radiation exposure to the liver with the aim of improving quantum noise, and correspondingly less radiation to the remaining abdomen. the aim of this study was to assess the efficacy of this algorithm on reducing noise in the liver. methods and materials: 80 consecutive patients for abdominal ct with same level of iterative reconstruction were included. there was no exclusion. the ct liver detection algorithm was enabled in the last 40 of these patients. region of interest in hounsfield units and standard deviation (sd) were measured in the left and right lobes of liver, spleen, psoas and bladder for all patients. radiation doses were also recorded. the results of the two groups were compared. results: sd reflected noise. in the liver detection algorithm group, there was a sd reduction by 10.1% in the right liver, 15.61% in the left liver and 15.83% in spleen. no significant change of sd was seen in psoas and bladder. a 5.6% overall radiation dose reduction was noted in this group. the application of this newly developed ct liver detection algorithm demonstrated a reduction in noise in the liver and spleen with no significant noise changes in the remaining abdomen. there was an added benefit of overall radiation dose reduction. author disclosures: k. buchan: employee; philips healthcare. impact of modified abdominal ct protocols for obese patients with filtered back projection and hybrid iterative reconstruction technique on image quality, radiation dose and low-contrast detectability: a phantom study s.t. schindera 1 , d. odedra 2 , d. mercer 2 , s. thipphavong 2 , p. chou 2 , z. szucs-farkas 3 , p. rogalla 2 ; 1 basle/ch, 2 toronto, on/ca, 3 biel/ch (sschindera@aol.com) sunday data were collected in a time period of 5-40 minutes for the t1w sequences. volunteers underwent subsequent t2w respiratory-gated mrc on a 3 t mri. for qualitative analysis a 5-point scale was used. contrast ratios were calculated for quantitative assessment. results: contrast-enhanced t1w mrc at 7t showed a homogeneous depiction of the intra-and extrahepatic biliary tract with a maximum enhancement 20 minutes post-contrast. vibe and flash ir provided a good image quality for the intra-(vibe 3.60, flash ir 3.67) and extrahepatic bile ducts (vibe 3.50, flash ir 3.72). quantitative analysis revealed high cr values for flash ir (cr 0.41 intrahepatic and 0.45 extrahepatic) due to a strong signal decrease of hepatic tissue and vessels. t2w tse at 7t revealed a poor image quality without diagnostic potential (2.22 intrahepatic, 1.93 extrahepatic). 7t vibe and flash provided superiority in the depiction of the intrahepatic bile ducts, while 3 t mrc was superior in the delineation of the extrahepatic biliary tract. conclusion: our results demonstrate the feasibility of contrast-enhanced imaging of the biliary ducts at 7t, particularly t1w flash with inversion recovery enables high-quality assessment of the biliary tract. purpose: volume rendering 3d-magnetic resonance imaging (mri) is able to show auditory pathways between the cochlea and the cerebellopontine angle in children with negative auditory brainstem responses and cochlear nerve structures undetectable by conventional high-resolution (hr) mri. methods and materials: twelve children (mean age ± 43.8 mo) with confirmed severe hearing loss by abr (auditory evoked brainstem responses) underwent hr-ct and hr-mri of the petrous bone. in addition, three-dimensional t2-weighted turbo spin-echo axial slices were obtained at 1.5 t and maximum intensity projections and 3d volume reconstructions were performed for visualisation of the cochlear anatomy. results: abnormal cochleovestibular anatomic findings such as incomplete partition type i (n=1), incomplete partition type ii (n=1), narrow internal auditory canal (n=3), splitting of the internal auditory canal and concomitant anomalies of the posterior labyrinth (n=2) were detected by hr-ct and hr-mri. interestingly, volume-rendered 3d inner ear reconstructions detected varying but communicating structures of the cochlea and the brainstem in all 12 cases. after cochlear implantation all twelve children showed obvious hearing reactions. conclusion: in contrast to conventional hr-mri, 3d-mri volume-rendering reconstructions are useful to detect aberrant and even tiny auditory path structures derived from the cochlea. children with severe hearing loss and hr-mri-based findings of missing cochlear nerve structures should be further screened with volume rendering 3d-mri during cochlear implantation evaluation. purpose: cochlear nerves aplasia represents a rare but possible congenital cause of sensori neural hearing loss (snhl) in children. early identification and accurate diagnosis are mandatory to correctly select auditory brainstem implantation (abi) candidates. the purpose of the study was to evaluate the contribution of a complete pre-operative radiological assessment based on ct and mri to prevent misdiagnosis and erroneous treatments. purpose: to correlate patient diameters and subjective image quality in low-voltage and standard-voltage ct of the upper abdomen in the same patient population, with the goal of identifying cutoff patient diameters for selecting patients for lowvoltage scans. methods and materials: 32 patients underwent mdct of the abdomen with arterial phase at 80 kv with angular dose modulation on 64-row mdct (test group). this was compared to a previous 120-kv scan on the same scanner. mean interval between scans was 139 days. patient transverse and sagittal diameters were measured at celiac axis level, and the mean was calculated. two radiologists by consensus graded image quality on a 5-point scale (5=excellent; 4=good; 3=moderate; 2=poor; 1=non-diagnostic; 3 was the chosen cutoff quality). image quality was correlated to the transverse, sagittal and mean diameter by means of an anova test. results: patient diameters were unchanged across exams (all p=ns). in 80-kv scans, image quality was significantly correlated to sagittal (p=0.034) and mean diameters (p=0.025), while a trend to significance was observed for transverse diameter (p=0.053). in 120-kv scans, image quality was not significantly correlated to patient diameters (all p=ns), and all patients received grade 4 or 5. in 80-kv scans, a subjective grade 3 corresponded to a transverse diameter of 329 mm and a sagittal diameter of 267 mm. conclusion: subjective image quality in low-voltage scans appears to be more influenced by patient size than at standard voltage scans. for our protocol, cutoff diameters for adequate image quality are transverse 329 mm and sagittal 267 mm. author disclosures: g.a. zamboni: speaker; guerbet. preliminary application of spectral ct imaging in the differentiation of hepatic tumours w. chen, x. ye, c. zhou; beijing/ cn (wenchen0629@yahoo.com.cn) purpose: to investigate the value of spectral ct imaging in differential diagnosis of hepatic tumours. this prospective study was institutional review board approved with patient consent. thirty-eight patients with hepatic tumours (22 men, 16 women, 63 lesions), including 11 patients with hepatocellular carcinoma (hcc), 17 with hemangioma (hh) and 10 with metastatic tumour (mt), underwent plain scan of spectral ct imaging and conventional contrast ct scan. contrast-to-noise ratio (cnr) of different energy levels and homologous kev of optimal cnr were calculated by the spectral analysis software. the authors also chose three regions (60-80kev, 50-90kev and 40-100kev) and calculated the slope rates of spectral curves. one-way anova followed by lsd post hoc tests were performed to compare parameters among hcc, hh and mt groups. the homologous kev of optimal cnr of hcc, hh and mt groups were 68.71±1.72, 67.23±1.93 and 67.16±2.79, respectively. the slope rate of 60-80-kev region in hcc group (0.446±0.201) was significantly higher than that in hh group (0.205±0.209). there were significant differences between hcc, hh and mt groups in the slope rates of 50-90-kev and 40-100-kev regions (p < 0.05). the slope rates were 0.481±0.199, 0.202±0.213 and 0.344±0.229, respectively, in 50-90-kev region and 0.565±0.231, 0.222±0.289 and 0.396±0.260, respectively, in 40-100-kev region. the 65-70-kev monochromatic imaging of spectral ct imaging is the best for detection of hepatic tumours and slope rates of spectral curves may be useful in differentiation of hepatic tumours. purpose: to assess the feasibility of magnetic resonance cholangiography (mrc) using biliary secreted gadoxetic acid at 7 tesla (t) and to compare it to t2-weighted (w) mrc at 3 t. methods and materials: 10 healthy volunteers were examined on a 7t mr-system. t2w tse, t1w vibe and flash with inversion recovery (ir) were acquired in coronal orientation. for dynamic imaging gadoxetic acid was administrated and s31 c a d e f g b 6-gkr=2*10 5 a.u. (p < 0.05); wipi values were: b-gkr=8*10 7 cm 3 /sec, 3-gkr=2*10 8 cm 3 /sec (p> 0.05), 6-gkr=6*10 6 cm 3 /sec (p < 0.05). 6-gkr mean diameters decreased in 8/10 patients, 6-gkr ceus parameters (pe, wir, wipi) decreased in all patients. conclusion: a reduction in pe, wir and wipi at 6 months after gkr suggested a depletion in tumour vascularization due to radiotherapy-induced necrosis. our preliminary results showed the feasibility of ceus perfusion analysis for um, which could provide reproducible, reliable and earlier parameters for the assessment of tumour response to gkr. evaluation of lacrimal drainage system obstruction using combined multidetector ct and instillation dacryocystography m. shweel, a. elshafaey, m. nasar, r. mohyeldien; elminia/eg (mohshweel@yahoo.com) purpose: to assess the use of combined multidetector computed tomography and instillation dacryocystography (ctdcg) in detection of the level of lacrimal drainage system (lds) obstruction. methods and materials: twenty-one patients with one-sided epiphora were our candidates for ctdcg. axial source and post-processing images were assessed for clear viewing and the ability to detect the level of lds obstruction. to our knowledge, no previous studies used this combination in the assessment of the lds obstruction. results: all patients tolerated the examination well. various levels of lds obstruction were detected, common canaliculus in 4 (19%) patients, lacrimal sac in 3 (14.2%), junction between lacrimal sac and nld in 9 (42.8%) and nld obstruction in 5 (23.8%) patients. the most common ctdcg findings were dilated opacified lacrimal sac with no opacification of the nasolacrimal duct (nld) in 9/21 (42.8%) patients. curved planner reformation (cpr) was excellent to detect the nasolacrimal duct (nld) obstruction. conclusion: ctdcg is a non-invasive patient friendly procedure that adds benefit in documentation and preoperative planning. parotid gland tumours shear wave elastography: a preliminary study s. espinoza-boireau, i. khettab, a. lacan melki, p. halimi; paris/fr (sophie.espinoza@gmail.com) purpose: to assess the feasibility of parotid gland tumours shear wave elastography. to establish normal parotid gland elasticity. to evaluate elasticity for the most common benign parotidian tumours (pleomorphic adenoma, warthin's tumour) and malignant tumours. methods and materials: prospective study including 30 consecutive patients with parotid gland tumour. they all underwent share wave elastography to measure tumour elasticity and contralateral normal parotid gland elasticity. the results were confronted with histological analysis or fine-needle aspiration cytology. results: elasticity measure was feasible in all cases. mean normal parotid gland elasticity was 7 kpa (n=25; 3-15). benign tumours elasticity was 17.8±8 kpa (n=18). malignant tumours elasticity was 37±18 kpa (n=3). pleomorphic adenomas elasticity was 15.3±8 kpa (n=12). warthin's tumours elasticity was 21.8±7.4kpa (n=6). conclusion: benign and malignant tumours seem to behave differently under shear wave elastography. complementary studies are required to establish relevant threshold values allowing proper elastography lesions discrimination. does heterogeneous echogenicity of the thyroid parenchyma influence the detection of multifocality and bilaterality for papillary thyroid carcinoma on preoperative ultrasound staging? s. herh, e.-k. kim, h. moon, j. kwak; seoul/kr (jinnyhs@hanmail.net) purpose: this study was to evaluate whether heterogeneous echogenicity of the thyroid parenchyma can influence the diagnostic performances of ultrasonography (us) in detection of multifocality and bilaterality of papillary thyroid carcinoma (ptc). between december 2010 and january 2011, 240 patients had preoperative staging us for ptc, and underwent total or near-total thyroidectomy. seven experienced radiologists performed preoperative us for t and n staging. underlying parenchymal echogenicity of the thyroid gland, multifocality, and bilaterality of the thyroid nodules were also evaluated. patients were divided into two groups according to the underlying echogenicity of thyroid parenchyma on us. to evaluate the diagnostic accuracy of preoperative staging us according to the underlying thyroid echogenicity, diagnostic performances including sensitivity, with cochlear implantation without benefits. all the children performed pre-operative functional tests, temporal bone ct and brain/cerebellum-pontine angle (cpa) mri. results: mri showed in all cases the absence of the cochlear branch of the eighth nerve bilaterally (38/38). unilateral facial nerve aplasia was present in one patient. associated inner ear malformations were present in 21/38 patients, in particular common cavity in 8/21, incomplete partition type 1 in 6/21 and semicircular canals malformations in 3/21. no brain anomalies were showed. ct scans better depicted the labyrinthine malformations, adding information about facial nerve canal and internal auditory canal (iac) size. 2/38 ct showed normal inner ear structures and iac size. providing accurate information about cochlear nerve and brain anomalies is crucial in the pre-operative assessment of snhl patients. mri is the only radiological technique that is able to directly demonstrate the presence or the absence of cochlear nerves. ct is not fundamental and provides complementary information; a negative ct pattern cannot exclude a cochlear nerve malformation. purpose: to test whether the size of the cochlear nerve measured in the internal auditory canal using three dimensional (3d) and multiplanar reconstruction (mpr) high-resolution mri affects the speech recognition outcome following cochlear implantation. the study was retrospectively performed on 51 patients with longstanding hearing loss (mean age of 54.5 years). mri was performed using a t2-weighted space sequence. mpr and 3d reconstructions were performed using 3d and inspace applications, respectively. the preoperative cross-sectional surface area of the cochlear nerve was measured by drawing a region-of-interest around the circumference of the nerve. speech recognition (sr) was tested using the freiburger-monosyllabic-words (mswt) and numbers-tests (nt) preoperatively, postoperatively, at 3-, 6-and 12-month follow-up. sr and size assessment were performed in a double-blinded fashion. the correlation between the sr and nerve size were tested using spearman's rank correlation test. purpose: gkr efficacy in the treatment of um, a hypervascular tumour, is conventionally assessed by clinical and ultrasound findings. previous reports showed that, in case of hypervascular lesions (hcc, melanoma metastasis, etc). changes in vascularization precede diameters reduction after treatment. hence, our aim was to evaluate ceus in the quantitative assessment of tumour response to gkr. methods and materials: ten patients, who underwent gkr, were enrolled. ceus was performed (sonovue bracco) with iu-22 atl (philips) and 5-9 mhz linear probe at baseline, at 3 and 6 months after gkr (bgkr, 3-gkr, 6-gkr). two main tumour diameters and different quantitative parameters related to blood volume (area under the curve in the wash-in phase; wash-in perfusion index -wipi; peak enhancement -pe) and blood flow (mean transit time; wash-in rate -wir; rise time -rt; time to peak) were evaluated using a dedicated software (sonotumor bracco). purpose: to determine the value of semiquantitative strain elastography for the evaluation of chronic thyroiditis. the study was conducted on 48 consecutive patients with chronic autoimmune thyroiditis and 53 healthy controls. semiquantitative strain elastography was performed to calculate the strain index value (strain ratio of the strap muscles to the thyroid parenchyma) to assess thyroid stiffness. for each lobe, measurements were obtained from upper, middle and lower part of the thyroid parenchyma. mean strain ratio values of patients and healthy controls were compared by the mann-whitney u-test. validity was analysed by receiver operating characteristic (roc) curves. the median strain ratio value of patients with chronic autoimmune thyroiditis (2.22) was significantly higher than that of healthy controls (1.22; p < 0.001). the optimal cut-off value for the prediction of diffuse thyroid pathology was 1.41. for this cut-off value, thyroid stiffness had 90% sensitivity, 71.7% specificity, 75% positive predictive value (ppv) and 88.4% negative predictive value (npv) for the presence of diffuse thyroid pathology. this cut-off point was exceeded by 89.6% of the patients with and 28.3% of the subjects in control group. si values showed mild positive correlation with the tsh levels (spearman r coefficient = 0.265). however, this difference did not reach statistical significance (p=0.069). conclusion: semiquantitative strain elastography seems to be a useful method for the assessment of chronic thyroiditis. further studies are warranted in larger patient groups to determine the reliability of sonoelastography in patients with chronic thyroiditis. purpose: to retrospectively assess the detection rate of intracranial hematomas achieved with the use of curved mips of the meningeal spaces, compared to reading transverse ct sections only. this retrospective study was approved by the institutional review board of our institution, which waived informed consent. 314 consecutive patients who underwent ct imaging for cranial trauma (n = 314; 155 men and 159 women; mean age, 58 ± 24 y; range, 2 -98 y) were included. four curved mips of the meningeal spaces with different thicknesses were rendered for each patient. four radiologists independently evaluated all cases. hematomas of less than 3 mm thickness were considered 'thin' throughout this study. the radiologists were blinded to patient names, and patient and group order was randomised. the results were compared to a standard of reference built by two experts. logistic regression with repeated measurements was used for statistical analysis. results: 121 intracranial hematomas were confirmed in 39 patients. for all readers, the reading time for hematoma detection was significantly shorter (3 -5 times, p <.001)) for curved mips. the mean lesion-based detection rate of all readers was 80% (193/242) for transverse sections and 83% (200/242) for curved mips. for thin hematomas, the mean detection rate rose from 20% (8/40) with transverse sections to 83% (33/40) with curved mips. specificity, positive predictive value (ppv), negative predictive value (npv), and accuracy were calculated and compared among the two groups. results: of the 240 patients, underlying echogenicity of thyroid was heterogeneous in 55 patients (22.9%), and homogenous in 185 patients (77.1%). forty-four (18.3%) of the 240 patients had multifocal lesions in one lobe, and 77 (32.1%) had bilateral lesions on pathologic examination. diagnostic performances of preoperative staging us did not show significant differences in detecting multifocality and bilaterality between patients with homogenous and heterogeneous parenchymal echogenicity. conclusion: heterogeneous echogenicity of underlying thyroid parenchyma does not significantly influence the detection of multifocality and bilaterality for ptc on preoperative us staging. role of elastography in the characterisation of thyroid nodules f. sogaro, p. tessitore, a. scrimieri, f. pittiani, a. borghesi, r. maroldi; purpose: this study aimed at evaluating the reliability of elastography in predicting malignancy of thyroid nodules. methods and materials: 59 patients with thyroid nodules, who underwent to grey-scale ultrasonography (us), elastography and fnc (fine-needle cytology), were prospectively enrolled from february to august 2012. for each nodule, grey-scale us parameters (hypoechogenicity, absence of halo sign, absence of colloid) were examined. findings at elastography were classified according to rago criteria (2010). cytological diagnosis were classified according to the siapec-iap criteria in tir1, tir2, tir3, tir4 and tir5. the diagnostic performance of grey-scale us and elastography were compared with cytological findings. tir1 and tir3 with indeterminate cytology were excluded from the study. results: 48 nodules were included: 41 tir2, 3 tir4 and 4 tir5. according to rago criteria 32 nodules were score 1, 2 nodules score 2 and 14 nodules score 3. the sensitivity, specificity, positive predictive value (ppv), negative predictive value (npv) of elastography were 71%, 78%, 35%, 94%, respectively. the combination of grey-scale us parameters (hypoechogenicity with absence of halo sign and colloid) showed 57% sensitivity, 76% specificity, 28% ppv and 91% npv. conclusion: elastography is not useful in the differentiation of malignant and benign thyroid nodules. however, elastography had a high probability in predicting cytological benign diagnosis (high vpn). moreover, elastography demonstrated a superior performance than the combination of grey-scale us parameters. the new approach to thyroid elastosonography -time-strain curvesmay aid the differentiation of nodules r.z. slapa, b. migda, w.s. jakubowski, j. bierca, j. slowinska-srzednicka; warsaw/pl (rz.slapa@gmail.com) purpose: to evaluate a new linear/non-linear approach to strain elastosonography of thyroid nodules, based on the analysis of time-strain curves and to compare it with classical elasticity score and thyroid strain ratio methods. methods and materials: during 2009-2011, 67 patients scheduled for thyroidectomy (62 with multinodular goitre and 5 with single thyroid nodule) were evaluated with b-mode and power doppler ultrasound of the whole thyroid. during ultrasound examination, 96 dominant nodules were examined with strain elastosonography with aplio xg with linear 5-17 mhz transducer. the stiffness of each thyroid nodule was evaluated with classical features of strain elastosonography qualitatively (with elasticity scores) and semi-quantitatively with thyroid tissue strain/nodule strain ratios with application of elasto q. moreover, a novel, original approach to elasticity data based on evaluation of time-strain curves was applied. results: 7 papillary carcinomas, 89 benign nodules. classical elastosonographic analysis with elasticity score and elasticity ratio on statistical analysis did not show significant difference between cancer and benign nodules (p-value, respectively, 0.431 and 0.156). on linear/non-linear analysis of time-strain curves excellent differentiation (p=5.6x10 -9 ) was possible with new parameter: the relative length of non-linear relaxation. with threshold 0.5: sensitivity 100%, specificity 85.4%, area under roc=0.975. the analysis of linear and non-linear elastosonography data may greatly improve differential diagnosis of thyroid nodules. further large-scale studies evaluating the usefulness of linear/non-linear elastosonography phenomena (involving evaluation of vioscoelasticity, e.g. shear wave spectroscopy) in differential diagnostics of thyroid cancer are warranted. methods and materials: this hipaa compliant retrospective study was irb approved. we included 52 patients who had undergone emergent ct scans of the abdomen and pelvis for abdominal pain with tube current modulation, automated kvp selection and safire (scan a) and compared their abdomen and pelvis ct scans with tube current modulation, 120 kvp, filtered back projection reconstruction algorithm (scan b). ctdivol, dlp, effective dose (dlp x k) and image noise values were compared between two protocols. paired samples wilcoxon test was used for analysis and p < 0.05 was considered significant. results: the median ctdivol were 12.73 mgy and 18.26 mgy for scans a and b, respectively (p=0.0002); the median dlps for scans a and b were 583.00 mgycm and 888.50 mgycm (p < 0.0001), respectively. the median effective dose was 34.38% lower with scan a compared with scan b (8.74 msv vs. 13.32 msv, p < 0.0001). the median image noise was significantly lower with scan a using safire (11.05 vs. 14.15, p < 0.0001). results: 100 kv were automatically selected in 82 patients, 120 kv in 12 patients and 140 kv in 6 patients of the autokv group. patient diameters increased with higher kv settings. the average ctdivol (9.4 vs. 12.9 mgy) and dlp (669 vs. 925 mgycm; p < 0.05) in the entire autokv group were 27%/28% lower than in the group with fixed 120 kv. this effect was even more pronounced in the patients in whom 100 kv were selected (ctdivol 8.1 mgy, -37%; dlp 571 mgycm, -38%). enhancement of parenchymal organs gradually increased with lower kv, while image noise was at a stable level. conclusion: software-based automated selection of the tube potential allows for significant dose savings in thoraco-abdominal trauma ct while image quality is maintained or even improved. especially younger patients involved in accidents may benefit the most from this development. usefulness of low-dose ct with or without adaptive statistical iterative reconstruction ( purpose: to determine the usefulness of low-dose ct in the diagnosis and exclusion of acute appendicitis and to compare with low-dose ct taken with asir. conclusion: curved mips of the meningeal spaces have the potential to shorten the detection time for epi-and subdural hematomas, increase sensitivity, especially for thin hematomas, and reduce the required operator experience for detection. author disclosures: h. ringl: patent holder. simple and easy way using time-intensity curve of perfusionweighted images to find penumbra in stroke patients within 4.5 hours of onset due to the carotid artery occlusion t. mori, t. iwata, y. miyazaki, m. nakazaki, y. takahashi; kamakura/jp (morit-koc@umin.net) purpose: the aim of our study was to investigate whether or not time-intensity curve (tic) of pwi can find penumbra in stroke patients with acute carotid artery occlusion. methods and materials: included were patients 1) who were admitted within 4.5 hours of onset between january 2006 and january 2011, and 2) in whom emergency mra suggested the affected carotid artery occlusion. we assessed, nihss on admission (nih adm), dwi-aspect score, tic types, successful recanalization (sr), nihss on the 7 th day (nih 7 th ), and in-hospital death. early neurological improvement (eni) was defined as nih adm-nih 7 th > 0. tics were generated on region of interests set at symmetrical positions of the bilateral mca territories. according to the time to peak (tp) and the peak signal (ps) comparing the affected side (a) with the contralateral side (c), we classified tic into four types and defined type 1 as tpa>tpc and psa<psc/2, type2 as tpa>tpc and psc/2<psa<psc, type3 as tpa>tpc and psa>psc, and type 4 as tpa=tpc. relationship between tic types, in-hospital death and eni were assessed. results: eighty-seven patients were analysed. there were 36, 39, 12 and 0 patients in tic type 1, 2, 3 and 4, 39 patients underwent reperfusion therapy (rt) and sr was achieved in 18 patients, and 29 patients died. tic type 1 was the only determinant of in-hospital death (p < 0.01) and sr coupled with tic type 2 was the determinant of eni (p < 0.01). conclusion: tic type 2 means penumbra and type 1 predetermines poor clinical outcome. author purpose: iterative reconstruction (ir) is a promising noise reducing technique with the potential to reduce radiation-dose with preserved study interpretability or improve image-quality at similar radiation-dose. one of the major drawbacks of ir is a longer reconstruction time which may be problematic in the emergency setting. the purpose of the current study was to compare reconstruction time and speed of ir and filtered back-projection (fbp) in two commonly encountered emergency imaging scan-protocols: total body trauma ct and pulmonary cta. methods and materials: fifteen patients underwent a total body ct after a traumatic event and twenty-five adults underwent a cta for evaluation of pulmonary embolisms on a 256-slice ct-scanner. all data were reconstructed using fbp and two ir-levels (idose 4 , philips healthcare). quantification of reconstruction time and speed was done with a self-written plug-in for imagej (us national institutes of health). the mean delay in reconstruction time on total body trauma cts was 44.4±8.1 and 44.9±7.0 seconds for idose 4 -levels 1 and 6, respectively, and on pulmonary ctas 10.1±9.6 and 12.0±11.8 seconds for idose 4 -levels 2 and 4, respectively. the mean reconstruction time and speed for total body trauma cts were 87.3±14.6, 131.7±16.7 and 132.2±17.9 seconds, and 20.1±1.6, 13.2±0.8 and 13.2±0.6 slices/s for fbp, idose 4 -levels 1 and 6, respectively, and for pulmonary munich/de (sonja.kirchhoff@med.uni-muenchen.de) purpose: in the past years the number of clinical-pathological autopsies decreased significantly due to various reasons. forensic autopsies are disposed not only with regional differences but, however, also with on an average decreasing frequency. especially in patients who died during trauma room management or emergency operation during critical care, no imaging could possibly be performed. therefore, after termination of all clinical procedures a critical analysis of death and evaluation of the standards of medical care is often not possible, although especially regarding medical quality management it is highly desirable. at least to partly close this information gap we performed a post mortem computed tomography (pmct)study. in this prospective study whole body pmct was performed in patients who died during trauma room management or emergency surgery leaving all installed foreign material, e.g. tube, drainage in place. the pmct findings were compared with clinical findings and if available with autopsy reports as well. results: between 1999 and 2008 46 patients were enrolled, 18 of whom underwent additional autopsy. the major clinical diagnosis which had finally led to the termination of resuscitation procedures was confirmed by the pmct findings. the autopsy report showed a high correlation in the corresponding cases to the pmct-findings. conclusion: pmct offers the possibility to improve quality management during trauma room management regarding the decision for terminating resuscitation efforts by verifying the important clinical findings. in addition, pmct findings support specifically the autoptic reporting. purpose: to assess how the portrayal of radiology in medical tv shows is perceived by the general population. a survey was conducted among adult patients scheduled for a radiological examination, technologists and radiologists. the survey gathered information regarding tv watching habits and interest in medical tv shows. questions addressing the accuracy in portraying radiology in comparison to reality (1-10 scale), appearance of radiological examinations and radiological staff were asked in regard to house m.d., er, and grey's anatomy. the online survey conducted among radiologists and technologists from two different academic institutions served as reference standard. results: a total of 126 patients and 240 professionals (133 technologists, 107 radiologists) participated. a moderate and significant correlation was found between the interest in medical tv shows and the perception that clinical reality was accurately portrayed in the group of patients (r=0.49, p=0.001) and technologist (r=0.38, p=0.001) but no correlation was found for radiologist (r=0.01). while > 60% in all survey groups noted the appearance of radiological examinations regularly to > 1/show, the appearance of radiological staff was perceived by 45.2-54.0% of patients, 31.6-47.4% of technologists and 15.9-23.4% of radiologists. er was ranked more accurate than grey's anatomy or house m.d. the more interest in medical tv shows prevails in patients and technologists, the more are modern medical tv shows perceived as accurate in the portrayal of radiology. radiological examinations are frequently utilised, but imaging is less often performed by radiological staff. this retrospective study includes 138 patients under 65 years-of-age with clinically suspected acute appendicitis, who underwent unenhanced low-dose ct on a 64 mdct. 84 patients (group a) underwent a low-dose ct 34 patients (group b) underwent a low-dose ct with asir. results: normal appendix was identified in 52 (61.9.%) in a versus 26 (76.5%) in b. in a 22 (26.2%) versus 6 (17.6%) in b were diagnosed with appendicitis. in a 10 (11.9%) studies versus 2 (5.9%) studies in b the appendix was not identified. in those where the appendix was not identified a conventional ct was performed. no one had appendicitis during one month follow-up for negative studies. the sensitivity and specificity of ct low-dose were 88.1% and 100%, respectively, and for low-dose ct with asir 94.6% and 100%, respectively. the sensitivity increased to 100% for the total protocol for both techniques. the effective dose mean was 2.4 msv ±0.8 instead of 2.62 msv ±0.9. conclusion: the low-dose ct is a suitable technique for the diagnosis or exclusion of acute appendicitis in young or middle-aged people, making possible inclusion as a radiological imaging test in the diagnostic algorithm of acute appendicitis. introduction of the asir improves the low-dose ct technique with a higher sensitivity for appendix evaluation which increased the diagnostic confidence, slightly lowering the dose. the purpose: to evaluate image quality of paediatric chest ct acquired at 70 kv. methods and materials: 130 consecutive children undergoing chest ct studies on a dual-source ct system were prospectively evaluated with a 70-kv scanning protocol. all scanning parameters were kept similar to those usually selected for standard 80-kv protocols, except the milliamperage. always selected according to the patient's weight, ref mas were increased by a factor of 1.6 to maintain comparable levels of radiation dose between newly introduced 70-kv and routine 80-kv protocols. image quality at 70 kv (group 1) was compared to that of a paired paediatric population (group 2) based on the age (±1yr), weight (±1 kg) and administration of contrast material, previously scanned at 80 kv on the same ct unit and prospectively stored in our database. group 1 and group 2 images were reconstructed with filtered-back projection. results: objective noise in group 1 was significantly lower than that measured in group 2 (9.9±6.3 hu vs 11.3±6.6 hu; p=0.03). subjective image quality of lung and mediastinal images in group 1 did not significantly differ from that of group 2 (p=0.18). in group 1, the mean dose-length-product was 15.4±2.3 mgy.cm (< 1yr; mean weight: 5.3 kg) (n=35); 18.3±2.1 mgy.cm (1-5yr; mean weight: 13.4 kg) (n=44), 24.4±3.9 mgy.cm (5-10yr; mean weight: 24.7 kg) (n=33) and 31.7±4.7 mgy.cm (10-15yr; mean weight: 33.1 kg) (n=18). conclusion: paediatric chest ct at 70 kv provides similar objective and subjective image quality to that achievable at 80 kv. results: from the records in the database, various anthropometric data were extracted, e.g. body mass and body length of more than 33000 patients, thoracic diameters and the volumes, densities and masses of lungs and mammalian glands of more than 2000 patients of all age groups. these data were compared to the anthropometric data of the mathematical mird phantoms provided by the finnish centre for radiation safety stuk. it can be shown that in mathematical mird phantoms of all age groups, body mass, body length and thoracic diameters are overestimated, whereas lung volumes and lung masses are underestimated. purpose: to assess the radiation dose delivered during dual-source chest ct examinations. we prospectively recorded the dose-length-product (dlp) of 506 consecutive children, evaluated in 4 age groups: group 1 (< 1yr; n=109; 21%) (mean weight: 5.33±1.99 kg), group 2 (1-5 yr: n=169; 33%) (mean weight: 13.35±3.92 kg), group 3 (5-10 yr: n=136; 27%) (mean weight: 23.77±6.36 kg) and group 4 (10-15yr; n=92; 18%) (mean weight: 36.83±7.78 kg). all ct examinations were performed with a dual-source ct system using a dual-source, single-energy scanning protocol obtained with thin collimation, high pitch and high temporal resolution, a weight-adapted selection of the kilovoltage and milliamperage, and systematic reconstruction of images using filtered-back projection. results: patients were scanned with a pitch of 2.0 (n=165; 33%) or 3.0 (n=341; 67%), at 80 kv (n=499; 99%) or 100 kv (n=7; 1%) with a milliamperage ranging between 40 and 90 mas. the mean duration of data acquisition was 525.8±192.8 ms. ct examinations consisted of contrast-enhanced (n=190) and noncontrast (n=316) studies, obtained in the context of acquired (n=280; 55%) or congenital (n=46; 9%) bronchopulmonary disease, cystic fibrosis (n=60; 12%), cardiovascular disease (n=91; 18%), oesophageal atresia (n=8; 1%) and miscellaneous causes (n=21; 4%). all examinations were of diagnostic image quality. the mean dlp value in each age category was 14.29±3.38 mgy.cm ( purpose: to standardise the scan protocol for ct scanners of participating centres in a multi-centre study (clinicaltrials.gov nct01270074) for the prevention of radiologically defined bronchiectasis in cf infants by ensuring the maximum image quality at the minimum radiation dose. methods and materials: three different sized phantoms (qrm, germany) were used to assess scanners' performance of automatic exposure control (aec). ctdi and dlp were recorded. the phantoms contained various inserts to assess slice-sensitivity-profile, in-plane spatial resolution, noise and the hounsfield unit (hu) scale. scans were made for several dose levels and reconstruction kernels. images were analysed with custom-made software (matlab, usa) to obtain the standard deviation of the noise, point-spread-function (psf) and slice thickness. results: eight different scanners with 64 slices or more from 4 manufacturers (ge, philips, siemens and toshiba) were assessed. despite differences in aec's performance, we obtained approximately the same dose level at each center by recommending site and age-specific aec reference levels. a constant image quality was only possible by matching the different reconstruction kernels measured psfs at full-width-at-half-maximum. in fact, large part of the differences between scanners was related to reconstruction kernels. the relatively high noise images corresponded with reconstructions using a kernel with edge enhancement such as the siemens b70 kernel or the ge lung kernel that are routinely used in chest imaging. conclusion: objective measurements on ct images allowed for matching of scan protocols among ct scanners of different manufacturers. use of routine protocols might introduce a bias in the (automated) image analysis. cystic fibrosis lung disease in children: correlation between mri and hrct scores c. purpose: high-resolution computed tomography (hrct) is known to be a sensitive means of detecting lung disease in cystic fibrosis (cf), with a significant radiation exposure. magnetic resonance imaging (mri) becomes increasingly important in the assessment of cf lung disease. the aim of this study was to establish the agreement between mri and hrct scores in a paediatric population. methods and materials: hrct and t2 and post-contrast t1 mri images were acquired on the same day from 17 cf patients (median age 12.7 years; range 9.1-20.2 years). two radiologists with either > 20 (hdlp) or 3 years (cs) of ex-were analysed and compared with the corresponding real scan length. for selected ct scanners, radiation doses achieved during the scanograms were reconstructed using mathematical mird phantoms. results: depending on the patients´ age, many scanograms considerably exceed the real scan region, thus unjustifiably raising the radiation exposure of the patient. the radiation doses due to ct scanograms are not neglectible as, e.g. the whole body dose achieved during a thorax scanogram can exceed the whole body dose caused by a conventional chest x-ray examination by a factor of 10. conclusion: an optimisation of scanogram lengths by defining specific anatomical landmarks for standard ct protocols, the optimisation of scanogram exposure parameters in paediatric ct examinations and their implementation into national and international guidelines seems to be necessary to fulfil the alara concept in paediatric ct. we established reference values for cardiac valve diameters in extreme preterm infants, based on bsa. biological variation, inaccuracy in assessment of patient characteristics, inter-operator variability, and limited spatial resolution may account for substantial variability in heart valve diameters found in this cohort. asymmetric lung perfusion in congenital heart disease: impact of differential pulmonary arterial anatomy and pulmonary vascular resistance o. kondrachuk, t. yalynska, r. tammo, i. iershova, n. rokytska; kiew/ua purpose: asymmetry of lung perfusion is relatively common in patients with congenital heart disease. the aim of the study was to evaluate the influence of differential pulmonary arterial anatomy and pulmonary vascular resistance on blood flow distribution in patients with asymmetric lung perfusion. we retrospectively identified 17 consecutive patients with congenital heart disease who had asymmetry of lung perfusion on phase-contrast mri. the mri examinations were performed on 1.5 t scanner. results: fourteen patients had left lung hypoperfusion (blood flow to the left lung < 35%) and three patients right lung hypoperfusion (blood flow to the right lung < 40%). branch pulmonary artery (bpa) regurgitant fraction (rf) was significantly greater in lung with decreased perfusion (16.2±19.0% vs. 1.8±2.8%, p < 0.001). there was moderate negative correlation between bpa rf and bpa differential pulmonary blood flow (r = -0.517, p = 0.002). moderate positive linear relationship between bpa size and bpa differential pulmonary blood flow was also found (r = 0.669, p = 0.003). there was no significant correlation between bpa rf and bpa size. conclusion: both bpa anatomy and bpa rf are the significant factors for determining right and left lung flow split. according to prior reports, bpa rf reflects differential pulmonary vascular resistance. consecutively at 80 kvp, 100 kvp, 120 kvp and 140 kvp, respectively, with constant mas settings using a dual-source ct. differences in calculated dual-energy ratios (deratio) between the tissues and iodine or gold were determined for different de spectra. the attenuation of gold has increased at higher kvp-settings compared to 80 kvp, while the attenuation of all other specimens decreased. the calculated de ratios at 80/100 kvp, 80/120 kvp and 80/140 kvp, respectively, were 1.31, 1.63 and 1.91 for iodine, 0.90, 0.88 and 0.92 for gold, 1.20, 1.30 and 1.45 for compact bone, 1.01, 1.03 and 1.08 for muscle. the difference between the de ratios 80/100 kvp, 80/120 kvp and 80/140 kvp, respectively, were 0.11, 0.23 and 0.46 for iodine and bone, 0.31, 0.51 and 0.53 for gold and bone, 0.29, 0.59 and 0.83 for iodine and muscle, 0.12, 0.15 and 0.16 for gold and muscle. conclusion: de ratio of gold remains relatively stable along the energy spectrum of diagnostic ct and allows a reliable material differentiation between gold and bone at contiguous low tube voltage settings (80 kv and 100 kv). thus, gold might have potential as a contrast agent for dect. potential use of intra-articular diluted high-relaxivity gadoliniumbased contrast agent for magnetic resonance arthrography ( purpose: gadobenate dimeglumine (gd-bopta) is a high-relaxivity contrast agent that tightly binds to plasmatic proteins, currently used in several clinical applications. our aim was to test in-vitro different concentrations of gd-bopta to be potentially used to perform mra. methods and materials: gd-bopta (multihance, bracco) was diluted in saline (nacl 0.9%) to achieve different concentrations (4 mmol/l, 2 mmol/l, 1 mmol/l, 0.67 mmol/l, 0.5 mmol/l). five ml of these solutions was injected in sterile pipes and was added with 0.5 ml of fresh synovial fluid withdrawn from a 71-year-old male knee. in a separate pipe (reference), 0.5 ml of synovial fluid and 5 ml of gadopentetate dimeglumine 2 mmol/l (gd-dtpa; magnevist) were injected. pipes were imaged using a t1-weighted sequence (te=9.8 msec, tr=678 msec, slice thickness 3.5 mm, fov 320x320 mm) at 1.5 t. for each pipe on each slice, signal intensity (si) was calculated. results: mean gd-dtpa si was 1290±48. mean gd-bopta si was 1406±36 (+9% to reference) at 4 mmol/l; 1532±36 (+15%) at 2 mmol/l; 1583±36 (+19%) at 1 mmol/l; 1494±44 (+14%) at 0.67 mmol/l; 1235±13 (-4%) at 0.5 mmol/l (p <.001). at post hoc analysis, all one-to-one comparisons were significantly different with exception of 2 and 4 mmol/l (p=.105). conclusion: versus gd-dtpa, a +19% peak si was achieved with half gd-bopta concentration. a similar si between the two agents was achieved at 0.5 mmol/l. gd-bopta high relaxivity and its potential binding with synovial fluid glycoproteins could explain these results. this may improve visibility of intra-articular tears when evaluated using gd-bopta mra. purpose: to optimise the contrast injection protocol for ct coronary angiography (ctca) to achieve more efficient utilisation of contrast agent by investigating the impact of reducing the volume of contrast agent on the attenuation of coronary arteries and sinus. methods and materials: a total of 105 subjects with low heart rate (² 65 beats/min) and suspected coronary artery disease were randomly divided into three groups with 35 subjects in each group. the patients in groups a, b and c were injected with a volume of 0.8, 0.7, and 0.6 ml/kg of contrast agent, respectively. in all cases, injection rate was 5.0 ml/s, followed by 30 ml saline flush at the same rate. ct values within the ascending and descending aorta, left main and right coronary artery orifices and coronary sinus were measured and the differences of contrast enhancement among the three groups were evaluated. the mean injection volume of contrast agent in groups a, b and c were 54.1, 47.9 and 41.1 ml, respectively (p < 0.001), and the scan delay time were 23.7, 23.4 and 22.2 s, respectively (p < 0.05). the ct values within the coronary sinus were 112.7, 93.7 and 81.2 hu for groups a, b and c, respectively (p < 0.001), perience in paediatric pulmonary disease scored independently hrct, using the scoring system developed by helbich et al, and mri using two scoring systems developed by helbich et al and eichinger et al. readers were blinded to clinical and functional data and to the other reader's findings. the agreements were assessed using the intraclass correlation coefficient (icc) and the bland-altman plot for the two readers and the two methods. the inter-reader agreement was excellent for the hrct scores (icc=96%), good for mri with the eichinger score (icc=84%), but less for mri with the helbich score (icc=68%). there was a very good correlation between hrct and mri-eichinger scores (icc=91%), but less between hrct and mri-helbich scores (icc=78%). the good inter-reader agreement and the high correlation between hrct and mri-eichinger scores support the use of lung mri for the follow-up of lung disease in paediatric cf patients. methods and materials: a total of 74 consecutive patients, with clinical vascular aortic disease, were evaluated on mdct16 slices scan (philips-brilliance16p, nl) using low-kv protocol (90 kv), high pitch (1.063) and automated tube current modulation. low contrast medium volume (50 ml) was administered at 4 ml/s. density measurements were performed at abdominal aorta, renal arteries and common iliac arteries. we also calculated the radiation dose exposure (dose length product, dlp). our results were compared with 40 patients investigated with standard contrast medium volume (100 ml) and standard ct-angiography protocol (120 kv; 350 mas). the noise level (signal-to-noise ratio, snr), the radiation dose (expressed as dlp) and amount of iodinate contrast were analysed and statistically compared between two different groups. results: in all of the patients we obtained an adequate vessel opacification of aorta and renal arteries. mean attenuation value in aorta was 305 hu, in iliac arteries was 288 hu and in renal arteries was 276 hu, without significant attenuation difference with the control group (aorta 339 hu; iliac arteries 358 hu; renal arteries 303 hu). the radiation dose exposure (meandlp: 509) was significantly lower (reduction of the 48%) in the low-kv protocol than standard examinations at 120 kv (mean-dlp: 952). the noise level calculated in low-kv protocol (meansnr 20) was not significantly higher than the value obtained in standard protocol (meansnr 28). conclusion: low-dose ct-angiography protocol represents a feasible technique that allows a significant reduction of contrast material and radiation dose exposure without losing diagnostic accuracy being useful also in these patients with renal failure. purpose: the use of low concentrated contrast material might be advantageous in terms of viscosity. therefore, the purpose of this study was to evaluate the use of low concentrated contrast material (240 mg iodine/ml) for coronary ct angiography in routine patients. methods and materials: 29 consecutive patients who were referred for routine coronary cta were scanned on a 2 nd generation dsct scanner (definition flash, siemens). patients received a standard contrast injection protocol as follows: iopromide 240 mg/ml (ultravist, bayer) with an injection rate of 9 ml/s (iodine delivery rate 2.16 g i/s) followed by a saline chaser with the same flow rate. contrast enhancement in the coronaries was measured proximal and distal in all coronaries. results were compared to our standard protocol with iopromide 300 mg/ml and flow rate of 7.2 ml/s (iodine delivery rate 2.16 g i/s). start delay was evaluated for both groups using the test bolus method. comparison between both groups was performed using sample t-test. results: coronary enhancement reached diagnostical attenuation in both protocols. overall comparison between enhancement with 240 mg/ml (mean 445 hu ± 114 hu) revealed no statistical significant differences with 300 mg/ml (mean 412 hu ± 92 hu) (p=0.101). attenuation levels in lad dist and cx dist were significantly higher in the low concentrated contrast material group (lad dist 387 vs 292 hu, p < 0.0001 and cx dist 392 vs 329 hu, p=0.003, respectively). conclusion: the use of low concentrated contrast material is feasible in coronary cta. higher flow rates are necessary, but lower viscosity might improve attenuation in the distal segments. the impact of mr contrast agent concentration on bolus geometry g. jost, h. pietsch; berlin/ de (gregor.jost@bayer.com) purpose: in contrast-enhanced mr-angiography, the luminogram is obtained during the first passage of gadolinium-based contrast agents (gbca). the bolus concentration in conjunction with the r1-relaxivity determines the vascular signal enhancement. the aim was to investigate the impact of a 1 molar gbca concentration on bolus geometry compared to a 0.5 molar agent, systematically. methods and materials: 6 göttingen minipigs were injected intravenously with gadobutrol and gd-dtpa in a crossover setting (0.1 mmol/kg, 1 ml/s). dynamic ct measurements (80 kv, 485 maseff, δt=0.3s) at the thoracal region were performed without table feed. time-density curves were determined and fitted by a gamma-variate function in the vena cava, the pulmonary artery and the ascending and descending aorta. ct-signals were transformed to gd-concentrations on the basis of phantom measurements. the administration of 1 molar gadobutrol led to a narrower (significantly lower full width half maximum) and steeper (significantly higher peak values) bolus and ct values within the ascending and descending aorta, and the coronary artery were higher than 300 hounsfield units in all three groups. conclusion: application of the 0.6 ml/kg protocol in ctca, a steady contrast enhancement in coronary artery, can be achieved using 640-slice volume ct. the influence of the contrast media protocol and the scan mode on arterial enhancement in cardiac ct e. talakic, d. stocker, p. täubl, r. maderthaner, f. quehenberger, h. schoellnast, m. tillich; graz/ at (emina.talakic@medunigraz.at) purpose: to assess the influence of contrast media protocol and scan mode on arterial enhancement in cardiac ct. methods and materials: 175 patients (mean age, 62; range, 18-86 years) who underwent cardiac ct were retrospectively divided into 4 groups related to scan mode (64-slice helical ct or 320-slice volume ct) and contrast media concentration (320, 350 or 400 mgi/ml) -group 1:, helical, 320 (75 ml); group 2: helical, 350 (90 ml); group 3: helical, 400 (70 ml), and group 4: volume, 400 (70 ml). injection rate was 5 ml/sec in all patients. roi measurements were performed in the aorta (coronary arteries level) and cardiac chambers to assess enhancement, and in the superior vena cava (svc) to measure the standard deviation of the attenuation values for assessment of inflow artefacts. spearman correlation and wilcoxon test were used for comparison. results: patients in group 3 showed significantly higher mean aortal enhancement than patients in group 1 or 2 (334 hu versus 286 hu and 306 hu). group 4 showed significantly higher aortal enhancement than group 3 (497 hu). group 4 showed significantly lower enhancement in the right atrium and ventricle than group 3. no significant difference in the standard deviation of attenuation was seen within the svc. conclusion: in cardiac ct, the volume mode led to significantly higher aortal enhancement and lower contrast within right atrium and ventricle compared with helical mode. scan mode, iodine dose and flow rate had no influence on heterogeneity of contrast within the svc. multislice ct angiography with direct intra-arterial ultra-low-dosecontrast injection for the evaluation of renal graft failure: initial study m. guzinski, j. kurcz, j. garcarek, m. sasiadek; wrocław/pl (guziol@wp.pl) purpose: to present initial experience with direct intraarterial ultra-low-dosecontrast ct angiography (ia-cta) and its application in assessing renal graft artery in patients with renal graft failure. methods and materials: ia-cta of renal graft was performed in 18 patients with renal graft failure (gfr2m/s. pig-tail catheter 4 f was placed in ipsilateral common iliac artery via common femoral artery. subsequently, spiral cta of pelvis was performed simultaneously to intraarterial administration at 4 ml/s of 6-8 ml of contrast diluted with saline to 18-24 ml. results: excellent contrast enhancement of renal graft arterial tree was observed in all patients. no complications associated with arterial access occurred. mean creatinine/grr levels prior to the ia-cta were 3.30 mg/dl and 27.4 ml/min, respectively. on the 5 th day following the study, mean creatinine/gfr levels amounted to 3.36 mg/dl and 27.8 ml/min, respectively. renal function deterioration was demonstrated on the 3 rd day after the procedure (creatinine 3.54 ml/dl, gfr 26.8 ml/min); nevertheless, it was not statistically relevant (p < 0.71). contrast-induced nephropathy occurred in only one patient (5.6%) with transient creatinine elevation by 92%. after detailed vessel analysis graft arterial stenting was performed in 10 patients, which improved renal function. the remaining 8 patients were treated conservatively. conclusion: trans-catheter ultra-low-dose-contrast ia-cta for imaging of renal graft arteries can be an effective method with low-risk of nephrotoxicity, which allows detailed graft arterial tree imaging, especially prior to interventional treatment of arterial-related renal graft insufficiency. feasibility in low kv ct angiography of the abdominal aorta: assessment of image quality, radiation exposure and contrast material volume c.r.g.l. talei franzesi, d. ippolito, p.a. bonaffini, v. bartolo, c. trattenero, s. sironi; monza/it (ctfdoc@hotmail.com) purpose: to assess the image quality, dose reduction and amount of iodinate contrast injected using low-kv ct angiography protocol for the study of abdominal aorta disease. shape compared to 0.5 molar gd-dtpa in all investigated vessels. the respective gd-concentrations (mggd/ml) for gadobutrol vs. gd-dtpa were 9.5±1.9 vs. 6.8±1.2 (vena cava), 3.4±0.4 vs. 2.4±0.3 (pulmonary artery) and 2.2±0.2 vs. 1.7±0.2 (ascending and descending aorta). the area under the bolus curve analysis yielded no significant differences between the gbcas. conclusion: a 1 molar gbca concentration leads to a more compact bolus shape with significant higher peak concentrations in the major thoracal vessels compared to a 0.5 molar agent. this might be especially relevant for the acquisition of 4d angiograms and for quantification of tissue perfusion. author disclosures: g. jost: employee; bayer pharma ag. h. pietsch: employee; bayer pharma ag. transarterial chemoembolisation (tace) in malignant liver metastases: evaluation of a fast c-arm ct acquisition protocol with a robotic multi-axis c-arm system t.j. vogl 1 , m. von roden 2 , e. mbalisike 1 , s. zangos 1 ; 1 frankfurt a. main/de, 2 forchheim/ de (t.vogl@em.uni-frankfurt.de) purpose: to evaluate potential contrast savings and reduction of motion artefacts in c-arm ct acquisitions with a higher rotational speed during interventional procedures. methods and materials: 24 patients (mean 56.8 yrs, range 33-83) were treated with transarterial chemoembolisation (tace). prior to the injection of the embolisation material, a c-arm ct with a new, fast acquisition protocol was performed. a robotic multi-axis c-arm angiographic system (artis zeego, siemens-healthcare, forchheim/germany) was used with a rotational speed of up to 100°/s. in this configuration, a c-arm-ct with a rotational trajectory of 200° was acquired in 3s versus 5s in a commercially available c-arm system. two different injection protocols were applied and evaluated regarding sufficient tumour visualisation and spatial resolution of the vessel tree in the resulting 3d-dataset. results: injection protocol 1 (6 ml contrast, 12 ml nacl, flow rate 3 ml/s, x-ray delay 3s, injection site: common hepatic artery) resulted in 3d images with a very good spatial resolution of the vessel trees but poor visualisation of tumours/metastases. injection protocol 2 (7 ml contrast, 20 ml naacl, x-ray delay 6s) resulted in 3d images with excellent spatial resolution and good visualisation of tumours/ metastases. from prior experience with a standard 5s protocol the corresponding c-arm ct acquisition would have required a contrast load of 8 ml and 8.5 ml, respectively. thus, the contrast saving of the fast acquisition protocol was 25% and 18%, respectively. the fast c-arm ct acquisition protocol 2 provides an interesting possibility to save contrast media during tace with excellent spatial resolution of the vessel tree and good visualisation of hypovascular tumours. purpose: functional mri of cerebrovascular reserve (cvr fmri) using vasoreactivity to hypercapnia may identify patients at risk of haemodynamical stroke among those with severe stenosis of the middle cerebral artery (mca). however, quantification remains challenging because of numerous methodological settings and their limitations. we aimed to provide a laterality index (limca) to better identify abnormal cvr in clinical practice. methods and materials: 100 volunteers (40 females; 49.5±21.4 years) without cervico-encephalic arterial stenosis had a cvr fmri using bold contrast with a block-design hypercapnic challenge (co2 7% mixed with: o2 93% (n=83) or air (n=17)), using nasal canula (n=57) or mask (n=43), 1.5 t (n=46) or 3 t (n=54). averaged end-tidal co2 pressure (etco2) was used as a physiological regressor for statistical analyses with a general linear model (spm8). we conducted regions of interest (roi) measures of %bold signal change/mmhg etco2 on segmented grey matter of the mca territories. we calculated a laterality index with limca=(left_cvrmca-right_ cvrmca)/(left_ cvrmca +right_ cvrmca). 99% confidence intervals (99%ci) were calculated. no adverse reaction to hypercapnia, including panic, anxiety, headache, or fatigue, was detected during and after cvr fmri. cvr values ranged from 0.14 to 0.48 with m±sd=0.26±0.07 %bold/mmhg etco2. the mean laterality index was 0.01 with an interval of fluctuation that covered 0.00. the standard deviation was 0.026. thus, 99%ci was ±0.07 for mca. li values were independent of age, gas mixture, sex, inhalation modality, and mr strength. conclusion: subjects without cervico-encephalic arterial stenosis have an absolute value of limca below 0.08 with a 99% probability. in purpose: non-invasive quantitative phase contrast mr angiography (qmra) has been utilised for several clinical indications, e.g. intracranial stenosis and aneurysms. the aim of this study is to validate the flow measurements of qmra (nova, vassol inc., chicago) by comparing the obtained velocities with qmra and doppler ultrasonography (dus) in-vivo. to our knowledge, no previous reports have addressed this issue. methods and materials: we retrospectively examined consecutive 24 patients (9 women, 15 men; mean age 63 years, range 24-80 years) with stenosis of arteries supplying the brain using qmra and dus. velocities were measured in a total of 209 arterial segments (110 extra-and 99 intracranial). results: overall there was a good correlation between velocity measurements with both techniques being statistically significant in all six extracranial and five out of seven intracranial segments. velocities were 56% higher in extracranial and 45% higher in intracranial segments obtained with dus comparing to those with qmra. the reversal of flow direction in the aca was detected consistently with both methods. conclusion: this preliminary study shows a rather good correlation between the velocities employed with qmra and dus. qmra represents a robust mri technique for flow measurements in a reasonable time, which can be integrated in the cerebrovascular mri work-up, especially when intracranial dus is technically not feasible. however, further in-vivo and in-vitro studies are needed to assess the need for technical optimisation of this technique. purpose: sensitive documentation of ischaemia is needed in clinical tia. we aimed to compare the sensitivity of dti, dwi and asl in the detection of acute ischaemia and further to investigate if chronic ischaemic changes after 8 weeks in the form of gliosis always follow. methods and materials: the first 40 consecutive patients included during first 3 months of an mri-protocol (dwi, dti and asl within 72 hours of symptoms) and 8 weeks follow-up protocol (t2 and dwi). patients were included by stroke consultants. lesion volumes on dwi, dti and follow-up t2 were compared. hyper-or hypoperfusion on asl was recorded. one senior neuroradiologist assessed the sequences in random order to prevent bias. results: fourteen patients had acute ischaemic lesions: 2 in the posterior fossa and 12 in the cerebral hemispheres corresponding to 35% of referred patients. thirteen of these developed gliosis in the affected area and of these 1 was noted only on dti and 1 only as post-ischaemic hyper-perfusion on asl. mean lesion volume was 1.2 ml. mean difference between volume on dwi and gliose volume was 0.42 ml =71% and between dti and gliose volume 0.29 ml=40% and dti volume were significantly closer (p=0.042). conclusion: these preliminary results indicate that tia causes a gliosis lesion consistently, and that the initial lesion as well as the extent of the permanent changes is better described using dti. asl seems to be able to contribute to the detection of tia as this may be sole mri-sign in some patients increasing detection rates with 5%. monday parameter for assessment of ischaemia. we analysed the ability of ttp maps to predict eventual infarcts in patients with mild stroke presentations. we retrospectively reviewed 164 consecutive patients presenting with acute stroke in less than 6 hours from onset. patients presenting with a nih stroke scale score < 5 were subjected to subgroup analysis. ttp perfusion deficit with delays of more than 3 seconds was considered significant for underlying ischaemia. the perfusion parameters were compared to follow-up imaging at 24 to 48 hours. results: 41 patients met inclusion criteria. 7 patients had identifiable thrombus. the ttp map had the highest sensitivity in detecting the small infarcts (92%), followed by cbv and cbf. importantly, ttp analysis provided very high negative predictive value (93%). however, there was a relatively lower specificity (64%) and a tendency to overestimate the infarct size. conclusion: ttp perfusion is highly sensitive in predicting small regions of ischaemia. high negative predictive value is helpful in differentiating stroke from mimics. purpose: to study the influence of the temporal sampling rate of ctp acquisitions on cerebral perfusion maps with noise-free synthetic data sets created with a digital phantom. methods and materials: noise-free synthetic data sets were created with a digital phantom which consists of a skull derived from a human skull phantom combined with arterial input and venous output functions, white matter (wm) and grey matter (gm) time-attenuation curves (tac) obtained from 5 patients. by manipulating the time tags ctp protocols with a total scan duration of 60s and a temporal sampling rate of 1-, 2-, 3-and 4s were simulated. the 1-s protocol was used as reference standard. the 2-, 3-and 4-s protocols were shifted with 1s to measure the influence of missing peak points of the curve, resulting in 1, 2, 3 extra data sets, respectively. cbf, cbv and mtt maps were calculated using pma (asist-japan). mean values of gm and wm of the protocols were compared with the reference protocol. de (kolja.thierfelder@med.uni-muenchen.de) purpose: our aim was to evaluate if the extent of volumetrically determined blood flow-volume mismatch in recently introduced whole brain ct perfusion (wb-ctp) can predict if a stroke is younger than 4.5 hours (time window for thrombolysis). we retrospectively analysed cerebral blood flow (cbf) and volume (cbv) maps and clinical data of 103 acute stroke patients. ct perfusion images were acquired with extended brain coverage of 10 cm in the z-axis. mismatch extent was defined as the fraction of cbf perfusion deficit without corresponding cbv abnormality and was determined volumetrically using osirix v.4.0 imaging software. a logistic regression analysis was performed to predict time from symptom onset of < 4.5 hours. four mismatch extent categories, cbf perfusion deficit and cbv infarction volume were entered as predictors into the model. results: mean time from symptom onset was 187 min±101 min. mean mismatch extent was 59.5%±31.1%. after correcting for age and gender, a mismatch extent of ³90% was highly predictive for a symptom onset of < 4.5hrs (n=18, or: 8.70, p=0.03). other categories of mismatch extend (³80% (or: 6.67, n=31, p=0.10), < 10% (n=13, or: 0.90, p=0.89), < 20% (n=19, or: 1.36, p=0.66) as well as cbf perfusion deficit volume (p=0.86) and cbv infarction volume (p=0.77) failed to predict time from symptom onset. conclusion: a large (³90%) volumetrically determined mismatch in wb-ctp is a predictor for the time from symptom onset in the critical time window. wb-ctp mismatch might, in these cases, help to identify patients eligible for thrombolysis when symptom onset is unknown (e.g. wake up stroke). whole brain ct perfusion: volumetric assessment of perfusion deficits in patients with acute ischemic stroke k.m. thierfelder 1 , l. purpose: whole brain ct perfusion (wb-ctp) eliminates the major drawback of restricted brain coverage in standard 2-slice ctp. our aim was to assess reliability and reproducibility of a newly introduced volumetric assessment method of perfusion deficits in wb-ctp in patients with acute ischemic stroke. methods and materials: 24 consecutive patients underwent 128-row wb-ctp with extended scan coverage of 10.0 cm in the z-axis using adaptive spiral scanning technique. volumetric analysis of cerebral blood volume (cbv), cerebral blood flow (cbf), mean transit time (mtt), time to peak (ttp), and time to drain (ttd) was performed twice by two experienced readers using dedicated imaging software with at least 2-week intervals between readings. inter-and intrareader agreement for individual perfusion parameter maps was assessed by intraclass correlation coefficients (icc) and bland-altman analysis. results: interreader agreement was highest for ttd (icc: 0.985), followed by cbf (0.969), mtt (0.949), cbv (0.935), and ttp (0.851). intrareader agreement was also highest for ttd (icc: 0.995), followed by mtt (0.979), cbf (0.977), cbv (9.942), and ttp (0.944). the perfusion deficits showed the highest absolute mean volume in the time-related parametric maps and did not differ significantly within this group, while mean cbf perfusion deficit volume was significantly smaller (each with p < 0.01). conclusion: volumetric assessment in wb-ctp in acute stroke patients is reliable and reproducible. it therefore might serve for a more accurate assessment of prognosis of stroke outcome and definition of flow-volume mismatch. ttd had the highest agreement and therefore might be a suitable parameter to define tissue at risk. time-to-peak (ttp) maps using whole brain ct perfusion in minor stroke: a diagnostic tool beyond penumbra measurement s. chakraborty, m.e. ahmad, j.k. wasserman, k. keyhanian, d. dowlatshahi, g. stotts; ottawa, on/ca (santanoo@gmail.com) purpose: the use of thrombolysis in minor stroke or fluctuating symptoms is controversial. treatment decisions may be influenced by identifying patients with large areas of tissue at risk and distinguishing stroke mimic. whole brain ct perfusion in toshiba 320 aquilon® ct scanner allows possible assessment of these parameters and is not limited to selective brain coverage as in previous generations of ct scanners. dynamic chest x-ray examination for regional ventilation function must be equivalent to lung scintigraphy. performance evaluation of automatic chest radiograph reading for detection of tuberculosis (tb): a comparative study with clinical officers and certified readers on tb suspects in sub-saharan africa p. maduskar 1 , l. hogeweg 1 , b. van ginneken 1 , h. ayles 2 ; 1 nijmegen/nl, 2 london/uk (p.maduskar@rad.umcn.nl) purpose: digital chest radiography (cxr) is used in high burden countries for suspect screening, active case finding and in prevalence surveys for tb diagnosis. an observer study was conducted to compare performance of automatic software with that of clinical officers and certified expert readers. a dataset of 166 digital cxrs (2048×2048, 0.25 mm, delft imaging systems, the netherlands) was collected at kanyama clinic, lusaka, zambia. sputum culture was used as reference. an observer study was conducted with four clinical officers who read x-rays in kanyama clinic, and with two readers certified to read cxrs according to crrs standard (university of cape town, south africa). a software system for detection of tb (cad4tb-1.08, diagnostic image analysis group, the netherlands) analysed all the cases. human readers and software scored all the images between 0 and 100. we report area under the receiver operating characteristics curve (az) with 95% confidence intervals and pairwise comparisons from bootstrap estimates. p < 0.05 was considered significant. there was no significant difference between any reader and the software, except for one clinical officer who performed significantly worse than automatic reading. conclusion: automatic computer reading has similar performance as clinical officers and certified readers. the software has potential of being used as a point-of-care decision tool, to diagnose tb or select subjects that should undergo further tests. diagnostic imaging costs before and after digital tomosynthesis implementation in patient management after suspected thoracic lesions on chest radiography e. quaia, e. baratella, g. grisi, r. cuttin, g. poillucci, s. kus, m. cova; purpose: to evaluate diagnostic imaging costs before and after digital tomosynthesis (dts) implementation in patients with suspected thoracic lesions on chest radiography (cxr). over a period of four years four-hundred-and-sixty-five patients (263 males, 202 females; age, 72.47±11.33 years) with suspected thoracic lesion (s) after cxr underwent dts. two readers prospectively analysed in consensus dts images. each patient underwent ct when a pulmonary non-calcified lesion was identified by dts, while ct was not performed when a benign pulmonary or extrapulmonary lesion or pseudolesion was identified. diagnostic imaging costs (including material, staff, and imaging system depreciation) were evaluated during the12-month preceding dts implementation and during the12-month after dts implementation. the average imaging cost per patient was calculated by normalising the costs before and after implementation of dts by the number of indeterminate cxr examinations in each of these periods. results: in 229/465 patients who underwent dts after suspicious cxr, dts showed 193 thoracic lesions and 36 pleural lesions, while in the remaining 236/465 patients lesions were ruled-out as pseudolesions of cxr. in the 12-month preceding dts implementation, the proportion of patients who presented suspected thoracic lesions and underwent ct was 271/811; after dts implementation, this proportion became 39/800. the average differential per-patient costs of cxr, dts, and ct examinations were 15.15, 41.55, and 113.66 euros, respectively. the perpatient change in diagnostic imaging costs before vs after dts implementation was -24.79 euros. conclusion: per-patient diagnostic imaging costs decreased after dts implementation in patients with suspected thoracic lesions. within each cross-sectional image the mean (adcmean), minimum (adcmin) and maximum adc (adcmax) was determined by two independent radiologists. an additional roi was placed into the cerebrospinal liquid and set as the reference tissue. statistical analysis included the wilcoxon test and p-values < 0.05 indicated statistical significance. results: the highest adc values were determined for the group of adenocarcinomas (adcmean, 1.98x10-3 mm2/s; adcmax, 2.44x10-3 mm2/s). significantly lower mean adcs were found for the squamous cell carcinomas (adcmean, 1.18x10-3 mm2/s; p < 0.0001) and small cell lung cancers (adcmean, 1.29x10-3 mm2/s; p=0.01). determination of the adc values did not reveal any difference between squamous cell and small cell carcinomas (p> 0.05). conclusion: diffusion-weighted mri with adc measurement at 1.5 t reliably enables the differentiation of adenocarcinoma from other histological subtypes in primary lung cancer and might therefore be of distinct value in the preoperative management of patients suffering from primary lung cancer. non-contrast-enhanced perfusion mri for preoperative assessment of lung function in patients with non-small-cell lung cancer ( purpose: knowledge about lung function defects is important for predicting functional outcome and optimising surgery in nsclc. fourier decomposition mri (fd-mri) has been introduced as a method to assess regional lung perfusion without contrast agents. this study evaluates fd-mri for preoperative assessment of lung perfusion in nsclc patients with dynamic contrast-enhanced mri (dce-mri) as standard of reference. methods and materials: 15 patients with nsclc were examined at 1.5 t. timeresolved images of the lungs were acquired in coronal and sagittal plane using a 2d-bssfp sequence. fourier decomposition was used to detect and separate periodic changes of lung proton density caused by respiratory and cardiac cycles. perfusion-weighted images were calculated by pixel-wise integration of the cardiac spectral line. fd and dce data were analysed visually for perfusion defects. perfusion proportions of pulmonary lobes were calculated quantitatively by regions-of-interest analyses. results: fd-mri provided diagnostic quality in 14 cases, but failed in one patient. sensitivity, specificity and accuracy of fd-mri for visual detection of perfusion defects were 78%, 92%, and 90%. quantitative evaluation of perfusion proportions provided good linear correlation between fd-mri and dce-mri for both upper lobes and both entire lungs (r=0.70-0.85). accuracy of fd-mri in the lower lobes (r=0.02-0.03) and the middle lobe (r=0.32) was compromised by artefacts from cardiac pulsation. conclusion: fd-mri is useful to detect regional lung perfusion defects in nsclc patients before surgery. for perfusion quantification, fd-mri is sufficiently accurate in both upper lobes and for bilateral comparison, but, in its present form, inaccurate in the middle lobe and both lower lobes. lung ultrasound in the elderly population: investigating the limit between physiological and pathological patterns a. chiesa, f. ciccarese, g. gardelli, f. feletti, u. regina, m. zompatori; bologna/it (ciccarese.f@gmail.com) purpose: the senile lung undergoes paraphysiological changes which have been described in several radiological and ct studies, but never investigated through ultrasound. the aim of the present study was to evaluate a group of elderly-nonsmoker-healthy patients in comparison with young subjects, by using ultrasound examination. methods and materials: 100 elderly subjects (> 70years-mean age: 79.4±6.9) and 50 young subjects (< 55years-mean age: 32.5±12.1) were submitted to lung ultrasound examination. we analysed the anterior, lateral and posterior surface of each lung to evaluate the presence/absence of a-lines and b-lines. fisher test was chosen to compare data obtained in the two groups. results: absence of a-lines was found in 94/100-94.0% of elderly versus 2/50-4.0% of young subjects (p < 0.0001). presence of b-lines was detected in 37/100-37.0% of elderly, with a higher prevalence in posterior lung fields; the number of b-lines was²3 per field (pf) in 27/37-73.0%, > 3pf in 2/37-5.4%; both ²3 and > 3pf-depending on the evaluated field in 8/37-21.6%. by contrast, 5/50-10.0% young subjects showed b-lines (²3pf in all of cases)-p=0.0004. to avoid misdiagnosis, we should consider that physiological ultrasound lung findings could be different among old and young people. the majority of old individuals did not present a-lines; moreover in a high percentage, b-lines were observed (²3pf in most of them). these results could be explained by a reduction of impedance between lung parenchyma and soft tissue (absence of a-lines) and by an increased thickness of interlobular septa (presence of b-lines). further studies should be proposed to define a cut-off between normal and pathological pattern. digital x-ray optical densitometry in assessment of respiratory function in patients with copd exacerbation n. gorbunov, v. laptev; novosibirsk/ru (n_gorbunov@hotmail.com) purpose: to evaluate respiratory function in patients with exacerbation of chronic obstructive pulmonary disease (copd) before and after treatment by means of a digital x-ray optical densitometry. the study group comprised 563 patients (140 females, 423 males; mean age 58±1.3 years, range 36-81 years). all of them were admitted to the clinic with an exacerbation of copd with different (1-3) stage. high-resolution digital radiographic device with a line x-ray sensitive silicate receiver was used. lowdose digital x-ray examination of the chest was performed both in inspiration and in expiration phases before and after treatment. regional and common pulmonary optical density was evaluated with further quantitative analysis of respiratory function. for these purposes the optical density gradient (odg) was used. all results were verified by high-resolution computed tomography (hrct). the optical density gradient before and after treatment has been changed. there was a 1.5-1.6 times increasing value of optical density gradient due to treatment of copd exacerbation. for patients with the first stage of copd the 64.7% odg increasing was estimated. for the second stage of copd odg increasing was 63.1% and for the third stage of copd it was 52.1%. there was a significant correlation between pulmonary optical density gradient and hrct density gradient before and after treatment (r> 0.3; p < 0.05). a digital x-ray optical densitometry by means of functional highresolution digital radiography allows optimising an evaluation of therapy response in patients with copd exacerbation combined with radiation exposure reduction. diffusion purpose: despite the improvement in technique/expertise, pancreatic surgery remains burdened with a high complication rate. our aim was to report our 12year single-centre experience about the clinical relevance and the interventionalradiological management of the early postoperative complications (treatment/ prevention) on 1285 patients submitted to pancreatic surgery. in 2000-2012, 1285 patients were submitted to pancreatic surgery (duodenum-cephalopancreatectomy, total-pancreatectomy, distal-pancreatectomy). patients were classified on the basis of the complication severity into 5 classes (clavien-dindo-classification): class-0=none, class-1/2=conservative treatment, class-3a=endoscopic/interventional-radiological, class-3b=surgery, class-4=intensive care, class-5=death. interventional-radiological management was as follows: ptc/biliary-drainage in case of biliary-fistulas (bile in surgical drainage, normal bilirubin levels, undilated biliary ducts at us) under us/fluoroscopic-guidance (right approach, puncturing along the course of the sixth-segment portal branch with 21g chiba-needle, or left approach if aerobilia/ adequate volume of left hepatic lobe); embolisation (microcoils/pva-particles) or covered-stenting (viabahn-gore) in case of bleedings of gastroduodenal/splenic arteries; percutaneous drainage (us/ct-guidance) of liquid/infected collections. pancreatic-islet-intraportal-autotransplantation was performed in case of totalpancreatectomy to prevent diabetes. results: patients were classified as follows: 524/1285 (40%) class-0, 210/1285 (16%) class-1, 361/1285 (28%) class-2, 72/1285 (6%) class-3a, 55/1285 (4%) class-3b, 24/1285 (2%) class-4, 39/1285 (3%) class-5. 72/1285 (class-3a) and were successfully treated as follows: 30/72 ptc/biliary-drainages, 27/72 liquid/infected collection percutaneous-drainages, 9/72 bleedings (7 embolisations, 2 coveredstenting), 6/72 endoscopic-procedures. 25/1285 underwent pancreatic-isletintraportal-autotransplantation. one bleeding/1 biliary-fistula needed 2 treatments. conclusion: in experienced centres of pancreatic surgery, complication rate can be reduced. complications can be, however, successfully diagnosed, managed and prevented by interventional-radiological procedures, limiting their clinical relevance and avoiding a high-risk surgical re-treatment. purpose: to evaluate technical feasibility and clinical efficacy of retrievable covered stents in treating post-surgical biliary leakage. methods and materials: from april 2008 to date, 16 patients (9 males, 7 females; mean age 52 years, range 18-83 years) were retrospectively studied. patients underwent placement of retrievable covered stents for treat post-surgical bile leaks. in 12 cases the procedure was performed by interventional radiologist using percutaneous trans hepatic access and in 4 cases by means of hybrid procedure (ptbd + ercp) with both interventional radiologist and endoscopist. the leaks involved cystic duct stump (n = 6), common bile duct anastomosis (n = 6), left extra hepatic duct (n = 1), right extra hepatic duct (n =2) and biliary confluence (n = 1). results: technical success with correct stent releasing was achieved in 15 cases; 1 case required post-dilatation ballooning. immediate clinical and lab test improvements were observed in all patients. post-operative imaging proved leak resolution in all cases. no early complications were observed. in 1 case late stent migration was reported 21 days after the procedure. twelve stents were removed without complication after a mean time of 59 days, with complete leak resolution. one stent comparison of assessment of preoperative pulmonary vasculature in non-small cell lung cancer patients by non-contrast-enhanced and 4d contrast-enhanced mr angiography at 3 t and by contrastenhanced thin-section mdct using a 64-detector row system y. ohno 1 , s. seki 1 , m. nishio 1 , h. koyama 1 , t. yoshikawa 1 , s. matsumoto 1 , s. satou 2 , k. sugimura 1 ; 1 kobe/jp, 2 ohtawara/jp (yosirad@kobe-u.ac.jp) purpose: to prospectively and directly compare pulmonary vasculature assessment before surgical treatment of non-small cell lung cancer (nsclc) patients by non-contrast-enhanced (non-ce) mr angiography, 4d ce-mr angiography and thin-section ce-ct. methods and materials: a total of 77 consecutive pathologically proven and clinically assessed stage i nsclc patients (41 males, 36 females; mean age: 71 years) underwent thin-section ce-ct, non-ce-mr angiography and ce-mr angiography, and surgical treatment. the capability for anomaly assessment of the three methods was independently evaluated by two reviewers using a 5-point visual scoring systems, and final assessment for each patient was made by consensus of the two readers. interobserver agreements for pulmonary arterial and venous assessment were evaluated with the kappa statistic. assessment of variations in overall pulmonary vasculature by the three methods was compared by means of receiver operating characteristic analyses on a per-patient basis. finally, sensitivity, specificity and accuracy for detection of anomalies were directly compared among the three methods by means of mcnemar's test. results: interobserver agreements for pulmonary artery and vein assessment were substantial or almost perfect (0.72²κ²0.86). for pulmonary arterial and venous variation assessment, non-ce-mr angiography, 4d ce-mr angiography and thinsection ce-ct showed no significant differences (p> 0.05) in terms of area under the curve, sensitivity, specificity and accuracy. conclusion: pulmonary vascular assessment of nsclc patients before surgical resection by non-ce-mr angiography can be considered equal to that by 4d ce-mr angiography and thin-section ce-ct. in vivo micro-ct and 18 f-fdg micro-pet imaging of spc-raf and spc-myc transgenic mouse models of lung adenocarcinoma t. rodt, c. von falck, m. luepke, k. hueper, r. halter, s. dettmer, c. boehm, j. borlak, f. wacker; hannover/de (rodt.thomas@mh-hannover.de) purpose: to report on micro-ct and micro-pet imaging of spontaneously developing lung tumour in spc-raf and spc-myc transgenic mice. technical considerations regarding periprocedural management and imaging technique are addressed; tumour quantification techniques are presented. dosage measurements are reported and potential adverse effects discussed. methods and materials: 4 wild-type control, 25 spc-raf and 7 spc-myc transgenic mice were examined in vivo using micro-ct (n=180) and 18 f-fdg micro-pet (n=14). specific periprocedural management was established. different respiratory gated and ungated micro-ct protocols were compared. a quantification routine for tumour load and growth was validated and examined in a follow-up study. 18 f-fdg micro-pet of orthotopic lung tumour was obtained; quantification was performed on lesion and lung region basis. findings were correlated to histology. thermoluminescence dosemeter measurements and dosage calculations for micro-ct and micro-pet were performed. results: no procedure-related deaths occurred for up to 547 days of follow-up. respiratory gated micro-ct protocols yielded better image quality compared with ungated protocols. intra-and inter-observer variability of the quantification routine were 5.1 and 6.5%, respectively. tumour quantification showed significant difference (p=0.043) between spc-raf transgenic and control animals in follow-up. longitudinal tumour development correlated to cross-sectional histological data from literature. micro-pet yielded a tumour-to-non-tumour ratio of 2.47 in spc-myc transgenic animals. micro-ct dosage ranged from 174 to 277 mgy. the estimated dosage calculated for micro-pet was 140 mgy. conclusion: micro-ct and 18 f-fdg micro-pet provide quantitative data on morphology and metabolism in orthotopic lung tumour. the techniques can safely be applied in animal model phenotyping and therapeutic studies. monday pancreatic cancer). 10 watts for 2 minutes was applied using bipolar endoluminal rf device (habib™ endohpb, emcision ltd., london, uk), placed in a block using guidewire technique. rfa is followed by self-expanding or balloon-mounted metal-stent (ms) placement. drainage catheter was repositioned for follow-up. results: duct patency restorated in 34 (97.1%) cases; in 1 (2.9%) case procedure filed because of guidewire conduction failure. all cases of balloonoplasty required the repeated procedure followed by stenting. 34 biliary patients maintained stent patency as long as they are alive. the mean stent patency was 115.9 ± 64.8 (50 -240) days. there was no 30-day mortality, haemorrhage or pancreatitis following rfa. one complication (bile duct perforation) was observed in a post-balloonoplasty patient on repeated (rfa&stenting) procedure; this case was managed percutaneally. percutaneous rfa treatment appears to be safe and effective in the management of inoperable biliary and wirsung duct block. randomised studies with prolonged follow-up are warranted. conclusion: viatorr plays an important role in tips scenario but its outcomes are strictly related to technical aspects such as intrahepatic tract completely covered, no concern about liver transplant, device never advanced in the portal vein for more than 3 cm, 10-mm viatorr has to be considered the best compromise. was removed 4 days after the procedure, during an open re-do for intra-abdominal bleeding. three stents are still in place. conclusion: placement and removal of retrievable covered stents appear to be technically feasible and could represent an excellent option in treating biliary disorders. bioabsorbable biliary stent in the percutaneous treatment of benign biliary stricture: preliminary experience g. mauri, c. michelozzi, v. pedicini, d. poretti, m. tramarin, f. melchiorre, g. cornalba, g. brambilla; milan/it (vanni.mauri@gmail.com) purpose: to report the outcome of patients treated with a novel bioabsorbable biliary stent for benign biliary strictures. methods and materials: ten bioabsorbable polydioxanone biliary stents (ella-dv biliary stent, ella-cs, czech republic) were deployed in 9 patients with increased level of bilirubin due to postsurgical benign biliary stricture. this stent is made of polydioxanone, a material that allows to obtain a high radial force, but that is reabsorbed by the body within 6 months. all patients had stricture recurrence after multiple standard bilioplasty (2 to 5). all patients were followed with clinical visit, ultrasound and serum bilirubin level. the procedure was successfully performed in all patients and immediate restoration of the normal caliber of the biliary duct was obtained. no immediate or late complications occurred and no patients had recurrence of the initial stricture (median follow-up 13 months, range 5-18 months). conclusion: percutaneous bioabsorbable biliary stent placement is feasible and effective in the treatment of benign biliary strictures and in which standard bilioplasty has failed. in the future, this novel treatment may replace percutaneous bilioplasty a retrievable biliary stent placement as soon as long-term follow-up data will be available. to have a y-configuration for the biliary drainage of both lobes of liver, we used two pieces of covered stent system: one covered main piece stent and one contra-lateral covered stent. before and 3 days after y-covered stent insertion, cholangiograms were obtained through the ihd for the evaluation of biliary drainage of both lobes of liver. we checked the blood bilirubin levels before, 1 week after and every 1 month after the stenting. results: they were 16 patients including 12 women and 4 men. they had inoperable intrahepatic cholangiocarcinomas in 15 and two metastatic biliary obstructions due to breast and stomach cancers. obstructive types were 2 in i, 7 in ii, 5 in iiia and 2 in iv. the placement of the y-shaped covered stent was successful in all cases. the mean follow-up period was about 6 months. all cases had showed adequate biliary drainages in the follow-up tubograms. the bilirubin levels had been normalised 2 weeks after being the y-covered stent inserted except one patient. there were no clinical infectious signs during the follow-up period. mean patency rate was about 6.2 months (185 days). a newly designed y-shaped covered stent would be clinically effective for the palliative treatment of hilar obstructive malignant carcinoma of liver. the comparison of balloon-occluded retrograde transvenous obliteration for gastric varices using liquid and foam sclerosants j. koizumi 1 , k. myojin 1 , c. itou 1 , n. mori 1 , t. sekiguchi 1 , t. hara 1 , t. ichikawa 1 , y. imai 1 , b. janne d'othée 2 ; 1 isehara/jp, 2 baltimore, md/us (jkoizumi@is.icc.u-tokai.ac.jp) purpose: liquid ethanolamine oleate which has been used traditionally for balloonoccluded retrograde transvenous obliteration (brto) of the gastric varices (gv) may cause severe complications including haemolysis, allergy, etc. if overdosed. thus, we introduced foam sclerotherapy to reduce the dose and compared the safety and efficacy of brto using liquid and foam sclerosants. methods and materials: forty-three patients with gastric varices were performed brto since october '01. of these, three patients were excluded because simultaneous tace or pse was performed. twenty patients using liquid ethanolamine oleate with iodine contrast (eoi) before march '05 and twenty patients using polidocanol foam (pof) after may '05 were included in this study. the success rates, side effects and complication rates were compared among the two groups. results: complete stasis of the gastric varices was obtained in all patients of both groups. abdominal symptoms during brto were significantly (p < 0.05) higher in eoi (55%) than pof (15%). postprocedure fever (> 38.0) was also significantly (p < 0.01) higher in eoi (55%) than in pof (0%). in both groups total bilirubin increased and platelet counts decreased significantly (p < 0.01). however, the decrease ratio of platelet counts was significantly (p < 0.05) higher in eoi (-21.1±15.8%) than pof (-9.4±13.1% purpose: digital linear tomosynthesis has recently been introduced not only for mammography but also for chest and musculoskeletal indications. the clinical utility in musculoskeletal applications has been validated in only a few reports. the purpose of the current study was to evaluate the clinical utility of tomosynthesis in suspect occult hip fracture. in a retrospective review 70 tomosynthesis hip examinations on 49 women and 21 men performed for further evaluation of suspect hip fracture were retrieved from the radiology archive. three observers scored the tomosynthesis scans separately from the radiography examinations, into the categories no proximal femur fracture, suspect proximal femur fracture (femoral neck, trochanteric, or greater trochanteric avulsion) or definite proximal femur fracture. ct, mri or clinical outcome was used as reference. results: observer variation was moderate to substantial for three observer pairs regarding radiography (k=0.56-0.8) and improved to substantial to almost perfect for tomosynthesis (k=0.76-0.93). eleven patients were operated on for femoral neck fracture. tomosynthesis detected ten of these, and the eleventh patient was operated on without diagnostic confirmation from any imaging modality. one patient had been operated with dynamic hip screw for intertrochanteric fracture. the remaining trochanteric fractures were incomplete and were treated conservatively. there were no false-positive tomosynthesis diagnoses reported. there were no significant falsenegative tomosynthesis diagnoses. the distinction between incomplete/complete trochanteric fractures and greater trochanteric avulsions is sometimes difficult. purpose: advanced core decompression (acd) is in clinical evaluation for patients with avascular necrosis (avn) of the hip. in opposition to standard core decompression, acd uses an expandable reamer allowing optimal debridement of necrosis after drilling a core to the femoral head. the bone defect is filled with a bone graft substitute. we aimed to constitute the therapeutic success of acd based on mri. methods and materials: twenty patients (17 males, 3 females, mean age 49.9 years) underwent 3 t mri of the hip prior to, 30 days and 0.5 -2 years after acd. the protocol included tirm, pd/t2w tse, high-resolution t1w, dess and t1w vibe sequences. sequences were evaluated regarding delineation of necrosis, bone, graft and transformation zone in between. the volume of necrosis was measured before and after acd. results: avn prior to acd as well as the defect filled with the graft after acd and the residual necrosis could be imaged with reproducible high quality at 3 t. t1w and pdw sequences provided best contrast to measure the volume of necrosis. each patient showed a reduction of necrosis after acd (17.7 % to 90.8 %, mean 43.0, sd 24.2). the granulation zone around the graft could especially be visualised by t2w tirm and pdw sequences. the arrangement of different layers correlated with histological findings. conclusion: structural changes and reduction of necrosis after acd can be monitored by mri. acd does significantly reduce the volume of necrosis in avn of the hip. the mre study after oral administration of peg solution provides an accurate assessment of small-bowel involvement, allowing an evaluation of disease activity in patients with known cd, reducing the radiation exposure in young patients. metal artefact reduction in hip prosthesis with iterative reconstructions f. morsbach 1 , s. bickelhaupt 1 , g. wanner 1 , a. krauss 2 ; b. schmidt 2 , h. alkadhi 1 , 1 zurich/ch, 2 forchheim/de purpose: to evaluate the effect of a novel iterative frequency split-normalised (ifs) metal artefact reduction (mar) on image quality of computed tomography (ct) in hip-prosthesis. in the first study-part, an artificial hip-phantom with steel and titan-based shafts, using three inlays of water, fat and contrast-media placed in the pelvis, was used to test and optimise the ifs algorithm. image quality and accuracy of ct number measurements of inlays were determined. in the second study-part, 41 consecutive patients with unilateral (n=32) or bilateral (n=9) hipprosthesis were included. datasets using filtered back projection (fbp), ifs and a previously published mar algorithm using linear-interpolation were reconstructed. two readers evaluated axial, coronal and sagittal ct image reformations for overall image quality and evaluated image quality of pelvic organ depiction; ct numbers in the urinary bladder, gluteal muscle and subcutaneous fat were measured. results: ex-vivo experiments revealed the best image quality for ifs. measurements of ct numbers of the inlays were more accurate for ifs. in patients, we found a significant improvement in overall image quality for all reformations (p < 0.001) and a significantly increased image quality of pelvic organs (p < 0.001) for the ifs algorithm. ct numbers of the bladder (p < 0.001) and muscle (p=0.043) were significantly less variable for ifs as compared with images reconstructed with fbp and the linear interpolation mar algorithm, whereas we found no significant difference for fat (p=0.159). the ifs algorithm significantly reduces metal artefacts from hipprostheses, increases image quality and improves measurement accuracy of ct numbers as compared with fbp and linear interpolation mar algorithms. purpose: computed tomographic (ct) colonography is a technique for detecting bowel cancer or potentially precancerous polyps. because retained fluid and stool can mimic pathology, ct data are acquired with the patient in both prone and supine positions. radiologists then match endoluminal locations between the two acquisitions to determine whether pathology is real. this process is hindered by the fact that the colon can undergo large deformations that often occur during repositioning of the patient. automated registration between datasets could potentially improve efficiency and diagnostic accuracy. we have developed software to establish correspondence between prone and supine endoluminal surfaces. an initialisation step generates image patches at the positions of haustral folds using depth map renderings and is optimised by virtual camera registration. additional neighbourhood information is then included in a markov random field model to establish landmark-based correspondences. subsequently, the complexity of the registration task is reduced by mapping both prone and supine surfaces onto a cylindrical domain in which correspondence is established using non-rigid image registration. monday recurrences in 3 patients (2 hepatic and 1 lung metastases) but missed a 7 mm sessile polyp and 2 flat lesions. ctc quality was inadequate in the 11% of patients. conclusion: ctc can be effective and represents a valid alternative to colonoscopy for surveillance for colorectal cancer recurrence after surgery. ct colonography: comparative study of experienced vs nonexperienced radiologists using 3d flythrough approach with and without cad software f. vecchietti, m. rengo, d. caruso, c.n. de cecco, d. bellini, a. laghi; latina/it (fabrizio.vecchietti@gmail.com) purpose: to compare performances of different experienced readers using a primary 3d flythrough approach with and without the use of a cad analysis. methods and materials: three readers evaluated 50 patients with 100 endoscopically proved polyps (ranging from 3 mm to 40 mm) and different colonic preparations (18 fluid tagging, 32 full cathartic preparation). dataset analyses were performed on a ge adw 4.6 workstation equipped with vcar colon software. per-polyp sensitivity, inter-reader agreement, mean reporting time and false positive were evaluated for each approach. results: less experienced readers increased per-polyp sensitivity, respectively, from 75% and 64% for 3d analysis to 86% and 74% for primary 3d+cad analysis with a significant difference (p=0.001 and p=0.04) while no significant differences were found for the expert reader (p=0.06). less experienced readers were faster when assisted by cad but no significant differences were found on mean reading time for all readers (p= 0.5/0.07/0.1). mean false-positive findings for cad standalone analysis were 12 (+-13). all readers decrease false positive when assisted by cad especially less experienced ones. inter-reader agreement was higher among all readers when assisted by cad ( methods and materials: seventy-five consecutive patients were prospectively randomised into two groups. both groups followed a low residue diet for two days before the examination. both preparations were based on fluid tagging, using a iodinate contrast medium (gastromiro). group 1 received 180 ml of fluid tagging agent the day before the study. group 2 received 60 ml of fluid tagging agent the day of the exam and 500 ml of a laxative agent (lovol-esse) the day before the study. patient acceptance was evaluated using a visual assessment scale. quality of bowel preparation was evaluated using quantitative (tagged fluid density and number of untagged residue per segment) and qualitative (homogeneity per segment on a 4 point scale) scores. results: bowel preparation was complete in all patients. no statistical significant differences for tagged fluid density, number of residue and tagging homogeneity between the two groups were founded. a significant higher patient acceptance was founded in group 2 (p=0.02). the preparation based on the combination of a laxative and a fluid tagging agents was better accepted. adding a laxative agent to a fluid tagging preparation did not improved image quality but was associated with an higher patient acceptance. moreover, the if a laxative agent is added to a fluid tagging bowel preparation the amount of iodine can be reduced. considering the latter as a reference method, ctc examinations were retrospectively and blindly initialisation, the method significantly improved the cylindrical registration (p < 0.001), achieving a mean error of 6.0 mm measured at 1743 reference points. the proposed method can successfully establish correspondence between prone-supine locations on the endoluminal surface derived from ct colonography. the ability to rapidly and automatically match polyps between acquisitions will facilitate ct colonography interpretation. (t.n.boellaard@amc.uva.nl) purpose: to evaluate whether a single intravenous alfentanil bolus has a clinically relevant analgesic effect compared with placebo in patients undergoing elective ct colonography. a prospective multi-centre randomised double-blind placebo-controlled trial was performed in 90 consenting symptomatic or surveillance patients scheduled for elective ct colonography. patients were randomised to receive either a bolus of 7.5 μg/kg alfentanil (n=45) or placebo (n=45). the primary outcome was the difference in maximum pain during colonic insufflation on an 11-point numeric rating scale (one-sided t test). we defined a clinically relevant effect as a maximum pain reduction of at least 1.3 points. secondary outcomes included total pain and burden of ct colonography (5-point scale), most burdensome aspect, side effects and recovery time measured by the aldrete score. results: maximum pain scores during insufflation were lower with alfentanil as compared with placebo, 5.3 versus 3.0 (p < 0.001). total ct colonography pain and burden were also significantly lower with alfentanil (2.0 vs. 1.6 and 2.1 vs. 1.7, respectively). with alfentanil fewer patients rated the insufflation as most burdensome aspect (56.1% vs. 18.6%; p=0.001). no clinically relevant desaturations occurred. episodes with desaturations < 90% spo2 and dizziness were more common with alfentanil (4.4% vs. 37.8%; p < 0.001 and 8.1% vs. 44.4%; p < 0.001). aldrete scores in the alfentanil group were significantly lower immediately after the procedure, but similar at 30 and 60 minutes. purpose: to evaluate the accuracy of contrast material-enhanced computed tomographic colonography (ctc) for follow-up after curative surgery for colorectal cancer without evidence of disease recurrence. methods and materials: 86 patients underwent ctc and colonoscopy (within 4 months) after colorectal cancer surgery. patients with the suspicion of disease recurrence underwent pathologic confirmation. patients performed bowel cleansing and faecal tagging; bowel distention was achieved using co2. both prone and supine scans, one after intravenous contrast material administration during the portal phase, were obtained using a 64-detector ct ("brilliance" philips with idose). images were reconstructed with a section thickness of 0.75 mm, transferred to a workstation and interpreted by one radiologist with experience reading several hundred ctc cases. sensitivity, specificity, positive predictive value (ppv), and negative predictive value (npv) of ctc for anastomotic and non-anastomotic colonic lesions (metachronous or flat lesions and polips) were determined and compared to endoscopy. results: ctc detected all 2 anastomotic recurrences, all 3 metachronous lesions (sensitivity and specificity=100%) and a perianastomotic recurrence. in 13 patients ctc depicted 16/17 polips > 5 mm (sensitivity=94.1%, specificity=100%, vpp=100%, vpn=98.6%, accuracy= 98.8%) and in 1 patient detected 1 of 3 flat lesions (sensitivity=33.3%, specificity=100%). ctc enabled detection of extracolonic prevalence and distribution was related to patient gender (p> 0.05). in sigma, advanced disease (grade 2/3) shows a significant positive correlation with reduced colonic distension (p < 0.05). no correlation was found between severity of sigmoid diverticula and symptoms onset. conclusion: prevalence and severity of diverticular disease increased over time in all colonic segments. an elevated number of asymptomatic diverticula is present in the right colon. an high percentage of patients with severe sigmoid diverticular disease remain asymptomatic. accuracy of water enema-mdct in colon cancer staging: a prospective study c. feasibility study of low-dose ct colonography using model-based iterative reconstruction: preliminary findings in 20 patients v. vardhanabhuti, c. roobottom; plymouth/uk (vvar@me.com) to compare image quality on computed tomographic (ct) images acquired at standard dose (sd) and low dose (ld) using adaptive statistical iterative reconstruction (asir) and model-based iterative reconstruction (mbir) techniques. methods and materials: 20 patients were prospectively recruited for the study with informed consent. they underwent standard dose (sd) and low-dose (ld) ct colonography. low-dose parameters were based on our phantom study with using vendor-specific automatic tube current modulation known as noise index. both sets of scans were reconstructed with asir and mbir. objective and subjective image qualities were assessed as well as diagnostic accuracies for significant lesions (e.g. polyps, cancer, etc). effective doses for each scans were recorded. results: objective image analysis supports significant noise reduction and superior contrast-to-noise ratio with low-dose scans using mbir technique (p < 0.05) despite being acquired at lower doses. subjective image parameters were equivalent for ld mbir and sd asir for both colonic and extra-colonic findings. diagnostic accuracies for polyp detection and other significant lesions were comparable. dose recorded were substantially lower for mbir (range 45-75% reduction compared with asir) with mean average being 4.2 msv in our population group. conclusion: mbir shows superior reduction in noise whilst maintaining image quality and most importantly substantial dose reduction can be achieved. more patients are being recruited to substantiate diagnostic accuracies data with full results to be presented at the ecr 2013. reviewed by two readers separately respectively having a degree of initial and advanced experience (for both primary 3d view). calculated values were sensitivity, specificity, nvp, pvp for patient-to-segment and both without and with the use of the cad system (im3d-turin) as the second reader. ]of sensitivity, specificity, nvp, pvp reported by the novice radiologist were respectively: 55%, 76%, 55% and 80%, while the values obtained by the radiologist with advanced experience were equal to 67%, 89%, 75%, 91%. with the use of cad as a second reader the novice player has achieved an improvement of the sensitivity to 62%, while the skilled reader did not obtain a significant increase of' diagnostic accuracy. the sensitivity and npv of ctc for flat lesions depend on the experience of the radiologist reader. cad seems to be an effective aid for the novice radiologist only. (thomas.knogler@meduniwien.ac.at) purpose: to predict early treatment response with three-dimensional texture features (tf) in patients with hodgkin lymphoma (hl) after radio-chemotherapy extracted from contrast-enhanced ct. methods and materials: 21 patients with histologically proven hl were included in this study. contrast-enhanced (18)f-fdg pet/ct was obtained on a dedicated pet/ct scanner. volumes-of-interest and long-and short-axis diameter were manually defined on 48 hl manifestations prior and post-radio-chemotherapy on the ct image stack. three-dimensional texture features derived from the grey-level histogram, co-occurrence matrix, run-length matrix and absolute gradient were calculated for the vois. a stepwise logistic regression with forward selection was performed to find classic radiologic features (i.e. lesion diameter, lesion volume) and tf, which correctly classify treatment response (i.e. full response and partial response). classification in pet/ct was used as reference. results: difference in short axis diameter best fit as classic feature with a sensitivity of 100%, a specificity of 54.5% and an accuracy of 89.6%. combination of "s_0_0_1_entrp" and difference of "vertl_fraction" best fit as tf with a sensitivity of 97.3%, a specificity of 72.7% and an accuracy of 91.7%. conclusion: texture features extracted from contrast-enhanced ct in patients with hl are superior in differentiation between responders and non-responders without the need for pet examinations, compared to classical radiological features. however, pet/ct as state-of-the-art imaging technique has a sensitivity and specificity > 90%, so that further research with larger patient number is needed to investigate this new method. (melvin.danastasi@med.uni-muenchen.de) purpose: to evaluate the agreement between true tumour volume and tumour volume derived from (i) a new formula based on longest lesion (recist) diameter, (ii) a new formula based on longest diameter and longest orthogonal (who) diameter. methods and materials: 89 baseline and follow-up cts were available in 20 patients with metastastic colorectal cancer from the randomised phase ii multicenter ciox trial. target lesions were defined at baseline and followed over time. lesions were evaluated by (i) semi-automated volumetry using siemens syngo.via and (ii) volumetric assement using a newly developed formula based on manual measurement of the longest diameter and the longest orthogonal diameter. true, who-and recist-based volumes were calculated. we compared the agreement of the true volume to the who-and recist-based volume. we also compared the agreement between 'true' and who-based volume relative changes by means of the intraclass correlation. results: a total of 151 lesions were evaluated. using a variance components model it was shown that the difference between true and recist-based volume is statistically significant (p < 0.001) indicating a substantial constant bias. purpose: tumour treatment by retargeted truncated protein derivatives of the human tissue factor (ttf) results in tumour vessel infarction, necrosis and subsequent tumour growth retardation and regression. a novel method of gadofosvesetenhanced mri, that enables the visualisation of the response to this treatment in real-time, is introduced. methods and materials: dynamic gadofosveset-enhanced mri (3 t) was performed in eight tumour-bearing (u87) nude mice. in the course of an ultrafast t1-weighted gradient echo sequence, a gadolinium-based blood pool contrast agent (gadofosveset trisodium) was injected intravenously via a tail vein catheter. after the maximum contrast intensity inside the tumour was obtained, 150 µl of ttf-ngr (a retargeted ttf derivative which binds to cd13-overexpressing tumour endothelial cells) were injected intravenously via a second tail vein catheter (n = 4; saline solution as control: n = 4), and the contrast behaviour of the tumour was monitored by region of interest (roi) analysis. results: following the injection of ttf-ngr (approx. 500 sec. after the beginning of the sequence), the contrast intensity inside the tumours of the treated mice decreased more instantly and more strongly than in the tumours of the control mice (auc 1121.3 ± 0.65 vs. 1164.4 ± 0.52 au). conclusion: gadofosveset-enhanced mri allows for the visualisation of the therapeutic response of tumours to anti-vascular treatment in real-time. considering the intended clinical application of ttf-ngr, this method might be a simple and quick surrogate parameter for the monitoring of the therapeutic response to vascular disrupting agents in humans. purpose: the specific growth pattern of pleural mesothelioma along the pleural surface makes therapy monitoring using common measurement criteria, such as recist 1.0, difficult. therefore, byrne et al. developed modified recist criteria for pleural mesothelioma. in this study we evaluated the accordance between experienced and less experienced readers for recist 1.0, recist 1.1, mre-cist, and who. methods and materials: a total of 43 baseline and follow-up-ct scans from 15 patients from a clinical multi-centre pleural mesothelioma trial were retrospectively evaluated by different experienced radiologist (about 1 year and more than 10 years), who selected target lesions independently according to mrecist, recist 1.0, recist 1.1 and who criteria. ct scans were then re-measured after an interval of greater than one month. the inter-and intra-reader variability using the different response criteria was analysed. results: both, the intra-reader-and inter-reader variability were best when using mrecist (95 % limits of agreement of -28.4/ 12.9 and of -32.1/ 20.7) compared 'with recist 1.0, recist 1.1 and who. further, regarding the objective response (pr = partial response, sd=stable disease and pd = progressive disease), mre-cist showed the most reliable intra-observer outcome with only one differently classified examination and the most reliable inter-observer outcome with four differently classified examinations. conclusion: our results suggest that mrecist is most reliable for treatment response evaluation of pleural mesothelioma between experienced and less experienced readers compared with recist 1.0, recist 1.1 and who. to confirm these findings, the inclusion of further readers and more patient data is warranted. use of multimedia structured reporting for tumour response assessment d. munich/de (wieland.sommer@med.uni-muenchen.de) purpose: the aim of this study was to define the role of mri in the pretherapeutic prediction of treatment response in patients with liver metastases of neuroendocrine tumours (net) undergoing radioembolisation. in 45 patients with proven hepatic metastases net, mri was performed at baseline (3 t mri scanner, gd-eob-dtpa). furthermore, pet-ct examinations with somatostatin-specific tracer 68 ga-dotatate were performed at baseline. the following imaging predictors were defined: patient age/gender, proliferation marker ki-67, tumourload (%), vascularisation of metastases, tumour necrosis and haemorrhage. the status of somatostatin receptor was defined by analysing mean and maximum suv in pet-ct. as primary end point we defined the progression-free survival (pfs) using recist criteria in mri follow-up examinations (every 3 months). the effects of the predictors on the progression-free survival were analysed using kaplan-meier statistics. results: the mean follow-up time was 445±411 days. the mean pfs was 699 days (95%ci 326-964). hypovascular metastases showed significant earlier progress (255 vs. 727 days; p < 0.01). a proliferation marker < 2% was significantly associated with a longer pfs than a proliferation marker between 2-20% and > 20% (p < 0.001 dimensions system 3d (hologic®). the distribution among the acr density patters was studied. all women underwent a "combo" study, which consisted of a 2d-dm (2 projections) and 3d-dbt (2 projections). the increase in the detection of additional breast cancers due to the 3d-tomosynthesis studies has been evaluated. chi-square test with spss for windows (15.0 chicago, il) has been used to evaluate if there were any statistically significant differences (p < 0.05 was considered statistically significant). the clinical, radiologic and pathologic findings are described. results: among all acr density pattern, 15 breast cancers were diagnosed with the 2d-dm studies (detection rate 0.54%). 7 additional cancers were diagnosed due to the 3d-dbt imaging findings (four in acr density patter 2, one in acr density pattern 3 and two in acr density pattern 4). the global detection rate increased to 0.79%. no statistical differences were found regarding the detection rate among all density patterns. conclusion: in our group of patients the use of 3d-dbt combined with conventional 2d-dm increased the rate of breast cancer diagnosis from 0.54 to 0.79%. no statistical significant differences were found among all acr density patterns. 3d-dbt may be useful not only in dense breasts (acr 3 and 4) but also in medium density breasts (acr 2). exams. we present a structured reporting system, called vision, which captures a radiologist's measurements and key images in an efficient manner to generate disease timelines and automate the calculation of recist. we analysed serial radiology reports from ten patients with cancer to determine if radiologists reported tumour measurements, saved measurements in pacs, and whether there was correlation of tumour metrics between exams. in addition, we created a structured reporting solution that uploads screen captures and audio descriptions of image findings to a computer server where each finding is labelled with anatomy and pathology terms, presented in a multimedia structured report, and can be used to calculate recist. results: the analysis of baseline and subsequent radiology reports revealed that radiologists reported measurements in 90% of cases, saved measurements in 20% of baseline and 50% of follow-up studies, and correlated measurements between exams in only 40%. the application of vision enabled a means to record tumour measurements in 100% of cases by providing a visual record of where target lesions were previously measured, facilitating the linking of image findings between examinations and displaying the findings in disease timelines. the vision structured reporting system provides a means for more reproducible tumour response assessment. to identify the potential of breast mri vs. standard prognostic factors to predict tumour recurrence after successful treatment of primary breast cancer. methods and materials: consecutive patients receiving staging mri and subsequent guideline-approved therapy of primary breast cancer at our academic breast centre were investigated. standard prognostic factors including tnm staging, tumour typing, tumour grading, progesterone/estrogen receptors, her2neu score and associated dcis component were assessed. follow-up was performed (endpoint: "tumour-recurrence" after complete remission). for analysis of breast-mri a dedicated cad software was used (computer-aided analysis). it enables semi-automatic analysis of enhancement characteristics of the whole tumour (3d analysis of early vs. delayed phase) and the "hot-spot" (i.e. voxel with highest washin/wash-out ratio). potential of breast mri characteristics vs. standard prognostic factors to stratify the endpoint separately and in combination was investigated using logistic regression. to identify significant and independent predictors, backward feature selection was applied (p entry /removal: < 0.05 /> 0.01). results: 223 patients were included (endpoint: n=13/5.8%, loss-to follow-up: n=7/3.1%). if tested separately, logistic regression identified moderate potential for breast mri (aucmri=0.79, p=0.001) and standard prognostic factors (auc-standard=0.71; p=0.01) to stratify the endpoint. if breast mri characteristics and standard prognostic factors were combined, predictive performance could be increased considerably (auccombined=0.90, p < 0.001, sensitivity=84.6%, specificity=87.3%). feature selection identified one standard prognostic factor (m-stage) and four breast mri characteristics (hot-spot: wash-in, washout-ratio; 3d-analysis: tumour voxels showing wash-out plus weak wash-in, tumour voxels showing plateau and weak wash-in) as the most significant and independent predictors of tumour recurrence. purpose: to estimate the influence of breast density on diagnostic performance of dbt added to dm (dm+dbt), focusing on recall rate reduction. methods and materials: seventy-five women were recalled for 77 findings on dm screening examination and further investigated according to usual protocols (additional dm views, ultrasonography, and/or core needle biopsy). the final conventional assessment was: 7 cancers (4 invasive ductal carcinoma, 2 invasive lobular carcinomas) and 68 negative/benign cases. before this conventional work-up, 1-or 2-view dbt was obtained (giotto, ims, italy) for an off-line further evaluation. two independent readers, blinded to final conventional assessment, retrospectively assigned a bi-rads score to each lesion on both dm only and dm+dbt. breast density was scored according to acr categories from 1 to 4. χ 2 test was used. results: none of the 7 cancers was missed on dm+dbt by each of the two readers; of 14 readings, 7 (50%) had an increased bi-rads score. of 136 readings of 68 benign/negative cases, density was acr1 in 24 (18%), acr2 in 60 (44%), acr3 in 42 (31%) and acr-4 in 10 (7%); the bi-rads score was increased in 3 (2%), unchanged in 61 (45%) and decreased in 72 (53%). bi-rads was decreased for 11/24 (46%) acr1, 34/60 (53%) acr2, 25/42 (59%) and 4/10 (40%) acr4 (p= 0.595). conclusion: breast density does not influence the capability of dbt, as added to dm, to decrease the bi-rads score of negative/benign cases recalled for further assessment at screening dm. recall rate reduction by adding double reading digital breast tomosynthesis (dbt) to digital mammography (dm) l.a. carbonaro 1 , r.m. trimboli 1 , n. verardi 1 , k. khouri chalouhi 2 , g. di leo 1 , f. sardanelli 1 ; 1 san donato milanese/it, 2 milan/ it (luca.carbonaro@gmail.com) purpose: to estimate the reduction in recall rate induced by adding double reading dbt to dm. methods and materials: during 21 weeks of screening-activity, women with at least one mammographic suspicious finding were further investigated according to usual protocols (additional views, ultrasonography, and core needle biopsy). before this standard exams, 1-or 2-view dbt was acquired (giotto, ims, italy). of a total of 1,286 dm screening-exams, 74 were initially recalled (recall rate of 5.8%) for 77 suspicious findings. two independent readers (who did not perform initial standard reading and blinded to final diagnosis) retrospectively evaluated dm and dbt. each lesion was scored according to bi-rads classification, considering 3, 4a-b-c, and 5 as recalls. results: two dbts (two findings) were excluded for technical problems. at combined dm+dbt evaluation each of the two readers recalled 37/72 (51%) women; considering each case judged as bi-rads 3-5 by at least one of the two readers as recalled (double reading), a total of 49 cases were recalled with a reduction in recall rate of 23/72 (32%). of 14 readings of 7 cancers (5 idcs, 2 ilcs), we had bi-rads upgrade for 7 (50%), confirmation for 6 (43%), and downgrade for 1 (7%). of 136 readings of 68 negative cases, we had a bi-rads upgrade in 3 (2%), confirmation in 61 (45%), and downgrade in 72 (53%). no cancers were missed. the use of double reading dbt as an adjunct to dm could allow for a reduction of recall rate by 32%, from 5.8% to 3.9%. detection rate for suspicious lesions of digital breast tomosynthesis in combination with digital mammography or 2d central projection imaging c. zuiani 1 , p. clauser 1 , v. londero 1 , c. molinari 1 , r. girometti 1 , a. taibi 2 , s. vecchio 3 , m. bazzocchi 1 ; 1 udine/it, 2 ferrara/it, 3 bologna/it (clauser.p@hotmail.it) purpose: based on a novel approach, digital breast tomosynthesis (dbt) may simultaneously acquire 2d and 3d images of the breast. variable dose geometry is used to give a sufficient dose in the central projection (2d-cp) for that image to be a 2d mammogram. we aimed to assess the detection rate for suspicious lesions (acr-birads 3-5) of dbt associated with digital mammography (dm) or 2d-cp. methods and materials: 45 asymptomatic women who performed dm and dbt with 2d-cp as screening examinations were included. two experienced radiologists, blinded to final diagnosis, evaluated images in separate sessions according to two different strategies of reading: dm+dbt (set-a) and 2d-cp+dbt (set-b). they assessed breast lesions as benign or suspicious in case of acr-bi-rads scoring of 1-2 and 3-5, respectively. discordant cases were reviewed in consensus. purpose: the aim of this study was to demonstrate the diagnostic significance of digital mammography with tomosynthesis (3d) versus digital mammography (2d) in the group of histologically proven multicentric breast cancer. in the group of 110 patients examined in this study, 2-d mammography showed suspicious breast lesions. all patients were sent to the oncology institute of vojvodina for further examination and biopsy. at our institution after initially clinical breast exam, 2d and 3d mammography were performed in the same act. all imaging procedures were performed on hologic selenia dimensions equipment. two radiologists independently read mammograms and core needle biopsy were performed in all birads 4 and 5 groups. all patients had fibroglandular or heterogeneously dense breasts (acr2 and acr3). results: in the group of 110 patients, pathologic findings revealed 80 unifocal and 30 multicentric cancers for a total of 152 malignant foci. all unifocal cancers were detected by both methods. with 2d mammography, additionally 15 suspicious lesions were found and using 3d mammography 31 suspicious mass were found. both 2d and 3d mammography showed the same 15 lesions but 3d mammography showed 16 "new" lesions which were obscured on 2d mammography. overall sensitivity was 82% (125/152) for 2d mammography and 94% (141/152) for 3d mammography (p < 0.05). results showed that in 10% of multicentric foci were in situ carcinomas (dcis). conclusion: 3d mammography was more sensitive than 2d mammography for the detection of multicentric foci in fibroglandular or heterogeneously dense breasts. the role of tomosynthesis after normal mammography according to acr density patterns j. etxano, p. slon, i. after a standardised preparation with 1l of oral water over 60 min, the patient is asked to empty the bladder. initially the patient receives intravenously (iv) 20 mg of furosemide. contrast administration consists of a fixed iv volume of 110-120 ml iobitridol 300 mgi/ml followed by 20 ml saline solution injected at a rate of 2-3 ml/s. after 10 min and subsequently every 2 min first low-radiation scouts are acquired breast tomosynthesis versus digital mammography: evaluation of diagnostic potential in women with abnormal screening mammograms m. a. shaaban; cairo/eg (marwaadelmm@hotmail.com) purpose: to compare the diagnostic potential of digital mammography with tomosynthesis. methods and materials: 100 women with abnormal screening mammograms,187 findings, and definite imaging or histopathological diagnosis were included. the screening mammography interpretation consisted of direct comparison of the tomosynthesis (dbt) examination with full field digital mammography (ffdm) images. the study radiologists subjectively rated the equivalence of the image quality of both the dbt and the ffdm examinations with no use of additional mammography, magnification views or comparison mammography. the next step was categorising the findings in both ffdm and dbt separately according to birads classification and the statistical analysis evaluated the p values of dbt and ffdm as well as their sensitivities. results: all findings categorised as birads 3 according to mammography showed reduction in number,particularly for masses, when examined with tomosynthesis. the image quality of tomosynthesis was subjectively rated as equivalent (53.5%) or superior (43.3%) to digital mammography in 96.8% of the total of findings; the test was highly significant (p < 0.001). for masses, tomosynthesis image quality was rated as equivalent in 40.5% or superior in 58.1% of findings. masses were 53% of findings in which tomosynthesis had superior image quality. the ffdm sensitivity was of 91.9 % compared with 95.2% for dbt. the diagnostic potential of digital breast tomosynthesis is superior to that of full-field digital mammography by evaluating their image quality and their sensitivity. based on a subjective analysis, dbt showed a significantly higher image quality compared with digital mammography in all finding types, especially in the characterisation of masses. purpose: to compare discordant screen-detected cancers in ffdm ("2d-mode") versus 2d plus tomosynthesis (2d+3d or "combo-mode") in a population-based screening program. methods and materials: oslo tomosynthesis screening trial (otst), a large prospective study comparing ffdm with 2d plus tomosynthesis in breast cancer screening, is part of the norwegian screening program. women 50-69 are invited biannually to mammography using independent double reading. the two main arms of otst have independent double reading. one 2d arm is modified with cad and one combo-arm with synthetic 2d. the four arms are read by independent radiologists. from 22.11.2010 to 31.12.2011, 121 screen-detected cancers were found. results: cancers detected: arm a (conventional ffdm) 77, arm b (2d+cad) 77, arm c (2d+tomo) 101, and arm d (synthetic 2d+tomo) 94. merging arm a and b ("2d-mode") and c+d ("combo-mode"), 90 cancers were detected by "2d-mode" and 119 by "combo-mode" (32.2% relative increase). discordant rate (screendetected cancer with tp score by only one reader) was 28.9% (26/90) for "2d-mode" and 36.1% (43/119) for "combo-mode". for cancers manifesting as spiculated mass or distortion (n=63) the discordant rate was 31.0% (13/42) for "2d-mode" and 30.6% (19/62) for "combo-mode". for cancers with microcalcifications the values were 25.7% (9/35) and 39.5% (17/43), respectively. conclusion: combined ffdm and tomosynthesis showed a 32% relative increase in cancer detection as compared with ffdm. discordant cancer rate was approximately the same or higher for "combo-mode" as compared with "2d-mode". independent double reading should be the standard of care when tomosynthesis is implemented into mammography screening. purpose: within narrow limits, the ct estimated size influences the prognosis for spontaneous passage of a ureteral calculus. in the present experiment, we tried to reduce the inter-reader variability in urinary calculus size estimation by measuring the variability before, immediately after and late after a training session. a retrospectively generated anonymous urinary calculi ct image data bank consisting of 50 unenhanced ct-stacks demonstrating ureteral or kidney calculi was used. eleven readers, radiologists and residents (mean experience 13 years) independently estimated the largest axial diameter of the calculi in three sessions: baseline, post-training and follow-up. immediately before the post-training session each reader received training on eight calculi aimed at reducing inter-reader variability without affecting the mean reader size estimate. follow-up session was performed four to eight weeks later without further training. results: per-calculus standard deviation between readers was 0.44, 0.42 and 0.51 mm and inter-reader limits of agreement were ±1.3, ±1.2 and ±1.5 mm for baseline, post-training and follow-up session, respectively. friedman test showed significant difference for per-calculus standard deviation (p < 0.001). pairwise wilcoxon signedranks test showed increased variability in follow-up session compared to baseline (p < 0.001) and post-training session (p < 0.001). the small reduction in variability in post-training session compared to baseline was not statistically significant. the small statistically non-significant reduction of inter-reader variability from the tested training protocol had no long-term effect, where an increase in variability was seen. other approaches such as reader-independent urinary calculus size estimation seem more promising for reduction of inter-reader variability. purpose: to assess the added value of functional sequences, using diffusionweighted imaging and apparent diffusion coefficient value, to conventional mri imaging examination in the differential diagnosis from benign and malignant focal liver lesions. methods and materials: a total of 53 patients with known focal liver lesions including 36 benign (25 angiomas, 8 fnh, 2 abscesses) and 18 malignant (9 metastases, 7 hccs, 2 cholangiocarcinomas) underwent 1.5-t mri examination (achieva, philips). the study was performed with a phased array multi-coil using a conventional protocol that included also diffusion-weighted imaging (dwi) with different b-values. the rois were manually drawn on focal liver lesions and on surrounding normal hepatic parenchyma in adc maps, and statistical analysis of adc mean values was performed. results: lesions were proved either by follow-up (benign lesions) or biopsy (malignant lesions).following mean adc values were obtained for different types of benign lesions: angiomas (1794.27±125, 2x10-3 mm2/sec), fnh (1486.74±156, 8x10-3 mm2/sec), abscesses (1133±145, 5x10-3 mm2/sec) while in the neoplastic lesions were: metastases (1025, 6±93x10-3 mm2/sec), hccs (887, 6±71, 10x10-3 mm2/sec) and cholangiocarcinomas (1285±25x10-3 mm2/sec). in normal hepatic parenchyma, mean perfusion values were (1158, 4±158, 7x10-3 mm2/sec). a statistical higher values (p < 0.001) were obtained in diffusion parameters among benign than those of malignant lesions (1563±142, 4 vs 1066±138, 3x10-3 mm2/sec). conclusion: diffusion-weighted images offer useful quantitative information (by evaluation of adc maps) that differs significantly in solid and malignant liver lesions, due to tumour different vascularity and cellularity. purpose: to identify the best mr sequences for pancreatic adenocarcinoma conspicuity and determine whether mr signal and apparent diffusion coefficient (adc) values correlate with pathological findings. methods and materials: 25 consecutive patients with pathologically proven pancreatic adenocarcinoma who underwent mri (1.5 or 3 t) before surgical resection were included. fat-suppressed (fs) t1-weighted gradient-echo (gre), fs t2-weighted fast-recovery fast spin echo, 3d fs dynamic t1-weighted gadolinium-enhanced gre during arterial, portal and delayed phases and diffusion-weighted imaging (dwi) with b values of 0 and 600 or 800 sec/mm2 were obtained. two observers reviewed mr sequences for size, signal characteristics and lesion conspicuity using a four-point rating scale. adc of tumours were calculated. histological characteristics (differentiation, fibrosis, necrosis) were correlated with mri features. results: 95% of pancreatic adenocarcinomas were hypointense on 3d fs t1 gre arterial phase, which was the best sequence for tumour conspicuity, followed by portal phase. dwi was not useful for delineating 26% of tumours. maximum diameter at pathological examination ranged from 18 to 60 mm (mean 33 mm). it was best correlated with mr tumour size on dwi. no correlation was found between adc (mean value : 1.76x10-3 mm2/sec) and differentiation, fibrosis or necrosis. all homogeneous hyperintense lesions on delayed phase (23% of tumours) were predominantly fibrous tumours. conclusion: 3d fs t1 gre arterial phase sequence is superior to dwi for pancreatic adenocarcinoma conspicuity but it underestimates the size of the tumour. dwi is the best sequence for size evaluation when the tumour is correctly delineated. quantitative data analysis of the diffusion-weighted mr-images in the differential diagnosis of metastatic liver disease of colorectal and pancreatic aetiology y. savchenkov, s. bagnenko, g. trufanov, v. fokin; st. petersburg/ru (yura_savchenkov@mail.ru) purpose: to develop differential diagnosis metastatic liver disease on the basis of quantitative data analysis of dwi. methods and materials: 57 metastatic liver lesions colorectal (37 lesions) and pancreatic (20 lesions) aetiology were analysed in 20 patients. we used dwi with the factors b-50,300,800,1200,1500s/mm2. all measurements were carried out within a single axial slice (for each pulse sequence separately). we used the coefficients, calculated on the basis of the ratio measured values in several organs, in different parts of the liver or in one and the same region of the liver. the most informative in the native study is the ratio of si lesionb300 /si aorta b300 , si lesionb50 /si aortab50 и si lesionb50 /si liverb50 (р<0.001). somewhat less informative demonstrated is the ratio of si lesionb300 /si liverb300 и adc lesion50-300-800 (р<0.001 and р=0.003 purpose: in clinical practice, the apparent diffusion coefficient (adc)-map is supposed to eradicate the t2-shine-through effect (t2-ste) potentially affecting the diffusion-weighted (dw) signal of focal liver lesions (flls) at higher b-value. we investigated whether this assumption is valid. methods and materials: included were forty-five patients with 73 focal liver lesions (54 malignant and 19 benign) detected on a 1.5 t system (cysts and haemangiomas were excluded from analysis). dw examination was performed using a single-shot echoplanar sequence with b values of 50, 500 and 800 sec/mm 2 , leading to the generation of (a) the adc-map, using a 3-point regression analysis and (b) the exponential adc-map (e-adc-map), using the b800/b50 images ratio, which provides a diffusion-weighted image with complete eradication of t2-relaxation time effects. by performing an analysis of differential signal patterns, two experienced radiologists in consensus estimated the prevalence of the t2-ste when combining dw images with the adc-map or e-adc-map. purpose: to develop a novel spectral reconstruction algorithm for digital breast tomosynthesis (dbt) that results in reduced artifacts and improved image quality. methods and materials: current reconstruction algorithms assume that the xray source emits a mono-energetic x-ray beam, resulting in artifacts and possibly sub-optimal image quality. to avoid this, a mathematical model of dbt acquisition that includes the spectral nature of the x-ray source was developed, resulting in a large scale non-linear inversion problem which we solve using an iterative, gradient descent method. the resulting algorithm was tested using breast phantoms with lesions resembling masses and calcifications. the breast phantoms were imaged with a clinical dbt system using the automatic exposure control system. the resulting spectral reconstructions were compared to the system's filtered backprojection (fbp) reconstruction, which assumes a mono-energetic x-ray source. the signal difference-to-noise ratios of the masses in the spectral reconstruction were all superior to those of fbp by a mean factor of 2.6. in addition, the masses exhibited better homogeneity and no artifacts in the direction of x-ray tube travel, typically seen in dbt images. the microcalcifications also resulted in improved signal difference and without artifacts seen in the fbp reconstructions. subjective comparison of images of heterogeneous breast phantoms showed an overall improvement in image quality, substantial reduction of artifacts, and lower noise. conclusion: spectral reconstruction can improve image quality and reduce artifacts in dbt images. this new algorithm also allows for investigation of novel acquisition techniques that could result in further improvements in dbt imaging. purpose: phase-contrast radiography is an emerging technique for producing medical imaging with more soft tissue contrast than traditional absorption radiography. the goal of this study is to evaluate the feasibility of phase contrast imaging using grating interferometer for clinical use. we developed a prototype of phase contrast x-ray imaging system using micro-focus x-ray source, grating interferometer and cmos detector. the source contains a tungsten anode x-ray tube that can operate from 38 kv at 0.35 ma and focal spot size of 0.3 mm. a specification of phase grating was 4.714um period, ni 6.08um height and 30x70 mm 2 area; and analyser grating was 2.4um period, au 20.3um height and 20x60 mm 2 area. with application of phase retrieval algorithm, phantoms such as acryl ball, honey bee and goldfish images were obtained. we compared with images of conventional absorption radiography and evaluated the phase intensity by phase stepping method. results: phase contrast image shows a detailed view of the edge of the acryl ball. on the phase contrast image there are dark and light lines running along the hole. these lines represent the phase-contrast edge enhancement effect. a similar effect is evident at the honeybee and goldfish images. the phase contrast edge enhancement effect is visible in the phase contrast radiography, but not in either of the absorption contrast image. the phase contrast imaging using grating interferometer will ultimately provide a novel x-ray imaging system that enables with high contrast, which can be valuable in medical imaging such as breast, cartilage and vessels. first in-vitro results of microbubbles as a scattering contrast agent for x-ray dark-field imaging measured at a first pre-clinical x-ray phase-contrast and dark-field ct scanner purpose: dark-field and phase-contrast imaging, which generate contrast from ultra-small angle scattering and refraction of x-rays in matter, have been shown to increase soft-tissue contrast and provide complementary information to conventional absorption-based imaging. to further improve image quality and explore possible alternatives to commonly applied iodine-based contrast agents, the use of microbubble-based ultrasound contrast agents as an x-ray scattering dark-field contrast medium was investigated. methods and materials: using the first pre-clinical phase-contrast and dark-field ct scanner with polychromatic x-ray source and grating interferometer installed on a rotating gantry, absorption, phase-contrast and dark-field images of microbubblebased contrast-agent samples were acquired in-vitro. for quantitative comparison, the contrast-to-noise ratio relative to a reference was calculated for varying detector resolutions (29-928 micrometer) in absorption and dark-field images. results: it was possible to generate an improved contrast-to-noise ratio in the darkfield image compared to the absorption-based image (6.88 versus 1.41, pixel size 29 micrometer) by exploiting the x-ray scattering through microbubbles. with larger pixel sizes (928 micrometer), the relative contrast gain increased to 78.82 for dark field, whereas, with 1.06, it remained in the same order of magnitude for absorption. the proved feasibility of microbubble-based dark-field contrastenhancement with clinically compatible pixel sizes, together with the large potential of the introduction of grating interferometry into a clinical environment as shown by the successful implementation of the technology into a rotating gantry, strongly promote the use of microbubbles as a dedicated dark-field x-ray contrast agent and warrant further investigation in an experimental in-vivo setting. images. four thicknesses of the combined phantoms were imaged with a digital mammography unit. of each thickness, four images were acquired under automatic exposure control. images were displayed under standard clinical conditions: first on two 5 megapixel medical grade monitors calibrated to the dicom gsdf standard, then on a 6 megapixel colour monitor, displaying the images in green-scale. greenscale was chosen as this wavelength matches a peak in human visual response. reading was performed with the sara 2 software which displays each cdmam cell under random rotation, reducing reader memorization. readers performed a 4-alternative forced choice task; five readers scored all images. results: threshold gold thickness (tgt) increased as beam quality and thickness increased, indicating a reduction in object detectability with increasing object thickness. results obtained for the grey-scale display had a higher tgt compared to green-scale results; tgt values obtained with green-scale display were between 7% and 31% lower than grey-scale display tgt. p values for the different diameters obtained from wilcoxon matched pairs tests ranged from < 0.01 to 0.68 for 2 cm and < 0.01 to 0.44 for 7 cm. conclusion: observer performance measured by c-d curves was equal or better for images displayed in green-scale rather than grey-scale, indicating potential benefit for using green-scale displays in medical applications. volumetric breast-density measurement using spectral mammography purpose: volumetric breast density (vbd) quantification is useful for assessing diagnostic accuracy and the risk of developing breast cancer. the purpose of this study is to evaluate spectral imaging as a method to improve the accuracy of vbd measurements compared to conventional non-spectral methods. the vbd is the volumetric fraction of fibro-glandular tissue in the breast. to measure vbd in a conventional non-energy resolved mammogram, assumptions have to be made on the breast thickness. spectral imaging, on the other hand, enables simultaneous measurement of breast thickness and glandularity by employing the spectral difference in x-ray attenuation between adipose and fibro-glandular tissue. spectral mammograms were acquired in a single exposure using a photon-counting mammography system. the vbd was measured by material decomposition based on calibration to tissue-equivalent material. for reference, vbd was measured with a conventional non-spectral method in a similar group of patients. results: spectral mammograms of 75 patients, aged 50-69 years, were examined. the correlation in vbd between contralateral breasts was r=0.97. 246 patients were examined with conventional methods, which returned a correlation between contralateral breasts of r=0.92. the vbd distribution was similar in the two groups as measured with the two different methods. conclusion: spectral imaging provides an efficient measure of vbd. the vbd distributions over the group of patients were comparable in the spectral and nonspectral measurements, but the correlation between contralateral breasts was tighter using spectral imaging, which indicates higher consistency. purpose: the feasibility of monochromatic dual-energy x-ray absorptiometry (dexa) using multilayer reflector for precise measurement of bone mineral density (bmd) was examined. methods and materials: a multilayer mirror was fabricated to select an x-ray peak with an energy of 40 kev and 59.3 kev generated from an x-ray tube with a tungsten target. experimental set-up of monochromatic dexa was installed by dual-energy of monochromatic x-rays source and czt detector. the performance of the system was evaluated using a dexa phantom, spectrometer and radiation dosimeter. we compared the image quality and the attenuation reduction characteristics of the phantom to determine precision of bmd on conventional polychromatic and monochromatic dexa. purpose: high vessel attenuation and a high contrast-to-noise (cnr) ratio are prerequisites for highly diagnostic abdominal ct angiography (cta) examinations. we compared image-quality of standard 120 kev polyenergetic images (peis) with calculated low-kev monoenergetic images (meis) in dual-energy cta studies of the abdomen. methods and materials: datasets of fifty patients (42 men, 71 ± 10 years) who underwent abdominal dual-energy cta were retrospectively evaluated. the 80-and 140-kev dual-energy image data was used to calculate meis in 10-kev intervals from 120 kev to 40 kev. vessel attenuation and image noise were measured in three regions-of-interest (infrarenal aorta, external iliac artery and superior mesenteric artery) and the signal-to-noise ratio (snr) and cnr were subsequently calculated. differences between measurements in meis and peis were evaluated using the student's t-test. results: snr and cnr of 70-kev meis were highest compared to meis at other low-kev levels. when comparing meis at 70 kev to peis, vessel attenuation and image noise were significantly higher in meis in all three regions-of-interest (+14%, +13%, +14%; p < 0.05 and +12%, +6%, +9%; all p < 0.05). snr was slightly increased in 70-kev meis (+4%, +7%, +6%; p < 0.05). cnr was also significantly higher in meis when compared to peis (+18%, +16% and +18%; p < 0.05). purpose: it was shown in mice the exposure to a high fat (hf) diet during early development increased the susceptibility to high-fat diet-induced hepatic steatosis and decreased markers of hepatic mitochondrial function. we aim to investigate whether early exposure to a hf diet also increases the susceptibility to cardiac fat storage and diminishes cardiac mitochondrial function and ejection fraction. methods and materials: male and female c57bl6 mice were fed a hf diet (45% kcal fat) or standard chow diet (9% kcal fat (lf)), starting at least 6 weeks before conception and continuing during gestation and lactation. from weaning onwards, all offspring were fed the hf diet, generating two groups: hf/hf and lf/ hf. cardiac function and myocardial fat content were measured in male offspring at 15 weeks of age (n=26) using magnetic resonance imaging and spectroscopy on a 7t mr system (bruker biospin gmbh). cardiac mitochondrial respiration was determined in parallel groups (n=11), using high resolution respirometry (oroboros instruments). results: at 15 weeks of age, the hf/hf group showed significantly higher cardiac lipid content (p=0.02) compared to the lf/hf group. no significant differences in cardiac mitochondrial function and ejection fraction were detected. conclusion: mice exposed to hf feeding during early development were more susceptible for high-fat diet-induced cardiac lipid accumulation. this was not (yet) accompanied by decreased mitochondrial function and/or decreased ejection fraction. cardiac and hepatic iron and heart function by mr in thalassaemia major patients treated with combined deferiprone and desferrioxamine regimen versus monotherapies: a multi-centre, observational and prospective study c. lge was significantly smaller in follow-up compared to the first examination (p=0.023). in multivariate regression analysis, rv oedema was the only parameter that was associated with a significant improvement of rv-ef. conclusion: the significant decrease of lge in the follow-up examination implies that the area of hyperenhancement might represent necrosis. we furthermore conclude that the extend of rv scar is too small to permanently impair rv-ef function in the majority of patients in follow-up. purpose: the factors governing periprocedural myocardial injury (pmi) and its influence on the prognosis at follow-up are not completely clear. we used delayed enhancement magnetic resonance imaging (lge mri) to assess myonecrosis after pci. methods and materials: forty-three patients with stable coronary artery disease were studied with 1.5 t mri before and after (within 72h) stenting of bifurcation lesions. the left ventricular function and lge were assessed. we performed angiographic measurements of the vessel diameters, and bifurcation angles pre-and post-intervention. systolic-to-diastolic increase of t1 was above average in lateral (p < 0.0001) and apical (p < 0.0001) segments. conclusion: t1 relaxation times of normal myocardium differ significantly between diastole and systole at 1.5 t. their strong correlation facilitates translation of diastolic and systolic t1 normal values. regional deviations from the mean systolic-to-diastolic increase of t1 might be associated with regional differences in myocardial perfusion. author disclosures: g. reiter: employee; siemens. a. greiser: employee; siemens. are the preferential patterns of myocardial iron overload preserved at the cmr follow-up? results: for each group there was a significant improvement in the global as well as in regional t2* values. for the whole patient population as well as for both groups, at basal the mean t2* value over the anterior region was significantly lower than the mean t2* values over the other regions, and the mean t2* over the inferior region was significantly lower than the t2* values over septal and lateral regions. the same pattern was present at the fu, with a little difference for patients with mild-moderate mio. in conclusion, a preferential pattern of iron store in anterior and inferior regions was present at both basal and fu cmrs, with an increment of t2* values at fu due to a basal cmr-guided chelation therapy. the anterior region seems to be the region in which the iron accumulates first and is removed later. the effect of partial volume averaging on peak velocity measurements in phase contrast magnetic resonance angiography (pcmra) j.c.l. rodrigues 1 , k. minhas 1 , g. pieles 1 , c. bucciarelli-ducci 1 , r. tulloh 1 , n.e. manghat 1 , c.j. occleshaw 2 , m.c.k. hamilton 1 ; 1 bristol/uk, 2 auckland/nz purpose: ecg-gated pcmra is an established non-invasive in vivo method to measure blood flow. by default, the siemens argus pcmra flow analysis software calculates a voxel averaged peak velocity. the voxel with the highest velocity in the data set is first determined. this value is then averaged with this the velocities of its neighbouring 4 voxels to generate the voxel averaged peak velocity. this may underestimate peak velocity. the aim of this study was to determine if voxel averaging leads to a lower calculated peak velocity. methods and materials: 145 peak velocity measurements in 14 different anatomical locations in 37 subjects (healthy volunteers, congenital and acquired heart disease patients) were analysed by default voxel averaging method and single voxel technique and compared. the effects of flow velocity, scan protocol (breath hold versus free breathing) and scanner type (siemens symphony versus siemens avanto) were also assessed. statistical significance was defined as p < 0.05. results: there was a highly significant mean percentage increase in peak velocity of 7.1% when peak velocity was calculated by single voxel compared with voxel averaging technique (p < 0.0001). significant increases in peak flow were observed by single voxel compared with voxel averaging regardless of patient type, anatomical location, cmr scanner or scan technique in terms of breathing command (p < 0.05). disabling the voxel averaging technique had no effect on the volume of flow recorded. the use of voxel averaging produces a consistent underestimation of peak velocity. at peak velocities > 300 m.s -1 , the error may be clinically significant, e.g. misclassifying the severity of aortic stenosis. for this reason, it is recommended that for the assessment of peak velocity by pcmra voxel averaging should not be used. purpose: to evaluate foetal brain maturation during twin pregnancies complicated with twin-to-twin transfusion syndrome (ttts). methods and materials: over a period of 4 years, we retrospectively evaluated 44 mris of women with monochorionic twin pregnancies complicated with ttts. mri scans were realized at an average of 31 weeks of gestation. all pregnancies complicated with ttts and successfully treated with fetoscopic laser were included. eighty-eight foetal brains were analysed and compared with an mri brain atlas and with the co-twin. biparietal brain diameter, cerebellar transverse diameter, sulcation, operculation, and myelination were analysed. results: among the 88 foetuses, 4 (4.2%) developed severe brain damage (unilateral brain atrophy, clastic lesion of corpus callosum with cyst) and showed unusual delay of brain maturation. in others cases of successfully treated ttts, we found no difference in brain maturation between twins. conclusion: brain maturation during twin pregnancies with treated ttts is well preserved except in cases with a severe vascular complication. purpose: very preterm infants suffer a wide range of neurodevelopmental disabilities. the purpose of the study was to assess the relationship between body growth and white matter (wm) microstructure maturation, in very low-birth weight, extremely preterm infants. methods and materials: twenty-seven extremely premature infants (gestational age: 29.11±1.9 weeks) with normal brain us studies and normal mri at term equivalent age (41.1±1.03 weeks) were enrolled in the study. using a diffusion-weighted sequence, fractional anisotropy (fa) was measured bilaterally in 16 fibre tracts with the region-of-interest method. the effect of sex and the relationship between somatometric measurements (birth and body weight, crown to heel length and head circumference) and fa was evaluated using a general linear model. two-tailed student's t-test was used to assess differences between small for gestational age (sga) and appropriate for gestational age (aga) infants. results: a positive correlation was found between body weight and fa in the anterior corona radiata, the posterior limb of internal capsule, the external capsule, the inferior fronto-occipital fasciculus, the superior longitudinal fasciculus, the middle cerebellar peduncles and the fornix. decreased fa was observed in the superior longitudinal fasciculus and the fornix in sga infants (p < 0.05). conclusion: in extremely premature infants body growth correlates with changes in wm microstructure. compromised growth at term equivalent age is associated with microstructural abnormalities in areas related to attention, language, memory and executive functioning. the "tail sign" in the differential diagnosis of vermian pathologies in foetuses under 24 weeks: role of foetal mri p. relationship between body growth and regional brain volume changes in extremely premature small for gestational age babies l.c. tzarouchi, a. drougia, a. zikou, a. charisiadi, p. kosta, l. astrakas, s. andronikou, m.i. argyropoulou; ioannina/gr (ltzar@cc.uoi.gr) purpose: extremely low birth weight and/or low gestational age has been associated with alterations in brain development. the purpose of the study was to assess whether early body growth catch-up reflects regional brain volume (rbv) changes by evaluating small for gestational age (sga) extremely premature babies (gestational age< 32weeks) at term equivalent age. methods and materials: twenty-five extremely premature infants (ga: 29.8±2.1 weeks) with normal brain us studies and normal mri at term equivalent age (41.5+1.6 weeks) were enrolled. thirteen were appropriate for gestational age at birth and at term (aga), 5 sga at birth and aga at term (sga+) and 7 sga at birth and term (sga-). t1-weighted high-resolution 3d images were segmented using the spm 5.0 and volumes of 90 individual gm areas were calculated using the ibaspm toolbox. two-tailed student's t-test was performed to test for differences in rbv between groups. results: there was no difference in rbv between aga and sga+ (body growth catch-up at term). in sga-(persistent body growth restriction at term), areas of late maturation (frontal lobes, caudate nucleus) presented lower rgmv. there was no difference in rbv between aga and sga-in brain areas of early maturation (occipital cortex, thalami) (p < 0.05). in extremely premature babies, body growth catch-up is associated with rbv catch-up at term equivalent age. rbv changes start from areas with great potential for early maturation. quality control in digital mammography: radiographers practice at 5 hospitals of lisbon c. tomás, c. gonçalves, c.i.s. reis; lisbon/pt (claudiatomas90@gmail.com) purpose: to investigate quality control/(qc) guidelines in use for digital mammography/(dm) in 5 hospitals, to identify radiographer's practice in qc concerning dm and to identify the causes of exam rejection/repetition. methods and materials: questionnaires were developed and applied to 30 radiographers working in dm (computed-radiography or direct-digital-mammography/ (ddm)) in 5 hospitals to characterise the qc practices (guidelines in use, performed tests, tests frequency). rejected/repeated analyses was performed in one hospital with ddm equipment using the checklist proposed by the international atomic energy agency/(iaea). results: guidelines for qc are followed by 70% (20) of the radiographers: 55% follow american-guidelines, 20% the portuguese, 15% the european/euref and 10% other guidelines. there is more than one guideline followed by radiographers in three institutions. the qc tests performed by radiographers in the same institution (proposed by iaea to test image acquisition and display systems) were not the same and in the right frequency. the main causes for mammography image rejection/repetition were improper positioning in 85% of the analysed images due to non-inclusion of pectoral muscle in mediolateral oblique projection and inner and outer quadrants asymmetry for craniocaudal projection. conclusion: in this group of hospitals with dm, there is no uniformity of qc practices. this can have impacts in mammography costs. this may be justified by the absence of certification programs concerning mammography departments. continuous education and training programs frequency to work with dm are not mandatory and also qc is not required by law in portugal. an investigation into the psychological anxiety of maltese women before and after a mammogram c. falzon; sta lucija/ mt (valeview@maltanet.net) purpose: to investigate whether there is a difference in anxiety levels between maltese women with and without a family history of breast cancer, before and after a mammogram. the study involved the participation of 150 maltese women aged 35 years and over. the women were divided into two groups; group 1 without and group 2 with family history of breast cancer. anxiety levels pre-and finally, mri made correct diagnosis in 4 of 6 foetuses with expansive formations, whereas in one of these cases we suspected a choledochal cyst and it was a gastric duplication and in another patient we diagnosed an ascites and it was an intrabdominal cystic lymphangioma. conclusion: our preliminary results suggest that mri has a supplemental value to sonography in anatomic evaluation and characterisation of gi abnormalities. ultrafast imaging sequence mri is helpful to confirm, refine or exclude us diagnosis. it also provides useful informations in prenatal counselling and perinatal management. purpose: in order to achieve high image quality with breast cancer screening mammography, the european guideline recommends training programs dedicated to radiographers. those training programs are very helpful for practitioners but back at their workplace it might be difficult for them to apply the achieved knowledge in their daily practice. to support radiographers to transfer good mammography practice in their daily screening activity, an online portfolio is realized by each radiographer during the following 6 months after the training session. methods and materials: every month, the trainee radiographer posts about 4 mammography examinations including the quality self-assessment on a dedicated electronic platform. experienced radiographers from the screening program of western switzerland comment the picture quality as well as the accuracy of the self assessment. tips and tricks, to improve quality, are also given. results: actually 26 portfolios have been completed. the majority of the radiographers appreciated the personalized comments given by the experts. they found the tips very helpful and they say the portfolio helped them to continuously improve the quality of the performed mammograms. nevertheless, some radiographers were upset because of the high time investment necessary to the realization of this kind of portfolio. conclusion: in western switzerland, where there are many decentralized breast cancer screening units, the online portfolio is an interesting tool to support radiographers with the development and the transfer of competences in their daily practice. purpose: this study aimed at measuring patient satisfaction in mammography exams and satisfaction-related factors. methods and materials: research was conducted in several private practice clinics with a total of 183 subjects using the myasthenia gravis questionnaire for assessing patient satisfaction concerning four dimensions: structure (physical environment), process (performing the exam), discomfort (physical and psychological) and general satisfaction (present and future). results: overall patient satisfaction was high (90%), with technical performance (process) and psychological discomfort having the major influence on patient satisfaction. exam costs and age had very low, or no impact, on satisfaction. also, the greater patient's education levels, the greater were their demands for process requirements, unlike patients with lower education levels which presented higher satisfaction levels. the great amount of patients of high age groups and respective pathologies may have influenced results when related to satisfaction and education level. the numbers of mammography exams have increased over the years and therefore it is essential to assess patient satisfaction so that improvements can be made. impacts of digital mammography in radiographers practice l. painho, t. . the anode-filter combination always used was w/rh. global iq was p (perfect) for cc, while in mlo the mean was g (good). the radiographers experience varied between 2 and 28 years. the compression force depends on breast compressed thickness. it can vary between 6 and 10n for breast thickness range of 45 to 76 mm. the technique suffered changes when the analogue was compared with digital technologies: the energy is higher, the intensity is lower and the anode-filter has changed from mo/mo to rh/rh and w/rh. breast symmetry absence on cc projection, inframammary folds absence and skin folds presence were the criteria not achieved more frequently in this study, according to european guidelines on quality criteria for diagnostic radiographer images. iq of all exams was classified as appropriated (perfect and good (362 out 373)). nevertheless, it is noticeable that some variation exists concerning the radiographer practice when comparing breasts with the same features. the radiographers experience and training can also affect the results. imaging ethics b. hofmann; oslo/ no (b.m.hofmann@medisin.uio.no) purpose: the benefits of modern medical imaging technology are obvious. however, the ethical challenges are less acknowledged. the purpose of the study is to highlight and to address core ethical challenges with modern medical imaging. a review of literature in radiology reveals a series of ethical challenges in modern medical imaging that are analysed with standard methods in modern bioethics. the ethical challenges are divided into four categories, i.e. challenges with 1) existing, and 2) new imaging techniques, 3) altered use of existing imaging techniques, and 4) challenges with basic concepts and end points in diagnostic imaging. a series of ethical challenges are identified within these categories, such as (radiation) safety, rationing, and justice (1), implementation without evidence-based outcome (2), reduced diagnostic accuracy, patient autonomy (3), and challenges with underuse, overuse, and futile imaging (4). conclusion: behind great benefits of modern imaging, a series of ethical challenges can be identified. while praising the benefits, the challenges need to be appraised to maintain confidence and trust in the profession, as well as a sound and fruitful development in the field. post-mammogram were measured using the well-established state and trait inventory for adults (stai) developed by c.d. spielberger. results: there was a significant difference (p0.05). a negative correlation was obtained when the mean s-anxiety scores (pre: group1, r=-0.123 and group 2, r=-0.245 and post: group1, r=-0.046 and group 2, r=-0.78) of both groups were compared with age. the factor causing anxiety in women was mainly related to the procedure because their anxiety diminished significantly after the mammogram. the correlation showed that those who scored high pre-mammogram anxiety also scored high post-mammogram anxiety. no significant difference in the anxiety levels between the two groups existed before and after the mammogram. a negative correlation existed between age and s-anxiety of the women, resulting in younger women being more anxious than older women. ergonomic and environmental assessment in digital mammography room: impact on radiographers' activity s. costa, e. oliveira, f. serranheira, s. viegas, c.i.s. reis; lisbon/pt (stefaniebcosta@gmail.com) purpose: to investigate ergonomic-characteristics of the equipment, environmental conditions and its impact on radiographers' activity and to identify opportunities to optimise the practice and reduce the probability of wrmsds occurrence. radiographer's mammography procedures were observed and organized in tasks time-scale-graphic. interviews were applied to 7 radiographers working in digital-mammography to characterise the practice (work patterns, mammographic equipment, exam room, environmental conditions) and to identify the presence of wrmsds symptoms. postural analyses were evaluated through video and pictures acquired during mammography positioning. measurements of angles were done with meazure2.0.158 software and classified according to the european standard/en100-4:2005+a1:2008. results: the task-time scale showed that the average duration of each exam is 5 minutes and also that the task which took more time was the indications given to the patient. 45.5% of the radiographers referred that the most exhaustive procedure is the positioning of mlo-view and short-stature patients (22.7%). in this specific case, the anatomical areas that can suffer more wrmsds are neck, arms and back presenting an angle of 87.2º, 118.6º and 63.6º, respectively. the visual contact with the patient was compromised only during the right-mlo-view acquisition. considering the environmental conditions the illuminance values are not in accordance with the guidelines. the ergonomic characteristics of the equipment do not provide comfort to the radiographers. in order to reduce the probability of work-related musculoskeletal disorders in mammography positioning and patient safety, new equipment features should be developed. environmental conditions are adequate concerning the international references for temperature and humidity but not for illuminance. accuracy of students, and radiographers, with and without, mammography post-graduation in interpretation of mammography images r.b.j. cópio 1 , k.b. azevedo 1 , a.f.c.l. abrantes 1 , l.p.v. ribeiro 1 , r.p.p. almeida 1 , c.a. silva 2 ; 1 faro/pt, 2 evora/pt (rita.copio.rc@gmail.com) purpose: to evaluate the sensitivity, specificity and diagnostic accuracy of radiographers with and without mammography post-graduation and last year students of the radiography course in the interpretation of mammography images. a grid of socio-demographic characteristics and view-dex software (viewer for digital evaluation of x-ray images) for the interpretation of mammography images by participants were used. each of the 16 cases was built with the four basic images. after viewing images, the 22 participants showed their level of confidence about the presence of abnormal radiological findings in relation to the case. the results obtained showed values of sensitivity of 81%, 89% and 80% for the last year students, radiographers without post-graduation and post-graduate radiographers, respectively. for specificity, the values were 63%, 75% and 50% for the same groups, respectively. with regard to diagnostic accuracy, the values obtained were 80% for the group of students in the last year, 88% for the group of radiographers without post-graduation and 78% for post-graduate radiographers. the mean response time was 46.9 seconds to the last year students, 59.8 seconds for radiographers without post-graduation and 64.6 seconds to post-graduate radiographers. the sensitivity, specificity and diagnostic accuracy varies between each group. however, there are not significant differences between them. also, participants with a higher formation have higher average response time. purpose: to compare different formats of llama-derived nanobodies as alternatives to monoclonal antibodies for specific in vivo near-infrared fluorescence (nirf) imaging of lymphomas in a mouse model. we used ecto-enzyme art2 on lymphoma cells as model target and compared three different formats of art2-specific nanobodies with a conventional antibody (150kd): a monovalent llama nanobody (15kd), a bivalent diabody (30kd), and a bivalent fc-fusion protein (80kd). all constructs were labeled with alexafluor680 and injected in nude mice, bearing art2-positive and art2negative tumors. circulating and excreted conjugates were monitored in plasma and urine and in vivo nirf-imaging was performed over 24h. tumor tissue penetration and target binding were analysed by facs and fluorescence microscopy. results: in vivo nirf-imaging revealed specific labeling of art2-positive tumors but not of art2-negative tumors with all af680-conjugates. the smaller nanobody and diabody revealed rapid renal elimination with highest signal-to-background ratios of art2-positive tumors. the larger fc-fusion protein and conventional antibody revealed long circulation times in plasma, resulting in unspecific background signals. facs and immunohistochemistry of tumors revealed deeper penetration and more homogenous labeling of tumor tissue with the nanobody and diabody than with the fc-fusion protein and conventional antibody. conclusion: renally excreted small nanobody-formats (< 60kd) can be used for specific in vivo imaging of lymphomas with a significantly higher signal-tobackground ratio than larger antibody-constructs (> 60kd) that are retained in circulation. therefore, single domain and bivalent nanobodies seem particularly suited for short-term diagnostic imaging, whereas reformatted nanobody-fc fusion proteins appear suited for long-term applications. the design of a dual-functional imaging contrast agent for targeting to tumour endothelial marker (tem8) q. quan 1 , x. huang 2 , j. xie 2 , y. yan 3 , h. gao 2 , g. zhang 1 , x. in control kit+/+ mice, the fmt signal for annexin v peaked at 6 hours after myocardial infarction with subsequent decrease at 24 hours and 7 days after onset of ischemic injury. kitw/w-v mice revealed an increased and prolonged in-vivo apoptosis signal, which was associated with progressive decline in heart function. bone marrow reconstitution was able to reduce cardiomyocyte apoptosis and rescue kitw/w-v mice from progressive heart failure. in-vivo apoptosis signal was verified after killed by apoptosis staining using immunohistochemistry (tunel) and flow cytometry (caspase-3). hybrid acquisition of x-ray computed tomography allowed exact localisation of the fmt signal to the left-ventricle and facilitated organ segmentation and attenuation correction. flow cytometry and determining the dissociation constant. for detecting apoptosis in vivo, cal-27 tumour-bearing mice were treated with pdt and injected with the annexin v probe two days and two weeks after therapy. the fluorescence intensity of the tumours was evaluated semiquantitatively over time. the annexin v probe showed nearly the same absorption (715 nm) and emission (750 nm) spectrum like the free dye and possessed a high binding affinity to apoptotic cells (kd-value 20 nm). therapeutic efficiency of pdt could be detected in vivo in the tumours via apoptotic cells shortly after therapy. our probe accumulated significantly stronger in treated tumours at two days in contrast to two weeks after therapy. conclusion: in summary, we could successfully image the therapeutic efficiency of pdt with the new designed fluorescence optical annexin v probe. apoptotic cells could be detected in the tumour short time periods (2 days) but not longer time (2 weeks) after pdt. bimodal nirf nanoparticles as an optical and mri contrast agent for imaging cells of the mononuclear phagocyte system j. purpose: even though approaches for multimodal imaging of targeted structures like in tumours have been suggested, fewer investigations have been made on bimodal optical and mr-imaging of inflammatory diseases via passive targeting of cells of the mononuclear phagocytic system (mps). however, non-targeted nanoparticles (np) could represent a simple and effective labelling tool being rapidly phagocytized from the blood stream by mononuclear cells which are then migrating to the site of inflammation. for the production of bimodal np iron oxide cores were enclosed by a near infrared (nir)-fluorochrome (ir780) and surrounded by a starchmatrix. the spectroscopic and mr-imaging properties of the bimodal particles were determined in agarose phantoms and in vivo using a near infrared fluorescence (nirf) small animal imaging system and 1.5 and 3 t-mri, respectively. in vivo optical and mr-imaging was performed on mice with hind leg oedema. results: a specific nirf-(average fluorescence signal 0.004 scaled counts/s for 25 µg/ml np) and mr-signal (1.5 t: r1=6 mm-1 * sec-1, r2=583 mm-1 * sec-1, r2*=613 mm-1 * sec-1) was detected for the bimodal np in vitro. in vivo-mr and nirf-imaging studies confirmed specific signalling of the particles within oedema. conclusion: our bimodal non-targeted fluorescent iron oxide np successfully labelled cells of the mps in vitro and in vivo without specific target recognition by antibodies. additionally, the ability of specific nir-signalling and mr-tracking of mononuclear cells makes them suitable for application as a simple and potent nirf-optical and mri contrast agent for visualisation of inflammatory diseases. purpose: quantitative t1-weighted perfusion imaging is promising. however, current software solutions are still semi-automatic and results are therefore potentially prone to observer-related bias. surprisingly, this aspect of dce-mri is still poorly investigated. we aimed to systematically address this matter using a dedicated imaging protocol and semi-automatic workflow for quantitative pharmacokinetic analysis. an ultra-fast high-spatial and high-temporal resolution protocol was used for t1-weighted perfusion imaging (magnetom aera @1.5 t; dynamic view-sharing 3d gradient-echo-sequence/twist: temporal-resolution: 1.81s, in-plane resolution: 1.1 mm 3 , 6 ml gadovist @2 ml/s, acquisition time: 62s). for the assessment of pharmacokinetic parameters (k trans , two-compartment tofts-model, fast arterial-input-function) a dedicated semi-automatic software solution was used. enhancing intracranial tumours were independently evaluated two times by one experienced neuroradiologist (> 4000 mri, 8-year experience in dce-mri). results of pharmacokinetic parameters for each reading were documented in a database. variability of k trans measurements was assessed by means of reproducibility (concordance correlation coefficient), precision (pearson ρ), accuracy (bias correction factor/cb), reliability (intraclass correlation coefficient), repeatability (coefficient of repeatability/cr) and systematic bias (bland-altmann plot: regression coefficient/rc). methods and materials: 40 patients (mean age 77 years, range 65-93) gave informed consent for this prospective research ethic committee-approved study and underwent two consecutive brain ct-scans, with normal radiation dose (nd) (ctdivol 57 mgy, 2.6 msv) and 30% reduced dose (rd). nd scans were reconstructed using filtered backprojection (fbp), while rd scans were reconstructed using fbp and two idose levels, id2 and id4. image quality was assessed with grading and ranking by six neuroradiologists. mean hounsfield units (hu) and noise were measured. data were analysed using linear mixed models, and the tukey method for multiple comparisons. results: for all reconstructions image quality was graded adequate for clinical use. image quality was graded good/excellent in 93% of cases for nd, 83% of cases for id4, 79% for id2, and 67% for rd. for all quality parameters id4 and id2 were graded better than rd (p < 0.0055 and p < 0.035) but worse than nd (p << 0.001). pooled ranking results were equivalent despite considerable variation in individual assessments. hu were identical between reconstructions. image noise was similar in nd, id2 and id4 but higher in rd. purpose: to determine whether mri susceptibility-weighted imaging can assist in discriminating between inflammatory pathologies and high-grade glioma. methods and materials: susceptibility-weighted imaging (swi) was performed at 3.0 t (siemens medical systems) and images were reviewed retrospectively in 17 patients with cerebral inflammatory pathologies and 25 patients with histologically proven high-grade gliomas. only gliomas without mr findings of haemorrhage on t1wi were included in the study. the morphological pattern of the susceptibility signal and the anatomic positional relationship between the contrast enhancement areas and susceptibility signals were retrospectively reviewed by consensus of 2 reviewers. the swi morphological pattern was scored as: patchy, nodular, dot-like or linear and designated as inside or outside the zone of contrast enhancement. results: in total, 17 clinically proven inflammatory diseases (7 parasitic granulomas, 3 inflammation-demyelinating and 7 neurovasculitis) and 23 lesions were reviewed. patchy, nodular, dot-like susceptibility were demonstrated in both inflammatory and neoplastic lesions, whereas linear susceptibility signals were only identified in the inflammatory diseases. nine of 23 (39%) susceptibility signals were situated outside the contrast enhancement areas in inflammatory pathologies with no susceptibility signals found outside the border of the contrast enhancement areas among all the high-grade gliomas. conclusion: on swi, linear susceptibility signal and/or susceptibility signal located outside the area of contrast enhancement was more frequently presented in inflammatory processes and not found with the high-grade gliomas. this finding may reflect a different pathophysiologic mechanism and distinction of bleeding/ microbleeding occurrence and presentation in inflammatory pathologies compared to high-grade gliomas. inter-session reproducibility of cerebral blood flow ( the morphology of s1-2 disc, l5 and s1 body and lumbar spinous processes were evaluated. the positions of aortic bifurcation (ab), right renal artery (rra), superior mesenteric artery (sma) and conus medullaris (cm) were described. comparing with wsl, the diagnostic error in numbering vertebral segments on lumbar mri was evaluated. in lumbarisation, all patients revealed a well-formed s1-2 disc with squared s1 body. a rhombus-shaped l5 body in sacralisation and a rectangular-shaped s1 body in lumbarisation were found. l3 had the longest spinous process. the most common sites of spinal and paraspinal structures were ab at l4 body (71.1%), rra at l1 body (53.6%) and l1-2 disc (34.1%), sma at l1 body (55.1%) and t12-l1 disc (31.6%), and cm at l1 body (44.8%). they were located higher in sacralisation and lower in lumbarisation. on lumbar mri, the diagnostic error in evaluation of vertebral segmentation was 14.1%. purpose: the presence of intravertebral gas in the lumbar and thoracic spine, usually secondary to trauma, is a well-recognised radiological phenomenon (kümmel's disease). however, intravertebral gas within a cervical vertebral body is a common but unknown process. we present a series of 27 patients with gas in the cervical vertebral bodies, not associated with traumatism. the aim of this study is to describe this radiological finding and its possible aetiology. methods and materials: our study group included 27 patients who underwent a routine neck ct examination for reasons not related with the cervical spine. all the patients presented air within a cervical vertebral body. we analysed several factors such as age, sex, location of the gas, history of radiotherapy, chemotherapy, the presence of degenerative disease, previous infections or corticosteroid therapy. results: the mean age was 67 years (age range 29-82), 21 men and 6 women. the main affected body was c6 (48%), followed by c5 (33%). most of the lesions were adjacent to the inferior endplate of the vertebral body. most subjects showed degenerative changes (96%), although none had gas within intervertebral discs. 34 % of the patients received radiotherapy. none of the patients had a history of trauma, infection or treatment with corticosteroids. the presence of gas within a cervical vertebral body seems to be a common but unknown process. this phenomenon could be related with cervical degenerative disease. further studies should be conducted to verify this hypothesis and to elucidate the nature of this finding. the study comprised of n=12 intracranial tumours, among these meningeomas (n=2), solitary metastasis (n=3), as well as who grade ii -iv tumours (n=7). compared to reference tissue, meningeomas were significantly stiffer. metastases were either slightly firmer or softer than reference tissue. who grade ii and iii tumours (n=4) were softer than white matter in all cases. the highest loss of tissue stiffness was represented by who grade iv tumours. viscoelasticity parameters were supplemented by a histopathology work-up. in summary, high who grade tumours were significantly softer than tumours of lower staging, the range of metastatic viscoelasticity was slightly higher than primary brain tumours. mre was well tolerated by all patients. conclusion: mr elastography of cerebral tumours at 3 tesla reliably quantifies tissue firmness for preoperative planning. according to our histology correlated preliminary results, tumour viscoelasticity may be an additional diagnostic parameter for non-invasive tumour differentiation. intra-and inter-scanner test-retest reliability of whole-brain arterial spin labeling perfusion mri b. wu, x. wu, x. lou, m. ge, l. ma; beijing/cn (646173826@qq.com) purpose: perfusion mri can be used to identify and monitor patients with acute ischaemic stroke. the objective of this study was to investigate whether it is possible to pool together whole brain arterial spin labelling (asl) perfusion imaging data at different times, or from different scanners, located at two different sites. eight healthy subjects were scanned on two different 3.0 t scanners with 3d pseudo-continuous labelling technique. scans were repeated intra-session and inter-session after 7-30 days. the asl data with two postlabelling delay time (pld) of 1.5 and 2.5 seconds were acquired. high-spatial-resolution whole brain t1-weighted images were also acquired for image registration and normalisation into a standardised space within the spm8. the cerebral blood flow (cbf) values of grey matter, white matter, frontal lobe, parietal lobe, occipital lobe, temporal lobe, putamen, posterior cingulate, and thalamus were extracted for comparison, using wfu pickatlas tool. the intra-and inter-scanner reliability was evaluated with the intraclass correlation coefficient (icc purpose: to quantify the changes of myocardial transverse relaxation times (δt2*) induced by hyperoxic respiratory challenge at different field strengths in an intraindividual comparison of healthy volunteers. methods and materials: blood oxygen level-dependent (bold) cardiovascular magnetic resonance (cmr) data were acquired in ten healthy volunteers (5 women; 5 men; median age 29 years, range 22-35 years) at 1.5 t and 3.0 t. medical air (21% o2), pure oxygen and carbogen (95% o2, 5%co2) were alternatively administered in a block-design temporal pattern to induce normoxia, hyperoxia and hyperoxic hypercapnia, respectively. parametrical t2* relaxation time maps were computed, average t2* values were derived from region-of-interest analysis by two independent and blinded readers in 16 standard myocardial segments on 3 short axis slices per patient. results: inter-and intra-reader correlations of t2* measurements were good (icc=0.75 and icc=0.79, both p < 0.001). under normoxia, the mean t2* values were 30.6+7.0 ms at 1.5 t and 27.6+7.6 ms at 3.0 t. both hyperoxic gases induced significant (p < 0.001) relaxation time increases δt2* (oxygen: 1.5 t, 3.5+5.9 ms; 3.0 t, 2.1+6.3 ms; carbogen: 1.5 t, 2.9+7.1 ms; 3.0 t, 4.3+7.6sm). as opposed to 1.5 t, the magnitude of δt2* response was higher at 3.0 t and under carbogen as compared with oxygen breathing (p < 0.01). the myocardial δt2* response to hyperoxic respiratory challenge can reliably be quantified with bold cmr. the magnitude t2* increases significantly with a higher field strength as well as with carbogen as compared to oxygen breathing. future studies are warranted to investigate the potential diagnostic role of bold response in assessing patients with coronary cardiomyopathy. we retrospectively reviewed the imaging features and enhancement pattern of the selectively involved white matter tracts in sixteen (16) genetically proven cases of leukodystrophy with brainstem and spinal cord involvement and elevated brain lactate (lbsl). all patients were presented with slow progressive cerebellar sensory ataxia with spasticity and dorsal column dysfunction. mri of the brain and spine and mrs of the brain were done to all patients. results: in all cases, mri showed signal abnormalities in the sensory and pyramidal white matter tracts in addition to inhomogeneous signal abnormalities in the periventricular and deep white matter, brain stem, cerebellar connections and dorsal columns of the spinal cord. the subcortical u fibres were spared in all cases. proton mrs showed consistent elevation of the lactate within the abnormal white matter. in eleven cases, diffusion restriction was found in most of the length of the corticospinal and sensory tracts in addition to involvement of the superior and inferior cerebellar peduncles and the mesencephalic trigeminal tracts. these parts of the white matter tracts also displayed heterogeneous enhancement after gadolinium administration. purpose: the purpose of this study was to evaluate the role of dti in assessing cervical spondylotic myelopathy (csm). we prospectively evaluated 65 patients with symptomatic csm. the joa (japanese orthopedic association) myelopathy score was used to assess the clinical situation, dividing patients into groups with minimum myelopathy (mim), moderate myelopathy (mom) and severe myelopathy (sem). all patients underwent examination on a 3.0 t mri scanner (verio, siemens). dti of the spinal cord was performed in 30 directions (b-value of 0 and 900). fractional anisotropy (fa), apparent diffusion coefficients (adc), eigenvalues (e1, e2.3) were measured. results: mean patient age was 58. 8 y/-12, 2 sd. according to the joa classification, 33 patients were classified into the mim group and 29 into the mom and 3 into the sem group. significant differences were seen in adc (0.9±0.2 vs 1.1±0.2) values and fa (0.7±0.1 vs 0.5±0.1) when comparing normal with pathological levels as well as in e1 (1.9±0.4 vs 2.3±0.4) and e2.3 (0.37±0.24 vs 0.5 ± 0.29), respectively. significant elevation of adc and reduction of fa was seen in absolute vertebrostenotic segments. significant elevation of e1 and e2.3 were seen in vertebrostenotic segments compared with normal. conclusion: our results suggest a high sensitivity of dti metrics in the assessment of csm. significant increases in longitudinal and transverse diffusion were seen in our results which might represent a novel biomarker of csm. molli was performed at a mid-ventricular slice location pre-and 4-20 min (2 min intervals) post-contrast administration. t1 values of the blood pool and the myocardium were measured for each time point and ecv assessment was based on myocardial δr1 assessment (pre and post) in relation to δr1 blood pool and incorporation of the haematocrit. results: while pre-contrast t1 values were similar (p=0.3), post-contrast t1 values were significantly shorter at any measured time point post-injection after gadobutrol application (p < 0.047). myocardial ecv data though calculated for both agents did not show significant differences (p> 0.21). in addition, ecv data related to both agents did not show any significant differences over the assessed time course of 4-20 min p.i. (p> 0.14, gadobutrol; p> 0.09, gadoterate meglumine). conclusion: gadobutrol leads to a significantly higher shortening of myocardial t1 values as compared to gadoterate meglumine. the ecv assessment which is independent of the ca properties can be adequately evaluated as early as 4 min p.i. in normal myocardium. purpose: existence of vortical blood flow in the main pulmonary artery as diagnostic criterion for diagnosis of pulmonary hypertension was analysed in 3-dimensional (3d) vector field and streamline representations. methods and materials: 50 subjects with known or suspected pulmonary hypertension (23 patients with and 27 without pulmonary hypertension, age 58±13 years) underwent right heart catheterisation and time-resolved, 3d phase contrast imaging of the main pulmonary artery. blood flow patterns were visualised as 3d velocity vector fields projected on 2-dimensional anatomical images (3d-vectors) and as 3d streamlines using 4d-flow software (siemens). relative period of existence of vortical blood flow within the cardiac cycle (tvortex) was evaluated. comparison of methods for using tvortex as diagnostic criterion for pulmonary hypertension was performed by receiver operating characteristic analysis. results: areas under the curve for diagnosis of pulmonary hypertension did not differ significantly (p=0.30) and were 0.998 (95%-confidence interval 0.983 to 1.000) in case 3d-vector vortex detection and 0.991 (95%-confidence interval 0.948 to 0.999) in case of streamline vortex detection. the optimal tvortex cut-off value maximising sum of sensitivity and specificity was tvortex=0.15 for both visualisations. resulting 95%-confidence intervals for sensitivity and specificity were 0.86 to 1.00 and 0.82 to 0.99 in case 3d-vector vortex detection and 0.79 to 0.99 and 0.82 to 0.99 in case 3d streamline vortex detection. conclusion: main pulmonary artery blood flow patterns provide an accurate tool for the diagnosis of pulmonary hypertension with the optimal tvortex cut-off value 0.15. s35 a c d e f g b conclusion: using mbir significantly reduced the need for vessel-wall boundary corrections compared to other reconstruction algorithms, particularly at the side of calcifications. thus, mbir improves the feasibility of automated plaque assessment in ccta and potentially its clinical applicability. calcium score of small coronary calcifications on multi detector computed tomography: a phantom study j.m. groen 1 , k.f. kofoed 2 , m. zacho 2 , r. vliegenthart 1 , t.p. willems 1 , m.j.w. greuter 1 ; 1 groningen/nl, 2 copenhagen/dk (m.j.w.greuter@umcg.nl) purpose: to assess the feasibility of a new phantom which enables establishment of a calcium scoring protocol for multidetector computed tomography (mdct) that yields calcium scores comparable to electron beam tomography (ebt) values and to physical mass. methods and materials: a phantom containing 100 small calcifications ranging 0.5-2.0 mm was scanned on ebt using a standard coronary calcium protocol, and on a 320-row mdct scanner using different scanning, reconstruction and scoring parameters (tube voltage 80-135 kv, slice thickness 0.5-3.0 mm, reconstruction kernel fc11-fc15 and scoring threshold 110-150 hu). the agatston and mass score were compared and the influence of the parameters was assessed. results: on ebt, the agatston and mass scores were 0-20, and 0-3 mg, respectively. on mdct, the agatston and mass scores were 0-20, and 0-4 mg, respectively. the agatston score on mdct differed 52% between 80 and 135 kv, 65% between 0.5 and 3.0 mm and 48% between fc11 and fc15. more calcifications were detected with a lower tube voltage, a smaller slice thickness, a sharper kernel and a lower threshold. an acquisition protocol with 100 kv and two reconstructions protocols could be defined. this protocol yielded agatston scores as close to ebt as possible, as well as mass scores as close to physical mass as possible. purpose: τo report 1-year results of a prospective randomised controlled trial investigating angioplasty with paclitaxel-coated balloons (pcb) versus plain balloon angioplasty for the treatment of failing arteriovenous dialysis access either a fistula (avf) or a graft (avg). this was a non-inferiority hypothesis trial registered in clinicaltrials.gov (nct01174472). enrollment criteria included an angiographic and clinical diagnosis of dysfunctional dialysis access due to at least one stenotic lesion in patients with avf or avg circuits. forty patients were randomised to undergo either pcb dilatation (n=20) or standard pta (n=20) of a venous outflow stenotic lesion. regular angiographic follow-up was scheduled every 2 months. study primary endpoints included technical success (defined as residual stenosis of the treated lesion > 30% without any significant dissection) and 1-year primary patency of the treated site (defined as angiographic visualisation of a patent lesion with < 50% restenosis and no need for any additional repeat procedure within the previously treated lesion due to failing access). results: baseline variables were comparably distributed among the two groups. technical success was 100% for both groups. additional post-dilation with a highpressure balloon was necessary in 11/20 (55%) of the pcb-treated cases. at 1 year, cumulative target lesion primary patency was significantly higher after pcb application (35% in pcb group versus 5% in pba group, p < 0.001, hr (95%ci) = 0.27 (0.13-0.58)). conclusion: pcb angioplasty might have a place in our quiver for the treatment of stenotic venous outflow lesions of failing dialysis access. for better trade-off of high temporal resolution, less noise and streak artefacts. this is combined with an automatic segmentation and suppression of catheter-induced streaks. this preliminary study included 5 in vivo porcine models. images were evaluated by experienced cardiologists with respect to noise, temporal resolution and artefact susceptibility. results: an enhancement of temporal resolution was shown by a decreased fullwidth at half maximum of catheter cross sections using sr 4d-fd-ct as compared to static reconstructions. motion-map-processing of individual phases increased the contrast-to-noise ratio for each heart phase, e.g. in the left ventricle by an average of 30%. visual impression confirmed a significant streak reduction. conclusion: first results show the potential of sr 4d-fd-ct for pragmatic 4dinterventional imaging. sr 4d-fd-ct allows for dynamic segmentation of cardiac chambers and valves. purpose: for quantitative measurement of left ventricular myocardial perfusion, stability of hu-values in dynamic ct-scans is essential. a phantom study is used to evaluate this stability over slices and time using the philips ict256-slice scanner. methods and materials: seven time series of ct-images with 11 slices (5 mm) over 30 seconds of a catphan phantom were acquired using the ict256 at 100 kvp/100 mas. six different regions of interest (roi) were placed into the water regions of the phantom for all slices and time steps. five rois were arranged in a star-like pattern in order to enable evaluation of intra slice variability. one roi covered the entire water-region. stability over time and slices as well as within each slice was statistically examined. the absolute difference in the mean values of the entire water roi in all seven phantom studies was maximum 5.4 hu. the examination of the inter-slice variability revealed a drift of maximal 0.057 hu/slice. over time, a maximal drift of 0.043 hu/s could be observed. the maximum intra-slice difference of the mean values was at 7 hu. this slightly higher value is due to beam hardening artefacts in the rois close to the high-density /bone simulating/ structure in the phantom. purpose: to evaluate the impact of iterative image reconstruction algorithms including adaptive statistical (asir) and model based (mbir) on the feasibility of automated plaque assessment in coronary computed tomography angiography (ccta) as compared to filtered-back-projection (fbp) reconstructed algorithm. methods and materials: three ex-vivo human hearts were imaged by ccta and reconstructed with fbp, asir and mbir. an automated plaque quantification software (vitrea cardiac solutions, mn) was applied for each of the algorithms to fit the outer and inner vessel-wall boundaries. each coronary cross section, in which the automated software detected wrongly the boundaries, was corrected in a random and blinded fashion. the percentages of corrections were compared between the reconstruction algorithms using chi-square-test. results: a total of 2295 ccta cross sections with 0.5 mm increments were assessed which equals to 765 co-registered triplets (fbp/asir/mbir). any boundary corrections were performed in a total of 712 cross sections (31.0%), including outer (n=400) and inner (n=381) vessel-wall. the percentage of corrected cross sections was lower for mbir (24.1%) as compared to asir (32.4%, p=0.0003) and fbp (36.6%, p < 0.0001), and marginal between asir and fbp (p=0.09). regional agreement of performed corrections existed between reconstruction algorithms (kappa=0.53). the benefit of mbir above fbp was associated to the presence of moderate and severe calcification (or: 2.9 and 5.7, p < 0.0001, respectively). were reviewed to classify arterial involvement according to: 1) tasc ii, 2) graziani's morphological classification, 3) joint vascular society council calf and foot scores. clinical results (healing, non-healing, major amputation) were compared to baseline clinical data and angiographic results. results: 202 percutaneous procedures were performed; the immediate technical success rate was 93.6%. preprocedurally, the mean±sd calf and foot scores were 7.8±1.6 and 7.3±2.3, respectively; 132 patients (65.3%) were in graziani's morphological classes 4 to 7; in 112 (55.4%) cases tasc ii was inapplicable, for the absence of femoro-popliteal lesions. post-procedurally, mean calf and foot scores were 4.8±2.3 and 5.9±2.6, respectively, and 86.6% of cases were into the graziani's classes 1 and 2, whereas tasc ii was inapplicable in all cases. healing and major amputation rates were 66.8% and 3.9%, respectively; only pre-and post-procedural foot scores were significantly associated with the clinical outcome (p <.05). conclusion: endoluminal revascularization represents a valuable treatment option in diabetic patients with cli. in this population, tasc ii is inadequate to describe peripheral arterial involvement. pre-and post-procedural foot scores represent the most significant angiographic parameter to evaluate treatment success, thus aggressive treatment of foot arteries should be attempted whenever possible. 12 months results of a randomised trial comparing mono-or dual-antiplatelet therapy in interventionally treated patients with peripheral arterial disease f.f. strobl 1 , j. schmehl 2 , k. brechtel 2 , t. zeller 3 , c.d. claussen 2 , g. purpose: in this trial, peri-and postinterventional dual antiplatelet therapy significantly reduced rate of target lesion revascularisation after 6 months. it is not known whether this effect persists after stopping clopidogrel. thus, we conducted an additional follow-up after 12 months. in this double-blinded, randomised trial, we enrolled 80 patients who were treated with pta or stenting in the upper leg. 40 patients received pre-and postinterventional dual therapy with aspirin and clopidogrel. the other 40 patients received same doses of aspirin and placebo instead of clopidogrel. clopidogrel/placebo was stopped after 6 months and patients remained on aspirin only. tlr and mortality rate were reevaluated 12 months after the intervention. results: we initially enrolled 80 patients (42 male, 70±10y), 40 in each group in the study. 12 months after the intervention, 36 clopidogrel and 37 placebo patients could be reevaluated. at 6 months, clopidogrel patients had significantly lower rates of tlr compared to placebo patients: 2 (5%) vs.8 (20%), p=0.04. after stopping clopidogrel/placebo, there was no more significant difference in tlr 12 months after study inclusion with 9 (25%) clopidogrel vs.12 (32.4%) placebo patients (p=0.35). mortality was 0 vs. 1 at 6 months (p=0.32) and 0 vs. 3 at 12 months (p=0.08). conclusion: in contrast to the first follow-up 6 months after the intervention according reduction of tlr, this advantage of dual antiplatelet therapy does not persist after stopping clopidogrel. prolonged dual therapy (> 6 months) should be evaluated and considered in patients with high risk for restenosis. comparing 2d angiography, 3d rotational angiography, and preprocedural ct image fusion with 2d fluoroscopy for endovascular repair of thoraco-abdominal aortic aneurysm v. tacher 1 , m. lin 2 , p. desgranges 1 , t. grünhagen 3 , a. luciani 1 , j.-p. becquemin 1 , j.-f. deux 1 , a. rahmouni 1 ; 1 creteil/fr, 2 briarcliff manor, ny/us, 3 best/nl purpose: to evaluate the feasibility of pre-procedural arterial phase computed tomography image fusion with intra-procedural fluoroscopy (or image fusion: if) road-mapping in endovascular repair of thoraco-abdominal aortic aneurysm (evr-taaa) compared to current road-mapping methods (2d and 3d angiographies) in terms of x-ray exposure, injected contrast volume, and procedure time. methods and materials: single-institution prospective study (internal institute approved), on 37 patients, informed written consent provided, and treated for evrtaaa. all interventions were performed on the same angiographic system. patients were consecutively placed in three groups in a seven-month period: "2d angiography" (2da) (9 patients), "3d rotational angiography" (3da) (14 patients) and "image fusion" (if) (14 patients). injected contrast volume, x-ray exposure (dose-area-product: dap) and procedure time were recorded. to compare the groups in terms of the above measures and general patient characteristics, statistical tests using fisher's exact, kruskal-wallis and mann-whitney were performed. results: patient characteristics and stenting types were similar between all three groups with no statistically significant differences (p-value> 0.05). the if lower limb multilevel treatment with drug eluting balloon: 12-month results from the "debellum" trial f. fanelli, a. cannavale, p. lucatelli, a. wlderk, c. cirelli, f.m. salvatori; rome/it (fabrizio.fanelli@uniroma1.it) purpose: to report 12-month results of the "debellum"-drug-eluting balloon evaluation for lower limb multilevel treatment-trial performed to evaluate the efficacy of drug-eluting balloon-deb versus conventional balloon catheter-ncb in the treatment of peripheral arterial disease. methods and materials: fifty consecutive patients (mean age 67±21 years) with symptomatic peripheral arterial disease were randomised between deb (25 patients-57 lesions) (inpact®-medtronic) and ncb (25 patients-65 lesions). inclusion criteria were native single or multiple stenosis or occlusion (mean lesion length 7.5 ± 3.5 cm) in the femoro-popliteal or below the knee (btk) regions. dilatation was performed in each group either for native lesions (26 deb; 30 ncb) or post-stent implantation (31 deb; 35 ncb). primary end points were late lumen loss (lll) at 6 and 12 months. secondary end-points were target lesion revascularisation (tlr), amputation and thrombosis rate. results: one-hundred-twenty-two lesions were treated: 75.4% in the femoropopliteal area; 24.6% btk; 21.3% total occlusions. lll was 0.5±1.4 mm (deb) vs. 1.6±0.7 mm (ncb) (p < 0.01) at 6 months and 0.64±0.9 mm (deb) vs. purpose: this study aimed at assessing retrospectively the middle-term clinical outcome of the femoropopliteal chronic total occlusion (ctos) treatment by means of directional atherectomy (da). methods and materials: between january 2008 and march 2012, 47 patients (51 limbs, patient age 70±10 years) were included in the study with mean follow-up of 20 months (6-51). 51 femoro-popliteal cto in 47 patients with severe intermittent claudication (n=15; 49.4%) or critical limb ischaemia (cli) (n=16; 51.6%) were treated with silverhawk or turbohawk atherectomy followed by angioplasty in 10 (32.2%) cases. clinical and uscd follow-up was set at 3, 6 and 12 months and yearly thereafter. immediate technical success, disease-free patient survival and target lesion revascularisation (tlr) rates were assessed with kaplan-meier analysis. results: technical success rate was 98% with a lesion length of 80±56 mm. limbsalvage and survival rates were 87.5 and 90.3% at 2 years, respectively. at 6, 12 and 24 months disease-free patient survival was 88.7, 79.9 and 64.6%. whereas adjunctive pta was performed in 32% cases to improve the angiographic result, 12% required an associated tibial vessel treatment. no perioperative mortality was observed. one complication (2%) occurred. conclusion: percutaneous directional atherectomy is a safe and effective technique in lower limb revascularisation. preliminary results supported by short-mid term data encourage use of da with silverhawk and turbohawk catheter in the femoro-popliteal obstructive lesions also in traditionally "forbidden districts". longterm data are missing. predictive value of angiographic scores for the integrated management of the ischaemic diabetic foot purpose: treatment of lumbar artery fed type 2 endoleaks (laft2e) after abdominal endovascular aneurysm repair (aevar) exhibits high failure and recurrency rates. we report our preliminary results of ct-guided direct sac puncture, followed by embolisation with the liquid embolic agent ethylene vinyl alcohol copolymer (onyx®). methods and materials: 17 male patients (mean age 76 ±6 yrs) with laft2e were included after failure of conservative treatment. all received ct guided direct sac puncture under local anaesthesia, followed by ct fluoroscopic embolisation with onyx 34® or 20®. follow-up examination included contrast-enhanced ultrasound (ceus) and dual-phase ct angiography every 6 months for at least 2 years (ongoing). results: technical success was achieved in all cases, requiring dual puncture of the aneurysm sac in 8 cases (47.1%). average duration of the procedure was 60 ± 12 min. in mean 7.5 ml of onyx 34® were used per procedure. in 6 cases onyx 20® was additionally used for complete filling of the endoleak. repeat intervention was necessary in 3 cases (17.3%) due to new endoleak development in the follow-up period of 12 ± 8 months. the procedure failed permanently in 1 case. complications such as major bleeding, spinal ischaemia or non-target embolisations were not observed. conclusion: completely ct-guided treatment of laft2e is a feasible and safe treatment alternative. difficulties lay in the determination of the necessary amount of onyx and the end point of the intervention. several punctures as well as repeat intervention might be necessary to achieve permanent endoleak occlusion. purpose: treatment of type 1 endoleaks after endovascular aneurysm repair (evar) can be challenging. we describe a technique for direct embolisation with the liquid embolic agent ethylene vinyl alcohol copolymer onyx by direct catheter access to the endoleak, and present first results. methods and materials: 18 patients (16 male, 2 female, mean age 72 +-7 yrs) with a type 1a (n = 13) or a type 1b (n = 5) endoleak were treated. in 13 cases, it was applied as stand-alone procedure, and in 5 cases in combination with stent graft extension. access was trans-brachial for type 1a endoleaks, and trans-inguinal for type 1b endoleaks. a multi-purpose catheter was placed between the aortic wall and the stent graft to access the endoleak, followed by coaxial introduction of a dimethyl sulfoxide (dmso) compatible micro-catheter into the endoleak, and consecutive onyx embolisation. results: technical success was achieved in all cases. a mean volume of 11 ml +-5 ml of onyx 34 was used. in 5 cases, additional coils were used as an anchor for onyx. 1 patient developed reperfusion of the endoleak during follow-up of 12 +-8 months, which was successfully treated with the same technique. non-target embolisation, catheter encasement, or anaphylactic reactions to dmso were not observed. the described technique is feasible, safe, and effective for treatment of type 1a and 1b endoleaks with excellent technical success rates, and low relapse rates. it can be used as stand-alone procedure or easily be combined with stent graft extension. conclusion: image fusion road-mapping for evrtaaa is feasible and is associated to a statistically significant reduction in contrast volume and a trend towards dap reduction while maintaining similar procedure time. the medium term follow-up was 24 months. cross-tabulations were checked with chi-squared test, or by fisher's exact test. survivorships were analysed by kaplan-meyer product limit method and by cox semiparametric regression. results: technical success was achieved in 98.7%. 14/77 presented endoleaks during the follow-up (type 1=7, type 2=6 and type 3=1). during the follow-up there were 7 mortalities, mean time 19.82 months (range 3-48). in survival rates there was no difference between hybrid procedures group (p=0.3387) and elective or emergency group (p=0.3608). there was a statistical difference on survival between the group that had endoleaks during the follow-up (p=0.0093) and who had had necessity of a second endovascular interventional (p=0.0184). statistical difference on survival was also seen between patients who developed type 1 and 2 endoleaks (p=0.0336). conclusion: tevar is a safe and effective treatment. the presence of endoleak, special type 1 and the necessity of a second endovascular intervention reduces significantly the survival. selective coverage of the left subclavian artery without recanalization in patients with patent vertebro-vertebral arterial communications during tevar: a single centre study m. lee; seoul/kr (eterna0@yuhs.ac) purpose: to evaluate the safety and effectiveness of selective coverage of the left subclavian artery (lsca) without recanalization during tevar in patients with patent vertebro-vertebral arterial communications and to assess morphologic change of the vertebral artery (va) after the procedure. methods and materials: among 126 patients who underwent tevar, 29 patients requiring lsca coverage without pre-emptive recanalization were retrospectively analysed. the patients' ages ranged from 45 to 84 years. vertebro-vertebral arterial communications in all patients were evaluated by contrast-enhanced computed tomography (cect), time-of flight magnetic resonance angiography, or conventional angiography. neurologic complications such as spinal cord ischaemia (sci) or cerebrovascular accidents (cva) were analysed. pre-and post-procedural changes in vas were evaluated on follow-up cect. the overall 30-day mortality was 6.9% (2/29). none of the patients had an sci or stroke of posterior circulation alone. cva from embolic infarctions occurred in two patients (7.4%). transient left arm ischaemic symptoms were present in 5 patients (18.5%), but none required secondary interventions. delayed development of type i endoleak occurred due to stent deformity in one patient, who underwent surgery. one patient required re-intervention after a pseudoaneurysm developed at the distal margin of the previously placed stent-graft at ten-month follow-up cect. hypertrophy of the right va after tevar was seen in 7 of 27 patients (25.9%); two patients showed bilateral hypertrophy of vas. conclusion: lsca coverage without recanalization can be safely performed during tevar in patients with patent vertebro-vertebral communications. hypertrophy of the right va was noted in 25.9% of patients after lsca coverage. purpose: double-bundle reconstruction with stump preservation has revolutionised the surgical treatment for anterior cruciate ligament (acl) injury. however, poor revascularization at the osteoligamentous interface (oi) of the tibia tunnel remains a major cause of graft complications. in this study, we applied dynamic contrastenhanced (ce) magnetic resonance imaging (mri) to quantify the oi enhancement values of the tibia tunnels and acl stump. we aimed to determine the relationship between graft complications and oi and stump enhancements. methods and materials: from october 2011 to april 2012, 34 patients were enrolled in our study (mean postoperative duration, 7.3 months). all patients underwent one 1.5-t mri study with the imaging pulse-sequence protocol of proton density-weighted imaging (wi), t2wi, pre-enhanced and post-enhanced t1wi, and dynamic ce mri. graft complications, including cystic degeneration and tear, were evaluated using pre-enhanced mri, and peak enhancement (epeak) values were acquired from a dynamic ce study. the receiver operating characteristic (roc) analysis was used to obtain optimal cut-off values for complicated grafts. results: our study included 28 patients (mean age, 25.5 years). nine patients (32.1%) had cystic degeneration and 1 (3.6%) had complete posterolateral (pl) bundle tear. mean epeak percentages for graft with or without complications were 84.19%/127.69% for anterior--medial (am) bundle, 107.54%/128.21% for pl bundle, and 171%/151.06% for stump, respectively. roc analysis yielded the optimal epeak cut-off values of 126%, 104%, and 35% for am bundle, pl bundle, and stump, respectively. conclusion: graft complications were directly associated with higher tibial oi values but inversely associated with higher stump values. purpose: to test if the posterior cruciate ligament (pcl) index is predictive of rotational knee kinematics during pivoting activities and anterior tibial translation (att) in patients after anatomic single-bundle (sb) anterior cruciate ligament reconstruction (aclr). sixteen patients with sb-aclr were prospectively evaluated with 3d-motion analysis during (1) descending and pivoting, and (2) landing and pivoting. the side-to-side difference of tibial rotation range of motion (ssdtr) between the aclr and the contralateral intact knee was calculated. att ssd was measured with a kt-1000 arthrometer. mri was used to measure the pcl index for the study group and a control group. linear regression models were used with pcl index as predictor of ssdtr for each task and side to side anterior translation differences. unpaired sample t-test was used to compare pcl index group means between the study and control group. the level of significance was set at α=0.05. results: pcl index of the aclr knee was significantly lower compared to the healthy control knee (p < 0.001). the pcl index was predictive of low ssdtr during pivoting after descending and landing tasks (r2=0.472, p=0.003 and r2=0.477, p=0.003 respectively). pcl index was not predictive of att with 134 n or maximum manual force (r2=0.13, p=0.17 and r2=0.009, p=0.726 respectively). the pcl index after anatomic sb aclr is predictive of rotational kinematics during dynamic pivoting activities. these results suggest that after anatomical aclr the pcl index can serve as an indicator of tibial-femoral position and may predict dynamic tibial rotation. microstructural evaluation of the cruciate ligaments with mr diffusion tensor imaging (dti): correlations with knee stability l. di clemente 1 , d. tortora 1 , v. panara 1 , m. savastano 1 , v. calvisi 2 , p. palumbo 2 , a. tartaro 1 , a.r. cotroneo 1 , m. caulo 1 ; 1 chieti/it, 2 l'aquila/ it (lorisdiclemente@gmail.com) purpose: the evaluation of knee stability is currently based on tibio-femoral sagittal plane motion measurement as evaluated using the kt-1000 arthrometer. conventional mri cannot evaluate knee stability. the aim of the study was to assess the use of mr-diffusion tensor imaging (dti) as a tool for a microstructural examination of the anterior and posterior cruciate ligaments and to correlate dti finding with clinically evaluated stability. methods and materials: 11 subjects (6 females) without previous history of knee injuries underwent mri using conventional and dti sequences. fractional anisotropy (fa) values were calculated in each anterior and posterior cruciate ligament within 3 different rois placed in the lower, middle and upper portion of the ligaments. knee stability was assessed using kt-1000 arthrometer in 4 progressive active displacements: 15 lbs, 20 lbs, manual maximum displacement and under quadricipital muscle contraction. statistical analysis was performed using independent t-test and kendall tau rank correlation test, where appropriate (p < 0.05). results: fas of the acl (mean: 0.573±0.047) were significantly lower compared with the pcl (mean: 0.676±0.046) (p < 0.001), whereas no side differences were noted. a significant negative correlation between fa and kt-1000 arthrometer values at 15 lbs was present in the pcl (r=-0.341; p=0.029). no correlations were observed between the fa and kt-1000 values in the acl. conclusion: functional assessment of the microstructural organisation of the cruciate ligaments with dti expands mri applications beyond simple morphological studies and could help bridge the gap between imaging and clinical evaluation of knee stability. the schatzker classification for tibial plateau fractures and the amount of articular depression were assessed using mdct. magnetic resonance images were evaluated for crucial and collateral ligament injury, meniscal tears and patellar retinaculum lesions. statistics included logistic regression and analysis of covariance. results: associated soft-tissue injuries were identified in 82% of the patients. logistic regressions revealed a significant impact of increasing amounts of tibial plateau fracture depression on the incidence of meniscus lateralis tears (p = 0.025) and lesions of the anterior cruciate ligament (p = 0.018). analysis of covariance demonstrated a significant correlation between the amount of articular depression and the absolute number of soft-tissue injuries (p = 0.001). conclusion: articular depression is a potential predictor of specific meniscal and ligamentous injuries in acute tibial plateau fracture. due to the high incidence of associated soft-tissue lesions, magnetic resonance imaging is generally recommended, especially in cases with distinct tibial plateau fracture depression at mdct imaging. anatomical risk factors in patients after patellar dislocation: a casecontrol study using mri t. köhlitz, s. scheffler, t. jung, e. wiener, b. vollnberg, g. diederichs; berlin/ de (bernd.vollnberg@charite.de) purpose: to assess anatomical risk factors in patients after lateral patellar dislocation (lpd) and controls using mri. methods and materials: mr images of 186 knees after lpd and of 186 age-and gender-matched controls were analysed. the presence of trochlear dysplasia was assessed by evaluation of trochlear inclination, facet asymmetry, and trochlear depth; patella alta was evaluated by insall-salvati-index and caton-deschampsindex; and lateralized force vector was measured by the tibial tuberosity-trochlear groove (tt-tg) distance. results: compared with controls, dislocators had significantly lower values for all three parameters of trochlear dysplasia (-32%, -32%, -44%) and significantly higher values for patella alta (+14%, +13%) and tt-tg (+49%) (all p < 0.001). trochlear dysplasia was observed in 112 dislocators (66%), of whom 61 (36%) additionally had patella alta and 15 (9%) an abnormal tt-tg. as isolated risk factors, patella alta (15%) and abnormal tt-tg (1%) were rare. only 25 dislocators (15%) had no anatomical risk factor. trochlear dysplasia in conjunction with abnormal tt-tg or patella alta is associated with a 37-fold and 41-fold higher risk. conclusion: most dislocators have anatomical risk factors, varying in severity and constellation. trochlear dysplasia is the main risk factor for lpd, while patellar alta and abnormal tibial tuberosity-trochlear groove distance may be additional factors. patient-specific evaluation of risk factors following lpd may help future management. early changes of trabecular bone structure in asymptomatic subjects with knee malalignment t. baum, j. penzel, m. sauerschnig, e.j. rummeny, k. wörtler, j.s. bauer; munich/ de (thbaum@gmx.de) purpose: knee malalignment is a risk factor for knee osteoarthritis (oa). the purpose of this study was to investigate whether alterations of trabecular bone structure can already be found in young, asymptomatic subjects with knee malalignment. methods and materials: forty-eight asymptomatic subjects (25 females, 23 males; age: 26±2years) without history of knee injury or surgery were included in this study. based on mr measurements, knee joint alignment of both lower extremities was assessed and subjects were divided into four groups (each including 12 subjects, i.e. 24 knees): neutral (up to 1° varus/valgus), mild varus (2°-4°), severe varus (greater 4°), and valgus (2°-4°). a t1-weighted 3d-flash sequence (spatial resolution: 0.25x0.25x1.2 mm³) was obtained of each knee at 1.5 t to determine histomorphometric and texture parameters of the trabecular bone in the medial/ lateral femur/tibia (mf,lf,mt,lt). the calculated parameters were compared between the four groups in each compartment using anova including bonferroni correction for multiple comparisons. purpose: we performed a randomised, double blinded, placebo controlled study to assess the effectiveness of lllt in patients with knee pain related to meniscal pathology. the study trial number is isrctn24203769. we only included symptomatic patients with tiny focus of grade 3 attenuation (seen only on 0.7 thickness sequences) or intrasubstance tears with spot of grade 3 signal intensity approaching the articular surface. none of the patients in the study group underwent arthroscopy or new mri investigation. a paired samples t-test was used to detect significant changes in subjective knee pain over the experimental period within groups, and anova was used to detect any significant differences between the two groups. results: pain was significantly improved for the lllt group than for the placebo group (f=154, p < 0.0001). pain scores were significantly better after lllt. four (12.5%) patients did not respond to lllt. at baseline, the average lysholm score was 77 ± 4.6 for the lllt group, and 77.2 ± 2.6 for the placebo group [p> 0.05]. four weeks after lllt or placebo therapy, the laser group reported an average lysholm score of 82.5 ± 4.6, the placebo group scored 79.0 ± 1.9. at 6 months, the laser group had an average lysholm score of 82.2 ± 5.7, an after one year they scored 81.6 ± 6.6 (f=14.82923, p=0.002). treatment with lllt was associated with a significant decrease of symptoms compared to placebo. in patients with small meniscal tears who do not wish to undergo surgery, lllt should be considered as a non-invasive alternative. is not clear, i.e. whether meniscal injury leads to cartilage degeneration or vice versa. therefore, we aimed to evaluate the impact of meniscal tears on adjacent, morphologically intact knee cartilage using t2 relaxation time, a sensitive biomarker for early cartilage degeneration, and compare with healthy controls. methods and materials: sixty-nine subjects without evidence of oa were recruited from the osteoarthritis initiative. thirty-five subjects (26-women) with a normal medial meniscus were used as controls (age 61±8, bmi 27±5). thirty-four subjects (20-women) had either a simple (non-displaced tear; n=19, age 61±9, bmi 28±5) or complex tear (displaced tear; n=15, age 60±9, bmi 29±5) of the posterior horn of the medial meniscus. none of the tear-subjects had morphological lesions of the medial tibio-femoral cartilage. t2-measurements were performed in the whole medial tibia (mt) and the medial femur compartments (mf), and in tibio-femoral subregions adjacent to the torn meniscus (smt & smf). multiple linear-regression models were used to compare mean t2-values of individuals with meniscal tears with normal controls. purpose: patients with good or complete response after neoadjuvant chemoradiation have excellent long-term outcome. minimal invasive treatment (i.e. transanal endoscopic microsurgery (tem) and wait-and-see policy) are increasingly considered as an alternative to major surgery. with this prospective cohort study we aimed to evaluate long-term outcome of strictly mr-based selected patients who have been treated with minimal invasive treatment. methods and materials: eight weeks after chemoradiation, endoscopy and restaging mri were performed (including diffusion-weighted mri for yt-staging and gadofosveset-enhanced mri for yn-staging). complete responders were selected for wait-and-see policy and good responders with small tumour remnant for tem. both treatment groups underwent intensive 3-to-6 monthly follow-up, using mr imaging (dwi+gadofosveset), cea, ct of thorax and abdomen and endoscopy was performed. long-term outcome was estimated with kaplan-meier curves. results: forty-one patients were included, thirty-three in the wait-and-see group and eight in the tem-group. mean follow-up was 26 months (range 6-91). for the tem-group, 4 patients had ypt0 and 4 had ypt2. two patients, both in the wait-and-see group, developed a local recurrence within two years and underwent surgery, leading to a 2-year local recurrence rate of 9%. both recurrences were detected on (dwi-)mri in an early stage. the cumulative probabilities of 2-year disease-free survival and overall survival were 93% and 100%, respectively. no recurrences occurred in the tem-group. conclusion: both selection and follow-up of good and complete responders after chemoradiation for rectal cancer with mri is feasible. long-term outcome so far is excellent. (dwi-)mri seems to be a reliable tool for early recurrence detection. diffusion-weighted-based volumetry in the assessment of response in patients with rectal cancer treated with neo-adjuvant therapy: feasibility study s.f. carbone, m. palumbo, v. ricci, l. pelliccia, e. cacchiarelli, l. volterrani; siena/it (fracarb@gmail.com) purpose: to establish the reproducibility of volumetric magnetic resonance diffusion (vdwi) and compare it with the conventional volume (vc) in the assessment of response in patients with rectal cancer treated with chemoradiotherapy (crt). we retrospectively examined 21 patients (mean age 68.9 years) with rectal cancer who have performed mri before and after 45 ± 15 days of the crt after undergoing anterior resection of the rectum. after surgery, yptn and trg (tumour regression grading) according to mandard classification were obtained. we considered patients with trg 1-2 responder and non-responder patients with trg 3-5. two radiologists, blinded, have extrapolated the volume vc and vdwi lesions pre-and post-crt. the inter-observer agreement and the agreement between vc and vdwi pre-and post-crt were calculated by intraclasscorrelation coefficient (icc). the inter-observer agreement for vc and vdwi was 0.948 and 0.916 respectively, while the correlation between vc and vdwi investigating pre-crt was 0.828 and in the post-crt in 0.151. after crt, vc shows a correlation with the trg of rho = 0.154 (p < 0542), while a significant linear relationship was evident between vdwi and trg with rho = 0556 (p < 0.05). post-crt the vdwi shows a significant difference between responders and nonresponders (p = 0.018). the vdwi is a reproducible quantitative technique in assessing the response to crt in patients with rectal cancer and shows a better correlation with the residue of the disease compared with the vc. therapy response assessment in locally advanced rectal cancer: comparison between functional dynamic and diffusion parameters in mri r. fusco, v. granata, m. petrillo, m. sansone, a. petrillo; naples/it (roberta.fusco@unina.it) purpose: we investigated the diagnostic performance of dce-mri and dw-mri in evaluating neoadjuvant chemo-radiotherapy (crt) response in larc. we compared a semiquantitative dynamic feature, the standardised index of shape (sis) and the diffusion parameters obtained using intravoxel incoherent method. purpose: to compare image quality and detection of clinical findings of the new warp sequence versus conventional optimised mr sequences in patients with total knee arthroplasty (tka). methods and materials: forty-two patients with tka underwent 1.5 t mri in this prospective study. slice-encoding metal artefact correction (semac), view-angle tilting (vat), and increased bandwidth were combined by the "warp"-turbo spin echo sequence. twenty-four patients underwent ct as a reference standard. coronal stir-warp and sagittal intermediate-weighted (pd) warp-sequences were compared to standard sequences optimised with high readout bandwidth (stir-hibw/pd-hibw). signal void was quantified. qualitative criteria (depiction of anatomy, distortion, blurring, noise) were assessed on a five-point scale (1, no artefacts; 5, severe artefacts) by two readers. clinical findings (e.g. periprosthetic osteolysis) were noted. a t-test (quantitative data) and a wilcoxon signed rank test (qualitative data) served for statistics. results: signal void areas were smaller for stir-warp than stir-hibw (mean; 20.1 cm 2 /27.0 cm 2 ), and for pd-warp than pd-hibw (14.2 cm 2 /16.5 cm 2 ; p <.001 for all comparisons). depiction of anatomic structures was better on stir-warp versus stir-hibw (2.9-3.7 vs. 4.2-4.9; p <.001), and on pd-warp versus pd-hibw (2.5-3.5 vs. 3.1-3.8; p <.007). distortion and image noise were lower for warp than for the standard sequences (p <.002), while blurring was similar for both techniques. there was a statistically significant advantage for detection of clinical findings for stir-warp versus stir-hibw (74 and 37 findings; p <.001) and for pd-warp versus pd-hibw (63 and 34 findings; p <.001). the warp sequences showed a statistically significant improvement for most image criteria. detection of clinically relevant findings was markedly increased. 14:00 purpose: to determine the diagnostic accuracy of mr in patients with rectal carcinoma by comparing post-chemoradiation mr imaging with pathological specimens. we enrolled 39 patients with a locally advanced rectal cancer. all patients received chemoradiation therapy before surgery. those patients underwent a neoadjuvant chemoradiation therapy followed by mr scans. the mr images were analysed by a team of two expert radiologists to whom clinical and histo-pathological findings were unknown. results: following neoadjuvant chemoradiation therapy, we observed 23 (59%) patients with a rectum disease staged ² t2 and 16 (41%) patients with a disease staged > t2, after mr images analysis. post-treatment histological staging (tnm) analysis revealed 13 patients with a disease > t2 and 26 patients with a disease ² t2. by arranging the kappa cohen test to find the agreement value between post-chemoradiation mr staging and histological response, we found that with a disease confined to the sierosa (² t3) the agreement was 83.6%. we found an agreement of 97.22% between mr and histology for a disease ² n1 and an accord of 33.33% for a disease more advanced than n1 (> n1). conclusion: mr is critical in discovering a t3 disease; moreover, with morphologic mr imaging we do not have always the opportunity to discern a few residual cancer cells hidden in the fibrotic tissue that could cause a crm involvement on histology. monday fascia infiltration was present on the surgical specimen. in 33 patients reticular (n=18) or linear-shaped (n=15) mesorectal enhancing strands were observed. reticular-shaped mesorectal enhancing strands were predictors of mesorectal fat infiltration (odds ratio, 7.36; 95% confidence intervals, 1.87-28.98; p < 0.05) but not of mesorectal fascia infiltration (0.86; 0.08-8.87; p=0.9). the enhancing strands reaching the mesorectal fascia represent a predictors of mesorectal fascia infiltration (3.61, 0.99-13.15; p < 0.05). the evidence of enhancing strands reaching the mesorectal fascia represents a predictor of mesorectal fascia infiltration and should suggest to intensify the crt. purpose: to show the utility of mdct assessing the tumour response in locally advanced colon cancer treated with neoadjuvant chemotherapy. methods and materials: 22 consecutive patients who underwent this therapy during a 15-month period were included. all tumours were staged before treatment using mdct 64 or pet-ct scan, and after neoadjuvant treatment other scan was performed by calculating the differences in tumour volumes making use of a dedicated software for semiautomatic volume segmentation, to assess tumour response before surgery. maximum standard uptake value (suv max) by pet-ct between the time of initial diagnosis and after neoadjuvant chemotherapy was also measured. surgical-related complications and oncological outcomes were obtained. results: tolerance to chemotherapy was excellent in 86.4% of patients and 95.5% completed the entire chemotherapy initially planned. after neoadjuvant treatment, 69.5% reduction of tumour volume was observed by ct-scan and up to 59.9% decrease of suvmax (standard uptake value) was achieved by pet/ mdct. none of the patients showed tumour progression during the preoperative treatment, and all of them underwent the previously planned surgical procedure. four patients developed postoperative complications. median time between the end of chemotherapy and surgery was 22 days. conclusion: preoperative chemotherapy induces a tumour response that can be measured by imaging methods (mdct). assessment of the variation in the contrast-to-noise ratio across a range of ct scanners in a multicentre perfusion ct study of colorectal cancer (prospect): a phantom study m. lewis, v.j. goh; london/uk purpose: to determine the effect of ct scanner models, iterative reconstruction (ir) and phantom size on cnr of perfusion ct scans. methods and materials: a 22-cm diameter water phantom containing different iodine contrast inserts from 2.5 mg/ml to 25 mg/ml was scanned on seven ct scanners from four manufacturers using the perfusion ct acquisition protocols of a multi-centre clinical trial in colorectal cancer (prospect). all acquisition protocols employed 100 kv and ~5 mm reconstructed slice. images were reconstructed with filtered back projection and iterative reconstruction, where available. ct numbers and background noise levels were measured and displayed ctdivol values noted. a sub-set of measurements was obtained on a 30-cm diameter phantom. the relationship between ct number and iodine density was determined for all datasets and cnr values calculated. results: a linear relationship between ct number and iodine density was observed, with small variations between ct scanners. no change in linearity was observed with ir of different 'strengths'. ctdivolvalues varied by a factor > 2. for the lowest density insert, cnr varied from 2.9 to 4.4. with ir, cnr increased by a factor of 1.15 to 2.3 depending on ir'strength'. cnr decreased by ~50% in the 30 cm phantom. the cnr varied by a factor of 1.5 across the range of scanners utilised in this mutlicentre study. the variation was largely due to image noise differences. ir does not affect contrast enhancement and can be used to achieve a given cnr at a reduced dose. author disclosures: v.j. goh: equipment support recipient; siemens healthcare, ge healthcare, texrad. research/grant support; nihr hta grant. methods and materials: 14 consecutive patients with larc were enrolled. patients underwent dce-mri and dw-mri (1.5 t, magnetom simphony tim, siemens, erlangen). an expert radiologist performed a manual segmentation of the whole lesion on a derived series obtained subtracting the basal and the 5 th post-contrastographic series and on dwi with b value=800. sis and pure diffusion coefficient, pseudo-diffusion coefficient and perfusion fraction were calculated pixel by pixel. after surgery, tumour regression grade (trg) was obtained. patients with trg 1-2 were considered responders and patients with trg 3-4-5 were considered non-responders. the value changes of each parameters from baseline to presurgical scan were assessed and correlated with the trg. sensitivity, specificity, roc analysis were applied. youden index was used to obtain the optimal cut-off value. mc-nemar test was performed to underline statistical difference. results: seven patients were classified as responders and 7 as non-responders at histology. the diffusion parameter (fraction perfusion) showed a sensitivity of 100%, specificity of 25% and area under roc 0.4750 (optimal cut-off value 86.3%); sis showed a sensitivity of 90%, a specificity of 100% and area under roc 0.7265 (optimal cut-off value 36.0%). a p value of < 0.05 was obtained comparing sis vs diffusion parameter. conclusion: sis can achieve the best results in discriminating patients responders from non-responders. reproducibility of mri texture analysis in primary rectal cancer s. gourtsoyianni 1 , g. ljungqvist 1 , a. khan 2 , r. glynne-jones 2 , b. ganeshan 3 , k. miles 3 , v. goh 1 ; 1 london/uk, 2 northwood/uk, 3 falmer/uk (sgty76@gmail.com) purpose: this study aimed at assessing the feasibility and reproducibility of mri texture analysis in rectal cancer. methods and materials: following irb approval, 14 patients (11 male, mean 68.3years) with primary rectal cancer underwent two baseline mris. t2-w axial sequences were exported for texture analysis (texrad, university of sussex). a laplacian of gaussian band-pass filter was applied to highlight different spatial scales (fine (1.0), medium (1.5-2.0) and coarse (2.5) texture). texture was quantified as entropy (e), uniformity (u), kurtosis (k), skewness (s) and standard deviation of the histogram (sdh) and recorded as for absolute scale values for each tumour. greater heterogeneity is represented by higher e, greater k, s and sdh and lower uniformity. overall group median values were recorded and reproducibility (testretest agreement) was assessed using bland-altman statistics. results: all tumours were greater than stage ii; mean length 5.5 cm. good reproducibility was achieved across all filters (1.0-2.5) for e, u and sdh with mean differences ranging from -0.007 to +0.002 for e; -0.11x10 -3 to + 0.001 x10 -3 for u; and +1.60 to +4.97 for sdh; and within subject coefficients of variation from 2.09-2.55% for e, 10.3-12.7% for u, and 14.3-16.1% for sdh. there was greater variability for k and s: mean differences ranged from +0.168 to + 0.334 for k; and +0.089 to +0.272 for s; within subject coefficients of variation from 31.3-93.7% for k, and 21.5-49.6% for s. conclusion: mri texture analysis is feasible in rectal cancer and a reproducible technique in the trial setting. predictors of mesorectal fascia infiltration on spectral pre-saturation inversion-recovery (spir) mr imaging sequence after gadolinium injection in patients with rectal carcinoma after neoadjuvant chemoand radiation therapy e. quaia, l. de paoli, a. gennari, b. cabibbo, m. cova; trieste/it (quaia@units.it) purpose: to retrospectively assess the value of spectral pre-saturation inversionrecovery (spir) mr imaging sequence after gadolinium injection to identify predictors of mesorectal fat and mesorectal fascia infiltration in patients with locally advanced rectal carcinoma after neoadjuvant chemo-and radiation therapy (crt). methods and materials: sixty-five consecutive patients (mean age: 68.93 years, range: 48-83 years, m:f 39:26) with locally advanced rectal carcinoma underwent crt followed by surgery. mr imaging was performed before and after completion of crt using t2-weighted fast spin-echo and t1-weighted spir sequences before and after gadolinium injection. mr images were assessed by two radiologists in consensus. the evidence of reticular (interwoven strands within the mesorectal fat creating a meshwork) or linear-shaped enhancing strands (strands travelling separately through the mesorectal fat) on mr images were retrospectively correlated to the histopathological findings. results: after crt the disease was either limited to the rectal wall (n=31 patients) or presented mesorectal fat infiltration (n=34 conclusion: cedm has a potential impact on the characterisation of breast lesions. intensely enhancing lesions are strongly indicative of a malignant nature, yet, overlap of enhancement patterns still exists and therefore further studies with a larger number of studied population are recommended. clinical feasibility of contrast-enhanced dual-energy mammography (cedem) with a tungsten (w)/titanium (ti) anode/filter combination: a prototype report t. knogler 1 , r. leithner 1 , m. hörnig 2 , f. semturs 1 , m. waitzbauer 1 , g. langs 1 , p. homolka 1 , k. pinker-domenig 1 , t.h. helbich 1 ; 1 vienna/at, 2 erlangen/ de (thomas.knogler@meduniwien.ac.at) purpose: to test the feasibility of cedem with a w/ti anode/filter combination for high energy images in a clinical setting. methods and materials: fifteen female patients with 15 breast lesions were included in this study. cedem was performed with a mammomat inspiration prototype (siemens, germany) before and after i.v. administration of 2-ml iomeron® 400 (bracco, italy) per kg b.w. at a rate of 3.5 ml/sec. dual-energy images were acquired with 28-32 kvp and a w/rhodium (rh) anode/filter combination for lowenergy and 49 kvp and a w/ti anode filter combination for high energy. weighted subtraction images were computed for diagnostic work-up. images were assessed by two readers with respect to lesion-enhancement and image quality. a histological work-up was performed in all lesions. results: histopathology revealed eight malignant lesions and seven benign lesions (size range from 8 to 38 mm). all malignant lesions enhanced and were seen from both readers on weighted subtraction images. benign lesions did not enhance thus they were not visualised on weighted subtraction images. image quality was rated excellent from both readers. based on the visibility of the lesion cedem allowed an accurate differentiation of benign and malignant breast lesions. conclusion: cedem with a w/ti anode/filter combination is suitable and feasible. lesion visibility and image quality were excellent. further research is needed to determine the value of cedem in a clinical setting. diffusion-weighted-based mri: volumetry and apparent diffusion coefficient s.f. carbone, m. palumbo, t. carfagno, v. ricci, l. pirtoli, l. volterrani; siena/it (fracarb@gmail.com) purpose: to assess the diagnostic accuracy of volumetric magnetic resonance diffusion (vdwi) and apparent diffusion coefficient (adc) in the assessment of response in patients with rectal cancer treated with chemoradiotherapy (crt). we retrospectively examined 30 patients (mean age 68.1 years) with rectal cancer, who have performed mri before and after 45 ± 15 days of the crt after undergoing to anterior resection of the rectum. after surgery, yptn and trg (tumour regression grading) according to mandard classification were obtained. we considered responders patients with trg 1-2 or with a negative follow-up recurrence in the next 12 months (only three cases). two radiologists, in consensus and using commercial software, have extrapolated pre-and post-crt vdwi of the lesions and calculated the adc. results: the adc did not show significant differences between responders and not-responders (p = 0.08 pre-crt, p = 0.1 post-crt); the vdwi of responders was significantly lower in both pre-crt (p = 0.0065) and in post-crt (p = 0.006) compared with not-responders vdwi. the accuracy in the evaluation of response was of 70 and 91%, respectively, for the adc and vdwi. the vdwi is more reliable than adc to assess the response to crt in patients with rectal cancer. computed tomography of the bowel: a prospective comparison study between four techniques m. revelli, f. paparo, l. bacigalupo, a. garlaschi, l. cevasco, e. biscaldi, g. rollandi; genoa/it purpose: our purposes were to compare the grade of bowel distension obtained with four different ct techniques dedicated for examination of small intestine (ct-enteroclysis and ct-enterography), colon (ct with water enema), or both (ct-enterography with water enema) and to assess patient tolerance towards each protocol. we recruited four groups of 30 patients. each group corresponded to a specific ct technique, for a total of 120 consecutive patients (65 male, 55 female; mean age 51.09±13.36 years). ct studies were evaluated in consensus by two gastrointestinal-dedicated radiologists who performed quantitative and qualitative analysis of bowel distension. presence and type of adverse effects were recorded. results: ct-enteroclysis provided the best distension of jejunal loops (median diameter 27 mm; range 17-32 mm) compared with all other techniques (p < 0.0001). frequency of patients with an adequate distension of the terminal ileum was not significantly different among the four groups (p=0.0608). at both quantitative and qualitative analysis ct with water enema and ct-enterography with water enema determined a greater and more consistent luminal filling of the large intestine compared with the one provided by both ct-enteroclysis and ct-enterography (p < 0.0001 for all colonic segments). adverse effects were more frequent in patients from the ct-enteroclysis group (p < 0.0028). conclusion: ct-enteroclysis allows an optimal distension of jejunal loops, but it is the most uncomfortable ct protocol. when performing ct with water enema, an adequate retrograde distension of the terminal ileum was provided in a high percentage of patients. ct-enterography with water enema provides a simultaneous optimal distension of both small and large bowel. s37 c a d e f g b excellent (0.9/0.9), but worse for vee (0.7/0.6). correlations of small arbitrary rois were lower for all parameters. conclusion: perfusion and permeability parameters of dce-mri of rcc are influenced by roi-size and positioning. the best inter-and intraobserver correlation showed definition of whole tumour roi with morphological sequences or plasma flow maps. evaluating tumours or monitoring antiangiogenic therapy, perfusion parameters are more reliable, while permeability parameters are more susceptible to interobserver variability. can a contrast-enhanced ultrasound nephrostogram be used instead of a fluoroscopic nephrostogram: preliminary findings m. daneshi, k. patel, d. huang, m. sellars, p. sidhu; london/uk purpose: the use of contrast-enhanced ultrasound (ceus) has extended beyond traditional uses, and the possibility to delineate percutaneous tubes and drains is achievable. we have compared the traditional fluoroscopic nephrostogram using iodinated contrast agents with ceus nephrostogram to ascertain the accuracy, utility and convenience of the ceus nephrostogram. the standard conventional nephrostogram was performed immediately prior to the ceus nephrostogram. the ceus nephrostogram technique involved diluting 0.2 ml of sonovue with 40 ml of normal saline and introduced into the renal collecting system via the nephrostomy tube. digital cineclips and still images were recorded to allow accurate retrospective comparison by two independent reviewers to the reference standard. results: twelve nephrostomies in 10 patients (median age 64 yrs, range 29-91 yrs, 6 females and 4 males) were performed and reviewed. the renal pelvicalyceal system was visualised in both ceus and fluoroscopic nephrostograms in 11/12 (92%) with one nephrostomy tube identified as being misplaced. the entire ureter was visualised in 6/12 (50%) with a ceus nephrostogram compared with 8/12 (75%) using traditional nephrostogram. fluoroscopic nephrostogram showed drainage of contrast into the bladder in 10/12 (83%) cases compared with 9/12 (75%) using ceus. conclusion: preliminary results suggest that ceus nephrostogram is a feasible method to confirm the correct positioning of the nephrostomy tube, image the ureters and determine if there is satisfactory drainage into the bladder. ceus nephrostogram is a suitable alternative for the traditional nephrostogram in patients with contraindications to iodinated contrast agents or if the procedure needs to be performed at the bedside. vena cava anomalies associated with horseshoe kidney on mdct t. ichikawa, j. koizumi, s. kawada, y. imai; isehara/jp (tamaki-i@mars.sannet.ne.jp) purpose: the incidence of vena cava (vc) anomalies in horseshoe kidney (hsk) patients is relatively high because of embryogenesis. we evaluated prevalence and variation of anomalous inferior vena cava (ivc) and superior vena cava (svc) in hsk patients detected using ct. methods and materials: seventy-one patients with hsk and 2292 patients with normal kidney (nk) who underwent chest ct were evaluated of prevalence and variation of anomalous svc and 205 patients with hsk and 1990 patients with nk who underwent abdominal ct were evaluated of prevalence and variation of anomalous ivc. we reviewed axial ct images with 5-mm reconstruction interval and compared prevalence of anomalous vc between hsk and nk patients using chi-square test. results: anomalous svc was identified in 3 patients (4.2%) in hsk patients: 2 double svcs and 1 persistent left svc without right svc and 5 patients (0.22%) in nk patients: 3 double svcs and 2 persistent left svc without right svc. anomalous ivc was identified in 8 patients (3.9%) in hsk patients: 1 preisthmic ivc with retrocaval ureter, 4 double ivcs, 2 left ivc, and 1 ivc with azygos continuation and 12 patients (0.6%) in nk patients: 8 double ivcs, 3 left ivc, and one ivc with azygos continuation. there was a significantly higher prevalence of anomalous vc in patients with hsk than in those nk on mdct (p < 0.001). conclusion: hsk patients were frequently found anomalous vc and detection of those anomalies in hsk patients is important during central venous catheter procedures and operation. or excision biopsy. qualitative analysis of cine loops was assessed for each ceus examination by two observers and consensus reached on the pattern and timing of tumour enhancement. perfusion quantification of the lesions was performed where possible, with time-intensity curves were analysed. results: distinct differentiation on enhancement patterns was observed between leydig cell and germ cell tumours. all 11 leydig cell tumours displayed intense early enhancement which persisted for longer than the normal testicular parenchymal enhancement. the germ cell tumours showed loss of the normal linear vascular pattern, but with a more rapid washout of contrast. quantitative analysis confirms the observation, with longer full width at maximum (fwhm) and slower contrast outflow on the time-intensity curves observed in leydig cell tumours comparing to germ cell tumours. with improved diagnostic confidence, testicular-sparing excisions were performed for 5 lesions following pre-operative ceus analysis and unnecessary orchidectomies avoided. we describe, to date the first, consistent differentiating characteristic ceus enhancement pattern in rare benign leydig cell tumours. this observation increases diagnostic confidence, thus allows for testicular-preserving options to be considered. purpose: to describe us and colour-doppler findings in testicular lymphoma and their mimics. we reviewed the us and colour-doppler findings in 10 pts with pathology-proven lymphoma of the testis and compared them with those in 7 patients in whom lymphoproliferative disease was suspected on clinical and us grounds and pathology showed only inflammatory changes. results: lymphoma patients' age range was 34-76 years. six had testicular involvement in systemic disease or recurrence; four had primary disease. one had bilateral involvement. seven testes in 6 patients were diffusely involved (4 homogeneously; 3 heterogeneously); four had nodular hypoechoic lesions which, in 1 testis, were multiple. all lesions, either focal or diffuse, were hypervascular, with vessels of normal rectilinear shape. in patients with nodular lesions, there was no distorsion of vascular course at the point where vessels entered the mass. findings suggested an infiltrative process, and were confirmed at pathology. the remaining seven patients had history and us features suggesting testicular lymphoproliferative disease. all had hypoechoic focal hypervascular lesions containing vessels with rectilinear course that were eventually proved inflammatory changes (2 chronic focal orchitis, 2 idiopathic granulomatous orchitis, 2 brucellosis, 1 tuberculosis). conclusion: in patients over 60 and/or with known lymphoproliferative disease, the presence of hypoechoic, hypervascular testicular lesion with absence of vascular distorsion must suggest lymphoma. care must be taken since, albeit rarely, inflammatory lesions may present the same imaging pattern in the absence of clinical signs and symptoms of inflammation. purpose: to assess the influence of region of interest (roi) size and positioning on parameters of perfusion and permeability and inter-and intraobserver variability of dce-mri of renal cell carcinoma (rcc) and metastases. methods and materials: 33 patients with rcc and 17 patients with metastases were examined with dynamic contrast-enhanced (dce) mri at 1.5 t with a half body weight-adapted dose of gadobutrol. analysis with a two-compartment exchange model provided four parameters: plasma flow (fp), plasma volume (vp), permeability-surface-product (ps) and interstitial volume (vee). arterial input function and retrospective respiratory triggering were applied. rois of the whole tumour, circular edge and an arbitrary vital region were defined on morphological sequences and on parametric plasma flow maps. consider tube current modulation (tcm). the aim of this study was to include tcm effects in mc dose simulations and to validate this approach. methods and materials: all measurements were performed on a somatom definition flash scanner (siemens healthcare, forchheim, germany) using three anthropomorphic phantoms: adult alderson-rando, 5-year-old child and 1-yearold child. the phantoms were scanned with a trunk protocol using an online tcm system (caredose4, siemens healthcare, forchheim, germany). organ dose values were measured using 94 calibrated thermoluminescent dosimeters (tld) for each phantom. mc simulations were performed using impactmc software (ct imaging gmbh, erlangen, germany) based on the 3d voxelised data derived from acquired ct images. the tool was modified to take tcm curves into account. the current values for different tube positions were extracted from the raw data using manufacturer software. simulated dose values were compared with tld measurements on a chip-by-chip basis. results: for mc calculations without taking tcm data into account the mean differences between measured and simulated dose values amounted to 92%, 83%, 71% for adult, 5-year-old child and 1-year-old phantoms, while modelling with tcm reduced the mean differences to 5.3%, 7.5% and 6.4%, respectively. conclusion: mc dose estimates including tcm data were in good agreement with measurements. this technique can significantly improve the accuracy of 3d-dose assessment. monday 23 kev; pixel size 5.4µm), or at a laboratory set-up with a conventional x-ray tube (n=3, 35 kvp, 70 ma, pixel size 100µm). tomographic images were reconstructed and compared to histopathology. independent readers determined vessel dimensions and signal-to-noise ratios (snr) between gb-pci and absorption images. results: in total, 51 sections were included in the analysis. images from both setups provided sufficient contrast to differentiate vessel layers. there was a strong positive correlation between pci and histology with respect for lumen, intima and vessel wall area for both synchrotron and laboratory-based measurements (pearson's r > 0.94 and p < 0.01 for all). synchrotron-based images were characterised by significantly higher snrs than laboratory-based images (p < 0.001). both gb-pci set-ups had superior snrs compared to corresponding absorption-based images (p < 0.001). inter-reader reproducibility was excellent, with iccs > 0.98 for synchrotron and > 0.84 for laboratory-based measurements. conclusion: our results demonstrate the feasibility of gb-pci for carotid atherosclerotic plaque imaging using both synchrotron and laboratory-based experimental set-ups. the technique holds promise for accurate vessel wall characterisation. single contrast medium dose peripheral mr angiography is feasible without subtraction using two-point dixon fat saturation purpose: to investigate the feasibility and image quality of subtractionless firstpass single contrast medium dose (0.1 mmol/kg) peripheral contrast-enhanced magnetic resonance angiography (mra) using two-point dixon fat-saturation (2dixfs) compared with conventional subtraction-based mra with regard to vesselto-background contrast, signal-to-noise ratio (snr) and subjective image quality. methods and materials: 28 patients (13m, 15 f; mean age±sd, 66±16) with known or suspected peripheral arterial disease underwent single contrast medium dose (0.1 mmol/kg body weight) 1.5-t mra using 2dixfs during first arterial passage of contrast material. results were compared with data obtained using a conventional, subtraction-based approach. a phantom study was performed to assess signal-to-noise ratio (snr) of both mra techniques. vessel-to-background (vtb) contrast and snr were measured and compared with the paired samples t-test. two experienced observers scored subjective image quality. fisher's exact test was used to compare subjective image quality. agreement regarding subjective image quality was expressed in quadratic weighted κ values. results: patient data showed improved vtb contrast in all anatomical locations with 2dixfs versus the conventional, subtraction-based mra method (all p < 0.001). subjective image quality was uniformly higher with 2dixfs when compared with subtracted images. in all cases this was significant (p < 0.03), except the aortoiliac arteries for observer 1 (p=0.052). phantom studies indicated a 15% higher snr with the dixon technique (31.9 vs 27.6). conclusion: this study demonstrates the feasibility of single contrast medium dose subtractionless lower extremity mra using 2dixfs method. both objective and subjective image quality are better compared with subtraction based mra of the peripheral vascular tree. correlation of cardiovascular risk factors and occult atherosclerotic findings using whole body magnetic resonance imaging of the vascular system in an asymptomatic patient collective: initial results s. mangold, e. randrianarisoa, p. krumm, c. bretschneider, a. seeger, k. rittig, b. balletshofer, c.d. claussen, u. kramer; tübingen/ de (stefanie.mangold@med.uni-tuebingen.de) purpose: to evaluate the prevalence of atherosclerotic disease, myocardial infarction and cerebrovascular disease in asymptomatic patients with cardiovascular risk profile including whole body magnetic resonance imaging (wb-mri) of the cardiovascular system into the framework of a comprehensive prevention concept. methods and materials: prospectively, 52 patients without any known cardiovascular disease (34 men, 18 woman, mean age 50.1±7.4 years) but suffering from cardiovascular risk factors such as arterial hypertension [aht], impaired glucose tolerance, hyperlipidaemia and obesity, were clinically assessed including family history, blood collection, blood pressure assessment and oral glucose tolerance test. furthermore, the carotid intima-media thickness [cimt], potentially indicative for atherosclerotic disease was assessed by ultrasound and a wb-mr angiography (1.5 t, avanto, siemens medical solutions) containing an examination of the of renal artery using respiratory triggered (rt) or breath held (bh) in reference to dynamic contrast mra (cmra). methods and materials: 33 patients were involved (median age 61 years). rt and bh nc mras using pg were obtained at 3 t (discovery mr750, gehc) using inflow inversion recovery (ifir) 3d fiesta with fan beam k-space view ordering in a coronal plane. cmra with 3d efgre was obtained as reference [0.1 mmol/kg gd-chelate, injection 3 ml/sec]. evaluation, image quality, artefacts (1 undiagnostic-5 excellent) and visualisation of aorta and renal arteries were ranked with 5-point scale. contrast was calculated (si artery/surrounding tissue). wilcoxon signed rank test and student's t test with bonferroni correction was used for statistical evaluation. results: all ncmras were diagnostic (3.7-4.7). scores for image quality and artefacts of rt ncmra were better than those of bh ncmra (ns) although visualisation of aorta was slightly better with bh than rt ncmra. rt ncmra provided better visualisation of distal renal arteries and better contrast than those with cmra (p < 0.05). contrasts of aorta and proximal renal arteries were slightly better in cmra than those in ncmras (ns). conclusion: with pg, homogenous si in aorta was obtained in ncmra. when image quality of rt ncmra is not enough to evaluate arteries, bh ncmra can be used as substitute. purpose: to evaluate the quality, the diagnostic performance and the radiation exposure of low-kv ct angiography protocol (100 kv) with ultra low-contrast medium volume (40 ml) in the assessment of the aorta disease. methods and materials: seventy patients with thoracic or abdominal aortic disease were prospectively examined with 256mdct scan (brilliance ict, philips) using ultra low-dose radiation protocol (100 kv; automated tube current modulation) and ultra low-contrast volume (40 ml; 4 ml/s; 350 mgi/ml). in the thoracic aorta assessment we performed ecg-gated retrospective protocol, necessary for the evaluation of ascending aorta. density measurements were performed on ascending, arch, descending, abdominal aorta, renal arteries and common iliac arteries. a control groups of 50 patients who underwent standard ct-angiography protocol (120 kv; 350 mas) and standard contrast volume (120 ml) were also evaluated. the obtained data in terms of radiation dose exposure (dose-length product, dlp), administered contrast and intravessels density were compared and statistically analysed. results: in every ct-exam we could correctly visualise and evaluate main branch of thoracic and abdominal aorta. no significant difference of density measurements was achieved between the low-kv protocol: mean attenuation value of thoracic aorta 304 hu, abdominal aorta 343 hu and renal arteries 331 hu; and control group: mean value of thoracic aorta 320 hu, abdominal aorta 339 hu and renal arteries 303 hu. the radiation dose exposure in low-kv protocol was significantly reduced (p < 0.05) in comparison with control group, obtaining the following value for thoracic scan: 490dlp and abdominal scan: 335dlp, while in control group we obtained for the thoracic scan: dlp625 and for the abdominal scan: dlp952, respectively. conclusion: low-kv protocol provides a comparable diagnostic performance with standard protocol, decreasing significantly the radiation dose exposure (over 40%) and allowing also a significant reduction of contrast material volume (40 ml), preserving renal function. x-ray phase-contrast imaging of arterial vessel wall: translation from synchrotron radiation to a conventional lab-based x-ray source h. hetterich 1 , m. willner 2 , s. fill 1 , f. bamberg 1 , j. herzen 2 , m. stockmar 2 , f. pfeiffer 2 , m.f. reiser 1 , t. saam 1 ; 1 munich/de, 2 garching/ de (holger.hetterich@med.uni-muenchen.de) purpose: phase-contrast imaging (pci) is a novel x-ray-based technique that provides excellent soft tissue contrast but so far was depending on synchrotron radiation. the aim of this study was to evaluate the feasibility of visualising human carotid arteries by grating-based pci (gb-pci) at two different experimental setups: (1) applying synchrotron radiation and (2) using a conventional x-ray tube. methods and materials: five ex-vivo carotid artery specimens were examined with gb-pci either at a synchrotron facility using a monochromatic x-ray beam (n=2; developed for adult trauma patients in 2008 and a novel approach based on recent literature and our additional observations. results: of the 14 years considered, 136 cases met the inclusion criteria. in 33 cases a nahi was assumed. 17 cases showed sdhy. only one sdhy case was assumed to be related to an accident. the new classification system for traumatic sdhy in children will be introduced and discussed. conclusion: as demonstrated for different sdhy appearances, neuroradiologists should be aware of the possible presentations of nahi. in addition, investigation of sdhy's may allow for new insights into the pathogenesis of phenomena such as the shaken baby syndrome. apparent kurtosis coefficient (akc) in brain: a feasibility study in paediatric populations i. d'errico, a. ciccarone, m. esposito, m. mortilla, c. fonda; florence/it (igni77@hotmail.it) purpose: diffusion-weighted imaging (dwi) depends on the b-values employed in acquisition. at low b values (lower than 500 s/mm2) the signal attenuation is bi-exponential and is influenced both by diffusion and perfusion. at high b values (higher than 1000 s/mm2) the signal attenuation is influenced by restricted water diffusion and hence follows a non-gaussian distribution. diffusion kurtosis imaging (dki) provides quantifiable information about the deviation from gaussian distribution in water diffusion process. our purpose was to apply dki method to paediatric patients with different pathologies (tumours, ischaemia) and to establish its feasibility in detecting brain diseases. we examined 20 patients from newborn to 16-year-old. diffusion weighted imaging was performed with 5 b values from 500 to 2500 with step 500 s/mm2. fitting all b values we were able to discriminate diffusion and kurtosis parameters. a home-made software performed all fitting and dwi, adc, akc maps. results: akc maps revealed additional information for tissue characterisation. in ischaemia, akc demonstrated more details of pathologic tissue changes and provided information about prognosis. in tumours, akc maps were used for discriminating low-grade from high-grade lesions revealing a better accuracy than conventional diffusion parameters. conclusion: akc maps are non-invasive methods that are well tolerated by paediatric patients and that provide a more detailed characterisation of neural tissue in the clinical context. their application in pathological conditions such as ischaemia and tumours provides additional information about microstructural tissue changes, differential diagnosis and prognosis. which t1 pulse should be used to study the preterm brain with a 3 tesla scanner? d. tortora, v. panara, p.a. mattei, s. salice, m. tagliamonte, c. briganti, a.r. cotroneo, a. tartaro, m. caulo; chieti/it (domenicotortora@hotmail.it) purpose: the loss of contrast on mr t1-weighted images obtained at 3 tesla (3 t) may negatively influence the detection of punctate hyperintense lesions, which are indicative of periventricular leukomalacia (pvl) in preterm neonates. in this 3 t mr study we compared the sensitivity of different t1-weighted sequences in identifying pvl. the presence of non cystic-pvl was retrospectively evaluated in 3 tesla (3 t) mr brain studies of 200 preterm neonates acquired at term-corrected age. in 30 neonates with pvl, t1 hyperintense punctate lesions were counted by two neuroradiologists in consensus on 4 different axial t1-weighted sequences: 3 mm inversion recovery (ir), spin echo (se), reformatted 3d-fast field echo (ffe) and 1 mm reformatted 3d-ffe. sequences were presented randomly. statistical differences of the number of hyperintense lesions detected by the different sequences were evaluated using the student's paired t test (p < 0.05). results: the greater number of t1 hyperintense punctate lesion was identified using the 1 mm axial reformatted 3d-ffe sequence (381 lesions), which resulted to be the most sensitive sequence in identifying pvl lesions (p < 0.0001). axial 3 mm ffe, ir and se sequences identified 213, 146 and 94 hyperintense punctate lesions, respectively. no statistical differences were found between 3 mm-t1 sequences (p> 0.05). conclusion: when using a 3 tesla mr scanner 1 mm axial reformatted t1-3d-ffe is the most sensitive t1-weighted sequence for detecting punctate hyperintense lesions which may affect the brain of preterm neonates. brain and the heart was performed. a vessel score, determined from the sum of arteriosclerotic changes of all evaluated vessel divided by the number of vessels with a range from 1, normal to 6, stenosis > 99%, was introduced and score's association with risk factors was assessed. results: the mean mri score was 1.51±0.18.the wb-mr angiography-based score was significantly associated with the body mass index [bmi] (p=0.024) and aht in combination with an elevated bmi (p=0.042). no significant associations were found for age (p=0.706), sex (p=0.502), impaired fasting glucose (p=0.277), hyperlipidaemia (p=0.218) and cimt (p=0.183) . no patients with myocardial infarction and 2 patients with cerebrovascular disease were found. conclusion: wb-mr angiography allows the detection of occult atherosclerotic disease in asymptomatic patients with cardiovascular risk profile especially in cases of aht and/or obesity. 14:00 purpose: to evaluate image quality and radiation dose of ultra-low-dose ct examinations of the inner ear performed using adaptive statistical image reconstruction (asir) in infants candidate to cochlear prosthesis implantation. we evaluated 24 infants (14 males, 10 females, age 4-29 months, mean 17 months) with sensorineural deafness who underwent ct of the inner ear before cochlear prosthesis implantation. out of them, 13 were imaged on a 128-row ct scanner (discovery ct750 hd, general electric, milwaukee, wi) using an ultra-low dose protocol (80 kv, 10 ma, 0.5s gantry rotation time) and a model-based iterative reconstruction algorithm (asir™), while in the remaining 11 ct had been performed on a 64-row scanner before the introduction of the 128-row ct equipment at our institution, using a regular paediatric protocol (100 kv, 30 ma, 0.5s gantry rotation time) with conventional filtered backprojection. dose-length product (dlp) values were obtained from dose reports generated from the scanner at the end of each examination. image quality was rated in blind by two radiologists using a likert scale (1=non-diagnostic through 5=excellent). results: none of the examinations were rated as non-diagnostic. image quality was comparable between the 128-and the 64-row ct group (4.45±0.63 vs 4.51±0.56, respectively; p=0.31). dlp was significantly lower in the 128-row ct group (5.46±0.35 vs 25.69±0.83 mgy*cm, respectively; p < 0.001). conclusion: compared with a regular paediatric protocol, ultra-low-dose ct of the inner ear with asir allows for markedly reduced radiation dose with preserved image quality. traumatic subdural hygromas in children between 0 and 2 years: a retrospective ct and mri study m.l. hahnemann 1 , a. schmeling 2 , m. schlamann 1 , m. forsting 1 , h. pfeiffer 2 , d. wittschieber 2 ; 1 essen/de, 2 münster/de purpose: non-accidental head injuries (nahi) represent a leading cause of death in infants. in this context, the role of traumatic subdural hygromas (sdhy) as possible acute or chronic finding in child abuse, especially in shaken-baby-syndrome, is not well understood and still a matter of debate. by modern imaging techniques, the present study aimed to investigate the characteristics of sdhy. methods and materials: from the years 1999-2012, we retrospectively analysed the images of all children between 0 and 2 years who were suspected to have a craniocerebral injury and got an initial cranial computer tomography at the university hospital essen. in cases where additional mr examinations existed these mr images were also analysed. all skeletal and cerebral pathologies, demographic data, and, if existing, related clinical anamneses and findings were recorded. all sdhy cases were classified according to both a classification system originally s38 c a d e f g b is a major cause too (n=26). spearman rho correlations between radiographer's time of experience and frequency of mri exams repetitions were poor and not significant (r=0.141; p=0.297). the correlations between radiographer's tiredness and frequency of mri exams repetitions were negative, weak and not significant (r= -0.151; p=0.263). the patients' movement may disrupt the examination or degrade the images with artefacts. the level of experience does not influence the repetitions of mri exams, it seems that senior radiographers do not have improvements in performance as it should be expected. it is recommendable to do training courses regularly to improve the performance and systematically evaluate. several features will need to be identified which would decrease the mri exams repetitions. functional mapping of the visual word form area with frequent words of the portuguese lexicon: an fmri study c. ferreira 1 , p. martins 2 , g. cunha 1 , n. canário 1 , c. nunes 1 , a.c. miranda 2 , j. ribeiro 2 , s. afonso 2 , m. castelo-branco 1 ; 1 coimbra/pt, 2 aveiro/pt (c_dferreira@yahoo.com) purpose: the visual word form area (vwfa), part of the fusiform gyrus in the temporal lobe underlies word form encoding. impairment of this region causes reading deficits, including alexia. the aim of this study is to functionally map vwfa at the individual subject level using frequent words of the portuguese lexicon, to develop a paradigm potentially useful for clinical patients. methods and materials: functional magnetic resonance images (fmri) were acquired in from nine subjects. the visual paradigm used consisted of 13 blocks (30 seconds block duration): 7 baseline (checkerboard stimuli), 3 blocks of frequent words and 3 of pseudo-words (40 words/pseudowords per block). general linear model analysis was performed using brainvoyager qx to identify brain regions encoding word form. results: an area corresponding to vwfa could be mapped in both hemispheres in all subjects at a statistical threshold of 0.001, corrected for multiple comparisons. seven of the cases had predominant activation in the left hemisphere, one has equivalent activations bilaterally and one subject has predominant activation in the right hemisphere. the number of activated clusters was significantly larger in the left hemisphere at the group level (p = 0.015, wilcoxon signed rank test). conclusion: bilateral activation was replicated in vwfa in all subjects, with a clear left hemispheric dominance demonstrating the robustness of the paradigm, making it potentially useful in a clinical setting, e.g. pre-surgical mapping. a survey of the various methods and techniques employed in myocardial stress testing k. borg grima 1 , l. rainford 2 , p. bezzina 1 , d. o'leary 2 ; 1 msida/mt, 2 dublin/ie (karen.borg-grima@um.edu.mt) purpose: literature suggests a range of pharmacological stress agents and radioactive tracers, together with a variety of defined protocols that may be used in conducting myocardial stress testing prior to cardiac scintigraphy imaging. an online survey was performed to evaluate current practice. methods and materials: a survey was developed comprising of twelve questions, by using 'survey monkey', which aimed to identify the variances present in conducting myocardial stress testing and in clinical protocol details if available. professional groups working in nuclear medicine, such as the medical-physicsengineering community and virtual radiopharmacy, were targeted. access to the survey remained open for eight months. forty-three members, including both radiographers and medical physicists responded from across europe and australasia. spss was used to evaluate the results obtained, based on chi-square tests and comparisons between multiple responses. results: the majority (72%) of the participants were from united kingdom, 18% from other european countries and 9% from australasia. in 39 centres pharmacological stress testing was performed either alone or in conjunction with exercise stress testing. the results indicated that 60% of the participants were aware of local stress test protocols; however, guidelines indicating which patients were not suitable for pharmacological stress tests may require clarification. conclusion: results suggest that for pharmacological stress testing there is a need for increased awareness of protocols, and across all responders the need for improved knowledge and understanding of local protocols was identified. this initial survey justifies further research towards increase protocol compliance and standardisation of practice during myocardial stress testing. templates were built taking into account the age of patients. artefact movements and eddy current distortions were removed. mean diffusivity (md) and fractional anisotropy (fa) were quantified together to the three principal directions of diffusion (eigenvectors) with their own eigenvalues (tensor diagonalization). so analysis of single fibre orientation for each voxel with a bayesian algorithm was executed. voxelwise statistical analysis of the fa, md and axial diffusivity data was carried out using tbss between focal cortical abnormalities sites and normal ones. results: different pattern of cortical organization and white matter projections are evidenced depending of lesional load and extension, site and age. in focal cortical abnormalities the tbss analysis revealed significant differences (p < 0.05) between affected cortical sites and normal ones. conclusion: different fa data were collected. the reductions of fa, the associated elevation of diffusivity in altered contiguous or distal area are evidenced. 14:00 purpose: the magnetic resonance imaging (mri) uses the magnetic field effects to its functioning. this study aimed to clarify the emf directive 2004/40/ec discussion which imposes limits to electromagnetic fields (emf) regarding the occupational exposure. methods and materials: it was explored policy documents, regulations, guidelines, laws and other official documents on this subject. to understand the reason of this controversy, the evidence of consequences from the emf exposure over professionals was analysed. from the information obtained an online survey was developed, with national and international coverage, towards 11 professional groups considered involved in the controversy. the opinions were analysed by the force field analysis diagram, through the policymaker k4-health™ application to speculate the influences, forces, power and strategies developed in this process. results and conclusion: from 50 respondents 62% do not know the esr's position, the directive and its contents. 60% know the safety measures to apply in the mr room and report adverse events for lack of compliance with safety standards, being the levels of sar, the most topic referred. they do not know the limits imposed and have no opinion about the directive's controversy (40%). the political impact is considered neutral (49%) against the negative clinical and economic impacts (54%) that falls over the equipment manufacturers (62%). the professional societies have most decision, followed by physicists, doctors, manufacturers, government decision-makers and health-managers. the manufacturers, radiographers and supervisors have median influence, and the patients have weak influence over this process. on this matter influences and pressure strategies over the european commission and council were recognised. radiographers perceptions of magnetic resonance imaging: a study of the causes that lead to the repetition of exams t.r. filipe 1 , l.p.v. ribeiro 1 , r.p.p. almeida 1 , s.i. rodrigues 1 , k.b. azevedo 1 , c.a. silva 2 , a.f.l. abrantes 1 ; 1 faro/pt, 2 évora/pt (tiagofilipe__@hotmail.com) purpose: to know how often repetitions of mri exams and sequences occur in radiology departments. a self-applied questionnaire was used as instrument and assigned to 57 radiographers who performed mri exams to determine which were the causes that lead to the repetition. the questionnaires were interpreted and statistically analysed through descriptive statistics and spearman's rho correlation. results: at a 95% confidence interval, the major results suggest that the patient's movement during the mri exams is the main cause to repeat this exams (mean of 3.88 on a 5-point likert scale). however, there are causes related to the radiographer's and the results showed that the introduction of wrong imaging parameters s38 a c d e f g results: the percentage of depression among mri technologists included in our sample was found to be 25% which is considered to be much more than the percentage (10%) found among the dentists in usa (6.5%) and among community population in saudi arabia. conclusion: it was found that there is a strong relationship between the incident of depression among mri technologists and the incident is higher among technologists working for more than 5 years. development and implementation of a synthetic data evaluation scenario for image fusion algorithms based on discrete wavelet transform and principal component analysis v. weiss; wiener neustadt/ at (volker.weiss@hotmail.com) purpose: successful image fusion reduces the amount of data without significantly reducing the amount of relevant information. this study aims to answer the question whether the image fusion results were calculated successfully and what successful image fusion actually means. the study presents two new approaches for the quantitative evaluation of image fusion schemes. it provides the development and implementation of a synthetic data evaluation scenario for image fusion algorithms based on discrete wavelet transform (dwt) and principal component analysis (pca). furthermore, it presents a medical application visualising and comparing fused axial ct slices, reconstructed from a ct volume data set with identical position but calculated with different convolution kernels. the study provides a ground truth data-based performance evaluation, as well as a comparison of the dwt and pca to each other by computing and visualising significant differences in their performance. results: in the present study, the dwt, compared to the pca, turns out to be the more powerful and therefore more suitable image fusion method, both qualitatively and quantitatively. conclusion: according to estimates of certain surveyed medical specialists, to whom the results have been shown, a serious diagnosis solely on the basis of fused images is conceivable. the fused images would also be conceivable for documentation purposes and printouts for the referring physicians. finally, storing fused image series instead of individual series would reduce the amount of memory required in long-term archives by half. image registration and fusion of ct and micro-ct of a sheep's cochlea s. leitner; berndorf/at purpose: the sheep's cochlea seems to be most similar to human ones. hence, it is of great interest in the fields of developing cochlea implants and improving operation techniques of electrode implantation in ent-(ear-nose-throat) surgery. methods and materials: for investigating the sheep as a suitable large animal model, data sets of high resolution micro-ct and ct of its cochlea were acquired. the research on inner-ear diseases and ent-surgery methods require image processing methods, such as image registration and image fusion. in this thesis, the micro-ct data set was registered with the ct data set in a common coordinate system using two different software packages. the registration was successful with both types of software. in order to evaluate the results visually, the fused multimodal data were represented by means of colour overlay as well as 3d rendering techniques. the basis of image-registration of these two modalities was laid and serves as comparison between the image information of the high resolution micro-ct and the conventional ct in order to overcome an interpretation gap between these two modalities. the appropriate 3d visualisation of the vestibule-cochlea system by means of the highest resolution image devices and medical image processing methods support fundamental research on macro-and micro-mechanical processes of hearing and basic understanding for developing therapeutic and preventive methods for ear diseases. purpose: scout images are essential in neuroradiology. though these images may have limited diagnostic quality, they visualise larger parts of the body. therefore, certain radiologic findings may be visualised only or largely in the scout images and truly constitute unexpected radiologic findings (uf). impact related to spinal location and imaging modality on to the incidence and distribution of uf remains unknown. methods and materials: 500 patients undergoing ct and 500 patients undergoing mri of spinal column between 11/01/2009 and 1/31/2010 are included. uf reported in the original dictations are separated into 3 groups: scout only (i), scout+diagnostic images (ii) and diagnostic images (iii) only. in addition to type of imaging and spinal location, locations and organ system of these findings are recorded. results: there were 81 uf in ct and 113 in mri group. in both groups, patients with uf were significantly older than the ones without uf, with a slight female preponderance. majority of uf in ct were seen in diagnostic images. uf seen only in scout images of ct were exception although these were significant findings. uf distribution in mri was more even. equal numbers of uf were seen in groups ii and iii. approximately 17% of uf seen in mri were present in group i. conclusion: scout images of neuroradiologic studies may harbour significant number uf. this is especially true in mri where 17% of uf seen only in scout images. although uf seen solely in scout images of ct is rare, these are predominantly significant findings. comparison of a 12-channel-with a 32-channel head coil using snr measurements c. vandulek, d. kaczur, e. vinczen, i. repa; kaposvár/hu (cvandulek@gmail.com) purpose: one of the key attributes characterising the quality of an mri head coil is the signal-to-noise ratio (snr). the purpose of this study was to compare a 12-channel-with 32-channel head coil using standardised snr measurements. the measurements were performed on a 1.5 t mri scanner. the snr measurements were performed on the coils' phantoms and on volunteers. the snr protocol consisted of axial t1 fse and t2 fse measurements. analysis of the snr calculations was performed using roi's positioned in the phantoms and the brain tissue of the volunteers. the results of the snr measurements of the phantoms show that the snr of the 32-channel coil is double that of the 12-channel head coil. however, the snr of the volunteers showed only a 65% increase of snr with the t1 fse measurement, and a 30% increase with the t2 fse on the 32-channel coil. there were no artefacts observed on either measurements of the phantoms and human volunteers. conclusion: this study confirmed a difference of the snr between the 12-and 32-channel head coil. while the phantom measurements showed a twofold increase of snr between the two coils, this rate was not confirmed on the human volunteers. the results of this study amplify the advantage of using the 32-channel coil for neuroradiological examinations (e.g. fmri, mrs), whereas the 12-channel coil is sufficient for routine brain examinations. psychological effect of chronic exposure to high magnetic field on mri technologists n.m. mishah, w. hamed; jeddah/sa (nabeel747@hotmail.com) purpose: the purpose of this study is to measure the incident of depression among mri technologists since they are chronically exposed to high magnetic fields that may carry occupational hazard on central nervous system and on their brain chemicals. this may cause a long-term psychological side effects such as depression. the data and the statistical information of this project were based on beck depression inventory bdi, 1996 version which is used by healthcare professionals as depression screening tool. the questionnaire of depression screening tool was delivered to all mri technologists working in major hospitals within large cities in makkah region. the total completed questionnaire received was 45 and only 40 was accepted with a rejection rate of 11.11%. the received data were analysed using a computer-aided statistical tool then the percentage of depression found among mri technologists included in our study will be compared to previous study conducted on dentists in usa and among community population in saudi arabia. s38 c a d e f g b conclusion: regorafenib significantly suppressed tumour perfusion and vascularity quantified by dce-ct in experimental colon carcinomas in rats with good to moderate correlations to an immunohistochemical gold standard. tumour response biomarkers assessed by dce-ct might be a promising future approach to a more personalised and targeted cancer therapy. author disclosures: k. nikolaou: research/grant support; bayer healthcare, germany. c.c. cyran: research/grant support; bayer healthcare, germany. contrast-induced nephropathy in patients undergoing intravenous contrast-enhanced computed tomography and the relationship with risk factors: a meta-analysis s.i. moos, j. stoker, s. bipat; amsterdam/nl (s.i.moos@amc.uva.nl) purpose: to summarise the incidence of contrast-induced nephropathy (cin) and to study associations between cin and risk factors in patients undergoing intravenous contrast-enhanced computed tomography (cect). we searched the medline, embase and cochrane databases from 2002 till july 2012. two reviewers checked inclusion criteria and extracted data. mean cin incidence and associations between risk factors and cin were pooled by random-effect approach. results: twenty-three articles with 20,000 patients (mean age 64.5 years, mean egfr at baseline 55.17 ml/min) were included. cin was defined as absolute or relative (44.2 µmol/l/> 25%) serum creatinine increase, mostly within 72 hours. all studies included a high proportion of patients with risk factors; chronic kidney disease (ckd) in 52% of all patients, diabetes mellitus (dm) in 14%, hypertension (ht) in 54% and congestive heart failure (chf) in 21%. the mean incidence of cin was 3.7% (95% ci: 2.5%-5.6%). data analysis showed an increased risk for cin in the presence of dm ((odds ratio 1.73 (95% ci: 1.07-2.82), p=0.03)) and ckd (2.52 (95% ci: 1.56-4.08), p=0.0002). ht and chf were not associated with an increased risk (p=0.07, p=0.19). the mean incidence of cin after cect was 3.7% and is associated with dm and ckd. the incidence of cin is mostly reported in studies with a high proportion of patients with risk factors. therefore, the reported cin incidence and associated risk factors for cect might be overestimated compared to the cin incidence in a general population undergoing cect. purpose: to determine whether contrast agent (ca) dose reduction to one-half and one-quarter of the standardised dosage allows for preserved image quality of renal mr angiography at 7t. methods and materials: mr examinations were performed in 6 healthy subjects on a 7t mr system (magnetom 7t), utilising a custom-built 8-channel rf body coil. dynamic 3d flash data sets were obtained pre contrast and 20sec after the application of contrast agent. examinations were performed at three different time points for injection of three dosages of ca (gadobutrol, bayer healthcare): (1) 0.1 mmol/kg body weight (bw), (2) 0.05 mmol/kg bw and (3) 0.025 mmol/kg bw. contrast ratios (cr) were measured pre and post contrast in the aorta and both renal arteries in correlation to adjacent psoas major muscle. qualitative analysis with regard to delineation of the pre-contrast and post-contrast renal arterial vasculature was performed by two radiologists using a five-point-scale (5=excellent to 1= non diagnostic). results: non-enhanced t1w mri provided an inherently high signal intensity of vasculature, yielding a good overall pre-contrast arterial delineation (mean 3.65). the application of contrast agent showed improved vessel delineation in qualitative and quantitative analysis for all three dosages, yielding comparable results in subjective ratings of qualitative analysis (mean0.025gd 4.55; mean0.05gd 4.50; mean0.1gd mean 4.60). quantitative analysis of contrast ratios showed only minor increase of mean values with increasing gadolinium dosage (mean0.025gd 0.08; mean0.05gd 0.15; mean0.1gd mean 0.18). conclusion: 7t ce-mra allows for a significant dose reduction to one-quarter while maintaining high image quality. diagnostic accuracy of dynamic gadoxetic-acid-enhanced mri and pet-ct in patients with liver metastases from neuroendocrine neoplasms purpose: to evaluate the diagnostic accuracy of dynamic gadoxetic-acid-enhanced mri parameters in comparison to standardised uptake values (suv) from both patients with proven liver metastases of neuroendocrine neoplasms (nen) up to three regions of interest (rois) were defined in metastases (> 2 cm) and liver tissue in morphological images. corresponding rois were defined in the dce-mri dataset and in the pet-ct dataset. diagnostic accuracy for all perfusion parameters were evaluated for the differentiation between metastases and liver tissue: arterial and venous plasma flow (apf and vpf), extracellular mean transit time (exmtt), extracellular volume (exvol), intracellular uptake rate (ur) of gd-eob-dtpa and arterial flow fraction (aff) as well as suvs derived either from 18 f-fdg or from 68 ga-dotatate-pet-ct. results: area under the curve for different dce-mri parameters was between auc=0.559 (extracellular mean transit time) and 0.901 (arterial plasma flow -sensitivity: 91.9%, specificity: 77.3%, cut-off value: 26.0 ml/min/100 ml). sensitivity and specificity of suvmean derived from 68 ga-dotatate were 92.6% and 93.8%, respectively (auc = 0.966). suvmean derived from 18 f-fdg-pet-ct showed a sensitivity and specificity of 95.0% and 91 cp class liver damage groups. chi square test was used for statistics and p < 0.05 was considered statistical significant. results: in poor hbp cases (n=76), er of hbp and sdp were 0.88±0.16 and 0.64±0.16. in control cases (n=20), er of hbp and sdp were 0.54±0.08 and 0.39±0.06. er of hbp and sdp in cp-a poor hbp (n=27), cp-b poor hbp (n=47), cp-c poor hbp conclusion: in most of the poor hbp image cases, sdp image improve parenchymal and vascular contrast except cp-c liver damage cases results: we found characteristic signal criteria in all analysed plaque components. applying these criteria gb-pci had a good sensitivity for the detection of fc/nc, iph and ca (all > 80%) and excellent specificity and accuracy (all > 90%) with good inter-reader agreement ([[unable to display character: &#1082;]]³0.72, p < 0.0001). there were excellent correlations for quantitative measurements of fc, nc and ca between gb-pci and histopathology (r³0.92). inter-reader reproducibility was excellent with icc³0.98 for all measurements. conclusion: gb-pci can identify and quantify atherosclerotic plaque components in a lab-based set-up with excellent correlation to histopathology. imaging of the therapeutic efficiency of photodynamic therapy with a new designed fluorescence optical annexin probe k. haedicke, s. gräfe, f. lehmann, w.a. kaiser, i. hilger; jena/ de (katja.haedicke@med.uni-jena.de) purpose: photodynamic therapy (pdt) destroys tumour tissue via generating reactive oxygen species after administration of a photosensitizer and illuminating the tumour with light. next to many other molecular processes, apoptosis occurs in the tumour after this therapy. we designed a new fluorescence optical probe based on annexin v to detect this therapeutic effect after pdt in vivo via non-invasive near-infrared fluorescence optical imaging. methods and materials: annexin v was labelled with the near-infrared dye dy-734-nhs and characterised spectroscopically. binding affinity of the probe to apoptotic tongue-squamous epithelium carcinoma (cal-27) cells was analysed by purpose: to evaluate the potential of the reconstruction algorithm idose to preserve image quality in brain-ct acquired with 30% reduced radiation dose and to evaluate image quality assessment methods. interaction of magnetically labelled multipotent mesenchymal stromal cells and e-/p-selectins monitored by magnetic resonance imaging in mice j. salamon, k. peldschus, d. wicklein, c. lange, h. ittrich, u. schumacher, g. adam; hamburg/ de (j.salamon@uke.de) purpose: this study's purpose was to analyse the influence of e-and p-selectins on the migratory pattern of magnetically labelled multipotent mesenchymal stromal cells (msc) in e-/p-selectin deficient (ko) and wildtype (wt) mice using mri and fluorescence microscopy. methods and materials: murine msc were labelled with fluorescent iron-oxide micro-particles and carboxyfluorescein succinidylester. the ability to bind selectins and the expression of typical msc markers were assessed by flow cytometry. labelled msc were injected into ko-and wt-mice applying doses of 5 × 104 cells intracardially, 1 × 106 cells intravenously and 5 × 106 cells intraperitoneally. mice underwent sequential mri at 3.0 t using high-resolution t2* 3d and 2d coherent gradient-echo sequences and histological evaluation after 7 days. results: expression of typical msc markers and binding abilities to e-/p-selectins were found similar after labelling. after intravenous cell injection in ko-mice significant snr decrease was assessed solely in the liver from day 0 to 1; wt-mice revealed an increasing snr decrease of liver, spleen and bone marrow within 7 days. after intraperitoneal injection no significant snr changes were observed in ko-mice; wt-mice showed an increasing snr decrease of liver, spleen and bone marrow within 7 days. after intracardiac injection multiple susceptibility artefacts could be detected no longer then day 4 in ko mice but persisted up to day 7 in wt-mice. fluorescence microscopy confirmed mri findings. conclusion: this study demonstrates that msc retain their binding ability to e-/p-selectins after magnetic labelling. e-/p-selectin deficiency in mice significantly alters the distribution of magnetically labelled msc. de (holger.haubenreisser@medma.uni-heidelberg.de) purpose: to prospectively compare the image quality of cranial computed tomography (cct) with thin slice widths using traditional filtered back projection (fbp) and sinogram-affirmed iterative image reconstruction (safire). methods and materials: 40 consecutive studies (19 men; 71.6±16.6 years) referred for cct were prospectively included. each cranial ct raw data set was reconstructed with fbp and safire with decreasing slice widths (5 mm-1 mm). objective image quality was assessed by measuring image noise in three predefined regions of the brain (white matter, thalamus, cerebellum) using identical regions of interest (rois). subjective image quality was assessed by 2 experienced radiologists by ranking the reconstructed data sets with respect to overall image quality. the mann-whitney u-test and cohen's kappa were used for statistical analysis. results: image noise was statistically significantly reduced in all safire images at identical slice widths when compared to the images reconstructed with fbp (4.26±0.43 hu vs. 7.67±1.19 hu at 1 mm slice width) (p < 0.001). mean signal attenuation for each region and slice width remained constant between the two reconstruction methods (p> 0.5). snr was comparable between 1 mm safire images and 5 mm fbp images. subjective image quality of safire images was rated consistently higher than that of the fbp images (p < 0.001). interobserver agreement was excellent between both radiologists (cohen's k = 0.79-0.86). conclusion: iterative image reconstruction significantly reduces image noise, while increasing image quality. in cct this may be used to decrease slice width and thus reduce partial volume effects, which may lead to increased diagnostic accuracy. purpose: the aim of our study is to demonstrate the effectiveness of 3d mri in the diagnosis of lumbar radiculopathy in comparison with clinical and neurophysiological data. methods and materials: 32 patients with l5 or s1 monoradiculopathy caused by a posterolateral or intraforaminal disk herniation underwent mri examination after preliminary clinical assessment and electromyography (emg). we performed conventional spin-echo and 3d coronal ffe sequences with selective water excitation (proset imaging). using 3d coronal ffe sequences indentation, swelling and tilting angle of the nerve root were evaluated. the tilting angle was compared with the asymptomatic contralateral side of the nerve root. all the data were processed using epi info 3.3 software (cdc, atlanta, ga, usa) and were compared by means of fisher exact test. results: proset sequence revealed abnormal tilting angle in 18 patients (57.2 %; p < 0.05), monolateral swelling or indentation of roots and spinal nerves in 28 patients (85.7%; p < 0.001). in 10 patients emg demonstrated an involvement of more than one nerve roots, whereas the proset revealed only one involved root. in 2 patients the nerve alterations were revealed only by emg. conclusion: emg has an improved ability to highlight the early changes of the roots caused by mechanical and biochemical alterations due to compression. proset imaging demonstrates high sensitivity in identifying the exact level of the involved root and can provide a useful tool to plan surgical treatments. purpose: to investigate the utility of dti in detecting nerve injury or neuropathic changes in proximal nerve segments in patients with peripheral neuropathy. methods and materials: twenty-four age-matched individuals with (n=14) and without (n=10) peripheral neuropathy underwent dti of a defined sciatic nerve segment. patients and controls were evaluated by clinical examination and nerve conduction studies at baseline and six months after the initial dti scan. four patients were scheduled for a second scan six months after the initial mri. results: the mean fa value was significantly lower in sciatic nerves from patients with peripheral neuropathy as compared to controls. sciatic nerve fa values positively correlated with clinical disability scores and electrophysiological parameters of axonal damage, i.e. the compound muscle action potential amplitudes of the peroneal and tibial nerve at baseline and six months after mri scan. no correlation was found with axial and radial diffusivities. conclusion: dti-derived fa values are a sensitive measure to discriminate healthy from functionally impaired human sciatic nerve segments. this technique might be potentially useful in estimating the proximal axonal degeneration burden in patients with peripheral neuropathies. purpose: the purpose is to describe the imaging features of the involved brainstem and spinal cord tracts in cases of leukodystrophy with brainstem and spinal cord involvement and brain lactate elevation (lbsl). the importance of craniovertebral and cervicomedullary angle on cervicogenic headache g. çoban 1 , i. çöven 1 , e.b. çifçi 1 , e. yıldırım 1 , c.a. yazıcı 2 , b. horasanlı 1 ; 1 konya/tr, 2 ankara/tr (drgokcencoban@gmail.com) purpose: many studies indicated that cervicogenic headache (ch) may originate from cervical structures innervated by the upper cervical spinal nerves and the trigeminal nerve branches. studies to date have not investigated whether the narrowing of the craniovertebral angle (cva) and cervicomedullary angle (cma) affects the nerve branches and causes pain. the aim of this study was to investigate the effect of the narrowing of the cva and cma values on the occurrence ch. methods and materials: between january 2011 and may 2012, 205 patients with the diagnosis of ch were included in the study. the pain scores in patients were carried out using a visual analogue scale from 1 to 4 (pain groups purpose: to assess the image quality after image-based processing of low-dose single-rotation intra-procedural 4d-fd-ct (sr 4d-fd-ct). multiple rotation contrast-enhanced 4d-fd-ct is associated with many c-arm projections (~1000 projections) and a high amount of contrast agent (ca). in this feasibility study, we used a single-rotation of the c-arm (artis zee biplane, siemens ag, healthcare sector, germany) accompanied by cardiac pacing acquiring a reduced number of low-dose projections (~100-400 purpose: to demonstrate that myocardial microvessels detection is feasible at high-resolution susceptibility-weighted mr imaging (swi). methods and materials: fourteen wistar rats underwent ex vivo cardiac mr imaging on a 4.7 tesla scanner using a cryogenic device. thin, tubular hypointensities within the myocardium of normal rat hearts at high-resolution susceptibility-weighted mr imaging (group 1, n=6) were presumed to be intramyocardial microvessels.to prove that these "strand-like" structures were microvessels, a reference map of the myocardial macrovessels (group 2, n=4) after direct intracoronary injection of barium sulphate, a viscous contrast media was defined. then, a superparamagnetic contrast agent (ferumoxsil, lumirem ®), an intravascular contrast agent, was injected to stack up the distribution of intramyocardial microvessels (group 3, n=4). for groups 2 and 3, 3d fast imaging with steady state in precession (3d fisp) sequences was performed. the results of images in group 1 (spatial resolution: 39 μm) and group 3 (spatial resolution: 39x39x39 μm 3 ) were qualitatively compared. results: after intracoronary artery injection of barium sulphate, the main coronary arteries were visible up to the third-order branches (group 2). beyond this level, the coronary microvasculature was opacified with ferumoxsil (group 3) as demonstrated by the presence of ferumoxsil inside the microvessels on mr-matched histological sections. the regional distribution of microvessels was similar between groups 1 and 3. conclusion: myocardial microvessels appear as "strand-like" structures on highresolution mri without injection of contrast media. this provides new methods for evaluation of neovascularization in preclinical models of myocardial infarction. purpose: to prospectively compare the image quality and homogeneity of cardiac t2-weighted dark blood images using a dual-source parallel radiofrequency (rf) transmission mr system with rf shimming at 3.0 t and conventional mr imaging at 3.0 t. methods and materials: dual-source parallel rf transmission 3.0 t mr system with local rf shimming was used to obtain t2-weighted dark blood images in 31 patients and compared with standard mri at 3.0 t. snr was determined in the interventricular septum (is), the lateral wall (lw), the right ventricular cavity (rv) and left ventricular cavity (lv) in the anterior wall (aw), posterior wall (pw) and in the left ventricular cavity (lv) in two-chamber orientation. (kerstin.bauner@med.uni-muenchen.de) purpose: to assess dynamic t1 shortening effects of equimolar doses of gadobutrol and gadoterate meglumine in myocardium and the effect on extracellular volume fractions (ecv) in an animal model. methods and materials: 10 rabbits underwent cardiac mri under general anaesthesia on a 1.5 tesla scanner using an 8-element knee coil. exams included ssfp cine imaging as well as pre-and post-contrast myocardial t1-mapping using a modified look locker inversion recovery (molli) technique. each animal was scanned twice with a 24-h interval after receiving either 0.1 mmol/kg gadobutrol methods and materials: twenty-five breast lesions classified suspicious in mammography or ultrasound (birads 4/5) were included in this prospective irb-approved study. all patients underwent 7t mri (siemens magnetom, erlangen, germany) using a dedicated 4-channel breast coil and a high temporal and spatial resolution 3d t1-weighted sequence (twist, fat-sat, 0.7 mm isotropic, temporal resolution 14sec, examination time 9 min) with a single dose of contrast agent (dotarem, guerbet). one patient had to be excluded due to insufficient data quality. two readers trained in different institutions independently assessed lesion morphology and enhancement kinetics and classified them according to bi-rads. lesion size, localisation and image quality were assessed. sensitivity, specificity, diagnostic accuracy and interrater agreement (kappa statistics) were calculated for both observers. the histopathological diagnoses were used as the standard of reference. results: there were three benign and 21 malignant lesions. mean histopathological size was 25 mm (range 8-51 mm). on the basis of lesion morphology and enhancement patterns, all lesions were correctly classified as benign (n=3) and malignant (n=21) by 7t ce-mri. sensitivity, specificity and diagnostic accuracy were 100%. interrater agreement for bi-rads ratings was excellent (0.928). kappa agreement for single bi-rads descriptors ranged between 0.709 and 1. conclusion: high spatial and temporal resolution imaging in clinical practice is feasible using 7t mri, revealing excellent diagnostic accuracy and interrater agreement. purpose: to study a potential role of quantitative mri (qmri) using t1/t2 ratios to differentiate benign from malignant breast lesions, assess contralateral breast involvement and monitor response to treatment. a cross sectional study of 41 women with 46 breast lesions were scanned with the mixed-tse pulse sequence, which is multispectral in t1 and t2, therefore, affords maps of t1/t2. patients were grouped according to histopathological stage of disease: untreated malignant tumor, treated malignancy and benign disease. qmri assessment of the same quadrant of contralateral breast that did not have cancerous lesion was performed and compared to the breast that was subjected to chemotherapy and/or radiation therapy in order to monitor response to treatment. results: elevated t1/t2 means of 6.44 ± 1.05 (n=7) were observed for biopsy proven malignant lesions and 5.98 ± 0.63 (n=21) for malignant lesions that were treated prior to qmri with chemotherapy and/or radiation as compared to 3.88 ± 0.43 (n=18) for benign lesions. the higher stage of cancer determined by histopathology analysis was also strongly associated with higher t1/t2 ratio (p= 0.0093). estrogen and progesterone receptors negative status was strongly correlated with higher t1/t2 ratio p=0.060 and p=0.0427, respectively. her2/neu receptor status showed no significant correlation with t1/t2 ratio (p=0.1506). the t1/t2 ratios provide measures that strongly correlate with histopathological findings. this quantitative information of tissue properties can provide basis for improving the specificity of diagnostic breast imaging and serve as a tool to assess response to treatment and contralateral breast involvement. improved differentiation of breast tumours using novel imaging system based on co-registered opto-acoustic tomography and ultrasound p. otto 1 , k. kist 1 , n.c. dornbluth 1 , t. stavros 1 , d. herzog 1 , b. clingman 1 , j. zalev 1 , p. lavin 2 , a. oraevsky 3 ; 1 san antonio, tx/us, 2 southborough, ma/us, 3 houston, tx/us (ottop@uthscsa.edu)purpose: a novel system called imagio combines ultrasound and opto-acoustics (oa) to more accurately distinguish malignant from benign tumours. we analysed readers' ability to assess probability of malignancy (pom) using oa versus conventional diagnostic ultrasound (dus) alone. methods and materials: 73 patients with breast masses were assessed with oa and dus. all the masses were biopsied. histology was the gold standard. oa employs near-infrared laser pulses at two different wavelengths (to provide contrast between oxygenated haemoglobin in benign lesions and de-oxygenated haemoglobin in malignant lesions) to illuminate tissues through a fibreoptic bundle incorporated into a prototype duplex hand-held ultrasound probe. it detects the laser-generated ultrasonic pressure waves that are then used for reconstruction of two-dimensional oa images. oa maps of total haemoglobin and blood oxygen purpose: to assess metabolic imaging of breast tumours with breast 18 f-fdg pet-ct and compare it with 3 t ce-mri. methods and materials: 159 suspicious breast lesions were included in this irb-approved prospective study. all patients were examined with 18 f-fdg pet-ct and 3 t ce-mri of the breast. the mri protocol consisted of a t2-w and a contrast-enhanced high-resolution 3d-t1-w sequence with a single dose of contrast agent (dotarem®, guerbet). all patients were subjected to prone 18 f-fdg pet-ct scanning. ct data were used for attenuation correction. breast pet-ct was assessed for 18 f-fdg-avidity of lesions. tumours were classified as positive when 18 f-fdg-uptake was greater than blood-pool activity. lesions within tissues demonstrating moderate/high physiologic background activity were considered positive if the activity was greater than the adjacent physiologic activity. 3 t ce-mri was assessed for lesion morphology and enhancement kinetics and classified according to bi-rads®. all lesions were histopathologically verified. results: pet-ct had a sensitivity of 96%, a specificity of 76% and diagnostic accuracy of 90%. ce-mri had a sensitivity of 100%, a specificity of 80% and a diagnostic accuracy of 94%. there were 46 benign and 113 malignant lesions (mean lesion size 26.03 mm; range 5-90 mm). the 5 false-negative lesions in pet-ct were small lesions (mean 11.2 mm), had a very low suv (mean suvmax 1.59) or were adjacent to tissue with high physiologic activity or low grade idcs. conclusion: 3 t ce-mri is superior to pet-ct for assessment of breast lesions, but dedicated breast pet-ct is a valid alternative in patients, who are unsuitable for mri. high spatial and temporal resolution breast imaging at 7 purpose: to validate a contrast-enhanced (ce) combined high spatial and temporal resolution imaging protocol for the assessment of breast tumours at 7 tesla in clinical practice. the aim was to evaluate the safety and efficacy of cra as local therapy for breast carcinomas with bone metastases. methods and materials: sixteen cra breast lesions, mean size 2.4 (range 0.8-6.7 cm) in thirteen consecutive patients, mean age 52 (36-81) with core-needle biopsy-proven breast carcinoma and bone metastases were enrolled in this study. 10 patients had one lesion and three patients had 2 lesions. under local anaesthesia and mild conscious sedation, the tumour and surrounding breast tissue were ablated with percutaneous ct-guided cra. cryoablation consisted of 2 cycles each of 10 minutes of freezing followed by a 4-min active thawing phase and a 4-min passive thawing phase for each one. ten patients underwent one cra session and two patients 2 cra sessions. one patient is treated with two sessions for the same lesion. results: all cra sessions were successfully completed and all breast tumours were ablated. morbidity consists in transient and mild ecchymotic changes and post-procedural oedema seen in two cases and alteration in skin pigmentation seen in the point of insertion of the cryoprobes in other two cases. the therapeutic outcomes were evaluated by contrast-enhanced tc or mri at 1-, 3-and 6-month interval. purpose: stereotactic vacuum-assisted biopsy (vabb) is the first choice technique to characterise suspicious microcalcification clusters; however, considerable proportion of understaged invasive cancer (idc) at subsequent surgical histology has been reported. bles, thanks to a radiofrequency excisional system, remove a larger not fragmented histological sample (25x20 mm, weight 3 g). our aim was to prospectively assess bles diagnostic and eventually therapeutic efficiency in a selected cohort of patients with suspicious microcalcification cluster. methods and materials: from september 2010, patients with small microcalcification cluster, < 1 cm, staged 4a-4b according to bi-rads classification system, were proposed for excisional biopsy with bles. written informed consent was obtained.results: up to now, 80 patients underwent bles at our centre; 32 of them (40%) had malignant lesion, 7 were idc and 25 (78%) in-situ (dcis) carcinoma. rationale of the study was to completely remove microcalcification clusters, obtaining enough surrounding tissue for histological margins' evaluation. complete histological concordance was obtained in 100% of atypical hyperplasia. all patients with dcis underwent surgical excision: upgrading to idc resulted in only 3/25 (12% underestimation proportion); among dcis cases, surgical excision demonstrated complete removal of the lesion by bles in 18/25 patients (72%). conclusion: in our experience, bles is a valid, simple and safe alternative to vabb, providing better diagnostic performance evaluated as histologic accuracy with lower underestimation rate compared to previously reported for vabb. in selected cases, particularly in small microcalcification clusters, bles may represent an interesting new therapeutic strategy considering the high rate of complete lesion removal. purpose: the objective of the study is to assess the use of "intact" breast lesion excision system as the primary method for histopathology diagnosis in suspicious small and borderline lesions as well as the unclassified microcalcifications. methods and materials: 58 cases were included (feb-august 2012). inclusion criteria: small lesion less than 20 mm, unclassified microcalcifications, asymmetric densities, focal distortion. results: 52 cases were successfully done, 88.5% (46 /52) cases were done under ultrasound guidance and 11.5% (6/52) cases were done under stereotactic guidance. 38.5% (20/52) lesions were removed using the 15 mm probe and 61.5% (32/52) lesions were removed using the 20 mm probe size. the main indication was complete removal of a small mass (20/52) followed by biopsy of unclassified microcalcifications, either without mass (8/52) or associated with a mass (8/52). asymmetry and distortion were the indications in (6/52) and finally clustered micro cysts (8/52). as regards the histopathology after total excision; 90.4% (47/52) of lesions were benign and only 9.6% (5/52) of lesions were malignant. fibroadenoma was the commonly encountered benign lesion in the study group, it was encountered in 38.5% (20/52), followed by papilloma found in 19.3% (10/52), followed first experiences with a self-test for dutch breast screening radiologists as a quality assurance tool j. timmers 1 , a. verbeek 1 , r. pijnappel 2 , m. broeders 1 , g. den heeten 3 ; 1 nijmegen/nl, 2 utrecht/nl, 3 amsterdam/nl (j.timmers@lrcb.nl)purpose: to evaluate the use of a self-test as a quality assurance tool for screening radiologists in the dutch breast cancer screening programme. methods and materials: 144 screening radiologists were invited to voluntarily complete a test set of 60 screening mammograms. the following grading criteria were assigned regarding the most suspicious lesion: location, level of suspicion, bi-rads, laterality, type (well defined mass, ill defined mass, spiculated mass, microcalcification clusters, architectural distortion and asymmetric density) and mammographic density are assigned. also, several reader characteristics, such as years of experience and number of cases read per year, were to be completed. case and lesion sensitivity and specificity were determined for all readers. the spearman correlation coefficient was used to determine correlation between reader characteristics and performance measured by the area under the receiver operator characteristics (roc) curve (auc). results: 112 radiologists completed the test set (78%). the mean age was 49 (range 33-68) and on radiologists read on average 10,000 (range 700-60,000) screening mammograms per year. the median auc value was 0.91, case sensitivity 91%, lesion sensitivity was 91% and specificity 94%. the auc was not correlated to reader characteristics. the test-set revealed interobserver variation in assigning lesion types. conclusion: overall, a good performance was seen among all screening radiologists. readers are able to determine their educational needs and compare it with peers during training or audits. it is therefore a useful quality assurance tool. medical education should be dedicated to reducing interobserver variation. transition from analogue to digital screening mammography significantly increases the proportion of women referred twice for the same lesion l.e.m. duijm, h. wiersma; eindhoven/nl (lemduijm@hotmail.com) to determine the effect of transition from analogue to digital screening on the proportion of women referred twice for the same lesion and to assess screening outcome. we included 302,912 consecutive analogue screens (obtained between january 2000 and april 2010) and 90,288 consecutive digital screens (obtained between july 2009 and july 2011). review of the screening mammograms of women who had been referred twice was performed to determine whether their initial and second referral comprised the same lesion. during 1-year follow-up, radiology reports, surgical correspondence and pathology reports of each referred woman were collected. results: the overall positive predictive value (ppv) of referral was 37.3% at analogue screening and 22.0% at digital screening (p < 0.001). among women who had only been assessed by analogue screens, 37 (0.9% of referrals) had been referred twice for the same lesion. these referrals included 13 malignancies (ppv 32.4%). among the 90,288 women who received their first digital screen following one or several previous analogue screens, 52 (1.9% of digital referrals, p < 0.001) were referred again for a lesion for which she had been referred previously at analogue screening. these second referrals included 8 malignancies (ppv 15.4%, p=0.03). conclusion: implementation of digital screening significantly increased the proportion of women referred twice for the same lesion. their ppv was significantly lower than the one found in women who had been referred repeatedly for the same lesion during analogue screening. purpose: to determine the impact of audits as a quality assurance tool to improve breast cancer screening performance. the dutch centrally organised breast cancer screening programme offers biennial mammography to women aged 50-75 years. a team of the national expert and training centre for breast cancer screening with peer radiologists conducts audits of all 16 reading units every 3 years as part of the quality assurance programme. data on screening outcomes are assessed and a on statistical significance and clinical relevance are: age, mass, calcifications, parenchymal deformity and asymmetric density. conclusion: with our nomogram we developed a tool to assist screening radiologists in determining the chance of malignancy based on mammographic findings. we propose cut-off values for assigning bi-rads categories in the dutch screening setting based on our nomogram which will need to be validated in future research. these values can easily be adapted for use in other screening programmes. purpose: automated 3d-breast ultrasound (abvs) is investigated as a six-monthly addition to annual breast cancer screening with mri+mammography (mm) in highrisk women (ltr> 50%). abvs, an inexpensive radiation-free technique, allows more frequent screening and temporal comparison. this study assesses effects of additional abvs examinations at baseline. the study population consists of 234 women in whom abvs and mm were performed on the same day. all abvs and mm examinations were read by one of 4 breast radiologist. the recall rate (rr), biopsy rate (br), cancer detection rate (cdr), sensitivity and specificity of abvs and mm screening were analysed. results: based upon mm, 28 patients were recalled for further examination (rr=12%). with abvs 12 of these patients were also recalled, as well as 17 other women. consequently, the rr increased to 45/234. biopsies were deemed necessary in 21 patients after mm and increased to 26 with abvs added, an increase from 9%-11%. 17 additional abvs findings were resolved with targeted ultrasound. in total 4 cancers were found by mm (cdr 1.7%, sensitivity 100%, specificity 89%). two of these cancers were also detected by abvs (cdr 0.9%, sensitivity 50% specificity 88%). the two missed cancers were retrospectively visible, but misinterpreted due to post-operative scarring. conclusion: adding abvs to high-risk mm screening increased rr and br at baseline. whether these negative effects are reduced when radiologists gain more experience and whether they are balanced by earlier detection of breast cancer due to the six-month interval of abvs remain to be determined.radiological review is performed (40 interval cancers, 40 screen detected stage-ii cancers and 40 consecutive recalled cases). the audit is completed with a report, summarising the results and giving recommendations. this study compares four audit series (1996-2000/2001-2005/2003-2007/2010-2011) . results: recall rates (subsequent screens) increased from 6, 10, 12 to 14 per 1000, respectively, in the four series. detection rates also increased from 3.3, 4.3, 4.7 to 5.7 per 1000. distribution of tumour size and lymph-node status of invasive tumours remained stable (p=0.4). the percentage interval and screen-detected stage ii cancers classified as "missed" during the review did not change (22% to 25%, p=0.1). review of consecutive recalled cases showed an increasing number of cases the audit team would not have recalled with a higher recall rate of the screening radiologists. conclusion: we found audits are helpful in controlling the balance between (false positive) recalls and detected breast cancers. it also serves as a learning and feedback tool as it triggers discussion between screening radiologists. overall, it can be seen as an important quality assurance tool. purpose: according to current dutch guidelines, all women following a positive screening mammogram are referred for a full hospital assessment including surgical outpatient clinic and radiology department. till 2007, all women with a positive screening mammogram in our screening region were only referred for further assessment to our radiology department. purpose of this study was to determine how often surgical consultation in women with a positive screening mammogram could be avoided by a radiological pre-assessment. methods and materials: all women with a positive screening mammogram, n=1014, referred to our radiology department from 2002 to 2007 were included. data were prospectively collected by a senior breast radiologist. in-hospital follow-up data were available till september 2012. descriptive statistics were used. percentage of patients only assessed by a radiologist was determined. negative predictive value for malignancy was calculated from the in-hospital follow-up. results: 427 of 1014 women (42%) were only assessed at the radiology department without further surgical consultation. during follow-up, 8 of these 427 women (2%) developed a malignancy in the same breast. at least 6 of these malignancies were located at a different location than the original screening findings which led to the initial referral. the estimated negative predictive value for malignancy was 99.5%. conclusion: by referring women with a positive screening mammogram to the radiology department for a pre-assessment, a surgical consultation was avoided in 42%, with an estimated negative predictive value for malignancy of 99.5%. purpose: to determine the ability of t1 mapping of liver on gd-eob-dtpaenhanced mr imaging (mri) for estimating liver function and to compare the estimated liver function to the model for end-stage liver disease (meld) score. methods and materials: 24 patients underwent gd-eob-dtpa-enhanced mri on a 3 t system. patients were classified into two groups: meld score < 9 (n=15) and meld score ³9 (n=9). two turboflash sequences (ti = 400 ms, 1000 ms) were acquired before and 20 minutes after gd-eob-dtpa administration to obtain t1 maps. t1 relaxation times were determined indicating gd-eob-dtpa liver-uptake and correlated to the meld score. results: significant changes between t1 relaxation times of non-enhanced mri (794 ms ±136 ms) and gd-eob-dtpa-enhanced mri (351 ms ± 141 ms) were observed (p < 0.001). t1 relaxation time for non-enhanced mri showed no significant differences (p=0.387) between the group with meld score < 9 (776 ms ± 157 ms) and the group with meld score ³9 (824 ms ± 90 ms). after administration of gd-eob-dtpa t1 relaxation time of patients with meld score < 9 (284 ms ± 104 ms) and patients with meld score ³9 (465 ms ±123 ms) shows a significant difference (p=0.002). the shortening of t1 relaxation time was significantly lower for patients with a higher meld score (p=0.002). conclusion: patients with advanced liver disease showed significantly lower changes in t1 mapping. therefore, evaluation of changes in t1 mapping of the liver parenchyma may serve as a useful method to determine whole liver function, to improve the estimation of segmental liver function and finally to define the grade of liver disease. liver dysfunction induced by amiodarone therapy: evaluation by sequential ct studies y. sonoyama, t. tajima, t. shiga, n. hagiwara, s. sakai; tokyo/jp (y-sonoyama@rad.twmu.ac.jp)purpose: to evaluate the relationship between the sequential changes of ct attenuation of the liver (ctl) and liver damage after administration of amiodarone (amd) for treatment of refractory ventricular arrhythmias. this was a retrospective study of 45 patients (26 men, 19 women: age range 19-89, mean 59) with amd administration. serum level of drugs (amd and desethylamiodarone (d-amd), a metabolic product of amd), the percentage of rises in serum alanine transaminase (alt) level (alt%) and total administered dose of amd at evaluation ct were evaluated and compared with the ctl. as regards to 23 patients who underwent ct before the initiation of amd administration, the medication periods and total administered doses of amd were compared with changes in ctl.results: there was a mild correlation between ctl and mean medication period (p=0.0238, r=0.337). there was a strong correlation between ctl and serum level of amd (p < 0.0001, r=0.699), whereas there was a moderate correlation between ctl and serum level of drugs (amd) (p < 0.0001, r=0.574). there were significant correlations between total doses of administered drug and the ctl (p=0.0008, r=0.480) and between alt% and the ctl (p=0.0078, r=0.420). conclusion: ctl was demonstrated to correlate with total administered doses of amd, alt%, medication periods and serum level of drugs, especially of d-amd. serial changes in ctl can be a sensitive less-invasive biomarker in patients treated with amd. the estimated population dose per caput is 1 msv, which is lower than corresponding dose in usa (3 msv) or in australia (1.7 msv). the highest average contribution is from ct, 56 %. from plain radiography, fluoroscopy and interventional radiology the proportional fractions are 19%, 17% and 7.5 % respectively. from diagnostic nuclear medicine procedures, the estimated mean effective dose per caput is 0.036 msv. heart and bone examinations contribute 40% and 36%, respectively. conclusion: there were high variations between countries in frequencies (for example, in thorax radiography about ten-fold between spain or portugal and germany) and typical effective doses (for example, in ct head four-fold between denmark and luxembourg). this presentation will review the available data in europe using graphs in which countries can be identified. furthermore, the procedures contributing most to the population dose are highlighted. purpose: to assess the feasibility of the volumetric estimation of the left liver lobe, with 3d ultrasound, with mri comparison and surgical specimen. methods and materials: the data of 19 consecutive patients referred for giving their left liver lobe to a child were reviewed (living donor transplantation program). the measurements of the 3d volumes of the segments ii and iii were performed retrospectively with comparison of the same evaluation performed with mri (the reference and routine technique for the preoperative assessment of the liver size). all the examinations were done twice by 2 experts radiologists and radiologists in training. the results were statistically analysed (variance test, gage r&r and bland-altman). 3d and mri measurements were compared and related to surgically proved volume quantification. results: intra-and inter-observators reproducibility was poorly conclusive (for us and mri): gage r&r analysis is related to a prr of 57% for us and 54% for mri. bland-altman analysis was giving an underestimation of volume measurements with us (bias from -11 ml to -44 ml). agreement limits (-1.96sd to +1.96sd) for the 4 observators were included between -174.3 ml and +103 ml (from -71.6% to + 43.5%). conclusion: correct estimation of the left liver lobe volume performed with 3d or mri is related to a low repeatability and a low reproducibility for both techniques. bland-altman analysis is also related to significative differences of volume measurement in both techniques. an accurate formula for a quick estimate of liver volume in polycystic liver disease m. chrispijn, t.j.g. gevers, j.p.h. drenth; nijmegen/nl (melissachrispijn@gmail.com)purpose: polycystic liver disease (pld) patients have severe hepatomegaly. primary aim of treatment is total liver volume (tlv) reduction. the gold standard to assess tlv is ct volumetry which involves manual delineating of the liver outline. this is time consuming and requires expertise. there is a clear need for an easy and fast approach to estimate tlv in routine practice. methods and materials: all pld patients with ³1 ct scan were considered for inclusion. we measured the liver in transverse (t), anterioposterior (ap) and craniocaudal (cc) directions and performed ct liver volumetry. we had access to an inception and a replication cohort. we performed multiple linear regression to predict tlv using the three dimensions in the inception cohort. liver volumes were transformed logarithmically. the goodness of fit of the prediction model was assessed and stated as r 2 . finally, we validated the prediction model in our replication cohort. results: the inception cohort included 54 pld patients (median tlv 3890 ml (range 1084-13611 ml)). all three diameters were significantly correlated with tlv (p < 0.001). the linear regression model resulted in the following formula: predicted tlv = 4,179+(0.009*t)+(0.007*ap)+(0.001*cc). our model predicted tlv accurately in the inception cohort (r 2 =0.907 adjusting and measuring ct dose in severely obese patients r. marcus, f. bamberg, k. neumaier, m.f. reiser, t.r.c. johnson; munich/ de (roy.marcus@med.uni-muenchen.de) purpose: ct in morbidly obese patients remains a challenge with respect to dose and image quality. automatic adaptation of parameters results in high dose length products which do not reflect the actual dose due to the shielding by the fat. aim of this study was to determine the actual dose and image quality. methods and materials: an alderson phantom was equipped with 116 thermoluminiscent detectors. scans were performed using three set-ups: (i) 'obese' phantom in 30-cm circumferential fat (simulating 175 cm/300 kg patient) with a dual--source protocol at 2x140 kvp with current modulation; (ii) obese phantom with automatic potential and current modulation; (iii) slim phantom with automatic potential and current modulation; dose was calculated according to ircp-103 and based on dlp. image quality was assessed subjectively and by image noise. patient-specific whole body voxel model for accurate monte carlo ct dose estimation n. saltybaeva, y. smal, d. kolditz, w. kalender; erlangen/ de (natalia.saltybaeva@imp.uni-erlangen.de) purpose: the accuracy of ct dose estimates based on monte carlo (mc) techniques is limited as data is only available for the scanned volume. the purpose of this study was to generate and to validate whole body voxel models using the patient ct images extended by established voxel phantoms. methods and materials: measurements were performed on a somatom definition flash scanner (siemens, forchheim, germany) using the anthropomorphic rando-alderson phantom. the absorbed dose was measured using a set of 90 calibrated thermoluminescent dosimeter (tld) chips for thorax protocols with tube voltage of 80, 100 and 120 kv. whole body voxel models were built as a combination of the patient ct images and the icrp adult male reference voxel phantom. mc simulations were performed using the impactmc software (ct imaging gmbh, erlangen, germany) for only the scanned volume and for the combined whole body model. measured and simulated dose values were compared for each tld chip. results: at 120 kv, the dose values obtained by mc simulations based on only ct images differed from tld measurements by 19% on average with a maximum difference of 37% for the border slices, while the whole body model allowed for a mean difference of 6%. the difference between measured and calculated results was reduced by 53%, 60% and 68% for 80, 100 and 120 kv, respectively, when using the whole body voxel model instead of the ct-scanned volume only. the proposed whole body voxel model for monte carlo simulations significantly improves the accuracy of patient-specific ct dose estimates. purpose: accurate patient dose estimation using ct imaging is important particularly as the modality is being increasingly used. body habitus varies and the use of monte carlo simulations for "standard man" phantoms does not provide accurate dose estimation for non-standard patient sizes. the study proposes an algorithm for dose estimation for an individual patient from simulated data from mathematical phantoms. the algorithm interpolates doses simulated for ornl mathematical phantoms accounting for differences on patient and phantom sizes. four patient models were produced using 2 anthropomorphic phantoms (representing 1-and 5-year-old children) with and without an additional fat-equivalent layer. all phantoms were scanned at 80 and 120 kv (trunk protocol). doses were measured with 60 tld dosimeters. additionally, dicom images were segmented for organs and data were used as input for dose simulation. all simulations were performed with validated tool (impactmc). doses for phantoms and patients were estimated from the mc simulations using the proposed algorithm. calculated and measured doses were compared. the algorithm improved accuracy in dose estimation by 49, 35, 30, and 21% for small thin, small thick, large thin and large thick phantom sizes, respectively, compared with estimates based on ornl phantoms only. for patient data the accuracy in lung dose estimates improved from 15 to 4%, and from 108 to 15%, for 2-and 6-year-old patients, respectively. conclusion: the proposed algorithm improves dose estimation accuracy for individual paediatric patients. it is simple and suitable for implementation in software tool for dose calculation. purpose: the combined availability of dicom radiation dose structured report and active personal dosimeters in interventional radiology (ir) can support the optimisation of radiation protection, both of patient and staff. methods and materials: for nine months, interventionalists performing interventional cardiology procedures have used a personal active dosimeter (doseaware, philips) worn over the apron. information is displayed in real-time and transmitted to a database. the patient dosimetry report (allura fd10, philips) has been also automatically collected for all procedures. a matlab routine integrates both information on procedure data and patient and staff exposures, providing a tool aiming to identify high and/or non-optimised exposures.results: on a sample of 45 coronary angiography and percutaneous angioplasty procedures the derived mean kap (sd, maximum) per procedure was 69.0 (53.1, 236.2) gycm 2 . the first operator mean (range) personal equivalent dose was19 (0.65 ÷ 27.3) µsv/procedure. the mean (sd) scatter equivalent dose measured on the c-arm at the machine isocentre level per unit of kap was 2.32 (0.50) µsv/gycm 2 . the availability of the dicom structured patient dosimetry report and the technology advancement of personal dosimetry can conveniently support the optimisation radiation protection process in ir. the described experience supports the initiative of isemir project (iaea, austria) that recommends the development of active dosimetry technology for a better monitoring of operators in ir and the development of a dicom operator structured dosimetry report as prerequisite to define and develop software platforms aiming to combine patient and staff exposure information.14:00 purpose: the purpose of this study was to evaluate the additional diagnostic benefit of high-resolution steady state vibe imaging in peripheral mra. in this retrospective irb-approved study 224 patients (72 women, 152 men, age 67.3±13.9) were included who had undergone a peripheral mra exam after injection of 0.1 mmol/kg gadobutrol including a large field of view mra, time-resolved mra of the calf station and steady state 3d vibe sequence (3 t siemens timtrio, 1.3 mm isotropic spatial resolution, pat 3, 1:26 min tacq per station) prior to the time-resolved mra. one board-certified radiologist rated image quality of the vibe sequences on an ordinal three-point scale and analysed the images for additional diagnostic findings. descriptive statistics and demographic patient data were used for further evaluation. the image quality of the vibe sequences of the pelvis, upper and lower leg was excellent in up to 88%, 84% and 47%, respectively. poor image quality was only detected in the upper (2%) and lower leg (6%). the vibe sequence yielded an additional diagnostic benefit in 44% of the patients overall. there was no significant difference in terms of additional findings between men and women (46% and 40%, p=0.4601). the patient sample revealed a distribution of 59% inpatients and 41% outpatients with additional pathology found in approximately 44% for each group. conclusion: steady-state 3d vibe sequences in peripheral mra yield additional relevant diagnostic findings in 44% and above in patients older than 60 years irrespective of gender and patient status.author disclosures: h.j. michaely: consultant; bayer healthcare. in set-up iii, measured and calculated dose agreed well (3.05 vs. 3.0msv). set-ups i and ii showed a discrepancy of 72% between measured and calculated dose (9.52 vs. 34.20msv and 10.69 vs. 37.43msv). image quality in set-ups i and ii was rated sufficient, compared to the excellent image quality in set-up iii. set-up.i. showed a lower image noise (9 vs. 33 hu) and lower dose (12%) than set-up ii. conclusion: morbidly obese patients receive higher dose in ct examinations, which is required to achieve diagnostic image quality. calculations based on dlp and standard conversion factors overestimate the dose by approx. 70% in 300 kg patients, while the actual equivalent dose remains within the reference limits. the effects of head size/shape, head positioning, and bow-tie filter selection on peak tissue doses from brain perfusion 256-slice ct k. perisinakis 1 , i. seimenis 2 , a. tzedakis 1 , a.e. papadakis 1 , j. damilakis 1 ; 1 iraklion/gr, 2 alexandroupolis/gr (kostas.perisinakis@med.uoc.gr) purpose: to determine peak doses to skin, eye lens, brain parenchyma and cranial red bone marrow (rbm) of adult individuals subjected to low-dose brain perfusion 256-slice ct studies, and investigate the effects of patient head size/shape, head position and bow-tie filter selection. methods and materials: peak doses to radiosensitive tissues were measured in 106 individual-specific head phantoms subjected to the standard low dose brain perfusion ct on a 256-slice ct scanner using a novel monte carlo simulation software. the effects of head size/shape, head position during acquisition and bow-tie filter on resulting peak doses were investigated. the effects of head mis-centering and use of narrow bow-tie filter on image quality were assessed. the mean peak doses to eye lens, skin, brain and rbm were found to be 124, 120, 95 and 163 mgy, respectively. patient head size/shape was found to have minimal effect on peak doses, since maximum differences were less than 7%. bow-tie filter selection and head mis-centering were found to have a considerable effect on peak tissue doses with minimal image quality deterioration. the use of the narrower bow-tie filter available resulted in 35% reduction of peak tissue doses. conclusion: typical peak doses to skin, eye lens, brain and rbm from the standard low dose brain perfusion 256-slice ct exposure are well below the corresponding thresholds for induction of deterministic effects. the use of narrow bow-tie filters may considerably reduce peak absorbed dose to all above radiosensitive tissues with minimal degradation of image quality. detector dose vs image quality in radiography with digital detectors: a visual grading analysis r. decoster, h. mol, d. smits; brussels/be (robin.decoster@hubrussel.be)purpose: the introduction of digital detectors in the radiology predicted a dose reduction. due to the dynamic range, radiographs of sufficient quality can be produced with a lower detector air kerma (dak). however, this reduction was not observed. some authors indicate a creep toward higher dak, explained by better appreciation of the radiographs due to a higher contrast-to-noise ratio. to investigate the relation between the dak and the appreciation of image quality by radiologists, 172 anterior-posterior (ap) radiographs of the knee and 152 radiographs of the pelvis where collected randomly in 19 radiologic centres. a visual grading analysis (vga) with a five-point scale was used to judge the image quality of seven anatomic structures. the mid-point of the scale was equalised to diagnostic image quality. six radiologists scored both datasets, in a controlled environment, with viewdex®. every observer received an instruction and a training dataset. to determine intra-observer variability twenty radiographs were repeated. results: the intra-observer variability was not significant (p> 0.05) in both datasets. the knee ap obtained a vga score of 3.92, the pelvis obtained vga score of 3.71. in both cases, the inter-observer correlations are high and significant. the correlation between the vgas and the dak (cr 1.54µgy-5.48µgy; dr 0.38µgy-6µgy) was not significant in either dataset. neither were other analyses based on technical parameters. the vga revealed a mean image quality higher than diagnostic necessary. based on the dak, an overexposure is suspected. the relation between the dak range and the appreciation of the radiograph needs further investigation. (m.a.m.dekker@rad.umcg.nl) purpose: skin autofluorescence (af) is a non-invasive marker for advanced glycation endproducts (ages) and predicts cardiovascular disease (mortality) in diabetes and renal disease. we examined whether skin af is increased in subclinical atherosclerosis and whether it is associated with the degree of atherosclerosis independent of diabetes and renal function. methods and materials: cross-sectional study of 223 patients referred for primary (pp;n=163) or secondary (sp;n=60) prevention. skin af was measured using the age-reader and the degree of atherosclerosis was assessed based on ultrasonographically detected plaques in carotid and femoral arteries (in pp only), and computed tomography-derived coronary artery calcium score (cacs .12], respectively; p = 0.005 and < 0.001). in controls and pad, skin af was higher in those with crp above median compared with below. in a multiple regression analysis, the association of skin af with the 3 atherosclerosis categories was independent of age, gender, diabetes, framingham risk score, and kidney function. conclusion: skin af is increased in subjects with subclinical and clinical atherosclerosis, independently of known confounders. these data suggest that ages are associated with the burden of atherosclerosis. author disclosures: a.j. smit: founder; diagnoptics. evaluation of metabolic changes within the normal appearing grey and white matters in children with growth hormone deficiency: magnetic resonance spectroscopy and hormonal correlation j. bladowska, a. zimny, a. zacharzewska, t.m. gondek, a. banaszek, t. żak, a. noczyńska, m. sąsiadek; wroclaw/pl (asia.bladowska@gmail.com) purpose: the pathogenesis of idiopathic growth hormone deficiency (ghd) in children, including possible cerebral metabolic alterations, remains unclear. the aim of the study was to evaluate the metabolic changes within the normal appearing brain in children with ghd using mr spectroscopy (mrs) and to correlate mrs measurements with hormonal concentrations. methods and materials: seventy-one children with ghd (mean age 6.9 yrs) and 11 healthy controls (mean age 8.4 yrs) were enrolled in the study. the mrs examinations were performed on 1.5 t scanner. voxels were located in the posterior cingulate gyrus (pcg) and the left parietal white matter (pwm). the naa/cr, cho/cr and mi/cr ratios were analysed in both groups. there were also evaluated correlations between the metabolite ratios and hormonal concentrations: growth hormone (gh) in two stimulation tests and gh during the night, as well as igf-1 (insulinlike growth factor) and igfbp3 (insulin-like growth factor-binding protein) levels.results: there was statistically significant (p < 0.05) decrease of the naa/cr ratios in pcg and pwm in children with ghd compared to the normal subjects. other metabolite ratios showed no significant differences. we found also statistically significant positive correlations between naa/cr ratio in pwm and igfbp3 level, as well as gh concentration in stimulation test with glucagon. the reduction of naa/cr ratios may suggest loss of neuronal activity within normal appearing grey and white matters in children with ghd, thus mrs could be sensitive marker of cerebral metabolic disturbances associated with ghd and additional indicator for therapy with recombinant gh. purpose: the microstructure of tissues and white matter tracts in vivo may be studied with dti. the alterations involving the cerebral cortex associated in various degrees with subcortical white matter abnormalities often affect the projection white matter tracts. the white matter in cortical brain abnormalities is evaluated with diffusion tensor imaging (dti) and tract-based spatial statistics (tbss). methods and materials: 65 patients (1year-14year range) 39 males and 26 females) with different pattern of cortical alterations were studied. the dti data was processed in fsl. for each dti exam, brain extraction only of images with b value equal to zero was performed so that a mask of entire brain was created. gadoxetic acid-enhanced hepatobiliary phase mri and high b-value diffusion-weighted imaging (dwi) in the differential diagnosis between benign to malignant liver lesions p. arcuri, g. fodero, s. roccia, s. molica, v. arcuri; catanzaro/it (arppaolo@alice.it)purpose: the aim of our experience was to evaluate the value of gadoxetic acidenhanced hepatobiliary phase imaging and high b-value dwi in the differential diagnosis between benign and malignant liver lesions. methods and materials: twenty-four malignant liver lesions (fourteen small hcc and ten metastatic lesions) and twelve benign lesions (five fnh, four adenomas and three regenerative nodules in cirrhotic liver) were studied. a retrospective evaluation was made. the qualitative analysis was obtained by the evaluation of two radiologists of the lesions's signal intensity compared with that of the surrounding liver parenchyma on hepatobiliary phase images and dwi (b-value=600s/mm2). the contrast-to-noise ratio (cnr) and relative contrast enhancement of lesions on hepatobiliary phase images and the apparent diffusion coefficient (adc) values were assessed (by rois) for quantitative analysis. statistical analysis was performed by the mann-whitney u test. p value less than 0.05 was considered statistically significant. in the qualitative analysis, nineteen malignant lesions (79%) and three benign lesions (25%) were hypointense on hepatobiliary phase images; five malignant lesions (21%) and nine benign lesions (75%) were iso-or hyperintense in the same phase. twenty malignant lesions (83%) and four benign lesions (33%) were hyperintense in dwi; four malignant lesions (17%) and nine benign lesions (75%) were iso-hypointense in dwi. in the quantitative analysis the mean relative contrast enhancement ratio of the malignant lesions was higher than that of benign lesions. conclusion: hypointensity on gadoxetic acid-enhanced hepatobiliary phase images and hyperintensity on dwi (b-factor=600 s/mm2) suggest malignant lesions rather than benign hepatocellular nodules. gadoxetic acid-enhanced mri of the liver: correlation between gadoxetic acid uptake and serum hepatic enzymes levels e. talakic purpose: to evaluate observer performance involving absolute visual grading analysis of image criteria using visual grading characteristic curves (vgc) and ordinal regression analysis during ct examination optimisation. methods and materials: images obtained from current and optimised head ct protocols (n=120) from 4 suites were presented using viewdex on advantage workstations for evaluation by radiologists (n=6), grading the visibility of anatomical structures sourced from the european guidelines on quality criteria for ct. results: vgc analysis in terms of the area under the curve showed no significant differences (p> 0.05) from the 0.5 threshold value, indicating similar image quality between data sets. ordinal regression analysis indicated no significant (p> 0.05) change in image quality in suites 1 and 3 but discriminated between the data sets for suite 2 and 4 (p < 0.05). analysis on individual criteria indicated a difference (p < 0.05) in image quality between the protocols for all criteria in suite 2 but no difference (p> 0.05) in suite 4. discussion: vgc curves demonstrated general trends between protocols. findings of ordinal regression analysis not only indicate significant differences in image quality but also identify specific anatomical criteria contributing to those differences. the importance of selecting the most appropriate method of analysis in optimisation techniques is highlighted as findings influence protocol implementation based on clinical requirements. conclusion: an overall 15% radiation dose saving was achieved as a result of optimisation of the head ct protocols. optimised protocols were implemented for initial diagnosis for three suites and only for follow-up cases excluding initial diagnosis for the remaining suite.14:00 measuring hepatic functional reserve using low temporal resolution gd-eob-dtpa dynamic contrast-enhanced mri: a comparison study with galactosyl-human serum albumin scintigraphy and indocyanine green retention k. saito 1 , j.r. ledsam 2 , s.p. sourbron 2 , t. hashimoto 1 , y. araki 1 , s. akata 1 , k. tokuuye 1 ; 1 tokyo/jp, 2 leeds/ uk (um07jrl@leeds.ac.uk) purpose: to investigate if tracer kinetic modelling of low temporal resolution dynamic contrast-enhanced (dce) mri with gadoxetic acid (gd-eob-dtpa) has the potential to replace technetium 99m galactosyl human serum albumin (gsa) scintigraphy and indocyanine green (icg) retention for the measurement of liver functional reserve. methods and methods: 28 patients (18 males, 10 females; mean age 67y) awaiting liver resection for various cancers underwent dcemri, gsa-scintigraphy and icg as part of routine pre-operative evaluation. examinations were conducted within a single month. underlying liver disease was present in 4 patients. the gd-eob-dtpa mri sequence acquired 5 images: pre-contrast, double arterial phase, portal phase, and 4 minutes after injection. gsa-scintigraphy images were acquired every 10s following contrast injection. contrast uptake rate (ur) and extracellular volume (ve) were calculated from dce-mri, and the ratio of gsa radioactivity of liver to heart-plus-liver and percent of contrast uptake at 15 minutes (lhl15 and lu15, respectively) from gsa-scintigraphy. icg retention at 15 minutes, child-pugh cirrhosis score (cps) and post-operative inuyama fibrosis biopsy criteria were also recorded. statistical analysis was with spss17. purpose: to investigate dynamic contrast-enhanced computed tomography (dce-ct) for monitoring the effects of regorafenib on experimental colon carcinomas in rats by quantitative assessments of tumour microcirculation parameters with immunohistochemical validation. methods and materials: colon carcinoma xenografts (ht-29) implanted subcutaneously in female athymic rats (n=25) were imaged at baseline and after a one-week treatment with regorafenib by dce-ct (128 slice dual source ct). the therapy group (n=13) received regorafenib daily (10 mg/kg bodyweight) via gavage. quantitative parameters of tumour microcirculation (plasma flow, ml/100 ml/min), endothelial permeability (ps, ml/100 ml/min), and tumour vascularity (plasma volume, %) were calculated using a 2-compartment uptake model. dce-ct parameters were validated with immunohistochemical assessments of tumour microvascular density (cd-31), tumour cell apoptosis (tunel), and proliferation (ki-67). results: regorafenib significantly (p < 0.05) suppressed tumour perfusion (12.8±2.3 to 8.8±2.9 ml/100 ml/min) and tumour vascularity (15.7±5.3 to 5.5±3.5 ml/100 ml/min). significantly lower microvascular density was observed in the therapy group (cd-31; 48±10 vs. 113±25, p < 0.05). in regorafenib-treated tumors, significantly more apoptotic cells (tunel; 11,844±2,927 vs. 5,097±3,463, p < 0.05) and significantly less proliferating cells (ki-67; 4,277±1017 vs. 4,841±1,593, p < 0.05) were observed. dce-ct tumour perfusion and tumour vascularity correlated significantly (p < 0.05) with microvascular density (cd-31; r=0.84 and 0.66) and inversely with apoptosis (tunel; r=-0.66 and -0.71). arterial phase, portal venous phase, hepatovenous phase, equilibrium phase, and hepatobiliary phase which was 20 minutes after gadoxetic administration. a test bolus was used to optimise the contrast injection protocol. signal intensity of the liver parenchyma in all phases was defined using region-of-interest (roi) measurements for enhancement calculation. serum hepatic enzyme levels (bilirubin; cholinesterase, che; aspartat-aminotransferase, ast; alanine-aminotransferase, alt; gamma-glutamyl-transpeptidase, ggt; alkaline phosphatase, ap) were available in all patients. spearman correlation test was used to test the correlation between liver enhancement during the different phases and serum hepatic enzyme levels.results: at late time points after contrast injection all serum hepatic enzymes were correlated with liver enhancement. bilirubin and che showed stronger correlations than the other serum hepatic enzymes and they became correlated at earlier time points. the strongest correlation was observed between bilirubin and enhancement during the hepatobiliary phase and between che and enhancement during the hepatobiliary phase. bilirubin showed negative and che showed positive correlation. the spearman correlation coefficient was -0.64 for bilirubin and 0.61 for che. conclusion: in gadoxetic acid-enhanced mri of the liver gadoxetic uptake during the hepatobiliary phase is strongest correlated with bilirubin and che serum levels, whereas the other serum hepatic enzymes show weak or moderate correlations. purpose: aim of the study is to evaluate the use of mrcp using hepatospecific contrast media (gd-eob-dtba) to confirm biliary leak suspect and treatment planning. methods and materials: 13 consecutive patients (7 males, 6 females -average age 64 years), during 13 months (april 2011 to may 2012) underwent mrcp study using gd-eob-dtba due to clinical suspect of biliary leak. using an 1.5 t mri scanner, t1-weighted 3d gre pulse sequences before and in hepatospecific phase, after gd-eob-dtba injection, were performed. all patients with biliary leak underwent endoscopic, interventional radiology (ir) or surgical approach for treatment. results: biliary leak was clinically suspected in 13 patients and underwent abdominal surgery (7 laparoscopic cholecystectomy, 5 various hepatic resections, 1 resection of a pancreatic-duodenal mass) after 33 days (av; range 4 to 107). in 11/13 biliary leak was found at 44 minutes (av; range 20 to 76 minutes) from gd-eob-dtba injection, from intrahepatic ducts (6/11) site, cystic duct stump (2/11), both intrahepatic and principal biliary duct (2/11) and from a biliodigestive anastomosis (1/11). biliary leak was confirmed and successfully treated by percutaneous transhepatic cholangiography (8/11), endoscopic approach (1/11), ir and endoscopic "rendez-vouz" technique (1/11) and by surgical laparotomy (1/11). in 2/13 patients, no biliary leak was found and only clinical monitoring was performed, with good outcome. any adverse reaction or technical problem occurred during the mrcp examination. conclusion: mrcp with gd-eob-dtba is an high sensitivity, safe and fast examination to confirm the suspect and to locate precisely a biliary leak, concurring best planning for treatment. n-acetylcysteine for the prevention of contrast-induced nephropathy in rats m.f. i̇nci 1 , i. şalk 2 , o. solak 2 , ü. vurdem 3 , r. i̇nci 1 ; 1 kahramanmaraş/tr, 2 sivas/tr, 3 kayseri/tr (drfatihinci@gmail.com)purpose: to date, there is no effective treatment of contrast-induced nephropathy (cin). n-acetylcystein (nac) has yielded some promising results recently in the prevention of cin. in this study, the structural effects of nac on cin were analysed. methods and materials: forty adult wistar albino male rats were randomly allocated to four groups. the first group was the control group (n=9) which received only distilled water; second group was the contrast group (n=10) which received cm; the third group was the contrast plus nac group (n=8) which received cm and was treated with nac; and the last group was nac group (n=10) which received only nac. at the end of the 3 rd day, the right and left kidneys were removed and reserved for histopathological examination. all tissue sections were examined with light microscope looking for histopathological changes by the same experienced pathologist, without knowledge of the prior treatment. histopathological examination was conducted in a blinded fashion, and glomerular injury scores, arteriolar injury scores and tubulointerstitial injury scores were calculated. results: there was a significant difference among the scores of glomerular injury, arteriolar injury and tubulointerstitial injury in all groups (p < 0.05).the scores of glomerular, arteriolar and tubulointerstitial injury of the group-1 and group-4 were not significantly different from each other (p < 0.05). renal injury scores in group-3 key: cord-021206-4zyqqgs0 authors: nan title: scientific and educational exhibits date: 2007 journal: nan doi: 10.1007/s10406-007-0215-8 sha: doc_id: 21206 cord_uid: 4zyqqgs0 nan learning objectives: to describe principles of ct perfusion studies. to describe standard perfusion protocol for 64-mdct in abdominal and pelvic neoplasia. to show theoretical deconvolution model for perfusion analysis. background: 64-mdct enables an adequate anatomic coverage and temporal resolution for perfusion analysis of solid tumor of abdomen and pelvis. perfusion studies offer an in vivo evaluation of tumor neo-vascularity. perfusional parameters evaluated by means of ct perfusion are blood volume, blood fl ow, mean transit time and permeability surface area product. procedure details: in our experience, we evaluated some cases of pancreatic tuomr, recatal cancer, urinary bladder and prostate cancer using a 64-mdct scanner (vct; ge). using the follwing parameters: 650 ma, 120 kv, 0.5 sec gantry rotation time, 5 mm slice thickness acquired for 50 seconds during i.v. administration of iodinated contrast medium (xenetix 350; guerbet). the anatomic coverage of the scan was of 4 cm. image analysis was performed on off-line workstation (adw 4.2; ge) using a dedicated software based on deconvolution alghorithm. software calculate a colored map pf different perfusional parameters and quantitative data of the same parameters in a region of interest. perfusional index may correlate with cancer response to neoadjuvant treatments. conclusion: ct perfusion studies represent a feasible and non invasive tool for in vivo evaluation of tumour neovascularity. 64-mdct offer the adequate temporal and spatial resolution for the application of perfusion study to solid tumor of the abdomen and pelvis. 3 t mri of the abdomen: challenges and solutions for clinical application m. kataoka 1 , t. koyama 2 , h. isoda 2 , a. kido 2 , k. tamai 2 , s. umeoka 3 , y. nakamoto 2 , y. maetani 2 , n. morisawa 2 , k. fujimoto 2 , k. togashi 2 ; 1 cambridge/uk, 2 kyoto/jp, 3 wakayama/jp (mk435@cam.ac.uk) learning objectives: 1. to outline some challenges and solutions for 3 t mri of the abdomen. 2. to illustrate some promising areas where 3 t mri has a clinical impact, with the use of emerging techniques. background: theoretical doubling effect of snr is the main reason of improving images at 3 t mri. however, 3 t mri of the abdomen seems challenging; susceptibility artifact is more prominent in abdomen due to abundant air-non air interface. weak rf penetration and rf inhomogeneity at 3 t degrades image quality in body trunk. with fourfold increase of specifi c absorption rate (sar), sar limit and heating effect can be critical. in this exhibit, solutions to these diffi culties are proposed. then potentially useful clinical applications of 3 t are discussed. procedure details: mr images of abdomen were obtained by 3 t (trio:siemens) unit using phased array coil. for solutions, a more homogeneous rf fi eld can be obtained by using dielectric pads. sar reduction can be achieved by modifying parameters or using specially-designed sequence. furthermore, the emerging technique of variable fl ip angle turbo-spin echo sequences can reduce the sar and provides high-resolution 3d images in the order of millimeter. promising techniques for 3 t include mrcp, breath-holding images. high-resolution images for the pelvis can provide better depiction for carcinomas of the uterine cervix, prostate and bladder. experimental techniques such as dwi /dti of abdominal organs can also take advantage of increased snr at 3 t. conclusion: despite some challenges, 3 t mri of the abdomen has a potential to improve image quality in a clinical setting. effect of diffusion-weighted image quality on abdominal apparent diffusion coeffi cient measurements t. yoshikawa, y. ohno, h. kawamitsu, m. fujii, k. sugimura; kobe/jp purpose: to assess the effect of diffusion-weighted image (dwi) quality on abdominal apparent diffusion coeffi cient (adc) measurements and the usefulness of anisotropic images. methods and materials: twenty-six patients (10 men and 16 women; mean, 58.1 years) who underwent dwi and were diagnosed not to have any abdominal diseases were analyzed. single-shot spin-echo echo-planar dwi was performed and one isotropic and three orthogonal anisotropic images were created. adcs were calculated for liver (four segments), spleen, pancreas (head, body, tail) , and renal parenchyma. image quality for each organ part was scored visually. we estimated the correlation between adc and image quality and evaluated the feasibility of using anisotropic images. results: adcs and image quality were affected by motion probing gradient directions in the liver and pancreas. a signifi cant inverse correlation was found between adc and image quality. the r values for isotropic images were -0.46, -0.48, -0.70, and -0.28 for the liver, spleen, pancreas, and renal parenchyma, respectively. anisotropic images had the best quality and lowest adc in at least one organ part in 17 patients. conclusion: dwi with the best quality among isotropic and anisotropic images should be used in the liver and pancreas. uncommon localisation of echinococcosis in the humans d. passomenos, a. athanassopoulou, m. michalakou, k. dalamarinis, l. fois; athens/ gr (dempasso@yahoo.com) purpose: we retrospectively reviewed the fi les of patients who have been hospitalized with the diagnosis of hydatid disease (hd) for the past 6 years in order to fi nd unusual sites on the human body hosting this disease. methods and materials: 294 patient fi les were checked out and patients' mean age was 56.3 years. all patients had a computed tomography study while mri study was done in 5 of them. diagnosis was made by imaging features and laboratory studies and verifi ed by pathologic study wherever feasible. results: echinococcal cysts were identifi ed in the spleen (5), kidneys (7), abdominal cavity (3), heart (2), thigh musculature (1), spinal canal (3), seminal vesicles (3), testis (1) and ribs (2). abdominal hd was manifested with symptoms of hydatidemesis in a case of a solitary left subdiaphragmatic calcifi ed cyst with gastro-cystic fi stula while abdominal obstruction was the fi rst sign of a disseminated intraperitoneal disease. cysts were calcifi ed in 18 (65 %) while cyst diameter ranged from 2 to 13 cm. primary disease was evident in 12 while abdominal hd was disseminated in 2. iv administered contrast media was given in 9, while typical confi guration of hd was identifi ed in 12 cases. surgical excision was undertaken in 7 cases. conclusion: although liver and pulmonary hd is the most common form of the disease, uncommon locations do exist with low incidence. imaging studies are of great value in depicting the nature, extend and possible complications of hd. mri is valuable in musculoskeletal forms, while ct in abdominal disease. focal splenic lesions: role of us, ct and mr imaging in their detection and characterisation i. delgado, j. puig, a. malet, a. darnell, d. gil-bello, j. martin; sabadell/es (idelgado@cspt.es) learning objectives: to illustrate the spectrum of non-traumatic spleen abnormalities. to describe the imaging workup for the most common splenic diseases. to determine the current role of us, ct and mr imaging in the detection and characterization of focal spleen lesions. background: spleen abnormalities have received little attention in the scientifi c literature. however, recent us, ct and mr imaging advances open new possibilities in the study of splenic diseases. procedure details: for educational purposes, we can classify focal splenic lesions into vascular disorders (infarcts), infectious diseases (granulomas, abscesse, and so on), benign tumours (cysts, hemangioma, hamartom,and so on), malignant tumours (metastases, lymphoma and sarcoma), and other hematologic and metabolic disorders (haemochromatosis, gamna-gandy bodies, extramedullary haematopoiesis). conclusion: although most splenic lesions are detected as incidental fi ndings and have a non-specifi c appearance, the combined use of current imaging tools can often reach the correct diagnosis. us, ct and mr imaging all play an important role in the detection and characterization of focal splenic lesions, and with suffi cient clinical information, they enable the differential diagnosis of these lesions. parallel imaging techniques for accelerated volumetric interpolated breathhold examination (vibe) magnetic resonance imaging of the upper abdomen d.y.h. huang, r. fernando, d. svasti-salee, j. dark, n. jeyadevan; london/uk (dr.deanhuang@gmail.com) learning objectives: to illustrate the concept of parallel imaging. to describe the use and indications of parallel-imaging accelerated vibe in upper abdominal mr study based on a series of 38 patients. the vibe is an established sequence which permits abdominal imaging in a single breath-hold. parallel imaging is a novel technique whereby parallel coils permit more rapid spatial localisation of signal independent of conventional spatial acquisition. this allows shortening of image acquisition time. it has previously been used largely with sequences that had high intrinsic signal. reports on the use of parallel imaging with sequences with low signal to noise such as the vibe sequence in abdominal imaging are limited. imaging findings: thirty-eight consective patients referred for abdominal mr imaging were included. all patients underwent abdominal mr study that included dynamic post gadolinium sequences with vibe. in addition, patients underwent further accelerated vibe sequences with parallel imaging optimised to minimise scanning time (13s vs. 20s). the images obtained with accelerated and conventional vibe sequences were reviewed by two experienced radiologists. the accelerated vibe sequence was comparable to conventional vibe sequence in providing clinically acceptable images. in addition, less motion artifacts were observed in the accelerated images in the sub-group of patients who had diffi culty in breath-holding, resulting in improved image quality. conclusion: we demonstrated the feasibility of parallel-imaging accelerated vibe sequence in upper abdominal mr imaging. the application of parallel imaging minimises scanning time and may be useful in patients who have diffi culty in breath-holding. spectrum of imaging fi ndings of autoimmune diseases of liver, biliary system and pancreas m.c. freund, i. graziadei, a. tzankov, k.m. unsinn, w. vogel, w. jaschke; innsbruck/at learning objectives: to be familiar with pathogenesis, pathology, clinical features, and management of autoimmune diseases of liver, biliary system and pancreas relevant to the radiologist. to be familiar with typical fi ndings of various imaging modalities (sonography, mdct, mri, mrcp, ercp) as well as complications and differential diagnosis of autoimmune diseases of liver, biliary system and pancreas. background: autoimmune diseases of liver, biliary system and pancreas are recognized as chronic progressive infl ammatory disorders of unknown etiology characterized by immunologic and autoimmunologic features, e.g. circulating autoantibodies and hypergammaglobulinemia. these diseases are associated with characteristic clinical and histologic fi ndings and include autoimmune hepatitis, primary biliary cirrhosis, primary sclerosing cholangitis, and autoimmune pancreatitis. imaging findings: this pictorial assay demonstrates relevant imaging fi ndings with emphasis on typical patterns for early recognition of autoimmune diseases of liver, biliary system and pancreas. also imaging fi ndings of complications of these diseases are shown, e.g. various types of cirrhosis, hepatocellular carcinoma, cholangiocellular and cholangiocarcinoma, biliary strictures, cholestasis, cholangitis, cholelithiasis and differential diagnosis displayed by cross-sectional imaging modalities peculiar for mentioned autoimmune disease. also, percutaneous imageguided procedures will be shown including biopsy, transhepatic cholangiography and drainage as well as endoscopic procedures including ercp and drainage for diagnosis and therapy. conclusion: although autoimmune diseases of liver, biliary system and pancreas are rare, early diagnosis with recognition of typical patterns can help avert the consequences of progressive disease and unnecessary surgery. role of contrast-enhanced ultrasound in the assessment of spleen hemangiomas t.v. bartolotta, a. taibbi, m. galia, g. malizia, l. la grutta, m. midiri; palermo/ it (tv_bartolotta@yahoo.com) learning objectives: to illustrate the enhancement patterns of splenic hemangiomas (shs) evaluated with contrast enhanced ultrasound (ceus). background: hemangioma, although infrequent, is the most common primary benign neoplasm of the spleen, with a prevalence ranging from 0.3% to 14% at autopsy. sh is often discovered as incidental fi nding during an abdominal scan conducted for other reasons and more frequently observed in adults with age range from 30 to 50 years, with equal frequency among men and women. some studies have demonstrated that ceus is helpful in diagnosing liver hemangiomas. procedure details: two experienced radiologists retrospectively reviewed by conensus baseline and sonovue ® -enhanced us of 17 patients (10 men, 7 women; mean age: 59.5 years) with 17 shs (mean size: 2.5 cm) -confi rmed by splenectomy (n=2), ct (n=16) and/or mri (n=10) -evaluating baseline echogenicity and dynamic enhancement pattern of each lesion, in comparison with adjacent spleen parenchyma. at ceus, 8/17 shs showed an isoechoic appearance throughout the vascular phase, whereas 1/17 sh was isoechoic in the arterial phase but became hypoechoic in portal-venous and delayed phases. 4/17 shs showed a rapid and complete fi ll-in in the arterial phase, but appeared isoechoic (n=2) and hypoechoic (n=2) in delayed phase respectively. 2/17 shs showed peripheral hyperechoic nodules in the arterial phase, followed by progressive centripetal fi ll-in. 2/17 hemangiomas appeared as hypoechoic lesion in all phases. conclusion: the majority of shs evaluated with ceus presented an isoechoic appearance throughout the vascular phase, showing in some cases contrast-enhancement patterns similar to that of liver. implementation of diffusion-weighted imaging in routine mr imaging of the abdomen t. gerukis, r. thomaidis, a. fotiadou, a. petridis, m. pilavaki, v. kalpakidis, p. palladas; thessaloniki/gr purpose: to evaluate the use of apparent diffusion coeffi cient (adc) measurements in the study of variable (histologically proven) abdomen lesions. methods and materials: single-shot echo-planar diffusion-weighted mr imaging (dwi) was added to the routine abdomen mr examination with a 1.5 t mr unit in 41 patients. images were obtained in 3 b-values (0, 500, 1000 s/mm 2 ) with generation of adc maps. quantitative analysis of adc was made by region-ofinterest measurements in normal and pathologic tissue of different abdominal organs (liver 22, pancreas 2, kidney 3, adrenal 4, bowel 4, ovaries 2, bladder 1, peritoneum 3 patients). the mean adc value of two patients with gist was 1.51 (x10 -3 mm 2 sec -1 ); in 4 patients with tumor recurrences (2 colon and 2 ovary cancers) it was 1.56; in 1 pancreatic cancer patient it was 1.45; in 1 adrenal metastasis from renal cancer it was 1.32; in 1 patient with desmoid tumor it was 2.04; in 4 hepatocellular carcinomas it was1.47. the mean adc of malignant lesions was in all occasions lower than that of the benign lesions. conclusion: evaluation of adc can give further information and may be used as a tool (in adjunction to the other available sequences and techniques) in successful characterization of malignant lesions in different abdominal organs, and we believe that it must take its place in everyday clinical practice. further accumulative experience is needed to defi ne the ranges of pathologic in each occasion. can we refi ne our use of mri in the management of breast cancer patients undergoing neoadjuvant chemotherapy? b.j.g. dall, s. kumar, k. franks; leeds/uk (j.mclenachan@btinternet.com) purpose: to review and refi ne the use of mri in breast cancer patients undergoing neoadjuvant chemotherapy. we performed a retrospective audit of 78 patients. everyone had a pre-treatment mri scan, a second scan following 2 or 3 cycles of chemotherapy and a third scan at the end of treatment. the volume, extent and activity of the disease was assessed and the response to chemotherapy scored (-1=progressed; 0=no response; 1=minimal response; 2=partial; 3=almost complete; 4= complete). the third mri scan was compared to the histology at surgery. results: extent of disease (fi rst mri): mri matched mammography and ultrasound in 62 patients (79%) and identifi ed additional disease in 17 patients (21%). sixteen of these patients had multifocal disease. response to chemotherapy (second mri): 10 patients who had a complete pathological response scored 2 or 3 on the second scan. extent of residual disease (third mri): size at mri equalled size at histology in 46 patients (61%), mri<histology 19 patients (25%), mri>histology 11 patients (14%). conclusion: it is now the policy of our multidisciplinary team to use mri after 2 cycles to change chemotherapy regimes, to plan surgery and to prompt u/s guided marker clip placement if wide local excision (wle) is likely to be a future option and mri shows a good response. the third mri does not always accurately refl ect residual disease, particularly if it is multifocal but it may not be necessary if a mastectomy is planned. it does provide important information in conjunction with mammography and ultrasound if wle is planned. role of diffusion-weighted mr imaging for characterization and differentiation of breast lesions f. pediconi, e. moriconi, f. altomari, a. roselli, s. padula, v. dominelli, c. catalano, r. passariello; rome/ it (federica.pediconi@uniroma1.it) purpose: to evaluate the role of diffusion-weighted mr imaging for the characterization and differentiation of breast lesions. methods and materials: thirty consecutive women (age range: 35-70 years) with 43 histologically confi rmed benign and malignant breast lesions were prospectively evaluated. all patients were examined at 1.5 t using a dedicated bilateral breast coil. the mr imaging protocol included axial fse t2-weighted sequences with fat-suppression, axial epi sequences sensitised to diffusion along 3 orthogonal directions, and pre-and post-contrast axial 3d gre t1-weighted sequences (gadobenate dimeglumine, gd-bopta; 0.1 mmol/kg). the average apparent diffusion coeffi cient (adc) value along the 3 orthogonal directions was calculated for all lesions. differences in main diffusivity (md) among the lesions were evaluated by means of a non-parametric two-tailed mann-whitney test. results: the 43 lesions evaluated comprised 6 fi broadenomas, 4 cysts, 13 invasive ductal carcinomas (idc), 12 invasive lobular carcinomas (ilc), 6 ductal carcinomas in situ (dcis) and 2 papilloma. the md was signifi cantly higher for cysts than for benign fi broadenomas (p < 0.0002) or malignant lesions (p < 0.0002). furthermore, the md was signifi cantly lower in malignant respect to benign lesions (p < 0.0004). conclusion: diffusion-weighted mr imaging is an inexpensive quantitative procedure that can potentially serve as a corollary to established mr techniques for characterization of breast lesions. based on diffusion properties, md maps provide valuable information for the characterization and differentiation of breast lesions. the effect of magnetic resonance mammography (mrm) on the clinical management of 512 women with suspected lesions during x-ray mammography or ultrasound f. pediconi, s. padula, f. altomari, a. roselli, v. dominelli, e. moriconi, c. catalano, r. passariello; rome/ it (federica.pediconi@uniroma1.it) purpose: to assess the impact of bilateral breast magnetic resonance mammography (mrm) on the clinical management of patients with suspected lesions during x-ray mammography or ultrasound. methods and materials: 512 consecutive patients with suspected lesions during x-ray mammography or ultrasound were evaluated with contrast-enhanced bilateral mrm between october 2002 and february 2005. indications of mrm included pre-operative staging (n=296; group 1), undetermined or suspected lesions (n=143; group 2), evaluation of mammarian prosthesis (n=52; group 3), and cancer screening in patients with familial risk (n=21; group 4). mrm, x-ray mammograms, sonograms, and histology were compared to determine the effect of mrm on clinical management in each group. results: mrm determined changes in clinical management in 72/296 (24.3%) patients in group 1. the altered management was due to a greater lesion size in 22/72 cases, multifocality or multicentricity in 15/72 cases, multifocality/multicentricity and greater lesion size in 5/72 cases, contralateral foci in 28/72 cases, and suspected pectoral muscle infi ltration in 2/72 cases. in group 2, mrm confi rmed possible benign lesion in 71/143 patients,suspected malignant lesion in 38/143 patients, and no lesion in 34/143 patients. in group 3, mrm confi rmed a suspected broken prosthesis in 40/52 patients and confi rmed an intact prosthesis in 12/52 patients. in group 4, breast mrm identifi ed an occult tumor in 8/21 women. conclusion: mrm demonstrates high sensitivity for the detection and characterization of suspected lesions. mrm can determine important changes in clinical management and can provide accurate guidance for per-surgical treatment. learning objectives: to describe and illustrate the sonographic appearances of various benign and malignant lesions encountered in the male breast, correlate them with the pathologic fi ndings, and determine recommendations for management. background: a majority of male breast lesions are benign, with gynecomastia being the predominant pathology. male breast cancer represents less than 1% of all male breast disease. the most common indication for breast imaging in a male patient is a palpable mass. sonography, in addition to mammography, is often performed for the evaluation of these lesions. imaging findings: the sonographic appearance of the normal male breast is reviewed. sonographic features of various male breast lesions are illustrated and the specifi c disease entities are reviewed. benign entities include gynecomastia, infection (abscess formation), and benign masses (lipoma, fi broadenoma, papilloma, sebaceous cyst). malignant entities include primary breast carcinoma (invasive ductal cancer, papillary carcinoma) and lymphoma. the sonographic and mammographic imaging features are reviewed and correlated with the pathologic fi ndings. the various disease entities are discussed along with their management. conclusion: sonography has been shown to aid in distinguishing benign from malignant male breast lesions. familiarity with the sonographic appearance of various breast lesions is essential in the prompt diagnosis and management of diseases of the male breast. the signifi cance of ultrasound detected masses within the pectoralis muscle m. diaz, a. alonso-burgos, m. pons, m. herraiz, l. pina, g. zornoza, b. zudaire; purpose: to assess the signifi cance of masses within the pectoralis muscle detected on routine breast ultrasound studies and the diagnostic management with percutaneous procedures. methods and materials: from may 2000 to september 2005, 10,389 routine breast ultrasound scans were performed at our institution. these cases were retrospectively reviewed searching for ultrasound detected masses within the pectoralis muscle that were diagnosed with percutaneous procedures (14g needle core biopsy and fi ne needle aspiration). clinical (age, palpation, previous surgery…), mammographic, ultrasonographic and pathologic fi ndings were studied. results: eight patients (0.07 %) had eight intramuscular masses (mean age 60.3 yrs; range 32-78). all patients had a previous malignant diagnosis (seven breast infi ltrating ductal carcinomas and one hodgkin´s lymphoma). two cases were palpable. mammograms were normal in all cases. ultrasound depicted fi ve irregular ill-circumscribed masses, two well-circumscribed masses and one seroma. seven 14g needle core biopsies and one fi ne needle aspiration (seroma) were performed, with good tolerance and no complications. pathology results were consistent with fi ve metastatic infi ltrating ductal carcinomas (including the intrapectoral seroma), one lymphoma, one fat necrosis and one schwannoma. conclusion: masses within the pectoralis muscle are extremely rare. a biopsy should be performed in these cases because of the high rate of malignancy, especially if the patient has a previous history of a malignant tumor. multiple logistic regression analysis of tumour descriptors for breast nodules diagnosed on ultrasonography j.t.s. ho, s.-w. hee, n. gupta; singapore/sg (ddihts@nccs.com.sg) purpose: breast ultrasonography (us) is a useful adjunct to mammography in characterising solid breast masses. we set out to develop and validate a simplifi ed diagnostic score from multiple logistic regression of us features to determine the likelihood of malignancy of a solid mass. methods and materials: 110 patients with 128 biopsies performed in the department of oncologic imaging, national cancer centre, singapore, from october 2003 to june 2004 were included in the study as a training set. images were reviewed in consensus by two radiologists blinded to the results of the biopsy. another group of 26 lesions that were biopsied from april to july 2003 in the same centre was used as a validation set. the categories of the tumour descriptors were: shape, margin, echo texture, echogenicity, sound transmission, calcifi cations, surrounding tissue and ductal extension. results: the training set comprised 98 (77%) benign and 30 (23%) malignant nodules. the simplifi ed diagnostic score with the form ds = 5 + 18c + 17t + 10m + 6et + 3s + eg -5st with a possible minimum value of 0 and a maximum value of 60 was used. based on the roc curve from the simplifi ed ds, a score of > 5 was considered to be malignant.results of the validation set were comparable to the training set, confi rming the validity of the simple diagnostic model. conclusion: a combination of us features may be used to predict malignancy, potentially allowing follow-up rather than biopsy in 27% of lesions in our validation set in this preliminary study. pregnancy; patients with previous breast surgery, radiotherapy or chemotherapy; tumours located less than 10 mm next to the skin or thoracic wall. informed consent was obtained from all subjects. rfa was carried out under local anaesthesia. the electrode probe was placed in the centre of the lesion under us guidance. all patients underwent conservative surgical therapy 2-4 weeks after rfa. complete limphadenectomy was done when axillary node metastases were demonstrated. sentinel node biopsy was done in the remaining cases. pathologic study included the conventional haematoxylin-eosin stein and the specifi c nadh-diaphorase study in a freezed specimen. results: ages: from 44 to 72 years (x:64±6.3). tumour sizes: between 4 and 14 mm. (x:8.5±2.8). complete ablation with negative nadh-diaphorase test was achieved in 17 cases. one case showed a slightly positive test. in another case, the intraductal component was found out of the rfa effect ring. no signifi cant complications were observed. conclusion: offi ce-based rfa under local anaesthesia is a safe, feasible and comfortable procedure, accurate in 90% of the pibc smaller than 20 mm. wider series are necessary to evaluate the technique. additional studies have to be directed to compare local recurrence taxes of rfa alone versus surgery. the background: papillomas are generally solitary tumors of the mammary ducts epithelium and are usually located near the nipple. patients typically report nipple discharge. imaging features of papillary neoplasms correlate to the gross pathology. mammograms and us are frequently normal. occasionally, we may fi nd in mammography cluster of suspicious microcalcifi cations, gross calcifi cations, benign-appearing mass or a combination of these fi ndings. us may reveal a welldefi ned, smooth-walled, hypoechoic mass or a smooth-walled, cystic lesion with solid components. galactography usually shows a fi lling defect. doppler sonography may demonstrate arterial fl ow. imaging findings: we have retrospectively reviewed the imaging fi ndings of intraductal papillomas from our pathology database. out of a total of 55 patients, mammography was performed in 53, us in 51 and ductography in 28. core-needle biopsy was performed in 20 cases with a positive result for intraductal papilloma. intraductal papilloma was silent in mammography in 58% (31/53). a solid intraductal lesion was found in us in 36% (18/51). ductography showed a fi lling defect in 93% (26/28). conclusion: intraductal papilloma has a wide spectrum of imaging manifestations depending on their hystologic subtype. we visualize them as intraductal lesions in galactography and usually in us. ackowledgment of the typical imaging fi ndings help the radiologist to make the correct diagnosis approach. mucinous carcinoma of the breast: mammographic, ultrasonographic and mri fi ndings with pathologic correlation e. domínguez-franjo, j. oliver goldaracena, s. alonso roca, m. arguelles pinto, e. peña fernandez; madrid/es (edfranjo@gmail.com) learning objectives: 1. to evaluate the mammographic, ultrasound and mri appearance of mucinous breast carcinoma and to correlate the imaging features with the histologic fi ndings. 2. to learn the clinical and radiological fi ndings that can forecast prognosis. background: mucinous carcinoma of the breast is a rare breast neoplasm that accounts for 1-7% of all breast carcinomas. they are more commonly found among elderly women. its prevalence is strongly age related. histologically, mucinous carcinoma can be divided into pure mucinous and mixed carcinoma depending on the volume of extracellular mucin. pure mucinous carcinoma has better prognosis and lower incidence of metastases. imaging findings: the mammographic, ultrasound and mri features are described and illustrated. the most common mammographic and ultrasonographic feature is an oval or lobular microlobulated mass with very high signal intensity on t2-weighted images, and such imaging fi ndings should suggest a diagnosis when present in an elderly patient. conclusion: it is important for radiologists to be familiar with a variety of imaging features of mucinous carcinoma and their histologic type. this exhibit shows our experience with mucinous carcinoma focused on: 1.clinical and imaging characteristics that should suggest diagnosis of mucinous carcinoma. 2. the mammographic, ultrasound and mri features of mucinous carcinoma that can predict prognosis. the multiple facets of breast fi broadenomas r. rakheja, m. el-khoury, k. khetani, l. kadoche, b. mesurolle, m.p. dufresne; montreal, qc/ca (rajan.rakheja@gmail.com) learning objectives: to illustrate the broad range of sonographic presentations and associated uncommon pathological fi ndings of fi broadenomas. background: fibroadenomas are among the most common breast lesions in pre-menopausal women. fibroadenomas typically present as palpable, oval, freely mobile, rubbery masses in young women. on ultrasound, a well-circumscribed, oval-shaped, homogenous hypoechoic mass is the most common fi nding. however, clinical presentation and sonographic appearance can be highly variable, while pathologic examination can very seldom demonstrate unusual accompanying pathological entities, such as carcinoma. imaging findings: review of our database found 443 fi broadenomas that were sonographically assessed and biopsied between september 2001 and march 2006 in our institution. fibroadenomas can be considered atypical either by their localization, occurrence in accessory breast tissue in the axilla, or by their sonographic features according to the bi-rads classifi cation, displaying suspicious or unusual sonographic appearance. fibroadenomas can also be associated with unusual pathologic components including extensive lobular carcinoma in situ, atypical ductal hyperplasia, ductal carcinoma in situ or even invasive ductal carcinoma. these cases will be illustrated and presented with special emphasis on their unusual features with pathological correlations. conclusion: while most fi broadenomas are easily diagnosed by a typical clinical and sonographic presentation, the radiologist should be aware of the possibility of rare presentations, ultrasound fi ndings and even associated malignancies. model independent perfusion parameters of breast tumors: potential for pathological characterization s. makkat, v. dewilde, m. dujardin, t. stadnik, s. sourbron, r. luypaert, j. de mey; brussels/be (smitha. makkat@vub.ac.be) purpose: to evaluate the usefulness of the regional perfusion parameters obtained with a model-independent analysis of second bolus t1-weighted dynamic contrast enhanced -weighted (t1-dce) data in the differential diagnosis of breast tumors. methods and materials: 73 female patients (24-89 years) with histologically proven breast tumors underwent the routine mr mammography protocol which included whole breast t1-dce and high-resolution fat suppressed sequences. a second bolus of 0.1 mmol/kg gd-dtpa was injected and a dynamic single slice turbofl ash acquisition (tr/te/fa/ti 4.9/2.4/50/196, 400 images with a temporal resolution of 0.3s) was performed at the slice where the lesion enhanced maximally. the relative signal changes of the second bolus sequence were deconvolved pixelwise by a model independent method to yield the impulse response function (irf). the tumor blood fl ow (tbf) and the tumor volume of distribution (tvd) were calculated as the maximum and the time integral of the irf respectively and the mean transit time (mtt) as the ratio tvd/tbf. mean values of these parameters were compared between benign and malignant groups. results: final diagnosis included: 20 benign and 53 malignant lesions. in all the malignant lesions, the parametric maps clearly delineated tumors from the surrounding breast tissue. mean tbf and tvd values were signifi cantly higher and mean mtt values were lower in the malignant tumors compared to the benign ones (p < 0.05). conclusion: a pixelwise model-independent perfusion analysis of the t1-dce data of breast tumors provides parameters of tbf, tvd and mtt. these perfusion parameters have the potential for the differential diagnosis of breast tumors. sono-mammographic diagnosis of gynecomastia n.m. abdel razek; cairo/eg (naglaabdelrazek@yahoo.com) learning objectives: to orient radiologists to the mammographic and ultrasonographic appearance of gynaecomastia, patterns of gynaecomastia and diagnosis procedures. the relation between the different mammographic patterns to the duration and the correlation between the mammographic and the ultrasonographic appearance to the histopathological types of gynaecomastia, and fi nally when to ask for fnb in gynaecomastia. background: gynaecomastia is the most important disease of the male breast; it is the commonest problem affecting the male breast, accounting for about 85% of breast masses. imaging findings: three mammographic appearances of gynaecomastia have been described: nodular, denderitic and diffuse patterns. nodular gynaecomastia b d e f a g appears as a focal retroareolar density. denderitic gynaecomastia appears as a retroareolar density with prominent extensions that radiate into the deeper adipose tissue. diffuse glandular gynaecomastia has a mammographic appearance similar to heterogenosly dense female breast; the glandular densities are either limited to the subareolar region or scattered throughout the whole breast. by ultrasonography, gynaecomastia has either focal hypoechic retroareolar lesion or diffuse echogenic hyper-refl ective parenchyma with or without prominent ducts, indicating development of the tldu. it was found that the denderitic type correlates with fi brous gynaecomastia and the nodular type correlates with fl orid type. these fi ndings are directly proportionate to the duration. fnb is reserved only in suspicious cases. conclusion: sono-mammography has provided satisfactory results in diagnosing gynecomastia as the commonest cause of breast lump in males. moreover, it correlates well with the radiographic fi ndings of different histological patterns. rare breast tumors: imaging fi ndings and radiologic -pathologic correlation c. martínez lara, b. arenas garcía, t. zamora martínez, m. baizán garcía, j. sevillano sánchez; zamora/ es (cmartinezl@ono.com) learning objectives: to illustrate the imaging fi ndings on mammography and sonography of rare breast tumors. we add a radiologic -pathologic correlation of each entity. background: the uncommon breast lesions cause a diagnostic dilemma and need a triple approach encompassing clinical, radiological and histological features. an exact diagnosis is crucial for the adequate management of the patient. procedure details: retrospective review was performed of 626 breast lesions diagnosed in our department between january 2004 and june 2006. all patients underwent diagnostic mammography or mammography and breast sonography. the accurate diagnosis was made by core needle biopsy. we present the imaging fi ndings and radiologic -pathologic correlation of 18 selected cases of uncommon breast tumors: six benign tumors (2 hamartoma, 1 granular cell tumor, 1 phyllodes tumor, 1 lactating adenoma and 1 intracystic papilloma) and twelve malignant tumors (4 mucinous carcinoma, 2 medullary carcinoma, 2 primary non-hodgkin lymphoma, 1 invasive papillary carcinoma, 1 malignant phyllodes tumor, 1 carcinosarcoma and 1 metastases from carcinoid tumor). the radiologist must know the imaging fi ndings of these unusual breast tumors and take them into account to make a correct differential diagnosis, which has a great impact on therapeutic strategies. diagnostic accuracy of dynamic multidetector row ct to evaluate axillary lymph node in patients with breast cancer d. kang, j. kim, y. jung; suwon/kr purpose: to investigate the usefulness of dynamic multidetector row ct (mdct) in the detection of axillary lymph node (ln) metastasis using morphologic criteria and quantitative analysis. methods and materials: fifty-nine patients with breast cancer underwent mdct preoperatively. 16-slice dynamic mdct was performed before, and 90sec and 5 min after an administration of nonionic contrast material. the morphologic features and contrast enhancement of the axillary ln were evaluated using multiplanar reformation and three-dimensional maximum-intensity projection. short diameter of ln, s/l (short diameter/long diameter) ratio and cortical change were evaluated as morphologic features of ln. contrast enhancement was quantitatively analyzed using a region-of-interest method to evaluate the enhancement rate and time-density pattern. results: the hilar obliteration and eccentric cortical thickening was the most sensitive predictor for metastatic ln. the density values at each scanning time were signifi cantly different for metastatic and non-metastatic ln. the sensitivity, specifi city, positive predictive value (ppv), negative predictive value (npv), and accuracy of mdct to detect metastatic ln using morphologic criteria were 81%, 82%, 83%, 79% and 81%, respectively, and the corresponding performances using quantitative analysis were 61%, 71%, 70%, 63% and 66%, respectively. in combined analysis of morphologic criteria and quantitative analysis, the overall sensitivity, specifi city, ppv, npv, and accuracy were 65%, 93%, 91%, 70% and 78%, respectively. conclusion: morphologic features detected on mdct help distinguish metastatic ln from non-metastatic, and was a more valuable diagnostic criteria than that of quantitative analysis. the quantitative analysis of axillary ln improved the overall specifi city and positive predictive value. quantitative refraction-based computed tomography with high resolution using synchrotron radiation e. hashimoto 1 , a. maksimenko 1 , s. ichihara 2 , y. arai 3 , h. sugiyama 1 , k. hirano 1 , d. shimao 4 , k. hyodo 1 , t. yuasa 5 , t. endo 2 , m. ando 1 ; 1 tsukuba/jp, 2 nagoya/jp, 3 shiojiri/jp, 4 inashiki/jp, 5 yonezawa/jp (ehashi@post.kek.jp) purpose: the ability of refraction-based contrast ct to depict breast cancer nest was tested by observing breast cancer of the human with synchrotron x-rays. reconstructed images of breast cancer show much detail that is noted in absorption-based ct. methods and materials: recently, we have developed a new computed tomography algorithm for refraction contrast that uses the optics of diffraction-enhanced imaging. we applied this new method to visualize soft tissue, which is not visualized by the absorption contrast. the meaning of the contrast that appears in refractioncontrast x-ray ct images must be clarifi ed from a biologic or anatomic point of view. it has been reported that the contrast is made with the specifi c gravity map with a range of approximately 10 µarc sec. the relationship between the contrast and biologic or anatomic fi ndings has not been investigated. we compared refraction-contrast x-ray ct images with microscopic x-ray images, and we evaluated refractive indexes of pathologic lesions on phase-contrast x-ray ct images. results: we focused our attenuation of breast cancer as samples. x-ray refraction-based computed tomography appeared to be the pathological ability to depict the boundary between cancer nest and normal tissue, and inner structure of the disease. the properties of the refraction contrast provide certain advantages over other contrasts such as absorption and phase-shift. the refraction contrast can show tiny details of the inner structure, which are invisible in other types of x-ray imaging techniques. another advantage of the contrast is the sensitivity to the low z materials. purpose: to analyze the clinical and imaging fi ndings of bi-rads category 3 breast lesions by mammographic and ultrasonographic (us) assessment ultimately diagnosed as malignancy in retrospect methods and materials: of 3,207 cases of us-guided core needle biopsy for 4 years, category 3 was given after biopsy, based on mammographic and sonographic evaluation, in 1,099 lesions (41.7%) that were composed of 462 palpable and 637 nonpalpable lesions. the fi nal pathology was malignancy in 18 lesions (1.6%). each lesion was retrospectively described using bi-rads mammographic and us lexicons, and it was assessed whether the lesions were compatible with category 3, and if not, which fi ndings suggested malignancy. results: of the 18 malignant lesions that were palpable in 12 (67%) and nonpalpable in 6 (33%), 9 lesions were compatible with category 3 both on mammography and on us, even in retrospect. of 9 lesions improperly categorized as category 3, 8 (89%) were palpable. four lesions (44.5%) were suspicious on mammography alone (calcifi cation: 2; hyperdense mass: 2), and 4 (44.5%) were suspicious on us alone (microlobulated or nonparallel mass: 2; skin retraction: 1; hypervascularity: 1) and 1 (12%) was suspicious on both examinations. conclusion: despite the retrospective nonblinded evaluation of mammography and us, many cases are placed in category 3. palpable bi-rads category 3 lesions should be more carefully assessed and should be safely managed by biopsy. papillary learning objectives: our purpose is to make a retrospective review of the imaging findings of the papillary carcinoma of the breast, and to correlate them with the histological results. background: papillary carcinomas represent 1-2% of breast carcinomas. histologically, they can be divided into in situ carcinomas, including intracystic and intraductal types, and invasive carcinomas. as a group, they are considered to have better prognosis than other breast carcinomas because of their usual slower growth. imaging findings: mammography and ultrasound (including doppler) were performed in all of the 34 patients in our series. evaluation of lesions with both techniques allowed us to consider most of the lesions as suspicious of malignity (76.4% or 26 of 34 cases), classifying them as 4 or 5 bi-rads categories. mri was performed in order to reject multicentricity in 10 patients. histologically, 38% (13 of 34) was classifi ed as invasive carcinomas. correlation between the different histological types and the imaging fi ndings is made observing solid nodules more often associated with invasive carcinoma than cystic lesions. we also review other different aspects in our series such as age of presentation, location, size and clinical signs. conclusion: acknowledgement of mammography and sonography features in papillary lesions allows the radiologist to suspect carcinoma. in our experience, solid papillary carcinomas are more frequently associated with histological invasion than cystic papillary carcinomas. radiofrequency ablation in breast tissue: experimental study for evaluation of heat conduction in the bovine udder b.m. stoeckelhuber 1 , c.u. bergmann-koester 1 , i. rudolf 2 , f. noack 1 , s. kapsimalakou 1 , a. lubienski 1 , t.k. helmberger 1 ; 1 luebeck/de, 2 birmingham, al/us (stoeckel@medinf.mu-luebeck.de) purpose: to evaluate the conduction of heat in radiofrequency ablation (rfa) in the bovine udder as a model for breast tissue. especially in superfi cial lesions near the skin surface, heat conduction and demarcation of the ablated tissue is an important issue. methods and materials: rfa in a lactating and a non-lactating bovine udder was performed. the needle was deployed under ultrasound guidance. the temperature was applied in 10-degree steps between 60 and 100ºc and maintained for 15 minutes at the tips of the prongs. the experiment was repeated three times for each temperature step in the lactating and non-lactating tissue. histopathologic assessment of the resected specimens was made. the diameter of the ablation zone and demarcation of the ablated tissue margin against the surrounding tissue with respect to the temperature applied was measured. results: in the non-lactating tissue, there is a direct correlation of the temperature and diameter of the necrosis zone. the maximum ablation diameter was 1.27 in the non-lactating tissue and 1.30 cm in the lactating tissue. there was a sharp demarcation between 0.1 and 0.2 cm in the non-lactating tissue. the transition zone in the lactating tissue was not well visualized below 80ºc, ranging between 0 and 0.2 cm. conclusion: there is little conduction of heat in bovine breast tissue. sharp demarcation of the ablation zone suggests accurate control of the heat, hence, ideal conditions for rfa in human breast tissue. b d e f a g impact of physiological bradycardia on myocardial high-energy phosphate metabolites measured by 31-p 2d csi c. wolf 1 , g. klug 2 , m. faulhaber 1 , t. trieb 1 , m. frick 1 , b. metzler 1 , w. jaschke 1 , m. schocke 1 ; 1 innsbruck/at, 2 würzburg/ de (christian.wolf@uibk.ac.at) purpose: 31-p-magnetic-resonance-spectroscopy (31p-mrs) is a unique tool to investigate in vivo high-energy phosphates (hep) in human heart. we intended to evaluate the impact of low-heart rates on myocardial high-energy phosphates (heps). furthermore, we aimed at comparing training induced. methods and materials: twenty-one male volunteers (mean age 46 ± 11 years) with a physiological heart rate (hr) below 55 bpm were compared to a group of 37 age-matched normofrequent volunteers (hr > 60 bpm). all volunteers underwent 31-phosphorous 2-dimensional chemical shift imaging (31p-2d-csi) and cine mr images in short and long-axis acquired using breathhold ecg-triggered cine bright blood sequences to assess their myocardial hep metabolism by determining phosphocreatinine to beta-atp ratios (pcr/b-atp) on the one side and heart morphology and function on the other side using a 1.5 tesla scanner. results: all volunteers were free of known cardiovascular disease. the detailed results of heart function (ventricular wall thickness, ventricular mass, volume of heart chambers, ejection fraction, stroke volume a.s.o). will be presented. in the spectroscopic evaluation, volunteers with a hr< 50 bpm showed signifi cantly higher pcr/b-atp ratios than volunteers with a hr> 60 bpm (2.46±0.37 vs. 1.65±0.33, **: p < 0.0001). conclusion: in this study, we observed a difference in myocardial hep metabolism between volunteers with bradycardia and normofrequent volunteers. to further determine the effects of endurance training or drug-induced bradycardia on myocardial hep metabolism, 31p-mrs might be of clinical importance since pcr/b-atp is a prognostic marker in patients with structural heart failure. high-resolution myocardial perfusion imaging at 3.0 t: comparison to standard 1.5 t perfusion studies and diagnostic accuracy in patients with suspected cad c. meyer, k. strach, d. thomas, m. hackenbroch, u. schwenger, h. schild, t. sommer; bonn/ de (carsten.meyer@ukb.uni-bonn.de) purpose: to evaluate high resolution myocardial rest perfusion (hrrp) in healthy volunteers at 3.0 t in comparison to 1.5 t and the technical feasibility and diagnostic accuracy of 3.0 t high resolution myocardial stress perfusion (hrsp) in patients with suspected cad. methods and materials: all perfusion studies were performed using a t1-tfe-sequence. seventeen healthy volunteers underwent a hrrp at 3.0 t (pixel size: 3.78 mm2) and 1.5 t (pixel size: 9.86 mm2). myocardial signal intensity (si) increase was assessed for 3.0 t and 1.5 t. image quality was evaluated on a four-point grading scale (4: excellent, 1: non-diagnostic) with respect to homogeneity of myocardial enhancement, blurring and presence of artifacts. nineteen patients with suspected cad hrsp was qualitatively assessed for stress-induced hypoperfusion. hemodynamically signifi cant cad was defi ned as stenosis > 70% in conventional coronary angiography. results: si increase in hrrp at 3.0 t was not signifi cantly different from that at 1.5 t (207% ± 43 vs. 199% ± 52, p> 0.05). image quality was signifi cantly improved at 3.0 t (3.1 ± 0.7 vs. 2.2 ± 0.4, p < 0.01). mean score of image quality was 2.7 ± 0.7. the mean si increase was 170% ± 30. sensitivity and specifi city of hrsp studies at 3.0 t for the detection of signifi cant cad was 90% and 78%, respectively. conclusion: hrrp at 3.0 t permits signifi cantly improved spatial resolution and provides signifi cantly improved image quality in comparison to a standard approach at 1.5 t. 3.0 t hrsp is feasible in patients yielding promising results for the detection of signifi cant cad. (1) to determine the usefulness of a new diffusion/convection (medium size) mr contrast media p846 in defi ning reperfusion after myocardial ischemia; (2) to compare the kinetics of p846 in occlusive and reperfused ischemically injured myocardium using inversion recovery echo-planar imaging (ir-epi), 3) to chrono-logically measure the extent of myocardial injury on p846-enhanced t1-weighted spin-echo imaging (t1-se). in this experimental study, rats were subjected to either of the following myocardial injuries: 30 min lad occlusion followed by 2.5 h reperfusion (n=8) to produce non-transmural infarction, or complete lad occlusion (n=8) to produce transmural infarction. mr imaging was performed before and after administration of 0.05 mmol/kg p846. ir-epi and t1-se sequences were repeatedly acquired to measure t1 and injury extent. histopathology was performed to measure true infarcted size. results: after administration of p846, reperfused infarct showed immediate enhancement on the t1-se images. this fi nding was confi rmed by the sequential measurement of t1 in the infarcted and peri-infarcted zones. in contrast, occlusive infarcts appeared as hypo-enhanced core surrounded by an enhanced rim after contrast administration. the slow wash-in and wash-out of p846 from myocardium provided differentiation between occlusive and reperfused myocardial injury for 60 min. the t1 values in the occlusive infarcted gradually increased in the 50-min observation period, but it did not reach those values that were obtained in the reperfused infarct. conclusion: p846 provides prolonged window of discrimination between occlusive and reperfused myocardial injury. p846 provided persistent (60 min) enhancement of peri-infarcted and infarcted myocardium. mri of cardiac and paracardiac masses: a pictorial review g.k. schneider, p. fries, m. boehm, h.-j. schaefers, i. kindermann; homburg a.d. saar/de (ragsne@med-rz.uni-sb.de) learning objectives: the purpose of this exhibit is to present mri fi ndings in both benign and malignant cardiac tumors as well as tumor-like lesions. when helpful ct imaging, catheter angiography and echocardiography as well as histologic specimens are presented, important fi ndings for diagnosis, staging and therapy planning will be highlighted. background: although cardiac masses are most frequently detected on echocardiography, mri is the method of choice to accurately evaluate and further characterize cardiac tumors. imaging findings: an overview of imaging techniques in cardiac mri together with proposed protocols to evaluate cardiac masses will be presented. based on mri fi ndings and other clinical data, algorithms that give the reader a large spectrum of information to characterize cardiac and paracardiac masses will be presented. case studies include common and rare benign and malignant as well as tumor-like lesions, with typical and atypical manifestation, and these will be correlated with histology and surgical images. conclusion: mri is a valuable tool in the evaluation of cardiac and paracardiac masses. the maximum information is gained if all clinical information together with results of other imaging modalities are taken into consideration. the minimal mr protocols to characterize a lesion should be understood to add important information in the work-up of cardiac and paracardiac masses. safety of cmr adenosine stress perfusion imaging in patients with coronary artery disease d. piotrowska, l. kownacki, o. rowinski, m. golebiowski, g. opolski, l. krolicki; warsaw/pl (dpiotrowska@plusnet.pl) purpose: the aim of this study was to assess safety of stress perfusion cmr imaging during adenosine infusion in high risk patients with three vessel coronary artery disease and early after acute myocardial infarction. methods and materials: 126 examination reports of high risk patients who underwent cmr in stress condition during adenosine infusion (140 ug/kg b.w./ min, over 4.5 min) were included in the study. 95 of studied patients had stable three vessel coronary artery disease and 31 patients were scanned within one week after acute myocardial infarction. we analyzed response pattern to adenosine infusion and frequency of adverse events. results: adverse events during infusion of the adenosine were observed in 56 patients (44%). the frequency of adverse events ranged from 16 % for warm feeling, 12 % for dyspnea and 8% for chest pain/discomfort to 7% for temporary atrio-ventricular block. all adverse events disappeared quickly without treatment. signifi cant systolic blood pressure drop (more than 20 mmhg) was seen only in patients with tree vessel disease and occurred mostly in fourth minute of adenosine infusion. only in 2 cases stress perfusion was not performed because of pressure drop. conclusion: stress cmr perfusion using 4.5 minutes adenosine infusion protocol is safe in patients with advanced coronary artery disease as well as early after acute myocardial infarction. sion scores between acute and chronic phases were also signifi cantly correlated (r=0.6, p < 0.05) and adhesion score in chronic phase was signifi cantly reduced compared with that in acute phase (1.3±1.0 versus 2.2±1.1, p < 0.05). in chronic phase, compared with acute phase, pericardial thickness was reduced and new lesion of pericardial adhesion was not found. conclusion: tagging mri is useful for assessment of pericardial adhesion and the image obtained one month after cardiac surgery can predict pericardial adhesion in a few years. fast cine sequences for evaluation of valvular heart diseases l. natale, a. meduri, a. lombardo, l. bonomo; rome/ it (lnatale@rm.unicatt.it) learning objectives: to understand relationships between fl ow disturbancies and different cine-mri techniques. background: valvular diseases cause fl ow disturbances and consequent fl ow voids on gre images depending on a variety of factors, especially echo time. procedure details: in 15 patients with mitral or aortic valvulopathies we compared area, length and subjective grading of turbulence jets using fast-gre (11 and 31 khz receiving bandwidth, prospective or retrospective gating) and ssfp cine sequences with echocardiography as gold standard. results: gre cine sequences with 12-14 msec tes display well the turbulence jets but require long scanning times and are often degraded by breathing artefacts. fast-gre sequences allow breath-hold acquisition but te is forced to a minimum default value, with consequent impaired detection of fl ow voids. in fast-gre with prospective gating, reduction of receiving bandwidth to 11-15 khz allows 8-11 msec tes, with more marked turbulence jets; fast-gre with retrospective gating allows the choice of any te coupled with a higher temporal resolution (at least 20 phases are required). in ssfp blood signal is due to t2/t1 ratio with variable turbulence jets evidence. good correlation with echocardiography and velocity mapping data has been obtained for retrospective gated fast-gre cine sequences. conclusion: turbulence jets assessment with fast sequences allows rapid semiquantitative evaluation of valvular function identifying patients needing velocity mapping measurements. fast-gre techniques showed different sensitivities mainly depending on echo time, but are generally suitable for fl ow assessment. ssfp techniques are not adequate for fl ow evaluation. left atrial remodeling after left atrial circumferential ablation for atrial fi brillation r.j. perea, t.m. de caralt, d. tamborero, l. mont, m. sanchez, r. salvador; barcelona/es (rjperea@clinic.ub.es) purpose: the purpose of this study is to evaluate the effect of left atrial circumferential ablation (laca) for af treatment in left atrial (la) volumes. methods and materials: forty-one patients who underwent laca for symptomatic drug refractory af were included. mri was performed only when patients were in sinus rhythm before laca and 4-6 months after it. la maximal volume (lamax), la minimal volume (lamin) and la ejection fraction (la ef) were compared. results: pre-procedural lamax and lamin were smaller and la ef was higher in the 30 patients (73%) with no arrhythmia recurrences during the follow-up. there was a signifi cant reduction of lamax, lamin and la ef after laca in the entire group. lamax and lamin reduction occurred in those patients with recovered sinus rhythm (97±19 to 85±19 ml and 58±18 to 52±15 ml, respectively; p < 0.05), as well as in those patients with relapsed af (117±33 to 95±30 ml and 80±26 to 73±29 ml, respectively; p < 0.05) after ablation. no changes were appreciated in la ef in patients with successful laca (40±12% to 38±10%; p < 0.05), but a reduction was noted in patients with af recurrences (33±8% to 24±10%; p < 0.05). conclusion: la inverse remodeling was present in all patients submitted to laca, regardless of the clinical outcome. intramyocardial injection of adeno-associated viral vector encoding vegf gene improves cardiovascular magnetic resonance measurements of perfusion and infarct resorption a. jacquier, d. saloner, a. martin, l. do, c.b. higgins, m. saeed; san francisco, ca/us (alexis.jacquier@ap-hm.fr) purpose: to determine the effects of cardiac-specifi c adeno-associated viral vector (aav) encoding for vascular endothelial growth factor (vegf) on regional myocardial perfusion and infarct resorption using magnetic resonance imaging (mri). methods and materials: mri was performed in swine at 3 days and 8 weeks after reperfused infarction. aav-vegf was injected 1h after reperfusion into the the role of mr imaging in various cardiomyopathies e. chun 1 , s.i. choi 1 , w. lee 2 , j.-h. park 2 ; 1 seong-nam/kr, 2 seoul/kr (drsic@radiol.snu.ac.kr) learning objectives: to learn the merit and the potential role of cardiac mri in the evaluation of various cardiomyopathies. background: the cardiomyopathies include a variety of diseases where the primary pathology directly involves the myocardium. cardiac mr (cmr) is proving increasingly valuable in the identifi cation and management in these conditions. procedure details: we will illustrate the various mr techniques such as delayed enhancement, stress perfusion mri, cine mri, tagged mri using harp software, and venc-mri (for the evaluation of diastolic function) in patients with cardiomyoaphty. also, we will present the characteristic mr fi ndings of ischemic, dilated, restrictive cardiomyopathy, arrythmogenic rv dysplasia, constrictive cardiomayoapthy, lv diverticulum, stress-induced cardiomyopahty, non-compaction, and myocarditis on the basis of our experiences. conclusion: familiarity with mri techniques and features of various cardiomyopathies is considered to be helpful for the accurate diagnosis and proper management. evaluation of tissue iron overload in b-thalassaemia patients: a comparative study between 3.0 t and 1.5 t i. seimenis, c. economides, e. eracleous, s. kokkis, t. posporis; nicosia/cy (yseimen@phys.uoa.gr) purpose: tissue iron overload in b-thalassaemic patients is routinely assessed with mri at 1.5 t. this work focuses on the differences and advantages of high fi eld measurements. methods and materials: t2 and t2* proton relaxation measurements in the heart and liver of twelve b-thalassaemic patients were obtained at 1.5 t and 3.0 t, using a respiratory-triggered multi-echo, carr-purcell-meiboom-gill spin-echo sequence (tr=2000 ms, te 1 ,te 2 ,…,te 16 =6, 12,…,96 ms) and a breathold multi-echo, k-space segmented, gradient-echo sequence (tr= 22 ms, te 1 ,te 2 ,…,te 8 =2.5.4.5,…,16.5 ms), respectively. both sequences were electrocardiographically gated and prescribed along the short cardiac axis. moreover, sequence optimization was pursued for 3.0 t measurements. the increased snr at 3.0 t can be used to increase in-plane spatial resolution, which is important for accurate myocardium delineation. since the water-fat-shift is larger at 3.0 t, fat suppression is suggested for high fi eld measurements. in the patient group studied, there was no signifi cant difference between t2 values measured at 3.0 t and 1.5 t, in terms of iron overload classifi cation (low, medium or high). with regard to t2* determination, heart t2* values obtained at 3.0 t were considerably shorter than the corresponding values obtained at 1.5 t in fi ve subjects. this may be attributed to the increased susceptibility effects at 3.0 t, and may suggest a tool for assessing iron distribution in ferritin and haemosiderin deposits. additionally, the advanced performance gradient system on the 3.0 t system allows the use of submillisecond tes, which are necessary for t2* determination in severe myocardial iron overload. conclusion: the use of 3.0 t seems to benefi t liver and, particularly, heart iron level determination in b-thalassaemic patients. assessment of pericardial adhesion after cardiac surgery by tagging magnetic resonance imaging a. ichinose, i. yoshioka, k. takase, s. takahashi; sendai/jp (azusa@rad.med.tohoku.ac.jp) purpose: assessment of pericardial adhesion after cardiac surgery is very important in the conduct of repeat surgery or prediction of right-sided cardiac function. in this study, we hypothesized that tagging magnetic resonance imaging (mri) is useful for assessment of pericardial adhesion. we performed tagging mri in consecutive 33 patients who underwent cardiac surgery one month ago (acute phase) and repeated the examination in 12 of them after more than 2 years (chronic phase). pericardial adhesion was visually scored (0=no adhesion, 1= mild adhesion, 2= severe adhesion) at two sites (post sternal bone site and right ventricular site) by one radiologist and one cardiovascular surgeon independently. the sum of scores at two sites (adhesion score) was obtained and compared between two readers or between acute and chronic phases. results: there was a signifi cant correlation between adhesion scores by two readers using spearman rank order correlation coeffi cient (r=0.4 p < 0.05). adhe-364 b d e f a g infarcted and peri-infarcted myocardium (n=6), the other 6 pigs served as control. cine sequences (tr/te=8/5 ms, 16 phases), gd-dota fi rst pass perfusion (sr-gre: tr/te=3/1.5 ms) and delayed contrast enhancement (ir-gre: tr/te=4.4/2.1 ms, ti=270-325 ms) were performed to measure lv function, area at risk (aar) and infarct size. at postmortem, the hearts were stained with histochemical ttc, masson's trichrome and isolectine b4 to characterize myocardium. results: aav-vegf prevented the deterioration of lv ejection fraction in treated animals at 8 weeks. aav-vegf animals showed greater reduction in the aar (39±2% at 3 days to 20±2% lv at 8 weeks) versus control animals (41±2% to 33±2%, p < 0.01). aav-vegf improves the reduction in extent of hyperenhanced myocardium in treated (19±2% at 3 days to 10±3% lv at 8 weeks) versus control animals (18%±2% to 15±2%lv, p < 0.01). ttc infarct size was smaller in treated (10±1% of lv) compared with control animals (14±3% of lv, p < 0.001). histology showed increase in thin-walled arterioles (38±2/mm² in treated versus 6±2/mm² in control) and capillaries (1065±78/mm² in treated versus 576±50/mm² in control) in the injection sites. conclusion: intramyocardial injection of aav-vegf signifi cantly improved mri measurements of myocardial function and perfusion. the therapy also increases infarct resorption by promoting angiogenesis. role of cardiac magnetic resonance imaging (mri) in the follow-up assessment of tetralogy of fallot (tof) repair p. serrano gotarredona, s. navarro herrero, l. aguilar sánchez, l. garcia camacho, i. gutierrez jarrín; sevilla/es (mp.serrano.sspa@juntadeandalucia.es) purpose: to assess the value of cardiovascular mri in the follow-up of tetralogy of fallot after complete reparative surgery. we include all the patients who were survivors of tof surgical repair and were explored by mri in our institution during the last two years. the protocol included 3d mr angiography (mra) to delineate pulmonary arteries anatomy; spin-echo and gradient echo sequences to delineate right ventricular outfl ow tract (rvot); balanced steady state free precession (b-ssfp) cine-imaging to quantify ventricular function; and phase-contrast velocity mapping (vec-mr) to quantify pulmonary regurgitation (pr). results: we studied 16 patients aged between 4 and 34, 11 of them older than eighteen years. the estimated value of ejection fraction of the right ventricle was over 50% in eight subjects, and under 40% in fi ve. up to thirteen had pr. vec-mr sequences concluded regurgitation fraction equal or over 50% in three cases, between 40 and 50% in two, between 27 and 40% in other seven. the last one had a pr of 10%. 3d mra showed pulmonary artery branches stenosis in seven cases. it was severe at the level of the anastomoses a case of prosthetic conduit placement because of rvot re-stenosis. b-ssfp sequences showed residual ventricular septal defect in two patients. conclusion: cardiac mri is a valuable method to evaluate and follow-up tof patients who had undergone complete surgical repair. it not only provides valuable anatomic information about rvot and pulmonary arteries, but also quantifi es ventricular function and pulmonary regurgitation. cardiovascular magnetic resonance in the follow-up of adults with corrected tetralogy of fallot: a useful tool to indicate reoperation? f. baudraxler, m. bret-zurita, e. cuesta, a. aroca, j. oliver, a. sánchez-recalde; purpose: to demonstrate that cmr can be a useful imaging modality to indicate reliably a re-operation in patients with repaired tetralogy of fallot (tof). to show the indications for reoperation in our patients. methods and materials: seventy-six cmr imaging studies of patients with repaired tof performed between january 2004 and september 2006 were reviewed. a 1.5 t signa lx 9.1 echo-speed ge mr system, body or cardiac array coils were used. se t1 ecg-gated, fiesta, pc flow sequences and mr-angiography 3d with mpr and vrt reconstructions were employed. morphology and size of cardiac cavities and aneurysms of the right ventricular outfl ow tract (rvot), right ventricular ed and es volume, stroke volume, cardiac output, ejection fraction (ef), pulmonary blood fl ow, and morphology of the pulmonary tree were analyzed. results: parameters provided by cmr which indicated reoperation were the following: right ventricular ed volume> 190 ml, ef less than 30%; regurgitation fraction more than 50% and aneurysm of rvot > 5-6 cm. forty-six reoperations were performed in 39 patients. the most common indications referred to aortic root and valve (n=10), right ventricle to pulmonary artery (rv-pa) conduit obstruction (n= 9), and enlargement of the rvot inserting a pulmonary valve prothesis (n=8). mean age at reoperation was 27 years and the average time between the corrective repair and reoperation was 19 years. conclusion: cmr is a diagnostic imaging modality to indicate reoperation in all our patients with repaired tof. however, we still need new techniques for a better interpretation of cmr parameters in order to determine the right moment for reoperation. cardiac mri in patients with previously treated congenital heart disease: long term follow-up results a. sias, a. balestrieri, c. politi, g. mallarini; cagliari/ it (alessandrosias@hotmail.com) purpose: the purpose of this study is to display the fi ndings of cardiac mr examinations performed on a group of patients treated for congenital heart disease when infants or children, after a period of relative well being which lasted for several years. methods and materials: among a sardinian population of about 1,200 patients surgically treated for congenital heart disease on an average of 15 years before we randomly selected 120 of them and examined with standard cardiac mr to evaluate the heart morphology, and whether they had any abnormalities which could have gone undetected with other follow-up examinations to which they had been routinely subjected. we discovered a number of pathological fi ndings which were not noted, or underevaluated with other imaging examinations and/or clinical examinations. conclusion: follow-up cardiac mr examinations in patients with congenital heart disease surgically treated, even after a long term interval after the intervention, can be useful in defi ning the evolution of cardiac morphology and the development of iatrogenic or surgery related abnormalities, which might go undetected by standard follow-up examinations. aortic coarctation: evaluation with cardiovascular magnetic resonance angiography using time-resolved imaging of contrast kinetics ( background: cardiac magnetic resonance (cmr) in children may be limited in unravelling all details concerning the heart and great vessels. cmr is very attractive, however, for it allows an optimal anatomical and functional analysis and does not require iodine nor radiation exposure. standard 3d magnetic resonance angiography (3d-mra) series may not reveal all anatomical abnormalities because of incorrect timing of peak enhancement. for a better display of the cardiovascular fi ndings, it would be desirable if one could reconstruct such structures at different contrast transit times. the 3d-mra with tricks, available in ge mr scanners, furnishes sequential mra gadolinium-enhanced series and allows the selection of the best contrast-enhanced series to study a particular vessel. it would, therefore, be very useful in the evaluation of aortic coarctation. imaging findings: patients' mean age was 1.2 years (0-12) and they were referred to either diagnose aortic disease or to post-treatment follow-up. all images underwent extensive time-resolved reconstructions at dedicated workstations and 3dvr data sets were reconstructed in order to unravel the anatomy of the aorta and its main branches. conclusion: tricks is a powerful tool in the evaluation of aortic coarctation for it allows precise identifi cation of the aorta disease and of additional cardiovascular malformations, such as pda. this was the fi rst mra technique to provide 3d temporal display of the fl ow-abnormalities. evaluation by mri of left ventricular remodelling and global functional recovery in patients treated with granulocyte-colony stimulating factor (g-csf) after acute myocardial infarction (ami) l. natale, a. bernardini, a. meduri, a. leone, f. crea, l. bonomo; rome/it (lnatale@rm.unicatt.it) purpose: to assess by mri the effect of i.v. administration of g-csf on global myocardial function after ami. recent data suggest better outcome and functional recovery in patients with ami treated with stem cells therapy, both with intracoronary delivery or hematopoietic precursor mobilization by g-csf. methods and materials: eight patients with anterior ami, treated with primary ptca (timi 3) and i.v. administration of g-csf (5 µg/kg for 5 days), were studied c 365 b d e f a g by 1.5 t mri within 7 days and after 3-5 months. functional, perfusion (fp) and delayed enhancement (de) studies were obtained. values were compared with eight control patients (anterior ami, primary ptca). fp and de were scored basing on number of segments involved and on transmural extension. correlation of fp and de with functional outcome and differences between the two groups, accounting for fp and de extent, were assessed with univariate (lr) and multivariate linear regression (mlr) and covariance analysis (ancova). results: lr showed signifi cant correlation between de-score and follow-up edv (fu-edv), esv (fu-esv), and ef (fu-ef). no signifi cant linear correlation with fp-score was found. mlr and ancova showed a positive trend in g-csf group for all functional indexes, accounting for differences in de (effect of g-csf, expressed as ls-means: fu-edv= -22.19±41.54 ml; fu-esv= -25.13±37.37 ml; fu-ef= +5.43%±10.07). the effect of g-csf approached statistical signifi cance only for fu-esv (p=0.06). conclusion: we found a positive trend with partial statistical signifi cance regarding global functional recovery in patients treated with i.v. g-csf after ami. these data, however, need to be confi rmed in a larger series. delayed enhancement in patients with dilated cardiomyopathy is unrelated to virus persistence or the presence of infl ammation in myocardial biopsies s. langner, j. ruppert, k. hegenscheidt, a. staudt, n. hosten; greifswald/de (langso@uni-greifswald.de) purpose: dilated cardiomyopathy (dcm) is a frequent cause of heart failure. some patients show delayed enhancement (de) in contrast-enhanced mri (cemri). the pathologic surrogate of de is unknown in dcm. virus persistence and myocardial infl ammation can be shown in a considerable proportion of myocardial biopsies of patients with dcm. the study compares the histological fi ndings with the presence of de in the cemri of dcm patients. methods and materials: twenty-two patients with dcm underwent cemri after myocardial biopsy. biopsies were taken from the right ventricular part of the interventricular septum (ivs) and analyzed for viral genomes and infl ammation. mri was performed on a 1.5 t mri scanner. images for de were acquired 20 minutes after injection of gd-dtpa and were visually assessed for de. this was categorized regarding the location in the myocardium and the distribution pattern. the most abundant pattern of de was a stripe-like lesion in the midwall portion of the ivs. there was no signifi cant correlation for de and the cardiac parameters. seven myocardial biopsies were positive for viral genomes (31.8%). three of the 7 virus-positive patients (42.9%) showed de versus 4 of the 15 virus-negative patients (26.7%), with no statistically signifi cant difference. myocardial infl ammation was detected in 12 patients (54.5%). de was present in 3 of these patients (25%) and in 4 of the remaining 10 patients (40%), with no signifi cant difference. the presence of delayed enhancement does not correlate to myocardial virus persistence or to the presence of myocardial infl ammation in myocardial biopsies of patients with dcm. meta-analysis: coronary calcium score as a predictor of atherosclerotic cardiovascular disease events in asymptomatic patients s.k. ternovoy, v.e. sinitsyn, s.p. morozov; moscow/ ru (spmoroz@mail.ru) purpose: to defi ne predictive value of coronary artery calcium (cac) scoring in identifying asymptomatic patients at higher risk of atherosclerotic cardiovascular disease (cvd) events (non-fatal myocardial infarction, coronary death, and coronary revascularization). the data from previously published studies (indexed in pubmed medline) were extracted for the meta-analysis. the studies should have reported cac scores and prospective registration of cvd events in order to be included in the meta-analysis. relative risk (adjusted for traditional risk factors) was used as a meta-meter for cvd events in 3 cac score subgroups of patients. we tested data for publication bias, applied q-test for heterogeneity, and analyzed individual weights of the studies. results: our meta-analysis included 8 studies. the studies were very heterogeneous in terms of patients' age, sex, race, and duration of follow-up. the pooled relative risk calculated on the basis of random effects model was 2.1 for cac scores 1-100; 5.0 for cac scores 100-400; and 9.3 for cac scores > 400. the analysis of the infl uence of individual studies on the pooled relative risk allowed identifying the outlying studies. the results of the meta-analysis demonstrate that relative risk of cvd events signifi cantly increased with higher cac scores. we conclude that cac score is the risk factor independent of cvd events, since the pooled relative risks were adjusted for traditional risk factors. the effect of outlying studies on the pooled estimates may be explained by the different representation of genders, blinded endpoint validations and registrations, and longer follow-up. the use of a ct cardiac bowtie to improve image quality and reduce patient dosage j. gao, x. sun, j. li, r. dai, g. wang, n. li; beijing/ cn (jianying.li@med.ge.com) learning objectives: to demonstrate the potential of using an application-specifi c bowtie to improve cardiac image quality and reduce patient dose. background: using application-specifi c bowties can reduce x-ray dose for ct imaging. ge vct provides a cardiac bowtie (cb) that redistributes x-ray fl ux to concentrate on the heart. this study evaluates the dose-reduction potential of such bowtie by comparing it to the use of traditional large bowtie (lb) using patient scan data. imaging findings: thirty cardiac patients in each group with similar sex, age, height, weight and heart rate distributions were scanned with lb and cb, respectively. two experienced radiologists quantitatively evaluated the image quality blindly in terms of the number of coronary arteries identifi ed, vessel edge sharpness and contrast agent clarity in the vessel using scores of 1-4, with 4 being the highest. ctdiw values and image noises for the two sets were measured and statistically analyzed using t-test. the image quality scores for the cb and lb groups were 3.73±0.34 and 3.72±0.29, respectively, with no statistical difference (p> 0.05). however, the ctdiw values for groups cb and lb were 77.66±6.97 mgy and 83.97±7.60 mgy, respectively, with t-test of p=0.0015 indicating statistically signifi cant lower dosage with cardiac bowtie. in addition, the noise measurements for the cb group was statistically lower than those of lb (27.80±4.33 vs. 30.05±3.18 with p=0.025). the application-specifi c cardiac bowtie on vct reduced the overall dosage to cardiac patients and image noise without adverse impact on other clinically relevant parameters. (4) with neither ncp nor cp. groups were compared as to age, sex, coronary risk factors (crfs). results: the 4 groups had 81.43,147, and 77 subjects, respectively. the incidence of hypertension and diabetes mellitus (dm) were higher in group (1) (69% and 36%) than in (4) (34% and 12%). the incidence of crfs, number of males, dm, hyperlipidemia (hl), and smoking were signifi cantly higher in (1) than in (2). in logistic models, hl and obesity (relative risks 2.40 and 2.52) were associated with incidence of fcp adjoining ncps. furthermore we divided group (2) into two groups: (2 a) with exclusive ncp without any cp or (2b) with ncp separate from cp. crfs were 2.6 (2b) and 1.5 (2 a) and that of (2 a) was similar to (4). conclusion: crfs were more frequent in subjects with fcp adjoining ncp than in other groups. fcp adjoining ncp may indicate the advanced arteriosclerosis. conversely, crfs were less frequent in subjects with exclusive ncp than in other groups with any ncp and/or cp but similar in subjects with neither ncp nor cp and presence of exclusive ncp may indicate early staged arteriosclerosis. presence of focal fatty infi ltration of the right ventricular wall in asymptomatic patients undergoing screening coronary calcium scoring on ebct j. kirsch, e.e. williamson, j. glockner; rochester, mn/us purpose: macroscopic focal fat deposition along the free wall of the right ventricle (rv) has been historically associated with arrhythmogenic right ventricular dysplasia. recently, it has been shown that this fi nding can be seen in patients without arvd. in this investigation, we assess the incidence of fatty infi ltration of the rv in a cohort of patients without clinical evidence of arvd. methods and materials: 120 consecutive patients undergoing non-contrast ecggated ebct for coronary calcium scoring comprised the study group. images were evaluated for the presence or absence of rv fatty infi ltration as well as additional fatty proliferation in the mediastinum, lipomatous hypertrophy of the interatrial septum, and changes of thoracic surgery. medical records were assessed to obtain age, gender, body-mass index, and arrhythmias detected on ecgs obtained within 6 months of imaging. patients with surgical changes were excluded to avoid falsenegatives secondary to artifact. images were evaluated, by consensus, by 2 of 3 dedicated cardiac radiologists. results: of the 120 patients, 12 were excluded due to lack of required information in the medical records and/or surgical changes. 12/108 (11%) patients had fatty deposition along the rv wall. conclusion: focal fatty infi ltration of the rv is a fairly common fi nding in the patient population, and should not be considered as defi nitive evidence of arvd. three learning objectives: to describe the wide spectrum of the anomalous pulmonary venous return. to understand pathophysiology and radiologic features of this entity and diverse post-operative anatomical and hemodynamic changes. to evaluate the utility of three-dimensional ct angiography in the diagnosis and management of this entity. background: anomalous pulmonary venous return shows diverse anatomical and hemodynamic spectrum, which range from isolated incidental fi ndings to components of more complex anomalies, most often congenital heart disease. correct diagnosis with ct angiography affects the patient's treatment and allows avoiding unnecessary invasive studies. procedure details: we retrospectively reviewed ct angiography with 3d reconstruction images of 41 consecutive patients with anomalous pulmonary venous return (16 papvr and 25 tapvr) from june 2002 to march 2006. twenty-nine pre-operative ct angiography were available and 21 post-operative ct angiography were available; among them, both pre-and post-operative ct angiography were available in 9 cases. we will show the diverse spectrum of anomalous pulmonary venous return and remind the check points in imaging interpretation to provide critical information for surgical planning and post-operative evaluation. conclusion: three-dimensional ct angiography provides precise and excellent overview of the diverse spectrum of anomalous pulmonary venous return, noninvasively. in addition, it allows in assessing other anomalies involving the bronchial tree or visceral organs. this exhibit will help you to understand the characteristic imaging features and diverse post-operative anatomical and hemodynamic changes of this entity, and to remind the information critical for surgical planning and postoperative evaluation. initial experiences of 'snapshot cine' -low dose prospective electrocardiograph (ecg)-triggering coronary 64-slice ct angiography (cta) m. kiguchi 1 , j. horiguchi 1 , k. ito 1 , k. marukawa 1 , c. fujioka 1 , m. ishifuro 1 , t. furukawa 1 , y. shen 2 , f. watanabe 2 ; 1 hiroshima/jp, 2 tokyo/jp (kiguchi@hiroshima-u.ac.jp) learning objectives: to demonstrate low radiation dose in 64-slice coronary cta using prospective ecg-triggering. to demonstrate reduction of banding and cone beam artifacts by 3d back projection (3dbp) algorithm. background: diagnostic capability of 64-slice cta for coronary artery disease has been already accepted and become a widely spread use. the major drawback of the technology is the high radiation dose caused by data acquisition with retrospective-ecg gating on which the raw data includes cardiac phases not contributing in image reconstruction. advancement of ecg-modulated retrospective-ecg gating technique and prospective ecg-triggering scan are strongly desired to overcome this problem. procedure details: a 64-row x 0.625 mm-collimation confi guration (40 mm) (ge healthcare) is used for data acquisition with prospective ecg-triggering. three or 4 x-ray exposures per examination with 5 mm overlapping cover 11 cm or 14.5 cm in z-axis. banding artifacts, which are caused by misregistration of data and have been observed so far on retrospective-ecg gating scan, are reduced. conebeam artifacts seen on multi-slice ct technology are also reduced by 3dbp algorithm. we present initial experiences of this software as to dose saving and image quality. the image quality was assessed on motion artifacts and data continuity (occurrence of banding artifacts), with relation to the scanning time and heart rate. conclusion: 'snapshot cine' 64-slice coronary cta using prospective ecg-triggering, with signifi cantly reduced dose, has a potential to replace retrospective-ecg gating cta. cardiac ct for the stratifi cation of cardiovascular risk in patients undergoing major non-cardiac surgery: background, rationale and possible diagnostic algorithm l. damiani, a.l. la fata, e. maffei, a.a. palumbo, f. notarangelo, a. aldrovandi, f. cademartiri; parma/ it (damianilaura@virgilio.it) learning objectives: to provide current methods and guidelines for stratifi cation of cardiovascular risk in patients undergoing major non-cardiac surgery. to understand the rationale for stratifi cation of cardiovascular regarding different implications of inducible myocardial ischemia in the surgical theatre. to provide an algorithm for stratifi cation of cardiovascular risk in patients undergoing major non-cardiac surgery that includes cardiac-ct. background: in daily clinical practice, patients undergoing major non-cardiac surgery need a stratifi cation of their cardiovascular risk. this is performed by means of scoring methods and diagnostic tests (i.e. ecg, stress-ecg). however, these tests are sub-optimal and because of their low sensitivity and specifi city may under/over-estimate the potential risk. conventional coronary angiography, which is the diagnostic gold standard, cannot be performed in all patients since it is invasive and the prevalence of signifi cant disease is intermediate or low. cardiac-ct is a non-invasive method for assessment of signifi cant coronary artery disease characterized by a high sensitivity and negative predictive value. in addition, it can provide the coronary atherosclerotic plaque burden and the type of lesions associated with an individual patient undergoing surgery. these additional informations can change surgical and anaesthesiological management. procedure details: 1. description of current scoring methods and guidelines for pre-operative cardiovascular risk assessment. 2. description of cardiac-ct features that may improve stratifi cation of cardiovascular risk. 3. description of a diagnostic algorithm for patients undergoing major non-cardiac surgery including cardiac-ct. conclusion: cardiac-ct may become in the future a standard diagnostic method for the stratifi cation of cardiovascular risk in patients undergoing major non-cardiac surgery. thrombi in the left cardiac appendix with state-of-the-art multislice ct: a reason for discussion between radiologists and cardiologists? to provide examples of discrepancy between those techniques (ultrasound positive and ct negative and viceversa). 3. to explain the possible reasons for this discrepancy. background: tte is not an optimal technique for the examination of the left appendix. tee is the current clinical gold standard but it is invasive and operator dependent. 64-slice ct is a non invasive modality providing a non operator dependent assessment of the cardiac chambers. the current generation of multislice ct scanners uses ecg-gating, sub-millimiter spatial resolution and good temporal resolution to provide increasingly accurate assessment of coronary artery. it also allows the detection. basics of ecg for ct of the heart: what radiologists need to know a.a. palumbo 1 , e. maffei 1 , l. damiani 2 , l. la fata 2 , a. aldrovandi 1 , f. notarangelo 1 , f. cademartiri 1 ; 1 parma/it, 2 palermo/it (alepalumbo@gmail.com) learning objectives: 1. to provide ecg fundamentals for correct ct setting. 2. to correlate ecg traces and ct appearance of coronary arteries. 3. to give tips and tricks for ecg post-processing editing for good image quality in patients with irregular heart rates. background: ecg and physical examination are the primary evaluations performed to overview heart conditions. the knowledge of ecg is becoming familiar to radiologists involved in non invasive cardiac imaging. several studies have demonstrated that the synchronization of the scan with an optimal ecg track (i.e. sinus rhythm, heart rate < 65 bpm, no premature beats) minimizes image motion artifacts and signifi cantly increases image quality. in clinical practice, patients with coronary artery disease may have irregular heart rates and software upgrades for ct-ca can help the radiologists to handle premature beats, bigeminism, irregular heart rhythms and other abnormalities. procedure details: drawings for the explanation of ecg basics are presented. several examples of heart beats abnormalities are shown and improvement of image quality is reported before and after ecg editing. a correct placement of ecg electrodes is mandatory to avoid signal artifacts: it is described how to get the best ecg signal. conclusion: in clinical practice, patients with coronary heart disease may have irregular heart rates. in the near future, irregular heart rhythm will be not considered as an exclusion criteria for ct of the heart and ecg-editing will become routine in enhancing the image quality and allowing the inclusion of more patients for cardiac ct. non background: atrial septal defects (asd) and patent foramen ovale (pfo) are one of the most common cardiac abnormalities. they predispone to cerebral ischemia as a result of paradoxical thromboembolism by right-to-left shunting under conditions or physiologic maneuvers that raise right atrial pressure (valsalva maneuver). percutaneous defect closure is reliable for a decade and it needs an accurate depiction of atrial anatomy for a correct surgical planning. since now, trans-esophagel echocardiography has provided the anatomical and functional informations. cardiac ct, thanks to an higher spatial resolution, a non-invasivity, a better reproducibility of measurements can provide excellent images of atrial anatomy, helping to correctly choose the best occluder device. procedure details: 64-slice ct allows a motion-free 3d images of asd and pfo. all dimensions of tissue surrounding the defect are measured in systole (during ventricular dyastole) and in dyastole (during ventricular systole). in particular, distance between atrial defect and aortic root and inferior vena cava is measured in ct and echocardiography. atrial defects and closure devices are compared in 3d visualization, before and after closure procedure. conclusion: this fi rst experience with ct for percutaneous defect closure of the atrium seems promising. cardiovascular malformations with intra and extracardiac shunts in adults: the to review congenital heart diseases with shunts. background: the prevalence of congenital heart diseases is approximately 1% of all births. detection of some of them, especially when combined with great vessels' anomalies, may cause some diffi culties using routine diagnostic techniques. application of msct for cardiac imaging is increasing and becoming more precise along with higher resolutions achieved in modern scanners. that enables both accurate visualization of central circulatory system and adjacent anatomical structures. imaging findings: examinations of 30 adult patients with variable cardiovascular defects performed with 8-row and 64-row scanner were processed. selected group contained: asd, vsd, patent ductus arteriosus, univentricular heart with transposition of great arteries, corrected transposition of great arteries, fallot's tetralogy, left and right sided partial anomalous pulmonary venous returns and persistent left superior vena cava. in addition, ct examinations after surgical corrections of some of the defects were presented. multiplanar and 3d reconstructions were acquired and shown with respect to educational purpose. conclusion: msct allows precise diagnosis of complex cardiovascular malformations and postoperative evaluation, being a valuable tool for imaging even complicated and infrequent anomalies of central circulatory system. moreover, multiplanar and 3d reformations allow visualization of congenital heart defects as ideal educational material. morphological atherosclerotic plaque analysis on coronary artery autopsy specimens using dual source computed tomography, micro computed tomography, and histopathology w. kristanto, r. dikkers, p.m.a. van ooijen, m.j.w. greuter, t.p. willems, m. oudkerk; groningen/nl (w.kristanto@rad.umcg.nl) purpose: to compare visualization of atherosclerotic plaques by dual source computed tomography (dsct), micro computed tomography (microct) and histopathology. methods and materials: eleven autopsy specimens of human coronary vessels were scanned with microct (siemens microcatii, siemens molecular imaging, knoxville, tennessee) without contrast agent and with dsct (somatom defi nition, siemens medical solutions, forchheim, germany) with contrast agent (mean 250 hu). the images were reconstructed at 48 µm voxel size (microct) and 0.6 mm slice thickness (dsct). histopathology analysis was performed afterwards for reference. from the reconstructed images, the morphology of the plaques was compared to the histopathological results. results: some calcifi ed spots found by histopathology were detected by dsct, but were overestimated in size. some soft plaques observed by histopathology were vaguely shown by dsct. smaller calcifi ed plaques and plaque ruptures were observed by histopathology, but could not be detected on dsct. microct clearly showed small calcifi cations and vessel wall thickening. a lower density structure, suspected as lipid pool, was observed inside one of the large calcifi ed plaques and a possible plaque rupture was also observed in one of the specimens on microct. conclusion: dsct tends to overestimate medium and large calcifi ed plaques whereas it misses the small ones. soft plaques are shown but vaguely. microct shows much more details on plaque morphology, as can be expected by its high spatial resolution. our fi ndings show that current clinical ct is mainly limited by spatial resolution. analysis of the fi ndings from microct and histopathology may help interpret the clinically available ct data. why do we misinterpret lesions on cardiac ct while compared with catheter coronary angiography? a critical review series collaborated with cardiologists t. lee, i. (sillyduck@ms11.url.com.tw) learning objectives: to understand the limitations and artifacts of ct coronary angiography. to understand when, how and why we misdiagnose in ct coronary angiography. to understand the possible reasons for the discrepancy between ct and catheter coronary angiography. background: ct coronary angiography is recently a hot topic. with the advent of mdct, this technique is gradually integrated into the clinical practice. but this technique is so new that the standards of training, interpretation and clinical practice are not established yet. what are the basic requirements of an 'interpretable' scan? when and why do we misinterpret? are the misinterpretations avoidable? these are important questions we will try to answer by this review series. procedure details: we retrospectively review 72 cases that underwent both the 40-detector row ct coronary angiography and catheter coronary angiography. all initial reports and images are critically reviewed by collaboration of two cardiac radiologists and a senior interventional cardiologist. using catheter coronary angiography as reference, all the misinterpretations are critically discussed. all the lessons learned are summarized with consensus. about the ct aspect, the discussed topics include respiratory motion, heart rate, heart rate stability, arrhythmia, image noise, interpretation skill, post-processing technique, reconstruction phase selection and window settings. some misinterpretations of catheter coronary angiography are also found during the review process and will be demonstrated and discussed in the exhibit. conclusion: most misinterpretations in ct coronary angiography are related to the techniques in interpretation, image acquisition and processing. most of them are potentially avoidable. multidetector purpose: to show typical anatomic pattern and variance of the left atrium-pulmonary veins complex (la-pv) studied by 16 slices multidetector ct (mdct) in atrial fi brillation (af) patients candidated to percutaneous ablation. the exact knowledge of this anatomic region is extremely important to increase the effi ciency and effi cacy of the procedure, and to reduce the related complications. methods and materials: in the last three years, 65 af patients (15 females, 50 males) underwent mdct cardiac examination using retrospective gating and dose modulation with reconstruction of 75% of rr ecg interval. results: in the patient population, we identifi ed 141 right pv, 11 of which were suprannumerary; 112 left pv, 19 of which common trunk and 1 suprannumerary. in 60% of patients, the anatomic pattern was typical (2 right and left pv) and in the remaining 40% atypical (23% 2 right pv and left common trunk; 2% 3 right pv and 3 left pv; 6% 3 right pv and left common trunk). in the defi nition of branching, mdct identifi ed 55 branchings of the right inferior pv, 41 of the right superior pv, 4 of the left superior pv, 6 of the left inferior pv and 2 of the suprannumerary veins. conclusion: mdct represents a fundamental diagnostic imaging tool in the anatomic defi nition of the pv that is characterized by great variability. radiologists must be familiar with anatomic variants and understand the importance of these variants to the refering cardiac interventional electrophysiologist. data was also collected on the extent of coronary artery disease (cad), peripheral vascular disease (pvd), and the treatment given to that patient. data regarding presence of associated cardiovascular and cerebrovascular disease in the pvd group were obtained from the patient's medical record. results: age and sex distribution were similar in both groups. prevalence of risk factors in both groups was as follows (cad/pvd): 77%/68% hyperlipidaemia, 55%/61% hypertension, 47%/69% smoking, 39%/44% positive family history and 17%/36% diabetes. in the pvd group, 42% and 23% had symptomatic cad and cerebrovascular disease, respectively. in the cad group, 12% had symptomatic cerebrovascular disease. coronary disease on investigation was more severe than in comparable studies conclusion: this study has shown that the prevalence of risk factors and associated co-morbidity are either comparable or higher than studies carried out elsewhere. higher prevalence of smoking and diabetes was noted in the pvd group. findings of the coronary and peripheral angiograms and the resulting treatment will be discussed. learning objectives: to discuss the acquisition protocol and reconstruction algorithm which provide optimal image quality of bypass grafts and native coronary arteries with dual-source ct. to address artifacts and interpretative strategy for ct coronary angiography in patients after bypass surgery. background: the recently introduced dsct scanner permits coronary imaging with high resolution (83 ms), which provides improved image quality in patients with higher heart rates when compared to earlier scanner generations. moreover the entire heart and graft course can be acquired within a single breath-hold of 8 to 12s. procedure details: in this exhibit, we provide examples of dsct coronary angiography in the evaluation of normal and diseased and occluded bypass grafts. different bypass surgery techniques are discussed and various examples shown. in addition, we address possible artifacts originating from graft orifi ce indicators, surgical clips and sternal wires, and discuss pitfalls in the evaluation of both bypass grafts and native coronary arteries. conclusion: dsct allows high-resolution scanning of the entire thorax within a single breath hold. we demonstrate image quality of dsct coronary angiography in patients with various heart rates after bypass surgery. we discuss the acquisition protocol and reconstruction algorithm, which provide optimal image quality of both cabg and native coronary arteries. learning objectives: 1. to modify the standard protocol of coronary imaging studies in order to depict ivs and right ventricle. 2. to recognize different kinesis pattern of ivs related to various cardiac diseases. background: regional kinesis alteration of ivs is associated with different cardiac conditions which may have both pathological and physiological meanings of which the most important are the following: a) left bundle branch block that may determine intra-left ventricular asynchrony and may represent an independent predictor of severe cardiac events in heart failure patients; b) pulmonary embolism that increase right ventricle pressure; c) constrictive pericarditis; d) restrictive cardiomyopathies; e) post-operative cardiac surgery. procedure details: a 64-msct scanner (lightspeed vct, general electric, milwaukee) was employed, using the following parameters: 64x0.625 collimation, pitch 0.24, 680 ma, 120 kv, rotation time 350 msec.; i.v. iodinate contrast agent was administrated with a double phase injection : 80 cc at 5 cc/sec followed by 20 cc at 4 cc/sec. beta-blockers were administered to patients with heart rate above 65 beats per minute (bpm). axial images were then reconstructed at multiple phases covering the cardiac cycle in increments of 5% of the r-r interval between 0% and 95%. after the reformatted images were transferred to a workstation, contiguous multiphase short-axis and long-axis images were generated using semiautomated interactive software (advantage windows 4.2, cardiq iii function, ge healthcare). conclusion: 64-msct is an effective imaging modality in depicting ivs contraction anomalies. learning objectives: to understand normal imaging characteristics of contrastenhanced ct images of myocardium and pericardium, together with a great variety of common and more rare pathologic conditions involving these structures. background: since the introduction of 16-and especially 64-slice, ct radiologists are increasingly involved in the execution and interpretation of ct images of the heart and coronary arteries. while there is extensive literature on the imaging of the coronary arteries, ct imaging features of the myo-and pericardium have been scarcely reported. imaging findings: it is the aim of this pictorial review to familiarize the radiologist with the common presentation on ct examinations of myo-and pericardium, including normal anatomy variations. furthermore, a wide variety of diseases like myocardium infarctions of different ages, congenital entities like non-compaction cardiomyopathy, pericardial cysts and other pathologies are reviewed. the images are collected from more than 3000 16-and 64-slice cardiac ct examinations gathered between 2003-2006. conclusion: pathology in the myocardium and pericardium is frequently encountered during ct examination of the heart and coronary arteries. solid knowledge of both normal and abnormal presentation of these structures will increase the diagnostic accuracy of the radiologist, as such limiting errors of interpretation. the infl uence of heart rate fl uctuation on cardiac image quality and the improvement by combining varispeed scan technique (vst) and multi sector reconstruction algorithm (msr) j. liao 1 , y. shen 1 , x. ge 2 , s. wu 2 , j. li 1 , j. at 60 and 105 bpm, the image quality with 0.5 s/r was better than the one with 0.6 s/r. but at 85 bpm, the image quality with 0.6 s/r was better than the one with 0.5 s/r. 3. at the higher hr (85 bpm, 105 bpm) and wider hr fl uctuation range, msr could improve the image quality signifi cantly (p < 0.05). conclusion: hr fl uctuation is an important reason that degrades the image quality. vst could optimize the matching of rotation speed and hr to improve image quality. msr could provide the better temporal resolution and it is effective in reducing the infl uence of hr fl uctuation. mdct-ca volume rendering/auto track vs. mpr/mip analysis to assess coronary artery stenosis v. alaimo 1 , g. runza 1 , l. la grutta 1 , m. galia 1 , g.f. lo re 1 , t.v. bartolotta 1 , f. cademartiri 2 , m. midiri 1 ; 1 palermo/it, 2 parma/ it (valalaimo@libero.it) learning objectives: to display as a correct approach to detect coronary artery disease is based on a careful evaluation of coronary tree by using manual track vessel analysis and mpr/mip reconstructing approach. to demonstrate as the degree of coronary arteries stenosis is infl uenced by different post-processing techniques. background: cardiac mdct is a non-invasive technique to recognize presence of coronary disease, thanks to the capability to identify vessels remodelling and coronary stenosis. in this exhibit, we will describe the use of different post-processing techniques for the assessment of coronary artery stenosis, such as vr/auto track approach and mpr/mip conventional assessment, which are compared. imaging findings: post-processing procedures were performed using auto-cage bone removal/auto track and mpr-mip/manual track vessels analysis. images obtained with the methods were compaired. conclusion: vr images of lad, crx and rca, clearly show the non-calcifi ed stenotic tract of the vessels, but often overstimate the degree of stenosis compared with mpr/mip assessment. stenosis of the marginal and diagonal arteries with a small diameter are diffi cult to assess with vr and auto track analysis. the correct approach for an accurate and complete evaluation of coronary tree cannot exclude the vessels analysis by mpr/mip reconstruction. utility of multislice computed tomography with a 64-data acquisition system for four-dimensional volumetric analysis using a pulsating phantom and considering pulsation rate and reconstruction methods n. funabashi 1 , n. mizuno 1 , k. suzuki 2 , m. terao 2 , k. nakamura 1 , f. maeda 2 , m. uehara 1 , i. komuro 1 ; 1 chiba/jp, 2 tateyama/jp purpose: to evaluate 64-das msct (light speed vct, ge) at 0.625 mm slicethickness, 0.35s/rotation, tube 120kv at 400 ma, ecg-gated for 4-d volumetric analysis, we used pulsating phantoms to measure end-diastolic (edv) and endsystolic (esv) volume and ejection fraction (ef) to assess reconstruction methods especially for higher pulsation rates. a pulsating device (az-631n, anzai medical) with contrast material (300 mgi/dl) diluted 10x with saline was moved at 40-110 to-and-fro movements/min. ecg-gated msct was performed x5 per pulsation rate. the edv and esv were measured using workstation (virtual place advance plus, aze). the mean edv and esv were 98, 97, 97 96, 95, 94, and 101% and 145, 143, 142, 144, 145, 149, 156 and 160%, respectively, compared coronary fl y-through or virtual angioscopy using dual source mdct data p.m.a. van ooijen, m. oudkerk; groningen/nl (p.m.a.van.ooyen@rad.umcg.nl) purpose: coronary fl y-through, or virtual angioscopy (va), has been studied ever since its invention in 2000. however, its application was limited because of the requirements for an optimal ct scan and time consuming post-processing. recent advances in post-processing software facilitate easy construction of va but until now, image quality was insuffi cient in most patients. the introduction of dual source mdct could prove to enable va in all patients. methods and materials: twenty patients were scanned using a dual source mdct (defi nition, siemens, forchheim, germany) using a standard coronary artery protocol. post-processing was performed on an aquariusworkstation (terarecon, san mateo, ca). length travelled per major branch was recorded in mm together with the time required in minutes. results: va could be performed in every patient for each of the major coronary arteries. the mean (range) length of the automated fl y-through is 80 (32-107) mm for the left anterior descending, 75 (21-116) mm for the left circumfl ex artery, and 109 (21-190) mm for the right coronary artery. calcifi cations and stenoses are visualized, as well as most side branches. mean time required was 3 min for lad, 2.5 min for lcx, and 2 minutes for the rca. conclusion: dual source mdct allows for high quality visualization of the coronary arteries in every patient because scanning with this machine is independent of the heart rate. this is clearly shown by the successful virtual angioscopy in all patients. potential clinical value of the va should be determined in the near future. and ef between ct and ilvg were 0.3±126.7 ml, 25.8±40.4 ml, and -21±24%, respectively. in 37 subjects with omi, the correlation coeffi cients between ct and ilvg for edv, esv, and ef were 0.79, 0.84, and 0.60, respectively (all p < 0.01), and the averages±2sd of the differences of edv, esv, and ef between ct and ilvg were 8.0±54.1 ml, 28.5±36.7 ml, and -20.5±24.5%, respectively. conclusion: in all subjects, estimates of edv, esv, and ef were signifi cantly correlated between ct and ilvg, but ct tended to underestimate ef. in subjects with omi, ct tended to overestimate edv and esv, and estimates of ef were less correlated between ct and ilvg in subjects with omi. these discrepancies may be due to capability of ct to estimate lv wall asynergy 3-dimensionally more accurately than ilvg. quantitative annual effect of atorvastatin on size and content of noncalcifi ed plaques of coronary arteries following atorvastatin treatment by multislice ct n. results: patency was confi rmed in 70% des (83, 50 and 50% with 3.5, 3, and 2.5 mm diameters, respectively), and in 87%bms (100, 88, 95 and 69% with 4, 3.5, 3, and 2.5 mm diameters, respectively). patency of 30% des (17, 50, and 50% with 3.5, 3, and 2.5 mm diameters, respectively) and 13% bms (0, 12, 5, and 31% with 4, 3, 5, 3, and 2.5 mm diameters, respectively) could not be confi rmed because of partial volume effects due to small size. 6% bms revealed a low ct area inside the stents (1 each with 4, 3.5, and 3 mm diameters). 4% bms revealed total occlusion (1 each with 3.5 and 3 mm diameters). conclusion: 64-slice msct is a non-invasive diagnostic modality with the potential for evaluating patency of des with a low incidence of restenosis, especially des with 3.5 mm diameter. however, due to partial volume effects, it remains diffi cult if the lumen is 3 or 2.5 mm. bms had a thinner slice thickness and bigger lumens, and their patency was easier to evaluate by msct. background: within the patients with chest pain and overt coronary artery disease, there are a large number of negative fi ndings. a small niche of these patients present with chest pain that mimics coronary artery disease and they may carry unusual fi ndings. in these patients, the diagnostic challenge may be diffi cult using the conventional diagnostic tools (i.e. history, physical examination, ecg, biomarkers, chest x-ray). ct coronary angiography is increasingly applied in the er settings for the assessment of patients with atypical chest pain because of its high negative predictive value in populations with low-to-intermediate prevalence of disease. a diagnostic spin-off of ct coronary angiography relates to its capability of showing any thoracic fi nding and therefore several different fi ndings, such as non coronary causes of chest pain, may arise (i.e. pulmonary embolism, aortic dissection, pulmonary artery fi stula, coronary fi stula, bronchogenic cyst, pericarditis, oesophageal disease, pulmonary sequestrum, mediastinal masses, etc). imaging findings: this exhibit will overview all causes of cardio-thoracic syndrome mimicking coronary artery disease. examples will be provided with patho-physiological explanation. conclusion: ct coronary angiography applied to cardio-thoracic syndromes is able to detect all major non-coronary causes of chest pain. for this reason, it is becoming the gold standard for chest pain assessment especially in er settings. coronary artery anomalies at 64-slice coronary ct angiography c. thilo, p. costello, u.j. schoepf; charleston, sc/us (thilo@musc.edu) learning objectives: the aim of this exhibit is: 1) to review the classifi cation of coronary artery anomalies. 2) to differentiate clinically signifi cant and insignifi cant variations. 3) to illustrate coronary anomalies based on 64-slice coronary ct angiography (ccta). 4) to emphasize small vessel anatomic variations. background: the increased use of cardiac ct leads to more frequent detection of coronary anomalies. improved temporal and spatial resolution of 64-slice ct enables visualization of small anomalies, which have been insuffi ciently described to date. imaging findings: the following imaging fi ndings will be reviewed and discussed: coronary anomalies: frequency and clinical signifi cance -normal variants -benign coronary anomalies -malignant coronary anomalies -coronary artery fi stulas -small vessels of the heart: anatomy and variants of the sinus node artery, conus branch, septal perforators, etc. conclusion: 1) coronary artery anomalies are more frequently detected since the introduction of ccta. 2) ccta with 64-slices enhances our knowledge on small vascular anatomy and small vessel variation. 3) in most cases, congenital anomalies are asymptomatic and incidentally detected. 4) in symptomatic patients with suspicion of coronary artery anomalies, ccta is emerging as the diagnostic modality of choice. comparison between iodine and gadolinium-enhanced multidetector ct coronary angiography: preliminary report p. carrascosa 1 , c. capuñay 1 , m. bettinotti 2 , a. goldsmit 2 , j. carrascosa 1 , r. pissinis 1 ; 1 san isidro/ar, 2 capital federal/ar (patriciacarrascosa@diagnosticomaipu.com.ar) purpose: to determine the sensitivity (s) and specifi city (sp) of gadolinium-enhanced ct angiography (gd-cta) and iodine-enhanced mdct (i-cta) for the detection of signifi cant coronary stenosis compared to digital angiography (da). methods and materials: eighteen patients with known coronary artery disease underwent gd-cta, i-cta and da. cts were performed with a 16-row ct scanner. for gd-cta, a volume of 0.4 mmol/kg of body weight of gadolinium was administered. for the i-cta, a volume of 100 ml of contrast material containing 350 mg/ml of iodine was administrated. the axial images and reconstructions of the coronary tree of both acquisitions were reviewed independently and directly compared. the degree of enhancement, the capability of an adequate delimitation of the coronary tree and the detection of coronary artery disease were evaluated. both acquisitions determined the presence of plaques and measured the coronary stenosis. those equal or above 50% where considered as positive fi ndings. results: gd-mdct angiography was successfully completed for evaluation in all patients. axial and multiplanar reconstruction images showed adequate visualization of the main coronary artery. the effects of injection of contrast materials on the heart rate and its fl uctuation in the 16-slice ct coronary angiography y. liu 1 , x.z. lin 1 , k.m. chen 1 , y. shen 1 , z. hao 2 ; 1 shanghai/cn, 2 shenyang/cn (lxzmm@yahoo.com.cn) purpose: to evaluate the effects of contrast medium (cm) injection on the heart rate and its fl uctuation in 16-slice ct coronary angiography (ctca). methods and materials: 140 cases that underwent 16-slice ctca were included in the study. during calcium scoring and ctca, waves of electrocardiogram (ecg) were recorded in two fl oppy disks. values of heart rate were recorded, and the differences between the sequential heart beats (d-hr) were calculated. all cases were classifi ed into three groups according to their heart rate: group 1: < 60 bpm; group 2: 60-70 bpm; and group 3: > 70 bpm. the ecg data of the three groups were compared statistically. ecg data of all the heartbeats and the fi rst fi ve beats after the cm injection were also compared. results: 239 ecg were included in total, in which 107 ecg were before cm injection and 132 after. the mean bpm of groups 1, 2 and 3 before cm injection were 56.01, 65.13 and 76.47 bpm and after cm injection were 55.26, 64.71 and 76.24, respectively. mean d-hr of groups 1, 2 and 3 before cm injection were 3.06, 3.27 and 5.52 bpm and after the cm injection they were 3.42, 4.28 and 6.47, respectively. mean d-hr of all the heartbeats and the fi rst fi ve beats after the cm injection were 4.44 and 2.76 bpm, respectively. conclusion: though the mean heart rate after cm injection was a little lower than that before cm injection, the fl uctuation of heart rate increased after cm injection during the 16-slice ctca. shortening the scanning time may decrease the fl uctuation of heart rate. to assess the incidence of pulmonary vein stenosis in patients submitted to atrial fi brillation ablation and to increase awareness of this clinical syndrome a. bajaj, d.t.d. barnes, p.a. vlachou, t. siva, j.j. entwisle; leicester/uk (amrita. bajaj@uhl-tr.nhs.uk) purpose: to assess the incidence of pulmonary vein stenosis in patients submitted to atrial fi brillation ablation and to increase awareness of this clinical syndrome. methods and materials: 174 consecutive cases had catheter ablation for atrial fi brillation over a period of two years 2004-2005. these were retrospectively reviewed on the radiology information system to look for any cross-sectional imaging of the thorax (multi-detector row ct/mr) performed within 6 months following the ablation. the images were then retrospectively reviewed to look for pulmonary vein stenosis. results: eighteen of the 174 patients had ct/mr within 6 months of the procedure. six of the 18 cases queried pulmonary vein stenosis on the initial request. six of the cases were done to evaluate the anatomy for redo procedure. of the remaining 6, 4 queried pulmonary embolism, 1 queried bronchiectasis and 1 was unclear. five patients presented with haemoptysis on the initial request. in 5 patients, the history of ablation was not stated on the radiology request. six (3.4%) patients had pulmonary stenosis. left superior pulmonary vein was the most commonly involved. remaining important radiological fi ndings also seen in the cases of pulmonary vein stenosis were consolidation and lung nodule. conclusion: pulmonary vein stenosis after catheter ablation is an important complication associated with signifi cant morbidity. our series showed a complication rate of 3.8%, with severe stenosis in a still smaller percentage. the reported incidence ranges from 3% to 42%. radiologist and clinicians should be aware of this condition in patients presenting acutely following ablation. learning objectives: 1) to remind of the major features of the most frequent congenital heart diseases (chd), including atrial septal defect (asd), ventricular septal defect (vsd), tetralogy of fallot (tof), transposition of the great arteries (tga) and coarctation of the aorta. 2) to expose ct and mr advantages and limits in these indications. 3) to give radiologists clues to better understand clinicians' questions and therefore to answer them better. background: because life expectancy of patients with a congenital heart disease (chd) has improved, thanks to better medical and surgical managements, and thanks too to great improvements in ct and mr imaging, radiologists are more and more faced with these particular conditions. moreover, as surgical techniques have become more sophisticated and complicated, the need for a precise anatomical description and for functional analyses has become crucial. ct and mri have these abilities and are complementary. but they also have some drawbacks. procedure details: we will illustrate this topic using numerous cases taken from our experience as a chd care center. all ct exams were performed on a multislice ct, either a 4 or a 64 detectors, whereas mr were performed on a 1.5 t magnet. ct and mr protocols varied, depending upon the congenital heart disease. conclusion: ct and mri are powerful tools for the non-invasive evaluation of chd. anyone performing these exams has to understand their advantages and limits in order to be able to answer clinicians' questions. immunologic lung diseases other than asthma and collagen-vascular disorders: an electronic teaching fi le c.m. plank, c. grosse, a. koller, l. stiebellehner, c. müller-mang, a.a. bankier; vienna/ at (christina.plank@meduniwien.ac.at) learning objectives: to familiarize radiologists with immunologic lung diseases other than asthma and collagen-vascular disorders. to elaborate classical patterns of presentation, clinical history, and radiological features of these disorders. to propose a systematic diagnostic approach based on clinical and radiological fi ndings. background: immunologic lung diseases other than asthma and collagen-vascular disorders include: 1) lung vasculitides (wegener's granulomatosis, churg-strauss syndrome, hypersensitivity vasculitis); 2) diffuse pulmonary hemorrhage; 3) eosinophilic lung disease (acute and chronic eosinophilic pneumonia, drug-induced lung disease); 4) extrinsic allergic alveolitis; and 5) amyloidosis. although these diseases are relatively common, there is little awareness of their etiology, their underlying pathomechanisms, their classifi cation, and their clinical and radiological manifestations. the purpose of the proposed electronic teaching fi le, therefore, is to elaborate a comprehensive diagnostic approach based on combined clinical and imaging fi ndings. imaging findings: the ct imaging fi ndings of the diseases will be the central part of our presentation. the ct fi ndings will be correlated with pathological specimens, and combined to typical clinical histories and presentations. the overall structure will follow most recent classifi cations of immunologic lung diseases other than asthma and collagen-vascular disorders. the format of the electronic teaching fi le will allow easy navigation through the information and provide an integrative comprehensive approach. conclusion: in the appropriate clinical setting, ct fi ndings in immunologic lung diseases other than asthma and collagen-vascular disorders are suggestive of the underlying disorders and allow in making the correct diagnosis with a reasonable level of confi dence. radiologic-pathologic correlations between intratumoral macroscopic and microscopic components in lung neoplasms e. quaia; trieste/it (quaia@units.it) learning objectives: to describe those intratumoral components in lung neoplasms that are depicted by imaging. background: different intratumoral components in lung neoplasms, which were evident at macroscopic and/or microscopic analysis, may be recognized in un-enhanced and contrast-material-enhanced computed tomography (ct) images. imaging findings: seventy lung masses (4-8 cm in diameter) in 70 patients (44 males, 26 females, mean age ± sd, 60 ± 15) were imaged by ct before and 25 seconds after intravenous injection of iodinated contrast agent (iodine 300 mg/ml; 150 ml; i.v. bolus injection). surgical/bioptic/autoptic specimens were analysed by macroscopic and microscopic/histologic analysis (hematoxylin and eosin staining, x20-x40 magnifi cation), and two observers identifi ed in consensus those intratumoral components that were depicted by ct images. macroscopic components: (1) internal colliquative necrosis in squamous cell carcinomas (n=30) appeared hypodense at un-enhanced ct, and without enhancement after contrast injection; (2) fi brotic component in adenocarcinomas (n=5) manifested as peripheral strands; (3) bronchiolo-alveolar carcinomas (n=2) presented as diffuse/confl uent parenchymal consolidations; (4) coagulative necrotic and haemorrhagic changes in small cells (n=15) and anaplastic carcinomas (n=10), which appeared, respectively, hypodense and hyperdense at un-enhanced ct, and without enhancement after contrast administration; (5) air-leak syndromes in hematopoietic stem cell transplant recipients with chronic gvhd-related bronchiolitis obliterans: thin-section ct fi ndings e. granell, r. guerrero, t. franquet, a. giménez, a. hidalgo, f. plancarte; purpose: to determine the incidence and the thin-section ct fi ndings of air-leak syndromes in a large group of hematopoietic stem cell (hsc) transplant recipients with chronic graft-versus host disease (cgvhd) related bronchiolitis obliterans (bo). a retrospective review of the medical records and imaging fi ndings identifi ed 158 allogeneic hsc transplant recipients with a proven diagnosis of cgvhd between january 1999 and december 2004. of the 158 transplant recipients, 9 had air-leak syndrome and proven cgvhd. the patients were 8 men and 1 woman ranging in age from 19 to 45 years (mean age, 28 years). the thinsection ct scans were retrospectively reviewed by two thoracic radiologists for the presence, appearance, and distribution of abnormalities. results: all cases were allogeneic hsc transplant recipients with cgvhd who acquired new respiratory symptoms and/or radiologic abnormalities. nine cases of air-leak syndrome occurred during the analyzed study period, for a 2-year estimated cumulative incidence of 2.1%, whereas its prevalence was 5.7%. among all the patients, pneumomediastinum (n=6) and pneumothorax (n=6) accounted for the majority of air-leak syndromes in our series; the remainder were due to subcutaneous emphysema (n=3) and pulmonary interstitial emphysema (n=2). a combination of different air-leak syndromes was observed in 6 cases. in all cases there existed an association between air-leak syndromes and cgvhd-related bo. conclusion: air-leak syndromes represent an uncommon late complication in hsc transplant recipients related to cgvhd and bo. the many faces of bronchioloalveolar carcinoma: a radiologic-pathologic pictorial review d. chourmouzi, e. papadopoulou, k. xinou, t. zaraboukas, a. drevelegas; thessaloniki/gr (dchourm@hol.gr) learning objectives: to describe the pathologic and radiologic types of bronchioloalveolar carcinoma (bac). to present the imaging features of each type of bac. to outline the main differential diagnosis. to emphasise the role of imaging evaluation in treatment and follow-up. background: bronchioloalveolar carcinoma (bac) is classifi ed as a subset of lung adenocarcinoma but has a distinct clinical presentation, tumor biology, response to therapy, and prognosis compared with other subtypes of non-small-cell lung carcinoma (nsclc). it is characterized by growth along alveolar septae without evidence of stromal, vascular, or pleural invasion. nonmucinous bronchioloalveolar carcinoma tends to be more localized and has a lower frequency of bronchogenic spread than mucinous bronchioloalveolar carcinoma. bac has received increasing attention in recent years due to its increasing incidence and its rate of sensitivity to epidermal growth factor-tyrosine kinase inhibitors (egfr-tkis). imaging findings: at computed tomography (ct), the single nodular form appears as a peripheral nodule or localized ground-glass attenuation with or without consolidation, frequently associated with bubble like areas of low attenuation and open bronchus signs. the lobar consolidative form may demonstrate the ct angiogram and open bronchus signs. the diffuse nodular form appears as multiple nodules or areas of ground-glass attenuation or consolidation. conclusion: understanding the radiologic fi ndings of bronchioloalveolar carcinoma on the basis of various morphologic and growing patterns is essential in the initial evaluation of patients with bac. high-resolution lung ct-scan is necessary to evaluate pulmonary involvement. imaging evaluation is also essential to assess therapeutic response and follow-up. pattern recognition in lobar collapse: can you read the signs? e. sonnex, r.a. coulden; leicester/uk (emer@prdg.demon.co.uk) learning objectives: to understand plain fi lm appearances and recognise the patterns of lobar collapse. these fi ndings are fully explained and corroborated by a 3-dimensional ct reconstruction. background: the diagnosis of lobar collapse is the 'bread and butter' of chest radiology but as 3-d imaging takes over, plain fi lm reporting skills are being lost. procedure details: we describe the classic patterns of lobar collapse on the plain chest radiograph with the aid of ct correlation to explain the appearances of: collapse and why it looks the way it does; how to use the silhouette sign; the causes of collapse; the features of collapse. conclusion: accurate diagnosis is based on recognised patterns. this presentation uses 3-d ct images to explain the recognised patterns of collapse in plain chest radiographs. (dad) . trali, the transfusion related acute lung injury is an uncommon complication of allogenic blood transfusion typically manifested by bilateral oedema, dyspnea, hypoxemia, fever and hypotension, in presence of a normal cardiac function. the main patterns are pulmonary infi ltrates and eosinophilia, acute pulmonary oedema and upper airway obstruction from laryngeal oedema. some drugs can also induce severe ali, such as valproic acid in treatment of neurological epilepsy that can induce alveolar haemorrage or gemcitabine during treatment for breast cancer. imaging findings: acute lung injury presents radiological and ct challenges. the chest x-ray demonstrates bilateral infi ltrates without signifi cant increase in cardiac size or vascular pedicle. ct demonstrates ground glass attenuation (a hazy increase in the lung attenuation with preservation of bronchial and vascular margins) in the middle regions and consolidation (increase in lung attenuation that obscures the broncho vascular margins, but the bronchogram sign can be present). the cyto/histological patterns of different ali stages explain the imaging features. the organic dust: radiographic and high resolution ct fi ndings of hypersensitivity pneuomonitis z. khaleel, r. lavakumar, c. viswanathan, g. avery, n. kennan; hull/uk (ziyadlk@hotmail.com) learning objectives: to illustrate pathogenesis of hypersensitivity pneuomonitis (hp). to demonstrate the natural history and physical fi ndings in hp. to defi ne and review the radiographic and hrct appearances of hp. background: hypersensitivity pneuomonitis, also known as extrinsic allergic alveolitis, is an infl ammatory lung disease in which inhalation of certain organic antigens repeatedly induces immunologically mediated reaction with granulamtous tissue formation. the targeted lung structures are the distal bronchioles and the alveoli. imaging findings: we will be reviewing the radiographic and the hrct fi nding in the clinical subtypes of hp. 1) acute phase: air-space opacifi cation with lower lobe predominance on radiographs and the fi ne nodules and diffuse alveolar consolidation on hrct. 2) subacute phase: fi ne reticulonodular pattern on radiographs and ground glass opacities with centrilobular nodules on hrct. 3) chronic phase: coarse reticulation with upper lobes predominance on radiographs and intraseptal and interseptal thickening, honeycombing and traction bronchioectasis on hrct. the defi nitive diagnosis of hp relies on a constellation of clinical, radiological, and laboratory fi ndings. although the imaging fi nding of hp can be nonspecifi c, certain pattern particularly on hrct would strongly suggest the diagnosis and facilitate prompt management of the disease. diffuse granulomatous lung diseases: high-resolution ct and pathologic fi ndings t. franquet 1 , n.l. müller 2 , t.v. colby 3 ; 1 barcelona/es, 2 vancouver, bc/ca, 3 scottsdale, az/us (19429tfc@comb.es) learning objectives: to illustrate hrct fi ndings of the most common granulomatous disorders of the lung, and to present a working differential diagnosis based on pathologic -radiologic correlation. background: diffuse granulomatous lung diseases are a group of lung diseases in which granulomas are an important component of the histologic fi ndings. the term granuloma has been used historically for all reactions rich in histiocytes and mononuclear cell infl ammation; more recently the term has been restricted to cases showing cohesive epithelioid histiocyte clusters usually with associated giant cells (i.e. sarcoid-like granulomas). we use the more restricted defi nition of granuloma in this review, but also include for completeness entities for which the term granuloma has been used historically. imaging findings: depending on the anatomic location and histologic characteristics of the abnormalities, diffuse granulomatous lung diseases may result in several ct patterns: a) nodules greater than 1 cm in diameter, b) small nodules, c) centrilobular nodules and branching lines (tree-in-bud pattern), d) bronchiolocentric infi ltrates, e) ground-glass opacities and consolidation, and f) low-attenuation and mosaic perfusion. conclusion: this review presents an approach to the differential diagnosis of pulmonary granulomatous disorders based on their hrct features and compares the hrct with the pathologic fi ndings. in the future could help the quantifi cation of these disorders. conclusion: mdct offers a new approach to the study of diffuse lung cystic disease. it allows a better characterization of the lesions and an easier visualization of the regional distribution of the cysts. four-dimensional multislice helical ct of the lung: comparison of retrospectively gated and static images in an ex-vivo system j. purpose: to analyze the image quality of retrospectively gated helical ct based on a comparison with static scans. methods and materials: five porcine lungs were infl ated inside a dedicated chest phantom and prepared with 8-14 nodules of ~1 cm. a water-fi lled diaphragm simulated contractions at a frequency of 8/min. images were acquired in a dynamic mode with a pitch of 0.1 (slice collimation 24x1.2 mm, rotation time 1s, slice thickness 1.5 mm, increment 1 mm). static scans at 0/25/50/75/100% inspiration were obtained with the same protocol, but without respiratory motion. the visual evaluation of image quality was based on multiplanar reformations of the 3d-data sets. stepladder-artifacts, partial projection artifacts and noise were judged semiquantitatively by two independent observers for the upper, middle and lower parts of the lung. scores of 0-3 were given for absent, minimal, large and diagnostically relevant artifacts. results: partial projection effects were only present in the dynamic scans (average artifact scores: 1.33). stepladder artifacts were prominent in dynamic series but also visible on static scans. both artifacts were less prominent in end-in-and end-expiration and predominated close to the. image noise predominated close to the diaphragm independently from the dynamic condition. a score of 3 was given 9 times (7/9 for kymographic artifacts), all for the region close to the diaphragm. the realistic ex-vivo study with direct comparison of retrospectively gated and static scans shows tolerable artifacts of retrospective respiratory gating and confi rms the high quality of 4d-ct. the acute lung injury (ali): a clinico-radiological correlation s. piciucchi 1 , c. learning objectives: 1) to demonstrate the imaging appearances of the respiratory complications of rheumatoid arthritis, systemic lupus erythematosus, mixed connective tissue disease, progressive systemic sclerosis, dermatomyositis, polymyositits and sjogren's syndrome. 2) to discuss the imaging features suggestive of each of the above conditions and the diagnostic pitfalls. background: the connective tissue diseases are autoimmune multisystem conditions that can affect the lungs. all components of the respiratory system including pleura, alveoli, interstitium, lymphatics, airways and vasculature can be involved. although there is a great deal of overlap between the imaging fi ndings in these conditions, there are features that can point the radiologist towards a particular diagnosis. imaging findings: patterns of respiratory involvement include pleural effusion or thickening, organising pneumonia, usual interstitial pneumonia (uip), nonspecifi c interstitial pneumonia (nsip), bronchiectasis, lymphoid interstitial pneumonia, lymphoma, obliterative bronchiolitis and nodules. acute pathologies such as alveolar haemorrhage and pulmonary embolism are also seen. these and others are shown on plain radiographs and ct images. the purpose of this exhibit is to show the wide spectrum of pleuropulmonary manifestations of connective tissue disease, and to point the radiologist towards a more specifi c diagnosis based on the imaging fi ndings. paraquat poisoning of the lung: initial and follow-up thin-section ct fi ndings in relation to ingestion amount of the paraquat m. park 1 , s. song 1 , s. park 2 ; 1 uijeongbu/kr, 2 seoul/kr (namaste-india@hanmail.net) purpose: to evaluate the patterns, distribution, and extent in relation to the ingestion amount of paraquat poisoning and evaluate the temporal lung changes on thin-section ct (hrct) scans. the study included 15 patients with urine-positive paraquat kit and pulmonary abnormalities in hrct scans. scans after hemodialysis were assessed for the presence, extent, and distribution of pulmonary abnormalities. six of the 15 patients, underwent follow-up ct scanning 5-20 days after initial ct. the abnormal fi ndings on the initial hrct scan consisted of ground-glass attenuations (n=9), consolidations (n=9), irregular lines (n=9), nodules (n=2), traction bronchiectasis (n=2), pleural effusion (n=4), and pneumothorax (n=1). the most common predominant fi nding that has the largest extent was ground-glass attenuation (n=7). on initial ct scan, the lesions showed bilateral (n=9), lower (n=6) and subpleural (n=6) zonal predominancy. the extent of lung involvement was well correlated to the amount of paraquat ingestion. the follow-up ct was performed in six patients. the ground-glass attenuation might be improved in extent (n=2) or progressed to consolidation (n=2). the new parenchymal abnormalities such as traction bronchiectasis and architectural distortion developed in the remaining two patients. conclusion: in paraquat poisoning, the most predominant fi nding at initial presentation was ground-glass attenuation and it was bilateral, lower and subpleural in distribution. the extent of lung involvement was well correlated to the amount of paraquat ingestion. on follow-up ct, fi brosis such as traction bronchiectasis and architectural distortion might develop. background: lymphomatous involvement of the lung is often asymptomatic or has non-specifi c symptomatology, thereby making diagnosis diffi cult. cavitating pulmonary lymphoma is a rare entity in both primary and secondary pulmonary lymphoma. diagnosis if also often hindered as infection (including superimposed infection), granulomatous disease, primary and secondary carcinomas, and drug reactions may have similar radiological fi ndings. imaging findings: from our experience with a number of cavitating pulmonary lymphoma patients and a review of literature, we will provide a diverse review of its pathophysiology, clinical and radiological presentations (location, distribution), and appearances (wall features, progression, and response to treatment). conclusion: this exhibit will provide an informative thorough guide and review of pulmonary lymphoma, its rare cavitating form, highlighting its presentation, radiological features, and progression, and distinguishing aspects from other cavitating lung pathologies. idiopathic interstitial lung disease: an analysis of the main radiological fi ndings. an integrated clinical, radiologic and histologic approach to diagnosis m. prieto del rey, x. gallardo cistare, e. castaner gonzalez, j. mata duaso, i. delgado alvarez, s. perez aguilera; barcelona/es (mprieto@cspt.es) learning objectives: to describe and illustrate the principal radiological and histological fi ndings for idiopathic interstitial lung diseases. to explain a strategy for the diagnosis of different types of idiopathic interstitial disease and determining their severity and prognosis. background: we review the radiological fi ndings for idiopathic interstitial lung diseases, grouped according to the american thoracic society/european respiratory society international multidisciplinary consensus classifi cation (ats/ers imcc) of 2001 into: usual interstitial pneumonia, non-specifi c interstitial pneumonia, desquamative interstitial pneumonia, respiratory bronchiolitis interstitial lung disease, cryptogenic organizing pneumonia, acute interstitial pneumonia, and lymphocytic interstitial pneumonia. imaging findings: we present representative cases of each of the seven ats/ers imcc categories, describing the clinical, radiological and histologic fi ndings. we provide high-resolution ct images showing the most characteristic fi ndings for each entity and discuss the differential diagnosis. conclusion: careful and thorough evaluation of the distribution, extension, and evolution of the radiological fi ndings together with the relevant clinical information enables a strategy to orient the diagnosis of the different types of idiopathic interstitial disease, their severity, and clinical prognosis. the diagnosis of interstitial lung diseases requires an integrated, dynamic evaluation of the clinical, radiological, and histological fi ndings. high-resolution ct is an important tool in the diagnostic work-up of diseases that affect the pulmonary interstitium. learning objectives: this poster should give an overview about the ct scan fi ndings and differential diagnosis of diverse pulmonary fungal infections in immunocompromised patients. pneumonias caused by aspergillus, cryptococcus, candida, histoplasma, mucor and geotrichum capitatum are illustrated. background: the importance of pulmonary fungal infections has increased substantially during the last decades, occurring in patients with neutropenia caused by malignancies, solid organ or stem-cell-transplantation, chemotherapy, corticosteroid-therapy or hiv-infection. because of unspecifi c clinical symptoms and the high morbidity and mortality of these infections, an early and non-invasive diagnose is very important. imaging findings: pulmonary aspergillosis comprises a broad spectrum of disorders. allergic broncho-pulmonary aspergillosis (abpa) is typically associated with upper lobe consolidations, mucous-plugging and central bronchiectasis. semi-invasive aspergillosis is characterized by progressive upper lobe consolidation that may cavitate and harbor mycetomas. the ct halo-sign and, later in the disease, the air crescent sign are characteristic fi ndings of invasive aspergillosis. cryptococcosis may manifest as a solitary lung mass, as multiple nodules or as segmental or lobular consolidations. in patients with candidiasis, air-space consolidation is most commonly seen with a lower lobe distribution. histoplasmosis presents with diffuse nodules, small linear opacities or focal or patchy areas of consolidation. the radiological manifestations of mucor mycosis can mimic those of invasive aspergillosis. geotrichum capitatum can present with bilateral non-cavitated nodules, consolidations and ground-glass-opacity. the ct fi ndings of fungal diseases may overlap. however, the knowledge of the various radiological appearances of fungal infections in combination with the patient's immunologic status allows narrowing of the differential diagnosis. . pleural effusion was only seen in 5 patients (13%). seventeen patients (22%) had single lobe involvement and the rest had multiple lobe involvement. in patients with single lobe involvement, 50% had the right upper lobe involved. in patients with multiple lobe involvement, 39% had all the lobes involved. apical involvement was seen in 16 patients (41%). there was a very high mortality; 21 patients (54%) did not survive. no signifi cant correlation can be made with the chest radiograph fi ndings and the outcome and duration of symptoms. conclusion: chest radiograph fi ndings in patients with melioidosis are very variable. it is also not frequently associated with cavitations and apical involvement, which were frequently seen in patients with pulmonary tuberculosis. the fi ndings may mimic other pulmonary infections. infl ammatory myofi broblastic tumor of the lung: ct -pathology correlation s.j. theodorou 1 , d.j. theodorou 1 , y. kakitsubata 1 , k. nabeshima 2 , s. kakitsubata 2 , s. tamura 2 , p.j. friedman 1 ; 1 san diego, ca/us, 2 miyazaki/jp purpose: infl ammatory myofi broblastic tumor of the lung is a rare, benign pseudotumor. the purpose of this study was to describe the ct fi ndings of infl ammatory myofi broblastic tumor of the lung with histopathologic correlation. methods and materials: ct images were obtained in 8 patients submitted to our institution over a 9-year period. there were 5 male and 3 female patients, with an age range of 22-73 years (mean age of 55 years). the presenting symptoms were chest pain and cough in 2 cases. for 6 cases, myofi broblastic tumor was an incidental fi nding on chest radiographs. histopathologic fi ndings were correlated with the imaging fi ndings in all cases. results: on radiographs and ct images, an ill-defi ned mass or nodule was seen in 5 patients (6 lesions), and a well-defi ned lesion was present in 3 patients (3 lesions). seven lesions were peripheral, and 2 were centrally located. during ct, 5 lesions were of heterogeneous attenuation, and 4 were homogeneous. increased perilesional parenchymal abnormalities, which were caused by peribronchial infl ammatory infi ltrates, were seen in 3 cases. the predominant histopathologic feature was organizing pneumonia type in 3 cases, lymphoplasmacytic type in 3 cases, and both organizing pneumonia and lymphoplasmacytic type in 2 cases. variable degree of fi brous histiocytoma type was noted in all cases. conclusion: because of variable imaging features, myofi broblastic tumor of the lung is often misdiagnosed as lung cancer. ct fi ndings combined with certain histopathologic features can suggest specifi c diagnosis. learning objectives: to illustrate radiological fi ndings of asbestos-related disease (ard) involving pleura and lung parenchyma with chest radiographs, conventional ct and high resolution ct. to emphasize diagnostic features enabling differentiation from benign and malignant lung masses associated with asbestos exposure. background: asbestos has been recognised as a potential hazard since the 1940s. ard is an occupational disease with a long latency period. our population had a great number of shipyard workers in contact with this dust. a long-term-follow-up of these workers is necessary. procedure details: ard comprises from pleural effusion and pleural plaques to asbestosis, term reserved to interstitial fi brosis, benign masses and malignant lung masses including mesothelioma and bronchogenic carcinoma. plain fi lms are used to identify presence and extension of asbestos related pleural and lung disease. conventional ct has been shown to be much more sensitive than chest radiographs in demonstrating these changes and can also identify fi ndings of parenchimal fi brosis such as pulmonary arcades, subpleural lines, parenchimal bands, reticulation and honeycombing. in addition, hrct can demonstrate thickened interlobular and intralobular lines. finally, this review will highlight typical characteristics that allows a specifi c diagnosis to determine benign and malignat lung masses, and will focus on spectrum of pseudotumor lesions including round atelectasis, fi ssural pleural plaques and mass-like fi brotic sheets. conclusion: rates of ard remain high in our population due to past occupational exposure and long latency period. typical imaging features of ard are described, with special attention to lesions that can mimic neoplastic masses. malignant mesothelioma: pictorial review of radiological-pathological correlation s. narayanaswamy, p. rao, a. george; plymouth/uk (arunagag2003@yahoo.com) learning objectives: to illustrate the spectrum of imaging and histological appearances, and to discuss the advantages and limitations of these investigations in the diagnosis and follow-up of patients with malignant mesothelioma. background: malignant mesothelioma is a highly aggressive tumour with an incidence progressively increasing with time. malignant mesothelioma has got a grim prognosis attributable to the late detection of the disease. the diagnosis is based on a combination of clinical history, radiological appearances and histology. despite all these modalities, diagnosis remains a challenging task to the medical profession as symptoms, imaging and the histological features often mimic other pathologies. imaging findings: computed tomography, magnetic resonance imaging, pet and histology play an important role in the diagnosis and staging of malignant mesothelioma. the spectra of radiological abnormalities noted are pleural effusion, plerual thickening, calcifi ed pleural plaques, interlobar fi ssural thickening, contracted ipsilateral hemithorax, evidence of local and distant metastasis. histologically, it is divided in to 3 distinct types, 1) epitheliod (60%), 2) sarcomatoid (15%) and 3) biphasic (25%). we present a pictorial review of all these distinct radiological and histological appearances, and also discuss briefl y the importance of these features in the diagnosis and staging of malignant mesothelioma. conclusion: a good understanding of the radiological and histological appearances is important as this will simplify and fasten the process of diagnosing malignant mesothelioma, enabling a larger number of patients to be diagnosed in the initial stages and undertake more successful treatment options. feasibility of micro-computed tomography in quantifi cation of murine bleomycin-induced lung fi brosis in in-vivo and postmortem conditions: correlation with pathologic score h. lee, j. goo, j.-g. im, k.-r. son, c. lee, c. park, e. chun; seoul/kr (rosaceci@dreamwiz.com) purpose: bleomycin-induced lung fi brosis (bilf) is an animal model of pulmonary fi brosis. the aims of this study were: (1) to quantify bilf using micro-ct in in-vivo and postmortem conditions and (2) to correlate the micro-ct scores with pathologic ones. methods and materials: after intratracheal instillation of bleomycin in eight mice, in-vivo baseline and 2 weeks (2w) (n=3), 4 weeks (4w) (n=3), or 8 weeks (8w) (n=2) follow-up micro-ct (skyscan 1076; skyscan, belgium) in in-vivo and immediate postmortem state were performed with 35 µm spatial resolution. on micro-ct, ground-glass opacities, consolidation, reticular opacities, honeycombing, and bronchial dilatation were scored. pathologic scores including infl ammation, parenchymal fi brosis, and airway fi brosis were obtained. spearman's correlation analysis to correlate micro-ct and pathology, kruskal wallis with duncan test to compare the 2w, 4w, and 8w groups, and wilcoxon signed rank test to compare in-vivo and postmortem micro-ct were performed. results: consolidation score in both of in-vivo (rho=0.44, p=0.01) and postmortem (rho=0.45, p=0.01) showed correlation with infl ammation score. score of bronchial dilatation in in-vivo (rho=0.49, p=0.02) and postmortem (rho=0.56, p=0.001) showed correlation with airway fi brosis score. in 2w group, consolidation score was higher than in 4w or 8w (p=0.03). in 4w and 8w groups, score of bronchial dilatation was higher than in 2w (p=0.02). only consolidation score of micro-ct was higher in in-vivo than in postmortem (p=0.04), and other scores showed no difference. the scores of micro-ct and pathology were well correlated. the results of quantitative assessment in in-vivo and postmortem state were nearly comparable. left-sided injuries are more frequent, the posterolateral aspect of diaphragm being the most common site of rupture. the preoperative diagnosis is often diffi cult because dr may be overlooked due to associated thoracoabdominal lesions. if the diagnosis is missed, intrathoracic herniation of abdominal organs may occur. subsequent gastrointestinal strangulation/obstruction will have a mortality rate of up to 50%. supine chest radiograph remains the initial screening tool after blunt trauma. helical ct, particularly multidetector-row scanners, allows more accurate analysis of the diaphragm, with the subsequent improvement in diagnosis. imaging findings: we reviewed chest radiographs and helical ct scans of 10 patients with surgically proved blunt dr. 100% were left-sided. we describe specifi c chest radiographic fi ndings and several ct signs indicative of dr, such as intrathoracic herniation of abdominal content, dependent viscera sign, collar sign, discontinuity of the diaphragm, absent diaphragm sign, and diaphragmatic thickening. five patients showed delayed presentation, 3 of them with severe complications: 2 intrathoracic gastric volvulus, 1 transverse colonic strangulation/obstruction. conclusion: dr usually requires prompt surgical repair to avoid delayed complications. diagnostic tools include chest radiograph and helical ct. familiarity of radiologists with diaphragmatic anatomy and radiology of dr is required to guide the management of polytraumatized patient. fibrosing mediastinitis -the spectrum of contrast-enhanced ct fi ndings a. devaraj, n. griffi n, a.g. nicholson, s. padley; london/uk learning objectives: to illustrate the spectrum of ct fi ndings of fi brosing mediastinitis. background: fibrosing mediastinitis is a rare condition characterised by excessive fi brous tissue deposition within the mediastinum. it may present as either an idiopathic condition or as a consequence of an underlying process such as tb or histoplamosis. procedure details: we retrospectively reviewed the clinical, pathological and imaging fi ndings on 12 cases of fi brosing mediastinitis obtained from our database from 1992 to 2006. fibrosing medisatinits diffusely infi ltrated the mediastinum in 5 patients and was localized in 7. eleven of 12 cases had narrowing of mediastinal structures, including 5 with pulmonary artery narrowing (41.6%), 4 with bronchial narrowing (33.3%), 3 with tracheal narrowing (25%) and one with narrowing of the pulmonary vein (8.3%). the presenting complaint was often associated with compression of a relevant mediastinal structure. the disease was considered idiopathic in 7 cases (58.3%) with a demonstrable aetiology in 5 cases (41.6%). eight out of 12 patients (66.6%) had additional pulmonary fi ndings on ct, including all patients with a known aetiology. conclusion: obstruction of vital structures by fi brosing mediastinitis frequently gives rise to complications and is accurately illustrated by contrast-enhanced ct. there is a high incidence of concomitant pulmonary fi ndings, in particular when an identifi able aetiology is present. congenital bronchial atresia: imaging fi ndings and endoscopic correlation y. pallardó-calatayud 1 , e. castañer-gonzalez 2 , a.j. revert-ventura 1 , j. camps-herrero 1 , a. caño-gomez 1 , e. mollá-olmos 1 ; 1 alzira/es, 2 sabadell/es (ypallardo@hospital-ribera.com) learning objectives: to describe and illustrate the characteristic imaging fi ndings of this rare entity and provide guidelines for its diagnosis. to show the correlation between imaging and endoscopic fi ndings. background: we retrospectively studied12 patients (7 m and 5 f; mean age: 36.7 yrs). all patients underwent chest x-ray and ct and 3 also underwent mri. all patients underwent bronchoscopy and clinical follow-up. imaging findings: chest x-ray fi ndings were branching tubular opacity (n=7), nodular opacity (n=3), consolidation (n=3), distal parenchymal hyperinfl ation (n=3), and parenchymal translucency (n=8). ct showed a mucous plug in all cases (n=12), with (n=3) or without air (n=9), severe stenosis of a segmental bronchus (n=11) with surrounding hyperinfl ation in 10 of these. five patients were studied with a 4-row multidetector ct. learning objectives: to familiarize with fetal thoracic mri in order to be able to recognize normal lung images and the most common thoracic abnormalities. to know the mr indications for the diagnosis of fetal thoracic abnormalities. background: ultrasonography is the primary imaging modality for prenatal assessment of fetal abnormalities. limitations of us include restricted fi eld of view, dependence on the skills of the operator and the diffi culty to obtain quality images due to maternal obesity or oligohydramnios. in spain, prenatal us is usually performed by gynaecologists rather than radiologists, and our experience is scarce. when a pulmonary fetal anomaly is detected, different options should be considered, such as in utero surgery, early neonatal surgery or therapeutic abortion, depending on the severity of the abnormality and the availability of a specialized hospital. it is fundamental to establish a precise antenatal diagnosis and the cases where us is inconclusive and doubts arise, must be solved by other reliable imaging modality. mr is safe during pregnancy, and the development of ultrarapid t2-weighted sequences makes it suitable for confi rming us fi ndings. imaging findings: we present our experience in fetal thoracic mri describing the characteristic imaging features of the normal lung and the thoracic abnormalities studied: congenital diaphragmatic hernia (4), congenital cystic adenomatoid malformation (3), pulmonary sequestration (2) and situs ambiguous with asplenia (1). conclusion: mri is the best choice for confi rming thoracic fetal anomalies when us is not conclusive. as radiologists, we must be familiar with its use and with the basic imaging features of these pathologies. the diaphragm is a musculotendinous structure that separates the thoracic and abdominal cavities. mri offers multiplanar capabilities and good tissues contrast resolution. review the anatomy and diaphragmatic and paradiaphragmatic processes and its appearances in mri. emphasis will be placed on diaphragmatic hernia and traumatic pathology. imaging findings: to assess hernias and their contents is the most common indication for diaphragmatic mri and coronal and sagital. t1-weighted offers an optimal visualisation of the hypointense diaphragm to evaluate the anatomy. mri also provides tissues characterization of the hernia contents. mri can be useful in evaluating for transdiaphragmatic extension of disease, primary or metastatic diaphragmatic or juxtadiaphragmatic tumors. conclusion: mri of the diaphragm permitted to evaluate small lesion or hernia anatomy and it can answer clinical diagnostic questions with important management implications that others studies of imaging cannot. knowing normal and abnormal processes allows for the best diagnosis. assessment of diaphragmatic motion after lung resection using magnetic resonance imaging r. takazakura, m. takahashi, n. nitta, k. murata, n. tezuka, s. sawai, s. fujino; otsu/jp (rtryu@belle.shiga-med.ac.jp) purpose: to quantitatively assess the impairment of diaphragmatic motion after lung resection using magnetic resonance imaging. in 44 patients (29 males and 15 females, mean age: 62.2 years) with lung cancer, diaphragmatic motion was measured during maximal deep slow breathing using a spoiled gradient-recalled-echo sequence before and after lung resection. the study group consisted of 34 patients who were examined using a 1.5-t unit in the supine position and 10 patients using a vertically open 0.5-t unit in both the sitting and supine positions. the infl uence of surgery sites and postures of the patients on the diaphragmatic motion after lung resection was investigated. the protocol of this study was approved by the institutional review board. we received written informed consent from all subjects. results: in all cases after the lung resection, the diaphragmatic motion of the operated side signifi cantly decreased (p < 0.001) and that of the non-operated side increased signifi cantly (p = 0.045). after left upper lobectomy and right bilobectomy, the diaphragmatic motion of the operated side decreased signifi cantly (p < 0.001), and that of the other side increased signifi cantly (p < 0.001). after right middle lobectomy, the diaphragmatic motion had not changed signifi cantly. the diaphragmatic motion of the operated side was impaired signifi cantly more (p = 0.035) in the supine position than in the sitting position. conclusion: our results indicated that magnetic resonance imaging (mri) was useful for quantifying the impairment of the diaphragmatic motion after lung resection. tubes, lines, and catheters in plain chest fi lms: an abc guide for the assessment of normal and pathological fi ndings d.d. cokkinos, g. giannakopoulou, e. daskalaki, m. avlianos, a. bouga, a. kontogiannis, n. gavalas; athens/gr (ggiannakopoulou@gmail.com) learning objectives: to illustrate the essentiality of evaluating the position of tubes, lines and catheters in chest x-rays. background: tubes, lines and catheters are common fi ndings on everyday radiographs, especially chest studies. it is essential to evaluate the placement and position of tubes and lines, such as central venous and arterial catheters, endotracheal and nasogastric tubes, thorax drains, and cardiac pacemakers. unfortunately, lack of familiarity with these devices leads to misjudgement of proper positioning, and therefore immediate or delayed complications. procedure details: we inspected retrospectively chest radiographs from 65 patients (neonates, children, and adults) and concentrated on identifying all tubes, lines and extraneous devices. we reviewed the fi lms with respect to normal positioning and malpositioning. we also looked out for complications associated with inappropriate positioning or malfunctioning devices, such as pneumothorax, air embolism, perforation and bleeding. in addition, we assessed the device's integrity and alignment, receiving valuable information for the patient's general health or lack thereof. conclusion: familiarisation with normal and abnormal fi ndings of tubes, lines and catheters is essential and leads to proper management and treatment of the patients. molecular targeted anti-cancer therapeutic agents for non-small cell lung cancer: mode of action, current results, and radiologic fi ndings after treatment using these agents c. . the knowledge about molecular targeted anti-cancer agents and familiarity with the images of the patients treated with these agents will be mandatory for the radiologists to determine the accurate tumor-response to the molecular targeted agents. the spectrum of diseases causing airway mucoid impaction j. euathrongchit 1 , n. learning objectives: to systemically review the imaging aspects of the spectrum of diseases causing mucoid impaction of the airways. background: mucoid impaction, mucus plugs, and bronchial mucocele are similar conditions resulting from accumulation of inspissated secretions such as mucus/ pus/ infl ammatory products within the bronchi, which are usually dilated. mechanisms resulting in this condition are abnormal mucociliary transport, excessive production of mucus, and collected mucous in bronchi distal to an airway obstruction. procedure details: in this exhibit, we follow the above mechanisms to display the variety and spectrum of presentations of mucoid impaction. conclusion: this educational computer exhibit reviews the spectrum of the radiographic features of mucoid impaction on chest radiographs, ct and mri and the underlying mechanisms responsible. c 383 b d e f a g pleuropulmonary manifestations of asbestos-related disease: computed tomography (ct) fi ndings z. khaleel, c. viswanathan, r. lavakumar, n. kennan, g. avery; hull/uk (ziyadlk@hotmail.com) learning objectives: to review and illustrate the imaging spectrum of asbestosrelated disease of the lungs and the pleura with emphasis on computed tomography (ct) fi ndings. background: asbestos fi bres inhalation is known to induce a range of pleural and pulmonary disorders. high levels of asbestos exposure have gradually been prohibited since the 1970s in many countries. prevalence of this disorder is still rising; however, this is secondary to the long latency period (20 years or longer) between initial exposure and development of the disease. imaging findings: benign pleural disease is the commonest encountered manifestation and includes pleural effusion, pleural plaques, rounded atelactasis and diffuse pleural thickening. although lung parenchyma is thought to be less sensitive to the effects of the fi bres than the pleurae, asbestosis is a well-recognised sequel to prolonged asbestos inhalation. malignant manifestations include bonchogenic carcinoma and malignant mesothelioma. owing to the accuracy of imaging in asbestos-related disease and the medicolegal implications of the diagnosis, the radiologist plays a pivotal role in the disease management. we aim to present a review of the ct/hrct fi ndings of this debilitating illness. spectrum of radiological appearance of chest ports and catheters: an exhibit for non-interventional radiologists m. diaz, a. villanueva, g. bastarrika, j. noguera, j. del pozo, a. alonso-burgos; learning objectives: to describe the radiological features (chest x-ray, ct and us) of chest ports and reservoirs (cr) commonly used for chemotherapy administration. to describe the radiological fi ndings of the complications that may occur with these devices. background: chest ports play an important role in the management of oncology patients who need frequent blood products, chemotherapy and other intravenous drugs. chest port related complications may arise during their placement, removal or the meantime and they may be asymptomatic. many cases of catheter-induced central thrombosis go unrecognized, but the incidence of pulmonary embolism in this group may be as high as 12%. plain fi lms, ultrasound and ct are useful for the prompt diagnosis of these complications. general and oncology radiologists rather than interventional radiologists play an important role in their detection. imaging findings: normal imaging fi ndings (plain fi lms, us, and ct) of the different ports and reservoirs and some common interpretation pitfalls, such as thrombus formation inside a vein, are described. radiological fi ndings of reservoir associated complications such as rotation, thrombosis, and infection and catheter related complications such as mural, tip and sleeve thrombosis, displacement, breakage, migration and infection are discussed. conclusion: appropriate knowledge of the normal cr appearance and radiological fi ndings of cr related complications is important in order to facilitate a prompt and effective diagnosis. general radiologists are encouraged to consider the cr as an area of interest when interpreting imaging studies. the knowledge of pathologic processes that affect the chest wall and its radiological fi ndings allow us to establish a specifi c diagnosis in a great percentage of the cases. however, when chest wall lesions show a non-specifi c radiological behaviour, imaging techniques provide a strategy in the workup of an accurate diagnosis, and is a useful guide for biopsy and for the surgical approach. thoracic manifestations of sickle cell disease in children e.j. helm, p.s. babyn, p. parkin; toronto, on/ca (paul.babyn@sickkids.ca) learning objectives: to illustrate the spectrum of thoracic pathology seen in sickle cell anemia as demonstrated by plain radiography, ct and mri background: sickle cell disease (scd) is a hemoglobinopathy characterized by changes in all major organ systems. the lung and heart are major target organs in this disease. specifi c manifestations of pulmonary disease include the acute chest syndrome and sickle chronic lung disease. cardiovascular manifestations include pulmonary hypertension, multiple chamber dilatation, myocardial ischemia and infarction. thoracic disease is frequently associated with other severe manifestations of sickle cell anemia such as neurological disease and bone infarction. imaging findings: we will illustrate the common and uncommon manifestations of scd including acute chest syndrome, chronic lung disease and pulmonary hypertension. in the acute chest syndrome, plain fi lm fi ndings may be subtle or absent. a rapid progression to multifocal consolidation and an ards type picture may occur. ct may demonstrate hypoperfusion and ground glass shadowing and better depicts early changes. plain fi lm fi ndings in chronic sickle lung disease include fi brosis and cor pulmonale. ct changes include interlobular septal thickening, reticular abnormalities, pleural tags and lobar volume loss. echocardiographic fi ndings of chamber dilatation and pulmonary hypertension have been extensively reported. spect imaging can demonstrate further fi ndings of ischemia or infarction. conclusion: thoracic disease due to sickle cell anemia has many different manifestations. although the chest radiograph has traditionally been used for assessment, other imaging modalities frequently add additional important information. congenital cystic adenomatoid malformation: is ct a useful predictor of histological type? n. griffi n, a. deveraj, a. nicholson, s. padley; london/uk (nyreegriffi n@hotmail.com) purpose: congenital cystic adenomatoid malformations (ccams) are rare congenital lung lesions recently reclassifi ed into 5 subtypes (0-4). subtype 1 may undergo malignant transformation. there is also overlap between type-4 ccams and type-1 pleuropulmonary blastomas. the aim of this study was to determine if pathological subtypes 1, 2 and 4 show characteristic changes on ct that may aid preoperative diagnosis methods and materials: ct studies were reviewed for 14 consecutive patients referred postnatally with the histological diagnosis of ccam on surgical resection. results: median age at the time of resection was 3.2 years (range:1.2-23.4). five patients were females. five patients had type-1 histology; 6 were type-2 ccam; and 3 were type-4 ccam. no type-0 or type-3 lesions were encountered. ct review indicated the following: most lesions were in the lower lobes (11). lesion size and cyst number were variable (from 1 to over 40 cysts), and did not depend on histological type. type-1 lesions had well-defi ned cysts, with maximum cyst diameter exceeding 4 cm. type-2 lesions had cystic change in 5 cases, with maximum cyst diameter measuring less than 2 cm. areas of reduced attenuation were also seen (5). type-4 lesions showed either microcystic (1) or macrocystic change (2), with mass effect demonstrated in all 3 cases, and contralateral mediastinal shift seen in 2 cases. one patient also had pleural nodules. imaging findings: imaging fi ndings are based on chest radiography and computed tomography. most frequent fi ndings in pulmonary infections are patchy, bilateral and rapidly progressive condensations associated with severe respiratory failure. in addition, 8 patients had brain lesions secondary to embolic dissemination. imaging fi ndings are fairly similar to those encountered in disseminated aspergillosis; however, all these patients had a fatal and rapid evolution, because this fungus is resistant to all anti-fungal therapies known. autopsy demonstrated necrosis and hyphae proliferation inside the thoracic and brain lesions. conclusion: scedosporium prolifi cans must be included in the differential diagnosis of rapid lung infi ltrates in deep immunocmpromised patients in some western regions of europe and australia. non pulmonary primary thoracic malignancies: a radio-pathological correlation a. donuru 1 , v. kandula 1 , a. barbieri 2 , j.j. entwisle 1 ; 1 leicester/uk, 2 northampton/uk learning objectives: the purpose of this exhibit is to describe the radiological fi ndings of various non-pulmonary primary thoracic malignancies. all the cases illustrated are pathologically proven. background: thoracic cancer comprises many different types of cancer that strike the thorax. some types are common, such as lung cancer and esophageal cancer. some are rare. imaging findings: the pathologies included are lymphoma (hodgkin's and non hodgkin's), breast cancer, oesophageal cancer, mesothelioma, sarcoma, thymoma, angiosarcoma, leiomyosarcoma, chondrosarcoma, ganglioneuroblastoma, malignant fi brous histiocytoma, rhabdomyosarcoma, haemangioendothelioma, plasmacytoma and neurilemmoma. conclusion: it is important for the radiologists to have an awareness of the imaging fi ndings of the above mentioned thoracic malignancies. when the diagnosis is not clear on a chest radiograph or on computed tomography it is strongly recommended that a biopsy is performed for pathologic confi rmation. normal variants-congenital thoracic anomalies in adults year old (37-74 years old) were included. 28 cases were analyzed. the ratio of primary and metastases was 17:6. mean tumor dimension is 37.9 mm. pathology were squamous cell ca (8), adenocarcinma (9), metastases (hepatocelluar ca (2), renal cell carcinoma (2), colon cancer (1), soft tissue sarcoma (1)). ct guided cryoablation was performed under the local anesthesia by guidance of ct. mean ablation is 2.4 per patient. sequential ct was acquired on 1, 3, 6 mo. ct fi ndings were analyzed (maximal dimension, mean attenuation). we analyzed sequential changes of volume and mean roi. nine of them were correlated with pet-ct for evaluation of viable component. major symptoms (cough, dyspnea, and hemoptysis) were assessed and showed improvement in symptoms. mean admission was less than 1 week. complications were pneumothorax (6), hemothorax (1), hemoptysis (10), pleural effusion (6). patients were followed for a mean period of 11 months (4-23 months). in metastases, perilesional necrosis was more prominent in immediate ct (within 1 week). six cases were increased dimension. necrosis was shown in fi ve cases. five have increased ct attenuation than initial ct. conclusion: cyoablation plays an important role in palliation of advanced cancer, post operative recurrence, or metastases. our study suggests that adequate palliation may be achieved by cryoablation applied to advanced cases. it was recently reported that the who classifi cation refl ects the clinical features of and is one of the prognostic factors for thymic epithelial tumors. fdg-pet exhibits accumulation, also refl ecting the malignancy of the tumor; it is useful in differential diagnosis according to the who classifi cation. it is believed that the procedure plays a key role in the diagnosis of thymic epithelial tumors. were reviewed by two radiologists in consensus. 1.2 mm thin-section ct fi ndings were evaluated about the size, density, shape, border margin, marginal irregularity, spiculation and lobulation. the density was measured by setting of roi in size of a maximum short-axis diameter of the lesion. the uptake of fdg was represented as maximum standardized uptake value (suv). these ct fi ndings and suv were statistically compared. results: tumor size and density were signifi cantly correlated with suv (p < 0.001). mean suv of lesions with lobulation and without lobulation were 8.4 and 5.9, respectively and suv of lesions with lobulation was signifi cantly higher than that without lobulation (p < 0.01). mean suvmax of lesions with spiculation and without spiculation were 4.2 and 7.5, respectively and suv of lesions with spiculation was signifi cantly lower than that without spiculation (p < 0.05). the other fi ndings were not signifi cantly correlated with suv. conclusion: a low fdg uptake of lung lesions in small size, with low ct density or spiculation are not reliable fi ndings to deny lung cancer. in contrast, a low fdg uptake of the lesion with lobulation-like fi nding or high ct density may suggest the lesion benign. value seventy-nine patients (10 f, 69m; mean age 62 years) referred for suspicious of lung cancer based on chest radiography fi ndings were studied. patients with previous diagnostic ct were excluded. image acquisition was performed with a combined pet-ct in-line system from head to mid-thigh, 50 minutes after intravenous administration of 370 mbq 18 f-fdg, and with administration of iodinated intravenous contrast, and water as oral contrast. biopsy and/or fi ne needle aspiration were obtained in all cases and served as standard of reference. results: pet-ct correctly classifi ed 71 patients as neoplastic. twenty-seven corresponded to adenocarcinoma, 14 to squamous-cell carcinoma, 25 to large-cell carcinoma and 5 to small-cell carcinoma. the remaining 8 patients were falsepositives corresponding to infl ammatory-infectious processes (3 abscesses, 3 tuberculosis and 2 neumonia) that simulate lung cancer. the sensibility and the predictive positive value were 100 and 89.87%, respectively. in all the patients, pet-ct avoided the performance of other imaging modalities such as contrastenhanced body ct and bone scintigraphy. conclusion: our initial results indicate that 18 fdg pet-ct may be useful as fi rstline imaging modality in patients with suspected lung cancer and help in avoiding other diagnostic procedures. the comparison of pet-ct and chest ct for staging in lung cancer d. kim, j. yang, j. byun, y. kim; gwangju/kr (dhk1107@hanmail.net) purpose: the goals of this study are to estimate the effi cacy of pet-ct and chest ct, alone and combined, in tumor staging and to exhibit various false (positive or negative) fi ndings mimicking true fi ndings. this study enrolled 33 patients with lung cancer who had undertaken pet-ct and chest ct. the age range of the consecutive patients is 35-81 years (mean age: 60.8 years). both studies were done within 27.1days. two independent readings were obtained from each test, and discrepancies were solved by consensus. bronchoscopic biopsy or percutaneous transthoracic lung biopsy was performed by one radiologist and one physician. all cases were confi rmed pathologically. the correlation of tumor stages by pet-ct or chest ct, and both studies combined were evaluated. also, various false-positive or false-negative fi ndings of pet-ct were demonstrated, thereby causing diffi culties in accurate staging. results: agreement in pet-ct for staging of lung cancer is 21.2% (7 cases). overestimated stage for lung cancer by pet-ct was seen in 12 cases (36.3%) and 8 cases (24.2 %) were interpreted to be in an underestimated stage. in 6 cases (18.2%), malignancy was not proved. diseases causing false-positive fi ndings were infl ammatory granuloma, reactive lymphadenopathy, and infl ammations such as pneumonitis, pneumonia, lymphoma. small cancer or small malignant lymph nodes showed false-negative pet fi ndings. conclusion: pet-ct and chest ct showed similar results in staging of lung cancer. two studies represented high conditional dependency. also, for the proper interpretation and accurate diagnosis of lung cancer by pet-ct, the various false fi ndings of pet-ct should be understood. dual results: pathology was 37 of squamous cell ca and 31 of adenocarcinoma. the stages were 6 ia, 11 ib, 9 iia, 12 iib, 14 iiia, 11 iiib, and 5 iv. there is a signifi cant correlation between suv of primary lesion and presence of nodal or distant metastases and ri value were higher than squamous cell carcinoma than adenocarcinoma. mean suv of each group is 16.1:5.6 (squamous:adenocarcinoma). the ri ratio is 20.5:12.5 (squamous:adenocarcinoma). the suv of the lymph nodes were similar pattern ri to the primary mass. conclusion: pet suv, independent of size, is a marker of biologic aggression that can predict the specifi c histopathology for non small cell cancer. higher level suv of primary mass favors squamous cell carcinoma than adenocarcinoma. 386 b d e f a g chest vascular perforating branches of the internal thoracic artery: an anatomical study using mdct angiography k. nakatani, h. maeda, n. hamada, t. yamanishi, k. miyatake, a. nishioka, y. ogawa; nankoku/jp (jm-nakakimi@kochi-u.ac.jp) purpose: breast reconstruction is a crucial technique for patients after breastconserving surgery. breast reconstruction with consideration of the breast blood supply offers the potential of avoiding complications such as breast scleroses and adiponecrosis. the present study aimed to determine the locations, courses and distributions of perforating branches of the internal thoracic artery (ita), the major artery infl ow to breast tissue from the inner side, using multi-detector row-computed tomography (mdct) angiography. methods and materials: subjects in this prospective study comprised 39 women with suspected breast cancer who underwent mdct angiography between april 2004 and december 2005. perforating branches of the ita were identifi ed on a dedicated workstation using transverse sections and 3-dimensional images. distributions of the identifi ed perforating branches were investigated. depth of perforating branches was measured and analyzed using simple regression analysis. results: a total of 48 perforating branches were found, with 27 branches (56.3%) originating in the second intercostal space and 7 branches (14.6%) originating in the third intercostal space. most branches from the second intercostal space turned horizontally after running cranially. most branches from the third intercostal space ran horizontally. a strong correlation was identifi ed between distance from skin to branches and adipose thickness at the shallowest and deepest points (p < 0.001). we succeeded in detailing the course, length and distribution of ita perforating branches using mdct angiography. these results for distribution and depth of ita-perforating branches will prove helpful in performing immediate breast reconstruction following breast-conserving surgery. and learning objectives: to review the embryologic features of the aortic arch specially focussed on right-sided aortic arch development. to describe the most relevant fi ndings of the right arch, great vessels and associated anomalies to aid potential surgical procedure. background: the right-sided aortic arch is an uncommon congenital defect of the aorta. it is present in 0.05% to 0.1% in radiological series. deletion in chromosome 22q11 is associated in 24% of isolated anomalies of laterality of branching of the aortic arch. using edward´ s hypothesis, three types are described: type 1, with mirror-image branching of the major arteries; type 2, with an aberrant subclavian artery; and type 3, with isolation of the subclavian artery. congenital heart anomalies are usually present in types 1 and 3. the initial fi ndings by the chest-x ray and barium swallow suggest the anomaly. however, cta or mra should be performed to confi rm the defi nitive diagnosis. background: ph is a complex life-threatening condition with numerous aetiologies. symptoms such as breathlessness on exertion, fatigue and chest pain are non-specifi c and are often attributed to more common disorders such as asthma delaying diagnosis. treatment has a profound impact on outcome. a specifi c diagnosis is important as therapeutic options range from surgical intervention to targeted medical therapy. since biopsy may be hazardous in this patient population, imaging plays a central role in establishing a diagnosis and guiding therapy. imaging findings: imaging features in ph can be divided into those that are common to all aetiologies and those that are disease specifi c. an understanding of the pathophysiology and classifi cation of the ph aids diagnosis. we will present imaging data from patients presenting to a national centre for ph and pulmonary thromboendarterectomy with pathologic correlation in specifi c cases. the radiologist plays a central role in the diagnosis of ph. it is important to be aware of the general and more specifi c imaging features in the spectrum of diseases associated with ph as early diagnosis and targeted therapies can improve the outcome. the importance of looking at the heart when interpreting standard thoracic ct e. castaner 1 , y. pallardó 2 , x. gallardo 1 , m. prieto del rey 1 , s. perez aguilera 1 , j. mata 1 ; 1 sabadell/es, 2 alzira/es (ecastaner@cspt.es) learning objectives: to familiarize viewers with the normal anatomic structures of the heart and pericardium to avoid mistaking them for pathologic processes. to explain the signifi cance of some incidental fi ndings. to emphasize the importance of looking at the heart when interpreting a thoracic ct study, especially in some particular clinical settings. background: important information concerning the heart can be obtained on both un-enhanced and contrast-enhanced ct of the thorax. cardiac disorders can often complicate or coexist with extracardiac thoracic disease, and may often remain unsuspected or underevaluated. correct analysis of images of the heart and surrounding structures depends on a thorough understanding of cardiac anatomy and on the ability to recognize the normal and abnormal appearances of the heart commonly observed on ct. imaging findings: we show anatomic structures that can be misinterpreted (crista terminalis, eustachian valve, fossa ovalis, coronary sinus, valves, pericardial recesses, paracardiac structures); some incidental fi ndings and their clinical value (calcifi cations, dilatations, fat deposition, increased or decreased myocardial density) classifi ed considering the structure involved: valves, chambers, pericardium. we comment on some clinical situations with possible cardiac repercussion: pulmonary hypertension, pulmonary embolism, neoplasms, and chest wall disorders. conclusion: knowledge of cardiac anatomy is essential to avoid mistaking normal anatomic structures for pathologic processes. it is important to know the clinical relevance of some incidental fi ndings and which of them will require further examinations. radiologists need to know conditions that may have an important effect on cardiac structure and function. msct and mri of the pulmonary veins: anatomy, anatomic variations and anomalous pulmonary venous drainage a. alonso -burgos, l. diaz, j. noguera, e. de luis, a. villanueva, j. larrache, g. bastarrika; pamplona/es (alonso@unav.es) learning objectives: to describe msct and mri features of the normal anatomy, anatomical variations, and anomalous returns of the pulmonary venous system. to emphasize the capability of msct and mri to non-invasively map pulmonary venous and left atrial anatomy before the percutaneous ablation. background: assessment of pulmonary venous and left atrial anatomy has become a hot topic among cardiac electrophysiologists, as radiofrequency catheter ablation is being increasingly used for atrial fi brillation. both msct and mri provide detailed and accurate anatomic information about the pulmonary veins and additional anomalies that are commonly associated with the development of atrial fi brillation. axial images and especially volume-rendered reconstructions allow to precisely determine the anatomy, anatomic variations, anomalous returns, and total number of pulmonary veins, thereby facilitating the interventional procedure. imaging findings: in this exhibit, normal pulmonary venous msct and mri anatomy and anatomical variations will be discussed. anomalous pulmonary venous returns as well as associated anomalies will also be illustrated. the role of msct and mri to non-invasively depict pulmonary venous and left atrial anatomy before the ablation will be emphasized. conclusion: msct and mri allow a rapid non-invasive assessment of normal pulmonary venous anatomy and associated anomalies. preprocedural exact delineation of these structures might facilitate the percutaneous intervention in patients with atrial fi brillation. background: central venous catheters and other devices are routinely used in the hospitable practice; for this reason, the correct knowledge of the thoracic venous anatomy is basic. mdct angiography is the best non-invasive method to describe it, and it offers us the possibility to diagnose thoracic venous disorders that could be important for placing catheters and, consequently, to avoid iatrogenic complications. procedure details: we employed 16 slice mdct for study of all chest on a single section helical. a table feed of 5 mm per rotation, and a reconstruction increment of 1.25 mm are used. 100 ml of non-ionic contrast material is injected at 4 ml/second, immediately followed by injection of 30-40 ml of saline solution at the same injection rate. the images were acquires at 20 seconds. at the workstation, we performed multiplanar reconstructions. conclusion: mdct angiography is the most reliable method in the non-invasive diagnosis of thoracic venous disorders. comparative analysis of methods for determination of blood fl ow parameters in non-small-cell lung cancer results: rbv pa from ed and ld were 10.1±1.0 ml/100 ml tissue and 38±5 ml/100 ml tissue, respectively. rbv idt was 10.0±2.0 ml/100 ml. ps from ed and ld were 23.5±2.0 ml/100 ml/min and 0.24±0.01 ml/100 ml/min. the rbv pa and rbv idt values showed signifi cant correlation (r=0.58, p < 0.05). relevant correlation between rbv pa as well as ps from ed and ld were not found. conclusion: our results support the statement that rbv and ps measurements are time-dependent and probably may not be calculated using late data sets. further research is needed for the determination of the appropriate time of data acquisition. the optimization of the dce-ct study protocol could improve the qualitative and quantitative assessment of functional tumor data. these parameters could serve as prognostic factors or may be used for follow-up studies. shortest guide to anatomy of pulmonary arteries evaluated in multislice computed tomography angiography g.j. staskiewicz, e. assessment of a pulmonary angiography 16-row mdct protocol using 100 kvp in comparison to a 120 kvp protocol: a prospective randomized trial p. mohr, s.a. peters, s.p. lemburg, v. nicolas, c.m. heyer; bochum/ de (christoph.heyer@rub.de) purpose: to implement a pulmonary angiography mdct protocol using 100 kvp, and to compare vessel enhancement, snr, cnr, radiation exposure, and subjective image quality to a protocol using 120 kvp. methods and materials: sixty patients were referred for evaluation of suspected pulmonary embolism by ct angiography on a 16-row scanner. patients were randomly assigned to a ct protocol using 100 or 120 kvp, respectively. all other scan parameters including tube current, collimation, and gantry rotation time were kept constant. contrast media was injected using bolus tracking. based on density measurements, pulmonary vessel opacifi cation and image noise were quantifi ed and snr / cnr were calculated. subjective vessel contrast was assessed by two radiologists in consensus. effective dose was calculated based on dlp/ctdi values. results of both protocols were compared using chi-square-test and student's t-test. the 100 kvp protocol showed a non-signifi cant higher mean vessel density than the 120 kvp protocol (387±130 hu to 318±113 hu; p=0.56) and a non-significant higher image noise (17±6 hu to 14±6 hu; p=0.84), resulting in almost identical snr (25±12 to 27±15; p=0.37) and cnr (22±11 to 23±13; p=0.51). furthermore, subjective image quality showed no signifi cant differences between the two protocols. mean effective dose of the 100 kvp protocol was signifi cantly lower compared to the 120 kvp protocol (1.37±0.39 msv to 2.44±0.98 msv; p < 0.001). conclusion: reduction of tube kilovoltage from 120 to 100 kvp resulted in significant reduction of effective dose in pulmonary 16-row mdct angiography without signifi cant loss of objective and subjective image quality. the post-processing of multi-slice ct in the interpretation of chest traumas w. yang 1 , c. beigelman-aubry 2 , a. brun 2 , p.a. grenier 2 ; 1 shanghai/cn, 2 paris/fr learning objectives: to outline the indication and advantage of multislice ct post-processing in the interpretation of chest traumas. to demonstrate several potential pitfalls in the interpretation and the method of avoiding these pitfalls with the post-processing technique. background: chest traumas are responsible for approximately 25% of traumarelated deaths. they are associated with high morbidity and mortality rates. ct, especially with the post-processing technique, including mpvr, mip, mip, volume rendering, provides fast, sensitive, and accurate evaluation of vascular, pulmonary, airway, skeletal and diaphragmatic injuries. imaging findings: 2d reformations provide a panoramic view of all the chest structures, allowing the detection of minor fractures. curved reformations provide information of excellent value in case of spine injuries. mip-mpvr may be used in the evaluation of vessel injuries as and costal cartilage injuries. mini-ip is useful in the detection of all lucent lesions, including pneumothorax. pneumomediastinum, tracheobronchial ruptures or pulmonary hernia. volume rendering is particularly helpful in case of thoracic cage trauma. the post-processing techniques used in the diagnosis of chest trauma are highly informative. a rigorous protocol with optimized use of reconstructions is required. computer-aided detection (cad) in lung cancer screening at chest mdct: roc analysis of cad vs. radiologist performance f. fraioli, l. bertoletti, m. mennini, r. lezoche, c. catalano, r. passariello; rome/it (francesco.fraioli@uniroma1.it) purpose: our aim was to compare the performance of radiologists against a cad algorithm for pulmonary nodule detection on mdct. methods and materials: three radiologists independently analysed 200 scans and assigned each nodule a confi dence score (1-3). cad was applied to all scans, successive readers re-evaluated all fi ndings of the cad, assigning, in consensus, a confi dence score (1-3). the reference standard was established by other two experienced chest radiologists. results were used to generate an froc analysis. the reference standard showed 124 nodules. sensitivity for readers i-ii-iii was: 48, 61, and 36%. a double and triple reading resulted in an increase in sensitivity up to 72%. with cad, sensitivity was increased to 91, 94, and 92% for readers i, ii, and iii. the area under the froc curve (az) was 0.53, 0.69, 0.42, and 0.80 for readers i, ii, iii, and the cad. differences between all readers and the cad were signifi cant (p < 0.05). for nodules > 6 mm az was 0.72, 0.88, 0.64 and 0.88 for readers i, ii, iii, and the cad. p was signifi cant between reader i and the cad and between reader iii and the cad, it was not signifi cant (p=0.9) between reader ii and the cad. for nodules < 6 mm, az was 0.18, 0.19, and 0.17 for readers i-iii and 0.63 for the cad. differences between all readers and the cad were signifi cant (p < 0.05). conclusion: cad can aid in daily radiological routine detecting a conspicuous number of nodules unseen by radiologists. pathological diagnosis was achived by surgery in 25 patients and with a follow-up in 5. sensitivity, specifi city and accuracy of malignant nodules was calculated by considering single slice vs total volume wash in and wash out of c.m. thirty pn with 18 benign and 12 malignant were included in our analysis. diagnostic criteria of malignancy included those nodules with a wash in of 25 hu and a wash out less than 30 hu. results: an almost perfect agreement was obtained between the two measurements in the diagnosis of benign nodules while a disagreement occurred in 2 pn histological malignant. in those nodules, a wash in enhancement greater than 25 hu was shown for both measurements but with a wash out respectively greater and smaller than 30 hu when single axial or volumetric assessment were performed. conclusion: volumetric assessment of the wash in and wash out curves appears more accurate and reproducible allowing a better evaluation of densitometric curves and reducing limits of single slice evaluation. moreover, dedicated software may provide a semi automatric analysis with a reduction in the evaluation time and more comparable results. impact of the digitalization of a radiology department in the detection of lung cancer in the emergency department i. herrera, m. garcía hidalgo, c. varela, c. ruiz, c. romero, j. pinto; purpose: to evaluate the impact of the digitalization of a radiology department in the detection of lung cancer in the emergency department (ed). we retrospectively reviewed and compared the number of lung cancer cases detected in the ed by using conventional (year 2003) and digital (year 2005) chest radiography. our radiology department became completely digital in 2004. this new situation brought the opportunity of having the images available at any time and made possible the later review of the images acquired at the ed by an expert radiologist. we analyzed the role of an expert radiologist together with the availability of previous images. results: in 2003, 112 lung cancers were detected and histologically confi rmed at our institution. thirty-eight (33.9%) were detected at the ed. twenty (52.6%) of them were detected by a radiologist and 24 (63.2%) patients had previous radiographs at our institution although no image was available. in 2005, 89 lung cancers were detected and histologically confi rmed. forty-fi ve (50.6%) of these cancers were detected at the ed. a radiologist reported as abnormal 73.3% of those cases. thirty-three (73.3%) were previously imaged at our institution. twenty-two (66.6%) were reported by a radiologist and 14 (36.9%) of them had the image available in digital format. the digitization of the ed increased the rate of lung cancers detected at this department. the number of cases interpreted by an expert radiologist, the availability of previous images and reports has also increased due to the digitization of the radiology department. towards international standardization of medical images distribution workfl ow through portable media e. avraham; plano, tx/us (eli@kodak.com) learning objectives: to demonstrate limitations in distributing medical images through portable cd media. to present a reliable workfl ow for importing and reconciling medical images using the ihe profi les "portable data for imaging" (pdi) and "import reconciliation workfl ow" (irwf). to demonstrate use cases for distributing and reconciling medical images through portable cd media. to enhance the portable media distribution workfl ow for non-imaging health it documents. background: the healthcare information distribution on cd media is rapidly increasing and reduces cost and network dependency. for example, operating rooms, dental and referral physicians increase their use of sharing images through cd media. the lack of standardization on the health cd data organization and data types reduces the client's capability to access the data and display it correctly. this educational exhibit proposes a standard solution, based on ihe profi les: pdi and irwf, to provide a reliable distribution of imaging information on interchange media for import, display and print. procedure details: this educational exhibit includes but is not limited to (1) demonstrating current limitations on distributing medical images through portable cd media, (2) presenting a reliable workfl ow for importing and reconciling medical images using ihe profi les pdi and irwf, (3) demonstrating the use cases for sharing medical images through portable media, (4) extend the portable cd media distribution for other non-imaging, health it ehr information. the standardization of the portable media distribution is improving the medical image distribution and sharing, which is a key in improving the patient health practices and reducing healthcare operational cost. internet guide for radiologists d. volpe, n. volpe, n. masiello, a. saponaro, a. carriero; novara/it (dvolpe@sirm.org) learning objectives: to describe the principal possibilities offered by the web and provide basic indications that will encourage inexpert people to embark on a personal exploration adapted to their needs and abilities. background: information interesting to physicians accounts for a large part of the multimedia world of the internet in both quantitative and qualitative terms. hundreds of the many sites containing medical information are dedicated to imaging diagnostics, their number is constantly growing, and their nature is constantly changing. this means that the information is dispersed and often half hidden in a vast range of site categories or local resources, thus making it diffi cult to evaluate its quality and reliability in an objective manner. procedure details: among the vast range of resources of radiological interest on the internet, we propose a classifi cation of the sites that facilitate navigation to the greatest extent and directly supply the type of information being sought. the sites have been grouped into seven ideal folders: catalogue sites, institutional sites, specialised sites, radiological image databases, on-line journals, sites offering teaching material, and discussion forums. conclusion: our aim is to propose a digital guide of free internet resources for radiologists. e-anatomy.org: a free interactive atlas of whole body sectional anatomy a. micheau, d. hoa; montpellier/fr (denis.hoa@campusmedica.org) learning objectives: to provide an e-learning website about sectional anatomy of the human body, with interactive self-study and assessment tools, based on more than 1500 mr and ct slices. background: on one hand, information and communication technologies (ict) act as a catalyst for innovation in learning, giving access to relevant, interactive, high-quality content. on the other hand, improvements in ct (e.g. multisection ct) and mr imaging (improved spatial resolution) deliver highly detailed images of internal anatomy. thus, interactive computer-based content and flash animations could be used to create new ways to teach sectional anatomy. procedure details: we chose normal ct and mr exams. more than 1500 slices were selected in order to cover the entire sectional anatomy of the human body. images were labeled using terminologia anatomica. we built a user-friendly interface, which allows to cine through multi-slice image series combined with textual information, 3d models and anatomy drawings. learning assessment is provided 390 b d e f a g by self-tests. all these teaching modules are available on the internet. conclusion: e-learning and interactive flash animation combined with the latest multi-slice ct and mr imaging technologies offer new ways to teach radiological whole body human anatomy. we provide a useful, free, interactive tool for the radiologist's everyday use; available online at http://www.e-anatomy.org. massachusetts, usa) was used for writing codes of both mathematical equations and the graphical user interface. technical aspect presented by this system can provide the 3 parts: (1) image processing and analysis using full-fi eld digital mammography, (2) quality control (qc) tools improved the effi ciency of periodic tests, and (3) gui-based checker for clinical breast examination and mammography fi ndings. granulometry was implemented in this program with basic imaging fi lter (smoothing, edge-enhancement and adaptive wiener fi lter). granulometry determines the size distribution of the region of interest (roi) in a mammogram. the software we developed for supporting breast cancer screening had a benefi cial effect to improve the effi ciency of qc and the diagnostic work of mammography. virtual colonoscopy: car versus non-car a. koshman; moscow/ru (falko77777@rambler.ru) purpose: to compare the results of 3d endoluminal analysis using computer assisted reading (car) with 3d endoluminal analysis non-car by experts for colorectal polyps detection. methods and materials: twenty-eight patients (19 males, 9 females, age range 45-68 years) underwent virtual colonoscopy procedure. all of them had undergone optical colonoscopy which revealed 52 polyps and was used as a reference standard. two radiologists read the datasets from virtual colonoscopy: one after the procedure, non-car; the other radiologist read the data sets using car. sensitivities were calculated. all reading times and number of false-positive results were documented. results: sensitivities for clinically signifi cant polyps of 5-9 mm and 10 mm or larger in diameter were: 64% and 75%, respectively for 3d non-car and 77% and 88% for 3d car (p=0.05). false positive rates (mean) were 4.3 and 1.2 for 3d non-car and 3d car, respectively (p=0.05). the average reading time for 3d non-car was 26.2 minutes (sd±3.8) and 18.3 minutes (sd±3.8) for 3d car (p=0.001). conclusion: using 3d car system provides higher sensitivity, lower false-positive rate and less time per case than 3d non-car. a novel wall thickness-mapped approach of clinical virtual bronchoscopy s. park, j. kim, j. goo, k. kim, h. lee, s. lee; seoul/kr (lunao78@snu.ac.kr) learning objectives: to understand an algorithm of automated assessment of airway wall thickness in chest ct images. to experience the wall thickness-mapped virtual bronchoscopy that visualizes color-mapped wall thickness at each part of airway. to appreciate effi ciency of pc-based application for the virtual bronchoscopy through developed-software. background: measurements of bronchial tree airway geometry can be used to evaluate and track the progression of disease affecting the airways, such as asthma, copd and cystic fi brosis, and to assess the effi cacy of new therapeutic approaches. this exhibit demonstrates a new method for wall thickness-mapped virtual bronchoscopy through measurement of airway wall thickness with a proposed algorithm. procedure details: we present an enhanced virtual bronchoscopy that allows assessment of wall thickness during the virtual fl y-through using the steps below. firstly, the airway trees are segmented, and then airway center-lines and bifurcation points at each generation are acquired with morphological analysis. then, we can calculate every wall thickness of each generation of the volumetric airway tree by using a proposed method based on vector analysis with perpendicular plane to airway. finally, our own software visualizes color-mapped virtual bronchoscopy that refl ects airway wall thickness, fl ying through the inner path of airway. conclusion: using ct scans of human cases, we present results showing that this new approach is convenient, accurate, automatic and well-visual in estimating airway wall thickness. our proposed method can provide pre-operative planning of the intervention for lung surgery with enhanced functional virtual bronchoscopy as a complementary tool for clinical diagnosis and several airway diseases. a statistical model for the geometric correspondence between differentview breast x-rays taken isochronically from a single breast j. teubl 1 , h. bischof 1 , m. blumenthal 2 ; 1 graz/at, 2 munich/ de (teubl@icg.tugraz.at) purpose: we investigated the reduction of false-positive detections of a mammographic cad system using a new statistical correspondence model. there is no accurate physical model available to solve the geometric correspondence problem between two different views of the breast; therefore, we propose a new statistical model derived from the cases of a large database. instead of a direct point-to-point correspondence, we infer the correspondence probability using a probability-estimation technique. the crucial point is the normalisation of point correspondences. in our method, one of the breasts is arbitrarily chosen as the norm breast. the lesions from all other breasts are normalised to this norm breast. this approach provides us with a suffi cient number of point correspondences in one breast to compute a statistical model. in the fi rst experiment comprising 993 breasts from the ddsm, we compared our statistical model with the recently proposed stripe model. we showed that the statistical model performed better (i.e. using 29% of the breast area as search space, we fi nd 90% of the lesions using our new method compared to 82% when using the stripe model). in the second experiment comprising a smaller set of 70 breasts, we showed that the geometrical correspondence was useful to reduce the number of false-positive detections. conclusion: if the geometric correspondence information is used, a mammographic cad system can achieve a higher accuracy. the method introduced in this paper outperforms the recently proposed geometric correspondence models. using dicom header to improve interventional radiology practice: purpose: to present the usefulness of the information contained in the dicom header of archived images for patient dosimetry and automatically audit the interventional procedures, and to introduce the consensus of the european sentinel consortium in this topic. methods and materials: information on dose, radiographic techniques, beam geometry, c-arm angulations, fi ltration, fi eld of view, collimation, acquisition protocols, post-processing, number of frames that are included in the dicom header were analysed using cd-roms from different interventional x-ray systems installed in several european hospitals. the usefulness of the different parameters to audit the clinical procedures is discussed. results: when looking at the dicom header, it is evident that a signifi cant amount of information for dosimetric purposes is contained in private tags. their format and meaning is unfortunately not easily available and even not well defi ned in the dicom conformance statement. the dose reports produced by most of the interventional x-ray systems are useful documents, which could help in the audit of patient doses and procedures allowing rough skin dose maps to be calculated retrospectively. the consensus document issued by the sentinel group states that dosimetric, technical and geometric parameters allowing the automatic audit of patient dose and radiological procedures should be contained in public fi elds of the dicom headers. the work in progress started by iec to standardize the structure of the dose reports will improve the present situation. development of software facilitating the extraction of dicom header information for patient dosimetry and quality control on line should be promoted. analysis of nine years of experience with "a walk through radiology" f. sendra, m.j. ruiz-gómez, o. torales, m. martínez-morillo; malaga/es (sendra@uma.es) learning objectives: to present a multimedia project focused on training medical students in the visual perception of radiological images and to review the experience in our institution since 1998. background: e-learning radiology resources are used to be focused on residents or specialists training, our project is addressed to medical students or general practitioners. it does not pretend to be an exhaustive lesson about radiology, but a practical tool to train the user's visual perception. procedure details: the application is a powerpoint based case collection of different image modalities, organized in normal and pathological series. after seeing each case, the user must go to the response screen where several commentaries and marks are shown with animated transitions. since 1998, this project has taken a part of the practical activities for last course of the medical students in our institution. questionnaires about performance with computers, evaluation of the application and open suggestions have been collected during this time. two cd-rom editions have been published in 2000 and 2002 and the next one will appear at the end of 2006. the purpose of these editions is to distribute to the students and professors at low cost. this project has also been adapted to html to be integrated as a web-based-training resource and version 3.1 is translated into fl ash presentations. conclusion: this exhibit presents the evolution of this project and the actual 3.1 version, which is presented into six languages spanish, english, french, german, italian, and portuguese, trying to spread "a walk through radiology" within european countries. web-navigation guidelines dedicated for radiologists a.n. chalazonitis 1 , g. tsimitselis 2 , j. tzovara 1 , v. nikolaou 1 , a. kontogiannis 1 , n. ptohis 1 ; 1 athens/gr, 2 larissa/gr (red-rad@ath.forthnet.gr) learning objectives: 1. to demonstrate simple and advanced web searching strategies. 2. to provide a list of reference and targeted engines for radiologydedicated search. 3. to identify useful web resources for radiologists. background: it is well known that the web or internet is a rich illimitable electronic source of information. however, navigation in this unbounded space requires a quiver of valuable tools named "search engines". three main types of search tools exist: search engines, metasearch engines and subject directories/guides. any radiological search depends on the strategy used. procedure details: in this exhibit, simple and advanced web searching strategies will be shown. methods on how to limit or increase results will also be presented combined with various examples. the technique of automated content-based image retrieval, needed to search into image databases, will be also discussed. a complimentary list of references with radiological resources, online databases and targeted engines for the most thorough search will be also provided for the participant. conclusion: even though there are several ways to search the web, a strategy map of radiology-focused navigation should be always available so that any radiologist can get the most information on the least number of web pages. its underlying architecture is based on a highly-scalable community framework that is ideally suited to support teaching, research, and administration rols allows users and administrators to defi ne different kinds of communities, where each community can be equipped with different tools and resources for shared work, dialogue, and investigation. rols "out-of-the-box" consists of a robust portal system, a comprehensive suite of collaborative applications, and an enterprise infrastructure layer based on open standards. the muols system and its architecture are based on four foundational ideas. 1. learning is inherently social and takes place most successfully in the context of communities. 2. there is no "right" pedagogical model for learning. 3. the source of innovation is the user, not the manufacturer. 4. successful online communities (learning communities even more so) must provide extraordinary amount of feedback to participants and administrators. first background: nine patients affected by: 1 atypical pancreatic pseudocyst, 5 endovascularly repaired abdominal aorta aneurysms, 3 foreign bodies retained in soft tissues were submitted to multidetector ct and to us-ceus examination. two imaging modalites were coupled, then correlated us probe position to the volume acquired by ct, using an electromagnetic tracker. in pancreatic pseudocyst and in endovascular grafts, ceus was performed as well. imaging findings: ceus-ct fusion imaging correctly defi ned a small lesion attached to cystic wall as "not solid". ceus-ct fusion imaging provided functional and morphologic information about aortic endoprostheses. us-ct fusion imaging rapidly identifi es the us position of foreign body in small parts, guiding surgical resection. conclusion: us-ct fusion imaging offers advantages in terms of cost-effectiveness, time and diagnostic accuracy in different fi elds of application. a web-based, user tailored and free of charge annotation and image editing program for interactive presentations and teaching fi les r. talanow 1 , m. grunewald 2 ; 1 cleveland, oh/us, 2 erlangen/de (roland@talanow.info) learning objectives: to develop an image annotation and presentation program available anytime and anywhere, for creating interactive annotations for teaching fi les and presentations in realtime, free of charge, user tailored, easy to use, with no programming skills and no additional program fi le download necessary. background: at this time there is no image annotation and presentation program available which creates interactive annotations in realtime, is free of charge, accessible from every computer worldwide and is user tailored. procedure details: we developed the multilingual online program annotate, which allows to create interactive image annotations and presentations. it is available over the internet and accessible worldwide from every computer with internet connection. the author does not need to have programming experience. the image edition as well as the linking and the source code are created automatically by the program. the created website is immediately available worldwide over the internet. the author can change the annotations and presentations at any time and the changes will be done in realtime. there is no need for a fi le transfer after each change. the program can be tailored for the individual user's needs. conclusion: annotate (www.annotate.org) is an image annotation and presentation program which is available anytime and anywhere, for creating and changing interactive teaching fi les and presentations in realtime. it is user tailored, easy to use and free of charge. there are no programming skills and no additional program fi le downloads necessary. the user's learning experience may be enhanced by offering multiple modes of presentation. interactive volume rendering 3d images for anatomy learning on lowend computers ö. smedby 1 , s. wirell 1 , j. kvist 1 , c. silén 1 , g. , volume rendering visualizations of high-resolution 3d ct datasets have been produced in quicktime vr format for self-study by medical and physiotherapy students. the images can be accessed on any network-connected computer with the free quicktime player installed. as demonstrated by this exhibit, the user can freely rotate the volume around both vertical and horizontal axes by dragging the mouse in the image. in addition, the user can easily zoom in and out. the images produced so far include the heart and great vessels as well as parts of the musculoskeletal system. the use of semi-opaque structures facilitate the presentation of, e.g., the relationship between coronaries and heart chambers or between patella and femur. in preliminary evaluations, the students give the material high ratings. conclusion: easy access over the internet and good interaction capabilities on low-end computers make this format attractive as an aid for anatomy learning. a new software platform for interactive vertebra radioanatomy and ct guided interventions learning s. aubry, a. pousse, p. sarliève, e. delabrousse, l. laborie, b. kastler; besançon/fr (radio.aubry@free.fr) learning objectives: to become familiar with advanced software for 3d interactive radio-anatomy learning. to learn about basics in rachidian radio-anatomy. to experience fundamentals of simulated ct guided interventions. background: the range of rachidian ct guided interventions is widening from day to day. this practice requires a perfect vertebra radio-anatomy knowledge and a high degree of interventional procedure culture. we present a software platform dedicated to vertebra radio-anatomy and ct guided interventions learning. procedure details: based on 3d high resolution modelisation of vertebra segments and of their vasculonervous environment from multidetector ct acquisitions, the presented tool simultaneously offers multiplanar reconstruction (mpr), 3d surface rendering, objects outlining on mpr. opengl based development allows interactive shading such as lighting or opacity modifi cations. furthermore, virtual 3d objects have been inserted in the volume in order to simulate the best of rachidian ct guided interventions (infi ltration, cementoplasty, rf). conclusion: this 3d modelisation package has the potential to improve radiologist's knowledge of the spine. radiologists are thus able to virtually practice approaches aimed at safe planning of a variety of ct guided interventions. automatic segmentation of the rectal tube in computer-aided detection for virtual colonoscopy p. boda, s. agliozzo; turin/it (piergiorgio.boda@i-medlab.com) purpose: computer-aided detection (cad) for virtual colonoscopy (vc) is a tool that allows to detect polyps from vc exams. during the exam, a rectal tube (rt) is placed in the patient for air insuffl ation. this tube is the origin of false positive (fp) detections in the cad system. we present a method for the automatic segmentation of the rt. methods and materials: two types of rts were used, which differ for their diameter and the plasticity. the fi rst rt (rt1) has a maximum diameter of 14 mm, whereas the second one (rt2) has a diameter of 8 mm and is more fl exible. exams were acquired on a multislice helical ct scanner with a tube current of 50 ma at 120 kv, a slice thickness of 1.25 mm and an interval reconstruction of 0.6 mm. patients were scanned in both supine and prone positions, after bowel cleansing and air insuffl ation. we studied 15 cases, for a total of 30 ct scans, four of them with rt1s and the rest with rt2s. the algorithm detected 96% of rts (29/30) and in all of these cases rts were completely tracked. it failed once for a rt of the second type. the visual inspection of this case showed that the lumen of the rt was almost entirely fi lled with fecal residus. we developed a robust automatic method for the segmentation of two types of rts for cad for vc. organic re-circulation of the information on network ( the purpose of this study is to develop a ct scanner system to reproduce key images that are specifi ed in a prior diagnosis. the ct scanner retrieves a dedicated dicom object from an image server and extracts a scan protocol of a previous study for application in the present study. the object is associated with a series of prior studies and includes information about scan protocol, scan range and the position of key images in the series. after acquiring a ct localizer in the present study, the operator registers the ct localizer to a prior one in the object, in order to fi t the patient's position using the anatomical landmarks. this operation enables the operator to fi t the scan range and image reconstruction range automatically. the ct scanner creates the new dedicated dicom objects associated with the present study that have spatial offset value for comparable images to prior key images. results: the acquired images have same scan conditions and same position of prior images within one slice difference. we developed a ct scanner that makes it easy to acquire comparable images to those of a prior study. a time of additional operation of current study does not give much effect for study throughput of the ct system. now, we are planning to standardize this dedicated object to make interoperability between different vendors and modalities. image retake analysis in digital radiography using dicom header information e. vano, j.i. purpose: retake analysis is a key aspect in any quality assurance programme and a basic tool to avoid unnecessary doses to patients in a radiology department. a methodology to automatically detect potential retakes using dicom header information is presented. methods and materials: a system called qconline was developed to help in the management of images and patient doses in a digital radiology department. images are sent to the pacs and to a dedicated workstation where the qconline runs. dicom header information is extracted and transferred to a database. relevant images can also be archived for inspection. the initial criterion for potential retakes was that 2 or more images have the same patient id, modality, description, projection and date. this criterion was applied over the 3,742 abdomen and 4,236 chest images. a sample of the images was assessed to determine the goodness of the method. the initial rejection criteria lead to a 15.4% retake rate in the abdomen examinations and a 4.5% for the chest examinations. after a thorough analysis of the supposed repeated images, the need for additional criteria such as orientation of the cassette (landscape/portrait) was demonstrated. the fi nal retake fi gures were roughly 50% of the automatic fi ltering from the database. conclusion: automatic retake analysis is a critical aspect in digital radiology. it allows detecting defi ciencies like wrong identifi cations, positioning errors, wrong radiographic technique, bad image processing, equipment malfunctions, artefacts, and so on. in addition, retake images fi ltered automatically and collected can be used for continuous training of the staff. feasibility of showing radiologic images on ipod: can pod save the space? h. funatsu, h. takano, m. kogure, a. imamura, t. kasai; chiba/jp purpose: ipod, a portable media player, is capable of displaying images and movies. carrying radiologic images in ipod would be useful for educating residents, communicating with other radiologists or referring physicians, or informing patients at bedside. the purpose of our study is to evaluate lesion conspicuity on ipod. methods and materials: fifty sets of key images of either computed tomography or magnetic resonance imaging were randomly collected from computerized database in our department. any lesions equal or less than 10 mm in diameter were excluded while collecting images. these 50 images with any fi ndings and 50 images without any fi ndings were installed on ipod. size and site of the each lesion were recorded. five blinded radiologists reviewed the images both on ipod and dicom viewer with a 4-week interval between sessions. conspicuity of the lesions was evaluated by using response receiver operating characteristic (roc) curve analysis. (d-ust@yandex.ru) purpose: to determine optimal compression settings and parameters for mr image compression. methods and materials: investigation included 40 patients with various pathologies and consisted of mathematical and visual approaches. the mathematical approach included searching for the quantitative quality index of compressed mr images (with analysis of currently approved quality index-compression ratio), compressibility tests, estimation of coders behavior. visual image evaluation was performed on nine 12-bit head and spine mr images by four observers. test images were compressed in jpeg, jpeg2000, jpeg-ls at various quality settings (q). results: image compression ratio (e.g. 8:1, 10:1 etc). is often used as a term equal to image quality, but it is unacceptable, because the visual quality of images with the same compression ratio may widely vary. visually lossless threshold depends on resolution (the lower resolution the higher quality settings required) and body zone (e.g. compressibility of spine images is better than head images). in our study the visually lossless threshold was between q jpeg = 85-92 and q jpeg-ls = 82-94 for four observers. jpeg-ls was the best coder for high quality mr images compression, while jpeg2000 is concluded to be unfi t. jpeg shows a little worse result than jpeg-ls. conclusion: compression ratio cannot be quantitative quality index. in visual analysis, jpeg-ls provided the best image quality with maximum compression. jpeg can be still useful due to good compatibility and high quality. jpeg2000 seems unacceptable because of high resolution and high compression orientation. quantitative evaluation of nodule kinetics using temporal subtraction in dynamic chest radiography with a fl at panel detector y. tsuchiya 1 , y. kodera 2 ; 1 shizuoka/jp, 2 nagoya/jp (yuichiro-rt@k9.dion.ne.jp) purpose: this study was performed to develop a method of using a temporal subtraction technique for evaluating the quantitative kinetic function of a lung nodule by dynamic chest radiography, and to investigate the clinical application of our technique by using a simulated nodule. methods and materials: dynamic chest radiographs (1344×1344, 12 bit, 3 fps, 10 sec) were obtained using a modifi ed fl at-panel detector system (cxdi-40g, canon inc, tokyo, japan). for respiratory phase synchronization, analysis of diaphragm kinetic was performed, and continuous subtraction in the expiratory phase was performed to obtain a temporal-subtraction image as output. the clinical effectiveness was investigated using radiographs of eight healthy volunteers (22-54 y/male) with a simulated nodule. the range of the enhanced region that appeared on the output image was manually measured. the differences between the known kinetic amount and result were calculated as detection error. signifi cance of difference was then evaluated by paired t-test. the movement tracks of the nodule could be visualized as a white region on the output image. the detection rate of the radiographs with 8 nodules was 75% (6/8). the maximum difference of ranges that were measured was less than 4 mm; the average of the absolute value of the difference was 3.69±4.82 mm. no statistically signifi cant differences were found between the known and measured amounts (p=.067). conclusion: dynamic chest radiograph with our computer analysis can clarify kinetic information regarding nodules and is effective as a screening examination for checkup or initial planning of radiation therapy. imaging biomarkers in colorectal cancer: texture analysis of hepatic ct b. ganeshan, k.a. miles, r.c.d. young, c.r. chatwin; falmer/uk (b.ganeshan@sussex.ac.uk) purpose: to assess the potential for computer analysis of liver texture during ct to provide biomarkers for patients with colorectal cancer and to identify possible biological correlates for relevant texture features. methods and materials: a feasibility study comprised 27 patients undergoing ct after primary resection of colorectal cancer, followed by an evaluation group of a further 32 patients. hepatic ct perfusion and survival data were available for both groups, with fl uorodeoxyglucose pet results accessible in the evaluation group. texture was assessed within regions of interest manually constructed over apparently normal liver whilst excluding major blood vessels and fat, and comprised band-pass image fi ltration at different spatial frequencies, followed by quantifi cation of liver texture. the feasibility study demonstrated that liver texture during the portal phase correlated with the hepatic perfusion index (r=-0.50, p=0.0074), and survival (r=0.49, p=0.0095). in the evaluation study, texture in apparently normal liver tissue in patients with hepatic metastases was different from patients with no tumour recurrence on unenhanced (p=0.026) and arterial phase images (p < 0.04), and from patients with extra-hepatic disease on unenhanced images only (p=0.014). among patients with no visible liver metastases on ct, texture analysis of portal phase images could identify those with extra-hepatic disease on pet (p=0.0035) and impaired survival (p=0.0074). the hepatic phosphorylation of glucose was identifi ed as a possible biological correlate for texture (r=-0.59, p=0.0062). conclusion: texture analysis of hepatic ct images obtained during routine clinical practice can provide biomarkers that refl ect hepatic physiology and identify patients with extra-hepatic disease and poor survival. novel approach to evaluate regional parenchymal pulmonary and aortic blood supply selectively with self-developed dual phase perfusion software in 64-slices ct x. xie, g. zhang, y. chen, z. li; shanghai/cn (adrianxie@163.com) learning objectives: to demonstrate that pulmonary arterial phase images and aortic phase images can be acquired with 64 slices ct. to develop windows-based software for processing semi-qualifi ed dual phases perfusion. background: pulmonary blood supply includes pulmonary and systematic circulation. regional blood supply imbalance is complex in some diseases, such as copd. with complicated scanning technique, non-contrast images, pulmonary arterial phase images and aortic phase images were acquired in one breath-hold with 64slices spiral ct. delay time was determined by a time-density curve. contrast was pushed forward by saline for better enhancement. then, pulmonary arterial phase and aortic phase data sets can be acquired. windows based software (dualx 2.0) was developed to analyze these selective dual phase images with delphi 9.0. procedure details: after image correction, pulmonary enhancement and bronchial enhancement can be calculated by subtraction technique. then, pulmonary ratio was calculated, which is the proportion of pulmonary enhancement in total enhancement. pseudo-color map also can be rendered to illustrate these parameters over non-contrast images. conclusion: pulmonary phase perfusion and aortic phase perfusion can be evaluated separately. purpose: to compare the dynamic information obtained from contrast-enhanced ultrasonography (ceus) and contrast-enhanced magnetic resonance (cemr) on two experimental tumor models exhibiting notable differences in vessel anatomy. methods and materials: six animals subcutaneously injected with a carcinosarcomatoid (a17) cell line and six animals injected with a carcinoma (bb1) cell line underwent ceus and cemr. ceus was performed on a technos (esaote, italy) with a bolus injection (0.01-0.05 ml) of sulphur hexafl uoride microbubbles (sonovue, bracco, italy) into a tail vein. the curve of enhancement (time-intensity) obtained by locating a roi over the tumor was used to calculate maximal intensity (mi) and slope (s). cemr was performed on a biospec scanner (bruker, germany) by injecting gd-dtpa-albumin (contrast media laboratory, university of california, usa). by locating a roi over the tumor, we calculated fraction plasma volume (fpv) and transendothelial permeability (kps). all the tumors were removed and analyzed histologically and immunohistochemically (cd 31). the vascularity of the two different tumor histotypes was comparatively evaluated by immunohistochemical, cemr and ceus analyses. results: considering the viable areas of the tumor, the vessels of a17 were signifi cantly (p < 0.00001) more numerous and smaller than those in bb1 tumors. cemr fpv and kps parameters were signifi cantly (p=0.00001) higher for the a17 tumors than for the bb1 tumors. ceus mi and s values were smaller in the a17 tumors than in the bb tumors (p=0.002). conclusion: our data demonstrate that particular histologic features, such as collapsed intratumoral vessels, can lead to a mismatch between ceus and cemr in studying tumor vascularization. learning objectives: to discuss the optimisation of acquisition parameters to maximize the ability of ferumoxtran-10 enhanced mr imaging (uspio-mri) at 3 tesla. to demonstrate tips and tricks for evaluating uspio-mri in combination with dedicated software for visualizing 3d localisation of lns. background: uspio-mri is shown to be extremely accurate for assessment of the ln status in prostate cancer patients. since positive ln smaller than 4 mm can be accurately detected with uspio-mri, appropriate high-resolution imaging is essential to maximize its clinical usefulness. clinical 3 t whole-body mr system, which is increasingly becoming available, is expected to enable imaging with a higher spatial resolution. aids with dedicated computer software are now essential in evaluation for numerous high spatial resolution images. imaging findings: the exhibit is based on our experiences of uspio-mri at 3 t in years, including 3 t-mri scanner with total imaging matrix. positive lns with 2 to 3 mm in diameter can now clearly visualised on uspio-mri at 3 t. thanks to multi-channel capability, both t1 and t2*-weighted image can be obtained with 3dft-volume data acquisition, which enable to acquire isotropic voxel t2*-weighted images, as well as t1-weighted images. these volume data are evaluated on dedicated software for visualizing 3d localisation of lns. conclusion: combination of novel techniques, 3 t-mri with tim technique and uspio, enable to visualise tiny positive lns on mri. optimisation of the acquisition parameter is essential to maximize the ability of uspio-mri. the help of computer technology is vital in handling numerous data to be evaluated. purpose: to assess the effi cacy of harmonic gray-scale ultrasonography using second-generation contrast agents (sonovue) in evaluating the response of hepatocellular carcinoma (hcc) after percutaneous treatment, and to compare the fi ndings of this imaging modality with those of dynamic magnetic resonance imaging (mri). a total of 27 patients with hcc treated by transarterial chemoembolization (16), ethanol ablation (10) or radiofrequency ablation (1) were included in the study. all of them were examined with second-generation contrast agents ultrasonography (cus) one month after the last percutaneous treatment. vascular fi ndings at cus were compared with the results of dynamic mri. contrastenhanced mri fi ndings were taken as the gold standard. tumoral response criteria considered at cus were: (1) persistence or absence of tumoral enhancement during arterial phase, (2) necrotic tumoral size. results: cus and mri, performed one month after hcc percutaneous treatment, found complete response in 13 of the 27 patients (48%) and no response in 14 patients (52%), respectively. comparing both imaging techniques, we obtained an agreement of 85% (kappa 0.70), a sensitivity of 85%, a specifi city of 86%, a positive predictive value of 85%, a negative predictive value of 86% and an accuracy of 85%. in 4 cases, cus and mri found different results. conclusion: cus is useful to detect residual hcc when compared with dynamic mri results. because of its low cost and high disponibility, it may reduce the frequency of dynamic mri in the follow-up of treatment response. learning objectives: to provide an educational review of the multifactorial elements of contrast-induced nephropathy. to review the current literature on etiology and prevention of contrast-induced nephropathy. to provide evidence-based approach/algorithm when assessing patients undergoing contrast enhanced procedure. to establish a protocol for patient care and follow-up. background: contrast-induced nephropathy has become an important cause of iatrogenic acute renal impairment and currently ranks as the third most common cause of hospital-acquired acute renal failure. although clinical presentation of cin is well described, precise mechanisms and management strategies for this complication continue to be a matter of debate. the incidence of cin (contrast induced nephrotoxicity) is dependent on both the defi nition of cin and the patient population investigated. the incidence of nephropathy is low in the general population, but patients with increased risk (patients with renal impairment and diabetes) have reported signifi cantly higher frequency (12-50%). procedure details: through a medline literature search and review of a number of current guidelines, we will establish an algorithm of best practice for all patients undergoing contrast-enhanced procedures. we will assess the current evidence on potential prophylaxis (prehydration, acetylcysteine, bicarbonate, fenoldopam, discontinuation of nephrotoxic medications prior to contrast-enhanced scans) and those patients that should be targeted for these treatments. we provide a thorough and concise review of this intricate area, which could be applied in all radiology departments to optimise patient care in a practical manner. effi purpose: to assess the diagnostic accuracy of gd-dota mra over tof mra for non-coronary arterial disease by comparing the percent agreement at the subject level of each mra method with x-ray angiography (defi ned as number of segment scores in agreement/ total number of segments evaluated for the subject x100). multicenter, open-label, fi xed sequence, paired trial in 100 subjects > 18 years [64 men, 36 women; mean age (±sd) 64.5 ± 13.7 years] with suspected non-coronary arterial disease and scheduled to undergo x-ray angiography were included and received an iv bolus of gd-dota 0.1 mmol/kg. results: the regions imaged for arterial disease were: renal (33.0%); aorto-iliac (31.0%); femoral (15.0%); carotid (12.0%); popliteal (6.0%); and calf ( the essence of iodinated contrast media: what every radiologist must know (2) to discuss the factors that infl uence image quality. (3) to evaluate the risk of anaphylaxis, nephrotoxicity or nonrenal adverse reactions, and to discuss the role of pre-medication regimen.(4) to be aware of the decisions one has to make before injecting iodinated cm. (5) to become acquainted with the appropriate treatment of such adverse reactions. (6) to discuss special situations (dialysis, metformin, pregnancy and lactation). background: iodinated contrast media (cm) are sterile iodine-containing solutions used in almost all diagnostic imaging methods. since their advent in the 1950s, they have revolutionized diagnostic imaging. although the diagnostic value of cm is enormous, other less desirable side effects also occur. procedure details: the purpose of this review is to address some of the main concerns that arise with the day-to-day use of iodinated cm. this presentation is divided by topics. it provides guidelines recommending precautions to prevent possible iodinated cm reactions. the authors discuss the need for informed consent and measurement of renal function, as well as the risk factors that may predict adverse events, and how to deal with patients who have had a prior reaction. the types and treatment of adverse reactions are discussed. conclusion: although iodinated cm are safe and widely used, adverse events occur and questions remain about their use, safety and interactions. every radiologist should be intimately familiar with cm. sixty methods and materials: ninety consecutive patients (53 men, 37 women; mean age: 57 years) were randomly assigned to one of three cta protocols: in group 1: 70 ml of contrast medium (300 mg iodine per milliliter [mgi/ml]; fl ow rate: 4 ml/s); in group 2: 60 ml of contrast medium (350 mgi/ml; fl ow rate: 4 ml/s); and in group 3: 50 ml of contrast medium (350 mgi/ml; fl ow rate: 5 ml/s) were intravenously administered. all contrast medium applications were followed by 20 ml of saline fl ush. the attenuation in hounsfi eld units (hu) was assessed from the ascending aorta to the thoracic aorta at the level of the aortic hiatus at fi ve different locations. the patients of all the three study groups showed diagnostically acceptable attenuation values of the thoracic aorta. the overall mean aortic attenuation was 258±54 hu in group 1, 274±83 hu in group 2 and 277±102 hu in group 3. group 1 had the most constant opacifi cation of the thoracic aorta and showed a trend to lower mean and maximum, but higher minimum and median attenuation values than groups 2 and 3; group 2 and group 3 showed a trend to lower attenuation values in the distal thoracic aorta than group 1. conclusion: different contrast medium ct protocols were evaluated and this resulted in acceptable diagnostic attenuation values in cta of the thoracic aorta. therefore, 64-detector row ct allows reducing the amount of contrast medium down to 50 ml, when an iodine concentration of 350 mgi/ml and a fl ow rate of 5 ml/s are used. the basic procedural knowledge of ultrasound contrast agents: a how-todo dvd rom-based audiovisual teaching guide p.s. zoumpoulis, i. 3. to present a step-by-step visual guide on how to prepare the patient, how to administer the solution, how to make control adjustments on us machine, and how to evaluate the sonographic fi ndings. 4. to establish a safe and credible procedure that minimizes complications and ensures true-positive results. background: the interaction between the "bubbles" and the us beam is explained with analytical drawings and real-time us videos. procedure details: contrast-enhanced ultrasound improves the detectability of pathology by revealing regions of increased vascularity. this medical e-book illustrates the steps taken to perform an ultrasound exam with use of ultrasound contrast agents. a detailed description of ultrasound contrast agents, how to prepare the solution, how to prepare the patient, administration of the solution, control adjustments of us machine to enable high-analysis contrast detection such as mi, tgc, gain, depth and focus and sonographic appearance of ultrasound contrast agents are provided in a user-friendly manner. the proper technique is demonstrated step by step. educational double video presentations included a simultaneous presentation of the real-time ultrasound exam and the examiner's technique. conclusion: user-friendly dvd rom-based visual guide with step-by-step procedural instructions on how to perform an ultrasound examination with ultrasound contrast agents. purpose: to evaluate the mechanisms of cytotoxicity of an iodinated contrast medium on renal tubular cell cultures. methods and materials: llc-pk 1 -cells were incubated with iomeprol and corresponding mannitol solutions (4.7-75 mg i/ml, 2-24 h). metabolic activity was assessed with 3-(4.5-dimethyl-2-thiazolyl)-2.5-diphenyl-2h-tetrazoliumbromid (mtt)-assay. the trypan-blue test was used to assess cell viability. to detect apoptosis, an elisa for the determination of oligonucleosomes in the cell lysate was performed. 5-bromo-2'-deoxyuridin (brdu)-incorporation into the dna was measured to assess proliferation. results: iomeprol induced a time-and dose-dependent inhibition of mtt-conversion (64-14%, at 4.69-75 mg i/ml at 24 h; 54-41%, at 2-24 h at 18.75 mg i/ml), which was signifi cantly stronger than that induced by mannitol (99-47% at 24 h, p < 0.001). after 24 h incubation with iomeprol and a recovery time of 2 h after removal of the contrast medium, there was only a small inhibition of mtt-conversion (96% and 89% at 4.7 and 75 mg i/ml, respectively). there was no signifi cant increase in the number of necrotic cells (8% in control; 8% and 10% after 24 h incubation with iomeprol at 37.5 and 75 mg i/ml, respectively; p> 0.05). as an indicator for apoptosis, the number of oligonucleosomes increased signifi cantly (20% difference to control at 37.5 mg i/ml after 24 h, p < 0.05). iomeprol induced a signifi cantly stronger inhibition of proliferation than mannitol (92% and 68% vs. 99% and 82% at 18.75 and 37.5 mg i/ml, respectively; 24 h, p < 0.001). the iomeprol-induced inhibition of mtt-conversion is mostly reversible, and is not associated with cell necrosis. the irreversible part may be due to apoptosis and decreased proliferation. evaluation of low-dose contrast protocols for 3d-cta of the aorta using 64-row multislice ct t. sakamoto 1 , d. utsunomiya 1 , s. okumura 1 , j. urata 1 , k. anami 2 , a. taniguchi 2 ; 1 kumamoto/jp, 2 bunkyo-ku,tokyo/jp (taka-sakamoto@skh.saiseikai.or.jp) purpose: 64-row multislice ct provides detailed data over a wide range in a short time, and reducing the amount of contrast medium used for 3d-cta has been attempted at many facilities. we conducted studies to investigate the optimization of contrast enhancement and to evaluate the usefulness of low-dose contrast protocols for 3d-cta of the aorta, based on clinical data. methods and materials: 3d-cta of the aorta was performed in 78 patients. nonionic contrast medium (300 mgi/ml) was injected at a rate of 3.0 ml/s, followed by a 20 ml saline fl ush injected at 3.0 ml/s. two protocols that differed in the amount of contrast medium injected [protocol a: 100 ml (26 patients) and protocol b: 50 ml (52 patients)] were evaluated and compared. the mean ct numbers and sd values in the ascending aorta, descending aorta, pulmonary artery, diaphragm, aortic branches, and external iliac artery were compared. the appropriate dose of iodinated contrast medium per kilogram body weight was also investigated for protocol b. the fi ndings of the present study indicate that the appropriate dose of contrast medium is 250 mgi/kg body weight to ensure optimal contrast enhancement in aortic 3d-cta. evalutation methods and materials: one hundred and thirty-four patients with 148 nodules of hcc treated with tace (n. 38) and with rfta (n.110) were admitted to our department for follow-up. nodules treated with rfta were divided retrospectively into two groups: 1) group 1 (41/110): immediate post-ablation evaluation using ceus was performed and, when necessary, immediate contrast-enhanced ultrasound-guided targeted re-treatment was carried out; and 2) group 2 (69/110): ceus was performed only for follow-up. therapeutic response was evaluated at one month with dynamic ct and ceus. sensitivity and specifi city of ceus and dynamic ct were calculated. results: after rfta, complete response was observed in 92.7% (group 1) and in 78.3% (group 2) with dynamic ct and in 92.7% (group 1) and 82.6% (group 2) with ceus. sensitivity and specifi city of ceus were 83% and 100%. after tace, complete response was observed in 47.4% of nodules with dynamic ct and in 39.5% with ceus. sensitivity and specifi city were 87% and 100% for dynamic ct and 100% for ceus. conclusion: contrast-enhanced ultrasound may be a more suitable technique to evaluate intratumoral residual blood fl ow following tace treatment. evaluation of the results between the two groups who underwent rfta showed a signifi cant difference in the ablation success rates. is contrast-enhanced ultrasound useful? principal radiological and clinical applications d. volpe, n. volpe, a. saponaro, n. masiello, p. neri, a. carriero; novara/it (dvolpe@sirm.org) learning objectives: to show the technical principles underlying ultrasound (us) contrast agents, imaging fi ndings, and principal radiological and clinical applications. background: the introduction of contrast agents has led to one of the most important advances in ultrasonography. us contrast agents are intravenously injected substances that are distributed by the blood fl ow to all organs, where they modify the characteristics of the tissues by increasing their ultrasonographic refl ectance. given the different types of vascularization of normal and pathological tissues, they offer a better means of characterizing focal lesions than b-mode echography. procedure details: contrast-enhanced us is more accurate than conventional echography in determining the number and size of focal lesions, and revealing capsular involvement, because it reduces the number of false-negative results. this more precise classifi cation of lesions has a considerable diagnostic and prognostic impact. we provide an overview of its principal radiological and clinical applications: focal lesions, trauma of solid abdominal viscera, vescicoureteral refl ux, and vascular diseases. the introduction of second-generation contrast media is changing the diagnostic perspective by giving radiologists an effective product of immediate use that eliminates all interpretative doubts and facilitates diagnosis. effects of non-ionic iodinated contrast media (cm) on patient heart rate during intra-cardiac or intra-arterial injection i. schmid 1 , d. purpose: to compare heart rate (hr) and systolic/diastolic blood pressure (bp) after intra-cardiac or intra-arterial injection of a non-ionic low-osmolar cm (iomeprol) and a non-ionic iso-osmolar cm (iodixanol). double-blind, randomized studies were conducted in 120 patients undergoing cardiac angiography (ca) and 96 patients undergoing peripheral intra-arterial digital subtraction angiography (ia-dsa). patients undergoing ca received iomeprol-350 (n=60) or iodixanol-320 (n=60). hr and systolic/diastolic bp was determined before and after initial injection during left and right ca (lca and rca) and left ventriculography (lv). differential effects were assessed using t-tests. patients undergoing ia-dsa received iomeprol-300 (n=49) or iodixanol-320 (n=47). hr and systolic/diastolic bp were evaluated before and after the fi rst 4 injections. repeated-measures anova and t-tests compared mean hr changes across the fi rst 4 injections and after the fi rst injection, respectively. monitoring for adverse events (ae) was performed in both studies. results: no signifi cant differences between iomeprol and iodixanol were noted in terms of mean changes in hr during lca (p=0.8), rca (p=0.9), and lv (p=0.8). in patients undergoing ia-dsa, no differences between cm were noted for effects on mean hr after the fi rst injection (p=0.6) or across the fi rst 4 injections (p=0.2). no differences between cm were noted regarding effects on systolic or diastolic bp. purpose: to evaluate the diagnostic advantages of intravenous uspio administration on t-staging of uterine carcinoma. methods and materials: seventeen female patients referred for gynecological carcinomas, 11 with corpus uterine cancer and 6 with cervical carcinoma underwent mr scan of the pelvis on a 1.5 t magnet. gre t2*w sequences (tr/te/fa/matrix/ acq. time: 1800 msec/15 msec/30°/230x512/13.51 min) were acquired on multiple planes before and 24 hours after iv administration of 2.6 mg/kg of body weight of sinerem (guerbet, paris, france). image analysis were performed by consensus by two radiologists and it included qualitative and quantitative analysis of signal intensity (si) of both normal myometrium and neoplastic lesions before and after sinerem administration. s/n and c/n were calculated. modifi cation of t-staging in images obtained after sinerem administration was also evaluated. statistical analysis was performed using wilcoxon test (p < 0.05). results: qualitative analysis showed a signifi cant decrease of si of normal myometrium after sinerem administration leading to a better lesion conspicuity. quantitative analysis showed a statistically signifi cant difference between si of myometrium on plain and sinerem-enhanced mr images assessed by means of t-test. c/n between lesion and normal myometrium signifi cantly increased following sinerem administration. in 13 patients sinerem-enhanced images provided additional information leading to more accurate t staging. conclusion: intravenous injection of sinerem provides a signifi cant decrease of si of normal myometrium with higher c/n between neoplastic lesion and normal myometrium increasing the conspicuity of neoplastic lesions. the learning objectives: we will explain the etiology of round ligament varices (rlv) in pregnancy and elucidate why they may have a similar clinical picture to an irreducible hernia. knowledge of this condition is clinically signifi cant as this may be misdiagnosed as an obstructed hernia, leading to unnecessary surgical intervention during pregnancy. as ultrasound (us) is the imaging modality of choice, we will review the us features that establish an accurate diagnosis. background: anatomically the round ligament extends from the lateral uterus to the labium majorus containing veins, arteries, lymphatics and nerves. pregnancy promotes increased venous fl ow and reduced venous tone, thereby predisposing patients to varicosities. clinically, rlv and inguinal hernias can be indistinguishable with similar anatomical sites, comparable positive cough impulses and both demonstrating reducibility with positional change. imaging findings: dilatation of the veins of the broad ligament and ovarian plexi cause a clinical entity called the pelvic congestion or pelvic pain syndrome. when this process extends into the round ligament, it becomes a more diffi cult diagnosis. however, the ultrasound and doppler appearances of this condition are unique and can be easily recognized. the true incidence of round ligament varices is unknown but is suspected to be higher than the small amount of reported cases in the literature through our series, we demonstrate that the diagnosis of rsv should be entertained in pregnant women presenting with a painful groin mass, and ultrasound should be performed in such cases to avoid unnecessary surgical exploration. hypointense ovarian lesions on t2-weighted magnetic resonance imaging: radiologic-pathologic correlation m. takeuchi learning objectives: to demonstrate various benign and malignant ovarian pathologies presenting as hypointense masses on t2-wi with pathologic correlation. background: hypointensity on t2-wi is an unusual fi nding of ovarian tumors and form a special diagnostic category. these lesions have some histopathologic characteristics, which shorten the t2 relaxation time of tissues and help to make differential diagnosis. imaging findings: t2 shortening due to dense collagenous tissue was observed in benign fi brous tumors such as fi bromas, thecomas, adenofi bromas, and brenner tumors, but rarely also observed in malignant tumors such as krukenberg's tumors with reactive stromal proliferation and malignant carcinoid tumors with neoplastic stromal proliferation. intense contrast-enhancement refl ecting hypervascularity of malignant tumors may be the diagnostic clue. rare solid malignant tumors with honey-combing appearance fi lled with mucinous materials or coagulated necrosis such as mucinous tumors or solid clear cell carcinoma may mimic benign fi bromas, and reticular contrast-enhanced internal patterns may suggest these tumors. coagulated necrosis with hemorrhagic clots in malignant germ cell tumors may show hypointensity, and elevation of specifi c tumor markers may be helpful for diagnosis. mucinous, or viscous proteinous materials in mucinous cystic tumors, and struma ovarii with colloid cysts may cause hypointensity in the cystic portions. repeated intra-cystic hemorrhage in endometrial cysts may cause hypointensity as "shading", but similar appearance may also be observed in some dermoid cysts and tubo-ovarian abscesses. conclusion: hypointensity on t2-wi may usually suggest its benign nature, but some malignant tumors also show hypointensity and preoperative diagnosis is important. www.cancerstaging.info: a free and customized online tool to facilitate quick and accurate staging of common female pelvis cancers based on imaging fi ndings r. talanow, s. shah; cleveland, oh/us (roland@talanow.info) purpose: to provide a free, comprehensive, web-based, on-the-fl y solution which is easy to use and aids in accurate staging of common female pelvis cancers, based on imaging fi ndings. the program runs on a 700 mhz pentium ii quad processor with microsoft server 2003 operating system. script languages include perl, javascript, dhtml. information about tumor classifi cations is stored in a mysql database. on-the-fl y staging is done by calculating and comparing the information provided by the user with the tumor classifi cation database saved on the server. the user may provide the information in several offered modes for the user's convenience. output of information is also offered in several modes to increase fl exibility and better integration into the reader's workfl ow. results: this web-based and customized program easily integrates into the radiologist's daily work from any monitor or pacs station. the interface is fl exible and easily adapts to the individual physician's preferences by seamlessly incorporating into the workfl ow. furthermore, it offers hyperlinks to more comprehensive websites for access to therapeutic and prognostic information for a particular malignancy. conclusion: www.cancerstaging.info is a free, web-based, customized tool that allows staging of common female pelvis cancers (i.e. cervical, ovarian, uterine and endometrial) based on imaging fi ndings, with hyperlinks to more informative and in-depth websites. it is an intuitive, user friendly educational program which makes staging of common female pelvis malignancies easy and accurate. learning objectives: to illustrate the value of color doppler us as an adjunct technique in the evaluation of those uterine pathologies in which detection and characterization of vascular structures allow an early diagnosis. background: ultrasonography (us) is the initial diagnostic modality in gynecological assessment. the transvaginal via is recommended, except in contraindicated cases (intact hymen, pregnancy of more than three months, and so on). color doppler us as an adjunct technique has become an effective tool in the evaluation of those uterine pathologies in which detection and characterization of vascular structures allow establishing early diagnosis, when the gray-scale ultrasound images are nonspecifi c or confusing. in this exhibit, we describe the value of color doppler us in the diagnosis of endometrial polyps, the distinction of leiomyomas and adenomyomas, the evaluation of de arteriovenous malformations, and the diagnosis of aneurysms and pseudoaneurysms. imaging findings: color doppler us contributes to the diagnosis of endometrial polyps by the identifi cation of vascular structures in the pedicle; permits the distinction between leiomyomas and adenomyomas bythe vascular distribution patron; plays an important role in the evaluation of de arteriovenous malformations, allows distinction from myomas with degenerative changes, and detects the presence of arteriovenous shunting. color doppler us also plays an important role in the diagnosis of aneurysms and pseudoaneurysms. conclusion: color doppler us with conventional techniques and power-angio are very useful in early diagnosis and the follow-up of many uterine pathologies. benign cystic ovarian masses with solid components mimicking malignancy: radiologic-pathologic correlation m. takeuchi learning objectives: to demonstrate various benign ovarian pathologies presenting as cystic masses with solid components on imaging mimicking malignancy with pathologic correlation. background: solid components of ovarian cystic masses may usually suggest their malignant nature, but some benign pathologies may also show the similar appearances mimicking malignancy. imaging findings: solid fi brous tumors (brenner tumor and adenofi broma) coexisting with cystadenomas show characteristic hypointensity on t2-wi refl ecting dense fi brous proliferation. small tiny cysts within hypointense solid portion (black sponge-like appearance) of adenofi broma are diagnostic. mural nodules with intense contrast-enhancement and very high intensity on diffusion-weighted images (dwi) may suggest malignancy, but benign dermoid nipple may show surface slight contrast-enhancement and very high intensity on dwi. solid portion of struma ovarii also show intense contrast-enhancement, and lobular appearance with hypointense colloid contents on t2-wi is characteristic. benign cystadenomas may contain small papillary vegetations with no or slight contrast-enhancement. pregnant decidual changes of endometriomas may show broad-based hyperintense mural nodules on t2-wi. irregular clots within endometriomas may mimic malignant component, and the absence of contrast-enhancement on subtraction images is the diagnostic clue. daughter cysts of mucinous cystadenomas, and ovarian parenchyma within peritoneal retention cysts may mimic solid mural nodules on ct or ultrasonography, and t2-wi can provide better tissue contrast for the correct diagnosis. conclusion: benign cystic lesions with neoplastic components (brenner tumors, adenofi bromas, teratomas and vegetations), reactive components (decidualized endometriomas), and non-solid components simulating solid portion (mucinous daughter cysts) should be differentiated from malignancy to avoid excessive surgical procedure. malignant transformation of mature cystic teratoma: analysis of imaging fi ndings and clinical data j. kim, s. park, j. kim, k. cho; seoul/ kr (lola1024@freechal.com) purpose: to evaluate the imaging fi ndings and clinical data predicting malignant transformation of mature cystic teratoma. in 11 patients with histopathologically confi rmed diagnosis, we analyzed the ct and mr fi ndings with regard to the presence of soft tissue components, tumor size, the angle between the soft tissue components and the inner wall of the cyst (acute or obtuse), and the confi guration of the inner border (regular or irregular). clinical and laboratory data including patient's age and tumor marker such as ca-125, ca 19-9, and afp, were also analyzed. in the analysis of the imaging fi ndings, nine (82%) of 11 tumors had soft tissue components and eight (89%) of nine soft-tissue-containing tumors showed an obtuse angle between the soft tissue components and the inner wall of the cyst. in nine (82%) patients, the maximum tumor diameter was greater than 10 cm and the patient's age was greater than 45 years. ca-125 was greater than 35 u/ml in six (67%) of nine patients and ca 19-9 was greater than 37 u/ml in three (75%) of four patients. conclusion: malignant transformation of cystic teratoma can be preoperatively predicted by combination of imaging fi nding and clinical data. spectrum of fi ndings of mullerian duct anomalies at mri p. paolantonio, r. ferrari, f. iafrate, c. de cecco, p. lucchesi, a. laghi; learning objectives: to illustrate some crucial mri technical features for the evaluation of normal uterine morphology and mullerian duct anomalies. to show spectrum of fi ndings of several mullerian duct anomalies at mri. to illustrate mri fi ndings useful in predicting the clinical impact of uterine anomalies in terms of infertility or risk of miscarriage. to illustrate mri fi ndings useful for treatment regimens assessment. background: since 1988, the american fertility society (afs) established a classifi cation of uterine malformations. because mullerian ducts defects are the result of a spectrum of mullerian ducts non-fusion, defi cient development and/or defective canalisation of the uterine cavity, the process may become arrested at any point in development. a complete assessment of uterine anatomy is mandatory in order to evaluate the impact of uterine malformation on women fertility and also to plan the optimal strategy of treatment. procedure details: in this exhibit, we describe an optimised mri protocol including high resolution t2 weighted tse sequence acquired on dedicated oblique planes for the evaluation of uterine morphology. we describe mr fi ndings of several mullerian duct anomalies according to the afs classifi cation with emphasis on different subtypes of septate uterus describing fi ndings useful to predict risk of recurrent miscarriage and to programme histeroscopical surgical treatment. conclusion: mri is a safe, non invasive and ionizing free method for diagnosis of uterine anomalies. mri allows a complete evaluation of uterine morphology useful in surgical approach planning. mri of the pelvis in mullerian duct abnormalities: is there a role in selecting patient for histerocopic metroplasty? p. paolantonio 1 , f. iafrate 1 , r. ferrari 1 , c. de cecco 1 , a. carnevale 2 , c. de angelis 2 , a. laghi 1 ; 1 latina/it, 2 rome/it (paolantoniopasquale@hotmail.com) purpose: selection of patient for histeroscopic metroplasty requires a complete assessment of uterine morphology usually achieved by laparoscopy that represent the gold standard in the evaluation of uterine morphology. the aim of our study was to assess the role of mri in selecting patients with mullerian duct fusion defect for hysteroscopic metroplasty. we prospectively investigate 25 females with known mullerian duct defect assessed at hysteroscopy. examination were performed using 1.5 t magnet equipped with phased-array coil acquiring high-resolution tse t2w sequence (tr: 3000 msec/ teeff 190 msec / etl: 29/ matrix 256 x 512) parallel to the long axis of the uterus. final diagnosis was assessed in all patients at surgery using laparoscopy in the assessment of uterine morphology. in 22 patients, hysteroscopic metroplasty was also performed. image analysis was performed by two radiologist in a blind consensus fashion. they qualitatively evaluate morphology of both uterus and endometrial cavity. mr fi ndings were compared with laparoscopic and hysteroscopic fi ndings. results: mri revealed uterine abnormalities in all patients. in detail, 15 patients b d e f a g were diagnosed as incomplete septate uterus, 5 as complete septate uterus, four patient as arcuate uterus and one patient as bicornuate uterus. mri fi ndings were correct in all cases, as confi rmed by hysteroscopy and laparoscopy. conclusion: mri is a valuable tool in the evaluation of uterine morphology. its use will help in sparing patients from laparoscopy, selecting patients for hysteorplastic metroplasty. diffusion-weighted mr imaging in uterine myometrial lesions with pathologic correlation k. tamai, t. koyama, n. morisawa, k. fujimoto, s. fujii, k. togashi; kyoto/jp learning objectives: 1) to illustrate mr features of uterine myometrial lesions on diffusion-weighted images (dwi) in correlation with pathologic fi ndings. 2) to discuss the advantages and limitations of dwi and adc measurement in evaluating uterine myometrial lesions. background: dwi can provide tissue contrast based on diffusion motion of water molecules, different from that of conventional mr sequences. adc values calculated from dwi are infl uenced by nuclear-to-cytoplasm ratio and cellular density that may be attributed to decreased adc values of malignant tumors. since dwi has been recently applied to the female pelvis, knowledge of its advantages and limitations is necessary for evaluating myometrial lesions. imaging findings: on dwi, the normal myometrium shows low intensity and the normal endometrium shows high intensity. the vast majority of ordinary leiomyomas and adenomyosis, which show low intensity on t2wi, also exhibit low intensity on dwi. in contrast, uterine sarcomas show prominent increased intensity on dwi. however, even benign lesions such as cellular leiomyomas and adenomyosis with proliferating ectopic endometrial tissues show high intensity on dwi, which can mimic malignancy. thus, careful evaluation of t2wi is mandatory for avoiding misinterpretation. although adc values of these myometrial lesions are usually lower relative to the normal myometrium, distinction between benign and malignant based on adc values may be diffi cult because of a considerable overlap. conclusion: dwi and adc measurements may have a limited role in distinguishing between benign and malignant myometrial lesions. however, careful interpretation of both dwi and t2wi may aid in estimating tissue characteristics of uterine myometrial lesions. results: ovv was revealed in 65 (47.79%) patients. the frequent clinical complaints were: low abdominal pain, disturbance of menstrual cycle. in 66% of cases, a combination of ovv with structural changes in ovaries was noted (multicystic or polycystic ovaries, the syndrome of ovary inanition). also, in 46% cases, along with ovarian structural changes the following were also noted: chronical infl ammatory disease in 46%, myoma in 28%, and endometriosis in 26%. in 82% ovv were noted bilaterally, in 12% on the left side, and in 6% on the right side. based on the diameter and location of varicosis, we defi ned 3 degrees of oov: i -one side dilatation of ovary vein to 5 mm, ii -bilateral ovv and dilatation of plexus venus uterovaginalis from 6 to 10 mm, iii -the dilatation above 10 mm in cases of total pelvic veins varicosis. reno-ovarian refl ux was positive in 53% by valsalvas maneuver. conclusion: tvcd is an effective and noninvasive modality in the diagnosis of ovv as a cause of female infertility. in 66%, this pathology with secondary changes in ovaries was combined with various dishormonal gynecological pathologies. learning objectives: to evaluate several points to meet the patient selection guidelines in screening pelvic mri for mr-guided focused ultrasound surgery (mrgfus) of uterine fi broids. background: currently, all treatment options for uterine fi broids are invasive and require several days of hospitalization and a few weeks of recovery. mrgfus is newly developed non-invasive procedure to reduce symptoms of uterine fi broids in an outpatient procedure. it combines mri to visualize the body organs, plans and guides the treatment, and monitors the treatment outcome in real time, with high-intensity focused ultrasound waves, which destroy the tissue. patients go home after the procedure and usually return to normal activities within a day or two. unfortunately, it cannot be applied to every patient with uterine fi broids. the decision to perform the mrgfus in patients with uterine fi broids is made according to the patient-selection guidelines in screening pelvic mri. imaging findings: in screening pelvic mri, several points must be evaluated carefully to meet the selection guidelines for mrgfus in uterine fi broids. these include the fi ndings of fi broids itself, obstacles to sonication pathway and relation to adjacent structure. conclusion: it must be requisite to know thoroughly the fi ndings in screening pelvic mri to select suitable patients for mrgfus in uterine fi broids. abdominal wall endometriosis: imaging -pathologic correlation e. de lama, l. aja, r. llatjos, j.a. narvaez; barcelona/es learning objectives: to review the underlying pathologic changes that create the imaging appearances of abdominal wall endometriosis at us, ct and mri. to learn the imaging appearances of abdominal wall endometriomas and to illustrate the usefulness of imaging-guide preoperative biopsy. to review the main differential diagnosis. background: abdominal wall endometriosis occurs in up to 1% all women who have had cesarean deliveries, and may be diffi cult to diagnose. procedure details: we will review: 1) pathologic changes in abdominal wall endometriomas. 2) us, ct and mri fi ndings correlated with pathologic changes. 3) usefulness of imaging-guide preoperative biopsy. in addition, differential diagnosis including nonneoplastic conditions, such as suture granuloma, ventral hernia, postsurgical hematoma or abscess, and neoplasms, such as a desmoid tumor, sarcoma, lymphoma, or metastasis will be reviewed. abdominal wall endometriomas are often non suspected clinically, but should be included in the differential diagnosis of a symptomatic mass in women who had cesarean deliveries. pathologic characteristics of abdominal wall endometriomas (surrounding infl ammatory reaction and fi brosis, degraded blood products) explain most of the imaging features. mr imaging of uterine cervical carcinoma: optimization of local staging and evaluation after therapy s.m. dias, a. ferrão, c. pina vaz; porto/pt learning objectives: to review the spectrum of magnetic resonance (mr) fi ndings clinically relevant for staging cervical carcinoma. to purpose technical strategies to optimize disease evaluation. to discuss clinical usefulness of mr for differentiation between recurrent disease and post-treatment complications. background: worldwide, cervical uterine cancer is second only to breast cancer as the most common malignancy in incidence and the third cause of death after breast and lung cancers in women. the féderation internationale de gynécologie et obstétrique (figo) classifi cation is the most commonly used staging system but it has recognized limitations that can be overcome with mr imaging. procedure details: the authors present the spectrum of mr fi ndings useful for staging and differentiate treatment complications from recurrent disease. technical strategies that can optimize local disease evaluation, such as intravaginal gel fi lling, are discussed. pitfalls, advantages and limitations of mr when compared to other imaging methods, namely mdct and positron emission tomography (pet), are listed and illustrated comprehensively. conclusion: magnetic resonance imaging is a powerful tool in the work-up of cervical carcinoma. it optimizes selection of the most suitable therapeutic strategy for each patient, as it provides a more effi cient staging of the disease, evaluating accurately important prognostic factors as tumour volume and presence of lymphatic disease. it has also interest in detection of recurrent disease and in evaluation of treatment effi cacy and associated complications. diagnostic pitfalls in evaluating mr gynecological disorders s. gispert, r. domínguez, x. merino, v. pineda, s. roche; barcelona/es (gisppi@yahoo.es) learning objectives: to review the possible pitfalls in the evaluation of gynecological disorders by mr imaging. background: mr imaging has an increasing role in evaluating female pelvis. the aim of the exhibit is to review the pitfalls in evaluating gynecological disorders. these pitfalls are roughly divided into physiological conditions that simulate organic lesions, benign conditions that simulate malignancy and malignant diseases that simulate benign conditions. according to the organ affected, we will show possible diagnostic pitfalls: uterus (pseudolesions related to uterine contraction that mimic leiomyoma or adenomyosis, adenomyosis that resembles uterine malignancies), ovary (appendicular mucocele or peritoneal cysts simulating ovarian tumors, ovarian atrophy simulating adenopathies), cervix (cervical carcinomas mimicking endometrial carcinomas), fallopian tube (hidrosalpinx resembling cystic masses), and vulva and vagina. conclusion: it is important to know the wide variety of mr pitfalls in gynecological disorders in order to distinguish possible mimicking lesions from real organic lesions. purpose: to evaluate the capability of mri in assessing pattern of recurrence threedimensional tumor volume and tumor response in patients with locally recurrent uterine cancer treated with concomitant chemo-radiation. methods and materials: twenty-four women who had undergone radical hysterectomy and with locally recurrent uterine cancer were enrolled in our study. all patients underwent gynecologic examination and mri to assess local recurrence. the recurrences were distinguished based on site: vagina, vaginal vault with or without pelvic wall extension, pelvic side wall. after diagnosis, the patients received concomitant chemo-radiation; then they underwent follow-up mri 45days after the end of treatment and then periodically every six months. pre-and post-treatment volumes were calculated by mri with ellipsoid formula and compared determining tumor response: complete, partial, no change, progression of disease. image analysis: mri showed 15 patients with central pelvic recurrence, 9 with recurrence in the pelvic side wall. the mean pre-treatment 3d-volume was 34.96 mm 3 (range 0.29-302.49 mm 3 ). the mean post-treatment 3d-volume was 14.06 mm 3 (range 0-302.49 mm 3 ). 13 patients had complete response, 8 partial response, 2 no change, 1 progression of disease. results: the site of response was associated to different prognosis; patients with recurrent tumor limited to vagina and vaginal vault showed better loco-regional control rates compared to patients with recurrence in the pelvic side wall. recurrent 3d tumor volumes < 50 mm 3 had better diagnosis than larger tumor volumes. furthermore, mri is an accurate non invasive method of distinguishing tumor from fi brosis. conclusion: mri permitted a good evaluation of pelvic recurrences and tumor response following chemo-radiotherapy. optimization of t2-weighted fast spin-echo sequence for female pelvis at 3 t mr imager k. fujimoto, t. koyama, k. tamai, n. morisawa, y. nakamoto, k. togashi; kyoto/jp (kfb@kuhp.kyoto-u.ac.jp) purpose: to optimize t2-weighted fast spin-echo sequence for female pelvis at 3 t mr imager. methods and materials: mri were obtained at 3 t-imager (siemens; trio) using 8ch phased-array coil in eight healthy volunteers. all scans were performed with sagittal section with thickness of 3 mm, interslice gap of 0.9-1.5 mm, fov of 260x195 mm without parallel imaging. scans were performed: 1) before and after injection of anticholinergic agent (buscopan), 2) with variable tr (8000, 6400, 4800, 3200), 3) with variable etl (21, 17, 13) 4) with variable band-width (bw) (175, 205, 235, 260, 300) , and 5) with variable te (79, 107-113, 148) with different types of rf pulse (low sar vs normal mode). sar of all scans was recorded. all images were qualitatively evaluated concerning artifacts, contrasts between b d e f a g both inner, outer layer of the myometrium, the endometrium, and those between cervical epithelium and stroma. quantitative measurement (snr, cnr) of these structures was also performed. results: scans without buscopan were considerably degraded by intestinal movements. longer tr generally provided better snr, although tr=8000 images in fi ve subjects were degraded by motion artifact from small intestine. tr=3200 were associated with high sar (96-99%) and decreased cnr in the uterine corpus (p < 0.05). etl=17 provided best images qualitatively. although lower bw images provided better snr, bw=175 images were associated with greater blurring. qualitative evaluation did not reveal remarkable difference between bw=205-260, te=79-113 images, although bw=300 and te=148 images had decreased snr. low sar rf pulse provided better snr without statistical signifi cance. conclusion: our preliminary data suggest that the optimal parameters of t2wi at 3 t include tr=4800-6400, etl=17, bw=205-260, te=79-113 with rf pulse of low sar type. administration of bustopan is essential. congenital mullerian anomalies: three-dimensional ultrasound fi ndings m. belloch ramos, f. raga baixauli, p. naranjo romaguera, f. bonilla bartret, f. bonilla musoles, j. palmero da cruz; valencia/es purpose: to asses the diagnostic value and the usefulness of three-dimensional (3d) ultrasound in detection of congenital mullerian anomalies, compared with other diagnostic methods (magnetic resonance, two-dimensional ultrasound, hysterosalpingography, laparoscopy and hysteroscopy). mullerian anomalies are related to reproductive problems, but true incidence is unknown. 3d ultrasound represents a useful noninvasive tool to evaluate these anomalies. a prospective study was undertaken from 1999 to 2005. a total of 10,352 women who went to a routine gynecological revision, were examined by 3d transvaginal ultrasound. all studies were stored in the hard disk and reviewed by three of the authors. mullerian anomalies were classifi ed according to american fertility society (asrm) classifi cation of 1988. results: 517 mullerian duct anomalies were detected in 10,352 patients (4.99%). arcuate (n=289, 59.8%) and septate (n=95, 18.3%) uteri were the most common malformations observed. the rest of anomalies observed were bicornuate (n=20, 3.8%), unicornuate (n=15, 2.9%) uteri and four des-exposed uteri. conclusion: this study with noninvasive and cheap technique suggests that the prevalence of these anomalies is near 4.99%. the most frequent malformation was arcuate uterus considered nowadays like a normal variant. des drug related uterus is rare today. improves diagnostic accuracy, with endometriotic cysts typically appearing with high signal intensity on t1-weighted images and demonstrating "shading" on t2-wi. small implants and adhesions are not well evaluated radiologically; therefore, laparoscopy remains the standard of reference for diagnosis and staging. although mr imaging is limited in its ability to depict small endometrial implants and adhesions, the advantages of mr imaging over laparoscopy include the ability to characterize endometriotic lesions and to evaluate extraperitoneal sites of involvement, contents of a pelvic mass, or lesions hidden by dense adhesions. the roles of the two modalities are therefore complementary. knowledge of the variety of mr imaging appearances of endometriosis and organ involvement is important for guiding a subsequent laparoscopic examination. the monsters of the female pelvis: pelvic teratomas revisited a. ghiatas, d. keramopoullos, c. tsagari; athens/gr (abraham@otenet.gr) learning objectives: to illustrate the imaging fi ndings of teratomas on various imaging modalities. to discuss the appropriate selection of imaging modalities and techniques and how to avoid imaging interpretation pitfalls. background: pelvic teratomas is a frequent incidental fi nding in the course of imaging evaluation of the female pelvis for pathology unrelated to teratomas. differential diagnosis of teratomas from other pelvic masses may be diffi cult unless the most optimal imaging modalities and techniques have been selected, which are able to demonstrate the specifi c features of this pathological entity. procedure details: 123 cases of pelvic masses were diagnosed as teratomas by ct, mri or ultrasound, or a combination of them. all cases underwent surgery and pathology results were compared to the imaging fi ndings. conclusion: in 119 cases, the imaging diagnosis of teratoma was in complete agreement with the surgical/pathology fi ndings, and in the remaining 4 cases, the diagnosis of teratoma was in agreement with the fi rst 3 diagnoses. factors selective uterine arteriography of consecutive 60 patients who underwent uae for symptomatic fi broids or adenomyosis were reviewed in regard to visualization of anastomosis with ovarian arteries. factors including arterial spasm, uterine volume, location of lesion, birth history, and history of abdominal surgery were analyzed. results: uteroovarian anastomosis was demonstrated in 25 of 60 patients (41.7%) and 34 of 120 uterine arteries (28.3%). there were 3 patients (5.0%) with visualization of anastomosis due to arterial spasm at the origin of the uterine artery, where the catheter was engaged. anastomosis was seen in fi broids at subserosal (33.3%), intramural (35.7%), submucosal (43.8%), and adenomyosis (42.9%). signifi cant difference was seen in the mean uterine volume: 547.1 cm 3 with anastomosis and 1024.0 cm 3 without anastomosis (p=0.027). anastomosis was demonstrated in 44.4% of patients with multiple fi broids and 30.4% with solitary fi broid (odds ratio 1.82), 46.4% with multigravida and 31.0% with nullipara (odds ratio 1.92), and 44.4% in patients with a history of abdominal surgery and 35.9% without surgery (odds ratio 1.43). uteroovarinan anastomosis is often demonstrated during uae irrespective of type and location of lesion. arterial spasm by catheterization is a defi nite technical factor. smaller uterine volume, multiple fi broids, and multigravida were considered as signifi cant factors of visualization of anastomosis. use of colour doppler for early detection of hemorrhage in ultrasound guided renal biopsies k. brabrand, a. günther, p. bache marthinsen, a.e. berstad; oslo/ no (knut.brabrand@rikshospitalet.no) purpose: to evaluate the use of colour doppler (cd) for early detection of hemorrhage after ultrasound guided renal biopsy. a linear cd signal may be observed along the biopsy tract showing blood fl ow out of the kidney into the perirenal tissue immediately after withdrawing the needle indicating a post biopsy hemorrhage. to evaluate the incidence and duration of cd bleeding after renal biopsies, a prospective study was performed using an acuson seqouia with a 4v2 transducer (cd frequency 2.5 mhz, scale 0.12m/s). 78 patients were included. there were 90 biopsy procedures in 83 renal transplants and seven native kidneys with a total number of 243 biopsy needle passes. for each needle pass the presence and duration of cd bleeding were registered. if cd bleeding was seen, cd guided compression was applied. results: cd bleeding was seen after 63 needle passes in 42 biopsy procedures. the incidence of cd bleeding increased with the number needle passes per procedure. the duration of cd bleeding exceeded four minutes in seven patients, of whom six developed a post biopsy hematoma. eight of nine of the post biopsy hematomas (mean diameter 2.2 cm) were preceded by cd bleeding. cd guided compression was applied in 42 biopsy procedures. conclusion: cd is useful in renal biopsies for early detection of post biopsy hemorrhage. the study shows that the duration of cd bleeding correlates with the severity of the bleeding. cd guided compression could possibly reduce the duration and volume of post biopsy bleeding. renal learning objectives: to familiarize the radiologist with the fi ndings of contrastenhanced ultrasonography (ceus) of the commonest primary renal tumors. to present these fi ndings in the setting of an integrated diagnostic approach. background: the high frequency of detection of renal lesions and the innovations in their treatment have increased the need for an accurate imaging diagnosis. this exhibit is based on the study of 68 renal tumors that were scanned before and after i.v. injection of a second-generation ultrasound contrast agent (sonovue, bracco). representative ceus images and the corresponding fi ndings of baseline and color doppler us, ct, mr and dsa are displayed. microscopic and macroscopic sections of the excised tumors confi rm these fi ndings and establish the fi nal diagnosis. imaging findings: numerous cases of renal cell carcinomas (clear cell, papillary and cystic varieties), urothelial neoplasms, angiomyolipomas, oncocyttomas (typical and atypical) and a multilocular cystic nephroma are depicted. several patterns of enhancement are described. the increased sensitivity of ceus in outlining the pseudocapsule, small cystic areas and heterogeneity in the perfusion of renal tumors is demonstrated. the tortuous pathologic vessels at the periphery of the rccs and the spoke-wheel pattern of the oncocyttoma are displayed. challenging cases, such as isoechoic tumors that mimic normal variants and small lesions that are imperceptible on baseline us, are also included. conclusion: compared to fundamental us of renal tumors, ceus may provide valuable additional information. ceus fi ndings correlate well with those of other imaging methods and can contribute to an accurate diagnosis. purpose: to investigate the perfusion characteristics of renal mass parenchyma and renal cortex in affected and normal kidney on 64-slice ct. totally 58 patients with renal mass were enrolled. 64slice spiral ct (siemens somatom sensation 64) was used for renal perfusion scan that began with a contrast bolus injection of 50 ml (370 mgi/ml) at a rate of 5 ml/s. surgical and pathological outcomes were collected for comparison. perfusion characteristics, including blood fl ow (bf), blood volume (bv) and permeability (pm) of renal mass parenchyma and renal cortex in affected and normal kidney were calculated from 'siemens body pct (vb20b)' software. results: renal clear cell carcinoma (rccc), renal pelvic transitional cell carcinoma (rptcc) and renal angiomyolipoma (raml) was pathologically confi rmed in 30, 5 and 11 of 58 subjects, respectively, while the remaining 12 subjects were with renal simple cyst (rsc). technical failures were experienced in 1 (1.7%) patients. perfusion parameters of tumor parenchyma were measured as follow: rccc: bf=92.9±26.6, bv=177.0±55.3, pm=110.4±32.9; rptcc: bf=46.5±22.1, bv=79.7±32.3, pm=63.3±19.4; raml: bf=50.7±17.6, bv=113.2±47.0, perme-ability=60.1±23.9; rsc: bf=7.1±6.1, bv=18.0±10.8, permeability=16.0±8.8. in all groups, perfusion parameters showed signifi cant differences (p < 0.01) between mass parenchyma and renal cortex in normal kidney, while there were no signifi cant difference (p> 0.05) in perfusion parameters between renal cortex in affected and normal kidney. there were signifi cant differences (p < 0.05) in perfusion parameters between parenchyma in any two kinds of renal masses, except for rptcc and raml (p> 0.05). conclusion: these four kinds of renal masses all have decreased perfusion characteristics. perfusion imaging with msct has potential clinical application value in differential diagnosis of renal mass. vascular complications after renal transplantation: us fi ndings i. de la pedraja, n. gomez, j. hernandez, m. ciudad, e. vaño; madrid/es learning objectives: 1) to illustrate the different types of vascular complications after renal transplantation, with emphasis on their characteristic chronology. 2) to be familiar with the ultrasound fi ndings that allow us to diagnose vascular complications in renal allografts. background: renal transplantation is the treatment of choice for severe endstage renal failure. because of this, it is very important for the common radiologist to know enough about the diagnosis and management of renal grafts complications, especially the vascular ones, which are a very frequent and severe reason of early graft failure and reject, and a common request of diagnostic procedures in the emergency room. imaging findings: we illustrate some examples of the different types of vascular complications associated with renal transplants, including graft artery and recipient iliac arterial system stenoses, arterial and venous thromboses, focal and diffuse infarcts, pseudoaneurysms and arteriovenous fi stulas. some examples not only of single kidney grafts complications but of "en bloc" transplants complications are presented. we also discuss the imaging features of vascular complications in grayscale sonography and doppler sonography, and, in some cases, the appearance of the subsequent fi ndings in mri and angiography. in addition, we emphasize the characteristic chronology of each vascular complication. conclusion: although angiography is still the "gold standard" in the diagnosis of vascular complications in renal transplantation, ultrasound is usually the fi rst step in the diagnostic procedure, and is a valuable technicque that allow the radiologists to make an early diagnosis of them. correlation of hemodialysis duration with enthesal site changes of hemodialysis patients by lower limb ultrasonographic examination u. kerimoglu, m. hayran, f.b. ergen, a. kirkpantur; ankara/tr (ulku09@yahoo.com) purpose: to evaluate the enthesal site changes of the lower limb of patients on hemodialysis utilizing glosgow ultrasound enthesitis scoring system, and to assess the correlation between the duration of hemodialysis and the score of patients. methods and materials: forty-nine patients who are on hemodialysis for at least 2 years were included in the study. the patients were subgrouped according to the duration of hemodialysis; 2 to 5 years (group 1, n=14), 5 to 10 years (group 2, n=15), 10 to 20 years (group 3, n=12) and more than 20 years (group 4, n=8). for each patient, the total score of guess, the mean score of guess for each group, total score for enthesophyte and erosion were correlated with the duration of hemodialysis. the mean of the total guess scores (8.8±3.0, 13.5±3.0, 17.9±4.5, 23.4±4.6 for groups 1-4, respectively) increased signifi cantly among gropus (p < 0.001, jonckheere-terpstra test). there was statistically signifi cant correlation between the duration of hemodialysis and total guess scores (p < 0.001, r s =0.81), especially for men. signifi cant correlation was seen between the duration of hemodialysis and total enthesophyte and erosion scores (p < 0.001). if severe enthesitis was to be defi ned as a total guess score of more than 18, a receiveroperating characteristic curve analysis reveals a cut-off point of 10 years (with 83% sensitivity and 93% specifi city) that results in severe damage (area under the roc b d e f a g curve: 0.92, 95% confi dence limits: 0.83-1.00). conclusion: kidney transplantation performed as early as possible, especially before 10 years, would prevent severe enthesitis. laparoscopic cryoablation (lc) of small renal cell carcinoma (rcc): mediumterm outcome after 5-year magnetic resonance (mr) imaging follow-up g. cardone, c. iabichino, a. cestari, p. mangili, g. guazzoni, g. balconi; purpose: this study aims to determine the safety and effi cacy of lc in the management of small rcc, and to assess its medium-term outcome after 5-year mr imaging follow-up. methods and materials: seventy-one patients underwent lc for a total of 75 treated tumors. all treatments were administered under laparoscopic us guidance. patients were followed-up clinically, biochemically, and by mr imaging 24 hours after surgery, and subsequently at 1, 3, 6, 12, 18, 24, 36, 48, and 60 months. all mr examinations were performed with a 1.5 t mr system using gre t1w, tse t2w sequences and ce dynamic gre fs-t1w sequence. results: cryolesions decreased in size by an average of 38% at 1 month, 46% at 3 months, 64% at 6 months and 80% at 12 months following lc. post-procedural mr ce-t1w images showed complete ischemia of all cryolesions. follow-up revealed no evidence of local or distant recurrence in 64/71 patients (90%). one patient showed local recurrence at 12 months; 3 patients demonstrated 1 metachronous nodule in the same kidney at 12, 18, and 60 months, respectively; 2 patients showed 1 metachronous nodule in the controlateral kidney at 18 and 24 months,respectively; 2 patients showed pancreatic metastatic nodules at 6 and 12 months. in 21 cases, a small perilesional haematoma was evident at 1 and 3 months after surgery. conclusion: our 5-year medium-term experience suggests that lc is a safe, well tolerated, and minimally invasive therapy for small rcc, and mr is an effective imaging technique in the follow-up of rcc treated with lc. primary renal lymphoma p. filis, e. protopapa, a. gyftopoulos, g. delimpasis, e. sammouti, e. seferos, a. fousteris; athens/gr learning objectives: 1. to evaluate the role of multislice ct and mri in primary renal lymphoma. 2. to become familiar with both typical and atypical manifestations of primary renal lymphoma. 3. to review the basic concepts of primary renal lymphoma. background: renal lymphoma is most often seen in conjunction with multisystemic, disseminated lymphoma. reports on primary renal lymphoma are scarce in the urological literature, the most part of them being secondary on a lymphomatous infi ltration of the kidneys. primary renal lymphoma (prl) as a clinical entity is not undisputed because the kidneys do not contain lymphatic tissue. multislice ct is the most sensitive and comprehensive examination for evaluation of the kidneys in patients with suspected renal lymphoma. in particular, it improves detection and characterisation of lymphomatous renal involvement by optimising contrast dynamics and data acquisition and is the current modality of choice for accurate staging of lymphoma. we report the case of three patients with an incidental mass on the kidney; their diagnosis and management are discussed. a literature review on currently recommended diagnostic practices will be presented. typical and atypical ct patterns which provide a diagnostic challenge will be discussed. procedure details: ct scans were performed on a multislice ct. magnetic resonance imaging was performed on a 1.5 tesla scanner. conclusion: multislice ct is useful in the evaluation of patients with suspected renal lymphoma; familiarity with the spectrum of fi ndings in renal lymphoma is important for accurate diagnosis and, when necessary, the recommendation of imaging guided percutaneous biopsy. ct-guided biopsies in patients with renal transplant and suspicion of rejection c. kalogeropoulou, p. kraniotis, p. zampakis, a. tsamandas, t. petsas; patras/gr purpose: renal biopsy is a necessary step in the diagnostic work-up of patients with a renal allograft, presenting with renal dysfunction and suspicion of rejection. we evaluated the safety and effi cacy of ct-guided core biopsies in renal transplant patients with deteriorating renal function and clinical suspicion of transplant rejection. methods and materials: during the last 2 years, we performed 20 ct-guided biopsies in 17 patients (14 male), mean age 37 (range 21-57) years. the indications for biopsy included: increased serum creatinine 70% (14/20), albuminuria 15% (3/20), delayed renal function 10% (2/20) and progressive functional decline 5% (1/20). the patients underwent pelvic ct and optimal site for tissue sampling was selected. all biopsies were performed using a 20g automated core biopsy needle. one pass per patient was performed. results: an average of 1 tissue core per biopsy was obtained. adequate tissue sample (≥3 glomeruli per specimen) was acquired in all cases. histological examination revealed tubular atrophy 5% (1/20), acute rejection 55% (11/20), chronic nephropathy 15% (3/20), acute tubular necrosis 10% (2/20), focal segmental tubular sclerosis 5% (1/20) and interstitial fi brosis 10% (2/20). technical success reached 100%. there were no major post-procedural complications. conclusion: core biopsy of the transplant kidney is an essential diagnostic tool for patients with dysfunctional renal transplant and suspicion of rejection. the procedure has a high diagnostic yield, infl uencing in a critical way any further management. ct-guidance offers the advantage of better targeting the kidney allograft in the pelvis, avoiding superimposed bowel loops, and hence decreasing the complication rate. measurement of glomerular fi ltration rate and renal blood fl ow using dynamic contrast comparison of sonoelastography guided biopsy with systematic biopsy: impact on prostate cancer detection l. pallwein, f. aigner, e. pallwein, v. fischbach, j. gradl, f. frauscher; innsbruck/ at (leo.pallwein@uibk.ac.at) purpose: we performed a prospective study to determine whether a limited biopsy approach with sonoelastography (se) targeted biopsy of the prostate would detect cancer as well as gray scale us guided systematic biopsy with a larger number of biopsy cores. we examined 230 men (mean age: 62.3) with a total psa of 1.25 ng/ml or greater. first investigator performed 5 or fewer se targeted biopsies into suspicious (stiffer) regions in the peripheral zone. hard lesions were considered as malignant. subsequently, another examiner performed 10 systematic prostate biopsies. the cancer detection rates of the 2 techniques were compared. results: cancer was detected in 81 of the 230 patients (35%), including 68 (30%) by se targeted biopsy and in 58 (25%) by systematic biopsy. the overall cancer detection rate by patient was not signifi cantly different for se targeted and systematic biopsy (p = 0.132). the detection rate for se targeted biopsy cores (12.7% or 135 of 1,109 cores) was signifi cantly better than for systematic biopsy cores (5.6% or 130 of 2,300 cores, p < 0.001). se targeted biopsy in a patient with cancer was 2.9-fold more likely to detect prostate cancer than systematic biopsy. conclusion: sonoelastography targeted biopsy detected as many cancers as systematic biopsy with fewer than half the number of biopsy cores. although an increase in cancer detection was achieved by combining targeted and systematic techniques in this screening population, sonoelastography targeted biopsy alone is a reasonable approach for decreasing the number of biopsy cores. transrectal ultrasound ( background: since trus is the most effi cient way to detect prostate cancer (prca), this e-book aims to teach the trus procedure in detection and staging of prca and correlate it with the histological fi ndings emphasizing the use and effectiveness of usca and local anesthesia prior to biopsy sampling. procedure details: this medical e-book is a multimedia dvd rom-based teaching fi le featuring 2500 us prostate images, 150 us video demonstrations, 400 video cases presenting clinical data and detailed description of trus techniques, chapters on prostate anatomy, trus technique for the detection and staging of prca (based on over 10,000 cases), color doppler, and the technique of usguided biopsies. the proper trus technique is demonstrated step by step. its educational role is based on video cases and double video presentations. the latter consists of a simultaneous presentation of the real-time ultrasound exam and the examiner's technique. a database is included in aiding the user to reach the correct diagnosis and to compare his sonographic image to histologically proven images of the database. conclusion: user-friendly dvd rom-based teaching fi le on the prostate with chapters on anatomy, pathology, ultrasound physics, sonographic appearance of the normal prostate, trus morphology, detection and staging of prca, local anesthesia, usca and comparative database. learning objectives: review the sonographic fi ndings of non-neoplastic pathologic processes involving the extratesticular structures in the adult patient. background: the scrotum is a fi bromuscular sac divided by a median raphe. it contains the testis, epididymis, spermatic cord, and associated fascial coverings. these structures can be affected by several pathologies including congenital, infl ammatory and neoplastic.ultrasonography is the primary modality for imaging the scrotum. it should be performed with the highest frequency transducer that provides adequate penetration. intratesticular versus extratesticular pathologic conditions can be differentiated with a high sensitivity. imaging findings: in this pictorial review, we describe and illustrate cases selected from our radiology department fi les of non-neoplastic extratesticular disorders in adults. the following pathologic entities are included: (1) fluid collections: hydroceles, hematoceles and pioceles; (2) epididymis: acute and chronic epididymitis, cysts, spermatoceles and granulomas; (3) spermatic chord: hematomas, torsion, lipomatous infi ltration and varicocele; (4) paratesticular masses: inguinal hernias. the information obtained with gray-scale and color doppler ultrasonography is suffi cient to enable diagnosis in most cases of non-neoplastic extratesticular disorders in the adult patient. because physical examination usually lacks specifi city for scrotal lesions, the radiologist should be in the position of making an early and correct diagnosis in order to direct further work-up and avoid severe complications. pre-treatment evaluation of prostate cancer with mri and threedimensional 1h-magnetic resonance spectroscopy: our experience s. giusti, m. lazzereschi, f. francesca, a. tognetti, d. caramella, c. bartolozzi; pisa/it purpose: our aim was to assess the accuracy of 1h-magnetic resonance spectroscopy (mrs) in patients with high prostate-specifi c antigen (psa) levels and biopsy proven prostate carcinoma, candidate to radical prostatectomy. methods and materials: twenty-one patients underwent mri and mrs for the evaluation of tumor location, local extent and aggressiveness of prostate cancer. our imaging protocol included axial, coronal and sagittal t2wi fse sequences and an axial t1wi fse sequence. for mrs, we used 3d chemical shift imaging (csi) spin-echo sequence. we divided the prostatic gland into six sextants and sensitivity, specifi city and accuracy of biopsy, mri, mrs, mri+mrs were calculated with pathological correlation. conclusion: combined mri and 3d 1h mrs of the prostate have a diagnostic advantage in tumor location over mri alone and over biopsy alone. in particular, a negative result at 3d 1h mrs is able to exclude the presence of cancer with high probability. we are further investigating whether there is a correlation between high gleason score and mrs sensitivity. the all studies were performed with a 1.5 t superconducting system. twenty-nine prostatic cancers (> 10 mm) in 34 patients were included. radical prostatectomy was performed in all patients within 2 months after mri. t2weighted image with fat saturation and adc map by each method were obtained. trace adc map of the normal prostatic tissue (peripheral zone: pz and inner gland: ig) and prostatic cancers were evaluated by each method. results: normal pz adc was 1.763 + 0.205 (×10 -3 mm 2 /s) by ss-epi, 1.496 + 0.939 (×10 -3 mm 2 /s) by lsdi. normal ig adc was 1.382 + 0.223 (×10 -3 mm 2 /s) by ss-epi, 1.258 + 0.866 (×10 -3 mm 2 /s) by lsdi. there was signifi cant difference between ss-epi and lsdi by student's t-test (p < 0.05). in three normal pzs, susceptibility artifacts arose from the air-fi lled rectum. prostatic cancer adc was 0.951 + 0.256 (×10 -3 mm 2 /s) by ss-epi, and 0.783 + 0.226 (×10 -3 mm 2 /s) by lsdi. two prostatic cancer adc by ss-epi were not calculated, because of susceptibility artifact arising from the air-fi lled rectum. all prostatic cancer adc by lsdi were calculated without susceptibility artifact arising from the air-fi lled rectum. conclusion: there was signifi cant difference between adc by ss-epi and by lsdi. adc by lsdi in both prostatic cancer and normal prostate were inherently insensitive to susceptibility artifacts. b d e f a g intra-and extra-testicular cystic lesions: us and mri fi ndings r. prada gonzález, g. tardáguila de la fuente, j. aguilar arjona, e. santos armentia, c. rivas, g. fernández; vigo/es (rachelpg@terra.es) learning objectives: 1) to review the clinical, pathological and imaging manifestations of scrotal cystic lesions. 2) to demonstrate the roles of us and mri in the diagnosis of scrotal cystic masses. background: when studying a scrotal mass, the two most important questions to be answered are whether the lesion is intra or extra-testicular, and whether it is cystic or solid. extratesticular masses, both cystic and solid, are usually benign. however, when the mass is intratesticular, the prognosis of cystic and solid masses is quite different. intratesticular solid lesions should be considered malignant, whereas intratesticular cystic lesions are most likely benign. therefore, although intratesticular cystic masses are rare, its recognition is important, in order to avoid unnecessary surgical intervention. procedure details: we study clinical, pathological and imaging manifestations of scrotal cystic masses. intratesticular cystic lesions include simple cysts, tunica albuginea cysts, tubular ectasia of the rete testis, testicular epidermoid cysts (misnamed cyst because it is solid lesion), abscess and, in some cases, infarctions and teratomas. extratesticular cystic lesions are hydrocele, hematocele, varicocele, spermatocele, papillary cystadenoma, spermatic cord cyst and hernia. us is the fi rst choice modality for studying these lesions. mri is seldom needed, but provides useful information when us results are inconclusive. in order to make a correct diagnosis and to prevent unnecessary surgical intervention, it is of the utmost importance to recognize imaging features of intra-and extra-testicular cystic masses. although ultrasound is the primary imaging modality for researching testicular lesions, mri proves to be an useful tool when the results of us are unclear. ultrasound appearances of intra-testicular tumours: gray-scale imaging features with histologic correlation to allow prediction of tissue type t. diagnostic value of pwi in prostate cancer and benign prostatic hyperplasia x. zhao, r. bai; tianjin/cn (xin-cheng@163.com) purpose: to evaluate the diagnosis and differential diagnosis value of pwi for prostate cancer (pca) and benign prostatic hyperplasia (bph). methods and materials: fifty-three cases were divided into three groups: group 1 included 23 cases of pca, group 2 included 22 bph cases, 8 cases were enrolled in group 3 as normal control. all subjects were examined with 1.5 t twin-speed infi nity with excite ii (signa; ge medical system). the sequence of pwi was axial single shot gradient recalled echo echoplanar imaging t 2 * wi. then the si-t curve and pwi parameters were obtained. to compare the difference of perfusion-related parameters including rne (relative negative enhancement integral), rmte (relative mean time to enhance) and rmsd (relative maximum slope of decrease) among three groups. results: in the peripheral zone (pz), the value of rnei of pca was higher than that of bph (t=11.64, p < 0.001) and normal (t=11.79, p < 0.001). the value of rmte of pca was lower than that of bph (t=3.50, p=0.002) and normal (t=3.78, p=0.001). in the central zone (cz), the value of rnei of pca was higher than bph (t=6.99, p < 0.001) and normal (t=10.32, p < 0.001). according to roc, the rnei had the best differential diagnosis effi ciency. the optimal threshold was calculated as 6.44 with a sensitivity of 91.3% and a speciality of 89.2% for differentiating pca. conclusion: rnei is an effective parameter to differentiate pca from bph. comparison purpose: the histologic grade of a prostate needle-core biopsy specimen can determine whether a patient with prostate cancer is a candidate for radical prostatectomy or another treatment. the aim of this study was to illustrate the concordance of gleason score between biopsy and radical prostatectomy. methods and materials: we retrospectively reviewed clinical and pathological data of 51 patients who underwent trus biopsy and radical prostatectomy between 2004 and 2005. of the included patients, 9 men had undergone a nonextended sextant biopsy scheme (type a), 33 patients a 6-10 extended scheme (type b), and 9 patients a 10-14 extended biopsy (type c). clinical parameters were available and sonography fi ndings were included. biopsy and prostatectomy specimens were reviewed by the same staff. the rate of grading concordance and the effect of different biopsy schemes (a,b,c) on the concordance rate was determined. results: the trus fi ndings and the number of cores affected were similar in the 3 groups (p < 0.011; p < 0.045) according to the jonckheere-terpstra test. the concordance between prostate biopsy and radical prostatectomy vacurg score was 2/9 cases [a scheme (22.2%)], 22/33 cases [b (66.7%)] and 8/9 cases [c (88.9%)] (z test -3.793; p=0.000). biopsy understaging was found in 7/9 cases (77.8%); 11/ 35 cases (33.3%) and 1/9 cases (11.1%), respectively, (z test -3.55) b d e f a g (z test -3.954; p=0.000). primary gleason pattern was predicted exactly by biopsy in 3/8 cases (37.5%); 26/35 cases (74.3%) and 9/9 cases (100%), respectively (z test -3.557; p=0.000). conclusion: extended needle biopsy signifi cantly increases the accuracy of biopsy gleason score for assessing fi nal prostate cancer grade. correlating radiological and histopathological staging for prostate cancer in a general nhs setting: do fi ndings live up to national standards? a. raza, s. higgins, r. mason, n. ryley; torquay/uk purpose: preoperative mri staging of prostate cancer is more accurate with higher strength magnets and endorectal coils; however, these are still not widely available in all uk hospitals. we assessed the degree of accuracy using a 1 tesla magnet and a pelvic array coil (a common setup throughout the uk). all patients subsequently underwent radical prostatectomy, and the results of preoperative mri staging were compared with histological fi ndings. methods and materials: thirty-three patients were identifi ed by the urology records from august 2003 to 2005. the imaging was performed with 1 tesla magnet without endorectal coils. all patients underwent radical prostatectomy. case notes were retrieved and reviewed in detail along with histopathology. mri studies were reviewed in a blinded fashion. results: 26/33 patients had an mri done (78.78%). 12/26 patients had mri and histopathological concordance (46.15%). 14/26 patients were non-concordant with histopathological results (53.84%). out of these 14 patients, 9 were false -ve and 5 were false +ve. the royal college of radiologists (uk) guidelines for reporting accuracy at mri range from 66 to 83%. this study using a 1 tesla magnet without access to endorectal coil had poor staging accuracy and possibly refl ects the current situation in many uk hospitals. access to endorectal coils or higher strength magnets is a major factor in increasing staging accuracy. this study arguably reports accuracy fi gures more representative of average nhs radiology services, and therefore raises important concerns about the validity of existing national standards and guidelines. the protocol consisted in fat-sat fast spin-echo t2 sequences, gd-enhanced dynamic study with 3d flash sequences (1 before and 5 after gadoteridol 0.1 mmol/kg, temporal resolution 35 s), t1-weighted fat-sat fast spin-echo sequence and 3d csi proton spectroscopy. dynamic sequences were post-processed with image subtraction (enhanced minus unhenanced) and intensity/time curves for targeted regions of interest. proton spectroscopy data were evaluated generating 1h spectra voxel-by-voxel, choline maps and choline/citrate ratio maps. conclusion: a complete protocol can be performed in less than 30 minutes, including morphologic images, dynamic study and 1h-mrs. prostate cancer: mr spectroscopy after radiation therapy -initial experience j. rembak-szynkiewicz, b. bobek-billewicz, w. senczenko; gliwice/pl (remszyn@wp.pl) purpose: to evaluate prostate mr spectroscopy after radiation therapy in patients with complete biochemical remission. methods and materials: combined endorectal mr imaging and mr spectroscopy in 12 patients after radiation therapy of prostate cancer without biochemical signs for recurrent disease was performed. patients with the prostate-specifi c antigen (psa) level below 1 ng/ml were chosen. no increase of psa rate within 3 months post examination was observed. 8/12 patients underwent external-beam radiation therapy, 3/12 patients underwent external-beam radiation therapy and prostate brachytherapy prior to our study. the mean radiation dose was 74gy. mr spectroscopy (medrad endocoil) was performed with 1.5t siemens avanto mr scanner. siemens software was used for three-dimensional (te=120 ms) 1 h-mr spectroscopic data acquisition and processing. the metabolite (cho, cr and cit) peaks were considered and (cho+cr)/cit was calculated. results: voxels with a (cho+cr)/cit ratio of 1 or more were found in 4/12 patients in prostate peripheral zone. voxels with value of a (cho+cr)/cit ratio of 1 and less in prostate peripheral zone were found in 8/12 patients. voxels with a (cho+cr)/cit ratio of 1 or more were found in 9/12 patients in prostate central zone; furthermore, in 3/12 patients this ratio was equal or below 1 in prostate central zone. conclusion: increased value of (cho+cr)/cit ratio may be found (appear) in patients with complete biochemical remission even after several months post radiation therapy. that can represent a presence of neoplasmatic cells in prostate months after radiation therapy despite lack of biochemical and clinical evidences of disease. where is the pelvic sidewall? an anatomical depiction with radiological and surgical correlates t.d. suaris, a. sahdev, r. reznek, a. rockall; london/uk (tamarasuaris@hotmail.com) learning objectives: to describe the anatomy of the surgical pelvic sidewall with annotated schematic drawings and ct and mri correlates. to illustrate with video clip the laparascopic dissection of the pelvic sidewall (psw) with cadaveric dissection of the pelvic sidewall, and compare the radiological and laparascopic views. to demonstrate with imaging the alteration of anatomical borders with reference to: primary invasive disease, post radiotherapy changes, post surgical changes, recurrent disease. to demonstrate examples of pelvic malignancies invading the psw to varying degrees. background: the assessment and staging of the spread of malignancy within the pelvis require detailed knowledge of the structures and anatomy of the pelvis. however, the exact delineation of the psw can be diffi cult on cross-sectional imaging. pelvic exenteration is a salvage procedure performed for centrally recurrent gynaecological cancers. the procedure involves en bloc resection of all pelvic structures. the surgery is complex and associated with high-rates of complication. psw involvement in these patients is a contraindication to radical or exenterative surgery. imaging findings: the surgical approach to the pelvic sidewall is based on layers from deep to lateral. understanding this approach, ct and mri images of the psw will be annotated to revise the layers of the pelvic wall. imaging will demonstrate the involvement of ureters, neurovascular structures, obturator nerves and vessels and obturator internus and piriformis muscles. the importance of understanding the complex anatomy of the pelvis on cross-sectional imaging allows correct interpretation of pelvic pathology. average equivalent doses/operation for the surgeon (pcnl) for a crystalline lens and hands: 74µsv and 222 µsv accordingly. the average effective dose level/operation (pcnl) is 5.4 times more than of retrograde operations. the greatest level of doses is measured on the eye which is located more closely to the x-ray source. the right hand dose level of the surgeon is 1.5 and left hand is 2.7 times more than those of the assistant (pcnl). the descended testes, herniated bowel, and varicoceles. uncommon masses include liposarcomas, testicular tumors, lymphoma, and neurofi brosarcomas. familiarity with the normal anatomy as well as the imaging characteristics of these masses is essential for correct image interpretation. imaging findings: via ct and mri images, this exhibit will review the embryology, male and female anatomy of the normal structures associated with the inguinal canal. we will also present the imaging features and the clinico-pathological background of common and uncommon masses located in the inguinal canal. conclusion: on completion of this exhibit, the attendee will become familiar with the anatomy, pathology, embryology and imaging characteristics of the common and uncommon masses in the inguinal canal. learning objectives: 1. to illustrate the spectrum of imaging features of tuberculosis of the genitourinary tract. 2. to review the differential diagnosis of genitourinary tuberculosis. background: tuberculosis is the most common cause of mortality from infectious diseases worldwide. the prevalence of this infection has increased over the past decade in most developed countries and extrapulmonary tuberculosis represents a a progressively greater proportion of the new cases. genitourinary tuberculosis is an important but uncommon form of tb, although it is the second most common form of extrapulmonary tuberculosis. diagnosis is often diffi cult and delayed because tb can mimic many other diseases. radiologic examinations are very useful to determine the presence of tuberculosis and to monitor de therapeutic effi cacy. imaging findings: this pictorial review illustrates the radiological features of genitourinary tuberculosis. it shows intravenous urography, retrograde pyelography, us, ct and mr images of differents stages of tuberculosis affecting the kidney, ureter, bladder and genital tract. conclusion: diagnosis of genitourinary tuberculosis is often diffi cult and delayed, as there are many pathologic conditions that can mimic this entity. although defi nitive diagnosis is established by cultive or histologic examination, radiologic examinations are useful in suggesting the presence of the disease and it is important for the radiologist to be familiarized with the fi ndings of genitourinary tb. demonstration of the anatomy of the right adrenal vein with multidetector row ct t. matsuura, k. takase, t. yamada, a. sato, s. takahashi; sendai/jp purpose: adrenal venous sampling is essential for an accurate diagnosis of primary aldosteronism. information about the anatomy of the right adrenal vein (rav) obtained by ct would be useful in planning adrenal venous sampling. the purpose of our study is to determine how frequently the rav could be identifi ed on mdct and what spectrum of anatomic variations was seen among the rav. methods and materials: post-contrast mdct were retrospectively reviewed in104 patients. ct scan was performed with a mdct (8-row) scanner (1 mm collima-tion, pitch 7). contrast material (100 ml, 300 mgi/ml) was injected at a rate of 3.5 ml/sec. axial slices of 1-mm thickness were evaluated. the following points were evaluated regarding the rav: the rate of visualization, the relationship to an accessory hepatic vein, the anatomy, including the location of the orifi ce in relation to the ivc, direction from the ivc, length and diameter. results: the rav was detected in 79 (76%) of 104 patients. the rav formed a common trunk with an accessory hepatic vein in 8%. the rav joined in the right posterior wall of the ivc in 97% and in the left posterior in 3%. the direction of the rav from the ivc was posterior and rightward in 77%, posterior and leftward in 23%, caudal in 89% and cranial in 11%. the length and diameter averaged 3.8 mm and 1.7 mm, respectively. conclusion: mdct enabled identifying the rav and delineating its anatomy, including the position and relationship to the ivc in most patients. learning objectives: to illustrate the use of additional series following unenhanced ct performed for suspected renal colic, to both improve diagnostic certainty and confi rm other important diagnoses. background: unenhanced ct is widely accepted as the primary investigation for suspected renal colic. renal cell carcinoma and transitional cell carcinoma may both present with loin pain or haematuria and non-urological pathology may mimic renal colic. in a cohort of cases from our institution, we found that additional series were required in 12% of cases to improve diagnostic certainty. to our knowledge, a review of this subject has not been published in the literature. imaging findings: from our cohort of unenhanced ct scans, we illustrate how additional series clarify an uncertain diagnosis. prone scanning can distinguish a bladder calculus from a calculus at the uretero-vesical junction. ct urography may differentiate a phlebolith from a ureteric calculus. parenchymal contrast enhancement can confi rm the diagnosis of renal or urothelial malignancy as well as characterize incidental complex renal cysts. contrast enhancement may also provide additional important diagnostic information in a range of non-urological pathologies. conclusion: additional series were required in 12% of cases following unenhanced ct for suspected renal colic to improve diagnostic certainty and confi rm other important diagnoses such as urological malignancy and non-urological pathology, both of which can mimic the presentation of renal colic. genitourinary tract disease in the emergency room: a pictorial review d. learning objectives: to review imaging fi ndings of genitourinary pathology in the emergency room in a third level hospital according to available diagnostic imaging methods (ultrasound, computed tomography, intravenous urography and interventional radiology). background: patients with genitourinary disease represent an important volume of the total number of consultations in emergency services and, therefore, in the daily work of the radiologist on call. the more frequent reasons for consultation in these patients include lumbar or genital pain, febrile syndrome, hematuria, anury or oligoanury, acute renal insuffi ciency and trauma, among others. during the last 18 months (january 2005-june 2006), over 6500 emergency sonography and 4300 ct exams were performed at our center. genitourinary pathology was involved in approximately 20% of these examinations, either suspected or not. the spectrum of fi ndings in these conditions has been reviewed during this period. imaging findings: the detected pathology was classifi ed, fundamentally, in infectious/infl ammatory conditions, obstructive disorders, trauma and complications associated with renal transplantation or other interventional or surgical procedures. imaging techniques were mainly ultrasonography and ct. intravenous urography was less frequently used. interventional radiology had also a therapeutic role in selected cases. the radiologist must be aware of the wide variety and high prevalence of emergency genitourinary pathology and its imaging fi ndings according to the available imaging techniques. he also must be aware of the possibilities of interventional radiology as a therapeutic approach in selected patients. (100%) with hr-t2wi. the overall accuracy was (74%) by t2wi mri and (79%) by hr-t2wi (p=0.001). as regards to lymph node staging, t2wi and hr-t2wi had equal accuracy (sensitivity 85.7%, specifi city 97% and overall accuracy 93%). conclusion: hr-t2wi is only slightly more accurate than t2wi in overall local staging (p=0.003) and has equal accuracy in lymph node staging. in invasive stages, however, hr-t2wi is signifi cantly more accurate (p < 0.001). value of multidetector ct in preoperative assessment of ureteropelvic junction obstruction a. mishra, j.n. bhaktarahalli; new dehli/ in (dranujmish@yahoo.com) learning objectives: to assess the role of multidetector computed tomography (mdct) in the evaluation of crossing renal vessel (crv) as the cause for ureteropelvic junction (upj) obstruction and to describe its technique. to outline its advantages over color doppler imaging and digital subtraction angiography (dsa). background: an accessory renal artery crosses the upj in only 11-39% of patients with upj obstruction. crv are usually located anterior to the upj and its preoperative identifi cation is of utmost signifi cance as it changes the surgical management. in this exhibit, we describe the usefulness of mdct and its advantages over color doppler imaging and catheter angiography. procedure details: mdct was done on 16-row mdct scanner. a plain scan was performed with a 10 mm. collimation through the kidneys to identify the renal poles and aortic bifurcation. 40 mg of injection furosemide was injected intravenously as a diuretic. 8-10 minutes later, a helical ct scan was performed from the level of the upper pole of the left kidney till the aortic bifurcation with an intravenous injection of 80 cc of injection iohexol (350 mg iodine/ml) at a rate of 4 ml/second with a scanning delay of 15-20 seconds, a collimation of 0.625 mm, table speed of 11 mm/sec and tube rotation period of 0.7 seconds during a single breath-hold. curved multiplanar reconstruction, maximum-intensity projection and volume rendering algorithms were applied. color doppler imaging and dsa were also performed for all the patients. conclusion: mdct angiography was superior to color doppler and dsa and showed 100% accuracy in detecting crv and establishing it as the cause for upj obstruction as confi rmed at surgery. complications conclusion: imaging techniques are useful in monitoring the placement of a ureteral stent, as they can demonstrate eventual associated complications, thereby allowing quicker and effective diagnosis, with subsequent reduction of the morbidity. purpose: ureteric calculi are the main consideration in the majority of patients presenting with acute fl ank pain. unenhanced spiral ct has become the imaging modality of choice in these patients not only because of its unrivalled ability to identify ureteric stones, but also because of its potential to identify other renal and non-renal pathologies. we report our experience with the use of ct kub and the clinical incidence of non-calculus renal and non-renal pathology in patients presenting with acute fl ank pain with a provisional clinical diagnosis of ureteric colic. we retrospectively reviewed 242 patients who underwent ct kub from jan 2005 to dec 2005 for suspected renal colic. we excluded patients with a known renal disease or previously diagnosed renal stones. results: 178 patients were included in the study after applying the exclusion criteria. incidence of stone disease identifi ed by ct kub was 45%. the majority of stones (44%) were found in the distal ureter and vuj. stone size of ≥5 mm was found in 34% of cases. secondary signs were reported in nearly 65% of patients with stone disease. alternative pathologies were identifi ed in 27 cases (15%). conclusion: unenhanced ct is an excellent modality for imaging patients with acute fl ank pain. non-calculus renal and non-renal pathologies can often be identifi ed on unenhanced low-dose ct performed for suspected renal colic. a careful search for these alternative diagnoses should be made in all cases and particularly when the examination does not identify a ureteric calculus. imaging in urogenital emergencies n.a. al-nakshabandi; riyadh/sa (nizarn@ksu.edu.sa) learning objectives: 1) familiarize the audience with the most urgent radiological emergencies in the urogenital system. 2) learn the most appropriate approach for these emergencies and how to reach an appropriate differential diagnosis. 3) learn the use of the appropriate modality. 4) identify the radiological signs associated with each of these emergencies. background: the use of imaging in urological emergencies is important to learn and manage. careful attention to the urogenital involvement in emergency conditions is a very essential step in the radiological evaluation of these conditions imaging findings: flank pain/ureteral colic is experienced by 2-3% of the population, with a 40-50% recurrence rate at 5 years. ct plays a valuable role in detecting the location of the stone and the presence of obstruction. urosepsis occurs secondary to pyelonephritis, cystitis, prostatitis, or any other cause of obstruction. ultrasound plays a valuable role in its diagnosis and intervention by placing a percutaneous nephrostomy catheter. ultrasound is utilized in acute renal failure to assess' renal size, parenchymal thickness and presence of obstruction. ct with or with out cystogram is optimal for blunt abdominal trauma when kidney, ureter or bladder injury is suspected. retrograde urethrogram can be done when a urethral injury is suspected. ultrasound can easily differentiate orchitis from testicular torsion. it is also valuable in confi rming the diagnosis of testicular rupture. the use of imaging in urogenital emergencies is of outmost importance. examples of imaging and management will be given. the role of ultrasound in infl ammatory bowel disease n. bharwani, n. stephens, j. pilcher; london/uk learning objectives: 1. discussion of the role of bowel ultrasound in infl ammatory bowel disease. 2. pictorial demonstration of typical ultrasound fi ndings. 3. advantages and disadvantages of ultrasound in ibd compared with other imaging modalities. background: high-resolution ultrasound has recently become a recognised tool in the evaluation of infl ammatory bowel disease (ibd). with advances in ultrasound equipment and novel imaging techniques, this modality is increasingly being used to diagnose patients at initial presentation, assess disease activity, identify complications, and monitor response to therapy. imaging findings: this pictorial review will highlight the features seen in ibd on high-resolution ultrasound, both in and outside the bowel wall. we will outline the role of spectral doppler in assessing the mesenteric circulation and that of power doppler in the monitoring of patients. the latter half of the discussion will focus on more recent techniques beginning to be employed in the assessment of ibd. this includes the application of microbubble contrast agents using both power doppler and harmonic imaging modes to try and measure mural infl ammation, and the role of non-absorbable, anechoic, oral contrast agents in distinguishing small-bowel strictures. barium studies, ct, and mri correlation will be provided, where appropriate. conclusion: high-resolution ultrasound is an evolving modality in the management of infl ammatory bowel disease. it can effectively be used to evaluate patients with clinically suspected ibd at fi rst presentation, and also to monitor known patients with regard to disease activity, luminal and mesenteric complications. including metachronous adenomatous polyp and cancer and recurred/metastatic cancer. representative cases for each category were selected and are presented with optical colonoscopic correlation. imaging findings: a colonic anastomosis typically presents as a web-like structure with a smooth and sharp border. distortion of the normal shape of an anastomotic ring can be caused by both insignifi cant lesions and signifi cant lesions. polypoid lesions at anastomotic ring are typically insignifi cant with protruded suture materials and suture granulomas being the most common etiology. irregularities of the anastomotic ring such as irregular depression or elevation may represent anastomotic recurrences. metachronous lesions have the usually morphology of a polyp or a mass at ctc elsewhere in the colon. ctc clearly shows perianastomotic recurrence or distant metastasis. peritoneal metastatic implant may also be detected at endoluminal fl y-through of ctc by noting an extrinsic compression by the lesion. conclusion: ctc is a benefi cial and noninvasive surveillance method for post-surgical colorectal cancer. knowledge of and familiarity with the normal and abnormal post-surgical fi ndings at ctc will help increase the role of ctc in post-surgical follow-up of colorectal cancer. colonic angiodysplasia has been increasingly recognized as a common source of acute and chronic bleeding in elderly patients, accounting for up to 50% of cases of obscure gastrointestinal hemorrhage. currently, imaging assesment of gastrointestinal vascular lesions relies on invasive procedures such as endoscopy or angiography, but mdct has gained acceptance as a minimally invasive technique for imaging of the vascular system. procedure details: we retrospectively reviewed 27 cases of colonic angiodysplasia diagnosed by mdct during past 5 years. in 24 cases, the examination was performed due to acute or chronic recurrent bleeding when colonoscopy failed to show the cause. in 3 cases, colonic angiodysplasia was an incidental fi nding in abdominal vascular studies. the mdct fi ndings include accumulation of ectatic and tortuous vessels within the colonic wall, early fi lling veins due to arterio-venous-type malformation development, enlarged arteries of the target area, and intraluminal contrast material extravastion in cases of active bleeding. conclusion: mdct is a useful tool for the diagnosis of colonic angiodysplasia especially in elderly patients with lower gi bleeeding when colonoscopy fails to establish the diagnosis, avoiding the need of invasive catheter angiography. impact of ct colonography with and without removal of diminutive polyps on colonoscopy demand a. laghi 1 , c. hassan 2 , r. ferrari 1 , f. purpose: to evaluate different combinations of magnetic resonance (mr) colonographic sequences and intraluminal contrast agents. methods and materials: 103 polyps, size from 3 to 10 mm, were created on the porcine colon. forty-nine polyps were 5 mm or smaller and 54 were larger than 5 mm. mr colonography was performed with the three-dimensional t1-high resolution isotropic volume excitation (thrive) or multislice two-dimensional balanced fast fi eld echo (bffe), using either the air enema or water-gd. enema. we evaluated the presence or absence of each polyp in the mrc compared to the simulated polyps. the diagnostic performance of each mr sequence-contrast agent combination was assessed for detecting polyps. to compare air and water-gd. enemas, polyp conspicuity was evaluated using a four-point scale under bffe sequence. the results were analyzed using wilcoxon's signed ranks test. the bffe using the water-gd. enema showed greater diagnostic performance. it had a sensitivity of 95.9%, a specifi city of 100%, a positive predictive value (ppv) of 100%, and a negative predictive value (npv) of 81.8% for polyps of 5 mm or smaller; and a sensitivity, specifi city, ppv, and npv of 100% for polyps larger than 5 mm. the bffe using the water-gd. enema was also signifi cantly better at enhancing polyp conspicuity compared to the air enema. conclusion: mrc with bffe using a water-gd. enema provided the greater conspicuity, with excellent diagnostic performance. role of fdg-pet/ct in the local staging of colorectal cancer e. selva, p.p. mainenti, g. avitabile, l. camera, g. storto, l. pace, m. salvatore; napoli/it purpose: to evaluate fdg-pet/ct as a diagnostic tool in the assessment of primary tumor extent (t) and lymph node metastases (n) in patients with colorectal cancer. methods and materials: twenty patients with diagnosis of colorectal cancer underwent fdg-pet/ct before surgery. t and n parameters were evaluated on images. < t2 lesions were defi ned as tumours confi ned to the bowel wall in absence of extra parietal radio-tracer uptake; t3 lesions as tumours with spiculated outer contour or with rounded or nodular advancing edges showing radio-tracer uptake; t4 lesions as tumours infi ltrating into adjacent organs in which radio-tracer uptake was present; n1 as fdg uptake in a cluster of three nodes each less than 1 cm in diameter or in a single node measuring at least 1 cm; n2 as fdg uptake in more than three nodes regardless of their size. t and n pet/ct staging was compared to histopathology. results: 20 adenocarcinomas were identifi ed: 1 lesion was classifi ed as t1, 3 as t2, 16 as t3; lymph-nodal involvement was present in 9 cases (5 n1 and 4 n2). all lesions were correctly identifi ed and localized on pet/ct images. fdg-pet/ct correctly identifi ed t stage in 18 of 20 (90%) patients (3/4 < t2 and 15/16 t3). n stage was appropriately determined in 17 of 20 (85%) patients (9/11 n0, 4/5 n1 and 4/4 n2). conclusion: fdg-pet/ct is a useful diagnostic tool in evaluating t and n parameters in patients with colorectal cancer despite the absence of iv contrast medium on ct scan. why did i miss appendicitis on abdominal ct? a pictorial review of appendix pathology on ct m.a. hanif, r. shukla, r. young; bristol/uk (asadhanif@doctors.net.uk) learning objectives: appendicitis is one of the most common causes for an acute abdomen, which can be missed on ct abdomen by the resident on call. we aim to present this poster as a pictorial review of different appendiceal pathologies with atypical presentations. this will help us analyse the factors leading to false-negative results on ct. background: appendicitis is a great mimicker of disease, not just clinically but also radiologically -especially in the adult patient. the diagnosis of acute appendicitis on computed tomography (ct) of the abdomen can prove to be diffi cult at times. variations in the position, length and location of the vermiform appendix along with the differences in the amount of intra-abdominal fat and clinical presentations contribute to this seemingly simple diagnostic dilemma. criteria for the diagnosis of appendicitis on ct are well documented in the literature. learning objectives: to describe acquisition parameters of ct-colonography protocols using different scanners generations moving from single slice spiral ct to the 64-mdct. background: nowadays, the "panorama" of technical approaches for ctc is expanding offering a wide spectrum of different possibilities. as technology continues to advance, there will be a continuing need to reassess the relative tradeoffs between scan width, image noise, patient dose, image artefacts, breath-hold times, and the number of reconstructed images to be viewed and archived. procedure details: we will discuss the relationship between collimation, tube current settings, patient dose exposure and accuracy in polyp detection of various ctc protocols valid for different scanner generations. we will offer some practical guidelines for ctc technique based on evidences of literature and on our personal experience of more than 800 ctc examinations performed on different scanners generation including a 64-mdct (vct; ge). conclusion: a single scanning protocol with identical parameters for all scanners and patients cannot be recommended due to technological differences as well as different clinical indications to ctc. what is possible is to offer general guidelines according to the consensus statement on ctc. collimation should not be larger than 5 mm for ssct and no larger than 3 mm for mdct. with the advent of 64slice mdct, sub-millimeter collimation will be mandatory, although clinical benefi ts are still unclear. was obtained before and 60 seconds after intravenous administration of gd-chelate. mr images were evaluated in conference by two observers by seeking for bowel abnormalities and were correlated with conventional colonoscopy (cc) in all cases and with surgery in 7/18 patients. results: mrc could be successfully performed in all cases, whereas cc was incomplete in 5/18 patients. mrc correctly defi ned bowel wall thickening, stenosis and extension of the infl amed colon in 4/5 patients with ulcerative colitis. in 10/12 patients with crohn disease, involvement of both large and small bowel was demonstrated; perianal abscesses (n=2) and fi stulas (n=2) were also identifi ed. in one remaining case, no abnormality was found at mrc and fi nal histological diagnosis was not surely diagnostic for ibd. conclusion: mrc with fecal tagging technique is a promising, minimally invasive technique for evaluation of the bowel in patients with suspected ibd. it can be used for the assessment of disease's extension, especially for those who cannot have cc due to severe pain and fecal residua. abnormal masses of the right iliac fossa: spectrum of imaging fi ndings a.e. mahfouz, h. sherif, n. morad; doha/qa (mahfouzae@yahoo.com) learning objectives: to learn the differential diagnosis of abnormal masses of the right iliac fossa and to illustrate the peculiar imaging features of each of these different masses with histopathological correlation. background: diagnosis of patients with symptoms related to the right iliac fossa may be diffi cult due to the wide variety of pathological processes which may involve the right iliac fossa. imaging may be helpful in diagnosis. imaging findings: abnormal masses of the right iliac fossa illustrated in this educational exhibit include appendicitis, appendicular abscess, mucinous adenocarcinoma of the appendix, cecal carcinoma, typhlitis, omental strangulation, infl ammatory bowel disease, ileocecal tuberculosis, and ileocolic intussusception as well as abnormalitis outside the gastrointestinal tract, which may be considered in the differential diagnosis. peculiar imaging features on different imaging modalities including ultrasonography, multidetector ct, scintigraphy, barium studies, and mr imaging with their pathological correlation will be presented. conclusion: modern imaging modalities are helpful for the correct diagnosis of of patients with symptoms related to the right iliac fossa. the purpose: preoperative radiotherapy with or without chemotherapy in the management of patients with locally advanced rectal cancer allows to decrease tumor size and stage, improves sphincter preservation and the ability to perform a curative resection. the aim of this study was the estimation of the role of mdct-colonography in the pre-surgical staging and restaging of rectal cancer, treated with pre-operative neoadjuvant therapy. methods and materials: twenty-eight selected patients with histologically proven rectal cancer with initial stage t3/4, n+ and m0 were studied. all patients underwent mdct-colonography with use of a standard protocol for preoperative staging before and 2-4 weeks after radio/radiochemotherapy. pre-operative tnm staging was correlated with surgical/histological fi ndings. results: histopathological evaluation of the resected tumor revealed complete response in one patient, partial response in 18 and stable disease in 9. reduction in tumors size was signifi cantly greater in responders than in non-responders and indicated a good reaction to therapy. 67% patients showed tumor downstaging and only 7% nodal downstaging after tnm restaging. mdct correctly staged t in 22 (78.5%) cases, t was overstaged in 6 (21.5%) due to peritumoral post-therapeutic fi brosis. mdct correctly staged n in 21 (75%), overstaged in 5 (17.8%) and understaged in 2 (7.2%) cases. conclusion: mdct-colonography is an accurate procedure for pre-operative staging and restaging tnm classifi cation in patients with rectal cancer treated with neoadjuvant therapy and can be used for treatment planning. the greatest diffi culty was distinction between t2 and t3 stage due to peritumoral post-therapeutic fi brosis. all patients underwent chemoradiation therapy (crt). dwi was performed using a 1.5 t whole body scanner equipped with a phased-array body coil. a single-shot spin-echo type of echo-planar sequence that provided diffusion weighting in the direction of slice selection was used to obtain dw images. the corresponding bvalue to the diffusion sensitizing gradients were b=1000 s/mm 2 . we evaluated the dw images measuring the adc value of the tumor and compared it with the effect of crt. the therapeutic effect was assessed according to the who criteria, using contrast-enhanced mdct and esophagography 4 weeks after the treatment. results: eight patients were responder and 5 were non-responder. all tumors were detected by dwi (accuracy 100%). the mean adc value of the tumor was signifi cantly lower than that of the normal esophagus (1.004 x 10 -3 mm 2 /s vs 1.756 x 10 -3 mm 2 /s, p < 0.0001). the mean adc value of the responder group was signifi cantly higher than that of non-responder group (1.187 x 10 -3 mm 2 /s vs 0.830 x 10 -3 mm 2 /s, p=0.0054). conclusion: this non-invasive modality could be a valid clinical diagnostic modality to predict the outcome of crt of advanced esophageal cancer. risk purpose: the aim of the study was to evaluate the role of doppler ultrasonography (us) of the portal vein in assessing the risk of esophageal variceal bleeding in patients with liver cirrhosis. methods and materials: transabdominal doppler us and endoscopy were performed in 38 patients (26 male, 12 female, mean age 54.8 years) with liver cirrhosis and esophageal varices. the variceal size and the presence of red signs were determined by endoscopy. following us parameters of the portal vein were recorded: diameter and cross-sectional area, blood fl ow velocity and blood fl ow volume, perfusion pressure gradient (ppg), and congestion index (ci). child-pugh score of liver function was also determined. the us parameters were compared to the endoscopic signs of esophageal bleeding risk. results: values of portal diameter, cross-sectional area, blood fl ow volume and ci were signifi cantly higher, while ppg was lower in patients with, than in patients without variceal red signs. only diameter, cross-sectional area, and blood fl ow volume were signifi cantly different among groups of patients with different variceal sizes. the blood fl ow velocity did not depend on the presence of red signs and variceal size. in addition, recorded us parameters did not reach level of significance between groups of patients with different child-pugh score. the sensitivities, specifi cities, and areas under roc curves of the analyzed us parameters were 62.5-82%, 47.2-79.8%, and 0.79-0.89, respectively. conclusion: according to our results, transabdominal doppler us might be of value in non-invasive assessment of the risk of esophageal variceal bleeding in patients with liver cirrhosis. a digital cineradiography with 6 frames/second acquisition was performed in all patients using bolus of 30 ml of liquid (60% weight/volume) barium. in 10 patients standing in the left posterior oblique position and prone in the right posterior oblique position, the oesophagus and oesophagogastric junction were also examined. the water siphon test was performed at the end of the procedure. results: in all patients, the evaluation of oesophageal motility disorder was possible. in 18 of them, the grade of the disorder was high and barium retention in the oesophagus was also detected. owing to the stagnation of liquid barium in the terminal oesophagus, the evaluation of oesophagogastric junction was possible only in 10 patients. of these patients, 7 presented a hiatus hernia and 8 a gastrooesophageal refl ux. conclusion: digital cineradiography is a suitable technique for evaluating the functional abnormalities of the oesophagus in patients affected by sclerodermia. learning objectives: to present a pictorial review of the radiological appearances of achalasia and pseudoachalasia with emphasis on endoscopic correlation. background: barium swallow remains a valuable imaging modality in patients presenting with dysphagia. pathologies such as achalasia and pseudoachalasia can be diffi cult to distinguish on barium swallow as typical fi ndings may not always be apparent. recognising the various radiographic appearances by the radiologist is critical for prompt and accurate patient management. imaging findings: we present a case series of achalasia and pseudoachalasia on barium swallow encountered at our institution. we emphasise the differences between the two pathologies both on imaging and on text as a learning experience. we also provide a review of the existing literature with reference to our experience. conclusion: barium swallow is an established method for evaluating patients with dysphagia. however achalasia and pseudoachalasia still remain diffi cult to distinguish; so awareness of the potential pitfalls with endoscopic correlation in all cases is emphasised to avoid radiological misdiagnosis. late evaluation of the swallowing function in patients with maxillofacial gunshot injuries by multimodality radiologic and complementary methods z.u. coskun 1 , s. ozturk 2 ; 1 bilkent, ankara/tr, 2 etlik, ankara/tr (unsalcoskun@yahoo.com) purpose: maxillofacial (mf) gunshot wounds having a tract between the mouth fl oor and the naso-orbital region may result in long-term swallowing disorders. here, we aimed to show late functional outcomes of the primary surgical treatments by using objective radiologic and complementary studies. methods and materials: 20 patients were included in the study. the mean age was 21±3. free osteocutaneous fi bula fl aps, iliac or calvarial bone grafts were used with fasciacutaneous fl aps. dento-palatal restorations were accomplished with dental and prostetic obturator implants. functional outcomes were assessed by: videofl uoroscopy, cine-mri, submental usg, fiberoptic endoscopic swallowing study (fees), functional emg. the results were compared to the control group (n:10) statistically. videofl uoroscopic studies showed pooling in vallecula and pyriform sinuses (n:16), delayed pharyngeal (n:12) and oral transit times (n:12), spilling out due to oral incompetence (n:10), nasal regurgitation (n:8), sublingual pooling (n:4), multiple swallowing action (n:3), and aspiration (n:2). cine-mri revealed reduced laryngeal elevation (15.4 mm) and epiglottic angle (10.5 o ). discordance and impaired oral fl oor muscles were observed. submental usg showed insuffi cient tongue movement resulting in bolus formation and transit impairment (n:8), restricted hyoid elevation (n:12), and submental muscle defects (n:12). fees revealed pooling in vallecula and pyriform sinuses (n:16), delayed epiglot closure (n:12) and impaired swallowing apnea (n:2). functional emg showed lower amplitude of submental and pharyngeal constrictors (n:12). conclusion: clinically, knowing the radiopathologic fi ndings in such patients may help the clinician in determining an algorithm to manage the secondary deformities as well as adding new surgical techniques such as replacement of submental muscles by functional muscle fl aps during primary surgery. 134 patients were treated with surgery alone and 84 patients (29 with 5x5 gy and 55 with 60 gy) were treated with preoperative pelvic radiotherapy. a complete postoperative histopathological examination was used as the gold standard. results: in pathology 73 of 218 (33%) tumors were classifi ed as t0-t2, and 145 (67%) were classifi ed as t3-t4. trus had an accuracy of 90% in detecting penetration of the rectal wall in the 134 patients treated with surgery alone. the accuracy of trus in patients treated with 5x5 gy was 82.3% (ns), and in patients treated with 60 gy, the accuracy was 55.2 % (p < 0.001). a high sensitivity was noted in all groups; however, the specifi city of trus rapidly decreased to zero with increased pelvic radiotherapy intensity, as the false-positives increased because of tumour shrinkage. this change in accuracy was not seen to the same extent with regard to lymph node metastases. conclusion: trus has a high accuracy in patients treated with surgery alone. the t-staging accuracy of trus is low in patients receiving high-dose pelvic radiotherapy due to down staging. purpose: the purpose of this study is to evaluate perfusion ct in assessing pathological features of rectal cancer before surgery. methods and materials: forty consecutive patients (23 men, 17 women; median age 62.8 years) with rectal cancer underwent perfusion ct, using the commercially available ct perfusion 3 software (ge medical systems, milwaukee, wi). all patients were followed by surgery, and we retrospectively investigated the correlations between perfusion parameters and pathological features (wall invasion, histological differentiation, lymph node metastasis, dukes' classifi cation). statistical analysis was performed with mann-whitney u test for comparison of two data sets, and kruskal-wallis test for comparison of multiple data sets. p < 0.05 was considered to indicate a statistically signifi cant difference. results: there were no correlations between perfusion parameters and wall invasion. well-differentiated tumors showed signifi cantly higher blood fl ow than the moderately-differentiated tumors (p = 0.03). there was a signifi cant tendency for the tumor with low blood fl ow, low blood volume or long mean transit time to show lymph node metastasis (p = 0.006, 0.01, 0.001, respectively). and there was a signifi cant correlation between dukes' classifi cation and blood fl ow (p < 0.0001), blood volume (p = 0.002), mean transit time (p = 0.001), and permeability surface area product (p = 0.004). in the near future, perfusion ct may help to assess pathological features of rectal cancer before surgery. within the node versus the size of the total node, categorized as 50%. this ratio was objectively calculated (ratioa) by the long and short axis diameter measurements of both the area of white region within the node and the total node. regions of interest (roi) were used to measure the signal intensity (si) within muscle (simuscle), total node (sitn), white (siwhite) and dark (sidark) region within the node. these measurements were used to calculate the ratios: siwhite/sidark and sitn/simuscle. a receiver operating characteristic (roc) analysis was performed. results: a lesion-by-lesion analysis of 228 lymph nodes was feasible. the area under the roc curve (auc) of border, short and long axis of the total node were respectively 0.66, 0.65 and 0.72. the auc for the estimated percentage and measured ratioa of white region within the node were 0.93 and 0.95, respectively. the roi could accurately be positioned in 207 lymph nodes. the auc of the ratios: siwhite/sidark and sitn/simuscle were respectively 0.76 and 0.90. the estimated ratio of white area within the node and the measured ra-tioa were very accurate for distinguishing between malignant and benign nodes. pre-surgical evaluation with positron emission tomography (pet) and magnetic resonance imaging (mri) of patients with locally advanced rectal cancer treated with neo-adjuvant radio-chemotherapy l. balestreri, e. borsatti, r. talamini, m. cimitan, s. morassut; aviano/it (lbalestreri@cro.it) purpose: to compare the diagnostic performance of pet and mri in correctly restage patients with advanced rectal cancer treated with neo-adjuvant radiochemotherapy before surgery. twenty-three patients with advanced rectal cancer (t3-t4) were studied with pet and mri before and after 5-fl uorouracil or raltitrexed-based chemotherapy and 45-50 gy of radiation therapy. pre-surgical scanning was performed 6 to 8 weeks after the end of the chemoradiation; the results were compared to the surgical specimen. particularly for pet, tumour response was considered evaluating standardized uptake value (suv) percentage decrease related to tumour regression grading (trg) at pathology. for mri, tumour response was considered evaluating: (1) tumour extension and size according to the tnm system. (2) circumferential resection margin (crm) measurement assessing the distance between extramural tumour and mesorectal fascia. results: strong correlation (spearman correlation coeffi cient r = -0.6) was found in between suv decrease > 80% and trg values of 1 and 2 (no residual disease or microscopic active disease). strong correlation (specifi city 100%, sensitivity 71%) was found between crm measurement with mri and on the surgical specimen. no statistically signifi cant correlation was found between t measurement with mri and on the surgical specimen. while pet provides reliable metabolic information about tumour response to therapy, mri provides reliable measurement of crm. both modalities must be performed to correctly restage patients before surgery. background: although adenocarcinoma is the most frequently encountered rectal tumor, familiarity with the cross-sectional imaging features of less common anorectal tumors as well as of their differential diagnosis is important because their prognosis and treatment are different. in this exhibit, we will describe the ct and mri features of such lesions based on a series of 30 patients treated in our department since 2003 with a pathologic correlation. procedure details: mucinous anorectal adenocarcinomas are characterised by a markedly hyperintense content on t2-weighted images, an enhancing solid component within the mass and their highly infi ltrative behaviour. villous tumors are large masses fi lling the rectal lumen and displaying frondlike projections. anorectal stromal tumors are large, well-marginated masses expanding the rectal wall and lack perirectal adenopathy. lymphomas display marked concentric wall thickening engulfi ng the rectum, with luminal restriction but minor obstruction and adenopathies. linitis and rectal metastases display a circumferential thickening of the rectal wall over a long segment. other uncommon tumors include carcinoid tumor, melanoma, anal condyloma. differential diagnosis include crohn disease, diffuse rectal angiomatosis, changes after radiotherapy, rectal endometriosis, diverticulitis. identifying key specifi c ct and mr imaging features can be helpful in suggesting a diagnosis. mri is a modality of choice to evaluate unusual anorectal neoplasms. high to review the current role of mri in the evaluation of these lesions. background: developmental cysts are the most common retrorectal cystic lesions in adults. they are classifi ed as epidermoid cysts, dermoid cysts, enteric cysts according to their histopathologic features. they may present with symptoms or with a complication such as infection or malignant degeneration. their differential diagnosis we review the mr imaging fi ndings with pathologic correlation of presacral cystic masses based on a series of 25 patients treated in our department. imaging findings: developmental cysts, among which tailgut cysts are the most frequent are characterized by well-defi ned, multilocular cysts with "daughter cysts". their wall is usually thin unless they are complicated. an enhancing wall with peri cystic infl ammation suggests infl ammation and additional internal enhancement evokes malignant degeneration. their signal intensity is variable, usually homogeneous, either isointense to muscle on t1-weighted images and isointense to fat on t2-weighted images or hyperintense on t1/hyperintense on t2 depending on their content. differential diagnosis includes anterior sacral meningocele, recurrence of mucinous rectal adenocarcinoma, cystic lymphangioma, necrotic sacral chordoma or leiomyoma, pyogenic abscess, schwannoma, peritoneal pseudocyst. conclusion: most lesions of the retrorectal space are developmental cysts but the differential diagnosis must be known. knowledge of the key imaging features of the retrorectal cystic lesions may help suggest the diagnosis and the information needed to plan treatment. preoperative n staging of rectal cancer evaluating from morphological feature using magnetic resonance imaging t. sazuka, s. okazumi, k. shuto, t. aoyagi, h. makino, r. mochizuki, t. ochiai, n. yanagawa; chiba/jp purpose: the purpose of this study is to evaluate the accuracy of magnetic resonance imaging (mri) in n staging of rectal cancer and to compare histological fi ndings. methods and materials: eighty-six patients of rectal cancer were enrolled in this study. all of the patients underwent surgery and proved histologically. prior to treatment, mri was performed with t2-weighted fast spin echo sequences using a 1.5 t whole body scanner equipped with a phased-array body coil. following fi lling the rectum with air of 200-250 ml from a placed tube, images were acquired with a slice thickness of 8 mm. every reconstruct axial, coronal and sagittal images of each node was evaluated. we classifi ed lymph nodes over 5 mm by 3 morphological features as follows: solitary/ confl uent, margin clear/ spicular, shaped fl at/ round. and we assessed those features in comparison with histological fi ndings. results: a total of 313 nodules were evaluated. all of confl uent nodules (n=11) were histologically metastatic (ppv 100%, specifi city 100%). when we defi ne metastatic node as any features of confl uent nodule, irregular margin or round shaped, the sensitivity was 91% and the specifi city 91%, ppv 78% and npv 97% in comparison with histological fi ndings. conclusion: this diagnostic method classifying by morphological features is noninvasive and may be valid with an acceptable detectability by no means inferior to enhanced or radiological modality. dynamic magnetic resonance imaging (mri) evaluation of levator ani muscle (lam) in patients with wall prolapse and intussusception pathologies of the rectum a. salzano, v. nocera, g. cavallo, e. montemarano, p. de feo, a. nunziata; naples/it (tonikus@libero.it) learning objectives: to describe mri dynamic appearance of lam in patients with rectal wall prolapse and intussusception, outlining the role and the advantages of dynamic mri for the assessment of anatomic and functional study of lam and evacuation disorders. background: dynamic mri allows to evaluate morphology and pathomorphologic changes of the lam during defecation. defecography well assesses rectal prolapses, but does not provide imaging of muscles of pelvic fl oor except indirect signs. dynamic mri provides a whole and direct visualization both anatomical and functional of lam and rectal prolapses. we illustrate a study of 23 female subjects (mean age of 61 years; range 47-74 years) previously investigated by defecography in order to obstructed evacuation. imaging findings: dynamic mri was carried out in different dynamic phases of pelvic fl oor, in breathe hold using t2-weighted scans. we diagnosed 16 rectal wall prolapses and 8 intussusceptions; all patients had rectocele and perineal descent syndrome. lam had reducted thickness in 16 cases and alterated signal in 4 cases. levator hiatus was large in 19 cases in the coronal plane with a typical shape of large cone. we focused a relationship between hiatal area, movements of rectal walls and descent of pelvic fl oor. conclusion: dynamic mri is considered a novel noninvasive imaging method of investigation in comparison to defecography, to understand the dynamics of lam and the pelvic fl oor descent disorders. mri provides better the relationship of rectal intussusception and wall prolapse related to pelvic organ mobility and dynamic shape changes of lam. diagnosis and follow-up of anoperineal fi stuals with phased-array mri: a pictorial review f. gonzález, g. blanco, c. juanco, n. valle, m. lopez, m. silvan; santander/es learning objectives: to describe the anatomy and imaging features of acquired anorectal fi stulas. to identify the mri fi ndings in the various types of anorectal fi stulas. to review the role of mri in the assessment of acquired anorectal fi stulas. background: the most commonly encountered and known anorectal fi stulas are anorectoperineal fi stulas occuring in crohns disease. however, there is a variety of less common fi stulas involving the anorectum. their causes include infection, infl ammation, neoplasms, trauma and iatrogenic injury. pelvic mri assessment has proved useful in the evaluation of fi stulas and has become an important part of diagnostic work-up before proper case management. imaging findings: we illustrate the mr fi ndings in fi stulas involving the rectum or anal canal or ileal or colonic pouch (in case of previous surgery) and the vagina, uterus, prostate, urethra, bladder, and ileum. we also present the features of complex anoperineal fi stulas. the current role of mri is discussed. we emphasize the role of mri in the follow-up after medical or surgical treatment. conclusion: phased-array pelvic mri is an accurate technique for the identifi cation of acquired anorectal fi stulas and their complications. mri exam is a noninvasive diagnosis method that allows us an accurate diagnosis and follow-up in patients with anoperineal fi stulas. imaging findings: small-bowel lymphomas are presented in wide spectrum of appearances included aneurismal dilatation, intra luminal polypoidal mass, mesenteric mass with irregular infi ltrating borders causing thickening of the walls and narrowing of the lumen and it may present just as diffuse circumferential mural thickening of the bowel walls with irregular narrowed lumen. mr sbft offers the advantage of excellent soft-tissue contrast and multiplanar imaging capabilities and absence of ionizing radiation over other modalities in studying small bowel lymphoma. over a 4-year period, we reviewed 260 mr sbft examinations for evidence of small bowel lymphoma. in all, 14 cases were identifi ed and subsequently histologically confi rmed. we provide a detailed radiological review of the appearances of these tumors at mr sbft. conclusion: mr imaging of the small bowel has moved in the recent years and the knowledge of the typical mr sbft appearance of small bowel lymphoma may aid the radiologist to suggest the diagnosis. purpose: to evaluate using magnetic resonance the effi cacy of oral infl iximab therapy in perianal fi stulizing crohn´s disease patients. to compare clinical and mri fi ndings in these patients, using the perianal crohn´s disease activity index (pcdai) and magnetic resonance imaging-based score (mrs). to evaluate the effi cacy of mri in the diagnosis and follow-up of this pathology. methods and materials: patients with perianal fi stulas due to crohn´s disease were enrolled into a prospective study, and were evaluated with pelvic mr previous to treatment and after a long-term follow-up of 24 months, in order to observe the evolution of fi stulous pathology. we use a 1.5 t system (magnetom avanto siemens®) with a phased-array coil. we applied the mrs modifi ed from assche to the images obtained. the clinical response was evaluated with the pcdai described by irvine. results: twelve patients were included in our study. six (50%) achieved complete responses, verifi ed with both pcdai and mrs. five (41.6%) showed no changes in mrs with partial response in the pcdai and 1 (8.3%) showed no response in both mrs and pcdai. conclusion: oral infl iximab is an effective treatment for patients with perianal fi stulas due to crohn´s disease. mr is a good method for the diagnosis of the perianal crohn´s disease and for the follow-up and evaluation of the treatment of these patients. the differences of the results in clinical and mr scores may be due to the subjective index that are evaluated in pcdai and the ¨placebo¨effect of the treatment. is virtual enteroscopy an acceptable method for detecting peutz-jeghers poliposis in the small bowel? e. turupoli, g. tóth, k. szeidl, á. komezei, á. szilvássyné takács; budapest/hu (turupoli@freemail.hu) purpose: hamartomas are usually considered histologically benign, but in the case of peutz-jeghers patients, there are reports of malignant changes in the polyps. we tried to assess the usefulness of virtual enteroscopy for the assessment of peutz-jeghers polyposis in the small bowel. our goal was to reach a good distension in the small bowel by virtual enteroscopy. in 15 patients with known peutz-jeghers polyposis in the stomach and colon, ct virtual enteroscopy was performed. patients were examined with a 16-row ct scanner using the following parameters: slice 1 mm, with overlap scans, reconstruction interval 0.5 mm. 120 ml i.v. contrast agent was administered at a rate of 3 ml/s with a scan delay of 50 s. we evaluated mural thickening, mural enhancement, stenosis, praestenotic dilatation. the results of mdct enteroscopy were compared with selective enterography and surgery. selective enterography and surgery were considered the gold standard. results: good small bowel distension was obtained in 13 cases, and suffi cient in 2 cases. mdct virtual enteroscopy showed 45 i.v. contrast-enhancing polypoid lesions in 8 patients. thirty-three lesions were smaller than 10 mm and 12 were larger than 10 mm. two polyps caused intussusception. selective enterography showed 36 polyps smaller than 10 mm, and 12 larger than 10 mm. mdct virtual enteroscopy had an overall per-lesion sensitivity of 91.6% for lesions smaller than 10 mm, and 100% for lesions larger than 10 mm. conclusion: mdct virtual enteroscopy in peutz-jeghers syndrome showed a high sensitivity in detecting polyps smaller than 10 mm. coeliac disease -incidence and radiological fi ndings of associated malignancy e. delappe, c. cronin, c. meehan, c. roche, j. murphy; galway/ie purpose: enteropathic-associated t-cell and b-cell lymphomas are recognised associations of coeliac disease; however, the exact prevalence is unknown. the purpose of this study was to determine the prevalence of associated gastrointestinal lymphoma or other malignancy in patients with chronic gluten-sensitive enteropathy. we describe the radiological features and distribution of these malignancies in our subject population. we retrospectively reviewed the radiological and pathological fi ndings of gastrointestinal tract malignancies in a total of 363 patients with coeliac disease referred to our institution over a fi ve-year period. assessment included disease presentation, location (duodenal, jejunum, ileum), stage and radiological features (wall thickening, abnormal mucosal pattern, local nodal involvement). we also reviewed the radiological fi ndings and prevalence of extragastrointestinal malignancies. results: a total of 14 new cancers were diagnosed in the total population sample (3.9%). of these, 5 had a diagnosis of oesophageal cancer (1.4%) and 3 (0.8%) had lymphomatous involvement of the gastrointestinal tract. there was a signifi cant increased risk of both oesophageal cancer and gastrointestinal lymphoma compared to that of an age-matched population (p < 0.05). we identifi ed a number of other gastrointestinal and extra-gastrointestinal malignancies in the sampled group including duodenal, colon, bladder, lung, ovarian, and carcinoid with no statistically signifi cant increased risk. conclusion: although coeliac disease has been shown to have an association with gastrointestinal lymphoma, other gastrointestinal malignancies such as oesophageal tumours also occur increasingly in such patients. this possibility must be considered when patients with known coeliac disease present with gastrointestinalrelated symptoms, which are atypical for their primary condition. duodenal and paraduodenal lesions: imaging fi ndings g. pekindil; manisa/tr (pekindilg@yahoo.com) learning objectives: to illustrate imaging features of various developmental, infl ammatory, neoplastic, traumatic and postsurgical processes that are located in or adjacent to duodenum. background: although primary diseases of doudenum are rare, several primary and secondary processes may involve duodenum due to its both intra and extraperitoneal localization, proximity to pancreas, stomach, hepatobiliary and intestinal system. procedure details: duplication, annular pancreas, malrotation and transient paraduodenal hernias are rarely seen congenital anomalies whereas diverticula may be seen more frequently. infl ammatory wall thickening may arise from ulcers, pancreatitis, crohn's disease, coeliac disease, henoch-schonlein purpura. many adjacent infl ammatory pathologies such as appendicitis, pancreatitis, cholecystitis may also have düodenal wall involvement and may cause "sentinel loop" apperence of dilated duodenum with air-fl uid levels. duodenal dilatation may arise from superior mesenteric artery syndrome. primary adenocarcinoma, paraganglioma, liposarcoma, gist, lymphoma, menetrier disease may cause noeplastic involvement of duodenum. also, metastatic lymphadenopathies of seminoma, mesothelioma, lymphoma may locate around duodenum. walls of duodenum may be thickened from adjacent malignancies such as cholangiocarcinoma, adenocarcinomas of stomach, colon and pancreas. cystic extrensic compression may arise from choledococel, intestinal lympangiectatic cysts, choledochal cyst, pseudocysts, policystic disease. foreign bodies located in duodenum such as metallic nail and traumatic hematoma can be revealed by ct. chlodecoduodenostomy, whipple operation and gastrojejunostomy may cause several changes of duodenum. since several different pathologies may affect or may arise from duodenum, radiologist should pay attention to duodenum as much as other adjacent organs in the interpretation of many sectional imaging modalities. utility of mdct enteroclysis in the evaluation of gastro-intestinal bleeding in small bowel diverticulosis: a pictorial review g. tóth, l. tóth, p. magyar, e. turupoli, k. hüttl; budapest/hu (totgez@freemail.hu) learning objectives: while small bowel diverticulosis is a rare entity and usually asymptomatic, it may cause acute or chronic symptoms and complications. because of its rarity, diagnosis is often delayed, resulting in unnecessary morbidity and mortality. nowadays, the diagnosis of small bowel diseases is frequently made by mdct enteroclysis. we present and discuss the typical fi ndings of mdct enteroclysis in 6 cases. background: small bowel diverticulosis is a rare disorder found in 0.2-3% of the adult population. most small bowel diverticula remain asymptomatic and are detected as an incidental fi nding, but they can also present a wide spectrum of complications, such as acute diverticulitis, hemorrhage, intestinal obstruction, perforation, malabsoption, and present as diffi cult diagnostic challenge. acquired small bowel diverticulosis predominantly involves the proximal jejunum, and is located on the mesenteric aspect of the small bowel, while the congenital meckel diverticulum is located on the antimesenteric aspect of the ileum, 30-60 cm from the ileocecal valve. ninety-three patients with suspected small bowel tumor were examined with a sixteen-row ct scanner (brilliance power 16), using the following parameters: coll. 16x0.75 mm with overlap scans, reconstruction interval 2 mm, after administration of methylcellulose by nasojejunal tube, before and after infusion of 120 ml iv. contrast agent, at the rate of 3.5 ml/s, with a scan delay of 50 seconds. in all the cases, multiplanar and curved planer reformatted images were performed. we evaluated mural thickening, mural enhancement, stenosis, praestenotic dilatation, perienteric reactions, lymph node enlargement. results were compared with sbe and surgical fi ndings. results: mdct detected 26 lesions, and sbe showed 23 pathological lesions. the comparison with sbe showed 2 ct false-positive cases due to poor bowel distension. three sbe false-negative cases were due to the small polipod lesions (< 10 mm). the fi nal diagnosis was adenocarcinoma in 5 patients, carcinod tumor in 3 patients, peutz -jeghers poliposis in 1 patient, adenomatous polyps in 3 patients, lymphoma in 3 patients, leiomyoma in 2 patients, leiomyiosarcoma in 1 patient, cd in 6 patients and adhesions in 2 patients. we found enlarged lymph nodes in 13 patients, and liver metastases in 7 patients. mdct fi ndings correlated well with the surgical fi ndings. conclusion: mdct enterography is a useful and reliable method for the diagnosis of small bowel tumors. background: adult small bowel intussusception has been regarded as a condition that always required surgery because up to 90% of the surgical reports said to be associated with a lead point abnormality. however, with the growing use of cross-sectional imaging in the evaluation of patients with abdominal complaints, the detection of enteric intussusception without a visible lead point disease has increased, creating a challenge in determining its diagnostic signifi cance and therapeutic approach. imaging findings: at ct, the presence of a bowel within bowel confi guration is pathognomonic for intussusception, having three different patterns depending on the severity and duration of the disease process. intussusceptions without a lead mass are usually transient, small and non-obstructing. experiments say they are due to disturbances in peristalsis and require only conservative observation. a lead point intussusception usually appears as a long abnormal target-like mass that may be associated with proximal bowel obstruction. identifi cation of the lead mass is not always easy; however, once recognized, surgical treatment should be recommended. conclusion: incidental enteric intussusceptions are being increasingly diagnosed posing a new diagnostic and therapeutic problem. not all this intussusceptions require aggressive work because most of them are intussusceptions without a lead point and therefore of no clinical importance. therefore, it is important to know the imaging characteristics that permit the distinction between them to prevent unnecessary aggressive therapeutics. results: side effects of the oral application of mannitol were noted in four cases (one case of vomiting and three cases of mild diarhea), no serious complication was present. the evaluable images with suffi cient distension of the bowel loops were obtained in 92 cases. signs of activity -mucosal and submucosal enhancement of thickened bowel wall -with or without fi stulisation were found in 41 cases, non-active cd in 22 cases (including 4 cases of stenosis), ulcerative colitis in 5 cases, enteritis in one case and normal fi nding in 31 cases. conclusion: mr enterography with 2.5 mannitol is a safe valuable imaging tool and should be used as the prime imaging modality in patients with suspected or known cd. purpose: the purpose of this study is to evaluate the correlation between tumor blood fl ow calculated with perfusion ct and clinicopathological status of gastric cancer. the study enrolled 30 consecutive patients who underwent surgery for advanced gastric cancer. perfusion ct was performed with a 16-row mdct using an intravenous injection of iodinated contrast material. sequential dynamic scans were performed on a single level where the tumor was largest in size. these dynamic images were reconstructed in the workstation to create a functional image. the new image was analyzed to calculate tumor blood fl ow (bf, ml/min/100 g tissue), using roi. we compared the bf in each patient and evaluated its correlation with the clinicopathological status of the gastric cancer. results: no signifi cant correlation was found between the bf level and the tumor location, diameter, or t-stage. the bf level was higher in the cn0 group than in the cn1/2 groups, and signifi cantly higher in pstage i/ii compared to pstage iii/iv. pathological examination revealed the bf level of the undifferentiated-scirrhous type, often with high-grade malignancy resulting in poor prognosis, to be signifi cantly lower than that of the differentiated-medullary type. the bf value of the gastric cancer acquired from perfusion ct may refl ect the histopathological structure of the tumor, including tumor vascularity and volume of extracellular matrix components of the tumor. this radiological imaging procedure is a valid modality to visualize the decreased tumor blood fl ow for assessing the malignancy level of gastric cancer, especially in those with high-grade malignancy. evaluation results: the tumor size was 4.9 ± 1.7 cm in diameter. the suv of all tumors was 4.0 ± 2.5, and the mi was 6.9 ± 6.5 (50 hpf). there was a signifi cantl correlation between suv and mi (r=0.50, p=0.011). based on the guideline, suv of the low-risk group (n=7) was 2.9 ± 1.4, intermediate-risk group (n=8) 2.6 ± 1.6 and low-risk group (n=10) 5.8 ± 2.8. suv level of high-risk group was higher than that of low group and intermediate group with a statistical difference (p=0.036, 0.007, respectively). when the cut-off suv level for high-risk group was established as 6.0, the positive predictive value and the accuracy rate was 100% and 85%, respectively. conclusion: fdg-pet may be an appropriately quantitative modality to distinguish high-risk group with acceptable diagnostic value. staging of gastric cancer: ct fi ndings and correlation between lymph node size and metastatic infi ltration a. gligorievski, k. gjoreski, a. karagjozov; skopje/mk (atgl@mail.net.mk) purpose: the assessment of lymphatic metastases is an important factor in the staging of gastric cancer. lymph node size has been used as one criterion for possible nodal metastasis. in a prospective morphometric study, the regional lymph nodes from 31 gastrectomy specimens of consecutive patients with primary gastric adenocarcinoma were analyzed. the lymph nodes were counted, the largest diameter of each node was measured, and each node was analyzed for metastatic involvement by histologic examination. the frequency of metastatic involvement was calculated and correlated to lymph node size. results: a total of 1253 lymph nodes were present in the 31 specimens examined for this study. a mean number of 40 lymph nodes (range 20-53) were found in each specimen. of these 1253 nodes, 922 (74%) were tumor-free and 331 (26%) contained metastases. the mean diameter of the lymph nodes free of metastases was 4.1 mm, whereas that of nodes infi ltrated by metastases was 6.0 mm (p <.0001). of the tumor-free lymph nodes, 735 (80%) were less than 5 mm in diameter, whereas 182 (55%) nodes containing metastases were less than 5 mm in diameter. of the 10 patients without lymph node metastases, 7 had at least one node that was 10 mm or greater in diameter; similarly, 15 (71%) of the 21 patients with node metastases had at least one node that was 10 mm or greater in diameter. conclusion: lymph node size is not a reliable indicator for lymph node metastasis in patients withgastric cancer. purpose: physiological fdg uptake in the stomach is often seen, especially at the oral end. water ingestion just before scanning would make stomach distention and thin the gastric wall, which may lead to apparent reduction of uptake in area of stomach. in this study, we assessed whether gastric distention using water ingestion suppressed physiological fdg uptake in the stomach. methods and materials: forty patients who had fdg whole-body pet imaging for cancer screening followed by gastric endoscopic examination were registered in this study. all patients took 400 ml of water for hydration and were administered 185 mbq of fdg intravenously. all patients were randomly divided into two groups with or without (additional) water. with water group, 20 patients had additional 400 ml of water immediately before pet imaging. the stomach regions were classifi ed into three areas: u (upper)-area, m (middle)-area, l (lower)-area. the degree of fdg uptakes in these three gastric regions were semi-quantitatively evaluated using suv. results: without water group, the mean suvs in the u-, m-, l-areas was 2.43±0.11, 2.31±0.11 and 2.13±0.13 respectively, while in water group, 1.94±0.16, 1.84±0.16 and 1.84±0.18, respectively. with water group, the suv in the u-and m-area were signifi cantly lower than that of without water group (p <.05). a signifi cant difference in fdg uptake was not observed among the three gastric areas in water group (p <.05). conclusion: additional water-intake immediately before pet imaging suppressed the physiological gastric fdg uptake. therefore, decrease of physiological stomach accumulation with this method has a possibility of improving diagnosing in this area. learning objectives: to be aware of the importance of fat stranding in locating the abdominal urgent pathology. to be familiar with the differential diagnoses depending of the fat stranding location. to differentiate the benign entities that resemble life-threatening diseases. background: ct plays a crucial role in differentiating the underlying causes of the symptoms in acute abdomen. fat stranding is a ct sign that helps in the evaluation of patients with acute abdominal pain in emergency radiology. it is no patognomonic though it warns us where to look at. fat stranding may arise from many causes that should be considered in the differential diagnosis. acute conditions that cause fat stranding include appendicitis, ischemia or perforation of the bowel, cholecystitis, trauma and surgery. imaging findings: we have made a pictorial review showing and describing the ct imaging features of the most common abdominal urgent pathology. we try to demonstrate how fat stranding on abdominal ct can help us to identify the crucial point of the acute abdominal at fi rst sight. once localized it, we describe the specifi c imaging fi nding that will lead us to a fi nal diagnosis. correct non-invasive diagnosis is important because treatment approaches for these conditions range from monitoring to surgery. we show some key-facts to help us to differentiate both groups. conclusion: fat stranding is a useful sign to localize the underlying pathology in acute abdomen. knowledge of ct signs accompanying it helps us to reach a fi nal diagnosis, and therefore a more accurate clinical decision. c 421 b d e f a g evaluation background: bowel and mesenteric injuries are detected in 5% of blunt abdominal trauma patients at laparotomy and rarely occur isolated. early diagnosis and treatment are critical to decrease morbidity and mortality. ct has become the primary modality for the imaging of these patients. however, radiological signs can be subtle and should be regarded as complementary to meticulous clinical assessment. imaging findings: ct fi ndings in bowel and mesenteric injury include the following: a. direct fi ndings of bowel injury: bowel wall disruption and oral contrast extravasation. b. direct fi ndings of mesenteric injury: intravenous contrast extravasation from mesenteric vessels. c. indirect fi ndings of bowel injury: free intraperitoneal/retroperitoneal air or fl uid. d. indirect fi ndings of mesenteric injury: diffuse bowel wall thickening, diffuse bowel wall enhancement, mesenteric infi ltration or haematoma. when indirect fi ndings of bowel or mesenteric injury are the only ct fi ndings, the need for surgical intervention is highly dependent on clinical judgment and can be necessary reassessment with ct 6-8 hours after the initial evaluation to elucidate the signifi cance on such fi ndings. conclusion: ct has been shown to be accurate for detecting bowel and mesenteric injury caused by trauma and is useful in predicting the need for either surgical repair or conservative management. the target sign on multidetector-row ct: spectrum of bowel diseases r. cianci, a. filippone, a. gorgoglione, m.l. storto; chieti/ it (r.cianci@rad.unich.it) learning objectives: to understand the signifi cance of target sign as seen on contrast-enhanced multidetector-row ct (mdct) of the abdomen. to illustrate various bowel diseases in which target sign may be observed. the target sign is a term used to indicate stratifi cation within a thickened bowel wall that consists of three layers: a inner and outer layer of high attenuation, respectively corresponding to contrast-enhanced mucosa and muscularis propria/serosa, and an intermediate layer of decreased attenuation corresponding to submucosa. the target sign is believed to represent hyperemia in the mucosa and the muscularis propria, serosa or both and edema or infl ammation in the submucosa. the target sign is commonly observed in idiopathic infl ammatory bowel diseases (ulcerative colitis and mostly crohn disease) and ischemic enterocolitis; it may be present in intramural intestinal hemorrhage, infectious enterocolitis, vasculitis (henoch-schönlein purpura, lupus erythematosus), radiation enterocolitis and bowel edema in cirrhosis. the fi nding of stratifi ed attenuation in a thickened segment, although non specifi c, most likely represents non neoplastic disease, with the exception of the rare occurrence of this sign in infi ltrating scirrhous carcinoma of the stomach and colon. potential pitfalls in the diagnosis are residual fl uid and oral contrast material fi lling the bowel lumen or the deposition of submucosal fat. the target sign may be seen on contrast-enhanced mdct scans as a non specifi c feature of non neoplastic bowel diseases. correlation with patient clinical history and associated ct fi ndings related to the bowel wall or mesentery may allow to narrow the differential diagnosis. multidetector background: isigo is a rare benign and self-limiting disorder, presenting with aspecifi c clinical symptoms that may mimic other acute abdominal conditions. the cause of isigo has been not established; it has been postulated that precipitating factors resulting in displacement of the omentum, such as sudden increase in abdominal pressure after heavy meals, overexertion, a sudden change in body position, coughing or sneezing, may cause venous stasis and thrombosis leading to omental edema and congestion, with hemorrhagic necrosis and extravasation of serosanguineous peritoneal fl uid. imaging findings: all typical imaging features of isigo are well recognizable on unenhanced ct scans; they include a well circumscribed, oval or cake-like fatty mass with heterogeneous attenuation, containing strands of soft tissue attenuation probably corresponding to fi brous bands and/or dilated thrombosed veins. the mass is usually right sided and most often located deep to the rectus abdominis muscle and anterior to the colon. it appears adherent to infl amed, thickened parietal peritoneum. there is frequently a small to moderate amount of free peritoneal fl uid. major differential diagnoses include appendicitis, cholecystitis, diverticulitis, epiploic appendagitis and, less frequently, primary benign or malignant neoplasms or metastatic peritoneal seeding. conclusion: to recognize mdct fi ndings of isigo is important in making the correct preoperative diagnosis in patients with acute abdominal pain. it may avoid unnecessary surgical explorative intervention. intestinal intussusception in adults: x-ray, us, ct, and mri fi ndings f. sandomenico, o. catalano, a. nunziata, v. de rosa, a. petrillo, a. siani; naples/it (tonikus@libero.it) learning objectives: to describe the imaging appearance of gastro-intestinal intussusception with a large range of diagnostic modalities in patients with a variety of intussusception locations (gastric, jejunal, ileal, ileo-colic, appendicular, colic, and rectal), presentations (acute, chronic, transient), and causes. to make the reader aware of the clues to a diagnosis and of the imaging features of complicated intussusception. background: intussusception is the herniation of one segment of the gastrointestinal tract into another (proximal to the former or, more frequently, distal). in adults, intussusception usually has a leading cause and may develop at different levels with a variety of clinical presentations. we illustrate all x-ray, us, colour-doppler, ct, and mri fi ndings in adult intussusception of the stomach, the small bowel, the appendix, and the large bowel. we report cases of obstructing, subacute, chronic, and even transient intussusception. we highlight the clues to a diagnosis and potential pitfalls. background: abdominal wall is a potential source of many pathologic processes. most of them are secondary to localized or systemic disorders, and primary lesion is uncommon. thus, most of abdominal wall lesion can be clues to the diagnoses of unknown or recurred underlying diseases. ultrasonography is a valuable tool in the initial screening and follow-up study after treatment. therefore, the chances of facing those lesions in us and the importance of recognizing them with a consideration of underlying causes are increasing more and more. imaging findings: in this exhibit, us fi ndings of the spectrum of diseases which are classifi ed into: 1) lesion adjacent to umbilicus; metastatic lymph node, urachal cyst, umbilical hernia, collateral vessels, 2) lesion associated with surgical incision; incisional hernia, heterotopic ossifi cation of midline incision, metastasis, 3) infl ammatory lesion; actinomycosis, abscess, necrotizing fasciitis, 4) neoplastic lesion; benign and malignant tumors, 5) others will be illustrated with ct and/or pathologic correlations. conclusion: to carefully evaluate abdominal wall lesions is sometimes a great diagnostic clue. gastrointestinal stromal tumours: imaging fi ndings with histopathological correlation s.k. lapsia, s. ramachandra, v. smith, s. ghai, s. ghai; stoke-on-trent/uk (jlapsia@hotmail.com) learning objectives: 1. recognise the spectrum of imaging features of primary gists with histopathological correlation. 2. discuss the differential diagnosis of gists. 3. review the imaging response to imatinib therapy. background: gastrointestinal stromal tumours (gists) are the most common mesenchymal neoplasm of the gastrointestinal tract arising from the interstitial cells of cajal. these cells express a tyrosine kinase growth factor receptor kit (cd 117), which has resulted in the advent of targeted molecular drugs such as imatinib. imaging findings: computed tomography (ct) is the imaging modality of choice for the assessment of gists. the majority of gists appears as large exophytic, heterogeneous enhancing masses on ct because of internal necrosis, haemorrhage or cystic degeneration. although, defi nitive diagnosis relies on histopathology, imaging can be suggestive of the diagnosis, and plays an important role in the detection of complications and identifi cation of metastases. differentiation from other primary gastrointestinal tumours can often be made on the basis of these specifi c fi ndings. this exhibit will demonstrate the spectrum of imaging features of gists, their differential diagnosis on imaging, and their behaviour following treatment with imatinib. in this educational exhibit, the typical imaging fi ndings of gists with histopathological correlation are illustrated. differential diagnosis and response to treatment are also reviewed. the importance of imaging in helping to make the diagnosis of gists and in their follow-up after treatment is of increasing importance because imatinib has dramatically improved the survival rates in patients with gists. normal sonographic anatomy of the inguinal canal g. rajeswaran, j. lee, j. healy; london/uk (grajeswaran@hotmail.com) learning objectives: the purpose of this exhibit is to describe the sonographic anatomy of the inguinal canal using ultra-high-frequency sonographic transducers, to aid accurate assessment of disorders involving this region. background: disorders involving the inguinal region can often be clinically diffi cult to assess. the advent of ultra-high-frequency probes has improved our ability to image the inguinal canal. however, a good understanding of the sonographic anatomy is fi rst required to prevent misdiagnosis. imaging findings: in this exhibit, we will document the required sonographic technique as well as common pitfalls encountered, followed by a detailed description and illustration of the sonographic anatomy of the inguinal canal. the structures described include the superfi cial and deep inguinal rings (and their boundaries), the walls of the inguinal canal, the inguinal ligament and the contents of the inguinal canal. conclusion: we have described the ultrasound anatomy of the inguinal canal to enable sonography of this area as a dynamic, non-invasive and inexpensive method of evaluating disorders of this region. retroperitoneal air was not uncommon in duodenal ulcer perforation (4 cases). renal infection was also responsible for the presence of pneumoretroperitoneum (5 cases) with or without the formation of abscesses. pancreatitis was responsible in 7 patients for the presence of air in the form of abscess or emphysematous pancreatitis. conclusion: trauma is by far the most common cause of retroperitoneal air collections, the second most frequent being perforation of a hollow organ such as duodenum, ascending or descending colon. other conditions may also produce small amounts of retroperitoneal air and they have to be taken into account for a proper diagnosis, especially in diabetics or in immunocompromised patients. activity methods and materials: thirty-four patients with beginning or relapsed ibd underwent us baseline exam and ceus. features of pathological bowel segment at baseline exam were: thickness of the wall more than 3 mm, loss of the echostratifi cation and increase of the vascularization at pwdoppler. after the dynamic study with sonovue, the degree and the pattern of the wall enhancement were evaluated. on the base of these features, the activity degree of the illness has been defi ned as: active, subactive or remittent. the ultrasound data were compared with the clinical activity index: rcp level and clinical symptoms. all the patients were followed up with ultrasound examination (baseline and ceus) in order to evaluate the response to the therapy correlated to the clinical features (40 examinations). in the follow-up, reduction of the thickness wall of the vascularization and of the enhancement pattern was considered remission features. learning objectives: to present typical appearances of peritoneal, omental and mesenteric diseases and to narrow the differential diagnosis for each morphological pattern. background: the causes of peritoneal, mesenteric and omental diseases could be divided into four major groups: infectious, infl ammatory, neoplastic, and vascular. the morphological changes in this anatomical region can be classifi ed into three basic patterns: solid well-defi ned masses (including cystic masses), ill-defi ned irregular masses and infi ltrative processes of the mesenteric and omental fat. procedure details: abdominal and pelvic mdct was performed with oral and/or intravenous administration of contrast material. the area between the diaphragmal dome and inguinal ligament was scanned. in each patient, the homogeneity of abdominal fat, the presence, attenuation and enhancement of the intraperitoneal mass, the surface and enhancement of parietal peritoneum, and the presence of mesenteric lymphadenopathy and ascites were analyzed. conclusion: peritoneum, omentum and mesentery can be affected either by primary pathologic conditions, or secondary by direct extension from adjacent organs, lymphatic and hematogenic dissemination, and peritoneal seeding. on the basis of clinical fi ndings and imaging appearance, the broad differential diagnosis of diseases in this region could be signifi cantly narrowed. the possible presence of mesenteric lymphadenopathy, peritoneal thickening and/or ascites can make the fi ndings more conspicuous. learning objectives: to illustrate radiological manifestations of the causes of obscure gi bleeding. to aid the differential diagnosis of gi bleeding. background: up to 5% of patients with recurrent gastrointestinal (gi) bleeding will remain undiagnosed by standard gastroscopy and colonoscopy. gastrointestinal (gi) hemorrhage is considered obscure when conventional investigations (esophagogastroduodenoscopy and colonoscopy) fail to detect bleeding lesions. on average, 27% of patients with obscure gi bleeding have small intestinal lesions. the causes of obscure gi bleeding include arterio-venous vascular malformation, angiodysplasia, ectopic varices (duodenal, jejuno-ileal, colonic, and peristoma varices), small bowel lipoma, small bowel stromal tumor, cholesterol crystal emboli, aortoenteric fi stula and radiation enteritis. diagnosing these lesions is frequently diffi cult because they tend to be inaccessible to routine endoscopy. imaging findings: using multidetector-row ct scanner, well-designed barium study, and angiography, we illustrate the various radiological fi ndings of obscure gi bleeding caused by splenic artery pseudoaneurysm, ectopic varices, arteriovenous malformation, and angiodysplasia. the cause of obscure gi bleeding can be detected in many cases by using variable imaging modality such as multislice ct, barium studies, and angiography. imaging features of primary extra-nodal lymphoma: a pictorial review j. quintero, p. puyalto, a. mariscal, c. roqué, i. guasch, a. oriol; badalona/es (jcquintero.germanstrias@gencat.net) learning objectives: the aim of this educational exhibit is to revisit the clinical presentation, classifi cation, distribution and radiological imaging fi ndings of the rare extra-nodal involvement of lymphoma. background: lymphomas are malignant disorders of lymphoid tissues which are subdivided into two broad groups: hodgkin's disease and non-hodgkin's lymphoma. lymphoma classically presents in lymph node sites. extra-nodal involvement may also be due to regional spread of nodal disease or haematogenous dissemination. the classifi cation of lymphoma is complex and still debated. the stage of the disease is classifi ed according to the ann arbor staging system. imaging findings: we reviewed all of radiological reports in the last fi ve years in our institution. we selected the cases with primary extra-nodal lymphoma and they were reviewed by two radiologists who were unaware of radiological fi ndings. we encountered 48 cases of primary extra-nodal lymphoma: thoracic: lung (7) and pleural (2); abdominal: gastrointestinal tract (10), abdominal viscera (6), urologic and genital tract (5), peritoneum (1); musculoskeletal: bone (3), muscle (2), skin b d e f a g and subcutaneous tissue (1); nervous system: brain (5) and spinal cord (1); other: salivary glands (2), breast (2) and thyroid gland (1). conclusion: extra-nodal manifestations of lymphoma are greatly diverse and may mimic a variety of both neoplastic and non-neoplastic conditions, depending upon the site of involvement. familiarity with the broad spectrum of primary extra-nodal lymphoma is important for enhancing lesion detection and improving diagnostic accuracy. multimodality imaging plays a critical role in detecting, characterising and staging the disease. ct fi ndings of chronic ambulatory peritoneal-dialysis-related conditions t. ichikawa, t. hashimoto, t. yamashita, j. koizumi, y. imai; isehara/jp (tamaki-i@mars.sannet.ne.jp) learning objectives: to illustrate the ct fi ndings of sclerosing peritonitis (sp) and other conditions related to chronic ambulatory peritoneal dialysis (capd) background: sclerosing peritonitis (sp) is a rare but serious complication of capd. sp is characterized by thickening of the peritoneum that encloses some or all of the small intestine, which could result in bowel obstruction and necrosis. imaging findings: this exhibit illustrates abdominal ct fi ndings of conditions related to capd focusing on sp. other conditions associated with capd are also discussed. we retrospectively reviewed abdominal ct of 48 patients on capd for more than 7 years. findings of sp were peritoneal thickening, peritoneal calcifi cation, located fl uid collections, and small bowel abnormalities. the most serious complication of sp was associated with bowel perforation in 1 case. other conditions such metastatic calcifi cation of soft tissue and joints due to renal osteodystrophy and vascular abnormalities such as atherosclerosis were also well depicted. in addition to axial images, we utilized opitimal multiplanar sections to visualize the entire peritoneal cavity. conclusion: ct is an important tool in the diagnosis of sp and other conditions associated with capd. knowledge of specifi c ct fi ndings of sp will lead to identifi cation of this rare complication of capd, and is benefi cial for differential diagnosis of peritoneal disease. other conditions associated with capd are also excellently depicted on ct. diseases of the mesentery, omentum and peritoneum g. learning objectives: to review the wide range of primary and secondary pathologic conditions that affect the mesentery, omentum and peritoneum. to describe the ct fi ndings of these conditions and to present some rare processes and their specifi c imaging fi ndings. background: the peritoneum, mesentery and omentum are important sources of primary pathologic conditions as well as common sites of secondary involvement from various primary processes. most of these conditions are common, but few others are very rare, and one should be aware of these. ct scan is an excellent tool in detecting disease in these anatomic regions and can be specifi c in diagnosing few of these entities. radiologists should be also aware of very rare conditions affecting these areas. the purpose: the aim of our study was determination of the infl uence of muscles' volume as well as all intraorbital structures' volume for the exophtalamos extend. methods and materials: forty-fi ve patients (90 orbits) were the study subjects with the clinically proved exophthalmos in whom the quantity assessment of eye ball muscles, fat tissue and eye ball was carried out using nsi application. nsi, the numerical segmentation image technique, is a new computer software that nearly automatically counts the intraorbital structures volume on the base of mri images. all patients underwent mri examination in 1.5 t scanner using head coil. the infl uence of the muscles' volume on the exophthalmos degree was statistically signifi cant: in a clinical method using hertl`s exophtalmometer r=0.357, p=0.000552 in a radiological method in comparison to the interzygomaticus line r=0.511, p=2.59221e-07. the infl uence of all structures' volume on the exophthalmos degree was, respectively, 0.441, p = 1.34334e-05; 0.492, p = 8.47986e-07. conclusion: nsi technique is a clinically useful application providing objective data calculated individually for each orbit. it is justifi ed to use the eye muscles' volume to estimate activity of the pathological processes graves ophtalmopathy. determination of the exophtalamos in a radiological way is more objective than clinically. the , and x-plan radiography to visualize the correct position of the implant. procedure details: the dct scan depicts vibrant site of implant better than x-plan radiography, with lower x-ray dose compared to ct. for cochlear implants, a single x-plan by stenvers projection can directly visualize the electrodes in the cochlea. all patients with brainstem or inferior colliculus implants underwent postoperative ct scan (12 hours) to exclude complications, and to assess correct implantation. the follow-up of these implants can be done only by x-plan radiography. conclusion: ct and dct scan could provide a reliable and relatively fast method to precisely determine the location of middle ear implants; we prefer dct in regards to ct because of the lesser x-ray dose administered; a single radiography is enough to visualize and follow-up brainstem or inferior colliculus implants. learning objectives: to outline the specifi c questions to the radiolgist with regard to cochlear implantation. background: cochlear implants are intended for patients with severe to profound sensorineural hearing loss (snhl). successful cochlear implantation depends on a variety of factors, including an intact cochlear nerve and a surgically accessible route for electrode placement. therefore, imaging evaluation consists a major part of the preoperative assessement. procedure details: twenty-eight patients, aged from 2 to 72 years who were candidates for cochlear implants were referred for imaging evaluation. all patients had severe snhl of various causes. high-resolution computed tomography (hrct) scans were performed most on single-detector ct scanner using the classic protocol. mri scans were acquired from a 1.5 and 1 tesla scanners with an axial high-resolution two-dimensional or three-dimensional (3d) fast spin echo t2-weighted sequence or 3d gradient echo (ciss or true fisp). non-enhanced and enhanced t1-weighted images through the temporal bone and axial fl air images through the brain were taken as well. twenty-four patients had both ct and mr examinations. these were reviewed based on a detailed analysis of known anatomical landmarks and variants related to the procedure. conclusion: ct is superior ino studying the bony structures of the inner ear and middle ear cavity and the course of the fallopian canal for surgical planning, whereas mri is superior in analyzing the soft tissues of the inner ear and the vestibulocochlear nerve. both modalities are equally effective in depicting labyrinth malformations. closed in one patient, anterior chamber was shallow. lens presented an irregular surface in 2 patients and was dislocated in one. hemorrhage was seen in two patients (1 vitreous (< 50%), 1 retina). 5 cts initially read negative were read positive in the retrospective review (lamellar lacerations (ll)); in all, a tiny air bubble was recognised in the cornea or at the sclerocorneal junction. in one of them, a foreign body was recognised. prospectively 22 fractures were diagnosed at ct, retrospectively 1 fracture was not recognised, and 1 was seen only in retrospect. nine patients with orbital fractures had intraorbital air (5 extraconal, 2 intraconal, 2 intra and extraconal). conclusion: ct fi ndings in globe trauma are the effect of mechanical impact. radiologists training signifi cantly improved ct accuracy. radiological purpose: the endoscopic surgery of the frontal sinus is confronted with two diffi culties: the nearness of noble organs and the complexity of fronto-ethmoïdal anatomy. the purpose of this work is to clarify radiological anatomy and variants of the frontal sinus and its ways of drainage and to show the importance of imaging in the investigation of this region. methods and materials: 100 patients presenting a sino-nasal infl ammatory disease were investigated between 2004 and 2006 (complicated acute or chronic sinusitis, mucoceles, sino nasal polyposis). they benefi ted all of a sinus endoscopic exam and a scanning of the facial massif containing an axial study and coronal, sagittal and curvilinear reconstructions in the plan of the fronto-nasal tract. results: imaging in these patients confi rmed diagnoses evoked clinically, permitted the study of complications, notably frontal sinusitis and the exact study of the fronto-ethmoïdal complex anatomy and its ways of drainage. anatomical detailed ct boards and various pathological correlations are presented. conclusion: imaging especially when realized according to a rigorous technique is an indispensable tool in the diagnosis of complications of the frontal sinusitis and in the anatomical study before surgery. results: ct showed a solid unilateral tumour (n=19), or bilateral (n=1), developing with the nasal cavity or paranasal sinuses and extending to the maxillary sinus (n=14), and to sphénoïd and frontal sinuses (n=5). it is associated with bone erosion (n=12) and bone condensation (n=2). mri showed a heterogeneous and lobulated tumour (n=16), and allowed categorizing patients according to the staging proposed by krouse: 1 case of stage1, 6 cases of stage 2, 7 cases of stage 3, and 2 cases of stage 4. association with epidermoïde carcinoma was noted in only 1 patient. conclusion: inverted papilloma is a rare benign tumour of nasal cavity and paranasal sinuses. it is locally aggressive. ct and mri assessment can accurately predict the extent of the tumour. preoperative staging by mri may be useful for planning an appropriate surgical approach. other lesions represented images traps for the radiologist gathering the whole of the anatomical structures which can wrongly lend with pathology like a canal confused to a fracture. the anatomical alternatives of the temporal bone to announce to the surgeon are not rare. they are alternatives being able to constitute an embarrassment with the initial surgical way or to predispose to surgical incidents. their knowledge is important for the radiologist and the surgeon to guide and adjust surgical procedure. visualization of ocular motor cranial nerves by 3d-fiesta f. man, z. wang, y. jiao; beijing/cn (daman001@163.com) purpose: to display the oculomotor cranial nerves by mri and to present an update on clinical applications of dominant congenital fi brosis of extraocular muscles (cfeom). methods and materials: mri was performed in 20 volunteers without strabismus and 3 cfeoms on 1.5 t mr unit (twinspeed, ge). a head coil was used. 0.6 mm thick slices without interslice gap were obtained in axial plane using three dimensional fast imaging employing steady state acquisition (fiesta) sequence without enhancement. oculomotor nerves were observed in oblique-axial and oblique-sagittal planes acquired with mpr. results: both oculomotor cranial nerves (cn3) were demonstrated well in oblique-axial and oblique-sagittal planes in 19 normal subjects (95%) except one. 32 abducens (cn6) of 40 nerves (80%) were displayed in oblique-sagittal planes. 25 trochlear nerves (cn4) of 40 (62%) were showed. different degree hypoplasia of motor nerves, especially cn6, was exhibited in cfeoms: all cn6s were very thin, in which 1 nerve could be seen normally coursing, 1 not found, and 4 traced superiorly among which 2 coursed to ipsilateral cn3. the 4 cn3s were strikingly small and 2 normal. the onsets of 4 cn4s were shown well and 2 not. conclusion: all ocular motor nerves can be seen in the subarachnoid cisterns by using 3d-fiesta. this is a precondition for exploiting the diagnostic potential of mr images in cfeoms. magnetic resonance ( fast field echo sequences from the resting position to the position of maximum oral opening. we evaluated signal intensity and morphology, disc position at various degrees of oral aperture, the morphology of the treated condyle, plate integrity, the onset of parotid complications, and the length of the treated mandibular branch in comparison with the healthy side. the follow-up examinations revealed, on the treated side, fi ve cases of anterior dislocations of the disc (25%), one of disc degeneration (5%), one parotid fi stula (5%), and one case of degenerative condylar osteoarthritis (5%). the surgical repositioning of the condyles does not always lead to morphological restoration without late skeletal anomalies. both trauma and surgical intervention can damage the meniscal capsulo-ligamentous containing apparatus. mr allows the identifi cation of complications due to the trauma and/or treatment, and the comparative evaluation of the condyles and joint function. use osteonecrosis and osteomyelitis of the jaws associated with i.v. bisphosphonate therapy for multiple myeloma and metastatic bone cancer: ct fi ndings a. lo casto, f. ganguzza, g. la tona, f. sorrentino, r. restivo, l. solazzo; palermo/it (antoniolocasto@hotmail.com) purpose: the i.v. bisphosphonates are widely used in metastatic bone cancer but in some patients it lead to osteonecrosis and osteomyelitis of the jaws. panoramic radiography and ct with dedicated dental software fi ndings of 8 patients treated with i.v. bisphosphonate therapy for metastatic bone cancer are described. methods and materials: 8 patients (5 women and 3 men, age range 66-86 years) affected by multiple myeloma (5/8 patients) or metastatic bone cancer (3/8 patients) and treated by i.v. bisphosphonate therapy for 3 months to 1 year were submitted to panoramic radiography and ct with dedicated dental software for dental pain and jaw swelling. in 2/8 patients, a fi stula in the skin surface of the chin with purulent drainage was also present. results: ct fi ndings in the jaws were: osteolytic area, diffuse hyperdensity of trabecular bone, bone sequestrum, thinning and erosion of cortical bone, periosteal bone reaction. in 2/8 patients, a fi stulous tract draining in the skin surface of the chin was also observed in the mandible. in 1/8 patient, only the maxilla was involved, in 5/8 patients only the mandible was involved and in 2/8 patients both jaws were involved. conclusion: ct with dedicated dental software is useful in the detection of osteonecrosis and osteomyelitis associated with i.v. bisphosphonate therapy, allowing a complete assessment of the diseases including the localization of eventual fi stulous tract. the modern ultrasound diagnosis (us) in the combat injuries of eyes v. troyan, k. slobodin; moscow/ru (carina-c@yandex.ru) purpose: the improvement of clinical-and-radiation diagnosis of structural changes in eyes and retrobulbar space after combat injuries. methods and materials: 284 cases of radiation examination for eye injuries occurred during conduct of military operations were analyzed. the ultrasound diagnosis with the help of high-frequency probes by transorbital approach was formed. during investigations, the possibilities of color doppler were used and eye anterior section was examined with the help of water boluses in different modifi cations. results: us method allowed developing the classifi cation groups of eye combat injuries, the us diagnostic syndromes and the radiation examination algorithm. the us high diagnostic informative capacity was noted in differentiation of retinal detachment; vascular tunic and vitreous body; in visualization and topical diagnosis of any intraocular foreign bodies more than 1 mm in size; in diagnosis of intraocular and retrobulbar hemorrhages and their sequelae. it also appeared effective in diagnosis and prognosis of development of infl ammatory posttraumatic changes in the eye based on the analysis of ratio blood fl ow velocity in retinal central artery/orbital artery; the degree of posttraumatic subatrophy and its development; in lens dislocation and change in its transparence. us is the method of choice in cases of "hydrodynamic" rupture of sclera and orbital osteal walls during eye severe contusion and in stab wounds. conclusion: complex us is a universal method for evaluation of structural changes in the eye after combat injuries that can be used for screening, pathologic process verifi cation under conditions of multi-purpose institution and for dynamic follow-up of treatment results. purpose: compare image quality of sinonasal cavities scans obtained with standard radiation dose and 50% reduced radiation dose with a 16-detector row ct scanner. the study includes forty patients referred to multislice ct (msct) scan of the sinonasal cavities for suspected chronic sinusits. twenty patients underwent msct examination at standard dose using the following protocol parameters: 16 x 0.625 mm detector confi guration, 0.562:1 pitch, 150 mas, 120 kv and 1.25 mm slice thickness. ct scan were obtained in the other twenty patients with half radiation dose by using a pitch of 1.375:1. in all patients, 1.25 mm axial and coronal images were reconstructed from raw data. all ct scans were reviewed by a neuroradiologist who evaluated, with a three-point quality scale, several anatomical structures and infl ammatory mucosal changes. the graded differences between the two protocols were evaluated using a t test. results: reduced dose scans were performed with a ctdivol of 23 mgy. no signifi cant image quality differences were observed between the two groups of patients. conclusion: dose-reduced msct helical examinations of the sinonasal cavities can be obtained using 1.375:1 pitch and 23 mgy ctdivol without signifi cant image quality loss. the presence of fi brovascularized area at the level of the equator of the partially wrapped porous ptfe sphere is revealed in 5 patients and was associated with the reduction of si from this zone on t2-wi. depth of germination was 1-8 mm. porous ptfe does not create any artifacts that allow to differentiate surrounding orbital structures − ocular muscles, optic nerve and orbital fat. magnetic resonance studies seem to be the best-suited imaging modality for assessing the fi brovascular tissue progression into porous ptfe spheres after enucleation and for identifying patients in whom vascularization has failed. preventing fess from turning into a mess: role of the radiologist d. ganeshan 1 , c. barwick 2 , n. purpose: the usefulness of 123i-imp for the diagnosis of orbital malignant melanoma is well recognized, but the estimation of the uptake is sometimes diffi cult because the images acquired 24 hours after injection may be so faint that the roi we draw becomes arbitrary. we evaluated a new semiquantitative procedure to estimate more easily and objectively the uptake of 123i-imp in patients with orbital malignant melanoma. methods and materials: first, we obtained the normal mri image of the brain, standardized by the fusion software included in neurostat. the standard rois were determined from the several slices for the orbit, and then they were adjusted to the standardized spect image of the 123i-imp. the uptake was calculated by voiclassic including the neurostat system. twenty patients with orbital tumor were assessed. we compared the uptake of the affected side of the orbit. retention index was calculated with decay correction. retention index= (delayed ratio-early ratio)/early ratio x 100 (%). results: it was possible to distinguish the melanoma from the other orbital tumors without the fusion image of the co-registered mr and spect images. when we set the cut-off level at ri≥100, sensitivity was 85.0%, specifi city was 86.7%, and accuracy was 85.7%. conclusion: semiquantitative parameters calculated by voiclassic including the neurostat system are useful and provide an objective method for the diagnosis of orbital malignant melanoma. learning objectives: to establish the key radiologic fi ndings to enable the differential diagnosis between craniofacial involvement of paget disease and of fi brous dysplasia. background: paget disease and fi brous dysplasia are 2 bone disorders, with frequent craniofacial involvement, in which imaging studies play a very important role in orienting the diagnosis and planning appropriate surgical treatment. fibrous dysplasia is a skeletal developmental anomaly of the bone-forming mesenchyme that usually affects young people, with craniofacial involvement in up to one third of the cases. paget disease is a bone formation/resorption disorder that normally affects people over 40 years of age, with craniofacial involvement in up to 60% of cases. like fi brous dysplasia, paget disease can present different radiologic patterns in function of the stage of the disease. imaging findings: we reviewed 10 cases of paget disease and fi brous dysplasia with bone involvement on craniofacial ct seen in our hospital. the key features to consider in the differential diagnosis between craniofacial involvement due to paget disease versus fi brous dysplasia are: a) whether or not bone involvement is symmetrical, b) whether or not it crosses sutures, c) the bone pattern, and d) the presence or absence of disease in the paranasal bones. we determined the key imaging fi ndings to enable the differential diagnosis between paget disease and fi brous dysplasia on the basis of density, involvement, and distribution of the lesions. learning objectives: to understand the pleomorphic presentation of retrobulbar hematomas, occurring after cranio-facial trauma, the radiologic techniques to investigate them, and the principal features useful to achieve the differential diagnosis. background: retrobulbar hemorrhagic lesions can be classifi ed in two groups: intraorbital hematoma and subperiosteal hematoma. subperiosteal hematomas represent a rare but well-defi ned clinical entity; they are more frequently seen in children, due to the loose adhesion of periostium in these patients, which can be easily detached from orbital bones by a hemorrhagic mass, with resultant proptosis and compromise of the optic nerve. infrequently, this kind of retrobulbar hemorrage can be associated to the presence of an extradural intracranial hematoma; and this condition is known as a real diagnostic and therapeutic emergency. diagnosis relies on computed tomography (ct) and magnetic resonance (mr). imaging findings: anatomy and radiologic anatomy; classifi cation; mr and ct features; cases series. conclusion: ct and mr allow a correct classifi cation, and provide critical information to the surgeon for mandatory treatment. correlation between multiplanar reconstruction sections and threedimensional ct images of the normal temporal bone n. fujii, y. inui, k. katada; toyoake/jp learning objectives: to demonstrate three-dimensional ct (3d-ct) images of the whole temporal bone, the mastoid cavity, the tympanic cavity, the auditory ossicles and the inner ear. to correlate multiplanar reconstruction (mpr) sections in various angles with 3d-ct images. to identify four specifi c sections of the ossicles, the images of which are reconstructed to allow viewing of the ossicular chain. background: recent advances in multislice ct (msct) have made it possible to obtain high-resolution isotropic volume data, allowing us to generate 3d-ct images of the temporal bone, in which small structures and intricately shaped ossicles are depicted clearly. furthermore, we have been able to reconstruct two-dimensional (2d) sections of the temporal bone, even the ossicles, from any desired direction with mpr without diffi culty. therefore, it has become possible to recognise an object that has small and complicated structures with 2d-3d correlation. procedure details: mpr and 3d-ct source data from a volunteer were acquired by a 0.5-mm, 4-row msct system, using a unique high-resolution image reconstruction algorithm. mpr sections showed conventional axial, coronal planes and four specifi c sections of the ossicles, which we have identifi ed for the purpose of viewing the ossicular chain. each structure has been indicated on both mpr and 3d-ct images and correlated with each other. conclusion: high-resolution mpr and 3d-ct images with msct depict the complicated anatomy of the temporal bone. 2d-3d image correlation and recognition helps to deepen understanding of conventional 2d sectional anatomy, and to identify the optimal section for observing a given object. on the lower compartment, the anterior was cochlea nerve foramen which had spiral shape, and the posterior was inferior vestibular nerve foramen. the position of single foramen is uncertain, usually located on in-posterior of iac fundus. in abnormal group, 9 ears were shown as iac fundus disorder and foramina absent, only 1 foramen was shown in 1 ear, 2 foramina in 4 ears, 3 foramina in 2 ears, 4 foramina in 2 ears; abnormal shape of cochlear nerve foramen was seen in 4 ears, spiral shape disappeared completely in 2 ears, small round shape was shown in 2 ears. conclusion: three dimensional imaging can improve the understanding and comprehension of iac fundus. ctve is useful in showing the normal structures and pathological changes of iac fundus. establishment of normal cochlea measurements on standard hrct images to aid diagnosis of cochlea hypolasia g. wuxian, g. ruozhen, c. baoting, w. min; jinan/cn (grz999@yahoo.com.cn) purpose: to establish normal measurements of cochlea on standard position images using mpr of hrct to aid diagnosis of cochlea hypolasia. methods and materials: hrct scanning of temporal bone was undergone in 50 volunteers (100 ears). the images of all cases were postprocessed using mpr. two standard images (position i and ii) were reconstructed and 9 structures of cochlea (named a-i) were measured. statistical analysis was done on different age groups, male and female groups, left and right groups in spss program. normative data of 9 measurements were established. 9 measurements of cochlea were also done in 42 cases (78 ears echo-planar diffusion-weighted mr imaging in the detection of cholesteatomas t. kodama, t. yano, s. tamura; miyazaki/jp (tkodama@med.miyazaki-u.ac.jp) purpose: to evaluate a single-shot echo-planar diffusion-weighted magnetic resonance imaging (mri) (epi-dwi) in the diagnosis of cholesteatoma in comparison with a single-shot fast advanced spin-echo sequence (fase-dwi). twenty-one patients with a primary or postoperative recurrent cholesteatoma were examined by epi-dwi and fse-dwi in addition to standard mri such as t1-and t2-weighted imaging. epi-dwi was performed by using parallel imaging with a reduction factor of two. because of its higher signalto-noise ratio (snr), epi-dwi was obtained with a thinner slice thickness and a higher spatial resolution than that of fase-dwi. image quality of epi-and fase-dwi was judged from: 1) contrast of the lesion, 2) image distortion and abnormal signal secondary to susceptibility artifacts, and 3) anatomical correspondence with other images. results: a cholesteatoma was correctly identifi ed as an area of obvious hyperintense signal on epi-dwi and fase-dwi in 15/21 (71%) and 18/21 (86%), respectively. among the six lesions that were missed on epi-dwi, fi ve lesions were smaller than 5 mm. in 15 patients whose cholesteatoma was correctly diagnosed on the epi-and fase dwi, snr of the cholesteatoma and cerebellum, and contrastto-noise ratio of the cholesteatoma to the cerebellum was not signifi cantly different between the both sequences. image quality of epi-dwi was judged inferior to that of fase-dwi in 12 patients mainly because of susceptibility artifacts. conclusion: to use epi-dwi sequences for evaluating middle ear cholesteatomas, susceptibility artifact is still the problem that should be resolved despite the application of parallel imaging. high-resolution computed tomography evaluation of congenital anomalies of the external auditory canal and middle ear a. skorokhoda; kyiv/ua (rdcams@svitonline.com) purpose: congenital anomalies of the external auditory canal are rather common. the degree of congenital deformities runs from total atresia to hypoplasia or stenosis of the eac, to microtia. embriological development of the eac and middle ear is linked so dysplasias are usually combined. we present the experience of 36 patients examination with external auditory canal and middle ear dysplasias from 1 to 12 years. in all cases we used high-resolution ct on somatom plus 4 (siemens, germany) in axial and coronal planes. the study included 6 cases of bilateral atresia (1-bony atresia, 1-membranous atresia, 4-atresia of external auditory canal with ossicular deformities and hypoplastic mastoids). unilateral atresia was found in 30 cases: 1-bony eac atresia; 5 -eac atresia with normal sized middle ear; 10 cases had ossicular deformities but normal mastoids, 11 unilateral atresia cases had ossicular deformities and hypoplastic mastoids, thick atresic plate and no ossicles was found in 5 cases. small tympanic cavities were in 14 cases. mandibular condyles were displastic in 8 unilateral cases. stenosis of eac occurred in 1 unilateral and 1 bilateral cases. combined inner ear mondini deformity was found in 1 case. anteriorly located descending facial nerve canal was noted in 12 cases. conclusion: high-resolution computed tomography is the most important preoperative test in patients with congenital aural atresia and evaluation of the changes in middle ear, otic capsule, ossicles, mastoids, temporo-mandibular joint, facial nerve canal for providing reconstructive and cosmetic operations. although it has been described as a "relatively common" benign neoplasm, study of the literature reveals that the incidence is not very high. it is a slow growing, vascular lesion seen more often in middle age females. usually it is not detected until an imaging study is performed for other reasons. although oca is histologically benign, it can displace intraorbital structures, and cause optic nerve compression or increased iop. painless, gradually progressive proptosis and visual disturbance are the main clinical signs. imaging findings: ultrasound when performed will reveal a smoothly marginated round or oval, hypoechoic lesion with presence of internal fl ow with color-doppler. computed tomography demonstrates a hyperdense intraconal lesion, with marked homogeneous contrast enhancement. commonly orbital bone expansion is seen. calcifi cation is rare. in magnetic resonance imaging, the lesion appears isointense to muscle on t1w1 and hyperintense on t2w1. it displaces the optic nerve without infi ltrating it. the iv administration of contrast material causes enhancement of the lesion. conclusion: knowledge of the radiological appearance in cases of oca is mandatory for its correct characterization, thus, facilitating optimal treatment. head and neck background: diffusion-weighted imaging is a new imaging modality, which has signifi cant role in the brain and, recently, in the head and neck. procedure details: diffusion-weighted mr imaging was done for 132 patients with head and neck tumor using single-shot echo-planar imaging with reconstruction of apparent diffusion coeffi cient (adc) map. diffusion-weighted mr imaging plays a role in differentiating benign from malignant head and neck tumors, and helps to select the site for biopsy. also, it can be used for differentiating metastatic from reactive lymph nodes and characterization of thyroid nodules. the adc value gives an idea about cellularity of the tumor that correlates with prognosis. after treatment, it can be used for differentiating recurrent tumors from post-treatment changes. conclusion: diffusion-weighted mr imaging can help in discriminating malignant head and neck tumor from benign lesions,and is used for characterization of cervical lymph nodes. also, it has a role in follow-up of head and neck cancer patients after treatment and prediction of outcome. purpose: to report change of diffusion-weighted imaging (dwi) of malignant melanoma in head and neck after carbon-ion radiotherapy. eighteen patients having malignant melanoma in the head and neck regions undertook carbon-ion radiotherapy at the national institute of radiological sciences, chiba, japan. we examined the patients using the dwibs (diffusion-weighted imaging with background body signal suppression) method before and after the treatment. adc (apparent diffusion coeffi cient) value was measurable in 9 of 18 cases (mean age: 65 yrs, age range: 56-78, 5 males and 4 females). we compared the adc value obtained before the treatment with the one obtained after the treatment. intera achieva 1.5 t nova dual system (philips medical) was used for the examination. the epi-based diffusion-weighted imaging sequence with spir fat suppression was applied at the settings of 2 b-values, namely 0 and 1000 sec/mm 2 , respectively. results: average adc value for all clinical cases were 0.897×10 -3 (s.d.: 0.142×10 -3 ) at pre-treatment and 1.355×10 -3 (s.d.: 0.573×10 -3 ) at post-treatment. adc values increased in 8 of 9 cases and decreased in 1 case. there was a signifi cant difference in adc value between pre-and post-treatment (p < 0.028). conclusion: dwibs examination for malignant melanoma in the head and neck showed signifi cant increase in adc value after carbon-ion radiotherapy. the adc value has the possibility of becoming a criteria when we judge the effect of the carbon-ion radiotherapy in malignant melanoma. learning objectives: to identify those patients who will benefi t a specifi c imaging study to rule out vascular lesions in the head and neck region. to describe the radiologic fi ndings and more frequent locations of these traumatic lesions. to establish which are the optimal imaging techniques to confi rm the presence of a vascular lesion and to characterize them. background: vascular lesions of the head and neck region are a clinical emergency with important morbidity and mortality, and appear frequently in polytraumatized patients who are diffi cult to evaluate. a high suspicion index is required and prompt realization of modern imaging studies is critical for an accurate and rapid diagnosis. imaging findings: we review the radiologic appearance of the main traumatic vascular lesions: arteriovenous fi stula, occlusion, dissection, pseudoaneurysm, and transection. we point out the locations where one should search for these lesions. we analyze the results of the different imaging techniques. conclusion: ct angiography (cta) and mr angiography (mra) allow prompt and accurate diagnosis of traumatic vascular lesions, which is crucial in the prognosis of these patients and ensures their correct management. conventional angiography remains the gold standard for the confi rmation of these lesions and enables an endovascular treatment, but is costly and not optimal as a screening technique, and is not exempt of serious neurologic complications. the use of non-invasive techniques (cta and mra) for the initial assessment of vascular lesions is growing rapidly. these techniques offer several advantages: they are non-invasive, less resourcedependent, and allow simultaneous evaluation of extravascular structures. effi ciency of ultrasonic elastography in the differential diagnosis (metastatic or reactive) of the enlarged cervical lymphnode f. alam, k. naito, t. tachikake, j. horiguchi, h. fukuda, h. yasutomi, n. hirai, k. marukawa, k. ito; hiroshima/jp (falam53@yahoo.com) purpose: evaluation of ultrasonic elastographic appearance of enlarged cervical lymph nodes and exploration of the diagnostic reliability in differentiating between metastatic and reactive cervical lymphadenopathy. methods and materials: realtime elastography of 60 enlarged cervical lymph nodes (28 metastatic, 32 reactive) from 25 patients (16 men, 9 women; age range: 11-85 years; 14 head-neck cancer, 11 having no malignancies) was performed. all the lymph nodes were evaluated for distribution and the percentage of stiff areas. then they were classifi ed using a 5-pattern system (1-5). pattern 1: stiff areas occupying the whole or almost whole lymph node (ln) with or without a thin rim of peripheral relatively soft areas. pattern 2: same as pattern1 with central relatively soft areas. pattern 3: stiff areas occupying more than 50% of the ln. pattern 4: stiff areas occupying not more than 50% of the ln. pattern 5: small stiff areas scattered into relatively soft area of the ln. the cutoff line for metastatic lesions was set between 3 and 4. patterns 1 to 3 were considered malignant and 4 and 5 were considered reactive. histopathological results and clinical fi ndings (including ct fi ndings) were considered as reference standard for analysis of elastographic fi ndings. results: sensitivity, specifi city, positive predictive value, negative predictive value and accuracy were 78.6%, 100%, 100%, 84.2% and 90%, respectively. conclusion: ultrasonic elastography showed excellent performance in the diagnosis of metastatic cervical lymphadenopathy. due to high specifi city of this method, invasive procedures might be reduced when ultrasonic elastographic result is positive for lymphnode metastasis. gnathic bones ( odontogenic tumors are composed of cellular constituents whose primary purpose is to form teeth or toothrelated structures (odontogenesis). numerous lesions can affect the gnathic bones, including odontoma (compound and complex), ameloblastic fi bro-odontoma, calcifying odontogenic tumor (pindborg tumor), odontogenic myxoma, cementoblastoma (cementoma), ameloblastoma, odontogenic keratocyst, and dentigerous cyst. the diagnosis of these processes can be tricky because of non-specifi c imaging features, atypical clinical presentation, and lack of familiarity with certain abnormalities. imaging findings: radiography, the modality most often used for initial evaluation, can be helpful for detecting cortical destruction. however, ct is more sensitive than radiography for detecting calcifi ed tumor matrix and cortical destruction. ct also provides delineation of the anatomic extent of the lesion, and can guide biopsy. in addition to imaging fi ndings, patient history, physical examination and histologic analysis are required to reach the correct diagnosis. the morphologic characteristics of odontogenic tumors and other lesions of the gnathic bones provide key diagnostic clues regarding the aggressive or non-aggressive behavior of the disease process. awareness of the radiologic presentations of abnormalities helps formulation of the most likely diagnostic choices. gnathic bones ( background: odontogenic tumor-mimicker lesions (non-odontogenic lesions masquerading as odontogenic lesions) may further complicate diagnosis. in the gnathic bones, a group of such lesions includes paget's disease, brown tumor, infl ammatory disease, aggressive infantile fi bromatosis, cleidocranial dysplasia, fi brous dysplasia, leukemia, multiple myeloma, maxillary sinus carcinoma, juvenile angiofi broma, and metastatic disease. although several of these conditions share some clinical, radiologic, and pathologic characteristics, they do have very different treatments and prognoses. imaging findings: although the imaging features of many lesions mimicking odontogenic tumors are non-specifi c, knowledge of the typical radiologic manifestations of odontogenic tumor-mimicker lesions often enables their differentiation from odontogenic tumors, and occasionally allows a specifi c diagnosis to be suggested. osseous expansion, an aggressive characteristic, may occur with non-malignant conditions, such as paget's disease. similarly, a rim of bone sclerosis around a lesion is a non-aggressive characteristic that, in rare circumstances, is present in malignant neoplasms. furthermore, local infl ammation is frequently associated with poorly demarcated osteolysis and periostitis, fi ndings that resemble those of a malignant tumor. conclusion: although aggressive lesions are commonly malignant and benign tumors are commonly non-aggressive, this is not uniformly true. consideration of certain imaging fi ndings of a lesion within the gnathic bones can narrow the broad differential diagnosis. evaluation of radiation damage to the microstructure of the parotid gland using mr microscopy t. kan, k. kodani, s. fujii, t. ogawa; yonagoshi/jp (jpfdt645@yahoo.co.jp) purpose: radiotherapy for head and neck cancer traditionally includes large parts of the parotid gland in the radiation fi eld and often leads to distressing oral complaints. the aim of this study is to elucidate the radiation damage to the microstructure of the parotid gland using mr microscopy. this study comprised 20 normal subjects without parotid disease and 20 patients treated with radiotherapy for head and neck cancer. mean dose to the parotid glands included in the radiation fi eld was 11.1 to 38.6 gy (median: 22.3gy). mr imaging was performed using a 40 mm microscopy coil before and after radiotherapy. axial fat-suppressed t2-tse images were obtained with a 1.5 t scanner. we assessed the radiation damage to the parotid parenchyma and duct using imagej (version 1.36 software program). the thickness of the parotid duct wall in the normal group was 0.31 to 0.62 mm (mean: 0.46 mm). in irradiated patients, thickening of the duct wall was observed (0.63-1.24 mm, mean: 0.93 mm) after radiotherapy. the difference of the wall thickness was statistically signifi cant (p < 0.001). in normal subjects, reticular pattern refl ecting the microstructure in the gland parenchyma could be clearly visualized, while thickening of the reticular pattern and atrophy of the gland parenchyma were observed in the radiotherapy group. conclusion: mr microscopy allows us to evaluate not only the volume reduction and signal intensity changes of the parotid gland, but also the microstructure of the gland parenchyma, thereby refl ecting the histopathological changes following radiotherapy. multi results: on both mcta and color duplex imaging, carotid body paraganglioma was characterized as highly hypervascular lesions, with anteromedial dislocation of the external carotid artery in 33 cases and posterolateral dislocation of the internal jugular vein in 7 cases. the duplex spectrum in the contributing external and internal carotid arteries showed a high fl ow and low-resistance pattern. in schwannomas and neurophibromas, vessel invasion had not been identifi ed, but close ring enhancement was revealed. on cds, tumor was revealed as hypovascular lesion with high-resistance pattern. neurogenic sarcomas were characterized as hypervascular tumors with invasion in internal jugular vein in four cases, while the distal part of the common carotid artery and its bifurcation could not been identifi ed in three cases. in all cases, intralesional fl ow and tumor relationship with adjacent vessels detected by cds and scta correlated well with the intraoperative fi ndings. conclusion: mcta and cds are an accurate diagnostic method for the precise evaluation of neck tumors. the methods provide valuable preoperative information regarding tumor vascularity and neck vessel compression or invasion. gnathic bones ( imaging findings: conventional (anteroposterior, lateral, and oblique), intraoral dental, and panoramic radiographs remain the mainstay in the assessment of osseous lesions involving the gnathic bones. ct and mr imaging provide further characterization of the intrinsic features of lesions affecting the ganthic bones and allow determination of the extent of involvement of the dentomaxillofacial complex and paranasal sinuses. principles of imaging interpretation include evaluation of the lesion location within the maxilla or mandible, shape, size, and rate of growth, pattern of bone destruction, demarcation, tumor matrix, septation, osseous expansion, cortical erosion, periosteal reaction, relationship of lesion to the adjacent tooth structures and sinuses, associated soft tissue mass, and marrow edema. conclusion: recognition of the key imaging fi ndings of non-odontogenic tumors and tumor-like lesions affecting the maxilla and mandible, combined with clinical evaluation and results from histopathology suffi ce for correct diagnosis. establishment of defi nitive diagnosis can help the surgeon avoid undue extensive or unnecessary surgery. were pathologically proven to be pleomorphic adenomas. the wide range of imaging fi ndings will be discussed. conclusion: all palpable tumors in this series were greater than 10 mm on presentation and most of tumors were unilateral and involved the superfi cial lobe of the parotid (over 90%). although pleomorphic adenomas had a wide range of size, heterogeneity, and enhancement characteristics, most tumors demonstrated a capsule with circumscribed borders. recognizing the pleomorphic adenoma may avoid unnecessary surgery. results: after administration of sonovue ® , malignant nodules showed absent (4/13), faint dotted (4/13) and diffuse contrast-enhancement (5/13); in this latter case inhomogeneous (4/5 cases) or homogeneous (1/5). benign nodules showed diffuse contrast-enhancement, both homogeneous (3/5) or heterogeneous (2/5). quantitative data confi rmed subjective fi ndings but ceus never modifi ed precontrast analysis. conclusion: ceus of thyroid gland is a feasible technique but overlapping fi ndings seem to limit the potential of this technique in the characterization of thyroid nodules. the comparative diagnostic yield of freehand versus ultrasound guided fi ne needle aspiration of thyroid nodules r. davis, m. rogerson, i. britton, j. oxtoby; stoke-on-trent/uk (robmdavis@hotmail.com) purpose: despite the risk stratifi cation provided by ultrasound and nuclear medicine, histology is the only discriminator of benign from malignant thyroid nodules. the method of obtaining cytology locally is hybrid, both freehand and ultrasound guided. the aim of this study was to determine which is the most successful at providing an early diagnosis. methods and materials: one hundred and ninety nine consecutive patients undergoing thyroid fi ne needle aspiration (fna) during a two year period (july 2004-july 2006) were included in a retrospective review. cytology was classifi ed as: (1) diagnostic or (2) non-diagnostic by a cytologist. freehand accounted for 29% (58/199) of samples, whilst the remaining 71% (141/199) were obtained by ultrasound guidance. results: diagnostic samples were obtained in 77% (154/199) of patients. this corresponds to a diagnostic yield of 62% (36/58) in the freehand fna group compared with 84% (118/141) in the ultrasound guided fna group. comparison of predicted versus observed events was performed with a chi-squared statistic of 9.78 (p < 0.001). conclusion: obtaining cytology by an ultrasound guided method is statistically signifi cantly more successful (p < 0.001) and should be the primary diagnostic technique in avoiding a delay in diagnosis. ct scans were obtained before and after the contrast medium administration (delay of 30 and 80 sec), with a thickness of 2.5 mm, and a reconstruction interval of 1.25 mm. ct fi ndings were compared to surgical results. results: ct examination resulted positive in 35 cases, negative in 15 cases and doubtful in 10 cases. 40/60 patients underwent surgery: surgery identifi ed 39 lesions (37 adenomas, 2 primary hyperplasia); in 2 cases surgery was negative, while in 8 cases the lesions interested an ectopic parathyroid gland. surgery confi rmed ct evaluation in 23/35 positive cases; in 8/10 doubtful cases, surgery confi rmed the location of the lesion in 5 cases, in 2 cases the lesions resulted to be ectopic, while in 1 case surgical exploration resulted to be negative. in 9/15 cases with negative ct fi ndings, surgery identifi ed the lesion in 8 cases, while 1 case resulted to be negative. the sensitivity and specifi city values results were 78% and 25%, respectively, with a diagnostic accuracy of 73%. conclusion: multidetector ct is an accurate second-level diagnostic technique in the detection of a parathyroid lesion, allowing the exploration of the entire cervical and mediastinal regions. radiologic 60.8% of patients showed benign cytologies and 10.8% malignant disease. 2 cases (4.3%) were indeterminate (follicular proliferation). on pet studies, 54% of the lesions showed positive uptake (suv max: 1.7-19). since there was an uptake overlap between benign and malignant lesions, all lesions with positive uptake underwent us-fna. three out of 7 cases with fi ne needle aspiration and biopsy proven malignancies had negative pet studies. nineteen benign lesions showed positive uptake (highest value suv max: 10). in our series, the incidence of primary thyroid cancer in patients with previous history of malignancy was 26% and for breast cancer patients it was 54%. conclusion: us guided fi ne needle aspiration is a useful method for characterisation of thyroid lesions with a positive pet result. the absence of uptake does not exclude malignancy. patients with previous malignancies, specially breast tumours, with positive pet results have greater incidence of thyroid malignancy. sonographic purpose: to evaluate pretracheal, jugular and paratracheal lymph nodes enlargement at us in patients affected by occult or chronic thyroiditis in active phase. we selected 154 patients who underwent neck high resolution sonography and color doppler. patients were divided into 3 groups: a group: 64 patients (42%) suspected of chronic thyroiditis in active phase; b group: 70 patients (45%) with clinical history of thyroiditis; c group: 20 patients (13%) with positive familiarity of thyroid pathology. in addiction, we considered the thyroid hormones and antibody titers, classifying four levels of gravity: normal (i°), low high (ii°), high (iii°), more high (iv°). results: a group: 27% showed antibody titers (iv°) and sonographic characteristics of cronic thyroiditis in active phase, with pretracheal (70%), jugular (59%), and paratracheal (35%) lymph nodes reactive enlargement. 15% showed antibody titers (iii°) and only pretracheal (13%) and jugular (2%) lymph nodes enlargement at us. b group: all patients had antibody titers (ii°-iii°) and sonographics chronic thyroiditis characteristics, with pretracheal (81%), jugular (63%) e paratracheal (25%) lymph nodes lipomatous enlargements. c group: 9% was negative from clinical-strumental point of view, while 4% had antibody titers (i°-ii°) and and only pretracheal (13%) and jugular (2%) lymph nodes reactive enlargement at us. the ultrasound evidence of neck lymph nodes enlargements, especially pretracheal, appears to be a very useful us sign of subacute or chronic thyroiditis. colour background: sonography is the main imaging tool in the assessment of patients with thyroid nodules. malignant thyroid nodules show a variety of doppler patterns that should be known in order to prompt further evaluation (cytology). procedure details: malignant nodules usually appear hypervascular, although hypervascularity is not specifi c for malignancy. conversely, absence of vascular signal is highly predictive of benign nature. a complete vascular halo around a nodule is highly predictive of its benign nature. absent vascular halo and intranodular vascularity are not specifi c for malignancy, but a combination of absent halo, microcalcifi cations, and intense fl ow is signifi cantly specifi c for its malignant nature (although insensitive). spectral analysis has a limited practical value. lymph nodes, node-to-vessel relationship, and jugular vein thrombosis can be evaluated. lymph nodes usually demonstrate peripheral vascularization with irregular signal distribution and alternated hypervascular and hypovascular intranodular areas. conclusion: cd and pd imaging has a signifi cant additional role in the us assessment of thyroid cancer and of metastatic cervical lymph nodes. troisier sign (left-sided supraclavicular metastatic lymph node): an old but still possible presentation sign of chest and abdomen tumours f. all parotid gland tumors were histologocally confi rmed: 13 pleomorphic adenomas, 7 warthin's tumors, 2 lymphoepithelial cysts, 1 schwannoma, 1 adenoid cystic carcinoma, 1 small cell carcinoma, 1 salivary duct carcinoma with pleomorphic adenoma, and 1 myoepitheial carcinoma. we obtained axial and coronal t1-weighted, t2-weighted and gd-t1-weighted images. we tried to evaluate prospectively tissue characterization of the parotid gland tumors and also to analyze the relationship of the tumors to the facial nerve. after the surgical resection of the tumors, we performed mr-pathologic correlation and confi rmed the relationship of the tumors to the facial nerve. results: from the mr-pathologic correlation, we could perform tissue characterization of the tumors. this information was useful for the differentiation of parotid tumors. in all cases, except for a few patients with large tumors, primary branches of intraparotid facial nerve were clearly identifi ed. conclusion: high-resolution mr images obtained by mr microscopy using 3 tesla mri is quite useful for differentiating parotid gland tumors and preoperative planning of surgical approaches for parotid gland tumors. preoperative localization of hyperfunctioning parathyroid glands using c-11 methionine pet: a comparison with 18 f-fdg pet and 99m tc-mibi scintigraphy h. wakamatsu 1 , s. nagamachi 1 , s. fujita 2 , k. kamimura 2 , r. nishii 1 , s. futami 1 , s. tamura 1 ; 1 kiyotake-cho/jp, 2 miyakonojo/jp purpose: preoperative localization of hyperfunctioning parathyroid glands in patients with hyperparathyroidism (hpt) is important. previously, we reported a direct comparison study using 99m tc-sestamibi (mibi), 99m tc-tetrofosmin, and 201 tl. in our previous study, 99m tc-mibi and 99m tc-tetrofosmin were equally useful and they were more useful than 201 tl. recent reports have shown the usefulness of 11 cmethionine positron emission tomography (pet), but the role of 11 c-methionine is not well known. we directly compared the detectability for localization of abnormal parathyroid glands using 11 c-methionine pet, 18 f-fl uorodeoxyglucose (fdg) pet and dual-phase 99m tc-sestamibi (mibi) scintigraphy to clarify the usefulness of 11 c-methionine pet. methods and materials: seven patients (3 men and 4 women), 6 primary hpt and 1 secondary hpt, were evaluated. we performed 11 c-methionine pet, 18 f-fdg pet, and dual-phase 99m tc-mibi scintigraphy on all patients and directly compared the detectability. they were operated and confi rmed histologically. results: in 6 patients with primary hpt (6 adenomas), 5 patients (83.3%) were correctly localized by 11 c-methionine and dual-phase 99m tc-mibi scintigraphy. but 18 f-fdg pet could detect only 1 of the 6 patients (16.7%). in 1 patient with secondary hpt, 11 c-methionine pet and dual-phase 99m tc-mibi scintigraphy could detect 2 of the 4 abnormal hyperplastic parathyroid glands (50%), but 18 f-fdg pet could not detect abnormal parathyroid glands. conclusion: in our preliminary study, 11 c-methionine pet and dual-phase 99m tc-mibi scintigraphy are equally useful for localization of hyperfunctioning parathyroid glands, but 18 f-fdg pet is not satisfactory for the localization of hyperfunctioning parathyroid glands. purpose: we study peripheral lymph (cervical, axillary and inguinal) nodes features in order to differentiate malignant adenomegalies from hypertrophic-reactive nodes. methods and materials: we practised high resolution ultrasonography with 7.5-13 mhz lineal probes in 100 patients (56 women and 44 men). the ages ranged from 7-78 years (mean age 51.4 years). results: 300 nodes were observed, with 181 benign and 119 malignant nodes. 130 benign nodes (71.8%) had oval shape (vasallo index ≥1.8) and echogenic centre. 21 benign nodes (11.6%) were oval, without central refringence. 20 nodes (11%) had kidney-like shape with echogenic centre. 98 benign nodes (54.1%) showed central arterial signal associated with intranodal vascular branching. 67 nodes (37%) showed central vascular signal alone. in 139 nodes (76.8%) there was low resistance (ir< 0.75) arterial signals and 19 nodes (10.5%) showed high resistance doppler signals (ir ≥or 0.75). 77 malignant lymph nodes (64.7%) appeared rounded (vasallo index < 1.8) without central echoes, heterogeneous and hypoecoic. 12 nodes (10.1%) were kidney-shaped, hypoechoic. 27 nodes (22.7%) were rounded, with eccentric echoes. 82 malignant nodes (68.9%) showed lateral vascular signals without central vascular signals; in 16 nodes (13.4%) a central vascular signal was recorded. 67 malignant nodes (56.3%) showed high resistance vascular signals. in 28 adenopathies (23.5%) the arterial signals were of low resistance. there was no doppler signal in 13 malignant nodes (10.9%). 10 neoplastic nodes (8.4%) showed vascular intranodal branching. conclusion: we can combine morphologic and vascular nodal features to differentiate accurately between malignant lymph nodes and hypertrophic-reactive nodes. us fi ndings in loco-regional metastasis from malignant melanoma a. cuñat, e. ponce, a. julve, m. pina, v. perez, e. belloch; valencia/es (acunat@telefonica.net) purpose: we describe the us fi ndings in lesions secondary to malignant melanoma. the lesions were located near the place of excision of the primary melanoma or in the fi rst lymphatic region. methods and materials: 10 patients were included from march '05 to march '06. the ages ranged between 47-79 years (mean age 65 years). all the patients had their malignant melanoma resected 6-24 months before the us exam. we practised high-resolution us with 7.5-13 mhz probes. we observed 18 rounded-oval, solid lesions and 2 fl uid-fi lled nodules. 17 lesions were hypoechoic and one had muscle-like refringence. 12 (60%) lesions were located inside subcutaneous fat over the surgical scar or at a distance 20-40 mm from the scar (8 nodes). the diameter of the lesions ranged from 3-13 mm for the non-palpable nodes (12 lesions, 60%), and 6.5-81 mm for the palpable ones (8 nodes, 40%). four lesions (20%) showed irregular vascular doppler signals, located in the periphery of the nodes, two with arterial low-resistance spectra, one with high resistance arterial spectra and one with venous fl ow. the remaining nodules did not showed vascular signals. conclusion: us examination of the surgical scar and fi rst lymph node station should be included in the screening for metastasis in patients with malignant melanoma excised. the non-palpable lesions are easily detected. venous chest port implantation in pediatric patients e. akgul, t. : 190) and ranged between 7 and 697 days. six (12.8%) patients died while ports were still being used. in the follow-up period, complications were encountered in 4 (8.5%) patients. in 1 patient, port was extracted because of infection in the fourth month. in another patient, incision of port pocket was resawn because of separation. in 2 patients, the needles could not be inserted into ports because the port base was turned upside down. in these patients, the ports were rotated to normal position manually. conclusion: in pediatric patients, implantation of subcutaneous venous chest ports should be preferably placed under imaging guidance by an experienced interventional radiologist because of the higher technical success and lower complication rates. transarterial embolization for the treatment of benign prostatic hyperplasia: a preliminary study on technical feasibility and safety in pigs sixteen large white adult intact male pigs were randomized into 2 groups: embolization (n = 8), control (n = 8). under general anesthesia, all animals underwent selective angiography on both sides. in animals of the group embolization, embosphere (500-700 µm) was used to embolize the prostatic branches. three months later, the animals in both groups, except one from group embolization with lameness of a hind limb, were evaluated on sexual function by breeding with adult female pigs. sexual function of the male pigs was subjectively evaluated by assigning 0-3 points. the animals were sacrifi ced following the sex test and the prostates were removed for pathological study. results: technical success was obtained in all animals that received embolization; no associated complication was observed. compared with those in the group control, the prostate size was signifi cantly reduced after embolization (p < 0.01); no difference on sexual function was noticed between the 2 groups (p > 0.05). pathological study suggested that particles of embosphere occluded arterioles inside the prostate; partial normal gland structure nearby the occluded arterioles disappeared with glandular atrophy and infi ltration of lymphocytes. conclusion: transarterial embolization of the prostate is technically feasible and safe in the healthy intact pigs. the embolization may reduce the size of the prostate without compromising the normal sexual function. analysis of factors related to restenosis after percutaneous angioplasty for native avf stenosis in patients of hemodialysis j. jang 1 , y. kim 1 , s. yang 2 , d. or ≥5year) , 4)duration of avf (< 5year or ≥5year), 5) hypertension, 6) smoking, 7)diabetes mellitus, 8) type of avf, 9) location of stenosis, 10) degree of stenosis (< 90% or ≥90%), 11) length of stenosis (< 1 cm or ≥1 cm), 12)degree of dilatation (< 90% or≥90%), 13) thrombus, 14) use of stent, and 15) type of balloon (conventional balloon or cutting balloon). results: there are fi ve factors related to restenosis after percutaneous angioplasty for native avf stenosis in patients of hemodialysis patency, which are: 1) duration of avf, 2) use of stent, 3) type of avf, 4)location of stenosis, and 5) length of stenosis. longer duration of avf and use of stent in the treatment of native avf stenosis demonstrated higher patency rate. also, cephalic arch of avf, brachio-cephalic stenosis, and longer length of stenosis were demonstrated higher patency rate. conclusion: factors related to restenosis after percutaneous angioplasty for native avf stenosis in patients of hemodialysis were included duration of avf, location of stenosis, use of stent, length of stenosis. budd ) ). advantages/disadvantages of each will be outlined. procedure details: based on a large experience of over 200 optional fi lter placements, technical issues with regard to placement of optional fi lters and complications encountered will be discussed. issues with regard to anticoagulation will also be discussed. conclusion: optional fi lters are now the fi lters of choice for ivc fi ltration. retrieval intervals differ between fi lter types, making the choice of fi lter important if retrieval is planned. continuous regional arterial infusion therapy for acute severe pancreatitis: between cumulative dosage of intraarterial administrated drug for the early stage and outcomes of patients purpose: to evaluate the correlation between cumulative dose of intraarterial administrated drug for the early stage of acute severe pancreatitis and outcomes of patients. thirty-fi ve patients with acute severe pancreatitis have undergone on initiation of continuous regional arterial infusion (crai) protease inhibitor, nafamostat mesilate, or gabexate mesilate, and antibiotics, ipm/cs, and intravenous administration of those. we retrospectively reviewed the day after disease onset, cumulative dose of intraarterial, and intravenous administrated these drugs at that time. cumulative intraarterial administrated doses, intravenous administrated, and total administrated doses were calculated. these factors were compared with outcomes that included mortality rate, periods of admission of the hospital and the intensive care unit (icu), periods that individual laboratory indexes indicated abnormal level. spearman rank correlation was used for statistical analysis. results: each crai was started within 72 hours after the onset on thirty-three patients (91%). the mortality rate was 2.4%. cumulative intraarterial administrated doses of nafamostat mesilate for the early stage had signifi cant correlation with normalization of crp (p=.033) and periods of admission of icu (p=.035). cumulative intraarterial administrated doses of ipm/cs for the early stage had signifi cant correlation with normalization of crp (p=.042). there was no correlation between other parameters and outcomes. conclusion: these results suggest that increased dosage of intraarterial administration of nafamostat mesilate, and ipm/cs at the early stage may reduce the period of high risked condition of acute severe pancreatitis. purpose: tips with bare-stents in patients with budd-chiari syndrome (bcs) has a very high incidence of shunt dysfunction (stenosis and occlusion) and the placement of 10 mm stents have a high incidence (43% according to literature) of encephalopathy. we assessed the medium-term response after placement of 8 mm ptfe-covered stents. in 2005, 9 patients (6 child-pugh b, 3 c) underwent tips with ptfe-covered stents (viatorr, gore, usa, 8 mm in diameter). long-term anticoagulation therapy was promptly instituted. 5 patients had a myeloproliferative disorder, 1 genetic thrombophilia, 3 with unknown etiology. 7 patients had ascites, non-responding to diuretic therapy, 1 had bleeding due to portal hypertension, 1 had hepatorenal syndrome. hvpg before and after the procedure was measured. all patients underwent color-doppler and laboratory exams after 48 hours and 1, 3, 6 months. after 6 months an angiography was performed. results: in 9 procedures, 19 stents were placed. in 4 patients, a transcaval puncture was needed. hvpg reduced from 24+6 mmhg to 11+2 mmhg (p < 0.001). after a medium follow-up of 15 months, 8 patients are alive, 1 dead 3 days after the emergency tips procedure. 2/8 patients had an early occlusion, resolved with thrombolytic therapy. 7/8 shunts are still open at color-doppler and angiographic study; all these patients had clinical and biochemical improvement. only 2 patients (22%) developed a transitory encephalopathy. conclusion: tips with 8 mm ptfe-covered stents obtained a good technical, clinical and hemodynamic success, at a medium term follow-up, with a lower incidence of transitory encephalopathy compared to 10 mm stents. there was no statistical difference in the clinical tumor response between the two groups. there was also no statistical difference in overall survival rates (p=.7770) between the two groups. conclusion: arterial infusion chemotherapy may be suitable for oral cancer and there was no different effi cacy between carboplatin and cisplatin regimens. bilateral vertebral artery aspiration to enhance retrieval of basilar artery embolism t.e. mayer; munich/ de (t.e.mayer@med.uni-muenchen.de) purpose: intra-arterial fi brinolysis has lowered the death rate in patients with brobasilar thrombosis, but recanalisation failures, the time-consuming procedure itself, and haemorrhagic complications are still major limitations of this therapy. therefore, a variety of retrievers are now under investigation, but still not satisfactory, since recanalizazion rates by the retrievers alone only reach 50%. therefore, we evaluated a novel mechanical recanalisation technique -remote bilateral simultaneous vertebral thromboaspiration -to enhance the effect of retrievers in distal basilar artery embolism. methods and materials: ten patients with acute basilar artery embolism were evaluated. they were treated with bilateral or in case of occlusion or hypoplasia of the contralateral vertebral artery (va) unilateral proximal thromboaspiration during the use of different retrievers or even without the use of a retriever. results: complete recanalisation of the basilar artery was achieved in all cases. no procedure-related complications were seen. eight patients survived. the clinical outcome will be reported. conclusion: this small pilot study showed that remote thromboaspiration in distal basilar artery embolism is safe. it can be successful alone, and might be useful in combination with mechanical retriever devices. larger and randomized studies are needed. percutaneous thrombin treatment of pseudoaneurysms in different arterial territories: pictorial review a. lüttich, j. perendreu, j. falco, j. fortuño, j. branera, p. bermudez; learning objectives: to review and illustrate percutaneous use of thrombin in the treatment of pseudoaneurysms in different arterial territories. background and procedure details: we illustrate our experience in the percutaneous thrombin treatment of pseudoaneurysm with a review of all cases treated in our centre with this method. most of the patients had pseudoaneurysms located in the femoral artery, humeral artery, tibial anterior artery, and splenic artery. we include also one case of an aortic endoleak post-endoluminal treatment treated with percutaneous thrombin injection. we show angiographic, ultrasonographic and ct images before, during, and post-procedure. conclusion: percutaneous thrombin injection to treat pseudoaneurysms is effective, fast and safe, and currently the treatment of choice in most of these cases. radiological treatment of venous stenoses after "piggy-back" technique liver transplantation ( purpose: to describe a new approach to transjugular intrahepatic portal shunt (tips) using percutaneous transhepatic-transjugular technique in patients with portal hypertension, whose hepatic venous anatomy was unsuitable for the standard procedure. methods and materials: portocaval shunts were created using a single percutaneous transhepatic needle pass in 5 patients. under sonographic guidance, we identifi ed on a single plane the left or right portal vein or one of their fi rst branches and its correspondent aligned left or right hepatic vein. both vessels were then punctured with a 20-gauge, 15-20 cm chiba needle. a 0.021 inch guidewire was advanced through the needle into the inferior vena cava, then the needle was removed and a 5 fr sheath was placed over the guidewire into the ivc. subsequently, a 0.035 inch hydrophilic guidewire was snared into the superior vena cava and withdrawn through the transjugular sheath. the rest of the procedure was completed in the standard fashion. the portocaval shunts were successful in all patients. there were no major complications during the procedures. one patient underwent olt 1 month later. in 3 patients, the shunts were patent at 6-12 month follow-up. one patient died due to liver failure 1 month after the procedure. conclusion: direct portocaval shunt creation using sonographic single transhepatic needle pass is a good alternative when standard procedures are diffi cult or impossible due to inadequate venous anatomy or abnormal anatomic relationship between the portal vein branches and hepatic veins. early purpose: severe symptomatic lower limb swelling is a recognised complication of compression or invasion of the ivc by intra-abdominal malignancy. symptomatic relief of symptoms by ivc stenting has been described as an effective means of palliation. however, there has been a reluctance to place stents across the origin of the renal veins due to the possibility of compromising renal function by a suggested reduction in renal blood fl ow. we analyse our experience with trans-renal ivc stenting and determine if there is a deleterious effect on renal function. we review 6 patients with intra-abdominal malignancy and associated symptomatic lower limb oedema that had compression of the ivc by nodes or tumour mass. diagnosis was made using contrast-enhanced ct or gadolinium-enhanced mri. all 6 patients had disease involving the ivc adjacent to the renal veins. using standard techniques, self-expanding stents were used to traverse the stenosis. all patients were monitored post-procedure with ultrasound to establish patency and regular serum creatinine levels to ensure the renal function did not deteriorate. results: there was a signifi cant symptomatic improvement in leg swelling following stenting in all of the treated patients. follow-up imaging demonstrated no delay in renal contrast enhancement. there was no signifi cant increase in serum creatinine levels. conclusion: ivc stenting for the treatment of lower limb swelling due to malignancy is an effective palliative method of reducing symptomatic lower limb oedema due to intra-abdominal malignancy and can probably be safely carried out without concern for renal function compromise. further studies are warranted. results: technical success was obtained in all 15 patients; in control group, technical success rate was 86%. coil embolization of collaterals was needed in 4 (26%) of 15 patients, which were signifi cantly lower than that in control group (47%) (p < 0.05). mean amount of sclerosant used was 15.0 ml, and was signifi cantly lesser than in control group (21.7 ml) (p < 0.05). one patient showed transient ascites for a few days after treatment, but no major complications were encountered. the selective obliteration technique using a coaxial balloon catheter system would reduce the necessity of coil embolization procedure of abundant collateral veins, and can also reduce the amount of sclerosant. this catheter system can simplify the technique for the treatment of gastric varices. the for the sclerosing therapy, used 3%-ed solution of thrombovar taken into account the calculations 10% from the volume of cystic content, which developed total contact with epithelial integument of cyst and caused an aseptic infl ammation of cyst walls. some patients after interventional radiology treatment were prescribed slight forms of antihypertensional medicines according to individual. results: among 206 patients, recovery with stable course of arterial hypertension was reached in 115 cases (56%). improvement has been observed in 85 cases (41.5%). in 6 (2.5%) cases, this treatment turned out to be ineffective. review of intra-arterial thrombolysis as a causative treatment of hyperacute cerebral ischemic stroke c. iosif, m. papathanasiou, a. gouliamos; athens/gr (christinaiosif@yahoo.gr) learning objectives: to review the current imaging and interventional protocols, the indications and requirements for the performance of intra-arterial thrombolysis as a causative treatment of hyperacute ischemic stroke. to describe the methodology and results worldwide of the last 15 years. to discuss the conventions and ideal conditions of function of the stroke units in accordance with the international experience of stroke units of excellence on the fi eld. background: cerebral ischemic stroke is the 3 rd leading cause of death and the 1 st cause of disability in the developed countries (europe 650.000 deaths/year, eusi 2003) with a heavy fi nancial and social cost. the establishment of an effective treatment is a very important medical and social issue. procedure details: intraarterial thrombolysis is effective when there is still viable brain tissue. patient selection is based on the therapeutic window since the symptoms onset, on the lack of clinical and imaging exclusion criteria and on the imaging confi rmation of occlusion of cerebral artery. the imaging protocols with ct-ct perfusion mad mr diffusion-perfusion are discussed, as well as the modifi cation of the time window according to the imaging fi ndings. the therapeutic approach is either intraarterial, with the use of thrombolytic medicine, either combined with intravenous infusion (i.v. glucoprotein inhibitor ιιb/iiia). the recanalisation rate is up to 70% considering the anterior circulation. major complication is hemorrhagic transformation. conclusion: intraarterial thrombolysis when performed in specialized centers is an effective etiological treatment of ischemic stroke and has a low complication rate when the inclusion criteria are kept. effects of continuous regional arterial infusion therapy for acute severe pancreatitis: correlation of pre-treatment disease severity and outcomes of patients purpose: to assess the correlation between severity parameters on initiation of continuous regional arterial infusion (crai) and outcomes of patients. methods and materials: thirty-fi ve patients with acute severe pancreatitis have undergone crai and intravenous administration of protease inhibitor and antibiotics. we reviewed severity parameters in these patients that included pre-treatment apach-ii score, ct severity index, laboratory indexes and the periods between disease onset and crai. these factors were compared with outcomes that included mortality rate, periods of admission of the hospital and the intensive care unit (icu), periods that individual laboratory indexes indicated abnormal level. spearman rank correlation was used for statistical analysis. results: thirty-three patients (91%) had undergone crai within 72 hours after the onset. among all patients, apach-ii score was 10.4 ± 4.8 (mean ± sd), ct severity index was 5.4 ± 1.9. despite disease severity, the mortality rate was extremely low (2.4%). there was no correlation between parameters of disease severity and other outcomes. conclusion: these results suggest that disease severity may not directly refl ect outcomes of patients when crai is performed in early stage of acute pancreatitis. biomechanical infl uences for intravascular stent fractures r. suri, e. sprague, d. marton; san antonio, tx/us (suri@uthscsa.edu) learning objectives: 1. to understand the signifi cance of stent fractures. 2. to evaluate the individual and synergistic role of vessel deformation, biological properties and biochemical factors that could play role in the disruption of the long term integrity of implanted intravascular stents. background: though percutaneous interventional treatment of stenotic vascular disease has been revolutionized with stent placement, sirocco trials and recent studies are reporting increasing incidence of stent fractures. the etiology and incidence of stent fractures is still unclear. imaging findings: 1. incidence and clinical signifi cance of intravascular stent fractures. 2. arterial deformation due to respiration and motion as an implicating factor for stent fractures. 3. physical and chemical factors (including ion leaching) and biological factors (including infl ammation) at the stent surface which could precipitate stent corrosion. 4. role of scanning electron microscopy (sem), atomic force microscopy (afm) and secondary ion mass spectroscopy (sims) in the in vitro evaluation of the stent surface. conclusion: various biological, chemical, physical and dynamic factors may play a potential role either alone or synergistically on the integrity of intravascular stents. this exhibit aims to evaluate these individual causative factors for stent fractures and to demonstrate the potential role of in vitro evaluation of the stent surface in predicting corrosion and stent fractures. acceleration of primary liver tumor growth rate in embolized hepatic lobe after portal vein embolization s. hayashi, y. baba, r. higashi, t. yoneyama, m. nakajo; kagoshima-shi/jp (hayashi@m.kufm.kagoshima-u.ac.jp) purpose: portal vein embolization (pve) is now widely accepted as a useful preoperative procedure in selected patients undergoing major hepatic resection. the purpose of this study was to retrospectively evaluate the effects of pve on the growth of liver tumors in the embolized lobe. we studied 8 patients (aged 48-79 years, mean age 70 years), of whom 6 had hepatocellular carcinoma (hcc) and 2 had cholangiocellular carcinoma (ccc) primary liver tumors. pve was performed for each segmental portal branch using fl uoroscopy. the growth rates of the tumors in the embolized lobe and non-embolized liver parenchyma were calculated using the ct volume values at the time of tumor identifi cation, and before and after pve. results: the mean tumor growth rate was 1.59±2.13 cm 3 /day before pve and 3.11±3.06 cm 3 /day after pve (p=0.011). the rate of tumor growth acceleration ranged from 1.50 to 7.62 (3.58±2.55) in the 6 hccs and from 1.04 to 1.26 in the 2 cccs. there was no apparent correlation between the tumor growth rate after pve and the growth rate of non-embolized liver parenchyma (6.53±3.68 cm 3 /day). these results suggest that the rate of liver tumor growth in an embolized lobe accelerates after pve, especially in cases with hccs; thus, caution is required. transcatheter arterial chemoembolization for an hcc before pve may be a reasonable option to suppress the tumor growth. therapeutic purpose: to study the role of therapeutic arterial embolization in the management of post-traumatic epistaxis. methods and materials: 16 patients with recurrent massive epistaxis (more than 100 ml) following trauma who were referred to our department are included in our study. all the patients did not respond to conventional therapy. each patient had exploratory angiography, which included the study of the internal (ica) and external carotid arteries (eca) on both sides with selective injections in the branches of the eca. the fi ndings were classifi ed as 1. active bleeding 2. pseudoaneurysm and 3. others. the abnormal vessels were embolized. results: 12 of the patients had abnormalities in the internal maxillary artery. of these, three patients showed active bleeding into the ethmoidal sinuses. other nine showed pseudoaneurysms in the distal branch closely related to a sinus. in all these cases, the vessel was embolized with pva particles. one patient had active bleeding from the ophthalmic artery since the external carotid artery was ligated at an other center and could not be embolized. in another patient, bleeding was from a pseudoaneurysm arising from the internal carotid artery, which was embolized by occluding the ica. in one patient, the angiogram was normal and both the internal maxillary arteries were embolized with gelfoam. none of the embolized patients had recurrent epistaxis. conclusion: exploratory angiography and therapeutic embolization is an excellent modality in the control of post-traumatic epistaxis. infrapopliteal purpose: to study the feasibility of infrapopliteal percutaneous transluminal angioplasty (pta) and to review the outcome of 125 consecutive infrapopliteal pta procedures and evolve guidelines for patient selection, procedure and post procedural care. patients with ulcer or gangrene were excluded from the study. the indication for pta was rest pain in 105 and intermittent claudication in 20. all the patients were diabetics and 75 of them were smokers. the patients were selected for pta when distal run off in at least one vessel was good. all the patients were on ticlopidine 250 mg bd or clopidogrel 75 mg od for at least 48 hours prior to the procedure and it was continued for 6 months post procedure. intravenous heparin was given for 24 hours post procedure. results: there was no technical failure. all the limbs showed clinical improvement in pain by 24 hrs and this improvement was maintained at 6 months in 115 (92%). the actual limb salvage rate at 1 year for 105 patients with critical limb ischemia was 90%. conclusion: infrapopliteal pta is feasible and safe. appropriate patient selection, premedication and wound-care are important for good results. (n=37), gelfoam (n=2) and coil (n=1), but coil and gelfoam were not used alone. the number and name of each emoblized artery during bae were recorded in addition to the number of baes for each patient. cessation and recurrence of hemoptysis following bae were also documented. the causes for hemoptysis in 21 patients were: pulmonary tuberculosis (n=16), anthracofi brosis (n=2), bronchiectasis (n=2) and lung cancer (n=1). embolized arteries included bronchial (n=55), intercostals (n=25), internal mammary (n=5), inferior phrenic (n=4), subscapular (n=1), lateral thoracic (n=2) arteries and costocervical trunk off the subclavian artery (n=2) in addition to some minor branches off the subclavian (n=7). those arteries off the subclavian arteries were usually affected when there was pleural thickening in the apical area. cessation of hemoptysis was achieved with a single bae (n=24, 61.5%), whereas either continuing or recurring hemoptysis was observed after 15 baes. however, after repeated baes, all hemoptysis stopped. conclusion: the cessation of hemoptysis was achieved by bae in all cases, although some were achieved by repeated baes. for a successful bae, it is important to understand the knowledge of various arteries causing hemoptysis. purpose: to evaluate the effi cacy and safety of a hybrid treatment for severe deep-venous thrombosis by combining clot aspiration, mechanical thrombectomy, and local fi brinolytic therapy. methods and materials: within a period of 5 years, 45 patients with severe deep venous thrombosis were treated with hybrid interventional procedures. after insertion of a temporary vena cava fi lter, thrombo-aspiration with a ptca guiding catheter and/or mechanical thrombectomy with oasis or modifi ed rotating pigtail catheter system were performed. additionally, continuous local fi brinolytic therapy and balloon pta/stenting were performed, if needed. the primary endpoint was venographic fi ndings of thrombus extraction. systemic thrombolysis and anticoagulation therapy followed. results: trans-femoral interventional radiological therapy was achieved in 42 patients. the approach was ipsi-lateral in 22 cases and contra-lateral in 20 cases. interventional techniques were as follows: manual clot aspiration 37,oasis thrombectomy 13, mechanical thrombus fragmentation using a modifi ed pigtail catheter 3, balloon pta 3, stenting 4, and continuous local catheter fi brinolytic therapy 16. successful venographic recanalization was achieved in 37 of 42 patients. a temporary vena cava fi lter was easily removed 9.2 days after the insertion in 37 patients. total dose of urokinase was 3,440,000i.u./6 days. complications: haemo-thorax 1, retroperitoneal hematoma 1, and puncture site hematoma 3. hybrid interventional treatment appears to be a rapid and safe improvement in patients with deep-venous thrombosis. this hybrid treatment may be a therapeutic option in patients presenting severe deep-venous thrombosis. partial background: for hypersplenism, portal hypertension, or hematologic disorders, pse is often performed. however, severe complications such as splenic abscess, gastritis, or pancreatitis may limit the indication. in order to reduce these risks, two different methods of pse were introduced using the mrxo. procedure details: prior to pse, diffusion-weighted images (dwi) including blood oxygenation level dependent (bold) images were performed for the splenic volumetry using a 1.5 tesla mr machine. after the celiac and superior mesenteric arteriography, splenic arterio (spa) ct was obtained to evaluate the splenic or pancreatic branches. segmental pse (s-pse) using microcoils with gelfoam particles or lp-nbca, or peripheral pse (p-pse) using microspheres were performed following the exclusion of gastric and pancreatic branches. splenic ischemic range was evaluated on bold images during the procedures and pursued up to 60-70%. conclusion: a control splenic volumetry was semiautomatically obtained using a workstation based on dwi. spa-ct allowed easy recognition of gastric and pancreatic branches and the exclusion before pse. the ischemic foci shown on bold images immediately after the procedures corresponded well to the non-enhanced area on ct one week later. although p-pse produced multifocal infarctions and may theoretically disturb abscess formation, the volumetry of ischemic (infracted) tissue is better evaluated on s-pse than p-pse. the mrxo is useful for safe and effective pse. carcinoids background: carcinoid tumours are one of the more frequently encountered endocrine tumours of the gastrointestinal tract, and can have a wide spectrum of presentations. the radiological appearance of carcinoids varies depending on their size, location, and on their variable biological behaviour, and can often be very diffi cult to diagnose. imaging findings: we retrospectively reviewed the imaging of histologically proven carcinoid tumours in our institutions for the last fi ve years. the clinical symptoms are varied and the diagnosis can be made biochemically or histologically. imaging is playing an ever-increasing role not only just in the diagnosis, but also in the treatment using percutaneous techniques. cases highlighted include carcinoids presenting as acute gastrointestinal bleeding and multifocal intra-abdominal masses. endovascular treatment appearances such as transarterial chemoembolisation (tace) with ct correlation pre-and post-procedure are also presented. conclusion: carcinoid tumours can have variable and unusual clinical and imaging presentations. familiarity with their appearance on imaging can be helpful for radiologists to avoid misdiagnosis and for initiation of proper treatment. interventional procedures have an increasing role in both diagnosis and treatment, leading not only to effective control of symptoms, but may also help prevent potentially dangerous complications. purpose: to assess the clinical effects of transcatheter arterial chemoembolization (tace) under corresponding portal vein occlusion (tace-pvo) for patients with hepatocellular carcinoma (hcc) and marked arterio-portal shunts (ap-shunts). the study subjects were 14 patients with unresectable hcc and marked ap-shunts who underwent embolization of the ap-shunts with coils and/or gelatin sponge particles (group a: n=7) or tace-pvo (group b: n=7). our primary aim was to assess the effi cacy of tace-pvo for patients with unresectable hcc and marked ap-shunts, and our secondary aim was to assess differences in therapeutic effects between groups a and b. results: no major complication resulting directly from the procedures was seen in either group. there was also no inter-group difference in the effectiveness of treatment for the ap-shunts. subsequent tace therapy was possible in 2 patients of group a and 6 of group b after treatment of the ap-shunts. a favorable response in terms of tumor necrosis exceeding 50% was seen in 28.6% of patients in group a, and in 100% of patients in group b (including 4 cases of complete tumor necrosis). the 1-and 2-year survival rates in group a were 28.6% and 0%, respectively, whereas the 1-, 2-and 3-year survival rates in group b were 85.7%, 85.7% and 42.9%, respectively. there was signifi cant difference (p=.038) of survival rates between group a and b. the tace-pvo method may be a safe and useful therapy for selected patients with unresectable hcc and marked ap-shunts. exploratory methods and materials: exploratory digital subtraction angiography was performed in 250 patients presenting with hemoptysis. the study included aortography, bronchial, intercostal, and subclavian angiography with selective injection into internal mammary arteries. embolization of all abnormal vessels was performed with pva sponge particles of 500-700 microns and 700-1000 microns. the recurrence of haemoptysis was assessed at 24 hrs, 1 month and 1 year. all the patients had chest radiograph prior to angiography. hrct of the lungs was performed if the radiograph was normal. bronchoscopy was performed when the radiograph did not show a defi nite evidence of tuberculosis. results: single vessel was abnormal in 53% and multiple vessels in 47%. on an average, 3.5 vessels were abnormal in the latter group with a range of 2-6 vessels. the commonest vessel to be involved was the bronchial artery (78%) followed by internal mammary (38%), the intercostal artery (27%) and the thyrocervical trunk (17%). 25 (10%) cases had recurrence of haemoptysis in the fi rst 24 hrs, 22 (8.8%) of these patients had an additional vessel, which was missed initially. 3% of the patients had normal arteriography and continued to have haemoptysis. an overall recurrence of 6% was seen at 1 year follow-up. if an area of pathology has multi-vessel involvement, embolization of all the vessels with 500-700-1000 microns pva particles gives good long term results. embolic learning objectives: 1. compare and contrast various embolic protection devices. 2. pictorially depict and classify procedural adverse events due to embolic protection devices during carotid interventions. 3. understand techniques to avoid and appropriately manage these adverse events. background: outfl ow embolic protection devices are used during carotid interventions, though their role is still controversial. they enjoy the benefi t of preventing neuroembolic complications; however, the use of these devices increases procedural time with associated increased risk of adverse events. imaging findings: procedural adverse events specifi c to embolic protection devices may be classifi ed into: (i) minor adverse events (resolve with appropriate management), and (ii) major adverse events (persist despite appropriate management and cause morbidity). minor adverse events may occur during device deployment (technical failure, or use of adjunctive procedures), stent/pta (device migration, pseudo-occlusion, arterial spasm responsive to nitroglycerine, transient neurological defi cits), or device retrieval. major adverse events maybe related to intraprocedural events (proximal device migration, arterial spasm refractory to nitroglycerine, fl ow-limiting dissection, persistent neurological defi cits) or device retrieval. knowledge of techniques to avoid and appropriately manage these adverse events is essential. the aim of this exhibit is to compare and contrast embolic protection devices, clarify their role with evidence based literature, classify device related adverse events, and present a pictorial essay of these potential complications with their appropriate management. preoperative diagnosis was performed through spiral computed tomography and in some cases digital subtraction angiography. results: all patients underwent endovascular repair using straight-tube commercial stentgrafts -talent (64), zenith (17) and gore (1). mean follow-up was 34 months (8-84 months). technically successful implantation was achieved in 81 patients. on patient with a type iii dissection required a hybrid procedure because of the continued growth of his aneurysm. two late migrations were observed on follow-up, which required additional intervention. seventeen endoleaks (20.7%) were observed of which 12 (46.2%) were present in dissections on the base of retrograde fl ow into the false lumen. conclusion: there is much enthusiasm for the use of endovascular devices, especially for the treatment of thoracic aneurysms; for it may indeed hold the potential for the greatest patient benefi t as conventional open surgical repair continues to offer serious morbidity and mortality rates. preliminary recently, some percutaneous devices have been developed to treat mitral valve insuffi ciency. the design of these devices is undergoing and will be based on non invasive imaging (i.e. ct and/or mri). 64-slice ct offers extremely high spatial resolution in cardiac imaging and can be platform both for the design of these devices and for the pre-interventional assessment of the individual patient. imaging findings: this exhibit will provide a anatomical and pathophysiological overview of mitral valve insuffi ciency as well as a pictorial essay of mitral valve disease as seen on ct. the percutaneous devices and the technique used for the treatment will be shown and described. the role of ct in the geometrical assessment of mitral valve and in the the planning of the percutaneous procedure will be exploited. conclusion: percutaneous mitral valve repair is becoming a new experimental fi eld in cardiology and new devices are under development. ct can provide anatomical information extremely useful for the planning of the procedure. this information is the benchmark for the design and the sizing of the devices for the individual patients. we anticipated that tearleader stent placement is more comfortable and this stent has a more favourable long-term patency rate for 2 years, but more episodes of dacryocystitis and stent migration have been demonstrated. purpose: percutaneous rfa of liver tumors has been extensively described and is considered safe and effective. targeted co 2 insuffl ation has been described by raman et al. as a way to manipulate intraabominal organs to gain safe access routes. however, these authors stressed several drawbacks to this technique, including possible increased bleeding, limited role of ultrasound guidance, and inherent risks in co 2 insuffl ation. we offer a new approach in using a balloon catheter as a diaphragmatic protective device. methods and materials: a balloon catheter was placed above the level of the hepatic dome in eight pigs under general anesthesia. approximately 50-70 ablations were performed with the balloon as a protective device. fourteen control lesions were performed without the balloon. thermal injury to the adjacent diaphragm was examined to determine depth of injury. the balloon catheter provides a protective barrier that is more stable in position than with saline infusion or co 2 insuffl ation. the risk of bleeding was not increased because the point of probe entry into the liver remained closely apposed to the abdominal wall. potential acidosis associated with co 2 insuffl ation was also never a concern. conclusion: our model of using a balloon catheter as a protective device has several advantages over the co 2 insuffl ation model, and provides a safe and effective way of expanding the use of percutaneous radiofrequency ablation of liver tumors that are in the undersurface of the diaphragm. additionally, this novel method may be used in the protection of other organs adjacent to areas being ablated. results were classifi ed as primary success when complete pain relief was obtained after a single ablation session, secondary success when two or three sessions were performed and failure when persistence of pain required another therapy. complications were also recorded. results: osteoid osteomas located in nearly every part of the skeleton including the spine were managed with this technique. primary success was obtained in 145 cases (94%), secondary success in 8 cases (5%), and failure in 2 cases (1%). in 2 cases, the procedure was complicated by secondary algodystrophy. conclusion: laser ablation is a safe and effective technique which could represent the mainstay therapy for osteoid osteoma. an investigation of brightness changes in ultrasound images due to variations of temperature in liver tissue during ex vivo and in vivo radiofrequency ablation a. montaseri, m. mokhtari dizaji, s. akhlaghpour, m. alinaghizadeh; tehran/ir (atmostellae@yahoo.com) purpose: a minimally invasive method for the treatment of liver malignancies is radiofrequency ablation, after which disease recurrence is probable, partially due to inadequate capability of temperature monitoring of the target tissue. the goal of this work was to study the possibility of real-time temperature monitoring of liver tissue undergoing rfa. for this purpose, variations of brightness in ultrasonic images acquired from ex vivo and in vivo experiments were investigated. in our ex vivo experiments, pieces of fresh bovine liver underwent rfa using active and passive needle electrodes and a microthermometer, which were inserted into the tissue using ultrasonography guidance. tissue samples were heated up to 70 °c and corresponding to each centigrade of temperature increase, ultrasonic images were acquired and delivered to a pc. variations of image brightness were investigated. in our in vivo experiments, the changes of brightness were studied in the ultrasonic images acquired during the rfa of liver malignancies of three patients. temperature increase was monitored using thermocouples at the tip of the rf electrode prongs. the ex vivo study showed that during tissue warm-up from 22 °c to 50 °c, brightness in ultrasound images increases linearly. as temperature rises from 50 °c to 70 °c, variation of brightness shows a non-linear behavior due to microbubble formation. the in vivo investigations showed good consistency with ex vivo results in the 40-60 °c interval. conclusion: it appears that changes of brightness in ultrasound images can be used for real-time thermal monitoring during rfa. fdg-micropet and diffusion-weighted mr image evaluation of early therapeutic effects of radiofrequency ablation on implanted vx2 rabbit tumor in the back muscle t. ohira, t. matsuoka, t. okuma, y. wada, k. koyama, k. nakamura, y. watanabe, y. inoue; osaka/jp purpose: to evaluate the early therapeutic effects of radiofrequency ablation (rfa) on implanted vx2 rabbit tumor in the back muscle using fdg-micropet and mr image. the bilateral back muscles of 7 rabbits were implanted with vx2. a week after tumor implantation, a leveen needle electrode was percutaneously inserted under ct guidance and radiofrequency was applied until maximum impedance. the other side of the vx2 remained as the control tumor. mr imaging was performed with a clinical 1.5 t instrument using a knee coil 2 days after rfa. spin-echo t1-weighted images (t1wi), fast-spin-echo t2-weighted images (t2wi), gd-enhanced t1-weighted images (ce-t1wi) and echo-planar-imaging-diffusion-weighted images (dwi) (b=50, 500, 1000 sec/mm 2 ) were obtained. apparent diffusion coeffi cients (adc) of ablated lesions and vx2 were measured. fdg-micropet was obtained 3 days after rfa. emission data were acquired 40-60 min after intravenous 18 f-fdg injection. rfa lesion-to-muscle (rf/m) and tumor-to-muscle (t/m) ratios were calculated. results: vx2 without rfa showed ring-shaped fdg accumulation and hyperintensity on t1wi, t2wi, ce-t1wi, and dwi, while ablated lesions showed less accumulation and hypointensity on all sequences. adc values and t/m ratios of vx2 without rfa were 1.69±0.35 × 10 -3 mm 2 /sec and 11.6±3.2, respectively. after rfa, adc values and rf/m ratios were 1.30±0.27 × 10 -3 mm 2 /sec and 0.5±0.3, respectively. adc values and rf/m ratios were signifi cantly lower than the vx2 without ablation (p < 0.05). histology showed coagulative necrosis and no viable on ablated lesions. conclusion: both fdg-micropet and mr images may be useful for evaluating early therapeutic effects of rfa. a new challenge for radiologists: ultrasound guidance in regional anesthesia l. learning objectives: to review the equipment and practical use of ultrasound relevant to the practice of regional anesthesia. to show the sonographic anatomy of the areas most frequently involved in regional anesthesia, and to become familiar with the imaging appearance of nervous structures. to describe and illustrate the sonographic appearance of peripheral nerves. to discuss the advantages of ultrasound-guided plexus and nerve blocks. background: the ultrasound guidance for nerve block was fi rst reported by la grange et al in 1978, but the interest has increased in the last 10 years due to the technological advances experienced in ultrasound and regional anesthesia. an optimal distribution of local anesthetic around the nerve structures is the key requirement for successful regional blocks, and ultrasound allows direct visualization in real time. ultrasound-guided regional blocks improve the quality (faster onset and duration), reduce the performance time and complications, and minimize the amount of local anaesthetic used. procedure details: it is essential to know the specifi c anatomy and the sonographic correlation of the areas usually involved in the regional blocks of the upper (interscalene, infraclavicular, axillar, and peripheral blocks) and lower extremities (femoral, sciatic, popliteal blocks). we describe and illustrate the technique used in our hospital by the department of anesthesia in collaboration with the radiology department. conclusion: utilization of ultrasound guidance for regional blocks is on the rise and has demonstrated to be an alternative to traditional methods of regional anesthesia. it enables quality nerve blocks, avoiding complications by optimal needle positioning. radiological purpose: to describe the technique and to evaluate the results of a radiologicalendoscopic combined approach in patients with biliary ducts iatrogenic damage. eighteen patients with complete biliary ducts transection underwent a radiological-endoscopic rendez-vous. the damage of the biliary ducts was due to trauma in 1 case and to videolaparoscopic colecistectomy in 17 cases. the procedure consists in re-establishing the continuity of the biliary ducts with a combined radiological-endoscopic approach, dilation, and placement of two percutaneous biliary drainages. after 4-6 weeks, the drainages are replaced with 3-6 endoscopic plastic endoprosthesis that are left for 12-14 months. the rendez-vous technique was performed successfully in all cases with fast resolution of the symptoms. two patients underwent surgery, while in 16 patients the biliary drainages were substituted with plastic endoprosthesis. after the removal of the endoprosthesis, 9 patients are asymptomatic after 3-18 months. seven patients are still in treatment with biliary endoprosthesis and are asymptomatic after 3-18 months follow-up. the radiological-endoscopic combined approach represents the only approach in patients with complete biliary duct transaction to delay or avoid the surgery. slice concept-the needle must remain in the plane of the ultrasound beam slice; angle of needle -poor refl ection at steep angles, good refl ection and therefore visualisation at shallow angles. this can be achieved by "heel toeing" the probe and choosing point of entry carefully; machine settings-adjusting depth, focus and gain plus using an appropriate frequency probe. conclusion: for ultrasound guided procedures to be carried out successfully and safely require visualisation of the needle. this diffi cult task can be simplifi ed by considering some applied physics and following some simple tips. percutaneous parapedicular access to the thoracic and lumbar vertebral bodies d.p. beall; oklahoma city, ok/us (dpb@okss.com) learning objectives: to demonstrate a technique for parapedicular access to the vertebral body. to present the anatomy of the spine as it relates to a safe and reproducible method of percutaneously accessing the vertebral body. background: the thoracic and lumbar vertebral bodies and pedicles differ in size and shape according to level. the method of accessing the vertebral bodies for percutaneous management of vertebral compression fractures and for biopsy has typically been via the parapedicular approach in the thoracic spine and the transpedicular approach in the lumbar spine. while the transpedicular approach is safe and effective, the ability to redirect the needle is limited, and there is a risk of fracturing the pedicle itself. procedure details: the parapedicular approach does not have the risk of pedicular fracture and the needle is more easily redirected with this approach, but the neurovascular structures are important to identify and avoid. the needle is placed in at the pedicle-body junction along the superior half of the pedicle and is directed toward the contralateral inferior vertebral endplate. the medial wall of the pedicle must not be transgressed prior to entering the posterior portion of the vertebral body. we present a technique for parapedicular access to the vertebral body that will provide a relatively avascular and aneural approach to vertebral body, is reproducible in the thoracic and lumbar spine, and will allow a consistent unilateral approach to the center of the vertebral body. ct step-to-step insertion of the needle and application of drugs after suffi cient contrast media application are performed. conclusion: ct guidance helps in avoiding puncture of vessels by direct visualization, thus enhancing safety. a multidisciplinary patient management improves results concerning pain and quality of life. a "how-to-do approach" will introduce the reader to ct-guided interventional pain management of the cervical spine. sedation learning objectives: 1. to present an overview of pharmacokinetics and pharmacodynamics of most widely used drugs for sedation. 2. to be acquainted with their principal indications and contraindications. 3. to explain the basic safety regulations to follow during a sedation procedure. background: nowadays, there are a high number of diagnostic and therapeutic procedures conducted under sedation, analgesia or immobilisation. because of this, radiologists often carry out the sedation procedures by themselves. it is the responsibility of the radiology and anaesthesia departments of every hospital to implement a working pattern based on collaboration among their staff, so that every radiologist becomes profi cient enough to guarantee high levels of safety and quality during a sedation procedure. procedure details: we present the basic pharmacokinetics and pharmacodynamics of the drugs most widely used (propofol, midazolam, etomidate, ketamine and fentanile), and their adverse reactions and treatment as well as their indications and contraindications. the basic notions necessary to recognise and verify (bis ® and entropy) the different consciousness levels are exposed. finally, the main safety rules of the american society of anesthesiologists about this issue are detailed. in order for radiologists to perform sedation procedures, it is of utmost importance for them to be acquainted with the basic pharmacology of the drugs employed, their indications and different options available for each procedure. similarly, it is necessary to become familiar with the management of the airway, the safety devices and basic and advanced cardiopulmonary resuscitation. ct-guided percutaneous radiofrequency ablation of the pulmonary and mediastinal unresectable tumors adjacent to the heart and large vessels c. pusceddu 1 , g. podda 1 , c. urigo 2 , f. meloni 2 , s. profi li 3 , g. meloni 2 ; 1 cagliari/it, 2 sassari/it, 3 tempio pausania/it (curigo@sirm.org) purpose: to verify the feasibility and safety of radiofrequency thermal ablation (rfa) under ct guidance in the treatment of malignant neoplasm adjacent to the heart and large vessels. methods and materials: twelve patients (mean age of 64 years) with unresectable primary and secondary pulmonary and mediastinal tumors (3 nsclc, 1 invasive thymoma, 1 mesothelial sarcoma and 7 metastases) were treated by ct-guided rfa. the tumors, 3 of the mediastinum and 9 of the lung, were adjacent to the aorta (7 cases), pulmonary artery (4 cases) or heart (3 cases) with potential thermal damage of these structures. all ablations were performed with a multitined expandable electrode under conscious sedation and local anesthesia. vital signs of the patients 446 b d e f a g were non-invasively monitored continuously. the therapeutic outcomes were evaluated by contrast-enhanced ct after 1 month; the absence of tumor enhancement ct image was considered to indicate complete tumor necrosis. two patients were re-treated. in a patient, an electrode is penetrated in the pericardium. results: in all cases, the procedure was technically successful. no intraprocedural arrhythmia occurred. morbidity existed in 3 cases of pneumothorax and 1 case of asymptomatic thickening of the pericardium. in the control ct after 1 month, there was complete necrosis in 7 cases and partial (from 70 to 90%) in the remaining 5 cases. conclusion: rfa of mediastinal and lung tumors adjacent to the heart and large vessels is feasible and safe because the blood fl ow causes a "heat-sink" effect adjacent to such structures and prevents undesired thermal damage. new needle guidance system to reduce ultrasound-guided biopsy operator dependence a. shaikh, n. bluvol, a. kornecki, a. fenster; london, on/ca (allisoncanada@hotmail.com) purpose: the speed of accurate ultrasound (us) guided biopsy is dependent on operator experience. we developed a needle guidance system (ngs) to increase the speed and accuracy of biopsy procedures using us. this system is composed of a passive articulated mechanical arm attached to an us transducer, providing real-time projected needle pathway overlay guidance. this ngs coupled to a cnb needle will result in accurate biopsy with shorter procedure time than those of freehand technique, thus potentially limiting the us biopsy operator dependence. methods and materials: biopsy targets composed of 2.5 mm blue pvac lesions were implanted within chicken tissue test phantoms. two radiologists experienced with us-guided biopsy and 3 inexperienced radiology residents performed biopsy of these lesions using both the free-hand technique and ngs (45 lesions per technique per participant). participants were alternately assigned to start with 1 of the 2 biopsy methods, which were video recorded and analyzed for procedure time. biopsy samples were examined for the presence of blue color, which was indicative of a successful biopsy. results: biopsy procedure time using the ngs was signifi cantly lower than the free-hand technique (p < 0.001). the average procedure time was shorter among experienced participants than among inexperienced participants when using the free-hand technique (p=0.037). equivalence in procedure time was found when physicians, both experienced and inexperienced with free-hand us biopsy, performed biopsy using the ngs (p=0.734). conclusion: our needle guidance system is increasing procedural effi ciency by improving the rates of successful biopsy and reducing the required physician experience to perform biopsy. complications of percutaneous rf ablation of primary and secondary liver tumours: report of a single center study p. the magnet-insertion procedure was performed under endoscopic and fl uoroscopic guidance. two coated rare-earth-metal (ndfebr) magnets (br = 1200 gauss, d = 10 mm, central hole d = 6 mm) were inserted by guide-wire and duodenal probe into the model. the fi rst magnet was pushed into the fi rst jejunal loop, the second one was placed into the stomach inversely. after reaching the adequate positions, the magnets were pushed down from the guide-wire to let them cohere. results: the exact positioning was possible; the magnets cohered across the gastric and jejunal walls successfully. expectedly, the pressure between the magnets leads to ischaemia and necrosis of the cohered gastric and jejunal walls, while reparing the granulation process along the magnets' edges yields adhesion between them, and fi nally an anastomosis will develop. conclusion: the experiment was executable even with common tools in a short period of time in an exact way. further developments are necessary regarding size, material and form of the magnets. with some slight technical corrections, the method seems to be suitable for animal experiments. percutaneous alcohol ablation and catheter drainage for the treatment of large hydatid cysts in liver s.k. puri, a. dev, s. ghuman, a. agarwal, a.s. puri, p.k. mishra, s.k. sarin; new delhi/ in (skpurigbph@yahoo.co.in) purpose: to evaluate the safety and effi cacy of percutaneous alcohol ablation using a catheter and subsequent drainage of the cavity in large, > 8 cm hydatid cysts in liver. sixteen patients (6 men and 10 women, aged 22 to 52 years) with 18 hydatid cysts were subjected to alcohol ablation and catheter drainage. all cysts were of gharbi type i and ii and the size ranged from 8 to 14 cm. the procedure was performed under us guidance (n=12) or ct guidance (n=4) using light sedation and local anesthesia. initial needle puncture and aspiration of fl uid were done to examine scoleces and rule out any biliary communication. to differentiate angiogenic profi le in tumors using α ν β 3 -specifi c uspio c. purpose: angiogenesis is essential for tumor growth and spread. in this study, α ν β 3specifi c ultrasmall superparamagnetic iron oxide (uspio) was generated and its potential to distinguish tumors with different angiogenic profi le was investigated. methods and materials: aptms-coated uspio with diameters of 10±3 nm were conjugated with rgd-peptides. rgd-uspio or plain particles were injected into nude mice bearing hacat-ras-a-5rt3 and a431-tumor xenografts. t 2 -and t 2 *weighted mr imaging and t 2 -relaxometry were performed 6 h after injection. tumor tissues were immunostained against cd61 and counterstained against cd31. area fractions of cd31 and α ν β 3 integrin positive vessels were determined. results: on t 2 *-weighted images, a strong heterogeneous decrease in signal intensity was found in hacat-ras-a-5rt3 tumors, while signal changes in a431 tumors were more homogeneous and less pronounced. both in hacat-ras-a-5rt3 and in a431 tumors, t 2 -relaxation times decreased signifi cantly (p < 0.05) more after the injection of rgd-uspio than after the injection of plain particles. in addition, the decrease in t 2 -relaxation time in hacat-ras-a-5rt3 tumors (28 ± 41 ms) was stronger than in a431 tumors (14 ± 8 ms). in line with the mr results, histological evaluation shows in hacat-ras-a-5rt3 tumors a heterogeneous vascularization with areas of high vessel density and large mature vessels. contrarily, in a431 tumors, the vessels were small and homogeneously distributed. furthermore, in hacat-ras-a-5rt3 tumors, signifi cantly (p < 0.01) higher area fractions of cd31 (1.9±1.1%) and α ν β 3 integrin positive vessels (1.0±0.5%) were found than in the a431 tumors (cd31/α ν β 3 integrin area fraction: 0.9±0.4%/0.3±0.1%). conclusion: molecular mri of angiogenesis using α ν β 3 -specifi c uspio can distinguish tumors with different angiogenic profi les in vivo. whole body diffusion weighted magnetic resonance in tumor imaging: technical improvement and preliminary results s. li, f. sun, h.d. xue, z.y. jin; beijing/ cn (lishuo_lee@yahoo.com.cn) purpose: to optimize the free breathing whole body diffusion weighted imaging (wb-dwi) protocol by using short ti inversion recovery diffusion weighted echo planar imaging (stir-dwepi) sequence and build in body coil. high resolution three-dimensional (3d) maximum intensity projection (mip) images were obtained and the feasibility in tumor patient screening was evaluated. methods and materials: 1) prescan procedure of stir-dwepi was modifi ed under the data from thirty volunteers scan. during each exam, an optimized center frequency was used to minimize the slice offsets in the consecutive scan station. prescan time was also reduced from 50 seconds to 20 seconds with even better station profi le. total scan time is 30 minutes for 5 stations 1.2m coverage; 2) thirty patients with histological proven malignant disease were scanned under the fi nal protocol by build in body coil for feasibility evaluation. the image quality and the degree of background body signal suppression were also assessed. results: free breathing wb-dwi is 100% successfully performed in this patients' group, without slice misregistration, fat contamination, signifi cant distortion or nonuniformity. the acquired 3d-mip images were adequate in depicting the malignant lesions on the total 30 patients with high sensitivity and accuracy, compared with pet or spect results. conclusion: high resolution images of wb-dwi can be obtained with these technical improvements. wb-dwi has a great clinical application value in the detection of primary and metastasis lesions of malignancies in the whole body. it has great potential in diagnosis and therapeutic assessment of tumors. changes purpose: to prospectively compare the agreement between low-dose unenhanced pet/ct and full-dose enhanced pet/ct in lesion detection and staging of hodgkin disease and non-hodgkin lymphoma. methods and materials: seventy-two biopsy-proved lymphoma patients underwent 18 fdg pet/ct that included a low dose unenhanced ct and a full-dose enhanced ct for initial staging. every patient had both pet/ct studies, and each one was evaluated by one pair of experienced physicians, a radiologist and a nuclear physician. both pairs were blinded to the other technique. lesion detection, number of sites affected in each anatomical region, and disease stage were assessed with both imaging modalities. agreement among techniques was determined by kappa statistics, and discordances studied by mcnemar's test. clinical, analytical, histopathologic, diagnostic enhanced-ct, pet, and follow-up data constituted the reference standard. results: for region-based analysis, no signifi cant differences were found between low-dose pet/ct and full-dose pet/ct, although full-dose pet/ct showed fewer indeterminate fi ndings and higher number of extranodal sites affected. agreement between both modalities of pet/ct was almost perfect for disease stage (k =0.92, p < 0.001). no statistically signifi cant differences were found between both modalities of pet/ct in the initial staging of patients with lymphoma, although full-dose enhanced pet/ct detected a larger number of anatomic sites affected, especially in extranodal regions, and provided fewer indeterminate fi ndings than low-dose unenhanced pet/ct. conjugation of single-chain antibody against human γ-seminoprotein to iron oxide and its in vitro identifi cation y.d. han 1 , y.g. zhang 1 , y. ji 1 , d.x. cui 2 , j.q. xu 1 , y.l. liu 1 ; 1 xi'an/cn, 2 shanghai/ cn (hanyuedong@ 126.com) purpose: to synthesize the conjugate of single-chain fv (scfv) iron oxide against human γ-seminoprotein, and identify its biological activity in vitro. methods and materials: e4b7 scfv gene was amplifi ed by pcr and then expressed by the rapid translation system. the product was studied by immunoprecipitation, western blotting, and immunofl uorescent staining, and subsequently conjugated with magnetic nanoparticles (mnp) 8 nm in diameter, which were further coated with aminosilane and pamam dendrimer. the conjugated and the unconjugated mnp were separately incubated with the prostate cancer lncap cells and then observed via transmission electrical microscopy (tem). results: the e4b7 scfv gene was successfully amplifi ed and expressed. the result of immunoprecipitation and western blotting showed that the expressed peptide was completely absorbed by the soluble cytoplasmic fraction and cell membrane of lncap cells, which is highly consistent with the result of immunofl uorescent staining. tem showed that the conjugate entered into the cytoplasm within 15 min, and the amount increased over time, unlike unconjugated mnp in the control group, in which the amount inside the cells was markedly less than that of the conjugate at the same time point, although they also entered into the cytoplasm. the scfv peptide against human γ-seminoprotein, and the conjugate of scfv-mnp were successfully fabricated, with the latter being uptaken by lncap cells. our studies indicate that this targeted probe can be developed for further molecular mr imaging. (b= 50, 500, 1000 sec/mm 2 ). results: tumor size at 1 and 2 weeks after implantation was 1.6±0.2 cm and 1.9±0.2 cm (±sd), respectively. the fdg-micropet image shows ring-shaped accumulation in the tumors. the t/m ratios of the tumor rim at 1 and 2 weeks, and tumor core were 11.6±3.7, 7.6±2.7, 3.3±2.6, and 4.0±2.9, respectively. the t/m ratio of the rim at 1 week was signifi cantly higher than at 2 weeks (p < 0.05). mr imaging shows a slightly hyperintense tumor on t1wi, hyperintense on t2wi and dwi, and ring-like enhancement on gd-t1wi. the adc values of the rim at 1 and 2 weeks, and the core were 1.60±0.4x10 -3 , 1.90±0.4x10 -3 , 1.51±0.5x10 -3 and 1.58±0.5x10 -3 (mm 2 /s), respectively. the adc values of the rim at 1 week were signifi cantly lower than those at 2 weeks (p < 0.05). conclusion: our preliminary study suggests that fdg-micropet and mr image can be used to characterize the vx2 tumor. in purpose: to develop a method for labelling human cytotoxic t-lymphocytes with superparamagnetic iron oxide particles (spios) for subsequent depiction with a conventional 1.5 t mr scanner. a cmv-specifi c cd8 + cytotoxic t-lymphocyte (ctl) clone was expanded in the presence of feeder cells, interleukin (il)-2 and il-15 and stimulated unspecifi cally with anti-cd3. after three days, ctls were labelled either by incubation with resovist or with resovist and lipofectin (20µg/ml) at 100 or 200µg fe/ml with an incubation time of 4 hours. cells (2x10 6 ) were imaged at 1.5 t (philips intera) 0, 2, 7 and 14 days after labelling using a fast multi-echo readout sequence to determine t2 * -relaxivity. resovist-uptake was confi rmed by immunofl uorescence using an antibody specifi c for the dextran-coating of resovist. specifi ty of ctls was determined by staining with a cd8-antibody and cmv-multimers. specifi c cytotoxicity was quantifi ed by a 51 cr-release-assay. iron uptake was measured by atomic emission spectrometry (aes). results: resovist-labelling of ctls was most effi cient using resovist (100µg fe/ml) and lipofectin. on days 0 and 2 after labelling, pronounced shortening of t2-and t2 * -relaxation times was observed which diminished substantially after 7 and 14 days. the mean iron concentration per cell was 0.9 and 0.8pg at 0 and 2 days after incubation and 0.1pg at 7 days. specifi ty and specifi c cytotoxicity of the cells was not altered by the labelling procedure. conclusion: labelling of human ctls can be achieved by incubation with resovist and lipofectin. a possible future application could be the monitoring of ctls after an adoptive cell transfer. molecular imaging of axillary lymph node by equivalent cross relaxation rate s. matsushima 1 , h. nishiofuku 2 , f. sasaki 2 , s. era 1 , y. kinosada 1 ; 1 gifu/jp, 2 nagoya/jp (smts@cc.gifu-u.ac.jp) purpose: equivalent cross-relaxation rate (ecr) imaging (ecri) is a measurement method that can be used to quantitatively evaluate a change in the structural organization of lymph nodes by mri. the aim of this study was to evaluate the utility of ecri as molecular imaging. methods and material: fifteen patients with histologically confi rmed invasive ductal carcinomas of the breast were studied. we adopted the off-resonance technique for preferential saturation of the immobile protons to evaluate the ecr values. the single saturation transfer pulse frequency was employed at the frequency 5 ppm downfi eld from the water resonance. the ecr value was defi ned as the percentage of signal loss between the unsaturated and saturated images. the ecri was constructed on the basis of the percentage of ecr. the 50 rois had a rectangle-sampling area of 0.3 mm 2 . the winroof software was used to analyze the number of cells. the normal organization showed that there were many cells and a higher ecr value. the lymph nodes with metastases showed that there were few cells and a lower ecr value. in the adipose tissue there were very few cells and the lowest ecr value. a statistically signifi cant difference was obtained in the ecr values of each tissue (p < 0.001). both numerical values are present on the fi rst correlation line (correlation coeffi cient = 0.92). in the axillary lymph node, ecr value related to the number of cells. therefore, ecri is a potentially useful method for molecular imaging in the lymph node. pathological animal models in the experimental evaluation of tumor microvasculature with magnetic resonance n. faccioli, p. marzola, f. boschi, m. d'onofrio, r. pozzi mucelli; verona/it (nfaccioli@sirm.org) purpose: to evaluate the applications of magnetic resonance and in particular of dynamic contrast enhancement magnetic resonance imaging (dce mri) in the study of tumoral microcirculation by means of animal tumoral models, evaluated before and after antiangiogenic treatment. methods and materials: forty-two mr exams were executed with intravascular contrast media in 21 rats: in 7 rats, tumors were induced by the subcutaneous injection of colon carcinoma cells, and in 14 rats by mammary adenocarcinoma cells. perfusional and permeability parameters of the implanted tumors were evaluated with two contrast media (b22956/1 and gd-dtpa37-albumin) to depict better the tumoral response after administration of two different antiangiogenic drugs (tamoxifen and su6668). by means of these parameters and histological examination, it was possible to obtain a map of the microcirculation. results: in all the examined animal models, the dce-mri shows that the enhancement is greater in the peripheral area than in the central area. after the antiangiogenic drug administration, the mean values of permeability and perfusion were decreased to 51% and 59%, respectively. the response to the treatment is different for each antiangiogenic drug. different contrast media allow a different capability to visualize the microcircle. conclusion: dce-mri permits the non-invasive evaluation of tumoral microcirculation, and in particular, of its size, dynamic characteristics and vascular grade before and after antiangiogenic treatment. eosinophilic granuloma b. graca, j. brito, a. canelas, p. belo-oliveira, c. marques, f. caseiro-alves; coimbra/ pt (pombas@gmail.com) learning objectives: to provide an educational and pictorial review of the radiological imaging features (plain radiography/ bone scintigraphy/ct/mri) and distribution of eosinophilic granuloma (eg). to illustrate the clinical features and peculiar radiological appearances of eosinophilic granuloma. to discuss differential diagnoses, in particular in differentiating eosinophilic granuloma from other primary bone tumours, metastases or osteomyelitis. background: langerhans cell histiocytosis is a pathological entity characterized predominantly by proliferation of a specifi c histiocyte (langerhans cells). the etiology and pathogenesis is still unknown. eosinophilic granuloma is the unifocal unisystem form of langerhans cell histiocytosis, typically characterized by bone involvement, usually in a monostotic pattern. nonetheless, it is important to be able to recognize this lesion and exclude diffuse involvement, particulary of the bone marrow, lungs, heart, liver, kidney and gastrointestinal tract, conferring an adverse prognosis. eg must be differentiated from neoplastic, infl ammatory and metabolic lesions, which have variable approaches in terms of prognosis and treatment. eosinophilic granuloma may resolve spontaneously. there are good results with intralesional injection of methylprednisolone. surgery, chemotherapy and radiotherapy are reserved for disseminated or complicated cases, which is rarely the case of eg. imaging findings: we divide our presentation by anatomical location, showing lesions of the calvarium, mandible, ribs, vertebra, and long bones, emphasizing the most important aspects in differential diagnosis, in different imaging modalities. conclusion: awareness and early identifi cation of eosinophilic granuloma allow appropriate management. we provide a review of the background, clinical presentation and radiological feature of eosinophilic granuloma. purpose: mri, radionuclide imaging and bone densitometry have been used for quantifying skeletal involvement in patients with gaucher disease (gd). in this study, we compared different quantitative/semiquantitative methods for assessing skeletal involvement in patients with gd based on mri, scintigraphy or dual-energy x-ray adsorptiometry (dexa). thirty-one patients with type-1 gd underwent mri, 99mtc-sestamibi scintigraphy and dexa. mri was performed with 1.5 t scanner; protocol included t1 and t2w tse sequences of lumbar spine and femora. all images were analysed by 2 radiologists and bone marrow changes were classifi ed on a 16-point semi-quantitative scoring system. 99mtc-sestamibi scintigraphy was semiquantitatively scored; dexa of the lumbar spine and femoral neck yielded the z-and t-scores. the relationship between mri, scintigraphic and dexa scores and different disease parameters (bone pain, skeletal complications, hepatomegaly, splenomegaly, platelet count, haemoglobin level, and plasma chitrotriosidase) was evaluated by the spearman's rank correlation test. results: a statistically signifi cant correlation was found between mri and scintigraphic scores (r = 0.694; p = 0.0001). moreover, both imaging scores were statistically signifi cantly correlated with several clinical parameters including platelet count, hepatomegaly, splenomegaly, haemoglobin level and presence of skeletal complications. on the contrary, the dexa-derived parameters were not correlated with any clinical and/or imaging scores. conclusion: our preliminary data indicate that both mri and 99mtc-sestamibi scintigraphy are reliable tools for assessing the severity of bone marrow involvement in patients with gd. learning objectives: to describe the clinical, pathological and radiological features of osseus tumours that contain osteoclast-like giant cells. to understand the pathologic basis of the radiologic features of these lesions. to realize the problems and pitfalls in the pathology assessment and discuss the clinical and radiological features that may allow differential diagnosis. background: differential diagnosis of bone lesions that contain giant cells requires the pathologist to consider an important number of possibilities. each lesion should be analyzed as a clinicopathologic entity and, therefore, the pathologist should be aware of the relevant clinical information and the radiologic evaluation of the lesions. procedure details: we have divided these lesions into two groups. the fi rst one includes lesions that can be mistaken for a benign giant cell tumor (bgct) because of its histologic similarity or its location in long bones extremities (chondroblastoma, giant cell reparative granuloma, cherubism, brown tumor of hyperparathyroidism and intraosseus nodular synovitis). the other group consists of lesions that also contain giant multinucleated cells but are histopathologically very different from bgct (osteosarcoma, osteoblastoma, osteoid osteoma, fi brous dysplasia, condromixoid fi broma, cemento-ossifying fi broma, aneurysmal bone cyst, fi brous histiocytoma, eosinophilic granuloma and paget disease) conclusion: the radiologist's role is essential to diagnose and treat osseus tumours that contain osteoclast-like giant cells, because it allows differentiation between them and informs about its biologic potential. periostic reaction, borders, soft tissue mass and calcifi ed matrix are the best radiological features that are helpful in differential diagnosis. location and patient age are the best clinical clues. interobserver reliability of a ct classifi cation system in the calcaneus fracture p. jiménez villares 1 , f. ruiz santiago 2 , a. peralta silva 1 ; 1 cádiz/es, 2 purpose: this study was designed to determine the interobserver reliability of a calcaneus fracture classifi cation scheme. for a fracture classifi cation to be useful, it must provide prognostic signifi cance and intraobserver reproducibility. most studies have found reliability and reproducibility to be poor for fracture classifi cation schemes. methods and materials: eighty-nine cases were selected that had an appropriate study of ct image from a trauma hospital center. two radiologists from the musculoeskeletar department reviewed all these studies. on each viewing, observers were asked to classify the fractures according to both the sanders and crosby-fitzgibbons and zwipp systems. interobserver reliability and reproducibility were assessed with computer-generated kappa statistics. results: sander classifi cation: the mean kappa value for interobserver reliability for fracture types i-iv was 0.852. crosby classifi cation: the mean kappa value for interobserver reliability for fracture types was 0.903. zwipp classifi cation: the mean kappa value for interobserver reliability for fracture types i-vi was 0.833. duparc classifi cation: the mean kappa value for interobserver reliability for fracture types i-v was 0.63. conclusion: although intraobserver kappa values reached substantial levels and the crosby-fitzgibbons system generally showed greater agreement, we were unable to demonstrate excellent interobserver reliability with either classifi cation scheme. the results indicate that in a carefully controlled paradigm, the interobserver reliability with a classifi cation system based on interpretation of a single carefully defi ned ct image was good in all the systems and better in the crosby classifi cation. spinal we studied 90 healthy adults with d-mri of the lumbar spine. rois were placed on each lumbar vertebral body, and mean signal intensity to time (sit) curves were generated for upper (l 1 -l 2 ), lower (l 3 -l 5 ) and all fi ve (l 1 -l 5 ) vertebrae and wash-in and wash-out rates, time to maximum slope and time to peak values were obtained. patient population was stratifi ed into men and women younger or older than 50 years, and sit curves were compared among these subgroups. multiple regression analysis of data was performed to investigate the effect of age and sex. results: perfusion of the upper lumbar spine was signifi cantly higher compared to the lower level (p < 0.05). individuals younger than 50 years showed signifi cantly higher perfusion compared to older ones for both spinal levels. women demonstrated signifi cantly increased perfusion compared to men of the same age in the upper lumbar spine only. all parameters except time to peak showed a moderate linear correlation with age (0.22<r< 0.32, p < 0.05). multiple regression analysis revealed age as the most signifi cant factor (p < 0.05) as compared with sex. to understand the pathologic basis of the radiologic features of these lesions. to highlight that anatomopathological fi ndings and radiological features are essential to reach a correct diagnosis. background: some vascular lesions of bone are relatively commonly encountered by radiologists, but are uncommonly seen by pathologists. patients can present with different symptoms and signs and while some tumours manifest as clearly benign, others have non-specifi c imaging features that may simulate malign neoplasms. in addition, sometimes pathology cannot easily differentiate between benign and malign lesions. imaging findings: among a wide sample of vascular bone tumours from our pathologic and radiologic database, the most representative examples have been selected to illustrate their main radiological and pathological characteristics. each tumour has been described and assigned to one of the two groups: benign or malignant. the most illustrative diagnostic images have been chosen from various imaging techniques (in particular, x-ray, ct and mr) and their subsequent anatomopathological images. the benign tumours that have been reviewed are: hemangioma, cystic angiomatosis, glomus tumor and gorham's disease. the malignant tumours that have been analyzed are: hemangioendotelioma, ephitheloid hemangioendothelioma and angiosarcoma. conclusion: after interacting with this exhibit, the radiologist will have an enhanced understanding of vascular bone tumors, including the histopathologic and radiologic features. both diagnostic tools are crucial to distinguish these lesions and to allow their proper management. osteoid osteoma: typical imaging patterns in various skeletal parts t. moser, x. buy, a. gangi; strasbourg/fr (gangi@rad6.u-strasbg.fr) purpose: to analyze imaging features of osteoid osteoma in a large series of cases involving the whole skeleton and to defi ne typical patterns for each location. a search in our database was performed to identify all cases of osteoid osteomas. diagnosis of osteoid osteoma was based on typical clinical and imaging fi ndings. additionally most cases underwent image guided ablation in our department and therefore biopsy results and long term follow-up were also accessible. cases were included in our analysis when at least ct scan images were available for review. for each case, we precised the exact distribution within the skeleton, and within the bone both longitudinally (e.g. epiphyseal, metaphyseal, diaphyseal) and transversally (e.g. cortical, cancellous, subperiosteal). a typical imaging pattern was defi ned for each location. results: a total of 158 osteoid osteomas were included in our analysis. distribution in the skeleton was as follows: upper limb (21 cases), spine (21 cases), femur (63 cases), tibia (28 cases), and remaining of the lower limb (25 cases). we were able to defi ne at least one typical imaging pattern in all major bones. conclusion: recognition of typical imaging patterns in most bones allows a more confi dent diagnosis of osteoid osteoma with ct scan. conclusion: wbld-mdct represents a reliable diagnostic tool for the assessment of multiple myeloma, allowing not only the detection of typical lytic bone lesions, but also of both medullary and extra-medullary myeloma involvement. medullary involvement was encountered in all stages of the disease, including patients without osteolysis, and was associated with signifi cantly elevated levels of ß2-microglobulin, a prospective prognostic marker. therefore, we suggest the inclusion of wbmd-ct into the diagnostic workup of mm patients. whole conclusion: evaluation of the course of medullary lesions at follow-up was essential, proving to be even more accurate than a combined evaluation of laboratory parameters and osteolytic lesions. bone fifty-four patients with clinically suspected bone marrow pathology underwent both conventional and dw mr imaging of the spine with adc maps generation and quantitative adc analysis. of these, 15 suffered from multiple myeloma, 14 had a known primary tumor, 2 suffered from lymphoma and 23 presented with acute back pain without medical history. results: in patients with multiple myeloma, quantitative analysis was able to differentiate between active disease (mean adc 0.62) and response to therapy (1.25). in 4 patients without medical history, the evaluation of the adc maps led to an investigation for a primary tumor. in 10 patients with a known primary tumor, the adc fi ndings were attributed to metastases (mean adc 0.61), while in 4 of them an osteoporotic fracture was found (1.65). in 10 patients out of 54, quantitative analysis added critical information that changed the therapeutic strategy. adc values were not signifi cantly lower in tumor infi ltration (0.62±0.21) than in normal bone marrow (0.77±0.35). conclusion: dwi with adc calculation, a method that studies bone marrow pathology on the basis of altered water-proton mobility, has been proved to be a useful tool (in adjunction to the other available conventional sequences) for differentiating between benign and malignant processes of the spine, and may increase the diagnostic potential of mr imaging in the assessment of spinal lesions. the skeletal manifestations of sickle cell anaemia u. shaikh, r. yaddavali, s. kumar, h. aniq; liverpool/uk (usmansh8kh@googlemail.com) learning objectives: to describe the various skeletal presentations of sickle cell anaemia, highlighting imaging fi ndings on conventional radiography and on mri. background: sickle cell anaemia (sca) is the most common inherited haemoglobinopathy. this haemolytic anaemia is characterized by abnormally shaped red blood cells (rbcs), which are removed from the circulation and destroyed by the reticuloendothelial system, leading to anaemia. however, more signifi cantly, the sickled rbcs cause vascular occlusion, leading to tissue ischaemia and infarction. patients with sca are at an increased risk of infection due to abnormalities in host defences and functional asplenia. sca affects multiple organs, with the clinical manifestations of sca being predominantly due to anaemia, vaso-occlusion and infection. imaging findings: the fundamental skeletal abnormalities consist of marrow hyperplasia, which leads to osteopaenia with a coarse trabecular pattern. in severe cases, medullary cavities are obliterated giving the appearance of generalized increased bone density. bone infarction secondary to vaso-occlusion is the hallmark of sca. in adults, it affects the ends of long bones, the central portions of vertebral bodies with typical 'h' shaped vertebrae and the femoral and humeral heads, resulting in avascular necrosis. in older children, the diaphyses of long bones are the site of predilection. areas of bone necrosis are susceptible to superadded infection, especially from salmonella. radiologists play a pivotal role in the clinical management of these patients and they should familiarize themselves with the various skeletal manifestations and complications of sickle cell anaemia, which we present in this pictorial review. purpose: to verify the bone mineral density in children and adolescents having fractures of the forearm and hand compared to children and adolescents without a fracture after similar adequate traumatic injuries. methods and materials: 100 x-ray examinations of the hand or forearm proving a fracture of children and adolescents after adequate trauma underwent a bmd calculation using digital radiogrammetry. all children and adolescents had to fi ll in a questionnaire regarding potential infl uencing factors of bone mineral density (drug intake, diseases, sportive activity, nutrition). bmd-z-score calculation used regional normative data of children and adolescents, which were obtained from images performed to exclude a fracture after adequate trauma. results: 80/100 images could be analyzed by dxr technology. 34/80 patients with fractures had a z-score of -1 (20/34 with a z-score of less than -2sd). mean bmd was -0.7 for both males and females. analysis was possible starting with 6 years of age. similar results were obtained for mci values. main reasons of bmd loss according to the questionnaire were defi cit of sportive activity and false nutritional intake (fast food). diseases and drug intake were without relevance conclusion: bone mineralization in childhood and adolescence is disturbed in a signifi cant number of children due to wrong nutritional intake and lack of sportive activity. this causes a higher fracture rate, even during growth. effects on peak bone mass are not yet verifi ed, but can be expected from the defi cit of bmd during growth. cartilaginous tumors in the hand: plain radiographic and mr imaging fi ndings y. an, j. kim; suwon/ kr (jeeykim@catholic.ac.kr) learning objectives: to review the radiographic appearances in various cartilaginous tumors occurring in the hand. background: cartilaginous tumor is the most common bone tumor in the hand. however, occasionally unusual imaging fi ndings or unusual location of tumors make it diffi cult to diagnose these cartilaginous tumors. procedure details: the cases presented include enchondroma, enchondroma protuberans, intracortical chondroma, ollier's disease, extraskeletal chondroma, osteochondroma with chondrosarcoma, and synovial chondrosarcoma. conclusion: examples of each entity as seen as plain fi lms and mr imaging will be presented. differential diagnosis in patients with chondroid tumors will be discussed. techniques sagittal proton-density-weighted and coronal t2*-weighted mr images with 1024×1024 matrix, 3 mm section-thickness, and 150 mm fi eldof-view were obtained by using a dedicated 8-channel knee coil on a 1.5 t scanner. for comparison, 512-matrix images were also obtained with identical sequences. focusing on the above-mentioned structures, paired images with 1024-and 512matrix were magnifi ed in a same scale on viewers. qualitative image analysis was performed using a four analysis of errors in the mr imaging evaluation of menisci of the knee p. van dyck; antwerp/be (pieter.van.dyck@uza.be) purpose: to determine mr accuracy for diagnosing meniscal tears and to discuss various causes of discrepancy between mr and arthroscopy. methods and materials: medical records of 100 consecutive patients who underwent mr and arthroscopy of the knee at our institution were retrospectively reviewed. twelve patients underwent prior meniscal surgery. twenty-three patients had 27 discrepancies between mr and surgical fi ndings. these were independently reviewed by two additional musculoskeletal radiologists in a double blinded fashion. original incorrect diagnoses were categorized as either unavoidable, interpretation error or equivocal for meniscal tear. results: mr accuracy was 88% for the medial and 85% for the lateral meniscus. of 27 incorrect mr diagnoses, 12 (44%) were unavoidable, 10 (37%) were equivocal b d e f a g and 5 (19%) were interpretation errors. of the 67 medial meniscal tears, 12 (18%) were missed. eight (67%) of these 12 were categorized as equivocal, including 3 postoperative menisci. of the 30 lateral tears, 12 (40%) were missed, 7 (58%) of which were categorized as unavoidable. of these 12, 11 (92%) showed fraying of the inner edge, which led to minimal resection (n=7) or had minimal tear treated conservatively (n=4). there were 3 false-positive diagnoses, all occuring in the lateral meniscus, 2 of which were unavoidable and 1was an interpretation error. conclusion: of all missed lateral meniscal tears, most are unavoidable and related to confusion between what represents fraying and what represents a tear. unavoidable false-positive diagnoses are infrequent and may be related to incomplete arthroscopic evaluation. subtle equivocal fi ndings still make mr diagnosis diffi cult, even for experienced radiologists. learning objectives: evaluate the imaging contribution in total hip replacement (thr) management. background: digital or plain fi lm imaging permits the diagnosis of a majority of thr complications. ct scan and mri, usually less useful, are becoming better adapted due to the performance of the latest machines and specialized software. imaging findings: main local complications are acute, consisting of implant fractures, joint dislocation and neighbouring bone fatigue fracture. chronic complications include soft tissue new bone formation, periarticular tendonitis, bursitis, recurent dislocation and, above all, device loosening without infection due to granulomatous reaction or with intercurrent infection. in case of recurrent dislocation, x-ray or ct scan can be used to evaluate the actual position of the devices and the possible wear. conclusion: hip replacement surgery has been one of the most common elective and semi-elective orthopedic operations for the past 25 years. radiography remains the mainstay of imaging evaluation of hip replacements. the various types of hip replacements can be recognized on radiographs, and many complications have specifi c appearances that the radiologist should be familiar with. pitfalls in post-surgical shoulder mri evaluations p. pastore, d. volpe, n. volpe, f. murgante, a. stecco, a. carriero; novara/it (dvolpe@sirm.org) learning objectives: to describe and recognize magnetic resonance imaging (mri) fi ndings that can be confused with pathological abnormalities in post-operative shoulder; to maximize the accuracy of mri imaging by providing the most appropriate pulse sequences. background: imaging post-operative shoulders has always been a matter of debate, the main controversy being whether mri or mr arthrography is the best means of answering diagnostic questions. published data and clinical experience show that conventional mri is effective in assessing full-thickness lesions, but less capable of differentiating partial lesions and normal fi ndings after surgery. procedure details: a number of factors may decrease the accuracy of mri in evaluating post-operative shoulders, including iatrogenic artefacts, surgical distortions of native anatomy, changes in the signal intensity of tissues, and image degradation caused by metallic artefacts. we show the key points for optimizing post-operative shoulder mri protocols and try to identify the best technical parameter among the most widely used pulse sequences. conclusion: when interpreting post-operative shoulder mr images, radiologists must be familiar with all possible pitfalls in order to avoid diagnostic errors. dynamic gadolinium-enhanced mr imaging in characterization of growth cartilage perfusion with epiphyseal vascular occlusion x. li, l. xia, h. zheng; wuhan/ cn (lilyboston2002@163.com) purpose: to determine the contribution of metaphyseal vascularity to epiphyseal and physeal perfusion with epiphyseal vascular occlusion by using dynamic gdenhanced mr imaging. twelve 2-week-old piglets were randomly assigned into either control or abduction group (12 proximal femurs in each group of 6 piglets). proximal femoral epiphyseal vascular occlusion was induced by maximal bilateral hip abduction for 2 hours. dynamic gd-enhanced mr imaging was performed in normal and abduction hips. for dynamic gd-enhanced imaging, spoiled gradientrecalled echo images with a temporal resolution of 3.0s were performed, and a total of 96 images were obtained. the enhancement ratios (er) in various regions of femoral heads were evaluated and correlated with histological fi ndings. results: in normal hips, we found no signifi cant differences in the er and the timing of enhancement between physeal cartilage and metaphyseal spongiosa (p> 0.1). however, in abduction hips, the er of physeal cartilage was lower than that of metaphyseal spongiosa and enhanced more slowly than metaphyseal spongiosa (p < 0.05). meanwhile, the er of epiphyseal cartilage remained lower and enhanced more slowly than physeal cartilage (p < 0.001). the er of physeal and epiphyseal cartilage in abduction was lower and enhanced more slowly than those in the normal (p < 0.001). more transphyseal vessels in abduction were found histologically than those in the normal (p < 0.005). conclusion: with epiphyseal vascular occlusion, enhancement seems to advance from the metaphysis into the physis and epiphysis, the metaphyseal vascularity might contribute to epiphyseal and physeal perfusion. this research is supported by nsfc (30370430). imaging the complications of total hip replacement j.m. moriarty, j. kerr, c. shortt, j. o'byrne, s. eustace; dublin/ie learning objectives: the objectives of this exhibit are to describe the anatomic basis behind the complications of total hip replacement, the radiologic features that describe these complications and the new innovations in diagnostic imaging of these features. background: of the 600,000 total hip replacements performed worldwide each year, it is estimated that 5% fail at some stage. the type of surgical approach used, prosthesis inserted and method of fi xation employed all have a role in the prevalence and form of complication that can ensue. the role of radiography, arthrography, ct, and mri in the diagnosis of these complications is rapidly evolving, particularly the use of metal artefact reduction techniques in mri. imaging findings: this exhibit presents a pictorial review of components, methods of fi xation and complications of total hip replacement. the exhibit reviews the role of radiography, scintigraphy, computed tomography, ultrasound, arthrography and mri in the assessment of common complications including loosening, infection, heterotrophic bone formation, muscular avulsions, and prosthesis impingement. furthermore, a detailed review of the use of mri with artefact reduction techniques in the evaluation of deep seated infection, iliopsoas bursitis and abductor avulsion will be presented. the diverse imaging modalities that may be employed in the evaluation of the myriad complications of total hip replacement is being constantly updated, re-evaluated and added to. in particular, the increasing sensitivity of certain mri sequences in the setting of metallic prostheses has led to the routine use of mri as a problem solving tool. to analyze the discordant fi ndings of anterior cruciate ligament (acl) on sagittal and oblique coronal mr images of the knee, and correlate with arthroscopic fi ndings as the standard. methods and materials: one hundred thirty-eight mr images of the knee in patients with suspected internal derangement who subsequently underwent arthroscopic surgery were included. two radiologists, unaware of clinical details, jointly evaluated acl on sagittal t2, proton density-weighted images initially and then on oblique coronal images. reviewers determined the status of acl as intact (i), partial (p), or complete tear (c) respectively. when interpretation of acl status was different between both imaging planes, cases were categorized as discordant and correlated with arthroscopic results. results: a discordant mr fi nding of acl was seen in 9 of 138 knees (6.5%). correlation of acl status on sagittal, oblique coronal images with arthroscopic fi nding was the following: c-p-p in 3, p-i-i in 2, c-i-i in one, c-p-c in 2, and i-p-c in one case. at arthroscopy, total rupture of ant-med bundle with partly intact post-lat bundle was observed in 3 c-p-p; displaced acl by fat tissue in intercondylar notch and torn meniscal fragment, deformed course by ligamentum mucosum adhesion in 2 p-i-i and one c-i-i; fi brous scar in 2 c-p-c and one i-p-c. a discordant fi nding of acl on sagittal and oblique coronal mr images was not frequent, and attributed to remained post-lat bundle, displaced course, and presence of scar. interpertation of acl on oblique coronal image seems more accurate than on sagittal images. osseous criteria for ankle instability o. magerkurth, a. frigg, b. hintermann, h. ledermann; basle/ch purpose: some patients suffer from recurrent ankle sprains even after operative ligament reconstruction. one reason could be a disadvantageous joint confi guration. the purpose was to evaluate those parameters of the osseous confi guration of the ankle joint that could determine stability. a larger radius of the talus and a smaller tibio-talar sector contribute to osseous instability. these fi ndings are of importance, showing that ankle instability may depend not only on competence of collateral ligaments but also on osseous joint confi guration. magnetic resonance imaging evaluation of articular cartilage after autologous osteochondral grafting i. herrera, s. fernández-zapardiel, y. herrero, m. céspedes, p. calvo, e. fandiño; toledo/es (babel10100@hotmail.com) learning objectives: to illustrate the appearance and outcome of the articular cartilage after treatment of osteochondral patology with multiple autologous osteochondral plugs (mosaicplasty) using magnetic resonance imaging (mri). background: articular cartilage damage is extremely common in today's society. osteochondral autotransplantation is a surgical technique that is being used increasingly in the treatment of symptomatic focal chondral or osteochondral defect. with more new surgical procedures being used to repair chondral defects, such mosaicplasty, there is an increasing demand for radiologists to evaluate these procedures. procedure details: there were 22 patients with focal chondral lesion (19 of the knee and 3 of the ankle) treated with mosaicplasty. clinical examination, x-ray and mri were performed on each patient before surgery. the mosaicplasties were normally done with arthoscopic and transferred autologous bone from the donor site to the recipient site into the cartilage defect. after the surgery, for the assessment of a cartilage repair procedure, we used mri general electric signa horizon lx 1.5 t with axial, coronal and sagittal planes with cartilage-sensitive sequences, such as fat-suppressed t2-weighted fast spin-echo/proton densityweighted or 3d gradient echo sequences. we evaluated the number of plugs, the graft integration to the adjacent hyaline cartilage and bone, congruence of the articular surface, the adjacent bone marrow, the status of the graft donor site as well as associated complications. conclusion: with its direct multiplanar imaging capabilities, excellent soft tissue contrast and spatial resolution, mri could be the method of choice for non-invasive follow-up of patients after mosaicplasty. shoulder virtual arthroscopy in glenohumeral instability: image gallery correlation with arthroscopy d. volpe, n. volpe, n. masiello, p. fornara, a. stecco, a. carriero; novara/it (dvolpe@sirm.org) learning objectives: our intent is to correlate virtual arthroscopy images with arthroscopic fi ndings, and to show an image gallery by means of virtual arthroscopic images of main shoulder pathologies. background: shoulder mr arthrography (mra) is now a well-assessed technique based on the injection of contrast medium solution, which fi lls the articular space and fi nds its way between the rotator cuff (rc) and the gleno-humeral ligaments. in case of gleno-labral pathology or partial rc tears, we use an additional sequence that allows obtaining virtual arthroscopy post-processed views to complete the mr evaluation of shoulder pathology. procedure details: mr arthrographic sequences (se t1w and gre t1 fat sat) are provided with a ge 0.5 t signa and the supplemental sequence is a 3d spoiled ge t1w positioned in coronal plane. virtual arthroscopy is performed by means of a dedicated software loaded on a work-station. conclusion: shoulder virtual arthroscopy may be useful in diagnostic accuracy, both as an adjunct to clinical and surgical planning, as well as an interactive tool for learning arthroscopic anatomy and pathology. purpose: to assess the value of virtual arthroscopy of the shoulder. methods and materials: forty patients with shoulder dislocation-translation and/or clinical signs of instability underwent 64 slices mdct arthrography and virtual arthroscopic reconstruction. all scans were performed using 64-detector row helical ct scanners with following parameters: 200 kv; 40 ma; thickness 0.6 mm; collimation 0.6; reconstruction increment 0.6 mm; matrix 512 x 512; preparation and acquisition time 10 min. the patients were examined in supine positions with the shoulder in neutral position; intra-articular injection was performed posteriorly, without fl uoroscopic control, administering 20 cc of room air. the data were downloaded to a workstation and virtual arthroscopy performed using a pc-based 3d reconstruction program. a surface rendering algorithm was employed for producing virtual arthroscopic images. prior to applying the surface rendering algorithm, a threshold value was specifi ed, corresponding to the center of the different density between bony tissue (the brightest pixel) and soft tissue. surface models then were calculated and displayed employing an imaginary light source results: mdct arthrography diagnosed 20 bankart lesions, 5 bankart osseous lesions, 5 cuff-rotator tears, 15 hill-sachs lesions and 2 slap lesions. virtual arthroscopy detected and visualized all lesions above-mentioned; it provides a further point of view of shoulder joint which is useful for orthopaedic surgeons planning arthroscopy or arthrotomy; it may also serve as a simulation in the teaching of orthopaedic trainees. conclusion: virtual arthroscopy is a new technique that has the potential to enhance the diagnostic performance of ct arthrography. the scapho-lunate joint and the scapho-lunate ligament: study by ultrasonography a.r. michaelides, a. foteinos, g. setakis, m. kastania, t. giannopoulos, s. chalkias; chios/gr purpose: the ultrasound (us) study of scapho-lunate ligament and scapholunate distance. we studied using us 100 wrist joints (50 healthy persons), with a superfi cial linear us transducer of high resolution (10 mhz). we measured 456 b d e f a g the distance between the scaphoid and lunate bones in (a) neutral position, (b) radial deviation, (c) ulnar deviation; and characterized the visualization of the scapho-lunate ligament in the palmar and dorsal surfaces. the visualization of the scapho-lunate ligament was characterized as completely visualized, partially visualized and non-visualized. results: the scapho-lunate distance was measured between 2.0 mm and 6.6 mm, with a mean diameter of 4.5 mm. the difference in this distance between left and right arm did not exceed 2.4 mm. there was no signifi cant change in the scapholunate distance during ulnar and radial deviation. the scapho-lunate ligament was completely visualized in 52/100 cases, and partially visualized in 23/100 cases, all being studied dorsally. the scapho-lunate ligament was better visualized by ultrasound in the dorsal surface compared to the palmar one. the scapho-lunate ligament is partially or completely visualized in 75% of wrist joints studied and this fi nding could help exclude scapho-lunate dislocation or subluxation. imaging patellar complications after knee arthroplasty p. melloni, r. valls, m. veintemillas, s. pérez, i. delgado, m. prieto; sabadell/es learning objectives: to illustrate and describe complications affecting the patella in patients with total or partial knee arthroplasty. background: we retrospectively reviewed 937 consecutive patients treated with total or partial knee arthroplasty in the last two years; 34 (1.42%) patients (22 women and 12 men) presented patellar complications. mean patient age was 74 years (range: 59-90 years). all underwent plain-fi lm radiography periodically. in determinate cases according to the clinical symptoms, patients underwent us. imaging findings: the most common patellar complications after total or partial knee arthroplasty were: fracture (n=9), instability (n=13), dislocation or luxation (n=4), osteonecrosis (n=5), infection (n=2), erosion (n=2), impingement on the prosthesis (n=3), patellar or quadriceps tendon tear (n=3), and loosening or rupture of the patellar prosthetic button (n=5). the mean interval from total knee replacement to patellar complication was 5 years and 7 months (range: 5 months-14 years). conclusion: patellar complications following knee arthroplasties are generally uncommon but often of potential clinical signifi cance. plain fi lms are essential for the evaluation of patellar complications after surgery and should be the initial imaging study performed. careful attention to initial prosthesis placement and comparison of follow-up images will allow subtle abnormalities to be detected in patellar complications. us may have a special role in the evaluation of soft-tissue structures around the patella. superfi purpose: fat-suppressed three-dimensional (3d) spoiled gradient-echo (spgr) mr imaging has been described to be accurate for detecting 50% or greater cartilage defects. the purpose of this study was to determine the accuracy of sagittal fat-suppressed 3d spgr imaging for detecting superfi cial cartilage defects of the medial femoral condyle. methods and materials: fifty patients who had arthroscopically confi rmed cartilage defects by an arthroscopist and had mr imaging were included in this study. sagittal fat-suppressed 3d spgr mr images were retrospectively reviewed by a radiologist. cartilage thickness was graded: grade 0, normal; grade 1, abnormal signal without a contour defect; grade 2, less than 50% reduction of cartilage thickness; grade 3, 50% or greater reduction of cartilage thickness; and grade 4, full-thickness cartilage defect. results: after arthroscopy, there were 68 cartilage defects in the medial femoral condyles: grade 2 (n = 21), grade 3 (n = 37), and grade 4 (n = 10). after fat-suppressed 3d spgr imaging, cartilage defects in the medial femoral condyles were graded as follows: grade 2 (n = 26), grade 3 (n = 33), and grade 4 (n = 9). sensitivity, specifi city, and accuracy for grade 2 cartilage defects were 90% (19/21), 85% (40/47), and 87% (59/68), respectively. cartilage grading showed a signifi cant correlation between fat-suppressed 3d spgr imaging and arthroscopy (r =.80, p <. 001, spearman's correlation). conclusion: sagittal fat-suppressed 3d spgr mr imaging is accurate for diagnosing superfi cial cartilage defects. thus, it is helpful for planning treatment that could be different between early and advanced cartilage defects. direct and indirect mr arthrography: advantages and disadvantages t.a.a. macedo 1 , l.p. souza 2 , l. farage 2 ; 1 são paulo/br, 2 uberlândia/br (tamacedo@hotmail.com) learning objectives: to demonstrate the pros and cons of direct and indirect magnetic resonance arthrography (mra). background: direct mra (dmra) with injection of gadolinium (gd) diluted in saline solution can be useful for evaluating certain pathologic conditions in the joints. it is most helpful in the shoulder; especially for outlining labral-ligamentous abnormalities and distinguishing partial-thickness from full-thickness tears in the rotator cuff; but it can be also useful in other joints, demonstrating labral tears in the hip, showing tears of the collateral ligament of the elbow, identifying residual or recurrent tears in the knee following meniscectomy, and assessing the stability of osteochondral lesions in the articular surface of joints. indirect mra (imra) can be done when dmra is inconvenient, or not logistically feasible. in this case, the mr images are acquired after an intravenous administration of gd-contrast media. between april 2005 and august 2006, we performed 29 dmra and 44 imra in our institution. procedure details: the direct arthrographies were perfomed using fl uoroscopy and ultrasound guidance and about 12-15 ml gd-diluted solution was injected in the shoulder. indirect mra was done after 10 ml (0.5 mmol/ml) intravenous injection of gd-contrast media (dotaren ® ,guerbet laboratories). all the examinations were performed in patients with rotator cuff, labral or slap lesions. conclusion: although imra is unable to fi ll the joint cavity, it does not require direct gd-contrast media injection and it is superior to conventional mr imaging when there is minimal joint fl uid. in addition, intravenous injection allows demonstrating vascularized or infl amed tissue. evaluation of anterior cruciate ligament (acl) autografts and allografts with magnetic resonance imaging (mri) i. tsifountoudis, i. kalaitzoglou, a. haritandi, i. economou, a.s. dimitriadis; thessaloniki/gr (jtsif@mycosmos.gr) learning objectives: arthroscopic reconstruction of acl is being performed with increasing frequency. although the procedure is performed with good success rates, early and late complications have been documented. our purpose is to demonstrate the normal appearance of the reconstructed acl with mri and to illustrate the diagnostic pitfalls and the postoperative complications. background: sixty-fi ve patients (58 males and 7 females; age range: 17-59) who had undergone acl reconstruction using either autografts or allografts were referred to knee mri (1.5 t) for acl graft control, between july 2004 and september 2006. the imaging protocol included t1-weighted, proton density-weighted and t2-weighted fast spin-echo images and stir images in all planes. if the graft was not optimally visualized, oblique sagittal t2-weighted images were obtained along the course of the graft. finally, gadolinium was administered intravenously in 7 cases. imaging findings: intact graft was depicted in 37 patients with continuous, homogeneous and low signal intensity. signs of roof impingement were found in 10 patients. the graft fi bers were absent due to rupture in 18 cases. localized arthrofi brosis (cyclops lesion) was detected in 8 patients. postoperative infection was diagnosed in 3 patients, migration of the interference screws in 3 cases and cystic degeneration of the graft was depicted in 2 patients. thickening of the harvested patellar tendon was seen in 3 patients and "regeneration" of the hamstring tendons in 18 patients. the knowledge of the normal mr appearance of acl grafts and the recognition of their complications are crucial for the appropriate management of symptomatic patients. magnetic resonance imaging in chronic ulnar-sided wrist pain: pictorial review j.s. sawhney, a. bajaj, r. bhatt, k. jeyapalan; leicester/uk (jasdevsawhney@yahoo.com) purpose: chronic ulnar-sided wrist pain management can be intimidating and confusing because of its vague and intermittent nature, complex anatomy and pathology and frustration that it induces in the patient and the doctor. this pictorial review attempts to present a spectrum of cases illustrating the anatomy and pathologies of this complex region as seen on mri. methods and materials: mri was done for 71 patients over a period of 3 years with chronic pain on ulnar side of wrist. 1.5 t scanner was used. sequences used were t1 axial and coronal, pd fat sat axial and coronal, t2 sagittal and stir sagittal. the abnormalities are categorised into osseous (bony and degenerative), ligamentous, tendinous, infl ammatory neurologic and miscellaneous. results: fracture non-unions of the hook of hamate (1), ulnar styloid process (1), hamate contusion (1), lunate avn (2). degenerative processes at pisotriquetral joint (4), midcarpal (triquetrohamate) articulation (2), distal radioulnar joint {instability (4) and synovitis (2)}. ulnar impaction syndrome (7). ligamentous injuries included scapholunate (6). tfcc, triangular fi brocartilage complex {tear (9) and degeneration (3)}. tendinopathies and tensosynovitis noted in e4-e6 compartment (5), fcu (1) and diffuse (3). infl ammation and erosions (3) related to rheumatoid disease. neurologic processes such as entrapment of the ulnar nerve in guyon's canal (1). miscellaneous group includes ganglia (4) and neuroma (1). no abnormality was found in 13 patients. conclusion: mri extends the possibilities of evaluating chronic ulnar wrist pain. its signifi cance lies in the non-invasive examination of various intraosseous as well as soft tissue abnormalities. evaluation of patellofemoral joint cartilage at high-resolution mr imaging using a microscopy coil: comparison with conventional mr imaging s. takao 1 , h. nishitani 1 , t. yamaguchi 2 , m. uetani 2 ; 1 tokushima/jp, 2 nagasaki/jp (takaos@mue.biglobe.ne.jp) purpose: mr imaging using a microscopy coil provides high-resolution images, which can be useful in demonstrating early cartilage abnormalities. the purpose of this study is to evaluate its diagnostic accuracy in evaluation of patellofemoral joint cartilage abnormalities. methods and materials:we evaluated 44 patellofemoral joints (43 patients) with mr imaging using a conventional knee coil and a microscopy coil; t2-weighted images and fat-saturated proton-density-weighted images were acquired respectively. retropatellar cartilage was divided into 9 parts and femoral cartilage into 3 parts, where the status of cartilage was graded into 0 (normal) to 4 (full thickness injury). the diagnostic accuracy was analyzed using surgical or arthroscopic fi ndings as a standard of reference. results: in 528 parts of cartilage, accuracy of mr grading using a microscopy coil and a conventional knee coil were 0.924 and 0.915, respectively, when grade 1-4 was considered to be positive, and 0.990 and 0.994, respectively, when grade 2-4 was considered to be positive. in 31 parts with grade-1 surgically confi rmed cartilage lesion (superfi cial lesions, soft indentation and/or superfi cial fi ssures and cracks), mr grading were correct in 9 with a microscopy coil and in 3 with a conventional coil. however, no signifi cant difference was seen statistically in the accuracy of both techniques. conclusion: this preliminary study indicated that high-resolution mr imaging using a microscopy coil could be useful in detecting early cartilage abnormalities. further study is required to obtain a statistically signifi cant result. learning objectives: 1) to describe the mr imaging fi ndings in the patellar tendon-lateral femoral condyle friction syndrome. 2) to consider the patellar tendonlateral femoral condyle friction syndrome in the differential diagnosis of patients with anterior knee pain. 3) to identify the patellar tendon-lateral femoral condyle friction syndrome in order to make a correct treatment. background: patellar tendon-lateral femoral condyle friction syndrome is a rare cause of anterior knee pain related to the clinical entity of fat pad impingement. mr imaging can reliable identify this entity, showing the soft tissue edema in the infrapatellar fat body in the anterolateral aspect of the patellofemoral joint. imaging findings: retrospective review of mr images in 51 knees (48 patients) with antero-lateral knee pain and a focal area of abnormal signal intensity in the inferolateral aspect of the patellofemoral joint was performed. patients with a meniscal tear or ligamentous injury were retrieved to exclude these facts as the cause of knee pain. abnormal patellar alignment was demonstrated in 28 knees. patellar tendinitis was noted in 8 cases. patellar confi guration type iii of wiberg was found in 22 knees. conclusion: mr imaging allows identifi cation of changes in patients with patellar tendon-lateral femoral condyle friction syndrome that should be distinguished from other causes of anterior or lateral knee pain. utility of four-dimensional arthrography of the acetabular labrum applying motion-gated multislice computed tomography: comparison with arthroscopy and harris hip score n. funabashi, s. kishida, y. harada, h. moriya, i. komuro; chiba/jp purpose: to analyze the kinesis and morphology of the acetabular labrum (al) non-invasively, we applied four-dimensional (4d) arthrography with motion-gated msct and compared the results with arthoscopy and harris hip score (hhs). methods and materials: forty-nine symptomatic patients (52 hips) underwent msct. before ct acquisition, contrast material was injected into the hip joint. the subject performed reciprocating hip fl exion-extension at the same rhythm as a pulsation simulator. then we performed mimic retrospective ecg-gating, that is "motion-gated", acquisition and were reconstructed to divide one movement into 10 segments. the kinematics and morphology of al were evaluated on 4d fi lms and the fi ndings were classifi ed into three groups: stabilized, irregular, and eccentric motion. hip arthroscopy was performed in 34 hips. labral lesions were classifi ed into four groups according to morphologic features (intact, fray, tear, and detached). hhs was also calculated depend upon patient state at the examination. results: of 46 hips with adequate images, 15, 11, and 20 revealed stabilized, irregular, and eccentric motion, respectively. of 16 without adhesive al on arthroscopy, 6 had irregular (average 48 hhs) and 4 had eccentric motion (average 58 hhs) and hhs tend to be higher in the eccentric group than in the irregular groups on 4d ct. conclusion: 4d arthrography of the al applying motion-gated msct can reveal both kinetic and morphological changes of al and can perform further stratifi cation in subjects with the american academy of orthopaedic surgeons class 0, or 1 or without "detached" morphological fi ndings by arthroscopy. impact of whole-body mr in the assesment of extension and follow-up of hemophilic artropathy r. domínguez, c. altisent, s. gispert, x. merino, v. pineda; barcelona/es (16966rdo@comb.es) purpose: the hemophilic artropathy (ha) is a progressive osteoarticular disease presumed to result from intra-articular and periarticular hemorrhage. the aim of this study is to defi ne the role of the whole-body mr (wb-mr) in the assessment of extension, degree of joint involvement, and follow-up of the ha. in this prospective study, we performed a wb-mr performed in 35 patients with ha and prophylactic treatment. mr protocol included t1-se, stir, and gre-t2 in the coronal and axial planes using several coils. the parameters evaluated were: 1) involvement of the important joints (shoulders, elbows, hips, knees, ankles), 2) bone or muscle-tendinous involvement (muscular atrophy, muscular haematoma, pseudotumor), and 3) other osteoarticular lesions not related to ha. the extension and degree of he were classifi ed according to the european score. results: in one third of the patients, the wb-mr detected ha in other joints not detected clinically, as synovitis, hemosiderin deposits or early artropathy. one third of the patients with clinical history of hemarthrosis of repetition did not show articular involvement or hemosiderin deposits by mr. other musculoskeletal pathologies not related to ha were identifi ed in 50% of the patients (meniscopathy, femoroacetabular impingement, labrum disease, avascular necrosis, fi brous defects), being important in order to stablish differential diagnoses. the wb-mr is a new useful imaging technique for the estadifi cation and follow-up of ha. it allows the evaluation of the response to the prophilaxis and treatment of the disease. it is also helpful for the differential diagnosis with intercurrent osteoarticular pathologies. mdct background: functional imaging might increase the role of imaging in muscular diseases, since sole assessment of muscle morphology reveals non-disease-specifi c results. intact sodium homeostasis is crucial for tissue viability. pathological changes of sodium homeostasis can be found in various clinical diseases, such as infarction, infl ammation, neoplasia, and muscular channelopathies. the implemented three-dimensional radial 23 na mri technique detected validly the tissue's sodium content. the acquisition time of 10 minutes and direct reconstruction of images and archiving them in pacs enabled a clinically feasible examination protocol. imaging findings: 23 na mri delivers reproducible data on sodium content within skeletal muscles. in various sodium channelopathies, 23 na mri detects intracellular sodium accumulation that is associated with muscle weakness and stiffness. also, the benefi cial effects of blocking the pathologic sodium channels by a dedicated medication can be quantifi ed. results of 23 na mri in vivo correlate signifi cantly to both electrophysiological in-vitro data of muscle fi bers derived from biopsies and muscle weakness in patients with sodium channelopathies. furthermore, 23 na mri detects altered myocellular sodium content in other ion channelopathies and dystrophic myopathies, as well as altered muscular sodium signal in acute autoimmune myositis. conclusion: 23 na mri can quantify skeletal muscle sodium homeostasis and is a promising functional imaging method, especially for muscular channelopathies. the correlation between sonography and disease severity in carpal tunnel syndrome e. alimoglu, h. ozcanli, s. dogan bayraktar, a. apaydin, s. tuzuner, e. luleci; antalya/tr (ealimoglu@akdeniz.edu.tr) purpose: to investigate the correlation between sonographic fi ndings and severity of carpal tunnel syndrome (cts). methods and materials: 118 wrists of patients with cts symptoms were included in our study. after clinical examination and electrodiagnostic study (enmg), sonography was performed in patients by a radiologist unaware of the physical examination and enmg results. the wrists showing both positive clinical fi ndings and enmg results were diagnosed as cts. the cross-sectional area of median nerve was measured at the level of the psiforme bone in sonography and the measurements over 10 mm² were accepted in favor of cts. the disease was categorized into three groups according to enmg results: mild, moderate and severe. the difference between the mean sonographic area values of the three severity groups was investigated to estimate disease severity. results: fifty-four wrists had positive clinical examination and enmg results. the mean area was 14.9±5.7 in these cases. the median nerve area was measured under 10 mm² in 7 cases. the sensitivity of sonography in the diagnosis of cts was 87%. the mean area of the median nerves was 11.1±3.4 mm², 14.4±4.5 mm², and 19.2±5.9 mm² in mild, moderate and severe groups, respectively, and the difference between them was statistically signifi cant (p=0.000, kruskal-wallis analysis). conclusion: the diagnostic usefulness of sonography in cts has been clearly shown previously. however, little attention has been paid to the correlation between sonographic fi ndings and severity of disease. in addition to its high sensitivity in the diagnosis of cts, sonography may also be helpful in estimating disease severity. the aim of this study is to analyze and correlate the size and mr imaging signal features of aggressive fi bromatosis with its behaviour. march 1985 and december 2005, 27 patients with at least two consecutive mri examinations and no surgery or radiation therapy in between were recorded. they underwent 107 mri examinations of 47 lesions, of which 29 were medically treated, while the remaining 18 did not receive any drug administration. each lesion was studied by size and signal changes in time on t2-injected and/or t1-weighted sequences. for size, we used the recist criteria. we classifi ed the signal in six increasing classes, and then we established the related variations in the time. results: seventy-nine per cent of lesions in the treated group and 82% in the not-treated group maintained size stability. the initial signal of stable or increase in size of lesions was most frequently high. there was a high rate of signal stability in time, whatever the initial signal and size changes were. the size changes were not correlated with the initial mr signal. only in the treated group, 3 decreases in size associated with signal decrease were observed. conclusion: fibromatoses are a group of soft-tissue tumors with variable characteristics on mri, but it is not possible to predict their behaviour from mri signal. assessment background: functional imaging might increase the role of imaging in muscular diseases, since sole assessment of muscle morphology reveals non-disease-specifi c results. perfusion, i.e. the blood fl ow per tissue and time unit including capillary fl ow, is an important functional parameter. pathological changes of skeletal muscle perfusion can be found in various clinical diseases, such as degenerative or infl ammatory myopathies. contrast-enhanced ultrasound allows for a sensitive detection of microvascularity in real-time. quantifi cation of perfusion is achieved by analyzing replenishment kinetics of the contrast agent. also, the effects of training schemes on muscle microcirculation can be assessed for separate muscle groups. imaging findings: contrast-enhanced ultrasound delivers reproducible perfusion data in volunteers. ceus visualizes exercise-induced hyperperfusion and can separate well-trained subjects from un-trained subjects. ceus-derived perfusion results in vivo correlate signifi cantly to capillarization in biopsies from these muscles. furthermore, ceus detects increased microcirculation in histologically proven acute autoimmune myositis with comparable accuracy as mri and additionally increases specifi city in diagnosis of myositis when a muscle edema -as such a non-specifi c fi nding -is evidenced by mri. moreover, the effects of muscle degeneration on microcirculation can be assessed. conclusion: contrast-enhanced ultrasound allows valid quantifi cation of skeletal muscle perfusion and is a promising functional imaging method for various myopathies. gas learning objectives: to illustrate the wide spectrum of causes of subcutaneous emphysema in the emergency room. to show the key fi ndings on ct and plain radiograph. to discuss the differential diagnoses. background: gas in soft tissue is a relatively common sign at the emergency room. it has a great importance due to its broad casualty, some of them totally benign, but others potentially lethal. we retrospectively reviewed the imaging fi ndings of patients with subcutaneous emphysema from our database of emergency pathology. we analysed the origins and the associated features. imaging findings: gas in soft tissue was found associated to traumatic, iatrogenic (surgical procedures, injection), or infectious causes (necrotizing fasciitis, fournier gangrene). it also was found associated with thoracic pathology causing pneumothorax and pneumomediastinum, and abdominal pathology related to intraperitoneal and retroperitoneal gas. diagnostic diffi culties and differential diagnoses are emphasized. radiologists must be aware of anomalous gas in soft tissue, because it may be the main or even unique sign to lead us to search the underlying pathology, which can be lethal. multi-detector-row ct of the muscles by using volume rendering techniques l. saba, g. caddeo, m. atzeni, f. corrias, d. ribuffo, g. mallarini; cagliari/it learning objectives: to analyze the mathematical concept to obtain vr images to defi ne the muscles. to learn the ct technical parameter to be used, as well as the slice thickness, increment, mas and kvs. to understand the current indications for performing multi-detector-row ct study of the muscles underlining radiation exposure, cost and diagnostic effi cacy background: multi-detector-row ct, by using fast scanning and thin collimation can obtain near-isotropic voxels, producing an excellent image detail. moreover, with the use of post-processing procedures it is possible to obtain volumetric images with an impressive visual impact (dissection-like images). with the use of correct techniques, by using in particular volume rendering (vr) reconstruction, it is possible to defi ne body musculature and to identify pathological alterations. the aim of this education exhibit is to describe how it is possible to obtain a correct visualization of the body muscles and to show volume rendered images that are possible to obtain. procedure details: we studied 12 patients by using a multi-detector-row ct (mdct). data obtained were re-processed and we obtained volume rendered images. for each patient, we generated multiple vr reconstructed images in order to defi ne the better strategies to evaluate different types of muscles. conclusion: mdct can obtain excellent visualization of the superfi cial musculature; in particular, it defi nes with accuracy normal anatomy. hibernoma: review the mri imaging in eleven patients m. de albert 1 , s. martínez 2 , j. narváez 1 , r. mast 1 , e. carreño 1 ; learning objectives: hibernoma is a rare benign soft-tissue tumour of brown fat cells. we describe the mr imaging fi ndings of eleven patients. background: cases were retrospectively identifi ed from the pathology database of two tertiary referral hospitals. patient age, sex and duration of symptoms were recorded. we retrospectively reviewed the mri of eleven patients with histologically proven hibernoma. imaging findings: patient group consisted of seven females and four males, with an average age of 35 years (range 25-63 years). six lesions were located in the thigh, one in the chest and four in the upper limb. six of the lesions were intramuscular, three were intermuscular and two were located in the subcutaneous fat. the majority of the cases demonstrated mr fi ndings of a well-defi ned, heterogeneous mass, slightly or clearly hypointense to subcutaneous fat, with prominent thin low signal bands on t1 w se images. the lesions failed to suppress fully on stir or fat-saturated t2-weighted images. six of the seven post-contrast studies evidenced signifi cant enhancement within the lesion. the mr fi ndings described should lead to consider this rare diagnosis in the assessment of an atypical fatty mass on mri. radiologic-pathologic correlation in fat tissue tumours of the extremities f. sandomenico, o. catalano, f. fazioli, a.r. de chiara, a. nunziata, a. siani; learning objectives: to give a comprehensive accurate guide of us, ct and mri fi ndings in various types of soft tissue lipomatous tumours of the extremity, with pathologic correlations during and after surgery. background: soft tissue tumours with prevailing fat tissue areas are lipomas, lipoblastoma, hibernoma and liposarcoma. liposarcoma is the second most common type of soft tissue sarcoma (10-35%). its histological subtypes are categorised as: well differentiated, dedifferentiated, myxoid, allomorphic and mixed type. procedure details: the lesions illustrated are identifi ed with relative ease on ct and mri, due to the typical density/signal of the fat. lipomas, however, can reveal small non-fat density/signal areas; in these cases vigilance is necessary. in malignant lesions, one can usually detect fatty areas that allow the diagnosis. in these cases, the non-fat areas, on which the biopsy is to be directed, are picked up with imaging. special attention should be focused on the density/signal intensity in tumour nodules and septation. myxoid liposarcomas have some particularity such as intramuscular position, pseudocystic aspect with peripheral enhancement, small solid nodules, or septa containing fat. the knowledge of the pathological and surgical substrate of the lipomatous tumours of the extremity soft tissues constitutes the base for the diagnostic imaging assessment and is fundamental for optimal patient management. the role of ultrasonography in patients with radial nerve pathology: comparison with magnetic resonance and surgery c. bertocchi, s. colopi, r. adani, p. torricelli; modena/it (clatommy@fastwebnet.it) purpose: to evaluate ultrasonography (us) accuracy in identifying radial nerve (rn) morphology and related pathologies compared to magnetic resonance (mr). methods and materials: fifteen patients with nr paralysis (6 had expansive and 9 traumatic pathology) were examined with radiography, electromyography, us (siemens-sequoia; linear probe 10-15 mhz) and mr (philips intera 1.5 tesla). surgical evaluation was performed in 10 patients. us and mr parameters evaluated were: identifi cation, thickness, integrity and structure of the rn. results: five patients had a spontaneous recovery of rn paralysis. in the remaining 10, us identifi ed correctly rn morphology, thickness, structure and anatomical relationship, compared to surgical evaluation. rm was unable to identify the rn in 5 cases because of the metallic material artefacts. in traumatic and expansive pathologies, mean rn thickness was 4.4 mm and 1.4 mm, respectively; the ecographic structure was ipoechoic with loss of the fascicolated normal pattern in traumatic lesions while normal in expansive ones. conclusion: us and mr are both useful for the diagnosis of rn pathologies. us is a dynamic, comparative and brief examination, useful when metallic material obstacles are used in mr evaluation. us, therefore, is also useful in planning surgery and in the follow-up. radiological background: gctts is part of a group of benign proliferative lesions of the sinovium of the joint, bursa and tendon sheath. it represents the most common of this group of lesions, both in its localized and its diffuse form. procedure details: we studied retrospectively 24 patients with gctts localized in hands (23 had a single tumor and the remaining patient had a multifocal involvement). diagnosis was made by means of excisional biopsy. in all cases, plain fi lms and mri were performed. size, shape, localization and osseus involvement were analysed, as well as mri characteristics such as signal intensity and contrast enhancement. cases of relapse after surgery were also recorded. regarding mri, in t1 weighted images all tumors were homogeneous and isointense, but they were more heterogeneous and predominantly hipointense in t2. after intravenous paramagnetic contrast administration, a homogeneous enhancement was demonstrated. in all cases, gradient echo sequences showed very low intensity areas. surgery was performed in every patient. in 6 of them, local relapse was detected. conclusion: gctts is one of the most frequent soft tissue masses of the hand, second in frequency only to ganglion. we are obliged to suspect it in every case of hand tumor, specially if it is localized in the fi ngers. mri is useful in the diagnosis due to the characteristic fi ndings of the tumor. benign peripheral nerve sheath tumors in the pelvis: ct and mr fi ndings z. jiang, w. peng, t. yang; shanghai/cn (issyjiang@yahoo.com.cn) purpose: benign peripheral nerve sheath tumors (bpnsts), which include neurilemomas and neurofi bromas, arise in the pelvic space are relatively uncommon. the purpose of our study was to characterize the ct and mr fi ndings of pelvic bpnsts. methods and materials: ct and mr images of 16 patients with a pathologically proven pelvic bpnst (11 neurilemomas and 5 neurofi bromas) were retrospectively reviewed. the following morphologic characteristics were evaluated according to tumor shape, size, position, margin, homogeneity and invasion into adjacent structures. when mri had been performed, signal intensity and the pattern of enhancement were also assessed. results: all 16 pelvic bpnsts were round in shape, with well-defi ned margins; the mean diameter was 8.2 cm (4-13 cm); they were usually located in the presacral region (12/16). tumors were typically heterogeneous with cystic change (11/16), but centrally massive cystic attenuation was more common in neurilemomas than in neurofi bromas (8/11 vs 0/5). in 2 cases, there was smooth expansion of a sacral foramen with marginal sclerosis (1 in each group). 7 patients underwent mri, t2wi showed hyperintense cystic areas and solid areas of mixed intensity. on ct or mri contrast-enhanced images, peripheral enhancement was apparent in 7 of 11 neurilemomas, whereas irregular enhancement was evident in 4 of 5 neurofi bromas. conclusion: both pelvic neurilemomas and neurofi bromas are typically round, large, well-circumscribed, heterogeneous tumors that are located in the presacral space. they can occasionally cause bony changes in the sacrum, but do not invade adjacent structures. centrally massive necrosis or peripheral enhancement favors the diagnosis of a neurilemoma. learning objectives: to illustrate the spectrum of typical imaging fi ndings of charcot's spine and to discuss the main differential diagnoses such as infectious spondylodiscitis. background: neuropathic arthropathy of the spine is a rare destructive condition of the spine, which is secondary to the loss of the protective proprioceptive refl exes. infection must be considered as a possible differential diagnosis in case of a charcot's spine with destructive lesions. imaging findings: plain fi lms, ct and mri with gadolinium injection are useful. this destructive process involves the disc space, the vertebral bodies and the facet joints. the thoracolumbar junction and lumbar spine are most frequently affected, and one or more vertebral segments may be involved. sclerosis or osteolysis may predominate, and the spinal changes are often initially thought to be due to vertebral osteomyelitis or metastasis. osseous fragments typically extend beyond the confi nes of the vertebral body margins into the musculature and the spinal canal. bone debris and effusion may result in a paraspinous mass containing calcifi cations. however, solid epidural masses are typically lacking. the presence of vertebral body sclerosis and osseous fragmentation are further imaging fi ndings that help differentiate neuropathic spine from other processes. conclusion: background and imaging are suggestive of the diagnosis. closed needle and even open surgical biopsies are often necessary to fi nally confi rm the charcot's spine and exclude infection. spontaneous vertebral fracture -investigation with conventional and diffusion mr imaging t. gerukis, m. tsoukala, a. fotiadou, e. vafeiadis, v. kalpakidis, p. palladas; thessaloniki/gr purpose: the spine is the most common location of bone metastases in patients with primary malignancy, and also of benign osteoporotic fractures, especially in the elderly and in those who receive long-term steroid therapy. conventional imaging techniques cannot always differentiate benign from malignant lesions. those can be better distinguished with the addition of tissue-apparent diffusion coeffi cient (adc) measurements. a total of 51 acute vertebral body compression fractures were found in 35 patients. twenty-eight fractures in 19 patients were due to osteoporosis (due to age or therapy), whereas 23 fractures in 16 patients were histologically proven to be due to malignancy. signal intensities on t1-weighted, short tau inversion recovery (stir) and diffusion-weighted images were compared. adc values of normal and abnormal vertebral bodies were calculated. results: benign acute vertebral fractures were hypointense and malignant acute vertebral fractures were hyperintense with respect to normal bone marrow on diffusion-weighted images. mean adc value was 0.51 (±0.23) x 10 -3 mm 2 sec -1 in metastatic acute vertebral fractures and 1.33 (±0.47) x 10-3 mm 2 sec -1 in osteoporotic acute vertebral fractures. these values were signifi cantly different. conclusion: diffusion-weighted mr imaging with quantitative evaluation of adc values allows the distinction of benign from metastatic vertebral compression fractures. it is a procedure that provides valuable additional information, and we believe that it must take its place in everyday clinical practice. mri presents no immediate impact on lumbar spine degeneration in adolescent elite athletes versus non-athletes h. hoff, i. platzek, u. reuter, k.-p. günther, m. laniado, p. aikele; dresden/ de (hansjoerg.hoff@uniklinikum-dresden.de) purpose: degenerative spine abnormalities start developing early in life and are frequent even among adolescents. the effects of sports on lumbar degeneration in adolescents have not been comprehensively evaluated yet. the aim of this prospective study was to compare the degree of spine degeneration in adolescent athletes and non-athletes. the lumbar spines of 111 adolescent elite athletes (56m, 55f; mean age: 15.4 years) and 20 non-athletes (10m, 10f; mean age:15.0 years) were examined using mri. the lumbar spine examination was performed with a 1.5 t mri scanner (somatom sonata, siemens, germany). sagittal pd, t1, t2 and tirm images and transverse t2 images were obtained. two radiologists evaluated the images using a previously designed checklist. results: the prevalence of pathologic fi ndings varied widely in both groups. 73% of the athletes and 70% of the comparison group were affected by protrusions. 27.9% of the athletes showed spondylarthrosis (non-athletes: 20%). decreased signal intensity of vertebral discs on tirm images was found in 30.6% of the athletes (non-athletes: 30%). there were no cases of nerve root or spinal compression. the chi-square test was used for statistical evaluation. there were no signifi cant differences concerning the most common degeneration signs (protrusions, disc degeneration and spondylarthrosis). the authors conclude that active participation in sports does not have a signifi cant immediate impact on spine degeneration in adolescents. however, in order to evaluate the long-time effect of sports on the spine, further follow-up studies are necessary. multi-slice ct of spinal metal implants: pictorial essay h.r. cairns, j.m. elliott, p. archbold, r.j. winder; belfast/uk (heathercairns@greenpark.n-i.nhs.uk) learning objectives: to recognise the difference in beam hardening artefact, produced by steel and titanium spinal implants, on multi-detector spiral computed tomography (mdct). to appreciate the effect of data acquisition parameters on the degree of artefact. to appreciate the effect of 3 different reconstruction kernels on the appearance of titanium metal artefact. to learn how to reduce the degree of artefact by altering mdct scanning and reconstruction parameters. background: steel and titanium metals are commonly used in spinal surgery with signifi cant impact on post-operative ct image quality. the artefact is due to beam hardening and it appears as streaking with signifi cant change in local ct number values. the streaking artefact can seriously detract our ability to visualise pathology in proximity to the implant, for instance, nerve root irritation, remaining bone/disc protrusion. procedure details: steel and titanium pedicle screws were positioned in a "dry bone" lumbar spine model. this was immersed in water. the model was scanned in a siemens (erlangen) 16-slice mdct scanner. twelve data sets were obtained using combinations of slice thickness (1.5, 0.75, 0.75 head protocol, and 0.6 mm) and reconstruction kernels (smooth, medium and sharp). artefact in each data set was assessed at the ct workstation and personalised workstation, using identical window settings, ct numbers and a line profi le technique. conclusion: a signifi cant difference was measured between steel and titanium pedicle screw artefact. the images presented have demonstrated that beam-hardening artefact can be reduced depending on the combination of slice collimation and kernel setting. biomechanical model to assess the fl exion/extension mobility of the lumbar spine: consideration of soft tissue artifacts a. curti, f. perona, g.l. ciavarro, g.c. santambrogio, g. andreoni, g. castellazzi, g. cornalba; milan/it purpose: skin-based measures obtained through optoelectronic system maybe a good technique to assess the functionality of the lumbar spine. however, soft tissue artifacts (sta) may be a signifi cant and relevant problem to accurately measure the mobility of the spine and so they had to be considered. methods and materials: 10 healthy people participated in the experimental setup. twenty-four markers (pills of oil e vitamin) were attached onto the skin in correspondence to vertebral reference points. six static fl exion/extension postures were acquired through a vertical mri (vmri). then a fl exion/extension movement of the lumbar spine was acquired through an optoelectronic system. the estimation of the position of vertebral center of rotation (cor) together with the knowledge of sta (obtained from previous studies) allowed the development of a new biomechanical model to assess the mobility of the lumbar spine. finally these data were validated comparing the results of the biomechanical model with a gold standard (vertebral mobility through vmri). results: this biomechanical model shows a metameric error of 2.7° ± 0.6° and global error of 9.1° ± 3.5°. these data are very good with respect to the traditional methods assessing the lumbar spine mobility with a mean error reduction of about 50%. conclusion: this biomechanical model estimates well the lumbar fl exion/extension mobility starting from 3d kinematic data acquired through an optoelectronic system, some anthropometrical characteristics, the relations of sta (previously found) and the cor (here estimated). so it may be a useful instrumentation to assess the functionality of the lumbar spine. b d e f a g ultrasound-guided interventional procedures in the foot and ankle m. vlychou, j. teh; oxford/uk (mvlychou@doctors.org.uk) learning objectives: this pictorial illustration of ultrasound-guided interventional procedures of the foot and ankle will review the indications, technique and possible complications. background: foot and ankle pain, both acute and chronic, are common indications for clinical investigation due to degenerative, infl ammatory or osseous pathology and sport injuries. ultrasound is an imaging modality that can be applied not only for the detection of the underlying cause of the problem, but also more importantly as a means of therapeutic and diagnostic intervention. misinterpretation of radiographs by emergency physicians: how big is the problem? y. thian, m. mateo, s. tay; singapore/sg (ylthian@gmail.com) purpose: to evaluate the rate of discrepancies in radiographic interpretation between emergency physicians and radiologists. the pattern of commonly missed radiographs and the nature of clinically signifi cant interpretation discrepancies leading to a change in management or adverse outcome were also studied. methods and materials: all radiographs obtained in our emergency department from january through february 2006 were fi rst interpreted by ed physicians and compared with the formal radiology reports. discrepant interpretations were marked for further study and classifi ed into one of four categories: false-negative interpretation by ed physicians, false-positive interpretation by ed physicians, false-negative interpretation by radiologists and false-positive interpretation by radiologists. discrepancies that necessitated intervention and adverse outcomes were also recorded from the clinical summaries. results: of the 7309 radiographic examinations generated during the study period, there were 152 (2.1%) false-negative misreads by the ed physicians and 115 (1.6%) overreads. only 22 examinations (0.3%) necessitated an alteration in clinical management as a result of the misreads. three adverse events were recorded during the study period as a result of radiographic misinterpretation, all of which were cervical spine radiographs. the most frequent type of false-negative interpretation was the chest radiograph. conclusion: only a small portion of radiographic misinterpretations by ed physicians necessitated a change in management. ultrasonography in this exhibit, we show the topographic anatomy of the brachial plexus and its distal branches, with special attention to its anatomical relationships and its ultrasonographic appearance. there are three anatomical regions to approach the brachial plexus: a) supraclavicular region, b) infraclavicular or anterior region of the shoulder and c) axilar region or root of the arm. we show the topographic anatomy of each of these three regions, and the different puncture techniques recommended for each area. conclusion: brachial plexus punctures allow the locoregional blockade of several regions of the upper limb. us enables to guide the puncture with great safety, diminishing complication rates and undesired side effects, such as nerve lesion or the intravascular injection of local anesthetic drugs. lesions were classifi ed as hypointense, isointense or hyperintense. results were compared with fi nal diagnosis established by pathologic examination (n= 5). statistical analysis was performed with student's t-test. results: benign bone tumours and soft tissue lesions were iso-to hypointense to adjacent normal bone marrow. malign bone and soft tissue tumours and benign bone lesions including infection and aseptic necrosis were hyperintense to normal bone marrow. malign tumours and infectious processes had positive contrast ratios, whereas benign musculoskeletal tumours had negative values (p < 0.001). conclusion: psif sequence may allow differentiation of malign and benign musculoskeletal lesions. malign tumours show hyperintensity, probably owing to altered water proton mobility in neoplastic tissue. benign lesions, except infection and aseptic necrosis of the bone, show hypointensity, refl ecting free water proton mobility. in infectious processes, hyperintensity may be attributed to infl ammatory cells, mucoid and proteineous matrix decreasing free water fraction in the interstitial space. normal sonographic anatomy of the foot with mri correlation g. ansede, j.c. healy, j.c. lee; london/uk (gonzaloansede@yahoo.com) learning objectives: to demonstrate normal sonographic anatomy of the foot with emphasis on short foot ligaments using schematic drawings and mr imaging for correlation. background: the oblique orientation of the foot ligaments and tendons can result in diffi culty identifying them on mr imaging. however, many of these structures can be identifi ed using high frequency sonography transducers. the four muscle layers of the sole of the foot. conclusion: sonography offers high resolution imaging of the tendons and ligaments of the foot. in addition, sonography is quick, relatively inexpensive, widely available and allows for dynamic evaluation of structures which can be easily clinically correlated at the time of scanning. however, sonography is operator dependent and optimal assessment can only be made with intimate comprehension of the normal sonographic anatomy. do radiologists need to report a&e trauma extremity fi lms? s. hussain, j. heron, l. farrell, a. ahmed; birmingham/uk (drsh9@hotmail.com) purpose: plain fi lm reporting still makes up a signifi cant proportion of the reporting work in radiology departments. trauma extremity fi lms on patients admitted via the accident and emergency department constitute the signifi cant majority. with these fi lms being looked at by radiographers (red dotting fi lms), trauma juniors and/or senior doctors, is there still a necessity for reporting of these fi lms by radiologists? previous published studies have shown that junior doctors reported as few as 32% of fi lms correctly. methods and materials: retrospective analysis was made of all patients who presented through the accident and emergency department at sandwell hospital, birmingham over two separate one-week periods. extremity fi lms were identifi ed and the report in the notes made by the clinician was compared with the consultant radiologist report. discrepancies were identifi ed and any fi lms where there was discord were double reported by another consultant radiologist to provide a "gold standard" report. results: sixty-four percent of the radiographs were agreed to be normal, 18% were agreed to be abnormal but 18% were abnormal, which were identifi ed by only one department. after double reporting, a&e had an error rate of 12%, with a false positive rate (identifying a fracture where none was present) of 23% and a false negative rate (missing a fracture where one was radiologically present) of 5%. errors were greatest with the shoulders, elbows and ankle x-rays. radiology had an error rate of 5%. conclusion: although a&e doctors have a high standard of reporting, with a low false negative rate, there is still a need for radiology to report all trauma fi lms. sonography of the musculoskeletal system: a how-to-do dvd rom-based audiovisual guide g. delimpasis, k. chatzimihail, a. michailidis, s. faitaki, i. bechrakis, a. plagou, g. adamakis, k. pahou, p.s. zoumpoulis; athens/gr (echo@hol.gr) learning objectives: 1. to outline basic us physics and us technology. 2. to present the examination technique of the musculoskeletal system. 3. to illustrate the main indications and limitations of the modality. 4. to present normal echoanatomy and correlate abnormal sonographic fi ndings with specifi c musculoskeletal disease. background: modern high-resolution sonography is increasingly employed in the diagnosis of musculoskeletal injury and disease. the present dvd rom is based on a series of lectures focused on facilitating training and incorporates technical aspects of proper us examination with features of normal and diseased echostructure of the joints. procedure details: individual topics include the fundamentals of us physics and technology, study of the shoulder (with particular focus on rotator cuff pathology), elbow, wrist and carpal tunnel syndrome, knee, as well as examination of the pediatric patient and us applications in non-traumatic musculoskeletal disease. normal sonographic appearances are identifi ed and juxtaposed to abnormal features associated with specifi c joint pathology. relevant doppler fi ndings, aberrations during dynamic scanning and common artifacts are also discussed. emphasis has been placed on delineating the signifi cance of appropriate transducer manipulation and selection of machine settings so as to optimize diagnostic results. "real-time" video fi les are used to demonstrate the correct technique through the simultaneous screen display of transducer positioning and obtained us images. furthermore, these "hands-on" sessions elucidate the merits of dynamic scanning. a bilingual approach has been carried out by complementing the main greek text with english subtitles. conclusion: sonography is a valuable modality for musculoskeletal imaging, provided it is implemented meticulously. ultrasound suspicion and add useful additional information. direct imaging of peripheral nerves is possible using cross-sectional modalities, such as ultrasound (us), computed tomography and magnetic resonance imaging (mri). in experienced hands, us provides an economic, fast, noninvasive and accurate evaluation of the mn from the axilla to the distal branches. imaging findings: in this article, we will fi rst present the normal anatomy of the mn through schematic drawing and selected images from cadaveric dissections. then, the technique of us examination and the normal us appearance will be illustrated. in the last part, representative us images with mri correlations and schematic drawings will be presented to illustrate a wide spectrum of the pathologic conditions. conclusion: us can effi ciently assess the normal mn and diagnose a wide variety of disorders. accurate knowledge of the us anatomy and scanning technique is an essential prerequisite. tumors conclusion: the incidence of scapular tumors is low. bone tumors involving the scapula as the sole site constitute an uncommon fi nding, with few cases reported. both benign and malignant neoplasms can be found. since early diagnosis is crucial for prompt therapy, imaging plays an essential role. plain radiograph is the primary modality in the diagnosis approach. however, computed tomography (ct) and magnetic resonance (mr) play a major role in establishing diagnosis and staging. extended fi eld-of-view sonography: does this technique provide additional information to conventional b-mode images? f. eksert, c. yucel, s. ozhan oktar, n. kadioglu, h. ozdemir; ankara/tr (cyucel@gazi.edu.tr) purpose: to compare the imaging fi ndings of lesions examined with b-mode and extended fi eld-of-view (efov) sonography and to demonstrate if efov technique provides additional information. methods and materials: sixty patients (32 males, 28 females) (age range:1-83 years, mean age: 47±18.3 years) with 61 lesions were involved in the study. 21/61 (34%) of the lesions were localized in the musculoskeletal system, 19/61 (31%) were in the neck area, 15/61 (26%) were in the anterior abdominal wall, 2/61 (3%) were in the peritoneal cavity, 1/61 (2%) was in the scrotum and 1/61 (2%) originated from the brachial artery. all lesions were examined with both the conventional b-mode and efov sonography. the fi ndings were evaluated independently by two radiologists. sonographic images obtained with each technique were scored for lesion characterization, and for simultaneous demonstration of the lesions and their relationships with surrounding tissues. wilcoxon signed rank test was used for statistical analysis. kappa scores were calculated to assess inter-observer agreement. results: wilcoxon test revealed that efov sonography was superior to b-mode imaging for both lesion characterization and for the determination of its relationships with neighboring structures (p=0.000). kappa scores refl ected moderate to good inter-observer correlation (0.186-0.454). conclusion: efov sonography is a practical and easily applied technique. this technique overcomes the problem of limited fi eld-of-view, which is one of the most important disadvantages of b-mode sonography. the simultaneous visualization of the lesions and surrounding structures in larger fi eld-of-views makes efov images more apprehensible compared with conventional b-mode images. is it necessary to review all casualty radiographs? s. nayak, m. chandramohan, c. groves; leeds, west yorkshire/uk (sanjeevnayak@hotmail.com) purpose: to check for any discrepancies in the plain fi lm reporting by the a&e doctors when rechecked by a radiologist. to look into the incidence of signifi cant misses that altered the patient management. the duration of the study was 30 days. a retrospective study was conducted at the bradford teaching hospitals, looking at all the casualty radiographs that were double reported by the radiologists. results: a total of 1122 a&e fi lms were reviewed by the radiologists. 1002 (89%) of them were agreed upon by the radiologists in correlation to the a&e diagnosis. 120 (11%) of the total were disagreed by the radiologists. 36 (3.2%) of these were considered as signifi cant misses. out of 120 disagreed fi lms, 60 letters were sent by a&e to the gp. of these, 18 needed further investigations 18 were recalled to the fracture clinic. the radiologists' reports on radiographs of the chest, face, skull, and wrist had the greatest effect on patient management. reports on the radiographs of fi ngers, hands, shoulders, long bones, and toes seldom altered treatment. purpose: thrombolysis has been shown to improve the 3-month outcome of patients with ischemic stroke, but knowledge of the long-term effect of thrombolysis is limited. the present study compares the long-term outcome of stroke patients who were treated with intra-arterial thrombolysis (iat) using urokinase with the outcome of patients treated with aspirin. the modifi ed rankin scale (mrs) was used to assess the outcome. one hundred seventy-three patients treated with iat and 261 patients treated with aspirin from the bernese stroke data bank were eligible for the study. a matching algorithm taking into account the patients' age and stroke severity on admission (as measured by the national institute of health stroke scale, nihss) was used to assemble an iat and an aspirin group. results: one hundred forty-four patients treated with iat and 147 patients treated with aspirin could be matched and included in the comparative analysis. the median nihss score was 14 in each group. at 2 years, 56% of the patients treated with iat and 42% of the patients treated with aspirin achieved functional independence (mrs 0 to 2; p = 0.037). clinical outcome was excellent (mrs 0 to 1) in 40% of the iat and in 24% of the aspirin patients (p = 0.008). mortality was 23% and 24%, respectively. the present study provides evidence for a sustained effect of iat when assessed 2 years after the stroke. the purpose: the aim of our work was to localize cortical areas involved in the processing of the visual stimuli with different complexities using fmri. in eight healthy volunteers (18-30 years old), conventional anatomical and fmri were performed on 1.5 t mr scanner. we used echo-planar imaging. for visual stimulation, we used matrix from 10x10 gabor elements. gabor element is a sinusoid fading under gauss law, which corresponds to receptive fi elds of primary visual cortex cells. in "simple" stimulus, most elements have preferred orientation. in case of "complex" stimulus, only a part of the elements have preferred horizontal or vertical orientation. the size, brightness and contrast of the stimuli were identical for chaotic and ordered patterns. post-processing includes: (1) calculating statistical map with t-student criterion of more than 4, where hypothesis h 0 assumes that mr-signal intensity in rest is equal to activation intensity; (2) for the identifi cation of anatomical structures, the resulting maps were fused with the anatomical image and then both images were transformed to space of atlas talairach. results: "complex" stimuli in comparison with "simple" stimuli caused activation on brodmann fi elds number 7, 9 and 37. when a patient must choose the preferred orientation of elements, click the left or right button of the mouse to discriminate between "complex" and "simple" stimuli; "simple" stimulus causes activation in the middle frontal gyros (brodmann fi elds number 9/10). conclusion: thus, "complex" stimulus causes additional activation in the parietal lobes. cases of active observation demonstrate an additional activation locus in the prefrontal cortex, which presumably, refl ects the work of the "central executive mechanism". anatomy of the normal and pathological visual pathways: a dti-fi ber tracking study a. paniagua bravo, l. muñoz almazán, j. guzmán de villoria lebiedziejewski, g. medrano seoane, j. crespo san josé; madrid/es (alvpaniagua@yahoo.es) learning objectives: mri diffusion tensor imaging (dti) was performed in 7 patients and 3 healthy individuals in order to study the visual pathway (vp). our purpose was to show its normal anatomy as well as the pathological changes in some diseases that involve it. background: diffusion weighted imaging (dwi) is a useful technique to obtain brain maps from the white matter tracts. our study is focused on the assessment of the vp after performing dwi maps to visualize the different parts of the vp. when compared to the results in normal subjects, the pathological features in patients can be classifi ed into 3 items: 1) diseases that lead to atrophy of the vp (ocular globe enucleation, multiple sclerosis, hypovitaminosis); 2) displacement of the fi bers caused by entities with associated mass effect (tumors); 3) infi ltrating lesions of the vp (neoplasms, pseudodotumoral demyelinitation plaques). procedure details: all the studies were performed on a 1.5 t mr unit by using a single-shot echo-planar imaging sequence (fl ip angle: 90º, tr: 2020, te:68, nsa:6) with b =800 mm 2 /sec. this protocol was modifi ed in 3 patients in order to obtain a better visualization of the pathology (tr: 8474, te: 68, nsa: 6). we also acquired an anatomical imaging 3d/dti. post-processing was made in a workstation using the philips pride software. we get 2d and 3d color maps from the vp. conclusion: dti is a useful technique to study the normal and pathological visual pathway. post-thalamic fi bers are easy to map, whereas the visualization of prethalamic fi bers is possible with a specifi c dti acquisition protocol. b d e f a g unavoidable effect of brain radiation. we reviewed fi ndings of routine mri in 41 cases of pathologically proven crn. background: it is imperative to distinguish crn from recurrent tumor in order to avoid unnecessary antineoplastic therapy and to administer therapy appropriate for the crn. there is no defi nitive imaging method to distinguish these conditions. we retrospectively reviewed all clinical cases of crn identifi ed histologically at surgery from hfh in the past 15 years. imaging findings: treated tumors included 34 gliomas, 5 metastases, 1 pnet and 1 ependymoma. central necrosis (37) and cysts (24) were common. t1 hyperintensity without contrast administration was seen in 17 cases. the most common pattern of enhancement seen in 35 patients included ill-defi ned borders, lack of a nodular component, and a central "swiss cheese" appearance. subependymal enhancement was present in 25 cases and corpus callosum enhancement was seen in 16. a pattern of enhancement in two adjacent lobes separated by the dura was seen in three cases. brain atrophy was present in 29 and leukoencephalopathy in 19 patients. : a "swiss-cheese" and ill-defi ned, non-nodular pattern of enhancement was most common. the high frequency of involvement of the corpus callosum and subependyma was unexpected, as these fi ndings are traditionally reported with tumor infi ltration. a pattern of enhancement in adjacent lobes separated by the dura is uncommon, but may be pathognomonic of crn when the imaging changes are consistent with the radiation fi eld dosimetry. dural lesions mimicking meningiomas: a pictorial review d. chourmouzi, g. boulogianni, k. manolakaki, k. drevelegas, t. zaraboukas, a. drevelegas; thessaloniki/gr (dchourm@hol.gr) learning objectives: to describe a number of neoplastic and nonneoplastic entities that radiographically and clinically mimic meningiomas. to outline the pathological and imaging characteristics of these entities. background: intracranial dural-based lesions can be due to benign or malignant processes. imaging characteristics cannot always discern between different pathologic conditions. a thorough clinical evaluation may reveal likely diagnostic possibilities. procedure details: an overview of the mri characteristics of dural lesions is presented. there is also presentation of some pathologically proven lesions including solitary fi brous tumor, gliosarcoma, hemangiopericytoma, melanocytoma, hodgkin's disease, plasmacytoma, infl ammatory pseudotumor, plasma cell granuloma, rosai-dorfman disease as well as metastatic carcinoma. the role of the advanced magnetic resonance techniques such as spectroscopy, diffusion and perfusion mr imaging is discussed. conclusion: the differential diagnosis of dural-based lesions in the brain varies from incidental and benign to symptomatic and malignant. careful vigilance in patient's history is essential. awareness that such lesions involve the dura may facilitate preoperative recognition and, in some cases, preclude unnecessary surgery. learning objectives: 1. to review pathophysiology and diagnostic criteria of mitochondrial disorder. 2. to investigate various neuroradiologic fi ndings in children with mitochondrial disorder and, particularly, unspecifi ed mitochondrial encephalomyopathies. background: mitochondrial disorders are a heterogeneous group of clinical syndromes associated with abnormalities of mitochondrial energy metabolism. the impaired energy production results from the overall dysfunction of mitochondrial respiratory chain, composed of 5 enzymatic complexes embedded in the inner mitochondrial membrane. we investigated the various neuroradiologic fi ndings in 40 children with mitochondrial disorder, and correlated them with the biochemical defect in the mitochondrial respiratory chain complex. imaging findings: children with mitochondrial disorder showed different patterns of brain mr imaging abnormalities. rapid progression of atrophy involving all structures of the brain with variable involvement of white matter were found in 29 patients, and the patients with complex i defi ciency showed more severe changes in serial scans; t2 prolongation of basal ganglia, thalami, brain stem and cerebellum in 18 patients with complex i or iv defi ciency; predominant cerebellar volume loss in 3 patients with complex i or iv defi ciency; and encephalomalacia of globi pallidi in 2 patients with complex i defi ciency. conclusion: children with mitochondrial disorder showed different features on brain mr imaging from a combination of various defects of mitochondrial respiratory chain complex. defects of different parts of the mitochondrial enzyme could result in the same abnormality on brain mr imaging, whereas identical biochemical defects could cause different imaging manifestations. learning objectives: 1. to illustrate the wide spectrum of intracranial lesions with ring enhancement on mri. 2. to categorize these lesions according to imaging fi ndings on dwi and calculated adc values. 3. to provide an easy-to-follow algorithm for the differential diagnosis of intracranial ring-enhancing lesions. background: ring enhancement is an unspecifi c mr fi nding occurring with a variety of aetiologies. it is most frequently encountered in neoplastic and infectious disorders, such as metastases, gliomas, and abscesses, but is also observed in vascular pathologies, such as resolving haematomas and infarcts. because of the variable clinical course and prognosis of these diseases, an early and correct diagnosis is necessary for choosing the appropriate therapy. procedure details: we present the broad spectrum of intracranial lesions with ring enhancement on mri with emphasis on the diagnostic impact of diffusion-weighted sequences and adc values. additionally, mr features that could be possibly helpful in distinguishing ring-enhancing brain lesions are discussed. conclusion: dwi has recently shown promise in differentiating ring-enhancing lesions such as brain abscesses and malignant neoplasms. combining the information of conventional mri and dwi with adc calculations, the correct diagnosis of ring-enhancing lesions can be achieved in a majority of cases. the dynamic study of csf circulation in hydrocephalic patients by means of magnetic resonance (mr): semeiotic technique and case gallery l. fortunelli 1 , v. annibale 1 , f. favano 1 , p. car 1 , p. spagnolo 2 , a. stecco 1 , a. carriero 1 ; 1 novara/it, 2 monza/it (lorenzofortunelli@virgilio.it) learning objectives: to describe the methodological aspects and advances of the cine pc technique for studying csf. to present a case gallery for each type of hydrocephalus. to describe the mr semeiotics of this technique. background: csf fl ow was previously studied by means of ct, a lumbar puncture (tap test) or ventriculocisternography. dynamic mr investigations are based on phase contrast sequence that provides quantitative and qualitative measurements of fl ow velocity and direction. the automatic planning of acquisition planes has recently become available. the indications for this examination are to characterise normotensive hydrocephalus and treated hydrocephalus. imaging findings: thirty-fi ve examinations were carried out using 1.5 tesla mr with an eight-channel phased array coil and cardiac trigger, and post-processing software for quantitative analyses. axial flair and sagittal csf drive sequences were used to localise the aqueduct of silvius, and axial csf qf (fast spin-echo 2d) for the quantitative analyses. csf pca is a sagittal pc angiography used to visualise csf fl ow. the post-processing analyses included the quantitative and qualitative data, with the creation of a cine-rm that visualises the csf circulation. the technique is optimised using "smartbrain". the technique was feasible in 100% of cases, all of which showed concordance between the cine pc images and clinical symptoms. the automatic planning method makes the technique easier to perform. virtual mr ventriculoscopy of the brain h. sherif, a.e. mahfouz; doha/qa (sherifhanan@yahoo.com) learning objectives: to introduce the technique of virtual magnetic resonance (mr) ventriculoscopy of the brain and to illustrate the ventriculoscopic appearance of the cerebral ventricles in normal persons and in patients with different diseases of the brain, which involve the cerebral ventricles. background: the recent advances in three-dimensionally acquired and displayed mr images and the use of virtual endoscopic technique in image processing have enabled virtual endoscopic examination of the cerebral ventricles. the present exhibit illustrates the appearance of the normal anatomy of the lateral, third, and fourth ventricles and the appearance of lesions related to the cerebral ventricles from an endoscopic viewpoint. procedure details: three-dimensionally acquired images of the brain have been performed by 3d fat-saturated t1-weighted turbo-flash (fast-low-angle shot) sequence covering the whole brain. images have been reconstructed by virtual endoscopic technique (colon, wizard, siemens, erlangen, germany). conclusion: virtual mr ventriculoscopy of the brain is a new technique of imaging of the cerebral ventricles, which may be useful in three dimensional evaluation of congenital and acquired abnormalities as well as abnormal masses related to the cerebral ventricles. continuously monitoring of the brain during severe insulin-induced hypoglycemia by diffusion-weightened mr imaging p. purpose: severe cerebral hypoglycemia with onset of neurological symptoms is frequently associated with reversible diffusion disturbances, which could be visualized as hyperintense lesions by diffusion weightened brain imaging particular in the splenium and the corona radiata region. this study is focused on the evaluation of hypoglycemic pathogenesis, especially with regard to the severity of insulin-induced reversible hypoglycemia. methods and materials: seven volunteers received an i.v. bolus of 0.15 u per kg body weight short acting insulin inducing hypoglycemia, while the individuals were continuously evaluated by a 1.5 t scanner (siemens sonata). diffusion-weightened echo planar sequences (4500/107 tr/te) were obtained without interruption. additionally, serum blood glucose levels were also continuously monitored using glucostix test strips; further more serum blood specimen were sampled for later laboratory measurements. examination was stopped as soon as serum glucose level was diminished to < 2.0 mmol/l or the subject wished to abandon the trial due to vegetative symptoms. images were independently analyzed by two radiologist. results: all subjects revealed a hypocglycemia < 3.0 mmol/l for at least 10 min, mean serum glucose level decreased down to 1.94 ± 0.4 mmol/l and one patient stopped examination at 2.6 mmol/l due to vegetative symtpoms. in the mri diffusion images, no alterations pointing at an infl uence of cerebral diffusion could be observed in all individuals. conclusion: short-time severe hypoglycemia (< 10 min) does not induce visible changes in mri diffusion imaging, suggesting long-time hypoglycemia maybe the relevant cause for observed reversible diffusion disturbance in mr imaging. primary learning objectives: to illustrate the spectrum of mr and proton spectroscopy fi ndings in primary lactic acidosis related to mitochondrial diseases in brain. to describe the advantages of proton mr spectroscopy evaluation. background: mitochondrial diseases constitute a complex and heterogeneous group of metabolic disorders caused by heritable abnormalities of the respiratory electron transport cascade. although mitochondrial dysfunction manifests over a wide range of clinical expressions, it most often affects the muscle and brain, where dependence on oxidative energy metabolism is highest. the most common clinical features are muscle weakness, lactic acidosis and a broad range of neurologic defi cits. in this exhibit, we will analyse mr and proton spectroscopy fi ndings of primary lactic acidosis related to mitochondrial disease. between january 1996 and january 2006, we analyzed mr and proton spectroscopy of 11 patients with lactic acidodsis and clinically suspected of mitochondrial disease. procedure details: nine patients had lesions bilateral and simetrics, hyperintense on flair and t2-weighted images and hypointense on t1-weighted images in brain stem and basal ganglia. three of them had thalamic involvement too. proton spectroscopy revealed elevated lactate and a n-acetylaspartate reduction, both in areas that appeared damaged. in 2 of 11 patients, mr was normal but proton spectroscopy showed similar fi ndings. conclusion: proton spectroscopy is a useful investigational tool in the study of mitochondrial diseases as it supplies additional information to that of conventional imaging, because it documents metabolic anormalies even in areas of the brain that appeared to be normal. observation of metabolic changes in tumour bed with proton mr spectroscopy in patients with primary gliomas during radiation therapy l. zarudzki, b. bobek-billewicz, w. senczenko, a. idasiak; gliwice/pl (lzarudzki@op.pl) purpose: to observe the time course of the proton magnetic resonance spectroscopy ( 1 h-mrs) changes in tumor bed, during radiation therapy, in patients with primary gliomas. we followed 19 patients who received an external radiation therapy for primary gliomas for 6-9 weeks (mean: 51 days; median: 49.5 days). all patients underwent brain surgery prior to the radiotherapy. the patients received fractioned doses of 54 or 60 gy in the lesion area. each patient underwent single voxel spectroscopy (svs te=135; te=30) before and just after the completion of the radiation therapy. the voxels of interest were chosen in the tumour bed, overlying the planning target volume (ptv). the following metabolite concentrations, normalized concentrations and their ratios were evaluated by the areas of the peaks after peak fi tting: naa, cho, cr, lac, lip0.9/1.3, glu+gln, ins. the spectra were verifi ed with lcmodel. results: after the completion of radiotherapy, we observed the increase in the normalized naa concentrations and naa/cr ratio and the decrease in the normalized cho, glu+gln, lip[0.9] concentrations and cho/naa ratio. the 1 h-mr spectroscopy has the capability of detecting early metabolic changes in the irradiated tumour bed after the completion of radiotherapy. the increase of naa and decrease of cho and glu+gln concentrations can be the result of the residual neoplasmatic infi ltrate's regression. the changes in other metabolite concentrations occurred, but were not signifi cant. atypical imaging findings: unusual imaging features of meningiomas are shown, such as infrequent locations (intraventricular, intraosseu); cystic or fatty degeneration; large edema; ring enhancement; low-adc values and increased permeability. we will also show cases that may be diffi cult to differentiate from meningiomas, not only tumoral (mesenchymal tumors, hemangiopericytoma, melanocytic lesions, shwannomas, dural metastases), but also non-tumoral lesions (aneurysms; dermoid and epidermoid cyst) conclusion: meningiomas account for 14-20% of intracranial tumors. the diagnosis is relatively easy when the tumor has characteristic radiological fi ndings. however, the radiologist must be aware of the less frequent imaging features in order to suggest the diagnosis in cases that meningiomas are atypical. most meningiomas are benign (90%), but there are also atypical (5-7%) and malignant (1-3%) variants that have specifi c histopathological characteristics. these meningiomas show unusual imaging fi ndings more frequently. the distinction between atypical and typical meningiomas is clinically relevant, because benign tumors recur in about 7-20% of cases, where as atypical variants recur in 29-41%. furthermore, the treatment is different in both cases. epileptogenic structural disorders in pediatric patients: mr imaging characteristics a. mallouhi, t. gotwald, e. haberlandt, g. feuchtner, e. trinka, s. felber, d. zur nedden; innsbruck/at (ammar.mallouhi@uibk.ac.at) learning objectives: 1. to provide an mr imaging overview of epileptogenic structural disorders in pediatric patients. 2. to familiarize with the key mr fi ndings necessary to assist in rendering a diagnosis. background: epilepsy is a chronic condition that results from abnormal excessive activity of a population of cerebral neurons. several brain structural disorders have been implicated in epilepsy in pediatric patients. imaging findings: in this exhibit, we illustrate a spectrum of brain structural disorders encountered in mr imaging of pediatric patients with intractable epilepsy and their implications on treatment planning including cortical development abnormalities (focal cortical dysplasia, schizencephaly, heterotopia, polymicrogyria), hippocampal sclerosis, vascular malformations, post-traumatic lesions, infections, tumors, neurocutaneous disorders (neurofi bromatosis i, tuberous sclerosis), and mitochondrial disorders. conclusion: magnetic resonance imaging is the radiological method of choice for the detection and characterization of parenchymal abnormalities that provoke epileptic seizures. conventional and high-resolution mr signal characteristics assist in determining a specifi c diagnosis. diffusion tensor imaging in the early stages of stroke can predict dysphage outcome x. wei, j. dai, h. shen, j. ma, l. ai, s. li, x. zhang; beijing/cn (weixinhua2007@163.com) purpose: to determine whether the degree of impairment of diffusion tensor imaging in the early stages of a stroke can predict the dysphage outcome. methods and materials: twenty-fi ve unilateral hemispheric stroke patients were enrolled to this study. diffusion anisotropy was measured by determining fractional anisotropy (fa) in the rois (region of interests) placed in the bilateral posterior limb of internal capsule (ic) during the early stages of stoke (average 7.3 days after stroke onset) and compared with dysphage outcome 3 months after stroke onset. results: seventeen patients with complete recovery were assigned to group one and 8 patients with persistent dysphage were assigned to group two. no signifi cant difference in fa between the bilateral posterior limb of ic in group one (p> 0.05). however, fa of the bilateral posterior limb of ic in effect side was lower than that of the intact side in group two (p < 0.05). the degree of impairment in diffusion anisotropy during the early stages of stroke appears to have the potential to predict dysphage outcome. flow-pattern on superselective middle cerebral artery (mca) angiography can predict tissue recovery after local recanalization treatment for hyperacute mca occlusion y. hori, h. kiyosue, h. mori, j. kashiwagi, h. nagatomi, y. sagara, s. tanoue, m. okahara, t. asano, r. shimada; oita/jp (horiyuzo@med.oita-u.ac.jp) purpose: in hyperacute middle cerebral artery (mca) occlusion, viability of brain tissue depends on the residual blood fl ow which could affect the outcome after local recanalization treatment (lrt). the purpose of this study is to investigate whether superselective mca angiography obtained prior to lrt could predict the recovery of ischemic brain tissue. methods and materials: thirty-six patients having hyperacute mca occlusion (32 patients of m1 occlusion, 4 patients of m2 occlusion) without signs of cerebral infarction on early ct underwent lrt. pretreatment superselective mca angiography via the microcatheter placed just distal to the occlusion site was executed to evaluate the fl ow-pattern in 60 (31 anterior trunks, 29 posterior trunks) of 68 trunks. the fl ow-patterns were classifi ed into three types: antegrade (n=28), retrograde (n=26), or stasis (n=6). the relationship between the degree of recanalization and follow-up ct fi ndings in each fl ow-pattern was investigated. results: cortical infarction occurred in 28 of 60 trunk territories. in antegrade type, 3 (21%), 8 (73%), and 3 (100%) territories had cortical infarctions in complete, partial, and failed recanalization, respectively. in retrograde type, 1 (14%), 2 (40%), and 5 (36%) territories had cortical infarctions in complete, partial, and failed, respectively. in stasis type, 6 (100%) territories had cortical infarctions regardless of degree of recanalization. the degree of recanalization is signifi cantly correlated with follow-up ct fi ndings in only antegrade type. conclusion: flow-pattern on superselective mca angiography has signifi cant relationship with brain tissue recovery. cases with antegrade fl ow-pattern would be a good indication for lrt. intraventricular brain tumors: a pictorial review j. sanchez 1 , p. puyalto 2 , c. majos 1 , c. aguilera 1 , l. aja 1 , j. acebes 1 ; learning objectives: to describe the characteristic radiological features of intraventricular tumours that may allow their appropriate recognition and precise diagnosis. background: intraventricular neoplasms are uncommon; they represent only the 10% of all intracranial tumours. due to their deep location within the brain, they usually have diffi cult surgical access and consequently more potential risks of complications and consequently imaging assessment previous to surgery is essential to evaluate the extension and location of these tumours. imaging findings: imaging features of 173 patients with intraventricular tumours were retrospectively reviewed. they showed a wide spectrum of radiological appearances that were non-specifi c, in many cases, making its differentiation diffi cult. the location of the mass within the ventricular system and the patient's age provided the most useful information, but other radiological features (calcifi cations, cysts, bleeding or enhancement) were helpful too. mr is the best technique to assess location and extent of the disease but in certain cases ct provides complementary evaluation of aspects such as calcifi cations or bleeding. conclusion: based on patient's age, location of the tumour within the ventricles and specifi c radiological features on mr, an accurate diagnosis can be made. regional gray and white matter volume abnormality in obsessive(ocd) . no studies were found that showed white matter (wm) abnormality. the purpose of this study was to assess both gm and wm volume abnormality in ocd patients using voxel-based morphometry (vbm). in addition, it provides a very important functional information that can be very useful in the differential diagnosis of several lesions including cerebral abscess or herpetic encephalitis. imaging findings: we have reviewed 27 studies performed at our department for evaluation of patients with suspected cns infection. 21 patients for brain abscess, including toxoplasma in aids patients, and pyogenic abscess. ctp showed ring enhancing lesions with vasogenic oedema in contrast enhanced ct with reduced cerebral blood volume (cbv) in the lesion in ctp. tumors have increased cbv. in addition, ctp permits a better depiction of residual enhancement of partially calcifi ed lesions. three patients of herpes simplex virus encephalitis showed regional hyperperfusion in the acute phase and hypoperfusion in the chronic phase. also, other 3 cases of other cns infections including fungal infections are described in our series. conclusion: ct perfusion could be included as a complimentary technique in brain ct studies because it provides useful funcional information, especially useful when mri is not available or for noncollaborative patients. metabolic changes observed with proton mr spectroscopy in normal human brain tissue during radiation therapy l. zarudzki, b. bobek-billewicz, w. senczenko, a. idasiak; gliwice/pl (lzarudzki@op.pl) purpose: to observe the time course of changes in the proton magnetic resonance spectroscopy (1h-mrs) values during radiation therapy in normal human brain tissue. methods and materials: we followed 18 patients receiving an external radiation therapy for primary gliomas for 2 months. all of the patients underwent brain surgery prior to the radiotherapy. the patients received 54 or 60 gy in tumour bed and 20-50 gy in the contralateral normal brain hemisphere. each patient underwent single voxel spectroscopy (svs, te=135; te=30) before and just after the completion of the radiation therapy. the voxels of interest were chosen in the contralateral normal brain hemisphere to meet an area between 30% and 50% isodose lines in the radiotherapy plan. the metabolite concentrations: n-acetylaspartate (naa), choline compounds (cho), creatine (cr), lactate (lac), lipids (lip), inositol (ins), glutamate and glutamine (glu+gln), their ratios and normalized concentrations were calculated. the spectra were verifi ed with lcmodel. results: there was a statiscally signifi cant decrease of total choline and inositol concentrations, their normalized concentrations and cho/cr, ins/cr ratios. the changes in the other metabolite concentrations were not signifi cant. conclusion: it is possible to detect and to evaluate in vivo early metabolic effects of radiation therapy in the normal human brain tissue with the proton magnetic resonance spectroscopy. the cause of the observed changes is unclear and might be due to the alterations of membrane composition related to the radiotherapy. cerebral organization of language processing for different input modalities in chinese: an fmri study y. yang, k. li, y. xu, h. shu; beijing/ cn (yyh_wj@sohu.com) purpose: the processing of chinese may be different from alphabetic languages such as english not only in the behavior but also in the neural mechanism. in this study, functional magnetic resonance imaging (fmri) was used to investigate the neural mechanism of semantic information processing. methods and materials: twelve normal subjects were scanned with a 1.5 t mr scanner. according to different modalities, there were auditory semantic judgment (asj), picture semantic judgment (psj), and word semantic judgment (wsj) involved in our experiment. when subjects heard a word or saw a white-black drawing picture/word, they must decide whether it is dangerous or not and press the corresponding button. a block design was employed and the baseline task was passively listening to a pure tone or viewing a cross. the fmri data were analyzed using the spm2. results: bilateral superior temporal gyrus, left inferior and middle frontal gyrus were activated during the auditory task. bilateral occipital regions, left inferior and middle frontal gyrus, and left parietal regions were associated with the processing of all the visual stimuli. however, the word task produced no more activation than the picture task in the prefrontal area or the temporoparietal region, which were reported in similar studies on english. the inferior and middle frontal gyrus may be related with semantic processing of chinese word regardless of the input modalities. it is showed that chinese words are to some extent more similar to pictures and the neural mechanism of chinese words processing is similar to that of pictures. whole brain real-time fmri of language and hand motor areas with prospective acquisition correction for movements (pace) c. zimmermann, s. langner, j. kuehn, m. domin, n. hosten; greifswald/de (christian.zimmermann.hgw@web.de) purpose: mapping of language and hand motor brain areas has become an important clinical application of fmri in neurology and neurosurgery. we assessed the feasibility of real-time fmri with prospective acquisition correction for movements (pace) in routine clinical examinations. methods and materials: twenty normal subjects and 11 patients with temporal lobe epilepsy or intracerebral tumors were examined at 1.5 t (siemens symphony). an 8-channel head coil was used for acquisition of anatomical t1 gre, t2 tse and an epi bold sequence. a semantic decision and letter-matching task alternated every 24 s. the motor paradigm was an alternating fi nger-tapping task of ten 30-s periods of activation. a z-score of 4 was chosen as cut-off. results: table time was under 20 min for language and 13 min for motor fmri. b d e f a g in 19/20 subjects language lateralization and in 20/20 the hand motor area were identifi ed. imaging was diagnostic in all patients. in all 17 right-handed subjects, speech areas were mainly located in the left hemisphere. two left-handed subjects showed different activation: one in the left and the other mainly in the right hemisphere. for the speech paradigm, 10 of the right-handed subjects showed right hemispheric activation of the cerebellum. one of the left-handed subjects had left and the other right hemispheric cerebellar activation. conclusion: real-time fmri is a feasible technique for noninvasive mapping of language and hand motor areas in clinical routine, providing reliable feedback of activation after 60 s of paradigm runtime. susceptibility weighted ( learning objectives: to demonstrate magnetic susceptibility as a means of contrast in mri. to describe data-acquisition and post-processing of susceptibilityweighted (phase) images (swi). to recognize artifacts. to demonstrate the technique in clinical cases and to compare it with standard mr imaging methods. background: magnetic susceptibility is a physical property of tissue that infl uences the mr-signal via the local precession frequency. different blood-oxygenation levels, cerebral iron concentrations and many pathologies produce contrast in both magnitude and phase of gradient echo images. procedure details: high resolution 3d fl ow compensated gradient-echo data are acquired at long te. matrix=512x256x36, te/tr/alpha=40/60/25 at 1.5 t, te/tr/ alpha=30/40/20 at 3 t. phase images are unwrapped with either a homodyne fi lter or a region-growing algorithm. the latter produces better results in magnetically inhomogeneous areas. the susceptibility-weighted mr phase images show a unique contrast independent of t1 and can be directly assessed and compared to the corresponding t1/t2*-weighted magnitude images from the same scan. multiplying masks computed from the phase with the magnitude produces susceptibility-weighted images, which allow assessment of vascular architecture and function (if acquired during hypercapnia and normoxia). swi of sturge-weber syndrome, tuberous sclerosis, tumors, arteriovenous malformations etc. provides additional information that is not accessible by conventional imaging. conclusion: susceptibility-weighted mr (phase) imaging of the brain provides valuable information at high spatial resolution. it facilitates detection of small lesions which may be missed by conventional methods. at 3 t acquisition time is reduced to 4-5 minutes due to shorter te and the option to use parallel imaging because of increased snr. the effi cacy of fusion three-dimensional-computed tomography (3d-ct) for following treated cerebral aneurysms by coil embolization m. ishifuro, j. horiguchi, y. kiura, k. ito, t. furukawa; hiroshima/jp (ishifuro@hiroshima-u.ac.jp) purpose: owing to metallic artifacts, vessels and coils cannot be observed in patients after coil embolization (ce) by cta. thus, the purpose of this study was to examine whether fusion ct could overcome this problem. methods and materials: ten patients underwent ce for cerebral aneurysm. cta was performed before ce, and plain ct was performed after ce. two sets of 3d images were constructed with 3d image analyses software (virtual place, aze). postoperative 3d coil images were fused with preoperative cta images in order to reduce artifacts due to the coils. we compared the coil locations on these fusion ct images to those on postoperative dsa. results: all 3d fusion images with cta and coils were successfully constructed. fusion ct could reveal postoperative fi ndings as accurately as dsa. also, we could evaluate the cases whose results were classifi ed as neck remnants. conclusion: fusion ct furnished as accurate information for postoperative fi ndings as did dsa; hence, it may be useful in predicting whether coil compaction will occur. brain mri of guadeloupean patients suffering from progressive supranuclear palsy l. giré 1 , a. lannuzel 2 , d. ben salem 1 , p. giré 1 , f. ricolfi 1 ; 1 dijon/fr, 2 pointe-à-pitre/fr (laurentpaulinegire@yahoo.fr) purpose: to describe brain mri features of guadeloupean progressive supranuclear palsy (gd-psp). in guadeloupe, a french territory in west-indies, a cluster of progressive supranuclear palsy-like taupathy has been reported with an unusual high frequency, maybe linked to the consumption of specifi c fruit and derived tea from the annonaceae family. methods and materials: thirty-four clinical gd-psp underwent prospective brain mri studies, from december 2004 to september 2005. mri evaluation was performed with a 1.5 t mr imaging (philips intera), in the university hospital radiology department of pointe-à-pitre, guadeloupe (france). the standard protocol included 6 sequences: sagittal t1-weighted turbo spin-echo, axial t2w tse (3 mm slices), coronal t2w tse (3 mm slices), axial t2 * ffe, axial t2w flair, axial protondensity. on each mri, brain atrophy (cortical, subcortical, posterior fossa) and signals abnormalities (hypo or hyper signals on t2w images) of midbrain, pons and basal ganglia were respectively measured and evaluated. each mri was reviewed independently by two neuroradiologists. results: eight of 34 gd-psp mri were not reviewable (motion artefacts). on the 26 exploitable cases, interobserver concordance of atrophy was good (p < 0.001). 80% had midbrain atrophy of which 32% presented a "hummingbird sign" on midsagittal t1w images. 75% had frontal atrophy. 19.2% presented an "état criblé" in the basal ganglia, without "hummingbird sign". two patients presented an unusual tegmental t2 hyperintensity. conclusion: gd-psp present a comparable or higher rate of midbrain atrophy than other psp described in literature. the "état criblé" presented by some of these atypical parkinson's syndromes may have an associated vascular origin. correlation of auditory simple reaction time ( studies propose that inter-individual differences in reaction time are due to physiological white matter differences, especially myelination; however, a proof is still missing. therefore, we aimed to fi nd a correlation between inter-individual reaction time differences and fractional anisotropy (fa), which is known to show white matter differences. methods and materials: twenty-two healthy students (right-handed, age: 23.1 ± 0.7 years) underwent an auditory simple reaction task based on the classic poffenberger paradigm. 8 blocks of 36 trials were conducted, preceded by 2 blocks of 36 practice trials with an inter-block pause of 30-60 s. whole head dti was performed using trse-epi sequence with an isotropic spatial resolution of 2 mm 3 . voxel-based regression analysis was conducted between fractional anisotropy and inter-individual asrt results. results: signifi cant negative correlation [pfwe (family wise error probability) = 0.032] was found in the right-central cerebellum. potent signifi cance was detected with right-sided stimulus presentation and response. no signifi cant correlation was observed, neither for left handed response nor left ear stimuli. discussion: our results imply an association between fractional anisotropy in the right-central cerebellum and asrt measures. presumably, the reason for this correlation is an infl uence of handedness on fa and asrt. since fa does not characterize specifi c tissue properties but represents an index of wm integrity, the micro-structural/physiological basis of these fi ndings requires further research from which important insights into the mechanisms of behavioral performance may be obtained. axonal damage and infl ammation relationship by 1h-mrsi and t2weighted mri in early relapsing remitting multiple sclerosis: the effects of subcutaneously interferon beta-1a treatment m.c. purpose: to examine the relationship between axonal damage in nawm in brainstem and infl ammatory activity in patients with early relapsing remitting multiple sclerosis (rrms) and to assess the effects of interferon beta-1a (ifnb1a) on metabolic brainstem changes and parameters of infl ammation. methods and materials: sixteen rrms patients treated with ifnb1a, twenty rrms patients untreated and ten healthy subjects were prospectively studied for two years. relapse rate (rr) was calculated annually. t2-weighted mr and 1h-mrsi were acquired at recruitment and at two years follow-up. t2-weighted lesion volume (t2lv) was measured. naa, cr and cho resonances ratios were calculated for the sum of the volume elements that represented the brainstem. disability was rated with edss and msfc. results: basal naa/cho ratio at brainstem was decreased in rrms compared with controls. after follow-up, there was a decrease in naa/cho (-9%) and naa/cr (-15%) while t2lv increased (18%) in rrms, without changes in controls. patients with more than one relapse showed lower naa/cho at follow-up. naa/cho correlated with edss. at follow-up, an inverse correlation was found between naa/cho and t2lv (p=0.008). ifnb1a was effective in reducing disease activity (annual rr and t2lv) but ineffective in delaying axonal damage (all rrms suffered metabolic decrements). conclusion: axonal damage begins and progresses from early stages of ms and has been related with clinical and radiological evidence of infl ammation. however, the stabilising effect of ifnb1a on infl ammatory activity appears not suffi cient in reducing neuroaxonal damage in a short-term study. longer periods of observations are needed to confi rm these preliminary fi ndings. in the analysis of 1 h mrsi one voxel in each hemisphere including the inferior colliculus was selected for quantitative analysis. jmrui program was used to analyze multivoxel. relations among peak areas of naa, cr and cho in the inferior colliculus were compared among groups in each region. spss 12.0 program was used for statistical analysis. results: colliculus showed signifi cant reduction of the ratio naa/cr in both hemispheres in schizophrenic patients compared with control subjects. in the comparation among groups hallucinators showed the smallest value of naa/cr followed by not hallucinators and controls. the comparison of the two types of schizophrenic patients did not show signifi cant differences in this localtion. the biochemistry of inferior colliculus, involved with auditory pathway, could be altered in schizophrenic patient with auditory hallucinations. in this study, mrs has shown metabolic differences between control and schizophrenic patients in these areas, without any signifi cant differences among hallucinators and no hallucinators. the functional connectivity study of acupuncture analgesia effect in human brain h. chen, j. dai, j. tian, w. qin, p. chen, z. zhen, l. ai, l. yang; beijing/ cn (hyc221@yahoo.com.cn) purpose: functional connectivity provides the functionally related and connected information among interdependence of brain regions. we used functional connectivity mri analysis to detect if there is a functional network associated with the effect of endogenous analgesia. methods and materials: fourteen right-handed chinese healthy college students [7 male and 7 female in the age of 22-26 years] were performed two functional mri examinations using 3 t siemens trio scanner. one was a resting state lasting for 15 minutes and the other was performed during a 3 minute acupuncture needle manipulation on the st36 followed by 15 minutes steady states scan. these two runs had an interval of 30 minutes. all data were preprocessed using spm2. the left side amygdala area was chosen as the roi. the seed timecourse was crosscorrelated with all other low-pass fi ltered voxels to form functional connectivity maps for each subject. finally to compare the difference of resting state connectivity and the resting state connectivity after acupuncture, a paired student t-test was implemented across subjects. the compelling similarity existed in the network of resting state before and after acupuncture. the main difference between the two networks was found in the limbic system, brainstem and cerebellum. conclusion: we conclude that the default endogenous analgesia functional network exists in human brain at a low level, and it could be increased to a higher level by acupuncture modulation. the association between the cavernous carotid artery calcifi cation (ccac) on ct and fractional anisotropy (fa) of the brain white matter using 3 t mri a. seko 1 , k. maeda 1 , y. nakano 1 , s. kitahara 2 , k. learning objectives: the aim of this exhibit is to illustrate a wide spectrum of usual and unusual manifestations of primary central nervous system lymphoma (pcnsl) and to highlight the role of ct and different mr sequences in the accurate diagnosis of this entity. background: pcnsl is an uncommon aggressive form of extranodal non-hodgkin lymphoma that originates in the cns without evidence of lymphoma in any other localization at the moment of diagnosis. it represents 0.5-2.0% of primary malignant lesions of the cns and affects brain, eye, meninges, cranial, spinal, and peripheral nerves. incidence during the last three decades has increased both in immunocompromised and immunocompetent hosts between 45-60 years old and has become the fi rst brain tumour in patients with the acquired immunodefi ciency syndrome. imaging findings: ct and mr show, mostly, an isolated mass involving deep grey matter, periventricuar regions and corpus callosum with or without surrounding edema. after contrast injection, the tumour may enhance diffusely and densely or in its periphery (ring enhancement) if central necrosis is present. if perivascular spaces or meninges enhance as well, the diagnosis of pcnsl should be strongly considerated. calcifi cations or bleeding are rarely seen. surrounding edema and multifocal lesions are more frequently seen in immunocompromised patients. conclusion: due to new therapeutical strategies, the outcome for patients with pcnsl is rapidly improving in recent years; although the fi nal diagnosis relies on stereotactic biopsy demonstrating lymphomatous cells, the radiologist plays an important role in the noninvasive diagnosis of pcnsl thanks to the imaging fi ndings provided by ct and the combination of different mr sequences. prospective results: group 1 included 38 males, 21-92 y, and 12 females, 41-80 y, with clinical onset 2-8 h before cct; mnihss was 0-28. group 2 also included 38 males, 27-81 y, and 12 females, 25-78 y. onset of symptoms was 3-8 h before cct, mnihss was 0-28. sensitivity in group 1 was 58.3%. detection of small ischemias in the basal ganglia was particularly poor. multimodality cct in group 2 showed true positive results in 32 of 50 cases, and false negative in 6 of 50 cases, with a sensitivity of 84.2%. ct angiography was helpful in selected cases for detection of intracranial stenoses/occlusions, but limited by motion artifacts. nine occlusions/stenoses of the intracranial arteries were diagnosed. conclusion: multimodality cct is superior to unenhanced early cct for detection of acute cerebral ischemia, and should serve as a basic diagnostic tool for establishing local stroke units. imaging of the central skull base: anatomic study i. pérez 1 , m. aperribay 1 , g. benito 1 , i. terreros 2 , a. dolado 2 , j. mendiola 2 ; 1 mondragón/es, 2 baracaldo/es (irunepe@hotmail.com) learning objectives: to review the anatomy of the skull base including the skullbase foramina and their content, the osseus anatomy of the pterygopalatine fossa, and the sutures and boundaries of the skull base. after reading this exhibit, the reader will be able to understand the complex anatomy of the skull base, to accurately delineate phatologic processes, and to understand the spread pathways of different lesions involving this complex region. background: the radiologist requires a thorough knowledge of the normal anatomy and the pathologic spectrum of the skull base. imaging plays a central role in the management of skull-base disease, because this region is, in general, inaccessible to clinical evaluation. ct is ideal for outlining the bone architecture, whereas mr imaging provides soft tissue details. the pterygopalatine fossa represents a major pathway of spread of malignancy and infection from the head and neck into the skull base. imaging findings: a pictorial review of the skull base with foramina and their content (foramen ovale, rotundum, spinosum, lacerum, yugular foramen, and carotid canal), the pterygopalatine fossa and its boundaries, and the sutures of the skull base (occipitomastoid, sphenosquamous, petrosphenoid fi ssure, petrooccipital fi ssure, pterygomaxillary fi ssure) is provided. conclusion: familiarity with the complex anatomy of the skull base is a prerequisite for the correct diagnosis and accurate delineation of skull-base lesions. ct and mr imaging are complementary modalities and are often used together to demonstrate the full disease extent. the the aim of this study was to determine whether the anatomy of the cow infl uenced the incidence, severity and location of these lesions. methods and materials: thirty term neonates with hie underwent mri with standard structural sequences and high-resolution 3d time-of-fl ight mr angiography. the cow was examined for completeness and anatomical variations. the presence and distribution of wm and bgt lesions were noted and the lesions were graded according to predefi ned criteria. the cow was complete in 50% of infants. bgt or wm lesions occurred in 21 infants, with severe changes in 7, moderate in 9 and mild in 5 infants. in those with severe changes, 6 had incomplete cow and 5 of these had an absent anterior communicating artery (a-com). the only 2 infants in the study with absence of both anterior and posterior communicating arteries had severe changes. the anatomy of cow did not infl uence the location of the lesions. the presence of specifi c anatomic variations in cow may infl uence the severity of ischaemic wm or bgt lesions in infants with hie. infants with incomplete cow may have limited ability to adequately perfuse the brain following a hypoxic-ischemic insult and therefore present with more severe lesions. imaging spectrum of cerebral amyloid angiopathy j. kim, k. ahn, s. jung, b.-s. kim; seoul/kr (jeeyoungkim@catholic.ac.kr) learning objectives: to demonstrate the various ct and mr imaging fi ndings and pathogenesis of cerebral amyloid angiopathy. background: recently, cerebral amyloid angiopathy (caa) has attracted attention for its close relationship to cerebral hemorrhage (ich), ischemic lesions, alzeheimer's disease (ad), and other types of dementia in the elderly. most common presentation of caa is massive isolated or multi-compartmental intracranial hemorrhage, but it is also found in association with subacute or chronic edematous lesion of the white matter with or without caa-related hemorrhage. procedure details: the ct and mr images of histologically proven or clinically diagnosed caa were described with regard to type (lobar or petechial hemorrhage), location, and relapse of cerebral hemorrhage and presence or absence of white matter change (leukoencephalopathy) with pathogenesis of these lesions. the usual presentation of cerebral amyloid angiopathy is spontaneous lobar hemorrhage in the elderly patients, especially in those patients more than 70 years of age. however, cerebral amyloid angiopathy presents various imaging fi ndings such as cortical petechial hemorrhage and subcortical or deep white matter change with or without cerebral hemorrhage. whole-brain three-dimensional ct perfusion k. yuba, k. ono, k. suzuki, y. yoshimoto, k. wada, d. yamana; meguro-ku,tokyo/jp (mishuku-ct@mishuku.gr.jp) purpose: ct perfusion functional evaluation is a promising method for evaluating blood fl ow in patients with cerebral ischemia. the conventional method suffers from the limitation that the area that can be evaluated is restricted. the present study was conducted to assess a new display method for evaluating the distribution of blood fl ow in the brain by combining whole-brain imaging and multiplanar reconstruction. to cover the entire brain, scanning was performed several times with the scan slice thickness reduced from 8 mm to 2 mm, and the number of scan slices increased from 4 to 16. saline solution was used in combination to reduce the volume of contrast medium, and a quantum denoising fi lter was used to minimize the exposure dose. for image processing, several data series were bundled into a single series. this technique permits multiplanar display of wholebrain blood fl ow, which is not possible with the conventional method. results: evaluation of this new display method for ct perfusion studies showed that three-dimensional display permits the cerebral blood fl ow distribution to be observed from any desired direction. this method makes it easier to visualize ischemic areas and is expected to prove useful as a new ct perfusion display method. conclusion: three-dimensional ct perfusion permits blood fl ow in the entire brain to be evaluated stereoscopically. this method fully exploits the advantages of a larger number of ct detector rows and is expected to gain widespread acceptance as a useful new ct perfusion imaging technique and display method. evaluation of cerebral metabolite patterns with proton mr spectroscopy in chronic renal failure patients: correlation with duration of hemodialysis s.e. kim, h. baik, h. yu, y. lee, g. kim; seoul/kr (tlwodc@hanmail.net) purpose: to evaluate cerebral metabolite patterns with proton mr spectroscopy (mrs) in chronic renal failure (crf) undergoing hemodialysis (hd) and to clarify if these fi ndings correlate with duration of hd. methods and materials: subjects comprised 15 crf patients undergoing hd and 15 healthy volunteers. short te (=32 ms) single voxel proton mrs and laboratory data were acquired in crf patients before hd and one day after hd. spectra were obtained from two voxels of interest positioned in the gray and white matter of parietal lobe. changes in n-acetylaspartate (naa), choline (cho), myoinositol (myo), glutamine/glutamate complex (glx) and creatine (cr) were analyzed and the results presented as ratios, with cr as the reference. metabolic ratios and laboratory data before and after hd were compared. correlations between each metabolite ratio and laboratory data, and between each metabolic ratio and duration of hd were evaluated. results: in crf patients, the cho/cr ratio and myo/cr ratio were signifi cantly elevated in gray matter and the myo/cr ratio was signifi cantly elevated in white matter compared with controls (p <.05). after hd, the cho/cr ratio was significantly reduced in white matter of crf patients (p <.05). there were no signifi cant correlation between each metabolic ratio and laboratory data, and between each metabolite ratio and duration of hd. the signifi cant elevation of the cho/cr ratio in gray matter and the b d e f a g myo/cr ratio in gray and white matter was found in crf patients compared with controls. there was no signifi cant correlation between cerebral metabolite ratios and overall time of hd. imaging learning objectives: 1. to describe and depict cns infections within the different compartments of the brain. 2. to illustrate characteristic imaging fi ndings attributable to specifi c pathogens. 3. to demonstrate infectious etiologies specifi c to immunocomprised and hiv patients. background: localizing a lesion within the intracranial compartment is the fi rst critical step in constructing a differential diagnosis. furthermore, certain types of infections have certain propensities for different anatomical regions within the brain and can possess certain imaging characteristics. of course, the imaging fi ndings must be placed in the context of the clinical setting particularly in immunocomprised and hiv patients. imaging findings: we present a pictorial review of infections within different compartments of the brain. pathology proven infectious cases will be presented in both immunocompetent and immunocompromised patients with discussion of the characteristic fi ndings of each pathogen and differential diagnosis. the radiologist plays a crucial role in identifying and narrowing the differential diagnosis of cns infections. a thorough understanding of the intracranial compartment anatomy and characteristic imaging fi ndings of specifi c pathogens as well incorporating the clinical information is essential to arrive at the correct diagnosis. histologic diagnosis of meningioma were studied in our center, 23 (9.3%) were atypical and 6 (2.4%) malignant. we reviewed the ct and mri fi ndings of these 29 patients with pathologically confi rmed atypical and malignant meningioma diagnosed. we illustrate different appearences of atypical and malignant meningioma. pitfalls, diagnostic diffi culties and differential diagnoses are emphasized. conclusion: after interacting with this exhibit the radiologist will improve his or her knowledge of atypical and malignant meningioma, including histopathology and radiologic features. 11c-sodium butyrate-pet in neurooncology n.a. kostenikov, l.a. tyutin, n.p. fadeev; st. petersburg/ru (crirr@peterlink.ru) purpose: the aim of the study was to determine the potential in diagnosis of pathological volume brain formations (pvbf) by pet with 11c-sodium butyrate (11c-sb). methods and materials: pet was performed in 143 patients (74 men and 69 women, at the age of 18-79 y.o). to identify tumors or to exclude an advance growth of tumors. according to the results of histological data, malignant tumors were revealed in 77/143 patients, benign tumors in 28, arterial venous malformations (avm) in 12, stroke diseases (sd) in 4, and cysts in 22. 2d-pet scans of the brain with attenuation correction («ecat exact 47 hr+», siemens) were performed in a dynamic mode immediately after intravenous administration of 550-650 mbq 11c-sb. we used tumor/normal tissue ratio (t/nt) as an index for semiquantitative data analysis, as well as analysis of activity/time curves. results: results of the studies showed pet with 11c-sb proved to be a highly sensitive (94.8%) technique in revealing brain tumors and it allowed to visualize clearly malignant and hypervascular benign tumors and to differentiate them from non-tumor masses of the brain. dynamic 11c-sb-pet allows to assess the grade of vascularity, the level of metabolism, the rate of uptake and utilization of fatty acids (fa), and to estimate indirectly the state of tumors oxygenation. the performed studies showed that dynamic pet with 11c-sb allows to visualize precisely malignant brain tumors and estimate their morphological state; the latter is of prognostic value in order to plan conservative therapy for brain tumors. susceptibility-weighted imaging ( purpose: to assess the fi ndings of susceptibility-weighted imaging (swi) with 3-tesla in acute ischemic stroke. methods and materials: twenty patients underwent ct and mr imaging with swi, diffusion-weighted imaging (dwi), and 3d-tof mra within the fi rst 5 days after the onset of acute ischemic stroke. the swi sequence is a high-resolution threedimensional (3d) imaging technique with 3-tesla. the susceptibility changes by the intraarterial clots or emboli, hemorrhage, and the enhancement of the regional vein in the abnormal perfusion area of the brain were assessed on swi. results: the intraarterial susceptibility changes by the fresh clots or emboli were visible on swi in 8 cases. swi showed distal clots or emboli that were invisible on both of mra and fl uid attenuated inversion recovery (flair) images in 6 cases. the hemorrhagic infarction occurred in 5 cases. the hemorrhage was shown on swi earlier than on ct image in each case. the enhancement of the regional vein in the abnormal perfusion area of the brain was shown in 6 cases on swi. all of them were within 2 days after the onset of acute ischemic stroke. five of the 6 cases were embolic infarction cases of the mca territory. conclusion: swi is an effective means that can provide additional information about the fresh intraarterial clots, hemorrhage, and the perfusion anomaly in the brain in acute ischemic stroke. bold fmri response in the motor cortex is strongly linked with vasoreactivity in patients with carotid artery disease c. ojango, s. goode, d.p. auer; nottingham/uk (msxco@nottingham.ac.uk) purpose: blood oxygenated level-dependent (bold) functional mri (fmri) has become a widely used technique to investigate brain activation. the method is based on haemdynamic changes and any alteration in neurovascular coupling, baseline blood fl ow or volume is likely to affect results. it has been shown that stroke and carotid artery disease reduce cerebrovascular reactivity (cvr) and this factor infl uences the response to motor tasks. we explored further the interrelation between the motor task induced signal change and the cvr in patients with carotid artery disease. methods and materials: six patients (age 55-80) with internal carotid artery stenosis (> 60%) were investigated with motor task and co 2 stimulation. the data analysis was performed with fsl software. the mean percentage of signal intensity change during the motor task and co 2 challenge was calculated separately for both motor cortices. results: there was a signifi cant correlation between the bold responses to the motor task and co 2 stimulation (pearson test 0.69, p=0.01). we did not fi nd differences in motor bold responses between the side of the maximum stenosis and the contralateral hemisphere. conclusion: these results confi rm the effect of vasoreactivity on bold response in patients with carotid artery disease and show that neurovascular coupling is linearly and strongly correlated with cvr. in the small sample, no difference emerged between hemispheres suggesting that the degree of stenosis may be less relevant for the bold response than cvr. the observed relationship is important for designing clinical fmri studies to avoid confounding effects from altered vasoreactivity. the value of perfusion mr to differentiate between low and high grade brain gliomas r. rodríguez-romero, j. vivancos-garcía, p. piñero gonzalez de la peña, c. monreal-rodríguez; sevilla/es (raroro@terra.es) purpose: to determine the value of magnetic resonance perfusion imaging to differentiate between low and high grade brain glioma. methods and materials: forty-seven patients with brain glioma were studied with conventional mri followed by dynamic susceptibility-weighted gadoliniumenhanced perfusion-mri. 14 were low grade gliomas (i-ii who) and 34 were high grade gliomas (iii-iv who). studies were performed with a 1.5t philips mr system. region of interest was measured in the 5-6 most vascularized areas of the tumor. the maximum cerebral blood volume (cbv) value was recorded for each area and divided by cbv of the contralateral periatrial white matter to obtain the relative cbv (cbvr purpose: endovascular stenting is evolving as the primary treatment option for cervical arterial dissections in symptomatic patients refractory to medical management. the tractability of balloon-or self-expandable stents into the tortuous intracranial vasculature is often diffi cult. six patients at our institution have been treated using the fl exible intracranial neuroform stent in tortuous dissected segments of the distal carotid and vertebrao-basilar arteries. we studied this population to evaluate this treatment approach. methods and materials: six patients with distal internal carotid or vertebralbasilar dissections were treated using intracranial neuroform stent. a total of 10 stents were utilized in 6 procedures. dissecting aneurysms were treated via stent assisted coil embolization. patients were followed with imaging and clinical assessment for a mean of 6.2 months. long-term integrity, technical and clinical outcomes were assessed. results: all patients were symptomatic from their dissections. presenting symptoms included tias, persistent pain, hemispheric infarcts, and sah. spontaneous (3), traumatic (2), and iatrogenic (1) etiologies were responsible for dissections. dissections were treated with single (n=5) or overlapping (n=1) neuroform stents. one patient required 3 tandem stents to reconstruct a long segment dissection. technical success was achieved in all patients (100%) with no residual fl ow limitation. dissection related mean stenosis improved from 84% pre-procedure to 26% and 9% on post-procedure and follow-up imaging respectively. there were no recurrent tias, infarcts, or subarachnoid hemorrhages. there were no long term complications. in certain cases of dissections affecting tortuous and redundant vasculature, neuroform stent appears to be a safe option for the endovascular management. background: gioblastoma multiforme is the most common primary malignant brain tumor in adults. accurate diagnosis is important for the establishment of therapy and prognosis. however, diagnosis is often diffi cult as this entity can display various imaging characteristics depending upon its histological structure and growth pattern. imaging findings: we exemplify atypical imaging fi ndings in six cases of histologically confi rmed glioblastoma. imaging features include lack of enhancement after contrast administration, primarily cystic or intraventricular growth pattern, subependymal and subarachnoidal spread as well as negative pet fi ndings. we correlate imaging fi ndings and histological structure to explain the displayed atypical mr morphology and signal properties. we illustrate how to improve diagnosic accuracy with the help of advanced imaging techniques such as mr spectroscopy, diffusion weighted imaging and perfusion weighted imaging. conclusion: atypical glioblastoma should be considered as a differential diagnosis in cerebral space occupying lesions with equivocal clinical and imaging fi ndings. diagnosis of atypical glioblastoma can be improved by the use of advanced mr imaging techniques. imaging in tropical infections of the brain j. singh, r. kulkarni; pune/ in (joshitasingh@hotmail.com) learning objectives: to depict the various infective brain pathologies commonly encountered in the tropical settings in india. to illustrate the various imaging features of these infections. background: tackling neuro-infections constitute an ever growing challenge to the radiologist and the physician alike. they continue to be a major cause of morbidity and mortality with evolving clinical and imaging profi les as the infective organisms adapt to more and more drug regimes. b d e f a g procedure details: we reviewed and compiled the imaging features of various commonly encountered brain infections in india. patients with tuberculosis, neurocysticercosis, chickungunya fever, dengue fever, japanese b encephalitis, herpes simplex encephalitis, neurobrucellosis and fungal infections were included in the study group. opportunistic infections in immunocompromised patients were also included in the study group. in this exhibit, we discuss the imaging features and the differential diagnosis of each of these conditions. areas of restricted diffusion not confi rming to any vascular territory in patients of chickungunya fever and demyelinating lesions in dengue fever were some uncommon characteristic imaging features seen in our study group. conclusion: imaging plays a crucial role in management of neuro-infections. characteristic clinical and imaging features may obviate the need for further investigations in the cost constrained or epidemic settings. background: central nervous system involvement with malignant lymphoma, whether primary or secondary is an uncommon disease, which is increasingly seen in immunocompromised individuals, particularly secondary to hiv or other haematological malignancies. there is high morbidity and mortality associated with cerebral lymphomas. imaging is important in diagnosing lymphomas and differentiating it from other mimics. ct is often the fi rst imaging modality, but mri is the most useful modality. imaging findings: the pictorial review illustrates the spectrum of imaging fi ndings seen in primary and secondary cerebral lymphomas seen in different imaging modalities, with particular emphasis in mri. ct scan shows hyperdense lesion, predominantly in the subspendymal region. mri shows solid, enhancing lesions in subspendymal region. ring enhancement is a feature of lymphomas arising in immunocompromised individuals. differential diagnosis of lymphomas include other solid tumours, toxoplasmosis, abscesses. the review discusses the salient features of each of these differential diagnosis. conclusion: primary and secondary central nervous system lymphomas have characteristic appearances in ct and mri scans. b lymphomas are the commonest to affect the brain. lymphomas are commonly seen in the subspendymal region. primary and secondary lymphomas have different features in imaging. intense enhancement is a feature of ring enhancement. radiological spectrum of lesions involving the hippocampus a. rovira-cañellas 1 , a. rovira-gols 2 , c. auger 1 , n. bargalló 1 , j. alvarez-linera 3 ; 1 barcelona/es, 2 sabadell/es, learning objectives: to illustrate the radiological fi ndings of several lesions that predominantly affect the hippocampus. background: the hippocampus, which forms a part of the limbic system, has a crucial role in cognition and memory, particularly in the formation of long-term memory. in vivo visualization of the hippocampus became possible with the advent of mr imaging, which has allowed the identifi cation of a variety of lesions that mainly affects this formation. imaging findings: many of the mr imaging examinations performed to identify structural abnormalities of the hippocampus are obtained in patients with temporal lobe epilepsy (medial temporal lobe sclerosis) and several forms of primary neurodegenerative dementia, particularly those of the alzheimer type (hippocampus atrophy). however, hippocampal changes can occur in a broad spectrum of disorders beyond dementia and epilepsy, including ischemic lesions (infarction within the posterior cerebral artery territory), primary brain tumours, infl ammatory and infectious diseases (viral and paraneoplastic encephalitis, demyelinating lesions), vascular malformations (cavernoma, arterio-venous malformation), and focal cortical dysplasia, as well as several neuropsychiatric disorders (schizophrenia, post-traumatic depression). the hippocampus may also be selectively affected in patients with neurofi bromatosis type i, and in the acute phase of transient global amnesia and status epilepticus. the hippocampus can be affected by a variety of processes that may present similar clinical fi ndings. mr imaging establishes the proper differential diagnosis with a relatively high specifi city when a suitable imaging protocol is used. the correlation between the fractional anisotropy (fa) value and the pathologic change at different stages of spinal cord injury in rats n. chen, k. li; beijing/ cn (cnddcndd@yahoo.com) purpose: to evaluate the correlation between the fractional anisotropy (fa) value and the pathologic change at different stages of spinal cord injury in rats. a total of 32 sd rats were medially divided into 4 groups. each group (n=8) received a completely transverse injury at the lever of t6. on each group, diffusion tensor imaging was performed by using a 1. necessary. the images were analyzed for patterns of involvement, frequencies and differential diagnosis entertained. results: the dorsolumbar region was commonly affected. in 45 patients, more than two regions were involved. contiguous involvement of adjacent regions was more common than skip lesions. there were three patterns of involvement: disk-vertebral lesion, those confi ned to the body and posterior arch lesion. lesions sparing disks (40%) were nearly as common as those involving both body and disc (47%). nearly 90% of disk-vertebral lesions were associated with paraspinal/epidural abscesses or cord compression, especially at the dorsolumbar junction. body lesions were also associated a high incidence (70%) of abscesses and cord compression. one-third of these lesions were confi ned to the body (thus mimicking secondaries, lymphoma). isolated posteriro arch involvement occurred in 13 patients. conclusion: spinal tuberculosis has a varied presentation and can mimic any disease of the vertebral column. isolated pedicle involvement and multifocal body involvement can closely mimic malignancy. purpose: mri has become a critical diagnostic imaging modality for spinal disorders. spine arthrodesis and arthroplasty devices are known to result in signifi cant artifacts on mri. we assessed and compared the artifact resulting from four different biomaterials utilized in clinical arthroplasty devices when encountered in the same shape. methods and materials: sheep lumbar spinal segments were harvested and the lower lumbar discs excised. circular discs of the various materials were then used to fi ll the spaces. polyethylene, medical ceramic, titanium, and chrome cobalt (cocr) alloy discs were used. images were obtained with a general electric 1.5 t mri unit in both sagital and axial sequences. the scans were reviewed by the authors (neuroradiologist and orthopedist) and the distortion graded between the various materials. the area of fi eld distortion and the device dimensions were also compared. results: the distortion from polyethylene was the least severe and cocr was the most severe on both sagital and axial mri scans. ceramic alone was mild with titanium causing an intermediate fi eld artifact. the cocr disc resulted in severe artifact on the mri image, resulting in artifact which was twice the dimension of the disc. the choice of biomaterial for spinal implants for arthrodesis and arthroplasty, in addition to design shape, will have a profound effect on the magnitude of mri artifact and on whether mri images are of any clinical utility after spinal surgical reconstruction. magnetic evaluation of spinal vessels with ce angiomr in suspicion of vertebral canal avm k. gruszczynska 1 , j. baron 1 , w. brojacz 2 , p. there is a degree of overlap between the imaging fi ndings in these conditions. however, certain fi ndings are helpful pointers towards the diagnosis of specifi c connective tissue diseases and conditions associated with vasculitis. examples of spinal cord compression, focal cerebral infarcts, multifocal white matter lesions, venous sinus thrombosis, intracerebral and subarachnoid haemorrhage, aneurysm, cerebral abscess, cytotoxic and vasogenic oedema in such cases are shown on ct and mr images. the purpose of this exhibit is to illustrate the spectrum of neuroradiological imaging fi ndings in connective tissue diseases and vasculitides, and to show features that allow the radiologist to distinguish between the differential diagnoses. neuroimaging manifestations in von hippel lindau disease: emphasis on unusual fi ndings a. patsalides 1 , e. tzatha 2 , n. patronas 2 ; 1 washington, dc/us, 2 bethesda, md/us (apatsalides@cc.nih.gov) learning objectives: in this exhibit, we present the neuroimaging manifestations of vhl disease, emphasizing on the unusual fi ndings. background: von-hippel lindau (vhl) disease is an autosomal dominant disorder with incomplete penetrance. neuroimaging manifestations include the presence of hemangioblastomas in the retina, brain and spine as well as endolymphatic sac tumors (elst). imaging findings: common and unusual imaging features of hemangioblastomas in the cerebellum, brainstem and spinal cord are presented and evolution in time is assessed. we show hemangioblastomas in uncommon locations such as the suprasellar area, cerebral hemispheres, internal auditory canals, cauda equina and leptomeninges, mimicking other tumors. we present the imaging abnormalities of elst and the range of involvement of the petrous bone as well as a variety of retinal hemangioblastomas and their complications. the spectrum of neuroimaging manifestations in patients with vhl disease is wide. awareness of the variety of imaging fi ndings and evolution in time is important for the complete understanding of this entity. lipomas, dermoids and epidermoids of the brain and spine: a pictorial review s.b. lachanis, a.n. chalazonitis, j. pontikis, g. tsimitselis, n. ptohis, i. tzovara; athens/gr (red-rad@ath.forthnet.gr) learning objectives: 1. to pictorially review the mr imaging features of cns lipomas, epidermoids and dermoids with various sequences. 2. to describe their distinguishing imaging features aiding their differential diagnostic approach. 3. to underline potential pitfalls in their differential diagnosis. background: lipomas, dermoids and epidermoids of the brain and spine, although rarely encountered, enter in the differential diagnosis of many other cns tumors. although their embryology is different, these lesions share a common feature: they represent "tissues at a false place", as mesencymal and cutaneous ectoderm tissues within cns structures. imaging findings: in this exhibit, we present a great number of cases of cns lipomas, dermoids and epidermoids. all cases have been drawn up from our teaching fi les. imaging characteristics (with all conventional and newer mr sequences), together with their differential diagnosis are pictorially presented. potential pitfalls in their differential diagnosis will also be discussed. conclusion: lipomas, dermoids, and epidermoids of the cns have distinguishing radiological appearance concerning especially their mri imaging characteristics. by appreciating these, together with their site of predilection and affected age spectrum, any radiologist can reach the specifi c diagnosis in a majority of cases. purpose: central and/or peripheral nervous system involvement (neuroborreliosis) is frequent in lyme disease and is often the fi rst presentation. aspecifi c white matter lesions on t2-weighted images (wi) in neuroborreliosis have been published in the literature. cranial nerve enhancement was frequently observed in our series. we present the magnetic resonance (mr) imaging fi ndings in 9 patients with proven neuroborreliosis. methods and materials: nine patients with positive serology for lyme were included in this retrospective study. 8 mr studies of the brain, 1 of the lumbar spine and 1 of the cervical spine were performed. mr imaging of the brain consisted of t1-wi, t2-wi, fl uid-attenuated inversion recovery (flair) and contrast enhanced t1-wi. spinal studies included t2-wi, as well as t1-wi before and after gadolinium injection. results: one brain study and the mr examination of the cervical spine showed no abnormalities. five brain studies displayed aspecifi c white matter lesions. in four patients, cranial nerve enhancement (3 vestibulocochlear nerve, 2 oculomotor nerve, 2 trigeminal nerve, 1 facial nerve, and 1 glossopharyngeal nerve) was observed. in one patient, right hemispheric cerebellitis and leptomeningeal enhancement was described. mr of the lumbar spine showed polyradiculitis of the cauda equina. conclusion: aspecifi c white matter abnormalities are frequently observed in patients suspected for neuroborreliosis. cranial nerve enhancement, cerebellitis, and polyradiculitis may narrow the differential diagnosis in these patients and neuroborreliosis must be considered when these fi ndings are encoutered, especially in endemic regions. contrast high-resolution ultrasound of infl ammatory bowel diseases in children u. zaleska-dorobisz, a. stawarski, d. sokolowska, b. iwańczak, k. moroń; wrocław/pl (atd@vassurg.am.wroc.pl) purpose: to present the usefulness of high-frequency standard and doppler ultrasound in the diagnosis and therapy monitoring of infl ammatory bowel diseases (ibd) in children. we studied 95 children, with mean age 13.5 years, with infl ammatory bowel diseases: thirty-fi ve with crohn disease (cd), 41 with colitis ulcerosa (cu), 19 with other ibd. we performed high-resolution 2d sonography to evaluate the bowel-wall thickness. intraparietal vascularisation was assessed with color doppler. superior or inferior mesenteric arteries fl ow, mean velocity, ri (resistance index) were measured in all patients. we compared clinical active disease, ultrasounds and colonoscopy. results: cd predominantly involved the small intestine. the bowel wall was greatly thickened more than 8-10 mm. mucosal ulcerations penetrated into the wall in 25 children; in 13 we found fi stulas and peritoneal abscesses. the mesentery and fat around the bowel was thickened in all children. uc was limited to the left colon. the colon wall was thickened more than 5-11 mm. mural infl ammation was located in the mucosal surface with superfi cial ulcerations and pseudo polyps (50%). color doppler revealed hyperemia with increased vascular supply of the involved bowel wall. the ri was signifi cantly lower in active disease. after treatment, ri values increased signifi cantly (p < 0.005). conclusion: high-resolution and doppler sonography can detect bowel-wall abnormalities in most ibd in children. doppler fl ow parameters in mesenteric arteries correlated strongly with disease activity. doppler us could be used for monitoring the treatment effi ciency. single-shot mrcp in the evaluation of pancreaticobiliary disease in children s. fitoz, a. erden, s. boruban; ankara/tr balloon dilatation of oesophageal strictures following surgical repair of oesophageal atresia f.a. kazmi, d. roebuck; london/uk (drfkazmi@doctors.net.uk) learning objectives: we describe and illustrate the technique, indications and complications of balloon dilatation of oesophageal strictures following surgical repair of oesophageal atresia based on a series of 30 patients. background: balloon dilatation of oesophageal strictures is well described in the adult literature. however, its role in the paediatric population after repair of oesophageal anomalies is less well established. post operative stricture occurs in 30-50% of patients with oesophageal atresia. this carries a high risk of malnutrition and aspiration to the lungs. it is the most common post surgical complication and typically occurs at the primary site of anastomosis. at our institute, we have one of the largest case series of patients undergoing balloon dilatation of strictures after surgical repair of oesophageal atresia. procedure details: all procedures were carried out under general anaesthetic. the oesophageal lumen was opacifi ed with water soluble contrast to correctly identify the location of the stricture. a 4 f catheter and hydrophilic guidewire were passed through the mouth and manipulated under fl uoroscopic guidance across the stricture and into the stomach. a balloon catheter (15-20 mm in diameter) and 3-6 cm long was passed over the guidewire and positioned across the stricture. the balloon was slowly infl ated with diluted water soluble contrast under fl uoroscopy until the waist on the balloon was obliterated. a post procedure oesophagram was then performed to check for oesophageal rupture. conclusion: balloon dilatation of strictures following surgical repair of oesophageal atresia is clinically effective, safe, relatively atraumatic and is without high risk of complications. infl a total of 84 children were enrolled: 56 with crohn's disease (cd) and ulcerative colitis (uc) and 28 healthy siblings as controls. lumbar spine bmd was measured by dxa and z-scores were obtained by comparison with age-and sex-matched normal values. bone age was measured in each patient by the method of greulich and pyle and abmd was calculated again using bone age instead of chronological age. multiple regression analysis was used to evaluate the relationship between ibd and potential risk factors. results: children with cd and uc differed for corticosteroid exposure. total duration of therapy (p=0.009), cumulative (p=0.03) and daily dose (p=0.004) of prednisone were signifi cantly higher in patient with uc. no signifi cant difference was found between cd and uc abmd. prevalence of low bmd (z score<-2) was higher for ibd patients respect to controls (p=0.026). abmd z scores were then calculated using bone age instead of chronological age and abmd was found signifi cantly low in uc patients (p < 0.01). conclusion: children with ibd should be evaluated for bmd and a corret interpretation of dxa results is important for identifying children at real risk for osteoporosis. low bmd has a high prevalence in children with ibd, but it has to be assessed using bone age instead of chronological age to avoid overestimation. purpose: to present an mr imaging protocol for the evaluation of iib disease and to assess its effi cacy in evaluating disease activity. methods and materials: mr imaging of the small bowel was prospectively performed in 15 patients (aged 9-15 years) with known or suspected iib disease. 2.5 lt of water solution with herbal fi bers was administered over 4hours through a nasogastric tube prior to mr examination. patients were scanned in the prone position using coronal and axial thin-slice (1.5 mm) 3d t1-weighted ge and t2-weighted bffe fat-suppressed sequences followed by dynamic study after contrast administration. quality of imaging, including small bowel distention, wall conspicuity, motion and susceptibility artifacts, was evaluated by two observers in consensus. disease activity was evaluated by presence and degree of mural enhancement and edema. the procedure was well tolerated by all patients. quality of imaging was considered excellent (n=10 patients), satisfactory (n=5) and non-satisfactory (n=0). imaging fi ndings included: wall thickening (> 4 mm) of the terminal ileum (n=11), jejunum loops (n=5), large bowel (n=3) and stomach (n=1), and luminal narrowing (n=2). seven patients showed early increased wall enhancement, implying active infl ammation, whereas four patients exhibited delayed mild enhancement of bowel wall consistent with inactive disease. extraluminal manifestations included mesenteric adenopathy (n=6), perienteric fi brofatty proliferation (n=6), ascites (n=2) and patulous ileocecal valve (n=2). conclusion: mri of the small bowel, using the current imaging protocol, is a welltolerable, non-ionising method for evaluating the presence, extent, activity and extraluminal manifestations of iib disease in pediatric patients. detection of tree-in-bud sign in cystic fi brosis by volumetric thin-section low-dose mdct: incidence, natural history and correlation to morphologic score and spirometry k.m. unsinn, h. ellemunter, j. eder, w.r. jaschke, m.c. freund; innsbruck/at purpose: to determine the incidence of tree-in-bud sign (indicating involvement of the peripheral bronchioles by infection and infl ammation) in patients with cystic fi brosis by volumetric thin-section low-dose mdct. to evaluate the natural history (i.e. reversibility) of tree-in-bud sign in patients with cystic fi brosis. to correlate the tree-in-bud sign to ct-morphology measured by bhalla score and to spirometry. methods and materials: all patients had proven cystic fi brosis (cf). volumetric low-dose multidetector (4, 16, or 64) row spiral ct (mdct) of the chest was performed in 40 patients (5-50 years) every second year without contrast administration in supine position at end-inspiration during single breath-hold with following scan parameters: contiguous 1.25 mm slice thickness/intervall, 120 kv, 10 ma, 0.8 sec rotation time/360°, standard and lung reconstuction algorithm. dose-length product (dlp) (mgy•cm) was recorded. two radiologists reviewed all images and arrived at consensus opinion regarding incidence and natural history (i.e. reversibility) of tree-in-bud sign with correlation to ct-morphology measured by bhalla score and to spirometry. the tree-in-bud sign was seen in 8/40 patients (20%) and occured at higher age (p < 0.05), at higher level of ct-morphological involvement as measured by bhalla score and at higher level of functional pulmonary impairment measured by spirometry (p < 0.05). in this patient population, the tree-in-bud sign was never reversible. conversion of recorded dlp (range) 08.50-22.52 (mgy•cm) resulted an effective dose (range) 0.12-0.33 (msv). the tree-in-bud sign represents a non-reversible sign in patients with cf occuring in later stage of disease and presumably indicating involvement of bronchioles. apneac oxygenation using cpap to perform computed tomography of the thorax in paediatric patients b. tagliaferri, u. sonvico, e. battaglia, m. del sante, f. boioli; milan/it (btagliafer@sirm.org) purpose: evaluation of the diagnostic accuracy of multi-slice spiral ct (msct) high-resolution computed tomography (hrct) in paediatric patients for the examination of the pulmonary parenchyma, maintaining continuous expansion of the lung (apneac oxygenation) through the use of cpap. methods and materials: an evaluation of 35 patients between the ages of 15 days and 2 years was conducted using msct-hrct. patients were examined with the siemens somaton sensation 16-ct scanner, using technical parameters enabling exposure to low doses, and ventilation was ensured manually using an ayres "t" tube for the time necessary for the preparation of the child until the end of the period of apnea. the examinations were carried out with and without peep, with a mean duration of 1 minute. results: in all the patients examined, the thorax was kept immobile and continually extended, enabling the avoidance of interpretative errors, facilitating the differentiation of pulmonary pathology with extreme precision, distinguishing the types of bronchial obstruction associated with air trapping and facilitating the evaluation of the lower segments of the lung parenchyma, where collapse often occurs. the modifi cation of some of the technical parameters (kv and mas) enabled us, furthermore, to carry out examinations at low doses in compliance with the european radioprotection standards. the pulmonary hyper-expansion obtained with this method enables the msct-hrct to be performed in paediatric patients, giving a correct evaluation of the pulmonary parenchyma without the use of artifi cial respirators. overview of paediatric orbital pathology: a pictorial review s. nayak, d. nayak; leeds, west yorkshire/uk (sanjeevnayak@hotmail.com) the spectrum of ocular and orbital pathology in the paediatric age group is quite different from that of adults. imaging studies serve an important role in the diagnosis and management of many of these abnormalities. systemic approach is required to understand the classifi cation and imaging features of orbital pathology. we have described them according to the three orbital compartments, namely, the globe/optic nerve sheath, intraconal and extraconal lesions. this extensive pictorial review outlines the various abnormalities of the paediatric eye and orbit for which imaging studies are often required, including infection, neoplasm, infl ammation and infi ltration, developmental anomalies, and trauma. imaging included in this review includes the relevant plain radiography, ct, ultrasound and mri features of various pathologies. additionally, the pertinent fi ndings are correlated with pictorial description of the relevant histopathology, fundoscopy features and relevant clinical ocular photographs. correlation of the results of imaging studies with pertinent clinical information allows the determination of specifi c diagnoses in most instances of paediatric orbital pathology. control children were neurologically and developmentally normal and also showed normal mri. mri was performed from 0 to 5 years of corrected age in both groups. we measured the ap diameter of the pons, the tegmentum and basis pontis, and corpus callosum length using t1-weighted midsagittal image. results: pontine diameters in all regions were signifi cantly smaller in the pvl group than in the control group. pontine diameters in the pvl group and control group were 1.66±0.21 (sd) and 1.87±0.23 mm (p < 0.001), respectively; tegmentum diameters were 1.23±0.20 and 1.36±0.19 (p < 0.001), respectively; basis diameters were 0.42±0.10 and 0.51±0.14 (p < 0.001), respectively; and the corpus callosum lengths were 5.02±0.90 and 5.51±0.76, (p < 0.001), respectively. when the agerelated pontine diameter differences were examined, there was signifi cant difference in pontine diameters after 12 months of age. we proved that pontine diameter in patients suffering pvl is significantly smaller than normal control. purpose: methylmalonic acidemia (mma) often presents with nonspecifi c neurological symptoms that leads to different imaging work-ups. better recognition of fi ndings of brain imaging (ct/mri) helps physicians suspect to mma diagnosis in earlier reversible stages of the disease. methods and materials: fifty-two brain images of the patients with confi rmed diagnosis of mma including 47 mr and 5 ct images were reviewed. the clinical data were also registered for each patient. the frequency of different radiological fi ndings were compared according to age,gender,clinical presenting symptom and duration of treatment. results: fourteen patients (26.9%) had normal brain images.the most common fi ndings of the images were (in order of frequency): ventricular dilation (32.7%), diffuse cortical atrophy (sulci dilation)(28.8%), periventricular white matter change (23.1%), corpus callosum thinning (15.4%), subcortical white matter lesions (11.5%), local cortical atrophy (7.7%) and cerebellar atrophy (7.7%). basal ganglia calcifi cation was seen in 2 patients both of whom presented clinically in neonacy. treatment duration seems to have an improving effect on the severity of ventricular dilation (less severity in those who have received the classic treatment for more than one year). children who presented with psychomotor delay had usually multiple radiological fi ndings while few fi ndings were seen among those presented with loss of consciousness and those detected by neonatal screening. conclusion: in addition to ventricular and sulci widening, myelination abnormality and basal ganglia changes, some other fi ndings are expected and rise the suspicion to mma including corpus callosum thinning, brain stem thinning, signal change due to focal infarct, bright signal in centrum semioval and putamen calcification. treatment with adequate duration may improve or prevent some structural changes in cns. learning objectives: to describe the principal location of facial fractures in pediatric patients and their radiologic appearance. to discuss the optimal imaging work-up for detection of these fractures in children, with emphasis on the important role of ct. to describe our experience in this fi eld in the last 10 years: epidemiology and main mechanisms of trauma. background: trauma is one of the main causes of morbidity and mortality in the pediatric age group, craniofacial fractures being accountable in a signifi cant part. there is great disparity in the available epidemiologic data and scant radiologic literature on this important subject. interpretation of facial radiographs is specially challenging in children, and ct is required in many cases; therefore, we must be familiarized with the unique characteristics of these fractures. we retrospectively reviewed facial fractures attended in our institution in the last 10 years. the total amounted to 320 diagnosed fractures in 282 patients < 16 years. we analyzed the mechanism of trauma, patient age and sex, fracture location, and radiologic features. we fulfi lled a bibliographic revision and compared our results to those in the literature. imaging findings: the most common were nasal fractures, succeeded by mandibular and orbital fractures. zygomatic, nasoetmoidal, frontal and panfacial fractures were found to be infrequent. the sex ratio was 1.7:1 (male/female). the main causes were accidental falls, followed by aggressions, motor-vehicle crashes, and sports accidents. conclusion: facial fractures in the pediatric age group have special characteristics, and therefore require subject-specifi c knowledge of the diagnosis, management, and follow-up. for the follow-up, 4 groups were defi ned: newborns with (1) lethal postnatal course (2) intensive respiratory care > 6 days and/or pulmonary hypertension (3) intensive respiratory care < 6 days, and (4) no need for additional respiratory support. in fetuses with oligohydramnios, fetal lung volumes were signifi cantly reduced (p < 0.01). the mean defi cit of lung volumes was 31% compared to normals. fetuses with a modal defi cit of 58.7% of lung volume deceased postnatally. reduced signal intensity of lung tissue was associated with lethal outcome in 6 of 8 newborns. differences of lung volumes and signal intensities between the groups 2-4 were less pronounced. fetuses with a high risk of pulmonary hypoplasia (group 2) showed signifi cantly reduced amniotic fl uid volumes, early onset and a long persistence of oligohydramnios. conclusion: fetal mr can reveal the degree of pulmonary hypoplasia in fetuses with oligohydramnios. reduction of fetal lung volumes over 50% of the expected value together with pronounced darkness of lung tissue on t2-weighted mr sequences is highly conspicuous for lethal outcome. magnetic resonance and computed tomography fi ndings in childhood background: tb still ranks as one of the most important communicable diseases and represents a major global health problem. although pulmonary tb tends to be the most common form of tuberculosis, the highest mortality and morbidity occurs with tb of central nervous system (cns tb), which develops in 4% of children with tuberculosis and has an high fatality rate and causes serious sequelae, especially during childhood. imaging findings: available imaging ct and mr studies of 18 patients (11 females, 7 males; mean age: 45.72 months) were retrospectively reviewed. all patients showed a basilar enhancement. other fi ndings were hydrocephalus (61%), intracranial tuberculomas (17%), and other nodular (11%) and ischemic lesions (11%). edema, either perilesional or diffuse, was found in 7/18 patients. severe ventricular dilatation was observed in 9/18 cases. two patients, with fatal involvement, showed severe hydrocephalus associated, respectively, with extended ischemic areas and intraventricular haemorrhage. conclusion: cross-sectional imaging, along with clinical data, may provide useful clues in the early diagnosis of cns-tb, and may helpful in preventing unnecessary morbidity and mortality. head and neck tumors in the pediatric age group -more than lymph nodes to be found g.k. schneider, k. altmeyer, p. fries, a. massmann, t. krenn, n. graf; homburg a.d. saar/de (ragsne@med-rz.uni-sb.de) learning objectives: this exhibit will present the wide spectrum of head and neck masses in children. special consideration will be given to describe the lesions ddx according to their anatomic localization. background: masses of the head and neck area are a commonly encountered problem in daily practice. the aim of this exhibit is to review ddx of head and neck tumors in children with special regard to their anatomic localization. mri and ct images will demonstrate the range of lesions from infl ammation to lymphoma, soft tissue tumors, and vascular abnormalities. imaging findings: the exhibit will review the different anatomic spaces to enable the reader to properly allocate a mass to its compartment. ddx will be explained with regards to their typical localization, imaging fi ndings and their clinical appearance. mri and when it is useful for ddx ct images will be demonstrated in case presentations. a special emphasis will be laid on pitfalls such as vessel abnormalities or pseudotumors. finally, readers will have the opportunity to test their knowledge in some quiz cases. conclusion: ddx of masses in the head and neck region of children goes far beyond simple lymph node enlargement versus lymphoma. depending on its localization, cervical cysts or tumors of neural origin may come into focus. soft tissue or bone tumors, pseudotumors, and abscess formations or vessel abnormalities all may present as circumscribed lesions. mri allows for exact tumor localization, and together with ct and cemra may identify lesions that need to undergo biopsy. fetal mri evaluation of anomalies of the neural tube and spine c. martín, a. lüttich, c. escofet, a. martín, i. delgado, s. perez, c. durán; purpose: to analyze the neural tube and spinal column anomalies detected prenatally at our centre over the last 10 years and evaluate the impact of fetal mri in the diagnosis. methods and materials: thirty fetuses with anomalies of the neural tube and spine were studied. all patients underwent obstetric us examination. intrauterine mri was performed in 22 cases; in the remaining 8, mri was not performed because indications went unobserved at us or further examination was considered unnecessary. mri was performed on a 1.5 tesla unit using ultrafast half-fourier acquisition single-shot turbo spin-echo (haste) sequences. images were analyzed by a pediatric radiologist and the fi ndings were compared to those of us. all anomalies were confi rmed after birth or at autopsy. results: the anomalies observed were acrania (n=3), encephalocele (n=3), iniencephaly (n=1), spina bifi da (n=8), diastomatomyelia (n=1), hemivertebra (n=3), kyphoscoliosis (n=2), amniotic band syndrome (n=1), osseous dysplasia with spinal involvement (n=3), caudal regression syndrome (n=1), sacrococcygeal teratoma (n=3), and conjoined twins (n=1). neural tube and spinal column anomalies were associated to anomalies in other organs in 17 cases. fetal mr provided additional information in 10 (45%) cases, and changed the therapeutic approach in 6 (27%). conclusion: prenatal diagnosis of neural tube and spinal column anomalies can predict fetal viability, orient the prognosis and management of the newborn, and has implications for genetic counseling. mr is a noninvasive method of fetal examination that provides additional information to us. in a factor of 5-10 if appropriate procedure protocol is used, with optimised setting for the x-ray system. purpose: to assess magnetic resonance urography (mru) in the morphologic evaluation of suspected urinary tract obstruction in infants and children. to try to evaluate the correlation between functional fi ndings in mru and nuclear medicine. methods and materials: 15 patients with sonographicallly suspected urinary tract obstruction were studied with mru (1.5 t), intravenous urography and nuclear medicine. procedure details: saline solution (nacl 9%, 10 ml/kg) and low-dose furosemide (1 mg/kg) were administered before beginning unenhanced mru (heavily t2-w sequences). after 15 minutes, 0.1 mmol/kg gd-dtpa was administrated to coincide with the maximal diuretic effect, and dynamic enhanced mru (coronal 3d frge sequences) was performed. the obstruction site and cause were detected in all cases by mr examination. diagnosis of the 30 kidneys includes: normal system (12), duplex system (4), pyeloureteral junction stenosis (9), ureterocele (3), ureteric ectopia (2), multicystic dysplastic kidney (1), megaureter (2), ureteral kinking (2), horseshoe kidney (2). time difference of 180 seconds in the excretion of normal and pathologic kidneys showed good correlation with the diagnosis of obstruction in nuclear medicine. conclusion: mru provides very high quality images. additional benefi ts include renal arteries evaluation and preprocedural planning for surgery. mru is a nonionizing imaging technique that allows both functional and morphologic evaluation in the same procedure and could replace other imaging modalities. the whole spectrum of sonographic patterns of normal and abnormal renal pyramids in infancy and childhood m. vakaki, p. papadoniou, a. simopoulos, k. tavernaraki, g. pitsoulakis, c. koumanidou; athens/gr (geop@hol.gr) learning objectives: to present the wide spectrum of sonographic patterns of renal pyramids in physiologic, as well as pathologic conditions that affect the renal medulla of pediatric patients. to emphasize the role of sonography, correlating the imaging fi ndings with etiology, which should be the basis for the appropriate differential diagnosis. background: it is well-known that the sonographic appearance of the developing 486 b d e f a g kidney differs from that in adults and changes from birth to adolescence. one of the characteristic unique features of the pediatric kidney is the hypoechoic appearance of its prominent medullary pyramids. various conditions modify this normal appearance. furthermore, the disease processes that affect the renal medulla in children differ from those in adults. imaging findings: the various sonographic patterns of normal and abnormal renal pyramids are illustrated. anatomic details, histopathology and suggested pathophysiologic mechanisms of the different causative pathologic entities are presented. these conditions represent a heterogeneous group of disorders and include the normal transient neonatal renal medullary hyperechogenicity, the severe obstructive urinary stasis and intratubular refl ux, polycystic kidney diseases (mainly autosomal recessive polycystic disease), renal candidiasis, sickle cell anemia, the various common and rare causes and types of nephrocalcinosis, etc. conclusion: renal sonography with state-of-the-art us equipment is very sensitive in the imaging study of renal medullary pyramids in childhood. knowledge of the specifi c sonographic features of the different pathologies affecting the renal pyramids supplemented by the necessary clinical information allows the narrowing of the differential diagnosis directing further diagnostic investigation, when necessary. the role of mr imaging in the pre-surgical evaluation of pre-sinusoidal hypertension secondary to portal cavernomatous transformation in children f. guerra-gutiérrez, j. fernández-cuadrado, j. gomez-patiño, a. alonso-torres, m. lópez-santamaría, n. leal; madrid/es (fl aguers@hotmail.com) learning objectives: to demonstrate the utility of magnetic resonance angiography (mra) in the pre-surgical evaluation of pre-sinusoidal hypertension due to portal cavernomatous transformation (phpct) in children. background: children with phpct may be treated by means of programmed surgery, and a pre-surgical imaging evaluation is crucial to defi ne the venous obstructive pattern, and, subsequently, to choose an appropriate surgical strategy. in that purpose, commonly, these children underwent a conventional angiography, which is an invasive technique. imaging findings: twenty-two children with phpct were evaluated. they all underwent a mra previous to programmed surgery in the past 10 years. we describe four major venous patterns: 1) principal portal vein (ppv) obstruction with patent and connected to each other superior mesenteric vein (smv) and splenic vein (sv) (n=14); 2) ppv obstruction with thrombosis of smv and patent sv (n=7); 3) generalized hypoplasia of the splachnic venous system (n=1); 4) any of the previous patterns with normal intrahepatic portal vein (n=5). the surgical procedure was chosen as follows: mesenteric-caval shunt with autologous jugular vein graft (n=11) in the case of the fi rst pattern; distal splenorenal shunt (n=5) and proximal splenorenal shunt, both indicated for the second pattern; mesenteric-left portal vein shunt (rex) for the fi rst pattern in association with the fourth pattern; non-derivative surgery (n=1) in the case of the third pattern. conclusion: mra is a useful tool in the pre-surgical evaluation of children with hpcpt. it gives accurate information that helps the surgeon to choose the most suitable surgical procedure. subcarinal left pulmonary artery sling in fi ve patients: assessing anatomical relationship between air-way and left subcarinal pulmonary artery sling and associated with tracheobronchial anomaly k. choo 1 , y. kim 2 , m. lee 1 ; 1 pusan/kr, 2 pucheon, kyunggi-do/kr purpose: the purpose of our study is to assess anatomical relationship between air-way and subcarinal left pulmonary artery sling and associated with tracheobronchial anomaly. we present chest radiography, ct and echocardiographic fi ndings of subcarinal left pulmonary sling in 5 patients (2 male, 3 female, mean age: 14.8 months). all patients had respiratory symptoms. echocardiography showed intracardiac anomaly such as vsd, asd, pulmonary atresia in 4 patients and abnormal coursing left pulmonary artery in all patients. single, 4-slice and 16 slice mdct were performed and axial images with 3 dimensional reconstructions were used for evaluation of anatomical relationships of tracheobronchial anomaly associated with subcarinal left pulmonary artery sling in all patients. results: one of the 5 patients had severe obstruction of left main bronchus by subcarinal left pulmonary sling, resulting in total atelectasis of lt. lung, with basically normal bronchial branch pattern. four of the 5 patients had about 50% obstruction of left main bronchus by subcarinal left pulmonary sling with associated bridging bronchus. the subcarinal pulmonary sling could cause obstruction of left main bronchus and be often associated with tracheobronchial anomaly, including bridging bronchus. in addition, the ct scan using axial images and 3 dimensional reconstructions could help to assess anatomical relationship between air-way and subcarinal left pulmonary artery sling and associated with tracheobronchial anomaly. (n=15), and cystic lymphangiomas (n=8). the sonographic fi ndings are illustrated and differential diagnosis is discussed. all cases were confi rmed surgically, or with clinical/sonographic follow-up. conclusion: sonography has been shown to be particularly helpful in confi dently evaluating abnormalities of the thoracic and abdominal wall and optimal treatment planning. pediatric radiologists, therefore, should be familiar with the embryology and anatomy, as well as with the sonographic features of various congenital and acquired pathologic disorders involving the thoracic and abdominal wall of children. imaging pediatric pseudo-malignancies: a retrospective review of 29 cases g. castellazzi, d. vanel, d. couanet, c. dufour, r.c. sigal, c. dromain; villejuif/fr purpose: two per cent of the children referred to our cancer center have pseudomalignancy. the aim of this study was to analyze and correlate their clinical and radiological fi ndings. methods and materials: from 1990 to 2006, 98 patients with "pseudo" cancers, referred by well-trained clinicians, were seen. twenty-nine had complete imaging and clinical history records and the fi nal diagnosis of proven non-malignant disease. there were 19 males and 10 females, between 1 and 17 years of age. the fi nal diagnoses were made through pathology (17), follow-up (12), and serologic analysis (1). results: frequent symptoms, variously combined and most frequently associated at the beginning, were: pain (17), fever (5), a mass (5), adenopathies (5), and walking diffi culties (3). one patient had two pseudo-malignancies. thus, 30 lesions were studied with the following diagnoses: malignant bone tumor (9), lymphoma (5), nephroblastoma (3), neuroblastoma (3), soft tissue tumor (4), nervous tissue tumor (4), small bowell neuroendocrine (1), and undifferentiated nasopharyngeal carcinoma (1). 138 various radiological examinations were performed. there were in fact 15 infections, 7 traumatic lesions, 3 chronic diseases, 3 congenital lesions, and in 2 cases no disease corresponding to the clinically suspicious symptoms was found. conclusion: pseudo-malignancies are rare and diffi cult to diagnose, even by welltrained teams. the aim of the poster is to propose a review of images of pediatric pseudo-malignancies referred to an oncologic hospital, to make the reader more familiar with those possible problems, allow an easier and faster diagnosis, and avoid unnecessary and sometimes dangerous treatments. learning objectives: to provide a free program for handheld devices as a reference database in pediatric plain film radiography which serves the well and less experienced pediatric radiologist to differentiate between physiological age-specifi c and pathological fi ndings. background: it is especially diffi cult for the inexperienced radiologist or the resident on-call to differentiate between physiological age-specifi c and pathological fi ndings due to developmental variations in the growing child. the suitable book is often unavailable. to solve this problem, an easy accessible format like handhelds would help in this situation. procedure details: over 450 images in pediatric skeletal radiography can be displayed in radiographic standard settings on a handheld device. all images are categorized by body regions, age and gender. the database can be queried through selection of all three criteria or by choosing each criterion separately. the latter offers itself mostly for determination of bone age using the left hand. each mode provides the user with at least one reference image according to each body region, age and gender. conclusion: this program is a free reference database for almost all standard images in plain fi lm radiography, from infancy to adulthood. the database serves the radiologist on-call and the less experienced pediatric radiologist to differentiate between physiological age-specifi c and pathological fi ndings. learning objectives: to illustrate the spectrum of ultrasound image fi ndings after wrist and distal forearm trauma in children with no fractures detected on plain fi lms. background: wrist and forearm injuries are common in adolescent and become more and more common in younger group of children, mostly due to decreasing age of starting the recreational or professional sport activity. the interpretation of clinical examination in a child is often more challenging than in adults; thus, in the presence of different clinical symptoms (wrist pain, oedema, limited movement) together with normal radiographic examination, the question arises about the nature of the wrist/distal forearm tissue injury. procedure details: in 64 children who attended our paediatric admission unit because of wrist/distal forearm trauma and in whom the standard plain fi lms did not reveal any fracture, a wrist ultrasound examination, according to actual essr guidelines, was performed. we focused on tendons evaluation (continuity, tears), joint effusion or occult fractures depiction and precise assessment of the extent of soft tissue oedema. we tried to discuss the correlation between the most common ultrasound fi ndings and the patient age, as well as the injury mechanism and clinical symptoms. conclusion: wrist ultrasound is a valuable imaging method in children after wrist/distal forearm trauma. it is particularly helpful in cases of an equivocal clinical examination and in the presence of normal radiographic results helps to assess the character of the tissue injury. learning objectives: the purpose of this educational exhibit is to emphasise the role of diagnostic and/or therapeutic ultrasonography (us) in diverse congenital and acquired musculoskeletal diseases in children and adolescents. background: us is a powerful diagnostic tool for the evaluation of musculoskeletal disorders owing to low cost, availability, non-invasiveness, multiplanar capability and real-time studies, which allow dynamic imaging. the absence of ionizing radiation is particularly valuable in children, but experience and proper training is required in the pediatric musculoskeletal pathologies. procedure details: a total of 120 patients who underwent sonographic evaluation in our tertiary center during the last 5 years were retrospectively evaluated. us examination was carried out with a sequoia 512 or an aspen (siemens-acuson), using high resolution technique, dynamic manouvres, contralateral comparison, color and power doppler, extended fov function and interventional procedures. other imaging techniques such as mri, ct or bone scintigraphy were also performed when diagnosis was unconclusive. congenital (dhd), traumatic, infl ammatory, infectious-toxic (transitory sinovitis, arthritis, pyomyositis, infectious bursitis, cat-scratch disease, subperiosteal abscess, infectious lymphadenitis, osteomyelitis), neoplastic (benign and malignant tumors of bones or soft tissues), foreign bodies, and vascular malformations will be presented with a selection of the most representative cases. conclusion: us is a rapid, nonionising and very sensitive technique for imaging musculoskeletal disorders in children and adolescents. it also offers the possibility of performing aspiration or biopsy procedures with diagnostic and therapeutic relevance. fine-streak artifact quantifi cation and removal in reconstructed ct images o.s. pianykh, p.m. boiselle, d. litmanovich, v. raptopoulos; boston, ma/us (opiany@gmail.com) purpose: streak artifacts in ct images can originate from a broad range of factors, and often may be controlled with improved scanning protocol parameters and patient positioning. therefore, a reliable method is needed to quantify the streak presence in the images, guiding the improvements in the scanning protocols and settings. streak-quantifi cation methods can also lead to better streak-removal algorithms. methods and materials: fine streaks, typically originating from the noise and photon starvation, can still be detected numerically in reconstructed ct images. our approach is primarily based on exploring streak-shape linearity, leading to the following image processing steps: ;inear image fi ltering to enhance streak-affected pixels; streak-searching methods, locating straight lines of pixels either raised or lowered compared to the surrounding pixel background; weighting detected streak lines proportionally to their length and severity; building streak "signature" of the image, showing streak presence by streak severity. results: our method provided high accuracy in locating and measuring streak artifacts. this quantifi cation method naturally extended to a streak-removal algorithm, which would "raise" or "lower" image streak pixels to eliminate the streaks. the proposed streak quantifi cation and removal algorithm can be successfully used to: (1) quantify fi ne streaks in reconstructed ct data. the quantity of image "streakeness" can then be used to improve image scanning parameters and to achieve higher image quality; (2) remove streak artifacts from the reconstructed ct images without any need for the raw data (generally unavailable). performance characterisitics of dyna-ct acquired by the threedimensional angiography system with fl at panel detector e. minota; kobe/jp (minota@fbri.org) purpose: the three-dimensional angiograph equipped with fl at panel detector (fpd) acquires a complete volume set during a single rotation, which can be used to reconstruct tomographic images similar to ordinary ct. we evaluated the performance characteristics of images acquired thus, including image noise, spatial resolution in the axial plane, section sensitivity profi le in z-plane (sspz), contrast noise ratio (cnr), distortion of an acrylic ball, and clinical images. we used a biplane c-arm angiograph with 30×40 cm amorphous silicon fpd (axiom artis dba, siemens medical solutions, germany). the sspz and axial spatial resolution were measured with miniature iron balls of 0.18-1.0 mm. the cnr was measured with a phantom containing agar cylinders of various diameter and contrast media density. the distortion was evaluated for an acrylic ball of 1 cm diameter at various distances from the center. data acquisition times were 5 sec (133 projections), 10 sec (248 projections), and 20 sec (495 projections). results: the image quality degraded as the object was away from the center or when the data acquisition time was short, probably due to the nature of cone-beam 3d reconstruction and the reduced number of views. correction fi lters improved the image artifacts. the distortion was considered clinically acceptable. although the image quality was lower than the ordinary ct, especially for low-contrast objects, it was considered clinically useful if appropriate data acquisition protocol and fi lters were used. this system is very valuable not only for brain angiography, but also for orthopedics and other fi elds where tomographic images are helpful. variation of the optimal reconstruction phase for cardiac ct imaging: analysis by a rawdata-based kymogram approach d. ertel, t. pfl ederer, s. achenbach, m. kachelrieß, w.a. kalender; erlangen/ de (dirk.ertel@imp.uni-erlangen.de) purpose: to analyze the dependence of the optimal reconstruction phase for cardiac ct imaging on the patient's heart rate by using a rawdata-based approach and to prove a patient-specifi c dependence. the rawdata-based synchronization signal (kymogram) is generated by a center-of-mass tracking [med.phys., 29 (7)] and provides directly a motion function of the heart. we identify the phase in the cardiac cycle with the lowest variation of the center-of-mass as representing the phase with the lowest velocity of the heart, assuming to be the optimal reconstruction phase for providing motion-free images. rawdata of 50 patients were used, scanned with a standard cardiac protocol, 64 slices of 0.6 mm, 0.33 s rotation time and concurrent ecg recording (sensation 64, siemens, forchheim). we correlated the identifi ed optimal reconstruction phase derived from our approach with the patient's heart rate to analyze the dependence of the optimal reconstruction phase on the heart rate. the probability to obtain the best achievable image quality in the systolic phase instead of the diastolic phase increased from 0% to 30% with increasing heart rate. however, individual analysis showed that the optimal reconstruction phase is more patient-specifi c than dependent on the heart rate. also, the optimal reconstruction phase in the diastolic phase shows a high variation of 20% over all patients. conclusion: a high patient-specifi c dependence of the optimal reconstruction phase for cardiac imaging was shown. only a slight correlation with the heart rate was observed. algorithms detecting the optimal reconstruction phase seem to be promising and essential. ct scan protocol optimization by the study of focal spot size infl uence on image quality w. qi, x. du, j. li, s. zhang; beijing/ cn (jianying.li@med.ge.com) purpose: to optimize ct scan protocols in various applications by analyzing the infl uence of focal spot size on image quality. methods and materials: a catphan500 ct phantom was scanned with large and small focal spots with the same dose by adjusting scan time. images were reconstructed using both standard and bone-plus kernels. modulation transfer function (mtf) and slice sensitivity profi le (ssp) were used to evaluate in-plane and z-axis resolutions, respectively. two radiologists evaluated and scored inner-ear images of 15 volunteers with large and small spots without knowing the scan techniques. the mtf values and fwhm values of ssp with small spots were always 5-10% better than those of large spots. with standard algorithm, the 10% mtf values were 6.94 lp/cm and 7.45 lp/cm for the large and small focal spots, respectively. for patient inner-ear images reconstructed with bone-plus kernel and 10 cm dfov, small spots outperformed large spots by 29 to 1. however, the visual advantage of using small spots decreased when the images were reconstructed by standard kernel and 25 cm dfov. the use of small spots improved both in-plane and z-axis spatial resolutions by 5-10% compared to large spots. the improved resolution translated into clinical diagnostic advantage for small dfov, high-resolution applications. however, this advantage decreased when large dfov and standard reconstruction algorithm were used, which suggested that one could have balanced usage of focal spots in these applications. image reconstruction using a combined algorithm for a translating and rotating volume ct ( purpose: we describe a new system, trvct (translating and rotating volume computed tomography), developed for a computed tomography image of a large object. it is a simple method and offers a low price. the key point of this new method is that it handles the movement of an object that is translating and rotating simultaneously. methods and materials: using a vertical linear array detector, one tomogram image can be acquired when the object is translating and rotating simultaneously. this method is completely different from that of a normal x-ray ct. we used a fan-beam x-ray. the direction axis for the detector and rotating axis are parallel. because a hundred or thousand tomograms with z-axis are from just one scanning, this system has excellent z-axis resolution and has the advantage that this technique can improve the resolution in the x-y plane with changing translating speed and frequency of data acquisition. the image reconstruction algorithm is composed of a modifi ed con-beam ct algorithm and parallel beam ct algorithm. radiation dose and risk from fl uoroscopically guided percutaneous transluminal angioplasty and stenting in the abdominal region j. stratakis, j. damilakis, d.k. tsetis, n. gourtsoyiannis; iraklion/gr (jstratak@med.uoc.gr) purpose: to estimate radiation dose and associated risks resulting from fl uoroscopically guided percutaneous transluminal angioplasty and stenting in the abdominal region. methods and materials: examination parameters for renal and aortoiliac procedures were derived using data from 80 consecutive procedures performed in our institute. organ and effective doses were estimated for endovascular procedures using the monte carlo (mc) transport code and an adult mathematical phantom. thermoluminescent dosimeters were used in an anthropomorphic phantom to verify the mc calculations. radiation-induced cancer and genetic risks were estimated using appropriate coeffi cients. results: results are presented as doses normalized to dose area product, so that the patient dose from any technique and x-ray unit can be easily calculated for iliac and renal pta/stenting sessions. the average effective dose varied from 15 to 24.5 msv depending on procedure scheme and the sex of the patient. differences of up to 17% were observed between mc-calculated data and data derived from thermoluminescent dosimetry. conclusion: male patients up to 59 years old are subjected to a signifi cantly fatal cancer risk. radiation-induced cancer risk may be considerable for younger individuals undergoing transluminal angioplasty with stent placement. application of a radiation therapy planning system for measurement of organ-absorbed doses inside the body during whole-body ct acquisition using homogeneous and heterogeneous phantoms and 30 clinical cases n. funabashi, t. fujibuchi, n. tanabe, m. uehara, i. komuro; chiba/jp (toshifujio@ybb.ne.jp) purpose: absorbed radiation doses on the body surface and inside phantoms can be measured using dosimeters during ct examinations, but measurements inside the body are diffi cult. therefore, simulation-based methods are often applied to estimate the latter, but this is rather time-consuming. we investigated a new method that uses a radiation therapy planning system (rtps). we used tough water and rando phantoms as homogeneous and heterogeneous phantoms, respectively, and measured absorbed radiation doses by ionization chamber and photoluminescence dosimeter (pld) compared to rtps estimates. furthermore, in 30 clinical cases acquired by multislice 120 kv ct (aquilion, toshiba), calculated the absorbed dose using an arc beam calculation system. results: in a homogeneous phantom, the difference between values measured by ionization chamber and those estimated by rtp were 0.13±7.66% at y axis, -1.09±17.64% at z axis, and 1.00±3.76% in the total irradiation fi eld. in a heterogeneous phantom, the difference between pld and rtp values was 4.97±20.48% for the body and -7.05±17.92% for the lung. conclusion: the rtp system may be a simple and useful tool for estimation of absorbed radiation doses inside the human body even during whole-body ct acquisition. (13) and vascular surgery (4) centres participated in this multi-centre study. individual extremity doses were monitored per procedure with highly sensitive detectors at fi ve positions: the forehead, both hands and both legs. doses to up to three staff members (physician, assistant, nurse) were simultaneously measured during a procedure and relevant exposure data (position, patient-dap-dose, protection) were registered. results: data was collected from a total of 280 procedures. the median dose per procedure to the physician's eyes (62 µsv) was signifi cantly lower than the doses to the legs (181 µsv) and hands (193 µsv) as most centres used an under table x-ray tube exposure geometry. a moderate to strong correlation between patient-dap-dose and dose to the physician was observed. at vascular surgery centres, dap-normalised staff doses were about three times higher than in angiography centres. in centres with a low workload, elevated normalised doses were observed. extrapolated data showed that two physicians may likely exceed both annual dose limits of the eyes (150 msv) and the skin of the legs (500 msv). about one third of the physicians removed themselves consistently from the patient during image acquisition. this proved to be a very dose effi cient working procedure. procedure details: first, ct numbers from ct images were converted into mass density and elemental weights of tissues required as input for dose calculations with geant4, which is a toolkit for the simulation of the passage of particles through matter. they were set by x-y coordinate, slice location, and slice thickness. they were exposed to x-ray from the x-ray tube simulator developed by us in geant4. the simulator exposes x-ray of any energy spectrum (tube volt: 60 kv-150 kv), any expose fi eld, etc. the absorbed doses at skin and at other organs were calculated. the fusion images of ct dose can be displayed by the viewer developed by us. the patient's absorbed dose at skin can be found correctly using monte carlo algorism without tlds. doses at skin and at other organs can both be estimated by the software developed by us. patients and medical staff can calculate the patient's exposure dose distribution by 2d fusion images of ct dose. 3d fusion images help them for the explanation of side effects from exposure and for obtaining informed consent from patients. a low-density board placed on the couch reduces a patient's skin doses in interventional procedures a. kawabe, y. nakagiri, y. takeda; okayama-city/jp (akawabe@md.okayama-u.ac.jp) purpose: in interventional procedures, scattered radiation generated on the interventional couch increases a patient's skin doses. here, we assumed that this low-energy scattered radiation is removed by air gaps between the couch and patient. however, it is physically impossible to produce air gaps between the couch and patient. to solve this problem, we have devised a new process. this process involves the use of a low-density polystyrene board, which acts as an air-gap substitute. the purpose of this study was to investigate the air-gap-reproducing effect of the low-density polystyrene board. the entrance skin dose (esd) was measured without interspaces between the couch and phantom (25 cm acrylic block), which was defi ned as a reference esd. low-density polystyrene boards (1 to 10 cm) were inserted between the couch and phantom, and esds were measured, respectively. these esds were compared with the reference esd. the low-density polystyrene boards with a 6 cm thickness, inserted between the couch and phantom, led to an esd reduction of about 10%. conclusion: the low-density polystyrene board simulated air gaps. in interventional procedures, these boards can be implemented easily and inexpensively in a clinical setting, resulting in reductions in a patient's skin exposure by as much as 10%, without affecting image quality. measurement of occupational exposure in a mobile pet unit m. de marco, s. maggi; ancona/it (black_dragon@libero.it) purpose: the routine handling of unsealed 18 f-fdg in a mobile pet unit, that is usually not provided with a hot cell, may result in the production of airborne radioactivity. the aim of our study was to quantify the occupational radiation exposure for a technologist working in a mobile pet unit, evaluating both internal contamination and external irradiation. methods and materials: internal exposure: each technologist was issued with a personal air sampler that collects the air that the worker is really breathing. external exposure: personal dose equivalent hp (10) has been quantifi ed using electronic dosimeters. occupational radiation exposures have been evaluated twice a week for six months based upon an operating pet effi ciency of 9 procedures/day. learning objectives: to describe the acceptance of radiation proctection courses for health care professionals in germany by an anonymous survey. background: maintaining safe utilization of ionizing radiation and radiation protection of staff, public and environment requires high levels of competencies. in 2002, the german radiation protection and x-ray ordinance put health care professionals employing ionizing radiation under an obligation to recertify theoretical and practical knowledge. personnel, i.e. physicians, physicists, radiographers, nurse-practioners and specialist staff, have to enrol for an offi cially approved radiation protection course every 5 years. 8 or 12 hour classes with a multiple choice tests are held by lecturers, radiation protection offi cers and experts in the fi eld. however, a preconceived opinion across all levels of professionalism declares radiation protection education and training redundant and costly. procedure details: course participants were asked to fi ll in an anonymous questionnaire [n=599, radiographers (45%), physicians 44%, including 25% consultants and 10% medical directors]. the survey itemized age, vocational training, professional group, fi eld of practice, course content, stimulus, practicality and course costs. 80% estimated the theory-practice-performance ratio as balanced. stimulus (great many 20%, many 57%, some 20%). the courses came to participants' expectations (fully 62%, for the most part 33%, partly 4%. full coverage of the expenses (120-150 euros) by the employer was reported by 65% of the participants. conclusion: although radiation protection is widely considered as a stepchild in health care delivery, professionals are aware of adequate education needs and training. c 493 b d e f a g principles of k-space sampling p. paolantonio 1 , r. ferrari 1 , f. iafrate 1 , m. rengo 2 , c. de cecco 1 , a. laghi 1 ; 1 latina/it, 2 rome/it (paolantoniopasquale@hotmail.com) learning objectives: to describe principles of k-space sampling. to offer an easy explanation of k-space physics for radiologist. to describe properties of k-space and to illustrate different k-space sampling strategies. to show how different portions of k-space contribute to the fi nal image appearance. to illustrate the rationale for centric, elliptic, spiral and partial k-space sampling strategies. background: k-space sampling represents a crucial step in mr image acquisition. the easy way to sample k-space is represented by a sequential mode that is also a time consuming procedure. k-space sampling strategy may be modifi ed in order to reduce acquisition time. a central or elliptic sampling of k-space is recommended for contrast-enhanced-mr-angiography in order to collect central line of k-space during the peak of vessel enhancement. procedure details: we show in a step by step form the image generation process focusing our attention on k-space sampling. we will describe how k-space is sampled in several pulse sequences commercially available. using graphic examples, we will describe different k-space sampling strategies. the knowledge of k-space sampling strategies is crucial for understanding mr image acquisition process. several k-space sampling strategies are available. using the appropriate k-space sampling strategy is useful in reducing acquisition times and in order to optimise image acquisition for the clinical purpose of mr-studies like happens in centric or elliptic sampling of k-space and contrastenhanced mr-angiography. background: an increased risk for mri-associated skin burns has been described for pictorial tattoos using iron coloured pigments. not until recently, permanent make-up, a new and rapidly spreading cosmetic technique, has been recognized for putting the patients at risk of burns by mr imaging. procedure details: neither iron pigments nor larger tattoo areas are required to induce burns in these patients. to gain a special colour effect cosmetic tattoos contain metals such as iron, copper and zinc. locally, electric current can be induced by any of these metals in a high-frequency magnetic fi eld, even if only subtle eye lining has been performed. this mechanism of locally induced electric current is responsible for possible dysesthesia and burns in patient's skin containing a cosmetic tattoo, e.g. permanent make-up during mri examination. a clinical example, review of the literature and recommendations for addressing this problem in the daily mr practice will be given. conclusion: permanent make-up, for medical purposes better adressed as cosmetic tattoo, can cause severe local damage to the skin during mri studies even if it is free of iron oxides. every mr radiologist should be aware of these risks and direct patient's management and staff training accordingly. combining a body coil for radio frequency transmission and an endorectal coil to receive signal. three-dimensional mri and mrsi data were collected with magnetic fi eld homogeneity in the selected volume obtained by shimming water with lipid suppression accomplished with selective inversion of lipid resonances. peripheral voxels were saturated to suppress periprostatic fat and air. we will review how data is then processed and how to interpret a prostate spectrum. conclusion: in summary, this poster serves to demonstrate the technical aspects of 3d mrsi including practical aspects of implementation and technical considerations. hopefully, radiologists will understand the basic principles of prostate mrs imaging, and by realising the feasibility and clinical possibility of providing mrsi will be encouraged to initiate prostate spectroscopy. conclusion: understanding the magnetic resonance imaging susceptibility effects and their infl uence on imaging appearance allows the clinical radiologist to make a wise selection among the broad range of imaging sequences available to minimize artefacts, enhance pathology detection as well as limit the differential diagnosis. liver imaging at 3.0 t: potential of diffusion-weighted black-blood echoplanar-imaging sequences for large-coverage volumetric imaging i.c. van purpose: to evaluate breath-hold diffusion-weighted black-blood echo-planarimaging (bbepi) as potential alternative for sar-intensive spin-echo sequences for liver imaging at 3.0 t. methods and materials: after institutional review board approval and informed consent were obtained, 14 healthy volunteers were scanned at 3.0 t, using an asset compatible 8-channel cardiac coil. parameters were set to cover the entire liver (25 cm z-axis) in one 25-sec breath-hold, and were varied interactively with regard to te, tr, diffusion b-value, slice thickness and voxel size. images were evaluated and compared to fat-suppressed t2w fast-spin-echo (fs-t2w-fse) for image quality, liver delineation, blurring, geometric distortions, fat-suppression, suppression of the blood signal, cnr and snr. results: the optimized short-(25 ms) and long-echo (80 ms) bbepi provided 2 mm and 4 mm slice thickness with full anatomic, single breath-hold liver coverage (100 and 50 slices, respectively), resulting in voxel size 3.1x2.6x2.0 mm 3 and 3.1x2.6x4.0 mm 3 . tr was 6600 ms. b-values > 20 s/mm 2 showed better suppressed blood signal, but b=10 s/mm 2 provided improved volume coverage and signal consistency. compared to fs-t2w-fse, bbepi provided: (1) comparable image quality, liver delineation and blurring; (2) acceptable geometric distortions; (3) improved suppression of fat-and blood-signal (p < 0.05); and (4) higher cnr and snr (p < 0.05). conclusion: our study shows that bbepi can be used for ultrafast, low sar, thin-slice morphologic imaging of the entire liver in a single breath-hold at 3.0 t, providing near-isotropic data with multiplanar reformatting capability. flair absolute purpose: to estimate absolute concentrations from mr spectroscopic measurements reference concentrations are required. commonly, either tissue water concentration or separate phantom solutions with known concentration are used. the purpose of the study was to acquire brain spectra in volunteers and to compare the variability of both methods. overall twelve volunteers were investigated by 1 h-2d-csi (steam; te=20 ms, tr=5000 ms) on a 1.5 t whole-body scanner (magnetom sonata, siemens) using the standard head coil. for three volunteers measurements were performed twice with identical sequence parameters except for the water suppression pulse which was switched on only during the fi rst measurement. spectra were evaluated by the lcmodel. results: comparison of absolute concentrations of the metabolites naa, cho and cr obtained with both methods showed stronger differences for voxels located in border areas of the selected volume. the differences between concentrations estimated by using naa and water as a reference were clearly more pronounced in the parietal region (naa: 5.4 vs. 7.0 mmol/l; cr: 3.2 vs. 5.4 mmol/l; cho1: 0.7 vs. 1.4 mmol/l) compared to the frontal region (naa: 6.4 vs. 7.2 mmol/l; cr: 3.9 vs. 4.6 mmol/l; cho: 1.1 vs. 1.2 mmol/l). this refl ects the spatial variations of the coil sensitivity. conclusion: as technical parameters like coil-sensitivity and load-factor affect measurements with and without water suppression in the same way, corresponding errors in the estimated absolute intensities can be avoided. therefore, if time allows an internal reference should be preferred compared to estimation by a reference solution without correction of the sensitivity profi le of the coil. assessment of a fast, 3d mri pulse sequence for use in polymer gel dosimetry i. seimenis 1 , p. baras 2 , p. papagiannis 2 , p. karaiskos 2 , a. angelopoulos 2 , p. sandilos 2 , l. vlachos 2 , b. pantelis 2 ; 1 nicosia/cy, 2 athens/gr (yseimen@phys.uoa.gr) purpose: the use of mri as a readout method for polymer gel dosimetry commonly involves long imaging sessions and, therefore, the technique has not been yet established in the clinical setting. this work evaluates the effi ciency and accuracy of a fast, 3d, dual-echo, k-space segmented turbo spin echo (tse) imaging pulse sequence. methods and materials: pabig polymer gel dosimeters were irradiated with an 192 ir high dose rate brachytherapy source, the 4 mm and 8 mm collimator helmets of a gamma knife unit and a custom made x-knife collimator of 1 cm diameter. profi le and dose distribution measurements derived from tse data were benchmarked against corresponding fi ndings obtained with the commonly used and optimised carr-purcell-meiboom-gill (cpmg) multi-echo cpmg sequence, as well as treatment planning calculations, monte carlo simulations, and fi lm and pinpoint ion ionization chamber measurements. results: the tse sequence was found to provide dosimetric results of comparable accuracy with those obtained from cpmg multi-echo acquisitions (within one pixel in the mri gel readout session, i.e. < 1 mm), and to accurately predict treatments planning calculations and conventional dosimeter measurements in a range of radiotherapy applications that involve very steep dose gradients and stringent dose delivery requirements and which require high spatial resolution in all three dimensions. conclusion: the signifi cant scan time reduction (64-fold) achieved with the proposed imaging sequence implies that the polymer gel-mri readout method could prove to be a useful and practical tool in modern clinical radiation therapy applications involving high doses and steep dose gradients. scientific and educational exhibits procedure details: we analysed with high resolution skin disorders in all cases. dermis and subcutaneous fat, and epidermis in such cases, changes were studied. mri gave useful informations about thickness, localization, signal changes, extension and relationship with surrounding structures of the lesions. in such cases, as phototherapy of sclerodermia, mri allowed evaluation of the effects of therapy. we obtained substantial informations for differential diagnosis in infl ammatory skin disorders. conclusion: mr imaging provides global analysis with high resolution of the various skin layers down to the hypodermis and the muscular facia. characterization of lesions and evolution with treatment are permitted. skin tumoral lesions are well analysed, mri is useful to reduce the number of skin biopsies on certain indications. "glare" lcd panel improves resolution performance of softcopy display for digital mammography t. yoneda, n. hashimoto; hakusan, ishikawa/jp (yoneda@nanao.co.jp) learning objectives: to improve understanding of the following points about monochrome lcd monitors which have been getting more popular for digital mammography: 1. surface coating of lcd panel can affect resolution performance of softcopy display. 2. "glare" panel has better resolution performance than "anti-glare" panel which is currently used for the majority of medical lcd monitors. background: as digital mammography has been getting more popular, monochrome lcd monitors have also been spreading among radiologists. however, higher resolution and contrast performances are required in order to achieve the accurate diagnosis of mammograms, for example detecting microcalcifi cations. we have developed new 5m-pixel monochrome lcd monitor with "glare" panel which improves resolution performance. imaging findings: established "anti-glare" panel has waffl ed surface to diffuse the refl ection of ambient light. but it also diffuses the light from the monitor's backlight. as a result, the displayed image is blurred especially on outlines compared to the original image. on the other hand, "glare" panel has fl at surface so that there is no blur with the displayed image. it means that there is no degradation of resolution performance with surface coating. conclusion: resolution performances of both panels were compared by measuring mtf (modulation transfer function). "glare" panel showed higher mtf than "anti-glare" panel, which proves the higher resolution performance of "glare" panel. of course, the ambient light in reading room has to be controlled to decrease the specular refl ection, but this higher resolution performance can contribute to the accurate diagnosis of mammograms. purpose: dna double-strand breaks (dsbs) are among the most signifi cant genetic lesions introduced by ionising radiation. during angiography, patients are exposed to x-rays for a long time with changing tube position, pulsing rate and fi eld of view. the biological effect of ionising radiation was examined in patients undergoing angiography using a method which was previously applied only in vitro and in computed tomography. methods and materials: individual dsbs were visualised by using immuno fl uorescence microscopy. the method is based on the phosphorylation of the histone h2 ax after formation of dsbs. blood was taken from twelve patients undergoing different angiographic procedures before, during and after the examination. additional in vitro irradiation of blood samples was performed (50 mgy) to evaluate the individual repair capacity. the dose area product (dap) ranged from 769 to 17587 microgy*m 2 , fl uoroscopy time ranged from 1:20 to 35:09 minutes. in all patients, the irradiation increased the number of dsbs. maximum of dsbs was found 15 minutes after the end of fl uoroscopy and ranged from 0.03 to 1.36 foci/cell. the number of dsbs showed a linear correlation to dap and fl uoroscopy time (r 2 =0.87 and r 2 =0.96, respectively). most of dsbs were repaired within 5 hours in vitro and in vivo. conclusion: gamma-h2 ax immuno fl uorescence microscopy is a reliable method to measure the induction and repair of dna damages caused by ionising radiation during angiography even if very small doses were applied. needle-based versus conventional storage-phosphor radiography in paediatric radiology j.m. fernandez, e. vano, c. prieto, j.m. ordiales; madrid/es (eliseov@med.ucm.es) purpose: to compare exposure requirements for similar image quality with needle-based and conventional computed radiography (cr) systems in paediatric radiography. methods and materials: image quality has been evaluated for both cr systems with a contrast-detail test object covered with varying thicknesses of acrylic to simulate clinical conditions. four series of images were obtained with two thick-496 b d e f a g nesses: 10 and 20 cm, and increasing tube voltages (60, 81, 102 and 125 kvp). images were acquired at 7 exposure levels. an image evaluation software was used to determine the threshold contrast of 15 circular holes with diameters ranging from 0.3 to 8.0 mm. statistical signifi cance of differences between the two digital systems was assessed. phantom and detector surface air kerma were measured, and correlated with cr exposure levels. results: a linear relationship was found between the number of detected holes and the logarithm of exposure. on average, the structured phosphor system required 55% less phantom entrance air kerma than the conventional phosphor plate. differences in exposure requirements were smaller with decreasing thicknesses of simulated tissue thickness and lower tube voltages (74% at 20 cm and 102 kvp, and 36% at 10 cm and 60 kvp). all differences were statistically signifi cant. conclusion: structured cr provides improved low contrast detectability and a potential for dose reduction compared with conventional cr. the best performance was achieved with conditions comparable to those for adult radiography (102 kvp and 20 cm of pmma). learning objectives: to provide insight into current practices of clinical applications of multi-slice computed tomography (msct) using the new generation of ct systems able to acquire simultaneously at least 16 sections, and to identify specifi c applications that justify the radiation exposure. background: rapid technical developments in ct have had a substantial impact on the applications of this technology. since ct is already associated with a relatively high (collective) patient dose, a review of current practices was performed. procedure details: administrative patient data on diagnostic applications corresponding to one contiguous year, and ct reports corresponding to 10% of the annual data have been retrieved from the information systems and referral forms of six radiology departments in different european countries. data pre-processing included coding the medical specialties, the age groups, anatomic regions, and most important coding of the diagnoses from medical details mentioned in the reports. the resulting database includes 70041 ct examinations, of which 54127 were referred by medical specialties concerning 33149 patients. to learn from these data, descriptive analyses have been performed. conclusion: ct examinations are predominantly performed on patients in the mid-and higher age categories. the highest referrals are by oncology; followed by surgery, internal medicine, neurology and neurosurgery. a substantial number of patients received more than 6 ct examinations in 1-year, mostly for oncology. most frequent diagnostic categories are neoplasms; followed by diseases of the musculoskeletal system, vascular system, respiratory system, digestive system, urinary tract, and nervous system. mtf and nps measurements including x-ray scatter -application in a digital mammography system h. perez-ponce 1 , p. monnin 2 , f.r. verdun 2 , a. noel 1 ; 1 vandoeuvre-lès-nancy/fr, 2 lausanne/ch (hpponce@softhome.net) purpose: detector characterization with modulation transfer function (mtf), noise power spectrum (nps) and detective quantum effi ciency (dqe) inadequately predicts image quality when the imaging system includes patient scatter. this contribution investigates the effect of x-ray scatter on the mtf and nps in mammography for characterizing the system in clinical situations. a full-fi eld digital mammography unit was characterized at 28 kv mo/mo at two beam qualities with and without x-ray scatter. pre-sampling mtf and nps without scatter were measured according to the iec 62220-2 standard. the same imaging parameters were measured again with a mammography test object that simulates x-ray scatter due to the breast. results: x-ray scatter causes a falloff of mtf [6% at very low spatial frequency (0.1 mm-1) and 9.5% for the rest of the spectra] and adds a constant amount of noise (3% from 0.5 to 2 pl/mm, 6% from 2.5 to 4 pl/mm and 8% from 4.5 pl/mm to the nyquist frequency). this increase in image noise is related to the amount of scatter integrated by the detector. the reduction of mtf and the increment of noise implies the drop of the dqe at all frequencies. the properties of an image receptor are properly characterized with a scatter-free beam. in clinical situations, detectors are used with x-ray scatter from the patient. the use of a test object including scatter to measure mtf and nps describes the resolution and noise properties of the imaging system with regard to scatter from the patient. the impact of nikola tesla on x-rays discovery m. hrabak, r. stern padovan, m. prutki, k. potocki; zagreb/hr (maja.hrabak@zg.t-com.hr) learning objectives: to present the role of nikola tesla's (1856 tesla's ( -1943 research in x-rays discovery and invention of modern imaging technologies. background: discoveries of nikola tesla represent basics of traditional, but also modern imaging techniques. tesla's work is present in every radiological department, including fl uorescent lights in viewboxes, alternating current (ac) supplying the equipment, tesla-knott generator used for x-ray equipment, etc. one of tesla's never completed work was experiments with what would later be called x-rays. procedure details: tesla's articles published on the topic of x-rays and their biological hazards in the new york electrical review in the years 1896 and 1897, tesla's biography, as well as medical papers mentioning nikola tesla were analyzed. conclusion: since april 1887, tesla began investigations using crookes tubes, and his own vacuum tube which was a special single-electrode x-ray tube without target electrode. it seems that by 1892, he became aware of what roentgen identifi ed as x-rays effects three years later. he didn't publicly declare his fi ndings nor make them widely known, and much of his research was lost in a fi re in his laboratory in new york in 1895. he was also among the fi rst to comment on the biological hazards of working with x-rays with the conclusion that distance was a useful safety factor. count-rate analysis in pet with lso detectors f. bonutti, r. padovani, o. geatti; udine/it (bonutti.faustino@aoud.sanita.fvg.it) purpose: the optimisation of the acquisition parameters in pet has the purpose to improve the quality of the diagnostic images. optimisation can be done by maximizing the necr that in turn depends on the coincidences rate. methods and materials: for each bed, the scanner (biograph duo, siemens) records the coincidences and the singles rates in a log-fi le. for each patient, we fi gure out the functions trues=t (s), randoms=r (s), scatters=s (s) (where s = single count rates) by fi tting the nema 70 cm phantom count rate curves on the measured clinical points, in order to analytically calculate the personalized pseudonecr (s) curve linked to the necr curve. results: for central beds, we estimate a missing activity of ~70% to get the pnecr_max, but the improvement in terms of snr that we could get is around 15%. we also estimated the correlation between the patient weight and the pnecr_max, in order to fi gure out which should be the scan duration of a single bed in function of the patient weight to acquire the same pnec. if we normalize the counts at the pnecr_max for the 70 kg patient, the bed duration for a 90 kg patient should be 230s, which is ~30 % longer. conclusion: although the analysis indicates that the fast electronics implemented in the scanner allows the use of higher administered activities, we found that this would involve a poor improvement in terms of necr. the attention can be instead addressed on the usefulness of higher bed duration for heavier patients. radiology learning objectives: to describe our experience in development of 'joint ventures' between a radiology department and a basic research physics department. to analyze pros and cons of this collaboration from little initial projects to participation in large eu projects. background: clinical radiologic departments and basic research physics groups live frequently far away in work and mind from each other. however, to create a collaboration group between a radiology department and a basic physics research group provides great benefi ts for both institutions. procedure details: we describe our experience, projects and lessons learned about how to begin a 'joint venture'. we analyze possible benefi ts for a radiology department from a physics group including: a) experience from informatics management providing different solutions for several problems of our departe-c 497 b d e f a g ment: advice for pacs and workfl ow, creation of an online database of radiologic cases, teleradiology; b) experience with management of european public money sources of money; c) performing basic research: in our case, with cad. possible benefi ts for a physics group from a radiology group: a) lessons from a different point of view b) application of basic research developed in practical applications more easy for marketing in the eu. in addition, basic research scientists have frequently a sensation of null practical application of their work, just the opposite of our daily clinical work. conclusion: creation of joint ventures between basic physics research groups and clinical radiologic departments can provide great benefi ts for both groups in scientifi c, economic and open-mind views. comparative evaluation of lcd with anti-glare panel and glare panel for digital mammography k. oda 1 , m. sawada 1 , a. ishikawa 1 , h. imai 1 , k. ichikawa 2 ; 1 anjo, aichi/jp, 2 nagoya, aichi/jp (oda@kosei.anjo.aichi.jp) purpose: many current lcds use anti-glare panels, which have a waffl ed surface to diffuse the refl ection of ambient light. however, this also diffuses the light from the lcd's backlight. the aim of this study was to compare the spatial resolution (modulation transfer function: mtf) and the noise (noise power spectrum: nps) of high-resolution lcds with anti-glare and glare panel for digital mammography. methods and materials: 21" lcds (2560 x 2048) with a anti-glare panel and a glare panel were evaluated. a uniform image and a bar-pattern image displayed on an lcd were measured with a high-resolution single-lens refl ex type digital camera (d70, nikon) equipped with a close-up lens. in order to avoid signifi cant errors caused by periodic components of the pixel structures, noise profi le data was processed by the hanning window. the lcd with a glare panel had better mtf characteristics and displays a sharper image outline. furthermore, the lcd with a glare panel had better nps characteristics than the lcd with an anti-glare panel. the lcd with a glare panel was excellent in physical characteristics by comparison with the lcd with an anti-glare panel for digital mammography. the glare panel was effective in a dark environment with no refl ections of surrounding light. visualization purpose: in certain cases, a coloration occurs under ultrasound investigation with color doppler, which is regarded as an artifact of a pseudo-fl ow. a fi ne-dispersive suspension moving in the direction opposite from the probe can be seen. the reasons and properties behind this phenomenon require further investigation. the experimental research was carried out. the highfrequency probe was submerged into a container fi lled with a suspension of talc in degassed water, and ultrasound scanning was performed. results: in the b-mode, displacement of talc elements to a direction opposite from the probe was visualized. in the color doppler mode with low prf values, this displacement was registered as coloration corresponding to movement from the probe. increase in intensity of the displacement was marked under the following conditions: focus shift to distant zones; implementation of doppler modes, especially power mode; increase of doppler frequencies. reduction of movement intensity was registered in the following cases: reduction of acoustic power level (at 40% quite stopped), increase of liquid viscosity (the suspension of talc in glycerin practically did not move). conclusion: visualization of streams in liquid accumulations is a refl ection of real liquid untwist, which can be explained by the well-known physical phenomenon -acoustic current. correct understanding of this occurrence enables us to interpret some phenomena that are found in pathological cystic formations. evaluation of patient entrance skin dose with an online measurement system in interventional neuroradiology y. takei the esd were different among interventional procedures greatly. the esd was fi ve times greater with tae than with tai procedure. in 4 patients with tae, the esd exceeded 2 gy, and they underwent transient loss of hair. the esd in tae for vascular diseases counted higher than in other procedures. it could be due to the fact that fl uoroscopy and angiography were performed more to understand the complex vascular structure such as arterovenus malformation (avm). conclusion: simultaneous esd monitoring was useful as an alarm so that doctors can reconsider their treatment strategy on the spot and radiological technologists the x-ray tube load to reduce the total patient dose. dose-reduction experiment during a cervical vertebrae examination r. pedersen, o. muharemovic, m. nielsen; copenhagen/dk (radiograf@privat.dk) purpose: the purpose of this experiment is to examine the possibility of dose reduction during a cervical vertebrae examination by adjusting predetermined parameters, and still maintaining acceptable image quality. methods and materials: data collected from 21 danish x-ray departments show a wide variation in parameter settings prior to a cervical examination. to assess the absorbed dose in the thyroid gland, tld (tablet lithium fl uoride) are used. the tablets are placed in the area of the phantom, which corresponds to the thyroid gland´s anatomical position. image quality is assessed using images of a specially designed plexiglass phantom, which is equivalent to a human phantom in density and overall composition. the plexiglass phantom has a built-in linear phantom and density holes that enable one to measure and assess the contrast in the images. results: signifi cant dose reduction was achieved by using pa instead of ap exposure, resulting in minimal image quality deterioration. by using aec in ap, pa exposure with 66 kv, one can reduce the dose signifi cantly. the best image quality is achieved under ap/pa exposure using grid ratio 12:1. however, with the ratio 8:1, we were able to observe a signifi cant dose reduction of up to 74%, but at the same time there was a slight deterioration of image quality. conclusion: this experiment shows that with a certain predetermined parameter regulation, a signifi cant dose reduction of 60-74 % is achieved in the thyroid gland. at the same time, a slight image resolution reduction is observed that does not affect the diagnostic quality of the image. increased aluminium fi ltration as a dose reducing tool in ap and lateral lumbar spine images of a phantom e. kelliher, c. d'helft, j. thompson, p. brennan; dublin/ie purpose: the cec guidelines (1996) recommend a minimum total fi ltration level of 3.0 mm aluminium equivalent for lumbar spine radiography. this phantom based study examined the effects of increasing aluminium fi ltration up to 7.0 mm on radiation dose and image quality. dose optimization is of added importance when lumbar spine radiography is performed on females of childbearing age, due to increased risk of cancer induction in young patients and the risk of irradiating an undiagnosed foetus. methods and materials: serial ap and lateral lumbar spine radiographs were taken of a tissue equivalent phantom, beginning at a total fi ltration level of 2.5 mm, and increasing in increments of 0.5 mm, up to 7.0 mm. three exposures were taken for each projection at each fi ltration level. tlds were used to measure entrance surface dose, reproductive organ dose and fetal dose. image quality assessment was performed using anatomical criteria based analysis. results: for the ap lumbar spine exposures, the optimal level of total aluminium fi ltration was 6.5 mm. this provided 34%, 18%, 27% and 19% reductions in entrance c 499 b d e f a g of the colon was carried out with two different methods, depending on which part of the intestinal tract was meant to be examined. method i: to achieve isolated distension of the colon, 5-10 ml of air was infl ated 30-60 times, then about 20 ml of air was pumped 10-15 times. if tension around the coecum was felt, scout view was done. method ii: to achieve distension of the colon and small bowel simultaneously, infl ation was started by pumping 20 ml of air 25-40 times, then about 15-20 ml of air was pumped 10-15 times. with this method, air can pass easily through the bauchim valve. results: distension of the colon was appropriate with both methods. in 140 cases, we wanted to produce isolated colon distension. it was succesful in 127 cases. in 50 cases, we wanted to examine small bowel too. it was successful in 47 cases. conclusion: with these two methods, a higher percentage of cases could be successfully examined. virtual colonoscopy of the colon and small bowel becomes more effective and the patient's unnecessary feeling of discomfort could be lessened. evaluation of optimal cardiac phase determination method using cardiac phase image subtraction in coronary ct studies t. yamaguchi, n. honma, k. satoh, k. urasawa; cyuo-ku,sapporo/jp (yamataka@eagle.ocn.ne.jp) learning objectives: to easily determine the optimal cardiac phases in coronary ct studies. to quantitatively evaluate the "elements of cardiac motion" in each cardiac phase. to compare this optimal cardiac phase determination method against conventional visual evaluation. to automatically determine the optimal cardiac phases. background: in current coronary ct studies, determining the optimal cardiac phases for depicting the coronary arteries is a time-consuming process that is based on visual evaluation. a quantitative evaluation method is therefore eagerly awaited. procedure details: the subjects were 40 patients who underwent cardiac ct studies. using data acquired by ecg-gated reconstruction, images of cardiac phases in the range from 0% to 99% were generated for three planes near lad #6 to #7, rca #1, and rca #2 using the relative delay method, and subtraction was performed repeatedly for images in consecutive cardiac phases. the in-plane sd values of the subtraction images were measured, and the mean sd value in each cardiac phase was plotted on a graph. the agreement rate between the phase with the minimum sd value and the optimal cardiac phase determined by visual evaluation was 83% within the range of 5% of the cardiac phase. excluding patients with atrial fi brillation, the agreement rate was 93%. the optimal cardiac phases for depicting the coronary arteries can be determined with good accuracy using this cardiac phase image subtraction method. not only can the optimal cardiac phase be determined automatically without visual evaluation, but the time required for coronary ct studies is substantially reduced. "how to" ct-enteroclysis: a guided step-by-step approach a. la fata 1 , l. damiani 1 , e. maffei 1 , a.a. palumbo 1 , t.v. bartolotta 2 , m. midiri 2 , f. cademartiri 1 ; 1 parma/it, 2 palermo/it (lafatalaura@virgilio.it) learning objectives: 1. to describe the various methods of ct-enteroclysis (ct-e) of the small bowel. 2. to give an overview of the different experiences worldwide (italy, germany and american). 3. to compare the different techniques for ct-e describing advantages and pitfalls. 4. to provide a pictorial assay of different diseases as they appear on ct-e. background: computed tomography enteroclysis (ct-e) is a technique for the assessment of the small bowel. it is performed after small bowel distension by administration of a high volume of contrast medium via a nasojejunal catheter followed by ct acquisition. ct-e combines the inherent advantages of conventional barium enteroclysis (i.e. homogeneous luminal distension resulting from volume challenge) with those of cross-sectional imaging (i.e. simultaneous detection of intraluminal, mural and extraintestinal abnormalities). however, it is a challenging technique with several steps that have to be optimised. imaging findings: the main variability observed between different protocols regards the choice contrast medium. german investigators use positive contrast agent (i.e. diluted barium sulphate suspension or water iodinated contrast material), american and italian investigators use neutral intraluminal contrast agents (i.e. water or 0.5% methylcellulose). differences are also reported in the choice of nasojejunal catheter (i.e. maglinte or rollandi techniques), in the use of sedation and in the preparation of patients. the optimised protocol for each indication will be provided in the exhibit. ct-e is a novel modality for the assessment of small bowel that may completely vicariate previously used modalities. information helpful for students in understanding isotropic resolution k. tsujioka, y. uebayashi, m. anzui, t. goto, t. sekitani, k. asano; toyoake-city aichi/jp (tsujioka@fujita-hu.ac.jp) learning objectives: this report illustrates a scanning method used to achieve isotropic resolution and a display method that allows for the effi cient use of isotropic resolution in image diagnosis. background: traditionally, we understand that ct scan images come from tomography. however, due to recent developments in helical scanning and multi slice ct technologies, ct scanning equipment has advanced from two-dimensional to three-dimensional data collection, and, similarly, ct images have shifted largely to three-dimensional observation of a section from a two-dimensional one. isotropic resolution is an essential factor in meeting current needs in ct technology. isotropic resolution means that the elements composing ct images hold equal, three-dimensional resolutions. imaging findings: for evaluating spatial resolution, a micro globe 0.18 mm in diameter made of tungsten was used. for evaluating contrast resolution, we used a dual glove phantom having a small difference in ct value. we also evaluated artifact. the results of the experiment found that change occurs in the x-y direction and the y axis direction depending on how parameters are set for scanning. in the actual clinical environment, we must consider such characteristics for parameter setting and also be aware of the optimization of isotropic resolution for ct image display. as this report serves to provide a description of parameter setting for ct scan, which has grown more complicated in recent years, we fi nd it helpful for students who are unfamiliar with ct operation. optimal scanning parameters for ct perfusion in patients with esophageal cancer h. sato, n. yanagawa, k. syutou, t. kazama, k. fukuchi, s. okazumi, t. ochiai; chiba/jp (hirotaka-sato0908@excite.co.jp) purpose: to determine optimal scanning parameters for ct perfusion in patients with cancer of the esophagus. methods and materials: forty-fi ve esophageal cancer patients underwent ct perfusion. scans were performed using a multi-detector row helical ct. the imageacquisition factors were the following: 4x5 mm collimation, 1.0sec/rotation, 120kv. forty ml of intravenous contrast was injected at a rate of 5 ml/sec followed by 20 ml saline. the delay between the start of injection and scanning was 5 sec in 33 cases and 10 sec in 14 cases. the tube current was set 40, 60, 80, 100, and 120 ma in esophageal cancer patients. all the data were reconstructed with 2.5 mm, 5 mm, and 10 mm. the shape of time density curve (tdc) was visually evaluated and the association of prognosis and blood fl ow was evaluated. results: the prognosis and blood fl ow was best correlated when the slice thickness was 5 mm. the shape of tdc was bad scanned at 60 mas in esophageal cancer patients. in one out of 3 esophageal cancer patients with delay time of 10 seconds, arterial enhancement started before the scanning. conclusion: in esophageal cancer patients, scan may be obtained at 5 mm-thickness, more than 60 mas, and delay time of 5 sec. to determine the optimal sd setting level in abdominal ct examinations n. yagi 1 , y. muramatsu 2 , r. sekiguchi 2 , h. sato 1 , s. tsukagoshi 1 , k. takahashi 2 , i. aizawa 2 , k. yokohama 2 ; 1 tochugi/jp, 2 chiba/jp (y_c_h_o_k_u@yahoo.co.jp) purpose: in ct-aec based on image quality (sd) setting, the sd level selected strongly affects the balance between exposure dose and image quality. the purpose of the present study was to determine the optimal sd setting level in abdominal ct examinations. methods and materials: unenhanced and enhanced (arterial-phase and latephase) helical ct images of 24 patients (17 men and 7 women) with hepatocellular carcinoma were acquired for follow-up without ct-aec. using this ct raw data, simulated images with 3 different sd levels (sd10, sd12, sd15) with ct-aec were reconstructed using a computer simulation program (raw-nasu, toshiba, nasu, japan). the images were reviewed by 5 radiologists who were blinded to the sd levels to evaluate the degree of diagnostic accuracy using the continuous confi dence judgment method (0 to 100). statistical analysis was conducted for the evaluation values of 3 of the radiologists, which showed normality. the mean evaluation values ± standard deviation were 44.0±24.8 (n=14) for sd10, 57.1±31.8 (n=15) for sd12, and 33.8±29.0 (n=15) for sd15. anova did not show a signifi cant difference among the 3 groups (p=0.096). however, the paired t-test showed a signifi cant difference between sd12 and sd15 (p=0.045). paleoradiology: methods and possibilities a. laki 1 , e. riedl 1 , l.a. kristóf 2 , i. szikossy 1 , i. pap 1 , g. forrai 1 ; 1 budapest/hu, 2 györ/hu purpose: radiology is a very useful method in paleopathology, in the diagnosis of pathological changes of ancient human remains. there is not enough reference data about technical parameters of paleoradiological examinations. the aim of our study was to develop and describe the methods of paloradiological examinations and the radiological study of mummies and ancient human bones. methods and materials: sixteen naturally mummifi ed human individuals and 30 bone remains were examined. the bones were at least thousand years old and originated from different places in hungary. the mummies were discovered in the crypts of dominican church, vác, hungary, from burials between 1731 and 1841. conventional radiographs on phosphor plates (at least two views), spiral ct and 1 mm hrct examinations were performed. from spiral ct data, 3d reconstructions were also made. results: in the cases of mummies, the conventional radiography parameters had to be reduced by about 75% because of the body's lost water content. summation was often unavoidable. obtaining and displaying ct scans also required special settings. the examinations of the bones most frequently revealed traumas and trepanation of the skull. many degenerative changes of the spine and the joint surfaces were detected. signs of rheumatoid arthritis, paget disease, facies leprosa and vertebral tuberculosis could be discovered. in the mummies, vertebral changes, pulmonary tuberculosis, fractures and other traumatic lesions were diagnosed. conclusion: radiological examination of ancient bones and mummies can help to diagnose pathological changes in these human remains. new methods for x-ray and ct examinations are necessary due to the special features. first postgraduate program in medical ultrasound for radiographers in norway i. aabel, r. stokke; gjøvik/ no (ingunn.aabel@hig.no) learning objectives: gjøvik university college, in collaboration with innlandet hospital trust, has developed a postgraduate programmeq in medical ultrasound for radiographers in norway (60 ects). the aim of the course is to educate sonographers with an understanding of the scientifi c principles and the practical applications. understanding and knowledge of the scientifi c principles will help radiographers in acquiring the skills necessary to apply this knowledge in practice. clinical competency is an important integral part of the programme. background: norway experiences a shortage of radiologists, especially in rural areas. the purpose of this education is to qualify radiographers to perform selected abdominal ultrasound examinations. procedure details: this course will be a part time study within 2 years and is organized in 4 modules as follows: module 1: physics of ultrasound, levels and sophistication of equipment image recording, and artefacts. module 2: topographic anatomy of abdomen, pathology. module 3: clinical practice, gained under guidance and supervision of radiologist. module 4: clinical practice and a written project on a set subject. the course is based on the guidelines developed by the european federation of societies for ultrasound in medicine and biology. structured theoretical and practical training are followed by competency assessment. conclusion: through this postgraduate programme in medical ultrasound, gjøvik university college is the fi rst educational institution in norway, providing a qualifi cation of radiographers as sonographers. clinical science of radiography and radiotherapy: a conceptual analytical study on the research focus of a new academic fi eld s. sorppanen; oulu/fi (sanna.sorppanen@oulu.fi ) purpose: the master's programme in radiography has been running in finland since 1999, and development of this new academic fi eld has been active. especially, the relationship with nursing science has been under discussion. this dissertation was purposed to clarify the research focus of this developing academic fi eld, especially in comparison to nursing science. the study was conducted according to the three-phase hybrid method of concept analysis, combining the theoretical and empirical approach. concepts of "nursing", "environment", "health" and "human being" were used as the starting point, because they are commonly applied but not clearly defi ned in radiography. data were collected in forms of literature, expert interviews and written material, and analysed with qualitative content analysis. results: concepts defi ning the research focus were found to be "clinical radiography and radiotherapy" (substitute for "nursing"), "environment", "health and illness" (substitute for "health"), and "human being". these concepts were also found to be connected to each other in several ways. each concept was provided with a theoretical defi nition, and a model was formulated to describe the research focus of this new academic fi eld, which was named as "the clinical science of radiography and radiotherapy". conclusion: results suggest that this new academic fi eld may be profi led by a distinctive research focus, diverging from that of nursing science. results also suggest that this new fi eld must be named as the clinical science of radiography and radiotherapy. results may be exploited in further academic development, theory development and education within radiography and radiotherapy. b d e f a g aortic intramural hematoma: prognostic ct fi ndings in the acute onset and follow-up c. sebastia, s. quiroga, h. cuellar, a. miranda, r. boye, a. alvarez; barcelona/es (mcsebastia@vhebron.net) purpose: the aim of this exhibit is to review the ct fi ndings of acute type b aortic intramural hematoma and to assess the prognostic value of these fi ndings. we evaluated 34 patients with type b (stanford) aortic intramural hematoma (imh) by helical ct at the acute onset and yearly thereafter. the series included 33 men and 1 woman, with a mean age of 67 years (range: 49-87). patients were followed-up for a mean of 5.6 years (range: 2-13 years). the initial aortic diameter (≥40 mm), imh thickness (≥10 mm) of the affected areas, imh length, and presence of tiny ulcers at the acute onset were statistically assessed and correlated with poor evolution. results: evolution was to healing in 56% of cases and to focal aneurysm formation in 44% of cases. there was no correlation between poor evolution and initial aortic diameter (≥40 mm), imh thickness (≥10 mm), or imh length. ten patients had small ulcers at the acute onset, and there was a correlation between the presence of these ulcers and aneurysm formation. no differences were found in the outcome (healing or aneurysm formation) between the fi rst and the last yearly control. the only ct fi ndings in the acute onset of aortic imh with prognostic value were the presence of tiny ulcers in the affected aorta. in addition, the fi rst-year evolution was predictive of the long-term evolution of this entity. emergency learning objectives: to check ct fi ndings of the most frequent causes of abdominal venous system emergency pathology. background: abdominal venous pathology cases presentation, by ct diagnostication, in the radiology department of our hospital in the last two years. imaging findings: we show several cases of: abdominal venous system traumatic pathology; aorta-inferior cava vein fi stula, aorta-gonadal vein fi stula; abdominal venous system primary and metastatic disease; septic thrombosis of the splenic vein, porta, superior and inferior mesenteric veins; acute venous thrombosis of a renal graft; thrombosis of the inferior cava vein and renal veins after pregnancy. the emergency radiologist should consider the abdominal venous system pathology in the differential diagnosis of the acute abdomen in order to achieve a premature diagnostic to reduce morbi-mortality. flat-panel ct as a new perinterventional imaging modality in aortic stentgraft procedures: work in progress e. rabitsch, h. illiasch, w. wandschneider, k.a. hausegger; klagenfurt/at (egonrabitsch@gmx.at) learning objectives: to evaluate the value of fl at-panel ct during aortic stentgraft procedures. background: flat-panel ct was performed in 12 patients immediately after endovascular treatment of aortic aneurysms (5 taa, 7 aaa) on the angiographic table. images were acquired with a rotating c-arm (axiom artis; siemens), acquisition time was 20 seconds. during a rotation of 200 degree, 538 projections were acquired. images were displayed in mip and vrt mode. eight patients got intraarterial contrast medium (cm). imaging findings: in all patients, the entire stentgraft was exactly shown and alignment of the prothesis along the landing zones was well displayed. the aneurismal sack was well shown in 11 patients (1 patient had traumatic rupture). 1 x an endoleak ii was detected, 2 x an angiographically verifi ed endoleak i was not detected (1x suboptimal cm timing, 1x no cm administered). aortic side branches were well shown in all contrast enhanced studies except 1 (suboptimal cm timing). in one patient, distal extension was considered due to suspected short stent-graft at the distal neck. flat-panel ct showed suffi cient neck coverage and no extension was inserted. conclusion: flat-panel ct is a promising imaging tool during stent-graft procedures and may be helpful especially in problematic procedures. renal . isotropic data sets of 0.5 mm slices were available for review and suitable reconstructions using a dedicated graphic workstation (vitrea 2, vital images inc, usa). six of these patients were excluded because of aortic stent placement, aortic dissection or surgery, renal atrophy. the fi nal study group for review consisted of 152 patients (97 men, 55 women). results: thirty-eight of the 152 patients (25%) had renal artery variants. there were 7 right and 6 left superior polar arteries; 15 right and 6 left inferior polar arteries. 33 accessory renal arteries arose from the aorta, 1 from the right common iliac artery. six accessory right arteries passed anterior to the inferior vena cava. two patients had double renal artery, 1 right, 1 left. two patients had precaval dominant right renal artery. the overall prevalence of precaval arteries was 5%. conclusion: renal artery variants are commonly observed during routine mdct examinations of the abdomen; 64-slice mdct scanners allow excellent depiction of these variants along all their course, and evaluation of relationships with adjacent structures. what is the advantage of angio-ct system equipped with 16-channel mdct? detection of feeding artery during transcatheter arterial chemoembolisation for hepatocellular carcinomas using 3d-ct angiography generated from the data set of ct hepatic arteriography m. hirata, t. kajiwara, t. tsuda, t. mochizuki; toon ehime/jp (masaaki@m.ehime-u.ac.jp) learning objectives: to demonstrate the usefulness of 3d-ct angiography (3d-cta) reconstructed from thin-slice data set of ct hepatic arteriography (ctha) obtained from 16-channel angio-ct system for detection of the feeding artery of hepatocellular carcinomas (hccs) in comparison with digital subtraction angiography (dsa). background: selective catheter placement into the feeding artery is important for effective treatment of hccs and avoidance of hepatic damage after transcatheter arterial chemoembolization (tace). however, it is sometimes diffi cult to recognize three-dimensional vascular anatomies on two-dimensional dsa alone. 3d-cta generated from ctha enables us to identify the exact feeding artery, which is sometimes diffi cult to depict by intravenous cta, because direct opacifi cation of hepatic artery allows us to produce very precise 3d-cta. information of the detailed vascular anatomy and bifurcation point of feeding artery is simultaneously available when we perform tace. procedure details: patients were injected with 15 ml of nonionic iodinated contrast material at 1.5 ml/sec via a 2.3 or 4 f catheter placed in the common hepatic artery. ctha was performed at 10 seconds after the start of injection. 3d-cta was rapidly generated on the imaging workstation equipped for angio-ct system. the vascular anatomies and the target artery for chemoembolization could be recognized easily, especially on the movie display of the 3d-cta, which gave hints of suitable selection of devices and helped us to make the effi cient strategy for selective tace. conclusion: 3d-cta generated from ctha is useful for the detection of feeding artery of hccs during tace. effi ciency of via dorsum pedis 3d-ct venography for varicose veins of lower extremities m. ishifuro, j. horiguchi, k. ito, t. sueda, k. sato, m. kiguchi, t. furukawa, c. fujioka; hiroshima/jp (ishifuro@hiroshima-u.ac.jp) purpose: the opacifi cation of lower extremities in ct venography (ctv) by intravenous injection of contrast media (cm) via an upper extremity vein is often poor for three-dimensional (3d) display. we assessed whether 3d ctv obtained via dorsum pedis, using the same scanning protocol as for ct arteriography, was useful for understanding the complicated structures of the venous system. methods and materials: in 10 cases, diluted cm (6:1 ratio of water and 300 mgi/ ml cm) of a total amount of 140 ml was injected into the dorsum pedis at a rate of 3.5 ml/sec. scanning was performed from foot to head after a delay of 35 sec. the total volume of cm was intended to acquire enough enhancement levels in the entire lower extremities. it was tested whether ct values of 500 hu or higher were obtained in the venous systems. results: both varicous and deep veins were enhanced over 500 hu in all cases. superfi cial veins sometimes did not reach 500 hu; however, they were well demonstrated on 3d ct. the 3d ctv helped surgeons in the ligation therapy of the saphenous vein. conclusion: three-dimensional ctv via dorsum pedis for lower extremities is a useful tool for the delineation of the venous systems, and helps surgeons as a navigator for ligation therapy. effect a prospective parallel-group randomized study of the abdominal aorta and splancnic arteries was performed with a mdct (ge lightspeed vct) in 40 patients divided in 4 groups. a non-ionic c.m. was injected with an iodine concentration of 300 mg/ml in group 1-2: (130 ml; injection rate 3 or 4 ml/sec) and of 370 mg/ml in group 3-4 (100 ml; injection rate 3 or 4 ml/sec). arterial enhancement of the aorta at 3 levels (celiac trunk, sma, renal arteries) and of iliac arteries was measured, mean values were calculated and statistical signifi cance was assessed. results: concentration of 370 mg/ml (injection rate 4 ml/sec) led to a signifi cantly higher enhancement of the aorta in comparison with 300 mg/ml at the level of celiac trunk (329 vs 236, p < 0.01), sma (325 vs 222 p < 0.01), renal arteries (301 vs 206 p < 0.01) and iliac arteries (169 vs 113 p=0.01; 167 vs 112 p=0.01). 3 ml/sec patients showed a lower enhancement but differences were not statistically signifi cant at the same levels. conclusion: an iodine concentration of 370 mg/ml leads to an higher enhancement and better delineation of abdominal aorta and smaller arteries compared to 300 mg/ml. difference between injection rates of 3 and 4 ml/sec is non statistically signifi cant. early postoperative bleeding following living donor liver transplantation: ct fi ndings compared with angiography s. hong, a. kim; seoul/kr (hongses@paran.com) purpose: the purpose of this exhibit is to discuss the clinical impacts of early postoperative bleedings after ldlt and ct fi ndings or ct angiographic fi ndings compared with angiography according to the various bleeding causes. emphasis is laid on evaluation of the possible bleeding arteries according location of hematoma and contrast leakage on ct scan. methods and materials: between march 2000 and oct 2003, 63 early postoperative bleeding in 50 transplants among 478 adult liver transplants were confi rmed by conventional angiography. all patients underwent twophase multidetector row ct scan before conventional angiography. the early postoperative bleedings after ldlt were caused by inferior phrenic artery bleeding (23.8%), jenunal branch bleeding (12.7%), rupture of a hepatic artery pseudoaneurysm (9.5%), right renal capsular artery bleeding (9.5%), intercostal and lateral thoracic artery bleeding after chest tube insertion site (9.5%), inferior epigastric and superior epigastric artery bleeding (6.3/1.6%), anastomotic site leakage (6.3%), liver surface oozing (4.8%), biopsy site bleeding (4.8%), gastroduodenal and pancreatoduodenal arcades bleeding (1.6%/3.2%), circumfl ex iliac artery (3.2%), and dissection of common hepatic artery (1.6%). conclusion: sudden developed hematoma as well as extravasation of contrast material in the same region on ct scan is thought to be predictive ct fi nding of early postoperative bleeding in posttransplant patients. careful consideration for these fi ndings can prevent the progression into catastrophic status that requires surgical management. b d e f a g aortas and 3 intramural hematomas of the ascending aorta) with a 16-row msct unit. in all cases, we performed a retrospective ecg-gated technique, followed by conventional msct study of the thoracic aorta. all cases were reconstructed in multiplanar, mip and vr reformations. dynamic cine-mode imaging of the aortic valves and thoracic aorta was also done in all cases. imaging findings: images of ascending aorta diseases and postoperative changes are depicted without cardiac motion artifacts; the coronary arteries and their relationship with aortic disease and surgery are assessed. dynamic studies of the aortic valves and thoracic aorta are presented. artifacts due to a loss of cardiac synchronization, breath motion and insuffi cient aortic coverage are shown. conclusion: ecg-gated msct allows precise evaluation of diseases and surgery of the ascending aorta and coronary arteries. dynamic studies allow evaluation of the aortic valve, movement of the intimal fl ap, detection of intimal tears and visualization of patent ductus arteriosus. thirty-two-detector row ct angiography of carotid and cerebral arteries: comparison of 40 ml and 60 ml of contrast material with a bolus chaser h. shinjyo 1 , n. takeyama 2 , y. ohgiya 1 , y. takahashi 2 , m. obuchi 2 , t. kitahara 2 , s. matsui 2 , y. kinebuchi 2 , t. gokan 1 , m. ishikawa 2 ; 1 tokyo/jp, 2 yokohama/jp (momiji@mtc.biglobe.ne.jp) purpose: to compare the diagnostic performance of mdct angiography (cta) of the brain and neck, using 40 ml and 60 ml of contrast material (cm). methods and materials: cta was performed using 32-mdct from the aortic arch (aa) to the parietal region. seventy patients were divided into 2 groups on the basis of cm (300 mg/ml) administration protocol: group1 (n=35) received 40 ml of cm with 25 ml of saline fl ushing at 4 ml/sec; group 2 (n=35) received 60 ml of cm in the same fashion. first, time to peak enhancement (ti) of the internal carotid artery (ica) at circle of willis (cw) was calculated by test bolus method. next, scan duration (sd) between aa and cw was calculated (collimation 1.25 mm; pitch 0.969; rotation time 0.4 sec). scan was started at [(ti+4)-sd] (sec) in group1, and [(ti+9)-sd] (sec) in group 2. thirteen rois were placed from aa to above the cw. mean attenuation of carotid arteries (caas) and cerebral arteries (ceas) were quantitatively analyzed. venous contamination (vc), and vr and mip images were also visually analyzed. results: although there was a statistically signifi cant difference (p < 0.05) in mean attenuation of each artery between both groups, the attenuation of all arteries in group 1 was over 200 hu, and analysis of vc in group 1 was better than that in group 2. visual analysis of caas showed no difference, and that of ceas in group 2 was better than group 1. conclusion: a 40 ml cm cta of the brain and neck may provide suffi cient attenuation and diagnostic performance. a vascular tree is known by mdct before gastrointestinal surgery h. funatsu, h. takano; chiba/jp learning objectives: in this exhibit, we illustrate the normal branching pattern of visceral arteries and their variants in the abdomen with use of volume rendering technique. background: multidetector-row computed tomography (mdct) has come to be recognized as a useful diagnostic tool for preoperative evaluation. for example, angiographic images can be easily acquired after administration of iv contrast media. there is a certain kind of vascular variant that can be a potential source of complication during laparoscopic-assisted surgery for its inherent property (e.g. limited view of the fi eld, loss of three-dimensional depth perception, limited surgical manipulation). therefore, preoperative vascular mapping in each anatomic site would help your colleague. imaging findings: replaced left hepatic artery arising from left gastric artery, common trunk of left gastric artery and common hepatic artery, tortuous course of splenic artery were all depicted and relevant to procedures of or complications after laparoscopic partial gastrectomy. resection of left gastric artery from which left hepatic artery branches can lead to liver dysfunction. whether ileocecal artery runs anterior to vein or not determines an approaching method for exposure of superior mesenteric vein during right hemicolectomy. delineating root of left colic artery would facilitate left colic artery preserving lymph node dissection during laparoscopic low anterior resection. conclusion: with recent widespread use of laparoscopic procedures, more detailed information about relevant anatomy is required. mdct providing 3d images could be an imaging method of choice for the purpose. the effect of cardiac function on aortic peak time and peak enhancement during ct angiography: a retrospective study s. sakai, t. okafuji, a. chishaki, h. yabuuchi, y. matsuo, t. kamitani, h. honda; fukuoka/jp (sakai@shs.kyushu-u.ac.jp) purpose: to investigate how cardiac function affects the magnitude and timing of aortic contrast enhancement during ct angiography (cta). methods and materials: twenty-nine patients (21 men, 8 women; mean age: 64.4±13.4 years; mean weight: 59.4±10.3 kg) underwent measurement of cardiac output within 2 weeks of coronary cta. during coronary cta, after a test injection, 90 ml of contrast medium was injected at 3 ml/sec and scanning was initiated after a delay based on the previously determined contrast transit time. the cardiac output of each patient was measured by the thermodilution technique, and the cardiac index was calculated. attenuation of the descending aorta was measured at the workstation every 3 sec with reference to the image acquisition time shown by dicom header information. then the aortic peak time and aortic peak enhancement of each patient were calculated. pearson's correlation coeffi cient analysis was used to investigate the relationships between the cardiac index and aortic peak time or aortic peak enhancement. the ranges of cardiac index, aortic peak time, and aortic peak enhancement were 1.11 to 5.30 (mean: 3.28±1.08) l/min/m 2 , 25 to 51 (mean: 38.3±7.5) sec, and 273.1 to 598.1 (mean: 390.4±72.1) hu, respectively. with an increase of the cardiac index, the aortic peak time decreased (r=-0.698, p < 0.0001) and aortic peak enhancement also decreased (r=-0.573, p=0.0009). conclusion: the aortic peak time and peak enhancement during cta are closely related to cardiac function. the role of advanced vessel analysis software to evaluate aortic diameter in patients with ascending aorta dilation a. ferraris, f. caraffo, m. oggero, s. rossetti, a. secinaro, c. venturi, m. martina, g. gandini; torino/it (francesca.caraffo@libero.it) purpose: to evaluate the "vessel analysis" software accuracy and usefulness versus direct axial slice measurements to estimate preoperative maximum aortic diameter in patients with ascending aorta dilation. we performed preoperative angio-ct with 16-row mdct ge lightspeed in 39 patients with ascending aorta dilation. four radiologists with different experience (1-10 yrs) revaluated ascending aorta maximum diameter with "advanced vessel analysis," an automatic system that is able to generate view true oblique cross sectional vascular images perpendicular to the vessel axis, and then evaluated the same patients with simple direct axial measures. then, we compared the results so obtained to test the interobserver variability with these 2 measurement methods. results: the mean of the maximum aortic diameters obtained by advanced vessel analysis was 51.19 mm. the mean of the maximum aortic diameters obtained with direct axial measures was 49.68 mm. interobserver difference was 0.08 mm with the use of "vessel analysis" software and 2.47 mm with direct axial measure. the maximum difference between the 2 radiologists with respect to the direct axial measurements was 21.01 mm, and while using vessel analysis it was 1.12 mm. conclusion: the routine use of "vessel analysis" software allows minimization of the interobserver bias, and increases the accuracy in the preoperative evaluation of ascending aorta dilatation. carotid artery wall thickness and stroke: evaluation by using multidetector-row ct angiography l. saba, g. caddeo, r. sanfi lippo, r. montisci, g. mallarini; cagliari/it purpose: the aim of this work is to determine if carotid artery wall thickness (cawt) evaluated by using multi-detector-row ct angiography (mdcta) is an effective parameter to consider as predictive of increased risk of stroke. in this retrospective study, we analyzed 154 patients by using a multi-detector-row ct scanner. in each patient, we measured cawt and measurements were made with an internal digital caliper. we divided patients into 2 groups: the fi rst group (group a) included patients without stroke (n = 98) and the second group (group b) included patients with stroke (n = 56), and we made a statistical analysis by using t-student test to asses the cawt difference in the 2 groups. results: measurements of the distal common cawt varied from 0.1 to 2.2 mm. in group a, average cawt was 0.8082 mm (0.279 sd) and in group b it was 1.107 mm (0.2 sd). cawt in group a patients showed statistical difference (p < 0.01) com-c 505 b d e f a g pared to group b. by using 1 mm as the threshold, we observed another statistical correlation (p < 0.0001) for stroke: in fact, patients with ≥ 1 mm cawt had stroke with an odds ratio 9.8. in comparison with patients with cawt < 1 mm. conclusion: results of our study suggest that an increased cawt is an indicator for risk stroke and this parameter can be used as risk factors besides other wellknown ones like diabetes, hypertension, smoking, dyslipidemia. purpose: to prospectively determine the feasibility of two different protocols in patients with peripheral arterial occlusive disease (paod) using the current generation of 64-detector row ct scanners. methods and materials: twenty patients with known paod underwent 64-cta (sensation cardiac, siemens). patients were randomly divided into two different groups (a, b) regardless of age or severity symptoms. group a was studied using a regular ct scan following the base rule of scan time=contrast material (cm) administration duration; thus, 10 patients received 80 ml of highly iodinated cm (400 mgi/ml) at 4 ml/s; scan time was 20 s and a bolus trigger technique was employed at the level of the proximal abdominal aorta and the acquisition started soon after the attenuation reached 150 hu. group b received 110 ml of the same cm (independently of scan duration or patient characteristics) with bolus tracking positioned at the level of the infrarenal abdominal aorta; scanning started 13 s after attenuation reached 150 hu. peripheral arterial tree was divided into 18 segments. quantitative and qualitative analysis was performed. results: in patients with fontaine ii or iii, analysis of attenuation values was signifi cantly (p < 0.05) different for the two groups. higher mean hu values and highest quality images were obtained with group b acquisition strategy. for group a, attenuation of distal arteries was weak in heavily diseased patients, resulting in poor image quality even for diagnosis. conclusion: 64-detector row ct angiography allows high spatial resolution angiographic assessment of patients with paod; cm administration strategy and scan acquisition protocol require fi ne adaptation to avoid run out the bolus. pitfalls in diagnosis of pulmonary embolism with ct angiography e. protopapa, a. gyftopoulos, p. filis; athens/gr learning objectives: 1. to demonstrate the causes of pulmonary embolism (pe) misdiagnosis with the use of ct angiography. 2. to become familiar with a range of pitfalls. 3. to highlight the radiologist's need to determine the quality of a ct pulmonary angiographic study. background: computed tomographic pulmonary angiography (cta) is the modality of choice at our institution for the evaluation of patients with suspected pulmonary embolism because of its high sensitivity. despite the high accuracy of this method, there are several pitfalls that cause indeterminate ct pulmonary angiography. these pitfalls may be a consequence of patient-related factors such as respiratory motion artifact, image noise and presence of pulmonary artery catheter. technical factors include mostly inappropriate window settings, partial volume artifact and stair-step artifact. furthermore, various anatomic and pathologic factors are responsible for the poor quality of the examination. the anatomic factors include partial volume averaging effect in lymph nodes and vascular bifurcation. finally, coexisting pathology can decrease the value of diagnosis such as mucus plug and tumor emboli. procedure details: the patients were examined using 8-detector row ct (ge). the examinations were performed with 4 ml/sec injection rate of 150 ml contrast agent and collimation 16x 0.75 mm with a pitch of 1.2 mm. conclusion: although cta is the standard at many institutions for pulmonary embolism diagnosis, there are several factors that reduce this ability. the radiologist is requested to evaluate the quality of the study and, if it is poor, he should identify which pulmonary vessels are rendered indeterminate and whether additional imaging is necessary. factors associated with vessel enhancement in ct pulmonary angiography and indirect ct venography h. arakawa, t. kohno, y. kaji, t. hiki; tochigi/jp (arakawa@dokkyomed.ac.jp) purpose: to determine the factors associated with contrast enhancement of pulmonary ct angiography (cta) and indirect ct venography (ctv). methods and materials: 242 patients underwent cta using bolus-tracking technique, of which 189 patients underwent subsequent ctv. we administered two different amounts of nonionic iodine contrast medium depending on the body weight of the patient: patients with body weight > 50 kg undergoing both cta and ctv received 450 mg i (group b), while other patients received 300 mg i (group a). the enhancement of vessels was subjectively estimated by the four-point scale and densities were measured at the predetermined levels. multiple regression analyses were performed with density as the dependent variable, and age, sex, weight, contrast medium, scan delay and presence of embolism as independent variables. results: the mean scan delay of cta was 19 seconds (sd: 3.3; range: 10-31). subjective estimate of enhancement quality in cta did not differ between the two groups (p = 0.778), while it was signifi cantly better in group b than in group a (p < 0.001) in ctv. multiple regression analyses revealed that body weight and age were the only signifi cant and consistent independent variables associated with enhancement of the pulmonary arteries. on the other hand, contrast medium, body weight and scan delay were the independent variables consistently associated with the enhancement of deep veins. conclusion: bolus-tracking technique showed relatively small variation in the scan delay time. age, body weight and contrast medium were the important factors associated with vessel enhancement in combined cta and ctv. purpose: to evaluate whether low-volume contrast material (cm) mdct angiography (cta) utilizing aortofemoral bolus transit time (taf) can provide suffi cient contrast enhancement. methods and materials: cta was performed using 32-mdct with 1.25 mm collimation. after surgical bypass graft of abdominal aortic aneurysms, 40 patients were divided into two groups. in group 1 (n=20), taf was acquired from time to peak aortic enhancement (ta) at l1 vertebra and time to arterial enhancement at femoral heads by twice-test bolus method. scan duration was arranged according to individual taf, and scan delay was 4 sec after ta. a 40 ml cm (300 mgi/ml) with 25 ml saline fl ush at 4.0 ml/sec was used for cta. in group 2 (n=20), ta was calculated only at l1 vertebra. scan delay was 9 sec after ta, and table speed was 38 mm/sec. an 80 ml cm was used for cta in the same fashion. mean aortofemoral attenuation and mean differentiation between maximum and minimum attenuation were quantitatively analyzed, and also cross-sectional, mip, and vr images were visually analyzed. results: although there was statistically signifi cant difference in mean aortofemoral attenuations (309.4 ± 41.8 hu in group 1 vs. 331.8 ± 64.1 hu in group 2), visual analysis showed no difference between both groups. it is interesting to note that mean differentiation between maximum and minimum attenuation was signifi cantly smaller in group 1 than that in group 2 (26.2 ± 14.1 hu vs. 61.8 ± 45.1 hu, p < 0.01). conclusion: low-volume cm cta can provide suffi cient aortofemoral contrast enhancement. visualization of the posterior gastric artery with ct angiography k. miyatake, k. nakatani, t. yamanishi, n. hamada, t. okabayashi, y. ogawa; nankoku/jp (jm-kanakana@kochi-u.ac.jp) purpose: the posterior artery (pga) is one of the important feeder arteries of the stomach. although the pga is unfamiliar with computed tomography (ct) imaging, lymphonode dissection in gastric surgery depends on how the pga branch and/or run. we evaluated the detectability of the pga with the 16-scanner multi-detector row ct angiography (cta). methods and materials: a total of 97 preoperative patients [60 men and 37 women, 29-94 years (mean 69.0 years)] underwent ct angiography. the presence and feature of the pga was assessed by 2 experienced readers using multi-planar reconstruction (mpr). the pga was detected in 84 patients (86.6%). in 83 of the 84, the pga had branched from the splenic artery. in one of the 84, the pga had branched from the celiac artery. no signifi cant differences were seen between age or sex, and visualization of the pga. conclusion: cta depicts the pga in a high percentage in this study. preoperative information of anatomical feature of the pga can be helpful for planning the surgical strategy. b d e f a g intraindividual comparison among source images, mip and vri algorithms in willis' circle anatomy and diseases assessment. case series and literature review f. favano, a. saponaro, l. fortunelli, f. travaglini, d. volpe, a. stecco, a. carriero; novara/it (chiccait@hotmail.com) learning objectives: to compare the anatomic visualisation and disease assessment of willis' circle offered by source images (sis), volume-rendered images (vris) and maximum intensity projections (mips), and to describe the advantages and disadvantages of each algorithm by means of a case gallery and review of the literature. background: although the assessment of source images provides precise local information concerning vessel diameter, source and area, it is often diffi cult to appreciate their spatial relationships and mentally reconstruct their global morphology. mips and vris are based on post-processing algorithms developed in order to improve the rendering of the overall morphology and/or spatial relationships of anatomic structures, but in addition to their strengths, they have weaknesses that can lead to artefacts and misinterpretations. procedure details: mips and vris are the most widely used means of showing mr angiography data; 3d image displays of vascular anatomy frequently provide excellent information. but both types of reconstruction are associated with disadvantages, such as the misrepresentation of spatial relationships and failure to detect eccentrically located stenoses. a case series is shown to illustrate these aspects. conclusion: vessels with low-signal intensities that may be partially or completely imperceptible on post-processing images can be seen on individual source images. in order to improve detection, it is essential to integrate the information coming from sis, vris and mips. normal the aim of this study is to evaluate the accuracy of mdcta in the detection of endoleaks aetiology in patients who have undergone endovascular repair (evar) of abdominal aortic aneurysm (aaa). methods and materials: 212 patients undergone evar for aaa. follow-up was performed using mdcta after 1, 6 and 12 months after the procedure and every 12 months. 32 patients with endoleaks detected at mdcta underwent to dsa to determine endoleaks aetiology. the results of the cta-based endoleak calssifi cation were compared to dsa. results: agreement between mdcta and dsa was observed in 28 patients (87%). in 2 patients mdcta classifi ed endoleaks as type 2 while dsa as type 1; in 1 patient classifi ed as type 1 at mdcta, dsa revealed type 2 endoleak; one patient with type 1 endoleak at dsa was incorrectly classifi ed as type 3 at mdcta. conclusion: mdcta seems to be a feasible technique in the evaluation of endoleaks aetiology. however, selective angiogram with dsa remains the goldstandard to manage endoleaks. atherosclerotic carotid plaque quantifi cation with multidetector computed tomography angiography t. background: besides carotid stenosis degree, atherosclerotic carotid plaque morphology has shown to be predictive for stroke. therefore imaging modalities are challenged to provide not only the severity of stenosis but also information on plaque morphology. state-of-the-art multidetector computed tomography angiography (mdcta) can accurately grade stenosis degree. with a custom made software program, we are now able to assess plaque volume and plaque component volumes. procedure details: it will be shown how to perform mdcta of the carotid arteries with good image quality, low use of contrast material and reduced perivenous artifacts. it will be shown how plaque and plaque component volumes can be assessed. it will be shown how these plaque volumes can be used to assess stroke risk, and what future developments can be awaited. in vivo assessment of atherosclerotic plaque and plaque component volumes in carotid arteries is feasible. prospective longitudinal studies which examine the relationship between plaque volume, plaque component volumes, and outcome have the potential to establish mdcta-based plaque quantifi cation as a stroke risk predictor. demonstration the scanning parameters included a detector row confi guration of 16x1.25 mm or 16x5 mm with retroreconstruction of 1.25 mm. after bolus injection of contrast medial materiel, arterial phase scans were obtained. multiplanar and curved planar reformation, parallel to the spinal cord, were evaluated and the detectability of the asa and the aka were analyzed. results: the asa was visualized on the scans of all the patients. the aka was visualized on the scans of 16 patients (80%), its segmental origin ranged from t8 to t12. analysis of hemodynamics in patient-specifi c stenotic carotid bifurcation using computational fl uid dynamics and mr angiography y.-j. xue, p.-y. gao, y. lin; beijing/cn (xueyunjing@126.com) purpose: to analyze fl ow pattern and hemodynamic variables in stenotic carotid bifurcation in vivo by combining computational fl uid dynamics (cfd) and mr angiography imaging. methods and materials: seven patients with carotid atherosclerosis underwent contrast-enhanced mr angiography of carotid bifurcation by siemens 3.0 t mr scanner. hemodynamic variables and fl ow patterns of the stenotic carotid bifurcation were calculated and visualized by combining vascular imaging postprocessing and cfd. results: as the extent of stenosis were commencing and aggravating, the stronger jets formed at the portion of narrowing and more prominent fl ow separation in the ica with regions of slow retrograde fl uid eddies in the lee of the stenosis. regions of elevated wall shear stress (wss) were predicted at the portion of stenosis and at the path of the downstream jet. areas of low wss were predicted on the leeward side of the stenosis, corresponding with the location of slowly recirculation turbulent fl ow. conclusion: cfd combined with mri can be used to simulate fl ow patterns and calculate hemodynamic variables in the stenotic carotid bifurcation as well as normal carotid bifurcation. the abnormal high wss may be relative to the rupture of vulnerable plaque. the secondary turbulent, recirculation fl ow associated with low wss regions on the downward of stenosis are likely to favor plaque development and thrombogenesis. a protocol for magnetic resonance renal angiography in suspected renovascular disease i. ahmad, p.s. lewis, a.h. choudhri; stockport/uk (abdul.choudhri@stockport-tr.nwest.nhs.uk) purpose: magnetic resonance renal angiography (mrra) is now thought the best non-invasive technique for assessing renovascular disease, with increasing demand putting pressure on our mr service, a limited resource. there being no consensus on indications for mrra, this study was performed to identify which patients would best benefi t from the procedure. methods and materials: provisional guidelines for requesting mrra were formulated, including: diastolic bp > 105 at any age; peripheral vascular disease; abdominal bruit; sudden increase in bp; high serum urea and creatinine and/or low serum potassium; bp not adequately controlled despite 3 medications. 100 consecutive patients referred for mrra were reviewed retrospectively, and the results correlated with the indications and patient management. renin and aldosterone measurements and renal ultrasound scans were also considered, where available. results: there was 92% compliance with the provisional guidelines. 92% of studies were diagnostic, 44% being abnormal, with a change in management in 88%. the results correlated well with clinical suspicion and ultrasound fi ndings, but not with serum urea, creatinine or renin measurements. conclusion: a written referral protocol for mrra can achieve good compliance and best use of a limited resource, reducing unnecessary requests and aiding non-specialists in selecting appropriate patients. these indications are proposed: i. high bp and age < 40 and ii. high bp and/or chronic renal failure (crf) with any of the following: audible vascular bruit; > 1.5 cm difference in bipolar renal length on ultrasound; unexplained pulmonary oedema; unexplained crf with other vascular disease; worsening of renal failure with ace inhibitor. hemodynamics hemodynamic variables at these carotid bifurcations were calculated and visualized by combining vascular imaging post-processing and cfd. results: a largest contiguous region of low velocity occurred at the carotid bulb. the eddy current and back fl ow was observed at bifurcation and outer part of proximal internal carotid and external carotid artery and the shapes of them changed with phase of cardiac cycle. the eddy current and back fl ow were signifi cant at middle of systolic phase and faded out quickly along downstream of internal carotid artery and external carotid artery. the wall shear stress map revealed a large region of low wall shear stress (wss) at carotid bulb and extended to the outer wall in the proximal end of internal carotid artery, the lowest value was below 0.5 pa. also there was a small region of low wss at the outer wall in the proximal end of external carotid artery. conclusion: cfd combined with vascular imaging can calculate and visualize the hemodynamic variables at carotid bifurcation in vivo. it is an interdisciplinary science of computer, radiology and hemodynamics and provides a new method of investigating the relationship of vascular geometry and fl ow condition with atherosclerotic pathological changes. bloodpool-enhanced mr angiography: optimization of scan protocols, evaluation and combination of conventional fi rst-pass with steady-state ultra-high spatial resolution imaging t. leiner, r.n. planken, m.w. de haan, j.m.a. van engelshoven; maastricht/nl (leiner@rad.unimaas.nl) learning objectives: to provide practical guidelines on how to perform blood poolenhanced high-quality fi rst-pass and ultra-high spatial resolution steady state mr angiography of abdominal and peripheral arteries using the latest technological developments, and how to evaluate such studies in order to maximize diagnostic yield. background: the recent introduction of the clinically approved blood pool agent vasovist enables steady state imaging of vasculature in addition to conventional fi rst-pass imaging. because of the increased distribution volume of the agent, there are major differences with regards to choice of optimal imaging parameters. procedure details: despite the much lower dose (0.03 mmol/kg vs. 0.3 mmol/ kg) and injection volume (9.0 vs 45.0 ml for a 75 kg person), fi rst-pass imaging yields equivalent image quality at identical imaging parameters. ultra-high spatial resolution equilibrium-phase imaging on the other hand demands increase of tr, decrease of bandwidth and fl ip angle to maximize vessel-to-background contrast. images are best evaluated in the transverse plane as well as with curved multiplanar reformations. the major teaching points of this exhibit are: 1) ultra-high spatial resolution steady state mr angiography of abdominal and run-off arteries is feasible in several minutes with voxel sizes in the order of 100-500 microns. 2) when using ultra-high spatial resolution, acquisitions venous enhancement will no longer interfere with image evaluation and assessment of disease. 3) because of the much longer intra-vascular residence time, blood pool agents enable imaging of additional arterial territories. learning objectives: 1. to illustrate the mr angiographic appearance of the different recanalization procedures used to treat ischemia of the lower extremities. 2. to review the complications following surgery including obstruction, stenosis and pseudoaneurysm formation. background: three-dimensional contrast-enhanced mr angiography represents a good alternative to catheter digital subtraction angiography (dsa) to assess peripheral artery graft patency. mr angiography is safer, faster, and less costly than dsa. postoperative graft surveillance is of particular importance, because fl ow impairment is the major cause of graft failure. it is important to detect early graft stenosis to improve the bypass patency rate. venous and expanded polytetrafl uoroethylene grafts are used to treat peripheral artery occlusion. autologous venous grafts have a primary and secondary graft patency superior to that of expanded polytetrafl uoroethylene grafts. imaging findings: mr angiography can identify accurately graft stenosis involving the proximal and distal anastomosis as well as the midportion of the graft course. aneurismal ectatic changes can also be assessed on mr angiography. metallic clip presence can represent a limitation on mr angiography; the susceptibility artifact produced by the clips can produce a misinterpretation of the images. source images should be evaluated to avoid misinterpretation of clip-induced susceptibility artifacts as stenosis. we present our experience with mr contrast-enhanced angiography for the evaluation of different types of vascular grafts used to treat peripheral arterial stenosis. we show the normal fi ndings, the complications and limitations we have found on mr images, using the dsa as a gold standard technique. color doppler sonography before, during and after endovenous saphenous laser ablation a. cina, s. venturino, c. di stasi, a. fiorentino, g. cina, l. bonomo; rome/it (acina@sirm.org) learning objectives: to describe the principles and technique of endovenous laser treatment of saphenous vein refl ux. to illustrate the color doppler us (cds) criteria for selecting patients suitable for the procedure. to teach how to perform cds during the procedure. to show cds fi ndings during follow-up and how to evaluate the outcome of the procedure. background: the procedure of endovenous laser ablation of the saphenous vein is simple and effective, with minimal side effects. cds is fundamental in selecting patients for the procedure, during the procedure and to verify the outcome of the treatment at the follow-up. procedure details: advantages and limits of the procedure. cds criteria for selecting and excluding patients. cds data required for the treatment. echo-guided puncture of the saphenous vein. checking the correct positioning of the laser probe. cds guide for the tumescent local anaesthesia. ruling out complications on the deep venous system. follow-up: how to evaluate the effectiveness of the treatment. tips and tricks of the procedure. conclusion: this exhibit will provide the knowledge necessary to perform cds before, during and after the endovenous treatment. the exhibit will also review anatomy, technique, cds inclusion and exclusion criteria for the treatment. temporal arteritis: avoidance of unnecessarily performed biopsies after color doppler us evaluation e. antypa, a. baltouka, a. parlamenti, m. skilakaki, d. ziaka, t. kratimenos, p. piperopoulos; athens/gr (baltoukamina@yahoo.com) purpose: the management of temporal arthritis is crucial, and the purpose of this study is to demonstrate the value of color doppler us (cdus) in the diagnosis of temporal arthritis and to permit the reduction of unnecessarily performed biopsies. methods and materials: cdus was performed in 32 patients, mean age 72 years, with clinical suggestion of active temporal arthritis. none of the patients was treated with cortical steroids previously. linear high-frequency transducers, 10-15 mhz, were used. the common temporal artery and its branches, frontal and parietal, were examined in all patients. the main sonographic criterion for a positive diagnosis was visualization of a periluminar hypoechoic halo and the suspicious areas were marked. biopsy was performed in all patients. additionally, in patients with positive cdus fi ndings of temporal arthritis, the biopsy was guided at the indicated suspicious sites. results: cdus fi ndings suspicious of temporal arthritis were reported in 14 patients. in all of them, the biopsy results were positive for temporal arteritis.the biopsy results in the remaining 18 patients were negative, as were the cdus fi ndings. the method of cdus evaluation of temporal arthritis, using a linear high-frequency transducer and assessing the characteristic sign of periluminal hypoechoic halo, leads to the direct diagnosis of temporal arthritis, and allows a proper medical approach to the disease. moreover, cdus guides the biopsy at the indicated areas and, additionally, contributes to avoid surgical biopsy in selected patients with typical sonographic fi ndings. the use of contrast-enhanced ultrasound in detecting type-ii endoleaks after endovascular abdominal aortic aneurysms repair (evar) a. drelich-zbroja, t. jargiello, a. drop, e. czekajska-chebab, m. szczerbo-trojanowska; lublin/pl (zbroanna@interia.pl) purpose: to assess the effi cacy of contrast-enhanced ultrasound in detecting type-ii endoleaks in the aneurysmal sac after evar. methods and materials: during the period 2005-2006, standard and contrastenhanced ultrasound with the use of sonovue were performed in 86 patients who underwent evar. ultrasound examinations and spiral ct were done 12 months after evar. the evidence of endoleak type ii was evaluated. results: in conventional doppler study, type-ii endoleaks were diagnosed in 3 patients, 2 from lumbar arteries (la) and 1 from inferior mesenteric artery (ima). contrast-enhanced ultrasound examinations revealed type-ii endoleaks in 9 patients, 6 from la and 3 from ima, and showed different mechanisms of c 509 b d e f a g endoleaks: 2 complex type-ii endoleaks and 7 simple endoleaks. all endoleaks were characterized by slow velocities with vmax from 11 cm/s to 18 cm/s. ct examinations detected type-ii endoleaks from ima in 4 patients and confi rmed 3 endoleaks from ima diagnosed with the use of sonovue and indicated 1 additional endoleak from ima. ct examinations showed only 5 type-ii endoleaks from la. there was 1 more endoleak from la diagnosed with the use of sonovue, which was not detected during ct. conclusion: the use of ultrasound contrast agents increased the diagnostic effi cacy of doppler examinations for detecting type-ii endoleaks. this examination is comparable to ct value in detecting type-ii endoleaks, but contrast-enhanced ultrasound examinations additionally show the mechanism of endoleak and the direction and velocities of blood fl ow. purpose: insulinoma is a rare functional pancreatic neuroendocrine tumor, usually localized in the body and tail of the pancreas. diagnosis is highly diffi cult, and performed by computed tomography, magnetic resonance and selective angiography of the pancreatic arteries by digital subtraction angiography (dsa). the purpose of the study was to analyze the diagnostic assessment of pancreatic dsa, computed tomography and magnetic resonance in 28 patients (21 females, 11 males; 41+8 years) with insulinoma. the tumors were localized in the pancreatic body in 17/28 patients (60.71%), in the pancreatic tail in10/28 patients (35.71%) and in 1/28 patient (3.57%) in the head of the pancreas. the diagnosis was confi rmed by pathohistology after the surgical treatment in all patients. the tumors were 12-49 mm in diameter and well vascularized. results: dsa detected insulinoma in 21/28 patients (sensitivity 75%). computed tomography detected insulinoma in 11/28 patients (sensitivity 39.28%, p < 0.05 vs. dsa), whereas magnetic resonance detected tumors in 15/28 patients (53.57%, p < 0.05 vs. dsa). in 7 patients in whom dsa failed to detect insulinoma, the diagnosis was achieved by computed tomography or magnetic resonance. the potential causes for dsa's failure to detect insulinoma are poor vascularization of the tumor and presence of extra gasses in the bowel. conclusion: digital subtraction angiography has better sensitivity than computed tomography and magnetic resonance imaging. so, it has a major role in the detection of insulinoma. lower limb venography: the forgotten "gold standard" a. saini, n. fotiadis, p. goutzios, r. dourado, f. kazmi, r. salter, c. sandhu, t. sabharwal, a. adam; london/uk learning objectives: over the last ten years, dulpex ultrasound has become the primary modality used to assess lower limb venous disease. as a result, the use of contrast venography has declined and in some institutions is rarely performed. this pictorial review is based on the authors' experience and aims to review the indications, techniques, venous anatomy and pathology as demonstrated by lower limb contrast venography. background: contrast venography has long been considered the 'gold standard' in the assessment of lower limb veno-occlusive disease and can effectively demonstrate thrombus within the below knee veins. since duplex ultrasound has the advantages of being non-invasive and does not use ionising radiation, it is favoured by both clinicians and patients as the initial diagnostic test for deep vein thrombosis. radiologists in training no longer have the exposure previously available and may not be familiar with the techniques or the appearances of common pathology. procedure details: the indications, technique and radiological appearances of lower limb venography are illustrated. emphasis is placed on common anatomical variants that are often poorly recognised by routine duplex ultrasound. the use of venography in the assessment of venous malformations, venous tumour encasement and in the post-phlebitic limb are also discussed. conclusion: venography remains the 'gold standard' in the assessment of lower limb venous disease. however, since this method is no longer in frequent use, it is imperative that radiologists remain familiar with the current indications, technique and interpretation of the test. a novel delivery system for hand injection of carbon dioxide in digital subtraction angiography m. cherian, p. mehta, p. gupta, b. madhavram, s.r. jayesh, t. kalyanpur, v. ilayaraja, n. sekhar, s. hedgire, d. raja; coimbatore/ in (drprashg@gmail.com) learning objectives: to demonstrate the feasibility of a plastic bag injection system for a hand injection of carbon dioxide in digital subtraction angiography. background: iodinated contrast agents are routinely used in procedures to diagnose and treat peripheral vascular disease. these agents are associated with contrast-induced nephropathy and allergic reactions in some individuals. to overcome these problems, carbon dioxide angiography has been developed as an alternative to standard iodinated contrast angiography. conventionally available co 2 injectors are expensive and require specialized cylinders which are not currently available in india. we developed a simple plastic bag delivery system to perform co 2 angiography at our hospital. procedure details: the problems associated with carbon dioxide: (1) co 2 comes in large cylinders under high pressure and thus the pressure has to be reduced close to atmospheric pressure before it is injected. (2) co 2 is colorless and requires closed circuit to prevent contamination with air. a blood bag was used in the circuit to reduce the pressure equal to that of the atmosphere and co 2 was aspirated through a three way stop cork into a 50 ml syringe. angiography was then performed in the lower limb arteries of 10 patients. digital subtraction angiography performed with a hand injection of carbon dioxide depicted the vessels in adequate detail in all the patients. we demonstrate a simple, safe and inexpensive system that delivers a known volume of co 2 at atmospheric pressure and effectively prevents contamination with room air. mallard, and so on) were studied and systemized in chronological order. we describe the works of the authors who were pioneers in vascular imaging, and whose works were historical landmarks. we display the progress that has been made in vascular imaging from conventional angiography to modern mri angiography. c 513 b d e f a g aneurysms in 14 patients. this study included 13 men and 1 woman (mean age: 70 years). one radiologist reviewed 13 computed tomographic (ct) studies, 5 arteriograms, 3 magnetic resonance (mr) studies and one doppler sonography. features evaluated included aneurysm size, shape, and location; branch involvement; arterial wall calcifi cation; gas; and periaortic and associated fi ndings. results: aneurysms were located in the thoracic aorta (n=5.5%), thoracoabdominal aorta (n=11%), infrarenal aorta (n=27.7%), iliac artery (n=27.7%), femoral artery (n=5.5%), tibial-peroneal arterial trunk (n=5.5%), and peripheral middle cerebral artery (n=16.6%). four patients had 2 infected aortic aneurysms.ct revealed 17 saccular (n=94.5%) and 1 fusiform (n=5.5%) aneurysms. paraarterial soft-tissue mass, stranding, and/or fl uid were present in 10 (n=55.5%) of 18 aneurysms, and early periarterial edema with rapid aneurysm progression and development was present in 2 (100%) patients with sequential studies. other fi ndings included psoas muscle abscess (n=5.5%), absence of calcifi cation in the aortic wall (n=44%), and periaortic gas (n=11%). angiography showed 5 saccular aneurysms with lobulated contour in 2 (40%). mr imaging showed 3 saccular aneurysms. conclusion: saccular aneurysms with rapid expansion and adjacent mass, stranding, and/or fl uid in an unusual location are highly suspicious for an infected aneurysm. chronic mesenteric ischemia: imaging fi ndings s. jiménez, a.b. delgado, a. sánchez, y. revilla, a. martínez, e. garcía; learning objectives: to describe the imaging fi ndings of chronic mesenteric ischemia (cmi) on duplex ultrasonography (dus), and their correlation with computed tomography angiography (cta), magnetic resonance angiography (mra) and angiography. background: cmi is an unusual but important cause of abdominal pain and weight loss, resulting from occlusion or severe stenosis of at least two of the three main splachnic vessels. understanding abdominal visceral circulation, its variants and collateral pathways that develop in patients with visceral artery stenosis is key to recognize cmi. atherosclerosis is the main cause of cmi (95% cases), usually involving the ostium of celiac artery (ca), superior or inferior mesenteric artery (sma or ima). other rarer causes are nonatheromatous lesions (dysplastic lesions, thromboangitis obliterans, radiation-induced lesions, takayasu arteritis…). imaging findings: evidence of visceral artery occlusion with noninvasive imaging such as dus, cta or mra could suggest cmi, if other causes of abdominal pain have been confi dently ruled out. in dus a peak systolic velocity greater than 275 cm/sec or end-diastolic velocity greater than 45 cm/sec seems highly specifi c for signifi cant sma stenosis. vascular obstructions, stenosis, collateral pathways and changes in the bowel wall can be depicted on both cta and mra. if endovascular treatment is proposed, angiography remains the diagnostic gold standard. conclusion: dus, as the preferred noninvasive screening test for sma and ca stenosis, followed by cta, mra or angiography allow us to make the diagnosis of cmi, as well as a valuation of extension, severity and number of affected arteries. takayasu's arteritis: a multi-modality pictorial essay j.p. banerjee, v. prabhudesai; hamilton, on/ca (pjbanerjee@hotmail.com) learning objectives: to better appreciate the imaging characteristics of takayasu's arteritis based on various modalities and thereby improve detection and surveillance of disease activity. background: imaging characteristics play a critical role in the diagnosis of takayasu's arteritis given that both clinical presentation and serological markers are non specifi c. traditionally, angiographic studies have primarily been used to demonstrate the vascular effects of this disease. however, employing additional and/or alternative modalities provide a more complete understanding of takayasu's arteritis. our institution serves as a local referral base for rheumatologic conditions and the department of medical imaging is routinely consulted in cases of suspected vascultitis. we have selected a group of patients whose imaging best illustrates the salient features of this clinical entity. the benefi ts and shortfalls of angiography, ultrasonography, contrast enhanced ct and mri are reviewed and a pictorial essay is offered to illustrate various fi ndings using these modalities. imaging findings: while angiography is the traditional gold standard for investigation of vasculitides, ultrasonography provides a non invasive alternative with fewer side effects, albeit at the expense of lower predictive value and operator dependance. cross sectional imaging by means of ct and mri also offer non invasive visualization of luminal pathology with the additional benefi t of demonstrating changes within the wall. conclusion: although knowledge of angiographic fi ndings of takayasu's arteritis aid in the evaluation of this disease, familiarity with imaging characteristics of other modalities allow the radiologist to better assess patients and offer additional and less invasive imaging options. current radiological approach for the diagnosis and follow-up of takayasu arteritis a.y. goktay, a. gulcu, t. celik; izmir/tr (yigit.goktay@deu.edu.tr) learning objectives: to evaluate the combined use of doppler us, mri, mr angiography and dsa for the diagnosis and follow-up of takayasu arteritis. background: takayasu arteritis is characterized by granulomatous infl ammation of the arterial wall which eventually leads to stenosis, occlusion and sometimes aneurysm formation. classical diagnosis has been based on characteristic fi ndings of the aorta and its major branches at conventional angiography or dsa. however, current developments in the fi eld of cross-sectional imaging have increased the diagnostic capacity of radiological methods even in the early systemic phase without any luminal abnormality. we present the combined radiological approach for the patients with takayasu arteritis. procedure details: cervical, renal, abdominal and extremity arterial doppler us examinations were performed for obtaining direct and indirect information about arterial fl ow and vessel wall. thoracoabdominal mri and mr angiography studies were performed on a 1.5 t scanner with body coil. multiplanar t2-weighted fat-suppressed, t1-weighted black blood inversion recovery before and after administration of gd-dtpa and contrast enhanced 3d mr angiography sequences were obtained. image interpretations were performed after post-processing studies. all luminal fi ndings were compared with dsa results. during the follow-up, us and mri fi ndings about vessel wall thickening and contrast enhancement of arterial wall were also evaluated. if necessary, endovascular treatments were performed according to the activity of the disease. background: dvt is a common vascular disease requiring prompt diagnosis and treatment but clinical assessment is often unreliable. d-dimer testing and pre-test probability scoring are used as guides for selection of the most appropriate investigation. vascular imaging remains essential for diagnosis and b-mode and doppler us, mdct and mri play an important role in the work-up of the disease. procedure details: the authors discuss advantages and limitations of each method in the evaluation of dvt, illustrating thoroughly the spectrum of fi ndings at us, mdct and mri. technical principles are outlined as fundamental tools to optimise disease detection and avoid potential pitfalls. conclusion: b-mode and doppler us is a cost-effi cient and widely available technique for initial evaluation of suspected extremity dvt. mdct and mri allow visualisation of affected areas non-accessible to us imaging. mdct with shorter acquisition times, greater coverage and reduced scan width provides excellent resolution in depiction of the disease, and detection of eventual complications as pulmonary thromboembolism. imaging features of the congenital and acquired abnormalities of the svc and the pulmonary vasculature k. burney 1 , h. young 2 , p. mccoubrie 2 , s. barnard 2 , m. darby 2 ; 1 southampton/uk, 2 bristol/uk (kburney@doctors.org.uk) learning objectives: to illustrate the spectrum of congenital and acquired abnormalities of the superior vena cava (svc). to present the congenital anomalies of the pulmonary veins and the associated anomalous drainage patterns seen. background: a wide range of clinical conditions can affect the svc. these include both congenital and acquired abnormalities. similarly, the pulmonary veins can be affected by a number of congenital anomalies, which can occasionally mimic other disorders and be associated with congenital heart disease. imaging findings: we retrospectively reviewed the imaging of patients with svc or pulmonary venous abnormalities treated in our hospital, and present a review of abnormalities as seen on various radiological investigations including ct, mri and plain fi lms. the congenital abnormalities of the svc highlighted include left-sided and double svc. acquired abnormalities including intra luminal defects caused by line-associated thrombus, svc stenosis secondary to multiple central line insertions or tumour invasion, extra luminal compression caused by mediastinal tumour and vascular aneurysms are demonstrated. partial anomalous pulmonary venous return (papvr) is a congenital abnormality in which one or more of the pulmonary veins are connected directly to the right atrium or to a systemic vein. we also present various patterns of papvr as seen on contrast-enhanced ct, as they may be associated with congenital heart disease. the development of the central systemic veins including the svc and pulmonary veins is a complex process subject to a number of variations. knowledge of some of the resulting variations can be of clinical importance. flow spectra were evaluated with doppler scan mode and fl ow parameters were calculated for the femoral, popliteal and calf arteries and veins. results: hit was proven by a positive platelet aggregation test in 20 patients (36%), 11 females and 9 male, who suffered lower extremities thromboembolic complications. fifteen patients (75%) had arterial thrombosis, most prominent of the common femoral, superfi cial femoral and posterior/anterior tibial artery. six subjects (30%) had deep venous thrombosis, most prominent of the common femoral and superfi cial femoral vein. conclusion: our study confi rmed the remarkably high incidence of thromboembolic complications, mostly arterial, in critically ill patients with hit. the routine cdus is appropriate in these patients since if silent arterial or venous thrombosis is identi developmental dysplasia of the hip in children: can mri features predict the need for surgical oseotomy? n. chew, p. mitchell, i. goutos, s. evans, a. hulme, j. lee, j. healy; london/uk (drchew@doctors.net.uk) purpose: open or closed reduction is undertaken to facilitate normal hip growth in children with ddh. however, a proportion of children who undergo hip reduction fail to develop deep well-formed acetabuli. these children will need to undergo pelvic osteotomy to improve cover of the femoral head and thereby reduce risk of premature osteoarthritis. we ascertain if the presence of abnormalities on mri immediately after hip reduction can predict long term hip dysplasia, therefore, aiding surgical fore-planning and reducing need for follow-up radiographs. methods and materials: nineteen hips with ddh were followed up over 4 years. all had initial reduction and post-reduction mri. mri fi ndings of 13 hips where acetabular dysplasia resolved by age four were compared with the 6 hips that underwent pelvic osteotomy for unresolving dysplasia. cartilage anlage shape, bony acetabular index, acetabular anteversion, lateral displacement due to panniculus, ligamentum teres and transverse ligament thickness, and whether the acetabular labrum was in a normal position or folded into the joint were were analysed and compared. the scans were analysed by two consultant musculoskeletal radiologists who were blinded to the outcome of each child. results: statistical analysis found none of the abnormalities on mri were predictive of persisting acetabular dysplasia in the older child. conclusion: although post reduction mri demonstrates anatomical abnormalities secondary to ddh, none of these were predictive of long term acetabular dysplasia. this suggests that the factors determining long term outcome are not visible on mri, but perhaps due to poor muscle dynamics or a biomolecular abnormality. radiological fi ndings in patients with stuewe-wiedemann syndrome surviving infancy r.d. langer, l. al-gazali, p. raupp; al ain/abu dhabi/ ae (rlanger@uaeu.ac.ae) learning objectives: to illustrate radiological fi ndings in the subgroup of patients with stuewe-wiedemann syndrome (sws), surviving the second year. background: sws is a rare skeletal dysplasia. mutations responsible have been recently identifi ed. the prevalence is high in the uae (0.5/10,000 birth). most sws patients die before the age of 2. out of 24 sws patients, 6 survived the second year. all came for regular orthopedic and pediatric checkups, or were admitted due to respiratory distress. patients received follow-up bone and chest radiographs; 1 underwent cct. our fi ndings have been compared to few published data. imaging findings: all children showed congenital dwarfi sm with progressive bowing of the extremities and demineralization. three had metaphyseal enlargements with coarse trabeculae. three developed progressive (kypho)-scoliosis and one spontaneous fracture. three children showed fragmented epiphyses. epiphyseal fl attening occurred in 4 patients. metacarpals and metatarsals were shortened and undertubulated. one patient developed an osteonecrosis of the talus. rips were broadened and osteoporotic with old fractures. all survivors repeatedly received chest radiographs due to aspirations, pulmonary infections, and pneumonias. two patients expired subsequently; they died from respiratory insuffi ciency. one girl developed a neurological defi cit due to left frontal infarction, which was caused by hypoxia. conclusion: while maroteaux reported a mean survival time of 2 months, several cases surviving infancy have been published, and are under surveillance. sws survivors after the second year show progressive bowing of the extremities with osteoporosis, a tendency to fractures, metaphyseal abnormalities, and severe (kypho)-scoliosis. pulmonary infections are less frequent after the second year. conclusion: the image plates will tested more with the phantom and after that the results will be tested with clinical use. the experienced radiology will analyse the image quality. the results will be introduced. these fi rst tests showed that it is possible to optimise the radiation dose and image quality easily according to the dimondiii process. optimization of patient exposure dose in low-dose scanning for ct colonography by adjusting dose according to patient weight y. hirano, k. sasaki, h. matsuya, s. katsuki, k. sasaki; otaru city, purpose: reducing patient exposure dose is important in ct colonography. in a previous study (ecr 2005) , we studied laboratory models and found that scanning with an air sd value (standard deviation value in the acrylic part) of approximately 35 or more results in poor visualization. air sd values vary according to patient size. in the present study, we investigated optimization of the patient exposure dose by adjusting the dose according to patient weight. methods and materials: patients were examined using a 16-row multidetector ct scanner and a 3d workstation. patient weight was measured before ct colonography. scanning was performed with an extremely low dose of 5 mas (70 patients) or 15 mas (37 patients), and the air sd values in the colon were determined in the upper abdomen and in the pelvic cavity. scan conditions were 120 kv, 1.0-mm scan slice thickness, and 1.0-mm reconstruction slice thickness. results: a positive correlation was observed between patient weight and air sd values in the colon. the correlation coeffi cients were 0.74 and 0.73 in the upper abdomen and 0.69 and 0.72 in the pelvic cavity for extremely low-dose scanning at 5 mas and 15 mas, respectively. conclusion: our previous study (ecr 2005) showed that air sd values of approximately 35 or more result in poor visualization, making it diffi cult to observe the tissue surface. the present study has shown that adjusting the dose according to patient weight is useful for optimizing the patient exposure dose in low-dose scanning while maintaining good visualization. how versatile is ct-aec? radiographic technique considering performance characteristics k.o. oosawa 1 , y.m. muramatsu 2 , s.t. terakawa 3 , t.m. mito 3 , s.n. nakahira 3 , y.h. hamada 3 , y.u. ueda 3 , i.f. fujimura 3 ; 1 sakurai nara/jp, 2 chiba/jp, 3 osaka/jp (alfa-k155@t-kadomatsu.net) purpose: ct automatic exposure control (ct-aec) is a new technique to optimize increasing exposure during ct examination. because different ct-aec systems use different operational principles, ct-aec cannot be expected to be effective when used thoughtlessly. the purpose of this study is to develop a radiographic technique that considers performance characteristics of different ct-aec systems, pursuing maximum dose reduction while ensuring image quality. methods and materials: two ct-aec systems from one manufacturer were investigated: (1) somatom volume zoom with care dose, and (2) sensation 64 with care dose4d (siemens, germany). the phantoms for evaluation are cone, elliptical, variable-xy and step phantoms (kyoto kagaku, tokyo). data was collected by changing abdominal ct scan parameters as appropriate. the data was converted to dicom images; image noise, tube current and absorbed dose (ctdiw) were obtained using a dedicated software program (bioarts, fukuoka). the relationship between tube current and image noise was compared for care dose and care dose4d. dose reductions from 10% to 30% were obtained in both aec systems compared with doses obtained without aec. while dose reduction depends on phantom size in both systems, the dependence changes with dose correction curves in care dose4d. the dependence of image noise on phantom shape is observed in care dose, but is not conspicuous in care dose4d. conclusion: a tube current correction table considering phantom size and shape was developed from the results, allowing dose reduction and comparable image quality from the two systems. can the isolated distension of the colon be infl uenced by adequate preparation during virtual colonoscopy, or, if needed, can adequate small intestine distension also be achieved? e. turupoli, k. szeidl, l. fehér, á. szilvássyné takács; budapest/hu (turupoli@freemail.hu) purpose: to develop a method by which the isolated distension of the colon can be achieved, or if the status of the small bowel is also questionable, to produce the distension of small bowel too. methods and materials: we performed 190 virtual colonoscopies. the infl ation conclusion: sd12 is the appropriate sd setting level for ct-aec in abdominal ct examinations. usefulness and optimal noise (sd) of auto-ma: survey among radiology technologists using16-slice mdct and esophageal cancer phantom study n. yanagawa, h. satou, t. kazama, t. iimori, k. shutou, s. okazumi, t. ochiai; chiba/jp (yanagawa@ho.chiba-u.ac.jp) purpose: image quality and radiation exposure are confl icting factors. recently, automatic determination of radiation dose (auto-ma) in ct scans has been developed. the purpose of this study was to determine optimal noise level at auto-ma. methods and materials: questionnaire was mailed to 99 institutions that have 16-slice mdct. the questions were usage of auto-ma, and the setting of noise level when it was used. a basic study was performed with small and large phantoms. the small (s)-phantom was a low-contrast phantom and 20 cm in diameter. the large (l)-phantom was made of the low-contrast phantom rolled with water-polymer absorber material. this was 35 cm in diameter. the largest diameter of the lesions demonstrating more than two-third of their profi le was searched. results: fifty-one institutions answered the survey. in 76% institutions, auto-ma was used and the standard deviation (sd) of auto-ma set between 6 and 15, but it was set constant in each institution. on phantom study when sd was set at 8, the largest profi le of lesions in l-phantom was 10 mm, while that in s-phantom was 12.5 mm. when sd was set at 10, the largest profi le of lesions in l-phantom was 12.5 mm, while that in s-phantom was 15.0 mm. conclusion: although sd of auto-ma was set constant in many institutions, phantom study suggested different optimal sds depending on patients' body habitus. manual labeling of brain tissues on mr images -a method to assess the quality of brain tissue volumes by automatic segmentation in a large population based study: the age, gene/environment susceptibility (ages)-reykjavik study b. oskarsdottir 1 , s. sigurdsson 1 , l. purpose: automated segmentation of brain tissue on mr images is critical to accomplishing analyses of mr scans acquired in large population-based studies, but manually labeled tissue is needed to check the accuracy of the algorithms. here we describe a method for manual labeling of brain tissues on mr images and assess the reproducibility of the method. methods and materials: the brain tissues on the mr images were labeled using "borderline", a software drawing tool specially designed for the ages-reykjavik study. borderline uses a wacom pen tablet as a human interface device for drawing and labeling anatomical landmarks. the tablet comes with a computerized pen interface and a drawing board, allowing the user to label multiple rois or tissue classes based on a multi-modal set of registered brain images. intra-rater variability was assessed based on 2 repeated measures from one observer on 5 pre-defi ned slices of the brain for cerebrospinal fl uid (csf), gray matter (gm), white matter (wm) and white matter lesions (wml), based on the 4 following mr sequences: 3d spgr t1, fse pd/t2, and flair t2. the intra-rater variability was calculated for each tissue class and each slice location individually using kappa statistics describing spatial agreement (dice similarity coeffi cient). results: kappa agreement for all tissue classes and all slice locations was excellent (mean k=0.856±0.088 and mean k=0.899±0.009, respectively). conclusion: a robust, highly reproducible method has been developed for manual labeling of brain tissues. an evaluation of computer-aided instruction courseware for mri physics d. koumarianos, e. mihalopoulou, l. costaridou, g. panayiotakis; patras/gr (dikoum@panafonet.gr) purpose: the evaluation of a computer-based instructional package designed to interactively teach mri concepts using media-rich animations. methods and materials: eighteen postgraduate students were prospectively, randomly assigned to receive instruction on the same mri topic from a textbook and a computer module. participants were evaluated by a multiple choice test 2 weeks before the lectures, at the end of the lectures and by a retention test after 1 month. they also completed questionnaires to rank their attitudes quantitatively and qualitatively toward the two instructional methods. mean test scores of the textbook and computer groups were compared by means of analysis of variance. results: the percentage of correct answers increased from 36.7% on the pretest to 70.3% on the posttest, and then decreased to 49.6% on the retention test administered 1 month after completion of the mri course. computer group students scored signifi cantly higher on their posttest (m=80.5, sd=9.4) when compared with the textbook group (m=61.3, sd=12.5, p=.003), while they seem to appreciate multimedia modules more when compared to textbook students (p=.003). the textbook learning group was equally satisfi ed with their method of instruction in comparison to the computer group (p=.230). students' rationale for expanding the use of multimedia in physics education seemed to focus on issues concerning motivation, instructional capabilities and content. conclusion: interactive animations are a useful and effective aid for teaching mri principles. the study demonstrated that the inclusion of properly designed multimedia modules enhances conceptual understanding far more than traditional methods do. atlas of normal and variant abdominal arteries. 3d anatomy with 64 channel multidetector-ct p. sedati, g. pelle, m. telesca, f. macrì, a. napoli, c. catalano, r. passariello; rome/it (psedati@hotmail.com) learning objectives: 1. to illustrate basic liver and renal vascular anatomy and its variation with multiplanar and 3d imaging using 64 detector row ct. 2. to provide an atlas of normal and variant vascular 3d anatomy. 3. to illustrate the basic principle of multiplanar and 3d imaging using 3d workstation and to explain how to optimize image quality. background: multi-detector ct (mdct) is now a standard type of clinical ct scanner. appropriate post-processing of mdct images enables the effi cient gathering of much more information than by just evaluating thin source images. post-processing techniques are useful both in clinical situations and for educational purposes. however, incorrect use of these techniques may hide important information. procedure details: 1) major vascular anomalies that involve the systemic arterial system of the abdomen are reviewed with emphasis on key imaging fi ndings and differential diagnostic features that allow for differentiation from other abnormalities. 2) review most important post processing technique and how to avoid important error. 3) understand which of such anatomical variants are related with specifi c clinical symptoms, syndromes or are important for a correct surgical planning. conclusion: recognition of abdominal vascular anomalies on imaging is important because several such variants may be associated with specifi c clinical symptoms, syndromes and other pathologic processes. major vascular anomalies that involve the systemic arterial systems of the abdomen are reviewed with emphasis on key imaging fi ndings and differential diagnostic features that allow for differentiation from other abnormalities. images were acquired in a multi-phase fashion: the arterial phase using bolus tracking technique (smart-prep), and the venous phase after a 70 second delay, at 2.5 mm of collimation, 2.5 mm of reconstruction interval, and 6 of pitch. the active bleeding sign (ab) was detected with mean attenuation values. images were reconstructed and rendered with mip and mpr algorithms. image evaluation was carried out by two experienced abdominal radiologists in a blinded-end fashion, and inter-observer agreement (cohen-test) was obtained. results: attenuation values ranged from 100 to 180 h.u. eighteen out of 20 patients had abdominal hemorrhage, whereas the ab sign was detected in 10 out of 20 patients. it was secondary to spontaneous bleeding from an intrahepatic pseudoaneurysm (n=1), rupture of a splenic artery pseudoaneurym (n=1), rupture of a giant renal angiomiolypoma (n=1), bleeding from an aorto-duodenal fi stula (n=2), bleeding from gastric ulcer (n=2), and rupture of a hepatic hemangioma (n=2). almost perfect agreement was obtained between the two readers in the detection of the ab sign (k=0.82, ci=95%). conclusion: mdct angiography and mpr reconstructions allowed satisfactory detection of active hemorrhage. the ab sign precisely localized the bleeding site, and therefore should be considered before therapeutic planning. advantages and disadvantages of ecg-gated multislice spiral ct (msct) in the study of the thoracic aorta c. sebastia, h. cuellar, s. quiroga, a. evangelista, r. boyé, a. alvarez; learning objectives: 1. to describe our protocol for studying the thoracic aorta with ecg-gated msct. 2.to demonstrate, with images and videos, the advantages of this technique for studying several thoracic aorta diseases. 3. to depict the pitfalls, artifacts and disadvantages of the ecg-gated technique for imaging the thoracic aorta. background: since january 2004, we have performed an ecg-gated msct technique in 27 patients with thoracic aortic disease (9 aneurysms-pseudoaneurysms of the ascending aorta, 3 type a acute aortic dissections, 6 chronic aortic dissections, 2 aortic coarctations, 1 patent ductus arteriosus, 3 postoperative ascending color doppler sonography before and after av haemodialysis fi stulas preparation a. cina, c. di stasi, s. venturino, e. muto, l. tazza, l. bonomo; rome/it (acina@sirm.org)learning objectives: purposes of this exhibit are: to describe how to perform a color doppler sonography (cds) examination before the creation of av fi stulas for hemodialysis and to show normal cds fi ndings and complications of av hemodialysis fi stulas. background: surgically created brescia-cimino arteriovenous fistulas and prosthetic loop grafts are common vascular accesses for hemodialysis. although angiography has been the traditional method of imaging, cds is now the standard technique employed before the fi stula creation and for evaluating dysfunctional hemodialysis access. procedure details: anatomy and surgical techniques -(1) cds methodology of study; (2) cds qualitative and quantitative data necessary before the fi stula preparation; (a) normal fi ndings after fi stula preparation; (b) complications: feeding artery occlusion; anasthomotic stenosis; venous stenosis; venous/graft thrombosis; anasthomotic pseudoaneurisms; infections; radial steal. conclusion: in this exhibit, we describe the role of cds in selecting arteries and veins for the preparation of av fi stulas for hemodialysis and the sonographic fi ndings of the more frequent complications. a detailed description of cds examination protocol before and after the fi stula creation is reviewed. purpose: the renal resistive index (ri) measured by doppler us has a well known prognostic signifi cation in vascular nephropathies and an elevated ri is currently associated with the diagnosis of nephroangiosclerosis. its value is more controversed in parenchymal nephropathies or in renal transplanted patients. our study correlated the ri with renal intraparenchymal parameters: endarterial sclerosis (esc) and interstitial fi brosis (if). methods and materials: the ri of 81 consecutive patients were measured by doppler us, just before renal biopsy. ri results were given as mean of 3 measurements performed at upper, lower and middle poles. the biopsy was made for the diagnosis of nephropathy (n=31) or for decline of renal function of kidney allograft (n=50). a histomorphological analysis was performed, using an automated methodology to determine the if and esc index. these parameters were correlated with the calculated ri for each patient (mann-whitney test). other parameters were evaluated especially creatininemia (cr) and cockroft glomerular fi ltration rate (cgfr). results: for patients having a native kidney biopsy, an independent positive qualitative and quantitative correlation statistically signifi cant, could be made between ri and cr, decline in cgfr, and esc index. no relation was noted with the if index. correlations were not signifi cant for transplanted patients. conclusion: ri is an exclusive non invasive index to diagnose the vascular sclerosis in native kidney and an elevated ri is a marker of poor prognosis renal function evolution in patients having nephropathy and chronic renal failure. colour background: celiac-mesenteric insuffi ciency is characterised by a hyper-affl ux to the celiaco-mesenteric district that may manifest itself asymptomatically, by means of aspecifi c pictures characterised by post-prandial pain (angina abdominis), or by means of dramatic conditions such as intestinal infarction. the risk factors are obesity, dyslipidemia, cigarette smoking, and antomical malformations such as fi bromuscular dysplasia, a high origin of the celiac tripod or hypertrophy of the arcuate ligament. procedure details: the fi rst diagnostic step when evaluating non-acute celiacmesenteric insuffi ciency is colour doppler us, which allows us to localize the site of the stenoses and measure their severity (expressed as% stenosis). we show the technique of performing such an examination and describe the semeiotic principles underlying it and b-mode echography: the evaluation of the presence of plaque, post-stenotic dilatation, and the quantifi cation of the degree of stenosis by means of the assessment of direct and indirect signs; and the colour doppler effects and fl ow acceleration. conclusion: the exhibit will review the indications and techniques, and provide the tips and tricks, and a complete case gallery. helical background: b-fl ow sonography is a relatively new sonographic technique that directly depicts blood echoes in a gray-scale presentation. this technique utilizes digitally encoded us technology and allows simultaneous imaging of blood fl ow, vessel walls and neighbouring tissues. the main imaging parameters are few (sensitivity, background control, gain control, focus number and location) and easy to use. imaging findings: b-fl ow sonography has several advantages over color and power doppler sonography: the information from both tissue and blood fl ow is identifi ed in higher resolution and higher frame rates. angle dependency, overwriting of the vessel walls by the color overlay, aliasing and perivascular color artifacts are eliminated. major indications for b-fl ow and areas of research are as follows: evaluation of carotid artery lesions and stenoses; follow-up of carotid artery stents; evaluation of hemodialysis fi stula patency and complications; evaluation of pseudoaneurysms and guidance for therapy; lymph node characterization; and abdominal applications like the investigation of portal vein thrombosis, cavernous transformation of the portal vein and budd-chiari syndrome. the technique has also some limitations such as decreased sensitivity with increasing depth and inability to obtain signals from a structure located deep to a calcifi ed plaque. also, fl ow directions are more easily recognized by color doppler than by b-fl ow. conclusion: b-fl ow technique provides higher resolution and higher sensitivity to fl ow without doppler artifacts. further improvements in the technique may overcome limitations and expand its clinical applications. learning objectives: 1. give an overview of the anatomy of the jugular, subclavian and axillary veins. 2. explain the techniques of cannulation of these veins, based upon anatomical landmarks, and correlate them with ultrasound (us)-guided approaches. background: central line catheterization is a clinically useful tool, performed for invasive monitoring the hemodynamic, respiratory, and fl uid status of patients, as well as for delivery of drugs and nutritive solutions. classically, techniques based upon anatomical landmarks have been used, but that may fail if any vascular anatomic variant exists. moreover, these techniques may cause complications as pneumothorax and hemorrhage after arterial injury. procedure details: after giving an overview of the anatomy of neck and shoulder, with special attention on anatomical relationships of veins, we expose the different catheterization techniques based upon anatomical landmarks. jugular vein can be catheterized by anterior, medium or posterior approaches, and subclavian vein by infra or supraclavicular approaches. us-guided cannulation technique is correlated with each of these approaches. finally, advantages and disadvantages of both techniques are summarized. conclusion: based on current literature, us can play an important role in the guidance of cannulation of central lines, as it can detect anatomical variations and venous thrombosis prior to the catheterization. nevertheless, it may reduce complication rates and number of attempts during catheterization. morphologic and hemodynamic study of gastrocnemius medial vein with color duplex ultrasonography in chronic venous insuffi ciency s. jiménez, a.b. delgado, a. sánchez, p. martín, s. zubicoa, j. leal; madrid/es (sarajimenezarranz@gmail.com) purpose: to describe the morphologic changes and hemodynamics of the gastrocnemius vein (gv) in patients with chronic venous insuffi ciency (cvi) with color duplex ultrasound (cdus). the study was performed in 222 lower limbs of 111 patients. 149 lower limbs presented clinical signs of cvi according ceap classifi cation and 73 lower limbs were normal. we carried out an anatomical study of the gv and muscle, and provided hemodynamic information about the incompetent veins by demonstrating the presence of refl ux. results: in 30% of limbs, the gv showed no refl ux and connections with superfi cial varicose veins through may's perforating veins (re-entry veins). 14% had gv refl ux associated with superfi cial varicose veins, in 2% the refl ux was due to post-thrombosis syndrome, and in 6% the refl ux was interpreted due to primary incompetence (no superfi cial varicose veins and no evidence of deep venous thrombus). 14% presented mainly gv stasis (enlargement, slow fl ow and symptoms of pain), and 10% displayed asymptomatic dilatation. in 22%, the study was normal (no enlargement and no refl ux), and the remaining 2% showed gastrocnemius muscle atrophy with dysfunction of muscular pump. the gv mean diameters in the cvi group were larger than those of the non-cvi group (0.82 cm vs. 0.53 cm). we also measured the venous fl ow velocities and fl ow-volume after muscular systole in the different groups. conclusion: cdus is a non-invasive technique that allows anatomical and functional studies of the gv in patients with cvi. it is also useful for physiopathological classifi cation and pre-therapeutic evaluation. arterial and venous thromboembolic complications in heparin-induced thrombocytopenia (hit) patients: color doppler sonography evaluation a. balanika, m. theodorakopoulou, m. lignos, c. baltas, e. melissari, a. gouliamos, a. armaganidis; athens/gr (mpaltas@hotmail.com) purpose: heparin-induced thrombocytopenia (hit) is estimated to occur in 1-5% of all patients receiving heparin. the purpose of this study was to investigate by color doppler ultrasonography (cdus) the incidence of thromboembolic complications in medically critical patients with hit. methods and materials: over a period of eighteen months, 55 intensive care unit (icu) patients (aged 39-89) presented with thrombocytopenia were investigated for hit and underwent arterial and venous cdus examination of lower limbs. orthopedic, surgical and cardiosurgical patients were not included in the study. we evaluated advanced multi-modality imaging of therapeutic angiogenesis and arteriogenesis: experimental in-vivo applications k. katsanos, d. karnabatidis, a. diamantopoulos, g.c. kagadis, p. kraniotis, d. siablis; patras/ gr (katsanos@med.upatras.gr) learning objectives: to familiarise radiologists and research scientists with advanced cross-sectional and angiographic in-vivo imaging modalities for the study of experimentally induced therapeutic angiogenesis and arteriogenesis. background: therapeutic angiogenesis (new vessel growth) and arteriogenesis (collateral vessel enlargement) constitute the frontiers of cardiovascular research in the reversal of ischemic myocardial and peripheral arterial diseases. in-vivo vascular imaging allows the quantifi cation of the angiogenic process and is necessary for the reproducible morphological and functional investigation of novel proangiogenic agents. imaging findings: experimental models of hindlimb or myocardial ischemia generally involve surgical or endovascular occlusion of the femoral or coronary arteries in animals. after the endogenous angiogenic response comes at rest, exogenous proangiogenic growth factors are administered and the evolution of therapeutic angiogenesis and collateralization is followed-up. non-contrast and contrast-enhanced cross-sectional studies with computed tomography (ct) and magnetic resonance (mr) may depict variations in tissue vascularity and enhancement after administration of contrast media. multiplanar reformatting along with volume-rendered cta and/or mra images may accurately display the morphology and bridging points of collateral vessels with diameter > 250 µm. moreover, dynamic image acquisitions during contrast administration and corresponding perfusion studies permit the functional assessment of the newly developed collateral vessels. finally, intra-arterial digital subtraction angiography delineates the newly formed vessels with great anatomic detail. recently developed post-processing computerised algorithms provide the capacity of segmentation, visualisation and quantifi cation of microvessels with diameters down to 50-100 µm. conclusion: modern applications of cross-sectional and angiographic vascular imaging with advanced post-processing and reformatting algorithms enable in-vivo morphological and functional experimental studies of therapeutic angiogenesis and arteriogenesis. imaging spectrum of the infectious and infl ammatory etiologies of aortitis r. suri, c.s. restrepo, k.n. chintapalli, s.r. prasad, d.w. postoak, b. toursakissian; san antonio, tx/us (suri@uthscsa.edu) learning objectives: 1. review the clinical spectrum of infectious and infl ammatory conditions of the aorta. 2. highlight the role of cross sectional imaging in the diagnosis and assessment of the extent of aortitis, thus helping in the management of these patients.background: infl ammatory/infectious conditions of the aorta and its major branches may present with nonspecifi c symptoms and are often missed clinically in the workup for fever of unknown origin (fuo). increased awareness of aortitis would facilitate appropriate management. imaging findings: 1. clinical signifi cance of aortic and major arterial infl ammatory conditions. 2. ct/mr/angiographic techniques and the role of image post-processing for dedicated evaluation of the aorta. 3. pictoral review of cross sectional imaging of a wide spectrum of aortitis due to vasculitidis (takayashu's arteritis, giant cell arteritis) and infection (granulomatous and other bacterial) involving the native aorta or after endograft or surgical repair. conclusion: increased awareness of aortitis and knowledge of the cross sectional imaging appearances helps to establish accurate diagnosis, which facilitates appropriate medical or surgical management. early diagnosis with ct and mr avoids life-threatening complications, thus, decreasing morbidity and mortality. a comprehensive pictorial review of anomalies of the superior and inferior vena cava e. sueyoshi, i. sakamoto, m. uetani; nagasaki/jp learning objectives: to provide a pictorial review of the embryology and anatomy of the superior and inferior vena cava. to show a detailed overview of cogenital and acquired diseases demonstrated by ct, mr, and/or angiography. to discuss the importance of careful analysis during the imaging interpretation. to discuss the prognosis of patients with these abnormalities. background: anomalies of superior and inferior vena cava are not rare. these abnormalities include congenital and acquired abnormalities associated with abnormal development, thrombosis, tumor, infl ammation, etc. procedure details: we provide a pictorial review of the embryology and anatomy of the superior and inferior vena cava. we show a detailed overview of congenital and acquired diseases demonstrated by ct, mr, and/or conventional angiography. we also discuss the importance of careful analysis during the imaging interpretation and the prognosis of patients with these abnormalities. conclusion: knowledge of this exhibit may be useful for the diagnosis and prediction of prognosis of patients with abnormality of the superior and inferior vena cava. interruption or congenital stenosis of the inferior vena cava z. koc, l. oguzkurt, s. ulusan; adana/tr (zaferkoc@superonline.com) purpose: to present the prevalence, clinical, and imaging fi ndings of interruption or congenital stenotic lesions of the inferior vena cava (ivc), associated malformations, and their clinical relevance. methods and materials: between march 2004 and march 2006, 7972 patients who had undergone consecutive routine abdominal multidetector row computed tomography were analysed for interruption or stenotic lesion of the ivc. results: prevalence of interruption (n = 8) or congenital stenosis (n = 4) of the ivc occurred in 12 (0.15%) of 7972 patients. four patients with interruption and 4 patients with congenital stenosis of the ivc were symptomatic with dvt (n = 4), leg swelling (n = 4), leg pain (n = 2), lower extremity varices (n = 2), hepatic vein thrombosis (n = 1), and hematochezia (n = 1). all four of the asymptomatic patients were from the interruption group, and these patients had interrupted ivc with well-developed azygos/hemiazygos continuation. eight symptomatic patients did not have a well-developed azygos/hemiazygos continuation, and drainage of lower extremity was mainly from collateral veins. additional fi ndings in 8 symptomatic patients were abdominal venous collaterals (n = 8), venous aneurysm (n = 2), lower extremity varices (n = 2), varicocele (n = 2), and pelvic varices (n=1). conclusion: interruption or stenosis of the ivc are rare on routine abdominal ct examinations and may cause different clinical fi ndings depending on the variant drainage patterns or collaterals. interrupted ivc is commonly asymptomatic if associated with well-developed azygos/hemiazygos continuation, whereas commonly symptomatic if well-developed azygos/hemiazygos continuation is not present. key: cord-023049-fio7cjj5 authors: nan title: 2017 peripheral nerve society meeting july 8–12, 2017 sitges, barcelona, spain date: 2017-06-22 journal: j peripher nerv syst doi: 10.1111/jns.12225 sha: doc_id: 23049 cord_uid: fio7cjj5 nan the peripheral nerve society was founded in 1994 from two groups of academic investigators, peripheral nerve study group and peripheral neuropathy association of america, interested in the basic biology and function of the peripheral nervous system and its application to the clinic. their invite only biennial meetings involved 80-125 attendees in cloistered settings organized by shoestring and local initiative. from this, we have grown remarkably. we now have an annual meeting of over 600 people including meetings within the meeting for the special interest groups in inflammatory, diabetic and hereditary neuropathy. with this substantial growth and the success of jpns, the journal of the peripheral nervous system the society continues to flourish. 2017 has proven to be a year full of exciting changes for the society. pns has transitioned from a biannual, to an annual meeting. next year, the meeting will be taking place at the renaissance baltimore harborplace hotel from 22-25 july in baltimore, maryland. the development of a new website has been completed, please visit www.pnsociety.com to see the new face of the society. finally, pns has adopted new executive staff. with their guidance and the leadership of an active and diverse board of prominent professionals in the field the peripheral nerve society continues to grow and anticipates more exciting changes in the year to come. the peripheral nerve society provides annual meetings, teaching courses, guidelines, and other resources to aid in the education of members. becoming a member of pns means collaborating with prominent global professionals in the field to develop and provide the best treatments for people with peripheral nerve diseases and setting standards of care within the field. please participate in our future by joining the pns, volunteering for a project aligned with your interests and sending your ideas for the future to the executive office, or board member. peles e 1 . 1 department of molecular cell biology, rehovot, israel. two schwann cell-dependent mechanisms control the presence of na + channels at the nodes of ranvier: i. clustering of the nodal complex by glia-derived proteins and ii. restriction of nodal proteins within the nodal gap by the paranodal junctions. these mechanisms depend on specific cell adhesion molecules that mediate the contact between myelinating glia and their underlying axons at the forming nodes and the paranodal junction. during myelination, na + channels initially clustered at heminodes that border each myelin segment. this process requires gliomedin, nrcam and neurofascin 186 (nf186), three cell adhesion molecules (cams) that mediate the interaction between schwann cell microvilli and the axon. na + channels clustering activity of gliomedin is tightly regulated by two distinct and functionally opposing proteolytic events. while the clustering activity of gliomedin is enhanced by its shedding from the surface of schwann cells by a furin protease, its activity is negatively regulated by bone morphogenetic protein 1/tolloid-like (bmp1/tld), and tolloid-like 1 (tll1) metalloproteinase. cleavage by these enzymes restricts the activity of gliomedin to the nodal area and prevents the formation of ectopic clusters along axons that are devoid of myelin segments, as well as below the myelin internodes. hence, proteolytic processing of gliomedin facilitates, yet limits, the clustering of na + channels to specific sites along the axon in a timely manner. furthermore, axon-glial contact mediated by gliomedin and nf186 at the nodes, not only plays a role in na + channel clustering during development, but also contributes to the long-term maintenance of na + channels at nodes of ranvier. in addition to clustering by gliomedin, the distribution of na + channels is restricted between two growing myelin segments by the flanking paranodal junction. at this site, axon-glia contact is mediated by a distinct set of cell adhesion molecules (i.e., caspr, nf155 and contactin) that also delineate the underlying axonal and glial cytoskeleton. this paranodal junction-dependent restriction of na + channels to the nodes is mediated by the spectrin-based paranodal axonal cytoskeleton. illa i 1 . 1 neuromuscular unit, neurology department, hospital santa creu i sant pau, universitat autònoma de barcelona, barcelona, spain. chronic inflammatory demyelinating polyradiculoneuropathy (cidp) is an autoimmune disorder of the peripheral nerves with clinical and immunological heterogeneity. currently, the diagnosis of cidp is based on clinical and electrophysiological criteria and does not take into consideration the presence of immune biomarkers. several autoantibodies against proteins of the node of ranvier in patients with cidp have now been described. these antibodies define specific cidp subtypes sometimes referred to as nodopathies and can have diagnostic and prognostic implications. anti-contactin 1 (cntn1) antibodies. we have described the presence of antibodies to cntn1 in a small subset of patients with cidp. these patients shared a phenotype and have poor response to ivig. the anti-cntn1 antibodies are predominantly igg4. pathological studies from skin and sural nerve biopsies of patients show morphological changes in the paranodes. experimental data supporting the pathogenicity of anti-cntn1 igg4 antibodies include: a) demonstration in vitro that the antibodies disrupt the binding of the cntn1-caspr1 complex to neurofascin-155 (nf155); b) intraneural injections of antibodies progressively and specifically disrupt the paranodal axo-glial junction; and c) chronic infusion of antibodies induced clinical and electrophysiological worsening in animals with experimental autoimmune neuritis (ean). anti-nf155 antibodies. antibodies to neurofascins were first reported in patients with guillain-barré (gbs) and cidp and subsequently, antibodies specific to the nf155 isoform were found in a small group (<3%) of patients with cidp. studies by us and confirmed by others have demonstrated that patients with cidp and anti-nf155 antibodies have a distinct phenotype that often includes a low-frequency tremor and poor responses to ivig. the autoantibodies are predominantly of the igg4 subtype. the passive transfer of monoclonal anti-neurofascin antibodies (which recognize all neurofascin isoforms) to mice with ean strongly exacerbated the severity of the pathology, but no studies have yet demonstrated that patient-derived anti-nf155 igg4 antibodies are pathogenic. a pathogenic role of the antibodies is however supported by sural nerve biopsies from patients with cidp and anti-nf155 antibodies that showed paranodal demyelination in the absence of inflammation, the loss of septate-like junctions and, the interposition of cellular processes between the paranodal loops and the axolemma. these alterations are reminiscent of those found in nfasc-null mice suggesting that anti-nf155 antibodies may specifically disrupt the nf155-cntn1-caspr1 complex at the paranodes. antibodies to other nodal proteins. recently neurofascin-186 and neurofascin-140 were reported as the main targets of autoantibodies in five patients with igg reactivity against the nodes of ranvier; the antibodies were predominantly igg4. these patients presented with clinical features distinct from those in patients with anti-nf155 igg4 antibodies. four of these patients had subacute onset of sensory ataxia without tremor. the presence of anti-caspr1 antibodies has been reported in two patients with inflammatory neuropathies, one classified as cidp, the other as gbs. both patients had intense neuropathic pain. the skin biopsy from both patients showed paranodal disruption. some patients whose sera show nodal or paranodal reactivity in teased nerve fiber preparations have antibodies against other nodal proteins, such as gliomedin or neuronal cell adhesion molecule (nrcam) . the skin is equipped with specialized mechanoreceptors that allow the perception of the slightest brush. indeed some mechanoreceptors can detect even nanometer-scale movements. movement is transformed into electrical signals via the gating of mechanically-activated ion channels at sensory endings in the skin. the sensitivity of piezo mechanically-gated ion channels are controlled by stomatin-like protein-3 (stoml3), which is required for normal mechanoreceptor function. under pathophysiological conditions following nerve injury or diabetic neuropathy the slightest touch can produce pain. it is at present unclear whether peripheral changes in sensory mechanotransduction may underlie hypersensitivity associated with neuropathic pain. here we have examined the role of the stoml3 modulation of piezo2 channels in mechanoreceptors and nociceptors to under pathophysiological conditions. we recently developed small molecules that act as inhibitors of stoml3 function. peripheral application of stoml3 inhibitors can alleviate hypersensitivity in models of neuropathic pain. our data strongly suggest that tactile evoked pain in models of peripheral neuropathy may be at least partly driven by sensitization of sensory mechanotransduction driven by stoml3. coleman m 1 . 1 john van geest centre for brain repair, cambridge, uk. axons are lost early in many neurodegenerative disorders of peripheral and central nervous system. the degeneration of transected axons (wallerian degeneration) can be slowed tenfold by overexpression of a variety of nad-synthesizing enzymes, such as isoforms of nmnat or the related mutant fusion protein, wld s . wallerian degeneration is also delayed by deletion of tlr adapter protein sarm1, a protein recently reported to promote nad degradation. it is important to understand fully the mechanism of wallerian degeneration because related mechanisms contribute to axon loss in a number of disease models, including models of peripheral neuropathies, parkinson's disease, multiple sclerosis and glaucoma. new data also suggest a role in hereditary spastic paraplegia. while depletion of nad is an attractive hypothesis for the mechanism of wallerian degeneration, especially as nad can be increased by dietary methods, it cannot explain a number of key observations. fk866, an inhibitor of nampt, blocks the nad salvage pathway and strongly depletes nad, including within axons. however, instead of killing axons as the nad hypothesis would predict, it does precisely the opposite: it phenocopies the protective effect of wld s . moreover, ectopic expression of the bacterial enzyme nmn deamidase, a protein absent in mammals, protects injured axons both in transgenic mice and in primary neuronal cultures, but it has no effect on nad levels either under basal conditions or in degenerating nerves. these observations fit better with a proposed toxic role for the nad synthesis intermediate nmn, a model that can also explain the protective effect of wld s . a full understanding of the pathway should identify a number of points where intervention could be a treatment for multiple axonopathies. as with any medical discipline, expansoin of knowledge about the fundamental science behing a disorder of the human nervous system comes part and parcel with a change in our understanding of the epidemiology of any given disorder or groups of disorders. recent advances in our fundamental understanding of inflammatory neuropathies of the peripheral nervous system have been accompanied by drastic changes in our understanding of the neuroepidemiology of these disorders -the specific populationss affected by peripheral neuropathies, as well as the varying importance / contributions of select peripheral neuropathies to the overall burden of peripheral nervous system (pns) disease, and how this shift in epidemiological understanding influences the clinical approach to diagnosis and management of patients with pns disease. the past few decades have witnessed a paradigm shift in many aspects of pns disease diagnosis and treatment; from the association of human immunodeficiency virus (hiv)-associated neuropathies; to the increassing recognition of hereditary / familial peripheral neuropathies; to the increased recognition of specific neuropathies such as multifocal motor neuropathy with conduction block. in addition, timely events such as the recent, and increasingly irrefutalbe evidence for a link between zika virus and a guillain-barré syndrome, and the rather unexpected resurgence of peripheral neuropathies due to previously 'exotic' etiologies such as lepromatous neuropathy require prompt clinical attention. this plenary session aims to describe the evolving neuroepidemiology of peripheral nervous system disorders, and how these changes may influnece the clinical approach to the diagnosis, prognostication, and treatment of otherwise 'unusual' periphal nerve diseases. oxaliplatin chemotherapy for colorectal cancer is seriously limited by neurotoxic side effects which are not fully understood. oxaliplatin-induced peripheral neurotoxicity (oipn) comprises an acute syndrome and a chronic sensory neuropathy. the acute symptoms, notably cold hyperalgesia, have been attributed to transient ion channel dysfunction, and the worse they are the more severe the chronic neuropathy that ensues. we designed a combined in vitro and in vivo project, using neurophysiology to better understand the pathogenesis of oipn. in the in vitro study, differentiated f11 cells (rat drg neurons x mouse neuroblastoma n18tg-2 cell line) were incubated for 24 and 48 hours in 7.5 m oxaliplatin, and their electrophysiological properties studied by patch-clamp. the treated f11 cells showed relatively depolarized resting membrane potentials, significantly decreased firing frequencies, and increased sodium current densities. moreover, a decrease in erg (ether-à-go-go-related gene) potassium current was also evident. in the in vivo study, we applied nerve excitability testing (net) to a wistar rat model of oipn. to investigate the acute syndrome, we compared behavioural and neurophysiological data of 2 animal cohorts (controls and oipn rats, n=9 each) before and after oxaliplatin administration (5mg/kg, iv). twenty-four hours after the injection we observed differences between the 2 groups in behaviour (cold plate test, p=0.008) and in superxcitability of motor axons (p=0.002). to investigate the chronic neuropathy, we compare a control group (n=10) with a treated group (n=10, oxaliplatin 3 mg/kg twice weekly x 4 weeks, iv). both groups are studied with behavioural, neurophysiological (sensory and motor nerve conduction studies, net), and pathological (caudal and sciatic nerve, skin biopsy, drgs) methods. data are collected at baseline, end of treatment and 6 weeks after treatment; to obtain a full net profile of all significant changes. in this highly translational approach to oipn, the in vivo net changes in the acute and chronic rat models can be matched on the one hand to findings from in vitro experiments, and on the other to clinical data, since net is also easily applied in humans. of these results. in denmark there is a unique situation to conduct epidemiological studies facilitated by the danish civil registration and the danish national hospital registry (dnhr). this enables us to identify all gbs patients in denmark in a given period. from the same period as the igos 1000 cohort was included we have identified all gbs patients admitted to or seen in outpatient's clinics of hospitals in denmark (september 1 st 2012 to december 31 st 2015). records from the population based danish cohort will be reviewed for demographic and clinical data and compared to the patients included in igos from denmark, as well as with the igos 1000 europe/america cohort. during this period 93 patients from denmark have been included in igos. the danish group is comparable to the europe/america group not counting the danish patients (n=640) of the igos1000 cohort in regard to sex and age at entry, gbs disability score at nadir, and percentage of patients needing mechanical ventilation. in the danish igos group 57% are males, the median age is 58(39-67) years, the mean(sd) gbs disability score at nadir 3.6 (1.0), and 18 % of the danish group needed mechanical ventilation. in the europe/america group 59% are males, the median age is 54(37-66), mean(sd) gbs disability score at nadir 3.5(1.0) and 17 % of the group needed mechanical ventilation. at the meeting we will compare and present data from the danish population based cohort as well as epidemiological data. chronic inflammatory demyelinating polyneuropathy (cidp) is a common autoimmune disease of the peripheral nervous system (pns) that causes sensorimotor impairment. mice with a dominant autoimmune regulator gene (aire) g228w mutation on the non-obese diabetic (nod) background (nod.aire gw/+ mice) develop spontaneous autoimmune peripheral polyneuropathy (sapp) resembling cidp. in sapp, demyelination is caused primarily by th1 t cells; however, the contributions of nerve-resident cells such as schwann cells are poorly understood. we identified a population of non-hematopoietic, integrin alpha 2+ (itga2+) cells in the pns that increases in frequency and number during sapp. these itga2+ cells coexpress numerous schwann cell markers including sox10, p75, s100b, myelin protein zero, and peripheral myelin protein 22, suggesting that itga2+ cells are schwann cell-like. additionally, during sapp, these itga2+ cells upregulate the extracellular matrix protein periostin (postn), which has recently been shown to promote macrophage recruitment and activation in inflammatory disease and cancer. our data indicate that macrophages are pathogenic during sapp. therefore, we hypothesized that itg2a+ cells promote macrophage recruitment during sapp via postn production. to test this hypothesis, we performed in vitro chemotaxis assays. conditioned media from nod.aire gw/+ nerve promoted significantly more macrophage chemotaxis than conditioned media from postn −/− nerve. furthermore, postn recombinant protein was sufficient to induce macrophage chemotaxis in vitro. our findings show that itg2a+ schwann cell-like cells mediate macrophage chemotaxis by upregulating postn during sapp and suggests postn as a novel target for the treatment of cidp. "wear-off" frequency will be analyzed by assessing the proportion of subjects with any given degree of gs and rods intracycle fluctuation and the proportion of cycles in which gs and r-ods fluctuation occurs. to determine the extent of "wear-off" the degree of difference between maximum and minimum gs, r-ods, tugs, onls, and vas scores will be analyzed. currently 22 subjects from 4 different sites have been enrolled (7 sites eligible for enrollment). this interim study report will provide preliminary representative data, demonstrating ivig "wear-off" effects on gs and other outcome measures. by better understanding the frequency and extent of ivig treatment-related fluctuations we expect that these results will help facilitate development of cidp treatment optimization strategies. we also expect that this information will be important in forming hypotheses to be tested in future studies (for example, comparing different dosage intervals, optimal ivig taper guidelines, or assessing the long-term outcome of short-term cycle to cycle clinical fluctuations). neuropathic pain is a frequent feature of peripheral neuropathy causing a significant impact on patients' quality of life and health care costs. resolving the genetic architecture of painful neuropathy will lead to better disease management strategies, risk stratification, and counselling. therefore, we aim to develop a reliable technique to rapidly and accurately re-sequence multiple genes in a large cohort of painful neuropathy patients at low cost. whole exome sequencing of thousands of samples remains expensive for clinical use. several targeted enrichment approaches are currently available to selectively enrich for genomic regions of interest. in this study, we compared the sensitivity, specificity, targeting efficiency, reproducibility of performance and cost effectiveness of truseq ® custom amplicon-next generation sequencing (tsca-ngs) and molecular inversion probes-next generation sequencing (mips-ngs) methods. for both methods, we constructed a targeted enrichment kit to capture the coding and exon-flanking intron sequences of nine sodium channel genes (scn3a, scn8a-scn11a, and scn1b-4b) expressed in nociceptive neurons. probes were designed for the two methods using their respective informatics pipelines. in total, 180 patients with diabetic and idiopathic neuropathy were tested by both methods. among the 180 patients, 70 patients were tested previously by sanger sequencing for scn9a-scn11a. approximately 39kb was captured and sequenced. 95% of the targeted regions showed an average coverage of ≥20x in tsca-ngs, and 96% in mips-ngs. we managed to identify 12 potential pathogenic mutations and 1294 polymorphism variants by mips-ngs and tsca-ngs. moreover, we observed a perfect agreement (100%) between sanger sequencing data and those obtained using mips-ngs and tsca-ngs. both ngs approaches showed user-friendly software to design probes and exhibited a similar on-target efficiency. although the overall coverage per region varied across different dna samples, it was sufficient to detect any variant in these regions. mips-ngs has more versatile assay design, demonstrated a high degree of flexibility with probes re-placement and >10x cheaper than tsca-ngs. mips-ngs is a reliable, flexible, and inexpensive method to detect genetic variations in thousands of patients. in our centers, this technology is currently implemented as a routine diagnostic tool for screening of sodium channel genes in painful neuropathy patients. alonso-jiménez a 1,2 , belvis-nieto r 3 , diaz-manera j 1,2 , illa i 1,2 , querol l 1,2 . 1 neuromuscular diseases unit, neurology department, hospital de la santa creu i sant pau, universitat autònoma de barcelona, spain; 2 centro para la investigación biomédica en red para enfermedades raras, ciberer, madrid, spain; 3 neurology department, hospital universitario dexeus, barcelona, spain. most acute demyelinating polyneuropathies have an immune-mediated pathogenesis and are included within the guillain-barré syndrome spectrum. occasionally, other mechanisms such as metabolic, infectious or toxic may lead to gbs-like presentations. thermatrim ® and pura alegria ® are different brands of the same illegal slimming product that is sold through online vendors and in which the exact composition is unknown. here we present a patient with an acute demyelinating polyneuropathy secondary to the intake of the slimming product "pura alegría". a 50 year-old woman with no remarkable medical history reported 7 days history of distal numbness in her feet that progressed in one week to her knees and her left hand. she had had an upper respiratory tract infection ten days prior to these symptoms. the neurological examination showed absent distal vibratory and arthrokinetic sensations and arreflexia in lower limbs, decreased vibratory sensation in her hands and a ataxic gate. the lumbar puncture showed 0.89 g/l of proteins with no cells. the emg fulfilled diagnostic criteria for acquired demyelination. intravenous immunoglobulin therapy was started but the symptoms kept worsening and corticosteroids were started. the patient mentioned then the slimming product. a brain mri showed diffuse leukoencephalopathy that was asymptomatic. steroids and the pura alegria slimming products were withdrawn and the patient recovered completely after one year of follow-up. "pura alegría", "thermatrim" and "thermatrim plus" are slimming products that were forbidden in spain after several cases of acute leukoencephalopathy and acute polyneuropathy. exact composition is unknown although the spanish drug agency detected the pesticide malonoben, a tyrosin kinase inhibitor, among the components. since 2014 nine cases of pura alegria/thermatrim neurological toxicity, including leukoencephalopathy and polyneuropathy have been described. all cases had good outcomes after treatment withdrawal, although recovery is slow and may be incomplete. our case highlights the need to carefully consider drug toxicity, including dietary supplements, in the differential diagnosis of gbs specially when evolution does not follow typical patterns. alvarez s 1 , klein d 2 , martini r 2 , moldovan m 1,3 , krarup c 1,3 . 1 center for neuroscience, university of copenhagen, denmark; 2 department of neurology, developmental neurobiology, university hospital würzburg, germany; 3 department of clinical neurophysiology, rigshospitalet, copenhagen, denmark. charcot-marie-tooth neuropathy type 1a (cmt1a) resulting from peripheral myelin protein 22 kda (pmp22) overexpression is the most common hereditary motor and sensory neuropathy in humans. the transgenic pmp22 (pmp22tg) mouse line c61 carrying 4 copies of the human pmp22 gene, has a slowly progressing neuropathy phenotypically like cmt1a with thin and abnormally thick myelin profiles and supernumerary schwann cells. in addition, pmp22tg nerves showed activated macrophages leading to axon-myelin compartment disruption and maldistribution of k+ channels (kohl b et al, am j pathol. 2010; 176: 1390) . the aim of the present study was to investigate the motor axon excitability in pmp22tg versus wt littermates. multiple measures of motor axon excitability under anesthesia were carried out by stimulation of the tibial nerve at ankle and "threshold-tracking" the plantar compound muscle action potential (cmap). at age 3 months, when the post-developmental maturation was nearly complete in the wt, the pmp22tg cmap showed an increase in latency by 29%. the cmap amplitude was decreased by 36%, although the mean motor unit size (mscan method) appeared unchanged indicating a lack of collateral sprouting. furthermore, pmp22tg showed abnormalities in both passive cable properties and voltage dependent parameters. at age 6 month, the cmap latency of pmp22tg was increased by 70% as compared to wt. in contrast to this marked conduction slowing along the tibial nerve from 3 to 6 months of age, the progression of excitability changes localized at ankle appeared modest. nevertheless, when pooling data from 3 to 6 months, the increase in pmp22tg latency was correlated (spearman p<0.05) with an increase in accommodation half-time during depolarizing electrotonus (+40% of threshold) from 29 to 35 ms and a reduction of the late subexcitable period of the recovery cycle from 16 to 9% of threshold, both changes consistent with a redistribution of k+ currents consistent with the maldistribution of k+ channels. our data suggest that in the pmp22tg cmt1a model, a functional, thus potentially reversible abnormality in k+ channel distribution, accumulates along the nerve and aggravates the conduction impairment due to impaired myelin formation and maintenance. alvarez s 1 , krarup c 1,2 , moldovan m 1,2 . 1 center for neuroscience, university of copenhagen, denmark; 2 department of clinical neurophysiology, rigshospitalet, copenhagen, denmark. mice heterozygously deficient of myelin protein p 0 gene (p 0 +/−) show a mild progressive dysmyelinating neuropathy, with conduction slowing and impaired excitability, phenotypically similar with charcot-marie-tooth disease type 1b (cmt1b). we found that in p 0 +/− the accumulating myelin abnormalities were paralleled by progressive changes in voltage-dependent motor axon function resulting in neurotoxic membrane depolarization (rosberg mr, et. al. neurobiol dis. 2016 93:201) . the aim of this study was to investigate the relationship between demyelination and motor axon function in p 0 +/−. demyelination of the right sciatic nerve by topic lysophosphatidylcholine (lpc) application was carried out in p 0 +/− and wild-type (wt) mice, in 1 year (mature) and 2 years (aged) groups. multiple measures of motor axon excitability under anesthesia were carried out by stimulation of the tibial nerve at ankle (distal to lpc demyelination) and "threshold-tracking" the plantar cmap responses. live imaging studies by cellvizio (mauna kea technologies, paris, france) confocal laser endomicroscopy were carried out in transgenic mice expressing the fluorescent reporter yfp in peripheral nerve axons under the thy1 promoter. in mature wt the sciatic morphological and electrophysiological demyelinating features following lpc could be readily observed at 2 hours but disappeared by 2 weeks. no morphological changes could be observed at the tibial level. consistently, no conduction or excitability changes could be observed at the right tibial neve level as compared to the left tibial nerve in wt. in contrast, in p 0 +/− the motor axon function was impaired at the tibial nerve level at 2 weeks after sciatic lpc demyelination. in mature p 0 +/−, although the cmap amplitude appeared preserved, the distal motor latency was prolonged whereas the excitability measures showed reduced deviations during threshold electrotonus and increased refractoriness at the expense of superexcitability of the recovery cycle, both consistent with membrane depolarization. furthermore, in aged p 0 +/− the delayed tibial conduction was associated with a drop in cmap amplitude and a prolongation of the strength-duration time constant. taken together these data suggest that focal demyelination aggravates membrane dysfunction along the entire motor axon in p 0 +/− providing a novel experimental model to explore the link between demyelination and axonal membrane dysfunction in cmt1b. amass l 1 , li h 1 , gundapaneni b 2 , schwartz j 1 , keohane d 1 . 1 pfizer inc., new york, ny, usa; 2 inventiv health inc., burlington, ma, usa. a number of factors can influence disease progression in transthyretin familial amyloid polyneuropathy (ttr-fap), a rare, fatal, hereditary amyloidosis. this analysis evaluated the specific role of baseline neurologic severity on neurologic disease progression in ttr-fap. a predictive model was created based on longitudinal data from val30met patients who participated in the tafamidis (a selective ttr stabilizer) clinical development program. data from the intent-to-treat population of the double-blind, placebo-controlled registration study (tafamidis group, n=64; placebo group n=61) and its two consecutive open-label extension studies in which all patients received tafamidis were used. the second extension study is ongoing, but a formal, prospectively-planned interim analysis was conducted with the cut-off date of december 31, 2014. this analysis focused on the first 12 months of treatment for the overall study cohort analyzed. the neuropathy impairment score-lower limbs (nis-ll) was used to assess neurologic functioning at baseline and at subsequent study visits. a linear mixed-effects model for repeated-measures (mmrm) analysis, with baseline nis-ll, treatment, and their interactions with time as fixed effects, was used, and the slope and intercept for each patient were included as random effects. patients were primarily caucasian with early-stage neurologic disease (baseline nis-ll mean [standard deviation]: tafamidis, 8.4 [11.4]; placebo, 11.4 [13.5] ). across both groups, disease progression increased with increasing levels of baseline severity (nis-ll) (p<0.0001). however, the predicted magnitude of change from baseline to month 12 for tafamidis was consistently less than that for placebo across a range of observed baseline nis-ll values, suggesting a disease-modifying effect of tafamidis. similar findings were observed for the nis-ll muscle weakness subscale. this mmrm analysis in patients with val30met ttr-fap demonstrates that disease progression strongly depends on baseline neurologic impairment and highlights the disease-modifying effect of tafamidis across a range of baseline levels of neurologic severity. clinicaltrials.gov identifiers: nct00409175, nct00791492, nct00925002. amino h 1 , misawa s 1 , sekiguchi y 1 , shibuya k 1 , watanabe k 1 , suichi t 1 , kuwabara s 1 . 1 department of neurology, chiba university, chiba, japan. guillain-barré syndrome (gbs) is a potential life threatening neurological disorder and respiratory insufficiency is one of the critical complications. eramus gbs respiratory insufficiency score (egris) is a method for predicting the chance of respiratory insufficiency in gbs. however, clinical characteristics and courses can vary for subtypes of gbs, whose occurrences differ for each region: acute inflammatory demyelinating polyneuropathy (aidp) is very common in european countries, whereas acute motor axonal neuropathy (aman) is frequently seen in asian countries. the aim of this study is to investigate the usefulness of egris in japan, where aman is more common than in the netherlands. clinical and electrophysiological profiles of consecutive gbs cases, who visited our hospital within 28 days after symptoms onset between 1998 and 2015, were reviewed. of the 150 gbs patients, 37 % were classified as aidp and 20% as aman according to the electrodiagnosis criteria by ho and colleagues. higher egris scores correspond to higher risk of respiratory insufficiency in total of the gbs patients, as well as in aidp patients. however, in patients with aman, egris scores did not always match the chances of respiratory insufficiency: up to 17% of the patients with low risk of egris showed respiratory failure, whereas only 25% of the patients with high risk of egris needs intubation/mechanical ventilation. in aman, associations with mechanical ventilation were seen for rapid progression (shorter duration between onset and hospital admission), more decreased vital capacity, and more frequent autonomic involvement. egris is useful also for japanese gbs patients. however, for aman patients, it should be used with discretion. another score to predict respiratory insufficiency might be required in asian countries. anandan c 1 , litchy wj 1 , laughlin rs 1 , leep hunderfund an 1 , naddaf e 1 . 1 mayo clinic, rochester, usa. in patients with suspected ulnar neuropathy, nerve conduction studies (ncs) are commonly requested to help with diagnosis and localization. however, routine ncs are often normal or not localizing. ulnar ncs recording from the first dorsal interosseous muscle (ncs-fdi) is thought to increase the diagnostic yield of electrodiagnostic testing, although not commonly considered. we developed a quality improvement strategy to routinely perform ulnar ncs recording from the abductor digiti minimi muscle (ncs-adm) as well as ulnar ncs-fdi in all patients referred for suspected ulnar neuropathy. we utilized the dmaic (define, measure, analyze, improve, control) model of process improvement to define our problem and create a map of the current process for ulnar neuropathy diagnosis in our electromyography laboratory. we determined baseline performance via review of distal sensorimotor polyneuropathy (dpn) is the most common complication of diabetes and risk factors beyond hyperglycemia have proven important particularly in type 2 diabetes (t2dm). only few prospective studies from early-stage t2dm exist. we aimed to study the development of dpn during the first 13 years after a screening-based diagnosis of t2dm. from the addition-denmark study 1445 participants were eligible for this study. dpn was assessed by the michigan neuropathy screening instrument questionnaire (mnsi) at four time-points during follow-up. dpn was defined by a mnsi score ≥ 4. 189 participants (13%) were positive in mnsi at baseline and thus excluded from this study. by kaplan-meier plot we evaluated the cumulative incidence of dpn and in cox proportional hazard models we calculated hazard ratios (hr) for the intervention groups in the addition trial and for various covariates proposed to influence the development of dpn. models were adjusted in steps for intervention group, age, sex, baseline mnsi, lipid-lowering and anti-hypertensive treatment. this study cohort consists of 1256 participants (59% men) with a median age of 60.8 years (p25;p75: 55.6;65.6) and median baseline hba1c of 6.3 (p25;p75: 6.0;6.9). a cumulative incidence of 10% was seen during 13 years of diabetes. there was no statistically significant difference in hr between the intervention groups or by sex but a significantly higher hr of 1.03 (95%ci: 1.00;1.07) was seen for age (per year). the highest hr was found for a history of cardiovascular disease (myocardial infarction or stroke) up to ten years prior to the diabetes diagnosis with a hr of 3.04 (1.38;6.68). weight, waist circumference, body-mass index and methylglyoxal (log 2 transformed) showed modest but statistically significant associations with incident dpn with standardized hrs of 1.35 (95%ci: 1.11;1.63), 1.35 (95%ci: 1.08;1.67), 1.39 (95%ci: 1.14;1.69) and 1.44 (95%ci: 1.12;1.86) respectively. this study demonstrates a fairly low cumulative incidence of dpn in people with screen-detected t2dm and provides evidence that macrovascular disease, obesity and oxidative stress are important risk factors for dpn even at the earliest stages of t2dm. andermann syndrome, also known as agenesis of the corpus callosum and peripheral neuropathy (accpn), is an autosomal recessive disorder with a broad spectrum of mild to severe neuromuscular and psychiatric consequences. the gene variants causing disease were first identified in french-canadian families. in the present study, we intended to phenotype and genotype a series of non-french-canadian familial cases presenting with charcot marie tooth disorder associated with agenesis/dysgenesis of the corpus callosum. for this purpose, seven families, 5 of consanguineous marriage, were studied. patients were clinically and para-clinically investigated using mri and electrophysiology (mncvs). for some, a sural nerve biopsy was taken. microsatellite markers around the accpn locus were used in two large families; followed by sanger sequencing of all the exons and intron-exons boundaries of the gene, in one patient from each of the 7 families. the age at onset of the disease was at birth in the patients from the largest consanguineous family (3 affected individuals). the biopsy from one patient showed a severe demyelinating neuropathy with many hypomyelinated fibres and mostly secondary axonal changes. these finding were compatible with electrophsiological data where the mncvs are of demyelinating range. dysgenesis of the corpus callosum in one patient and agenesis in another sib were revealed by mri. we identified one homozygous truncating mutation in this family. interestingly, no causative variant was found in a patient from another family and showing homozygous haplotype. two different heterozygous variants were identified at one hit in two patients from two non-consanguineous families. genetic investigations will be continued to identify the possible second hit. in the 4 remaining families, no variant was found. the negative family cases will be subjected to ngs. at this stage, it is tempting to speculate on the genetic heterogeneity of accpn in our series. baba m 1 , suzuki c 1 , ogawa c 2 , tomiyama m 1 . 1 department of neurology; 2 diabetes center, aomori prefectural central hospital, aomori, japan. in 2007 we introduced a staging system of severity of diabetic polyneuropathy (dpn) by nerve conduction study (ncs) of the lower limb: sensory ncs of the sural nerve and motor ncs of the tibial nerve. the system consists of five stages; ncs-0 (normal): no abnormalities, ncs-1 (mildly abnormal): presence of delay of mcv, scv, minimal f-wave latency, or positive a-wave, ncs-2 (moderately abnormal): decrease in sural snap less than 5uv, ncs-3 (severely abnormal): decrease in plantar muscle-cmap to 2-5mv, ncs-4 (ultimately abnormal): plantar muscle-cmap lost or less than 2mv with trace of sural-snap. to examine validity of the system, we conducted 5-year prospective observation on development of diabetic foot (df) by the ncs staging system. in addition, occurrence of ischemic heart disease (ihd) and stroke (is), and death of neuro-vascular events were also counted. 1n 2007-09, we carried out ncs in 308 diabetics, and categorized them by the ncs staging system: 6% was ncs-0, 38% was ncs-1, another 38% was ncs-2, 10% was ncs3, and 7% was ncs-4. we then followed them and prospectively counted the occurrence of df, ihd and is in 230 patients (mean age 57ys). the occurrence of df during the following 5years was; ncs-0: 0%, ncs-1: 0%, ncs-2: 1%, ncs-3: 16%, ncs-4: 24%. occurrence of any of df, ihd and/or is was as follows; ncs-0: 0%, ncs-1: 6%, ncs-2: 31%, ncs-3: 54%, ncs-4 59%. there was no death from nsc-0, −1, and −2 groups (n=189), while two from ncs-3 group (n=24) were found dead in a bed or on a driver's seat, and other two from ncs-4 group (n=17) died of sudden cardiac arrest or infection after foot amputation. in summary, the present ncs grading system seems to work satisfactory not only for diagnosis of severity of the current dpn, but also for prognostic prediction of the dpn-related foot and vascular events. bacon c 1 , feely sme 1 , shy me 1 . 1 university of iowa hospital, iowa city, ia, usa. for patients with charcot-marie-tooth disease, also known as hereditary motor and sensory neuropathy, the rasch modified cmtnsv2 is a validated measurement of symptoms and impairment. the score is comprised of nine parameters of a clinical examination, including nerve conduction studies (ncs) . each parameter has an individual score ranging from zero to four, with the composite score having a maximum of 36 prior to rasch modification. for patients who do not complete a ncs, the cmt exam score (cmtesv2) is used, with a maximum score of 28 before rasch modification. one parameter of the cmtesv2 is the vibration sense. using a rydel tuning fork, a care-giver measures vibration sense in a patient's feet, ankles, and knees and a score is determined by the severity of reduced vibration sense. in 80 cmt1a patients, 50% received a score of 3 out of 4, noted by a reduced vibration sense at the knee. in order to capture a more sensitive vibration measurement, we tested ways of taking the total raw score of the rydel tuning fork at each point of vibration sense, the toe, ankle, and knee bilaterally. scores range from zero to 48, with 48 reflecting full vibration sense. in this modified measurement, vibration sense scores varied in wider distribution. for cmt1a patients captured in this studied, a modified vibration sense score results in a potentially more sensitive total cmtesv2 score. bae dw 1 , an jy 1 . 1 st. vincent's hospital, the catholic university of korea, suwon, korea. diabetic lumbosacral radiculoplexus neuropathies (dlrpn) are usually subacute painful, monophasic, asymmetrical lower limb neuropathies with incomplete recovery due to ischaemic injury and microvasculitis. the diagnosis relies mostly on clinical suspicion and characteristic electromyographic findings. however, in acute phase, neuroimaging has more important diagnostic significance than electrophysiological studies. here we describe mri and ultrasound findings in a 59-year-old woman with dlrpn who was diagnosed with diabetes three years ago, but has not received any other treatment. she had a 7-day history of acute-onset severe pain with weakness of muscles innervated by left femoral and obturator nerve and decreased sensation in left l2-l4 dermatome. nerve conduction studies showed reduced amplitude in left femoral nerve and electromyography showed only increased insertional activity in left iliopsoas muscle and no volitional activity in muscles innervated by left femoral and obturator nerve. ultrasound revealed increased cross-sectional area (csa) of left femoral and lateral femoral cutaneous nerve. mri showed enhancement in left l3, 4 nerve roots and proximal femoral nerve and increased signal intensity in left iliacus and iliopsoas. we diagnosed her with dlrpn and started corticosteroid. nerve ultrasound has not been previously reported in a patient with cabin air in commercial airliners originates from aircraft engines or auxiliary power units. this bleed air may occasionally be contaminated with hydraulic fluids and engine oil that contains a number of potentially hazardous chemicals including tricresyl phosphate (tcp). over the last years reports are emerging about aircrew members that experience symptoms such as tingling or burning of extremities in addition to headache, and vertigo. this "aerotoxic syndrome" is controversially discussed in the literature and has been attributed to exposure to organophosphate contaminated cabin air. since tcp has been associated with peripheral neuropathy we aimed to determine the frequency of peripheral neuropathy among frequent flyers. 84 civilian air crew members and frequent flying passengers (m:f = 35:49, median age 48 years, median exposition time in aircrafts of 12.000 hours) were examined at the university hospital of cologne or at the frankfurt airport (iata code fra) by a detailed questionnaire of past medical conditions, a standardized neurological examination and nerve conduction studies of sural, tibial, and ulnar nerves. we identified 5 subjects with clinical and electrophysiological evidence for large fiber peripheral neuropathy. incidence of peripheral neuropathy was not correlated to exposition time in aircrafts. in addition 11 subjects showed signs of ulnar neuropathy, 13 subjects reported abnormal vibration sensation, 27 subjects suffered from gait imbalance and 50 individuals reported tingling of extremities. our study shows a 5.95% prevalence of large fiber peripheral neuropathy among frequent flyers. comparison of these data with prevalence rate in an age-matched control group will reveal a possible association of chronic exposure to cabin air and risk for peripheral neuropathy. the high incidence of the symptom tingling in our cohort warrants further studies to determine the risk for small fiber neuropathy in this condition. intravenous immunoglobulin (ivig) are human igg derived from plasma pools of healthy donors. although there are studies in literature evaluating their effectiveness in different pathological animal models, there are no data about their possible role on bortezomib (btz)-induced peripheral neuropathies. female wistar rats were treated following a preventive schedule (btz and ivig co-treatment for 3 and 8 weeks) and a therapeutic schedule (4 weeks of btz treatment followed by a 4-week ivig-btz co-treatment). caudal nerve conduction velocity (ncv), plantar and dynamic tests were performed at different time points. animals were sacrificed after 3ws (acute phase) or 8ws (chronic phase) and tissue samples (dorsal root ganglias -drg-, sciatic nerve, caudal nerve, skin) were collected for morphological, morphometrical and immunohistological analysis.in the preventive schedule, ivig was not able to rescue caudal ncv reduction caused by btz neither after 3 nor after 8 weeks of co-treatment. same results were observed in the therapeutic schedule. on the other hand, the evaluation of mechanical allodynia and cold hyperalgesia showed that ivig injection protected from btz effect in both treatment schedules. morphometric analysis evidenced that, even if not statistically significant only the preventive schedule has a tendency to protect the caudal nerve from btz damage. this result is consistent with the morphological evaluation of the nerve. also, intra-epidermal nerve fibers density was preserved in the preventive schedule but not in the therapeutic one. finally, sciatic nerve and drg macrophage infiltration levels tended to be reduced in the therapeutic schedule and were brought back to ctrl (rats not treated or injected with ivig alone) levels in the preventive one. in conclusion, we were able to demonstrate for the first time that ivig treatment especially used as preventive treatment option may reduce btz-induced neuropathic painful pointing out the possible role of inflammation in the pathogenesis of this invalidating pathology. this work was supported by kedrion spa. we studied the prevalence, the molecular cause and clinical presentation of hereditary motor neuropathies in a large cohort of patients from the north of england. detailed neurological and electrophysiological assessments and next generation panel testing or whole exome sequencing were performed in 105 patients with clinical symptoms of distal hereditary motor neuropathy (dhmn, 64 patients), axonal motor neuropathy (motor cmt2, 16 patients) or complex neurological disease predominantly affecting the motor nerves (hmn plus, 25 patients) . the prevalence of dhmn is 2.14 affected individuals per 100.000 inhabitants (95% confidence interval: 1.62-2.66) in the north of england. causative mutations were identified in 26 out of 73 index patients (35.6%). the diagnostic rate in the dhmn subgroup was 32.5%, which is higher than previously reported (20%). we detected a defect of neuromuscular transmission in 7 cases and identified potentially causative mutations in 4 patients with demyelinating multifocal motor neuropathy. many of the genes were shared between dhmn and motor cmt2, indicating identical disease mechanisms therefore we suggest changing the classification and include dhmn also as a subcategory of cmt. abnormal neuromuscular transmission in some genetic forms provides a treatable target to develop therapies. barohn rj 1 , gajewski b 1 , pasnoor m 1 , brown l 1 , herbelin l 1 , kimminau k 1 , jawdat o 1 , parks c 1 , shlemon p 1 , dimachkie mm 1 and the pain-controls study team 1 . 1 the university of kansas medical center, kansas city, ks, usa. cryptogenic sensory polyneuropathy (cspn) is a common slowly progressive neuropathy that affects adults and presents with significant neuropathic pain for which multiple medications have been tried including antiepileptics, antidepressants, topicals and narcotics. a web based survey among neuromuscular experts suggested pregabalin as being more effective than other medications, however there are presently no comparative studies to assess the most effective medication. the objective of this study was to determine which of the 4 pharmaceutical therapies (pregabalin, duloxetine, nortriptyline or mexiletine) is most effective for neuropathic pain and best tolerated in cspn. to achieve this objective we performed a prospective randomized open labelled comparative effectiveness adaptive design study of cspn patients through the patient centered outcomes research institute (pcori). cspn patients who fulfilled the inclusion and exclusion criteria were enrolled into this study. patients underwent a baseline neurological evaluation and randomly assigned to one of the 4 neuropathic medications for 3 months. the primary outcome is the change in likert-like pain scale. the secondary outcomes included nih pain interference scale, nih fatigue interference scale, nih sleep disturbance scale, sf-12 and adverse events. the outcome measures are performed at baseline, month 1, 2 and 3. statistical analysis using bayesian adaptive design developed by berry consultant software will be performed to determine winner and losers (winner = greater than 2 point improvement in pain). total number of patients to be enrolled is 400. recruitment has been challenging and a number of recruitment techniques have been used. to date, there have been 292 patients screened, 288 patients randomized from 40 us sites. anticipated completion of enrollment by june 2017 and end of final patient assessment by september 2017. interim analysis performed after first 100 patients completed their 3months as part of bayesian adaptive design analysis and occurs every 13 weeks. the distribution of randomization of patients to the 4 medications at last adaptive design randomization was 29.6% to medication 1, 30% to medication 2 , 20.8% to medication 3 and 19.6% to the 4 th medication. this study may give physicians and patients evidence for future management of cspn patients. transthyretin amyloidosis (attr), which encompasses a group of disorders with significant clinical variability, is caused by transthyretin (ttr) derived amyloid deposition. the clinical aspects of autonomic nervous system involvement in attr are only partially known. the ongoing, multinational, longitudinal, observational transthyretin amyloidosis outcomes survey (thaos) provides the opportunity to expand our understanding of dysautonomia in attr. data from all symptomatic subjects enrolled in the thaos registry with a diagnosis of attr (cut-off date: january 14, 2016) were assessed for the presence and temporal course of autonomic symptoms, genotype and phenotype associations, and clinical burden according to the frequency and severity of symptoms. of 2362 symptomatic subjects enrolled in thaos, 1006 (42.6%) had autonomic symptoms at enrollment including: gastrointestinal (1399 subjects, 59.2%), urinary (494, 20.9%), erectile dysfunction (329, 13.9%), orthostatic hypotension (223, 9.4%), xerophthalmia (183, 7.7%) and dyshydrosis (93, 3.9%). subjects with autonomic manifestations, compared with those without, were younger (mean age [standard deviation, sd] of 50.2 [15.1] vs 57.8 [17.7] years), with a longer duration of attr symptoms (9.7 [7.1] vs 6.7 [6.5] years). autonomic dysfunction was less common with wild-type attr (27 of 329 subjects, 8.2%) than in mutation groups: val30met (824/1471, 56.0%); non-val30met/non-cardiac (114/355, 32.1%); and "cardiac mutations" (val122ile, leu111met, thr60ala, or ile68leu mutations; 41/207, 19 .8%). similarly, time (mean [sd] , years) from first attr symptoms to onset of autonomic symptoms, was longest for wild-type attr (10.1 [11.4] ) followed by "cardiac mutations" (6.3 [7.7]), non-val30met/non-cardiac (5.1 [6.7]), and val30met (2.8 [4.9] ). autonomic symptoms were present at disease onset in over a third of subjects (355, 35.3%) . autonomic dysfunction was less frequent in subjects with cardiac phenotype (73 of 460 subjects, 15.9%), than with mixed (259/497, 52.1%) or neurologic (765/1171, 65 .3%) phenotypes. the burden of autonomic symptoms (mean [sd] ) varied by genotype, val30met (4.3 [4.0] , non-val30met/non-cardiac (3.5 [3.1], "cardiac mutations" (2.5 [2.6]), wild-type attr (1.6 [1.2]), and by phenotype, mixed (5.5 [5.0]), neurologic (3.9 [3.4]), cardiac (1.7 [1.2]). dysautonomia is common, and a significant burden, in subjects with hereditary forms of attr. its prevalence is higher in val30met than in other genotypes, and in the neurologic or mixed phenotypes. the objective of this study is to assess the usefulness of motor unit number index (munix) technique in charcot-marie-tooth type 1a (cmt1a) disease and to test correlation between munix and clinical impairment. munix technique was performed in abductor pollicis brevis (apb), abductor digiti minimi (adm) and tibialis anterior (ta) muscles in the non-dominant side. a munix sum score was calculated by adding munix of these 3 muscles. muscle strength was measured using the mrc (medical research council) scale. disability was evaluated with several functional scales including cmt neuropathy score version 2 (cmtnsv2) and overall neuropathy limitation scale (onls). 33 cmt1a patients with known pmp22 gene duplication were enrolled. the munix of the adm, apb and ta muscles were correlated with the mrc of the corresponding muscle (p<0.05). munix sum score was correlated with clinical scales: cmtnsv2 (r=−0.54, p<0.01), onls (r=−0.57, p<0.01). in conclusion, munix correlates with muscle strength and clinical measurements of disability in cmt1a patients. the munix technique evaluates motor axonal loss and correlates with disability. the munix sum score may be a useful outcome measure of disease progression in cmt1a. the objective of this study was to assess the usefulness of mri in charcot-marie-tooth type 1a (cmt1a) disease and to test correlation between muscle fat fraction and clinical impairment. mri was performed in the non-dominant lower limb of cmt1a patients and healthy controls. fat fraction of tibialis anterior muscle, cross section area and volume of sciatic nerve were determined. muscle strength of dorsiflexion was measured using a dynamometer. disability was evaluated with cmt neuropathy score version 2 (cmtnsv2). 15 cmt1a patients with known pmp22 gene duplication were enrolled. fat fraction of tibialis anterior muscle was significantly increased in patients compared to healthy controls. it was correlated with muscle strength (r=−0.62, p<0.05) and cmtnsv2 score (r=−0.65, p<0.05). cross section area and volume of sciatic nerve were significantly increased in patients compared to healthy controls. in conclusion mri fat fraction correlates with muscle strength and clinical measurement of disability in cmt1a patients. it may thus be a useful outcome measure of disease progression in cmt1a. basta i 1 , peric s 1 , cobeljic m 1 , bjelica b 1 , bozovic i 1 , kacar a 1 , nikolic a 1 , rakocevic stojanovic v 1 , stevic z 1 , lavrnic d 1 . 1 neurology clinic, clinical center of serbia, school of medicine, university of belgrade, belgrade, serbia. there is a complete lack of data about epidemiological and clinical features of chronic inflammatory demyelinating polyneuropathy (cidp) in serbia and surrounding countries. furthermore, there is a striking scarcity of information about quality of life (qol) in cidp patients and all qol studies have been conducted in countries with high standards of health care. in august 2016 we have designed the iness (inflammatory neuropathy study of serbia) in order to comprise as many patients with cidp from serbia, republic of srpska (bosnia and herzegovina) and montenegro covering population of more than nine million people. our first aim is to analyze overall impact of cidp on physical, mental and social areas of life measured with generic, symptom specific and disease specific questionnaires -sf-36, inqol and cap-pri, respectively. furthermore, we aim to analyze influence of the disease on patients' working status and presence of depressive mood measured by beck's inventory. following features of patients are included: sociodemographic data, clinical aspects of the disease, level of disability, severity of sensory symptoms, presence of comorbidities, electrophysiological characteristics, as well as fatigue, autonomic symptoms and neuropathic pain. we intend to define the most significant predictors of decreased qol in order to focus on patients with the highest risk and to improve care of cidp. we also want to see if cidp patients in complete remission as per clinical findings still have reduced quality of life. we have recruited 58 patient so far and we expect to include around 80 subjects overall. we will present the first data of the study at the pns meeting 2017. beaudonnet g 1 , prud'hon s 1 , cauquil c 2 , labeyrie c 2 , not a 2 , bouilleret v 1 , adams d 2 . 1 neurophysiology chu bicêtre, le kremlin bicêtre, france; 2 neurology chu bicêtre, le kremlin bicêtre, france. familial amyloid neuropathy (fap) is a life-threatening disease of autosomal dominant inheritance due to transthyretin (ttr) gene mutation, a liver-produced protein. current treatments slow down its natural course and are indicated from the very first objective symptoms. we aimed to evaluate two neurophysiological markers: sympathetic skin response (ssr) and heart rate variability (hrv) in the early detection of sympathetic damages due to fap. ssr and hrv were assessed in 21 ttr gene mutated patients with neither clinic nor electroneuromyographic abnormalities and 21 controls matched on gender and age. cases were recruited consecutively from current care in the french reference center for rare diseases of bicetre university hospital. ssr was recorded on the two palms and on the sole of the left foot with 3 to 7 stimulations between 15 and 20 ma. hrv was registered during three conditions of 60 seconds each: normal breathing, deep breathing (6 cycles of 5 seconds of inspiration and 5 seconds of expiration) and valsalva manoeuver during 15 seconds. valsalva ratio, defined by the ratio between the longest and shortest rr intervals, was significantly higher in the control groups after bonferroni correction (means of 1.556 and 1.929, respectively, p< 0.0001). there was no significant difference between the two groups for any ssr parameter, although means of amplitudes were systematically higher in controls than among cases. our results confirm that autonomic nervous fibers are damaged early in both clinical and electroneuromyographic asymptomatic patients mutated on the ttr gene. valsalva ratio seemed to be the most discriminative marker. long-term follow-up with test repetition and confrontation with cardiologic assessment will help to precise how these tests could be used in current care. they might help to identify high risk patients to propose them an appropriate early treatment and could be used to follow treatment efficacy. familial amyloidotic polyneuropathy (fap) was originally characterized by andrade as an axonal neuropathy which subsequently was found to be associated with a number of mutations in the plasma protein transthyretin (previously named prealbumin). it is now recognized that cardiomyopathy may be a significant factor in a majority of patients with the hereditary form of transthyretin amyloidosis (fap) and many of the transthyretin (ttr) mutations are associated with cardiomyopathy with no or minimal signs of peripheral neuropathy. attr-wt also called senile cardiac amyloidosis and senile systemic amyloidosis is recognized as late-onset, usually in the 8 th or 9 th decade of life, and the fact that the majority of patients are males. transthyretin neuropathy proven by nerve biopsy has been rarely reported in this population. here we report our experience with patients having attr-wt characterized by cardiomyopathy but also with varying degrees of peripheral neuropathy. clinically, the neuropathy appears as typical axonal or mixed axonal/demyelinating neuropathy as is seen in fap. pathologically, two types of ttr deposition have been found, (1) intraneural ttr amyloid deposits as seen in fap are present in some patients and (2) other patients have extensive vascular deposition of amyloid in both perineural arteries and veins without deposits within nerve trunks. in conclusion, peripheral neuropathy may definitely be a part of the attr-wt clinical presentation and with the increase in numbers of attr-wt cardiomyopathy patients being identified, it is important to ascertain whether any evidence of peripheral neuropathy is due to the amyloidosis and not to compounding syndromes such as diabetes mellitus type ii. besora s 1 , santos c 2 , izquierdo c 1 , martinez-villacampa m 2 , simó m 1 , bruna j 1,3 , velasco r 1,3 . 1 neuro-oncology unit, hospital universitari de bellvitge-institut català d́oncologia, ĺhospitalet, barcelona, spain; 2 medical oncology department, institut català d́oncologia, ĺhospitalet, barcelona, spain; 3 department of cell biology, physiology and immunology, institute of neurosciences, universitat autònoma de barcelona and centro de investigación biomédica en red sobre enfermedades neurodegenerativas (ciberned), bellaterra, spain. oxaliplatin (oxa) is the first-line chemotherapy agent in the treatment of colorectal cancer (crc). oxa-induced peripheral neuropathy is the most frequent long-term side-effect. retreatment with oxa is frequently considered in patients as salvage treatment. patients receiving oxa-based chemotherapy regimen at least twice at our institution between 2000 and 2016 were reviewed. the aim of this study was to investigate whether retreatment with oxa increases the risk of developing or worsening previous oxa-induced peripheral neuropathy. the severity of neuropathy was measured by national cancer institute-common toxicity criteria (nci), total neuropathy score (tns) © and nerve conduction studies. one hundred twenty-five crc patients were included. median age was 64 years. after first-line oxa-based chemotherapy, 67.2% of patients developed neuropathy according nci, after a median of 11 [1] [2] [3] [4] [5] [6] [7] [8] [9] [10] [11] [12] [13] [14] [15] [16] [17] cycles. severity of neuropathy was grade 1 (26.7%), grade 2 (31%), and grade 3 (9.5%). median time to retreatment with oxa was 30 months. frequencies of neuropathy before retreatment were as follows: 60.2% grade 0, 32.4% grade 1, and 7.4% grade 2. after retreatment, severities of neuropathy were 34.4 % grade 1 and 38.4% grade 2. no patient developed grade 3. 22.4% of patients did not develop neuropathy. peripheral neuropathy was the reason for stopping prematurely treatment after first-line and retreatment in 20.5% and 16.4% of patients, respectively. worsening of previous nci score was observed in 30.8% of patients. the great majority of patients (69.2%) remained within the same nci score than before retreatment after median 8 [1] [2] [3] [4] [5] [6] [7] [8] [9] [10] [11] [12] [13] [14] cycles. among those patients that did not develop neuropathy after first treatment (n=39), only 11 and 5 patients developed grade 1 and 2, respectively, after a median of 7 [1] [2] [3] [4] [5] [6] [7] [8] [9] [10] [11] [12] cycles. among those patients who initially developed grade 2 and 3 neuropathy, no differences in tnsc © scores just before and after finishing retreatment with oxa were identified (6 [3-11] vs 6 [4-12], p=0.214). retreatment with oxa in crc patients is a feasible option even in patients who developed moderate or severe neuropathy previously. lack of worsening of previous neuropathy is observed in the great majority of patients. neurological monitoring of patients candidates to retreatment with oxa should be considered. bessaguet f 1 , sturtz f 1 , magy l 1,2 , desmouliere a 1 , bourthoumieu s 1 , demiot c 1 . 1 ea 6309 -myelin maintenance & peripheral neuropathy, faculties of medicine and pharmacy, university of limoges, limoges, france; 2 department of neurology, reference center for rare peripheral neuropathies, university hospital of limoges, limoges, france. prolonged pressure and the resulting local ischemia are widely accepted as the primary etiology of skin pressure ulcers (pus) but precise mechanisms of their formation remain unclear. in this study, we wanted to study the potential role of sensory small nerve fibers in regulation of inflammation during pus formation. to achieve this goal, we developed a mouse model of a purely sensory neuropathy and this was induced by resiniferatoxin (rtx). in this model, seven days after a single injection of rtx (50 g/kg; ip), mice present a thermal and mechanical hypoalgesia associated with large substance p (sp) and calcitonin gene-related peptide (cgrp) depletion without neurodegeneration. this model mimic quite well what is observed in early stages of sensory nerve fiber defect. studies have shown that sp and cgrp are involved in cutaneous inflammation regulation. in fact, these neuropeptides are released by sensory fibers and are pro-inflammatory mainly through recruitment of immune cells and vasodilation. thus, we studied gene expression of pro and anti-inflammatory cytokines by a rna array approach during pus formation in control and rtx mice. seven days after a single injection of rtx, epidermis, dermis and subcutaneous tissue layer were pinched with magnetic plates during 12 hours. pressure induced a stage 3 pus. gene expression was evaluated in each compressed area 24h after pressure. results showed mainly a down-regulation of gene expression in pus of rtx mice compared to control mice. a decrease of cgrp/sp in skin sensory small fiber increased pus formation associated with an increase of interleukins (il)-1, il-4, il-11 and il-20 expression and a decrease of il-16 expression in rtx mice. supplementary experiments with rt-qpcr for each cytokine will be necessary to confirm these preliminary results. these observations suggest a cgrp/sp role in regulation of cytokines expression during pus formation. the new inflammatory profile exhibited in this study might help in the design of new treatments improving the quality of life of neuropathic patients prone to developing bedsores. bhattacharyya bj 1 , jayaraj nd 1 , belmadani a 2 , ren d 2 , rathwell ca 1 , hackelberg s 1 , miller rj 2 , menichella dm 1 . 1 department of neurology, northwestern university, chicago, il, usa; 2 department of pharmacology, northwestern university, chicago, il, usa. painful diabetic neuropathy (pdn) is one of the most common and intractable symptoms of diabetes, affecting 25% of diabetic patients. the hallmarks of pdn are neuropathic pain and small fiber degeneration, manifested by the loss of dorsal root ganglion (drg) nociceptor axons. neuropathic pain is associated with nociceptor hyper-excitability in the absence of physiologically appropriate stimuli. in states of neuropathic pain, drg nociceptors become increasingly responsive to a variety of excitatory influences, including inflammatory cytokines. in particular, we have shown that stromal cell derived factor-1 (sdf-1) and its receptor cxcr4 are necessary for the generation of neuropathic pain in mouse models of pdn. however, the molecular mechanisms leading to the hyper-excitability of drg nociceptors in pdn are unknown, as are the mechanisms leading to small fiber degeneration. this fundamental gap in our knowledge represents a critical barrier to progress in developing novel therapeutic approaches for pdn. the objective of this study is to identify the molecular cascade linking cxcr4/sdf-1 chemokine signaling to drg nociceptor hyper-excitability, neuropathic pain, and small fiber degeneration in pdn. drg nociceptors can be identified by a series of molecular markers, including expression of the sodium channel na v 1.8. indeed, >90% of na v 1.8-expressing drg neurons are nociceptors. feeding mice a high fat diet (hfd) for several weeks induces glucose intolerance, obesity, and mechanical allodynia, a particular pain hypersensitivity associated with pdn. using the hfd model combined with dreadd receptor technology, we have shown that reducing excitability of na v 1.8-expressing neurons prevents and reverse neuropathic pain, neuronal calcium overload, mitochondrial dysfunction, and small fiber degeneration. furthermore, we have shown that cxcr4 receptors are necessary for neuropathic pain and small fiber degeneration in pdn. taken together these data demonstrate that na v 1.8 nociceptor hyperexcitability in pdn is driven through the activation of cxcr4 receptors. inhibition of hyperexcitability can prevent and reverse the development of pdn. furthermore, these observations will advance our understanding as to how changes in excitability, calcium influx, and mitochondrial dysfunction in nociceptors contribute to neuropathic pain and small fiber degeneration in pdn, which is a critical barrier to progression for effective and disease modifying treatment for pdn. bianco m 1 , terenghi f 1 , gallia f 1 , nozza a 2 , scarale a 1 , fayoumi mz 1 , giannotta c 1 , morenghi e 3 , nobile-orazio e 1 . 1 poems (polyneuropathy, organomegaly, endocrinopathy, m protein and skin changes) syndrome is an unusual multisystem disease with neurological disability due to a severe disabling polyneuropathy, with high mortality by multiorgan failure. peripheral blood stem cell transplantation (pbsct) is considered the treatment of choice for poems while lenalidomide is the most promising therapy for patients not eligible for pbsct. the aim of the present study was to compare the long-term effects on clinical, biological and neurophysiologic parameters in patients with poems treated with lenalidomide or pbsct. the clinical, biological and neurophysiologic data were reviewed in 15 poems patients treated with pbsct (n: 6) or lenalidomide (n: 9). the mrc sumscore on 16 muscles, onls scale, vegf serum levels and nerve conduction studies were assessed before (t0) and after 1 (t1) and 2 years (t2) of treatment and the differences were compared using anova. combining the two groups of patients, there was a significant improvement after treatment in the mean mrc sumscore (t0 = 65±15; t1 = 69±11; t2 = 71±8; p = 0.000), in the mean onls score (t0 = 5.6+2.6; t1 = 3.6+1.9; t2 = 3.5+2; p = 0.000), in the ulnar mean distal motor latency (t0 = 3.8±1.2 msec; t1 = 3.3±0.4 msec; t2 = 3.0±0.4 msec; p = 0.02), distal compound muscle action potentials amplitude (t0 = 6.8±2.8 mv; t1 = 7.2±3.2mv; t2 = 7.4±2.9mv; p = 0.0000), motor conduction velocity (t0 = 37.4± 10.7 m/sec; t1 = 43±9 m/sec; t2 = 47.9±9.3 m/sec; p=0.0003) and serum vegf levels (t0 vs t1: p = 0.011; t0 vs t2: p = 0.010). the difference was also significant when we separately analyzed patients treated with lenalidomide and pbsct and there was no difference between the two groups in any of the analyzed parameters. treatment with pbsct and lenalidomide significantly and similarly improved clinical, biological and neurophysiologic parameters in patients with poems syndrome up to two years. since pbsct may not be suitable for all patients, lenalidomide may represent an effective and a valuable alternative in these patients or in those relapsing after pbsct inducing a prolonged clinical, biological and neurophysiologic improvement. bis d 1 , tao f 1 , abreu l 1 , sleiman p 2 , hakonarson h 2 , zuchner s 1 and inherited neuropathy consortium. 1 dr. j.t. macdonald department for human genetics, hussman institute for human genomics, university of miami, miami, fl, usa; 2 center for applied genomics, the children's hospital of philadelphia, philadelphia, pa, usa. inherited peripheral neuropathies are clinically and genetically heterogeneous diseases that can cause distal muscular atrophy and sensory loss. alleles in over one hundred different genes have been shown to cause peripheral neuropathies; yet, greater than 50% of axonal neuropathy patients do not receive a genetic diagnosis. large scale exome studies are now beginning to be sufficiently powered to perform mutational burden analysis. this approach compares damaging allele frequencies of cmt cases with a control group to identify additional causes for neuropathies. this approach will also identify genes that require an oligogenic inheritance to cause a phenotype. in a deviation from the classic linkage-based and heuristic variant filtering approaches to gene identification, we are performing burden analyses in a large cohort of 382 cmt families. in 113 known neuropathy genes, we saw that neuropathy cases carried on average 7.04 rare, non-synonymous variants, while 927 unrelated non-neuropathy controls harbored 5.76 variants (p=4.23e-06, mann-whiney u-test). enrichment of rare, non-synonymous variants in cmt disease genes within inherited peripheral neuropathy cases suggests the presence of multiple weaker alleles in individual patients. we also performed an unbiased exome-wide gene-based burden analysis and ranked genes after multiple testing correction. several new candidate genes were identified that need further follow up conformational studies. a number of known cmt and related genes were observed in the list of top candidates. we are currently analyzing additional aspects of this sample and are actively seeking more cmt exomes to enlarge our study. in summary, statistical methods traditionally reserved for more 'common' phenotypes' increasingly are becoming available for rare disease genetics. c57bl/6 mice were treated with bortezomib alone or in combination with monastrol. neuropathic changes were assessed by nerve conduction studies and histological analysis. analysis of axonal morphology was performed with light and electron microscopy. anti-neoplastic properties of monastrol alone and in combination with bortezomib were assessed in different blood cancer cell lines. prolonged treatment with bortezomib induced a sensory neuropathy in mice. significant changes in axonal morphology correlated with reduced function of peripheral nerves. the administration of monastrol substantially ameliorated morphological features of axonal alterations and sensory neuropathy. cytotoxicity studies in blood cancer cell lines showed no interference of monastrol with the cytostatic effects of bortezomib. our data indicate that monastrol may alleviate bortezomib induced neuropathy. the favorable cytotoxic profile of monastrol makes it an interesting candidate as neuroprotective agent to prevent bortezomib-induced neuropathy. boczonadi v 1 , meyer k 2 , gonczarowska-jorge h 3,4 , bartsakoulia m 1 , roos a 1,3 , bansagi b 1 , zahedi rp 3 , talim b 5 , bruni f 6 , kaspar b 2,7 , lochmüller h 1 , boycott km 8 , müller js 1 , horvath r 1 . 1 jwmdrc, wtcmr, igm, newcastle university, newcastle upon tyne, uk; 2 rinch, columbus, oh, usa; 3 leibniz-institute für analytische wissenschaften-isas-e.v., dortmund, germany; 4 capes foundation, brazil; 5 department of pediatrics, hacettepe university children's hospital, ankara, turkey; 6 dbbb,university of bari aldo moro, bari, italy; 7 department of neuroscience, the ohio state university, columbus, oh, usa; 8 department of genetics, cheo, university of ottawa, ottawa, canada. while autosomal dominant mutations in gars, encoding the glycyl-trna synthetase, have been identified in patients with charcot-marie-tooth peripheral neuropathy (cmt2d) and distal spinal muscular atrophy type v (dsma-v), autosomal recessive mutations cause mitochondrial disease affecting skeletal muscle and heart. gars is a bi-functional enzyme and it is responsible for normal protein translation both in mitochondria and the cytoplasm. in this study we have focused on the mitochondrial function of the gars by investigating a mouse model (gars c210r) , human fibroblasts and induced neuronal progenitor cell lines (inpcs). mild mitochondrial abnormalities were detected in skeletal muscle of the gars c210r mice while no other tissues were affected. control and patient fibroblasts harboring gars mutation were directly converted into inpcs. we identified tissue specific impairment of mitochondrial function in neuronal cells carrying not only recessive but also dominant gars mutations, suggesting neuron-specific effects of mitochondrial alterations.comparative proteomic analysis of inpcs showed significant changes in 41 mitochondrial proteins. furthermore, the reduction of the vesicle-associated membrane protein-associated protein b (vapb) and its downstream pathways in gars-deficient inpcs suggests that altered mitochondria-associated endoplasmic reticulum (er) membranes (mam) may also contribute to the motor neuropathy. boczonadi v 1 , king ms 2 , bansagi b 1 , roos a 1,3 , eyassu f 2 , borchers c 4 , lane m 1 , ramesh v 5 , lochmüller h 1 , pyle a 1 , griffin h 1 , smith ac 2 , chinnery pf 1,2 , alan j robinson aj 2 , edmund rs kunji ers 2 , horvath r 1 . 1 jwmdrc, wtcmr, igm, newcastle university, newcastle upon tyne, uk; 2 mitochondrial biology unit, medical research council, cambridge; 3 leibniz institute of analytic sciences (isas), dortmund, germany; 4 uvic-genome bc proteomics centre, vancouver, canada; 5 paediatric neurology, royal victoria infirmary, newcastle upon tyne foundation hospitals nhs trust, newcastle upon tyne, uk. members of the mitochondrial carrier family (slc25) transport nucleotides, keto acids, amino acids, fatty acids, co-factors and inorganic ions across the mitochondrial inner membrane. several inherited diseases with very variable clinical presentations are associated with dysfunctional mitochondrial carriers. we report a patient with childhood-onset spinal muscular atrophy and mitochondrial myopathy caused by a homozygous mutation in slc25a21, encoding the mitochondrial oxodicarboxylate carrier (odc). the mutation renders the carrier dysfunctional and, consequently, 2-oxoadipate cannot be imported into the mitochondrial matrix. computer modelling of the metabolic defect caused by the mutation predicted that the impaired transport leads to accumulation of 2-oxoadipate, pipecolic acid and the known neurotoxin quinolinic acid, which were precisely confirmed by targeted metabolomics in serum and urine. exposure of 2-oxoadipate and quinolinic acid reduced the level of mitochondrial complexes in sh-sy5y cells in-vitro suggesting a possible pathomechanism. here we demonstrate that 2-oxoadipate and quinolinic acid are toxic for spinal motor neurons and their increased levels may contribute to neuropathy. and families have been reported. interestingly, most mutations target the same amino acid residue (k141e, k141m, k141n, k141t) in the highly conserved -crystallin domain of the hspb8 protein. the spectrum of diseases caused by mutations in the hspb8 gene was recently expanded to distal myopathy. hspb8 is ubiquitously expressed, but is highly expressed in motor neurons and muscles. the hspb8 is a chaperone that participates in clearing misfolded poly-q containing proteins such as mutant huntingtin and ataxin-3 involved in respectively huntington's disease and spino-cerebellar ataxia. hspb8 directly interacts with the co-chaperone bag3 and their role in chaperone-assisted selective autophagy is well described. to delineate the molecular deficits and functional consequences of hspb8 mutations we generated a knock-in (ki) mouse model for the k141n missense mutation mimicking the neuropathy phenotype. we observed that homozygous mutant mice (hspb8 k141n/k141n ) develop a progressive axonopathy, with decreased compound motor action potential amplitudes, and loss of large and medium myelinated axons. this results in locomotor deficits with an impaired performance at the rotarod and grip strength tests. at the ultrastructural level, the hspb8-ki model displays severe signs of axon degeneration and a clear myofibrillar myopathy, as observed in some patients with hspb8 mutations. interestingly, hspb8 positive aggregates were found in the sciatic nerve and gastrocnemius muscle of our mutant mice. additionally, our model allowed us to generate hspb8 knock-out (ko) mice using the same targeting vector. strikingly, the homozygous hspb8-ko animals do not show any sign of axonopathy and display a much milder myopathy than the hspb8-ki animals. these data suggest that part of the pathomechanisms is due to toxic gain-of-function of the mutant protein. boutahar n 1 , reynaud e 1 , nasser y 1 , camdessanché jp 1 , antoine jc 1 . 1 university hospital, saint-etienne, france. dysimmune sensory neuronopathies (snn) depend on neuron cell death induced by an inflammatory reaction in dorsal root ganglia. we have recently identified the intracellular tyrosine kinase (trk) domain of the fibroblast growth factor receptor-3 (fgfr3) as the target of antibodies in a subset of patients with non paraneoplastic snn. fgfr3 is one of the four fgfrs and has been involved in sensory neurons maintenance during development and cell death induction after axotomy. fgfrs ligand fixation results in the activation of several intracellular pathways through adaptator protein interactions with the trk domain. in particular ras activation may lead to cell proliferation or apoptosis through erk1/2 or p38 map kinase signaling. the p38 mapk pathway is also involved in neuronal cell death induced by nmda and ampa receptor activation. as fgfr3 is a cell surface protein, human antibodies may interfere with the receptor functioning as a growing number of evidence has showed with other cell surface antibodies in neurological diseases. to test this hypothesis we developed an in vitro model using fvbn mice cortical neurons culture exposed to a rabbit polyclonal antibody reacting with the trk domain of fgfr3. comparatively to normal rabbit iggs, the fgfr3 antibody induced neuron cell death in a dose dependent manner. neuron cells were exposed to fgfr3 antibody concentration leading to 10-20 % cell death in absence or presence of the p38 mapk inhibitor sb203580 and the expression of fgfr3, glur1 subunit of ampa receptors and nr1 subunit of nmda receptor was measured by quantitative rt-qpcr. the fgfr3 antibody induced an upregulation of fgfr3 while the glur1 and nr1 subunits were modulated. these changes were prevented in presence of sb203580. these preliminary results indicate that anti-fgfr3 iggs may interfere with the functioning of the intracellular domain of the protein and the expression of nmda and ampa receptors through the p39 map kinase pathway. this model may be used to test the effect of human anti-fgfr3 iggs in vitro. braathen gj 1 , tveten k 1 , holla øl 1 , busk øl 1 , hilmarsen ht 1 , svendsen m 1 , høyer h 1 . 1 section of medical genetics, department of laboratory medicine, telemark hospital, skien, norway. next-generation sequencing (ngs) has during the last years entered the clinical diagnostics. ngs has proven to be very efficient in the diagnostics of disorders where multiple genes can be involved. our ngs-based targeted gene panel consists of 99 hereditary neuropathy genes, i.e. mostly charcot-marie-tooth genes. this study is a retrospective study of clinic samples received between may 1 2014 and february 1 2017. we describe the identified novel likely pathogenic sequence variants, according to international guidelines. in this period we identified novel, not previously described, likely pathogenic sequence variants in the following genes: aars, fgd4, gan, hint1, litaf, lrsam1, mme, mpz, nefl, pmp22, sbf1, sh3tc2 and yars. there is now a large range of genes causing hereditary peripheral neuropathies and many likely pathogenic sequence variants. likely pathogenic sequence variants are not only identified in old well established neuropathy genes but also in the newer genes like mme. modelling brown-vialetto-van laere syndrome in c. elegans mutations in slc52a2 and slc52a3, which encode the riboflavin transporters rfvt2 and rfvt3. patients with rfvt2 deficiency exhibit proximal and distal limb weakness, sensory ataxia, diaphragmatic paralysis, optic atrophy, sensorineural deafness and bulbar palsy. riboflavin is critical for the biosynthesis of flavin mononucleotide and flavin adenine dinucleotide, essential cofactors for carbohydrate, amino-acid and lipid metabolism. mutations in slc52a2 reduce or abolish rfvt2 expression resulting in impaired riboflavin uptake into sensory and motor neurons. high-dose riboflavin treatment can improve or stabilise a patient's condition, however the optimum dose and long term effects of riboflavin treatment, and disease pathomechanisms remains poorly understood. to further understand the pathophysiological consequences of slc52a2 mutations, we propose developing an animal model for bvvl. caenorhabditis elegans (c. elegans) are small round transparent nematodes extensively used for studying the genetics and molecular biology of neurodegenerative diseases. there are two c. elegans riboflavin transporter genes, rft-1 and rft-2. based on protein sequence homologies and expression profiles for both genes, rft-1 is the ortholog of rfvt2. the expression of rft-1 is regulated by riboflavin availability and knock-down of the rft-1 gene by sirna perturbs c. elegans development. our aim is to develop a knock-in c. elegans model of bvvl. human rfvt2 and c. elegans rft-1 protein sequences were aligned with clustal omega to identify conserved amino acid residues associated with bvvl mutations. the amino acid involving the l339p rfvt2 mutation is conserved in rft-1 (residue l324). to create our model, we will introduce the l324p rft-1 mutation into the rft-1 locus in c. elegans genomic dna using crispr/cas-9 technology. this bvvl c. elegans model will allow us to explore the pathogenic consequences of rfvt2 deficiency underlying motor nerve degeneration and to evaluate drug therapy regimes by determining the optimal riboflavin dose and treatment initiation, and trialing other compounds that may improve benefits seen with riboflavin supplementation. chronic inflammatory demyelinating polyradiculoneuropathy (cidp) is an autoimmune-mediated inflammatory disease of the peripheral nervous system. cidp can present chronic progressive or relapsing-remitting courses and can predominantly affect motor but also sensory nerve fibers causing weakness of proximal and distal muscles. it represents the most common chronic autoimmune neuropathy and is pathologically characterized by focal inflammatory-mediated demyelination followed by axonal degeneration. recently, we have developed a new animal model for cidp, the chronic-ean, induced in lewis rats by active immunization with s-palmitoylated p0 (180) (181) (182) (183) (184) (185) (186) (187) (188) (189) (190) (191) (192) (193) (194) (195) (196) (197) (198) (199) peptide. this model fulfills electrophysiological criteria of demyelination with axonal degeneration, a result confirmed by immunohistopathology. the late phase of the chronic disease is characterized by an accumulation of il-17 + cells and macrophages in sciatic nerves and as well as high serum il-17 levels. it is a reliable and reproducible animal model for cidp that can now be used for translational drug studies for chronic human autoimmune-mediated inflammatory diseases of the peripheral nervous system, particularly cidp, for which, there is a real need for new immunotherapies. the aim of this study was to test the therapeutic efficacy of ivig and a recombinant fc fragment (fcrec) in this new cidp animal model. treatments with ivig and fcrec proved effective in preventing further progression of cidp in rats. the therapeutic treatments not only decreased the maximal clinical scores of the cidp rats compared to albumin treatment but also abolished the disease chronicity. interestingly, a better efficacy of fcrec treatment compared to ivig was demonstrated at histological level, with the myelinated fibers well preserved and the greatly reduced accumulation of macrophages and il-17 + cells in sciatic nerves. ivig and fcrec therapeutic activities in this model can also be followed by measurement of antibodies in the serum and could therefore be used as biological markers. the current study provides for the first time direct evidence that ivig is effective in the treatment of cidp rats and suggests that a novel fcrec compound is more effective than ivig. it will contribute to the development of more effective and safer drugs for the treatment of autoimmune peripheral neuropathies like cidp. each time, one measurement with supramaximal stimulation according to the conventional ncs and another measurement with 50% enhanced stimulation intensity were conducted. we analyzed the results with special consideration of minimal and maximal fiber velocities and of the velocity with maximal fiber proportion. as a result, we detected statistically significant differences between cidp patients and controls in all these parameters. compared with controls, cidp patients had slower minimal and maximal fiber velocities and also the spectrum of motor conduction velocities was definitively shifted to slower velocities. slower minimal conduction velocities could be detected in some cidp patients by using the enhanced stimulation intensity. interestingly, in some cidp patients the conventional ulnar ncs were normal, but the collision technique showed fibers with a conduction velocity of less than 35 m/s, indicating demyelination. to our knowledge, this is the first study using hopf's collision technique systematically in cidp patients. significant differences between the variation of ulnar motor nerve conduction velocity of cidp patients and controls could be detected. this method also showed signs of demyelination in some cidp patients with normal ulnar ncv. by enhancing stimulation intensity above the threshold of supramaximal stimulation in conventional ncs, the collision technique may be even more valuable. the clinical course of guillain-barré syndrome (gbs) is highly variable and some patients may develop treatment-related fluctuations (trfs) as an indication of ongoing disease activity and temporary treatment effect. other patients present as gbs, but subsequently develop repetitive relapses as an indication of acute-onset chronic inflammatory demyelinating polyneuropathy (a-cidp). this distinction is important because treatment may differ. we determined the frequency and clinical presentation of patients with gbs-trf and a-cidp in the first 1000 patients included in the international gbs outcome study (igos) with a follow-up of at least 12 months. thirty-eight patients (4%) were excluded because of alternative diagnoses. of the remaining 962 patients, 40 (5%) had at least one trf, 35 (4%) had a-cidp. preliminary analysis showed no significant differences between the 3 groups (total-gbs, gbs-trf and a-cidp) for sex, age, sensory symptoms, cerebrospinal fluid results and mechanical ventilation. a-cidp patients had a median age of 54 years (iqr 40-70), 66% was male, and all patients were treated in the acute phase of the disease (intravenous immunoglobulins (ivig) (31), plasma-exchange (pe) (3) or methylprednisolone (mp) (1)). gbs-trf patients has a median age of 57 years (iqr 40-67), 48% was male and all patients received treatment (ivig (35) and pe (5). gbs-trf patients showed more antecedent events (78% versus 49%, p=0.011), a higher gbs disability score (≥3) at nadir (100% versus 86%, p=0.018) and less frequently developed ataxia (32% versus 71%, p=0.001) than patients with a-cidp. onset to nadir was longer in a-cidp than in gbs-trf (33 days (iqr 12-60) versus 17 days (iqr 8-33), p=0.023) and the total gbs group (9 days (iqr 5-13), p=0.000). the time until the first clinical deterioration tends to be longer in the a-cidp patients (median 41 days (iqr 26-56) versus median 31 days in the gbs-trf group, not significant). the diagnosis a-cidp was made after a median of 69 days . in conclusion, this first analysis identified distinctive characteristics of gbs-trf and a-cidp in support of a different pathogenesis that may help with early identification of these disorders in clinical practice. additional results will be presented at the conference. chronic inflammatory demyelinating polyneuropathy (cidp) is a disorder with a highly diverse clinical presentation, electrophysiological phenotype, response to treatment and outcome. this heterogeneity may indicate the presence of distinct subtypes of cidp, which may have a different pathogenesis and require more personalized treatment. the international cidp outcome study (icos) is a prospective, observational, international multi-center study that aims to describe this variation in clinical and electrophysiological subtypes and to define the clinical and biological determinants of these subtypes, disease activity, treatment response and outcome. in addition icos aims to provide an infrastructure for conducting new (therapeutic) studies in cidp, similar to the international gbs outcome study (igos). all patients fulfilling the efns/pns (2010) diagnostic criteria for cidp can be included in icos, independent of age, duration and severity of disease or treatment. we collect information on neurological deficits, diagnostic characteristics, various validated clinical outcome measures, previous and current treatment and we collect biomaterials (dna, cerebrospinal fluid, nerve biopsies and repeated serum samples). icos was started as a pilot study in 3 dutch university centers. by february 2017, 78 patients were included in icos, 35 patients recently diagnosed with cidp and 43 previously diagnosed patients. included were 49 (63%) males and 29 (37%) females with a median age of 63 years (iqr 52-71). the current cohort consists of 52 classic (sensory-motor) cidp, 16 madsam and 5 pure motor variants. of the 43 patients diagnosed in the past, 36 patients (84%) were treated (intravenous immunoglobulins (ivig) (29), prednisolone (2), subcutaneous immunoglobulins (scig) (2), dexamethasone (1), plasma-exchange (1) and ivig with methylprednisolone (mp) (1)). the 35 recently diagnosed patients all received treatment (ivig (12), dexamethasone (3), plasma-exchange (1) and 19 patients were treated in a pilot study with ivig with methylprednisolone (mp)). the protocol has been evaluated and adjusted and will be shared with other researchers via the inflammatory neuropathy consortium and igos consortium. our aim is to include at least 1000 cidp patients worldwide with a minimum follow-up period of 2 years. dominant mutations in glycyl trna synthetase (gars) cause inherited axonal neuropathy (charcot-marie-tooth type 2d). mutations in the mouse gars gene cause a similar phenotype, and represent valid disease models. we routinely use two mouse strains, one with a severe neuropathy, and one with a milder, later onset neuropathy. using these mouse models, we are exploring the mechanisms through which gars mutations cause peripheral axon degeneration. efforts include ribosome tagging to isolate ribosome-associated mrnas specifically from motor neurons, and non-canonical amino acid tagging to visualize and isolate newly synthesized proteins. taking advantage of the anatomy of motor neurons, we are able to analyze cell bodies separately from peripheral axons in both of these approaches. in addition, we are using these mouse models for preclinical studies testing gene therapy approaches to treat cmt2d. consistent with our previous genetic studies in mice, knockdown of the mutant transcript, while preserving sufficient levels of the wild type, is a very successful approach when administered before the onset of neuropathy. we are now testing this approach in mice after the onset of symptoms, and in mice carrying a mutant gars allele associated with human disease. these studies are potentially translational, and also address mechanistic questions such as the timing and cell autonomy of the pathophysiology. burnor e 1 , yang l 2 , hao z 1 , patterson k 1 , quinn c 1 , scherer ss 1 , lancaster e 1 . 1 the university of pennsylvania, philadelphia, pa, usa; 2 the second xiangya hospital, central south university, hunan, china. autoantibodies to two isoforms of neurofascin (nf155 and nf186) have been reported in patients with guillain-barre syndrome (gbs) or chronic inflammatory demyelinating neuropathy (cidp). it is not clear which of these responses reliably distinguish autoimmune neuropathies from other severe neuropathies, which responses are transient versus persistent, or which responses may target multiple isoforms of neurofascin. in addition, approximately 30% of neuropathy patients have no known cause, and it is unknown whether a subset of these patients may have autoantibodies to neurofascins. we have studied cohorts of patients with autoimmune neuropathy (n=150), genetic neuropathy (n=100), and idiopathic neuropathy (n=40) for igg and igm responses to neurofascins. neurofascin antibodies were found in 12 (8%) of patients with autoimmune neuropathy, and 3 (7.5%) idiopathic neuropathy patients, but only 1% (1 of 100) in patients with genetic neuropathy. follow-up serum samples were available for 7 positive cases. persistent responses were associated with chronic neuropathy while transient responses were seen in gbs or with remission of cidp. most patients had responses specific to either nf155 of nf186. however, a particularly severe, treatment-resistant form of cidp, approaching a locked-in state, was seen in a patient with a unique response to all three isoforms of neurofascin (nf186, nf155, nf140). treatment of this patient with rituximab resulted in clinical improvement and resolution of the neurofascin antibody response. in conclusion, autoantibodies to neurofascins distinguish autoimmune neuropathies from severe genetic neuropathies, but the clinical phenotype may depend on the persistence and isoform specificity of the immune response. antibodies to the common domains shared by nf155 and nf186 may portend a severe but treatable neuropathy. a subset of idiopathic neuropathy patients may have an autoimmune mechanism. burns j 1,2 , sman ad 1 , cornett kmd 1 , wojciechowski e 1,2 , walker t 1 , menezes mp 1,2 , mandarakas mr 1 , rose kj 1,2 , bray p 1,2 , sampaio h 2 , farrar m 2,3 , refshauge km 1 , raymond j 1 and the fast study group. 1 university of sydney, new south wales, australia; 2 sydney children's hospitals network (randwick and westmead), new south wales, australia; 3 university of new south wales, sydney, australia. exercise has undisputed benefits for human health and potentially as a treatment for neuromuscular disease. but there is also a risk of harm due to overwork weakness. we report the results of a 24-month randomised, double-blind, sham-controlled trial evaluating progressive resistance exercise of foot dorsiflexor muscles in pediatric cmt. sixty patients (47 cmt1a, 1 cmt1e, 2 cmt1f, 1 cmt2a, 2 cmt4c, 4 cmtx1, 3 cmtx3) aged 6-17 years were randomly assigned to undergo 24-weeks (72 sessions) of moderate-intensity progressive resistance exercise or sham exercise. the primary endpoint was change in isometric dorsiflexion strength between groups assessed by hand-held dynamometry (expressed as a z-score based on age-and sex-matched normative reference values, positive values indicate an improvement in strength). the primary safety endpoint was change in muscle and fat volume of the muscles responsible for dorsiflexion by mri between groups. secondary outcomes were function (balance, long jump, 6-min walk test), walking ability (3d gait analysis), self-reported ankle instability, parent-reported quality of life (physical summary, psychosocial summary and global impression of change scores), and adverse events. fifty-five (92%) children completed the trial. adherence was comparable between exercise (77%) and sham (81%) groups. while patients experienced muscle soreness during training in the exercise group, adverse events did not differ between groups. the mean z-score for dorsiflexion strength increased in the exercise group by 8% at 24-months (from −2.5±1.0 to −2.3±0.9) and decreased in the sham group by 24%, mirroring the natural history of cmt (from −2.1±0.7 to −2.6±1.2). between-group ancova-adjusted difference at 24-months was 0.6 (95%ci, 0.03 to 1.12; p=0.041). the mean scaled scores for mri muscle volume and fat volume were comparable between groups at 24 months (p>0.05). the global impression of change scores favoured the exercise group at 12-months (p=0.021) and 24-months (p=0.009). there was no other measurable effect of exercise. pre-specified subgroup analyses according to age (6-11 years vs. 12-17 years) showed a larger treatment effect with exercise in adolescents. targeted progressive resistance exercise was effective at halting progression of dorsiflexion weakness without detrimental effect on muscle morphology or other signs of overwork weakness in children with cmt. byung-nam y 1 , yoon-ho h 2 , suk-won a 3 , seok-jin c 4 , jung-joon s 4 . 1 inha university hospital, incheon, south korea; 2 seoul metropolitan government boramae medical center, seoul national university, seoul, south korea; 3 joong ang university hospital, seoul, south korea; 4 seoul national university hospital, seoul, south korea. a 51 years old female patient visited the hospital with weakness in both upper limbs from 9 months under the suspicion of motor neuron disease with the finding of extensive denervation changes on electromyography. whole spine mri showed ventral nerve rootlet enhancement in the c and t bundles. the emg had confirmed active denervation changes in the muscles innervated by bilateral c5∼c7 roots. the cerebrospinal fluid culture test showed a protein (csf) elevation to 65 mg / dl. she got a steroid pulse therapy. she had the symptoms of dry mouth and dry eyes during the recent 2 years. a salivary gland scan test was performed for the possibility of sjögren's syndrome, and as a result, absorption of the contrast agent in both parotid and submandibular glands was decreased. the shammer test showed 8 mm on the right side and 7 mm on the left side. she was diagnosed of sjögren's syndrome. after 2 weeks, overall strength improvement was observed, and bilateral shoulder abduction was improved to mrc grade 4 or higher. the follow-up spine mri also showed that the initially seen ventral nerve root enhancement was disappeared. the case had visited the hospital with major symptoms of weakness and atrophy of the muscles, showing similar pattern to motor neuron disease, and was diagnosed as inflammatory polyradiculopathy and confirmed as primary ss during differential diagnosis. this case suggests that primary ss may induce inflammatory polyradiculopathy, which shows motor symptoms as major symptoms rather than sensory symptoms, and that a fast and accurate diagnosis is needed in terms that it can be treated with steroids and appropriate immune suppressive agents. traumatic injuries to peripheral nerves are frequent. however, effective pharmacological treatments are lacking. curcumin, a polyphenol found in rhizomes of curcuma longa, has been shown to develop antioxidant, anti-inflammatory, and neuroprotective properties. however, due to its poor hydrosolubility and its extensive metabolism, the use of large curcumin doses is required for therapeutic purpose. the aim of the present study was to investigate the effects of a local infusion of a low curcumin dose on nerve regeneration and functional recovery after sciatic nerve injury in rats. the experiments were conducted in 200 g sd male rats submitted to unilateral sciatic nerve crush at d0. curcumin was solubilized in polyethylene glycol and continuously administered using osmotic pumps (0.2 mg/day until d35) with a catheter delivering the drug near the lesion site. functional analyses using von frey, beam walking, static sciatic index (ssi) and grip strength tests were carried out at d0 (reference test) and every week after injury (d7, d14, d21, d28 and d35). in addition, an evoked electromyogram was performed at d0 and d35. after euthanasia (d35), nerve and muscle samples were collected and analyzed by light and electron microscopy. functionally, a significant improvement of the mechanical sensitivity (+34%) was observed at d14 in the curcumin-treated group (n=12) vs. vehicle group (n=12). in curcumin-treated group, skillful walking and finger spacing of the ipsilateral paw (ssi) were fully restored respectively at d28 and d35 contrary to vehicle group. furthermore, curcumin treatment improved the grip strength recovery (+24% at d35). the electrophysiological results indicated a full recovery of motor nerve conduction velocities (mncv) after 35 days of curcumin treatment, while mncv remained altered in vehicle group (79% of the mncv at d0). morphometric analysis of nerve sections using g-ratio showed an improvement in the thickness of the myelin sheath in curcumin treated animals (+13% vs. vehicle group). histological investigation of gastrocnemius muscle indicated decreased neurogenic lesions in curcumin group. proteomic analysis is currently under investigation to understand the mechanisms involved in curcumin effects. our data could lead to the development of new therapeutic strategies in peripheral nerve regeneration using low doses of curcumin. previous studies suggest that the metabolic syndrome (mets) is associated with distal symmetrical polyneuropathy (dsp), and that diabetes, pre-diabetes, and obesity are the main metabolic drivers. the aim of this study is to investigate the association of mets components with retinal and cognitive function in a bariatric surgery cohort prior to surgery. patients were recruited from the adult bariatric surgery clinic at the university of michigan and lean controls from a research website (no mets components based on ncep/atpiii definition). participants underwent extensive metabolic phenotyping including a glucose tolerance test and fasting lipid profile. dsp was defined using the toronto consensus definition of probable clinical neuropathy. retinal function was measured with frequency doubling technology perimetry (average mean deviation), and cognitive function with the nih toolbox (composite score). univariate linear regression models were used to evaluate the association between mets components and retinal and cognitive function. to date, we have recruited 45 bariatric surgery participants and 21 lean controls. in the bariatric population, the mean (sd) age was 47 (11.1) with 78% female compared with a mean age of 46.5 (11.3) with 76% female in the lean group. in the bariatric group, 35.6% had diabetes, 31.1% pre-diabetes, and 33.3% normoglycemia. the dsp prevalence was 0% in lean controls, 6.7% in normoglycemic, 7.1% in pre-diabetic, and 31.3% in diabetic bariatric participants (p<0.001 for trend). retinal function was 0.01 (2.97), −0.21 (2.59), −3.36 (4.50), and −1.98 (4.27) (p=0.02 for trend), and cognitive function was 115.0 (12.0), 115.2 (20.0), 118.5 (20.9), 107.4 (14.4) (p=0.36 for trend) in these same groups for lean controls, normoglycemics, pre-diabetics and diabetics, respectfully. pre-diabetes (−3.2, 95%ci: −5.97,-0.34) was the only mets component associated with retinal function, and waist circumference was the only one associated with cognitive function (−1.76, 95%ci −3.4,-0.1). dsp and retinal function, but not cognitive function decline with worsening glycemic status. similar to previous data for dsp, pre-diabetes and obesity are associated with retinal and cognitive function respectively. interestingly, while clinical dsp is common in this population, clinical retinopathy and dementia are not, indicating that dsp may be the first metabolic complication in the morbidly obese. and anti-cntn1 antibody-positive cases were confirmed by cba and were of igg4 subclass in half of them. by cba we identified additional 3/150 (2%) anti-caspr1 seropositive patients, whose isotype is currently being tested. sera of anti-nfasc155 and anti-cntn1 igg4 seropositive patients and patients with anti-caspr1 antibodies stained paranodes by indirect immunofluorescence on mouse teased nerve fibers. of note, 35 seronegative patients for known antibodies showed reactivity against node and/or paranodes. compared to other 35 seronegative cipd patients, seropositive patients had more frequently subacute onset of the neuropathy and a younger age at onset, particularly for nfasc155 or caspr1 antibodies. weakness was more severe and was often associated with proprioceptive loss, sensory ataxia and tremor. neuropathic pain was not a feature of caspr1-seropositive patients. frequent findings were increased distal motor latencies and temporal dispersions on nerve conduction study and a higher protein level in csf. finally seropositive patients tended to have a higher disability and showed worst response to ivig. rituximab was effective in one patient with anti-nfasc155 antibodies and two patients with anti-cntn1 antibodies showed good and persistent recovery after cyclophosphamide. prevalence of antibodies was 7% in italian cidp patients and their presence was associated with distinctive clinical features. their determination, followed by characterization of igg subclass in positive cases, has clear clinical impact, by helping to guide therapeutic choices. the reactivity against nodal and paranodal components in sera from patients without known antibodies suggests that other targets could play a role in the autoimmune response in cidp and they still need to be identified. mutations in amynoacyl trna synthetases (arss), enzymes that catalyse the covalent attachment of amino acids to their cognate trna, are responsible for autosomal dominant cmt2, intermediate cmt (cmt-i) and dhmn. we report the case of a male of italian ancestry who first presented with bilateral ankle clonus at three months, followed by toe walking and ankle instability. the ankle clonus subsided during adolescence. in the third decade he developed progressive walking difficulties followed by distal sensory loss. neurological examination at the age of 37 revealed a steppage gait, distal lower limb weakness, decreased pinprick to the ankles, and reduced vibration sensation at the knees. reflexes were brisk in the upper limbs, reduced at the knees and absent at the ankles. muscle tone was increased in the lower limbs and plantar responses were extensor. nerve conduction studies revealed an axonal neuropathy. brain and spinal cord mri were normal. sanger sequencing of pmp22, gjb1, mpz , gdap and mfn2 were negative. sureselect focused exome sequencing (agilent technologies, santa clara ca, usa) demonstrated a c.986g>a, p.arg329his mutation in aars. the p.arg329his mutation in aars has previously been reported in 7 families with intermediate or axonal motor-sensory neuropathy, and in one case was associated with sensory-neuronal deafness. cns involvement has not previously been described with this mutation. mutations in aars have been associated with a range of phenotypes including cmti, cmt2 and dhmn with variable age on onset ranging from 0 to 55 years (mean 24 years). of note, the aars p.gly102arg mutation has been reported in a family with cmt2 and pyramidal signs. this study provides further evidence that pyramidal tract involvement can be an early feature of cmt2n due to mutations in aars, further expanding the spectrum of arss-associated phenotypes. small fibres in the skin are vulnerable to damage in metabolic or toxic conditions such as diabetes mellitus or chemotherapy resulting in small fibre neuropathy and associated neuropathic pain (np). whether injury to the most distal portion of sensory small fibres due to a primary dermatological disorder can cause np is still unclear. recessive dystrophic epidermolysis bullosa, (rdeb) is a rare condition in which mutations of proteins of the dermo-epidermal junction lead to cycles of blistering followed by regeneration of the skin. damage is exclusive to the skin and mucous membranes, with no known direct compromise of the nervous system. it is increasingly recognised that most rdeb patients experience daily pain, the aetiology of which is unclear but may include inflammation (in the wounds), musculoskeletal (due to atrophy and retraction scars limiting movement) or np. in this study we investigated the incidence of np and examined the presence of nerve dysfunction in rdeb patients. around three quarters of patients presented with pain of neuropathic characteristics which had a length dependent distribution. quantitative sensory testing of the foot revealed striking impairments in thermal detection thresholds combined with an increased mechanical pain sensitivity and wind up ratio (temporal summation of noxious mechanical stimuli). nerve conduction studies showed normal large fibre sensory and motor nerve conduction however skin biopsy showed a significant decrease in intraepidermal nerve fibre density. autonomic nervous system testing revealed no abnormalities in heart rate and blood pressure variability however the sympathetic skin response of the foot was impaired and sweat gland innervation was reduced. we conclude that chronic cutaneous injury can lead to injury and dysfunction of the most distal part of small sensory fibres in a length dependant distribution resulting in disabling np. these neuropathic pain (np) following peripheral nerve injury is associated with hyperexcitability in damaged myelinated sensory axons which begins to normalise over time. we investigated the composition and distribution of shaker type potassium channels (kv1 channels) within the nodal complex of myelinated axons following injury. at the neuroma that forms after damage, expression of kv1.1 and 1.2 (normally localised to the juxtaparanode) was markedly decreased. in contrast kv1.4 and 1.6, which were hardly detectable in the naïve state, showed increased expression within juxtaparanodes and paranodes following injury, both in the rat and in humans. within the dorsal root (a site remote from injury) we also noted a redistribution of kv1 channels towards the paranode. blockade of kv1 channels with dtx after injury reinstated hyperexcitability of a-fibre axons and enhanced mechanosensitivity. changes in the molecular composition and distribution of axonal kv1 channels, therefore represents a protective mechanism to suppress the hyperexcitability of myelinated sensory axons that follows nerve injury. members of the francophone anti-mag cohort group are listed in "appendix". appendix polyneuropathy with anti-mag igm antibodies is classically progressive, predominantly sensory, and distal with ataxia and sometimes postural-intention tremor. we assessed clinical, biological, electrophysiological, and histopathological features in patients with igm gammopathy and anti-mag antibody titres higher than 1000 btu. we focused on characteristics of patients according to the anti-mag antibody titres at diagnosis. we retrospectively and prospectively analysed standardized report forms of 202 patients from fourteen french-speaking neuromuscular centres. mean age at onset was 62.6 years (range 25-91.4). mean time between symptoms onset and last follow-up was 8.4 years (0.3-33.3). about 33.2 % of patients presented with a "variant" clinical phenotype independently of anti-mag titres (< or ≥ 10 000 btu). this included acute or chronic sensorimotor polyradiculoneuropathies, paucisymptomatic sensory polyneuropathy and multifocal neuropathy. at the most severe disease stage, 22.4% of patients were significantly disabled. anti-mag antibody titres at diagnosis were low (<10 000 btu), medium (10 000-70 000) or high (≥70 000) in respectively 11, 51 and 38 % of patients. patients presented with mgus or waldenström's macroglobulinemia in respectively 68 % and 29 % of cases. sixteen percent of patients did not meet the electrodiagnostic criteria of definite demyelinating neuropathy, independently of anti-mag titres (< or ≥ 10 000 btu). nerve biopsy, performed in nineteen patients, provided support to the diagnosis of anti-mag neuropathy in some particular issues (low titres of anti-mag, unusual clinical or electrophysiological phenotype). we assessed the degree of probability (probable, possible or uncertain) that patient neuropathies are directly related to anti-mag antibodies, according to anti-mag titre, electrophysiological data and nerve biopsy characteristics if available. it appears uncertain in 5 patients with low anti-mag titres (2.5 % of the whole population). the clinical phenotype didn't appear to be different according to anti-mag antibody titre. many of the patients with low anti-mag titres presented "genuine" anti-mag neuropathy as demonstrated by edx studies, clinical presentation and sometimes nerve biopsies. for a small proportion of these patients, a direct relation between neuropathy and anti-mag antibodies is uncertain due to atypical clinical presentation, axonal neuropathy pattern or nerve biopsies, and positivity of antigangliosides antibodies. we assessed therapeutic management, response to immunotherapies and adverse events in a cohort of 202 patients presenting with igm gammopathy and anti-mag antibody titres higher than 1000 btu. we retrospectively and prospectively analysed standardized report forms of 202 patients from 14 french speaking neuromuscular centres. mean age at onset was 62.6 years (range 25-91.4). mean time between symptoms onset to diagnosis and last follow-up were respectively 3.1 (0-30) and 8.4 years (0.3-33.3). anti-mag antibody titres at diagnosis were low (<10 000 btu), medium (10 000-70 000) or high (≥70 000) in 11, 51 and 38 % of patients. patients presented with mgus or waldenström's macroglobulinemia in respectively 68 % and 29 % of cases. seventy eight percent (n = 158) of patients received immunotherapies. transient response to ivig or plasma exchanges at six month was observed in less than 30 and 20% of patients respectively. chemoimmunotherapies and rituximab were more frequently administered in the group of patients with malignant hemopathies (n = 65) compared to mgus (n = 137) (mean lines of therapy = 1.2, range 0-4, sd 0.7 versus 0.85, range 0-3, sd 0.85, p = 0.002). more than 45% of patients (n = 92) received rituximab monotherapy. clinical worsening, mostly transient and reversible, was observed in 11/92 patients after rituximab. clinical response to rituximab at 6 months and/or during 7-12 months follow-up period was observed in 31.5% of patients, and correlated with anti-mag titre ≥ 10 000 btu (30/31 responder versus 50/61 non-responder patients, p = 0.05). at 7-12 months follow-up, responder patients presented shorter symptom duration compared to non-responders, though not significant after logistic regression (3.6 years, range 0.13-16.23, sd 3.7 in 29 responder patients versus 5.1 years, range 0.13-17.6, sd 4.2, in 63 non responder patients, p = 0.1). in some cases, electrodiagnostic studies were recorded during rituximab treatment follow-up and showed in responder patients a clear improvement of motor conduction velocities. these data may support another clinical trial to study benefice of rituximab in anti-mag neuropathies early in the disease. it raises issues about the value of incorporating electrodiagnostic parameters as end-points. schwann cells (scs) are essential for axon integrity and myelination in the uninjured pns. after pns injury, scs function as "first responders" , undergoing phenotypic re-programming and orchestrating many processes that lead to functional nerve repair. receptors in scs that contribute to sc repair programs remain incompletely understood. we identified a member of the ionotropic glutamate receptor (igr) family, n-methyl-d-aspartate receptor (nmda-r), in scs that is upregulated after nerve injury and acts as a co-receptor with ldl-receptor related protein (lrp1). lrp1 is a well-known regulator of the sc response to pns injury. herein, we used pcr to profile igr expression in cultured rat scs. obligate receptor subunits required for assembly of nmda-rs, ampa-rs, and kainate receptors were identified. treatment of rat scs with 40-100 microm glutamate or 0.5-1.0 microm nmda robustly activated akt and erk1/2. the response was transient and bimodal; glutamate concentrations greater than 250 microm failed to activate cell-signaling. phosphoprotein profiling demonstrated other cell-signaling and transcription factors regulated by glutamate in rat and human scs, including p70 s6-kinase, glycogen synthase kinase-3, ribosomal s6 kinase, c-jun, and creb. activation of cell-signaling by glutamate in scs was blocked by eliminating calcium from the medium, by the selective nmda-r antagonist, mk801, and by genetic silencing expression of the obligate nmda-r nr1 subunit. phosphoinositide 3-kinase/pi3k functioned as an essential upstream activator of both akt and erk1/2 in glutamate-treated scs. by activating pi3k and erk1/2, glutamate promoted sc migration. glutamate (200 microm) or nmda (20 microm) injected into crush-injured sciatic nerves robustly activated p-erk1/2 in both myelinating and non-myelinating scs in vivo. these results identify igrs as potentially important cell-signaling receptors in scs that may promote axon-glial interactions. understanding the function of sc nmda-r is important given current efforts to develop nmda-r-targeting drugs for patients with pain, depression, and alzheimer's disease. while frequently overlooked in a therapeutic context, scs are extremely important in the pathogenesis of chronic neuropathic pain. if these drugs modulate the activity of sc nmda-r and sc physiology, the response to pns injury may be altered and the possibility that neuropathic pain develops increased. candayan a 1 , atkinson d 2 , durmus tekce h 3 , parman y 3 , jordanova a 2 , battaloglu e 1 . 1 department of molecular biology and genetics, bogazici university, istanbul, turkey; 2 center for molecular neurology, antwerp university, antwerp, belgium; 3 istanbul medical school, istanbul university, istanbul, turkey. charcot-marie-tooth (cmt) disease is a group of inherited peripheral neuropathies affecting one in 2500 individuals worldwide. the disease presents both clinical and genetic heterogeneity. so far, mutations in 80 genes and 10 loci are associated with cmt with autosomal dominant, autosomal recessive, x-linked and mitochondrial inheritance. despite the advances in genetic testing, approximately 35% of all cmt patients worldwide remain without a molecular diagnosis. we have investigated 93 unrelated cmt patients of turkish descent, in all of which pmp22 duplication has been excluded previously. we used multiplex amplification of specific targets for resequencing (mastr) assay to sequence exonic regions of 28 common cmt genes. recurrent mutations were identified in 14 cases in mfn2, gjb1, mpz and hint1 genes. we have also identified novel variants in 11 cases in mfn2, pmp22, gars, aars, ighmbp2 and gdap1 genes, all of which are very rare or not present in the variation databases and are predicted to be pathogenic by in silico tools. familial segregation analyses are ongoing for novel variations. mfn2 and gjb1 genes were the most commonly mutated causative genes in this cohort. cases without molecular diagnosis after the mastr testing are candidates for further analyses such as whole exome sequencing or whole genome sequencing. outcomes of the current study and our previous experience with turkish cmt patients suggest a high genetic heterogeneity. our insight is that different genetic strategies or larger panels are essential to determine the causes underlying cmt especially in regions where rare recessive types of the disease can be observed due to high frequency of consanguineous marriages. capoccitti g 1 , giannini f 1 , ginanneschi f 1 , casali s 1 , insana l 1 , rossi a 1 . 1 university of siena, siena, italy. several efforts have been made to elaborate new electrophysiological criteria for early diagnosis of guillain-barré syndrome (gbs) and to differentiate demyelinating (aidp) from axonal (aman/amsan) forms. the aims were to verify the diagnostic power of total cmap (tcmap) duration, firstly applied in gbs field. this parameter was compared with commonly used neurophysiological measures, including negative phase cmap duration (ncmap), and was added to modified rajabally criteria. we reviewed the clinical and electrophysiological data of 38 patients with gbs (level 1 or 2 of brighton clinical criteria). each patient underwent at least two neurophysiological studies, the first within 2 weeks, the second between 3 and 7 weeks from symptom onset. at least four motor and three sensory nerve conduction studies were recorded for each test. regarding early diagnosis, the binary logistic regression model with multiple variables, including ncmap duration, showed that the 3 features of predictive model presenting greater significance (p <0.1) were tcmap duration, sural sparing and a-waves. among these, tcmap duration showed greater significance (p = 0.002). the tcmap was diffusely prolonged in aidp compared to aman/amsan, already in first examination and confirmed in the second one. roc analysis for tcmap duration in aidp vs. aman/amsan showed: cut-off 15.7 ms, auc 0.89, ppv 91.3%. we propose the tcmap duration as a new useful electrophysiological measure for early diagnosis of "generic" gbs and for early differentiation between aidp and aman/amsan. moreover, the prolongation of tcmap, the presence of a-waves and sural sparing represent a strongly diagnostic predictive triad of aidp. aifm1 (apoptosis-inducing factor, mitochondrionassociated-1) has captured great attention from biomedical researchers due its critical role in the regulation of cell apoptosis. this flavoprotein is typically located in the mitochondrial intermembrane space where it is associated with respiratory chain complex-i. upon a cell-death insult, aifm1 is cleaved into a 57kd protein that is released into the cytosol. the 57kd peptide may enter the nucleus to trigger chromosome condensation and fragmentation, initiating a caspase-independent pathway of apoptosis. however, this nuclear translocation may be blocked by cytosolic heat-shock protein-70 (hsp70) that binds with the fad domain (aa 150 -228) of aifm1. mutations in aifm1 gene have resulted in several clinical phenotypes, including a family with cmtx4 (glu493val). clinical deficits in these patients usually involve multiple organs. in this study however, we identified a family with a novel missense mutation (phe210leu) in aifm1 that developed a late-onset sensory motor axonal polyneuropathy by nerve conduction criteria. the proband and affected siblings exhibited distal muscle weakness and atrophy with normal cognitive and cranial nerve functions. there was no obvious phenotype from other organs. interestingly, this phe210leu mutation affects a highly conserved amino acid at the center of the fad domain. we hypothesize that this mutation impairs the binding between aifm1 and hsp70, leading to an enhancement of cell-death signaling. this family therefore provides a unique opportunity to explore how altered apoptotic signaling affects peripheral nerve system. supported by grants from ninds (r01ns066927) and the national center for advancing translational sciences (ul1tr000445 chronic inflammatory demyelinating polyneuropathy (cidp) can be the key symptom leading to diagnosis of associated lymphoma. patients with diagnosis of cidp according to efns/pns criteria associated with b cell lymphoproliferative disorders (bld), in one center, between november 2013 and november 2016 were included. demographical, clinical, nerve conduction, immunological, histological data and response to treatment were recorded retrospectively. eight patients (5 men), median age 70yo were included. onset of polyradiculoneuropathy was either chronic (n=6) or acute (n=2). neurological condition led to diagnosis of bld in all but one case, because of onset (n=4) or worsening of neuropathy (n=3). clinical presentation was that of cidp in 5 patients or pseudo-canomad in 2 and plexopathy in one. lymphoma type was: lymphoplasmacytic (n=3), diffuse large b cell (n=2), small lymphocytic (n=1), marginal zone (n=1), unclassified small b cell (n=1). only 2 patients presented with lymphadenopathies. bld was diagnosed in all 8 patients on myelogram or bone marrow biopsy, performed because of cytopenia (n=2), atypical (n=3) or severe (n=3) neuropathy. monoclonal gammapathy was identified in 5/8 patients (igm n=4, igg n=1). neuromuscular biopsy was performed in 6 patients and disclosed endoneural infiltration in 2. anti-neuronal or antigangliosides antibodies were positive in 5 patients. none of the patients presented a systemic autoimmune disease, hemolytic anemia associated with bld (n=2). immunomodulating treatment was administered in all patients (ivig n=7, plasma exchange n=3, steroids n=3) and immunosuppressants (n=1). immunochemotherapy for lymphoma was initiated because of lymphoma type or severity in 3 cases, in 5 cases because of the associated neuropathy. median follow-up was of 8 months after treatment initiation. four out of 5 patients treated within 3 months of neurological onset improved as well as one out of 3 patients whose preexisting neurological condition had worsened. two patients presented neurological relapse during progression of lymphoma. two patients died. unusual presentation of cidp -i.e., rapid progression or treatment failure -should lead to further testing for associated lymphoma. because general symptoms and lymphadenopathy often lack, diagnosis requires analysis of bone marrow with lymphocyte phenotyping. early treatment with immunochemotherapy was associated with better prognosis in our series. cardiac scintigraphy is a useful tool for the diagnosis, prognosis and pre-symptomatic early detection of familial amyloidosis-associated neuropathies three main types of familiar amyloidosis: transthyretin (ttr), apolipoprotein a1 and gelsolin. cardiac involvement is a leading cause of morbidity and mortality; one new described mutation strongly related with isolated cardiac amyloidosis is the ttr val122ile. the discovery of tests that allow early diagnosis of cardiac involvement in amyloidosis and to infer about the etiology of the disease is of major importance. in a cohort of patients with different types of familiar ttr amyloidosis, we aimed to assess the role of 99mtc-3,3-diphosphono-1,2-propanodicarboxylic acid (99mtc-dpd) in detecting myocardial amyloid infiltration. we enrolled four patients diagnosed with late familiar amyloidosis, which mutations were documented at deoxyribonucleic acid analysis: three patients with ttr val30met mutation and one patient with ttr val122ile mutation. three patients were asymptomatic for cardiac involvement and one patient (val122ile mutation) had a previous diagnosis of heart failure. myocardial uptake of 99mtc-dpd scintigraphy was semiquantitatively and visually assessed at five minutes and three hours.the uptake of 99mtc-dpd highly demonstrated amyloid in cardiac area in two out the three cases of ttr val30met and in ttr val122ile. ttr val122ile case presented the highest uptake due to the exclusive deposition of amyloid in cardiac area resulting in severe heart failure. in hereditary transthyretin-related amyloidosis, including the mutations ttr val30met and val122ile, 99mtc-dpd cardiac scintigraphy can identify infiltration even in asymptomatic individuals, allowing an early diagnosis of cardiac compromise in this group of diseases. we can consider that this non-invasive test would be a tool with potential importance in the diagnosis, prognosis and pre-symptomatic early detection of cardiac amyloidosis, giving emphasis on its applicability in familial forms of amyloidosis. cervellini i 1 , galino j 1 , zhu n 1 , birchmeier c 2 , bennett dl 1 . 1 ndcn university of oxford, oxford, uk; 2 max-delbrück-center for molecular medicine, berlin, germany. erk/mapk pathway has a critical role in pns development since its involvement in many physiological processes. sustained erk1/2 mapk activation in schwann cells enhances myelin growth during development and overcomes signals ending myelination leading to a continuous myelin production. however, strong activation of erk has also been shown to cause schwann cells dedifferentiation and demyelination in vivo. our aim was to investigate whether a mild activation of this signalling pathway in adult schwann cells (scs), by expression of gain of function mek1dd allele, could have a beneficial role in remyelination and regeneration after injury. erk/mapk activation in adult scs in plpcreer t2 ;mek1dd mutant mice, did not affect myelination during development. following sciatic nerve injury, wallerian degeneration was enhanced in mutants pushing towards a dedifferentiation stage of scs as previously described. however, mapk activation was detrimental during regeneration with a delay in functional recovery and a negative impact in both myelinated and non-myelinated fibres compared to controls. one month after injury the total number of axons in mutant sciatic nerves was half of the controls. although no differences in g-ratio have been found in the two groups, mutants presented a higher number of myelinated axons showing myelin disruption with start of myelin decompaction, lack of cajal bands, abundant sc processes surrounding axons and a shorter sc elongation, as seen by decreased internodal distance. in addition, we found a negative effect of mapk activation also in small diameter axons with the presence of abnormal remak bundle structures, reduced number of c-fibres/remak bundle and a significant decrease in intra epidermal nerve fibres density in the skin. we concluded that mild mapk activation has a different role in development and remyelination where negatively affects axon survival, myelin stability, remak bundle formation and small fibres regeneration. cervellini i 1 , galino j 1 , zhu n 1 , bao lu 2 , bennett dl 1 . 1 ndcn, university of oxford, oxford, uk; 2 harvard medical school, boston, ma, usa. neprilysin (nep) is an endopeptidase which has been of interest due to its potential role in neurodegeneration and pain as a consequence of its ability to degrade amyloid and substance-p respectively. nep expression is not limited to cns and it has been reported to be expressed in schwann cells, nodes and schmidt-lanterman incisures. our interest in this gene was related to recent findings that have associated homozygous and heterozygous nep mutations with charcot-marie-tooth type-2. in old mice lacking nep subtle morphological changes have been reported. our aim was to determine whether nep expression was modulated by nerve injury and to investigate its role in axon regeneration and re-myelination. we find that nep gene expression was decreased after nerve crush and furthermore was dependent on the growth factor (and pro-myelin signal) neuregulin-1. in control mice nep expression was transiently reduced and returned to baseline at day 28 after injury, in neuregulin-1 knock-out (ko) mice, in which re-myelination was impaired, the expression was still decreased at day 28. in assessing behavioural measures of locomotor and sensory function one month after sciatic nerve crush, nep ko mice showed a functional regeneration comparable to wt, as seen by sciatic functional index measurement, beam and toe spreading tests. the only significant difference we observed between wt and ko was in the sensorial test, showing ko mice recovering faster in the pinch test by 13 days after crush. the results for all the tests at baseline did not differ between the two groups. detailed histological analysis of nerve repair was undertaken using electron microscopy. there was no difference between wt and ko in total axon number, g-ratio, axon diameters and other myelin features one month post crush. in summary, although nep expression is regulated by nerve injury in a neuregulin-1 dependent fashion this endopeptidase is dispensable for axon regeneration and re-myelination after nerve injury in the rodent. diabetes neuropathy is a common complication of diabetes, and neuropathic pain has a detrimental impact on quality of life. this study investigated sensory nerve excitability properties to elucidate the axonal changes of diabetic neuropathy. a total of 95 diabetes patients (93 type ii, and 2 type i) were enrolled in this study. clinical assessment, nerve conduction studies, and nerve excitability testing data were analyzed to determine axonal dysfunction in diabetic neuropathy. among those patients, seventeen subjects had complained of spontaneous painful sensation over feet or hands (painful cohort), and seventy-eight patients had no sensory symptoms or decreased the sensation over foot (non-painful cohort). sensory nerve excitability of the painful cohort showed reduced late subexcitability (p=0.01), increased superexcitability (p=0.03) in compared to the non-painful cohort. there is no difference in disease duration, blood glucose levels (hba1c) between these two cohorts. these findings suggested the possible pathogenesis of painful sensory axons might be hyperpolarized or slow potassium channels dysfunction. these insights our further understanding of painful diabetic neuropathy, and may provide a basis for neuroprotective or therapeutic approaches for painful polyneuropathy. the main purpose of this study was to assess the clinical feasibility of diffusion tensor imaging (dti) for the diagnosis of chronic inflammatory demyelinating polyradiculoneuropathy (cidp). between march 2013 and december 2015, we prospectively enrolled 15 patients with definite cidp according to the efns 2010 criteria and two control groups: 15 healthy volunteers matched on age and sex and 15 patients with cmt-1a. using a 3-t magnetic resonance imaging scanner, we obtained dti scans of brachial plexus of these 3 groups and prepared fractional anisotropy (fa) maps, and compared these values between groups. adc values and cervical nerve roots diameters on stir sequences were evaluated too. two neuroradiologists, blinded to clinical informations, reviewed mri studies independently. in all patients with cidp, we also performed clinical evaluation and electroneuromyography. significantly decreased fa values (p<0.001) and increased adc values were observed in cidp patients compared with healthy subjects. there is no significant difference between cidp and cmt group. inter-observer concordance was excellent for fa values ( c=0.891; p<0.001) and moderate for adc values ( c=0.537; p<0.001) and cervical nerve root diameters ( c=0.495; p<0.001). there is a significant correlation between fa and disease duration (r = −0.5, p <0.05), inclusion mrc score (r = 0.56, p <0.05) and between fa mesured on c7c8 and incat score at inclusion (r = −0.53, p <0.05). no significant correlation is observed between fa and electrophysiological indices. compared with healthy subjects, cervical nerve root diameters were significantly increased (p<0.001) in patients with cmt and cidp. contrary to fa values, moderate level of concordance was found between inter-observers measurements of diameters (cclin = 0.495). our preliminary data prove the clinical feasibility and reproductibility of dti for the evaluation of plexus and cervical nerve roots in patients with cidp. cheng yj 1 , teng a 1 , goh ejh 1 , umapathi t 2 . 1 yong loo lin school of medicine, national university of singapore, singapore; 2 department of neurology, national neuroscience institute, singapore. the sural-sparing pattern of the sensory nerve action potentials (snap) of guillain-barré syndrome (gbs) has been attributed to greater immunological injury of the blood-nerve barrier at its most vulnerable regions. we asked if entrapment sites, such as median nerve at the wrist, are more predisposed than the distal nerve endings to such injury. we compared the median snap with radial snap measured antidromically at digit 1 in gbs patients whose nerve conduction study showed the sural-sparing pattern. the terminal nerves at digit 1 are of similar length, but those of median nerve are prone to compression, often subclinically, at the carpal tunnel while those of radial nerve are not. we defined the sural-sparing pattern as a greater decrease in median and or ulnar snap than that of the sural, compared to age and height-matched normal controls. a total of 35 gbs and miller fisher patients from our institution's database were studied. 15 patients had the sural-sparing pattern, of whom 1 had pre-existing carpal tunnel syndrome. of the remaining 14 patients with sural-sparing, 11 had abnormal median snap at digit 1, while 3 had both abnormal median and radial snaps at digit 1. none had isolated abnormality of the radial digit 1 snap. among the 3 cases that had abnormal median and radial snaps at digit 1, the mean percentage decrease when compared to age and height matched norms was greater in median nerve compared to radial nerve (97% and 75% respectively). of the 20 patients without sural-sparing pattern, 18 had normal snaps; 1 patient had inexcitable sensory nerves while the other had a length-dependent decrease in snap. in the latter patient, unlike those with sural-sparing, there was no differential decrease of median snap over radial snap at digit 1. our findings suggest that the disruption of blood nerve barrier at entrapment sites rather than the distal nerve endings may underlie the pathophysiology of the sural-sparing pattern seen in gbs. chiba a 1 , uchibori a 1 , gyohda a 1 . 1 kyorin university, tokyo, japan. serum igg anti-gq1b antibody is the most specific biomarker for fisher syndrome and its related disorders (fs-rd), but approximately 10-30% of the patients are seronegative for it in conventional assays (gq1b-seronegative). some molecules need ca 2+ cation to interact with their ligands, and antibodies with such a property (ca 2+ -dependent antibodies) are reported. we have found that such a ca 2+ -dependency is also present in igg anti-gq1b antibody, and majority of gq1b-seronegative patients with fs-rd have this type of antibodies. in 66 patients with final clinical diagnoses as fs-rd (fisher syndrome, guillain-barré syndrome with ophthalmoplegia, bickerstaff brainstem encephalitis, and acute ophthalmoplegia), 55 were seropositive for igg antibodies against gq1b-related antigens (isolated gq1b in 53, and gq1b-conatinig complexes in two) in conventional elisa using phosphate-buffered saline. in the remaining 11 patients, eight (73%) turned positive for igg antibody against gq1b-related antigens (isolated gq1b in seven and gq1b-conatinig complexes in one) in elisa using ca 2+ -added tris-buffered saline. the reaction strengths increased depending on ca 2+ concentration, and reached to nearly maximum level in the physiological concentration. all the patients with the ca 2+ -dependent antibodies were also positive for igg antibody against gt1a-related antigens, suggesting that the terminal disialo residue common to both the gangliosides would be important as an epitope also for the ca 2+ -dependent antibodies. in the 55 patients with ca 2+ -non-dependent antibodies, only two showed increased titers of igg anti-gq1b antibody by adding ca 2+ , and 31 showed significantly decreased titers. this difference in the effect of ca 2+ -addition between ca 2+ -dependent and ca 2+ -non-dependent antibodies suggests that ca 2+ would not be just an enhancer of the antigen-antibody reaction. there are four single bonds between the two pyranose rings in the terminal disialo, and those rotatable bonds make it possible for the disialo structure to take various conformations. a molecular model shows that the distance between two minus-charged carboxy groups in the disialo could vary from nearly zero to approximately 1,000 pm and that the disialo would take specific conformations, if divalent ca 2+ cation, which size is approximately 400 pm in diameter, interacts with these two minus-charged groups. the ca 2+ -dependent antibodies might recognize such particular conformations of gq1b. charcot-marie-tooth disease (cmt) is a genetically and clinically heterogeneous disorder with variable inheritance modes. it is characterized by loss of muscle tissue and touch sensation, predominantly in the feet and legs but also in the hands and arms in the advanced stages of disease. as several molecules have been reported to have therapeutic effects on cmt, depending on the underlying genetic causes, exact genetic diagnostics have become important for executing personalized therapy. aminoacyl-trna synthetase (arss) genes encode enzymes responsible for charging trna with corresponding amino acids. arss are ubiquitously expressed, essential enzymes responsible for performing the first step of protein synthesis. specifically, arss attach amino acids to their cognate trna molecules in the cytoplasm and mitochondria. recent studies have demonstrated that mutations in genes encoding arss can result in neurodegeneration, raising many questions about the role of these enzymes in neuronal function. mutations in six cytoplasmic ars genes have been reported as the cause of cmt. this study was performed the whole exome sequencing to identify genetic defects in 392 korean cmt patients from 280 unrelated families. variants were sorted with cmt gene list that includes almost 80 genes were related cmt neuropathy, and additionally sorted wes data as ars genes. capillary sequencing for family members and more than 500 controls revealed five novel mutations, c.598g>a (p.d200n), c.794c>t (p.s265f), and c.1007c>a (p.p336h) in gars; c.2398c>a (p.p800t) in mars; 241_242ga>at (p.d81i) in yars gene in each family. the mutation sites were well conserved between different species and each mutation were located in the well-conserved catalytic domain or between two catalytic domains or anticodon-binding domain. in silico analysis predicted all mutations may affect protein function. clinical features were similar to those reported in other countries, but differed in terms of age at onset and degree of disability. we believe that those novel ars mutations are the underlying causes of the each family. a 64-year-old man presented with a 26-year-history of weakness in biltearal upper limbs. he was complaining of intermittent fasciculation of upper and lower limbs with gradually worsening of paresthesia for 20 years. dysphagia and dysarthria were also presented 5 years ago. there was no patient affected muscle weakness and bulbar symptoms in his family members. in neurological examination, the patient had weakness in biltereal upper and lower limbs (mrc grade 3) and prominent distal sensory loss were combined in length dependant pattern. deep tendon reflexes were absent on bilataral biceps and knee joints. in nerve conduction study, there was consistent with demyelinating sensorimotor polyneuropathy. molecular diagnostic analyses those spinobulbar muscular atrophy (sbma) and mutation related to peripheral myelin protein 22 (pmp22) gene were performed and confirmed expansion of expansion of a polymorphic cag in androgen-receptor (ar) gene and deletion of pmp22 gene. smba, also known as kennedy disease, is an adult-onset, x-linked recessive trinucleotide, polyglutamine (poly-g) disorder caused by expansion of a polymorphic cag tandem-repeat in exon 1 of ar gene on chromosome xq11-12. charcot-marie-tooth disease (cmt) is the most common hereditary neuropathies and cmt cases with motor conduction velocities(mcvs) of upper limb below 38 m/s are defined as demyelinating (cmt1) and those with mcvs above 38 m/s are defined as axonal (cmt2). most families with cmt1 linked to duplication of pmp22 gene on the short arm of chromosome 17(17p11.2), called cmt1a. the reciprocal deletion of pmp22 gene is a responsible genetic defect in 70% of hereditary neuropathy with liability to pressure palsy (hnpp). these "classical" phenotypes of cmt1a and hnpp have been considered which are determined by different mutation mechanism of the same gene. however, an overlap of cmt1a and hnpp due to pmp22 gene deletion was reported that suggestion the phenotype of hereditary neuropathies may differ variably. herein, we report a patient who simultaneously presented clinical and electrophysiologic features of smba and cmt1a with genetical confirmation of cag expasion and deletion of pmp22 gene. charcot-marie-tooth type 1a disease (cmt1a) is an inherited peripheral neuropathy stemming from overexpression of pmp22 protein in schwann cells due to the duplication of the pmp22 gene. this leads to abnormal schwann cell differentiation and dysmyelination, eventually leading to axonal loss and muscle wasting. no approved treatment is currently available for cmt1a. we conducted a systems biology level analysis of the signaling network putatively underlying the processes driving cmt1a pathology. based upon this, we identified and tested three repurposed drugs -baclofen, naltrexone and sorbitol -alone and in combination to determine their ability to rescue aberrant myelination in cultures derived from cmt1a transgenic rats overexpressing pmp22 gene. to this end, we studied a validated in vitro co-culture model of sensory neurons and schwann cells adapted to 96-well culture plates. this model allows measurement of the appearance of myelin proteins as an index of the physiological process of in vivo myelination. total myelin length was quantified with an automatic image analyzer following pmp22 immunostaining. we first determined the full dose-response curves of single drugs, emphasizing their promyelinating activities. we then tested binary combinations of very low and inactive doses of each drug and compared these to the activity of the combination of the three, namely pxt3003. whereas combination of any two drugs was not significantly active at the doses tested, combination of all three produced a synergistic improvement in myelination. these findings clearly demonstrate the necessity of using pxt3003 over its single components and highlight the value of pleiotropic combinational repurposing of drugs at low doses as a novel approach for rapid drug development in cmt1a and other disorders. autonomic dysfunction is frequently observed in guillain-barré syndrome (gbs) and affects approximately 75% of the patients. it has been shown that the sweating function can be impaired in gbs. the aim of the present investigation is to summarize the current knowledge on sweating disturbances in gbs patients. we have used appropriate terms to systematically search for references published until 2016 and indexed in the following databases: medline, embase, lilacs and cochrane. the inclusion criteria were a diagnosis of gbs and a description of the methods used to test the sudomotor function. the search was limited to the english language. relevant information about study design, methods of assessing the deficit of sweating, patient's characteristics and main results were collected. we selected 13 original references for the final analyses. the majority of the studies were cross-sectional in nature and there were two longitudinal studies. the severity of sweating impairment varied according to the applied method, ranging from normal to almost sympathetic nervous system failure. in seven research papers, the sympathetic skin response was used to evaluate the sudomotor function in 99 patients, and approximately 30% demonstrated abnormal results. however, researchers used different stimulation protocols and parameters to interpret their results. regarding whole-body sweating test, four research papers applied the thermoregulatory sweating test in 14 patients and they showed areas of anhidrosis on the lower limbs in all of them. eight patients presented sweating impairment on the upper limbs and abdominal wall. results on the sudomotor axon reflex test suggested a length-dependent pattern of sweating loss according to one case report. in another study, eight gbs patients were tested only on the distal leg and foot dorsum and the authors proposed an association between post-ganglionic sudomotor function and antiganglioside antibodies. the present literature review showed that the studies of sweating disturbances in gbs patients included only small cohorts. future studies with larger patients sample sizes are necessary to investigate the patterns of sweating loss in gbs and their changes along the follow up. funding: grants #2013/03150-3 and #2012/07165-2, são paulo research foundation (fapesp). sensory neuronopathy (sn) represents a rare subgroup of peripheral neuropathies characterized by degeneration of primary sensory neurons at the dorsal root ganglia on the spinal cord. depending on the neuronal population affected, its clinical presentation may manifest as gait ataxia, proprioceptive sensory loss and positive and negative sensory symptoms. although a few reports have mentioned areas of anhidrosis in sn, we were not been able to find previous case series studies on the sweating function in sensory neuronopathies. the aim of the present investigation was to study the whole-body distribution of sweating on both anterior and posterior surfaces in patients diagnosed with sn. quantitative sensory testing for cold and warm sensation threshold (method of levels) was performed on the dorsum of the hands and feet in a randomized order. we tested the thermoregulatory sweating using a sweat chamber (44 0 to 47 ∘ c air temperature and 30% relative humidity). the oral and skin temperature was monitored and the test time did not exceed 45 min. in order to study the sudomotor axon reflex we employed the q-sweat device on standardized body sites. the test was performed on both sides, simultaneously. we included seven patients (three male; mean age 50.25 years) with a mean disease duration of 67.7 months (range 24-180) and a confirmed diagnose of sn. patients presented an asymmetrical loss of cold and warm threshold on hands or feet compared with healthy control (p<0,05). regarding the tst results, we found a striking variation of sweating disturbances, ranging from small areas of anhidrosis on the trunk to complete failure of the sympathetic nervous system. two patients underwent the axon reflex test and there was an asymmetrical and mostly distal pattern of sweating loss in one of them and a distal-symmetrical on the second one. our findings indicate a great variability of sweating losses in sn, not overlapped to the sensory loss areas. currently, we are testing more patients in order to confirm our results. funding: grants #2013/26410-0, #2013/03150-3 and #2012/07165-2, são paulo research foundation (fapesp). diet, exercise, and inflammation are established modulators of peripheral nervous system function, including pain. prior work examining exercise consistently demonstrates a benefit on heightened pain from a number of acute and chronic pain models. in the present work, we investigated several parameters of peripheral nerve function relevant to pain in rats bred for high (high capacity runners, hcr) or low running capacity (low capacity runners, lcr). the longtime selective breeding of these rat substrains has created divergent intrinsic aerobic capacities and predisposition of metabolic conditions between lcr and hcr rats. examination of the role of sex in the development of chronic pain has established key differences in males and females. to understand gender specific differences, this study focused on female rats to understand the role of metabolic status and peripheral nerve function in females. our analysis identified numerous parameters of peripheral nerve function relevant to pain and neuropathy that are different among lcr and hcr female rats. lcr female rats display reduced hind paw mechanical sensitivity, increased hind paw intraepidermal nerve fiber density and trka-positive epidermal axons, increased numbers of langerhans and mast cells in the hind paw dermis, and increased overall fat mass relative to body weight compared to female hcr rats. examination of sensory and motor nerve conduction velocities, thermal sensitivity, and mrna expression of selected genes relevant to peripheral sensation found no differences between hcr and lcr females. together these results suggest that a genetic component of aerobic capacity and metabolic status can influence sensory sensitivity and specific aspects of inflammation and immune responses in peripheral tissues, which may lead modify the animal's responses to tissue damage and painful stimuli. the lcr and hcr rat model will provide a useful model in the future to assess the involvement of metabolic status in the development of pain. ivig is often considered treatment of first choice in chronic inflammatory demyelinating polyradiculoneuropathy (cidp) because of its rapid onset of action and its relatively safe long-term adverse event profile. clinical trials published so far focused on a loading dose of 2.0 g/kg ivig and/or a standard maintenance dosage of 1.0 g/kg ivig once every 3 weeks, but have not investigated different dosing options. this study is a prospective, double-blind, randomized, parallel group, multi-center phase iii efficacy study and will be conducted in 44 centres in canada, eu, russia, ukraine and australia. 140 adult patients with definite or probable cidp according to the efns/pns criteria will be enrolled and randomized 1:2:1 to receive either 0.5 g/kg or 1.0 g/kg or 2.0 g/kg ivig (panzyga ® ) for seven maintenance infusions at 3-week intervals during the dose-evaluation phase. the starting loading dose will be 2.0 g/kg ivig (panzyga ® ) for all patients. primary objective: efficacy measured as percentage of responders (decrease in adjusted incat score by at least 1 point) in the 1.0 g/kg ivig (panzyga ® ) arm (given every 3 weeks) at week 24 as this should corroborate the existing and published evidence on efficacy of ivig in cidp. secondary outcome: percentage of responders at week 24 in the 0.5g/kg and 2.0 g/kg ivig (panzyga ® ) arms relative to baseline and compared to the 1.0 g/kg arm. the procid study aims to confirm published clinical results obtained with the 1.0 g/kg standard dose and will in addition evaluate one higher and one lower maintenance dose, with the aim to offer cidp patients a more adequately dosed and effective treatment policy. * este medicamento no se encuentra comercializado en españa. understanding the rate of disease progression in patients with charcot-marie-tooth disease (cmt), both within and between subtypes is important for clinical prognosis and is crucial for clinical trial design. due to the progressive nature of cmt, intervening at the earliest stages of the disease is a priority. measuring progression of a disease with both motor and sensory deficits requires a multi-item composite scale. the cmt pediatric scale (cmtpeds) is a well-tolerated psychometrically robust 11-item scale measuring fine and gross motor function, strength, sensation and balance for children and adolescents aged 3-20 years with cmt. the aim of this study was to determine the rate of disease progression of children and adolescents within and between genetic subtypes of cmt. 206 (103 female) participants aged 3-20 years enrolled in the inherited neuropathies consortium were included in this study. demographic, anthropometric and diagnostic information were collected at baseline and 2-year follow-up. disease progression was measured with the cmtpeds. on average cmtpeds scores progressed at a rate of 2.4 points over 2-years (14% change from baseline, p<0.001). there was no difference in rate of disease progression between males and females. of the most common genetic subtypes, 111 participants with cmt1a/pmp22 duplication progressed by 1.8 points (12% change from baseline, p<0.001), nine participants with cmt1b/mpz mutation progressed by 2.2 points (11% change), six participants with cmt2a/mfn2 mutation progressed by 6.2 points (23% change) and seven participants with cmt4c/sh3tc2 mutation progressed by 3.0 points (12% change). participants with cmt2a progressed faster than those with cmt1a (p=0.02). children with cmt1a progressed consistently during childhood and adolescence while children with cmt1b and cmt2a progressed faster during childhood than adolescence. overall, children with cmt progress at a significant rate over 2-years according to the cmtpeds. understanding the rate at which affected children deteriorate is essential for adequately powering clinical trials of disease-modifying interventions. queen square, london, uk; 2 department of neurology, university of iowa carver college of medicine, iowa city, ia, usa; 3 department of neurogenetics, the national hospital for neurology and neurosurgery, ucl institute of neurology, london, uk; 4 department of molecular neuroscience, ucl institute of neurology, london, uk and national hospital for neurology and neurosurgery, queen square, london, uk. in recent years, targeted ngs panels have changed the diagnostic work-up in patients with inherited neuropathies. however, there is limited data on the impact of targeted ngs panels on the diagnosis of cmt patients in everyday practice. the aim of this study was to investigate the impact of targeted ngs panels on the diagnosis of cmt across two tertiary referral centres in the united kingdom (london) and united states (iowa). in london, 128 patients with a diagnosis of cmt (previous pmp22 duplication and common cmt genes excluded in appropriate cases) underwent targeted ngs panel sequencing covering 50 genes associated with cmt and 26 additional genes associated with hsp or als. a variable number of genes, ranging from 11 to 76, were analysed depending on the clinical phenotype of the patients. a definite molecular diagnosis was achieved in 37 cases (28%) including pathogenic and likely pathogenic mutations in sh3tc2 (5 cases), gjb1 (4 cases, including 2 cases with mutations in the promoter and 3'utr regions), gdap1 (3 cases), fgd4 (3 cases), aars (2 cases), ighmbp2 (2 cases), mpz (2 cases), nefl (2 cases). vus were further identified in 20 patients. the diagnostic rate was higher in demyelinating cmt cases (21/42, 50%), compared to cases with axonal cmt (10/53 19%), dhmn (4/20, 20%) and hsn (1/13, 8%). in iowa, 50 patients were investigated by ngs panels covering 18 to 79 genes associated with cmt. a molecular diagnosis was reached in 22/50 (44%), and in particular 8/10 (80%) demyelinating and 14/40 (35%) axonal cmt cases. the most frequent genes identified were gjb1 (6 cases), mfn2 (4 cases), sh3tc2 (3 cases) and ighmbp2 (2 cases). vus were identified in 22 patients, including 5 cases with novel variants in aars, warranting additional testing such as segregation of the variant in the family or functional validation studies. in clinical practise, targeted ngs panels represent an effective approach for the diagnosis of cmt. the lower diagnostic rate in london is likely to be due to prior sanger sequencing and exclusion of mutations in common cmt genes in this patient population. more than 80 genes are known to cause cmt and an even larger number are known to cause peripheral neuropathy as part of a more complex neurological disorder. despite the use of custom panels, a significant proportion of patients with inherited neuropathy have no molecular diagnosis. the aim of this study was to investigate the diagnostic yield of a 6000 disease-associated gene exome (sureselect focused exome, agilent technologies, santa clara ca, usa) in the diagnosis of cmt and in cases with complex neurological syndromes associated with neuropathy. thirty-one patients with molecularly undiagnosed inherited neuropathy were analysed with sureselect focused exome sequencing. six patients had a more complex phenotype including learning difficulties, cerebral white matter changes, ataxia and pyramidal tract involvement. a genetic diagnosis was achieved in 13/30 (43%) of cases by detecting a mutation in cmt-associated genes mpz (2 cases), aars, nefl, bscl2, bicd2 and trpv4. of note, six cases had mutations in genes which are not covered by currently available diagnostic targeted ngs panels, including kif1a, polg, mme (2 cases), dnajb2, and a novel candidate gene. the average coverage was higher compared to the usual coverage of whole-exome sequencing; 95% of the targets were covered at 30x or more, and 98% of the targets were covered at 10x or more. this study provides evidence that the sureselect focused exome is a useful tool for the diagnosis of cmt and complex neurological disorders and provides further insight into the phenotypic spectrum of genes associated with inherited neuropathy. changes in the cis-regulatory sequences of a gene's untranslated regions (utr) are increasingly recognised as a significant cause of inherited disease in humans. for example, variants in the non-coding region of gjb1 account for 10% of all mutations in our cohort of cmtx patients. one of the biggest challenges in analysing the large number of non-coding variants in a gene is identifying those that are disease-causing and those which are polymorphisms. the aim of this study was to implement a reliable method for the in-vitro functional validation of non-coding variants in the promoter and 3'utr regions of gjb1. in our cohort of cmtx patients we have previously identified seven mutations (c.-592_591inst, c.-570g>a, c.-529t>g, c.-529t>c, c.528t>c, c.-527g>c, c.-459c>t) in the promoter region and one novel mutation in the 3'utr (c.876c>t), which were considered likely to be pathogenic based on the clinical phenotype, segregation in affected family members and absence in control databases. we have now generated a luciferase-based reporter system and optimised it in a hela cell line. mutations in the promoter region were generated by site-directed mutagenesis using a commercially available gjb1 promoter clone (genecopoeia). our preliminary results show a reduction of luciferase activity for the c.-528t>c and c.-592_591inst mutations compared to the wild-type promoter. this difference was increased when transcription factors sox10 or egr2 were co-transfected with the 528t>c and c.-592_591inst mutations respectively. validation of other variants is currently ongoing. if successful, our study will provide a useful tool for the validation of mutations in non-coding regions of gjb1. moreover, it will constitute a proof-of-principle approach to the functional validation of non-coding variants in other cmt genes known to cause disease by a loss of function. recessive and dominant mutations in leucin-rich repeat and sterile alpha-motif-containing 1 (lrsam1) have been associated with cmt2p. lrsam1 is a ubiquitin e3 ligase containing a ring domain in its c-terminal, which is crucial for correct protein folding and ubiquitination activity. to date, the majority of dominant mutations reported have resulted in a frame shift disrupting a major portion of the ring-domain, although point mutations in this domain have also been described. the aim of this study was to report the prevalence, clinical features and genetic findings of patients with cmt2p in our centre. we performed targeted next-generation sequencing in 57 genetically undiagnosed cmt2 patients and identified 6 cases with heterozygous mutations in lrsam1 (10.5%) from 6 unrelated families. the mutations identified included frameshift insertions and deletions, a non-frameshift deletion and non-sense and missense point mutations. all of the mutations were novel and were located in or flanking the ring domain. the average age of disease onset was in the 3 rd decade but an earlier onset was reported in two cases. four had a positive family history in keeping with autosomal dominant inheritance. symptoms at presentation were heterogeneous and encompassed distal numbness, unsteadiness, distal weakness of upper or lower limbs and foot deformities. positive sensory symptoms, including tingling and shooting pains, and cramps were also frequently reported. neurological examination showed mild to moderate distal atrophy and weakness, with early ankle plantar flexion involvement in three patients. loss of vibration and reduced joint position sense were often prominent in the lower limbs and appeared to be disproportionate to the degree of weakness and impairment of pinprick sensation. ankle jerks were absent but knee and upper limb reflexes could be normal or brisk. after an average disease duration of 20 years, all but one patient was able to walk independently. nerve conduction studies showed a sensory and motor axonal neuropathy with normal conduction velocities. our study highlights that mutations in lrsam1 are a relevant cause of cmt2 and are associated with prominent large fibre sensory loss. in recent years, the implementation of ngs panels for the molecular diagnosis of cmt has increased the number of patients with a genetic diagnosis. nevertheless the interpretation of a particular variant as disease causing can be challenging especially when multiple variants are identified in a single patient. we report two illustrative cases of such challenges. the first index case was born of non-consanguineous healthy parents. he presented with falls in early childhood. over the years he developed foot deformities and progressive length dependent weakness. he had multiple orthopaedic operations to his feet. the past history was also notable for kyphoscoliosis, sensorineural deafness from the age of 30 and bilateral cataracts. nerve conduction studies at the age of 54 revealed a demyelinating neuropathy consistent with the clinical phenotype of cmt1. his younger brother had a similar, although more severe phenotype. a litaf (c.115c>t,p.pro39ser) mutation was identified by sanger sequencing and was present in both affected brothers but also in the unaffected sister. ngs for cmt1-associated genes was therefore performed and identified two compound heterozygous pathogenic mutations detected in sh3tc2 (c.2860c>t, p.arg954*;3303delg, p.arg1101serfs*15), which segregated with the disease in the family. the second case describes a brother and sister with early onset demyelinating cmt associated with scoliosis and cranial nerve involvement. the male proband underwent ngs and a single previously reported pathogenic intronic splice-site mutation in sh3tc2 (c.286-2a>c) was found. relative read-depth analysis of ngs was performed to look for possible copy number variants in sh3tc2, thus identifying a deletion of exon 7, which was confirmed by long pcr. cruz-velásquez gj 1 , miramar-gallart md 2 , alarcia-alejos r 1 , roche-bueno jc 1 , rodríguez-valle a 2 , capablo-liesa jl 1 . 1 neurology service, university hospital miguel servet, zaragoza, spain; 2 genetics unit, clinical biochemistry service, university hospital miguel servet, zaragoza, spain. charcot-marie-tooth disease (cmtd) defines a clinical and genetically heterogeneous group of inherited peripheral neuropathies characterized by chronic motor and sensory impairment. the type cmtd-4 also known as cowchock syndrome, is the product of the mutation in the apoptosis inducing factor mitochondria associated 1 gene (aifm1). it is a slowly progressive, recessive, x-linked disease characterized by axonal neuropathy, deafness, and cognitive impairment. our purpose is to describe 2 new cases, brothers, children of non-consanguineous parents, with a characteristic phenotype and a new mutation in the aifm1 gene. both siblings present from childhood, progressive weakness in lower limbs with diffuse amyotrophies. needing tenotomy before the 7 year due to equinovarus foot. likewise they develops sensory deafness and one of them requires unilateral support at 39 and the other wheelchair at 38, this one need a pacemaker for an atrioventricular block at 40. with brain functions and normal language, sensorial deafness, proximal and distal weakness in the four limbs with intense amyotrophies, predominantly distal. tactile and painful sensitivity decreased in glove and sock pattern. an extensive metabolic and biochemical study was normal. the electroneurography demonstrates an axonal neuropathy without response in most of the nerves explored. the electromyography shown a myogenic pattern with distal predominance. brain mri was normal in both cases. through a genetic study by exoma targeting 53 genes associated with cmt and inherited related neuropathies was identified the homicigosis mutation in the aifm1 gene (p.glu366lys), located in the chromosomal region xq26.1 (cmtx4). cowchock syndrome is a rare entity, with few cases described in the literature. the in silico analysis indicates in 7 of the 9 predictors used (provean, sift, polyphen2, lrt, mutationtaster, mutationassessor and condel) , that it is a deleterious variant. we audited all patients with peripheral neuropathy caused by a paraprotein, who received treatment and attended king's college hospital peripheral nerve service between 2004-16. patients were identified retrospectively from our database of patients attending the peripheral nerve outpatient clinic. clinical information was obtained retrospectively from hospital electronic patient records. we excluded patients with poems syndrome or in whom the neuropathy was not felt to be caused by the paraprotein. we identified 61 patients with a diagnosis of paraproteinaemic neuropathy. we excluded four who did not fulfill the diagnostic criteria and eleven who had received no treatment or were under diagnostic study. we included 46 patients in the final audit. 45 (98%) had igm paraprotein. the haematological diagnosis was monoclonal gammopathy of undetermined significance (mgus) in 65%, waldenstroḿs macroglobulinaemia 30%, and lymphoma or plasmacytoma 5%. after treatment, overall 13 (28%) patients improved neurologically, 11 (24%) stabilised, and 22 (48%) worsened. in the 19 patients who received more than one type of treatment, we analysed outcomes according to the most powerful treatment received. 23 patients received rituximab alone of which 5 (22%) improved, 6 (26%) stabilised and 12 (52%) worsened. nine patients received rituximab combined with cyclophosphamide or bendamustine, of which 3 (33%) improved, 2 (22%) stabilized and 4 (44%) worsened. eight patients received intravenous immunoglobulin, of which 3 (38%) improved, 2 (25%) stabilized and 3 (38%) worsened. four patients received other chemotherapy, of which 2 improved, 1 stabilised, 1 worsened. two patients received corticosteroids and both worsened. there was improvement in 7/29 (24%) with mag antibodies and 6/17 (35%) without. there was improvement in 5/26 (19%) with mgus and 5/14 (36%) with haematological malignancy. there was improvement in 11/32 (34%) with kappa light chains and 2/14 (14%) with lambda. factors associated with better outcome (by univariate analysis) were negative mag antibodies, kappa light chain, and haematological malignancy. there was no significant difference between treatments in the proportions who improved. cumberbatch m 1 , cox a 1 . 1 addenbrooke's hospital, cambridge, uk. treatment of patients with autoimmune neuropathies such as chronic inflammatory demyelinating polyradiculoneuropathy (cidp) and multifocal motor neuropathy (mmn) has centred on the use of intravenous immunoglobulin (ivig). however, ivig therapy is associated with systemic side-effects, treatment wear-off effects and regular hospital attendance. subcutaneous immunoglobulin (scig) is an efficacious alternative that can be flexibly dosed, self-administered at home and avoids the 'peaks' and 'troughs' observed with ivig. these factors may combine to improve patient satisfaction and alleviate hospital capacity issues. here, we report on clinical and patient experience of switching from hospital-based ivig to home-based manual push scig for the treatment of cidp and mmn. this was a clinical case series of 10 patients (8 cidp, 2 mmn; mean age 59.5 years) who were clinically stable on ivig and wished to switch to manual push scig. starting scig dose was equivalent to the final ivig dose for each patient (mean 0.23 g/kg week). clinical efficacy (medical research council sum score, 10-m walk, modified inflammatory neuropathy cause and treatment score, overall neuropathy limitations scale, romberg test) and patient-reported outcomes (36-item short form health survey , life quality index [lqi] ) were assessed at baseline and at regular intervals until the final visit (10-14 months after switching). at baseline, patients cited 'convenience' as their primary reason for switching to scig. eight patients completed the full assessment period and successfully undertook administrations at home (via hospital-at-home service in 2 cases). dose adjustments, based on clinical need, were required in 6 patients. treatment efficacy and patient quality of life, measured by sf-36, were maintained after switching to scig; overall patient satisfaction, measured by lqi, increased from 75% to 90%. in the lqi, 'convenience', 'travel time/cost' and 'interference-work' were significantly improved (p<0.05) after switching to scig therapy. adverse events included mild erythema and localised swelling, as expected for a 20 ml subcutaneous injection. these findings suggest that manual push scig therapy is a viable alternative to ivig for patients with cidp and mmn, as it maintains disease stability, is more convenient for patients and may help ease hospital capacity concerns. cumberbatch m 1 , soares regua d 1 , cox a 1 . 1 addenbrooke's hospital, cambridge, uk. intravenous immunoglobulin (ivig) is used to treat a number of chronic autoimmune neurological diseases. in most centres, infusions are given at slow rates as there is a perception that this reduces the risk of adverse events (aes). this results in longer in-patient admissions, or frequent day case attendances, impacting on both the patients' quality of life and hospital capacity. however, there is little evidence to suggest that slow infusion rates are required. we used the manufacturer recommendations to optimise infusion rates and reduce the time patients spend in hospital. we report a retrospective audit which describes the impact of different ivig infusion rates on patients' clinical condition. the audit comprised three 6-month assessment periods: january-june 2015 (cohort 1; infusion rates of 1.2 ± 0.1 ml/kg/hr, n = 27); january-june 2016 (cohort 2; 2.4 ± 0.1 ml/kg/hr, n = 42) and july-december 2016 (cohort 3; 3.9 ± 0.2 ml/kg/hr, n = 39). clinical data were reviewed to determine: patient demographics, duration of infusion; time spent in hospital; and incidence of aes. the three cohorts were well matched in terms of patient demographics (14 patients were treated in all 3 treatment periods). cohorts 2 and 3 had significantly shorter treatment episodes than cohort 1 (3.2 and 2.7 vs. 4.1 hours, p<0.01), spent less time on the unit over the 6 month period (25.6 and 20.3 vs. 39.4 hours, p<0.05) and had fewer admissions/patient (6.5 and 5.9 vs. 8.5, p<0.05). the overall incidence of confirmed aes (mainly headaches) was similar across the cohorts (cohort 1: 15%; cohort 2: 19%; cohort 3: 18%). these findings indicate that increases in ivig infusion rate are well tolerated and significantly reduce treatment time, which benefits patients and offers potential cost savings and reduced pressures on hospital capacity for healthcare providers. cunningham me 1 , yao d 1 , meehan gr 1 , barrie ja 1 , willison hj 1 . 1 university of glasgow, glasgow, uk. one mechanism of injury in the acute motor axonal neuropathy (aman) form of guillain-barré syndrome (gbs) is the attack of peripheral nerve axons by anti-ganglioside antibodies (agabs). rodent models have demonstrated that that binding of these antibodies activates the complement cascade, resulting in the insertion of the terminal component, membrane attack complex (mac) into the axonal membrane. complement activation also results in the release of anaphylatoxins, which are known to recruit phagocytic immune cells to the site of injury. our current in vivo mouse model of agab and complement-mediated injury are acute and severe, resulting in respiratory distress over several hours of such magnitude to warrant termination of experimental procedures. to observe and potentially target immune cell infiltration following agab and complement-mediated injury, a subacute model extending over days is required. here, we demonstrate the development of such a model. to compare differences in immune cell infiltration subacutely under control and injury conditions, mice with endogenous expression of egfp in monocytes and macrophages underwent a modified agab and complement-mediated injury, resulting in a less severe phenotype than previously published models. six days following injury, immune cells in the diaphragm were compared by immunofluorescence and flow cytometry. flow cytometry found overall presence of neutrophils was significantly increased in the diaphragm. macrophages were also increased in injured mice, although did not achieve statistical significance at this timepoint. these results were reflected in immunofluorescent staining of the diaphragm where egfp+ macrophages were quantified surrounding the neuromuscular junction (the primary injury target in this model). the development of an extended mouse model of agab and complement-mediated injury is important, since acute models do not take into consideration either the late-term effects of complement-mediated activation at the nerve membrane, or the recovery phase. future studies will look at the effect of inhibiting complement activation on the presence of immune cells in distal motor nerves. family-54 is a large australian family with an autosomal dominant form of dhmn (dhmn1: omim %182960) -a group of length-dependent neurodegenerative disorders affecting the lower motor neurons leading to chronic disability. we recently reported a novel 1.35 mb chromosomal insertion within the dhmn1 locus which we hypothesise is likely to cause disease by dysregulating the expression of one or more nearby genes. studying gene dysregulation in peripheral nerve disease is challenging as the relevant tissues (spinal cord and peripheral nerve) are not easily accessible in patients. therefore, alternative strategies are needed to elucidate the disease mechanisms and pathways involved in peripheral nerve degeneration. to address this problem, we have devised a two-tiered strategy to assess dysregulation of candidate genes using patient lymphoblast and fibroblast cell lines. these cell lines can be easily established, are minimally invasive to obtain, and will harbour the natural mutation and genetic background of patients. our strategy firstly uses lymphoblast gene expression profiles as an initial screening tool to prioritise candidate genes for assessing altered expression. differentially expressed genes will then be modelled in c.elegans where behavioural and nerve morphology can be assessed. using rt-pcr, we have screened 21 dhmn1 candidate genes in patient and control lymphoblast cell lines. eighteen candidate genes were expressed in lymphoblasts. twelve of the eighteen genes were prioritized for further analysis based on expression in both lymphoblast and neural tissues. quantitative analysis using qrt-pcr taqman assays revealed that ube3c, was differentially expressed between patients and controls. it is important that patterns of differential expression can be recapitulated in neural cell-specific models. as part of our second strategy, we have generated patient and control induced pluripotent stem cell derived motor neurons (ipsc-mns) from reprogrammed fibroblasts. using this model, we will perform rna-seq and qpcr experiments to examine disease-relevant alterations in gene expression in neural tissue. we predict that utilization of these two strategies will shed light on the pathogenic mechanisms underlying the dhmn1 insertion and provide useful insights of pathways leading to peripheral nerve degeneration. the outcome of guillain-barré syndrome remains unchanged since plasma exchange and intravenous immunoglobulin were introduced over 20 years ago. pathogenesis studies on gbs have identified the terminal component of complement cascade, the membrane attack complex, as a key disease mediator and thus a therapeutic target. the inhibition of complement in guillain-barré syndrome (ica-gbs) trial looked at the first use of c5 pathway inhibition with eculizumab in humans with gbs in a randomised, double-blind, placebo-controlled trial. its primary outcome was to look at safety and tolerability of administration concomitantly with ivig and in the context of severe (gbs disability score 3 or greater) disease. participants were recruited for a 6 month period, with regular follow up. 28 subjects were screened, with 8 (29%) being randomised. the two main causes for failure to proceed were participant concerns around eculizumab side effect profile, specifically the meningitis risk, and also intercurrent infection precluding treatment. five received eculizumab for four weeks, alongside standard intravenous immunoglobulin treatment, with 3 receiving placebo. the safety outcomes, monitored via adverse events capture at each trial visit, showed eculizumab to be well tolerated and safe when administered in conjunction with ivig. the most common adverse events were mild derangement in transaminases or infection. there were no infusion reactions. primary and secondary efficacy outcomes were captured via gbs disability scores, mrc sum scores, rasch overall disability scores and overall neuropathy limitation scores. for the primary efficacy outcome at 4 weeks after recruitment, 2 of 2 placebo and 2 of 5 eculizumab-treated subjects had improved by 1 or more grades on the gbs disability score. all patients had improvements in other measured parameters. this trial highlights the challenges in recruiting acutely unwell patients, due to time constraints and intercurrent infection. although the small sample size precludes a statistically meaningful analysis, these pilot data indicate further studies on complement inhibition in gbs are warranted. charcot-marie-tooth disease (cmt) affects about one in 2.500 people. currently more than 44 genes have been identified, with the most different phenotypes. the majority of cases in western countries are autosomal dominant and classified as demyelinating and axonal according to electroneuromyography (enmg). the clinical condition is characterized by weakness and predominant sensory changes in the feet and hands. sometimes there are different phenotypes. recently, variants in heterozygotes in the hars gene (histidil-trna synthetase) have been described associated with cmt called type 2w.to report a case of cmt-sensitive phenotype with a probable new mutation in hars gene (p.leu41arg).a male patient, adopted son, caucasian, drug addict, for three years suffered pain in lower limbs, of great intensity, refractory to drug treatment. the examination showed retrognathism, abolition of patellar and achilleas reflexes, painful and thermal anaesthesia and apalesthesia in the feet.the enmg showed reduced sensory action potentials in sural and superficial fibular nerves. laboratory investigations for painful polyneuropathy of thick and fine fibres was normal. sural nerve biopsy revealed axonal predominance neuropathy. exome sequencing revealed a mutation in the hars gene with a pathogenic variant in heterozygosity, with replacement of the amino acid leucine at position 41 by arginine. our patient, although we did not know the antecedents, presented painful polyneuropathy, whose genetic research, although not unequivocal, indicated a variant called cmt w. few cases of this variant were described, with several mutations. our case revealed mutation hitherto unknown (p.leu41arg). we conclude by the importance of a thorough genetic evaluation, in cases of sensory polyneuropathy of unknown cause. small fiber neuropathy (sfn) is a condition that affects the small a -and c-fibers, leading to severe neuropathic pain and autonomic dysfunction. several sodium channel gene mutations have been found in patients with sfn, with scn9a-gene mutations being the most frequent. because current available sodium channel blockers are not selective for na v 1.7, these treatments often result in numerous side effects. lacosamide is an anticonvulsant that targets specific sodium channels with a slow-inactivation state, while sparing those with normal activity. several mutations of the scn9a-gene with an impaired slow-inactivation of na v 1.7 have been found in patients with sfn. therefore, a positive effect of lacosamide on pain reduction in these patients is expected. the primary objective of this study was to determine the effect of lacosamide versus placebo on pain in subjects with scn9a-associated sfn. secondary objectives were to determine the effect of lacosamide on autonomic symptoms, sleep interference, and quality of life, and to examine the safety and tolerability. the lacosamide-efficacy-'n'-safety in sfn (lenss) study was a randomized, placebo-controlled, double-blind, crossover-design study. subjects were randomized to start with lacosamide and end with placebo or vice versa. during both of the two phases of the study, the subjects were treated for a period of eight weeks of 200mg bid, preceded by a titration period, and ended by a tapering period. patients filled in a pain diary twice daily and scored a set of validated questionnaires on autonomic symptoms, sleep interference, and quality of life at multiple study visits. in total 25 patients with scn9a-associated sfn were included between november 2014 and february 2017. the subjects had a median age of 58 years, ranging from 24 to 78 years. sixty percent of the patients were female. the final results of the study, including the primary and secondary outcomes, will be presented. de la oliva n 1 , del valle j 1 , navarro x 1 . 1 department of cell biology, physiology and immunology, institute of neurosciences, universitat autònoma de barcelona and centro de investigación biomédica en red sobre enfermedades neurodegenerativas (ciberned), bellaterra, spain. intraneural interfaces must be in intimate contact with nerve fibres to have a proper function, but it has been shown that this is compromised due to the foreign body reaction (fbr). this fbr is the first response of the nonspecific immune system against an implanted device and is characterized by a first inflammatory phase followed by a second antiinflammatory and fibrotic phase. this process results in the formation of a tissue capsule around the interface causing function loss due to the physical separation between the active sites of the electrode and nerve axons. taking this into account, here we have tested several anti-inflammatory drugs such as dexamethasone, ibuprophen and maraviroc to reduce macrophage activation as well as clodronate liposomes to reduce monocyte/macrophage infiltration. moreover, sildenafil have been administered as an antifibrotic drug to reduce collagen deposition in a fbr model with longitudinal parylene c-based intraneural devices implanted in rat sciatic nerve. briefly, animals were systemically treated with dexamethasone, ibuprophen, sildenafil, maraviroc or clodronate liposomes for two weeks, and nerve damage, inflammatory reaction and matrix thickness around the implant were assessed. treatment with dexamethasone, ibuprophen or clodronate liposomes significantly reduced the inflammatory response in the nerve in comparison to saline group while sildenafil or maraviroc had no effect on iba1 positive cells infiltration in the nerve. however, only dexamethasone was able to significantly reduce the matrix deposition around the implant after two weeks of treatment. these results support the idea that inflammation triggers the foreign body response in peripheral nerves and a potent anti-inflammatory treatment with dexamethasone could have a beneficial effect on lengthening intraneural interfaces lifespan. de la oliva n 1 , del valle j 1 , navarro x 1 . 1 department of cell biology, physiology and immunology, institute of neurosciences, universitat autònoma de barcelona and centro de investigación biomédica en red sobre enfermedades neurodegenerativas (ciberned), bellaterra, spain. intraneural interfaces functionality decreases over time, among other factors, due to the foreign body response (fbr), which encapsulates the implanted devices and physically separates the active sites from the nervous tissue. here we have studied the fbr to parylene c or polyimide thin devices implanted in rat sciatic nerves, assessing thickness of the tissue capsule, signs of inflammation and nerve damage. we have characterized the responsible cells of this response and several molecular mediators over 8 months of implant to find differences between the fbr to both materials. after 2 weeks of implant, the inflammatory response due to the surgery was already decreased, whereas in the implanted nerves it reached its highest levels to then decrease at chronic time points. besides, the amount of foreign body giant cells (fbgc), as a result of macrophage fusion, found in the tissue capsule around the implant also increases progressively to reach a maximum after 2 weeks. on the other hand, molecular analysis of the environment revealed a peak of inflammatory cytokines during the first day of implant to return to standard levels thereafter. however, an increase on ccls molecules was found at later time-points for both materials. with regard to the capsule thickness, all the devices were surrounded by a tissue deposition which appeared soon after the implantation. however, in the case of polyimide devices, the tissue capsule showed a peak 2 weeks after the implant and signs of remodeling thereafter, while the parylene c devices showed a second increase from 8 to 16 weeks in comparison to polyimide devices. immunohistochemical and electron microscopy analysis revealed two different cell types implicated in the fbr in nerve to both materials: macrophages, in close contact with the interface, and fibroblasts which appear after 8 weeks surrounding the tissue capsule. although further analyses are needed to elucidate the differences in the fbr to parylene c and polyimide polymers, these results can help to determine therapeutic targets in order to reduce this response and to improve the intraneural interfaces lifespan. delmont e 1 , antoine jc 2 , paul s 3 , boucraut j 4 , attarian s 1 . 1 referral centre for als and neuromuscular diseases, marseille, france; 2 referral centre for neuromuscular diseases, saint etienne, france; 3 immunology laboratory, saint etienne, france; 4 immunology laboratory, marseille, france. peripheral neuropathies with antibodies against myelin associated glycoprotein (mag) are chronic sensory neuropathies characterized by the presence of an igm monoclonal gammopathy and high levels of anti-mag antibodies. these antibodies recognize a specific epitope called human natural killer 1 (hnk1) shared by nk lymphocytes and several components of the peripheral nerve (mag, p0, pmp22, sgpg, phosphocan). recently an elisa test has been developed to detect antibodies against hnk1 epitope. our objectives were to determine the sensitivity and the specificity of anti-hnk1 antibodies in the diagnosis of anti-mag neuropathy and to know if these antibodies were correlated with the severity of the disease. anti-hnk1 antibodies were assessed in 42 anti-mag neuropathies and in 102 negative controls: 29 chronic inflammatory demyelinating polyradiculoneuropathies (cidp), 3 miller fisher syndromes, 11 sensory neuronopathies, 58 length-dependant axonal sensory polyneuropathies, 5 healthy controls. in anti-mag neuropathies, were recorded age, disease duration, incat sensory sum score (iss), overall neuropathy limitation scale (onls), rasch-built overall disability scale (rods), mrc sum score, anti-mag antibodies titer, peak dosage of the igm monoclonal gammopathy. anti-hnk1 antibodies were measured with gangliocombi™ mag elisa test and anti-mag antibodies with anti-mag autoantibodies elisa test both from buhlmann company. anti-hnk1 antibodies were positive in 41/42 anti-mag neuropathies, and in 1/102 controls (sensitivity 98%, specificity 99%). in anti-mag neuropathies, anti-hnk1 titer was correlated with sensory deficiency evaluated with the iss score (r=0.5, p=0.006) and with disability evaluated with the rods (r= −0.4, p=0.013) and onls scales (r=0.4, p=0.025). anti-hnk1 titers were not related to age, disease duration, mrc sum score, anti-mag antibodies titer, peak dosage of the paraproteinemia. anti-mag antibodies titers were associated with none of the characteristics of the patients with anti-mag neuropathy. anti-hnk1 antibodies have good sensitivity and specificity in the diagnosis of anti-mag neuropathy. compared to anti-mag antibodies, their value is that their titers are related to the disease severity. these results need to be confirmed in a larger prospective cohort. chronic inflammatory demyelinating polyradiculoneuropathy (cidp)is a heterogeneous and treatable immune-mediated disorder that critically lacks biomarkers to support diagnosis. recent evidences indicate that paranodal proteins (contactin-1, contactin-associated protein-1, and neurofascin-155) are the targets of autoantibodies in a subset of patients with cidp showing distinct clinical presentations. particularly, these biomarkers appear to have clinical relevance and help to orientate therapeutic choice. here, we examined five patients presenting an igg reactivity against the nodes of ranvier and the axon initial segment. using a proteomic approach, cell-based assays and elisa, we identified neurofascin-186 (nfasc186) and neurofascin-140 (nfasc140) as the main targets of autoantibodies at the nodes of ranvier. four patients displayed predominantly antibodies of the igg4 subclass, whereas one patient presented igg3 antibodies that activated the complement pathway in vitro. these antibodies recognized different epitopes than the previously described anti-neurofascin-155 igg4 suggesting different pathogenic functions. accordingly, patients with anti-nfasc186/140 igg showed a distinctive clinical presentation. most patients had a severe phenotype associated with conduction block or decreased distal motor amplitude. tremors or neuropathic pain were not observed. four patients presented with a subacute-onset and sensory ataxia. of interest, the neuropathy occurred concomitantly with nephrotic syndromes in two patients and with an igg4-related retroperitoneal fibrosis in one patient. this suggested that autoantibodies could be responsible for the occurrence of both disorders. intravenous immunoglobulin and corticosteroids were effective in three patients, and one patient improved following cyclophosphamide and rituximab treatment. clinical remission was found to correlate with the depletion of anti-nfasc186/140 antibodies and the loss of igg reactivity toward the nodes of ranvier. in addition, recovery of conduction block and of distal motor amplitude were observed following remission and suggested a nodo-paranodopathy. our data demonstrate that nodal antigens are the target of autoantibodies in a subgroup of patients with cidp. this emphasizes that the pathogenic mechanisms involved in chronic immune-mediated demyelinating neuropathies are broad and may include dysfunctions of the nodes of ranvier. mutations in the neurofilament heavy (nefh) gene have been recently identified as a rare cause of autosomal dominant, axonal charcot-marie-tooth disease (cmt2). the clinical spectrum of this condition remains to be delineated. we report two french families with an axonal, predominantly motor, dominantly inherited form of cmt caused by two previously unreported mutations in the nefh gene. twelve patients belonging to two different families were included in the study. they displayed an axonal motor and sensory neuropathy, with no mutations in known axonal cmt2 genes. a remarkable feature in all patients was the early involvement of proximal muscles of the lower limbs, occurring approximately 10 to 15 years after the onset of motor deficit. proximal weakness affected predominantly the iliopsoas muscle, whereas quadriceps and hamstring muscles were relatively preserved. muscle weakness and muscle wasting progressed rapidly, with most of the patients requiring walking assistance after 20 years of disease evolution. three patients in family 1 had brisk reflexes. nerve-conduction velocity studies displayed evidence of a motor and sensory axonal neuropathy predominantly affecting the lower limbs. original deletions of 2 nucleotides near the end of the coding sequence of nefh were identified: in family 1, c.3008_3009del (p.lys1003argfs*59), and in family 2 c.3043_3044del (p.lys1015glyfs*47) causing a frameshift. interestingly, this frameshift leads to the loss of the terminating codon and to the translation of 40 additional amino acids encoding a cryptic amyloidogenic element, suggesting that this type of mutations could induce protein aggregation. consistently, we showed that overexpression of the mutated forms of nefh in a human neuroblastoma cells induced the formation of protein aggregates. we also observed that it triggered caspase 3 activation and apoptosis. using electroporation of chick embryo spinal cord, we confirmed in vivo that mutated nefh formed aggregates and triggered apoptosis of spinal cord neurons. altogether, this suggests that these mutations in nefh cause protein aggregation and neurotoxicity in neurons expressing nefh. progressive loss of such neurons would explain the early motor involvement and the pyramidal signs observed in some patients. our results provide a physiological explanation to the presence of cmt and als clinical features in affected patients. del valle j 1,2 , delgado-martínez i 1 , righi m 3 , santos d 1,2 , cutrone a 3 , bossi s 4 , d'amico s 3 , micera s 3,5 , navarro x 1,2 . neuroprosthetic devices that are aimed to restore sensorimotor limb function of amputee patients require highly selective electrodes designed to establish a tight relationship with the nerve, allowing the bidirectional transduction of signals between nerve fibres and the interface and enabling close-loop control from the user. differently from extra-or intraneural interfaces, regenerative nerve electrodes are designed to enable electrical interface with regrowing axonal bundles of injured nerves, aiming to achieve high selectivity for recording and stimulation. however, most of the developed designs pose an obstacle to the regrowth mechanisms due to low transparency and cause an impairment of the nerve regeneration. in this work, we present a novel double-aisle planar regenerative electrode, a new type of highly transparent, non-obstructive regenerative electrode, which allows the selective stimulation and recording of separated nerve fascicles. the design consists of a thin and flexible double-sided electrode longitudinally inserted across a conduit thus creating two separated aisles in which regenerating fascicles can independently regrow after nerve transection. electrodes implanted in acutely transected nerves of rats showed the capability of selectively stimulating and recording different fascicles inserted in the aisles. moreover, chronic implantation of the electrode in a nerve gap of 6mm after sciatic nerve section allowed for fascicle regeneration and reinnervation of distal muscles as confirmed by the high number of myelinated axons inside each aisle, good biocompatibility, and adequate nerve conduction. in addition, three and six months after implantation, independent stimulation and recording of each separately regenerated fascicle were possible. our results demonstrate the potential contribution of the doubled-aisle regenerative electrode to selectively interface different fascicles of an injured nerve with no deleterious effects on nerve regeneration. therefore, this multi-aisle regenerative electrode may be suitable for neuroprosthetic applications, such as prostheses for the restoration of hand function after amputation or severe nerve injuries. demichelis c 1 , garnero m 1 , franciotta d 2 , cortese a 2 , callegari i 2 , mancardi gl 1 , schenone a 1 , leonardi a 3 , benedetti l 1 . 1 department of neuroscience, rehabilitation, ophthalmology, genetics, maternal and child health, university of genoa and irccs aou san martino-ist, genoa, italy; 2 laboratory of neuroimmunology, irccs, "c. mondino" national neurological institute, university of pavia, pavia, italy; 3 u.o. neurology, asl1 imperiese, imperia, italy. querol et al. showed that neurofascin155 (nf155) antibodies identify a chronic inflammatory demyelinating polyradiculoneuropathy (cidp) phenotype characterized by severe polyradiculoneuropathy, poor response to intravenous immunoglobulins (ivig), and disabling tremor. neurological improvement after therapy with rituximab has been previously reported in three patients with cidp with igg4 anti-nf155 antibodies. herein we describe the acute-onset of a case of cidp positive for nf155 igg4 antibodies resistant to conventional therapies and responsive to rituximab. the patient is a 64 year-old woman who presented acute onset ataxia and gait disturbances; her symptoms progressed over two weeks and distal weakness, numbness and paresthesias appeared too. the nerve conduction study was suggestive for a motor-sensory polyradiculoneuropathy mainly demyelinating. the cerebrospinal fluid analysis showed elevated protein level and normal cellular count. the patient was initially diagnosed with guillain-barré syndrome (gbs) and treated with plasma exchange without improvement. an ivig cycle was started with a partial relief but at the time of admission to the rehabilitation center the patient still had a marked weakness in all four limbs. after six months she presented a further clinical deterioration and she was restricted to wheelchair. there was no response to additional treatment with ivig, while pulse corticosteroid treatment determined a significant clinical improvement. during the next 6 months, despite the maintenance of steroid therapy, the patient presented a progressive deterioration and she was again restricted to wheelchair. postural and intention tremor appeared at upper limbs and became progressively more disabling. anti-nf155 ab dosage resulted positive. rituximab was administered at a dosage of 375 mg/m 2 /weekly for 4 weeks. after three months the tremor improved, allowing her to eat independently and the patient was able to walk with bilateral support. antibodies anti-nf155 were negative. after six months she walked without support and she was able to stitch crochet. as previously reported, in this case a cidp positive for igg4 nf155 developed severe polyradiculoneuropathy with predominant distal weakness, ataxia, disabling tremor and resistance to conventional therapies. interestingly the onset was gbs-like. the correct identification of these cidp subtypes has diagnostic, prognostic and therapeutic implications. rituximab con be useful in these patients. demir ö 1 , yazıcı t 2 . 1 department of neurosurgery, university of gaziosmanpaşa school of medicine, tokat, turkey; 2 department of neurosurgery, kent hospital, giresun, turkey. it is still challenging problem to maintain motor and sensory functions of peripheral nerve after nerve transection. after the nerve injury, calcium concentration in the damaged area increases. then the calcium ions act like cytotoxic agents in the damaged area. nifedipine is calcium channel blocker. we aimed to investigate the effects of nifedipine on nerve regeneration by modulating calcium in the damaged area. twenty-four swiss albino male rats were divided into two groups. left sciatic nerve transection surgery was performed to the all rats in both groups. then the all transected nerves were sutured primarily with epineural interfascicular method. in the experimental group, the anastomosis sites were wrapped with a piece of gel foam soaked into diluted nifedipine solution. in the control group, the anastomosis sites were wrapped with a piece of gel foam soaked into saline solution. we evaluated the effect of nifedipine by using functional, electro-physiological and histopathological studies after the surgeries. in the postoperative second week, walking test was performed and sciatic function index was calculated. in the postoperative third week electroneuronography (enog) was performed. there are significant differences between two groups. nifedipine improved nerve recovery functionally (p<0.001) and electro-physiologically (p<0.001). in the postoperative fourth week, we performed histopathological examination. in the experimental group with nifedipine there were more organized axons that reached the aim. we conclude from these results that nifedipine is an effective nerve protective agent when used locally at the anastomosis site after the transection of the nerve. the lack of effective, disease-modifying therapies for cmt highlights the need for novel preclinical models suitable for drug discovery. studies in rodent models of cmt tend to be time-consuming, and findings so far have translated poorly into clinical trials. primary and induced pluripotent stem cell (ipsc)-derived neuronal cultures are an established model of neurological diseases. however, due to the random distribution of neuronal bodies and neurites that happen when plating these cells, this system is not ideal to investigate axonal, length-dependent processes like peripheral neuropathies and particularly cmt. to optimize this well-established model system, we developed a robust human platform to study axonal morphology and physiology based on motor neuron neurospheres. we differentiated motor neurons from human induced pluripotent stem cells, purified them by magnetic sorting and cultured them in suspension until they formed neurospheres. floating neurospheres can be maintained in agitation for months as a reliable source of motor neurons. after neurospheres are platted, axons rapidly grow out of them in a radial fashion, resembling dorsal root ganglia cultures. this configuration allows for a better visualization of axons in imaging studies and for continued axonal growth over at least a 50-day period. axons grew at an average rate of 500 micrometers/day and reached up to 1 cm in length. neurospheres can be fixed and stained allowing for morphological analysis and investigation of protein distribution in axons. this system is also ideal for time-lapse imaging to study axonal transport of organelles and neurofilament kinetics. lastly, our motor neuron neurosphere system lends itself well for high content screening platform. neurospheres can be plated in 96-well plates where multiple compounds can be tested and the axons easily imaged by a high content screening microscope. in summary, we developed a new platform to investigate motor axons in vitro, which are particularly useful to study length-dependent processes such as inherited peripheral neuropathies and may facilitate the identification of new therapeutic compounds using high content screening systems. mutations in the neurofilament light chain (nfl) gene cause autosomal dominant axonal charcot-marie-tooth neuropathy (cmt2e). nfl is a major component of the neuronal cytoskeleton, and is believed to function in conjunction with nfm and nfh to provide structural support for the axon and regulate axon diameter. despite the significant advances in understanding its biological basis, there is still no effective, disease-modifying therapy for cmt2e, in part due to the paucity of preclinical models suitable for drug discovery. the development of novel preclinical platforms that can faithfully mimic mechanisms of axonal degeneration in vitro would be an essential and valuable resource to better understand the biology of cmt2e and identify potential targets for therapy development. to address this, we generated control and cmt2e patient-derived motor neurons and cultured them in suspension until they formed neurospheres. immunostaining of cmt2e neurospheres with nfl and tubb3 antibodies revealed numerous areas of nfl accumulation in n98s cmt2e axons, resembling the accumulations of mutant nfl protein seen in the processes of catecholaminergic neuronal cell line cad overexpressing several nfl mutants. further analysis demonstrated that areas of nfl accumulation were also immunopositive for nfh, pnfh and nfm and that at least nfl and nfm co-localized in the same areas of deposits. taken together, these results demonstrate that abnormal axonal neurofilament distribution is a feature of cmt2e ipsc-derived motor neurons and involve all three neurofilament subunits. we also developed an image analysis routine to allow for automatized quantification of neurofilament distribution. preliminary quantification of nfl signal intensity revealed that axons from patients have a weaker nfl signal compared to control axons, but present several signal peaks above the range observed in controls, which related to the areas of nfl accumulation. these results suggest that nfl accumulates in certain regions of cmt2e axons but is reduced in the areas with no accumulation. these findings can be readily adapted into a high content screening platform and will be used to identify compounds able to reverse this axonal phenotype. in summary, we identified a strong axonal phenotype in human cmt2e motor neurons with potential as a screening platform for drug discovery. nodal and paranodal proteins have been identified as antigens in peripheral inflammatory neuropathies, however the frequency and clinical relevance of antibody responses against these targets remain poorly investigated in gbs. patients with acute onset inflammatory neuropathies were identified by exploration of the local databases of the departments of neurology and the institute of neurology of the medical universities in innsbruck and vienna. patient data, electrophysiological classification and presence of anti-gangliosid antibodies were retrospectively retrieved by review of patient records. only patients with typical clinical presentation and electrophysiological results consistent with one of the subtypes of gbs were included in the study. among forty-nine patients, thirty-five were classified as aidp, six aman, three amsan, three mfs, and two pharyngo-cervico-brachial gbs. 21 of the included patients had anti-ganglioside-antibodies. ten patients with the initial suspicion of aidp had a disease duration of more than 6 months and were reclassified as cidp. all patient and twenty sera of control patients with non inflammatory polyneuropathy were screened by an optimized tissue based assay using rat brains for immune responses against surface antigens, and by cell-based assays with transfected hek cells for antibodies against contactin1 (cntn1), contactin2 (cntn2), contactin-associated-protein1 (caspr1) and neurofascin-155 (nf155). in the tissue based assay some of the patients showed a light neuropil staining. none of gbs patient's sera had antibody reaction to cntn1, cntn2, caspr1 or nf155 in cell-based assays. among the cidp patients, two patients demonstrated reactivity against cntn1 with similar clinical presentation as previously described. none of the control patients had any antibody reaction to the performed tests. our results suggest that antibody responses to cntn1, cntn2, caspr1 or nf155 are absent in austrian gbs patients, although more patients will be screened to substantiate these preliminary results. furthermore, it remains to be established whether antibodies against cntn1 may predict a chronic course in acute onset inflammatory neuropathies. a few variants of chronic inflammatory demyelinating polyradiculoneuropathy (cidp) have been described with a frequency of 1-50%. their relation and possible evolution into typical-cidp remain unclear, as is their treatment response possibly because of differences in diagnostic criteria. we used the data from a web-based database on italian patients with cidp to determine the frequency and characteristic of these variants, the possible evolution into typical-cidp, and their treatment response. all the patients were assessed at study entry and the disease course before inclusion was analyzed. by february-2017, we included 360 patients (227 men, 133 women), aged 12-89 years (median 59 years) with a mean disease duration of 8.2 years (range 0.5-52 years) and complete data available from 320. based on the clinical data and our revised diagnostic criteria, 84 patients (26%) were classified to have atypical cidp at onset and for the following two years including 29 with dads (9%), 22 with motor cidp (7%), 20 with sensory cidp and 2 cisp (6.2%), 11 with lewis-sumner syndrome (3.5%), and 2 with recurrent cranial neuropathy. at study entry, 36 patients (43%) had progressed into typical cidp after 2-38 years (median 5 years) while 48 (57%, 15% of total) still had atypical cidp after 0.5-28 years (median 4 years) with a similar proportion of progression (50-60%) within each group. the diagnosis of atypical cidp at entry fulfilled efns/pns criteria in 59 (70%). csf studies were diagnostic in 47/58 (81%) patients, nerve biopsy in 5/13 (38%), and nerve imaging in 8/9 (89%) tested patients. similarly to typical cidp, 81% of treated patients with atypical cidp improved after treatment with a proportion of response varying from 67% to 100% in the different forms. most patients with sensory or motor cidp had however an unsatisfactory response to steroids. this study shows that he proportion of patients with atypical cidp varies during the course of the disease with almost 50% of the patients evolving into typical cidp within 5 years from onset. in addition, response to treatment is frequent in atypical cidp even if not all the forms respond to the same therapies. only few studies investigated the frequency of antecedent events and comorbidities in patients with chronic inflammatory demyelinating polyradiculoneuropathy (cidp), and little is known on the role of possible predisposing factors, dietary, and lifestyle habits, on the onset and progression of the disease. we used the data from a web-based database on italian patients with cidp to determine the frequency of antecedent events and comorbidities and the possible role of predisposing factors including lifestyle and dietary habits and exposure to toxic agents, using a structured questionnaire. partners of patients served as controls. impairment was evaluated using the mrc sumscore and disability with incat and r-ods scales. logistic regression was used to calculate odds ratio (or) with 95% confidence interval (ci) for the risk of cidp. sex and disease-duration were included as covariates. by february-2017, 360 patients were enrolled, with complete data on 340 patients for antecedent events and comorbidities and 295 patients and 273 controls for lifestyle habits. ninety-two patients (27%) reported an antecedent event, mostly infection or vaccination (20%). one or more comorbidity were present in 71% of the patients including hypertension (35.5%), thyroid disorders (17%) and diabetes (12.6%) and in 53% influenced the choice of initial therapy. exposure to toxic environmental agents (odds ratio [or] = 2.55; 95% ci, 1.42-4.55), cigarette smoke (or = 2.02; 95% ci, 1.4-2.93), and dietary supplements (or = 1.97; 95% ci, 1.08-3.58) were associated with a higher risk of cidp while rice consumption was associated with a reduced risk (or = 0.47; 95% ci, 0.25-0.87). concerning disease severity, more severely affected patients more frequently consumed raw-meat (or = 2.19; 95% ci, 1.05-4.58) and white meat (or = 1.65; 95% ci, 1.03-2.63), while rice (or = 0.42; 95% ci, 0.20-0.92) and soft drink consumption (or = 0.57; 95% ci, 0.36-0.93) and physical activity were associated with lower disability (or = 0.47; 95% ci, 0.29-0.77). this study confirms that comorbidities are frequent in patients with cidp and often influence the choice of initial therapy. in addition preliminary data show that toxic exposure and some lifestyle and dietary habits may influence the onset and progression of cidp. doppler k 1 , schuster y 1 , weishaupt a 1 , sommer c 1 . 1 department of neurology, university hospital würzburg, würzburg, germany. autoantibodies against the paranodal protein contactin-1 have recently been described in patients with cidp. in most patients, autoantibodies of the igg4 subclass are predominant and are supposed to be pathogenic. the role of igg3 anti-contactin-1 is so far unclear. in the present study, igg of three different patients, one with igg3 anti-contactin-1, one with a low titer of igg4 anti-contactin-1 and one with a high titer of igg4 anti-contactin-1, and of controls were injected into the sciatic nerves of lewis rats. nerve conduction studies of the injected nerve and motor and sensory testing were performed before and after injection. conduction blocks and motor deficits were detectable in the two patients with high titers of igg3 and igg4, not in the patient with low titers. the percentage of conduction blocks was 83.3% in rats injected with igg of the igg3 patient and 35% in those injected with igg4. motor deficits were detectable in both patients with conduction blocks but were most apparent in the patient injected with igg of the igg3 patient. no differences in sensory testing were observed. conduction blocks and motor deficits improved after five days and were normal after seven to eight days. our data give the first evidence of pathogenicity of igg3 anti-contactin-1 autoantibodies, not only igg4. igg of the igg3 patient induced a more severe clinical and electrophysiological phenotype compared to the igg4 patient. remarkably, this reflected the clinical phenotype of the patients, as the igg3 patients showed an acute-onset of sensorimotor symptoms at the time of blood withdrawal whereas the igg4 patient presented with a more chronic course of disease. doppler k 1 , frank f 1 , koschker a-c 2 , reiners k 1 , sommer c 1 . 1 department of neurology, university hospital würzburg, würzburg, germany; 2 endocrinology and diabetes unit, department of medicine i, university hospital würzburg, würzburg, germany. axoglial dysjunction and paranodal demyelination have been discussed as potential mechanisms of nerve fiber damage in diabetic neuropathy. studies on human tissue are limited, as nerve biopsies are invasive and only rarely performed in patients with confirmed diabetic neuropathy. skin biopsy has recently been suggested as a good tool to analyze paranodal and nodal changes of myelinated fibers. in the present study, we analyzed the paranodal and nodal region in myelinated fibers of skin biopsies of 35 patients with diabetic neuropathy, 17 patients with diabetes mellitus without neuropathy, and 30 normal controls. immunofluorescence of skin sections with antibodies against caspr, neurofascin, sodium channels and myelin basic protein was performed to assess paranodal/nodal architecture, segmental demyelination and myelinated nerve fibers. staining with antibodies against protein gene product 9.5 was used to quantify unmyelinated nerve fibers. we found an increase of elongated ranvier nodes and a dispersion of neurofascin at the distal leg in patients with diabetes mellitus with and without neuropathy and at the finger in patients with diabetic neuropathy. an increased dispersion of caspr was only found in biopsies of the finger in patients with diabetic neuropathy. our data show that skin biopsy is an appropriate tool to analyze nodes of ranvier in patients with diabetes mellitus. structural nodal changes are detectable in diabetic neuropathy, and even in diabetic patients without neuropathy. dourado me 1 , fernandes u 1 , vital al 1 , ramos e 1 , urbano jc 1 , sena a 1 , queiroz jw 1 , jeronimo smb 1 . 1 federal university of rio grande do norte, natal, brazil. the erasmus gbs outcome score (egos) is a validated prognostic model that uses acute phase and easy-to-obtain clinical characteristics to determine outcome at 6 months in patients with gbs. this study aims to assess the validity of egos in rio grande do norte, brazil, and to compare with another european study. data collected prospectively from a cohort of 324 patients with gbs of rio grande do norte, brazil, between june 1994 and august 2016, was assessed. ninety patients were excluded for missing data or diagnoses of miller fisher syndrome and atypical forms of gbs. to calculate the egos, the gbs disability score was assessed in the second week of disease and at 6 months. to compare this study with the european one in independent group proportions, we used the student's t-test, being considered statistically significant p<0,005. the 234 patients included were divided in four groups based on egos. thus, 21 patients had egos between 1 and 3; 89 had egos between 3.5 and 4.5; 93 had egos 5 and 31 had egos between 5.5 and 7. in the first, second, third and fourth group, 0 (0%), 3 (3.4%), 10 (10.8%) and 6 (19.4%) of the patients were unable to walk independently after six months of the disease, respectively. overall, of the 234 patients analyzed, 19 (8.1%) had poor outcomes in this study. in the european paper, based on the same group division, 1 of 193 (0.5%), 16 of 226 (7%), 43 of 161 (27%) and 94 of 182 (52%) were unable to walk independently. comparing both studies, the patients of this study were younger, more seriously ill in the first weeks and with more sensitive deficits. there were no difference relative to sex, cranial nerves deficits and presence of anti-gangliosides antibodies. using the student's t-test for ability to walk after 6 months according to egos stratification, we achieve in the first group p=0.1629; in the second p=0.0784; in the third p=0.0004; and in the fourth p<0.0001.the egos did not have a good capacity to predict the ability to walk after 6 months of gbs in rio grande do norte, brazil. historically, guillain-barré syndrome (gbs) epidemics are rarely seen. between 1994 and 2014, we treated and followed 264 cases of gbs in the state of rio grande do norte with a yearly incidence of 0.3/100,000. no seasonality was observed. the mean age of the patients was 27 years (range, 1 -83), with 50% of the cases younger than 20 years. demyelinating variant was the most frequent subtype of gbs. in march 2015, the first report of autochthonous transmission of zika virus (zikv) was determined in natal, brazil. later that month, we documented an increase in incidence of gbs in natal, brazil. the incidence in 2015 was of 0.69/100.000. of the 38 cases of gbs diagnosed in 2015, 24 were diagnosed from march through may, which coincided with the outbreak of zikv in natal, brazil. eighteen patients (75% of the 24 cases) had a history of rash and fever prior to onset of gbs symptoms, with the median age of 45 years (range, 15-69) . the electroneuromyography studies of these 18 patients indicated that 16 (88.9%) had acute inflammatory demyelinating polyneuropathy, 1 (5.5%) had acute motor axonal neuropathy, and 1 (5.55%) was inconclusive. the mean time from onset of zikv infection symptoms to onset of the gbs were 7 days (range, 3-30). the mean time of nadir was 7 days (ranged, 4-25) . cranial neuropathies were present in 12 patients (66.66%). nine patients were bedridden (50%) and 3 (16.66%) required mechanical ventilation. the mean protein content of the central spinal fluid was 0.77 g/l, with the white blood cell count below 5/mm in all patients. they were all treated with intravenous igev. they all improved quickly. anti-gm1 was negative in all patients. rt-pcr was negative for dengue, chikungunya and zika. serum mac-elisa igm for zika and dengue was made in 11 patients and it had 100% of positivity. prnt for zika and dengue had 100% positivity. in summary, we report a geographically and temporally defined cluster of gbs associated with an outbreak of acute rash in the state of rio grande do norte, brazil. as the prevalence of diabetes mellitus continues to increase worldwide, diabetic complications represent a growing burden to patients and society. distal symmetrical polyneuropathy (dsp) is a common complication that affects up to 30% of diabetic patients. dsp reduces patient quality of life due to chronic pain, ulcerations, and may lead to lower extremity amputations. despite its high prevalence, the mechanisms underlying diabetic dsp are poorly understood and several mechanisms are believed to play a role. we hypothesize that diabetic dsp arises from microvascular complications characteristic to diabetes. specifically, capillary dysfunction -disturbances in capillary flow patterns -is a likely candidate to explain development of dsp, as it can limit oxygen and nutrient delivery to nervous tissue, causing nerve dysfunction and damage, and thus development of dsp. we will study this hypothesis utilizing the state-of-the-art blood flow imaging techniques to visualize and quantify endoneureal blood flow and then link these findings with measures of dsp (e.g. nerve conduction velocity; intra-epidermal nerve fibre density) in animal models. we will include several animal models of diabetic dsp caused by either type 1 or type 2 diabetes. two photon microscopy and optical coherence tomography allow visualisation and quantification of capillary transit times and blood flow within peripheral nerves at high resolution. we hypothesise that changes in blood flow patterns and subsequent impairment of nutrient and oxygen delivery to nervous tissue precede the onset of diabetic dsp. if our experiments support this prediction, we will attempt to develop interventions that improve capillary blood flow to prevent or delay the development of dsp. duman o 1 , saracoglu m 1 , haspolat s 1 , bozkurt o 1 . 1 department of child neurology, akdeniz university hospital, antalya, turkey. axonal polyneuropathies are very heterogeneous group of diseases which are very rarely seen during infantile age. some of them may be accompanied by developmental retardation, severe muscle weakness and progressive course. we aimed to present two cases of axonal sensorymotor neuropathy with infantile onset and atypical course. our 1-year-old boy patient was admitted to our clinic for progressive gait loss since one month. he was the first offspring of consanguineous parents with normal prenatal and natal history. electromyography revealed axonal sensorymotor polyneuropathy. metabolic and cerebrospinal fluid (csf) examinations for etiology were all normal. brain and spinal magnetic resonance imaging (mri) were normal. he had partial benefit from oral steroid treatment. in the course of disease along with four neuropathy attacks he had significant benefit from serial intravenous immunoglobulin treatments in two years clinical course. a 6 month-old girl who is the first offspring of nonconsanguineous parents was admitted to the clinic for acute tetraparesis. axial sensorymotor polyneuropathy was detected in the electromyography. metabolic and cerebrospinal fluid (csf) examinations were normal. she had three more acute polyneuropathy attacks during ivig cessation period. both patients revealed with serial immunoglobulin treatments but unresponsive to riboflavine treatment. we aimed to discuss our rarely seen and the pathogenesis is not completely understood cases' course. serial ivig treatment may be helpfull for such patients' treatment. transthyretin-related familial amyloid polyneuropathy (ttr-fap) is an autosomal dominantly inherited disorder caused by mutations of the transthyretin (ttr) gene. the mutant amyloidogenic transthyretin protein causes the systemic accumulation of amyloid fibrils that result in organ dysfunction. ttr-associated fap is a progressive and fatal disease, if left untreated, and should be considered in the differential diagnosis of any person presenting with a progressive polyneuropathy, particularly with accompanying autonomic involvement. the clinical, electrophysiological, histopathological, and genetic characteristics of 21 patients from turkey (6 female, 15 male) from eleven families with polyneuropathy and mutations in ttr were evaluated. two patients had no family history of ttr-fap and were considered as sporadic cases, and the remainders were familial cases displaying an autosomal dominant inheritance pattern. sequence analysis of the ttr gene revealed five mutations (p.val30met, p.glu89gln, p.gly53glu, p.glu54gly and p.gly47glu). most common mutation was p.val30met (in 6 unrelated families). mean age at disease onset was 41.4±14.2 years (range 21-66 years). the most commonly reported initial complaint was paresthesia in the feet (asymmetric in three patients). four patients (2 male) with the p.glu89gln mutation presented with carpal tunnel syndrome. two patients with the p.gly53glu mutation showed episodes of dysarthria and hemiparesis, consistent with this genotype. seven patients died during the follow-up period as a result of systemic involvement. this study suggests that our cohort of ttr-fap patients from turkey exhibits clinical and genetic heterogeneity. ebenezer gj 1 , liu y 1 , judge dp 2 , cunningham k 1 , truelove s 3 , carter nd 1 , sebastian b 1 , byrnes k 1 , polydefkis m 1 . 1 department of neurology, johns hopkins university, baltimore, md, usa; 2 division of cardiology, johns hopkins university, baltimore, md, usa; 3 department of epidemiology, johns hopkins bloomberg school of public health, baltimore, md, usa. effect of amyloid deposition on cutaneous nerves was assessed in subjects with pathogenic ttr variants and control subjects. three groups of 20 subjects each including ttr-fap patients, age/gender-matched healthy subjects and disease controls as well as 10 ttr mutation carriers without neuropathy (ttr-nopn) and 2 with al-amyloid underwent neurological examination and 3mm skin biopsies. 50 micron sections were stained with anti-pgp9.5, anti-ttr and congo red. amyloid burden with imagej, intraepidermal (ienfd) sweat gland (sgnfd) and pilomotor densities (pmnfd) measured and correlations between amyloid burden, fiber subtype, neuropathy impairment score-ll (nis-ll) and nis sensory subscore were evaluated. ienfd, sgnfd, and pmnfd were all significantly reduced in ttr-fap patients vs. healthy controls while mutation carriers had intermediate reductions. lower nerve fiber densities were associated with nis-ll (p<0.001). congo red staining revealed brilliant red amyloid deposits with apple-green birefringence within dermal collagen, sweat glands, and arrector pili muscles. amyloid infiltration was observed in the endoneurium and perineurium of small fiber sensory and autonomic nerves that innervate sweat glands and arrector pili muscles. cutaneous amyloid deposition was detected in 70% of ttr-fap and not in healthy or disease controls subjects. both al and 2/10 ttr-nopn subjects were congo red positive. amyloid burden was inversely correlated with ienf (p<0.001, r=−0.63) sgnf (p<0.001, r=−0.67), pmnf (p=0.005, r=−0.50) distal leg densities, and correlated with nis-ll (p=0.001, r=0.57) and nis sensory subscore (p=0.004, r=0.54). wild-type ttr staining was less prominent in pathogenic ttr carriers. the diagnostic sensitivity and specificity to detect amyloid in skin were 70% and 100% in ttr-fap. the repeat measurement of the amyloid burden from the same section with imagej was r 2 =0.81, p<0.0001 and different sections from the same biopsy was r 2 =0.91 and p<0.01. we conclude that endoneurial amyloid contributes to sensory and autonomic nerve injury. amyloid burden correlated strongly with sensory/autonomic axon densities and nis-ll. skin punches offer a convenient alternative to establishing a tissue diagnosis. amyloid burden is an attractive biomarker marker for ttr-fap and treatment effect. the study was supported through a grant from pfizer. ebenezer gj 1 , truelove s 2 , polydefkis m 1 . 1 department of neurology, johns hopkins university, baltimore, md, usa; 2 department of epidemiology, johns hopkins bloomberg school of public health, baltimore, md, usa. we investigated differences of unmyelinated sensory nerve fibers in the distal limb among 45 healthy-weight subjects (bmi < 25kg/m 2 ) and 72 overweight/obese subjects (bmi ≥ 25kg/m 2 ), aged 20-69 years. subjects underwent neurological examination and 3mm skin punches from distal leg (dl), thigh (dt), and proximal thigh (pt) sites, from which 50 micron sections were stained with anti-pgp9.5 antibody; intraepidermal nerve fiber density (ienfd; fibers/mm) and epidermal thickness were assessed. a second dl biopsy was processed for electron microscopic examination and both thick and thin sections were examined for ultrastructural changes. multivariable linear regression models were used to assess the effect of age, gender, height and weight. after controlling for height, age, and obesity, females were found to have lower distal leg ienfd (−2.6; p=0.02). increasing age and height were significantly associated with decreasing dl ienfd, with decreases of −1.6 fibers/mm per 10 years (p<.001) and −2.55 fibers/mm per 10cm (p<0.001), respectively. even after controlling for height, being overweight/obese was associated with reduced dl ienfd, with 2.5 fibers/mm lower dl enfd than healthy-weight individuals (p=.01). these findings remained consistent across distal thigh and proximal thigh enfd, though not all associations remained significant. the epidermis was thicker in obese subjects across the lower limb, most pronounced at the distal leg (μm, mean± sd, healthy-dl:101±14.76, dt: 99.0 ± 10.3, pt: 107.7±12.2, obese-dl:129.1± 48.3, dt:117± 33.0, pt:116.4±20.2). under em very few intact dermal nerve bundles were identified at the proximal thigh sites. the atrophic and degenerating axons were seen with perineurial infiltration by dense collagen in obsess/overweight subjects but not age/gender matched controls. obesity further accelerates attenuation of epidermal nerve fibers across the lower limb even after controlling for other associated factors. echaniz-laguna a 1 , geuens t 2 , petiot p 3 , péréon y 4 , adriaenssens e 2 , haidar m 2 , capponi s 2 , maisonobe t 5 , fournier e 5 , dubourg o 5 , degos b 5 , salachas f 5 , lenglet t 5 , eymard b 5 , delmont e 6 , pouget j 7 , juntas morales r 8 , goizet c 9 , latour p 3 , timmerman v 2 , stojkovic t 5 . 1 strasbourg university hospital, strasbourg, france; 2 peripheral neuropathy group, vib department of molecular genetics and institute born bunge, university of antwerp, antwerpen, belgium; 3 lyon university hospital, lyon, france; 4 nantes university hospital, nantes, france; 5 hôpital de la pitié-salpétrière, paris, france; 6 nice university hospital, nice, france; 7 marseille university hospital, marseille, france; 8 montpellier university hospital, montpellier, france; 9 bordeaux university hospital, bordeaux, france. in this study, we describe the phenotypic spectrum of distal hereditary motor neuropathy caused by mutations in the small heat shock proteins hspb1 and hspb8 and investigate the functional consequences of newly discovered variants. among 510 unrelated patients with distal motor neuropathy, we identified mutations in hspb1 (28 index patients/510; 5.5%) and hspb8 (4 index patients/510; 0.8%) genes. patients have slowly progressive distal (100%) and proximal (13%) weakness in lower limbs, mild lower limbs sensory involvement (31%), foot deformities (73%), progressive distal upper limb weakness (29%), mildly raised serum creatine kinase levels (100%) and central nervous system involvement (9%). we found a broad range of disease onset with some patients presenting with foot drop at the age of 5 years, and others presenting symptoms only after 60 years. disease progression was slow in all patients, and even with a disease duration of more than 40 years patients were still able to walk. none of our patients were wheelchair dependent. muscle pathology, nerve pathology and electrophysiology showed in all cases a slowly progressive, mostly symmetrical and predominantly distal motor axonal neuropathy. mild sensory involvement was observed upon nerve conduction studies, mostly the lower limbs, in 42% of cases. we identified 12 hspb1 and 4 hspb8 mutations, including respectively 5 and 3 not previously reported. transmission was either dominant (78%), recessive (3%) or de novo (19%). three missense mutations in hspb1 (pro7ser, gly53asp, gln128arg) cause hyperphosphorylation of neurofilaments, while the c-terminal mutant ser187leu triggers protein aggregation. two frameshift mutations (leu58fs, ala61fs) create a premature stop codon leading to proteasomal degradation. two mutations in hspb8 (lys141met/asn) exhibited increased binding to bag3. we demonstrate that hspb1 and hspb8 mutations are a major cause of inherited motor axonal neuropathy. mutations lead to diverse functional outcomes further demonstrating the pleotropic character of small heat shock proteins. eftimov f 1 , querol l 2 , rajabally ya 3 and on behalf of all participants of the 231st enmc workshop. 1 academic medical center, amsterdam, the netherlands; 2 hospital de la santa creu i sant pau, universitat autònoma de barcelona, spain; 3 aston university, birmingham, uk. although chronic inflammatory demyelinating polyneuropathy (cidp) is a treatable neuropathy further research is urgently needed to define the diagnostic clinical and electrophysiological boundaries of cidp and its subtypes, and to define the role of biomarkers in supporting the diagnosis, monitoring disease activity and predicting response to treatment and outcome. in recent years, several national registries and biobanks have been developed to enable systematic data collection in cidp. an international registry with large number of patients is needed to allow answering many important questions and develop validated prognostic models to predict outcome in individual patients with cidp. at the inflammatory neuropathy consortium (inc) meeting in 2016, the inc members agreed that a european neuromuscular center (enmc) workshop would be the ideal setting to reach a consensus on the infrastructure of database and biobanks. the 231 st enmc workshop will take place on may 12-14, 2017 with participants representing 12 different countries. primary objective of the workshop is to reach a consensus on inclusion and exclusion criteria, core sets and recommended sets of clinical data, diagnostic data and follow-up points and a manual of operations for collection of biomaterials. a secondary objective is to construct an infrastructure to allow sharing data between different databases and biomaterials. conclusions of the consensus meeting and outline of further perspectives will be presented at the peripheral nerve society meeting in 2017. eichinger kj 1 , burns j 2 , cornett k 2 , bacon c 3 , shepherd m 4 , mountain j 1 , sowden j 1 , shy r 5 , shy me 3 , herrmann dn 1 . clinical outcome assessments that measure functional ability are important endpoints for clinical trials. dr. burns has led the development/validation of a functional outcome assessment (cmtpeds) for individuals with charcot marie tooth disease (cmt) ages 3-20 years in the inc rdcrn. the cmtpeds is reliable and sensitive to change. however a validated functional outcome measure (fom) for adults with cmt is needed. our data in 18-21 year-olds indicated that the cmtpeds could be modified for adult use. however, some items of the cmtpeds (e.g. balance beam and jumping) have floor effects in adults with cmt. we have developed an adult cmt-fom modeled on the cmtpeds, and refined based on literature review, patient interviews, a large-scale cmt patient survey and expert opinion. the cmt-fom is a performance-based scale comprising 13 items that are combined to form a composite score to quantify functional ability of adults with cmt. the cmt-fom shares 9 items with the cmtpeds. four items were added to measure functional abilities relevant to adults (sit to stand, 10 meter walk/run, stair climb, and timed up and go test). the cmt-fom scoring mirrors the cmtpeds. to generate a score ranging from 0-52, raw item scores are converted to z scores, based on age-and sex-matched normative reference values form the 1000 norms project and categorized to a 0-4 likert along a continuum of impairment levels. we have conducted a pilot study of the cmt-fom in adults with cmt1a (9 male, 12 female, age 39.7 ± 16.1 yrs) of differing severity (cmt exam score (cmtes) range 1-20). the cmt-fom is feasible, individuals were able to complete all items, and takes 35 minutes to perform. the mean cmt-fom score was 22.0 ± 8.2 (range 11-37). concurrent validity of the cmt-fom is supported by an association with the cmtes (r = 0.51). the overall score did not demonstrate floor or ceiling effects. in summary the adult cmt-fom is well-tolerated and captures upper and lower limb strength, dexterity, balance, speed, ambulation and endurance. the cmt-fom requires validation in a large longitudinal cohort, prior to application in clinical trials. estilow t 1 , glanzman am 1 , burns j 2 , cornett kmd 2 , menezes mp 2 , shy r 3 , moroni i 4 , foscan m 4 , pagliano e 4 , pareyson d 4 , laurà m 5 , bhandari t 6 , muntoni f 6 , reilly mm 5 , finkel rs 7 , sowden j 8 , eichinger k 8 , herrmann dn 8 , shy me 9 , yum sw 10 , ramchandren s 11 and on behalf of the inherited neuropathies consortium. 1 cmt is associated with progressive impairment of the hands. reducing this impairment by treating children who are in the early stages of the disease is crucial. studies assessing measures of cmt hand function in children and their associations with patient-reported outcomes are lacking. we analyzed the upper extremity items from the cmt pediatric scale (cmtpeds) and pediatric cmt quality of life scale (pcmt-qol) in 179 children ages 8-18 years enrolled in the inherited neuropathies consortium, to explore the relationships between measures of hand function (impairment, activity, and activities of daily living), and patient-reported outcomes. weak grasp (67%), hand pain (30%), and tremor (40%) were prevalent impairments. performance on activity level tasks, the nine hole peg test (9hpt) and functional dexterity test (fdt), were impaired in 68% and 78% of the cases, respectively. patients reported difficulty "sometimes" to "always" in opening a jar/lid (46%), zipping/buttoning (20%), writing (19%), carrying a plate without spilling food (17%) and putting on shoes (16%). patients reporting tremor showed significant differences on the 9hpt (p=.04). grip strength was shown to have a moderately significant correlation with performance on the fdt (r=.50; p<.0001). stepwise multiple linear regression showed that grip strength (beta=−.01; p<.001), hand pain (beta=.86; p<.001) and fdt (beta .01; p<.001) were predictive of ability to open a jar (adjusted r 2 =.35; p<.001. grip strength (beta=−.003; p<.001), and fdt (beta .01; p<.001) were predictive of ability to carry plate without spillage (adjusted r 2 =.19; p<.001). grip strength (beta=−.003; p<.01), 9hpt (beta=.01; p<.05) and fdt (beta .01; p<.001) were predictive of ability to put on shoes (adjusted r 2 =.23; p<.001). hand pain (beta=.39; p<.001) and fdt (beta .02; p<.001) were predictive of ability to zip/button (adjusted r 2 =.22; p<.001). hand pain (beta=.61; p<.001) and 9hpt (beta .01; p<.05) were predictive of ability to use a pen/pencil (adjusted r 2 =.09; p<.001). children with cmt present with frequent limitations in adl performance impacting qol. the upper limb measures of the cmtpeds are associated with hand performance and interventions to improve grip strength and reduce pain should be investigated further with respect to their impact on improving function, and ultimately qol. evans me 1 , morrow jm 1 , wastling s 2 , sinclair cdj 2 , fischmann a 3 , shah s 2 , emira ak 2 , hanna mg 1 , yousry ta 2 , thornton js 2 , reilly mm 1 . 1 mrc centre for neuromuscular diseases, ucl institute of neurology, london, uk; 2 neuroradiological academic unit, ucl institute of neurology, london, uk; 3 university of basel hospital, basel, switzerland. responsive outcome measures are needed in charcot-marie-tooth disease (cmt) to allow adequately powered clinical trials to test novel therapeutics. we have shown high responsiveness of mri quantified intramuscular fat accumulation in calf muscles of cmt1a patients over 12 months. the aim of the present study was to assess the responsiveness and longitudinal validity of quantitative mri over a 4 year follow-up period. we undertook two further sets of quantitative mri, myometric and clinical assessments in the original mrc centre cmt1a quantitative mri cohort. mri sequences included fat quantification using the 3 point dixon fat-water separation method, t2 quantification and magnetisation transfer imaging. of the 20 patients with genetically confirmed cmt1a were assessed at baseline (11 male, mean age 42.8 ± 13.9 years), 17 underwent repeat assessments a median on 12 months (data already published), 14 underwent repeat assessments at a median of 27 months, and 11 underwent a final assessment at a median of 49 months. the primary outcome measure currently being analysed is mean calf muscle fat fraction at a single axial slice a fixed distance distal to the knee joint. results of this analysis and correlation with clinical measures will be presented at the peripheral nerve society meeting. fainmesser y 1 , dori a 2,3 , drory ve 1,3 . 1 department of neurology and neuromuscular service, tel-aviv medical center, tel-aviv, israel; 2 department of neurology, sheba medical center, ramat gan, israel; 3 sackler faculty of medicine, tel aviv university, israel. the use of anabolic drugs by those who wish to increase lean body mass is widespread and not well supervised medically. a 36 years old man was referred for evaluation of a slowly progressive sensory and motor disturbance in the distribution of the left ulnar nerve. his symptoms began 10 months after repeated self-injections of anabolic steroids and vitamin e into the biceps and triceps brachii muscles bilaterally. his examination showed increased muscle mass of the injected muscles with a hard-rubbery consistency, atrophy and weakness of left interossei, mild weakness of the bilateral biceps brachii and sensory loss in an ulnar nerve distribution. nerve conduction studies showed a left ulnar neuropathy with reduced motor and sensory response amplitudes and denervation in the left first dorsal interosseus, as well as mild myopathic changes with significantly reduced insertional activity in both biceps muscles. mri of the soft tissues of the arms showed massive fibrosis and infiltration of fat in the arm muscles compressing the ulnar and median nerves on the left. neurolysis of the left ulnar nerve was performed, and the ulnar nerve was found enclosed in a fibrotic mass throughout the entire length of the upper arm. the brachial artery and the median nerve were similarly enclosed in fibrotic tissue and were released. a biopsy of the affected muscles showed muscle necrosis and fibrosis. the patient was treated with physiotherapy and losartan with only mild improvement in the consistency of the muscles, but without clinical improvement in ulnar nerve function, and worsening of nerve conduction. this case illustrates severe peripheral nerve damage due to entrapment in massive muscle fibrosis following improper intramuscular injection of anabolic steroids for cosmetic purposes. fabrizi gm 1 , testi s 1 , høyer h 2 , braathen gj 2 , squintani g 3 , bertolasi l 1 , ferrarini m 1 , taioli f 1 , cabrini i 1 , pancheri e 1 , cavallaro t 1 , tonin p 1 . 1 department of neuroscience, biomedicine and movement, university of verona and department of neuroscience, aoui verona, italy; 2 section of medical genetics, department of laboratory medicine, telemark hospital, skien, norway. inherited diseases of nerve and muscle may overlap phenotypically or coexists as facets of the same disorder. two families whose probands were initially diagnosed with a lower motor-neuron (lmn) syndrome and a hereditary distal motor neuropathy (dhmn) turned out to represent a vcp (valosin-containing protein)-related syndrome and a gne (udp-n-acetylglucosamine 2-epimerase/n-acetylmannosamine kinase)-related "distal myopathy" . both conditions shared the presence of rimmed vacuoles (rv) in muscle biopsies. in family 1, the 61 year-old male proband had a lmn syndrome manifesting at age 58 years (wasting/weakness, cramps, fasciculations of thigh muscles, later involving the distal upper limbs). his 64 year-old brother had lower limb weakness and diffuse pain in bones/joints since age 54. the father was diagnosed with a "muscular dystrophy" thirteen years before dying a 76 years; by age 69 years he had developed a behavioural frontotemporal dementia (ftd). electrodiagnosis (edx) disclosed myopathic changes with ongoing denervation together with a mild sensory-motor axonal polyneuropathy in the proband, and a chronic sensory-motor axonal polyneuropathy in the brother. mri showed fatty replacement of weakened muscles in both siblings and diffuse changes of bones consistent with paget disease (pd) in the elder sibling. in family 2, a 32 year-old african woman was affected by weakness and wasting starting at the distal lower-limb muscles at age 23 years and soon progressed proximally; parents were not consanguineous and two sisters out of six siblings, deceased in their thirties for post-partum complications, had a similar disease. edx mainly disclosed a neurogenic process with ongoing denervation. muscle biopsies from the three family-1 patients and from the family-2 proband showed a myopathy with rv. next-generation sequencing demonstrated a heterozygous c.277c>t change of vcp leading to a known pathogenic p.arg93cys substitution in all family-1 patients, and two compound heterozygous c.1441g>a and c.1561g>a changes of gne in the family-2 proband leading to known p.ala481thr and p.ala521thr substitutions. vcp is known to cause autosomal dominant amyotrophic lateral sclerosis-14, charcot-marie-tooth disease type 2y or inclusion body myopathy (ibm) with pd and ftd (ibmpfd); gne causes the autosomal recessive nonaka myopathy (alias ibm2). both cases emphasize the clinical and neurophysiological heterogeneity of those disorders. fargeot g 1 , vandendries c 2 , labeyrie c 1 , viala k 3 , theaudin m 1 , adams d 1 . 1 neurologie, crmr nnerf, aphp, filnemus, chu bicêtre, le kremlin-bicêtre, france; 2 neuroradiologie, crmr nnerf, aphp, filnemus, chu bicêtre, le kremlin-bicêtre, france; 3 neurologie, groupe hospitalier universitaire pitié salpêtrière, paris, france. the diagnosis of cidp is often challenging, especially when electrophysiological signs of demyelination are lacking. plexus mri has documented nerve abnormalities in small series of typical cidp but its contribution in patients with no electrophysiological signs of demyelination remains to be proved. we report the results of plexus mri in a serie of patients suspect of having cidp without efns pns definite electrophysiological criteria. we did a retrospective study of 44 patients consulting in kremlin bicetre and pitié salpétrière hospital. lumbar or brachial plexus mri (or both) were performed and we assessed nerve trophicity, t2-stir signal intensity and gadolinium enhancement as well as the topography of abnormalities. a consensus diagnosis was made by a group of experts (based on clinical data and other supportive criteria) and allowed us to classified patients in "cidp" or "other diagnosis". the practical contribution of plexus mri to the diagnostic algorithm has been studied. diagnosis of cidp was made in 27 patients. mri was abnormal in 67% of cidp patients and showed nerve roots hypersignal/hypertrophy/enhancement in respectively 66.7/55.6/25.9% of patients. the pattern of abnormalities was often asymetrical (77.8%), diffuse (47.1%) or multifocal (41.2%). after unblinding, the mri confirmed the diagnosis of experts in 61.4% of patients and changed the diagnosis in 20% of patients. plexus mri has shown to be useful in our serie to confirm the diagnosis of experts or to modify it in 9 patients (20%) . the "classical" pattern described in definite cidp (diffuse nerve root hypertrophy and hypersignal) was documented in 30% of our cidp patients whereas less typical pattern (focal or multifocal abnormalities, hypersignal without hypertrophy) was found in 37%. plexus mri seems usefull when facing patients suspected of having cidp when electrophysiological criteria are not met: both symetrical diffuse or asymetrical multifocal patterns can be found and should be always correlated to the clinical examination and other supportive criteria. the specificity of such abnormalities remains to be studied. feely sme 1 , rebelo a 2 , abreu l 2 , tao f 2 , bacon c 1 , zuchner s 2 , shy me 1 . 1 university of iowa, iowa city, ia, usa; 2 dr. john t. macdonald department of human genetics and hussman institute for human genetics, miller school of medicine, university of miami, miami, fl, usa. mutations in bcle-associated athanogene 3 (bag3) have been shown to cause a distal myofibrillar myopathy and cardiomyopathy that can severely affect children or only affect adults depending upon the particular mutation. children with severe cardiomyopathy and myopathy have also developed axonal peripheral neuropathy, consistent with the known localization of bag3 in neurons as well as in muscle. we have identified two large autosomal dominant families with adult onset charcot-marie-tooth disease (cmt2) with the identical novel missense mutation pro209ser, a codon previously shown to cause severe or mild myopathy depending on the amino acid substitution. these families expand the phenotypes caused by mutations in bag3 to include cmt2 and provide an additional example of adult onset cmt2 that may previously have been diagnosed as chronic idiopathic axonal neuropathy (ciap). feely sme 1 , saade d 1 , shy me 1 . 1 carver college of medicine, university of iowa, iowa city, ia, usa. myelin protein zero (mpz), expressed only by myelinating schwann cells, has sequence alterations that have previously been reported to cause demyelinating, intermediate, and axonal forms of charcot marie tooth (cmt) disease. we describe a rare duplication in mpz which is causing an early onset, demyelinating form of cmt in our patient. patient was a product of a normal pregnancy and delivery. early milestones were delayed. she began walking at 23 months of age. she was not able to keep up with her peers and was the slowest runner. she started wearing smos at 3 years of age and afos by 11 years of age. she was diagnosed with scoliosis at 2 years of age and started wearing a brace at 3 years. her examination at 11 years of age showed that her fdi, apb, and adm were all 4/5 bilaterally. weakness in her lower extremities included 4/5 foot eversion and 3/5 great toe dorsi flexion. she had tight heel cords bilaterally. pinprick sensation was reduced throughout in her upper and lower extremities and absent at her toes bilaterally. vibration sensation with a rydel tuning fork was absent at her toes and ankles and reduced at her knees and fingers. nerve conduction studies were performed and revealed no responses in all sensory nerves tested with the exception of the radial nerve which had normal latency and mildly slowed conduction velocity (37 m/s). prolonged latencies, demyelinating range slowing (between 13-16 m/s), and low cmap amplitudes in almost all segments of the median and ulnar motor nerves were also observed. these findings were consistent with a hereditary sensorimotor demyelinating polyneuropathy. she was diffusely areflexic and her total cmt pediatric score (cmtpeds) was 34/44 which is in the severe range. her cmt neuropathy score (cmtns) was 14/36 in the moderate range. the duplication of mpz has previously been identified as a rare cause of cmt1b. inherited neuropathy consortium is part of the nih rare diseases clinical research network (grant#1u54ns065712-01). feely sme 1 , saade d 1 , shy me 1 . 1 carver college of medicine, university of iowa, iowa city, ia, usa. mutations in egr2 cause a severe, demyelinating form of cmt, cmt1d. we describe a novel mutation in egr2 which led to extreme variability in severity in a family. proband was a 12 year old girl who was the product of a normal pregnancy and delivery. early milestones were on time. problems with walking started at 2 years of age. at 2.5 she was unable to use stairs, run, or jump. at 4 she was wearing bilateral afos. by 5 she was using a wheelchair and started breathing assist at night. she lost arm lift but could still hold a pen. by 10 she could not ambulate independently and breathing assist was required day/night. she lost the ability to write and developed a head drop. by 12 years she could not sit up. on exam her head and neck muscles were 4/5. upper limbs, deltoids, biceps, wrist ext/flex, finger ext, fdi, and adm were 0/5 bilaterally. triceps were 2/5; finger flexors and apb were 1/5 bilaterally. lower limbs were 0/5 and she had contractures on the right. sensory examination was normal. she was diffusely areflexic. ncvs were absent. both the cmtns and cmt pediatric score were severe at 26/36 and 42/44. exome sequencing revealed a r381l variant in egr2 which was likely pathogenic. the probands' mother also had this mutation. she had no reported symptoms at the age of 33 with strength at 5/5 throughout with the exception of left foot eversion which was 4+/5 and great toe dorsi flexion which was 4-/5 bilaterally. sensory exam showed a decrease of vibration and pinprick sensation at left toe. she had a normal gait, tandem gait and could toe walk, but not heel walk. she was diffusely areflexic. ncvs showed absent sensory responses. motor ncvs showed her latencies were prolonged and velocities reduced (29-33 m/s). cmtns was mild (5/36). additional family members who had the r381l mutation were evaluated including maternal grandmother who was moderately impaired (19/36) and maternal aunt who was severe (26/36). no other mutations that could cause another known neuropathy or myopathy were identified and mitochondrial sequencing was normal. inherited neuropathy consortium is part of the nih rare diseases clinical research network (grant#1u54ns065712-01). fisgun a 1 , luan x 1 , hoke a 1 . 1 johns hopkins university, baltimore, md, usa. molecular mechanisms that underlie slow distal axonal degeneration seen in chemotherapy induced peripheral neuropathy (cipn) are unclear. however, several identified molecular targets suggest shared mechanisms with wallerian degeneration. since spontaneous mutation in wlds mice and genetic deletion of sarm1 gene lead to slow wallerian degeneration, we asked if wlds or sarm1 knockout (ko) mice are resistant to distal axonal degeneration induced by several chemotherapy agents. we chose chemotherapeutic drugs from 3 different classes of agents, paclitaxel (taxane), cisplatinum (platin-based drugs) and bertozomib (proteasome inhibitor), to model cipn in mice. primary outcome measure was evaluation of epidermal nerve fibers in the hind paw plantar footpads. secondary outcome measures included thermal sensation and nerve conduction studies. sarm1 ko mice were almost 100% protected against development of sensory neuropathy but the protection in wlds mice was partial. this study confirms the pivotal role sarm1 plays in mediating axonal degeneration and identifies inhibition of sarm1 activity as a potential therapeutic target for prevention of cipn. florio f 1 , scapin c 1 , ferri c 1 , feltri ml 2 , wrabetz l 2 , d'antonio m 1 . 1 myelin biology unit, san raffaele scientific institute, milan, italy; 2 hjkri-university of buffalo, ny, usa. myelin protein zero is the most abundant structural protein in myelin of the pns. in humans, more than 200 mutations in p0 are associated with hereditary neuropathies. deletion of serine 63 causes charcot-marie-tooth (cmt) 1b disease in humans and a similar demyelinating neuropathy in mice (wrabetz et al., 2006) . p0s63del protein is misfolded and is retained in the er where it gives rise to a dose-dependent unfolded protein response (upr) (pennuto et al., 2008) . the upr results in the activation of transcriptional and translation control programs that reduce protein synthesis and increase the folding and degradative capacity of the cell. usually, when this first response is not sufficient the cells may activate apoptosis resulting in cell death. however, in p0s63del schwann cells there is no cell death suggesting that these cells may respond differently to chronic stress. transcriptomic analysis performed on p0s63del nerves showed increased expression of transcription factors normally present only in the early phases of differentiation such as c-jun, sox2 and id2 (d' antonio et al. 2013) . in order to understand the role of the expression of these factors in the peripheral nerve myelination we used ex vivo and in vivo approaches and we showed that sox2 and id2 act as negative regulators of myelination. these results suggest that the expression of sox2 and id2 may contribute to the hypomyelination observed in p0s63del mice. as such, we reasoned that their ablation could ameliorate the phenotype. surprisingly, the ablation of these factors in the p0s63del mouse severely worsens the neuropathy bursting schwann cell differentiation and increasing the expression of both p0 wild type and mutant allele with concomitant exacerbation of the upr. this suggests that the overexpression of early differentiation factors in schwann cell under chronic er-stress is an adaptive mechanism that limits differentiation and reduces the expression of toxic proteins. intravenous immunoglobulin (ivig) is the treatment of choice for the guillain-barré syndrome (gbs). the working mechanism of ivig in gbs is undefined, but most likely all potential effects are dose dependent. the pharmacokinetics (pk) and pharmacodynamics (pd) of ivig in gbs are highly variable between patients and a rapid consumption or clearance of ivig is associated with poor recovery. in the current study we developed a model to predict the pk of a standard dosage of ivig (0.4 g/kg for 5 consecutive days) in individual patients with gbs. non-linear mixed-effects modelling (nonmem) was used to construct a model based on a cohort of 177 gbs patients, with a total of 811 sequential serum igg levels. the final model accurately describes the day to day increment in igg levels during the 5-day course and the initial rapid fall and graduate decline to steady-state levels thereafter. we explored several potential covariates that improved the predictive capabilities and decreased the between-subject variation in the model. the model including these covariates were evaluated successfully (bootstrap analysis) and through numerous simulation studies each based on 1000 (simulated) gbs patients. in conclusion, a first accurate and robust nonmem model for the pk/pd of standard ivig treatment in gbs was developed. the model can be used to predict the pk in individual patients applying a few simple baseline characteristics. in addition, the effect of different treatment regimens of ivig in gbs on a population pk/pd level can be simulated. this modeling technique is a new tool to optimize the pk in individual patients and the study design for new trials with ivig in gbs. forese mg 1 , pellegatta m 1 , rivellini c 2 , podini p 3 , quattrini a 3 , previtali sc 2 , taveggia c 1 . axonal neuregulin 1 (nrg1) type iii is an essential instructive signal for peripheral nervous system (pns) myelination, as its expression determines whether axons are myelinated as well as the thickness of the myelin sheath. we recently demonstrated that gamma-secretase cleavage of nrg1 type iii generates an axonal intracellular fragment, which translocates in the nucleus to upregulate the expression of the prostaglandin d2 synthase (l-pgds) gene in neurons. l-pgds catalyzes the conversion of prostaglandin h2 into prostaglandin d2 (pgd2). we also showed that specific inhibition of l-pgds activity impairs in vitro myelination. accordingly, myelin in l-pgds null mice is noticeably thinner, thus indicating that l-pgds is a new modulator of developmental pns myelination. previous studies have shown that prostaglandins are involved in the process of wallerian degeneration (wd) and axonal regeneration after injury. thus, to determine whether l-pgds and pgd2 could be important in pns regeneration and remyelination, we performed sciatic nerve crush injury in 2 months old l-pgds null and wild type control mice and we analysed nerves by morphologic, biochemical, histological and molecular approaches at different time points (t) after crush. we focused on three phases: degeneration (t3 -t7), axon regeneration (t14 -t21) and remyelination (t60). our results indicate that in l-pgds null mice the amount of myelin proteins synthesized after crush as well as the number of remyelinated fibers do not change, suggesting that l-pgds might be dispensable for remyelination. however, we observed an increased number of macrophages in null nerves during regeneration (t14), possibly as a consequence of an increase in the blood-nerve barrier (bnb) permeability, indicating potential alteration in the regeneration process in l-pgds null mice. these results suggest that l-pgds could have a different role in developmental pns myelination and after injury. whether other prostaglandins and synthases might compensate for l-pgds activity is currently under investigation. fornasari be 1,2 , raimondo s 1,2 , ronchi g 1,2 , crosio a 3 , budau ca 1 , el soury m 1 , muratori l 1,2 , tos p 4 , battiston b 3 , geuna s 1,2 , gambarotta g 1 . 1 department of clinical and biological sciences, university of turin, italy; 2 neuroscience institute cavalieri ottolenghi, turin, italy; 3 microsurgery unit, health and science city, cto, turin, italy; 4 hand microsurgery and surgery, gaetano pini hospital, milan, italy. to repair nerve gaps following severe peripheral nerve injuries, chitosan tubes were proved to give good results, comparable with those obtained with nerve autografts, the gold standard technique. to further improve peripheral nerve regeneration using chitosan tubes, a conduit enrichment strategy was developed using longitudinal skeletal muscle fibres, which have been previously shown to be good fillers in the "muscle in vein" experimental paradigm, where they played a trophic and a structural role. to this aim, rat median nerve gaps were repaired using two different conduits: 10mm chitosan tubes filled with a longitudinal piece of pectoralis major muscle ("muscle in tube") and hollow chitosan tubes. samples were harvested at early time points (1, 7, 14, 28 days) for biomolecular and morphological analysis, and later (3 months) for stereological analysis. autologous nerve grafts were used as gold standard positive control in the early time points. biomolecular analysis carried out on in vitro degenerating muscle and on "muscle in tube" at early time points show that the muscle produces high levels of soluble isoforms of neuregulin1, a key factor for schwann cell survival and activity, usually released by schwann cells after nerve injury. functional assay and stereological analysis carried out on the distal part of regenerated nerve 3 months after nerve repair, show no significant differences in the regeneration outcome between hollow chitosan tube and "muscle in tube" groups. therefore, we conclude that for short gaps (≤10mm), both hollow chitosan tube and "muscle in tube" are good techniques to repair nerve defects and we suggest that the "muscle in tube", which spontaneously releases neureg-ulin1, might be a promising strategy to promote regeneration when the gap is longer or the repair is delayed in time. foucquier j 1 , bertrand v 1 , jouve e 2 , truillet r 2 , mandel j 1 , laffaire j 1 , blin o 2 , magy l 3 , lehert p 4,5 , hajj r 1 , guedj m 1 , cohen d 1 , attarian s 2 . 1 pharnext, issy-les-moulineaux, france; 2 aix marseille université, aphm, marseille, france; 3 hôpital dupuytren, limoges, france; 4 university of melbourne, melbourne, vic 3010, australia; 5 faculty of economics, louvain, belgium. charcot-marie-tooth disease type 1a (cmt1a) is a rare disease belonging to a group of inherited, progressive, chronic motor and sensory peripheral neuropathies. the charcot-marie-tooth neuropathy score (cmtns) (shy et al., 2005) and the overall neuropathy limitations scale (onls) (graham & hughes, 2006) are considered as the main clinical scales for evaluating progression of disability associated with cmt. as cmt1a is a slowly progressive neurodegenerative disease, the choice of endpoints and their ability to monitor small changes over time remain a major concern for clinical drug development. with this in mind, we studied a cohort of 225 french cmt1a patients with a follow-up ranging from 3 months to 8.5 years resulting from the merge of two multicentre clinical trials (micallef et al., 2009; attarian et al., 2014) and a non-interventional study (unpublished) . the sensitivity to change of both cmtns and onls were assessed using a mixed effect model estimating annual progression with time in years, cmtns or onls baseline value as covariates, study centre as a fixed factor and patients as a random effect to account for the repeated measures. disease progression was estimated to be +0.13 points per year on the cmtns (p = 0.0037) and +0.052 points per year on the onls (p = 1.1x10 −5 ), both corresponding to a deterioration of impairment and disability. while both endpoints have similar and favourable properties, our set of observations led us to conclude that the onls could be more promising to monitor disease progression in cmt1a. frasquet m 1,2 , lupo v 3 , mas f 1,4 , vílchez r 2 , chumillas mj 1,5 , espinós c 3 , sevilla t 1,5,6 . 1 hospital universitari i politècnic la fe, valencia, spain; 2 instituto de investigación sanitaria la fe, valencia, spain; 3 centro de investigación príncipe felipe, valencia, spain; 4 eresa, valencia, spain; 5 centro de investigación biomédica en enfermedades raras (ciberer), valencia, spain; 6 departamento medicina, universitat de valencia, valencia, spain. mutations in the bicd2 gene are a cause of dominant spinal muscular atrophy, lower extremity predominant (smaled). we report six patients belonging to three spanish families who carry three different novel mutations in the bicd2 gene. we describe clinical, electrophysiological and magnetic resonance imaging (mri) data. we provide results of muscle biopsy of one patient and skin biopsy for the study of epidermal nerve fiber density (enfd) of other two patients. genetic diagnosed was reached using a gene panel for genetic testing of cmt and dhmn. three novel mutations in the bicd2 gene that segregated with the disease were detected: p.val485gly; p.tyr557his and p.s681l. the most frequent clinical phenotype consisted of mild weakness in proximal muscles of lower limbs combined with foot deformities. one patient had prominent sensory symptoms and abnormalities on sensory examination. other two patients had minor sensory abnormalities on examination. in one patient sensory and motor nerve action potentials were reduced, in the rest of patients electrophysiological studies showed normal motor and sensory nerve responses, with chronic denervation predominantly in muscles of lower limbs. mri studies at the level of tight and calf were performed in all patients. the most affected muscles were rectus femoris, vastus lateralis and medial gastrocnemius. mri studies at the level of feet were obtained from five patients and showed that there was not fatty infiltration in intrinsic foot muscles. mri at the level of pelvis muscles performed in four patients showed marked fatty infiltration of gluteus medius muscle in two of them. muscle biopsy performed in one patient showed myopathic features. skin biopsy was performed in two patients of the same family. in the older patient, who had minor sensory abnormalities on examination, there was a marked reduction of enfd that followed a length-dependent pattern. in conclusion, we report three new pathogenic mutations in the bicd2 gene. in our study we include mri findings at the level of pelvis and feet, which allow us to better define the pattern of muscle involvement related with this gene. our results also raise the subject of a possible sensory involvement in the disease. hereditary neuropathy with liability to pressure palsies (hnpp) is an autosomal dominant disorder that usually results from deletions in the pmp-22 gene. the neuropathy is unique in that it manifests with recurrent mono-neuropathies at common sites of compression. while spontaneous recovery from episodes of nerve injury usually occurs, it is often incomplete, and over time patients may develop a length dependent polyneuropathy. given the relapsing/remitting nature of hnpp symptoms, standard clinical scores, such as the cmt neuropathy score, are not effective at capturing the severity or progression of the disease. a specific tool is therefore needed for measuring clinical severity of hnpp in preparation for emerging clinical trials. in the current study, we evaluate a new pilot measure, the hnpp severity score (hnpps). the score is composed of 32 patient reported questions addressing current and prior sensory and motor symptoms, and the impact of symptoms on quality of life, followed by 7 items based on a motor examination. total scores vary from 0-85, with higher scores indicating increased disease severity. in this study, the hnpps was administered to 41 patients with genetically confirmed hnpp at the ucl institute of neurology. subjects included 21 males and 20 females with a mean age of 41 years (+/−15, range 16-70). the mean hnpps was 24.4 points (+/−12.4, range 3-56) and the data did not demonstrate major skew. the cronbach alpha for the hnpps was 0.90, and items based on the physical examination showed the least variability. a modest correlation was observed between the hnpps and the cmt examination scores (pearson correlation 0.57, ci 0.3-0.74). we conclude that the hnpps may be a useful measure of clinical severity in hnpp, and should be refined in larger patient cohorts. fridman v 1 , sillau s 1 and on behalf of the inherited neuropathies consortium (inc) 2 . 1 university of colorado hospital, aurora, co, usa; 2 university of iowa hospitals and clinics, iowa city, ia, usa. the most common of the hereditary neuropathies (hn) is cmt1a, an autosomal dominant demyelinating neuropathy that results from duplications in the pmp-22 gene. recent advances in defining the pathomechanisms of the disease have led to an increasing number of potential therapies; however, the absence of reliable natural history data and the paucity of sensitive clinical outcome measures have been barriers to effective clinical trials. the charcot marie tooth neuropathy score (cmtns) was developed to quantify impairment and measure progression in hn. it was observed that while the score discriminates well between mildly and severely impaired patients, it tends to cluster together patients in the middle range of severity. to improve the score's sensitivity, rasch analysis-based weighted category responses were developed. we report a longitudinal study of weighted cmtns and cmt examination scores (cmtes) over a three-year time frame in patients with cmt1a. baseline, one year, two year and three year wcmtnsv2/wcmtesv2 scores were available for 434/730, 49/236, 31/148 and 17/74 patients respectively. mean wcmtns (sd)/wcmtes (sd) scores were as follows: 19.2(7.2)/12.7(6.5) at baseline, 19.0 (7.1)/13.0(6.0) at one year, 22.1 (7.6)/13.7 (6.3) at two years and 22.7 (7.6)/14.1(6.8) at three years. a mixed regression model showed significant change in wcmtns and wcmtes at 2 years (mean change from baseline at 2 years was 1.7 points (p=.003) for wcmtns and 0.59 points (p=.02) for wcmtes. significant change as compared to baseline was also seen at 3 years (mean change from baseline 2.0 points (p=0.02) for wcmtns and 0.69 points (p=0.04) for wcmtes. we conclude that weighted cmtnsv2 scores show change over the first three years of the inherited neuropathies consortium natural history study and are a helpful measure of progression in cmt1a. fridman v 1 , novak p 2 , david w 1 , macklin ea 1 , mckenna-yasek d 1 , walsh k, oaklander al 1 , brown r 2 , hornemann t 3 , eichler f 1 . 1 massachusetts general hospital, boston, ma, usa; 2 university of massachusetts medical school, worcester, usa; 3 university hospital zurich, zurich, switzerland. hsan1 is an autosomal dominant, severe sensory motor polyneuropathy caused by mutations to serine palmitoyl-coa transferase. mutations shift the substrate preference from serine to alanine leading to formation of neurotoxic 1-deoxysphingolipids (1-deoxysl). treatment with high-dose l-serine has been shown to reduce 1-deoxysl accumulation and improve neuropathy in transgenic hsan1 mice. we report a two-year, delayed-start, placebo-controlled clinical trial evaluating the safety and efficacy of oral l-serine in hsan1. eighteen hsan1 subjects were equally randomized to l-serine (400 mg/kg/d) or placebo for 1 year. at 48-weeks, the placebo group crossed-over and all participants took open-label l-serine for one additional year. sixteen subjects completed their 96-week visit, and no serious adverse events related to l-serine were reported. participants randomized to l-serine experienced a decline in charcot marie tooth neuropathy scores (cmtns) over 1 year relative to placebo (−1.8 units, 95% ci −3.3 to −0.3, p = 0.02). both groups improved in the second year of the study, with a diminished difference in cmtns at 96 weeks (−1.45 units, 95% ci −3.7 to 0.81, p=0.20). skin biopsies from the distal leg site were largely devoid of intra-epidermal nerve fibers (ienf), but at 1 year, a greater increase in ienf density was seen in participants on l-serine versus those on placebo (median change of 8 vs. 0 fibers/μm 2 , p=0.014). 1-deoxysl levels declined among participants on l-serine versus those on placebo after one year of treatment (60% decrease in deoxysphinganine vs. 9% increase on placebo, p < 0.001), and placebo participants experienced similar declines in 1-deoxysl levels after crossing over to l-serine. we conclude that l-serine is a safe and potentially efficacious treatment for hsan1. fu liong h 1 , yusuf r 2 . 1 regional neuromuscular clinic, queen elizabeth hospital, university hospitals of birmingham, birmingham, uk; 2 school of life and health sciences, aston brain centre, aston university, birmingham, uk. the relationship between guillain-barré syndrome (gbs) and malignancy is uncertain. under the diagnostic criteria of paraneoplastic neurological syndrome (pns) by euronetwork, 2004, neuropathy with no definite onconeural antibodies identified due to gbs has been classified as "non-classical" paraneoplastic disorder. we retrospectively analyzed data of 118 consecutive patients admitted with gbs from birmingham, u.k. (2001) (2002) (2003) (2004) (2005) (2006) (2007) (2008) (2009) (2010) (2011) (2012) to calculate the relative cancer risk using different definitions and determined characteristics of malignancy-associated gbs. patients were classified according to 2 definitions: 1) all cases of malignancies excluding preceding diagnoses >1 year before gbs and with no evidence of malignant disease activity at the time of gbs diagnosis, and 2) malignancies diagnosed >2 years post-gbs onset as per pns criteria. total number of gbs patients with malignancy was 10 (9.2%). a total of 6 patients (5.5%) fulfilled requirements for inclusion as malignancy-associated gbs as per existing criteria for pns. associated malignancy consisted of angioimmunoblastic t-cell lymphoma (1), poorly differentiated squamous cell carcinoma of nasal septum (1), gastric adenocarcinoma (1), hepatocellular carcinoma due to hepatitis b (1), rectal carcinoma with liver metastasis (1) and myelodysplastic syndrome (1). malignancy was globally commoner in our gbs cohort compared to the general population (odds ratio: 2.08; ci: 1.06-3.71; p = 0.036). however, this was unconfirmed if paraneoplastic criteria were applied. gbs patients with cancer were significantly more likely to be older (p = 0.043), hyponatremic (p = 0.037) and demonstrate more electrophysiological axonal loss (p < 0.05). cerebrospinal fluid (csf) protein levels were lower in the malignancy group (p = 0.002) and neurological improvement was less likely (p = 0.023). in-patient mortality was significantly higher in patients with malignancy (p < 0.01). none of the patients in the malignancy group had positive anti-ganglioside antibodies or anti-neuronal antibodies (anti-hu, yo, ri, crmp5). we conclude global cancer risk is higher in gbs than in the general population, although definition-dependent. application of the strict published criteria for paraneoplastic syndrome reduced the number of cases and suggested absence of a link. malignancy requires consideration in elderly, hyponatremic subjects with normal csf protein, severe electrophysiological axonal loss who fail to improve post-treatment. fu liong h 1 , aude-marie g 2 , anne-catherine an 3 , emilien d 4 , julien c 3 , shahram a 5 , yusuf r 6 . 1 anti-myelin associated glycoprotein antibody (anti-mag) neuropathy is a slowly progressive neuropathy resulting in disability through distal sensory more than motor deficits and tremor. there are currently no evidence-based treatments for anti-mag neuropathy and the effect of the disease on quality of life (qol) in this patient population is unknown. our objective was to assess determinants of qol in patients with anti-mag neuropathy. the sf-36 questionnaire was assessed in 55 patients, from marseille, angers (france) and birmingham (united kingdom). routine clinical evaluations included mrc sum score, incat sensory score, inflammatory rasch built overall disability score (i-rods), ataxia score, jamar grip dynamometry, timed 10 meter-walk, neuropathic pain symptom inventory (npsi) score, and fatigue severity score (fss). there were 38 males and 17 females. mean age was 71.5 years (sd: 10.3 years). mean disease duration was 7.4 years (s.d.: 5.9 years). there were no significant differences between the french and u.k. cohorts in terms of gender distribution, age, disease duration, anti-mag antibody titre. all physical assessments, including mrc sum score (p=0.87), jamar grip dynamometry (p=0.54), onls (p=0.11), irods (p=0.66), incat sensory score (p=0.60), 10-meter timed walk (p=0.46), ataxia score (p=0.65), tremor score (p=0.25), were comparable. prevalence and/or severity of pain (p=0.55), fatigue (p=0.86), restless legs syndrome (p=1) and cramps (p=0.54) were also similar. physical component summary (pcs) and mental component summary (mcs) of the sf36 questionnaire were significantly lower than in reported normal subjects of both countries (p<0.001). all sf-36 qol domains correlated with i-rods, except mcs for which significance was however approached (p=0.056). pcs correlated with mrc sum score, ataxia score, timed 10 m-walk, tremor, jamar grip dynamometry, npsi pain score, fss and level of social support. mcs correlated exclusively with fss and level of social support. in multivariate regression, pcs was associated independently with i-rods (p<0.001) and npsi pain score (p=0.011), whereas mcs was associated independently with fss (p=0.022). qol is accurately predicted in anti-mag neuropathy by the i-rods and fss, lending support to their use in clinical and research settings. effective measures to improve qol should include tremor and neuropathic pain treatment, fatigue management and improved social support. fu liong h 1 , yusuf r 2 . 1 regional neuromuscular clinic, queen elizabeth hospital, university hospitals of birmingham, birmingham, uk; 2 school of life and health sciences, aston brain centre, aston university, birmingham, uk. the electrophysiological diagnosis of guillain-barré syndrome (gbs) is dependent on a number of abnormalities affecting different parameters in peripheral nerves on nerve conduction studies (ncs). diagnostic sensitivity varies with different electrodiagnostic criteria, practices as well as extensiveness of nerve study. however, the most efficient method of performing electrophysiology for guillain-barré syndrome (gbs) is unknown. we retrospectively analyzed electrophysiological data of 97 consecutive gbs patients from birmingham, uk (2001-2012), studied ≤ 3 weeks post-onset. we first identify abnormal nerves from various regions which produced gbs electrodiagnosis using the recently described criteria by rajabally et al. we subsequently used pre-established hypothetical nerve conduction study protocols to determine the potential optimal method of achieving electrodiagnosis. we found the sensitivity of electrophysiology for each gbs subtype was dependent on the upper and lower limb nerves tested. in acute inflammatory demyelinating polyneuropathy (aidp), abnormalities were predominant in the arms, whereas leg abnormalities predominated in axonal gbs. in aidp, the most common abnormal parameters were distal motor latency (46.4%) and conduction block (46.7%), and the most frequently affected nerve was the median (40.1%). prolonged f-waves were present in 32% and f-waves were absent in 29%. mcv was the least frequently abnormal (23.7%) with demyelinating range slowing, significantly lower than cb or dml prolongation (p<0.001 in both cases). in axonal gbs, reduced motor amplitudes (38.1%) and conduction block (35.1%) were the most common parameters, and the most frequently abnormal nerve was the tibial (46.9%). f-waves were absent in 32.1%. 12.5% of all motor nerves were unexcitable, significantly more common in lower limb nerves compared to upper limb nerves (p=0.03). on comparison of different hypothetical ncs protocols (2 unilateral protocols with 2 nerves, 2 with 3 nerves as well as the protocols with 4-nerves and with exclusive bilateral upper limb and lower limb testing), unilateral 4-nerve (median, ulnar, common peroneal and tibial) testing produced the highest diagnostic sensitivity for both aidp (95.6%) and axonal (91.1%) gbs. electrodiagnostic sensitivity in gbs is thus dependent on nerves tested and parameters considered. each subtype preferentially involves specific nerves and parameters. these findings may help per-procedure interpretation, improve electrodiagnostic sensitivity, and reduce patient discomfort. funakoshi k 1 , nagashima t 1 , kokubun n 1 , hirata k 1 , yuki n 2 . 1 department of neurology, dokkyo medical university, tochigi, japan; 2 department of neurology, mishima hospital, nagaoka, japan. recently, igg anti-ganglioside complex (gscs) antibodies have been reported in patients with guillain-barré and miller fisher syndrome. some researchers (nobile-orazio et al., 2010) reported igm anti-gscs antibodies in multifocal motor neuropathy (mmn) and other chronic immune-mediated neuropathies. in ten of eleven mmn patients with anti-gm1 antibody, there was a decreased reactivity to gm1/gd1a compared to single antigen gm1. similarly, in one of two chronic inflammatory degenerative polyradiculoneuropathy (cidp) patient with anti-gm1 antibody, there was a decreased reactivity to gm1/gm2, gm1/gd1a, gm1/gd1b, gm1/gt1b compared to gm1. these relationships were defined negative interaction. in one cidp with anti-gd1b antibody, anti-gm1/gt1b and -gm2/gt1b reactivity increased although gm1 and gm2 were negative (positive interaction). in japan, on the other hand, this correlation remains unclear. sera were investigated from one mmn patient (38 y/o male) with anti-gm1, and anti-gd1a antibody, one cidp patient (72 y/o female) with anti-gm1, and one subacute sensory motor polyradiculoneuropathy (70y/o male) with anti-gd1b, and anti-gq1b. igm antibodies to gscs gm1/gd1a were tested with a mixture of gm1 and gd1a (each 5 pmol/well) as antigen. anti-gm1/gd1a antibodies were judged to have positive interactions when the optical density was 0.5 greater than the sum of the antibodies against individual gm1 and gd1a, and negative interactions when the optical density was 50% or less compared to the antibodies against individual gm1 or gd1a. antibodies to at least one combination of two of the six gangliosides (gm1, gm2, gd1a, gd1b, gt1b, and gq1b) were similarly tested and judged for positive or negative interactions. in one mmn, anti-gm1/gd1a had negative interactions. in one cidp, anti-gm1/gd1a, and anti-gm1/gq1b had negative interactions. in one subacute sensory motor polyradiculoneuropathy, various anti-gscs antibodies including gd1b or gq1b had negative interactions. in the cidp patient mentioned above, anti-gm1/gt1b or anti-gm2/gt1b had no positive interactions. the relationship between this attenuated reactivity presumably driven by adjacent gangliosides and the mechanism of chronic immune-mediated neuropathies needs to be clarified. galino j 1 , cervellini i 1 , zhu n 1 , stöberl n 1 , fricker fr 1 , lee g 1 , hütte m 1 , lalli g 2 , bennett dl 1 . 1 the nuffield department of clinical neurosciences, john radcliffe hospital, university of oxford, oxford, uk; 2 wolfson card, king's college london, guy's campus, london, uk. schwann cells (scs) are the myelinating cells in peripheral nerve system and are important for normal peripheral nerve development and repair. rala and ralb are small gtpases that have been implicated in neural tube closure, neurite branching and have been described as upstream effectors of proteins involved in cell migration and membrane dynamics. due to their potential role in sc function here we investigated, by genetic ablation in transgenic animals of one or both gtpases, their importance in sc function in adulthood and in nerve repair. we showed that ral gtpases are dispensable for sc function in the naïve state. however ral signalling (provided by rala or ralb) is required for effective remyelination of axons following nerve injury. moreover, absent ral signalling produced defects in axon reinnervation of distal organs and a delay in motor function recovery after nerve injury. we also studied the ral dependent cellular mechanisms that may be responsible for impaired sc remyelination and noted abnormal sc lamellipodia formation that prevent normal axial and radial axon remyelination. this work demonstrates for the first time a novel mechanism for ralgtpases that controls sc lamellipodia formation and their importance in normal sc function during peripheral nerve repair. garcía-lareu b 1,2,3 , ariza l 2 , cobianchi s 1,4 , chillón m 1,2,5,6 , navarro x 1,3,4 , bosch a 1,2,3 . tumor necrosis factor (tnf) alpha has been implicated in the pathogenesis of diabetic peripheral neuropathy (dpn), among other inflammatory demyelinating diseases and neuropathic pain. tnf alpha is a pro-inflammatory cytokine that can act at several stages in the demyelination process. it is produced by schwann cells (scs) in the peripheral nervous system (pns) after nerve injury and released into the local environment to attract and activate macrophages at the site of injury, contributing to wallerian degeneration. in vivo studies demonstrated a local inflammation in the sciatic nerve of rats after injection of tnf alpha, followed by demyelination and axonal degeneration. furthermore, the application of tnf alpha resulted in acute mechanical hiperalgesia, a main characteristic of neuropathic pain and therefore tnf alpha is postulated as a biomarker for painful changes after nerve injury. with the aim to characterize tnf alpha effects in chronic neuropathic pain and in diabetic neuropathy, a transgenic mouse model overexpressing tnf alpha cdna under the peripheral myelin protein p0 promoter was generated. here we characterized the overexpression of tnf alpha in myelinated scs at different stages of myelination (postnatal days 5, 21 and 65) showing that high levels of tnf alpha in sciatic nerve leads to the downregulation of the major pns myelin proteins (p0, mbp, pmp22, mag) compared to wild type mice, correlating with the loss of structured myelin and an increase in p75ntr, a marker for immature and non-myelinated scs in the sciatic nerve. iba1 staining showed high levels of macrophage infiltration in both sciatic nerve and spinal cord tissues, compared with wild type animals. stress conditions were induced by sciatic nerve crush surgery after which recovery and subsequent remyelination were delayed in the transgenic mice, as evaluated by the sciatic functional index (sfi) and electrophysiological tests. on the other hand, mechanical and thermal nociception seemed to be unaltered, with or without lesion. this model could be helpful in the characterization of the role tnf alpha in pain development, injury and dpn as well as in developing efficient therapeutic strategies to modulate such pathological conditions. garcía-sobrino t 1,2 , blanco-arias patricia 2,3 , vidal-lijó mp 4 , quintáns bea 2,3 , sobrido mj 2,3 , pardo j 1,2 . 1 department of neurology, hospital clínico, santiago de compostela, spain; 2 neurogenetics research group, instituto de investigaciones sanitarias (idis), santiago de compostela, spain; 3 genomic medicine group (u711), centre for biomedical network research on rare diseases (ciberer), spain; 4 department of neurophysiology, hospital clínico, santiago de compostela, spain. charcot-marie-tooth (cmt) disease is a genetically heterogeneous group of hereditary motor and sensory neuropathies. more than 80 genes were involved in the disease pathogenesis. the objective of this study was to assess the genetic distribution of cmt disease in galicia (northwestern spain). patients were diagnosed as cmt if they had a consistent neurological and/or neurophysiological examination or if they had sensory motor neuropathy with a positive family history. a total of 215 cmt adult patients (55% females) were evaluated with a median age of 48 [39-60] years. the molecular diagnosis was achieved in 168 patients (78%) with a higher success in cmt1 (60%) than cmt2 (20%). globally, pmp22 duplication was the most frequent finding (55%), followed by mutations in mpz (11%), mfn2 (8%), gjb1 (8%) and gdap1 (6%). in cmt1, with expception of the pmp22 duplication, pathogenic variants in egr2, nefl and mpz gene were most common. pathogenic variants in mfn2 and gdap1 accounted for 70% of cmt2 patients. several patients referred to our institution as cmt2 were diagnosed as hereditary motor neuropathy (hmn) and pathogenic variants in the bscl2 gene were the most frequent. pathogenic variants not previously related to cmt were identified in mpz, mfn2, gjb1, egr2, nefl and sh3tc2 genes. sporadic or autosomal recessive (ar) cmt accounted for the 30% of all diagnoses. the genetic epidemiology of cmt in galicia follows a similar pattern to other populations, although some remarkable features are axonal gdap1 and demyalinating egr2 pathogenic variants as well a seemingly elevated proportion of ar cases. mutations in mpz gene are associated to a wide range of phenotypes. the r98c, in particular, is associated to a severe and early onset disease. some cmt patients respond to immunosuppressive or immunomodulatory treatment, some of them harbouring mpz mutations. we present the case of a 34-year-old brazilian female with a severe cmt1b (r98c) that presented an acute episode of worsening after a febrile exanthematic disease. she complained of tingling, stopped walking without support, and could not raise her arms. her emg showed an asymmetrical reduction of motor cv, reduced amplitudes, severe temporal dispersion and possibly conduction block. csf protein was 130mg%, with normal cell count. diagnosed as gbs, she received ivig. curiously, she markedly improved, regaining the functional status of youth, recovering functions that she had long lost. on emg, motor amplitudes improved significantly, but cv remained the same. reviewing carefully her past history, we identified some motor fluctuations along her adult life. at age 26, while pregnant, she developed positive sensory symptoms, became unable to get up from the chair and could not walk without assistance. after delivery, she improved, but did not return to baseline. one year later, she presented a new transitory functional worsening after an influenza illness. her parents were healthy but two out her 3 children have a severe cmt. her first daughter never walked and died at the age of six. six months after treatment with ivig, she faced a new relapse. we pulsed with corticosteroids, with great response. she remains stable to date, four months after treatment. the episodic fluctuations and the evident response to treatment clearly suggest an associated immunomediated process. the fast improvement of the amplitude with maintenance of cv suggests that another mechanism in addition to demyelination and axonal degeneration is involved. we propose the existence of an associated channelopathy. funded by cnpq, faepa, pronas (ministry of healthy) gbs is an acute, immune-mediated neuropathy that comprises three major subtypes: aidp, aman, and amsan. on clinical grounds, this distinction is based on nerve conduction studies (ncs): aidp is a demyelinating neuropathy, aman is an axonal motor neuropathy, and amsan, an axonal sensory and motor neuropathy. recently, it has been demonstrated that axonal gbs, in addition to axonal degeneration, may present conduction block (cb) that can progress to axonal regeneration or revert, characterising a reversible conduction failure (rcf), a finding usually associated to good prognosis. patients presenting axonal cb are frequently diagnosed as having aidp, a mistake that can be avoided with two sets of ncs, one as early as possible and the second after three weeks of disease. following these recommendations, we retrospectively classified a brazilian group with gbs followed in our institution that had been submitted to two ncs sets. from september 2010 to january 2017, 52 patients fulfilled clinical criteria for gbs at clinical hospital of ribeirão preto and had more than one ncs accomplished. at least four motor nerves (median, ulnar, peroneal, and posterior tibial) and five sensory nerves (medial, ulnar, radial, sural, and peroneal superficial) were evaluated in each examination, according to routine procedures. first ncs revealed 12 patients with aidp (23%), 29 cases of axonal gbs (21 aman, 8 amsan, 56%), and 11 patients with equivocal results (21%). at follow-up study, 15 patients (29%) had their classification changed. the main shifts were from aidp to axonal group and from equivocal results to aidp. aidp increased to 31% (n = 16), axonal gbs increased to 69% (n = 36, 22 aman, 14 amsan), and there were no more equivocal patients. although the majority of studies have shown that aidp is more frequent in western countries while axonal gbs predominates in eastern countries, we found a different pattern of distribution in our population, with predominance of the axonal subtypes. the considerable increase of axonal gbs at follow-up studies reinforces that serial emg are mandatory for accurate diagnosis of gbs subtypes. prospective studies are now being carried out in order to confirm these results. in amyloid light chain (al) amyloidosis, misfolded light chain (lc) accumulates and causes progressive peripheral neuropathy (pn) and progressive failure of critical organs such as the heart and kidneys. progressive ascending sensorimotor neuropathy is often a related clinical finding. the deposition of toxic lc amyloid in peripheral nerves is associated with paresthesias, pain, muscle weaknesss, orthostatic hypotension, and diarrhea or constipation in approximately 35% of patients with al amyloidosis. there are no approved treatments for al amyloidosis. current therapeutic approaches for al amyloidosis are intended to limit lc production but do not directly target misfolded lc deposited as amyloid in organs. we report phase 1/2 trial results of neod001, an investigational monoclonal antibody that targets misfolded lc and may neutralize circulating lc aggregates and clear insoluble deposits. trial inclusion criteria were one or more plasma cell-directed treatment completed before enrollment, partial or greater hematologic response to any previous therapy, and persistent organ dysfunction. neod001 was administered intravenously every 28 days during a dose-escalation phase (27 patients; 0.5, 1, 2, 4, 8, 16, or 24 mg/kg in a 3+3 study design) and an expansion phase (42 patients; 24 mg/kg). we assessed safety, tolerability, pharmacokinetics, immunogenicity, organ responses based on consensus criteria, and pn responses using the neuropathy impairment score-lower limb (nis-ll). neod001 treatment was not associated with dose-limiting toxicities or serious adverse events, drug-related discontinuations, or antidrug antibody development in any patient (n = 69). of patients with measurable pn at baseline (n = 11), 82% achieved pn response based on the nis-ll score after 9 months of treatment, which resulted in a median 23% nis-ll score reduction (mean baseline nis-ll, 28.1). in a best response analysis, 53% of cardiac-evaluable patients (n = 36) and 64% of renal-evaluable patients (n = 36) met respective criteria for organ response. improvements in neuropathy have not been previously shown in al amyloidosis. these results demonstrated that monthly neod001 infusions were safe, well tolerated, and associated with responses across three different organ systems. gervais cbl 1 , ross ma 1 , goodman bp 1 , khoury ja 1 , muzyka i 1 , smith be 1 . 1 mayo clinic in arizona, scottsdale, az, usa. this work describes clinical, examination and electrophysiologic findings in a cohort of patients with length dependent sensorimotor peripheral neuropathy (ldsmpn) with ventral abdominal sensory loss. ldsmpn affects the longest nerve fibers, namely those innervating structures in the feet and hands. what is less well appreciated is that length dependent involvement of sensory nerve fibers in ldsmpn from the thoracic segments gives rise to ventral abdominal sensory loss. consecutive patients seen for ldsmpn (n= 77) were evaluated for the presence or absence of ventral abdominal sensory loss. demographic variables, symptoms and quantitative neurologic findings (neuropathy impairment score [nis]) were examined using descriptive statistics. final diagnoses were noted. ventral abdominal sensory loss to pinprick (which was asymptomatic in all patients tested) was documented in 52/77 ldsmpn patients (67.5%), mean age was 61.7 years (range 33-89), m:f gender ratio was 1.7 (33:19), mean nis was 19.1 (range 0-77), ncs/emg abnormalities were found in 60/77 patients (the remaining 17 showing objective evidence of small fiber sensory involvement). ldsmpn patients without ventral abdominal sensory loss (n=25) had a mean age of 59.4 (range 31-77), m:f of 2.6 (18:7), and mean nis of 21.8 (range 0-95). no patient (0/77) had dorsal torso sensory loss between the shoulder and buttock levels on either side. diagnoses of the ldsmpn patients with vs. without ventral abdominal sensory loss included charcot marie tooth or other hereditary neuropathy (n=3 vs.1), abnormal carbohydrate metabolism (n=17 vs. 3), idiopathic (n=12 vs.10), hypothyroidism (n=6 vs. 2), inflammatory (n=9 vs. 5) and other (n=5 vs. 4). ventral abdominal sensory loss appears to be common in patients diagnosed with ldsmpn of a variety of causes including inherited neuropathies; in addition to those innervating distal limb territories, distal sensory fibers from the thoracic region represent another category of length dependent involvement in ldsmpn; 3) the clinical examination of ldsmpn should include the ventral abdomen. gibbons c 1 , garcia j 1 , casasola m 1 , freeman r 1 . 1 beth israel deaconess medical center, harvard medical school, boston, usa. objective: to determine the relationship between measures of autonomic function, electrochemical sweat conductance (esc) and intra-epidermal (ienfd) and sudomotor nerve fiber density (sgnfd). background: structural and functional measures of small fiber neuropathy have been studied in patients with diabetes, but little information comparing these techniques exists. design/methods: we studied 25 patients with diabetes (ages 57±11yrs, gender 9f) and 14 healthy control subjects (age 54±13yrs, gender 7f). subjects underwent examination scores (nis-ll), quantitative sensory testing, autonomic testing (heart rate variability, valsalva maneuver, tilt test), esc, and 3 millimeter punch skin biopsies at the distal leg and distal thigh for ienfd & sgnfd. results: there were strong correlations between exam scores (nis-ll) and biopsy ienfd (r=−0.83, p<0.01 distal leg; r=−0.78, p<0.01 distal thigh), and sgnfd (r=−0.61, p<0.05 distal leg; r=−0.73, p<0.01 distal thigh). moderate correlations were noted between exam scores and qst (r values 0.3-0.5, p<0.05), ienfd and qst (r=0.40-0.47). modest correlations were noted between esc and parasympathetic function (r=0.33-0.47, p<0.05). modest correlations were noted between esc and ienfd (r=0.34, p<0.05, but only at the distal leg) and esc and nis-ll (−0.33, p<0.05). no correlations between exam scores and autonomic function were noted. no correlations were detected between esc and sgnfd (r=−0.09-0.32) or esc and sympathetic adrenergic function (r=0.06). conclusions: differences between tests are expected based on our understanding of the pathophysiology and natural history of diabetic neuropathy. exam scores, qst results and biopsy results do correlate, and are consistent with prior studies. in contrast, there was little relationship between tests of autonomic function and exam scores, similar to prior studies and our understanding of autonomic function and differences in p. esc had little correlation with either exam scores or biopsy ienfd or sgnfd. there was a modest correlation between esc and parasympathetic function. the exact relationship between esc and diabetic peripheral neuropathy is not clear, and further research studies are needed to determine the role this technique has in clinical practice. objective: to determine the optimal tissue thickness of skin biopsy sections for studies of cutaneous nerve fibers. background: although analysis of intra-epidermal nerve fiber density (ienfd) is routinely reported using 50 μm thick tissue sections, many recent studies of peripheral alpha-synuclein deposition use 20 or 10 μm frozen sections, or 5 μm paraffin embedded tissue sections. design/methods: we compared the results of biopsies from 30 patients with parkinson's disease (pd), using 4 tissue sections each of 50, 20 and 10 μm thickness. tissues were stained with pgp9.5 and stained for phosphorylated alpha-synuclein (p-syn). the total number of dermal structures (hair follicles, sweat glands, pilomotor muscles) were quantified, nerve densities analyzed, and the frequency of p-syn positive results. we also studied 5 μm paraffin embedded tissue samples from 11 patients with pd. results: in the 30 biopsies of patients with pd there were no differences in the number of sweat glands, hair follicles or pilomotor muscles in 50, 20 or 10 μm sections. there were significantly fewer blood vessels noted in 20 and 10 μm sections compared to 50 μm sections (p<0.05). ienfd and sgnfd declined with tissue thickness (p.0.01, all) and there was increased variability in results in thinner tissue sections. there was a highly significant reduction in p-syn positive sections in thinner tissue sections (p<0.001, all tissues compared to 50 μm sections). paraffin embedded tissue sections had significantly lower nerve densities and positive p-syn results (p<0.01) compared to all frozen tissue sections of 50, 20 and 10 μm thickness. thinner tissue sections carried a greater risk of false positive result or indeterminate results due to difficulty interpreting overlap with pgp9.5. conclusions: tissue sample thickness plays a critical role in interpretation of skin biopsy results. thinner tissue sections, or paraffin embedded tissue sections, do not provide equivalent data and significantly underestimate nerve densities and positive alpha-synuclein results with increase false positive results despite similar numbers of dermal tissue structures. ace-083 is an investigational protein therapeutic that acts as a localized ligand trap for myostatin and other negative regulators of muscle growth. local injection of ace-083 into the gastrocnemius muscle of wild-type, mdx, and sod1 mice produced dose-dependent increases in muscle mass and force without systemic effects. in a phase 1 single-center, double-blind, placebo-controlled dose escalation study in post-menopausal women, unilateral injections of ace-083 into the rectus femoris (rf) or tibialis anterior (ta) muscle were generally safe and well tolerated. mean percent changes from baseline in muscle volume of the injected muscle were +14.5% in the rf and +8.9% in the ta at the highest dose administered with minimal changes observed in the contralateral side and placebo-treated subjects. frequent related aes (≥15%) included injection site pain, pain in extremity, injection site discomfort, and muscle twitching, with similar incidence in ace-083 and placebo-treated groups. all aes were grade 1-2 and reversible. together, these preclinical and clinical results support further studies of ace-083 in myogenic and/or neurogenic diseases with focal loss of muscle strength and function, including cmt. a phase 2 study is ongoing in facioscapulohumeral muscular dystrophy (fshd). study a083-03 is an ongoing multicenter, two-part, phase 2 study to evaluate the safety, tolerability, pharmacodynamics, efficacy, and pharmacokinetics of ace-083 in patients with cmt1 and cmtx. part 1 is open-label and will enroll up to 3 dose-escalating cohorts (6 patients per cohort); part 2 is randomized, double-blind, and placebo-controlled, and will enroll an additional 24 patients. ace-083 will be administered bilaterally to the ta muscle once every three weeks for up to five doses. a safety review team will meet periodically throughout the study to review safety data and make dosing recommendations, including the recommended dose level for part 2. eligible patients must have genetically confirmed cmt1 or cmtx with mild-moderate weakness in ankle dorsiflexion. safety and tolerability will serve as the primary outcome for part 1, muscle volume evaluated by mri for part 2. additional outcome measures of interest include strength by quantitative muscle testing, function by motor tests, and quality of life by the cmt-health index questionnaire. our study was aimed to evaluate the functional and morphological consequences of cellular and humoral responses in chronic inflammatory demyelinating neuropathy (cidp), using extensive standardized high-resolution sonography (hrus) and nerve conduction study (ncs) protocols in incident treatment-naive patients. we enrolled 50 consecutive, newly diagnosed, treatment naive patients with cidp. in addition to all relevant clinical examinations, all patients underwent a standardized ncs and extensive hrus protocol, of median, ulnar, tibial, fibular and sural nerves. we assessed standard nerve and fascicle size, and echogenicity. we found focal sonographic enlargements in multiple nerves and nerve segments with and without ncs abnormalities. the degree of nerve hypertrophy was not associated with presence of ncs features of demyelination, i.e. 84/132 (64%) of median nerve segments showed enlargement without strong decrease in motor conduction velocity and 102/111 (92%) hypertrophic median nerve segments revealed no conduction block. a lower distal cmap of median nerve was related with lower mrc sums-scores (p < 0.001). we found no correlation between age, disease duration or mrc sum-score and nerve size. cellular and humoral responses in cidp may lead to nerve enlargement along the length of nerves, that can be detected by hrus, whereas ncs allows identification of its' specific focal disruption in nerve function. the most common complication of diabetes is peripheral neuropathy, which has prevalence as high as 50% and is characterized by damage to neurons, schwann cells and blood vessels within the nerve. the concept of schwannopathy as an integral factor in the pathogenesis of diabetic neuropathy is re-emerging, and it is now known that schwann cells cultured in hyperglycemic environments underproduce neurotrophins and exhibit loss of axonal associations, further indicating a non-optimal glial cell activation and function. furthermore, the increased expression of p75 ntr in myelin sheaths around fibers that are susceptible to axonal degeneration in diabetic neuropathy suggest an important role for this molecule in disease progression. with this project, it is our main goal to evaluate how disruption of p75 ntr signaling in the schwann cells affects the pathophysiology of diabetic neuropathy. by using a fluorescent live/death cell viability assay, our preliminary data indicate that wild-type schwann cell cultures present increased cell death rate 24h after stimulation with high levels of glucose. the p75 ntr has a highly recognized role in the activation of death signals and when absent, we observed that schwann cells are significantly more resistant to apoptosis in hyperglycemic conditions. the role of p75 ntr receptor signaling in neuron-schwann cell communication and myelination under in vitro diabetic conditions was investigated with primary schwann cell-sensory neuron co-cultures. after eight days of ascorbic acid stimulation, both under euglycemic and hyperglycemic conditions, myelination was assessed by confocal microscopy using specific markers for neurons and myelin. results highlight a compromised ability of wild-type schwann cells to myelinate axons when exposed to a hyperglycemic environment, which was even intensified in co-cultures with schwann cells lacking the p75 ntr . to complement the in vitro studies, we are modeling type 2 diabetes in a p75 ntr schwann cell conditional ko mouse model and plan to investigate nerve mrna expression profile to disclose genetic regulation depending on this receptor signaling and its modulatory role in endoneurial hypoxia and neuroinflammation. the results from this project will provide an integrated vision of how impaired schwann cell activity guides neuropathy progression. gondim faa 1 , barreira aa 1 , cruz mw 1 , cunha fmb 1 , de freitas m 1 , frança mc jr 1 , marques w jr 1 , nascimento ojm 1 , oliveira asb 1 , pereira rc 1 , pupe c 1 , rotta ft 1 , schestatsky p 1 . 1 panelists on behalf of the scientific department of peripheral neuropathy, brazilian academy of neurology, brazil. neuropathy is one of the most common neurological manifestations of several diseases and sfn has been progressively receiving more attention in the medical literature. the aim of this study is to generate a set of recommendations to define and diagnose sfn in brazil. a group of 13 neurologists, members of the scientific department of peripheral neuropathy from the brazilian academy of neurology reviewed a preliminary draft prepared by the first author that was distributed by email. the panelists got together on 6.4.2017 at the city of fortaleza, brazil, to discuss and finish the text for the first submission of the manuscript. sfn can be defined as a subtype of neuropathy characterized by selective involvement of unmyelinated or thinly myelinated sensory (sometimes also autonomic) fibers. it is usually characterized by sensory (pain/dysesthesias/pruritus) or combined sensory and autonomic complaints, associated with an almost entirely normal neurological examination (except for sensory changes). electromyography is normal. a growing list of medical conditions has been linked to sfn, although there is no evidence-based literature to support the use of any specific set of screening tests to diagnose the etiology of sfn (the panelists will suggest a basic screening panel). sfn may also serve as a fallacious but useful terminology to uncover discrepancies in the normal values from different neurophysiology laboratories. in brazil, skin biopsy is not usually performed and initial forms of leprosy may have predominant small fiber involvement. there are several tests to demonstrate involvement of small sensory and autonomic fibers. skin wrinkling test, sympathetic skin responses & heart rate variability (conducted on emg machines) and thermoregulatory sweat test may be low-cost screening alternatives. after the final meeting on 6.4.2017, we finished the first draft for submission to arquivos de neuropsiquiatria (together with a translation to portuguese as supplementary material), the official journal of the brazilian academy of neurology to serve as a source for the definition and diagnosis of sfn in brazil. the final draft will be submitted after presentation at the pns meeting in barcelona on 7.2017. the lower cranial nerves (lcn) include the paired glossopharyngeal, the vagal, the accessory and the hypoglossal nerves. these are involved in the execution of swallowing, speech, phonation, tasting, as well as sensory and autonomic functions. lcn can be affected in central and peripheral nervous system diseases. this study investigates the use of ultrasound (us) to detect lesions of the peripheral course of lcn. in addition mri can be used in unilateral lcn local lesions to demonstrate indirect signs of nerve lesions such as muscle atrophy. the patients were examined in supine position with the neck in maximum extension with either a regular or a portable us system (logiq e and logiq e9 ge healthcare, milwaukee, wisconsin) and high frequency transducers (12 to 20 mhz). according to the detected pathology longitudinal or transversal images were recorded. a series of exemplary observations are demonstrated. in one case a paraganglioma in the glossopharyngeal nerve at the carotid sinus was found. in another patient an us of the thyroid gland revealed a nerve tumor, which was later identified to be a schwannoma. in another case multiple neurofibroma were identified in the vagal nerve during a routine neurofibromatosis screening. us has become also important in investigations of lesions of the accessory nerve, following damage by surgery. nerve continuity and scar formation can be distinguished. lesions of the hypoglossal nerve can be caused by tumor infiltration. in one patient an infiltration of the nerve by a squamous cell carcinoma, and in another case by a low grade sarcoma were detected. in addition mri demonstrated an atrophy of the tongue. identification and assessment of the lcn from the point of exit of the skull to their endpoint can be pursued by us techniques, which have been described for the individual nerves. us is easily applicable and -in addition to the "static" image of the mri -allows assessing nerve positions during different movements, as well as detecting muscle movements as fasciculations. mri can also be used to detect not only more proximal lesions, but also changes of the skeletal muscle by denervation. grümme l 1 , hattenhauer st 2 , wolffram k 2 , kleinschnitz c 1 , mausberg ak 1 , stettner m 1 . 1 university hospital essen, essen, germany; 2 heinrich-heine-university, düsseldorf, germany. in chronic inflammatory demyelinating polyneuropathy (cidp), t cells are suspected to play a crucial role in myelin destruction. cd4 and cd8 t cells contribute to the inflammatory process, while the exact mechanism of myelin damage is still under debate. to elucidate the molecular interaction of t cells and myelin sheets, we compared neuritogenic and control cells in a live imaging in vitro model. the myelinated fibres of rat dorsal root ganglia (drg) served as model for the peripheral nervous system. drgs of embryonic (e16) lewis rats were cultured; myelination was initiated after one week in vitro and continued for two additional weeks. lewis rats immunized with p2 and neuritogenic t cells of the lymph nodes were obtained ten days after immunization. control t cells were prepared from healthy rats. for vital tracking, neuritogenic t cells were stained with orange cell tracker, while the control cells were labelled with cfse. myelin detection in vital cultures was assessed by incorporation of c16 fatty acids conjugated with a fluorophore into the myelin layer. experiments were performed in a conditioned microscope chamber, the two t cell populations were added simultaneously to the drg culture and migration was tracked using live cell imaging. we observed differing migration patterns for neuritogenic and control t cells. the velocity as well as the directionality was altered. after initial contact, the non-neuriotgenic t cells in close proximity to myelin subsequently decreased over time, while the numbers of neuritogenic t cells close to myelin remained stable. long term incubation with neuritogenic t cells affected the myelin integrity in regard to the intermodal length as well as the myelin ratio. further experiments will elucidate the specific effects of neuritogenic t cells to decipher the role of t cells during inflammation in the pns, which could be useful in developing targeted therapies. gundapaneni b 1 , sultan mb 2 , keohane dj 2 , schwartz j 2 . 1 inventiv health inc., burlington, ma, usa; 2 pfizer inc., new york, ny, usa. transthyretin familial amyloid polyneuropathy (ttr-fap) is a rare, life-threatening disorder caused by protein destabilizing ttr gene mutations, broadly classified as val30met (the most common mutation worldwide) and non-val30met genotypes. tafamidis, a highly-specific ttr-stabilizer, is the only medicine approved to delay neurologic progression in ttr-fap. the objective of this post-hoc analysis was to compare the effects of tafamidis on neuropathy progression in patients with val30met and non-val30met genotypes. val30met patients were participants in a randomized, double-blind, placebo-controlled clinical trial of tafamidis, while non-val30met patients were participants in an open-label tafamidis study. patients were grouped into three cohorts: val30met tafamidis (n=64); val30met placebo (n=61); and non-val30met tafamidis (n=21). baseline disease severity and change in disease severity from baseline to month 12 was assessed using the neuropathy impairment score-lower limbs (nis-ll). the effect of tafamidis in the val30met and non-val30met cohorts versus the val30met placebo cohort was determined using a mixed-effects model for repeated measures (mmrm). at baseline, patients in the non-val30met cohort were older, had longer symptom duration, and more advanced neurologic impairment than the val30met cohorts. at month 12, the baseline-adjusted mean ± standard error change in nis-ll was comparable between the val30met tafamidis and non-val30met tafamidis cohorts (1.60±0.78 and 1.62±1.43, respectively). these changes were smaller than that observed in the val30met placebo cohort (4.72±0.77; p=0.0055 vs val30met and p=0.0592 vs non-val30met) indicating less disease progression. based on predicted values from the mmrm analysis, the size of the change in nis-ll across the full range of baseline nis-ll scores was remarkably similar in the val30met tafamidis and non-val30met tafamidis cohorts and was consistently smaller than that observed in the val30met placebo cohort. moreover, in all three cohorts, as baseline nis-ll increased, the predicted level of disease progression also increased. in conclusion, while controlling for baseline disease severity, tafamidis delayed disease progression to a comparable extent in val30met and non-val30met patients. the similar trajectories of disease progression across val30met and non-val30met patients suggest that these two genotype groups may be more similar than previously considered. clin-icaltrials.gov identifiers: nct00409175; nct00630864. gutmann l 1 , shy m 1 . 1 university of iowa, iowa city, ia, usa. post tetanic potentiation (ptp) is a physiological phenonmenon seen with disorders of the neuromuscular junction (nmj). it is caused by the influx of ca++ into the terminal axon during the tetanus resulting in an increased number of acetylcholine (ach) vescicles released by each axonal action potential. in myasthenic syndromes it results in improved nmj function by increasing the probability of achieving a large enough end plate potential to generate a muscle action potential. ptp has different appearances depending on whether the nmj defect is pre-synaptic or post-synaptic. in pre-synaptic defects (the most common being lambert-eaton syndrome) there is an increased amplitude of the muscle action potential after a tetanus that persists up to minutes. prolonged ptp has now been reported in 2 disorders, one on a genetically determined neuropathy/myasthenic basis and the other on an acquired toxic origin. prolonged ptp up to 60 minutes was reported in 2 families with a motor neuropathy (having leg weakness and foot deformites) and a congenital myasthenic syndrome caused by a heterozygous mutation of the synaptotamin ii (syt2) gene (c920t>g p.pro308[p.asp307ala] and c923g>a [p.pro308leu]). electrophysiological testing showed features of a presynaptic defect with prolonged ptp persisting up to 60 minutes. the same phenomenon has been noted in the acquired pre-synaptic defect caused by botululinum toxin. the ptp continued up to 21 minutes. syt2 is the synaptic vescicle calcium sensor in the terminal axon, allowing for fusion of ach containing vescicles with the presynaptic membrane and the synchronous release of ach. the fusion requires a complex assembly process involving snare proteins. both the syt2 gene mutation and botulinum toxin affect normal syt2 function, the mutation by altering amino acids in the calcium-binding domain and the toxin by binding to syt2 as well as gangliosides gd1a and gt1b on the neural membrane. the mechanism for the ptp prolongation remains unknown. prolonged ptp appears to be a unique physiological abnormality resulting from altered syt2. this phenomenon has been decribed to occur in syt2 mutations causing congenital motor neuropathy/myasthenic syndrome and botulism. the abnormality may represent a physiological marker for a presynaptic nmj defect involving altered syt2. hachisuka a 1,2 , senger j 3 , curran m 3 , chan km 1,3 . 1 division of physical medicine and rehabilitation, university of alberta, edmonton, canada; 2 department of rehabilitation and medicine, university of occupational and environmental health, kitakyushu, japan; 3 division of plastic surgery, university of alberta, edmonton, canada. background: motor unit number estimation (mune) techniques are valuable tools in neuromuscular disease. among them, the multiple point stimulation (mps) is one of the most common used. contamination by distant single motor unit potentials (smups) generated by neighboring muscles is a potential confounding factor. this is particularly problematic in ulnar neuropathy, one of the most common neuropathies in humans. reason being that the ulnar nerve innervates the majority of hand muscles. the goals of this study are to test the hypotheses that 1) distant smups all have an initial positive deflection and 2) elimination of smups generated by distal muscles will significantly lower the mune results in the hypothenar muscles. methods: to address the first hypothesis, we tested 10 subjects by stimulating their median nerve while recording smups simultaneously over the hypothenar and thenar muscles. for the second hypothesis, we carried out mps mune of the hypothenar muscles using multi-channel recordings placed over ulnar innervated intrinsic muscles across the hand. when a smup with an initial positive deflection was detected at the hypothenar electrodes, its original was systemically tracked through all the recording channels. results: in the first series of experiments, in accordance with the dipole theory, all smups recorded at the hypothenar recording electrodes had an initial positive polarity. in the second series of experiments, of the 41 studies carried out in 28 subjects, distant smups generated by muscles other than those in the hypothenar eminence represented 17±9.5% (mean±sd) of the overall sample. mune calculated using only smups generated by the hypothenar muscles was 423± 204, compared to 537±290 if all smups were included (p < 0.05). the extent of increase in mune was highly correlated with the proportion of distant smups found in each study (r = 0.89, p < 0.05). conclusion: in contrary to some studies suggesting that smups from distant muscles could have an initial negative deflection, we found all smups from distant muscles had a positive deflection. exclusion of those smups from the sample had a significant impact on the mune results. hagiwara w 1 , konno s 1 , kihara inoue m 1 , fujioka t 1 . 1 toho university, tokyo, japan. matrix metalloproteinase (mmp) plays crucial roles in developing immune-mediated neuritis as guillain-barré syndrome (gbs) and its animal model experimental autoimmune neuritis (ean). to investigate the intraneural expression of mmps during ean and the effect of a phosphodiesterase-3 inhibitor cilostazol (clz) on it, ean rats were treated with either 30 mg/kg/day of clz or vehicle from one day post immunization (dpi). to induce ean female lewis rats were immunized with synthetic peptide from bovine p2 protein. cauda equina (ce) were removed in several time points, total rna was extracted and reverse-transcribed to obtain cdna that was subjected to real-time pcr analysis for expression of mmp-7, mmp-9 and tissue inhibitor of matrix metalloproteinase-1 (timp-1) messages. mmp-7 and mmp-9 messages peaked at 7 dpi, that is presymptomatic phase of ean. all rats developed motor paralysis at 11 dpi, mmp-7 and mmp-9 messages subsided at this moment. however, timp-1 message reciprocally increased at 11 dpi, persisted through 21 dpi. treatment of clz suppressed motor paralysis of ean significantly. mmp-7 message peaked at 14 dpi and mmp-9 message peaked at 11 dpi. on the other hand, both messages at 7 dpi were suppressed compared to untreated ean rats. timp-1 message in clz treated rats peaked at 14 dpi coincided with motor paralysis peak. both mmp-7 and mmp-9 messages might result in subsequent upregulation of timp-1 that finally downregulates mmps activity and inflammatory process. clz treatment suppressed and delayed expression of mmps and facilitate timp-1 expression, resulting suppression of ean. the precise mechanism of expression of mmps and timp-1 remain unclear, however, that mmp-7 and mmp-9 messages peaked at 7 dpi suggests involvement of pro-inflammatory cytokines such as tumor necrosis factor-alpha or interleukin-1. clz might suppress these cytokines resulted in mmps down regulation. mmp-9 less affected by clz and thus stimulated timp-1 expression at 14 dpi. clz might rational treatment for immune-mediated neuropathy via mmps modulation although further investigation especially in-vivo study is needed. haidar m 1 , de winter v 1 , asselbergh b 1 , bouhy d 1 , timmerman v 1 . 1 peripheral neuropathy research group, vib, university of antwerp, antwerp, belgium. the small heat shock protein hspb1 (hsp27) gene is ubiquitously expressed and encodes for a chaperone protein with essential cellular functions. our lab was the first to identify missense mutations in hspb1 responsible for axonal charcot-marie-tooth neuropathy (cmt2f). since then we became interested in understanding the physiological functions of hspb1 and its association with cmt neuropathies. we demonstrated the involvement of hspb1 in microtubule stability. because of the link between autophagosome formation and its intracellular transport, and microtubules stability, we believed that the macro-autophagy process could be regulated by hspb1. macro-autophagy is a cellular housekeeping process during which autophagosomes target, envelop and degrade aberrant protein aggregates and damaged organelles. there is strong evidence for an essential role for autophagy in the maintenance of neuronal homeostasis; hence its impairment can lead to a neuropathic condition. our data indicate that macro-autophagy is disrupted by hspb1 cmt-causing mutations. combining novel microscopy and interactomics techniques we unravelled the way different cmt-causing mutations in hspb1 impair the autophagic pathway. our data present the impairment of autophagy as a possible pathomechanism for cmt-causing hspb1 mutations. hajjar h 1 , gautier b 1 , berthelot j 1 , gonzalez e 1 , gess b 2 , young p 2 , tricaud n 1 . 1 institute of neurosciences of montpelllier, inserm, university of montpellier, montpellier, france; 2 universitätsklinikum münster, klinik für schlafmedizin und neuromuskuläre erkrankungen, münster, germany. cmt1a, the most common of charcot-marie-tooth diseases, results from the duplication of peripheral myelin protein 22 (pmp22) gene. this gene encodes for a small protein of 22 kda, pmp22, mainly produced by schwann cells and the excess of pmp22 leads to demyelination. there is no cure for this disease but one approach for a treatment is gene therapy. a transgenic rat model exists for cmt1a, which possesses 3 copies of the mouse pmp22 gene. our goal is to provide a proof of principle for gene therapy in peripheral nerves using this rat model of cmt1a. our strategy is to reduce the overexpression of mouse pmp22 protein in rats schwann cells using short hairpin rnas (shrnas). shrnas are small non-coding rnas that specifically bind to targeted mrnas resulting in their degradation. we tested for the efficiency of several shrnas targeting mouse pmp22 in vitro to find two shrnas that reduce pmp22 levels. the shrnas have been cloned in an adeno-associated serotype 9 (aav9) viral vector together with green fluorescent protein in order to detect infected cells. aav9 was selected for its high transduction rate of myelinating schwann cells, for its good diffusion and low immunogenicity. we plan bilateral injections in the sciatic nerve of control and diseased rats. the efficiency of this gene therapy will be checked by assessing muscle strength (grip test), way of walking (catwalk), mobility (rotarod) and nerve conduction velocity of treated cmt1a rats versus non-treated. the process of myelination and myelin maintenance in schwann cells will be analyzed by biochemistry and electron microscopy. biochemical tests include western blot for pmp22 protein expression in sciatic nerve, immunohistochemistry for pmp22 protein expression in myelinating schwann cells and pcr for mrna pmp22 expression. if the therapy is successful in rats, it could possibly be later on used in clinical trials. ultrasound is a widely-used tool in diagnosing carpal tunnel syndrome (cts). several different methods for sonographical evaluation of median nerve damage exist, such as calculating the ratio of cross sectional areas (csa) of median nerves in various sites. this enables detection of actual nerve swelling proximal to the carpal tunnel as an expression of median nerve damage inside the carpal tunnel (as seen in cts). in comparison to other diagnostic methods no data exist about the prevalence of cts like changes in an unselected population. a series of 166 non-selected fresh cadavers were examined. 332 arms of 166 fresh, non-embalmed whole body cadavers were examined. the medical record did not allow to obtain conclusive information on the peripheral nerves. using a regular ultrasound system with a 14 mhz transducer, median nerves were identified and tracked along their course in the forearms. csa measurements of the median nerves were performed at two sites in each arm: 1.) halfway between the elbow joint and wrist, 2.) directly proximal to the carpal tunnel. csa ratio was calculated with the following formula: csa ratio = csa wrist (cm 2 ) csa forearm (cm 2 ) csa ratio < 1.5 was found in 282 (84.93%) arms, csa ratio ≥ 1.5 in 40 (12.04%) arms and csa ratio ≥ 2 in 10 (3%) arms. csa ratio ≥ 1.5 was detected in 17.58% of women and 12% of men. the overall mean (± sd) age was 80.52 ± 10.04 years. men (78.56 ± 10.16) were significantly younger than women (82.14 ± 9.6; p = 0.001). a weak but significant correlation between age and csa ratio was found in women (spearman -− 0.185; p=0.013), but not in men (p=0.79). the mean bmi for csa ratio ≥ 1.5 was 26.54 ± sd 5.35. based on a csa ratio ≥ 1.5 as a criterion for cts, the present ultrasound results are consistent with the average cts prevalence reported in previous studies, which were obtained with electrophysiological methods. this study on a large unselected series of cadavers confirms the comparability of both methods. instrumental activities of daily living (badl and iadl), falls and gait patterns in the large, prospective, population based rotterdam study. in total, 1445 participants of this study (mean age 71 years, 54% women) underwent a polyneuropathy screening involving a symptom questionnaire, neurological examination and nerve conduction studies. screening yielded four groups: no, possible, probable and definite polyneuropathy. participants were interviewed about badl (stanford health assessment questionnaire), iadl (instrumental activities of daily living scale) and frequency of falling in the previous year. in a random subset of 977 participants, gait was assessed with an electronic walkway (gaitrite). associations of polyneuropathy with badl and iadl were analyzed continuously with linear regression, and dichotomously with logistic regression. history of falling was evaluated with logistic regression and gait changes were evaluated with linear regression. we found that participants with definite polyneuropathy had more difficulty in performing badl and iadl than participants without polyneuropathy. polyneuropathy related to worse scores of all badl (especially walking) and three iadl components (housekeeping, traveling, and shopping). participants with definite polyneuropathy were two times more likely to fall, and these falls more often resulted in injury. participants with polyneuropathy had worse gait parameters on the walkway, including lower walking speed and cadence, and more errors in tandem walking. in summary, chronic polyneuropathy is strongly associated with significant impairment in daily life. recognition of polyneuropathy and related disability is very important in order to inform, support and possibly treat patients, and to prevent future falls and dependence in daily functioning. patients with polyneuropathy often suffer from tingling sensations, numbness, weakness and pain. these symptoms are used in several screening questionnaires, most of which were developed for high-risk patient groups, such as individuals with diabetes mellitus. in most tools equal weights are applied to all symptoms, while some might be more informative than others. we evaluated the diagnostic value and frequency of occurrence of individual symptoms of chronic polyneuropathy and constructed and validated a simple screening questionnaire that can reliably help to diagnose polyneuropathy in low-risk patient groups. in a multi-step procedure, we initially compiled a twelve-item questionnaire concerning symptoms of polyneuropathy. the questionnaire was completed by 117 polyneuropathy patients and 188 controls (headache, transient ischemic attack, multiple sclerosis). we calculated the sensitivity, specificity and likelihood ratios of each individual symptom. next, stepwise multivariable logistic regression was used to create a compact model, able to discriminate cases from controls using only the most informative symptoms. a simple scoring system was subsequently developed based on the regression coefficients of this reduced model. external validation was subsequently conducted in a population of 140 cases with chronic idiopathic axonal polyneuropathy and 96 controls without polyneuropathy. performance was assessed with discrimination (area under the curve, auc), and calibration. numbness and tingling feet were most frequently reported by polyneuropathy patients and had the highest sensitivity. feeling as if walking on cotton wool and allodynia of the feet had the highest specificity. multivariable logistic regression yielded a model that contained these four symptoms, complemented with balance problems and tingling hands. based on this regression analysis, the erasmus polyneuropathy symptom score (e-pss) was created, a score ranging from 0 to 14. this polyneuropathy symptom score had a good performance (auc 0.92) in de derivation set and proved to be valid in the external population (auc 0.95). in this study, we created a simple, validated polyneuropathy symptom score (e-pss) that takes both the individual value of only six different symptoms and its frequency into account. this tool can be helpful as screening instrument in clinical practice and for future studies on polyneuropathy. multiple sclerosis (ms) is traditionally viewed as a central nervous system disease. to date, there is no unequivocal evidence implicating involvement of the peripheral nervous system (pns). this study aims to prove whether the pns is additionally affected and if so, to detect, localize and quantify these peripheral nerve lesions in patients with multiple sclerosis (ms) by applying high-resolution mr-neurography (mrn) with large anatomical coverage in combination with standard electrophysiological and neurological tests. we prospectively enrolled 34 patients with confirmed ms (>3 years), two patients with clinically isolated syndrome (cis), and 35 age-/sex-matched healthy volunteers. any other potential causes for a concomitant polyneuropathy were excluded. all ms patients underwent detailed neurological and electrophysiological testing. 3 tesla mrn with large anatomical coverage from lumbar plexus and spinal nerves down to ankle level was performed in all participants by using fat-saturated, t2-weighted turbo-spin-echo (tse) sequences (tr/te 5970/55 ms) and a dual echo tse sequence for t2-relaxometry (tr 5210 ms; te 1 /te 2 12/73 ms). a 3d t2-weighted, fat-saturated space sequence (tr 3000 ms; effective te 210 ms) was used for imaging of the lumbar plexus. manual segmentation of spinal/sciatic/tibial/peroneal nerves was performed on a total of 15,975 axial slices. besides evaluation of nerve t2w-signal, detailed quantification of nerve lesions by analyzing morphometric (nerve caliber) and microstructural markers (proton-spin-density and t2-relaxation-time) was conducted. mean lesion load at thigh level was higher in ms (151.5±5.7) vs. controls (19.1±2.4;p<0.0001). nerve proton-spin-density was also higher in ms (tibial/peroneal: 371.8±7.7 / 368.9±8.2) vs. controls (tibial/peroneal: 266.0±11.0 / 276.8±9.7;p<0.0001). in contrast, t2-relaxation time was significantly higher in controls (tibial/peroneal: 82.0±2.1 / 78.3±1.7) vs. ms (tibial/peroneal: 64.3±1.0 / 61.2±0.9;p<0.0001). proximal tibial and fibular nerve caliber was also significantly higher in ms (tibial: p<0.0015; fibular: p=0.0049). for the first time, pns lesions in ms patients could be visualized and quantified in vivo by high-resolution mrn. lesions are indicated by an increase of proton-spin-density and a decrease of t2-relaxation-time. nerve caliber as a morphometric criterion also significantly increased. this proof-of-concept study may offer new insights into the pathomechanism of ms and might have future implications on therapeutic approaches. immunoglobulin g (igg) fc-gammars confer diverse effector functions by linking the cellular and humoral arms of the immune system that has been involved in the pathogenesis of guillain-barré syndrome (gbs). in the post-polio era, the polymorphisms of fc-gammar and their relevant knowledge have become one of the main targets for new therapeutic strategies for the treatment of gbs patients. differences in severity and frequency of gbs subtypes found between south-asian and western populations can be attributed to their genetic susceptibility. therefore, we aimed to determine fc-gammar polymorphic alleles (fc-gammariia: h131/r131; fc-gammariiia: v158/f158; fc-gammariiib: na1/na2) and their possible link with gbs on the currently available large gbs cohort in bangladesh. fc-gamma r polymorphisms of 151 gbs patients and 151 healthy controls were genotyped using sequence-specific pcr. for validation, we carried out the sequencing of some samples for fc-gammariia and fc-gammariiia alleles. no significant differences were found regarding the distribution of fc-gammar genotypes and allele frequencies in gbs patients and controls. fc-gammar-h/h-131 genotype was significantly predominant in patients with severe disease compared to patients with mild disease (p=0.02, or, 2.8; 95% ci, 1.2-6.6). no other significant associations were found in gbs patients for candidate alleles and disease severity. fc-gammariiia-f/f-158 was found to be significantly predominant in anti-gm1 antibody positive gbs patients compared to anti-gm1 antibody negative patients (p=0.02, or, 2.5, 95% ci, 1.2-5.3). fc-gammariiia-v158 alleles were significantly higher in patients with poor prognosis when compared to patients with good outcome (p=0.047, or, 1.76, 95% ci, 1.02-3.02). no significant association of fc-gammariiib genotypes and alleles were found with gbs patients, disease severity and disease outcome. extensive subgroup analysis revealed no significant association in genotype and allele frequencies between aman and aidp subtype. in conclusion, igg fc-gammar polymorphisms do not constitute significant risk markers for susceptibility to gbs, however homozygous fc-gammariia-h131 might be involved in the severe form of gbs. in addition, fc-gammariiia-f/f-158 might play an important role in the molecular mimicry against nerve gangliosides in gbs. further studies that enroll a large number of patients (e,g. igos) are required to confirm the present findings from different geographical areas. hayes jm 1 , o'brien pd 1 , backus c 1 , feldman el 1 . 1 department of neurology, university of michigan, ann arbor, mi, usa. peripheral neuropathy (pn) is a common complication observed in patients with impaired glucose tolerance and type 2 diabetes. male mice fed a high fat diet (hfd) develop metabolic impairments and pn serving as an appropriate animal model to study pn development and progression. it is well documented that female mice fed a hfd display a degree of protection against hfd-induced metabolic changes with mice retaining relatively normal insulin sensitivity. this protection is attributed to differences in fat accumulation and to the anti-diabetic effects of estrogen. based on these sex-dimorphisms we hypothesized that hfd-fed female mice would also exhibit resistance to developing pn. in the present study male and female c57bl6/j mice were fed either a standard diet (10% kcal fat; sd) or a high fat diet (60% kcal fat; hfd) from 5wk. at 16wk, 24wk and 36wk, neuropathy phenotyping was performed on all groups complemented with longitudinal metabolic assessments including insulin tolerance testing (itt). neuropathy phenotyping consisted of hindpaw latency to heat stimulus, motor and sensory nerve conduction velocities (ncvs), and terminal intraepidermal nerve fiber (ienf) counts. assessment of insulin resistance through itt demonstrated that during early hfd feeding, female hfd-fed mice exhibited relatively normal insulin responsiveness, while male hfd mice exhibited insulin resistance. despite this finding, 16wk female hfd mice displayed a similar pattern of pn to that of their male counterparts, with similar fold-changes in hindpaw latency and sensory and motor ncvs. therefore, although female hfd-fed mice exhibit resistance to hfd-induced metabolic changes, they display a pn comparable to male hfd-fed mice suggesting that systemic insulin resistance does not mediate pn. further studies are underway investigating the role of insulin signaling in the peripheral nerves of female hfd-fed mice. anti-mag (myelin-associated glycoprotein) neuropathy is a disabling autoimmune peripheral neuropathy caused by monoclonal immunoglobulin m (igm) autoantibodies that recognize the carbohydrate epitope hnk-1 (human natural killer-1). this glycoepitope is highly expressed on adhesion molecules, such as mag, present in myelinated nerve fibers. since the pathogenicity and demyelinating properties of anti-mag autoantibodies are well established, current treatments aim at a reduction of autoantibody levels. however, the therapies applied so far are primarily immunosuppressive and lack selectivity and efficacy. we therefore hypothesized that a significant improvement of the disease condition could be achieved by selectively neutralizing the pathogenic anti-mag antibodies with carbohydrate-based ligands mimicking the natural hnk-1 glycoepitope. in an inhibition assay, a mimetic (mimhnk-1) of the natural hnk-1 epitope inhibited mag-binding by pathogenic igm antibodies from patient sera, however only with micromolar affinity. therefore, considering the multivalent nature of the mag-igm interaction, polylysine polymers of different sizes were substituted with the mimetic. with the most promising polylysine glycopolymer pl 84 (mimhnk-1) 45 the inhibitory effect on patient sera was improved by a factor of up to 230,000 per epitope, consequently leading to a low nanomolar inhibitory potency. since clinical studies indicate a correlation between the reduction of anti-mag igm levels and clinical improvement, an immunological surrogate mouse model for anti-mag neuropathy, producing high levels of anti-mag igm, was developed. the observed efficient removal of these antibodies with the glycopolymer pl 84 (mimhnk-1) 45 represents a first step towards an antigen-specific therapy for anti-mag neuropathy. hinder lm 1 , mendelson f 1 , backus c 1 , feldman el 1 . 1 university of michigan, ann arbor, mi, usa. in the united states 17% of children and young adults are obese and at risk of developing prediabetes. prediabetic patients largely develop the same macro-and microvascular complications as patients with type 2 diabetes, including peripheral neuropathy (pn). moreover, recent clinical data suggest normoglycemic obese patients develop pn. central obesity, characterized by excess fat storage in visceral white adipose tissue, leads to systemic metabolic dysfunction largely due to an imbalance between pro-inflammatory/anti-inflammatory adipokine production. subcutaneous adipose tissue is considered 'benign', but adopts a visceral-like phenotype in response to metabolic stress, with reduced thermogenicity, reduced brown adipose identity, and increased pro-inflammatory gene expression. the popliteal adipose tissue (pat) depot, corresponding to subcutaneous adipose, is adjacent to the peripheral nerve affected in pn, contains the lymph node for lymphatic drainage of the hind limb, and expands following local, sterile hind paw inflammation. the aim of the current study was to characterize pat changes in the high fat diet (hfd) mouse model of obesity and pn, and consider its contribution to peripheral nerve dysfunction. we previously reported c57bl6/j mice fed 60% hfd from 5-16 wk develop obesity, 'prediabetes' and pn; and switching mice back to a standard diet from 16-24 wk improves metabolic and pn phenotypes. at 16 and 24 wk pat was bilaterally dissected and the lymph node removed. the left pat was processed for histomorphometry, and the right pat for rt-qpcr. at 16 wk hfd was associated with a significant shift in adipocyte size-frequency distribution, with a greater number of larger adipocytes. switching the hfd mice back to standard chow from 16-24 wk restored the size-frequency distribution towards age-matched controls. rt-qpcr was performed to assess changes in thermogenicity (ucp1), brown adipose identify (cidea) and sterile inflammation (saa3). at 16 and 24 wk hfd pat had reduced thermogenicity and brown adipose identify, and increased sterile inflammation. this switch towards a visceral-like phenotype was reversed in the hfd mice switched back to standard chow. in summary, hfd-induced changes in pat histomorphometry and adipose identity closely associate with pn phenotype. these preliminary data suggest a potential role for pat-nerve signaling in pn. hinder lm 1 , backus c 1 , hayes jm 1 , feldman el 1 . university of michigan, ann arbor, mi, usa. peripheral neuropathy (pn) is a common and debilitating complication of obesity and diabetes that triggers pain and loss of sensation. substantial nerve damage occurs in many patients prior to noticeable symptoms and no treatments are currently available; therefore, there is a critical need to identify treatment strategies that impact the underlying disease pathogenesis. our in vivo fluxomics data in the bks-db/db mouse model of type 2 diabetes (t2dm) and pn suggest that 'metabolic reprogramming' occurs in the t2dm nerve to downregulate mitochondrial oxidative phosphorylation of substrates derived from glycolysis and fatty acid beta-oxidation. therefore, we hypothesize that distinct systemic metabolic alterations occur in obesity and diabetes which induce tissue-specific metabolic reprogramming within the peripheral nerve, altering fuel utilization and ultimately leading to tissue dysfunction. we contend that identifying conserved bioenergetic profiles across mouse models of pn will provide insight into key pn mechanisms. the current study utilized two mouse models of pn: the 60% high fat diet (hfd) mouse model of obesity and prediabetes at 20 wk of age (16 wk hfd), and the leptin receptor-deficient bks-db/db model of t2dm at 24 wk of age. mitochondrial function was determined in primary dorsal root ganglia (drg) neurons and sural nerve tissue from both models using the seahorse xf24 analyzer. resting mitochondrial oxidative metabolism was upregulated in drg neurons from mice with pn, with increased resting atp production and maintained mitochondrial coupling. in contrast, resting atp generation was decreased in sural nerve from mice with pn, with decreased coupling efficiency. relative spare respiratory capacity was attenuated in both drg neurons and sural nerve from mice with pn, indicating that mitochondria were less able to increase respiration in response to an energetic challenge. moreover, mitochondrial copy number was unchanged in drg neurons, but decreased in sural nerve tissue of mice with pn compared with respective controls. these data suggest a change in absolute number and function of sural nerve mitochondria, and a conserved cross-model proximal-distal bioenergetic profile in pn. we are currently exploring the relationship between these changes and pn pathogenesis. hoang ttn 1 , umapathi t 2 . 1 175 hospital, ho chi minh city, vietnam; 2 national neuroscience institute, singapore. ho chi minh city (hcmc) is the biggest metropolitan city in southern vietnam. its population is more than ten million. adult patients with neurological disorders are seen at six city public hospitals, including 175, hospital. there has been no systematic study of guillain barré syndrome (gbs) at hcmc or in vietnam in general. we are in the process of starting a prospective gbs database that we hope to expand to the other public hospitals at hcmc. here we describe our experience from 2016. we saw 5 gbs patients at 175, hospital. most of the cases were admitted in the rainy season, from late april to november, when mosquito-borne flavivirus infections are more common. patients were seen in the first week of illness and reported antecedent fever. two patients had diarrhea. diagnoses were made largely on clinical features, cerebrospinal fluid analysis and nerve conduction study. clinical findings include limb weakness, numbness and vii cranial nerve palsy. extraocular eye movements were affected in one patient. none had respiratory involvement severe enough to require artificial ventilation or intensive care. there were no pure miller-fisher syndrome cases; we suspect this might be related to the mild deficits that did not prompt hospitalization. nerve conduction studies showed typical features such as loss of f waves and abnormal blink reflex. the electrophysiology of 3 patients' was dominated by demyelinating changes, one case was largely axonal and the remaining patient had normal electrodiagnostic study. repeat nerve conduction studies were not feasible because of limited resources. neurologists use corticosteroids as the main treatment. intravenous immunoglobulin and plasma exchange are costly and not reimbursed by medical insurance. we are currently preparing to systematically study gbs in southern vietnam, specifically with regards to possible role of antecedent flavivirus infections. we are also exploring the possibility of using low volume plasma exchange as a feasible cost-effective therapeutic modality. about 10% of patients with guillain-barré syndrome (gbs) treated with intravenous immunoglobulin (ivig) or plasma exchange deteriorate after initial improvement or stabilization -a phenomenon that is termed treatment-related fluctuation (trf). it is important to distinguish acute onset cidp (a-cidp) from gbs-trf during early course of the disease, because their therapeutic strategies and prognoses are different. herein, we describe a patient with gbs-trf, but with an extended progression phase that exceeds 8 weeks. a 27-year-old woman was admitted due to acute onset progressive leg weakness and diplopia that had developed 2 weeks prior (onset, d0). on neurological examination, right facial palsy was also observed. lower extremity weakness was moderate in proximal and distal muscles (mrc grade iv) with absent knee and ankle jerks. sensory examination revealed no abnormality in all modalities. she denied any recent diarrhea or upper respiratory infection, and vaccination. albumino-cytologic dissociation was noted in csf analysis; white blood cell count of 3/ l and protein level of 104.2 mg/dl. nerve conduction study revealed demyelinating sensorimotor polyneuropathy with prolonged distal latency and conduction blocks. anti-ganglioside antibodies (gm1 igm/g, gd1b igm/g, and gq1b igm/g) were all negative. following ivig treatment, she was discharged with considerable improvement (d20). 11 days later, she was re-admitted due to deterioration of leg weakness and hand clumsiness (d31). after another ivig treatment, she was discharged with clinical improvement (d49). 17 days later, however, she was admitted again (d66) due to another considerable deterioration with four extremity weakness being worst at this time (mrc grade ii-iv in upper extremity, grade ii in lower extremity). a-cidp was considered given the progression phase exceeding 8 weeks, but, we decided to give another treatment with ivig instead of a switch to corticosteroids because of uncertainty regarding distinction between a-cidp and gbs-trf. she was significantly improved following ivig treatment, and finally discharged (d92). thereafter, there has been no further deterioration during long-term follow-up of 1 year. conclusively, this is a rare case of gbs with extended progression phase and trf. we propose that this could be referred to as subacute inflammatory demyelinating polyradiculoneuropathy (sidp) with trf. hsieh s 1 , chao c 1 . 1 national taiwan university hospital, taipei, taiwan. transthyretin (ttr)-related familial amyloid polyneuropathy (fap) constitutes a major etiology of adult-onset hereditary neuropathies worldwide, in particular, a mutant ttr of ala97ser (ttr-a97s) in taiwan, the most common cause of acquired genetic neuropathy with adult onset (>50 years of age) of taiwanese patients. fap is a pan-modality neuropathy involving motor, sensory, and autonomic components of the peripheral nervous system with early involvement of small fibers as a major symptom. the early symptoms of fap are sometimes minimal and difficult to ascertain, mainly related to the fact that conventional electrophysiological examinations were not sensitive enough to detect small fiber neuropathy. skin biopsy with quantification of intraepidermal nerve fibers (ienf) has become one of the standard approaches to diagnose small fiber sensory neuropathy based on pathological documentation of nociceptive nerve degeneration. to explore the issue of early biomarkers in fap, we performed skin biopsy and compared ienf density with parameters of nerve conduction studies (ncs) and quantitative sensory testing (qst) on 36 subjects (23 men, aged 55.1 ± 11.1 years) with genetic confirmation of ttr-a97s: 17 patients and 19 carriers. the ienf densities were significantly reduced compared to the age-and gender-matched controls in carriers (4.05 ± 2.01 vs. 10.39 ± 3.75 fibers/mm, p = 0.0057) and patients (0.84 ± 1.06 vs. 7.96 ± 2.39 fibers/mm, p = 0.0012). the latter was consistent with our previous report (neurology, 75:532-538, 2010) . the abnormal rate of ienf density was significantly higher than that of ncs and qst, respectively. in conclusion, there was significant skin nerve degeneration in carriers with ttr-a97s. compared with qst and ncs, ienf density assessment had the highest abnormal rate and highest sensitivity to detect neuropathic changes in the early stage of fap. charcot-marie-tooth type 2p (cmt2p) has been associated with frame-shift mutations in the ring domain of lrsam1 (an e3 ligase). this study describes families with a novel missense mutation of lrsam1 gene and explores pathogenic mechanisms of cmt2p. this american family with dominantly inherited axonal polyneuropathy reveals a phenotype similar to those in previously reported non-us families. the affected members in our family co-segregated with a novel missense mutation cys694arg that alters a highly conserved cysteine in the ring domain. this mutation leads to axonal degeneration in the in vitro neuronal cell-line. moreover, using protein mass spectrometry, we identified a group of rna binding proteins (including fus, a protein critically involved in motor neuron degeneration) that interacted with lrsam1. the interactions were disrupted by the cys694arg mutation, which resulted in reduction of intranuclear rna-binding proteins. a knockin mouse of cys694arg has been created for further explorations of cmt2p mechanisms and therapeutic development. together, our findings suggest that the mutant lrsam1 may aberrantly affect the formation of transcription machinery. given a similar mechanism has been reported in motor neuron degeneration of amyotrophic lateral sclerosis, abnormalities of rna/rna-binding protein complex may play a role in the neuronal degeneration of cmt2p. supported by grants from ninds (r01ns066927) and the national center for advancing translational sciences (ul1tr000445). this double-blind, multicenter, parallel-group trial randomized (1:1) adult participants (n=106) with chronic inflammatory demyelinating polyradiculoneuropathy being treated with intravenous immunoglobulin (ivig) or corticosteroids to 0.5 mg fingolimod (n=54) or placebo (n=52) once-daily. previous treatment was discontinued (ivig) or tapered (corticosteroids). in the total trial population, there was no significant difference between the groups in the primary outcome, time-to-first confirmed worsening (≥1-point increase on the adjusted inflammatory neuropathy cause and treatment [incat] scale vs. baseline), or time-to-first any worsening (confirmed on incat assessment or unconfirmed). no significant difference between the two treatment groups was shown on secondary outcomes; change from baseline in grip strength and rasch-built overall disability scale (r-ods) at six months or trial end. analyses of pre-specified subgroups were performed for primary and secondary outcomes. this trial evaluated the efficacy and safety of fingolimod in chronic inflammatory demyelinating polyradiculoneuropathy (cidp). corticosteroids, intravenous immunoglobulin (ivig) and plasma exchange are recognized treatment options but no other immunomodulators demonstrated efficacy in a controlled trial. fingolimod has been shown to be efficacious and is approved for the treatment of relapsing multiple sclerosis. results from experimental autoimmune neuritis in rats suggested that it might show an effect in cidp. in this double-blind, multicenter, parallel-group trial, cidp participants receiving ivig or corticosteroids were randomized to once-daily fingolimod 0.5 mg or placebo (1:1). participants were stratified by inflammatory neuropathy cause and treatment disability (incat) scores and prior treatment. previous ivig treatment was discontinued after one final course before randomization. previous corticosteroid treatment was tapered over 8 weeks. the primary outcome was time-to-first confirmed worsening (≥1-point increase on the adjusted incat score versus baseline). secondary outcomes included change in grip strength and rasch-built overall disability scale (r-ods) score from baseline to month 6 and at trial end. the trial was stopped for futility by an independent data monitoring committee after a pre-planned interim analysis based on pre-specified criteria. in all, 54 participants received fingolimod (ivig: 41, corticosteroids: 13; age: 54.3±13.32 years [mean±standard deviation]; male: 68.5%); 52 received placebo (ivig: 41, corticosteroids: 11; age: 54.6±11.68 years; male: 57.7%). the percentage (95% confidence interval) of participants free from confirmed worsening at the trial end was not significantly different between fingolimod (41.5% [22.7%-60.3%]) and placebo (43.2% (27.7%-58.7%); p=0.91). in the first 45 days, approximately 20% participants experienced worsening. at trial end, approximately 40% participants had no worsening. there was no significant difference after six months or at the trial end (whichever occurred earlier) in the secondary endpoints. adverse events were reported in 41/54 and 44/52 participants in the fingolimod and placebo group, respectively. there were no deaths. nine participants in the fingolimod group and 4 in the placebo group had serious adverse events. adverse events leading to trial drug discontinuation occurred in 7 (13%) participants on fingolimod and none on placebo. no new safety signals emerged in this trial. acknowledgment: the authors consulted for or were employed by the study sponsor novartis pharma ag, basel, switzerland. myelin sheath enwraps non-nociceptive mechanoselective abeta-afferents transmitting touch/vibration sense. a prominent reduction in the mechanical stimulus required to evoke a withdrawal response in rodents, a phenomena interpreted as mechanical allodynia, arises due to peripheral nerve/myelin damage. evidence has emerged that nerve injury-induced mechanical allodynia depends on the adaptive immune/t cell activity in female but not male rodents. having previously demonstrated both the release of the cryptic 68-104 peptide regions of myelin basic protein (mbp68-104) following sciatic nerve chronic constriction injury (cci) and the direct, robust and t cell-dependent ability of the pure mbp68-104 peptides to induce mechanical allodynia after injection into the intact sciatic nerve, we hypothesized that mbp68-104 contributes to sexual dimorphism in mechanical allodynia. the pure mbp84-104 wild-type (wt), its histidine (his)89 mutant or scramble peptides were administered into an intact sciatic nerve fascicle in male and female rats or mice, followed by von frey testing. intra-sciatic mbp84-104-wt peptide induced robust and lasting allodynia in females. in contrast, males responded with a brief and mild decline in mechanical sensitivity for one day post-injection of both wildtype and control peptides. the algesic ability of mbp84-104-wt was diminished in the his89 mutant. we here present the molecular changes in the sciatic nerve, drg and the spinal cord after the intra-sciatic mbp84-104 injection in male and female animals. in addition, using the biotin-labeled mbp84-104 peptide and the hrp-labeled goat anti-rat igg/igm antibodies, we developed an elisa to quantitatively assess seropositivity for the specific anti-mbp84-104 peptide igm/igg autoantibodies in female and male rats post-cci. human serum from female patients with multiple sclerosis was used for control. our work corroborates the findings of sexual dimorphism of mechanical hyperpathia and suggests its potentially autoimmune nature in females. iijima m 1 , nishi r 1 , ikeda s 1 , kawagashira y 1 , koike h 1 , sobue g 1 , katsuno m 1 . 1 nagoya university, nagoya, japan. non-obesity diabetic (nod) b7-2 knockout (ko) mice are characterized by chronic and progressive neuritis and expected as models of immune-mediated neuropathies, especially cidp. hindlimb-predominant weakness due to inflammatory demyelination followed by axonal degeneration begins from around twenty week-age in all female mice until thirty week-age. to clarify the efficacy of immunoglobulins as immune-regulating therapeutics and the similarity of pathogenesis of human cidp, we injected intraperitoneally human-derived immunoglobulins (ipig, 20mg/mg bw/week) and saline as a control to totally forty female mice. clinical and pathological estimations in sciatic nerves were performed in time series. as a result, the ipig-treated group was protected from weight loss which could be related to axon loss followed by muscle atrophy as well as inflammatory demyelination between twenty-five week-age and thirty week-age compared to the control. in addition, the pathological findings in sciatic nerves showed that ipig apparently suppressed inflammatory infiltrates. about the subsets of inflammatory infiltrates, while macrophages (cd68+) and lymphocytes (cd4+) highly existed and suggested to play a main role in the neuritis until thirty week-age, only macrophages naturally disappeared after thirty week-age without any therapeutic induction. immunoglobulins effectively suppressed only macrophages although that did not suppress cd4+ lymphocytes. in conclusion, nod b7-2 ko mice respond to immunoglobulins in a similar manner to human cidp and this efficacy is due to the suppression of macrophage-dominant pathogenesis. therefore, macrophage-derived pathogenesis is for the main target of immunoglobulin therapy and we should focus on the lymphocyte-derived pathogenesis which might plays an important role in non-responders to immunoglobulins. ikeda s 1 , nishi r 1 , kawagashira y 1 , iijima m 1 , koike h 1 , katsuno m 1 , sobue g 1,2 . 1 department of neurology, nagoya university graduate school of medicine, nagoya, japan; 2 research division of dementia and neurodegenerative disease, nagoya university graduate school of medicine, nagoya, japan. chronic inflammatory demyelinating polyneuropathy (cidp) is an acquired immune-mediated polyradiculoneuropathy that is characterized by heterogeneous clinical manifestations. typical cidp is defined as neuropathy manifesting in a progressive manner, stepwise manner, or with recurrent symmetrical proximal and distal weakness and sensory impairment in all four limbs. although they occur at a lower proportion than the so-called typical cidp, atypical forms, such as multifocal acquired demyelinating sensory and motor (madsam), distal acquired demyelinating symmetric (dads), pure sensory, pure motor, and focal, are considered to cidp subtypes. thus far, pathological features characterizing each clinical subtype have not been fully elucidated. we analyzed clinical and pathological correlations in 114 consecutive cidp patients who underwent sural nerve biopsy and fulfilled the definite or probable efns/pns criteria. there were 64 male and 50 female patients. the age at biopsy was 58.1 ± 16.1 (mean ± sd) years, and the duration from the onset of neuropathy to biopsy was 27 ± 49 months. fifty-five percent (n = 63) of the patients were classified as having typical cidp. regarding atypical cidp, madsam (n = 15, 13%), dads (n = 18, 16%), and pure sensory (n = 16, 14%) subtypes were the major subtypes, while pure motor (n=1, 1%) and focal (n=1, 1%) subtypes were rare. no significant difference was found among these subtypes in terms of sex, age at biopsy, and disease duration. sural nerve biopsy specimens revealed that the densities of large myelinated fibers significantly decreased in the madsam subtype than in the other subtypes (p = 0.003). in addition, the variation in nerve fibers among fascicles was more conspicuous in the madsam subtype than in typical cidp (p=0.04). patients with the dads subtype tended to show the formation of onion-bulbs. in conclusion, pathological findings of sural nerve biopsy specimens were different among the cidp subtypes. further studies are needed to clarify mechanisms leading to different pathological features. small volume plasma exchange (svpe) can be an affordable and potentially effective alternative form of plasma exchange. svpe is the repeated removal of small volumes of supernatant plasma over several days via sedimentation of patient whole blood. the aim of this study is to assess the clinical feasibility and safety of svpe in patients with gbs in low-income countries. twenty adult patients with gbs diagnosed as per the criteria for gbs of the national institute of neurological and communicative disorders and stroke (ninds) were enrolled for svpe at a centre in bangladesh. serious adverse events (sae) were defined as the number of patients developing severe sepsis associated with the central venous catheter (cvc) or deep venous thrombosis in the limb where the cvc is placed for svpe. the svpe procedure was considered safe if less than 5 of 20 svpe-treated gbs patients have a sae, and feasible if eight litres of plasma could be removed in at least 15 of 20 svpe-treated gbs patients. among the 20 cases who received svpe, 13(65%) patients were male and the age range between 19 to 55 yrs. all the patients were quadriplegic and bedbound at enrolment for svpe with a median mrc score of 20 (iqr, 0-29). cranial nerve involvement, autonomic dysfunction and requirement for assisted ventilation were observed in 11(55%), 9(45%) and 3(15%) patients respectively. electro physiologically 15(75%) patients were motor axonal and 5(25%) patients were sensory-motor demyelinating type. during the svpe none of our patients experienced sae and one patient experienced central line associated blood stream infection. common adverse effects were transient intravenous fluid responsive hypotension during the svpe sessions in 10(50%), cv catheter insertion site hemorrhage in 10 (50%) and hypersensitivity reaction to fresh frozen plasma in 5(25%) patients. there was no hypo-albuminemia, anemia or electrolyte imbalance observed in most patients (95%) treated with svpe. improvement in one or more grade of the gbs disability score at four weeks after the onset of svpe was observed in 14(70%) patients. in conclusion svpe can be a safe, feasible and cost effective alternative to standard pe in the developing countries. guillain-barré syndrome (gbs) is a descriptive disease entity defined by a set of clinical, electrophysiological and laboratory criteria. various clinical phenotypes exist that may be triggered by different antecedent infectious events. although the disease appears to affect primarily the elderly in developed countries, but, scenario is different in developing countries. bangladesh has made an impressive progress towards the eradication of poliomyelitis, and no new cases have been reported since 2000. gbs, an acute polyradiculoneuropathy, is the most frequent cause of acute flaccid paralyis. the crude incidence rate of gbs in <15 years of age reported here appears to be 2.5× to 4× higher than that reported in the literature. we conducted a hospital based observational study including 600 patients fulfilling the national institute of neurological disorders and stroke (ninds) criteria for gbs patients between 2010 and 2016 in dhaka medical college hospital, dhaka, bangladesh. detailed clinical, electrophysiological, serologic and microbiological data were obtained. gbs affected predominantly in young adults males (m/f=2:1) living in rural areas. antecedent events were recorded in >70% of patients; frequent events being gastroenteritis (>40%) and upper respiratory tract infection (18%). more than 60% of the patients were bed-bound (gbs disability score 4) at entry and about 20% patients required mechanical ventilator. about 90% patients did not receive specific treatment either intravenous immunoglobulin (ivig) or plasmapheresis due to high expensive treatment cost. 13% patients had died during hospitalization. 60% of patients had an axonal variant of gbs and evidence for a recent c. jejuni infection (55%). c. jejuni infection was significantly associated with serum antibodies to the gangliosides gm1 and gd1a, axonal neuropathy, and greater disability. in conclusion, the majority of the patients do not receive standard treatment with ivig in view of its high price. therefore, we developed low-cost treatment strategies and conducted a safety and feasibility trials for small volume plasma exchange (svpe) on gbs patients in bangladesh. in future, it is essential to conduct a phase ii clinical trial to assess the efficacy of svpe for low-in-come countries. prognosis of guillain-barré syndrome (gbs) has not improved in last two decades. current therapies (intravenous immunoglobulin, ivig and plasma exchange, pe) had been proved to be effective on two third of patients in developed world. unpredictable and poorly understood clinical course of gbs hamper treatment development. in bangladesh, most patients affected by gbs cannot afford specific treatments with ivig or pe instead most of them receive only supportive care. therefore, we aimed to compare the outcome of ivig treated patients with supportive care patients in improvement of gbs disability score and mrc sum score by using world's largest gbs cohort in bangladesh. we conducted a prospective observational study enrolling 600 gbs patients between 2010 and 2016 from dhaka medical college hospital and national institute of neuroscience and hospital, dhaka, bangladesh. only 53 gbs patients (9%) received standard ivig treatment. in current analysis, 53 ivig treated patients and 53 age, sex and severity matched controls (supportive care only) were considered. outcome of both groups were compared using fisher's exact or chi square test and survival analysis were performed by kaplan meier method using log rank test. among 106 patients (cases and controls), male/female (62/44), median age 19 years, 60% patients were bed-bound, one-fourth patients required mechanical ventilation and 63% were axonal. we did not found any significant differences of treatment outcome in both cases and control groups in gbs disability score (week 4: p=0.82, 6 months: p=0.84) and mrc sum score (week 4: p=0.71, 6 months: p=0.86). survival analysis revealed, the differences of time required for independent locomotion, improvement of one gbs disability score and improvement of mrc score were not statistically significant between treatments (ivig) and supportive care patients. in conclusion, our analysis showed that standard dose of ivig use has no considerable advantage to improve specific outcome measures among gbs patients in bangladesh. as the phenotype of gbs in bangladesh is different from developed world; therefore, an efficacy trial for ivig is needed for developing countries like bangladesh or new targeted therapeutic strategies can append beneficial effects for gbs patients. isose s 1,2 , watanabe k 1 , omori s 1 , sekiguchi y 1 , beppu m 1 , shibuya k 1 , amino h 1 , suichi t 1 , misawa s 1 , kuwabara s 1 . 1 graduate school of medicine, chiba university, chiba, japan; 2 national hospital organization chiba east national hospital, chiba, japan. diabetic neuropathy is a frequent cause of neuropathic pain, suggesting the small-fiber involvement. additionally, persistent peripheral pain-related inputs could cause neuronal hyperexcitability and complex interactions of the nociceptive pathways, i.e., central sensitization. to investigate the pathophysiology of neuropathic pain in diabetic neuropathy, we studied pain-related evoked potentials (preps) after selective intraepidermal electrical stimulation (ies) to a-deltaand c-fibers in diabetes patients with neuropathic pain (n=24) and without neuropathic pain (n=20). we also conducted a longitudinal study to assess changes in preps and pain profiles in patients with neuropathic pain 3 months after the start of treatment with duloxetine. this study is registered with the umin clinical trials registry, umin000017130. ies was applied in the hand and foot, and preps were recorded from the cz electrode referenced to the linked earlobes. we evaluated prep latencies, amplitudes, and amplitude ratios of preps after c/a-delta -fiber stimulation. in the conventional nerve conduction studies, patients with neuropathic pain significantly showed conduction slowing and decreased snap amplitudes in the median and sural nerves compared with those in patients without neuropathic pain. in pain-related sep studies, there were no significant differences in prep amplitudes and latencies after a-delta -or cfiber stimulation between the patients with neuropathic pain and without it. prep amplitude ratios after c/a-delta -fiber stimulation tended to increase in patients with neuropathic pain compared to patients without pain. after the treatment with duloxetine, c/a-delta -prep amplitude ratios were significantly decreased after both hand and foot stimulation, and as for numerical rating scale (nrs) scores as the intensity of pain. patients with less pain relief showed the tendency of higher c/a-delta prep amplitude ratios before treatment compared to patients with better pain relief. the correlation between reduction of c/a-delta prep amplitude ratios and nrs reduction did not reach statistical significance. this pain-related sep study demonstrated that abnormal cortical response in patients with neuropathic pain could improve after the treatment with duloxetine, this might reflect the cortical hyperexcitability as a central sensitization. this study is funded by shionogi & co., ltd. the sponsors played no role in the design and management of the study, collection and analysis of data, interpretation of the results, or the writing of the writing of the report. peripheral nerve injury is commonly associated with traumatic injury which is often amenable to surgery. despite improved methods in surgical repair, functional recovery remains a challenging clinical problem that often leads to significant morbidity in patients. alternative therapies that could augment surgical repair may be beneficial in functional outcomes. neuroinflammation is a complex pathway with different cellular components and cytokines that are activated following peripheral nerve injury. macrophages are responsible for the breakdown of debris following injury as well as promotion of regenerative signals. macrophage polarization is the process by which macrophages take on phenotypically distinct functions based on the local environment and signaling cues. exercise has been shown to drive macrophage polarization from a pro-inflammatory m1 phenotype towards an anti-inflammatory m2 phenotype in numerous tissues, but remains uninvestigated in the peripheral nervous system. the purpose of our study was to identify how exercise affects macrophage polarization, motor and sensory function, and neuroregeneration following sciatic nerve crush. c57bl/6 mice underwent sciatic nerve crush injury and were then given access to running wheels (exercised) or not given access to running wheels (sedentary) for 4 weeks. exercised mice ran an average of 2.9 km per night. injured exercised mice were protected from the development of thermal hyperalgesia when compared to injured sedentary mice. exercised mice had fewer paw slips on beam walk testing compared to sedentary mice. no differences were measured in mechanical sensitivity or motor coordination and balance assessed by rotarod. while motor nerve conduction velocities were significantly reduced for injured mice compared to uninjured controls, motor nerve conduction velocities from injured exercised animals were significantly higher than injured sedentary animals suggesting improved nerve recovery with exercise. injured sciatic nerves from exercised mice demonstrated increased m2 macrophages compared to sciatic nerves from injured sedentary mice. the behavioral changes and altered macrophage polarization correlated with increased epidermal nerve fiber density, improved myelination, and increased in vitro neurite outgrowth from injured exercised animals. therefore, exercise alters macrophage polarization towards an anti-inflammatory phenotype which improves repair and recovery of the injured peripheral nerve. jack mm 1 , shah k 1 , everist b 1 , reyna j 1 , hylton p 1 . 1 university of kansas medical center, kansas city, ks, usa. diffusion tensor imaging (dti) has long been used to evaluate the location and integrity of white matter tracts in the brain. dti uses quantitative data and directionality of water diffusion to determine axonal connectivity of the nervous system. the technology has only recently been utilized in limited settings in the peripheral nervous system due to challenging technical factors and lack of widespread availability. magnetic resonance (mr) neurography or peripheral neurography is a technique which uses diffusion to differentiate between intraneural and perineural tissues. it allows for fascicle patterns to be visualized particularly in the setting of peripheral nerve sheath tumors. peripheral nerve sheath tumors of various pathologies cause surrounding nerves to be involved or displaced in a range of directions. this technique helps determine the anatomic location of these nerve fibers in relation to the mass, which is particularly helpful at distinguishing neuromas from schwannomas. this data is invaluable to the surgeon to ensure a safe and low morbidity operation. while this technology has benefit particularly with surgical planning, it has been underutilized due to the challenges of requiring complex software to produce fiber tracks and the inability to translate these images into the operating room. here, we utilized brainlab software that is commonly available and utilized in surgical suites to produce images of the radial nerve fiber tracts with an associated peripheral nerve sheath tumor prior to surgical resection. while the software is commonly used in the central nervous system, it has not been reported to have been used in the peripheral nervous system. this software offers a high usability and produces anatomically correct and reliable fiber tracts. this technique overcomes the reliance on highly specialized software and extensive training required for use that most other tractography software has. utilizing peripheral neurography in this case allowed for complete surgical resection without postoperative deficits. this data offers clinicians an option to investigate peripheral nerve fibers in various pathologic states, to plan appropriate operative trajectories to peripheral nerve pathology, and to improve surgical outcomes for patients with peripheral nerve sheath tumors. jacobsen b 1 , parry g 2 , allen j 2 , walk d 2 , muley s 1 , ortega e 1 . 1 barrow neurological institute, phoenix, az, usa; 2 university of minnesota, minneapolis, mn, usa. chronic inflammatory demyelinating polyneuropathy (cidp) is an immune mediated neuropathy that is responsive to immunomodulatory agents such as glucocorticoids, intravenous immunoglobulin (ivig) and plasma exchange (pe). the specific immunopathogenic mechanisms of cidp remain unclear but there is increasing interest in nodal proteins as a site of the immune attack. even though the majority of patients respond to one of the aforementioned immunomodulatory agents there are some who are unresponsive or incompletely responsive to these first line agents and other more aggressive treatments may be necessary. cyclophosphamide and stem cell transplantation may be effective but are associated with considerable morbidity. anecdotal reports suggest that rituximab may be beneficial for some patients that fail first-line therapy, especially if they have antibodies to nodal proteins. we present four patients with intractable cidp who responded to rituximab. one of the three patients had diabetes. disease duration prior to starting rituxan was short (4 months) in two patients and longer 24 and 27 months in the other two. all patients had failed treatment with glucocorticoids and ivig, and in two, plasma exchange and ivig-pe were also ineffective. two of the four patients were quadriparetic and non-ambulatory. two 1 gm doses two weeks apart of intravenous rituximab were instituted in all patients. all patient tolerated the treatments well without adverse effects. all patients responded within four weeks and continued to improve at six months. other immunomodulatory agents were successfully tapered but not totally discontinued. it remains unclear whether antibodies to nodal proteins were present in these patients. in conclusion, although rituximab efficacy remains uncertain on the basis of randomized controlled clinical trials, it may be beneficial in selected patients otherwise intractable to first-line treatments. further studies are necessary to better understand which patients may benefit most from rituximab and where in the treatment algorithm rituximab should be applied. neuropathic pain is a chronic condition seen in patients suffering a direct injury to the peripheral or central nervous system or an indirect injury due to, e.g., diabetes or multiple sclerosis. current treatment options fall short of preventing or completely relieving patients of their pain. for years, research has focused on understanding the role of neurons in neuropathic pain pathogenesis while overlooking the role of supportive cells in general and satellite glial cells (sgcs) in the dorsal root ganglion in particular. these cells not only buffer the neuronal microenvironment they are also involved in controlling the electrical activity flowing through the neurons and in neuropathic pain pathogenesis. the aim of this project is to understand the role of sgcs in neuropathic pain development and thereby aid the identification of new drug targets. to purify the sgcs from adult mice we optimized a fluorescently activated cell sorting (facs) protocol. the success of our purification method was confirmed using qrt-pcr and visual inspection of the sorted cells. finally, we are running rna sequencing on sgcs after peripheral nerve injury to compare their transcriptome to that of uninjured cells at different time points. the results from our study are likely to deepen our understanding of how sgcs contribute to the development and maintenance of neuropathic pain. guillain-barrésyndrome (gbs) is an immunemediated disorder in the peripheral nervous system (pns) triggered by molecular mimicry against nerve gangliosides. one of the cell surface receptors (fas)-ligand (fasl) interaction transmits apoptotic signal to eliminate the auto-reactive b and t-cells, which generates cross-reactive antibody against nerve cells. host genetic polymorphism of fas and fasl may alter their expression and induce aberrant apoptotic response to develop gbs. therefore, we determined the single nucleotide polymorphisms (snps) of both fas receptor (−1377g/a and -670a/g) and fasl ligand (−843c/t) in gbs patients (n=100) as well as healthy controls (n=97) using the lightcycler technique. serum level of soluble form of fas and fasl was measured using commercially available sandwich elisa kit. comparison of genotype, allele and haplotype frequencies was done with the gbs subgroups based on the clinical and serological data. ag heterozygote (p=0.0494, or=2.5, 95% ci=1.03-6.1) and polymorphic g-allele (p=0.0387, or=1.9, 95% ci=1.1-3.5) of fas receptor -670a/g promoter snps were significantly associated with anti-ganglioside (gm1) antibody positive gbs patients. in addition, −670g-allele (p=0.02, or=4.8, 95% ci=1.3-17.4) and -1377g/-670g haplotype (p=0.0251, or=4.833, 95% ci=1.3-18.04) were predominantly associated with the axonal variant of gbs patients. serum soluble form of sfas (median levels 259 pg/ml vs. 221 pg/ml, p=0.0373) and sfasl (median levels 260 pg/ml vs. 202 pg/ml, p=0.0528) were found to be elevated in anti-gm1 antibody positive gbs patients compared to anti-gm1 negative patients. no significant association was found in genotypic distribution between gbs patients and healthy controls. in conclusion, fas/fasl promoter snps are not a susceptible factor for gbs but could be one of the influencing factors to develop cross-reactive anti-ganglioside antibodies in gbs patients in bangladesh. furthermore, functional studies with a larger sample size (using cohort like international gbs outcome studies-igos) are required to explain the immune pathogenic role of these snps for gbs patients. jang sy 1 , yoon ba 1 , shin yk 1 , yun sh 1 , jo yr 1 , park ji 1 , shin kj 2 , kim jk 1 , park ht 1 . 1 dong-a university, busan, south korea; 2 inje university, busan, south korea. myelination is essential for the proper function of the nervous system. schwann cells, which form the peripheral myelin sheath, have the unique ability to dedifferentiate and to destroy the myelin sheath under various demyelination conditions. during schwann cell dedifferentiation-associated demyelination in wallerian degeneration after axonal injury, schwann cells exhibit myelin and junctional instability, down-regulation of myelin gene expression and autophagic myelin decomposition. however, in inflammatory demyelinating neuropathy, it is still unclear how schwann cells react and contribute to segmental demyelination before myelin scavengers, macrophages, are activated for myelin clearance. here, we show that schwann cell dedifferentiation-associated demyelination is a mechanism involved in the initial demyelination observed in a mouse model of inflammatory demyelinating neuropathy using ultrastructural, biochemical and microarray analyses. myelin uncompaction and myelin membrane instability generated by dedifferentiated schwann cells lead to autophagolysosome-dependent cytoplasmic amputation between the axon-containing myelin sheath and the schwann cell body, resulting in the formation of the "myelin corpse", thereby allowing macrophages to phagocytose the myelin corpse in the end stage of segmental demyelination. we found myelin corpse formation in inflammatory demyelination to be a process similar to the myelin rejection during wallerian degeneration, which appeared to be dependent on schwann cell autophagolysosome activation since schwann cell-specific atg7 knockout mice exhibited delayed myelin rejection following nerve injury. finally, lysosome inhibition in schwann cells not only prevented segmental demyelination but also delayed the progression of clinical stages by suppressing the myelin corpse formation in inflammatory demyelinating neuropathy. thus, our findings indicate that demyelination by schwann cells and macrophages might be part of a process that includes sequential divisions of labor with respect to myelin rejection and digestion, respectively. in conjunction with previous studies showing schwann cell dedifferentiation and autophagy in toxic and hereditary neuropathies, the concept of "schwann cell dedifferentiation-associated demyelination" provides insight into the development of possible therapeutic strategies to prevent schwann cell demyelination in peripheral demyelinating neuropathies. methods: electrophysiological data, the charcot marie tooth exam score (cmtes), and bmi from 112 patients with known cmt1a were obtained and analyzed. results: when controlled for age, bmi does not affect studies of ulnar motor nerve conduction in ctm1a patients, but rather specific components of the cmt exam scores (cmtes, loss of pinprick sensation and motor strength in the lower extremities). discussion: bmi and clinical components of the cmtes are correlated, but it is uncertain which is the primary effect -i.e., whether the reductions in pinprick sensation and motor strength in the lower extremities lead to a higher bmi, or higher bmi results in these signs. introduction: charcot-marie-tooth disease type 1 c (cmt1c) is a rare, dominantly inherited neuropathy caused by mutations in the lipopolysaccharide-induced tumor necrosis factor (litaf) or small integral membrane protein of the lysosome/late endosome (simple) gene. methods: we present a case series comprised of 10 patients in whom cmt1c is caused by a gly112ser substitution in the encoded protein. we focus on clinical presentation, electrodiagnostic analyses, and our findings in the context of previously described cases. results: the gly112ser mutation causing cmt1c is a mild form of cmt, as patients walked on time, had less weakness than those with charcot-marie-tooth disease type 1a (cmt1a), had a charcot marie tooth neuropathy score (cmtns) indicative of mild disease, and had faster ulnar and median motor nerve conduction velocities compared to those with cmt1a. discussion: the g112s mutation in litaf seems to be clinically indistinguishable from a mild presentation of cmt1a. jha mk 1 , russell k 1 , lee y 1 , rothstein jd 1 , morrison bm 1 . 1 johns hopkins university, baltimore, md, usa. peripheral nerves are highly dependent on metabolic energy to maintain both basic cellular functions such as axon transport, na+/k+ ion gradients, and myelination, as well as to support regeneration following injury. though glucose certainly provides some metabolic support, our recent studies have shown that monocarboxylates, such as lactate, pyruvate, and ketone bodies, also contribute to recovery from peripheral nerve injury. monocarboxylate transporters, particularly mct1, are the predominate transporters for monocarboxylates in the peripheral nerve. in a recent publication, we found that mct1 heterozygous null mice, which express 50% less mct1 in all cells, have slowed nerve regeneration and reduced myelination following sciatic nerve crush. this study was limited by the global reduction of mct1, which is widely expressed in schwann cells (sc), dorsal root ganglia (drg) neurons, endothelial cells, macrophages, and perineurial cells within the regenerating peripheral nerve. to better understand the mechanism by which mct1 contributes to normal nerve function and nerve regeneration, we produced and validated conditional mct1 null (mct1loxp) mice that allow selective deletion of mct1 from scs, drg neurons, endothelial cells, or macrophages through mating to cell-specific cre lines. we are currently quantifying peripheral nerve development, aging, and regeneration in each of these mouse lines. following sc-, but not drg-, specific mct1 knockdown, sensory peripheral nerves develop demyelination by 4 months of age, manifest by reduced myelin thickness, increased g-ratio, and reduced conduction velocity. studies are ongoing in cultured scs to determine the mechanism for demyelination. neither sc nor drg knockdown of mct1 impairs nerve regeneration following sciatic nerve crush. these results suggest that sc-specific mct1 is critical for maintaining myelin in sensory, but not motor, peripheral nerves as they age. they also suggest that mct1 expression in peripheral nerve cell types, other than sc and drg, is important for nerve regeneration. ongoing studies are determining the contribution of mct1 in other peripheral nerve cell types, particularly endothelial cells and macrophages, to normal development and regeneration following injury. our results will clarify the role of lactate and its transporter, mct1, in peripheral nerve function, potentially suggesting novel targets for demyelinating neuropathies or nerve injuries. small fiber neuropathy (sfn) is a condition in which the smallest nerve fibers are affected, characterized by neuropathic pain and autonomic dysfunction. according to international criteria, sfn diagnosis is based on clinical symptoms in combination with abnormal temperature threshold testing (ttt) and/or reduced intraepidermal nerve fiber density (ienfd) in skin biopsy. skin biopsy is moderately sensitive, invasive and the process is time consuming and expensive. ttt is a widely available diagnostic tool, but lacks specificity. previous studies introduced stimulated skin wrinkling (ssw) as an objective, non-invasive diagnostic tool to detect sympathetic nerve dysfunction in sfn by means of a categorical assessment. however, our unpublished data has shown that inter-observer reliability of categorically assessed ssw is quite low. in this current study we will use a new digital method for ssw quantification: the digit wrinkle scan© (dws©). the primary study objective is to define normative values for dws© expressed as total wrinkle length per fingertip surface (mm/mm 2 ). subsequently we investigate the applicability of dws© in patients with definite sfn, based on abnormal iefnd and/or ttt, determining the dws© sensitivity and specificity, as well as its validity. for this cross-sectional study, we will include 60 healthy participants and 200 patients diagnosed with sfn. eligibility is based on meeting the inclusion and exclusion criteria and providing written informed consent. skin wrinkling is induced by emla (eutectic mixture of local anesthetics) cream© application and captured by taking pictures. the primary outcome measure is total length of wrinkles per mm2 as shown on the photographs, which will be calculated by a new software program. patients are stratified according to age and gender. based on the results of healthy participants, normative values will be defined. inter-and intra-observer reliability will be determined. in the sfn group, additional correlation analysis will be conducted to determine the correlation between dws© and different outcome measures (sfn-symptom inventory questionnaire, visual analogue pain scale, neuropathic pain scale, sfn-rasch-built overall disability scale, ienfd and ttt). we expect to provide digitally quantified ssw (dssw©) normative values that can be used in clinical practice in the diagnostic workup for sfn. cmt2, characterized by axonal degeneration, is an inherited motor and sensory neuropathy accounting for about 20% of total cmt patients. the cmt2 subtype shows on its own, a vast genetic heterogeneity with more than 140 mutations in 26 known genes rendering the identification of relevant drug targets and therapies very challenging. so far, only hdac inhibitors have shown promising results in mouse models for hspb1 mediated axonal cmt (cmt2f), albeit such a single gene approach may have a limited relevance at clinical levels owing to the limited number of patients per genotype. in this study, we investigated common causative molecular players of cmt2 associated axonal degeneration. for this, an itraq based proteome analysis was performed on five patient's derived lymphoblasts bearing different cmt2 causal mutations alongwith respective age and gender matched unaffected controls. software-assisted interpretations of the obtained data led us to identify two proteins which were significantly downregulated in cmt2 patients compared to controls. these two proteins were then validated using western blotting and qpcr on patient derived lymphoblasts and fibroblasts. our results prompted us to unveil whether these two proteins can be used as potential biomarkers for identifying cmt2 patients. therefore, through a europe-wide collaboration, we constructed a cohort of 43 cmt2 patients and 21 healthy controls. these two proteins exhibited significant downregulation in this cohort suggesting a potential new role of these proteins as cmt2 biomarkers. remarkably, we were also able to validate the significant decrease in ineurons (neurons differentiated from patient derived ipscs) strengthening the importance of our finding and also suggesting the relevance of these proteins in the pathogensis of axonal cmt. this will be the first study involving multiple cmt causal genes at once, thereby holding the potential to offer new drug targets and potential biomarkers with wider application both clinically and pharmaceutically. mesenchymal stem cells (mscs) represents a valuable source of stem cell therapy, can differentiate into various cell types. we investigated of the neuromuscular potential of human tonsil-derived mscs (t-mscs) for neuromuscular regeneration in trembler-j mice that is considered to be a model for charcot-marie-tooth disease type 1a (cmt1a diseases), which is involving hereditary motor and sensory peripheral neuropathies. the t-mscs differentiated toward skeletal myocytes, as evidenced by increased expression of skeletal muscle-related markers (including troponin i type 1, and myogenin) and the formation of myotubes in vitro. in situ transplantation of t-msc-derived myocytes (t-myocytes) into gastrocnemius in trembler-j mice, a mouse model of cmt1a, enhanced motor function, as identified with recovery by a compound muscle action potential (cmap) amplitude. and the regenerated shape of the sciatic nerve and skeletal muscle by immunochemistry, without the formation of teratomas. furthermore, the expression levels of nerve growth factor (ngf) and glial cell line-derived neurotrophic factor (gdnf) were significantly increased in t-myocyte compared with t-mscs in vitro. these results indicate that the transplantation of t-myocyte can be a therapeutic option of cell therapy for the neuromuscular regeneration in hereditary peripheral neuropathy, comprising cmt1a disease. kagiava a 1 , karaiskos c 1 , richter j 2 , tryfonos c 2 , lapathitis g 1 , sargiannidou i 1 , christodoulou c 2 , kleopa ka 1,3 . 1 neuroscience laboratory, the cyprus institute of neurology and genetics, nicosia, cyprus; 2 department of molecular virology, the cyprus institute of neurology and genetics, nicosia, cyprus; 3 neurology clinics, cyprus school of molecular medicine, the cyprus institute of neurology and genetics, nicosia, cyprus. x-linked charcot-marie-tooth disease (cmt1x) is a common form of inherited demyelinating peripheral neuropathy resulting from mutations affecting the gap junction protein connexin32 (cx32). using a cx32 knockout (ko) mouse model of the disease, we have shown that targeted expression of virally delivered cx32 results in morphological and functional improvement. since patients with cmt1x express mutant forms of cx32 in schwann cells, that could potentially interact with virally delivered wild type (wt) cx32 through dominant-negative effects, we also treated mutant mice expressing the t55i, r75w and n175d mutations associated with cmt1x on a cx32 ko background. all three mutants were localized in the perinuclear compartment of myelinating schwann cells consistent with retention in the er (t55i) or golgi (r75w, n175d) with loss of physiological expression in non-compact myelin areas. following intrathecal delivery of the human gjb1 gene we could detect the virally delivered wt cx32 correctly localized in the non-compact myelin areas only in t55i/cx32ko mutant mice, but not in the other two mutants, suggesting dominant effects of the r75w and n175d mutant but not of the t55i mutant. gjb1 treated t55i/cx32 ko mice showed improved motor performance, along with lower ratios of abnormally myelinated fibers and reduced numbers of inflammatory cells in all tissues examined compared to mock-treated animals. in contrast, gjb1 treated r75w and n175d mutant mice showed only slight but not statistically significant improvement. this study provides additional proof of principle for a clinically translatable gene therapy to treat cmt1x even in the presence of endogenously expressed cx32 mutants, since at least one er-retained cx32 mutant did not interfere with the expression of virally delivered cx32 allowing a therapeutic benefit similar to cx32 ko mice. however, golgi-retained mutants may interfere with virally delivered wt cx32 and other approaches besides gene addition may be needed for effective treatment. funding: muscular dystrophy association (grant mda 277250 to kak). kaida k 1 , kadoya m 1 , koike h 2 , iijima m 2 , takazaki h 1 , ogata h 3 , moriguchi k 1 , shimizu j 4 , nagata e 5 , takizawa s 5 , chiba a 6 , yamasaki r 3 , kira j-i 3 , sobue g 2 , ikewaki k 1 . 1 national defense medical college, tokorozawa, japan; 2 nagoya university graduate school of medicine, nagoya, japan; 3 kyushu university, fukuoka, japan; 4 university of tokyo, tokyo, japan; 5 tokai university school of medicine, isehara, japan; 6 kyorin university, tokyo, japan. antibodies to a glial protein, neurofascin (nf)155 have recently been identified in approximately 10% of patients with chronic inflammatory demyelinating polyneuropathy (cidp), which are igg4-predominant. igg4 anti-nf155-associated cidp may be a distinct subtype from typical cidp in terms of clinical features and response to immunotherapy. however, a diagnostic criterion of anti-nf155-associated cidp has not established yet. to develop optimal criteria and design the best treatment plan for the anti-nf155-associated cidp, procedures for determining anti-nf155 antibodies should be simplified, prevalent, and reproducible, as well as being accurate. cell-based assay (cba) has hitherto been utilized for determining antibodies to nf155 in sera from patients, results of which have been confirmed by immunohistochemistry (ihc) using teased nerve fibers from rodents. these methods are the most reliable techniques, while not necessarily easy-to-use and easy to maintain in most laboratories. in the present study, we aimed to validate the diagnostic utility of a conventional enzyme-linked immunosorbent assay (elisa) for determination of anti-nf155 antibodies and the igg subclass. sera from 191 patients with efns/pns criteria-met cidp were examined with elisa using human recombinant nf155. to verify elisa results, ihc on rat sciatic nerves, western blot (wb) and cba using nf155-transfected and naive hek293 cells were conducted. the human nf155-based elisa clearly distinguished between anti-nf155 antibody-positive and -negative sera. fifteen cidp patients (8%) were igg4 anti-nf155 antibody-positive, which were confirmed by wb, ihc and cba studies. none of disease controls or healthy subjects had positive results. twenty-five sera randomly selected from 176 anti-nf155-negative cidp sera were also negative on cba. the anti-nf155 activities on elisa were significantly positively-correlated with those on cba (p < 0.01). analyses of clinical and laboratory findings showed that anti-nf155-associated cidp was characterized by younger onset, distal dominant phenotype, tremor, sensory ataxia, higher protein levels in cerebrospinal fluid, and poor response to ivig, which were consistent with those in previous studies. this elisa combined with determination of the igg4 subclass is a simple and reliable method for initial screening for anti-nf155 antibodies. the genetic abnormality responsible for x-linked charcot-marie-toothy neuropathy subtype cmtx3 was recently identified by whole genome sequencing to be a 78 kb insertion into chromosome xq27.1. the clinical profile of cmtx3 in childhood is not well described. we reviewed the clinical characteristics, neurophysiological profile and cmt pediatric scale (cmtpeds) assessments of 11 children with genetically confirmed cmtx3. cmtx3 was characterized by early onset, and early and progressive hand weakness. most affected children were symptomatic within the first two years of life. the most common presentation was with equinovarus foot deformity in the first year of life. cmtpeds analysis in these children revealed that cmtx3 progressed more rapidly (4.3 ± 4.1 points/2 year, n=7) than cmt1a and cmtx1. grip strength in the second decade of life in most affected males was two standard deviations below age-and sex-matched normative reference values. the most severely affected individual was wheelchair bound at 14 years of age and two individuals had no movement in the small muscles of the hand in the second decade of life. there was only a single symptomatic female identified and she had mild signs. nerve conduction studies showed a demyelinating sensorimotor neuropathy with motor conduction velocity in eight children while one child had a length-dependent sensorimotor axonal neuropathy. understanding the unique phenotype of cmtx3 is essential for directing genetic testing, as the cmtx3 insertion will not be detected on the snp microarrays, multi-gene panels or whole-exome sequencing currently used for the diagnosis of cmt. the early onset of disease coupled with rapid progression means that many children with cmtx3 will have severe disability within the first two decades of life and hence early diagnosis is needed for early commencement of rehabilitation. kapoor m 1 , catania s 2 , sarri-gonzales s 1 , lunn mp 1 , manji h 1 , reilly mm 1 , carr as 1 . 1 centre for neuromuscular diseases, national hospital for neurology and neurosurgery, london, uk; 2 department of neurophysiology, national hospital for neurology and neurosurgery, london, uk. the conventional dosing of ivig in cidp and mmn is based on treatment trials that used bolus and maintenance dosing of ivig between 1-2.5g/kg. there are rare published articles reporting the efficacy of higher maintenance ivig doses. we present three cases of inflammatory neuropathies, who are currently stabilized on ivig doses of 2mg-8mg/kg of ivig per month, refractory to standard dose ivig and other immunosuppressants. the first case is a 35 year-old-lady with cidp who presented with 3 episodes of ascending sensory disturbance, weakness, and diplopia. she had activity related fluctuations and pre-dose deterioration on 2g/kg/month ivig. she then had an acute deterioration with mrc sum score dropping from 70 to 49 even with additional plasma exchange. her bilateral foot drop (mrc grade 2-3) and fluctuations persisted with an increase of ivig to 4.6g/kg/month. she is now clinically stable (ankle dorsiflexion mrc grade 4-5, mrc sum score 67) on mycophenolate and 80g ivig weekly (5.3g/kg/month). case 2 is a 45-year-old male fitness instructor with mmn and sjogren's syndrome. he presented with recurrent proximal and distal weakness that responded to 2g/kg of ivig and deteriorated with iv methylprednisolone. he had peri-dose fluctuations, intermitted proximal weakness, and persistent foot drop (ankle dorsiflexion mrc grade 2-3) at 2.83mg/kg/month, worsening to mrc grade 1-2 on 4.33g/kg/month and fluctuating between mrc grade 0-3 on 5.7g/kg/month. an increase of ivig to 180g weekly (8.52g/kg/month), has resulted in mmn rods scores of 50/50, improved distal power and return to full capacity at work. case 3 is a 52-year-old man with predominantly upper limb cidp. he received 2g/kg ivig without any benefit, had no response to 2 doses of plasma exchange, 10 doses of cyclophosphamide or 1 dose of rituximab between 2010 and 2012. since 2013, he has received 2g/kg/month ivig with improvement of mrc sum score from 50 to 68. these cases highlight that some patients require a much higher than conventionally prescribed dose of ivig, and that these doses are tolerated over years without serious adverse events. idiopathic rapid eye movement sleep behaviour disorder (irbd) has been identified as a precursor of alpha-synucleinopathies, such as parkinson's disease, dementia with lewy bodies, multiple system atrophy. several studies linked changes in cutaneous innervation with central nervous system pathology in neurodegenerative disorders. recently small fiber neuropathy and alpha-synuclein deposition in the skin found to be a potential biomarker in parkinson's disease. we evaluated the epidermal innervation of 18 irbd patients and 22 age and sex-matched controls from skin punch biopsies from the distal leg using pgp9.5 immunohistochemistry. furthermore, a battery of clinical examinations were performed on patients and controls alike, including structured interviews, clinical motor and non-motor questionnaires and rating scales (e.g. unified parkinson's disease rating scale [updrs], non-motor symptoms questionnaire [nms-quest] and beck depression inventory, epworth sleepiness scale, evaluation of cognitive and olfactory functioning as well as blood samples. irbd patients, compared to controls, showed a significant reduction in intraepidermal nerve fiber density (p = 0.037), whereas the axon swelling ratio, did not differ between groups. patients with irbd reported non-motor symptoms more frequently than controls (updrs i, nms-quest). olfaction and daytime sleepiness differed between both groups, whereas there were no differences regarding cognition. these in vivo findings demonstrate small fiber neuropathy in irbd patients that are associated with non-motor symptoms indicating that peripheral abnormalities may occur early in irbd. they warrant larger scale longitudinal studies in order to investigate their prognostic value. katz j 1 , lewis r 2 , spatafora d 3 . 1 california pacific med center, san francisco, usa; 2 cedars-sinai medical center, los angeles, usa; 3 neuropathy action foundation (naf), santa ana, usa. multifocal motor neuropathy (mmn) is a rare condition that affects 0.6 in every 100,000 individuals worldwide and is associated with motor dysfunction and moderate to severe disability. the neuropathy action foundation conducted a global survey to determine the impact of mmn on patient quality of life (qol) and gaps in patient/provider educational needs. the first global mmn qol survey was an 87 item internet questionnaire available between january 21 and july 21, 2016. the survey focused on three primary areas: timely and accurate diagnosis, the efficacy of treatment, and the impact of the disease on patients qol. the survey was completed by 214 patients from 24 countries. the majority of respondents said they were diagnosed between the ages of 41 and 65 years (56.52%), more than 67% reported that it took more than one year to be diagnosed and more than 44% reported that it took 2-3 years or longer to be accurately diagnosed. with respect to treatment options : 91.43% reported receiving intravenous immune globulin and 8.57% reported receiving subcutaneous immune globulin therapy. other therapies being used to treat mmn were gabapentin (6.6%), and pregabalin (5%). almost half (49.49%) said that mmn often impacts their overall schedule. half of the participants reported that mmn often or always interferes with their employment; 46% had difficulty typing on a computer or using a telephone, 46.19% had trouble concentrating, and 38.07% said they had to work really hard to pay attention or else they would make a mistake. this is the first assessment of mmn from a patient's perspective. the survey highlighted critical issues relating to the diagnosis, management, and impact on the qol of individuals with mmn. the data also identified gaps and insights in provider education relating to proper diagnoses and management of the condition from a patient's perspective. katz j 1 , levine t 2 , dimachke m 3 , barohn r 3 . 1 forbes norris center, san francisco, ca, usa; 2 phoenix neurological institute, phoenix, az, usa; 3 kansas university medical center, kansas city, ks, usa. in the united states, cidp cases are submitted to insurance companies to determine whether ivig therapy is appropriate. this is done using specified diagnostic criteria, which reduce diagnosis to a boolean analysis, where a disease can only be present or absent. this leaves no room for uncertainty, even when it truly exists. boolean criteria are useful for clinical trials, but fall short where real decisions are made under uncertainty and based on perceived cost/benefit analysis. this project attempts to elucidate root causes of uncertainty and to find solutions to this dilemma. we asked 8 cidp experts to select a single diagnosis in 29 cases where ivig was approved using the submitted case records. while there was agreement on many cases, in the five most "uncertain" cases no more than 4 reviewers agreed on a single condition, who chose up to four separate entities. among these, at least three reviewers diagnosed an immune neuropathy in all five. the root cause of the disagreement, to a large degree was unclear documentation (aunts) which consisted of pasted, missing, and disorganized data. reviewers missed useful information, admitting it was too difficult to fully parse records. to resolve uncertainty, reviewers admitted to discounting certain reported datum to help fit the entity they suspected, such as reported therapeutic responses or certain electrodiagnostic/exam findings. other disagreement, however, reflected the complexity of neuropathy diagnosis, such as knowing if improvement was due to natural history or treatment, unawareness of rare presentations, or analyzing a true uncle (complex case). reviewers used bayesian (select most likely diagnoses from a list) and fuzzy logic (compare best fits to base cases). when the "best" diagnosis did not fit the base case, they had to re-interpret the data. improving review procedures requires eliminating aunts by collecting all key information and simplifying how records are presented. it also needs more advanced data methods to analyze common and rare borderline presentations (uncles like mama v pma, cidp v cspn, etc..), developing diagnostic algorithms that address real uncertainty, educating prescribers and patients on process, and creating systems that measure outcomes longitudinally after induction or tapering of therapy. keisuke y 1 , miyuki m 1 , motoi k 1 , susumu k 1 . 1 department of neurology, faculty of medicine, kinki university, osaka, japan. anti-ganglioside antibodies are closely associated with clinical phenotype and specific symptoms in acute immune-mediated neuropathies. igg anti-gq1b antibodies are specifically associated with miller fisher syndrome (mfs), bickerstaff brainstem encephalitis (bbe) and guillain-barré syndrome (gbs) with opthalmoplegia (gbs-op). in addition, ganglioside complexes (gscs) containing gq1b also can be targets in such diseases, and might be associated with the clinical features. however, factors regulating clinical phenotype in those gq1b-associated antibodies-positive diseases have not yet been known. for investigating the differences of antibody reactivities among those diseases, we examined, using combinatorial glycoarray, igg antibodies to ten individual glycolipids [gm1, gm2, gm4, gd1a, gd1b, gq1b, galactocerebroside (gal-c), lactosylceramide (laccer), ga1, sulfatide] and 45 glycolipid complexes consisting of two of the glycolipids listed above in sera from 36 patients with gbs-op who were positive for anti-gq1b antibody by elisa (gbs-op-gq1b), 40 patients with mfs with the clinical triad (opthalmoplegia, ataxia, and areflexia), and 27 patients with bbe. by combinatorial glycoarray, overall sensitivity of antibodies to gq1b and gscs containing gq1b was 97.2% (35/36) in gbs-op-gq1b, 87.5% (35/40) in mfs, and 74.1% (20/27) in bbe, respectively. there were no significant differences in antibody reactivities between mfs and bbe. it is notable that antibodies to gscs containing gd1b were more frequently found in gbs-op-gq1b patients than in mfs or bbe patients (e.g., gd1b/sulfatide: p=0.024 and p<0.01, respectively). presence of the antibody reactivities to gscs containing gd1b may possibly be related with clinical features of gbs-op-gq1b, including frequent need of artificial ventilation. kennedy r 1,2,3 , carroll k 1,3 , paterson k 2 , ryan mm 1,2,3 , mcginley jl 2,3 . 1 royal children's hospital, parkville, australia; 2 university of melbourne, parkville, australia; 3 murdoch childrens research institute, parkville, australia. problems with walking and footwear fit are often reported by children and adolescents with charcot-marie-tooth disease (cmt). a cross-sectional, case controlled study of gait was conducted in children with cmt and typically developing (td) children. gait was assessed barefoot and in two types of the participants' own typical footwear; optimal (e.g. athletic shoes) and suboptimal (e.g. slip-on footwear). the aims were to determine differences in spatio-temporal (s-t) gait variables between children with cmt and td children; and to investigate the effect of footwear choices. twenty-nine independently ambulant children aged 4-18 years with confirmed genetic or clinical diagnoses of cmt, and 29 age and gender matched td children participated (mean age 11.5 years; 40 males). exclusion criteria included developmental disorders, other neuromuscular conditions or musculo-skeletal diseases that could affect gait, and lower limb injury or surgery in the preceding 6 months. assessment included s-t gait patterns, footwear characteristics, 10 metre run, and cmtpeds. gait was assessed at self-selected speed with an electronic walkway (gaitrite™), with 6 trials for each condition. the primary gait variable assessed was speed; other variables included step length, step time, cadence, base of support width and step-to-step gait variability. across all footwear conditions children with cmt walked more slowly ( regeneration of cutaneous unmyelinated axons is known to be slowed in dm-patients and after 3-months, the density of intraepidermal nerve fibers (ienf) does not return to baseline levels after chemical or mechanical axotomy. however, the long-term outcome of regeneration in dm or control subjects is not known. additionally, it is not clear if the regeneration of sensory distal axons is length-dependent. here we measured the rate of axonal regeneration 6-months after chemical denervation using a capsaicin model in dm patients (n=11/37 dm1/dm2) without neuropathy, and 5 controls. dm skin punches were performed at distal thigh at baseline, 48-hours post-capsaicin, and at 28, 90, 150 and 180 days. blood glucose and hgba1c were measured at baseline, 90, 150 and 180 days. healthy controls had skin punches at both distal leg and proximal thigh at baseline, after capsaicin chemical axotomy, and days 28, 60, 90 and 180. regeneration rate was significantly higher at the thigh in healthy controls (0.1 fibers/mm/day (95% ci: 0.04-0.18 fibers/mm/day) compared to dm (p=0.043), but no difference between dm1 (0.07 fibers/mm/day 95% ci: 0.01-0.13 fibers/mm/day) or dm2 (0.06 fibers/mm/day 95% ci: 0.01-0.12 fibers/mm/day) (p=0.4). comparing regeneration rate at different time intervals, showed that regeneration was significantly slowed between day 150 and 180 dm patients, while it continued with the same rate in controls. blood glucose or hga1c had no effect on regeneration rate. ienfd returned to baseline in controls by 6-months (118% of baseline) while it is did not in dm subjects, 76%/58% (dm1/dm2) of ienfd baseline, (p=0.003 dm vs. controls). there was no difference in regeneration rate ienfd %-baseline by 6-months at distal leg and proximal thigh in controls (p=0.61). these results suggest that the rate and outcome of regeneration is independent of the length of the axon. additionally diabetic patient have incomplete nerve regeneration after 6 months regardless of diabetes type or the level of glycemic control. regeneration of axons slowed down over time in patients with dm and reached a plateau after 150 days. kiessling p 1 , lledo-garcia r 2 , watanabe s 3 , langdon g 4 , tran d 2 , bari m 2 , christodoulou l 2 , price g 2 , smith b 2 , byrnes w 5 , brock m 5 , jolles s 6 . 1 ucb pharma, monheim, germany; 2 ucb pharma, slough, uk; 3 ucb pharma, braine-l' alleud, belgium; 4 ptx solutions ltd, london, uk; 5 ucb pharma, raleigh, durham, usa; 6 university hospital of wales, cardiff, uk. ucb7665 is a humanised high-affinity monoclonal igg antibody developed to bind human neonatal fc receptor (fcrn), selectively inhibiting igg salvage and recycling. conditions such as myasthenia gravis (mg) are characterised by pathogenic igg autoantibodies; inhibition of fcrn may provide a suitable therapeutic approach. 1 this phase i, double-blind, dose-escalating, first-in-human study (nct02220153) evaluated the safety and pharmacology of ucb7665. forty-nine healthy adults (mean age 44 years, range 22-65) were randomised and received a single dose of intravenous (iv) or subcutaneous (sc) placebo (n=7 and n=6, respectively), or a single dose of iv or sc ucb7665 (1, 4 or 7 mg/kg; n=6 per dose, per administration). subjects were followed up until day 85. one placebo iv subject did not complete the study. twenty-seven of 36 subjects (75%) receiving ucb7665, and 9/13 (69%) receiving placebo, reported ≥1 treatment-emergent adverse event (teae) of mild/moderate intensity. severe teaes occurred in four subjects, all in the ucb7665 7 mg/kg iv group (headache [n=3], back pain [n=1]). no serious aes occurred. incidence of infections was similar with ucb7665 and placebo. the most frequently reported infection was nasopharyngitis. treatment-related teaes were reported by 67% of subjects receiving ucb7665 and 54% receiving placebo: the most common in the ucb7665-treated groups were headache (14/36; 39%) and vomiting (9/36; 25%); these occurred more frequently with the iv than sc route. non-linear increases in ucb7665 plasma concentration-time profile with increasing dose were observed with ucb7665. serum igg was reduced in a dose-depended manner with ucb7665 iv and sc: decreases from baseline to day 10 with ucb7665 iv were 14.5%, 33.4% and 47.6% for 1, 4 and 7 mg/kg doses, respectively, and 16.8%, 25.9% and 43.4%, with ucb7665 sc doses, respectively. these data indicated that the fcrn inhibitor ucb7665 effectively reduced serum igg, with sc administration generally better tolerated than iv. further to these observations, the efficacy, safety and tolerability of ucb7665 sc for chronic-intermittent treatment of moderate-to-severe mg are being evaluated in an ongoing phase ii, multi-centre, randomised, double-blind, placebo-controlled study (eudract 2016-002698-36 middle east respiratory syndrome (mers) has a high mortality rate and pandemic potential. however, very little information has become available on this syndrome since it first erupted in 2012. this study aimed to evaluate the frequency of neurological complications and their clinical presentations in mers. we reviewed the medical records of all patients who were diagnosed with laboratory-confirmed mers coronavirus (cov) infections and subsequently admitted to a single reference center for mers treatment during the 2015 outbreak in korea. in total, 4 patients (17.4%) reported neurological symptoms during or after mers-cov infection. the potential diagnoses in these 4 cases included bickerstaff's encephalitis overlapping with guillain-barré syndrome, critical illness polyneuropathy or other toxic or infectious neuropathies. neurological complications did not appear concomitantly with respiratory symptoms, but were instead delayed by 2-3 weeks. neuromuscular complications were not rare in mers-cov-infected patients, and they may have previously been underdiagnosed. understanding neurological manifestations is important in an infectious disease like mers, because evaluation is frequently limited during treatment, but it can interfere with prognosis and sometimes require modification of treatment. kim hj 1 , hyun jk 1 , kim tu 1 . 1 dankook university, cheonan, south korea. the diagnosis of carpal tunnel syndrome (cts) is based on clinical symptoms, physical examinations and supported by nerve conduction study (ncs). ultrasonographic examinations can be performed to assess peripheral nerves with less discomfort and the surrounding anatomic structures. while the usefulness of ultrasonography (usg) in the cts has been reported, no study to date has compared the diagnostic utility of various usg findings for cts. we investigated the correlation of various usg findings to the clinical symptoms/signs and ncs findings in patients with cts. twenty-eight hands (17 patients) with cts based on electrodiagnostic criteria and clinical symptoms such as tingling sensation or pain in the first to third fingers, burning sensation, paresthesia and weakness of hand grip power. all subjects were examined with usg. cross-sectional area (csa) and flattening ratio (fr) of the median nerve was calculated at level of radio-ulnar joint, pisiform and hamate. swelling ratio of the median nerve and palmar displacement of the flexor retinaculum was also calculated. clinical assessment was conducted using the boston carpal tunnel questionnaire (bctq) scale and historical-objective (hi-ob) scale. the analysis of correlation between usg findings and clinical symptom scales/ncs findings was performed using correlation analysis. the csa of the median nerve at level of radio-ulnar joint was significant correlated with bctq scale, hi-ob scale, distal motor latency, and conduction velocity (cv). the csa of the median nerve at level of pisiform was significantly correlated with hi-ob scale, distal motor latency, and cv. the fr of the median nerve at level of radio-ulnar joint was significantly correlated with bctq scale, hi-ob scale, distal motor latency, and cv. the swelling ratio of the median nerve was also significantly correlated with distal motor latency and cv. in patients with cts, csa of the median nerve at level of radio-ulnar joint was most closely related to ncs findings and clinical symptoms. so, csa of the median nerve at radio-ulnar joint might be a complementary tool for the diagnosis of cts. kitaoji t 1 , tsuji y 1 , ashida s 1 , yamada t 1 , ishii r 1 , tanaka a 1 , mizuno t 1 . 1 department of neurology, graduate school of medical science, kyoto prefectural university of medicine, kyoto, japan. the case was a 73-year-old woman. first, she noticed paresthesia in the right plantar eight months before admission and in the left plantar four months before admission. three months before admission, she developed muscle weakness in her feet. the muscle weakness and paresthesia extended to the lower legs in a few months. twenty days before admission, she experience difficulty in walking. on admission, the muscle weakness was observed in the legs, especially in the right tibial anterior muscle (ta). there was severe sensory disturbance and loss of deep tendon reflex in the legs. she had trouble walking due to the weakness and sensory aphasia. in nerve conduction study (ncs), conduction block was observed between the ankle and popliteal in both tibial nerves. the blood level of angiotensin converting enzyme (ace) was elevated. cerebrospinal fluid analysis was normal. there was no enhancement in the lumbar nerve roots shown on mri. gallium-67 scintigraphy showed hot spots on bilateral hilar lymph nodes and mediastinal nodes and biopsy of mediastinal nodes showed non-caseating epithelioid granuloma. therefore, we diagnosed her with sarcoid peripheral neuropathy by sarcoidosis. by using the nerve ultrasound, partial spindle-shaped nerve enlargement was observed at the part of conduction block in the left tibial nerve. we started the treatment with methyl prednisolone (1000mg, 3days) and oral prednisolone therapy (1mg/kg/day). after treatment, the paresthesia and muscle weakness in the legs had gradually improved. the partial enlargement in the left tibial nerve also improved on the 52-hospital day. in ncs, the conduction block improved, however, the compound muscle nerve potential of tibial nerve decreased because of axonal damage. this partial spindle-shaped nerve enlargement by using ultrasound has never been reported in sarcoid peripheral neuropathy before. the nerve ultrasound may be useful for evaluation of therapeutic effect of sarcoid peripheral neuropathy. peripheral nerve injuries are still debating problems in the world because of poor recovery. there is absolutely a need for new therapeutic agents to improve outcome by altering nerve regeneration. there are some studies in the literature about some therapeutic agents that used in the cases of peripheral nerve injuries. despite these studies, an agent with clinical use has not been presented yet. in this experimental study, we aimed to analyze the effects of curcumin (cur) in the cases of peripheral nerve injuries. forty rats were randomly and equally divided into four groups. the first group was control group. rats in this group were not operated. right sciatic nerve injuries were performed to the other groups. the second group was operation group with no therapeutic agent. the third group was operation and local cur applied group. the fourth group was operation and systemic cur applied group. electrophysiological evaluations were performed with electroneurography (enog) before and after the surgeries. systemic use of cur although caused improvement in the enog values but could not make a positive contribution to the nerve regeneration statistically. additionally local use of cur made negative effect to the nerve regeneration statistically. according to our statistical results we could not recommend cur as a nerve protective agent. klein cj 1 , wu y 1 , jentoft me 1 , mer g 1 , spinner rj 1 , dyck pjb 1 , dyck pj 1 , mauermann ml 1 . 1 mayo clinic, rochester, usa. intraneural perineurioma is a hypertrophic peripheral nerve tumor having immunoreactivity to epithelial membrane-antigen, negative for s-100. the origin of perineurial cells is debated to be similar to meningeal cells. ip does not metastasize, but motor deficits accumulate over time from tumor growth in nerve and plexus. after schwannomas and neurofibromas, perineuriomas are the most common nerve tumor of young adults. a chromosome 22q deletion has been reported in one patient. we identified16 ip cases from our previously published clinical cohort with available flash frozen ip tissue for dna isolation. wes with cnv analysis and cgh microarray analysis (agilent 2x400k superprintg3) were performed on extracted dna; 7 had available germline dna (lymphocytes and buccal tissue). we compared the exome data against online and in-house control data (∼100,000) examining variants less than 0.0001 frequencies, predicted damaging or nonsynonymous. wes identified three novel, heterozygous, damaging mutations in tumor necrosis factor receptor-associated factor 7 (traf7) in 10 of 16 (60%) cases; p.l519p (n=3), p.h521r (n=3) and p.s561r (n=4). mutations were within the wd40 domain, p.l519p, p.h521r within exon 17 and p.s561r within exon 18, and mapped to a limited region of traf7 with protein structure modeling. two of 16 cases (12.5%) showed macroduplications/deletions on multiple chromosomes, including chromosome 22, confirmed with cgh microarray analysis and cnv results from exome data analysis. four of 16 (25%) had no discovered mutation. age of onset or severity did not correlate with type of mutations. this study provides strong evidence that traf7 is a specific tumor driver of ip. mutations in traf7 are also linked to benign intracranial meningiomas suggesting a shared pathogenesis and close origins of perineurial and meningeal cells. study supported by: mayo foundation and the mayo center of individualized medicine. klein i 1,2 , bobylev i 1,2 , lehmann hc 1,2 . 1 university hospital cologne, cologne, germany; 2 center for molecular medicine cologne (cmmc), cologne, germany. peripheral neuropathy is a common side effect of paclitaxel. clinical evidence suggests that the delivery mechanism of paclitaxel formulations influence time course and severity of paclitaxel induced peripheral neuropathy. in a preclinical model we studied access, distribution and toxicity of two paclitaxel formulations (nanoparticle albumin-bound paclitaxel (nab) and solvent-based paclitaxel) in the peripheral nervous system (pns). c57bl/6 mice were treated with 5 mg/kg or 10 mg/kg of nab-paclitaxel or solvent based paclitaxel. kinetics of paclitaxel in neurons was assessed by a newly established immunostaining technique. neurotoxicity was evaluated by functional assays and nerve morphology. paclitaxel accumulated mostly in dorsal root ganglia, whereas distal nerve segments showed only low uptake of paclitaxel. treatment of mice with the two paclitaxel formulations resulted in paclitaxel uptake mostly in nf200+ larger fiber neurons. in ib4+, and cgrp+ small fiber neurons, paclitaxel was less frequently detected. nab-paclitaxel was incorporated more rapidly compared to solvent-based paclitaxel but neurons also showed a faster clearance of nab-paclitaxel compared to solvent based paclitaxel. functional assays and nerve conduction studies indicated that nab-paclitaxel was less neurotoxic compared to solvent-based paclitaxel. this is the first study that characterizes in detail the access of nab-paclitaxel and solvent based paclitaxel into the pns. our findings have important implications to understand the pathomechanisms of paclitaxel induced neurotoxicity and to develop neuroprotective strategies by preventing access of paclitaxel to the pns. the aim of our study was to investigate the etiology of neuropathy in patients with rheumatoid arthritis (ra). subjects were 9 neuropathy patients with ra admitted to our department. laboratory investigations, nerve conduction studies (ncs) and sural nerve biopsy were performed. mean patient age was 66.1 years (range, 41-84 years), and mean disease duration was 10.5 years (range, 2-24 years). clinical diagnosis for neuropathy was rheumatoid vasculitis (rv) in 5 patients, rv with acute motor axonal neuropathy (rv-aman) in 1 and chronic inflammatory demyelinating polyneuropathy with ra (ra-cidp) in 3. rheumatoid factor (4/5) and rheumatoid arthritis particle agglutination (3/3) was high and c4 tended to be lower in the rv group (rv and rv-aman). anti-ganglioside antibodies were examined in 4 patients, with positive results in 2. an rv-aman case was diagnosed with motor-dominant clinical presentation and the presence of anti-galnac-gd1a immunoglobulin (ig)g antibody. no other cases with rv were examined for anti-ganglioside antibodies. positive results for anti-gm1 and gm2 igg antibody were seen in one ra-cidp patient. we evaluated sural/median (s/m) ratio) for sensory nerve action potential (snap). s/m ratio was low in rv cases (4/5) and high (3/3) in immune-mediated cases, suggesting a so-called normal sural abnormal median pattern in immune-mediated neuropathies. the rv-aman case showed a moderate value in s/m ratio. nerve biopsy revealed thinly myelinated nerve fibers in ra-cidp cases compatible with demyelination, while the rv group showed the typical pathology for necrotizing vasculitis. rv cases were treated with prednisolone (psl), intravenous methylprednisolone, intravenous cyclophosphamide and increased psl dose. ra-cidp and rv-aman were treated with intravenous ig. in conclusion, neuropathy in ra can be divided into vasculitic and immune-mediated groups. ncs, and the s/m ratio of snap with some laboratory parameters in particular, may be of use in differential diagnosis and deciding treatment strategies. koh s 1 , wong shj 2 , loh kw 2 , chng ysk 3 , pawa c 3 , ei ma 4 , lee bjh 2 , subramaniam t 5 , umapathi t 1 . 1 national neuroscience institute, singapore, singapore; 2 lee kong chian school of medicine, nanyang technological university, singapore; 3 yong loo lin school of medicine, national university singapore, singapore; 4 tan tock seng hospital, singapore; 5 khoo teck puat hospital, singapore. treatment-induced neuropathy of diabetes mellitus (dm) (tind) is an acute painful autonomic neuropathy that develops with abrupt improvement in glycaemic control. typically, type 1 or 2 dm patients on insulin or oral hypoglycaemic agents (ohga), present with painful neuropathy and autonomic dysfunction within 8 weeks of rapid improvement in glucose control. current emphasis to achieve good glycaemic control rapidly may inadvertently increase incidence of tind, hence the impetus to understand risk of over-zealous glycaemic control. we therefore set out to study the occurrence of tind in a dm cohort of a tertiary hospital. we screened all patients who had two hba1c measurements between 2014 and 2015. during this period, approximately 5000 patients were seen per year. we found 1562 patient-encounters that showed hba1c decrease of ≥2% over 3 months or ≥4% over 6 months. we then used a structured checklist of tind symptoms to shortlist 62 cases. these case-encounters were scrutinised and classified as; 'probable tind': acute painful neuropathy and acute dysautonomia with temporal relationship to the decrease in hba1c; 'possible tind': acute painful neuropathy or acute dysautonomia or uncertain temporal relationship to decrease in hba1c; unlikely tind: alternative explanation exists for symptoms. only one case was deemed 'probable tind'-a middle-aged man with newly diagnosed type 2 dm who presented to emergency department with palpitations and worsening 'frozen feet' sensation that disturbed sleep. his hba1c decreased by 2.3% in 2 weeks. his symptoms improved within a month with neuropathic pain medications and resolved 4 months later. he also developed maculopathy and proliferative retinopathy. ten months later, he developed significant proteinuria. four other cases were classified as 'possible tind' while the remaining 57 were unlikely tind. our study is limited by retrospective design and reliance on hospital records. nevertheless, our findings suggest that tind is uncommon in a general cohort of dm patients. on the other hand, the number of patients with painful neuropathy and acute dysautonomia symptoms contemporaneous with rapid decline in hba1c raises the intriguing possibility that forme fruste of tind exists and one should interrogate the rate of hba1c decline in dm patients with these symptoms. koike h 1 , kadoya m 2 , kaida k 2 , ikeda s 1 , kawagashira y 1 , iijima m 1 , kato d 3 , ogata h 4 , yamasaki r 4 , matsukawa n 3 , kira ji 4 , katsuno m 1 , sobue g 1 . 1 nagoya university graduate school of medicine, nagoya, japan; 2 national defense medical college, tokorozawa, japan; 3 nagoya city university graduate school of medical sciences, nagoya, japan; 4 kyushu university, fukuoka, japan. we investigated the morphological features of chronic inflammatory demyelinating polyneuropathy (cidp) with autoantibodies directed against paranodal junctional molecules, particularly focusing on the fine structures of the paranodes. sural nerve biopsy specimens obtained from 9 cidp patients with anti-neurofascin 155 antibodies and 1 patient with anti-contactin 1 antibodies were assessed. these antibodies were examined using sera obtained from 131 patients with cidp who fulfilled the criteria of the european federation of neurological societies/peripheral nerve society. thirteen cidp patients without these antibodies were also examined to compare pathological findings. characteristic light and electron microscopy findings in transverse sections from patients with anti-neurofascin 155 and anti-contactin 1 antibodies indicated a slight reduction in myelinated fiber density, with scattered myelin ovoids, and the absence of macrophage-mediated demyelination or onion bulbs. teased-fiber preparations revealed that segmental demyelination tended to be found in patients with relatively high frequencies of axonal degeneration and was tandemly found at consecutive nodes of ranvier in a single fiber. assessment of longitudinal sections by electron microscopy revealed that detachment of terminal myelin loops from the axolemma was frequently found at the paranode in both anti-neurofascin 155 and anti-contactin 1 antibody-positive cidp patients compared with antibody-negative cidp patients. patients with anti-neurofascin 155 antibodies showed a positive correlation between the frequencies of axo-glial detachment at the paranode and axonal degeneration, as assessed by teased-fiber preparations (p < 0.05). in conclusion, paranodal dissection without classical macrophage-mediated demyelination is the characteristic feature of patients with cidp with autoantibodies to paranodal axo-glial junctional molecules. koike h 1 , ikeda s 1 , takahashi m 1 , kawagashira y 1 , iijima m 1 , misumi y 2 , ando y 2 , ikeda si 3 , katsuno m 1 , sobue g 1 . 1 nagoya university graduate school of medicine, nagoya, japan; 2 kumamoto university, kumamoto, japan; 3 shinshu university hospital, matsumoto, japan. peripheral neuropathy is the cardinal feature of familial amyloid polyneuropathy (fap), but its mechanism has not been fully elucidated. we used electron microscopy to examine schwann cells and endoneurial microvessels. sural nerve biopsy specimens from 49 fap patients with transthyretin val30met mutation were assessed. patients were consisted of 11 early onset cases from endemic foci and 38 late onset cases from non-endemic areas. loss of nerve fibers with or without neighboring amyloid deposition was a common feature. the amount of amyloid deposition was greater relative to the extent of nerve fiber loss in early onset cases than in late onset cases. the atrophy of schwann cells, particularly nonmyelinating cells, that were apposed to amyloid fibrils was more conspicuous in early onset cases than in late onset cases. the numbers of endothelial cell nuclei, endothelial cell profiles, and occluded microvessels were significantly increased in the fap patients compared with 37 patients with nutritional/alcoholic neuropathies (p < 0.05, 0.01, and 0.01, respectively). findings suggestive of the disruption of blood-nerve barriers, such as the loss of tight junctions and the fenestration of endothelial cells, were also more frequently found in the fap patients (p < 0.001), irrespective of the presence or absence of amyloid deposition. in conclusion, these findings suggest that direct insult of amyloid fibrils causes schwann cell damage resulting in the predominant loss of small-fiber axons characteristic of early onset cases. in addition, vasculopathy may also participate in the pathogenesis of neuropathy, particularly in late onset cases. kolb n 1 , smith ag 2 , singleton jr 2 , beck s 2 , howard d 1 , dittus k 1 , karafiath s 2 , mooney k 2 . 1 university of vermont, burlington, vt, usa; 2 university of utah health, slc, ut, usa. chemotherapy induced peripheral neuropathy (cipn) is a major cause of morbidity due to numbness, pain, and gait instability. this prospective study compares the current standard care for cipn symptom management to a new care delivery model which utilizes an automated symptom tracking program paired with a nurse practitioner led intervention triggered by moderate to severe symptoms. all participants beginning taxane or platin based chemotherapy called a telephone based automated symptom tracking program daily (symptom care at home -sch) to report chemotherapy related numbness and tingling. sch tracked the presence and severity of neuropathic symptoms and their interference with activities of daily living (adls) on a 0-10 scale. participants were randomized to two groups. the usual care (uc) group was advised to call their oncology provider for recommendations on symptom management. in the nurse practitioner (np) group, when symptom severity was ≥ 4 participants received automated self care strategies and a call from a nurse practitioner to provide treatment recommendations based on consensus guidelines. 252 patients participated in the study. mean duration of follow up was 90.2 ± 39.9 days with 81.1 ± 40.3 calls. the np group had fewer days with any neuropathic symptom (12.7% ± 18.3 vs. 21.1% ± 26.1, p=0.005), with moderate to severe neuropathic symptoms (7.5% ± 12.4 vs. 15.4% ± 22.8, p< 0.001) or days of distress from neuropathic symptoms (12.7% ± 18.3 vs. 21.1% ± 26.1, p=0.005). on days with moderate to severe symptoms participants also reported burning (20.4 ± 30.3 %), weakness (18.4 ± 27.2%), balance problems, (17.9 ± 28.1%), and tripping (16.7 ± 28.3%). there was no significant difference between groups in the interference in adls (np 3.3 ± 1.9 vs. uc 3.8 ± 2.1, p=0.08). overall the automated telephone system effectively identified neuropathy symptoms and their severity. compared to usual care in which patients must independently reach out to their care team for symptom management, sch is effective in decreasing symptom prevalence, severity and distress. kouton l 1 , kremer l 2 , tard c 3 , morales r 4 , kuntzer t 5 , attarian s 1 , boucraut j 6 , delmont e 1 . 1 referral centre for als and neuromuscular diseases, marseille, france; 2 neurology department, strasbourg, france; 3 neurology department, lille, france; 4 neurology department, montpellier, france; 5 neurology department, lausanne, switzerland; 6 immunology laboratory, marseille, france. antibodies against proteins of the node of ranvier have been recently described in severe chronic inflammatory demyelinating polyradiculoneuropathies (cidp). they target paranodal proteins, namely contactin (cntn1) and neurofascin 155 (nf155). cell-based assay and elisa are available in research, but no gold standard technic is admitted for the detection in routine of these antibodies. our objective was to evaluate if flow cytometry analysis is an efficient technic to detect antibodies against ctn1 and nf155 in a large cohort of cidp patients. flow cytometry analysis were performed on a bd facs-diva. human embryonic kidney (hek) cells were transfected either with nf155 or cntn1. sera were diluted 1/100. antibodies anti-cntn1 or nf155 were revealed using fitc conjugated anti human igg antibodies. delta mfi (mean fluorescence intensity) was calculated as mfi of transfected cells less mfi of non-transfected cells. measures were normalized using positive controls and 60 negative controls from healthy blood donors. 156 sera of cidp patients from different french neuromuscular referral centres were analysed with flow cytometry. respective delta mfi were 25 (standard deviation 22) and 34 (standard deviation 29) for antibodies against nf155 and cntn1 in cidp antibodies negative patients. antibodies against nf155 were found in 3 patients (respective mfi 2036, 79, 15591) and against cntn1 in two other patients (respective mfi 4693 and 708). isotype of these antibodies was igg4 in 3 patients and igg4 and igg3 in the remaining patient. all the patient had severe cidp. four patients had poor response to intravenous immunoglobulins (ivig) and have been treated with immunosuppressive drugs. as usually reported, the patient with anti-nf155 antibodies had postural tremor. flow cytometry seems effective to detect antibodies against nf155 and cntn1. compared to other assays, benefits of flow cytometry are: to analyse a large number of sera in the same time and to give objective numerical results expressed in mfi that can be compared to the results of other samples. further studies are needed to confirm that flow cytometry can be the best test to assess antibodies against cntn1 and nf155 in routine. the mechanism by which intravenous immunoglobulins (ivig) improves peripheral nerve function in multifocal motor neuropathy (mmn) is unknown. the rapid clinical improvement following ivig could be related to blocking complement deposition on gm1 epitopes, change in ion-channel properties of affected motor axons, or both. the present study investigated median nerve motor excitability parameters at 37 ∘ c just before ivig administration as well as at the peak of clinical improvement in 17 patients with mmn. the investigated nerves were characterized either by conduction block (n= 5), demyelinative slowing without block (n= 3), or motor axon loss (n=9). the results of motor excitability testing in mmn showed no difference between pre-and post ivig recordings. clinical assessment of apb muscle showed increase in mrc score in 6 patients and decrease in 1 patient after ivig administration. in 10 patients mrc score of the apb remained the same. those findings indicate that clinical changes following ivig administration are not related to excitability parameters of affected motor axons in mmn. where impulse conduction is blocked or markedly slowed in motor axons but is normal in sensory axons. sensory symptoms or signs are usually absent but have occasionally been reported in skin areas innervated by nerves with prominent motor axon loss. although the mechanism of selective motor involvement in mmn is unresolved, it may be related to differences in antigenic properties between motor and sensory axons or differences in biophysical properties. the objective of the present study was to compare ion-channel activity in both motor and sensory axons of nerves affected by mmn. affected nerves had to have motor conduction block, demyelinative slowing on motor ncs, or motor axon loss, whereas sensory ncs had to be normal. we performed excitability tests of motor and sensory axons in affected median nerves of 20 mmn patients and 20 healthy controls at 37 ∘ c. conditioning and test stimuli were delivered at the median nerve at the wrist; cmaps were recorded from the thenar muscle and snaps from the 3rd digit. results of motor excitability testing in mmn showed fanning-out of threshold electrotonus, decreased i/v slope, and increased superexcitability, all compatible with persistent hyperpolarization of resting membrane potential in motor axons. sensory excitability testing in mmn showed decreased subexcitability but was otherwise normal. this may indicate minimal involvement of sensory axons in mmn. krarup c 1,2 , moldovan m 1,2 , alvarez s 1 , ciano c 3 , pisciotta c 3 , pareyson d 3 . 1 university of copenhagen, copenhagen, denmark; 2 rigshospitalet, copenhagen, denmark; 3 fondazione irccs istituto neurologico c. besta, (incb), milan, italy. mutations in the gene coding for myelin protein zero (mpz, p 0 ) are associated with different forms of charcot-marie-tooth (cmt) disease. we describe a family harboring a frameshift mutation (c.306dela / p.asp104thrfster14) in the p 0 gene, predicted to result in a nonfunctional p 0 truncated very early in the extracellular domain. this offered the rare opportunity to assess the consequences p 0 deficiency in absence of the potential gain-of-function effects of the mutations itself. conventional conduction studies and multiple measures of nerve excitability by "threshold tracking" were carried out in 2 heterozygote parents (aged 63 and 52) and their two homozygote sons (aged 31 and 39). in the homozygous patients, all distal limb cmaps and snaps were absent. for neurophysiological assessment, the spinal accessory nerve was stimulated at the neck and cmap was recorded over the upper trapezius muscle. eight normal subjects, mean age 34, were used as control. the two sibs showed a severe phenotype with early onset, severe scoliosis, complete loss of distal movements and relevant proximal weakness, cmt examination score (cmtes) 23-25/28; both heterozygous parents had very mild adult-onset neuropathy with cmtes <4/28. control subjects had a trapezius cmap with a latency of 6.2 ms and an amplitude of 7.4 mv. heterozygotes had a mild cmt type 1b phenotype, with a cmap latency of 7.5 ms and an amplitude of 2.9 mv whereas the homozygotes had a severe neuropathy with a cmap latency of 35.9 ms and an amplitude of 0.2 mv. consistently, the homozygotes had a more severe impairment in excitability with a rheobase of 16.2 ma as compared to 4.7 ma in the heterozygote and 3.5 ma in controls. deviations in excitability measures were similar to our previous reports in p 0 +/− and p 0 −/− mice. mathematical modeling, indicated both altered passive cable properties due to dysmyelination and depolarizing features with increased na+ currents. our data suggest that p 0 deficiency is associated with impaired axonal na+ channel function, arguing for the translational value of na+ channel blocker treatments as found in p 0 null mouse models. krishnarajah s 1 , divino v 2 , mallick r 1 , dekoven m 2 . 1 csl behring, king of prussia, pa, usa; 2 quintilesims, fairfax, va, usa. chronic inflammatory demyelinating polyneuropathy (cidp) is a rare neurological disorder of the peripheral nervous system. the objectives of this retrospective real-world study were to compare demographic and clinical characteristics among cidp cases and matched controls and to assess cidp treatment utilization. adults newly diagnosed with cidp between 7/1/2010 and 6/30/2014 were identified in the quintilesims pharmetrics plus health plan claims database (first diagnosis date termed the index date). eligibility requirements were: confirmation of cidp (second cidp diagnosis or initiation of cidp therapy) within 1 year of initial diagnosis, continuous health plan enrollment in the 6 months prior to diagnosis (the pre-index) and the 2 years following diagnosis (the follow-up), and no cidp diagnosis or use of cidp therapy in the pre-index. a total of 1,041 cidp cases met the study eligibility criteria. cases were direct-matched to controls based on age, gender, region, health plan, and payer type at index, and pre-index charlson comorbidity index score. the final sample consisted of 790 cases matched to 790 controls (both: mean [sd] age 49.7 [11.4]; 53.7% male; 63.9% commercially-insured). alternative pre-index diagnoses among cases included inherited neuropathies (38.9%) and chronic acquired polyneuropathies (17.6%). in the pre-index, neuropathic pain (39.7% vs. 2.9%), back pain (30.5% vs. 10.1%), and use of opioids (33.4% vs. 16.2%) and anti-convulsants (30.6% vs. 5.1%) were significantly higher among cases compared to controls (p<0.0001 for all). median total pre-index healthcare costs were 2.2x higher for cases than controls ($4,751 vs. $2,209, p<0.0001). over the follow-up, median total healthcare costs were 8.2x higher for cases than controls ($47,827 vs. $5,823, p<0.0001 [mean $116,330 and $15,586] ). cidp-related therapy costs accounted for 51.4% of total healthcare costs for cases. the majority of cases (83.2%) initiated cidp therapy over the follow-up, in a mean of 115.5 (146.3) days from initial diagnosis. half (48.7%) of cases initiated treatment with corticosteroids only, while 24.8% initiated ivig only. over the follow-up, 69.1% of cases used any corticosteroid, while 34.3% used any ivig. our findings suggest a substantial clinical and economic burden of cidp compared to matched controls. corticosteroids and ivig were most commonly used to treat cidp. kronlage m 1 , baeumer p, pitarokoili k 2 , schwarz d 1 , schwehr v 1 , godel t 1 , heiland s 1 , gold r 2 , bendszus m 1 , yoon ms 2 . 1 department of neuroradiology, heidelberg university hospital, germany; 2 department of neurology, st. josef hospital, ruhr university of bochum, germany. objective: to evaluate large coverage magnetic resonance neurography (mrn) in chronic inflammatory demyelinating polyneuropathy (cidp). methods: in this prospective study 18 patients with cidp and 18 healthy controls were examined by a standardized mrn protocol at 3 tesla. lumbosacral plexus was imaged by a t2-weighted 3d-sequence (1 mm isotropic voxel size); peripheral nerves of the upper and lower extremity by axial t2-weighted turbo-spin-echo sequences (0.5 x 0.3 mm in-plane resolution). lesions were characterized by nerve cross sectional area (csa) and t2-weighted signal (nt2). additionally, t2-relaxometry of the sciatic nerve was performed using a multi-spin-echo sequence. all patients received a complementary electrophysiological exam. results: patients with cidp exhibited increased nerve csa and nt2 compared to controls (p < 0.05) in a proximally predominating pattern. roc analysis revealed best diagnostic accuracy for csa of the lumbosacral plexus (auc = 0.88) and nt2 of the sciatic nerve (auc = 0.88). csa correlated with multiple electrophysiological parameters of demyelinating neuropathy (f-wave latency, nerve conduction velocity) of sciatic and median nerve, while nt2 only correlated with f-wave latency of sciatic and not median nerve. t2-relaxometry indicated that mr-signal increase in cidp was due to increase in proton-spin-density (p < 0.05), and not increase in t2-relaxation time. conclusion: both nt2 and csa might aid in diagnosis of cidp, but csa correlates more robustly with electrophysiological parameters. since best diagnostic accuracy was shown for proximal nerve locations, mrn may be a useful complementary tool in select cidp cases. kühnemund j 1 , wetzel c 2 , bégay v 2 , moshourab r 3 , lewin gr 2 . 1 mdc & bih, berlin, germany; 2 mdc, berlin, germany; 3 charité, berlin, germany. damage of peripheral sensory nerves due to diabetes, herpes zoster infection, chemotherapy or trauma can cause chronic neuropathic pain. common symptoms include increased pain sensation (hyperalgesia), touch-induced pain (allodynia), paresthesia and spontaneous pain. we currently have poor understanding about the underlying molecular mechanisms at the peripheral level and treatment of patients suffering from neuropathic pain is inadequate. recent meta-analysis studies show that common first-line medications only yield nnts (numbers needed to treat) between 10.6 to 6.4. it is still unclear to what extent allodynia can be attributed to changes in the physiological properties of intact sensory afferents. in this study, we aimed to elucidate whether changes occur in intact sensory afferents that innervate the plantar skin of the hind-paw following induction of neuropathic symptoms. this question was of particular interest considering that blocking mechanotransduction in the skin can alleviate mechanical hypersensitivity in neuropathic pain models (wetzel et al 2016 nature neuroscience 20(2):209-218). we used the chronic constriction injury (cci) model in mice which is behaviourally characterized by robust mechanical hypersensitivity. we made electrophysiological recordings from primary afferent neurons which had intact axons passing through the constriction to innervate the plantar skin using an ex-vivo skin-nerve preparation. we were able to record from 220 myelinated afferent fibers and 72 unmyelinated c-fibers with receptive fields in the control uninjured plantar skin as well as plantar skin of cci mice. we will present evidence that changes in the mechanosensitivity of sensory fibers innervating the glabrous skin may contribute to the symptoms of neuropathic pain. neuropathology, national hospital for neurology and neurosurgery, london, uk; 5 irccs foundation "carlo besta" neurological institute, milan, italy; 6 neurogenetics unit, national hospital for neurology and neurosurgery, london, uk; 7 nuffield department of clinical neurosciences, oxford, uk; 8 department of clinical neurophysiology, norfolk and norwich university hospital, uk. hsn1 secondary to sptlc1/2 is a rare slowly progressive neuropathy resulting in marked sensory loss, especially nociception and significant motor deficit. despite most of the patients having the same c133w mutation in sptlc1, there is marked heterogeneity in the phenotype. l-serine oral supplementation has been suggested as potential therapeutic candidate however the lack of outcome measures is a major limiting factor in the initiation of a clinical trial. we undertook a natural history study to identify outcome measures that are responsive enough to be used in a clinical trial. the assessments used were cmt neuropathy score (cmtns version 2 and cmtns version 2 rasch modified), mri of calves and thighs, computerised myometry, quantitative sensory testing (qst), comprehensive neurophysiological assessment, proximal thigh skin biopsy for intra-epidermal nerve fibre density (ienfd), plasma dsl levels and patient based questionnaires (neuropathic pain symptom inventory and sf-36v2). standardised response mean, srm (mean change/standard deviation of change) was used to compare responsiveness between tests. 35 patients were recruited: 31 with sptlc1 (c133w) and 4 with sptlc2 mutations. when analysed as a whole cohort, proximal calf mri fat fractions showed the most significant change over 12 months. ienfd, plasma dsl levels, npsi and sf-36v2 showed minimal change or the change was not in the clinically expected direction. for subsets of the remaining assessments which showed the highest responsiveness, the cohort was sub-divided into mild-moderate (cmtns ≤20) and severe (cmtns>20) subgroups. in the mild-moderate subgroup, the greatest improvement in responsiveness was seen in computerised myometry (ankle plantarflexion: srm=−0.80 and ankle eversion: srm=−0.79). in the severe subgroup, qst (vibration detection thresholds on hands: srm=−0.80 and face: srm=−0.92 and pressure pain threshold on the face: srm=1.27) and proximal calf mri fat fractions (srm range=0.73-1.26) showed the greatest improvement. focusing on subgroups classified according to disease severity improved the responsiveness of some tests into the highly responsive range with mri still being the best outcome measure. this will reduce the number of participants required to power a clinical trial and might be a possible solution for designing a clinical trial for a rare, slowly progressive disease with a heterogeneous phenotype. kugathasan u 1 , clark aj 2 , suriyanarayanan s 3 , laurá m 1 , wilson e 1,4 , kalmar b 4 , greensmith l 1,4 , hornemann t 3 , reilly mm 1* , bennett dlh 2* . 1 hsn1 secondary to sptlc1/2 mutation is a slowly progressive sensory motor neuropathy leading to profound sensory loss with variable but often severe motor deficit. the genes sptlc1 and 2 encode for the essential enzyme serine palmitoyltransferase (spt) which catalyses the rate limiting step in the sphingolipid de-novo biosynthesis. mutations in these two genes alter the substrate specificity of spt leading to the synthesis and accumulation of atypical metabolites called 1-deoxysphingolipids (1-deoxysl). plasma levels of 1-deoxysl are raised in hsn1 patients. deoxysphingolipids have been shown to be toxic in avian and by our group, in mammalian primary drg and motor neuron cultures. firstly, this study looked at the effects of 1-deoxysl on the survival and neurite integrity of human ipsc derived sensory neurons following exposure to different concentrations of deoxysphingolipids. later, we determined if there was autonomous 1-deoxysl production in hsn1 patient ipsc derived sensory neurons. sensory neurons were differentiated from human ipscs using a combination of small molecular inhibitors. deoxysphingolipids were found to be neurotoxic in this model after 48 hours of treatment. in control lines, there is a significant reduction in neuronal survival following treatment with both 1-deoxysphinganine (1-deoxysa) and 1-deoxymethylsphinganine (1-doxmethsa). a clear dose-dependent increase in the expression of the axonal injury marker, atf3, is seen with both 1-deoxysphngoid bases. in both instances, 1-deoxysa is more neurotoxic than 1-doxmethsa, which is similar to the findings in avian and mammalian primary neuronal cultures. autonomous 1-deoxysl production is seen in ipsc derived neurons obtained from three different hsn patients with the levels being significantly greater than that seen in multiple control lines. this is the first study to demonstrate that human ipsc derived sensory neurons can be used as an in-vitro model for hsn1, providing a great opportunity both to probe the pathomechanisms mediating deoxysphingolipid toxicity and to test potential therapeutic agents. recent studies have demonstrated an association between autoantibodies directed against antineurofascin-155 (anti-nfasc155) and a subpopulation of cidp patients characterized by sensory ataxia, tremor and poor response to ivig treatment. here we report on the clinical features of three patients who developed acute changes in their phenotype during the course of their neuropathy, a potential clue to recognize a neuropathy with predominantly humoral dysimmunity. case reports: our index patient had developed sensory changes over 6 weeks, followed by irregular locomotion, and muscle weakness with general areflexia. a first run of ivig improved the patient in a week, but he relapsed within 10 days. a second ivig course with prednisone again normalized deficits within 10 days. ivig runs and rituximab were still necessary to treat a 2 nd , and then a 3 rd relapse before obtaining complete improvement. the course of the neuropathy was 5 months. two other patients were encountered with more chronic courses but in whom periods of worsening or improvement suggested a relapsing-remitting neuropathy, either spontaneously or following immunomodulating treatments. in all three, extensive work-ups were negative, anti-nfasc155 igg4 were positive, and detailed repeat nerve conduction studies demonstrated fluctuating conduction blocks. discussion: our report underscores that in chronic cidp patients a relapsing-remitting course could be encountered as a key feature of anti-nfasc155 neuropathy. this not yet described characteristic course could be of value when deciding using rituximab instead of immunomodulating treatments. kusunoki s 1 , morikawa m 1 , kuwahara m 1 , ueno r 1 , samukawa m 1 , hamada y 1 . 1 faculty of medicine, kindai university, osaka-sayama, japan. anti-glycolipid antibodies are often detected in sera from patients with autoimmune neuropathies, such as guillain-barré syndrome (gbs), chronic inflammatory demyelinating polyradiculoneuropathy (cidp), and multifocal motor neuropathy (mmn). not only individual glycolipid antigens but also mixtures of two different glycolipids (glycolipid complexes) are sometimes recognized by serum antibodies. to investigate antibody activities against large number of glycolipid complexes in serum samples from patients with gbs, mmn, and cidp, we examined igm and igg antibodies against 10 glycolipids [gm1, gm2, gd1a, gd1b, gq1b, galnac-gd1a, lm1, galactocerebroside (gal-c), asialo-gm1 (ga1), and sulfatide] and 45 glycolipid complexes consisting of two different glycolipids listed above, by using combinatorial glycoarray. serum was obtained from 100 patients with gbs, 100 patients with cidp and 24 patients with mmn, all in the acute or relapsing phase. serum was also obtained from 30 healthy controls and 99 patients with other neurological diseases. we investigated the relationships between the clinical features and presence of those antibodies. high titers of igg antibodies were detected almost exclusively in gbs patients. in contrast, igm antibodies were frequently present in mmn and gbs. among the anti-glycolipid complex antibodies in gbs, anti-gm1/sulfatide, anti-ga1/sulfatide, anti-gm1/gd1a, and anti-gq1b/sulfatide igg antibodies were common (20, 19, 17, and 14 patients, respectively). igg antibodies against antigens containing gm1 were significantly correlated with pure motor gbs (p < 0.01) and those against antigens containing gq1b were significantly correlated with gbs with ophthalmoplegia (p < 0.01). in seven of the 14 patients with anti-gq1b/sulfatide complex antibodies, the antibodies were specific to the gq1b/sulfatide complex rather than the individual gq1b and suldfatide antigens. moreover, four patients did not have antibodies other than those to the anti-gq1b/sulfatide complex. in patients with mmn, igm antibodies to antigens containing gm1 or galnac-gd1a were present in 50% and 37.5%, respectively. glycoarray is efficient for detecting antibodies against numerous glycolipid complexes in immune-mediated neuropathies. we need further investigations on other immune-mediated diseases using larger number of antigens. kuwabara s 1 , misawa s 1 , sekiguchi y 1 , susumu kusunoki 2 and the jet-gbs study group 3 . 1 department of neurology, chiba university, chiba, japan; 2 department of neurology, kindai university, osaka, japan; 3 japanese eculizumab trial for guillain-barré syndrome, chiba, japan. guillain-barré syndrome is a monophasic immune-mediated neuropathy, but a substantial number of patients with severe disease have poor recovery, even if treated with immunoglobulin. recent studies suggest that complement activation plays a pivotal role in gbs-associated axonal degeneration, and eculizumab is a monoclonal antibody that specifically binds to complement component 5 and inhibits complement activation. jet-gbs is an investigator-led, phase 2, randomized, placebo-controlled trial conducted in 13 hospitals, this trial aims to investigate the safety and efficacy of eculizumab for treatment of severe gbs. 34 patients were randomly assigned (2:1) to treatment with immunoglobulin plus either eculizumab (900 mg/day; n=23) or placebo (n=11) once weekly for 4 weeks. the primary outcome measures are safety and efficacy (the proportion of subjects who regain their ability to walk independently at week 4). the secondary outcome measures included the proportion of subjects who were able to walk independently at week 24, and other measures such as mrc sum scores, nerve conduction parameters. enrollment for the trial began in august 2015, and follow-up of the last patient was completed in october 2016. analyses will be made in april 2017, and the results will be presented at this meeting. this trial is registered with clinicaltrials.gov identifier: nct02493725, and funded by the japanese agency for medical research and development, and alexion pharmaceuticals inc. neurofascin 155, a paranodal protein in peripheral nerve, is a target antigen for autoantibodies in a subset of chronic inflammatory demyelinating polyneuropathy (cidp). anti-neurofascin 155 antibody-positive cidp is characterized by onset at younger age, tremor, and refractoriness to ivig. we have treated four patients with anti-neurofascin 155 antibody-positive cidp at kindai university hospital. anti-neurofascin 155 antibody was detected by both elisa and cell-based assay in those patients. igg subclass was predominantly igg4 in all four cases. the median age of the patients at admission was 39.5 years [range: 30-43 years]. among the four patients, three had tremor, and two had severe cerebellar ataxia. cerebrospinal fluid protein levels were remarkably increased [median: 494.5 mg/dl, range: 216-882 mg/dl]. although ivig treatment was administered in all four patients, the responses were poor or partial. in contrast, plasma exchange (pe) was performed in all four patients and the clinical symptoms dramatically improved in two of them. corticosteroids were also effective in those two patients. sural nerve biopsy was performed in all four patients. although sensory nerve action potentials of the sural nerves from those patients were not evoked, the transverse semithin sections of sural nerves from three patients revealed only slight or mild loss of myelinated fibers. partial paranodal demyelination was observed in teased-nerve fibers from three patients. in addition, abnormal paranodal lesions such as loss of the transvers bands were observed by electron microscope in all four patients. those electron microscopic findings were not observed in control patients with anti-neurofascin 155 antibody-negative cidp. anti-neurofascin 155 igg4 antibody-positive cidp shows distinctive clinical and pathological features. labeyrie c 1 , besson f 2 , vandendries c 3 , cauquil c 1 , beaudonnet g 4 , not a 1 , durand e 2 , adams d 1 . 1 neurologie adulte, chu bicêtre, le kremlin bicêtre, france; 2 médecine nucléaire, chu bicêtre, le kremlin bicêtre, france; 3 clinique bizet, paris, france; 4 unité de neurophysiologie clinique, chu bicêtre, le kremlin bicêtre, france. study of the proximal portion of the peripheral nervous system (pns) is difficult because less accessible to electrophysiological exploration and biopsy. the indications of mri are increasing in proximal neuropathies to analyse morphology of the roots, plexus and proximal nerves: integrity of the nerve bundle, inflammation or infiltration of these structures. pet-computed tomography (pet-ct) can detect infiltration of the proximal segments of the pns, with hypermetabolism of roots, plexuses and large nerve trunks. pet-ct is also useful in detection of solid neoplasm which can infiltrates pns and primary nerve sheath tumors. however, spatial resolution of pet -ct scan is limited to explore the roots and plexuses for moderate hypermetabolisms. we believe that a mild hypermetabolism could be highlighted in inflammatory neuropathies or in mild tumor infiltrations. we performed a fusion of whole body pet (performed because of suspected neoplasia) and plexus mri (pet-mri) images in ten patients with a peripheral neuropathy for which we suspected proximal involvement. the pet-ct and mri were first read separately, then with merge of the images by a nuclear physician and a neuroradiologist. five out of ten patients presented with hypermetabolism of pns (hmpn+) on pet-mri: root (n=4), and/or dorsal root ganglia (n=2). median sul of lesions was 1.9. among the hmpn+ patients: hypermetabolism was already apparent on pet-ct in 2 cases, the merge invalidated abnormalities seen on pet-ct in 2 patients and mri detected additional lesions, not visible on pet-ct, in one patient. all hmpn+ patients had hypersignal and or hypertrophy of pns on mri either diffuse (n=4), or multifocal (n=1). among hmpn-(no hypermetabolism) 2 out of 5 (40%) had abnormal mri (1 multifocal and 1 diffuse). gadolinium enhancement was found in all patients receiving gadolinium in the hmpn+ (n=4) and only in 2/5 patients in the hmpngroup. final diagnoses of hmpn+ patients were neurolymphoma in one (20%), and idiopathic cidp in the 5 others (80%) with histological proof on nervous root biopsy in one of them. final diagnosis in hmpn-patients was cidp in 4 out of 5 and sequelae of neuropathy in relation to lymphoma without relapse for the last one. cidp was more disabling (onls≥4) in hmpn+ than in hmpn-group 100% vs. 20%. pet-mri could be helpful to detect a proximal inflammation of the pns, and to plan further testing. further studies are needed to evaluate the prognostic value of hmpn+. lancaster e 1 , li j 1 , liem r 2 , scherer ss 1 . 1 perelman school of medicine, university of pennsylvania, philadelphia, pa, usa; 2 columbia university school of medicine, new york, ny, usa. heterozygous nefl n98s/+ mutant mice are the first animal model of a charcot-marie-tooth disease 2e (cmt2e). people with this mutation have a severe, early onset axonal neuropathy. axons in the mutant mice have reduced number of neurofilaments and decreased diameters. they also show early onset of tremor and abnormal hindlimb clasping behavior. we measured the compound action potentials (caps) from tails every 4 weeks from the same cohort of nefl n98s/+ mutant mice and their wt littermates from 8 to 48 weeks. even at the age of 8 weeks, the amplitude of mutant caps was only ∼20 % of wt caps (29 ± 3.7 microv, n=15 vs 142 ± 10.7 microv, n=15), and the caps stayed substantially smaller than those in wt mice for 48 weeks (40 ± 6.0 microv, n=13 vs 263 ± 26.7 microv, n=15). the conduction velocity and the duration of caps in mutants were slower and wider compared to those of wt. separate cohorts of mice (n=6 mutants and n=6 wt) were sacrificed at different time points for analysis by light microscopy. in caudal nerve of mutant mice, the number of axons was significantly reduced compared to that of wt at 8 weeks and, by 48 weeks, it was reduced more than 50%. this model system may be useful for preclinical studies of treatments for cmt2e since the animals show progressive neuropathy over 48 weeks, which can be objectively measured electrophysiologically and anatomically. despite more than 90 cmt genes identified today, at least 50% of cmt2 patients do not carry a mutation in any of these genes. progress in gene identification in recent years suggests that there are still many more cmt2 disease genes to be discovered; however, it has become rare to gather support from multiple large families that allow for conclusive linkage analysis. we have studied multiple extended dominant cmt2 families with linkage support for a gene at chromosome 1p13.1. originally a czech family yielded a two point lod score of 2.4 at this locus and a family from southern italy showed a lod score of 3.2. whole exome sequencing of multiple family members identified missense mutations in the gene atpase na+/k+ transporting subunit alpha 1 (atp1a1). atp1a1 has not been associated with human diseases thus far. in expression studies on teased fiber preparations we already confirmed predominant expression in the nodes of ranvier of peripheral nerves. through collaborative efforts in the inherited neuropathy consortium and beyond we identified five additional multigenerational families via exome or sanger sequencing resulting in a total of seven unique segregating missense changes: leu48arg, ile592thr, ala597thr, asp601phe, pro600ala, pro600thr and asp811ala. five of these mutations fall into a remarkably narrow motif associated with the sodium binding structure of atp1a1, flanking the flexible hinge motif. functional studies in different model systems (mammalian cell lines, xenopus oocytes, patient fibroblast lines) are underway to determine whether a loss or a dominant gain-of-function represents the disease mechanism. taken together, we show strong support for a major new dominant cmt2 gene, atp1a1. this finding represents a new pathway and an attractive new target for therapy development in axonal cmt. laurá m 1 , ramdharry g 1,2 , singh d 3 , kozyra d 1 , skorupinska m 1 , reilly mm 1 . 1 mrc centre for neuromuscular diseases, ucl institute of neurology, london, uk; 2 school of rehabilitation sciences, st george's university of london/kingston university, uk; 3 royal national orthopaedic hospital, stanmore, uk. charcot-marie-tooth (cmt) disease is the most common inherited peripheral neuropathy. foot deformities are frequent complications and orthopaedic surgery is often required. however there are no evidence based guidelines on the type or timing of the surgery. only few studies have described the long-term results of surgical procedures and evidence regarding optimal surgical management of these patients is lacking. we prospectively studied surgical management of cmt patients attending our centre. we collected data and assessed cmt patients before and after surgery. data included: history of ankle instability, pain, skin condition, details of physiotherapy and orthotic management, assessment of lower limb strength, charcot-marie-tooth examination score (cmtes), foot posture index, ankle dorsiflexion range of movement and specific questionnaires (foot index and manchester-oxford foot questionnaire, modified fatigue severity scale and modified falls efficacy scale), details of surgical procedures. patients were assessed yearly after surgery. so far 23 patients (16 males and 7 females, age range 20 -58) have been evaluated prior to surgery. all patients but one had genetically confirmed cmt (18 cmt1a, 3 cmtx, 1 cmt4a). 12 patients have been assessed after 1 year, 6 patients after 2 years, 7 patients after 3 years and 1 patient after 4 years from surgery. a wide range of surgical procedures were performed by one dedicated orthopaedic surgeon. preliminary results showed reduction of number of falls in 5/9 (55%) patients and improvement of callosities in 6/12 (50%) patients at 1 year follow up. there was also significant improvement of alignment of the operated foot (p=0.02) and pain (p=0.003). there were no significant changes in measures of strength and ankle range of motion. further analysis on a larger number of patients will be important to determine the long-term outcome of surgery. data acquired from this study will help develop orthopaedic intervention guidelines and identify areas for further research. lavigne-moreira c 1 , oliveira mf 1 , marques vd 1 , onofre ptbn 1 , dos santos acj 1 , nascimento ojm 2 , barreira a 1 , marques w jr 1 . 1 division of neuromuscular diseases and neurogenetics, department of neurosciences and behaviour sciences, clinical hospital of ribeirão preto, university of são paulo, ribeirão preto, brazil; 2 department of neurology, fluminense federal university, rio de janeiro, brazil. fap associated to ttr mutations is defined as a length-dependent axonal sensory and motor polyneuropathy that at early stages affects mainly the small nerve fibers, associated to autonomic and thermo-algesic sensations. the expected emg pattern was that of an axonal sensory and motor polyneuropathy, but in fact several unexpected patterns may be found. in this study we present the results found in a brazilian population with ttr mutation. patients were divided in three groups: ttr-met30 of early onset, ttr-met30 of late onset and ttr non-met30. in the first group (ttr-met30 of early onset), 10 (34.5%) examinations were normal, 12 (41.4%) were axonal, 5 were demyelinating fulfilling pidc criteria, one suggested a predominately motor polyneuropathy and the final one presented a lower motor neuron disease pattern. in the second group (ttr-met30 of late onset), 4 (44.4%) had an axonal pattern, 2 (22.2%) had an intermediate cv, 1 (11.1%) had a demyelinating pattern, 1 had a lumbossacral pattern and the final one had no definite pattern. among the non-ttr met30, two patients had the ttr -asp38tyr, one presented an axonal pattern, while the second presented initially an axonal pattern, that changed to a demyelinating pattern in the second examination. patients with ile107val mutation presented an axonal neuropathy associated to cts. most patients with demyelinating or intermediate pattern were treated with corticosteroids or ivig, with no satisfactory results. this small series of patients shows clearly that fap-ttr is associated to several emg patterns in addition to the expected sensory and motor axonal polyneuropathy. this variability is present in the same family and in the same patient in different occasions. clinicians should be alert to these possibilities to do not delay diagnosis and treatment. identifying the mechanisms involved in this variability could improve our knowledge of this intriguing disease. lavin tm 1 . 1 greater manchester neurosciences centre, salford royal hospital, manchester, uk. subcutaneous immunoglobulin (scig) has evidence from small trials for its use following intravenous igg (ivig) loading in chronic inflammatory demyelinating polyneuropathy (cidp). potential advantages of scig include stable igg levels and reduced complication rates. scig de novo can be considered as igg levels gradually rise with subcutaneous delivery and maybe beneficial for patients for whom complications are a concern. we present 3 cases of cidp who were initiated on subcutaneous immunoglobulin g (2g/kg/month, 20% scig, hizentra, csl behring) following corticosteroids; without intravenous igg loading. patient 1 is 67 year old with a history of ihd with a progressive lower limb sensory changes and sensory ataxia over 3 years. neurophysiology confirmed sensory demyelinating changes. he did not respond to corticosteroids. concerns were raised about the potential risk orf adverse cardiac events with iv immunoglobulin. scig therapy was introduced at 30g weekly. initial therapy has been well tolerated and objective measures (rods-cidp score, jamar grip strength, 9 hole peg) have remained stable through initiation, and at 3 months. patient 2 is 65 yr old male with a past history of branch retinal vein thrombosis. he developed a sensorimotor polyneuropathy over 2 years with neurophysiology fitting efns criteria for cidp. given concerns regarding previous thrombosis, a trial of scig was given at 34g/week, with resolution of sensory ataxia and improvement in objective markers (jamar grip strength, rods-cidp score, 9 hole peg) at 3 months. unfortunately an adverse event occurred of an urticarial skin reaction. patient 3 is a 55 yr old male who presented with motor predominant cidp. there was no response to corticosteroids but improvement following plasma exchange. due to a past history of transient ischaemic attack, scig was started. there has been a positive response after 3 months with improvement in walking distances and stable objective markers (rods-cidp score, grip and pinch strength). our cohort remained neurologically stable during initiation of scig, with 1 adverse reaction. our experience would support further trials in this area regarding the efficacy of scig compared to ivig in both the short and long term. diabetic peripheral neuropathy is the most common and debilitating complication of diabetes and it is associated to neuropathic pain and non-traumatic amputations. despite the economic burden and human costs, nowadays there is not a specific treatment to cure diabetic peripheral neuropathy. hyperglycaemia and dyslipidemia-mediated oxidative and endoplasmic reticulum stress has been linked to diabetic peripheral neuropathy, among other altered pathways. in order to study in more detail the molecular mechanisms that lead to the development of diabetic peripheral neuropathy we set up in vitro models of the disease using nsc-34 (motoneurons) and med17.11 (sensory neurons) cell lines or primary cultures of dorsal root ganglia and motoneurons exposed to saturated fatty acids. it has been reported that palmitic acid is able to induce endoplasmic reticulum stress and oxidative stress in multiple cell types including schwann cells and myenteric neurons, resulting in a good model of dyslipidemia-mediated stress. here we found that palmitate induces upregulation of the molecular chaperone bip/grp78 and the ccaat-enhancer-binding protein homologous protein (chop) mrnas and a dose-dependent downregulation of the apoptosis marker bcl-2 in primary cultures. moreover, palmitic acid induces loss of neuron dendrites and cell death at high doses and upregulation of heme oxygenase (ho-1) and chop at lower doses in the nsc-34 cell line. we are currently characterizing multiple molecules implicated in oxidative stress, endoplasmic reticulum stress and inflammation pathways in these cell types to find new therapeutic targets to treat type 2 diabetic sensorimotor polyneuropathy, that will be subsequently validated in the db/db mouse model by pharmacological or gene therapy strategies. lee bjh 1 , ohnmar o 2 , wong j 1 , koh sj 2 , umapathi t 2 . 1 lee kong chian school of medicine, nanyang technological university, singapore; 2 national neuroscience institute, singapore. treatment-induced neuropathy of diabetes mellitus (dm) (tind) is an acute painful peripheral neuropathy and autonomic dysfunction that occurs within 8 weeks of tight glycaemic control. therapy with either insulin or oral hypoglycaemic agents (ohga) may result in tind. the quantum and rate of decline in hba1c predicts development and severity of tind. both type i and ii dm patients are prone to this iatrogenic complication. besides the expected morbidity associated with painful somatic and autonomic neuropathy, tind patients also develop life-threatening eye complications such as maculopathy. with greater awareness, we picked up at least 3 typical cases of tind in recent few months. however, there was a fourth possible tind case, whom we feel deserves special attention. the circumstances surrounding this case are common and may go under-recognised in acute hospitals. a 66 year-old man with 11-year history of poorly controlled type ii dm was admitted with a partial left middle cerebral artery stroke. one month before admission, his hba1c was 14.4%. his hospitalization was prolonged because of his considerable disability that required rehabilitation. he stayed 11 weeks. his blood sugar was difficult to control with hyperglycaemic episodes requiring 2 ohgas and insulin. the highest capillary blood glucose recorded was 20 mmol/l. he also had 3 episodes of hypoglycaemia. three weeks into hospitalization, he developed severe orthostatic hypotension. he came to our attention two months later when he was sent for autonomic screening tests for severe postural hypotension, in spite of therapy with fludrocortisone and midodrine. his hba1c was 9.6%. he had marked orthostatic hypotension suggestive of sympathetic dysfunction. we were not able to discern if he had a painful neuropathy because of his aphasia. there was no recent ophthalmology review. we suggested a diagnosis of possible tind. he was discharged with lower doses of ohga. however, 1 day after discharge, he attended the emergency department for a syncopal episode. this case raises intriguing questions on the safety of glucose control paradigms commonly employed in patients with acute stroke and myocardial infarction as well as the possible role of major fluctuations in blood glucose in the development of tind. lee hs 1 , kim sm 2 . 1 presbyterian medical center, jeonju, korea; 2 yonsei university college of medicine, seoul, korea. the occurrence of peripheral neuropathy by a tumor within or compressing a nerve in neurofibromatosis (nf) type 1 and 2 is relatively well known. however, nf presenting with demyelinating polyneuropathy unrelated to tumor masses is rarely reported. we report a rare presentation of an nf patient with demyelinating polyneuropathy of subacute onset. a 30-year-old woman was referred to our hospital with paresthesia on both limbs 5 months before. she was healthy and had no family history. the symptoms worsened over the next 3 months, tremor and weakness in both limbs occurred. although she treated as a chronic inflammatory demyelinating polyneuropathy (cidp) with intravenous steroid and immunosuppressant in another hospital, symptoms were getting worse. bifacial numbness and left eyeball pain occurred 2 weeks ago and she visited our hospital. on neurologic examination, bilateral facial sensory hypoesthesia and symmetrical both limbs weakness (mrc grade iv+) were observed. decreased touch and pinprick sensation on both limbs were observed like stocking-glove distribution. the reflexes were sluggish. on nerve conduction study, sensorimotor demyelinating polyneuropathy with conduction blocks and temporal dispersions was observed. bilateral r1, r2 responses were prolongation on facial blink test. mri of cervical spine and brain revealed contrast enhancing tumor-like enlargement of multiple nerve roots and cranial nerves. nerve biopsy was performed on right supraorbital nerve, neurofibromatous changes were observed. the symptom deterioration was stopped without treatment. gene test dose not revealed nf type 1 and 2. on review of the literature, polyneuropathy in nf patient can result from tumor masses within the proximal nerve roots, or along the peripheral nerve, or in the extramedullary lesion affecting neighboring nerve roots. thus, axonal type polyneuropathy and focal amyotrophy have been reported in nf. demyelinating polyneuropathy has not been reported before in our knowledge. although the etiology of demyelinating polyneuropathy in nf requires further clarification, some authors claim that unknown local toxic or metabolic influences of the endoneurial pathological cells on adjacent nerve fibers. in this patient, atypical symptoms were observed in cidp such as cranial nerve involvement and stocking-glove sensory distribution. in this case, a nerve biopsy can be helpful the accurate diagnosis. lee jy 1 , yoo jh 1 , kang dk 1 , bae js 1 . 1 department of neurology hallym university, seoul, korea. acute disseminated encephalomyelitis (adem) is an uncommon post-infectious inflammatory demyelinating disorder of central nerve system, while guillain-barre syndrome (gbs) is a prototype of acute post-infectious peripheral neuropathy. previous reports regarding the coexistence of these relatively rare diseases suggest that certain immunogenicity within central and peripheral nerves may share a common autoimmune process during the disease course. a previous healthy 20 years old man was admitted because of fever, headache, nausea and myalgia in department of infectious disease. two weeks before admission, he suffered from watery diarrhea for 3 days and spontaneously recovered. at initial presentation, he had high fever(39 ∘ c), headache and myalgia and intermittent horizontal diplopia. a few days after admission, he began to complain of drowsy mentality, bilateral extremities weakness, especially lower limbs, dysarthria, bilateral facial paralysis, urinary retention, dyspnea. on neurologic examination, he had mildly drowsy mentality, symmetric muscle weakness scoring 4 of 5 on bilateral hip, knee flexion and finger extension, but he had no sensory symptoms. he showed gazed evoked nystagmus with no extraocular muscle palsies. deep tendon reflexes were not present. pulmonary function test revealed a severe restrictive pattern. csf studies disclosed a dissociative increase of protein contents (66mg/dl) without pleocytosis. anti ganlioside antibody assay identified an anti-gt1a igg positivity in his serum. nerve conduction study (ncs) showed prolonged motor terminal latencies and slow motor conduction velocity on multiple nerves. in contrast, sensory ncs revealed no abnormal findings. imaging studies unexpectedly revealed apparently symmetrical lesions across bilateral brainstem and basal ganglia suggesting a diagnosis of adem. after both ivig and high dose steroid treatment, he remarkably recovered from disturbed mental state and motor weakness. about 1month after the symptom onset, he could walk with assistant aid and discharge to other hospital for rehabilitation. our case suggest that certain component of autoimmunity simultaneously result in both cns and pns inflammation. specific immunological mechanism is remained to be elucidated. although we could not conclude whether cellular component or humoral component is dominant for our case, the presence of anti gt1a antibody suggest a role of humoral mechanisms. the aim of this study is to evaluate whether peripheral neuropathies and headaches affect the same subgroups of patients with ibd. since 2004, we have established a cohort study to evaluate the prevalence and incidence of neurological diseases in patients with ibd. over a period of 2 years, all patients with ibd (either crohńs disease or ulcerative colitis) were invited to participate in a study designed to evaluate the risk factors for the presence of headaches and peripheral neuropathy in ibd. a separate group of control patients (age-matched relatives of ibd patients) was also formed. after a clinical interview and neurological examination, patients were invited to undergo skin wrinkling test (swt) to evaluate small fiber function and/or electromyography. headaches were present in 49.3% of the patients with ibd, and were more common in patients with ulcerative colitis than in control patients (p<0.05). migraine comprised 61.2% of all cases of headache and was more prevalent in patients with crohńs disease than control patients (p<0.05). tensional headaches were also common affecting 25.4% of the ibd patients. electromyography was abnormal in 21.1% of the ibd patients tested (19/90). swt was abnormal in 42.2% of the ibd patients tested (38/90). 14.4% of the ibd patients had abnormal swt but had no neuropathy symptoms. patients with abnormal swt or emg were not more likely to have headaches (p=0.30 and 0.87, respectively). overall, patients with symptomatic polyneuropathy were not more likely to have headache (p=0.48). patients with abnormal swt or emg were also not more likely to have migraine (p=0.43 and 0.28, respectively). patients with abnormal swt or emg were also not more likely to have tension-type headache (p=0.31 and 0.62, respectively). in summary, although highly prevalent in this population of brazilian ibd patients, primary headaches and neuropathy do not affect the same subgroups of ibd patients. further studies are necessary to understand the mechanisms of both conditions in ibd patients. leitao amf 1,2 , araújo df 1 , marques h 2 , pamplona l 2,3 , souza mh 2,4 , nbraga ll 2,4 , gondim faa 2,4 . the aim of this study is to evaluate whether peripheral neuropathies and headaches affect the same subgroups of patients with ibd. since 2004, we have established a cohort study to evaluate the prevalence and incidence of neurological diseases in patients with ibd. over a period of 2 years, all patients with ibd (either crohńs disease or ulcerative colitis) were invited to participate in a study designed to evaluate the risk factors for the presence of headaches and peripheral neuropathy in ibd. a separate group of control patients (age-matched relatives of ibd patients) was also formed. after a clinical interview and neurological examination, patients were invited to undergo skin wrinkling test (swt) to evaluate small fiber function and/or electromyography. headaches were present in 49.3% of the patients with ibd, and were more common in patients with ulcerative colitis than in control patients (p<0.05). migraine comprised 61.2% of all cases of headache and was more prevalent in patients with crohńs disease than control patients (p<0.05). tensional headaches were also common affecting 25.4% of the ibd patients. electromyography was abnormal in 21.1% of the ibd patients tested (19/90). swt was abnormal in 42.2% of the ibd patients tested (38/90). 14.4% of the ibd patients had abnormal swt but had no neuropathy symptoms. patients with abnormal swt or emg were not more likely to have headaches (p=0.30 and 0.87, respectively). overall, patients with symptomatic polyneuropathy were not more likely to have headache (p=0.48). patients with abnormal swt or emg were also not more likely to have migraine (p=0.43 and 0.28, respectively). patients with abnormal swt or emg were also not more likely to have tension-type headache (p=0.31 and 0.62, respectively). in summary, although highly prevalent in this population of brazilian ibd patients, primary headaches and neuropathy do not affect the same subgroups of ibd patients. further studies are necessary to understand the mechanisms of both conditions in ibd patients. the classic guillain barré syndrome (gbs) is characterized by motor weakness, hyporreflexia, but limited sensory deficits. sensory variants involving either small or large fibers or both are unusual and represent a diagnostic challenge. we described 6 patients presenting with the sensory variant of gbs and retrospectively analyzed the clinical and electrophysiological findings of patients fulfilling the criteria for sensory gbs according to oh et al. criteria. six patients were identified (mean age 38 years: range 15-54 years). four had a previous infection. they all consulted due to distal painful paresthesias and allodynia. on examination the 6 patients presented normal strength and normal cranial nerves through the course of the disease with reduced knee and ankle reflexes in 3 patients. distal hyperesthesia to pinprick was identified in 3 and one of them additionally had hyperhidrosis and constipation. two additional patients presented hypoesthesia to pinprick and temperature. one patient had distal proprioceptive sensory loss with sensory ataxia. csf albumin cytological dissociation was present in 3 patients. nerve conduction studies (ncs) identified a sensory motor demyelinating neuropathy in 2 patients. among the 4 with normal ncs, 2 had abnormal cold and warm threshold in their qst evaluation. all patients received symptomatic treatment for the neuropathic pain and only two ivig therapies. longstanding pain, fatigue or both were persistent findings in 5 patients after a mean follow up of 6 months. in conclusion the sensory variant of gbs is both an infrequent presentation and a diagnostic challenge. longstanding pain and fatigue are common persisting findings. the epidemic of zika virus (zikv) throughout the americas and asia, and the subsequent rise in reported cases of guillain-barré syndrome (gbs) caused worldwide concern. as of january 2017, 76 countries have reported evidence of mosquito-borne zikv transmission and in 16 of these countries, a sudden increase of gbs has been reported. moreover, case studies and a case-control study further indicate that zikv may trigger gbs. however, accurate diagnosis of both zikv and gbs in many of these studies is disputed, and a comprehensive description of the clinical phenotype of gbs related to zikv is lacking. the international gbs outcome study (igos) is a prospective observational study on the factors determining the onset, clinical course and outcome of gbs. at present, a research consortium of 150 centers from 19 countries has included 1461 patients in igos. our aim is to investigate zikv-related gbs in igos as is already occurring in colombia. in igos-zika, data on clinical features and ancillary investigations will be collected in zikv endemic areas according to the igos protocol with some modifications. first, igos-zika has a case-controlled study design to define the association between gbs and zikv and other arboviruses. second, urine samples will be collected and additional questions on preceding events will be asked, focusing on arbovirus infections. third, a more limited follow-up is required. our aim is to recruit additional centers via the inflammatory neuropathy consortium (inc) and centers in all arbovirus endemic regions that are willing to participate. the focus of igos-zika will be on the accuracy of the diagnosis of both gbs and zikv and on defining the associated clinical phenotype, course and outcome. igos-zika provides the opportunity to combine data and biobanks from various geographical regions using a standardized protocol and to compare these data with data and biosamples already collected in igos. studying these cases will help to optimize diagnostics and care for gbs patients in arbovirus endemic countries and provides a unique opportunity to further understand the pathogenesis of gbs. moreover, this study design and network can be used to adequately respond to other future viral epidemics related to gbs. lerat j 1 , cintas p 2 , dzugan h 1,3 , magdelaine c 1,3 , sturtz f 1,3 , lia as 1,3 . 1 service de biochimie et génétique moléculaire -chu de limoges, limoges, france; 2 service de neurologie et d'explorations fonctionnelles -chu de toulouse, toulouse, france; 3 ea6309-université de limoges, limoges, france. pharc syndrome is an autosomal recessive neurodegenerative pathology leading to demyelinating polyneuropathy, hearing loss, cerebellar ataxia, retinis pigmentosa and early-onset cataract. these various symptoms can occur at different ages, so that pharc syndrome can be a differential diagnosis of charcot-marie-tooth disease (cmt) associated with deafness. only 13 abhd12 mutations have been reported in 33 patients. we described the 14th mutation and compared our results to the literature data. we analysed by next generation sequencing (ngs) strategy using a targeted cmt and associated neuropathies 92-gene panel the dna of a 36-year old male who has suffered from demyelinating sensory and motor polyneuropathy and ataxia since the age of 15. bilateral sensorineural deafness was diagnosed at the age of five. bilateral congenital cataracts were operated on at the age of 28. a new large complex homozygous mutation, with one deletion of seven base pairs and one insertion of 38 base pairs, was detected. by analyzing our patient data and those of the literature, we evaluated that, in pharc syndrome, sensorineural deafness always occurs as the first feature in late teens. the ophthalmological symptoms are cataracts that occur at a mean age of 25 yo and then retinis pigmentosa at a mean age of 29. demyelinating sensory-motor polyneuropathy is the most variable characteristics, which occurs in the thirties. we report the first large complex homozygous mutation in pharc syndrome, which is certainly under-diagnosed. therefore, it seems interesting to include abhd12 in the panels of the five symptoms, especially deafness ones. chronic inflammatory demyelinating polyradiculoneuropathy (cidp) is a chronic disabling disease that often improves with immune therapy. to date, the most reliable diagnostic criteria for cidp are the 2010 efns/pns revised criteria, with a reported sensitivity of 80% and specificity of 90%. we implemented a web-based database to collect data from patients with cidp followed by italian centers with expertise on cidp to determine the frequency and characteristic of cidp and it variants, the diagnostic criteria used for their diagnosis, the possible evolution into typical cidp, the association with specific anti-nerve antibodies, and their response to therapy. all the patients were evaluated at the time of inclusion and will be followed for two years to monitor their outcome and response to therapy. by february 2017 we included 360 patients with cidp and variants (227 men, 133 women), aged 12-86 years (median 59) with a mean disease duration of 8.2 years (range 0.5-52 years). based on clinical symptoms, cidp was defined as typical in 85% and atypical in 15%. the diagnosis of typical cidp fulfilled efns/pns criteria in 84% of the patients while nerve conduction studies were not diagnostic in 14% (grouped as clinical cidp) or not available in 2%. we analyzed the frequency of supportive criteria for the diagnosis of cidp in patients with clinical cidp and found that increased csf proteins, demyelination or cell infiltration on nerve biopsy and imaging abnormalities consisting with cidp on us or nmr were present in 81%, 47% and 57% of the patients, respectively. a relapsing course was present in 79% of patients with clinical cidp, increasing the reliability of the diagnosis for cidp. in addition an improvement after one or more therapies was reported by 87% of the patients, with a positive response to ivig in 74%, steroids in 52% and plasma exchange in 59%, similarly to what observed in patients fulfilling efns/pns criteria. in 84% of the patients with clinical cidp two or more supplementary criteria for cidp were present. this study on a large population of patients is providing useful information that may help to revise the current diagnostic criteria for cidp. li j 1 , cannell m 1 , suragani r 1 , pearsall r 1 , kumar r 1 . 1 acceleron pharma inc, cambridge, usa. charcot-marie-tooth (cmt) is the most common hereditary peripheral neuropathy and is characterized by demyelination and/or axonal damage of peripheral nerves and muscle weakness. foot drop, steppage gait, and foot deformities are a typically seen in cmt patients. consequently, falls are commonly reported in these patients. improvement of dorsiflexor muscle function to prevent falls may improve quality of life and activities of daily living in patients with cmt. ace-083, a locally-acting ligand trap that binds growth and differentiation factors (gdfs) and activins, has previously been shown to increase muscle mass and force in both duchene muscle dystrophy (dmd) and amyotrophic lateral sclerosis (als) mouse models. in the current study, we evaluated the therapeutic effects of ace-083 to improve muscle strength in the trembler (tr-j) mouse model of cmt1a. these mice harbor a mutation in the peripheral myelin protein 22 (pmp22) known to cause cmt1a. seven-month old (b6.d2-pmp22 tr-j /j) mice were administered ace-083 (100 g, twice weekly) intramuscularly to one of the unilaterally tibialis anterior (ta) muscle for 4 weeks. the contractility of the ta muscle was evaluated during isometric contraction. all data were compared to the uninjected contralateral control hind-limb. after 4 weeks of ace-083 treatment, ta muscle mass was increased by 63% (p<0.01) and its physiological cross-sectional area was increased by 69% (p<0.01). the increase in muscle mass correlated with an increase in strength, with maximum tetanic force and twitch force improved by 65% (p<0.001) and 44% (p<0.001), respectively. in addition, temporal properties during isometric contraction, such as maximum rate of contraction and relaxation, were accelerated by 46% and 56% respectively (p<0.001) in the ace-083-treated ta muscle compared to its contralateral hind-limb. pathological and biochemical assessment of ace-083-treated mice showed enlarged myocyte area (+14%, p<0.05) and reduced atrogin-1 mrna expression (−49%, p<0.001). together, these results demonstrated that ace-083 attenuates the degree of muscle atrophy and also improves muscle function in a mouse model of cmt1a. the current study provides proof of concept for the use of ace-083 as a therapy for cmt to improve dorsiflexor muscle function and alleviate foot drop. we have generated a rat model of charcot-marie-tooth disease 2a (cmt2a) harboring the p.arg364trp mfn2 mutation, whose human counterpart results in a severe, early-onset axonal neuropathy. the mutation was made using zinc finger nuclease-mediated genome editing in fertilized rat eggs. a large cohort of mutant and wt littermates were characterized behaviorally and found to develop multiple motor deficits that worsened over time. nerve conductions of the tail (caudal nerve) was performed on a separate cohort of mutant (n=14) and wt littermates (n=13) every 4 weeks from 8 to 48 weeks. mutant rats showed a progressively decline in the amplitude of the compound action potential after 20 weeks, whereas the amplitude progressively increased in their wt littermates. separate cohorts of rats were sacrificed at 7, 40, and 48 weeks and analyzed by light microscopy. in mutant rats, there was a reduced density of myelinated axons and active axonal degeneration in distal but not proximal nerves, and in the fasciculus gracilis of the cervical spinal cord at 40 and 48 weeks. these findings were not present in the 7-week-old cohort of mutant rats, or in wt rats at 7 or 40 weeks. a genetically authentic animal model of cmt2a that develops a progressive, length-dependent axonal neuropathy will be a valuable tool for examining the pathogenesis and treatment of cmt2a. lindborg ja 1 , niemi, jp 1 , defrancesco a 1 , zigmond re 1 . 1 case western reserve university, cleveland, usa. traditionally the role of immune cells in nerve degeneration and regeneration has focused on the infiltration of inflammatory monocytes into the distal nerve after nerve injury and the phagocytosis by the resulting macrophages of myelin and axonal debris, thereby clearing a path for regenerating axons. therefore, it was surprising when we discovered that in ccr2 knockout (ko) animals, in which the entry of these inflammatory monocytes does not occur, that wallerian degeneration precedes normally. we now report that the reason for this is that neutrophils and schwann cells compensate for the decrease in macrophage accumulation. furthermore, nearly complete depletion of circulating neutrophils by systemic injection of an antibody to ly6g leads to an inhibition of myelin clearance both in ccr2 ko and in wild type animals. on the other hand, we have demonstrated a second site of macrophage accumulation in wild type animals, namely around axotomized sensory neurons in dorsal root ganglia (drgs). blockade of that accumulation, for example as occurs in ccr2 ko animals, leads to a dramatic impairment of nerve regeneration. to examine the relationship between macrophages and regeneration further the monocyte chemokine ccl2 was overexpressed in drg neurons in intact animals by viral infection using an aav5 containing the ccl2 coding sequence. the resulting overexpression of ccl2 led to the accumulation of macrophages in drgs even though no injury had taken place and subsequently to an increase in the intrinsic growth capacity of the sensory neurons. examination of changes in gene expression in the drgs in these animals revealed increased expression of the cytokine leukemia inhibitory factor and an increase in its downstream signaling pathway that involves the phosphorylation and nuclear translocation of stat3. strikingly, pharmacological blockade of stat3 activation inhibited the increase in the neurons' growth capacity produced by the virus. these results reveal unexpected interactions between immune cells and neurons facilitating nerve degeneration and regeneration and could lead to therapies to improve regeneration after injury or in disease. lin j 1,2 , qiao k 1,2 , huang j 1,2 , zhao cb 1,2 , lu jh 1,2 . 1 institute of neurology, fudan university, shanghai, china; 2 department of neurology, huashan hospital, fudan university, shanghai, china. we used terminal latency index (tli) as a tool in differentiation between poems syndrome and chronic inflammatory demyelinating polyradiculoneuropathy (cidp). comparison of median and ulnar nerve conduction studies including motor conduction velocity (mcv), distal motor latency (dml) and terminal latency index (tli) were studied in 18 poems patients, 58 matched cidp patients and 30 normal controls. in this cohort, the average age at evaluation was 51.56±8.77 years old in poems group and that of 58 cidp patients was 46.34±16.38 years old. except the ulnar terminal latency index in cidp group, poems and cidp patients demonstrated prolonged distal latencies, low conduction velocities and increased terminal latency indexes compared with the normal group. reduced conduction velocities and higher terminal latency indexes in poems group than in cidp group was found. increased tli was demonstrated in 55.6%(median nerve) and 52.9%(ulnar nerve) poems and that in cidp patients was 25.9%(median nerve) and 22.4%(ulnar nerve). decreased tli was found in 24.1%(median) and 20.7%(ulnar) cidp patients and none in poems. temporal dispersion (td) and conduction block (cb) were more often seen in cidp patients with increased tli than that in poems. compared with cidp and poems showed greater slowing of the intermediate nerve segments and relatively more uniform demyelination. about 25% cidp demonstrated more distal conduction slowing and more td and cb especially in those with increased tli. terminal latency index combined with td and cb may be helpful in differentiating poems from cidp. lin y 1 , sung j 1 , chang t 1 , jowy t 1 . 1 department of neurology, taipei municipal wanfang hospital, taipei, taiwan. the purpose of our study is to exam whether electrophysiology changes could be detected in prediabetes patients and to discover the possible mechanism of nerve injury in prediabetes stage. we analysis and compare the nerve excitability test data between prediabetic patients and age-matched normal control subjects. prediabetes is defined by american diabetes association (ada) as one of the three following: hba1c 5.7% to 6.4%, fasting glucose 100mg/dl to 125mg/dl, and 2 hour oral glucose tolerance test 140 to 199 mg/dl. patients with radiculopathy, myelopathy, entrapment neuropathy such as carpel tunnel syndrome, and polyneuropathy were excluded. the strength-duration time constant (sdtc) and superexcitability showed significant difference (p<0.05) between two groups. we also find increased threshold electrotonus in depolarization (ted) and reduced relative refractory period (rrp) and refractoriness in 2.5 msec. these early changes in prediabetic patient are similar in nerve excitability feature of diabetic patients. however, the above changes are not found in motor axonal excitability test. our data supports that nerve excitability test may be a useful, non-invasive, and less time dependent tool to detect peripheral nerve injury in prediabetic stage. the sensory axons are more vulnerable than motor axons. superexcitability is the most sensitive parameter in prediabetes. transthyretin-related familial amyloid polyneuropathy (ttr-fap) is an autosomal dominant disorder caused by mutations of ttr gene and is associated with variable penetrance. ttr-fap is rare, except for endemic areas. this is a retrospective study of ttr-fap patients diagnosed at our center between 1970-2016. we identified four families with different ttr mutations. in one family with v71a mutation, nine family members over four generations diagnosed with ttr-fap was followed since 1970. in the other families the index cases with different mutations were identified between 2014-2016. affected family members with v71a mutation developed severe progressive polyneuropathy with cachexia, with onset of the disease between ages 29 and 44. three patients presented with marked visual symptoms (one patient underwent vitrectomy). nine patients died 4 to 11 years after disease onset. two patients (sisters) underwent liver transplantation -one died after 11 years of disease at age 40, second is 49 years old and wheelchair-bound as her symptoms continue to progress. the ttr mutations diagnosed in the index cases of three other families are: d38v, f33l and v30m. they all presented with similar clinical picture of late-onset ttr-fap with predominant progressive axonal sensory, motor and autonomic polyneuropathy. all three index cases were men, the onset of symptoms was between 50-54 years with numbness and paresthesia in the feet followed by weakness and autonomic dysfunction. all had excessive weight loss resulting in cachexia and were diagnosed with cardiomyopathy. no patient suffered from visual symptoms. all three patients progressed to stage ii of ttr-fap -walking with assistance. time to diagnosis was 3.5-5 years. due to advanced stages of their disease these patients were not suitable for therapy with tafamidis or the liver transplantation. the ttr d38v (p.d58v) was confirmed as a de novo mutation, which is uncommon in ttr-fap. in the remaining families carriers of ttr mutations were identified and are followed up. pedigree analysis of the family with f33l mutation revealed affected members who with high probability died from ttr-fap. our study suggests that patients with ttr-fap in poland exhibits clinical and genetic heterogeneity. liu x 1 , fan d 1 . 1 department of neurology, peking university third hospital, beijing, china. objective: to identify the gene mutation of chinese charcot-marie-tooth pedigrees and investigate the correlation among the clinical manifestation, electrophysiology and mechanism of different genotype. methods: we included 105 pedigrees with cmt enrolled in our hospital from january, 2007 to december 2013. we recorded clinical features, cmtns and electrophysiological data at diagnosis. the patients underwent mutation analysis of pmp22, cx32, mpz, mfn2, hspb1, hspb8 using mlpa, dhplc and sanger gene sequencing. results: we found 31 pmp22 duplication pedigrees (29.5%), 8 cx32 pedigrees (7.6%), 4 mfn2 pedigrees (3.8%), 3 mpz pedigrees (2.8%) conclusions: in chinese han population, the proportion of pmp22 duplication is relatively low, the majority of clinical manifestation is classical cmt. axonal cmt can show isolated lower extremity injury, with central nervous system involvement. hmn may be an underestimated clinical types, the identification should be done with caution in differential diagnosis. liu y 1 , liu b 1 , sebastian b 1 , wozniak km 1 , wu y 1 , slusher b 1 , polydefkis m 1 . 1 johns hopkins school of medicine, baltimore, usa. chemotherapy-induced peripheral neuropathy (cipn) is a common dose-limiting toxicity in the treatment of many cancers. most cipn studies preferentially focus on sensory fiber loss and dysfunction. here, we compared the structural and functional recovery of autonomic fibers in sweat glands (sweat gland nerve fiber density, sgnfd) and sensory fibers (intra-epidermal fiber density, ienfd) in mouse footpads after exposure to a maximum tolerated dose (mtd) of several common chemotherapy agents. additionally, we assessed footpad sweat production as a functional correlate to sgnfd reductions. female balb-c mice (3-animals/group) were treated with a mtd of four anti-tubulin drugs: paclitaxel (pca, 30 mg/kg), ixabepilone (ixa, 2 mg/kg), eribuline (erib, 1.2 mg/kg), vinoelbine (vino, 11 mg/kg), or corresponding placebo given intravenously, mwf for two weeks. recovery was assessed at 24-hours, 1, 2, 4, 8, 12 and 24 weeks following the last dose. footpads were processed to visualize epidermal nerve fibers using pgp9.5 and autonomic nerve fibers with tyrosine hydroxylate and pgp9.5. ixabepilone-treated mice experienced significant reductions in sgnfd at 24hrs, while ienfd nadir occurred at a later time point, 2-weeks. the recovery to baseline levels occurred more quickly for ienfd (4-weeks) than sgnfd (8-weeks). in contrast, vinorelbine and eribuline treated mice experienced a maximum deficit in sgnfd and ienfd at 24hrs and sgnfd recovery was slower (24-weeks) compared to ienfd (4-weeks). pca-treated animals showed more severe ienfd and sgnfd deficits compared to the other agents with both ienfd and sgnfd not recovering completely until 24-months. reductions in th-sgnfd were comparable or more pronounced to decreases in pgp9.5-sgnfd for all agents and timepoints. pca-treated animals demonstrated reductions in footpad sweat droplet number thereby providing a functional correlate. together, these data indicate that in mouse models of cipn, autonomic nerve fibers are affected more severely than sensory nerve fibers, and also recover more slowly than intraepidermal nerve fibers. autonomic dysfunction may be an important and under-appreciated consequence of chemotherapy exposure. the pi 3-kinase vps34 (pik3c3) synthesizes phosphatidylinositol 3-phosphate (pi3p), a lipid critical for both endosomal membrane traffic and macroautophagy. human genetics have implicated pi3p dysregulation, and endosomal trafficking in general, as a recurring cause of demyelinating charcot-marie-tooth (cmt) peripheral neuropathy. here, we investigated the role of vps34, and pi3p, in mouse schwann cells by selectively deleting vps34 in this cell type. vps34-schwann cell knockout (vps34 scko ) mice show severe hypomyelination in peripheral nerves. vps34 −/− schwann cells interact abnormally with axons, and there is a delay in radial sorting, a process by which large axons are selected for myelination. upon reaching the promyelinating stage, vps34 −/− schwann cells are significantly impaired in the elaboration of myelin. nerves from vps34 scko mice contain elevated levels of the lc3 and p62 proteins, indicating impaired autophagy. however, in the light of recent demonstrations that autophagy is dispensable for myelination, it is unlikely that hypomyelination in vps34 scko mice is caused by impaired autophagy. endosomal membrane traffic is also disturbed in vps34 −/− schwann cells. we investigated the activation of the erbb2/3 receptor tyrosine kinases in vps34 scko nerves, as these proteins, which play essential roles in schwann cell myelination, are known to traffic though endosomes. in vps34 scko nerves, erbb3 was hyperphosphorylated on a tyrosine known to be phosphorylated in response to nrg1 exposure. the overall level of erbb2 was also decreased during myelination. our findings suggest that the loss of vps34 alters the trafficking of erbb2/3 through endosomes. abnormal erbb2/3 signaling may contribute to the hypomyelination observed in vps34 scko mice. lombardi r 1 , devaux j 2 , cortese a 3 , dacci p 1 , benedetti l 4 , demichelis c 4 , lauria g 1 . 1 irccs foundation "carlo besta" neurological institute, milan, italy; 2 aix-marseille université, marseille, france; 3 irccs c. mondino national neurological institute, pavia, italy; 4 university of genoa and irccs aou san martino-ist, genoa, italy. the recent identification of igg4 anti-neurofascin (nfascin) antibodies in a group of patients has widened the spectrum of presentation for chronic inflammatory demyelinating polyradiculoneuropathy (cidp). these patients can be distinguished by disabling tremor, poor response to intravenous immunoglobulin and distal and sensory disturbances. cell-adhesion molecule nfasc155 and cntn1 are expressed on the paranodal junction (pnj) of nodes of ranvier, and play key roles on sodium channel clustering and glia-axon interactions. quantification of unmyelinated intraepidermal nerve fibers (ienf) is a useful parameter employed in small nerve fiber pathology diagnosis. in addition the immunohistochemistry evaluation of dermal nerve fibers allows to examine morphological changes of myelin sheath and ranvier nodes structure. we performed immunofluorescent colocalization studies using antibodies to visualize axons (protein-gene-product 9.5, neurofilament, tubulin), sheath of myelin (myelin-basic-protein) and specifically nodal/paranodal/juxtaparanodal structures (pannfascin, nfascin155, nfascin186, caspr, cntn1, potassium and sodium channels) in skin tissues from seronegative and seropositive cidp patients. we analyzed axon and myelin sheath damage, abnormal nodal-paranodal-juxtaparanodal architecture and morphometric parameter as internodal length of ranvier nodes. our results on skin biopsies from three igg4 nfasc155-positive cidp patients revealed complete loss of nfasc155 staining at the paranodes, asymmetrical paranodes and widening of the nodes of dermal myelinated nerve fibers. one igg4 cntn1-positive cidp patient showed abnormal nodal/paranodal immunostaining with different features as compared with igg4 nfasc155-positive patients suggesting specific changes. however, such alterations were not found in four seronegative cidp patients. our data support the hypothesis that examining specific axonal and myelin markers could provide diagnostic and prognostic clues on nodo-paranodopathies. the goal of this study is attempt a possible correlation between the presence of serum autoantibodies and structural changes in nodal/paranodal regions of dermal nerve fibers in cidp patients. knowledge of autoantibodies expression in the peripheral myelinated nerves of cidp patients could serve for stratifying patients and potentially guiding personalized treatments. lunati a 1 , lerat j 1 , dzugan h 1,2 , rego m 2 , magdelaine c 1,2 , bieth e 4 , calvas p 4 , cintas p 5 , gilbert-dussardier b 6 , goizet c 7 , journel h 8 , magy l 9 , toutain a 10 , urtizberea j 11 , sturtz f 1,2 , lia as 1,2 . charcot-marie-tooth disease is one of the most frequent inherited peripheral neuropathies (1/2500). so far, mutations in more than 80 genes have been identified causing either the demyelinating form (type 1) or the axonal form (type 2). duplication of pmp22 gene is the most frequent cause of autosomal dominant demyelinating form. autosomal recessive demyelinating form is often due to sh3tc2 gene mutations. patients suffer then from early severe neuropathy starting in the first decade. scoliosis and deafness are often observed. we analysed 200 patients suffering from peripheral neuropathy, by multiplex-ligation-dependant-probe-amplification (mlpa), followed by targeted next-generation-sequencing (ngs) using a 92-gene custom panel designed for the diagnosis of charcot-marie-tooth and associated neuropathies. mutations of interest were verified by sanger sequencing. diagnosis was positive for 114 patients. as expected, the most frequent mutation was the pmp22 duplication detected in 30 patients. deletion of pmp22 was observed in 18 patients and pathogenic point mutations were detected in 66 patients. sh3tc2 gene appeared to be the most frequently mutated with nine patients diagnosed. associated with known mutations, four new mutations have been identified: two nonsense mutations and two missense mutations. all these patients presented deafness and/or scoliosis. sh3tc2 appears to be an important gene involved in charcot-marie-tooth disease, often associated with deafness and /or scoliosis. it is important to pay attention to these associated symptoms in charcot-marie-tooth patients in order to guide their diagnosis and to improve their medical care. lupo v 1,2 , frasquet m 3,4 , sánchez-monteagudo a 1,2 , barreiro m 3 , alberti ma 5 , casasnovas c 5 , quintáns b 4,6,7 , camacho a 8 , domínguez c 8 , sedano mj 9 , pelayo al 9 , pardo j 10 , sobrino t 10 , sobrido mj 4,6,7 , sevilla t 3,4 , espinós c 1,2 . mme (membrane metalloendopeptidase) mutations, inherited in an autosomal recessive fashion, have been recently identified in 10 japanese probands (higuchi et al. 2016) . thus, mme has been included in the list of cmt genes as a new autosomal recessive axonal form, cmt2t (mim 617017), and moreover, it is considered a strong candidate for the genetic diagnosis of unsolved late-onset cmt2 cases. in fact, few months later auer-grumbach et al. (2016) reported 19 european probands with autosomal dominant late-onset cmt2 and mutations in mme. we have investigated a clinical series of 190 patients diagnosed of motor or sensory-motor peripheral neuropathy using an updated version of our custom gene panel, which includes mme. in this study, we report 6 probands with cmt2, intermediate cmt or dhmn/cmt2 and homozygous or compound heterozygous mutations in mme, and 1 proband with cmt1 and a heterozygous mutation in mme. we have identified 7 different type of mutations: 1 novel splice donor variant, 1 frameshift, 2 nonsense and 3 missense mutations. the two nonsense changes, p.trp24* and p.arg448*, and the splice donor variant c.196+1g>a, were detected in homozygous or compound heterozygous state in 3 patients, while the frameshift mutation, p.pro156leufs*14, was detected in homozygous or heterozygous in the remaining 3 patients. strikingly, the two nonsense and the frameshift mutations had been previously reported as causative for autosomal-dominant cmt2t (auer-grumbach et al. 2016) . out of three missense mutations, one is novel (p.his712tyr), and two are reported in control databases (p.asn689lys and p.arg748trp). this study shows that the autosomal recessive cmt2t is common in spanish population, and moreover, it suggests that screening of mme using gene panel testing could help to improve diagnosis of unclarified inherited peripheral neuropathies cases. funds: isciii (pi12/00453, pi15/00187); fundació per amor a l' art. inherited peripheral neuropathies (ipns) encompass a group of disorders highly heterogeneous, clinically and genetically. charcot-marie-tooth (cmt) disease is closely related to distal hereditary motor neuropathy (dhmn) or distal spinal muscular atrophy (dsma), and some patients show additional signs associated with amyotrophic lateral sclerosis (als). targeted gene panel and exome sequencing are considered to be powerful and cost-effective tools for diagnosis of these disorders. we have investigated a clinical series of 226 patients diagnosed of motor or sensory-motor peripheral neuropathy: 24 families were investigated by exome sequencing and, 202 cases were tested using different updated versions of a gene panel . each version comprises 104, 111 or 119 ipn genes, respectively and it shows a high coverage performance: percentage of analyzable target base with >20 coverage was 99,99%. both exome and gene panel capture libraries were based on sureselect capture technologies (agilent technologies), and sequencing was performed in miseq or hiseq illumina equipment. we have identified novel genes and novel mutations in known genes, broadening the phenotypical spectrum associated with ipns. exome sequencing has allowed us to identify causative gene in 58% of familiar or sporadic cases: morc2, aars, bscl2, kif1a, gars, egr2, fig4, dnajb2, drp2, ighmbp2, dao, sod1, fig4 . gene panel testing has been mostly performed in sporadic cases, and it has allowed us to identify either disease-causing or candidate mutations in 40% of cases: kif1a and bicd2 were the most common genes mutated. update gene panels neuro 111 and neuro119 have revealed novel mutations in genes recently associated to cmt2 and cmt1 disease: mme and pmp2, respectively. in sum, both strategies have helped us to achieve a more accurate clinical and genetic reclassification of these disorders, an impossible challenge using conventional sequencing methods. our study expands the clinical phenotype previously associated to known ipn causing-gene, and emphasizes that gene panels should be considered as a first diagnosis method for unclarified ipn patients. funds: isciii (pi12/00453, pi12/00946, pi15/00187); fundació per amor a l' art. magy l 1 , mathis s 2 , goizet s 3 , tazir m 4 , vallat j-m 1 . 1 department and laboratory of neurology, national reference center for rare peripheral neuropathies, chu limoges, france; 2 department of neurology, chu bordeaux, france; 3 department of medical genetics, chu bordeaux, france; 4 department of neurology, chu algiers, algeria. charcot-marie-tooth (cmt) disease is a hereditary neuropathy with a relatively homogeneous phenotype but is genetically heterogeneous. moreover, nerve conduction studies distinguish different forms, adding another level of complexity. the current classification of cmt being difficult to understand for physicians, scientists and patients, we presented and published a proposal for updating this classification, based on inheritance, nerve conduction findings and gene/mutation involved. inputs from colleagues prompted us to conduct a survey in order to try to reach some consensus about our proposals. we conducted an internet survey between october and december 2016. the link to complete the survey was sent several times by email with an introduction to more than 300 people. participants were contacted through the emailing list from the last cmt meeting in venice (september 2016) and additional physicians and scientists who are involved in cmt care and research were contacted as well. one hundred seven people from various countries (mainly france, italy and the usa) answered the survey. most (81%) of the participants were between 30 and 60 years of age, 60% being physicians and 37% being scientists. the vast majority (65%) considered the proposal constituted an improvement over the historical classification whereas 23% wanted to keep the old one. about the order of information, 39% of participants thought the mode of inheritance should come first, whereas 33% felt the phenotype should be placed at the beginning. ninety-one percent of people thought cmt should be kept as a generic name for hereditary sensory and motor neuropathy. for pure sensory neuropathy, 48% favoured hsn over hsan although 41% thought the opposite and 80% of participants felt dhmn should be kept for distal motor neuropathy. about nerve conduction findings, 70% of participants thought the intermediate phenotype has to be kept and 68% favoured our proposal to replace "1" by "de" (for demyelinating) and "2" by "ax" (for axonal). finally, 88% of responders thought that genetic information should be included in the classification of cmt. overall, our proposal of a new classification received a very good appreciation from physicians and scientists implicated in the care of patients with hereditary neuropathy. mallik r 1 , hubsch a 2 , gaida a 2 , barnes d 3 . 1 csl behring, kop, usa; 2 csl behring, bern, switzerland; 3 csl behring, ottawa, canada. the risk of hemolytic events (hes) with intravenous immunoglobulin (ivig) therapy appears to be linked to the isoagglutinin (anti-a and anti-b) level of the specific ivig product. using published anti-a and anti-b titers for seven ivig products and corresponding he rates reported to the eudravigilance database, we developed a mathematical model to predict the risk of he to patients receiving ivig products of given anti-a and anti-b levels. modeling was performed separately for the risk to patients with blood groups a, b, ab and o and the overall population risk was estimated assuming a blood group distribution of 42% a, 10% b, 4% ab and 44% o. applying the prediction model, we calculated the he risk for an ivig product produced via a chromatographic process (privigen ® , csl behring) a) without any isoagglutinin reduction measures (2007) (2008) (2009) (2010) (2011) (2012) (2013) , b) with an anti-a donor screening program eliminating approximately 5% of donors with high anti-a titers (2013) (2014) (2015) , c) incorporating an anti-a/anti-b specific immunoaffinity chromatography (iac, igisolo tm ) step in the manufacturing process (since 2016) and d) with both measures (b and c) combined; as well as for an ivig product produced with a cohn-like cold ethanol fractionation process (carimune ® nf/sandoglobulin ® , csl behring). isoagglutinin titers in ivig products, measured by european pharmacopoeia direct assay, were provided by dr c bellac, swissmedic, bern, switzerland. the predicted risk was highest with the chromatographically purified ivig without isoagglutinin reduction (1.87 cases expected per 1000 kg ivig used). anti-a donor screening reduced the predicted risk to 0.78 cases/1000 kg. a greater risk reduction was predicted with the iac isoagglutinin reduction step (0.11 cases/1000 kg). the combination of both methods produced little benefit (0.09 cases/1000 kg) versus iac alone. the predicted hemolytic risk with ivig produced by cohn-like ethanol fractionation was low (0.09 cases/1000 kg). an observational cohort study to confirm these hemolytic risk reductions is in progress. at present, the observed hemolytic risk for anti-a donor screening appears consistent with the prediction calculated by the model; results for iac isoagglutinin reduction are expected in 2019. the cmt infant scale (cmtinfs) is an outcome measure of functional ability for young infants and children aged <5 years. cmtinfs aligns with the cmt pediatric scale and cmt neuropathy score to measure disease severity across the lifespan. to measure gross motor and fine motor function, cmtinfs comprises of two subscales: 16 gross motor (e.g. head control, crawling, walking, jumping and hopping) and 15 fine motor function items (e.g. grasping, reaching, tearing paper and buttoning). overall and subscale-specific function is expressed as a z-score based on normative reference values (positive z-scores indicate poorer function). a total of 109 controls aged 0-58 months (mean age 22, sd 15m) have been assessed across australia (n=75), thailand (n=33) and usa (n=1). total cmtinfs z-scores did not differ significantly between sites (australia vs thailand) (p=0.293) or gender (p=0.126). data collection is ongoing and infants aged <5 years are eligible for inclusion. to date, 17 infants (53% male) aged 8-58 months (mean age 36, sd 16m) with a range of cmt subtypes (13 cmt1a, 1 cmt1d, 1 cmt4c, 1cmt x3 and 1 unidentified gene) have been assessed with cmtinfs. mean total z-score for infants with cmt (1.5, sd 2.4, range: −0.9 -8.0) was significantly higher than controls (0.0, sd 1.0, range: −2.0 -3.6, t=−2.50, p=0.023). differences between affected infants and controls were larger in infants older than 12 months. infants with cmt1a (cmtinfs z-score 0.8, sd 1.6) and cmt4c (z-score 0.1) were less affected than cmtx3 (z-score 3.5) and cmt1d (z-score 8.0). the gross motor function subscale differed significantly between cmt cases and controls (2.4, sd 3.8 vs 0.0, sd 1.0; p=.019) and a significant difference was also observed for the fine motor function subscale (0.7, sd 1.5 vs 0.0, sd 1.0; p=0.009). reliability, factor and rasch analysis of the cmt-infs is underway to assess validity. initial results support the sensitivity of cmtinfs in distinguishing between infants with and without cmt. preliminary analyses also suggest the scale is sensitive to genetic subtype. with increased power, cmtinfs promises to become a useful outcome measure of disease severity and function in infants with cmt. manso c 1 , querol l 2 , mekaouche m 1 , illa i 2 , devaux j 1 . 1 aix-marseille université, marseille, france; 2 universitat autónoma de barcelona, barcelona, spain. contactin-1, contactin-associated-protein-1 (caspr1), and neurofascin-155 (nfasc155) are essential for the formation of paranodal axoglial junctions. igg4 autoantibodies to contactin-1, caspr1, and nfasc155 are associated with subsets of patients with chronic inflammatory demyelinating polyradiculoneuropathy (cidp) presenting with common clinical features. anti-contactin-1 igg4 autoantibodies have been shown to be pathogenic and to affect the paranodal axoglial junctions in vivo and in vitro. by contrast, the pathogenic effect of anti-nfasc155 igg4 have not been demonstrated. here, we purified anti-nfasc155 igg4 from cidp patients' plasma and investigated their effects after passive transfer. to determine whether these antibodies can pass the paranodal barrier, we performed intraneural injections of anti-nfasc155 igg4 autoantibody. by contrast to anti-contactin-1 igg4, anti-nfasc155 did not penetrate the paranodal regions after intraneural injections, but bound to the surface of the schwann cell. to perform chronic exposure, lewis rats were implanted with intrathecal catheter and anti-nfasc155 igg4 were administrated in a daily manner during three weeks. igg4 to nfasc155, but not control igg4, induced progressive clinical deteriorations characterized by gait ataxia and hindlimb paraparesis. these deteriorations were associated with nerve activity loss in motor spinal nerves and with a selective loss of the paranodal specialization characterized by the disappearance of the caspr1/contactin-1/nfasc155 complex at paranodes. the passive transfer of anti-nfasc155 igg4 thus seem to induce similar pathogenic effects as the anti-contactin-1 igg4. however, the pathogenic mechanisms leading to paranode disappearance appear different. our findings indicate that igg4 directed against nfasc155 are pathogenic and further show that these antibodies are reliable biomarkers of a specific subset of cidp patients. better fit the needs of the consortium and improve patient experience. these enhancements include creating mobile friendly webpages, updating enrollment form content, access to a customized dashboard, and the ability of registrants to explore their data in comparison to other registrants. we will review these enhancements in depth, and demonstrate their impact on the growth and development of the rdcrn inc contact registry. martinez c 1 , hubsch a 2 , watson dj 3 , shebl a 4 , wallenhorst c 1 , simon tl 3 . 1 institute for epidemiology, statistics and informatics gmbh, frankfurt, germany; 2 csl bering ag, bern, switzerland; 3 csl behring llc, king of prussia, usa; 4 csl bering gmbh, marburg, germany. hemolytic anemia (ha) is a complication of intravenous immunoglobulin (ivig) treatment, particularly in patients receiving high dose ivig for immune modulation, such as guillain-barré syndrome or chronic inflammatory demyelinating polyneuropathy. the primary mechanism for the increased risk is believed to be passive acquisition of anti-blood group a and b antibodies (isoagglutinins) from the ivig product. to reduce the quantity of isoagglutinins, an anti-a donor screening was implemented for the ivig privigen ® from 2013-15 and donors with high titers were excluded from contribution to pooled plasma. anti-a donor screening was replaced since 2015 with an immunoaffinity chromatography step, which decreases isoagglutinins to a greater extent, but no data are available to test its clinical effectiveness. to test the effectiveness of the donor screening, two cohorts of patients treated with privigen ® before and after start of donor screening were identified from a hospital-based administrative database of 862 us hospitals with in-and outpatient discharge diagnoses, procedures, drug utilization and laboratory tests between 1/2008 and 12/2012 (period 1) and between 10/2013 and 12/2015 (period 2). privigen ® dose per kg body weight was estimated from the daily quantity administered and age-and sex-specific us population body weight estimates. ha within 30 days of privigen ® use was assessed from manual records review and the incidence rate of ha in the two periods compared. incidence rate ratios (irr) of ha were adjusted for sex, age, treatment setting, indication and dose per kg body weight using period 1 as reference. the incidence rate of ha was 1.05/10,000 person-days (95% confidence interval: 0.82-1.34) in period 1 (68 has in 644,756 person-days) and 0.82 (0.58-1.12) in period 2 (39 has in 476,931 person-days). the adjusted irr was 0.82 (0.55-1.23). significantly less ha risk was found with high dose (≥1.75 g/kg body weight) privigen ® , irr 0.48 (0.22-1.04, p=0.03). we conclude that anti-a donor screening and exclusion of donors with high anti-a titers from plasma pools is associated with a decreased risk of ha with ivig. matsumoto a 1 . 1 department of neurology, keijinkai jozanki hospital, sapporo, japan. subacute myelo-optico neuropathy (smon) is the intoxication of clinoquinol with main clinical symptoms of paresthesia and spasticity of legs. these symptoms have been considered to be elicited by the disturbance of spinal cord and peripheral nerve as the intoxication of clinoquinol. however, as to the patients with smon who have been still living after the onset of disease, the examination of nerve conduction velocities are in normal ranges and the clinical symptoms of peripheral neuropathy are not observed now. in order to investigate whether the peripheral neuropathy were observed in the early stage of smon, we investigated the longtidunal changes of electrophysiological results in 4 patients who could examine the nerve conduction studies from early stage of smon until the present time. as to the disturbance of pyramidal tract functions (myelopathy) in smon patients, the central motor conduction times were calculated by transmagnetic stimulation of motor cortex, cervical roots and lumbar roots. the peripheral nerve conduction velocities of sensory nerve were examined with the sural nerves. as the results, in 4 patients with smon who could examine the electrophysiological examination from the early stages of smon until 20 to 27 years later, the central motor conduction times of leg muscles from motor cortex to lumbar roots were prolonged in the smon patients compared to the normal cases. these results suggest the presence of disturbances of conduction velocities of spinal cord. conduction velocities of sensory nerve velicities (sncvs) showed the delayed sncvs of sural nerves(24-33m/sec) at the first examination from the onset of 2-5 years. however from 20 to 27 years later, sncvs of these cases were covered to35-42m/sec. from these electrophysilogical examinations, it was suggested that the presenting main symptoms of smon were the disturbance of myelopathy, and the disturbance of peripheral nerve function had been recovered after onset of smon being elapsed a long time, natural killer (nk) cells are part of our innate immune system with regulatory and effector functions. they comprise the first line of defence in the recognition and destruction of virus-infected and pathologically altered cells. different studies suggest that the treatment with intravenous immunoglobulins (ivig) has an immunomodulatory effect on nk cells. ivig is a first-line treatment for various autoimmune diseases in particular in chronic inflammatory demyelinating polyneuropathy (cidp). the lack of a predictive marker for ivig responsiveness in cidp avoids the early preservation of non-responding patients. to better understand the effect of ivig in patients with cidp, we tested whether ivig treatment altered the nk cell status. additionally, we analysed if the alteration in the populations may serve as a surrogate marker in predicting the outcome of ivig treatment. using semi-quantitative pcr and flow cytometry in the peripheral blood of patients with cidp, we analysed the effects of ivig on the nk cell population before treatment initiation and 24h after first dose and correlated the changes with the reponsiveness to ivig. ivig administrations induced a reduction in the expression of several typical nk cell genes. interestingly, this ivig-induced reduction of nk cells was reversible four weeks after the ivig treatment. flow cytometry data revealed that ivig reduced the cytotoxic cd56dim nk cell population, while regulatory cd56bright nk cells remained almost unaffected or were even increased. interestingly, we found that the observed effects on nk cells almost exclusively occurred in cidp patients who responded to ivig therapy. correlation between the changes in the nk cell population and treatment efficiency suggests a crucial role for nk cells in the immunomodulatory mechanism of ivig. further studies are warranted to investigate whether the differences in the nk cell status of patients with cidp represent a reliable surrogate marker in predicting the outcome of ivig therapy. mccray b 1 , sullivan j 1 , woolums b 1 , aisenberg w 1 , lloyd t 1 , sumner c 1 . 1 johns hopkins university, baltimore, usa. mutations in transient receptor potential vanilloid (trpv4), a calcium-permeable non-selective ion channel, cause charcot-marie-tooth disease type 2c (cmt2c). trpv4 is unique in that it represents the only membrane-expressed ion channel in cmt and thus a potential therapeutic target. previous work has suggested that trpv4 mutations lead to gain of channel function and toxicity in cultured cells. neuropathy-causing mutations of trpv4 largely cluster in the cytosolic ankyrin repeat domain (ard) that is known to mediate protein-protein interactions, suggesting that pathogenesis may be related to disruption of such interactions. in order to identify trpv4-interacting proteins, we performed two unbiased proteomics screens and identified multiple cytoskeletal-modifying proteins including syndapin-1, a neuronal protein known to promote axonal outgrowth by influencing the actin cytoskeleton. in cultured cells, we have shown that trpv4 and syndapin-1 co-localize to highly dynamic actin-rich cellular processes and together stimulate robust neurite extension, but this facilitation of neuritogenesis is impaired by disease-causing mutations in trpv4. we have also shown that over-expression of syndapin reduces trpv4-mediated calcium influx in cultured cells and rescues toxicity of mutant trpv4. in addition, syndapin over-expression suppresses mutant trpv4 phenotypes in a drosophila model of trpv4-related neuropathy. further, we have demonstrated that treatment of drosophila with a specific trpv4 channel antagonist ameliorates trpv4 mutant toxicity. together, our data highlight the importance of trpv4 interaction with cytoskeletal proteins such as syndapin-1 in the pathogenesis of cmt2c. specifically, our results suggest that mutations in trpv4 disrupt the normal role of trpv4 in regulation of cytoskeletal dynamics and that interactions with the cytoskeleton reciprocally modulate trpv4 channel function and influence toxicity of mutant trpv4. mcgonigal r 1 , yao d 1 , barrie ja 1 , crawford c 1 , willison hj 1 . 1 university of glasgow, glasgow, uk. guillain-barré syndrome (gbs) is in part mediated by anti-gm1 ganglioside antibodies induced by preceding infections. anti-gm1 antibodies target plasma membrane gm1 that is extensively distributed in both glial and axonal membranes, particularly at the node of ranvier. antibodies deposited at this site in models of gbs are associated with complement deposition, conduction block, structural disruption of ion channels and macrophage infiltration. the wide distribution of the gm1 ganglioside target leads to unwanted complexity in ascribing pathological outcomes to injury of cell-specific membranes, in particular unravelling the consequence of paranodal schwann cell membrane injury on axonal function, and vice versa. to overcome this impasse, we have generated transgenic mice through glycosyltransferase manipulation that express gm1 exclusively in neurons or glia, thus allowing us to very specifically target and injure axonal or glial membranes with a single anti-gm1 ganglioside antibody. through this route we can create mouse models of both the axonal and demyelinating forms of gbs, induced by a single anti-gm1 antibody, thus creating otherwise highly comparable conditions. here, we show anti-gm1 antibody binding is restricted to the nodal axolemma in galnact −/− -tg(neuronal) mice and conversely to paranodal loops in galnact −/− -tg(glial) mice. when anti-gm1 antibody and a source of complement is added to a nerve-muscle ex vivo injury paradigm, there is a loss of axonal integrity (i.e. loss of neurofilament immunolabeling) when the neuronal membrane is targeted in galnact −/− -tg(neuronal). conversely, axonal integrity is maintained when the paranodal membranes are decorated by antibody and complement products ex vivo in galnact −/− -tg(glial) mice. in a passive immunisation model in vivo, galnact −/− -tg(neuronal) mice acutely develop weakness, respiratory dysfunction, associated complement deposition, and degenerative pathology in distal axons. in contrast, galnact −/− -tg(glial) mice have significantly fewer abnormalities under the same acute conditions. these data indicate the high vulnerability of axonal membranes to acute injury and underline the importance of developing specific axonal protection strategies. in summary, targeting the nodal axolemmal or glial membranes allows us to study associated nodal pathology, and determine the downstream consequences on function and axon fate, currently a major area in gbs clinical research. memon a 1 , madani s 1 , schultz l 1 , grover k 1 , arcila-londono x 1 , sripathi n 1 , ahmad bk 1 . 1 neuromuscular division, department of neurology, henry ford hospital, detroit, michigan, usa. objective: to differentiate sensory electrophysiology, tli and treatment response in patients with paraproteinemic cidp. background: low tli has been reported as a useful electrophysiological marker for mag-cidp. to our knowledge comparison of sensory electrophysiology and tli of paraproteinemic cidp subgroups have not been previously reported. methods: retrospective review(january 2000-december 2015) of 89 patients with cidp fulfilling electrophysiological criteria(aan ad hoc subcommittee and albers and colleagues).cidp patients with diabetes(n=18) were excluded. 71 patients were divided into idiopathic (n=40) and paraproteinemic cidp(n=31). paraproteinemic cidp sub-groups: mag(8), non-mag(8) and igg(15) were compared to idiopathic cidp(40). these groups were compared for demographics, history of cancer, csf protein, sensory conductions, tli measurements and response to treatment using chi-square tests for binary and categorical variables and t-tests for continuous measures. results: there was a higher proportion of females in idiopathic-cidp compared to non-mag-cidp (50% vs 13%). idiopathic group having a higher proportion of patients on monotherapy(59% vs 50%) and combination therapy(38% vs 17%) compared to non-mag. higher mean csf protein compared to mag-cidp(p=0.001) was seen in the idiopathic. the difference between idiopathic and igg-cidp was significant for overall rx response(p=0.025) and rx response in patients with follow-up(p=0.01). for both variables, patients in the idiopathic group had a higher proportion of patients on combination therapy and lower proportion of no treatment offered compared to patients in the igg-cidp. 50% of non-mag-cidp patients had a history of cancer vs 0% of mag-cidp. none of the other differences were significant. there were no group differences in sensory electrophysiology and tli. conclusions: sensory electrophysiology and tli may have no value in differentiating paraproteinemic cidp. csf protein is higher in idiopathic cidp compared to mag-cidp. idiopathic-cidp has a higher proportion of females compared to non-mag-cidp and a higher proportion of patients on combination therapy compared to igg-cidp. cancer screening should be considered in patients with non-mag-cidp. memon a 1 , madani s 1 , ahmad bk 1 , schultz l 1 , grover 1 , arcila-londono x 1 , sripathi n 1 . 1 department of neurology, henry ford hospital, detroit, michigan, usa. introduction: sensory electrophysiology and terminal latency index (tli) differences have been described in various cidp sub-groups. objective: evaluate electrophysiology, tli and treatment response in idiopathic and diabetic cidp. methods: retrospective review of 147 patients with cidp who underwent electrodiagnostic evaluation (january 2000 -december 2015 . 89 patients fulfilled electrophysiological criteria described by ad hoc subcommittee of american academy of neurology (aan) and albers et al. we excluded patients(31) with acute inflammatory demyelinating neuropathy, hereditary sensorimotor neuropathy, vasculitis and polyneuropathy with paraproteinemia. 58 patients were divided into idiopathic(40) and diabetic(18) groups. these groups were compared for age, sex, history of cancer, csf protein, response to treatment, sensory response abnormalities and tli measurements using chi-square tests for binary and categorical variables and t-tests for continuous measures. all testing was at the alpha=0.05 level. results: group differences for age, sex, history of cancer, csf protein and treatment response were not significant. comparing tli values in measurable responses, the difference between the two groups for tibial tli was significant (p=0.012), with idiopathic group having a lower mean as compared to the diabetic. tli values differences for median, ulnar and peroneal nerves were not significant. the difference in abnormal rates of sensory responses was significant for the sural nerve with the idiopathic group having a lower rate compared to the diabetic group (80% vs 100%, p<0.05). no differences were noted for the ulnar, median and radial nerves. tibial tli and sural sensory responses have some value in differentiating the two groups. larger prospective studies are needed to confirm our findings. ivig is an important treatment option for cidp. although recommended by treatment guidelines, little is known about the consequences of temporary ivig withdrawal to assess ongoing immunoglobulin need. path is a randomized, double-blind trial of the subcutaneous immunoglobulin (scig) igpro20 (hizentra ® , csl behring) in cidp. before scig randomization, subjects underwent periods of ivig withdrawal (12 weeks or until pre-determined indications of clinical deterioration) and ivig restabilization (igpro10; privigen ® , csl behring). subjects not showing deterioration during withdrawal period were withdrawn from study. to proceed to scig randomization, subjects had to achieve "cidp stability" (no relevant change in incat score at last two restabilization visits and at least the same total score as at screening). 245 subjects entered the ivig withdrawal period. 208 (85%) of these qualified for igpro10 restabilization; 28 subjects (11%) were not ivig dependent, and 9 (4%) were withdrawn for other reasons. one subject withdrew consent before igpro10 dosing. at the end of the igpro10 restabilization period, cidp stability was achieved in 83% of subjects (22 did not reach stability, 13 were withdrawn for other reasons). post-study follow-up information was available for 16/22 subjects who did not reach stability: 9 (56%) had improved to baseline clinical status and 7 had not, meaning at least 87% of the subjects improved to their pre-study status. during the restabilization period, 188/207 subjects (91%) improved in at least one of the predefined outcome measures. on average, subjects improved by 1.2 points in incat total score, 5.7 points in i-rods centile score, 12 kpa in mean grip strength (dominant hand), and 3.6 points in mrc sum score. improvement occurred with a median of 23 days after the first igpro10 dose in one or more efficacy outcome measures and in 99% of cases after the third igpro10 maintenance infusion. headache and nasopharyngitis were the most frequently reported adverse events (aes) during restabilization. aes deemed causally related were mostly mild or moderate. no unexpected aes or laboratory or vital sign findings associated with igpro10 occurred during the study. in summary, igpro10 reversed neuromuscular disability and improved activity/participation after previous clinical deterioration during an ivig withdrawal period. pmp22 duplication is the most frequent cause of charcot-marie-tooth disease (cmt). since it discovery, more than 80 genes have been identified to be potentially responsible for cmt disease. however only single nucleotide variations (snvs) or small indels have been described. this could be due to the new sequencing strategy (ngs), especially ngs by amplicon sequencing, for whose few convenient tools are available and easily usable to detect cnvs responsible for inherited disease. to overcome this problem, we designed "cov'cop", a user-friendly tool able to detect cnvs among amplicons sequencing data. using the run's coverage file provided by the sequencer, "cov'cop" simultaneously analyzes all the patients of the run using a two-stages algorithm containing correction and normalization levels and provides an easily understandable output, showing with various colors, potentially deleted and duplicated amplicons. we validated our method on several datasets, including those of our targeted ngs panel screening 89 genes known to be involved in cmt and close pathologies. cov'cop detected easily pmp22 duplication and deletion in our patients, confirmed by mlpa. in addition, cov'cop permitted the detection of new cnvs different from the pmp22 duplication, in cmt patients. we confirmed these cnvs by quantitative pcr and cgh array. we present here one of these cnvs: the duplication of aars gene detected in cmt patients and we discuss the pathogenicity of this new cnv. additional cnvs responsible for cmt disease are probably still to be discovered and we believe that cov'cop will help molecular geneticists to rapidly identify them. poems (polyneuropathy, organomegaly, endocrinopathy, m-protein, and skin changes) syndrome is a rare cause of demyelinating neuropathy associated with plasma cell dyscraisia and vascular endotherial (vegf) overproduction. although number of therapeutic interventions for plasma cell dysorders have been applied to poems syndrome, there have been no randomized clinical trials. this phase 2/3 double blind, randomized, placebo comtrolled trial was performed to investigate the safety and efficacy of thalidomide for patients with poems syndrome who are not eligible for stem-cell transplantation. the primary endpoint was the reduction rate of serum vegf concentrations at 24 weeks in intention to treat analysis. additional outcomes of long-term extension study included progression-free survival. twenty-five poems patients were randomly assigned to either thalidomide plus dexamethasone or placebo plus dexamethasone from nov 11, 2010, to july 3, 2014. one patient in the placebo group was excluded from analyses because of a protocol violation. the adjusted mean serum vegf reduction rate at 24 weeks was 0.39 (sd, 0.34) in the thalidomide group compared with −0.02 (0.54) in the placebo group (p=0.04). the kaplan-meier rate of progression-free survival at 12 months was 0.77 in the thalidomide group, as compared with 0.50 in the placebo group (hr, 0.373 ; 95% ci, 0.080 to 1.343). in the randomized study period, mild sinus bradycardia was more frequent in the thalidomide group than in the placebo group (54% vs 0%; p=0.006). thalidomide suppresses serum vegf concentrations and lengthened pregression-free survival in poems patients who are ineligible for stem cell transplantation. although thalidomide treatment has a risk of bradycardia, the benefits would exceed the risk. this study is registered with the umin clinical trials registry, umin000004179. montes-chinea ni 1 , coutts m 1 , vidal c 1 , courel s 2 , rebelo a 2 , abreu l 2 , zuchner s 2 , saporta, ma 1,2 . 1 department of neurology, university of miami, miami, usa; 2 department of human genetics, university of miami, miami, usa. autosomal dominant mutations in synaptotagmin-2 (syt2), a synaptic vesicle protein that functions as a calcium sensor for neurotransmission, have been previously linked to presynaptic neuromuscular junction (nmj) dysfunction and motor neuropathy in two families. both pathogenic mutations (asp307ala and pro308leu) were located in the c2b domain of syt2, which is essential for neurotransmitter release at the nmjs. we report a family with a new missense mutation in the c2b domain of syt2 and a similar phenotype characterized by a slowly progressive, predominantly motor neuropathy and evidence of presynaptic nmj dysfunction on nerve conduction studies. the index case is a 50 year-old woman with gradually progressive weakness of her extremities. she had normal developmental milestones, but was found to have bilateral high arched feet and hammertoes and occasional falls around the age of 8. she gradually developed progressive leg weakness, worsening bilateral hand cramping, weak handgrip, and only mild paresthesias on distal extremities. family history is remarkable for similar symptoms reported by her maternal grandfather, two maternal uncles, her mother and a younger sister. her neurological exam revealed inability to walk on heels or toes, significant distal lower extremity weakness and absent ankle deep tendon reflexes. cranial nerve examination and coordination were normal and there were only non-specific sensory changes in the lower extremities. emg/ncs revealed normal sensory responses throughout; however, motor nerve evaluation demonstrated globally reduced amplitudes with a >200% increment after brief isometric contraction. further electrophysiological evaluation with slow (3hz) repetitive nerve stimulation of the right ulnar motor nerve revealed a 40% decremental response in amplitude and a >200% increase in amplitude immediately after a one-minute period of sustained muscle contraction, which rapidly extinguished after one minute. voltage-gated calcium channel (vgcc) antibodies and a chest ct were normal. targeted sanger sequencing revealed an ile371lys mutation in syt2, which is located in the c2b domain and is predicted to impair protein function. syt2-related neuropathy is a rare disease, but should be suspected in patients presenting with a combination of pre-synaptic nmj dysfunction (resembling lambert-eaton myasthenic syndrome) and a predominantly motor neuropathy, especially in the context of a positive family history. charcot-marie-tooth (cmt) disease affects roughly 1 in 2,500 individuals and is described as an inherited peripheral neuropathy primarily affecting distal muscles. limited studies detail patient-reported impact of muscle weakness on functional activities. this anonymous survey was developed with input from clinical experts and patient interviews and aimed to better understand the prevalence and impact of various cmt clinical manifestations on patients' lives. the survey was administered online to the hereditary neuropathy foundation's (hnf) patient contact database and is ongoing through june 2017. here we present preliminary data on patient characteristics and disease impact for 626 cmt patients collected february 17-21, 2017. respondents were mostly female (61%) and mostly from the us (74%). median age (range) at symptom onset was 14 years (0-84 years), at diagnosis was 36 years (2-83 years), and at present was 55 years (6-89 years). the sample was representative of all cmt types (cmt1,2,3,4 ,and x). the most common physical and clinical manifestations of cmt were problems with balance (87%), ankle weakness/foot drop (81%), loss of feeling or abnormal sensation in the lower leg/foot (81%), and hand muscle weakness (78%). maintaining balance, walking long distances, and climbing up and down stairs were key challenges associated with ankle weakness/foot drop. foot drop was considered by 72% to be the primary factor contributing to falls, which averaged 2.5 falls to ground per month. of those with foot drop, 86% had bilateral weakness. a majority of respondents (76%) used some form of assistive device for mobility, including ankle-foot orthotics/below-the-knee leg braces (40%), canes/walking sticks (34%), and custom foot orthotics/inserts (26%). the most common drug therapy included pain and anti-inflammatory medications (41%). foot surgery was the most common surgical procedure received (24%) and toe surgery was the most common surgery considered (23%). key symptoms that affected quality-of-life "very much" included problems with balance (65%), ankle weakness (foot drop) (62%), and fatigue (49%). these data suggest a high prevalence of lower leg muscle weakness; therefore, therapies aimed at improving ankle weakness and the resulting foot drop and imbalance may be beneficial to patients' daily functioning and quality of life. morano m 1,2 , gambarotta g 1 , ronchi g 1,2 , cillino m 3 , fornasari be 1,2 , fregnan f 1,2 , tos p 4 , cordova a 3 , moschella f 3 , geuna s 1,2 , raimondo s 1,2 . 1 department of clinical and biological sciences, university of turin, orbassano (to), italy; 2 neuroscience institute of the "cavalieri ottolenghi" foundation (nico), university of turin, orbassano (to), italy; 3 plastic and reconstructive surgery. department of surgical, oncological and oral sciences, university of palermo, palermo, italy; 4 hand microsurgery and surgery, gaetano pini hospital, milan, italy. nerve fiber regeneration and complete functional recovery after peripheral nerve injury do not always occur and can be influenced by many factors including patient age, gender, lesion site, injury severity, size of the gap between damaged nerve stumps and time interval that elapses before performing surgical repair. the poor outcome occurring after a long delay can be due to loss of the neuron ability to regenerate, loss of the schwann cell ability to support regeneration and, of course, progressive muscle atrophy. the aim of this study was to investigate the nerve regeneration after delayed repair and to study the degenerative processes of the denervated distal nerve stump and denervated muscle. in particular, the analyses were focused on the role of nrg/erbb system, that is expressed both in nerve and in muscle tissue, during degenerating and regenerating processes. functional recovery analysis performed after nerve repair showed that only the group repaired immediately and not the groups repaired with a delay of 3 or 6 months, recovered partially. nevertheless, morphological analyses demonstrated that, despite the delay, the nerve fibers are still able to regenerate, even if they are fewer and smaller than the immediate repaired group. moreover, the analysis of the nrg1/erbb system showed a significant decrease of soluble nrg1 in both degenerating and delayed-repaired nerves. the poor outcome after delayed nerve regeneration might be explained by schwann cell impairment and the consequent ineffective support for nerve regeneration. as regards denervated muscle analysis, results showed that erbb receptors expression is related to the innervated state of the muscle, with an upregulation of erbb2 clearly associated with denervation state. interestingly, nrg1 isoforms are differently regulated depending on the type of nerve injury. future experiments will be needed to address the in vivo efficacy of different isoforms of nrg1 both in injured nerve and denervated muscle. we planned a multicenter, prospective, randomized, single blind, controlled study to evaluate the efficacy and safety of an innovative rehabilitation protocol based on the use of treadmill training in a cmt1a population. the protocol required that subjects were blindly randomized into two treatment groups, spe (three months of respiratory, proprioceptive and stretching exercises) or trespe (the same treatment plus aerobic training at the treadmill). subjects were evaluated at baseline (t0), after three month of treatment (t1) and further three months of follow up free of therapy (t2). the full assessment included: 6-mwt (primary outcome measure), 10-mwt, walk-12, short physical performance battery (sppb); lower limbs dynamometric strength evaluation; berg balance scale (bbs); cmt neuropathy score; medical outcomes study short form 36 (sf36). a total of 53 subjects (mean age of 52.1±11.9 years) were recruited. at t1 we found a significant improvement in both groups in the 6-mwt (p<0.05), 10-mwt (p<0.05), bbs (p<0.05) and sppb (p<0.01), while at t2 only the 6-mwt was still significantly improved (p<0.05) in the spe group. no significant differences between groups were observed for any of the outcome measures. performances on walk 12 did not significantly change during follow-up (p=0.27). concerning the sf36, we did not observe consistent changes during follow-up or consistent differences comparing the two treatments. in conclusion, this multicenter, prospective, randomized, single blind, controlled study shows that the combination of respiratory, proprioceptive and stretching exercises has a positive impact on the performance of cmt patients, especially regarding walking tests. the aerobic exercise at the treadmill, is well tolerated but apparently does not add any further improvement to the conventional treatment. we speculate that the relatively low clinical severity of the patients, due to the selection criteria, may have prevented a positive effect of treadmill exercise. müller m 1 , dohrn m 1 , romanzetti s 1 , reetz k 1 , gess b 1 . 1 university rwth aachen, department of neurology, aachen, germany. muscle mri is increasingly used in neuromuscular patients to detect changes in muscle volume, muscle fat infiltration and edema. muscle mri are mostly analyzed by qualitative means as quantitative analysis is time-consuming and not well established. here, we developed a novel method for semi-automated segmentation of muscle mri data sets. based on axial t1-weighted dixon mri stacks, muscle volumes were quantified by an adapted water-shed algorithm. muscle volumes of thighs and calves were determined separately and the ratio of thigh/calf was calculated. 24 myopathy, 8 neuropathy patients and 28 healthy controls were included in the study. muscle volumes determined by semi-automated segmentation were very similar to manually segmented data sets, differences being <2%. this was the case for patients as well as healthy controls. the time-saving effect of automated segmentation was very strong (400 vs 30 min. per patient). muscle volumes of the thigh and also of the calf of myopathy patients showed a highly significant difference (p<0.001) compared to healthy subjects. in neuropathy patients there was a just significant difference (p<0.05) of muscle volumes compared to healthy patients that did not sustain in bonferroni's multiple comparison test. the ratio of thigh/calf muscle volume was significantly different comparing patients with myopathy and neuropathy (p<0.05). subgroup analyses of different groups of myopathy patients showed highly significant differences (p<0.001) in myositis, limb-girdle-muscular dystrophy and metabolic myopathy, compared to healthy patients, but no significant differences in-between these groups. taken together, the data shows that automated segmentation of muscle mri allows for exact and fast quantification of muscle volumes in neuromuscular patients. higher patient numbers are necessary to test differences between specific disease groups. further studies should also address the possible use as a marker of disease progress for clinical studies or therapy monitoring. murakami t 1 , nishimura h 2 , nagai t 1 , hemmi s 1 , kutoku y 1 , sunada y 1 . 1 department of neurology, kawasaki medical school, kurashiki, japan; 2 department of pathology, kawasaki medical school, kurashiki, japan. familial amyloidotic polyneuropathy (fap) is an autosomal dominant hereditary systemic amyloidosis caused by mutation of transthyretin (ttr) gene, and usually shows sensory dominant polyneuropathy and autonomic neuropathy at the initial stage. the pathogenesis of neuropathy is not well understood, and explained by several mechanisms, including such as mechanical compression, vessel occlusion, ttr toxicity and schwann cell dysfunction. we describe a sporadic patient with late-onset fap due to ttr e61k. she noticed dysesthesia first in the foot at age 70. the symptoms were slowly progressive, and abnormal sensations were extended up to the both upper arms and the both knees at age 76. distal muscle weakness and atrophy was also observed in the extremities. she noticed difficulties in walking and frequent diarrhea. echocardiogram revealed diffuse left ventricular hypertrophy, suggesting cardiac amyloidosis. amyloid deposits were not detected in the endoneurim or perineurium of the sural nerve 7 years after the onset of the disease, but a marked loss of myelinaed and unmyelinated nerve fibers was observed in it. ttr-derived amyloid deposits were confirmed in the peroneous brevis muscle, salivary gland and heart tissue. dna analysis revealed the heterozygote mutation, p.e81k (e61k)/c.241g>a, of ttr gene, and she was diagnosis as fap. these findings suggest that the proximal parts of peripheral nervous system might be strongly involved by ttr aggregates or amyloid fibrils. blood-nerve barrier in the distal part of peripheral nerves could be preserved until later in the patient. several biopsy sites other than nerve may be helpful and necessary for diagnosis of ttr amyloidosis in mild or late-onset fap as our case. amyloidgenic element (cae) encoded by the 3' utr. this study also identified a de novo c.3015_3027dup frameshift mutation predicting p.lys1010glnfs*56 in nefh from a cmt2 family with atypical clinical symptom of proximal dominant weakness. this mutation is located near the previously reported frameshift mutations, suggesting a mutational hot spot. these relatively frequent deletion/duplication events with this resign might be caused by the putative hairpin structure. patient's lower limb mri revealed a marked hyperintense signal changes in the hip muscles than those in the thigh or lower leg muscles. this study also observed an anticipation pattern of earlier onset (12 yrs old for mother to 6 yrs old for daughter) and more severe symptoms in later generation. therefore, this study suggests that the stop loss and translational elongations by the 3' utr of the nefh mutations may be relatively a frequent genetic cause of axonal peripheral neuropathy with the specific characteristics of proximal dominant weakness and an anticipation pattern. neil j 1 , haghi ashtiani b 2 , choumet v 3 , musset l 1 , léger jm 2 . 1 department of immunology, pitié-salpêtrière hospital (ap-hp), paris, france; 2 department of neurology, national referral center for rare neuromuscular diseases, pitié-salpêtrière hospital (ap-hp), paris, france; 3 institut pasteur, emerging diseases epidemiology unit, paris, france. the myelin-associated glycoprotein (mag) is a transmembrane glycoprotein localized in periaxonal shwann cells and oligodendroglial membranes of myelin sheaths. mag contains a carbohydrate epitope (hnk-1) that is a target antigen in autoimmune peripheral neuropathy associated with monoclonal igm gammopathy. in these neuropathies, numerous studies report the absence of correlation between the titers of anti-mag antibodies and the disease course. anti-mag titers and igm level at diagnosis are not always associated with disease severity and there is not good correlation between pre-and post-treatment anti-mag titers in patients who respond clinically to immunomodulators. mag belongs to siglec-4a family and the linkage of sialic acid to the underlying sugars is an important determinant of siglec binding. mag shows high affinity for alpha-2,3-linked sialic acid (2,3-sa).moreover, human monoclonal igm possesses 5 heavy chain glycosylation sites at asn 171, 332, 395, 402 and 563 with sialylated olidgosaccharides and high-mannose type oligosaccharides. igm may bind to mag via these glycan epitopes as an alternative and additional route of antigen binding other than through the fab v regions. this mag-glycans igm interaction may be clinically neutral but could lead to an overvaluation of the biological results. in this study, we analyzed 8 sera from patients with igm reactivity against mag: 7 of them had an anti-mag neuropathy with various degrees of severity, and the last one had igm monoclonal gammopathy, strong serum anti-mag reactivity but no neurological disease. igm were extracted and purified from these sera by affinity chromatography. for each batch, an aliquot was digested by jack bean alpha-mannosidase and anti-mag reactivity was performed by elisa and indirect immunofluorescence (iif), before and after demannosylation. these extracts, tested in an iso quantitative way with regard to the original serum, showed a decrease of activity (elisa) and intensity (iif) after demannosylation. furthermore, elisa anti-mag was carried out in 49 sera from patients with igm monoclonal gammopathy without neurological impairment: 6 of them (12.2%) showed a significant biological response. taking into account the fact that anti-mag antibodies are pathogenic (in animals models), these results support the hypothesis of neutral intermolecular interactions between igm and mag. ng cjb 1 , ng jph 2 , tay lb, t 3 , umapathi 3 . 1 yong loo lin school of medicine, national university of singapore, singapore; 2 lee kong chian school of medicine, nanyang technological university, singapore; 3 national neuroscience institute, singapore. recent developments have validated non-invasive means of measuring central arterial blood pressure (casp) and have shown that casp and peripheral blood pressure (pbp) are unidentical entities. patients with postural orthostatic tachycardia syndrome (pots) have marked tachycardia with no associated decrease in pbp. we asked if the reflex tachycardia, which corresponds to postural dizziness in these patients, could be a result of a decrease in casp. two male patients, 19 and 21 years of age, with clinical features typical of pots went through a complete battery of autonomic screening tests. the sympathetic and parasympathetic responses were normal other than a heart rate increase of 31 and 41 beats per minute, respectively, on standing. there was no significant decrease or increase in pbp on standing for 2 and 5 minutes. casp was measured non-invasively by a device bpro r that imputes the measured radial waveform onto the brachial blood pressure to generate a pressure waveform from which a numerical casp value is derived. the casp measurements for both patients did not decrease on standing for 2 and 5 minutes. our preliminary observation suggests that the basis of tachycardia in pots patients may not be a decrease in central blood pressure. we are proceeding to systematically study more pots patients to corroborate the above observation. we are also trying to compare the difference between pbp and casp in pots and age, gender-matched normal controls. the major limitation of the study is the model-based mathematical derivation, rather than direct measurement, of casp. we are proceeding to systematically stud y more pots patients to corroborate the above findings. ng jph 1 , ng cjb 2 , t umapathi 3 . 1 lee kong chian school of medicine, nanyang technological university, singapore; 2 yong loo lin school of medicine, national university of singapore, singapore; 3 national neuroscience institute, singapore. recent developments have validated non-invasive means of measuring central arterial blood pressure (casp) and have shown that casp and peripheral blood pressure (pbp) are unidentical entities. orthostatic hypotension (oh) is a prominent component of autonomic dysfunction (ad), the consequent hypoperfusion of vital organs responsible for considerable morbidity and mortality. these structures are exposed to casp rather than pbp. we sought to understand the relationship of casp to peripheral blood pressure (pbp) in patients with autonomic dysfunction exposed to orthostatic stress. we reviewed autonomic function tests of patients tested at our laboratory over a 3-year period. the patients were divided into 5 cohorts: (1) no ad and no oh (2) no ad, with oh (3) mixed ad (4) parasympathetic dysfunction (5) sympathetic dysfunction. casp was measured non-invasively by a device, bpro r , that imputes the measured radial waveform onto the brachial blood pressure to generate a pressure-wave form from which a numerical casp value is derived. the difference and ratio of casp to pbp was recorded at rest and after 2 minutes of standing. out of 361 patients 168 had complete data and a definitive final diagnosis. cohorts 1-5 had 74, 48, 15, 18, 13 patients respectively. mean casp-pbp difference in cohorts 1-5 were −10.55, −11.02, −11.59, −13.44, −8.69 respectively at 0 minutes, and −13.52, −13.15, −13.18, −10.11, −8.46 respectively at 2 minutes. mean casp/pbp ratio in cohorts 1-5 were 0.91, 1.08, 0.92, 0.91, 0.93, 0.93 respectively at 0 minutes, and 0.89, 0.90, 0.89, 0.92, 0.92 respectively at 2 minutes. there was no significant difference in the response of casp and pbp to orthostatic stress across abnormal cohorts 2 to 5 and in comparison with the "normal" cohort 1(p=0.268 to 0.983). there was also no relationship to symptoms, namely postural dizziness. in conclusion, autonomic dysfunction does not seem to affect the casp-pbp relationship as measured by non-invasive means. the absence of true normal controls, the exclusion of significant number of patients because of incomplete data and the model-based mathematical derivation rather than direct measurement of casp are limitations that we aim to address in follow-on studies. niu jw 1 , guan hz 1 , cui ly 1 , guan yz 1 , liu ms 1 . 1 the department of neurology, peking union medical college hospital, chinese academy of medical sciences, beijing, china. we aimed to explore the correlation between afterdischarges in motor nerve conduction studies and clinical motor hyperexcitability in patients with voltage-gated potassium channels (vgkc) antibodies. six patients with positive serum antibodies to contactin-associated protein-like 2 (caspr2) or/and leucine-rich glioma-inactivated protein 1 (lgi1) were recruited, including 5 with autoimmune encephalitis, and 1 with cramp-fasciculation syndrome. electromyography (emg), nerve conduction studies (ncs) and f waves were performed, and afterdischarges were assessed. one patient was followed up. five patients had clinical evidence of peripheral motor nerve hyperexcitability (myokymia or cramp), and four of them had abnormal spontaneous firing in concentric needle electromyography. prolonged afterdischarges following normal m waves were present in all six patients, including the two patients who had no emg evidence of peripheral nerve hyperexcitability (pnh). in the patient who was followed up, afterdischarges disappeared after treatment with intravenous immunoglobulin (ivig). afterdischarges in motor nerve conduction study might be more sensitive than needle electromyography for detecting peripheral motor nerve hyperexcitability in patients with vgkc antibodies, and could disappear gradually in accordance with clinical improvement and reduction of antibodies. in our research, multiple sites measurement of cross sectional areas (csa) by ultrasound was performed to differentiate charcot-marie-tooth type 1a (cmt1a) and chronic inflammatory demyelinating polyradiculoneuropathy (cidp). twenty-eight patients with cidp, 9 patients with cmt1a, and 14 healthy controls (hc) were recruited prospectively. consecutive ultrasonography scanning was performed from wrist to axilla on median and ulnar nerves. csas were measured at 10 predetermined sites of each nerve. cmt1a had significantly larger csas at all sites of median and ulnar nerves (all p<0.01). in cmt1a, csas increased gradually and homogeneously from distal to proximal along the nerve, except potential entrapment sites. cidp displayed three different morphological patterns, including mild enlargement in 15 patients, prominent segmental enlargement in 12, and slight enlargement in one, among which different treatment responses were observed. all patients with mild nerve enlargement treated with intravenous immunoglobulin (ivig) were responsive (7/7), while less than half of those with prominent segmental enlargement (3/7) were responsive (p<0.01). the patterns of csa enlargement were different in cmt1a and cidp patients. consecutive scan along the nerve and multiple sites measurement by ultrasound could supply more detailed morphological feature of the nerve and help to differentiate cidp from cmt1a. guillain-barre syndrome (gbs) mainly consists of acute inflammatory demyelinating polyradiculoneuropathy (aidp) and acute motor axonal neuropathy (aman). in aman, conduction block (cb) could be reversible or followed by axonal degeneration. we aimed to identify the correlation between existence of cb and the functional outcome for patients with gbs. 52 gbs patients were prospectively recruited for serial electrophysiological tests and disability evaluation. all patients received treatment of intravenous immunoglobulin (ivig), and their disabilities were evaluated on the hughes functional grading scale before and 1 month after treatment. patients were classified into aidp, aman, equivocal or normal according to electrodiagnostic criteria described by rajabally et al. aman patients who had follow-up nerve conduction studies were further classified into three groups. group 1 was typical aman without conduction block, group 2 had reversible conduction block, group 3 had conduction block and subsequential axon degeneration. electrophysiological study results showed 20 aidp, 24 aman, 7 equivocal and 1 normal. probable or definite conduction block was observed in 11 aidp patients and 16 aman patients. aman with cb had higher reduction of hughes grade at one month (1.71±0.83 vs 0.43±0.79,p=0.003), and lower percentage of patients with slow recovery (unable to walk independently at six months) (7% vs 57%, p=0.025) compared with aman without cb. there were no significant differences between aidp with cb and without cb, in the reduction of hughes grade at one month. among the 13 aman patients who were followed up, 4 were typical aman without cb (type1), 7 had reversible cb (type 2), 2 had cb and subsequential axon degeneration (type 3). hughes grades at nadir were similar, while patients with reversible cb (type 2) had the largest hughes grade reduction at one month (type 2-2.14 vs type 1-0.25 vs type 3-1.5). none of the patients with axon degeneration (type1) showed rapid recovery, while 86% of those with reversible cb (type 2) had rapid recovery (improvement by two or more hughes grades within four weeks after onset). electrodiagnosis of aman with conduction block, especially reversible conduction block, might be a marker of good recovery. we report a follow-up study of nerve ultrasound in a patient with primary neurolymphomatosis. a 54-year-old female presented with 5-months history of asymmetric limb pain, paresthesia, and weakness. electrodiagnostic studies and spinal cord mri showed an axonal neuropathy involving cervical and lumbosacral root, brachial plexus and left median nerve. detection of malignant b lymphocytes by cytology and flow cytometry of cerebral spinal fluid confirmed the diagnosis of b-cell non-hodgkin lymphoma. nerve ultrasound showed dramatic enlargement of upper, middle and lower trunks of left brachial plexus (cross sectional area-csas 21 mm 2 , 30 mm 2 , 26 mm 2 respectively), middle trunk of right brachial plexus (csa 15 mm 2 ), and proximal part of left median nerve (csa 15-18 mm 2 ). five months later, after five chemotherapy of rituximab and high-dose methotrexate, and intrathecal injection of cytosine arabinoside and dexamethasone, the patient had clinical improvement. nerve ultrasound also showed alleviation of nerve enlargement. the csas of upper, middle and lower trunks of left brachial plexus were 5 mm 2 , 14 mm 2 , 14 mm 2 respectively; the csa of middle trunk of right brachial plexus was 11 mm 2 ; the csa of proximal part of left median nerve was 12-13 mm 2 . peripheral nerve ultrasound could help locate the distribution of nerve involvement, and reveals disease progression. nolano m 1 , provitera v 1 , stancanelli a 1 , caporaso g 1 , saltalamacchia am 1 , borreca i 1 , lullo f 1 , califano f 1 , lanzillo b 1 , iodice r 2 , manganelli f 2 , barone p 3 , santoro l 2 . 1 irccs "salvatore maugeri" foundation, institute of telese terme (bn), italy; 2 "maugeri" clinical and scientific institutes irccs, institute of telese terme (bn), italy; 3 center for neurodegenerative diseases (cemand), department of medicine and surgery, neuroscience section, university of salerno, italy. a peripheral nerve involvement has been demonstrated in pd with the evidence of a small fiber pathology as possible intrinsic feature of the disease and a higher occurrence of large fiber neuropathy in patients longtime treated with l-dopa. however the role that disease itself and ldopa have on small and large fiber pathology in pd is still debated. we studied morphology and function of cutaneous innervation, in 85 idiopathic pd patients (49 male, aged 60.7±10.9), including 47 naïve and 38 l-dopa treated subjects without electrophysiological signs of neuropathy, with the aim to assess and characterize small and large fiber involvement and the effect of l-dopa on it. all patients underwent a screening to rule out potentially neurotoxic conditions such as glucose intolerance, dysendocrinopathies, vitamin e, b12 and folic acid deficiency, hepatic or renal failure, hiv or connective tissue disorders. skin biopsies were obtained from thigh, leg and fingertip from the more affected side and bilaterally from thigh and leg in 35 patients. samples were processed with indirect immunofluorescence technique using primary antibodies to mark different sensory and autonomic fiber populations. density of intrapapillary myelinated endings (ime), meissner's corpuscles (mc) and epidermal nerve fibers (enfs) was obtained as well as a semi-quantitative assessment of sudomotor, pilomotor and vasomotor innervation. further evaluation included sympathetic skin response, quantitative sensory testing and dynamic sweat test. morphological and functional findings were compared with data extracted from our age and sex stratified normative dataset. ienf, ime, mc densities were lower (p<0.01) compared to controls in both naïve and l-dopa treated patients without differences between them except for mc density that was lower in l-dopa treated subjects (8.7±5.6 vs 14.5±8.9/mm2). a loss of autonomic nerves was also found in both groups compared to controls. significant abnormalities (p<0.01) of thermal sensory thresholds, tactile thresholds, mechanical pain perception and reduced sweating output were present and similar in both groups. our work confirms in pd an intrinsic peripheral nerve pathology involving both small and large fibers. small fiber pathology isn't affected by l-dopa treatment while sensory large fibers involvement, already present in naïve patients worsens with ldopa treatment. noto y 1 , garg n 1 , li t 1 , timmins hc 1 , park sb 1 , shibuya k 1 , kiernan mc 1 . 1 brain and mind centre, the university of sydney, sydney, australia. the diagnosis of amyotrophic lateral sclerosis (als), a progressive, fatal neurodegenerative disorder defined by combined upper and lower motor neuron involvement, remains clinically based. the purpose of this study was to determine the ultrasound appearance of peripheral nerves in als patients, and to investigate whether parameters such as distal/proximal ratios of nerve cross-sectional areas (csas) may effectively differentiate disease mimics from als. nerve ultrasound of the median, ulnar, and tibial nerves was performed in 53 als patients compared to 32 mimic patients (23 patients with peripheral nerve hyperexcitability syndromes (pnhs) and 9 patients with multifocal motor neuropathy (mmn)). comparison of nerve and the distal/proximal ratios was undertaken by ultrasound and compared across clinical and neurophysiological parameters.compared to normal controls, csa of the median nerve at the upper arm was decreased in als (p <0.001). in comparison to als mimic disorders, csa at the proximal site of the median, ulnar and tibial nerve and the forearm/upper arm ratio of the median and ulnar nerves had diagnostic values. in addition to csa of the median, ulnar, and tibial nerves, the median and ulnar nerve forearm/upper ratios may provide a useful marker in for the diagnosis of als. approximately 1 in 2,500 individuals are diagnosed with charcot marietooth (cmt) disease, making it the most common hereditary peripheral neuropathy. there is no documented cure for cmt, however, many of those affected, report difficulty with mobility, imbalance, and weakness of the feet and hands. in the general population, patients reporting difficulty walking, falls and/or fear of falling, and poor strength are often referred to physical (pt) and occupational therapists (ot) to skillfully address the impairments and help restore function and quality of life (qol). for patients diagnosed with cmt this is unfortunately not the norm, often leaving patients without any skilled guidance on managing their functional impairments. 11 patients (6 males) with a mean age of 52.27 years (27-74), went through a progressive and skilled pt intervention over the course of 3 months. the program included: therapeutic activities and exercise, neuromuscular reeducation, and manual techniques to address the documented deficits. patients were progressed through the program based on the borg scale. each patient was assessed prior to and post the commencement of the program with the berg balance scale, 6 minute walk test, timed up and go, sit to stand in 30 seconds, 20 foot self selected and fast gait speed, the lower extremity functional scale, activities balance confidence form, upper extremity functional index, oswestry, and the sf-36 qol measure. the patients were seen by the same skilled pt 2-3 a week for 12 weeks. all but 2 patients improved in all measures taken, indicating an improvement in function and overall quality of life. participants reported a total of 8 falls in the 3 months prior to the initiation of the study and only 1 fall was reported during the 3 month pt intervention. this study makes a strong case for the utilization of skilled pt to address deficits in patients with cmt. additionally, the utilization of objective, valid and reliable outcome measures in this population may help healthcare practitioners establish baseline function and response to change. a large randomized control trial is recommended to study the effects of a specific pt intervention on outcome measures in patients with cmt. ogata h 1 , fujita a 1 , yamasaki r 1 , matsushita t 1 , kira ji 1 . 1 department of neurology, neurological institute, graduate school of medical sciences, kyushu university, fukuoka, japan. clinical features of chronic inflammatory demyelinating polyneuropathy (cidp) patients with autoantibodies against neurofascin (nf)155, one of the paranodal proteins, have been elucidated while the relation between anti-nf155 antibody levels and long-term clinical course in these patients still remains elusive. we retrospectively collected clinical, electrophysiological and immunological data of three anti-nf155 antibody-positive cidp patients. they were all males and their ages at onset were 16, 26, and 34 years old. their clinical severity was evaluated by deep tendon reflexes (dtrs), grip strength and hughes functional scale. anti-nf155 antibody levels were measured by flow cytometry using hek293 cell lines stably expressing human nf155. after immunotherapies of various combinations, including intravenous immunoglobulin, plasmapheresis, corticosteroids and other immunosuppressants, were introduced, their clinical parameters were gradually improved. decreased or absent dtrs were normalized and grip strength was increased by more than 10 kg. hughes functional scale scores were decreased by at least one point compared with those at nadir. ncs findings of all three patients also showed obvious amelioration. for example, their f wave latencies in the right ulnar nerve were improved from 63 to 38 ms, from 48 to 35 ms, and from 64 to 38 ms, respectively. anti-nf155 antibody levels after treatment were decreased in two patients whose pre-and posttreatment sera were available. when dose of oral prednisolone was being tapered, they experienced re-exacerbation of clinical parameters, especially dtrs and grip strength. their ncs findings and serum anti-nf155 antibody levels were also deteriorated. exacerbation of these laboratory data in one patient preceded his clinical fluctuation, which suggests that ncs and serum anti-nf155 antibody levels could be used as early disease activity markers. in this case series, not only clinical but also laboratory data support a notion that anti-nf155 antibody-positive cidp patients were reactive to combined immunotherapies including corticosteroids. even though various treatments were administered to them, efficacy of oral corticosteroids seemed to be dose-dependent. optimal disease activity markers and immunotherapies for long-term maintenance of remission in anti-nf155 antibody-positive cidp should be identified. evaluated by deep tendon reflexes (dtrs), grip strength and hughes functional scale, after starting immunotherapies, ohnmar o 1 , kamyw 2 , ng lfp 2 , t umapathi 3 . 1 university of medicine 1, yangon, myanmar; 2 singapore immunology network, a*star, singapore; 3 national neuroscience institute, singapore. singapore's zika virus (zikv) outbreak started in late august 2016. over a period of 2 months, we studied 8 patients enrolled into our institution's prospective guillain-barré syndrome (gbs) database for relationship to zikv infection. we also studied 3 gbs controls that were seen before the established outbreak and 3 non-gbs controls. the 8 index cases tested negative for zikv pcr in blood and urine. we proceeded to test zikv igg, igm, dengue virus (denv) igg and igm, and neutralization assays against zikv and denv. one patient with anti-gq1b igg positive miller fisher syndrome had detectable zikv igm and zikv igg. the serum showed low titre denv igm and denv igg. follow-up serum at about 2 months showed increase in zikv igg. we believe this patient has zikv-gbs. one patient with acute motor sensory axonal neuropathy and another with acute inflammatory demyelinating polyneuropathy had high zikv igm but low denv igm and igg. another patient with mfs showed high levels of zikv and denv igm but low igg. the latter two patients had gbs before the zikv outbreak in singapore. we suspect these 3 patients could have zikv-gbs, but are awaiting convalescent sera for confirmation. two patients seen during the outbreak had detectable levels of zikv igg but serial testing showed a decline after a period of 2-3 months. the initial and follow-up sera showed raised denv igm and igg levels in one and raised igg levels in the other. in addition, both had stronger neutralizing capacity against denv than zikv suggesting that the initially detectable zikv igg levels was due to cross reactivity with previous denv infection. four patients, 1 gbs control and 2 non-gbs controls also showed serological response consistent with previous exposure to denv. one normal control showed nil exposure to both viruses. in summary, using various overlapping serological methods we diagnosed 1 definite and 3 suspect zikv gbs cases. our findings highlight 1) insensitivity of blood and urine pcr to diagnose zikv-gbs 2) the problems of interpreting zikv serology from cross-reaction with denv 3) serial serology increases diagnostic accuracy. okar sv 1 , ergunay k 2 , bekircan-kurt ce 1,3 , erdem-ozdamar s 1,3 , tan e 1,3 . 1 department of neurology, hacettepe university, ankara, turkey; 2 virology unit, department of medical microbiology, hacettepe university, ankara, turkey; 3 neuromuscular disease research laboratory hacettepe university, ankara turkey. guillain-barré syndrome (gbs) is an acute monophasic immune-mediated polyradiculoneuropathy. it is believed that acute inflammatory demyelinating poliradiculoneuropathy is caused by t-cell mediated autoimmune response targeting peripheral nerve myelin. molecular mimicry plays a role in the pathogenesis of some gbs cases. this mechanism has been well demonstrated in the acute motor axonal neuropathy (aman) variant, in which autoantibodies to camphylobacter jejuni share epitopes with peripheral nerve gangliosides. this molecular mimicry mechanism can be attributed to some cases with atypical triggers such as zika virus or west nile virus infections. moreover there are accumulating clinical data for vector borne viral infections triggering gbs. we evaluated vector-borne viral infections in our gbs and aman patients. eight patients with gbs, two patients with aman and as a control group, seven patients with normal pressure hydrocephalus were included. gbs and aman was diagnosed with clinical, electroneuromyograpic and cerebrospinal fluid (csf) findings. cerebrospinal fluid serum and urine samples were examined for vector borne viral infections via generic flavivirus and phlebovirus pcr. we also documented our patients prognostic scores such as modified erasmus gbs outcome score (megos) and modified erasmus gbs respiratory insufficiency score (megris). the mean age of the patients was 56,8 (24-74 years) , six of them were female. all csf, serum and urine samples of our patients and control patients were negative for flavivirus and phlebovirus families. the preliminary results of our study in this our small cohort did not show any correlation between the vector-borne viral infections and gbs. further studies with broad number of patients are needed for more suggestive results. neuromyotonia (nmt) consists of spontaneous motor unit activity that reflects increased peripheral nerve excitability, leading to involuntary, persistent muscle activity, visible as muscle twitching at rest, with generalized, easily provoked cramps. since the first electrophysiological (emg) description of nmt by denny-brown and foley (1948) , there has been discussion about the origin of the abnormal electrical activity recorded in needle emg studies. we studied two patients. patient 1's nmt is aggravated by cold, and he has an associated non-progressive mild polyneuropathy with demyelinating features. he is now 73-year-old and has been followed in our centre for 20 years. he is negative for anti-vgkc antibodies. firstly, he was treated with carbamazepine and phenylhydantoin with poor response, but he has shown major improvement on intravenous immunoglobulin (ivig) during the last 15 years. patient 2 is a 62 year-old man with nmt, followed for 1 year, with high titters of anti-vgkc antibodies (505 pmol/l; normal<72). he improved on ivig during the last 12 months. screening for neoplasia was unremarkable in both patients (negative anti-neuronal antibodies, in particular anti-hu, anti-yo and anti-ri antibodies; normal computerized tomography scan of the chest and abdomen). in addition to routine studies, we tested synchronicity to spontaneous discharges in different motor units in simultaneous recordings made with two needle electrodes in the first dorsal interosseus muscle. time-locked fasciculations in these double recordings would represent abnormal ectopic activity initiated in a nerve trunk with ephaptic stimulation of a nearby axon. in patient 1, this research protocol was applied once, 15 years after regular ivig treatment. patient 2 was investigated before and 1 year after ivig. both patients improved after ivig, mirrored by a striking decrease in the amount of spontaneous activity on emg. moreover, our technique did not detect synchronous spontaneous activity (time-locked fasciculations) on the second assessment, although this was predominant before treatment in patient 2. in nmt, abnormal discharges originate both in distal axonal branches and in more proximal segments. it appears that ivig is more effective in blocking antibody activity in proximal axonal segments, perhaps related to factors such as blood-nerve barrier, temperature or differing ion channel distributions. celiac disease (cd) is a chronic, multisystem and immune-mediated disorder characterized by small-bowel sensitivity to dietary gluten in genetically predisposed individuals. neurological manifestations may occur in about 10% of patients, including peripheral nerve involvement. recent growing evidence strongly suggests that peripheral neuropathy in cd may be autoimmune and associated with anti-ganglioside antibodies. a 36-year-old woman presented with slowly progressive weakness of her right hand and fingers extensors. medical and family history were unremarkable. on examination, muscle strength (medical research council-mrc) was scored 0 for right wrist and finger extensors, 2 for right abductor pollicis longus and 4 for right ankle dorsiflexion. right triceps brachii and brachioradialis reflexes were weak, but normal elsewhere. the remainder of the neurological examination was normal. neuroaxis magnetic resonance was unremarkable, specifically with no gadolinium-enhancing lesions. motor and sensory nerve conduction studies were normal. no conduction block or abnormal temporal dispersion was found. needle electromyography showed severe neurogenic changes with abnormal spontaneous activity in right radial-innervated muscles, and chronic neurogenic changes in homolateral tibialis anterior, peroneus longus and extensor digitorum brevis. ganglioside antibody testing was positive to igg anti-gm2 antibody, but negative to anti-gm1 and other anti-ganglioside antibodies. additional blood tests were unremarkable, in particular cryoglobulin testing was negative. intravenous immunoglobulin improved weakness, as right extensors of the wrist and fingers scored 3 (mrc). a monthly treatment was initiated, which after 6 months was changed to every 2 weeks to preserve function. a diagnosis of mama was established. later, cd was diagnosed in her daughter due to chronic diarrhoea. our patient underwent anti-tissue transglutaminase antibodies determination and small-bowel biopsy after 7 years disease' duration, and a diagnosis of cd was made. gluten-free diet was started, but her neurological picture did not change after six months. in our case the presence of igg anti-gm2 antibody may support a causal link between mama and biopsy-confirmed cd, and the lack of response to gluten-free diet may be explained by chronic axonal injury induced by memory t-cells. this case broadens our knowledge about neurological manifestations in cd, raising a probable association with purely axonal multifocal motor neuropathies and anti-ganglioside antibodies. õunpuu s 1,2 , pogemiller k 1 , acsadi g 3 , pierz k 1,2,4 . 1 center for motion analysis, connecticut children's medical center, farmington, ct, usa; 2 school of medicine, university of connecticut, farmington, ct, usa; 3 division of neurology, connecticut children's medical center, farmington, ct, usa; 4 division of orthopaedics, connecticut children's medical center, farmington, ct, usa. orthopaedic surgical intervention of the foot and ankle is performed in persons with charcot-marie-tooth (cmt) for improving foot pain, ankle instability, orthosis fitting/comfort issues and shoe wear. the impact of these surgeries on ankle function during gait is not known. therefore, the goal of this study was to measure gait changes in ankle function following surgical intervention by means of computerized motion analysis. fourteen patients with cmt (10±4 years pre and 14±5 years post-operative) with bilateral orthopaedic surgery were included. all patients had a plantar fascia release plus some combination of other soft-tissue (posterior tibialis and tendo-achilles lengthenings; extensor hallucis longus, peroneus longus and anterior tibialis transfers) and bony procedures (metatarsal and cuboid osteotomies). all patients completed two gait analyses (pre and on average 3.8 years post-surgery) during barefoot walking using a standardized 3d motion analysis protocol. the changes in ankle kinematics and kinetics and temporal-spatial parameters were analyzed in reference to a control group of patients with cmt without intervening surgeries with 2.2 years between gait analyses as well as normal reference data. the surgical group showed a significant increase in height between the pre and post-operative analyses and no changes in walking velocity (pre: 105±24, post: 103±21, normal: 127±10 cm/sec). similarly, the ankle kinematics and kinetics showed no changes as a result of surgery. however, there was a trend for increased peak ankle dorsiflexion (pre: 13±9, post: 16±5, normal: 13±3 degrees). as in the surgical group, the control group showed an increase in height but no simultaneous increase in walking velocity (test 1: 102±18, test 2: 104±20 cm/sec). the control group also showed no changes in ankle kinematics and kinetics suggesting that the impact of the disease is, for the most part, not noticeable over 2.2 years. the results show that surgical intervention that primarily addresses foot alignment does not negatively impact ankle kinematics and kinetics during gait. the comparison with the control group supports this finding. however, there are some other findings such as the increase in peak dorsiflexion during stance in some patients that will need to be examined further in larger cohorts. õunpuu s 1,2 , pogemiller k 1 , pierz k 1,2,3 , acsadi g 2,4 . 1 center for motion analysis, connecticut children's medical center, farmington, ct, usa; 2 school of medicine, university of connecticut, farmington, ct, usa; 3 division of orthopaedics, connecticut children's medical center, farmington, ct, usa; 4 division of neurology, connecticut children's medical center, farmington, ct, usa. ankle-foot-orthoses (afos) are commonly prescribed for patients with charcot-marie-tooth (cmt) to improve gait and reduce ankle instability and falling. there are no studies that examine bracing outcomes using objective evaluations. the purpose of this study was to examine the impact of various afo designs on gait parameters in children and adolescents with cmt. we predicted that the afos would improve excessive and delayed peak dorsiflexion in stance and equinus in swing. fifteen patients (mean age 12±5 years) were analyzed barefoot and with their prescribed afos by means of a standardized motion analysis protocol. a full clinical examination was also completed including strength and passive range of motion measures. the afos included solid, hinged and posterior leaf spring (tapered, less supportive) designs. sagittal plane ankle kinematics and kinetics and temporal-spatial parameters were analyzed in comparison to normal controls. walking velocity improved from 95±26 to 108±21 cm/sec demonstrating the functional benefits of afos. ankle plantar flexion angle at initial contact improved from −8±8 to −1±4 degrees demonstrating improvement in drop foot in swing and at initial contact reducing the risk of tripping. however, the degree of peak ankle dorsiflexion in stance remained the same and excessive at 17±5 degrees barefoot and 16±5 degrees with afos suggesting that in many patients the afo design was not sufficiently supportive. peak ankle plantar flexor moment showed improvement from 0.69±0.29 to 0.79±0.25 nm/kg highlighting the improved base of support provided by the afos that compensate for ankle plantar flexor weakness. however, peak power generation was reduced from 1.48±0.80 to 1.11±0.39 w/kg indicating that some of the available ankle strength was impeded with the afos. the results of this study suggest that orthoses can provide improved gait outcomes which will improve overall function. however, there are individual differences in patient impairment (strength, range of motion and bony deformity) and associated gait presentation that need to be accounted for in afo design. afos do not always function as intended due to the complex interaction between patient impairment, orthosis stiffness and orthosis design. motion analysis can assist in identifying the specific afo needs for an individual with cmt. painous c 1 , lópez-pérez ma 2 , illa i 1,3 , querol l 1,3 . 1 neuromuscular diseases unit, neurology department, hospital de la santa creu i sant pau, barcelona, spain; 2 hospital san pedro, logroño, la rioja, spain; 3 centro para la investigación biomédica en red en enfermedades raras (ciberer), madrid, spain. chronic inflammatory demyelinating polyradiculoneuropathy (cidp) is an autoimmune neuropathy with a heterogeneous clinical spectrum. specific autoantibodies define different clinical phenotypes. cidp with nf155 antibodies constitutes a specific cidp subset in which a high incidence of postural and intention tremor has been described and that responds poorly to immunoglobulins. we report a patient with an anti-nf155 positive cidp that presented head, voice and limb tremor that improved with immunotherapy. a 64-year-old man with unremarkable medical history, presented at the age of 61 with progressive distal weakness and paraesthesia. numbness, gait ataxia and action tremor involving voice, head and limbs appeared sequentially. the emg showed features of acquired demyelination fulfilling cidp diagnostic criteria. a first course of intravenous immunoglobulins was ineffective. the weakness, ataxia and tremor worsened significantly, needing two walking aids first and becoming wheelchair bound later on. he received six plasmapheresis cycles that were also ineffective and oral corticosteroids (1mg/kg) were started with mild improvement. after corticosteroid tapering the patient developed a severe relapse and was referred to our centre. five plasma exchange cycles followed by rituximab (375mg/m2, 6 doses) were added to the corticosteroids. three months later the weakness, ataxia and tremor, including the head and voice tremor, started to improve significantly. six months later the patient presented a significant improvement and was able to walk unaided. the anti-nf155 antibody titres fell from 1/72900 pre-rituximab to be undetectable. limb tremor is known to occur in patients with inflammatory neuropathies and, specifically in anti-nf155+ cidp patients but, to our knowledge, this is the first report of a cidp patient presenting with head and voice tremor ever reported. the improvement of tremor with immunotherapy strongly suggest that anti-nf155 autoantibodies are involved in its pathogenesis, expanding the phenotype of anti-nf155 specific clinical features. palaima p 1 , peeters k 1 , l. pelayo-negro a 2 , garcía a 2 , gallardo e 2 , garcía-barredo r 2 , de vriendt e 1 , infante j 2 , berciano j 2 , jordanova a 1 . 1 vib and university of antwerp, center for molecular neurology, molecular neurogenomics group, antwerp, belgium; 2 university hospital "marqués de valdecilla", santander, spain. charcot-marie-tooth disease type 2g is an autosomal dominant and slowly progressing inherited neuropathy which was first described over 30 years ago. it has been attributed to a single spanish family consisting of 33 individuals with 13 affected members spanning four generation. initially, the genetic defect was linked to a 13.2mb region in 12q12-q13.3. however, extensive sequence and structural variant analyses using whole genome sequences (wgs) of three affected individuals did not reveal any known or novel genetic causes within the region. over the last decade, serial clinical re-evaluation of the entire pedigree was performed leading to changes to the affection status of seven individuals redefining the disease-linked region to chr9q31.3-q34.2 (z max = 4.39 at theta = 0). additional family members were then submitted for whole exome sequencing. this has led to the identification of a novel missense variant in the e3 ubiquitin-protein ligase lrsam1 (p.cys694tyr) that was previously not covered by wgs. the variants co-segregated with disease and were absent from controls. other mutations that are known to disrupt the ring domain of lrsam1 have been previously reported to cause both autosomal dominant and recessive cmt type 2p (cmt2p). unlike prior reports, we demonstrated that the mutation does not influence overall protein levels of lrsam1, nor of its ubiquitylation target tsg101 in patient derived lymphoblasts. transcriptomics analysis identified significant upregulation of another e3 ubiquitin-protein ligase (nedd4l) and of a key regulator of axonal degeneration (tnfrsf21). notably, magnetic resonance imaging of lower-limb musculature systematically showed fatty atrophy in both clinical and subclinical mutation carriers emphasizing its use for the identification of mildly affected members. our findings demonstrate that the isolated genetic entity cmt2g is caused by a missense mutation in lrsam1 and should be reclassified as cmt2p. moreover, we reveal novel molecular players associated with lrsam1 dysfunction, and highlight pathways and therapeutic targets shared with amyotrophic lateral sclerosis and alzheimer disease. damage to peripheral nerves is a prerequisite for neuropathic pain. however, it remains unclear why some neuropathy patients have pain, but others with identical nerve conduction, qst and ienfd do not. we propose to examine the distribution of trpv1 and its co-localization with cgrp and sp in epidermal nerve fibers in patients with and without neuropathic pain. we aimed to define the expression pattern of trpv1 in normal healthy subjects first, and study the co-localization of trpv1 with cgrp and sp in normal controls and patients with painful neuropathy. skin biopsies from neuropathy patients and normal subjects were utilized. anti-trpv1 antibody generated in our university with support from ninds-funded dept. of neuroscience monoclonal core (ns050274) was used. combined immunohistochemistry were performed to identify co-expression of trpv1 with cgrp, sp and pgp 9.5. the distribution of trpv1 in controls revealed a proximal to distal gradient similar to that observed for ienf labeled by pgp 9.5. trpv1 staining was more intense in nerve terminals in the epidermis. combined immunostaining revealed that 65% of pgp 9.5 labeled fibers in the epidermis were trpv1+, while 78% of cgrp+ fibers trpv1+. patients with pain had a higher density of trpv1+ fibers compared to that of patients with numbness. a greater proportion of cgrp+ fibers (94%) in the painful patients were trpv1+. expression of trpv1 in controls exhibits a distal to proximal gradient. trpv1 expression and co-localization with cgrp were altered in neuropathic pain patients, suggesting that this receptor plays an important role in pathological states. activation of the nop-receptor (nop-r) by its endogenous ligand nociceptin/orphanin fq or non-peptide agonists modulates nociception and analgesia in neuropathic pain models. the wide distribution of nop-r and its endogenous ligand represents an attractive treatment target. since pain is the most prominent feature in pc, we defined expression of the nop-r in plantar skin biopsies and assessed whether alterations exist in pc-affected vs pc-unaffected and anatomically matched control skin. skin biopsies from k6a pc and control subjects were immunohistochemically stained for nop-r. combined immunostaining for nop-r with pgp 9.5, neurofilament h (nfh) and cgrp was used to define nop receptor expression in the epidermis and upper dermis. robust nop-r was detected in epidermal keratinocytes and a subset of pgp9.5+ fibers in both epidermis and dermis. staining was inhibited through pre-incubation with a nop-r blocking peptide and western blot analysis using homogenized human skin tissue demonstrated a band at ∼50kd consistent with nop-r molecular weight. nop-r expression occurred in dermal nfh+ a beta-fibers in all groups though no cgrp+ fibers co-expressed nop-r. pc-affected skin had slightly lower nop-r expression than in pc-unaffected skin and a similar pattern in anatomically matched locations from healthy control subjects was observed. nop-r is expressed in human plantar skin epidermal keratinocytes as well as a subset of epidermal and dermal nerve fibers. these fibers are pgp 9.5+, cgrp-and many co-express nfh. nop receptor is a viable pharmaceutical analgesic target in pc patients irrespective of its slight down-regulation as compared to pc-unaffected skin. this work was supported by grünenthal gmbh. pareyson d 1 , stojkovic t 2 , leonard-louis s 2 , reilly mm 3 , laurà m 3 , parman y 4 , battaloglu e 4 , tazir m 5 , bellatache m 5 , bonello-palot n 6 , sacconi s 7 , guimarães-costa r 2 , attarian s 6 , latour p 8 , megarbane a 2 , schenone a 9 , ursino g 9 , sabatelli m 10 , luigetti m 10 , santoro l 11 , manganelli f 11 , quattrone a 12 , valentino p 12 , murakami t 13 , scherer ss 14 , dankwa l 14 , shy me 15 , bacon cj 15 , herrmann dn 16 , pisciotta c 1 , previtali s 1 , bolino a 1 . 1 milan, italy; 2 paris, france; 3 london, united kingdom; 4 istanbul, turkey; 5 algiers, algeria; 6 marseille, france; 7 nice, france; 8 lyon, france; 9 genoa, italy; 10 rome, italy; 11 naples, italy; 12 catanzaro, italy; 13 kurashiki, japan; 14 philadelphia, usa; 15 iowa city, usa; 16 rochester, usa. cmt4b1 and b2 are characterized by recessive inheritance, early onset, severe course, slowed nerve conduction, myelin outfoldings, association with loss-of-function mutations in myotubularin-related protein-2 and −13 (mtmr2, mtmr13/sbf2), respectively, involved in the metabolism of ptdins3p and ptsins(3,5)p 2 phosphoinositides, key regulators of membrane trafficking. in a multicentre retrospective study to better characterise cmt4b, we collected a minimal dataset of information including cmtes/cmtns on 41 cmt4b patients, 27 cmt4b1 (14 unrelated families) and 14 cmt4b2 (11 families). cmt4b1 patients were younger and with earlier onset than cmt4b2: last visit was performed at a mean age of 22 years (sd 12.5; range 1-48) for cmt4b1 and 35 years (13.1; 16-59) for cmt4b2; disease onset occurred at a mean age of 2.8 years (3.2; 0-13) in cmt4b1 as compared to 5.9 years (5.3; 1-20) in cmt4b2; delay in motor milestones occurred in 15/26 cmt4b1 and 4/14 cmt4b2 subjects. eleven cmt4b1 patients became chair-bound, whereas all cmt4b2 subjects but one are still ambulant, although with afos for 9 patients and requiring unilateral support in two cases. both disease types are characterised by vocal cord involvement (9/26 cmt4b1 and 6/14 cmt4b2); respiratory involvement was seen almost exclusively in cmt4b1 patients (n=8, four requiring non-invasive ventilation and one tracheostomy, as compared to one cmt4b2 patient on niv at age 49); two cmt4b1 subjects and an affected cmt4b1 relative not included in the present study died of respiratory complications. glaucoma (n=4) and buphthalmos (n=2) occurred only in cmt4b2. cmtes/ cmtns scores were higher in cmt4b1 patients in spite of their younger age, indicating more severe disease: cmt4b1 = cmtes mean 17.9 (n=20; sd 6.0; range 8-28/28), cmtns mean 30.2 (n=10; sd 4.8; range 19-36/36,; cmt4b2 = cmtes mean 16 (n=13; sd 5.0; range 6-26/28), cmtns mean 25 (n=12; sd 4.7; range 19-34/36). our data confirm that cmt4b1 is more severe than cmt4b2. interestingly, mtmr2 interacts with mtmr13. mtmr2 is a catalytically active phosphatase, whereas mtmr13 is a catalytically inactive protein, known to increase mtmr2 enzymatic activity. thus, in cmt4b2 nerves a residual enzymatic activity of mtmr2 may result in a less severe clinical phenotype as compared to cmt4b1. the charcot-marie-tooth disease (cmt) national registry is fully operative (https:www.registronmd.it) with collection of clinical/genetic information (minimal dataset) and reporting of clinical scales; 537 cmt patients have registered thus far and have chosen one of the 9 reference centers; information collected during the ad hoc visit have been entered in the registry for 420 of them. registered patients have the chance to participate to a study that requires filling online self-reported questionnaires related to five important issues: disease course and complications during pregnancy; use, efficacy and tolerability of orthotics and assistive devices; outcome of surgery for skeletal deformities; safety of anesthesia; occurrence of sleep disorders (including evaluation of fatigue, anxiety and depression). by february 2016, 201 patients and 36 relatives/friends (as healthy controls) have filled the questionnaires. we are performing a first explorative analysis of results, but data collection on all questionnaires will be prolonged until novemebr 30, 2017, to obtain a larger sample. pregnancy: 46/73 cmt women had at least one pregnancy; complications ranging from mild to severe occurred in 44/108 pregnancies vs 9/42 in controls. cmt worsened in 7 pregnancies (6 patients) with no recovery in 5 instances. prenatal diagnosis was performed in 8/108 pregnancies. satisfaction related to surgical procedures for foot deformities, assessed with vas (score 0-10), was 6.4±3.5 (n = 110). repeat surgery was required in 9/72 instances. sleep: the epworth sleepiness scale questionnaire revealed abnormalities of sleep in 44/142 cmt patients (31%) and in 5/30 controls (17%). the vast majority of cmt subjects (123/138; mean 9.1 ± 3.2), but also of controls (27/30; 8.6 ±2.9) were not good sleepers according to the pittsburgh sleep quality index (psqi) (range 0-21, 0 good sleep). fatigue: scores of modified-fatigue impact scale (range 0-82, 0 no fatigue) were higher for cmt (mean 33±18.2) than controls (mean 16.6±12.5). hospital scale for anxiety and depression: 63/138 cmt subjects had mild-to-severe anxiety and 35/138 mild-to-severe depression as compared to 7/29 and 4/29 controls, respectively. data analysis on orthotics and anesthesia is ongoing. in conclusion, the first data analyses confirm that there are problems related to all the five domains explored, that will need to be specifically addressed in patients' care. supported by telethon-uildm grant gup13006. charcot-marie-tooth disease (cmt) is the most frequent motor and sensory peripheral neuropathy and is known to have the uniform demyelination. the traditional definition of conduction block is the reduction of negative peak of compound muscle action potential (cmap) of proximal segment relative to adjacent distal segment more than 50%. in this study, we tried to find the frequency of conduction block in cmt1a patients and to investigate the differences of the clinical manifestation. we enrolled unrelated 48 cmt1a patients (26 males and 22 females) with pmp22 duplication and undertook nerve conduction studies from 2011 to 2015. stimulation sites were wrist, elbow and axilla for median nerve study. eleven patients (22.9% of all enrolled patients) had ncs features suggestive of conduction block. compared to cmt1a patients without conduction block, functional disability scale was significantly higher in cmt1a patients with conduction block (p < 0.05). however, onset age and disease duration were not different between cmt1a patients with and without conduction block. in addition, conduction block was more frequently observed in distal segments than proximal segments. we suggest that the frequency of conduction block in cmt1a patients is not low, and there is some heterogeneity of demyelination in cmt1a patients. also, in cmt1a patients, the conduction block might have relationship with clinical disability. park jg 1 , park ms 1 . 1 yeungnam university college of medicine, daegu, korea. the subacute combined degeneration (scd) is diagnosed by a characteristic clinical manifestation, spinal mri, and decreased serum vitamin b12 levels. we report a case of scd with elevated homocysteine and methlymalonic acid level in the situation of spurious elevation of vitamin b12 concentration. an 80 years old man presented with progressive gait disturbances and sensory disturbances. about a year ago, he felt both hands and feet paresthesia and gait disturbances. four months before the visit, nerve conduction tests were performed elsewhere due to symptoms. polyneuropathy was found. the laboratory test showed megaloblastic anemia. however, serum vitamin b12 concentration was increased to 1649 pg / ml (normal: 200-950 pg / ml). his symptoms progressed gradually. at presented, neurological examination showed spasticity of the lower limb without weakness, and vibration and position sensation were decreased in both lower limbs, and showed ataxic gait. spinal cord mri showed a lesion with a long t2 high signal intensity from c1 to t4 in the posterior column of the spinal cord. further laboratory test were added, then while folate was normal level but homocysteine at 21.2 umol/l (normal: 5-12 umol/l), and methylmalonic acid at 2.9 um / l (normal: 0-0.4 um / l) were increased. finally, scd caused by vitamin b12 deficiency was diagnosed. in addition, gastric endoscopy was performed to find the cause of vitamin b12 deficiency and chronic atrophic gastritis was found. after cobalamine treatment for 6 months, hemoglobin level was improved and his symptoms were all improving with a little gait disturbances. false-elevation of vitamin b12 level could lead to delayed diagnosis and cause irreversible changes in the nervous systems. one of the most commonly used methods to measure vitamin b12 concentrations is competitive-binding assay, which may result in normal levels even with vitamin b12 deficiency due to the effect of anti-intrinsic factor antibodies. when vitamin b12 deficiency is suspected, even if the vitamin b12 concentration is normal, additional tests of homocysteine and methylmalonic acid should be considered. parman y 1 , durmus h 1 , deymeer f 1 , oflazer-serdaroglu p 1 , battaloglu e 2 . 1 istanbul university, istanbul faculty of medicine, department of neurology, istanbul, turkey; 2 bogazici university, istanbul, turkey. hereditary motor and sensory neuropathies, also called cmt neuropathies, are the most common group among the hereditary neuropathies. cmt subtypes are grouped by axonal, demyelinating or intermediate phenotype, or by autosomal-dominant (ad), autosomal-recessive (ar) or x-chromosomal inheritance. cmt-2 is considered axonal and characterized by distal muscle wasting, mild sensory loss and normal or near-normal nerve conduction velocities. mutations in more than 18 genes are known to be able to cause autosomal dominant (ad) or recessive (ar) cmt-2 to date. the genetic heterogeneity in charcot-marie-tooth (cmt) is a challenge for genetic diagnostics. clinical clues and frequencies of mutations in cmt genes from large cohorts may help to develop strategies for efficient genetic testing. here, we present the clinical, electrophysiological and genetic features of 31 patients from turkey, diagnosed as genetically confirmed cmt-2 in the department of neurology, istanbul faculty of medicine our clinic between 1990 and 2015. genetic testing was performed for gdap1 by dna sequencing and samples from 16 patients were exome sequenced (wes). twenty-one male and ten female patients from 16 unrelated families were investigated. segregation was ar in eight, ad in six families and two were isolated cases. intraand interfamilial variability in the age of onset with a range of 2-48 (mean 12.6 ± 9.8 years) and disease progression rate were striking. slowly progressive weakness and atrophy of distal muscles in the feet and/or hands were the most common presenting symptoms. mfn2 was found in four unrelated ad kinship and in 2 unrelated ar kinships and was most common gene mutated among whole cohort. gdap1 was the most commonly mutated gene among ar families (5/8). wes revealed further mutations in aars, nefl, kif1b and hspb1, however, the causative mutation could not be identified in known cmt2 genes in about 40% of patients. our data indicates the marked intra-and inter-familiar phenotype variability in cmt-2 as previously described in literature. many more genes causing arcmt-2 remain to be discovered. pasnoor m 1 , veerapaneni k 1 , murphy r 1 , statland jm 1 , kimple d 1 , hamasaki a 1 , glenn md 1 , herbelin l 1 , barohn rj 1 , jawdat o 1 , dimachkie mm 1 . 1 department of neurology, neuromuscular division, the university of kansas medical center, kansas city, ks, usa. electrodiagnostic (edx) studies involving electromyography/nerve conduction study (emg/ncs) are useful for diagnosis of neuromuscular disorders. although these are safe procedures, emg and ncs often evoke anticipated pain and anxiety. there are no published research studies to support the notion that providing detailed information to patients prior to these procedures would reduce procedural pain and ameliorate anxiety levels afterwards. the objective of this study was to perform a prospective survey to assess anticipated pain and anxiety in patients presenting for edx studies, design a detailed patient education form, and assess the change in perceived pain and anxiety pre and post procedure in the standard of care (soc) education versus the printed detailed education instrument group. after completing a brief pain/anxiety questionnaire, patients were randomly assigned to either soc verbal education group or to read the detailed education form. another brief questionnaire was completed post procedure. seventy-eight patients were enrolled at the time of abstract submission, 41 in intervention and 37 in soc groups. mean age of patients enrolled was 58±15 years. pain was anticipated by 81% patients as a visual analog scale (vas) score mean of 4.9±2.5 with no significant difference between both groups (p=0.86). post-procedural pain was reported in 75% of patients with mean pain score of 5.3±2.2 and no significant difference between the two groups (p=0.09). anxiety pre-procedure was reported by 35% patients with a mean likert-like score of 5.3±2.2 score in all cases (p=0.12 between both groups). post-procedural anxiety frequency was reduced to 8% with mean level of 4.5±2.6 (p=0.72 between both groups). most patients reported pain with both emg and ncs (53%). we found that edx testing evokes moderate pain in most and in some cases moderate anxiety level. the detailed education intervention did not attenuate the frequency or severity of pain. post-procedural anxiety was expectedly reduced in severity and frequency in both groups with a suggestion that anxiety severity is lesser in the detailed education group but numbers were small. further studies with more detailed questionnaire and perhaps web-based education in larger population may be useful to reduce pain/anxiety in patients presenting for edx studies. pasnoor m 1 , roach c 1 , barohn rj 1 , statland j 1 , jawdat o 1 , dick a 1 , glenn m 1 , dimachkie mm 1 . 1 department of neurology, neuromuscular division, the university of kansas medical center, kansas city, ks, usa. diagnostic criteria for chronic inflammatory demyelinating polyneuropathy (cidp) have been designed for use in clinical trials. there is limited data on the comparative diagnostic utility of these criteria in the clinic setting and it is unknown if some of these criteria are better for predicting treatment response. the objective of this study is to compare the sensitivity of various diagnostic criteria and review treatment response. after obtaining local irb approval, we performed a retrospective chart review of cidp patients seen at the university of kansas medical center between 2008 and 2014. we abstracted the clinical, electrodiagnostic, and treatment information. we determined the frequency of patients fulfilling each of the following criteria: efns 2010, aan, saperstein and incat. we defined treatment response based on treating physician's impression of change, patient-reported functional improvement or one point grade change in the mrc grade. fifty-three cidp patients charts were reviewed, 15 were excluded due to missing data. mean age was 51.5, and 16(42%) were female. elevated csf protein was seen in 18/23(78%). twenty-eight (73%) fulfilled efns definite criteria, 5 (13.16%) efns probable, 10 (26.3%) aan, 20 (52.6%) incat, and 20 (52.6%) the saperstein criteria. treatment response in patients who fulfilled efns definite/probable criteria included 20/22 to ivig, 5/8 to iv or oral corticosteroids, 2/3 to mycophenolate mofetil; among patients who fulfilled aan criteria, these were respectively 8/9, 2/3 and 1/1; among those meeting incat criteria 10/15, 5/7 and 1/2; and for saperstein criteria it was12/17, 4/6 and 1/2. half to two-thirds of patients responded to plex based on different criteria. while all cidp criteria can similarly predict ivig treatment response, the efns 2010 criteria are most sensitive for the clinical diagnosis of cidp. pellegatta m 1 , canevazzi p 1 , forese mg 1 , podini p 2 , quattrini a 2 , taveggia c 1 . 1 division of neuroscience and inspe, axo-glia interaction unit, san raffaele scientific institute, milan, italy; 2 division of neuroscience and inspe, experimental neuropathology unit, san raffaele scientific institute, milan, italy. axonal nrg1 type iii is an essential instructive signal for pns myelination, since its expression determines whether axons are myelinated and also the thickness of the myelin sheath. previous studies have shown that secretases' cleavage controls nrg1 type iii activity at post-transcriptional level. specifically, the beta-secretase bace-1 cleavage of nrg1 type iii promotes myelination, whereas the alpha-secretase tace inhibits pns myelination by inactivating nrg1 type iii. after a damage, the axon located distally to the site of injury degenerates and loses the myelin sheath, following a process termed as wallerian degeneration. unlike the cns, axons in the pns can regenerate and regrow. several studies have shown that regeneration is favored by the trans-differentiation of schwann cells, which start to create a permissive environment for axonal regrowth. in addition, it has been shown that nrg1 regulates the early stages of the dedifferentiation process and is essential for creating a permissive environment to regeneration. similarly, the beta secretase bace-1 promotes pns regeneration and remyelination. in the present study, we analyzed the role of the alpha-secretase tace during wallerian degeneration. our data indicate that tace is upregulated in sciatic nerves after injury, distally to the site of damage. since tace is expressed in schwann cells and axons, we analyzed the role of both glial and neuronal tace during degeneration and regeneration processes. thus, we performed crush injury in sciatic nerves of two different transgenic lines carrying a conditional deletion of tace either in schwann cells (p0-cre//tace flox/flox ) or in neurons (chat-cre//tace flox/flox ). the analyses of the different phases of the wallerian degeneration in these animals suggest a role of glial tace during the early stage of the process. in fact, we observed an increased number of myelinated axons only in p0-cre//tace flox/flox mice, while we did not detect substantial differences in mutant chatcre//tace flox/flox mice. these results suggest that even during regeneration tace has an inhibitory role, as deletion of tace in schwann cell likely induces the activation of a neuro-protective program that we are currently investigating. péréon y 1 , nizon m 2 , küry s 2 , besnard t 2 , quinquis d 2 , boisseau p 2 , magot a 1 , mussini jp 1 , mayrargue e 3 , barbarot s 4 , bézieau s 2 , isidor b 2 . 1 reference centre for neuromuscular disorders; 2 dept. of genetics; 3 dept. of paediatric surgery; 4 dept. of dermatology, university hospital, nantes, france. the hereditary sensory and autonomic neuropathies (hsan) constitute a clinically and genetically heterogeneous group. hsan are associated with sensory dysfunction, altered pain and temperature perception with varying degrees of autonomic dysfunction, and abnormal small fibers neurodevelopment. more than ten genes have been described so far in the hsan group. original classification encompassed four entities, but additional subgroups continue to be described. hereditary sensory neuropathies (hsan) type ii are characterized by autosomal recessive inheritance, onset at birth and self-mutilating behavior. until now, one homozygous frameshift variant, c.[577_580del], p.(lys193phefs*37), was reported in arl6ip1 (adprribosylation-like factor 6-interacting protein 1) in a consanguineous family. patients presented with spastic paraplegia, diffuse sensory and motor polyneuropathy and acromutilation. the disorder was classified as autosomal recessive spastic paraplegia spg61. here, we described a new patient with congenital insensitivity to pain, sensory neuropathy, self-mutilation, and spastic paraplegia. whole exome sequencing showed a homozygous frameshift variant c. [577_580del], p.(lys193phefs*37) in arl6ip1. the protein harbours reticulon-like short hairpin transmembrane domains and has a role in endoplasmic reticulum shaping. the variant causes an additional c-terminus hydrophobic domain which could alter its function. arl6ip1 interacts with atlastin-1 responsible for spg3a and hsan type 1d. this report highlights the role of arl6ip1 in pathophysiology of insensitivity to pain and spastic paraplegia. péréon y 1 , nguyen a-l 1 , leclair-visonneau l 1 , fayet g 1 , nguyen j-m 2 , magot a 1 . 1 laboratoire d'explorations fonctionnelles, hôtel-dieu, nantes, france; 2 département de statistiques médicales, hôtel-dieu, nantes, france. carpal tunnel syndrome (cts) is responsible for sensory and/or motor symptoms that may be increased by wrist flexion or extension (phalen sign). previous studies have shown that short duration (e.g.5 min or less) flexion or extension was not responsible for significant changes of median nerve conduction parameters. the objective is the study was to determine how prolonged extension (reverse phalen's test) affects median and ulnar nerve conduction parameters in normal subjects. after providing informed consent, 30 normal subjects (17 females, age rank 18-55 years) underwent motor and sensory testing of both median and ulnar nerves from the dominant side. edx testing was performed using standard techniques with wrist in neutral position, then during passive wrist extension (90 ∘ ) for 30 minutes, with sequential recording of both motor action potential (cmap) and sensory action potential (snap) latencies and amplitudes every 5 minutes after extension onset. ulnar nerve conduction parameters remained unchanged in all the subjects. regarding median nerve, 4 groups of subjects could be individualized: 12 subjects with no changes; 8 subjects with only significant decrease of snap amplitude (−50%); 6 subjects with both snap amplitude and velocity decrease; 4 subjects with both cmap and snap significant changes. when present, changes did not appear before 10 min, with snap decrease being the earliest observed abnormality. prolonged wrist extension was responsible for median nerve edx parameter modifications in 18/30 normal subjects. sensory fibers were firstly affected, corresponding to the chronology clinically encountered in cts. based upon these results, the same protocol will be used in patients presenting with mild clinical cts, in order to try and identify an additional edx technique being useful in the diagnosis of cts. one could also wonder whether the subjects with the most important changes would be more prone to present cts in the future. perez-siles g 1,2 , drew a 1,2 , ellis m 1 , kidambi m 1 , takata r i 4 , speck-martins c e 4 , hagerman k a 5 , siskind c e 5 , day j w 5 , ginzberg m 6 , nicholson g 1,2,3 , kennerson m l 1,2,3 . 1 northcott neuroscience laboratory, anzac research institute, sydney, australia; 2 sydney medical school, university of sydney, sydney, australia; 3 molecular medicine laboratory, concord repatriation general hospital, sydney, australia; 4 sarah network rehabilitation hospitals, brasilia, df, brazil; 5 department of neurology, stanford health care, stanford, ca, usa; 6 pediatric neuromuscular unit, wolfson medical center, holon, israel. mutations in the atp7a gene cause of x-linked hereditary distal motor neuropathy (dhmnx). to date, missense mutations (t994i and p1386s) in this copper transporting atpase are the only confirmed mutations causing dhmnx in two independent families. next generation sequencing (ngs), including whole exome and whole genome sequencing, is increasing the rapid detection of variants in genes known to cause disease, however the absence and size of additional families, make it challenging to determine the pathogenic or benign status of variants identified. we have recently identified new variants in atp7a in patients with progressive peripheral neuropathy, suggesting further genetic heterogeneity of dhmnx. two of these new variants, pe840v and pm1311v, are located at highly conserved amino acids within domains of atp7a (a-domain and p-domain, respectively) that are critical for the catalytic cycle of the copper transporter. we have also identified a third variant (c.3802-9a>g) located 9 bases upstream exon 19 that is predicted to abolish a conserved branch-site, a consensus intronic sequence necessary for the processing of immature rna during splicing. our recent investigations using both patient fibroblasts and an atp7a conditional knock in mouse model for dhmnx expressing atp7a t985i , the orthologue of the human atp7a t994i mutation, showed reduced atp7a protein levels and defective retrograde trafficking of atp7a, as pathological hallmarks of dhmnx atp7a causative mutations. to elucidate if the newly identified pe840v, pm1311v and c.3802-9a>g atp7a variants are pathogenic, we have systematically assessed patient fibroblasts harbouring these mutations for altered parameters previously found in the pathogenic t994i atp7a mutation. we predict that functional characterisation of atp7a using patient fibroblasts harbouring newly identified variants will provide the evidence to ascertain whether these variants are disease causing. establishing a systematic functional readout for atp7a variants will improve accuracy of genetic counselling and patient management of dhmnx in those cases where genetic evidence is limited. this study represents a complementary and necessary approach to the use of ngs, for validating the pathogenic status of variants identified and for expanding the genetic heterogeneity of dhmnx. month of birth (mob) have been defined as a risk factor for more than 50 diseases. for instance, susceptibility for multiple sclerosis (ms) seems to be associated with being born in may, while lower risk of ms is observed in those born in november. there are no studies that assessed potential association between mob and a risk for guillain-barré syndrome (gbs). we sought to determine if the risk of gbs is associated with the mob. study included 446 gbs patients diagnosed in serbia, montenegro and republic of srpska in the period from january 1, 2009 until december 31, 2015. mob of patients and of general population were compared. patients with gbs had tendency to be born in october (27% increase compared to general population, p=0.07) and were less likely to be born in june (28% decrease, p=0.05). when consider specific seasons, gbs patients were more likely to be born in winter months (16% increase, p<0.05). no associations were found between month/season of birth and disease severity. results of this pilot study showed that gbs patients are more likely to be born in cold months, and less likely to be born in june. this might be explained by higher exposure to different pathogens during pregnancy in cold months. in accordance with this, it is well known that early exposure to infective agents reduces risk of allergic and autoimmune diseases. further studies are needed to test our findings in different cohorts and in regions with different climate. these results may shed new light on the disease pathogenesis. majority of patients with guillain-barré syndrome (gbs) tend to have a successful recovery, but in number of them significant long-term consequences may negatively affect their quality of life. aim of this research was to analyze the outcome of the disease one year after the acute episode of gbs. among 82 patients diagnosed with gbs in seven tertiary centers in serbia, montenegro and republic of srpska during 2014, 57 subjects were retested after one year (62% males, mean age 57±16 years). functional disability of patients was estimated based on the gbs disability scale (gds). severe form of the disease (gds score 4-6) was registered in 50% of patients at admission, 73% at nadir, and 24% on discharge. after one year follow-up period, 14% of patients had no symptoms of gbs, 42% had mild symptoms, 24% was able to walk but not to run, 8% needed unilateral support during walking, while 3% was wheelchair bound or bedridden. lethal outcome was registered in three patients during acute phase of gbs and in four more during one-year follow-up. paresthesias were present in 60% of gbs patients, musculoskeletal pain in 40%, and fatigue in 21% one year after acute phase of the disease. factors associated with the worse functional outcome (gds grade above 1) after one year were: age above 70, preceding respiratory infection, and worse gds on discharge. one year after the onset of the disease, significant number of our gbs patients had neurological impairments including sensory symptoms, pain, fatigue and muscle weakness which may significantly affect patients' everyday functioning. phetteplace je 1 , saade d 1 , bacon c 1 , shy me 1 . 1 university of iowa hospitals and clinics, iowa city, ia, usa. charcot-marie-tooth (cmt) disease, also known as hereditary motor and sensory neuropathy, is a heritable peripheral neuropathy caused by genetic mutations in many different genes. cmt type 1a is the most common form of cmt. individuals affected with cmt1a commonly have distal muscle atrophy, foot deformities, abnormal gait, and reduced nerve conduction velocities caused by demyelination of the peripheral nerves. cmt1a is known to be caused by a duplication of the pmp22 gene at 17p11.2. the proposed disease mechanism of cmt1a is believed to be increased gene dosage of the pmp22 gene, although the exact function of pmp22 is not known. there have been previous reports in the literature of individuals who carry a homozygous duplication of pmp22, therefore having four copies of the gene. however, many of these reports have focused on adult patients who symptoms may not vary significantly from individuals who harbor only a duplication of pmp22. a 23 month old male presented to the university of iowa hospital due to a family history of cmt1a and concern for delay in independent ambulation. he was known to have both a maternal and paternal family history of cmt1a, although the families were believed to be unrelated. on exam he was unable to walk independently, but could take a few steps when his hands were held. per report he began crawling and scooting at 18 months of age. he was not found to have any structural abnormalities or atrophy in his upper or lower extremities. electrodiagnostic testing revealed a demyelinating neuropathy. only one nerve was tested, as the patient was unable to tolerate additional shocks. the peroneal nerve was found to have a nerve conduction velocity of 7 m/s. based on the clinical presentation, electrodiagnostic examination and family history deletion and duplication testing for pmp22 was performed. this testing revealed a homozygous duplication of pmp22, which has been previously reported to cause cmt1a. this case supports the gene dosage disease mechanism, as our patient appears to be more severely affected than a typical infant or toddler affected with cmt1a. piscosquito g 1 , saveri p 2 , provitera v 1 , stancanelli a 1 , ciano c 3 , magri s 4 , taroni mpz mutations are associated with the demyelinating early-onset charcot-marie-tooth (cmt) type 1b and with the axonal later onset cmt2i/cmt2j. paresthesias/dysesthesias and pain have been already reported in some cmt types and also in cmt2i/j. we report 16 patients (13 from 5 families, 3 sporadic cases,) carrying the mpz c.306dela mutation (p.asp104thrfster14). this is predicted to be a loss-of-function mutation, leading to p0 haploinsufficiency. most of the subjects have genetic ancestry from puglia region (southern italy). two patients carried the mutation in homozygosity, showing a severe phenotype: onset at birth, severe scoliosis, proximal weakness, distal limb plegia, no autonomous walking, cmt examination score (cmtes) 23-25/28. all the other heterozygous patients had mild adult-onset (mean age 33, range 20-56) neuropathy, walked without aids or ankle-foot orthoses, had cmtes <4/28. five showed mild foot deformities, 5/16 had foot and 7/16 hand weakness (mrc never less than 3/5), 10/16 sensory loss in lower limbs (ll). paresthesias/dysesthesias (mostly tingling and burning in type) localized in hands and ll were reported by 15/16 subjects, neuropathic pain by 10/16. in the homozygous patients, all cmaps and saps were absent. in all other subjects, motor conduction velocities (cv) were >31 m/s (range 31-50 m/s) and sensory cv >29 m/s (range 29-62 m/s). cmaps as well as saps were normal or moderately reduced in amplitude, indicating only slight axonal loss. we confirm that heterozygosity is associated with very mild cmt, whereas homozygosity causes a very severe neuropathy. our data suggest that paresthesias and neuropathic pain are very common and should be considered as part of the phenotype. although the clinical picture suggests a small fiber neuropathy, no such evidence is provided in the current literature. in the attempt to further investigate this field, we found in a 37-year-old male patient of our series that all thresholds were increased at quantitative sensory testing, and several abnormalities of small nerve fibers were present in skin biopsy. apparently, p0 aneuplody causes neuropathy and small fiber involvement through a mechanism different from other mpz missense mutations. poitras t 1 , chandrasekhar a 1 , singh v 1 , martinez j 1 , zochodne dw 1 . 1 neuroscience mental health institute, and division of neurology, department of medicine, university of alberta, edmonton, alberta, canada. a microarray mrna analysis of dorsal root ganglia examined in long-term diabetic mice yielded an unexpected upregulation of a unique set of proteins known as major urinary proteins (mups 1&2). originally, this family of barrel shaped proteins was described as including mediators of pheromone secretion in the urine of rodents, apparently unconnected to other functions. we identified its unanticipated expression in sensory neurons of adult mice and rats and explored its potential impact on the properties of these neurons. analysis of rat and mouse sensory neurons showed widespread and pan-neuronal cytosolic mup expression, not only in the cell body, but also in distal sensory projections located in the dermis of the footpad. to assess the role that mup might offer in the growth behaviour of adult neurons, we examined sirna-induced knockdown of mup on pre-injured dissociated drg primary cultures. mup knockdown in both species showed a significant increase in neurite outgrowth following mup sirna treatment when compared to a scrambled sequence control. mice treated with streptozotocin (stz) model features of human type 1 diabetic polyneuropathy, including decreases in multi-fiber motor and sensory measurements, and changes in thermal sensation in the extremities. to explore the potential role of mup upregulation specifically in diabetes, we examined the impact of non-viral intranasal injection of mup sirna on indices of neuropathy in chronic type 1 diabetic mice. following treatment, mice treated with mup sirna showed improvement in both motor and sensory nerve conduction velocities compared to scrambled controls. taken together, this data suggests that mup plays a growth-suppressive role in both diabetic and non-diabetic neurons and may also contribute to the electrophysiological and behavioral abnormalities associated with diabetic polyneuropathy. the repurposing of mups in sensory neurons identifies an interesting role for a supposed pheromone protein. [supported by cihr, cda and adi] enhancement of their outgrowth properties (singh et al, 2015) . here we asked whether similar activation, using low dose capsaicin, might similarly ramp up the regenerative activity of sensory neurons. using rat adult primary sensory neurons, we identified a dose dependent relationship between capsaicin exposure and their outgrowth with enhancement at lower doses and expected neurotoxicity at higher doses. doses that enhanced outgrowth were nonetheless associated with rises in intraneuronal calcium. we next tested whether a similar impact of trpv1 activation in vivo might exist. we used a high sciatic crush injury mouse model to assess the impact of capsaicin at low (100um) or high (1mm) doses applied directly at the site of axon outgrowth after injury. by 28 days following the single application of capsaicin, low doses of capsaicin showed more rapid recovery of thermal, but not mechanical sensation, whereas high dose capsaicin showed no significant difference compared to vehicle treated mice. in parallel with the neurotoxicity observed in vitro, the high dose capsaicin resulted in a decrease in sensory nerve conduction velocity, while the low dose showed no significant difference when compared to the vehicle treated animals. there was no impact on motor axon recovery. taken together, subtoxic trpv1 activation with intraneuronal calcium mobilization, as applied to regenerating sensory axons, enhances their outgrowth after injury, and improves behavioural recovery similar to that following extracellular electrical stimulation. [supported by cihr] hereditary transthyretin (hattr) amyloidosis is a rapidly progressive, life-threatening disease caused by ttr gene variants, resulting in ttr misfolding and amyloid deposition in multiple organs, including peripheral nerves. hattr amyloid polyneuropathy has prominent small fiber involvement characterized by neuropathic pain and dysautonomia. measurement of intraepidermal and sweat gland nerve fiber density (ienfd, sgnfd) in skin biopsies has been useful in identifying small fiber abnormalities in hattr. we report the effect of patisiran, an investigational rnai therapeutic for the treatment of hattr, over a 24-month period on ienfd, sgnfd and dermal amyloid content from the phase 2 open-label extension (ole) study. skin biopsies (distal leg, distal thigh) were obtained every 6 months for up to 2 years within the phase 2 ole study (patisiran 0.3mg/kg iv, q3w, nct01961921) and analyzed in a blinded manner by a central laboratory. all analyses are exploratory; nominal p-values are reported without adjustment for multiple testing. twenty-seven patients enrolled; preliminary data indicated patisiran was generally well tolerated; resulted in sustained mean serum ttr lowering of ∼80% for >24months and a mean 6.7-point decrease in mnis+7 (n=24). twenty-four patients underwent serial skin punch biopsies. at baseline, mean ienfd was 10.2 and 3.5 fibers/mm, while mean sgnfd was 6.8 and 3.8 m/mm 3 for distal thigh and distal leg, respectively. amyloid was detected in ∼80% of skin biopsies, mean baseline dermal amyloid content 10.9% and 15.8% for distal thigh and distal leg, respectively, which inversely correlated with ienfd and sgnfd. overall, ienfd was stable throughout the 2-year treatment. sgnfd increased over time relative to baseline, reaching statistical significance at 6, 12, 18 and 24 months for distal thigh (p<0.05, all time points) and at 24 months for distal leg (p=0.004). dermal amyloid content decreased over time and reached statistical significance at 6, 18 and 24 months for distal thigh (p<0.05, all time points) and at 6, 12, 18, and 24 months for distal leg (p<0.05, all time points). in summary, improvements in sgnfd and dermal amyloid content observed over a 2-year period suggest that these parameters have the potential to serve as biomarkers of response to patisiran treatment. polydefkis m 1 , neuhaus s 1 , doherty l 1 , ebenezer gj 1 . 1 department of neurology, johns hopkins university, baltimore, md, usa. misdiagnosis and delayed identification of an etiology for sensory neuropathies hampers adequate management and delays initiation of therapy. we present several cases that illustrate variable presentations of amyloid neuropathy (an) and an complicated by amyloid arthropathy. a 59-year-old former college athlete developed painless difficulty walking. he was unable to keep up with family members during routine outings and subsequently was unable to navigate uneven ground during a hike, something he had previously excelled at. balance decreased, making bicycling difficult. neurological evaluation 12-months after symptom onset led to a diagnosis of peripheral neuropathy. a reversible neuropathy panel was normal though a1c was elevated (6.5%). over several months, his strength/sensation deteriorated despite diet improvement, losing 20lbs and a1c improvement (5.9%). upon referral, emg revealed a sensorimotor neuropathy with markedly reduced/absent sural, peroneal and tibial motor amplitudes. there was mild orthostasis. nis was 84. skin biopsies revealed severe ienfd, sgnfd reductions and positive congo red staining, confirmed with birefringence. a sural nerve biopsy confirmed amyloid deposits. genetic testing revealed the ttr-fap variant leu58his. there was no history or suspicion for a family history of amyloid. a 60-year-old male with a history of controlled diabetes x20 years developed abrupt onset of rls 6 months after a lymphoma diagnosis. treatment with rituximab led to radiographic resolution of the lymphoma though the patient developed progressive peripheral neuropathy confirmed by ncv/emg. new-onset early satiety, mild orthostasis and ed emerged. skin biopsies demonstrated a lichenoid pattern of amyloid deposition consistent with aa-amyloid. a 72-year old woman with leu58his ttr-fap since 2002 developed progressive leg weakness, reduced ability to walk and low back pain. emg demonstrated progression of her sensorimotor neuropathy and superimposed multilevel radiculopathy. spine mri demonstrated severe lumbar stenosis requiring surgical decompression. postoperatively, she regained strength, walking more easily. congo red staining of vertebral bone demonstrated widespread positive staining with birefringence consistent with amyloid arthropathy. these cases illustrate to wide sprectrum of amyloid neuropathy presentation, an example of amyloid arthropathy-induced spinal stenosis and the utility of skin biopsy to diagnose and manage amyloid neuropathy. the differentiation between hereditary neuropathy and chronic inflammatory demyelinating polyneuropathy (cidp) in children is especially significant because of completely different treatment possibilities and prognosis in these conditions. the aim of the study was to compare electrophysiological abnormalities in a group of children and young adults with demyelinating neuropathy of chronic or subacute onset. retrospective analysis of clinical and nerve conduction study (ncs) data included 3 children and 4 young adults with charcot-marie-tooth neuropathy x type 1 (cmtx1), 24 children with charcot-marie-tooth neuropathy type 1a (cmt1a) and 18 children with cidp. in our study 6/7 cmtx1 had both axonal and demyelinating changes in ncs study. the aan and efns electrophysiological cidp criteria were fulfilled in 2/7 cmtx1, 23/24 cmt1a and 17/18 cidp patients. additionally 3 patients with cmtx1 are classified with efns criteria as "probable/possible cidp". a distal compound muscle action potential (dcmap) was >9ms in all cmt1a and 14/18 cidp patients but none with cmtx1. abnormal median/normal sural snap (amns) parameter was observed in 4//18 cidp and 1/7 ctmx1 patients but not any cmt1a patient while abnormal sural/normal median snap (asnm) parameter was found in 2/18 patients with cidp. a difference between conduction velocities (cv) of two corresponding nerves >10 m/s was seen in 4/7 cmtx1 and 5/18 cidp patients but no one with ctm1a. one patient with cmtx1 had especially conspicuous difference between nerve conduction in lower limbs, with axonal neuropathy and demyelinating features, and upper limbs with no changes. one 3-years-old patient with genetically confirmed cmtx1 had no abnormalities in ncs. electrophysiological data of cmtx1, cmt1a and cidp indicate diffuse demyelination, however in cmtx1 axonal changes coexist, seen in 6/7 patients, and asymmetrical abnormalities between corresponding upper and lower limb were observed in 4/7 patients. our study has showed that duration of dcmap is useful not only in diagnosing an inflammatory neuropathy but also in differentiating cmtx from cidp. however presence of the not homogenous abnormalities in ncs in patients with cmtx may mimic inflammatory neuropathy. prada v 1 , mori l 1 , francini l 1 , accogli s 1 , ursino g 1 , gemelli c 1 , schizzi s 1 , grandis m 1 , bellone e 1 , mandich p 1 , schenone a 1 . 1 department of neurosciences, rehabilitation, ophthalmology, genetics and maternal and child health, university of genoa, genoa, italy. the overwork weakness (ow) problem in cmt disease has been debated for long time. it has been reported that the non-dominant hand (ndh) of patients with cmt disease is stronger than the dominant hand (dh) as a result of ow and some authors verified this hypothesis using mrc on different muscles (van pomeren, 2009 ). more recently, piscosquito et al. (2014) found that the ow phenomenon does not exist using a dynamometer and the 9 hole peg test, a dexterity test. we recruited 60 cmt patients and 60 healthy controls. we evaluated the strength of the 3-pinch and of the hand-grip with a dynamometer, the opposition ability with the thumb opposition test (tot) and applied an instrumental testing of hand function using the sensor engineered glove test (segt), which previously demonstrated its sensitiveness to measure severity of hands dysfunction in cmt patients. tot was significantly higher in the ndh compared to dh (ndh=8,23±1,60; dh=7,74±1,90, p<0.05) in cmt patients, instead there was no difference in dh and ndh in healthy controls. in the evaluation of 3-pinch and of the hand-grip, ndh performed slightly but not significantly better than the dh (3-pinch: dh=53, 25±29, 05 n; ndh=54, 75±29, 76 n; 81±31, 11 n; ndh=62, 36±32, 20 n, p:ns) . in normal controls we confirmed the 10% rule (noguchi & demura, 2009 ). finally, segt results were similar between the ndh and dh in cmt patients but in normal controls there was a better performance in the dh. in conclusion, this study supports the existence of the overwork weakness in cmt, evident in every measurements. dexterity and overall ability of the hands impaired in the dh, probably because of compensating movements, compared with the healthy controls in the weaker hand. finally, our results support the importance of avoiding supramaximal exercises and educating the cmt patients to prevent incorrect movements, which may overload the hand muscles. prasad k 1 , ohnmar o 2 , teng a 3 , cheng yj 3 , umapathi t 1 . 1 national neuroscience institute, singapore; 2 yangon general hospital, yangon, myanmar; 3 yong loo lin school of medicine, national university of singapore, singapore. antecedent infections that have been linked to guillain-barré syndrome (gbs) include campylobacter jejuni, haemophilus influenza, epstein-barr virus, cytomegalovirus, mycoplasma pneumoniae and influenza a virus. in south-east asia, the burden of mosquito-borne flavivirus infections is considerable. even in a small country like singapore, with a population of only 5.5 million and in spite of excellent sanitation and public health measures, dengue virus (denv) infections can exceed 20,000 a year. both symptomatic and asymptomatic denv infections are associated with gbs. zika virus (zikv) infections were detected in singapore in late august 2016. doctors working in south-east asia anecdotally report that gbs cases increase after rainy season when mosquitos breed. we are currently planning studies to estimate the hitherto unknown burden of gbs associated with denv, zikv and other mosquito-borne viruses in this region. as a preliminary step, we reviewed the 27 gbs cases seen at our institution in 2016 for evidence of denv and zikv. three out of the 20 tested cases were positive for denv serology. one of these 3 was also positive for denv pcr. all these 3 patients had symptomatic dengue. two had acute inflammatory demyelinating polyneuropathy (aidp) and 1 acute motor axonal neuropathy (aman) subtype of gbs. none the 16 patients tested were positive for zikv pcr in serum and urine. one patient, with miller fisher syndrome (mfs), had serological evidence of recent zikv. he did not have clinical zikv symptoms. in 2 mfs cases, the initial detectable zikv igg was later proven to be due to cross reactivity with previous denv infection. in 3 cases (1 amsan, 1aidp, 1 mfs) the initial zikv igm was raised. we await analysis of convalescent sera to decide if they indeed had zikv or the results were related to previous and co-infection with denv. our preliminary findings indicate that flavivirus infections may account for at least some of the gbs cases in singapore. the lack of symptoms in some cases and the interactions between zikv and denv antibodies make accurate diagnoses challenging. prior r 1,2 , benoy v 1,2 , vanden berghe p 3 , van den bosch l 1,2 . 1 ku leuven-university of leuven, department of neurosciences, experimental neurology and leuven research institute for neuroscience and disease (lind), leuven, belgium; 2 vib-center for brain & disease research, laboratory of neurobiology, leuven, belgium; 3 laboratory for enteric neuroscience, translational research center for gastrointestinal disorders, k.u. leuven, leuven, belgium. charcot-marie-tooth disease (cmt) is the most common inherited neurodegenerative disorder of the peripheral nervous system. it is divided into two main subtypes, a demyelinating subtype (cmt type 1) and an axonal form (cmt type 2). cmt is a length-dependent disease, in that it effects the longest neurons in the body, thus the muscles in the peripheral regions are affected first and foremost. moreover, the majority of cmt patients share a classical phenotype with shared pathological hallmarks, such as distal muscular atrophy, reduction in nerve conductions, etc. but also molecular pathological hallmarks, like the breakdown in the transport of organelles and vesicles in neurons in a process called axonal transport. currently, there is no cure or effective treatment available to cmt patients. histone deacetylase 6 (hdac6) has been shown to be a key regulator in axonal transport. moreover, inhibiting hdac6 has been demonstrated to stabilize microtubules, which act as molecular tracks for motor proteins and facilitates axonal transport of cargos. our labs current focus is on cmt type 1a, the main cause of cmt, which is caused by a duplication of a segment of chromosome 17p11.2 containing the gene encoding peripheral myelin protein 22 (pmp22). pmp22 is mainly expressed by schwann cells, the cells that myelinate neurons in the peripheral nervous system. in the work presented, the commercial mouse schwann cell-line, sw10 cells, was transfected to overexpress pmp22 using a lentivirus vector system to mimic that of cmt1a patient schwann cells. the overexpression of pmp22 was confirmed using immunofluorescence and western blot techniques. these transfected sw10 schwann cells were then co-cultured with primary mouse dorsal root ganglion neurons (drgs) isolated from adult mice. these co-cultures where then analysed after 3 weeks in vitro for axonal transport. the investigated groups were: a co-culture of drgs + sw10 cells, a co-culture of drgs + sw10 cells transfected with pmp22, and a co-culture of drgs + a sw10 cell-line transfected with green fluorescent protein using a lentivirus vector system, and a monoculture of drgs. furthermore, this work demonstrates that the overexpression of pmp22 in schwann cells can impair axonal transport in co-cultured drgs in comparison to the other co-culture groups. moreover, these axonal transport defects were able to be rescued by the treatment of a hdac6 inhibitor, tubstatin a. to conclude, selective hdac6 inhibitors have been shown to be a beneficial treatment for a number of cmt subtypes in preclinical studies in our lab and offer as a viable treatment for a currently, untreatable debilitating disease. provitera v 1 , caporaso g 1 , stancanelli a 1 , piscosquito g 1 , di caprio g 1 , saltalamacchia am 1 , santoro l 2 , nolano m 1 . 1 "maugeri" clinical and scientific institutes irccs, institute of telese terme (bn), italy; 2 department of neurosciences, reproductive and odontostomatological sciences, university 'federico ii' of naples, naples, italy. the observation of rate and patterns of cutaneous nerves regrowth after mechanical or pharmacological distal axonotmesis, has proven to be an excellent tool to study human nerve regeneration in normal and pathological conditions. most of the observations, however, are referred to small fibers, possibly due to the availability of excellent models of reversible distal cutaneous small fiber axonopathy. no such model is available to study the regeneration of myelinated fibers in human. we studied regrowth of cutaneous large fibers in fingertip of patients with carpal tunnel syndrome after surgical decompression. we recruited 15 patients (m/f 4/11; age 46.9±8.8 years) with carpal tunnel syndrome candidate to surgery. patients underwent clinical and electrophysiological evaluation, quantitative evaluation of discriminative threshold at 3rd fingertip. in the same site, patients also underwent 2mm punch skin biopsy. skin sections were stained by immunohistochemical techniques and cutaneous innervation was analyzed by confocal microscopy. meissner corpuscles and their myelinated afferences were assessed following previously published procedures. twelve months after surgery, patients repeated functional evaluation and underwent a second skin biopsy two mm apart from the first one. mean density of mcs/mm2 was 31.5±18.8 at time 0 and 34.2±17.7 at follow-up, mean density of myelinated endings was 24.4±14.0 at time 0 and 30.8±18.9 at follow-up. however, not in all patients regeneration occurred. based on the variation of mc density between time 0 and follow-up we were able to identify patients in which active regeneration had occurred. in this subgroup mean density of mcs/mm2 was 23.1±16.6 at time 0 and 36.6±18.7 at follow-up (p<0.01) with a mean delta of +13.5. in the same group, mean density of myelinated endings was 18.6±13.4 at time 0 and 29.9±20.1 at follow-up (p<0.01) with a mean delta of +11.3. we describe morphological patterns associated to nerve regrowth in the biopsies of patients in which nerve regeneration occurs. we propose an in vivo model to study regeneration of large myelinated fiber endings in human skin. in addition to the count of nerve endings, the identification of patterns associated to nerve regeneration can increase the diagnostic yield of skin biopsy. the most common type of charcot-marie-tooth disease is caused by a duplication of pmp22, leading to dysmyelination, axonal loss and progressive muscle weakness (cmt1a). currently, no approved treatment for cmt1a patients is available. among others, preclinical therapeutic approaches aim to correct the pmp22 overexpression in order to ameliorate axonal loss and muscle weakness. we previously reported that the novel polytherapeutic drug pxt3003, a low-dose combination of baclofen, naltrexone and sorbitol, improved dysmyelination and axonal loss after long-term application in adult pmp22 transgenic rats, a known animal model of cmt1a. interestingly, after short-term application in young cmt1a rats we observed a long-lasting prevention of muscle weakness as well but without obvious effects on dysmyelination and axonal loss. improved distal motor latencies in the electrophysiological recordings and a shift in the axonal diameter distribution raised the hypothesis that therapy may improve the neuromuscular endplate pathology as another therapeutic target for cmt1a. here, we report a preclinical trial in adult cmt1a rats treated from postnatal week 6 for 12 consecutive weeks as the most effective regimen in order to facilitate a deeper understanding of the mode-of-action of pxt3003. long-term therapy effects were confirmed by an ameliorated behavioral phenotype, improved distal motor latencies and also nerve conduction velocity in the electrophysiological recordings. histological analysis revealed an increased number of neuromuscular endplates, which were lowered to wildtype level after pxt3003 treatment. further investigations include detailed analysis of peripheral nerve myelin thickness, internodal and nodal length, terminal axonal sprouting at the neuromuscular endplate and muscle fiber subtyping in treated cmt1a rats. charcot-marie-tooth disease (cmt) is a rare hereditary neuropathy for which novel treatments are being developed and urgently needed. only few clinical trials and natural history studies have been performed. evaluation of intervention efficacy is hampered by slow progression and lack of sensitive outcome measures. the interindividual disease variability is high and prognostic disease measures are not established for cmt patients. previously, we have identified skin-derived disease and progression biomarkers in a large european and us-based cmt1a cohort. within the german charcot-marie-tooth disease network (cmt-net, www.cmt-net.de) we aim to establish easier accessible biomarkers in blood of cmt1a patients. blood analysis is less invasive and can be repeatedly performed during clinical trials and routine patient care. we have started clinically assessing approximately 150 young, adolescent and adult cmt1a patients at 3 clinical centres (münster, münchen, göttingen) including a large set of clinical outcome measures (cmtnsv2, onls, 10mwt, 6mwt, walk12, 9hpt, sf-36, fss, psqi, ess, bdi-ii). we will sample blood and skin tissue once a year at 0, 12 and 24 months for an observational period of 2 years. tissue samples will be analyzed on the transcriptional, translational and epigenetic level. we envision that the diagnostic and progression biomarkers may be used to measure therapeutic effects within clinical trials and later in clinical routine monitoring. this is the first trial testing "circulating" biomarkers from blood in a prospective observational trial in cmt1a patients. igm peripheral neuropathy is a slowly progressive and heterogeneous disease with symptoms ranging from mild foot numbness and minor imbalance to severe neuropathic pain and sensory and motor dysfunction. international consensus regarding assessment and treatment of patients with igm peripheral neuropathy is lacking. this might be caused by the repeated use of suboptimal outcome measures, the small trial sizes with low numbers of treated patients, the indolent disease course needing a longer follow-up period to capture relevant changes, or the possibility that administered treatments were not aggressive enough. the imagine study is an international, multi-centre, prospective, observational cohort study, which will result in a unique collection of a large number of prospectively collected and highly standardized clinical data, and a biobank from a large population of well-defined patients with igm peripheral neuropathy. the main objective is to describe in detail the variation in clinical subtypes, clinical disease course, past and current practice of treatment, antibody titres, and clinical picture at the various levels of assessing outcome. patients being at least 18 years, and fulfilling the international criteria for igm peripheral neuropathy are eligible. exclusion is primarily based on concomitant diseases influencing peripheral nerve function. several study parameters measuring weakness, sensation, activity and participation, ataxia, pain, and quality of life are of interest. in february 2017 an enmc kick of meeting is organized, bringing together an igm peripheral neuropathy study group. the meeting will focus on the development of a core set of outcome measures to be used in future studies in igm peripheral neuropathy. the imagine study started in the netherlands in september 2016, and to date 51 patients were included. the imagine study starts in the united kingdom, italy, and france in the beginning of 2017. centres recruiting at least 10 patients with igm peripheral neuropathy are eligible to participate in the study. during the pns 2017 global recommendations from the enmc meeting, as well as the first results of the imagine study, will be presented. puget s 1 , paolantonacci p 2 , burlot l 2 1 lfb biomédicaments, les ulis, france; 2 lfb biotechnologies, les ulis, france. in dysimmune neuropathies patients (mmn, cidp, gbs), ivig have become the gold standard due to their efficacy and tolerability. acute renal impairment, a rare but serious adverse event, can be induced by all ivig. its incidence is not determined precisely for each ivig. it mostly occurs in patients at risk, with pre-existing conditions (prior renal insufficiency, diabetes, mellitus, arterial hypertension, elderly > 65 years old, dehydratation, hypervolemia, sepsis, paraproteinemia or concomitant use of other nephrotoxic drugs) and treated by immunomodulatory doses. as the number of these patients increases over the years, the choice of ivig in association with the precautionary measures will be decisive to reduce or avoid the occurrence of this adverse event. from 1990s to 2000s, the nephrotoxicity of ivig has been explained by tubular toxicity related to osmotic nephrosis. sucrose, a stabilizer of some ivig, has been implicated as one of the causes of this. even if several new ivig without sucrose are used, renal impairment cases have been described and studies have highlighted that sucrose is not the only ivig stabilizer associated with tubular damage. however, in a recent study, renal impairment cases (4/5) have occurred in cidp elderly patients treated by free-sucrose ivig. the occurrence of renal failure seemed to be low (only 1/5) for patients treated with sucrose-ivig in association with precautionary measures (hydratation, adaptation of dosage according body mass index, rate infusion). otherwise, since 2010s, cases of renal impairment secondary to hemolysis have been increased with some ivig but would be rare for full ethanolic fractionated products as they have been identified to generate very low occurrence of hemolysis. the occurrence of renal impairment related to ivig seems to be multifactorial, need to find out all causes (mechanisms of different stabilizers, hemolysis, and concentration of ivig). registries would be helpful for physicians to define the incidence, relative risk of ivig-related renal impairment and the right ivig in association with precautionary measures in these patients at risk. the published ultrasound (us) studies on chronic inflammatory demyelinating polyradiculoneuropathy (cidp) report diffusely increased cross-sectional area (csa) of nerves. these data have not been correlated with histological patterns. to date, no further information about us ultrastructural nerve modification has been provided because of limited frequency range (10-20 mhz) of the us probe. the aim of this preliminary study is to evaluate the correlation between histological findings from sural nerve biopsies and us patterns found with uhfus (50 mhz) from sural nerve at the ankle. four patients with cidp underwent uhfus nerve evaluation of clinically affected sural nerve before undergoing a sural nerve biopsy. us findings included: cross-sectional area of the nerve, connective tissue depth and changes in echogenicity of fascicles. those data were then compared to the histological findings obtained in transversal and longitudinal sections. in all patients, uhfus nerve changes were as following: csa was increased; connective tissue was thickened and in two of the four patients hyperechogenicity of fascicles was observed. also, thanks to the ultra-high-resolution of the probe, a direct correlation of the histological and us images was possible, so as a direct measurement of internal microstructure of the nerve. uhfus may be of adjunctive diagnostic value in cidp assessment. more detailed images of sural nerve can be obtained compared with high-frequency us, allowing a better evaluation of the internal structure of the nerve. the increased csa observed in all our subjects seems to relate to an enlargement of connective tissue, as confirmed by the histological study. in particular, we have observed a hyperechogenicity of fascicles in most severe patients; in those cases, histology confirmed an increase of endoneurial depth. we speculate that those findings may explain a preliminary involvement of connective tissue in the pathogenesis of the cidp; our findings of nerve enlargement may be tool to monitor disease activity in cidp, and better understand disease pathogenesis. further studies are needed to confirm these findings and additional data are being processed and will be presented during the meeting. puma a 1 , cambieri c 2 , panicucci e 1 , desnuelle c 1 , raffaelli c 3 , sacconi s 1 . high-resolution ultrasound (hfus, 20 mhz) of peripheral nerves is a valuable non-invasive, painless complement to neurophysiology, especially in the workup of cidp. nevertheless, the current spatial resolution of echographic images doesn't allow a detailed study of the nerves. ultra-high frequency ultrasound (uhfus, 50 mhz) is a new tool with a 3-5 times higher spatial resolution than traditional hfus. the aim of this preliminary study is to evaluate sensory and motor nerves structural characteristics found with uhfus in patients with definite cidp. seven patients with cidp underwent uhfus nerve evaluation of median, ulnar, peroneal and sural nerves, bilaterally. us findings included: cross-sectional area of the nerve, connective tissue depth, nerve vascularization and changes in echogenicity of fascicles. patients also underwent electroneurography (eng) and plexus mri. in all patients, uhfus nerve changes were as following: csa was increased; connective tissue was thickened. two of the seven patients presented an epineural hypervascularization, observed at the doppler evaluation; none of them was treated by iv immunoglobulines. echographic changes were present even in the absence of mri abnormalities (root hypertrophy). eng characteristics correlated with the us patterns. uhfus may be of adjunctive diagnostic value in cidp assessment. more detailed images of nerves can be obtained compared with high-frequency us, allowing a better evaluation of the internal structure of the nerve. the increased csa observed in all our subjects seems to relate to an enlargement of connective tissue. in particular, uhfus allows a more detailed study of nerves, demonstrating that the structural abnormalities hit connective tissue, while -conversely to previous studies -fascicles anatomy seems to be spared. we did not show nerve vascularization except in non-treated patients. we speculate that those findings may explain a preliminary involvement of connective tissue in the pathogenesis of the cidp; our findings of nerve enlargement may be tool to monitor disease activity in cidp, and better understand disease pathogenesis. further studies are needed to confirm these findings and additional data are being processed. purcell l 1,2 , wojciechowski e 1,2 , gibbons p 1,2 , jamil k 1,3 , menezes, m 1,2 , burns j 1,2 . 1 sydney children's hospitals network (randwick and westmead), new south wales, australia; 2 university of sydney, new south wales, australia; 3 universiti kebangsaan, kuala lumpur, malaysia. 6-20% of children with cmt are reported to have hip dysplasia. we aimed to investigate the relationship between radiological hip dysplasia indicators and walking pattern in children with cmt. thirty children (15 female; 11.4±3.2yrs; 146±16.4cm; 44±18.3kg 21 cmt1a, 4 cmtx1, 2 cmtx3, 2 cmt1f, 1 cmt2a) underwent 3d gait analysis (3dga), and had an anterior-posterior pelvis radiograph within 6 months of assessment. radiographs were reviewed by two orthopaedic surgeons, and the reliability of 14 measures of dominant limb hip health via radiograph was assessed. of the 14 measures, 8 measures had an intraclass correlation coefficient >0.75 between raters, and the more experienced surgeon's measures were used for further analysis. the 8 measures of acetabular index (ai), centre edge angle (cea), neck shaft angle (nsa), medial joint space, head width, lateral uncoverage, migration percentage and triradiate were used to investigate correlations with kinematic and kinetic 3dga variables of the pelvis and dominant limb hip, knee and ankle in 3 planes, temporal spatial parameters and gait profile score. 3dga data were captured with an 8-camera vicon nexus motion capture system using the lower body plug-in-gait model. gait data were compared to 50 typically developing children (35 female; 9.8±3.8yrs, 140±19.6cm, 39±19.0kg). five of 30 affected children had a migration percentage >20 ∘ , representing 17% of our sample. maximum hip abductor moment in terminal stance was significantly lower than normative reference values, and was moderately correlated with 3 of the 8 radiographic measures (ai r=−0.52, p=0.023; nsa r=−0.50, p=0.006 and medial joint space r=−0.59, p=0.001). walking speed (normalised to leg length) was correlated with medial joint space (r=0.51, p=0.004) head width (r=−0.68, p=0.0001) and triradiate (r=−0.51, p=0.004 the ganglionopathies are a unique group of disorders with a varied etiology which includes autoimmune disorders, paraneoplastic syndromes and toxin induced causes. it has been observed that despite extensive investigations the cause of a sensory neuronopathy is often idiopathic in approximately 40-50% cases. electrodiagnostic criteria to diagnose a possible ganglionopathy requires at least one sensory action potential absent or three sensory action potentials <30% of the lower limit of normal in the upper limbs plus less than two nerves with abnormal motor nerve conduction study in the lower limbs. ulnar sensory-motor amplitude ratio values (usmar) lower than 0.71 is useful in differentiating ganglionopathy from axonal length-dependent neuropathy. we performed a retrospective analysis of 25 patients who were either admitted or evaluated in the outpatient department in department of neurology, nizam's institute of medical sciences, with a possible ganglionopathy as per the diagnostic criteria proposed by camdessanchéet al. consecutive patients who sought treatment during a 5 year period with a clinical pattern of sensory neuronopathy were analysed retrospectively. we reviewed the electrodiagnostic studies of patients and calculated the ulnar sensory-motor amplitude ratio values in comparison with 25 patients with a clinical and electrophysiological diagnosis of diabetic axonal sensorimotor neuropathy. the clinical profile of a ganglionopathy from the indian subcontinent comprised of a prominent sensory ataxia as the initial presenting clinical manifestation with a predilection towards involvement of large-fiber sensory modalities. electrophysiologically a pattern of absent snaps was characteristically encountered with a significant value of usmar less than 0.7, enabling differentiation from axonal length-dependent neuropathy. rahman im 1 , jahan it 1 , nahar s 1 , khalid mm 2 , jahan i 1 , hayat s 1,3,4 , islam z 1 . 1 guillain-barré syndrome (gbs) is a post-infectious autoimmune polyradiculoneuropathy where immune response is triggered by molecular mimicry between glycolipid antigens expressed by an infective agent such as campylobacter jejuni (c. jejuni) and human peripheral nerve gangliosides. cd1 molecules are mhc-like structures specialized in capturing and presenting a variety of glycolipids to antigen-specific t lymphocytes. the objective of this study was to investigate the possible role of coding region polymorphisms of cd1 genes in the pathogenesis of gbs in bangladeshi population. single nucleotide polymorphisms (snps) of exon 2 of cd1a (*1/*2) and cd1e (*1/*2) in 200 well defined gbs patients and 200 healthy controls were studied to delineate their effect in developing gbs. we genotyped exon 2 of both cd1a (cys/tryp) and cd1e (gln/arg) genes through pcr-rflp. to validate these findings, direct sequencing of pcr product was performed for at least 10 samples for each position. we found no differences in genotypes and allele frequencies of both genes in gbs patients compared to controls. however, compared to control individuals with cd1a*2/cd1e*2 haplotype were 2.3 times more likely to develop gbs, whereas individuals with cd1a*2/cd1e*1 haplotype had a reduced relative risk by 4.3 times. a positive association of cd1a*2/cd1e*2 haplotype was observed only in axonal form of gbs (27.8% vs. 10.8%, p = <0.01). haplotype cd1a*1/cd1e*2 was prevalent among anti-gm1 antibody positive gbs patient compared to anti-gm1 antibody negative patients (39.8% vs. 28.3%) though it was not statistically significant. snps in cd1a and cd1e were not associated with antecedent c. jejuni infection, disease severity and disease outcome at 6 months of follow up. in conclusion, cd1 polymorphisms are not a susceptibility or disease causing factor in gbs. conversely, increasing knowledge of this field may offer new dimension for the research to elucidate better answer for disease pathogenesis and also contribute to conduct high power meta-analysis. extensive genetic testing was performed on a unique patient, who received national media attention due to her severe cmt phenotype. the index patient was never able to walk independently, had difficulty breathing and swallowing and demonstrated aspiration by a barium swallow study. nerve conduction velocity testing revealed velocities of 10 m/s in her upper extremity. she required continuous positive airway pressure (cpap) for an upper respiratory infection and developed bilateral vocal cord paralysis. we used the combined brief assessment of motor function (bamf) scale to evaluate her disability. her fine motor scale was a 7/10, her upper extremity gross motor scale was a 6/10 and her lower extremity gross motor scale was 3/10. unfortunately, she died at age 5 in her sleep, presumably from respiratory arrest. the proband's father was asymptomatic, however, his neurological exam showed pes cavus bilaterally and mild atrophy of the first dorsal interossei muscles in his hands. his nerve conduction velocities were slowed to 30 m/s in the upper extremities and his cmt neuropathy score (v2) was 9/36. we performed whole exome and subsequently whole genome sequencing in the trio. comprehensive structural variant analysis for copy number variations, large deletions, and recombinations was completed by a combination of software tools. known cmt genes were excluded as the underlying cause and the only viable candidate gene remaining was sh3tc1. we showed expression of sh3tc1 in peripheral nerve and schwann cells. sh3tc1 is a paralogue to sh3tc2, which causes the recessively inherited dysmyelinating form cmt4c. sanger sequencing confirmed the variants in our family, p.v41m (c.121g>a, chr4:8207042) and p. a1076p (c.3226g>c, chr4:8235184) , and showed the segregation of the heterozygous variations. we hypothesize that the heterozygous paternal allele had a minimal effect and let to a very mild or subclinical form of peripheral neuropathy. of interest, the recessive sh3tc2 gene has also been shown to cause mild aberrant forms of peripheral nerve degeneration in carriers of heterozygous disease alleles. in summary, this paper will present genetic and molecular evidence from an extensive n=1 study proposing a novel cmt1 gene. charcot-marie-tooth (cmt) is an important cause of morbidity worldwide. it is a heterogeneous disease manifesting as progressive weakness, wasting and loss of feeling in a length-dependent pattern. there are an increasing number of cmt-related genes in the literature. more recently, recessive mutations in the hint1 gene have been reported as causative of predominant motor axonal neuropathy associated with neuromyotonic discharges on emg. one of the characteristics of autosomal recessive cmt is it varying frequency in different populations and ethnic groups. we sought to evaluate the frequency of mutations in the hint1 gene in a brazilian cohort with axonal hereditary neuropathy. all patients included in this study born within south east area of brazil. the group consists of consecutive patients with axonal neuropathy screened for recessive or sporadic axonal neuropathy in the neurogenetics laboratory of clinical hospital of ribeirão preto. direct sequencing of the coding region of hint1 gene was done. among 100 patients screened, 98 were suspected of having recessive axonal neuropathy without neuromyothonic discharges, and two have axonal neuropathy associated with neuromyothonic discharges on emg. we did not find any disease causing mutations among our patients. some previously reported studies reported a high frequency of mutations in the hint1 gene among recessive axonal neuropathies in some european countries. our results demonstrated that frequencies of mutation underlying genetic hereditary neuropathies are different between different ethnic groups and have implications for the organization of services management of cmt, for genetic counseling, and for gene flow in different world populations. funded by cnpq, fapesp, faepa, pronas (ministry of health). rodriguez-menendez v 1 , ballarini e 1 , malacrida a 1,2 , ceresa c 1 , semperboni s 1,2 , meregalli c 1 , cavaletti g 1 , nicolini g 1 . 1 school of medicine and surgery, experimental neurology unit, university of milano-bicocca, monza, italy; 2 phd program in neuroscience, university of milano-bicocca, monza, italy. bortezomib (btz) is a proteasome inhibitor widely used for multiple myeloma treatment. btz induced peripheral neuropathy (bipn) is the most frequent adverse effect. bipn in humans, is a dose dependent painful sensory neuropathy characterized by nerve axonopathy and a tendency to recover in the follow-up period after btz withdrawal. bipn affects principally dorsal root ganglia (drg) and different rodent models have shown alterations in sensory neurons, small unmyelinated axons, large myelinated axons, axonal mitochondria and schwann cells. in this work, we evaluated the effects of btz in vitro on drg neurons isolated from adult mice. our interest focused on dystonin, a protein able to interact with all the three components of cytoskeleton (microtubules, microfilaments and intermediate filaments) and able to bind map1b (a mt-associated protein) through which can influence golgi apparatus morphology. there are different neuronal isoforms of dystonin and in particular dystonin-a2 is able to modulate tubulin acetylation and stability through interaction with map1b. it is noteworthy to underline that map1b expression in the mature nervous system is restricted to sensory neurons. western blot analysis demonstrated that a treatment with 10nm btz induces a statistically significant decrease in tubulin acetylation. this result does not go along with our previous study where we observed a tubulin polymerization increase after btz treatment. therefore, we have decided to focus our interest on soma organelle organization that is well known to be dependent from cytoskeleton structure. immunofluorescence images showed an altered distribution of acetylated tubulin in soma cytoplasm after 24 hour treatment. moreover, confocal analysis of cis golgi (gm130) demonstrated that in btz treated neurons the normal golgi structure is lost showing a spot-like non perinuclear labeling distribution. additionally, dystonin distribution seemed comparable to that of cis golgi apparatus suggesting that btz could induce a change in dystonin localization which in turn affects golgi organization, probably through map1b.these data suggest that the cytoskeleton alterations, induced by btz, could probably cause wrong maturation and trafficking alteration of golgi vesicles consequently impairing the correct sensorial function. romão tt 1 , aleixo bfl 1 , wedemann d 1 , herculano fgn 1 , prado h 1 , cal h 1 , pupe c 1 , bittar c 1 , nascimento ojm 1 . 1 universidade federal fluminense (uff), rio de janeiro, brazil. acute motor and sensory axonal neuropathy (amsan) is a clinical variant of guillain-barré syndrome (gbs) which has rarely been reported in association with human immunodeficiency virus (hiv) and neurosyphilis. we describe a case of a 21-year-old woman who started with muscle weakness in the left leg followed by weakness in the right leg and in upper limbs in one month. motor symptoms were followed by urinary and fecal incontinence. no preceding symptoms, as diarrhea or fever were referred. neurological examination showed global areflexia with impairment of vibratory and tactile modalities, as well as loss of proprioception. pinprick sensation was moderately compromised. no impairment of higher mental functions was observed. other causes of neuropathies were ruled out. cerebrospinal fluid (csf) examination showed 0 cell/mm 3 , increased protein level, normal glucose level and negative vdrl test. blood analysis showed hiv 1 and 2 positive serology tests, vdrl 1:16 and positive t. pallidum hemagglutination assay. igm cytomegalovirus antibody was negative, cd4 was in normal range and hiv load was undetectable. cranial and spinal cord magnetic resonance imaging revealed extensive involvement of the posterior spinal cord tracts which supports the diagnosis of neurosyphilis. nerve conduction studies showed a significant reduction in compound motor action potentials amplitudes, particularly at lower limbs, and absent sural nerve responses. electromyography revealed positive waves and fibrillation at lower limbs. treatment with methylprednisolone, human intravenous immunoglobulin and ceftriaxone has been settled, resulting in improvement of upper limbs paresis and sphincters dysfunction. antiretroviral therapy was initiated. this amsan case is associated with central nervous system involvement, encompassing an encephalomyeloradiculopathyrelated to hiv/t. pallidum co-infection. c.jejuni is the main etiological agent associated with amsan, but there are some reports of hiv/cmv co-infected patients who presented this gbs variant. facing a patient with amsan, mainly when cns involvement is present, it is of crucial importance to undergo investigation of an ongoing infectious process, such as hiv and syphilis, considering the impact of early treatment on prognosis. roodbol j 1,2 , yiu e 4 , doets a 1,2 , de wit mcy 2 , monges ms 5 , van nes s 6 , catsman-berrevoets ce 2 , van den berg b 1,3 , jacobs bc 1,3 and on behalf of the igos-kids consortium. only a few prospective cohort studies so far have investigated the clinical presentation and course of guillain-barré syndrome (gbs) in children using age-adjusted outcome scores. in 2015 we started a study based on the igos protocol but adjusted for children with gbs (igos-kids). (pediatric)neurologists from argentina, australia and the netherlands joined forces to determine the clinical and biological determinants of disease progression and recovery in gbs in children from different geographical areas. for each age category specific pain scales are used including the comfort score for children < 4 years old, pain faces revised age 5-12 years old and numerical rating scale in children ≥ 12 years old and outcome measures. a new strength score was developed: gbs kids score. this score will be used and validated in addition to the mrc-sum score. the onls, r-ods and fss are also be used in igos-kids. age-dependent quality of life questionnaires were added to the igos-kids protocol, namely the pedsql and the pedsql multidimensional fatigue scale. these scales are available for children ≥ 2 years old. an activity score validated for neuromuscular disorders for children ≥ 6 years old was also added. currently there are 13 children included in igos-kids, eight children from australia and five from the netherlands. additional clinicians and researchers interested in gbs in children are most welcome to participate in igos-kids. prognostic models have been developed to predict the highly variable clinical course of guillain-barré syndrome (gbs) in adults. the clinical course of gbs is equally variable in children, but the current prognostic models have not been validated in children. in this study, we aimed to identify in children with gbs the characteristics at hospital admission that predict the clinical severity and outcome. the study was conducted in two patient cohorts from europe: one (largely) german cohort of 265 children and one dutch cohort of 140 children. clinical information was obtained regarding preceding infection, first symptoms, neurological deficits at admission and nadir, results of additional investigations (cerebrospinal fluid and nerve conduction studies). clinical severity, course and outcome was defined by the gbs disability score, especially the ability to walk unaided, at a follow-up of 1 month, 2 months, 3 months and 6 months after onset of symptoms. univariate and multivariate regression analyses were performed initially on the two separate cohorts. combined the cohorts consisted of 405 children (age median 7 years, range 0-17 years) including 222 boys (55%). the median duration between onset of symptoms and hospital admission was 4 days (range 62). pain at admission was remarkably frequent and present in 129 (71%) children. in the combined cohorts, 77 children (18.4%) developed respiratory failure and one child died. multivariate regression analysis showed that in both cohorts strong predictors of respiratory failure available at hospital admission were cranial nerve involvement, a higher gbs disability score and a shorter period in days between onset of symptoms and admission. this information was used to develop and validate a prognostic model for children with gbs that will be presented at the conference. in conclusion, based on the analysis of two independent cohorts of patients the predictors of respiratory failure and clinical recovery were identified and validated. similar factors were identified for adult patients, although the prognosis in children in general is better than in adults. this information will be used to develop a simple prognostic model for current clinical practice to predict the chance of respiratory failure and outcome in children with gbs. the negative trials of vitamin c in cmt1a have highlighted the lack of sensitive outcome measures in charcot-marie-tooth disease (cmt). neurofilaments are abundant neuronal cytoskeletal proteins and their concentration in blood is likely to reflect axonal breakdown. we therefore examined plasma neurofilament light chain (nfl) concentration as a potential biomarker in cmt. blood samples were collected from 75 patients with cmt and 67 age matched healthy controls over a 1-year period. disease severity was measured using the weighted cmt examination and neuropathy scores. plasma nfl concentration was determined using an in house developed simoa assay based on the nfl antibodies from the nf-l light elisa kit (umandiagnostics). plasma nfl concentrations were significantly higher in cmt patients (median: 26.0 pg/ml; iqr: 17.3-33.6) than in controls (median: 14.6 pg/ml; iqr 11.0-21.1, p<0.0001) and correlated with disease severity as estimated by the weighted cmt examination (n=75, r=0.43, p<0.0001) and neuropathy scores (n=30, r=0.37, p=0.044) . concentrations were also significantly higher when subdividing cmt patients by genetic subtype; cmt1a (n=31, p<0.001), sptlc1 (n=20, p<0.001) and gjb1 (n=11, p=0.011) or into demyelinating, cmt1 (n=48, p<0.0001) or axonal, cmt2 (n=27, p<0.001) forms compared to healthy controls. there was no significant difference in the plasma nfl concentration after 1 year in patients with cmt (n=9, mean difference −1.07 pg/ml, 95% confidence interval −8.2 -6.0) or healthy volunteers (n=13, mean difference −1.2 pg/ml, 95% confidence interval 2.8 -0.5) which is unsurprising as cmt is a slowly progressive disease in which the rates of axonal degeneration are likely to be constant and elevated. in summary, we have shown that plasma nfl levels are significantly raised in patients with cmt and that they correlate with disease severity. this is of relevance not only for the field of cmt but for peripheral neuropathies in general, and suggests that plasma nfl holds promise as a biomarker of peripheral neuropathy in both routine practice and clinical trials. neurolymphomatosis (infiltration of the peripheral nervous system by lymphoma cells) is a rare and usually devastating condition belonging to the spectrum of lymphoma-associated neuropathies. cerebrospinal fluid examination with cytologic examination, flow cytometry and clonality testing by pcr may show malignant cells especially when nerve root involvement is prominent. however, nerve biopsy remains a useful tool to confirm the presence of malignant cells invading the nerve. neuropathological features are important and pcr-based immunoglobulin or t-cell receptor clonality testing on nerve fragments may add notable value for the diagnosis of neurolymphomatosis, although this has not been systematically investigated. we retrospectively studied clinicopathological data and clonality results of nerve biopsy samples in patients with nl from 2 centres, performed between 2005 and 2016. among 16 patients with nl, we found 94% of b-cell lymphoma and one t-cell lymphoma. nl was the first manifestation in 62,5% of patients. the main clinical pattern was symmetrical progressive sensorimotor polyneuropathy in 38% of patients and pain was a prominent feature in 81%. clonality testing showed a monoclonal rearrangement in 14 (88%) cases, oligoclonal rearrangement and no amplification in 2 (6%). the main histological pattern was perivascular infiltration of predominant b-cells in the epineurium, without signs of vasculitis. the extent of axon loss was highly variable between patients. various chemotherapeutic regimens were used and the median overall survival was 19 months. only one case showed a monoclonal pattern among 22 control nerve samples from patients with other types of neuropathy including vasculitis and cidp. overall, we found that clonality testing on nerve biopsy specimens may provide decisive information on the presence of neurolymphomatosis, with a sensitivity of 87.5%, a specificity of 95.4%, a positive predictive value of 93.3% and a negative predictive value of 91.3%. we confirm the utility of nerve biopsy for the diagnosis of nl and show the great yield of pcr-based clonality testing to assess the malignant feature of peripheral nervous system lymphoid infiltrates. despite an accurate diagnosis, neurolymphomatosis still remains a devastating disease with an overall poor prognosis. in the last years, cumulative data have shown that patients with amyotrophic lateral sclerosis (als) and mouse models of the disease present loss of small epidermal and dermal nerve fibers and sensory dysfunctions, in addition to the classical motor symptoms. our objective is to characterize this small fiber neuropathy and to clarify if axonal loss involves all sort of fibers equally, or if there is some specificity. for this purpose, we performed an immunohistochemical characterization of total intraepidermal nerve endings (protein gene product; pgp9.5), peptidergic (calcitonin gene-related peptide; cgrp) and nonpeptidergical nerve epidermal endings (isolectin b4; ib4) of the sod1 g93a mouse at different stages: presymptomatic stage (8 weeks), disease onset (12 weeks) and in symptomatic stage (16 weeks). the sympathetic sweat gland innervation was immunolabeled for vasoactive intestinal peptide (vip) from very early stage (4 weeks) to disease onset (12 weeks). the results showed a marked reduction of the intraepidermal nerve fibers already in the presymptomatic stage compared to the wildtype littermates (p<0.05). this axonal loss affected more markedly the nonpeptidergic axons from the disease onset stage (39% axonal loss, p<0.05), whereas no significant differences were found in the cgrp positive fibers (14.3% axonal loss). a reduction of the sympathetic innervation of the sweat glands was also found from the disease onset stage (29% axonal loss, p<0.05). in summary, we have found that nonpeptidergic and sympathetic innervation of the skin are predominantly affected in the sod1 g93a mouse model. these findings suggest that this specificity could be used as an accessible biomarker for the disease. hereditary and inflammatory neuropathies are peripheral nerve disorders of different pathophysiology whose identification is crucial for therapeutic approach. diagnosis of cmt is easy when there is a family history, disease course is slowly progressive, neurophysiological findings are homogeneously abnormal. cases of cmt1 patients with inflammatory-like phenotypes leading to a misdiagnosis of chronic inflammatory demyelinating polyradiculoneuropathy (cidp) have been described. the presence of "red flag signs", such as slowly progressive decline, mild sensory symptoms, minimal electrophysiological progression and no response to therapy should prompt re-evaluation of the diagnosis of cidp. the introduction of nerve neuroimaging has contributed to the diagnostic work-up. we describe 7 cmt patients (5 men, 2 women, mean age 58.6 ± 14.4 yrs, mean neuropathy duration 14.6 ± 8.9 yrs) with genetically confirmed cmt, who were initially diagnosed with cidp. neurophysiology showed demyelinating features in 5 patients, the remaining 2 patients had axonal features. csf analysis showed albumin-cytological dissociation in 3 patients, oligoclonal igg bands were present in 1 patient. nerve ultrasound in 2 patients with demyelinating neuropathy showed diffuse increased cross-sectional area. mr-neurography in one patient confirmed diffuse nerve hypertrophy and increased signal intensity, supporting the hypothesis of a overlap syndrome. all patients were treated with immunomodulatory therapies. among 5 patients with demyelinating features, 3 patients underwent ivig for 6 months, without benefit; the remaining 2 were treated with steroids, showing temporary improvement. the 2 patients with axonal neuropathy complaining of a progressive history, underwent ex adjuvantibus plasma exchange and ivig, without benefit. given the lack of benefit from therapies, screening for hereditary neuropathies was performed. among 5 patients with demyelinating neuropathy, 2 had cmt1a, 1cmt1b, 1cmt1d. among the 2 patients with axonal neuropathy, one was diagnosed with cmt 2k. in 2 patients an overlap syndrome was present. several clinical and laboratory features (csf protein elevation), might contribute to the misdiagnosis of cidp in cmt patients. refractoriness to immune-modulatory treatment should rise the suspicion of a hereditary neuropathy. an overlap cmt/cidp syndrome may be considered, in front of acute/subacute deterioration and/or proximal muscles involvement. two patient with an overlap syndrome showed benefit after either steroids or ivig. ruiz m 1 , tripodi sm 1 , campagnolo m 1 , zara g 1 , salvalaggio a 1 , ruggero s 1 , toffanin e 1 , anglani m 2 , briani c 1 . 1 neurology, department of neuroscience, university of padua, padua, italy; 2 neuroradiology, padua hospital, padua, italy. facial diplegia is a rare regional subtype of guillain-barrè syndrome characterized by rapidly progressive bilateral facial palsy in absence of other cranial neuropathies, ataxia or limb weakness. the diagnosis is based on history, clinical examination, laboratory data. the outcome of this variant appears to be better than that of classical gbs. although about 50% of gbs patients clinically exhibit facial nerve involvement, there are only few reports that demonstrate mri gadolinium facial nerves enhancement. a 45-year-old previously healthy man sought neurological advice for the acute onset of right perioral paresthesias and hyposthenia at the extensor hallucis longus bilaterally. in the previous month, during a trip to china and japan, he had suffered from gastroenteritis. at neurological examination he presented with bilateral extensor hallucis longus hyposthenia. ankle jerk reflexes were absent. one week later, he developed bilateral facial palsy. neurophysiology disclosed absence of activity in the facial nerves innervated muscles bilaterally and signs of mild partial denervation at right l5 metamer. csf analysis showed increased protein levels (73 mg%) and 2.3 leucocytes/ l. serological tests for infectious agents were negative and serum levels of angiotensin converting enzyme were normal. antibodies to monosialoganglioside gm1 of igg isotype were positive (1/12800). 3t brain mri showed, after gadolinium administration, marked bilateral enhancement of the facial nerves in their extra-and intra-canalicular segments. 3t lumbosacral mri scan ruled out the presence of disc diseases as well as signal modifications within conus medullaris and cauda equine nerve roots. the patient was treated with iv immunoglobulins (0.4 g/kg/die for 5 days) with benefit on facial weakness. at follow-up examination 2 months later, the patient presented a further improvement of the facial diplegia and neurophysiology disclosed a partial recovery of activity in the facial nerves, with persistent axonopatic damage. bilateral extensor hallucis longus hyposthenia persisted. in conclusion, we report on a regional subtype of guillain-barrè syndrome with the curious association of facial diplegia and bilateral extensor hallucis longus hyposthenia, and igg anti-ganglioside antibodies, that are not commonly described in facial diplegia. moreover, we provide 3t brain mri evidence of facial nerve involvement. rumora ae 1 , tabbey ma 1 , lograsso g 1 , dolkowski j 1 , haidar j 1 , lentz si 2 , feldman el 1 . 1 department of neurology, university of michigan, ann arbor, usa; 2 department of internal medicine, division on metabolism, endocrinology and diabetes, university of michigan, ann arbor, usa. diabetic neuropathy (dn) is the most common complication of diabetes affecting up to 60% of diabetic patients. the pathogenesis of dn in type 2 diabetes is directly related to the metabolic syndrome associated with the western diet composed of elevated levels of long chain saturated fatty acids (sfas) and low levels of medium chain sfas. long chain sfas are associated with insulin resistance and dyslipidemia while medium chain sfas have been associated with decreased lipid accumulation and improved mitochondrial function. since dn is primarily a disorder of the sensory dorsal root ganglion (drg) neurons, we sought to evaluate the impact of sfa hydrocarbon chain length on mitochondrial trafficking mechanisms that are critical for distributing atp throughout drg axon to provide energy for synaptic transmission. we hypothesize that sfas with longer hydrocarbon chains will impair mitochondrial trafficking whereas medium length sfas will not impact mitochondrial movement along the drg axon. in this study, we examined the impact of sfa hydrocarbon chain length on mitochondrial trafficking, directionality and velocity in primary mouse drg neurons. drg neurons were treated with increasing concentrations of long chain sfas, stearate and palmitate, or medium chain sfa, laurate, ranging from 31.25 to 250 micromolar for twenty-four hours. drg neurons treated with long-chain sfas, palmitate and stearate, showed a significant decrease in the percentage of motile mitochondria whereas medium chain sfa, laurate, does not alter mitochondrial motility. we next assessed whether motile mitochondria in drg neurons treated with palmitate or stearate exhibited altered directionality or velocity of mitochondrial trafficking. palmitate and stearate treatments resulted in a trending decrease in the number of mitochondria trafficking in both anterograde and retrograde directions. furthermore, 62.5 to 250 micromolar palmitate and stearate induced a significant decrease in mitochondrial velocity. laurate treatment, on the other hand, retained directionality and velocity of mitochondrial trafficking. these results suggest that hydrocarbon chain length of saturated fatty acids plays an important role in regulating mitochondrial trafficking mechanisms in dorsal root ganglion neurons. impaired mitochondrial trafficking in drg neurons exposed to elevated levels of long-chain sfas may play a critical role in the progression of dn. dyslipidemia is a critical factor that contributes to the development of diabetic neuropathy (dn). the progressive nerve damage associated with dn correlates with the dyslipidemic state characterized by elevated circulating levels of harmful saturated fatty acids (fas) and low levels of beneficial unsaturated fas. in dn, primary sensory dorsal root ganglion (drg) neurons exhibit energy dyshomeostasis and mitochondrial dysfunction, however, little is known about the differential impact of saturated and unsaturated fas on mitochondrial mechanisms in drg neurons. mitochondrial trafficking is an essential mechanism for transporting mitochondria throughout drg axons to provide cellular atp for neuronal function and neurotransmission. since mitochondrial trafficking is regulated by metabolic flux, we sought to determine whether saturated fa, palmitate, and unsaturated fa, oleate, have differential effects on mitochondrial trafficking in drg neurons. we evaluated mitochondrial trafficking patterns and the mitochondrial membrane potential (mmp) in primary drg neurons treated with physiologically relevant concentrations of palmitate, oleate, and combinations of both fas. primary drg neurons treated with 62.5 to 250 micromolar palmitate induced a significant and dose-dependent reduction in the percentage of motile mitochondria. these palmitate treatments also induced a dose-dependent reduction in mitochondrial velocity but did not impact the directionality of mitochondrial movement. alternatively, 31.25 to 250 micromolar oleate treatments did not impair the percent of motile mitochondria, the direction of mitochondrial movement, or mitochondrial velocity. since palmitate and oleate have differential effects on mitochondrial motility, we next assessed whether oleate could counter the inhibitory effect of palmitate on mitochondrial trafficking. surprisingly, oleate/palmitate mixtures at ratios of 1:1 or 2:1 prevented palmitate-induced impairment of mitochondrial trafficking. we assessed the impact of palmitate and oleate on mmp by staining palmitate and oleate-treated drg neurons with tetramethylrhodamine methyl ester. drg neurons treated with 250 micromolar palmitate exhibited an increase in the percentage of depolarized mitochondria while mitochondria in oleate-treated drg neurons retained mmp. interestingly, drg neurons treated with 1:1 oleate/palmitate mixtures also maintained polarized mitochondria. these results suggest that saturated and unsaturated fas have a distinct impact on mitochondrial trafficking mechanisms in drg neurons and that equimolar ratios of oleate/palmitate can prevent impairment of mitochondrial trafficking. of g alpha-13 in m 1 r overexpressed sensory neurons significantly reversed the m 1 r-induced reduction in relative levels of total neurite outgrowth (mean±sd: 347.96±190.12 (control) vs 545.40±321.97 (g alpha-13 knockdown), p<0.0001, n=406 neurons). further, treatment of m 1 r overexpressing neurons with mt7 or pirenzepine sequestered g alpha-12/13 proteins at the m 1 r and significantly reversed the impaired cytoskeleton-mediated reduction in total neurite outgrowth (mean±sd: 895.9±172.9 (control), 1887±807 (+100nm mt7), 1706±507.5 (+1 micromolar pirenzepine); n=224, 230 and 198 neurons, respectively; for treated groups p value=0.0001 vs control by one-way anova). mt7 and pirenzepine also significantly restored mitochondrial trafficking and abundance of mitochondria in the distal neurites. our findings suggest a novel mechanism in which modulation of m 1 r influences tubulin polymerization, mitochondrial distribution in nerve terminals and controls axonal outgrowth and regeneration. funded by cihr and nih. muscarinic receptors are a group of five g-protein coupled receptors (gpcrs) that are targeted by drugs for the treatment of several human pathophysiological conditions. we have recently shown that selective (pirenzepine) and specific (muscarinic toxin 7: mt7) antagonists of the muscarinic acetylcholine type1 receptor (m 1 r) induced elevated neurite outgrowth and protected from small and large fiber neuropathy in adult sensory neurons in various animal models (calcutt et al., 2017) . one of the major cellular effectors activated by gpcrs is extracellular signal-regulated kinase (erk). the erk signaling cascade regulates a variety of cellular processes including growth and proliferation. both g protein and beta-arrestin mediated signaling pathways can lead to erk activation by phosphorylation through different kinases. activated erk in turn can phosphorylate about 200 cellular substrates, thereby mediating diverse functions. in this study, we have analyzed beta-arrestin recruitment, as part of the receptor internalization process induced by agonist/antagonist binding. in addition, we studied phosphorylation of erk by mt7 and pirenzepine using isoelectric focusing with phospho-erk specific antibodies and a variety of cell-based assays including beta-arrestin and g protein (gnas/gnasl/gnaq/gna11/gna12/gna13) knockout cell lines. our study revealed that beta-arrestin is recruited to the m 1 r upon mt7 and pirenzepine treatment. treatment with 100nm mt7 and 1 micromolar pirenzepine significantly increased the dual phosphorylation of tyr202 and tyr204 residues of erk1/2 in primary rat sensory neurons (p<0.0001) in comparison to muscarinic agonist carbachol (10 micromolar) and general antagonist atropine (50 micromolar). we have identified multiple distinct phosphorylation events on the m 1 r by isoelectric focusing that are specific to mt7 and pirenzepine induction. further, we have shown that mt7 and pirenzepine-mediated erk phosphorylation is dependent on both g protein and beta-arrestin recruitment to m 1 r. finally, we reveal that increased erk phosphorylation by mt7 and pirenzepine significantly (p=0.005 and 0.063, respectively) increased phosphorylation of camp responsive element binding protein (creb) at ser133. these results show for the first time that antagonists of the m 1 r can activate the erk signaling pathway and possibly drive phenotypic change in adult sensory neurons. funded by cihr # mop-130282. charcot-marie-tooth disease (cmt) is representative of inherited neuropathies affecting an estimated 1 in 2500 people. the immense advances in gene discovery gained from next-generation sequencing (ngs) projects have revealed the extent of cmt's genetic heterogeneity, with over 90 loci already identified. this knowledge is rapidly translated into clinical comprehensive gene testing panels, often containing over 100 genes. such a large genomic space will invariantly yield variants of uncertain clinical significance (vus) in nearly any person tested. this rise of the number of vus creates major challenges for genetic counseling. in addition, less individual mutations in already known genes are being published as the academic merit is decreasing, and most such testing now happens in clinical laboratories. we propose to capture more of this data in the cmt field to gain a more complete collection of alleles in cmt genes, ideally in conjunction with detailed phenotypic data. this represents a rational approach to eventually reduce the number of vus. thus, we have created a unique, community-driven variant database for cmt researchers and clinicians. the inherited neuropathy variant browser provides simple, user-friendly access to currently reported cmt variation, including patient-level genotypic and phenotypic information. we have also designed an interactive rating system of genetic variation to assist the community with interpretation of vus. for the initial release, we have collected genetic variation, along with genotypic and phenotypic data when available, from published literature, clinical lab reports, and our in-house database. we highly encourage new submissions of not only observed pathogenic variation, but also variation of unknown significance. the goal is to provide a platform for the cmt community to store, share, and discuss genetic data in order to resolve variation of uncertain significance as a joint-effort. with active participation, we aim to provide the community with a more complete mutational spectrum in cmt genes to assist allelic interpretation and patient diagnosis. neurofilaments are strictly neuron-specific intermediate filaments crucial for maintaining axonal architecture. pathogenic mutations in nefl, which encodes the light chain of neurofilament, cause dominantly and recessively inherited charcot-marie-tooth neuropathy (cmt). the nefl-associated neuropathy can be either axonal (type 2e) or demyelinating (type 1f). most pathogenic nefl variants are dominantly inherited missense mutations, which are thought to cause disease by inducing nefl aggregation, leading to the disruption of axonal transport. however, investigation of disease mechanisms caused by the mutations has been complicated by the neuronal specificity of nefl. we identified a homozygous nefl variant c.1099 c>t predicting a nonsense change p.arg367* in a patient with early-onset cmt. to elucidate the disease mechanism, we used pluripotent stem cells, reprogrammed from patient's skin fibroblasts, to differentiate patient-specific spinal motor neurons. the motor neurons revealed a near complete loss of nefl mrna, and absence of nefl protein. our results establish that nefl is not essential for the development of human nervous system but its absence causes progressive axonal neuropathy. we currently profile the transcriptomic alterations of the motor neurons lacking nefl using single cell rna sequencing to identify compensatory pathways. friedreich's ataxia (frda) is the most common autosomic recessive ataxia, due to a trinucleotide expansion within the frataxin gene. within the wide phenotype, frda patients present also with an axonal neuropathy whose pathological mechanisms are not completely known. eight patients (5 women, mean age 34.6 yrs, range 20-45) with genetically confirmed frda underwent neurophysiological and nerve ultrasound evaluation at four limbs bilaterally. echogenicity and cross-sectional area (csa) of median, ulnar, radial, peroneal, tibial, and sural nerves were recorded. mr neurography and diffusion tensor imaging (dti) analysis were performed in one patient; fractional anisotropy (fa), radial (rd) and axial (ad) diffusivity of median, radial and ulnar nerve were calculated at proximal, intermediate and distal sites. all patients presented with sensory axonal neuropathy. seven patients (88%) presented with increased csa of median and ulnar nerves at arm and axilla. mean median nerve csa at mid-upper arm was 20.9 mm 2 (normal values < 11 mm 2 ), mean ulnar nerve csa at mid-upper arm was 13.6 mm 2 (normal values < 8 mm 2 ). mean median nerve csa at axilla was 13.8 mm 2 (normal values < 11 mm 2 ), mean ulnar nerve csa at axilla was 9.9 mm 2 (normal values < 8 mm 2 ). mr neurography (performed in one patient) confirmed diffuse swelling and signal hyperintensity of median and ulnar nerves at the arm and dti analysis showed abnormal values of fa, ad and rd along the whole course of evaluated nerves thus suggesting a wide alteration of nerves structure. frda patients presented with an axonal neuropathy characterized, at ultrasound, by a nerve enlargement strictly limited to mid-upper limbs in all patients, findings that cannot be solely explained by a dying-back axonopathy, as suggested by several authors. neither a dorsal root ganglia neural loss could explain by itself our findings, because a diffuse csa reduction would have been expected. on the whole, these findings represent a peculiar feature in frda, but its pathophysiologic meaning remains unclear. inherited peripheral neuropathies are an important health concern for which there is currently no disease-modifying therapy. dogs are affected by a variety of peripheral neuropathies that are breed-specific, indicating a strong genetic component. the use of in-bred populations, such as pure-bred dogs, is advantageous for genetic dissection of disease. acquired peripheral neuropathy (apn) is an inherited late-onset generalized polyneuropathy with high prevalence in labrador retrievers. the most prominent features of apn, laryngeal paralysis and pelvic limb weakness, are associated with the longest peripheral motor nerves in the dog. the pathologic features of apn are similar to human peripheral neuropathy. our aim is to understand the genetic and pathologic features of apn for development of this condition as a naturally occurring large animal model for human disease. we performed a genome-wide association study (gwas) and short-read high-depth whole genome sequencing (wgs) to investigate the genetic underpinning of apn in the labrador. our gwas data indicates that apn is an autosomal dominant disease. the initial analysis from the wgs study resulted in a potential causal variant with an autosomal dominant pattern; this variant is associated with an axonal gene. the neuropathologic progression and histologic features of apn are poorly defined. using genetic markers from our gwas study, we are able to confidently identify labradors with pre-clinical apn, from which nerve biopsies can be obtained. preliminary analysis of biopsies from labradors suggest apn is an axonopathy. further histologic data from preclinical and symptomatic dogs is being obtained to further define the pathogenesis in this model. mutations in morc2 lead to an axonal form of neuropathy (cmt2z). to date, nine families have been published with mutations in the morc2 gene, showing that this gene is frequently involved in cmt. while the recent genetic data clearly established the causative role of morc2 in cmt2z, its phenotypic consequences in patients and role in neuronal biology remains to be clarified. therefore, we aim to look for altered genetic and biochemical pathways with a transcriptomic approach in order to investigate the role of morc2 in hereditary peripheral neuropathy. we have performed transcriptomic analysis using a human gene expression microarray (v3 8x60k, agilent technologies), in three hek-293t cell lines: control, morc2 knock-down (kd) and the overexpression of the most common morc2 mutation, the p.r252w (np_001290185) (kr). differential gene expression assessment was carried out using limma moderated t-statistics. standard analysis techniques perform one test for each gene. thus, for each gene, a t-test statistic is reported together with its corresponding p-value. in this analysis we have used the conventional multiple testing p-value correction procedures proposed by benjamini hochberg to derive adjusted p-values. the preliminary results reveals that kd shows up-regulated genes involved in transmission of nerve impulse and cilium metabolism, suggesting that morc2 might act at this level in the peripheral nervous system. otherwise, kr shows a major alteration of main axonal metabolic pathways, including the overexpression of genes related to the generation of neuronal action potential, transport through the axon and its targeting in synapse formation. kr also shows a marked alteration of gene expression related to organization, assembly and cilium movement and with the axonemal dynein complex assembly. this study provides an important step towards understanding the pathomechanism underlying to morc2 p.r252w and its role in cmt2z. aifm1 encodes a mitochondria associated apoptosis inducing factor. mutations in aifm1 lead to a wide spectrum of neurodegenerative disorders: cowchock syndrome; a combined oxidative phosphorylation deficiency 6 (coxpd6) with severe encephalomyopathy; x-linked deafness with peripheral sensory neuropathy; spondyloepimetaphyseal dysplasia (semd) with mental retardation; and an infantile motor neuron disease. previous studies showed severe defects in mitochondrial metabolism, related to redox function, mitochondrial fragmentation, and respiratory deficiencies. in addition, some mutations impair the protein expression of aifm1 and cause an increase in caspase-independent apoptosis. by targeted next-generation sequencing, we detected the aifm1 c.629c>t (p.phe210ser), in a 12 year-boy. this mutation was confirmed in his 7 year-old affected brother. electromyography and nerve conduction velocities studies revealed an axonal polyneuropathy with exclusive involvement of motor fibers, with an early childhood-onset. both children currently show normal cognitive and cranial nerves functions. the in silico structural modeling of human aifm1 showed that the mutation of a phenylalanine to serine at position 210 disrupts the hydrophobic interaction between phe210 and pro207, and consequently, it destabilizes an alpha-loop domain. cartoon of protein superposition between two different human aifm1 structures suggest that a lack of constraints in this region could affect the interaction between 517-533 helix and the 190-202 -hairpin regions, a very important stage for the functional activity of the aifm1 protein. patient-derived fibroblasts were used to investigate the pathological effect of the p.phe210ser mutation: fibroblasts from patients show a similar mrna but different protein expression of aifm1 compared to healthy control fibroblasts. however, they have an aberrant morphology, from fibroblastic to polygonal shape, and they are larger than control fibroblast; mitochondria from mutant fibroblasts are markedly fragmented compared to controls; the viability of the patient's fibroblasts is lower, but it does not correlate with an increase in apoptosis. instead, it seems to be caused by an increase in the expression of genes activating the senescent program, like p21 and p16. our study confirms that variable effect of different mutations on the protein function may contribute to the clinical variability observed in aifm1 patients. funds: isciii (pi12/00453); fundació per amor a l' art. sango k 1 , takaku s 1 , niimi n 1 , yako h 1 . 1 diabetic neuropathy project, tokyo metropolitan institute of medical science, tokyo, japan. coculture models of neurons and schwann cells have been utilized for the study of myelination and demyelination in the peripheral nervous system; in most of the previous studies, however, these cells were obtained from the primary culture with embryonic or neonatal animals. because it is recognized that some biological properties of both neurons and schwann cells change with maturation and aging, culture systems of adult animal cells appear to mimic peripheral nerve degeneration and regeneration better than those of immature animal cells. we have established spontaneously immortalized schwann cell lines from long-term cultures of adult fischer rat peripheral nerves. one of these cell lines, designated ifrs1, has been shown to retain distinct schwann cell phenotypes, such as spindle-shaped morphology with expression of glial cell markers, synthesis and secretion of neurotrophic factors and cytokines, and fundamental ability to myelinate neurites in cocultures with adult rat dorsal root ganglion neurons and nerve growth factor-primed pc12 cells. our current investigation focuses on the establishment of the coculture system of ifrs1 cells and nsc-34 motor neuron-like cells. nsc-34 cells were seeded at a low density (1 x 10 4 /ml) and maintained for a week in serum-containing medium supplemented with non-essential amino acids and brain-derived neurotrophic factor (bdnf, 10 ng/ml). after overnight exposure to mitomycin c (mmc, 1 micro g/ml), nsc-34 cells were cocultured with ifrs1 cells (1 x 10 5 /ml) and maintained in serum-containing medium supplemented with bdnf (10 ng/ml), ciliary neurotrophic factor (cntf, 10 ng/ml) and coenzyme q10 (1 micro m). under this culture condition, overgrowth of nsc-34 cells was prevented and gradual movement of ifrs1 cells toward the neurites emerging from nsc-34 cell bodies was observed. double-immunofluorescence staining carried out at day 28 of the coculture showed myelin protein zero-immunoreactive ifrs1 cells surrounding the beta iii tubulin-immunoreactive neurites. this coculture system can be a beneficial tool to study the pathogenesis of motor neuron diseases (e.g. amyotrophic lateral sclerosis, charcot-marie-tooth diseases and immune-mediated demyelinating neuropathies) and novel therapeutic approaches against them. santos pp 1 , torezani gs 1 , maciero l 1 , pagliarini lfd 1 , romão tt 1 , abunahman ms 1 , ferreira is 1 , bittar c 1 , pupe c 1 , nascimento ojm 1 . 1 universidade federal fluminense (uff), rio de janeiro, brazil. zika virus (zikv) is a flavivirus related to dengue, yellow fever and west nile viruses, and has been recently associated to the occurrence of neurological complications in children and adults. previous studies have linked zikv to the development of guillain-barré syndrome (gbs), myelitis, meningoencephalitis and ophthalmological manifestations in adults. guillain-barré syndrome (gbs) encompasses a spectrum of post-infectious neuropathies characterized by different distributions of weakness and sensory impairment. serum anti-ganglioside antibodies are often found and are related to different clinical patterns. recently we have encountered patients in rio de janeiro, brazil, with distal edema in lower limbs, acute weakness, pain and sensory disturbances during the acute stage of an acute febrile exanthematous illness. the symptoms persist for up to 7days, with complete resolution afterwards, without specific therapy. blood concentrations of muscle enzymes show normal values, and electromyography and nerve conduction studies (emg/ncs) are usually unremarkable. of note, all cases have had positive rt-pcr for zika virus, indicating an illness that occurred during the viremic phase of this arbovirus infection, and complete recovery within the expected timeframe for the resolution of the systemic viremia. there is a subset of patients who developed acute weakness very early after the initial viral symptoms, with clinical, laboratorial and electrophysiological findings that substantially differ from gbs. we describe three cases with similar features suggestive of an acute infective polyneuritis (aipn). one might hypothesize that zikv might lead to a direct neurotropic injury, significant enough to cause weakness and sensory complaints, but not severe enough to cause permanent damage, resolving in conjunction with decreasing blood viremia. we consider that these patients differ from classical gbs because their illness begins during the acute febrile stage of an infective illness and the clinical course is more rapid leading to complete resolution in a few days. savransky a 1 , mozzoni j 2 , massaro sanchez mp 1 , reisin r 3 , monges ms 1 . 1 department of neurology, hospital de pediatria j.p. garrahan, buenos aires, argentine; 2 department of physical therapy, hospital de pediatria j. p garrahan, buenos aires, argentine; 3 department of neurology, britain hospital, buenos aires, argentine. our objective is to describe a series of children with guillain barré syndrome (gbs) included in the igos protocol. as part of the igos multicenter protocol, pediatric patients meeting gbs diagnostic criteria, who consulted within the first 2 weeks of symptom onset and had parental consent to participate in the study were included. patients were also offered to participate in the extended 3-year protocol. all patients were evaluated according to the igos protocol. patients were recruited between october 2013 and june 2015. twenty-four patients, eight girls, participated. ages ranged from 6 months to 14 years (mean 5.8 years). all patients agreed to participate in the extended protocol, which was completed by 10 of them. eight patients completed the 2-year follow-up and are still under evaluation. five patients were lost to follow-up.twenty-two had the classic variant of gbs and two miller fisher. radicular pain in the back or lower limbs was reported by 70%. twenty-three patients underwent lumbar puncture and albumin-cytological dissociation was found in 22. in all cases, csf was stored for proteomic studies. all patients underwent emg showing aidp in 22, and amsan and aman in 1 each. one patient with aidp developed to cidp. in 13 patients full-spine mri was performed and cauda equina enhancement was found in every case. three patients required ucip, two with invasive and one non-invasive ventilation. all patients were treated with gammaglobulin, with a second dose at 2 weeks in cases with a poor response. all 19 patients who followed the protocol were evaluated with the gbs disability score. median score was 4 at baseline and between 0 and 1 at the 2-year assessment. we describe a series of children with gbs as a part of an international protocol including patients of different ages. pain was a frequent and early symptom and could be determined despite the young age of our patients. most patients fully recovered. we were invited to participate in igos kids to better assess this age group. saysavath k 1 , somchit v 2 , t. umapathi 3 . 1 mittaphab hospital, vientiane, lao pdr; 2 setthathilath hospital vientiane; 3 national neuroscience institute, singapore, singapore. laos people democratic republic is a country of 6.5 million people in south east asia. largely agricultural, its capital and metropolis is vientiane. adult neurological services are concentrated at mittaphab hospital, vientiane serviced by three neurologists. on the average about six cases of guillain-barré syndrome (gbs) are seen per year. it is believed that most patients do not seek medical attention. cases appear to cluster during the rainy season. most patients present late, often at the second week of illness when recovery is unapparent after seeking treatment from traditional medicine doctors and at district hospitals. a substantial number of patients seek treatment at hospitals across the border, in neighboring provinces of thailand. common antecedent symptoms are viral prodrome and diarrhea. miller fisher syndrome appears to be rare, possibly because of the mild deficits that do not prompt patients to seek medical attention. diagnosis is made largely from clinical features and from spinal fluid analysis. nerve conduction studies are not available. patients are often treated with steroids by internists. intravenous immunoglobulin and plasma exchange are not available. common complications include pneumonia, autonomic dysfunction (fluctuating blood pressure), pressure sores and depression. patients who develop respiratory failure are nursed at a twelve-bedded intensive care units. plans are afoot to set up a prospective gbs database, systematically study antecedent infections, including of flaviviruses, and develop low-volume plasma exchange as a feasible therapeutic modality. a gene therapy approach for treating cmt4c neuropathy schiza n 1 , markoullis k 1 , richter j 2 , tryfonos c 2 , kagiava a 1 , sargiannidou i 1 , christodoulou c 2 , kleopa ka 1,3 . 1 neuroscience laboratory; 2 department of molecular virology; 3 neurology clinics, cyprus institute of neurology and genetics and cyprus school of molecular medicine, nicosia, cyprus. charcot-marie-tooth type 4c (cmt4c) is the most frequent form among recessively inherited demyelinating neuropathies and results from mutations in the sh3tc2/kiaa1985 gene. sh3tc2 mutations cause loss of function of the sh3tc2 protein suggesting that gene replacement therapy may be useful for treating cmt4c. sh3tc2−/− mice develop all major aspects of the human pathology including early onset progressive peripheral neuropathy with hypo-and demyelination along with decreased motor and sensory nerve conduction velocities, offering a relevant model for testing treatments for cmt4c. in order to develop a gene replacement strategy for cmt4c, we generated a novel lentiviral vector, lv-mpz-sh3tc2.myc, to drive expression of the human sh3tc2 cdna under the control of the myelin protein zero (mpz/ p0) promoter specifically in myelinating schwann cells. a c-terminus myc tag was included to facilitate expression analysis. a control vector (mock) was also produced in which the sh3tc2 cdna was replaced by the egfp reporter gene. we first confirmed expression of hsh3tc2 in hela cells transfected with the pcdna3-cmv-sh3tc2.myc vector. immunofluorescence analysis confirmed a strong expression of sh3tc2 specifically at the plasma membrane with additional localization in a dotted pattern intracellularly. for in vivo gene delivery we used both intraneural and intrathecal injections of the lv-mpz-sh3tc2.myc vector in 2-week to 4-month old sh3tc2−/− mice. expression of virally delivered hsh3tc2 was assessed 4 weeks after injection. immunofluorescence analysis showed hsh3tc2 immunoreactivity in perinuclear schwann cell cytoplasm in sciatic nerve teased fibers of sh3tc2−/− mice following both intraneural and intrathecal delivery, while lumbar intrathecal gene delivery resulted additionally in expression of hsh3tc2 in the lumbar roots. real time pcr analysis confirmed hsh3tc2 mrna expression in both lumbar roots and sciatic nerves. thus, we have developed a novel lentiviral vector for schwann cell targeted gene delivery to treat cmt4c and for testing possible therapeutic effects in the mouse model of the disease. hereditary neuropathies are a group of disorders which are characterised by the systemic impairment of peripheral nerves. more than 200 neuropathies are associated with causative gene defects [1]. charcot marie tooth (cmt1a) neuropathy is the most frequent hereditary neuropathy, triggered by a mutation in the peripheral myelin protein gene 22 (pmp22). cmt1a leads to a primary loss of myelin sheath and afterwards to a degeneration of axons [2] . symptoms appear with the degeneration of axons, whereas demyelination is thought to be largely asymptomatic. for that reason, we investigate in the mechanisms of axonal degeneration. for our analysis, we used purified axoplasma without detectable myelin proteins of the sciatic nerves of 20 weeks old pmp22-c61 mice. in this early stage of the axonal degeneration sarm1 was significantly increased. the nad + concentration in the axoplasma was dramatically reduced. this correlates to the previous finding that sarm1 promotes axonal degeneration by cleavage of nad + . additional studies showed an increase of the nad + -dependent axonal protective factor sirt3 in pmp22-c61 sciatic nerves. nmnat-1, known as the active component of the wallerian degeneration slow gene, was unaffected in axoplasma of pmp22-c61 sciatic nerves. summarised, these results indicate that the pathway of sarm1, nad + and sirt3 may play a critical role in axonal degeneration in neuropathy. we report two unrelated czech patients with cmt4b2, both sporadic cases in the family. patient 1 is a 27 year old man with congenital glaucoma after 8 ophthalmological surgeries. his early motor development was normal. at the age of 10 years parents noted gait problems, first neurological examination was at the age of 11 years, when emg showed diffuse motor and sensory neuropathy with severely decreased ncv (22-29 m/s). he developed foot deformities (pes cavovarus) and underwent corrective orthopedic surgeries at the age of 16 years. after several dna tests for demyelinating cmt the sfb2 gene was sanger sequenced and a novel missense mutation p.ile45asn was found in homozygous state in the patient and in heterozygous state in both parents. the patient was later tested also by ngs of a panel of all 78 genes to be causal for hereditary neuropathies and no other potentially causal variants were detected. patient 2 is 35 years old man, with normal early motor development. at the age of 4 years parents noted gait problems with distal leg weakness which progressed into distal leg plegia at the age of 9 years. hand weakness was noticed since the age of 10 years. he has severe atrophies of distal muscles of all extremities, is self ambulant. at the age of 25, emg showed unrecordable responses from nerves of lower limbs and ncv was measurable only on ulnar nerve and was 13 m/s. at the age of 30 years increased intraocular pressure was diagnosed and he uses anti glaucoma eye drops. after many single gene tests for demyelinating cmt, we used ngs of a panel of 97 genes known to be causal for hereditary neuropathies and two novel heterozygous, probably pathogenic variants affecting invariant splice sites were detected: c.1601-2a>g and c.5232-10_5244del, both confirmed by sanger sequencing. the first variant is also in the father, but the second is probably de-novo (not detected in parents, despite correct parentity). sekiguchi y 1 , kikuchi si 1 , konno si 1 , sekiguchi m 1 . 1 department of orthopaedic surgery, fukushima medical university school of medicine, fukushima, japan. carpal tunnel syndrome (cts) is the most common entrapment neuropathy. ultrasonography can be used to detect anatomic changes in cts. more recently, it has been shown that doppler ultrasonography can detect increased intraneural blood flow in cts. the purpose of this study was to determine the most suitable finding of pre-and postoperation in cts by ultrasonography. a total of 40 wrists of 25 patients with nerve conduction study (ncs) proven cts were evaluated with ultrasonography. we measured the median nerve's cross-sectional area (csa) and intraneural blood flow of median nerve by ultrasonography. the correlation between these ultrasonographic measurements, ncs severity and duration of clinical cts symptoms was analyzed. the csa (mean, 13 mm 2 ) was no significantly reduction after successful carpal tunnel release. morphologic median nerve changes may persist for a longer period regardless of successful surgery and clinical improvement. however, intraneural blood flow is increasing after successful carpal tunnel release. we conclude that doppler ultrasonography results strongly correlate with post operated cts improvement. hence doppler ultrasonography is a useful method for functional improvement of pre-and post cts operation. senger jl 1 , chan km 1 , olson jl 1 , webber ca 1 . 1 university of alberta, edmonton, canada. the beneficial effects of a preinjury crush conditioning lesion (cl) on peripheral nerve regeneration is well-documented in animal models. no human studies have been attempted to date, given the ethical dilemma of deliberately injuring an intact nerve, and the difficulty in predicting the timing of a nerve injury. recent studies demonstrate that 1 hour of electrical stimulation (es) produces effects similar to cl in neuronal cultures. this, coupled with a surgical environment favoring nerve transfers, in which an intact nerve is deliberately cut to reinnervated a denervated muscle, means that es may be clinically translatable to enhance regeneration. this study hypothesizes that es prior to nerve injury will enhance nerve regeneration. twelve sprague-dawley rats were divided into four groups based on conditioning-type to the mid-common peroneal (cp) nerve: es (4), crush (4), sham-es (2), and naïve (2). one week following conditioning, they underwent a cut/coaptation of the cp nerve at the sciatic trifurcation. post-cut day 14, nerves and dorsal root ganglia (drgs) were collected. axonal counts of nerves stained with nf-200 revealed similar regeneration between es and crush (3.2 vs. 3.8 mm, p=0.6648) that was superior to sham-stimulation (1.3 mm) or no-conditioning (1.0 mm, p<0.05). a greater number of axons at the distal tip were present in animals that received either type of conditioning compared to the unconditioned cohorts. drgs were stained with neuronal injury marker growth associated factor-43 (gap-43), and satellite cell glial cells with glial fibrillary acidic protein (gfap). significant increase in gap-43 expression at three days was observed in es and crush cohorts compared to sham or naïve (p<0.001) cohorts. the satellite glial cells of es and crush conditioning showed a significant increase in gfap expression (29.3% and 39.3% respectively) compared to sham (8.6%) and naïve (13.5%) drgs. by demonstrating similar improvements in axon regeneration, this proof of principle project suggests that es conditioning may produce regenerative outcomes comparable to the classical crush injury model. in turn, this suggests that es may be a promising method for delivering conditioning lesions in clinical trials for conditioning nerves prior to surgical intervention. we report a unique case of newly developed waldenstrom's macroglobulinemia (wm) in a patient with chronic inflammatory demyelinating polyneuropathy (cidp) with antibodies against myelin-associated glycoprotein (mag) and sulfatide who was undergoing treatment with intravenous immunoglobulines (iv-ig). subsequent rituximab infusions did not have a positive impact. patients with wm can develop demyelinating and axonal polyneuropathies and few patients have anti-mag and/or anti-sulfatide antibodies. anti-mag antibodies (4% of wm) are associated with sensorimotor axon loss and demyelination and anti-sulfatide (5% of wm) with sensory axonal loss. rarely, both antibodies can be present, with a more severe clinical phenotype. cidp associated with anti-mag and anti-sulfatide antibodies can represent independent entities, not associated with wm. there are no reports to date of patients with cidp associated with anti-mag and anti-sulfatide antibodies that developed wm during immunomodulatory therapy with iv-ig. in addition, subsequent rituximab infusions after the iv-ig were stopped have not been proven beneficial, as has been previously reported for anti-mag cidp patients. seventy-six year old right-handed gentleman presented with persistent numbness in his left foot, three months following artificial disc placement in his lumbar spine. gradually he developed sensory ataxia. no radicular signs were present on exam or impingement on serial spine mri's. ncs/emg studies were consistent with a cidp variant with severely prolonged distal motor latencies. serum anti-mag and anti-sulfatide antibodies were elevated. chronic therapy with iv-ig was able to partially stabilize the symptoms; however, six years later he newly developed wm. subsequent infusions with rituximab, after iv-ig was stopped, did not improve the clinical picture or the ncs/emg findings. wm can newly develop in an autoimmune setting, such as cidp associated with anti-mag and anti-sulfatide antibodies. in this particular case, there was an ongoing immunomodulatory therapy for our cidp patient, as he had monthly iv-ig infusions. this may reflect a possible induction of pathological b cell clone proliferation during the iv-ig treatment. subsequent rituximab infusions, after the iv-ig was stopped, did not improve the symptoms or the demyelination features on ncs/emg. he continues to be symptomatic despite efforts. charcot-marie-tooth disease (cmt) is an inherited neuropathy without known cure (prevalance: 1:2500). duplication of the gene encoding the peripheral myelin protein of 22kda (pmp22) underlies the most common subtype cmt1a. severely affected cmt patients suffer from sensory and motor symptoms with wheelchair-boundness. the clinical phenotype is highly variable and is determined by the amount of axonal loss, but the molecular mechanisms of the disturbed neuron-glia interaction are poorly understood. risk factors have not been investigated. therefore, cmt-net, a german network funded by the german ministry of education and research (bmbf, bonn, germany) includes interdisciplinary expertise from molecular biology, neurology, neuropathology and human genetics in order to identify genetic and non-genetic risk factors of disease severity of cmt by: (i) examining the mechanisms of the disturbed axon-glia-interaction and neuronal vulnerability, (ii) identification of genetic modifiers and (iii) novel therapeutic targets, (iv) validating outcome measures in children and adults, (v) establishing a biobank and (vi) exploring the disease burden via an internationally harmonised patient registry. cmt-net includes three service structures cmt-net will focus on cmt1a, but also includes rarer subforms. we will provide the scientific basis for the development of translational approaches to therapy in patients. our approach bridges cutting edge molecular screening techniques, transgenic animal models of altered axon-glia interactions (fly, chick, mouse, rat), state-of-the-art genomic technologies and human patient trials in order to understand and treat the disease aggravation in cmt. sezer g 1 , tekol y 2 , sezer z 2,3 . 1 erciyes university, betül ziya eren genome and stem cell centre, kayseri, turkey; 2 erciyes university, school of medicine, pharmacology department, kayseri, turkey; 3 erciyes university, good clinical practice and research centre, kayseri, turkey. analgesic effects of antidepressant drugs are well known for a long time, however, their systemic side effects limit their usage as an analgesics. venlafaxine is an antidepressant drug that has different structure. our purpose was to investigate whether systemic analgesic effect has been proved drug, venlafaxine, has local peripheral antinociceptive action. we applied vanlafaxine (25 μl 50, 100, 200, 400 μg) to male, sprague-dawley rats' paws by intraplantar injection and also by intraperitoneal route (5, 10, 20, 40 mg/kg) in formalin test, a model for acute and tonic pain. we also pretreated another groups of rats with 2 mg/kg naloxone (opioid receptor antagonist), 2 mg/kg cpt (adenosine a 1 receptor antagonist) or saline (ip.) before 200 μg/paw venlafaxine injection. to check the effect is local or not, we determined the blood levels of venlafaxine in at different time points after both the local and systemic applications by gc-ms method. datas were expressed as number of flinches and total time for biting/licking of the injected paw over phase 1 (0-12 min) or phase 2 (16-60 min) and analyzed using the student's t-test. venlafaxine induced antinociception at 100, 200 and 400 μg concentrations by the local peripheral application and at 20, 40 mg/kg doses by the systemic application in formalin test and the effects were comparable. pretreatment with naloxone diminished the effect of venlafaxine in the both phases, however, it was not statistically significant. pretreatment with cpt decreased venlafaxine induced antinociception only in phase 1. neither naloxone nor cpt changed formalin induced nociceptive behaviors alone. this is the first that determines the peripheral antinociceptive actions of venlafaxine in rat formalin test. with roles of opioid and adenosine a 1 receptors in this action. our results suggest that venlafaxine has local peripheral antinociceptive effect and such an activity may led to trials for to use this drug as a cream-gel formulation for analgesia in clinics in the future. topical application might permit the attainment of higher and more efficacious concentrations in the region of the sensory nerve terminal, with limited systemic side effects. shah a 1 , hoffman em 1 , klein cj 1 , staff np 1 . 1 mayo clinic, rochester, usa. cipn is a common dose-limiting complication for patients with cancer. the long-term disease burden of cipn is compounded by increasing cancer survivorship, yet there are minimal data on long term outcomes following onset of cipn, especially in population-based studies. we utilized the rochester epidemiology project to examine incidence and disease burden of cipn among individuals of olmsted county, minnesota with neurotoxic chemotherapy exposure between 2006 and 2008. clinical records were queried for the presence of neuropathic signs, symptoms and icd-9 diagnostic codes as well as for patient provided information on impairment with activities of daily living and use of pain medications. a total of 511 individuals with incident exposure to neurotoxic chemotherapy agents between 2006 and 2008 were identified. based on aan criteria for identifying peripheral neuropathy, 268 (54.4%) of these individuals were determined to have cipn, while 241 (45.6%) controls did not. the median time from incident exposure to reported symptom onset was 71 days (iqr 28.5-122). patients with cipn received a neuropathy icd-9 diagnosis in merely 37 cases (13.8%). median survival following incident chemotherapy exposure among all cases and controls was 5.0 years with a significantly longer mean survival in cases with cipn as compared to that of controls (6.4 years vs. 1.8 years, p<0.0001). in addition to acute effects in cipn, individuals surviving greater than 5 years following exposure to neurotoxic chemotherapy continue to self-report increased symptoms of numbness (or 2.8, 95% ci 1.6-5.2) and pain (or 1.9, 95% ci 1.1.3.2) of the extremities. through utilization of patient provided information, our study was able to collect data on long-term impairment associated with previous history of exposure to neurotoxic chemotherapy. our results are consistent with previous reports of the high incidence of cipn in the first two years following incident exposure. additionally, our results provide evidence of high incidence of cipn independent of individual chemotherapeutic agent used. additionally, our results indicate icd-9-cm diagnostic code attribution may dramatically underestimate the magnitude of cipn. increased survival following exposure to neurotoxic chemotherapy and its long-term disease burden necessitates further study of among survivors. the utility of quantitative muscle ultrasound as a marker of disease severity in charcot-marie-tooth (cmt) disease subtypes was investigated. muscle ultrasound was prospectively performed on 252 individual muscles from 21 cmt patients (9 cmt1a, 8 cmtx1, 4 cmt2a) and compared to 120 muscles from 10 age and gender-matched controls. muscle ultrasound recorded echogenicity and thickness in representative muscles including first dorsal interosseus (fdi) and tibialis anterior (ta charcot-marie-tooth (cmt) disease is the most frequent inherited peripheral neuropathy, and there is currently no available cure. the most common subtype of cmt, cmt1a, is completely associated with duplication of the pmp22 gene, which encodes peripheral myelin protein 22 of schwann cells. previous studies of cmt1a mainly relied on rodent models, and it is not yet clear how pmp22 overexpression leads to the phenotype in patients. based on induced pluripotent stem cell (ipsc) technology, we herein developed a brand new in vitro cell model of cmt1a, called cmt1a-hipscs, in the hopes of simulating the developmental progress of the disease and gaining new insights into its pathogenesis. here, we efficiently derived ncscs from cmt1a-ipscs and assessed the potential of the isolated cmt1a-neural crest stem cells (ncscs) to differentiate into peripheral neurons and schwann cells using defined media. we found that, unlike normal control ncscs, cmt1a-ncscs rarely generated schwann cells. instead, cmt1a-ncscs produced numerous endoneurial fibroblasts in the schwann cell differentiation system. we further established a pmp22-overexpressing ipsc model, and obtained similar results when pmp22-ncscs were subjected to schwann cell differentiation. these results suggest that the development of schwann cells in cmt1a patients is interrupted by the duplication of pmp22. with the exception of the demyelination-remyelination process, developmental disabilities of schwann cells should be considered as an underlying cause of cmt1a. shimoi t 1 , yamada t 2 . 1 international university of health and welfare, tochigi, japan, 2 cmt japan, tokyo, japan. charcot-marie-tooth (cmt) disease is the most common hereditary motor and sensory neuropathy. our preliminary report suggests that a certain cmt patient has the recruitment disorder of motor units during muscle fatigue and this disorder may be a factor of "super fatigability" in motor neuropathy patients. if the "super fatigability" occurs, we would expect patients with this characteristic to become slower in recovery from muscle fatigue than patients without this characteristic. in order to verify this hypothesis, we measured characteristic of recovery from muscle fatigue in charcot-marie-tooth patients with electromyographic study. twenty three participants were asked to maintain their 75% of maximal voluntary isometric contraction (mvc) of elbow flexor until exhaustion as the fatigue exercise. in addition, the participants asked to perform 5s of their 50% of mvc at 30, 60, 90, 120, 180, 240, 300, 360, 420, 480s after the fatigue exercise as recovery tasks. the surface emg (semg) signals of biceps brachii muscle were determined during the exercise and tasks. muscle force, median power frequency (mdpf) and the root mean square of semg amplitude (rms) were used as objective parameters of muscle fatigue. borg scale was used as a subjective parameter of muscle fatigue. six of twenty three participants showed significant decrease of rms during the fatigue exercise. in consideration of this result, we compared alteration of mdpf in recovery task between six participants with decrease of rms (abnormal group) and seventeen participants with increase of rms (normal group). as the result, the abnormal group had at least 180s as the recovery time from muscle fatigue in contrast with 90s of normal group. the recovery time from muscle fatigue in subjective parameter was shorter than the time in objective parameters in each group. our data support the "super fatigability" hypothesis. and that hypothesis may induce "hidden muscle fatigue". comparison between complex regional pain syndrome type 1 and 2 based on electrophysiologic, imaging and clinical findings shin jy 1 , moon jy 1 , sung jj 1 . 1 seoul national university hospital, seoul, republic of korea. complex regional pain syndrome (crps) is a constant regional neuropathic pain characterized by various kinds of motor, sensory, and autonomic changes. conventionally, the crps is divided into type i and ii according to the absence and presence of nerve injury. but the pathogenesis of crps is not fully understood yet. and there is still no systematic comparative study between crps type i and ii. we compared between crps type i and ii using multimodal approaches including electrophysiologic, imaging, and clinical findings. the 171 patients (135 type i and 36 type ii) diagnosed with crps using the international association for the study of pain (iasp) diagnostic criteria were included. type i and ii were divided by electromyography and nerve conduction study. we obtained clinical information such as continuing pain, allodynia, hyperalgesia, edema, temperature, skin color, sweating, trophic change from patients. all patients were evaluated by bone scan, thermography, quantitative sudomotor axon reflex test (qsart), quantitative somatosensory test (qst). the ratio of qsart and temperature threshold abnormality in type ii was higher compared to type i (85.7% vs 62.7%, 66.7% vs 46.3% respectively, p = 0.01 and 0.03), among clinical symptoms, sweating change significantly high in type ii compared to type i (77.8% vs 38.7%, p = 0.04). other electrophysiologic and imaging, clinical findings were not significantly different in both type. in this study, we identified that crps type i and ii are distinguished not only by the nerve injury but also by the sudomotor function, and qsart can serve as a good technique to differentiate between crps type i and ii. it is estimated that there are two distinct pathogenesis in crps. our results may be helpful to diagnose crps correctly and understand the pathogenesis of crps. sjogren syndrome (ss) is an autoimmune inflammatory disorder of exocrine glands resulting in xerophthalmia and xerostomia. ross syndrome is a rare entity characterized by tonic pupil, hyporeflexia, and segmental anhidrosis. we present a 33-year-old hispanic woman with debilitating sensory and autonomic neuropathies, and persistently elevated anti-ss-a and anti-ss-b antibodies, without the classic sicca complex. she initially developed diarrhea and an ear infection, then felt toe and later leg numbness, which eventually spread to her cheeks and tongue, over few months. four years later, her thumbs and index fingers started tingling. also, she developed orthostatic lightheadedness, tachycardia, segmental hypohidrosis of the right abdomen, and hyperhidrosis of the remaining trunk, intermittent erythema, chronic diarrhea, and a 40-pound weight loss. her exam demonstrated orthostatic hypotension, bilateral tonic pupils and light-near dissociation, sectoral palsy of the right iris sphincter, stocking-distribution diminished sensation to all modalities, pseudoathetosis, areflexia, dysmetria, intention tremor, romberg, and sensory gait ataxia. mri of neuraxis demonstrated t2-weighted hyperintensity in the dorsal spinal cord from c4 to the lower thoracic level, with mild atrophy. electrodiagnostic testing was consistent with moderate-to-severe, length-dependent, asymmetric, sensory polyganglionopathies. csf showed 6 oligoclonal bands. serology showed elevated antinuclear antibody (1:1280, reference < 1:40), ss-a (148, reference < 20 u), ss-b (79, reference < 20 u), and rheumatoid factor (24, reference < 14 iu/ml) titers. the remaining workup was negative for infection (syphilis, hiv, htlv, hepatitis, lyme disease), paraneoplastic syndrome (anti-hu and ganglionic nicotinic acetylcholine receptor antibodies), pyridoxine intoxication, malignancy (chest/abdomen/pelvis ct, breast ultrasound, axillary lymph node flow cytometry, colon and esophagus biopsy), celiac disease, vitamin deficiency, autoimmune disease (anti-aquaporin 4 and anti-gq1b antibodies), and adrenoleukodystrophy. the patient received ivig and steroid with some gait improvement and currently takes mycophenolate. midodrine and fludrocortisone resolved her dizziness. this case highlights an important, treatable sensory ganglionopathy and systemic autonomic neuropathy due to sjogren syndrome, and illustrates the overlapping clinical triad of ross syndrome, which may guide future management. siles am 1,2 , assylbekova d 1,2 , diaz-manera j 1,2 , rojas-garcia r 1,2 , cortes e 1,2 , gallardo e 1,2 , illa i 1,2 , querol l 1,2 . 1 neuromuscular diseases unit, neurology department, hospital de la santa creu i sant pau, univeristat autònoma de barcelona, barcelona, spain; 2 centro para la investigación biomédica en red en enfermedades raras (ciberer), madrid, spain. inflammatory neuropathies are a heterogeneous group of peripheral nerve diseases that respond to immune-therapies. chronic inflammatory polyradiculoneuropathy (cidp) and multifocal motor neuropathy (mmn) are two chronic inflammatory neuropathies responding to intravenous immunoglobulins (ivig). b lymphocytes are involved in their pathogenesis. while widely used in clinical practice, ivig's mechanism(s) remain not completely understood. ivig are reported to lead to b-cell anergy and to increase regulatory t-cell function and frequency. regulatory b cells (bregs) are a rare subset of b lymphocytes that suppress immunopathology acting upon several target cells in the immune system. impaired breg yields have been described in a plethora of autoimmune conditions. the presence of regulatory b cells in inflammatory neuropathies and the effect of ivig therapy on their frequencies has not been studied. the aim of this study is to describe the frequencies of bregs in cidp and mmn and the effect of ivig on their frequencies. patients fulfilling diagnostic criteria for cidp or mmn and 14 matching controls were included. pbmcs were obtained by gradient centrifugation before ivig infusion and one week after treatment. b-cells were isolated with negative selection magnetic beads, cultured and activated with the tlr9 agonist odn and anti-human igg+iga+igm. il-10 secretion capacity was assessed by flow-cytometry. twenty-eight patients were included of whom 20 where cidp and 8 mmn. of all patients included, 16 received ivig and were suitable for pre and post ivig breg frequency comparisons. breg frequencies did not differ in patients (before ivig treatment) and controls (p= 0.8518, mann whitney test, two-tailed). however, the frequencies of bregs significantly increased one-week after treatment with ivig (p=0.0121, wilcoxon matched pairs test, two-tailed). when stratifying by disease subtype, breg frequencies increased in cidp patients after ivig (p=0.0391, wilcoxon matched pairs test, two-tailed) and in mmn (p=0.1563, wilcoxon matched pairs test, two-tailed) although results did not reach statistical significance in mmn. this is the first study that studies the breg frequencies in cidp and the first study that addresses the effect of ivig on breg frequencies. our study provides the proof of principle that bregs could become a biomarker for response to ivig but this would need a larger and prospective study. siles am 1,2 , martínez-hernández e 3 , diaz-manera j 1,2 , rojas-garcia r 1,2 , gallardo e 1,2 , illa i 1,2 , graus f 3 , querol l 1,2 . paraneoplastic neuropathies (pn) are rare, immune-mediated disorders of the peripheral nerve with important prognostic implications. ectopical expression of neural antigens in the tumor leads to the development of onconeural antibodies. several autoantibodies associate to pn, including anti-hu, anti-caspr2 or anti-cv2 antibodies but a significant proportion of pn lack identifiable antigens. adhesion molecules that are autoantigens in other neuropathies, like contactin-1, are present in several types of tumors. our study proposes a systematic screening of autoantibodies against neural cell-adhesion molecules and neural structures to detect novel antigenic reactivies in pn. thirty-five patients followed in our centre and at the neuroimmunology-multiple sclerosis unit at hospital clínic de barcelona, with pn fulfilling diagnostic criteria of possible (n=8; 22.9%) and definite (n=27; 77.1%) paraneoplastic disease were included. serum samples were obtained and tested by immunocytochemistry against contactin-1 (cntnt1), neurofascin 155 (nf155) and the cntn1/caspr1 complex. primary cultures of dorsal-root ganglia (drg) and rat schwann cells were incubated with patients' sera to detect antibodies targeting neural structures. ten individuals (28.6%) presented with a tumor and a neuropathy involving both sensory and motor symptoms. the remaining 25 patients (71.4%) presented with a tumor and a classical sensory neuronopathy without anti-hu or any other onconeuronal antibody. among the latter, 8 (22.9%) patients were diagnosed with small-cell lung carcinoma. the rest of the 27 individuals (77.1%) associated diverse malignancies. we did not detect any sera reacting against cntn1, nf155 or the cntn1/caspr1 complex. in igg antibody screening experiments, 12 patients (34.3%) reacted against drg neurons, 3 of them (8.6%) reacting strongly, and 3 patients (8.6%) reacted mildly against rat schwann cells. in igm experiments, 5 patients (14.3%) reacted slightly against drg neurons and 11 patients (31.4%) against rat schwann cells, 4 of them (11.4%) featuring strong staining. experiments screening antibodies against motor neurons and immunoprecipitation assays are ongoing. overall, 20% of patients reacted strongly against either neurons or schwann cells. our study did not detect antibodies against the neural adhesion molecules cntn1, nf155 and the cntn1/caspr1 complex in patients with pn. however, a significant proportion of pn patients harbour antibodies targeting neural structures, which suggests that novel neoplasm-associated antigens remain to be discovered. simmons m 1 , tao f 2 , abreu l 2 , zuchner s 2 , li j 1 . 1 department of neurology, vanderbilt university school of medicine, nashville, tennessee, usa; 2 hussman institute for human genomics, university of miami, miami, florida, usa. objective: despite of a shared genetic mutation of the trisomy of chromosome 17p12 (c17p12), patients with charcot-marie-tooth type-1a (cmt1a) present with a high variability of their disease severities. the underlying cause for the variability is still unclear. in this study, we tested a hypothesis whether a second genetic mutation known to damage the nervous system is also present in cmt1a patients with early onset and severe phenotypes. methods: from a cohort of 72 patients with cmt1a mutation (chromosome 17p12 duplication), we identified 11 patients with an early onset (< or = 5 years of age) of the disease. four of the eleven also had dna testing for a panel of 50 known cmt-related genes and sequencing of mitochondrial dna in addition to the dna testing for c17p12 duplication. results: besides the c17p12 duplication, we identified three additional mutations in the four patients with early onset. the mutations were a missense mutation of arg67his in mpz gene, an a10044g mutation in mitochondrial trna for glycin and a homozygous mutation of c17p12 duplication. three of the four had symptomatic onset at birth. one showed symptoms at 3 years of age. conduction velocities were severely reduced in all four patients (from 15 to 6m/s). interpretation: traditional approaches to identify genetic modifiers, including snp association, assume that those modifiers are clustered in a small region of human genome and shared by the studied patients. however, our study suggests that genetic modifiers in cmt1a may be highly diverse and scattered throughout the genome, which could make the conventional approach via the genetic variants association difficult. supported by grants from ninds (r01ns066927) and the national center for advancing translational sciences (ul1tr000445 sjogren's syndrome(ss) is a systemic auto-immune disease that apart from exocrine glands may affect any organ. involvement of peripheral nervous system results in wide spectrum of neuropathic manifestations. the aim of our study was to evaluate the clinico-electrophysiological patterns and pathological characteristics of neuropathy in sjogren's syndrome (ss) patients presented to neuromuscular clinic in a tertiary hospital from south india. this is a retrospective study from the departments of neurology, rheumatology and pathology from nizam's institute of medical sciences. twenty one patients with diagnosis of ss and peripheral neuropathy between 2010 to 2016 were analysed. clinical records, conventional nerve conduction studies, lip and nerve biopsy reports were collected.in 21 patients with ss associated neuropathy,male to female ratio was 2:1. in 14(66.7%) neuropathy was the initial manifestation,while in 4(20%)exocrinopathy preceded neuropathy. the patterns of neuropathy included mononeuropathy multiplex(mnm) in 7 patients (30%),ganglionopathy in 4 (20%),length dependant, trigeminal, autonomic neuropathy and cidp in 2(10%)and cranial neuropathy in 1(10%).eighteen(86%) were seropositive..schirmer's test was positive in 13(61.9%).nerve biopsy showed vasculitis in 5 patients, demyelinating and axonopathy in 2 patients each.we conclude that neuropathy is frequently the initial presentation of ss.mnm is the common pattern followed by ganglionopathy. pattern of neuropathy helps in arriving at the diagnosis of ss. confirmation of ss is not by mere serology. schirmer's test and lip biopsy are equally essential for the diagnosis especially in seronegative patients when clinical index of suspicion is high. siskind ce 1 , tesi rocha c 2 . 1 stanford health care, palo alto, ca, usa; 2 stanford university, stanford, ca, usa. here, we report the first case of a human found to have a homozygous, presumed disease causing variant in the arl6ip1 gene, causing charcot marie tooth disease (cmt) with central nervous system findings. the proband was born at term with apgars of 3 and 9 at 1 and 3 minutes. he was found to have iugr and was hospitalized for 9 days for weight gain. he developed respiratory distress during the admission and was intubated. due to inability to extubate, he was transferred to stanford children's hospital, where he remained for three months. noted during admission was hypotonia, areflexia, minimal voluntary movment, sinus tachycardia, and dysautonomia. brain mri found polymicrogyria and cerebral underdevelopment with generally normal-appearing brainstem, with moderate ventriculomegaly. ncs found length dependent polyneuropathy with axonal degeneration. follow up muscle and nerve biopsy found immature muscle and amyelinating neuropathy the patient had normal plasma amino acid, acylcarnitine, lactate, pyruvate, urine organic acid testing, opththalmology exam, newborn screen, and normal array cgh. genetics ordered whole exome sequencing through baylor genetics laboratory (houston, tx, usa), which found a homozygous nonsense variant in arl6ip1 : c.346c>t, p.r116x. a second child had been identified by baylor with two variants in this gene. that child had hypotonia, respiratory distress and seizures, and a muscle biopsy consistent with sma. the parents of that child chose to withdraw care at 3 months of age. our patient's parents continued with aggressive therapies, including tracheostomy and g-tube for feedings. he had several subsequent hospitalizations for respiratory distress, possible seizure activity, and buldging anterior fontenelle, but now, at two years of age, has made developmental progress and is living at home with his family. he is able to smile, reaching for toys and swatting objects. he has little voluntary movement, and no longer responds to light touch stimuli. overall, this is the first picture of a child affected with a severe amyelinating form of cmt that causes weakness, hypotonia, and possible seizures, with the main concerning feature being the severe respiratory distress that may be life threatening, but can be managed with extreme care. charcot marie tooth (cmt) disease is the most common inherited peripheral neuropathy. patients frequently ask whether pregnancy will affect their cmt, whether cmt will affect their pregnancy, the optimal delivery and whether they or their child will have a higher risk of complications during pregnancy or delivery. so far few studies address these questions. currently no guidelines exist for the management of pregnancy, delivery and postnatal care in cmt patients. the aim of the study is assess the impact of pregnancy on cmt and assess how cmt affects pregnancy, delivery and care of the new born baby. we designed a retrospective questionnaire with expert help from an obstetrician with a special interest in pregnancy in patients with medical conditions. the questionnaire is divided into four parts (prior, during, after pregnancy and delivery) and includes 29 questions on impairment, falls, pain, fatigue and respiratory complications during those periods; type of delivery, possible complications, details of anaesthesia and difficulties looking after the baby in the first months postpartum. so far 48 women (85 pregnancies) with cmt and related disorders have answered the questionnaire. 50% of patients had cmt1a, the remaining had various subtypes of cmt and related disorders. patients reported deterioration of cmt symptoms during pregnancy in 34% of pregnancies with resolution of symptoms after pregnancy in 52% of pregnancies. of symptoms questioned walking (29%), balance (28%), and hand function (17%) deteriorated the most. there was an increased use of orthoses and walking aids during pregnancy. the majority of women (59%) had natural delivery, 17% were assisted and 28% had caesarian sections which was similar to the uk population (26%). no complications with anaesthesia were reported. the survey is currently ongoing. we plan to survey 100 consecutive patients. data acquired from this survey will provide valuable information on current practice and will inform future guidelines and standard of care in charcot marie tooth disease. multifocal motor neuropathy (mmn) is a slowly progressive disorder in adults, characterized by asymmetrical limb weakness, mainly affecting the arms. despite beneficial effect of immunoglobulins, weakness gradually progresses. a major determinant of muscle weakness is the degeneration of affected motor axons. treatments aiming to reduce loss of motor axons require objective tools to quantify such an effect. therefore, we applied the compound muscle action potential (cmap) scan, which is an electrophysiological method that, with increasing transcutaneous stimulus-currents, successively activates all motor units (mus) in a muscle. it captures the contribution of enlarged mus due to reinnervation by the presence of relative large discontinuities in the scan. the aim of the present study was to identify pathophysiological changes of mu-loss and reinnervation in mmn patients by means of the cmap-scan. recordings were obtained from 12 mmn patients. cmap-scan recordings were performed in the median nerve at the wrist where motor responses were recorded from the thenar muscle. we determined the number of largest cmap-scan discontinuities by means of a novel marker, d50, where a low number is indicative of mu-loss and enlarged mus. furthermore, we applied the recently developed method of professor hugh bostock for obtaining a mu-number estimate from the cmap-scan. the median peak cmap amplitude was 7.6 mv (range 3.2 -12.1 mv) and median d50 was 43 (range 12 -54). in three mmn patients with a normal maximum cmap amplitude (>5 mv) a reduced d50 (<25) was found indicative of mu-loss and enlarged mus. furthermore, d50 and the estimate of mu number were significantly related (r = 0.85, p < 0.001, n = 12). the findings suggest that the cmap-scan is a sensitive tool in detecting the underlying pathological changes of reinnervation and mu-loss in mmn, more so than standard maximum cmap amplitude. it is quick and easy to perform and has the potential to be useful for follow-up studies. smith ag 1 , thurgood b 1 , revere c 1 , hauer p 1 , aperghis a 1 , singleton jr 1 . 1 university of utah, salt lake city, utah, usa. corneal confocal microscopy (ccm) directly and quantitatively assesses corneal innervation including nerve fiber length (nfl) and density (nfd). ccm has shown promise as a diagnostic test. we have previously demonstrated that ccm has a diagnostic performance for diabetic neuropathy (dpn) similar to skin biopsy with assessment of intraepidermal nerve fiber density (ienfd) and nerve conduction studies (ncs). the responsiveness of these surrogate measures to dpn progression and their relation to clinically meaningful outcomes has not been well explored. 144 diabetic patients undergoing annual retinopathy examination were recruited. each underwent ccm, ienfd, ncs including sural sensory and peroneal motor responses, the utah early neuropathy score (uens), the norfolk quality of life -diabetic neuropathy (nqol-dn, a validated neuropathy specific qol scale), and a 6 minute walk test (6mwt). 55 with dpn based on symptoms (82%) or signs underwent repeat testing at 9 months and 35 at 18 months. at baseline, nqol-dn correlated with sural sensory amplitude (ssa) (−0.295, p<0.0004), peroneal motor conduction velocity (pcv) (−0.466, p<0.0003) and ienfd (−0.317, p<0.001). no ccm metric was related to qol. 6mwt distance correlated with ssa (0.320, p<0.0002), nfl (0.250, p<0.0038) and nfd (0.217, p<0.0124). over 18 months, there was a significant worsening in dpn signs assessed by the uens (increase 1.43 +/− 0.65, p<0.037). ssa declined 0.78 uv (p<0.079) and ienfd 1.8 fibers/mm (p<0.063). there was no change in any ccm metric, pcv or nqol-dn. these findings suggest measures of distal axonal integrity are most sensitive to neuropathy progression, with ienfd having the greatest responsiveness. in contrast, ccm was not responsive to dpn progression. both ncs and ienfd (but not ccm) were significantly correlated with neuropathy-specific qol, whereas ncs and ccm measures correlated with physical functioning. the responsiveness of ienfd and ssa, and their relationship to qol support their selection as endpoints in dpn clinical trials. chronic inflammatory demyelination polyradiculoneuropathy (cidp) affects 1 in 10,000 people, and is marked by chronic autoimmune infiltration of peripheral nerves and destruction of the myelin sheath. with current therapies, only 26% of cidp patients achieve complete remission. to produce more effective, mechanism-based therapies, we study mice with a partial loss of function g228w substitution in the autoimmune regulator (aire) gene on the non-obese diabetic (nod) background (nod.aire gw/+ ) that develop spontaneous autoimmune peripheral polyneuropathy (sapp) resembling cidp. autoimmunity can result from defective immunosuppression. the potent, immunosuppressive cytokine interleukin 10 (il-10) is increased in the peripheral blood mononuclear cells (pbmcs) of active phase cidp patients relative to remission phase patients. further, pbmcs from cidp patients produce il-10 in response to the myelin protein p2. despite these findings, whether il-10 is important for cidp pathogenesis is not known. thus, we sought to determine the role of il-10 in sapp. il-10 was highly upregulated in sciatic nerves of nod.aire gw/+ mice with sapp, suggesting it may play an immunosuppressive role in pathogenesis. however, genetic ablation of il-10 in nod.aire gw/+ mice lead to a paradoxical delay in disease development. age-matched il-10-deficient nod.aire gw/+ mice exhibited no sciatic nerve infiltrate and no reduction in nerve conduction during electrodiagnostic studies. interestingly, the delay in sapp was specific, since the incidences of five other autoimmune manifestations in il-10-deficient nod.aire gw/+ mice were unchanged relative to il-10-sufficient nod.aire gw/+ controls. importantly, il-10-deficient nod.aire gw/+ mice did not have colitis, which is consistent with previous studies of il-10 deficiency on the nod background. il-10 is known to perform effector functions in autoimmunity by promoting b cell secretion of immunoglobulins. however, genetic ablation of b cells did not affect neuropathy development in nod.aire gw/+ mice, suggesting b cells are dispensable for pathogenesis and unlikely to mediate the protective effect of il-10 deficiency. il-10-deficient nod.aire gw/+ cd4+ t cells, which are sufficient to transfer sapp, exhibited increased activation, increased interferon gamma secretion, and preserved nerve-specific t cell activation. these data suggest t cell activation and priming are unperturbed and not the mechanism of protection. in summary, our data showed that il-10 was paradoxically an effector cytokine in sapp. long exercise test (let) has been used especially in myotonic syndromes and muscle channelopathies. marked decrement in compound muscle action potential (cmap) amplitude after prolonged exercise was previously reported in patients with paramyotonia congenita, hyperkalemic or hypokalemic periodic paralysis. we describe a patient with secondary hypokalemic paralysis who showed abnormal let results. a 43-year-old man presented with ascending flaccid paralysis which evolved in a hyperacute fashion. the patient became quadriplegic after two hours. initial laboratory evaluation revealed severe hypokalemia, with normal thyroid function. we performed electrodiagnostic studies including long exercise test as proposed by mcmanis et al. nerve conduction study was normal, but marked decrement in cmap amplitude (up to 60% decrease after 10 minutes) was noted after prolonged exercise. despite oral and intravenous potassium replacement, serum potassium level was not corrected as expected. the unusual clinical course prompted for evaluation of secondary etiologies. abdomen computed tomography scan revealed a 1.5 x 1.0 cm-sized mass in the left adrenal gland. aldosterone to renin ratio was elevated, suggestive of primary hyperaldosteronism. genetic study for cacna1s mutation turned negative. after receiving laparoscopic adrenalectomy, the patient experienced no further attacks, and also was able to stop his antihypertensive medication. let may show abnormal results in condition with reduced membrane excitability, even without true channelopathy. according to international criteria, the diagnosis small fiber neuropathy (sfn) is based on clinical symptoms in combination with a reduced intraepidermal nerve fiber density (ienfd) in skin biopsy and/or abnormal temperature threshold testing (ttt). the sensitivity of skin biopsy is moderate to good, although ienfd is normal in about 67% of patients with sfn complaints. furthermore, ttt is a widely available diagnostic tool, but lacks specificity. corneal confocal microscopy (ccm) has been described and is used in clinical practice as an objective, non-invasive diagnostic tool to detect small nerve fiber damage in patients with diabetes mellitus. this study examines the applicability of ccm in patients with sfn, and the value of ccm as an additional diagnostic tool in sfn. we will include 20 healthy participants to compare the results with the recently published ccm normative values, and 200 patients referred to the sfn center maastricht with the clinical picture of sfn. corneal nerve fiber density (cnfd), branch density (cnbd), fiber length (cnfl), and the tortuosity coefficient (cnft) will be determined in all participants. the results will be compared with the ienfd and ttt. preliminary results will be presented. southanalinh k 1 , 1 university of health sciences, vientiane capital, lao p.d.r. located in south east asia, lao pdr is a landlocked country with a population of about 6.8 million inhabitants. the health indicators are among the lowest in south east asia. the total health caregivers in 2014 consisted of 14,964 persons corresponding to a ratio of 2.2 health workers per 1000 inhabitants. the main network for health care service provision remains the public system. its health care facilities consist of four central teaching and referral hospitals; five regional hospitals, including one teaching hospital; 13 provincial hospitals; 135 district hospitals, and about 970 health centers. only one in seven sick people receives modern health care treatment. most people rely on self-medication and/or reliance on self-healing. neurological care is a very new field. knowledge of common neurological disorders among both the lao population and medical staff is only beginning to be spread. there are three neurologists in the country. six neurology residents are currently being trained in a three-year program supported by the association pour la promotion des neuro-sciences au laos (association for the promotion of neuro-sciences in laos) and the asean neurological association. indeed, resources are scarce. in the peripheral nerve diseases domain for example, we have only one electromyography machine that was only temporary used when emg experts from france and from singapore came to teach residents. a significant mismatch between the provision of specialized neurologic services and the needs for them exists, especially in rural areas. also, health insurance is not available for the majority. as a consequence, patients have to bear the costs themselves, which constitutes a limit to the access of available healthcare facilities. neurologic training centers, laboratory facilities and equipments are limited. optimizing available human resources, integrating primary, secondary, and tertiary healthcare tiers and making medical treatment more affordable are need to improve neurologic care in the developing world. in certain low-income countries with limited human and financial resources, it may be difficult for governments to apply some of these recommendations on their own. in these circumstances, it is suggested that countries work with international agencies, nongovernmental organizations or other partners to put their plans into practice. spina e 1 , topa a 1 , iodice r 1 , tozza s 1 , dubbioso r 1 , ruggiero l 1 , santoro l 1 , manganelli f 1 . 1 department of neuroscience, odontostomatological and reproductive sciences, university of naples "federico ii", naples, italy. chronic inflammatory demyelinating polyradiculoneuropathy (cidp) is a disabling disease and about 10% of patients may become persistently disabled over time. our aim was identify clinical prognostic factors of long-term disability in a large series of cidp patients. we collected data from 50 cidp patients with definite diagnosis according efns/pns criteria and positive response to first-line therapies (immunoglobulin or corticosteroids) including sex, age of onset, phenotype, disease duration, course of disease (monophasic/relapsing-remitting or chronic progressive) and disability at the time of diagnosis assessed using the modified rankin scale (baseline mrs). all patients had clinical assessment of disability through mrs within the last 6 months (last mrs). ordinal logistic regression model was applied to evaluate the relationship among the clinical parameters and last mrs, considered as ordinal outcome (0-6). anova test for repeated measures was applied to test the overall effects of different course on disability accumulation while t-test was performed to evaluate inter-group differences for parametric variables. we found a significant relationship between last mrs and the course of disease [p<0.000, z=4.05, or: 14.91]. disability accumulation was greater in patients with chronic progressive course than those with monophasic/relapsing-remitting course of disease [p=0.04]. moreover, patients with progressive course were older [p=0.01]. our data suggest that chronic progressive course of disease may be a major negative prognostic factor for long-term disability in cidp patients. to note that a chronic progressive course of disease is also associated with an older age from the beginning and a more pronounced worsening over the course of disease. sprenger a 1 , lichtenstein t 2 , henning t 2 , lehmann hc 3 . 1 department of neurology, university hospital of cologne, cologne, germany; 2 institute of diagnostic and interventional radiology, university hospital of cologne, cologne, germany; 3 department of neurology, university hospital of cologne, cologne, germany. an unresolved problem in the treatment of inflammatory neuropathies is the lack of valid and reliable diagnostic biomarkers to evaluate axonal damage. we investigated if "diffusion tensor imaging" (dti) and mri t1w multi echo dixon imaging are eligible methods to determine proximal nerve injury in chronic inflammatory demyelinating polyneuropathy (cidp). in this prospective observational cohort study the sciatic nerve of 11 cidp patients and 11 age matched healthy controls was investigated. all subjects underwent multimodal mri imaging to determine fractional anisotropy (fa) and muscle fat fraction of the biceps femoris and quadriceps femoris muscle. patients were evaluated by mri, clinical examination and nerve conduction studies at baseline and after six months. the mean fractional anisotropy (fa) value was significantly lower in the sciatic nerve from cidp patients compared to controls. fat fraction of the biceps femoris and quadriceps femoris muscle were significantly higher in cidp patients compared to controls. mri outcome parameters remained unchanged after six months. our study demonstrates the utility of mri imaging to differentiate between "healthy" and functional constricted proximal nerve segments. we postulate that dti and dixon mri might be eligible methods to assess proximal nerve damage in cidp. the presence of peripheral myelin protein 2 (pmp2) has been known for decades, but its functional role was uncovered only recently. recent characterization of pmp2-deficient mice revealed a role of pmp2 in the lipid homeostasis of myelinating schwann cells. in this study, we analyzed the functional impact of pmp2 on myelination. to decipher the role of pmp2, experimental demyelination was performed in myelinating dorsal root ganglia cultures, and in vivo re-myelination was assessed after experimental peripheral nerve damage. we used the myelinating dorsal root ganglia (drg) model in pmp2-deficient schwann cell cultures, combined with an established de-and remyelinating protocol in order to analyze myelination in vitro. we also performed experimental nerve crush in pmp2-deficient mice. morphometric parameters were defined for the in-vitro experiments and functional parameters such as nerve conduction velocity and the clinical score were additionally measured for the in vivo experiments. structural analyses of the drg cultures revealed fibers expressing myelin basic protein (mbp) and pmp2, as well as fibers positive for mbp alone. in contrast to our previous in vivo data, we were also able to detect myelin segments that stained positive for pmp2, but were negative for mbp. pmp2-deficient drg-cultures demonstrated slightly greater nodal lengths than the control cultures. this trend was significantly augmented after in vitro de-and remyelination, which also resulted in decreased internodal lengths only now, while conserving an intact myelin structure. concomitantly, in vivo nerve crush gives rise to a more severe phenotype in pmp2-deficient mice than in wild-type controls. consistent with this, nerve conduction studies showed a delay in remyelination, and analysis of semi-thin sections demonstrated an altered fiber structure in the peripheral nerve biopsies. together, these data suggest that in addition to its role in glial cell lipid homeostasis, pmp2 also plays a role in remyelination of the injured peripheral nervous system. anti-mag neuropathy remains a difficult diagnosis to treat given its limited therapeutic options. of all interventions, rituximab has emerged as the most effective, although its effect has been with mixed results, especially in patients with advanced axonal loss. lenalidomide is another promising immune modulating therapy, whose effect has been well demonstrated in neuropathy associated with poems (polyneuropathy, endocrinopathy, organomegaly, m-spike protein, and skin changes) syndrome, a condition that has several striking parallels to anti-mag neuropathy. the use of lenalidomide has not been previously described in anti-mag neuropathy. herein, we describe a case of lenalidomide-responsive anti-mag neuropathy in a patient with advanced axonal loss. suichi t 1 , misawa s 1 , sato y 2 , beppu m 1 , sekiguchi y 1 , shibuya k 1 , watanabe k 1 , amino h 1 , kuwabara s 1 . 1 department of neurology, graduate school of medicine, chiba university, chiba, japan; 2 clinical research center, chiba university hospital, chiba, japan. polyneuropathy, organomegaly, endocrinopathy, m-protein, and skin changes (poems) syndrome is a rare cause of demyelinating neuropathy associated with plasma cell dyscrasia and vegf overproduction. several diagnostic criteria for the disorder have been published, but sensitivity/specificity analyses, and their validation have never been performed. the aim of this study is to establish valid diagnostic criteria for poems syndrome. 104 consecutive poems patients, seen at chiba university hospital since 2000, were screened. of these, we have set a gold standard group of poems syndrome, based on treatment response and exclusion criteria during 1-year follow-up, and 66 patients was diagnosed as having definite poems syndrome. we also collected 30 patients with cidp (demyelinating neuropathy control) and 30 with multiple myeloma, primary amyloidosis, or mgus (m-protein control). criteria for poems syndrome was defined as having two of the three major criteria (polyneuropathy, m-protein, and elevated serum vegf level) and at least two of the four minor criteria (extravascular volume overload, skin changes, sclerotic bone lesions, and thrombocytosis) which were determined by logistic regression analyses. according to the criteria the sensitivity was 99%, and the specificity was 100%. our results indicate that the proposed criteria have an excellent diagnostic accuracy, and are useful in clinical practice, presumably leading to early diagnosis and treatment. intraepidermal electrical stimulation (ies) is a new technique to that assesses the function of a-delta fibers in the epidermis. using this technique, we previously reported that the epidermal pain threshold was two-hold in asymptomatic diabetic patients than in normal subjects (muscle nerve 54: 146-149, 2016 ). subsequently, we reported that the elevated pain threshold negatively correlated with intraepidermal nerve fiver density (jpns 18: s112, 2013). empirically, it is known that lowering the skin temperature makes it less likely to feel pain. therefore, it is necessary to investigate whether the results of ies are affected by skin temperature. the aim of this study was to investigate the influence of a low skin temperature on pain threshold. we recruited 10 subjects with a mean age of 54.6 years. for nociceptive stimulation, we used an ies method with a concentric micro-needle electrode that was developed specifically for the selective stimulation of cutaneous a-delta fibers. we placed the ies electrode onto the extensor digitorum brevis and began stimulation with intensity strong enough for the subject to feel a pricking sensation, then reduced the current in steps of 0.01ma until no sensation was felt. we defined pain threshold as the minimum electrical intensity at which a subject felt a pricking sensation. firstly, we measured pain threshold at skin temperature above 35 degrees celsius. then, we put an ice pack on the extensor digitorum brevis for 10 min to lower the skin temperature, and measured pain threshold at skin temperatures below 33 degrees. mean pain threshold values above 35 degrees and below 33 degrees of skin temperature were 0.102 and 0.33 ma (p<0.05), respectively. our data indicated an elevated pain threshold in epidermis with a low skin temperature. one of most common methods for nociceptive stimulation is painful co2 laser stimulation. some co2 laser stimulation studies reported pain threshold increased with a low skin temperature. our result is similar to that of co2 laser stimulation. pain threshold using ies is very easy and non-invasive technique. it may be useful for the evaluation of small fiber neuropathy. svačina mkr 1 , röth p 1 , bobylev i 1 , sprenger a 1 , zhang g 2 , sheikh ka 2 , lehmann hc 1 . 1 department of neurology, university hospital cologne, cologne, germany; 2 department of neurology, university of texas, houston, usa. intravenous immunoglobulins (ivig) are an effective treatment in guillain-barré-syndrome (gbs). in most patients, the optimal ivig dose and regime is unknown. in serum and ivig preparations, immunoglobulin (ig) g form igg dimers, which are assumed to consist of idiotypic/anti-idiotypic antibody pairs. however, data about kinetics of igg dimer formation in gbs are lacking. to study igg dimer formation, c57bl/6 mice were injected with ivig and anti-gd1b antibody or pbs. blood sera were collected 24h, 48h and 1 week post injection. a third cohort received an anti-gd1a/gt1b antibody and blood was collected 48h post injection. igg was extracted and subtyped into polymeric, dimeric and monomeric fractions using the äkta fplc system. dialysed dimeric and monomeric igg fractions were examined for the presence of anti-ganglioside antibodies by anti-ganglioside antibody elisa. further, blood samples from 10 gbs patients were collected before (pre-ivig) and after treatment with ivig (post ivig). serum samples were examined for igg dimers and monomers using the äkta fplc system. in the mouse model, a maximum peak of igg dimer formation was observed 48h post injection. in gbs patients' samples, igg serum levels and igg dimer content was significantly higher after treatment with ivig. we demonstrate here the feasibility to assess igg dimer formation in an animal model and in gbs patients' samples after treatment with ivig. 48h after ivig treatment appears to be the optimal time point to assess igg dimer formation. further studies are warranted to determine the utility of igg dimer formation as surrogate marker for treatment response in gbs. svaren j 1 , moran jj 1 , wu x 2 , gutmann l 2 , shy m 2 . 1 university of wisconsin-madison, madison, wisconsin, usa; 2 university of iowa, iowa city, iowa, usa. development of outcome measures for clinical trials in cmt1a is a major challenge given the slowly progressive nature of the disease. outcome measures can be used to measure a) target engagement for a given therapy, as well as b) disease process and c) disease burden. several candidate therapies have been shown to reduce pmp22 levels in cmt1a rodent models and thereby ameliorate the symptoms of pmp22 overexpression. measuring pmp22 mrna reduction in human trials has so far been limited to analysis of skin biopsies by qrt-pcr, which did not demonstrate clear elevations of pmp22 mrna during, nor a reduction following, ascorbic acid trials. the analysis of skin biopsies is hampered by variable amounts of schwann cells (sc) in skin biopsies, as well as the variable amount of pmp22 in sc as previously established by immuno-em in cmt1a skin biopsies (katona et al., 2009) . therefore, it is important to develop optimal normalization criteria to address the variability inherent in skin biopsy analysis. ideally this will employ normalization to sc-specific genes that are not altered by cmt1a status. to optimize normalization, we have performed rna-seq analysis of skin biopsies from patient and control skin biopsy samples. analysis of these data after normalization to read depth indicated that pmp22 levels were 1.5 fold higher in cmt1a patient samples compared to control skin biopsies. however, there was significant variability in pmp22 levels particularly in cmt1a samples, which may be due to variable amounts of schwann cells in cmt1a skin. using a combination of sc-specific genes for normalization, we were able to reduce the apparent variability and optimize the differential levels between cmt1a and control skin biopsy samples. we also identified other sc-specific genes that were apparently induced in cmt1a skin biopsies relative to control. these studies provide a new framework for gene expression analysis in skin biopsies, enabling more precise evaluation of pmp22 levels in clinical trials for cmt1a as a measure of target engagement. in addition, the normalization framework may also be applicable to other types of cmt. chronic inflammatory demyelinating polyneuropathy (cidp) is the most common chronic autoimmune neuropathy, with an estimated prevalence of between 1 and 9 per 100,000 people. it can cause temporary disability in the affected individuals and may eventually lead to permanent disability or death. cidp is commonly treated with intravenous immunoglobulin (ivig) therapy or corticosteroids. octagam ® 5% is licensed for cidp in france, while octagam ® 10% is licensed for cidp in germany and belgium. this analysis presents data from three open, multicenter, non-interventional, single-arm, non-controlled studies of a post-authorisation safety surveillance (pass) program for the subset of patients receiving octagam ® 5% or 10% for neurological indications, focusing on patients with cidp. briefly, data from in-and out-patients in austria, france, germany, and uk treated with octagam ® for neurological disorders were collected by physicians and analyzed to assess safety and tolerability of the treatment. of 2314 patients included in the three studies, 260 patients (11.2%) received octagam ® for neurological indications, of which 58 patients (22.3%; mean age 64.6 years [range 18-88]) had cidp. the mean dose of octagam ® per course was 0.8 g/kg bw for patients with cidp; for the other neurologic indications, the dose ranged from 0.2 (for multiple sclerosis) to 1.4 g/kg bw (for guillain-barré syndrome). premedication was not needed in 84.3% of these patients. the development of clinical appearance since last observation (mean: every 9.7 months) was assessed for 41 of the 58 cidp patients by their treating physicians. the majority of observations (81.1%) assessed the patients as stable and 16.6% showed even an improved clinical appearance. only 2.3% of the observation periods resulted in deteriorations. adverse drug reactions were rare: of the 3374 infusions received by patients with neurological disorders, 0.44% of infusions were associated with an adr (0.61% of infusions in cidp patients). overall, treatment with octagam ® was effective and well-tolerated in patients with cidp. these results are consistent with data for the overall patient population (including patients with primary and secondary immunodeficiencies, dermatological and other diseases). szepanowski f 1 , szepanowski lp 1 , kleinschnitz c 1 , kieseier bc 2 , stettner m 1 . 1 department of neurology, medical faculty, university duisburg-essen, essen, germany; 2 department of neurology, medical faculty, heinrich-heine-university, düsseldorf, germany. lysophosphatidic acid (lpa) is a pleiotropic signaling lipid that acts as ligand for at least six specific g protein coupled receptors. schwann cells (sc) are known to mainly express the lpa 1 receptor subtype. an emerging body of in vivo evidence has linked lpa with injury induced peripheral nerve demyelination as well as neuropathic pain. however, the molecular mechanism underlying its demyelinating effect has remained largely unclear. myelinated dorsal root ganglia (drg) cultures were treated either with lpa, lpa + am095 (lpa 1 antagonist) or vehicle. we assessed myelin basic protein, tumor necrosis factor alpha (tnf-alpha) as well as the sc differentiation marker sox10 by immunocytochemistry. additionally, myelin was investigated by sudan black staining. to better understand the relevance of lpa 1 signaling for demyelination in vivo, we performed sciatic nerve crush in c57bl/6 mice treated with am095 at 10 mg/kg in order to study schwann cell expression of tnf-alpha, sox10 and sox2, a marker for sc dedifferentiation, by immunohistochemistry. in drg cultures, lpa caused a significant reduction of myelin as demonstrated by both sudan black staining and immunocytochemical analysis of myelin basic protein. demyelination was paralleled by an upregulation of tnf-alpha as well as downregulation of sox10. lpa mediated effects were found to be blocked by addition of the lpa 1 receptor antagonist am095. in c57bl/6 mice, am095 treatment prior to crush injury increased sox10 expression in scs in the distal nerve stump while reducing the number of cells expressing sox2. these data indicate that lpa may be a critical factor to shift scs towards an injury-associated phenotype and contribute to the onset of wallerian degeneration. szepanowski lp 1 , szepanowski f 1 , kleinschnitz c 1 , stettner m 1 . 1 department of neurology, university hospital essen, essen, germany. glyphosate-based formulations comprise the world's most commonly used herbicides. in non-resistant plants, glyphosate exerts toxic effects most likely via inhibition of aromatic amino acid synthesis by interfering with the shikimate pathway. while glyphosate is the active ingredient, herbicidal formulations contain several adjuvants, including polyethoxlated alkylamines (poeas). although glyphosate has long been considered safe for use in humans and animals, several studies have implicated glyphosate and/or the commonly used adjuvants in cytotoxicity, carcinogenicity and endocrine disruption. furthermore, glyphosate-based herbicide has been reported to mediate neurotoxicity in immature rat hippocampus involving glutamate excitotoxicity. however, it remains unclear whether glyphosate alone or in combination with its adjuvants may have detrimental effects on myelin integrity in the peripheral nervous system. myelinated dorsal root ganglia (drg) cultures were treated over the course of ten days with either pure glyphosate or a glyphosate-based herbicide at concentrations of 0.05 %, 0.005 % and 0.0005 %. the concentration of the glyphosate-based herbicide was matched with regard to glyphosate content (36 %). controls were treated with equal amounts of vehicle adjusted for the ph. subsequently, cultures were stained with sudan black and myelin content was assessed by determining the number of internodes per neurons. while glyphosate, regardless of its concentration, did not show any effect on myelin content, the glyphosate-based herbicide caused significant demyelination in a concentration-dependent manner. notably, at 0.05 %, drg cultures were completely devoid of myelin and appeared severely necrotic. these data raise the possibility that not glyphosate itself, but rather the adjuvants in glyphosate-based herbicide formulations may cause demyelination. the open question whether demyelination is a direct effect of the adjuvants or a consequence of increased cellular glyphosate uptake due to permeabilization warrants further investigation. tan cy 1 , tan mp 1 , yeoh ky 1 , goh kj 1 , shahrizaila n 1 . 1 department of medicine, university of malaya, kuala lumpur, malaysia. in guillain-barré syndrome (gbs), autonomic dysfunction is common and accounts for significant morbidity and mortality. there have been many studies investigating the electrodiagnosis of gbs but few have studied autonomic dysfunction in gbs. the current study comprehensively investigates quantitative autonomic function in patients with gbs and its variant. ten gbs patients were prospectively recruited and the results were compared to 10 age-and gender-matched healthy controls. a series of autonomic function tests including computational (power spectrum analysis of heart rate variability (hrv) and baroreflex sensitivity (brs) at rest) and challenge tests (deep breathing, eyeball compression, active standing, valsalva manoeuvre, isometric exercise and ice-water hand immersion) were performed. parasympathetic function was represented by high frequency (hf) hrv, heart rate responses to deep breathing, eyeball compression, valsalva manoeuvre and active standing. sympathetic function was represented by low frequency (lf) hrv, blood pressure responses to active standing, sustained handgrip and ice-water hand immersion. in the frequency domain analysis of hrv, low frequency (lf: 89.47±85.92 vs 226.97±158.16; p=0.027), high frequency (hf: 35.10±37.18 vs 158.11±140.97; p=0.008) and total power spectral densities (psd: 188.03±121.59 vs 532.71±359.57; p=0.015) were significantly reduced in patients compared to controls. the mean up slope (7.38±4.41 vs 11.86±5.53; p=0.034), down slope (7.32±4.53 vs 13.41±5.07; p=0.011) and total brs slope (7.32±4.37 vs 12.65±5.24; p=0.024) were significantly lower in the gbs group. the diastolic rise in blood pressure upon ice-water hand immersion was significantly lower in gbs group compared to controls (3.1±4.0 vs 14.0±11.3; p=0.008). our findings suggest that computation dependent tests (hrv and brs) were sensitive at detecting autonomic dysfunction and baroreceptor reflex insensitivity in gbs patients. in contrast, ice-water hand immersion was the only reliable challenge test making it useful as a bedside measure of autonomic function in gbs patients. sjögren's syndrome (ss) is an autoimmune disease that affects both east and west. nevertheless, we still have limited knowledge of how autoantibodies in ss affects the peripheral nervous system. in this study, we investigated the peripheral neuropathy in ss and sicca complex using the nerve excitability test, to elucidate how peripheral nerves are affected. we have enrolled a total of 22 patients with ss or sicca complex. of these, two patients were excluded due to co-morbid carpal tunnel syndrome. each patient received clinical evaluation, examination for ssa/ssb antibodies titer, the nerve excitability test, conventional thermal quantitative sensory test, and conventional nerve conduction study. compared to 33 normal control subjects, motor nerve excitability test of ss patients with positive ssa or ssb antibodies (n = 14) were found to have increased rheobase (p<0.05), increased relative refractory period (rrp) (p<0.01), increased refractoriness at 2.5 ms (p<0.01), increased accommodation toward depolarizing current in threshold electrotonus (te) (p<0.05), and decreased superexcitability (p< 0.05). the sensory axonal study in seropositive ss also revealed increased rrp (p<0.01), increased refractoriness at 2.5 ms (p<0.01), and increased accommodation toward hyperpolarizing current in threshold electrotonus (te) (p<0.05). meanwhile, in seronegative ss and sicca complex (n = 6), we found no significant axonal properties changes. the present study revealed that peripheral nerves are affected differently in seropositive ss and in seronegative ss/sicca complex. in seropositive ss, motor axons tended to be depolarized, and both sensory and motor axons have increased refractoriness. the findings suggested that ssa and ssb antibodies might play a role in the inactivation of transient sodium channels. the effects of the antibodies on transient sodium channels might be the basis of peripheral neuropathies and even cardiac arrhythmias and heart block in ss. charcot-marie-tooth disease type 1a (cmt1a), caused by the pmp22 duplication on chromosome 17p11.2, is the most common subtype of inherited peripheral neuropathies and affects 1 in 10,000 individuals worldwide. while sharing the same genetic cause, cmt1a patients often present great variability in their phenotypic presentation and disease severity. the cause of the phenotypic variability is largely unclear. in this study, we performed genome-wide association study (gwas) to identify novel genetic modifiers of various phenotypes in cmt1a. dna samples from 971 cmt1a patients were genotyped on illumina omniexpress platform. after standard quality control, the dataset includes 600k markers in 857 individuals (644 individuals from european ancestry, and 213 individuals from asian ancestry). we focused our analyses on the european population. logistic regression in plink was used to analyze the association between the clinical outcomes and patients' genotypes in an additive model. for cmt neuropathy score (cmtns), the analysis was performed using linear regression in plink, adjusting for patients' age. the analyses yielded several suggestive association signals. an association peak on chromosome 6 was identified in difficulty with eating utensils (lead snp rs12192704, chr6:30792270, p=1.15e-06, odds ratio=3.25). the peak is located within a non-coding gene linc00243. hearing loss showed an association peak on chromosome 5 (lead snp rs7720606, chr5:126551732, p=2.22e-07, odds ratio=3.457), located in an intergenic region near the megf10 gene. in foot plantar flexion, an association signal was identified in the dscam gene on chromosome 21 (lead snp rs2249498, chr21:41431874, p=5.13e-07, odds ratio=2.437). cmtns showed an association signal on chromosome 1 (lead snp rs12137595, chr1: 4094068, p=1.14e-07, beta=3.014), located within an intergenic region close to dffb, c1orf174, and linc01134. while these suggestive signals require further validation, our study provides novel insights into the genetic architecture of cmt1a. novel genetic modifiers may serve as potential targets for therapeutic interventions in the future. teng a 1 , ohnmar 2 , kalpana p 2 , chai yh 2 , umapathi t 2 . 1 yong loo lin school of medicine, national university of singapore, singapore; 2 department of neurology, national neuroscience institute, singapore. we present an intriguing diagnostic puzzle, that was eventually cracked serendipitously. a 50-year-old man was seen for bilateral ptosis. evaluation for myasthenia gravis was negative. nevertheless, a diagnosis of ocular myasthenia gravis was made and he was put on pyridostigmine. he did not respond. the ptosis progressively worsened. he sought a second opinion. at this evaluation, he was noted to have complex ophthalmoplegia without diplopia, bilateral facial weakness and mild bulbar weakness. he had no sensory complaints. the limb examination was remarkable for slightly reduced reflexes, normal strength, and other than increased vibration threshold at the toes, intact sensory examination. repeat serological and electrodiagnostic work-up for myasthenia gravis was negative. a myopathic disorder such as chronic progressive external ophthalmoplegia was considered. serum creatine kinase and lactate were normal. he underwent biceps muscle biopsy which showed increased cox-negative and sdh positive fibers, supporting the then clinical impression of a mitochondrial cytopathy. at this point, he underwent blepharoplasty to improve his vision. routine histological examination of the levator palpebrae muscle showed amyloid deposits. this prompted a review of the earlier biceps biopsy, which revealed amyloid deposits that were not appreciated before. at this point, the significance of the patient and his son's history of lattice corneal dystrophy became apparent. he also reported that his late mother had similar facial appearance as his. the patient's nerve conduction study showed length-dependent sensory axonal polyneuropathy, right carpal tunnel syndrome and bilateral facial neuropathy. he had no definite symptoms of autonomic neuropathy. cardiac evaluation was unremarkable. the final diagnosis of familial gelsolin amyloid polyneuropathy was made. genetic confirmation for the patient and his family is being planned. we highlight the key clinical features of gelsolin neuropathy. the symmetric cranial neuropathy can resemble a muscle or neuromuscular junction disorder and the relative sparing of the cardiac muscle, somatic and autonomic nerves contrasts with transthyretin-related amyloid polyneuropathy. neuropathy is one of the most common long-term complications of diabetes. furthermore, 25% to 50% of diabetic neuropathy patients will develop neuropathic pain. the pathophysiology of neuropathic pain in diabetic peripheral neuropathy is complex and not fully understood. a potential mechanism is a change in voltage gated sodium channels, such as nav1.7. loss of function mutations in this channel cause insensitivity to pain, whereas gain of function mutations have been linked with different pain syndromes including small fiber neuropathy. in a cohort of 190 patients with diabetic peripheral neuropathy we investigated whether mutations in nav1.7 were associated with diabetic neuropathic pain. twelve nav1.7 variants were identified in nine participants all within a cohort of 111 participants with painful diabetic peripheral neuropathy. five of these variants were previously associated with pain disorders: v991l, m932l; w1538r, r185h, l1267v. among the other variants two of them met the criteria of potential pathogenicity based on predictive algorithms and were further studied. functional analysis by whole cell patch clamp showed that one of these variants (m1852t) drastically impairs the inactivation of the channel by shifting the steady-state fast-inactivation towards more depolarizing potentials. there were no phenotypic difference between those participants with pathogenic variants and those participants without pathogenic variants. no rare nav1.7 variants were found in 79 participants with painless diabetic peripheral neuropathy. these observations suggest that mutations in nav1.7 may contribute to painful diabetic peripheral neuropathy. tholance y 1 , rosier c 1 , f bouhour 2 , psimaras d 3 , kuntzer t 4 , taieb g 5 , créange a 6 , delmont e 7 , camdessanché jp 1 , antoine jc 1 . 1 university hospital, saint-etienne, france; 2 university hospital, lyon, france; 3 university hospital, paris, france; 4 university hospital, lausanne, switzerland; 5 university hospital, montpellier, france; 6 university hospital, creteil, france; 7 university hospital, marseille, france. dysimmune sensory neuronopathies (snn) encompass paraneoplastic snn and snn associated with systemic autoimmune diseases such as sjögren syndrome, lupus or inflammatory bowel or rheumatic diseases but also a number of apparently idiopathic cases. biomarker antibodies are well-known in paraneoplastic snn but are lacking in non paraneoplastic cases. from a mono-center retrospective study we identified in 2015 anti-fgfr3 antibody as a potential biomarker of dysimmunity in patients with idiopathic or systemic autoimmune disease associated sensory neuropathy. the identified patients were more frequently women and had a non lenthg dependent neuropathy suggestive of snn. anti-fgfr3 antibody was the only immunological marker in 2/3 of cases at initial work-up although 1/3 of patients eventually developed with time systemic autoimmune disease. to confirm the incidence and the clinical pattern of patients with anti-fgfr3 antibodies we launched a prospective multicenter french study including patients with a sensory neuropathy suspected to be a snn of no paraneoplastic, genetic or metabolic origin. we present here the results on the first 82 included patients compared to 54 healthy blood donors. anti-fgcr3 antibodies were searched by elisa using the trk intracellular domain of the protein (invitrogen©). we found 7 patients positive for anti-fgfr3 antibody (8.5%). these patients were 5 women and 2 men aged 63.7 years as a mean (44-91). the neuropathy was acute and subacute in one patient respectively and progressive in the 5 others. six patients fulfilled the diagnosis criteria of snn and the last one had a sensory neuropathy in the lower limb with abnormal sensory action potentials in the four limbs suggesting snn without reaching the requested criteria. one patient developed uveitis which is a new symptom with anti-fgfr3 ab. an unclassified dysimmune context was present at the initial work up in 3 patients and one patient developed sjögren syndrome with follow-up. as a whole the clinical pattern of these patients is consistent with that of the initially published series. the lower prevalence of positive sera may be due to more stringent criteria used for elisa but needs to be confirmed on the complete prospective series. peripheral neuropathy research registry (pnrr) neurological assessment was scored using the total neuropathy score clinical version (tnsc), comprising pinprick and vibration sensibility, deep tendon reflexes, strength and patient symptom report. compound sensory action potential (csap) amplitudes were recorded antidromically at the lateral malleolus, stimulating the sural nerve at the mid-calf. of the total sample, 75% reported lower limb neuropathy, with 44% of patients reporting 'quite a bit' or 'very much' severity of tingling and numbness in their feet. the average sural csap amplitude was 10.4±1.1 v and 40% of patients had sural amplitudes below the lower limit of normal for age. the total tnsc score correlated with the pro fact-gog ntx13 score (r = −.532, p<.001) and sural amplitude (r = −.338, p <.05). vibration sensibility correlated with the overall fact-gog ntx13 score (r =−.338, p <.05), and sural amplitude (r = −.299, p <.05). sural amplitude correlated with patient reported severity of numbness and tingling in the lower limbs (r =−.3, p <.05) but not with the overall fact-gog ntx13 score. patient reports of neuropathic symptoms in the lower limb correlate with both objective neurophysiological and clinical measures of neuropathy severity. identifying links between objective neurophysiological markers and patient reported outcomes are critical to assess the impact of clinical interventions. tomaselli pj 1 , gouvea sp 2 , nyshyama kfs 2 , nicolau n jr 2 , lourenço cm 1 , marques w jr 1,2 . 1 division of neuromuscular diseases, department of neurosciences and behaviour sciences, clinical hospital of ribeirão preto, university of são paulo, ribeirão preto, brazil; 2 neurogenetics, department of neurosciences and behaviour sciences, university of são paulo, ribeirão preto, brazil. mutations in the gab junction beta 1-protein gene (gjb1) are the second most frequent cause of charcot-marie-tooth disease (cmt), accounting for approximately 10% of cmt cases worldwide. the gjb1 codes for connexin 32 protein (cx32). in the peripheral nervous system, the cx32 is expressed in the schwann cells and allows intercellular traffic of ions and small molecules between opposed cells. we analysed retrospectively detailed clinical and neurophysiological data of five families carrying novel gjb1 mutation submitted for testing at our neurogenetics laboratory. mutations were identified by bidirectional sanger sequence analysis of gjb1 coding region. we identified a total of 11 subjects from five different kindreds with novel mutations (p.a96v, p.l144w, p.l165q, p.f193s, p.r224l). these five novel mutations segregate with phenotype, are located in highly conserved amino acids among gjb1 and other gab junction protein sequences and among different species, are not present in any public database (exac, dbsnp and 1000 genome database), and were not found in 100 normal brazilian controls. in silico analysis, predict these variants to be pathogenic, there was no male-to-male transmission; males were more severely affected than females. four out seven female have subclinical neuropathy and were only identified after clinical and electrophysiological evaluation. the conduction velocities were in the intermediated range in the males patients and higher in the females included in this study. we describe five new pathogenic mutations causing cmtx1 in a brazilian population and expand the number of causative mutations in the gjb1 gene. funded pure neural leprosy (pnl) is a slowly progressive, predominantly sensory patchy neuropathy presenting with positive and/or negative sensory symptoms, which are usually followed over time by distal asymmetrical weakness. despite rare, monomelic involvement in leprosy has already been reported. we sought to describe the clinical and electrophysiological patterns of an unusual leprosy neuropathy presentation. clinical data were retrospectively collected from nine patients who had monomelic involvement and were referred for further investigation to the emg lab. seven out nine patients were male. four patients had a brachial plexus like presentation and five have a lumbosacral plexus like presentation. the initial complaint was hypoesthesia in four patients, tingling in two patients and hypoesthesia with tingling in two patients. severe pain was observed in just one patient. all individuals from the group of patients with lumbosacral plexus-like presentation and three with brachial plexus-like presentation had no sensory nerve action potentials (snaps) for all nerves tested in the affected limb with or without motor involvement. one patient with brachial plexus-like presentation had focal slowing of conduction velocity with temporal dispersion of both median and ulnar nerves in the affected limb. one patient with plexus-like presentation had snaps with low amplitude of all nerves in the affect limb. the diagnosis of leprosy was confirmed by nerve biopsy findings, anti-pgl1 antibody, and positive response to specific treatment. nerve biopsy was performed in four patients, and the bacillus was found in two. the anti-pgl1 antibody was positive in four patients. plexus mri was performed in two patients and was normal. we found the distribution of motor and sensory symptoms were restricted to on limb in this group of patients. as a typically patchy disorder pnl may affect any nerve, although the reason why damage are restrict to only one limb has to be elucidated. the description of these cases increases the clinical spectrum of leprosy neuropathy. this possibility should be considered in the differential diagnosis of patients with plexopathy from endemic areas after excluding other causes. funded ataxia with oculomotor apraxia type 1 (aoa1) is a very complex disorder characterized by an early-onset progressive cerebellar ataxia with cerebellar atrophy and peripheral neuropathy and it is caused by recessive mutations in the aprataxin gene (aptx ). when the neuropathy is present, it has been described in 100% of cases as primarily axonal. we describe a case of aoa1 due compound heterozygous mutations in aptx associated with demyelinating neuropathy. the patient was born from healthy and non-consanguineous parents and presented in the first decade with progressive cerebellar ataxia, multidirectional ophtalmoparesia, oculomotor apraxia, choreiform movements of limbs and peripheral neuropathy. he had normal cognition and stopped walking at age of 19. blood tests were unremarkable with normal levels of leucocytes, serum proteins, immunoglobulin, cholesterol, vitamin e, and alfa-feto protein. brain mri showed severe cerebellar atrophy. the motor conduction velocity in the upper limbs was slow with preserved amplitudes. the distal latencies and the minimal f wave latencies were prolonged. there was no evidence for superimposed acquired demyelinating neuropathy. direct sequencing of the aptx gene revealed two variants, c.544-2a>g, p? and c.837g>a; p.w279x. the first variant is novel and affects a highly conserved acceptor splice site of exon 5. the other variant is the most common portuguese variant, the nonsense mutation w279x is located in exon 6. parental dna was tested and confirmed the variants were in different alleles. the presence of a demyelinating neuropathy in aoa1 suggests that phenotypic variability in this condition may be larger than previously considered. at the same time, it increases the differential diagnosis of inherited conditions with cerebellar ataxia and demyelinating neuropathy. finally, this finding opens the functional effects of the aptx gene. funded by: cnpq, fapesp, faepa, pronas (ministry of health). topa a 1 , spina e 1 , iodice r 1 , tozza s 1 , ruggiero l 1 , dubbioso r 1 , esposito m 1 , santoro l 1 , manganelli f 1 . 1 university of naples "federico ii", naples, italy. we report our 2-year experience of subcutaneous immunoglobulin (scig) in a cohort of patients with chronic inflammatory demyelinating polyneuropathy (cidp) from a tertiary care neuromuscular center. we analyzed data from 13 cidp patients (8 males and 5 females, mean age: 58 ± 11.4 years; mean age at onset: 45.9 ± 12.4 years; disease duration: 11.9 ± 8.3 years) treated with scig and with a follow-up period of 24 months. all patients were previously responders to intravenous immunoglobulin (ivig). eight patients had a typical cidp and five patients had an atypical variant of cidp. five patients switched to weekly maintenance scig therapy (continuous regimen) because of short-lasting response to ivig therapy. eight patients with a longer lasting response to ivig received scig with a pulsed regimen similar to that used for ivig (from 1 to 3 cycles per year); seven of them because of difficulty in hospitalization and one for allergic reaction to ivig. changes in clinical status were assessed over the period of follow-up by using clinical evaluation of muscle strength, modified rankin scale, overall neuropathy scale and inflammatory neuropathy cause and treatmentsum score. in 9 patients we evaluated also six minute walking test, 9 hole-peg-test and 10 meter walking test. all the five patients treated with a continuous regimen of scig remained clinically stable throughout the follow-up period. among the patients receiving pulsed scig treatment, 4 out of 8 (50%) responded to scig similarly to ivig, while three patients (37.5%) worsened and needed to be treated again with ivig and the other one (12.5%) stopped any therapy. subcutaneously administered immunoglobulin were well tolerated and no patients complained of adverse events. in conclusion, our findings confirm that continuous scig therapy is efficacious in maintaining clinical stability in patients with short-lasting response to ivig. moreover, our data suggest that pulsed therapy with scig may represent an alternative therapeutic option for the treatment of a subset of cidp patients. touvier t 1 , ferri c 1 , mastrangelo r 1 , glimcher l 2,3 , wrabetz l 4,5,6 , d'antonio m 1 . 1 myelin biology unit, division of genetics and cell biology, san raffaele scientific institute, dibit, milan, italy; 2 department of cancer immunology and virology, dana-farber cancer institute, boston, usa; 3 department of medicine, harvard medical school, boston, usa; 4 hunter james kelly research institute, university at buffalo, buffalo, usa; 5 department of biochemistry, university at buffalo, buffalo, usa; 6 neurology, jacobs school of medicine and biomedical sciences, university at buffalo, buffalo, usa. mpz glycoprotein is an abundant product of terminal differentiation in myelinating schwann cells. the mutant mpzs63del causes charcot-marie-tooth (cmt) 1b disease in humans and a similar demyelinating neuropathy in transgenic mice. mpzs63del protein is retained in the endoplasmic reticulum (er) of schwann cells and induces an unfolded protein response (upr) characterized by activation of perk, atf6 and ire1/xbp1 pathways. we have previously reported that activation of chop and gadd34, two downstream mediators of perk, is pathogenetic in mpzs63del mice (pennuto, 2008; d' antonio, 2013) but the role of the other upr branches remains to be investigated. in this study, we investigated the role of the er stress sensor enzyme ire1 and of xbp1 -a transcription factor specifically activated by ire1 -in mpzs63del pathogenesis. we generated a new mouse model with schwann cells-specific ablation of xbp1 and in parallel we exploited mpzs63del dorsal root ganglia (drg) explant cultures in which xbp1 signaling is modulated by gain/loss of function approaches. we observed that absence of xbp1 dramatically worsens hypomyelination and electrophysiological/locomotor parameters in young and adult mpzs63del neuropathic animals. interestingly we observed that perk, atf6 and ire1-mediated ridd signalings are upregulated in neuropathic animals lacking xbp1. this suggests that activation of xbp1 targets have an essential role in limiting mpzs63del toxicity, which cannot be compensated by other stress responses. moreover, we demonstrated in mpzs63del drg cultures that inhibition of xbp1 splicing by 4u8c (cross, 2010) decreases myelination whereas activation of xbp1 splicing by quercetin (wiseman, 2010) slightly ameliorates myelination. altogether, these data demonstrate that xbp1 pathway has a critical adaptive role in mpzs63del neuropathy and suggest that activation of this pathway may be beneficial for cmt1b and perhaps for a broad range of neuropathies characterized by upr activation. tozza s 1 , bruzzese d 2 , iodice r 1 , esposito m 1 , dubbioso r 1 , ruggiero l 1 , topa a 1 , spina e 1 , santoro l 1 , manganelli f 1 . 1 department of neuroscience, reproductive sciences and odontostomatology, university of naples "federico ii", naples, italy; 2 department of public health, university federico ii of naples, naples, italy. in cmt1a patients, the clinical impairment progressively increases over time and correlates with the axonal loss. evidence has suggested that the decline of physical performance in cmt1a patients may reflect a process of normal ageing. the aim of our study was to describe, by a case-control cross-sectional design, the progression of physical impairment with ageing in cmt1a patients. we enrolled 70 cmt1a patients (26 m; range 20-81 years) and 70 sex-and age-matched healthy controls. to assess physical performance, all patients and controls underwent 10-meter walk test (10mwt), 6-minute walk test (6mwt) and 9-hole peg test (9hpt) of their dominant (d) and non-dominant (nd) sides. moreover, to assess clinical disability, impairment and quality of life in the cmt1a group we used the charcot-marie-tooth neuropathy score (cmtns), the mrc sum score and the short form-36 (sf-36) questionnaire. the linear regression model was used to evaluate the changes over time of clinical measures in patients and controls. the chow test was used to determine whether the ageing had a different impact on clinical measures for the two groups. physical performance worsened with ageing in both patients and controls, but with a greater slope for cmt1a patients [difference in slopes: 10mwt, 0.15 (c.i. 0.07 to 0.23), p<0.001; 6mwt, −4.59 (c.i. -6.41 to −2.77), p<0.001; 9hpt-d, 0.59 (c.i. 0.39 to 0.78), p<0.001; 9hpt-nd, 0.37 (c.i. 0.20 to 0.53), p<0.001]. the rate of deterioration of physical performance was not different between patients and controls until the 50 th year of age. after the 50 th year of age the rate of deterioration became greater in cmt1a group [difference in slopes: 10mwt, 0.31 (c.i. 0.02 to 0.61), p<0.039; 6mwt, −7.13 (c.i. -12.02 to −2.24), p<0.006; 9hpt-d, 1.47 (c.i. 0.72 to 2.21), p<0.001; 9hpt-nd, 1.11 (c.i. 0.62 to 1.6), p<0.001]. moreover, in cmt1a patients also cmtns, mrc sum score and sf-36 worsened with ageing and with a greater rate of deterioration after the 50 th year of age. our study demonstrates that clinical decline in cmt1a patients goes parallel to the normal ageing process until the 50 th year of age, whereupon the clinical deterioration accelerates. tsouni p 1 , devic p 2 , moura b 1 , planque e 3 , bédat-millet al 4 , devaux j 5 , steck aj 1 , delmont e 6 , hottinger af 1 , kuntzer t 1 . 1 dcn, chuv, lausanne, switzerland; 2 centre de référence maladies neuromusculaires, hospices civils de lyon, lyon, france; 3 cabinet médical, epinal, france; 4 département de neurologie, chu de rouen, rouen, france; 5 cnrs, crn2m-umr 7286, université aix-marseille, marseille, france; 6 centre de référence maladies neuromusculaires et sla, hôpital la timone, marseille, france. new therapeutic options in immuno-oncology have allowed significant progress in the management of melanomas. treatment usually consists of a combination of two monoclonal antibodies targeting cytotoxic lymphocyte-associated protein 4 and programmed cell death-1. as a result, the immunologic barrier protecting tumor cells is overcome allowing an antitumor response. we report 6 cancer patients with immune checkpoint inhibitor-induced neuropathies as a complication of this immunomodulating oncologic treatment. case reports: our index patient developed severe myalgia 4 days after introduction of ipilimumab-nivolumab followed by painful paresthesias of the face and extremities 1 day after the 2nd cycle of treatment. generalized areflexic quadriparesis (mrc4) with gowers'sign and distal loss of vibratory sensation were found. a 5-day course of ivig plus corticosteroids (cs) had no effect. three monthly ivig courses were necessary to improve the deficits at 3 months. a survey of sfnp members revealed 5 other patients with similar acute courses but with phenotypes varying from sensorimotor deficits with areflexia and myalgia to purely sensory ataxic forms following immunomodulating treatment. work-up including anti-nodal antibodies were negative in 3 patients. from the other 3, 2 had abnormal csf and 1 had necrotizing myopathy. detailed repeat ncs demonstrated signs of nerve hyperexcitability and of demyelination or conduction blocks. evolution was slowly favorable following ivig and cs. discussion: our report underscores that atypical acute generalized demyelinating neuropathies are induced by these novel treatments. they may be associated with severe myalgia or other systemic toxic effects. discontinuation of the oncologic treatment depends on severity of symptoms. outcome was slowly favorable following ivig or cs, albeit slower than in the case of primary inflammatory neuropathies, probably given the long half-life of the monoclonal antibodies. gap junctions (gjs) are membrane channels found in most tissues connecting adjacent cells or different cell compartments as in schwann cells. they are involved in electrical connectivity and metabolic homeostasis allowing the passage of small molecules such as ions, second messengers, nucleotides and peptides. an important functional role of peripheral nerve connexins is suggested by their involvement in x-linked inherited neuropathy as well as in acquired neuropathy caused by oxaliplatin. although gjs play a role in electrical connectivity their specific role in the formation of the sciatic nerve compound action potential (cap) remains unclear. the aim of this study was to investigate the role of peripheral nerve connexins in the electrical responses of the mouse sciatic nerve under normal and stress conditions. for this purpose we used sciatic nerves of three different mouse models, the cx32 knockout (ko), cx29 ko and the cx32/cx29 double knockout (dko) mice. using our ex vivo model for extracellular recordings we exposed sciatic nerves from different genotypes to three different gj blockers: octanol, 18-beta-glycyrrhetinic acid (gra) and octanoic acid (oa) and recorded the cap. amplitude and duration of the cap were used as an indication for the effects of the different blockers on the cap formation. all gj blockers caused a gradual decrease of the cap without any changes in the duration of the cap in all genotypes, suggesting progressive disturbance of axonal membrane excitability in the absence of one or two gj proteins. comparison of the three genotypes showed that cx32 may play a dominant role in the maintenance of the cap formation since nerves from cx29ko mice proved to be more sensitive to the gj blockers compared to the cx32ko nerves showing a faster decline of the cap amplitude. moreover the effect of gj blockers was similar in cx32ko and dko nerves. finally, the effect of gj blockers on the dko nerves implies the presence of another gj protein. in conclusion, our results confirm the direct functional involvement of cx32 gj channels and cx29 hemichannels in the cap formation and indicate the existence of at least one more connexin in peripheral nerve. ca(2+)-dependent anti-ganglioside antibody in seronegative guillain-barré syndrome uchibori a 1 , gyohda a 1 , chiba a 1 . 1 kyorin university, tokyo, japan. we have reported ca 2+ -dependent igg anti-ganglioside gq1b antibodies in gq1b-seronegative patients with fisher syndrome and its related disorders (fs-rd). in patients with fs-rd who were gq1b-seronegative in conventional assays using phosphate-buffered saline without ca 2+ , 73% turned seropositive for gq1b-related antigens in assays using ca 2+ -added tris-buffered saline. objective: we investigated whether ca 2+ -dependent anti-ganglioside antibodies was present also in ganglioside-seronegative patients with other clinical disease types of guillain-barré syndrome (gbs) other than fs-rd. methods: the subjects were the following: 23 patients with final clinical diagnosis as gbs (acute motor axonal neuropathy [aman], n = 6, and acute inflammatory demyelinating polyradiculoneuropathy [aidp], n = 17), and 5 patients with final clinical diagnosis as sensory ataxic neuropathy (san), n = 5. all subjects were ganglioside-seronegative in the conventional assays. we assayed serum igg antibodies against various gangliosides (including asialo-gm1) in elisa using tris-buffered saline as a basal buffer in both ca 2+ -added and -non-added conditions. increase of the optical density (od) more than 0.1 in ca 2+ -added condition compared with ca 2+ -non-added one was taken significant, i.e. positive for ca 2+ -dependent antibody. results: ca 2+ -dependent antibody was negative in all aman and san patients. in aidp, the antibody titers (ods) against gainac-gd1a were significantly increased in 2 patients, and those against asialo-gm1 were increased in 2 other patients in ca 2+ -added condition. however, the titiers of those ca 2+ -dependent antibodies were all at low level. conclusions: in clinical disease types of gbs other than fs-rd, ca 2+ -dependent igg antibodies against ganglioside were detected in a few patients with aidp, but the positive rate and the antibody titers were low compared with case of gq1b-seronegative fs-rd. ca 2+ -dependent antibodies against ganglioside are considered to be more specific for gq1b. the aim of the study was to investigate the relationship between median sensory conduction of median nerve and ulnar nerve in patients diagnosed with carpal tunnel syndrome. two hundred and eighty-six hands with carpal tunnel syndrome and 52 hands in control group were investigated. patients were staged clinically and electrophysiologically. diagnosis of carpal tunnel syndrome was made according to the presence of paresthesia, pain in the innervation area of the median nerve, weakness and atrophy in the median nerve innervated muscles, positive phalen and tinel tests. median motor and sensorial nerve conduction study, including first, second, third finger and palm, and ulnar motor and sensorial nerve conduction of fifth finger studies were performed to all patients and control group. the ratio of distal latency and velocity of nerve conduction of first, second, third and palmar branches to fifth finger was calculated. distal latency of first, second, third finger and palm of patients with cts are longer and velocity is more slowly than controls. in addition to these findings, the velocity of fifth finger is also slower and distal latency of this one is longer than healthy subjects. the most sensitive method of classifying the carpal tunnel syndrome as normal, mild and moderate is the ratio of distal latency and velocity of second finger (p<0.001). carpal tunnel syndrome is the most common encountered neuropathy. in nerve conduction studies can be used the ratio of distal latency and velocity of second finger as determine the degree of carpal tunnel syndrome. the most surprising finding of this report is the nerve conduction studies of fifth finger. the subclinical susceptibility of fifth finger can be explained by overusing of wrist. ursino g 1 , gemelli c 1 , grandis m 1 , reni l 2 , bellone e 1 , geroldi a 1 , gotta f 1 , mandich p 1 , ferrara m 1 , schenone a 1 1 dinogmi university of genoa, genoa, italy; 2 irccs-aou san martino hospital genoa, genoa, italy. charcot-marie-tooth (cmt) neuropathy represents a clinically and genetically heterogeneous group of hereditary peripheral neuropathies characterized by chronic motor and sensory impairment. to date mutations in up to 80 genes may cause cmt. the aim of this study is to describe our large population of cmt patients, and, within this, highlight specific phenotypes. the cmt clinic in genova, started in 2004. during the years, patients underwent complete neurological, rehabilitative, neurophysiological examinations and genetic testing. the patients were routinely tested for common genes (as pmp22, gjb1, mpz, mfn2), while in specific cases we followed the candidate gene approach testing single genes based on the genotype-phenotype correlation. however, the ngs techniques were used when routine genetic testing was negative and a clear genotype-phenotype correlation could not be identified. 679 cases are present to date in our database of cmt patients. in 185 (27.2%) patients, in spite of a clinical diagnosis of cmt, a genetic diagnosis is still lacking; 175 (25.7%) patients had alternative diagnosis (i.e hereditary spastic paraparesis etc.). instead, in 319 patients (46.9%) a defined genetic diagnosis was reached, 180 of them being females (56.4%) and 139 males (43.5%). among these, except for the more common cmt1a, hnpp and cmt1x phenotypes, we frequently observed patients affected by cmt1b and cmt2f. according to most literature data, we observed 21 (6.5%) patients with cmt1b and 8 patients (2.5%) affected by cmt2f. at the first visit, the cmt1b phenotype was clearly length-dependent: 71.4% patients showed impairment of the lower limbs and saving of the upper limbs; in terms of severity of the neuropathy, the mean cmtns was 11.9 and the mean age was 48.8 years. similarly, 75% of patients affected by cmt2f, present with the same phenotype; the mean cmtns at the first visit was 8.1 and the mean age was 63.1 years. in conclusion, based on the experience of the genova cmt clinic, we describe a large population of cmt patients and a specific phenotype in cmt1b and 2f patients, characterized by involvement of the lower limbs and selective sparing of the upper ones, which may help in addressing the diagnostic algorithm. non-freezing cold injury (nfci) develops following sustained exposure to cold temperatures, resulting in tissue cooling but not freezing. this can result in persistent sensory disturbance of the hands and feet including numbness, paraesthesia and chronic pain. both vascular and neurological aetiologies of this pain have been suggested but remain unproven. we prospectively approached patients referred for clinical assessment of chronic pain following non-freezing cold injury between 12 february 2014 and 30 november 2016. of 47 patients approached 42 consented to undergo detailed neurological evaluations including: questionnaires to detail pain location and characteristics, structured neurological examination, quantitative sensory testing, nerve conduction studies and skin biopsy for intra-epidermal fibre assessment. of the 42 study participants all had experienced nfci whilst serving in the united kingdom armed services and the majority were of african descent (76.2%) and male (95.2%). many patients reported multiple exposures to cold. the median time between initial injury and referral was 3.72 years. pain was principally localised to the hands and the feet, neuropathic in nature and in all study participants associated with cold hypersensitivity. clinical examination and quantitative sensory testing were consistent with a sensory neuropathy. in all cases large fibre nerve conduction studies were normal. the intra-epidermal nerve fibre density, however, was markedly reduced; 90⋅5% of subjects having a count at or below the 0⋅05 centile of published normative controls. using the neuropathic pain special interest group (neupsig) of the international association for the study of pain (iasp) grading for neuropathic pain 100% had probable and 95⋅2% definite neuropathic pain. chronic non-freezing cold injury is a disabling neuropathic pain disorder due to a sensory neuropathy. why some individuals develop an acute painful sensory neuropathy on sustained cold exposure is not yet known but individuals of african descent appear vulnerable. screening tools, such as the dn4 questionnaire, and treatment algorithms for neuropathic pain should now be used in the management of these patients. funded by the wellcome trust and the uk ministry of defence guillain-barré syndrome (gbs) is highly heterogeneous regarding clinical presentation, course, electrophysiological subtype and outcome. in part this variety is associated with differences between geographical regions, although this had not been investigated in a single comparative study. one aim of igos is to define the influence of the geographical origin on the heterogeneity of gbs. in igos all gbs patients within 2 weeks of onset can participate, independent of age, variant, severity and treatment. in february 2017, 1456 patients were included from 19 countries. the first 1000 inclusions in igos were used in this analysis. seventy-five patients (8%) were excluded because of alternative diagnoses (n=59, including 35 a-cidp), protocol violations (n=5) or missing data (n=11). of the remaining 925 patients, 60% were males and 40% female with a median age of 51 years (iqr 33-65). at entry 73% presented with tetraparesis and 11% with paraparesis. during follow-up 19% needed mechanical ventilation and 7% died. of all gbs patients 81% received treatment (91% ivig, 9% pe). the remaining 19% received supportive care only (mild gbs or low social-economic status). antecedent events were reported in 76% of patients, including upper respiratory tract infection (36%) and gastro-enteritis (26%) as the most frequent events. the pure motor form was the predominant subtype in patients from bangladesh (69%). in europe/americas and asia (without bangladesh) the predominant subtype was the sensorimotor form (69% in europe/americas and 43% in asia). in asia (without bangladesh) there was a relatively larger proportion of patients with mfs/mfs-overlap syndrome (22%) than in other regions (1-11%, p<0.001). the proportion of patients able to walk unaided at 12 months after follow-up was 87% in europe/americas, 73% in bangladesh and 93% in asia (without bangladesh). kaplan-meier analysis comparing electrophysiological subtypes of gbs (as reported by neurologist) showed that patients with inexcitable nerves or axonal neuropathy needed more time to regain the ability to walk unaided than the patients with demyelinating or equivocal result (log-rank test, p < 0.001). these findings demonstrate the extensive geographical differences in gbs. future igos studies will investigate the role of genetic and environmental factors that additionally could explain these differences. van den bergh pyk 1 , attarian s 2 , grapperon am 2 , nicolas g 3 , cassereau j 4 , rajabally ya 5 , delmont e 2 , woodard jl 6 , piéret f 7 and the university of louvain gbs electrodiagnosis study group * . 1 corticosteroids are considered as one of the first line treatments for chronic inflammatory demyelinating polyneuropathy (cidp). different types of corticosteroids are used and there are no comparative studies assessing the improvement rates, remission rates, tolerability and the side effect profiles of these treatment regimens. in addition, there are currently no reliable predictors of favorable treatment response to steroids, which would greatly ease the choice of first line treatment. in this retrospective study we will compare efficacy, tolerability and safety of three different corticosteroid regimens used as first line treatment in three large cidp centers in netherlands, serbia and italy. treatment naïve cidp patients who received either pulsed dexamethasone, pulsed methylprednisolone or daily prednisone will be included in the study. data will be extracted from patient charts. the primary outcome is the percentage of treatment responders at 6 months after start of first treatment, in which treatment response is defined as subjects who improved after treatment and are either without treatment after six months or are still being treated with the first chosen therapy. secondary endpoints include the remission rates and in case of a relapse, the mean duration of remission to relapse; the discontinuation rate within 6 months of treatment due to inefficacy, adverse events or intolerance; and the frequency of adverse events and serious adverse events (sae) during treatment or within 1 month after stopping treatment. furthermore, we will explore the value of previously reported potential predictors of treatment response. results will be presented at the peripheral nerve society meeting 2017. van lieverloo g 1,2 , musters a 2 , adrichem m 1 , esveldt r 2 , doorenspleet m 2 , klarenbeek p 2 , van schaik i 1 , de vries n 2 , eftimov f 1 . 1 academic medical center, department of neurology, amsterdam, the netherlands; 2 academic medical center/university of amsterdam, department of clinical rheumatology and immunology, amsterdam, the netherlands. following reports that pathogenic antibodies are present in a minority of patients with chronic demyelinating inflammatory neuropathy (cidp), we studied whether oligoclonal expansions of b-cell clones are present in patients with cidp. recently, we developed a new method for b-cell receptor (bcr) repertoire landscaping based on high throughput sequencing (hts) of rna extracted from blood. bcr repertoire was analyzed in 30 patients with cidp: 10 patients with active disease and starting treatment (group 1), 10 patients with stable disease using intravenous immunoglobulin (ivig) treatment in which treatment withdrawal was attempted (group 2), and 10 patients in remission (i.e. no treatment in the last 12 months, group 3). clinical parameters and sampling was performed at baseline (group 1, 2 and 3), at 6 months after start of treatment (group 1), at 6 months or earlier in case of relapse in group 2 and at baseline only in group 3. most cidp patients had highly expanded bcr clones, regardless of disease activity and response to treatment. however, in group 1, the most expanded b-cell clones at baseline showed no overlap with the expanded bcr clones after improvement. based on these preliminary data expanded bcr clones are observed in the peripheral blood of most cidp patients, regardless of disease activity (active, stable disease or remission/cure). functional characterization of these expanded clones remains to be performed. van rijs w 1 , fokkink wjr 1 , tio-gillen ap 1 , brem md 1 , jacobs bc 1 , huizinga r 1 . 1 erasmus mc, university medical centre, rotterdam, the netherlands. myeloid cells, including monocytes, macrophages and dendritic cells, are critically involved in the induction of adaptive immune responses, clearance of pathogens and in the initiation of tissue repair. in the guillain-barré syndrome (gbs), macrophages are present in the peripheral nerve, where they phagocytose (damaged) myelin and axons. dendritic cells (dc) are increased in the cerebrospinal fluid of patients with gbs. however, the composition and phenotype of monocytes and dc subsets in the peripheral blood is unclear and it is unknown if these cells can be used as biomarker to monitor disease activity or response to treatment. here we investigated the frequency and phenotype of six myeloid subsets in the peripheral blood mononuclear cells (pbmc) using advanced 13-color flow cytometry. pbmc were isolated from 20 patients with gbs, before and after immunomodulatory treatment, and 20 age and gender-matched, healthy controls. the frequency of total monocytes, determined as percentage of cd45+ cells, was increased in gbs patients compared to controls (p<0.05). the monocyte population was skewed towards more intermediate (cd14+cd16+; p<0.05) and less non-classical (cd14-cd16+; p<0.01) monocytes. classical (cd14+cd16-) and intermediate monocytes as well as cd1c+ dc expressed significantly higher levels of cd38 compared to healthy controls. in contrast, the expression of cd40 and siglec-7 was significantly higher in the non-classical monocytes of gbs patients compared to controls. no differences were observed in the expression of cd69, cd80, cd83 and siglec-1. immunomodulatory treatment strongly reduced the frequency of non-classical monocytes and all dc populations in cd45+ pbmc. the expression of cd40, cd1c and hla-dr was reduced in classical monocytes after treatment. in addition, siglec-7 expression was reduced in several monocyte and dc populations after treatment. in summary, our data identify significant changes in the monocyte compartment in gbs. the decrease in non-classical monocytes may suggest that these cells have migrated to peripheral tissues, promoting the differentiation of classical monocytes into intermediate monocytes. further analysis should reveal whether these changes are related to preceding infections, disease severity and response to treatment. in mme. the two mutations were absent from control databases (e.g. exac), affected highly conserved aminoacids and were predicted to have deleterious effects by in silico analysis. unfortunately, both parents were deceased and we were therefore unable to prove that the two mutations reside on separate alleles. mme encodes the metalloprotease neprilysin whose role in peripheral nervous system is still unclear. higuchi and colleagues have described 10 japanese cmt2 families with late-onset sensory-motor axonal neuropathy and recessive loss-of-function mutations in mme. we report two novel missense mutations in mme in a case of late-onset cmt2. we hypothesize an autosomal-recessive mode of inheritance as most likely given the clinical phenotype and the absence of a family history. anti-contactin-1 (cntn1) antibodies were recently identified in a subgroup of patients with chronic inflammatory demyelinating polyneuropathy (cidp) showing acute/subacute onset of severe sensory-motor neuropathy and poor response to intravenous immunoglobulin (ivig) and corticosteroids. these antibodies belong to the igg4 isotype and interact with cntn1-neurofascin 155 (nf155) complex at paranodes leading to loss of nodal integrity. a 59-year-old man presented with acute onset of distal weakness in the lower limbs, four limbs paraesthesias and sensory ataxia. at clinical examination ankle swelling was also observed. nerve conduction study showed a demyelinating polyneuropathy and cerebrospinal-fluid examination revealed cyto-albuminologic dissociation. sural nerve biopsy disclosed diffuse loss of myelinated fibres. at routine blood test serum albumin was reduced and proteinuria was 10 gr/24 hours, thus leading to the diagnosis of nephrotic syndrome. kidney biopsy showed changes consistent with membranous glomerulonephritis, together with sub-epithelial deposits of immune complexes and complement deposition. treatment with ivig and corticosteroids did not improve neurological status, while membranous glomerulonephritis showed moderate response to ivig. a six-month course of cyclophosphamide was started leading to normalization of renal function and muscle strength and partial improvement of sensory ataxia. the patient did not require any further treatment and after 10 years his condition remains stable. cntn1 antibodies were tested on a recently collected patient's serum and resulted positive on both elisa and cell-based assay. the patient here reported showed the typical clinical features of anti cntn1-associated cidp including older age, acute onset, severe motor impairment and sensory ataxia. the contemporary occurrence of membranous glomerulonephritis was reported in only one other case. contactin-1 is expressed at low levels in the kidney and a direct damage of anti-cntn1 antibodies could be hypothesized. alternatively, renal damage might have been secondary to unspecific immune complexes deposition. a good response to anti-cd20 rituximab was recently reported in patients with cidp associated with anti-cntn1 and anti-nf155 antibodies. notwithstanding this single-case observation, our report suggests that also cyclophosphamide may be considered an effective therapy in anti-cntn1 antibodies-associated cidp and membranous glomerulonephritis, leading to persistent clinical remission. velasco r 1,2 , besora s 1 , santos c 3 , sala r 1 , izquierdo c 1 , simó m 1 , gil-gil m 1,3 , jiménez l 3 , pardo b 3 , calvo m 3 , palmero r 3 , clapés v 4 , bruna j duloxetine is the only agent demonstrated effective in treating pain related with chemotherapy-induced peripheral neuropathy (cipn). patients with symptomatic cipn treated with duloxetine were retrospectively collected in a single-institution. aim of the study was to evaluate the drug's efficacy and rate of compliance. only patients with cipn with distressing positive symptoms (pain, numbness and/or paresthesia), and non-progressive disease were included. cipn was graded employing the total neuropathy score (tns © ) and national cancer institute-common toxicity criteria. response to duloxetine was assessed with patient global impression of change (pigc) scale (1: no benefit; 7: excellent response). consecutive first one-hundred cipn patients treated with duloxetine were analyzed. median age was 62 (29-81). 59, 37, 2 and 2 received platinum, taxane, bortezomib and vincristine-based regimen, respectively. median tnsc © was 9 (1-17). severity of neuropathy was grade 1 (20%), grade 2 (66%), and grade 3 (14%). sixteen patients were on treatment with other analgesic agents. median time from finishing chemotherapy to duloxetine initiation was 6 months [0-63]. median pigc score was 3 [1-7]. among responders, 45.5% and 54.5% scored low (2-4) and high (5-7) benefit, respectively. fifty-seven (57%) patients discontinued early duloxetine due to intolerable side effects (n=37) the goal of this study was to determine whether predicted fork stalling and template switching (fostes) during mitosis deletes exon 4 in peripheral myelin protein 22 kd (pmp22) and causes a gain-of-function mutation associated with peripheral neuropathy in a family with charcot marie tooth disease type 1e. two siblings previously reported to have genomic re-arrangements predicted to involve exon 4 of pmp22 were evaluated clinically and by electrophysiology. skin biopsies from the proband were studied by rt-pcr to determine the effects of the exon 4 re-arrangements on exon 4 mrna expression in myelinating schwann cells. transient transfection studies with wild type and mutant pmp22 were performed in cos7 and rt4 cells to determine the fate of the resultant mutant protein. both affected siblings had a length-dependent demyelinating neuropathy with severely slow nerve conduction velocities (<10 m/sec). rt-pcr studies of schwann cell rna from one of the siblings demonstrated a complete in frame deletion of pmp22 exon 4 (pmp22delta4). transfection studies demonstrated that pmp22delta4 protein is retained within the endoplasmic reticulum and not transported to the plasma membrane. our results confirm that that fostes mediated genomic rearrangement produced a deletion of exon 4 of pmp22, resulting in expression of both pmp22 mrna and protein lacking this sequence. in addition, we provide direct experimental evidence for endoplasmic reticulum retention of the mutant protein suggesting a gain-of-function mutational mechanism consistent with the observed cmt1e in this family. pmp22delta4 is another example of a mutated myelin protein that is misfolded and thus likely to contribute to the pathogenesis of the neuropathy. in poems and cidp, distal limb nerve conduction studies are limited in identifying demyelination and detecting treatment effects in severely affected patients. blink reflex r1 latency may help to not only identify demyelination but also provide a meaningful treatment outcome measure especially in severely affected patients. poems and cidp patients having undergone routine nerve conductions and blink reflex testing were identified. correlation between r1 latency, limb nerve conduction studies and neuropathy impairment scores (nis) was calculated with treatment. blink reflexes were performed in 182 patients (124 poems, 58 cidp; nis range: 12-145 points). overall, r1 latency prolongation occurred in 64.3% of patients (65.3% poems, 62.1% cidp). patients with r1 prolongation (>13ms) had more severely affected nerve conductions in both poems (ulnar cmap 2.6mv vs 4.5mv, p=0.001) and cidp (ulnar cmap 2.0mv vs 6.1mv, p< 0.001). r1 latency correlated with nis severity in poems better than cidp (r 2 =0.24 vs 0.10, p=<0.001 vs. 0.014). follow-up nis and r1 latency evaluations after treatment were available in 31 patients (16 poems, 15 cidp). the r1 latency changes were concordant with the nis changes in 94% of poems and 60% of cidp patients. in severely affected patients [ulnar cmap amplitude ≤0.5mv (9.9%: 18/182)] except for one, all had prolonged r1 (>13ms), allowing for treatment follow up and initial diagnosis. blink reflex r1 latencies are valuable in defining demyelination in severely affected poems and cidp patients, but also provide a sensitive, early treatment outcome measure among those same severely affected patients. watson dj 1 , martinez c 2 , wallenhorst c 2 , hubsch a 3 , shebl a 4 , simon tl 1 . 1 csl behring llc, king of prussia, usa; 2 institute for epidemiology, statistics and informatics gmbh, frankfurt, germany; 3 csl behring ag, bern, switzerland; 4 csl behring gmbh, marburg, germany. chronic inflammatory demyelinating polyneuropathy (cidp) rarely occurs in children. clinical trials in pediatric patients have not been performed and there are little data on therapy with intravenous immunoglobulin (ivig). we performed an observational trial to investigate the risk of adverse events of special interest (aesi) with ivig, i.e. hemolytic anemia, aseptic meningitis, acute renal failure, thromboembolic events and anaphylactic reactions. the study cohort was derived from the us premier perspective database and consisted of patients <18 years with a diagnosis of cidp (icd-9 cm diagnosis code 357.81) treated with the ivig privigen ® (csl behring, bern switzerland) between jan 2008 and dec 2015. we identified 17 pediatric cidp patients: 3 preschool children (age 2-5 years at first treatment for cidp), 6 children (6-12 years) and 8 adolescents (13-18 years); 9 females and 8 males; 14 white, one black and two allocated to "other race". six patients had a history of other ivig use for guillain-barré syndrome, one patient for myasthenia gravis and one for immunodeficiency before the diagnosis of cidp. the mean privigen ® dose calculated from the cumulative quantity of privigen ® per treatment episode and the corresponding age-and gender specific median of the us population body weight estimate was 1.3 g/kg body weight. the number of recorded treatment episodes per patient ranged from 1 to 21. using an at-risk period of 30 days for hemolytic anemia, and 10 days for other aesi after each privigen ® administration, no aesi were observed in the 17 patients with cidp with a total of 3720 person-days at-risk for ha and 1380 person-days at-risk for other aesi. this observational study shows that ivig (privigen ® ) is used for treatment of cidp in pediatric patients with or without concomitant conditions and revealed no particular safety issues in this patient group. hsn-1 is a peripheral neuropathy most frequently caused by missense mutations in the sptlc1 or sptlc2 genes, which code for two subunits of the enzyme serine palmitoyltransferase (spt). spt catalyzes the first and rate limiting step of de novo sphingolipid synthesis. it has been shown that mutations in spt cause a change in enzyme substrate specificity which results in the production of two atypical sphinganines, deoxysphinganine (dsp) and deoxymethylsphinganine (dmsp), rather than the normal enzyme product, sphinganine (sp). levels of deoxysphingolipids are elevated in the blood of hsn-1 patients and this has been shown to cause the peripheral nerve damage characteristic of the disease, which affects both sensory as well as motor axons. however, the underlying pathomechanism of how deoxysphingolipids damage neurons remains elusive. here, dsp and dmsp-mediated neurotoxicity was examined in primary mouse motor and sensory neurons, by assessing cell survival and neurite outgrowth following exposure to different concentrations of sp, dsp or dmsp. the abnormal enzyme products were found to have a rapid and dose-dependent neurotoxic effect in primary neurons. we also explored the potential mechanisms that underlie deoxysphingolipid neurotoxicity, by characterizing mitochondrial function and changes in calcium handling. we found that mitochondrial dysfunction and calcium handling deficits may be key mediators of abnormal sphingolipid neurotoxicity, in both motor and sensory cell models. specifically, we revealed mitochondrial abnormalities, signs of endoplasmic reticulum stress and dysfunction of store-operated calcium channels. we propose that early deficits in mitochondria and calcium handling may underlie deoxysphingolipid neurotoxicity and thus present potential therapeutic targets for hsn-1. months. one patient was excluded because the decrease in hba1c was not contemporaneous with weight loss. the mean and median decrease in bmi per month was 2.01 and 1.82 respectively. the mean and median interval between surgery and decrease in hba1c was 88.2 and 89.5 days respectively. records of these 14 patients were scrutinized and classified as: 'probable tind': acute painful neuropathy and acute dysautonomia with temporal relationship to the decrease in hba1c; 'possible tind': acute painful neuropathy or acute dysautonomia or temporal relationship to decrease in hba1c is uncertain; 'unlikely tind': when an alternative explanation exists for symptoms. only one patient was classified as 'possible tind': a 50-year-old woman who developed neuropathic pain in both lower limbs 1 month after a rapid hba1c decline of 5.2% and about 5 months after bariatric surgery. she had no documented autonomic symptoms. our study is limited by small cohort size, retrospective design and reliance on hospital records. nonetheless, it demonstrates that besides nutritional neuropathies, tind should also be considered in dm patients who develop peripheral neuropathy after bariatric surgery. in another study, we found tind is uncommon in a general cohort of diabetic patients. the occurrence of 1 'possible tind' in only 14 dm patients corroborates earlier data that weight loss may act in tandem to increase the risk of tind. woolums bm 1 , tabuchi m 1 , sung h 1 , sullivan jm 1 , mamah c 1 , yang m 1 , blum id 1 , wu mn 1 , sumner cj 1 , lloyd te 1 . 1 johns hopkins university, baltimore, usa. dominant missense mutations in the gene encoding the cation channel transient receptor vanilloid, family member 4 (trpv4) cause inherited neuropathies including charcot-marie-tooth disease 2c (cmt2c). in vitro, mutations in trpv4 that cause cmt2c cause a gain of trpv4 channel function and increased intracellular calcium which subsequently leads to cellular toxicity. however, the mechanisms by which cmt2c mutations in trpv4 lead to neuronal dysfunction in vivo remain poorly understood. we generated transgenic drosophila that express either wild-type or a cmt2c causing trpv4 mutant (trpv4 r269c ) to assess the effect of trpv4 r269c on neuron function in vivo. selective expression of trpv4 r269c in drosophila ccap neurons (n ccap ) results in a failure of drosophila wing expansion that is blocked by genetically inactivating the channel pore, demonstrating the requirement of channel function in mediating this phenotype. perforated patch clamp analysis of n ccap reveals that trpv4 r269c causes a calcium-dependent increase in n ccap neuronal excitability. this hyperexcitability is restored to control levels by application of a trpv4 selective antagonist. high level expression of trpv4 r269c causes synaptic and dendritic degeneration, both of which are rescued genetically by inactivating the channel pore or pharmacologically by feeding larvae a trpv4 selective antagonist. we conducted a genetic screen in n ccap and found that camkii knockdown potently suppresses the trpv4 r269c mediated wing expansion phenotype and selectively rescues degeneration of synapses but not dendrites. we also find that trpv4 r269c , but not controls, disrupts mitochondrial transport in axons by increasing the number of stationary mitochondria. our data demonstrate that trpv4 r269c elevates neuronal intracellular calcium which disrupts mitochondrial transport and mediates neurodegeneration through compartment-specific calcium-mediated signaling pathways, and supports the further investigation of trpv4 antagonists as potential therapeutics for the treatment of cmt2c. mood disorders, including anxiety and depression, are commonly observed among chronic pain patients with prevalence estimates ranging from 3 to 35%. comorbidity between mood and chronic pain disorders has been linked to altered limbic regulation of the hypothalamic-pituitary-adrenal (hpa) axis. stress activates the hpa axis and can initiate and/or exacerbate symptoms related to both chronic pain and mood disorders. previous studies from our laboratory have investigated the influence of early life stress on mechanical pain hypersensitivity, visceral hypersensitivity and behavioral evidence of mood disorder later in life. here, we are testing the hypothesis that chronic stress exposure in adulthood can increase somatic and visceral sensitivity and anhedonic behaviors in a mouse strain with a genetic predisposition to anxiety. adult, female a/j mice were exposed to repeated foot shock stress for 10 continuous days and tested for alterations in mechanical sensitivity, sucrose preference, visceromotor response (vmr) during urinary bladder distension, and serum corticosterone levels. mice that underwent shock stress had a significantly decreased mechanical withdrawal threshold in the hind paw compared to their baseline and sham group measurements. sucrose preference was measured prior to shock exposure and throughout the shock paradigm as an indicator of anhedonic behavior. mice that underwent shock stress displayed a trend toward decreased sucrose preference, indicating anhedonia, in comparison to mice in the sham group that did not display anhedonia. mice that underwent shock stress displayed significant increases in vmr during bladder distension compared to sham mice. finally, serum corticosterone levels were significantly higher in the mice that underwent shock stress compared to sham mice, indicating a stress-induced increase in hpa axis output. together these data suggest that chronic stress exposure can induce mechanical allodynia, visceral hypersensitivity, and depression-like behaviors in an anxiety-prone mouse strain. future studies will incorporate gene expression in the hypothalamus, amygdala, and hippocampus, as well as investigation of possible downstream peripheral neuroimmune modulation and neuronal morphology changes. guillain-barré syndrome (gbs) is an acute monophasic immune-mediated neuropathy. as prognostic markers of gbs, modified erasmus gbs outcome score (megos), erasmus gbs respiratory insufficiency score (egris), and δigg have been reported. however, the proportions of subtypes of gbs are known to be different between the western countries and japan, it remains to be elucidated whether those markers can also be applied to gbs in japan or not. we here investigated retrospectively 177 gbs patients and determined the megos and the egris of those cases. among them, δigg could be obtained in 79 cases. we evaluated the prognosis using gbs outcome score (functional grade: fg) at 6 months; we called good prognosis when fg at 6 months was less than 3 and poor prognosis when that was 3 or more. as a result, in 25 cases with higher score than 6 at megos on admission 8 cases (32%) had poor prognosis and in 32 cases with higher score than 9 at megos at day 7 of admission 13 cases had poor prognosis. in 25 cases with higher score than 6 on egris 14 cases (56%) needed the mechanical ventilator. patients with good prognosis had higher δigg(average: 1008mg/dl) than patients with poor prognosis(average:528mg/dl). we calculated the cut-off value of δigg in 79 patients, which was 1108 mg/dl. 36 patients with higher δigg than 1108 mg/dl could significantly walk independently at six months (p<0.05). 9 patients (21%) had poor prognosis in 43 patients with lower δigg than 1108 mg/dl. 99 (60%) of 164 patients were treated with the single cycle of intravenous immunoglobulin (ivig). other patients (40 %) were treated with the combined therapies, such as intra venous methylprednisolone and/or plasmapheresis or the second cycle of ivig in addition to ivig. although there was no difference in prognosis between patients with the single cycle of intravenous immunoglobulin (ivig) and patients with the combined therapies, in the 24 patients who had fg>3 and megos >6 on admission, the combined therapies made better prognosis than the single course of ivig (p<0.05). we found that megos, egris and δigg were also available in japan. the efficacy of the combined therapies in severe gbs patients should be investigated in the future large scale prospective studies. yiu em 1,2,3 , burns j 2,4,5 , menezes mp 4,5 , ryan mm 1,2,3 and for the paediatric cmt best practice guidelines consortium. 1 royal children's hospital melbourne, melbourne, victoria, australia; 2 murdoch childrens research institute, melbourne, victoria, australia; 3 university of melbourne, melbourne, victoria, australia; 4 university of sydney, new south wales, australia; 5 sydney children's hospitals network (randwick and westmead), new south wales, australia. charcot-marie-tooth disease (cmt) often presents during childhood. common symptoms include weakness, limb pain and cramps, foot deformity, and balance impairment. guidelines for the optimal management of common problems experienced by children with cmt do not currently exist. development of these guidelines will provide an evidence base for the management and monitoring of children with cmt. a series of systematic literature reviews utilising the grade (grades of recommendation, assessment, development, and evaluation) approach were conducted to answer pre-specified key clinical questions related to the management of paediatric cmt. these included treatment recommendations for symptoms such as weakness, pain, balance impairment, joint deformity, and impaired upper limb function, and anticipatory monitoring for associated complications such as hip dysplasia. this yielded minimal to no evidence for the pre-specified clinical questions, and evidence-based management recommendations could not be made. consensus-based statements will therefore be formulated via a three-round delphi process, to be conducted in 2017. the delphi panel will consist of local and international medical and allied health professionals who have experience in the management of children with cmt. efficacy of pxt3003 in the treatment of adult patients cmt1a (n=80) was shown in a multicenter, randomized, double-blind, placebo-controlled phase ii study (attarian et al. 2014) . pxt3003 taken 2x/day, orally, for 12 consecutive months was well tolerated and safe. significant improvement of disability was observed for the highest tested dose, thought indicative for an early, meaningful change in disease course (meta-analysis by mandel et al., 2015) . this formed the rationale to initiate a multicenter, randomized, double-blind, placebo-controlled pivotal phase iii study (clin-icaltrials.gov: nct02579759) of pxt3003 in mildly to moderately affected cmt1a patients in december 2015. the primary objective is to assess the efficacy of 2 doses of pxt3003 compared to placebo on disability as measured by the mean change from baseline overall neurology limitations scale (onls) score at month 12 and 15. furthermore, efficacy on the proportion of responders (i.e. improvement of onls), impairment (cmtns-v2), functional tests (10-mwt, qmt, 9-hpt), electrophysiological parameters (cmap, snap and ncv) and quality of life (eq-5d, vas) are secondary endpoints. pursuant this study, patients will be eligible for a 9-month extension study, in which pxt3003 assigned patients will continue with the previously assigned dose, whereas placebo patients will be randomized to one of the two pxt3003 doses. the study is conducted in 30 investigational sites in 8 countries (eu, canada and us). in december 2016 patient randomization was completed (n=323). the screen failure rate was 26%, as expected (437 patients were screened). the independent dsmb recommended to continue the study as planned following a safety analysis on the first 100 patients treated for >3 months. preliminary baseline characteristics are based on 313 patients (data not cleaned). the study population had a mean age of 40.8±13.3 years (range 16-65; male 41.2%) of which 97.8% had a confirmed genetic diagnosis of cmt1a. the mean cmtns-v2 was 13.9±3.09 and the mean motor nerve conduction of the ulnar nerve was 23.4±11.3 m/s. ten patients withdrew from the study, 3 due to adverse events unrelated to study treatment. the last patient completing the study is expected in march 2018. zhang g 1 , ghosh p 1 , lin j 1 , ghauri a 1 , sheikh ka 1 . 1 department of neurology, university of texas health science center at houston, houston, tx, usa. assessment of epidermal nerve fiber density and its structure integrity is critical for the diagnosis and evaluating the effectiveness of potential therapies in small fiber neuropathies. currently, skin biopsies, at multiple sites, are most commonly used to assess these diseases. these studies are expensive and time consuming due to cumbersome processing and quantification techniques and serial biopsies over time are often not feasible due to costs and patient acceptance. moreover, vast majority of normative data for skin biopsies in humans are available only for few distal sites and a significant proportion of patients with small fiber neuropathies have focal or regional symptoms not involving the commonly biopsied sites in the leg. live imaging could overcome these limitations and provide a noninvasive real time assessment of epidermal nerve fibers all over the body. we previously found that anti-ganglioside antibody (aga) is an effective neuronal delivery vector for transport of various cargos, such as fluorescent dyes, to peripheral nerves. in the current proof of concept study, we examined whether non-invasive multiphoton microscopy can be used to probe/image the epidermal nerve fibers in living animals after systemic and/or local delivery of fluorescently conjugated aga. we found that the individual nerve endings in skin and cornea are distinctly labeled, and visualized under two-photon microscope. the epidermal nerve fiber labelling by fluorescent-tagged aga was further validated using transgenic mice selectively expressing yellow fluorescent protein in their nervous system. in-vivo multiphoton imaging provide a tool with potential for dynamic longitudinal evaluation of small fiber neuropathies, including nerve degeneration and regeneration, without tissue removal. thus, the use of multiphoton microscopy in conjunction with fluorescently labeled aga as neuronal vector can have many research and clinical applications, such as labeling and live visualization of epidermal nerve fibers to assess small sensory nerve fibers in health and disease. zhou y 1 , tavori h 2 , lee s 1 , al salihi m 1 , fazio s 2 , notterpek l 1 . 1 mcknight brain institute, university of florida, gainesville, florida, usa; 2 knight cardiovascular institute, oregon health and science university, portland, oregon, usa. the majority of hereditary neuropathies are due to abnormalities in peripheral myelin protein 22 (pmp22), whose genetic variants include increased expression (gene duplication), haploinsufficiency (gene deletion), or point mutations. phenotypic heterogeneity in clinical presentation is common among hereditary neuropathy patients even within the same family, the cause of which has not been determined. to investigate the role of pmp22 in the pathogenesis of the neuropathies we have generated and characterized pmp22 null (pmp22 −/− ) mice (amici et al., 2006 ) whose peripheral nerves show alterations in lipid metabolism (lee et al., 2014) . to examine the molecular changes underlying these abnormalities we determined the expression of cholesterol synthesis (srebp2 pathway), and cholesterol uptake, transport and efflux genes (lxr pathway). in affected nerves, we found the cholesterol synthesis pathway inhibited, while the lxr pathway, and particularly apoe and abca1, upregulated at the mrna and protein levels. since pmp22 is expressed at low levels in the liver, the central organ for the regulation of cholesterol in the body, we studied liver tissue form pmp22 −/− mice. liver from pmp22 −/− mice showed significant hepatomegaly, clear features of microvesicular steatosis, as well as marked increase in lxr pathway genes and proteins (abca1 and apoe), as compared to wt. ultrastructural studies identified lipid droplets and significantly enlarged mitochondria in the liver of male pmp22 −/− mice, which is not due to mitochondria fusion, as the levels of mfn 1 and 2 remained similar to wt. as disturbed hepatic cholesterol homeostasis induces the activation of kupffer and stellate cells, we determined the extent of inflammation in nerve and liver tissues from pmp22 −/− mice with leukocyte (cd11b) and macrophage markers (cd68). in nerve sections, we detected an increase in the number of cd11b+ cells, which was confirmed by western blots. in the liver of pmp22 −/− mice we found a significant increase in cd68-reactive kupffer cells and elevated levels of tnf-alpha. the severe dysregulation of cholesterol metabolism in nerve and liver, including neuroand hepatic inflammation in the absence of pmp22 − suggest that dysregulated cholesterol metabolism and inflammation may act as a disease modifier in pmp22-dependent neuropathies. our aim was to ascertain frequency of and risk factors for tee, arterial (ate) and venous thromboembolic events (vte) in neuromuscular patients receiving regular ivig. we performed a retrospective case-note review of 112 inflammatory neuropathy patients receiving regular ivig treatment. we collected the following data over a 30 month study period this analysis suggests tee incidence is higher in ivig treated patients than comparable population-based rates. examination of tee occurrence in age and vascular risk factor matched ivig-treated and ivig-naïve individuals is required to appreciate the excess risk associated with ivig treatment. référence des maladies neuromusculaires et la sla, hôpital de la timone ha) and whether temporal dispersion (td) parameters are helpful. fifty-eight patients diagnosed according to asbury and cornblath (1990) were prospectively included between january 2015 and september 2016. edx1 and 2 were performed 1-12 (mean=5) and 23-51 days (mean=33) after disease onset, respectively. there were no differences in classification consistency between ho and ha at edx1 (p=0.41) and edx2 (p=0.30), but more patients were classified as aman when comparing ra with ho and ha at edx1 (p<0.01). at edx2, ra classified more patients as equivocal with ho (p<0.001) and as aman with ha (p<0.001) 31) or edx2 (ho, fe p=0 30; ra, fe p=0.5; ra with td, fe p=0.64). gm1, gd1a, gd1b and gq1b igg antibodies were tested (willison at edx1, only ho showed maybe more antibodies with aman compared to aidp (fe p=0.02, phi=−0.38) and with aman compared to equivocal cases since correlation with factors associated with axonal gbs, in casu rcf and antibodies, is far from exclusive, the usefulness of edx subtype classification using specific criteria sets, remains doubtful. the frequency of rcf indicates that nodal/paranodal alterations may represent the main pathophysiology in more gbs patients than currently thought ruiz m 1 , lessi f 2 , cacciavillani m 3 , riva m 2 , salvalaggio a 1 , campagnolo m 1 , briani c 1 . 1 neurology, department of neuroscience, university of padua, padua, italy; 2 hematology and clinical immunology unit, department of medicine, university of padua, padua, italy; 3 cemes, data medica group, padua, italy.arsenic trioxide (ato) is highly effective in treatment of acute promyelocytic leukemia (apl). it is licensed in italy for treatment of relapsed-refractory apl and for first line chemotherapy in low risk patients. ato most frequent side effects are well described, but less is known on ato induced. we describe 2 apl patients who were treated with all-trans retinoic acid (atra)/ato as first line therapy. the characteristics of ato induced neuropathy was prospectically analyzed by neurological evaluation using both the total neuropathy score, clinical version (tnsc) (a validated scale for chemotherapy induced peripheral neuropathy) and neurophysiological assessment. patients have been evaluated at baseline, at the end of the induction phase, at the end of ato/atra treatment and 1 year after discontinuation of treatment. baseline neurophysiology was performed at the end of induction phase. both patients were men, respectively 41 and 53-yr-old. none of the patients had previous history of neuropathy. baseline tnsc was 0 (no clinical signs of neuropathy) in both patients. neurophysiological evaluation performed after the end of induction cycle did not reveal signs of peripheral neuropathy in both patients. patient 1 received 387 mg of ato during induction, total 1,040 mg. patient 2 received 311 mg of ato during induction, total 1,188. both patients developed leg numbness during consolidation cycles and patient 1 also hand numbness. tnsc at the end of therapy was 1 in patient 1 and 3 in patient 2. neurophysiology at the end of therapy detected signs of sensitive axonal neuropathy in both patients. they received full doses of ato consolidation (0.15 mg/kg/day for 5 days/week, on alternate months for total 3 months and tretinoin 2 weeks on 2 weeks off). during the first year of follow-up both tnsc and neurophysiology 1 year after the end of consolidation cycle were consistent with full recovery. our patients developed sensory axonal neuropathy during ato therapy, that clinically manifested during consolidation cycles and improved up to complete recovery during follow-up. published case reports show that outcomes may not be as good as in our patients. a multicenter prospective study evaluating the characteristics of ato-induced neuropathy in apl is ongoing. ruiz m 1 , campagnolo m 1 , salvalaggio a 1 , cacciavillani m 2 , taioli f 3 , fabrizi gm 3 , briani c 1 . 1 department of neuroscience, neurology unit, university of padua, padua, italy; 2 data medica group, emg unit, cemes, padua, italy;mutations in the mitochondrial copper-binding protein sco2, cytochrome c oxidase assembly protein, have been reported in several cases of fatal infantile cardioencephalomyopathy with cox deficiency. we identified compound heterozygous variants in sco2 in two unrelated patients with isolated length dependent axonal sensorimotor polyneuropathy of variable clinical severity (axonal autosomal recessive charcot-marie-tooth disease type 4, cmt4) by whole exome sequencing. although peripheral neuropathy has been described as a secondary feature in a few cases of fatal infantile cardioencephalomyopathy, the disease onset, clinical phenotype and survival in our patients differ significantly from the previously described cases. our patients developed predominantly motor neuropathy; moreover, they are still alive and they have not developed cardiomyopathy, which is the main phenotype and cause of death at early infancy in reported patients. both of our patients harbor mutations adjacent or near the conserved copper-binding motif (cxxxc), including the common reported pathogenic variant e140k and the novel change d135g. in addition, each patient carries a second mutation located in the same loop region of the protein, p169t and r171q. western blots from fibroblasts from these cmt patients showed reduced levels of cox2, a subunit of complex iv, indicating cox deficiency. our findings demonstrate that cmt4 can be the predominant phenotype associated with sco2 mutations, pointing to a broader phenotypic heterogeneity. the mechanism linking mitochondrial respiratory chain dysfunction to isolated axonal loss of variable severity remains to be elucidated. the muscarinic acetylcholine (ach) type 1 receptor (m 1 r) is a metabotropic g protein-coupled receptor expressed by adult sensory neurons. cholinergic signaling through muscarinic receptors can modulate axonal plasticity in invertebrates and lower vertebrates. we have recently shown that selective (pirenzepine) and specific (muscarinic toxin 7: mt7) m 1 r antagonists elevate neurite outgrowth and protect from small and large fiber neuropathy in adult sensory neurons in various animal models (calcutt, et al., 2017) . furthermore, we demonstrated that excessive cholinergic signaling due to m 1 r overexpression caused a significant reduction in neurite outgrowth (calcutt, et al., 2017) . the mechanism of m 1 r-antagonist driven neurite outgrowth remains poorly understood, however, we have proposed that ach constrains axonal outgrowth via m 1 r activation. cholinergic signaling is mediated via recruitment of trimeric g proteins, of which g alpha-12 and g alpha-13 regulate cytoskeleton dynamics by control of tubulin polymerization. activated gtp-bound g-alpha proteins destabilize microtubules by increasing the intrinsic gtpase activity of tubulin. we have therefore tested the hypothesis that cholinergic signaling regulates neurite outgrowth via modulation of g protein mobilization and the dynamics of the tubulin cytoskeleton. we found that over-expression of m 1 r in adult sensory neurons induced dissolution of the tubulin cytoskeleton in distal neurites. g alpha-13 expression in adult sensory neurons was significantly higher (p<0.001, 7-fold) than g alpha-12. subsequent knockdown the peripheral neuropathy research registry (pnrr) is a multicenter collaborative research project sponsored by the foundation for peripheral neuropathy to advance the science in distal symmetrical polyneuropathies (dsp). the registry was designed to prospectively characterize clinical phenotype and natural history of patients with dsp and obtain biofluids to identify new causes and genetic modifiers of dsp with careful genotype/phenotype correlations, and to develop biomarkers. the enrollment in the registry is still ongoing but an interim analysis was carried at the end of december 2016. eligible study participants were 18 years or older with a diagnosis of idiopathic, diabetic, chemotherapy-or hiv-induced peripheral neuropathy. they were examined by a physician at one of the six consortium members (johns hopkins university school of medicine, icahn school of medicine at mount sinai medical center, beth israel deaconess medical center, northwestern university medical center, university of utah medical center and kansas university medical center). the collected data set included (1) a detailed questionnaire, discussing their symptoms, medical history and family history, (2) a standardized neurological examination form, (3) electrodiagnostic evaluation and (4) diagnostic laboratory testing. blood samples (whole blood, plasma and serum) were collected for future biomarker and genotyping evaluations. at the end of 2016, complete data sets and blood samples were collected from 1150 patients. 31% had diabetic pn, 10% had hiv-associated pn, 7% had chemotherapy induced pn and 52% were diagnosed with idiopathic pn. detailed analysis of clinical presentation, examination findings and diagnostic investigations will be discussed at the presentation. standardized phenotyping with linked bio-specimen banking will help establish the minimum data set required for neuropathy diagnosis and support genotype-phenotype correlations with next generation sequencing technologies and development of novel biomarkers. pnrr data will improve our understanding of disease mechanisms paving the way for new therapeutic discoveries in painful and non-painful neuropathies. chemotherapy-induced peripheral neuropathy (cipn) is a major side effect of treatment, typically presenting as a sensory neuropathy. symptoms include pain, paraesthesia, and numbness in the extremities, resulting in functional impairment. increasingly, patient reported outcomes (pros) are utilized to accurately examine the impact of cipn symptoms on patient function. however, the links between objective neurological assessment and pro measures remain ill defined. this study aimed to identify links between neurophysiological measures and pros in patients treated with neurotoxic chemotherapy. assessments were conducted in 45 patients (f= 31, mean age 53.8 ±1.9 years) who had completed neurotoxic chemotherapy on average 9.7 ± 2 months previously (platinum-based n=17, taxane-based n=21 or taxane/platinum combination therapy n=7). patients reported the presence and severity of neuropathic symptoms via the fact-gog ntx13, a validated patient questionnaire. clinical the most important neurological side effect of a large number of anti-cancer drugs is a painful peripheral neuropathy. mainly chemotherapeutics that interfere with microtubules, including the plant derived vinca-alkaloids such as vincristine, are well known to cause chemotherapy-induced peripheral neuropathies (cipn). to date, few treatments are available and focus on symptom alleviation and pain reduction rather than on preventing the neuropathy all together. for the first time, we highlight the potential of specific histone deacetylase 6 (hdac6) inhibitors as a preventive therapy for cipn, using novel rodent models for vincristine-induced peripheral neuropathies (vipn), characterized by a sensory axonopathy. one reason so few therapies are available, is because the exact pathophysiological mechanisms are poorly understood. mounting evidence proposes axonal transport, a pathway frequently disturbed in neurological disorders, as a major player in the pathophysiology of vipn. proper axonal transport requires dynamic microtubules which are highly modulated by post-translational modifications. since vincristine interferes with the polymerization of microtubules, we reason disturbances in microtubule dynamics, and by extension axonal transport, could contribute to vipn. we illustrate that increasing acetylation of -tubulin after hdac6-inhibition, can restore vincristine-induced defects in axonal transport in cultured dorsal root ganglion neurons. also in vivo, -tubulin acetylation was restored in the saphenous nerve and dorsal root ganglia, two sensory tissues that are affected by vincristine. ultimately, this correlates to a reduced severity of the neurological symptoms, both on the electrophysiological and on the behavioral level. moreover, we discovered that hdac6-inhibition was not only protective against neurotoxicity, but also reduced tumor progression in a mouse model for acute lymphoblastic leukemia. taken together, our results show that hdac6-inhibition is an ideal strategy to prevent vipn with beneficial effects both on the neurotoxicity as well as on tumor growth.approximately two-thirds of cidp subjects need long-term corticosteroids or intravenous immunoglobulins (ivig), with ivig being slightly preferred based on safety profiles. subcutaneous ig (scig) is an alternative option for ig delivery but has not previously been investigated in a large-scale clinical trial in cidp.we performed a randomized, double-blind trial in cidp investigating 0.2 and 0.4 g/kg weekly doses of scig igpro20 (hizentra ® , csl behring) versus placebo in 172 subjects for maintenance treatment. ivig-dependent adults with definite or probable cidp according to efns/pns criteria were eligible. the primary outcome was the percentage of subjects with a cidp relapse (1-point deterioration on adjusted incat disability score) or who were withdrawn for any other reason during the 24-week scig-treatment period. multiple secondary endpoints were assessed. superiority of at least one igpro20 dose over placebo was tested one-sided using the cochran-armitage trend test for the primary outcome and the jonckheere-terpstra tests for secondary outcomes.the primary outcome occurred in 33% of high-dose scig, 39% of low-dose scig, and 63% of placebo subjects (p < 0.001); cidp relapse occurred in 19% of high-dose scig, 33% of low-dose scig and 56% of placebo subjects (p < 0.001), respectively. both scig doses were superior to placebo (low-dose vs placebo p = 0.007; high dose vs placebo p < 0.001). median incat score, mrc sum score, and grip strength remained stable in scig subjects. high-dose scig prevented the r-ods decline seen with low-dose scig and placebo (p < 0.001). all placebo subjects deteriorated on measures of strength and disability.causally related adverse events occurred in 47 (27%) subjects (18% placebo, 30% low dose, and 35% high dose).scig igpro20 was efficacious and safe as maintenance treatment. mutations in metalloendopeptidase (mme) gene have been associated with autosomal-recessive late-onset charcot-marie-tooth type-2 (cmt2). to date, all patients have had at least one truncating mutation, either in homozygosity or in trans with a missense mutation. more recently, loss-of-function and missense heterozygous mutations were also identified in autosomal-dominant cmt. we report the case of a previously healthy caucasian woman, born to healthy unrelated parents, who presented at the age of thirty-nine with numbness and cold sensation in the lower limbs. subsequently she developed progressive gait disturbance and impaired hand dexterity. her homozygous twin presented at the same age with similar symptoms. the family history was otherwise uneventful, in particular neither neuropathy nor dementia were described. neurological examination at the age of fifty-three revealed a steppage gait, distal upper and lower limb atrophy and weakness, distal sensory loss and bilateral pes cavus. deep tendon reflexes were normal in the upper limbs and absent in the lower limbs. nerve conduction studies revealed an axonal sensory and motor neuropathy. a sural nerve biopsy revealed a reduction in myelinated nerve fibers and active axonal degeneration. targeted sanger sequencing of mpz , gjb1, gdap1, nefl, fkrp, bscl2, hspb8 and mfn2 were negative. sureselect focused exome sequencing was therefore performed and identified two missense heterozygous mutations [c.263g>a,p.c88y;c.1279t>c,p.y427h] or lack of efficacy (n=20). most frequently reported adverse events were cognitive (26%), gastrointestinal (14%) and genitourinary (9%). discontinuation due to perception of lack of efficacy was more frequently reported by men (75% vs 25% p=0.001). women presented higher punctuations on pigc scale compared with men (3.8±2.1 vs 1.9±1.7, p=0.005). pigc scores were significantly higher in patients receiving taxane (3.8±2.4) than platinum (2.5±1.9) agents (p=0.027). no significant differences according severity of neuropathy neither type of chemotherapy were observed in drop-out and retention rates. patients with long-lasting cipn (>6 months) reported lower pigc scores (2.1±1.7 vs 3.7±2.3, p=0.008) and higher frequency of suspension due to adverse events (22% vs 15%, p=0.039) and less rate of continuation of duloxetine (12% vs 26%, p=0.024). more than one-third of patients with disturbing cipn discontinued duloxetine prematurely due to intolerable side-effects. low tolerability, male gender and long-lasting cipn may limit duloxetine usefulness in the treatment of symptomatic cipn. verboon c 1 , jacobs bc 1,2 and the igos consortium. 1 department of neurology, erasmus medical centre, rotterdam, the netherlands; 2 department of immunology, erasmus medical centre, rotterdam, the netherlands.the efficacy of intravenous immunoglobulin (ivig) in guillain-barré syndrome (gbs) has only been demonstrated in severely affected patients who are unable to walk independently. although there is no proof that ivig is effective in milder forms of gbs, some neurologists are treating these patients with ivig considering that even milder forms of gbs may result in poor recovery, residual deficits, fatigue or pain.we determined the effectiveness of a single course of ivig (2 g/kg in 2-5 days) in relatively mild forms of gbs in the ongoing observational international gbs outcome study (igos). the gbs disability score, mrc sum score and patient reported outcome measures (prom) were compared at 4 and 26 weeks. ordinal logistic regression analysis was used to determine the effect of ivig on the gbs disability score, adjusted for previously identified prognostic factors.data were analyzed from the first 1300 patients enrolled in igos by december 2016, including 238 patients with mild gbs at entry, of which 68 patients (29%) were treated with supportive care, while 170 patients (71%) received ivig (start ivig after onset of symptoms in days, median 6, iqr 4-9). at baseline, patients in the ivig treated group compared to the untreated group less frequently had pure motor gbs (10% versus 31%, p<0.001) and axonal damage or unresponsive nerves (7% versus 19%, p=0.032), but a worse gbs disability scores at nadir (p=0.005). the adjusted common odds ratio for a better gbs disability score at 4 weeks was 2.81 (95% ci 1.34-5.89). at 4 weeks, the median mrc sum scores and prom were not significantly different between treated and untreated patients. however, more patients in the ivig group showed complete recovery of muscle strength at 4 weeks than patients in the control group (71% versus 53%) (p=0.01) and more frequently showed full neurological recovery on the gbs disability scale (13% versus 3%, p=0.03). additional results will be presented at the conference.based on the results of this interim analysis in observational data, we conclude that patients with a relatively mild form of gbs may benefit from a single course of ivig. despite treatment with intravenous immunoglobulin (ivig), many patients with guillain-barré syndrome (gbs) recover insufficiently. we primarily aimed to determine whether a second ivig course (2 g/kg in 2-5 days) in patients with a poor prognosis improves outcome on the gbs disability scale after 4 weeks. we included patients from the prospective, observational international gbs outcome study (igos) treated with ivig and who had a poor prognosis on the modified erasmus gbs outcome score (megos). of 1300 patients enrolled in igos, 239 patients were eligible; 200 patients (84%) were treated with one ivig course (control group); 19 patients (8%) received an 'early' second ivig course (1-2 weeks after start first course) and 20 patients (8%) a 'late' second ivig course (within 2-4 weeks). one week after study entry, patients receiving an 'early' or 'late' second ivig course had significantly worse gbs disability scores and mrc sum scores than controls, implying the need for adjustment of baseline characteristics. the adjusted common odds ratio for a better gbs disability score at 4 weeks was 0.69 (95% ci 0.19-2.42) for the 'early' group, and 0.51 (95% ci 0.15-1.73) for the 'late' group, suggesting worse outcomes with a second course of ivig compared to controls. at 6 months, 10 patients (71%) in the 'early' second ivig group, 100 patients (65%) in the control group and only 2 (18%) in the 'late' second ivig group were able to walk unaided (p=0.006). the adjusted common odds ratio for a better gbs disability score at 26 weeks was 1.66 (95% ci 0.44-6.21) for the 'early' second ivig group and only 0.53 (95% ci 0.14-1.96) for the 'late' second ivig group. in gbs patients with a poor prognosis, we did not find a beneficial effect of a second course of ivig after 4 weeks follow-up. our results suggest that an 'early' administered second ivig course might improve outcome at 26 weeks. given the limitations of this observational study, a randomized controlled trial with a larger number of gbs patients with a poor prognosis being treated early in the disease course is needed to confirm or refute these results. vidal c 1 , bhatt n 1 , agudelo c 1 , mahapatra a 1 , saporta ma 1 . 1 department of neurology, university of miami miller school of medicine, miami, usa.multifocal motor neuropathy (mmn) is an inflammatory demyelinating chronic neuropathy characterized by progressive asymmetric weakness in the distribution of two or more peripheral nerves, without objective sensory loss or upper motor neuron signs. the cardinal neurophysiological finding is conduction block outside the usual sites of nerve compression. supportive clinical criteria include high titers of anti-gm1 antibodies, good response to ivig, increased cerebrospinal fluid (csf) protein (<1g/dl) and magnetic resonance imaging (mri) with diffuse swelling of the brachial plexus. we report a case of a 31 year old woman with a two month history of progressive muscular weakness which began in the right upper extremity, described as difficulty in gripping objects, writing and typing on the computer, followed by progressive lower extremity weakness with difficulty rising from a chair and left foot drop. she also complained of pain in her right trapezius and scapular area. she denied any tingling or numbness. on neurological examination there was right scapular winging and asymmetric weakness predominantly involving the right upper and left lower extremities. reflexes were absent throughout. lumbar puncture revealed albuminocytological dissociation (wbc 0 and protein 1.13 g/dl). ncs revealed slow conduction velocities for both ulnar and median nerves and a median nerve conduction block at the forearm segment. sensory nerve action potentials were normal for all tested nerves. needle emg revealed acute denervation of right periscapular muscles. brachial plexus mri showed symmetric bilateral thickening from trunks to peripheral nerves. anti-gm1 igg/igm were negative. two days after lumbar puncture and the beginning of ivig, patient presented binocular diplopia on extreme left lateral gaze. brain mri with and without contrast showed no intracranial pathologies. after five days of ivig, patient was discharged with significant clinical improvement and recovery of the right scapular winging. diplopia improved a week after discharge. we report an atypical multifocal motor neuropathy case. although this patient fulfills all clinical criteria for mmn, we report some features usually not found in mmn such as scapular winging and a mild and transient left vi nerve palsy. mmn should be included in the differential diagnosis of scapular winging. vlckova e 1,2 , raputova j 1,2 , srotova i 1,2 , sommer c 3 , üçeyler n 3 , birklein f 4 , rebhorn c 4 , rittner hl 5 , kovalova e 1,2 , nekvapilova e 1,2 , belobradkova j 6 , olsovsky j 7 , weber p 8 , dusek l 9 , jarkovsky j 9 , bednarik j 1,2 . despite many studies addressing biomarkers for pain in diabetic polyneuropathy (dpn), little is known about why it affects only a certain proportion of dpn patients. the somatosensory system plays a key role in the pathophysiology of neuropathic pain (neup) and subgroups with different sensory profiles might respond differently to pain treatment. we aimed to characterize sensory phenotypes of patients with painful and painless diabetic neuropathy and to assess demographic, clinical, metabolic, electrophysiological and psychological parameters related to the presence of neup in a large cohort of well-defined dpn subjects.this observational cross-sectional multi-centre cohort study (performed as part of the ncrnapain eu consortium) of 232 subjects with dpn (non-painful, ndpn, n=74; painful, pdpn n=158) associated with diabetes mellitus of type 1 and 2 (median age 63 years, range 21-87 years; 92 women) comprised detailed history taking, neurological examination, laboratory tests, quantitative sensory testing, nerve conduction studies, neuropathy severity scores, and neuropsychological questionnaires. all parameters were analysed with regard to the presence and severity of neup. the presence and severity of neup were positively correlated with severity of neuropathy and thermal hyposensitivity (p<0.001). a minority of pdpn patients (14.6%) had a sensory profile indicating thermal hypersensitivity; this was associated with less severe neuropathy and better response to pain therapy. the presence of neup was also associated with female gender (p<0.001) and with higher cognitive appraisal of pain as assessed by the pain catastrophizing scale (p<0.001), while parameters related to diabetes (duration, hba1c, microangiopathy) showed no influence on neup presence and severity. this study confirms the necessity of comprehensive dpn phenotyping and underlines the importance of the severity of neuropathy that should be taken into account in the stratification of patients with pdpn for analgesic treatment and drug trials.people with charcot marie tooth disease (cmt) experience slowly progressive muscle weakness, sensory loss and musculoskeletal changes over time. this leads to disability and risk of comorbidities due to inactivity. exercise is important to maintain general health but may also help to improve symptoms of cmt. we conducted a randomised controlled crossover trial of aerobic exercise to ascertain the effect of training on fitness levels, muscle strength, function and general well-being. in addition, we monitored the safety of training and feasibility of participation in this type of exercise in local community gyms. motivation, confidence and barriers to exercise were explored using qualitative interviews. the recruitment target was 30 people. in total 282 people with cmt 1a were approached to participate and 191 were unable to commit to the trial or did not meet the study criteria on initial screening. thirty-one people underwent more detailed screening but three failed to meet the study criteria, five people withdrew before starting and three withdrew part way through the study. the data for the 23 people who started the study were analysed using a random effects model. there was a 76% participation level in the training and it was well tolerated with no increases in pain or blood serum creatine kinase. an increase in vo2peak (ml/min/kg) was observed in the cmt group with (pre training: n=21, 22.28 ±4.43, 95% ci 20.57 to 24.28; post training: n=21, 24.52 ±4.40, 95% ci 22.62 to 26.33; pre control: n=18, 22.67 ±5.29 95% ci 20.22 to 25.05; post control: n=18, 22.94 ±4.22, 95% ci 21.00 to 24.83) . there was wide between subject variation leading to a small overall effect size with cohen d of 0.1302785 (95% ci:-0.33 to 0.59). a tentative regression model showed no effect of group or time point. there were no major changes in other measures of impairment, function or patient reported outcome measures. this pilot study showed that a community based model of training had a small effect on cardiopulmonary fitness, and was well tolerated with good participation. ankle-foot orthoses (afo) are commonly prescribed for children with charcot-marie-tooth disease (cmt) to manage foot drop, however the type and severity of functional impairment results in gait deviations that might require alternate orthotic designs. the aim of this study was to identify 3d gait patterns of children with cmt based on severity of functional weakness (based on heel walk, toe walk and foot drop items during gait using the cmt pediatric scale) to inform a design pipeline for 3d printed orthoses. 3d gait data were captured with an 8-camera vicon nexus motion capture system using the lower body plug-in-gait model in 60 children with cmt (34 male; 11±3.1yrs, 147±16.8cm, 44±17.4kg), of various cmt types: 47 cmt1a, 1 cmt1e, 2 cmt1f, 1 cmt2a, 2 cmt 4c, 4 cmtx1, 3 cmtx3 and compared to 50 typically developing children (15 male; 9.8±3.8yrs, 140±19.6cm, 9±19.0kg). data were subdivided into three groups denoting increasing severity of dorsiflexion and plantarflexion weakness: no difficulty heel or toe walking (cmt nd ), difficulty heel walking (cmt dh ), difficulty toe and heel walking (cmt dth ). the cmt nd group showed a near-normal gait pattern. the only significant differences noted at the ankle were reduced peak dorsiflexion in stance (p<0.05), indicating that an orthotic intervention may not be required. in addition to reduced peak dorsiflexion, the cmt dh group demonstrated significantly reduced dorsiflexion in swing (foot-drop) and a reduced dorsiflexor moment in loading response (p<0.001). this suggest, the cmt dh group would require a flexible afo to allow activation of the plantarflexors during push-off, prevent foot-drop and restore a heel rocker in loading response. in contrast, the cmt dth group presented with significantly delayed and increased peak dorsiflexion in stance and reduced plantarflexion and power at push-off (p<0.05). they also had significantly increased mean knee extensor moment (p<0.05) revealing early signs of 'crouch gait'. therefore, the cmt dth group would require a rigid afo to limit the amount of dorsiflexion and assist movement of the ground reaction force anterior to the knee during stance. three distinct gait patterns at the ankle were identified in children with cmt, indicating patient-specific orthotic design pathways to target specific functional impairment. wojciechowski e 1,2 , chang a 1 , cheng t 1,2 , little d 1,2 , menezes mp 1,2 , hogan s 2 , burns j 1,2 . 1 university of sydney, new south wales, australia; 2 sydney children's hospitals network (randwick and westmead), new south wales, australia.children with cmt are often prescribed ankle-foot orthoses (afo) to manage lower limb impairment such as foot drop and foot deformities. they are handmade by plaster cast followed by thermoplastic moulding. this traditional approach provides limited design options, can be costly, with long outpatient wait times. 3d printing, also known as additive manufacturing, has the potential to transform the way orthoses are prescribed, designed and manufactured. the aim of this review was to evaluate the evidence of 3d printing afos compared to traditional manufacturing methods, for children with cmt. there are currently no studies evaluating the application of 3d printing afos for children with cmt. however, a small, but emerging evidence base exists for 3d printed afo's in adults from studies including healthy participants and populations with rheumatoid arthritis, post-polio syndrome, foot drop and ankle weakness secondary to injury. samples sizes ranged from 7-38 participants for studies related to in-shoe orthoses and from 1-10 for studies related to afos. the methods of 3d printing included sterolithography, selective laser sintering and fused deposition modelling using materials such as nylon 11, nylon 12, polylactide, polycarbonate and abs. 3d printed afos were comparable to traditional manufactured orthoses in terms of patient-perceived comfort, temporal-spatial parameters, plantar pressure measurements and 3d gait analysis. however, the effects of long-term usage and durability of 3d printed afos has not been investigated. 3d printing orthoses have potential advantages including increased design possibilities, improved productivity, higher compliance, and reduced labour needs. disadvantages include redesigning clinical pathways, limited evidence base for clinical effectiveness, limited biocompatible materials, occupational safety considerations and a high level of expertise required for software operation and fabrication of devices. further research is required to determine the feasibility of 3d printed afos for children with cmt, and the most appropriate and effective printing pathway, materials to improve health outcomes of affected patients. wong shj 1 , koh sj 2 , lee bjh 1 , chng ysk 3 , pawa c 3 , subramaniam t 4 , cheng ksa 4 , umapathi t 2 . 1 lee kong chian school of medicine, nanyang technological university, singapore; 2 national neuroscience institute, singapore; 3 yong loo lin school of medicine, national university singapore, singapore; 4 khoo teck puat hospital, singapore.treatment-induced neuropathy of diabetes mellitus (dm) (tind) is a complication of rapid glycaemic control. individuals present with neuropathic pain and autonomic dysfunction within 8 weeks of improvement in glucose control. the use of both insulin and oral hypoglycaemic agents has been associated with tind. its severity is determined by the rate and quantum of hba1c decline. other predisposing factors include anorexia and weight loss. we studied the incidence of tind in dm patients who have undergone massive weight loss and hba1c decline after bariatric surgery. we screened electronic records of 159 patients (74 dm, 85 non-dm) who underwent bariatric surgery between 2012 and 2015. 14 dm patients fulfilled the tind hba1c criteria of a decrease of ≥2% over 3 months or ≥4% over 6 key: cord-021087-n4epxwn9 authors: nan title: ecr – final programme: scientific and educational exhibits date: 2004 journal: nan doi: 10.1007/s10406-005-0142-5 sha: doc_id: 21087 cord_uid: n4epxwn9 nan contrast enhanced ultrasonography (ceus) of pancreatic masses m. d'onofrio, s. vasori, u. rozzanigo, s. caffarri, n. faccioli, c. procacci; verona/it purpose: to evaluate the role of ceus in the study of solid and cystic masses of the pancreas. materials and methods: 100 masses of the pancreas, found on conventional us, were studied with ceus, by using sonovue (bracco) on a sequoia 512 (acuson). a dynamic observation from the early contrastographic phase (during arterial enhancement), to the late contrastographic phase (after venous enhancement) was possible. all the lesions were cytologically/histologically proved. the results were compared with those obtained at spiral ct and/or mri. seven distinct enhancement patterns were observed: 1) rapid intense enhancement in the early contrastographic phases with microbubble entrapment in the late phase [14 neuroendocrine tumors, 4 metastases from hypervascular tumors, 3 poorly differentiated carcinomas]; 2) moderate enhancement in the early contrastographic phase, resulting hypoechoic in the late phase [6 poorly differentiated carcinomas, 1 acinar cell carcinoma, 18 neuroendocrine tumors]; 3) capsular enhancement in the earliest phases [1 solid and papillary epithelial neoplasm; 2 neuroendocrine tumor]; 4) no enhancement [32 ductal adenocarcinomas and 2 neuroendocrine tumor]; 5) progressive enhancement [1 solid and papillary epithelial neoplasm]; 6) "parenchymographic" enhancement [12 inflammatory masses]; 7) parietal nodules and septas enhancement [4 cystic tumors] . results: ceus correctly characterized 74/84 (88%) solid pancreatic tumors. in particular all (32/32) the ductal adenocarcinomas were correctly diagnosed. small nodules and septas of pancreatic cystic tumors, not visible at conventional us, were detected at ceus. conclusions: ceus can demostrate macrocirculation and microcirculation of solid pancreatic masses and can improve the characterization of cystic pancreatic lesions. is dual-phase spiral ct adequate for the confirmation of resectability and preoperative staging of pancreatic carcinoma? s. mylona, l. thanos, a. pagonas, v. kalioras, s. lyra, n. batakis; athens/gr purpose: to present the value of dual-phase spiral ct for the confirmation of resectability and pre-operative staging of pancreatic carcinoma. materials and methods: in a period of 4 years 184 patients with pancreatic carcinoma underwent dual-phase spiral ct for preoperative staging. ct scans after iv administration of contrast material with an electronic injector were obtained in the arterial (scan delay = 20 sec) and in the portal venous phase (scan delay = 50 sec) under a protocol with a total volume of 150 ml, flow rate 5 ml/sec. we have correlated the ct findings with surgical-pathologo-anatomic findings. results: dual-phase spiral ct was positive for pancreatic carcinoma in 178 patients (96.7%). in 6 patients it was false-positive (3.3%). in 44 (78.4%) out of 55 patients it showed hepatic metastases, in 33 (64.7%) out of 51 patients it showed lymph node enlargement, in 49 (88%) out of 60 patients vascular invasion, and in 8 (66.6%) out of 12 patients peritoneal metastases. the accuracy of the method was up to 90%. conclusion: dual-phase spiral ct is a safe, noninvasive, and accurate method to investigate pancreatic carcinoma and should be considered as the standard preoperative method for assessing lesion resectability. assessment of resectability of pancreatic head cancer with ct imaging g.g. karmazanovsky, v.a. kubyshkin, a.v. kotchatkov; moscow/ru purpose: to investigate the value of preoperative ct in assessment of resectability of pancreatic head cancer. methods and materials: eighty-nine patients (52 males and 37 females; mean age 60) with pancreatic head adenocarcinoma were investigated with spiral ct with bolus intravenous contrast enhancement. all of the patients were operated on. whipple procedures were performed on 56 patients and palliative operations were performed on 33 patients. results: tumors of 24 patients were considered unresectable. 11 patients (group 1) had tumors that were encircling superior mesenteric or portal veins (8 pts), superior mesenteric (2 pts) or hepatic arteries (1 pts) completely. no fat layer was identifiable between the tumors and the vessels. 13 patients (group 2) had ct appearances of tumors that partially (less than 2/3 of the circumference and in less than 20 mm) circumscribed the vessels. tumors of all group 1 patients were not resectable with a negative margin. among group 2, four patients (30.8%) had unresectable tumors; six patients (46.1%) had tumors that were difficult to dissect from the vessels; 3 patients (23.1%) had no evidence of vascular involvement and in fact went through curative surgery. conclusion: the ct findings predicted correctly surgical findings in 21 of 24 unresectable tumors (87.5%). when the tumor partially circumscribed the vessels ct was not to be relied upon in predicting whether or not the tumor was fixed against the vessels. contrast-specific ultrasound (cs-us) imaging of the spleen: a pictorial essay of traumatic and nontraumatic disorders a. nunziata 1 , o. catalano 2 , m. mattace raso 2 , i. matarazzo 2 , a. siani 2 ; 1 naples/it, 2 pozzuoli/it learning objective: to illustrate the appearance of several splenic lesions as shown during real-time, contrast-specific, harmonic imaging. background: contrast-enhanced, low-mechanical index us is a new technique allowing continuous, real-time assessment of splenic abnormalities. in our institution we use the technology named contrast tuned imaging (esaote, italy) and we employ a second-generation, sulfur-exafluoride based, microbubble contrast agent (sonovue-bracco, italy). the contrast agent, at a volume of 2.4 or 4.8 ml, in injected through a peripheral vein and a 20 g needle, using a three-way stopcock and a 5-ml normal saline flushing. imaging findings: a wide spectrum of splenic disorders is depicted: injury, spontaneous hematoma, abscess, capillary and cavernous hemangioma, lymphomatous infiltration, metastasis, splenomegaly, and accessory spleen. several potential pitfalls are also shown. conclusion: contrast-specific us is being used with increasing frequency in the evaluation of the spleen. this is a superficial organ, with an almost homogeneous echotexture and with a dense and persistent contrast-enhancement; these characteristics make the spleen an optimal organ to be studied with contrast-specific us. radiologists should be aware of the typical and atypical appearance of splenic disorders as shown at contrast-specific us imaging. the spleen: normal variants and pathologies (imaging review) s. vessal, a. anbarasu, s.b. rai, w. shatwell, r. ramachandra; birmingham/uk learning objectives: to familiarise with the normal anatomy of the spleen. to further demonstrate common variations and splenic pathologies encountered in clinical practice. background: the spleen is the largest single mass of lymphoid tissue seen in the body. we familiarise with its normal image appearance using ct, uss and mri. the pattern of contrast enhancement of the spleen during the arterial and venous phases in ct can mimic disease by forming pseudomasses. normal variants such as splenunculus, splenic clefts/lobulations, liver wrap-around, wandering spleen as well as congenital heterotaxic syndromes will be discussed. a spectrum of splenic pathologies are demonstrated and the list of differential diagnoses that should be considered when seeing splenomegaly, cystic lesions, solid lesions and splenic calcification. examples of splenic trauma -laceration, subcapsular and intraparencymal haematoma will be discussed and complications such as splenosis demonstrated. image findings: images of the spleen on plain radiography, ct, mri, uss and radionuclide imaging from our institution are demonstrated along with imaging protocols. conclusion: there are several normal variants of the spleen which should be readily recognised. congenital abnormalities of the spleen such as polysplenia are rare, this should not be misdiagnosed as splenosis. it is useful to assess the presence and extent of splenomegaly. further classification of parenchymal lesions into cystic or solid can be made. solid lesions can be further subclassified into those with calcification. this poster demonstrates some splenic pathologies, a clear list of differential diagnosis is essential in interpreting any splenic lesion. non-traumatic acute splenic lesions: role of ct f. garibaldi, y. hetmaniak, b. gallix, j.-m. bruel; montpellier/fr learning objectives: 1-to illustrate a pictorial review of various acute splenic pathologies of non traumatic origin. 2-to learn characteristic imaging features of spontaneous spleen rupture or splenic infarction. 3-understand the pivotal role of abdominal ct when acute splenic pathology is suspected. background: splenic pathology is rarely suspected in patients with acute pain of the left upper abdominal quadrant. ct imaging is a well established tool for splenic injury of traumatic origin but ct features of non traumatic acute splenic pathology are less known. the purpose of this exhibit is to review the main causes of non traumatic acute splenic lesions and to describe their specific ct patterns. b d e f a g procedures: material consisted of 30 patients with acute non traumatic splenic pathology who underwent multiphase contrast enhanced ct examination of the abdomen. the medical report of these patients were reviewed. cases were categorized according to the presence of the main ct patterns we found: spontaneous rupture, ischemic lesion, abscess or pseudo cyst or complicated tumoral involvement. conclusion: helical ct, in association with patients history and biology results is accurate to characterize the severity and the causes of acute non traumatic splenic injury. the new ultrasound who-classification for diagnosis, staging and follow-up of patients with cystic echinococcosis (ce) w.p. hosch, g.w. kauffmann, t. junghanss; heidelberg/de learning objects: the new who-classification provides, for the first time, a standardized sonomorphological staging of echinococcal cysts. we demonstrate the clinical value of this classification with examples from our cohort of patients. specific signs supporting the diagnosis of ce, and criteria for assessing cyst viability are presented. this allows staging of cysts relevant for treatment decisions (surgery, percutaneous drainage (pair), albendazole or "watch&wait") and treatment monitoring. background: ultrasonography plays a central role for diagnosis and follow-up of abdominal ce due to problems regarding sensitivity and specificity of clinical symptoms and serological tests. this technique allows the staging of cysts with respect to the involution process (spontaneous and treatment induced). the treatment options of ce have broadened in recent years with percutaneous drainage (pair), medical treatment and "watch&wait" as preferable strategies over surgery for specific cyst stages. in 2001 a standardized classification has been published by who allowing inter-observer comparison of treatment decisions and follow-up. procedure details: 55 patients with a follow-up of up to 4 years have been seen in our referral centre for ce since 1999. apart from 3 patients with pulmonary lesions and 1 patient with a spinal manifestation, all other patients had abdominal cysts (63 hepatic, 1 spleen, 1 kidney, 1 peritoneal). we evaluated the value of the who-classification for diagnosis, therapeutic decision making and follow-up. conclusion: on the basis of the who-classification ultrasonography is not only an excellent tool for the primary diagnosis of ce but also very valuable for clinical decision making and monitoring treatment response. the spectrum of manifestations of metastatic malignant melanoma c.s. ng, v. kundra, m.j. jacobson, j. szklaruk, d.g. bedi; houston, tx/us learning objectives: 1. to gain an appreciation of, and be alert in clinical practice to, the wide range of sites, both common and uncommon, of metastases from malignant melanoma, including the lymphatic, central nervous, and musculoskeletal systems, thorax, abdomen and pelvis. 2. to become familiar with the radiologic appearances of metastatic melanoma on ct, mr, and ultrasound. background: malignant melanoma is a tumor that is increasing in incidence throughout the world, with a widely varying prognosis and distinctly capricious behavior. if, and when, the tumor metastasizes it can spread in an expected manner; however, frequently both the timing and sites of dissemination can be entirely unpredictable. imaging findings: this exhibit will present the wide range of manifestations of metastatic melanoma throughout the body, including the lymphatic, central nervous, and musculoskeletal systems, chest, abdomen and pelvis, and soft tissues, as identified by the major cross-sectional modalities of ct, mr, and ultrasound. the hypervascular and hemorrhagic tendency of the tumor, and its typical mr signal characteristics, will be illustrated. the exhibit will demonstrate the typical sites of metastases, namely lymphatics, brain, lungs, and liver; but will also illustrate the wide spectrum of more unusual sites of dissemination, including meninges, pleura, pancreas, gallbladder, gastrointestinal tract, genitourinary tract, peritoneal cavity, skeletal muscle and bone. the illustrative examples will be correlated with the tnm staging system. conclusions: metastatic malignant melanoma has an extremely wide spectrum of manifestations. practicing radiologists should be alert to these manifestations. malignancies in the aids affected population other neoplasms such as cervical cancer, hodgkin's disease and others have been observed with an increased incidence, probably because of the longer survival of aids patients. the aim of our exhibit is to describe ct and mr features of aids related neoplasms. procedure details: we reviewed ctand mr findings of 484 aids patients examined between 1986-2003, amongst which 178 demonstrated pathologically confirmed neoplasms. ct's were performed by using spiral (plus, plus 4, siemens, erlangen, germany), and multislice ct equipment (lightspeed 16 ge medical systems, milwaukee, usa); mr examinations were performed by using a 1.5 unit (vision; siemens medical systems, erlangen, germany) . we demonstrated 65 nhls, 9 hodgkin's disease, 61 ks, 6 cervical cancers, 8 leukaemias, 3 testicular, 2 larynx, 3 lung, 2 breast, 2 esophagus, 2 stomach, 3 liver, 4 kidney, and 4 adrenal carcinomas, 1 intrahepatic multinodular cholangiocarcinoma and 3 stromal tumors of the gastrointestinal tract. 45/65 nhl showed extranodal involvement to the liver (19/65), brain (13/65), lung (16/65), pleura (2 primary effusion lymphomas with lymphomatous cells in the pleural effusion and no identifiable tumor mass) and gastrointestinal tract (12/65). ks involved the gastrointestinal tract (12), lung (16), liver (6), larynx (1), muscle (1) , adrenal gland (1), spleen (2), pancreas (1) . conclusion: ct and mr proved useful in the evaluation of the variegate pathologic findings of aids related neoplasms. abdominal imaging of post transplant lymphoproliferative disorders (ptld) k. burney, i. lyburn, r. hopkins; cheltenham/uk learning objectives: this exhibit will review the pathogenesis, staging and abdominal imaging findings of post-transplant lymphoproliferative disorders (ptld) seen in cardiac, lung, renal and liver transplant organ recipients. background: post-transplant lymphoproliferative disorders (ptld) are a complication of immunosuppression in solid organ transplant recipients. we reviewed the imaging of patients with a histologically proven diagnosis of ptld treated at our sub-regional oncology unit over the past 5 years. conclusion: ptld is estimated to occur in between 2-5% of patients. clinical manifestations are variable ranging from focal disease with graft dysfunction to systemic illness. ptld may be unsuspected or more extensive than expected and imaging plays an important role in diagnosis, staging and follow-up. ct (and to a lesser extent us) is the imaging modality of choice. does clinical examination of polytrauma guide properly ct evaluation? a. kalai, y.k. maratos, t. loeb, o. clément, g. frija; paris/fr learning objectives: to know the new definition of polytrauma patient based on the risk factor. to know that a whole body scanner is indicated in polytrauma patient. to know the ct protocol in polytrauma. background: the evaluation of the polytrauma patient is still most of time based on regional ct oriented with the clinical finding. based on our experience in 100 patients this exhibit purposes a systematic evaluation with whole body scanner. major findings and pitfalls are illustrated. procedure details: whole body scanner includes: axial head ct, cervical spine helical ct with sagittal and coronal recontructions, helical ct with contrast iv with an arterial phase on the thorax and portal phase an the abdomen and pelvis, sagittal reconstruction on the dorsolombar spine. the severity of the lesions after the clinical evaluation were compared to the iss (index severity score) after the whole-body scan. 30% of the patients had at least one missed lesion when compared to clinical assessment .the average iss of these patients was higher and there was a surmortality. conclusion: whole-body scanning is highly recommended for polytrauma victims in order to enable prompt and early treatment of lesions which might have been missed at the initial clinical evaluation. radiological exploration of the embalmed cadaver of eva peron c. gotta, a. buzzi; buenos aires/ar learning objectives: to exhibit for the first time a medical document of eva perón's embalmed cadaver. background: eva perón was juan domingo peron's wife (he was president in argentina between 1946 argentina between and 1955 argentina between , and between 1973 argentina between and 1974 . for her political and social action she is known worldwide. she died of a cervix cancer in 1952. when she died, she weighed less than 30 kg, so many people doubt that her embalmed cadaver (small and consumed) belonged to her. the cadaver was embalmed by dr pedro ara, professor of anatomy at the school of medicine of the university of cordoba. he was born in zaragoza, spain, and he was established in argentina in the decade of 1930. professor ara carried out excellent work with eva peron's cadaver. contrary to the classical technique, eva peron's embalmed body conserves its viscera. imaging findings: when the régime was overthrown in 1955 eva peron's cadaver was deposited in the general confederation of work ("confederacion general del trabajo", cgt). the new authorities doubted of the authenticity of the cadaver. radiological exams were made by dr guido gotta (father of one of the authors), who confirmed that the body corresponded to a human being, and that there was evidence of neoplasia (abdominal nodules, bone metastasis). conclusions: besides its medical use, thanks to its capacity to examine the interior of bodies, since their discovery x-rays were used for other purposes. in this case, they were used to determine the authenticity of eva peron's embalmed cadaver. imaging of complications of drug abuse s. van background: the material is culled from our databank of the emergency department of our institution. the age of the patients in our series ranged between 17and 30-years-old. imaging findings: complications of drug abuse in the drug addict will be classified according to their pathogenic mechanism or by their way of administration. pathologically, complications are usually due to their vasoconstrictive and thrombogenic effect on different organs, including the brain (stroke), heart (myocardial ischemia), the gastro-intestinal system (ischemic colitis), the nose (nasal septum perforation due to cocaine snorting). a direct toxic effect of drug metabolites is another pathogenic mechanism resulting in tissue necrosis, as typically seen in liver cell necrosis due to ecstacy. the route of administration (intravenously, orally, inhalation or smoking) may also reflect the radiological presentation. local abscess formation, septic thrombophlebitis, septic pulmonary emboli or bloodborn infections result from intravenous access, whereas inhalation and smoking may result in pneumothorax, pneumomediastinum and epidural pneumatosis. indirect complications, such as an increased risk for traffic accidents can be attributed to the additive effect of a cocktail of drugs and/or alcohol. complications related to smuggling are due to accidental rupture of packed drugs in the gastrointestinal lumen. the radiologist should be aware of the possible causal relationship with drug abuse, especially when those complications are encountered in a young population. abdominal background: there is a broad spectrum of neurogenic tumors that involve the abdomen. in this exhibit, we will describe the variable radiologic findings of abdominal neurogenic tumors. this study included 46 patients with abdominal neurogenic tumors which were confirmed histologically by surgical resection (n = 29) or us guided biopsy (n = 17). two radiologists reviewed radiologic findings retrospectively and correlated with pathologic results. imaging findings: we categorized them into 3 groups by cell of origin; nerve sheath origin (schwannoma in 7, neurofibroma in 4, plexiform neurofibromatosis in 1, malignant peripheral nerve sheath tumor in 3), paraganglionic cell origin (paraganglioma in 7, pheochromocytoma in 8), and ganglion cell origin (ganglioneuroma in 5, ganglioneurofibroma in 2, ganglioneuroblastoma in 1, neuroblastoma in 8). conclusion: although abdominal neurogenic tumors show a broad spectrum, some neurogenic tumors revealed characteristic radiologic findings and correlated well with pathologic findings. familiarity with various neurogenic tumors in the abdomen is helpful in the approach of the diagnosis. purpose: to illustrate the broad spectrum of imaging findings (ct, us, urography and barium contrast studies) of patients with proven abdominal tuberculosis. we review between january 1998 and july 2003, the typical and atypical imaging findings of 52 patients that had a final diagnosis of genitourinary (13), adrenal (3), bowel (14), peritoneal (5), and hepatosplenic (16) tuberculosis. results: most patients had been at increased risk because of drug abuse, alcoholism, aids and steroid therapy. radiological findings included low density lymph nodes, splenomegaly, hepatomegaly, intrasplenic and intrahepatic masses, ascities, diffusely thickened and enhanced peritoneum, mottled low density masses in the omentum, pleural effusion, thickening of the bowel, adrenal enlargement, atrophy and calcification, fallopian tube fibrosis, uterine atrophy and adhesions, ureteral and bladder fibrosis, and different patterns of renal hydronephrosis and calcification. conclusion: patients with aids had more severe form of involvement than those who did not have aids. sonography was the only imaging modality to demostrate septations within the tuberculous ascites, but showed the fewest morphologic details in renal tuberculosis. ct is the imaging modality that best determined the extent of intrabdominal tuberculosis. recognition of these manifestations should help optimize the correct diagnosis and management of tuberculosis in order to obtain a favorable outcome, biopsy is mandatory in almost all cases. predictive to develop a predictive model for the presence of esophageal varices (ev) in patients with hepatic cirrhosis (hc). this model would limit the endoscopic screening to the group of patients with high risk of bleeding from ev. methods and materials: 42 consecutive patients with hc were included in this prospective study (20 men, 22 women; mean age 59.7). physical and laboratory examinations, upper gastrointestinal endoscopy and doppler ultrasonography were recorded. patients were divided in two groups: 1) no ev or small ev, 2) medium or large ev. the distribution of clinical, biochemical, and doppler ultrasonographic variables were compared in each group. the u statistic of mann-whitney was performed for the quantitative variables, whereas the chi-square or the fisher's exact tests were used for the qualitative ones. variables were also included in a multivariate stepwise logistic regression model. a roc-analysis was performed. results: in the stepwise logistic regression, presence of medium or large ev was independently predicted by splenomegaly, decreased platelet count, hcv infection and a decrease of the maximum portal flow velocity (mpv). the discriminating ability of the prediction rule was high, with an area under the roc curve of 0.92 (95% ci: 0.80-0.98). conclusion: patients with hc should be screened by upper gastrointestinal endoscopy only if splenomegaly, low platelet count, infection by hcv and decreased mpv are present, since these parameters confidently predict the existence of medium or large ev. premier experience of multiphasic contrast material-enhanced dynamic study on 3.0 tesla magnetic resonance (mr) imaging t.-j. hsieh, g.-c. liu; kaohsiung/tw purpose: to evaluate the accuracy and sensitivity of a dynamic contrast material-enhanced three-dimensional (3d) volumetric breath-hold hepatic magnetic resonance (mr) imaging examination on a 3.0 tesla machine. methods and materials: 3.0 tesla mr imaging with serial multiphasic contrast material-enhanced dynamic study was performed in 69 patients with hepatocellular carcinoma (hcc). all patients had pathologic comfirmation by fine needle biopsy and followed angiographies were performed in 1.5months. each test result was interpreted independently by two radiologists. separate reading sessions were performed for images from the multi-phases. sensitivity and positive predictive values were calculated for each reading session. results: one hundred twenty-nine early-enhancing lesions were detected in the 69 patients on the 3.0 tesla mr images. the followed angiographies showed 152 hypervascular tumor stains. all the lesions showed in the mr images were identified in the angiographies. the breath-hold dynamic examination on 3.0 telsa showed a overall sensitivity of 84.8%. conclusion: multiphasic contrast material-enhanced dynamic study on 3.0 tesla magnetic resonance (mr) imaging 3.0 tesla mr imaging is insensitive for the diagnosis of hccs. role the insulinomas are rare functional pancreatic neuroendocrine tumours. the most common clinical presentations include hypoglycaemia (< 2.8 mmol/l), confusion, and loss of consciousness. diagnosis is difficult, and performed by computed tomography, magnetic resonance or selective angiography of the pancreatic arteries by digital subtraction angiography (dsa). the aim of the study was to analyse head-to-head the diagnostic value of pancreatic dsa, computed tomography and magnetic resonance in 29 patients (25 female, 4 male; 37 ± 6 years) with insulinoma. the diagnosis was established by pathohistology after the surgical treatment in all patients. the tumours were localised in the pancreatic body in 20/29 patients (69%), in the pancreatic tail in 8/29 patients (27%) and in 1/29 patients (4%) purpose: to estimate variants in the anatomic structure of the gallbladder, the biliary and pancreatic ducts and to develop a technique of research. material and methods: 780 patients underwent complex mri using a 1.5 t unit. t2w haste, t1w turboflash, including fs, and mrcp (single-slice turbose and multi-slice haste in different orientations) were acquired. 65 patients also examined with ercp. results: in 18% of patients the merger of the hepatic lobar bile ducts was extrahepatic. 21% revealed an additional right hepatic duct, more than half running into the common bile duct (cbd) low. the low fusion of the cystic duct and cbd was revealed in 19% of the patients, and its left arrangement in 23%. anomalies in the form of the gallbladder are revealed in 35% and additional pancreatic duct in 10% of patients. in 13% patients the main pancreatic duct and cbd had a common ampoule, in more than 64% of cases they enter the duodenum parallel, in 13% cases separately. it is expedient to study the mutual relationships of ducts, parenchyma and vessels with application of t2-w haste. general submission about bile and pancreatic ducts and gallbladder allows receiving single-slice tur-bose. for better analysis of details of anatomic structure it is necessary to study of source images multi-slice haste in different orientations. the results of research especially are useful for planning of operative treatment. conclusions: complex mri, especially reception of t2-w images and realisation of mrcp, is an excellent tool for revealing variants in anatomic structure of the gallbladder and ductal system. the clinical utility of diffusion imaging out of the central nervous system y. murakami 1 , k. imoto 1 , n. aito 1 , t. sakamoto 1 , m. yamasaki 2 , a. furukawa 2 , r. ito 2 , k. murata 2 ; 1 kohka/jp, 2 shiga/jp the clinical utility of diffusion imaging out of the central nervous system is not yet clear. the purpose of this prospective study is to determine the role and the clinical usefulness of diffusion-weighted mr imaging combined with conventional mr imaging for the detection of visceral disease without of the central nervous system. material and methods: one hundred and thirty-four cases who were referred to our hospital for the examination of visceral disease without the central nervous system (including 114 cases with neoplasms and 20 cases with inflammatory disease, upper abdomen; 48, pelvis; 51, other organ; 35) were investigated. mr imaging (1.5 t) was performed using a diffusion-weighted single-shot spin-echo echoplanar sequence, t2-weighted fast spin-echo sequence, and t1-weighted spin-echo sequence. an experienced reviewer evaluated the diffusion-weighted mr images for the presence of a high-signal-intensity lesion and compared with other mr sequences. imaging findings were correlated with findings from histological specimen in 20 patients and with findings from clinical follow-up examination in other patients. results: diffusion-weighted mr imaging depicted 62 high signal intensity lesions, including 56 cases with malignancy and five cases with inflammation, and a case of castleman's disease. in three patients with lymphomas, high signal intensity lesions reflected the activity of the disease process. there was no high signal intensity lesion in cases with eight adnexal diseases. conclusion: diffusion-weighted mr imaging out of the central nervous system may possibly be useful for the extent or the activity of malignant or inflammatory disease. evaluation of computed tomography for assessment in lipodystrophy syndrome j.a.g.s. gallego, f.m.a.i. ardoy, s.p.u. padilla, f.g.r. gutierrez; elche/es purpose: lipodystrophy syndrome (peripheral fat loss and/or visceral fat accumulation) is a main problem in hiv-patients treated with antiretroviral therapy. the diagnosis is based on physical examination and/or standardized questionaires so there is a need for quantitative diagnostic tools. the aim of this study is to evaluate computed tomography (ct) to measure fat distribution in hiv patients. methods and materials: 61 hiv-patients (44 men) were included. lipodystrophy was diagnosed clinically on 31. subcutaneous limb adipose tissue area and their percentage were measured by a single slice at mid thigh and mid arm by ct. the subcutaneous (sat), visceral (vat), and total (tat) abdominal adipose tissue as 362 b d e f a g well as the vat/tat, sat/tat and vat/sat ratios were calculated by a single slice at umbilical level. results: vat/tat and vat/sat ratios were significantly greater in lipodystrophic than in non-lipodystrophic patients: 0.62 vs 0.41, p < 0.01 and 2.48 vs 0.38, p < 0.01 respectively in men. 0.38 vs 0.25 p < 0.05 and 1.14 vs 0.32 p < 0.05 in female patients. sat/tat and mid thigh fat tissue percentage were significantly lower in lipodystrophic patients: 0.36 vs 0.57 p < 0.01 and 0.1 vs 0.2 p < 0.01 respectively in men. 0.6 vs 0.75 p < 0.05 and 0.26 vs 0.46 p < 0.05 in female patients. no significant differences were found at mid arm. a vat/sat ratio > 0.98 for men and > 0.35 for women had a sensitivity of 83% and 85% respectively and a specificity of 70%, to diagnose lipodystrophy syndrome. conclusion: computed tomography may be a useful technique to quantify lipodystrophy in hiv-infected patients. withdrawn by authors ultrasonographic assessment of body fat distribution in type ii diabetes mellitus of insulin resistant type and its relation to anthropometric measurements n. previous studies have shown that in subjects with type ii diabetes mellitus of insulin resistant type there is a relation between cardiovascular diseases and obesity, insulin resistance and body fat distribution. in these patients body fat distribution assessed with dexa and antrophometric measurements were correlated with ultrasonographic fat assessments. materials and methods: 28 subjects (14 male and 14 female with mean age of 55.5 ± 8.4) in whom type ii diabetes mellitus of insulin resistant type was diagnosed with homa (homeostasis model assessment) were enrolled in the study. their weights, heights, abdominal diameters, and gluteal diameters were recorded. body mass index (bmi, kg/m²) and the ratio of abdominal diameter to gluteal diameter (a/g) were calculated. subcutaneous (fatsc), preperitoneal (fatpp), and visceral (fatv) fat thicknesses were ultrasonographically assessed. results: there was a significant correlation between bmi and fatsc or fatv (p < 0.01); and between total fat ratio and fatsc and fatv (p < 0.05 and p < 0.01, respectively). there was no relation between a/g and fatsc, fatpp and fatv. conclusion: ultrasonographically assessed subcutaneous and visceral fat thicknesses in type ii diabetes mellitus patients of insulin resistant type may be used as prognostic factors of cardiovascular diseases. withdrawn by authors c-099 mri of the upper abdomen using a new free-breathing navigator triggered t2-weighted tse-sequence (pace-tse) c. klessen, p. asbach, r. kirsch, b. hamm, m. taupitz; berlin/de purpose: to evaluate image quality of a new free-breathing navigator triggered t2-tse sequence (pace = prospective acquisition correction) for magnetic resonance imaging of the upper abdomen in comparison to a established standard breath-hold t2-weighted sequence. materials and methods: prospective evaluation of 30 consecutive patients with various pathologies referred to our clinic for mri of the upper abdomen. all patients were examined at 1.5 t (siemens magnetom quantum) using the following sequences: pace-tse (work-in-progress sequence,320 x 224 matrix, fov 320 mm, axial slice orientation, tr 2340 ms, te 80 ms, turbo factor 21, 42 slices, 4 mm slice thickness, n = 2 excitations), breath-hold haste sequence (256 x 154 matrix, axial slice orientation, tr ∞, te 63 ms, 23 slices, 7 mm slice thickness, n = 1 excitation). three independent abdominal mri experienced radiologists reviewed all images and evaluated motion artifacts, liver-spleen contrast, depiction of intrahepatic vessels, depiction of the pancreas and the adrenal glands and overall image quality on a 4-point scale. in addition, to directly evaluate the influence of the respiratory trigger technique, in 10 patients the t2-tse sequence was repeated with the respiratory trigger function switched off. results: mean examination time of the pace-tse was 7.2 minutes. the depiction of anatomical details and contrast was significantly better (p < .05) using the pace-tse sequence compared to the standard haste sequence. the pace-t2-tse sequence has the potential to significantly im-prove recognition of anatomical details and contrast compared to standard breathhold haste imaging. reactive lymph node hyperplasia: a diagnostic problem in the staging of hodgkin's disease (hd) l. ilic-todoric, b. lukac; belgrade/yu purpose: therapeutic approach to hd requires determination of the disease extent to supra/infradiaphragmatic lymph nodes (ln) . a problem appears when ln are of borderline size or only slightly enlarged. should such a finding on ct be considered as reactive hyperplasia or a pathological finding? the purpose of this report is to solve this dilemma. methods and materials: infradiaphragmatic spiral ct scan was performed in 250 patients with histologically confirmed supradiaphragmatic hd. bipedal lymphography represented the gold standard for final staging. taking reactive hyperplasia into consideration, we estimated and statistically analysed ct's ability to differentiate benign and malignant conditions, and its value for staging. results: lymphography showed infradiaphragmatic disease in 48% of patients, 21% of whom had enlarged ln, while in 79% ln were of normal size or smaller. of the total number of patients, reactive hyperplasia and lymphographically normal findings were found in 21% and 31% of patients, respectively. ct detected enlargement in 41% of patients, and in 20% of these this finding concurred with the lymphographic one. ct could neither detect affected normal/reduced ln, nor differentiate reactive from malignant hyperplasia. postlymphographic restaging of the disease showed that 37% of patients would be understaged and 21% overstaged on the basis of ct finding only. conclusion: reactive hyperplasia represents a risk of up/downstaging if staging relies on ct only. errors can be partially assigned to the inadequate interpretation of the ct findings, which cannot be taken for granted when ln are of borderline sizes. in such cases additional diagnostic procedures are necessary. purpose: to compare the diagnostic accuracy of mr (magnetic resonance) images with msct (multislice ct) for preoperative t-staging in patients suffering from cardiac cancer. materials and methods: mr and msct were performed in 25 cases of cardiac cancer diagnosed by biopsy prior to operation. mr and msct scans were performed on two different days. mr sequences included fset1w, fset2w, fse t1w with fat suppression and dynamic enhanced fspgr with fat suppression; msct was applied with dynamic triphasic contrast enhancement. all these findings were prospectively analyzed by two doctors separately and correlated with the surgery pathological findings. statistic work was performed with spss. results: according to histopathologic staging, the accuracy for t1-staging detected with mr and msct were 70% and 55% respectively, 75% and 62% for t2staging, 87% and 69% for t3-staging, 89% and 60% for t4-staging. compared with msct, dynamic enhanced and delayed mr with fat suppression was superior for revealing the involvement of esophagus and aorta, early stage of invasiveness and providing more evidence in t2 from t3 or t3 from t4 staging (p < 0.05). among these mr plain scan sequences, t1w with fat suppression was outstanding in depicting the gross features of the tumor, presence of ulceration, and adjacent lymph node swelling. diagnostic accuracy determined by roc analysis was marginally higher with mr scan than with msct scan in t-staging of cardiac cancer. conclusion: mr is superior in t-staging of cardiac cancer and can be used to optimize the therapeutic strategy, thus avoiding unnecessary operation. multidetector ct and virtual endoscopy of the esophagus s. mazzeo, d. caramella, e. neri, p. giusti, c. cappelli, r. bertini, a. belcari, c. bartolozzi; pisa/it purpose: to assess the diagnostic capabilities of multidetector ct in various esophageal pathological conditions. methods and materials: thirty-three patients underwent a multidetector ct study after esophageal distension by means of effervescent powder administered after induction of hypotonia. all acquired images were post-processed with 2d and 3d software tools. the ct data was compared with the results of conventional radi-ology (33), endoscopy (28), or surgery (14) . follow-up ranged between 4 and 15 months. results: esophageal distension in the upper and middle third was classified as "good" in 32/33 cases (97%); in the lower third, esophageal distension was "good" in 21/33 cases (64%). final diagnoses were: leiomyoma (6), squamocellular carcinoma (6), adenocarcinoma (4), esophageal infiltration by thyroid cancer (2), benign polyposis (2), chronic esophagitis (5), post-sclerotherapy stenosis (1) , no abnormalities (7). when good distension was achieved, the thickness of unaffected esophageal wall was < 3 mm (range between 1.5 and 2.4 mm, mean 1.9 mm). pathological wall thickening was observed in 25/33 cases (76%) with values ranging between 3.6 and 36 mm (mean 9.6 mm). spiral ct demonstrated 21 true positive cases and 7 true negative cases. there were 4 false negative cases and 1 false positive case. sensitivity was 84%, specificity 87%, diagnostic accuracy 85%, positive predictive value 95%, negative predictive value 64%. conclusions: evaluation of the esophagus with multidetector ct proved to be a promising and easy to use technique, allowing panoramic exploration, virtual endoluminal visualization, accurate longitudinal and axial evaluation, and simultaneous evaluation of t and n parameters. (ibd) . to describe the technique of barium tagged dark-lumen mrc. to outline the advantages, disadvantages and limits of the method. background: conventional colonoscopy (cc) is the most widely used method for the assessment of the extension and the activity of ibd. however, cc is an invasive technique and requires long-lasting bowel preparation. furthermore, not infrequently the examination of the entire colon and terminal ileum wouldn't be possible due to severe pain or fecal residue. these disadvantages are eliminated with barium tagged dark-lumen mrc which makes this examination more tolerable and acceptable by patients. imaging findings: ten patients who present with symptoms of ibd underwent cc first and subsequently mrc. for fecal tagging, barium sulphate-containing contrast agent is given with meals, beginning 48 hours before the examination. for mrc the colon was filled with 2000 ml of diluted barium. after intravenous administration of 0.1 mmol/kg gd-dtpa, coronal t1-weighted three-dimensional gradient-echo sequence is performed. additional fat-saturated axial two dimensional gradient-echo and coronal true-fisp sequences are obtained. colon segments are interpreted seperately (rectum, descending, transverse, ascending colon, caecum) when assesing the extent of the disease. bowel wall thickening and congestion of marginal vascularity are considered as signs of the disease. out of sixty segments, 50 of them had colonoscopic correlation. of these in 42 (84%) the extent of disease correlated with cc. non-correlation of findings of mrc and cc was detected in 8 (16%) patients. conclusion: barium tagged dark lumen mrc can be used for the assesment of the extent of ibd. evaluation of ct gastric virtual endoscope (ve) findings: comparison with real gastric fiberscope (gf) lesions k. inamoto, k. kouzai, k. hamada; osaka/jp learning objectives: to check ve findings compared with 66 gf lesions in 63 cases. to learn about images of ve and to consider possibilities to use ve clinically. background: gf is an invasive examination for patients. if ve can be used for checking pathologies of gastric diseases it will be beneficial to detect malignant changes of the stomach in their early stage. procedure details: md-ct images were obtained on the same day as gf with somaton sensation 16, siemens, erlangen, germany. thin slice ct images with 1 mm thickness were reconstructed to ve images by surface rendering and volume rendering with advantage workstation 4.0_0.3 with volume analysis voxtool 3.0.26e, ge, milwaukee, wi.usa. results indicated that ve images succeeded in showing subtle alteration of mucosal folds. gastric cancer, polyp, ulcer, erosion and gastritis were clearly visualized. by comparison studies between ve and gf, a sensitivity 92.7%, specificity 90.9%, positive predictive value 98.1%, negative predictive value 71.4% and accuracy 92.4% were calculated. conclusion: 3d md-ct examination of the stomach is noninvasive except for radiation exposure. it will be expected as a new technique of the stomach examinations. gastrointestinal stromal tumor: current concepts and imaging characteristics j.h. lee, k. kim, c. park, w. jeong, j. lee, e. kang, i. cha, h. seol; seoul/kr learning objects: to provide an in-depth review of gastrointestinal stromal tumors (gist's) with their epidemiology, histopathology, clinical manifestations and the most up-to-date therapy. to describe radiologic features of gist's. to discuss differential diagnosis of gist's throughout the abdomen. background: gastrointestinal stromal tumors (gist's) are unique neoplasms that occur throughout the gastrointestinal tract, mesentery, omentum, and retroperitoneum. they are the most common mesenchymal neoplasm of the gastroin-testinal tract and are defined by their expression of kit (cd117), a tyrosine kinase growth factor receptor. the expression of kit is important to distinguish gist's from other mesenchymal neoplasms such as leiomyomas, leiomyosarcomas, schwannomas, and neurofibromas and to determine the appropriateness of kit-inhibitor therapy. imaging features of gist's vary depending on tumor size and organ of origin. since most gist's arise within the muscle layer of the gastrointestinal tract, they most commonly have an exophytic growth pattern and manifest as dominant masses outside the organ of origin. procedure details: the purpose of this exhibit is to provide an in-depth review of gist's with their epidemiology, histopathology, clinical menifestation and differential diagnosis. this exhibit will also reflect our experience in the radiologic evaluation of patients with gist's, with emphasis on the typical findings present on small bowel series, ultrasonography and ct (including 3d images using multidetector ct). examples of unusual gist's and pathologic correlation as well as the most up-to-date therapy will be included. conclusion: after interacting with this exhibit the radiologist will have an enhanced understanding of gist's including histopathology and radiologic features. imaging of jejunal and ileal primary tumors with pathologic correlation b. rodríguez-vigil, m. lamas, t. berrocal, j. fernández, v. tarín, a. alvarez; madrid/es learning objectives: to illustrate the spectrum of usual and unusual primary neoplasms involving the jejunum and ileum. to evaluate the efficacy of barium studies, us, ct and mr imaging in the management of these tumors. to understand the radiologic findings on the basis of pathologic correlation. background: preoperative diagnosis of jejunal and ileal neoplasms can be a challenge for both clinicians and radiologists. symptoms are nonspecific and endoscopy is commonly unsatisfactory. since early diagnosis is crucial for prompt therapy, imaging plays an essential role. tumors develop in all histologic components of the small intestine including epithelial cells, lymphoid tissues, lymphatics, vessels, nerves, and muscle. imaging findings: we retrospectively reviewed the imaging findings of jejunal and ileal neoplasms from our digestive pathology database. findings were correlated with pathology in all cases. specific neoplasms addressed include benign (adenoma, leiomyoma, lipoma, familial polyposis, hemangioma, lymphangioma and fibroma); and malignant neoplasms (adenocarcinoma, carcinoid tumor, lymphoma, leiomyosarcoma, direct extension to the small bowel from extraintestinal tumors, and metastasic lesions). enteroclysis is the primary and most effective radiologic modality in the evaluation of these neoplasms. ct should be the complementary radiologic modality and used for staging. mri may help in specific cases. pitfalls, diagnostic difficulties and differential diagnoses are emphasised. conclusions: evaluation of patients with small bowel neoplasms frequently requires multiple imaging modalities for diagnosis and treatment planning. because of the characteristic imaging appearances of many of these tumors, this exhibit will help the radiologist in training to better understand and recognise jejunal and ileal neoplasms. imaging findings of sigmoid diverticulitis: a pictorial essay of anatomy, pathology, differential diagnosis and radiologic treatment options m.c. freund, j. bodner, e.m. gassner, m. rieger, a. gschwendtner, w.r. jaschke; innsbruck/at learning objectives: to understand the anatomy and pathology of sigmoid diverticula and of the mesosigmoid. to be familiar with the typical findings of different imaging modalities in sigmoid diverticulitis and its complications and differential diagnosis. to be familiar with percutaneous and endovascular radiologic treatment options including abcess drainage and embolization for diverticular bleeding. background: sigmoid diverticulosis and diverticulitis represents a commonly encountered disease in western countries. an exact diagnosis is a prerequisite for further therapy. imaging findings: different imaging modalities are proposed for detection of self-limiting or complicated sigmoid diverticulitis e.g. abdominal radiography, contrast enema, ultrasound and even catheter angiography. during the last years ct has evolved to be a primary diagnostic imaging modality in patients with left lower abdominal pain. this pictorial essay will demonstrate the relevant anatomy of the sigmoid, mesosigmoid, and vascular supply as well as the typical pathology of the diverticula and its inflammatory complications including diverticulitis, peridiverticulitis, perforation, contained abcess in the mesosigmoid or rarely free intraperitoneal perforation with peritonitis, as well as fistula formation, obstructhe learning objectives: to depict the ct imaging spectrum of the faeces sign, which is a consequence of small bowel occlusion, and to illustrate its causes. background: abdominal ct scan has been shown to be the most valuable technique, in confirming the diagnosis of small bowel occlusion and to depict the site, level and cause of occlusion. very few studies have focused on the contents of the bowel. particulate faeces-like material mixed with gas bubbles within the lumen of a dilated small bowel loop is always a pathological condition. it is the result of a delayed intestinal transit. to access prevalence, characteristics of this ct sign, and differential diagnosis, we have reviewed 87 ct scans of small bowel occlusion over a period of two years. imaging findings: our analysis suggests that the small bowel faeces sign is probably more frequent than the previous reported studies, in demonstrating 11 cases of small bowel faeces sign mainly observed in the ileal loops, and pointing to the site of occlusion. faeces sign appeared as tubular gas bubbles mixed with particulate matter with no capsule in dilated segments of small bowel loop, due to adhesions, closed loop, and tumours (adenocarcinoma, carcinoid). differential diagnosis of two phytobezoars is also illustrated and discussed. conclusion: small bowel faeces sign may not be confused with colonic segments leading to a failure to recognize the exact level of obstruction. moreover, it represents a sentinel sign in determining the site of occlusion and consequently the cause of the obstruction. imaging appearances and predictors of disease response in metastatic gastrointestinal stromal tumours (gist) treated with imatinib s. cox, b. lanka, m.b. taylor; manchester/uk learning objectives: to evaluate changes in radiological appearances in patients with metastatic gist treated with imatinib. to highlight any specific imaging features that can be used to predict disease relapse. background: imatinib (glivec, sti-571) is a kit tyrosine-kinase inhibitor drug, recently developed and found to be effective in the treatment of metastatic gist. we reviewed the pre-and post-treatment imaging findings on ct in ten patients. the duration of treatment varied from two to forty one months. the pre-treatment, eight and sixteen weeks scans were reviewed, along with the scans at the time of any relapse. the sites of metastases, size of lesions and cystic change were assessed. imaging findings: metastases were present in the liver and peritoneum in seven patients each; mesentery and retroperitoneum in four and two patients respectively; splenic, renal and subcutaneous in one patient each. one patient had progressive disease at eight weeks. nine patients responded to treatment. the maximum reduction in size of the metastasis was at eight weeks. most metastases underwent cystic change with treatment, particularly in the liver and peritoneum. two patients are known to have relapsed at fourteen and fifteen months. in both cases, cystic metastases developed more solid components prior to disease progression as indicated by an increase in the tumour volume. conclusion: ninety percent of the patients responded to treatment. cystic change in the liver and peritoneal metastases correlates with disease response to imatinib. an increase in solid components may be a useful predictor of disease relapse. ct appearances of neoplasms of the small bowel as a cause of obstruction s. sadiq, d. markham; swansea/uk learning objectives: this poster presents a pictorial review of the ct appearances of primary and secondary tumours of the small bowel in patients presenting with obstruction, including neoplasms that are the lead point of an intussusception. background: patients presenting with small bowel obstruction in two district general hospitals over the last twelve months and who were subsequently investigated by ct were selected. the imaging features of those with a neoplastic aetiology were reviewed. image findings: the imaging reflects recent studies examining the incidence of primary small bowel tumours. adenocarcinoma, non-hodgkins lymphoma, carcinoid and leiomyosarcoma comprise the majority. secondary tumour deposits also lead to small bowel obstruction. we demonstrate those that metastasize intraperitoneally (such as ovarian carcinoma), haematogenously (such as melanoma), or by local tumour extension (such as liposarcoma and bladder carcinoma). conclusion: it is well established that ct is a valuable diagnostic procedure in patients with acute small bowel obstruction. it is not only useful in distinguishing obstruction from ileus, but frequently establishes the cause of obstruction. small bowel neoplasms are rare but have a high mortality since tumour-related symptoms occur late and are non-specific. endoscopy is not feasible in most cases, as enteroscopy is limited to specialist centres. small bowel contrast studies do not reach the high level of accuracy obtained in the evaluation of the upper and lower gastrointestinal tract. ct not only allows tumour detection, but demonstrates possible complications and offers the possibility of pre-operative staging in the acute or elective situation. ct in adult intussusception: radiologic-pathologic correlation c. triantopoulou, p. maniatis, i. siafas, n. giannakou, c. avgerinos, c. dervenis, j. papailiou; athens/gr learning objectives: review the ct characteristics of bowel intussusception in adults through a wide variety of cases. emphasize the ability of ct imaging in narrowing the diagnostic possibilities and defining the cause of intussusception. stress the need for familiarization with the different aspects of this rare entity. background: intussusception is a relatively common cause of intestinal obstruction in children but is a rare clinical entity in adults. however, there is a lead point in 80% of adult cases. 12 cases of adult intussusception were retrospectively reviewed. all ct examinations were conducted on a spiral unit with administration of both oral and intravenous contrast agent, using slice thickness of 5-7 mm anda pitch of 1. site, level, cause and degree of obstruction as well as signs of threatened bowel viability were evaluated and correlated with surgical findings and pathology examination. imaging findings: 8 cases of ileocolic intussusception and 4 of ileoileal were revealed. in 9 patients findings included: 3 cases of polypoid lesions, 2 malignant neoplasms, 1 lipoma, 2 inflammatory diseases and in 1 adhesions due to preceding surgery. in the other three cases no underlying pathology was proven so they were characterized as idiopathic conditions. all neoplastic lesions were correctly depicted before surgery while in the case of lipoma a specific diagnosis was made. ct is a powerful tool in adult intussusception, providing valuable information regarding the involved enteric segments, the underlying pathology and possible local complications, thus assisting in preoperative planning. diagnosis of perforation of stomach or duodenum on multislice computed tomography j.-i. nishimura, t. ohkoshi, y. yamamoto, t. inoue; yokohama/jp learning objectives: a review to determine the variety and relative conspicuity of findings in patients with perforation of the stomach or duodenum. background: multislice computed tomography (ct) gives us detailed information as thin-slice sagittal, coronal, and 3-dimensional images rapidly. a small volume of free air can be detected, and the perforation holes were predicted in some cases. during a 2-year period 21 patients with perforation of the stomach or duodenum underwent preoperative ct scans. there were 16 men and 5 women averaging 54.2 ± 15.6 (29 to 84) years old. all patients underwent to surgical treatment, and all sites of perforation were confirmed. imaging findings: levels of perforation were the antrum of stomach (n = 1), body of stomach (n = 5), duodenal bulb (n = 14), and descending limb of duodenum (n = 1). ct images showed local extraluminal gas near the perforation sites in 17 patients (81%), local ascites near the perforation sites in 15 patients (71%), edematous wall of perforation sites in 19 patient (90%), dirty increased density in the fat tissue in 19 patients (90%), and a perforation hole in 8 patients (38%). diffuse extraluminal gas and ascites were showed in 7, and 8 patients respectively. in 18 of 21 patients (86%), we could predict the level of perforation. conclusion: multislice ct is a valuable method in the diagnosis of perforation in stomach or duodenum. the diagnosis can be established rapidly with high sensitivity. defecographic imaging of anorectal sphincter dyssynergia syndromes: our experience in 680 subjects a. nunziata 1 , a. salzano 2 , p. de feo 1 , a. de rosa 1 , f. de rosa 1 , m. covello 3 ; 1 naples/it, 2 frattamaggiore/it, 3 napoli/it learning objective: anorectal sphincter dysfunction can be responsible for evacuation difficulties and constipation; in addition, pelvic floor disorders can be associated. by using defecography associated with videoproctography, the evacuation time and the sphincters' opening time can be assessed, obtaining further information about the physiopathology of rectal empting and anal sphincter function. the aim of this study is to have functional radiological parameters of anal activity to detect anorectal sphincter dyssynergia syndrome. background: on a consecutive series of 680 patients suffering from constipation we assessed by defecography combined with videoproctography 33 cases of sphincter dyssynergia syndrome (16 males and 17 females with mean age of 45 years, range of 17-34 years). all patients underwent clinical examination and endoscopy; 26 patients were investigated by anorectal manometry. imaging findings: in all patients defecography with videoproctography provided a sphinter opening delay > 40 s (normal values: 1-40 s) and increased evacuation time > 68 s (normal values: 3-68 s). manometry revealed anal hypertonia in 13 cases. conclusion: defecography associated with videoproctography is an accurate, simple and non-invasive method to approach anosphincteral pathology, permtting study of this particular type of terminal constipation, which is difficult to demonstrate using other techniques. background: gist are rare mesenchymal tumors of the abdomen, for which an effective, molecular-targeted therapy with imatinib mesylate has been recently developed. imaging findings: 35 pts with advanced gist (24/35 with liver lesions and 33/ 35 with peritoneal involvement) undergoing therapy with imatinib mesylate. all pts had a baseline mr, and then at 2, 4, 6, 12 months during treatment. pts responsive to therapy (31/35) showed: a) tumor decrease in size (with an in-crease in tumor volume at 2 months from treatment start in some cases (17%) due to necrosis or bleeding): b) hypointensity of the lesions on t1w images (lesion was hyperintense in rare case due to bleeding) and hyperintensity of the lesions on t2w images (correlating with the amount of degenerative tissue or necrosis): c) hypovascularization of the lesions on contrast-enhanced t1w images in comparison to pre-treatment assessment, due to the presence of degenerative tissue or necrosis: e) evidence of peritoneal fluid in all pts at the first months, reabsorbed in the following months. conclusions: mri is useful to identify tumor response to imatinib mesylate in advanced gist as from the early months of therapy with the following indicators of treatment activity: a) size of lesions; b) signal intensity; c) vascularization; d) amount of degenerative tissue or necrosis; e) presence of peritoneal fluid. crohn's disease: spectrum of findings on helical contrast enhanced ct enterography a.j. madureira, r. cunha, p. varzim, f. magro, i. ramos; porto/pt learning objectives: to illustrate the spectrum of imaging findings of smallbowel crohn's disease at contrast enhanced spiral ct after oral hyperhydratation with isotonic solution (ct enterography). background: spiral ct has become one of the most valuable methods in the assessment of parietal inflammatory changes and extraluminal involvement in small-bowel crohn's disease. the accuracy of this technique depends on the presence of well distended bowel loops. procedure details: after oral hyperhydration with 2000 ml of isotonic polyethylene glycol electrolyte-balanced solution, contrast enhanced ct of the abdomen and pelvis was performed with a collimation of 7 mm and 5 mm, respectively. the following ct findings were evaluated: wall thickening, parietal contrast enhancement, extraparietal anomalies (lymph nodes, vessels and mesenteric fat), and presence of inflammatory complications (abscesses, fistulas). the spectrum of findings of small-bowel crohn's disease is thoroughly illustrated and discussed based on our experience with over 50 patients. conclusion: this method provides important information about the extent and activity of small-bowel crohn's disease and its extraluminal involvement and is a potential alternative to small-bowel ct enteroclysis. bowel intussusception in adults: an imaging review h.d. roach, j.m. hanson, r. bagree, c. evans, a. yong; cardiff/uk learning objectives:to outline the mechanism and causes of intussusception in the adult population. to provide a review of the imaging findings in intussusception using several imaging modalities. background: bowel intussusception is more commonly associated with the paediatric population, but can occur in adults, affecting virtually any part of the gastrointestinal tract. in adults there is more often an underlying structural lesion, which acts as a lead point. imaging findings: bowel intussusception has a classical appearance on barium studies and cross-sectional imaging and occasionally a lead point can be identified. due to the underlying structural causes, surgery is more often required in adults than children, resulting in the availability of histopathologic specimens for correlation. however within the small bowel even in adults it has been shown that the majority of cases are self-limiting. in this exhibit, we review the imaging findings of intussusceptions affecting various sites in the gastrointestinal tract using different modalities. conclusion: bowel intussusception is less common in the adult population, but is often associated with underlying structural lesions. the imaging findings are reviewed here. can double contrast barium enema exams incidentally detect terminal ileum tumoral lesions? c. gotta, s. merola, e. sanabria, m. landi, s. ballester, c.a. dominguez; buenos aires/ar learning objectives: to describe a number of radiological signs, found in barium enema double contrast exams in 28 patients, that are specific or suspicious of terminal ileum tumoral lesions. background: since 1972 there have been few reports about radiological signs in double contrast barium enema exams that can help in the diagnosis of terminal ileum pathology. some of them use glucagon to improve the reflux of contrast material through the ileo-cecal valve in order to allow the visualization of the reviewing the available literature, there are no reports which describe specific radiological signs on this matter. procedure details: a total of 28 cases of tumoral terminal ileum pathology were found. all lesions were seen for the first time at the double contrast barium enema, and lately examined and characterized by the follow through or small bowel enema. in most of them abdominal computed tomography was performed. 20 cases had histological confirmation based on surgical specimens. of the remaining 8 cases, 4 were lipomas with typical densitometric values diagnosed by computed tomography, thus these patients did not undergo surgery. the other 4 lesions described as polipoid did not have histological confirmation as the patients refused surgical resection. conclusion: double contrast barium enema can detect the presence of terminal ileum tumoral pathology even when not yet clinically suspected. there are a few radiological signs which allow the radiologist to recognize and diagnose it. background: magnetic resonance is a powerful diagnostic tool for abdominal imaging, particularly for extra-visceral tissue depiction. newer pulse sequences, such as single shot fast spin echo (ssfse) and steady state free precession (ssfp) with a water solution infusion via naso-jejunal tube can accurately depict the bowel lumen in a fashion similar to conventional double contrast enema. furthermore 3d and 2d fast t1 weighted sequences with iv contrast administration allows the evaluation of wall involvement. imaging findings: findings are summarized into lumen abnormalities, wall involvement and extra-luminal alterations. corresponding dcsbe are shown and compared. signs of disease activity at mre plus conventional mri are stressed. contribution of different pulse sequences is evaluated. conclusions: mre plus conventional mri is feasible in the diagnosis, staging and follow-up of crohn's disease. subtle mucosal lesions are still poorly depicted, compared to dcsbe. extra-luminal involvement is superbly showed, particularly by new ssfp sequences. disease activity signs seem to be the added value of magnetic resonance in crohn's disease assessment. diagnosis and staging of colorectal carcinomas using multislice ct colonography (msctc): pictorial essay with pathologic correlation r. iannaccone, a. laghi, c. catalano, a. lamazza, f. mangiapane, s. trenna, d. marin, a. schillaci, r. passariello; rome/it learning objectives: to assess the role of msctc in the detection and staging of colorectal carcinoma. background: 150 patients affected by colorectal carcinoma underwent colonoscopy and msctc on the same day. 100 patients free of colonic lesions were included as a control group. ct parameters were: collimation, 4 x 1 mm; effective mas, 80-165; and kvp, 120. msct colonography was performed before (prone position) and after (supine position) intravenous administration of contrast material with a 60-sec delay-time. msctc images were interpreted by two radiologists on a workstation. the results of msct colonography were correlated with colonoscopy and with the results of the histopathologic examination performed on the resected surgical specimen. intra-operative ultrasonography was used as the reference standard for the presence of liver metastases. sensitivity and specificity for tumor detection and staging accuracy (according to the tnm classification) of msctc were calculated. imaging findings: surgery revealed 164 carcinomas (150 primary and 14 synchronous lesions) in 150 patients. colonoscopy failed to visualize the entire colon in 21 patients due to obstructive neoplasms and missed all 14 synchronous carcinomas. msctc provided a complete evaluation of the colon in all cases, correctly identified all primary and synchronous carcinomas (164/164; sensitivity, 100%), and yielded three false-positive diagnoses (specificity, 98.8%). msctc also detected 21 polyps (18 true-positives and three false-positives). overall, msctc correcly staged 136 of 150 primary tumors (overall tnm staging accuracy, 90.6%). conclusion: msctc can be proposed as a comprehensive diagnostic test for the pre-operative evaluation of patients with known, or strongly suspected, colorectal carcinoma. gastrointestinal to present the characteristic features of malignant gist and correlated these with histopathologic findings. background: in our pathologic database from 1998 to 2002, we found 31 patients with gist and retrospectively reviewed their radiologic findings. thirty one ct, four us, and four barium studies were included. imaging findings: involved organs were as follows; 13 in the small bowel (42%), 10 in the stomach (32%), five in the rectum (16%), two in the mesentry (7%) and one in the colon (3%). on histochemical analysis, eight were classified as benign (26%), six as borderline (19%) , and 17 as malignant (55%). mean tumor size was 7.1 cm (1.2 cm-22 cm): benign (mean;4.3 cm, range;1.2 cm-10 cm): borderline (mean;6 cm, range;5 cm-9.3 cm): malignant (mean;8.9 cm, range;4 cm-22 cm). multiplicity was demonstrated in one benign and one malignant tumour. six cases showed microscopic metastasis to the surrounding lymph nodes without evidence on radiologic imaging. ct features were relatively smooth margination and homogeneous enhancement of smaller tumors. poor margination with surrounding infiltration, central necrosis or ulceration was seen in larger tumors. no evidence of intestinal obstruction, peritoneal seeding or ascites was demonstated. barium examination showed a well demarcated, smooth marginated tumor with normal overlying mucosa. some ulceration was seen in larger masses (bull's-eye sign). us features were welldemarcated homogeneous hypoechogenicity of small masses, hyperechoic foci of ulcerated masses. the characteristic radiologic findings of immunohistochemically kitpositive malignant gist were large tumor size, poor margination, central necrosis or ulceration. the clinical significance of each feature and differential points from benign gist or other conditions will be discussed. learning objectives: to illustrate ct findings of common and uncommon duodenal diseases with pathologic correlation. to demonstrate a comprehensive ct anatomy of the duodenum and adjacent organs. to describe the pitfalls on ct interpretation of duodenal diseases. background: the duodenum may be involved by secondary process as well as primary pathology because it is close to adjacent organs including the stomach, pancreas, liver, gallbladder, hepatic flexure of the colon, aorta, ivc, right kidney and adrenal. duodenal pathology can be overlooked on ct interpretation but understanding of ct anatomy of the duodenum and adjacent organs may be helpful in the diagnosis of various duodenal pathology. procedure details: helical ct during the portal phase with water as an oral contrast agent was performed for better detail of duodenal lesions. we reviewed ct findings with pathologic correlation in 41 patients with various duodenal diseases. duodenal diseases were classified as follows; congenital (duplication, malrotation, diverticulum, and annular pancreas), trauma (intramural hematoma, iatrogenic perforation by endoscopy), inflammatory (perforated peptic ulcer, secondary process by pancreatitis or cholecystitis), primary neoplasms (lipoma, adenoma, adenocarcinoma, lymphoma, and gastrointestinal stromal tumors), secondary invasion of adjacent neoplasms (pancreas, stomach, colon, and gallbladder), bezoar, and postsurgical afferent-loop syndrome. conclusion: helical ct during the portal phase with water as an oral contrast agent provided a comprehensive view of the duodenum and adjacent organs. understanding of ct anatomy and the pitfalls on ct interpretation was helpful in the diagnosis of various duodenal diseases. to investigate utility of mr volumetry for resectable rectal cancer before and after preoperative concurrent chemoradiotherapy. methods: 104 patients with respectable locally advanced rectal cancer underwent preoperative concurrent chemoradiotherapy. among them, 78 patients (55 men and 23 women; median age 55 years; range, 27-75 years) who had mri before, and 1 month after concurrent chemoradiotherapy were enrolled into this study. radiation of 45 gy/25 fractions was delivered to the pelvis, followed by a 5.4 gy/3 fractions boost to the primary tumor. chemotherapy was administered concurrently with radiotherapy and consisted of 2 cycles of 5-fu (500 mg/m 2 / day) and leucovorin (20 mg/m 2 /day) for five days during the first and fifth weeks of radiotherapy. surgery was performed 4-6 weeks after the completion of chemoradiation. mr volumetric examinations for tumor volume before and after chemoradiotherapy were perfomed in workstation software using t2-weighted axial images. results: according to dworak grade, grade 1 was present in 26.9% (21/78), grade 2 in 44.9% (35/78), grade 3 and 4 in 14.1% (11/78), respectively. primary tumor downstaging occurred in 57.7% (45/78). the mean tumor volume was 21.1 cm 3 (1.4-80.3 cm 3 ) in mr volumetry before chemoradiotherapy and 6.5 cm 3 (0-34.8 cm 3 ) in after chemoradiotherapy. when the tumor volume reduction rate was correlated with the dworak grade, mean tumor volume reduction rate was 58.8% (15.90-100%) in grade 1, 66.1% (0-94.8%) in grade 2 and 73.9% (34.5-100%) in grade 3 and 4. the tumor volume reduction rates demonstrated statistically significant differences among dworak grades. conclusion: in mr volumetric evaluation for rectal cancer before and after preoperative chemoradiotherapy, tumor volume reduction rate is well correlated with histologic reduction grade. functional the rectum was insufflated with air. we used t2-weighted haste sequences at rest, squeeze and strain, in the axial and sagittal planes. we also performed a dynamic study using a t2-weighted haste modified sequence, acquiring a single mid-sagittal slice, repeated every second for 20 seconds, starting with the patient at rest then in squeezing and finally in straining. mr findings were compared with evacuation proctography, considered as gold standard. rectocele and pelvic floor descensus were graded either with the standard reference values, and with modified values obtained from normal volunteers. results: mri vs evacuation proctography identified 13/15 rectoceles, 25/28 anorectal junction descents, 7/9 rectal prolapses, and 4/6 diskinetic pubo-rectalis syndromes. mri detected additional findings in 30% of patients (4 enteroceles, 10 uterine descents, 11 cystoceles, 4 perianal pathologies-abscesses, anal fistulas). mri, using specific reference values provided 90% sensitivity, 93% accuracy, 84% npv for the anorectal junction descent, while using conventional values provided 63% sensitivity, 75% accuracy and 57% npv. conclusions: defeco-mri requires a short examination time, is well accepted and gives reliable information for the diagnosis of posterior pelvic disorders. specific reference values should be used to correct the bias of the supine position. correlation between mr findings and pathology in evaluation of the affected bowel wall in crohn's disease f. maccioni, m. colaiacomo, a. bruni, a. cocco, s. parlanti, f. siliquini, m. marini, a. marcheggiano; rome/it purpose: to correlate mr findings with the corresponding pathologic specimens obtained at the level of the pathologic wall in patients with crohn's disease (cd). method and materials: 27 patients with known cd underwent mri after oral administration of a superparamagnetic contrast, using t2-weighted plain and fatsuppressed haste sequences, and gd-enhanced t1-weighted flash sequences on axial planes. degree and pattern of wall signal, wall thickness and abnormalities of perivisceral fat were evaluated. disease activity was evaluated using standard clinical scores. endoscopic or surgical pathologic specimens were obtained in all patients (gs) . mr findings were inter-correlated and correlated with pathologic findings (gs) either prospectively or retrospectively, with a sideby-side analysis of results. results: high wall gd-enhancement and high t2 wall signal were observed in patients with active disease and diffuse transmural inflammatory cells infiltrates at gs (n. 14). in patients with active disease a layered pattern of gd-enhancement was observed, associated with either submucosal oedema or fibrosis at gs (n.8); in this group of patients, however, t2-weighted images showed high or low wall signal in presence of oedema or fibrosis, respectively. in patients with non active disease poor gd-enhancement and low t2 wall signal were observed and preoperative evaluation of early gastric cancer for laparoscopic gastrectomy by 3d-ct angiography using 16-row multislice ct angiography s. kumano 1 , h. miki 1 , t. mochizuki 2 ; 1 onsen-gun/jp, 2 ehime/jp purpose: the purpose of this study was to determine the efficacy of 3d-ct angiography (3d-cta) using 16-row multislice ct (msct) in the pre-operative simulation of laparoscopic gastrectomy for early gastric cancer. method and materials: twenty patients with early gastric cancer underwent ct examination using 16-row msct (0.625-mm x 16). 2 ml/kg of 300 mgi/ml contrast material was intravenously injected at a rate of 4 ml/sec. timing for the arterial phase scan was determined by using a test bolus injection. portal phase scan was performed 70 s after the start of bolus injection. for 3d-cta, ct images of 0.625 mm thickness were reconstructed at 0.625 mm intervals. with a computer workstation, 3d-cta was produced using volume rendering and maximum intensity projection techniques. results: 3d-cta demonstrated the left gastric artery (lga), right gastric artery (rga) and left gastric vein (lgv) in all cases. 3d-cta also demonstrated the lga arising from the celiac trunk in 19 cases and from common hepatic artery (cha) in one case; the left hepatic artery (lha) from the lga in two cases; an accessory lga from lha in one case; and the rga from the proper hepatic artery in 13 cases, from the cha in five cases, and from the lha in one case. regarding the venous system, 3d-cta demonstrated lgv flowing into portal vein in 10 cases, splenic vein in 9 cases, and the junction of portal and splenic veins in one case. conclusion: 16-row msct 3d-cta clearly demonstrated the vascular anatomy in all cases that is necessary for laparoscopic gastrectomy, and was thought to be useful for the preoperative simulation of laparoscopic gastrectomy. douglas pouch hernias: evaluation with entero-colpo-defecography m. estienne 1 , m. moretti 1 , m. valle 1 , p. meinero 2 , o. brunetti 1 ; 1 lavagna/it, 2 santa margherita ligure/it purpose: to assess the usefulness of entero-colpo-defecography (ecd) in the evaluation of douglas pouch hernias and to improve the technique by a simple and non-invasive method. methods and materials: 73 female patients (mean age: 63 years) with clinical symptoms of obstructed defecation underwent ecd. our standard technique includes: 500 ml of diluted barium suspension given orally at least 1½ hours before examination; a small gauze opacified with iodamide placed into the vagina; rectal filling with 200 ml of thick barium paste. static and spot lateral radiographs of the pelvis are obtained at rest, during squeeze and push, and during and after evacuation. if widening of the rectovaginal space (rvs) is observed during the dynamic phase, in the absence of an enterocele, a barium sigmoid enema is performed and further lateral films are obtained at maximum straining. results: widening of rvs was observed during ecd dynamic phase in 16 of the 73 patients (22%). thirteen of these patients had small bowel loops prolapsing into rvs (enterocele). for the three remaining patients, in which the widening of rvs could not be explained by enterocele, we performed a sigma barium enema demonstrating the presence of a sigmoidocele. we did not find a peritoneocele without bowel contents. conclusions: douglas pouch herniations may account for symptoms of obstructed defecation. defecography alone is not able to evaluate the hernia contents and peritoneography is an invasive technique. visualization of douglas pouch hernias is improved by the use of our ecd technique allowing a correct identification of enteroceles and sigmoidoceles. were prospectively studied by mdctc and compared with colonoscopy. all patients were referred to ct immediately after colonoscopy. ct was performed with 16 x 0.75 mm, 120 kv and 50 mas in both supine and prone positions after colonic air insufflation. this method was well tolerated for all patients. independently, two experienced radiologists interpreted axial, sagittal and coronal images and 3d endoluminal reconstructions (virtual colonoscopy). in cases of disagreement, the diagnosis was established by consensus. sensitivity, specificity, predictive values and kappa test were analysed. both methods were compared with chi-squared test. results: in our series, the prevalence of colorectal polyps was 49%. when polyps were 5 mm in size or greater mdctc had a 96% sensitivity, 97% specificity, 92% pvp and 99% pvn. the agreement between colonoscopy and mdct was observed in 91%. no statistical differences were found between these methods. conclusion: ct colonography is emerging as a potential alternative to conventional colonoscopy in the screening of colorectal cancer. 16 row mdctc represents a reliable imaging method to detection of colorectal polyps with a high accuracy, particularly when the polyp size is 5 mm or greater. this suggests an improvement over single slice ct. a. kalogera-fountzila, c. kouskouras, a. lefkopoulos, n. fotiadis, d. karanikolas, i. tsifountoudis, a.s. dimitriadis; thessaloniki/gr purpose: to prospectively evaluate the characteristic spiral ct features of intestinal ischemia and necrosis in patients with acute abdomen. materials and methods: twenty patients, aged 15-92 (median 67), were examined in a three year period, using helical ct without oral contrast administration and after intravenous injection of contrast medium. the clinical manifestations consisted of acute abdomen and/ or sepsis in all patients. the diagnosis of bowel ischemia was confirmed with surgery, where colonic and/ or small bowel resection was performed in 18 patients within 24 hours. one patient with the presence of portal gas was found to be normal at surgery and one patient died before surgery and had a confirmatory autopsy. results: the causes of critical intestinal ischemia were diverse, including superior mesenteric artery thromboembolism in 3 (15%) patients, inflammation in 5 (20%), intussusception in 1 (5%), volvulus in 2 (10%), adhesions in 4 (20%), hiv infection in 1 (5%) and unknown etiology in 5 (25%). spiral ct identified necrosis of colon and small bowel in 9 (45%) patients, necrosis of small bowel only in 4 (21%), and of colon in 5 (26%). suggestive findings included intramural air in 13 (65%) patients, thickening of the bowel wall in 14 (70%), thinning in 4 (20%), double or concentric ring sign in 8 (40%) and bowel dilatation in 13 (65%). presence of increased density of mesenteric fat was noted in 7 (35%), mesenteric vein dilatation in 10 (50%), free intraperitoneal air in 3 (15%) and peritoneal fluid or blood in 13 (65%). conclusion: spiral ct can accurately demonstrate signs of bowel ischemia and is often helpful in determining the primary cause of ischemia or necrosis. a comparison of single and multi row ct colonography in the detection of colorectal polyps p. vagli, e. neri, s. picchietti, g. naldini, m. rossi, c. bartolozzi; pisa/it purpose: to compare the diagnostic accuracy of single and multi row ct colonography (ctc) for detection of colorectal polyps. materials and methods: between 1996 and 2003, seventy-two consecutive patients with a moderate to high risk of developing colorectal cancer underwent ctc followed by complete cc within 24 hours. ctc was obtained by means of single row ct (n = 20) and multi-row ct (n = 52). sensitivity and specificity of single and multi-row ctc for detection of colorectal polyps was determined by means of lesion location in four colonic segments (cecum-ascending c-a, transverse t, descending d, sigmoid-rectum s-r). results: all colonic segments were completely visualised in each patient both by single and multi row ctc study. ctc identified 63 polyps (< 6 mm) in 44 pa-tients (c-a n = 17, t n = 17, d n = 19, s-r n = 10) , and 33 polyps (6-20 mm) in 24 patients (c-a n = 5, t n = 3, d n = 12, s-r n = 13) . ctc generated 28 false positives (fp) for polyps smaller than 6 mm and 10 fp for polyps 6-20 mm. false negatives (fn) were 4 for polyps < 6 mm, and 2 for polyps 6-20 mm. sensitivity of single and multirow ctc for detecting polyps were 80% and 89% respectively for polyps < 6 mm, and 83% and 94% for larger polyps 6-20 mm (p < 0.01). overall sensitivity and specificity of ctc for small polyps (< 6 mm) was 88% and 87% respectively. overall sensitivity and specificity increases for larger polyps (6-20 mm) at 94% and 96% respectively. conclusion: multi-row ctc demonstrated a higher diagnostic accuracy than single-row ct in detection of colorectal polyps. paring the two ct techniques, considering patient discomfort and respiratory artifacts. results were compared with double-contrast small bowel enema and evaluated by two experienced radiologists. the integrated diagnosis showed 10 negative patients, 15 with signs suggestive for crohn's disease, 1 with reflux ileitis, 1 with ischemic ileitis and 3 with non-specific ileitis. ct detected 48 positive loops (sensitivity 92%, specificity 77%, diagnostic accuracy 88%); conventional radiology showed 42 positive loops (sensitivity 93%, specificity 100%, diagnostic accuracy 94%). ct-enteroclysis false positives were due to poor bowel distention and false negatives to proximal bowel localization of disease; conventional study false negative cases were due to unseparable loops. mild respiratory artifacts were present in 66% (12 of 18 patients) of sdct examinations vs 16% (2 of 12 patients) of mdct examinations. conclusions: mdct-enteroclysis in comparison with sdct-enteroclysis reduces scanning time, respiratory artifacts and patient discomfort, allows a better spatial resolution, more evident on mpr, and improves pathological pattern representation. detection and staging of gastric lesions combining axial ct and virtual endoscopy images s. visconti, v. panebianco, m. celestre, t. celano, d. tancredi, f. iafrate, r. passariello; rome/it purposes: the aim of our study was to develop a virtual endoscopy examination protocol for the stomach after co2 distention, and to identify agc lesions according to borrmann's classification based on tumor morphology. methods and materials: virtual endoscopy of the stomach was performed in 33 patients with gastric lesions. the stomach was distended with 6 g of top effervescent granules used for double contrast upper gi studies (duogas, bracco), after intramuscular injection of 20 mg of scopolamine butylbromide. all patients underwent a spiral ct volume zoom examination (120/80/1 mm/1 mm/8 mm/0.l5 sec kv/mas/slice-coll./slice-width/feed-rot/rot.time). in 7 cases spiral ct was repeated in a prone position because of a limited gastric distension by air. real time endoscopy images were reconstructed using a volume rendering technique with a dedicated workstation and specific software (vitrea 2.2-vital images), and evaluated combined with axial images by two radiologists. one week later a fiberoptic gastroscopy was performed in all patients. results: image quality was graded as optimal in 30 cases. in 3 cases the stomach was not distended. virtual endoscopy correctly showed gastric lesions (ulcerative lesions n = 16, vegetating lesions n = 12, benign lesions n = 5). we found a good correlation with surgical specimens in 14 cases. the actual role of virtual gastroscopy combining axial ct and ve images is to evaluate the locoregional and distant extension (perigastric tumor involvement, distant metastasis) of tumors. it's potential roles are replacing barium studies and examining patients with surgical gastric exclusion. traumatic bowel perforation after blunt abdominal trauma: analysis of the ct findings according to the perforation site and the elapsed time since the trauma h. kim, h. shin, s. park, s. park, h. kim, w. bae, i. kim; cheonan/kr purpose: to evaluate the efficacy of ct in predicting the perforation site and the differential findings according to the elapsed time from the trauma in patients with bowel perforation after blunt abdominal trauma. methods and materials: abdominal ct's of 57 patients with bowel perforation after blunt abdominal trauma confirmed by surgery were retrospectively analyzed without knowledge of the surgical results. the interval from the trauma to ct was 2 to 72 hours (mean, 7 hours). the ct findings of traumatic bowel perforation including extraluminal air collection, segmental bowel wall thickening, localized inter-mesenteric fluid, bowel wall discontinuity, and mesenteric hematoma were analyzed. the predicted perforation sites were classified as: duodenum, jejunum, jejuno-ileal junction, ileum, and colon. based on the mean elapsed time (7 hours), the patients were divided into the early lapse group (n = 37) and the late lapse group (n = 20), and the differential ct findings were analyzed. results: diagnostic accuracy of predicting the perforation site was: duodenum (100%), jejunum (81%), jejuno-ileal junction (100%), ileum (93%), and colon (20%). extraluminal air collection was more frequently seen in the late lapse group (80%) than in the early lapse group (43%) (p < 0.05), whereas other ct findings showed no statistically significant difference in the incidence. contrast-enhanced magnetic resonance imaging of the terminal ileum in children with crohn's disease p. paolantonio, a. laghi, o. borrelli, c. miglio, m. celestre, d. marin, s. cucchiara, r. passariello; rome/it introduction: to evaluate the diagnostic value of gadolinium enhanced mri with polyethylene glycol solution as oral contrast agent (ce-peg-mri) in revealing inflammation of the distal ileum in children with crohn's disease (cd) and in differentiating them from other inflammatory bowel diseases. subjects and methods: seventy-five consecutive paediatric patients referred for suspected cd underwent ileo-colonoscopy with biopsy and ce-peg-mri. the distal ileal mucosa was assessed by endoscopic and histological scores. the cd activity was measured by means of paediatric crohn's disease activity index (pcdai). results: active cd was diagnosed in 26 cases, active ulcerative colitis (uc) in 18, spondyloarthropathy and indeterminate ileo-colitis in 11. in all cd patients ce-peg-mri showed a high concordance with endoscopy and histology. of the 18 uc patients the ce-pegmri was negative in 15 and showed mild parietal contrast enhancement of the terminal ileum in 3 of the 7 patients with backwash ileitis. among the group of spa patients, ce-peg-mri was negative in 4 and revealed mild parietal contrast enhancement in 7. no increase in wall thickness in any of the uc and spa patients was demonstrated. sensitivity and specificity of ce-peg-mri were 84% and 100%, respectively. the test optimally correlated with endoscopic and histological scores (r: 0.94; r: 0.95, respectively) as well as with the pcdai in the cd patient group (r: 0.91). conclusions: high correlation of ce-peg-mri with ileal endoscopy, histology and pcdai makes this test of great interest as a tool for monitoring the clinical course and the effect of therapy in cd patients. small bowel sonography in celiac disease after oral administration of sonographic contrast medium p. mirk, r. foschi, i. de vitis, l. guidi, a. vecchioli-scaldazza, p. marano; rome/it purpose: to assess the usefulness of sonography in celiac disease after small bowel loop filling by sonographic contrast medium. materials and methods: 33 consecutive patients with clinical suspicion or diagnosis of celiac disease were prospectively examined by us before and after (30'-40') drinking of 500-750 ml of an isosmotic water solution of polyethilene glycol. 14 patients had celiac disease (positive histology or aga or ema antibodies); 19 patients had previous celiac disease but were clinically negative, or had other benign disorders, and were considered as normal. results: after contrast administration intestinal loops were better or slightly better shown in 12/33 and 16/33 patients (36.3% and 48.4%), or unchanged in 5/33 (15.5%). among celiac patients, observed intestinal abnormalities were: segmental dyskinesia; transient intussusception; reduced number of jejunal folds; increased number of ileal folds; hypotonic dilated fluid-filled loops; increased intestinal motility. extra-intestinal abnormalities in celiac patients were: spleen size reduction; mesenteric lymphadenopathy; liver steatosis; free peritoneal fluid. 4 celiac patients had no detactable abnormalities (false negatives); there were no false positives. overall accuracy was 87.8% (sensitivity: 71.4%; specificity: 100%; ppv 100%; npv 82.6%) conclusions: small bowel filling by sonographic contrast medium improves us evaluation of wall thickness, mucosal fold pattern, and intestinal motility. transient intussusception was the single most diagnostic sign, whereas other features were less specific and of limited value unless found in combination. preoperative mri and transrectal us in the staging, and post-irradiation therapy restaging, of rectal cancer i. miucin-vukadinovic; sremska kamenica/yu purpose: the goal of the study was to determinate and compare the value of mri and transrectal us (trus) in the staging, and post-irradiation therapy restaging, of rectal cancer. this study was designed to evaluate the down-staging effect of preoperative radiation. method and materials: 34 patients (range, 38-86) with biopsy-proven rectal can-cer underwent imaging using a 1.5 t scanner and transrectal us (7.5 or 10 mhz transducer) before, and after radiation therapy (50 gy, a daily fracton of 2 gy, 5 days a week).tumors were staged according to the tnm staging system. two observers independently scored the tumor stage. the standard of reference was histopathology (after surgical resection). results: all patients underwent radiotherapy before surgery for rectal carcinoma. before radiotherapy mr examination detected 20.6% t2 (b1), 41.2% t3 (b2), 8.8% t2n1 (c1) and 29.4% t3/4n1 (c2) tumors. down-staging of one or more t stages occurred in 44.1% with tumor regression in 23.5%. the mri tumor stage agreed with the histological stage in 86% of patients. trus correctly staged 81% of lesions. t category was correctly restaged after preoperative radiation in only 61.8%. conclusion: preoperative radiotherapy is becoming the standard of care for resectable, locally advanced adenocarcinoma of the rectum. mri and trus enable selection of appropriate patients for preoperative radiotherapy. preoperative trus can establish the depth of penetration of a tumor and showed less sensitivity for lymph node staging. mri showed better diagnostic accuracy (with tendency for overstaging) then trus for interpretation of complete pelvic status in the pre-and post-irradiation period. echographic efficacy evaluation of gastric ulcer treatment s. pimanau, n. mikhailava; vitebsk/by purpose: the objective of this study was to investigate the possibilities of noninvasive abdominal echography in efficacy evaluation of chronic peptic ulcer pharmacotherapy. method and materials: 87 patients with gastric ulcers in the exacerbation phase were examined before the course of pharmacotherapy and after it. ultrasound investigation was carried out after administration of 400-500 ml deaerated liquid. on echography a chronic gastric ulcer was visualized in 84 cases. in the acute exacerbation phase the peptic ulcer was deep, filled with echogenic contents, the ulcer edge being sharp and overhanging. periulcerous infiltration was hypoechogenic, 50-90 mm long, 6-12 mm thick, and its area made up about 400-900 mm 2 . the peripheral edge of periulcerous infiltration seemed sharp. in the course of effective treatment both ulcer dimensions and periulcerous infiltration area reduced on echograms. periulcerous infiltration reduction speed made up about 10 mm 2 /day. the reparative process was also accompanied by ulcer flattening. in cicatrization the ulcer was not visualized on echograms, a hypoechogenic stripe 3-4 mm thick generally remaining. in the absence of reparation, the echographic picture of the ulcer and periulcerous infiltration didn't change essentially. parallel endoscopic study of the stomach revealed either coincidence with echographic findings of qualitative characteristics of the reparative process positive dynamics or its absence. in 6 cases the results of ultrasound and endoscopic investigations didn't coincide; echograms showed slight infiltration with a central small echogenic area at the site of ulcer regarded as ulcer reparation, while endoscopy revealed a red scar. conclusion: thus, abdominal ultrasound investigation of the stomach enables reliable evaluation of gastric ulcer dynamics in the course of conservative treatment. comparison of multi-slice ct-colonography in ultra-low-dose technique with high resolution video-colonoscopy in the detection of colorectal polyps m. cohnen, c. vogt, k. andersen, a. saleh, a. beck, s. vom dahl, v. aurich, d. häussinger, u. moedder; düsseldorf/de purpose: to prospectively compare msct-colonography using an ultra-low-dose technique (uld-msctc) with high-resolution video-colonoscopy (hr-vc) as the standard technique for detection of colorectal cancer and polyps. patients and methods: 115 patients underwent msct-colonography (uld-msctc) after standardized oral bowel cleansing immediately before video-colonoscopy (hr-vc). patients were scanned with an ultra-low-dose msctcolonography protocol (10 mas, ctdiw eff: 1.14 mgy). after noise reduction using an mathematical algorithm by dedicated software, uld-msct-colonographic images were analyzed by a team of two readers in a blinded fashion and the results were compared with the results of hr-vc. results: 150 lesions were detected by hr-vc in 115 patients. sensitivities for detection of polyps < 5 mm, 5-10 mm, and > 10 mm in size were 76% (73 of 96 polyps), 91% (30 of 33 polyps) and 100% (9 of 9 polyps) respectively. all colorectal tumors (4 of 4, 100%) were prospectively diagnosed. the sensitivity to detect flat lesions was 50% (4 of 8 flat lesions). the overall specificity was calculated at 87%. the calculated effective dose ranged between 0.75 and 1.25 msv. conclusions: uld-msctc has an excellent sensitivity and specificity for the detection of colorectal lesions > 5 mm despite a significant reduction in radiation exposure. defecographic the pelvic floor in straining state descended an average of 1.62 cm from the inferior margin of the ischial tuberosity, its broad range of position from -5.2 cm to 0.8 cm implying a wide variation of anorectal angle and perineal descent. mild degree rectocele with less than 2 cm of depth was found in 12 out of 29 cases. rectal intussusception was noted in six and rectal incontinence was seen in one. formation of rectocele and intussusception during defecation was common in asymptomatic young volunteers. the wide range of defecographic measurements warrants the necessity of other complementary studies on anorectal function to improve the diagnostic accuracy. therefore, the interpretation of defecographic findings should be made with caution and should not be used as the sole criteria for selection of a treatment modality. right-side colonic diverticulitis: sonographic and ct findings (differential diagnosis) e. blanc, m.j. martínez, t. ripollés, m. agramunt, c. soto, r. pastor; valencia/es purpose: to describe the sonographic and ct features in right-side colonic diverticulitis and to differentiate this entity from other right-side acute abdominal conditions. methods and materials: 16 patients with a final diagnosis of diverticulitis of the ascending colon or cecum were retrospectively reviewed. sonography was performed in all patients and ct in 13. the following findings were evaluated: the presence of an inflamed right colonic diverticulum, pericolonic infiltration, focal colonic wall thickening and the identification of a normal appendix. the diagnosis was confirmed by surgery, clinical course, or barium enema. results: sonography and ct showed pericolonic inflammation and focal colonic wall thickening in all cases. the inflamed diverticulum was seen with sonography and ct in 15 (94%) and 13 (100%) patients respectively. the normal appendix was identified with sonography in 7 (44%) and with ct in 5 (38%) cases. the initial diagnosis was: right-side colonic diverticulitis (n = 11), acute appendicitis (n = 2), perforated colonic carcinoma (n = 2) and an inflammatory mass (n = 1). conclusions: right-sided colonic diverticulitis is a condition that can clinically mimic other causes of right abdominal pain like acute appendicitis, perforated colonic carcinoma, salpingitis, ileocecal inflammatory pathology, epiploic appendicitis and omental infartion. in this series the most common sonographic and ct findings included the presence of a right colonic diverticulum with thickening of the adjacent pericolonic wall and pericolonic infiltration. both ultrasound and ct can be extremely useful in the early diagnosis of this entity avoiding unnecessary surgery procedures, in a primarily benign and self-limiting condition that can be treated conservatively. an accurate scanning technique for detecting recurrent rectal cancer: enhancement of early-phase dynamic helical ct j. tanaka, s. tsukuda, a. heshiki; iruma-gun/jp purpose: to evaluate the usefulness of dynamic enhancement of helical ct in the detection of local recurrence of resected rectal cancer. in 142 patients with a history of curatively resected t2 or t3 rectal cancer, follow-up plain ct indicated that they had a loco-regional recurrent tumor; consequently, they underwent follow-up pelvic helical ct providing accurate early-phase contrast enhancement in the lower pelvic region. the patients were divided into four groups according to grade of contrast enhancement of the suspected mass-like lesion before and after contrast enhancement, and correlation between groups and results obtained by biopsy and/or surgery was assessed. if no correlation was found, patients were followed up for a period lasting from 400 days to two years. as of june 2002, results had been obtained for 80 patients; and correlation between these results and grouping by contrast enhancement ratio was analyzed. results: all patients in the highest-grade group (n = 10) had local recurrence. when only the highest-grade group was considered positive, there were no false positives and only one false negative. conclusion: our results suggest that early-phase contrast enhancement is useful for accurately detecting recurrent rectal cancer. this can be easily achieved using smartprep function, and should be used to distinguish recurrent tumors from post-surgical scar tissue, because these two tissue types do not exhibit similar enhancement patterns. staging of gastric carcinoma by mr imaging in vitro c. sato 1 , s. naganawa 1 , h. kumada 2 , t. miura 2 , t. ishigaki 1 ; 1 nagoya/jp, 2 toyohashi/jp purpose: to evaluate the accuracy of cancerous invasion to gastric wall with magnetic resonance imaging in vitro. twelve specimens of gastric carcinoma were examined with a 1.5 t mr using a small loop surface coil. they were fixed in formalin within 2 days prior to imaging. the field of view was 30 mm, a matrix size was 256 x 256, and the section thickness was 2 mm. the t1-and t2-weighted images were obtained. two radiologists evaluated the mr images independently, and consensus was obtained if there were any discrepancies between the two. findings on mr images were compared with histopathologic findings. results: mr images depicted the normal gastric wall as consisting of the 4 layers clearly. cancerous invasion was detected in 4 of 12 specimens with mucosal invasion, 3 with submucosal invasion, 2 with the invasion to muscularis propria, 2 with subserosal invasion, and the rest that extended into the serosa. the mr imaging-determined grade correlated with the histopathologic findings for 11 of 12 tumors. the overall accuracy was 91.6%. conclusion: mr imaging has an accurate diagnostic capabilities for the evaluation of the cancerous invasion to the gastric wall in vitro. the results of the present study may encourage the further development of an endoscopic surface coil. role to investigate the value of mri in the overall assessment of crohn's disease (disease activity, disease extension, complications). method and materials: 119 consecutive patients with crohn's disease underwent mri in the context of a clinical evaluation including biochemistry, endoscopy, histology and radiology. all patients underwent mri after oral administration of a superparamagnetic contrast agent, using standard sequences (haste t2weighted, with and without fat-suppression and gd-enhanced t1-weighted flash). two independent radiologists evaluated mr images on printed films. disease length, presence of strictures, fistulae, abscesses, phlegmons and any other abdominal complication were evaluated at the level of each segment. gold standard (gs) for morphological assessment were: barium studies, ct or us, and surgery when performed. at the level of the affected segments bowel wall thickness, t1 wall gd-enhancement, t2 wall signal, t2 fibro-fatty proliferation signal were evaluated and graded (0-3) to assess disease activity. gs for disease activity were endoscopy, biological activity and cdai. results: mri detected 90% of overall disease length, 75% of fistulae, 92% of strictures; adhesions were overestimated. in 11% of patients mri showed complications requiring surgery (1 hydronephrosis, 4 abscesses, 5 phlegmons, 1 pancreatic duct stone, 1 enterovesical fistula, 2 ovarian involvements). the following mri findings were statistically correlated with the clinical and biological signs of active disease: bowel wall thickness (r = 0.59), wall gd-enhancement (r = 0.84), t2 wall signal (r = 0.80), t2 fibro-fatty proliferation signal (r = 0.76). learning objectives: to recognize usual and unusual radiologic findings of pseudomyxoma peritonei with pathologic correlation. background: pseudomyxoma peritonei is a rare neoplastic condition in which gelatinous intraperitoneal fluid collections associated with mucinous disseminated implants are observed. although a ruptured appendiceal mucocele is the most common cause, pathologies arising from other origins may cause this condition with various imaging manifestations. imaging findings: the usual imaging findings were of mucinous, fluid-like material spread over the peritoneal cavity with organ scalloping observed in the liver, splenic and mesenteric margins, with central displacement of small intestinal loops. within the material, cyst-like round structures may be observed and clarified by the septal enhancement on contrast-enhanced images. punctate, annular, or curvilinear calcifications may be disseminated. dropping appendiceal mucocele or a rare urachal tumor located in the female pelvis may simulate an ovarian tumor and be misdiagnosed as gynaecological disease. demonstration of the continuity to the cecum or urachus was the diagnostic clue. localized disease in the female pelvis may simulate ovarian carcinomatous peritonitis, and scalloping of the uterine margin may suggest this condition. because synchronous mucinous tumors of the ovary and the appendix may occur, careful observation to detect the slight irregularity of the omentum adjacent to the cecum is necessary to avoid overlooking an occult primary appendiceal lesion. conclusion: to recognize various imaging findings is important to make the correct preoperative diagnosis. in particular occult appendiceal lesions must not be overlooked. multiplanar observation on ct and mri was important to recognize the complex organic-pathologic relationships to identify the primary neoplasm. retroperitoneal cystic masses: ct findings d. yang, h. kim, j. kang, t. seo, h. kim, s. kim, j. kim; incheon/kr learning objectives: to illustrate the ct findings of the different types of retroperitoneal cystic masses. background: retroperitoneal cystic masses, which arise within the retroperitoneal space but outside the major organs of that compartment, are uncommon. however, the widespread use of computed tomography (ct) for evaluating abdominal and retroperitoneal diseases has increased the detection rate of retroperitoneal cystic lesions. in this exhibit, we conduct a literature review and present the ct findings of our own patients to illustrate the ct appearance of different types of retroperitoneal cystic masses. imaging findings: a variety of ct features were identified in various retroperitoneal cystic masses. the disease entities include cystic lymphangioma, retroperitoneal mucinous cystadenoma, müllerian cyst, cystic change of paraganglioma, epidermoid cyst, cystic teratoma, tailgut cyst, mucocele of appendix, perianal mucinous adenocarcinoma, cystic change of leiomyosarcoma after chemotherapy, pancreatic and nonpancreatic pseudocyst, lymphocele, urinoma, and hematoma. conclusion: knowledge of ct findings of various retroperitoneal cystic masses may be helpful for differential diagnosis. learning objective: our purpose is to describe the ct and mr findings of cystic dystrophy of the duodenal and gastric wall in heterotopic pancreas (cdhp) which allows an accurate diagnosis of this pathology usually associated with chronic pancreatitis. background: cystic dystrophy in heterotopic pancreas is characterized by the development of cysts in heterotopic pancreatic tissue localized in the duodenal or gastric wall. cyst formation is related to cystic dilatation of an anomalous duct bordered by pancreatic excretory epithelium, or to pseudocysts caused by pancreatitis of the heterotopic pancreas. we reviewed ct and mr findings in five patients with cystic dystrophy in heterotopic pancreas (cdhp). they underwent spiral ct (n = 5) and mr/ cholangio-mr (n = 2). diagnosis was confirmed by endoscopic us in all cases. three cases were pathologically proven after surgery. imaging findings: the ct and mri findings of cdhp consists of cysts, (normally multiple), located in the inner wall of the second part of the duodenum and less frequently in the stomach. the duodenal or gastric walls affected are thickened and inflammatory changes are observed around the cysts. signs of chronic pancreatitis are frequently seen. mr/ cholangio-mr shows high intensity lesions corresponding to the cysts. conclusion: cdhp presents some ct and mr features which permit an accurate and reliable diagnosis. when a cystic lesion is found in the duodenal or gastric wall cdhp should be included in the differential diagnosis with other cystic masses such tumors or abcesses. , and thanks to its favorable influence on serum glucose and lipid profiles, this technique is the preferred treatment for patients with severe type i diabetes mellitus and end-stage renal disease (simultaneous pancreatic-kidney transplantation) . therefore an understanding of the anatomic configuration and the spectrum of postsurgical complications is needed. imaging findings: we retrospectively reviewed computed tomographic scans (ct), ultrasounds (us) and doppler studies of 14 patients who had undergone pancreatic transplantation using portal-enteric drainage in our hospital between january 2002 and july 2003. we review the usefulness, limitations and potential pitfalls of ct and us. acute postoperative complications, including acute rejection, transplant pancreatitis, peripancreatic collections and abscess, pseudocysts, vascular complications (thrombosis, pseudoaneurysm) and exocrine leaks, are depicted. furthermore, ct-guided percutaneous biopsy and drainage is a safe and an alternative method for obtaining tissue from the transplanted pancreas with graft dysfuntion, and collections. conclusion: knowledge of normal anatomic configuration and the radiologic appearance of normal pancreatic transplant will allow proper interpretation and early treatment of the spectrum of portsurgical complications in this kind of pancreatic allograft. the more common current gastric bypass procedures include the roux-en-y procedure and bilio-pancreatic diversion with duodenal switch procedure. the more typical complications of these surgeries include anastomotic leaks and stenoses, both of which have been reported in the current literature. more atypical complications, however, have not been comprehensively demonstrated. imaging findings: gastric bypass/gastric stapling is a common surgical procedure at our institution. we have encountered several atypical complications, documented with flouroscopic studies using water soluble contrast. we offer five unusual complications which include the following: internal herniation through the small bowel mesentery, internal herniation through the transverse mesocolon, external herniation through the abdominal wall incision, enterocutaneous fistulas, roux-en-y configuration with anti-peristaltic inversion of the gastroenteric roux limb, and incorrect anastomosis of the roux limb with the excluded stomach (resulting in a roux-en-o configuration). conclusion: our findings expand those of the current literature to include the more infrequent complications of gastric bypass surgery. in the fluoroscopic evaluation of post-operative gastric bypass patients, a thorough understanding of expected post-operative bowel configuration is essential. in addition to assessing anatomical abnormalities, it is equally important to assess for abnormalities of motility. in this study, we performed a retrospective review of the medical records and imaging studies of 37 patients with proven fmf, diagnosed between 1992-2002. imaging findings: the commonest clinical manifestation were recurrent peritoneal attacks with abdominal pain (75.6%) and fever (40.5%). abdominal imaging findings included ileus (n = 12), focal peritonitis (n = 3), ascitis (n = 2), splenomegaly (n = 5), and hepatomegaly (n = 2). one patient developed fatal peritoneal mesothelioma, and 13.5% of patients developed amyloidosis with sonographic findings of renal parenchymal disease or cardiomyopathy. arthritis was second in frequency occurring in 36.1% of patients. radiographs were normal (n = 4) or showed joint effusion and soft tissue swelling (n = 4) due to synovitis. two patients developed seronegative destructive arthropathy. pleuritis was encountered in 13.9%. polyarteritis nodosa (pan) was present in 2 patients, multiple sclerosis in one, and autoimmune hemolytic anemia in one patient. conclusion: fmf predominantly involves abdominal viscera but can affect other organs. the majority of patients have nonspecific imaging findings and the radiologic diagnosis is rarely considered. amyloidosis, mesothelioma, and destructive arthropathy are potential serious complications of fmf. polyarteritis nodosa, multiple sclerosis, and autoimmune hemolytic anemia are rare associations or coincidence with fmf. mucosal associated lymphoid tissue lymphomas: imaging evaluation with pathologic correlation d. voultsinou, t. gerukis, n. staurogianni, k. anastasiadou, a. anagnostopoulos, p. palladas; thessaloniki/gr learning objectives: to identify the radiological features of extra nodal non hodgkin malt lymphoma. to illustrate the spectrum of appearance of the disease in its various locations in the human body. to list the various imaging strategies. to discuss the differential diagnosis. background: mucosal associated lymphoid tissue (malt) lymphoma arises in extranodal mucosal lymphoid tissue and has only been recognized recently. it affects several extranodal structures such as the stomach, the lung, the eye and the salivary glands. it is generally low grade and has an indolent course, as it remains long confined to the initial site. in this exhibit we describe and illustrate the most common radiological patterns of malt lymphoma. imaging findings: we retrospectively reviewed clinical and radiographic records in 17 cases with confirmed low-grade gastric malt lymphoma. the study group consisted of 10 men and 7 women (mean age 62 years). the predisposing factors of malt lymphoma, number and location of lesions, and course of the disease were evaluated. we determined the most probable diagnosis on the basis of the radiologic findings and correlated them to pathologic and immunohistochemical findings of endoscopy, biopsy and bone marrow examination.10 out of 17 patients presented with malt lymphoma of the stomach, 2 in the parotid gland, 2 in the lung, 2 in the large intestine (sigmoid colon, rectum), 1 in ileocecal valve and 1 in the orbit rectal malt lymphoma coexisted in one patient, and parotid gland and lung lymphoma in 2 patients. all patients were treated with chemotherapy. the disease resolved in 15 patients. the correlation of imaging, endoscopic and pathologic findings significantly contributes to diagnosis and follow-up of malt lymphomas, early diagnosis of which results in complete regression. to describe a new approach to ct colonography for detecting colo-rectal polyps with multidetector row ct (mdct). to display the results and to present the benefits provided by this technique. background: virtual dissection‚ (gems) is an original application to display the entire inner surface of the colon without the need for navigation. the method consists of displaying the straightened and flattened colon using surface rendering. we performed 30 virtual colonoscopies with a ge lightspeed 16 mdct. the acquisition parameter and each step of the imaging procedure will be described. procedure details: all patients underwent ct colonography in both supine and prone positions, the following parameters were used: 120 kvp; 80-150 mas; 2.5mm collimation; 1.25-mm reconstruction intervals and rotation time, 0.5-0.75 sec. the colon was assimilated to a cylinder manually defined. time to display the straightened and flattened colon using surface rendering was about 5 minutes. normal aspect, polyps and artifacts were displayed. polyp detection was faster and easier with this method compared to axial images and the usual virtual endoscopy mode with forward and reverse viewing fly-through volume rendered movies. conclusion: this method makes it possible to stretch the colon virtually and to cut it along its axis similar to a real dissection on the pathologist's (1) and luschka duct (2). ce-mrcp succesfully revealed the origin of the leak in 7 patients. conclusion: contrast enhanced mr cholangiography with iv mangafodipir trisodium can accurately diagnose the presence and location of bile duct leaks in patients who have undergone laparoscopic cholecystectomy. internal hernia of the anterior part of the abdomen: imaging in the multidetector-row ct era n. hongo, h. mori, s. matsumoto, y. okino, a. adachi, a. kaku; oita/jp purpose: internal hernia of the anterior part of the abdomen (ihapa) is difficult to diagnose preoperatively because of its rarity and lack of imaging landmarks. the purpose of this study is to clarify the ct features of ihapa by ct, especially with multi-detector row ct (mdct). methods and materials: the ct scans in 8 patients with surgically confirmed ihapa through a transverse mesoclolon (n = 4) or an omentum (n = 4) were retrospectively reviewed; furthermore, the transverse mesocolic type was classified into intramesenteric type (n = 2) and transmesenteric type (n = 2). special attention was paid to the herniated sac-like appearance, hernial orifice, running course of the omental fat and transverse colon. results: the closed loop of the small bowel was observed in all cases. a sac-like appearance, enclosed by transverse colon was identified in both cases with intramesenteric type, but was not observed in other types of ihapa. fatty continuation between the hernial orifice and omentum was identified in two out of four cases with omental type of ihapa. furthermore, the transverse colon passed above to the hernial orifice in all cases with omental type, while this finding was not observed in any of the transverse mesocolic type. conclusion: the relationship between the hernial orifice and transverse colon, and sac-like appearance enclosed by transverse colon are the diagnostic key of ihapa on ct. particularly, mdct would become feasible to diagnose the ihapa preoperatively, even though it lacks of vascular landmarks. contrast enhanced mri using oral peg solution in the follow-up of patients with known crohn's disease m. scettro, a. grasso, f. monetti, g. rescinito, g. rollandi, c. neumaier; genoa/it purpose: aim of our study was to analyze, in the context of an extensive evaluation, crohn's disease activity index (cdai), and conventional enteroclysis, the value of mri to identify disease extension and complications in patients with known disease. material and methods: abdominal mri of 29 patients in a period of 12 months with a diagnosis of crohn's disease were analyzed by two experienced gastrointestinal radiologists, in consensus, looking for any intestinal and extra-intestinal abnormality. mri studies were performed on a 1.5 t (intera nt, philips) with a phased array coil. mri was performed using a polyethylene glycol (peg) solution 378 b d e f a g as oral contrast agent to distend the small bowel (ce-peg-mri), using standard sequences (ss-tse t2 and tfe t1 with fat saturation after gd-dtpa and buscopan 10 mg i.v.) . results: mr imaging had an overall sensitivity of 98% and a specificity of 93% for active disease. bowel wall enhancement (ratio of signal intensity of abnormal to normal bowel > 1.3:1), bowel wall thickening greater than 3/4 mm and increased mesenteric vascularity were useful in identifying active disease. the experience shows that the method is complementary to conventional enteroclysis in the detection of superficial and transmural abnormalities in patients with crohn's disease. in addition, ce-peg-mri can provide excellent information concerning mesenteric involvement, disease activity, and complications of crohn's disease. finally mri may become a gold standard in the identification of recurrant disease. withdrawn by authors the number of x-ray based examinations (using a contrast medium) of the oesophagus, stomach, and large bowel, decreased by 34%, 94% and 80%, respectively. x-ray based examination of the small bowel and plain radiography of the abdomen remained unchanged. endoscopies of oesophagus / stomach and the large bowel increased by nearly 350%. x-ray based examination of the biliary tract almost disappeared with us, ercp and mrcp taking over. the annual collective effective dose for the all gi tract examinations was reduced by 61%, from 18.4 mansv in 1983 to 7.1 mansv in 2002. the shift in modalities used for diagnostic imaging of the gastrointestinal tract from x-ray examination to us, endoscopies and mri resulted in a significant reduction in exposure to ionising radiation of patient, and need to be considered when discussing further development and structure of diagnostic imaging in general. perfusional enhanced ultrasound in the diagnostic evaluation of sicca syndrome g. argalia, d. salera, g. giuseppetti; ancona/it purpose: sicca syndrome is a relatively common disorder especially among older women. it may be caused by an autoimmune disorder like sjogren's syndrome (ss) or by several other illnesses. our purpose is to evaluate the diagnostic possibilities of contrast enhanced ultrasound in the characterization of sicca syndrome. we studied 60 consecutive patients with sicca syndrome, 40 affected by ss (23 with primary sjogren's syndrome, 17 with secondary sjogren's syndrome due to connetivitis) and 20 patients with a sicca syndrome not related to ss. all patients were selected according to the european community study group diagnostic criteria for sjogren's syndrome (the gold-standard of the study) and underwent contrast enhanced ultrasound examination with timeintensity curve analysis obtained before and during saliva stimulus, salivary glands scintigraphy and labial gland biopsy. results: 40 ss patients had an echo contrast enhancement before and during saliva stimulus significantly lower (p < 0.001) than the non ss ones. the 23 patients with primary ss showed a significantly lower enhancement during saliva stimulus than the secondary ss patients (p < 0.005); no statistically different enhancement was seen in basic conditions (p = 0.069). in the study group (60 subjects with sicca syndrome) the enhanced ultrasound showed a sensitivity of 87.5%, a specificity of 85% and an accuracy of 86.7% on the diagnosis of ss. our experience confirmed the good diagnostic accuracy of salivary glands scintigraphy and labial biopsy. the preliminary results show this method is useful in the functional study of parotid glands in the characterization of sicca syndrome. fusion imaging of 3d angiographies of arteries and veins around the stomach by multiphase fusion technique under a single-breath hold using 16 row multidetector row ct: its usefulness for preoperative simulation and intraoperative navigation of laparoscopy-assisted gastrectomy m. matsuki, h. kani, i. narabayashi; takatsuki/jp purpose: gastric arteries and veins can vary between patients; therefore, it requires much time to ligate arteries, and veins can be damaged during regional lymph node excision under laparoscopy-assisted gastrectomy (lag). we evaluate the efficacy of fusion imaging of three-dimensional angiographies of arteries and veins around the stomach by the multiphase fusion technique under singlebreath hold using 16 row multidetector row ct (mdct) in the preoperative simulation and intraoperative navigation of lag. methods and materials: contrast-enhanced ct scan using 16 das mdct was performed on 10 patients before lag. images at both arterial and venous phases were obtained under a single-breath hold. three-dimensional ct angiographies at the arterial and venous phases were reconstructed using the volume-rendering technique and then fused. 1) the detectability of the left gastric artery (lga), right gastric artery (rga), left gastric coronary vein (lcv), right gastric vein (rgv) and helens' gastrocolic trunk (gct) on the multiphase fusion images was evaluated in comparison with the surgical findings. 2) in intraoperative navigation, the clinical usefulness of multiphase fusion imaging was evaluated. results: 1. in nine of ten patients (90%), the multiphase fusion images could demonstrate clearly, simultaneously and three-dimensionally the lga, rga, lcv and gct without a respiratory gap. 2. we could arrange and rotate a multiphase fusion image to correspond to the operative view, which was very useful in the intraoperative navigation of lag. the multiphase fusion imaging is considered to be very useful in the preoperative simulation and intraoperative navigation of lag. three-dimensional endosonographic guidance of needle positioning in interstitial brachytherapy a.f. christensen, m.b. nielsen, s.a. engelholm; copenhagen/dk interstitial brachytherapy is used in the treatment of anal carcinoma, so far without image guidance during needle positioning.the aim of the study was to describe a procedure for optimizing needle positioning guided by three-dimensional (3-d) endosonography. twelve patients who received external radiation therapy for anal carcinoma were referred for interstitial brachytherapy under 3-d endosonographic guidance. the procedure was initiated by anal endosonography performed with a 10 mhz rotating endoprobe. cross-sectional images of the anal sphincters were stored on a 3-d system during retraction of the endoprobe. afterwards, any projection could be reconstructed. from this scanning the optimal positioning of the needles was determined. the needles containing radioactive isotopes were inserted through holes in an externally fixated disc. repeated endosonography assured that optimal tumor coverage was obtained by adjusting the number, loading or position of the needles. in all patients endosonography was able to visualize the extent of the tumor and the position of each needle so that both the distance from needle tip to upper tumor border, as well as the distance from the anal orifice to the lower tumor border could be determined. in 8 patients endosonography showed a, at least 2 clock-positions larger circumferential tumor size than manual examination. this made an increase in number of needles necessary. in 5 patients endosonography influenced the extent of loading of the needles. in 2 patients endosonography led to a change in positioning of the needles. 3-d endosonography guidance of interstitial brachytherapy in anal carcinoma seems possible, which may influence the radiation coverage. to determine ct criteria that allows accurate classification of interstitial hernias. methods and materials: ct scans of 13 patients with surgically proved spigelian hernia (n = 7) or interparietal inguinal hernia (n = 6) have been retrospectively reviewed. ct assessment included: 1) assessment of the hernial sac (anatomic situation, extension, content) and 2) assessment of the fascial defect (anatomic situation, relationship to the inferior epigastric vessels). results: in all cases (n = 13), the hernial sac was located between the internal and external oblique muscles. the fascial defect was located at the spigelian aponeurosis, above the inferior epigastric vessels in the seven cases of spigelian hernia, and at the internal inguinal ring, lateral to the inferior epigastric vessels in the six cases of interparietal inguinal hernia. conclusion: assessing only the hernial sac does not allow accurate classification of interstitial hernias. diagnosis is established by precise analysis of the anatomic situation of the fascial defect. the role of magnetic resonance cholangiography in patients with biliaryenteric anastomosis y.a. akhmetov; almaty/kz purpose: the study was aimed at investigating the role of mr-cholangiography (mrc) in the examination of patients treated with biliary-enteric anastomosis. methods and materials: mrc was performed in 23 patients (13 female and10 male, mean age: 59.9 years) undergoing biliary-enteric anastomoses (18 hepatico-jejunostomies and 5 choledocho-duodenostomies). mrc was performed with a non-breath-hold 3d turbo spin echo sequence (tr = 5000 msec, te = 700 msec, etl = 128) with an acquisition time from 4 min to 6 min. 11 patients subsequently underwent percutaneous transhepatic cholangiography (ptc) in order to confirm the mrc findings and to perform a therapeutical procedure. 4 patients with choledochoduodenostomy were examined with ercp. the remaining 8 patients, with no evident symptoms or signs of bile duct dilation, were examined during their surgical follow-up without the performance of any invasive procedure. the degree of bile duct dilation was correctly evaluated with good panomaric assessment of the ducts and site of anastomosis in all 23 patients. both dilated and non-dilated bile ducts were well depicted. mrc correctly showed stenosis of anastomosis in 10 of 10 patients, 5-18 mm stones in 9 of 9 patients and bile ducts irregularities in 3 of 5 patients with cholangitis. conclusion: mrc is a safe, noninvasive technique in the study of biliary-enteric anastomoses and can be used to the screening of symptomatic patients. mrcp images may serve as a guide for planning of interventional procedures. cystic duct imaging using both magnetic resonance cholangiography (mrc) and 3d learning objectives: to describe the indications and diagnostic limits of each procedure, to present the steps taken to perform each procedure as well as the possible complications, and potential pitfalls. background: the early diagnosis of breast cancer is a challenge in breast imaging work-up. to detect malignancy in non-palpable breast lesions without unnecessary open biopsies, percutaneous biopsy of the suspect lesion should be undertaken. percutaneous breast biopsy can be performed under sonographic or x-ray guidance. whatever method is used, certain principles apply. exhibit details: the exhibit will be divided into subsections focusing on the indications and diagnostic limits of each procedure, the necessary equipment for each method and the steps taken to perform each procedure through sample cases. we will focus on practical issues such as needle size, site of entry, number of tissue probes that we need to take according to the lesion type. also the avoidance of complications, and other useful tips will be presented. a special reference will be made to the histological findings that require surgical excision and the potential pitfalls in case of false negative samples. we will also present a short time follow-up diagram for the histologically confirmed benign lesions. conclusions: whenever a non-palpable breast lesion is considered for biopsy, either x-ray or ultrasound guided procedures are performed. each method has its indications, advantages and disadvantages, and the examiner should be familiar with those factors for proper procedure selection. the use of carbon marking after stereotactic 11-gauge vacuum-assisted breast biopsy and during advanced breast results: eleven cases were considered fn (6%). a) four cases were found after 14-g core biopsies: two architectural distorsions initially diagnosed as radial scars proved to be malignant after surgery, and one case of microcalcifications, first diagnosed as adenosis, underwent 6 month follow-up corresponding to a ductal carcinoma in situ. also a ductal carcinoma in situ was found inside a fibroadenoma (first diagnosed as fibroadenoma). b) also seven cases were found after vacuum-assisted biopsies, all of them microcalcifications that were confirmed in the radiograph of the specimen: five cases were initially diagnosed as atipical ductal hyperplasia and corresponded to four ductal carcinomas in situ, and one infiltrating ductal carcinoma; the remaining two cases were first reported as ductal ectasia and interstitial microcalcifications, becoming two ductal carcinomas in situ (one of them was diagnosed 12 months later after core biopsy). the average diameter of the lesion was 31.5 mm. none of the lesions were removed completely. conclusion: results such as radial scar, atypical ductal hyperplasia, interstitial microcalcifications and ductal ectasia may occult a carcinoma after needle core biopsies. the percutaneous triple sample (fnac, core biopsy, and cylinder smears) in breast cancer diagnosis: results in 77 patients i. vizcaino, v. torres, s. picó, e. blanc, c. soto, s. isarria; valencia/es purpose: to evaluate a combined method to sample tumoral tissue in breast cancer. a prospective study using at the same time fnac, core biopsy and cylinder smears was performed in 77 patients. we used a 25 g needle (1-2 passes) and a thin-wall 16 g needle (2-5 cylinders, 1 mm/1 cm sized). smears of core biopsy cylinders were systematically prepared to cytological examination. the lesions were targeted using palpation, ultrasound, coordinates plate, and a stereotactic device depending on the lesion. all patients had breast cancer. the results were evaluated regarding the sensitivity to breast cancer diagnosis. the overall sensitivity of three-way diagnosis was 99% (the false negative case was a non-palpable dcis that showed necrosis in cylinder and no tumoral cells in both, fnac and cylinder smears). the sensitivity of fnac was the same as core biopsy: 86%. the sensitivity of cylinder smears was 95%. benign tissue in cylinders with malignant cells in cylinders smears was seen in 7 cases (2 dcis, 1 necrotic medullar carcinoma, 1 intracystic carcinoma and 3 idc). fibrous tissue was found in the cylinders of these 7 cases. the combination of fnac, core biopsy and cylinder smears show a high sensitivity to breast cancer diagnosis. cylinder smears must be obtained systematically in core biopsy in order to prevent the false negative results. weak cohesion of tumoral cells can explain this phenomenon. purpose: mammographic follow-up of patients after conservative treatment for breast cancer by screen-film mammography is difficult and sometimes impossible due to the post-radiation and surgical changes. digital mammography (dm), with post-processing tools, might facilitate the reading. the purpose of this presentation is to evaluate the accuracy of dm and to describe the post-therapeutic changes in these patients. materials and methods: dm (senograph 2000d, gems®) was performed in 77 patients 3 and 6 months after conservative treatment (surgery and radiotherapy) for breast cancer. mammograms were indepedently read by two senior radiologists. both radiologists performed screen-reading, using commercially available post processing tools (magnification, zoom, contrast inversion, thickness compensation). they evaluated the overall image quality. the following features were also analysed: breast density (according to birads classification), skin thickening, parenchymal changes with glandular oedema (4 grades), scar and microcalcifications. results: all dm were considered as of diagnostic quality by both radiologists. importance of glandular oedema was correlated to breast density (birads 4, n = 16; oedema 4, n = 14), (birads 3, n = 41; oedema 3, n = 48). analysis of skin and dermal thickness was facilitated by the algorithm of thickness compensation. visibility of scars (n = 54) and microcalcifications (birads 2, n = 21; bi-rads 3-4-5, n = 6) was improved by digital magnification and digital contrast variations. conclusion: digital mammography due to the post processing tools seems to facilitate dramatically reading of mammography in patients with previous conservative treatment for breast cancer, and helps to delineate post-therapeutic changes. the conclusions: it appears that the achievable image quality of a system not only depends on detector characteristics but also on available combinations of target, filter and tube voltage. therefore image quality comparisons show different results using optimized spectra for each digital system, compared to using the same spectrum for all systems. to show a short way to present breast mr dynamic imaging obtained using 1-mm 3 isotropic 3d acquisition and single-voxel proton spectroscopy. background: during a standard breast mr exam, including a precontrast shorttau inversion recovery (stir) or fast spin-echo t2-weighted fat-sat and a dynamic gd-enhanced 3d sequence, at least 700 native and subtracted images are produced. moreover, maximum intensity projections (mips) of a subtracted phase and dynamic curves must be shown. if performed, proton spectra could be given with localizing images, too. procedure details: seventy breast mr exams were performed at our department as follows: 40-slice axial stir; 128 t1-weighted 3d gradient-echo coronal 1-mm partitions (384 x 192-mm field-of-view; 384 x 192 matrix; 1-mm 3 voxel) with 0.1 mmol/kg gd-chelate and 120-s time resolution (4 postcontrast phases), giving 680 native and 512 subtracted for a total of 1192 images; single-voxel spinecho (te 135 ms) proton spectroscopy. we present firstly an axial mip of the first subtracted sequence similar to cranio-caudal x-ray mammography (xm) views, two lateral mips similar to lateral 90 degrees xm views, and a coronal mip. then, only selected images are presented: stir, precontrast t1-weighted, and postcontrast subtracted images (morphology); percent enhancement-to-time curves for regions of interest (dynamics); proton spectra with/without choline peak at 3.14-3.34 ppm and lipids peaks (metabolism). representative cases will be shown in correlation xm, ultrasound, and pathologic proof. conclusion: breast mr high-resolution imaging and proton spectroscopy can be effectively summarized in no more than 24 images (2 x 16-in-one films), 2% of the acquired/subtracted 1192 images. mr guided interventional procedures in breast pathology management i. herraiz, l. concepción, j. ballesteros, a. fernández-moscoso, j. gallego, m. garcía-franco; alicante/es; presented by s. lopez-celanda; alicante/es learning objectives: to descibe mri-guided core biopsy of mri-suspected lesion, hook wire placement or clip marking for excisional biopsy of non-palpable, mri-only visualized lesions. procedure details: all procedures were performed on a 1.5 t philips gyroscan intera unit. standard ce breast mri imaging protocol included a dynamic volumetric t1-weighted acquisition prior and after gd-dtpa injection employing a bilateral surface coil. localization was achieved either by employing a stereotatic device or by triangulation methodology with external markers with a flexible unilateral surface coil. imaging acquisition was tailored to each case. titanium clips (inrad®) or nitinol (somatex®). 15 g titanium coaxial needles (somatex®) and 16 g automatic biopsy gun were employed (tsk acecut®,). our series includes 44 patients with 56 mri suspected lesions. reevaluation of them with conventional methods (mammography and sonography) allowed location of half of them resulting finally in a total of 36 mri-guided interventional procedures. this includes 20 mri-guided core biopsies in lesions measuring 5-12 mm, 9 mriguided presurgical hook wire localization and 7 clip placements to assist location of a mri visible single lesion. pathologic evaluation resulted in 10 cases of infiltrative ductal carcinoma and 18 benign lesions. the only biopsy false negative result was in the smallest lesion (5 mm). conclusions: all mri-suspected lesions must be reevaluated by conventional methods. in mri-only visible lesions we favor clip marking or hook wire location if size is smaller than 7 mm. in lesions highly suspicious for malignancy additional clip marking during core biopsy procedure is recommended. background: accuracy of pre-treatment diagnosis of breast carcinoma extension is essential in order to plan the most effective therapeutic approach. extension of carcinomas can be difficult to interpret on 2d images, especially if their distribution is segmental or irregular. also, additional multifocal or multicentric foci can be problematic to localize in respect to the main tumour and the anatomy of the remaining breast. it is furthermore important for breast surgeons to apprehend the extent of the disease in radiological images in order to plan the surgical approach. procedure details: t1-weighted flash 3d pre-and post-contrast images were obtained in patients diagnosed with breast cancer on core biopsy. analysis of images was done with a dedicated software for breast mri (asymedâ). parametric images for maximum enhancement speed, maximum enhancement, multiplanar and 3d reconstructions, speed of enhancement curves and enhancement curves are analysed in each patient. 3d images were viewed as video clips with a 360 degree rotation around both breasts. maximum tumor diameter was measured in all images and distribution was reported following surgical anatomy. all shown cases have been histopathologically proven in respect to size and extension. conclusion: besides analysis of morphology and speed of enhancement curves, maximum enhancement speed parametric 3d images stand as a useful approach to tumor extension, giving additional information and an overall view of distribution of the disease in respect to breast anatomy. background: the rate of breast cancer recurrence is 1-2% per year. follow-up of patients after conservative surgery includes a periodic clinical examination and a mammography every 6 months during the first 2 years and every year thereafter. post-treatment changes may mimic or obscure recurrent cancer. diagnostic problems are encountered with conventional imaging and fine-needle aspiration cytology. increased vascularity and vascular permeability occurs in recent scars and inflammation; however majority of scars 6 months after surgery do not enhance significantly at mrm while all malignancies do. imaging findings: in our series all cases of proved recurrence showed over 70% maximum signal intensity enhancement at minute 1 and plateau or washout dynamic curve at mrm. only two cases of scar showed more than 70% maximum signal intensity enhancement at minute 1 and the curve in all benign cases was gradual. the quantitative data should be always correlated with the morphology of enhancement curve. irregular shape or margins and inhomogeneous enhancement proved to be important criteria for recurrence assessment. conclusion: mrm appears a valuable tool to differentiate post-treatment changes from recurrent carcinoma and to guide the pathological confirmation. its high negative predictive value may have an impact on follow-up of treated breasts. the correlations between enhancement parameters and histopathological findings were analyzed using stepwise multiple regression analysis, student's-t test and spearman moments correlation coefficients. results: significant correlations were determined between the presence of lymph node metastasis and tumor size (r = 0.397, p < 0.01), contour characteristics (r = 0.369, p < 0.05), and edge characteristics (r = 0.495, p < 0.01). a highly significant correlation was found between histological grades and qualitative enhancement patterns (r = 0.403, p < 0.01). statistically significant differences were found between the groups with and without lymph node metastasis regarding enhancement in the 1 st minute (p < 0.01) and tic slope (p < 0.05). a significant difference was found between the histological grades i and iii regarding all quantitative enhancement parameters, whereas no difference was found between the grades i-ii, and ii-iii. conclusion: dce-mri helps to predict prognostic factors of breast cancer by revealing qualitative and quantitative enhancement features of the primary tumor. additional morphological factors further improve our ability to predict lymphatic metastasis. we measured the number of vessels, the major systolic velocity (ps), the end diastolic velocity (ed), the resistance index (ri) and the glosing index (pi) appearing in all the slices we took. we noted the maximum and minimum values of all the above parameters that appeared in the same mass in different slices and calculated the differences. results: for the benign tumors the mean values for the differences between the maximum and the minimum number of vessels was (diffves) 3.26 (p < 0.00), the diffps was 3.23 cm²/sec (p < 0.00), the diffed was 2.38 cm²/sec (p < 0.01), the diffri was 0.12 (p < 0,03) and diffpi was 0. reliability of us-diagnosis of metastatically affected regional lymph nodes in the presence of female breast cancer e. shevchenko, a. zubarev; moscow/ru purpose: analysis of false-positive and false-negative results of us in diagnosis of metastatic lymph nodes (l.n.) in breast cancer. materials and methods: 346 patients with breast cancer (stages t1n0-t3n2) were examined on hdi 5000 atl philips with morphological verification. 105 patients (30.35%) had metastatic deposition in regional l.n. results: precision of us-diagnosis of unchanged l.n. was equal to 0.86, specificity -60.7%, sensitivity -84.8%. false-negative results were found in 15 cases (4.3%). in b-mode the oval shape remained unchanged in all 15 cases, cortical layer and core were differentiated. thickness of cortex: 0.15-0.3 cm, node size: 0.3 x 0.5 cm-1.2 x 0.9 cm. in 10 cases blood flow was located in portal region, 5 cases -1 longitudinal vessel in center of the l.n. sizes of the l.n. with micrometastases were up to 1.2 cm. we had false-positive results in 27 patients (7.8%). round shape was found in 11 cases, oval -in 12, in 4 patients 2 l.n. joined together in 1 irregularly shaped node. in 10 cases there was uneven thickening of cortex in one pole of node with size fluctuation. differentiation of cortex and core was absent in 17 cases and echogenity was diffusely lowered. subcapsular vessels were located in 14 cases, aberrant vessels -in 1, distortion of central vessel -in 6, local absence of perfusion -in 1. false-positive cases corresponded to sinus-histiocytosis, hyperplasia of lymphoid tissue. conclusion: only use of the full complex of us-symptoms of metastatically affected l.n. lets us improve the precision of diagnosis. inter-and intraobserver agreement in breast ultrasonography: significance of internal echoes at image interpretation j. tsutsumi, k. shimamoto, m. ikeda, a. sawaki, h. satake; nagoya/jp purpose: to evaluate the significance of internal echoes among diagnostic us criteria for breast lesions. materials and methods: 100 breast masses (50 benign, 50 malignant) were interpreted by 6 radiologists and 20 radiological technologists using a four-point rating scale, and the kappa statistics were employed for analying interobserver agreement. to assess reproducibility in judgments, double reading was done in 50 cases, and a total of 150 cases were interpreted for each observer. us criteria included shape, border, boundary echoes, internal echoes (homogeneity and echo level), posterior echoes, lateral shadow, gland surface, depth-width ratio (d/w) and total impression in differentiating benign from malignant lesions. to evaluate the significance of internal echoes at us image interpretation, us images were modified to make the internal echoes invisible by painting with black color using the adobe photoshop. : roc analysis showed a significant difference in diagnostic performance between the original us images and modified us images (p < 0.05). the kappa value of posterior echoes was highest whereas that of boundary echoes showed the lowest value in both the original and modified us images. inter-observer agreement in shape, border, and category in the original images was significantly higher than that in the modified images (p < 0.05). reproducibility in boundary echoes and gland surface was fair, and that in posterior echoes and the d/w was good. can a mammogram dictate to you the diagnosis? a review of characteristic mammographic findings a.n. chalazonitis 1 , j. tzovara 2 , t. vrakatselis 1 ; 1 athens/gr, 2 ioannina/gr learning objectives: participants will obtain an approach to various mammographic patterns and improve their diagnostic skills in breast imaging. background: mammography is considered by far the single most important imaging modality for breast diseases. except from radiologists with vast experience, many other physicians without specific knowledge are unable to discriminate normal from abnormal findings in the mammograms. imaging findings: the main aim of this exhibit is to provide a pictorial review of characteristic radiological findings in 15 different mammograms. various examples due to different causes are illustrated and mammographic findings, as well as differential and final diagnosis are also discussed. all cases have been selected by reviewing our hospital teaching files. conclusion: our exhibit will allow participants to challenge their skills in the detection of both normal and abnormal mammographic signs. breast imaging and histopathologic correlation of fibroadenomas in patients with transplanted kidney: different features from usual fibroadenoma e. son 1 , e.-k. kim 2 , k. oh 2 ; 1 sungnam/kr, 2 seoul/kr learning objectives: to analyze the imaging and histopathologic features of fibroadenomas in kidney transplanted patients and to compare findings of fibroadenomas in kidney transplanted patients with those in a control group. background: from 1990 to 1999, 1,438 patients underwent renal transplantation at our institute. all patients received immunosuppressive therapy with cyclosporin a and steroid after renal allograft. we examined ten female patients who were diagnosed with fibroadenomas during chemotherapy, and compared the data obtained with that of fibroadenomas in the normal population. procedure details: twenty-two fibroadenomas developed in ten patients. eight of the 10 patients had multiple fibroadenomas and 7 had bilateral fibroadenomas. the mean diameter of the fibroadenomas was 4.17 ± 2.5 cm. by mammography the lesions were spherical in shape and had a well circumscribed margin with a high density mass. none of the lesions showed calcification or spiculation. sonographic findings of the masses showed relatively high echogenecity with higher l/t ratios than benign masses, however, features of homogeneous internal echo and well circumscribed margin were consistent with benign. conclusion: the fibroadenomas that developed in patients with renal transplantation showed a tendency to be multiple, bilateral and larger than those in the control group. these fibroadenomas also exhibited a more rapid growth, a more spherical shape and an unusually high internal echo and higher l/t ratio than usual fibroadenomas. to present mammographic and ultrasonographic (us) findings in various types of reconstruction using autogenous myocutaneous flap after mastectomy or breast conserving operation. background: breast reconstruction is an integral part of a woman's breast cancer management and yields positive psychological benefits for the patient. autologous tissue reconstruction has gained in popularity in part owing to adverse publicity regarding prosthetic implant safety. it can alter breast anatomy and architecture drastically. in this exhibit, we describe mammographic and us findings in the various types of reconstruction using autogenous myocutaneous flap after mastectomy or breast conserving operation. procedure details: mammography and ultrasonography obtained in patients who had undergone reconstruction mammoplasty using the autogenous myocutaneous flap procedure were reviewed to facilitate recognition of both normal and abnormal postoperative appearances of the various types of reconstruction using autogenous myocutaneous flap after mastectomy or breast conserving operation. normal mammographic and us findings include predominance of fatty appearance, surgical clips, and surgical scars. abnormal mammographic and us findings include fat necrosis, calcifications, and locally recurrent carcinoma. us findings of fat necrosis were cystic, complex and solid appearing masses with circumscribed or ill-defined margins in peripheral portions of flap. us finding of locally recurrent carcinoma was ill-defined heterogeneous hypoechoic lesions in reconstructed breast, similar to those of primary breast cancer. conclusions: breast reconstruction using autogenous myocutaneous flap has increased in popularity with various methods. mammography and sonography facilitated excellent visualization of normal and abnormal findings of various reconstructed breasts using autogenous myocutaneous flap. extramammary pathology mimicking breast disease e. rabanal, r. rosell, j. salvia, r. garcia; sabadell/es learning objectives: to present the imaging findings in cases suspected initially of breast disease which turned out to have extramammary pathology. background: we reviewed our records for the last ten years. during that time, 76,443 mammary studies were performed. all cases with extramammary pathology were selected. they were classified into two broad categories: those which had abnormal physical findings (palpable mass or skin thickening) and those with abnormal findings in the mammogram (calcifications, nodules and thickened lymphatics). imaging findings: cases were classified as follows: microcalcifications secondary to filariasis. we will see more of these cases due to increased immigration. it's important to know this entity to make the correct diagnosis and avoid unnecessary examination or biopsy. uniform skin thickening and/or oedema, secondary to systemic disease (sclerodermia), congestive heart failure or lymphoedema. palpable skin nodules (infected sebaceous cysts), simulating mammary abscesses. chest wall disease: empyema necessitatis draining into the breast. extramammary (chest wall) lipomas and dercum's disease. neurofibromas in von recklinghausen's disease. the imaging findings of these processes will be reviewed and their salient features described in order to suggest the correct diagnosis. conclusion: it is important to know the features of extramammary disease in order to make the correct diagnosis, avoiding further examinations and unnecessary invasive procedures. the reality of microcalcifications in breast tissues shown by synchrotron radiation imaging j. okamoto, y. kanemaki, k. imamura, n. ehara, y. inada, i. maeda, k. miyamoto, y. nakajima, m. fukuda; kawasaki/jp purpose: the aim of this study was to approach the reality of microcalcifications of benign and malignant diseases using synchrotron radiation imaging, and to make a comparison with conventional x-ray images. materials and methods: surgical and biopsied specimens fixed in wax blocks were imaged using synchrotron radiation (sr), and conventional mammography unit (conv) as well. studied were 98 patients (40 benign, 58 malignant). sr imaging was performed at spring-8 in japan in refraction-enhancement mode. conv images were evaluated visually using a magnifying glass. sr images were inspected on a monitor without magnification. morphology of microcalcification was categorized to 3 groups: small round, amorphous (am), and pleomorphic (pl). results: 1,319 calcifications were observed in 98 conv images and 9,225 calcifications in sr images. 7,906 of 9,225 (86%) were invisible in conv images. sr imaging revealed that great numbers of specks were recognized collectively as a single calcification in conv images, and 949 of 1,319 calcifications in conv images were found to consist of multiple specks. the incidence was especially higher in am and pl types (602/755 and 187/204, respectively). comparing malignant with benign diseases, there was a striking contrast in am-type calcifications; majority of am-type calcifications in malignant diseases were found as collectives of fine specks (84/432), to the contrary 69/170 in benign (p < 0.0001). conclusion: synchrotron radiation imaging showed that majority of amorphous and pleomorphic type calcifications, especially of amorphous type of malignant diseases, in conventional images were essentially collectives of multiple specks. psychological perceptions of women due to mammographic follow-up b. barreau 1 , r. gilles 1 , s. tastet results: 129 women answered the questionnaire. all women were satisfied with the mammography and the medical staff except that the mammography was painful in 56 cases. for 24 women, the period between mammographic follow-up was too long. in 33 women, the quality of life was altered. communications of the experience to a relative was frequent (100/129 cases) but satisfactory in only 25 cases. for 113 women, medical information was considered relevant. the median of the scale of stress was 5 (0-10). there is two pickaxes, one at 2, the second at 5. "low-stressed" women could have an avoidance coping. "high-stressed" women could use a helplessness-hopelessness coping strategy. conclusion: women reported relevant medical information and comprehension of the short follow-up -mammography. they were reassured by the medical care, but the evaluation of the scale of stress was high, probably due to the diagnosis. mammographic density changes in postmenopausal hormone therapy: effects of various agents using a new scoring system s. orguc, c. göktan, g.y. ovali; manisa/tr purpose: to evaluate the changes of mammographic breast density due to postmenopausal hormone replacement with various agents using a new scale and to compare the new scoring system with the classical methods. materials and methods: 222 women who received hormone replacement therapy in celal bayar university hospital between 1999-2003 were examined with baseline and follow-up mammograms. the effects of various hormone regimens, selected according to the gynecological status, were evaluated by two radiologists. wolfe classification and a new scoring system were used to assess the change of mammographic density. the new scale divides each breast into ten wedge shaped slices on the cc positioned mammograms. change of density is scored according to the number of slices, which have an increase of density in comparison with the baseline mammograms. the results were statistically evaluated to compare the effects of various hormone regimens using a control group of 75 patients who did not receive any hormonal therapy. statistical analysis was also carried out to determine the effect of using different scales. results: tibolone effected breast density is less than preparations containing oestrogen. degree of mammographic change differs depending on the scale used. the new scale is more sensitive in depicting changes of breast density. conclusion: preparations containing oestrogen effect the mammographic density more than tibolone regimens. the new scaling system is highly efficient and objective in determining the changes of breast density. to evaluate sensitivity and specificity of positron emission tomography (pet) and 18-f-fluorodeoxyglucose (18f-fdg) in breast cancer diagnosis and to assess tumor dissemination. materials and methods: 62 patients were examined: 10 without mammary disease, 10 with fibrous cystic mastopathy, and 42 with breast cancer, which was hystologically proven. pet-scans (ecat exact 47) in "whole body" mode were performed 90 min after intra-venous injection of 370-420 mbq 18f-fdg. the t/ nt ratio for radiopharmaceuticals was evaluated. results: in all patients with malignant tumors the t/nt ratio for pet-18fdg was higher than 2.0 (m ± m = 7.2 ± 0.99). it was shown that pet has a high diagnostic accuracy in breast cancer detection with sensitivity 97% and specificity 100%. pet scanning in the "whole body" mode was allowed to assess dissemination of tumor process with high accuracy. pet 18f-fdg sensitivity was around 87.8% to100% in diagnosis of regional and distant metastases. it was related to metastases localisation. conclusion: pet with 18f-fdg has high diagnostic accuracy in diagnosis of breast carcinoma and staging of tumor extent. results women aged between 45-65 were invited in three rounds in the mentioned period of time. bilateral mammography with double projection was performed, and read in a double blind manner, according to the strict, prescribed methods. if needed, additional mammographic x-ray, us, fnab and core biopsy was performed. results: the acceptance rate was low, around 35.7% (13532 women were screened during five years). we called back around 6% of the screened patients for additional x-ray examination (1.5%) or for us (4.5%). we performed fnab in 3% of all cases (405 women). 301 cases were proven benign. the overall rate of hystopathologicly verified invasive cancers per 1000 women were 8 (104 patients). we could detect an increasing rate of small cancers and better lymph node state by the time, because around 88% of the examined women were already screened by us before, during the 5-year-period. number of interval carcinomas was nine (0.07%). conclusions: comparing to european standards our screening program was the same, but the acceptance rate was lover. the high non-acceptance rates can be explained mainly by the cross-screening possibilities of budapest, hungary and because the high risk population is not informed well enough. however, due to the mental hygenic program running in hungary, we could detect an increased number of inquisitive women. tubular carcinoma of the breast: clinical, mammographic and ultrasonographic findings f. zandrino 1 , m. calabrese 2 , l.e. bacigalupo 2 , f. musante 1 ; 1 alessandria/it, 2 genova/it purpose: tubular carcinoma is a well differentiated invasive adenocarcinoma, with a prevalence ranging from 1 to 10% of all carcinomas of the breast. the purpose of this presentation is to analyse its clinical, mammographic, and ultrasonographic features, with histopathological correlation. materials and methods: in a retrospective review of 472 consecutive histologically proven carcinomas of the breast, 14 pure (tubular component of at least 75%) tubular carcinomas were found (2.97%) in 12 women (age 54 ± 10 yrs). results: three lesions were palpable. on mammography, five were not detectable; the remaining presented as nodules with spiculated (3 lesions) or irregular (2) margins, spiculated nodules with microcalcifications (2), distorsion (1), or asymmetric density (1). on us, 1 lesion was not detectable; the remaining presented as hypoechoic lesions with irregular (12) or well defined (1) borders. for 12 tumours, diagnosis of carcinoma was made with cytology; in 2 cases core biopsy: in the first a complex sclerosing lesion with atypical cells was suggested, in the second differential diagnosis between tubular carcinoma and sclerosing adenosis was proposed. lesion size was 10.1 ± 5.1 mm. only in 1 patient were metastatic axillary nodes found. conclusion: in our series, tubular carcinoma presented mainly as a non-palpable, small-sized lesion, with non-specific mammographic patterns and a hypoechoic ultrasonographic appearance. lymph node metastases are rare, as previously reported in the literature. dose distribution in tangential irradiation for breast h. ohtani, s. usui, y. jincho; tokyo/jp purpose: skin injury, lung disease and conservation radiation therapy for breast is reported. in a previous investigation, local management and survival rates were reported on the face of treatment effect's records, but the real irradiation doesn't become clear. this report is to measure the dose distribution of the effect on the critical organ by tangential irradiation of the left breast. materials and methods: measurement was performed with a semiconductor detector. irradiation was performed with x-ray beams at 124 degrees. irradiation field sizes were established 10×20 cm 2 to investigate influence by field sizes. irradiation was done on the wedge of 30 degrees. results: dose equivalent was accurately measured with semiconductor detectors. from the results, breasts, thyroid gland, heart, both lung fields, kidney, ovary, and uterine doses become clear. the dose distribution at tangential irradiation of left breast was measured. consequently, the breast in which a radiation injury tends to be encountered, lung field, and the dose of important internal organs could be obtained. the necessity to confirm the dose distribution in the body for tangential irradiation in breast preservation treatment, refers to a radiation injury, and this study estimates these doses. the to assess the influence of 24 days of repetitive hyperbaric simulations on the form and structure of single-lumen silicone gel-filled implants. materials and methods: 6 new implants from 2 different manufacturers and 2 removed implants were submitted for 68 simulated dives in a hyperbaric chamber, with an average of 3 dives a day and with a maximal depth of 18 m. a standard x-ray and mri were performed before, after 11 and 24 days of repetitive diving, and 43 days after the experiment. mri was performed using a 1.5-t superconductive magnet (symphony-, siemensag, erlangen, germany) with a body and spine coil, and a gradient echo t1-w sequence (3d flash), slice thickness 2 mm. the prostheses were checked for bubble formation, volume changes, integrity and morphological appearance. results: there were no significant changes in form, nor in shell integrity. after 11 days of repetitive diving, there were some tiny bubbles in the implants, confirmed by x-ray and mri. after 24 days, there were significant bubbles in 4 of the implants (increase in implant volume up to 10%); in the other 4 there was a slight increase in number and volume of bubbles. there was no significant change in the bubbles 43 days after the last dive. the significant bubble formation in some single-lumen silicone gelfilled implants after 24 days of repetitive diving, raises concern about the influence of repetitive stress on the lifespan of implants in correlation with the number and depth of dives. resection of non-palpable breast cancer using 3d imaging created by multislice helical ct: a new interventional technique to design resection lines in breast preserving surgery k. oda, t. kubota, h. satake, a. sawaki, t. ishigaki, y. nimura; nagoya/jp purpose: we report a new method for an adequate segmental resection of nonpalpable breast cancer employing an interventional technique using three-dimensional images of contrast-enhanced ct. materials and methods: eight patients with non-palpable breast cancer (dcis 6, invasive carcinoma 2) were included in this study. diagnosis of carcinoma was made by cytology, but the extent of the lesion could not be clearly shown by us. one hour before the operation, contrast-enhanced helical ct was performed using a toshiba aquilion (toshiba corp. tokyo) with the patient in the supine position, following the insertion of vats (video assisted thoracoscopic surgery) markers (hakko, japan) under us guidance. ct scan was performed 75 seconds after the injection of contrast medium. the detector row configuration was 4 x 1-mm. maximum intensity projection (mip) was performed on three-dimensional reconstruction (3d-ct). using three-dimensional images of ct, anatomical relationship of vats markers, nipple and carcinoma demonstrated as a well-enhanced focal-clumped lesion or segmental lesion was evaluated and lines of resection with 2 to 3 cm surgical margin were designed. curative resection was confirmed in x-ray films of resected specimens based on the relationship between the lesion and the vats markers in preoperative three-dimensional ct images. results: in all 8 cases, adequate segmental resection with cancer free surgical margins was accomplished and the cosmetic results of the surgery were satisfactory. conclusion: three-dimensional images of contrast-enhanced ct with this interventional technique is a useful method to design resection lines for non-palpable mammary carcinomas. european breast screening performance: does case volume matter? h.j. scott 1 , a.g. gale 1 , d. wooding 1 , d. walter 2 ; 1 derby/uk, 2 augsburg/de purpose: u.k. breast screening radiologists typically read over 5,000 screening cases per annum, whereas in europe this figure is much lower as in many countries national breast screening programs are in their infancy. the performs scheme in the u.k. permits radiologists annual self-assessment of their filmreader skills. as part of the eu funded european breast cancer network a number of german radiologists have now read the current performs assessment set. we investigated whether real-life case volume affects reading performance by the comparison of matched groups of radiologists from these two countries. we analysed the data from current sets of difficult recent screening cases. for each case individuals identified which key mammographic features were present, whether the case was abnormal and should be recalled or not. for this analysis the participants were matched on age, gender, film-reading protocols and years of experience. assessment of case volume was elicited by questionnaire data. the radiologists were compared on several key performance measures; cancers detected, correct recall and correct return to screen, signal detection performance statistics and real-life screening practice. results: it was found that whilst the performance of the german radiologists on the current test sets was excellent (correct cancer detection rate > 85%) on average they performed less well than their uk counterparts. we argue that this is closely related to the volume of cases read per annum by individuals within each country, and theoretically their performance will be equivalent as their case volume increases. the cytogenetic method of dosimetric control for screening mammography v. demin, e. djomina; kiev/ua purpose: it is advisable to study a degree of risk due to the unfavourable consequences of irradiation of the breast with screening mammography in ukraine after the chernobyls disaster. the correlation of cytological (cytogenetic) and physical findings were accomplished. the test-tubes with donor human blood were placed on upper and lower surfaces of breast of tissue-equivalent aldersons phan-tom. the test-culture of lymphocytes of human peripheral blood were used for biological dosimetry. physical dosimetry are realised with the thermoluminescent system alnor. the chromosome aberrations are becoming 13 + 2.5% on the upper surface of breast (normal control level is 3%) on mammography in two projections (upper-lower and lateral), the fragments of chromosome type are 7%, radiation markers -dicentric chromosome are 1.5%; equivalent dose is 6.08%. conclusion: there is a risk of radiation induced genetic lesions in breast tissue after mammography. instability genome is a basic radiation carcinogenesis. this is very real for women in ukraine after the chernobyls disaster. efficiency of the multidetector row ct in the diagnosis of breast cancer and evaluation of intraductal spreading h. kani, m. matsuki, i. narabayashi; takatsuki/jp purpose: the purpose is to analyse the efficiencies of multidetector row ct (mdct) in the diagnosis of breast cancer and evaluation of intraductal spreading. materials and methods: pathologically diagnosed 82 breast lesions from 75 patients were examined by mdct. the lesions included the following: 68 invasive carcinomas, 2 noninvasive ductal carcinomas, 2 fibroadenomas, 3 papillomas and 7 other benign lesions. non-contrast ct and contrast-enhanced ct scans at 60, 120 and 240 sec after the start of enhancement were performed using 4 row mdct. the imaging was performed under the following conditions: 0.5-sec gantry rotation speed, 5.5 helical pitch, 1 mm slice thickness and reconstruction intervals of 1 mm. the items examined were as follows: 1) in time-enhancement patterns during four phases, the early enhancement and plateau patterns were defined as a malignant tumor and gradual enhancement pattern was defined as a benign lesion. its ability in the diagnosis of malignant tumor was evaluated in the comparison with histopathologic findings. 2) the abnormal enhancement continuing to the tumor at 120 sec after the start of enhancement was estimated as intraductal spreading of breast cancer. the detectability of intraductal spreading was evaluated by the comparison with histopathologic findings. results: 1. the sensitivity, specificity and accuracy of the diagnosis of malignant tumor were 95.4%, 63.6% and 89.6%, respectively. 2. the sensitivity, specificity and accuracy of the detactability of intraductal spreading of breast cancer were 87.0%, 81% and 83%, respectively. conclusion: mdct is very useful for the diagnosis and preoperative estimation of breast cancer. an exploratory study about mammographic practice (acr 3 from bi-rads) three months after a medical continuing education on breast cancer b. barreau 1 , s. tastet 2 , m. deghaye 1 , v. picot 2 , i. brault 1 , p. marelle 1 , l. ceugnart 1 , d. aucant 1 , s. haber 1 ; 1 paris/fr, 2 bordeaux/fr objectives: evaluation of practices, three months after a medical continuing education, when abnormalities acr 3 (probably benign) are detected on mammography. materials and methods: a questionnaire (33 items) about these practices was sent to 755 radiologists three months after medical continuing education (may-december 2002) . the answers were analysed with chi-square test. results: 225 radiologists completed the questionnaire; 102 radiologists practiced breast screening; 211 used the bi-rads classification; 204 radiologists followed-up the abnormality with a short interval, 36 made a biopsy and 11 overclassed the image; 148 radiologists asked for advice from other radiologists, 49 from an expert, 45 submitted to a multidisciplinary committe and 15 asked for a second reading. a short interval-follow-up disturbed 115 radiologists about an eventual unfavourable evolution of the abnormality and 57 radiologists about legal problems; 36 had difficulty in explaining to patients the short interval-followup. the median of the scale (0 to 10) of the radiologists perceived stress is 3. conclusion: these french radiologists have consistent practices with the bi-rads classification and the anaes recommendations. they may have difficulties in explaining the procedure to patients. the radiologist's ethic is based on the "primum non nocere". c 391 b d e f a g histopathological perspective on the first german mammography screening project: a two year review g. gohla 1 , u. sauer 1 , p. hanisch 1 , w. boecker 2 , h. junkermann 1 , u. bonk 1 ; 1 bremen/de, 2 münster/de purpose: the aim of this investigation was to critically review the role of the histopathologist in a mammography screening project. materials and methods: the first model mammography screening project in germany has been running in bremen for the last two years. all women between 50 and 70 years of age have been offered mammography and any suspect findings were investigated by core biopsy. these cases were reviewed in the pathology dept. of the university münster and discussed at a weekly multidisciplinary meeting. lesions were classified using the 5 point b classification scale as recommended by the european union. results: in the first two years of the screening project, a total of 22000 women had mammography. suspicious areas were detected and core biopsies were obtained from 401of these women. 46 % were classified b5 (malignant) 46% of these cases were classified b1,2 (regular breast tissue, benign) and 8% of these cases were classified b3 and b4 (atypia probably benign, suspicious of malignancy). in 90% of all cases there was agreement amongst the reviewing histopathologists, but in 10% there was no interobserver consensus. these disagreements centered on flat epithelial atypia, atypically hyperplasia and papillary lesions. the consensus amongst experienced breast histopathologists is satisfactory in clearcut cases, but it should be improved in less well classified lesions. these lesions are more likely to be seen in a screening situation and in core biopsies. in this area it is certainly advisable to cooperate closely with the clinician and radiologist. usefulness of multi-slice ct for nonpalpable breast lesions with microcalcifications: correlation with mammographic findings h. satake, a. sawaki, k. shimamoto, s. ishigaki, k. oda, t. imai, t. ishigaki; nagoya/jp purpose: to evaluate the usefulness of multi-slice ct for nonpalpable breast lesions with microcalcifications, compared with mammographic findings. materials and methods: 40 cases with nonpalpable microcalcification of the breast recommended for biopsy on mmg. they included 26 malignant lesions (ductal carcinoma in situ, n = 18; ductal carcinoma in situ with microinvasion, n = 8) and 14 benign lesions (mastopathy, n = 6; intraductal papilloma, n = 2; other, n = 6). on multi-slice ct images, the presence of focal or segmental enhancement in the region consistent with microcalfications was regarded as positive diagnosis for malignancy. all mammographic and ct findings were assessed with a consensus between two radiologists. results: 4 cases of benign lesions pathologically were assessed as "suspicious malignant" on mmg, while, in three of them, focal or segmental enhancement appeared on multi-slice ct. although seven cases of breast cancer were assessed as "probably benign" on mmg, six cases acquired focal or segmental enhancement on ct. for cancer diagnosis, the sensitivity of mmg and multi-slice ct were 69.2% and 96.0%, specificity was 71.4% and 57.1%, and negative predict value were 58.8% and 88.9%, respectively. breast conservation surgery with simulation using 3d ct images was performed successfully in 17 cases of breast cancer. the sensitivity and the negative predict value of multi-slice ct for nonpalpable breast microcalcifications were superior to those of mmg. when biopsy is recommended according to mmg, additional examination of multi-slice ct enables the indication for biopsy to be more optimized and is useful for planning the treatment. the value of magnetic resonance imaging in the assessment of adult patients with corrected transposition of the great arteries s. shine, e. kavanagh, c. we fully illustrate the morphology, contrast enhancement and mobility of myxomas in rare locations such as the right ventricle and unusual attachment to the tricuspid valve. background: although benign myxoma is the most common primary cardiac tumor (25%), it remains a rare finding with an incidence of 0.5 per million population per year in the western world. myxomas are found in the left (75%) or right (20%) atrium and seldom in the ventricles. these pedunculated tumors typically arise from the atrial septum near the fossa ovalis and much less frequently from the mitral valve. intracardiac obstruction and systemic emboli are the major complications. imaging findings: myxomas in an uncommon cardiac location should be differentiated from other primary (malignant) and secondary (thrombus; metastasis) cardiac tumors. mri allows visualization of the narrow pedicle, its attachment and the changing tumor shape and mobility during the cardiac cycle, unlike most malignant processes. in contrast to most thrombi, myxomas have low signal intensity on cine gradient-echo images and show contrast enhancement. the water-rich myxomatous stroma, fibrous stroma, calcifications and hemorrhage account for the heterogeneous t2-weighted se images. increased interstitial space in the myxoid region and inflammatory zones enhance after intravenous gd-dpta on t1-weighted se images. lobular tumor surface and higher volume increase the pre-and postoperative risk for systemic emboli. furthermore, the exact location on mri is most helpful in planning the surgical access. conclusion: myxomas in uncommon locations can be differentiated from other cardiac tumors by evaluating tumor morphology, mobility and enhancement. how to study with cmr a patient submitted to ross procedure: a step by step follow-up protocol r. ribes 1 , a. luna 2 , j. vida 1 , p. caro 3 ; 1 cordoba/es, 2 jaen/es, 3 cadiz/es learning objectives: to describe an adequate protocol to study patients submitted to ross procedure with mr. to identify and quantify postsurgical complications in this group of patients with mri. b d e f a g background: ross procedure is widely accepted as one of the best methods for aortic valve replacement, especially in children and young adults. ultrasound is usually used in their follow-up, but tit offers a limited evaluation of the right outflow tract, being important to discard homograft stenosis. mri overcomes the limitations of ultrasound and may replace the number of digital subtraction angiograms traditionally performed in the follow-up of these patients. procedure details: we describe step by step our mr protocol, to study patients submitted tothe ross operation. examples of the mr features of common presentations and complications are shown from our series of 53 patients. our protocol consists of the following steps: • black-blood coronal and transverse turbo spin echo t2-weighted images. • cinemr gradient-echo sequences allow functional qualitative assessment of themotion of valves and chambers, the detection of either valvular regurgitation orstenosis, and areas of altered myocardial contractility or relaxation. we perform gre-cinemr sequences in left two chamber, right two chamber, fourchamber, short axis (at several levels from the apex to the base), left ventricular outflow tract, right ventricular outflow tract, and aortic rootviews. • phase contrast images are performed to obtain quantitative data about magnitude anddirection of blood flow through the right and left ventricular outflow tracts. conclusions: cmr allows an accurate evaluation of patients submitted to ross procedure and identification of the postsurgical complications. the causes of focal outpouching of the left ventricle are as follows: 1) true aneurysm; a chronic complication of myocardial infarction, which contains the endocardium, epicardium, and thinned fibrous tissue replacing the myocardium, 2) pseudoaneurysm; a consequence of rupture of the ventricular free wall due to acute infarction and confined by the pericardium, 3) diverticulum; a congenital outpouching of ventricular wall including all of three layers, and 4) hibernating myocardium due to chronic ischemia with paradoxical outpouching at systole. mr imaging is useful in differentiating these causes by using variable imaging sequences to evaluate the myocardial contractility, perfusion and viability. in this exhibit, we will show the usefulness of mr imaging to differentiate these pathologies using various mr imaging sequences. imaging methods and findings: cardiac mr imaging methods include; 1) cine imaging for wall motion analysis, 2) first pass myocardial perfusion imaging, and 3) delayed enhancement imaging. images were obtained along the short axis and horizontal long axis of the heart. by analyzing the shape, contractility, motion, perfusion, and contrast enhancement, it is possible to differentiate the causes of the outpouching lesion of the left ventricle. conclusion: cardiac mr imaging is useful in differentiating various causes of focal outpouching of the left ventricle. features of cardiac disease demonstrated on ct pulmonary angiography s. conclusion: ctpa is an increasingly frequently used investigation for the detection of pulmonary embolism. most patients investigated have pathology other than pe as a cause of their symptoms. frequently information about the heart is yielded that provides important clues to determine the cause for the presenting symptoms and signs or reveals co-existing pathology. with this investigation being used more frequently in daily practise in many patients with unexplained breathlessness or chest pain it is important to have a clear understanding of the features of cardiac disease as seen on a ctpa. mri has been done twice -10-20 days and 12-24 months after surgery. mri was performed with a 1.0 t mr imager using ecg-gated t1-se (or t1-tse), bright-blood gre-cine-technique and phase-contrast mri. results: 9 pts (of 20) had a positive dynamic study of heart chambers dimensions and volumes in early postoperative stage. in the area of prostheses signal of low intensity was defined in all the patients (artifacts). narrow flow of low signal intensity along the prostheses leaflets corresponded to normal function of prosthesis (46 of 50 valves). 4 pts had signs of mechanical valve dysfunction (3mitral paravalvular leaks, 1 -aortic prosthetic valve stenosis). mri data were in agreement with the results of echocardiography. mri was able to diagnose such postoperative complications as atelectasis (4), mediastinal haematoma (2), pleuritis (2). conclusion: mri could give an objective information about heart morphology (chamber dimensions, hypertrophy degree) and mechanic valve functioning (normal and abnormal flow) in patients after surgery. it can be safely performed in patients with artificial heart valves. negative calcium scoring: can it rule out severe stenosis? p.m. carrascosa 1 , c. capuñay 1 , p. garcia merletti 1 , p. johnson 2 , s. chandra 2 , r. pissinis 1 , j. carrascosa 1 ; 1 buenos aires/ar, 2 cleveland, oh/us objective: to determine the presence of stenosis greater than 50% (in at least one coronary vessel) proved by digital angiography (da) in patients with a negative calcium score and correlate findings with ct angiography. methods: 30 patients were evaluated. cts were performed with a 4-row ct scanner. the calcium score was calculated according to the agatston method. a calcified plaque was defined as a lesion of at least two adjacent pixels with signal intensity above 130 hu. the second enhanced acquisition was performed following the administration of 130 ml of non-ionic contrast with 4 x 1 mm collimation and 0.5 mm slice increment. das were performed on a digital angiographer. meascar car car cardiac diac diac diac diac urements were done by means of qca. stenosis was considered positive if it was greater or equal than 50%. results: there were 14 patients with high grade calcium score. eleven had positive da for at least 1 coronary artery and in 3 cases the da did not show severe stenosis. there were 14 patients with negative calcium scores (grade 0), 5 had negative da findings, and 9 had positive da findings. in these patients, the contrast ct acquisition revealed that the cause of the stenosis was due to soft plaques. conclusion: high grade calcium scores predict severe stenosis. negative results do not exclude them. in this study the 33% of the patients had negative calcium scores but significant stenosis due to soft plaques. a contrast ct acquisition instead of the calcium score will be necessary to rule out all the severe stenosis. positron emission tomography and 13n-ammonia application to evaluate myocardial blood flow in the asymptomatic patients with coronary artery calcification d.v. ryzkhova, i.e. itskovich, l.a. tyutin, l.a. kofal; st. petersburg/ru the purpose of this study was to assess myocardial blood flow (mbf) in the asymptomatic patients with coronary artery calcification (cac). methods: 26 symptom-free patients with cac were included in study. all of them hadn't any symptoms of cad (chest pain, severe arrhythmia, heart failure) and myocardial infarction history. the patients with significant myocardial hypertrophy weren't included. the myocardial blood flow at rest (mbf rest) and during dipyridamole test (mbf stress) was evaluated by 13n-ammonia dynamic pet ("ecat exact 47", siemens). the coronary calcium score (ccs) was measured by msct coronaroangiography ("somatom volume zoom", siemens) using the agatston method. results: myocardial perfusion abnormalities during stress test were revealed in 9 patients with cac, there were patients with silent ischemia (1 st group). we observed normal myocardial perfusion at rest and during stress test in the remaining 17 patients (2 nd group). the mean values of total ccs were less than 100 units and close between the both group (89.27 ± 11.84 units vs. 84.9 ± 9.44 units, p = ns). mbf-values at rest didn't differ between the both patients' groups (76.58 ± 8.0 ml/100 g/min vs. 74.46 ± 9.25 ml/100 g/min, p = ns). mbf stress mean values were significantly decreased in the 1 st group (137.1 ± 35.6 ml/100 g/ min vs. 207.8 ± 39.7 ml/100 g/min, p < 0.005). the ccs less than 100 units isn't a reliable marker of flow-unlimiting stenoses in asymptomatic patients.soft lipid-laden plaques is a cause of myocardial ischemia in symptom-free patients with cac and low ccs. these patients should undergo stress studies to detect silent ischemia. detection and assessment of myocardial inflammation and fibrosis by echo-densitometry and ce-mri in patients with mild and medium myocarditis: validation by wbc-mibi spect m. deryugin, i. itskovitch, v. soukhov, s. boytsov, a. svistov; st.petersburg/ru background: echo-densitometry and ce-mri are novel methods for assessment of inflammatory myocardial infiltration (imi) and myocardial fibrosis (mf). the purpose of the current study was to validate these methods in patients with mild/medium myocarditis using wbc-mibi spect. methods: ce-mri was performed in 53 patients using t1-weighted turboflash inversion recovery. inflammation was evidenced by use of threshold method (signal intensity > +2.0 sd). left ventricle echo-densitometry performed in long-axis views from left parasternal border at es/ed with following percentage cyclic variation indexes (cvi) calculation. spect was performed 16-20 hrs p.i. of 750 mbq 99mtc-wbc and 10 min p.i. of 99mtc-mibi. results: all patients were divided into 3 groups based on scintigraphic data: first group -20 patients with diffuse leukocytes uptake that considered as imi; in second group there were 21 patients with local leukocytes uptake and abnormal mp (imi+mf); third group consisted of 12 patients with only mf. control group patients (n = 7) had normal mp and no leukocytes uptake. cvi was 38 ± 10% in controls; 10.6 ± 21% in 1 st ; -5.2 ± 22% in 2 nd and -19 ± 23% in 3 rd group. ce-mri was able to detect imi in 88% of patients. regression analysis revealed good correlation between imi by ce-mri and by wbc-spect (r = 0.70, p < .01). furthermore, good correlation was found between cvi and 99mtc-mibi uptake (r = 0.51, p < .01) both for imi and mf detection. conclusion: ce-mri enables exact detection of imi as compared to wbc-spect. the results of videodensitometry studies demonstrated that different types of imi were associated with definite cvi percentage, while cvi became negative with mf appearance. one-year ct evaluation of pulmonary veins following percutaneous cryoablation in patients treated for atrial fibrillation b. ghaye 1 , d. szapiro 1 , c. background: pulmonary vein isolation (pvi), using radiofrequency energy, for treatment of atrial fibrillation (af) has been associated with complications including pulmonary vein (pv) stenosis or thrombosis. the purpose of this study was to prospectively evaluate the pv morphology following cryoablation. method: 50 patients underwent percutaneous pvi in 3 academic centers. contrast-enhanced, single-slice or multi-slice spiral ct (1-2.5 mm thick slices) was obtained before, 3 and 12 months following pvi. all examinations were read blinded to the location(s) of ablation. pvs were evaluated quantitatively and qualitatively: the diameter at ostium and at 1 cm from ostium were measured. the presence and location of luminal irregularity or thrombosis was also assessed. the aims of this study were comparison of the local myocardial contraction between the myocardium with de and without, and evaluation of myocardial de's prognostic significance in patients with congestive heart failure due to nonischaemic dcm. materials and methods: delayed enhanced mri and myocardial tagged images were taken in 27 patients (55 ± 16 yrs, 21 male) referred for congestive heart failure due to nonischaemic dilated cardiomyopathy, whose left ventricular (lv) end-diastolic volume index > 90 ml/m2 and lv ejection fraction < 50%. the patients were followed for a mean of 12 ± 6 months. results: myocardial de was present in 13 patients (48%). in these 13 patients, the average amount of myocardial de was 6 ± 11% of lv myocardium (2-54% of lv). myocardial axial thickening was 13 ± 23% in the segments with myocardial de, and 28 ± 27% without (p = 0.001). myocardial circumferential shortening was 6 ± 10% in the segments with myocardial de, and 10 ± 7% in without (p = 0.004 electron beam ct (ebct) in the detection of abnormal myocardial contrast enhancement in patients with recent and chronic myocardial infarctions t. vesselova, v. sinitsyn, s. ternovoy; moscow/ru purpose: of the study was to determine the occurrence of low-density areas in the myocardium of the left ventricle (lv) in patients with myocardial infarction (mi) seen during non-invasive ebct coronary angiography. material and methods: 35 patients (51.5 ± 12.0 years old) with ischemic heart disease and mi were included in the study. in 16 patients with first myocardial infarction (mi) ebct was performed during first 2 weeks after coronary event. in 19 patients ebct was done 12 months after an mi. ebct angiography and venticulography were done with imatron c-150 imager. results: low-density areas in lv myocadium were seen on ebct images in all patients with mi. in 35% of patients these findings were accompanied by myocardial thinning and in 20% cases intracavitary thrombi were present. in 8.6% patients with transmural mi low-density myocardial regions were visualized on non-contrast images. in 22.9% patients with mi subendocardial low-density zones were seen. results of ebct were in agreement with myocardial scintigraphy. characteristics of hypodense areas (hu values) in patients with recent and chronic mi were similar. calcifications and significant stenoses of coronary arteries were found in all patients with old mi, the mean (sd) agatston score was 293.5 ± 311.5. in patients with subacute mi the mean agatston score was 194.9 ± 328.0 (ns). four patients from this group had coronary score = 0. conclusion: during ebct coronary angiography most of the low-density areas corresponded to sites of previous myocardial infarctions. some of these areas may correspond to hypo-perfused areas of ischemic, but viable myocardium. progression of coronary artery disease in relation to coronary stenosis morphology: quantitative coronary angiography analysis j. saponjski, m. ostojic, b. beleslin, v. vukcevic, m. nedeljkovic, s. stojkovic, a. dordjevic/dikic, i. nedeljkovic; belgrade/yu objective: the aim of this study was to analyze progression and regression of coronary stenosis in relation to stenosis morphology. the study group consisted of 53 patients (43 male, 10 female; mean age 54 ± 11 years). coronary stenoses were analyzed by quantitative coronary arteriography including percent diameter stenosis (%ds) and changes in obstruction diameter between two arteriographies. according to the ambrose angiographic lesion morphology 4 groups were identified: group i (n = 18)-simple concentric lesion morphology, group iia (n = 20) -simple eccentric lesion morphology, group iib (n = 22) -complex lesion morphology, and group iii (n = 6) with complex and multiple coronary stenoses. the follow-up period between first and second arteriography were similar for all groups (i, 8 ± 9 months; iia, 11 ± 10 months; iib, 7 ± 8 months; iii, 6 ± 5 months; p = ns). results: progression of coronary artery disease was identified in 66%, 75%, 80% and 100% of lesions in ambrose groups i, iia, iib, and iii, respectively. on the contrary, regression of coronary stenosis was documented in 33%, 25%, 20% and 0% of lesions in groups i, iia, iib, and iii respectively. however, comparing the lesions with non-significant and significant stenosis (cut-off point 50% ds), progression of coronary stenosis was higher for the lesions with ds < 50% for all groups (except group iii where all the lesions were with ds > 50%), reaching statistical significance in group i (i, +0.52 ± 0.55 vs -0.24 ± 0.32 mm, p < 0.01; iia, 0.61 ± 0.80 vs 0.13 ± 0.32 mm, p = ns; 0.66 ± 0.69 vs 0.33 ± 0.56 mm, p = ns). conclusion: coronary lesion morphology of simple type was associated with lower rate of coronary stenosis progression. noninvasive the aim of this study was to assess coronary microcirculatory function in postmenopausal women. methods: we measured myocardial blood flow (mbf) with a 13n-ammonia pet scan at rest, during cold pressor testing (cpt) for an indirect measurement of endothelium-dependent vasomotion, and during dipyridamole hyperemia (endothelium-independent vasomotion) in 16 postmenopausal women without coronary artery disease. 10 young healthy women served as controls. results: rest-mbf and hyperemic-mbf did not differ between the young and the postmenopausal women (rest: 76.3 ± 12.6 vs. 82.4 ± 14,.1 and dipyridamole: 220.3 ± 38.4 vs. 216.8 ± 34.9 ml/100 g/min; ns). coronary flow reserve was similar between the two groups (the young women: 2.96 ± 0.91, the postmenopausal women: 2.71 ± 0.86; ns). cpt induced a similar increase of rate-pressure product in the young and the postmenopausal women (10580 ± 730 vs. 9659 ± 1653 beats/min/mmhg), cpt-mbf was significantly decreased in the postmenopausal women (64.2 ± 12.3 ml/100 g/min) compared with the young women (87.48 ± 14.7 ml/100 g/ min; p < 0.05). conclusion: pet with 13n-ammonia during cpt is a noninvasive imaging technique to detect mbf abnormalities, which associated with endothelial dysfunction in postmenopausal women. contrast-enhanced magnetic resonance imaging at true end-diastole to quantify reproducible transmural extent of myocardial hyper-enhancement y.-j. kim, b. choi, k. choe; seoul/kr purpose: to determine feasibility of contrast-enhanced mri (ce-mri) at true enddiastole (ed) free from limitation of time for inversion-recovery and trigger window for quantifying transmural extent of infarction. methods and materials: mri was performed in 18 patients with myocardial infarction. cine imaging and ce-mri with same registered slices in short axis were performed. to allow true ed ce-mri, ecg synchronization should use two rrintervals for one acquisition of a segment of k-space by setting the heart rate to half that of the true heart rate. trigger delay time was adjusted to the rr-interval for imaging at ed and to the sum of rr-interval plus the time between r-wave and the end-systole (es) determined in cine images for imaging at es. results: wall thicknesses of the ed and the es ce-mri were greater than those of the ed and the es cine images (7.5 ± 1.3 mm > 6.2 ± 1.4 mm, 9.4 ± 1.8 mm > 8.6 ± 1.8 mm respectively). subendocardial hyperenhancement was detected in 13 patients. among them, systolic wall thickening was observed with cine imaging in 8 patients and the transmural extent of hyperenhancement measured on ed ce-mri decreased by 5-30% on es ce-mri proportional to the degree of systolic thickening of the epicardially nonenhanced myocardium. transmural hyperenhancement in 4 patients showed no difference in thickness between enddiastole and end-systole. conclusion: ce-mri at ed is constantly possible by using two rr-interval per acquisition of a segment of k-space and useful to avoid the variation in infart sizing with irreproducible cardiac phase other than end-systole in case of subendocardial infarction. comparison of computed tomography (ct) and magnetic resonance (mr) for screening of pulmonary veins (pvs) complications of cryotherapy for percutaneous ablation of atrial fibrillation (af) b. ghaye 1 , d. szapiro 1 , l.-m. rodriguez 2 , c. timmermans 2 , r.f. dondelinger 1 ; 1 liège/be, 2 maastricht/nl purpose: to prospectively compare ct and mr for evaluation of potential complications, including stenosis or thrombosis of pvs, of cryoablation for af. methods and materials: 21 patients underwent percutaneous cryo-ablation of af. cardiac spiral ct and mr were performed before the procedure, at 24 hours, and at 3 months following af cryo-ablation. ct was performed with spiral ct (pq 5000, phillips, eindhoven, the netherlands) using 2 mm thick slices reconstructed every 1 mm, 1-s rotation time, 120 ma and 130 kv per rotation following iv peripheral injection of 120 ml of 30% iodinated cm. mr was performed on a 1.5 t symphony va15 system (siemens, erlangen, germany) using a multi-slice t1-weighted dark-blood turbo-spin-echo pulse sequence and bright-blood cine trufisp sequence. all ct and mr examinations were quantitatively and qualitatively read blinded to the location(s) of ablation. results: for ct, the mean diameters at la-pv junction and at 1 cm from ostium were 1.6 (0. (1996.1-2002-6) . associated cardiac and extracardiac anomalies were evaluated on fetal echocardiography. postnatal diagnosis or autopsy were correlated with fetal echocardiography. results: in 30 fetuses with right aortic arch, combined congenital cardiac diseases were as follows, tof (8), vsd(1), and dorv with pulmonary stenosis (1) . associated extracardiac anomalies were oligohydramnios(2), arthrygryposis(1), splenic cyst (1), and shortening of long bones(1). on postnatal echocardiography, previously non-diagnosed vsd were found on two neonates and tga without vsd in one neonate. overall incidence of combined cardiac defects is about 43.6%. conclusion: right aortic arch associates variable cardiac defects and extracardiac anomalies in about half of fetuses. prenatal diagnosis of right aortic arch must be followed further echocardiography and targeted fetal sonography for exact diagnosis. potential myocardial iron content evaluation by mr in β β β β β-thalassemia major patients treated by deferoxamine or deferipron m. galia, m. midiri, t. bartolotta, a. maggio, r. lagalla; palermo/it purpose: to evaluate the usefulness of mri to assess myocardial iron content in patients with β-thalassemia major treated by deferoxamine b mesylate (df) or deferiprone (l1) chelation therapy. method and materials: 72 consecutive patients with β-thalassemia major (35 treated by df and 37 by l1) underwent, at enrollment and after one year treatment, heart mri (1.5 t unit) with an electrocardiogram-triggered gradient-echo t2 weighted sequence. liver mri was obtained at the same time in all patients. measurements of the heart to muscle signal intensity ratio (hsirs) were compared between the two groups and with laboratory parameters, liver iron concentration (lic) and liver to muscle signal intensity ratio (lsirs). results: hsirs were significantly increased in df (t = -2.8; p = < 0.01) and l1 group (t = -3.1; p = < 0.01) after one year treatment. no statistically significant difference in the values of hsirs was present between the two groups at the beginning (p = 0.25; t = 1.13) and after one year treatment (p = 0.20; t = 1.28). hsirs were inversely correlated to lic (r = 0.52; p = < 0.001) but not to ferritin levels (r = 0.10; p = 0.18). a positive correlation was found between the variation of hsirs and that of lsirs (r = 0.52; p = < 0.001), and a mild correlation (r = 0.40; p = < 0.001) was found between the γ-glutamyltransferase levels and the hsirs values. conclusion: mri is usefull to detect hsirs variations during iron chelation therapy. moreover it is non-invasive and easily repeatable. application of 123-iodine labelled 15-iodinepentadecanoic acid for detection of myocardial viability in patients with chd and resting regional lv dysfunction v. soukhov, i. savicheva, a. partsernyak, a. svistov; st.petersburg/ru purpose of this study was to assess 123-iodine labeled 15-iodinepentadecanoic acid ( 123 i-pda) -synthetic radiolabeled free fatty acid with the potence for detection of myocardial viability. methods: 107 patients (80 male and 27 female, mean age 49 ± 8 yrs) who had history of myocardial infarction and resting regional left ventricular dysfunction were examined. blood supply, regional myocardial oxidative metabolism and regional metabolic substrate utilization were assessed by spect at 3-5 and 35-40 min after i.v. injection of 400 mbq with 123 i-pda. echocardiography with low doses of dobutamine was used for measuring inotropic reserve. results: early 123 i-pda spect demonstrated high specificity in diagnostics of perfusion defects (up to 85%). the delayed images showed foci of remaining higher activity in regions of ischemic, but viable myocardium. 387 of a total of 1050 myocardial segments had abnormal resting wall motion. in 189 of them no oxidative metabolism and inotropic reserve were detected, that indicated scarred myocardium. 314 of them were considered to be viable as they demonstrated both oxidative metabolism and inotropic reserve. conclusion: 123 i-pda as an agent for simultaneous perfusion and oxidative metabolism evaluation may be used for identifying myocardial viability. diagnostic value of this method in combination with low doses of dobutamine echocardiography even in the cases of severe myocardial metabolic damage is nearly equal to pet with 18 fdg and should be applied for detection of viable myocardium. comparison of mri and nuclear medicine in detection and analysis of left ventricular infarction r.m. macmillan 1 , t. vakhtangadze 2 , m.r. rees 2 ; 1 philadelphia, pa/us, 2 bristol/uk aims: to compare standard spect perfusion imaging with last contrast enhanced mri for the detection of infracted myocardium. materials and methods: 34 patients (13 female, 21 male) from two centres with proven myocardial infarction by ecg, clinical and echo criteria underwent stress/ rest tc99 sestamibi gated spect scanning with a dual headed gamma camera and late contract enhanced mri on identical 1.5 tesla scanners in each centre using a protocol which imaged 15 minutes after injection of 0.1 mmol/kg iv gadolinium. analysis of segments used a 17 segment system, with a total of 578 segments analysed in both imaging methods. results: 183 segments demonstrated scars on mri and 132 segments demonstrated scars on isotope imaging. comparison of isotope imaging to mri showed that 8 segments who had scars on isotope scanning failed to show on mri whilst 42 scars on mri were not demonstrated on nuclear imaging. the majority of these scars were small or sub-endocardial. in some cases these scars had islands of functioning myocardium within them. some scars seen as completely non perfused defects on nuclear imaging were demonstrated to be partial thickness scars on mri. there was no significant difference in the findings from each centre indicating reproducibility and transferability of technique and findings. mri was able to detect smaller scars than nuclear imaging and viable myocardium in proximity to scar tissue. prenatal diagnostics of obstructive heart lesions g. spanovic 1 , i. jovanovic 2 , v. parezanovic 2 , a. zvezdin 1 ; 1 novi sad/yu, 2 belgrade/yu purpose: aim of prenatal diagnostics of obstructive heart lesion is to make right decision about the way leading further pregnancy, and decision about the time, place and way of labor. sensitivity and sensibility of fetal echocardiography are very high -between 95 and 98%. methods and materials: 2 648 fetuses were examined in period of seven years. 40 fetuses with the diagnosis of some obstructive lesions of the heart were investigated. control group was made of 120 fetuses with normal echocardiograms divided into four groups according to gestational weeks. echocardiographic techniques used: m-mode, 2 d and doppler techniques. results: examination were made between 20 and 39 weeks of gestation. all cardiac structures show linear growth with progression of pregnancy. both halfs of the fetal heart are the similar size. 32 obstructive lesions of the left heart and 8 lesions of the right heart were diagnosed. there is statistically significant difference in size of the left and right structures in fetuses with obstructive lesions according to each other and also the same structure of the normal fetal heart. conclusions: obstructive lesions of the left heart were diagnosed much more frequently (80%) than the obstructive lesions of the right heart (20%) in the examination material. left heart hypoplastic syndrome was dominated lesion-75% of obstructive lesions of the left heart and 60% of all diagnosed obstructive lesions. difficult obstructive lesions are progressive, have poor prognosis and present one of the indications for abortion. background: encouraged by beautiful cardiac multislice ct (msct) images presented at radiology and cardiology meetings, and by the favorable preliminary reports on high diagnostic value, more and more radiologists consider starting up their own cardiac msct program. the quality of the examinations initially obtained then, however, often does not live up to the high expectations. procedure details: a common cause for insufficent image quality is the poor attention to detail during image acquisition. in fact cardiac msct depends on the skill and dedication of the ct-technician. as an international training center for cardiac msct, we have noticed some common mistakes likely made by less experienced operators. generally, the basic procedures issues tend to go wrong: e.g., positioning the patient, placing the ecg-electrodes, choosing appropriate filtering, applying basic cardiac anatomy and physiology knowledge, etc. we will provide a step-by-step "how-to" pictorial with tips and tricks for successful cardiac ct imaging, illustrated by many examples of "right and wrong". issues addressed include handling of patient and workflow, data acquisition, and standardized image post-processing. conclusion: a step by step approach to cardiac msct scanning prevents scan failure. tomographic imaging of sinus venosus defects with multidetector ct angiography (mdcta) and magnetic resonance imaging-angiography (mri-mra) j.c. hellinger, a. napoli, f. chan; stanford, ca/us learning objectives: 1. describe tomographic imaging techniques for assessment of sinus venosus defects (svd). 2. illustrate intra and extracardiac anomalies during mdcta and mri-mra for svd. background: svd with associated partial anomalous pulmonary venous return (papvr), accounts for 1-2% of congenital heart anomalies. clinical presentation is nonspecific and thus, diagnosis relies on imaging. transesophageal echocardiography (tee) and digital subtraction angiography (dsa) have been established as standard for this purpose. however, both are invasive and not without risk. mdcta and mri-mra are alternative noninvasive means to image these patients. mri offers the additional benefit to assess shunt ratios with cine phase contrast (pc) sequences. in this exhibit, we highlight our experience with mdc-ta and mri-mra in 9 exams having surgically proven svd-papvr. procedure details: five exams were performed on 8 or 16 channel mdct. contrast was injected at 4 cc/sec, employing bolus trigger technique. two of the 16-mdct were retrospectively ecg-gated with 0.625 mm thickness. non-gated studies were acquired at 1.25 mm, with a pitch of 1.35-1.375 and rotation time of 0.5-0.6 seconds. sequences employed in the four mri-mra exams included ecggated t1, balanced steady state free precession, pc, and 3d-spgr angiography. 3d post-processing employed volume rendering and maximum intensity projection techniques. conclusion: anatomic defect size and location; number of abnormal veins) and dynamic evaluation for svd-papvr corroborated tee, dsa, and/or surgical findings. we identified on all mdcta, a jet of contrast crossing the defect into the left atrium (ct shunt sign). our preliminary experience indicates tomographic imaging is a reliable noninvasive alternative to tee and dsa for assessment of svd-papvr. to sensitize radiologists to the application of reformatting and 3d-reconstuctions in cardiac ct which depict the coronary arteries in a manner consistent with standard catheter angiography in routine clinical practice. to demonstrate a step by step approach to acquistion, optimized reconstruction techniques, and read-out algorithms in the evaluation of the coronary vessels. background: recent advances in the temporal and spatial resolution of mdct have opened the door to the use of ct in routine cardiac diagnostics, which is evolving rapidly as a noninvasive method. ct coronary angiography has compared favorably with conventional catheter coronary examinations, however new reconstruction and visualization methods are continuously being developed and are often lacking in meeting the demands of the routine clinical setting. it is crucial that radiologists become attuned to the standard approach to the coronary angiogram used in clinical cardiology so that advantage is not lost in the competition to provide services. procedure details: in this educational module, we present a step by step assessment of coronary vessels based on 3d-reconstructions of isotropic mdct datasets with special consideration to projections and visualization techniques which correspond with the standards of clinical cardiology. optimization of time consuming 3d renderings of ecg triggered datasets as well as read-out algorithms are demonstrated in examples for normal coronary vessels in addition to representative cases of coronary artery pathology. the resulting effective temporal resolution is 94-188 msec (depending on heart rate and reconstruction algorithm). larger volumes can be studied with isotropic spatial resolution and higher temporal resolution. the capability to scan larger volumes increases the feasibility and the accuracy of this technique in the visualisation of coronary artery bypass grafts (cabg). the scan protocol to evaluate cabgs with 16-row msct is described. different types of conduits (arterial and/ or venous), artefacts (surgical clips) and distal anastomoses of the graft are illustrated with dsa correlation. furthermore, atherosclerotic graft's disease (stenoses and occlusion) as well as native coronary artery disease is displayed with dsa. conclusion: ecg-gated 16-row multislice ct coronary angiography with 0.375 s gantry rotation time provide improved image quality in the evaluation of cabg. significance objective: to compare the msct and pet results in studying the condition of myocardial blood supply and to decide advisability of using them together. materials and methods: 53 patients with suspected diagnosis of coronary artery disease were examined by msct and pet. msct data was obtained using siemens volume zoom ct scanner. retrospectively ecg-gating image reconstruction was conducted. pet was performed on ecat-exact-47 (siemens) with 13n ammonia at rest and during pharmacological test with vasodilatators (adenosine, dipyridamole). results: the first group comprised 16 (30.2%) patients without stenoses in coronary arteries according to the results of msct. pet also didn't detect reduction in perfusion of myocardial ischemic genesis in these patients. the second group included 10 (18.9%) patients with low-grade (< 50%) stenosis of coronary arteries. in these patients pet at rest and during stress didn't reveal a reduction in perfusion of myocardium. invasive coronarography was not performed for the 1 and 2 groups. the third group included 23 (43.4%) patients with different grades of stenosis in coronary arteries, according to the msct. there was reduction in perfusion in the corresponding myocardial segments revealed during at rest and/ or stress-pet. there was invasive coronarography done for these patients, which confirmed the existence of stenosis. methods and materials: ten volunteers (m:f = 8:2, mean age 55) without ischemic heart disease and 34 consecutive patients (m:f = 20:14, mean age 56) with ischemic chest pain underwent ct coronary angiography (sensation 16, siemens, germany). reconstruction was done around -400 ms from r peak and multiplanar reformation and volume rendering were included. myocardial bridge was determined by demonstration of tunneled segment dip into myocardium. invasive coronary angiography was performed in 12 patients. results: twelve tunneled segments in lad were detected in two volunteers (20%) (n = 2) and 9 patients (26.5%) (n = 10). nine were located in middle lad (2 in volunteers, 7 in patients) and 3 in distal lad (in patients). with 4 to 36 mm in length, 0 to 4.5 mm in greatest depth. the cross-sectional areas of tunneled segments were 39% smaller than those of the just proximal and 10% smaller than those of just distal to the tunneled segments. calcification in lad was detected in 1 volunteer and 4 patients with myocardial bridge but not in tunneled segment itself. significant stenosis was detected in proximal lad of two patients and mild stenosis in one patient which were confirmed by invasive coronary angiography. five patients showed only myocardial bridging in lad without coronary arterial stenosis. conclusion: msct directly visualizes tunneled segment within myocardium and gives useful information about myocardial bridging and neighboring coronary arteries. multi-detector row ct for the assessment of atrial septal defect and pulmonary venous drainage in adults g. morgan-hughes, a. marshall, c. roobottom; plymouth/uk purpose: to evaluate retrospectively ecg-gated multi-detector row computed tomography (ct) for the full evaluation of secundum and sinus venosus atrial septal defects (asd), in adults, in comparison to trans-esophageal echocardiography (toe). materials and methods: twelve patients undergoing toe for further assessment of presumed asd, as a prelude to definitive treatment, also underwent retrospectively ecg-gated multi-detector row ct. the multi-detector ct scans were compared to toe for defect and pulmonary vein visualisation. secundum asd sizing; measurements, before possible device closure, were compared, and virtual angioscopy of the right atrium was evaluated for direct, three-dimensional defect visualisation. results: larger secundum asds (greater than 2.0 mm) were well visualised with multi-detector row ct, but smaller defects and sinus venosus defects were not. for maximal secundum defect size there was a mean difference between the techniques of 0.9 mm (limits of agreement minus 5.5 to plus 3.6 mm). overall there was moderate agreement for the defect and rim sizing measurements. pulmonary venous drainage was universally fully and correctly evaluated with multidetector ct, which compared favorably to toe. virtual angioscopic visualisation of secundum defects was possible in 4 patients, but the images produced were considered of limited clinical value. conclusions: retrospectively ecg-gated multi-detector row ct offers alternative imaging of asd in adults, allowing visualisation of significant secundum defects, pulmonary venous drainage and defect sizing. further investigation, to establish the accuracy of defect and rim sizing measurements and to re-explore direct defect visualisation with advanced post-processing tools, is required. detection of necrotic myocardial segments using multi-slice computed tomography: comparison with nuclear medicine p. 1.3 mm slice width, 0.6 mm slice increment and 130 ml of non-ionic contrast (320 mgi/ml) administered with a delay scan of 18 seconds. nm and cts datasets were reoriented perpendicular to the left ventricle long axis. segmental analysis was performed on 18 segments within the short axis planes (6 basal, 6 mid-ventricular and 6 apical segments). a positive nm finding was defined as a perfusion defect within a segment at both rest and stress. a positive ct finding was defined as a hypo-intensive region within a segment. statistical analysis was performed using a 95% confidence interval calculated by the exact binomial method. results: 360 segments were evaluated on both nm and msct. nm detected 59 necrotic segments whereas msct detected 50. there were 50 true-positive, 281 true-negative, 20 false-positive and 9 false-negatives findings. the sensitivity was 84.7%, specificity 93.4%, positive predictive value 71.4% and negative predictive value 96.9%. conclusion: msct showed high sensitivity and specificity for the detection of myocardial necrotic segments compared with nm. evaluation of myocardial bridging by multislice computed tomography p.m. carrascosa 1 , c. capuñay 1 , m. vembar 2 , p. johnson 2 , r. pissinis 1 , j. carrascosa 1 ; 1 buenos aires/ar, 2 cleveland, oh/us to determine the usefulness of multiphase reprocessing msct coronary angiography in the identification of myocardial bridging (mb) and the detection of related ischemia. methods: 220 patients were studied. cts were performed in a 4-row ct scanner with 4 x 1 mm collimation, 0.5 mm slice increment and 130 ml of non-ionic contrast. ten patients with mb diagnosed with msct were evaluated with nuclear medicine (nm). rest and stress studies were performed with 30mci technetium 99m sestamibi. segmental analysis were performed on 18 segments within the short axis plane (6 basal, 6 mid-ventricular and 6 apical) in both methods. positives nm findings were defined as a perfusion defect within a segment at both rest and stress. positives ct findings as hypo-intense region within a segment. results: all the mbs were placed in the lad. da detected 11 cases, whereas msct only 10. the sensitivity was 90.9% and the specificity 100.0%. in 3 cases the mb of the lad had greater diameter in the 95% phase and they were compressed in the 75% phase. six cases showed ischemia in the nm studies. there were 4 true-negatives, 5 true-positives and 1 false-negatives findings. the sensitivity was 83.3% and specificity 100%, positive predictive value was 100% and the negative predictive value was 80%. conclusion: msct can detect the presence of mb in coronary arteries. it is essential for this identification a multiphase reprocessing of the ct data and can also detect the presence of myocardial perfusion defects. to predict the local, gonadal, thyroidal and eye dose with and without different protection devices in retrospective-gated multi slice ct of the heart. material and methods: radiation dose was measured with an alderson phantom and a digital dose meter with and w/o an infradiaphragmatic lead drape, a cervical lead protection and an eye shield. measurements were done with the ionization chamber placed over the heart, uterus, thyroid gland and eyes. helical ct of the heart was performed with an aquilion msct (toshiba). the dose was determined with slice collimation and pitch between 1 and 2.5 using constant voltages and current-time-products for retrospective gated ct. results: local dose over the heart ranged from 142 to 584 µsv. gonadal dose was determined with 61 to 190 µsv w/o lead protection and 23 to 39 µsv using a circular infradiaphragmatic lead drape, meaning a gonadal dose reduction of up to 80%. with use of protection devices the dose to the thyroids could be reduced by 36.5% and 39% in terms of using an eye shield. conclusion: radiation causing gonadal dose in cardiac ct is predominantly extracorporal radiation and only in a lesser degree due to scatter radiation from inside the body. an effective dose reduction of 80% can be achieved by consequent use of a circular lead drape closely adapted to the inferior helical range. the use of organ adapted shields covering the thyroids or eyes mainly results in a decrease of the surface dose and is recommended as well for all patients receiving cardiac ct. images were acquired using a 4-row spiral ct scanner with 0.5 s gantry rotation time. in all patients detailed clinical, ecg, us and scintigrafic (when available) data were collected in order to identify the presence of mi. when a patient with mi was found, mdcta images were analyzed on both axial and multiplanar reconstruction in order to confirm the presence of an infarcted area. results: our study population included 33 patients who previously underwent coronary percutaneous transluminal angioplasty (pta) and stent placement (a total number of 45 stents) and 14 patients with previous by-pass surgery. after clinical assessment, mi was found in 17 patient (9 septal, 4 apical, 3 anterior wall of left ventricle, 1 infero-septal). mdct was able to detect the presence of mi in 14/17 cases (82.3%), showing a regional hypoattenuated area and wall thinning. in all cases, localization and extention of ischemic area were perfectly correlated with clinical known data. in two patients with sub-endocardial involvement, mi could was not detectable with mdct. in one patient the presence of motion artefacts affected image quality and myocardial scar wasn't visualized. the presence of mi is usually well depicted with retrospective ecg gated mdct. mdct coronary angiography: optimization of the image reconstruction phase y. nagatani, r. takazakura, n. nitta, m. takahashi, k. murata; otsu/jp purpose: to investigate the relationship between the heart rate and the optimal image reconstruction phase in mdct coronary angiography. material and method: 37 patients underwent cardiac mdct (8 das) (aquilion8, toshiba, japan) to obtain coronary angiography. scan data were subsequently reconstructed at 10 different kinds of phases in ecg wave. these methods can be classified as follows according to the used wave in ecg; 1).the center of the reconstruction phase is positioned at the peak of t-wave (method t-p), the end of t-wave (method t-e) and the midpoint of descending curve of t-wave (method tm). 2).the end of the reconstruction phase is positioned at the peak of p-wave (method p). 3).the center of the reconstruction phase is positioned using nterval (method r30, 40, 50, 60, 70, 80) . all patients were classified into 3 groups according to their heart rates (hr) (group 1; hr < 60 (n = 14), group 2; 60 < hr; < 70 (n = 10), group 3; hr < 70 (n = 13)). two radiologists assessed image quality in blind fashion and scored as follows (2:good,1:fairly, 0: bad). bonferroni/dunn test was performed for statistical analysis. results: in group 1, significantly better image quality was achieved in method p, rr70, rr80 than other methods. among them, highest image quality was obtained by method p. the best result was obtained by method p in group 2 and tm in group 3. conclusion: optimal image reconstruction phase in mdct coronary angiography shifts from late diastolic phase to late systolic phase as heart rate increases. assessment of aorto-coronary bypass grafts patency by 16 detector rows computed tomography g. two out of five tumors (right atrium lipoma and aortic valve fibroelastoma) were discovered in a routine msct study of coronary arteries and left ventricle myxoma in an elective coronarography. atypical left ventricle myxoma with mitral stenosis and epicardial cyst were primary visualized in transoesophageal echocardiography. results: both methods allows to evaluate tumors size, localization and structure. the biggest advantage of echocardiography was aknowledged possibility of evaluation of lesions mobility while the biggest advantage of msct was possibility of both 3d and 2d imaging in arbitrary planes using multiplanar reformations with evaluation of tumor relations towards adjacent tissues and simultaneous visualisation of coronary arteries. conclusions: msct and echocardiography (tte and tee) are complementary methods in diagnosis of primary cardiac tumors. usefulness of 16-slice multidetector row computed tomography (msct) in assessment of dilated cardiomyopathy s. hosoi, t. mochizuki, t. haraikawa, j. funada; ehime/jp purpose: the purpose of this study is to show the potential benefits of 16-slice msct for the diagnosis of dcm. we studied 30 consecutive patients, including 10 dcm, 10 coronary artery disease (cad), and 10 patients with non-cardiac disease as a normal control. dcm was diagnosed on the basis of the clinical data by cardiologists. the msct system used in this study was a lightspeed 16 (ge medical systems) with available gantry rotation speeds of 0.4 sec. all cardiac images reconstructed were divided into 10 phase data sets in a r-r interval on ecg. end-diastolic (ed) and end-systolic (es) phase could be visually extracted, and the lv wall thickness and volume was measured. moreover, the segmental lv wall motion was evaluated by the cardiac movie image which was reconstructed using the 10 phase data. results: image quality of mdct were considered sufficient for this analysis. concerning about the rate of coronary artery stenosis, dcm group were significantly less than cad group (p < 0.01). in dcm group, both lv wall thickness of ed and es were smaller than other groups (p < 0.01). lv volume between dcm and cad group had no significant difference. lv wall motion in dcm group had a tendency to be diffusely hypokinetic. conclusion: using 16-slice msct, lv function and coronary artery stenosis was able to be evaluated and distinguished the features of dcm and cad. this study revealed a potential ability of mdct as a useful method for the diagnosis of dcm. background: a variety of pulmonary complications occur in bone marrow transplant (bmt) recipients and are a major cause of morbidity and death. imaging findings: hrct is useful in detection of pulmonary abnormalities, but these findings are generally non-specific. these complications, which reflect the immunologic status of the patients, occur in three phases. this pattern can be used to interpret ct scans. the neutropenic phase (up to 3 weeks after bmt) is characterized by fungal infections, alveolar haemorrhage, pulmonary oedema, and drug reactions. at ct, fungal infections like angioinvasive aspergillosis appear as nodules surrounded by a halo of ground-glass attenuation; alveolar haemorrhage and drug reactions, as bilateral areas of ground-glass attenuation or consolidation. the second phase (3 weeks to 100 days after bmt) is dominated by cytomegalovirus pneumonia, which appears as multiple small nodules with areas of consolidation or ground-glass attenuation, and pneumocystis carinii pneumonia again mostly as ground-glass attenuation. the late phase (more than 100 days after bmt) is characterized by bronchiolitis obliterans revealing bronchial dilatation and a mosaic pattern of attenuation, bronchiolitis obliterans with organizing pneumonia (boop), the ct findings usually being patchy consolidation or ground-glass attenuation and chronic graft-versus-host disease. conclusion: if ct findings are considered in relation to the time elapsed after bmt, diagnostic options can be narrowed sufficiently to enable accurate diagnosis. small pulmonary nodules: an easy approach to the differential diagnosis j. rimola, x. gallardo, e. castañer, j.m. mata, a.m. quiles, p. bermúdez; sabadell/es learning objectives: to know the anatomy of the secondary pulmonary lobule, which is essential to the interpretation of high-resolution ct (hrct). to learn an easy way to approach the differential diagnosis of small pulmonary nodules. background: a wide variety of pathologies may present with small pulmonary nodules, which are defined as rounded opacities smaller than 1 cm in diameter. differences in appearance, distribution and attenuation of nodules provide useful clues for correct diagnosis. helical ct and hrct enable correct identification and characterization of small nodules. imaging findings: we illustrate different examples of multinodular lung diseases in an easy-to-understand way. a simple algorithm is used to help in the differential diagnosis. we classify nodules according to distribution (centrilobular, perilymphatic or random) and show the most representative cases of each pattern. we present a wide variety of entities, including: infections such as tuberculosis (endobronchial spread or miliary tb), nontuberculous mycobacteria, fungus; sarcoidosis; tumors (lymphangitic carcinoma, hematogenous metastases); silicosis and coal worker's pneumoconiosis; hypersensitivity pneumonitis; cryptogenic organizing pneumonia; histiocytosis; etc. conclusion: an easy way to assess multiple nodular opacities in the lung is useful to reach an accurate diagnosis. differential diagnosis of unilateral hyperlucent lung m. nishino 1 , k. hayakawa 2 , h. hatabu 1 ; 1 boston, ma/us, 2 kyoto/jp learning objectives: to review differential diagnosis of unilateral hyperlucent lung, understand pathological mechanisms causing the findings, and to be familiar with the imaging findings and clinical manifestations characteristic in each condition. background: unilateral hyperlucent lung on chest radiograph is seen with various pathological conditions. the conditions include both acute and chronic processes, and thus need accurate and prompt diagnostic evaluation. the findings on chest radiograph can provide clues to differentiate various causes of this condition and help to achieve proper management. imaging findings: we present cases of unilateral hyperlucent lung, emphasizing specific imaging findings along with characteristic clinical manifestations. the cases include proximal interruption of pulmonary artery, pulmonary hypoplasia, swyer-james syndrome, congenital lobar emphysema, foreign body aspiration, and bochdalek hernia. findings on chest ct which can confirm or support the diagnosis are also reviewed and discussed. conclusion: familiarity with the characteristic imaging findings of unilateral hyperlucent lung is essential for radiologists to make accurate diagnosis for appropriate patient management. multislice ct of primary and multisystemic pulmonary vasculitis: a patternbased approach to differential diagnosis k. marten 1 , m. prokop 2 , p. schnyder 3 , e.j. rummeny 1 , c. engelke 1 ; 1 munich/de, 2 utrecht/nl, 3 lausanne/ch . clinical and radiologic features of these tumors are often indistinguishable from those of malignant tumors. however recognition and early diagnosis of these lesions may allow for conservative treatment and excellent patient outcome. the aim of this study is to illustrate the ct findings of variable benign tumors of tracheobronchial tree and correlate with the pathologic findings. imaging findings: this study included 15 patients with benign tracheobronchial tumors which were confirmed histologically by surgical resection (n = 13) or bronchoscopic biopsy (n = 2). the tumors were classified the anatomic locations of the lesions into trachea (n = 4), bronchus intermedius (n = 1), lobar bronchus (n = 8), and segmental bronchus (n = 2). pathologic diagnoses were hamartoma (n = 5), leiomyoma (n = 3), lipoma (n = 2), schwannoma (n = 2), amyloidoma (n = 1), inflammatory polyp (n = 1), and bronchial adenoma (n = 1). ct demonstrated all tumors confined in the tracheobronchial lumen. 10 of 11 bronchial tumors occluded the bronchial lumen completely, resulting in distal parenchymal collapse. to enhance the limitations of chest x-ray and axial chest ct slices in estimating the volume of pleural effusions. this interactive presentation will allow the reader to test himself, comparing his own subjective estimation to the real volume computed from 3d shaded surface displays (ssd). to outline the usefulness and ease of post-processing with spiral ct to obtain a true assessment of the pleural fluid volume. background: assessment of the volume of pleural effusions is very imprecise both on chest x-ray and axial chest ct slices. the amount of fluid may be required by clinicians for therapeutic purposes. 3d ssd of the effusion provides rapid computation of its volume. in this exhibit we will recall the physiopathologic mechanisms involving the preferential locations of pleural effusions. we will show pleural effusions of various volumes on chest ct along with the corresponding chest x-rays and the precise volume of the effusion computed from 3d reconstruction. procedure details: various cases of free or collected pleural effusions on spiral chest ct (ct twin and mx 8000 idt), are presented, including coronal and sagittal reformations. ct images stand along with the corresponding chest x-ray, obtained in the upright and supine position, and with the computed volume of the effusion using 3d reconstruction. conclusion: pleural volumetry is readily available using spiral ct data recontruction. it should be more often used, to assess the amount of fluid to withdraw with thoracocentesis, before drainage or for monitoring in intensive care unit patients. lung consolidations in various clinical entities: clinico-radiologic correlation presented in an interactive cd-rom in html format s. mylona, s. tandeles, l. thanos, s. lyra, p. ellinas, n. mpatakis; athens/gr learning objectives: to present lung consolidations as found in ct and plain radiographs in various clinical entities. to give a differential diagnosis based on clinical and radiologic features. background: radiologists often encounter lung consolidations in plain radiographs and lung ct. there is a broad spectrum of clinical entities, which either present as lung consolidations or involve lung consolidations. clinical information and radiologic features help to approach the right diagnosis. procedure details: 30 cases are presented in a question and answer format using html resources in an interactive cd-rom. reference is made to proper diagnostic work up and to other relevant clinical information. histopathological confirmation is presented where it is needed. conclusion: radiologists must be trained to deal with patients presenting with lung consolidations using clinical and radiological features. hrct patterns of cardiogenic pulmonary edema e. chambrier, s. zafatayeff, y. badachi, p.a. grenier, c. beigelman-aubry; paris/fr learning objectives: to be familiar with typical and atypical hrct appearances of pulmonary edema based on 50 patients. to emphasize the role of hrct in suggesting this diagnosis in the setting of acute dyspnea, especially if pulmonary embolism is suspected. background: pulmonary edema, a frequent cause of acute dyspnea, can be clinically difficult to detect. hrct is crucial in suggesting this diagnosis, particularly when pulmonary embolism is suspected. actually, bolus intravenous injection of iodinated contrast in case of pulmonary edema may worsen heart failure and lead to patient death. imaging findings: the hrct signs of pulmonary edema are usually divided into interstitial and alveolar patterns, and both can be associated. classic signs of interstitial edema, which accounts for 70% of cases, are peribronchial and peribronchovascular thickening, septal lines, ground glass opacity, pleural effusion, cardiac enlargement and pulmonary veins dilatation. alveolar edema is characterized by bilateral, patchy or coalescent areas of airspace consolidation, predominantly basal and perihilar. butterfly pattern is found in 5% of cases. atypical patterns are due to preexisting lung or heart disease, such as right upper lobe edema related to mitral regurgitation, or heterogeneous distribution of edema due to preexisting lesions of emphysema or constrictive bronchiolitis. highly selected cases will be used to illustrate typical and atypical patterns. the varied hrct appearances of cardiogenic pulmonary edema have to be recognized in order to delay the performance of angioct of pulmonary arteries if pulmonary embolism is suspected. smoking-related interstitial lung diseases: radiologic-pathologic correlation a. hidalgo, t. franquet, a. giménez, r. pineda, m. madrid; barcelona/es learning objectives: 1. to review the radiological findings of smoking related interstitial lung diseases and their pathologic correlations. 2. to provide some radiological clues for the correct diagnosis. background: interstitial lung disease (ild) represent a heterogeneous group of lung disorders of known or unknown cause. recently, it has been appreciated that cigarette smoking is related to the development of several ilds including desquamative interstitial pneumonia (dip), respiratory bronchiolitis-associated interstitial lung disease (ribld), pulmonary langerhans'cell histiocitosis (plch) and idiopathic pulmonary fibrosis (ipf). procedure details: we reviewed the plain radiograph, ct, and hrct findings of four intersitital lung disorders that have been linked to smoking. several examples of the radiological forms of srild and their differential diagnosis are provided. we will also show how the radiologists can get the diagnosis through some clinical and radiological clues. the link between several interstitial lung disease and smoking has been recently indicated. radiologists have to be aware of these entities and to suggest a diagnosis as accurate as possible by the knowledge of clinical context and the radiological features. the spectrum of ct appearances in pulmonary amyloidosis a. aylwin, p. gishen, a. nicholson, s. copley; london/uk learning objectives: to review the ct appearances of pulmonary amyloidosis. background: amyloidosis has three main histopathological subgroups, with typical imaging characteristics: 1) tracheobronchial disease with plaques, nodules or circumferential thickening of the trachea or segmental airways; 2) nodular parenchymal disease with single or multiple nodules demonstrating sharp lobulated margins, spiculated masses simulating tumours, and a rare form associated with sjögren's syndrome and lymphocytic interstitial pneumonitis (nodules and lung cysts); and 3) diffuse alveolar septal disease showing ground glass opacification, interlobular septal thickening, and traction bronchiectasis on hrct. it is often possible to divide cases into localized amyloidosis with tracheobronchial deposition or nodular disease, or the systemic type with diffuse parenchymal disease or lymphadenopathy on the imaging findings, but cases demonstrating overlapping features are not uncommon. procedure details: the ct appearances of 8 cases of biopsy-proven pulmonary amyloidosis will be demonstrated. the spectrum of ct appearances of pulmonary amyloidosis of both localised and systemic types will be demonstrated. the ct features of localized and systemic disease may overlap. thoracic conclusion: incidence and imaging features of these complications will be illustrated. paraquat poisoning of the lung: a study of 47 patients with paraquat intoxication for 21 years a. ichinose 1 , k. kimura 2 , m. tsuboi 1 , h. saito 1 , t. ishibashi 1 , s. takahashi 1 ; 1 miyagi/jp, 2 akita/jp learning objectives: to analyze 47 patients who had taken paraquat intoxication and to compare those with 24% paraquat intoxication to those with 5% paraquat-diquat intoxication, especially with respect to the change of their chest x-rays and ct. background: paraquat is a widely used herbicide that has toxic effects on the lungs, liver, and kidneys. paraquat has been known to induce acute pulmonary fibrosis, causing progressive respiratory failure and death. in japan, 5% paraquatdiquat product has been used since 1986, in place of 24% paraquat product,. however, there is no report that compares the influence these products have on the lung. procedure details: there were 39 patients from whom chest x-rays were taken, and 22 of those (56.4%) had abnormal findings, which were composed of 10 ground-grass patterns, 4 reticulogranular patterns, 4 pulmonary edemas, 4 cardiomegalies and pulmonary congestions, 2 pneumothoraxs, and 1 mediastinal emphysema. pulmonary edema was found only in the patients with 24% paraquat intoxication; in all cases, the plasma paraquat concentration was much higher than others. all reticulogranular patterns were found a few days later, and those in the patients with 5% paraquat-diquat intoxication were potentially reversible. conclusion: 24% paraquat product has more influence on the lung than 5% paraquat-diquat product. pulmonary fibrosis caused by 5% paraquat-diquat product is potentially reversible. thoracic parenchymal abnormalities, enlarged lymph nodes, pleural effusion, and pleural thickening were evaluated. in 46 patients who underwent surgical biopsy or autopsy, the ct-pathological correlation was performed with the actual specimens. imaging findings: on the ct scans, abnormal findings were seen in 60 patients (69.0%). the ct findings consisted of ground-glass attenuation (n = 37), centrilobular nodules (n = 25), thickening of bronchovascular bundles (n = 22), and consolidation (n = 13). these abnormalities were predominantly seen in the peripheral lung parenchyma (n = 26). pathologically, these findings corresponded with atypical lymphocytes infiltration along the interstitium and the alveolar spaces. pleural effusion and enlarged lymph nodes were found in 22 patients and 27 patients, respectively. conclusion: the ct findings in patients with adult t-cell leukemia/lymphoma consisted mainly of ground-glass attenuation, centrilobular nodules, and thickening of the bronchovascular bundles in the peripheral lung. these ct findings, though non-specific, are considered as suggestive of thoracic involvement in patients with adult t-cell leukemia/lymphoma. high resolution ct imaging of the lung for patients with primary sjögren's syndrome c. lohrmann, m. uhl, k. warnatz, n. ghanem, e. kotter, o. schaefer, m. langer; freiburg/de purpose: to assess pulmonary abnormalities in patients with primary sjögren's syndrome using high-resolution computed tomography (hrct). the hrct scans of 24 patients over a ten-year-period with diagnosis of primary sjögren's syndrome were retrospectively reviewed regarding the presence, extension and distribution of 16 pathological findings. results: 19 patients (79.2%) showed pathological findings and in 5 (21.8%) the hrct scan was normal. a predominance of abnormalities in the lower lobes and subpleural areas was detected. bronchiectasis, thin-walled cysts and small pulmonary nodules in 11 patients (46.2%), ground-glass attenuation and emphysema in 9 patients (37.8%), interlobar-septal thickening in 7 patients (29.4%), honeycombing in 6 patients (25.2%), bronchial wall thickening and tree-in-bud pattern in 5 patients (21.0%), mosaic perfusion in 4 patients (16.8%), and architectural distorsion in 3 patients (12.6%). airspace consolidation, air trapping, large nodules (10-30 mm) and masses (> 30 mm), mediastinal lymph node enlargement (> 15 mm) and free pleural fluid were seen each in 1 patient (4.2%). in 8 of 11 patients (73%) with thin-walled cysts areas of ground-glass attenuation were detected. conclusion: hrct seems to be contributive to the characterization of the wide variety of lung abnormalities in primary sjögren's syndrome. airway disease alone or in association with the presence of varying degrees of interstitial disease represent the main findings in accordance with earlier reports. unexpectedly, almost half of the patients have thin-walled cysts on the hrct scans, which etiology is unclear but could be associated with areas of ground-glass attenuation indicating lymphocytic interstitial pneumonia. investigation of the bulky hilum: how accurate are radiologists at detecting hilar pathology on the chest radiograph? s. desigan, d. murray; london/uk purpose: to determine the accuracy of radiologists in detecting hilar pathology on chest radiographs. materials and methods: a retrospective study was performed, analysing the chest radiograph and computed tomography (ct) findings of 15 patients, all of whom had initially been referred for thoracic ct as part of the investigation for a "bulky hilum" as detected on chest radiography. 15 radiologists, comprising 7 consultants and 8 specialist registrar trainees who were blinded to the initial ct findings, were asked to assess the chest radiographs for the presence or absence of a hilar mass and their recommendations for clinical follow-up in each case were recorded. they were then scored for accuracy as compared to the thoracic ct results. the results showed marked variation between observers in the two groups. the participants had an accuracy of 55%, sensitivity of 68% and specificity of 51%. positive predictive values of registrars and consultants were 34% and 45% respectively. negative predictive values were 67% for registrars and 76% for consultants.the group as a whole detected only 3 out of 5 hilar masses confirmed by ct. the wide range of responses demonstrates the very subjective nature of interpretation of the lung hila on chest radiographs, and the difficulty involved in correctly identifying or excluding hilar masses on chest x-rays. one of the most useful aspects of this study has been to provide feedback to individuals for educational purposes and personal audit. b d e f a g m. paslawski, w. krupski, k. krzyzanowski, j. zlomaniec; lublin/pl purpose: the aim of the study is to evaluate the diagnostic value of hrct in revealing small bronchiectases and bronchiolectases in patients with previously diagnosed pneumoconiosis. the study comprises a group of 38 patients, 21 men and 17 women, aged between 23 and 74 years, with pneumoconiosis in which hrct was performed. hrct was performed in all patients in the prone position, from the level of the apices to the level of the diaphragm. the collimation of the scans was 2 mm, with 1 cm intervals between sections. the hrct examinations were assessed retrospectively by two radiologists, and the presence and character of bronchiectases were noted. results: bronchiectases were seen in 22 patients (58%). in 15 of them the "signet-ring sign" and "tram track sign" were seen, with lack of normal tapering. bronchi were visible in peripheral lung areas, within 2 cm from the parietal pleura in 10 patients. 4 patients had varicose bronchiectases with the typical "string of pearls" appearance. in 2 patients, cystic bronchiectases were seen, presenting with the picture of "cluster of grapes". conclusions: bronchiectases is very often seen in patients with pneumoconiosis, especially in advanced stages. hrct is the modality of choice to diagnose the presence of small bronchiectases and bronchiolectases. typical hrct patterns include "signet-ring sign", "tram track sign", lack of normal tapering, and visible bronchi in peripheral lung areas, within 2 cm from the parietal pleura. in varicose bronchiectases, the "string of pearls" appearance, and in cystic bronchiectasis, the "cluster of grapes" appearance are typical. introspective background: spns occur on 1 in 500 chest radiographs with 30% being due to lung cancer. conventional imaging is fairly effective in determining the nature of the spn, although 15-20% remain indeterminate following ct scan. the spn will often have needle biopsy either via bronchoscopy or percutaneously which have a recognised complication rate of 5-10%. depreotide is a tc-99m labeled analogue of somatostatin with affinity to receptors types 2, 3 and 5. various tumours including lung cancer, breast cancer, lymphoma and neuroendocrine tumours express these receptors. we undertook a retrospective review of one years' referrals for depreotide imaging comparing the results with subsequent biopsy or surgical histology where available. additionally we assessed if the referring clinical question had been answered. results: 24 depreotide studies performed, with 18 showing increased uptake within the spn. 6 patients (25%) with positive studies had had a previous indeterminate lung biopsy thus enabling planning of further biopsy or wedge resection with frozen section. depreotide and histology agreed in all 17 patients who had subsequent histology of the spn (16 malignant, 1 benign). further biopsy was avoided in 5 out of 6 patients with negative studies. specific answers were given to the clinical referring question in 23 cases. conclusion: depreotide effectively determined the nature of the spns with ability to avoid biopsies in the 25% of patients with benign disease and to prompt further invasive investigation following an indeterminate biopsy. pleural invagination in progressive massive fibrosis (pmf) in silicosis and mixed dust pneumoconiosis h. arakawa, k. honma, h. shida, h. mori, y. saito; tochigi/jp purpose: invagination of the pleura often accompanies progressive massive fibrosis (pmf) in pneumoconiotic lung. to elucidate the relation between pmf and the pleura covering them, we conducted a retrospective study comparing ct and autopsy findings in silicosis and mixed dust pneumoconiosis (mdp). the study group was an autopsy series of 58 consecutive patients with complicated silicosis or mdp. ct images were examined to determine the location, shape, composition and size of pmf, distance between the lesion and the covering pleura, presence of pleural thickening, a band-like structure between the lesion and pleura, and pleural effusion. autopsy data were reviewed for the presence of pleural thickening and invagination and were compared with the ct findings. results: we identified 120 pmf lesions. pleural invagination was found in 39 (32.5%) pmf and was always associated with pathologically determined pleural thickening. ct images showed pleural thickening in 36 (92.3%) and invagination in 17 (43.6%) lesions. 13 lesions were associated with ipsilateral pleural effusion (p < 0.01). statistical analysis revealed pleural invagination was associated with pleural thickening (p < 0.001) and proximity of the lesion to the pleura (p < 0.01) but not with radiographic profusion of pneumoconiotic opacities, or the shape, composition, size of pmf (p > 0.05). 5 pmf were radiographically identical to rounded atelectasis. conclusions: fibrous thickening of the pleura and invagination into the adjacent pmf are not uncommon in advanced silicosis and mdp. some lesions resemble rounded atelectasis. ct is beneficial in assessing these pathologic features. imaging the aim of this teaching exhibit is to illustrate a spectrum of usual and unusual cystic diseases involving the lung, and to evaluate the efficacy of plain radiographs and computed tomography (ct) imaging in the diagnosis and management of these conditions, with emphasis in high resolution ct (hrct). we retrospectively reviewed the imaging findings of patients with diffuse cystic lesions involving the lung from our data base of thoracic pathology. a cystic lesion was defined as an air-containing, well-defined space, variable in size. the pertinent embryology and pathologic basis of the radiographic findings are discussed. pitfalls, diagnostic difficulties and differential diagnoses are emphasised. results: specific topics addressed include diffuse cystic diseases of the infancy (bronchopulmonary dysplasia, pulmonary interstitial emphysema, types i, ii, and iii congenital cystic adenomatoid malformation, chronic eosinophilic pneumonia, and pneumatoceles), and diffuse cystic diseases of the adulthood such as honeycomb lung (secondary pulmonary fibrosis), langerhans cell histiocytosis, pulmonary lymphangioleiomyomatosis, tuberous sclerosis, and lymphoid interstitial pneumonia. we also include pulmonary diseases simulating cysts such as congenital diaphragmatic hernias, diffuse bronchiectasis, and emphysema. conclusions: hrct is an adequate imaging modality to assess diffuse cystic disease of the lung, allowing an excellent visualisation of the cysts as well as other secondary findings (distribution, size, location, and wall thickness). because many of these disorders have characteristic imaging appearances, this exhibit will help practising radiologist to better understand, recognise and differentiate cystic diseases involving the lung. beware the normal chest x-ray in suspected lung cancer: a pictorial review of the potential pitfalls a.k. basu, k. jeyapalan, j. entwisle, r. bhatt; leicester/uk purpose: to demonstrate that a standard pa chest x-ray can be falsely reassuring in patients where there is a high index of clinical suspicion for lung cancer. we reviewed the patients with suspected lung cancer whose chest x-rays were radiologically normal and had further ct cross sectional imaging. emphasis was placed on the hidden review areas on a standard pa chest x-ray, e.g. the mediastinum, the apices, behind the diaphragm and behind the heart. we present a pictorial review of these hidden areas and illustrate the potential lesions not seen on a "normal" chest x-ray. results: ct can often demonstrate lesions not visible on chest x-ray. conclusion: a normal pa chest x-ray may be falsely reassuring in patients suspected of having lung cancer. therefore in patients with a high index of clinical suspicion a ct should be carried out despite the normal pa chest x-ray with careful review of the hidden review areas. should a chest radiograph be requested in all cases of febrile neutropenia admissions? a study in a university hospital a.v. acharya, a.k. burnett; cardiff/uk purpose: to evaluate the clinical utility of obtaining chest radiographs, in the absence of chest symptomatology, in patients admitted with acute neutropenic sepsis. methods: prospective study of 35 in patients with febrile neutropenia admitted to the haematology ward was carried out in this university hospital over a period of 4 months. symptoms & signs, chest x-ray findings and changes in management because of these findings were assessed in these patients. we also conducted a questionnaire survey of haematologists of south wales regarding obtaining chest radiographs in these patients. results: chest radiographs were obtained in 88.5% of the patients at the time of diagnosis of febrile neutropenia but only 22.8% of the patients had chest signs/ symptoms. if chest signs/symptoms were present, 37.5% had abnormal chest x-rays and this influenced change in clinical management. in the group where chest signs/symptoms were absent, radiographs were normal and no change in management resulted from a chest radiograph. the survey of haematologists suggested that majority of them (58%) requested chest radiographs in acute neutropenic sepsis irrespective of presence or absence of chest signs or symptoms. in neutropenic patients with no chest signs/symptoms, a chest radiograph on admission is not likely to be abnormal and is unlikely to change the management. on the basis of our study we suggest that the chest radiographs in these patients in the absence of clinical signs or symptoms, are of little value. this would however not exclude the possibility that other imaging approaches would be of clinical value. low to evaluate the usefulness of low dose thin-section ct by multidetector-row ct (mdct) for lung cancer screening in both the determination of malignancy or benignancy and the differential diagnosis. methods and materials: 73 cases with pathologically proved solitary pulmonary nodules, which sizes were less than 3 cm in diameter, were entered into this study. after the routine full dose thin-section ct (1.25 mm collimation, fov 20 cm, pitch 3:1, 120 kvp, 200-ma/rotation, 0.5 second/rotation, high-spatial frequency algorithm), additional two kinds of low dose helical thin-section ct (2.5 mm collimation, pitch 6:1, 40-(in initial 36 cases), 20-(all 73 cases), 10-(in remaining 37 cases) ma/rotation) were scanned using a mdct scanner (lightspeed qxi, ge, milwaukee, wi). using roc analysis, an observer performance study, in which three observers indicated the confidence level for the determination of malignancy or benignancy for each nodule, was done. in addition, three observers recorded the final diagnosis of each case. accuracies of the final diagnosis were compared by mcnemer's test. in the determination of malignancy or benignancy, there was no significant difference among these four kinds of thin-section ct (full dose, 40-, 20-, and 10-ma/rotation; mean az = 0.896, 0.874, 0.872, and 0.894, respectively). accuracy of the final diagnosis by low dose thin-section ct (40-, 20-, and 10-ma/ rotation; 68%, 69%, and 69%, respectively) was significantly lower than that of full dose thin-section ct (81%) (p < 0.005). conclusion: efficacy of low dose thin-section ct by mdct is comparative to that of full dose thin-section ct in determining whether small nodules are malignant or not. lung cancer screening using low-dose spiral ct: preliminary results in 404 asymptomatic smokers s. giunta, m. crecco, f. facciolo, l. carpanese, v. cilenti, m. caterino, p. visca, m. mottolese; rome/it purpose: to evaluate the feasibility of lung cancer screening using low-dose spiral ct and to present initial baseline data from a non randomized screening trial using low-dose spiral ct. methods and materials: 404 asymptomatic smoker volunteers, aged 55 years or older who had smoked 20 packs-year or more, underwent baseline low-dose multislice spiral ct (volume zoom siemens) of the chest without contrast material enhancement following the elcap protocol. annual repeat screening was performed on 62 participants. lesions up to 5 mm were deemed non suspicious and low-dose ct was repeated after 12 months. results: at baseline, 559 non calcified nodules were identified in 204 participants. 21 nodules were larger than 10 mm. biopsy of 14 lesions revealed nsclc in 8 cases (5 adenocarcinoma, 1 squamous cell carcinoma, 1 large cell carcinoma, 1 adenoid cystic carcinoma). of these 3 were stage i (37.5%); 2 stage ii (25%); 2 stage iii (25%) and one stage iv (12.5%). 6 were benign lesions (3 hamartomas, 1 lymph node, 2 fibrosis). in 2 cases the pet was negative, in 3 cases the nodules resolved after antibiotics; 2 participants refused biopsy. conclusion: low-dose spiral ct seems to be a promising method for screening lung cancer. our preliminary cancer screening results with low-dose spiral ct, demonstrated a prevalence of asymptomatic cancers in 1.98% of a smoking population including a high proportion of early tumor stages. pathological mismatched findings of specimens between ct guided biopsy and resection in noguchi's classifications of small peripheral lung adenocarcinoma s. yoshida, h. ue, s. itou, y. murata; nankoku/jp purpose: we sometimes experience mismatched pathological findings of specimens between preoperative ct guided biopsy and resection in the noguchi's classification of small peripheral lung adenocarcinoma. in this study we discuss the mismatched pathological findings in each case and explored the possibility of reducing the incidence of mismatch. we selected 9 cases, in which preoperative ct guided biopsy and consecutive resection were performed. tumors were peripheral lung adenocarcinoma of 2 cm or less in diameter. the final diagnosis by resected specimen of these cases were 3 type b, 4 type c and 2 type f peripheral adenocarcinoma. we compared hrct findings of them to identify the ct density in each tumor. results: though the final pathological findings show 3 type c tumors, the specimen by ct guided biopsy show only type a or b tumors. further more, though the final pathological findings show 2 type f, not having a replacement growth pattern, the specimen also show type a or b, having a pure replacement growth pattern. conclusion: pathological mismatched findings between ct guided biopsy and resection were observed. additional ct image comparison between mediastinal and lung window settings gave us probable information about the tumors having replacement growth patterns or not. before performing ct guided biopsies, image recognition about the solid density helped us choose the most suitable biopsy site. with more thorough information derived from hrct and biopsy on the types of tumors patients have, physicians can offer patients more accurate prognosis. purpose: to analyze high-resolution ct (hrct) findings in asthmatics and control subjects, and to evaluate the relationship between hrct findings and pulmonary function tests in asthmatic subjects. to try to evaluate the correlation between the bronchial wall thickening (bwt) with pathologic findings and reflect the thickness of epithelial basement membrane on basis of the hrct findings. materials and methods: using hrct, the author analyzed the ratio of bwt, the frequency of bronchial dilatation, the extent of air trapping and centrilobular nodules. in addition, the author assessed hrct findings of 52 asthmatic patients for correlation with pulmonary function tests and then obtained bronchoscopic biopsy at the second divisional branch of 12 patient among the 52 asthmatics. the author measured the thickness of the epithelial layer and basement membrane after h-e stain and then statistically compared with bwt on hrct. results: among the total 52 asthmatics, bwt on hrct showed significant correlation with fev1 (p = 0.006) and tlc (p = 0.012). pefr (p = 0.04) shows significant correlation with the air trapping on hrct statistically. among the 12 patient of 52 asthmatics, bwt on hrct shows statistically significant correlation with basement membrane thickness on pathology, but not with epithelial layer thickness on pathology (p = 0.023, r = 0.642). the ratio of bwt between asthmatics and control subjects are significantly different on hrct. the grade of bwt shows significant different fev1 and tlc statistically, and that of extent of air trapping reveal significant different pefr statistically. the bwt on hrct reflect the thickness of epithelial basement membrane. computer-aided diagnosis: a shape classification of pulmonary nodules imaged on high-resolution ct s. iwano, t. nakamura, t. ishigaki; nagoya/jp purpose: the purpose of this study was to decide whether the computer image analysis could classify shape of pulmonary nodules like radiologists. materials and methods: based on the high-resolution ct (hrct) findings, two radiologists classified 70 pulmonary nodules (5-35 mm in diameter) into 7 types of shape: round (n = 20), lobulated (n = 12), polygonal (n = 8), tentacle (n = 7), spiculated (n = 7), ragged (n = 8), and irregular (n = 8). on the other hand, an image processing computer software extracted several quantitative measures of the shape of each nodule from dicom data of hrct images. to identify the contour of the pulmonary nodules, -300 hu was used as the predefined threshold values. these quantitative measures were contrasted to the classification by radiologists. results: as quantifiable features to characterize nodule shape, the circularity (= 4π*area/ perimeter 2 ) and the second moment were suitable. the combination of the circularity and the second moment could classify round, tentacle, spiculated, ragged, and irregular nodules. however, it was difficult to separate lobulated from polygonal nodules. conclusion: computer image analysis of hrct could classify round, tentacle, spiculated, ragged, and irregular pulmonary nodules like radiologists. this method may be useful for the differentiation between malignant and benign nodules. hrct of the lungs in cystic fibrosis: more sensitive marker of cf lung disease than lft m. polakovic, h. kayserová, p. boruta; bratislava/sk purpose: our study was aimed at determining the usefulness of hrct in evaluating pathomorphological changes of lung parenchyma, the reversibility of these changes, and correlation of these changes to pulmonary function and mutations in cftr gene. two hrct examinations of the chest were performed on 63 cf patients (36 males, 27 females) with lft (maximal interval: two weeks) in the period of 1999 to 2003. follow-up studies were evaluated by a modified bhalla scoring system and compared with initial studies. lung function testing was performed on a mir spiro-bank, using ers 1993 (zapletal) predicted values. in group with df508/df508 genotype (22 pts) the first examination mean score reached 8.7 (rl)/8.7 (ll), second 10.7 (rl)/9.7 (ll). lung function tests were: first examination -fvc 73%, fev1 74%, mef50 69% and second one fvc 81%, fev1 78%, mef50 66%. for groups with df508/other genotype (28 pts) and other/other genotype (13 pts) similar results were obtained. conclusion: hrct is a more sensitive method of evaluating pathologic process in lungs of cf patients than lft. lft is a more complex examination, and the results of pulmonary functions are modified by the physical status of the cf patient (nutrition, strength of muscle, acute exacerbation) and his/her ability to cooperate with spirometry (age). severe mutations of cftr gene in genotype are accompanied by an increasingly high hrct score in spite of therapy applied and stable lung functions. high resolution computed tomography in the diagnosis of bronchiolitis obliterans syndrome after lung transplantation a.e. berstad, t.m. aaløkken, a. kolbenstvedt, ø. bjørtuft; oslo/no purpose: to evaluate the clinical value of high resolution computed tomography (hrct) of patients after lung transplantation. materials and methods: hrct with insp-and expiratory scans was performed in 36 patients (19 women, 10 single-and 26 double lung-, including two heartlung transplanted) who had survived for 11 months or more. the median followup time was 36 months (range 11 to 72 months). air trapping was evaluated on expiratory scans constructed from two short spiral scans in two levels with minimum intensity projection (minip)-reconstruction. the degree of air trapping was classified on a 0 to 16 scale according to the affected surface area. a score of 3 or more was defined as significant air trapping. results: 13 patients developed the bronchiolitis obliterans syndrome (bos) as defined by reduction of pulmonary function test results to less than 80% of the best postoperative values after a median time of 12 months. 10 of these had an air trapping score of 3 or more. among patients without bos (n = 23), 7 patients showed significant air trapping. the sensitivity, specificity and accuracy of a score of 3 or more in the diagnosis of bos were 77, 70 and 72% respectively. bron-chiectasis developed more frequently in bos than in non-bos patients (69 and 39%, respectively). conclusions: hrct, including expiratory scans with minip-reconstruction, or development of bronchiectasis was of limited accuracy in diagnosing bos after lung transplantation. hrct indices and pulmonary function tests in patients with chronic bronchial asthma c. kalogeropoulou, d. kalampoka, p. zampakis, i. tsota, k. spyropoulos, t. petsas; patras/gr purpose: to quantitatively evaluate the presence and extent of low attenuation areas on chest high-resolution ct (hrct) in patients with chronic bronchial asthma and correlate such findings with the pulmonary function tests (pft). we examined 15 patients (m: 6 and f: 9, age 48.5 ± 11.55 yrs) with chronic bronchial asthma. all patients underwent inspiratory and expiratory hrct as well as forced spirometry, maximum voluntary ventilation, somatic plethysmography and cardiopulmonary exercise test. hrct images were evaluated for the presence and distribution of low attenuation areas. objective quantification of low attenuation areas was obtained by determining the relative area of pixels representing lung tissue with a density below -910 hu (pixel index). the resulting pixel index was determined for a single slice at the upper middle and lower zone. results: pulmonary function parameters correlated well with pixel index during expiratory scan. there was significant correlation between the upper part of the lung and forced vital capacity (fvc),%fvc, forced expiratory volume in 1 sec (fev1), maximum voluntary ventilation (mvv) and total lung capacity (tlc). the middle part of the lung correlated with fvc, fev1, fef25-75 and resistance. the lower part of the lung was also correlated with fev1, fef25-75, residual volume (rv) and total resistance. pixel index during inspiratory hrct scans did not correlate with pulmonary function tests. conclusions: expiratory hrct in asthmatics correlates well with pulmonary functions, which suggests that in asthmatics substantial gas trapping may occur during expiration because of severe airway narrowing and/or airway closure. thoracic imaging during treatment with pergolide r. dore, a. gervasio, m. braschi, v. vespro, g. meloni, c. nascimbene; pavia/it purpose: pergolide is a dopaminergic agonist widely used in the treatment of parkinson's disease. toxicity has been described in the form of fibrosis, inflammation of the pleura, retroperitoneal fibrosis, constrictive pericarditis and inflammatory lung infiltrates. we analyzed thoracic abnormalities in patients who have been taking pergolide long term and the possible differential diagnosis. hospital, "s.matteo" irccs, a group of neurological patients treated with pergolide underwent chest ct, because of clinical and chest x-ray abnormalities. we scanned each patients before and after intravenous injection of contrast medium; the lung parenchyma was evaluated with high resolution algorithm; three patients with pulmonary opacities also underwent fnab. results: all patients had round atelectasis associated either with pleural plaques of vary entity or with atypical and reactive pleural effusion. the thickest pleural plaques were located in the costovertebral angles, followed by the diaphragmatic pleura without effusion. in all the cases the pleural plaques in the parietal side were definetly irregular, linear in the lung side. association with lung interstitial septal thickening was inconstant. conclusions: although our cases are few in number and need further validation, pleural involvement, either fibrotic or inflammatory, always seem to be associated with pulmonary abnormalities. ct pleural signs are non specific; differential diagnosis may include tumors, asbestos exposure and inflammatory disease; however the association with relevant lung round atelectasis is significant. these ct findings must be held in mind and thought to be due to toxicity in patients treated with pergolide. the chest radiological appearances of severe acute respiratory syndrome methods and materials: 54 patients with sars confirmed clinically had serial chest plain films, 23 of whom also underwent chest ct scans. the radiological appearances and evolution patterns of sars were analyzed retrospectively. based on the extent and duration of the lesions on the chest plain films, the patients were classified into three types: simple type (type i) in which the lesions were limited, progressive type (type ii) in which more than three lungs fields were involved, and prolonged type (type iii) in which the lesions remained for more than six weeks. the follow-up chest plain films and ct scans were analyzed comparatively in 18 patients of this group discharged from the hospital after clinical cure. results: in 54 cases, on the chest radiography, 15 cases showed predominately pulmonary parenchymal lesions in the form of ground-glass opacity and consolidation, 5 cases showed predominately interstitial infiltration and 34 cases showed both parenchymal and interstitial lesions. the radiological appearances were nonspecific with good patient prognosis in type i (n = 12), and the radiological appearances were relative specific with high patient fatality rate (16%) in type ii (n = 25). all of the patients (100%) in type iii (n = 17) had residual lesions. ct was superior to the chest plain film on detecting residual lesions. the radiological appearances of sars were relatively specific. the exact diagnosis of sars must combine radiological appearances with the clinical, epidemiological and laboratory findings. hrct to identify hrct features that indicated predisposition to potentially fatal asthma and to evaluate serial follow-up hrct scans of patients with nearfatal asthma (nfa). abnormalities of the large airways (bronchial wall thickness) and small airways (centrilobular thickening and air trapping) were measured semi-quantitatively on hrct scans of 24 non-nfa, 16 nfa, and 16 control subjects. in addition, these abnormalities were re-evaluated after intensive and relatively long-term (> 6-month) treatment with inhaled steroids. results: centrilobular thickening was observed in 36% of mild asthma cases, in 70% of moderate to severe asthma cases, and in 100% of nfa cases. centrilobular thickening, but neither bronchial wall thickness nor the area of air trapping, was significantly increased in nfa, as compared with mild or moderate to severe asthma (p < 0.05, respectively). in the 7 non-nfa and 5 nfa patients who underwent follow-up hrct scans, only bronchial wall thickness was decreased significantly in the nfa cases (p < 0.05), while bronchial wall thickness and centrilobular thickening were significantly decreased in the non-nfa cases. these small airway abnormalities were partially reversible in the both groups. residual centrilobular thickening after long-term steroid treatment was significantly higher in nfa than non-nfa patients. the results of our study indicate that extensive small airway abnormalities may be associated with nfa, and that these abnormalities are partially reversible after the successful control of asthma symptoms. a. kalogera-fountzila, a. haritanti-kouridou, a. lefkopoulos, g. sevas, a. tzinas, a. sarafopoulos, a.s. dimitriadis; thessaloniki/gr purpose: we prospectively studied aids and non-aids immunocompromised patients with lung infection in order to evaluate the hrct findings, to characterize the infection and seek for differences in appearance of pcp in the two groups. methods and materials: 19 hiv positive patients were referred to the special infectious diseases unit and 11 non-aids immunocompromised patients were referred to the oncology unit of our hospital with a diagnosis of clinically suspected pulmonary infection. all patients were evaluated with hrct (1.5 mm collimation, 10 mm interval, 140 kvp, 175 mas, and 1-s scan time). all non-aids immunocompromised patients had bronchoalveolar lavage, sputum culture, or ct guided biopsy as well as did 10 of the hiv-positive patients which revealed pcp. in the rest of the patients pcp was confirmed after successful anti-pcp treatment. the data were calculated using the chi square test. results: all patients in both groups had the typical findings of pcp, such as presence of ground glass appearance (patchy or diffuse), consolidation (focal or diffuse), bronchiectasis or bronchioloectasies, septal thickening, cysts and nodules. the incidence of consolidation, especially diffuse, was a significantly higher finding in non-aids patients (p = 0.029). on the contrary, presence of ground glass in a central/perihilar distribution (p = 0.017), septal thickening (p = 0.032) and bronchioloectasis (p = 0.032) was significantly higher in aids patients. conclusion: hrct findings of pcp in non-aids immunocompromised patients are more aggressive, with diffuse consolidation as the cardinal sign and are associated with a more advanced disease. primary and secondary lung malignancies treated with percutaneous radiofrequency ablation: to describe the important ct findings to evaluate for therapeutic efficacy on follow-up ct after rf ablation for the lung cancer. the study group included 17 lung cancers and 4 metastatic nodules in 21 patients. all patients underwent follow-up helical ct examinations immediately, one month later, and then every three months after percutaneous rf ablation. two reviewers interpreted the ct findings with consensus. the serial changes in the enhancement pattern, size, peripheral groundglass opacity, and other findings in the treated area were assessed on the follow-up ct. sensitivity, specificity, and the positive predictive value for evaluating the complete ablation using enhancement pattern on immediate follow-up ct were determined using the chi-square test. in the completely ablated group (n = 9), the ablated lesions demonstrated absolutely no contrast enhancement on follow-up ct and the mean percentage of ablated lesion size decreased at 3, 6, 9, 12, and 15 months (5.5%, 14.8%, 43.2%, and 43.2%, respectively) compared with immediate follow-up ct. in the partially ablated group (n = 12), the ablated lesions demonstrated varying patterns of enhancement and the mean percentage of ablated lesion size showed a gradual increase after the 6-month follow-up ct scans. enveloped ground glass opacity surrounding the tumor was seen in 5 (23.8%) of 21 lesions on immediate follow-up ct. conclusion: of the ct findings of lung malignancy after rf therapy, the enhancement pattern and the change in size of the ablated lesion are the most important factors in determining whether complete ablation can be achieved. (ip) is an uncommon benign lesion characterized by an irregular growth of inflammatory cells. the purpose of this study was to evaluate ct findings of the thoracic inflammatory pseudotumor. methods and materials: chest ct findings of pathologically proven seven thoracic ip were reviewed retrospectively. mean age of the patients was 52 years old (35-62 years). pre-and post-contrast enhancement ct were performed in all patients. location and contour with margin of the lesion, pattern of contrast enhancement, calcification in the lesion, lymphadenopathy, associated parenchymal or pleural lesion were reviewed. clinical findings of the patients were also evaluated. results: six were in the lung parenchyma (five in peripheral, one in central; four in upper lobe, two in lower lobe), and one was in the anterior mediastinum. average size of the lesions was 6.7 cm (3-14 cm). of the six parenchymal lesions, three revealed as ill-defined mass-like consolidation, two as well defined masses, and one as speculated mass. one mediastinal mass showed ill-defined margin. all lesions showed heterogeneous contrast enhancement. three had eccentric calcification. none had satellite nodule. four cases had adjacent pleural thickening or effusion. lymphadenopathy was noted in one patient. they complained of mild fever (n = 3), hemoptysis (n = 2), coughing (n = 1), weight loss (n = 1). four patients had past history of pulmonary tuberculosis. conclusion: thoracic ip showed variable ct findings. however, when dealing with a peripheral pulmonary mass with heterogeneous contrast enhancement without remarkable lymphadenopathy, the radiologists should always include ip among the entities of the differential diagnosis. early to highlight the potential benefit of including fdg-pet in an early lung cancer detection protocol. materials and methods: from september 2000 to october 2002, 506 asymptomatic smokers (mean age 54.5 years, sd 8.65, mean tobacco consumption 42.55 pack-years) were studied with ldct. repeat short-term high-resolution ct follow-up was done for non-calcified pulmonary nodules (ncpn) < 10 mm to exclude growth. ncpn 10 mm or more were considered as potentially malignant and complementary fdg-pet scanning was recommended. biopsy was recommended for ncpn found to be positive on the fdg-pet. results: 144 ncpn were found in 101 (20%) asymptomatic subjects. the diameter of the largest ncpn was: 5 mm or less in 49 (48.5%) participants, > 5 -< 10 mm in 36 (35.6%) and 10 mm or more in 16 (16%). 13 subjects underwent fdg-pet exam (7 positive, 6 negative). among the fdg-pet positive ncpn 5 were resected (lung cancer), 1 underwent fine needle aspiration cytology (fnac) (non-specific / necrosis). the remaining subject refused further work-up. ct follow-up was decided for the other ncpn. results will be updated after inclusion of more participants. this ldsct based screening programme demonstrated a prevalence of 5 lung cancers in a population of 506 (0.99%) asymptomatic subjects at high risk, all with surgical stage t1n0m0. addition of fdg-pet to the protocol may reduce the number of invasive procedures for histologically benign nodules. technical aspects postprocessing procedures after mdct for airway and lung diseases a.-l. brun, c. beigelman-aubry, y. badachi, p.a. grenier; paris/fr learning objectives: to be familiar with the postprocessing procedures after multi-detector row ct (mdct) which can optimize the assessment of airway and lung disease. background: axial slices are considered as the gold standard for analysis of airways and lung diseases. since the era of mdct, excellent reformations, and 3d reconstructions have become available and frequently used in case of airway disease. infiltrative and cystic lung diseases may also benefit from these techniques, provided that they are optimally used. procedure details: all 2d and 3d reconstruction techniques available were retrospectively applied on mdct volume data set from patients with airway and/or lung disease, using various parameters. optimized multiplanar volumetric reconstruction and 3d ct bronchography are particularly well adapted for assessing tracheobronchial stenosis and bronchiectasis. maximum intensity projection is recommended for assessing small nodular and mosaic perfusion patterns. minimum intensity projection is helpful: 1) to detect and assess ground glass opacity; 2) to visualize the airways within any lung parenchymal lesions, helping guide selective bronchial aspiration and bronchoalveolar lavage; and 3) to depict bronchial adenolectasia in patients with copd or bronchiectasis. virtual endoscopy is particularly helpful in depicting tiny nodulation of the tracheobronchial mucosa in granulomatous and malignant diseases. highly selected cases will be used to illustrate the most striking additional information provided by postprocessing techniques in airway disease, infectious lung disease, and diffuse infiltrative lung disease. postprocessing procedures in addition to axial slices allow an excellent assessment of tracheobronchial and parenchymatous diseases, particularly concerning their depiction, characterization and extent assessment. volume rendering: less-time consuming and accuracy technique in diagnosis of rib fractures e. chavarri, c. trinidad, e. guerra, g. fernandez, c. delgado, p. moreno de la santa; vigo/es learning objectives: to asses the useful of volume rendering 3d images (vr) in the evaluation of rib fractures using a 16-slice multidetector ct. to compare vr and conventional images in determining the number and location of fractures. to describe the advantages of vr over conventional images. background: multislice ct has improved the resolution in evaluation of traumatic patients because it permits thinner slices and multiplanar reconstructions with near isotropic voxel. however, the number of images to be evaluated is greater and the diagnosis of rib fractures remains difficult due to the obliquity of costal arches in the axial view. we evaluated chest ct examinations in 54 patients with rib fractures. in this exhibit, we describe ct technique, reconstruction parameters and the advantages of vr over conventional images to ensure number and location of rib fractures. procedure details: a 16-slice multidetector ct was performed using the following parameters: 90 mas, 120 kv, 16 x 1.5 mm collimation, during a single breath hold. images were reconstructed with 3 mm thickness, 50% overlapping and soft tissue kernel filter (b40). two experimented radiologists analysed axial, multiplanar and vr images. the number of fractures, location and part of arch fractured (anterior, medium and posterior) was described. conclusion: volume rendering is more accurate than conventional images in determining the presence and location of rib fractures, particularly when arches are fractured in more than one site. also, it is a less time consuming technique with better diagnosis confidence. we recommend its use in a routine practice for chest-ct in traumatic patients. c 409 b d e f a g volume rendering 3d bronchography imaging of the airways with 16 multidetector row ct c. trinidad, g.c. fernandez, m. rodriguez-castilla, c. martinez, e. guerra, f. tardáguila; vigo/es learning objectives: to describe the technique of 3d volume rendering bronchography (vr-b) with 16 multidetector row ct. to evaluate the usefulness of vr-b of the tracheobronchial tree in clinical practices comparing with axial and multiplanar reconstructions. background: multidetector row ct allows superior imaging resolution in axial and multiplanar images, and also contributes to advances in 3d-volume rendering that can now be feasible in clinical routine practice. in this exhibit, we will describe the ct technique and vr-b parameters to obtain good quality 3d images for visualization of central and small airways. in addition, we will evaluate the role of this technique in clinical practice and in different pathologies of the tracheobronchial tree. procedure details: 50 patients with airways pathology due to different etiologies were prospectively studied with 16-row multidetector ct. images were acquired at end-inspiration during a single breath-hold with 16 x 0.75 collimation detector and reconstructed with 1 -2 mm collimation, 0.5 -1 mm increment (overlapping 50%) and soft tissue kernel filter (b30). vr-b images were showed using -150 to -750 uh window with, -526 to -250 uh window level, 35% opacity and unshaped. conclusion: good quality vr-b images are feasible in daily practice. in patients with benign stenosis of the central airways additional information in assessing length and degree is provided. this technique improves confidence diagnosis in extrinsic compression by malignancies. however, no additional benefit in the evaluation of endobronchial lesions and bronchiectasis is shown. clinical procedure details: all scans covered from the vocal cords to the mainstem bronchi. ct parameters included a slice thickness of 2 mm, a reconstruction interval of 1 mm, a pitch of 3.5 mm, and a table speed of 7 mm per rotation. data were obtained during a single-breath-hold acquisition in a craniocaudal direction. twodimensional reformation images including multiplanar reconstructions (mpr), multiplanar volume reconstructions (mpvr), and three-dimensional reconstructions (external and internal rendering) were obtained at a workstation (vitrea 2; vital imaging). the main applications of msct in airways disease as well as its limitations and pitfalls are emphasized. specific topics addressed include congenital airways anomalies (anomalous origin of bronchi, vascular rings, tracheomalacia, bronchopleural fistula), extrinsic airways compression, tracheal and bronchial wall infiltration (bronchogenic carcinoma, angiosarcoma), intraluminal airways masses (carcinoid tumor), inflammatory diseases and posttraumatic and iatrogenic airways injuries. conclusion: msct provides very high-quality image postprocessing (multiplanar and three-dimensional images), overcoming limitations inherent to sdct. additional benefits include preprocedural planning for bronchoscopy and surgery, and a more comprehensive spatial anatomy for both radiologists and referring physicians. ultrasound: guided aspiration of supraclavicular lymph nodes in patients with suspected lung cancer m. kumaran, r. benamore, r. vaidhyanath, j. entwisle; leicester/uk learning objectives: to illustrate the utility of ultrasound-guided supraclavicular lymph node aspiration in the cytological diagnosis of lung carcinoma. we describe our preliminary experience in 19 patients over the last 4 months. background: lung carcinoma is the leading cause of cancer death in the uk. histological diagnosis traditionally requires invasive techniques to obtain tissue, such as bronchoscopy, mediastinoscopy or image-guided lung biopsy. we have introduced this technique in patients who have at least n2 disease on staging ct. if positive, this helps both to stage the patient and provide a cytological diagnosis. it may prevent the need for more invasive techniques, such as percutaneous lung biopsy or mediastinoscopy. procedure details: all patients were scanned and nodes over 10 mm in size were aspirated under ultrasound guidance, using a 21 gauge green needle. a capillary "coring" technique was employed, without suction and aspiration. the samples were then expelled from the needle into cytospin fluid, for cytological examination. the procedure could be performed without local anaesthetic and as an out patient. of the 19 patients examined, 16 had significant lymphadenopathy. of these, 12 had positive malignant cytology, although 2 had indeterminate cell type. 4 samples showed no evidence of malignancy and pet confirmed no evidence of supraclavicular nodal involvement in 1 case. conclusion: this is a promising non-invasive technique in the staging and diagnosis of patients with lung cancer. simulated low radiation dose ct angiography of pulmonary arteries d. tack 1 , v. de maertelaer 2 , c. suess 3 , p. muller 4 , p. scillia 2 , w. petit 2 , p. gevenois 2 ; 1 baudour/be, 2 brussels/be, 3 forchheim/de, 4 charleroi/be purpose: to compare standard dose and simulated low-dose ct angiography of pulmonary arteries (ctpa). raw data of ctpa acquired in 21 consecutive patients with pulmonary emboli (pe) were included. ct acquisitions (volume zoom, siemens) were: 4 x 1 mm, 120 kv, 90 effective mas. from the native raw data, four sets of simulated raw data were generated with 60, 40, 20 and 10 effective mas, respectively. from each raw data set, ct slices were reconstructed with 1.25 mm thickness and 0.8 mm increment, and with a soft tissue kernel. three readers who were blinded to the patients names and to the simulated mas levels analyzed the ct series twice, in random order. pe in 6 central pulmonary arteries (pa) and 20 segmental pa were graded with a four-point scale. agreements (kappa statistics) and readers performances using 90 mas as the gold standard were calculated. results: all pe seen at 100 mas were depicted at all lower radiation dose levels. intraobserver agreements were independent from the radiation dose but strongly depended on the reader's experience. agreements were good for central pe but only moderate for peripheral pa branches. accuracy of low-and lower dose ctpa ranged from 95 to 100%, and were independent from the radiation dose (p < 0.001) but not on the reader. conclusion: reducing the radiation dose during ctpa is feasible with high accuracy, and may have less influence on ctpa interpretation than may have changing the reader or repeating a reading. receiver operator characteristic analysis of observer performance in virtual bronchoscopy p. maniatis, c. triantopoulou, h. labrakis, k. malagari, i. tsalafoutas, i. siafas, j. papailiou, d. kelekis; athens/gr purpose: to evaluate the observer performance with the combined interpretation on a workstation of vb, axial, coronal and sagittal images against hard-copy films of thin section ct in low grade bronchial abnormalities using receiver operating characteristic (roc) curves. patients and methods: 369 bronchial sections in 41 patients were evaluated in a prospective observer study using spiral ct data. exclusion criteria included occlusions, high-grade bronchial stenoses (> 50%) and tracheal lesions. all patients underwent a spiral ct acquisition with 3 mm collimation. two reconstruction intervals were used: 1 mm for virtual bronchoscopy and 2 mm for thin section ct. both examinations were reviewed by two independent radiologists. the findings were correlated with those of flexible bronchoscopy and the statistical analysis was done with receiver operating characteristic curves. results: a total of 62 lesions were identified by flexible bronchoscopy. areas under curves for virtual bronchoscopy and multiplanar reconstructions were 0.972 and 0.949 for the two observers respectively, while areas 0.913 and 0.896 were provided from thin axial ct images (by the two observers respectively). these results differed at statistical significant level (p < 0.05 for the first observer and p < 0.01 for the second observer). the combination of multiplanar reconstructions and virtual bronchoscopy in simultaneous viewing on a workstation is particularly useful for the evaluation of low grade bronchial abnormalities at statistical significant level when compared to thin section axial ct images alone. b d e f a g optimization of voltage combination for chest radiography in a new dualenergy subtraction system n. bandai 1 , h. tagashira 1 , m. yoshimoto 1 , t. kiriyama 2 , t. maruyama 2 ; 1 onsen-gun/jp, 2 matsuyama/jp the new dual-energy subtraction system allows the fast (200 millisecond) acquisition of two, high and low voltage images using csi:tl amorphous silicon flat-panel technology. the purpose of this study was to determine the best combination of the voltage for the soft tissue of the chest radiography. the dual-energy subtraction imaging increases the sensitivity and specificity of the pulmonary nodule detection in the chest radiography by reducing the contrast of overlying the bone structures. the range of the high voltage is from 120 kvp to 150 kvp and the low voltage is from 60 kvp to 80 kvp, respectively. the physical factor such as contrast, density and graininess and the anatomical factor such as visibility of the vessel were evaluated by five radiologists using the normalized-rank approach. all rank orders were transformed to the distance scale by the statistical method. the ranking in the low voltage was better in the order corresponding to 60 kvp, 70 kvp and 80 kvp (p < 0.05). the ranking in the high voltage showed better in the order corresponding to 140 kvp, 150 kvp, 130 kvp and 120 kvp. there were significant differences (p < 0.05) except the distance scale between 140 kvp and 150 kvp. the best combination for the soft tissue of the chest in a new dualenergy subtraction system was 140 kvp (high voltage) and 60 kvp (low voltage). spiral low-dose ct of the chest: a "one-stop-shop" modality for early detection of the leading causes of death g. bastarrika, o. cosín, j.c. pueyo, á. alonso, d. cano, j.j. zulueta; pamplona/es purpose: spiral low-dose ct (ldct) can identify very small lung cancers in high-risk individuals. the purpose of this study is to assess feasibility of quantifying coronary calcium using non ecg-gated ldct exams performed in individuals participating in an early lung cancer detection programme (elcdp). a comparative study was performed in 48 asymptomatic smokers included in an elcdp (44 male, 4 female; mean age 59.7 years; sd 8.2). subjects consecutively underwent a ldct of the chest and an ecg-gated cardiac ct with a four-row msct scanner (volume zoom, siemens, erlangen, germany). standard parameters were employed: ldct: 120 kv, 20 mas, 1 mm slice, 1 mm coll., 6 mm table feed, 0.7 mm rec. interval; ecg-gated cardiac ct: 120 kv, 133 mas, 3 mm slice, 2.5 mm coll., 3.75 mm table feed, 1.5 mm rec. interval. retrospective reconstruction using the raw data from the ldct was performed reproducing the specific ecg-gated ct parameters. intraclass correlation coefficient (icc), paired-sample t-test and bland and altman plot were employed for the statistical analysis. the paired sample t-test showed there was not a systematic bias in the measures of calcium (p = 0.31). the icc for the overall calcium score and for the different main coronary arteries showed and excellent agreement (overall icc 0.958, 95% ci 0.927-0.976). conclusion: a clear correlation when evaluating quantification of coronary calcium with both ct techniques is observed. a single ldct exam may be useful for early detection of leading causes of death: lung cancer and coronary artery disease. dual energy in digital chest x-ray: material and methods: patients scheduled to undergo routine chest ld-msct were examined either without (10 mas, 120 kv, 1.3 mm slice width fused to 3 mm effective width, spiral acquisition, n = 10) or with ecg-triggering (10 mas, 2.5 mm slice width, axial incremental acquisition, n = 10, age-, sex-and bmi-matched) on a philips mx8000 4-row msct scanner. three independent radiologists scored axial slices at four different levels (carina, apical, mid-cardiac, basal), using a four-point scale for discrimination of pulmonary structures in the hilar region, the lung core and the subpleural region. mediastinal structures were scored on a three point scale. scores were compared using wilcoxon's test. results: for the more experienced ct radiologist, delineation of pulmonary structures did not improve significantly with ecg-triggering (p = 0.08), while improvement in the delineation of mediastinal structures was highly significant (p = 0.004). for the less experienced ct radiologist, there were no significant differences between ld-mscts with and without ecg-triggering for either pulmonary or mediastinal structures (p = 0.39 resp. p = 0.34). although not formally evaluated in this study, both radiologists reported a higher quality of sagittal and coronal mprs from non-triggered data due to lower susceptibility to breathing artifact. conclusion: results indicate that ecg-triggering improves delineation of moving structures (heart, mediastinum) in ld-msct of the chest. ecg-triggering improves delineation of pulmonary structures only in paracardial lung tissue. results: time-distance curves of the breathing-cycle using mri correlated highly significantly with spirometry (p < 0.0001). vc calculated by the model was similar to vc measured in spirometry (5.00 l vs 5.15 l). tvc correlated highly significant with spirometry (p < 0.0001). vertical parameters had a more profound influence on tvc change than horizontal parameters. conclusions: dynamic mri is a simple non-invasive method to evaluate local chest wall motion and respiratory mechanics. it widens the repertoire of tools for lung examination with a high temporal resolution. influence the aim of this study was to investigate influence of reconstruction filters on image quality in ct chest exams. methods: 20 patients were examined with standard chest scanning protocol. after scanning, images were reconstructed with smoothing filter. both set of images were filmed under the same conditions. in blinded assessment, three radiologists independently rated films for overall image quality and chest anatomic details (1 -unacceptable, 2 -substandard, 3 -acceptable, 4 -above average, and 5 -superior). for all exams and reconstruction filters image noise were measured in relation to the descending thoracic aorta. results: for all three readers overall image quality was higher for standard filter. image quality for standard protocol was 3.75 and for images reconstructed with smoothing filter 2.97. average image noise for images reconstructed with standard filter was 36.4 and for images reconstructed with smoothing filter the noise was 15.8. all three radiologists rated greater chest anatomic details for standard protocol images. for both protocols the best-rated detail was that of the trachea and main bronchi (4.15 standard, 3.18 smoothing), and the worst was that of the esophagus (2.87 standard, 2.20 smoothing). the greatest difference between rates of the two protocols was for paratracheal tissue (3.41 standard, 2.27 smoothing) and the smallest for carina and lymph node area (3.31 standard, 2.67 smoothing). conclusion: standard filter is better in visualization of all anatomic detail in general chest exams including mediastinal structure and lymph node area. greater image noise for image reconstructed with standard filters does not influence visualization of anatomic detail. usefulness new quality assurance systems for the evaluation of detectability of lung nodules on the digital chest radiograph y. fujiwara, k. higashimura, h. kimura, h. itoh; fukui/jp purpose: the goal of this study is to develop a new quality assurance system for evaluating detectability of lung nodule of the digital chest radiograph. method and materials: first, we made an oval shaped phantom, which simulated lung tissue such as muscle, fat, and pulmonary field. then several nodules with variable ct values were inserted into the center of the phantom. second, we took images of the phantom using ct and digital radiography (dr) with a flat panel detector.the contrast of the nodules relative to the pulmonary field were measured both on chest ct and dr. the relationship between contrast from ct and dr was analyzed in regression using 3 rd order polynomial. finally, the same analysis was also performed on nodules from clinical cases with lung cancer (n = 70), and clinical data was fitted into the same polynomial line. results: all nodules with the ct value less than 250 in the difference between nodules and lung field could not be detected on dr. the relationship between the contrast from ct and dr in clinical cases was also regressed with the same 3 rd order polynomial line from the phantom data. the current result is very useful for the evaluation of the detectability on chest dr. when one want to check it using variable nodules with known ct values, if the contrast of the nodules on dr is not regressed on above line, the assurance of dr might be problematic and/or dr system may need to be reconditioned. 412 b d e f a g pulmonary thromboembolism: acute versus chronic (pictorial review) a. oikonomou 1 , c.j. dennie 2 , j.m. seely 2 , f.r. matzinger 2 , f.d. rubens 2 , p.k. prassopoulos 1 ; 1 alexandroupolis/gr, 2 ottawa, on/ca learning objectives: to present the spectrum of imaging findings that allow the differentiation of acute pulmonary embolism (ape) from chronic thromboembolic pulmonary artery hypertension (cteph) based on chest radiography and helical computed tomography (ct). background: patients with a prompt diagnosis of ape may recover completely following anticoagulation therapy. in a minority, pulmonary emboli do not completely resolve leading to organization, artery obstruction and ultimately to cteph. although the evolution process of ape to cteph has not been fully elucidated, the distinction of the two entities is critical since the treatment of ape is conservative, while cteph warrants pulmonary thromboendarterectomy. imaging findings: radiographic findings of ape are nonspecific and include atelectasis, peripheral consolidation and pleural effusion. localized lung oligemia with associated dilatation of a central artery is extremely rare. right ventricular and central pulmonary enlargement, patchy oligemia and peripheral scars may be seen in cteph. the cardinal signs of ape on ct angiography are central or completely occluding arterial filling defects, which may be associated with peripheral airspace disease and pleural effusion. eccentric filling defects adherent to the vessel wall, irregular intimal thickening, abrupt vessel narrowing or tortuosity are features of cteph. dilatation of central arteries, abrupt vessel cut-off and peripheral scars are more common in cteph than in ape but arterial webs, bands and mural calcifications are only observed in cteph. if arterial findings suggestive of cteph are present, the addition of mosaic oligemia on hrct is pathognomonic of cteph. conclusion: ct allows differentiation of ape from cteph. pulmonary hypertension: ct of the chest in pulmonary veno-occlusive disease a. resten, s. maître, m. humbert, f. capron, g. simonneau, d. musset; clamart/fr purpose: pulmonary veno-occlusive disease is a rare cause of pulmonary hypertension and often difficult to distinguish from severe primary pulmonary hypertension. unfortunately, medical treatment of the primary pulmonary hypertension by prostacyclin (pgi 2 ) can be fatal in veno-occlusive disease and an early pre-therapeutic diagnosis of this uncommon condition is critical. so, the aim of the study was to evaluate ct of the chest as a non invasive approach of this disease. we reviewed cross-referenced records from 1996 to 2001 in our departments of radiology and pathology and identified 15 patients with an initial pre-therapeutic ct and a pathologically confirmed pulmonary venoocclusive disease. ct scans were compared with the ct scans of 15 consecutive patients with a pathologically confirmed primary pulmonary hypertension. results: ground glass opacities were significantly more frequent in pulmonary veno-occlusive disease (p = 0.003), abundant, with a random repartition, and a preferentially centrilobular distribution (p = 0.03). sub-pleural septal lines, and adenopathy were also significantly more frequent (p < 0.0001). the association of these three findings appeared to be quite pathognomonic of pulmonary venoocclusive disease as the cause of pulmonary hypertension (specificity = 100%) with a 66% sensitivity. conclusion: on the initial pre-therapeutic chest ct, association of ground glass opacities (particularly with a centrilobular distribution), septal lines, and adenopathy are indicative of pulmonary veno-occlusive disease in patients displaying pulmonary hypertension. caution must be taken before initiating vasodilatator therapy in the presence of such radiological abnormalities. .0 x 1.6 mm 3 ) was performed during and after a single injection of 0.1 mmol/kg body weight of gadomer. image data was compared to pre-embolism gd-dtpa-enhanced mri and post-embolism thin-section multi-slice ct (n = 2). snr measurements were performed in pulmonary arteries and lung. results: one animal died after induction of pe. in all other animals, perfusion mri and mra could be acquired after single injection of gadomer. at perfusion mri, pe could be detected by typical wedge-shaped perfusion defects. while the visualization of central pe at mra correlated well with ct, peripheral pe were only visualized by ct. gadomer achieved a higher peak snr of the lungs compared to gd-dtpa (21 ± 8 vs. 13 ± 3). conclusion: contrast-enhanced 3d perfusion mri and mra allow the assessment of pe using a single injection of the blood pool contrast agent gadomer. c 413 b d e f a g detection of pulmonary emboli with thin slice (3 mm) maximum intensity projection reconstructions of multi-detector ct pulmonary angiography s.k. venkatesh, s. wang, p. goh; singapore/sg purpose: to compare thin-slice (3-mm) maximum intensity projection (mip) reconstructions with 3 mm axial scans for detection of acute pulmonary emboli. materials and methods: multi-detector ct pulmonary angiography (4 x 1 mm, 1.5 pitch; 0.5 sec) was performed in 18 patients. from each raw data set, axial 1 mm and 3 mm scans were reconstructed. thin-slice (3 mm) mips in axial, coronal and rotational planes were reconstructed from 1 mm axial data using a 3d workstation. the 90 data sets were reviewed for evidence of embolus on a per vessel basis by 2 radiologists with discrepancies resolved by consensus. emboli demonstrated on the axial 1 mm images were taken as standard for comparison. results: pulmonary emboli were detected in 336 vessels (mean of 18.7 emboli per patient) with 35.8% in subsegmental arteries. the thin-slice mip images demonstrated more emboli as compared to axial 3 mm images. axial and rotational 3 mm mip images detected most of the emboli (95.2% and 92%). significant advantage of axial and rotational 3 mm mips over axial 3 mm images was seen at subsegmental artery level (92.5% and 89.2% versus 41.7%) (p < 0.05). among the mips, axial mips detected the most number of emboli in upper and middle lobes, whereas the rotational mip detected slightly higher emboli in the lower lobes. conclusions: thin slice mips are superior to axial 3 mm for pulmonary embolus detection. the advantage of mips is most significant at the level of subsegmental artery level and beyond. we recommend routine use of axial 3 mm mips in the detection of pulmonary embolus. primitive angiosarcomas of the pulmonary arteries: difficulties in ct diagnosis r. dore, m. mantelli, v. vespro, d. savulescu, g. digiulio; pavia/it purpose: primitive angiosarcomas of the pulmonary arteries are very uncommon tumors. the radiologist should consider them in the differential diagnosis with thromboembolic disease, in patients with clinical suspicion of pulmonary embolism, as early surgical treatment may be beneficial. between 1993 and 2003, at our hospital, "s.matteo" irccs, we identified three cases of primitive angiosarcomas of the pulmonary arteries, subsequently confirmed at surgical examination, on chest cts of patients with clinical suspicion of thromboembolism. we used a single-slice spiral ct scanner (24 sec., 3-5 mm collimation), with iv contrast injection at high flow rate. both pulmonary parenchyma and vasculature were evaluated, along with the enhancement pattern of the endoluminal lesions. results: in all 3 cases, the left main pulmonary artery was affected (the distal segment in one case and proximal segments in two). in one patient, the right main pulmonary artery was also involved. all the vascular lesions were occlusive, without anterograde flow and extravasal diffusion. in two patients, contrast enhancement of the endoluminal mass was better detected in the delayed scan. in one patient, contrast enhancement had a periferical distribution. in all the patients, there were no parenchymal signs of thromboembolic disease. conclusions: primitive angiosarcomas of the pulmonary arteries are associated with occlusion of the main pulmonary artery and lack of parenchymal signs. as the differential diagnosis between massive thromboembolic disease and primitive angiosarcoma may be difficult with monophasic ct scan, the evaluation of the contrast enhancement of intraarterial lesion in the delayed phase becomes fundamental. purpose: to demonstrate the imaging features of chronic thromboembolic pulmonary hypertension (ctph) on chest ct scans and to evaluate the correlation between the extent of mosaic pattern of lung attenuation and hemodynamic measurements. methods and materials: chest ct scans of 50 patients with ctph were reviewed to assess vascular and parenchymal changes. in all patients diagnosis was confirmed by surgery. the diameter of the main pulmonary artery (pa) and the ratio of the diameters of the main pulmonary artery to the ascending aorta (rpa) were correlated with mean pulmorary artery pressure and pulmonary vascular resistance. mosaic attenuation was quantitated by adding the number of abnormal lobes (including lingula, score 0-6). this score was correlated with the hemodynamic measurements. results were analysed by regression analysis and spearman's correlation. results: thrombi were observed in the central pulmonary arteries in 79% of cases. in all ct scans a mosaic pattern of lung attenuation was found. scars related to the pleural surface were identified in 69% of cases, bronchial artery collaterals in 60%. ct scans showed dilated pa in 98% and rpa ≥ 1 in 90%. mean pulmonary artery pressure correlated more strongly with rpa than with diameter of pa. the score of mosaic attenuation showed a strong correlation with pulmonary vascular resistance (r = 0.66; p < 0.0001). to be able to recall the most common ct and mr intrathoracic manifestations in patients with breast cancer. 2. to be able to describe the radiologic features of this entity. 3. to be able to recall helpful clues for narrowing the differential diagnosis and appropriately directing patient management decisions. background: breast cancer is a common cancer in women and is second only to lung cancer as a cause of cancer-related deaths in women. the thorax is a common site of metastasic disease and complications related to surgery, chemotherapy, radiotherapy and autologous bone marrow transplantation. imaging findings: the purpose of this exhibit is to review the ct and mr findings of the various intrathoracic manifestations occurring in patients with breast cancer. these include complications related to direct extension of tumor, to metastatic spread, and complications secondary to treatment. the complications can be divided into those that affect the chest wall (chest wall invasion, chest wall metastases, axillary and internal mammary lymphadenopathy, local recurrence, postradiotherapy sternal and costal tumors, surgical complications), mediastinal and hilar manifestations (lymphadenopathy, abscess formation, lymphatic obstruction), pulmonary manifestations (lymphangitic carcinomatosis, pulmonary metastases, endobronchial metastases, neoplastic emboli, lung infections related to immunosuppressive therapy, obliterative bronchiolitis post bone marrow transplantation) and pleural manifestations (pleural effusion, pleural metastases). conclusions: knowledge of the full spectrum of radiologic manifestations of the thoracic complications of breast cancer is useful in diagnosis and in preventing diagnostic errors. bronchogenic cysts: range of radiological appearances f. almolani, p.m. logan; dublin/ie learning objective: to review and illustrate the range of plain film, ct and mri appearances of bronchogenic cysts. background: bronchogenic cysts are one of the congenital cystic lesions in the chest. it has variable appearances on imaging and overlapping features with other mediastinal lesions. it is often identified incidentally. imaging findings: we reviewed the imaging on 30 proven bronchogenic cysts. plain radiographs and ct images were available for all cases. mri images were available in 8 cases. most of bronchogenic cysts have a classic mediastinal location and well defined margin on plain films, with homogeneous low density appearance on ct. however they can be found within the lung parenchyma, be cystic or cavitary, have thick walls and be seen to expand. on mri, fluid levels can be demonstrated. occasionally, they can be multiple or co-exist with significant unrelated pathology. conclusion: bronchogenic cysts have a wide range of imaging appearances and familiarization with these appearances is essential for appropriate inclusion of the diagnosis within a list of differential diagnoses. imaging appearances of mediastinal cystic lesions s.p. prabhu, k. burney, p. goddard; bristol/uk learning objectives: to illustrate the radiological appearances of various mediastinal cystic lesions using various imaging modalities. background: cysts of the mediastinum constitute a small but important diagnostic group, representing 12 to 18% of all primary mediastinal tumors. mediastinal cysts can be classified based on their aetiology, and include bronchogenic, oesophageal duplication cysts of foregut origin, mesothelial derived pericardial and pleural cysts, cystic thymic lesions, and other miscellaneous cysts. neuroenteric cysts may develop by abnormal septation of the embryogenic germ cell layer, which closely associate with the vertebral column. in addition, mesothelial cysts, including pericardial and pleural cysts, and thymic cysts also occur in the mediastinum, as well as other rare cysts. imaging findings: characteristic location and internal architecture of different mediastinal cystic lesions are used to aid the clinician in formulating a diagnostic plan. plain chest radiographs can identify mediastinal cysts in a large proportion of cases. ct usually reveals well-circumscribed rounded masses of water density or a little higher and is useful in delineating the size, shape, and extent of the mediastinal masses. characteristic fluid signal on mri performed in selected patients differentiates the benign cystic lesion from solid mediastinal masses. mri has therefore succeeded in providing valuable pre-operative specific diagnostic confirmation in regard to mediastinal cysts in selected cases. in this pictorial review, we review the radiological appearances on plain radiographs and cross-sectional imaging for the entire spectrum of cystic lesions of the mediastinum. non-infectious radiographic manifestations of bone marrow transplantation: a pictorial review d. beckett, j. oliff; birmingham/uk learning objectives: to illustrate the radiological manifestations following stem cell transplantation for haematological malignancy. to outline the incidence, clinical presentation and role of imaging within this patient sub-group. background: bone marrow transplantation (bmt) is a critical therapeutic intervention for a variety of pathological conditions. the complications of bmt include chemotherapy and radiation toxicity, graft versus host disease, recurrent malignancy and miscellaneous conditions. complications of allogenic bmt manifest in a variety of clinical settings affecting all organ systems. plain radiography, contrast enhanced studies, sonography, ct, mri and interventional techniques are essential in diagnosing these complications and evaluating their response to therapy. imaging findings: pulmonary manifestations include drug and radiation toxicity, bronchiolitis obliterans, bronchiolitis obliterans organizing pneumonia, lymphocytic interstitial pneumonitis and diffuse alveolar haemorrhage. gastrointestinal presentation with veno-occlusive disease, typhlitis and pneumatosis intestinalis are also reviewed, as are central nervous, musculoskeletal and cardiovascular system manifestations. the spectrum of imaging findings following bmt is diverse. a firm understanding of the clinical presentations and incidence in combination with typical radiological findings is essential in the successful management of this patient sub-group. thoracic manifestations of chronic renal failure a.m. barnacle, p.g. gishen, s.j. copley; london/uk learning objectives: to review the radiological spectrum of thoracic manifestations of chronic renal failure, including the more unusual imaging appearances. background: the effects of chronic uraemia are evident in a multitude of organ systems, including the pulmonary, cardiovascular and musculoskeletal systems. imaging findings: the poster illustrates common thoracic manifestations such as pulmonary oedema and uraemic pericarditis. more unusual manifestations of chronic renal failure such as metastatic pulmonary calcification, renal osteodystrophy, amyloidosis and peritoneal dialysis fluid collection within the mediastinum are highlighted. plain radiographic and ct imaging findings of both these common and more unusual pulmonary manifestations are reviewed. the study illustrates the diversity of thoracic manifestations encountered in chronic renal failure patients and the less well recognised sequelae that should not be overlooked when imaging such patients. background: while the availability of bone marrow transplantation is improving and increasing numbers of adults and children are undergoing the procedure for the treatment of a wide variety of malignant tumours and haematological disorders, it remains a procedure which carries with it a very significant complication risk. despite prophylactic therapy, patients remain at particularly high risk for bacterial, viral and fungal infection in the post-procedure time period. infectious complications are diagnosed and monitored using plain radiography, ultrasound, ct, mri, image-guided biopsy and less often, nuclear medicine. other commonly encountered complications requiring radiological investigation include hepatobiliary complications, veno-occlusive complications and graft-versus-host disease. imaging findings: this educational exhibit demonstrates the radiological appearances of the spectrum of common and unusual complications encountered by patients who have undergone bone marrow transplantation, as depicted using a wide variety of imaging modalities. conclusion: while bone marrow transplantation is a life saving procedure it still retains a high degree of morbidity and unfortunately a wide range of complications can arise following the procedure. the role of the radiologist in using a number of imaging modalities to accurately diagnose and follow these complications remains an important one. air-space pattern lung metastasis l. herraiz, a. cima fernandez, s. dieguez, m. grande, m. sanchez nistal; madrid/es learning objectives: to identify and describe the imaging findings on air-space pattern in lung metastasis. background: lepidic pattern growth in lung metastasis is an uncommon manifestation of disseminated malignancies, mainly described in gastrointestinal adenocarcinomas. on ct, differentiation from other lung diseases as multifocal pneumonia, bronchiolitis obliterans organizing pneumonia (boop) and brochioloalveolar carcinoma (bac) may be difficult, and diagnosis of bac cannot be made with confidence if a primitive extrapulmonay adenocarcinoma has not been ruled out. imaging findings: we reviewed x-ray films and ct studies of 8 patients with proven air-space pattern lung metastasis. metastasis was classified as air-space disease when it showed one or more of the following ct findings: air-space nodules, including cavitating and pseudocavitating nodules; parenchymal consolidation containing air bronchogram and focal or diffuse ground-glass opacities. the primary tumors were colorectal adenocarcinoma in 5 patients; pancreatic adenocarcinoma in 1; adenocarcinoma of the ampulla of vater in 1 and infiltrating duct breast carcinoma in 1. in 1 patient the diagnosis of pulmonary disease preceded the discovery of primary malignancy and was synchronous in 2 other patients. cavitating nodules were seen in 5 patients; parenchymal consolidation in 3; ground-glass opacities were seen in 3; pseudocavitated nodules in other 3 patients; solid nodules in 3; nodules with air bronchogram in two; mass with air bronchogram in 2 and lymphangitic carcinomatosis in 1 patient. conclusions: air-space pattern is an uncommon manifestation of lung metastasis. differentiation from boop, multifocal pneumonia and bronchioloalveolar carcinoma can be difficult because this can be the onset of the disease. imaging of chest wall disorders j. lee, k.-n. lee, s. kim, j. lee, m. roh; busan/kr purpose: to illustrate the radiologic features of a wide spectrum of chest wall disorders according to anatomic location. we have retrospectively reviewed the radiologic findings of patients with chest wall lesions pathologically proven by biopsy or surgery between january 1999 and july 2003. we excluded cases of pleural effusion or thickening, chest wall invasion by lung cancer or mediastinal malignant tumor, and secondary metastatic lesions. all patients had plain films and spiral ct scan with intravenous contrast enhancement. several patients underwent supplementary mr with gadolinium enhancement. results: pleural lesions include empyema, tuberculous empyema, empyema neccessitatis, localized fibrous tumor of pleura, malignant mesenchymal cell tu-mor, malignant mesothelioma, pleuroblastoma, fibrosarcoma, angiosarcoma and asbestos-related pleural plaques. muscle and subcutaneous fat are involved in poland's syndrome, inflammation, abscess, tuberculous abscess, empyema neccessitatis, post-operative hematoma, epidermal cyst, intramuscular hemangioma, elastofibroma dorsi, pectoralis muscle fibromatosis, neurofibromatosis, malignant schwannoma, muscle involving nhl, subcutaneous t-cell lymphoma and extraskeletal ewing's sarcoma. rib lesions include chronic inflammation, osteochondroma, enchondroma, eosinophilic granuloma, and plasmacytoma. sternal lesions include chronic inflammation and pigeon breast. a case of chondrosarcoma of the t7 vertebral body is also included. a wide of spectrum of disease processes affect the chest wall. the ct and mr imaging has enabled precise localization and differential diagnosis of chest wall lesions. therefore, familiarity with these radiologic features will make accurate diagnosis possible and and allow for optimal patient treatment. standardized in all patients 120 ml contrast-agent was injected with a flow-rate of 3.5 ml/sec, scan delay was 25 sec. results: in 231 (69%) of 335 patients chest injuries were detected. the following posttraumatic thoracic injuries were revealed: in 97 patients (42%) emphysema, in 23 (10%) hematoma of chest wall; in 50 patients (21.6%) fracture of the thoracic spine, 177 (76.7%) fractures of the ribs, 29 (12.6%) of clavicle, 15 (6.5%) of sternum, 26 (11.3%) of scapula; 127 (55%) patients had a pneumothorax, 68 (29.4%) a hematothorax, 2 (0.9%) a tension pneumothorax; 93 patients (40.3%) had a lung contusion, 12 (5.2%) a lung laceration; 23 patients (10%) had a pneumomediastinum; 4 (1.7%) a rupture of thoracic aorta; 1 (0.5%) rupture of a supraaortal ar tery and 4 (1.7%) a rupture of diaphragm. no injuries of tracheobronchial system, esophagus or the heart were detected. conclusion: a standardized msct examination protocol represents the preferred screening method in the evaluation of patients who have sustained chest trauma. purpose:to find out important ct findings for the prediction of prognosis of thymoma with a survival analysis. materials and methods: 45 patients with thymoma, who underwent surgical resection, were retrospectively analyzed. clinical data were collected from chart review. preoperative plain and contrast enhanced ct was performed in all patients. two independent chest radiologists evaluated ct images paying special attention to diameter, contour, shape, cystic or necrotic portion, calcification, mediastinal fat obliteration, invasion of adjacent mediastinal structure, thickening of adjacent pleura, infiltration of adjacent lung, infiltration of adjacent chest wall, pleural effusion, pericardial effusion, mediastinal lymphadenopathy, enhancement pattern, and degree of enhancement. kaplan-meier survival curves were generated. influence on survival for each ct finding was analyzed by logrank test. results: cystic or necrotic portion, calcification, mediastinal fat obliteration, invasion of adjacent mediastinal structure, thickening of adjacent pleura, infiltration of adjacent lung, infiltration of adjacent chest wall, pleural effusion, pericardial effusion, mediastinal lymphadenopathy, homogeneous enhancement pattern and high degree of enhancement were seen in 40%, 43%, 71%, 39%, 12%, 6%, 10%, 6%, 6%, 2%, 70% and 56% of patients respectively. the ct finding that were most predictive of survival was calcification (logrank test: p = 0.001). cystic or necrotic portion (p = 0.01), infiltration of adjacent chest wall (p = 0.001), and pleural effusion (p = 0.003) were independent predictors of long-term survival. there were no differences in survival for the other findings. conclusion: calcification, cystic or necrotic portion, infiltration of adjacent chest wall, or pleural effusion on ct suggest poor prognosis of thymoma. 416 b d e f a g low attenuation splenic lesions found at chest ct: differential diagnosis and investigation a.k. choudhary, e.l. senior, n.j. screaton; cambridge/uk learning objectives: 1. to illustrate the causes of low attenuation splenic lesions. 2. to discuss clinical and imaging features which aid diagnosis in patients with known or suspected malignancy. background: abnormalities of the spleen are commonly encountered during ct of the thorax and abdomen in patients with suspected thoracic disease, posing diagnostic difficulty particularly in patients with otherwise operable malignancy. we present a pictorial review of low attenuation splenic lesions in patients with suspected thoracic disease. the most common causes are benign (including pseudocysts caused by trauma, infection or infarction), infections (mycobacterial, fungal, hydatid), sarcoidosis, haemangiomata, and lymphangiomatosis. malignant causes include lymphoma and metastases (lung, breast, melanoma, stomach, liver, colon). in patients with known malignancy, splenic metastases are rare in the absence of widespread metastatic disease. although the morphological pattern on ct may suggest malignancy (multiplicity of lesions, irregular margins, enhancement and splenomegaly), other imaging studies may be complementary. on ultrasound focal anechoic lesions are typical of benign cysts while multifocal or diffuse solid lesions are suggestive of malignancy. on mri heterogeneous lesion signal is suggestive of malignancy. in cases where morphological imaging is non-specific, fdg-pet may play an important role. the accuracy of splenic biopsy in indeterminate lesions approaches 90% but significant complications occur in 10.3%. conclusion: isolated low attenuation splenic lesions must not be considered synonymous with metastases even in patients with known cancer. awareness of the differential diagnosis and further imaging permit accurate diagnosis and management. evaluation . whole-body msct scan were performed using the following protocol: 1) native head and neck: 5 mm slice thickness, um mode, reconstruction 2.5 mm; 2) administration of 50-120 ml nonionic contrast media using automatic injector at flow rate of 4 ml/sec and smart prep feature; 3) thorax, abdomen and pelvis scan: 3.75 mm slice thickness, us mode, reconstruction 1.8 mm; 4) scan time under 1 minute; 5) images were used for mpr and 3d-vr. results: in management of polytrauma patients, time is of the essence. in 75 high-risk patients who were selected for msct examination following injuries were found: 12 cranial (sub and epidural hematoma, contusion, fracture etc); 63 thoracic (hematothorax, lung contusion, pneumothorax etc); 40 abdominal (contusion and hematoma of parenchymal organ, retroperitoneal bleeding); 34 aortic (rupture, dissection, periaortal hematoma); 68 fractures (mostly ribs -17 [22%] and pelvis -14 [18%]) conclusion: in our hospital msct represents the major diagnostic tool in the management of high-risk polytrauma patients, reducing time spent outside of emergency unit. it is a fast and reliable method for diagnosis of skeletal trauma, parenchymal organs and aortic injuries. the radiologist becomes important member of the trauma team in management of acute polytrauma patients. learning objectives: to illustrate the fundamentals of digital imaging, the basic operations of image display and manipulation, the principles of image compression and filtering. backgound: radiological scanners generate digital images and image interpretation is performed using dedicated workstations. the knowledge of digital imaging, image compression and filtering is crucial to understand the new technologies and the post processing operations. procedure details: the structure of a digital image, the encoding algorithm, the operations for image display and manipulation, and the compression algorithms are described. a phantom and clinical cases are used to show the influence of these aspects on the quality and information of the images. conclusion: several aspects affect the information and the quality of digital images. the basic criteria for assessing image quality are defined. web-based radiology-teaching library for board examination of radiologists with object-oriented database system n. we have developed a web-based radiology-teaching library for a board examination of radiologists in japan. this library receives imaging cases from all of japan via the internet. the web-based radiology-teaching library is developed with an object-oriented database, and it is readily available with a simple operation to radiologists. the submission process makes full use of the internet. the reviewers, who are expert radiologists, carefully review the submitted cases. when the reviewed case is sent back to the submitter with the reviewers' comments, the submitter should correct their text and images according to the reviewers' comments in order to obtain the reviewers' approval. the computer assists these processes automatically, and it enables submitters and reviewers to do collaborative work in registering cases without temporal or spatial restriction. finally, approved cases can be registered to our library. results: up to august 2003, our radiology-teaching library has collected 1264 imaging cases in all subspecialties. in these cases, 616 cases have been registered. in august 2002, the board examination of radiologists in japan has been performed with selected cases from this library in all subspecialties. conclusion: our library is readily available to radiologists who do not have much computer knowledge. our web-based radiology-teaching library will be useful for the education of all radiologists. pacs: ergonomic considerations c.l. arnoldus, c.j. zylak, m. flynn; detroit, mi/us learning objectives: ergonomic issues associated with picture archivial and communication systems (pacs) should be addressed during the early phase of incorporation in the radiology department. this reviews how a large tertiary care teaching hospital addressed these issues. background: existing computer and alternator workstations in the radiology department were observed for six months. the radiologists were surveyed on workstation issues related to space, noise, lighting, and repetitive motion. a pacs ergonomic work group consisting of radiologists, physicists, and administrators accepted the task of addressing these issues and recommending solutions. procedure details: on non-ergonomic workstations, repetitive strain occurred. of the forty-one radiologists on staff, four who used computer workstations extensively had elbow and shoulder tendinitis from extended periods of reach while manipulating images with the mouse. carpal tunnel symptoms, neck strain from periods of flexion or extension, and eye fatigue were also experienced. alternators placed near monitors reflected light and ghost images on monitor screens. eye level evaluation of films was not possible with fixed monitor height. crowded workstations and alternators were observed. based on the findings, adjustable workstations with articulating keyboards, mousing surfaces with gel wrist rests, flat screen liquid crystal display (lcd) monitors, and multi-adjustable posture support chairs were evaluated. placement of view boxes and ambient lighting issues were addressed. adjustable height workstations for small group consultation and conferencing will be strategically located. voice amplification is being considered. conclusion: ergonomic issues should be identified early before pacs transition to allow a workplace design to maximize workflow and minimize repetitive strain. withdrawn by authors in any single patient we use the same position during each scan to get proper images coregistration. during body scans patients were instructed to breath freely, but not deeply, and not to move. we used a dedicated system for image fusion that combines volumetric information from pet, ct and mri to get proper coregistration in all cases. conclusion: metabolic and anatomical information can be combined precisely to asses anatomic locations of lesions and artifacts with proper coregistration obtained with separate scanners using dedicated software. background: current limitations with regard to medical image quality control and consistency have been discussed previously. we have recently suggested proposals to several american industrial and scientific bodies aimed to improve image quality performance criteria for both clinical and diagnostic images. although some regional and national guidelines and regulations exist, practical universal standards have not yet been achieved. procedure details: this exhibit shows how international radiology and technical societies, regulatory groups, and standards agencies may collaborate in order to improve medical image quality performance and standards, including but not limited to (1) performance criteria for softcopy and hardcopy, (2) extending communication and control standards for the performance of output devices, and (3) initiation and support for research into the relationship between display physical metrics and diagnostic performance, to assess clinical consequences of variations in image quality metrics, and to define what constitutes image quality from a diagnostic perspective. the exhibit has presented some initial steps that will improve the consistency and reproducibility of medical images in electronic imaging systems. the international medical community has an opportunity to build upon the work of many regional and national efforts in a collaborative effort to improve medical image quality with anticipated benefits to patient care, medical practitioners, and the medical industry. 418 b d e f a g modeling and simulation of the blood flow using multi-slice ct: application of computational fluid dynamics s. yamamoto 1 , s. hamada 1 , t. johkoh 1 , s. murai 1 , s. yoneyama 2 , s. maruyama 1 , n. tomiyama 1 , m. komizu 1 , h. nakamura 1 ; 1 osaka/jp, 2 tokyo/jp learning objectives: to understand the prediction based medicine model using computer fluid dynamics (cfd). to support the informed consent of the patient using four-dimensional display. to describe the technical procedure of ct scanning for blood flow analysis. background: aortic aneurysms or dissecting aneurysms are serious and lifethreatening conditions that requires early diagnosis and prompt surgical treatment. it is difficult to directly measure the blood flow and pressure without invasive examination. computer simulation is one of the solutions for non-invasive diagnosis, or for comparison of pre-and post-operative measurement of the blood flow and pressure. in this exhibit we will describe the application of cfd based on four-dimensional vessel reconstructions from multi-slice ct data. procedure details: the volume data (0.5-2 mm slice thickness) was acquired from half-second multi-slice ct (aquilion, toshiba, tokyo, japan). segmented vessels were converted surface display by marchine cubes method. input parameters of blood were applied as an ideal incompressible fluid. steady and transient analysis of cfd was performed using commercially available software (acusolve, acusim software, mountain view, ca) by a finite element method. original program modules for image processing of both vector and medical (di-com) data was implemented on a commercially available workstation (amira 3.0, tgs, san diego, ca). variable dynamic display of both steam line of blood and blood pressure was superimposed on the three-dimensional ct data (multi planer reformat, maximum intensity projection and volume rendering etc) conclusion: modeling and simulation applications to the blood flow could enable us to build rapid prototypes of the models for quick visual validations. using remote asp and internet-2 for integrating digital radiological images with a regionalinformation system in a new population-based purchasing system for public healthcare provision o. barbero 1 , j. guanyabens 1 , c. rúbies 1 , j. fernández 1 , j. maideu 2 , i. cerdà 2 ; 1 sabadell/es, 2 vic/es to learn about the improvements in health care management due to the implementation of several integrated his/ris and pacs in a regional area.to learn how new technologies like java, internet 2, asp and remote image archival can be used to improve health care management and provision. background: a pilot project to evaluate the possibilities of digital radiology in the improvement of health care is underway within the framework of the catalan health service's strategic plan to establish a system in the county of osona(*), not far from barcelona (spain). the sharing of information forms the backbone of the project, the aim being to enable all authorized healthcare personnel to have 24-hour-a-day access to all digital information and images from examinations performed in all healthcare centers in the county, whether private or public. procedure details: for the evaluation and analysis: 1. improvements brought about in healthcare services; 2. organizational impact; 3. cost-benefit analysis; 4. elements to take into account for the system's implementation and extension. from the technological point of view: 1. remote asp archive; 2. high-speed internet-2 links; 3. information systems integration based on web, java, xml and dicom. the analysis and evaluation of the results of this innovative project and health care provision strategy will be presented in ecr. (*) the health care ministry will pay a fixed amount of money per person and per year to all the health care providers of the area in exchange for public health care services. a new parameter enhancing breast cancer detection in computer aided diagnosis of x-ray mammograms k. murase 1 , n. tanki 1 , m. iinuma 1 , h. kubota 1 , m. nagao 2 ; 1 osaka/jp, 2 matsuyama/jp purpose: to introduce a new parameter enhancing breast cancer detection in computer aided diagnosis (cad) of x-ray mammograms. we used the database of mammograms generated by japan society of radiological technology. this includes 17 patients with benign masses and 17 patients with malignant masses. the age ranged from 33 to 71 years (56.9 ± 11.0 years). the new parameter called 3-dimensional fractal dimension (3d-fd) was obtained from the slope of the graph with the logarithm of the cutoff value on the horizontal axis and that of the number of pixels with a gray level above the cutoff value on the vertical axis. in addition to 3d-fd, the conventional image features such as eccentricity (e) and curvature (c) were extracted. the conventional fractal dimension (c-fd) was also calculated using the boxcounting method. the artificial neural networks were used as a classification algorithm, and a receiver operating characteristic (roc) curve and the area under the roc curve (az) were calculated to evaluate the diagnostic accuracy in the task of differentiating between benign and malignant masses. results: when using e, c, c-fd and age as inputs, the az value was 0.87 ± 0.07. on the other hand, when 3d-fd was added to inputs in addition to the above parameters, the az value was significantly improved to be 0.93 ± 0.09. the 3d-fd is a new parameter which can enhance breast cancer detection in cad of mammograms, because it is effective for discriminating between benign and malignant masses. web computed radiography: a solution for x-ray examinations in africa d. soft tissue tumor distributed decision support system m. robles, l. marti-bonmati, j. garcía-gómez, c. vidal; valencia/es purpose: to provide distributed decision support services in soft tissue tumor (stt) to assist the radiologist. previous studies have shown the capability of pattern recognition techniques to classify between benign/malignant character and different histological groups. methods and materials: radiologist access to the stt distributed decision support services is achieved using a graphical interface, with four windows that offers the main system functionalities areas: 1. access to local or distributed stt registers that contain the features to study. new data can be imported from microsoft access formatted files or other databases. 2. statistical analysis that provides the graphical representation and reports of statistical and evaluation information like probability distributions per class, correlation studies, roc curves. 3. graphical representation of stt registers provides graphical representation of stt features from the protocol, using pca-transformation, or feature selection. 4. automatic classification access to stt classifiers distributed web-services, developed with pattern recognition technology. results: a location independent and multi-platform system has been developed to provided decision support services for radiologists dealing with stt diagnosis. the system architecture considers the access from hospitals using local or distributed data and connections to clinical decision support servers. the nodes maintenance and upgrade are automatically controlled by the architecture. conclusion: this system helps radiologists with novel and powerful methods in stt diagnosis and characterization. it provides access to distributed data, statistical analysis, graphical representation and pattern recognition classification. grid technology will incorporate more facility, security and powered communications to the stt distributed decision support services. integration of broadband teleradiology into picture archiving and communication system (pacs) y. zhao, k. chen, z. yao, d. wu, z. pan, b. guo; shanghai/cn purpose: the availability of broadband wide-area networks (wans) facilitates a range of new applications in healthcare. teleradiology is increasingly integrated into picture archiving and communication system (pacs). this paper introduces a broadband telemedicine system for transmitting interactive audio and video signals, and high-quality medical images directly acquired from a hospital-wide pacs. methods: a high-performance telemedicine system was developed over the existing metropolitan broadband multimedia network in shanghai to exploit the possibilities offered by internet protocol (ip) over synchronous digital hierarchy (sdh) technology to support real-time tele-consultation for medical imaging. a trial session was held with two channels of fiber-optic connection transmitting real-time duplex audio/video signals and high-quality dicom images between rui jin hospital and shanghai international convention center, 10 kilometers apart. the system enabled direct retrieval of dicom images from the pacs, and allowed to use interactive telediagnosis tools for image visualization and processing. results: during the teleradiology session, dicom images archived at the pacs were readily accessed without any loss of information. a number of functionalities of visualization software were utilized and tested, combined with real-time videoconference session. the system was proven robust, efficient and providing for high performance. conclusion: the broadband telemedicine system under study has given us a useful insight about the potential of applying broadband technology in healthcare, especially the performance of videoconferences with telediagnosis of radiological images. with the close integration of teleradiology into a hospital-wide pacs, it yields sufficient sound and image quality for remote educational and clinical collaboration. performance assessment of a wavelet contrast enhancement method in dense parenchyma based on simulated lesions s. skiadopoulos, l. costaridou, p. sakellaropoulos, c. kalogeropoulou, e. likaki, g. panayiotakis; patras/gr purpose: evaluation of an adaptive wavelet-based contrast enhancement method in dense parenchyma based on simulated radiopaque lesions. methods and materials: sixty normal mammographic images of dense breasts were selected from the ddsm database. simulated radiopaque lesions of known image characteristics, such as low contrast (0.8%-5%) and unsharp contour (0%-80%), were generated and superimposed in dense breast areas. this resulted in a case sample that is difficult to achieve and verify with real lesions. all images with simulated lesions were processed by the wavelet-based method. evaluation was carried out by an observer performance comparative study between the wavelet-processed images and original ones. the sample was presented to three experienced radiologists, classifying each simulated lesion with respect to contour type, using a five-point rating scale. a binormal roc curve was individually fitted to the scores of each observer with a maximum-likelihood procedure and the area under the roc curve (a z ) as well as the 95% confidence interval were calculated, for each technique. results: combining observers' responses, the a z values are 0.930 and 0.813 and their corresponding confidence intervals are (0.882, 0.961) and (0.743, 0870) for wavelet method and original one, respectively. this difference in a z values is statistically significant (students' t-test, p < 0.05), indicating the effectiveness of the wavelet method. conclusion: improved contour characterization of low contrast simulated lesions sample is achieved with the use of the wavelet-based contrast enhancement method. use of simulated lesions sample servers for verification purposes, required to assess the performance of various digital image post-processing techniques. estimating the arterial compliance in early stages of atherosclerosis: evaluation of a new index on the curve-fitted doppler sonograms n. erdogan, s. kara, f. dirgenali, m. okandan; kayseri/tr purpose: to develop a computational method to define a new index to estimate the arterial compliance in early stages of atherosclerosis. the doppler data was obtained from a nonstenotic arterial site (carotid artery) in patients with femoropopliteal atherosclerosis (n = 10) and healthy volunteers (n = 8) using the audio output of a commercial color doppler ultrasound unit. the signals were transferred to a personal computer and two dimensional sonograms were plotted by fast fourier transformation. smoothing and curve-fitting operation is performed on the sonograms. a moving average method was used for smoothing and interpolant-cubic spline was processed to make curve-fitting. the time interval between the first transmitted peak (t 1 ) and the second compliance peak (t 2 ) in the arterial waveform was evaluated as a new index. our preliminary data showed no significant difference between healthy subjects and the patients with regard to the acceleration, resistivity and pulsatility indices, although a significant difference exists for the new index (11.0 ± 1.9 msec for patients vs. 33.0 ± 2.5 msec for healthy people). the proposed new index on the the curve-fitted fast fourier transformation sonograms seems to be promising in assessing the cardiovascular risk by detecting the degree of compliance in atherosclerotic vessel walls before the overt clinical symptoms develop. however, its efficacy and prognostic implications need to be confirmed by large scale studies. the contribution of virtual endoscopy (ve), in the imaging of the upper airways and tracheobronchial tree a. morichovitou, a. manolitsas, s. stratilati, i. tsitouridis; thessaloniki/gr purpose: the purpose of our study is to demonstrate the contribution of virtual endoscopy in the imaging of the upper airways and tracheobronchial tree. we studied 43 cases, (26 male and 17 female, aged 32 to 71 years old, mean 51 yrs), with tracheobronchial diseases. the virtual endoscopy images were compared with those of actual endoscopy in 13 patients. the examinations were performed using a picker pq5000 spiral ct scanner and a picker voxel q visualization workstation. thickness: 3 mm, pitch: 1.5, overlap: 66% (1 mm). results: ct virtual endoscopy depicted the anatomical structure of nasopharynx, larynx, trachea, and main bronchi in all patients as the actual endoscopy. the results show that virtual endoscopy can study the tracheobronchial tree as far as the segmental bronchi, and sometimes the subsegmental bronchi (in 6 patients). in addition, it can evaluate the extraluminal location of the lesions. 39 lesions in 36 patients were shown by virtual endoscopy (12 occlusions, 21 stenosis, 6 compressions) and in 7 patients the examinations were negative. the findings were always in agreement with those of the actual endoscopy and surgical findings. we studied the results of the two methods and describe the advantages and disadvantages of each of them. conclusion: virtual endoscopy can be used in the primary evaluation of the patient before actual endoscopy is performed. it can be used for preparing, guiding and controlling actual endoscopy or in the postoperative follow-up when immediate biopsy is not necessary. pancreatic duct imaging using the curved thin-slab minimum intensity projection method t. ogura 1 , t. ikari 2 , t. tachikawa 2 , a. kamei 2 , k. takano 2 , s. asahara 2 , n. fujita 2 , m. shimizu 2 ; 1 maebashi/jp, 2 tokyo/jp purpose: the recent wide use of curved mpr was applied for pancreatic duct imaging, but curved mpr requires a great deal of skill for the trace of narrowed and tortuous pancreatic duct. mis-tracing on pancreatic duct has led to various artificial images such as false pancreatic stenosis. so novel curved thin-slab minimum intensity projection methods have been employed to obtain correct pancreatic duct image. the purpose of this study is to explain the protocol, reconstruction method, and describe the potential advantages and various problems of this method in the diagnosis of pancreatic diseases. materials and methods: pancreatic duct image was reconstructed from three dimensional volume data using multidetector-row ct (qx/i, gems) scans. axial images were taken with 1.25-mm collimation, a table speed of 3.75 mm/rot and 0.5 mm image reconstruction intervals. image processing was performed with the virtual place (m.i.lab). results: this method was successful in depicting a wide range of tortuous pancreatic ducts. also the narrowed pancreatic duct is easily visualized, and even branch ducts. the characteristic of this method is that we can easily make a pancreatic duct image quickly and with little dependence on expert technique. in abdominal studies, this method enabled the visualization of the narrow, bending pancreatic duct, reducing false pancreatic stenosis, and also could be applied for screening examination for anomalous union of pancreaticbiliary ductal system in the future. evaluation of the optimal scanning protocol for ct virtual endoscopy using a 16-slice scanner w. wojciechowski 1 , w. de wever 2 , a. urbanik 1 , g. marchal 2 , r. chrzan 1 , j. kozub 1 ; 1 krakow/pl, 2 leuven/be purpose: the objective of this study was evaluation of optimal scanning protocol for ct virtual endoscopy using a 16-slice scanner in a phantom study. methods and materials: using the mdct scanner somatom sensation16 (siemens, germany), ct-images of a phantom were performed, with diferent combinations of slice-thickness (0.75, 1, 2, 3, 5 mm), pitch (0.5, 1, 1.5), slice-collimation (16 x 0.75 and 16 x 1.5) and reconstruction increment (50% and 100%). the phantom consists of simulated round lesions of different size (diameter between 1 and 10 mm) placed into a thin-walled plastic tube of 6-cm diameter. quantitative analysis was assessed by evaluation of changes in size and shape of the lesions and calculation of sensitivities. qualitative analysis was perfomed by evaluation of lesion's blurring of stairstep artifacts and rippling artifacts. results: overall sensitivity was 100% with slice thickness 0.75, 1 and 2 mm and not dependent on pitch. the smallest lesions (diameter 1 mm) were not detected with slice-thickness of 3 and 5 mm. image quality of endoluminal images was graded as optimal for slice-thickness 0.75 mm and 1 mm. there was no statistical significant difference in quality using a different pitch in these images. however mild rippling artifacts were documented together with an increase in pitch value. conclusion: slice-collimation and slice-thickness are the most important parameters in selection of on optimal scan-protocol for ve: slice-collimation of 16 x 0.75 and slice-thickness of 1 mm seem to be optimal. pitch and increment are less important, although values of 1 and 50% seem to be optimal. selection of optimal parameters is also depended on lesion size. automatic methods and materials: fully automatic and manual methods were developed and compared using in vivo studies. this tool allowed automatic determination of a region of interest (roi) with background correction. by means of this technique, a roi was set, corrections performed and calculation of different parameters (flow, stroke volume and velocity) and flow curves made. this tool was designed using matlab 6.5 (mathwork, inc, natick, usa) with a friendly graphical user interface. comparisons were performed by means of intraclass correlations (icc). this model was validated in 20 patients, 11 men and 9 women, age range: 45-79 years-old. mr examinations were performed on a 1.5-t system (gyroscan nt intera, the netherlands) with a phase contrast sequence. image parameters were as follow 256 x 512 matrix; fov, 160 mm; 3 mm slice thickness; tr 53 msec, te 11, 2 excitations, flip angle 15° and 20 cardiac phases with use of peripheral retrospective gating. the automatic method performed significantly better than the manual analysis, icc of 0.72-0.98 and 0.30-0.81, respectively. at the same time partial volume effect caused by inclusion of stationary tissue was corrected. conclusion: automatic setting of roi flow measurements at the cerebral aqueduct is feasible with an adequate reproducibility. it makes the measurements independent of the radiologist, generalizing the calculus of flow parameters. virtual duodenoscopy on the basis of high-resolution mrcp data for the simulation of ercp procedures t. yamagishi 1 , k.h. höhne 2 , k. abe 1 ; 1 tokyo/jp, 2 hamburg/de purpose: ercp has been regarded as one of the most difficult endoscopic procedures for a trainee because of a high possibility of technical failures. therefore, it is considered useful to prepare a rehearsal of ercp. we present a virtual duodenoscopy for practical ercp simulation. the hr-mrcp data sets are imported into the voxel-man program (institute of medical informatics, university hospital hamburg-eppendorf, germany). an interpolated movie of the duodenal inner surface is computed by tracing where the endoscopic tip goes through to the duodenal papilla following the actual ercp procedure. three orthogonal radiological planes of the source mrcp are integrated into the movies, which are showing the conic extent of the endoscopic viewing field. the usefulness of making a prior simulation for a successful ercp was evaluated. the post-processed endoscopic view is precise and realistic enough to execute a practical simulation of ercp, following the actual procedures step by step, e.g., which angle and position of the endoscopic tip is best for the cannula insertion into the common bile duct. the movie created can indicate an ideal approach to the duodenal orifice in exactly the same way performed by ercp experts. the radiological planes are useful as external images like x-ray fluoroscopy. a practical simulation of ercp can be performed by a combination of hr-mrcp data and the voxel-man interactive visualization program. the presented method can provide useful information prior to actual ercp. to review the physics of the interaction between the us beam, the "bubble" and the corresponding us image of the liver and portal system. to estimate the degree of portal hypertension through better visualization of collateral pathways using usca. background: a short historical review of the evolution of usca is followed by a detailed presentation of the physics and technology of recent usca. the interaction between the "bubbles" and the us beam is explained with analytical drawings and real-time us videos. procedure details: the technique and the protocol of the hemodynamic examination of the hepatic veins and the portal system are explained. a detailed anatomical review of the portal venous system is presented with special attention to the main collateral pathways present in cases of portal hypertension. the findings of imaging methods (us, ct, mr) as well as endoscopic methods are presented and their limitations are underlined. new non-invasive hemodynamic us imaging of the main collateral pathways (gastric and esophageal varices, splenorenal, splenogastric, retroperitoneal anastomoses, recanalization of the paraumbilical vein) are described and presented in images and videos after administration of second generation usca. c 421 b d e f a g the benefits as well as the limitations of usca, including those caused by artifacts, are thoroughly discussed so that an unbiased conclusion on new diagnostic possibilities in the study of the portal hypertension can be drawn. clinical impact of liver specific contrast agents in liver imaging a. ba-ssalamah, m. uffmann, s. mehrain, s. schweighofer, w. schima; vienna/at learning objectives: to illustrate the usefulness of liver specific contrast agents in identifying morphological and functional features of focal liver lesions. to educate radiologists about new mr liver specific contrast agents and mr imaging techniques. to demonstrate the value of the combined use of liver specific and non liver specific contrast agents as a problem solving tool. background: liver specific contrast agents used in combination with non-specific gadolinium chelates may serve as a problem solving tool in the diagnosis of focal liver lesions. hepatic focal lesions with atypical imaging appearances usually need further assessment, namely biopsy, particularly in patients with history of malignant disease. liver specific contrast agents offer new opportunities for liver imaging and provide information about the functional and morphological features of focal liver lesion. currently a variety of contrast agents, subdivided in different categories are available for clinical use in mri of the liver. procedure details: in this exhibition, we describe the use of reticuloendothelial system-specific iron oxide particulate agents, hepatocyte-selective agents, nonspecific gadolinum chelates and the combined use of these contrast agents for a large variety of liver diseases.we distinguish between specific imaging characteristics for various liver diseases and nonspecific imaging characteristics that may be found in both malignant and benign focal liver diseases. the combined use of liver specific and non liver specific contrast agents is a valuable tool for the diagnostic work up of special focal liver lesions and may replace the invasive biopsy in the vast majority of cases. doppler rescue: a review of the use of ultrasound microbubble contrast agents in the visualisation of the large vessels k. satchithananda, m.e.k. sellars, s.m. ryan, p.s. sidhu; london/uk learning objectives: understanding of the types of ultrasound contrast agents available and nature of enhancement. understand when these agents could be used to improve diagnostic images and cost effectiveness. an appreciation of the clincial appearances of "doppler rescue" in different areas of vascular imaging. background: ultrasound (us) assessment of the vascular system remains an accurate imaging modality despite the advancement of magnetic resonance angiography. us allows real-time, multi-planar and safe assessment of the vasculature which is convenient to both operator and patient. limitations of us, es-pecially in the vascular system are well documented. full diagnostic doppler assessment is not always possible for a variety of reasons. color doppler assessment greatly improves vascular imaging and recent technical advances have further improved the capabilities of doppler us. a further important development is the introduction of microbubble contrast, which allows previously non-diagnostic studies to become interpretable and avoids further imaging: termed "doppler rescue". image findings: the use of microbubble contrast will be illustrated in the cerebral circulation using trans-cranial us, the extra-cranial carotid system, the liver vasculature, renal artery and the peripheral arterial system. conclusion: both color doppler enhancement and low mechanical index b-mode non-linear imaging will be demonstrated. one learning objectives: initial work-up of trauma patients is time-critical. diagnostic demands require different examination techniques including unenhanced and several contrast enhanced scans for musculoskeletal, angiographic and parenchymal diagnosis. 16-channel mdr-ct overcomes previous technical limitations, which used to require thickening of slices or segmenting for whole body coverage. we therefore developed a multi-phase contrast protocol allowing acquisition of musculoskeletal, angiographic and parenchymal organ information in a single scan. ct technique and contrast protocol, advantages and limitations of this procedure are described and illustrated. procedure details: 12 consecutive trauma patients were examined on a 16channel mdr-ct (philips, mx8000idt). after exclusion of cerebral hemorrhage application of iodine contrast media (400 mg iodine/ml, imeron 400, altana, germany) was started with a bolus of 40 ml at a flow of 2.0 ml/sec, followed by a pause of 40 sec. subsequently, a second 60 ml contrast bolus (3.5 ml/sec) is followed by a saline chaser. the ct-scan is initiated with a delay of 85 sec using a collimation of 16 x 1.5 mm, slice thickness of 2 mm and an increment of 1 mm. results: this protocol provides excellent diagnostic image quality covering all issues of trauma work-up. within a table time of less then 10 minutes all relevant pathologies were assessed as proved by further clinical follow-up. all fractures including two petrosal ones were detected. parenchymal pathology included lacerations of liver, spleen, and kidneys. all arterial and venous hemorrhages were diagnosed without the need of additional diagnostic work-up. intravenous, oral and, rectal contrast media for abdominal spiral ct examinations: when to use, how much, how fast, and when to scan a.n. chalazonitis 1 , j. tzovara 2 ; 1 athens/gr, 2 ioannina/gr leaning objectives: to optimise the choice of contrast media initiation parameters for abdominal single slice spiral ct examinations, tailored to each specific organ and to the most common clinical conditions. background: introduction of multi-slice spiral ct permitted greater flexibility in abdominal examinations. however single slice spiral ct still remains a powerful tool in routine imaging practice. procedure details: the aim of this exhibit is to describe lesion or organ behaviour before and/or after contrast material initiation in order to help the participant to understand why, when and how these agents should be administrated for optimal abdominal single slice spiral ct evaluation. contrast volume, flow rate and scan delay before initiation, are discussed. the influence of patient weight and circulatory parameters such as cardiac output and inflow obstructions on contrast enhancement will be also analysed. special techniques in order to achieve optimum gi opacification will be also discussed. purpose: to compare hepatic signal intensity change using superparamagnetic iron oxide (spio)-enhanced mr imaging with scintigraphy using technetium-99mgalactosyl human serum albmin (99mtc-gsa) and a visual grading score, in patients with hepatic dysfunction. methods and materials: forty-six patients with hepatic dysfunction who underwent spio-enhanced mr imaging and scintigraphy with 99mtc-gsa were examined prospectively. in terms of clinical cirrhosis severity, 46 patients were classified into four group; 16 patients were classified as non-cirrhotic, 18 were classified as group a, 10 as group b, and 2 as group c (child-pugh classification). on mr imaging, t2-fast field echo (t2-ffe) images were obtained before and after the administration of spio. to assess the effect of spio, post contrast relative reduction in signal-to noise ratio (reduction-snr) was calculated. the findings of 99mtc-gsa-scintigraphy were classified into 5 types according to visual grading score. the clinical cirrhosis severity, reduction-snr, and visual grading score were analyzed with nonparametric methods. the clinical cirrhosis severity was positively correlated with visual grading score (spearman rank test, p < .0001). there were significant differences between the clinical cirrhosis severity and the reduction-snr on t2-ffe and between the visual grading score and the reduction-snr (kruskall-wallis test, p < 0.0005, all comparisons). the index of blood clearance (hh15) was positively correlated and the receptor index (lhl15) was negatively correlated with the reduction-snr on t2-ffe (spearman rank test, p < 0.0001, all comparisons). conclusion: to evaluate the reduction-snr on spio-mr imaging is helpful in predicting not only kupffer cell function but also hepatic function as assessed by 99mtc-gsa-scintigraphy. are efficient contrast agents available for use with ultra-high field mr imaging? r.n. muller, p.a. rinck, l. vanderelst, a. roch; mons/be purpose: molecular mr imaging requires specific markers exhibiting high relaxivities at ultra-high fields (3-11 tesla). although there are theories on the design of optimal paramagnetic centers, actual relaxivities are still below expectations. methods and materials: measurements of relaxivites s -1 mm -1 ) to establish nuclear magnetic relaxation dispersion profiles of existing and possible future contrast agents were performed on two field cycling relaxometers and on a 4.7 t mr research machine. results: at high field, r 1 and r 2 of small gadolinium complexes are low and decrease; high-field relaxivities can be increased through reduction of molecular motion. to some extent, it is possible to increase the r 2 of small dysprosium complexes. nmrd profiles of superparamagnetic particles reveal a high r 2 /r 1 ratio at ultra-high fields. however, one particle of 5nm contains around 2,500 iron ions, whereas one macromolecular complex contains one or a few gadolinium ions. assuming equivalent relaxivites, the gd complex should carry approximately 2,500 ions to present, per molecule, the same relaxivity as the magnetic particle which leads to a molecular weight increase of 400,000. conclusion: for small complexes of dy, r 2 can be modestly increased at high fields. both r 1 and r 2 of gd complexes can be enhanced at high fields by an increase of the molecular size, however, only r 2 keeps increasing. superparamagnetic particles seem clearly more efficient. this fact will be of paramount importance in the context of molecular imaging. they will act as negative agents. results: the contrast ratios of rat abdominal aorta and portal vein on the first to fifth contrast imaging were higher for nms60 than those for gd-dtpa with every injection doses. the peak contrast ratios of aorta and portal vein for nms60 were 1.4-1.7 and 1.7-2.2 times as high as those for gd-dtpa. the renal excretion of nms60 was as fast as gd-dtpa. conclusion: nms60 showed stronger contrast enhancement for the rat vascular system, especially the portal vein and provided mr angiograms of higher image quality when compared with gd-dtpa at the same injection dose. 3d-fspgr imaging was performed before and after 5, 15, 30, 60, 120 min. delineation of popliteal lymph node (pln) and lymph duct (ld) (extremity region, iliac, para aorti, thoracic duct) was examined.on the evaluation of ld, visual evaluation ("good visualization": ++, "visualization": +, "poor visualization": ±, "no visualization": -) was carried out. on pln, snr was calculated as follows: snr = si (pln)/sd (noise). results: in gd-dtpa (125, 250, 500), gd-eob (125, 250) and gd-bopta (125, 250, 500), grading of ld from lower extremity region to para-aortic region was "good visualization" or "visualization". in gd-dtpa (50), grade of ld from lower extremity region to para-aortic region was "poor visualization". on the other hand, using gd-eob (50), gd-bopta (50), we could see ld from lower extremity region to iliac region.we found only ld of lower extremity region in gd-dtpa-dea (50, 125).these grades were "good visualization" or "visualization". each concentration besides gd-dtpa (50), contrast enhancement of plns were very well. the pln almost showed peak value after enhancement for most cases (24/26) in five minutes. we saw pln very well after enhancement 30 minutes later, and, at the time of gd-dtpa (500), gd-eob-dtpa (125, 250), gd-bopta (250, 250, 500), gd-dtpa-doa (50, 125), snr value was more than 20. conclusion: using hepatobiliary agents and extracellular agent we were able to do good mr lymphography. optimized iv contrast administration protocols for diagnostic pet/ct imaging t. beyer, g. antoch, s. rosenbaum, l. freudenberg, t. fehlings, j. stattaus; essen/de purpose: we compared different iv-contrast injection protocols for pet/ct-exams (dual-slice) to assess their efficacy in avoiding high-density artifacts on ct and subsequent false positives on corrected pet. methods: four groups of 10 pet/ct-referrals (370 mbq fdg at 90 min pi) each were investigated with/-out iodinated contrast (300 mg/ml) application: (a) without, (b) multi-phase 90/50 ml (3/1.5 ml -1 ) cranio-caudally with 30 s delay, (c) 90/40/40 ml (3/2/1.5 mls -1 ) cranio-caudally with 50 s delay, and (d) 80/60 ml (3/1.5 mls -1 ) caudo-cranially with 50 s delay. ct-based attenuation correction (ac) of the pet was applied routinely. ct image quality (iq) was graded 1 (very good), 2 (good), or 3 (insufficient) by three radiologists. image quality and artifacts were reported for head/neck, thorax, and abdomen. two nuclear medicine physicians reviewed the ac-pet images for potential artifacts from iv-contrast without knowledge of the ct, and reported lesion-to-background (l/b) values for potentially related uptake on pet. all reviewers were blinded to the contrast protocol and patient names. results: average ct iq was poorest (3.0) for protocol a across all regions, but improved to 1.4 (b), 1.0 (c), and 1.1 (d). high-density (> 1200 hu) ct artifacts were introduced only in the upper thorax in 73% (b) and 53% (c) of the patients. mean l/b in corresponding artificial lesions was 1.8 and 2.0, respectively, thus resembling false positives. protocol d resulted in artifact-free images. pet/ct iq increased in the presence of iv-contrast agents. highdensity artifacts from bolus injection may lead to false positives on ac-pet. the artifacts can be avoided by alternative contrast administration protocols (e.g. d). contrast enhanced ultrasound in the evaluation of hepatic metastases treated using radiofrequency ablation: 24 hours, 1 and 3 months follow-up assessment g.a. vorkas, i.a. chryssogonidis, c.a. papadopoulos, e. syndouka, k. lytras, l. grassos; thessaloniki/gr purpose: this study evaluates the importance of periodic follow-ups in the assessment of hepatic metastases treated with radiofrequency ablation (rf) using contrast-enhanced sonography. materials and methods: 36 hepatic metastases in 17 selected patients were included in our study. all lesions were studied with ce-us using real-time, continuous scanning with esaote esatune equipment with the cnti software, enabling non-destructive imaging at low mi, following intravenous bolus administration of 2.4 ml of a second-generation agent (sonovue-bracco). the enhancement patterns of lesions were assessed during the arterial, portal and late phases. the examination was conducted pre-ablation, 24 hours, 1 month and 3 months after thermoablation. purpose: an up-to-date study showed that for high-risk patients the nonionic, dimeric radiographic contrast medium (rcm) iodixanol had less nephrotoxicity than the nonionic, monomeric rcm. the lower incidence of secondary effects is often attributed to the lower osmolality of the dimeric rcm. to compare the effect of dimeric iotrolan to monomeric iohexol and iomeprol independently of their osmolality, we have modelled the vascular activity of the rcm. in an organ bath, isolated segments of porcine renal arteries, uncontracted or precontracted by 10 micromol/l phenylephrine, were incubated with increasing concentrations of iotrolan-300, iohexol-300, iomeprol-150 and mannitol solution iso-osmolal to the rcm. results: expressed in terms of concentration of iodine in the buffer as well as in terms of concentration of the rcm-molecule in the buffer, iotrolan induced a significantly lower relaxation than the monomeric rcm (p < 0.05). there was no significant difference between the two monomeric rcms iohexol-300 and iomeprol-300 (p > 0.05). the iso-osmolal formulation iotrolan-300 induced a smaller relaxation than the iso-osmolal formulation of iomeprol-150 (p < 0.05). precontracted segments were strongly relaxed by all the rcms as compared to mannitol (p < 0.05). iotrolan had no significant effect on the basal tone of the vessel whereas iohexol and iomeprol induced a small relaxation effect. conclusion: independently of its osmolality and dilution effect, dimeric iotrolan causes less relaxation of isolated, precontracted segments of porcine renal arteries than monomeric iohexol and iomeprol. this effect can be attributed to the different biological properties of the monomeric and dimeric rcm-molecules. ultrasound contrast agent in the study of traumatic splenic rupture g. caruso 1 , g. salvaggio 1 , g. bellissima 1 , v. ricotta 1 , g. ascenti 2 , r. lagalla 1 ; 1 palermo/it, 2 messina/it purpose: to evaluate the role of ultrasound contrast agent (uca) in the identification of traumatic splenic lesion. materials and methods: from may to july 2003, 20 consecutive patients were admitted to the emergency department for blunt abdominal trauma. ultrasound examinations were performed with an atl-hdi 5000 machine with a 5-2 mhz convex trasducer capable of fundamental and harmonic imaging. patients were studied before and after uca (2.5 ml of sonovue®). multi-detector computed tomography was used as the gold standard. all examinations were performed within 24 hours. results: ninety seconds after uca administration, homogeneous contrast enhancement of the whole of the splenic parenchyma was observed in 16 patients. in four patients, no contrast enhancement was observed in a subcapsular splenic area: inferior splenic pole (n = 3) and mid-portion of the spleen (n = 1). multidetector ct performed in the portal venous phase confirmed traumatic splenic rupture in four patients, and showed an unremarkable spleen in the remaining 16 patients. conclusion: ultrasound after sonovue administration is useful in showing traumatic splenic rupture. contrast-enhanced, wide-band phase-inversion harmonic power doppler imaging of hepatocellular carcinoma j.r. janica; bialystok/pl purpose: to determine whether examination of hepatocellular carcinoma by wideband, pulse inversion sonography offers excellent accuracy in depiction of specific characteristics of these pathologies. 424 b d e f a g eighteen patients were examined. the presence of hcc was confirmed by ultrasound-guided biopsy or surgical resection. all patients, prior to enhanced sonography, had undergone b-mode gray scale sonography, color doppler, and power doppler examinations. after injection of 2.5 g of levovist intravenously, analysis of contrast agent arrival was performed by wide-band, pulse inversion power doppler sonography. the b-mode gray scale sonography, color and power doppler sonography were non-specific for hcc in 4 cases in our examination. however, based on the wide-band, phase inversion power doppler sonography findings, all patients with hcc were diagnosed. all typical anatomical features of hcc as chaotic appearance with irregular paths, breaks in calibre and arteriovenous shunts were clearly visible. in 2 cases, computed tomography had failed to disclose pathology while pulse inversion sonographic images were completely suggestive, which was later finally confirmed by histologic examination. conclusions: our data demonstrates the usefulness of wide-band, phase inversion power doppler sonography in the diagnosis of hepatocellular carcinoma by visualizing all characteristic anatomical details. characterization of small liver lesions with contrast enhanced harmonic sonography (ceus) in patients with chronic liver disease p. cabassa, r. taranto human comparative study on zinc and copper excretion via urine after administration of magnetic resonance imaging contrast agents j. kimura, t. ishiguchi, j. matsuda, a. nakamura, s. kamei, k. ohno, k. murata; aichi/jp purpose: to evaluate the in vivo kinetic stability of magnetic resonance (mr) imaging contrast agents, excretion of zinc and copper via urine were studied for three gadolinium (gd) chelate complexes. methods and materials: urine samples were taken before, three hours, and six hours after intravenous administration of gd-dtpa-bma, gd-dtpa, and gd-dota at 0.1 mmol/kg to each of five patients who underwent contrast-enhanced mr imaging. five patients who had non-contrast mr imaging were evaluated as controls. urine was assayed for quantitative analysis of zinc and copper using atomic absorption analysis. results: gd-dtpa-bma caused the highest increase in zinc excretion among the three agents, 1795 ± 1273 µg at 3 hours and 985 ± 434 µg at 3 to 6 hours. gd-dota did not cause a significant increase in zinc excretion, 75 ± 39 µg at 3 hours and 78 ± 65 µg at 3 to 6 hours. gd-dtpa caused moderate increase in zinc excretion, 665 ± 240 µg at 3 hours and 378 ± 173 µg at 3 to 6 hours. excretion of copper did not show a significant difference between the three agents. the difference in zinc excretion among the mr contrast agents reflects in vivo transmetallation of the gd chelate complexes and correlates with the respective stability of the contrast agent. gd-dota was found to be the most kinetically inert among the three agents tested. effect of contrast material pushed with saline solution using a dual injector on enhancement of abdominal aorta, portal vein, and liver parenchyma in multidetector row ct of the liver f. tatsugami low-high and high-low biphasic injection forms in ct examinations of the upper abdomen l. martí-bonmatí, e. tobarra, e. arana, s. costa; valencia/es purpose: our objective was to analyze the influence of different biphasic injection rate protocols in abdominal ct. a double-blind, randomized, parallel group study was designed and conducted in 60 patients without differences regarding gender, age and weight. all of them were studied with the same ct helical protocol. patients were randomly distributed into three groups: a) monophasic (120 ml at 2.5 ml/s); b) low-high biphasic (120 ml, the first 60 ml at a rate of 2 ml/s and the other 60 at 2.5 ml/s); and c) high-low biphasic (120 ml, the first 60 ml at a rate of 2.5 ml/s and the other 60 at 2 ml/s). all the patients were injected, through an antebrachial route, with 300 mg i/ml non-ionic contrast media. all ct scans were obtained at the portal phase with a fixed delay time of 55 seconds. contrast enhancement was evaluated by attenuation coefficients measurements at liver, inferior cava and portal veins, renal cortex, superior aorta and aortic bifurcation. results: the biphasic protocols obtained statistically higher enhancement at the aortic bifurcation (anova, p = 0.003). however, there was no other statistically significant difference (anova, p > 0.05) among the three protocols at the different levels. although non-significative, enhancements following monophasic protocol were always higher than those obtained with biphasic protocols, with the exception of aortic bifurcation. conclusion: monophasic injection of contrast agents on helical ct of the upper abdomen gives higher enhancement of parenchymal and venous structures. no significant difference was observed between low-high and high-low biphasic protocols. quantitative analysis showed a statistically significant difference between si of myometrium on plain and sinerem-enhanced mr images assessed by means of t-test. c/n between lesion and normal myometrium significantly increased following sinerem administration. in four patients sinerem-enhanced images provided additional information leading to more accurate t staging. conclusions: intravenous injection of sinerem provides a significant decrease of si of normal myometrium with higher c/n between neoplastic lesion and normal myometrium. sinerem-enhanced mri provides better evaluation of myometrial neoplastic invasion increasing the conspicuity of neoplastic lesions in patients with endometrial and cervical carcinoma. further studies are necessary in order to realize the physiologic mechanism of myometrial uptake of sinerem. purpose: verification of radiological methods with histology has always been difficult due to poor correlation of slice thickness, orientation and confinement to two dimensions. a method for a quantitative three-dimensional reslicing of histological sections is introduced (patent pending epa03008877.7) permitting exact matching of slice geometry. this will enable proper correlation with radiological data. hacatras tumor (mouse) were examined by acquiring dynamic t1-weighted mr images and mr microangiography. the tumors were subsequently serially sectioned (5 ìm slice thickness) and vessels stained with immuno-fluorescence markers. slices were digitally captured with a microscope, assembled in the sectioning plane and co-registered in the vertical axis. a ray-tracing algorithm performed three-dimensional visualization allowing the virtual re-slicing of the histological sections to create thick-slices (1.5 mm) in accordance with mri slice geometry. thick-slices were processed as parameter-maps of marker volume density, giving information beyond the area density signal of immuno-fluorescence images. results: 3d-reconstructions of immuno-fluorescence images displayed diffuse angioarchitecture which is typical for malignant tumors. resliced images revealed the exact architecture of vessel structures seen on mra. also, large single vessels could be clearly delineated on reconstructions. parameter maps of vessel density in virtual thick slices matched well with mr-parameter maps. the quantitative 3d approach to histology essentially improves correlation of histological and radiological data due to proper matching of slice geometry. as this new method can be used with any histological stain, it provides a tool for verification of new molecular imaging techniques by means of histology. monitoring a human fibrosarcoma (ht 1080) was implanted in nude mice and grown up to a size of 5-10 mm. tumor bearing animals were intravenously injected with a vascular targeting agent (vta) inducing selective thrombosis of tumor neovasculature (treatment group) or saline (controls) respectively. mri (1.5 t) was performed using an ultrasmall superparamagnetic iron oxide agent (uspio, shu 555 c, schering®) 4 hours after initiation of treatment. iron oxide-induced change in r2* (∆r2*) was measured using a t2 w dual echo-epi sequence. ∆r2* values of tumor tissue were calibrated by ∆r2* of muscle for determination of the vascular volume fraction (vvf). parametric ∆r2*-maps were calculated for visualization of tumor perfusion patterns. correlative immunhistochemistry was performed for assessment of the treatment effects in both groups. results: ∆r2*-maps revealed a clear reduction of tumor perfusion in treated animals compared to controls. anti-angiogenic tumor treatment resulted in an approximate 80% decrease of iron oxide induced susceptibility effects. vvf was significantly reduced after injection of the thrombogenic peptide ( the in vivo detection of arthritis by autofluorescence using an antigen-induced arthritis (aia) model was investigated. material and methods: for autofluorescence investigations of joints, a mobile fluorescence-detector was designed consisting of a lens/mirror system attached to a conventional spectrofluorometer and of optimized fiber optic cables leading to and from the site of investigation. measurements were performed in 7 arthritic and 7 healthy mice. 15 aia-and 3 healthy mice were used for histological examinations. results: at the exudative stage (day 1) of aia, a decrease of fluorescence signal intensities (arbitrary units, a.u.) for excitation wavelengths of 300 nm (emission at λ = 355 -365 nm; mean signal intensity 11.8 ± 2.0 a.u.) and excitation at 360 nm (emission at λ = 475 -485 nm; mean signal intensity 24.7 ± 3.2 a.u) were observed. signals increased on day 7 (maximum of cellular infiltration; mean signal intensity 20.32 ± 7.59 for λ exc = 300 nm and 52.97 ± 12.0 for λ exc = 360 nm). chronic inflammation (day 14 and 21) led to a signal decrease again. signal intensities of nad(p)h differed significantly (p ≤ 0.05) from controls at days 1 and 7. conclusion: arthritis influences autofluorescence signals in-vivo. the detected excitation/emission pairs can be assigned to collagen/elastin and nad(p)h. autofluorescence of nad(p)h can be a helpful tool for detecting arthritis noninvasive and in real-time. postpartum uterus: what is normal? what is pathological? evaluation with ultrasound and ct i. escape, j. martinez, f. bastart, l. ortega, c. solduga; barcelona/es learning objectives: to know the normal findings, mean diameters and evolutive changes in postpartum uterus and uterine cavity, in early, middle and late puerperium with ultrasound and ct. to differentiate them from pathological conditions. background: the majority of postpartum patients undergo an unremarkable clinical course. a small percentage of patients develop serious complications in the abdomen and pelvis. endometritis, the most common cause of fever in the postpartum period, complicates 2-3% of vaginal deliveries and up to 85% of cesarean sections. post partum hemorrhage is most often caused by uterine atony and retained products of conception, and complicates 1-2% of vaginal deliveries. imaging findings: in early puerperium, uterus is most often retroverted and empty with fluid and debris in the cervical area. intrauterine cavity increases on days 7-14 post partum with fluid and debris in the whole cavity and it may be normal to see an intracavitary echogenic mass. ap diameter of the uterus diminishes progressively in 6-8 weeks. endometrial gas is occasionaly visualized after normal vaginal delivery in the immediate puerperium and disappears within 1-2 weeks. it can be difficult to differentiate from endometritis, which can progress to pelvic inflamatory disease. endometrial stripe decreases during puerperium; if it remains thickened, complications such as retained products of conception or hypotonic uterus may be suspected. doppler us can be useful for differentiating between them. we describe these features with ultrasound and ct. conclusion: it is important to recognize normal postpartum uteral findings in order to differentiate them from pathological conditions. pelvic floor dysfunction: interest of mr imaging of ortheses and prostheses j. villeval 1 , m. de graef 1 , r. guillon 1 , c. courtieu 1 , a. maubon 2 , j. rouanet 1 ; 1 montpellier/fr, 2 limoges/fr learning objectives: to display the mri appearance in static and dynamic conditions of intra-vaginal device and post surgical procedures used for the treatment of pelvic floor dysfunction. background: we retrospectively analysed 26 mr exams performed before and after surgical treatment and 20 mr exams without and with intra vaginal device of 23 patients with pelvic floor dysfunction: urinary incontinence (tension-free vaginal tape n = 3, artificial urinary sphincter n = 4, intra vaginal device n = 10) and pelvic prolapse (intra vaginal device n = 2, promontofixation n = 2, prosthetic b d e f a g plaques permacol and polypropylène in recto-vaginal and uretro-vaginal wall n = 2). mri consisted of t2 turbo spin echo, t1 turbo spin echo and dynamic single shot sequences. imaging findings: we will show the mri appearances of the devices in static and dynamic conditions. prosthetic plaques and tension-free vaginal tape appear as low signal intensity structures which are difficult to visualize compared to promontofixation, artificial urinary sphincter and intra vaginal device. mr imaging represents a good functional post operative evaluation for prosthetic plaques and intra-vaginal device in pelvic prolapse with dynamic studies especially in cases of suboptimal post treatment outcome. conclusion: a radiologist involved in pelvic mri should be aware of the various surgical treatments of pelvic floor dysfunction in order to avoid misinterpretation and evaluate their functional results. mri allows detection of complications for a better collaboration between radiologist and pelvic floor surgeon. pathologies of the uterine endometrial cavity: usual and unusual manifestations and pitfalls on magnetic resonance imaging m. takeuchi background: the endometrial cavity may demonstrate a spectrum of imaging manifestations ranging from normal, to that of a reactive, inflammatory, and benign and malignant neoplastic cause. imaging findings: thickened endometrium or endometrial mass included benign endometrial hyperplasia or polyps, endometrial carcinomas or carcinosarcomas, and gestational trophoblastic diseases. hyperintensity similar to the endometrium suggested rather benign hyperplastic lesions. hyperplasia or polyps associated with adjuvant tamoxifen therapy tended to be large masses with cystic changes and prominent stromal proliferation. myometrial thinning suggested malignancy but was occasionally overestimated because of the fragility of the myometrium with adenomyosis. submucosal leiomyoma with edematous change may mimic endometrial mass, and demonstration of the continuity to the myometrium was the clue to its myometrial origin. uterine sarcomas may involve endometrial cavity, and endometrial stromal sarcomas often showed endometrial masses with characteristic myometrial invasion. adenomyomatous endometrial polyp may simulate endometrial stromal sarcoma due to arborescent smooth muscle components which resemble the preserved bundles of myometrium within the tumor on t2-weighted images. fluid collection in the cavity was well visualized on mri to distinguish between hydro-, pyo-, and hematometra. conclusion: to recognize various imaging findings of the uterine endometrial cavity; it is important to make a correct preoperative diagnosis to avoid unnecessary or excessive surgical intervention and to preserve the fertility of the patients. learning objectives: to demonstrate wide variations of the fluid collection in the female pelvis with pathophysiologic correlation and evaluate the diagnostic clues to the differential diagnosis. background: there are various situations with fluid collection in the female pelvis. although physiologic ascites is often observed in the reproductive era, other pathophysiologic fluid collection with both benign and malignant conditions may occur. imaging findings: mucinous ascites with organ scalloping in pseudomyxoma peritonei is characteristic. hemorrhagic ascites, which shows high attenuation on computed tomography (ct) and is well visualized on magnetic resonance imaging (mri) may be observed with malignant tumors, adnexal torsion or ruptured endometriosis. lactate detection on magnetic resonance spectroscopy (mrs) may suggest its malignant condition. non-neoplastic diseases such as ovarian hyperstimulation syndrome, pelvic inflammatory diseases, endometriosis, adnexal torsion and massive ovarian edema may cause accompanying fluid collection with adnexal enlargement. benign tumors may cause ascites, such as meigs' and pseudo-meigs' syndrome, and malignant tumors may cause carcinomatous peritonitis with fluid collection. ascites in postmenopausal woman is an unnatural finding and may suggest adhesion due to old inflammation or surgical procedure, or existence of hidden neoplastic disease. ascites in a tumor-bearing woman may suggest an advanced stage of disease with occult tumor implants. localized fluid collection like peritoneal retention cyst is observed in adhesive pelvis after surgery, inflammation or endometriosis with characteristic contour shape. conclusion: to evaluate the nature or biochemical components of ascitic fluid by mri and mrs may be helpful for the differential diagnosis. recurrent ovarian cancer: patterns and spectrum of imaging findings m. moon, s. kim, j. cho, y. lee; seoul/kr learning objectives: to illustrate the spectrum of imaging findings of the recurrent ovarian cancer. background: ovarian cancer is the most common cause of death among the gynecological malignancies. the treatment of ovarian cancer has traditionally been initial surgical staging and cytoreduction, followed by adjuvant chemotherapy. then, a second look operation is performed to reassess the tumor status after first line chemotherapy. once pathological complete response is defined, the management of ovarian cancer depends on non-invasive methods such as serology and cross sectional imaging. on the follow-up evaluation, identifying patients with minimal recurrent disease is important as it provides the best chance for complete clinical response and long-term survival following second-line chemotherapy. imaging findings: recurrent ovarian cancer usually manifests as local recurrence, peritoneal seeding and nodal recurrence. vaginal stump recurrence is the most common manifestation of the local recurrence. peritoneal seeding presents as ascites, peritoneal enhancement, peritoneal nodularity, and/or mesenteric infiltration on cross sectional imaging. nodal recurrence is most commonly seen in the external iliac group, which is not the presumed site based upon anatomic studies. although hematogenous dissemination is less frequently seen in the recurrent ovarian cancer, hepatic or pleuropulmonary involvement is a relatively common manifestation of hematogenous spread. the unusual manifestations of hematogenous dissemination include metastases in the extrahepatic abdominal solid organs, bone, central nervous system, and abdominal wall involving subcutaneous fat or muscle. conclusion: familiarity with the patterns and spectrum of imaging findings of recurrent ovarian cancer will facilitate accurate diagnosis and prompt treatment. ing of cervical carcinoma. the particular advantages of mri over ct include its multiplanar imaging capability and its superior depiction of soft tissue planes. accurate staging of cervical carcinoma at presentation is essential from the point of view of prognosis and also for management planning, as patients who present with stage iia or lower grade carcinoma proceed to surgery, and those with higher grade tumours are treated primarily with radiotherapy. recurrent disease is also best depicted using mri. patients can present with or develop a wide variety of complications as a result of their tumour and mri can be of particular advantage in the investigation of local complications. imaging findings: this educational exhibit illustrates the mr imaging findings of cervical carcinoma of all grades. we also demonstrate the mr imaging features of a wide variety of local and distant complications, including local invasion, fistula formation, small bowel obstruction and obstructive hydronephrosis. conclusion: mri is the imaging modality of choice for the diagnosis and staging of primary cervical carcinoma. it is also of benefit for the investigation of disease related complications and for the investigation of recurrent disease. the most common is serous papillary carcinoma. these tumors can show totally solid appearance, but mainly solid mass with some cystic portions is more common. they have unique imaging findings especially on mr in that papillary masses with branching pattern are frequently accompanied by peritoneal seeding masses. serous surface papillary carcinoma of the ovary, a distinct subtype of these tumors, is mainly located on the surface of the ovary. sometimes normal ovaries can be found inside papillary masses on mr, which is a very unique and striking appearance. brenner tumor and endometrioid carcinoma are another subtypes of epithelial tumors that can show solid appearance. extensive calcifications can be found in some solid brenner tumors. endometrioid carcinomas are sometimes accompanied by endometrial pathologies including endometrial carcinoma. conclusion: knowing these characteristics can help make correct diagnosis on ct and mr, especially differential diagnosis with metastatic tumors. wide spectrum of uterine leiomyomas mr imaging: radiologic and pathologic correlation h.k. kim; seoul/kr learning objective: to provide an in-depth review of uterine leiomyomas with their epidemiology, histopathology, clinical manifestations and the most up-todate therapy. to describe radiologic feature of usual and unusual appearance of uterine leiomyomas on mr image and histopathologic correlation. to discuss differential diagnosis of uterine leiomyomas from gynecologic and non-gynecologic disorder. background: leiomyomas are the most common uterine neoplasm and are composed of smooth muscle with varying amounts of fibrous connective tissue. imaging features of uterine leiomyomas vary depending on tumor size, location, degeneration and other histologic findings, and specific types of unusual leiomyomas. uterine leiomyomas are classified as submucosal, intramural or subserosal. the common types of degeneration are hyaline (> 60% of cases), cystic, myxoid, red and hemorrhage. degenerated leiomyomas have variable appearances on t2-weighted and contrast-enhanced images. specific types of unusual leiomyomas include lipoleiomyoma and myxoid leiomyoma, which have characteristic mr findings enough to differentiate from other gynecologic and nongynecologic disease. the differential diagnosis of leiomyomas includes adenomyosis, solid adnexal mass, focal myometrial contraction, and uterine leiomyosarcoma. the purpose of this exhibit is to provide in-depth review of epidemiology, histopatholoy, clinical manifestations and differential diagnosis. this exihibit will also reflect our experience in radiologic evaluation of patients with leiomyomas, with emphasis on the typical and atypical findings on pelvic mri. examples of unusual uterine leiomyomas, pathologic correlation as well as the most up-to-date therapy will be included. after interacting with this exhibit the radiologist will have enhanced understanding of uterine leiomyomas including histopathology and radiologic features. experience of mri in women with suspected and known endometriosis: a pictorial review r. benamore, l. grosvenor, a. liddicoat; leicestershire/uk learning objectives: review of imaging features in women with endometriosis since introduction of a 1.5 t magnetic resonance (mr) scanner. women were referred when they did not wish to undergo laparoscopy or where surgical intervention and visualisation was difficult. background: endometriosis affects women during the reproductive years between 25 and 29, with an estimated prevalence of 5-10%. presentation range from pain (symptoms and severity do not correlate) to asymptomatic (diagnosed during infertility investigations). endometriosis (functional glands and stroma outside normal endometrium) is characterised by deposits, endometriomas (cysts) and adhesions, commonly ovarian but is documented to involve any site within the peritoneum and extraperitoneum. mr is noninvasive with high sensitivity and specificity, small foci appearing hyperintense on t1 and variable signal on t2 weighted images. endometriomas (> 1 cm) appear hyperintense on t1 and hypointensity on t2, with hyperintense foci on t2 dependant on age of haemorrhage. fat saturation sequences are essential to improve lesion conspicuity on t1. we reviewed all women referred for investigation of suspected endometriosis, and for evaluation of disease extent and sites (notably recto-vaginal pouch) in known cases of endometriosis. procedure details: sequences used were axial t1, sagittal t2, axial oblique fat saturation (tirm) and narrow section coronal t2 imaging. mr identified endometriosis involving ovaries, bilateral thick walled and unilateral endometriotic cysts, extra-ovarian disease within peritoneum and soft tissue. fibroids and simple ovarian cysts were common, with evidence of concurrent endometriosis. conclusion: mr detected small foci of endometriosis outside of the ovaries. there was a high incidence of other gynaecological pathologies allowing early review and treatment. 3d transvaginal sonography in uterine leiomyomas with hysteroscopic and pathomorphological correlation v. gazhonova, k. sokolskaya, t. kurganskaya, a. zubarev; moscow/ru purpose: to determine the possibilities of 3d transvaginal (tv) sonography in preoperative assessment of uterine leiomyomas and to correlate the findings with hysteroscopic, laparoscopic and macroscopic data. method and materials: 31 women with symptomatic uterine leiomyomas were evaluated before myomectomy and hysterectomy. multiplanar images of the uterus were created in 3d tvs. preoperative location of the leiomyomas, and interactions with uterine cavity, cervix and iliac vessels were assessed in each case. us results were compared with hysteroscopy in 6 pts, laparoscopy in 7, open surgery in 5 and pathomorphology data in 13 pts. results: surgical management was changed after 3d tvs examination in 8 cases. 3d coronal images allowed better location of the submucous and centripetal leiomyomas especially in multiple closely lying fibromyomas. 3d tvs results correlated with hysteroscopy in 91% (10/11) of cases vs. 64% (7/11). 3d power doppler tvs provided precise evaluation of the pedunculated submucous and subserous leiomyomas thus enabling adequate myomectomy. in comparison to macroscopic data of the uterus, 3d tvs were superior to 2d tvs in differentiation of the type of leiomyomas in 92% vs. 69% of cases, and in assessment of the interactions with the cervix in 100% vs. 62%. multiplanar reconstruction of the coronal planes on 3d tvs improved determination of the uterine cavity interactions with large subserous-interstitial leiomyomas before laparoscopic myomectomy. conclusion: 3d tvs is a useful complement to 2d tvs in preoperative assessment of leiomyomas. accurate evaluation of the leiomyomas on 3d mpr can decrease the possibilities of intraoperative hemorrhage and uterine trauma. b d e f a g treatment of the symptomatic large and multiple uterine fibroids by uterine artery embolization s. speca, a.m. costantini, c. di stasi, g. tropeano, v. summaria, p. marano; rome/it purpose: to evaluate the potential usefulness of uterine artery embolization as an alternative to traditional surgery (hysterectomy or myomectomy) for the treatment of symptomatic large or multiple fibroids. material and methods: 38 premenopausal women, aged 33-55 years (mean age 42.7), who presented with menorrhagia, pelvic pain, and/or mass-related symptoms due to large (< or = 12 cm) or multiple fibroids (> or = 3 cm) and were unwilling to undergo surgery or had an increased surgical risk, underwent bilateral uterine artery embolization. before embolization all pts underwent to a complete clinical examination, a basal fsh and estradiol dosage, a vaginal and ureteral tampon, a papanicolau test, a trans abdominal and trans vaginal ultrasonography and color doppler flowmetry. for embolization we used polyvinyl alcool particles, embosphere or spongostan. detailed clinical and ultrasound follow-up were obtained at regular intervals (1-31 months). the procedure was technically successful in 37/38 patients. a mean clinical follow-up of 14 months for pain, mass-related symptoms and menorrhagia was done. 95% of the patients treated reported a marked to complete symptomatic improvement. only 1 patient experienced no changes in her symptoms. nobody had immediate or late complications. a median reduction of 65% in the uterine volume and a median decrease of 78% in the dominant fibroid volume were observed in 28 patients who had follow-up ultrasounds for up to 6 months. conclusions: in our experience artery uterine embolization may provide an important therapeutic alternative for women with symptomatic large or multiple fibroids who desire to avoid surgery. how to conduct quantitative evaluation of uterine neoplasms using gddynamic contrast-enhanced mri k. hayasaka, y. tanaka materials and methods: 53 women with histopathologically proved cervical carcinoma underwent preoperative t2-weighted fast spin-echo, dynamic imaging using gradient-echo and postcontrast t1-weighted spin-echo mr imaging with a phased-array surface coil. the axial plans in each sequence were reviewed at separate sessions by three radiologists blind to the histopathologic data. results: for the conspicuity of tumor, dynamic and t2-weighted images showed high detectability more than postcontrast t1-weighted images. most appropriate enhancing time in dynamic study was 90 seconds. in assessing parametrial invasion, the accuracy of t2-weighted, dynamic and contrast-enhanced t1-weighted mr imaging was 76.1%, 79.9% and 78%, respectively; no statistically significant difference was observed. conclusion: dynamic imaging is useful in assessing tumor visualization, and the most adequate enhancing time in dynamic study is 90 seconds. but in diagnosis of parametrial invasion, the addition of dynamic mr images does not improve the accuracy compared with t2-weighted images alone. (16), on clinically progressive disease (8) or patient death (21). 15 patients had undergone previous surgery (14 radical hysterectomy, 1 trachelectomy). 30 patients had non-surgical treatment (chemo and/or radiotherapy). a recurrent mass was identified in 45 patients (mean size 5 cm, 1.4-9 cm). on t2w, the recurrence was hyperintense in 87%. in the post-surgical group, the recurrence was in the vaginal stump in 12 patients (80%) with parametrial involvement in 13 (87%). in the non-surgical group, the recurrence was in the cervix in 20 patients (67%) with involvement of vagina in 57% and uterus in 40%. uterosacral ligament and/ or pelvic sidewall involvement was present in 18 patients (40%). bladder invasion was suspected in 22% and rectal in 20%. nodal enlargement was seen in 53%. bone metastases were present in 4 patients while 13 had dxt changes (3 sacral insufficiency fractures). recurrence in the pelvic muscles was also seen. conclusion: recurrent disease in patients with cervical carcinoma usually involves the cervix or vagina, however can present with varied manifestations. knowledge of the site and pattern of disease recurrence can help in early and accurate detection of recurrence. hysterosalpingography: is still useful in the diagnosis of peritubal pathology? s. deftereos, j. manavis, g. alexiadis, g. kafetzis, p. prassopoulos; alexandroupolis/gr purpose: to reevaluate the role of hysterosalpingography in the diagnosis of adhesions related to infertility and in patients managment. materials and method: 54 consecutive patients with more than two years infertility underwent hysterosalpingography (hsg), followed by laparoscopy. patients with infertility related to uterine abnormality were not included. diagnosis of peritubal adhesions was based on the presense of the following six imaging findings: convoluted tubes, vertical tubes, loculation of contrast medium in peritoneum, halo effect, ampullary dilatation or fixed laterodeviation of the uterus. results: in total, 92 tubes were delinated. no abnormality was detected in 7 tubes on both hsg and laparoscopy. laparoscopy disclosed adhesions in 51 tubes. diagnosis of adhesions was made in 46 tubes (18 correct, 28 false positive), when the presence of one abnormal sign on hsg was considered as criterion; and in 40, when two or more signs are present (33 correct, 7 false positive). ten live births five to eight months after hysterosalpingography occured. conclusions: accurate diagnosis of adhesions on hsg requires the presence of at least two abnormal signs. the six-month interval between hsg and laparoscopy might be shortened when adhesive peritubal involvement is radiologically suspected. laparoscopy is less indicated when no abnormality is detected on hsg. withdrawn to illustrate ct-urographic patterns of neoplasia of the collecting system. background: conventional excretory urography and conventional computed tomography (ct) were considered the standard techniques used to examine patients with urinary tract neoplasia. multi-detector row ct offers high speed of acquisition and high resolution images, allowing axial and 3d urographic acquisitions. imaging findings: 15 pts with transitional cell carcinomas were analysed. all patients underwent unenhanced and post-contrast ct axial scans, followed by a urographic acquisition in the excretory phase (2 mm collimation, 1.5 mm reconstruction interval). 3d reconstructions of excretory phase images were created with on an independent workstation using a mip algorithm. neoplastic lesions were visualised as solid papillomas in 3/15 cases, as wall thickening of the collecting system in 11/15 cases and as solid tissue in the renal sinus in 1/15 case. lesions were more evident on the source axial images of the excretory phase urographic acquisition. in the post-contrast images, the lesions resulted quite vascularized. urinary tract dilation was evaluated in 13/15 patients. dilation was better evaluated on the 3d mip ct-urographic images in the case of normal renal excretory function and on the source axial images of urographic acquisition in the case of functionally excluded kidneys. conclusion: ct-urographic axial and 3d images combined with conventional ct imaging allowed good evaluation of urinary tract neoplasia. the more frequent pattern was the wall thickening of the collecting system (74% cases), associated to urinary tract dilation (87% cases). renal background: lc is a minimally invasive surgical technique for patients with small renal masses; mr provides an effective tool for imaging follow-up of renal lesions treated with lc. methods and materials: 32 pts with 41 renal masses underwent renal lc. all patients underwent follow-up mri 24 hrs after surgery, and at 1, 3, 6 and 12 months. mr examinations were performed using gre t1w, tse t2w and ce fs-gre t1w sequences. two radiologists reviewed mr images for i) signal intensity, ii) size, iii) vascularization, and iv) perinephric changes after treatment. imaging findings: a) t1w images showed 25 isointense cryolesions, and 16 cryolesions isointense to renal parenchyma with hypo-or hyper-intense foci. on t2w images all cryolesions were hypo-intense with iso-or hyper-intense foci; b) 24 hrs after treatment all cryolesions were more than 1 cm larger than the original masses; cryolesions decreased in size of an average of 38% at 1 month, 46% at 3, 64% at 6, and 80% at 12 months; c) ce-fs-gre t1w images showed complete ischemia of cryolesions in 38 cases; d) 6 cases showed a perinephric haematoma at 1, 3 and 6 months. the more significant mr pattern in the follow-up of renal lesions treated with lc were the decrease in size of the cryolesions over time and the complete ischemia of the cryolesions. (47), benign obstruction (24), not obstructed (7) and transplanted kidneys (18). procedure details: we used ultrasound-guidance in 139 cases and ct-fluoroscopy-guidance in 51 cases. the technique was standard seldinger. most patients received 6-or 10 f. nephrostomy catheters. we had 10 access failures, usually in patients with nondilated systems. we encountered 5 major complications (bleeding and two big urinomas) and only 20 minor complications. catheter dislodgement was relatively frequent (32 cases). conclusion: urinary diversion at renal level is necessary in the following clinical situations: as short-term palliation in a terminal case, as a temporary measure prior to definitive diversion, to relieve obstruction where immediate surgical intervention is not feasible and for prolonged drainage where surgical intervention is not indicated. since its first description in 1955, percutaneous nephrostomy has developed into a technique that is now routinely used for a wide range of clinical applications. imaging of angiomyolipoma focused on the clinical issues k.-s. cho, y. jung, s. kim, j. kim; seoul/kr learning objectives: to discuss the role and findings of us, ct and mri in the detection and diagnosis of angiomyolipoma. to discuss the complication of angiomyolipoma and confusion in differentiation from other malignant neoplasm. to discuss the clinical issues of angiomyolipoma including the natural history concerning growth, efficacy of biopsy for diagnosis, and association with tuberous sclerosis. background: angiomyolipoma is the most common benign neoplasm of the kidney and consists of mature adipose tissue, smooth muscle and thick-walled blood vessels derived from perivascular epithelioid cells. although most angiomyolipomas are asymptomatic and cause no problem, some cases raise important clinical issues. (1) angiomyolipomas may be complicated by risk of hemorrhage and cause confusion in differentiation from malignant neoplasm when they contain minimal amount of fat. (2) angiomyolipomas are often related with the stigmata of tuberous sclerosis. (3) the natural history of this benign neoplasm has been controversial, with regard to growth on follow-up images. (4) the efficacy of biopsy for diagnosis is controversial when image findings are indeterminate. procedure details: in this illustration, we evaluate the role and findings of ultrasonography, computed tomography and magnetic resonance imaging in the detection and diagnosis of angiomyolipoma. discussion will be focused on the important clinical issues. conclusion: multi-detector row ct is the most accurate diagnostic modality for evaluation of angiomyolipoma especially in cases with minimal amount of fat in tumor or associated with complication. mr can differentiate minimal fat angiomyolipoma from small renal cell carcinoma. characterization to understand how to further characterize incidentally detected renal masses found on ct by using the appropriate modality with optimal techniques. backgrounds: due to advances in ct technology and its wide spread use for imaging a variety of abdominal conditions, small renal masses are being incidentally detected more frequently on ct. since at least half of renal cell cancers are detected incidentally by imaging, the cost and time for further imaging of small renal masses may increase. in addition, some renal cell cancers may be cystic and it is important to have a strategy for dealing with cystic renal lesions that do not meet the ct criteria for simple cysts. imaging findings: we will discuss and show a variety of small incidental renal masses detected on unenhanced and single phase contrast-enhanced ct. topics discussed will include the following: ct criteria for distinguishing lesions that do not need further imaging for characterization from lesions that require further imaging for characterization; technical considerations affecting imaging findings; updated bosniak classification for cystic lesions; pitfalls in interpretation; and an algorithmic approach for "indeterminate" masses by using ultrasound, dedicated renal ct, mri, or percutaneous biopsy. the majority of small renal masses incidentally found on ct can be characterized or managed through an appropriate diagnostic pathway. color-duplex imaging (cdi) and magnetic resonance angiography (mra) in reno-vascular disease l. olivetti 1 , g. rozzi 1 , p. pecchini 1 , p. ravani 1 , l. grazioli 2 , e. botturi 2 , i. laparoscopic cryoablation of small renal cell carcinoma: medium term outcome. g. cardone, p. mangili, a. cestari, g. balconi; milan/it purpose: to determine safety and efficacy of laparoscopic cryoablation in the management of small renal cell carcinoma and to assess its medium term outcome. methods and materials: 27 patients underwent laparoscopic cryoablation of 29 tumors between july 2000 and june 2003. all treatments were delivered under laparoscopic us guidance. patients were followed up clinically, biochemically and by mr imaging 24 hrs after surgery, and subsequently at 1, 3, 6, 12, 18 and 24 months. results: 24 hrs after treatment all cryolesions were more than 1 cm larger than the original masses; cryolesions decreased in size by an average of 38% at 1 month, 46% at 3, 64% at 6 and 80% at 12 months following cryoablation. early post-procedure mr images showed complete ischemia of all cryolesions. follow-up (mean 16 months) revealed no evidence of recurrence in 24/27 patients. one patient showed local recurrence at 12 months, one patient demonstrated an metachronous nodule in the same kidney at 12 months and another patient showed a pancreatic metastatic nodule at 6 months. no significant rise in creatinine was noted post-procedurally. after surgery, retroperitoneal effusion was found in all cases; 6/29 cases showed an intralesional haematoma, 28/29 cases showed low signal intensity foci due to haemostatic material and 3/29 cases showed a perilesional haematoma at 1 and 3 month follow-up. conclusions: our medium term experience suggests that laparoscopic cryoablation is a safe, well tolerated and minimally invasive therapy for small renal cell carcinoma, and mr is an effective imaging technique in the follow-up of renal lesions treated with laparoscopic cryoablation. results: echographic findings postbiopsy were normal, or with loss of corticomedullary differentiation, enlargement and gross edema. clinical indication in transplanted kidneys was deranged renal function, and in native kidneys, nephrotic syndrome. acute rejection was the most frequent diagnosis in transplanted, and focal glomerulosclerosis in non transplanted kidneys. we observed 17 cases (13% of all procedures) of postbiopsy complications (5 haematomas, 5 perirenal collections, 3 decreased vascularization, 2 arterio-venous fistulaes and 2 deranged renal function), but none of them were significant. 3 of them (7.8%) were in native kidneys, and the remaining 14 cases (18.59%) were in renal allografts. we show an alternative way to perform the procedure in order to minimize patient risks and maximize results. we conclude that complications may be more frequent in renal allografts than in native kidneys. the complex preoperative assessment of patients with renal masses with complex mri-study i. platitsyn, e. zaytseva, a. zubarev, v.v. gazhonova; moscow/ru purpose: to study possibilities of complex mri-study in patients with renal masses in preoperative planning of renal surgery. material and methods: 30 patients with renal masses detected by us were evaluated with complex mri-study. complex mri-study included mri before and after ce, 3d ce-mra and 3d ce-mru using fast 3d mra gre sequence were performed with 1.0 t system (magnetom harmony, siemens). dsa was used as diagnostic correlation as a gold standard. the obtained mr-data were compared with the results of surgical operation and histopathology. the renal tumors were identified with mri-study in 26 patients; 4 patients had cystic lesions. hypervascular masses were found in 20 patients, hypovascular masses in 6 patients. in one cases of cystic lesion detected with mri-study the patient had hypovascular cysto-solid masses. next, renal vascular variants were revealed: unilateral ara were detected with 3d mra in 9 cases, with dsa in 10 cases; bilateral ara -in 2 and 2 cases (consequently); triple unilateral ara -in 1 and 1cases (consequently); multiple ara -in 1 (4 arteries) and 1 (5 arteries) cases (consequently); the sensitivity of 3d ce-mra was 92%. 3d ce-mru provided high-quality images of the urinary tract in all cases. mrstudy showed an almost complete correlation with results of operative treatment, histopathology and dsa. conclusion: complex mri-study allows noninvasive preoperative assessment of renal tumors localization, morphology and vascularisation, renal arterial system, renal parenchyma, urinary tract and perirenal region. it is valuable for planning of renal surgery. in all cases, the 3d free-breathing sequence was superior to the breathhold rare sequences in terms of spatial resolution, with equivalent contrast, and without significant motion artifacts. as a result, the level and length of stenoses were always better demonstrated with the 3d sequence than with the breathhold rare sequences. mip reconstructions allowed analysis of the entire urinary tract with different projections. the duration of the 3d sequence (3 minutes) was comparable to the overall duration of the rare sequence, which requires several slice positioning to explore the entire urinary tract. less t2-weighted sequences (haste and trufisp) were superior to 3d sequences to analyse the cause of obstruction, as they visualised the ureteric wall and the adjacent structures. the 3d turbo spin echo sequence is robust and especially useful in case of tortuous ureters. this sequence has now replaced the rare sequences in our protocol. haste and trufisp sequences remain useful to analyse the ureteric wall and the adjacent structures. prenatal ultrasonographic findings of multicystic dysplastic kidney: emphasis on cyst distribution m. moon, j. cho, m. song, y. lee; seoul/kr purpose: we retrospectively analyzed multicystic dysplastic kidneys to evaluate the prenatal sonographic characteristics, emphasizing the distribution of cysts. a total of 43 cases was included in this study. the sonographic assessment included the site of the involved kidney, the size of the multicystic dysplastic and the contralateral normal kidney, the distribution of cysts, and associated anomalies. according to the distribution of cysts, multicystic dysplastic kidneys were categorized as subcapsular and random distribution, and interobserver agreement was determined using cross table analysis. the largest longitudinal diameters of the multicystic and the contralateral normal kidney were measured and data were plotted on the normal reference chart. results: multicystic dysplastic kidney was left sided in 55.8%, right sided in 34.8% and bilateral in 9.3%. subcapsular distribution of cysts was observed in 68.2% (n = 15) for radiologist 1, 59.1% (n = 13) for radiologist 2. interobserver agreement was excellent (k = 0.697). the longitudinal diameter of the multicystic dysplastic kidney was above the 95% in 68% and that of the contralateral normal kidney was normal in 70%. there were major anomalies in 2 cases and fetal karyotyping was offered in 18 cases including 2 cases with associated major anomalies. the results were always normal. conclusion: subcapsular distribution of cysts in multicystic dysplastic kidney is more common than random distribution, so the distribution of cysts may be helpful in the prenatal diagnosis of multicystic dysplastic kidney. tubular extraction rate of mag3 in patients with impaired renal function s. beatovic, e. jakšic, r. han; belgrade/yu purpose: to analyze whether clearance of mercaptoacetyltriglycine (mag3), which is equal to its tubular extraction rate (ter) could serve as a sensitive parameter of renal function impairment. methods and materials: investigation was carried out in 107 patients, who were divided into nine groups, according to the diagnosis and the degree of renal failure. dynamic renal scintigtraphy was performed 20 minutes after i.v. injection of 150-220 mbq of mag3. ter was determined by single-sample, volume distribution method using the standard solution of labeled mag3. results: results of ter were correlated with blood urea nitrogen (bun), serum creatinine (cr) and creatinine clearance (ccr). significant linear correlation between ter and ccr was found (r = 0.76; p < 0.0001). correlation between ter/ bun and ter/cr was exponential (r = -0.78 and r = -0.82, respectively; p < 0.0001). conclusion: analysis of our results show that ter is a more sensitive parameter than ccr, cr and bun, especially in mildly deteriorated function. in advanced renal failure, the sensitivity of ter is similar to the sensitivity of bun and cr. daily we found some significant correlation between pulsatility indices (pi), resistance indices (ri) and renal volume (trv), with creatinine blood level (cr) in the patients with normal evolution, if we correlated the parameters using 12-day data. there was significant correlation between ri and cr in patients with nf (12 days, p = 0.04). in the patients with atn there was significant correlation between trv and cr (12 days, p = 0.02). significant correlation between trv and cr was found in rd evolution (12 days, p = 0.032) and between pi and cr (20 days, p = 0.029) in patients with rejection. these results confirm the findings obtained by dissection in five cadavers. the analysis of ct scans of retro-extraperitoneal pelvic processes demonstrates the inferior extension of the renal fasciae to the pelvis. these fascial planes serve as pathway for the spread of retro-extraperitoneal processes from the abdomen to the pelvis and vice versa. one can so explain, for example, the occurrence of an abcess in the prevesical space in case of sigmoid diverticulitis. to investigate the effect of alpha-blockers on prostatic blood flow and by means of power doppler image quantification. materials and methods: 11 patients suffering from lower urinary tract symptoms (luts) were treated with alpha-blocker for 5 weeks. transrectal power doppler ultrasound (trpdus) of the periurethral prostate as well as comparative cystometry were performed before and after therapy. for trpdus an acuson sequoia 512 (acuson, mountainview, usa) fitted with a high frequency transrectal probe (ec10-c5) was used at standardized machine settings. color pixel density (cpd) was calculated with computer assistance from transrectal power doppler images using scion image image analysis software. cpd and standard urodynamic parameters were recorded in each run at filling volumes of 0 ml, 100 ml and maximum cystometric capacity. in presence of nacl, mean cpd rose by 8% at 100 ml and by 27% at full distension, whereas with kcl filling, mean cpd rose by 30% at 100 ml and by 42% at full bladder capacity. after therapy, mean cpd was significantly increased at empty bladder by 44% compared to mean cpd before therapy. during nacl filling, mean cpd rose by 50% at 100 ml and by 77% at full distension, while in the presence of kc1, mean cpd rose by 77% at 100 ml and by 103% at full bladder capacity. conclusions: using trpdus and cpd, relative changes of periurethral prostatic blood flow could be quantified. alpha-blocker lead to a significant increase of prostatic blood flow. these results may explain the therapeutic effects of alphablockers on luts. superselective results: using grey-scale trus, 32 prostate tumors were hypoechoic before treatment. using 3d pd trus, 19 tumors (46%) were hypervascular before treatment. during treatment the tumors' echogenicity increased gradually, focal fibrosis was detected; the degree of vascularity decreased gradually. in 12 months the fibrosis was not revealed in 15 (36.5%) tumors and the hypervascularity was revealed in 5 (12.1%) patients that correlated with negative clinical response to hormonal treatment in 5 patients. conclusion: 3d trus is an informative method in the assessment of the response to hormonal treatment of pc. methods: seven patients with adenocarcinoma of the prostate were scanned supine on a 1.5 t system. prior to imrt and during the 7-week treatment course, 5 mm transverse, coronal and sagital haste-t2-weighted images of the pelvis were acquired weekly. the bladder and rectal volumes, position of the prostatic margins, and center of prostate (cop) relative to the bony pelvis were measured. results: all pre-treatment positions were within a 3.6 mm range from the ontreatment mean position in each patient. the cop variability in the ap, cc and ml directions were 2.6, 2.4 and 1.5 mm, respectively. the largest prostatic margin variability was 3.2 (posterior) and 2.6 mm (cranial and caudal). beyond a rectal volume of 57.1, a strong correlation was found between rectal volume and anterior cop movement (p = -0.90). a weak correlation (p = -0.31) was found between bladder volume and cranial cop movement. beyond 160.8 ml, the mean variability of the cranial and caudal margins increased up to 1.3 mm, between 300 and 400 ml 4.4 mm, and above 400 ml 6.6 mm. the pre-treatment prostate positions were representative of ontreatment positions. a 5.3 mm ctv expansion in any direction was sufficient to ascertain 95% coverage of the ctv within the ptv, assuming a rectal volume < 57.1 ml (rectal suppository) and bladder volume around 150 ml (voiding followed by drinking 500 ml of water to keep small bowel away from treatment field). local results: there was no significant difference between the number and severity of complications in the group with local anesthesia compared to the group without anesthesia. there were no significant side effects caused by the infusion of the anesthesic drug. however the infusion of the drug may cause a degradation of the trus image. air bubbles are sometimes infused with the drug causing a "fuzzy" image, which results in a degree of difficulty in guiding the needle. a thorough trus examination of the prostate prior to the anesthesia helps the radiologist in planning the biopsies in advance and thus guiding the needle to the appropriate area, even through a "fuzzy" image. conclusion: us-guided local anesthesia, before trus biopsy, is useful for assuring patient cooperation during this often painful procedure and essential if trus findings call for a large (more than 10) number of biopsies. conclusion: conventional mr images combined with pyelo-urographic techniques allowed a good evaluation of urinary tract neoplasia. more frequent patterns were solid papillomas or wall thickening of the collecting system (90% cases), associated with collecting system dilatation (85% cases). there is a "difficult zone" located 2-5 cm below the iliac vessels. examination with mild compression is used to solve this problem. color doppler sonography is valuable to distinguish the ureter from vessels. conclusion: abdominal sonography is a cheap and informative method in the diagnosis of ureteral disorders and may replace traditional technologies. trauma of the urinary system: spectrum of findings at helical ct a.j. madureira, c. tavares, l. melao, i. ramos; porto/pt learning objectives: to review and illustrate the spectrum of imaging findings associated with blunt and penetrating trauma to the urinary system on helical ct. to discuss the importance of an appropriate technique and the major pitfalls encountered. background: injury of the urinary system is a common complication of major abdominal trauma. helical ct is a powerful imaging modality in the evaluation of patients with suspected injuries of the adrenal gland, kidney, ureter and bladder. the renal injury ct classification system is valuable and clinically important as it serves as a guide for patient management. procedure details: the authors present a comprehensive review of the imaging findings in common and rare traumatic lesions of the adrenal gland, kidney, ureter and bladder based on the experience of a level 1 trauma center. the indications for helical ct are discussed and a special emphasis is placed in the use of an appropriate technique and discussion of the major pitfalls that may be encountered. conclusion: helical ct is a useful modality in the diagnosis, grading and followup of patients with trauma to the urinary system. helical ct protocols should be optimized and adapted to the clinical situation in question. characterization learning objectives: this poster will present the anatomical waxes dedicated to urogenital anatomy which are displayed at the museum "la specola" of florence. background: teaching gross human anatomy is traditionally based on demonstration and study of the different organs and systems directly on corpses. however, availability of specimens for this purpose can be difficult for a variety of problems and, at present, anatomical models made of plastic material and electronic files are used in most schools of medicine. these problems have been always present in the history of medicine. to overcome this, in 1771, a special laboratory was established at the "imperial regio museo di fisica e storia naturale" of florence to create a collection of anatomical waxes, copied from anatomic dissections, to enable three-dimensional anatomic studies with schematic drawings and captions indicating anatomical details. imaging findings: from 1771 to 1893, the laboratory prepared a large number of models, and the collection in florence consists of about 1500 pieces. in the collection there are over 200 preparations, showing the complete urogenital system in the male and the female. special models have been created to demon-strate sectional anatomy, the internal structures of the kidney, the relationships of the prostate with the bladder base and the seminal vesicles, the penis, the vagina and the uterine cavity. many waxes depict the gravid uterus and the foetus, with its vasculature and its relations with placental vessels. conclusion: this allows the collection to be considered as the first 3d "textbook" of anatomy in medical history. characterisation of adnexal masses with magnetic resonance imaging a. saini; london/uk learning objectives and background: the accurate assessment of adnexal masses remains a challenge. to determine key differentiating features of adnexal masses, we retrospectively reviewed the magnetic resonance (mr) characteristics in 45 patients and correlated their appearances with the findings at histopathology. imaging findings: benign solid lesions were characterised by fat, haemorrhage or fibrous components. mature teratomas (n = 4) possessed high fat content. haemorrhage was a predominant feature of endometriomas (n = 7) but also seen in some malignant tumours. fibromas (n = 2), cystadenofibromas (n = 3), benign brenner tumours (n = 2) and fibrothecomas (n = 1) that have a similar fibrous component shared a distinctive short t2 relaxation. benign cystic lesions comprised serous or mucinous cystadenomas (n = 5), were recognised as thin walled uni-or multilocular cysts. borderline (n = 4) and malignant epithelial tumours (n = 8) were predominantly cystic and distinguished by papillary projections and the secondary features of malignancy, such as ascites, rather than their tissue signal intensity. malignant solid primary ovarian masses were less common. clear cell carcinomas (n = 2) were recognised by a predominantly solid mass with more modest cystic elements. granulosa cell tumours (n = 2) had variable amounts of cystic change and intratumoural haemorrhage. immature teratomas (n = 1) contained circumscribed foci of variable signal-intensities. inflammatory masses (n = 3) also presented as complex adnexal cysts. in these cases, the clinical history and examination was key in making the diagnosis. the ability to manipulate tissue contrast with mr imaging makes it an invaluable tool in the assessment of complex adnexal masses enabling characterisation and identification of features associated with less common pathology. to discuss the imaging features so that when this tumor is encountered the diagnosis may be considered. to correlate the pathologic characteristics with the imaging findings. to discuss the key elements to be included in the differential diagnosis and to provide examples of them. background: urachal adenocarcinoma is an extremely rare malignant neoplasm that develops from embryonic remnants and has a variable clinical course. clinical, pathologic and imaging findings were retrospectively evaluated for 6 patients with urachal adenocarcinoma referred from 4 centers. imaging studies (ct, n = 6; mri, n = 2) were reviewed for morphologic features, such as tumor size, homogeneity, margins and degree of enhancement. imaging findings: the mean tumor size was 3.5 cm. the tumors were heterogeneous in 4/6 patients, with irregular margins in 6/6, calcifications in 1/6 and strongly enhanced in 6/6. all tumors extended anteriorly from the bladder dome; endoscopy was normal in all cases. enlarged lymph nodes were visible in 2/6 patients. histologically proven invasion of the bladder dome was detected in 2/6 patients and invasion of the anterior abdominal wall in 1. 3d reconstructions in the sagittal plane (n = 2) evoked a urachal mass and assessed its relationship with the urinary bladder, umbilicus and rectus muscles. all tumors were resected. conclusion: multimodality imaging is essential to obtain an early and accurate diagnosis of urachal adenocarcinoma. multiplanar ct and mr give the best assessment of the extent of tumor invasion. reduction of ionising radiation exposure to patients due to new imaging technology for medical diagnostics of the urinary tract: a retrospective study covering 20 years in a norwegian referral hospital a. nyquist 1 , i. børretzen 2 , h. olerud 2 , b. bjørnarå 1 , t. gudmundsen 1 ; 1 drammen/no, 2 oslo/no purpose: to examine possible changes in ionising radiation doses to patients (collective effective dose) undergoing diagnostic imaging procedures of the urinary tract over the last 20 years in view of shift in modalities from conventional x-ray examination to ultrasonography (us). retrospective study of all patient files for the period from 1983 to 2002. the number of plain radiographs, intravenous pyelography (ivp), ultrasonography (us), computer tomography (ct) and magnetic resonance imaging (mri) examinations were registered. for each type of examination the mean effective radiation dose were obtained from the norwegian radiation protection authority (nrpa) as published in 1997. the number of plain radiographs of the lower abdomen covering the urinary tract increased by approximately 50%, ivps were reduced by 70%, and ct examination decreased by 40%. mri examinations did not play any significant role in examining the urinary tract. us of the urinary tract increased from 8 in 1993 to 1129 in 2002. this shift in modalities from totally x-ray based procedures, to nearly exclusively us often supplemented with one plain radiograph, caused a decrease in the annual collective effective dose for this group of patients with 66% from 6.8 mansv in 1983 to 3 mansv in 2002. the shift in modalities used for diagnostic imaging of the urinary tract from conventional x-ray to almost exclusive use of us, resulted in a significant reduction in exposure to ionising radiation of patients, and need to be considered when discussing further development and structure of diagnostic imaging. comparison of the adrenal vein sampling value between primary aldosteronoma and nonfunctioning adrenal adenoma: evaluation with receiver operating characteristic ( , voiding cystourethrography, urethroscopy and biopsy. combined retrograde and voiding sug with saline and echocontrast media levovist® were used in 16 pts with urethral obliteration and chronic suprapubic catheters. the transperineal or transrectal ultrasound was performed to evaluate anterior and posterior urethra respectively. the images obtained allowed detailed morphology assessment of the urethra at different levels. results: compared with rug, the sug more accurately measured stricture length and diameter that was confirmed by measurements at optical urethrotomy (11 pts) and urethroplasty (12 pts). the introduction of contrast agents enhanced the visibility of the flow in the most strictured segment (less than 0.4 mm), which was diagnosed by rug as urethral obliteration in 5 pts. the ce sug accurately diagnosed diverticula (5), false passages (3), which were confirmed by urethroscopy in all pts. conclusion: our preliminary results show, that the combined retrograde and the voiding power doppler sonourethrography with ultrasound contrast media might be an effective support in diagnostics and in the planning of treatment of patients with complex strictures and urethral obliteration. ce sug is an informative method in the differential diagnostics of patients with urethral obliteration and complex strictures. differentiation of adrenal adenomas from metastases with unenhanced ct using a scoring system h. gufler 1 , g. eichner 1 , a. results: attenuation values on unenhanced ct were significantly lower for adenomas than for metastases (9.8 ± 12 hu versus 32.8 ± 24.9 hu, p < 0.05). the combined score parameter including all ct criteria showed the largest area under the roc curve. the highest predictive power suggested by the model was calculated with a cut-off point at 7.05 for benign lesions with a sensitivity of 1.0 and a specificity of 0.9688. at 6.75 points the scoring system yielded a sensitivity of 95.8% and a specificity of 96.9%. conclusion: compared to densitometry alone, diagnostic accuracy in the differentiation between adrenal adenomas and metastases is improved by including all ct criteria in the evaluation. the presented scoring system is simple but efficient and easy to use in the clinical routine. eswl of the unusually located stones in pediatric patients z. siric, m. radovanovic, a. slavkovic; nis/yu aim: to show the possibilities of lithotripsy in the treatment of bladder and urethral stones in pediatric patients. in a twelve year period, we treated 92 pediatric patients, aged from 8 months to 14 years, by eswl. in 3 children, stones were located in the urinary bladder, and in the urethra in another 2. all of them were male patients; we decided to use eswl instead of invasive methods of treatment. eswl procedures were performed under general anesthesia in 4 and under sedo-analgesia in 1 patient. during treatment, the patients were placed in the prone position (patients with bladder stones) or in a modified supine position (perineal approach for urethral stones). an average 3000 shock waves were applied per patient with a maximal energy of 3.0 kv. average duration of treatment was 35 minutes. results: successful fragmentation was achieved during the first session in 4 patients. in 1 patient with a urethral stone, the fragmentation was not satisfactory and the treatment was repeated 7 days later. complete elimination of stone fragments was achieved during the first 3 days in the patients with successful first treatment, but was not achieved at all in the patient with repeated treatment. cystoscopy was performed and the stone was found within a urethral diverticulum. there were no complications in our patient group. conclusion: eswl in our experience seems to be useful as a non-invasive method in the treatment of stones with in unusual locations. it could be recommended in male patients without anatomical variations of bladder and urethra. methods: this is a retrospective study of helical ct of 42 patients that showed iliopsoas abnormalities (11 neoplasms, 12 abscesses, 14 hematomas, 2 cases of atrophy and 3 of calcifications). the study group included 33 men and 9 women, 9-90 years old (mean 58 years). all studies were obtained over a 10-year period. final diagnosis were correlated with different ct features to determine findings that could be used to differentiate these abnormalities. these included enlargement of the iliopsoas muscle, irregular margins and fat infiltration, attenuation of the lesion, calcification, bone fracture and associated adenopathy. result: psoas pathology is more frequent in men (p < 0.05). low attenuation and heterogeneity are the most reliable ct features of iliopsoas abscesses (p < 0.05). the sensitivity and specificity of low attenuation for the diagnosis of abscesses are 24% and 92% respectively. the specificity of heterogeneity for the diagnosis of abscesses is 100%. bone fracture is useful for the diagnosis of hematoma (p < 0.05). bone fracture is 53% sensitive and 85% specific for diagnosis of hematoma. conclusions: low attenuation, heterogeneity and bone fracture are helical computed tomography features useful for differentiating iliopsoas pathology. results: all masses were classified correctly by both analysis. the mean percentage of signal intensity on subtraction images were 200 ± 63 (means ± sd) and nonadenomas 29 ± 7 (means ± sd), respectively. the difference between two groups was statistically significant (t test, p = 0.000). our results show that chemical shift subtraction imaging is an objective technique that allows the adrenal adenomas to be differentiated from the other tumors. the objectivity of the technique may help the unexperienced radiologists to improve their interpretation. 13 patient (56%) had uretheral dilatation. the mru visualized the dilatation and determined the obstruction level in 13 cases (100%). the excretory urography detected uretheral dilatation and determined the obstruction level in 10 cases (77%). the mru detects with great accuracy the dilatation and also, obstruction level in patients with obstructive uropathy and could be used as an alternative to excretory urography in specific cases. oro objective: many congenital dysplasias of the osseous labyrinth have been identified. differentiation of these dysplasias is essential for patient management. the purpose of this study is to describe the imaging findings which can be found in anomaly of the inner ear. we retrospectively reviewed imaging findings of 11 children with congenital sensory neural hearing loss (8 male, 3 female, mean age 5.0 years, age range 1-14 years) who had ct (n = 8) and mr imaging (n = 10). ct was performed on a ge hispeed/i scanner (general electric medical systems, milwaukee, wis, usa). 1.0 mm thick direct coronal axial sections were obtained with bone algorithms. mr was performed on a ge signa mr/i with temporal t2 fse thin section 1 mm scan and routine brain axial, coronal, flair, fse t2, se t1, coronal fse t2, sagittal se t1 weighted images. results: there were cochlear aplasia with large vestibule (n = 1), cochlear hypoplasia (n = 1), mondini malformation with large vestibular aqueducts (n = 1), mondini dysplasia with large vestibule (n = 1), large vestibular aqueduct and endolymphatic sac (n = 5), small internal auditory canal (n = 1) and large vestibule (n = 1). four cases were involved unilaterally. seven cases had combined deformities. five cases had cochlear implant. conclusions: both ct and mr can be used to look at inner ear malformations, but often both techniques are complementary. ct is preferred when associated middle or external ear malformations must be excluded. mri is preferred when subtle changes in the membranous labyrinth or abnormalities of the nerves in the internal auditory canal must be visualized. purpose: benign paroxysmal positional vertigo (bppv) is probably the most common cause of vertigo and the most common peripher vestibular disorder. bppv has been postulated to be the result of freely floating debris of degenerative otoconia in the endolymph of a semicircular canal (sc), canalolithiasis or debris that becomes adherent to the cupula of the semicircular canal. the key in determining the diagnosis of bppv is still examination performing positioning manovers and the use of frenzel glasses. differential diagnosis can be difficult. the aim of this study was therefore to provide a new diagnostic approach by 3d-nmr technique. our special interest has been if there was a structural change in the sc or the cupula, which could be identified in patients with incurable vertigo compared to those with self-limited disease. methods and materials: we investigated 10 normal and 10 bppv subjects using a 1.5 t ge mri with 3 d data set: tr 4320, te 238, 1 mm slices, 512 x 512 matrix, 22 x 22 fov, 1.0 nex. results: all bppv patients had pathological filling defect of the sc before therapy which must be considered as an anomaly canalolithiasis. we postulate there must be structural changes in its lumen which makes the endothelium adhesive which is recognizable in hr-3d-mr as a filling defect. conclusion: a significant improvement in quality of high-resolution mri of the inner ear using ciss could be obtained at 3.0 t despite potential drawbacks. to obtain at 1.5 t, the same snr would require approximately double measuring time, optionally increasing the risk for an accidental head movement which may prove detrimental at high resolution. (2), dysplasia of the vestibule with or without abnormality of the lateral scc (2), mondini-deformation (2), cochlear dysplasia and absence of cochlear nerve (1) and dysplasia of the modiolus (1). one patient showed labyrinth hemorrhage at the time of mri. ten cases presented typical clinical features of a progressive hearing loss. in 6 patients a constantly moderate or profound sensorineural hearing loss was present since early childhood. one patient was deaf. one patient suffered from a pendred syndrome. conclusion: a large vestibular aqueduct is a common finding in patients with suspected inner ear malformation. nevertheless, especially in isolated lva, it is sometimes missed in routine work. even if there is no therapy, an early diagnosis is needed to explain to the patient, the cause of hearing loss, the prognosis and behaviour which can possibly delay progression. color digital radiography density measurements in differentiation of periapical granulomas and radicular cysts i.k. rozylo-kalinowska; lublin/pl purpose: the differentiation of periapical granulomas and radicular cysts is crucial for decision on conservative or surgical treatment and therefore influences the success and long-term results of the treatment. although radiograms are a valuable diagnostic tool, relying solely on the evaluation of these images may lead to mistakes in the choice of treatment. the aim of the study was determination of possibile applications of digital radiography density measurements in differentiation of periapical granulomas and radicular cysts of inflammatory origin. the material consisted of 355 digital periapical radiograms obtained using digora, rvg and dixi 2 digital radiography systems in patients aged 20 to 84, divided into two groups: 259 granulomas and 102 radicular cysts. by means of digora 2.0 software, maximum and minimum densities were measured along a line and the difference between these densities was calculated. the largest dimensions of the lesions were measured both perpendicular and parallel to the root canal axis. results: the differences between the results for granulomas and cysts were statistically significant. when the difference of densities exceeded 85.6, the lesion was a cyst and when it was below 45.9, a granuloma was diagnosed. combined application of two criteria, namely the calculated difference between densities and the largest dimension, increased diagnostic possibilities of radiological differentiation of granulomas and radicular cysts. conclusion: it was proved that to some extent it was possible to differentiate granulomas and radicular cysts by means of digital radiography software. ameloblastomas d e f a g x-rays, ct and mri. the use of 3d-ct and dentascan proved especially helpful in determining tumor dimensions. histological examination of the lesions showed that 6 were of the follicular type, 3 presented as mural ameloblastomas, 2 were squamous type, 1 plexiform and 1 was a malignant ameloblastoma. results: in 1 patient the extension of disease was proven inoperable. in 7 patients various types of mandibulectomies along with immediate reconstruction were performed. in 3 cases of mural ameloblastomas local excision only was performed, whereas in 2 patients the mandibular defect was reconstructed with a titanium plate. conclusion: in large monolocular lesions treatment can be conservative surgery, whereas in large multilocular lesions radical surgical treatment that includes segmental ostectomies with immediate reconstruction of either vascularized or autogenous bone grafting is the treatment of choice and produces the best post operative results. the interpretation of the 3d reconstruction images and the dentascan are of great importance when such an operation is decided upon. differential growth in vestibular schwannoma g.c. bockeler, v. nandapalan, t. lesser, h. lewis-jones; liverpool/uk purpose: mri plays a pivotal role in the management of patients with vestibular schwannoma (vs), yet there are no universally agreed guidelines on the use of this expensive investigation. this study analyses the site, size and morphology of vs referred for possible intervention. where clinically a wait-and-watch approach was chosen, growth of vs was determined on subsequent imaging. methods and material: mr images of 78 patients with unilateral vs referred to a tertiary centre were classified according to the site of vs with respect to the internal acoustic canal. a variety of measurements were obtained to determine the most sensitive method of measurement. growth was expressed as absolute and relative change in the direction of the largest increase in size. results: vs showed growth in 35% of patients, 63% remained static and 3% regressed. growth was most frequent in vs with an intra-and extracanalicular component whereas purely intracanalicular vs showed no growth. the initial size did not predict growth. growth rates were largest in predominantly extracanalicular vs. conclusion: our findings confirm previous findings of infrequent and smaller growth in purely intracanalicular vs and more frequent and larger growth in predominantly extracanalicular vs. an incremental delay in follow-up imaging of the former vs appears justifiable in the absence of new symptoms. conversely most vs require close monitoring as even small changes in size may lead to symptoms necessitating invasive treatment. sonographic sialadenitis/sialolithiasis: ultrasound is accurate in the assessment of acute and chronic inflammation and abscess formation. it has replaced sialography in many centres for evaluating suspected stone disease and duct dilatation. granulomatous disease: sarcoidosis and sjögren's syndrome may both involve the submandibular glands. ultrasound is able to delineate the phases of disease progression in sjögren's and is also used in lymphoma surveillance in these patients. other lesions of the submandibular space: including adenopathy, cystic hygroma, brachial cleft cyst, ranula and lipoma may mimic submandibular gland lesions and are readily identified sonographically. conclusion: ultrasound represents a safe, widely available and accurate means of assessing the submandibular space and is able to delineate and characterize lesions. ultrasound can be used to guide aspiration or biopsy and reduce the need for surgical excision. ultrasound-guided core biopsy of the parotid gland: results of 100 patients k.k. lewis 1 , m. williams 2 , d.c. howlett 1 , g. manjaly 1 , a.b. moody 1 , n. violaris 1 ; 1 eastbourne/uk, 2 brighton/uk purpose: to evaluate the role of ultrasound-guided biopsy in the management of palpable parotid lesions. materials and methods: one hundred patients were included in this prospective study over a 5-year period. initial ultrasound examination was performed using a 5-10 mhz high frequency transducer. guided biopsies were taken under local anaesthesia (single operator) with a spring loaded variable throw (15 mm/22 mm) biopsy gun using 18 or 20 g needles with an average of 2 passes per patient. results: in 100 patients, biopsy revealed 50 benign neoplasms, 24 malignant lesions (including 6 primary and 6 secondary lesions as well as 12 lymphomas) and 26 other pathologies including sarcoidosis, tuberculosis, reactive lymphadenopathy, sjogren's and actinomycosis. only 6 lymphoma patients needed surgery for further histological grading. diagnostic accuracy was 100% for benign versus malignant pathology in the 54 patients who underwent subsequent surgery. there was 96% correlation between biopsy and operative histology with only two non-correlates. these involved misdiagnosis of squamous cell carcinoma and mucoepidermoid carcinoma. these would have required further histochemical staining for differentiation. surgery was avoided in forty-six patients after biopsy diagnosis. there were no immediate complications of biopsy. conclusion: ultrasound guided biopsy gives 100% benign versus malignant pathological differentiation. it also has 96% correlation with operative histology. correct pre-operative diagnosis influences the decision to undertake conservative or radical surgery and unnecessary surgery can be avoided. a core of tissue allows histopathological analysis where assessment of tissue architecture, tumour grading and immunochemical staining is possible. this is invaluable for accurate diagnosis. contrast enhancement of the cochlear aqueduct in mr imaging: its frequency and clinical significance t. nakamura 1 , s. naganawa 1 , h. fukatsu 1 , y. sakurai 1 , i. aoki 2 , a. ninomiya 2 , t. nakashima 1 , t. ishigaki 1 ; 1 nagoya/jp, 2 tochigi/jp purpose: there have been no previous reports on contrast enhancement of the cochlear aqueduct in magnetic resonance (mr) imaging. the purpose of the present study was to evaluate the frequency and significance of this finding. methods and materials: thirty-one patients (15 men and 16 women; age range 18-81 years) with otologic symptoms (sudden sensorineural hearing loss, vertigo or tinnitus) were examined using contrast-enhanced imaging on a 1.5 t mr scanner. the normal ear served as the control. two radiologists evaluated contrast enhancement in the area of the cochlear aqueduct. result: forty-eight of 62 ears (77.4%) showed contrast enhancement of the cochlear aqueduct, but no significant differences in the frequency of contrast enhancement were observed between patients with and patients without vertigo, tinnitus, sensorineural hearing loss, cerebellopontine angle tumors or a highriding jugular bulb. in addition, no gender or age-related differences were noted. conculusion: contrast enhancement of the cochlear aqueduct was frequently observed, but the frequency of enhancement in symptomatic ears was not significantly higher than in control ears. the results of this study may prove helpful in avoiding unnecessary examinations and potential diagnostic confusion. high-resolution mr imaging of basaliomas of the facial soft tissue with a microscopy coil h. gufler, c. zörb, w.s. rau; giessen/de purpose: to correlate the tumor extension measured on high-resolution mr images with histology. patients and methods: five patients with basaliomas of the facial soft tissue were examined before surgery with high-resolution mri using a 1.5 tesla system with a 47 mm microscopy coil. axial t1-and t2-weighted tse images were obtained from all patients before gd-dtpa application and additional axial and/ or sagittal t1-weighted sequences with and without fat suppression after cm application (fov 60 mm, matrix 256 x 256, slice thickness 1.5 mm, acquisition time 5-7 minutes). qualitative analysis of mr images was performed by two radiologists who measured the extension of the tumor and decided whether bone erosion or infiltration of the orbit or of the nasal cartilage was present. results: t1-weighted unenhanced axial images proved to be the most useful sequences in predicting the extension of the basaliomas. for the evaluation of b d e f a g orbital invasion, additional sagittal t1-weighted unenhanced images were helpful. the extension of the lesions correlated well with the results on histology. in one case, however, nasal cartilage infiltration was not correctly diagnosed on the basis of high resolution mr. conclusion: high-resolution mr imaging using a microscopy coil is a promising method to predict the exact extension of basaliomas of the facial soft tissue. three orbit mri of the superior oblique muscles to measure the asymmetry in patients with iv nerve paresis m.a. eleta, f. shokida, f. seclen, j. gabriel, c. zanchez, f.a. eleta; buenos aires/ar purpose: to evaluate the section of the superior oblique muscles (so) in patients with unilateral congenital or acquired pareses to detect asymmetry and the relationship between the degree of vertical deviation and mri measurements. method and materials: from march 1999 to september 2002, 32 patients underwent orbits mri. seventeen patients had unilateral so muscle paresis: 13 congenital and 4 acquired. fifteen patients had normal so. the area of the superior oblique muscle in the section of maximun width was obtained in primary gaze position, supra and infraversion. asymmetry of the superior oblique muscles was defined arbitrarily as the difference between both so in the same patient and the measurement was compared with the values obtained in the normal group of patients. results: mean maximal difference was 14.2 ± 3.3 mm 2 (p < 0.01) between the healthy and paretic eye. in the normal group of patients it was 4.3 ± 1.6 mm 2 (p < 0.02). eleven out of the 13 patients with congenital paresis showed asymmetry of the superior oblique (84. 6%). asymmetry determination of the superior oblique muscles disclosed 76.5% sensitivity and 97% specificity. the relationship between vertical deviation and the maximal difference between the section of the normal versus the paretic eye was p > 0.05. conclusion: imaging of the superior oblique muscles in patients with congenital iv nerve paresis showed significant asymmetry in the section area with regard to the contralateral muscle. however, no correlation was found between the degree of vertical deviation and interocular asymmetry. high resolution gray scale and color doppler imaging was performed in more than 100 patients using a high frequency linear array transducer. various planes of imaging of the eye correlating with drawings of normal anatomy are shown. views are used to illustrate the complex anatomical relationships. an overview of the normal anatomy and pathologic conditions is presented with clinical correlation. results: evaluation with high resolution gray-scale and color doppler ultrasound can often determine diagnosis without further imaging procedures. us is sometimes insufficient to evaluating a deep structures of the orbit. paradigmatic us images from different pathologic entities of the eye (for instance: intraocular foreign bodies, haematoma, cataract, vitreal pathology and ablation of the retina etc.) are shown. conclusion: adequate knowledge of the anatomy of the eye and orbit is needed to correctly limit the differential diagnostic possibility of pathology of the eye and orbit. us is an available method for an accurate diagnosis of the eye with ct, and preferably mr, being reserved for cases which require additional information about deep structure, or those with in which there is discrepancy between the sonographic and clinical diagnosis. nasopharyngeal angiofibroma: the role of angiography in diagnosis and treatment a. szymanska, r. pietura, a. drelich-zbroja, m. szymanski, m. szczerbo-trojanowska; lublin/pl background: nasopharyngeal angiofibroma (na) is a rare, benign, unencapsulated tumour affecting adolescent males. surgery and radiotherapy are main treatment modalities. we evaluated typical angiography findings of na, its role in defining tumour blood supply and treatment planning. material and methods: forty patients with jna (38 males and 2 females aged 12 to 57) underwent angiography. we assessed tumour vascular composition, its location in relation to the maxillary artery (ma), feeding vessels and feasibility of preoperative embolization. relationship between stage of tumour, presence of intracranial extension and internal carotid artery (ica) blood supply were statistically evaluated. results: on angiograms, all tumours presented intensive inhomogenous blush. 97.5% of tumours were supplied by ma, 15% by ascending pharyngeal and 7.5% by the facial artery. in 30% of tumours, feeding vessels originated from the ica and in 1 (2.5%) case from the vertebral artery. the relationship between ica blood supply and tumour stage was statistically significant. ica blood supply had no correlation with the presence of tumour intracranial extension. two patients with abundant ica supply were disqualified from surgery and underwent irradiation. in 2 patients with previous external carotid atery ligation, preoperative embolization of vascular recurrent tumour was not feasible. in 33% of cases ma was displaced by tumour lateral extension. conclusions: angiography shows typical features of na (nasopharyngeal, highly vascular tumour supplied by ma), confirms diagnosis of this tumour and enables preoperative embolization. analysis of tumour blood supply is useful in determining best therapeutic approach. angiography visualises displaced ma, which helps the surgeon identify and ligate it during tumour removal. is an increased capsular width a reliable indirect indicator of temporomandibular joint effusion? f. tognini 1 , d. manfredini 1 , v. zampa 1 , g. tognini 2 , m. bosco 1 ; 1 pisa/it, 2 parma/it purpose: to establish the most accurate cut-off value of ultrasonographic (us) capsular width which consents to discriminate between temporomandibular joints (tmj) with and without magnetic resonance (mr) effusion. the study group consisted of 69 patients who sought treatment for temporomandibular disorders (tmd). all the tmjs (n = 138) were evaluated in order to detect the presence of effusion by means of us and mr. ultrasonographic examination allowed measurement of the capsular width, in the sagittal-oblique scans, as the distance between the hyperechoic lines representing condylar surface and the glenoid fossa. after capsular width was measured, roc curve analysis was performed to establish the most accurate cut-off value to discriminate between joints with and without mr effusion. results: diagnostic accuracy of us to predict mr evidence of tmj effusion was good (area under the roc curve = 0.817). us sensitivity was high for values lower than the cut-off value of 1.95 mm (true positive rate (tpr) = 83.9%; false positive rate (fpr) = 26.3%), while specificity was high for values higher than the cut-off value of 2.15 mm (tpr = 71.0%; fpr = 11.8%). conclusion: ultrasonography proved to be accurate in detecting the presence of effusion in the temporomandibular joint. analysis of receiver operating characteristic curve seems to reveal that the critical area of capsular width indicating effusion is that around the value of 2 mm. patients were referred for ct angiography of carotid arteries in our institution. of these patients, 10 were found to have carotid body tumors and were included in the study. all tumors were confirmed with several imaging modalities (us, msct, mr, digital subtraction angiography and somatostatin scintigraphy) and with histologic examination performed on the resected surgical specimen. imaging findings: the us (including power-and color-doppler scanning), msct angiography, mr angiography, digital subtraction angiography and somatostatin scintigraphy findings of 12 carotid body tumors were reviewed. tumors were unilateral in eight cases and bilateral in the remaining two patients. all lesions were well-defined (ranging in size from 1.0 to 6.5 cm) and located within the carotid bifurcation, causing splaying of the carotid branches. all tumors were highly vascularized (mainly by branches of the external carotid artery) and no sign of malignancy was identified. after pre-operative embolization, all lesions were surgically removed with no complications and were confirmed to be carotid body tumors at histology. the diagnostic possibility of a carotid body tumor has to be considered when a solid mass is detected within the carotid bifurcation. imaging studies are essential to differentiate carotid body tumors from other masses of the neck (lymphadenopathy, tumors, cysts, etc). imaging background: evaluation of cervical spaces is an important procedure for patients with cervical pathology because it assesses the prognosis of the patients and helps to select adequate treatment. ultrasound, computed tomography and magnetic resonance play an important role in the imaging diagnosis of this area. however, before examination of pathology, a clear understanding of the anatomy of cervical spaces is essential. the neck is divided into eight regions, enabling the radiologist to examine all areas of the neck in a systematic way in order not to miss a lesion. procedure details: we have reviewed all the normal studies of the neck that were performed during the last year using at least one of the three techniques. we selected the most illustrated cases to describe the anatomy of the cervical spaces. the neck is a complex anatomic area. this education exhibit helps the radiologist to have a better knowledge of imaging of the cervical spaces. preoperatively, the thyroid nodules were assesed in terms of number, compressibility, texture, complexity, margins, volume, vascularity, interactions with great vessels and the presence of thyroid, parathyroid and cervical lymph nodes. 3d usa multiplanar reconstructions (mpr) reslicing thyroid nodules for virtual surgery were created. us results were compared with intra-operative findings and final pathomorphology. results: fifty-three patients had operations (39 lobectomies, 7 thyreoidectomies including 2 with lympadenectomies and 7 thyroid resections). six cancers, 26 adenomas, 15 colloid nodules, 14 goiters and 9 with thyroiditis were found. demonstration of the nodules in three orthogonal planes by 3d usa and assessment of the nodule's character and vascularity helped to change surgical management in 8 cases; in 2 cases post puncture morphological diagnosis and in 9 cases operation was rejected. 3d usa was superior to conventional 2d in differential diagnosis of thyroid nodules. the preliminary decision to perform a lobectomy or a total thyroidectomy was based on variety of factors, many of which were delineated by detailed ultrasound examination. preoperative evaluation of thyroid vascular anatomy and mpr of the nodules were of value for changing surgical management for thyroid resections and in rejecting the necessity of operation. conclusions: 3d usa is a useful complement to conventional ultrasound that allows precise preoperative evaluation of thyroid nodules which influences surgical management. the value of mr imaging and mr angiography in the differential diagnosis of carotid space tumors p. virtual laryngoscopy: comparison with fiberoptic laryngoscopical findings z. celej 1 , a. wygoda 1 , c. przeorek 1 , w. przeorek 1 , j. baron 2 , a. siemianowicz 2 ; 1 gliwice/pl, 2 katowice/pl purpose: to evaluate the concordance between virtual and direct laryngoscopy in the estimation of laryngeal carcinoma staging. material and methods: multislice ct and direct laryngoscopy were used to examine 10 patients with laryngeal carcinoma. ct data were obtained on a sixteen row detector (0.75 mm slice thickness, pitch factor 1) during free breathing and "e" phonation both before and after contrast enhancement. the patients were examined before radiotherapy and surgical treatment. postprocessing was performed using multiplanar rendering (mpr) and virtual laryngoscopy (vl) as a surface rendering algorithm with boundary density of -600,-400 and -200 hu. all ct examination results (mpr and vl) were compared with fiberoscopy. virtual images created at boundary density of -200 hu revealed better concordance to direct laryngoscopy. every case of laryngeal carcinoma, even plain infiltration at t1 stage, was correctly diagnosed by virtual endoscopy. the disorder of vocal cord function was better demonstrated in fiberoscopy. virtual laryngoscopy is complementary to fiberoptic endoscopy and should be combined with axial slices and mpr images for the estimation of laryngeal carcinoma staging. ultrasound characteristics and histopathologic correlation in primary thyroid carcinomas c. to describe the technique and problems related to spect/ pet/ct/us image fusion in the neck region and to demonstrate the clinical relevance of the information gained by multimodality imaging on a series of 58 patients with neck tumors, lymph node metastasis, graves disease and chronic ent inflammations. background: small tumors or subtle changes in inflammatory diseases cannot be detected in only one imaging series. multimodality imaging allows for a combination of functional and anatomical information in one dataset and therefore gives more detailed informations on distinct changes. procedure details: for reproducible immobilization of the patient, an individual mold of the patient's head, neck and shoulder was produced using the bodyfix vacuum device (medical intelligence, schwabmünchen, germany). up to 8 modality-specific markers were reproducibly attached to the skin and to the mold. the data-sets were transferred to the treon stealthstation navigation system (medtronic inc.) and image fusion was performed based on the markers and anatomical landmarks. image fusion allowed precise correlation of suspicious tracer-enhancements to tumorous contrast-enhanced nodules on the ct images. in patients with graves disease and ent inflammations focal disease in homogeneous tissues was uncovered due to increased tracer uptake. us images were used for screening and to depict vascularisation. the presented method aids in the detection of tumors and lymph node metastasis in the neck area, influencing the surgical strategy in most patients. in patients with graves disease and chronic inflammations the real amount of inflammation can be determined. lemierre's syndrome (necrobacillosis): the imaging findings s. powell, m. powell, d. bakshi, j. evans; liverpool/uk learning objectives: the purpose of our poster is to demonstrate the imaging findings in the rare and interesting lemierre's syndrome (necrobacillosis), to heighten clinincal suspicion and therefore allow more rapid diagnosis. background: lemierre's syndrome is the triad of pharyngitis, internal jugular vein thrombosis and pulmonary infection. the causative organism is fusobacterium necrophorum. this is a commonly fatal disease requiring both the radiologist and clinician to keep an index of suspicion. the diagnostic findings include pharyngitis with direct local invasion into the lateral pharyngeal space and thrombophlebitis of the internal jugular vein. metastatic infection is common and the usual site is pulmonary (80%). imaging findings: the imaging findings include pharyngitis with direct spread of infection into the lateral pharyngeal spaces. internal jugular vein thrombosis and pulmonary infiltration leading to cavitation are the next most common findings.other findings include pleural effusions, spinal and brain abscesses, septic arthritis and ivc thrombosis. a variety of imaging modalities are employed to assess the patient with disseminated fusobacterial infection. conclusion: our poster aims to provide a comprehensive collection of imaging findings in lemierre's syndrome. lymph node staging in head and neck cancer: a pictorial review s. connolly, h. lewis-jones, r. hanlon; liverpool/uk learning objective: the purpose of this poster is to describe and show the anatomical location of the lymph node levels as described by the american joint committee on cancer. it will also cover some of the difficult diagnostic areas involved in reporting head and neck staging images. background: as a radiological department attached to a large head and neck unit, we have wide experience of head and neck cancer. the extent and level of cervical node involvement is probably the most important prognostic factor for patients with a primary squamous cell carcinoma. node level has also been shown to be a highly significant predictor of survival. procedure details: using anatomical drawings and cross sectional images of pathology that we have encountered in our department, we will show examples of nodes in the described levels. the pictorial review will include examples of normal reactive nodes as well as typical examples of extracapsular spread, squamous cell cancer metastatic nodes and lymphoma. we will also depict some of the more unusual cases we have experienced, such as histologically proven recurrent metastatic nodes, which on imaging grounds appeared benign and cystic, along with some examples of intraparotid nodal disease. the pictorial review will allow greater understanding of the staging process of head and neck cancer and its implication on patient prognosis and survival. ten patients with squamous cell carcinoma of the neck (t2-4, n2-3) planned for primary radiochemotherapy were examined at several time points in the course of the 6 weeks therapy (before, after beginning, and at 3 and 6 weeks). the examinations were performed with aplio us-system (toshiba) with 7.5 mhz broadband transducer. pd and adf (either 2d and 3d) were applied pre and post application of ultrasound contrast agent (intravenous bolus of 2.4 ml sonovue). the methods were compared by visual assessment. results: both ce adf and pd are sufficient to depict blood supply. while pd delivers better b-mode information, adf allows continuous examination due to the lower mi thus giving more time to acquire 3d data set and determining signal intensity time curve after one bolus application of contrast. adf showed less artifacts concerning blooming and cluttering in number and extent in almost all cases. in 5 cases, we were able to demonstrate a perfusion after 6 weeks of therapy but in 3 it was only possible using ce techniques. conclusion: although pd delivers more b-mode information adf is the method of choice since it has the same sensitivity for detecting blood vessels but allows continuous examination and is less susceptible for artifacts. conclusion: percutaneous islet cell transplantation appears to be a simple and clinical promising radiological intervention and an alternative to surgical pancreas transplantation in patients with type 1 diabetes refractory to insulin therapy. imaging findings and procedure details: diagnostic imaging and interventional minimally invasive percutaneous procedures in disk diseases are reviewed through an interactive hypertext-based teaching file with images and movie demonstrations. ct, mr imaging and discogram findings in disk pathology will be described including degenerative disk diseases, spondylosis, disk herniations, traumatic disk diseases, septic diskitis, and postoperative disk diseases. techniques, indications, contraindications, complications and results of percutaneous minimally invasive procedures of intervertebral disk diseases will be described and illustrated. these procedures include percutaneous periradicular and epidural steroids injection, percutaneous diskogram, diskal biopsy and drainage, percutaneous radiofrequency and laser nucleotomy. conclusion: for disk disease with appropriate indications, minimally invasive interventional radiologic procedures are able to relieve pain and to minimize the risk of disability. colonic stents in acute malignant colorectal obstruction: 78 cases p. bermudez bencerrey, j. falco fages, j. perendreu sans, j. fortuño andrés, m. alcantara moral, d. gil bello; sabadell/es learning objectives: to illustrate our experience with colonic stents in the treatment of acute obstruction from colorectal cancer. to describe the results and complications of the procedure based on a series of 78 patients. background: colorectal cancer is an important health problem with a high morbidity and mortality rate. between 10-30% of patients with colon cancer present with acute obstruction. 70% of acute obstructions are in the left colon and rectum, and only 40% of left sided carcinoma colonic obstructions can be treated with intraoperative lavage and subtotal colectomy. the rest of the patients need a temporary or, more probably, permanent colostomy with an important impact on quality of life. in this exhibit we will describe the use of colonic stents as a temporary treatment prior to elective surgery of left sided colon and rectal cancer and as a palliative treatment in the unresectable colon cancer. between july 1997 and august 2003, 78 patients with acute colonic obstruction were treated with colonic stents in our department. the procedure, indications, contraindications, and the results are described and illustrated. procedure details: plain abdominal radiography and abdominal ct was performed to all patients prior to the procedure. two different types of colon stents were used: enteral wallstent (boston scientific) and hanarostent (mitech co., ltd.) conclusion: clinical resolution of the obstruction was achieved in 84%. anastomosis was successfully performed in 95% of the patients undergoing surgery. major complications developed in 13% (5 perforations, 5 obstructions and 3 migrations). palliative treatment was effective in all cases. saline injection of solid tumours prior to radiofrequency ablation: our experience a.m. camenzuli, a. attard, j.c. evans; liverpool/uk learning objectives: 1. to outline the procedure we have adopted to instil saline into the tumour. 2. to describe the appearances of complete necrosis on the inital, early and late follow-up scans. 3. to describe the complications and patterns of recurrence of tumours after radiofrequency ablation. background: the injection of saline to potentiate the effects of radiofrequency ablation in solid organ tumours in experimental models is well described in the literature. we have injected saline prior to ablation into primary hepatocellular carcinomas, colorectal metastases to the liver and primary renal cell carcinomas. procedure and iimaging details: using either ultrasound guidance or ct and under general anaesthesia, we lace the tumour with 5 ml of 30% saline via a coaxial needle. a radioablation probe is then placed along the needle -the latter is then removed prior to applying the rf pulse. we routinely ablate the track along which the probe has travelled to avoid seeding. routine follow-up with a dual phase abdominal ct scan is done at 1 month and 3 months. the appearances of ablated tumours, recurrences and complications are reviewed in this presentation. conclusion: saline infiltration is a safe and effective way of potentiating radiofrequency ablation of solid tumours in the liver and kidneys. percutaneous background: renal abscess is a collection of purulent material confined to the renal parenchyma. it is often life threatening leading to septicemia and is difficult to manage only with the use of antibiotics especially in immuno-compromised patients. ct is currently the most accurate modality in detecting and following renal abscesses. treatment with ct-guided percutaneous drainage and appropriate antibiotics can be very useful. in a period of two years we treated 13 patients with renal abscesses. we demonstrate the technique and discuss the indications and complications of ct-guided percutaneous drainage of renal abscesses. the procedure is performed with the patient in prone position under local anesthesia supplemented with minimal sedation. initially a 22gauge chiba needle is passed into the renal abscess under ct guidance. on confirmation of an abscess we use a pigtail trocar catheter of 8 to 10f for the drainage. conclusion: ct-guided percutaneous drainage is an effective and well-tolerated method for the therapeutic management of renal abscesses. the imaging features and percutaneous drainage of mediastinal abscesses secondary to oropharyngeal infection s. sadiq, s. owen, r. evans; swansea/uk learning objectives: oropharyngeal infection, such as dental abscess and acute pharyngitis, are recognised but rare causes of mediastinal abscess formation. we highlight the use of multimodality imaging and percutaneous image guided drainage. the hospital records of four such patients, including casenotes, microbiology data and imaging were reviewed. the clinical courses were followed in order to identify the causative pathogen and illustrate the imaging features and subsequent radiological interventional management. the patients presented over a two-year period. the age range of these patients was sixteen to forty seven. the primary aetiology in three patients was a dental abscess. the fourth patient had an acute pharyngitis. image findings: a combination of ultrasound (us), computed tomography (ct) and magnetic resonance imaging (mri) of the neck and thorax was used to define the anatomical compartments involved. radiological placement of an 8fpigtail catheter using us or ct avoided a major surgical procedure in all patients. the common pathogen isolated was streptococcus viridens. patients were treated with the appropriate antibiotics and all made an uneventful recovery. conclusion: an understanding of the anatomical spaces of the neck and their communication with the mediastinum is demonstrated and we recommend that in this condition, which has a high mortality when managed surgically, interventional radiology is an effective treatment option with a low complication rate. complications occurring after drainage are not uncommon and add to the morbidity of the procedure. the authors display their experience in handling complications (remedial procedures with appropriate images) that occurred in 100 patients with malignant biliary obstruction, in whom ptbd and/or stenting was performed over a 2-year-period. the authors will also list precautions to be observed to prevent such complications. procedure details: severe hemorrhage was treated by catheter repositioning, angiographic embolization of pseudoaneurysm and coil embolization of a portal vein branch rent via a ptbd tract. cholangitis and bilomas required placement of additional drainage catheters. a migrated plastic stent was repositioned with vascular snare. a ring biliary catheter that broke during procedure, the proximal part lying in peritoneal cavity, was removed by image guided forceps, followed by replacement. blocked plastic stents were removed endoscopically or via the percutaneous route by canulation with a guidewire followed by replacement. ring biliary catheter and additional stents plastic/metallic stents were used for blocked metallic stents. pericatheter leaks responded to flushing, wire passage or larger catheter exchange. conclusion: it is important to be aware of complications that occur during ptbd and stenting, and how to deal with them before embarking on a full time biliary decompression program. intellectual property: development and protection c. cook 1 , m. rees 2 ; 1 weston-super-mare/uk, 2 bristol/uk learning objective: to discuss the different methods of intellectual property (ip) protection. to review the methods of interventional radiology device product development. background: there are many ways of protecting intellectual property. we discuss each of these in turn. we discuss the differences between the methods used in the united states and the european union. we also discuss the methods of product development. details: trademark, copyright, patents are all reviewed. we discuss the need for patent attorneys and specialist ip management units. we describe the different types and levels of protection available. we also discuss specific means by which an idea can be developed, then protected. we look at the methods available to link with development companies, leading to manufacture. all the principles are specifically discussed with respect to the development of a interventional radiological device. there are numerous ways of protecting ip, and we describe each of these in turn. in addition we look at the means of developing and ultimately manufacturing a radiological interventional device. purpose: ethanol injection (pei) and radiofrequency (rf) are the percutaneous radical therapies most frequently employed in europe to treat liver tumors in non surgical patients. we present our experience in these techniques over the last 16 years at the hospital clinic in barcelona. since 1987 multisession pei was applied in 328 patients with hepatocellular carcinoma (hcc) (uninodular ≤ 5 cm or multinodular 3 ≤ 3 cm). rf was performed in 114 patients since 1998: 73 hcc, 39 metastasis and 2 others. ct and us (with contrast agents in the later years) were used for efficacy assessment. results: pei: initial complete response (cr) = 70.4%. extra and intratumoral recurrence = 20 and 22%. one, 3 and 5 year survival rates in child a patients = 90, 58 and 38% and in child b patients = 79, 35 and 12% (mean follow-up = 48 months). rf: cr in hcc patients = 67%. extra and intratumoral recurrence = 19 and 17%. one, 2 and 3 years survival rates = 83, 68 and 52% (mean follow-up = 30 months). in patients with metastasis cr = 61%, with a recurrence rate = 41% (mean follow-up = 12 months). major complications, that includes hemoperitoneum, liver abscess, needle-tract seeding and cardiovascular death are 1.5% in pei and 6.1% in rf. conclusion: pei and rf are effective local curative methods in liver tumors, with more frequent major complications in the rf group. and excellent (7-10). the efficacy was also evaluated with the days until the patients unable to move started to walk again after pvp. results: pvp was technically successful in all patients with three cases of minimal complications. the mean vas score for 198 patients was 7.16 before pvp compared with 2.05 after the procedure. on the degree of improvement, the groups of ineffective, poor, effective and excellent consisted of 4.0, 9.6, 56.1 and 30.3% of patients, respectively. 166 patients (86.5%) could walk the next day after pvp and the mean value until ambulation was 1.56 days. conclusion: pvp is a safe and effective treatment for relieving severe pain of osteoporotic vertebral compression fractures, leading to avoid various complications associated with prolonged immobilization in aged patients. effect of vessel size on creation of pulmonary radiofrequency lesions in sheep: assessment of the "heat sink" effect k. steinke 1 , k.s. haghighi 2 , k.k. hazratwala 2 , d.l. morris 2 ; 1 basle/ch, 2 sydney/au purpose: to evaluate the effect of vessel size on radiofrequency lesion creation in the lung with respect to potential for perfusion-mediated heat sink effect and for vascular and bronchial injury. methodology: radiofrequency lesions targeted to tissue encompassing a variety of vessels were created in vivo in the lung of 10 cross-bred sheep. the access was either open after thoracotomy along the 5 th intercostal space, or percutaneous. acute, subacute and chronic changes have been investigated, with immediate, 96 hours and 28 days sacrifice of the sheep post ablation. macroscopic and histopathologic analysis of the vessels and bronchi was performed. the degree of vascular and bronchial injury and viability of perivascular pneumocytes were recorded. results: heat sink effect, macroscopically indicated by invagination of the lung tissue between the vessel and the radiofrequency lesion, was not observed in vessels with a diameter less than 3 mm. half of the vessels 3 mm or smaller were thrombosed, while the arteries of the same size looked to be patent. macroscopically no vessel wall injury could be detected. all vessels 5 mm and above showed a certain extent of invagination, no clots were visible. occasionally within the bronchial lumen small amounts of dark solid material was seen, macroscopically believed to be consolidated blood-tinged sputum. the histopathological results are expected soon. conclusion: as already shown for liver vessels, lung vessels seem to also have a perfusion-related heat sink effect, consistently seen in vessels above 5 mm in diameter. peritoneal seeding of hepatocellular carcinoma after radiofrequency ablation: post-rf bleeding was detected in 4 cases. two of these patients had hepatic arterial embolization performed due to severe bleeding. in terms of seeding pattern, massive perihepatic and ometal masses were seen in 2 cases and multiple small peritoneal nodules were noted in a further 2 cases. other cases showed 1 small single mesenteric mass and 1 gastrohepatic ligament thickening. the rate of peritoneal tumor seeding after rf ablation of hcc was 2.7%. the capsular attachment, tumor bulging and post-rf bleeding seems to be risk factor of peritoneal seeding after rf ablation of hcc. r. marcello, l. broglia, m. castellana, g. gasparini, m. castrucci; rome/it purpose: the aim of our study was the evaluation of the spio contrast-enhanced mr pattern of malignant focal liver lesions treated with percutaneous radiofrequency ablation. methods and materials: 23 focal liver lesions were evaluated with magnetic resonance (1.5 tesla philips, the netherlands), with spio (resovist schering, germany) contrast media after rf percutaneous ablation. lesions ranged in size from 1.6 cm. to 5.0 cm. mr examination sequences protocol was as follows: tfe t1w and ffe dynamic study before contrast media injection and after 15 and 40 sec spio iv administration; tse t2w and spir tse t2w before contrast media injection and after 10-13 min after spio injection. all patients underwent mr imaging evaluation after 10 days, 30 days and 3 months the procedure was carried out. the signal intensity appearance was examined in order to identify size, signs of absence, residual or recurrence of neoplastic tissue. the gold-standard was clinical and ct imaging follow-up. results: spio enhanced sequences were superior in conspicuity, presence or absence and residual or recurrence of tumoral tissue. in 60% of lesions a homogeneous pattern was observed within the lesion with a hyperintense peripheral rim; in 20% of cases inhomogeneity of lesions was observed in examinations performed at 10 days. residual tumor was depicted at 30 days examination as presence of hyperintense foci localized within the treated area. in this preliminary study spio appeared to be an efficacious contrast agent for detection and follow-up of percutaneous rf ablated focal hepatic lesions, especially on t2w and the 40 sec t1w dynamic mr study. radiofrequency ablation of hepatic dome lesions g. papaioannou, l. thanos, a. nikita, e. alexopoulou, d. loggitsi, d.a. kelekis; athens/gr purpose: to present the additional difficulties and technical peculiarities of radiofrequency ablation (rf) for hepatic dome lesions. materials and methods: 19 patients with focal subphrenic hepatic lesions (8 hccs, 11 metastases) underwent percutaneous ct-guided rf ablation. electrodes with 7 or 9 active tips were advanced under ct-guidance. although technically difficult due to the great needle angulation and penetration of a long hepatic portion, transhepatic route was followed in all cases. transpulmonary penetration was considered high-risk due to the large diameter of the electrode. results: all patients experienced mild discomfort during the procedure. three complications were noted: 2 small subcapsular hematomas and 1 pleural effusion, which were treated conservatively. 75% of the hccs and 81.2% of the metastatic lesions showed signs of complete necrosis immediately post procedure. residual non-necrotic tumour was present in 4 cases and repetition of the procedure was required. tumour recurrence was demonstrated in 2 patients (10.52%) on 1-year follow-up control and was treated with a new session of rf ablation. overall, 25 rf sessions were performed. conclusion: hepatic dome lesions can be treated successfully with rf ablation. careful planning and technical skill are required due to their location. results: no treatment complications were noted. the patients recovered well post injection. ct performed in both children after three months showed ossification of the lytic lesions, allowing the cervical braces to be removed. conclusions: to our knowledge no prior experience in endosteal cervical steroid injection has been reported. these two cases confirm the improvement of osteolytic lesions in children with lch after treatment with endosteal infusion of steroids. stabilisation of the cervical spine was particularly beneficial, as the children were no longer in pain and removed the need for cervical braces three months after the treatment. the influence of radiofrequency ablation on hepatic vessels in porcine liver k. satoh, k. nakamura, m. hamuro, y. sakai, n. nishida, y. inoue, r. yamada; osaka/jp purpose: the objective of this study was to clarify the influence of radiofrequency ablation on hepatic blood vessels. hepatic rfa was performed on 18 swine (mean body weight: 22 kg). the livers were removed either immediately following ablation, 1 week or 3 weeks after ablation. the patency of vessel was determined by ct, and the extent of endothelial disorder with diameter less than 1.0 mm was determined histopathologicaly. the portal vein patency rate of immediately, or 3 weeks after rfa were: 43.5 ± 6.9%, 11.7 ± 20.3% (less than 1.0 mm), 76.5 ± 20.9%, 75.5 ± 25.1% (3.0 mm and more). hepatic vein patency rate were: 42.5 ± 21.0%, 5.6 ± 9.7% (less than 1.0 mm), 76.9 ± 14.1%, 75.6 ± 30.8% (3.0 mm and more). the patency rate was higher for larger vessel diameters. the patency rate of the portal and hepatic veins with diameters less than 3.0 mm was found to decrease with time. at 3 weeks after ablation, the patency rate for vessels with diameters of 3.0 mm and over were significantly higher (p < 0.05) compared to those of diameters less than 2.0 mm. endothelialization were found in patent vessels from 1 week to 3 weeks after ablation. conclusion: endothelization was confirmed from 1 week to 3 weeks after rfa in patent vessels. blood vessels with diameters of 3.0 mm and over maintain high patency even after rfa. it is therefore possible to maintain blood flow in the distal area of hepatic parenchyma following ablation for hepatic tumors, thus rfa has a limited impact on hepatic function. in three cases, a successful second trial after an initial failure was performed. the procedure was performed by means of a transhepatic (n = 63) or a transperitonea l (n = 76) access route. during procedure, the seldinger technique was used (transhepatic approach, n = 63, transperitoneal approach, n = 62) in 125 patients, while in the remaining 14 patients the procedure were performed using a trocar technique with a transperitoneal approach. chiba needles (20g, mdtech, denmark, n = 22), jelco needles (16g, johnson & johnson, usa, n = 67) and secalon catheters (16g, ohmeda, uk, n = 36) were used for initial puncture of gb. only minor complications such as abdominal pain (n = 16), hemorrhage (n = 2), referred pain (n = 4) occurred in 21 cases (15%). abdominal pain is more frequent in transhepatic approach (18%) than in transperitoneal approach (7%), but not statistically significant (p = 0.061). overall complication rate is lower in transperitoneal approach (8%) than in transhepatic approach (24%)(p = 0.016). according to puncture needle, there is no significant difference in complication rate between the chiba needle (18%) and the 16 g needle (jelco needle and secalon catheter, 16%). conclusion: percutaneous cholecystostomy has proved to be safe and effective treatment for patients with acute cholecystitis. t.v. bartolotta, t. angileri, m. midiri, f. sorrentino, g. sparacia, a. carcione; palermo/it purpose: to evaluate the ct role in treatment of lumbosciatalgia through chemonucleolysis with oxygen-ozone (o2-o3) mixture with periradicular and periganglionic technique. materials and methods: from january 2000 to june 2002, 145 patients (85 women, 60 men; age range: 30-75 years) with lumbosciatalgia, underwent intradiscal, periradicular and periganglionic treatment with o2-o3 mixture, corticosteroids and anaesthetics. the analysis of the results was made by visual analogue scale (vas) 1 day before treatment (t0) and, respectively, 4 weeks (t1), 3 months (t2), 6 months (t3) later. all the procedure was performed in a step-wise fashion and controlled by ct scans: from positioning the needle in the centre of the nucleus polposus to mixture administration within the nucleus and in periradicular and periganglionic sites. results: in 125/145 (86.2%) patients a partial remission of the complaints just after the first treatment (vas 6 at t1) was observed; vas was 4 at t2 and at the last evaluation, six months later (t3), it was 2. in 20/145 (13.8%) patients vas was 8 at t1 and another treatment was performed, with an improvement of vas at t2 and t3 respectively of 6 and 3 in 15/20 cases. the remaining 5/20 patients did not show any improvement even after the second treatment and vas ranged from 8 to 10 at t3. conclusions: chemonucleolysis with o2-o3 mixture with periradicular and periganglionic technique under ct guidance is a reliable and competitive method in treatment of lumbosciatalgia. multiple in 22 patients with malignant biliary obstruction of the hilum and unavailable bilateral access, drainage of biliary tree was obtained with one percutaneous access through which multiple stent deployment was performed with a cross-positioning technique. the first self-expandable endoprosthesis was positioned in the common bile duct. thereafter a balloon catheter was inserted along a previously introduced guide wire to dilate the mesh of the stent. after having removed the catheter, a second stent was implanted through the dilated wall of the first stent, across the hilum. overall 47 stents have been cross-implanted. in 20 patients 2 stents have been inserted, in 1 patient 3 stents, in another patient cross-positioning of 4 stents was required. results: no relevant complications have occurred. patient survival and stent patency rates were comparable with those of multiple-access stenting technique. the procedure is generally more protracted implying an increased radiation exposure for both the patient and the operator. conclusion: biliary stenting with one percutaneous access and cross-positioning technique is a useful procedure in all cases in which bilateral access in not possible. it reduces the risks connected to multiple passages of liver parenchyma though at the expense of a longer time of exposure for both the patient and the radiologist. results: in 10 (91%) patients pain relief was complete within one to two days after injection. one (9%) patient with multilevel hemangioma failed to respond. we did not observe any complications. conclusion: percutaneous vertebroplasty is a promising therapy for patients with painful vertebral hemangiomas. this method is effective, with low risk of complications, and may be appliciable to asymptomatic cases as a preventive treatment. percutaneous a retrospective analysis was performed of 127 percutaneous nephrostomies in 107 patients (74 male, 33 female; age range: 6 days-16 years). twenty patients had bilateral nephrostomies and 5 patients were recatheterized. the procedures were performed with sonographic and fluoroscopic guidance under sedation or general anesthesia. the catheters (5.7-10 fr) were placed either with a seldinger technique or an accustick introduction system. results: percutaneous nephrostmy catheters were placed due to up junction obstruction in 37 patients, uv junction obstruction in 10 patients, posterior urethral valve in 7 patients, neurogenic bladder in 10 patients, congenital anomalies in 9 patients, trauma in 3 patients, stones in 14 patients, tumor in 1 patient and renal insufficiency in 6 patients. pyonephrosis was detected in 17 patients. nine dislodged catheters were replaced percutaneously. all procedures were carried out successfully. no procedure related mortality was seen. one patient arrested right after the procedure because of methemoglobinemia due to local anesthetic and treated with methylene blue. no other major complications were detected. catheter dislodgement and infection were detected in 9 and 1 patients, respectively. duration of catheterization was between 1 and 150 days. all the catheters were removed after medical, surgical or percutaneous treatments. conclusion: image guided percutaneous nephrostomy in pediatric population is a safe and effective procedure with low mortality, morbidity and high success rates. percutaneous ct-guided facet screw fixation in lumbar spines: technical aspect h.y. kang, s.h. lee; seoul korea/kr purpose: to report our experience of the technique of percutaneous ct-guided facet screw fixation of 18 cases in lumbar spines. the ct gantry has an angle tilt limitation of approximately 28.5 degrees, but the z-axis (coronal) angle of facet joints is about 40-50 degrees. thus under local anesthesia, positioning was head first, prone with cephalad elevation of upper body to compensate for the facet angle. after selecting the route of the procedure, the guide wire and fixed screws were inserted, after measurement of the size of fitting screw. this procedure was performed in 18 patients, with combination of anterior lumbar interbody fusion (alif, 16 patients) and cases of discitis (2 patients). results: all procedures of facet screw fixation with alif were performed successfully, there were no definite malpositioning of screw or segmental instability on postoperative images at one month follow-up. in cases of discitis, the procedure were performed also successfully, but with more slightly decreased disc height on image at one month follow-up. the controlateral translaminar facet screw fixations were performed at the levels of l3-4 and l4-5, and ipsilateral transfacet screw fixations were done at l5-s1 level. conclusion: percutaneous ct-guided facet screw fixation in lumbar spines was a safe and reliable procedure for a method of spinal fusion. minimally invasive management of benign biliary diseases a. doros, v. weszelits, a. peter, a. nemeth; budapest/hu purpose: report our experience in treating percutaneously benign biliary strictures, fistulas, post-operative leakages, residual stones/sludge, bilomas and abscesses. in the last five years, 27 patients (20 women, 7 men, 18-68 years) with benign biliary diseases were referred to our interventional radiology unit. twenty patients underwent laparoscopic or open cholecystectomy, six had residual stones, three had biliary fistulas. twenty patients had hepatico-or duodeno-jejunostomy stenoses, four had cholangitis-induced liver abscesses, and three had chronic pancreatitis. results: forty percutaneous biliary interventions were performed with good longterm results. strictures were dilated 22 times. six metallic stents were placed into three patients. two plastic stents were placed in one patient with a rendez-vous maneuver. two fistulas were treated with drainage and glue. five stones were removed percutaneously with balloons or dormia baskets. one patient with chronic pancreatitis was treated with a metallic stent. another patient underwent insertion of three metallic stents for intrahepatic stenosis. of the four abscesses, two were surgically and one was percutaneously drained. one patient had two small abscesses treated with iv antibiotics. conclusions: percutaneous management is useful in selected benign biliary diseases. dilatation, stone extraction, and abscess drainage can be performed successfully. in difficult cases combined surgical, endoscopic and percutaneous approach must be chosen. role of aspiration-lavage in the treatment of abscesses in the gallbladder bed after laparoscopic cholecystectomy a.b. stoian, z.a. sparchez, r. badea; cluj napoca/ro purpose: the evaluation of the efficacy of ultrasound guided aspiration followed by lavage with antibiotics in the treatment of gallbladder bed abscesses after laparoscopic cholecystectomy. materials and method: 20 patients with gallbladder bed abscesses were treated percutaneously between 2000-2002. the abscesses were located in gallbladder bed with extension into subhepatic area 35% (7/20). the volume of aspirated pus was 5-20 ml (average 15 ml). the first step of the treatment was the abscess puncture by a transhepatic 65% (13/20) or another approach 35% (7/20) using an 18 g needle (1.2 mm). after pus aspiration, the cavity was washed 2-3 times with a metronidazol + ampicillin solution, the amount of antibiotics once injected being half the amount of the aspirated pus. oral or iv antibiotics (corresponding to antibiogram) were administrated for 7-10 days. in the case of fluid reaccumulation the treatment was repeated. background: ptpe is a reliable tool to induce liver regeneration of the nonembolized lobe. this facilitates extended right resection in e.g. klatskin tumor, hcc or liver metasases. between 1998 and 2000 we performed 80 ptpe. in three cases we noted a failure in regeneration of segment ii + iii but a growth of segment iv after right lobe embolization. in 10 portal vein ligations which regularly spare segment iv the regenerative outcome was significantly reduced compared to ptpe including segment iv. procedure details: in 9/10 patients we use a subxiphoidal access to puncture the left portal vein under us-guidance, otherwise a transhepatic right intercostal access. via 5f guiding catheters a 2.5f microcatheter is placed in each segmental branch in order to apply 5-8 ml histoacryl-lipiodol solution in total. segment iv branches are difficult to reach because of the configuration of the rex recessus anatomy. since the left lateral segments lie adjacent, the emolization of segment iv is critical and has to be performed with the utmost care to prevent spill over of embolzation material. conclusion: segment iv turnes out to be the key for optimal portal vein embolization results. although bearing the risk of embolization material displacement to segment ii and iii the better results clearly suggest application of this technique. 3. palliation of duodenal obstruction via trans-oral route (n = 5) and trans-gastric route (n = 4). procedural details and results: for group 1 and 2, and the trans-oral route in group 3, the technique is essentially an extension to the well established technique of oesophageal stenting of malignancy (except longer wires and catheters are used when more distal stenting is required). as more distal lesions are tackled, the intrinsic difficulty of manipulating long wires and catheters increases and gives way to the more direct transgastric route approach of group 3. this is also an extension to the well established technique of radiological insertion of gastrostomy using t-bar fixation. failure of insertion occurred in 2 patients in the duodenal obstruction group via the trans-oral route. there were no immediate or delayed complications and no re-interventions were required. five patients (30%) returned to normal diet, 6 patients managed semi-solid diet (40%) and 5 patients (30%) had no significant improvement post stent insertion respectively. the mean survival for groups (2) and (3) (i.e. primary carcinoma) was 58 days (range 10 to 224 days). conclusion: radiological placement of gastroduodenal stents is effective for palliation of upper gi malignancies. impact of multi-detector-row-ct (16x) prior to angiographic intervention m.s. juchems, s. pauls, h.j. brambs, a.j. aschoff; ulm/de learning objectives: to demonstrate the additional impact of contrast enhanced multi-detector-row-ct angiography (mdr-cta) compared to digital subtraction angiography (dsa) for planning of angiographic intervention. backround: in selected cases a pre-interventional cta can be useful to facilitate angiographic intervention. we selected four patients with different disease entities (pulmonary av malformation; bleeding caused by hepatic aneurysmosis and from renal pseudoaneurysm after partial renal resection; hepatocellular carcinoma (hcc) prior to transarterial chemoembolization (tace) with aberrant arteries) from our collective who underwent cta prior to angiographic intervention. procedure details: all ct scans were performed using a 16 channel multi-detector-row-ct (philips mx8000 idt). both multiplanar reconstructions (mpr) and slab maximum intensity projections (slab mip) were performed. after cta, patients underwent angiographic intervention (coil embolisation in the first three, tace in the last case). mdr-cta can demonstrate the exact extent and localize multiple vascular malformations, as demonstrated in the first case. in addition, mdr-cta can not only find the cause of hemorrhage but also demonstrate the exact localization of the specific vascular pathology (2 nd and 3 rd case). these findings facilitate the intervention, resulting in decreased in three children, a renal artery stenosis between 80 and 90% due to fibromuscular dysplasia was discovered. in two of these three, the stenosis was unilateral and in one bilateral. in the remaining child, a long stenosis of unknown etiology was discovered. procedure details: in all patients, ptra was performed after having exactly defined the morphology and the hemodynamics of the renal artery stenoses. in three children we have achieved very good. results: ptra was successful resulting in an increased diameter of the arterial lumen. ptra was repeated and unsuccessful in one child with a severe stenosis and an emphasised "recoil" phenomenon. autotransplantation was therefore performed. reference is made to current controversies on this issue. background: endoluminal repair is an acceptable treatment modality for abdominal aneurysms. implant selection is based on the aneurysm's neck anatomy, resulting in two main implant groups; those fixed above the level of the renal arteries, and those fixed below this level. each group presents advantages and disadvantages that should be considered in the selection process. type i endoleaks are the most common complications derived from implant selection. procedure details: in order to select the implant, the patient should undergo a contrast-enhanced abdominal ct scan with coronal reconstructions to image in detail the abdominal aorta, and measure the size of the aneurysm, the distance from the renal arteries to the upper border of the aneurysm, and several other measurements needed. alternatives are abdominal aortic dsa and mra. the two main features that will determine the fixation site are the neck's shape and distance. sealing is always infrarenal. suprarenal devices provide better fixation, although some series report small renal parenchyma infarcts, due to emboli. infrarenal devices are easier to handle, provide for small corrections one placed, but cannot be placed in tortuous necks. conclusions: two main implant groups are used in endoluminal abdominal aneurysm repair, the suprarenal and infrarenal fixation devices. proper patient selection is needed to decide which device is to be used, in order to minimize post-procedural complications. in-vivo transcatheter implantation of a new aortic stent-valve for the temporary relief of acute aortic insufficiency m. hashimoto 1 , t. kaminou 1 , p. haage 2 , y. ohuchi 1 , k. nakamura 1 , k. sugiura 1 , y. noishiki 3 , r.w. günther 2 , t. ogawa 1 ; 1 yonago/jp, 2 aachen/de, 3 yokohama/jp purpose: acute aortic regurgitation is a life-threatening condition, particularly when associated with type a aortic dissection or aortic ectasia. the aim of this animal study was the evaluation of a novel temporary stent-valve as a potential temporizing measure to prevent progression to sudden death until conventional surgical repair can be performed. an umbrella-shaped highly porous polyester mesh valve was placed in the subcoronary portion with the attached metallic stent fixed in the ascending aorta. the prosthesis (stent-valve) was implanted in 6 pigs via the right carotid artery through an 8fr introducer. the efficacy of the valve was assessed by aortography, pressure measurement and electrocardiography. 1 hour after the implantation, the animals were killed and the stent-valve was subjected to macroscopic examination. results: a severe peri-prosthetic leak and cardiac arrest due to the deep implantation of the stent-valve were seen in 1 case. although, a few premature ventricular complexes were seen in 1 and slight blood stagnation in the valsalva sinus was seen in two, excellent performance of the mesh valve was demonstrated in 5 of 6 cases. there was no significant thrombus formation inside the umbrella valve. the presented new temporary stent-valve shows promise for possible future clinical application. further studies are necessary to assess valve thrombogenicity and coronary flow. percutaneous (1996) (1997) (1998) (1999) (2000) (2001) (2002) (2003) with hepatic posttransplantation biliary complications who required treatment with interventional radiology techniques. 12 were pediatric patients and 12 were adults. diagnostic percutaneous transhepatic cholangiography (ptc) was performed in all patients, followed by placement of an internal-external biliary drain in the same procedure. in 10 patients presenting with stenosis in the area of the anastomosis, dilatation with balloon angioplasty was also carried out. in 2 patients with biliary calculi, lithotomy was performed followed by expulsion of the calculi to the digestive tract. one patient presented with a massive biliary leak that did not respond to percutaneous drainage and required implantation of a metal prosthesis. results: the transhepatic approach was used for the diagnostic study, for locating the cause of the complication and to carry out the therapeutic maneuvers required for its resolution. in the 24 patients studied, the initial outcome of percutaneous treatment was satisfactory (100% technical success) and in 16 of them (66%) it was the definitive therapeutic measure. among the remaining 8 patients, 4 underwent surgical re-anastomosis and 4 re-transplantation. drainage placement was beneficial in all patients, allowing elective surgical treatment once the infectious-obstructive complication was resolved. conclusion: interventional radiology plays an important role in the therapeutic management of hepatic post-transplantation biliary complications. ptc allows precise early diagnosis of the complication. the interventional technique reduces the need for reoperation, thereby reducing associated morbidity and mortality. a comparative study of transjugular intrahepatic portosystemic shunt and transcatheter sclerotherapy for gastric varices t. ninoi 1 , k. nakamura 1 , n. nishida 1 , y. sakai 1 , t. kitayama 1 , m. hamuro 1 , r. yamada 1 , y. inoue 1 , t. kaminou 2 ; 1 osaka/jp, 2 yonago/jp purpose: the rupture of gastric varices (gv) is a serious complication in patients with portal hypertension. transjugular intrahepatic portosystemic shunt (tips) and transcatheter sclerotherapy (ts) are effective treatments of gv. the effects on the portal pressure completely differ in tips and ts. however, to our knowledge, no comparative study of the two treatments for gv has been reported. the purpose of this study was to compare tips with ts on gv bleeding and survival. materials and methods: a total of 139 cirrhotic patients with gv underwent endovascular treatment. of the 139 patients, 104 without hepatocellular caricinoma were enrolled in this study; 27 patients were treated by tips, and 77 patients by ts. gv bleeding and survival rates were compared between the tips and ts groups. multivariate analysis was used to identify the prognostic factors for gv bleeding and survival. results: the cumulative gv bleeding rate at 1 year was 20% in the tips group, and 2% in the ts group (p < 0.01). the prognostic factor associated with gv bleeding was the treatment method. the cumulative survival rates at 1, 3, and 5 years, were 81%, 64%, and 40%, in the tips group, and 96%, 83%, and 76%, in the ts group, respectively (p < 0.01). the prognostic factors for survival were the treatment method and the child-pugh classification. conclusion: ts may be more useful for gv than tips in consideration of gv bleeding and survival. results: tpsae was technically feasible in all patients without procedure-related complications. despite significant higher injury grade (3.7 vs 2), higher rate of active contrast extravasation (38% vs 3%) and higher amount of hemoperitone-um on ct, secondary bleeding rate requiring splenectomy was lower in the tp-sae group (2.7% vs 10%). conclusion: tpsae is a feasible and safe procedure in the treatment of splenic injury. tpsae allows a non-operative management despite a selection of severe splenic injuries with one of the lowest reported secondary splenectomy rates. recanalization of acute vertebro-basilar occlusion by a coronary waterjet thrombectomy device t.e. mayer, g.f. hamann, h. brueckmann; munich/de purpose: with a death rate of more than 50%, vertebrobasilar thromboembolism still remains a dangerous disease. this high rate can be mainly attributed to the overall failure of recanalization of 30%, depending on the extensiveness of the clot. this is especially in multisegmental occlusions, where the recanalization rate is very low and mortality is about 90%. we investigated the feasibility of using a coronary mechanical device based on the bernoulli effect (angiojet) for rapid recanalization. methods: ten patients with acute vertebrobasilar occlusion were included in the pilot study. inclusion depended on the presence of multisegmental intracranial (8 patients) or any extracranial occlusions and coma lasting no more than 8 hours. local intra-arterial fibrinolysis had failed in two patients before the angiojet was used, and thrombolysis was administered to two patients afterwards (rt-pa). five patients underwent additional intracranial balloon or stent angioplasty, and five received platelet inhibition by tirofiban. results: treament was primarily done with the angiojet and succeeded in complete recanalization in 90% of the patients (97% of the vessel segments). addition of fibrinolysis resulted in success in 100% of patients and segments. three hemorrhages were associated with additional thrombolysis, tirofiban, or both. seventy percent of the patients survived, and 60% had moderate to excellent outcome. the use of the coronary angiojet in the vertebrobasilar system is feasible. a success rate of 100% recanalization was achieved in a pilot study. compared to historical data of multisegmental thrombosis, the death rate was cut in half and good neurological outcomes increased. experience of transradial and transulnar abdominal angiography and intervention t. sato, m. kajikawa; hiroshima/jp purpose: in coronary angiography and angioplasty, transradial and transulnar approach has currently been accepted as an alternative catheterization method to transfemoral or transbrachial approach. the purpose of this study was to report practical and clinical applicability of these methods in abdominal angiography and intervention. methods and materials: between february 1999 and august 2003, 263 abdominal examinations were tried transradially or transulnarly in 167 cases. 111 cases were for liver or gall bladder tumor, 35 cases were for other abdominal tumors, 17 cases were due to gastrointestinal bleeding, 3 cases were for renal or superior mesenteric arterial thrombosis and 1 case was for ulcerative colitis. 193 examinations were with further intervention. 27 cases were examined twice, 14 cases were examined 4 times, 1 case was examined 4 times, 4 cases were examined 5 times, 1 case were examined 6 times and 2 cases were examined 7 times during this period, transradially. results: radial puncture was failed in 8 examinations (3.1%) and changed to brachial puncture. in 5 cases with weak radial pulsation, ulnar puncture was tried. in cases of hepatocellurar carcinoma, superselective catheterization was also available and transarterial chemoembolization was done. in cases of abdominal branch aneurysm, successful coil embolization was done in 3 cases and a femoral approach was needed on another occasion for complete embolization in one case. no puncture site hematoma was seen. radial arterial stenosis was found in 2 cases at the next examination. no cerebrovascular problems were noted. conclusion: transradial and transulnar approach are alternative catheterization methods even in abdominal angiography and intervention. pre-and post-operative ct scans before discharge, at 1, 3, 6 months and biannually thereafter were performed; pla and pima were evaluated in each followup scan and the number of pla was counted.these data were correlated with the frequency of el-ii. pre-and postoperative volumes of the aneurysmal sacs were measured from ct data. results: median follow-up was 24 months (range 6-36 months).in total 706 ct scans were performed and analyzed. six months after stent-graft implantation pima and/or at least 2 pla were seen in 45 patients (50.5%); 11 patients (12.4% of the study cohort) had an el-ii. no el-ii was seen in patients without pla/ pima. three groups were identified and compared: patients without pla/pima/ el-ii and patients with pla/pima with/without el-ii. a tendency to minor mean volume loss in patients with pla/pima and a significant trend to volume increase in patients with el-ii in later follow-ups was seen. conclusion: there is a high incidence of pla/pima in patients after evr. persistent lumbar and inferior mesenteric artery perfusion is associated with significantly higher el-ii rates after evr of aaa. significant differences in volume changes in later follow-ups were seen between patients with or without el-ii. chemoembolization of hepatocellular carcinoma in candidates for orthotopic liver transplantation: histopathologic findings s. terraz, p. majno, l. rubbia, p.-a. schneider, c.d. becker; geneva/ch purpose: to evaluate the effects of selective transarterial chemoembolization (s-tace) in patients with suspected hepatocellular carcinoma (hcc) before orthotopic liver transplantation (olt). materials and methods: 36 candidates for olt, with viral or alcoholic cirrhosis and a total of 64 nodules suspected to be hcc (1-5 nodules of 0.7-5.7 cm), underwent s-tace with doxorubicine/lipiodol in 1-3 sessions. catheter position was segmental or subsegmental in 71% and unilobar in 29%. particles were added unless complete stasis was observed. the delay between s-tace and olt was 129 (5-500) days. histologic findings of the explanted livers was correlated with all clinical, biologic and radiologic parameters. results: based on the final diagnosis, 58 nodules were hcc, five were regenerative nodules and one was focal nodular hyperplasia. we observed total or neartotal necrosis (> 90%) in 35 (60.4%) hcc nodules and no dissemination was present. twenty-three hcc (39.6%) nodules were partially necrotic; in 13 of these, capsular and/or vascular invasion were present. one patient developed a pseudoaneurysm at the puncture site; no other complication was observed. conclusion: s-tace leads to complete necrosis in the majority of hcc nodules. olt candidates with a long waiting period should be followed by repeated imaging studies, in order to be able to prevent tumor regrowth or spread by repeating s-tace when necessary. kasabach merritt syndrome: treatment with transarterial embolization k.s. malagari, d. antonopoulos, d. loggitsi, d. danassi, a. rigopoulou, a. sissopoulos, a. nikita, g. papaioannou, d. kelekis; athens/gr aim: kasabach merritt syndrome is a rare life threatening condition characterized by consumption coagulopathy, most often associated with liver hemangiomas. we report on the value of transarterial embolization in the treatment of this condition. material and methods: two patients are included in the study (mean age 63 yrs, range 52-74). both were women. kasabach merrit was the first manifestation of the liver lesion in one patient and a complication of a known cavernous liver hemangioma in the second. hct values were 33% and 28%, plt 4,000 and 5,400/ mm 3 , fibrinogen 98 and 77 mg/dl respectively. spiral ct of the liver showed typical hemangiomas with a lace-like enhancing pattern (mean diameters 5 and 14 cm respectively). patients were infused with platelets, fresh plasma, cryoprecipitates, aprotinin and antithrombin prior to embolization. one patient required also 6 units of packed red blood cells. selective hepatic angiography was performed prior to embolization, followed by superselective injection of the feeding vessel(s). microspheres of 300-500 microns were injected under fluoroscopic guidance until cessation of flow. the procedure was uneventful in both patients. partial restoration of plt cell count was observed from the following day and within a week fibrinogen levels and plt levels were completely restored in one patient and partially to the other. conclusions: transarterial embolization may be life saving in kasabach merritt since it can safely control coagulation abnormalities and allows planning for more definitive treatment including surgical resection or liver transplantation for non operable hemangiomas. in vivo characteristics of microspheres injected into the hepatic arteries of rabbits: angiographic and microscopic comparison of embosphere and beadblock m. takahashi, y. saida; tsukuba/jp purpose: the authors presently utilize non-resorbable microspheres (ms) for the transarterial embolization (tae) of hepatocellular carcinoma (hcc). to correlate their clinical features and in vivo characteristics, two different types of industrially-produced ms, injected into the hepatic arteries of rabbits, were microscopically compared. eight japanese-white rabbits were divided into four groups. hepatic arteries were selectively catheterized by the femoral approach. in each group, lipiodol, embosphere (40-120 and 100-300µ) or beadblock (100-300µ) were injected. ms were prepared as a 10 ml suspension with contrast material, in which 2 ml ms were contained. animals were sacrificed immediately after the injection. the liver was excised with ligation of all major vessels. sections were made in the radiate plane along with hepatic arteries. results: lipiodol spread into the hepatic sinusoid and reached the central veins. they were found also in the peribiliary plexus (pbp). ms reached maximally glisson's sheath but was not found around the pbp nor the sinusoids. embosphere occluded the artery after an injection of some milliliters. microscopically they were often clustered and compressed but their spherical shape was maintained. smaller embosphere penetrated deeper than larger one. beadblock once occluded the artery with a smaller amount of suspension than embosphere. after a few minutes, however, the arterial flow resumed and additional injections were possible. microscopically they formed casts and tend to reach deeper tissue than embosphere of the same size. conclusion: embosphere is elastic but robust, while beadblock is plastic, forming casts in the vessel. these characteristics explain much of their features at the time of injection. the at another patient 30 hours after the implantation the rupture of common femoral artery aneurysm was stated. there were also observed certain post-hospitalization complications which included: a) clotting of stent-graft leg in 2 cases b) leak type i which demanded implantation of additional element of stent-graft in one case c) small leaks type i in 3 cases and type ii in 2 cases which did not demand any further intervention-the type ii leaks were observed in 3 cases 6 months after the operation d) the increase of parietal circular thrombus inside the main part of the stent-graft in two cases e) complaints connected with the internal iliac artery occlusion were declared by 4 patients. the catheter has four microsurgical blades that cut directly into the stenotic plaque during inflation. recently they were proposed for the use in peripheral arterial system using a balloon diameter raging from 4 up to 5.5 mm. material and methods: seven consecutive patients (mean age 58 years) were treated with cutting balloon pta (cb-pta) from june until september 2003. all of them had severe multiple, calcified stenosis of the femoro-popliteal artery, maximum 2 cm in length, never treated before. all patients had important associated risk factors such as insulin-dependent diabetes mellitus, hyperlipoproteinemia and smoking. results: cb-pta was technically successful in all patients, with lumen diameter improvement at least of 50% or residual stenosis less than 20%; moreover we never observed major dissection of the intimal plaque and we never required stent placement. conclusion: cb-pta in lower limb calcified stenoses is a promising technique that seems to be superior to pta alone, without requiring stenting in femoropopliteal arteries. aneurysm diameter in all patients were > 5 cm (average diameter were 6.9 cm, range, 5.5-10.4 cm). the mean follow-up was 17 months. average hospital stay after the intervention was 7-9 days. results: the stent-grafts were successfully deployed in all patients. control spiral ct 24 hours after the procedure revealed endoleak in 5 patients (15.6%). spiral ct follow-up on 7 th day following the intervention showed that in 4 patients endoleak spontaneously stopped and in one patient small endoleak was seen, but it also stopped within a month following the intervention. in two patients (6.3%) acute thrombosis of iliac graft extensions was diagnosed a month after the intervention. in both cases successful endovascular thrombolysis was performed with good clinical outcome. in one patient (3%), progression of atherosclerotic disease resulted in migration of the stent-graft two years after the placement of the graft. reintervention was done with successful deployment of additional aortic extension of the stent-graft. average reduction of aneurysm diameter was 8.2 mm (range, 0-32 mm). conclusion: endovascular treatment of aaa with talent stent-graft is a safe and effective procedure. in patients with well defined indication it is safe alternative to open surgery procedure. direct thrombin injection for non-femoral pseudoaneurysms r. corso, m. solcia, m. castoldi, r. vercelli, m. intotero, a. rampoldi; milan/it purpose: percutaneous thrombin injection under sonographic guidance has been shown to be an effective and well tolerated treatment for a iatrogenic femoral pseudoaneurysms. for these reasons some authors suggest thrombin injection as alternative treatment also in other body districts. we illustrate our experience, techniques and results in the ablation of pseudoaneurysms of different etiologies and locations whit direct thrombin injection. materials and methods: from june 2000 we treated six patients, age range 33-75 years, affected with pseudoaneurysms developed after iatrogenic trauma in three patients (arising from radial, posterior tibial and thoraco-acromial arteries), post-pancreatitis (splenic and superior mesenteric arteries) in two patients and in one patient after spontaneous rupture of renal angiomyolipoma in tuberous sclerosis. two patients were anticoagulated. the diameter of pseudoaneurysms varied between 2.4-11.5 cm. after disinfection of the entry site, we slowly injected bovine thrombin (1000 u/ml of solution) percutaneously under ultrasound guidance in four cases, while in two cases we injected directly the thrombin in the pseudoaneurysm cavity with a fluoroscopically guided endovascular angiographic catheter. results: all interventions were successful and showed no immediate or late complications. doses of thrombin needed varied between 200-6000 units (0.2-6 ml of solution). a complete thrombosis of the pseudoaneurysm sac was accomplished within minutes of thrombin injection. no recurrence was seen at the follow-up. conclusion: in selected cases, direct thrombin injection may be useful in treating non-femoral pseudoaneurysms resulting in rapid and persistent occlusion. in our limited experience it represents a safe and effective minimally invasive technique and an alternative to surgical repair. the purpose: bronchopulmonary sequestration is a combined lung and vascular anomaly witch is usually surgically treated. in those cases witch the anomaly is mostly vascular, coil embolization is a safe alternative to surgery. method and materials: coil embolization of intrapulmonary sequestration was performed in three adult patients, two of them admitted with hemoptysis and the third one with low left thoracic pain and fever. the initial diagnosis was made by ct and confirmed with angiography. we embolised the feeding arteries using coils (from 3 to 6 mm, cook). angiography after embolization indicated almost complete occlusion and all patients were discharged the next day. results: there were no immediate nor long term complications. follow-up ct was performed six months and one year later, at witch time there was complete occlusion of the anomalous artery. all patients are asymptomatic at present. conclusion: arterial embolization of intrapulmonary sequestration with a predominant vascular component, is a less invasive method of occluding the anomalous artery in selected patients and is a safe alternative method to surgery. emergency endovascular repair of ruptured hepatic artery pseudoaneurysm with coronary stent-graft: two cases a. park; pusan/kr purpose: to report two cases of successful emergent endovascular treatment of ruptured pseudoaneurysm from the hepatic artery using balloon expandable coronary stent-grafts. materials and methods: case 1. a 65-year-old male underwent whipple's operation for a cholangiocarcinoma in the distal common bile duct, but his postoperative course was complicated by serious blood loss from a ruptured pseudoaneurysm in the common hepatic artery. using premounted coronary stent-grafts (jostent, jomed, germany), the neck of the aneurysm was completely excluded. case 2. a 66-year-old male underwent surgical treatment of a klatskin's tumor and hepaticojejunostomy. four weeks later, an episode of gastrointestinal bleeding prompted celiac angiography. active bleeding from a small pseudoaneurysm in the right hepatic artery was controlled with endovascular deployment of a premounted coronary stent-graft (jostent, jomed, germany). the final angiogram demostrated a total exclusion of the aneurysm with preservation of the arterial lumen. results: transcatheter embolization using a variety of embolizing materials has been considered the treatment of choice for true or false hepatic artery aneurysms. however stent exclusion of the hepatic artery bleeding in an emergent situation has been reported only in few cases. for patients with a compromised blood supply due to portal vein occlusion or exclusion of important collateral pathways by surgical operation, a stent-graft may become the procedure of choice. in emergent situations of hepatic artery bleeding, endovascular implantation of a stent-graft may be an alternative procedure to transcatheter embolization or surgical repair. materials and biomaterials for interventional radiology t. hasebe 1 , a. shimada 2 , t. suzuki 3 , y. matsuoka 3 , h. yoshimura 2 , s. kuribayashi 1 ; 1 tokyo/jp, 2 sagamihara/jp, 3 hiyoshi/jp learning objectives: 1. to describe the most often used interventional devices (id) benefiting from the recent intensive research activity to improve their functionality or their biocompatibility. 2. to provide an update on the current status of new materials and biomaterials available in the field of vascular and non-vascular interventional radiology, including our original experimental data 3. to discuss the importance and the safety issues related to the use of biomaterials and coating materials concerning id. background: in the past decade, interventional radiology has allowed percutaneous access devices and therapeutic implants to be more reliable and effectively used due to the availabiliity of new materials. currently, there are several passive or active stent coatings commercially available with good results in preliminary studies. these materials more often result from industrial research and less frequently from medical research. procedure details: in this paper, we discuss biomaterials currently available for use, together with new biomaterials for the vascular or non-vascular id, such as, for example, the drug-eluting stents, coils for embolization, and biliary/ureteral catheters or stents. finally, we discuss the future of biomaterial use in interventional radiology with the original data in our laboratory (e.g., antithrombogenic and biocompatible stent coating: diamond-like carbon). conclusion: biocompatible issues are very critical for id in order to coexist with living tissue without causing harm. considering the recent advances in new materials with biological effects, we believe the biomaterials will soon constitute a new core of interventional radiology. the radiologists should establish new research domains and complete new and effective products. clinical usefulness of a unified multidetector-ct we can always generate a control image during intervention without repositioning the patient. we have performed highly integrated imaging diagnosis and interventional therapy with this system in more than 200 patients. procedure details: angiography assisted multidetector-ct was performed for the diagnosis and the target therapy of hepatic, pancreatic, adrenal and renal tumors and uterine myomas. in addition, multidetector-ct assisted angiography and interventional therapy was performed for vascular recanalization, such as aortic and peripheral vascular stent therapy; for endovascular treatment of aneurysms and for percutaneous therapy of varices, with a variety of three-dimensional reformatting techniques. we also performed several interventional procedures, such as percutaneous biopsy, biliary and abscess drainage, with this system. conclusion: we introduce our highly integrated intervetional ct system with technical merits to clinical use. background: ct is the imaging method of choice to evaluate hemodynamically stable patients with significant blunt abdominopelvic trauma. contrast enhancement is essential for the diagnosis of many visceral injuries in these patients. it has been demonstrated that contrast-enhanced ct is valuable in the detection of active extravasation of contrast material. the detection of contrast extravasation is critical because it indicates an ongoing, potentially life-threatening hemorrhage. imaging findings: the purpose of this exhibit is to review our experience with active contrast extravasation in patients with blunt trauma to the abdomen and pelvis. findings of contrast-enhanced ct are correlated with those of conventional angiography. the role of angiography and transarterial embolization in patients with active extravasation on contrast-enhanced ct will be discussed. conclusion: contrast extravasation on ct can be used to localize anatomic sites of hemorrhage and to guide immediate angiographic or surgical intervention in patients with abdominopelvic trauma. state-of-the-art ct enables a more detection of contrast extravasation than is possible with conventional and single detector helical ct. for the presented in vitro study, peas (mean diameter 9.4 mm) were embedded within a gel-phantom in order to simulate small target lesions. positional data of the patient and of the needle guide mounted to the robot arm were acquired via an optical tracking system (ndi polaris). a preliminary ct calibration procedure allowed assignation of 3d coordinates to each 2d pixel of the particular ct scan for fast and accurate intervention planning. the best needle trajectory was defined graphically by simply selecting skin entry point and target point -appropriate position and angulation of the robotic arm were calculated and sent to the robot controller. after confirmation of the planning, the robot moved to the start position using different modes of motion. the coaxial biopsy was performed manually using a 17-gauge puncture needle, combined with an 18-gauge biopsy needle and an automated biopsy device. the complete intervention could be monitored and documented by means of superimposed information on the actual ct scan. to prove efficacy of biopsy the length of the harvested specimen, as well as the distance between actual needle tract and centre of the lesion was measured. results: biopsy specimens were successfully obtained from all 20 targets with only one needle pass necessary. radial distance between needle trajectory and centre of the target was surpassing clinical requirements. conclusions: robotic assisted biopsies with high accuracy were feasible using ct guidance. a new laser guidance device for ultrasound guided percutaneous biopsy a.e. samir, j. koukounaras, p. u, a. moorhouse, m. brooks; melbourne/au introduction: ultrasound guided needle placement is usually performed by inserting a needle along a path in the plane of the ultrasound beam. this permits visualisation of the needle in "real time", allowing accurate needle placement. a novel laser guidance device that facilitates needle placement during ultrasound guided biopsy is presented. methods: a laser module was constructed by mounting a laser diode in a nylon tube. a lens was used to transform the pencil laser beam into a linear alignment beam. the laser module was mounted on an ultrasound probe using a customdesigned clip that consisted of two polycarbonate half shells. the linear laser beam was calibrated to be coplanar to the ultrasound beam. no probe modifications were necessary. fourteen biopsy operators performed eight free hand and eight laser guided biopsies each of capsicum-stuffed olives suspended in gelatine phantoms. endpoints measured were: (1) time to biopsy, (2) sample quality and (3) perceived usefulness. the laser beam was visible on the surface of needles ranging from 14 to 22 gauge in size. when the needle was inserted colinear to the laser beam it was visible on the ultrasound image. a significant difference in procedure time or sample quality was not observed. however, 71% of operators stated that laser guidance had a positive effect on the procedure, and 79% said that they would use it in the future. conclusion: a probe-mounted laser guidance device is perceived to facilitate accurate ultrasound guided needle insertion by the majority of operators in a pilot study. planning of the intervention is on basis of ct-imaging data sets acquired immediately before an intervention. spatial relation between imaging space and targeting device is either established by using of an optical tracker system or via robot registration based on a ct data set. after graphically selection of the target point and manual pre-positioning of the device, correct needle angulation will be set automatically by the system. during the intervention, the robot kinematic holds the needle guide in a defined position/ orientation to the patient's body -needle insertion will be performed manually by the physician. results: the developed system is easy-to-use and does not interfere to the clinical work-flow. system accuracy and clinical relevance currently is being tested in a series of in vitro tests. the designed and realized prototype of a modular automated needle guide allows positioning of a biopsy needle based on an intra-operatively planning with good cost/benefit ratio. effect of radiotherapy and ischemia on rat liver z. vigvary, p. kupcsulik, a. szijartó, o. hahn; budapest/hu aim: the aim is to create a model of a liver resection combined with intraoperative irradiation for micrometastases. this combined ischemic-reperfusion and irradiation injury of the liver has not yet been investigated. methods: normothermic segmental liver ischemia were created on 250-280 g male wistar rats. rats were divided into four groups for 30, 45, 60 and 90 minutes of ischemia. hepatic microcirculation was studied by laser doppler flowmeter. histological alterations were followed. i, ii, iv lobes were exposed to 0, 25 and 50 gy of cs-137 ã-radiation. alp, alt, ast, ldh, bilirubin and tnf-á tests were performed. results: reperfusion was assesed by post-ischemic flux plato maximum (pm), by area under the curve (rt) and by the time to maximum flux level (rmi). flowmetery showed a nonlinear fashion of reperfusion according to ischemic period. after 30 and 45 minutes ischemia the rate of the reperfusion is almost the same. 60 minutes of ischemia represents an intermediate lesion in term of recovery. after 90 minutes, minirapid deterioration of flux (below 20% of control) was observed. survival is rather determined by the length of the ischemic period, than the irradiation dose. low dose irradiation (25 gy) with short-term ischemia (30 min) did not result in increased liver enzymes and resulted only in minimal histological changes. the group of 25 gy irradiation with normotherm, short-term ischemia seems to be tolerable for the tumor-free liver. conclusion: liver toleratse irradiation injury suprisingly well and preconditioning promotes restitution of liver circulation after ischemic injury. purpose: the aim of the study was to assess radiation exposure to the radiologist incurred with ct fluoroscopy. the spectrum of indications and radiation exposures for the radiologist were assessed for an 8-month period. scatter exposures were measured with and without radiation protection devices: without and with placement of a lead drape on the patient, with and without use of thin rubber radiation protection gloves. in addition, scatter radiation was determined for a combination of lead drape and radiation protection gloves. results: there is a wide variety for the use of ct fluoroscopy ranging from diagnostic biopsy procedures to therapeutic interventions such as radiofrequency ablation of liver metastases and ct fluoroscopy-guided osteosynthesis of fractures. scatter exposure rates to the hand of the radiologist ranged from 1 to 320 micro sv per case without use of a lead drape and radiation protection gloves. the lead drape reduced the scatter exposure to the hand of the radiologist by 65 percent. radiation protection gloves reduced scatter radiation by 36 percent. the combination of both radiation protection devices was most effective in decreasing the dose by 76 percent. conclusion: ct fluoroscopy is a useful targeting method with a wide variety for interventional procedures. however, significant radiation exposures may occur. therefore, the radiologists should be aware of different techniques of ct fluoroscopy guidance and the methods to reduce scatter radiation. purpose: workforce planning, deskilling scenarios and risk containment are generating a need for interventional training processes remote from patients. fixed models lack ultimate realism, and animal models lack pathology with political problems in the uk. virtual environments for interventional needle puncture training require accurate haptics, based on force relationships between tools and tissues, and visualization. to achieve this demands advancements in tissue segmentation, assignment of tissue properties and generation of synthetic images from abnormal patient anatomy and pathology. these challenges require wideranging expertise and will probably take over a decade to achieve fully. no existing simulator model covers interventional radiological needle access procedures (eg: targeted biopsy, nephrostomy, biliary and abscess drainage). thus a substantive collaboration is essential to develop appropriate virtual training environments. internet search highlighted key development areas and, together with conventional networking, relevant departments and individuals were located with major involvement in medical simulations. results: the craive collaboration was established and comprised interventional radiologists, computer scientists, physicists, clinical engineers and psychologists. the key challenges of interventional procedures have driven specific proposals for accurate representation of haptics, from measured in vivo forces, within imaging-derived, immersive, simulated environments. conclusion: achieving effective simulator modeling for training and rehearsal requires research advances and further development in the underlying technologies. while currently beyond the scope of any research group or individual company, a substantive new collaboration, craive, aims to develop interventional radiological simulator models, initially based on a spectrum of interventional needle access procedures. and 72% (on low dose mode) reduction. image quality measurements were consistently superior (90% higher resolution in fluoroscopy and 41% in dsa) with significantly more low contrast iodine targets and moving wires detected and a larger dynamic range or working thickness range. the results of our first clinical investigations give further evidence for superior image quality. conclusions: on all modes, dose monitoring and image quality of the digital flat panel system compared favorably to the conventional image intensifier system. the results of our first clinical investigations on image quality based on our routine daily practice will be presented. differential diagnosis of femoral head bone marrow edema pattern i. kalaitzoglou 1 , p. papadopoulou 2 , a.s. dimitriadis 1 ; 1 thessaloniki/gr, 2 kavala/gr learning objectives: to present the imaging features which help in the differential diagnosis of the femoral head "bone marrow edema pattern". background: bone marrow edema of the femoral head is a non-specific mri finding associated with various painful conditions of the hip like osteonecrosis, idiopathic transient osteoporosis, transient bone marrow edema syndrome, migratory osteoporosis and stress fracture. a total number of approximately 400 hip mri examinations were performed in three different diagnostic centers from january 1997 to july 2003. bone marrow edema was present in 80 cases. procedure details: mri units used ranged from 0.5 to 1.0 tesla and the examination protocols included t1 se and t2 fse fat-sat or stir axial and coronal images, while sagittal images and contrast administration were reserved for specific cases. patients with typical findings leading to the diagnosis of osteonecrosis or fracture were excluded. the remaining patients had non-specific bone marrow edema of the femoral head which was demonstrated as diffuse, ill defined, low signal intensity on t1w images, high on t2w and stir images, and extended to the femoral neck region. in half of the patients follow -up examinations were also available. we selected and present the imaging criteria, at presentation and follow -up, which can lead to an early specific diagnosis. conclusion: bone marrow edema of the hip has to be correctly interpreted in order to avoid overtreatment in transient and self-limiting conditions. the presence of subtle subchondral lesions and the temporal evolution are usually key to diagnosis. periosteal reactions: the spectrum of radiological appearances with histopathologic correlation i. pinilla, d. bernabéu, c. martín-hervás, a. alvarez, a. bravo, f. lópez-barea; madrid/es learning objectives: the aim of this exhibit is to illustrate the spectrum of imaging features of periosteal reactions with plain radiography, computed tomography (ct) and magnetic resonance imaging (mri) with emphasis in pathologic correlation. imaging findings: 1284 patients with histologically proved diagnosis of benign and malignant lesions in our institution between january 1991 and december 2002 were identified from the pathology data base. imaging findings with plain radiography, ct and mri were retrospectively reviewed and correlated with key pathologic features. the various patterns of periosteal reaction are arranged into the following categories: continuous (smooth, lobulated, and ridged shells, solid, single lamella, laminated or "onion skin", and parallel spiculated or "hair on end" reactions), interrupted (buttres, codman triangle, lamellated, and spiculated reactions), and complex (divergent spiculated or "sunburst", and combined reactions). the most representative cases of each form of periosteal reaction are displayed. specific topics addressed include benign and borderline bone tumors (osteoid osteoma, osteoblastoma, periosteal chondroma, aneurysmal bone cyst, giant cell tumor, langerhans cell histiocytosis, and adamantinoma), primary malignant bone tumors (osteosarcoma, chondrosarcoma, ewing's sarcoma and non-hodgkin's lymphoma), skeletal metastases, and non-neoplastic conditions such as osteomyelitis and myositis ossificans. the changes in the periosteum are common and important imaging features of bone diseases. recognizing and understanding the different radiological patterns and underlying histopathologic changes help the radiologist to narrow the differential diagnosis. this teaching exhibit gives an overview of the wide spectrum of radiological appearances of periosteal reactions together with histopathologic correlation. in mr images, spin-echo (se) t1-weighted images (t1-wi) and t2-wi were obtained and gd-dtpa contrast enhanced images were obtained in 5 cases. in these cases, the location, the radiographic findings, signal and enhanced pattern on mri were analyzed. imaging findings: in 5 cases, the tumor located in epiphysis (45.5%), in 2 cases in apophysis (18.2%), in 3 cases in apo-metaphysis (27.3%), in 1 cases in epimetaphysis (9.0%). in all cases, the tumor was depicted as radiolucent area and in 5 cases, the sclerotic margin was recognized. in all cases, the tumor was revealed as iso-intensity comparing with surrounding muscle on t1-wi. on t2wi, in 7 cases, the tumor revealed as iso-intensity with bone marrow and in the other 4 cases, it revealed as low intensity. on t2-wi, in 8 cases, high intensity area was included which corresponds to the cystic degeneration. in all 5 cases, the tumor was moderately enhanced on contrast enhanced t1-wi. in 2 cases, t1-t2-prolonged lesion which is considered to be the reactive inflammatory change were shown in the bone marrow around the tumor. conclusion: to analyze the image characteristics of chondroblastoma is important to approach the exact diagnosis of bone tumor. chondrosarcomas background: parosteal osteosarcomas represent only 3-4% of all osteosarcomas, and have better prognosis than the classical osteosarcoma.they are frequently low-grade tumors, which may rarely dedifferentiate into high grade sarcomas. imaging findings: mr images performed on 1-1.5 t mr system of 10 histologically proven cases of parosteal osteosarcoma were retrospectively analyzed for the bones involved, location and the relationship between the signal intensity and the grade of the tumor.there were 8 females and 2 males. ages ranged from 17 to 50 (mean 32.9). most commonly affected bone was femur, on its distal end, posterior aspect (7). histological grading was described as follows:grade i: hypocellular stroma with subtle atypia; grade ii: mild increase in stromal cellularity and more prominent cytologic atypia, grade iii: marked pleomorphism with high cytologic atypia and mitotic rate, also called dedifferentiated type. regarding the described grading above, 6 of our cases were grade i (low), 2 were grade ii (intermediate) and 2 were grade iii (high). on mri, all of the parosteal osteosarcoma cases were of hypointense signal intensity on t1-weighted images and were hyperintense on t2-weighted images with no exception. on gadoliniumenhanced images, heterogeneous contrast enhancement was observed. conclusion: in our study, mri signal intensity was the same in all of the cases; hypointense on t1-weighted images and hyperintense on t2-weighted images; regardless of the grade of the tumor. giant cell tumor of knee: imaging findings of the most common site v. zampa, s. giusti, c. spinelli, s. ortori, c. bartolozzi; pisa/it learning objectves: 1. to describe imaging findings useful for an effective diagnosis 2. to discuss the main differential diagnosis with giant cell tumor (gct) of knee. background: gct is a relatively common skeletal tumor. it is a benign but locally aggressive and destructive lesion composed of primitive histiocytes and large, multinucleated giant cells. the most frequent symptom is pain, local swelling, limited range of motion and pathologic fracture (10%). location of gct and age of patients suggest the diagnosis. it usually affects long tubular bones and, in particular around the knee, the most common site is distal femoral and proximal tibia (50 and 40% of all tgc). the main differential diagnoses include osteosarcoma (teleangectatic or fibrogenic), malignant fibrous istiocytoma, chondromyxoid fibroma and aneurysmal bone cysts. treatment of choice is surgical resection but recurrence is frequent. imaging findings: on radiography gct appears as an eccentric and geographic bone lysis, associated with a narrow zone of transition and lacking surrounding sclerosis. ct is superior to conventional radiography in outlining the extent of the tumor and in demonstrating cortical invasion but mr is currently the best imaging modality in determining extra-osseous extent, articular surface involvement and tumor recurrence with optimal definition of either osseous sclerosis or pseudocapsule. the signal characteristics of the lesion on the different mr sequences will be described to find out if they can help in differential diagnosis. conclusion: radiologic appearances of gct is important in allowing prospective diagnosis, guiding therapy, and facilitating early detection of recurrence. superscans: a pictorial review s.a. o'keeffe, t. geoghegan, w.c. torreggiani; dublin/ie learning objectives: the objective of this poster presentation is to pictorially describe the causes, findings and interpretative pathways of patients undergoing radionuclide bone scintigraphy resulting in a superscan. background: a superscan is a radionuclide bone scan which demonstrates markedly increased, homogenous skeletal radioisotope uptake relative to soft tissues and is usually associated with absent or faint renal images. a retrospective analysis of all whole body radionuclide bone scans performed over a fiveyear period was performed to identify the presence of superscans. analysis was based on review of reports identified on a computerised radiology information system (ris). images were reviewed in association with other relevant imaging and in select cases, with laboratory data and clinical notes. a variety of cases were then selected for this pictorial review. imaging findings: a total of 6222 whole body bone scans were performed in our institution in the last five years. 11 superscans were selected for inclusion in this pictorial review. the vast majority of superscans identified were related to metastatic disease of which prostate cancer dominated. superscans were also identified secondary to hyperparathroidism, metabolic bone disease including osteomalacia and pagets disease. conclusions: in this pictorial review, we describe the patho-physiological pathways resulting in the appearances of a superscan. in addition, we pictorially demonstrate a variety of causes resulting in superscan. finally, interpretative pathways of analysis and helpful signs are suggested. usefulness of 3d reformations in the assesment of spondylolisthesis and spondylolisis of the lumbar spine e. vilar bonacasa, p. sanchez santos, j. torres nuez, g. martinez sanz; teruel/es learning objectives: to obtain images that provide a full and direct view of the pars interarticularis in order to determine the isthmal affectation in lumbar spondylolisthesis. background: nine patients with spondylolisthesis of the lumbar spine among 46 sent to our department for ct study during the last year were performed a volumetric acquisition from l3 or l4 to s1 instead of the conventional axial scanning. later, a 3d image was obtained and modified in the work station, to achieve a view of the pars interarticularis from the vertebral canal. procedure details: using this method, we obtained images wich allowed us to asses the isthmal affectation in a direct way in all patients. moreover, it permits the study of the repercussion of vertebral bodies slide over the vertebral canal and the intervertebral foramina. conclusion: convencional ct has some limitations to determine exactly the type and degree of isthmal affectation in spondylolisthesis as well as its repercussion on intervertebral foramina. helical ct, using volumetric acquisition with three-dimensional reformations can resolve those limitations. morphology in these cases, the improvement of the skeletal pain were scored in five-levels by patients' interview from 5 = marked improved to 1 = worse and the duration of the symptom's improvement was monitored. results: a total of 39 taes (mean 1.9 times) were performed. all procedures were technically successful. skeletal pain was relieved in 17 patients (81%) between 3 = slightly and 5 = markedly improvement. in 15 of 18 patients with malignant lesions, the duration of pain relief ranged from one to 60 months (mean 8 months). no serious complications were observed except for a case with transient neurogenic bladder. conclusion: tae using sap-ms was a safe and effective treatment for the pain control with long duration of unresectable bone tumor. bone marrow edema at mri: diagnostic clue to the underlying cause of knee pain a. blanco, m. martinez, e. parlorio, m.a. corral, s. torres; murcia/es purpose: bone marrow edema (bme) is usually associated with traumatic injuries of the knee but there are other conditions, often unsuspected, that can cause this pattern. our purpose was to evaluate the patterns of distribution of bme in patients with knee pain and try to correlate them with their possible underlying cause. we retrospectively reviewed mri examinations of 723 patients referred for knee pain, with or without history of trauma, during a 26month period. the examinations were performed in a 1.5 t unit using our standard protocol which included fluid-sensitive sequences. in some cases intravenous gadolinium was used. results: 95 patients (13.1%) showed bme with variable distribution, resulting from: acute trauma (57), stress fracture (4), degenerative disease (19), spontaneous osteonecrosis (8) and osteochondritis dissecans (6) of the femoral condyle, soft-tissue infection (1), excesive lateral pressure syndrome (1), iliotibial-band friction syndrome (1), transient bme (3), tumor (4), and nonspecific (9). in many cases associated with trauma, the distribution of edema allowed to explain the mechanism of injury and predict with accuracy the soft-tissue abnormalities that may be present. conclusion: bme patterns at mri can help to establish the possible cause of knee pain. when there is a history of acute trauma, edema shows typical features that can give the clue to a possible mechanism of injury. on the other hand, if clinical data is not clear, the distribution of edema can orientate to other unsuspected pathologic conditions. appropriate recognition is necessary for an accurate diagnostic and therapeutic orientation. percutaneous percutaneous thermoablations was performed with radionics cool tip rf generator system by using probes with 1 or 2 cm unprotected tip applied for 4 minutes in the center of the lesion. the procedure consisted of localizing the osteoid osteoma on ct imaging and positioning within the lesion a kirschner wire, rigged on a hand-drill device. once the nidus was engaged we proceeded to exchange the thread of kirschner for a rf probe and emit the radio waves. results: at a mean follow-up of 21 months the treatment has been considered effective in 91% of the cases. in four patients pain has subsequently recurred; one of these cases has been treated for a second time with success. in two cases procedural complications of minor degree, represented by limited cutaneous burns have occurred. conclusion: in our experience ct-guided percutaneous radiofrequency treatment of osteoid osteoma proved to be effective in 91% of the cases. deprived of severe complications it may represent an uncomplicated, minimally invasive, rapidly effective procedure, alternative to the surgical treatment. order to obtain the load-to-fracture, the specimens were tested destructively at side impact. results: in the standard regions of interest, correlations between fracture load and bmd (bmc) ranged from r 2 = 0.64 to r 2 = 0.70, p < 0.001 (r 2 = .65 to 0.75, p < 0.001). for the newly defined roi in the upper neck of the proximal femur, significantly higher correlations between bmd, bmc and fracture load (r 2 = 0.76 and 0.81, respectively; p < 0.001) were obtained. only a weak statistical relationship between fracture load and fnal was found (r 2 = .23, p < 0.001). normalization of fracture load with respect to fnal of the specimens did not significantly improve results. the mechanical competence of the hip highly depends on the bmd and bmc of the proximal femur. of all the regions of interest analysed in this study a newly defined roi in the upper neck showed the strongest correlation with fracture load. under in-vitro conditions, only a weak association between mechanical strength and fnal was observed. or secondary (n = 10) diagnostics were analysed visually. the final diagnosis based on histology, imaging and follow-up. results: histologically the primary lesions were es (n = 10), pnet (n = 13) and osteomyelitis (n = 1). the sensitivity and specificity of fdg-pet for disease (presence of et, and/or its metastases) were 95 and 75% respectively. fdg-pet and/ or other imaging modalities detected altogether 138 focal lesions. sensitivity and specificity regarding focal lesions were 78 and 75%. this lower sensitivity is due to small lesions. wbs detected all 11 primary bone lesions present at wbs investigation, but only 8 of 70 bone metastases in four patients, while fdg-pet detected both the primaries and metastases. conclusion: fdg-pet investigation is a valuable method in case of et-s. concerning the detection of bone metastases of et-s fdg-pet is superior to wbs, while for the depiction of small lesions mainly represented by pulmonary metastases fdg-pet is less sensitive than helical ct. the determination of the role of whole body fdg-pet in the diagnostic algorithm needs further investigations. the role of an optimized mr protocol in the detection of osteomyelitis neighbouring metallic bone implants g. michailidis 1 , n. economopoulos 2 , c. kontopoulou 2 , s. argentos 1 , n.l. kelekis 2 ; 1 piraeus/gr, 2 athens/gr purpose: osteomyelitis presents as a complication in a percentage of patients after metallic bone-implant placement. early and accurate detection is crucial for proper treatment. conventional mr images are usually severely degraded from intense artifacts, rendering interpretation often impossible. we report our results using an optimized mr imaging protocol in detecting foci of osteomyelitis near metallic bone implants. materials and methods: during the last year we examined 17 patients (12 men and 5 women, age range 25-70) with metallic bone implants and clinical suspicion of osteomyelitis. the mr protocol consisted of t2-weighted stir and single shot turbo spin echo sequences. for t1 and t1 contrast-enhanced images we employed turbo spin echo sequences with slice thickness of 3 mm, echo train length > 10, minimum echo spacing and minimum te. diagnosis of osteomyelitis was based on the detection of one or more of the following findings: subperiosteal fluid, bone sequestrum, fistula and abscess. results: all mr examinations were of diagnostic quality with minimal artifacts present. in 6 patients one or more of the above mentioned findings were present and were diagnosed with osteomyelitis. in the remaining 11 patients no findings suggestive of osteomyelitis were observed. confirmation was obtained by followup and clinical outcome. conclusion: with the use of an optimized scanning protocol mri may overcome its limitations caused by metallic artifacts and is able to detect foci of osteomyelitis in patients with metallic bone implants. primary methods and materials: 9 patients were included, aged 20 to 72 years old. flat bones (pelvis = 2, sternum = 2) were involved as well as metaphysis of tibia (n = 3) and femur (n = 2). pathologic diagnosis was obtained in all cases. results: in long bones, tumor originated from the medulla, excentered and metaphyseal in location. in all cases, agressive patterns were present such as osteolysis, cortical break and tumoral extension in surrounding soft tissues, lack of peritumoral reactional osteocondensation. periosteal reaction was present in one case. no calcification was noted. on mr imaging, tumors demonstrated intermediate signal intensity on the t2-weighted images with heterogeneous enhancement following gadolinium injection. pathological findings included smooth muscle cells with interlacing fascicles of spindle cells, without osteoid production or cartilagineous matrix. despite adequate surgical resection, metatastatic diseases appeared in 8 cases. conclusion: primary leiomyosarcoma of bone is a rare tumor which must be included in the diagnostic possibilities in case of agressive purely osteolytic lesion. results: patients included 32 females and 39 males (aged from 9 to 61 years) with pain in extremities. osteogenic sarcoma was diagnosed in 34 patients, ewing sarcoma -19, chondrosarcoma -11, bone lymphoma -7. in 7 cases on plain film bone damage wasn't detected. on bone scintigraphy, the majority of lesions showed greater than mild uptake, in 11 cases showed no uptake. at mr imaging isointense or low t1w signal and increased t2w signal was present in all cases. specific cellular constituents (e.g. fibrous, chondroid, blastic or teleangiectatic components), can modify signal characteristics. lesions that are primarily blastic, and, therefore, sclerotic on plain film radiographs, demonstrate low signal intensity on both t1-and t2-weighted sequences. edema characterized by indistinct margins, is a poor indicator of malignancy. conclusion: study shows that there is overlap in the radiological appearances of primary malignant bone tumors especially in the early stages. magnetic resonance imaging is shown to be a useful and sensitive modality in the detection and evaluation of bone tumors. mr imaging accurately assesses soft tissue and synovial involvement, as well as marrow infiltration, which may be radiographically silent. in patients with extremity pain mr imaging is necessary and mri data wasn't correlated with conventional radiology. all of them were underwent lateral flexion-extension radiography and lumbar mr imaging. differences of interspinous distances at flexion-extension radiography were analyzed at upper, lower, and spondylolisthetic segments. the mr features of the interspinous ligament were divided into 2 groups according to their signal intensities: group 1, with inflammatory type presented as high signal intensity at t2-weighted image and low signal intensity at t1-weighted image, and group 2, fibrotic or fatty type. the incidence of the interspinous ligament with the inflammatory type was analyzed on the spondylolytic segment and the upper and lower segment without spondylolysis, respectively. results: spondylolysis at l3, l4 and l5 levels were 3, 30 and 72, respectively. of 105 patients, the inflammatory type of the interspinous ligament was 25 (24%) on the spondylolisthetic segment and 54 (51%) on the upper segment without spondylolysis (p < 0.05). the mean difference of interspinous distance on the spondylolisthetic segment and the upper segment were 8.4 mm and 10.0 mm, respectively (p < 0.05). in patients of isthmic spondylolisthesis, the upper segment without spondylolysis showed more inflammatory type of the interspinous ligament on mr imaging than spondylolisthetic segment probably due to interspinous hypermobility. advantages of multislice ct in the diagnosis of traumatic osseous disease c. remaining cases, to assess the articular surface involvement and the real extension of the fracture. the isotropic mpr reconstructions carried out with the multislice ct scanners allow us to scan the patient in only one position, usually the axial plane, saving time and using less radiation dose. the mpr reformats takes an important role in the final diagnosis of many cases. the consideration of positioning in radiography for the waist of the scaphoid bone fractures s. matsubara; hiroshima/jp purpose: the most common type of scaphoid bone fracture is the transverse fracture of the waist (central 1/3). however, traditional positioning in radiography frequently fails to visualize bone fracture line. this may be caused by the fact that x-rays cannot be irradiated perpendicularly onto the scaphoid long axis. in this study, we searched optimal limb position for visualizing the waist of the scaphoid bone. method: in 30 volunteers, the scaphoid bone was taken in the ulnoradial direction at 40°ulnar deviation (group a) and 40° ulnar deviation with the fist clenched (group b). images measured the angle between the cassette plane and long axis of the scaphoid (c-s) and the angle between the cassette plane and the volar tilt (c-v). result: the c-s angle in group a was 32.5 ± 9.9° and in group b was 15.8 ± 7.5°. the c-v angle was 12.1 ± 3.2°. we devised new positioning that lift distal side of forearm upward at about 30° in group a, at about 15° in group b. these positioning make the long axis parallel to the cassette plane. especially, the later view was able to visualize the ulna-scaphoid joint more clearly without overlap of radius and scaphoid bones as compared to traditional method. conclusion: in fractures of the scaphoid, in which early diagnosis is critical, optimization of first-choice x-ray imaging is a key factor, and an additional image involving a 15° scaphoid waist view will be useful. background: mri imaging is a very powerful tool in the evaluation of the acl, with higher sensitivity than the clinical examination of the knee. some of its lesions are well known and easily identifiable, but others require careful interpretation and familiarity with the spectrum of acl pathology. over 3000 knee mri examinations performed in three different diagnostic centers from january 1997 to july 2003 were reviewed retrospectively. acl lesions were found in approximately 200 knees. procedure details: mri units ranged from 0.5 to 1.0 tesla, and various imaging protocols were used, with t1 and t2 coronal and sagittal images obtained in all cases. traumatic tears were the most common lesions identified. tears were classified as acute or chronic, complete or partial. we illustrate and discuss the primary and secondary findings of acl tears, as well as the imaging criteria in the evaluation of the postoperative acl. we also present fractures of the anterior tibial spine with acl avulsion, acl ganglion cysts and mucoid degeneration, which are less commonly seen. in the examination of the acl pathology the radiologist should evaluate multiple signs and be aware of some less common pathologies in order to effectively contribute to the clinical management. ultrasound and x-ray findings in painful shoulder involvement in rheumatoid arthritis l. rutkauskiene; vilnius/lt learning objectives: to illustrate and compare conventional x-ray and ultrasonography diagnostical possibilities of painful shoulder in ra. background: up to 60 percent of rheumatoid patients have shoulder pain. a rational decision on the treatment of shoulder disease in rheumatoid arthritis depends on an accurate assessment of its cause and the extent of rheumatoid involvement. imaging details: a group of 25 ra patients, who reported a pain in the arm and/ or limitation of the active movement, were examined first with conventional anterioposterior and obligue -outlet -view with 12-15 angulation x-ray of both shoulders. the most common findings were: joint space narrowing, erosions, subchondral cysts, irregularities of greater tuberosity, deformity and flattening, superior migration of humeral head, erosions in acromioclavicular joint, sometimes soft tissues swelling. ultrasonography study was performed with a 8. results: clinical signs and symptoms (pain and swelling) due to foot involvement were present in 3 (13%) of the patients while frequency of involvement was 21 (91%) with mr imaging assessment. the most common involved anatomical region was the hindfoot (83%) following by midfoot (69%) and ankle (22%). the mr imaging findings were bone erosions, achilles tendinitis, para-articular enthesophyte, joint effusion, plantar fasciitis, joint space narrowing, subchondral sclerosis, soft tissue edema, bone marrow edema, enthesopathy of the achilles attachment, plantar fascia attachment, and plantar ligament, subchondral edema, retrocalcaneal bursitis, subchondral cysts, subchondral fissures, and bone ankylosis. conclusion: mr imaging may detect bone, soft tissue, cartilage, tendon, and joint abnormalities in as patients, even if as patients did not have clinical signs and symptoms of foot involvement. this imaging modality may be of importance especially early diagnosis of inflammatory changes in the foot. additionally, familiarity of the typical mr appearances of foot involvement in as patients may be helpful in narrowing the wide differential diagnosis of spondyloarthropathies. mr handle meniscal tear using the following criteria: a) bow tie sign; b) double posterior cruciate ligament sign; c) coronal truncation sign; and d) displacement of the free meniscal fragment. results: in 54/676 cases a bucket-handle meniscal tear was identified. in 6 of these latter an infero-medial displacement of a free fragment of the medial meniscus was identified. in all 6 cases a lesion of the posterior horn involving the inferior articular surface was observed on axial plane. on coronal plane was observed the truncated triangle aspect of the peripheral, not displaced, meniscal portion. on all planes the displaced free meniscal fragment was identifiable as a little hypointense formation, medially to proximal tibial extremity, inferiorly to meniscal plane and deep to tibial collateral ligament. in all cases diagnosis was confirmed by arthroscopy. conclusions: mri allowed the detection of the infero-medial displacement of a free meniscal fragment thus helping the arthroscopic approach. high-resolution mri of ulnotriquetral ligament injury and its anatomical variations with a microscopy coil t. ueno 1 , h. yoshioka 2 , t. tanaka 1 , y. kujiraoka 1 , m. shindou 1 , k. ooyama 1 , y. saida 1 ; 1 tsukuba-shi, ibaraki/jp, 2 boston, ma/us purpose: to demonstrate ulnotriquetral ligament (utl) injury and its anatomical variations using a microscopy coil. materials and methods: 50 patients (26 males and 24 females with age ranging 14-67 year-old), who suffered ulnar side wrist pain and suspected triangular fibrocartilage complex injuries, were investigated in 1.5 t mri system with a microscopic coil (47-mm in diameter). axial and coronal t2*-weighted images, sagittal and coronal proton density-weighted images, coronal stir images were obtained with a 50-mm fov and a 1-1.5 mm of slice thickness for all patients. result: utl was identified in 49 patients and its injuries were found in 32 patients. regarding anatomical variations, in proximal side, utl always connected to volar radiocarpal ligament and disc proper. however, there were many variations of the attachment to triquetrum bone. in 26 patients, 2 bands attached to triquetrum at different site: one attached to the distal aspect of triquetrum, and another attached to a notch which was found at volar aspect of triquetrum. in 12 patients, one attached to proximal side of the notch. 3 patients showed separate 3 utl bands. conclusion: high-resolution mri with a microscopy coil is a promising method to demonstrate utl injury. it would be useful to know normal anatomical variations for understanding the mechanism of utl injury. pictorial review of diagnostic imaging techniques in hip arthroplasty follow-up j. rimola, p. melloni, r. valls, p. bermúdez, d. gil, a. massuet; sabadell/es objective: to evaluate the spectrum of findings for plain-film radiography and other imaging techniques in patients with early or late complications of hip prostheses. we describe the usefulness of each imaging technique in follow-up. background: over the last 14 years more than 200 hip replacements have been performed in our hospital annually. all patients are followed up immediately after surgery, at 6 months and then yearly or when necessary, using plain films and sometimes sonography (us) and/or computerized tomography (ct). us and ct are used to confirm or rule out osteointegration of the prosthesis and complications such as periprosthetic abscess and/or hematoma. imaging findings: we analyzed radiological features of the normal and pathological evolution of hip prostheses. we describe early complications (affecting 5.2% of patients), such as infection, cement extrusion, and periprosthetic fracture, as well as late complications (affecting 9.2% of patients), including aseptic loosening, osteolytic lesions, heterotopic calcifications, migration of the acetabular component, femoral diaphysis fracture, and dislocation of the prosthesis. conclusion: plain films are essential for evaluation and detection of hip arthroplasties. us is usually used to guide percutaneous aspiration of soft tissue. ct enables correct assessment of osteointegration of hip prostheses. results: with wrist arthroscopy as the standard of reference, average sensitivity and specificity of non-enhanced mri, for tears of the tfcc were 0.82 and 0.77 respectively and 0.98/0.97/ for arthroscopy. conclusion: mr imaging-plays a major role in evaluation and management of traumatic wrist injuries, improves clinicians diagnostic accuracy and reduces the need for arthroscopy. these preliminary results illustrate the ability of mri to assess the integrity of the tfcc and suggests its use as the first imaging method following plain radiography in the evaluation of patients with chronic posttraumatic pain on the ulnar side of the wrist. wrist arthroscopy is a more valuable technique in determining the location, size, and extent of ligament injuries within the wrist. high 18 patients (2 women, 16 men; mean age: 32 years) referred from e.r. for a suspect traumatic dislocation of the a-c joint. all patients underwent plain x-ray examination (conventional projections integrated by "outlet" view and stress projections) and hrus scan (longitudinal and axial scan planes of interested ligaments) of both the interested and contralateral a-c joint. ultrasonographic criteria of lesion were considered the absent recognition of the ligament and strong echostructural inhomogeneity a-c joint. measures of a-c and coraco-clavicular (c-c) distances were drawn by means of both methods. dislocation's degree was defined according with rockwood's classification. results: in 6/18 cases of indirect trauma, diastasis of the a-c joint (2-5 mm), was observed, whereas c-c joint was not involved and c-c ligaments were normal. in 12/18 patients with direct trauma, distracting lesion of the a-c ligament was observed in 4 cases, and involvement of both a-c and c-c ligaments with diastase of both joints was observed in the remaining 8 cases. a complete correspondence of the two methods was observed. conclusion: hrus enables early anatomical-structural changes detection and lesion's degrees assessment in acute traumatic lesions of the a-c joint, and could be considered more than complementary to x-ray exam in the emergency clinical setting, mantainig its role in the follow-up. ligaments and ac joint soft-tissue morphology, acromioclavicular distance and coracoclavicular distance were evaluated. sonographic findings were correlated with the results of conventional radiographic examination, which was performed in all cases with anteroposterior projections, taken with and without weights, and with "outlet" projection. sonographically, all patients presented lesion of ac ligament with high amount of sero-hemorrhagic fluid inside and outside the joint. in 6/18 patients, which had indirect trauma, we observed ac joint dislocation with ac ligament lesion that was not associated to involvement of cc joint and ligament. in 12/18 patients, which had direct trauma, we observed lesions of ac and cc legaments with associated joints dislocations. conclusions: ultrasonography, if performed with appropriate technique and adequate transducer, is accurate in the evaluation of acute traumatic ac joint lesion and dislocation, integrating and correlating well with the informations offered by conventional radiography. study of the mr imaging of the posterolateral structures of the normal knee c. yu, k. li; beijing/cn puropse: through the study of the mri appearance and localization of the posterolateral structures (pls), to provide a practicable method for intactly displaying them. methods: thirty tibial bone specimens were observed to establish the bony landmark for localizing the knee. in 50 cadaver knees, the angles between lateral tibial plateau and the long axis of the individual structure of pls were measured. then we can determine the scan methods of the oblique mr images based on above results. the routine and oblique scans of t 1 wi were performed in 40 normal knees. the display effect and appearance of the pls were observed in mri. the lateral tibial plateau is a stable bony landmark for measuring and localizing of the knee. in the pls, the fibular collateral ligament can be intactly displayed on 70° posterior coronal oblique images in 34 cases (85%). the popliteus can be better seen on either 60° posterior coronal oblique in 34 cases (85%) or 45° medial sagittal oblique planes in 36 cases (90%). the popliteofibular ligament can be intactly appreciated on both 60° posterior coronal oblique in 32 cases (80%) and 70° lateral sagittal oblique images in 34 cases (85%). although the arcuate ligament and the fabellofibular ligament can occasionally be seen on routine and oblique images, their presence rate is low. the oblique mr imaging can intactly display the main structures of pls, and can be an useful tool in diagnosing these structures' injuries. patients are also asked for the presence of their prolonged physical activity in their life. results: 5 patients had type ii, 4 patients had type i and 3 of them showed type iii patellar shapes, out of 12. 2 patients had patella alta whereas all others stayed in normal range as patellar position. in 4 patients' case no other abnormalities were seen apart from the signs of iliotibial band friction syndrome and three of them had shown type iii patellar shape. conclusions: no apparent correlation was found between iliotibial band friction syndrome and patellar position. as it is much more rare in the normal population wiberg type iii patella showed considerably high prevalance in our study. shoulder to assess by mri the potential benefit and efficacy of selective meniscectomy combined with radiofrequency ablation in cystic degeneration of the lateral meniscus treatment. materials and methods: sixty-one patients entered this study. 28 patients underwent arthroscopic selective meniscectomy and 33 patients underwent arthroscopic selective meniscectomy and radiofrequency treatment (arthocare, sunnyvale, ca) of the meniscal remnant. all of them were submitted three months later to mri and clinical evaluation. in 15 case mri examination was performed before and after the surgical treatment. mri examination was performed using a dedicated 0.2 t (artoscan esaote italy) and a 1.5 t superconductive unit (ge signa horizon usa) employing se t1-w, se t2-w and ge t2-w sequences on axial and longitudinal scan planes. in 7 case arthro-rm was also performed. clinical evaluation included physical examination and questionnaire. results: clinical evaluation did not show statistically significant discordance between the two groups. mri follow-up after 3 months demonstrated a very clear decrease of the degenerative spots inside the meniscal remnant in the group with combined treatment respect to the group treated only with selective meniscectomy. conclusion: in conclusion our experience considers mri the method of choice in the evaluation of post surgical treatment of degenerative cystic diseases of the lateral meniscus of the knee. high-resolution ultrasonography of the extrinsic carpal ligaments: examination technique and performance d.v. guntern, n. favarger, p. schnyder, n.h. theumann; lausanne/ch purpose: to develop an examination technique to visualize the extrinsic carpal ligaments by ultrasonography and to assess the performance of high resolution ultrasonography in the visualization of different parts of these ligaments. the extrinsic carpal ligaments of 9 wrists of 9 healthy volunteers were examined with a 15 mhz linear array transducer by two muskuloskeletal radiologists in consensus. an examination technique was developed for each extrinsic carpal ligament (radioscaphocapitate, radiolunotriquetral, palmar scaphotriquetral, dorsal scaphotriquetral, palmar ulnotriquetral, dorsal ulnotriquetral, dorsal radiotriquetral and radial collateral ligaments). delineation of the proximal attachment, the body and the distal attachment of each ligament was evaluated as good, poor or absent. results: with a profound knowledge of the anatomy, especially of the osseous landmarks, an easy and fast examination of the extrinsic carpal ligaments by high resolution ultrasound is possible. the more superficial ligaments such as the dorsal scaphotriquetral and the dorsal radiotriquetral ligaments are well visualized by high resolution ultrasound whereas ligaments in a deeper position, such as the proximal and distal insertion of the palmar scaphotriquetral and the distal insertion of the radioscaphocapitate are less well visualized. high resolution ultrasonography is an accurate method to visualize the extrinsic ligaments of the wrist. direct mr arthrography of the glenohumeral joint with capsular distension using a posterior approach r. drescher, j. ludwig, f. rubenthaler, o. köster, g. schmid; bochum/de purpose: evaluation of the clinical use of direct mr arthrography of the glenohumeral joint with maximum distension of the joint capsule in patients with glenohumeral instability using a posterior approach. patients and methods: direct mr arthrography of the shoulder joint was performed on a 1.5 t system in 30 patients (12 women, 18 men, mean age 36 years). 17 right and 13 left shoulders were evaluated. all patients had anterior or bidirectional instability (18 posttraumatic, 12 constitutional). using a fluoroscopically guided posterior approach, 10 ml iopamidol 250 m and 5 ml 0.2% mepivacaine were injected, followed by a 1% dilution of dimeglumine gadopentetate in 0.9% sodium chloride until full capsular stretching was achieved. mr sequences were t1-weighted spin-echo axial and oblique-coronal, fat-saturated t1 3d axial and oblique-coronal, and axial t2 flash-2d. results: arthrography was possible in all patients. the total amount of intraarticularly injected fluid was 30-60 ml (mean 38 ml). no complications occurred. mr imaging showed significant capsule distention in 11 patients (37%) and ventral capsule defects in 5 patients (17%). 14 labral lesions (11 anterior, 3 posterior), 3 bicipital tendon lesions (1 complete, 2 partial ruptures) and 2 partial ruptures of the rotator cuff were noted. 13 patients underwent surgery. regarding labral lesions, sensitivity of mri was 88.9%, specificity was 75%, and diagnostic accuracy was 84.6% compared with surgical results. conclusions: glenohumeral direct mr arthrography allows accurate detection of labral and tendinous lesions. maximum capsular distension allowed preoperative evaluation of capsular laxity as a source of shoulder instability. anterior talofibular ligament injury: evaluation with mr imaging j. ishida 1 , j. yoshigi 1 , h. okizuka 2 , k. ooae 1 , m. takao 1 , t. yoshizako 1 , k. izaki 1 , n. uchida 1 , h. kitagaki 1 ; 1 izumo/jp, 2 himeji/jp purpose: inversion stress is most frequent injury of all ankles. atfl is the weakest of lateral collateral ligaments and first to rapture. the purpose of this study is to evaluate the usefulness of high-resolution mri for diagnosis of atfl disruption divided into acute and chronic phase. method and materials: 32 patients suspected atfl disruption underwent mri (1.5 t). 18 cases were in acute phase (< 10 days) and 14 cases were in chronic phase (> 1 month). axial spin-echo (se) t1-wi (tr/te = 720/20, fov 18 cm, 2 mm/ 0.2 mm, 512 x 512, 2 nex,) and axial fast se t2-wi (tr/te = 3500/96, etl7, fov 18 cm, 2 mm/0.2 mm, 512 x 512, 2 nex,) were obtained with an extremity coil. atfl disruption was diagnosed when either finding is positive:discontinuity, irregularity, non-visualization of aftl, and high signal intensity lesion in atfl on t2-wi. results: arthroscopy confirmed atfl disruption in 14 cases in acute phase and 472 b d e f a g 12 cases in chronic cases. in acute phase, sensitivity was 93%, specificity was 100%, and accuracy was 94%. only 1 false negative was seen. in chronic phase, sensitivity was 67%, specificity was 50%, and accuracy was 66%. 4/12 was false negative. conclusion: in acute phase, mri was accurate for evaluation of aftl disruption. however, in chronic phase, mri was less accurate because granulomatous tissue after disruption cannot be detected with mri. ct arthrography of the shoulder a. gligorievski, z. temelkovski; skopje/mk purpose: to present ct arthrography (cta) as a new method in our practice in order to point out its advantages and to compare the results with conventional arthrography and mr arthrography. we describe the technique of the examination in detail, performed at the institute of radiology in cooperation with an orthopaedic surgeon and radiologist that form the diagnostic-therapy team. cta performed with 18 patients, aged 25 to 62, 12 men and 6 women. conventional arthrography was performed in 7 and mra in 11 patients. results: 7 patients presented with lesion of the glenoid labrum, 5 with rotator cuff lesion, 2 with a frozen shoulder, 2 with a hill-sachs lesion, 1 with biceps brachi tendon subluxation and 1 case with slap lesion. we report our first experiences and the results gained are compared to similar recent studies as well as to the conventional radiologic techniques. cta is a method of choice in case of frozen shoulder and glenohumeral instability, but mra is better in case of rotator cuff lesion. we can conclude that cta is a sophisticated method of extreme diagnostic value in the evaluation of the humeral joint especially in case of glenohumeral instability. the invasiveness of the method is small, no complications have been noticed and compared to mr it is significantly cheaper and more available for the medical centers equipped with a ct scanner. mr imaging of the metatarsophalangeal joint with standard mr imaging: evaluation of six patients with clinical suspicion of plantar plate disruption p. hauser; lausanne/ch purpose: to report the mr imaging findings of painful injured metatarsophalangeal joints (mtpj) in case of clinical suspicion of plantar plate (pp) tear. a series of 13 patients with clinical suspicion of pp rupture of first (mtpj 1) or second (mtpj 2) ray underwent mr studies with 1.5 tesla units with use of an extremity coil. the patients lay on their back with the ankle in plantar flexion and the toes in extended position. the standard mr imaging protocol performed in all specimens consisted of t1 weighted spin echo sequences in sagittal and coronal plan and t2 fse fat satured sequences in sagittal, coronal and transverse plan. the examinations were interpreted separately by two musculoskeletal radiologists assessing whether or not a pp rupture and associated lesions were present. after the imaging study all the patients underwent surgical revision in a mean delay of one month. results: tears of the pp were visualized in 9 cases, degenerative lesions of the pp were visualized in two cases and two other cases showed no lesion. the mr imaging results concerning pp rupture although allowed depiction of several associated lesions including injuries of the extensor hood, the collateral ligament complex, ostechondral lesions and joint deformities. conclusion: although surgical treatment is generally the rule for hallux valgus deformities, surgical repair is also often required in cases of traumatic injuries of the mtp joints. the force of accord between radiologists and surgical observation of pp ruptures is good. mrt monitoring of autologous hyaline cartilage grafts c. müller, e. grönewäller, c.d. claussen, f. schick; tübingen/de purpose: seven different mr sequences were compared to localize cartilage defects in knee and to evaluate the stage of maturation of the hyaline cartilage graft. methods: mrt was performed in 19 patients aged 17-48 years with autologous transplantation of a hyaline cartilage tissue graft after a knee trauma. examination dates were: before transplantation to localize the defect, and 6 weeks, 3, 6 and 12 months after transplantation to control the morphology and the maturation of the autologous graft. standard t2-and proton-density weighted turbo spin echo (tse) sequences, t1-weighted spin echo (se) sequences, gradient echo (gre) sequences with and without magnetization transfer (mt) pulses as well as experimental diffusion weighted gre sequences (psif) were used. results: for depiction of the graft short time after surgery t2-weighted tsesequences showed the best results, to identify potential secondary damages before transplantation pd weighted sequences were superior. 6 and 12 months after transplantation spoiled 3d-gre-sequences displayed the graft in high spatial resolution. from the diffusion measurements no statistically significant discrimination between cartilage and graft was obtained at any time, whereas, different images from gre-sequences with and without mt pulse provided high contrast between cartilage and surrounding tissue. the quantification of the mt effect showed an assimilation of the graft to the original cartilage within 12 months. conclusion: mrt should be performed before every transplantation because cartilage defects and secondary damages can be detected clearly. after transplantation mrt can easily identify the graft and detect hypertrophy or debonding in early stage. quantitative macroradiographic study with fractal signature analysis measures bone loss in the rheumatoid arthritis hand l. disini 1 , m. foster 2 , j. buckland-wright 1 ; 1 london/uk, 2 loughborough/uk purpose: fractal signature analysis (fsa), a computerised method of textural analysis, permits the separate measurement of changes in vertical and horizontal trabeculae based on the fractal dimension over a range of trabecular widths (fractal signature). we determined whether the fsa of high definition macroradiographs (x5 magnification) quantified differences in trabecular organisation at sites of osteopenia and erosion formation in the rheumatoid arthritis (ra) hand. methods: sixty-seven ra patients had macroradiographs of the left hand. the distal radius was scored and grouped from very mild (ra1) to moderate (ra4) disease. macroradiographs were digitised and fsa of horizontal and vertical trabecular organisation were measured in the radius at sites of osteopenia, erosion formation and a mid-shaft site. the fractal signatures were compared to 11 healthy non-arthritic subjects using the t-test. results: compared to the non-arthritics, fsa at the distal radius in groups ra1 to ra4 measured a significant reduction (p < 0.05) in fractal signature at the osteopenic and mid-shaft sites, affecting small to large sized vertical trabeculae, and at the erosion site, involving small and medium sized horizontal and vertical trabeculae. the reduction was smallest in ra1 and greatest in ra4. conclusion: fsa quantified the trabecular bone loss in the distal radius of ra patients of increasing radiographic severity based on a proportional reduction in fractal signature. disease related bone loss involved varying trabecular widths with vertical trabeculae at the osteopenic site and both vertical and horizontal trabeculae at the erosion site. potentially, fsa can distinguish changes consequent to bone-mediated ra drug treatment. the results: the value of 3d ct reconstructions in external projections was the highest in revealing of the osteophytes of anterior margins of vertebral bodies; the anterior osteophytes were found in 33 (82.5%) patients on 3d ct images. the 3d ct reconstructions cut off in sagittal plane along the spinous process were the best imaging modality in evaluation of the osteophytes of the posterior margin of the vertebral body, which were seen in 34 cases (85%) and in evaluation of narrowing of the intervertebral foramens (14 cases -35%). conclusions: 3d ct reconstructions are valuable in determining the localization and the extent of the cervical spine osteophytes. they are the imaging modality of choice in assessment of the degenerative narrowing of the intervertebral foramens. 3d ct reconstructions should be the integral part of ct examination of patients with the neck pain. purpose: the aim of our study was to determine the incidence of jspa in croatian population in the last 6 years in relation to other rheumatic diseases and the presence of hla -b 27 in children with jspa. as the cause of jspa is still unknown, the strong association with hla -b 27 suggests genetically determined mechanism. methods and materials: the patients from 1 to 18 years of age diagnosed during the period 1997-2003 at department of paediatric rheumatology, university hospital zagreb following strict criteria of european spondyloarthropathy study group. we identified 681 newly diagnosed patients with rheumatic disease using hospital and outpatient records. results: 69 were identified as having jspa (9.8%) amongst 8,358 patients with rheumatic disorders. sex ratio was 22 females against 47 males, mean age of 13.6 years. 55 patients had undifferentiated spondyloarthropathy (79.7%), 4 patients had reiter's syndrome (5.8%), 6 had arthritis of inflammatory bowel disease, i.e. crohn's (8.7%), two patients had psoriatic arthritis (2.9%), and two had ankylosing spondylitis (2.9%). ocular complications were present in 24 patients (34.8%), enthesitis in 51 (73.9%), sacroileitis in 60 (86.9%) and peripheral arthritis in all 69 patients (100%), diagnosed radiologicaly. hla -b 27 was present in 49 patients (71.1%). conclusion: our epidemiological study showed similar incidence of jspa among other rheumatic diseases in childhood and adolescents (9.8%) compared to results of american, canadian and british studies in which this incidence is 7.9 -9.8%. however, the presence of hla -b 27 antigen is lower (71.1%). postprocessing optimization of computed tomography data of acetabular fractures v. moschenko, t. shamova, a. sklyarenko, i. bobkova; kharkov/ua purpose: to study diagnostic opportunities of postprocessing programs -multiplanar (mpr) and 3d shaded surface display (ssd) reconstruction of ct data on acetabular fractures. methods and materials: 21 patients aged 15 -57 with acetabular fractures in various terms since the moment of trauma (from 2 days to 15 months) were examined. plain radiographs and ct with the subsequent application of programs mpr and ssd were conducted. the acetabular fractures classification by judet -letournel was used. results: use of postprocessing programs allowed in 3 (14.3%) cases to specify a type of fracture and character of deformation of acetabulum, therefore in 2 (9.5%) -the originally prospective conservative treatment was replaced by operative. considering complexity of choice certain reformations mpr and ssd for analysis and documenting of views, we used standard projections: for mpr -1) along anterior column, 2) along posterior column, 3) along both columns; for ssd -1) anteroposterior view of the pelvis; 2) direct projection (lateral view) of the acetabulum; 3) obturator oblique view of the pelvis; 4) iliac oblique view of the pelvis. in 18 (85.7%) cases use of only these projections was enough to establish the type of acetabular fracture. conclusion: use of mpr and ssd in ct data postprocessing allows establishing the type of acetabular fractures that defines a choice of treatment tactics. our standard protocol of mpr and ssd reduces analysis time of research results and creates conditions for uniform perception of injuries by all participants of diagnostic process. conclusion: routine x-ray projections prove insufficient to establish a diagnosis in 1/5 th of the cases. confusion is caused by overlaying of fracture edges and pelvic bone in the direction of x-ray beams. the latter makes hardly visible the small posterior fragment, too. therefore, ct scanning is required for the diagnostic protocol of displaced femoral head fractures. is learning objectives: to describe us and mr imaging findings of nerve infiltration by extrinsic masses, including lipomas, hemangiomas, non-hodgkin lymphomas and ganglion cysts. to learn to differentiate between these pathologic conditions. to emphasize the role of us and mr imaging in the management of these lesions to further delineate the nature and extent of the process. background: in addition to peripheral nerve sheath tumors (e.g. neurofibromas, schwannomas and malignant peripheral nerve sheath tumors), there are softtissue masses, such as hemangiomas, lymphomas and ganglion cysts, which do not originate from the nerve itself but may occasionally infold among the nerve fascicles and expand into the neural tissue. the intraneural growth of these masses is rare, may cause nerve dysfunction and local symptoms and should not be confused as the more common nerve sheath tumors. imaging findings: 12-5 mhz us and 1.5 t mr imaging findings for a series of eight retrospectively collected cases of masses infiltrating nerves are illustrated with emphasis about the different pathogenetic mechanisms of intraneural infiltration. hemangiomas involved the median and ulnar nerves, ganglion cysts the peroneal nerve, non-hodgkin lymphomas the sciatic and median nerves. correlation of imaging findings with gross surgical views is provided in 6/8 cases. conclusion: high-resolution us and mr imaging can detect nerve infiltration by extrinsic masses. knowledge and recognition of the characteristic imaging features can aid in the proper diagnosis and treatment of these lesions. mri of lipomatous soft tissue tumors: radiologic pathologic correlation m. pilavaki, d. chourmouzi, g. boulogianni, a. drevelegas; thessaloniki/gr purpose: to study the mr imaging findings for each type of lipomatous soft tissue tumors and to correlate them with the pathological findings. we studied retrospectively the mr examinations of 36 patients with histological proven lipomatous soft tissue tumors. the histological types of the tumors were: 21 lipomas, 1 fibrolipoma, 1 lipoblastoma, 3 lipomatosis and 10 liposarcomas (4 well-differentiated, 5 myxoid, and 1 mixed type) t1-, t2-, and fat-suppressed and t1-weighted images after administration of gadopentetate dimeglumine were obtained. the signal intensity on different sequences, the internal characteristics, the presence of septa and other nonadipose component, revealed on the mr images and the degree of contrast enhancement of septa and nonadipose component were evaluated. results: from the group of 26 benign lipomatous lesions 11 lesions were without a recognizable nonadipose component. 14 lesions had thin septa without contrast enhancement. in case of fibrolipoma areas of nonadipose component correlated with fibrous tissue. in the group of well-differentiated liposarcomas 1 had thin septa and 3 thick septa with mild contrast enhancement. the 6 remaining liposarcomas had thick septa with 5 of them having a nodular and globular non-fatty component with enhancement after the administration of paramagnetic agent. conclusion: statistically significant imaging features favoring a diagnosis of liposarcoma included the presence of thick septa, enhancement of septa and the presence of nodular or patchy nonadipose components. imaging features suggesting benignancy included thin septa with no enhancement relative to muscle and no recognizable nonadipose component. guidelines for diagnosis of soft tissue lipomatous masses (stlm) g. chave, d. ranchere-vince, p. meeus, p. thiesse; lyon/fr learning objectives: to clarify the steps of pretreatment diagnostic procedures in case of soft tissue lipomatous masses (stlm). to describe the mri findings for lipomas and liposarcomas. to develop the principles of percutaneous biopsy. background: differential diagnosis between lipomas and liposarcomas, especially atypical lipomas is not always easy. despite similarities, differential diagnosis can be reliably established employing image parameters. nevertheless, the staging process of stlm culminates in biopsies, allowing to manage the proper treatment. biopsies can be performed percutaneously using imaging guidance. an open biopsy with the resection of the entire mass is disputed when the stlm is composed essentially of fat on mri imaging to avoid the misdiagnosis of benign lipoma. each procedure must be carefully planned: an inadequate biopsy may fail to allow proper diagnosis, have a negative impact on survival, and ultimately necessitate an amputation to accomplish adequate margins of resection. procedure details: after the description of characteristics and different histological subtypes of lipomas and liposarcomas, we will describe the mri findings for each diagnosis, according to a review of the litterature by illustrating with mri imaging of patients followed in our center. we will develop the principles of percutaneous biopsies according to litterature and our experience. conclusion: accurate diagnosis of stlm is based on three factors: clinical presentation, radiological features and pathologic evaluation. the importance of careful planning and performance of biopsies cannot be overemphasized because errors may have a negative impact on survival and impede proper diagnosis. high background: clinical assessment of extensor tendon injuries is not straightforward because of the peculiar anatomy of these tendons made of several interconnecting layers and different attachment sites in the fingers. the development of very high-frequency "footprint" transducers has improved the ability of us to scan the extensor tendon complex in the fingers, allowing accurate depiction of the central and lateral slips of the extensor tendon, and the sagittal and lateral bands of the extensor hood. imaging findings: paradigmatic 12-5 mhz and 15-7 mhz us images from a series of retrospectively collected cases with a variety of extensor tendon injuries in the fingers are illustrated, including partial and complete rupture of the central slip (boutonnière deformity), tears of the lateral slip, avulsion injury of the terminal tendon (mallet finger), injury of the sagittal band over the metacarpophalangeal joint with tendon instability (boxer knuckle). dynamic us is essential to diagnose injuries of the extensor hood mechanism. correlations of us findings with schematic drawings and the results from 1.5 t mr imaging are also provided. conclusion: high-resolution us is promising for evaluating the extensor tendons complex in the fingers. it can identify and characterize a variety of abnormalities. by providing unique information on these tendons, us has potential for major impact on treatment planning. high-resolution us of tenosynovitis in the wrist and hand a. picotti 1 , l.e. bacigalupo 2 , r. podestà 2 , g. succio 2 , f. pugliese 2 , s. bianchi 3 , c. martinoli 2 ; 1 siena/it, 2 genoa/it, 3 geneva/ch learning objectives: to describe the spectrum of tenosynovitis of flexor and extensor tendons in the wrist and hand by means of high-resolution us. to correlate us findings with clinical features and mr imaging. to emphasize the role of us in the management of these lesions to further delineate the nature and extent of the process. background: tenosynovitis of wrist and hand tendons are common and account for a high percentage of orthopaedic consultations. they can be related to local causes, particularly overuse due to sport or occupational activities or may be the result of systemic musculoskeletal disorders. imaging findings: paradigmatic 12-5 mhz and 15-7 mhz us images from a series of retrospectively collected cases with a variety of tenosynovitis in the wrist and hand are illustrated with emphasis on the pathogenetic mechanism of tendon disease, including de quervain disease, intersection syndrome, extensor pollicis longus, extensor carpi ulnaris, flexor carpi radialis and flexor digitorum tenosynovitis. the main findings in infectious and hypertrophic tenosynovitis are also described and a spectrum of unusual causes producing them is reported, including foreign bodies and conflict with fracture residuals and osteosynthesis material. conclusion: due to its widespread availability, low cost and high spatial resolution, high-resolution us is an excellent tool for investigating a variety of tenosynovitis of the wrist and hand. background: the patients with inflammatory myopathies (inclusion-body myositis (ibm) = 4, polymyositis (pm) = 3 and dermatomyositis (dm) = 1) underwent whole-body mr muscle screening examination. mr examination is performed at six different levels: neck, shoulder, abdomen, pelvic girdle, and upper and lower leg. t1-and t2-weighted images with and without fat suppression were performed for each level. signal intensity of muscles, volume and the symmetry of involvement were quantified in 54 individual muscles on each side. imaging findings: ibm, dm and pm are rare diseases with clinical and histopathological similarities. ibm usually does not respond to immunosuppressive therapy. therefore, it is necessary to distinguish these entities correctly. ibm is characterized by more frequent fatty infiltration, atrophy, inflammation, a distal predominance, and anterior group involvement. the finding of selective involvement of the medial gastrocnemius and of the vasti with sparing of rectus femoris is typical for sporadic ibm. the selective involvement of flexor digitorum profundus is also highly suggestive for ibm. t1, t2 and fat-sat images contain different but complimentary information. pm and dm predominantly affect muscle groups of the shoulder girdle and the thighs. a newly introduced mr technique provides an excellent overview of all diseased muscles in the body. moreover, it helps us to distinguish ibm from other iims. mri may help establish the diagnosis, suggest appropriate sites for biopsy, and enable assessment of disease progress or regression over time. background: elastofibroma dorsi is a rare, typically slow-growing, often bilateral, para-neoplastic formation. it's composed by fibro-elastic and adipose tissue and is selectively localized along the postero-lateral side of thoracic wall, under the scapula. the certain diagnosis is cyto-histological. mri was the hitherto elective diagnosis. all cases of elastofibroma in our series were studied with us; some of them also with ct and mri; in a retrospective analysis us allowed to suspect presence of elastofibroma in all patients: 3 of them underwent surgery that confirmed the diagnosis. procedure details: in our series the us examination, performed with 7.5-10 mhz linear probe, showed solid masses, sometimes in both sides, with badly visible margins, hypoechoic with inside hyperechoic stripes, obliquous from the transducer plan. conclusions: in all cases us and clinical findings allowed the diagnosis of elastofibroma dorsi. the mri, performed in 3 patients that underwent surgery, confirmed the us findings. the remaining 2 patients are undergoing follow-up with us. so, us findings, within site, slow growth and possible presence of bilateral masses, allow the diagnosis of elastofibroma dorsi, avoiding costly mri. a comparison between ultrasound, echo-color-doppler, and mri in the evaluation of achilles enthesopathy in psoriasis: preliminary results f. maggi, f. di gregorio, c. de simone, c. pagliarello, m. politi; rome/it purpose: psoriasis is often associated with achilles enthesopathy. this study compares the efficacy of ultrasound, echo-color-doppler and mri in the evaluation of early signs of achilles enthesopathy in psoriatic patients. methods and materials: 22 consecutive psoriatic patients, 17 men, 5 women, mean age 48 years (age range 19-72), mean pasi score 14, entered the study. all patients underwent sonography of the achilles tendon and peritendinous structures with aplio (toshiba) equipped with a linear multifrequence (8-13 mhz) transducer; the study was completed with color-doppler analysis. an mri study, before and after gadolinium, was then performed using e-scan xq (esaote), 0.2 tesla superconducting magnet. axial and sagittal t1 and t2 weighted, sagittal ge and stir sequences were obtained. after gadolinium, axial and sagittal t1 weighted sequences were obtained. results: the more frequent us findings were microcalcifications inside the achilles tendon (27% of cases) and signs of bursitis (27%), while uncommon there were degenerative lesions and signs of peritendinitis. completion with echo-color-doppler did not add significant data to us study. mri imaging showed degenerative lesions and peritendinitis as well as us, but was not able to identify any microcalcification. all the alterations were identified in the basal study; administration of gadolinium did not allow any additional pathological finding. conclusion: our preliminary results show that mri, especially with low magnetic field, is not sensitive compared to us in detecting early changes of achilles enthesopathy in psoriatic patients, while echo-color-doppler and enhanced mri sequences had limited utility in diagnostic imaging of early stages of this pathology. characterization high resolution us and mri in the evaluation of plantar fibromatosis i. gallesio, s. parodi, r. pastorino, d. schettini, m. falchi, e. silvestri, g. garlaschi; genoa/it purpose: plantar fibromatosis is a benign fibroproliferative disorder of the plantar fascia clinically presenting subcutaneous nodules in the foot sole. this study aimed to evaluate the application potential of us and mri performance in detection of these lesions. material and method: 7 patient with palpable nodules suspected plantar fibromatosis were evaluated. the us examination was performed by means of a high resolution transducer through tranverse and longitudinal scans along with evaluation of intra-nodular vascularization by power-doppler. mri was performed by means of a 1.5 t unit with axial and sagittal planes. t1 weighted mri images after administration of iv contrast medium were acquired from two patients. results: 11 nodules were, overall, detected, most of them located in the medial plantar fascia. all nodules were oval-shaped, hypoechoic at us and hypointense at mri. considering number and size of nodules, us and mri overlapped (were strikingly similar). moreover, nodules showed hypervascularization at power-doppler, confirmed at mri with paramagnetic contrast medium. this pattern might suggest a different pathoanatomical condition of these lesions, as hypervascularization is a sign of an early stage lesion, featuring a large fibrovascular proliferation. no correlation was found between vascularization degree and symptoms the latter resulting from the neurovascular structures disorder. conclusions: us associated with power-doppler is the first choice method in the evaluation of plantar fibromatosis, able to detect number, size and activity pattern of nodules, leading to a pre-surgery diagnosis. in severe plantar fibromatosis mr is to be considered a complementary method in evaluation of the extent. purpose: conventional mri is a well-accepted technique in evaluating soft tissue tumors. however it is not specific in differentiating benign and malignant lesions. in this study the differential value of the dynamic contrast enhanced mri (dce-mri) was investigated. methods and materials: turbo flash dce-mri was performed on 27 subjects (2-74 yrs) with soft tissue tumors. enhancement in the 1 st min (e1), 2 nd min (e2), maximum enhancement (emax), and time-signal intensity curve (tic) slopes were calculated. discriminant analyses were performed to reveal parametric differences of the benign and malignant lesions. results: histopathological diagnosis of benign (n = 9) tumors were hemangioma (n = 3), neurogenic tumor (n = 3) lipoma (n = 2) and desmoid (n = 1), whereas malignant lesions (n = 18) were classified as liposarcoma (n = 5), osteosarcoma with soft tissue component (n = 5), malignant fibrous histiocytoma (n = 5), synovial sarcoma (n = 2) and giant cell tumor (n = 1). for malignant lesions mean values for e1, e2 and emax were 98%, 102%, and 119%, respectively. mean tic slope was 2.75. for benign lesions the above mentioned values were 43%, 66%, 76%, and 1.43, respectively. anova based discriminant analysis was correctly classified 74% of the lesions to benign and malignant groups using e1, 78% of the lesions using e2 or emax, and 82% of the lesions using tic slope. the combination of the above mentioned parameters had resulted a 93% accuracy (p < 0.001). conclusion: dce-mri parameters are the surrogate markers of tumoral microcirculation and tissue perfusion. these parameters may be used as key factors when deciding proper treatment alternatives and to reveal malignant transformations. the relation of flexor retinaculum laxity with age, gender, and hand dominance t. altinok, h.m. karakas; malatya/tr purpose: carpal tunnel syndrome (cts) is an entrapment neuropathy involving the median nerve within its fibroosseous tunnel at the wrist. one of the main radiologic parameters in diagnosing cts is the palmar displacement (pd) of the flexor retinaculum in this study, possible physiologic factors that may affect the palmar displacement and decrease the sensitivity of this criterion were investigated. materials and methods: 160 normal wrists of 40 male and 40 female with ages between 20 and 58 (mean: 39.6; sd: 11.2) were ultrasonographically investigated with 4-7 mhz linear transducer. pd values obtained were correlated with with age, gender, and hand dominance was analyzed. results: there was no significant difference between different genders and between dominant and non-dominant hands regarding palmar displacement. when considering all subjects this parameter was varied between 0.50 and 3.70 mm (mean: 2.00; sd: 0.64). palmar displacement exhibited a very strong correlation with age (p < 0.0001; r = .635 and r = .544, for dominant and non-dominant hand, respectively). when considering all subjects, linear regression between both factors was found to be 0.589 (p < 0.0001). the sensitivity of pd in diagnosing carpal tunnel syndrome was variously reported to be lower than other radiologic criteria. we have found this relative insensitivity to be originated from the age dependent laxity. the cut-off value of 2.5 mm given in the relevant literature must therefore be considered normal for the paients older than 55 years of age. the use of the normalization data presented may help to improve the sensitivity of the palmar displacement. vascular soft tissue tumor discrimination with mr image findings by pattern recognition techniques c. vidal, j. garcía-gómez, l. marti-bonmati, m. robles; valencia/es purpose: to discriminate within soft tissue tumors (stt) those with a vascular origin from other histological groups by using pattern recognition techniques with mr image findings. a total of 346 consecutive patient with confirmed musculoskeletal stt from different european centres were examined with mr. t1and t2-weighted fat-suppression or stir images were obtained in all subjects. the recorded variables were: age, clinical presentation, localization, size, shape, mr signal intensity, margins, homogeneity, edema, t1-hyperintense tracts, mul-tiplicity, target appearance, muscular atrophy, intratumoral hemorrhage, calcification, intratumoral fat, fibrosis, fascial relationship, bone alterations, vessels. the k-nearest neighbour (knn), support vector machine (svm) and decision trees (dt) were used to classify vascular from cystic, fatty, nervous, synovial and fibrous origin. the sample was splitted with 30% of cases used as test. results: efficacy of vascular in front of each histological group using knn was high (nervous 0.95, cystic 0.93, fibrous 0.85, fatty 0.84 and synovial). vascular vs. all other stt gave an efficiency of 0.97 with dt, 0.95 with svm and 0.93 with knn. conclusion: discrimination of vascular from nervous and cystic origin was easier than from fatty, synovial and fibrous stt. however, the overall values were very high. the computer assisted diagnosis in the discrimination of the vascular histological group from the others in stt diagnosis is possible by using pattern recognition techniques. spring ligament chronic injury on mr imaging a. iovane, m. midiri, m. galia, t. bartolotta, r. lagalla; palermo/it purpose: to evaluate the usefulness of mr to depict spring ligament (sl) and to visualize its chronic abnormalities even when associated to injury of the posterior tibial tendon (ptt). materials and methods: mr images from 185 patients (102 female and 83 male; age range 35-62 years), with clinical suspect of injury of the ptt, were retrospectively examined for sl normal appearance and abnormalities. all exams were performed by a 0.5 t mr using t1 weighted spin-echo and t2 weighted fast spinecho sequences on the axial plane.10 asymptomatic control patients (7 female and 3 male; age range 33 -63 years), were examined in the same interval time using t1 weighted spin-echo and t2 weighted fast spin-echo sequences on an oblique plane (45°), parallel to sl. we evaluated if sl was totally or partially visualized, sl thickness and signal intensity. results: in all control patients sl was completely visualized, 4-5 mm thick and homogenously hypointense. 120/185 patients had injury of ptt. among these 120 patients sl was visualized in its medial portion in 78 patients of which 56 had chronic abnormalities of ls. at standard mr examination was not possible to visualize the inferior portion of sl in almost all 185 patients. conclusions: mr seems to be an important diagnostic technique to evaluate sl abnormalities. the high association of sl lesions with ptt injury has to be known and considered when studying patients with proved advanced ptt injury in order to plan correctly the mr study to sl whole examination. primitive muscular hydatidosis: a pictural review of 11 cases a. konan, h. rajhi, n. mnif, m. karray, m. zlitni, r. hamza; tunis/tn purpose: soft tissue involvement by hydatid disease remains unusual even in endemic areas. in this report our aims are to review the imaging findings of muscular hydatidosis and underline possible peculiarity. we review retrospectively 11 patients (4 men, 7 women) who underwent surgery for primitive muscular hydatid disease. imaging technique used included ultrasonography (n = 11), ct scan (n = 7) and magnetic resonance imaging (n = 4). results: ultrasonography found multiple anechoic and hypoechoic cystic lesions (n = 10), necrozing tumor-like lesion (n = 1). ct scan showed evidence of multivesicular cysts in all cases. mri showed typical liquid lesions (n = 3), heterogenous signal due to scraps (n = 1) and evaluate accurately the extent of involvement. conclusion: in our experience multivesicular cysts is the main lesion showed in primitive hydatidosis soft tissue. ultrasound is still in routine relevant to detect muscular hydatidosis; ct scan and mri confirme the diagnosis and are helpful to demonstrate the relation between cysts and adjacent structures and evaluate extent of involvement before surgical management. results: 115 mri showed degenerative signs. in 30% disc enhancement was peripheral, parallel to the end plates.the disk enhancement was at l4-l5 in 35% and l5-s1 in 47%. it was found in 86% of end plates inflammation and in 88% of fatty changes. it was found in 6% of stage ii and iiia normal or earlier degenerative stages, 21% of stage iiib and 57% of iv stage latter degenerative stages. 10 biopsies were performed avoiding disc infection. 5 of the 15 mri of patients with ankylosing spondylitis showed large contrast enhancement parallel to the end plates without end plates inflammation. 10 mri of operated patients showed linear uptake parallel to end plates associated with enhancement in the posterior part of operated disc. 10 mri of patient with infectious spondylitis showed central disk enhancement with end plates inflammation in 100% and vertebral abscess in 50%. conclusion: disc enhancement parallel to end plate is a disc degenerative sign in operated and non-operated disc. it may be present in inflammatory conditions as ankylosing spondylitis. central disk enhancement appears to be an infection sign. effectiveness of us-guided core needle biopsy in the diagnosis of musculoskeletal lesions i. lecumberri, j.l. del cura, o. gorriño, i. lópez, a. legorburu, d. grande; bilbao/es purpose: to evaluate effectiveness and accuracy of ultrasound (us) guided core needle biopsy in musculoskeletal lesions. material and methods: us guided core needle biopsies were performed in 111 patients with musculoskeletal lesions imaged by us. all lesions were tumors on us exam, except two that appeared as ill-defined alterations in soft tissues. twelve were arising from or involving bone. location of the lesions was axial in 54 and in extremities in 57. results of core biopsy were correlated with the final diagnosis, that was based on the exam of surgical specimen in 53 patients who were operated on, and in clinical course in the rest. results: no complications occurred. core biopsy was considered diagnostic in 108 cases. fifty-two lesions were finally diagnosed as malignant and 59 were benign. in 11 cases final diagnosis was different from that of core biopsy. two lesions with non-diagnostic result were finally diagnosed as malignant and another one as benign. five lesions, benign in core biopsy, were diagnosed as a different benign entity after surgery. three lesions, considered benign after core biopsy, were finally diagnosed as malignant. us-guided core needle biopsy achieved 90% sensibility, 100% specificity, 100% positive predictive value and 95% negative predictive value to detect malignancy in musculoskeletal lesions. in us-visible musculoskeletal lesions, us-guided core biopsy can establish a diagnosis with great accuracy and frequently can avoid other explorations. thus, it should be considered a stable technique in the management of musculoskeletal pathology. extra-abdominal desmoid tumours in the post-partum period: diagnosis and staging with ultrasonography and mri l. dogliotti 1 , m. bazzocchi 1 , n. gandolfo 1 , f. pugliese 2 , f. prefumo 2 , g. serafini 1 ; 1 pietra ligure/it, 2 genoa/it purpose: the extra-abdominal desmoid tumour (eadt) is a rare disease more common in young females. this study describes the ultrasonographic features of eadts, and compares them with mri in the diagnosis and staging of the disease. a total of 12 lesions of the anterior abdominal wall and perineum have been assessed with ultrasonography and mri. six of them were subsequently diagnosed as eadts at histology. of these, 5 were located in the anterior abdominal wall and one, the largest, was embedded within the perineal muscles. all patients were female and reported being pregnant in the year preceding the diagnosis. three had delivered by caesarean section. the ultrasound examination were performed with a 12-5 mhz multifrequency transducer. mri imaging employed tse-t1w sequences with and without gadolinium, and tse-t2w sequences with and without fat suppression. results: in the cases of eadt ultrasonography showed solid homogeneous masses, slightly hypoechogenic compared to the adjacent fibromuscular structures. in the 5 anterior abdominal wall cases, the margins were clearly identified on a transversal plane but spiculated and irregular along the longitudinal plane in 3 out 5 cases. the large perineal lesion (diameter 6 cm) appeared dyshomogenous, but margins were regular and clearly identifiable. at color doppler exami-nation, all lesions showed a rich vascularisation. mri confirmed the fibrous nature of the lesions and helped in the differential diagnosis with endometriosis. conclusion: eadts appear as solid, homogeneous, clearly delimited lesion at ultrasonography. mri is useful for excluding endometriosis in case of dyshomogeneous lesions. retrospective analysis of ultrasound guided core biopsy in the diagnosis of soft tissue masses f.j. perks, i. beggs; edinburgh/uk purpose: to assess the accuracy of ultrasound guided core biopsy of soft tissue masses. we reviewed 65 soft tissue biopsies in 62 consecutive patients. diagnoses were compared to the post excision diagnosis in 28 patients. all core biopsies were performed by the same radiologist using ultrasound guidance. biopsies were performed as outpatient procedures. results: 3 biopsies repeated. 56 (85%) biopsies diagnostic of a wide range of benign and malignant disease. 24 of 28 (86%) biopsies accurately representative of post excision histology. 28 biopsies diagnosed disease that did not warrant excision. 4 false negative biopsies when sampling liposarcoma, lymphoma, chondrosarcoma and metastasis. overall sensitivity and specificity was 87.8% and 100% respectively. there were no complications. the purpose of this exhibit is to describe the imaging features of sapho in adults. this retrospective study included 24 patients (13 women, 11 men). all imaging procedures, radiographs, ct, mri and scintigraphy, were reviewed. background: sapho (acronym for synovitis, acne, pustulosis, hyperostosis and osteitis) is a syndrome of obscure cause, commonly considered to represent a seronegative spondylarthropathy, affecting especially young adults and children and leading to osteoarticular and skin manifestations. osteosclerosis, cortical thickening, enlargement of bone, arthritis are the predominent radiologic pattern, but periostitis and soft tissue swelling also may be seen and these findings can simulate osteomyelitis, sarcoma, lymphoma. imaging findings: of the 24 patients, topographic localizations were the upper anterior chest wall (82%), spine (50%), periphral bones and joints (46%), pelvis (30%), mandible (12.5%). the main radiologic findings correlated with hyperostosis, osteitis and synovitis. the radiologist plays a major role in the diagnosis: this exibit reviews the radiologic appearance of this syndrome and illustrates difficulties in differential diagnosis. erdheim-chester disease: detection and staging with multimodality imaging a. miquel 1 , e. dion 2 , c. graef 2 , y. menu 1 , p. grenier 2 , j.-d. laredo 2 ; 1 le kremlin-bicêtre/fr, 2 paris/fr learning objectives: to illustrate the clinical, radiological and histological spectrum of findings in erdheim-chester disease. to be able to recognise the disease in a patient with elementary symptoms. to describe the imaging modalities that are necessary for a precise staging of the disease. background: erdheim-chester disease is a multisystemic histiocytosis associated with characteristic skeletal abnormalities. bone (bone pain), skin (xanthomas), orbits (exophthalmos), pituitary gland (diabetes insipitus), retroperitoneum (hydronephrosis) and lungs may be affected by the disease. the relashionship of the disease with langerhans cell histiocytosis is still unclear. seventeen patients with erdheim-chester disease were evaluated between 1990 and 2001, using conventional x-rays, us, ct, bone scintigraphy and mri. radiological-pathological correlations were available in 15 cases. imaging findings: osteosclerosis of long bones in lower limbs is the most common feature (15/17 cases) and should be a trigger for the diagnosis. mri demonstrates replacement of the high signal of the bone marrow by a decreased signal on t1 and t2-weighted images. atypical osseous manifestations include involvement of ribs, skull and pelvis; focal lytic lesions are seldom encountered (3/17). visceral involvement may affect pituitary gland, orbits, pericardium, lungs, kidneys and retroperitoneum. pathologic study shows accumulation of lipid-laden histiocytes and fibrosis. conclusion: bone lesions are rather specific and should suggest the diagnosis of erdheim-chester disease. detection of visceral involvement, sometimes asymptomatic, requires imaging of brain, lung and retroperitoneum. histological analysis is necessary to assess the diagnosis and differentiate the disease from other cases of histiocytosis, especially langerhans cell histiocytosis. the learning objective: we aim to highlight the manifestations of myeloma using referrals from such specialities as haematology, orthopaedics and general medicine. the classical appearances of myeloma are presented with aids to enable the radiologist confirm the diagnosis and differentiate from other pathologies of similar appearance. background: multiple myeloma is the commonest primary malignant neoplasm and therefore as pathology the radiologist should be mindful of its many appearances. imaging findings: through a pictorial review we show not only the classical appearances of myelomatosis on plain film and bone scans but we also present its' appearance on ct scan and mri. the limitations and benefits of each modality are discussed. furthermore we highlight the recent findings which show that not only is mri better at staging multiple myeloma but compared to the dated "durie and salmon" criteria it negates the need for repeat blood and urine samples. conclusion: multiple myeloma may not always present with classical appearances and therefore it is paramount that a radiologist be aware of some of the unusual forms. through an assortment of imaging modalities we present not only the characteristic appearance but also atypical varieties. vertebral development: normal and abnormal aspects-interactive a. marinescu, a. pavel, h.c. ionescu, g. iana; bucharest/ro learning objectives: the program is conceived as an interactive lesson for those who wants to easy understand the vertebral development and also the pathology of an inadequate development. it is addressed to any radiologist in training. background: the vertebral development consists in three stages: mesenchymal, cartilaginous and bony. during this development appear many centers of the future vertebrae (mesenchymal, chondrifications and ossifications centers).o:p> procedure details: using a graphic presentation (originally and schematically) of the vertebrae for any stage and a color convention (the mesenchimal stage is represented in orange, the cartilaginous stage in blue and the third -the bony stage in pink); you can follow all the steps of the vertebral development. the program is interactive, meaning that you can follow the graphic presentation of the steps of the vertebral development, but also: • if you want to know more about the elements on the graphics, you can use the left button of the mouse clicking on the red sign. • before "details" and you will get the information and explanations. then, you can come back to the slide with the marks ü "details". • you can see, for each type of pathology which can occur in different steps of vertebral development, a graphic presentation and radiography (you press the left button of the mouse on the red sign before "pathology". conclusion: all the radiology trainees in our department have been satisfied with the program, instead of reading some arid pages for this topic. nevoid background: nevoid basal cell carcinoma syndrome (nbccs) is a rare autosomal dominant inherited disorder with complete penetrance but variable expressivity. although many radiologists are familiar with typical findings (e.g. major criteria) of this disease there are also findings that are only rarely demonstrable (e.g. minor criteria). imaging findings: we present nbccs-findings of 5 patients. they include numerous pathologies such as multiple cutaneous basal cell carcinomas, odontogenic jaw cysts, ectopic calcifications of the falx cerebri as well as palmar or plantar pits. characteristic images of the patients faces as well as bifid or fused ribs, vertebral anomalies, bridging of the sella turcica, flame shaped pseudocysts of the hands, lymphomesenteric cysts as well as increased frequency of tumors particularly medulloblastomas and ovarian fibromas that are also very important to recognise will be shown. the radiological findings are specific for this disease and may confirm the diagnosis in combination with the clinical presentation. furthermore early diagnosis as well as periodical follow-up examinations is very important since the nevi after puberty turn out to be aggressive. imaging with pathological correlation of sacral and presacral lesions s.a. o'keeffe, t. geoghegan, w.c. torreggiani; dublin/ie learning objectives: the objective of this poster presentation is to pictorially review the imaging of a series of patients with sacral and presacral lesions and to correlate these with pathology. background: presacral tumours are extremely rare accounting for less than 1 in 40,000 hospital admissions. there are many pathological causes as this is an anatomical area of embryologic fusion. a review of reports on the radiology information system (ris) was undertaken to identify those patients who had prein this pictorial review, we describe the anatomical contents of the presacral space and correlate this with the possible pathological causes of a lesion in this area. in addition, the imaging and pathology of a selection of sacral and presacral tumours is presented and methods of analysis of imaging are suggested. diagnosis background: chordomas are very rare tumors, for which standard medical therapies are lacking. following detection of pdgf-r expression in tumor samples, it was decided to treat some patients with advanced chordoma with imatinib mesylate on an individual basis. these patients were treated at the istituto nazionale tumori, milano, italy, as from august 2002. imaging findings: five pts with advanced disease (4 with sacral, one with clivus chordomas) undergoing imatinib mesylate were evaluated with mri at baseline, and then every 2 months. four pts showed hints of tumor response. these were: i) minor and slow decrease in size in the pt with the longest follow-up, following a transient initial increase in size, which was seen in all pts; ii) hypodensity of lesions on t1w images and hyperintensity on t2w images; iii) hypovasculature of lesions on contrast-enhanced t1w images in comparison to baseline assessment. conclusion: actual responsiveness of chordomas to molecular-targeted therapy with imatinib mesylate is left to be determined. however, preliminary observations suggest that mri may be useful to assess tumor response. signs of response may be subtle, likely depending on changes in tumor tissue rather than (or before) decrease in size. groin pain in athletes: mri findings f. idoate saralegui; pamplona/es learning objectives: this exhibit reviews the rmi findings in athletes with groin pain. background: groin pain is a common complaint in athletes, particularly prevalent among soccer players. this condition is frequently multifactorial, and the differential diagnosis can cover a rather broad area of entities, mainly involving adductor muscle and tendinous group, pubic bone even inguinal hernia. between january 1998 and august 2003, 90 athletes with groin pain were examined at our institution. the mri findings of the possible causes of groin pain in athletes are described and illustrated. imaging findings: the examinations were performed in a 1 tesla imaging system (magnetom impact expert, siemens) with a surface coil. t1-weighted spin echo and t2-weighted fat suppressed turbo spin echo images were obtained in axial plane; stir a t2-weighted turbo spin echo sequences were performed in coronal plane. the pathological findings observed were: osteitis pubis, stress fracture of pubic bone, muscle tears (adductor, obturator, rectus abdominis, pectineus, iliopsoas, gracilis and rectus femoris groups), abdomino fascial abnormalities, inguinal hernia, bursitis and inflammation conditions of the spermatic cord. conclusion: mri depicts adequately the numerous pathologic entities related to groin pain in athletes. infection background: prosthetic, graft or catheter infection, irrespective of location, invariably equates with a poor outcome. modern aseptic technique, in addition to the use of antibiotic-coated prostheses, have dramatically reduced the incidence of such infection. aggressive antibiotic suppression is effective in fewer than 30% of cases, the remainder requiring removal of the infected prosthesis, with associated morbidity, and occasionally, mortality. clinical signs and symptoms are frequently non-specific, including lethargy, pyrexia and anorexia. it is for this reason that quite often the task of locating a causative factor relies upon the expertise of the radiologist. imaging: using a pictorial review we depict the numerous pitfalls in the radiological diagnosis of prosthetic and endovascular graft infections. in addition, a guide to radiological imaging of less frequently encountered infections, such as those of breast and penile prostheses, ventriculo-peritoneal shunts, intra-ocular lens, cardiac pacemakers and valves, will be provided. the limitations and benefits of conventional radiography, digital subtraction angiography, computed tomography, ultrasound, magnetic resonance imaging and radio-isotope scintigraphy with respect to the site of infection will be explored in turn. the radiological diagnosis of infection of synthetic materials is notoriously difficult. the use of these materials for therapeutic, cosmetic and palliative purposes is ever-increasing. it is therefore of vital importance that the radiologist be aware of the advantages and disadvantages of available imaging modalities in arriving at a confident, swift diagnosis. a new method for radio frequency of lumbar disc in treatment of chronic low back pain n. azulay 1 , m. forgerit 2 , a. moumouh 1 , e. alava 3 , p. vandermarq 1 , j.-p. tasu 1 ; 1 poitiers/fr, 2 niort/fr, 3 barcelona/es purpose: treatment of chronic low back pains remains a challenge for physicians. recently, radio-frequency heating of inter vertebral disc has been proposed, as an alternative to surgery. we propose here a new method of discal radiofrequency in which heated water is used to spread the thermal energy. materials and methods: seventeen patients were included prospectively according to the criteria used in previous intra discal radiofrequency studies. the catheter is placed in the nucleus and heated water is used as thermal conductor to burn the annulus nociceptors. intra discal pressure and impedance measurements were used to control the energy delivered during the procedure. clinical results were evaluated by the oswestry score. the treatment was scored as a success with at least a 50% pain reduction on global perceived effect on oswestry score. the global oswestry before treatment was 50.6 points and 25 points 480 b d e f a g after corresponding to a 50.6% improvement. on the 17 patients, 12 were successfully treated (71%). we have shown that injection of heated water is sufficient to spread thermal energy to the anular nociceptor. this method is technically more simple than previous techniques using anular needle, avoiding navigation of the catheter through the anulus. ultra low dose ct in navigated closed reduction and percutaneous screw fixation of pelvic ring fractures h.g. staedele, r. huegli, s. meckel, a.l. jacob, h. roser, p. messmer, j. roth; basle/ch purpose: to reduce radiation doses in image-guided pelvic closed reduction and percutaneous fixation crpf without compromising guidance quality and procedural outcome. prospective study including patients with pelvic ring fractures treated with ct-guided crpf. patients received 2 screws which were navigated over guide pins. imaging modality used was a single slice scanner (general electric, usa). tube current was reduced by 50% with every step starting with routinely used scan parameters for diagnostic and interventional procedures (200 ma). if the image quality was good the next control scan was performed with 50% reduction of ma again. results: 13 patients with 16 fractures underwent crpf. 9 were males, 4 females, with a mean age of 39 years (range 23.3-88.9). dose reduction was possible in all patients in 2 to 4 steps ending up in 50 ma (n = 3), 25 ma (n = 4) and 10 ma (n = 9) respectively. 10 ma is the lowest current provided by the ct. number of misplaced screws was 0. number of additional correction of guide pin was 0. number of fallbacks to the next dose level was 0. conclusion: by lowering scan doses no relevant morphological information needed for safe guidance of instruments and implants was lost. scan protocols can be changed to lower ma values without compromising the safety of crpf. immediate procedural outcome was not affected. withdrawn by authors pelvic painful syndrome in athletes: diagnostic imaging evaluation l. zugaro, f. iannessi, a. catalucci, a. barile, c. masciocchi; l'aquila/it purpose: to describe the imaging features of the anterior and posterior painful syndrome in athletes. materials and methods: 28 athletes (23 males, 5 female) suffering from pelvic pain (groin pain = 13 and hamstring syndrome = 15) underwent mri after plain film and ultrasound preliminary evaluation. in 5 patients ct evaluation was also performed. mr examination was performed using a 1.5 t unit (ge medical system). proton density, t1 weighted and t2 weighted sequences on axial and coronal planes were employed. in one case mri was also obtained after surgical treatment. in all cases mri demonstrated pathological findings: anterior painful syndromes were related to osteitis pubis, bursitis, inguinal hernia, post-traumatic muscular lesions and stress fractures. hamstring syndrome was related to insertional pathology of hamstring tendons, inflammation disease of regional bursae and fibrotic changes of fatty tissue surrounding the ischial tuberosity. conclusion: anterior and posterior pubic painful syndromes are painful conditions often affecting athletes. mri provides a correct evaluation of these syndromes enabling an adequate therapy. the value of qualitative and semiquantitative ultrasonographic findings in the differential diagnosis of superficial lymph node enlargements o.o. okten 1 , n. tuncbilek 1 , h.m. karakas 2 ; 1 edirne/tr, 2 malatya/tr purpose: the value of the gray-scale (gsusg), color doppler (dusg), and power doppler (pdusg) ultrasonography in the differential diagnosis of superficial lymph node enlargements were evaluated. the study group was consisted of 36 males and 17 females (2-74 yrs old, mean age 36.1 yrs) in whom physical examination had revealed superficial lymph node enlargement(s). all patients were investigated with power doppler usg (sonoline elegra advanced, siemens, germany) using 7.5 mhz linear transducer. longitudinal/transverse dimensions (l/t), edge characteristics and hilar echogenecity of lymph nodes were evaluated with gsusg. pulsatility (pi) and resistivity (ri) indexes were calculated using cdusg. vascular pattern described as hilar or non-hilar were determined by pdusg. above parameters were analyzed to determine their differential diagnostic values using anova based discriminant analysis. results: when clinical data and histopathological findings were combined, 31 subjects were diagnosed as lymphoma, and 22 cases were classified as lymphadenitis. multiple comparison analysis of qualitative gsusg and pdusg features consisting of edge characteristics, hilar echogenecity and vascular pattern was able to differentiate lypmhomatous lymph nodes and lymphadenitis with 87% accuracy (p < 0.001). in contrary, semiquantitative features (ri, pi and l/t) were not able to classify lymph nodes (58% accuracy, p < 0.05). conclusion: semiquantitative rdus parameters are not valuable in the differential diagnosis of superficial lymph node pathologies. qualitative usg and pdusg features, on the other hand, may be used as an alternative work-up to cytological studies in patients in whom diagnostic surgical procedures cannot be performed. modern imaging in langerhans cell histiocytosis a. geoffray, k. oudjhane, l. lau, s. weitzmann; toronto, on/ca purpose: to review imaging features of pediatric langerhans cell histiocytosis (lch) with particular attention to cross-sectional imaging and aggressive cases. we reviewed retrospectively the imaging database of all the cases treated in our institution for lch during a 5 years period (january 1998 to december 2002). there were 45 patients, 30 boys, 18 girls, with an age range of 3 weeks to 13 years. results: 2 patients had no imaging anomalies and were excluded. among the 43 with anomalies, 16 had a solitary bone lesion (skull 3, orbit 3, spine 4, iliac 1, long bones 5), 19 had multiple bone lesions associated with other organ involvement in 6 (lung 4, liver and spleen 2, thymus 1), 7 patients had no bone lesions (1 cervical adenopathy, 2 abdominal involvement, 2 abdominal and lung, 1 pituitary gland, 1 middle ears), 1 patient had lch associated with neuroblastoma, and presented with lymphadenopathy, mediastinal and sacrococcygeal masses. imaging modalities were conventional radiography in 100%, nuclear scans 95%, ct 93%, mr 76%, us 62%. conclusion: lch in children is characterized by a wide spectrum of organ involvement. cross sectional imaging is useful in assessing the diagnosis and managing the most aggressive cases. can calcaneal spur help in the evaluation of a painful heel? n. sabir, s. demirlenk, b. yagci, n. karabulut; denizli/tr purpose: to determine the value of presence of calcaneal spur in evaluating painful heels. materials and methods: 145 heels of 66 female and 11 male patients with a mean age of 45.7 ± 9.8 years and mean body mass index (bmi) of 35.0 ± 10.5 complaining of bilateral (n = 68) and unilateral (n = 9) heel pain were studied. lateral radiographs of the 145 symptomatic and 163 asymptomatic heels were obtained to assess presence of calcaneal spur. mr imaging of the symptomatic heels was performed using 1.5 t superconductive system. the images were taken and reviewed for presence of plantar fasciitis (pf). heel pad thickness was also measured. results: calcaneal spur was seen in 72 of 145 (49%) symptomatic and in 13 of 163 (7.9%) of asymptomatic heels. mr has revealed pf in 68 of 145 (46.9%) painful heels and calcaneal spur was present in 53 of the cases with pf. calcaneal spur was significantly correlated with weight (p < 0.001), bmi (p < 0.001), age (p = 0.029), heel pain duration (p = 0.003) and pf (p < 0.0001). no correlation was seen between calcaneal spur and both height and heel fat pad. conclusion: although calcaneal spur is not the cause of pain, it may provide an objective assessment of the changes due to chronic repeatitive trauma to plantar fascia secondary to obesity or age. on the other hand foot radiography should be part of the initial diagnostic methods as it helps in excluding different causes of heel pain. purpose: the positive areas in scintigraphy of sentinel lymph nodes are sometimes difficult to be anatomically identified. we have examined the usefulness of bone scintigraphy performed together with lymphoscintigraphy for identification of the anatomical positions of the positive area in lymphoscintigraphy. materials and methods: sixteen patients, 12 cases of malignant melanoma and 4 cases of squamous cell carcinoma were examined by lymphoscintigraphy. nine patients, 7 cases of malignant melanoma and 2 cases of squamous cell carcinoma, were examined by bone scintigraphy together with lymphoscintigraphy. the patients were divided into three groups. in the first group, lymphoscintigraphy was performed alone. in the second group, the patients were first injected intravenously with tc-99mhmdp or tc-99mmdp and then lymphoscintigraphy was performed after intradermal administration of tc-99m sulphur colloid. three hours after injection of tc-99mhmdp or tc-99mmdp, bone scintigraphy were taken. in the third group, lymphoscintigraphy was performed 30 minutes after bone scintigraphy. result: anatomical identification of the positive areas in lymphoscintigraphy was difficult when used alone, whereas their identification became easier when used together with bone scintigraphy. when bone scintigraphy was performed after lymphoscintigraphy, evaluation of lesions in the bones near the original focus was sometimes not easy. however, evaluation of lymphoscintigraphy was not affected by prior performance of bone scintigraphy. conclusion: identification of the anatomical positions of the positive areas in lymphoscintigraphy was easier when used together with bone scintigraphy than in lymphoscintigraphy alone. in cases of the joint use, lymphoscintigraphy should be operated after bone scintigraphy. ultrasonographic detection of iatrogenic foreign bodies in an in vitro study i.k. rozylo-kalinowska, l. barczewski, e. szczepanik, r. lenard; lublin/pl purpose: sometimes foreign bodies being parts of surgical appliances remain in soft tissues as a result of iatrogenic faults. their presence is dectected clinically or radiologically, when the objects are radiopaque. nevertheless, radiolucent or faintly radiopaque objects often are a diagnostic challenge as their presence is difficult to diagnose on the basis of conventional radiograms. the purpose of the study was application of ultrasonography for detection of radiolucent and faintly radiopaque foreign bodies in an in vitro model. examples of radiolucent and poorly radiopaque foreign bodies such as plastic fragments of syringes, intravenous catheter, different cotton and gauze swabs, were embedded in containers filled with gelatine, which served as a model of soft tissues as well as played the role of a stand-off pad. the ultrasound scanning was performed by means of atl hdi 3500 machine with a high-frequency broadband linear transducer. results. there was determined the possibility of detection of various types of foreign bodies. there were described ultrasonographic image patterns of different objects. image findings: all types of used materials were well visible and hyperechoic in ultrasound image. plastic objects caused appearance of reverberation artifacts. the swabs produced characteristic patterns of internal structure. variations in ultrasonographic image patterns of foreign bodies studied in vitro allowed differentiation of various types of the examined materials. conclusion: ultrasonography may become a useful, widely available and costeffective tool in detection and localisation of foreign bodies of iatrogenic origin that otherwise remain undetected. spectrum of mr findings of herniation pit of the femoral neck m. ferrer, r. dominguez, m. romera, e. castella, x. merino, l. casas; barcelona/es background and purpose: herniation pit of the femoral neck has been considered a normal variant. this lesion is located in the superior aspect of the femoral neck, below the anterior cortex of the femur. the aim of this study was to describe the spectrum of magnetic resonance imaging (mri) findings associated with herniation pit of the femoral neck. material and methods: we retrospectively reviewed the mr studies in patients with hip pain performed in our hospital over the last 10 years. a total of 12 patients presented herniation pit. the features analyzed included: type of herniation pit (unilateral/bilateral), iliofemoral ligament thickening and asymmetry, iliopsoas muscle/femoral head relationship, acetabular coverage angle, cervicodiaphisary angle, femoral anteversion angle, and associated imaging findings (synovitis). results: in patients with hip pain and herniation pit, the following data were found: no other apparent cause of the pain (25%), iliofemoral ligament thickening (100%), decreased acetabular coverage angle (80%), altered cervicodiaphisary angle (90%). the elevated incidence of alterations in acetabular coverage and cervicodiaphisary angle in herniation pit, together with other alterations in stabilizing elements, lead us to suggest that, rather than a separate entity, herniation pit can be considered a component of the spectrum of adult hip dysplasia. b d e f a g high resolution ultrasound of the peripheral nerves of the lower limb: technique of examination and normal us appearance x. montet 1 , s. bianchi 1 , c. martinoli 2 , j. fasel 1 ; 1 geneva/ch, 2 genoa/it objective: to present the basic normal us appearance of peripheral nerves evaluated in vitro and in vivo. to describe the examination technique, the normal us findings and the main anatomic variations of the nerves of the lower limb. materials and methods: us images were obtained with commercially available equipment utilizing two linear probes (5-12, 7-15 mhz). the normal us appearance of a peripheral nerve was evaluated by in vitro examination a human sciatic nerve. sonograms were then obtained in normal volunteers and correlated with mri and images from anatomic textbook. results: the in vitro us appearance of the a normal peripheral nerve correlates well with the internal nerve structure. fascicles appear as hypoechoic bundles embedded within the hyperechoic connective tissue. the normal anatomy of the sciatic, peroneal, tibial nerve is first briefly described. then for each nerve the scanning technique is presented with emphasis on patient position, probe orientation and dynamic maneuvers. to improve the understanding of us images, correlative drawings showing the adjacent anatomic structures and diagrams showing the position of the probe are presented. high frequency transducers allow a detailed analysis of even smaller peripheral nerves. we present a practical manner to realize a us examination of the nerves of the upper extremity as well as us images of normal nerves and of their main anatomic variants. withdrawn by authors radiologic and sonographic examinations in patients with heterotopic ossifications j. nagy; budapest/hu purpose: to evaluate the diagnostic capability of radiologic and ultrasonographic examinations in patients (pts) with heterotopic ossifications (ho). during the last four years we have examined 107 pts (23 women, 83 men; age: 51 /20-90/ years) in case of the clinical suspicion of ho. dynamic conventional radiologic and ultrasonographic (7.5 mhz linear transducer) examinations were performed. results: in the background of ho, spinal cord injury (43 pts, 40%), brain injury (37 pts, 34%), limb damage (19 pts, 18%), orthopedic surgery (5 pts, 5%) or limb amputation (3 pts, 3%) were found. the most frequent localizations of ho were as follows: one side (53 pts) or on either of the sides of the hip (40 pts), elbow (13 pts), knee (8 pts), hip + knee (4 pts) or rare localizations (around the femoral stump) (7 pts). more than one localization was found in half of the pts. when the clinical suspicion of ho was not proved by radiology, dynamic ultrasonographic examinations were positive in each cases (17 pts, 16%). conclusions: (1) ho can occur in more than one localization after cns or limb injuries, (2) the most frequent localization was around one or both hip joints, (3) sonographic examinations showed earlier positivity compared to conventional radiology, (4) rare localizations of the ho can induce differential diagnostic problems in clinical practice. ultrasonographic experiences of spine-related lesions in patients with back pain: correlation with mri w. jin; incheon/kr purpose: multiple paraspinal lesions or spine-related lesions have been overlooked on transabdominal ultrasonograhic examination. therefore, we correlated transabdominal ultrasonographic findings with mri findings in spine-related lesions. materials and methods: 50 patients were underwent transabdominal ultrasonographic examinations for routine check prior to surgery. they were 28 men and 22 women aged 17 to 70 (average, 45) years. all patients also were checked with mri. in transabdominal ultrasonographic examination, compression of abdominal wall and inner contents were done. after this, we observed closely the contour of body, the height of body, disc height, and paraspinal lesion. results: in 50 patients, there were 1) compression fractures or burst fractures; 23 patients, 2) spondylitis; 7 patients, 3) bone tumorous condition; 2 patients, 4) abscess formations in paraspinal muscle; 3 patients, 5) ankylosing spondylitis; 1 patient, and 6) disc herniation; 14 patients. in these patients, transabdominal ultrasonographic findings were relatively correlated with mr findings, but lesions in posterior and middle elements of spine could not be evaluated with transabdominal ultrasonographic approach. conclusion: despite of many limitations of transabdominal ultrasonographic examination for detection of spine and paraspinal lesion, when spine and paraspinal structures or lesion are visible on transabdominal ultrasonography, ultrasonography suggested to be a screening method in patients with back pain. in particular, ultrasonography was superior to mri in detecting the minimal change of anterior disc, prediscal space, or anterior longitudinal ligament of spine. creation of a radiological musculoskeletal database (db) for statistic referrement, differential-diagnosis and didactic use (stuart project) s. trupiani, e. baldan, r. stramare, c. saccavini, l. bacarini, g. feltrin; padua/it purpose: to create a radiological db, with normal and pathologic cases, to be used for statistic endings, differential-diagnosis and for consultation. the db is available to everyone who as investigation or consultation needs or else for cases submission; for this reason is necessary to follow some fixed criteria unless the case is not accepted. the submission modalities have a starting schedule that contains: patient's anagraphic data, documentation source, sequence of technical-methodological procedures used, a description of every semeiological aspect contained in every single image, gamuts criteria-based diagnosis and final diagnosis. the cases are resumed by acr code. the definitive diagnosis, that contain a synthesis of anatomical-clinical and diagnostic aspects about the pathology observed, is open to critical observations by everyone that is consulting the db. every db consulter is able to introduce his opinion in a special window. the case report ends with a bibliographic correlation that contains the latest literature articles about the argument. the db contents can be utilized as a cases archive for clinical research (for this aspect, very important is the acr code), or as a support in the diagnostic report making, or as a didactical archive. moreover the db users can exchange their opinions, modify or add informations for every case by the web. ment was present in 15 cases (93.7%) and 4 discal involvement was present in 1 case (6.3%). 15 patients had soft tissue involvement and abscess was present in 2 patients. all cases showed vertebral and discal enhancement. 9 patients showed diffuse involvement of vertebral corpus and 5 patients showed endplate involvement. 2 cases showed both vertebral corpus and endplate involvement. intervertebral space narrowing was present in 13 cases, height loss in vertebral body was observed in 2 cases and 16 cases showed end plate deformities. we detected epidural extension in 6 cases, posterior longitudinal ligament (pll) elevation in 12, spinal cord compression in 9 and root compression in 2 cases. conclusion: spondylodiscitis is a rare complication of brucellosis and it can cause permanent neurologic deficits and spinal deformities. mri is a very sensitive and non invasive imaging technique which must be firstly preferred for the early diagnosis of spondylodiscitis. imaging findings: a total of 31 aneurysms in 26 patients were evaluated. all were proved at surgery. five small aneurysms were not depicted at 3d-cta-ssd (three were less than 3 mm, two were less than 5 mm). but only three small aneurysms were missed in 3d-cta-vrt (two were less than 3 mm, one was less than 5 mm). in 21 (81%) of the 26 patients, 3d-cta-vrt gave additional informations: orientation (n = 11), defining exact neck anatomy (n = 16), incorporation of vessels into aneurysm (n = 10), lobulation (n = 10), and blebs of aneurysms (n = 8). conclusion: 3d-cta-vrt is superior to 3d-cta-ssd in the detection of very small aneurysms and evaluation of complex anatomy of intracranial aneurysms. gadolinium enhanced ultra-fast mra: a primary diagnostic tool in the recognition and follow-up of dural sinus thrombosis s. gaudino, t. tartaglione, f. molinari, v. valentini, c. colosimo; rome/it dural sinus thromboses (dst) are not extremely rare, they still account for 5% of ictus in young adults. they need an accurate diagnosis at the onset of symptoms, and during the follow-up, to reduce the risks related to prolonged thrombolytic therapy. digital subtraction angiography (dsa) and, in the last years, phase contrast mr angiography (pc mra) with conventional mr sequences have become the methods of choice for dst diagnosis. our purpose was to evaluate the usefulness of gadolinium-enhanced ultrafast mra (ge-uf mra), routinely employed in supra-aortic vessel evaluation, in the diagnosis and follow-up of dst. materials and methods: we retrospectively evaluated 12 patients with diagnosis of dst, studied using 1.5 t magnet, conventional se, tse and ge-uf mra sequences. we could compare ge-uf mra images with dsa in 3 patients and pc mra in 5 patients. results: in all 3 dsa controlled patients, we found a complete agreement between ge-uf mra and dsa concerning location and extent of dst. in all 5 patients with both ge-uf and pc mra, the overall dst diagnosis was identical, even if the diagnosis of minimal dural sinus involvement was easily and definitively assessed with uf-ge mra, which allows a superior diagnosis confidence. conclusions: our preliminary experience suggests that ge-uf mra is a very fast modality, is easily obtained and analyzed and has a superior diagnostic confidence compared to pc mra. in our opinion ge-uf mra should be proposed as the primary diagnostic tool in the recognition and follow-up of dst. imaging imaging appearances: the images were obtained using unenhanced ct and routine mri sequences for brain imaging (ie sagittal t1, axial t2 and coronal proton density weighted sequences). fat suppression sequences were sometimes used for further clarification. the characteristic ct and mri appearances of intracranial fat and the anatomical location of the lesion allow the provision of a narrow differential diagnosis using routine imaging protocols. this facilitates decisions on the need for further imaging modalities. background: vascular dementia represents a very heterogeneous diagnostic category. utilizing the ninds-airen criteria and a centralized imaging rater to determine eligibility for enrollment in recent large-scale clinical trials testing new treatments for vascular dementia has provided increased consistency in the diagnosis of vad. the diagnostic criteria for probable vascular dementia include the development of dementia temporally related to stroke with neuroimaging confirmation. the criteria include a table listing brain imaging lesions associated with vascular dementia. in this study, 520 patients have been screened for the presence of cerebro-vascular disease using brain ct or mri. imaging findings: the wide spectrum of neuroradiological features that are associated with vad may result from cerebral small-vessel disease with extensive leukoencephalopathy or lacunes (basal ganglia or frontal white matter), or may be the consequence of single strategically located infarcts or multiple infarcts in large-vessel territories. it may also be the consequence of global cerebral hypoperfusion, intracerebral hemorrhage or other mechanisms such as genetically determined arteriopathies. conclusion: neuroimaging is required for confirmation of cerebrovascular disease in vad and provides information about the topography and severity of vascular lesions. neuroimaging may also assist with the differential diagnosis of dementia associated with normal pressure hydrocephalus, chronic subdural hematoma, arteriovenous malformation or tumoral diseases. imaging spectrum of cerebral complications after cardiac surgery e. testempassi, g. katsou, v. vantali, m. kolios, d. exarchos, d. chondros; athens/gr learning objectives: to present a systematic approach to imaging findings of cerebral complications caused by cardiac surgery. to review and understand the mechanisms and pathophysiology of cerebral involvement after cardiac surgery. background: a wide spectrum of neurologic complications may occur after cardiac surgery, such as motor, sensory or visual disturbances, stupor or depression of consciousness. the role of imaging in differentiating a variety of conditions that may cause the above neurologic symptoms is very important. morphology and patterns of cerebral lesions also enables an assessment of the pathophysiology and hemodynamics of brain complications after cardiac surgery. we retrospectively reviewed the brain ct images of 94 symptomatic patients, who previously had cardiac surgery performed. imaging findings: a variety of common and uncommon findings on ct and mr images of neurologic complications after cardiac surgery are illustrated. acute infarctions involving a vascular territory, hemorrhagic infarctions, multiple infarctions, watershed infarctions, bilateral infarctions, braistem and cerebellar infarctions, uncal herniation, brain edema and inflammatory processes are depicted. preoperative cerebral ct or mr images are helpful in diagnosing new lesions in patients with old infarctions, lacuna or ischemic leucoencephalopathy. the radiologist must be familiar with the imaging appearance of complications that affect the brain after cardiac surgery. imaging findings of an ethmoidal dural arteriovenous fistula with venous drainage in the vein of galen v.t. skiadas, a. prasouli, p. mitseas, g. kottas, s. laxanis; athens/gr learning objectives: to illustrate the mri, mra and angiographic findings of an ethmoidal dural arteriovenous fistula (avf) in the anterior cranial fossa. background: ethmoidal avfs are rare vascular anomalies. only 129 cases have been presented since 1963, when they were first described by lepoire. they can be either congenital or acquired lesions. ethmoidal arteries are the main feeding vessels. the vast majority drain to the superior sagittal sinus and to the cavernous sinus. the presenting symptom is intracranial hemorrhage, mostly subarachnoid or intracerebral. their propensity for hemorrhage justifies immediate surgical removal of the lesion. imaging findings: an mri scan was performed demonstrating an abnormal region of signal void, suggesting a vascular anomaly involving the base of the left frontal lobe. for further evaluation, the patient underwent an mra examination. a vascular linear lesion, probably a vein, at the base of the left frontal lobe and enlargement mainly of the left, as well as of the right ocular artery was discovered. a digital subtraction angiography (dsa) was performed and an edaf on the left ciribriform plate supplied by bilateral ethmoidal arteries was revealed. it drained via a dilated abnormal vein to the left vein of galen. so far, only one other case has ever been reported with venous drainage to the vein of galen. conclusion: specific mri and mra imaging findings should arouse the suspicion of an edaf and dsa can effectively demonstrate the nidus of the lesion, as well as the feeding and draining vessels and confirm the diagnosis. functional based on the hypothesis of focal cortical inhibition, low-frequency transcranial magnetic stimulation (tms) was used, resulting in a slight reduction of hallucinations in some patients. in this case study, functional magnetic resonance imaging was employed to image blood oxygenation level dependent (bold) effect changes in the temporal lobes under tms-therapy. methods: in a curative attempt, a 30-year old schizophrenic patient (dsm-iv) with medication resistent acoustic hallucinations was treated with low-frequency tms (fstim = 1 hz) over a four week period. fmri was performed in a 1.5 t clinical scanner using the standard head coil and a ge-epi sequence. the tmseffects were detected based on the event related bold-fmri of auditory hallucination and auditory hallucinations rating scale. fmri was performed prior to and after the tms series to visualize possible cortical activation changes in the stimulated area. data analyses were performed with spm99 (http:// fil.ion.ucl.ac.uk.spm). results: after the third week, the patient presented a reduced frequency of acoustic hallucinations of approx. 50%, while the loudness of the hallucinations remained unchanged over the 4 weeks of stimulation. fmri demonstrated a bold effect activation reduction after tms in speech related areas, which exceeded the local stimulation area. discussion: fmri data revealed an activation reduction in temporal and temporo-parietal areas after tms corresponding to the clinical recovery. the combination of tms and functional imaging is promising, allowing an insight into neuro-biological mechanisms during tms intervention, which may help to improve treatment success. went immediate hyperbaric oxygen (hbo) therapy and the initial result was excellent. he was discharged with subtle weakness in the right lower extremity. the second woman didn't undergo hbo therapy and was discharged with left hemiparesis. imaging findings: mr imaging with diffusion-weighted images (dwis) and adc maps were performed at admission. the first man showed high signal intensities bilaterally of the perirolandic cortex and occipital cortex on t2-weighted images (t2wis) and dwis. these areas showed dark signal intensities on adc maps, suggesting cytotoxic edema. the second woman showed high signal intensities bilaterally of the perirolandic cortex, bilateral globus pallidus and left occipital periventricular white matter on t2wis and dwis. these areas also showed dark signal intensities on adc maps. conclusion: mr imaging findings are similar to co poisoning in that cytotoxic edema involves the globus pallidus bilaterally. but we experienced some different mr imaging finding to co poisoning in that cytotoxic edema involves the perirolandic area bilaterally, which can be seen in profound perinatal asphyxia in term infants. computed tomography angiography ( volumic acquisition of the brain with multislice detector ct at arterial phase is analyzed systematically with 2d maximum intensity projection (mip). in most cases, volume rendering reconstructions are also performed. all patients with negative cta have a conventional cerebral angiography to visualize entire intracranial circulation. cta and conventional cerebral angiography are performed by 4 senior neuroradiologists. imaging findings: multislice detector cta explores all the locations of intracranial aneurysms. cta is a quick and reliable technique for the detection and therapy planning of intracranial aneurysms. rarely, cta depicts arteriovenous malformations. in some cases, hemorrhage suggests cerebral venous thrombosis that is also diagnosed on cta. we present selected cases emphasizing the utility and the limits of the technique. conclusion: cta is a non invasive, reliable tool to explore patients with non traumatic intracranial hemorrhage. the use of cerebral cta by expert neuroradiologists allows a significant reduction of the number of emergency diagnostic angiography required. brain activations during bi-script reading in chinese: a direct comparison of alphabetic and non-alphabetic reading using functional magnetic resonance imaging (fmri) y. li 1 , x. feng 1 , y. chen 2 , w. tang 1 ; 1 shanghai/cn, 2 oxford/uk learning objectives: a direct comparison between reading alphabetic and nonalphabetic scripts was done using fmri during bi-scripts reading of chinese characters and its alphabetic sound symbols known as pin yin. background: six mandarin speakers and skilled readers of chinese participated in this study. all the subjects were right handed. experiments were performed on ge mri scanner at the huashang hospital. sixteen slices covering the whole brain were collected with blood oxygenation level dependent (bold) sequence. the anatomical images were obtained in the transverse plane during the same scan session with 3d fspgr sequence after the functional measurements. the four types of stimuli were distributed equally in two main conditions i.e. chinese and pinyin. in each condition, half stimuli were words and half were non-words. data analysis was carried out using feat, the fmrib easy analysis tool, an extension of medx. imaging findings: the activations in the right inferior frontal gyrus, the left fusiform gyrus, the bilateral cuneus and the bilateral superior frontal gyrus were stronger for chinese character reading than for pinyin reading. the activations in the bilateral supramarginal gyus, the bilateral superior parietal gyrus and the bilateral middle frontal gyrus, however, were stronger for pinyin reading than for chinese character reading. different parts of the middle temporal gyrus were also activated for reading these two scripts. the low hemispheric lateralisation for both chinese character and pinyin reading indicate an important role for both hemispheres in reading. conclusion: fmri is one of the best methods of illustrating difference of brain activations during alphabetic and non-alphabetic reading. mri of the brain in inherited neurometabolic disorders: a pictorial review s.p. prabhu, s.a. barnard, n. stoodley, s.a. renowden; bristol/uk learning objectives: to illustrate typical mri appearances of the brain of patients with inborn errors of metabolism and toxic inherited white matter disease. a simple algorithm to unravel the possible cause of imaging findings is incorporated as part of this presentation. background: the diagnosis of a neurometabolic disease is usually suggested by clinical history and physical findings and is confirmed by appropriate special studies, which may include neuroradiological investigations. when the patient is referred with a nonspecific diagnosis, such as delayed development, the aim is to suggest the possibility of a neurometabolic disorder and initiate further evaluation including possible therapy and genetic counselling. on occasion, routine neuroradiological studies may incidentally produce results suggestive of a neurometabolic disorder. imaging findings: disorders including glutaric aciduria, pyruvate dehydrogenase deficiency, leigh's encephalopathy, maple syrup urine disease, methylmalonic aciduria, adrenoleukodystrophy, metachromatic leukodystrophy, krabbe's leukodystrophy and pelizaeus-merzbacher disease are illustrated. a pattern approach based on which part of the brain is affected is used to provide an aid to the diagnosis. conclusion: magnetic resonance imaging plays an important role in the identification, localisation and characterisation of underlying white matter abnormalities in affected patients and is also extensively used to monitor the natural progression of such disorders and the response to therapy. background: to compare 3d-dsa with 2d-dsa and 3d multi-detector ct angiography (cta) with vrt in the detection and evaluation of intracranial aneurysms. imaging findings: a total of 101 aneurysms were evaluated. seven very small aneurysms (diameter less than 3 mm) and two small aneurysms (less than 5 mm) that were not depicted at conventional 2d-dsa and 3d-cta-vrt were depicted at 3d-dsa and all were proved at surgery. in 72 (90%) of the 80 patients, 3d-dsa gave additional informations: orientation (n = 26), defining exact neck anatomy (n = 60), incorporation of vessels into aneurysm (n = 30), lobulation (n = 32) and blebs of aneurysms (n = 35). conclusion: 3d-dsa is superior to 2d-dsa and 3d cta-vrt in the detection of very small aneurysms and evaluation of complex anatomy of intracranial aneurysms. low background: dwi is a useful diagnostic tool that improves our background understanding to pathology. the b-value choice has a significant repercussion on signal-to-noise ratio, dwi contrast and t2 shine-through phenomenon. we have created a straightforward animated microsoft power point presentation showing diffusion physical principles and its imaging consequences. the dwi studies from 50 normal subjects and 50 patients (including brain tumours, encephalitis, demyelinating and cerebrovascular diseases) were further analyzed. all studies were 486 b d e f a g carried out with three different b-value (1000, 2000, 3000 s/m 2 ). exponential images and apparent diffusion coefficient (adc) maps were subsequently computed. in normal individuals, the signal and adc in the hemispheric white matter, basal ganglia and brain cortex were measured. lesions' signal with different bvalues, and their contrast rate on computed maps, were subjectively compared. imaging findings: when we visualised some acute lesions, higher b-values improved contrast compared with lower b-values. other lesions, like tumours, showed mixed dwi intensities and their contrast also improved with high b-value images. exponential and adc maps were useful for discarding t2 shine-through effects, moreover with low b-values, but contrast rate was significantly dismissed. conclusion: high b-value dwi provides a better contrast and a reduced t2 shinethrough phenomenon but it does not display more lesions than low b-value dwi. as computed maps add useful information to that provided by dwi, it seems that the b-value choice depends on each group preferences. utility of mr spectroscopy, diffusion and perfusion mr imaging in the evaluation of brain lesions in aids patients l. . diffusion weighted imaging were performed using a diffusion gradient of 1000 sec/mm 2 applied in three axis planes. mr perfusion was performed using tr 1500 ms and te 90 ms, following bolus infusion of intravenous contrast material, obtaining relative cerebral blood volume maps (rcbv). to determine metabolites a mr spectroscopy (mrs) was performed with single-voxel press-30 sequence. we classified the brain lesions in two majors groups: one with brain lesions that cause mass effect (n = 26) and the other with infiltrating white matter lesions (n = 14). three patients did not have any lesion. mass effect lesions could be inflammatory/infectious diseases: toxoplasmosis (n = 9), tuberculosis (n = 5), cryptococcosis (n = 2) and neoplasic lesions: lymphoma (n = 10). as infiltrating white matter lesions, we included progressive multifocal leukoencephalopathy (n = 4), hiv encephalopathy (n = 6), cmv infection (n = 1) and hsv infection (n = 1). brain infarct (n = 2) is an important condition in aids patients and is more prevalent than in the general population. the mrs, diffusion and perfusion mri have been shown to be extremely useful in characterizing and making the correct diagnosis of brain lesions in aids patients. "string-knot shape" enhancement: a presenting feature of cerebral sparganosis in mri c. shuguang; shanghai/cn learning objectives: to describe the mri character of cerebral sparganosis. background: the cases of cerebral sparganosis have shown a trend of increased frequency with the change of eating habits, especially eating under-cooked products of snake or frog. there is sparse literature available which illustrates nonspecific findings of cerebral sparganosis in mri including nodular lesions, white matter degenerations or haemorrhages. mr imaging of six patients with cerebral sparganosis were reviewed retrospectively in our exhibit. imaging findings: all six cases of cerebral sparganosis showed a single lesion. the location of lesions were superficial with three in the parietal lobe, one in the frontal lobe, one in the temporal lobe and one in the posterior part of brain stem. five lesions were irregular in shape and about 3 cm diameter with moderate hypointensity on t1wi and hyperintensity on t2wi. a presenting feature of the parasitic granuloma was a "string-knot shape" enhancement, which was demonstrated in 5 cases. one case showed a cystic lesion with peripheral enhancement. there was slight hyperintensity surrounding the nodular lesions which corresponded to edema. no white matter degenerations or hemorrhages were revealed which had been described by previous studies. diagnosis of sparganosis was made on the basis of characteristic enhancement in mri for 5 cases and one was diagnosed as parasitic infectious disease. during surgery, live larvas of sparganum were successfully removed in five cases with "string-knot shape" enhancement lesions. in the case with a cystic lesion, only fragments of worm body were obtained. conclusion: "string-knot shape" enhancement is a characteristic mri finding which has a high value in diagnosis of cerebral sparganosis. cystic lesions of the brain: a pictorial essay with mr imaging s. cakirer, m. basak, e. serin, i. ince, m. birinci; istanbul/tr learning objectives: to illustrate the spectrum of intracranial cystic lesions. to clarify the underlying reasons for specific mr appearances. to define the role of additional mr sequences for differential diagnosis of cystic lesions with similar appearances. background: intracranial cystic lesions are common in radiological practice. the differential diagnosis of intracranial cystic lesions includes a wide spectrum of diseases and is much easier with the use of standard and advanced mr imaging techniques including diffusion and perfusion-weighted studies and mr spectroscopy. between january 2002 and august 2003, 358 patients with intracranial cystic lesions were studied in our institute. mr imaging characteristics of the lesions, the underlying reasons for the specific mr appearances and the role of additional mr sequences for the differential diagnosis were defined following the categorization of the lesions. imaging findings: intracranial cystic lesions can be categorized into five groups. they include cystic components of primary and secondary neoplasms (glioblastoma multiforme, pilocytic astrocytoma, pleomorphic xanthroastrocytoma, ependymoma, ganglioglioma, central neurocytoma, hemangioblastoma, macroadenoma, craniopharyngioma, metastases), benign developmental cysts (arachnoid cyst, colloid cyst, epidermoid cyst, dermoid cyst, pineal cyst, rathke cleft cyst, choroid plexus cyst), post-infectious and inflammatory cysts (abscess, parasitic cysts including cystisercosis and hydatid cyst, multiple sclerosis, adem), post-traumatic or post-infarct cysts (porencephalic cyst, encephalomalacic cyst, leptomeningeal cyst) and normal variant cysts (enlarged tumefactive perivascular spaces, cavum septum pellucidum, cavum vergae). the underlying reasons for mr appearances of cystic lesions, role of additional sequences for their diagnosis and differential diagnoses between lesions with similar appearances have been evaluated. cta was performed on a single-slice spiral ct scanner (hispeed lxi, ge) with slice thickness 1 mm, reconstruction interval 0.5 mm and pitch 1. an area from base of the skull to above the clinoid processes was covered. a non-ionic contrast medium was injected in cubital vein (370 mgi/ml, 4 ml/ s, 100 ml) and scanning started after delay of 15-20 s. corresponding 3d image reconstructions (maximum intensity projection (mip) and volume rendering (vr)) were produced at accompanying workstation (aw 4.0, ge). conclusion: intracranial aneurysms were visualized in 35 of 41 patients, but only 23 were further evaluated. although intra-arterial dsa is still regarded as "gold standard" in diagnostic evaluation of the sah, cta can serve as guidance for intervention. proton mr spectroscopy of the brain: patterns and pitfalls in diagnosis of brain tumors c.c.t. lim, h. parmar, h. yin, v.g.e. chua; singapore/sg learning objectives: to review typical spectral patterns of brain tumours and non-neoplastic lesions and to understand the potential mimics and pitfalls in using proton magnetic resonance spectroscopy (mrs). background: mrs provides metabolic information that is independent of conventional mr imaging. mrs has been applied to distinguish brain tumors from other diseases and is available on many clinical scanners. post-processing of single-voxel and multi-voxel studies may be presented either as metabolic spectra or parametric maps in the latter. imaging findings: in brain tumours, there is elevation of choline (a marker of cell membrane turnover) and decreased n-acetyl aspartate (a neuronal marker) and creatine (an energy substance). lactate and mobile lipids are sometimes present. conversely, non-neoplastic lesions typically do not show increased choline. lactate is sometimes detected in ischemia, abscess and demyelination. toxoplasmosis and tuberculomas typically show a dominant lipid peak. bacterial breakdown products including acetate, alanine and succinate are detected in abscesses. occasionally, increased cellular infiltrates and reactive astrogliosis may result in elevated choline levels, mimicking tumour. conclusion: with increasing clinical application of mrs, radiologists should be familiar with common spectral patterns of brain disease as well as the potential pitfalls in interpretation. decreased signal intensity on t2-weighted mri in the basal ganglia in patients with white matter disorders p. arguis, s. capurro, j. berenguer, t. pujol, m. olondo, j.m. mercader; barcelona/es learning objectives: to describe some aspects of brain iron metabolism which can be studied by mri. to learn how decreased signal intensity on t2-w images in the basal ganglia can be seen in several white matter disorders. background: the iron is taken up by capillary endothelial cells in basal ganglia and then is transported axonally to projection sites where it is used in local metabolism, there the iron is stored in oligodendroglia cells. interruption of normal axonal transportation of iron caused by white matter abnormality might lead to increased accumulation of iron at the basal ganglia since it could still be taken up but not be transported. it is generally accepted that there is a correlation between the accumulation of iron in the extrapyramidal system and the degree of hypointensity observed at this site on t2-weighted images. imaging findings: low signal intensity on t2-w images were observed in the basal ganglia in 14 patients with different white matter disorders (congenital, multiple sclerosis, postradiation toxicity, ischemia, aids-related and tumoral). mr studies were performed with a 1.5 t scanner. conclusion: decreased signal intensity on t2-w images in the basal ganglia can be seen in several white matter disorders. typical background: wernicke encephalopathy (we) is a severe neurologic disorder caused by thiamine deficiency related to malnutrition or malabsorption of b1 vitamin that occurs mainly, but not exclusively, in alcoholic patients. we reviewed the risk factors as well as the usual and unusual clinico-radiological features including two cases in non-alcoholic patients (one with gastroesophageal reflux and other with pyloric stenosis secondary to biliogastric reflux). a third of patients with acute we present with the classic clinical triad: opthalmoplegia, ataxia and confusion. other initial manifestations are hypothermia, hypotension, coma, nutritional polyneuropathy, cardiovascular involvement. early diagnosis is crucial because of non-specific clinical findings, a high mortality rate but a possible complete recovery with immediate thiamine replacement. imaging findings: typical mr findings include symmetrical signal changes in medial thalami, tectum and periaqueductal region. in the acute stage, enhancement after contrast injection may be visible in these regions as well as in the mamillary bodies, but at chronic stages atrophy is the main finding. atypical features described include signal changes in the cerebellum, dentate nuclei, pons, red nuclei, basal ganglia and central and precentral sulci. massive haemorrhages are rare whereas microscopic foci are frequent. differential diagnosis includes de/dysmyelinating disorders, infarctions and creutzfeldt-jakob variant but symmetrical distribution of findings rules out most of them. conclusion: we is a reversible, severe disorder and a high index of suspicion is recommended to diagnose it, even in non-alcoholic patients. to determine whether functional mr imaging sequences (diffusion tensor, tractography, perfusion, spectroscopy, blood oxygenation level dependent-bold), can help add new information to the pre-surgery approach to brain tumors. to determine the efficiency and efficacy of these news tools in evaluating brain tumors. during the period of 6 months, mr exams of 25 patients with brain tumors (17 men, 8 women; mean age 47.5years) were performed in a 1.5 t clinical scanner (siemens, germany) , using mr clinical standard protocol and functional sequences (diffusion tensor imaging, perfusion, spectroscopy and bold sequence). all the patients had their histopathology diagnosis confirmed by brain biopsy and surgery; glioblastoma multiforme (n = 9), anaplastic astrocytoma (n = 6), low grade glioma (n = 6), gliomatosis cerebri (n = 1) and metastases (n = 3). high grade glioma and metastases had hyperperfusion, high picks of choline and low n-acetylaspartate (naa). low grade glioma and gliomatosis cerebri had low relative cerebral blood volume, low naa, high choline and myoinositol. diffusion tensor imaging showed alterations of the main tracts within and nearest the high grade tumors. low grade tumors had main tracts dislocated but not interrupted. the white mater tract were preserved in gliomatosis cerebri. bold sequence identified the sensory-motor and language activating areas. mr imaging has been used to evaluate brain tumors. with new neuroimaging advanced tools, we can do this analysis in a more accurate and precise way and it takes less time than it was thought to. it is a huge contribution to the evaluation and management of patients, providing a type of diagnosis close to histopathology diagnosis. individual approach to recanalization treatment of acute ischemic brain contrast-enhanced mra were obtained three to five days after the insult. we retrospectively reviewed the mr findings and clinical courses of 193 patients with anterior circulation territorial infarction. those with ica and mca lesions were divided into six and five groups respectively, according to the level and mechanism of the occlusion. pwi findings can be another factor in the management planning. here, we will present representative cases of each group and discuss the management with thorough consideration of various factors, such as pattern and type of arterial occlusion, the extent of dwi/pwi mismatch, the duration of the ischemia, age of the patient, the severity of neurologic deficits, or use of other anticoagulants, etc. we believe that mr imaging is very helpful in the evaluation and management planning of patients with hyperacute stroke. the treatment should be individualized to enhance the effectiveness and safety of the various treatment modalities. similarities and differences in functional connectivity of the prefrontal cortex: task in episodic memory (em), task-and item-related processes have been postulated to contribute to asymmetries in cortical involvement with the prefrontal cortex (pfc) being of particular interest. this study demonstrates task-and itemrelated differences in functional connectivity of pfc in verbal vs non-verbal em. methods and materials: twelve healthy volunteers performed visual non-verbal (line drawings of known objects) and verbal (abstract words) em tasks undergoing o-15-butanol-pet to measure regional cerebral blood flow. using correlation analyses, functional connectivity of item-related (verbal vs non-verbal) processes during episodic encoding and retrieval was assessed. results: across all tasks/items we observed strong prefrontal interactions regarding the dorsolateral (dl) and frontopolar (fp) pfc. during encoding we found bilateral but left dominant pfc interactions with any material, right dlpfc showed no interactions during the abstract word condition. during retrieval of pictures we found an increase of right fppfc interactions and a symmetrical increase of dlpfc interactions. during retrieval of abstract words we observed an increase of left fppfc interactions, while right dlpfc showed no interactions. memory performance was higher for pictures vs words. conclusion: firstly, our results support the idea of a common bilateral pfc involvement across different stimuli and mnemonic operations. secondly, item-related processes point to a left lateralized pfc involvement for words and a bilateral pfc involvement for pictures. these data support the "dual coding" hypothesis, introduced by paivio (paivio, 1971; paivio 1991) , postulating a double (verbal and non-verbal) processing pathway for pictoral stimuli, hence a supplementary mnemonic strategy to increase memory performance. perfusion weighted dynamic susceptibility ( method: fifteen patients with unilateral 70-90% carotid artery stenosis were studied with dsa and perfusion-weighted dynamic susceptibility (dsc) mri and were compared to 15 age/sex matched controls. regional cerebral blood volume (rcbv) and mean transit time (mtt) values were calculated in the middle cerebral artery (mca) and borderzone (bz) territories. all patients underwent tea within one week from mri and were re-examined one month after surgery. results: there was no significant difference in rcbv and mtt values between the hemispheres in the symptomatic patients. there was a significant difference in mtt values in the borderzones between patients and controls. after tea we found a decrease of mtt of both hemispheres in bz territories while the remaining hemodynamic parameters persisted unchanged. the decrease in mtt values after tea lead these values to be similar to those of normal subjects. the results of our study suggest that there is an adequate compensation of unilateral stenosis when it is less than 90%. a hemodynamic compensation mechanism between the two hemispheres, particularly for the distal border zone territories that tend to have a slower mtt with respect to the control subjects before tea, and the restoring of mtt values in the bz after surgery, seems to be demonstrated as well. parkinson's disease: pre-and post-apomorphine perfusion evaluation with dynamic susceptibility contrast (dsc) mri f. gaudiello, s. marziali, a. ludovici, e. ferone, r. floris, g. simonetti; rome/it purpose: our aim was to study whether dsc-mri perfusion method may detect an altered pattern of regional cerebral blood flow (rcbf) in parkinson's disease (pd) patients in comparison to normal subjects and whether this altered pattern may be normalised by apomorphine. material and methods: twenty subjects affected by idiopathic pd according with the brain bank criteria were enrolled for this study. nineteen normal subjects were included as controls. ten of them performed a retest procedure. pd patients, after at least 20 days of therapy withdrawal, were submitted to perfusion dsc-mri. sixteen of them were retested after apomorphine injection at least 24 hours. relative regional blood flow was evaluated by using regions of interest (roi) of 50 pixels manually placed in different region of basal ganglia. results: pd patients showed a significant inter-hemispheric asymmetry due to a higher perfusion in the more affected side (< 0.01), while normal subjects did not. pd exhibited an abnormal "asymmetry index" in the measured nuclei. dsc-mri performed after subcutaneous apomorphine injection did not show any significant asymmetry in pd patients. retest in normal subjects did not show any significant variation. conclusion: dsc-mri of basal ganglia confirms the asymmetry observed in pet studies of pd, suggesting this method as a promising technique in neurodegenerative diseases. b d e f a g steeper (r = 0.68, p < 0.001) comparing to wm (r = 0.49, p < 0.05) and almost negatively linear. conclusion: our study shows that ageing effects on metabolite concentrations are more pronounced in the gm regions of the brain. determination of absolute metabolite concentrations, rather than use of ratios only, is essential for characterizing age-related changes in brain metabolites. diagnosis of cerebral vascular malformations with ct angiography in patients with subarachnoid hemorrhage s. stathopoulou 1 , c. kokkinis 1 , n. makris 1 , a. petinelli 1 , k. vassiou 2 , m. vlychou 2 , p.j. papadaki 1 , g.m. zavras 1 , j.b. fezoulidis 2 ; 1 athens/gr, 2 larissa/gr purpose: to evaluate the diagnostic accuracy of spiral ct angiography in patients with subarachnoid hemorrhage due to vascular malformations. methods and material: one hundred and fifty-eight patients suffering from subarachnoid hemorrhage (sah) underwent ct angiography (cta) as well as intraarterial digital subtraction angiography (ia-dsa). cta was performed using spiral ct with 150 ml of intravenous contrast at 4 ml/sec, after a delay of 20 sec. slice thickness 0.8 mm and a reconstruction index of 0.5 was used. axial slices and multi-planar reformatting (mpr), maximum intensity projection (mip) and 3d surface shaded display (ssd) reconstructions were reviewed. ia-dsa followed in all patients. there was comparative study between two methods. results: twelve cases of vascular malformations were diagnosed by cta and these comprised 9 arteriovenous malformations and 3 venous angiomas. in 10 cases, the cause of sah was vascular malformation and in 2 cases was an incidental finding. in comparison with ia-dsa, cta missed only a small dural arteriovenous malformation but diagnosed a small venous angioma missed by ia-dsa. these two malformations appeared without hemorrhage. conclusion: cta is a useful non-invasive method in detection of cerebral vascular malformations causing sah, with similar results to ia-dsa. even though ia-dsa offers more anatomical detail in the evaluation of supplying and draining vessels, cta can be a useful diagnostic tool as the tridimensional aspect offers additional information in the therapeutic planning of these vascular malformations. material and methods: ct angiography (cta) was performed using spiral ct with 150 ml of intravenous contrast at 4 ml/sec, after a delay of 20 sec. a slice thickness of 0.8 mm and a reconstruction index of 0.5 were used. axial slices and multi-planar reformatting (mpr), maximum intensity projection (mip) and surface shaded display (ssd) reconstructions were studied to evaluate aneurysm characteristics. then the image data was analyzed using volumetric 3d rendering technique to succeed endoscoping imaging. this technique extracts ct numbers in the boundary region between the vessel wall and contrast media within the vascular lumen. results: forty cases of cerebral aneurysms were detected by cta. with the technique of ct virtual angioscopy, we assured an excellent visualization of the inner contours of the vessels including the neck and the dome of the aneurysm (fly through). also 3d morphology of the internal structure of the aneurysm was demonstrated (fly around). the size of the sac (true lumen) and the neck were exactly estimated. blood vessels flowing into and out of aneurysms were visualized. in 9 patients with ruptured aneurysms that were operated, virtual angioscopy showed the site of rupture, wich was confirmated by operation. conclusion: virtual angioscopy following spiral cta is a very useful technique supplementary to cta in non-invasive evaluation of cerebral aneurysms and selection of the most appropriate therapeutic modality. serial mri in adult-onset rasmussen's encephalitis reveals two main radiographic and clinical variants n. danchaivijitr, r. nicholas, t. smith, i. hart; liverpool/uk purpose: rasmussen's encephalitis (re) is a rare autoimmune disorder that classically affects one cerebral hemisphere. it is characterized by intractable epilepsy with progressive neurological deterioration and usually presents in childhood. adult onset re was believed to have a more benign clinical course and imaging features are less well described. here, we characterize the mri brain findings of a series of adult onset re patients and correlate with the clinical progression. we retrospectively reviewed the serial mri brain scans of 6 patients with pathologically confirmed adult onset re (53 scans in total). five patients had complete series of annual mri studies from their onset. clinical data including neurological signs, cognitive deficits and functional disability were recorded prospectively. results: we recognized 2 patterns of imaging findings; 4 patients had focal increase signal on t2w in subcortical white matter of the temporal lobe. later, these were followed by ipsilateral hemispheric atrophy. these patients had a rapidly progressive clinical course in which neurological deficits occurred within 12 months after onset. the second group (2 patients) had initial focal cortical atrophy followed later by diffuse atrophy of affected hemisphere without evidence of high signal changes. in addition, bilateral involvement and caudate atrophy were more frequent than childhood variant. conclusion: adult re can be difficult to diagnose because the early mri findings can be subtle and physicians may be unaware of the possible presentation of one hemisphere atrophy without inflammation. pattern of initial mri features may help to predict clinical course of the disease. radiofrequency neurotomy for the treatment of headache associated with the third occipital nerve g.b. marshall, c. siwak, b. frizzell; calgary, ab/ca purpose: to assess the efficacy of a fluoroscopically-guided neurotomy technique in patients with cervicogenic headache associated with the third occipital nerve. methods: retrospective analysis of 15 patients (12 women and 3 men) who underwent third occipital neurotomy for cervicogenic headache. these patients had failed conservative treatment and were selected based on response to facet joint injection and medial branch block. neurotomy procedures were completed by two radiologists. a chart review of pre-and post-procedural pain levels was undertaken in addition to follow-up patient interview to determine whether they had improvement in their activities of daily living and recreation. results: all 15 patients reported a reduction in the frequency of their headaches. pain levels reported on a visual analog scale dropped from a pre-procedural mean of 8.6/10 to a post-procedural mean of 2.5/10. the mean duration of pain relief was 9.4 months, with 9 of the 15 patients describing ongoing relief of symptoms. all 15 patients reported restoration of activities of daily living, albeit for varying lengths of time. no significant complications were encountered. this radiofrequency neurotomy technique may be a useful means of providing symptomatic relief from cervicogenic headache associated with the third occipital nerve. the study justifies proceeding to prospective evaluation of the technique. functional magnetic resonance imaging (fmri) study of memory functions in elderly and young healthy controls and alzheimer's disease (ad) patients a. urbanik, m. binder, b. sobiecka, j. kozub, m. kuniecki; krakow/pl purpose: the aim of the study was to assess differences in the neural correlates of nonverbal memory functions in pathological and normal ageing. methods: thirty-six volunteers were examined in a 1.5 t mr scanner. three groups of twelve subjects were examined: young and elderly healthy controls, and patients with probable ad diagnosis. subjects were required to memorize complex geometrical figures. after the scanning session, they were all asked to redraw these figures. their performance was scored. image data were analysed with spm99 statistical package. results: both control groups copied drawings more accurately than the ad group. in all groups, the most prominent differences were seen in frontal regions and the occipital lobes, extending to the temporal. for each group this pattern was dissimilar. for the ad group moderate activation in the occipital lobe was observed, but no activation in frontal lobes. in turn, the elderly group revealed quite weak activation in occipital lobes and strong bilateral activation in the frontal lobes. finally, in the young adults group there was very prominent activation in occipital lobes, as well as in the frontal lobes, with apparent left-hemispheric dominance. we have succeeded in revealing differential patterns of brain activation in the studied groups during nonverbal memory encoding. our results suggest that a successful encoding requires an involvement of frontal lobes, that are probably responsible for the strategic aspects of memory functions. as was shown in the elderly control group, frontal lobes can compensate for the deteriorated visual memory which is known to decline over time. the special features of cerebral hemodynamics were studied in 52 patients with chiari 1 malformation (cm) with the help of magnetic resonance angiography (mra) and transcranial dopplerography (tcd). mra data analysis (58) revealed the frequent presence of vertebrobasilar system (vbs) maldevelopment and embryonic type of circle of willis. tcd data analysis (100) discovered vertebrobasilar insufficiency and bilateral blood flow increase in the intracranial part of the internal carotid arteries giving evidence of the compensated blood flow from the carotid system to the vbs. 21% of patients with cm and communicating hydrocephalus had tcd signs of intracranial hypertension. the most significant changes in cerebral hemodynamics were found in patients with marked pathology and older than 30 years. conclusions: 1. changes of cerebral hemodynamics in patients with chiari 1 malformation are conditioned by a complex of various causes; vertebrobasilar system underdevelopment, extravasal compression of the vbs arteries, rombencephalon hernia (cm) compensated blood flow from internal carotid system to vbs and the presence of intracranial hypertension. 2. the role of vascular factors in pathogenesis of the clinical signs of chiari 1 malformation is confirmed. acute disorders of cerebral ischemic circulation in vbs and syncopal conditions were mainly found in patients with the 2 nd /3 rd degree chiari malformation above 30 years of age, that correlates with the greatest changes of cerebral hemodynamics by transcranial dopplerography findings. routine mr imaging in parkinsonian syndromes m. cosottini, r. ceravolo, g. lazzarotti, u. bonuccelli, m. michelassi, c. bartolozzi; pisa/it purpose: to assess the usefulness of routine mri in the differential diagnosis of parkinsonian syndromes such as multiple system atrophy type p or c (msa p and msa c), supranuclear palsy (psp), and corticobasal degeneration (cbd) from idiopathic parkinson disease (pd). we retrospectively evaluated 142 patients with extrapyramidal signs and symptoms that had been followed for five years until a definitive clinical diagnosis. ninety five patients had pd, 25 msa p, 3 msa c, 15 psp, 4 cbd. mr examinations were obtained with 0.5 and 1.5 t equipment in 52 cases and 90 cases, respectively. axial dp-t2 and sagittal t1-weighted images were evaluated considering the most frequently abnormal findings reported in parkinsonian syndromes. pd mr examination was supposed to be normal. results: using the reported radiological criteria, imaging by mri revealed a sensitivity and specificity of 66% and 96% in psp, 60% and 96% in msa p, 100% and 100% in msa c, 75% and 99% in cbd. a correct diagnosis of atypical parkinsonian syndrome was made in 70% of patients with extrapyramidal signs and symptoms. conclusions: several features on brain mr imaging may improve the diagnosis of atypical parkinsonian syndromes and pd in a substantial proportion of patients. brain with done by pc mra and the intracranial circle was evaluated with 3d tof mra. dsa was then performed to confirm the grading of stenosis and to depict the presence of collateral intracranial compensatory circles. patients were divided into two groups on the basis of the presence (group 1) or absence (group 2) of a regional or hemispheric perfusion defect detectable at visual inspection of mtt map. results: in group 1 (six patients) there was a prolonged mtt, a reduced cbf and an increased cbv in two cases. a poor depiction of mca with mra and a significant reduction of mbf in the mca homolateral to ica stenosis (103 ml/ min), as well as an angiographic impaired willisian compensation with a recruitment of vessels arising from the external carotid artery and from superficial collateral supply was detected in group1. conclusions: pwi reveals oligemic abnormalities in only some patients with ica stenosis. increased mtt and reduced cbf are associated with an impaired willisian collateral supply. probably, bolus dispersion may influence the pwi-detected oligemia in ica stenosis. specificity results: statistical differences were found between the dementias group (ad and vd) and the non-demented group (depression and mci). the ratio choline/ creatine (cho/cr), myoinositol/creatine (mi/cr) and n-acetylaspartate/creatine (naa/cr) showed differences between the studied pathologies, only in ppgm, without significant differences in rtl. naa/mi and mi/cr distinguished between ad and the other pathologies, in ppgm, with the best area under the roc curve for naa/mi, showing the higher sensitivity (82%) and specificity (73%) for the diagnosis of the ad. conclusion: 1 h mrs is a non-invasive tool for the study of ci, showing biochemical information to differentiate ad, vd, depression and mci. the metabolical alterations observed contribute to the differential diagnosis with a high sensitivity and specificity in pathologies with ci, in particular for the diagnosis of ad. value of transcranial doppler (tcd) measurements and "hyperdense middle cerebral artery" sign on ct for acute ischemic stroke prognosis y.t. efendiev, l.b. khalilova; baku/az methods: ct examination was carried out on the first day of stroke for 100 patients (age range 35 to 47), who had ischemic infarcts in the middle cerebral artery (mca) territory and repeated on the 3 rd , 7 th and 40 th days. "hyperdense middle cerebral artery" sign reflecting active intraluminal thrombosis was found in 52 patients. the same 52 patients had tcd on the 1 st day. results: symmetric blood flow velocity (bfv) in both mcas was revealed in 41% of the patients. in this group, clinical course was rather auspicious in more than 70% of patients. infarcts area in these patents had limited, cortical (73%) and subcortical (27%) localization. no lethal outcome was noted. asymmetric blood flow with decreased mca bfv by more than 20% on the affected side was noted in 32% of the patients. in this group, the infarctions had cortico-subcortical localization on final ct. the clinical course was more severe and complicated than in the first group.one lethal case occurred. in 27%, tcd demonstrated signs of hyperperfusion of hemodynamics with increased of mca bfv by more than 20%, on the affected side, combined with high peripheral resistance index. infarcts had mainly deep basal location, and 3 lethal cases occurred. later ct detected hemorrhagic transformation of necrotic area (5 cases, 33%). conclusion: "hyperdense middle cerebral artery" sign on ct is significant for early diagnosis of stroke, whereas the tcd measurements in mca is important to predict the clinical course and possible impairment at the early stage of the disease. b d e f a g imaging of brain parenchymal and leptomeningeal metastases from lung cancer: significance of contrast enhancement mri m.p.i.m. jakimovska, t. markoski, m. grunevski, s. jakimovska, s. jovanoska; skopje/mk purpose: to estimate significance of iv application of paramagnetic contrast in mr imaging in diagnosis of parenchymal brain metastases, especially leptomeningeal carcinomatosis seeding from lung cancer. next purpose is to compare sensitivity between ct and mr imaging. material and methods: thirty-six patients with lung cancer were evaluated radiographicaly to determine the present of metastases in cns. we used ct as a screening tool and mr after i.v. application of gddtpa. results: our series with 36 patients included 27 or 75% with non small-cell lung cancer and 9 patients or 25% with small-cell lung cancer. three patients (33%) of 9 with small-cell lung cancer had occult metastatic disease to the brain. eight patients (28%) of 27 with non small-cell lung cancer had metastatic disease to the brain parenchyma. in this series, leptomeningeal metastases were not found. ct scans were performed in all 27 patients, mri was performed in 15 cases, some with i.v. application of gddtpa, and in 8 patients brain metastatic disease was found. post contrast mr imaging presents leptomeningeal carcinomatosis as thin linear enhancement along the cortical surface, which follows the gyral pattern of the cortex. conclusion: all patients with lung cancer have to be investigated for brain metastases because of a great percentage (about 30%) of occult metastatic disease. contrast enhanced mr of the brain is a superior method compared to ct because of excellent contrast resolution, is safer and has multiplaner abilities. to demonstrate meningeal seeding, contrast enhanced mri is the modality of choice. evaluation of the uselfulness of high b-value diffusion-weighted mr imaging in patients with acute cerebral infarction h. hirota 1 , e. shimosegawa 2 , k. takahashi 3 , m. mineta 1 , t. yamada 1 , w. yamamoto 1 , k. nagasawa 1 , h. sato 1 , t. aburano 1 ; 1 asahikawa/jp, 2 akita/jp, 3 iowa, ia/us purpose: we occasionally encounter cases without distinct abnormal findings on conventional diffusion-weighted mr imaging despite there being obvious clinical findings of acute cerebral infarction. our purpose was to evaluate positive predictive value of high b-value diffusion-weighted mr imaging in subjects with acute cerebral infarction. we prospectively assessed 21 subjects with acute cerebral infarction within 12 hours from the onset. all examinations were performed with 1.5 t unit using single-shot echo planar diffusion-weighed mr imaging at three different b values of 1000, 2000 and 3000 s/mm 2 . seven days later from the onset, we re-examined the subjects with t2 weighted image for confirming the final diagnosis. four experienced neuroradiologists assessed each diffusionweighted images for the presence of cerebral infarction and then compared the findings of each images with those of t2 weighted images. we divided the findings of each diffusion-weighted images into five categories by location of abnormal signal intensities and calculated true positive rate in each categories. purpose: arterial visualization of intracranial 3d-cta is difficult in the area of the skull base. this is due to the close proximity of the internal carotid artery and skull base and the fact that they both have almost the same ct values. accordingly, subtraction artifacts due to misregistration are unavoidable using the conventional subtraction method. even a slight difference of the start position in data between pre-and post-contrast ct may lead to the production of considerable artifacts. nowadays, subtraction of two sets of volume data has become possible on a workstation. we assessed whether this technique was useful in intracranial 3d-cta. methods and materials: subtraction was performed in both phantom and patients and the accuracy was tested. results: precise measurement was shown to be possible in the phantom experiment. following this, several clinical cases were applied. conclusion: subtraction is effective due to being almost free of misregistration. does an interpolated high resolution matrix improve the detection of brain hyperintensities on flair images in multiple sclerosis? f. sardanelli, a. fausto, g. spadaccini, b. cotticelli; milan/it purpose: to test whether an interpolated high resolution matrix improves the detection of brain hyperintensities on flair images in multiple sclerosis (ms). materials and methods: seven ms patients (1 male, 6 females, 23-68 years old, median 36) underwent brain mr at 1.5 t using a fast-flair para-axial sequence (tr/te/ti = 8300/135/2500 ms; fov 230 mm; 20 no-gap 5-mm slices; matrix 256 x 256; pixel size = 0.9 x 0.9 mm; time 3'36"). the sequence was repeated changing only from the standard 256 2 matrix to an interpolated 512 2 matrix with a pixel size of 0.45 x 0.45 mm. the two sequences were read on a remote console in a random blinded fashion, using a one-in-one format and free windowing, grading them as certain (c) or probable (p); for confluent plaques, only the lesions with more than half the contour detectable were counted. wilcoxon test was used. results: a total of 530 hyperintensities (c/p = 401/129) with 256 2 and of 550 (431/119) with 512 2 were counted. they ranged in total 9-147 (median = 72) with 256 2 and 8-178 (79) with 512 2 ; c hyperintensities 3-127 (60) and 3-160 (59); p hyperintensities 6-25 (20) and 5-29 (18), respectively. data were similar in 6/7 patients; in the remaining patient (female, 36 years old) total hyperintensities were 147 (256 2 ) and 178 (512 2 ), with a c/p of 127/20 and 160/18, respectively. in spite of this outlier, no significant overall difference was found between 256 2 and 512 2 for total, c, and p hyperintensities (p > 0.447). conclusion: interpolated matrices do not significantly improve the detection of brain hyperintensities on flair images in ms. a method for reducing radiation exposure in cerebral perfusion study using multi-detector row ct t. nanjo 1 , k. murase 1 , y. sugawara 2 , m. hirata 2 , t. mochizuki 2 ; 1 osaka/jp, 2 onsen-gun/jp purpose: radiation exposure during ct perfusion study is a serious problem. the purpose of this study was to devise a method for reducing radiation exposure in cerebral perfusion studies using multi-detector row ct. methods and materials: nine patients (6 males and 3 females; mean age 68.4 years) participated in this study. following a standard protocol for ct perfusion study, continuous (cine) scans (0.8-1.0 sec/rotation x 60 sec) consisted of four 5-mm-thick contiguous slices performed after an injection of iodinated contrast material (30-40 ml) using a multi-detector row ct scanner (light speed qx/i, ge). new image data were generated by thinning out the original images thus acquired. the thinned-out images were interpolated by linear or cubic interpolation. the functional images of perfusion parameters such as cerebral blood flow (cbf), cerebral blood volume (cbv) and mean transit time (mtt) were generated from these images by applying deconvolution analysis based on singular value decomposition pixel by pixel. we calculated the correlation coefficients between the perfusion parameters obtained from original and thinned-out images for 15 regions of interest in the grey and white matter. results: when using 10 continuous images with a scan time of 0.8-1.0 sec and the thinned-out images with a scan interval of 1.6-2.0 sec, the radiation exposure could be reduced to 56.0-58.3%, with the correlation coefficients of cbf, cbv and mtt being kept greater than 0.9. conclusion: this method can reduce radiation exposure while keeping the accuracy of perfusion parameters equivalent to that obtained from original images. dynamic scanning. the data acquisition conditions (analysis algorithm, analysis matrix, contrast medium injection rate, image reconstruction algorithm and exposure dose) were optimized while maintaining high quantitative analysis capabilities. cerebral blood flow was then measured in 13 volunteers in their 20 s, 10 in their 30 s, 12 in their 40 s, 14 in their 50 s, 11 in their 60 s, and 10 in their 70 s. none of the subjects had cerebral blood flow disorders. results: the use of optimized data acquisition conditions provided high reproducibility while permitting the exposure dose to be reduced by 50% or more. a decrease in cerebral blood flow with advancing age was confirmed in ct dynamic perfusion studies. the use of optimal data acquisition conditions allows the exposure dose to be reduced and provides high reproducibility while permitting acceptable quantitative cerebral blood flow analysis. this has made it possible to determine age-specific normal values for cerebral blood flow in dynamic ct perfusion examinations. it is expected that dynamic ct perfusion analysis will prove clinically useful for the assessment of diffuse cerebrovascular diseases and chronic-stage blood flow disorders, as well as for the diagnosis of acute-stage cerebral infarction. diffusion weighted imaging (dwi) epi on low field mr system (0.2 t): comparison with 1.5 t and preliminary report on clinical use in brain ischemia p. purpose: this study assessed the diagnostic value of low field dwi in brain stroke. the secondary goal was to compare apparent diffusion coefficient (adc) values obtained in high and low systems. methods: dwi were performed in 2 groups of volunteers, on 0.2 t and 1.5 t systems. dw images at b = 0 and 900 mm 2 /s were recorded. adc values from 17 regions of interest (roi) were compared. forty patients with acute symptoms of cns stroke were examined by ct and mr, 2-10 h after symptoms onset. dwi-epi images were obtained. follow-up mr 2 weeks later were set as a reference. results: statistical analysis showed significant differences of adc values dependent on roi location within the brain hemisphere. there was no difference between right and left hemisphere. adc values for low and high field systems were similar. in 30 patients, ischemic lesions were found in the first examination. follow-up confirmed 24 infarcts. four patients out of 10 with negative dwi revealed infarction in follow-up mr. sensitivity, specificity, and diagnostic accuracy were 87.5%, 50%, and 78%, respectively. conclusions: low field systems are capable of diffusion weighted imaging. for the same b value, adc values at 0.2 t and 1.5 t are similar. in clinical practice dwi on low field mr systems can be used as a fast and reliable tool for detection of acute ischemic lesions in the brain. advantages of a 3d multislab t2 turbo spin echo magnetic resonance (tse mr) sequence for high resolution brain imaging b. it is feasible to scan the whole brain with t2 contrast in 1 mm³ isotropic resolution with high snr and cnr using a multislab 3d tse sequence. postoperative multidetector-row ct angiography ( (2), hemimegalencephaly(2), bilateral perisylvian syndrome(2), lissencephaly(2) and focal cortical dysplasia(9). all were the subject of conventional brain mr imaging studies using the mp-rage (magnetization-prepared rapid gradient-echo) sequence and the resulting 3-d data sets were processed on a commercially available workstation. abnormal gyral configurations were reviewed. results: abnormal gyral patterns were seen 15 of 18 patients. the configuration and orientation of affected gyri were clearly evaluated in the brain surface-rendering image. in two cases of the schizencephaly (involved the frontal lobe), there were wheel shaped broad gyral pattern of the superior, middle, and inferior frontal lobes. in two cases of the hemimegalencephaly, there were thick gyral pattern and enlarged ipsilateral brain. in two cases of the lissencephaly, the frontoparietal cortex was not delineated and showed a markedly thick and smooth gyral pattern. in two cases of the bilateral perisylvian syndrome, there were opened insular cortex and a thickened gyral pattern. in the focal cortical dysplasia, there were irregular serrated or thick and enlarged gyri. in patients with cerebral cortical dysplasia, brain surface-rendering mr imaging detects a detail gyral pattern and involvement site of abnormal gyri. it can create difficulties in the differential diagnosis and can therefore cause problems in choosing the appropriate therapy. this is especially true in cases with alzheimer's versus lewy-body disease ((dlb), which require different therapeutical approach. we applied 1h-mrs to assist the diagnostic process and to look for specific differences in the metabolic content of the brain tissue in these two entities. methods: 1h-mrswas performed using 1.5 t scanner in t1-weighted images in 3 orthogonal planes in 24 elderly subjects with consensus criteria dlb (n = 12), nincds-adrda ad (n = 12), and normal control subjects (n = 10). 1h-mrs was performed with single-voxel (svs) technique using steam sequence (tr 2000 ms, te 20 ms). voxel was positioned in the temporal, occipital lobe and centrum semiovale. results: in both alzheimer's and lewy-body group, 1h-mrs showed changes in the metabolite pattern in all voxel locations, with the most distinct expression within temporal lobes. naa and creatine peaks were lowered in both patients groups, comparing to the controls. in spectra of lewy-body patients myoinosytol peak remained unchanged as opposite to the alzheimer's where it was increased. conclusions: 1h-mrs can be an additional, very important tool in dementia studies and differential diagnosis of this group of diseases. in dlb patients 1h-mrs is feasible but there are difficulties in scanning patients in the later stages of the illness due to tremor and the degree of brain atrophy. the activation tasks consisted of left finger movement, sensory stimulation, listening to comprehension (for sensory language area), word generation (for motor language area) and working memory. the reference function was boxcar waveform. activation maps were thresholded at uncorrected p = 0.0001. the thresholded activation maps were placed into talarach's space. results: cerebellar activation was observed in the motor, the word generation and the working memory tasks. in the hot sensory and listening comprehension tasks, there was not any visible activation in the cerebellum. left and right posterior cerebellar (declive) activation was observed in the left motor task. ipsilateral cerebellar activation was more prominent than contralateral cerebellar activation during the left motor task. left posterior cerebellar (declive) activation was observed in the working memory task. left posterior cerebellar (declive) and both anterior cerebellar (culmen) activations were noted in the word generation task. conclusion: cerebellar activation was observed in the afferent actions of the brain including motor, motor language and working memory tasks. there was no activation of the cerebellum in the efferent action of the brain including sensory and sensory language tasks. the cerebellum is involved in a variety of functional tasks including motor, word generation and working memory. the brain smell centres: comparison of localisation and activation in male and female subjects using functional mr imaging (fmri) m.d. marchwicka-wasiak, b. goraj; lodz/pl the study was conducted in order to determine and to compare the location and activation of smell brain centres in females and males brains using olfactory nerve-mediated (geraniol) and combined olfactory and trigeminal nervemediated (patchouli) stimulants. methods: ten normal volunteers (five women and five men), right-handed, nonsmokers, without any cns diseases were examined to determine the activated cortex areas during stimulation by geraniol and patchouli. mr brain scans were obtained using a 1.5 t clinical scanner, with the head-neck coil. the imaging was performed in each subject using se and epi sequences with a blood-oxygenlevel-dependent (bold) effect. the individual inhaled odorized air during the 30 seconds period and alternating room air over the same period. the mean pixel intensity of activated images was substracted from the mean pixel intensity of preactivated images. results: the olfactory system-mediated stimuli (geraniol) evoked bilateral activation of female brain smell centres compared to right hemisphere centre activation in male brains. the exposure to the olfactory and trigeminal nerve-mediated stimuli (patchouli) showed more activated regions in both sexes than to the olfactory nerve-mediated stimuli. conclusion: fmri proved to be a useful method to compare the location and activation of male and female brain smell centres. we compared the group of psp patients with that of control subjects and found a highly significant difference in antero-posterior midbrain diameters (mann-whitney test: p < 0.005), absolute midbrain volumes (p < 0.005) and naa/ cr ratios (p < 0.01), as well as a significant difference in total intracranial volume-normalized midbrain volumes (p < 0.03). we also found out a significant correlation between naa/cr ratios and antero-posterior midbrain diameters in psp patients (spearman's rank correlation test: rs = 0.7619, p < 0.05). the aim of this study was to compare the diagnostic accuracy of t2 fast spin echo (t2fse), fluid attenuated inversion recovery (flair) and inversion recovery (ir), in evaluating hippocampal sclerosis and to determine a costeffective protocol for this disease process. in this prospective study, 48 patients (aged 6 months-55 years) with drug-resistant temporal lobe epilepsy (based on clinical symptomatology and electroencephalographic (eeg) registrations) were evaluated by mri with a 1.5 tesla unit. the protocol consists of axial t1 and pd/t2 se, and flair, t2fse and ir in a coronal plain perpendicular to the long axis of the hippocampus. whenever necessary, we applied t1 + gd se in axial and coronal planes. films were interpreted by two experienced neuroradiologists. sequences were statistically analyzed in pairs using wilcoxon sign ranks test. results: there were 33 patients (68.75%) with mr and eeg findings suggestive of hippocampal sclerosis. eight of them underwent therapeutic surgery and there was histopathologic confirmation of the diagnosis. flair detected hyperintensity of the hippocampus in 31/33 (94%) and was much more sensitive than t2fse (18/33 p = 0.002) and pd/t2 (11/33 p = 0.000). reduced hippocampal size (28/ 33), atrophy of hippocampus (22/33) and enlarged temporal horn (24/33) were better detected with ir than t1 (9/33 p = 0.000). conclusion: a mr protocol using thin coronal sections angled perpendicular to the hippocampus with flair and ir sequences is cost-effective for mesial temporal sclerosis because it is highly sensitive, inexpensive, quick and easily applicable in most units. reversibility of the brain white matter changes in adults with late diagnosed and treated phenylketonuria m. gizewska, l. cyrylowski, d. koziarska, p. nowacki, a. walecka, m. walczak; szczecin/pl purpose: phenylketonuria (pku) is an autosomal recessive disorder related to absent or reduced activity of phenylalanine hydroxylase what leads to increased plasma phenylalanine (phe) concentration. because screening the whole newborn population for pku in poland began in the late 1980s, many pku adults have been diagnosed and treated very late. patterns and extent of the brain white matter changes in these patients is described. in this paper, 13 late diagnosed and treated adults with pku, including 9 males and 4 females, is presented. the mean age at diagnosis was 37.2 y (range 18 -50). microcephaly was present in 7, seizures in 4, aggressive behavior in 3; all but one had speech difficulties, including total mutism in 7. mri of the head was performed on 1.5 t unit with fse and flair sequences without contrast medium administration. results: mri of the head detected white matter changes, hyperintense on t2weighted images, in all but one patients. all but one of them had changes in parietal and/or occipital regions. the treatment with low-phe has been introduced in 3 with improvement in all of them. the follow-up mri were performed after mean 8.7 months, revealing decreased severity of the white matter changes in all, from mean 20 (according to cleary's scale) on the initial mri to 7.3 on the follow-up. our results indicate the possibility of white matter changes reversibility in late diagnosed and treated pku adults. conclusion: dwi is thought to be useful in the diagnosis of cns infections. in our experience, dwi may allow the differentiation of brain abscess from necrotic or cystic brain tumor. dwi is also a useful tool to differentiate subdural and epidural empyemas. detection . coronal views were performed for flair imaging, and coronal and axial views for dp and t2-weighted imaging. images were reviewed by two seniors radiologists in consensus for localisation of the signal abnormalities. results: lesions of the olfactory system were observed in 23 patients (82%). signal abnormalities were localised in the temporal lobe in 15 cases (54% with 10 cases of unilateral lesions and 5 cases of bilateral lesions) and in the orbito frontal cortex in 19 cases (68% with 17 cases of bilateral lesions and 2 cases of unilateral lesions). with flair, dp, and t2 weighted imaging, lesions was detected respectively in 56%, 38% and 48%. olfactory bulb signal abnormalities were diagnosed in 19 cases (68% with 3 cases of unilateral lesions and 16 cases of bilateral lesions). for this localization, the accuracy of flair, dp and t2 sequences was respectively 46%, 63%, 54%. in post-traumatic anosmia, coronal flair and coronal pd imaging is required to detect respectively signal abnormalities in the parenchyma and in the olfactory bulbs. t2 weighting imaging seems to be inferior. cerebral hydatid disease: ct and mr imaging findings y. bükte, s. kemaloglu, h. nazaroglu, a. uyar, c. akgül, m. simsek; diyarbakir/tr purpose: cerebral hydatid disease is very rare, representing only 2% of all cerebral space occupying lesions, even in the countries where the disease is endemic. the aim of this study was to describe the discriminative computed tomography (ct) and magnetic resonance (mr) imaging features of cerebral hydatid disease. we retrospectively reviewed the imaging findings of 18 patients with pathologically confirmed cerebral hydatid disease over a period of 13 years (1990) (1991) (1992) (1993) (1994) (1995) (1996) (1997) (1998) (1999) (2000) (2001) (2002) . among these patients, there were 17 cases of echinococ-b d e f a g cus granulosis and 1 case of echinococcus multilocularis (alveolaris). they were 12 male (66.7%) and 6 female patients (33.3%), ages ranging from 7 to 50 years with an average age of 21.8 years. results: common ct and mr imaging findings of e. granulosis lesions were well-defined, smooth thin-walled, round or spherical, homogeneous cystic lesions with no contrast enhancement, no calcification and no surrounding edema. the lesion seen in e. multilocularis showed a well-defined multiseptated mass consisting of solid and cystic components with calcifications of solid portions. cystic lesions with surrounding hyperintense area of perifocal edema, complete and incomplete rim of contrast enhancement were seen in two patients and were labeled as complicated and infected cysts. conclusion: although the cystic cerebral hydatid disease could be equally well demonstrated on ct and mr examinations, ct is superior in detecting calcification of the cyst, when present. mr is better in demonstrating cyst capsule, detecting multiplicity and defining the anatomic relationship of the lesion with the adjacent structures and helps in surgical planning. ct it may be used to identify regional differences within a patient. qualitatively, single scan cbv maps were noisier than maps using the dynamic method. conclusion: cbv estimates from a single contrast-enhanced scan may identify abnormal areas. however, differentiation between normal and abnormal regions is not as pronounced as when using quantitative, dynamic methods. virtual endoscopic imaging of cerebral ct angiography (veccta) in selecting patients for neurosurgical intervention or endovascular treatment r. prpic-vuckovic, m. rados, m. batinica, j. papa, m. seronja-kuhar; zagreb/hr purpose: to assess the usefulness of virtual endoscopic cerebral ct angiography data analysis in patients with aneurysm rupture before making a decision between neurosurgical intervention or endovascular treatment. materials and methods: during a one-year period, mscta was performed in 35 patients after a conventional ct proven subarachnoid hemorrhage. images were acquired using msct lightspeed ultra, ge. helical data acquisition followed after rapid i.v. administration of contrast material (3.5 ml/sec), with 18-23 sec delay. data was postprocessed on ge advantage workstation ultra v4.0 using reconstruction protocols mip (maximum intensity projection), ssd (shaded surface display), vr (volume rendering) and ve (virtual endoscopy). results: detailed analysis of aneurysmal neck, dome, vessel of origin and surrounding vascular or bone structures was acquired by ssd, mip or by high-accuracy vr protocol. modified surface rendering and ve protocol were used for endoscopic mode viewing to visualize neck shape, accessibility from the parent vessel, presence of thrombotic clots or calcifications inside the aneurysm and vessel of origin, as well as to define orifices of branches arising from the dome. conclusion: accurate characterization of morphology of the aneurysm, especially depiction of orifices and aneurysmal neck are essential for choice between neurosurgical intervention or endovascular treatment. when endovascular treatment is an option, it is useful to know angulation between parent vessel and neck and real volume of aneurysmal dome for proper estimation of coil size and shape. vr and ve imaging of the aneurysmal sack and surrounding anatomy may provide additional useful information for endovascular treatment or neurosurgical intervention. we have demonstrated the existence of non-monoexponential diffusion in the human csc that can be approximated by fast and slow diffusion components. our results are within the limits of human brain and full dti data for the rat spinal cord. the aim of this study is to review the embryology and the development of this structure. to describe the normal ct and mr appearances and to show the neuroradiological findings of pathology that can effect the craniocervical junction. background: the craniocervical junction is an anatomical crossroads with characteristic pathologic entities, mainly malformative and traumatic in origin. we illustrate the normal anatomy of the craniocervical junction and a wide spectrum of pathological conditions involving this structure through a selection of cases from a retrospective review of the ct, mr and plain-film examinations carried out in our centre over the last five years. imaging findings: normal anatomy and a wide spectrum of pathologies affecting the craniocervical junction are illustrated by ct and mr examinations. we group the findings according to etiology: malformation, trauma, infection, inflammatory and tumor, placing emphasis on the radiological features and the differential diagnosis. conclusion: ct depicts the bony structures of the craniocervical junction superbly while mri shows the neurological components better, enabling excellent characterization of lesions and recognition of all potential types of disorders that need to be recognized by general as well as neuroradiologists. the spectrum of t1 hyperintensities of the sellar region f. with the introduction of high field strength it is expected to overcome the limited signal to noise ratio and subsequently decreased spatial resolution in routinely used standard field strength 1.0 -1.5 tesla mr scanners. this would have clinical impact in the preoperative work up of patients with sellar processes. imaging findings: in this exhibit we present a large variety of sellar diseases using 3 tesla mr imaging with emphasis on detection of microadenomas and visualization of anatomic structures. furthermore, the differentiation between infiltration or just compression of the medial wall of the cavernous sinus in case of macroadenoma is illustrated. the excellent visualization of normal anatomy and tumor topography makes this technique a very valuable tool for planning neurosurgical operations. cns manifestations following stem cell transplantation: a pictorial review d. beckett, a. banerjee, j. oliff; birmingham/uk learning objectives: to illustrate the spectrum of radiological manifestations in the central nervous system and head and neck following stem cell transplantation for haematological malignancy. to outline the advantages and limits of plain film radiography, cross-sectional imaging, interventional radiology and radionuclide imaging. background: bone marrow transplantation (bmt) is a critical therapeutic intervention for a variety of pathological conditions. the complications of bmt include chemotherapy and radiation toxicity, graft versus host disease, recurrent malignancy, infection and miscellaneous conditions. complications of allogenic bmt manifest in a variety of clinical settings. the neurological system is commonly affected. in this presentation we will review the incidence, clinical presentation and the radiographic findings of cns involvement following stem cell transplantation. plain radiography, contrast material enhanced studies, sonography, ct, mri and interventional techniques are essential in diagnosing these complications and evaluating their response to therapy. imaging findings: findings may be broadly classified into either infective, cerebrovascular or treatment induced. common infective manifestations include human herpes virus 6, invasive mucormycosis and central nervous system tuberculosis. classical image findings of haemorrhage and infarction are seen in addition to graft versus host disease cerebrovascular angiitis. infarcts, diffuse white matter disease and cortical atrophy are seen following total body irradiation. the imaging findings of posterior leukoencephalopathy in cyclosporin toxicity is illustrated. the spectrum of imaging findings in the central nervous system is diverse. a firm understanding of the clinical presentations and incidence in combination with typical radiological findings is essential in the successful management of this patient sub-group. b d e f a g background: diffusion weighted imaging has been widely used in stroke patients to detect early acute cerebral infarction and find out ischemic penumbra. however, we often unexpectedly encounter restricted diffusion on dwi of nonvascular origin mimicking hyperacute or acute infarction in clinical practice.we reviewed nonvascular diseases with restricted diffusion on dwi for past three years by retrospective selection. imaging findings: the characteristic findings mimicking hyperacute or acute infarction are high signal intensity and low apparent diffusion coefficient values, mainly distributed in the white matter and incompatible with arterial territory with no stenoocclusive lesion on mr angiography or conventional angiography, and are reversible. these findings may increase possibility of nonvascular diseases such as infection, inflammation (viral or bacterial encephalitis), hemorrhage, leukodystrophy, toxic (anti-cancer drugs, co poisoning), metabolic origin and tumors. conclusion: we present various diseases, under certain clinical settings, and systematically discuss the mechanism of restricted diffusion in a limited number of specific diseases. background: in patients with vitamin b12 deficiency, symptoms related to the spinal cord may often help to find the diagnosis. however, in patients with atypical symptoms mri shows typical findings often diagnostic for scd. beneath a general discussion, we present 2 cases of scd in whom mri findings were leading to the diagnosis of b12-deficiency. patient 1 presented with tingling in her extremities. neurologic examination showed a subacute loss of proprioception and profound loss of vibration sense. vitamin b12 serum levels were normal. t2w-mri showed increased signal in the posterior columns of the spinal cord. dwi showed disturbance of diffusion in the same location. patient 2, who practiced a vegan alimentation, was admitted with incomplete paraplegia with signs of spasticity. vibration sense and proprioception were impaired as well. mri revealed the typical findings of severely increased signal within the posterior columns of the spinal cord. both patients presented in very early stages of the disease. in summary, the mri findings showed typical signal hyperintensities in t2w images in the posterior columns of the cervical and/or thoracic myelon-segments. conclusion: even in patients with subtle atypical symptoms, mri with its typical findings often allows the diagnosis of scd even in the rare case of normal levels of vitamin b12. fiber tracking and tensor metrics in diffusion tensor mr imaging c.c.t. lim, h. yin, m. xu, f. hui; singapore/sg learning objectives: to review anatomical patterns and distribution of white matter tracts in the brain and to understand the potential uses of diffusion tensor imaging (dti), including pathological disruption and destruction of fiber tracts. background: dti is a new mr imaging technique that non-invasively visualizes white matter fiber tracts and may have potential to assess demyelination and other brain disorders. using single shot echo planar imaging (tr 7000-9000/te 90-100 ms, 3 mm section thickness, b value 800-1000 s/mm 2 in 6-54 non-collinear directions at 1.5 and 3 t) and offline post-processing of diffusion tensor metrics (fractional anisotropy, mean diffusivity and principal eigenvector) and fiber connectivity images (using fast marching tractography) could be studied. imaging findings: in normal patients, the fractional anisotropy (fa) maps clearly visualized white matter tracts as areas of high fa compared to gray matter. the corticospinal tracts, corpus callosum and optic radiations could be consistently identified. abnormalities such as brain neoplasm, cerebral infarction and multiple sclerosis lesions showed decreased fractional anisotropy and elevated mean diffusivity. principal eigenvector maps of water diffusion showed deviation in the direction of the white matter tracts surrounding benign brain neoplasms and malformations. conclusion: quantitative in vivo information on water diffusivity, degree of directionality and directional vector in space, that are not available on conventional mr imaging, can be measured in dti studies. with a potential new clinical application of dti, radiologists should be familiar with anatomy and pathology of the white matter fiber tracts. neuroimaging of background: multiple gliomas are rare findings with variable incidence (2.4 to 10%). they can by classified according to: a) time of presentation as early = synchronous (at initial diagnosis) or late = metachronous (diagnosed during the treatment); b) the imaging characteristics as multicentric (arise independently in different sites, there is absence of macroscopic connections or way of dissemination) or multifocal (they spread from primary tumor to other areas in the brain, with evidence of routes of dissemination). we reviewed documentations of 109 patients with diagnosis of glial tumor who grade iii-iv who underwent surgery between january 2001 and december 2002. in all patients radiological and histological diagnosis was performed and 8 cases were established as multiple glioma. imaging fingings: most of the patients had one bigger lesion and 2 or 3 smaller ones. the lesions were usually hyperintense on t2-weighted images and hypoor isointense on t1wi with strong postcontrast enhancement. most of them had moderate edema. we recognized 6 multicentric and 2 multifocal gliomas, 7 were synchronous and one metachronous. conclusion: multiple gliomas are often radiologically reported as metastasis, sometimes as lymphomas or infectious diseases. the differential diagnosis of multiple masses in the brain is very important for therapeutic consequences and multiple glioma should considered because of suggested increasing frequency of this entity. if strong postcontrast enhancement and moderate edema around the lesions are observed, this diagnosis should be suggested. role background: gks is a method of treatment allowing the delivery of a conformal radiation dose to a stereotactically defined target. the significant development of interest in the role of gks as an alternative or adjunct to the neurosurgical management of many brain disorders, requires accurate and reliable methods of acquisition of image modalities for the stereotactic planning. imaging and procedures: between december 1999 and august 2003, we treated 650 patients for a large variety of indications (metastases 26%, vascular malformations 7%, trigeminal neuralgia 14%, pituitary adenoma 3%, primary brain tumor 8%, other tumors 6%, vestibular schwannoma 19%, meningioma 18%, other functional < 1%). all patients had an mri combined with ct in stereotactic conditions. some patients also benefited from stereotactic dsa (n = 43) or pet (n = 57). in all cases, mr was used to delineate a target before radiosurgery. ct was always used as a control for mr distorsion. dsa was used in combination with angiomr for all arteriovenous malformations. when the tumor was ill-defined, we anticipated some limitation of target definition (infiltrative lesions, recurrence of metastases, pituitary adenomas) and also used stereotactic pet. we present a pictorial review illustrating the role of neuroimaging for appropriate targeting in gks. these images are also critical for the evaluation of the potential risks and complications. the complementary information provided by the combination of various imaging modalities allows appropriate and accurate delineation of a target volume before stereotactic irradiation. to familiarize non-greek radiologists with the definition of greek eponyms and to emphasize on those terms and words that have been derived from greek mythology. background: medical eponyms serve as mnemonics, add color to medical writing and are useful shorthands in medical communications. a long catalogue with the most representative greek medical terms is listed. the exact definition and meaning of each word is explained and a short narrative of the relative myth is presented for the neuroanatomical terms which gained their name from greek mythology. conclusion: accurate knowledge of the meaning of these words will help the radiologist to remember the terms and make their learning fun. preoperative to present the potential of diffusion tensor imaging (dti) and colored coded fractional anisotropy (fa) maps in identifying the anatomy of white matter tracts for pre-operative planning. materials and methods: dti data were acquired using dw-se-epi sequences and a 1.5 t mr-unit, with the following parameters: tr 6000-10000, 18-28 slices, 5 mm slice thickness, 1.5 mm intersclice gap, 64 x 64 matrix and gradients encoding in 25 directions, b-1500 sec/mm 2 . data were acquired in normal subjects and 13 patients with brain tumors, avm's or seizure foci being considered for surgery. fa images and corresponding colored coded maps were generated. also, fse t2 or flair images were acquired in identical locations for comparative use. results: major white matter tracts (intrahemispheric, interhemispheric, and brain stem) were readily visualized, including the following: superior longitudinal fasciculuus, superior fronto-occipital fasciculus, inferior longitudinal fasciculus, inferior fronto-occipital fasciculus, uncinate fasciculus, corpus callosum, cingulum, optic radiations, anterior commissure, corona radiata, internal capsule, pyramidal tracts, medial lemniscus, medial longitudinal fasciculus, cerebellar peduncles and gracile and cuneate fasciculi. the spatial relationships of these tracts and resectable lesions were analysed, with particular attention to the risk of a postoperative deficit. all results were correlated with the pre-and post-operative deficits. conclusion: white matter anatomy can now be imaged using dti/fa and access to pre-operative eloquent white matter mapping has great potential to improve the outcomes of neuro-surgical candidates. the future management of neuro-surgical patients will be impacted by future refinements and developments of this technique. to present a retrospective analysis of our experience in the endovascular coil trapping for ruptured vertebral artery (va) dissecting aneurysms. materials and methods: we treated 9 patients who presented with acute subarachnoid hemorrhage due to rupture of a vertebral artery dissecting aneurysm. embolization of the entire segment of the dissected site with detachable platinum coils (internal trapping) was performed in all patients. in one patient with posterior inferior cerebellar artery (pica)-involved va dissecting aneurysm, internal trapping of the aneurysm followed by occipital artery-pica bypass was performed by a neurosurgeon. results: coil embolization was successful in all 9 patients. there were no procedure-related complications. there was no sign of infarction in the pica territory in all patients. there was no recurrent bleeding or ischemic symptoms during the follow-up periods. follow-up angiography showed complete occlusion of the aneurysm without recurrence in all patients. conclusion: endovascular coil embolization is a safe and highly effective treatment of ruptured va dissecting aneurysms. high-grade stenoses of the carotid artery were treated with stent implantation. dw mr imaging of the brain was performed a day before and after the endovascular treatment. all patients underwent neurological examination before and after the procedure. results: dw mr images showed a total of 12 new hyperintense lesions in 5 (31%) of the 16 procedures performed. eight lesions were ipsilateral to the treated vessel and 4 lesions, in 2 patients, were contralateral. these patients with contralateral lesions also had new ipsilateral lesions. the lesions were located in parietal lobe (n = 5), periventricular (n = 2), occipital lobe (n = 1), frontal lobe (n = 1) and corona radiata (n = 1). all lesions measured < 5 mm in diameter. none of the patients had neurological symptoms. results: angiographic occlusion was complete in 84 (72%) and 30 (68%) aneurysms in groups a and b, respectively. mean percentage of volumic occlusion in these groups was 30.9 and 29.2%, respectively. perioperative morbidity and mortality rates were 4 and 2%, respectively in group a, and were respectively similar in group b. no significant difference between the two groups was observed. however, percentage of volumic occlusion correlated with sac-to-neck ratio smaller than 1.5 (p = 0.061) and with sac size (p = 0.002), except when 3 or more threedimensional coils per aneurysms were used (p = 0.222). the better the percentage of volumic occlusion, the better the percentage of angiographic occlusion (p = 0.004). percentage of volumic occlusion was an independent predictor of angiographic complete occlusion (p = 0.001). wfns grade 5 was an independent predictor of perioperative mortality (p = 0.043). the use of three-dimensional coils improved the coil-packing and angiographic and volumic occlusion of aneurysms with a neck greater than 4 mm at the time of treatment, provided the sac-to-neck ratio was 1.5 or greater and the largest number of three-dimensional coils were positioned first. minimum apparent diffusion coefficient: a quantitative parameter for prediction of malignancy of gliomas preoperatively x. yun; sendai/jp introduction: in gliomas, choline signal (cho) correlates with total membrane metabolism, apparent diffusion coefficient (adc) inversely with cell density, cho*meanadc with each cell's metabolism. we examined which parameter is the most reliable in prediction of malignancy of gliomas. methods: twenty-three pathologically proven glioblastomas (gbm) and 22 anaplastic gliomas (ag) were retrospectively evaluated with preoperative mri with mr spectroscopy (mrs) and dwi. ki67 index was counted to evaluate pathological malignancy. to evaluate clinical malignancy, we selected 31 cases in which at least enhancing lesions were removed and classified into progressed and stable groups. the minimum adc (madc) of gbm was shown to be significantly lower than ag (p = 0.0001). the highest value of madc in gbm was 0.964, and the lowest in ag was 0.698. using this threshold, 31 subjects were divided into 3 groups; a: gbm with madc < 0.698 (n = 9); b:gbm and ag with 0.698 < madc < 0.964 (n = 15), c: ag with madc < 0.964 (n = 7). six cases in group a were classified as progression (4 pathologically proven recurrence, two dissemination) and all cases in group c were stable. six cases in group b showed progres-sion (2 recurrence, 1 dissemination). fisher test showed significance (p = 0.03). in group b, the madc of 5 progressive gbms was significantly lower than 3 stable gbms (p = 0.033). the ncho and ncho*meanadc showed no difference between gbm and ag (p = 0.12, p = 0.28). inverse correlation was found between ki67and madc (p = 0.0005), no correlation was found between ki67 and ncho (p = 0.22) and meanadc*ncho (p = 0.58). the madc suggestive of cell density was the most reliable in prediction of malignancy of gliomas preoperatively. usefulness methods: forty-one cases of skull base lesions (24 meningiomas; 6 petroclival, 7 clinoidal, 4 olfactory, 2 in foramen magnum, 2 spheno-petro-clival, 1 in the planum sphenoidale, 1 in posterior pyramid and 1 in pca; 5 acoustic schwannomas, 3 epidermoids, 2 pituitary adenomas, 2 craniopharyngiomas, 2 posterior fossa aneurysms, 1 trigeminal schwannoma, 1 dermoid and 1 juvenile angiofibroma) have been evaluated. data was collected, fused, integrated and reconstructed by a dedicated stealthstation system for neuronavigation. ct images were acquired on axial non-overlapping slices, 1-3 mm thick; mri images were obtained with 1.5 t device, same field of view and thickness. results: neuronavigation was possible in all cases and was successfully applied in pre-operative planning and during surgical procedures. we calculated some data to check the efficacy of the method, having a mean fiducial error of 0.7 mm and an accuracy value at 6 cm of depth 1.7 mm. discussion and conclusion: imaging fusion for pre and intra-operative neuronavigation provided, in all cases, great advantages in the choice of the best approach, placing of bone flap, early identification of deep normal or distorted anatomic or pathologic structures and their eventual encasement or involvement by the pathologic primary process, correct definition of tumor boundaries and meningeal implant and relationship with functional areas. neuronavigation appeared ideal for skull base meningiomas making surgical maneouvres safer, more effective and less invasive. a study of mr diffusion changes in normal appearing white matter (nawm) of patients with relapsing remitting multiple sclerosis (ms) f. gaudiello, s. marziali, a. ludovici, e. ferone, r. floris, g. simonetti; rome/it background and purpose: the aim of our study was to monitor water diffusion changes over time in nawm of patients with relapsing-remitting ms and to monitor water diffusion changes in patients with different disability status (edss) and with different clinical status (poussè). methods: we selected 18 subjects who had completed a 6 month follow-up. the mr scans were obtained at baseline, at 3 months and at 6 months. two regions of interest (roi) were placed in each hemisphere in the nawm in each mr study and the apparent diffusion coefficient (adc) value were calculated in patients and in 15 healthy controls. results: tadc in nawm in patients was significantly higher then in controls (controls mean tadc ± sd = 0.731 ± 0.015 mm 2 /sec x 10 -3 ; patients mean tadc ± sd = 0.7655 ± 0.108 mm 2 /sec x 10 -3 ; p < 0.01). in nawm in patients with higher edss, tadc was significantly higher then in patients with lower edss (patients with higher edss: mean tadc ± sd = 0.778 ± 0.044 mm 2 /sec x 10 -3 ; patients with lower edss: mean tadc ± sd = 0.752 ± 0.050 mm 2 /sec x 10 -3 ; p < 0.01). tadc in nawm in patients with poussè was significantly higher then in patients without poussè (patients with poussè mean tadc ± sd = 0.786 ± 0.022 mm 2 /sec x 10 -3 ; patients without poussè mean tadc ± sd = 0.760 ± 0.049 mm 2 /sec x 10 -3 ; p < 0.01). purpose: evaluation of uveal melanoma imaging characteristics in ultrasound, computed tomography and magnetic resonance imaging and correlation of those findings suggestive of melanoma. material and methods: eleven patients (8 men, 6 women, age 30-75 years) with possible diagnosis of uveal melanoma were evaluated. the patients underwent ophthalmoscopic and ultrasonographic examination followed by ct and mr examination. ct imaging was performed with 3 mm axial pre-and post-contrast and coronal post-contrast sections. axial and coronal 3 mm t1 and t2 images were obtained, followed by post-contrast t1 images in axial and coronal direction. additional t1 fat-sat post contrast images were also obtained depending on the relative position of the melanoma in order to evaluate possible extra-orbital extension. results: of the melanomas, six were located in the left globe, ranging from 2 mm to15 mm in size and most commonly on the lateral wall. the tumors appeared as hyperechoic lesions on us with a reflectivity range of 50-70%, suggestive of melanoma. retinal detachment was detected in four patients. on ct images the melanomas appeared as homogenous slightly enhancing lesions, while in two patients, the tumor was less obvious due to the retinal detachment. on mr images the tumors appeared as homogenous hyperintense lesions on t1wi in five patients. characteristic signal void on t2wi due to melanin deposition was noted in three patients. conclusion: ultrasonography appears to be a valuable tool in tissue differentiation of uveal melanoma although magnetic resonance, and to a lesser degree, computed tomography are more specific in evaluating the extra-orbital extension. purpose: gadobenate dimeglumine (gd-bopta: t1 relaxivity in blood = 9.7 mmol -1 s -1 ) was evaluated to determine whether the high relaxivity offers advantages over other agents for cns imaging. methods: preliminary studies evaluated gd-bopta at cumulative doses up to 0.3 mmol/kg to ascertain the optimal dose for mri of cerebral metastases. two phase iii controlled trials were conducted to compare gd-bopta at cumulative doses up to 0.2 mmol/kg with gadodiamide (gd-dtpa-bma) at cumulative dose up to 0.3 mmol/kg. two intra-individual, blinded, fully randomized comparative studies were conducted in patients with cerebral gliomas or metastases to determine differences in quantitative (tumor contrast, cnr ratios) and qualitative (lesion contrast, delineation, internal morphology, structure) enhancement parameters versus gadopentetate dimeglumine (gd-dtpa) and gadoteric acid (gd-dota) at a dose of 0.1 mmol/kg. in patients with metastases a dose of 0.1 mmol/kg gd-bopta proved sufficient for most situations while a cumulative 0.2 mmol/kg dose provided additional information in certain cases. comparative studies revealed that 0.1 mmol/ kg gd-bopta offers improved performance compared to 0.1 mmol/kg gd-dtpa-bma and that cumulative 0.2 mmol/kg gd-bopta is equivalent to cumulative 0.3 mmol/kg gd-dtpa-bma. the intra-individual comparative studies revealed superior qualitative enhancement performance for gd-bopta compared to both gd-dtpa and gd-dota for all evaluations. the subjective assessments were confirmed by the objective measurements of signal intensity and cnr which were significantly higher for gd-bopta (p < 0.01). discussion: gd-bopta is a safe and valuable contrast agent for the assessment of cns neoplasms offering statistically significant advantages over gd-dtpa, gd-dota and gd-dtpa-bma for brain lesion enhancement. the in 5 cases the examinations were performed before the treatment, in 4 patients as an assessment of drug treatment. in 7 cases the efficacy of stereotactic effect (se) was assessed on the suitable target structures. results: a metabolism decrease (md) in the right caudate head (ch) was noted in two patients before drug treatment. in two patients hypermetabolism was observed in the anterior cingulate (ac). follow-up examinations revealed a md in the ac and an metabolism increase (mi) in the right ch in these patients. in one case an mi in both dorsal thalami (dt) was observed. a md in both dt before drug treatment was seen in two cases. a bilateral mi was noted in dt by followup examinations in these patients. in all cases of se, it revealed a md in suitable structures. in 3 cases, a md was observed in ac and both the ch. in two cases, a md was seen in the ac, in 2 a bilateral md in the dt. changes of glucose metabolic rate were associated with severity of clinical manifestations in all cases. this data proves participation of limbicostriatal system in forming aod. our results demonstrate the possibility to use 18 f-fdg pet for aod diagnosis and estimation of treatment efficiency. b d e f a g magneting resonance imaging in 120 patients with intractable partial seizures: a preoperative assessment a. lefkopoulos, a. kalogera-fountzila, c. kouskouras, n. fotiadis, g. spanos, e. papadopoulou, a.s. dimitriadis; thessaloniki/gr purpose: the aim of this study was to assess the prevalence of detected structural abnormalities in medically intractable epilepsy, especially those who are amenable to a surgical therapy, and also to evaluate the sensitivity of different dedicated mr sequences. materials and methods: one hundred and twenty patients (aged 6 months-64 years) with medically intractable partial seizures underwent an mri examination in a 1.5 t unit, with t1 and pd/t2 se in an axial plane and fluid attenuated inversion recovery (flair), t2fse and inversion recovery (ir) in a plane perpendicular to the long axis of the hippocampus. whenever necessary, we applied t1 se + gd dtpa in axial and coronal planes. results: seventy-nine of the 120 patients had a pathological scan (65.8%). abnormalities were hippocampal sclerosis (hs) in 30 patients (25%), cerebral tumors in 12 patients (10%), vascular malformations in 9 patients (7.5%), cortical infarcts in 8 patients (6.7%), cerebral infections in 4 patients (4.2%) and 15 patients with developmental disorders (5 cortical dysplasias, 4 pachygyrias, 2 polymicrogyrias, 3 subcortical heterotopias and 1 patient with tuberous sclerosis). all patients with cerebral tumors and eight patients with hs were operated and there was a pathologic confirmation of the diagnosis. patients with vascular malformation underwent a therapeutic embolization. flair had higher sensitivity in detecting hippocampal sclerosis and cerebral infarcts while ir was particularly useful in detecting developmental disorders. conclusions: mr imaging, with an epilepsy dedicated protocol, plays a cardinal role in locating and characterizing anatomic epileptogenic foci in patients with refractory epilepsy and helps in defining the type of treatment. the purpose: the aim of this study was to evaluate the possibilities of combined pet/ct imaging in detecting glioblastomas and in estimation of efficiency of their surgical treatment and radiotherapy. materials and methods: seven patients (4 men, 3 women, age between 26-70 years) with biopsy-proven glioblastomas were scanned before and/or after treatment by pet/ct (biograph, siemens). a dose of 180 to 220 mbq fluorine-18 fluorodeoxyglucose (fdg) was administered for each pet scan with an acquisition time of 6 minutes for bed and interactive reconstruction. acquisition time for ct was 25 seconds, bringing the total acquisition of combined pet/ct study to 15 minutes. results: three patients with high-grade astrocytomas demonstrated hypometabolic fdg nodules without contrast enhancement at ct scan before surgery. two patients showed nodules with hypermetabolism of fdg (suv 16-18) and intensive enhancement of contrast medium due to the recurrence of tumor after combined therapy. in one patient, after radiation therapy, the region of treatment had decreased uptake of fdg and increased enhancement of contrast medium at ct because of radionecrosis. conclusion: it was confirmed that combined pet/ct study could effectively determine whether a lesion was malignant and provide evidence of tumor recurrence. the collection of prominent medullary (white matter) veins appears like a "medusa head" on mr angiographic images and gadolinium-enhanced 3d-tof sequences; this sign is considered pathognomonic. conclusion: mri is of great value in the accurate identification and morphologic specification of vascular abnormalities. traditionally, these cases required invasive diagnostic imaging. va correct identification is very important because this anomaly is asymptomatic but the ablation can induce venous infarctions. abdominal imaging findings: gastrointestinal tract (gi), hepatobiliary system and the pancreas are involved in cf. the gi complications include obstructive (distal intestinal obstruction syndrome, intussusceptions, fibrosing colonopathy, post surgical adhesions) and non-obstructive conditions (pneumotosis intestinalis, gastroesophageal reflux, duodenitis, and rectal prolapse). liver pathology includes steatosis, cirrhosis, and portal hypertension. the pathological mechanism of cirrhosis may be due to obstruction of the biliary ductules with thickened secretions and secondary inflammation producing fibrosis. biliary tract abnormalities include gallstones, micro gallbladder, and sludge. excessive loss of faecal bile acids due to pancreatic insufficiency is associated with increased lithogenicity of the bile. the pancreatic abnormalities include fat infiltration, fibrosis, atrophy and occasionally cysts and calcification. the primary problem is the plugging of the intralobular ductules by inspissated viscid mucus. conclusion: abdominal symptoms in patients with cf may be due to the various causes related to cf or may be due to coincidental pathology e.g. appendicitis, renal disease. the radiologist should keep an open mind and not restrict his thought process only to the conditions related to cf. neck masses in infants and children: a pictorial review j.r.a. turkington, a. paterson, l.e. sweeney, g. thornbury; belfast/uk learning objectives: this poster presents a pictorial review of pediatric neck masses and their imaging features. particular emphasis is applied to the anatomical site of the mass to aid in differential diagnosis. background: infants and children with neck masses frequently present to the radiologist for further evaluation. the most common aetiologies include congenital lesions and their complications, lymphadenopathy and malignant masses. the role of the radiologist is to differentiate between these conditions using im-aging modalities such as ultrasound and colour doppler, ct and mri. where appropriate, the radiologist will also stage lesions for management purposes, and aid in guiding aspiration or biopsy. imaging findings: the radiological appearance of congenital lesions such as thyroglossal duct cysts, branchial cleft cysts, cystic hygromas, haemangiomas, dermoid cysts and sternomastoid "tumours" are discussed. cervical lymphadenitis and abscesses, and neoplastic masses such as neurogenic tumours, rhabdomyosarcoma, neuroblastoma and lymphoma are also described. lastly, lesions of the thyroid and salivary glands are evaluated. it must be emphasised that the radiological findings should always be interpreted in conjunction with the patient's age, the clinical history and the findings on physical examination. conclusion: neck masses are common in children and a frequent cause of attendance at a&e departments. identifying the anatomical site and radiological appearance aids the differential diagnosis. conclusion: a typical osteoarticular lesion in a typical site can alert you to the diagnosis of sapho, but an unusual site or a primary presentation with no skin lesions will make diagnosis harder or there may be misdiagnosis. children may be seen in a number of specialties, which can lead to unnecessary delays in diagnosis and possible incorrect treatments. this makes the radiologist pivotal in the diagnosis of sapho, although the differential diagnosis should always be considered. to demonstrate the problems which can be caused when trauma x-ray films are incorrectly marked when using the red dot system. background: many radiographs are returned to accident and emergency departments without formal radiological reports, and the red dot system, whereby radiographers attach a red dot to radiographs which they suspect to be showing a fracture, is a widely practised system, used throughout the national health service. it is acknowledged that whilst this system can be beneficial to accident and emergency departments it is not without its problems. procedure findings: our poster examines the problems which can arise in children where normal variants are often highlighted as "fractures" by radiographers. most of the common misinterpretations occur in the appendicular skeleton, e.g. normal variants of epiphyseal ossification or accessory epiphyses, especially of the metacarpal and metatarsal bones. other common "errors" include the pisiform, or os trigonum and accessory ossification centres for the medial and lateral malleoli. in the axial skeleton, vascular markings in the skull, facial bone sutures and end plate ossification centres for the vertebral bodies are some of the commoner areas of concern. conclusion: issues are raised for both accident and emergency departments and for radiology departments if these "errors" are not minimised, including patient complaints of over-diagnosis and potentially unnecessary treatment and follow-up visits. the radiology of pediatric extracorporeal membrane oxygenation: normal appearances and complications a.m. barnacle, m.p. hiorns; london/uk learning objectives: to demonstrate the normal appearances of the pediatric chest during extracorporeal membrane oxygenation (ecmo). the spectrum of radiological abnormalities arising from the complications of ecmo is illustrated, including cannula position and anticoagulation complications. background: ecmo is a means of cardiopulmonary bypass therapy used in patients with cardiorespiratory failure who are unresponsive to conventional intensive care interventions. there is a range of indications for ecmo therapy in the pediatric population, which include congenital diaphragmatic hernia and cardiac disease. there are a number of complications associated with the use of ecmo, many of which are related to the high levels of anticoagulation required during therapy. radiological assessment prior to the commencement of treatment and sequential imaging during therapy are mandatory, and appropriate imaging protocols are discussed. imaging findings: the normal radiological appearances of the chest during ecmo therapy are demonstrated, including the correct positions of both va and vv ecmo cannulae. several technical points are highlighted, to avoid the misinterpretation of certain radiographic appearances. the radiological manifestations of a wide range of complications are illustrated. these include intracranial haemorrhage and extra-axial collection, haemothorax, peritoneal collections and vascular complications. inappropriate cannula positions are also reviewed. the radiologist must be familiar with both the normal and abnormal imaging appearances during ecmo therapy and should be aware of the range of potential complications. the importance of sequential imaging is highlighted and appropriate imaging protocols discussed. acute disseminated encephalomyelitis or multiple sclerosis: what tips the balance? s. avula, a. ghatak, n. wright, r. appleton; liverpool/uk learning objectives: to identify the imaging features and clinical parameters which help to distinguish between acute disseminated encephalomyelitis (adem) and multiple sclerosis (ms) in children. background: both adem and ms are disseminated inflammatory disorders affecting the central nervous system. distinction between the two is difficult, especially at the initial presentation when the prognosis and risk of relapse is an important issue. this exhibit will highlight the salient distinguishing features stated in the literature and illustrate cases of adem and ms which presented over a three year period. procedure details: literature review of childhood adem and ms was carried out and a retrospective review of cases presenting over a three year period with a subsequent diagnosis of adem or ms was performed. there is a considerable overlap between the imaging and clinical features of adem and ms. though there are a few features that predominate in either condition, the temporal progression of the disease with presence of new lesions with or without relapse of symptoms as noted in ms, is the most important factor in distinguishing the two. mri in assessment of fetal renal anomalies j.l. hughes, w. jan; london/uk introduction: in patients with renal anomalies causing severe oligohydramnios, the lack of fluid around the fetus significantly degrades the ultrasound image, making assessment of the fetal abdomen difficult. the presence of renal anomalies has great postnatal significance and successful antenatal counselling depends on the availability of the most complete information. the advent of fast mr sequences has allowed the acquisition of high signal to noise ratio images of the fetus even in the absence of amniotic fluid. we discuss the technique of mr of the fetal renal tract. we describe the normal appearances fetal kidneys on mr and present data on illustrative cases where mr provided additional information over and above a detailed ultrasound examination. methods: t2w single-shot rapid acquisition with relaxation enhancement (rare) and t1w 2d fast low angle shot (flash) were obtained of the fetal kidneys in the three orthogonal planes. all images were acquired without fetal sedation with the mother in the supine position within 20 minutes. comparison ultrasound and mr images are presented. results: mri is able to diagnose and assess a variety of renal anomalies such as renal aplasia, dysplastic renal tissue, polycystic kidney disease, congenital hydronephrosis, and ectopic renal tissue. conclusions: fetal mr offers further information over ultrasound examination and hence allows appropriate ante-natal counselling. pediatric urethral anomalies a. sharma, s. maroo; glasgow/uk imaging evaluation of neonatal cystic pelvic masses v.v.t. mascarenhas, a. duarte, l. lobo, j. fonseca-santos; lisbon/pt learning objectives: to describe imaging features of cystic pelvic masses (cpm) in the newborn. to outline main differential diagnosic pitfalls. to emphasise the role of imaging evaluation in treatment and follow-up orientation. background: neonatal cpm are among the most common abdominal masses in the neonate and usually first suspected during fetal ultrasonography. a more precise diagnosis in the neonatal period is essential to an adequate orientation in treatment and follow-up. on this regard, imaging evaluation, particularly us and mri as the main techniques, undertake a pivotal role. we describe diagnostic imaging features, differential diagnosis limitations and a systematic diagnostic approach to cpm among selected cases in our department. imaging findings: we reviewed the referred cases based on sex, location, relation to adjacent anatomic structures and morphological features. main diagnostic entities considered were pre-sacral (sacrococcygeal teratoma and myelomeningocele) and non pre-sacral masses (genitourinary related namely hydrocolpos, ovarian cyst, bladder diverticulum; digestive tract related e.g. duplication cyst; others, particularly lymphangioma). morphological imaging findings according to their uni-or multilocularity, simple or complex components and the presence of specific findings were considered. ultrasound was the first and sometimes the only imaging modality performed. selected cases were further evaluated with other imaging modalities such as conventional contrast studies (e.g. cystography) or mri. conclusion: although there is a wide range of entities presenting as a cpm in the neonate, a systematic imaging approach allows a more precise diagnosis or at least a considerable narrowing of diagnostic possibilities in the majority of cases, which is essential for therapeutic orientation. normal sonographic appearance of kidneys and adrenals in neonates and young infants: unique distinctive features m. vakaki, g. pitsoulakis, h. manoli, c. koumanidou; athens/gr learning objectives: to familiarize residents in radiology or pediatric radiology with the sonographic characteristics of neonatal and infantile kidneys and adrenals. backround: the kidneys are the most commonly sonographically examined abdominal organs during the first months of life. the adrenals, due to their position adjacent to kidneys, are almost always clearly visualized during the renal sonogram. their sonographic appearance is quite different from that in older children and adults and often causes misleading incorrect diagnoses. imaging findings: examples of various normal sonographic findings of the kidneys and adrenals in neonates and young infants are presented and embryologically, anatomically or functionally explained. they include the hyperechogenicity of the renal cortex, the "enlarged" hypoechoic pyramids, the fetal lobulation, the inter-renicular septum, the transient neonatal renal medullary hyperechogenicity, the papillary projections in the pyelocalyceal system, the renal pyelectasis, the large and hyperemic neonatal adrenals and even more. these sonographic interpretations are often misdiagnosed as abnormal conditions, which are also provided. conclusion: this exhibit will allow an interesting way for young radiologists and pediatric radiologists to learn the common, but also the rare sonographic appearances of neonatal and infantile kidneys and adrenals. this knowledge is essential in order to prevent misdiagnoses and needless further investigation. background: difficulties with blind corticosteroid injection of the subtalar joint are commonly encountered in children with jra. ultrasound (us) guidance can make the puncture more accurate by directly showing the needle tip within the joint. procedure details: twelve consecutive patients with jia who had clinical signs of active arthritis and intraarticular fluid or synovial proliferation in the subtalar joint detected at us received either a blinded injection (n = 7) or a us-guided (n = 5) injection with free-hand technique using high resolution (12-5 mhz) us. patients were assessed at 24 hours, 2 months and 6 months of follow-up to compare the level of clinical response and the frequency of complications between the two treatment groups. conclusion: although significant improvement was documented in both groups of patients with respect to baseline, those injected under us-guidance had a lower clinical dysfunction score at 24 hrs and 2 months follow-up. no major complications were noted. our preliminary results indicate that intraarticular corticosteroid injection of the subtalar joint in children with jia is more accurate and successful when performed under us guidance. background: doppler sonography is a well-established technique to evaluate a number of pediatric abdominal conditions, but the field of diagnostic applications is now on the brink of major changes. many contrast-specific modalities have been developed in recent years by academic researchers, ultrasound scanner manufacturers, and pharmaceutical companies. our aim is to update the diagnostic value of conventional doppler modalities, and to analyse potentially useful applications and indications for the more recently developed techniques. imaging findings: specific entities will be used to illustrate clinical principles that can be applied to multiple clinical situations. topics addressed include: vascular patency (arterial or venous thrombosis or stenosis, biliary atresia, liver and bowel transplantation, and surgical shunts); anomalous vessels and tubular structures (dilation of the biliary tree vs. blood vessels, pulmonary sequestration, varicocele); and evaluation of hyperemic and ischemic lesions (appendicitis, intussusception, pyelonephritis, orchitis / testicular torsion). conclusion: b-mode sonography, as well as doppler techniques, have a key role in pediatric diagnosis for several reasons (non-invasivity, lack of ionizing radiation, sonographic access is better than in adults, no need for anesthesia or sedation). understanding the physical principles that govern doppler imaging is essential for its successful clinical application. symptomatic cases: n = 8. mean onsd right eye = 5.5 mm (sd = 0.7), mean onsd left eye = 5.7 mm (sd = 0.9). a wilcoxon signed ranks test showed no significant difference between these results. using the largest reading for each eye when well and symptomatic: mean asymptomatic onsd = 4.8 mm (sd = 0.8, n = 8), mean symptomatic onsd = 6 mm (sd = 0.8, n = 8). a wilcoxon signed ranks test showed a significant difference in these results (p = 0.008). conclusion: onsd increases in acutely raised icp. our results suggest that children with spina bifida and shunted hydrocephalus cannot be assumed to have onsd within the normal range even when clinically well. in the long term we aim to compile new onsd reference ranges for children with shunted hydrocephalus. withdrawn by authors hyperechoic foci in the kidney: an incidental sonographic finding in neonates and infants m.a. pourbagher, a. pourbagher, f. tiker, z. koc, e.a. niron; adana/tr purpose: the purpose of this study was to determine the incidence and significance of non-shadowing hyperechoic foci in the kidney and to evaluate metabolic disturbances in these patients. in a period of 3 years abdominal ultrasonography (us) was performed as a screening procedure in 2532 neonates and infants. a followup us was performed in 50 of 76 (38 female and 38 males) patients with hyperechoic foci in the kidney approximately 2-24 months after the initial examination. all patients underwent metabolic evaluation, including serum electrolyte measurement and 24-hour urine collection. results: non-shadowing hyperechoic foci were detected in 76 (3%) patients (100 kidneys). the size of foci were 1-5 mm (mean 2 mm). the foci were located in the lower pole calix in 66%, upper pole calix in 4% and middle zone calix in 30% kidneys. sixty kidneys had single, 12 had 2 and 28 had 3 or more foci. at 2-24 months follow-up the clearance for foci was 74%. size and site of foci has no relation with foci clearance. urinalysis showed elevated urinary calcium in 3 and hematuria in 8 patients. in 2 patients foci were passed without intervention, and uric acid was the dominant foci composition in both patients. serum electrolyte measurement were normal in all patients. the incidence of hyperechoic foci in our study was 3%. that is usually discovered incidentally during sonography of the abdomen and generally resolve spontaneously. follow-up of the patients is advocated with us and urinalysis. germinal matrix morphology in antenatal ventricular dilatation k.m. koprivsek 1 , t. vanderheyden 2 , s. counsell 2 , j. allsop 2 , a. stonebrige-foster 2 , s. kumar 2 , n. fisk 2 , m.a. rutherford 2 ; 1 sremska kamenica/yu, 2 london/uk purpose: the germinal matrix (gm), a densely cellular zone lining the lateral ventricles, and give rise to the developing cortex. the mri appearance of gm during fetal development has been well-documented, but data about gm morphology in pathological conditions is sparse. antenatal ventricular dilation (vd) is associated with significant neurological morbidity. we used antenatal magnetic resonance imaging (mri) to measure the gm in fetuses with and without vd. methods: retrospective analyses were conducted of fetal mr images acquired over a 2-year period, using fast t2 weighted sequences. in 70 fetuses (normal ventricles in 44, vd in 26 cases), we evaluated the signal characteristics and the maximum germinal matrix diameter (gmd) at three sites: the anterior and posterior ventricular horns and the caudothalamic notch (ctn). between-group comparisons of gmd in normal and fetuses with vd were made using a students t-test. results: gm had the same low signal intensity regardless of ga and/or ventricular volume. none of the infants with vd had evidence of gm haemorrhage. the mean gmd in controls showed a linear decrease with brain maturation. in fetuses up to 28 weeks of ga with normal ventricles the gmd was greatest at the ctn. the similar pattern of changes in gmd was measured in vd group, where the mean gmd at the tcn were slightly, but not significantly lower then in controls (t = 1.48: p > (0.05)). conclusion: gm diameter decreased with increasing gestational age. we did not detect any significant difference in gm morphology in the group of fetuses with antenatal vd. contrast enhanced color doppler ultrasonography in diagnosis of scrotal lesions in children u. zaleska-dorobisz, e. czapiga, k. moron; wroclaw/pl purpose: to investigate the usefulness of ultrasound with contrast agent levovist-schering (usca) for the detection scrotal lesions in children. between 2000-2002, 39 boys with scrotal masses were examinated. mean age was 13.6 years and ranged from 1-17. diagnostic assessment included in all cases conventional us, color doppler and power doopler before and after the adminstration of contrast agent keeping the same methodology in every examined patient. focal testicular lesions (cystic and solid tumor) and extratesticular structures were documented regarding size, localization, range, vascularity and ultrasound diagnosis. in testicular tumors, the degree of tumor vascularity was subjectively graded from 0 to iv. the ultrasound diagnoses were compared to the final diagnoses based on clinical tests, surgical and histological examination. results: 11 testicular and extratesticular tumors showed more enhancement than adjacent testicular parenchyma, seen between 15 to 60 s (mean 29 s) and 55 to 252 s (mean 83 s) after injection. the duration of enhancement was 15 to 210 s (mean 80 s). cross sections and adjacent vessels were only seen in: teratoma, embryonal carcinoma and yolk sac tumor. conclusions: usca is an important and significant aid in the diagnosis of scrotal diseases, in the assessmentof of degree of vascular change and is predictive of malignancy. mr features of the preterm children with athetotic cerebral palsy k. hayakawa, t. kanda, y. yamori; kyoto/jp purpose: the recent development of the neonatal intensive care medicine has caused not only a dramatic decrease in the incidence of kernicterus, but also marked improvement in the survival of premature babies. consequently, the incidence of pure athetotic cerebral palsy has decreased, whereas the incidence of spastic cerebral palsy associated with athetosis, termed mixed cerebral palsy, has increased. the purpose of this study is to evaluate the brain mr features of this condition and to assess the frequency of basal ganglia injury. the subjects consisted of 14 boys and six girls diagnosed with mixed cerebral palsy. their gestational age range from 28 to 34 weeks (average = 29 weeks) and the birth weight ranged from 635 g to 2732 g (average = 1455 g). mr brain scans were assessed with particular attention to the basal ganglia. imaging of pancreatic disorders in pediatric patients y. herrero, t. berrocal, c. prieto, j. fernández, m. parrón, r.r. lemos; madrid/es purpose: the aim of this teaching exhibit is to illustrate a wide spectrum of usual and unusual disorders involving the pancreas in children, and to evaluate the efficacy of ultrasound (us), duplex and color doppler sonography, endoscopic retrograde cholangiopancreatography (ercp), computed tomography (ct) and magnetic resonance (mr) imaging in the diagnosis and management of these conditions. methods and materials: the imaging findings of patients with disorders involving the pancreas were reviewed from our database of pediatric pancreatic pathology. ultrasound was performed in all cases, while ct, and mri were performed in all tumors and whenever us and doppler images were not conclusive. ercp was used to study the pancreatic ducts. the embryologic and pathologic bases of the imaging findings are discussed in appropriate cases. the key findings at each imaging modality are shown and compared with the underlying pathologic features when available. pitfalls, diagnostic difficulties and differential diagnoses are emphasized. results: specific topics addressed include congenital anomalies (pancreas divisum, annular pancreas, ectopic pancreas, pancreatic cysts, cystic fibrosis, shwachman-diamond syndrome, von hippel-lindau syndrome, and nesidioblastosis); acute and chronic pancreatitis; pancreatic cyst and pseudocysts; primary neoplasms (insulinoma, cystadenoma, and papillary cystic carcinoma); metastasis of burkitt lymphoma; and miscellaneous (hemochromatosis, cushing's disease, steroid and cytostatic therapy, and parenteral nutrition). conclusion: evaluation of patients with pancreatic disorders frequently requires multiple imaging modalities for diagnosis and planning surgical correction. because many of these disorders have characteristic imaging appearances, this exhibit will help practicing radiologist to better understand and recognize pathologic processes affecting the pancreas. imaging congenital vertebral disorders in pediatric patients m. fernández -velilla, t. berrocal, a. royo, a. fernández, j. gutierrez, n. gómez-león; madrid/es purpose: to illustrate a wide spectrum of usual, unusual and exceptional congenital anomalies involving the vertebrae, and to evaluate the efficacy of plain radiographs, computed tomography (ct) and magnetic resonance (mr) imaging in the management of these conditions. methods and materials: we retrospectively reviewed the imaging findings of patients with congenital abnormalities involving the vertebrae from our database of spinal pathology. abnormalities were divided into isolated vertebral anomalies and anomalies associated with systemic diseases or syndromes. plain radiographs were performed in all patients. ct or mr were performed whenever plain radiographs were inconclusive. the embryology and pathologic basis of the radiographic findings are discussed. pitfalls, diagnostic difficulties and differential diagnoses are emphasized. results: specific topics addressed include anomalies in number (vertebral agenesis, sacral agenesis, omovertebral bone); anomalies in size and shape (vertebral and sacral hypoplasia, hemivertebra, occipitalization of c1, os odontoideum, lumbarization, sacralization); anomalies of fusion (blocked vertebra, klippel-feil abnormality, spina bifida, butterfly vertebra, coronal cleft vertebra); anomalies of alignment (spondylolisthesis, spondilolysis, scoliosis); neural arch defects (absence of the pedicle and lamina); caudal spinal anomalies with anorectal and urogenital malformations (terminal mielocystocele, caudal regression syndrome, vacter association, oeis complex, currarino triad); and skeletal dysplasias (achondroplasia, thanatophoric dwarfism, chondrodysplasia punctata, spondyloepiphyseal dysplasia, and mucopolysaccharidoses). conclusion: evaluation of patients with vertebral abnormalities frequently requires multiple imaging modalities for diagnosis and planning treatment. because many of these disorders have characteristic imaging appearances, this exhibit will help trainee radiologist to better understand and recognize pathologic processes affecting the vertebral spine. defecography in chronically constipated children a.d. yang, m.-t. cheng, k. lee; changhua/tw purpose: to evaluate the defecographic findings in children suffering from chronic constipation. between may 1999 to august 2003, we performed a prospective study of 47 children (24 boys, 23 girls) with an age range of 3 -18 years old who fit the criteria for chronic constipation in our institution. defecography was performed using flouroscopy with radiographs were taken during different phases of defecation; the whole study was video recorded. results: of the 47 children studied (42) children were found to have abnormal defecographic findings: partial relaxation to non-relaxation of the puborectalis muscle on defecation was found in 18 patients; anterior rectocele in 16, posterior rectocele in 11, rectal intussusception in 20, mucosal prolapse in 17, rectal prolapse in 4; sigmoidoceles in 15: grade i (11), grade ii (2), grade iii (2). conclusion: 1. the defecographic findings that are seen in adults could also be found in children. 2. defecographic evaluation could be a potentially valuable and simple radiologic study which could be used in the evaluation of children suffering from chronic constipation. evaluation of the usefulness of 3d ct reconstructions of multifragmented fractures in children m. wozniak, e. dybiec, p. wieczorek; lublin/pl purpose: the aim of the study was the evaluation of the usefulness of 3d ct reconstructions in the imaging of post-traumatic alterations of the bones in children. the analysis was based on 39 three dimensional ct reconstructions of the fractured bones. there were cases of extensive, complex bone fractures, when evaluation based on conventional radiographs was insufficient. all examinations were performed on a shimadzu sct 7800tx scanner. surface and volume rendering were employed in the processing. the results of the study show that 3d reconstructions allow very precise evaluation of post-traumatic alterations, especially in the bones of complex anatomical structures. they enable the imaging of small fracture fissures invisible on conventional radiographs and ct. in the cases of bone indentations 3d reconstructions allow very detailed evaluation of the depth of indented fragments, their displacement and rotation. results: 797 ct examinations were performed over the nine month study period. examinations using tube current of more than 100% greater than protocol were noted. these reduced from 37% of examinations prior to the introduction of the protocol to 16% following its introduction. reductions were most noticeable in helical examinations of thorax, abdomen and pelvis. conclusion: weight related protocols reduce the tube current used and thus the radiation dose in a large percentage of paediatric ct examinations. this has proved to be an effective method of reducing dose both in this study and in previous studies. bone sarcomas as a second malignancy in children c. renal dysplasia and intrarenal reflux in boys with posterior urethral valves: high resolution sonographic findings m. vakaki, g. pitsoulakis, h. manoli, c. koumanidou; athens/gr purpose: voiding cystourethrography (vcug) is considered the gold standard for the diagnosis of the posterior urethral valves (puv) and the accompanying vesicoureteral reflux (vur) in boys. however, its contribution to the characterization of intrarenal pathology, which is considered to be of great prognostic value, is minimal. it is only with recently introduced high resolution ultrasonographic equipment that details of disturbed renal architecture can be visualized. materials and methods: 12 infant boys with puv, aged 1 day to 7 months were examined sonographically with 5-8 mhz convex and 5-12 mhz linear transducers. the presence of puv was confirmed with vcug in all cases. results: apart from the classic sonographic findings of puv, which were also demonstrated, findings specific to the kidney included: a) bilaterally increased renal parenchymal echogenicity and loss of corticomedullary differentiation (12/ 12), which with b) small cortical cysts (8/12) imply renal dysplastic lesions, c) increased medullary echogenicity, cupping of dilated calyces, which is attributed to intrarenal reflux (3/12), d) hypoechoic lines pointing towards rounded calyces, corresponding to the pelvotubular backflow of urine (2/12), e) small subcapsular urinomas (2/12), f) urinoma and urine ascites (1/12) and g) intrarenal abscesses (1/12) and fungal balls in the collecting system (2/12), due to post-surgical candidiasis of the urinary tract. conclusion: ultrasonography with high-resolution transducers is able to visualize underlying renal pathology and to image the parenchymal architecture, contributing not only to the diagnosis but also to the definition of the prognosis in boys with puv. meningiomas within the vertebral column are even rarer. we present the imaging characteristics of 7 meningiomas (5 intracranial and 2 intracanal) in 4 girls and 3 boys, aged 3.5-14 years (mean age 8.6 years). these meningiomas were diagnosed during 10 year period (1992) (1993) (1994) (1995) (1996) (1997) (1998) (1999) (2000) (2001) (2002) (2003) . none of the studied children had previously been treated with radiotherapy. both children with vertebral meningioma suffered from neurofibromatosis. the imaging studies included brain ct (5/7) and mr of the brain (5/7) and vertebral column (2/7) before and after intravenous administration of gd-dtpa. the histologic examination after the surgical tumor resection showed meningioma of the transitional type in 6 children and co-existing malignant elements in the 7 th child. following tumor resection, 6 children were free of symptoms and no other treatment was required. in contrast, the patient with the meningioma with malignant elements was treated with chemotherapy and radiotherapy, after subtotal tumor resection. conclusion: imaging of meningiomas (intracranial and intracanal) provides essential information for surgical planning, demonstrating the extraparenchymal nature of the neoplasm, its location, its dimensions, possible calcifications, as well as its effects on adjacent anatomic structures. rare hepatic vascular anomalies in pediatric patients z. harkanyi, g. balazs, g. tasnadi; budapest/hu purpose: to present a selection of rare cases of hepatic vascular anomalies in pediatric patients. us, helical ct and mr were used in the diagnosis and in the follow-up of these lesions. various venous anomalies were detected including intrahepatic arterio-portal and porto-hepatic shunts. a case of porto-caval shunt was also identified. the most frequent anomaly was portal cavernoma due to portal vein thrombosis. one case of caval web has been followed up for 15 years. another case of budd-chiari syndrome has been followed up for two years. several cases of hepatic and portal vein anatomic variations are also documented. 2d and color doppler us was used as the first line examination in the diagnosis and follow-up different congenital hepatic vascular anomalies. helical ct, cta and, more recently, mra has been used for further analysis of these lesions. conclusions: us is still the first method for the evaluation of the pediatric liver and the hepatic vessels. color doppler is the modality of choice for functional evaluation of the vascular anomalies and is also useful in the follow-up of the patients. contrast-enhanced mra and cta is helpful in selected cases to demonstrate the extent of the lesions and other associated anomalies, such as development of systemic collaterals. acute [1992] [1993] [1994] [1995] [1996] [1997] [1998] [1999] [2000] [2001] [2002] [2003] , 24 (n = 24) children with septic sacroiliitis and/or acute osteomyelitis of the pelvic bones were imaged by our radiology department. other laboratory tests were already performed and in 15 (15/24) young patients, material from needle aspiration had been sent for cytological examination. the imaging initial approach included plain film study and triple-phase 99 tc radiophosphate scan. in addition, 19 (19/24) patients underwent mri examination and 12 (12/24) children had ct. the laboratory results confirmed the diagnosis of osteomyelitis and/or that of septic sacroiliitis. the retrospective study of the imaging examination results indicated the superiority of scintigraphy and of mri in the diagnosis of these entities. plain film radiographic signs of disease were observed only in 5 patients (5/24) though the bone scintiscan was positive in all 24 patients (24/24). the ct examination was positive in 10 young patients (10/12) while mri's sensitivity was 100% (19/19). at the end of therapy all patients recovered completely. conclusion: a bone scan is warranted in every case of clinically suspected osteomyelitis and/or septic sacroiliitis in which the radiographs are unrevealing. however, mri is a useful adjunct in the evaluation of the bone edema, the detection and localization of abscess and in the demonstration of the soft tissue extent of the infectious process. the results: hrct showed that 16/51 of the cases had bronchiectasis, with cystic fibrosis as the underlying cause in 5 cases. 2 cases had bronchiolitis obliterans and 2 cases had macleod's syndrome. 2 cases with aspiration pneumonia had gastroesophageal reflux, and a intrabrochial foreign body was detected in one case. one case had bronchopulmonary dysplasia, and 2 had tb lymphadenitis compressing bronchi. chest radiography revealed findings of bronchiectasis only in 5 of the 16 cases. hyperaeration was detected in the chest radiographs of only 3 cases out of 18, whose hrct revealed air trapping. hrct showed peribronchial thickening in 18 cases, however, chest radiography showed the same finding in 5 patients. hrct made it possible to observe linear densities caused by linear atelectasis / scars in 12 cases. hrct showed the underlying pathology and consequent pulmonary lesions in 22 out of 51 cases, and linear densities in 12. conclusion: hrct has a significant role in detecting the underlying abnormalities and consequent lesions in children with recurrent pulmonary infections. compared to chest radiography, hrct gives much more information. analysis of doppler signals: application for detection of fetal movements a. kribeche, s. benderbous, m. berson, d. kouame, l. pourcelot; tours/fr the objective is to develop and validate a new doppler ultrasound system allowing the imaging of fetal movements in real time. we describe the prototype of new ultra-sound sensors and present the results obtained in pregnant women. the apparatus enabling us to acquire the signals coming from fetal activity consists of 12 ultrasonic sensors, a doppler module and a computer provided with a chart of acquisition of the signals. after suitable recording and signal processing, fetal heart rhythm (fhr) and the fetal breathing movements (fbm) are extracted. study of the doppler signals after fast fourier transform enables us to characterize the fetal movements in term of the amplitude, displacement and frequency. estimate of displacement is obtained by calculating the phase of the signal resulting from the analytical filtering of the doppler signal and to separate the direction from the doppler signals. results: twenty recordings were carried out on four women in their last quarter of pregnancy. during the last quarter of pregnancy, the fhr is approximately 130 beats.min -1 . however, the fhr that we detected is about 134 beats.min -1 . we are thus in the presence of the fetal heart rhythm. conclusion: this is the first time that parameters giving the fetal movements are extracted. as a first approach, the fft gives satisfactory results. assesment of skeletal age with hand and wrist sonography: could a standardised method replace radiography? s. megremis, g. cavallo, m. michalakou, e. kehagias, n. segkos, e. agianniotakis, e. sfakianaki; iraklion/gr purpose: to investigate the capability of hand and wrist sonography in skeletal age assessment, and to propose a technique that could be commonly used. materials and methods: forty-two children, aged 0 months to 16 years, underwent a left hand radiograph for skeletal evaluation. they were also sonographically examined on the same hand, with focus on distal epiphyses of radius and ulna, carpal ossification centers, adductor sesamoid bones of metacarpophalangeal joint of the wrist and the cartilage of the third's finger distal phalange. scanning and measurements were obtained in both transverse and longitudinal planes, and the images were digitally recorded for further evaluation. results: all areas of interest were identified both in the left hand radiograph as well as in the sonographic examination, for each individual. furthermore by dorsal and palmar scanning of the carpal ossification centers, accurate mapping and measurements were feasible. gaining experience, and developing a common procedure, we were able to progressively minimize most technical difficulties. conclusion: hand and wrist sonography promises an accurate, safe and cost effective assessment of skeletal age. detailed knowledge of hand and wrist anatomy, and familiarization with a standardized method, as the one we propose, in acquiring and interpreting images is indispensable. in addition, the designation of sonographic charts for the evaluation of skeletal age could be possible in the future. the role of hepatobiliary scintigraphy in the differential diagnosis of neonatal hepatitis, intrahepatic cholestasis, and biliary atresia e. palócz, t. györke, k. bártfai, l. balogh, l. szönyi, i. máttyus, é. kis, t. verebély, e.k. makó; budapest/hu purpose: biliary atresia (ba), intrahepatic cholestasis (ihc) and neonatal hepatitis (nh) are the main causes of neonatal direct hyperbilirubinaemia (ndh). the distinction of ba needing early surgical intervention from nh and ihc syndromes is essential, but difficult. the impact of hepatobiliary scintigraphy (hsc) in the differential diagnosis of ndh was evaluated. methods and materials: 28 hscs of 25 patients (age: 10 days-6 months) with ndh were included in our retrospective study of a five years period. after administration of 1.85 mbq/kg (min.: 9 mbq) 99mtc-brida serial abdominal images were performed up to 24 hours. the scintigraphic diagnoses (sd) of ba, ihc, nh and indeterminate (ind) were defined based on visual scoring of liver uptake, intrahepatic radiopharmaceutical transport and bowel activity. sds were compared with clinical diagnoses (cd), which were based on laboratory, histological or operative findings and/or clinical follow-up. results: the cds were: 12 ba, 9 ihc, and 7 nh. the sds were: 10 ba, 5 ihc, 7 nh, 6 ind were correct in 14 and false in 8 cases, while the cd in the 6 ind cases was ba. regarding the shortage of bowel activity as a basis for sd of ba the sensitivity and specificity of hsc in the diagnosis of biliary atresia were 100 and 75% respectively. conclusion: our results suggest that hepatobiliary scintigraphy is a useful tool in distinguishing ba requiring urgent surgical intervention from other kinds of pathologic conditions causing ndh, but that it is unreliable in further narrowing of the differential diagnosis. various radiologic findings of wilms' tumor y.-w. kim 1 , w. kim 2 , i.-o. kim 2 , k. yeon 2 ; 1 busan/kr, 2 seoul/kr purpose: wilms' tumor is the most common pediatric renal mass. although it usually manifests as a solid intrarenal mass with a pseudocapsule and distortion of the renal parenchyma and collecting system, some atypical radiologic findings may produce diagnostic confusion. the purpose of our exhibit is to illustrate various radiologic findings of wilms' tumor. we retrospectively reviewed radiologic findings of 60 cases, which were pathologically proven from 1996 to 2001 (the age of patients; between 2 months and 9 years). results: this exhibit includes: 1) typical intrarenal wilms' tumor (n = 19), 2) wilms' tumor with vascular invasion (n = 7; renal vein 4, ivc 4, right atrium 3), 3) wilms' tumor with perirenal extension (n = 11; psoas & ln 1, perirenal hematoma 6, subcapsular hematoma 2), 4) wilms' tumor with extension into the urinary tract (n = 6; renal pelvis 4, ureter & bladder 2), 5) wilms' tumor with metastasis (n = 6; lung 4, bone 1, pleura 2, mediastinum 1, scrotum 1), 6) bilateral wilms' tumor (n = 4), 7) wilms' tumor in a horseshoe kidney (n = 1), 8) atypical wilms' tumor (teratoid wilms'; n = 1, cystic wilms'; n = 3, extrarenal wilms'; n = 1, intrapelvic wilms'; n = 1). the knowledge of these various radiologic findings of wilms' tumor can be helpful in the diagnosis and management of the tumor. extracorporeal shock wave lithotripsy monotherapy for pediatric urinary tract calculi z. siric, a. slavkovic, m. radovanovic, m. mrvic; nis/yu purpose: to show the safety and efficacy of extracorporeal shock wave lithotripsy (eswl) for the urolithiasis in the pediatric age group and to evaluate the complications encountered after the treatment. material and methods: 84 children (age range 8 months to 14 years) with 183 stones underwent eswl. kub were taken on the day after treatment. if stonefree status was achieved, the patient was followed with ultrasonography and urinalysis every six months. if fragments < 4 mm were present, follow-up was repeated every 3 months. results: stone size ranged from 0.5 to 2.5 cm. 64 kidneys, 27 ureters and 3 bladers underwent 165 eswl sessions. retreatment was required in 43% patients. the mean number of sessions per child was 1.9. mean fluoroscopy time per session was 0.79 min. the overall success rate was 90%, but the stone -free status was achieved in 62% of children. the composition of the stones were struvite and calcium oxalate in the majority of the patients. auxiliary procedures (jj stents) were used in 27% children. transient hematuria, ecchymoses and colic p p p p pedia edia edia edia ediatric tric tric tric tric were the complications encountered after treatment in 31% of children. perirenal haematoma was identified in one patient. 22 (26%) children developed obstruction and 11 required nephrostomy. conclusions: eswl is non-invasive procedure suitable for stones in all locations in the pediatric patients. it may be the first-line treatment for all pediatric urinary tract calculi, although the long-term effects of lithotripsy on the kidney are unknown. imaging to meckel's diverticulum (n:9), small bowel tumour (n:2), duplication enteric cyst (n:1), postoperative (n:6) and bowel wall hemorrhage (as in henoch-schonlein purpura (n:5). the enema failed to reduce the intussusception in all cases. all children underwent definitive surgery rather than inappropriate treatment by attempted radiological reduction. conclusion: abdominal sonography is the most efficient examination for the diagnosis of intestinal intussusception. various pathological lead points in intussusception can now be defined by ultrasound. secondary intussusception treatment is surgical. diagnostic value of diffusion weighted mr imaging in pediatric cerebral neurological diseases y. oksuzler, h. cakmakci, s. kurul, m. oksuzler, e. dirik; izmir/tr purpose: to detect the diagnostic value of diffusion weighted (dw) magnetic resonance (mr) imaging in different diseases involving the cerebral white and gray matter and to compare the diffusion properties with age matched normal children. conventional and dw mr imaging was performed in 18 children with neurologic disorders, and 25 normal control subjects. neurological disorders included neurodegenerative brain diseases (n: 6), anoxic encephalopathy (n:4), acute disseminated encephalomyelitis (adem) (n:3), encephalitis (n:1), subacute sclerosing panencephalitis (sspe)(n:4). apparent diffusion coefficients (adc) were measured from the brain lesions and 12 normal appearing white and gray matter areas in study group. 12 normal appearing areas were also measured in the control group. results: adc values obtained from the normal subjects were similar to values described in the literature. adc values of study groups were significantly different from the control subjects. adc values for the neurodegenerative disease group, anoxic encephalopathy group, adem group, encephalitis, sspe group, were respectively between 0.33 x 10-3-2.1 x 10-3 cm 2 /s, 0.10 x 10-3-2.03 x 10-3 cm 2 /s, 0.55 x 10-3-0.93 x 10-3 cm 2 /s, 1.02 x 10-3-1.58 x 10-3, 1.07 x 10-3-1.46 x 10-3 cm 2 /s. conclusion: although this study is limited due to population size and disease heterogeneity dw mri provides useful and complementary information regarding the degree of involvement in different pediatric neurological disorders. clinical presentation and mri findings in non-accidental trauma in children under two years of age p.c. sundgren 1 , m. petrou 1 , j. jennings 1 , j. ksar 1 , j. smythe 1 , b. foerster 2 , p. maly 1 , p. eldevik 1 ; 1 ann arbor, mi/us, 2 lund/se purpose: to describe the clinical presentation and illustrate the mri findings in suspected non-accidental brain trauma in children under two years of age. we reviewed the hospital charts and the mr reports of 15 patients examined due to clinical suspicion of non-accidental brain trauma. we noted the clinical presentation and the mri findings in each case. both the radiological diagnoses and the final diagnoses were extracted and compared, and the impact of the mri examination on the clinical course of the patient was evaluated. results: subdural hematoma was the most common finding seen in 13 of the 15 patients, petechial hemorrhages and brain edema was other common findings in these patients. discussion/conclusion: non-accidental brain trauma is not uncommon and in most cases ct of the brain is the method of evaluation. mri is only performed in a limited number of cases, for example, when dating the abnormalities is crucial, and to evaluate for additional findings of axonal shearing injury. examples of this will be illustrated. congenital hip dysplasia: mri after reduction of the femoral head e. svedström; turku/fi purpose: in the treatment of developmental dysplasia of the hip, maintenance of the correct position of the reduced femoral head is very important. many modalities such as conventional x-ray images, tomography, ct and us have been used in the evaluation of the femoral head position after reduction. these techniques either use ionizating radiation or require an experienced examiner. they might even be subject to technical limitations or sometimes be inaccurate. this poster describes the use of mri in the assessment of femoral head position after closed or open reduction. mri studies with an open-configured 0.23 t mr-imager were performed on four children. some of these children (0-8 months of age) were studied multiple times during the follow-up. no sedation was used. coronal and axial sequences were used. position of the femoral head, appearance of the limbus and formation of the pseudoacetabulum were noted. results: all mri studies were successfully performed without any sedation. the plaster did not reduce image quality in any of the studied hips. in four still-dislocated hips mri showed correct diagnosis. in two of these hips an inverted limbus could correctly demonstrated. conclusions: accurate diagnosis is very important after reduction of the femoral head. these children commonly require multiple imaging studies during followup. therefore, mri and us, which do not use ionizating radiation, are the preferred modalities. after reduction, mri findings are easily reproduced and are accurate. even other findings like inverted limbus in interposition and formation of pseudoacetabulum can be demonstrated. 516 b d e f a g practical experience with the application of the "digital addendum of the european protocol for quality assurance in mammography" h. bosmans 1 , f. rogge 1 , a.-k. carton 1 , k. young 2 , r. van engen 3 , m. thijssen 3 , g. marchal 1 ; 1 leuven/be, 2 guildford/uk, 3 nijmegen/nl learning objectives: to teach different aspects of the digital addendum (da) to the european protocol for quality control in mammography: • the purpose of the tests as described in the document. • the test methods. • the applicability of the test methods and the discussion of the first measurement results. background: digital mammography is a new imaging modality for mammographic applications. in order to assure sufficiently high quality standards, new test protocols had to be developed. a group of european medical physicists has cooperated under the coordination of the european breast cancer network and euref. the first publication is expected for october 2003. the (pre-released) version (aug. 2003), work in progress, has been evaluated on different full field digital mammography (ffdm) systems and is the basis of the present teaching session. procedure details: following systems were included: senographe 2000d (ge), senoscan (fischer), 5000ma (fuji), ac3 (fuji), embrace cr (agfa) and embrace dr (agfa). the tests as described in the protocol included direct performance tests, contrast detail analysis, patient dose measurements and physical measurements such as mtf and dqe. for these last measurements, acceptable and achievable levels have not yet been defined. the help of a service engineer was necessary in most systems to get access to raw data. the tests as proposed in the protocol could then be performed. contrast detail analysis is the most critical part and should be automated to reduce interobserver variability. patient doses were comparable or lower than doses in conventional mammography. the acquisition of mtf and dqe requires a further standardization of the method. the digital addendum in its current phase was applicable to all systems tested so far. practical experience is growing and will add to the applicability and value of the document. anisotropic resolution in helical cone-beam ct reconstruction d. heuscher 1 , s. utrup 1 , f. noo 2 ; 1 highland heights, oh/us, 2 salt lake city, ut/us learning objectives: to describe how the different aspects of helical cone-beam reconstruction affect spatial resolution in all three dimensions. to demonstrate that depending on the radial and angular position of a voxel, this resolution can be anisotropic. to describe appropriate filtering and interpolation steps that can be taken to reduce these effects. background: a number of methods have been described recently that provide either exact or near-exact reconstructions of helical cone-beam scan data. in this exhibit, we will describe key aspects of the implementation of these reconstruction algorithms that affect spatial resolution. we will show how the anisotropy of in-plane resolution can be related to the corresponding effect in single-slice 2d reconstructions. alternative filtering and interpolation steps will be suggested. procedure details: fwhm slice-sensitivity profile and in-plane resolution measurements were performed on helical reconstructions of a phantom consisting of seventeen 0.25 mm diameter spherical beads located at 0, 100, and 200 mm radii. the scans used an mx8000-idt 16 x .75 mm detector configuration with a 1.25 pitch factor. single-slice 2d reconstructions were performed on the same phantom using both fan and parallel convolution-backprojection algorithms to produce comparative in-plane measurements. alternative hi-order interpolation and voxel-dependent filters were investigated to produce nearly isotropic resolution. conclusion: significant spatial variation in resolution can be observed in exact or near-exact helical cone-beam reconstructions. a more uniform and isotropic result can be achieved by using hi-order interpolation to produce parallel projection data along with longitudinal voxel-dependent filtering. comparison in pet/ct studies iv contrast agents increased the suv of the mediastinum to 2.5 (0.5) and the liver to 2.8 (0.6). these increases in suv were coincident with changes in ct density from 30 hu to 156 hu (mediastinum) and from 52 hu to 97 hu (liver). suv values in the colon wall seem unaffected by positive oral contrast compared to pet: 1.5 (0.4) vs 1.3 (0.2). conclusions: physiologic suv from pet/ct appear somewhat higher than suv from standard pet when the ct is acquired with standard volumes of iv contrast media. adventures in non medical radiography a.a. alhajeri, d. mckenna, b. tuohy, c. roche, p. mccarthy; galway/ie learning objectives: to demonstrate the non-radiological use of familiar imaging modalities and show how far we have come since the first x-rays of mrs. roentgen's hand. background: today, x-rays technology has a wide application and is presently in use in fields as diverse as engineering, art, forensic pathology and security. procedure details: through a pictorial review we show how x-rays have a role in non-medical applications. we demonstrate how law enforcement agencies have adapted x-ray technology to screen luggage at airports, sometimes even using ct. furthermore newer technology in use in europe has been developed, termed "back scatter", which makes possible the detection of illegal immigrants and contraband material concealed within trucks. the characterisation of the bony skeleton with the aid of x-rays is not only helpful in identification but sometimes can also indicate to the forensic pathologist the mode of death. industrial engineers are able to evaluate the integrity of a structure with the aid of x-rays. examples include the examination of airplane engines and pipes for hairline fractures, unidentifiable to the unaided eye. in the art world, x-rays have been used to detect forgeries and even to create original art works. conclusions: this poster reaffirms the benefits of different imaging modalities showing how technology developed for medical imaging has been adapted for use in non-medical areas. radiation-induced temporary hair loss after cerebral perfusion studies with multi-detector ct y. imanishi, a. fukui, h. niimi, s. nakaji, k. nozaki, y. furuya, m. uzura, s. hashizume, y. nakajima; kawasaki/jp learning objectives: learning presence of complications by a cumulative or multiplier effect of radiation exposure from multiple diagnostic techniques. background: as various imaging technologies become increasingly advanced, they make it possible to get various kinds of information and large amount of imaging data. in some imaging technologies, the radiation dose increases with the ability to obtain better images or more detailed information. imaging findings: we encountered 3 cases of temporary bandage-shaped hair loss, which was caused by perfusion studies of the head by multi-detector computed tomography (mdct) for evaluation of blood flow in the brain. in all of the 3, digital subtraction angiography of the head was performed within a period of the ct perfusion studies. this suggested the possibility that radiation exposure from angiography performed in serial examinations, combined with the perfusion studies effectiveness of a new dual-energy subtraction system using csi:tl amorphous silicon flat-panel technology h. tagashira, n. bandai, m. yoshimoto, y. yasuhara; ehime/jp learning objectives: to describe the theory of the new dual-energy subtraction system. to demonstrate the system with chest radiology cases. background: lung cancer is the current leading cause of cancer death and continues to be increasing. chest radiography has been shown to have relatively low sensitivity and specificity for the detection of the pulmonary nodules. this new dual-energy subtraction system allows the fast (200 millisecond) acquisition of two, high and low voltage images and provides soft tissue and bone structure image of the chest with relatively low dose. procedure details: the radiologists' performance for reporting chest radiographs was evaluated by use of receiver operating characteristic (roc) analysis. the performance of radiologists was improved significantly when the dual-energy subtraction image was used (p < 0.01). conclusion: diagnostic accuracy will be improved by using this dual-energy subtraction system. longitudinal filters for uniform cone-beam resolution d. heuscher, s. utrup; highland heights, oh/us purpose: this presentation demonstrates the non-uniform longitudinal resolution inherent in today's cone-beam reconstructions and how, through the appropriate use of longitudinal filtering, improvements in image quality can be achieved. simulations and scans for acquisition geometries of 16 or more detector rows were evaluated. a circular half-scan (hs) and a helical scan (pitch factor 1.25) were performed on an mx8000idt using a 16x.75 mm detector configuration. a phantom consisting of 17 steel beads was used to measure longitudinal resolution at 8 angles and 3 radii. simulations were performed using the same phantom geometry, including a 32x.75 mm helical scan. a voxel-dependent filter was used to achieve uniform longitudinal resolution and compared to projectionbased filtering. both real and simulated thorax phantoms were used to evaluate the effects on image quality. results: resolution measurements demonstrate an angular variation in longitudinal resolution for large-pitch helical and circular hs cone-beam scans. the fwhm ssp measurements varied by over 15% and 25% at 100 and 200 mm radii respectively. reconstructions with projection-based filters did not reduce this variation. similar results were observed for helical scans with the larger cone angle (32 x .75 mm detectors), wherein the resolution pattern varied at half the frequency along the longitudinal direction. applying voxel-dependent longitudinal filtration achieved uniform resolution, demonstrating improved image quality in both real and simulated scans. conclusion: there is an inherent non-uniformity of longitudinal resolution for cone-beam scans, particularly for large-pitch helical and circular half-scans. uniform resolution can be achieved using voxel-dependent filters. potential of phase contrast in x-ray imaging p. monnin 1 , r. meuli 1 , j. hoszowska 2 , j.-f. valley 1 , f.r. verdun 1 ; 1 lausanne/ch, 2 grenoble/fr purpose: one of the limitations of conventional radiology is that small or weakly absorbing structures cannot be detected on images. coherent properties of an x-ray beam produce phase contrast images where a change of the refraction index of tissues translates into an edge enhancement phenomena on the images that allows the detection of weakly contrasted structures. this study shows the feasibility of implementing the in-line holography principle with an aim to imaging very small structures. material and methods: phase-contrast images were obtained using synchrotron radiations at esrf (grenoble, france). images of 20 to 100 micrometer nylon wires, immersed in different media, were recorded with a ccd camera (1.8 micrometers pixel size) in different imaging conditions. images were compared with the results obtained by means of fresnel diffraction theory. the coherent x-ray beam and the defocusing distance between the structures to be imaged and the detector produced phase contrast images of the wires. the comparison of the recorded images with the predicted image formation from the fresnel diffraction theory revealed the performance of this technique in terms of sensitivity, geometrical and energy requirements. images of a biological sample (i.e. pork kidney, cam's) were also produced where very fine low contrast structures, unnoticed in pure absorption contrast, appeared. the potential of the technique in neo-vascular process imaging will also be discussed. the potential of in-line holography techniques to improve image contrast of biological tissues has been demonstrated. experimental the aim of the present study was to evaluate y3al5o12:ce (yag:ce) phosphor for radiographic and mammographic imaging. yag:ce, which has never been previously used in diagnostic radiology, emits green light with very short decay time (70 ns). it is expected to match the spectral sensitivities of most photodetectors. radiographic test screens of various coating thickness (13-166 mg/cm 2 ) were prepared in laboratory employing yag:ce phosphor in powder form with 8.0 µm median grain size. luminescence emission efficiency (emitted light over x-ray exposure) and light emission spectrum were experimentally evaluated as a function of x-ray tube voltage employing both tungsten and molybdenum target x-ray tubes. in addition, the spectral compatibility of yag:ce emission spectrum with orthochromatic films, photocathodes, ccd arrays and amorphous silicon photodiodes, used in both conventional and digital radiography, was determined. results were compared with other phosphor materials (gd2-o-2s:tb, csi:tl) currently employed in medical imaging. results: maximum yag:ce emission efficiency was observed for 107 mg/cm 2 screen at 40-50 kv using tungsten target x-ray tube. emission spectra peaked at 553 nm. the spectral compatibility with amorphous silicon photodiodes (0.937) and ccds (0.951) was found to be very high, better than the corresponding compatibility of csi:tl, as mostly used in digital radiography detectors currently. conclusion: considering the yag:ce performance, its short emission decay time and its spectral compatibility with amorphous silicon detectors and ccds, this phosphor material is appropriate for use with digital radiography detectors. b d e f a g reduction of eddy current artifacts in echo planar diffusion tensor imaging with a stimulated echo preparation g. steidle, f. schick; tübingen/de purpose: diffusion-tensor-imaging (dti) using se-epi in tissue with short t2 values, such as kidney or skeletal muscle, suffers from a poor snr for higher bvalues. using a stimulated-echo diffusion preparation, sufficiently high b-values can be obtained by increasing the mixing time (tm) rather than te. a diffusionweighted stimulated-echo epi sequence is proposed which minimizes the influence of eddy currents (ec) without any increase in the minimum te or acquisition time. methods and materials: assuming a monoexponential decay for the ec with time constant λ, gradient pulses can be implemented within the tm interval such that eddy current effects proportional to exp (-λ x t) will vanish. in-vivo dti measurements were performed in human calf musculature on a 1.5 t siemens sonata unit. measurement parameters were te = 37 ms, tm = 100 ms, tr = 4000 ms, b = 0 resp. 500 s/mm 2 , matrix 64 x 64, fov 200 mm, nex = 4, slice thickness 8 mm. diffusion weighting was applied in six directions in order to calculate the diffusion tensor. results: diffusion images were acquired with and without ec correction. images without ec correction showed obvious scaling and shearing distorsions whereas in images obtained with ec correction no significant distorsions were observed. conclusion: diffusion-weighted mr imaging using epi is very sensitive to image distorsions caused by eddy currents. inserting additional gradient waveforms in a stimulated-echo epi sequence drastically reduces these artifacts and allows a calculation of the diffusion tensor in various tissues with low t2/t1 ratios without significant misregistration. rf-induced artifacts due to aneurysm clips in mrt at 3.0 t u.a. lauer, h. graf, f. schick, c.d. claussen; tübingen/de purpose: metallic implants such as aneurysm clips may cause enlarged artifacts at higher magnetic field strengths, not only due to susceptibility effects. aneurysm clips made of ti-alloy were investigated with special respect to mr-imaging results and possible rf-induced artifacts. materials and methods: 10 aneurysm clips were measured in gd-dtpa doped water at 1.5 t and 3.0 t with adapted se-sequences. additionally, two models made of copper were investigated at 3.0 t. to separate rf induced effects, the transmitter voltage was bisected stepwise to verify the rf-induced deviation of the local flip angle near to the implant. this was also done with 3d-tse sequences. results: in comparison to 1.5 t, more pronounced hyperintense zones were found at 3.0 t. they were independent of the exchange of phase-and frequency-encoding direction (swap) and became more pronounced at reduced transmitter voltage. comparative investigation of two cu-models and one selected ti clip at reduced transmitter voltage revealed rf induced effects depending on inductive and capacitive structures of the clip. conclusion: metallic implants have to be considered carefully at 3.0 t due to the electrical conductivity. rf-induced artifacts can appear not only for longish objects but also on smaller devices. in the case of aneurysm clips, a slight rfinduced effect could be detected. potential patient endangering due to a local enhancement of the secific absorption rate (sar) can be estimated as negligible. optimum is currently recommended as a consistent image display function. however, while the cielab function is still in use in europe, comparative evaluation of these two functions for optimum display function has not yet been reported. the purpose of the present study was to identify which of gsdf and cielab is the optimum display function for thoracic ct imaging by means of visual contrast analysis (vci), i.e. the ratio of luminance contrast to ct value contrast. methods and materials: monochromatic 1m lcd monitor and photometer of luminance calibration tool kit (data ray corp, westminster, usa) were used. the luminance contrast of this monitor was measured by a photometer displaying gsdf and cielab. luminance change and digital driving level (ddl) that corresponded to ct value (hu) were tabulated. ct value was represented by window setting of thoracic ct imaging, i.e. for mediastinum (ww:150~350, wl:30) and lung (ww:1400~2000, wl:-500) using gsdf and cielab. the ratio of luminance contrast to ct value contrast was calculated as visual contrast index (vci). the vci of gsdf and cielab was evaluated using t-test. result: using t-test, vic of cielab was significantly higher than that of gsdf in window setting of thoracic ct imaging (p < 0.01). based on visual contrast index analysis, cielab was more useful than gsdf as a monitor display function of thoracic ct imaging. we suggest that cielab is the optimum monitor display function of thoracic ct imaging because it intrinsically has excellent luminance contrast characteristics. follow-up of patients subjected to high skin radiation dose as a consequence of repeated interventional cardiology procedures r. padovani, g. bernardi, e. quai, m. signor, h. toh; udine/it purpose: as part of a quality assurance program, to retrospectively evaluate cumulative skin dose (csd) received by patients subjected to repeated interventional coronary procedures and to detect radiation induced skin injuries in patients who have received the highest dose. materials and methods: from april 1998 to february 2002, 5039 cardiac procedures, coronary angiography (ca) and percutaneous transluminal coronary angioplasty (ptca) have been performed on 3332 patients. mean dap was 78.6 gycm 2 . patients with a cumulative dose-area product (dap) higher than 300 gycm 2 have been extracted. they were 78 patients (2.3%), 17 female and 61 male, mean age 71 years, who underwent a mean number of 4.5 procedures resulting in a mean cumulative dap of 335 gycm 2 and a maximum value of 995 gycm 2 . from dap, csd has been estimated adopting 4.3 and 8.7 10 -3 cm -1 as conversion factors for ca and ptca, respectively. clinical follow-up has been performed adopting the lent-soma methodology and scale. results: the highest csd estimated was 6.7 gy and only 25 patients (32%) exceed a skin dose of 3 gy. no skin injuries were detected at clinical follow-up. these results allow to estimate a frequency for skin injuries of less than 3.10 -4 in patients undergoing repeated cardiac procedures. the results of this study implies that the frequency of skin injuries may be very low when a quality assurance programme, including regular patient dose monitoring, periodic evaluation of procedure protocol, quality control of equipment and operator training, is established. ultrasound purpose: ultrasound is the most frequently used diagnostic imaging modality. the main problem of ultrasound, however, is interobserver variability. the intention of the development of ultrasound computer tomography was to increase the reliability of ultrasound imaging and to supply standardized images similar to other cross section imaging procedures. methods and materials: instead of a manually-controlled linear transducer array, we used ultrasound computer tomography (usct) to image a volume directly. a few thousand ultrasound transducers were arranged in a cylindrical array around a tank containing the object to be examined coupled by water. every single transducer was small enough to emit an almost spherical sound wave. while one transducer was transmitting all other transducers worked as receivers simultaneously. afterwards a different transducer emitted the next pulse. for volume reconstruction each transmitted, scattered and reflected signal was used. in an experimental set-up a phantom containing nylon filaments, straws, and a cadaveric forearm were investigated. results: nylon filaments with a diameter of 0.1 mm were visualized. the skin and soft tissue of the cadaveric forearm were clearly detectable but the bone structures could not be delineated sufficiently. usct supplied reproducible image sequences. conclusion: usct promises to supply standardized high quality three-dimensional images without ultrasound shadowing artifacts and without interobserver variability. furthermore, the tissue is not deformed, in principle offering multimodal image fusion with other cross section imaging modalities. prior to clinical set up extended development especially of large transducer element tubes and improvement of software is necessary. multicentre assessment of a complexity index for ptca procedure a. peterzol 1 , e. quai 1 , r. padovani 1 , g. bernardi 1 , j. kotre 2 , a. dowling 3 ; 1 udine/it, 2 newcastle/uk, 3 dublin/ie purpose: multicentre assessment of a procedure-severity-based complexity index (ci) for the introduction of reference levels (rls) in percutaneous transluminal coronary angioplasties (ptca) as a function of procedure complexity. materials and methods: 204, 75 and 104 ptcas performed at three different centres were investigated. multiple linear stepwise regression analysis, including clinical, anatomic, and technical factors, was performed in order to obtain fluoroscopy time (ft) predictors. based on the regression coefficients of the emerging model a scoring system was defined, and a ci was obtained by adding up the single scores for each individual procedure. since a good correlation (r = 0.41; p < 0.001) was found between the dose-area product (dap) and the resulting ci, the latter was used to classify dose values into three groups. ci groups were determined by means of an anova test: different sets of groups were explored until the matrix of pairwise comparison probabilities reached a minimum value (p < 0.001). the resulting dap and ft third quartiles corresponding to each ci group are suggested as preliminary rls in ptca as a function of procedure complexity. results: ptca preliminary rls: (i) for dap values: 54, 76 and 127 gycm 2 , and (ii) for ft: 12, 20 and 27 min, respectively for the three ci groups: low, medium and high complex procedures. the possibility to introduce rls as a function of procedure complexity, as confirmed by this multicentre study, can improve the process of patient dose optimisation in interventional cardiology. investigation of the radiation detection properties of lu2sio5:ce and gd2o2s scintillators for applications in medical imaging d. nikolopoulos, p. liaparinos, d. margetis, d. linardatos, p. mellisaropoulos, k. kourkoutas, g. panayiotakis, d. cavouras, i. kandarakis; athens/gr purpose: the aim of this study was to use monte marlo techniques to examine the detection efficiency of three ce-doped fast emitting scintillators, yap (yalo3: ce), lso (lu2sio5:ce) and gos (gd2o2s:pr, ce, f) when used with photon energies and coating thicknesses employed in medical imaging. a general monte carlo code has been generated for tracking photons in the energy range covering all medical imaging applications (diagnostic radiology, nuclear medicine). simulated scintillator materials were selected to be in blocks and arrays of dimensions equal to those usually employed in medical imaging. the results for the yap scintillator, showed that the fraction of the incident photon energy which was totally absorbed decreases very rapidly for energies higher than 80 kev (e.g. from 65% at 100 kev to 10% at 511 kev for 0.01 mm coating thickness). lso was better than yap, its absorption efficiency being significantly higher (p < 0.001) at 20-25 kev (mammography), 60-100 kev (x-ray imaging), 140 kev (gamma ray imaging) and at 511 kev (positron imaging). gos was also found to exhibit significant detection efficiency in the whole energy range examined (e.g. from 100% at 10 kev to 98% at 100 kev for 0.01 mm coating thickness), however its applications are limited due to its longer decay time. conclusion: lso was found to be of adequate efficiency for most imaging applications, while yap could be considered most suitable for x-ray mammography applications. analyses of physiological kinetic functions in dynamic chest radiography by the use of time series spectroscopy y. tsuchiya 1 , y. kodera 2 , m. tsuchiya 1 , a. fukui 1 , s. itou 1 , y. machida 2 ; 1 shizuoka/jp, 2 nagoya/jp purpose: the purpose of this study was to distinguish between movement of diaphragm and heart wall, and to evaluate the kinetic function of these structures in dynamic chest radiography with computer aided diagnoses. we obtained a dynamic chest radiograph of one healthy volunteer during respiration to assess the distinction between structures and another radiograph of a patient during a left ventriculogram to evaluate heartbeat calculation using an image intensifier system. we performed fft and band pass filter processing to obtain an intensity curve of the spectrum of dynamic chest radiography and detected the "change-point" of the phase by using characteristic analysis. fifty-five kinds of band pass filters were used to compare "detection rate of change-point", "matching rate of heartbeat" and "heartbeat error". results: movement of diaphragm and heart wall could be extracted selectively by the use of an extreme low pass filter (0.0~0.03 cycle/mm) and middle frequency pass filter (1.4~2.2 cycle/mm). we obtained 100% of matching rate, when detection rate was 100% with these two kinds of filters. there was correlation significantly between them (r = 0.779, p < 0.05). improvement of detection rate decreased heartbeat error. but there was no significant difference between them by the non-repeated measures anova (p = 1.061). conclusion: our method was effective in analysing the dynamic chest radiograph in order to evaluate precise kinetic function, when suitable filters were used. therefore it is expected to apply for computer-aided diagnoses. reduction of ionising radiation exposure in patients as a consequence of new imaging technology for medical diagnostics of the spine: a retrospective study covering 20 years in a norwegian referral hospital a. nyquist 1 , h. olerud 2 , b. bjørnarå 1 , l. borgen 1 , t. gudmundsen 1 ; 1 drammen/no, 2 oslo/no purpose: to examine possible changes in ionising radiation doses to patients (collective effective dose) undergoing diagnostic imaging procedures for spinal problems over the last 20 years in view of the shift in modalities from conventional x-ray examination and myelography to computed tomography (ct) and later on to magnetic resonance imaging (mri). retrospective study of all patient files for the period from 1983 to 2002. the main modality groups for each of the three parts of the spine (cervical, thoracal, lumbar) were: conventional radiographs, myelography, ct, and mri. for each type of examination the mean effective radiation dose were obtained from the norwegian radiation protection authority (nrpa) as published in 1997. the number of conventional x-ray examinations performed was nearly unchanged. use of myelography reduced by 50%, 100%, and 95% for the cervical, thoracal and lumbar regions, respectively. ct usage increased steadily, remained nearly unchanged, and was reduced by nearly 90% for the cervical, thoracal, and lumbar regions, respectively. the annual collective effective dose from examinations the spine was reduced by 48% in our hospital from 6.1 mansv in 1983 to 3.2 mansv in 2002. the shift in modalities from conventional x-ray and myelography to ct and mri resulted in a significant reduction in patient exposure to ionising radiation. the results may be explained by our intended policy to select mri insted of ct whenever possible, and is an overture to the discussion of the further development and structure of diagnostic imaging in general, and for the spine in particular. dose evaluation for clinical proton beam with standard dosimetry 01 h. ohtani 1 , t. hiraoka 2 , h. saitoh 1 , t. irifune 1 , t. katoh 1 ; 1 tokyo/jp, 2 chiba/jp purpose: the standard dosimetry was revised on august 2002 in japan; it had calling standard dosimetry of absorbed dose in external beam radiotherapy (standard dosimetry 01). the purpose of standard dosimetry 01 are the establishment of traceability for dose of radiotherapy and quality assurance / quality control, according as we measure the dose of high-energy radiation using the standardized international method. we explained the dosimetry of absorbed dose with the standard dosimetry 01 for proton beams and the depth dose was measured with the reference ionization chamber and the parallel plate ionization chamber. the maximum energy of the proton beam used in this study was 70 mev. electric separation induced radicals were calibrated for squarer field of 3×3 cm 2 with some ionization chambers. the absorbed dose to water calibration factor is obtained by the reference ionization chamber calibrated 60 co gamma rays. the remainder range in water calibrated the beam quality conversion factor for proton beam. using these coefficients, the absorbed dose was calibrated. the absorbed dose used the parallel plate ionization chamber was relatively decided by the results for the reference ionization chamber. conclusion: the absorbed dose for proton beam was calibrated at each depth. dosimetry in water was recommended on the standard dosimetry 01. however, it is difficult that we have the waterproof dosimeter. we suggested that the method and problem for proton dosimetry using the standard dosimetry 01. 520 b d e f a g kinetic analysis of the temporomandibular joint with computer-aided detection system n. bandai 1 , s. sanada 2 , k. ueki 2 , s. funabasama 2 , s. tsuduki 3 , y. otani 2 , t. matsui 2 ; 1 onsen-gun/jp, 2 kanazawa/jp, 3 otsu/jp purpose: the purpose of this study was to develop a method of kinetic radiography and a computer-aided detection (cad) system for quantitative evaluation of the temporomandibular joint (tmj). methods and materials: dynamic images of the tmj were obtained from one healthy volunteer by digital fluoroscopy in the lateral view on the right and left sides. the accumulated image subtraction technique extracted the condyle in each image. a sequential similarity detection algorithm (ssda) was employed to trace the movement path and the velocity of the condyle. results: there were no significant differences between by manual and computer analysis. the shape of the path of the right condyle was smoother than that of the left condyle. the size of the maximum vertical and horizontal movements of the condyle were 4.6 ± 0.1 mm and 15.0 ± 0.2 mm, respectively. the velocity of the movement of the condyle was higher in the area close to the articular eminence than in any other area during the opening and closing of the mouth. conclusion: our cad system will contribute to the kinetic analysis of the tmj for screening, follow-up study, and informed consent, providing speed, quantitation, and cost-effectiveness. assessment of fetal dose in x-ray examinations of pregnant patients a.j. servomaa 1 , a. kettunen 2 ; 1 helsinki/fi, 2 oulu/fi purpose: when a pregnant woman undergoes examination of the lower abdomen or pelvic area, the fetus is directly irradiated. determination of the absorbed dose to the fetus is therefore of interest as a basis for risk estimates. in finland, the practice with regard to both estimation of the dose to the fetus and recording of the examination in patient records varies considerably. the fetal dose calculated by means of various dose calculation methods are compared and the results presented. methods and materials: using the "fetdose" and "pcxmc" programs, the normalized fetal dose was calculated for abdominal and pelvic examinations of various radiation qualities, esd and conceptus depths. the doses obtained were compared against those reported in the literature. the calculated nuds (normalized uterus doses) obtained for various parameters by means of various calculation methods agree, with reasonable accuracy. the nud occurring in a pelvic ap examination (80 kv, 3 mmal filtration, fsd 80 cm) is about 0.40 for a gestational age of 0-7 weeks and for a fetal depth of 8 cm. the dose to the ovaries differs slightly from the dose occurring to the uterus during the same examination. detailed data about the nuds in various common radiography examinations are presented. the results of calculations obtained with different programs show the same nud with reasonable accuracy. normalized fetal doses and radiation risks corresponding to the european esd recommendations in conventional radiography examinations may help the radiological staff to assess the significance of the exposure to the fetus. withdrawn by authors quality advances via noise reduction in laser imaging t.r. lindquist; oakdale, mn/us purpose: noise sources in medical imaging and printing can limit diagnostic accuracy but are often not assessed quantitatively. a method is described for objectively quantifying noise by means of a film digitizer and analysis software. a second method, based on human perception of simulated nodules on films with varying amounts of noise, is also described. in the first method, a film digitizer scans a print of a constant gray level image. the scanned digital image file is then processed by software that: (1) extracts and averages density data from narrow horizontal and vertical strips, and (2) performs one-dimensional fast fourier transform (fft) processing to yield a noise power spectrum (nps) for each horizontal or vertical strip. in the second method, a computer program is used to synthesize a test image with very low contrast dots ("nodules") superimposed on a gradually changing background. in timed experiments, prints of these images are placed on a light box, and an observer is asked to mark the locations where the dots are believed to be present, after which the true and false positives are counted. results: prints were made on a variety of medical imagers, using film with a variety of quality levels. prints made with the latest laser imager and film yielded lower measured noise and higher perception scores than prints made with prior technology. conclusion: measurable progress has been made in reducing the noise level of medical imaging printers. this is further demonstrated by improved perception of subtle details. estimation of maximum skin dose and average lung dose in coronary angiography procedures a. karambatsakidou, p. tornvall, n. saleh, p.-o. löfberg, a. fransson; stockholm/se purpose: a comparison of phantom and patient based techniques to estimate the maximum skin dose (mesd) and average lung dose from coronary angiography procedure is described. conversion factors for the dose to the skin and lung, normalized to the dose-area-product (dap), have previously been obtained from measurements using an alderson phantom. in this study, measurements on patients using slow radiographic film and diodes were used in combination with the software winods to evaluate the impact of different operators, and of variations in patient size, on these factors. the transmission ion chamber integrated into the angiographic unit was used to measure dap. the conversion factor for mesd from the phantom simulation was reported as 3.8 msv/gycm 2 . the corresponding value for measurements on patients in this study was 3.7 ± 0.7 msv/gycm 2 (1 sd; 18 patients). no significant difference in conversion factor between the operators was found. the lung dose varied with the body mass index (bmi). in slightly overweight patients (bmi: 27-30), the lung dose was about 16% lower than in normal sized patients (bmi:19-26) for the same dap-value, while for overweight patients (bmi > 30) this difference increased to 24%. conclusion: measurements on phantoms and on patients yield similar conversion factors for mesd in coronary angiography procedures. the bmi-value seems to be a robust indicator of the variation in dose to internal organs from such procedures. with film/diode measurements, the differences in techniques (geometry; projections) between operators can be easily verified, and as such be integrated into the training of new angiography operators. radiation doses in a newly installed flat-panel digital system in interventional cardiology department v. tsapaki, s. kottou, n. kollaros, p. dafnomili, v. neofotistou; athens/gr purpose:the purpose of the study was to investigate the radiation doses of the newly installed flat-panel fluoroscopy (fpf) system in an interventional cardiology (ic) department and to examine possible methods of technique optimization regarding the new digital system. materials and methods: fifty coronary angiographies (cas) and 50 percutaneous transluminal coronary angioplasties (ptcas) were investigated. patient data were: sex, age, weight, height, dose area product (dap), fluoroscopy time (t) and total number of frames (f). further more, dose rates in all fluoroscopic and cine modes were measured. image quality was assessed using a dedicated test tool. results: median values of dap, t and f were: 27.7 gycm 2 , 4.1 min and 876 in ca and 51.1 gycm 2 , 12.7 min, 1184 in ptca. our results are comparable with those found in the recent literature. regarding the technical characteristics of the digital system, the high contrast resolution (hcr) is not affected by fluoroscopic mode, whereas low contrast resolution (lcr) is slightly decreased in the lowest mode. the results of the study concerning the fpf system lead to the conclusion that the lowest fluoroscopic mode and the lowest frame rate should be used routinely for dose optimization and that the new digital technology has comparable radiation dose to the conventional technology. purpose: an earlier study using the mte scanner enabled us to register in vivo wave-like activity of the skin electrical landscape (sel), which is supposedly macroscopic manifestation of intercellular communication. the present study of the chaotic sel activity was done to try to find out distinctive dynamic features between melanoma and adjacent tissues. methods and materials: mte is a new functional, non-invasive digital imaging modality, which enables dynamic visualization of the skin and underlying tissues in terms of spectral electroimpedance and electropotential parameters, with high spatial and temporal resolution (~ 0.5 mm). non-thermal mm-emf (4 min) and weak mf (< 0.001 t) were used as test influences. initial and induced sel dynamics have been graphically and statistically analyzed. specifically, the throughimage-sequence analysis resulted in detailed dispersion maps of the scan-area. the sels of (i) healthy and allergic subjects, and (ii) those with cutaneous melanoma were investigated. results: primary melanoma manifested not only as a sharp electro-abnormality, but also as a distinctly stable/hyposensitive zone (sigma = 0.0 -1.0%) in all measurement parameters.this hyposensitive zone(s) was surrounded by islet areas of marked hypersensitivity (sigma is up to 50%). dispersion range of the more distant environment had intermediate values. in cases of allergy, strongly pronounced dependence of the mm-emf response upon time of investigation was observed at the same subject, i.e.: from sharply marked reactions at the stage of sensitization to practically indistinguishable ones during remission. in healthy subjects, in most cases, significant trigger reversible changes of histograms were registered in response to both tests. intracranial elastance analysis using mri in normal-pressure hydrocephalus t. miyati 1 , m. mase 2 , m. onoguchi 1 , h. kasai 2 , m. hara 2 , k. yamada 2 , y. shibamoto 2 , s. matsunaga 1 , t. kasuga 1 ; 1 kanazawa/jp, 2 nagoya/jp purpose: in order to assess the state and dynamics of the intracranial system in normal-pressure hydrocephalus (nph), intracranial elastance (ice) was measured with magnetic resonance imaging (mri). the ice index, which is the ratio of pressure to volume change, was obtained with alperin's method; intracranial volume and pressure changes during the cardiac cycle were calculated from the net transcranial blood and cerebrospinal fluid (csf) flow measured with phase-contrast (pc) cine mri. ice indices were determined in patients (n = 13) with nph, brain atrophy or asymptomatic ventricular dilation (vd), and in healthy volunteers (control group; n = 11). concurrently, a time constant of the integral of the csf response function, which represents the intracranial mechanical property was determined with pc cine mri. the changes in ice indices were also analyzed after intravenous injection of acetazolamide. these values were then compared with the volume-pressure response (vpr) during the shunt operations. results: the ice index in the nph group was significantly higher than in the control or vd group, but no difference was found between the control and vd groups. the ice index increased in all groups after an acetazolamide injection because of an increase in cerebral blood volume. there were significant correlations between the ice index and the time constant. a positive correlation was noted between the ice index and the vpr. conclusion: ice analysis measured by pc cine mri makes it possible to noninvasively obtain a detailed assessment of intracranial state and dynamics in the nph and to assist in diagnosis of the nph. quantification of magnetization transfer by sampling the transient signal using mt-prepared single-shot epi g. helms 1 , g.e. hagberg 2 , c.d. claussen 1 , f. schick 1 ; 1 tübingen/de, 2 rome/it purpose: using trains of mt-pulse and epi readout, the transition to steady state can be measured with higher accuracy than the steady state. a novel quantification method based on sampling transitions at different repetition periods (pr) is introduced. gaussian mt-pulses of 6.4 ms duration and flip angle of 720 degrees were repetitively applied at 1 khz offset at pr = 8, 16, 26, 100, 200 ms. an axial slice through the centrum semiovale of the brain was measured by single-shot se-epi (50 ms te, 5 mm thickness, 20 cm fov, 64 x 64 matrix). in brain tissue, the signal dependence was described by analogy to progressive partial saturation, where the direct saturation is increased by pr-dependent mtcontribution proportional to macromolecular content and differential saturation. macromolecular content, kinetic and relaxation parameters and the saturation were estimated by a global non-linear least-square fit of the signal equation for rois in cortical grey matter (gm) and central white matter (wm). results: the macromolecular content was (15.6 ± 0.6)% in wm and (9.5 ± 0.6)% in gm, the apparent relaxation rates (0.92 ± 0.2) 1/s and (0.70 ± 0.05) 1/s. the apparent transfer rates were (30.1 ± 0.7) 1/s and (23.4 ± 2.8) 1/s. macromolecular saturation of a single mt-pulse was (38.2 ± 0.1)% in wm and (40.0 ± 3.2) in gm; the direct effect on water less than 1%. signal correction for csf contributions was necessary. conclusion: quantitative mt-mapping of the whole brain may become feasible in vivo at higher field strengths by means of permutation of the slice order. 522 b d e f a g the concept of radiography in health sciences: a concept analysis s. sorppanen 1 , a. servomaa 2 ; 1 oulu/fi, 2 helsinki/fi learning objectives: to clarify the content and uses of the concept of radiography in health sciences and to compare it to the concept of radiography in physics and technology. background: in the field of radiography, theoretical research related to concepts has so far being rare. nevertheless, the concept development is an important part in constructing theories and clarifying the identity of a discipline. in finland, the discipline of radiography started in 1999 at the university of oulu, and since then it has offered radiographers academic education in their own field. for being able to build its own knowledge base and theories to be used in developing the profession and education of radiographer, and for being able to stand for its position as an independent academic discipline, the young discipline of radiography needs systematic conceptual clarification and development. procedure details: the concept of radiography was analysed using so-called evolutionary method of concept analysis (presented by rodgers). the contents and uses of the concept were studied by determining the concept's characteristics and by observing these characteristics in the cross-disciplinary comparison. the data consisted of literature and internet pages, and were analysed using deductive-inductive content analysis. conclusion: the concept of "radiography" in health sciences can be determined as "dual, dynamic, social and situation-related expertise of radiographers in the use of radiation, which is based on a versatile synthesis". it seems to be wide and complex in nature, and radiographer-centered. the content and the use of the concept varies according to the discipline. measurement of distribution of horizontal dose amount to chest x-ray by gafchromic film k. nishikiori 1 , m. miyazawa 2 , a. otonashi 3 ; 1 habikino/jp, 2 itabashiku/jp, 3 suita/jp learning objectives: to illustrate horizontal dose distributions of human diagnostic level in the chest phantom by gafchromic film and glass dosimeters. to point out the characteristics of horizontal dose distributions by materials in ten shots and in fluoroscopy. background: in general, we use an ionization chamber dosimeter or tld to measure dose distribution of diagnostic level. however tld can not indicate horizontal and consecutive dose distributions, because it has only scattered dose data. consequently, we used gafchromic film to obtain a horizontal consecutive dose distribution of human diagnostic level. imaging findings: 1. first, we placed a gafchromic film and glass dosimeters in the specific place of the chest phantom. then we irradiated the chest phantom with diagnostic level x-rays. the dose distribution which was acquired by the film and glass dosimeters was then analyzed. 2. next, we examined the result of fluoroscopy. 3. the results of the first method were compared with the result of the fluoroscopy and the difference between the distributions in 1 (gafchromic film and glass dosimeters) and 2 (fluoroscopy) examined. the characteristic dose distributions of the incidence dose in diagnostic level were confirmed by both horizontal dose distributions. 1. horizontal dose distribution which was specific and consecutive data could be obtained from the gafchromic film. 2. horizontal dose distribution which was specific and scattered data could be acquired by glass dosimeters. we obtained almost the same as results in fluoroscopy. horizontal dose distribution of fluoroscopy showed a sharp reduction on the subcutaneous tissue of the chest phantom. barium enemas: are radiographers up to it? p. vora, a. chapman; leeds/uk aim: to determine the types and rates of complications encountered by radiographers when performing double contrast barium enemas. a similar complication rate to those encountered by radiologists will reassure those who have adopted this new skill mix and encourage its further development whereas an increase in complications may point to areas where radiographer training needs to be improved. materials and methods: 741 questionnaires were posted to radiographers who had in the last 5 years attended one of the biannual leeds barium enema training courses. results: of 741 questionnaires posted 407 (54.9%) were returned completed. approximately, 348,433 barium enema examinations had been performed. 59 radiographers reported 87 complications, including 13 intraperitoneal and 11 extraperitoneal perforations. there were five deaths (mortality rate -1 in 69,687). the five deaths included two of the twenty-four (10%) perforations, two of the forty-five (5%) cardiac events and one cva that occurred during an examination. conclusions: radiographers have been regularly performing dcbes for almost a decade. the mortality rate for radiographer performed double contrast barium enemas is similar to that reported for radiologists. a slightly higher than expected rate of perforation is noted in this study and so this is an area where radiographer training should be targeted. the level and incidence of the fear in patients subjected to radiological examinations e. czekajska-chehab, m. makara-studzinska, a. koczynasz, i. nowak, a. drop; lublin/pl purpose: analysis of incidence and intensity of fear in patients subjected to diagnostic procedures. methods: an anonymous survey concerning the occurrence and level of fear connected with radiological examinations was conducted among 320 individuals: 170 patients attending for various contrast examinations and 150 women before mammography, using the questionnaire prepared by the authors. the level of fear was evaluated according to the adopted scale in relation to the obtainable maximum values. results: 252 out of 320 individuals (79%) reported their fears before planned radiological examinations. the frequency of fear was extremely high for mammography (98%) and lower for contrast procedures (61%). the strongest fear was associated with the uncertainty of diagnosis and length of waiting for results (86-94%). the fears of patients before contrast examinations were mostly related to results and harmful effects of radiation. the fears concerning allergic reactions were reported by almost a half of patients before ct, urography and barium enema. in patients before contrast procedures the highest fear level was related to the uncertainty of results (77-86%). the lower level (45%) was associated only with urography. the fears about the examination itself, allergic reactions or harmful effects of radiation showed similar intensity (52-79%), irrespective of the kind of examination. conclusions: fears before radiological examinations are common and concern over a half of patients subjected to contrast procedures and almost all of those before mammography. the most common causes of fear include: uncertainty about diagnosis, exposure to harmful effects of radiation and length of waiting for results. audit of adequacy of inpatient ct requests: implications and consequences w. chooi, p. heath, m.j. bull; sheffield/uk purpose: vetting of ct requests ensure that the examination is justified in accordance to local guidelines and also allow the radiologist to select the most appropriate ct protocol. however the provision of poor clinical information severely limits this step. this audit aims to determine the prevalence of inadequate clinical details in ct request forms and also identify trends that result in poor referring technique. methods and materials: for a two week period all inpatient electronically generated ct request were prospectively monitored. outpatient & out-of-hour requests were excluded. results: out of a total of 126 requests, 102 were successfully audited (81%). the types of examinations included ct head 63 (62%), abdomen 19 (19%), thorax 13 (13%), abdomen and thorax 2 (2%), and musculoskeletal 2 (2%). problems were encountered with 39 requests (38%). the most common problem encountered was that of inadequate or misleading information (n = 20). others issues included better alternative examination (n = 2), undisclosed renal impairment (n = 4), failed examinations due to agitated patients (n = 2), ward cancellations (n = 4), requests without contact details (n = 7), and wrong ward details (n = 5). as a result 20 of these requests were not performed. the majority of these requests are completed by junior doctors. conclusion: vetting of ct requests is an essential first step towards a successful ct examination. the provision of inadequate clinical information is prevalent and junior doctors require closer supervision when completing ct requests. to determinate whether use of high iodine concentration contrast medium offers more complete information. diagnosis and follow-up of aortic dissection with multislice computed tomography y. herrero, m. martí, j. echeveste, m. fernández-velilla, g. garzón, n. gómez-león; madrid/es purpose: to assess the utility of multislice computed tomography (msct) in the diagnosis and follow-up of aortic dissection. materials and methods: seventy-one patients referred to rule out aortic dissection underwent msct following a standardised protocol. the volume of interest was the entire aortoiliac system, 120 ml of non-ionic iodinated contrast were administered at a flow rate of 3 ml/sec. a collimation of 3 mm, table speed of 16 mm per rotation, pitch of 4 and reconstruction interval of 2 mm were used. multiplanar (mpr) and three-dimensional reconstructions (external rendering) were obtained in a workstation (vitrea 2; vital images plymouth, minn). aortic dissection was diagnosed when an intimal flap separating the true and false lumen was observed. patients diagnosed with aortic dissection underwent an endovascular repair (stentgraft placement). follow-up ct examinations after endovascular repair were acquired with the same msct protocol, after performing a basal nonenhaced study. complete closure of the entry site, and both stent-graft and visceral arterial branches patency were considered as adequate stent-graft function signs. results: nine of the 71 patients were diagnosed with aortic dissection (six acute and three chronic dissections), two of which involved the ascending aorta and seven the descending thoracic aorta. follow-up demonstrated in all cases a residual abdominal aortic dissection with progressive decrease in size of the false lumen. conclusion: msct determined the exact anatomy of the dissection flap, the location of the entry and reentry sites, and the major branch vessels that were supplied by the true lumen. endovascular stent-graft placement for treatment of thoracic aortic aneurysms m. fernández -velilla, g. garzón, i. acitores, f. ibáñez, l. riera; madrid/es learning objectives: to assess the safety and efficacy of endovascular stentgraft placement for repairing descending thoracic aortic aneurysms in high-risk patients. to analyse the major associated complications. to show our experience in the management of these patients over a six-year period. background: by helping patients avoid open surgery, endovascular aneurysm repair minimises the perioperative derangement of pulmonary, renal, cardiac, and gastrointestinal function. the greatest potential benefit is in high-risk patients who have large aneurysms and who are poorly suited to any of the current alternatives. procedure details: endovascular aneurysm repair was performed in 39 highrisk patients who could not undergo conventional repair. the feasibility of endovascular treatment and the prosthesis' size was determined based on preoperative spiral ct and intraoperative angiography findings. stent-grafts were surgically inserted through exposed femoral arteries with fluoroscopic guidance. the anaesthetic technique was either epidural or general. endovascular grafts were constructed with gianturco stents and polytetrafluoruroethylene (ptfe) graft. stent-grafts were placed in 12 disecting, 21 atherosclerotic, five traumatic, and one post-coarctation descending thoracic aortic aneurysm. 68% of them were chronic. we analysed the results obtained in both stable patients, in which an elective treatment was performed of sacular, fusiform, traumatic and chronic dissection aneurysms, and in emergency patients (intramural bruise, penetrating ulcer, and aortic dissection). conclusion: endovascular treatment of thoracic aortic aneurysms offers considerable benefits. long-term follow-up is needed to ascertain the durability of the procedure especially in dissecting aneurysms. an interdisciplinary and experienced team is needed to manage endovascular and surgical treatment. radiologic appearances of thoracic outlet syndrome: evaluated by pat optimized 3d contrast enhanced mr angiography and intraarterial dsa ö. özsarlak, o. d'archambeau, f. delrue, p.m. parizel; antwerp/be learning objectives: thoracic outlet syndrome: pat optimized contrast enhanced (ce) mra and intraarterial digital subtraction angiography. background: seventeen patients clinically suspected of having a vascular thoracic outlet syndrome were retrospectively reviewed. the patient population consists of 10 women, and 7 men with an age range between 14 and 65. in eight patients, ce-mra was performed in 1.5 t mr system. gre flash 3d mr angiography with care bolus technique was used with a pat acceleration factor of two. the remaining nine patients were examined by intraarterial, and intravenous dsa of the upper extremity. all examinations, including mra were performed both in neutral and in adson positions with abduction of arms. imaging findings: none of the patients showed abnormality during neutral position. examinations repeated during adson position revealed 22 subclavian artery lesions in 17 patients: 8 occlusions, 8 high-grade stenoses, and 6 mild-grade stenoses. in 8 patients, the lesion was located on the left side, in 2 patients on the right side, and remaining 7 patients' lesions were bilateral. conclusion: a review of the functional anatomy, clinical symptoms, ce-mra and dsa findings are presented with illustrative cases. the advantages of patoptimized ce-mra are highlighted. mri evaluation of patients with peripheral vascular malformations g. calabrese, g. falda, g. lucchini, a. cazzulani; garbagnate milanese/it learning objectives: to define a mri protocol to study patients with angiodysplasia in order to evaluate soft tissues and bone involvement and to demontrate the appearance of the vascular malformations. background: imaging studies must show all the abnormal vessels and provide information on the degree of surrounding tissue involvement. in this exibit we describe the mri findings in 15 patients with angiodysplasia of the lower or upper limbs. procedure details: t1 weighted fse sequences and t2 weighted fe sequences in the sagital and coronal planes were acquired. a sagital t2 fse sequence b d e f a g with 16 echos and fat-saturation was used to demonstrate vessels with slow flow. dsa and dsv were performed to proceed to embolization or operation. t1 images gave good morphological demonstration of muscle involvement. on t2 fe images the presence of small vessels within the subcutaneous fat or within the bones was easily shown. images acquired with the 16 echos t2 sequence were processed with the m.i.p. function to show the abnormal vessels; this sequence was especially useful in the venous malformations and in some cases the draining veins were also identified. conclusion: mri is the technique of choice to demonstrate the anatomic extent of the lesions and their relationship to the adjacent soft tissues. even if mra is improving from the technical point of view, still it remains quite complex and time consuming. in our protocol a simple t2 sequence showed to be a good method to demonstrate abnormal vessel with slow flow. occlusion background: thrombosis of the ivc and its tributaries is most commonly associated with malignancy, resulting from direct invasion by carcinoma of the kidney, liver or adrenal gland. thrombosis of the ivc secondary to benign causes is less common. predisposing factors include pregnancy, connective tissues disorders and coagulation abnormalities. recognition of caval thrombosis on ultrasound may be difficult. however, depiction of the ivc on both contrast-enhanced computerised tomography and mri is more accurate. although non-contrast mri is useful for demonstrating ivc occlusion, contrast-enhanced mr venography offers the opportunity for rapid evaluation in a single breath-hold. imaging findings: the normal appearance of the ivc as demonstrated by mri is illustrated, along with examples of ivc occlusion associated with both benign and malignant pathology. simple rules for differentiating bland versus tumour thrombus are presented and illustrated. a method for optimising the timing of data acquisition for ce-mra is presented. the merits of "indirect" versus "direct" ivc mr venography are also discussed. finally, artefacts that may mimic ivc thrombus are described. conclusion: mri/mra accurately evaluates the ivc. the multiplanar imaging capabilities, lack of ionising radiation, coupled with the added benefit gained from the use of intravenous gadolinium based contrast agents in mra, makes mri the modality of choice in evaluating patients with suspected ivc occlusion. the swollen leg: the various etiology and its ct venography findings w. jun, w. lee, j. chung, j. park; seoul/kr learning objectives: to illustrate the various causes of swollen legs. to recognize the characteristic imaging findings of various causes of swollen legs. to evaluate the accuracy of ct venography in the differential diagnosis of the etiology in patients with swollen legs. background: the swollen leg is a common clinical problem that complicates many medial and surgical disorders. clinical applications of computed tomography (ct) venography have increased with the improved technology of multidetector ct systems. ct venography showed the diagnosis of dvt and other soft tissue disease in patients with swollen leg. for the past two years, ct angiography of lower limbs was performed in 180 patient (age 19-92 years) with swollen legs. the various causes and imaging findings of swollen legs are described and illustrated. imaging findings: the characteristic imaging findings of acute deep vein thrombosis (dvt) are a definite intraluminal filling defect, venous distension and muscle compartment enlargement. findings of chronic dvt are small, thick-walled, poorly enhancing veins and presence of collaterals. findings of lymphedema are skin thickening, subcutaneous tissue thickening, fat infiltration: lines parallel to skin and perpendicular to skin. findings of cellulitis including necrotizing fasciitis, are fascial thickening, fat infiltration, focal fluid collection, soft -tissue gas and muscle involvement. conclusion: ct venography showed promise for the diagnosis of dvt and other soft tissue disease in patients with swollen legs. ct venography is the modality of choice when clinical and other imaging findings are indeterminate. the aorta revisited: spectrum of findings on helical ct a.j. madureira, j.p. jesus, j. loureiro, i. ramos; porto/pt learning objectives: to review the imaging findings of the anatomical variants and disease processes that may affect the aorta from the aortic valve to the bifurcation. to describe the pitfalls that may be encountered. background: helical ct is a frequently used method in the evaluation of diseases affecting the aorta. it provides invaluable information in the assessment of acute aortic syndromes and is often employed in diagnosis and follow-up of dissection, aneurysm and bypass surgery. procedure details: the imaging findings of the diseases that may affect the aorta are presented based on the experience of our tertiary care hospital and level 1 trauma center. the anatomical variations of the aortic arch vessels, acute aortic syndromes, aneurysmal disease and aortic bypass surgery are discussed and illustrated thoroughly. conclusion: helical ct is a firstline imaging method in the evaluation of aortic disease due to it's widespread availability, good spatial resolution and speed. learning objectives: to illustrate the mr findings that differentiate severe carotid artery stenosis with a tiny residual distal lumen from patients with total carotid artery occlusion. background: due to the small but substantial stroke risk in patients undergoing digital subtraction angiography, contrast enhanced magnetic resonance angiography (m.r.a.) has become the standard for evaluation of carotid occlusive disease in many centres. m.r.a. is highly accurate in differentiating significant stenosis (70%-99%) that requires carotid endarterectomy, from insignificant (< 70%) disease. m.r.a. is also highly accurate in differentiating severe stenosis from occlusion. however, demonstration of a string sign depends on careful interrogation of the source images as the residual patent lumen may not be visualised on standard maximum intensity projections. given the clinical importance of differentiating between these two groups, we present and contrast the imaging findings of patients with significant carotid stenosis and those with total carotid artery occlusion. imaging findings: we describe the varied findings in both patients with total carotid artery occlusion and those with severe stenosis. we present a simple algorithm for rapid evaluation of patients referred for differentiation of severe stenosis from occlusion. background: anomalies of ivc and renal veins occur with a prevalence of 0.07% to 8.7%, and are easily identified on ct, frequently incidentally. if unidentified, they can be misinterpreted as pathology (adenomegaly, retroperitoneal masses, normal venous structures and/or collaterals during acquired obstruction) or can lead to morbidity during radiologic and surgical procedures (positioning ivc filters, varicocoele sclerotherapy, renal venous sampling, shunt placement for portal hypertension, liver or kidney transplantation, ivc ligation for thromboembolic disease, abdominal aortic aneurysm repair). we describe the ct findings in 48 cases of anomalies of the ivc and the lrv. imaging findings: 20 female and 28 male patients, aged 20-76 years, were studied. we found 4 anomalies of the suprarenal segment (interrupted ivc with azygos continuation), 26 anomalies of the renal segment (18 circumaortic lrv, 8 retroarotic lrv), and 18 anomalies of the infrarrenal segment (1 retrocaval ureter, 6 transposition of the ivc, and 11 duplications of the ivc). one patient with agenesis of the ivc with azygos continuation had profound venous thrombosis, and another had bronchiectasis. in any other case the anomaly was responsible for the patient's symptoms. results: mean size of the ascending aorta in these patients at initial presentation was 7.4 cm (range 5.0 to 12.5 cm). dissection of the ascending aorta occurred in 50%. median size of ascending aorta at time of dissection was 5.6 cm. all patients underwent surgery for their aneurysms. the postoperative mortality was 6.3%. we have compared the two groups of marfan's syndrome patients whom had dissections: with an aortic-root diameter from 7.0 to 12.0 cm (70%) and with an aortic-root diameter from 5.0 to 7.0 cm (30%). there is correlation between the aortic-root diameter and the probability of aortic dissection. analysis to isolate risk factors for dissection revealed that size larger than 6.0 cm increased the probability by 40%. the incidence of dissection increased with aneurysm size and the radiological criteria for surgical intervention in marfan's syndrome are aneurysm diameter of 5.0 cm. maximal information about size and dissection of aneurysms in marfan's syndrome patients are obtained from analysis of angiography data. an evaluation of internal carotid artery and cerebral blood flow volume using color duplex sonography in patients with vertebral artery hypoplasia m. acar, b. degirmenci, a. yucel, r. albayrak; afyon/tr purpose: vertebral artery hypoplasia (vah) may be defined as va flow volume below ~ 30 to 40 ml/min using color duplex sonography. the aim of this study was to evaluate the effect of va hypoplasia on internal carotid artery (ica) flow volume and cerebral blood flow (cbf) volume. materials and methods: in this study, 17 patients with va hypoplasia and 20 control subjects with normal va flow volume were enrolled. the patients and control subjects were 50-75 years of age. the ica and va flow volumes were determined by using color duplex sonography. cerebral blood flow volume was calculated as sum of flow volumes in the ica and va of both sides. the ica and cbf volumes of patients with va hypoplasia were compared with control group flow volumes. results: in va hypoplasia and control group, there were no significant differences between ica flow volumes of right and left sides (222 ± 70 versus 260 ± 87 ml/ min; p = 0.16 on the right side, 211 ± 117 versus 236 ± 73 ml/min; p = 0.45 on the left side) or sum of flow volumes of both ica (434 ± 144 versus 495 ± 127 ml/ min; p = 0.18). however cbf volume tended to be lower in patients with va hypoplasia than control group. conclusion: evaluation of cbf using color duplex sonography is noninvasive and easily applicable to all patients and provides valuable diagnostic data. to the best of our knowledge, this is the first study demonstrating lower sbfv and normal ica flow volume in patients with va hypoplasia. the floating layer: a new sonographic sign of ruptured abdominal aortic aneurysm a. nunziata 1 , o. catalano 2 , m. mattace raso 2 , f. sandomenico 2 , a. siani 2 ; 1 naples/it, 2 pozzuoli/it purpose: in patients with ruptured abdominal aortic aneurysm we have occasionally seen a floating layer, similar to the intimal flap recognizable in patients with aortic dissection but slightly thicker. we reviewed our series to assess the overall prevalence, specificity and diagnostic significance of this finding. materials and methods: in a 6 year period (from january 1997 to december 2002) we have evaluated with us, 388 consecutive patients with abdominal aortic aneurysm (larger axial diameter of the aorta > 30 mm). twenty-nine aneurysms were proven to be ruptured (sonographic and/or ct diagnosis) and were surgically confirmed. the remaining 359 patients were not symptomatic and were proven to have a non-ruptured aneurysm at follow-up. results: a floating membrane was found in 8 out of 29 patients with ruptured aneurysm (28%) and in none of the subjects with non-ruptured aneurysm. the image appeared as a thick layer floating within the aneurysm lumen, clearly detached from a more or less eccentrically placed luminal thrombosis (present in all 8 cases), with a paradoxical movement unrelated to overall vessel pulsation. the floating layer is an uncommon but specific sonographic sign of abdominal aortic aneurysm rupture. recognizing this findings should lead to prompt surgical treatment, without need for further imaging (contrast-enhanced ct). color duplex measurement of cerebral blood flow volume in patients with polycystic ovary syndrome m. acar, a.s. cevrioglu, b. degirmenci, a. yucel, r. albayrak, m. yilmzer; afyon/tr purpose: polycystic ovary syndrome (pcos), one of the commonest endocrinopathies in the human, is known to be associated with risk factors for cerebrovascular disease. we want to determined whether there is a change in cerebral blood flow volume in pcos. we reported 30 women with pcos and 20 healthy women with similar body mass index (bmi). both groups of women were aged 16 to 35 years. we detected internal carotid (ica) and vertebral artery (va) flow volume using color duplex sonography. cerebral blood flow (cbf) volume was determined as the sum of flow volumes of internal carotid and vertebral arteries of both sides. results: there were no significant differences between patients with pcos and control group in cbf volume or the bilateral sum of flow volumes in the ica and va. but bilateral mean velocity of va was significantly lower in patients with pcos compared to control group. correlation between age of patients and mean velocity of va and ica were assessed with pearson correlation analysis. in control group, mean velocity of va and ica was inversely correlated with age (r = 0.61, p = 0.005 versus r = 0.59, p = 0.006). however no correlation was found for patients with pcos. conclusion: this is the first study demonstrating normal cbf volume using duplex sonography in pcos. it is known that the increased risk factors for cerebrovascular disease does not increase stroke mortality in pcos. normal cbf volume and absence of decrease in va and ica mean velocity by aging may be protective mechanisms. thoracic aortic calcification in the elderly g.s. karlsdottir, t. aspelund, s. sigurdsson, g. eiriksdottir, l. launer, t. harris, v. gudnason, r. detrano; kopavogur/is purpose: though demographic associates of coronary and abdominal aortic calcification in elderly persons are known, similar information about the thoracic aorta is not available. we developed a protocol for scanning the thoracic aorta from the aortic bulb to the descending aorta at the level of the cardiac apex. methods and materials: computed tomographic images were acquired with a siemens sensation 4 scanner, using sequential mode and prospective ecg gating. the ct images were processed using calcium scoring software for coronary arteries, which is modified in order to label areas and quantify calcium in the thoracic aorta. the thoracic aorta is divided into three segments: arch, ascending, and descending. these segments are labeled and calcium within them quantified and results expressed in agatston scores. results: agatston scores were acquired from 676 individuals (263 men, 413 women) with an age range of 66-92 (mean 75) years. there was a 34% increase (95%ci: 22%-45%) in the total agatston score for every 5 years of age for men, and 49% (95%ci: 40%-58%) for women. there was no significant difference between men and women in the age group 66-70 and, men in the age group 85+ had significantly lower scores than women. conclusion: a robust method for quantifying calcium in the thoracic aorta has been established. age and gender distributions of thoracic aortic calcification in the elderly show strong age dependance for both genders but significantly stronger for women than for men. b d e f a g materials and methods: ct scans of fourty patients (mean age 70 years, 18 female: previous aortic repair (n = 13), atherosclerosis (n = 10), trauma (n = 8), other (n = 9)) with aortic or supraaortic emergency were reviewed for aortic rupture (ar), aortic or supraaortic fistula (af), covered aortic perforation (cap) with transection (at), dissection (ad), or ruptured ulcer (rau), and rapid aortic aneurysm expansion (raae). morphological findings were correlated by dsa, surgery or post-mortem. results: there were 10 ar, 8 af (4 tracheobronchial, 3 oesophageal, 1 duodenal), 17 cap (4 at, 7 ad, 6 rau) and 5 raae. cta was diagnostic in all cases except five af: four were diagnosed by dsa, one at post-mortem. in 34 cases, cta correctly determined the decision of patient management. one separate vertebral artery origin was missed. two patients died before surgery. 36 patients underwent emergency repair (22 surgical, 14 endovascular); two were observed. five thoracic af were treated by endovascular repair, two by surgery, one infradiaphragmatic af by surgery. conclusion: cta is valuable for diagnosing aortic and supraaortic emergencies and determining their treatment. however, in suspected af complementation by dsa is usually required. low materials and methods: seventy-five patients with peripheral arterial disease, divided into three groups of 25, underwent mdcta. mdcta scanning protocol was: collimation 4 x 2.5 mm, thickness 3 mm, gantry rotation time 0.5 s, kv 120, delay time 28 s. the only variable among the three groups was mas, respectively 130, 100 and 80, with a resultant ctdiw of 13.2, 10 and 7.9 mgy. all patients underwent dsa within 72 hours from cta. the volume of contrast medium (0.7 gi/ kg of iomeprol 400 mgi/ml), injected at 3.8 ml/s, was flushed with 40 ml of saline. 3d real time interaction approach on a dedicated workstation was performed in all cases, with different reconstructions algorithms. image quality and degree of stenosis were independently evaluated by 2 blinded readers. results: regarding image quality no significant difference was found among three protocols. slight artefacts related to beam hardening were present in the pelvis with the lower mas protocol without impairment of diagnostic quality. interobserver agreement was substantial to almost perfect in all cases. the sensitivity, specificity and accuracy resulted of 96, 93 and 94%, independent of the mas value. conclusions: low-dose mdcta provides qualitatively acceptable images. it also appears accurate in the assessment of patients with peripheral arterial disease providing results comparable to higher dose protocols. image noise on native lowest dose protocol can be reduced or eliminated by thickening mip or mpr images. diseases had lymphadema, 26 (5.5%) had superficial venous thrombosis, 6 (1.3%) had popliteal vein or artery aneurysm. nine (1.9%) limbs had pseudoaneurysms (8 femoral and 1 located at the tibial-peroneal trunk), 4 (0.8%) had avf (3 detected to be femoral and 1at the level of the external iliac artery). four (0.8%) had either abscess, or enlarged lymph nodes in the groin, compressing the veins, and 6 (1.3%) had some kind of musculoskeletal problem (muscular tear). conclusion: complete venous evaluation with duplex imaging can be very helpful in the determination of the underlying cause of leg swelling. dvt is the commonest. sonographic assessment of intima-media thickness (imt) and plaque morphology of the carotid system: a comparative study a.a. kotis 1 , p. brestas 2 , l. guindaglia 1 , g. chatzakis 1 , k. papanastasiou 1 ; 1 rhodes/gr, 2 athens/gr purpose: to investigate the potential association of increase in imt with carotid artery disease extension, plaque morphology and formation of carotid bifurcation stenosis. materials and methods: 250 patients 140 females and 110 males referred for color duplex ultrasound were included. risk factors for cerebrovascular disease were recorded. measurements of common carotid (cca) imt adjacent to the bulb and carotid bifurcation plaque characterization and classification were realized. coefficients of variation and k-statistics were used for assessment of variability in imt measurements and plaque characterization respectively. controversy cases underwent shu 508a contrast agent injection. results: significantly higher imt values were measured a) in men than in women (p < 0.05) b) on the left side compared with the right (p < 0.01). mean imt measurements showed positive linear relationship with age. we identified plaques in 205 of 280 carotid bulbs and stenosis (> 50%) in 60 of them. echogenic us plaque appearance (121/280) predominated in comparison with echolucent (84/ 280) and relationship of lumen stenosis with the presence of echolucent plaques (p < 0.05) was found. multiple regression model revealed significantly higher imt values in patients with plaques at any side (p = 0.019), with more evident difference in those with stenosis (p < 0.001). the magnitude of plaques correlated significantly with imt. there was no relationship between plaque echogenity and imt (p > 0.05). we realize the existence of correlation between increase in imt in cca and extent of carotid bifurcation atherosclerotic disease. color doppler ultrasonography is accurate and reproducible for assessment of imt and detection of carotid plaque morphology and evolution. to emphasize the role of mr angiography in the evaluation of renovascular disease, and to discuss the performances, advantages and limitations of different mr angiography techniques. materials and methods: more than 200 mr angiograms of renal arteries were reviewed for the presence of any anatomic variations, the number of renal arteries, the presence of renal artery stenosis, occlusion, or other arterial diseases together with the limitations, artifacts and pitfalls of the technique. more than 100 examinations were performed after applying parallel acquisition technique with acceleration factors up to 4, using a 12-channel phased array body coil. influence of pat on slice thickness, image matrix, total examination time, and image quality are discussed. results: phase contrast acquisitions are extremely helpful in evaluating flow patterns in the renal arteries, and offer unique information about the flow velocity patterns. pat using sense reconstruction algorithm leads faster 3d mra acquisitions. this results in, not only shortening the examination time, but also shortening the breath-hold time, and providing better image quality due to decreased motion artifacts. pat-optimized 3d contrast enhanced mr angiography is unique among noninvasive imaging modalities in that it offers a comprehensive 3d evaluation of renal anatomy, and renal vascular territories in a very short acquisition time. the main challenge in the evaluation of renovascular hypertension is the detection of hemodynamically significant renal artery stenosis. a combination of different techniques (phase contrast and contrast-enhanced mra) yields the best results, comprising both morphologic and functional information. possibilities results: pathologic changes in the visceral arteries were revealed in 31 cases, including 14 findings with various grades of stenosis of the coeliac trunk, 11with stenosis of the sma, 6 -occlusion of the splanchnic arteries. causes of visceral ischemia were: atherosclerosis (the main cause), found in 23 patients, aorto-arteriitis -in 2, coarctation of abdominal aorta -in 1, extravasal compression-in 5. high correlation between conventional angiography and ce-mra was determined in 28 patients. the functional phase-contrast mra was done in 18 patients with stenoses of small and middle degree; it gave an opportunity to acquire information on flow parameters and to elaborate the grade of stenotic changes. the ce-mra with pc-mra gives a chance to determine the grade of stenosis with high accuracy, visualize colateral vessels, to get information on flow parameters in damaged splanchnic arteries. b d e f a g imaging findings: all degrees of local vascular damage were seen. various imaging modalities may be employed in characterising such lesions, including ct, mri and conventional angiography and venography. an addict may injure any vessel during injection and the superficially placed femoral vessels are particularly susceptible to damage. septic vascular complication is common. arterial injury resulting in haematoma formation, arterial dissection and thrombosis, arteriovenous fistula and mycotic aneurysm formation is shown. a case of torrential haemorrhage from a ruptured pseudo-aneurysm treated with coil embolisation is demonstrated. deleterious effects secondary to the injected substance, including distal ischaemia and tissue necrosis, are demonstrated. venous thrombosis is common and can be shown by multiple imaging modalities. infected venous pseudo-aneurysms with secondary septic embolisation may occur. conclusion: it is important for radiologists to become familiar with the appearance of vascular complications occurring in the setting of injection drug use. early imaging to define disease extent and possible complication is important in this difficult patient group. carotid intima-media thickness ( the aim of the study was to investigate the probable association of atherosclerotic disease with endothelial cell adhesion molecule icam-1, vcam-1 and e-selectin levels. carotid imt was measured by high resolution ultrasonography of the common carotid arteries in 45 predialysis patients with esrd, 83 patients on chronic haemodialysis (hd) and 35 controls. compared with controls, esrd and hd patients had increased imt (p < 0.01 and p < 0.01 respectively), as well as serum icam-1 (p < 0.0001 and p < 0.0001 respectively) and vcam-1 (p < 0.0001 and p < 0.0001 respectively) levels. imt was correlated with age in controls, esrd and hd patients (p = 0.002, p = 0.001 and p = 0.0001 respectively). no correlation was found between imt and other cardiovascular (cv) risk factors such as gender, lipid levels, mean arterial blood pressure, ca x p products or hd duration in hd patients. in univariate analyses, imt was correlated with history of cv events, logcrp and icam-1 both in esrd (p = 0.01, p = 0.04 and p = 0.03 respectively) and hd patients (p = 0.04, p = 0.02 and p = 0.003 respectively). moreover, compared with patients with normal imt, esrd and hd patients with increased imt (> 0.82 mm) had increased icam-1 (p = 0.03 and p = 0.003 respectively). multivariate analyses showed that icam-1 was a strong independent correlate of imt values both in esrd and hd patients (p = 0.03 and p = 0.004 respectively). vcam-1 and e-selectin levels failed to be a significant contributor to imt. in conclusion, chronic uraemia is associated with advanced atherosclerosis. in patients with esrd, both on conservative treatment and on hd, icam-1 levels are potentially a useful surrogate marker of the extent of atherosclerosis. evaluation of tumor microvessels using monochromatic x-ray after administration of angiogenesis inhibitor t. yamashita, s. imai, n. maehara, a. yamamoto, m. kobatake, y. kajihara; kurashiki/jp purpose: to quantitatively evaluate changes in tumor microvessels using synchrotron radiation in vivo after fr-118487 administration as an angiogenesis inhibitor. the fr-118487 agent (using propylene glycol as a solvent) was continuously infused subcutaneously to 30 rabbits with vx2 carcinoma implantation at auricles. the rabbits were divided into six groups: control-3 and control-7 received only propylene glycol for three or seven days, fr-1-3 and fr-1-7 received 1 mg/day/kg of fr-118487 for three or seven days, fr-3-3 and fr-3-7 received 3 mg/day/kg for three or seven days. microangiograms using a synchrotron radiation system were obtained to evaluate the tumor microvessels and tumor size. results: compared to control-3 group, fr-x-3 groups showed no significant tumor size difference (fr: diameter = 4.03 ± 0.59 mm, volume = 38.38 ± 8.48 mm 3 , control-3: 5.07 ± 0.57 mm, 55.40 ± 8.41 mm 3 ), but microangiologically fewer vessels were observed. fr-x-7 groups presented significant difference (fr: diameter = 5.37 ± 0.45 mm, volume = 68.02 ± 14.40 mm 3 , control-7: 9.91 ± 0.56 mm, 512.66 ± 71.14 mm 3 ), and many irregular vessels, findings similar to control-3. there was no significant difference in tumor size and microangiographic findings between fr-1-x and fr-3-x. conclusion: our study demonstrates the application of new technique to examine antiangiogenic effects in vivo. the growth of the vx2 carcinoma were sup-pressed remarkably in the fr-7-day-groups, and the microangiographic findings were similar to those of control-3. the synchrotron radiation microangiogram is a useful tool to evaluate antiangiogenic agent. early atherosclerotic changes in hiv positive patients treated with protease inhibitors m. cristofaro, n. petrosillo, l. rovighi, c. bibbolino; rome/it purpose: antiretroviral therapies with protease inhibitors (pi) produce derangement of lipid metabolism with possible occurrence of early atherosclerotic changes. aim of this study is to evaluate onset of early atherosclerotic changes of epiaortic vessels in hiv positive patients, treated with pi. purpose: hematoporphyrin (hp) accumulates in arteriosclerosis selectively and shows specific fluorescence spectrum change in accordance with the stages of the sclerosis, and this fact is under discussion as to its availability to diagnosis and therapy. we paid our attention to the fact that hp accumulates in the interface of swollen collagen type iv and lipid. we assumed such a model of atheroma, and we examined the possibility of a photodynamic therapy for arteriosclerosis using collagen type iv and phosphatidyl choline liposome. material and method: we added hp to collagen type iv, then the liposome containing cholesterol to the mixture, and examined the agglutination state of the protein-lipid complex. afterwards, we irradiated that complex with led pulse of 680nm for one hour, and examined scattered spectroscopy, interference spectroscopy using 680nm semiconductor laser and high sensitivity ccd in order to observe the hp and the agglutination state of complex, and, then, analyzed the alteration of protein-lipid complex in terms of fourier analysis. result: hp gave influence to the various state of assembly of protein-lipid complex. in addition, protein-lipid integration state was changed by the irradiation of light pulse and the change of scattered light that signifies the state of dispersion was observed. conclusion: this study suggested that the molecule composition of the proteinlipid complex in the plaque was changed by the irradiation of light pulse after the addition of hp, and that the photo stimulation could contribute to the decomposition of the cumulated lipid and the stabilization of plaque. depiction of arterial branches in the abdomen using multidetector-row ct n. terayama 1 , o. matsui 1 , k. ueda 2 , t. kobayashi 1 contrast medium (300 mgi) was administered intravenously at a rate of 3 ml/sec. parameters of data acquisition were as follows: a slice thickness of 0.625 mm, reconstruction intervals of 0.4 mm, a pitch of 1.375, and fov of 35 cm. axial images were transferred to advantage workstation 4.0 (ge medical systems) and multi-projection volume reconstruction (mpvr) images were obtained. if the origin of each arterial branch and the route until the target organ was depicted, we regarded that the branch was visible. results: coeliac, superior and inferior mesenteric, renal, intercostal, lumbar, right and left hepatic, and anterior and posterior pancreaticoduodenal arteries were visible in all cases. cystic, right gastric and dorsal pancreatic arteries were visible in 20 cases (95%), in 18 cases (82%) and in 17 cases (77%), respectively testicular arteries were visible in 4 cases (44%), and in 4 cases (44%), respectively. conclusion: reformation images of mdct can visualize thin arterial branches in the abdomen experimental lung injury prior to the ct examinations. in addition, segmental and subsegmental pulmonary embolism was artificially induced in four healthy pigs. scanning was performed using a 16-slice msct protocol using contour finding and adaptive thresholding, both plain and enhanced ct volumes were separated into lung parenchyma, vascular structures and airways. the high contrast information was used to locally match and align sub-volumes. the matched parenchymal volumes were low pass filtered, subtracted and normalized to the enhancement level in a major vessel. results: scanning was successfully performed during a total ~15 s scanning time in all pigs. post-processing was technically feasible, even in underlying experimental lung injury. in pe, filling defects corresponded to areas of decreased enhancement. conclusion: it is expected that this imaging technique will increase the sensitivity and specificity of msct determination of arterial input function for measurement of brain perfusion index with tc-99m compounds using a solid-state gamma camera y. uenishi, k. murase, m. nagayoshi, m. kawamata, m. takasawa, n. oku, a. takahashi, j. hatazawa; osaka/jp purpose: cerebral blood flow (cbf) can be non-invasively quantified using the brain perfusion index (bpi) determined from radionuclide angiography (ra). for measurement of bpi, accurate determination of arterial input function (aif) is necessary. we have developed a method for the automatic extraction of aif using fuzzy clustering and a solid-state gamma camera (digirad). methods and materials: ra was performed using tc-99m hmpao for 120 sec with a digirad placed on the heart and a 4-head spect (spect2000h). for comparison, the data were also acquired using a conventional gamma camera (rc-2600i). the aifs were obtained using fuzzy clustering (aif a ) and manual drawing of a region of interest (roi) (aif m ) from the region of aortic arch. the rois were also drawn over the left and right cerebral hemispheres. the bpi values were calculated using spectral analysis (bpi a : bpi obtained using aif a , bpi m : bpi using aif m ). the deadtimes of digirad and rc-2600i were measured using the reference source method. results: the mean and sd of bpi m became larger with increasing roi size, while the bpi a was almost constant regardless of roi size. the sd of bpi a was smaller than that of bpi m . the deadtime of digirad (0.92 ± 0.63 µsec) was much less than that of rc-2600i (5.00 ± 0.95 µsec). furthermore, the deadtime of digirad was almost constant regardless of the volume of phantoms, while that of rc-2600i increased with increasing volume. the proposed method appears promising for calculation of the bpi, because it allows automatic and objective determination of aif. spectroscopic imaging of radiation-induced effects in the brain after brachytherapy g. bajzik 1 , j. julow 2 , i. repa 1 ; 1 kaposvar/hu, 2 budapest/hu purpose: the effect of brachytherapy, characterized by rapid dose fall off from the radiation source, is different compared to external radiation. we used proton mr spectroscopic imaging to investigate brain tissue response to brachytherapy. methods and materials: twenty glioma patients treated with surgery and/or brachytherapy were studied with mr imaging (t2 weighted images and post contrast t1 weighted images) and 2d proton mr spectroscopy (tr: 1500 ms, te: 135 ms, voxel size 3.3 cm 3 ). brachytherapy resulted in central necrotic zone, surrounded by an enhancing rim (demarcation zone) and an outer edematous zone on mr images. in each patient sample, spectra of the three zones and the normal appearing white matter were analyzed. results: in demarcation zone, choline/creatine (cho/crea) ratio (2.9 ± 1.33 vs. 1.04 ± 0.23, p = 0.004, two-tailed unpaired student's test) and choline/n-acetylaspartate (cho/naa) ratio (1.43 ± 0.53 vs. 0.74 ± 0.28, p = 0.003) was increased compared to normal white matter. in edematous zone cho/crea ratio was increased (1.31 ± 0.33 vs. 1.04 ± 0.23, p = 0.007), cho/naa ratio was not different (0.9 ± 0.39 vs. 0.74 ± 0.28, p = 0.21) compared to normal white matter. in demarcation zone we found elevated cho/crea ratio (2.9 ± 1.33 vs 1.31 ± 0.33, p = 0.03) and cho/naa ratio (1.43 ± 0.53 vs 0.9 ± 0.39, p = 0.006) compared to edematous zone. in the central necrotic zone we could only detect lipid and/or lactate peaks. conclusions: mr spectroscopy demonstrates significant spectral differences in the brain following brachytherapy. tumor recurrence can be suspected in cases where focal choline accumulation is detected. does ct-perfusion imaging based on parametric deconvolution permit prediction of infarct volume in acute stroke? g. bohner 1 , a. förschler 2 , c. zimmer 2 , r. klingebiel 1 ; 1 berlin/de, 2 leipzig/de objectives: suitability of quantitative ct-perfusion (ctp) imaging for assessing the early as well as final infarct volume in acute stroke patients. material and methods: twenty-two patients with acute cerebral ischemia underwent ctp on admission. parameter maps of cerebral blood perfusion (cbp), cerebral blood volume (cbv) and mean transit time (mtt) were generated using a parametric deconvolution algorithm. additional diffusion weighted imaging (dwi) was performed in seven cases. volume of diffusion abnormality was compared with the infarct volumes as assessed by two blinded neuroradiologists for each of the perfusion maps. in addition, final infarct volumes were determined on the basis of follow-up studies. results: mean volumes of ischemia as assessed by cbp, cbv and mtt were 38.5, 15.9 and 41.3 ml respectively. amongst the patients in whom dwi was performed, six showed perfusions deficits in all perfusion images. in one patient, who had no dwi abnormality, perfusion deficits only were found on cbp and mtt images. mean volume of dwi changes was 25.1 ml. the most significant correlation was found between the extent of cbv reduction and dwi infarct volume (r = 0.899, p < 0.01). mean final infarct volume was 27.7 ml for all patients. cbv reduction showed the best correlation (r = 0.838, p < 0.01) with final infarct volume. conclusion: our findings suggest that cbv maps based on the ctp technique applied in this study permit prediction of infarct volume in early stroke, so ctp would deliver information about the ischemic penumbra. hepatic encephalopathy in alcoholic and non-alcoholic subjects: correlation of magnetization transfer ratio, apparent diffusion coefficient and critical flicker frequency m. cohnen, g. kircheis, h.-j. wittsack, f. miese, f. wenserski, a. saleh, d. häussinger, u. moedder; düsseldorf/de purpose: to correlate quantitative changes of water content in brain parenchyma using magnetization transfer imaging (mti) with different stages of hepatic encephalopathy (he). materials and methods: forty-three patients with hepatic encephalopathy and 15 age-matched control subjects underwent mr imaging (1.5 t vision, siemens) including mti, mr-spectroscopy (mrs) and diffusion weighted imaging (dwi). liver cirrhosis was due to alcohol in 26 patients whereas non-alcoholic disease was found in 17. patients underwent assessment of critical flicker frequency (cff) as test for he with a frequency under 39 hz considered pathologic. magnetiza-tion transfer ratios (mtr) and apparent diffusion coefficient (adc) values were determined in basal ganglia, posterior white matter and pons using roi-measurements. single-voxel mrs was performed using a steam sequence (te = 20 ms, tr = 1.5 s) assessing basal ganglia and posterior white matter. results: mrs showed typical findings with decreased myo-inositol combined with increased glutamine/glutamate with increasing degree of he indicated by a reduced cff. compared to controls, mtr showed a significant decrease both in the basal ganglia as well as in the posterior white matter. in alcoholic subjects, this was independent from the degree of he, whereas in posthepatitic cirrhosis a correlation was found. a non-significant increase in adc was noted with a decrease of cff in both groups. conclusion: the results may indicate an increase of free protons in the brain parenchyma of patients with he possibly supporting the hypothesis of a lowgrade cerebral edema. the differences between alcoholic and non-alcoholic subjects may hint at a general brain damage due to alcohol independent of hepatic failure. assessment of cerebral blood flow values obtained from dynamic perfusion computed tomography: a comparison with positron emission tomography h. yokote, k. nakayama, t. okamura, n. tsuyuguchi, k. kitamura, n. ozawa, s. minamikawa, t. tashiro, y. inoue; osaka/jp purpose: among imaging modalities measuring regional cerebral blood flow (cbf), dynamic perfusion computed tomography (ct) studies are easy to perform and readily available without specialized equipment. however, quantitative studies comparing perfusion ct with positron emission tomography (pet) have been few. we assessed the correlation of cbf values obtained from perfusion ct and pet. methods and materials: eleven patients with various cerebrovascular diseases underwent perfusion ct and pet. the perfusion ct studies were performed with a four-channel multi-detector row ct scanner. four contiguous 8-mm ct sections were cine-scanned during a 36 ml bolus of intravenous contrast medium at a rate of 4 ml/s, with a total acquisition time of 50 s. cbf maps were obtained from perfusion ct data by central volume principle and deconvolution method. on cbf maps of both perfusion ct and pet, multiple regions of interest (roi) were drawn independently, including frontal, temporal, parieto-occipital territories, caudate nucleus, thalamus and white matter in both hemispheres. rois were visually matched by agreement of three radiologists. mean cbf values of multiple rois with both ct and pet were compared through linear regression analysis. results: correlation coefficients for individual analysis ranged from 0.657 to 0.833, overall 0.553. linear regression analysis showed moderate correlation between perfusion ct and pet values (slope = 0.668, intercept = 21.958). conclusions: our study has shown moderate correlation of cbf values between perfusion ct and pet. despite the various alterations of cerebral blood flow in our cases, perfusion ct studies were validated to be an easy-to-perform imaging technique to assess cbf values. ageing of the cerebrum: assesment with quantitative proton mr spectroscopy j. ostojic, r. semnic, d. kozic, d. bogdanovic, m. prvulovic; sremska kamenica/yu introduction: aging is recognized to originate from a diversity of mechanisms that blur the limits between normal and pathologic processes. the purpose of this study was to determine the early effect of normal aging on the regional distribution of brain metabolite concentrations, including n-acetylaspartate (naa), choline (cho) and creatine (cr). methods: seventy nine volunteers, ages 16 to 75 years, were examined by localized single-voxel proton mr spectroscopy at 1.5 t using press 135 sequence.voxels 2 x 2 x 2 cm were placed in the middle white matter (wm) of the centrum semiovale in the left hemisphere and in the occipital gray matter (gm) of posterior parietal lobes. the ratio of naa/cho were calculated, as well as absolute concentrations of naa, cr and cho.quantification was performed using method of external standard. results: absolute concentrations (mm/kg) of cho increased with age both in wm (r = 0.42, p < 0.05) and in gm (r = 0.57, p < 0.05). cr concentrations were much higher in gm than in wm and significantly higher in the old than young subjets (r = 0.41, p < 0.05). the change of wm cr with age failed to meet p < 0.05 criteria. naa concentration was higher in gm than in wm and did not differ between young and old subjects. the age dependency of gm naa/cho ratio was technical inadequacies of plain films in an emergency department b. rajashanker, f. jabeen, r.w. whitehouse; manchester/uk purpose: 1. to assess the diagnostic quality of radiographs performed in the emergency department in a major referral hospital. 2. to determine the type and number of inadequacy encountered most often. materials and methods: two specialist registrars (trainees) in radiology, reviewed 800 plain films performed in a busy emergency department. films were examined for inadequacies, which impair the diagnostic quality of the examination. despite artefacts or exposure problems, if a reasonable diagnostic conclusion could be made, the film was considered to be adequate. if a film was found to be inadequate, clinical details (that could have contributed to the poor quality) were looked at, and taken into consideration. artefacts obscuring the area of interest, inadequate collimation, incomplete examinations and improper exposure factors were considered as inadequate. the number and the type of inadequacy, the type of examination were noted. results: 1. the study showed that about 9% of the total films performed were inadequate. there are no national figures we could find to compare our results with to evaluate the performances on our emergency department. 2. the type of inadequacy encountered most often was the presence of jewellery obscuring the area of interest (27%), followed by artefacts caused by clothing (10%). chest radiograph was the most frequently encountered inadequate examinations (55%). conclusion: national guidelines regarding target quality radiographs that need to be achieved in institutions need to be published. the inadequacies were pointed out for better performance in future. drug courier pays a high price for easy money b. szabó, z. mocsári, s.o. farkas, p. magyar, á. takács, k. karlinger, e.k. makó; budapest/hu purpose: the aim of this study is to show the most common methods for examining drug couriers and their results. method: native abdomen ct scans and native abdomen x-rays and us examination were performed on probably positive patients. in the year 2003 until now we examined 19 patients. four positive cases were found. one of them after the ct examination died in the hospital, because leakage of a capsule. conclusion: swallowers before traveling swallow 2-3 cm long, 1 cm diameter capsules, which they hope to retrieve after traveling. stuffers insert drug filled corpus alienums into the rectum or vagina. the danger of this type of drug smuggling is the braking or bursting of the capsules, leading to potential fatal drug overdose. steps to european union from europe: reforms of education of hungarian radiographers a. maléta, z. mocsári, s.o. farkas, á. mester, k. karlinger, e.k. makó; budapest/hu purpose: the aim of this presentation is to show a short summary of the education of hungarian radiographers currently and in the future. method: assessment based on the bologna contract new education system with the cooperation between the society of hungarian radiographers and hungarian ministry of education according to the european directives. results: the base of the modular education system is already laid down. the construction and edition of the new scientific books and the preparation of the teachers and professors has already commenced. conclusion: since the hungarian educational system of radiographers has a history of nearly ninety years we need to use the lessonst of the past into the new system. since the result of the reforms requires a long time, well-organized feedback mechanisms is needed to ensure the effectiveness of the reforms. origin of military radiology: first use of x-rays in ottoman empire a. tunaci, n. yildirim, y.i. ulman, e. yekeler, h. genchellac, m. tunaci, g. acunas; istanbul/tr x-ray usage as a diagnostic device was realized in turkey first time at the military medical school in 1896 by esad feyzi, who was an intern and physics assistant. this new invention attracted attention so much that dr. salih and rifat osman also joined him and they started to work in a small unit, where they practiced radiographic examination.the following year, yildiz portable military hospital was reserved for wounded patients from the battlefield of the ottoman-greek war. this mobile hospital, which was activated in 1892, was exported from germany and comprised duquer system pavilions that were reassembled within 10 hours. they took away the x-ray equipment from the military medical school to yildiz and began to produce images of bullet and shrapnel pieces from the patients sent from the battlefield. kuttner and nasse from german red cross came to istanbul in 1897. they were surprised to see that this new invention was already being used there. on the greek side english physicians used two x-ray devices that were transferred from england to pire harbour on may 1897. therefore the ottoman-greek war took its place in medical literature as the first war that radiographic images were taken, first by the turkish and soon after by german and english physicians. references stated that english physicians took x-ray images of wounded greek soldiers and there is no record about greek physicians taking part in this work. turkish physicians continued to work on radiographic images during the war which they had started shortly after the discovery of x-rays. to demonstrate how to perform a numeric flow simulation in patient-specific vessels based on isotropic ctdatasets. to illustrate the possibilities of this promising tool on clinical cases. background: cfd was introduced recently to investigate the behaviour of blood flow. different studies determined cfd as a valuable method to demonstrate the flow and pressure. most studies use simplified standard models for the simulations. this exhibit explains methodological aspects of cfd and how numeric flow simulations are performed in patient-specific vessels based on high-resoloution ct datasets. possible applications of cfd in the cardiovascular field are discussed. procedure details: isotropic ct-angiography data are used to segment the vessels. after generation of a surface mesh using the marching cube algorithm, the model is transferred into a volume mesh and the different entities and walls were defined. specific parameters as velocity at the inlet boundary, flow parameters, and material specific parameters have to be assigned in a next step.the simulation itself provides detailed information about flow-behaviour and pressure. this helps to identify possible zones for development of artherosclerosis or, especially in aneurysms, locations for a possible rupture. furthermore, blood flow can be quantified and e.g. effects of stent-graft implantations or the benefit of a coronary bypass can be demonstrated. conclusion: cfd in combination with patient-specific patient-data is a promising method to visualise flow-effects. in the near future cfd will also gain increased importance for pre-interventional planning of vascular procedures. background: evaluation of the central veins is easily achieved with contrastenhanced mr angiography. "indirect" ce-mrv, a technique where the veins are evaluated during the "venous" phase has been largely replaced by "direct" ce-mrv, a technique whereby dilute contrast agent is injected into the upper extremity veins and imaging is performed during the first-pass. imaging findings: in order to overcome t2*-induced susceptibility-effect commercial strength contrast-agent is diluted with saline. in our institution we use a 6% solution (3 cc of contrast agent in 50 cc saline). 1-3 cc of contrast is injected over the duration of the breath-hold scan (tr/te/flip 5 msec/2 msec/40 deg, matrix 512 x 200, fov 400-450 mm x 360 -450 mm. 32-60 slices, 4 mm interpolated to 2 mm). mask subtraction of a pre-contrast scan is performed. the spectrum of findings in normal and diseased veins is illustrated. examples of thrombosis, stenosis and occlusion of the central veins will be illustrated. common pit-falls and artefacts will also be emphasised. conclusion: "direct" ce-mrv is an effective modality for evaluating the central veins. a simple robust method is presented, along with examples of the appearance in normal and pathological states. multidetector row ct angiography of the lower extremities for the assessment of traumatic vascular injury e.e. williamson, j.c. hellinger, a. napoli, g.d. rubin, d. fleischmann; stanford, ca/us learning objectives: 1. to describe the ct angiographic (cta) technique used in the evaluation of traumatic lower extremity (le) vascular injury. 2. to illustrate the spectrum of vascular and nonvascular pathology found during le-cta in the setting of trauma. background: digital subtraction angiography (dsa) has long been considered the imaging standard for traumatic vascular injury. cta is a more readily available, noninvasive imaging alternative which is less expensive, less resource intensive and can be used to assess bone and soft tissue injuries without the need for additional imaging tests. in this exhibit we highlight our experience with cta in 27 trauma patients.procedure details: all examinations were acquired using 8 or 16-channel multidetector-row ct (mdct). contrast media was administered at 4-5 cc/sec using bolus-tracking technique. thin section images were obtained from one vascular segment above the level of trauma through to the foot with collimation of 1.25 and pitch of 1.35-1.5. table feed and gantry rotation speed were adjusted to optimize scan duration to match the peripheral delivery of iv contrast. all studies were reformatted in 3-dimensions using volume rendering, maximum intensity projection and curved planar reformation techniques. conclusion: the spectrum of direct vascular injuries included large and small vessel occlusions, pseudoaneursyms, active extravasation, and vasospasm. nonvascular pathology with indirect effects on the vascular system included complex fractures, open soft tissue wounds, hematomas, and joint effusions. ct angiography of the extremities is a promising technique in the evaluation of traumatic le arterial injury with the ability to assess nonvascular injuries without the need for additional studies. there is a wide range of imaging techniques available for mrv evaluation of the central chest veins, including conventional non-contrast time of flight imaging and contrast enhanced methods such as the newer vespa (venous enhanced subtracted peak arterial) sequences. imaging findings: examples of common central venous pathologies will be illustrated from our database of over 120 patients, who underwent mr at 1.5 t using various sequences including non contrast time-of-flight, and post gadolinium true fisp, t1-weighted vibe and 3d flash sequences. typical scan parameters included matrix 512 x 200, fov 400-450 x 360-450 mm, 32-60 slices, 4 mm interpolated to 2 mm. common pathologies demonstrated included thrombo-embolic disease, central venous obstruction due to local tumour extension, congenital and acquired venous stenoses, av fistulas and infected venous pseudo-aneurysms. conclusion: mrv is a robust, highly accurate and non-invasive technique for assessment of central venous pathology. accuracy of automated centerline approximation algorithms for lower extremity vessels in a cta phantom a. la cruz 1 , m. straka 1 , a. köchl 1 , m. šrámek 1 , e. gröller 1 , d. fleischmann 2 ; 1 vienna/at, 2 stanford, ca/us purpose: the accurate determination of the central vessel axis is a prerequisite for automated visualization (curved planar reformation) and quantitation. the purpose of this work was to assess the accuracy of different algorithms for automated centerline detection in a phantom simulating the peripheral arterial tree. materials and methods: six algorithms were used to determine the centerline of a synthetic peripheral arterial vessel (aorto-to-pedal arteries, diameter 18-0.6 mm) dataset (256 x 256 x 768, voxel size 0.5 x 0.5 x 0.5 mm). they are ray-casting/ thresholding (rct), ray-casting/maximum gradient (rcmg), block matching (bm), fitting to ellipse (fe), center of gravity (cog), and randomized hough transform (rht). gaussian noise with a sigma: 0, 5 and 10 was used to observe the accuracy of the method under noise influence. the accuracy of automatic centerline determination was quantified by measuring the error-distance between the derived centerlines, and the known centerline course of the synthetic dataset. results: bm demonstrated unacceptable performance in large vessels (> 5 mm) when the shift used was less than 3 voxels. rcmg demonstrated a greater error (mean of the error 4.73 mm) in large diameter (> 15 mm) vessels than in small diameter (< 15 mm) vessels (mean of the error 0.64 mm). because rht and fe use canny edge detector preprocessing, both are sensitive to noise. cog and rct keep the mean of the error-distance significantly smaller (0.7 mm and 0.9 mm respectively) than all other algorithms. conclusion: cog and rct algorithms provide the most efficient centerline approximation over a wide range of vessel diameters. detection of the adamkiewicz artery by subtraction magnetic resonance angiography h. hyodoh, r. shirase, h. akiba, m. tamakawa, k. hyodoh, k. aratani, n. kawaharada, k. morishita, m. hareyama; sapporo/jp purpose: to assess the ability of magnetic resonance angiography (mra) to depict the adamkiewicz artery. materials and methods: fifty-one patients with thoracoabdominal disease underwent mra of the bypass graft region. subtraction maximum intensity projection (mip) images and cine-mode displays were produced to identify the adamkiewicz artery, its side of origin and branching level, and the drainage vein. for statistical analysis, signal intensity ratio (snr) and contrast noise ratio (cnr) were also calculated. results: in 46 (90.2%) of the 51 patients, at least one adamkiewicz artery was seen to arise from an intercostal artery. two adamkiewicz arteries were identified in 9 (19.6%) of the 46 patients. spinal drainage veins were visualized in 41 (80.4%) of the 51 patients, a single drainage vein in 30 of the 41 (58.8% of the total patient group) and two drainage veins in the remaining 11 (21.6% of the total patient group). in 19 of the 46 patients, both the adamkiewicz artery and the drainage vein were detected during the early phase. conclusion: subtraction mra depicts the adamkiewicz artery in a high percentage of patients. 16-row multislice computed tomography of pulmonary veins: assessment before and after cryothermal energy ablation r. maksimovic 1 , f. cademartiri 2 , m. scholten 2 , l. jordaens 2 , p.m.t. pattynama 2 ; 1 belgrade/yu, 2 rotterdam/nl purpose: electrical isolation of the pulmonary veins (pvs) with radiofrequency ablation in treatment of patients with paroxysmal atrial fibrillation is associated with pv stenosis. cryothermal ablation (ca) is a new promising method in treatment of these patients. although initial experience of ca showed no associated pv stenosis, results at follow-up have not been reported. the aim of the study was to assess pvs for the presence of stenosis three months after ca by contrast enhanced angiography on 16-row detectors multislice computed tomography (msct). materials and methods: twenty four patients (mean age 52.6 ± 7.6 years, 15 males) with symptomatic atrial fibrillation underwent ca in 46 pvs. all patients underwent complete clinical work-up, electrophysiological study, ultrasonography and msct angiography before ca. msct pulmonary angiography was performed three months after the procedure to evaluate ostium and the proximal 10 mm of all pvs. results: dimensions of the treated pvs remained unchanged: the coronal ostial diameter was 19.1 ± 2.4 preprocedural vs. 18.6 ± 2.4 mm at follow-up, p < 0.05, ratio of coronal and axial diameter 1.2 ± 0.2 vs. 1.2 ± 0.1, p < 0.05, respectively and the coronal diameter of the proximal 10 mm from the ostium 17.1 ± 2.5 mm vs. 16.5 ± 2.2 mm, p < 0.05, respectively. conclusions: ca of pvs in atrial fibrillation has not been associated with stenosis at the orifice and proximal 10 mm of the pvs after three months follow-up. msct pulmonary venography is a reliable, noninvasive method for assessment of pvs in a three-dimensional manner prior to ablative treatment and during the follow-up period. magnetic resonance venography without contrast media for patients with lower extremity varicose veins j. koizumi 1 , m. wada 2 , t. horie 1 , e. kimura 1 , i. muro 1 , k. myojin 1 , t. niibori 2 , y. imai 1 ; 1 isehara/jp, 2 wako/jp purpose: to compare three different sequences of magnetic resonance (mr) venography without contrast media for patients with varicose veins below the knee. materials and methods: for 23 patients with lower extremity varicose veins, mr-venography using time-of-flight (tof), fat suppressed t2-weighted turbo spin echo (tse) and balanced turbo field echo (btfe) were compared.the original images on 1.5 tesla gyroscan (philips) were transferred to a workstation (m900 quadra, ziosoft inc.) and 3d images were reconstructed using maximum intensity projection (mip), multiplaner reformation (mpr), and volume rendering (vr) techniques. for analysis, the veins were divided into superficial, deep venous systems, perforating and varicose veins, and were evaluated using three points scale by a radiologist and a surgeon.results: superficial, deep venous systems and perforating veins were best visualized on btfe (p < .05), while varicose veins were equally visualized on tse and btfe. tof provided poor visibility except in popliteal veins. coexisting arterial system seen on btfe could be discriminated from the deep venous system especially on axial reconstructed images. the varicose veins connected with the superficial venous systems and perforating veins on the surface of the muscle were easily recognized on vr only using btfe. conclusions: mr-venography using btfe displays the best images of the whole venous system in patients with varicose veins below the knee. magnetic resonance angiography in potential live renal donors: a joint radiological and surgical audit a. mizzi, g. roditi, m. subramaniam; glasgow/uk purpose: to assess the impact of joint surgical and radiological audit on the accuracy of mra reports in the evaluation of potential live renal donors. materials and methods: we analysed the case records of live renal donors who underwent gadolinium enhanced mra as part of pre-operative evaluation to assess renal vasculature between august 1999 and july 2002. in cases of discrepancy between mra reports and surgical findings, studies were retrieved to the mri workstation and subjected to detailed joint clinical and radiological review. scan quality was assessed and sources of discrepancy were identified. results: there were 45 donors, 23 men and 22 women. reported mra findings were fully confirmed at surgery in 38 of 45 cases. these scans were not analysed further. in 7 donors, the findings at surgery were discrepant with the radiological reports. there were 4 cases of "missed" early branches and 3 cases of "missed" accessory arteries. in the first year of audit there were 4 discrepant cases out of 18 (22%), all of which were radiological reporting errors. the number of discrepant cases in the second year dropped to 2 out of 19 cases (11%). neither of these was a radiological reporting error. there was one "missed" early renal artery branch in the third year of audit, which was visualised on mra review. conclusion: the accuracy of preoperative mra in potential live renal donors is high. radiological reporting of mra examinations is improved through careful clinical feedback, audit and interdisciplinary co-operation. 3d contrast-enhanced mr portography to scan the entire volume of upper abdomen with maximal spatial resolution using parallel acquisition techniques: preliminary experience d. horák, m. herman, j. bucil, j. klein, j. nekula; olomouc/cz purpose: to assess the feasibility and to evaluate the benefit of a 3d contrastenhanced (ce) mr portography (mrp) covering the entire volume of upper abdomen with maximal spatial resolution using grappa (generalized autocalibrating partially parallel acqusitions). materials and methods: 12 patients were examined before or after surgical creation of porto-systemic shunt. t1-weighted 3d angiographic sequence with 3d centric reordering optimized using a grappa factor of 2 was performed at a 1.5 t scanner (siemens symphony maestro class) in three phases after administration of 30-40 ml of 0.5-molar or 15 ml of 1-molar gadolinium-dtpa followed by 20 ml saline solution into the canula in antecubital vein. anatomical postcontrast t1-weighted 3d spoiled gre with fat saturation was added. parameters of hires 3d-ce-mra sequence: in-plane resolution = 1.5 x 0.9 mm, number of partitions = 80, slice = 2.5 mm, partial-fourier = 6/8, fov = 400, tr/ te/fa = 3.55/1.28/25, ta = 27 sec. results: large evaluated volume hires mrp sequence is suitable for detailed postprocessing (subvolume mips) in any plane, imaging borderline vessels like recanalized umbilical vein or retroperitoneal collaterals, usually best seen in portal phase. robust protocol can be very easily adapted for uncooperative patients covering the same evaluated volume. functional information (flow direction) can be added with phase contrast mra flow quantification sequence. conclusion: our preliminary results show that the application of grappa allows to capture the whole portal vascular system without missing any important collateral with high spatial resolution in cooperative patients and with sufficient spatial resolution in non-cooperative ones. it's possible to image the flow in surgically placed porto-systemic shunts. gadobenate dimeglumine (multihance®) in contrast-enhanced mr angiography m. kirchin 1 , r. la ferla 1 , m. daprà 1 , g. pirovano 2 , a. spinazzi 2 ; 1 milan/it, 2 princeton, nj/us purpose: gadobenate dimeglumine (gd-bopta) has high t1 relaxivity in blood (r1 = 9.7°mm-1 s -1 ) compared to other gadolinium agents. this review is aimed at defining the usefulness of gd-bopta for ce-mra. methods: preliminary intraindividual, crossover studies were conducted in healthy volunteers to compare gd-bopta and gd-dtpa at the same dose and injection rate for mra of the abdominal aorta and run-off vasculature. subsequently, phase ii multicenter trials were performed in the renal/abdominal arteries (n = 94 patients), the pelvic arteries (n = 136 patients) and the carotid arteries (n = 163 patients) to establish the optimum dose of gd-bopta for ce-mra. standard unenhanced and contrast-enhanced sequences were employed and images were evaluated by independent, off-site blinded radiologists on the basis of segmental and overall diagnostic quality scores per patient and dose. the crossover studies demonstrated significantly greater signal intensity enhancement after gd-bopta compared to gd-dtpa both in the abdominal aorta and run-off vasculature. the phase ii studies revealed dose-related trends for the contrast-enhanced images in each territory and good correlation between readers. the greatest increase in diagnostic quality from unenhanced mra to ce-mra occurred at 0.1 mmol/kg bw while a higher dose of 0.2 mmol/kg bw provided little or no additional benefit. ce-mra led to an increased number of patients with lesions detected and increased reviewer confidence for lesion characterization. conclusions: ce-mra with gd-bopta is more efficacious than unenhanced mra and appears superior to ce-mra with conventional gadolinium chelates. the optimum dose for ce-mra of vascular disease is indicated to be 0.1 mmol/ kg bw. influence of ct scanner and observer on volume measurement: five glass phantoms filled with diluted contrast material underwent one single-detector row ct (sdct) and two multi-detector row ct (mdct) examinations. for each ct scanner the clinical protocol for ct angiography of the abdominal aorta was used. in a first step the resulting 15 volumes were measured using a special software with automatic outline detection without need of manual segmentation and thus without intra-and interobserver variability to evaluate differences between the ct scanners. in a second step the volumes were measured by three observers using a standard software for manual outline detection to assess inter-and intraobserver variability. results: there was no statistically significant difference between the ct scanners with the corresponding standard protocols (p = 0.27). inter-and intraobserver variability was 7.2 and 2.6 ml and lead to significant difference in volume measurement between the observers (p = 0.002). conclusion: volume measurement does not seem to be influenced by the used ct scanner. the interobserver variability is significant, but slight. consequently, changes of the volume of abdominal aortic aneurysms in follow-up ct angiography after endovascular repair can be considered as true change and not as scanner related. 16-slice multi-detector ct angiography in the assessment of stenoocclusive disease of the carotid artery bifurcation and vertebral artery origin s. lee, h. roh, h. byun; seoul/kr purpose: to determine the accuracy of 16-slice multi-detector ct angiography (16-mdcta) in the assessment of steno-occlusive disease of the carotid artery bifurcation and vertebral artery origin. materials and methods: in 24 patients, 48 carotid arteries and 48 vertebral arteries were evaluated with 16-mdcta and conventional digital subtraction angi-ography (dsa). standardized 16-mdcta acquired from the circle of willis to the aortic arch. 16-mdcta data were displayed with maximum intensity projection (mip) for carotid and vertebral arteries and with volume rendering (vr) for carotid artery. the percent diameter stenoses of the carotid artery bifurcation and vertebral artery origin were measured separately on mip, and/or vr ct images and dsa. the carotid stenosis was graded as no, mild (< 30%), moderate (30-70%), severe (> 70%), and occlusion with nascet criteria. the vertebral artery stenosis was also assessed with the same five-grade scale. the results of 16-mdcta were correlated with the gold standard of dsa. results: all carotid and vertebral arteries were assessable on mip and/or vr ct images. correlation between stenosis measured with 16-mdcta and that measured with dsa were good (pearson correlation: on carotid mip images, c = 0.983, < 0.001; on carotid vr images, c = 0.992, < 0.001; on vertebral origin mip images, c = 0.984, < 0.001). the aggrement rate of stenosis grading between 16-mdcta and dsa was also high (91.7% on carotid mip; 93.8% on carotid vr images; 91.7% on vertebral origin mip images). conclusion: 16-mdcta has a high accuracy for the evaluation of carotid and vertebral artery stenosis and provides multiplanar information preoperatively. does high iodine concentration contrast agent improve arterial enhancement in mdct angiography of the run off vessels? comparison of three different iodine concentration contrast agents f. venditti, c. catalano, m. francone, f. fraioli, a. napoli, v. votta, r. passariello; rome/it purpose: to evaluate whether a high iodine concentration contrast agent may determine a greater arterial contrast enhancement in the visualization of aortoiliac and peripheral vessels. materials and methods: sixty-six patients, randomly divided into two groups, a and b, were studied with a multi detector-row ct (mdct) scanner. both groups were divided in three subgroups (a1 = 300, a2 = 350 and a3 = 400 mgi/ml; b1 = 300, b2 = 350 and b3 = 400 mgi/ml) in which different iodine concentrations were injected. in group a variable flow rates were used. in group b the flow rate was kept constant at 3.5 ml/s. quantitative and qualitative analyses were performed at predefined fixed vascular segments. results: in both groups a greater density value was achieved using the high concentration contrast agent, in particular at the level of the superficial femoral artery for subgroup a3 and at the level of the popliteal artery in subgroup b3. for all vascular segments the best enhancement was visualized for group b3. no statistical significant differences were achieved between the two different groups in the visualization of sub-popliteal vessels. conclusion: our study demonstrates that the use of a high iodine concentration contrast agent increases arterial enhancement of the peripheral arterial tree using mdct scanner. multidetector ct angiography in arterial occlusive disease of the lower extremities: a step forward in vascular diagnostic procedures? m. maggi, s. alborino, e. paci; ancona/it purpose: multidetector computer tomography (mdct) angiography is a new available technique for studying arterial disease of the lower limbs. in this study we report our experience with mdct angiography in evaluating atherosclerotic lesions of peripheral arteries. materials and methods: 60 patients (36/24 male/female, age 63 ± 10, 45 in 2 and 15 in 3 rutherford category) were investigated by mdct between april 2002 and march 2003, 30 patients underwent digital subtraction angiography (dsa) of the lower extremities within 20 days from mdct angiography. we used a 4-8 channels ge medical system ct-scanner, 18 needle-cannula, flow rate 4 ml/ sec, 150 ml iodinated contrast medium 300/350 mgi/ml, bolus tracking program (smart prep). mip and volume rendering reformations were used. dsa and mdct angiograms were blindly evaluated by two vascular radiologists according to the following parameters: stenosis (lumen reduction 50-99%), occlusion (> 99%), absence of lesion (< 50%) in 1140 arterial segments, 19 for each patient. therapeutical implications of mdct angiography were also evaluated. results: concordance between mdct angiography and dsa was 92.3% in detecting and 96.9% in excluding lesions, 66.7% in defining stenosis and 85.5% for occlusions. in 21/30 patients percutaneous approach was modified according to ct images. conclusions: mdct angiography could be considered as the first step in diagnostic procedures of peripheral arterial disease and could also modify therapeutical strategy and vascular radiologist's performance. further studies are needed value of long-term routine ultrasound assessment of hemodialysis fistulae in comparison with clinical parameters a. wojciechowski, m. golebiowski, m. grzeszczyk, w. kania; warsaw/pl purpose: the aim of the study was to correlate the results of clinical and ultrasonographic long term follow-up of hemodialysis fistulae. the utility of routine ultrasound examination was discussed. materials and methods: 86 patients underwent doppler ultrasound evaluation of dialysis fistulae. patients were randomly assigned for evaluation. in addition routine tests for blood cell count, hematocrit, kt/v, urr and blood pressure in the venous line were available in all patients. all patients had native fistulae. a single unit (atl ultramark 9 hdi) was used for ultrasound examinations. results: results of laboratory and clinical parameters were abnormal in almost 50% of patients. low levels of hematocrit (< 30%) were observed in 47.7%, albumin (< 4.0 g/l) in 36.6%, elevated pressure in venous line (> 140 mmhg) in 22.1%. abnormal kt/v (< 1.0) and urr (< 60%) in 32.6 and 36.6% respectively. us revealed: pseudoanerysms in 5.8% of patients, hematomas adjacent to the fistula 10.5%, arterial steal syndrome in 11.6%, stenosis in 25.6% and mural thrombi in 40.7%. in 8.1% of patients brachial artery blood flow was less than 300 ml/min and in 7% of cases dialysis fistula flow was greater than 2100 ml/min. conclusion: only 11.6% patients had no abnormal either clinical, morphological nor flow parameters. 44.2% of patients had abnormal clinical and us morphological parameters. colour doppler ultrasound is more sensitive than clinical or laboratory methods in detection of hemodialysis fistula dysfunction. it is strongly recommended to start regular ultrasound examinations of all dialysed patients. material and methods: 50 patients with brescia-cimino-shunts were examined by independent examiners with i. a. dsa and vascular ultrasound. all patients had a shunt-volume of less than 400 ml/min., an angiographical stenosis of the anastomosis of at least 50% or changes of the venous portion of the shunt were examined. studies were performed with the aid of a multifrequency ultrasound probe (5-10 mhz, logic 700, 9, ge) using b-mode, color coded duplex (ccd) and b-flow, first of all in the brightness modification. results: in the group of anastomotic stenosis measurements of intrastenotic diameter gave for i. a. dsa values of (average: 2.33 mm), for b-mode (average: 2.56 mm), for ccd (average: 2.88 mm), for brightness mode of b-flow (average: 2.27 mm) and for b-flow with b-mode information values of (average: 2.37 mm). the best agreement with dsa was achieved by brightness mode of b-flow. while in b-flow in cases of anastomotic lesion or venous stenotic lesions, hypoechogenic vessel wall alterations were detected, they were not seen in b-mode in any case and not reliably in ccd due to blooming artifacts. in cases of venous aneurysm and vascular elongation a flow detection free of artifacts was only demonstrated by b-flow. conclusion: ultrasound b-flow detects anastomotic stenosis of hemodialysis fistula better than other ultrasound modes. the visualization of hypoechogenic vessel wall alterations and the degree of stenosis is also better appreciated by this mode. ultrasonographic assessment of internal mammary artery in the screening of radiotherapy induced coronary artery disease n. tuncbilek 1 , o.o. okten 1 , h.m. karakas 2 ; 1 edirne/tr, 2 malatya/tr purpose: radiotherapeutically treated breast carcinoma patients are prone to the development of iatrogenic fibrosis and plaque formation in coronary vasculature. in this group of patients, early changes in the diameter and the flow characteristics of internal mammary artery, hypothesised as the surrogate markers of the coronary artery disease, were ultrasonographically (usg) investigated. the study group was consisted of 33 breast cancer patients with ages between 23 and 77 (mean age 47.3 yrs) and 15 age-matched control subjects. all patients were radiotherapeutically treated 6 to 24 month ago. internal mammary arteries were ultrasonographically investigated with 7.5 mhz linear transducer in longitudinal planes. diameters of the arteries were measured in m-mode; resistivity indices (ri), pulsatility indices (pi), peak systolic and end diastolic values were measured with color doppler usg. mean values of the above mentioned parameters were statistically compared among patient and subject groups. results: mean diameter of the internal mammary arteries were found to be 19.02 mm in patients and 36.57 mm in control subjects. there was a statistically significant difference between two groups regarding the stated parameter (p < 0.001). in contrary, the difference of ri, pi, peak systolic and end diastolic values were not statistically significant in two groups studied. conclusion: shortly after radiotherapy the diameter of the internal mammary artery significantly decreases but its flow spectrum does not change. ultrasonographically performed simple diametric measurements may be used as rapid and noninvasive screening tests to predict the development of coronary artery disease. assessment and follow-up of endovascular repair of aortic aneurysm with multislice computed tomography m. fernández -velilla, m. martí, y. herrero, j. echeveste, g. garzón, n. gómez-león; madrid/es purpose: to evaluate the usefulness of multislice computed tomography (msct) after placement of endovascular stent-grafts for treatment of aortic aneurysms. matrials and methods: seventy-six patients underwent msct angiography following treatment of thoracic or abdominal aortoiliac aneurysm with endoluminal stent-grafts. msct was performed from the supracoeliac aorta to the femoral artery bifurcation in patients with aneurysm affecting the abdominal aorta (n = 70), and from the thoracic inlet to the femoral bifurcation in patients with thoracic aneurysm (n = 6). the standardized protocol consisted of a nonenhanced ct (3 mm collimation, pitch of 4, reconstruction interval of 2 mm, table speed of 16 mm per rotation and a single-breath-hold acquisition), followed by a contrast-enhanced ct. all images were postprocessed in a workstation (vitrea 2; vital images, plymouth, minn). the image postprocessing included multiplanar reformats, mip, shaded-surface display, and volume rendering. the studies were assessed for stenosis, thrombosis, perigraft leakage, migration, angulation of graft, and enlarging sac size without visible endoleak (endotension). follow-up ct was performed prior to discharge and at six and twelve months after intervention. results: after stent-graft placement in the 76 patients, ct demonstrated graft permeability in 76 (100%), perigraft leaks in 17 (22%), angulation of the graft in 9 (12%) and endotension in 2 (2.6%). conclusion: msct was able to study the entire aorta with a maximal and homogeneus opacification. the msct technique allowed fast scanning, great anatomic coverage during a single breath hold, few motion artefacts, and high spatial resolution in the longitudinal plane, improving the diagnostic accuracy of the examinations. evaluation of vertebral artery using color duplex sonography: comparison of vertebral artery velocity and flow volume measurements for diagnosis of vertebrobasilar insufficiency m. acar, b. degirmenci, a. yucel, r. albayrak; afyon/tr purpose: the aim of this study was to compare the measurements of vertebral artery (va) flow velocity and flow volume for diagnosis of vertebrobasilar insufficiency. matrials and methods: we examined 96 patients referred for evaluation of vertebrobasilar insufficiency. net va flow volume and mean systolic flow velocity were determined by using color duplex sonography. we grouped the patients into three: group 1 consisted of patients with severely damped va flow volume (< 120 ml/min), group 2 moderately damped (120-200 ml/min) and group 3, normal (> 200 ml/min). the mean systolic flow velocities in each group were compared by one-way anova. results: damped va flow volume was determined in 56 of 96 patients, of these patients 18 had severely damped, 38 had moderately damped, 40 had normal va flow volume. mean va systolic flow velocities of group 1, 2 and 3 were 32 ± 12, 42 ± 10 and 46 ± 8 cm/sec, respectively. mean va systolic flow velocity in group 1 was significantly lower than that of group 2 (p = 0.001). however there were no significant differences between va systolic flow velocities in group 2 and group 3 (p = 0.2). conclusion: according to our findings, measurement of va velocity is enough for diagnosis of vertebrobasilar insufficiency in patients with severely damped va flow volume but may not always be helpful in differentiation of moderately damped flow volume from normal. therefore we conclude that for the diagnosis of vertebrobasilar insufficiency, measurement of volume in addition to velocity is necessary in detection of moderately damped va flow volumes. rotational angiography of femoropopliteal arteries after percutaneous transluminal angioplasty (pta): preliminary results f. pozzi-mucelli, m. belgrano, g. tona, r. pozzi-mucelli; trieste/it purpose: to report our experience in rotational angiography (ra) after pta of the femoropopliteal arteries and to compare this modality to standard anteroposterior (ap) projection. materials and methods: forty patients underwent pta of the femoropopliteal arteries in the last 12 months. twentysix were stenoses (lenght: 1-5 cm) and 14 occlusions (lenght: 3-10). in all cases pta was successful and the result was checked with ap projection and with an ra acquisition. the procedure were performed on the philips integris allura system providing the ra tool. results: ra after pta was successful in all cases. in 42% of cases there was no difference between the static ap projection and ra, whereas in 47% the static acquisition, compared to ra, underestimated the degree of residual stenosis by 10-30%. in about 40% of these cases a disagreement on the presence and extent of subintimal flaps between static and rotational acquisition was identified. in another 11% of cases there was substantial agreement on the residual stenosis but not on the pta-induced dissection which was always better identified on ra. conclusions: ra allowed optimal evaluation of all cases improving the information on the conventional technique based on one or two projections. in our experience this information modified our therapeutic approach leading to repeated balloon angioplasty or stenting in 46% of cases. all the diagnosis were confirmed by digital angiography or surgical treatment. in the first group (endoluminal repair), the complications were: a) periprosthetic hematoma (n = 2); b) neointinal hyperplasia (n = 2); c) partial stent-graft thrombosis (n = 4); d) total stent-graft thrombosis of an iliac branch (n = 7); e) endoleak type ii (n = 4); f) endoleak type iii (n = 4), separation of the stents' components (n = 1). in the second group (surgical repair) we observed: a) periprosthetic infections (n = 3); b) supraprosthetic aneurysm (n = 1); c) pseudoaneurysm (n = 2); d) aortoenteric fistula (n = 2). conclusion: cta is accurate, fast and minimally invasive imaging method in the evaluation of complications after abdominal aortic aneurism repair. interobserver agreement in the ct evaluation of carotid artery stenosis p.m. carrascosa 1 , f. meli 1 , c. capuñay 1 , t. sampere 1 , e. martin lopez 1 , d. smith 2 , s. chandra 2 , j. carrascosa 1 ; 1 buenos aires/ar, 2 cleveland, oh/us objective: to determine the usefulness of ct angiography (cta) in the detection and quantification of carotid stenosis in comparison with da. materials and methods: thirty-eight carotid arteries were evaluated in 19 patients with transient ischemic attacks. ctas were performed with a helical ct scanner (pq 5000; picker). images were evaluated by two radiologists, who were blinded to the percentage of stenosis determined by da. the stenosis were considered positive if they were ≥ 70%. different methods of stenosis quantification (nascet(n), esct (e) and area quantification (a)) were performed on the same vessel to determine the sensitivity and specificity of each one in comparison with da. interobserver variability of the three methods was evaluated. statistical analysis: kappa coefficient was performed to determine the interobserver variability. results: observer 1: sensitivity: n: 94%, e: 77% and a: 94% and specificity: 91%, 87.5% and 87.5% for each method, respectively. observer 2 = sensitivity: n: 77%, e: 77% and a: 74% and specificity: 91%, 87.5% and 95% for each method, respectively. kappa: 0.83, 0792 and 0.78 for n, e and a respectively. conclusion: cta showed high s and sp in the carotid stenosis quantification, specially with the nascet method. emergency multislice ct angiography (mscta) in patients with suspected aortic dissection r. stern padovan, m. lusic, b. oberman, k. potocki; zagreb/hr purpose: the purpose of the study was to evaluate positive msct-angiography findings in patients with spontaneus-nontraumatic aortic dissection. mscta is a noninvasive, time-saving radiological procedure for patients with aortic dissection because they need prompt and accurate diagnosis and treatment. aortic dissection is defined as a separation of the inner aortic wall layers. it is divided by stanford classification into type a that involves the ascendent aorta and type b involves distal to the origin of the left subclavian artery. materials and methods: mscta was performed in 42 patients (14 (33.5%) female and 28 (66.7%) male age 18 -81) with clinically suspected aortic dissection over a period of 14 months on lightspeed ultra 8 slices, ge. slice thickness was 2.5 mm with 50% overlap of reformatted images. we injected 100-120 ml of nonionic contrast material at a flow rate of 4 ml/sec with smart prep feature. mip and mpr were usually used. results: aortic dissection was found in 29 (67.4%) patients. 21 (72.4%) had acute aortic dissection and 8 (27.6%) chronic type. acute aortic dissection stanford type a was found in 13 (62%) and type b in 8 (38%). in 13 patients we did not find aortic dissection but other ct findings could explain the symptoms: aa, rupture of aa, mesenteric ischemia, pericardial effusion. conclusion: mscta is noninvasive, rapid and relatively comfortable radiological procedure for patients with suspected acute aortic dissection in cardiovascular emergency. this technique enables correct and detailed diagnostic information and obviates catheter aortography. diagnosis of aortic and supraaortic emergency with ct angiography: how does aortic morphology influence the choice of treatment? c. engelke 1 , k. marten 1 , a. chavan 2 , j.f. reidy 3 , a.-m. belli 3 , e.j. rummeny 1 ; 1 munich/de, 2 hannover/de, 3 london/uk objective: ct angiography (cta) is the imaging method of choice for diagnosis of aortic and supraaortic emergency. in this retrospective evaluation of patients with aortic or supraaortic emergency undergoing intial cta at four european centres diagnosis and determination of treatment are reviewed. the assessment of diagnostic value of vmax, vmin, pi, ri measurements in the diagnosis of coeliac trunk stenosis before and after levovist injection -roc curves analysis a. drelich-zbroja, t. jargiello, w. krzyzanowski, p. kurczab, m. szczerbo-trojanowska; lublin/pl purpose: to assess the diagnostic value of vmax, vmin, pi, ri measurements in the diagnosis of coeliac trunk stenosis before and after levovist injection. in 100 patients doppler examination of coeliac trunk before and after levovist injection was performed measuring vmax, vmin, pi, ri. in conventional doppler 23 and after levovist administration 29 stenoses were diagnosed. number of diagnosed stenoses in relation to number of normal coeliac trunks was representative enough to perform the statistical analysis using roc curves. results: 1. the areas under curves (aucs) for vmax, vmin, pi, ri, before and after levovist. 1a. before levovist: aucvmax = 0.947*, aucvmin = 0.860*, aucpi = 0.537 ns , aucri = 0.509 ns . 2a. after levovist: aucvmax = 0.984*, aucvmin = 0.918*, aucpi = 0.551 ns , aucri = 0.546 ns . *p < 0.05 when compared with auc = 0.5; ns-not significant when compared with auc = 0.5 2. the comparison of aucs for vmax and vmin before and after levovist. aucvmax after levovist -aucvmax before levovist = 0.037 ns , aucvmin after levovist -aucvmin before levovist = 0.058 ns , aucvmax before levovist -aucvmin before levovist = 0.087*, aucvmax after levovist -aucvmin after levovist = 0.066*. *p < 0.05; ns-difference not significant conclusions: only vmax and vmin are useful in the diagnosis of coeliac trunk stenosis. the diagnostic value of vmax is significantly higher than diagnostic value of vmin. the use of levovist has no an effect on diagnostic value of vmax and vmin. the effect of body mass index on the ultrasonographic measurements of the portal venous system n. tuncbilek 1 , o.o. okten 1 , s. guldiken 1 , h.m. karakas 2 ; 1 edirne/tr, 2 malatya/tr purpose: the effect of body mass index (bmi) on portal venous diameter and pulsatility index was investigated. the study group consisted of 29 obese and 12 control subjects with normal bmi. inferior vena cava (vci) and portal vein (pv) diameters and their pulsatility indices (pi) were prospectively evaluated with 3.5 mhz convex transducer. diametric measurements were employed in m-mode imaging. the difference between obese and normal subjects regarding above mentioned parameters and their correlations with pi are investigated. results: bmi varies between 16.8 and 22.2 kg/m 2 in control, and between 28.3 and 44.5 kg/m 2 in obese subjects. in control subjects, mean pi is 0.65 for pv and 0.75 for vci. in obese patients, these values are 0.49 and 0.65, respectively. pi for pv significantly differs between two groups (p < 0.01) whereas vascular diameters for vci and pv, and pi for vci are not statistically different. in both groups there is a negative correlation between pi and bmi (for control subjects: r = -0.415, p < 0.01; for obese subjects r = -0.519, p < 0.01). conclusion: pi of the portal venous system is regarded as the surrogate marker of right cardiac function. however factors such as inspiratory and expiratory intraabdominal pressure changes are known to affect this parameter. when considering pi as a marker of right cardiac function, attention must be paid to the relation of pi and bmi, proved by this study to be one of these factors. significance of patent pyloric branch in hepatic arterial infusion chemotherapy s. yoshioka, y. yasuhara, t. murakami, s. kumano, t. mochizuki; ehime/jp purpose: to investigate the clinical significance of the patent pyloric branches after right gastric artery (rga) embolization for arterial infusion chemotherapy. materials and methods: sixty-six patients who received catheter placement in the hepatic artery for arterial infusion chemotherapy were retrospectively recruited from the pool of clinical records between 1998 and 2003. two interventional radiologists reviewed the digital subtraction angiographies (dsas) and clinical records of these patients. they assessed the following items by consensus: 1) location of the rga, 2) frequency of the patent pyloric branchs after coil embolizaton of the rga, 3) outcome of arterial infusion chemotherapy through the catheter. results: the location of the rga could be determined in 58 patients. rga-coil embolization was performed in 36 patients. in 7 patients, fine pyloric branchs were patent after embolization. they were too fine to be embolized by the catheter technique. in 2 of these 7 patients, the catheter was successfully placed to avoid the drug infusion into the pyloric branch. the clinical outcome of the other 5 patients were as follows: one patient received the arterial infusion chemotherapy without any complication. one patient experienced transient abdominal pain in the course of arterial infusion chemotherapy. two patients received replacement of the catheter because of abdominal complication. the last patient received surgical ligation of the rga because of reopening of the rga. conclusion: the frequency of abdominal complication in arterial infusion chemotherapy was not negligible in the cases with patent pyloric branchs after rga embolization. erdheim-chester disease: imaging features c. graef, e. dion, p. cluzel, r. renard-penna, j. haroche, b. wechsler, c. beigelman-aubry, p.a. grenier; paris/fr learning objectives: to be familiar with the radiologic features of erdheim-chester disease, a rare form of non-langerhans cell histiocytosis of unknown etiology. background: the disease is characterized by tissue infiltration with lipid-laden foamy histiocytes, polymorphic granuloma of inflammatory cells and collagen fibrosis. the patients have a mosaic of infiltrative involvement of various organs. bone involvement is almost always present but often clinically asymptomatic. the prognosis depends on the severity of cardiovascular, renal or cerebral involvement. imaging features of 10 histologically proven cases were reviewed. imaging features: radiological bone involvement was present in all cases, characterized by bilateral and symmetrical spongy bone densification, cortical thickening and periostosis of long bones from the metaphysis to the diaphysis associated with scintigraphic tracer uptake. renal and perirenal involvement seen on ct scans consisted of bilateral and symmetrical perirenal tissue infiltration (hairy kidney) (n = 6), extended to the adrenal fossae, the renal sinuses, and the proximal ureters. cardiovascular involvement consisted in 1) thoracic and abdominal circumferential periaortic tissue infiltration (coated aorta) with extension to the coronary, supraaortic and pulmonary arteries, and abdominal branches, 2) stenosis of renal or mesenteric arteries (n = 3), 3) involvement of pericardium (n = 2) and myocardial mass (n = 1). tissue infiltration involved pituitary in one case and orbits in another one. conclusion: a diagnosis of erdheim-chester disease should be considered in patients who demonstrate bilateral and symmetric densification of the long bones with increased uptake on scintigraphy in association with perirenal fat infiltration and/or a periaortic fibrosis. human nk-92 cells were labeled with ferumoxides and ferucarbotran using simple incubation, lipofection and electroporation techniques. incubation times were varied from 2-24 hours and added contrast agent concentrations were varied from 100-300 microgram fe/1000000 cells. pellets of labeled cells and non-labeled controls were evaluated by mr imaging. the cellular iron oxide uptake was proven by prussian blue stains and spectrometry as a standard of reference. in addition, cell viability was tested with the trypan blue exclusion test. differences between labeled cells and non-labeled controls were tested for significance using the t-test. results: nk-92 cells could be labeled with ferucarbotran and ferumoxides by lipofection and electroporation, but not simple incubation. lipofection had to be performed for 24 h, but resulted in only minor, not significant impairment of cell viablility (88-92%) compared to controls (96-98%), while electroporation caused cell labeling within seconds, but reduced the viablility of the cells significantly (61-74%), thereby necessitating additional cell culture time for cell recovery. the intracellular iron oxide uptake was proven histologically and quantified by spectrometry. ferucarbotran and ferumoxides-labeled cells could be depicted by a significant signal decline on t2*weighted mr images. conclusion: human nk-92 cells can be labeled with ferucarbotran and ferumoxides by lipofection and electroporation. optimized labeling techniques allow a subsequent cell depiction with a standard 1.5 t mr scanner. which temporal frame rate is necessary in quantitative dynamic ³he-mri? c. heussel 1 , a. dahmen 1 , f. lehmann 1 , m. salerno 2 , k.k. gast 1 , h.-u. kauczor 1 , j.p.i. mugler 2 , e.e. de lange 2 , w. schreiber 1 ; 1 mainz/de, 2 charlottesville, va/us purpose: dynamic ³he-mri permits regional analysis of distribution ventilatory kinetics. dedicated post-processing offers image-based lung function parameters. sliding window reconstruction of interleaved-spiral acquisitions provides high temporal rates, but do functional parameter values depend on the temporal frame rate? methods and material: single-slice coronal dynamic ³he-mri was acquired continuously for 15 s during free respiration. image reconstruction was performed using sliding window technique with 3.4 ms data sampling-time (repetition-time 10 ms). post-processing was performed using a self-written software with linear motion correction for calculation of: rise time (tr, interval of lung-signal from 10% to 90% of peak signal), delay-90 time (td90, interval of trachea-signal 50% and lung-signal 90%), amplitude (peak lung-signal), and peak flow (pf, maximum signal slope). analysis was done for 6 rois using a temporal resolution of 20 ms, 120 ms, and 240 ms (2 nd , 12 th , and 24 th image). this study included 4 exemplary patients (asbestosis, 2 x asthma, copd) so far. results: post-processing of the data-sets lasted 30 to 120 mins at an actual pc (2.4 ghz p4, 2 gb ram). tr ranged from 418 to 1707 ms (median 859 ms), td90 ranged from 228 to 1427 ms (median 753 ms), amplitude ranged from 13 to 557 a.u. (median 130 a.u.), pf ranged from 12 to 710 a.u. (median 207 a.u.). no relevant difference was detected in the evaluation of different temporal frame rates for all patients or within an individual patient. conclusion: since these preliminary data suggest a limited effect of high temporal frame rates, improvement of spatial rather than temporal resolution might be the emphasis in the future. to determine the compensatory mechanisms involved in recovery of motor function following resection of the supplementary motor area (sma) and their relation to the clinical characteristics of recovery. subjects and methods: thirteen patients referred for surgery of low-grade gliomas located in the sma were compared to nine healthy controls using fmri before and after surgery during self-paced movements of both hands, successively. activation within regions of interest (rois) (primary sensorimotor cortex (smc), premotor cortex (pmc), sma) were compared and tested for correlation with anatomical characteristics of the tumor and resection, and clinical data. interaction analysis between rois was performed using partial correlation. results: tumor growth induced preoperative underactivity in the adjacent sma and overactivity in the opposite sma. postoperative recovery was associated with recruitment of the lateral premotor cortex in the healthy hemisphere. in the affected hemisphere, pre-and postoperative correlations between sma, pmc and smc were decreased. in the healthy hemisphere, postoperative correlations between pmc and sma or smc were increased. shortened onset and duration of recovery was associated with preoperative changes in sma activation. conclusions: these findings suggest that tumors induced a dysfunction in activation and connectivity of the ipsilateral sma, which was partially compensated by a recruitment of the sma in the healthy hemisphere. this preoperative remodeling of sma activity did not prevent the occurrence of the postoperative deficit but was associated with shortened recovery. sma resection was compensated by the recruitment of an ipsilateral premotor circuitry. the use of internet filters to build a radiology education and teaching resource p. davison, j. revell, m.r. rees; bristol/uk purpose: to develop a resource for radiology undergraduate and postgraduate education from a series of research projects dealing with internet filter aided search. supported by a research and education grant from the ear. materials and methods: two independent research projects into internet search were examined for their application to radiology education and these methods were compared to conventional image search protocols. this experience was translated into constructive advice for undergraduate students undertaking special study modules in radiology. the two internet filters developed were designed to improve accuracy of text search and to improve the search results from image search enquiries in radiology and medical subjects. a second iteration of the image search filter was developed to produce a web crawler that selected images from previously carried out text searches. the text and image based filters were tested with other search engines over a preset number of criteria. results: both the text based search facility and the image based facility showed advantages when compared to conventional search methods. the image search facility was successful in handling medical searches compared to common search engines and the web-crawler was efficient at producing a large number of images from selected sites. these methods were used to develop medical students skills in the use of the internet and has been used in the construction of radiology image based special study projects. conclusion: web based filter programmes and education in search techniques can result in improving the efficiency of internet based material for radiology education. single breath-hold subtraction: novel approach to diagnosing pulmonary embolism by multi-slice ct (work-in-progress) j.e. wildberger 1 , a.h. mahnken 1 , h. ditt 2 , m.u. niethammer 2 , e. spüntrup 1 , e. klotz 2 , r.w. günther 1 ; 1 aachen/de, 2 forchheim/de purpose: in the work-up of pulmonary embolism (pe), ct allows for direct visualization of emboli. in addition, perfusion defects permit direct assessment of the extent of pe, using color-coded lung densitometry. this new image processing technique has been deployed for a 4-slice multi-slice ct (msct) system. for further improvement, a subtraction technique within a single breath-hold will be mandatory. materials and methods: three healthy pigs underwent lung lavage to induce c-960 assessment of the angioarchitecture and hemodynamic characteristics of cerebral avms by contrast enhanced static and non enhanced dynamic mr angiography m. essig; heidelberg/de purpose: the aim was to improve the definition of the angioarchitectural components of the avm based on a dynamic mra (dmra) and a high resolution 3d multi-bolus and multi-phasic contrast-enhanced mra (ce-mra). both techniques will be compared with 3d-tof-mra and transfemoral high resolution plain film angiography performed for treatment planning. materials and methods: dmra will be performed by tracking a blood bolus through a vessel structure using the spin labeling technique star (signal targeting with alternating radiofrequency sequences). time-resolved ce-mra will be acquired with an ultrashort 3d fast low-angle shot (flash) sequence (tr/te 2.3/0.9 msec) using asymmetric k-space sampling in readout, phase-encoding, and partition directions. results: all used sequences were successful in the assessment of patients' cerebral avms. the integration of acquired images into the treatment planning protocol was possible for all modalities. the different avm compartments, feeding arteries, avm nidus, and draining veins were detected easily and best on the dmra. the method also allowed to hemodynamically assess the malformations: small avms generally showed shorter shunt times, however, a short shunt-time was associated with a higher risk of bleeding. ce-mra also proved to be superior than tof-mra in the assessment of the angioarchitecture, however, the time resolution of the dynamic varient was too slow to achieve a substantial hemodynamic characterisation. discussion: dmra and ce-mra are better suited than tof-mra to assess avm angioarchitecture. the differentiation of different compartments of the malformation and the hemodynamic assessment is best seen with dmra. diagnostic investigations in relation to determination of paramagnetic centres and free radicals in the model of testicular tumor metastases m. kekelidze, f. todua; tbilisi/ge purpose: to assess the possible connections between diagnostic imaging (spiral ct, mri) of retroperitoneal metastases of testicular tumor and the detection of paramagnetic centres and free radicals in the resected lymph node tissue after retroperitoneal lymph node dissection (rplnd). materials and methods: 23 patients with stage i morphologically confirmed nonseminomatous testicular tumors were subjected to rplnd. diagnostic imaging included abdominal spiral ct with iv contrast and mri. specific tumor markers (afp, cgt) were detected. highly sensitive (10 10 -10 11 spin/gas) electron paramagnetic resonance (epr) of 46 resected lymph node tissue was performed to detect the presence of paramagnetic centres and free radicals (fe 2+ , mn 2+ , n0) signals. ct or mri scans were judged as positive or negative for rp metastases on the basis of size, contrast enhancement criteria and compared with morphological and epr data. results: in 14 patients estimated as n0 on ct and mri the increased signals of free radicals were revealed in 2 tissues. among 9 patients (n1) with 18 resected lymph node tissue, 5 showed low signals of fe 2+ mn 2+ n0 and 13 material (morphologically confirmed as metastatic) high signals of free radicals, while the increased presence of paramagnetic centers were not detected in these tissues. spiral ct and conventional mri fail to detect micrometastases in 3 cases. there exists real correlation (p < 0.02) between the increased signals of free radicals (fe 2+ , mn 2+ , n0) and low stage metastatic lesions of rp lymph nodes, which can reflect the connection between particular molecular events and malignant degeneration. diagnostic accuracy of gadolinium-enhanced mr-angiography vs. contrastenhanced helical ct in the diagnosis of pulmonary embolism in the presence of lung infiltrate: an animal study t. franquet, s.e. kalloger, a. oikonomou, s.l. macdonald, e.m. baile, r.j. mayo; barcelona/es purpose: to compare gadolinium-enhanced mr angiography with contrast-enhanced spiral ct for the detection of small pulmonary emboli in pigs with and without pneumonia. materials and methods: ten female juvenile pigs were anaesthetized, intubated and ventilated. sub-segmental sized pulmonary emboli were introduced by injecting 4.5 mm methacrylate beads into the external jugular vein. lung infiltrates were simulated by intra-bronchial injection of human plasma. animals were imaged in the supine position at suspended inspiration with 15 cm h20 peep. contrast media was injected via brachial vein. dual gradient (twinspeed) 1.5 t mr images were acquired using 3 dimensional spoiled gradient-echo time of flight sequence; tr 4.8 msec, te 1.2 msec, 45* flip angle, 6 mm section thickness, 32 cm fov, 256 x 160 matrix, one average. two mra sets, pulmonary arterial and venous, were acquired in 39 seconds. contrast enhancement was provided by 20 ml of gd dimeglumine followed by 20 ml of normal saline, injected at 2 ml/sec. non-contrast and contrast enhanced ct images were obtained using an 8 track spiral ct; 1.25 mm detector aperture, 90 ml contrast at 3 ml/sec. subtraction perfusion images were calculated by subtracting contrast enhanced from non-contrast ct images. after imaging the pig was euthanized and a methacrylate cast of the pulmonary vasculature was obtained and used as a "goldstandard". cta, cta with subtraction perfusion images and mr images were independently interpreted by two observers in a blinded fashion. results: no significant difference (p > 0.05) was seen between cta, cta with subtraction perfusion images and mr for mean sensitivity (86%, 88% and 68%) or mean specificity (94%, 94% and 73%), respectively. no significant difference (p > 0.05) was seen in sensitivity or specificity between pigs with and without infiltrates. a prospective power analysis based upon this preliminary data indicates that the addition of two more readers (n = 4) would yield significant differences (p£0.05) between cta and cta with subtraction perfusion images compared to mra for sensitivity and specificity. conclusion: preliminary results indicate that cta and cta with subtraction perfusion images provide improved detection of sub-segmental sized pe in comparison to gadolinium-enhanced mra. key: cord-015359-gf32a6f1 authors: nan title: b scientific sessions (ss) date: 2002 journal: eur radiol doi: 10.1007/s00330-002-0002-9 sha: doc_id: 15359 cord_uid: gf32a6f1 nan this icon indicates a pre-selected scientific paper to be judged by the subcommittee chairmen. the final winners of the best paper within one topic will be announced at the closing ceremony and presented with a diploma and their prize (€ 1500.-) in (a)symptomatic high-grade internal carotid artery (ica) stenosis, ultrasound and digital subtraction angiography (dsa) are the established techniques for grading ica stenosis; contrast-enhanced magnetic resonance angiography (cemra) is replacing dsa. aim of this study was to evaluate the diagnostic accuracy of cemra in studying the carotid arteries and to compare cemra with dsa findings. two mra protocols, differing in acquisition voxel size, were used to assess whether intravoxel dephasing effects could modify diagnostic accuracy of cemra. 34 patients were studied: 20 (group 1) underwent a cemra protocol with an acquisition voxel size of 1.07 mm 3 and 14 (group 2) with a voxel of 0.40 mm 3 . dsa was perfomed in all patients. morphology and degree of stenosis were evaluated, and a qualitative analysis comparing cemra and dsa findings was obtained. diagnostic accuracy and correlation with dsa results for ica stenosis were calculated in all patients and, separately, in the two groups. cemra diagnostic accuracy and agreement with dsa were respectively 94 % and k = 0.84; no significant difference was found among the two groups. qualitative analysis revealed a better correlation between cemra and dsa images in group 2 than in group 1. these data suggest that cemra could be a powerful tool for the non-invasive evaluation of atherosclerosis of neck vessels. stenosis overestimation of cemra is confirmed; reduction of voxel size, decreasing the dephasing intravoxel effect, allows to minimize it, with a better correlation of cemra and dsa findings; yet, no diagnostic gain is obtained in the patients' classification according to nascet criteria. mri perfusion changes in unilateral symptomatic internal carotid artery stenosis: evaluation of middle cerebral artery and border territories f. gaudiello, g. manenti, f. garaci, r. floris, a. bozzao, g. simonetti; rome/it background and purpose: to determine, with dynamic susceptibility contrast magnetic resonance imaging (dsc-mri), the hemodynamic changes occurring in patients with unilateral internal carotid artery stenosis (icas). methods: 15 patients with symptomatic unilateral icas (over 70 % by nascet criteria) as assessed by digital subtraction angiography and 15 age and sex matched control subjects underwent dsc-mri. on a separate workstation rcbv and rmtt were calculated on the basis of signal decay rate during the passage of gadolinium bolus through the sampled. middle cerebral artery (mca) and distal border territories (mca to posterior and anterior circulation) were evaluated in all patients. results: patients with unilateral icas did not showed statistically significant hemodynamic changes (rcbv and rmtt) between the two hemisphere both considering mca and border territories. comparing patients and controls statistically significant differences were found only for rmtt values in the border territories (increased, p = 0.005). conclusions: dsc-mri is a valuable tool for measurement of hemodynamic changes in the presence of carotid disease with hemodynamic impairment. based on our data no significant perfusion changes occurs between the two hemispheres in patients unilateral symptomatic icas. this indicates compensatory mechanisms between the two hemispheres in the cerebro-vascular reserve distribution. only rmtt values changes (increased) in the border territories (of both hemispheres) differentiate patients with icas from normal controls. correlation of doppler-and duplex ultrasonography based grading of unilateral internal carotid artery stenosis and blood volume flow quantification in brain supplying arteries using 2d cine phase-contrast mr imaging k.w. neff, a.k. kilian, s. meairs, a. schwartz, c. düber; mannheim/de purpose: correlation of unilateral internal carotid artery (ica) stenosis grading based on doppler-and duplex ultrasonography and the hemodynamic changes in brain supplying arteries. methods and materials: 72 patients with unilateral ica stenosis at the level of the bifurcation between 50 % and 98 % and 15 age-matched normal controls were examined using a 2d cine phase-contrast mr technique. blood volume flow was measured in both icas and the basilar artery (ba). the ultrasonography based grading of stenosis was compared to the changes in blood flow in the stenosed ica and to the changes in the contralateral ica and the ba. results: ica stenoses greater 70 % were hemodynamically relevant. with increasing stenosis, a decrease of blood volume flow in the ipsilateral ica was determined with a high linear correlation of r = 0.86. normal controls showed a blood volume flow in an ica of 256.8 ± 29.1 ml/min. in patients with 70 % stenosis a mean blood volume flow of 229.1 ± 32.2 ml/min; with 80 % stenosis 165.1 ± 52.3 ml/min and patients with 90 % stenosis a reduction of mean blood flow in the stenosed ica to 80.4 ± 25.1 ml/min. with decreasing blood flow in the stenotic ica an increasing blood volume flow in the contralateral ica was found. in patients with unilateral ica stenosis greater than 85 % a significant increase in ba blood flow was documented. the comparison of ultrasonography based grading of unilateral ica stenosis and blood volume flow determination in patients with hemodynamically relevant ica stenoses demonstrates a high correlation between increase of stenosis, decrease of ipsilateral blood flow and collateralization of brain supplying circulation. doppler ultrasound, multidetector ct and gd-mra in the assessment of carotid artery stenosis e. ferone, c. pistolese, s. fabiano, r. floris, a. spinelli, a. bozzao, g. simonetti; rome/it aim of the study was to prospectively compare gadolinium-enhanced magnetic resonance (mr) angiography, computed tomographic angiography with multidetector capabilities (md-cta) and doppler ultrasound for use in detecting atheromatous stenosis and plaque morphology at the carotid bifurcation. conventional angiography was available in all cases; surgical specimens were also available in many cases. methods and materials: 42 carotid arteries (in 21 patients) were analyzed by using md-ct, enhanced mr angiography, and dsa. the following features were analyzed: degree of stenosis on the basis of north american symptomatic carotid endarterectomy trial criteria, luminal surface and presence of ulcers. results: there was significant correlation between md-cta, enhanced mr angiography, and doppler for degree of stenosis. with enhanced mr angiography and ct angiography, degree of stenosis was underestimated in two of 44 cases (1 mild and 1 moderate). no case of overestimation with enhanced mra and md-cta was found. severe internal carotid artery stenoses were detected with high sensitivity and specificity: 100 % and 100 %, respectively, with ct angiography; 96 % and 100 %, respectively, with enhanced mr angiography. luminal surface irregularities were most frequently seen at md-cta as demonstrated by surgical specimens. conclusion: there was a significant correlation between md-cta, enhanced mr angiography and dsa in evaluation of carotid artery stenosis. cta was however slightly better than mra in detecting surface alterations. fucan, a natural polysaccharide from algal origin, inhibits intimal hyperplasia after stent implantation in normocholesterolemic rabbits we tested the hypothesis that fucan, a sulfated polysaccharide inhibitor of smcs proliferation in vitro, may reduce intimal hyperplasia in vivo. we performed a pharmacokinetic study on a rat model and a restenosis study on a rabbit model. a single dose of fluorescent fucan and heparin were administered to 10 rats and serum and urine were collected over time. serum and urine concentration and pharmacokinetic parameters were calculated. ten normocholesterolemic rabbits were treated with daily intramuscular injection of fucan (5 animals) or saline (5 animals) after stent implantation in both iliac arteries. fourteen days after injury animals were sacrified and histomorphometric analyses were performed. blood samples were systematically collected. results: fucan exhibited high plasma levels and a prolonged half-life (7 h 30 min) compared to heparin (1 h) after intravenous and intramuscular administration. fucan reduced intimal hyperplasia by approximately 60 % after stent implantation in rabbits (1.79 ± 0.4 vs 0.73 ± 0.2 mm 2 , p < 0.005). intimal hyperplasia inhibited was associated with a better longitudinal organization of cells layers. no toxic effect was noted in treated animals. blood samples showed no anticoagulant activity. conclusion: fucan, a natural polysaccharide of algal origin, reduces markedly intimal hyperplasia in a rabbit restenosis model without anticoagulant activity. methods: endovascular treatment was performed in 39 patients with 42 aneurysms presenting with an unruptured aneurysm either of the anterior (n = 31) or posterior circulation (n = 11). 8 patients had a previous sah from another aneurysm and 10 had neurological symptoms due to the aneurysm. in 21 patients the aneurysm was an incidental finding. aneurysm size was small in 18 (25 mm). occlusion rates was divided into complete (100 %), subtotal (95 -99 %) and incomplete (< 95 %). results: endovascular treatment was technically feasable in 38/42 aneurysms. complete or nearly complete occlusion was achieved in 34/38 aneurysms. in four aneurysms of the ica only incomplete obliteration could be achieved. procedural complications included one case of thrombembolic vessel occlusion with narrowing of the parent artery due to coil protrusion, resulting in anterior cerebral infarction. with the exception of one patient with a mild deficit, all had a good recovery according to the glasgow outcome scale, resulting in a morbidity of 2.4 % and a mortality of 0 %. conclusion: endovascular treatment in patients with unruptured aneurysms is an effective alternative with low morbidity and mortality and should be considered the first option for treatment. we designed three chains of calcium made from small cortical chicken bone fragments. before the fragments were fixed with glue onto tape, volume measurements using water displacement and mass measurements using a precise balance (mettlar h35ar) were performed. during open-heart surgery the chains then were sutured to the pig heart (n = 4) covering the coronary bed of each major epicardial artery as lad, cx, and rca in order to simulate real coronary motion. in each pig we performed a series of prospectively gated sequential and retrospectively gated half-scan and multisector helical scans (lightspeed plus, gems, milwaukee, wi) using a range of scanning parameters (ma, kv, slice thickness). we evaluated the agatston score as well as the volume and a mass score for each chain and each pig. results were compared to water displacement volume measurements and balance mass measurements. the cortical bone frag-purpose: electron beam computer tomography (ebct) and multislice computer tomography (msct) are used to evaluate the amount of sclerotic plaque in coronary arteries in clinical practice. to investigate the potential of both ct techniques to identify calcified coronary lesions, we compared the results of ebct and msct with intravascular ultrasound (ivus) and histology. methods: five human autopsy coronary arteries were fixed in a saline perfused bath with vessel side branches and sutures defined as landmarks: a total of 81 vessel cross sections (vcs) were randomly assigned to undergo all 4 investigative steps. ivus was performed with an automated pull back system (0.5 mm/s). vessels were scanned with ebct (imatron, 3 mm slice thickness, 3 mm increment) followed by msct (siemens plus 4 volume zoom, 4 × 1 mm spiral mode, 3 mm slice thickness purpose: to evaluate the reliability of ca-score measurements of identical multislice ct (msct)-derived raw data obtained by the traditional agatston method and a volume score using different software systems. methods and materials: 22 asymptomatic patients with known or suspected coronary heart disease were scanned on a multidetector ct system (somatom volume zoom, siemens) with retrospectively ecg-gated 4-slice spiral scanning. data was acquired with a 4 × 2.5 mm collimation. continuous volume data sets were reconstructed in the enddiastolic phase with 3 mm slice thickness. for each patient reconstructions without (3 mm non-incremental -ni) and with a 50 % overlap (1.5 mm incremental -i) were performed. two observers independently performed calcium-scoring using the agatston (as)-and volume-score (vs) on two software systems, the calcium-scoring (siemens) and the accuimage-scoring-system. replicated ca-scoring was performed by each observer. the data was categorized into score groups 0; 1 -10; 11 -100; 101 -400; > 400. results: intra-and interobserver reliability was 0.94 -1.0 for both scoring methods (as i/ni and vs i/ni). when ca-scoring measurements were repeated on different scoring software systems, the kappa statistics were found to be 0.75 for as i, 0.69 for as ni, 0.75 for vs i, and 0.75 for vs ni, resulting in different risk stratifications in up to 14 % of the patients. conclusion: intra-and interobserver agreement was excellent using the same software. the two different softwares do not yield the same calcium quantities. there were significant differences with regard to interobserver reliability, resulting in different risk stratifications. the interpretation of calcium quantities should acknowledge which type of software was used. thirteen patients with heterozygous fh (mean ± sd; age 17.9 ± 3.4 a) and 13 controls were studied. endothelium-dependent, flow-mediated dilation (fmd) and endothelium-independent, nitroglycerin-induced dilation (nmd) were assessed in the brachial artery using high-resolution ultrasound. in addition, fh patients were evaluated for coronary calcium using ecg triggered multidetector ct. results: fmd was significantly reduced in heterozygous fh patients compared to controls (10.7 ± 5.3 % vs. 17.3 ± 4.6 %; p = 0.002). in contrast, nmd values were similar in both study groups (17.7 ± 6.5 % vs. 21.0 ± 6.3 %; p = 0.22). on multiple stepwise regression analysis, a significant correlation was found between fmd and total cholesterol (r = −0.68; p = 0.0003) as well as between fmd and vessel size (r = −0.43; p = 0.01). calcifications of the aortic root or the major epicardial coronary arteries were not detected. conclusions: endothelial dysfunction is present in the brachial artery of heterozygous fh already in the second and third decade of life without evidence of calcification of the aortic root and the coronary artery tree and is independently related to total cholesterol. thus, altered vascular function precedes morphological evidence in the course of atherosclerosis. therefore at this early age endothelial function testing seems to be more appropriate to evaluate fh patients developing atherosclerosis and to assess the short-term effects of therapeutic interventions. the association between electron-beam ct detected coronary calcification and mri detected cerebral white matter lesions j.c. de groot 1 , r. vliegenthart 1 , j.c.m. witteman 2 , m.m.b. breteler 2 , a. hofman 2 , m. oudkerk 1 ; 1 groningen/nl, 2 rotterdam/nl purpose: coronary calcification is associated with angiographically detected coronary artery disease. cardiovascular risk factors are associated with cerebral white matter lesions (wml), which in turn play a role in cognitive decline. we investigated whether coronary calcification is associated with wml. materials and methods: participants were recruited from a population-based study of elderly patients aged 60 -90 years. during 1995 -96, cerebral mri (1.5 t) scans of 554 subjects (response 63 %) were obtained on which the severity of deep subcortical wml (scwml) and periventricular wml (pvwml) was estimated using a semi-quantitative scale. during 1998 -2000 thoracal electron-beam ct scans were obtained and coronary calcium scores (according to agatston) are available for 221 of these subjects. wml was dichotomised in severe (upper quintile) versus mild to moderate (other quintiles) and the calcium score was dichotomised in severe (upper tertile) versus mild to moderate (other tertiles) for additional analyses. results: mean age was 72.3 years (50 % women). mean severity of scwml was 1.2 (range 0 -15.9) and of pvwml 2.2 (range 0 -9). median calcium score was 125.3 (interquartile range 19.5 -501.4). subjects with higher calcium scores had more scwml (rho = 0.15, p = 0.02) and tended to have more pvwml (rho = 0.12, p = 0.08). when adjusted for age and sex, severe calcium scores were associated with the presence of severe scwml (or = 2.3, p = 0.05) but not with severe pvwml (or = 1.8, p = 0.19). conclusion: preliminary analyses show that coronary calcification is associated with cerebral scwml and as such may be indicative for a generalised vascular disease process. coronary calcification detected by electron-beam computed tomography is associated with mortality r. vliegenthart 1, 2 , h.-h.s. oei 2 , a. hofman 2 , j.c.m. witteman 2 , m. oudkerk 1 ; 1 groningen/nl, 2 rotterdam/nl purpose: coronary calcification is closely related to the amount of coronary atherosclerosis, but its predictive value for cardiovascular disease and mortality has not been well established. we studied the association between coronary calcification and mortality in the population-based rotterdam coronary calcification study. materials and methods: from 1997 -2000, rotterdam study participants were invited for electron-beam ct scanning to detect coronary calcification. calcifications were quantified according to agatston's method. calcium scores of 2013 scanned subjects (46 % men, mean age (standard deviation, sd), 71 (5.7) years) were used in the analyses. the rate ratios of mortality between categories of the calcium score were calculated. results: 40 % of men had a calcium score above 500, while 24 % had a calcium score above 1000. corresponding percentages for women were 17 and 4, respectively. during a mean follow-up period (sd) of 2.4 (0.7) years, 80 subjects died (51 men, 29 women). the age-adjusted relative risk for death was 3.6 (95 % confidence interval (ci), 1.4 -9.4) for men with a calcium score above 500 compared to men with a calcium score of 0 -100 (reference category). men with a calcium score above 1000 had a 4.5 times increased risk (95 % ci, 1.7 -11.9) compared to the reference category. in women, the relative risks were 2.3 (95 % ci, 1.0 -5.6) for calcium scores above 500, and 2.8 (95 % ci, 0.9 -8.3) for calcium scores above 1000, compared to the reference category. conclusion: the amount of coronary calcification detected by electron-beam ct is predictive for all-cause mortality. methods and materials: 20 consecutive patients (11 men and 9 women; mean age 64 years) with surgically treated mitral valve disease underwent preoperative contrast-enhanced, retrospectively ecg-gated mdct. two readers assessed visibility of the mitral valve annulus, mitral valve leaflets, tendinous cords, and papillary muscles using a four-point grading scale. abnormal findings of the mitral valve, such as thickening of the mitral valve leaflets, presence of mitral annulus calcification (mac) and calcification of the valvular leaflets, were compared to preoperative echocardiography and intraoperative findings. results: visibility of mitral valve annulus and mitral valve leaflets were good or excellent (grade 2 and 3) in 15 patients (75 %), and in 19 patients (95 %) for papillary muscles; visibility of tendinous cords was inferior. mdct yielded a 95 -100 % agreement with echocardiography and surgery with regard to thickening of mitral valve leaflets and presence of calcification of the mitral valve annulus and mitral valve leaflets. conclusion: retrospectively ecg-gated mdct allows good to excellent visualization of anatomical details of the mitral valve and its apparatus except for tendinous cords, and demonstrates high agreement between echocardiography and surgery with regard to the diagnosis of mitral valve abnormalities. with increasing experience a diagnostic niche may open up for preoperative assessment of mitral valve pathology using mdct, especially for patients for whom echocardiography is of limited use, e.g., for patients with suspected perivalvular abscess. conventional parathyroidectomy is a difficult operation and unsuccessful in 5 % to 10 % of cases. to improve the efficacy, preoperative (mibi) spect scintigraphy and intraoperative radio-guided localization of parathyroid adenomas with γ probe and a quick pth assay were used. methods: forty patients with the diagnosis of primery hyperparathyroidism were studied with (mibi) spect scintigraphy. we combined the preoperative administration with the intraoperative γ probe examination to identify the exact localization of parathyroid adenomas. the intact parathyroid hormone was measured by irma method (schering cis bio international). results: in all cases parathyroidectomy was performed successfully and the preoperative localization was always confirmed. after five minutes parathyroidectomy pth concentrations decreased more than 55 % compared with the highest preexcision value. at follow-up, serum calcium and pth levels were normal in all patients. in hyperparathyroidism, the combined use of preoperative imaging mibi-spect and intraoperative γ probe examinations improved the success rate of parathyroidectomy. the most helpful use of quick pth in patients is its ability to give the surgeon quantitative assurance that all the hyper functioning parathyroid tissue has been removed. 3d ultrasound technology for the calculation of thyroid volume and the evaluation of benign cystic, nodular disease v. osti, l. cova, l. solbiati, m. tonolini, d. della chiesa; busto arsizio/it purpose: to assess whether three dimensional sonography (3d-us) can permit reliable and easily calculated volumes of the thyroid and nodules. methods and materials: 24 patients, aged 33 -67, underwent 3d-us of the thyroid gland. ten patients had prior hemithyroid resection for multinodular disease and presented with goitre relapse. after examination, all had surgical resection. the surgical specimen volume at pathology was compared with the volumes calculated using 3d-us. the remaining 14 patients had either single or multiple, cystic nodules. following 3d-us, these nodules underwent percutaneous needle aspiration of the fluid content with measurement of the aspirated volume prior to ethanol injection. us examinations were performed using linear, 10 mhz probes (voluson 530d and 730d, kretztechnik, austria). volume acquisitions were automatically achieved by transverse scans, with the addition of coronal oscillations of the transducer crystals. subsequently, both automatic [n = 9] and/or manual [n = 15] 3d reconstructions were performed, including volume calculations, for either the entire gland [n = 10] or the nodules [n = 14] . results: comparison between surgical specimen volumes and in-vivo volumes calculated by 3d-us demonstrated a restricted margin of error of 6 % for automatic reconstruction, and 4 % for manual reconstruction. the quantitative assessment of the fluid aspirated from cystic nodules was identical to the 3d-us calculation (margin of error < 1 %). conclusions: 3d-us allows easy and accurate estimation of the volume of the thyroid gland and of nodular, cystic thyroid lesions. these measurements will undoubtedly provide both surgeons and interventional radiologists additional potentially useful information prior to procedures. role of color-doppler sonography in graves' disease diagnosis and follow-up after 131 i therapy v. summaria, a. costantini, v. rufini, m. garganese, g. maresca, s. speca; rome/it purpose: to assess the usefulness of cds in evaluating activity of graves' disease and the response to 131 i therapy. methods and materials: several cds patterns: thyroid volume (tv), parenchymal hypoechogenicity (ph), parenchymal vascularity (pv), peak systolic velocity (psv) in inferior thyroid arteries (ita), were evaluated in 51 patients with graves' disease divided in 4 groups: 13 pts at first diagnosis; 12 pts during antithyroid drug treatment; 11 euthyroid pts after withdrawl of therapy; 15 pts who relapsed into hyperthyroidism. all pts in the latter group underwent radioiodine therapy (rt) and cds was performed 1, 3, 6 months after rt. 13 healthy subject were included as control group. results: all 40 pts with hyperthyroidism showed an increase of tv, pv and psv in ita, compared with patients in remission and with control subjects. in pts within group 2, cds values were lower, but not significantly different from those in group 1. ph was found in 40/51 pts, without a statistically significant difference between pts with hyperthyroidism and pts in remission. in pts within group 4, a significant decrease (p < 0.1) of tv and psv mean values in ita was observed in 11/15; the others pts, with residual signs of hyperthyroidism underwent further rt. materials and methods: forty two patients with 57 nodules were prospectively enrolled in this study. the nodules were studied in a transverse plane with conventional high frequency b-mode imaging and with sono-ct (atl hdi 5000, l12-5 linear probe). the data were transferred on a pc (hdi lab). after selecting two comparable images in both modes, three parameters of quantification were measured using region of interest: the difference of contrast between the nodule and the adjacent thyroid (db), the slope of the transition between the nodule and the adjacent tissue (db/cm). the nodule heterogeneity was evaluated as the standard deviation of the mean signal intensity normalized with the mean signal intensity (linear units). the contrast between the nodule and the adjacent thyroid was systematically greater with sono-ct (mean 4.3 db). the transition slope was higher with sono-ct. the average difference between the sono-ct slope and the conventional b-mode slope was 5.2 db/cm. the heterogeneity index was superior in 83 % of cases with this modality. however, sono-ct imaging exhibited a blurring artifact when the probe was moved too fast, despite the use of a unique focal zone. conclusion: the objective evaluation using appropriate quantification technique showed a significant improvement in the visibility of thyroid nodules with both sono-ct when compared to conventional b-mode imaging when the linear probe was moved very slowly. pre-biopsy investigations included scintigraphy and thyroglobulin levels. then we examined the us characteristics of the nodule (low reflectivity, irregular margins, thick-irregular halo, intranodular blood flow pattern, hypervascularity, invasion of vessels and adjacent structures, vessel encasement). in 25 patients the nodule was solitary and not palpable and in 20 patients the disease was multinodular with a nodule having characteristics suspicious for malignancy. we performed us guided fna biopsy using 21 g needle. we used negative pressure on the syringe to obtain material through the needle. it is important to allow the pressure to equalize before removing the needle. the cytological specimen obtained was examined by cytopathologist. a post biopsy us was performed to exclude complications. the following results were obtained: follicular ca (n = 1), papillary ca (n = 1), undiferentiated ca (n = 1), hashimoto thyroiditis (n = 6), colloid and bening follicular cells (n = 7), blood (n = 5), nodular hyperplasia (n = 22), colloid and activated lymphocytes (n = 1), colloid and histiocytes (n = 1). conclusion: us guided fna is safe, fast and low cost method to determine the nature of thyroid nodules and exclude malignancy. papillary stenosis: differential diagnosis with mr-cholangiography using a cholecystokinetic drug m. di girolamo 1 , l. azzarri 2 , r. di nardo 1 , c. rende 1 , g. brughitta 2 , v. david 1 ; 1 rome/it, 2 grottaferrata/it purpose: to differentiate with mr-cholangiography (mrcp) inflammatory papillitis from functional papillary stenosis, using a cholecystokinetic drug. methods and materials: 17 patients with papillary stenosis diagnosed with ercp underwent mrcp before and 30 minutes after i.v. injection of ceruletide (takus, farmitalia, italy) . this drug stimulates the activity of the gallbladder and promotes the relaxation of oddi's sphincter. mrcp was performed by using 3-d non-breathholding, fat-suppressed turbo se sequence (tr: 3000 ms; te: 700 ms; n.ex.: 4; etl: 128; matrix: 128 × 256; acq. time: 5 min 12 s) on coronal planes with 0.5 t superconductive magnet (gyroscan t5 iii, philips medical system). the 3d coronal images were post-processed with mip algorithm. results: in 13 patients mrcp diagnosed fibrotic papillary stenosis while in 4 patients detected functional papillary stenosis that in 3 cases was confirmed by ercp with manometry. the diagnosis was based on the evaluation of the mbd calibre after drug administration: a partial reduction of the calibre is typical of functional papillary stenosis while the persistence of the same calibre allows the diagnosis of fibrotic papillary stenosis. mrcp could also exclude choledocholithiasis whose clinical symptoms can simulate papillary stenosis. conclusions: it is possible to differentiate with mrcp between fibrotic and functional papillary stenosis, without performing invasive procedures like ercp with manometry. this differential diagnosis is very important: in fact, fibrotic stenosis should be treated with sphinterectomy while functional papillary stenosis does not need any particular treatment. methods and materials: 52 patients (25 women, 27 men) with confirmed psc were examined with mri at 1.5 t comprising: t1-weighted spoiled gradient echo (sge), t2-weighted fat-suppressed turbo spin echo, haste, and serial postgadolinium t1-weighted sge sequences without and with fat-suppression. two radiologists reviewed retrospectively all images independently and in a consensus reading. the evaluations comprised: the imaging pattern of the liver parenchyma; the presence and grade of intrahepatic biliary ductal dilatation; the presence of areas of parenchymal atrophy or abnormal signal and/or gadolinium enhancement. results: a "diffuse pattern" of liver cirrhosis was observed in 17 of 52 patients (33 %). a "large macronodular pattern" (regenerative nodules ≥ 3 cm) was observed in 28 of 52 patients (54 %) with nodules showing low signal on t1-and t2-weighted images and low gadolinium enhancement. intrahepatic biliary ductal dilatation was observed in 44 of 52 patients (85 %) with a "general distribution" in 18 patients (35 %) and a "segmental distribution" in 26 patients (50 %). peripheral wedgeshaped areas of abnormal parenchyma showing atrophy were observed in 24 patients (46 %) and without atrophy in 18 patients (35 %). the signal intensity on t1-/t2-weighted images was usually low/high. gadolinium enhancement was typically late in areas with atrophy and early in areas without atrophy. conclusion: the spectrum of mri appearances of psc is diverse and comprises distinct patterns. large regenerative nodules are a frequent finding and may help to establish the diagnosis. for 17 months, 7 patients were diagnosed to have incomplete pancreas divisum on ercp and six of them underwent mrcp after secretin stimulation. the maximal diameter and length of pancreatic duct (ventral, dorsal, and main duct) and the angle between the main pancreatic duct (mpd) and the communicating channel (cc) were measured on ercp. morphologic changes of the pancreatic duct, the presence of santorinicele, the shape of cc, and associated bile duct anomaly were analyzed on ercp and mrcp. results: ercp showed dominant dorsal duct and foreshortened ventral duct with a small communication between the two ducts. the mean caliber of dorsal, ventral, and main duct was 3.8 mm, 4.2 mm, and 4.2 mm, respectively. the angle between the mpd and the cc was acute in 3 patients, right angle in 2, and obtuse in 2. the cc was classified into short (n = 5) and long (n = 2) types. the morphologic features of pancreaticobiliary duct included: santorinicele in 2, beaded appearance of pancreatic duct in 5, pancreaticoliths in 3, and bile duct anomaly in 1. mrcp successfully demonstrated the presence of the cc and associated morphologic features of the pancreaticobiliary duct in all 6 patients. purpose: since evaluation of bile ducts in mrcp can be complicated by other fluid filled structures as pancreatic or bile duct cysts superimposing the region of interest and the clinical relevance of a dilated bile duct regarding functional stenosis may be unclear we investigated the hepatobiliary contrast medium gd-bopta as a positive contrast enhancer for intra-and extrahepatic bile ducts in mri. material and methods: 34 patients were investigated on a 1.5 t scanner (magnetom vision, siemens, erlangen) using unenhanced t1 an t2 w breathhold sequences as well as 2d-and 3d-mrcp. to evaluate contrasted biliary structures 60 to 90 min after cm administration (gd-bopta, 0.05 µmol/kg bodyweight) a 3d gre sequence as well as t1w axial images were applied. results: in the majority of the patients (28/30) bile duct structures could be delineated by the mrcp sequence. however the identification of the common bile duct in the region of the pancreatic head was not possible in 6 patients. in 7 patients following pancreatitis or cholelithiasis a dilatation of the common bile duct was observed with unclear functional relevance, in 4 patients following resection of the pancreatic head the anastomosis of the common bile duct could not be displayed in detail in mrcp. ce mrcp was able to delineate the bile duct in 8 of the 10 unclear cases, functional relevance of dilatation could be evaluated in 4 of 7 patients. conclusion: in unclear cases gd-bopta can be helpful for a better delineation and functional evaluation of bile duct structures. follow-up of suspected pancreatic intraductal papillary mucinous tumours (ipmt) of collateral branches: preliminary results g.m. carbognin, a. guarise, e. dalla chiara, n. pagnotta, c. procacci; verona/it purpose: to verify the evolution of suspected collateral branches ipmt assessed as benign at the first imaging control. methods and materials: 14 patients with a presumptive diagnosis of benign branch duct ipmt formulated by ercp (#6) and/or mrcp (#10). diagnosis on the basis of the following criteria: (1) no previous pancreatitis; (2) one/multiple cystic lesion/ s, homogeneous liquid content, thin wall, no parietal proliferation; (3) maximum diameter of the lesion < 3 cm; (4) normal main pancreatic duct (mpd). the patients were submitted to mrcp follow-up every 6 months. two observers reviewed all the mrcp examinations. results: mean duration of the follow-up: 10.5 months (range: 3 -28 months). 12/14 (86 %) lesions with the requisite for benignity reported in literature, did not show any morpho-structural modification during the follow-up. in 1 case the lesion manifested rapid growth after 3 months, along with what seemed to be a small parietal nodule. at intervention, it was a retention cyst in a mild focal pancreatitis. in the other case, multiple apparently benign lesions were present, which demonstrated slight growth over 13 months of follow-up. nevertheless, the patient was submitted to strict mrcp monitoring, since a total pancreasectomy would have been warranted. conclusion: among those considered, lesions of different nature could be present. however, the evolution of all these lesion, when the sign of malignancy are absent, is so slow to justify the follow-up in the elderly, in the presence of high surgical risk or whenever the multiplicity of the lesions would require a largely demolitive intervention. results: mrt and mrcp were false positive in a patient with a benign stricture due to an inflammatory pseudotumor and false negative in two patients (suspected granulation tissue after prior surgery and contrast enhancement of the wall of the bile duct after interventional therapy). except for one false negative patient mrcp revealed stenosis of central bile ducts in all patients. in 15 patients a well demarcated mass was seen while 12 patients revealed circumferential tumor spread along the bile ducts. most lesions appeared hyperintense on t2-weighted images (n = 22) and hypointense on unenhanced t1-weighted images in all cases. contrast enhancement was either lower (n = 21) or higher (n = 7) than normal liver parenchyma. t2-weighted images and gadolinium-enhanced fat-suppressed t1weighted images showed best lesion conspicuity and tumor margins in 12 and 13 patients respectively. combined ercp, us and ct suggested hilar cholangiocarcinoma in 21/28 (75 %) patients. mrt with mrcp appears to be the most sensitive imaging modality for detection of hilar cholangiocarcinomas and may replace us, ct and ercp in the evaluation of suspected malignant bile duct obstruction. information supported by mrcp: consistency and repeatability t. gorycki, b. bobek-billewicz, m. studniarek, p. jagodzinski, k. grabska; gdansk/pl purpose: to compare decisions of radiologists watching mrcp images in order to find the strongest features on mip reconstructions which characterise biliary strictures. materials and methods: mrcp mip reconstructions (0.5 t gyroscan nt) from 80 cases of biliary stricture had undergone estimation by three independent observers who performed linear measurements on mrcp images concerning morphology of the biliary stricture including stricture length, proximal ductal dillatation and distance from stricture to hepatic ducts junction. last of the measurements has introduced information about stricture localisation along the biliary tree. measurements were compared in two stages: between two observers as well as counting their mean values against third observer. the analysis included change, consistency and repeatability values with relative repeatability coefficient (rrc). results: repeatability counted with rrc presented values from 3.7 % to 12.12 %, consistency did not exceed 1.52 mm when stricture length or proximal biliary dilatation were measured and 2.5 mm when stricture was localised along biliary duct. conclusion: mrcp mip reconstructions are valuable and easily understood images in radiologists' every day practice when morphology and localisation of biliary stricture is discussed. the most reliable conditions seem to be stricture length and stricture localisation. assessment of the role of translabial perineal ultrasonography (tpus) to evaluate urinary stress incontinence in females c. roy, d. pfleger sr., e. castel sr., h. lang sr., c. saussine sr.; strasbourg/fr purpose: assess the usefulness of translabial perineal ultrasonography (tpus) in the evaluation of the two mechanisms (hypermobility of bladder neck and intrinsic sphincter deficiency) of urinary stress incontinence (usi). method/materials: 52 women (mean age: 58.7) underwent us with translabial perineal approach (7.5 mhz transvaginal probe) located on the perineal floor, behind urethral meatus. examinations performed in sagittal and coronal, in decubitus and standing positions, at rest, and during pelvic floor contraction and straining. bladder was filled with 200 -300 ml of urine. morphology of the bladder neck (funneled) was evaluated to diagnose isd. to evaluate hbn, position and displacements of bladder neck was evaluated calculating the distance using inferior border of the symphysis pubis as reference according an orthogonal system, in sagittal plane. the diagnosis of hbn was based on a displacement up to 1.5 cm. correlation was made with clinical evaluation and urodynamic testing results. results: among 35 patients with the clinical diagnosis of hbn, tpus confirmed a displacement and depicted in 8 cases an additional isd in front of funneling of bladder neck at rest and straining. among 17 patients with diagnosis of isd; us confirmed an abnormal bladder neck. an association with bladder neck hypermobility was found in 10 cases of this group. for the diagnosis of cystocele (20 cases), correlations were excellent, but without additional findings for tpus. conclusions: tpus is easy to perform and no time consuming. it provides a perfect assessment of bladder neck during static and dynamic studies. it allows the diagnosis of associated mixed types of usi with a better classification of these disorders. dynamic fast mri of pelvic floor dysfunction in females using a t2-w turbo spin echo technique: value of knee flexion lateral position in comparison with conventional supine position c. roy, f. mayer sr., j. pfeiffer sr., e. castel sr., c. saussine sr.; strasbourg/fr purpose: evaluate organs displacements due to patient position by using a knee flexion lateral versus supine position and its role in the quantification of abnormalities. materials and method: 55 women symptomatic for pelvic floor descent and 27 asymptomatic were explored with dynamic sagittal mri (1.0 t) using a t2w tse sequence (tr/ete: 13950/100 ms) at rest, pelvic floor contraction, maximal straining and two series: supine and lateral position with knee flexion. distances from bladder base, cervix and anorectal junction perpendicular to the pubococcygeal line were measured in the sagittal plane. in symptomatic patients, correlations with clinical evaluation and colpocystorectography was performed. results: at rest and contraction, there was no significant difference. during straining; for asymptomatic patients mean descent differences of bladder base, cervix and anorectal junction between the two positions were 1.5 cm (± 0.5), 1.8 cm (± 1), 2 cm (± 0.9), respectively and for symptomatic patients 4.8 cm (± 1), 4.5 cm (± 0.8) and 6 cm (± 1), respectively. the lateral position revealed 5 rectoceles and 10 additional cystoceles with 4 enteroceles associated to rectal prolapse. the highest displacements in lateral position were better correlated with clinical findings. conclusion: dynamic mri in lateral position is easy to perform, is more reliable to assess pelvic floor prolaps and to detect associated defects of other compartments. role of translabial perineal ultrasonography in females after surgical treatment of urinary stress incontinence by tension vaginal tape (tvt): a prospective study c. roy, d. pfleger sr., e. castel sr., h. lang sr., c. saussine sr.; strasbourg/fr purpose: the efficiency of tvt unknown. to assess the morphologic and dynamic modifications of bladder neck in order to better understanding its action. method/materials: 41 females (mean age: 58.7) underwent translabial perineal us (7.5 mhz transvaginal probe located on the perineal floor behind urethral meatus) in sagittal, decubitus and standing positions, at rest, during pelvic floor contraction and straining, before and after surgery. bladder was filled with 200 -300 ml. position, morphology, and displacements of bladder neck were calculated using inferior border of the symphysis pubis as reference according to an orthogonal system. correlation was made with clinical findings and urodynamic results. results: tvt was always perfectly seen as linear hyperechoic structure; against lower third (31), middle lower third junction (8) and upper third (2) of urethra, respectively. before surgery, 15 cases had funneling of bladder neck in addition to hypermobile bladder base. after surgery, all bladder necks were closed, located at rest above the inferior portion of symphysis. in decubitus position, displacements before and after tvt were 30 -7 mm (m = 18.2 ± 1.2) and 45 -9 mm (m = 20.6 ± 0.5) at pelvic floor contraction and straining respectively. in standing position, they were 10 -5 mm (m = 7.2 ± 0.7) and 18 -3 mm (m = 8.2 ± 0.6) respectively. among 5 cases of dysuria, tvt was located against the middle (3) or upper part (2) with angulation. conclusions: tvt procedure limit excessive movement of bladder neck. it must be located against the lower third of urethra. us examination is reliable to detect malpositions. in 20 patients with symptomatic uterine fibroids cemra (symphony-siemens; 1.5 t) of the pelvic and uterine vessels combined with conventional mr imaging was performed. we used a breath-hold 3d flash cemra (tr/te 3.6/1.3, fa 25°) and injected gadolinium (0.1 mmol/kg b.w.) at a rate of 3.0 ml/s. clinical value of the arterial and venous cemra for the planning of the uae was evaluated. after the mr-imaging biphasic uae was performed. the selective and superselective dsa sequences were compared with a vessel by vessel technique with the cemra. results: all cemra were technically successful and all topographically relevant segmental/subsegmental arteries could be evaluated. the common iliac, external iliac, internal iliac and uterine artery could be identified in all cases. the vascular 3d information of mra provides additional information for the planning of the intervention and the superselective catheter placement. the arterial cemra phase allowed an exact demarcation of the hypervascular fibroids in 19 patients, thus defining the primary access site for the intervention. the venous phase did not provide an additional diagnostic information. the time for the interventions and the radiation could be reduced by using the diagnostic information of cemra in 18 of the patients. cemra combined with mri of the pelvis appears to be an important diagnostic tool for analysing the volume and location of the fibriod and planning of the vascular access. withdrawn by author b-0117 11:25 clinical stage i carcinoma of the uterine cervix: value of preoperative mr imaging in assessing parametrial invasion s. sironi; milan/it purpose: the purpose of this prospective study was to assess the efficacy of different mr imaging techniques in the evaluation of parametrial tumour invasion in patients with early stage cervical cancer. methods and materials: 73 consecutive patients, clinically considered to have stage 1b tumour (confined to the cervix), underwent mr imaging studies at 1 t, according to the following protocol: fast spin-echo (fse) t2-weighted, gadoliniumenhanced se tl-weighted, and fat-suppressed gadolinium-enhanced se tlweighted sequences. images obtained with each sequence were evaluated for parametrial invasion with the use of histopathological findings as the standard of reference. results: in the assessment of tumour infiltration into the parametrium, with fse t2-weighted images accuracy was 83 %, with se tl-weighted gadolinium-enhanced images was 65 %, and with se tl-weighted gadolinium-enhanced fat-suppressed images was 72 %. the difference between the accuracy rate achieved with fse t2-weighted images, and those obtained with the other two mr sequences was statistically significant (p < 0.05). the high negative predictive value (95 %) for the exclusion of parametrial tumour invasion was the principal contributor to the staging accuracy obtained with fse t2-weighted imaging. conclusion: unenhanced fse t2-weighted imaging is a reliable method in determining the degree of tumour invasion in patients with early stage cervical cancer. our data suggest that contrast-enhanced sequences, even with the use of fat suppression technique, have a limited value in the assessment of tumour extension. methods and materials: mri of the pelvis was performed 24 h after i.v infusion of uspio (2.6 mg fe/kg b.w.) in 9 patients (mean age 48 years) with gynecologic tumours (6 cervical, 2 endometrial carcinomas, 1 malignant mixed mullerian tumour) who were scheduled for surgery. axial t1w se, t2w fse (fatsat), fspgr, sagittal and oblique t2w fse sequences were acquired on a 1.5 t system. next to the primary tumour, lymph nodes were staged prospectively using newly established criteria and results correlated with histology. results: mri correctly diagnosed the primary tumour as stage i in 7 cases and stage ii in 1 case respectively. in 1 case preoperative diagnosis of stage iv led to a change in the therapeutic approach and chemotherapy was given. in this case, multiple malignant iliac nodes were demonstrated. no surgical proof was available. 58/62 of the lymph nodes detected on mri, in which a histological correlation was available, were correctly staged (accuracy 94 %). 1 node was false positive; 3 micrometastasis < 5 mm were missed. conclusion: according to our preliminary results, uspio-enhanced mri of the pelvis has the potential to become an important tool for preoperative assessment of uterine tumours. the prognostic significance of high-resolution ct morphology compared to a histological diagnosis in usual interstitial pneumonia (uip) and nonspecific interstitial pneumonia ( in idiopathic pulmonary fibrosis (ipf) both histological and ct features are known to predict outcome. the aim of this study was to compare the prognostic significance of the histological diagnosis (uip vs nsip) and ct findings. materials and methods: 53 biopsy proven cases of uip and nsip were diagnosed by consensus by two histopathologists. the hrcts were scored semiquantitatively by 4 observers with regard to the proportion of ground glass opacity to reticulation (1 = predominantly ground glass, 2 = mixed ground glass and reticulation, 3 = predominantly reticulation). in addition the exact proportion of ground glass opacity was recorded. results: 32/53 cases were classified as uip and of the 21/53 classified as nsip 5/21 were cellular and 16/21 fibrotic. at follow up (median 33 months) there were 22/53 deaths. both an increasing extent of ground glass opacity and a lower semiquantitative ct score were associated with a better outcome (p = 0.02, p = 0.01 respectively). the histological diagnosis of nsip was also associated with lower mortality (p = 0.05). on bivariate analysis hrct provided the more powerful prognostic information. conclusion: in terms of prognosis hrct features in ipf provide much information with little added value from the histological diagnosis. correlation between histologic features and ct morphology in idiopathic pulmonary fibrosis (ipf) s.m. ellis 1 , s.r. desai 1 , d.m. hansell 1 , a.g. nicholson 1 , t.v. colby 2 , r.m. du bois 1 , a.u. wells 1 ; 1 london/gb, 2 scottsdale, az/us purpose: there is increasing evidence that the profusion of fibroblastic foci seen at histology in ipf is predictive of mortality. the aim was to determine whether high-resolution ct appearances correlate with prognostically important histological features. the hrct scans of 34 histologically confirmed cases of ipf were scored by two observers according to the proportion of macro (≥ 4 mm) and microcystic (< 4 mm) honeycombing, fine reticulation and ground glass opacity. their relationships to histological scores of fibroblastic foci and macrophages were examined. results: there was a positive correlation between the proportion of combined hrct score of macro and microcystic honeycombing and the number of fibroblastic foci on histology (p = 0.04). a further positive correlation was found between the extent of ground glass opacity and the macrophage score (p < 0.01). there was no correlation between any histological feature and the extent of fine reticulation on hrct. purpose: to describe the radiological (thin section ct) findings correlated to activity and remission in anca associated pulmonary-renal small vessel vasculitis (svv) material and methods: we used retrospective analysis of 37 cts, 27 in disease activity (8 first manifestations, 19 relapses) 10 im remission of 17 patients with pulmorenal syndrome (9 wegener, 4 microscopic polyangiitis-mpa, 3 churg-strauss-syndrome, 1 idiopathic crescentic glomerulonephritis following the chapel hill classification) 7 women, 10 men, median 65.5 years (34 -84). the diagnosis was established by clinical presentation (cough, dyspnoea, hemoptysis and/or fever associated with significant hematuria or progressive renal failure), anca titers (11 c-anca, 5 p-anca, 1 anca negative) and renal biopsy in all patients. results: pulmonary involvement defined by pathological ct occured in all patients. nodules with (n = 4) or without (n = 2) cavitation, ground glass opacity (n = 5), air space consolidation with (n = 6) or without (n = 9) cavitation and interstitial septal thickening (n = 4) were detected. local interstitial infiltration and nodules in wgs, diffuse interstitial alveolar infiltration in mpa and css, neither lower versus upper lungfield involvement nor side preverence were evident. radiological course of pulmonary involvement was the best indicator for therapeutic success after immunosuppression, occured earlier compared to renal symptoms and was a stronger indicator in first manifestations then in relapses for disease activity. conclusion: thin section ct as the most sensitive radiological examination detects and classifies efficiently the extent of pulmonary involvement of svv, most likely air space consolidation and ground glass opacity, it proves to be the most efficient therapeutic monitor indicating remission. traction bronchioloectasis on hrct in simple pneumoconiosis d. ryu; kangnung/kr objective: traction bronchioloectasis and focal pericicatrical emphysema in p type pneumoconiosis have been well known in pathologic report. however, traction bronchioloectasis, earlier finding of p type pneumoconiosis has not been yet radiologically reported. therefore, we describe traction bronchioloectasis on hrct in p type pneumoconiosis and assess its incidence among small rounded opacities (p, q, r). we retrospectively analyzed the hrct scans of 11 patients that showed small rounded opacity less than 1 centimeter. the study group had a history of occupational exposure to dust and was comprised of all men, 47 -67 years old (mean age 60). type p, q, r rounded opacity consisted of 5, 2, 4 patients respectively. two radiologists assessed with consensus whether traction bronchioloectasis was present or not, and its incidence at three levels (aortic arch, carina, and between carina and diaphragm). the degree of traction bronchioloectasis was classified as follows: score 1: 1 -5 traction bronchioloectasis were visible at each scan level; score 2: 5 -10 traction bronchioloectasis; score 3: over 10 traction bronchioloectasis. the total score was the sum of three level score. result: all patients showed traction bronchioloectasis. the degree of traction bronchioloectasis decreased with increase of nodule size; p type 6.8; q type 4; r type 2.3. conclusion: traction bronchioloectasis is an early finding of pneumoconiosis with centrilobular dot or branching structure on hrct. such findings could be helpful to differentiate pneumoconiosis from other diseases showing centrilobular nodule. viewing efficiency of soft-copy reading of high-resolution ct of the lungs s.m. ellis, x. hu, l. dempere-marco, g.-z. yang, d.m. hansell; london/gb purpose: soft-copy ct reading is increasingly common and offers the radiologist a choice of many viewing formats. using eye-tracking data we have assessed the efficiency of reading high-resolution ct of the lungs comparing two fundamentally different viewing formats. the eye movements of 2 experienced radiologists viewing hrct's demonstrating diffuse lung disease (n = 6), airways disease (n = 6) or normal appearances (n = 4) displayed on a single monitor were recorded. the time taken to view each case, the number and duration of fixation points, the number of movements between sections and the proportion of these leading to fixation were calculated. the viewing formats used were 4 sections displayed simultaneously (2 × 2) and single sections displayed at full screen size (stack mode). sections in both formats were viewable by sequential scrolling. results: the number, duration of fixation points, and the number of movements between sections were greater in the 2 × 2 mode (p = 0.03, p = 0.05 and p < 0.001 respectively. however, the proportion of movements between sections leading to a fixation point was greater in stack mode (p < 0.001). there was no significant difference in the overall time taken on each case. the viewing efficiency of soft copy reading of lung hrct is greater with sections presented in a 2 × 2 format compared to a stack mode, despite the tendency towards non-fixation movement between sections in the 2 × 2 format. the group of most severe cases (parasitemia > 5 %, presence of complication) included 53 pts (19 %). radiographic pulmonary examination was performed in 200 pts. results: pulmonary radiographic changes were founded in 23 pts (43 %) with severe malaria. 21 pts (91 %) had solitary or multiple pulmonary infiltration. one patient had hospital acquired pulmonary infection during artificial ventilation, while noncardiac pulmonary oedema with fatal outcome was noted in one patient. the therapy in this group of patients was based on quinine/arthemeter parentally. in 40 pts (81 %) tetracycline, erythromycin or clindamycin was added as second antimalarial drug. all pts who suffered from pulmonary complications received also various antibiotics parenteral (ampicilin/ceftriaxon/cefotaxim/imipenem, ciprofloxacin, aminoglycoside, vankomcin) according to severity of pulmonary changes, bacteriological findings (blood, sputum) and up to date therapetutical recommendations. conclusion: severe malaria is often connected with pulmonary manifestations, which implies prolonged course of healing and even fatal outcome (noncardiac pulmonary oedema). the value of post-contrast flair in the detection of brain metastasis a. patsalides, j.a. butman, n. patronas; bethesda, md/us in this study we assessed the value of post-contrast flair in the detection of brain metastasis. brain mri studies were performed in 160 patients with melanoma and renal cell carcinoma. fluid attenuation inversion recovery (flair) and t1-weighted (t1-w) scans were obtained before and after contrast administration in each patient. each of these techniques was evaluated blindly by two radiologists who diagnosed the presence of metastatic tumors by consensus agreement. follow up studies were available in patients with positive studies and the temporal changes of the lesions were used to confirm the diagnosis. cases. at one month the mean serum creatinine level had decreased from 359 ± 138 mmol/l to 298 ± 87 mmol/l, blood pressure was reduced in all the patients from 160/82 ± 24/14 mmhg to 145/80 ± 16/10 mmhg and drug therapy was reduced from 3.3 ± 1.3 drugs to 2.4 ± 1.5 drugs. results were maintained at 3 months. conclusions: in cases of renal impairment, renal ptra/s using gadolinium chelates as radiographic contrast agents can be performed using standard digital subtraction angiography (dsa) equipment. gd-dota (0.3 mmol/kg) can be administered intra-arterially without any effect on renal function up to a total volume of 45 ml. carotid artery stent implantation with cerebral protection: multicenter experience of 320 procedures f. castriota 1 , b. reimers 2 , n. corvaja 3 , r. manetti 1 , c. cernetti 2 , c. di mario 3 , p. pascotto 2 , a. cremonesi 1 , a. colombo 3 ; 1 cotignola/it, 2 mirano/it, 3 milan/it background: distal embolization of debris during percutaneous carotid artery stenting may result in neurological deficit. methods/results: 320 consecutive procedures (308 patients) of elective carotid stent implantation with cerebral protection performed in 3 different centers were included in a prospective registry. cerebral protection was performed using filter devices (80.6 % of procedures), occlusive distal balloons (17.2 %), and endoluminal clamping of the common and external carotid artery (2.2 %). all lesions were > 70 % diameter stenoses (mean 82 ± 8 %). mean age of the patients was 67 ± 11 years, 83 % were males, and 58.7 % of patients had had a previous stroke or transient ischemic attack. in 313 procedures (97.8 %) it was possible to position a protection device. in 9 of 55 procedures using distal balloon protection, this was not tolerated by the patient (2.8 %). in 317 procedures (99.1 %) a stent was successfully placed. neurological complications during the procedure, in-hospital and during 30 days of follow-up, occurred in 6 patients (1.9 %). these were 1 major stroke (0.3 %; amaurosis of ipsilateral eye), 3 minor strokes (0.9 %), and 2 transient ischemic attacks (0.6 %). protection device related complications, all without neurological symptoms, occurred in 8 procedures (2.4 %). these were 7 distal dissections (3 required additional stents and 1 lead to occlusion of the internal carotid artery) and 1 filter entrapment requiring surgical removal. major adverse cardiac events during the 30 days of follow-up occurred in 2 patients (0.6 %). conclusions: routine use of cerebral protection during carotid artery stenting appears feasible. in this study the incidence of neurological complications was low. fresh dwi lesions after stenting of the internal carotid artery v. moeller; homburg a. d. saar/de purpose: our aim was to reveal the number of thrombembotic events after stenting of the carotid artery. methods: 38 patients underwent stenting of the carotid artery. afterwards patients were neurologically examined and underwent mr imaging. stenting was performed without protective devices. systemic anticoagulation was started three days in advance. in 10 cases predilatation of the stenotic vessel was performed. results: 40 stents were succesfully placed. 4 patients developed neurological deficits, 1 had a minor stroke, 3 a transient ischemic attack. retrospectively anticoagulation was found to be insufficient in one of these cases. 3 months after the intervention none of the patients had developed neurological deficits. diffusion weighted mr imaging detected fresh lesions in 16 patients. the medium degree of stenosis was 88.2 %, this being significantly higher than the 82.7 % among those without new lesions on dwi. furthermore the mean age of the first group was thromboembolic events -a challenge in interventional neuroradiology i.q. grunwald, v. möller, w. reith; homburg a. d. saar/de purpose: thromboembolic events are the most frequent complication in the endovascular treatment of intracranial aneurysms with gdcs. at the moment diffusion-weighted imaging is the most sensitive method for their early detection. our aim was to evaluate the number of ischemic events by using diffusion-weighted mri. method: before and within 48 hours of endovascular treatment with gdcs 13 patients with 15 asymptomatic aneurysms were studied with diffusion-weighted images. during positioning of the coils and for another 2 days the patients were heparinised. a neurological examination took place before and after coiling as well as on discharge. results: occlusion of the aneurysm was achieved in all cases. dwi showed small, fresh hyperintense areas in 6 cases. they were all located in the vascular territory of the aneurysm and have to be seen as intervention-related. none of the patients had clinical symptoms. occurance of thromboembolic events did not correlate with the number of coils used. conclusion: regarding the frequency of thromboembolic events, even though they are mostly silent, dwi monitoring should follow intervention. we assume that the thrombembolic lesions are due to embolic fragments that migrate from the aneurysm as well as due to ischemic events of other origin (vasospasm, arteriosclerosis). therefore we think that in the endovascular treatment of asymptomatic aneurysms systemic anticoagulation should be performed. purpose: for most of the pregnant women who underwent an obstetric flow study using color doppler imaging, we calculated low velocity values from the foetal middle cerebral artery in comparison to literature. the aim of this study was two-fold: to define the normal flow values of the foetal and maternal arterial systems and to compare the results with the literature. methods and materials: 124 healthy pregnant women of various gestational age who underwent a color doppler examination were studied after having an uncomplicated pregnancy and labour. pulsatility index (pi), resistance index (ri), peak systolic/end diastolic ratio (s/d ratio) values were calculated for the foetal aorta (fa), foetal middle cerebral artery (fmca), umblical artery on the maternal (mua) and foetal (fua) side and the maternal uterine artery (uta). the results were compared with the published literature. results: 20 to forty week pregnancies were divided into 10 different groups, each group represented a period of 2 weeks of gestational age. for each group, the studied parameters were defined and presented in a diagram. flowmetric values are helpful in defining the existing or potential abnormalities in the foetus. the published literature was used to compare patient flowmetric study results. in our study, we found significant differences for fmca and ua values compared with the published data. to study the relationship of uterine artery impedance measured as pulsatility index (pi) and resistance index (ri) on the outcome of in vitro fertilization -embryo transfer cycles. methods: 55 women in the age group between 25 -42 a were studied on the day of embryo transfer by performing tranvaginal color doppler sonography. uterine artery pulsatiliy index, resistance index and endometrial thickness were calculated. subsequently pregnancy rates were calculated. results: the pregnancy rate was 35 % in patients with a pulsatility index 2.45 ± 0.54 and resistance index 0.85 ± 0.04. in patients with a pulsatility index higher than 3.00 and resistance index higher than 0.91 the pregnancy rate decreased significantly to 15 %. purpose: in addition to histologic evaluation of the effect of antiangiogenic treatment with anti-vegf receptor antibodies, a functional investigation of tumour vascularisation was performed using contrast enhanced, intermittent power doppler sonography in tumour bearing nude mice. methods and materials: 10 thymus-aplastic nude mice with hacat-ras-tumours were examined weekly for 4 weeks after i.v.-bolus injection of levovist with intermittent power doppler sonography. this further developed method allowed statements about the quantification of blood flow and volume by varying the time delay between doppler imaging sequences to be made. besides other vascularisation parameters like time of arrival, slope of the curve, maximum and plateau phase of the colour pixel density (pcd) and mean colour value were measured. five mice were treated with a vegf-receptor antibody during the examination period. results: while without contrast agent nearly no blood flow was visible, the tumours showed clearly visible enhancment of doppler signal after injection of levovist. tumours without therapy showed an increase in pcd signals during the tumourgrowing phase. mice with antiangiogenic treatment showed a signal decrease in the first monitoring examination, even in growing tumours. there was a limitation of doppler signals to the periphery of the hacat-ras-tumours whilst untreated tumours showed a homogenous enhancement except in necrotic areas that were found in later phases. conclusion: contrast enhanced sonography enables vascularisation measurements of hacat-ras-tumours and the monitoring of antiangiogenic therapy. therapeutic effects could be visualized before a macroscopic change of tumour size was observed. furthermore intermittent doppler sonography enables objective perfusion parameters in ultrasound. we prospectively examined the va origin with cds using a 4 -8 mhz endovaginal transducer in 244 vas in 122 consecutive subjects referred for evaluation of carotid and vertebral arteries. we also evaluated va origins of the same subjects using a 5 -8 linear transducer and compared the visualization rates of both transducers. the criteria for visualization of va origin was identification of origin of an artery arising from the subclavian artery and entering the transverse foramen at the c6 level. angle-corrected peak systolic velocity (psv), end diastolic velocity (edv), and resistive index (ri) were determined. angiography was available for comparison in 40 vas of 20 subjects. results: two aplastic right vas of 2 subjects were excluded. the va origin was visualized in 241 (99.6 %) of 242 vas (120 right and 121 left vas) with the endovaginal transducer and 161 (66.5 %) of 242 vas (97 right and 64 left vas) with the linear transducer. psv, edv, and ri of 241 vas were 61.9 ± 29.6 cm/s, 15.3 ± 9.9 cm/s, and 0.75 ± 0.08 (mean ± sd), respectively. angiography revealed stenosis (> 50 %) of the va origin in 2 vas (psv > 150 cm/s at cds) and normal patency in 38 vas. in the only one of 242 vas missed at cds with the endovaginal transducer, the va was shown to arise directly from the aorta at angiography. conclusion: cds with an endovaginal transducer was a very useful and efficient method to visualize the va origin. doppler sonography of sympathetic vasomotor response in patients with diabetic foot syndrome a. hlawatsch 1 , j. bauer 1 , v. kuhl 1 , s. mink 2 , m. eicke 1 ; 1 mainz/de, 2 heilbronn/de purpose: neurophysiological assessment of the peripheral autonomic system is limited. continuous wave doppler sonography of the radial artery can be used to measure the sympathetic vasomotor response (svr). we studied 25 patients (mean age 63 a) with diabetic foot syndrome. the data from 4 mhz cw doppler sonography before and after sympathetic stimulation by coughing (leading to a temporary disappearance of diastolic flow) were compared with normal controls. correlation was made with nerve conduction studies and the extent of radiologically visible media sclerosis. results: under baseline conditions, the mean flow velocity was similar in diabetics and controls, but the resistance index (ri) was significantly higher in diabetics (1.1 vs. 0.8). after coughing no significant difference in the ri or the duration of the response was noticed between patients and controls, but the onset of the response was significantly delayed in the study group (2.1 vs. 1.5 s). no correlation was found with nerve conduction studies and radiologic results. conclusion: radial artery svr is an independent and sensitive marker for autonomic function. 14:00 -15:30 room i interventional radiology liver tumor ablation -metastases purpose: to evaluate in vitro and in vivo the use of mr-guided interstitial thermotherapy with rfitt in bipolar technique and to compare electrodes with active and non-active tips. material and methods: a newly designed internally cooled rf probe (∅ 3 mm) was used. both electrodes were 18 mm in length, the inserted insulator between both electrodes was 8 mm in length. for cooling, distilled water was used at flow rates between 40 and 130 ml/min and the power was between 40 and 70 w. three patients with a liver metastases were treated under local anesthesia. in vitro studies were done to compare electrodes with an active tip with electrodes with a nonactive tip. during mr measurements the rf generator was switched off. results: mri allowed a reliable visualization of the electrodes and the insulator in between. the experiments documented that a rf power of 40 w with an irrigation rate of 40 ml/min results in the largest possible area of coagulative necrosis with a diameter of 34 mm × 46 mm. the treatment of the patients was performed without any complications. the advantage of the active tip is that subcapsular lesions can also be treated using this bipolar rf technique with the active tip as the distal electrode. conclusion: mr-guided rfitt using a internally cooled, irrigated bipolar rf electrode results in a coagulative necrosis which is comparable to those of mr-guided laser induced thermotherapy (litt) . with the active tip as the distal electrode subcapsular lesions can also be treated with the bipolar system. to determine the value of multiplanar and 3d post-processing techniques for guidance of the ablative probe to an optimal position before radiofrequency treatment of liver lesions. methods and materials: 21 patients with malignant hepatic tumors (hcc n = 6, metastases n = 15) underwent radiofrequency ablation. following conventional ctguided (siemens volume zoom©, biopsy mode) positioning of the ablative device, its position was re-evaluated using multiplanar (mpr) and volume rendering 3dreformations. the position of the ablative device was characterized qualitatively based on the following scale: central -probe is localized within the central 20 % of the tumor; marginal -probe is lateralized towards the periphery of the tumor; outside -probe-position outside of the tumor. suboptimal positioning was corrected following initial ablative therapy to assure complete ablation of the tumor and imaging was repeated. results: multiplanar and 3d renderings proved superior over imaging in the axial plane in determining the position of an ablative device within liver tumors (p = 0.008). in 9 out of 21 patients the probe position was considered to be central on axial images whereas multiplanar and 3d renderings only revealed marginal probe localisation. axial, multiplanar and 3d renderings yielded identical results in the remaining 12 patients. comparing multiplanar and 3d reformative techniques, no significant difference was shown in determining the ablative device position. conclusion: mpr and 3d renderings aid in optimising the probe position for ablative therapy in a substantial number of patients. as a correct probe position is crucial for the success of an ablation procedure, these viewing techniques should be implemented without delay. clinical diagnosis was always underestimated at initial presentation. imaging modalities were requested for cerebral ischemic attack (2/3), cephalalgia, photophobia and tinnitus (1/3). initial imaging diagnosis was delayed (> 3 days) in all cases, as patients were referred for brain evaluation and carotid artery disease. follow up clinical and imaging examination demonstrated: a death (n = 1) serious brain damage (n = 1), complete recovery after antiobiotherapy and anticoagulotherapy (n = 1). conclusion: delayed diagnosis of septic thrombosis of the lateral sinus is probably related to its non-specific clinical symptoms. therefore, in patients with an history of diabetes immunodepression or of infection of the face or of the temporal bone, a careful examination of the skull base should be performed to determine the permability of the brain venous sinuses, the status of the mastoid cell pneumatization of the temporal and occipital bones and the normality of the related fatty spaces. objective: conventional or digital 2d dacrocystography and ct dacocystography is usually carried out after the catheterization of a lacrimal canaliculus. we tried to evaluate the quality of opacification on ct scans after simple instillation of contrast medium, without any catheterization. patients and methods: 39 patients (78 nasolacrimal ducts) were explored for lacrimal pathways obstruction by ct scans after instillation of diluted water soluble contrast medium instillation. a complementary ct acquisition after catheterization was performed when the first ones did not show any opacification. results: ct dacrocystography after instillation is a well tolerated and safe technique. in our study, it allowed detection all pathologic lacrimal canals; 7 normal lacrimal pathways (after catheterization) were not opacified after instillation (false positives). the sensitivity of the method was 100 %, its specificity 84 %. conclusion: ct dacrocystography after ocular instillation is an easy, physiologic and sensitive method to evaluate lacrimal obstruction. we propose it as the first step test, the catheterization being used only when there is total absence of opacification after instillation. results: inflamatory causes are responsible of lacrimal duct obstruction. we found no post-traumatic lesions, dacryolithiasis or nasolacrimal neoplasms. dcg evaluated lacrimal ducts and the nasal meatus. dct was performed only in patients with simple intubation or endoscopic dacryocystorinostomy to exclude all postsurgical complications of the surrounding nasolacrimal duct tissues or an inflammatory process of paranasal sinuses. discussion and conclusion: dcg and dct have almost the same sensitivity and specificity in a morphological study of nasolacrimal ducts. crystallin dosage is 0.04 to 0.2 msv in dcg and 1.8 to 2.6 msv in dct. dct with 3d reconstruction gives good spatial and anatomic details (orbital, etmoidal and nasal bone). dcg is always the gold standard in the imaging of the lacrimal ducts, but we propose dct to check possible post-surgical complications. purpose: poag is an ocular disease based on a progressive optic neuropathy, visual-field defects and elevated intraocular pressure. our purpose was to compare with color doppler the blood flow of the main orbital arteries of normal, atherosclerotic and glaucomatous subjects. methods and materials: we evaluated with color doppler (atl hdi 5000) the blood flow of ophthalmic artery (oa), central retinal artery (cra), nasal and temporal short posterior ciliary artery (spca). peak systolic velocity, end diastolic velocity and resistive index (ri) of each artery were considered. we examined 3 group of patients: 30 normal subjects (group a), 30 patients (> 50 years) with positive risk factors for atherosclerosis (smoking, hypertension) (group b) and 30 patients affected by poag (group c). inclusion criteria in group c were: iop > 21 mmhg, visus > 5/10, pseudoexfoliatio presence. results: all the arteries of group b showed higher ri than group a, with low end diastolic velocities. spca (0.87 ± 3.3) and cra (0.85 ± 2.6) of group c showed significantly higher ri than group a, but no significant ri differences were found in oa of group c (0.76 ± 4.2) and group a (0.77 ± 2.7). conclusion: normal, atherosclerotic and glaucomatous subjects can be distinguished by color doppler evaluation of the blood flow of the main orbital arteries. orbital color doppler can be useful in the diagnosis of poag and in the monitoring of these patients. which parameter should be used for rapid assessment of extraocular muscle enlargement in patients with graves' ophthalmopathy? z. szücs-farkas, j. toth, l. galuska, e. balazs, e.v. nagy; debrecen/hu purpose: to find the most accurate, easy-to-measure parameter that can be used as a substitute for extraocular muscle volume assessment in patients with graves' ophthalmopathy. subjects and methods: 70 orbits of 35 patients were examined in a conventional 1 t mr scanner and the rectus muscles evaluated. the diameter at the largest extent of the muscle belly, as well as the long and the short diameters and the cross sectional areas in a preselected coronal scan were measured for each muscle and compared with the corresponding muscle volume measured on contiguous t1w transverse slices. results: the measured coronal area correlated well with the volume of the superior (r = 0.694) and inferior (r = 0.783) recti. the largest transverse diameter showed strong correlation with the volume of the lateral (r = 0.868) and medial (r = 0.869) recti. for the latter muscle, the coronal area also exhibited a high correlation with the volume (r = 0.838). coronal cross-sectional areas can be well estimated by measuring both the short and long coronal muscle diameters (r values were between 0.914 and 0.966). p was less than 0.0001 for every above mentioned correlations. conclusions: in graves' ophthalmopathy, the volume of three of the rectus muscles seems to be well estimated by measuring their cross sectional area on a single coronal slice, while the largest transverse diameter of the lateral rectus is suitable for the same purpose. purpose: a prospective study was performed to determine the accuracy of unenhanced, enhanced and early delayed (15') enhanced ct densitometry in differentiating adenomas from non adenomas and to evaluate the usefulness of absolute and relative percentage of washout. methods and materials: 37 oncology patients with 44 undetermined adrenal masses were all studied by unenhanced, enhanced and 15 minutes delayed enhanced helical ct scans. attenuation values of all adrenal masses on each type of scan was measured by mean of a region of interest and then used to calculate absolute and relative percentage wash-out. proof of diagnosis was ct and/or mr follow-up (6 -36 months) in 31 patients; percutaneous ct guided biopsy in 5 patients; surgery in 1 patient. results: on unenhanced ct scans, with attenuation threshold of 18 hu, specificity and sensitivity for the diagnosis of adenoma were 100 % and 93 % respectively. on 15 minutes delayed ct scans, with an attenuation threshold of 38 hu, specificity and sensitivity for the diagnosis of adenoma were 100 % and 90 % respectively. moreover, all adrenal masses were correctly characterised as benign or malignant on delayed scans with a relative percentage washout of 35 % and an absolute percentage washout threshold of 50 %. conclusion: unenhanced and early delayed enhanced ct attenuation values can characterise an adrenal mass as a benign adenoma with high specificity and acceptable sensitivity. the percentage change in washout of contrast media can be a useful adjunct to absolute ct attenuation values in differentiation of adrenal adenomas and nonadenomas. ct adrenocortical carcinomas and pheochromocytomas: assessment of wash-out at delayed contrast-enhanced p.i. reittner 1 , m. korobkin 2 , p. wehrschütz 1 , k.w. preidler 1 , d.h. szolar 1 ; 1 graz/at, 2 ann arbor, mi/us purpose: to measure the changes in washout of contrast material on contrast medium-enhanced computed tomographic (ct) scans in patients with adrenocortical carcinomas and pheochromocytomas. materials and methods: fifteen patients with proven adrenocortical carcinomas and 17 patients with pheochromocytomas underwent helical ct. unenhanced ct was followed by enhanced ct at 60 seconds and 10 minutes. 121 adrenal masses (74 adenomas and 47 metastases, respectively) in 108 patients served as reference data. results: the adrenocortical carcinomas and pheochromocytomas enhanced significantly lesser than the adenomas at 60 seconds (p < 0.001). at 10 minutes, both the absolute and relative percentage loss of enhancement were significantly greater for the adenomas than for the adrenocortical carcinomas and pheochromocytomas (p < 0.001), respectively. delayed-enhanced ct at 10 minutes (sensitivity, 92 %; specificity, 95 %) was more accurate for differentiation of adenomas and adrenocortical carcinomas and pheochromocytomas than unenhanced ct (sensitivity, 82 %; specificity, 95 %) conclusion: adrenocortical carcinomas and pheochromocytomas exhibit similar wash-out than do adrenal metastases, but significantly lesser than do adrenal adenomas. the percentage change in washout of contrast material is a useful adjunct to absolute ct attenuation values in differentiation of adrenal adenomas and adrenocortical carcinomas and pheochromocytomas. incidence of malignancy in complex cystic renal masses (bosniak category iii): should biopsy precede surgery? m.g. harisinghani, k. jhaveri, d.a. gervais, p.f. hahn, j. varghese, p.r. mueller; boston, ma/us purpose: we sought to determine the incidence of malignancy and to assess a possible role for image guided biopsy of this category of renal masses materials & methods: of the 397 renal biopsies performed at our institution between 1991 and 2000; a total of 28 patients with 28 category iii lesions, were identified for analysis. there were 18 men and 10 women with age range from 40 to 70. the incidence of malignancy, based on surgical pathology or imaging follow up, and percentage of lesions proceeding to surgery, among these 28 lesions, was determined. the surgical results were correlated to the biopsy findings results: of the 28 biopsied category iii lesions, 17 were malignant (16 renal cell carcinoma, 1 lymphoma) and 11 were benign (4 hemorrhagic cyst, 1 oncocytoma, 3 inflammatory cysts, 2 adenomas, 1 focal glomerulosclerosis). seventeen of the 28 (60.7 %) lesions (16 renal cell carcinoma, 1 inflammatory cyst) had surgical resection following the biopsy. all lesions proceeding to surgery had pathological diagnosis identical to the pecutaneous image guided biopsy results. non-surgical patients had radiological follow up for minimum 1 year conclusion: the incidence of malignancy in bosniak category iii is 60.7 % (95 % confidence interval). presurgical renal biopsy and radiological follow up is useful in identifying non-malignant lesions in this category, thus avoiding unnecessary surgery in up to 39 % of patients method and materials: prospective analysis of 25 patients with histopathologicaly proved rcc included enhanced mdct studies in arterial and corticomedullary phase (detector configuration: 4 × 1 mm, rt 0.5). we compared 3 reconstruction protocols (slice width/reconstruction interval: 1.25/0.7 mm, 3/1.5 mm, 5/2.5 mm). in addition, multiplanar reconstructions (mpr) in 5, 3 and 1.25 mm coronal planes were assessed. finally, low-dose ct urography (delay 10 min) with mpr reconstructions was performed in the excretory phase. image data of all reconstructions were analysed for the size of the lesion, tnm staging, morphological, and enhancement characteristics by two radiologists. histopathological data were used to determine the efficacy of the different ct reconstruction protocols. results: different reconstruction protocols (5, 3 and 1.25 mm) have no influence on the evaluation of tumour size and t-staging. however, assessment of lymph node size was improved in 12 % of the patients by using thinner slice width and 1.25 mm mpr reconstruction. vertical tumour size and v. cava infiltration was more precisely assessed by evaluation of mpr-than axial reconstructions. in all patients ct-urography demonstrated sufficient opacification of the collecting system. conclusion: axial reconstruction protocols are equally suited for the t-staging of rcc. a mdct protocol using additionally 1.25 mm mpr reconstructions and lowdose ct urography appears effective as a "one-stop" protocol for a proper staging of rcc and eliminates further investigations such as iv urography. b-0178 14:40 0.59 (95 % ci: 0.22 -0.95) for the n-stage. the average tumour size was 5.2 cm. all accessory arteries and veins were correctly described. the renal pelvis was opacified in 94 %, the proximal ureter in 89 %, and the distal ureter in 77 %. distant metastases were found in 2 cases and 3 patients showed tumour extending into the renal vein. conclusion: isotropic multislice ct of the kidneys with a modified injection protocol provides good correlation with pathological tumour stage, allowing cta and ct-urography calculation from the same dataset and, thus, may represent a universal imaging technique in renal cancer staging. histopathological correlated, staging of renal carcinomas by multislice ct and high performance mri p.j. hallscheidt, s.o. schoenberg, g. riedasch; heidelberg/de aim: to evaluate the accuracy of multislice-computed tomography (ct) and magnetic resonance imaging (mri) in staging renal carcinoma and planning of nephron sparing surgery. material and methods: in a prospective study 58 renal carcinomas were preoperatively examined for tumour staging by multislice ct and mr imaging and correlated with histopathological staging. triphasic ct imaging was performed with a siemens volume zoom with a reconstructed slice thickness of 1 mm. 3d and coronal reconstructions were used to improve planning of the surgery. in mr imaging (siemens vision) additional to the transversal t1-weighted ge sequence with and without gdtpa, and a transversal t2 weighted respiration triggered tse, a coronal t1-weighted ge sequence with gdtpa and fat saturation were acquired. in addition a multi phase 3d angio after gdtpa injection was performed. results: in early stage renal carcinoma ct and mr imaging provide similar staging accuracies. in all cases multi slice ct allowed us to identify all renal masses, especially in multifocal renal cell carcinomas. accessory arteries could be identified in all cases, too. multiphase mri allows detection and differentiation of renal masses, especially in caval infiltration. conclusion: multislice ct and 3d reconstruction integrate essential information from angiography, venography, urography and 2d ct in a single imaging modality. in multislice ct all tumours in multifocal renal cell carcinoma were detected. in advanced renal carcinoma mri was superior to ct imaging, especially in diagnosing tumour thrombus. consequently the extent of tumour thrombus may be assessed by mri which therefore may replace conventional cavography. small renal masses: value of contrast-enhanced colour doppler imaging a. klauser, g. janetschek, g. helweg, r. peschel, l. pallwein, d. zur nedden, f. frauscher; innsbruck/at purpose: we assessed the value of a microbubble based ultrasound (us) contrast agent for blood vessel enhancement in colour doppler imaging (cdi) of small renal masses. methods and materials: 51 patients with "indeterminate" small renal masses (< 3 cm in diameter) underwent prospective cdi before and after intravenous administration of the contrast agent levovist® (schering ag, berlin, germany). the degree of tumour vascularity was subjectively graded from 0 to iv (indicating an increasing vessel count) and the peak systolic velocity (psv) was measured. cdi findings were compared with those obtained at histopathological examination. results: intra-and/or peri-tumour vessels were detected in 26 lesions (51 %) by unenhanced cdi and in 48 lesions (94 %) by enhanced cdi. the detection of vascularity was increased by contrast administration (p = 0.006, mcnemar test). higher grades of tumour vascularity (grade iii and iv) were found more often in malignant renal masses (p < 0.01). psvs higher than 80 cm/s were found only in malignant lesions. based upon receiver operating characteristic analysis, enhanced cdi (az = 0.789) is more accurate than unenhanced cdi (az = 0.576) for differentiating benign from malignant renal masses (p < 0.004). conclusions: enhanced cdi is superior to unenhanced cdi in the detection of tumour vascularity, and in the discrimination between benign and malignant small renal masses. assessment of renal masses with contrast enhanced sonography using pulse inversion imaging and fso69 j.-m. correas 1 , m. claudon 2 , a. lesavre 1 , a. méjean 1 , l. bridal 1 , o. hélénon 1 ; 1 paris/fr, 2 nancy/fr purpose: to evaluate the efficacy of contrast-enhanced sonography of renal masses using a fso69 (optison®, mallinckrodt, usa), with quantification of the signal intensity. materials and methods: 24 renal masses were studied with pulse inversion imaging (pii) at baseline and following a bolus injection of fso69 (1, 2, 3 and 4 ml, randomised dose, 6 patients per dosage group, atl hdi5000, c5-2 probe). cineloops were transferred to a pc for quantification with hdi lab. the cortical and solid mass enhancement was calculated as the difference between the signal intensity of a region of interest located upon the normal cortex and the mass before and after injection (db). the final diagnosis was obtained by ct, mri and/or surgery (adenocarcinomas 16, complex cysts 5; hamartomas 3). results: cortical enhancement was correlated with the dose (r = 0.98) and was consistently greater when the mechanical index was lower than 0.4. the detection of normal and atypical cysts was improved and was correlated with ct and mri features. renal mass delineation was improved except when the enhanced mass signals matched with the normal surrounding cortex (2 cases). the visibility of the necrosis within the lesion was comparable to the ct and mr appearance. the peak enhancement was: 9.6 db ± 4.0 db for the cancers, 5.8 db ± 3.5 db for the hamartomas and 0.8 db ± 0.5 db for the complex renal cysts. conclusion: pii of renal masses following fso69 injection improved the detection and the characterization of renal masses, particularly in small tumours and complex cysts. purpose: combined inhibition of the synthesis of nitric oxide and prostacycline predisposes rats to renal injury from radiographic contrast media (rcm). the reliability of these pharmacological manipulations was investigated. methods and materials: adult male sd rats were injected with l-name (10 mg/kg), indomethacin (10 mg/kg) and rcm (or normal saline) 15 minutes apart. serum creatinine (cr) was measured prior to and post these pharmacological insults. results: a significant increase in serum cr (from 54.66 ± 8.39 to 171.96 ± 24.49 µmol/l and from 80.95 ± 6.73 to 204.76 ± 16.73 µmol/l, n = 5/group) was observed 24 hours after injection of 6 ml and 8 ml of high osmolar rcm diatrizoate respectively. the increase in serum cr recovered spontaneously 7 days after the injection. no significant change in renal function was observed in the control group receiving 8 ml/kg of normal saline (n = 5) or after injection of 4 ml of diatrizoate (n = 5). the increase in serum cr observed with 6 ml of diatrizoate was significantly higher (p < 0.01) in comparison to the rise induced by equivolume of the low osmolar iopromide (serum cr was 68.47 ± 8.39 µmol/l pre contrast and 143.59 ± 32.03 µmol/l 24 hours post contrast, n = 5). the calcium channel blocker diltiazem (10 mg/kg i.p., 30 min prior to contrast injection) prevented the rise in serum cr observed with 6 ml of diatrizoate. the protective effect was less with lower doses of diltiazem. conclusion: the used animal model is reliable and capable of reproducing previously established observations. the protective effect of a calcium channel blocker has also been shown. purpose: aim of the study was to evaluate the efficacy of gadobutrol as contrast agent for diagnostic chest and abdominal ct compared to iodinated contrast media in a porcine animal model. methods: in 7 pigs spiral cts of the chest and abdomen were performed using 2 ml/kg bw gadobutrol (gadovist, schering, germany) given by single intravenous injection (siemens somatom plus 4; slice: 5 mm, table feed: 7.5 mm, reconstruction increment: 5 mm). one week later the same animals were examined under the same protocol using iopromide (ultravist 300; schering, germany; 2 ml/kg bw). in 3 additional animals serial cts were performed using gadobutrol on day 1 and iopromide on day 7 to detect contrast media kinetics, peak enhancement and time enhancement-product in important vascular regions and parenchymal organs. peak enhancement (net increase compared with native baselines) were measured in houndsfield units (hu) in defined regions of interest. additionally, diagnostic quality and accuracy of the cts were evaluated on a two-step scale by three independent blinded investigators. results: in vivo, the mean peak enhancement 0, 5, 10, 30, 60 and 120 seconds in the abdominal aorta after injection of 2 ml/kg bw gadobutrol and iopromide was 40, 200, 224, 261, 118, 95 hu and 41, 232, 298, 152, 143 , 123 hu respectively. all cts using gadobutrol were classified as diagnostic with excellent differentiation of vascular and parenchymal structures. conclusion: computed tomography with 1 mol gadobutrol resulted in an excellent contrast peak enhancement. computed tomography using gadobutrol is feasible and a possible alternative to iodinated contrast material. use of artificial neural networks in predicting adverse drug reactions in patients receiving contrast media e. grossi 1 , m. buscema 2 , a. seeberg 3 ; 1 milan/it, 2 rome/it, 3 constance/it neural networks (anns) are mathematical algorithms tools are able to determine the existence of subtle correlations between series of data and a particular outcome, and once "trained", can predict output data on the basis of the input data. although neural networks have been applied in various areas of medical research, they have not been previously applied to the prediction of adverse events to contrast media. materials and methods: anns (provided by semeion research centre, rome, italy) were used to predict adverse events occurring in over 600 patients receiving iomeprol 300 (300 mg i/ml) within a large observational clinical study performed by bracco-byk gulden in 6 german radiological centres. the database consisted of 76 independent variables obtained from the case report forms. during an optimising process based either on linearity criteria or specific evolutionary algorithms, just 9 independent variables resulted as best predictors of the prognostic target. the sample size was divided into two random subsamples: the training one (the only one containing the dependent variable) and the testing one. in the testing phase the overall prediction accuracy ranged from 91.6 to 95.6 %. these values were reproducible along ten consecutive experiments with independent networks of the same type trained in different random subsamples. these results indicate that neural-network analysis can be used to predict adverse effects of contrast media within a given class. mr imaging of atherosclerotic plaque with new ultrasmall particles of iron oxide (7228) compared to sinerem® in hyperlipidemic rabbits c.u. herborn 1 , t.c. lauenstein 1 , f.m. vogt 1 , c. corot 2 , j.f. debatin 1 , s.g. rühm 1 ; 1 essen/de, 2 aulnay-sous-bois/fr purpose: to evaluate a new uspio compound 7228, compared to sinerem® (both guerbet, france) as a marker of macrophage activity in atherosclerotic plaques. materials and methods: experiments were conducted on 4 heritable hyperlipidemic rabbits aged 4 -6 months. imaging was performed on a whole body scanner using the transmit/receive head coil. after initial 3d mr angiography of the thoracic aorta with conventional paramagnetic contrast agent (gd-dota), animals were injected once with either 7228 (n = 2) or sinerem® (n = 2) at equal doses. 3d mr angiography was repeated daily over 5 days. on day 6 the rabbits were euthanized for histopathologic evaluation of the aorta. results: 3d mras with gd-dota revealed no abnormal findings in any of the animals (n = 4). luminal signal intensity at different days was comparable between both compounds with no significant differences regarding the time-evolution of t2* effects. susceptibility effects within the aortic wall became evident on day 2 in both groups reaching the maximum after 4 days. these changes were more pronounced in the 7228 group without amounting to a statistical significance. histopathology proved slightly increased fe uptake in macrophages of atherosclerotic plaques of the two rabbits injected with 7228 compared to those who received sinerem®. conclusion: both uspio agents cause susceptibility effects within atherosclerotic plaques detectable by 3d gre sequences. since phagocytosis of 7228 seems to be superior to sinerem® it can be assumed that lower doses of this compound are suited to allow better visualization of active plaque in atherosclerotic disease. a.r. rudisch 1 , c. kremser 1 , w. judmaier 1 , h. zunterer 1 , j. griebel 2 , a. de vries 1 , w.r. jaschke 1 ; 1 innsbruck/at, 2 neuherberg/de aim: this study aimed to compare perfusion-index-values (pi) of gadolinum-dtpa (gd-dtpa) obtained in malignant tumors with pi's of normal tissue (muscle). material and method: perfusion data were obtained in histological proven primary rectal carcinoma and in left sided gluteus maximus muscles (n = 23). perfusion data were obtained by magnetic resonance imaging (mri) measurements using a specially ultrafast t1-mapping sequence in a 1.5 t whole body scanner. t1-maps were acquired in intervals of 14 s or 120 s before, during and after constant rate infusion of gd-dtpa. in order to investigate the relevance of spatial heterogeneities of microcirculation in tumors and muscles, relative frequency distributions of pi's were computed with equal class intervals of 0.021 ml/min/g. not only the mean pi but also the relative fraction of pi £ 0.126 ml/min/g between tumor tissue (0.093 ml/min/g ± 0.021; 89.1 %; ±12.1) and muscle tissue (0.037 ml/min/g ± 0.012; 99.8 %; ±0.6) was statistically significantly different (both p < 0.001, mann-whitney-u-test). discussion: our results can offer additional information about higher nurtrients supply, e.g. chemotherapeutic agents, to tumor tissue than to muscle tissue caused by high pi's and a higher relative fraction of high intratumoral pi's. the presentation was supported in part by grants from schering, germany and austria. can necrosis avid-mr-imaging with metalloporphyrins differentiate between stunned and infarcted myocardium: results of an experimental study in dogs p. reimer 1 , j. bankert 1 , c. bremer 2 , k.-u. jürgens 2 , t. filler 2 , t. weber 2 , b. tombach 2 ; 1 karlsruhe/de, 2 münster/de purpose: to investigate whether stunned myocardium may be differentiated from infarcted myocardium by metalloporphyrin-enhanced-mri. materials and methods: 10 open-chest anesthetized dogs underwent reversible (15 min; n = 5) and permanent (n = 5) pneumatic occlusion of the left anterior artery (lad) to induce myocardial stunning and myocardial infarction, respectively. mri was performed at 1.5 t obtaining ecg-triggered short and long axis t1-w tse at baseline and every 30 min following injection of gadophrin-2 (50 µmol/kg bw) up to 6 hours. postmortem, needle biopsies were taken from the lad-perfused and a remote area. ex vivo, mri (t1-w tse) and ttc staining were performed. results: gadophrin-2 enhancement was slightly higher in stunned myocardium than in remote regions but significantly higher than in infarcted areas when measured in the long axis. all regions showed highest signal intensity 30 min following injection followed by a decrease over time. conclusion: gadophrin-2 enhanced mri may serve as an additional tool besides functional measurements such as tagging or perfusion to differentiate stunned from infarcted myocardium. assessment of angiogenic tumor burden by susceptibility mri using long circulating iron oxide nanoparticles c. bremer 1 , m. mustafa 1 , a. bogdanov jr. 2 , v. ntziachristos 2 , a. petrovsky 2 , r. weissleder 2 ; 1 münster/de, 2 boston, ma/us purpose: to evaluate iron-oxide enhanced mri for the assessment of the angiogenic burden of various tumors methods and materials: a variety of tumors (9l-gliosarcoma, du4475-breast cancer, ht1080-fibrosarcoma and eoma-hemangioendothelioma) with various angiogenic potential were implanted into nude mice. tumors were imaged at 1.5 t using a pd-w ge sequence before and after i.v. injection of magnetic iron oxides nanoparticles (mion). ∆-r2* maps were calculated for all tumors and the relative tumoral blood volume was determined by roi-analysis. tumors were stained for cd31 for quantification of the microvessel density (mvd). moreover, vegf expression was analyzed for each cell line by western blotting and elisa. a subset of animals was injected with a tc-labeld intravascular tracer for measuring the blood volume distribution in vivo. results: blood volume maps generated by mri revealed a significantly higher tumoral blood for eoma-(6.6 ± 0.9 %) and ht1080-(5.5 ± 0.8 %) compared to du4475-(3.1 ± 0.4 %) and 9l-tumors (2.1 ± 0.3 %). mvd correlated well with the mr-data with eoma-and ht1080-tumors revealing a higher mvd (150 ± 13 and 81 ± 5 counts per field) compared to du4475-and 9l-tumors (43 ± 3 and 39 ± 2 counts per field). moreover, mri data closely correlated with tc-blood volume maps and the vegf expression patterns conclusions: mri with long circulating iron oxides can be utilized to assess tumoral angiogenesis. since iron oxide based particles are widely available, this technique can be readily adapted for clinical use. 1999) . a 3-month clinical follow-up was obtained in all patients who were not anticoagulated. results: for a longer mean z-axis coverage (group 1: 152 mm; group 2: 110 mm; p < 0.001), the mean duration of data acquisition was shorter with msct (group 1: 17 s; group 2: 21 s; p < 0.0001). examinations devoid of respiratory and cardiac motion artifacts were more frequent in group 1 than in group 2 (p < 0.001). in the absence of significant difference in the quality of vascular enhancement, the porportion of examinations interpretable down to the subsegmental arteries was higher in group 1 (57.5 %) than in group 2 (13 %) (p < 0.0001). the benefits of msct were more marked for patients with underlying respiratory disease and did not lead to a higher detection rate of peripheral pe. the negative predictive value of ssct and msct were 100 % and 99 %. conclusions: improvement in image quality on msct scans accounts for the improved diagnostic accuracy of scta, especially for patients with impaired respiratory function. incidental detection of pulmonary emboli on routine multislice ct of the chest c. ciccotosto, m.l. storto, f. guido, a. di credico, a. guidotti, l. bonomo; chieti/it purpose: to determine the prevalence of pulmonary embolism (pe) incidentally detected on routine multislice ct (msct) scans of the chest and to assess the influence of window width and level on pe detection. methods and materials: between january 1 and august 31, 2001, 542 routine contrast-enhanced ct scans of the chest were performed in 485 patients using a msct scanner (4 × 1 mm or 4 × 2.5 mm collimation; 5 mm slice width). ct angiographic studies performed for suspected pe or evaluation of the thoracic aorta were excluded. ct scans were retrospectively reviewed by 2 chest radiologists for the presence and site of pulmonary emboli using a cine-view mode on a dedicated workstation and 2 different widow settings: w = 400 hu, l = 40 hu (standard) and w = 600 -700 hu, l = 100 -150 hu (wide). results: unsuspected pe was present in 21/485 (4.3 %) patients, with an inpatient prevalence of 4.7 % (18/386) and outpatient prevalence of 3 % (3/99). most patients (15/21; 71.4 %) with unsuspected pe had cancer. the proximal extent of pe involved the main pulmonary artery in 5 patients, a lobar artery in 10, a segmental or subsegmental artery in 6. use of a wide window setting allowed detection of pe in 2 more patients than did the standard one. unsuspected pe was found in as many as 4.3 % of patients undergoing a routine study of the chest with msct, with a higher prevalence among patients with malignancy. the use of a wide window setting is recommended when interpreting routine msct of the chest in order to improve unsuspected pe detection. low kvp settings improve contrast enhancement and reduce radiation exposure in spiral ct of pulmonary emboli c. weidekamm, m. prokop, c.j. herold; vienna/at purpose: higher contrast of iodinated contrast material at low kvp settings may be used to compensate for increased image noise at lower exposure dose. we evaluated this concept for spiral ct of patients with suspected acute pulmonary embolism. we compared a standard protocol using 140 kvp, 175 mas (ctdi vol = 12.4 mgy) to a protocol using 100 kvp and 125 mas (ctdi vol = 3.8 mgy). we evaluated two groups of 25 consecutive patients, for whom identical scan parameters (3 mm collimation, 5 mm feed, 2 mm increment) and contrast injection protocols were used (140 ml, 3 ml/s, 20 s start delay). we measured the enhancement of the pulmonary artery in an roi at the level of the pulmonary trunk. for the enhancement of small arteries, we measured the maximum ct number in peripheral pulmonary arteries at the level of the aortic arch and at the lung bases. we determined the percentage of segmental and subsegmental arteries with sufficient quality for pe evaluation. to test the influence of observer experience on the accuracy of ct venography (ctv) for diagnosis of acute deep thrombosis (dvt) and to identify potential sources of misinterpretation. methods and materials: 64 patients with clinical suspect of pulmonary embolism (pe) underwent combined ct pulmonary angiography and ctv, using a multislice ct scanner. ctv was performed in the caudo-cranial direction, 3 minutes after administration of 140 ml of contrast material (300 mg i/ml). scan parameters were: 4 × 2.5 mm collimation, 5 mm slice width, and 5 mm reconstruction increment. ctvs were analyzed independently and in a blinded fashion for the presence of acute dvt by three readers: (a) an experienced radiologist in body ct, but without experience with ct imaging of pe; (b) a fellow in ct; (c) a third-year resident without any formal experience with ct imaging of pe. ct scans were scored on a 4-point confidence scale and different causes of interpretation errors were analyzed. the gold standard was lower extremity sonography. results: interobserver agreement was moderately good (k = 0.60; 95 % confidence interval), whereas interobserver disagreement occurred in 5 (9 %) cases. the two observers with ct experience were more accurate than the less experienced one (p < 0.02) who made a higher number of false-positive diagnoses. the most frequent causes of misinterpretation were chronic thrombosis and arterial thrombosis. no clear differences were found among the 3 readers for the error type. conclusion: ctv in addition to ctpa is a relatively accurate method for evaluation of dvt. ct diagnosis of acute dvt improves with general ct experience. conclusions: a pre-therapeutic hr-ct should always be done before medical treatment by epoprostenol. if poorly defined nodular opacities, septal lines, pericardial effusion, pleural effusion, and adenopathies are found, the pre-therapeutic strategy should be discussed again, in order to prevent patients from the risk of a paradoxical aggravation under medical treatment by epoprostenol. purpose: surgical repair of ventral hernias has been changed during the last years. this is due to new biomaterials as expanded polytetrafluoroethylene soft tissue patch (eptfe), which lets a transabdominal preperitoneal technique. this laparoscopic hernioplasty has a lower morbidity and recurrence rate, whereas it needs an accurate follow-up to assess complications which require readmission. in this prospective study we considered eight patients who underwent a laparoscopic repair of ventral hernia with an eptfe mesh between march 2000 and june 2000 at our institution. in all cases ct of the abdomen was performed after 30 days to evaluate the position of the mesh which is visualised as an higher density bandlike structure. results: in one patient after 30 days ct scan showed a fluid collection; one patient became syntomatic after 50 days and a new ct scan was performed with iv contrast medium which showed an infected fluid collection whith enhancing. conclusion: ct scan is a useful technique to assess post-operative complication of laparoscopic repair of ventral hernias, such as sieromas, abscess, hematomas, bowel obstructions and recurrences and is a great advantage to an accurate follow-up evaluation. methods: patients admitted with acute abdominal pain for which no immediate surgical intervention or ct was indicated, were randomised to "early ct" (within 24 hours of admission) or to follow "standard practice". diagnoses and confidences (on a 5-point scale) were documented by surgeons on admission and again after 24 hours. the admission, 24 hour, and final diagnoses (established at surgery and/or 6 months follow-up) were assessed by two reviewers for changes (to more serious, or less serious conditions, or "no change"). results: 55 patients were randomised to "early ct" and 63 to "standard practice". early ct reduced the length of hospital stay by 1.1 days, but this reduction did not reach statistical significance (p = 0.17). only 50 % (59/118) of admission diagnoses proved to be correct on follow-up, improving to 75 % (89/118) after 24 hours (both independent of the randomisation arm). although early ct was not associated with a significant change in diagnostic confidence at 24 hours, comparison with the final diagnosis revealed that early ct missed significantly fewer serious diagnoses (p = 0.006). there were 7 in-patient deaths, all in the "standard practice" arm. conclusions: ct undertaken early during an admission for acute abdominal pain may have favourable effects on length of hospital stay and mortality, and it is able to identify unforeseen diagnoses and complications, particularly those of a potentially serious nature. objective: to correlate isolated blunt spleen, and liver injury in children with presence and amount of free-fluid on ct scan. methods: 134 paediatric patients (range 3 months to 17 years) with isolated solid organ injury (liver or spleen) was confirmed with enhanced ct scan and graded according to the asst guidelines. the presence, location and amount of free-fluid was recorded. free-fluid was quantified as 0 = no fluid, 1 = small amount, 2 = moderate, 3 = large for each of the 3 anatomic areas. results: 134 paediatric patients with an isolated spleen (n = 66) or liver (n = 68) injury from blunt trauma were identified. free-fluid was noted in 101 injuries overall (75 %), more commonly with spleen (82 %) than liver (69 %) injuries. as injury grade increased, so did the frequency of free-fluid (grade 1 50 % to grade 5 100 %) and the total volume of free-fluid in the three quadrants (grade 1 0.75 to grade 5 5.6). the total volume of free-fluid was greater for splenic injuries (3.1) than liver injuries (1.7). the pelvis was the most common location for free-fluid (liver 53 %, spleen 71 %) and had the greatest mean amount of free-fluid (liver 0.9, spleen 1.5) of the 3 anatomic areas evaluated. (1) there is a direct correlation between the severity of the isolated injury and the frequency and amount of associated free-fluid. (2) the pelvis was the most common location to detect free-fluid and had the greatest estimated volume. whole body spiral ct in trauma patients -part i: assessment of cervical, thoracic and abdominal soft tissue and organ injuries t. albrecht, j. von schlippenbach, k.-j. wolf; berlin/de purpose: to assess the accuracy of standardized "whole body" spiral ct in the initial work-up of cervical, thoracic and abdominal soft tissue and organ injuries in trauma patients. method: 46 patients with potentially life-threatening injuries underwent a spiral ct of the neck (unenhanced; 3/5/3), the chest, abdomen and pelvis (150 ml contrast agent, 5/7.5/5) immediately after resuscitation. the ct findings were compared with the final diagnoses at discharge or death. in 22 patients abdominal sonography and ct were also compared. the final diagnoses were: cervical haematoma (n = 1), haemothorax (n = 15), pneumothorax (n = 11), pulmonary contusion (n = 12), mediastinal haematoma (n = 4), aortic dissection (n = 1), retroperitoneal haematoma (n = 6), renal haematoma/laceration (n = 4), hepatic haematoma (n = 3), splenic haematoma/rupture (n = 3), mesenteric laceration (n = 1), and isolated intraperitoneal haemorrhage (n = 2). spiral ct showed all these injuries with the exception of a delayed splenic rupture. in the 22 patients with sonography available, ultrasound missed 2 hepatic, 1 splenic and 1 renal injury. furthermore sonography produced two false positive findings: 1 haemopericardium and 1 renal contusion. conclusion: the initial standardized "whole body" ct used provided fast, comprehensive and accurate diagnosis of cervical, thoracic and abdominal soft tissue injuries in trauma patients. it is superior to sonography in assessing abdominal injuries. it should be preferred over a targeted approach with selective ct of certain body areas according to sonography results and the clinical situation since it is time efficient and often reveals unsuspected injuries. part ii: b-0898 (ss 1810a) b a c d e f 152 single-phase helical ct protocol in the evaluation of patients with suspicion of pancreatic carcinoma m. imbriaco, l. camera, m. romano, p. mainenti, e. soscia, a. puzziello, m. salvatore; naples/it purpose: to evaluate the diagnostic accuracy of single-phase (sp) helical ct in the detection and assessment of resectability of patients with suspicion of pancreatic carcinoma (pc). methods and materials: 78 (mean age: 62 ± 11 years) patients with a suspicious pc were studied. unenhanced scan was followed by one set of scans (5 mm beam collimation, 3 mm reconstruction intervals, pitch 1.0, 120 kv, 220 -240 ma) in the caudo-cranial direction, from the inferior hepatic margin to the diaphragm, with a scan delay of 50 s after i.v. contrast administration. results: a final histopathological diagnosis based on surgical findings was obtained in 57 patients, in the remaining 21 fine needle aspiration biopsy followed by 2 years clinical follow up showed no evidence of malignancy. final diagnosis was pc in 52 cases and chronic pancreatitis in 26. of the 52 tumors, 8 patients had surgically resectable disease and 44 were unresectable. sp helical ct showed a diagnostic accuracy for assessment of tumor detection of 93 % with sensitivity and specificity of 94 % and 92 % and positive and negative predictive value of 96 % and 89 %, respectively. the overall accuracy of sp helical ct to determine resectability or unresectability of pc was 92 %. conclusion: sp helical ct is an effective technique for the detection and assessment of resectability of patients with suspicion of pc. due to the lower radiation burden and to the lower cost a sp of acquisition in a caudo-cranial fashion might be considered the protocol of choice when evaluating patients with suspicion of pc. secretin assisted ct of the pancreas: is it of benefit for pancreatic tumour staging or diagnosis? s.m. lyon, t. fotheringham, p. o'sullivan, m.f. given, m.j. lee; dublin/ie purpose: to determine the effect of secretin assisted ct on contrast material delivery to the pancreas. methods: 31 patients (mean age 70; range 47 -88) were enrolled. triple phase helical ct of the pancreas was performed on successive days. unenhanced and enhanced ct in the pancreatic phase and pv phase was performed without (day 1)and with (day 2) secretin (100 iu) given at t = 0 s (n = 10), t = 60 s (n = 5), t = 120 s (n = 5), t = 180 s (n = 4), t = 240 s (n = 4), t = 300 s (n = 3). percent enhancement of the pancreas and pv system was calculated using roi's obtained from studies with and without secretin. two radiologists scored the images using a five point scale for: pancreas/tumour contrast, pv, smv and duodenal mucosal enhancement. results: overall mean pancreatic enhancement was 125 % without secretin and 132 % with secretin. no significant difference in pancreatic enhancement was noted when secretin was given at t = 0, t = 60 s, and t = 300 s. however, significantly increased pancreatic enhancement was noted (secretin vs no secretin) at t = 120 s (12 %), t = 180 s (66 %) and t = 240 s (30 %) (p < 0.05). pv/smv enhancement was significantly increased in the pancreatic phase in all secretin studies (p < 0.05). qualitatively scores for pancreas/tumour contrast, pv/smv and duodenal mucosal enhancement were all increased on secretin studies. conclusion: secretin administration increases pancreatic enhancement which aids tumour identification. early enhancement of duodenal mucosa and pv/smv is helpful for staging. for optimal results secretin should be given 2 -4 minutes before iv contrast administration. further patients are being recruited and study completion is estimated for november 2001. high resolution multislice spiral ct in pancreatic cancer: preoperative detection and assessment of resectability f. fraioli, c. catalano, f. pediconi, a. laghi, a. napoli, s. vagnarelli, m. danti, r. passariello; rome/it purpose: to prospectively evaluate multislice ct (msct) in the preoperative diagnosis and assessment of resectability in patients with clinical suspicion of pancreatic carcinoma. material and methods: 26 patients referred for suspected pancreatic carcinoma underwent msct. immediately prior to the examination, patients were given 300 -500 ml of tap water; i.v. scopolamine (20 mg/ml) was administered to reduce intestinal peristalsis. unenhanced volume was first acquired, followed by the postcontrast acquisitions, during arterial and portal venous phases. the post-contrast volumes were acquired afeter injection of 140 ml of non ionic c.a. at 4 ml/s. images were evaluated using a real time interactive 3d approach by two observers, in terms of lesion identification and conspicuity, infiltration of peripancreatic fat, vascular involvement of major peripancreatic arterial and venous vessels, adenopathies and liver metastases. results: pancreatic carcinomas were identified in 22 of the 26 referred patients; in 4 cases no abnormalities were detected. tumors were located in the head in 13 cases, the isthmus in 3 cases and in the tail in 6 cases. peripancreatic spread was seen in 12 cases. vascular involvement was identified in 10 cases. adenopathies were present in 14 cases, while liver metastases in 6 patients. 3d real time interaction with multiplanar reformations appeared particularly useful in the evaluation of vascular involvement and above all in the detection of liver metastases. conclusion: high resolution msct with multiplanar reformations is a very accurate technique in the identification and staging of patients with suspected pancreatic carcinoma. to develop, test, and evaluate an automatic brain contour segmentation technique for multispectral mri data of the human brain based on radial basis functions (rbf) neural networks. methods and materials: 17 healthy male volunteers (aged 23 -32 years) were examined employing a standardized mri sequence protocol (t1w mp-rage, t2w/ pdw se, ir, anatomically correct image registration) on a 1.5 t system. automatic brain tissue classification was performed by a 3-layer feed-forward rbf neural network: image data were transformed to a 33-dimensional feature space with 3 spatial and 30 gray level coordinates of each voxel and its neighborhood. for comparison, manual interactive brain contour tracing was performed by two neuroradiologists on each data set. five data sets served as training data. the procedure was tested on the remaining 12 data sets. contingency tables were calculated w.r.t. results of human interactive contour tracing and compared to interobserver variability of manual segmentation. results: computation time for automatic brain segmentation was 31 ± 2 min on a sun ultrasparc workstation. mri acquisition time was 27.5 min for the sequence protocol. manual processing time for interactive contour tracing of the training data was 110 ± 14 min. the ratio of voxels classified differently in manual and automatic segmentation was 2.5 ± 1.2 %. this is comparable with the interobserver variability for manual brain segmentation (2.4 ± 1.0 %). conclusion: automatic tissue classification by rbf neural networks is a powerful method for brain segmentation from extracerebral anatomical structures. although comparable w.r.t. segmentation quality, the rbf approach is considerably less time-consuming than manual contour tracing by human operators. purpose: for medical applications in the field of computer assisted surgery it is essential to complement human visual systems. in order to develop new ultrasound based minimally invasive therapy systems in the head and neck region we combine both mr and 3d ultrasound data. materials and methods: mr and ultrasound datasets from the head and neck region were prealigned manually and filtered using adaptive filtering techniques. the prealigned data were matched for the first time using our biomechanical model based on a linear elasticity model recently developed for nonrigid registration of mr datasets of the brain. in order to reduce the computational effort this model uses as input parameters a sparse deformation field estimated from the images as well as predefined homogeneous tissue parameters. results: mr acquisition technique leads to rigid nondeformed datasets. ultrasound techniques offer resolution capacity of higher quality specially for soft tissue diagnostics and therapy. but ultrasound volume datasets show distorted and deformed anatomical structures. in order to prealign the data all images need to be resampled using both global affine transformation and interpolation. after being carefully prealigned an edge enhancement was carried out using adaptive filter techniques. it is shown in some cases of the neck region, that it is possible to match both data types using a linear elasticity model. the resulting images show clearly that the method can be used with slightly deformed ultrasound data. up to now the model is limited to high quality image data with a highly optimized data acquisition. using mri and ct data with the nasa virtual glovebox; a simulation system for life science experiments aboard the iss s. wildermuth 1 , j. smith 2 , c. bruyns 2 , n. teodorovic 1 , r. boyle 2 , p.r. hilfiker 1 ; 1 zürich/ch, 2 moffett field, ca/us purpose: the international space station will provide an orbiting research facility for addressing fundamental questions on the long-term effects of microgravity on living systems. many of these life science experiments will require the use of the space station glovebox facility, a contained reach-in environment where astronauts will handle animals and collect biological samples. to aid in this endeavor, virtual environment technologies are being developed to assist astronauts in training and performing complex experiments in the space station glovebox. this "virtual glovebox" (vgx) is designed to integrate ultra-high resolution imaging technology and force-feedback devices with highfidelity graphics and real-time computer simulation engines to provide a realistic immersive environment. here, we describe the prototype vgx system and its initial simulation environment using ct and mri datas. material, methods, and results: the virtual glovebox was designed and developed for three main applications: engineering evaluation of operational efficiencies for glovebox equipment, experimental design for on-orbit life animal research and simulation for training astronauts to perform biological experiments in space. different animal models are built based multidetector-ct (mdct) and mri datasets. we present high resolution mdct data to reconstruct anatomy of small animals and represent them as deformable objects within a linear mass-spring simulation system. the vgx combines elements of aerospace flight simulator technologies with new imaging techniques (high resolution ct and mri datasets) and medical simulation systems to provide a versatile, state-of-the-art virtual environment for training astronauts in biology research tasks. development of the function of the high speed virtualized bronchoscopy system and it's medical significance h. natori 1 , m. mori 1 , h. takabatake 1 , k. mori 2 , j. toriwaki 2 ; 1 sapporo/jp, 2 nagoya/jp purpose: we previously developed the virtualized bronchoscopy system which enables us to do intrabronchial high speed free navigation with special functions for clinical application and education in the medical school. we report the medical significance of the developed system. materials and methods: chest helical ct data were stored with dicom format. on the onyx2 (silicon graphics inc), bronchial air space was extracted and three dimensionally reconstructed with surface rendering. this bronchial tree was used a c d e f 154 as the virtual environment of this system. external view of the bronchial tree with the view point marker and its trace, ct image at the view point, intrabronchial view for navigation were displayed on the crt. the system had the anatomical database of the bronchial tree for automatic display of the bronchial name and for the bronchial name quiz. the system had interactive artificial cough as a sonic alert against wall irritation by the virtualized bronchoscope. results: even faster speed than real bronchoscopy was obtained for navigation conducted by the mouse. the system enables navigation into the peripheral bronchus for example b1bi. navigation into the peripheral intrabronchial space was possible beyond the narrowing portion. the system displayed proper bronchial names. its accuracy was dependent on the spatial resolution of thin slice ct data. conclusion: a high speed virtualized bronchoscopy system with special feature based on the ct data was developed. this system is useful for anatomical education for students, training to get their bronchoscopic skill for residents, and for preliminary examination simulator of real bronchoscopy. concept of a ct based orthopaedic simulation enviroment for movement analysis and osteotomy planning t.c. mamisch 1 , j. kordelle 2 , p. everett 3 , m. das 3 , f.a. jolesz 3 , r. kikinis 3 , r.m.m. seibel 1 ; 1 mülheim a. d. ruhr/de, 2 gießen/de, 3 boston, ma/us purpose: the goal of the presented study was to investigate the relation between the proximal femur and the orientation of the epiphysis, to determine if the acetabular development is influenced by the femoral neck orientation, and to simulate reorientating osteotomy. material/methods: three-dimensional reconstructed models based on ct data sets of 22 patients scfe were reviewed. measurement of the hip joint geometry was performed by using a newly developed interactive software to determine projected angles. a phantom scan was performed to validate the accuracy of the tool. a computer program for simulation of movement based on cartilage filtering techniques and osteotomy developed by the authors, served for study execution. results: we found a significant positive correlation between the femur version and the version of the femoral epiphysis. furthermore, there was a highly significant positive interdependence between the shaft-neck-angle and the shaft-epiphysis-angle. there was no correlation between the epiphyseal orientation and the anteversion and inclination of the acetabulum. conclusion: the study of the hip geometry demonstrates a significant correlation between the femoral orientation and the epiphyseal alignment. in response to these results, we suggest that there is an interrelation between the development of the proximal femur and the epiphyseal growth plate, wich influences the planning of reorientating osteotomy purpose: in addition to tumour size, the therapeutic effect after neo-adjuvant chemotherapy is histopathologically described by regressive changes. the aim of this study was to evaluate whether regressive changes affect the accuracy of preoperative mri tumour measurement. in an ongoing study initial and preoperative mri was performed in 31 patients with advanced breast cancer. beside t-1w flash 3d pre-and post contrast mri, a fast turboflash sequence was used for the dynamic examination. the time-intensity curves were parameterised by a pharmacokinetic two compartment model and colour-mapped. in consideration of the conventional mri, tumour diameters were measured using the colour-mapped images and compared with the histologically determined tumour size. regarding sclerosis, cytopathic effects and invasive residuals the histological regression was classified between 0 and 4. results: in 12 cases without regressive changes (grade 0), the correlation (spearman rank test) between mri and histopathological tumour measurement was 0.88 (p < 0.0002). in 17 patients with regressive changes grade 1 -3 the correlation was 0.48 (p < 0.0538), without any tendency for systematic over-or underestimation (p = 0.32). compared to tumours without regressive changes, those with grade 1 -3 were associated with a distinct decrease of pharmacokinetic parameters (amplitude and distribution constant rate) derived from time-intensity curves (p < 0.037 resp. p < 0.034). in two cases without residual tumour (grade 4), a complete response was observed by mri. conclusion: histological regression of breast tumours after neo-adjuvant chemotherapy leads to an inaccuracy of preoperative mri tumour measurement. in addition to the lost tumour continuity the decrease of contrast uptake complicates the demarcation of residual tumour. (axial t1 3d ffe, axial and sagittal t2* ffe, axial and sagittal t2 tse) . two experienced radiologists analysed the lymph nodes regarding size, morphology, and signal intensity before and after sinerem®. the results were compared with histopathologic findings. results: a total of 123 lymph nodes were detected equally by pre and post-sinerem® mri. 200 lymph nodes were diagnosed by histology. a node-by-node correlation between mri findings and histology could be achieved in 93 lymph nodes. 10/93 lymph nodes were true positive, 75/93 true negative, 3/93 false negative, 5/93 false positive. sinerem®-enhanced mri revealed a node-by-node sensitivity, specificity, and accuracy of 77 %, 94 %, and 91 %, respectively. however, in the overall lymph node assessment for each patient sinerem®-enhanced mri did not miss any lymph node metastases. conclusion: sinerem®-enhanced mri is an accurate method in the assessment of lymph node metastases in patients with breast carcinomas and is superior to plain mri. in our institute we performed 297 breast mri examinations for different clinical queries. we used a 3d-dynamic contrast-enhanced fspgr sequence and a 1.5 t mr unit. before the examination patients underwent a careful clinical-anamnestic evaluation; in fertile women mri was carried out between 7 th and 22 th day of menstrual cycle; previous mrx and/or us examinations were reviewed; patients were recommended for the highest compliance in order to reduce motion and breathing artefacts. results: among 106 cases with an histological equivalent we observed 20 false results. the 6 false negative cases were performed before the 10 th day of menstrual cycle (2 in situ carcinomas, 2 small fibroadenomas, 2 sclerotic adenosis). false positive results were 14: 6 due to a hormonal therapy recently suspended or still active, 4 due to the presence of the so-called ubos (unidentified bright breast objects), 4 in which examination was performed after the 18 th day of menstrual cycle. in literature breast mri diagnostic accuracy varies from 65 and 90 %. this large variability is mostly due to pitfalls in cases selection and examination timing. we recommend an optimal examination timing (10 th -16 th day of the menstrual cycle); a 6 months interval after hormone or radiotherapy. purpose: this study was designed to investigate the relationship between greater tuberosity irregularities, subacromial space, age and rotator cuff tears in the subacromial impingement syndrome. methods and materials: sonographic examination of 67 symtomatic shoulders (age range of patients from 33 to 79 years) were performed. the rotator cuff, greater tuberosities and subacromial space were evaluated. full and partial thickness rotator cuff were given equal significance. supraspinatus degeneration was graded according to the neer classification. the sonographic finding of tears was confirmed surgically. a student's t test, and logistic regression analysis were used to analyze the data. results: sonography showed the greater tuberosity to be irregular in 78 % of 47 shoulders with a rotator cuff tear and in 75 % of 20 shoulders with supraspinatus degeneration. the thickness of supraspinatus outlet ranged from 8.5 mm to 2 mm in shoulders with rotator cuff tear and from 9 mm to 3.7 mm in shoulders with supraspinatus degeneration. subacromial space: with tihckness < 6 mm was found in 70 % of rotator cuff tears and a thickness > 6 mm was found in 60 % with supraspinatus degeneration. statistical significance was detected (p < 0.001) for the association of greater tuberosity irregularity and rotator cuff tear and for the association of subacromial space thickness < 6 mm and rotator cuff tear. patients and methods: the study population comprises 109 randomly selected patients suffering from rheumatoid arthritis. a radiograph of the left hand was acquired for each patient and subjected to a new automated method for estimating bone mineral density (bmd) from a plain hand radiograph using the pronosco x-posure system™. this system digitizes a radiograph with a scanner and derives subsequently a bmd, a metacarpal index (mci) and a porosity index (pi) from automated radiogrammetrical measurements of the three middle metacarpal bones. the severity of the decease was graded by two radiologists using the larsen score. a third radiologist reviewed the incongruent scored cases. results: the x-posure system was capable of providing a bmd estimate in all 109 cases. mean value of bmd decreased from 0.55 ± 0.08 (score 1)g/cm 2 to 0.44 ± 0.11 (score 5) g/cm 2 . mean mci-values decreased from 0.44 ± 0.08 to 0.33 ± 0.10. no significant change of pi was observed. correlation of bmd, mci, pi and severity score was -0.44, p < 0.05; -0.40, p < 0.05 and -0.07, n.s., respectively. conclusion: the new densitometric system based on radiogrammetry seems to be able to detect differences of bone mineralization depending on the severity of rheumatoid arthritis. with suitable normative data, the new technology may be able to reduce additional radiation exposure in the future, especially in patients receiving a radiograph of the hand for e.g. diagnostic purposes. and normal subjects (n = 48) with equal mean age and sex ratios underwent electron-beam ct of the thoracic spine. images were acquired using the single slice mode (slice thickness 1.5 mm, scan time 0.1 s, matrix number 512 × 512, field of view 34 cm). for bone density analysis, cortical, transitional, and medullary zones were semi-automatically segmented on four consecutive images of the vertebral bodies. averaged histograms were acquired according to zones and proportions of five density intervals (a: 55, d: > 130, e: -1024-1024) were measured by custom-made software. firstly, the feasibility of this method was evaluated by comparing normal and osteoporotic groups. secondly, verification was performed by measuring the "coefficient of variance". thirdly, the feasibility was compared with quantitative ct using intervals c and e in medullary zone, since the interval e in medullary zone was used on quantitative ct. results: in the medullary zone, intervals a-d showed significant differences between osteoporotic and normal subjects, while analysis of whole density measurements (interval e) could not reveal a significant difference between both groups. intra-and inter-observer errors of intervals c-e were lower than 5 % in all zones. in the normal subject group, inter-subject variability of interval c was exclusively lower than 5 %. therefore, interval c in all zones became the region for the histographic bone density analysis method. conclusion: bone density analysis using histographic intervals was feasible to diagnose osteoporosis and superior to quantitative ct. purpose: micro-ct may offer a worthwhile opportunity to analyse so called patterned injuries in bone. in the field of forensic science, it has not been possible until now to non-destructively document such damages to bone. materials and methods: based on a real murder case, porcine pelvic bones were experimentally stabbed with multiple knives. afterwards these bone samples were examined with a micro-ct system developed at the imp erlangen. this cone beam scanner can achieve an isotropic resolution from 10 to 100 µm for sample diameters from 1 to 40 mm. resolution in the specific bone samples is 30 to 75 µm depending on the sample size. so far analysis has been performed by visual inspection of double oblique slices of the reconstructed volume to optimally display the plane cut by the knife using impact view (vamp gmbh, erlangen, germany). additionally the stabbing wounds were quantitatively evaluated by measuring distances and angles. results: the micro-ct datasets of the injured bone samples were used to obtain those 2d slices that optimally showed the stabbing wounds inside. based on the measured distances and angles it was easily possible to uniquely identify the size and shape of the injury-causing knife in straight stabs. in the field of forensic pathology micro-ct provides a new and advantageous tool for the non-destructive examination and analysis of patterned tool marks in bones. by using the micro-ct technology new horizons are opened for matching a possible injury-causing instrument against the patterned lesion in the bone. a bone defect (diameter 6 mm) was generated in the calvaria of 12 adult rats in general anaesthesia. this defect was filled with a threedimensional extracellular matrix gel inoculated with osteoblasts, marked with lipophilic tracer components, latter to proof viability. implants were covered by gore-tex patches. the cells phenotype was determined by antibody staining. ms-ct examinations were performed 24 hours, 2, 4, 6, 8 and 10 weeks after implantation in short anaesthesia using a siemens somatom volume zoom unit (siemens, erlangen, germany). acquisition parameters were: collimation 2 × 0.5 mm, tube current 40 to 80 mas at 80 to 120 kv, reconstructed slice thickness/increment 0.5/ 0.3 mm. thin sagittal multiplanar reformations (slice thickness 0.5 mm, overlapping 0.5 mm) out of coronar acquisition were performed. the rats were sacrificed, the implants histologically examined, and correlated with ct findings with respect of defect size and ossification. results: in all cases there was an absolute correlation between ct-findings and histological findings concerning the size of the defect and the presence of mineralised bone matrix. conclusion: ms-ct is a very sensitive and specific diagnostic tool for this and similar studies. with respect to refinement and reduction of animal experiments following the directive 86/609/eec of the council of the european union ms-ct allows tremendous reduction of the number of animals to be sacrificed (in this study two-thirds). 3d-navigation with an infrared-based camera system for biopsies using spiral-ct datasets -initial preclinical results c.r. krestan, s. grampp, p.l. peloschek, m. pretterklieber, c. czerny, h. imhof; vienna/at purpose: to assess the accuracy and feasibility of biopsies with a novel 3d-navigation system (ct-sightline: philips medical system, best, netherlands) which is based on spiral-ct datasets. methods: this navigation system uses an infrared based camera, which can track the biopsy needle and the patient position by infrared light reflected from mounted passive spheres. the spiral ct dataset (philips, secura tomoscan 7000) gained during the procedure can be linked with the position of the instruments and the patient position. we used needle-marked water melons for biopsy purposes. after scanning the object, target and entry point are located by the physician. the accuracy of the simulated biopsies with 14 and 16 g standard coaxial biopsy systems was determined by a target scan. the table position of the target scan and the gantry tilt are given by the navigation system. results: we performed 18 biopsies (targeting of needle-tip) using water melons. the mean distance between the biopsy needle tip and the target needle tip was 5.3 ± 3.6 mm (range: 0.8 -9.2 mm). the average time for the procedure after set-up of the navigation-system was 15 minutes on average. conclusions: our preliminary results suggest that this navigation system allows accurate targeting of biopsy needles at defined regions of interests within a reasonable procedure time. the advantage of this system is the potentially safer and more accurate positioning of the biopsy needle at different targets. further studies and clinical evaluation will determine the value of this system in performing minimally invasive procedures. to explore the novel application of a methodology known engineering as pq diagrams to characterise the evolution of ischaemic stroke. methods: five acute stroke patients were imaged with diffusion tensor imaging (dti) at presentation, 1 week and 3 months on a 3 t magnet using a previously described dti data acquisition scheme. each dataset was then processed on a voxel-by-voxel basis, and each tensor was decomposed on into its p (isotropic) and q (anisotropic) components. when p and q are taken as axes of a cartesian plane, the evolution of tissue (e.g. due to pathology) can be visualized as characteristic trajectories or signatures in this plane. in this study, p, q, and the standard indexes relative anisotropy (ra) and fractional anisotropy (fa), were computed for the lesion (l) and contralateral control (c) regions, for each patient at each time point. results: all patients showed the same characteristic trajectories consisting of: an acute (pl < pc, ql < qc), subacute (pl ≈ pc, ql < pc), and chronic (pl > pc, ql < qc) stages. percentage acute changes in q, ra and fa for the five studies were: ∆q = 51 %, 69 %, 50 %, 51 %, 0 %. ∆ra = 3 %, 44 %, 14 %, −6 %, −110 %. ∆fa = 2 %, 35 %, 14 %, −5 %, −89 %. conclusion: ra and fa are less sensitive than p and q to detect diffusion changes associated with early ischaemia. in particular, q seems to be the most sensitive parameter to detect early loss of anisotropy in tissue; pq diagrams provide a powerful analytical and visualization tool to investigate the evolution of stroke. advances in diffusion imaging using sensitivity encoding (sense) r. bammer 1 , f. fazekas 2 , m. auer 2 , s.l. keeling 2 , m. augustin 2 , r.w. prokesch 1 , m.e. moseley 1 ; 1 stanford, ca/us, 2 graz/at purpose: diffusion-weighted single-shot epi (sshepi) is currently one of the most important tools for the diagnostic assessment of stroke patients, however it suffers from well known artifacts. sensitivity encoding (sense) was employed to greatly enhance the quality of diffusion-weighted echo-planar imaging (epi) in stroke imaging and for diffusion tensor imaging (dti). methods and materials: eight healthy volunteers and a consecutive series of stroke patients (n = 8) were examined with diffusion-weighted sense-sshepi using different reduction factors (1.0 < r < 3.0). moreover, in eight volunteers the potential of sense to improve dti was investigated. dti scans were carried out with regular (42 × 128; r = 2.0) and high resolution acquisition matrices (42 × 256; r = 2.0). to further improve the image quality, new reconstruction and co-registration algorithms were applied. results: derived maps of the trace of the diffusion tensor and of fractional anisotropy were of high quality. measured direction-dependent diffusion-coefficients and isotropic diffusion values were comparable to previous findings but showed less fluctuation. overall, the geometric distortions were substantially removed and the resolution enhancement was remarkable. all patient examinations were diagnostic and of better quality than conventional sshepi. the efficient use of thrombolysis requires robust algorithms for patient selection in acute stroke. intracranial vessel status and properties of brain tissue perfusion are predictive of cerebral ischemia. we present first clinical results using a multimodal multislice ct concept. material and methods: sixteen patients (age 34 to 90 years) with suspected cerebral ischemia and onset of symptoms within 6 hours (mean 2.6 h) were included in this prospective study. we performed noncontrast ct (ncct) followed by perfusion ct (pct) and ct angiography (cta). at the level of basal ganglia pct data were acquired using a 4 × 5 mm collimation after injection of 40 ml of cm (flow 8 ml/s). two consecutive slices of 10 mm slice thickness were reconstructed. cerebral perfusion maps (cbf, cbv, ttp) were calculated using ctp software. the size of the ultimate cerebral infarction was measured by follow-up ct or mri. results: in nine patients significant perfusion deficits were noted in one (n = 1) or both (n = 8) slices. four patients with normal pct showed small supra-or infratentorial infarctions outside the section levels. no false-negative pct results were seen. cta revealed major vessel occlusion in five patients. ncct showed early signs of infarction only in three individuals. conclusion: pct improves the sensitivity for the detection of cerebral ischemia in the section levels compared to ncct and can estimate the ultimate size of infarction. cta might localize the underlying pathomorphology. the presented multimodal ct concept is an accurate and reliable method for the assessment of acute stroke. the preliminary study of ct perfusion imaging in tias k. li, j. lu, x. du; beijing/cn purpose: to evaluate the application of ct perfusion imaging on transient ischemic attacks (tias). methods: conventional ct and ct perfusion imaging were performed on a group of tias and control group of normal adults. cerebral blood flow, cerebral blood volume, and time to peak enhancement were measured within specific regions of the brain on ct perfusion imaging. quantitative analysis was used for these images and comparative analysis was performed on these two groups to evaluate the differences on perfusion images between tia patients and control group. results: a gradient of perfusion between the gray matter and the white matter was shown on the ct perfusion images of normal adults and tia patients. persisting abnormal perfusion changes of decreased cerebral blood flow were found on about 86 % ct perfusion images of tia patients. abnormalities were detected on time-to-peak images of all tia patients with diffuse or regional prolonged time to peak enhancement. conclusions: perfusion ct can provide valuable hemodynamic information and depict abnormalities of perfusion in the patients with tias. prognostic value of admission perfusion ct in acute stroke patients: comparison with admission mr m. wintermark, j.-p. thiran, p. maeder, s. binaghi, p. schnyder, r. meuli; lausanne/ch purpose: comparison between perfusion-ct and dwi-/pwi-mr in acute stroke patients at the time of their emergency evaluation methods and material: 13 acute stroke patients underwent perfusion-ct and dwi-/pwi-mr on admission. 9 were treated with thrombolytic agents. the size of infarct and ischemic lesion (infarct + penumbra) on the admission perfusion-ct was compared to that of the mr abnormalities on the adc map and on the relative cerebral blood volume (rcbv), cerebral blood flow (rcbf), time-to-peak (rttp) and mean transit time (rmtt) maps extracted from pwi studies. the most significant correlations were found between the infarct size on the admission perfusion-ct and the abnormality size on the admission adc map (r = 0.971; p < 0.001) and between the size of the ischemic lesion (infarct + penumbra) on the admission perfusion-ct and the abnormality size on the rmtt map calculated from admission pwi-mr (r = 0.930; p < 0.001). information provided by both imaging techniques about cerebral infarct and total ischemia (infarct + penumbra) are similar, with slopes of 0.910 and 0.925, respectively. conclusion: perfusion-ct and dwi-/pwi-mr are equivalent in the identification of cerebral penumbra in acute stroke patients and in their selection for thrombolytic therapy. perfusion-ct takes advantage from its availability and from its feasibility in acute stroke patients, as part of their admission imaging survey. a novel ct brain perfusion algorithm for improved measurement of low flow regions: clinical results a.j. cook ii. 1 , s. pohlman 2 , s. lin 2 , p.c. johnson 2 , a. cook 1 ; 1 ravenna, oh/us, 2 highland heights, oh/us purpose: accurate quantitative measurements of ct perfusion studies will make a significant impact on patient care. low flow regions, associated with minimal contrast enhancement and poor signal to noise ratios, are susceptible to difficulties using traditional perfusion calculations. we propose a novel signal enhancement algorithm for analysis of low flow regions. methods: 30 ct brain perfusion cases were acquired. a low flow improvement technique, which works by clustering similar tissue types, was applied to each case. gray matter and white matter regions were manually segmented. for quantitative measurements, perfusion values and ratios were calculated for each region before and after the low signal correction. for qualitative evaluations, four radiologists reviewed the corrected and uncorrected images. the corrected images were found to be visually superior to the uncorrected images, particularly in terms of reduced noise and improved distinction between gray and white matter. perfusion values for the corrected images (gray matter: 75.9 ml/100 g/min, white matter: 29.1 ml/100 g/min) were closer to physiological norms than uncorrected images (gray matter: 84.0 ml/100 g/min, white matter: 46.7 ml/100 g/min). the gray/white matter ratio, typically reported in the literature to be approximately 3:1, improved from 1.9:1 for the uncorrected images to 2.8:1 for the corrected images. regions with no blood flow, such as the ventricles, were also more accurately depicted on the corrected images. conclusion: initial results using our approach for low signal enhancement is very promising and could potentially provide more accurate quantitative measurements using ct perfusion. to evaluate the effect of dose reduction on diagnostic performance, using a digital chest imaging system in which amorphous selenium serves as the x-ray detector. material and methods: 247 patients were examined with the selenium system. three sets of images were made in each patient: one set with a standard x-ray dose, one set with 55 % of the standard dose, and one set with 35 % of the standard dose. all 741 images were read by two radiologists. the diagnostic value of each set of images for detection of pulmonary, mediastinal and pleural pathology was analyzed with receiver operating characteristic (roc) methodology, using computed tomography (ct) as the reference standard. we also assessed the effect of the sex, height and weight of the patients on the diagnostic performance of the readers. a c d e f 166 conclusion: we found no statistically significant difference between the radiologists' performance in detecting abnormalities with standard x-ray dose images, and the performance with images made with 55 % and 35 % of the standard dose. sex, height and the weight of patients had no influence on diagnostic performance. withdrawn by author b-0259 10:40 flat panel x-ray detector: reduced radiation exposure for the detection of simulated interstitial lung disease, nodules and catheters u. rapp-bernhardt, t.m. bernhardt; münster/de purpose: evaluation of a flat panel detector (fd) using amorphous silicon with respect to detection of simulated interstitial lung disease, nodules and catheters and reduction of radiation exposure compared with an asymmetric screen-film system. materials and methods: an experimental model was used to determine the detection of reticular, micronodular, linear, ground glass patterns, nodules and catheters which were superimposed over an anthropomorphic chest phantom. 19200 observation fields were evaluated using the fd with the simulated speed of 400, 600 and 1600 and compared with the asymmetric screen-film system with the speed of 400. five radiologists performed receiver operating characteristics (roc) for a five-level confidence scale. the areas under the roc-curves showed no statistically significant differences between the two detector systems at the same speed with respect to the detection of all simulated lesions (p > 0.05). the fd with a digital speed of 800 yielded in decreased diagnostic performance compared with the asymmetric screen-film system, however, these results were not statistically significant (p > 0.05). using the fd with a digital speed of 1600 lead to statistically inferior results in the detection of catheters and nodules over obscured lung (mediastinum) as well as micronodular lesion over lucent lung (p < 0.05). conclusion: these results suggest that a dose reduction up to the digital speed of 800 is possible for fd. image quality of computed radiography and flat panel detector radiography: evaluation of simulated subtle lung abnormalities h. tagashira, k. arakawa, m. yoshimoto, j. ikezoe; shigenobu/jp purpose: to evaluate the image quality of computed chest radiography (cr) and flat panel detector radiography (fpd) for diagnosing subtle lung abnormalities. materials and methods: we studied the differences of observer performance among computed radiography (new type computed radiography (fcr 5501d, pixel size 100 µm, dual side (front and back) read out by laser beam of imaging plate) and flat panel detector radiography (indirect type with screen, canon cxdi-11, pixel size 160 µm). simulated nodule, ground-glass opacity and reticular shadow were made of acrylic resin, sand ground down and softened gauze with urographin (contrast material), respectively. a simulated abnormality was placed on the back of the thorax of each volunteer (n = 50) in order to overlap the right or left lung parenchyma and each volunteer was examined with three different modalities with the same exposure condition. so, total of 200 unilateral lungs were obtained, and of these 200 unilateral lungs, 100 lungs had one of the simulated abnormalities, and the remaining 100 lungs were normal. five chest radiologists evaluated these 200 unilateral lungs with roc analysis with continuous confident scale. the area under the roc curve (az) was used to evaluate the results. results: for all simulated abnormalities, dual read-out type cr (fcr 5501d) showed the best result (az = 0.820), followed by fpd (az = 0.780). however, in case of reticular simulated abnormalities, fpd showed the best result, followed by dual read-out type cr. conclusion: dual read-out type cr and fpd showed extremely high image quality. first experiences with a detector-based dual energy system for thorax radiography j. ricke, f. fischbach, u. teichgraeber, t. freund, r. felix; berlin/de purpose: to assess the influence of dose on the image quality of subtracted soft tissue and bone images generated by a dual energy system based on a flat panel detector. materials and methods: 88 patients were randomized in 2 groups. one group received a dual energy examination at a xqi revolution (ge medical systems, usa) with an intended approximative speed pair of 400/1000 for high and low energy shot, the other group with an intended approximative speed pair of 200/ 500. for data analysis, subgroups were specified according to additional dose measurements at the detector. image quality indicators were noise, residual bone structures, motion artefacts of pulmonary vessels, heart and aorta, display of retrocardiac ribs or other bone structures, display of lung apex or retrocardiac lung. image review was performed blinded by two experienced radiologists in consensus applying a rating score of 1 to 5. linear regression and chi square tests were performed for statistical analysis. results: overall image impression was rated good with no significant improvement of image quality with increasing dose. however, a trend for decreased noise in soft tissue and bone images was noted with higher dosage as well as increasing residual bone structures. conclusion: increased dose did not improve image quality significantly. dual energy thorax imaging at a flat panel detector proved potential as a future routine application. digital bedside chest radiography with and without antiscatter grid: impact on image quality and display of low contrast details m. uffmann, k.s. exter, i.m. nöbauer-huhmann, c. balassy, j. sailer, c.j. herold, c. schaefer-prokop; vienna/at purpose: use of an antiscatter grid also for bedside chest radiographs improves image quality however at the expense of increased dose requirements. image processing in digital radiography offers the option for optimising detail contrast. purpose of the following study was a) to test whether contrast enhancing processing compensates for increased scatter radiation if no grid is used and b) whether further dose reduction is feasible. materials and methods: routine chest films with storage phosphor plates (st vn, fuji) were performed on 24 icu patients on 3 consecutive days using an antiscatter grid and an acquisition dose approximating 250 speed system, without grid and an optimised image processing, and without grid and additional dose reduction of one third. all images were overlaid by a 9 element matrix with small fragments of various catheter types (n = 120). 4 readers evaluated the hardcopies for the presence of catheter fragments and diagnostic image quality. results: areas under the roc curve for the detection of catheter fragments were statistically equivalent for all images irrespective of the use of a grid or reduction of acquisition dose (0.92, 0.93 and 0.93, resp.). visualisation of lung parenchyma and monitoring lines was rated comparable for all 3 image types. visualisation of mediastinal and retrocardiac areas, however, was rated significantly poorer in images obtained without grid and reduced dose. conclusion: digital bedside chest radiographs can be obtained without an antiscatter grid by using optimised image processing. however, further dose reduction results in significant loss of image quality in high absorption areas. detection of simulated chest lesions using soft-copy reading: comparison of an amorphous silicon flat-panel detector system and a storage phosphor system j. goo, j.-g. im, j. kim, m. chung, j. seo, h. kim; seoul/kr purpose: to compare observer performance using soft-copy images produced by an amorphous silicon flat-panel detector system and a storage phosphor system for the detection of simulated chest lesions. materials and methods: to test the diagnostic performance of these two systems, we used four types of simulated lesions (nodules, micronodules, lines, and reticular opacities) that were superimposed over an anthropomorphic chest phantom. digital chest radiographs were acquired by amorphous silicon flat-panel detector radiography (3k matrix, 12 bits) and by storage phosphor radiography (4k matrix, 10 bits). six board-certified radiologists evaluated soft-copy images on a high-resolution video monitor (2560 × 2048 × 8 bit). a total of 14400 observations were analyzed in terms of receiver operating characteristics (roc). results: averaged performance in terms of the detection of nodules was significantly better (p < 0.05) on the flat-panel detector system than on the storage phosphor system (area below roc curve [az] values: 0.93 ± 0.015 and 0.85 ± 0.033). for micronodules, lines, and reticular opacities, no significant detection differences in averaged performance were found between the flat-panel detector and storage phosphor system (az values: micronodules, 0.86 ± 0.020 and 0.76 ± 0.049; lines, 0.85 ± 0.031 and 0.75 ± 0.051; reticular opacities, 0.96 ± 0.015 and 0.92 ± 0.022). in the evaluation of soft-copy images, the amorphous silicon detector system appears to be superior to the storage phosphor system for the detection of pulmonary nodules. the total realistic examination time in multi-slice-ct is 5 min 28 s faster than in single-slice-ct. due to shorter scanning time a reengineering of preparation and post-processing phase enables to increase the number examinations per day with multi-slice ct. process simulation showed to be superior to cpm/pert due to higher flexibility and ability to consider cycle overlap and determine cycle times. evaluation of a new patient transfer board (ptb) for diagnostic er-/icupatient-management in diagnostic ct t. schroeder, s. ruchholtz, s.g. rühm, s. heistrüvers, h. kuehl, j.f. debatin; essen/de purpose: multislice ct has vastly reduced scan times. rather than data collection, patient transfer and positioning has thus become the rate limiting step particularly for polytraumatized er-and icu-patients. to speed transfer to and positioning onto the ct table, we developed a patient transfer board (ptb) enabling the "en-bloc"-transfer of patient and life-support equipment. the ptb was assessed on 20 acute trauma-patients and 50 icu-patients. patients were placed on the ptb directly in the er/icu before transfer to the ct room. transfer-times between patient arrival in the er and completing of the radiological diagnostic procedures (er-patients) and the in-roomtimes in the ct (er-and icu-patients) were measured by stop-watch and compared to those determined in matched populations (40 acute trauma, 100 icu) examined without the ptb. results: the ptb enabled the "en-bloc transfer of er-/icu-patients and support equipment". the handling of the ptb was easy, and intuitive. the ptb had no adverse effect on image quality. transit-times between arrival of trauma patients in the er and completing the radiological diagnostic procedures including ct were reduced from 39 to 31 minutes (213 %, p < 0.05). the in-room-times in the ct (er-and icu-patients) were reduced from 14 to 9 minutes (36 4 %, p < 0.05). the ptb was well accepted by the medical staff. conclusion: the ptb is a simple device capable of vastly shortening patient transfer and positioning times onto ct-tables. the ptb accelerates the diagnostic management of er-and icu-patients and hence increases ct patient throughput. iliocaval thrombi were simulated using clotted bovine blood. four experimental set-ups were performed with 10 interventions each. thrombus particles and distribution were measured in the effluent. mechanical thrombectomy (mt) was performed using the ptd alone. secondly, a newly developed vena cava filter was inserted before and removed immediately after the intervention without manipulation within the filter. in a third procedure, the filter was filled with thrombus and closed without any fragmentation. finally, the filter was completely filled with thrombus material and mt was performed within the filter using the ptd. results: running the ptd in the flow circuit led to a maceration of 67.9 % of clots into particles below 500 µm. in the second set-up, additional placement of the filter safely prevented embolization of particles above 500 µm. closing the filled filter within the flow circuit macerated 75.2 %, while additional mt within the occluded filter led to a dissolution of 90.4 % of the initial clot weight. the ptd proved as an effective and safe device for clot fragmentation in this experimental set-up. the use of a cava filter is mandatory to prevent embolization of thrombus fragments. even large clot burdens can be further macerated easily by the ptd within the filter basket before removal. clinical evaluation of these two devices in iliocaval thrombosis is promising. cost effectiveness assessment of port devices chemotherapy implant in 200 m0 breast cancer patients: radiological versus surgical placement evaluation p.y.r. marcy sr. 1 , c. bailet 1 , n. magne 1 , e. chamorey 1 , j.c. machiavello 1 , j.c. gallard 2 ; 1 nice/fr, 2 caen/fr purpose: to report the feasibility and cost effectiveness of two venous chemotherapy port implantation techniques in 200 m0-breast cancer patients. material and methods: radiological venous arm port (r) and surgical subclavian (s) implantation techniques were retrospectively evaluated in an homogeneous set of 200 m0 breast cancer patients treated with adjuvant/neoadjuvant chemotherapy. mean age was 55.7 a [55.5 a, n = 100 (r); 55.9 a, n = 100 (s)] and the f/m sex ratio was 1.0. initial feasibility was evaluated for both techniques. procedure related direct costs and outcome were respectively evaluated. results: initial technical failures rates (r/s) were 4 % and 9 %. mean implant duration time was 168/222 days, the overall complication rate (r/s) was 9 %/13 % (chi2 test p = 0.5) (0.24 -0.4/1000 patient-days). mean implant duration time without any complication or death was 193 d vs 233 d. median number of chemotherapy courses was 6 (r = s). 6 %/7 % of the devices had to be removed prematurely. complications included device-related sepsis (n = 2 vs 5), skin dehiscence (n = 3), deep venous thrombosis (n = 1 vs 4), catheter occlusion (n = 1 vs 0) and fissuration migration (n = 1.1 vs 0.0) of the catheter. direct costs (r/s) were respectively 230.8 vs 219.1 • . conclusion: both techniques are successful and safe, with a 5 % higher relative cost for r placement. both are indicated for breast cancer adjuvant chemotherapy. b a c d e f 168 balloon angioplasty and stenting of subclavian and brachiocephalic benign venous obstruction b. guadagni, m. cariati, g. cittadini, g. de caro, c. ferro; genova/it purpose: report our clinical experience of the treatment with balloon angioplasty and/or stent placement of subclavian or brachiocephalic benign venous stenosis or obstruction in patients undergoing hemodialysis. materials and methods: among 27 patients with subclavian (n = 13) or brachiocephalic (n = 15) venous stenosis or obstructions, 10 were treated with pta alone and 17 with pta and stent placement. technical success and primary and assisted primary patency rates were calculated. results: technical success was 100 %. the ten patients treated with pta alone had good immediate results. primary patency rates at 6 months, 1 year and 2 years were respectively 90 %, 80 % and 80 %. two patients required additional procedures with repeated pta and stent placement (wallstent) with an assisted patency rate of 100 % at 2 years. 24 wallstents were inserted immediately after failed angioplasty in 17 patients because of early restenosis and unsuitablility for angioplasty. primary patency rates at 6 months, 1 year and 2 years were respectively 76 % (13/17), 61 % (8/13) and 70 % (7/10). eight patients required multiple reinterventions for restenosis or thrombosis with additional angioplasty and/or stent placement. assisted patency rates at 6 months, 1 year and 2 years were respectively 100 % (17/17), 92 % (12/13) and 80 % (8/10). conclusion: endovascular treatment of subclavian and brachiocephalic benign venous stenosis or obstructions with pta alone and/or stent placement can provide prolonged use of a hemodialysis access site. close clinical surveillance and multiple reinterventions are usually necessary to maintain stent patency. follow-up was available in 19 patients over 20 months. in this period 11/19 patients (57.9 %) had another treatment: pta of intra stent stenosis in 23 cases; stenting of restenosis after pta in 4 cases; positioning of a second stent in 2 cases. results: in total we performed 62 procedures, with a full technical success in 59 (95.1 %), 2 (3.2 %) were technically unsuccessful and 1 complication ocurred (1.7 %): rupture of the treated vein. primary patency rates were 82 % at 3 months, 53 % at 6, 17.6 % at 12 and 5.8 % at 24 months. secondary patency rates were 100 % at 3 months, 55.5 % at 6, 33.3 % at 12 and 22.2 % at 24 months. conclusion: interventional procedures allow treatment of stenoses with a high grade of technical success but the high incidence of restenosis requires continuous monitoring and frequent re-intervention to maintain the functionality of the hemodialysis vascular access. mechanical thrombectomy to preserve vital venous access in patients with subclavian vein thrombosis p.m. vos, h.j. baarslag, j.a. reekers; amsterdam/nl purpose: deep venous thrombosis is one of the most important catheter related complications in patients with central venous lines. preservation of venous access may be vital for these patients. feasibility of percutaneous mechanical thrombectomy of subclavian vein thrombosis in patients with central venous lines was evaluated. materials and methods: 7 patients (3 male; 4 female) with a mean age of 50 years were included. all patients had central venous catheters in the thrombosed subclavian vein. catheters were placed for chemotherapy 5, nutrition 1 and dialysis 1. before the procedure venography was performed to evaluate the level and extent of the thrombosis. if there was extensive thrombosis with extension in the brachial veins, patients were not included. mechanical thrombosuction was performed using a 6 or 7 french hydrolyser catheter (cordis j&j, 700 psi, 5 ml/s). prior to the procedure 5000 u of heparin was given intravenously. all patients were treated with anti-coagulants after treatment. re-establishing flow with or without wall adherent thrombus was defined as a clinical success. results: in 5 cases, percutaneous mechanical thrombectomy was successful. in these 5 patients the central venous line could be preserved. in 2 patients re-canalization of the subclavian vein thrombosis could not be established due to wellorganized (longstanding) thrombus clots. in one patient with a clinical success, reocclusion occurred 2 months after the procedure. conclusions: percutaneous mechanical thrombectomy of subclavian vein thrombosis in patients with central venous lines is feasible if the thrombosis is acute and not too extensive. factors that influence the results of percutaneous transluminal angioplasty for hemodialysis access dysfunction k. maeda, a. furukawa, m. yamasaki, m. onishi, k. furuichi, t. nagata, s. aoki, m. takahashi, k. murata; otsu shiga/jp purpose: to evaluate factors that influence the initial success rate and long-term results of percutaneous transluminal angioplasty (pta) for hemodialysis access dysfunction. methods and materials: a total of 81 pta procedures were performed in hemodialysis shunts with stenosis (61 procedures) or occlusion (20 procedures) in 47 patients between 1997 and 2001. initial success rates were compared between patients with stenosis and occlusion. in cases where initial success was obtained, cumulative rates of shunt-patency (crp) were evaluated to assess whether the following three factors may influence the long-term results; length of stenosis (≤ 3.5 cm vs > 3.5 cm), length of patent period of the primary shunt (≤ 12 months vs > 12 months) and diameter of the balloon used for angioplasty (≤ 4 mm vs > 4 mm). results: overall initial success rate was 87.7 % (stenosis: 98.4 % vs occlusion: 55.0 %). overall crp at 3, 6, and 12 months were 81.5 %, 54.9 %, and 44.4 %, respectively. crp was significantly higher in patients with shorter stenosis compared to patients with longer stenosis (93.8 %, 72.1 %, and 63.1 % vs 70.8 %, 37.1 %, and 20.6 %, respectively, p < 0.01). crp was significantly higher in patients with longer patent period of the primary shunt compared to patients with a shorter period (83.7 %, 67.8 %, and 63.8 % vs 81.4 %, 36.9 %, 21.5 %, respectively, p < 0.01). conclusion: pta is technically highly successful in patients with shunt stenosis (not occlusion) and a better prognosis is expected in patients with shorter stenosis and patients with a longer patent period of the primary shunt. long-term follow-up of vena cava filters: clinical and radiological findings s.c.a. herber 1 , t. knodel 1 , j. schneider 1 , c. düber 2 , m. thelen 1 , m.b. pitton 1 ; 1 mainz/de, 2 mannheim/de purpose: to evaluate the clinical efficacy, mechanical stability and safety of vena cava filters (vcf) in patients for prophylaxis of pulmonary embolism. material and methods: retrospective analysis of 80 patients undergoing vcf for thrombosis (dvt) in 9/80 and pulmonary embolism (pe) in 71/80 patients. 3 filtertypes were inserted (73 lgm; 8 antheor; 1 cook tulip) using a femoral approach in 66/80 and a jugular approach in 14/80 patients. follow up included ultrasound, conventional x-ray and ct-scans. results: no periinterventional complications occured. 71/80 patients were anticoagulated (51/80 marcumar, 20/80 heparin). mean follow-up was 40.9 months (range 14 -113 months). 54 patients are still alive. mean survival was 28 months (range 8 -40 months). 26 patients died (tumour progression n = 16, others n = 10). there was no evidence of further pe, but 3 dvt recurred during long-term follow-up. in 68/80 cases correct filter deployment was achieved including a suprarenal position (n = 3). technical problems with filter deployment occured in 12 of 80: incomplete opening (n = 8), non-opening of filters (n = 2), filters tilted > 15° (n = 2). follow up demonstrated significant filter migration in 28/80 with a mean migration of 19 mm (range 7 -48 mm), 7/28 within 30 days and 20/28 showed late filter dislocations (> 12 months). fractures of filter struts occured in 4 cases (2 lgm, 2 antheor) and perforation of struts through the venous wall occured in 2 (antheor). conclusion: vcf has a low periprocedural complication rate but significant migration, some filter fractures and strut perforations were seen. due to the low incidence of re-thrombosis under anticoaglation, vcf is restricted to very selected cases. patients and methods: 117 patients underwent percutaneous implantation of a snf from 1993 through to 1999. patient reports were retrospectively analysed for complications during and after implantation and deep venous thrombosis and pe before and after implantation. helical-ct with contrast media and plain abdominal radiography were performed on 35 patients, helical-ct alone on 2 patients. we checked the position and configuration of the snf and looked for perforation of the filter legs through the wall of the inferior vena cava (ivc). the ivc and deep pelvic veins were analysed for patency. results: during implantation 10/117 (9 %) patients had minor complications, major complications were reported in 0.9 % (1/117). pulmonary re-embolism was documented in 9/117 (7.7 %) patients. there was no significant increase in thrombosis of the deep pelvic veins or the ivc after implantation. 1/35 (2.9 %) examined patients showed a single strut fracture of the snf. tilting more than 15° was seen in 7/37 (19 %) patients. dislocation of the snf more than 10 mm occurred in 1/35 (2.9 %) patients and perforation through the wall of the ivc in all 37 patients. we found no occlusion of the ivc. the snf is easy and safe to implant. in our investigation, complication rates during and after implantation were low. the snf effectively prevents pe. (june 1999 to september 2001 . the estimated period of protection against pulmonary embolism was less than 15 days. before insertion, color duplex sonography was performed in all patients. all filters were implanted and retrieved through a femoral approach. the position and condition of the filters was assessed immediately and 4 days after insertion. results: there were no placement complications in any patient. no clinical manifestations of pulmonary embolism occurred during the filtration period or during removal. implantation time was 7 to 12 days (mean 9 days). there were no filter thrombosis at the time of retrieval in 8 patients. one patient required reinsertion of a gunther temporary vena cava filter 8 days after the first insertion because thrombus was captured. in two patients, permanent filtration was subsequently requested, in one due to an ongoing contraindication to anticoagulation whilst in the other due to sizable clot captured in the gunther temporary filter. one other patient died of causes unrelated to the procedure. there were no complications of retrieval. no damage was detected at the insertion site. clinical and imaging follow up of the patients did not demonstrate any pathology. conclusions: gunther temporary vena cava filters are easy and safe to use and effective in protecting against pulmonary embolism in high risk patients. tips creation using self-expandable stent-graft covered with eptfe (viatorr): first experience and short-term follow-up v. chovanec, a. krajina, m. lojik, j. raupach, p. hulek; hradec kralove/cz purpose: to evaluate technical success of tips dedicated stent-graft implantation and short-term patency. materials and methods: between february and september 2001, 13 patients (7 female, 6 male) aged 16 -76 years with end stage liver disease underwent tips procedure. liver cirrhosis was due to alcohol abuse (6/13), hepatitis (2/13), liver fibrosis (1/13), unknown cause (3/13) and mixed etiology (1/13; patient with hepatitis c and wilson disease). the shunt was created using eptfe covered selfexpandable nitinol stent-graft (viatorr, w.l. gore), which was placed from the portal vein to the ostium of the hepatic vein. the 2 cm non-covered part of the stentgraft was placed into the portal vein branch which remained patent. tips procedure was done using a standard technique and with antibiotic prophylaxis. the tips patency was assessed by doppler us at discharge and then at 1 and every 3 months. the follow-up period ranged from 1 to 7 months (mean 4 months). results: all tips were technically successful with a significant decrease in the portosystemic gradient (from 18.4 mmhg to 7.9 mmhg) without clinical complications and all were fully patent. in one patient (7.7 %) two stent-grafts had to be results: due to technical failures 2 patients were excluded from the evaluation. in the remaining 100 patients the exam rendered diagnostic image quality from the carotid arteries to the tibial vessels (3000 segments). apart from the clinically suspected pvd, additional clinical relevant disease was found in 21 %. 16 patients had a renal artery narrowing, in 13 patients a carotid arterial stenosis was detected, and 2 patients showed an aaa. conclusion: noninvasiveness, three-dimensionality, extended coverage and high contrast conspicuity are the characteristics of the applied whole body 3d mra approach allowing for a quick, risk-free, and comprehensive evaluation of the arterial system in patients with atherosclerosis. the impact of cardiovascular and colorectal disease processes can be diminished if recognized and treated at an early stage or pre-stage. inherent noninvasiveness and lack of harmful side effects make mri ideal for preventive imaging. the goal of this study was to assess the impact of a screening mr examination, encompassing depiction of the brain, the arterial system, the heart and the colon. materials and methods: 28 healthy subjects (mean age 53.3 a, range: 39 -76 a) were evaluated. using a high performance mr system (siemens sonata) equipped with a rolling table platform (angiosurf), mri of the brain (t1w, t2w and tof sequences), whole-body mr-angiography (five contiguous 3d gre acquisitions), cardiac mri (truefisp cine and ir-turbo flash) and eventually mr-colonography (3d gre imaging following administration of a water enema) were performed. paramagnetic contrast was administered i.v. prior to mr-angiography and for mrcolonography. all examinations were evaluated by two experienced radiologists. results: the compound mr examination was well tolerated by all 28 patients. mean examination time amounted to 61 (± 6) minutes. a total of 14 unsuspected pathologies were detected: colorectal polyps (4), cerebral aneurysms (1), aortic aneurysm (2), stenosis of renal arteries (1), stenosis of femoral arteries (2), reduced myocardial ef (2) and mitral regurgitation (2). conclusion: multi-organ screening with mri within a short time is possible. a considerable number of disease pre-conditions requiring subsequent treatment were identified. further work will be required to determine the true value of such an approach. the use of diluted contrast media in equipment with co2 software t. moreno sánchez, e. lopez jimenez; huelva/es objective: to determine the cost-effectiveness and efficiency of angiography of the abdominal aorta and lower extremities using diluted contrast media and co2 postprocessing software for obtaining diagnostic images. subjects and methods: forty patients with peripheral vascular disease were evaluated by co2 software-digital substraction angiography with diluted iodinated contrast material (ioversol 240, diluted at 30 %). results: diluted contrast was well tolerated by all patients with no complaints despite the severity of the vascular disease. good image quality was achieved for the aorta and iliofemoral arteries in all cases. the popliteal artery and distal tree images were of good quality in 35 patients. for the remaining five, it was necessary to use pure contrast along with the co2 software. conclusion: contrast diluted angiography with co2 software can be used as an alternative to pure iodinated contrast material for obtaining arteriograms of the abdominal aorta and lower limbs. the diagnostic quality is equivalent to that obtained with conventional methods. the lower dose of contrast reduces the risk of adverse reactions, increases the cost-effectiveness of the procedure and is more comfortable for the patients. the use of the co2 software produces good quality diagnostic arteriographic images with more comfort for patients, less secondary effects and less cost. the time for completing the study is similar to the conventional one and less time consuming than co2 lower extremities angiography. material and methods: cduv was performed using manual injection and digital substraction angiography in 40 consecutive patients (77 upper limbs). images were read on a 1k high brillance digital workstation. the international anatomic nomenclature was used to divide the superficial venous network into 16 segments per limb. two senior radiologists independently assessed the patency of all segments according to the following grading: absent or non-opacified (grade 1), poor quality (grade 2), small calibre (grade 3), good quality (grade 4). in the case of discrepancy, a consensus was reached by reviewing the images. the kappa-test was used to assess the inter-observer correlation in each of the 16 different venous segments. results: overall, grade 1 was seen in 24 %, grade 2 in 13 %, grade 3 in 12 % and grade 4 in 51 %. mean κ was 0.72 (p < 0.05) for the right side and 0.71 (p < 0.05) for the left side. the worst correlation (k = 0.55) was obtained for veins at the elbow level. conclusion: cduv allows satisfactory imaging of the upper limb venous network with good agreement between the observers. special attention must be paid to obtain good images at the elbow level. intraarterial digital subtraction angiography with carbon dioxide and nonionic gadodiamide in incomplete renal failure h.-p. dinkel, h. hoppe, i. baumgartner; berne/ch purpose: to evaluate the benefit of gadolinium for intraarterial use in diagnostic and therapeutic angiography in patients with incomplete renal failure. methods: 17 patients with planned peripheral or renal vascular interventions (1 iliac, 10 femoral, 3 renal, 3 transplanted kidneys) and renal insufficiency underwent digital subtraction angiography with intraarterial administration of gadolinium (1 gadolinium-dtpa, 16 gadodiamide). gadolinium was used selectively after peripheral catheter placement, usually as an adjunct to carbon dioxide (co2) if the quality of co2-angiography (n = 14) was insufficient to assess the distal run-off vessels or did not sufficiently characterize stenotic lesions. in 16 of 17 cases gadolinium yielded good or satisfactory results that were superior to those of co2-angiography in each case. this applied to the calf and femoropopliteal region in patients with femoropopliteal occlusions, but at times also to the aorto-iliac vessels and the renal arteries. mean serum creatinine level after angiography (295 µmol/l) was not significantly different from the initial level (279 µmol/l), p > 0.37. conclusion: gadolinium is a viable alternative contrast agent in digital subtraction angiography and percutaneous transluminal angioplasty (pta). it enhances the diagnostic evaluation of stenoses and run-off vessel. non-ionic gadodiamide is preferable to hyperosmolar gadolinium-dtpa. for economical reasons and since the maximal applicable dose of gadolinium is currently restricted to 0.4 mmol/kg bodyweight (40 -80 ml) its combined use with co2-angiography is recommended. evaluation of the aorto-iliac and renal arteries: intraindividual comparison of 3d mr angiography and mdct angiography j.k. willmann, p.r. hilfiker, t. pfammatter, j.e. roos, b. marincek, d. weishaupt; zürich/ch purpose: to compare contrast-enhanced 3d mr angiography (mra) and multidetector row spiral ct angiography (cta) in the assessment of the aorto-iliac and renal arteries, using digital subtraction angiography (dsa) as the standard of reference. methods and materials: dsa, mra and cta were performed in 39 consecutive patients with suspected occlusive arterial disease. two readers assessed all mra and cta data sets independently; a third reader evaluated the dsa images. all reviewers were unaware of the results of the other imaging modalities. for data analysis, the arterial system was divided into 16 segments, and a 4-point grading system was applied to assess arterial luminal stenosis. time for post-processing and reading times of mra and cta data sets were noted. results: for readers 1/2 sensitivities of cta were 80 %/83 % and specificities 96 %/96 %; mra had sensitivities of 91 %/92 % and specificities of 97 %/96 % for detection of hemodynamically significant stenosis (> 50 %). interobserver agreements for both mra and cta were good (kappa = 0.74 and 0.67). intermodality agreement between cta and mra for readers 1/2 were 0.73/0.70. post-processing of cta data sets was significantly more time consuming (mean 15 minutes) compared to post-processing of mra data sets (mean 4 minutes) (p < 0.001). similarly, reading time for evaluation of cta was longer than reading time of mra (4 versus 2 minutes). conclusion: both mra and cta demonstrate a similar diagnostic performance compared to dsa in the assessment of occlusive disease of the aorto-iliac and renal arteries. due to shorter post-processing and reading times, mra seems to be more suited to clinical routine. correlation of spatial resolution in multislice ct and angiography in kidneys p.j. hallscheidt, c.c. cardenas, j. boese; heidelberg/de aim: the aim of this study was to evaluate the maximum spatial resolution of multislice ct in comparison to digital subtracted angiography. material and methods: 15 kidneys were catheterised with a 4 french straight catheter and under went mulitslice-ct in an early arterial phase with a reconstructed slice thickness of 0.2 mm. the data were evaluated in mip and 3d reconstruction and the resolution was compared to conventional dsa angiography, which was performed after the ct scan. results: in reconstruced multislice ct with isotropic voxels all segmental and subsegmental arteries could be delineated. the reconstructed ct data allowed similar spatial resolution to dsa, but additionally the segmental anatomy could be evaluated. discussion: reconstructed multislice ct gives similar spatial resolution, with delineation of subsegmental arterial branches, as angiography. but the 3d data allows additionally the delineation of the segmental anatomy which is essential for the planning of nephron sparing surgery. material and methods: 51 patients with a clinical or ultrasound suspicion of renal artery stenosis were examined with mscta after a bolus injection of 100 ml of non-ionic c.a. at 4 ml/s. in most cases the renal artery study was part of a run off examination for patients with peripheral arteriopathy. a fixed time delay of 25 to 28 (in presence of abdominal aortic aneurysm) seconds was used in all cases. images were interpreted by 3 blinded radiologists either on axial or reconstructed images. in all patients dsa was performed within 72 hours and considered the gold standard. sensitivity, specificity, positive predictive value (ppv) and negative predictive value (npv) for the assessment of degree of stenosis and evaluation of supernumerary arteries were calculated. results: we evaluated 123 renal arteries. mscta provided good to excellent diagnostic quality in all cases; all 21 supernumerary arteries were correctly demonstrated. regarding the degree of stenosis the values of sensitivity, specificity, ppv and npv were respectively 100 %, 95 %, 100 % and 92.6 %. cta was superior to dsa in the delineation of calcification. in 4 cases with ostial calcified plaque the stenosis, moderate at dsa, was overestimated with mscta and considered severe. multislice spiral cta provides excellent arterial delineation in patients with suspected renal artery stenosis. the limited amount of contrast agent used lends itself to use in patients with partially impaired renal function. to evaluate the utility of mri for the assessment of angiodysplasia compared to conventional duplex us, venography and arteriography. methods and materials: 14 patients (9 male, 5 female; age range, 10 -64 years) with clinically diagnosed angiodyplastic abnormalities of the extremities were examined on a 1.5 t whole body scanner (magnetom sonata, siemens, germany). based on a localizer sequence axial/coronal t1-, heavily t2-weighted (stir) as well as axial t1-weighted sequences post contrast were acquired to determine the extent and type of the arteriovenous malformation. in addition dynamic contrastenhanced (0.2 mmol/kg gd-bopta, multihance, bracco, italy) 3d gradient echo sequences were collected. a board certificated radiologist as well as an angiologist analysed the mr data sets for lesion depiction, determination of extent and involvement of neighbouring structures as well as characterisation of the malformation. results were compared to findings from duplex us, conventional venography and intraarterial arteriography. results: all mr examination were of diagnostic quality. a total of 16 arteriovenous malformations (venous malformation: n = 11, arteriovenous fistulae (avf): n = 2, posttraumatic avf: n = 3) were depicted. the stir sequence was helpful in the determination of the extent of the vascular malformation which was often underestimated by 3d mra alone, whereas dynamic 3d mra was mandatory for the classification of the lesion. these findings correlated well with the combination of conventional venography (n = 11) and duplex-us (n = 16). conclusion: mri appears to be valuable in the assessment of angiodysplastic lesions of the extremities. the protocol should combine dynamic contrast-enhanced 3d gre-sequences with heavily t2-w (stir) sequences. material and methods: all procedures were done on a multislice-spiral-ct (siemens somatom plus 4vz) using a standardized ct-fluoroscopy technique. robot assisted punctures were executed using a remote-controlled robotic system (unitedrobotsystems, evolution1) with unrestricted flexibility of movement. interventions performed were either punctures of contrast-media filled capsules, placed in a soft-tissue-phantom, or interventions within the spinal column of human bodies, such as vertebroplasty or discography. evaluation parameters were accuracy and application of the system, access to the patient and procedure time for the intervention. results: using robotic assistance high accuracy was achieved for all interventions. each lesion within the soft tissue phantom was punctured precisely (20/20). interventions on the spine (10) and the intervertebral discs (8) were performed without significant deviation from the approach determined initially. though application of the system was simple, free access to the patient was often aggravated by the scanner and robotic design. a marked learning curve was observed, thus leading to a significant reduction in intervention time in the course of all procedures (40 %) conclusion: a robotic system may be useful for ct-interventions in the spine, significantly reducing the radiation dose to the radiologist. as examination time is still markedly increased and patient access remains difficult, the system configuration has to be further optimized for the clinical setting. purpose: percutaneous vertebroplasty is used to strengthen the pathologic vertebral body and reduce pain in some diseases involving the spine. the purpose of this study was to evaluate segment stability and clinical status in patients who received vertebroplasty after radiofrequency ablation of spinal tumors. methods and materials: 23 vertebroplasties with polymethylmethacrylate were performed in 14 patients who had been treated with radiofrequency ablation of inter-or paravertebral tumors in the thoracic and/or lumbar spine. vertebroplasty was indicated due to presence or imminent tumor related vertebral fractures and presence of imminent neurological deficits. operations were carried out under ct/ fluoroscopy guidance under local anesthesia and on an out-patient basis. at follow-up, preoperative mr images were compared with follow-up mr-images in addition to clinical examination. follow up ranged from 3 to 12 months. results: at follow-up, mr images of treated vertebral bodies showed no signs of sintering or refracture. clinical examination showed improved mobility of the spine in 13 patients (92.9 %). in none of these patients was the presence or progression of neurological deficits diagnosed. 1 patient (7.1 %) was restricted in motion due to a new tumor in another segment. no intra-or postoperative complications were reported. our results indicate that image-guided percutaneous vertebroplasty seems to be a safe and effective, minimally invasive method to stabilize pathologic vertebral bodies in patients who have received radiofrequency ablation of spinal tumors. purpose: frequent complications of osteoporosis are fractures, especially in the vertebral bodies of the thoracic and lumbar spine. the purpose of this study was to ask whether percutaneous ct-/fluoroscopy-guided vertebroplasty can cause pain reduction in patients with fractured osteoporotic vertebral bodies. methods and materials: 25 verebroplasties were performed on 17 patients with osteoporotic vertebral body fractures. patients suffered from superior or inferior endplate fractures, combined end plate fractures without loss of height and combined end plate fractures with loss of height. inclusion criteria were new osteoporotic vertebral body fractures with acute pain as well as older fractures with persistent pain. exclusion criteria were fractures causing a narrowing of the spinal canal and neurological deficits, tumors, cement allergy and haemorrhagic diathesis. the procedure was carried out on an outpatient basis under local anesthesia and was performed under combined ct/fluoroscopy-guidance. follow up examinations were carried out after an average of 2 days and after 3 months. pain was assessed with the help of a visual analogue scale. results: at the time of the first follow up, patients reported on an average relative pain reduction of 29.9 %. after 3 months the patients obtained an average of 33.4 % relative pain reduction according to the visual analogue scale. conclusion: ct/fluorscopy-guided percutaneous vertebroplasty of osteoporotic vertebral body fractures is a gentle, effective and minimally invasive method to reduce symptomatic pain in the affected region. it can be carried out on an outpatient basis under local anesthesia, which results in direct mobilization and rehabilitation. steroid injection in sciatica due to lumbar disk herniation: technical aspects and clinical results (80 patients) d. krause, f. cognet, m. dranssart, d. ben salem, s. chapuy, j. lerais, j. cercueil, j. couaillier; dijon/fr purpose: to assess the feasibility and efficiency of foraminal or intracanalar steroid injections in cases of sciatica due to disk herniation. materials and methods: between january 1999 and january 2001, 80 patients presenting with typical sciatica, resisting usual medical treatment (four weeks), underwent a prospective protocol of pain treatment. a percutaneous approach was performed using ct guidance under local anesthesia. in foraminal lateral herniation (25 %), the 22 g needle tip was positioned through the soft tissues. in intracanalar herniations (75 %), the needle tip was advanced directly into contact with the posterior part of the root, through the ligamentum flavum (homo-lateral or contra-lateral approach in case of a narrowing lumbar tendency). in all cases the steroid injection (dexamethasone acetate 20 mg) was rigorously epidural. the procedure was possible in all cases, without any complications or side effects. the analysis of the results was based on a multi-factorial analysis: analogue visual scale for pain intensity measurement; family g.p questioning; professional activity recovery; stopping medical treatment. the mean follow-up was more than nine months. good or excellent clinical results were observed in 70 % of cases, poor results (without surgical intervention) in 20 % of cases and failures in 10 %. conclusion: this less aggressive and non expensive technique, performed under very precise ct guidance, is particularly adapted to ambulatory patients with encouraging results. effect of ct-guided lumbar facet joint infiltration on lower back pain r. knapp, a. glück, j. lukasser; kufstein/at purpose: ct-guided lumbar facet joint infiltration is a valuable tool in treating lower back pain. the duration and quality of pain relief is evaluated. methods and materials: 60 patients suffering from lower back pain caused by osteoarthritis of the facet joints underwent ct-guided lumbar facet joint infiltration with bupivacain and hydrocortisone. only one facet at one lumbar level was treated. evaluation of pain relief and change in medical treatment over a period of one year was performed with a questionaire. results: 58 patients (97 %) felt a complete relief of pain after a mean time interval of 5.2 days after the infiltration. after one year 19 patients (32 %) remained free of pain. 16 patients (27 %) improved markedly or reported rarely any pain, whereas in 25 patients (42 %) the pain recurred to the same extent as before the infiltration. the pain free interval after infiltration was a mean of 110 days. before infiltration 55 of the patients (92 %) took one or more different oral analgesic drugs. one year after infiltration 28 patients (51 %) still needed analgesics. in 25 patients (45 %) who took two or more different drugs before treatment this was reduced to 5 patients (9 %) after one year. no adverse effects of the infiltration were seen during the study interval. conclusion: ct-guided lumbar facet joint infiltration is a save and effective treatment for patients with lower back pain caused by osteoarthritis of the facet joints. purpose: offical recommendations for obtaining informed consent for operative or ir procedures are that the patient is consented by the operator. the purpose of the study was to identify the proportion of european interventional radiologists who conform to these guidelines. materials and method: a questionnaire was designed and consisted of thirteen questions on current working practice and opinions on informed consent. the questionnaire was distributed to 786 european interventional radiologists who were members of irish or british societies of interventional radiologists and members of cirse. the anonymous replies were then entered into a database and analysed. results: 254 (32.3 %) questionnaires were returned. institutions were classified as academic (56.7 %), 40.5 % non-academic (40.5 %) and private (40.5 %). 83.5 % of responders do not use specific consent forms and 61 % have patient information leaflets for procedures. although 72.8 % of radiologists consent patients for some procedures, junior medical staff (house officers or senior house officers) consent patients in 58 % of replies. over half (56.3 %) did not feel that their current policy was adequate. comments from responders indicated that there is insufficient time for radiologists to consent all patients. suggestions to improve current local policies included radiology outpatient clinics and radiology nurses visiting patients on the wards or in outpatient clinics. conclusion: only 24.8 % of european interventional radiologists follow current guidelines for obtaining informed consent. the causes identified were resource limitations and in particular constraints on time. optimizing material management in interventional radiology departments methods and materials: after compilation of a comprehensive stock list of all disposable materials necessary for interventional radiology an abc-analysis was performed with focus on high quality and high volume materials (a-articles). based on ordering frequency, all a-articles were subjected to xyz analysis, which is based on predicting the probability of requirement of the article. on this basis capital binding costs were considered with an annual interest rate of 8 % assumed. results: current inventory control reveals an annual capital binding for all articles of $ 250000 mainly due to a-articles, which accounted alone for $ 200000. if articles are bought in a just-in-time (jit) mode instead of mid term, stock costs could be reduced by $ 130000, thus storage time is shortened and capital binding is reduced and $ 10000 can be saved. with a stock turnover of the remaining material of 9 months, which matches our experience, jit-buying of articles can lead to an additional cost reduction of $ 5000. altogether $ 15000 could be saved, which means a relative cost reduction in stock of 6 %. besides this, there are lower costs for renting space and expiration dates of articles can better be controlled. late improvement of regional myocardial wall motion in the area of infarction after acute ptca in a 6-month follow-up study using delayed contrast enhanced magnetic resonance imaging: is "bright" really "dead"? purpose: acute recanalization in myocardial infarctions (mi) has shown to be of benefit with respect to global myocardial function and prognosis. the aim of our follow-up study was to investigate late effects of acute coronary angioplasty (ptca) on regional wall motion after the subacute phase of mi. patients and methods: 17 patients underwent mr imaging at 1.5 t after acute ptca in the subacute phase of mi and a second time 6 months later. corresponding short axis slices encompassing the left ventricle (lv) were acquired with standard cine and delayed contrast-enhanced magnetic resonance imaging (cemri). target parameters were the percentual size of infarction (psi (%)) and percentual wall thickening (pwt (%)) in the infarct area (ia) and the remote area (ra). results: psi was similar in the subacute phase and at 6 month's follow-up (22.2 and 21.9 %, respectively; n.s.). pwt improved significantly in ia (21.9 and 37.9 %, p < 0.05) in contrast to ra (46.4 and 38.4 %; n.s.), whereas global myocardial function did not change significantly. this late improvement was only observed in transmural mi. patients with subendocardial myocardial infarction did not show any further improvement. conclusion: pwt improved in ia after acute ptca even after the subacute stage of transmural mi in this 6-month follow-up study. this phenomenon could be explained by a prolonged stunning in transmural infarctions and contradicts the hypothesis that "bright" in delayed cemri represents nonviable tissue in all cases. contrast-enhanced (ce) mr can clearly depict definitive necrotic areas after myocardial infarction: the high resolution of mri permits discrimination of subendocardial versus transmural infarction. follow-up with cine mri allows documentation of functional recovery of both subgroups. methods: 30 patients (26 males, mean age 56 years) underwent emergency ptca ± stent for ami. mr controls were done on day 1, 3, 7 and 28 after ami using a 1.5 t unit (siemens, sonata) with the following protocol: (1) multiple truefisp (tr 3.2 ms, te 1.6 ms) along the short axis to assess lv volumes and wall motion abnormalities; (2) 3d inversion recovery sequence (tr to rr, te 1.64 ms) 10 -15 min after administration of gd-dtpa to visualise infarcted myocardium ("late enhancement"). results: 12 patients showed transmural infarction in late enhancement. all of these patients had wall motion abnormalities in the same segments which persisted over the observation period of 28 days. 21 patients had myocardial segments with non-transmural enhancement in late enhancement. improvement of the wall motion abnormality was shown in 11/21 patients. the transmural group showed a decrease of ef (0 -7 %) and the non-transmural group an increase (0 -4 %). conclusions: transmural infarction with late enhancement has a worse functional outcome in the involved myocardial segment and the entire ventricle than nontransmural infarction. longer observation periods than 28 days may be required for monitoring the outcome of non-transmural infarction. b a c d e f 174 combined first-pass and delayed contrast enhanced mri in the assessment of myocardial viability after acute infarction l. natale 1 , a. meduri 1, 2 , a. lombardo 1 , a. giordano 1 , r.m. razmi 2 , p. marano 1 ; 1 rome/it, 2 birmingham, al/us purpose: to define the role of mri in the assessment of myocardial viability we compared mri, rest 99 tc sestamibi spect and dobutamine echocardiography (de). methods and materials: 18 consecutive patients with first ami (63.9 a, 16 anterior, 2 inferior, 8 primary ptca, 4 thrombolysis) underwent mri, spect and de within the first week after onset of symptoms. mri was performed with a 1.5 t scanner (ge signa horizon echospeed); short axis single slice first pass (iv 10 ml gd-dtpa, 3 ml/s) and multi-slice delayed t1 imaging were performed. using a 16 segments lv model, both segmental analysis and percent infarct area were analyzed. segments were classified as: (1) normal first-pass, absent or delayed hyperenhancement; (2) hypoenhancement at first-pass, delayed hyperenhancement; (3) hypoenhancement both at first-pass and delayed imaging. in delayed images, segments out of first-pass slice were classified at delayed imaging as normal, hyperenhanced and hypoenhanced. patterns 2 and 3 and patterns hyper-and hypo-were considered non viable. results: segmental analysis results were poor, particularly if compared with de (sensitivity 70 %, specificity 78 %); infarct area analysis (at least 2 viable segments) was better (vs de and spect respectively: sensitivity 76 % and 72 %, specificity 83 % and 88 %). conclusions: patterns 1 and 3 respectively identify viable and non viable tissue. pattern 2 or delayed hyperenhancement is less specific as 25 % viability was demonstrated at de and/or spect. first pass plus delayed imaging are superior to delayed imaging alone (sensitivity and specificity with de and spect respectively 76 % vs 72 %, 84 % vs 78 %, p > 0.05), but multislice first pass is mandatory. comparison of magnevist™ and gadophrin-3 for the assessment of acute and chronic myocardial infarction j. barkhausen 1 , w. ebert 2 , c. heyer 2 , j.f. debatin 1 , h.j. weinmann 2 ; 1 essen/de, 2 berlin/de purpose: to investigate whether the area of hyperenhancement using extracellular contrast agents is larger compared to the region demarcated by a necrosisspecific contrast agent. methods and materials: 15 rabbits underwent thoracotomy and permanent occlusion of a branch of the left coronary artery. two animals died prior to imaging, 8 animals were examined 48 hours following occlusion and 5 animals were imaged six weeks following induction of the infarction. all animals received 50 mmol/kg of a necrosis-specific contrast agent (gadophrin-3, schering, berlin/germany) 24 hours prior to the mr examination. continuous short axis views were collected on a 1.5 t mr scanner using an ecg-triggered ir-turboflash sequence. imaging was repeated 10 minutes after additional injection of 100 mmol/kg of magnevist (schering, berlin/germany). the area of hyperenhancement demarcated following gadophrin-3 injection was compared with hyperenhancement seen on gadophrin-3 plus magnevist enhanced images and with ttc staining. results: in animals with acute myocardial infarction hyperenhancement was detected in 27 slices. the mean difference in the size of hyperenhancement seen on the two different in-vivo mr scans was −1.8 ± 6.0 mm 2 (p > 0.05). both measurements showed excellent agreement with ttc-staining. chronic infarctions showed no enhancement following gadophrin-3 injection, whereas application of magnevist resulted in hyperenhancement. conclusion: in acute myocardial infarction the area of hyperenhancement following gd-dtpa application does not exceed the area of hyperenhancement seen on gadophrin-3 enhanced images. the combination of gadophrin-3 and magnevist can distinguish acute and chronic infarction because chronic myocardial infarctions do not enhance with gadophrin-3. multi-slice first pass myocardial perfusion imaging: first results comparing saturation recovery (sr) truefisp 2d und sr turboflash 2d pulse sequences s. miller 1 , m. fenchel 1 , o. simonetti 2 , u. kramer 1 , u. helber 1 , n.i. stauder 1 , j. finn 2 , c.d. claussen 1 ; 1 tübingen/de, 2 chicago, il/us purpose: to compare two different pulse sequence techniques for multi-slice first pass myocardial perfusion imaging. methods: using 1.5 t (magnetom sonata, siemens, erlangen) 14 patients and 6 volunteers were examined using both sr truefisp 2d and sr turboflash 2d pulse sequences. t1-weighting was enhanced applying a 90° saturation recovery preparation pulse. sequence parameters were tr 2.4 ms, te 1.2 ms for truefisp 2d and tr 1.8 ms, te 0.8 ms for turboflash imaging with a 280 -300 mm field of view and 80 × 128 matrix. contrast injection was standardized to 5 ml (5 ml/s flow rate) resulting in a dose of 0.025 -0.035 mmol gd-dtpa/kg per injection. data evaluation included signal intensity (si) over time analysis and determination of baseline and peak signal and contrast to noise ratios (s/n, c/n). an automated post-processing software (argus, siemens) was used to derive perfusion parameters simax, slope, time to peak and area under curve. results: with diastolic ecg-triggering 2 -4 slices/rr-interval were acquired. values of s/n baseline were comparable (truefisp 5.2 ± 2.4, turboflash 4.5 ± 2.4, p > 0.3), but superior results of s/n simax (9.2 ± 5.4 vs. 6.1 ± 2.6, p < 0.006) and c/n (4.0 ± 2.1 vs. 1.6 ± 1.1, p < 0.0001) could be obtained with truefisp. additionally, analyzing individual myocardial segments, absolute and dynamic ranges of slope and area under curve were 2 -9 fold higher (slope 3.8 ± 2.2, area under curve 4.5 ± 2.2, p < 0.0001) using sr truefisp compared to sr turboflash imaging. conclusion: superior results for multi-slice first pass perfusion imaging can be obtained using sr truefisp 2d imaging compared to sr turboflash 2d. myocardial perfusion assessment with dynamic p792 enhanced mri compared to 99 tc-sestamibi-spect: phase ii european multicenter trial j. bremerich 1 , m. friedrich 2 , b. wintersperger 3 , f. brunotte 4 , j. piek 5 , n. al saadi 2 , t. schindler 1 , s. friedrich 2 , m.f. reiser 3 ; 1 basle/ch, 2 berlin/de, 3 munich/de, 4 dijon/fr, 5 amsterdam/nl purpose: to compare mri enhanced with the new rapid clearance blood pool agent (rcbpa) p792 with the gold standard 99 tc-sestamibi-spect for the assessment of myocardial perfusion. materials and methods: by september 2001 40 patients with subacute myocardial infarction were included in 5 european centers. dynamic first pass and delayed equilibrium phase mr images were acquired after injection of 0.0065 or 0.013 mmol/kg p792 (guerbet, france) at injection rates of 2 ml/s or 4 ml/s. mr was conducted at 1.5 t with phased array coils. mr images were acquired in the short axis during first pass of p792 with a dynamic saturation recovery turboflash sequence (magnetom vision/symphony; siemens, germany or cvi; general electrics, usa). subsequently equilibrium phase inversion recovery mri were acquired 5 and 10 min after contrast injection to assess late enhancement. ∆si and si-upslope were calculated. results were compared with 99 tc-sestamibi spect as gold standard. results: p792 was well tolerated by all patients. with 0.013 mmol/kg infarction was readily detected on dynamic first pass mr images as hypointense areas. with 0.0065 mmol/kg infarction was not visible in all patients on dynamic images, but upslope and delta si were attenuated. location and extent correlated well with 99 tc-sestamibi-spect. infarction was also visible on inversion recovery mr images. the results from this study exhibit the potential interest of a new gadolinium based intravascular contrast agent in assessing qualitatively and quantitatively hypoperfused myocardium on p792 enhanced mr images during first pass and equilibrium phase. this study was supported by guerbet, france. quantitative first-pass myocardial perfusion mri in patients with coronary artery disease after successful revascularization v. gramovitch, v.e. sinitsyn, m. gordin, o. stukalova, e. noeva, s.k. ternovoy, e. chazov; moscow/ru purpose: to determine the potential value of quantitative myocardial perfusion mri in the assessment of successful coronary intervention. method and materials: we studied 9 pts (9 men, age 49 ± 10 years, weight 80 ± 9.7 kg) with 1 -3 vessel cad and normal left ventricular (lv) function before and after (2 nd day to 1 month) coronary intervention. all pts underwent either ptca (7/9, stent 6/7) or cabg (2/9). mri was performed using a 1.0 t siemens magnetom scanner with snapshot-flash sequence. perfusion was assessed by injecting the contrast agent gd-dtpa-bma (omniscan, nycomed amersham) via the antecubital vein before (1 st bolus 8 ml) and after dipyridamole (0.56 mg/kg, 2 nd gd bolus 12 ml). myocardial and blood si were converted to concentration of gd according to the in vitro calibration curve and fitted by one-compartment model by saturday b a c d e f 175 the use of a custom written program. eleven normal and 11 segments supplied by stenotic coronary arteries (³ 50 % diameter stenosis) with successful intervention afterwards (residual stenosis < 50 %) were included in the final analysis. results: myocardial blood flow was similar in normal and "stenotic" segments at base line (1.21 ± 0.49 and 1.28 ± 0.37 ml/min/g of tissue) but significantly lower in "stenotic" segments during hyperemia (1.44 ± 0.57 vs. 2.52 ± 0.94 ml/min/g, p < 0.05). coronary vasodilator reserve (the ratio of flow during hyperemia to flow at base line) was significantly lower in "stenotic" segments than in normal (1.2 ± 0.36 vs. 2.1 ± 0.75, p < 0.05) and normalized completely after successful revascularization (3.1 ± 1.45). conclusion: quantitative mr perfusion assessment may be useful for the follow-up of patients with cad after coronary intervention. myocardial perfusion in the human heart: quantitative assessment using a spin-labeling technique at 2 t f. fidler, c.m. wacker, p.m. jakob, w.r. bauer, a. haase; würzburg/de purpose: the aim of this study was to determine myocardial perfusion of the human heart using a spin-labeling technique without exogenous contrast agent. method and materials: an ecg-gated fast saturation recovery flash sequence was implemented using a 2 t scanner (bruker) with a homebuilt quadrature surface coil for signal reception. t1 measurements were performed after global and slice-selective saturation under resting conditions and adenosine-induced stress. exams were obtained breathing room air (air) and pure oxygen (oxy). 10 ecgtriggered enddiastolic midventricular short axis views were acquired in a single breathhold of about 15 s in 9 healthy volunteers. results: myocardial perfusion was calculated as p = 2.5 ± 0.7 ml/g/min (rest, air), 4.8 ± 1.1 ml/g/min (stress, air) and 1.6 ± 0.6 ml/g/min (rest, oxy). t1 of lv (rv) blood was 1700 ± 100 ms (1600 ± 120 ms) (air) and 1440 ± 45 ms (1560 ± 150 ms) (oxy). the presented spin-labeling method is a robust alternative for quantitative perfusion evaluation and allows repeated measurements without contrast agents. oxygen induced changes of t1 (myocardium and blood) are detectable and may therefore become important in patients with coronary artery disease. purpose: in small larynx tumors (t1, t2) the presence of spread is crucial in determining adequate surgical or laser-surgical treatment. therefore, the purpose of the study was to determine sensitivity and specificity of preoperative multi-slice helical ct (msct) for the infiltration of various glottic laryngeal structures. material/methods: 30 patients with suspected laryngeal cancer were investigated on a msct scanner (siemens plus 4 volume zoom) with 4 × 1 mm collimation, 0.5 seconds rotation time in a single breathhold. multiplanar reconstructions (mpr) in sagittal and coronal planes were reconstructed in all patients and rated in consensus. all findings regarding tumor spread into the glottic fat, crossing the anterior commissure, infiltration of the arytenoids and the extension along the vocal cords were compared to surgery and histology. the sensitivity and specificity of msct regarding the infiltration of the glottic region were 93 %, 85 %. regarding infiltration of the anterior commissure sensitivity and specificity were 85 %, 94 %, respectively; regarding the infiltration of the anterior part of the vocal cords 89 % and 92 %, and regarding the infiltration of the arytenoids 83 % and 96 %, respectively. sagittal mprs were especially helpful regarding the surfaces of the arytenoids and the anterior commissure, and coronal mprs were most helpful in the evaluation of the vocal cords. the detection of spread of supraglottic laryngeal tumors is crucial in determining best treatment, as the preoperative assessment decides to what extend surgical therapy can be offered. thus, the purpose of the study was to determine sensitivity and specificity of multislice helical ct (msct) for the identification of infiltration of supraglottic laryngeal structures. material/methods: investigations on a msct scanner were performed in 30 patients with suspected supraglottic laryngeal cancer, with two entire acquisitions; one in breathhold and one in phonation. multiplanar reconstruction's (mpr 3 mm thickness) in sagittal and coronal plane were reconstructed in all patients. the findings were separately evaluated regarding tumor spread into the pre-epiglottic fat, the anterior commissure, the laryngeal and the superficial side of the epiglottis and the piriform sinus, and were compared to surgery and histology. results: regarding infiltration of the piriform sinus sensitivity and specificity were 86 % and 96 %, regarding the infiltration of the laryngeal side and the superficial side of the epiglottis 100 % and 93 %, and regarding the anterior commissure 85 % and 94 %, respectively. the cumulative sensitivity and specificity of msct regarding the infiltration of the entire supraglottic region were 89 % and 95 %, respectively. while the mprs were felt to be of general benefit, sagittal mprs were especially helpful regarding both surfaces of the epiglottis, and coronal mprs were mot helpful in the evaluation of the piriforme sinuses. the extend of supraglottic laryngeal tumor spread can be depicted with high accuracy using msct. referred pain in oropharynx carcinoma: a clinical symptom finds its anatomical correlate in mri h.c. thoeny, k.t. beer, r.h. greiner, p. vock; berne/ch purpose: is there a correlation between mri and the prognostic symptom of referred pain to the ear in patients with oropharynx carcinoma? method/materials: irritation in the region innervated by the glossopharyngeal nerve can be transmitted as pain to the ear due to connections between the glossopharyngeal nerve and the tympanic nerve. in a prospective study 36 consecutive patients, median age 59 (range, 41 -76 years) with oropharynx carcinoma underwent mri before radical radiotherapy. 21 patients had referred pain to the ear, 15 did not. the protocol included axial pd/t2-weighted tse sequences, axial, coronal, and sagittal t1-weighted se sequences before and/or after contrast medium administration. examinations were performed on two 1.5 t mris (magnetom vision, siemens, or signa, ge). two independent, blinded radiologists analyzed the mri studies for alterations of anatomical structures (effacement, signal alteration, or contrast medium enhancement) of the oropharynx and adjacent regions. a twosided 2 test was used to compare variables. results: patients with referred pain to the ear showed significantly more alterations of the following structures innervated by the glossopharyngeal nerve: palatoglossus (p < 0.002), stylo-(p < 0.006) and palatopharyngeus (p < 0.004), and constrictor pharyngis (p < 0.04) muscles; hard palate (p < 0.005), tonsil (p < 0.002), pre-epiglottic space (p < 0.03), and posterior soft palate (p < 0.003). no difference could be observed for structures innervated by different cranial nerves. conclusions: alterations of structures innervated by the glosso-pharyngeal nerve showed a significant association with referred pain to the ear in patients with oropharynx carcinoma. the symptom of reflex-otalgia has, therefore, an anatomical correlate in mri. virtual laryngoscopy with multislice ct enables grading of upper airway stenosis h. hoppe, h.c. thöny, h.-p. dinkel, p. zbären, p. vock; berne/ch purpose: to compare the efficiency of noninvasive virtual laryngoscopy in depicting and grading upper airway stenosis with multislice ct versus fiberoptic laryngoscopy. methods and materials: multislice ct and fiberoptic laryngoscopy were used to examine 116 upper airway sections (supraglottis, glottis, subglottis, trachea) from 29 patients (n = 19 malignant upper airway pathology, n = 5 benign upper airway pathology, n = 5 control group without upper airway pathology). ct data were obtained on a toshiba asteion multislice ct in 4 × 1 mm collimation, pitch 5.5/4 and 1 mm reconstruction interval. postprocessing was performed using surface rena c d e f 176 dering and multiplanar reformats (mpr). ct images were independently interpreted by two radiologists. fiberoptic laryngoscopy was the gold standard of reference. results: virtual laryngoscopy and mpr accurately demonstrated upper airway stenosis caused by intraluminal tumor growth. there was a close correlation (r = 0.94) between virtual laryngoscopic and fiberoptic laryngoscopic grading of stenosis. virtual laryngoscopy was limited in the differentiation of mucus and appositional tissue folds from tumor, which was more reliable with mpr and axial ct slices. furthermore, subtle mucosal irregularity could not be defined. conclusion: virtual laryngosopy with multislice ct enables high-resolution endoluminal imaging of the upper airways with a short scan time despite thin collimation, but should be combined with axial ct-slices and mpr readings. virtual laryngoscopy was especially useful for evaluation of subglottic and tracheal stenosis, which may be difficult to assess with fiberoptic laryngoscopy. it is a reliable non-invasive method for the assessment of upper airway stenosis as a complement for fiberoptic laryngoscopy. purpose: to evaluate the potential of mr-guided laser-induced thermotherapy using a high power irrigated laser application system for the treatment of recurrent head and neck tumors. materials and methods: 27 recurrent tumors in the head and neck tumors (recurrent squamous cell carcinoma n = 24, recurrent pleomorphic adenoma n = 3) were treated using mr-guided laser-induced thermotherapy and a newly developed irrigated power application system which allows power settings 6 times higher than the conventional system. a total of 53 laser applications were performed using 37 laser applicators. mr thermometry was performed using a temperature sensitive t1-weighted gradient echo sequence for monitoring thermal induced changes in signal intensity. follow up studies were performed using plain and contrast enhanced mr. results: all procedures could be performed under local anesthesia. laser applicators with an active length of 2 or 3 cm were used with 24 or 36 w respectively (12 w/cm active length of the laser applicator). the application time was between 4 and 15 minutes. all lesions showed a very rapid heat distribution. we were able to induce coagulative necrosis in all patients. clinical relevant improvement of clinical symptoms was observed in 24 lesions. the treatment of 3 lesions resulted in no improvement of clinical symptoms. conclusion: mr-guided litt using a high power irrigated laser application system proved to be an reliable and effective method to treat recurrent tumors in the head and neck region. mr-thermometry allowed monitoring of laser induced temperature changes during litt. fat suppressed t1 sequences in the evaluation of "t" factor in carcinoma of the tongue s. cappabianca, a. barberi, l. pasqualetto, g. colella, r. grassi; naples/it purpose: comparison between se t1, dp and t2 sequences and t1 fat-suppression sequences in staging of lingual carcinoma methods: 47 patients with lingual carcinoma underwent mri exam using a 1 t superconducting scanner. in all cases se sequences dp-t2w were obtained; t1w and t1w with selective fat suppression before and after intravenous administration of gd-dtpa were also acquired. two different groups of radiologists evaluated independently the dp-t2 and t1 sequences, and the dp-t2 and t1-fs sequences, in order to define the extension of the neoplasm ("t" factor). mri findings were compared with pathological staining. results: dp-t2 and t1: tumour not detectable n = 3; t1 n = 4, t2 n = 6, t3 n = 20, t4 n = 12. dp-t2, t1 and t1-fs: tumour not detectable n = 2; t1 n = 5, t2 n = 6, t3 n = 23, t4 n = 9. surgery/pathology: tumour not detectable n = 0; t1 n = 8, t2 n = 7, t3 n = 20, t4 n = 10. dp-t2w and t1w sequences diagnostic accuracy 93.3 %; dp-t2w, t1w t1-fs sequences diagnostic accuracy 95.5 %. conclusion: our data suggests that in the local staging of lingual carcinoma the use of se-t1 sequences with selective fat suppression can improve diagnostic accuracy of mri in evaluation of tumour volume. withdrawn by author ultrasonographic detection of iatrogenic accessory nerve palsy p. kovacs, g. bodner, a. gardetto, h. piza-katzer, w.r. jaschke; innsbruck/at purpose: to report the ultrasonographic findings of 4 cases of iatrogenic accessory nerve palsy after lymph node biopsy and neck dissection and to demonstrate feasibility of ultrasonography (us) in detecting the accessory nerve in three cadaveric specimens. methods and materials: 4 patients (range 42 -65 years) presented with neck and shoulder pain after surgical intervention in the neck region (2 after lymph node biopsy, 2 after neck dissection). us was performed with a linear broad-band transducer (5 -12 mhz) working on a hdi 5000 (atl). in 3 fresh cadavers the accessory nerve was detected by means of us and marked with blue ink. following, the accessory nerve was exposed carefully. results: in the right lateral cervical region of two patients, who underwent lymph node biopsy, we found a hypoechoic mass, in which a tubular structure ended. we suspected a cut accessory nerve. in two patients with unilateral neck dissection us revealed a tubular structure ending in a hypoechoic scar measuring 3 cm in length. in all cases the trapezius muscle showed hyperechoic texture, suggestive of muscular atrophy. us findings were confirmed by electroneurographic testing and surgical nerve inspection. on us the accessory nerve appears a small tubular structure (diameter 0.7 mm) lying just under the superficial layer of cervical fascia. in all specimens the nerve was correctly marked by means of us showing blue stained accessory nerves after dissection. conclusions: the capability of high resolution us allows detection of the normal accessory nerve and of iatrogenic accessory nerve palsy. saturday materials and methods: to date, 5 small (< 3 cm) and 5 large (> 3 cm) solid renal tumours and 2 cystic complex renal masses (< 3 cm) were evaluated by ultrasound (us), color doppler (cd) and pihi. pihi was performed after levovist injection by high mi (1.0 -1.2) intermittent manual triggered stimulation every 10 -15 seconds, during vascular (20 -60 seconds) and late phase (60 -120 seconds). helical ct pattern and/or histologic findings were considered as the reference procedures. results: reference procedures classified 3 small solid tumours and 5 large solid tumours as renal adenocarcinomas, 2 small solid tumours as angyomiolipomas and 2 cystic complex renal masses as cystic papillary tumours. small solid renal adenocarcinomas were hypoechoic (n = 2) or hyperechoic (n = 1) on us with a basket arterial pattern on cd. large solid adenocarcinomas appeared inhomogeneous with no vascular pattern, while angiomyolipomas appeared hyperechoic with peripheral venous flows. cystic complex renal masses revealed thick septa and a peripheral solid portions on us with a basket arterial pattern on cd. on pihi small solid renal adenocarcinomas appeared hyperechoic on vascular phase and isoechoic (n = 2) or hypoechoic (n = 1) on late phase. large renal adenocarcinomas revealed increased conspicutiy of necrotic intratumoural zones and inhomogeneous enhancement. renal angiomyolipomas revealed dot-like enhancement. cystic renal adenocarcinomas revealed peripheral enhancement limited on septa or solid portion. during a 6-month period, variable renal masses including renal cell carcinoma (n = 10), transitional cell carcinoma (n = 2), acute pyelonephritis (n = 3), angiomyolipoma (n = 1), and traumatic renal contusion (n = 1) were evaluated with cha us (logiq 700 expert series; ge medical systems) using microbubble contrast agent. us images were obtained before contrast administration and with a bolus injection of 4 g of microbubble contrast agent (300 mg/ml of levovist; schering) in every 10 -15 s for 5 min. the contrast enhancement patterns of variable renal masses were assessed. result: 10 renal cell carcinomas showed more enhancement than adjacent renal parenchyma was seen between 16 to 57 s (mean, 30 s) and 51 to 252 s (mean, 82 s) after injection. the duration of enhancement was 13 to 208 s (mean, 80 s). one angiomyolipoma showed heterogeneous enhancement from 27 s to 84 s. all transitional cell carcinomas showed no definite enhancement. three acute pyelonephritis and one traumatic renal contusion showed focal perfusion defects that were not apparent on pre-contrast scan. conclusion: cha us with microbubble contrast agent is an effective us technique in the evaluation of both tumour vascularity and renal perfusion abnormality. withdrawn by author (5). all patients were followed-up clinically, biochemically and by ct both early (< 7 days) and at 6 monthly intervals. results: one patient demonstrated a minor internal injury to the psoas muscle. no significant rise in creatinine was noted post-procedurally in 7/8 patients (mean rise: 3.6 µmol/l; range −8.1 to 19.8 µmol/l). one patient with von hippel-lindau syndrome had 4 tumours treated in a single kidney. there has been a gradual post-treatment rise in creatinine, from 130 to 233 µmol/l. early post-procedural ct demonstrated complete tumour necrosis in 9/11 tumours. two tumours (3.0 and 5.5 cm) required additional ct-guided treatments of residual crescents of viable tumour. follow-up (mean 7.4 months, 82 patient months, range 1 -17 months) revealed no evidence of local or distant recurrence. conclusions: early experience suggests rfa is a safe, well-tolerated, and minimally invasive therapy for renal cell carcinoma. in the era of nephron-sparing surgery rfa may have a role in the management of small problematic rcc. drug-induced mr-pyelography in the evaluation of renal collecting system malformations, tumours, renal calculi and obstructed renal ureters m. di girolamo 1 , a. grossi 1 , a. roncacci 1 , r. di nardo 1 , l. azzarri 2 , v. david 1 ; 1 rome/it, 2 grottaferrata/it purpose: drug-induced mr-pyelography (dimrp) is a diagnostic technique for the evaluation of obstructed and non-obstructed renal collecting systems. a c d e f 178 method and materials: 10 normal volunteers and 135 patients underwent dimrp. the examination was performed with a 3-d non-breath-holding fat-suppressed turbose sequence (tr: 3000 ms; te: 700 ms; n.ex.: 6; etl: 128; acq.time: 9 min) on coronal planes. these acquisitions were post-processed with a mip algorithm. to obtain maximum filling of the collecting system, the diuresis was pharmacologically induced by administering i.v. 250 ml of saline solution together with 20 mg i.v. of furosemide. one mr acquisition was performed 10 minutes after diuresis induction. 5 normal volunteers and 115 patients had undergone ivu and ascending pyelography was performed in 15 cases. results: we always obtained an excellent anatomical evaluation of the renal collecting system that was considered comparable to that obtained with ivu. it was always possible to study the renal collecting system malformations, even in patients with known contraindication for i.v. administration of contrast media. renal calculi larger than 2 mm were always identified by the analysis of 3d coronal scans. dimrp is particularly important for the detection of ureteral stones. 24 patients had non-functioning kidneys on ivu: in 23 cases with obstructive uropathy the site of the obstruction was determined and using conventional mri, abdominal plain radiograph and urinary cytology, the cause was always determined. conclusions: dimrp is recommended for patients with contraindications for i.v. administration of contrast agents; in non-functioning kidneys is considered the best diagnostic imaging modality to perform after us, especially in case of ureteral obstruction. filling defect artefacts in magnetic resonance urography g. girish, w.k. chooi, s.k. morcos; sheffield/gb purpose: (1) assessing the prevalence of filling defect artefacts (fda) in magnetic resonance urography (mru). (2) presenting the characteristic features of fda, that can differentiate them from true filling defects (tfd). method/materials: mru's of 45 patients with neurogenic bladder dysfunction were reviewed to assess the prevalence of filling defects within the pelvicalycyal system (pcs) and ureter. heavily t2 weighted fast spin echo techniques with fat saturation were used. these included axial images 5 mm (thick)/2 mm (gap), slab images (75 mm thick) of retroperitoneum and volume coronal imaging of kidneys and retroperitoneum with 3d and maximum intensity projections. dilatation of pelvicalyceal system as well as features of filling defects (central, eccentric, complete) were graded. clinical course and plain films were reviewed to determine significance of filling defects. results: filling defects were present in 27 pts (60 %). prevalence of filling defect artefacts amounts to 22/45 (49 %) and that of true filling defects was 11 %. the following are the characteristic features of fda that differentiate them from true filling defects: (1) vast majority of fda occurred in axial t2 weighted images and very rarely in slab and maximum intensity projection images. (2) fda's were usually small, centrally placed (94 %) and noted mostly in pelvicalyceal system (41.8 %) and the upper third of the ureter (39.5 %). (3) true filling defects were bigger in size and seen in two or more image sequences. conclusions: (1) awareness of these artefacts will avoid misinterpretation and prevent further unnecessary investigations or interventions. (2) when in doubt, correlation is suggested with other mri sequences, plain abdomen radiograph and clinical presentation. purpose: differentiation of healthy kidneys from those with haemodynamically significant stenosis or those with renoparenchymal disease. methods and materials: in 79 kidneys with suspected renal artery stenosis (confirmed stenosis n = 38, no stenosis found n = 41) or parenchymal disease (n = 30) renal flow and perfusion measurements as well as mr angiography were performed. flow measurements were done using an ecg gated cine phase flash sequence, perfusion was measured using an arterial spin labeling fair sequence. contrast enhanced mr angiography was done with a fast 3d gre sequence in a single breath hold. data was compared to that from 31 healthy volunteer kidneys and correlated to serum creatinin levels. results: substantial differences in mean renal artery flow and perfusion were found in kidneys with renal artery stenosis or parenchymal disease compared to healthy kidneys. in addition perfusion measurements showed significant agreement to 99 tc renal scintigraphy. using the discriminant analysis we were able to achieve a specificity of 79 % and a sensitivity of 90 % in terms of separating healthy kidneys from those with either vascular, parenchymal or combined disease. on the contrary, renal volume measurements did not show any significant differences. the combination of mr angiography, flow measurements and mr perfusion measurements offers a comprehensive way for assessment of both renovascular and renoparenchymal disease. it offers a non invasive way to separate normal individuals from either those with haemodynamically significant stenosis or those with underlying renoparenchymal damage. functional imaging of the kidneys using pure o2 inhalation r.a. jones, n. grenier, m. ries, c.t.w. moonen; bordeaux/fr purpose: because of its paramagnetic effects, pure o2 reduces the t1 of lungs. our purpose was to investigate the intra-renal signal intensity changes induced by the dissolved molecular oxygen in blood. materials and methods: nine volunteers were imaged while breathing normal atmosphere and pure o2 alternatively with an inversion prepared, segmented, half fourier tse sequence for t1 measurement and a multiple echo gradient echo sequence for t2* measurement. roi were positioned on the cortex, the medulla, the liver and the spleen. subtraction and cross-correlation images were also obtained after dynamic t1w acquisitions during three successive phases (air-o2air) results: the only significant intrarenal change was the reduction of t1 within cortex while o2 breathing (882 ± 59 ms vs 829 ± 70 ms, p = 0.0001) and a reduction of t1 within the spleen. neither significant change of t1 within the medulla and the liver nor significant change of t2*, in all organs, were observed. the effect was not related to flow because no change was noted between selective and nonselective inversion pulses. the observed t1 change induced by pure o2 within the cortex is related to the high arterial blood volume without o2 consumption. the absence of change within the medulla is probably related to the high o2 consumption and shunting effect. is to distinguish it from other entities for prognostic and management purposes. it is the unusual cases of lch that often create a particular diagnostic dilemma. however, careful analysis of the radiographs including the site of involvement and behavior, coupled with a detailed demographic and clinical history, can be suggestive of the diagnosis. methods and materials: 542 consultation cases, including 730 skeletal sites, submitted to the armed forces institute of pathology, were analyzed for unusual manifestations of lch. five unusual manifestations were evaluated including cortical involvement, disease at birth, presence of fluid levels, circumferential "pencilling", and involvement of the mandibular inferior cortex. results: unusual demographics included 46 non-caucasian cases. unusual sites of involvement were the epiphysis (2), apophysis (1), cervical spine (13), posterior elements of the spine (8), soft tissues (2), cortical involvement (6), and atypical locations (sternum, middle and distal phalanx). unusual manifestations included crossing the physis (1), crossing calvarial sutures (6), fluid levels (2), erosion of the inferior mandibular cortex (1), transforming from sclerotic to lytic (2), brain invasion (1), circumferential "pencilling" (5), sequestrum in noncalvarial sites (2), unusual size of a lesion (1), and bone expansion (4). these unusual appearances may mimic other diseases including paget disease, fibrous dysplasia, ewing sarcoma, coxa vara, and metaphysitis. conclusion: recognition of the spectrum of unusual manifestations of lch is helpful in allowing distinction from other differential diagnoses. the imaging of 6 patients (4 female, 2 male; age range 13 -55 a, mean age 24.8 a) with biopsy-proved subperiosteal aneurysmal bone cyst was reviewed. radiologic studies inculuded radiographs (n = 6), ct (n = 2), and mr images (n = 6). evaluation included patient demographics, lesion location and size, radiographic features, and intrinsic characteristics on ct and mr images. review of histologic specimens was carried out by an experienced musculoskeletal pathologist. results: all lesions were located at the surface of long tubular bones (femur 3, tibia 2, humerus 1); three involved the diaphysis, two the dia-/metaphysis, and one exclusively the metaphysis. lesion size ranged from 2.5 to 6 cm in maximum diameter. radiographs and ct images always showed a superficial bone defect, which on radiographs demonstrated irregular margins in four cases. all lesions caused an interrupted periosteal reaction (shell 3, trabeculated shell 1, codman angle 2). mr images always showed a multicystic appearance with hypointense rim, contrast-enhancing cyst walls, and fluid levels. edema of adjacent soft tissues was present in all cases. conclusion: aneurysmal bone cysts in a subperiosteal location can demonstrate an aggressive radiographic appearance. mr imaging appears to be most valuable in differential diagnosis, since it can demonstrate typical morphological features of the underlying process. rib sonography: can we obtain more information than with conventional radiologic studies? s.h. paik, m. chung, y. yoon, j.-g. im, j. ahn; seoul/kr purpose: we performed this study to evaluate whether high-resolution ultrasonography can give more information concerning rib lesions than plain radiography or bone scintigraphy. method: we selected 20 patients with high uptake rib lesion on bone scintigraphy. plain radiography and rib ultrasonography were performed on these patients. ultrasonography was performed using linear 12.5 mhz transducer. we analyzed cortical disruption, mass, callus formation, hematoma, deformity and bone destruction by rib ultrasonography. we considered radiologic findings and clinical information in the diagnosis. purpose: innovative therapeutic protocols of musculoskeletal tumors include neoadjuvant and antiangiogenic approaches. functional tumor imaging including dynamic contrast enhanced (dce) mri and fdg-pet seem to be capable techniques to evaluate ongoing response during therapy. aim of this study is to assess the clinical utility of dce-mri in such cases. materials and methods: within a therapeutic phase i protocol, dce-mri was included as a surrogate marker to assess the tumor prior and during therapy. after neoadjuvant treatment, surgical resection was performed with histological correlation as well as detailed micro-array analysis. mri was performed on a 1.5 t clinical system using optimized fast 3d gradient echo sequences. standard gd-chelates were given at 0.1 mmol/kg bw and the studies post processed using a pc based environment facilitating quantification and visualization. results: dce-mri could be performed and quantified in all cases. the enhancement patterns observed revealed a wide variability with areas of high uptake and rapid washout correlating to active tumor areas and regions of contrast agent trapping seen in less vascularized, necrotic areas. areas with decreased enhancement correlate with response to therapy. in more than 1/3 of the cases, active tumor areas were only detected by functional imaging, not seen otherwise and confirmed histologically. conclusion: functional imaging is an essential tool to assess ongoing therapy in musculoskeletal tumors, it is robust and can be used as surrogate marker in therapeutic trials. whole body mr imaging with a rolling we assessed a single whole-body mri examination for detection and staging of metastases and compared the results with findings of nuclear bone scintigraphy and ct examination. materials and methods: 37 patients with known primary malignancies were included in this study. patients were examined on a mr system (siemens sonata) equipped with a rolling table platform (bodysurf) allowing the swift movement of the patient through the magnet bore as well as through a phased array surface coil. t1w 3d vibe data sets were collected in five stations following the intravenous application of paramagnetic contrast covering the body from skull to the knees. the chest and abdomen were imaged with t2 haste and t1 flash before contrast. mean examination time amounted to 15 (± 3) minutes. mri findings were compared to results obtained with skeletal bone scintigraphy and ct-scans of the abdomen and chest. results: all pulmonary and hepatic metastases > 6 mm detected by ct were identified by whole-body mri. skeletal scintigraphy detected bone metastases in nineteen patients. in eighteen patients mri confirmed these lesions. in one patients presenting with bone metastases in the ribs mri failed to reveal the osseous lesions, whereas in four other patients mri detected bone metastases missed by scintigraphy and eventually confirmed by biopsy. conclusion: vibe whole-body mri screening for metastases correlated well with ct and scintigraphy. use of the rolling table platform provides the basis for a comprehensive whole-body exam in merely 15 minutes. early therapeutic evaluation of bone metastases from breast cancer: histopathology, mr imaging and ct i. ciray, g.k.o. åström, h. lindman, h. nordgren, j. bergh, h.k. ahlström; uppsala/se purpose: evaluation of early therapeutic changes in breast cancer bone metastases using various parameters of mri, ct and histopathology. materials and methods: 20 metastatic bone lesions in 17 breast cancer patients were examined with mri and ct, and were subsequently biopsied under ct-guidance before initiation of chemotherapy and 6 courses later (median). the changes in size and signal intensity (si) on t1-weighted and long te inversion-recovery turbo-spin-echo (long te ir-tse) mr sequences and in density on ct were measured. the histopathological changes in the amount of tumor and fat cells, in the density of fibrosis and in the trabecular bone were evaluated. results: the amount of tumor cells was decreased in 16 (responding) and was increased in 4 lesions (progressive). si could not be measured in one responding lesion. there was no change in the tumor size and si on t1-weighted sequence in 8 of 15 responding lesions. there was an increase in si on long te ir-tse sequence of 11 of 15 responding lesions. two progressive lesions remained unchanged, one increased in size and the other in si on t1-weighted sequence with no alteration on long te ir-tse sequence. density increased in 12 of 16 responding lesions and in 3 of the 4 progressive lesions on ct images. conclusion: an increase in si in metastatic lesions on long te ir-tse sequence may indicate an early therapeutic response while a t1-weighted sequence is of limited value. an increased density on ct can be measured in both responding and progressive lesions. belgian soft tissue neoplasm registry (bstnr) j.l. gielen, p.m. parizel, a.m.a. de schepper; antwerp/be introduction and objectives: based on epidemiological data from the usa, the total number of new cases of malignant soft tissue tumors in belgium is estimated at 200 per year. this low incidence and the overmedicalization with numerous university hospitals and large general hospitals with mr-equipment available limits the number of cases seen in each hospital and per year and hampers the gaining of expertise in this field. to cope with these disadvantages, the department of radiology of the university hospital of antwerp in cooperation with all mr centers (47) in belgium created a belgian soft tissue neoplasm registry ("bstnr"), starting the registration on january 1, 2001. material and methods: internationally accepted standard procedures are used in the development of the electronic database in order to guarantee future and systematic availability of the data. a clinical and statistical indexing of biomedical imaging and image-related information based on the attributes of image acquisition procedures and on the diagnostic image obeservations is applied. in this way, an electronic image data selection by image related, acquisition related as well as disease related criteria will be possible. results: until now 330 cases of soft tissue tumor sent by the cooperating centers have been registered. the bstnr achieves 3 objectives: (1) to provide the referring radiologist with a second opinion about diagnosis and differential diagnosis within 48 hours; (2) to create a digital archive at the disposal of national or foreign researchers; (3) to obtain epidemiological information about the prevalence of stt in belgium. the vascularity in malignant lesions was significantly greater than in benign (benign: 0.96 m%cda, malignant: 5.88 m%cda, p < 0.001). vascular heterogeneity (sd%cda) showed similar results, albeit less significant (p < 0.01). there was a monotonic linear relationship between m%cda and sd%cda with increasing tumor grade. best separation was achieved between benign, intermediate and high grade (p < 0.001). there was a clear correlation between increasing tumor grade and higher vascularity (m%cda). separation between benign and low grade was possible, but less significant (p < 0.08). this correlates to histopathology, where vascular markers are low -similar to benign -for this group. conclusions: qpd shows the potential to differentiate benign from malignant softtissue tumors. it can measure increasing vascularity and vascular heterogeneity and reliably predict higher-grade malignancy. qpd therefore is a promising new non-invasive method both diagnostically and prognostically. after gd administration there was no significant enhancement of the nodules. our findings were then confirmed in all cases with the exception of one patient in whom arthroscopy did not find the lesion as it was located outside the synovial membrane. conclusion: mr provides a good and detailed evaluation of the different recesses of the knee and demonstrates high diagnostic accuracy in the evaluation of pvns enabling lesion characterization. to verify the benefits introduced by a new cr system for digital mammography, using a dual-side reader and transparent imaging plates. methods and materials: two kinds of breast phantom have been used to compare the performance of two different cr systems employed in digital mammography. they are the high resolution imaging plate hr-v coupled with the fcr 5000-r reading unit and the last fuji cr system including transparent ips and a dual-side reader. this detects also the laser-stimulated light propagating toward the back of the plate, which was previously removed from the hr-v plates. consequently, the detection efficiency and the signal-to-noise ratio are increased, resulting in a better image quality. phantom images have been taken for different values of entrance dose. the images produced by the two cr systems have been scored by three expert observers and the results compared in terms of both contrast-detail curves and detail visibility. the benefits of the new cr system are emphasized by the contrastdetail curves and the cirs phantom scoring. the new system permits a dose reduction of about 30 %. the spatial resolution is heavily better and exceeds 7 lp/mm for the new system, while is slightly lower than 5 lp/mm for the previous. the contrast-detail analysis shows a gain of 13 % in disk size and 6 % in contrast. saturday purpose: dry and conventional laser printers have become an equipment for producing images from digital mammography. purpose of our study was to compare image quality of a dry versus a conventional laser imager for digital mammography. materials and methods: two view mammograms of 80 patients with different breast composition (pattern i -iv) and mammograms of 44 patients with pathologic lesions were printed on a conventional wet laser imager (agfa scopixlr 5200) and a dry laser imager (kodak dryview laserimager 8600). all examinations were performed on a full field digital system (senographe 2000d, ge). two radiologists independently scored images side by side on the following aspects: delimitation of the skin, subcutis, musculature, glandular tissue, fat, and calcification. each comparative aspect was rated by using a five-level scale. in case of a breast lesion (masses n = 22, calcifications n = 22) lesions characteristics and resulting birads-classification were assessed. additionally, artefacts were noted. objective comparison was performed in accordance to instructions of the producers. results: a total of 248 digital mammograms were assessed. breast parenchyma of different composition and pathologic lesions were equally displayed by dry and conventional laser imagers. dry laser images showed significantly more artefacts at the film surface (73.6 % vs. 22.6 %, p < 0.001). however, these artefacts did not influence image interpretation. conclusion: compared to a conventional wet laser imager, a dry laser imager is capable of producing images of equal quality. the dry laser imager offers advantages with regard to handling, installation, maintenance, and environmental criteria. full-field digital mammography and patient dose reduction g. gennaro, c. di maggio, e. bellan; padova/it purpose: to estimate the dose reduction factor allowed by the full-field digital mammography. methods and materials: exposure parameters and breast characteristics have been collected from 300 screen-film (ge senographe dmr) and 300 digital mammograms (ge senographe 2000d) randomly distributed. from the track/filter combination, kv and mas values and breast thickness we estimated the entrance skin dose by using the ipem (institute of physics and engineering in medicine) data. results: data analysis shows a mean dose reduction of 32 % for the digital system. it is mainly due to the larger dynamic range of the digital detector, which permits the use of rh/rh combination in almost 60 % of considered cases without image quality degradation. in screen/film the mo track was needed in most cases, while the rh/rh choice was convenient only for 20 %. moreover, by analysing data as a function of breast thickness, the digital system shows an extra dose reduction for each track/filter combination due to its higher quantum efficiency compared with the screen/film system. conclusion: the digital system delivers an entrance skin dose 30 % lower than the screen-film system. a quality control phantom for full field digital mammography: first experience p. baldelli 1 , c. di maggio 2 , m. gambaccini 1 , g. gennaro 2 , d. giannopoulou 1 , a. taibi 1 ; 1 ferrara/it, 2 padova/it purpose: to verify the usefulness of a simple phantom to monitor some quality control parameters in full field digital mammography. methods and materials: a phantom has been developed for periodic quality control measurements on a full field digital mammography system ge senographe 2000d). the phantom allowed us to verify the detector linearity, uniformity, contrast and spatial resolution and the reproducibility and stability of both the detector and the automatic exposure control system (aop). the system stability was daily controlled by using four different exposure settings. the raw images have been used for data analysis. results have shown that the presented phantom is able to give information on the detector characteristics and can detect any problem related to the system stability. the collected data have verified that the detector response is linear with a high correlation degree, for both the mo/mo and rh/rh combinations. the non-uniformity was lower than a few percent. the detector response variability was lower than 1 % when manual exposure is employed while the fluctuation in the aop choices was less than 5 % for the three available settings (std, cnt and dose). the phantom used was found useful to check the key detector performance parameters and the system stability. it is fast and easy to use, as required for a quality control. full-field digital mammography -comparison of hardcopy versus softcopy reading s. obenauer, s. luftner-nagel, k.-p. hermann, u. fischer, e. grabbe; göttingen/de purpose: to evaluate the feasibility of using a mammography workstation for the interpretation of digital mammography images in comparison to the results of hardcopy reading. materials: mammograms performed on a digital full-field mammography system (senographe 2000d, ge) of 50 patients were evaluated as softcopies and hardcopies by 2 readers. 19 of the 50 patients had histologically proven carcinomas, the remainder showed no malignancies after a follow-up of 2 years. the softcopies were displayed on a 2.5 × 2k monitor, the hardcopies were printed on a laser printer (scopix, agfa). the mammograms were evaluated with respect to image quality, artefacts, presence of masses and microcalcifications. all detected lesions were categorized according to the bi-rads classification. the time for this evaluation was written down. post-processing in softcopy evaluation (windowing and levelling, zooming, inversion) and additional views like spot views in both methods were also timed. results: diagnostic accuracy of the classification of the malignant lesions according to the bi-rads categories showed no significant differences between soft-and hardcopy. more time was needed for the evaluation of softcopies than for hardcopies. additional views were recommended in hardcopy more often than in softcopy evaluation (26 versus 21 for reader 1, 20 versus 18 for reader 2). postprocessing was used in 9 cases by reader 1 and in all cases by reader 2. the evaluation of softcopies needs more time than those of hardcopies, especially when post-processing is performed. however, it seems that softcopy reading reduces the need of additional views without change of diagnostic accuracy. full-field digital mammography (ffdm): intrapatient comparison of direct magnification versus monitor zooming u. fischer, f. baum, s. obenauer, s. luftner-nagel, d. von heyden, e. grabbe; göttingen/de purpose: our goal was to compare digital magnification mammograms with images zoomed from the digital contact mammogram in patients with microcalcifications. materials and methods: 55 patients with 57 microcalcification clusters were evaluated with a ffdm system (senographe 2000d, ge). in addition to a digital contact mammogram, a digital magnification mammogram (factor 1.8) and two images zoomed from contact mammogram with magnification factors of 1.8 and 5 -8 were obtained in each patient. the image quality (1 = perfect to 5 = inadequate) and the characterisation of microcalcifications (bi-rads™ 2 -5) were evaluated by 4 readers. the results were compared to histopathologic findings in 35 patients (37 lesions) and follow-up in 20 patients. in patients with mammographic microcalcifications, monitor zooming of the digital contact mammogram is equivalent to direct magnification ffdm. therefore, monitor zooming allows a reduction of the radiation exposure and an optimization of the work-flow. b a c d e f 182 full-field digital mammography -comparison of different exposure protocols s. obenauer, k.-p. hermann, e. grabbe; göttingen/de purpose: to evaluate the potential of radiation dose reduction in full-field digital mammography (ffdm) compared to screen-film mammography (sfm). materials and methods: ffdm was performed by using an amorphous silicon detector with a cesium iodide scintillator layer (senographe 2000 d, ge). sfm was performed by using a state-of-the-art system (senographe dmr, ge) combined with a dedicated screen-film. an anthropomorphic breast phantom with superimposed egg shell fragments (50 -200 µm) was used to evaluate the detectability of microcalcifications. contact mammograms and magnification views (m = 1.8) performed with both the digital and the screen-film system were compared. images were exposed automatically (aec mode) by using a molybdenum/ molybdenum (mo/mo) anode-filter-combination, 28 kvp and 63 mas (protocol a, dose ~100 %). dose reduction in digital mammography was achieved by using protocol b with mo/rh and 31 kvp (dose ~60 %) and protocol c with rh/rh and 32 kvp (dose ~40 %). the detectability of microcalcifications was assessed by 3 well-experienced readers with a confidence level ranging from 1 to 5. a receiver operating characteristic (roc) analysis was performed. results: in protocol a the area under the roc-curve (az) for contact views performed by the screen-film system was 0.63 and for those performed with the ffdm system 0.68. for the conventional and digital magnification views az was 0.70 and 0.79, respectively. for the protocol b/c the az value reached 0.74/0.65 for the contact views, and 0.81/0.77 for magnification views. conclusions: compared to screen-film mammography the digital mammography system allows an equivalent detection rate of microcalcifications at a slightly lower radiation exposure. comparison between analogue and digital reading performance in screening mammography a.a.j. roelofs 1 , s. van woudenberg 1 , j.h.c.l. hendriks 1 , a. boedicker 2 , c.j.g. evertsz 2 , n. karssemeijer 1 ; 1 nijmegen/nl, 2 bremen/de purpose: to investigate the use of a digital reading station for screening mammography and to compare results with analogue reading. materials and methods: 500 cases, 125 screen-detected cancers, 125 interval cancers, and 250 non-cancers, were collected from the dutch breast cancer screening program. for each patient, mammograms from two prior screening rounds were collected in addition to diagnostic mammograms. diagnostic mammograms and pathology reports were used to establish ground truth. all mammograms were digitised and processed by a cad system (r2 imagechecker, los altos, ca). experienced screening radiologists participated in a study in which each of them read one film the two prior screening mammograms of all 500 cases in randomised order and blinded to the detection results. the readers were asked to annotate potential abnormalities, and estimate the likelihood of malignancy of each finding they reported. a subset of 100 cases with visible cancers on the prior mammograms and 175 non-cancers were randomly selected. this subset was reread on a dedicated workstation we are developing for screening mammography, by a subset of 5 radiologists 1.5 years after their first reading. the workstation was has two highresolution monitors (barco). results were evaluated using roc analysis and compared to the results obtained with analogue reading. results: no significant difference in screening performance between analogue and digital reading was found, provided cad was available for microcalcification detection. conclusion: using a dedicated reading station for mammography, soft-copy reading of digital mammograms in screening is possible without loss of quality. management through pacs and digital telemammography a. grueva, m. mahesh; baltimore, md/us purpose: digital telemammography (dtmg) is rapidly developing into a mature technology due to advances in digital image acquisition, database design and communications infrastructure. current film-screen mammography has a number of inherent limitations, which can be overcome effectively with dtmg. since acquisition display and storage can be optimized independently, screening sensitivity is increased. the initial goal was to provide dtmg in a screening environment with radiologist teleconsultation. technical issues in planning the establishment of dtmg screening infrastructure include network design, image compression, archiving, and special viewing station. displays, picture archiving and communications systems (pacs), image storage and processing architecture are examined, all at a concrete functional level of dtmg. a component-based approach to software development is described and is validated for each of the abstract system requirements for future breast screening computing environments and information management. research approach is telediagnosis, teleconsultation, and telemanagement. results: the implementation of this architecture is described and analysed from image and clinical data. workstations and comprehensive database development is the most difficult and expensive technology for teleimaging and information management. full-field dtmg with technical components, study protocols, and preliminary results of a study are analysed. conclusion: the study shows the dtmg system to be successful in fulfilling the goals, dtmg is also considered in the general context of an integrated regional health telematics network, emphasizing its role and its interaction with other information and networking services for decision treatment strategies. dtmg standard needs to be further evaluated for quality of telemammography and for cost effectiveness. material & methods: seventeen subjects affected by drug resistant cryptogenic partial epilepsy underwent long-term computer assisted video-eeg monitoring and dsc mri in the same day. mri data were compared with eeg findings, and accuracy of perfusional mri was analyzed considering the spiking rate and the type of epilepsy. results: dsc mri showed a relevant asymmetry in a region compared to the contralateral areas in 8 (47 %) out in 17 patients, suggesting the presence of a relative focal hyperperfusional pattern. this area corresponded to the epileptogenic focus or to the hemisphere involved. in the genesis of epileptic discharges in 7 (77.7 %) out of 9 patients showing a higher spiking rate (hsr) conversely, all patients with a low spiking rate (lsr group) did not show significant asymmetry indexes in perfusional pattern. moreover we found that dsc-mri seems to be very sensitive for detection of epileptogenic focus in patients affected by temporal lobe epilepsy (tle). in 5 (83.3 %) of 6 hsr-tle patients dsc-mri showed a relative hyperperfusion region concordant with eeg focus or hemisphere involved in the genesis of epileptic discharges. conclusion: perfusional mri is a noninvasive procedure that provides useful additional information to better localize the epileptogenic zone, when the interictal epileptiform activity is sufficiently elevated. saturday materials and methods: eleven patients (6 females, 5 males), affected by intractable epilepsy were included. brain lesions were: 4 mesial sclerosis, 3 brain tumors, 2 cortical gliosis, 1 encephalomalacia, 1 cortical displasia. mri studies were performed on a 1.5 t scanner. fmri volumes were acquired according to a block paradigm of 6 alternating (rest-task) phases, including 10 scans for each phase. bold contrast images were obtained by echo-planar fid sequences (fov = 250, tr = 0.8 ms, te = 54 ms, thickness 3 mm). high resolution mprage sequence, covering the whole head, served as basis for the integration of anatomical, meg and fmri data. magnetic field recordings were performed using a whole head meg system, equipped with 165 integrated squid magnetometers. the location of magnetic field source during intercritical activity identified by meg was found to be in close proximity to the lesion in 6 cases. a displacement of the source with respect to the lesion was found in two cases. in three cases meg was not able to reliably locate a source. functional markers (sensory areas identified by meg and motor areas identified by fmri) where in accordance with the known cortical organization. conclusion: these preliminary results are encouraging toward the use of morphological mri, fmri and meg in the identification of the functional areas within the affected region. quantitative 1 h mrs investigations of the regional and age dependences of metabolite content in the human brain v.a. rogozhyn, z.z. rozhkova; kiev/ua purpose: the aim of our work is a quantitative study of the age and regional dependences of cerebral metabolism using primary spectral parameters of main metabolites. materials and methods: 65 healthy volunteers (age range 25 -75) were examined by 1.5 t magnetom vision (siemens). spectra were obtained in two locations of each brain hemisphere: in the occiput (gray matter), and in the forehead (white matter). all spectra were recorded with the steam sequence: tr/te 1365/ 135; 1500/270, 20 ms; voi = 2 × 2 × 2 cm 3 . results: for the normal brains the peak areas of 1 h mrs signals from n-acetylaspartic acid (naa), total creatine (cr) and choline (cho) were obtained. we define the metabolite concentration as the ratio of the peak area to the sum of all the peak areas. we have found a "fine structure" of the average metabolite concentrations which depends on the relative values of peak areas. to describe this fine structure we introduce the triad t* = {a, b, c}, where a, b, and c are the unequal peak areas of the signals from naa, cr and cho, respectively. we believe that each of the three peak areas takes three values: 1, 2 and 3, to represent symbolically six possible spectral configurations: t = {1*, 2*, 1/4, 6*}. the triads 1* = {3, 2, 1} and 2* = {3, 1, 2}denote the most frequent configurations in the spectra. metabolic variations with age are especially noticeable in the left forehead for them. we have built spatial maps of the age dependences of metabolite content in the normal brain. our results serve as the background for the description of brain pathologies. mrs data for the quantitative description of the brain metabolism in patients with brain tumors v.a. rogozhyn, z.z. rozhkova; kiev/ua purpose: the aim of our study is to propose the quantitative indicators of metabolic changes in the human brain and brain pathologies. methods and materials: 72 patients with gliomas (of various grades of anaplasty) or meningiomas, together with 65 healthy volunteers were examined using a 1.5 t magnetom vision (siemens). all spectra were recorded in 4 brain locations with the steam sequence: tr/te 1365/135; 1500/270, 20 ms, voi = 2 × 2 × 2 cm 3 . the peak brain areas of 1 h mrs signals from n-acetylaspartic acid (naa), total creatine (cr) and choline (cho) were obtained for all subjects. we introduce the metabolite concentration as the ratio of the peak area to the sum of all the peak areas. we describe the metabolic state of the brain in each voi by the triad t* = {a, b, c}, where a, b and c are the unequal peak areas of the signals from naa, cr and cho, respectively. each of the areas takes three values: 1, 2 and 3, to give six symbolic spectral configurations: 1* = {3, 2, 1}, 2* = {3, 1, 2}, 3* = {2, 3, 1}, 4* = {1, 2, 3}, 5* = {2, 1, 3} and 6* = {1, 3, 2}. the frequency of appearing each of the triads in spectra depends on the brain state. the triads 1* and 2* denote the most frequent configurations in the spectra. and the triads 5* and 6* we observed only in the pathological brains: both in the tumor location and in the intact tissue. we give a quantitative classification of the brain state by creating spatial triad maps. this essentially amplifies mri examinations of patients with brain pathologies. proton mr spectroscopic imaging and fdg-pet in irradiated glial brain tumors h.-p.w. schlemmer 1 , m.p. lichy 1 , m. henze 1 , p. bachert 1 , s. sammet 1 , a.a. maudsley 2 , j. debus 1 , g. van kaick 1 ; 1 heidelberg/de, 2 san francisco, ca/us purpose: to assess the clinical utility of proton mr spectroscopic imaging ( 1 h mrsi) for evaluating suspicious brain lesions after radiotherapy of glial brain tumors. methods and materials: in this ongoing study 17 patients with irradiated gliomas (who grade 2, n = 12; grade 3, n = 4; grade 4, n = 1) were examined by 1 h mrsi and positron emission tomography with [ 18 f]-2-fluoro-2-deoxy-d-glucose (fdg-pet) to evaluate suspicious brain lesions. the mr protocol included multiplanar t2w turbo spin echo mri, 1 h mrsi (press, tr/te 1500/135 ms; spatial resolution 8.75 × 8.75 × 15.0 mm 3 ), and pre-and post contrast t1w-spin echo mri. relative signal intensity ratios of choline-containing compounds (cho), total creatine (cr), and n-acetyl-aspartate (naa) were determined both in lesions and in contralateral normal tissue using the program sitools. fdg-standard uptake values of the lesions were obtained from pet examinations and were related to normal gray (suvgr) and white matter (suvwm). lesions were classified as neoplastic (p) and non-neoplastic (np) based on mri follow-up or biopsy. results: significantly enhanced intensity ratios cho/cr and cho/naa were observed in p compared to np (p = 0.05 for both ratios) and compared to the contralateral normal tissue (p = 0.01 and p = 0.00003, respectively). in all patients cho/naa and cho/cr correlated with fdg-standard uptake values, e.g., cho/cr and suvwm: r = 0.58, p = 0.01. conclusion: parameters from 1 h mrsi are helpful for differentiating neoplastic from non-neoplastic lesions after brain tumor radiotherapy. moreover, the correlation with glucose metabolism indicates that mrs parameters may also indicate tumor grade. proton magnetic resonance spectroscopy ( 1 h mrs) of brain meningiomas at long echo time c. majós, j. alonso, c. arús, c. aguilera, m. serrallonga, j.j. acebes, j. cabiol, j. gili; barcelona/es purpose: to assess the utility of 1 h mrs in the categorization of meningioma with especial emphasis in their differentiation with respect to other brain tumors. methods and materials: single voxel "in vivo" 1 h mrs at an echo time of 136 ms was carried out in 37 patients with meningioma. a data-set of 93 spectroscopic exams of brain tumors acquired under identical conditions was used for comparison. this data-set included 15 low-grade astrocytomas, 14 anaplastic astrocytomas, 30 glioblastomas and 34 metastases. fitted area of seven resonances of interest (lipids at 1.30 ppm, lact at 1.35 ppm, ala at 1.45 ppm, nac at 2.02 ppm, glx at 2.35 ppm, cr at 3.03 ppm and cho at 3.20 ppm) was calculated. we searched for the resonances that better discriminated meningioma from every other tumor type. an empirical algorithm for bilateral discrimination between meningioma and the other tumors was produced on the basis of these findings. the performance of the algorithm was assessed by means of the leave-one-out method. results: high ala, low or absent lipids, high glx, low cr and high cho were found to be the most characteristic trends of meningioma. when applied in pair-wise discrimination with the other tumors, these findings produced 91 % successful classification outputs, 7 % unsuccessful and 2 % "unclassifiable". conclusion: single voxel 1 h mrs provides biochemical information from meningioma that can be satisfactorily applied in its categorization. according to our results, high ala, glx and cho, as well as low lipids and cr are characteristic spectroscopic signatures of meningioma. a c d e f 184 materials and methods: 22 patients who underwent supratentorial cortical/subcortical infarction were studied, 3 months after the onset of clinical symptoms of ischemic stroke the mr studies were performed on 1.5 t system. the results of spectra approximation (presented as metabolite ratios: naa/cr, naa/sum, chol/cr, chol/naa, lac/naa, lac/sum, lip/naa and lip/sum were subjected to statistical analysis. mr spectra were recorded from a tissue adjacent to area of infarction and normal appearing brain region: contra and ipsilateral internal capsule. spectra from stroke patients were compared with control group from 32 healthy volunteers recorded with the same techniques. results: the statistical analysis revealed significant differences between data obtained from the various regions in the patients who had undergone ischemic stroke and between the infarcted and control groups. proton mr spectroscopy detects changes in cerebral metabolites levels also in apparently normal regions. in contralateral brain regions, as well as in the internal capsule we have noticed significant reduction in choline, creatine and naa; we found correlation between clinical outcome and mri/mrs findings. conclusions: proton mrs is a very useful tool for evaluating major changes in cerebral metabolite levels in infarcted patients. our preliminary results of h mrs, mri and clinical data support the idea that metabolic leasions distant from the infarcted tissue can be responsible for clinical course and have predictive value. fingerprinting of the etiological agent in brain abscesses using proton mr spectroscopy m. garg jr., r.k. gupta, m. hussain, k.n. prasad, s. chawla, r. kumar, n. hussain; lucknow/in purpose: in vivo proton mr spectroscopy data was analyzed from 70 cases of proven brain abscess(s) to look for the possible metabolites that may act as marker for the specific group of bacteria. methods and materials: data from 70 patianets with proven brain abscess by pus aspiration, bacterial culture, and histopathology of the wall were analyzed to look for spectral pattern relationship with the bacterial culture. in vivo data was obtained using single voxel steam (te = 20 ms) and se (te = 135 ms) sequences. results: the in vivo spectra show the following 4 patterns: • abscesses in 4 patients showing only lipids (1.33 ppm, 0.9 ppm) and without amino acids (0.9 ppm) and showed m. tuberculosis on smear and culture. • abscesses in 16 patients showing succinate (2.4 ppm) and/or acetate (1.92 ppm), along with lipid/lactate (1.33 ppm) and amino acids (0.9 ppm) and showed anaerobic bacterial growth namely peptococci, peptostreptococci, and bacteroides. • abscesses in 20 patients showing only lipid + lactate (1.33 ppm) and amino acids (0.9 ppm). orgainsms seen on culture in these were either aerobes (pseudomonas, nocardia) or facultative anaerobes (staphylococcus, proteus, and escherichia coli). two patients with this pattern also showed anaerobic bacterial growth (peptostreptococci). • abscesses in the remaining 30 patients were found sterile on culture. these patients were on treatment with broad spectrum antibiotics at the time of spectroscopy and show lipid + lactate (1.33 ppm) and amino acids (0.9 ppm) only. conclusion: our data suggests that it may be possible to group the brain abscesses on the basis of metabolite pattern seen in vivo and may be of value in improved management of these cases. subclinical cerebellar neuropathy as a result of chemotherapy in proton magnetic resonance spectroscopy b. ciszkowska-lyson, l. krolicki, a. janowicz-zebrowska, a. teska, e. tacikowska, m. krzakowski, s. budrewicz; warsaw/pl purpose: of our study was to evaluate the central neurotoxicity of chemotherapy using mri and mrs, in patients with lung cancer who were treated with cisplatin and vinca alkaloids. we expected to find a reduction in n-acetylaspartate, as a result of the neurotoxicity of chemotherapy. methods: 31 patients aged 42 to 73 years underwent before and after chemotherapy: clinical examination; mri of the brain, mrs (press, tr 1500 ms, te 80 ms) voi of 8 ml localized in centrum semiovale (cs) and hemisphere of cerebellum. each patient's naa/cr and cho/cr ratios have been analyzed statistically. analysis was carried out separately for cs and cerebellum. none of the patients demonstrated clinical manifestation of cns neurotoxicity. mri did not reveal any abnormalities caused by chemotherapy. analysis of naa/cr and cho/cr ratios in cs did not show significant differences before and after chemotherapy. analysis of the cerebellar spectra showed significant decrease of naa/cr ratio (p < 0.05) and time dependent decrease of cho/cr ratio (p < 0.05) after chemotherapy. analysis of pearson's correlation showed very strong linear relationship between naa/cr and cho/cr ratios (p < 0.001), both at cs and cerebellum. conclusion: decreased naa/cr ratio can indicate the neuronal loss caused by chemotherapy. decreasing cho/cr ratio could be associated with damage of myelin. the mrs results suggest presence of subclinical selective cerebellar neuropathy caused by chemotherapy. the mrs revealed different reaction to chemotherapy at cs and cerebellum. these initial results indicate that proton mr spectroscopy is a potentially useful modality for detecting early stage of the cns neurotoxicity caused by chemotherapy. the liver and splenic parenchyma were surveyed and evaluated before and after embolization with plain helical ct, including volumetry of the liver and spleen. results: dsa examinations revealed a dilated splenic artery (n = 18) or gastroduodenal artery (n = 4) combined with slightly decreased perfusion of the hepatic arteries, while immediately after successful embolization normal perfusion of the hepatic arteries was noted. volumetric measurements before and after embolization showed no significant changes in liver parenchyma (6 % -10 %, mean, 6 %), and an alteration in spleen volume (11 % -27 %, mean, 16 %) in comparison with initial measurements. clinical follow-up examinations revealed a normalization of the previously elevated hepatic enzymes and a normalization of the liver function tests after successful embolization. complications were observed in 4 patients (infarction of the spleen). the preliminary results reveal that in liver transplant candidates with splenohepatic and gastroduodenal steal syndrome, successful embolization of the splenic artery results in a improvement in organ perfusion with normalization of function tests. were noted after 11 sessions (5.9 %). the number of sessions of tace, pancreatic location of primary tumour, extent of hepatic involvement and use of tace as a first line non-surgical treatment were significant for response rates in an univariate as well as a multivariate analysis. when survival from date of tace was considered, previous resection of primary and number of tace sessions were significant on univariate and multivariate analysis, while location of primary, histopathological grading and extent of hepatic involvement were significant only on univariate analysis. the digestive location of the primary tumor appears to be the strongest positive prognostic indicator for both response to tace and survival. use of at least 2 tace sessions per patient is recommended. poor prognostic indicators are presence of extra-hepatic lesions (nonresected primary and/or extra-hepatic metastases), poor histological differentiation of the tumor and more than 60 % involvement of liver. (2), kidney (2), spleen (1), brain (1). mostly there was an asymptomatic clinical course postprocedure. in six cases there were serious complications (3 × pneumonia, 1 × renal failure, 1 × cholecystitis) which resolved after two weeks. without evidence of displacement of lipiodol, there was one renal failure, one abscess of the liver and one case of hepatic encephalopathy. post-embolization syndrome (pes) with abdominal pain, nausea and vomiting, subfebrile temperature and pleural effusion was seen in 59 % (41/69) for a period of a few days. no rupture of an embolized hcc and no reflux embolization was observed. conclusions: unexpected displacement of embolisation material is not seldom, but mostly clinically inapparent. in cases with complications, symptomatic therapy is sufficient and successful. the frequent postembolization syndrome is transient and can be easily managed. transcatheter arterial chemoembolization (tace) as a first line treatment for liver metastasis from digestive neuroendocrine tumors a.j. roche, b.v. girish, v. kuoch, t. de baère, e. baudin, m. ducreux; villejuif/fr purpose: to report the outcome in patients who underwent tace as a first line non-surgical treatment methods and material: from jan. 1990 to dec. 2000 fourteen patients with progressive unresectable liver metastases from digestive neuroendocrine tumor were treated with tace (mean of 3.6 sessions) before any non-surgical treatment (somatostatin analogue, chemotherapy or interferon). liver involvement was less than 50 % in 11 patients. the size of the largest lesion ranged from 1.5 to 10 cm. the number of lesions was more than 10 in 8 patients. ten patients presented with carcinoid symptoms. tace was performed with doxorubicin emulsified in lipiodol® and gelatin sponge particles. results: a symptomatic response relating to flushes and/or diarrhea was complete in 7/10 cases and partial in 2/10. an objective morphologic response was noted in 12/14 cases. one patient developed transient renal failure and hypertension after the first tace. there was no procedure-related mortality in the series. the 5 and 10-year survival from diagnosis was respectively 83 % and 56 %. six patients were alive at the end of the study after 27 to 100 months from first tace and 38 to 142 months from diagnosis. three of them were successfully palliated for 55, 69 and 100 months with only tace as treatment (they received 9, 3 and 8 sessions respectively). the control rate of carcinoid syndrome with tace is comparable to somatostatin analogues. long term clinical, as well as morphological palliation, is possible in unresectable liver metastases from digestive neuroendocrine tumors with a few sessions of tace as early and exclusive treatment. material and methods: 220 tace in 54 consecutive patients with hcc. sequential tace (interval: 6 weeks) was performed using a suspension of 10 mg mitomycin c and 10 ml iodized oil (lipiodol). follow-up included pre-and post-interventional ct scans and laboratory measurements (liver-function parameters; afp). the number of lesions and tumour size were investigated using spiral ct. results: mean follow up was 17 months (range 6 to 50). 35 patients are still alive (mean survival 23 months, range 7 -50 months). 152 lesions were detected on the initial ct scans. size of individual lesions was < 20 mm (i), 21 -50 mm (ii), and > 50 mm (iii) in 42.8 %, 38.2 % and 19 %. over all median change of tumour size was -8.2 % (range -61 % to +82 %). median change depending on the initial lesion size was -7.7 % (i), -9.5 % (ii), and -3.8 % (iii). stable disease was noted in 33/54 patients. 10/54 patients had significant tumour regression and liver transplantation was successfully performed. tumour progression was noted in 14 patients with multilocular hcc and tumours > 50 mm. complications occurred in 3 patients, pancreatitis in one and dissection of the hepatic artery in two. there were no periinterventional deaths. conclusion: sequential tace in primary hcc is an effective therapy in patients with small tumours. because of tumour size control and avoidance of new tumour lesions, tace is a promising method to bridge the time to liver transplantation or to change patients into a transplantable condition. hybrid mri: transarterial chemoembolization of liver metastases using interactive mr guidance t.j. vogl, j.o. balzer, s. zangos; frankfurt a. main/de purpose: to evaluate the effectiveness of mr guided transar terial chemoembolization (tace) of liver metastases by employment of a hybrid mri system. in a newly built suite with fully interactive high field (1.5 t) mri and c-arm angiography units, elective tace was performed in 30 patients. an interactive table was positioned between the mri and angiographic unit, and allowed repositioning of the patient on a carbonfibre-plate within 20 seconds. arterial access was successfully achieved by employment of the dsa-unit and a mr compatible angiography catheter was superselectively positioned in the tumor feeding artery. the patient was then positioned in the mr unit and gd-enhanced dynamic mri (turboflash) via the catheter revealed the regional perfusion and verified the correct catheter position prior to tace. results: in 14/30 patients immediate embolization of the tumor bearing liver segments was performed. in 14 patients repositioning of the catheter and in 2 patients a change of vascular access was necessary. therapy monitoring using mri therefore resulted in the repositioning of the catheter tip in 53 % of the embolization maneouvers. dsa control immediately after tace revealed successful tace of the appropriate liver segments. conclusion: the presented hybrid system optimizes complex tace procedures in patients with liver metastasis. mri guidance enables the exact identification of the tumor bearing liver segments and correct catheter placement. uterine artery embolisation for symptomatic fibroids: results in 400 women w.j. walker, j.-p.j. pelage; guildford/gb purpose: to evaluate the mid-term efficacy, adverse events and complications of uterine artery embolisation (uae) in women with symptomatic fibroids. to assess reduction in uterine and dominant fibroid volumes using ultrasound imaging and magnetic resonance imaging (mri). methods and materials: four hundred women were treated between december 1996 and february 2001. indications for treatment were menorrhagia, menstrual pain, abdominal swelling or urinary frequency. imaging was performed before embolisation and at regular intervals thereafter. clinical evaluation was made at regular intervals after embolisation to assess patient outcome. results: bilateral uae was achieved in 395 women whereas 5 women had a unilateral procedure. with a mean clinical follow-up of 16.7 months, menstrual bleeding was improved in 84 % of women and menstrual pain was improved in 79 %. the mean changes in uterine and dominant fibroid volumes were 55 and 73 % using ultrasound (performed at an average of 9.7 months after embolisation) and 53 and 64 % with mri (performed at an average of 6.4 months). three (1 %) infective complications requiring emergency hysterectomy occured. 23 (6 %) patients had clinical failure or recurrence and nine (2 %) had a hysterectomy. 26 (7 %) of women had permanent amenorrhea after embolisation including 4 patients under the age of 45. thirteen pregnancies occurred. 97 % of women were pleased with the outcome. conclusion: uterine artery embolisation is associated with a high clinical success rate and good fibroid volume reduction. infective complications requiring hysterectomy and amenorrhea under the age of 45 are rare but major complications. embolization of bleeding arteries from pelvic trauma n.-e. klow 1 , a. riise 2 , m. brekke 1 , o. roise 1 ; 1 oslo/no, 2 fredrikstad/no purpose: to study the effects of arterial embolization after pelvic trauma in hemodynamically unstable patients. material and methods: from 1994 to 2000, 17 patients were included, three women and 14 men, mean age 35 years (from 16 to 72 years). all patients were admitted with trauma to the pelvis, but freqently multiorgan trauma was present. the pelvic fractures were bilateral in five, a sacral fracture was present in seven and diastasis of the symphysis pubis in seven. over the 24 hours immediately before embolization the need for whole blood transfusion was 18 ± 17 units (range 2 -64). results: all 17 patients were successfully embolized. fourteen had embolization of one internal iliac artery (iia), one both iia and a lumbar spinal artery, one a lumbar spinal artery, and one a superficial femoral artery branch. in 15 patients coils were used exclusively, in one gelfoam and in one coils and gelfoam were combined. the total need for blood transfusion after the embolization was 0.8 ± 1.0 units (range 0 -3). three patients died during the hospital stay, and no deaths were related to the procedure or rebleeding from the pelvic arteries. conclusion: embolization of arteries bleeding from traumatic injuries of the pelvis is a life saving procedure with a high procedural success rate. the procedure can be done on call, in hemodynamically unstable patients, and should probably be performed in an early stage of bleeding. intraarterial chemotherapy of malignant pelvic tumors under tourniquet occlusion of the femoral vessels p.d. niggemann 1 , s. murata 2 , h. tajima 2 , y. okajima 2 , k. ichikawa 2 , h. kawamata 2 , t. kumazaki 2 ; 1 aachen/de, 2 tokyo/jp purpose: to evaluate the possible benefit of intraarterial chemotherapy in malignant pelvic tumors under tourniquet occlusion of the femoral vessels. methods and materials: the difference in contrast enhancement of 55 regions in 23 malignant pelvic tumors was evaluated with and without tourniquet occlusion of the femoral vessels. in nine patients (group a) two ct scans of the pelvis, one and five minutes after starting an intraarterial contrast medium injection under tourniquet occlusion, were performed and then two ct scans after injection of the same dose without tourniquet occlusion were performed. in the remaining 13 patients (group b), the study was done in the opposite order. results: in group a, a mean change of the contrast enhancement of all tumors was 0.6 hounsfield units (hu) after one minute and −3 hu after five minutes. in group b, a mean change in contrast enhancement of 2.1 and 0.8 hu at one and five minutes respectively was observed. in patients with prostate tumor, the results were 5.2 and 3.9 hu respectively in patients from group a and 14.1 and 10.2 hu in patients from group b. the average of both groups together showed an increase of 8.9 and 6.5 hounsfield units respectively. conclusion: an increase in the contrast enhancement of malignant pelvic tumors due to tourniquet occlusion of the femoral vessels has been observed only in patients with prostate cancer after one and five minutes. therefore intraarterial chemotherapy under tourniquet occlusion of the femoral vessels only seems to yield a benefit in poorly vascularized tumors. purpose: to establish a high resolution mri (hr-mri) protocol for precise and repeated non-invasive analysis of selected atherosclerotic vessel segments in vivo and to compare the results with intravascular ultrasound (ivus). materials and methods: 7 patients with atherosclerotic disease of the superficial femoral artery were examined on a magnetom vision, siemens using axial t1-w, fat-saturated contrast enhanced t1-w, t2-w and 3d-tof sequences. contrast enhanced mra was used to display the detailed vasculature for precise orientation. maximum matrix size was 320 × 512, minimum voxel size 0.49 × 0.49 × 2.0 mm. ivus (3.5 f, 40 mhz) images were recorded with a standardized motorized pullback system (pullback speed 1.0 mm/s). parameters analysed were minimum and maximum luminal diameter and cross sectional lumen area. vessel wall calcification was determined by 900 steps. results: 123/123 segments were available for comparison between hr-mri and ivus. intra-and interobserver repeatability for exact assignment of vessel segments was high (r = 0.92, r = 0.87). there was a good correlation for luminal parameters (correlation coefficients ranging from 0.82 to 0.98 depending on the plaque burden). no correlation was found for cross sectional vessel area. calcification could be classified with a sensitivity of 91 %, a specificity of 93 %. accuracy was 93 %. conclusion: our hr-mri protocol is highly accurate for non-invasive assessment of atherosclerotic lesions in human femoral arteries. the results are comparable with ivus as known reference standard in vivo. purpose: to evaluate ultrasonography as a method of characterizing plaque surface configuration and plaque internal structure in comparison to in vitro angioscopy and pathological specimens. the carotid plaque specimens of 15 patients were examined by in vitro angioscopy and histopathological examination after carotid endarterectomy (cea) in a comparative study with preoperative ultrasonography. colorcoded ultrasonography was obtained with a 7.5 mhz linear transducer (logic 500, ge). transverse and longitudinal sections were recorded from the bifurcation area as well as from the proximal internal carotid artery. the plaque surface was characterized as smooth if the plaque surface did not show any disruptions. further, the echogenic structure was recorded by grey scale analysis. after cea the inner surface of the plaque was visualized by a 1.4 mm angioscope. the results were compared with histopathological findings. results: peak flow velocity (mean: 2.77 m/s, range 1.76 -4.24 m/s) demonstrated a > 60 % stenosis in all cases. the median of gray scale analysis (gsm) was 55 with a high correlation between both investigations (p < 0.01; r = 0.954). in comparison to pathological findings there was a correct detection of plaque surface in 86.6 %. pathological classification of plaque composition revealed no correlation to computer-assisted analysis (p = 3.85; r = -2.63). conclusion: detection of an ulcerated plaque surface by ultrasonography is difficult with a wider degree of variation when compared with direct visualisation of the surface and pathological examination. computer-assisted analysis of the morphology provides a high interobserver correlation, however, there was no correlation between the gsm and histological findings in this series. common carotid artery intima-media thickness (cca-imt) and carotid plaque echogenicity: correlation with cardiovascular risk factors in patients with acute ischemic stroke g. terzis, a. chrysanthopoulou, g. gioldasis, a. kalogeropoulos, c. paschalis, j.a. dimopoulos; patras/gr purpose: to correlate the cca-imt and the echogenicity of the carotid plaques with the main cardiovascular risk factors in patients with acute ischemic stroke. methods and materials: 535 consecutive patients (male 344, female 191, mean age 67.6 years) with acute ischemic stroke were studied with b-mode and color doppler ultrasonography during may 1999 to july 2001. cca-imt was evaluated and four types of plaques were defined by their echostructure. type i: uniformly echolucent, type ii: predominantly echolucent, type iii: predominantly echogenic and type iv: uniformly echogenic. cardioembolic and undetermined strokes were excluded. all patients were evaluated for a history of smoking, hypertension, diabetes or hypercholesterolemia. smoking, hypertension and diabetes were all significantly associated with an increased cca-imt (p < 0.01 for all subgroup comparisons). hypercholesterolemia had no significant effect (p = 0.67). smoking was associated with an increased cca-imt (p = 0.0032) independently of other risk factors. hypertension was significantly associated with diabetes (p = 0.0033) as a risk factor. smoking, hypertension and diabetes had no significant effect on the type of the plaque (p = 0.374, p = 0.607, and p = 0.636 respectively). hypercholesterolemia was significantly associated with type i plaques (p < 0.05). a trend for advanced echogenicity was observed among smokers (p >> 0.1). smoking, hypertension and diabetes but not hypercholesterolemia were significantly associated with an increased cca-imt in patients with acute ischemic stroke. smoking, hypertension and diabetes were not associated with a specific type of plaque, but hypercholesterolemia was clearly associated with type i plaques. high-resolution mr of carotid atheroma: a non-invasive tool for assessing plaque morphology and potential risk? j.h. gillard 1 , m.t. gaskarth 1 , m.j. graves 1 , r.a. coulden 1 , h. wilson 1 , n.m. antoun 1 , m. goddard 2 , p.j. kirkpatrick 1 ; 1 cambridge/gb, 2 papworth/gb purpose: whereas current imaging techniques provide excellent structural information including the quantification of vascular stenosis, they provide no information of the degree of functional plaque stability. risk of rupture is more closely related to plaque composition and macrophage content than size. thus angiographic appearances are an inaccurate predictor of risk; even large atherosclerotic lesions may not produce a significant stenosis at angiography. we aimed to use highresolution mr to evaluate plaque morphology in patients being evaluated for carotid endarterectomy. methods: blood-suppressed fast spin echo imaging was performed using a dedicated surface coil (t1, t2, proton density, and chemical shift selective fat suppression; spatial resolution 0.24 × 0.24. × 3 mm) in 29 patients with symptomatic carotid disease. gadolinium-enhanced elliptic centric mra was also performed and compared with conventional digitally subtracted angiography (dsa). histopathological examination was carried out on 4 specimens. results: 37 plaques were identified, 15 of which were eccentric, extending outside the limit of the "normal" vessel wall. there was no significant difference in the degree of stenosis (using nascet criteria) assessed with dsa and gd-enhanced mra (p = 0.11). high-resolution axial mr measurements, however, demonstrated more severe stenoses than was apparent from 4 projection dsa (mean difference 11 ± 13 %, p < 0.005). mr correctly identified plaque constituents (fibrin, lipid and focal hemorrhage). conclusion: high-resolution carotid mr appears to be a useful tool in evaluating plaque morphology and effectively assesses plaque volume and degree of arterial narrowing. it may be an effective tool in evaluating plaque risk and the effects of pharmaceutical interventions. in 18 patients with btm (mean age 25.8 ± 7.6 year, 55.5 % male, mean hemoglobin 10.2 ± 1 g×dl -1 , mean serum ferritin 2396 ± 1754 ng×ml -1 , 44 % on optimal chelation therapy) without cardiac disease or diabetes mellitus and 18 healthy control subjects, flow-mediated dilatation (fmd) was measured as a percentage change of the post-ischemic right brachial artery (ba) diameter. endothelial-independent, nitroglycerin-induced vasodilatation (nid) and cca imt were also assessed. the study groups were matched for age, gender, body surface area, blood pressure and smoking habits. serum cholesterol levels were lower in the patient group (102 ± 39 versus 178 ± 30 mg⋅dl −1 , p = 0.001). the brachial artery diameter was 4.07 ± 0.66 mm in patients and 4.06 ± 0.52 mm in healthy subjects. post-ischemic increase in the brachial artery blood flow was 555 ± 383 % (p < 0.01) for patients and 1072 ± 6.61 % for healthy subjects. fmd was 5.97 ± 2.3 %(p < 0.001) for patients and 10.44 ± 44 % for healthy subjects. nid was 14.86 ± 6.22 % for patients and 16.66 ± 4.23 % for healthy subjects. cca imt was 0.539 ± 0.078 mm for patients and 0.453 ± 0.072 mm for healthy subjects. fmd and thickness of the carotid arterial wall did not correlate with serum ferritin levels. conclusions: in patients with thalassemia major, endothelial function of conduit arteries is impaired and cca imt is increased. our findings suggest a proatherosclerotic milieu with reduced bioavailability of nitric oxide, probably due to the iron-induced, high oxidative stress in these patients. functional imaging of the aortic wall by ecg-gated multislice-ct: an ex vivo experiment m.-k. ganten 1 , j. boese 1 , d. leitermann 2 ; 1 heidelberg/de, 2 prague/cz purpose: ecg-gated multislice-ct (msct) allow imaging with increased temporal resolution. the aim of this study was to evaluate the possiblity of obtaining functional information determining aortic-wall-elasticity in an ex-vivo experiment. elasticity is a piece of clinically relevant information not yet widely accessible. methods & materials: 16 samples of porcine aortas were examined ex-vivo. to imitate physiologic circulation an artificial heart phantom emitting an ecg signal was used to perfuse the samples with pulsatile flow and varying pressures. aortic wall elasticity can be determined by dividing the relative change in vessel area by the corresponding pressure change. as a reference, the wall distension was measured using an optical system with high temporal and spatial accuracy. ecg-gated ct images were acquired with a standard ct-angiography protocol applying specially developed reconstruction algorithms. this allowed us to obtain images with improved temporal resolution of about 100 ms. the aortic cross-section was determined from the images by manual segmentation. the accuracy of the crosssectional changes measurements was evaluated by comparison between the optical and the ct data. results: determination of aortic wall elasticity was possible in all samples. elasticity, expressed as mean compliance, was 1.4 × 10 −5 /pa. precision of the manually determined values was in the order of 10 % compared to a precision of about 1 % for the reference optical method. cross-section changes obtained from the ct images were in line with the error bounds obtained from the optical measurements. conclusion: our study shows that aortic wall elasticity determination using ecggated ct is feasible. this allows functional information about the aortic wall to be obtained. patient studies are required to investigate the in-vivo applicability. detection of atherosclerotic plaque using gadofluorine enhanced magnetic resonance imaging j. barkhausen 1 , w. ebert 2 , c. heyer 2 , j.f. debatin 1 , h.j. weinmann 2 ; 1 essen/de, 2 berlin/de purpose: to visualize atherosclerotic plaques independent of luminal narrowing using t1-w contrast enhanced mri. methods and material: 5 watanabe heritable hyperlipidemic rabbits (9 -18 months) and 5 age-matched controls (white newseeland) underwent magnetic resonance imaging of the aortic arch using a 1.5 t mr system (magnetom symphony, siemens ag, erlangen, germany) before and 48 h after injection of 100 mmol gadofluorine (schering ag, berlin, germany). a haste sequence (tr 700 ms, te 60 ms) and a t1-weighted inversion recovery turboflash sequence (tr 300 ms, te 4 ms, ti 120 ms) were used for data acquisition. immediately following the mr examination the animals were sacrificed and the aorta was stained with sudan. ex vivo imaging of the stained aortic specimens was performed. additionally, the gadolinium concentration in plaques and normal aortic wall was measured by means of inductively coupled plasma atomic emission spectrometry. results: plain mr imaging revealed no plaques in the aortic arch in either animal group. enhancement occurred in the aortic wall of all whhl rabbits but not in the vessel wall of the control group. sudan staining demonstrated multiple plaques in the aortic arch of the whhl rabbits and using ex vivo imaging the area of hyperenhancement matched the area of plaques stained with sudan. the gadolium concentration was 51 ± 21 nmol/g for normal aortic wall in the control group and 531 ± 144 nmol/g for plaques. conclusions: gadofluorine enhances atherosclerotic plaques thereby permitting the detection of plaque independent of luminal narrowing. vessel wall mri of the descending aorta: comparison with transesophageal ultrasound n. abolmaali, m. langenfeld, c. schick, r. kraforst, v. schächinger, t.j. vogl; frankfurt a. main/de purpose: to evaluate the validity of high-resolution contrast-enhanced mri of the aortic wall and to prove comparability of plaque morphology detected by transesophageal ultrasound (teus). is there additional information in mri? methods and materials: we performed mri in five patients (median age: 62 years) in whom aortic wall thickening and plaques of varying morphologies were detected by teus. after sequence optimisation in cadaver studies, all mr-examinations were performed with a 1.5 t scanner (magnetom symphony quantum, siemens) with the cp-spine surface coil (supine position) using ecg-triggered t1weighted tse-sequences with dark-blood-preparation and fat-suppression before and after iv-administration of 0.1 mmol/kg bw gadolinium-dtpa (gd). slice thickness was 5 mm, in-plane-resolution using a 256 2 matrix was 0.5 × 0.5 mm 2 . the heart-frequency dependent acquisition time for 10 slices was 10 -14 minutes. roi-measurements of the aortic wall before and after contrast enhancement were performed and mri was correlated with the teus findings. results: thickened wall segments and plaques of the descending aorta detected by teus were visualized by mri. different morphologies with evidence of fatty deposits were detected. unaffected aortic wall revealed two layers and signal isointensity compared to striated musculature. after iv-administration of gd most parts of the aortic wall did not enhance (< 6 %) while wall thickening and plaques showed considerable enhancement (22 -59 %) solely of the inner layer of the aortic wall. conclusion: high-resolution mri of the aortic wall provides similar morphologic information as teus does. additionally the distinct enhancement of the inner aortic layer may correspond to an inflammatory process of the vessel wall. , metastases (n = 11, mainly colorectal), carcinoid (n = 5) and two benign liver tumours. 3 patients were excluded from follow-up. results: mean survival for all patients was 15.2 months, with an adjusted mean survival of 16 months for hccs and 15.2 months for metastases. there were three major and five minor post-procedural complications but no deaths. an average of 57 % of tumour was ablated as assessed by per-procedural thermal mapping, with an average of 49.4 % of tumour ablated assessed by pre and post ablation gadolinium-enhanced mris. average tumour size was unchanged after ablation. in patients with multiple liver tumours ablated tumours grew significantly less than untreated tumours over the same time period (108 % compared to 196 % growth over an average follow up period of 5.8 months). conclusions: mr guided laser thermal ablation of primary and secondary liver tumours is safe and feasible and produces a better survival in patients with hcc than would be expected in untreated patients, as well as a mean survival in patients with metastases at least equal to the longest median survival in untreated patients. percentage viable tumour was decreased by a mean of 49.4 % per lta session. contrast enhanced harmonic sonography (ceus) used in the interventional room (ir) during radiofrequency (rf) ablation treatments: how to save time and reduce patients' discomfort l. solbiati, t. ierace, m. tonolini, l. cova, v. osti, p. marelli; busto arsizio (va)/it purpose: to evaluate usefulness of ceus performed during rf ablation procedures to assess the therapeutic result prior to ending the treatment session. materials/methods: 61 patients with 1 -5 hcc in liver cirrhosis (42 patients) or 1 -4 metastases from colorectal (10), breast (3), gastric (2) and endocrine (4) cancers underwent single session percutaneous rf ablation with cool-tip electrodes, under general anesthesia, in the ir. before and 5 -10 minutes after ending each treatment session, continuous mode, low mechanical index, ceus with a second generation contrast agent (sonovue, bracco) was performed. a total of 86 lesions were examined. when, residual enhancement was detected within treated tumors, a second targeted electrode insertion was carried out. when complete tumor avascularity was demonstrated, general anesthesia was terminated. contrast-enhanced helical ct (cect) was performed in all cases 2 -15 days after ablation. results: in 67/86 (77.9 %) lesions no post-ablation residual enhancement was found with ceus. subsequent ct showed unablated portions of tumors in 8/67 (11.9 %) lesions (all larger than 5 cm) and complete necrosis in the remaining 59 saturday in 19/86 tumors in 17 patients, ceus showed either single or multiple intralesional areas of residual enhancement in arterial and/or portal phase, 1 -2.5 cm in size. all these likely viable portions were immediately targeted with 1 -2 electrode insertions, until no residual areas were demonstrated. on subsequent cect, only in 2/19 (10.5 %) of these tumors, 1 -1.5 cm residual areas were found requiring new rf treatment. to prove the hypothesis that t1w thermal mapping is reliable and achievable in mr guided laser tumour ablation. methods & materials: 110 mr guided laser thermal ablations (lta) of liver, kidney and uterine tumours were studied. after laser fibre placement, near real-time grey and colour scale thermal maps are produced. previous work showed t1 signal is inversely proportional to temperature below 55°c (the point of irreversible tissue necrosis). measurements included: (i) percentage (%) of cases in which the thermal map provided sufficient information to control the procedure (ii) ability of grey and colour scale maps to demonstrate size (centimeteres) and conspicuity (10 point scale) of thermal lesions (iii) factors causing thermal mapping failure. results: (i) thermal mapping was successful in 84 % uterine, 74 % hepatic, and 20 % renal ablations. (ii) for hepatic/uterine tumours, size and conspicuity of thermal lesions were significantly greater on the colour than grey scale mapping. for uterine ablations, mean lesion size was 3.1 cm (colour) and 2.5 cm (grey, p = 0.001, paired student's t-test), while mean conspicuity was 7.3 (colour) and 1.7 (grey, p = 0.001). for liver ablations mean lesion size was 3.1 cm (colour) and 1.7 cm (grey, p = 0.001) while conspicuity was 7.5 (colour) versus 3.7 (grey, p = 0.001). (iii) patient movement (n = 24), fibre charring (n = 2), magnetic field distortion & reconstruction errors (n = 2) caused mapping failure. in hepatic & uterine thermal maps the colour scale produced significantly greater sized lesions with significantly greater conspicuity than the grey scale. t1w signal thermal mapping was reliable and successfully achieved in 73.7 % of procedures. the most important challenge on the follow-up of radiofrequency treated hypovascular liver metastases: the differentiation of coagulative necrosis from viable tumor. is there a role for contrast enhanced sonography? l. solbiati, m. tonolini, l. cova, d. della chiesa, v. osti; busto arsizio/it purpose: to assess if contrast enhanced harmonic sonography (ceus) can be useful for the differentiation of radiofrequency-induced coagulative necrosis from viable hypovascular liver metastases. materials and methods: 29 metachronous colorectal liver metastases (mean size 2.7 cm) in 9 patients treated 2 -9 months beforehand with rf ablation and systemic or intraarterial chemotherapy underwent conventional us and continuous mode, low mechanical index, ceus with a second generation contrast agent (sonovue, bracco) due to suspicion of local recurrence. triphasic contrast-enhanced helical ct (in all cases) and fnab (10 cases) were performed to confirm recurrence. results: usind ceus in arterial and very early portal phases, 25/29 metastases showed intense, predominantly peripheral enhancement. in full portal phase, complete disappearance of the enhancement was observed, with homogeneously hypoechoic appearance. the same arterial ct demonstrated enhancement, although less evident than with ceus, in only 10 of these 25 metastases (40 %). us-guided fnab was performed in at least one metastasis for each patient, with diagnosis of viable adenocarcinoma cells. in the remaining 4/29 lesions no enhancement was found with either ceus or ct and fnab (in 2/4 nodules) did not yield viable tumoral cells. conclusions: differentiation of coagulative necrosis from unablated or recurring hypovascular tumor is a diagnostic challenge. ceus demonstrates marked arterial enhancement of the viable tumor portions, better and with higher sensitivity than with ct. this finding could represent a quick and valuable tool for post-ablation follow-up. such arterial enhancement (more intense than that observed before ablation) raises a suspicion of more active neovascularity in uncompletely ablated tumors there was no effect on survival by tumor size, number of tumor nodes or the grading. however, the survival of 50 % of the patients with a child c cirrhosis or with afp levels > 1000 ng was less than 6 months with nobody living longer than 36 months. in patients with child a cirrhosis and/or normal afp levels the mean survival was 14 and 17 months, resp. 10 % of these patients lived more than 60 months. conclusion: tace is an effective therapy that may prolong the patients survival in patients with non-resectable hcc. however, child class in cirrhotic patients and elevation of afp levels have to be considered as prognostic factors for a life extending tace therapy. purpose: to evaluate a neoadjuvant treatment protocol for large sized liver metastases performing repeated transarterial chemoembolization (tace) and litt (laser induced thermotherapy) in patients with unresectable liver tumours initially unsuited for litt material and methods: 519 patients with different malignant liver tumours were evaluated between january 1999 and september 2001. tace was performed with 50 mg/m 2 mitomycin c, 10 ml/m 2 lipiodol and microspheres. the tumour volume was measured by mr-imaging. lipiodol retention and perfusion of the tumours were evaluated by ct and angiography. after response to tace and reducing the tumor size 106 patients (16 patients with hcc, 59 patients with metastases of colorectal cancer, 17 patients with metastases of breast cancer and 14 patients with metastases of different primary cancer) could be treated with mr-guided litt 4 to 6 weeks post embolization. these patients received 2 to 6 (mean: 3.6) tace before litt. results: repeated tace enabled a significant reduction in tumour size and/or tumour perfusion in 106 patients, forming the basis for the performance of mrguided litt procedure for a complete ablation of the tumour. in 178 tumors lesions 203 laser interventions archived a complete tumour ablation. the initial tumour volume pre-litt presented with a mean of 30.1 ml, the resulting necroses was 73.4 ml. the local tumour recurrence rate was 7 % in the 6 month control, the rate of side effects 11 %. conclusion: repeated tace alteres the size and structure of primary unresectable liver metastases and expands the indication for mr-guided litt. results: tace treatment were performed successful in 99.9 %. only in 2 cases sondage of celiac trunk and performing tace was not possible. during the tace procedure in 12 cases an occlusion of the a. hepatica was evidenced with good collateral arteries, so that tace could performed. in one case perforation of a. hepatica propria resulted in a small subhepatic bleeding. no therapy associated mortality was observed. only minimal side effects like pain (53.8 %), nausea (30.8 %), vomiting (20.5 %), fever (43.6 %) and apokamnosis (82.1 %) were associated with the tace, which could be managed by oral medication easily. in 15 patients aszites was documented after tace treatment. in 6 patients intrahepatic abscess cavities were evidenced and treated with percutaneus drainages. conclusion: tace in liver tumors proved to be a safe oncologic treatment in an outpatient setting. side effects must be treated fast to reduce failure. extrahepatic recurrences after radiofrequency ablation treatment of hepatocellular carcinoma: spectrum of imaging findings m. tonolini, l. solbiati, t. ierace, v. kirn, p. marelli; busto arsizio/it purpose: to describe diagnostic aspects and particularly ct findings of extrahepatic relapses observed after treatment of hepatocellular carcinoma. materials and methods: during a six-year span, 226 patients (aged 32 -88 years) with chronic hepatitis or cirrhosis were diagnosed with hepatocellular carcinoma confined to the liver and treated percutaneously with radiofrequency (rf) ablation. a total of 313 treatment sessions were performed. post-therapeutic follow-up is based upon serum alpha-fetoprotein levels and ct examination. results: mean duration of follow-up was 17 months. after successful treatment, actuarial probability of neoplastic relapse is 30.7 % after 1 year and 58.5 % after 2 years. 88 patients had recurrence of hepatocellular carcinoma after a variable time interval (mean 7.3 months). extrahepatic neoplastic relapse was observed in 14 patients, half of these without active hepatic disease. distribution of extrahepatic sites of recurrence was as follows: abdominal lymph nodes (6 cases), bone (3), peritoneum (2), adrenal (2), lung (1). five patients (2.2 %) had a second primary extrahepatic neoplasm. conclusion: extrahepatic hepatocellular carcinoma is considered rare and occurring in advanced stages, but may represent a modality of post-treatment relapse. the distinctive hypervascularity of this tumor histology may be observed in adenopathy and adrenal metastases. second primary neoplasms should be considered in the differential diagnosis of lesions observed during follow-up. radio-frequency (rf) ablation of liver tumors: postprocedural appearances on multiphasic spiral ct p. cabassa, l. romanini, d. guidetti, f. simeone, a. maggi, l. grazioli; brescia/it purpose: to describe the spectrum of ct findings of liver malignancies treated with rf. materials and methods: 40 histologically proven malignant liver lesion (35 hcc, 5 methastasis, size range 1.6 -7.5 cm) in 37 patients (26 male, age range 44 -82 years) were treated with rf (using either internally-cooled electrode or le veen needle electrode). multiphasic spiral ct at 1, 4, 6, 12 months (and every 6 months after 1 year) was performed for follow-up. spiral ct included unenhanced and enhanced arterial and portal venous phase images. absence of contrast enhancment within the lesion was considered as complete ablation. the location (local intrahepatic, remote intrahepatic) and morphology of tumor recurrence were rewiewed. any other findings (perilesional hyperemia, thad etc) were recorded. results: complete necrosis was described in 31 lesions (77.5 %) at 1 month, partial necrosis in the remaining 9 lesions (22.5 %). local tumor recurrences (persistence) appeared in three patterns: nodular, halo or gross enlargement. 4/31 lesions (12.9 %) tumor-free at 1 month showed tumor persistence at 4 months. analysis of these cases showed that residual disease was probably masquerade by perilesional hyperemia, a common finding at 1 month. any lesion considered complete ablated at 6 month didn't show tumor recurrence in the following controls. 15 cases showed remote intrahepatic recurrence. pseudolesions as thad or a-v fistula were common findings expecially in early controls. the median follow-up was 13 months (range 6 -34 months). conclusion: knowledge of any ct findings after rf ablation is important but correlation with timing of follow-up is mandatory to avoid misdiagnosis. ct-guided aspiration and drainage of suppurative residual cavities after hydatidectomy a.i. ikramov, n.m. djouraeva; tashkent/uz purpose: to evaluate the efficacy of ct controlled intervention procedures in infected residual cavities after hydatidectomy. material and methods: ct-guided drainage was conducted on 62 patients with infected residual cavities after hydatidectomy. age varied between 14 and 76 years (mean 39.6). size of cavities ranged from 4.5 cm up to 12 cm. 76.3 % of cavities were located in the right lobe. in homogenous low density collections (+10 ± 18 hu) with thin walls an fna procedure was used to allow aspiration. in other cases (37) with high density collections (+25 ± 30 hu) we performed percutaneous drainage with 9 -18 f pigtail catheters. in 12 cases when cavity sizes were more than 10 cm we performed drainage via two catheters. results: in 93.5 % of patients ct-guided interventions allowed us to achieve a full recovery. repeated aspirations (from 2 up to 5) were conducted in 12 cases. one complication occurred (partial lung collapse). in 4 cases with ineffective drainage surgical conversion was needed. conclusion: ct-guided drainage procedures can be an effective method of treating suppurative residual cavities after hydatidectomy and may be an alternative to surgical treatment. in none of the patients was contrast material administered for mri. 90 patients also underwent cardiac catheterization within two months after mri examination. all patients were examined with percutaneous echocardiography. the results were compared to the anatomical situs and functional parameters. patients with abnormal coronary arteries were excluded from this study. results: in 70 of 90 patients (77 %) cardiac catheterisation and mri examinations provided results which led to the same clinical decisions. discordance between the two methods occurred in the assessment of pulmonary stenosis, in the evaluation of spongy myocardium, and straddling of mitral or tricuspid valves. overall there was no significant difference between mri and cardiac catheterisation in the pre-and postoperative evaluation of congenital heart disease (chd). conclusion: mri can be more beneficial in difficult patients especially with complex postoperative situs. cardiac catheterisation should only be performed when mri is questionable. percutaneous echocardiography still remains the first diagnostic tool in the evaluation of chd. saturday methods: 29 patients with an established echocardiographic diagnosis of tricuspid valve insufficiency grade ii or grade iii and planned combined reconstruction of tricuspid and mitral valve were prospectively included and examined with mri. sequences included continuous short axis truefisp cine sequences of the whole heart for volumetry of atria and ventricles, phase contrast (pc) through-plane flow measurement and cine sequences for assessment of valvular function. patients were randomized and treated either by devega annuloplasty or by carpentier ring implantation. in 12 patients, postoperative results were obtained 2 -3 months after surgery. results: 21 of 29 patients examined had an absolute arrythmia, thus impairing diagnostic quality especially for flow measurements. atrial volumetry in these cases showed no discernible contraction, and through plane flow measurement in the valvular plane showed no a-wave. in all patients, the degree of insufficiency was established with pc-flow correlated with 4 chamber view cine sequences and echocardiographic findings. in the follow-up-studies, no significant differences between the surgical treatment groups could be detected. conclusion: cardiac mri with pc-flow measurement and cine sequences seemed to be well suited for evaluation of atrial function and valvular morphology and function before combined valvular reconstruction. atrial volumetry is less useful than valvular flow measurement. cine sequences in the valvular plane allowed for sizing of the valvular ring. purpose: severe pulmonary regurgitation late after total correction for tetralogy of fallot leads to progressive right ventricular dilatation and an increased incidence of severe arrhythmias and sudden death. mri was used to assess the effect of pvr on rv function and pr. materials and methods: 26 adult patients who underwent pulmonary valve replacement in our institution between 1998 and 2001 were studied. mean age at initial repair was 5.5 ± 3.6 years and mean duration of follow-up was 30.0 ± 8.9 years. cardiac mri was performed 6.2 ± 3.7 months before and 7.7 ± 2.3 months after pvr. pulmonary regurgitation (pr), rv end-diastolic volume (rvedv), right ventricular end-systolic (rvesv) and rv ejection fraction (rvef) were measured. results: preoperative pr was 45 % (range from 25 to 64 %). after pvr, 20 out of 26 patients (77 %) showed no residual pr. rvedv decreased from 305 ml ± 87 ml to 210 ml ± 62 ml (p < 0.01) and rvesv decreased from 181 ± 67 ml to 121 ± 58 ml (p < 0.01 purpose: retrospectively ecg-gated 3d volume data from multislice spiral ct (msct) coronary angiography enables image reconstruction in diastolic and systolic phase of the cardiac cycle. thus, the objectives of our study were to determine lv ejection-fraction (lv-ef) from msct data set and to compare the results to cine magnetic resonace imaging (mri). materials and methods: 28 patients (60.6 ± 8.5 a) with coronary artery disease (cad) underwent msct coronary angiography (somatom volume zoom, siemens ag; 4 × 1 mm slice thickness, 120 kv, 300 ma; 140 ml nonionic cm, flow 3 ml/s). an additional cine mr study was performed at a 1.5 t mr unit (breath-hold flash 2d sequence, tr 80 ms, te 4.8 ms, flip angle 20°, slice thickness 6 mm). from msct data set retrospectively ecg-gated axial images were reconstructed in systolic and diastolic phase (acv reconstruction algorithm). enddiastolic and endsystolic lv volumes were determined from multiplanar reformations (slice thickness 6 mm) in short-axis image orientation (3d volumetry) to assess lv-ef. cine mri data was analyzed by using the implemented argus™ software in shortaxis image orientation. multiplanar reformations from msct data set allowed good delineation of endocardial and epicardial contours. systolic reformations showed slight motion artifacts in patients with a heart rate above 75 b.p.m. enddiastolic (r = 0.92), endsystolic (r = 0.90) lv-volumetry and lv-ef determination (r = 0.90) from msct data set demonstrated good correlation to cine mri. conclusion: in patients evaluated for cad, retrospectively ecg-gated 3d volume data set from msct angiography provides lv volumetric and functional data in good correlation to cine magnetic resonance imaging. after intravenous administration of contrast media (120 ml, 370 mg/ml iodine, flow 3 ml/s) scanning was initiated by bolus tracking and performed using a ecg-gated protocol at 40 mas and 120 kv, collimation of 4 × 4.0 mm, pitch of 1.2:4 and 0.5 s rotation time. the raw data was reconstructed with 50 % reconstruction pitch every 10 % of the r-r interval. images were transferred to external workstations for diagnostic interpretation of the chest (easy-vision, philips) as well as the cardiac data (alato-view, toshiba). studies were evaluated with regard to image quality. left ventricular function parameters were calculated and were compared with echocardiographic measurements using pearson's correlation coefficient and student's t-test for paired samples. results: diagnostic interpretation of the images was feasible in all patients without recognizable reduction in image quality. the radiation dose of the modified protocol did not exceed the exposure of a routine chest ct. retrospective reconstruction of diastolic and systolic cardiac images succeeded in all patients, only minor motion artifacts occurred in 9 cases due to cardiac arrhythmia. comparison between msct and echocardiographic measurements revealed no significant differences in the mean values of the function parameters (p < 0.05 in all cases) and a good correlation between both modalities: diastolic/systolic wall thickness r = 0.88/ 0.84; diastolic/systolic diameter r = 0.91/0.86 and ef r = 0.82. conclusion: using a modified protocol for routine chest scanning, msct allows a reliable, fast calculation of heart size and function without additional radiation exposure. b a c d e f 192 value and reproducibility of multidetector-row ct in the assessment of cardiac function c. herzog, a. mehtap, n. abolmaali, j.o. balzer, s. schaller, t.j. vogl; frankfurt a. main/de objective: to explore the value and accuracy of multislice-cardiac-ct in the assessment of functional cardiac parameters. materials and methods: 23 patients prospectively underwent multislice-ct (siemensplus4vz, germany) and invasive angiocardiography. using retrospective ecg-gating scanning parameters were 4 × 1 mm collimation, pitch 1.5 and 500 ms rotation time. based on a proportional reconstruction algorithm two datasets were obtained from the endsystolic, endiastolic phase respectively. effective slice thickness amounted to 2 mm, increment to 1 mm. measurements were performed in 10 mm thick slices cut orthogonal to the short axis of the heart. functional parameters determined were endiastolic (edv) and endsystolic ventricular volume (esv), segmental wall thickening and ejection fraction (ef). all measurements were performed using a mri-proved evaluation software (argus 2.3 wip, siemens, germany). invasive angiocardiography served as a reference measuring method using centerline analysis for functional evaluations. results: concerning evaluation of the ejection fraction, the wilcoxon test for matched pairs did not reveal significant differences between the two methods (tukey confidence interval: p = 0.95). however ca tended to overestimate ef by 4.5 %. the limits of agreement between ct and ca in ef were ±24.2 %. significantly higher differences between both methods were found for edv rather than for esv, again values being overestimated by ca. the best correlations for edv, esv and ef were obtained in patients with dcm. hypokinetic wall areas were detected with a sensitivity of 87.5 % (21/24), hyperkinetic regions with 92.6 % sensitivity (25/27). conclusion: multislice-cardiac-ct provides precise evaluation of functional parameters such as ejection fraction, wall thickening or endiastolic and endsystolic volume. to evaluate left ventricular volumes and systolic function using multirowdetector spiral computed tomography (mdct) with retrospective ecg gated biphasic data reconstruction in comparison to left ventriculography (lvg). methods and materials: 25 patients underwent routine mdct coronary angiography using retrospective ecg-gating. dedicated algorithms allowed for a temporal resolution of 250 ms. contrast enhancement was provided by administration of 120 ml of iopromid. to assess lv volumes and systolic cardiac function biphasic reconstruction at end-diastole (ed) and end-systole (es) was performed. data reconstruction timing was based on the ecg trace with placing the ed window at −100 ms before the r-wave and the es window to cover the t-wave. short axis views were reconstructed from ed and es data sets and the simpson rule used for calculation of ed volumes (edv), es volumes (esv), stroke volumes (sv) and ejection fractions (ef). data were compared to results of lvg. results: edv (r = 0.59) and sv (r = 0.56) showed good correlation with lvg, whereas esv (r = 0.88) and ef (r = 0.82) showed very good correlation. mdct significantly overestimated edv (md: 22 ± 36 ml; p = 0.0045) and esv (md: 39 ± 22 ml; p < 0.0001) whereas sv (md: −17 ± 27 ml; p = 0.008) and ef (md: − 17 ± 9 %; p < 0.0001) were significantly underestimated. mdct intraobserver variability ranged between 4 % and 6 %. conclusion: ecg orientated biphasic reconstruction of coronary mdct data sets allow for estimation of lv volumes and systolic function without the need for additional scanning. however, with current possible temporal resolution cardiac volumes are consistently higher in mdct and therefore sv and ef are underestimated in comparison to ventriculography. r. rienmüller, g. reiter, u. reiter, n. gagarina, a. ryabikin, b. schröttner; graz/at purpose: comparison of left ventricular volumes and muscle mass studied by electron beam tomography (ebt) and magnetic resonance (mr) evaluated by a geometry-based model as well as 3d methods in patients with suspected or known coronary heart disease. materials and methods: 40 patients were studied by ebt (ecg gated, multislice mode, 50 ms exposure time, intravenous contrast agent application) in long axis view and by mri (1.5 t field strength, 40 mt/m gradients, cine-truefisp) in 4 chamber view. enddiastolic (edv) and endsystolic (esv) volumes as well as left ventricular muscle masses (lvmm) were evaluated by a single-plane ellipsoid model. in addition mri short axis scans were performed in 23 patients to use simpson rule (argus software) to determine the above parameters. results: correlation between ebt and mri ellipsoid model is r = 0.87 (95 %-confidence interval is 0.76 to 0.93) for edv, r = 0.92 (0.85 to 0.96) for esv and r = 0.82 (0.68 to 0.90) for lvmm. correlation between ebt and mri simpson approach is r = 0.92 (0.81 to 0.96) for edv, r = 0.93 (0.83 to 0.97) for esv and r = 0.79 (0.55 to 0.91) for lvmm, respectively. relative standard deviations of the differences of single paired measurements varied in the range of 15 % to 25 %. conclusion: both ebt and mr methods may be used to determine left ventricular volumes and mass. the differences of standard deviations implicate the need to determine ranges of normal values for all evaluation approaches in clinical routine. background: several tumor-host biological factors seem to be valuable predictors for the prognosis of patients with squamous cell carcinoma (scc) of the head and neck, such as the peritumoral lymphocytic infiltration (pli) or a sharp tumor border. in particular, significant associations have been reported between the presence of pli and the absence of cervical adenopathy. preoperative biopsy specimens are often insufficient for an evaluation of these criteria. therefore, this study was performed to examine whether an elevation of peritumoral ct-values correlates with the presence of pli. moreover, correlations with present cervical adenopathy were obtained to check whether an elevation of peritumoral ct-values can be regarded valuable in predicting a prognosis. methods: in total, 45 patients with primarily resected scc were involved (pt1 = 8, pt2 = 13, pt3 = 9, pt4 = 15); 28 patients were pn-positive. all tumors were histopathologically analyzed regarding the presence of pli and a sharp or infiltrating tumor border. based on standardized ct examinations, repeated roi-based density measurements were obtained in vital parts of the tumor boundary. statistics were performed to find dependencies between pli, pattern of tumor invasion, cervical adenopathy, t classification, and ct densities. results: our results show that an elevated peritumoral ct-density is a highly specific and sensitive sign for the presence of pli. moreover, there were significant statistical correlations of present pli and elevated peritumoral ct-values with absent regional lymph node metastases. our results show that the evaluation of peritumoral ct-values appears to be a valuable prognostic co-factor, useful in the majority of patients (especially in patients without clinically detectable cervical metastases). clinical trial of the accuracy of a freehand and sensorless three-dimensional power doppler ultrasound system measuring the diameters, volumes and vascularity of malignant primaries of the neck m. keberle, m. jenett, d. hahn; würzburg/de purpose: the diameters, volumes, and vascularity of malignant primaries of the neck have substantial impact on staging and prognosis. the purpose of this study was to determine the accuracy of a novel freehand and sensorless three-dimensional power doppler ultrasound (3d pdus)technique in the assessment of these parameters. saturday method: 24 patients with squamous cell carcinomas of the neck underwent conventional ultrasound in b-and power doppler-mode (us), 3d pdus, and computed tomography (ct). diameters (sagittal, longitudinal, and transverse) and volumes of the tumors were correlated with hand-segmentated ct images, and tumor vascularity with us. results: 3d pdus and ct were highly correlated regarding diameters and volumes (correlation coefficients r = 0.98/p < 0.001 and r = 0.98/p < 0.001, respectively). 3d pdus and us highly correlated regarding vascularity (r = 0.92/p < 0.001). conclusion: although 3d pdus is based on a freehand and sensorless data acquisition, it appears to be as accurate as ct or us for measurements of diameters, volumes, and vascularity of neck malignancies. in spite of the excellent results it has to be noted that this technique requires a lot of training and its general use has to be employed with caution. prognostic significance of the revised tnm staging 1998 in patients with locally advanced nasopharyngeal carcinoma (ncp) a. kalogera-fountzila, c. kouskouras, n. fotiadis, e. vakali, g. sevas, c. christoforidis, l. papadopoulou, a.s. dimitriadis; thessaloniki/gr purpose: to evaluate the prognostic significance of specific anatomical structure involvement related to the revised tnm staging (1998) in patients with locally advanced npc. materials and methods: ct images of 132 patients, who were treated in our hospital with radiation or chemotherapy and radiation, were retrospectively reviewed. we analyzed, the ct scans performed prior and after the completion of treatment. results: there were 99 men and 33 women (median age 54 a). histology was undifferentiated carcinoma in 104 patients and scc in 28. the paranasopharyngeal space was found to be involved very commonly (98 %). degree 1 (d1) of paranasopharyngeal extension included 27 % of the patients, d2 39 %, and d3 32 %. the incidence of osteolysis was 33 % (clivus 20 %, foramen rotundum 5 %). cavernous sinus involvement was present in 15 % and carotid sheath in 38 %. retropharyngeal nodes were found in 42 % of the patients. t2b (65 %) and t4 (20 %) as well as n1 (29 %) and n2 (50 %) were more frequent. after the completion of treatment 81 patients demonstrated complete response. after a median follow up of 79 months 31 complete responders have relapsed. median time to progression for all patients was 37 months and the median survival 55 months. cox univariate analysis revealed, age, t1, t2, paranasopharyngeal extension and cavernous sinus involvement, as significant prognostic factors for survival. the revision of tnm staging, in our study, was useful in the prognosis of npc. the degree of extension of the tumor into the paranasopharyngeal space has to be considered in future tnm staging revisions. the prognostic value of mri in nasopharyngeal carcinoma s.s.a. lingawi, y.f. ragab, m. mansour; jeddah/sa purpose: to evaluate the role of mri in the prediction of nasopharyngeal carcinoma (npc) response to radiotherapy. material and methods: 52 npc patients had mri before and after radiotherapy to the local disease and to the nodal involvement. the mri assessed the size, site, signal intensity, enhancement pattern and extension of the regional disease in 25 anatomical sites. radiotherapy was delivered using x-rays of 4 -6 mv linac. purpose: head and neck tumors show considerable variation in perfusion pattern and biological behavior as well as response to chemoradiation. the high frequent acquisition of multislice ct data after a contrast medium bolus allows quantification of tumor perfusion. the aim of this study was to assess therapy-induced changes of tumor perfusion early after initiation of treatment. methods and materials: dynamic msct was performed in 22 patients with histologically proven head and neck cancer before and 3 weeks after initiation of chemoradiation. after bolus injection of 80 ml contrast medium, two 10 mm-sections through the largest tumor region were scanned for 40 s (siemens somatom volume zoom). the arterial input function was derived from the largest arterial vessel in the field of view. perfusion values were calculated using graphical analysis and displayed as parametric color coded images. standardized circular regions of interest were drawn on the area displaying highest perfusion. the tumor area was determined by the product of the maximum perpendicular diameters. results: at baseline, all tumor lesions were visible in parametric images by enhanced perfusion values (0.474 ml/min/ml ± 0.212), however the perfusion pattern was very inhomogeneous. the tumor area was 1007 mm 2 ± 736. three weeks after initiation of chemoradiation, tumor perfusion increased to 0.493 ml/min/ml ± 0.214, whereas tumor area decreased to 734 mm 2 ± 960. there was no correlation between perfusion and tumor size changes (r = 0.185). these results indicate that chemoradiation induces significant changes of tumor perfusion. standardized assessment is possible by perfusion msct. evaluation of radiation response with dynamic gadolinium-enhanced mri for head and neck cancer: correlation of hemodynamic changes with pathology n. tomura, k. omachi, k. kato, s. takahashi, i. sakuma, k. sato, j. watarai, m. sageshima; akita/jp purpose: to assess the diagnostic value of dynamic gadolinium-enhanced mr imaging in the evaluation of response to radiation therapy for head and neck cancer, and to correlate hemodynamic changes after radiation therapy with pathology. methods and materials: mr imaging was prospectively performed before and after radiation therapy in 26 patients with various head and neck cancers. a dynamic gd-enhanced study was performed using a fast spgr sequence. the maximum slope of increase (msi) on the time-intensity curve was displayed as a colorcoded image. ratios were obtained for peak time of enhancement (tpr) and intensity of maximum enhancement (mer), as well as the msi (msir) between the a c d e f 194 tumor and normal muscles. tpr, mer, and msir after therapy were compared with those before therapy. pathologic specimens after radiation therapy were acquired in 23 patients. histological grading of radiation changes was divided into grades i -iv. tpr, mer, and msir after therapy were compared with histological grades. results: a significant difference (p < 0.05) was observed in msir before and after therapy. although only 4 of 19 patients with grade ii (viable tumor cells present) or iii (only non-viable tumor cells) showed a msir < 2.5, all patients with grade iv (no tumor cells) showed a msir < 2.5. conclusion: msi quantitatively reflects the treatment response of radiation therapy for head and neck cancer. color-coded msi display is feasible for depicting hemodynamic changes following radiation therapy. scintigraphic prediction of resistance to radiation and chemotherapy in patients with head and neck tumors k. sato, n. tomura, o. watanabe, k. sasaki, j. watarai; akita/jp purpose: 99 tc-sestamibi (mibi) spect was compared with 201 tlcl spect for prediction of multidrug resistance and radioresistance in patients with head and neck tumors. materials and methods: eighteen patients (age range: 48 -76 a, mean 63 a) with tumors in the head and neck region (larynx in 6, oropharynx in 5, hypopharynx in 5, oral cavity in 1, maxillary sinus in 1) were evaluated with dual-isotope spect imaging using 99 tc-mibi (600 mbq) and 201 tlcl (111 mbq) at 15 (early) and 120 (delayed) minutes after the injection. quantitatively, tumor-to-background (t/b) ratio of tracer uptake was calculated in the early and delayed phases of each tracer, and retention index was calculated as follows: [(delayed ratio − early ratio)/early ratio] × 100 (%). using radiation and chemotherapy concurrently, the patients were classified into partial remission (pr) and no change (nc) groups. the relationship between therapeutic response and tracer uptake was analyzed. the detectability of resistance to radiation and chemotherapy was examined. results: the delayed ratio for 99 tc-mibi in the nc group was significantly lower (p < 0.05) than that in the pr group. there was no significant correlation between t/b ratio and tumor response using 201 tlcl. there were no significant differences in the early ratio and the retention index with respect to the tumor response in both 201 tlcl and 99 tc-mibi spect images. conclusion: 99 tc-mibi spect may be more effective than 201 tl spect for prediction of multidrug resistance and radioresistance in patients with head and neck tumors. purpose: to evaluate the need for doubling the effective mas in obese patients when performing low dose multi-row detector ct (ldmrdct) for the assessment of ureteric lithiasis. materials and methods: 106 consecutive patients with known body mass index (bmi), and clinical suspicion of renal colic were referred for a ldmrdct with the volume zoom (siemens) and 120 kv, 30 mas, 4 × 2.5 mm collimation, 0.5 s/rotation, pitch of 1.5. a second acquisition limited to the region with artefacts, using the same parameters but 60 mas, was obtained if necessary. slice thickness and increment were of 3 and 2 mm respectively. workstation based assessments of ureteric lithiasis were later performed by 3 radiologists who were unaware of the final results, and compared all clinical, surgical and radiological results available. effective dose was computer simulated and correlated with bmi. results: intra and interobserver agreements were greater than 0.88. the prevalence of ureteric lithiasis was 36 % and the accuracy of ldmrdct ranged from 95 to 98 %. effective doses for males and females were 1.2 and 1.9 msv respectively at 30 mas and 0.5 and 0.8 msv respectively in 20 patients with focused acquisitions at 60 mas. a bmi of 35 was found to be a threshold over which all patients needed 60 mas. conclusions: ldmrdct with 30 mas in patients with normal weight and with 60 mas in those with bmi greater than 35 is an accurate method for assessment of ureteric lithiasis, resulting in a dose similar to a 3 film ivu. mdct was used with 4 × 1.0 mm collimation, 100 mas, and 120 kv (ctdi = 11.4 mgy). we compared 3 reconstruction protocols (slicewidth/reconstruction interval: 1.5/0.7 mm, 3/1.5 mm, 5/2.5 mm). in addition, multiplanar reconstructions (mpr) in coronal plane were performed. 3 experienced readers analyzed each scan. presence, number, size of calculi and additional findings not associated with urinary stone disease were evaluated. results: mdct was positive for calculi in 107 cases independent of axial reconstruction protocols. coronal mpr's were helpful in evaluation of the precise stone location, although on 5 mm mpr's significantly less calculi were depicted. there was also no significant difference between performed protocols in evaluation of additional findings. conclusion: axial reconstruction protocols (1.5/0.7 mm, 3/1.5 mm, 5/2.5 mm) are equally suited in the diagnosis of urinary stone disease. coronal mpr's are helpful in the evaluation of precise stone location, however very small calculi may be missed on 5 mm coronal reconstructions. purpose: this study investigates the possibility of using combined blood oxygen level dependent (bold) imaging and diffusion weighted imaging to detect pathological changes in renal tissue induced by chronic renal hyper-filtration. the apparent diffusion coefficient (adc) and the t2*value within the four inner compartments of the kidneys of 17 rats with diabetes mellitus were compared with the results obtained from a control group of 16 rats. furthermore, the influence of the hyper-filtration on the blood-oxygen saturation was evaluated by comparing the t2*-values before and after the active tubular transport was reduced by injecting furosemide. results: all compartments of the diabetic kidney showed significantly (p < 0.05) lower t2*-values compared to the control group. in particular, the very low values in the outer stripe of the outer medulla (t2*-normal: 69.4 ± 10.9 ms; t2*-diabetic: 51.4 ± 13.9 ms) indicated either hypoxia due to hyper-filtration or renal blood volume changes. diffusion imaging of the same area showed significantly lower adc values (adc-normal: 1.45 ± 0.26; adc-oedema: 1.19 ± 0.25 [10 -9 m 2 /s]) that correlated with pathological findings on biopsy. conclusions: bold-contrast imaging appears to be able to depict tissue that is at risk of suffering from ischemia by revealing information about the balance between tubular workload and delivery of oxygen and may thus reflect a measure of the reserve capacity. the diffusion measurements reveal complimentary information -adc imaging is not sensitive to the current energy metabolism but reflects the pathological changes within the tissue. therefore adc-measurement might be a sensitive indicator of the severity of the induced ischemic lesions. virtual endoscopy of moderate or non dilated renal pelvis and calices with unenhanced 3d t2-weighted static fluid mr urography: a prospective study c. roy, c. vasilescu sr., l. solair sr., c. tuchmann sr., c. saussine sr., d. jacqmin sr.; strasbourg/fr purpose: to assess the accuracy and usefulness of virtual endoscopy (ve) by mr to study moderate dilated renal cavities. method/materials: 33 patients, having excretory tumours (n = 18), calculi (n = 11), and extrinsic compressions (n = 4) underwent mru (1 t philips) using t2 3d tse (tr/ete: 1800/500 ms, etl: 130, 80 slices, slice thickness: 0.6 mm, 256 × 256, fov: 240, ta: 4 min 21 s. ve were reconstructed using volume rendering and were interpreted (mip reconstructions, sources images) by two radiologists. correlation was made with conventional endoscopy/pathological findings. results: mean operator time was 20 min. endoluminal masses (up to 3 mm) were depicted by source images and ve, but missed by mip in 5 cases (2 tumours, 3 stones). morphologic assessment (smooth or irregular surface, position, number, surface extension) was more pertinent on ve than on sources images. blood clots (3 cases) were misdiagnosed as tumoural polyps. a smooth surface with abrupt margins was present for all stones and in 8 cases of tumoural process. an irregular surface was only present in tumoural processes. ve images did not allow evidence of intramural extension of the tumour. assessment of surface alone did not allow to differentiate between a calculus from a smooth polyp. conclusions: ve is easily feasible in moderate or non dilated renal cavities. it permits precise location and number of filling defects with delineation of the surface extension. it is not really time consuming and it seems to be a promising modality for optimal visualization of pelvo-caliceal pathology. in 2 patients the process progressed to abscess formation. retracted cortical scars in 9 patients reflected the healing phase. the ivu was normal in 16 of 18 patients with early lesions showing minimal delay of contrast excretion in the collecting system in 2 patients. conclusions: early cortico-medullary and nephrographic phase spiral cts are highly sensitive in detection of compromised parenchyma in the pyramids indicating papillary necrosis and thereby allow treatment at a time when the disease process is still reversible. methods/materials: we minimize patient dose by adapting the tube current to anatomy in two ways: a local projection angle dependent tube current modulation that minimizes the current for projections of low attenuation is combined with a global tube current control that adapts the tube current 360° mean level to the anatomic level. our method uses the projections currently scanned to "foresee" the behavior while scanning the next 180° segment. based on user-defined image quality parameters (selected by choosing the desired reconstruction kernel and the image noise standard deviation in hu) the tube current curve is computed. the approach has been tested in simulations and phantom measurements on a somatom volume zoom scanner (siemens, forchheim, germany). to further reduce the projection noise we have implemented a raw data-based maf approach. it locally smoothes the projection values of highest attenuation. maf is utilized as a preprocessing step during image reconstruction; the algorithms are implemented on the syngo explorer workstation (vamp, moehrendorf, germany). results: maf reduces image noise by up to 50 % and thereby allows for respective dose reduction. the combination of aec and maf allows to secure this reduction and to increase it further. conclusions/discussion: the combination of aec and maf allows to greatly reduce patient dose for a given image quality over complete anatomical ranges. the user simply specifies the desired image quality instead of setting the "mas-value" or other parameters. spiral imaging properties of a 16-slice ct-system t.g. flohr, k. stierstorfer, h. bruder, j. simon, s. schaller; forchheim/de purpose: the spiral imaging properties of a newly introduced 16-slice ct system (siemens, forchheim, germany) are evaluated. the 16-slice ct system provides a novel image reconstruction technique for multislice spiral ct (adaptive multiple plane reconstruction ampr) which takes into account the cone-angle of the measurement rays and allows for a free selection of the spiral pitch. for a given collimation (e.g. 16 × 0.75 mm), a variety of different spiral slice widths is available. we measured spiral slice sensitivity profiles, image noise in a centered 20 cm water phantom and dose (ctdi 100) as a function of the spiral pitch in the range 8 to 24. in our definition, the spiral pitch is the purpose: aim of our study was to establish a complete analytical description of noise and resolution in x-ray computed tomography (ct) and to predict trends for patient dose with respect to future developements in ct technology. we performed various simulations to validate the analytical predictions of pixel noise dependency on sampling distance in parallel beam geometry and the convolution filter. further, we measured image noise and high contrast resolution on a clinical ct scanner (siemens somatom volume zoom), thereby operating with all available scan modes. data sets were reconstructed with several convolution filters. results: noise variance at the center of a typical 20 cm water phantom varies with the inverse third power of the sampling distance. the tests with measured data showed that the convolution filter influences noise and resolution directly with variance depending linearly on the total area under the squared modulation transfer function (mtf). based on the measurements we were able to derive noise equivalent quanta for the ct scanner under examination. conclusion: due to the interdependence of noise and resolution, which is an intrinsic property of tomographic reconstruction from projections, it can be predicted that the dose necessary for constant noise level and unchanged object size will increase by a factor of x 3/2 when the resolution element is reduced by 1/x. this has direct implications for future ct systems that employ flat panel detectors with sampling distances down to 0.1 mm, thereby yielding a tenfold improved resolution compared to today's high-end ct scanners. method and materials: 50 patients with head and neck tumours were scanned using a multislice ct scanner (somatom volume zoom, siemens medical solutions, germany) with a high resolution protocol. reconstruction was performed using dedicated reconstruction software (impactir, vamp gmbh, germany) with the standard algorithm and the maf approach. we measured the noise for 6 anatomical regions at the level of the humeral heads. image quality, image noise and the diagnostic value comparing the standard reconstructions to the multidimensional adaptively filtered images was rated. results: the use of maf significantly improves image quality by reducing noise levels and by removing noise structures in the images. noise is reduced by 39 % on average, depending on the patient shape and the anatomical regions. the overall image quality is rated significantly better with maf in comparison to the standard reconstruction without any loss of image sharpness. especially the visualization of the cervicothoracic junction is drastically improved for all examinations, whereas the image quality of the upper neck is unchanged. the differentiation of anatomical and patholocical structures is enhanced in particular in the upper mediastinum and in the supraclavicular regions. the reduction of image noise, the improvement of image quality and the high diagnostic accuracy achieved with maf without any loss of image sharpness offers new perspectives to reduce patient dose. the reduction in patient exposure and image quality and noise were evaluated. to assess the noise, the standard deviation of the density of the trachea and the aorta were used. for the image quality a three point scale: worse -equivalentbetter. the mean dose reduction in the modulated scans was about 29 % (p < 0.001). in the area of the shoulder it was about 35 %, of the thorax and abdomen about 25 % and of the pelvis about 29 %. the noise of the images in the modulated scans was between 17 % (p = 0.01) at the level of the trachea bifurcation and 15 % (p = 0.06) at the level of the aorta bifurcation higher compared to the standard scans. with attenuation-based on-line modulation of tube current in 21 cases the diagnostic image quality was assessed as equivalent to the images using the standard protocoll. in 3 cases the image quality was worse. the use of attenuation-based online modulation of tube current allows a substantial dose reduction without a diagnostic relevant decrease in image quality. characterizing coronary artery motion using multi-slice ct m. vembar 1 , d.j. heuscher 1 , d.e. smith 1 , d.d. matthews 1 , s. chandra 1 , m. garcia 2 ; 1 highland heights, oh/us, 2 cleveland, oh/us purpose: 3d motion of proximal regions of the coronary arteries during the cardiac cycle were measured from image data obtained from multi-slice computed tomography to identify cardiac phases for optimal coronary imaging and to provide a realistic model for cardiac simulation. methods and materials: spiral ecg-gated contrast-enhanced 1 mm retrospectively reconstructed scans were performed on patients with heart rates ranging from 49 to 75 bpm using four-slice ct (marconi mx8000) at a temporal resolution of 250 ms. using landmarks along the proximal regions of the coronary arteries (left main and anterior descending (lm and lad), right coronary artery (rca) and left circumflex (lcx)), we obtained estimates of 3d position and velocity of these arteries during a cardiac cycle. identifying phases with minimum velocity, we correlated the image quality in these regions with the estimates obtained. results: motion characteristics varied depending on the artery, with the highest degree of motion being observed for rca. the points at which the lowest velocities occurred correlated well with the images in which the arteries could be best viewed. though more than one minimum was observed within a heart cycle for all arteries, the most consistent image quality was observed at 70 -85 % of the cardiac cycle. we were able to estimate the 3d motion of the three major coronary arteries. by identifying the phase in the cardiac cycle with lowest velocity, imaging of each coronary artery can be optimized. using these estimates in characterizing cardiac motion also provides realistic simulation models for future cardiac ct applications. and t2-weighted (haste) sequences in coronal (5 mm) and axial (4 mm) plane, followed by a coronal gadolinium-enhanced-acquisition with fat saturation (flash 2d in accordance to the recist criteria for evaluation of tumor response, target lesions were analyzed. t2 weighted, native and dynamic enhanced t1 mri were acquired. shape and character were described. size was taken as the clinical gold-standard for response criteria progression, stable disease or regress. 3 groups of patients were compared: response (n = 19); stable (n = 6); progression (n = 3). signal-to-noise (snr) measurements in t1 and t2 were obtained and correlated with size. results: preliminary results show that sti-571 changes morphological characters of the target lesions dramatically. in the response group decreasing lesions correlate with snr in dynamic t1 mri (r = 0.78; p < 0.01) but not in t2 (r = −0.13). in the progression group mri shows no significant correlation between size and dynamic t1 (r = 0.43) but in t2 images (r = 0.99; p < 0.01). these findings are concordant to the morphological change from solid to cystic or necrotic lesions. the information of mri in the early follow-up is helpful to individualise the management of patients in a timely way and to keep patients with increasing, but morphologic-changing tumor leasions in the study protocol. saturday material and methods: a prospective, randomized and double-blind trial was conducted in 50 patients randomly distributed into 2 groups: the control group (received only an oral solution) and a treated group (received the oral solution plus a subcutaneous injection of 20 mg of butylscopolamine 10 minutes before the mr examination). breath hold t1w gre images were obtained. quantitative image analysis was performed of the signal intensity of the liver and in background air anterior and lateral to the patient. a qualitative analysis of the subjective image quality was also done, and the adverse reactions were registered. results: the groups were homogeneous regarding age, sex and weight distribution. no significant differences in the signal intensity of the liver and in the incoherent noise measurements were found between both groups. gastrointestinal noise was statistically lower for the butylscopolamine group compared to the control group. there was also a statistical difference in the image quality between groups: optimal studies were only found in the butylscopolamine group. regading adverse events, there was non-significant differences between groups. to define the spiral ct findings in patients with superior mesenteric vein (smv) thrombosis and to compare these with surgical findings. material and method: abdominal ct examination of 12 patients with partial or total smv thrombosis were retrospectively reviewed by two radiologists. the level of the thrombus, patency of portal vein and intestinal findings were noted. these findings compared with the surgical findings in patients who were operated following smv thrombosis. results: in 10 of the 12 patients (83.3 %) there was complete thrombosis of smv and 2 patients (16.7 %) thrombus was partial and non-occlusive. in one patient with complete smv thrombosis, air was observed within smv and portal vein. portal vein was totally thrombosed in 8 patients (66.7 %), partially thrombosed in 2 patients (16.7 %) and patent in 2 patients (16.7 %). all 10 patients with complete thrombosis smv were operated and smv thrombosis was confirmed in these patients. small bowel resection was performed in 9 patients and sigmoid colon resection was performed in 1 patient. ischemic changes in small bowel could be detected preoperatively in 8 of the 9 patients who had small bowel resection. colonic wall thickening was observed in 5 patients including the patient with sigmoid resection. colonic ischemia was not confirmed by surgical findings in other 4 patients. conclusion: spiral ct can reliably demonstrate the presence, level and extent of the smv thrombus. spiral ct can also detect ischemic changes in the intestine and especially small bowel findings correlate well with the surgical findings. to determine whether ultrasound-guided delineation of the tumour bed after breast conserving surgery can improve the accuracy of conventional electron boost planning. methods and materials: 20 patients underwent post-operative radiotherapy plus electron boost following wide local excision for breast cancer, were selected at random. conventional boost planning was undertaken using clinical examination, surgical details and pre-operative imaging, and a standard boost field recorded. next ultrasound was used to delineate the tumour bed and an optimum boost field calculated using parameters including cavity size measured by ultrasound, 10 mm margin and 5 mm error margin. the standard and optimum fields were compared and potential areas of under and over-treatment of the standard field calculated. clinically acceptable values for these were set at 0 % of optimum boost area for under-treatment and 300 % of optimum area for over-treatment. the dmni visualisation and sampling management include galactography (ggr), mr and ultrasound ggr, fiber-ductendoscopy to investigate patients with intraductal abnormality. using ductal lavage (dl) and saline retrieval we tested material collected from breast ducts cells by methylationspecific pcr (msp) methylated alleles of cyclin d2, rar-, and twist genes detected in fluid from mammary ducts or endoscopically visualized dcis. northern blot analysis was performed for expression in epithelial cells. results: we were successful in intraductal cannulation, endoscopies and molecular testing, resulting in 96 % diagnostic accuracy. high-risk subjects were enrolled in two groups of a previous history of breast cancer and, a gail index score m 1.7 or brca 1/brca 2 positive status. of 502 eligible subjects suspicious/malignant cells were detected in 2 8 % (36/502). a comprehensive database created from imaging, interventions and molecular study protocols explored current pathology management. mr, ultrasonography dgr, and ductoscopy revealed papillomas but no high-grade intraductal lesions correlated with the lavage cytology. immunohistochemistry, histology grading, and the relevance of diagnostic certainty were considered. the dmni is feasible for early breast cancer conservation and prevention. evaluation of cellular samples for tumour biology and molecular imaging are the strongest predictors of the outcome. diagnosis, risk assessment, and prognosis emphasise the indicators for breast dcis, dmni and for survival rates. preoperative assessment of axillary lymph node involvement in breast cancer by ultrasound r. wenke, l. sanders, a. grosse, i. schreer; kiel/de purpose: to assess the sensitivity of ultrasonographic axillary lymph node detection and accuracy of different sonographic signs of malignancy in correlation with histopathological examination. material and methods: we examined 61 patients with preoperative histologically proven breast cancer. in 34 patients conventional axillary dissection was performed, 27 patients underwent excision of sentinel lymph node (s). clinical examination was performed independently. sonographic criteria included lymph node size, form, shape, presence or absence of hilar reflex, echogeneity, cortical rim thickening and vascularisation. results: ultrasonography detected 0 -7 lymph nodes (mean 2.66) were detected in level 1 and 0 -2 (mean 0.5) in level 2. histologically 2 -29 (mean 12.07) were detected in level 1 and 0 -9 (mean 3.01) in level 2. in 20 patients (31.74 %) axillary lymph node metastasis was detected histopathologically. sonographically suspicious lymph nodes were inferred in 23/61 (36.5 %) patients. in 4 cases (20 %) lymph node metastasis was missed, including one case of micrometastasis. clinical examination revealed only 9/20 (45 %) axillary metastases. sensitivity of ultrasonography was therefore 80 %, specificity 82.9 %, positive predictive value 69.5 % and negative predictive value 89.5 %. a satisfying prediction of axillary lymph node involvement can be achieved by means of ultrasonography. the lack of detection of micrometastases and of lymph nodes smaller than 5 mm is still a problem. the false positive rate (7) could possibly be decreased by an optimised combination of morphologic aspects. with a negative predictive value of 89.5 % ultrasonography can be a powerful tool in pre-selection for sln biopsy and the necessary follow-up of these patients. .5 g needle with appendant coil was used. after the procedure the distance from the coil artefact to the lesion was measured in two planes (sagittal, transverse). all lesions have been histologically proven by excisional biopsy 12 to 72 hours after the mr-guided localisation. results: localisation and excision of the lesion was successful in all cases. each mr-guided procedure lasted 45 -150 minutes (mean 66 min). 20 % (11/55) of the lesions were malignant. in most cases (75 %, 41/55) the coil was placed immediately adjacent to the lesion. the coil was placed up to 10 mm and 11 -15 mm (mean distance 1.8 mm, range 0 -15, sd 3.5) away from the lesion in 20 % (11/55) and 6 % (3/55) of cases respectively. conclusion: mr-guided localisation of only mr-detectable breast lesions with an embolisation coil system is easy to perform and results in a high precision. the coils are hocked into the tissue and detectable by specimen x-ray. the aim of our study was to investigate the feasibility and potential of cryosurgery in the therapy of breast cancer. materials and methods: 21 patients (60.5 ± 9.4 a) with histologically proven breast cancers underwent cryotherapy. after ultrasound-guided placement of the cryo probe in the tumour, two freeze/thaw cycles with a duration of 7 and 5 minutes respectively were carried out. the diameters of the occurring iceballs were measured sonographically. the patients were operated within 1 to 5 days later. the operation specimens were evaluated histologically. the maximum diameters of the iceballs were between 21 and 31.8 mm. the surface of the iceballs was well definable in ultrasound. 6 tumours with a diameter below 16 mm and one tumour with a diameter of 19 mm did not show rests of invasive cancer after treatment. 3 of them had dcis in the surroundings. subtotal necrosis was observed in 14 tumours which had a diameter of 16 mm or greater. conclusion: after these first cases cryotherapy seems to be promising in the treatment of small breast cancers. the low detection rate of surrounding dciscomponents in pre-interventional mri of breast cancer results in remaining dcis after cryotherapy. in larger breast cancers two or more cryo probes should be used to achieve larger iceballs. purpose: to examine the effectiveness of a potential minimal-invasive method for the elimination of breast tumours by magnetic heating. methods: a human adenocarcinoma (mx-1 cells) was implanted into 16 scid mice. after intratumoral application of iron oxides (7 ± 3 mg per 350 mm 3 tumour tissue; average particle diameter: 10 nm), mice were exposed to an ac magnetic field (4 min; amplitude: 6.5 ka/m, frequency: 400 khz). 4 controls did not receive an iron oxide application. temperatures at the tumour and rectum were monitored and quantified as total heat doses (thd = temperature × time). dna damages were investigated using the comet assay (percentage of dna in the tail). a calibration curve between temperature and dna damage was determined. results: intratumoural temperatures ranged from 59°c to 96°c (thd from 105 to 315°c × min), the percentage of the total cellular dna in the tail was of 67 ± 23 %. in controls, no significant temperature elevation was observed and only 8 ± 2 % of the dna was found in the comets tail. in vivo and in vitro experiments showed a temperature threshold for cell destruction of 55°c. conclusions: reliable tumour cell destruction is possible by magnetic heating. methods and materials: mr images of the eurospin-to4 phantom were obtained using standard 2d se, 2d tse, 2d-spoiled gre and 3d mpr sequence types and evaluation of spatial and high contrast resolution was performed. all images were transferred to a standard pc workstation utilizing a dicom protocol. these images were then converted to the four most commonly used image file formats on the web: tiff, jpeg, gif and png. a total number of 136 images using different file formats and compression ratios were evaluated. image quality a c d e f 206 (iq) was evaluated by consensus by three reviewers utilizing a 5 point grading scale (1: poor, 2: moderate, 3: good, 4: very good, 5: excellent). image size to image quality ratio's (is/iq) were also calculated for all images. results: minimal is/iq was obtained when working with low compression (20 -30 %) jpeg images and moderate to high compression (60 -80 %)png images. high compression jpeg images showed severe image distortion while maintaining acceptable spatial resolution. this problem was not encountered in png images. is/iq was quite satisfactory on gif images. tiff images were of excellent quality but with larger image sizes. the optimum compression levels were tested on routine brain and abdominal mr examinations with results comparable to phantom measurements. conclusion: the study determined the acceptable compression levels for jpeg and png mri images used for educational purposes on the web. the newly introduced png format offers high image quality with acceptable file sizes. • checking about 1000 homepages of international radiological institutes, • inquiries to eufora -a popular mailing list, • asking about 100 medical students and residents in radiology. the 100 favorite on-line teaching programs in radiology were evaluated by representatives of the target group -100 students and 10 residents in radiologyaccording to user friendliness, didactic, interactivity, content and layout. results: we created an on-line list (radlist) of categorized and evaluated on-line teaching files in radiology, ranked according to user friendliness, didactic, interactivity, content and layout. conclusion: radlist (http://www.radlist.uni-erlangen.de/) is a useful on-line tool for students and residents in radiology to find their way within thousands of internet teaching files in radiology. radlist will be updated regularly. open connectivity and interoperability of web based medical teaching file servers using xml-based web services t. schaaf, j. hohmann, k.-j. wolf; berlin/de purpose: support of automated access to dynamic webbased medical teachingfile-servers. the connectivity and system interaction should be realized with the help of consistent methods based on common standardized concepts and protocols. methods and materials: by using soap (simple object access protocol) as the fundamental information exchange protocol in cross-language and cross-platform communication, the herewith provided webservices offers a consistent application interface to dynamic generated data of our medical teaching-file-server. soap is an standardized (http://www.w3.org/tr/soap) and xml-based (extensible markup language; http://www.xml.org) protocol consisting a framework for describing the exchanged messages and their processing, rules for expressing instances of application-defined datatypes and definitions for representing remote procedure calls and remote responses. we have extend our multimedia teachingfile-server, built with no-cost common software components, with an php-based (php: hypertext preprocessor; http://www.php.net) soap-adaptor and could thereby offer the dynamic medical teaching-knowledge encapsulated in a medical webservice. since soap could be combined with existent common transport protocols such as http (hyper text transfer protocol), our webservice is seamless internet accessible. results: the php-based soap-adaptor handles the application-driven xml-defined messages addressing the server-stored procedures for accessing the medical teaching-file-data via the inter-/intranet. thus this application interface addresses the same database functions used by the beside existent human-computer-interface, our webservice provides the same programmed security issues. conclusion: the soap-ready extension of our multimedia dynamic webbased medical teaching-file-server supports the application layer interoperability through a consistent xml-based interface. thereby the provided medical knowledge could be easily accessed and integrated in decentralized, webbased knowledge-and workflow application frameworks in healthcare environments. building up a teaching system out of the radiological workflow a. schroeter 1, 2 , k. annacker 1, 2 , t. geisbe 1 , m. kroll 1, 2 , j. martin 1 , j. holstein 1 , d.h.w. groenemeyer 1 , h.g. lipinski 2 ; 1 bochum/de, 2 dortmund/de purpose: the aim is the development of a radiological teaching system, whose contents of the learning contexts are inferred directly from the radiological work routine. this system pulls dicom images, dicom presentation states and findings out of the ris and pacs to transfer them to an html learning text whitin an embedded dicom viewer. methods and materials: a radiologist will select a few images and send them to the teaching system together with the finding and presentation states. a learning text will then be extracted out of the finding. this text will be converted to an html page with an embedded java-based dicom viewer to visualize the medical images. within the html text, buttons will provide a context-referred view of the images via dicom presentation states. so all that radilogists will have to do, is to perhaps correct some text phrases or the layout. results: the result is a teaching system with its contents pulled out of the normal radiological workflow making it possible to transfer dicom images, presentation states and findings to interactive learning texts. dicom images can be freely manipulated and presentation states can be applied to achieve a context-referred view of medical images. conclusion: the efficiency of learning can be increased by being as close as possible to the real-life diagnostics and by making the images available for free manipulation. building up a learning case is quite easy because image data and views on these images already exist. webbased knowledge transfer in a radiology department for scientific and educational purposes j. hohmann, t. schaaf, k.-j. wolf; berlin/de purpose: to implement a basic system which allows: (1) scientific chats and interactive lectures, (2) live broadcast of scientific events, (3) access to teaching-files and examples in a medical image database. materials and methods: (1) the hyperchatsuite by fh software (www.fhsoftware.net) is freeware and allows common and private chat rooms as well. (2) for evaluation purposes of the live broadcasting the no-cost realsystem server basic (www.realnetworks.com) was installed which allows up to 25 concurrent users the access to the delivered data stream. realsytem servers supports up to 45 media types and different operating systems. (3) part of the teleteaching/-learning system is an access to teaching files and the medical database (introduced on ecr 2000). the medical database consists of open source components (mysql, www.mysql.com; apache, www.apache.org; php, www.php.net) and is in use since last year. results: (1) we conceptualised a lecture together with scientific groups in the usa regarding the principles of digital imaging. after performing initial testlectures this lecture will be held next term at our radiology departement. (2) the benjamin franklin contest 2001 was availaible as our first live broadcasted videostream of about 4 hours. (3) due to the flexible structure of the former medical image database the added functionalities with teaching files consisting of multi-media-data were easily achieved. conclusion: since the parts of the system fullfills our expectations in first trials we now have to get more experience during next term or year to find out about the advantages and disadvantages and to yield the necessary changes. current concepts in digital conference communication in radiology m.v. knopp, h. von tengg-kobligk, f.l. giesel, p.l. choyke; bethesda, md/us purpose: clinical conference of cases as well as group conference with clinician or research partners is one of the bases of radiological interaction in academia and hospitals. while pacs and all the advances in telecommunication have changed tremendously our work, these concepts have not been embraced sufficiently in conference communication. our group based in a major academic and research institution investigated the different capabilities available such as telephone (isdn) based systems picturetel, direct satellite links and web based approaches. the different systems were assessed using objective criteria such as speed, costs, image resolution etc. and subjective criteria using a questionnaire. results: many radiologists feel at unease using digital conferencing mostly due to lack of experience. after training, it was readily used and a code of conduct was helpful for training purposes. while image quality and speed is still superior with commercial systems, innovative uses of web based applications with concurrent b-0439 09:35 improving the workflow with central scheduling: introducing a "rad call center" p. gocke, a.p. bruckmann, j.f. debatin; essen/de purpose: to improve the workflow in a radiological department with central scheduling, by introducing a radiological call center (rcc) method/materials: with a separate module of our ris (radiological information system) we were able to introduce a central electronic scheduling. appointment schemes were created for all work places, time table-based or list-based. one central telephone number was assigned to the newly etablished radiological call center. rules were created for scheduling, and staff were trained by a telephone and marketing coach. results: with central electronic scheduling, the task of scheduling is removed from every workplace and focused on one center with specially trained staff. this center is an efficient tool offering flexible workload balancing. information about daily workload is available for every employee. especially helpful in workflow optimization was the introduction of 'virtual work places' were patients can be scheduled for urgent investigations and directed to the next available appointment. conclusions: central scheduling by a radiological call center improves workflow and enables a department to (re)direct patient flow and balance work load. inherent advantages were optimis ation of investigation strategies and avoidance of double/unnecessary investigations. acceptance of referrers is good (only one central telephone number!), especially when offering add-ons like a radiological advice service. work flow analysis using process simulation in a routine ultrasound division c. gillessen, u.k.m. teichgräber, j. ricke; berlin/de purpose: (i) to evaluate a routine ultrasound workflow by means of project graph technique (pgt) and process simulation (ps) and identify ways to redesign and improve it. (ii) to evaluate pgt and ps for significance and feasibility in workflow management. a workflow analysis of a routine ultrasound division was performed by: 1. observation and definition of work steps to perform an ultrasound examination. 2. time measurements of 500 activities using a software tool for parallel work step measurement. 3. designing a project graph. 4. pgt: calculation of operational measures. ps: generating operational measures by applying process simulation on network plan. 5. identification of reasons for delay. 6. process redesign and re-evaluation. results: average realistic examination time for abdominal ultrasound was 44 min 52 s. average simulated examination cycle time with 3 ultrasound devices, 3 examiners and 2 technicians was 10 min 42 s. by increasing personnel, average cycle time was reduced but average personnel slack time increased. major structural work flow deficits were not identified under given circumstances. replacing paper and film work associated activities with activities as expected with an electronic archive reduced total work effort by 16 %. major advantages of simulation over npt were the ability to consider cycle overlap and to calculate cycle times. conclusions: (i) under given circumstances, the observed work flow showed high efficiency. major effort reduction by the introduction of an electronic report and image archive is predicted. (ii) process simulation is superior to pgt in evaluating workflows and anticipation of the effect of variations. is speech recognition the best reporting method for any case? p. gocke, c. hogh, e.r. gizewski, j.f. debatin; essen/de purpose: to decide in which cases speech recognition is the best method for reporting, and in which cases other existing methods should be preferred method/materials: in our department, 'instant reporting' is performed by residents typing preliminary reports into a ris (radiological information system) based reporting module using a special ms winword 2000 environment. additionally, we have reporting stations equipped with a state-of-the-art speech recognition system (latest dragon naturally speaking professional with radiological dictionary). to compare both methods, the residents hand-stopped the time needed for generating the first, preliminary report for three different types of investigations: ct, skeleton and chest x-ray. results were discussed and tips were delivered for developing efficient auto-texts and macros. results: for ct, speech recognition was faster (4 min 49 s ± 1 min 44 s) than typing (5 min 10 s ± 1 min 32 s). for chest x-rays, there was no significant difference (speech recognition: 1 min 58 s ± 46 s, typing: 2 min 5 s ± 1 min 6 s). for skeleton x-rays, typing was faster (1 min 35 s ± 44 s) than speech recognition (2 min 4 s ± 58 s). conclusions: in many cases, speech recognition is an adequate technique for radiological reporting, but especially in cases of short and standardizable reports an autotext-and macro-based reporting technique is faster and more convenient. long-term experience with speech recognition of more than 240000 dictations t. ybinger, w. kumpan, f. karnel; vienna/at purpose: x-ray departments are increasingly under pressure to reduce costs and save time. this paper presents the experience of many years of using speech recognition to optime our services. the kaiser-franz-josef-spital in vienna is a 720-bed hospital which specializes in oncology and infectious diseases. a speech recognition system for producing reports was integrated into our ris early in 1998. since then the system has proved itself by completing more then 240000 dictations. we also investigated the efficiency increase achieved by using the system and its influence on our work processes. results: speech recognition is used to transcribe more than 98 % of our reports. we have been able to reduce the turnaround time for our reports by 35 % to an average of 8 hours. despite a high number of trainee doctors, 95 % of all reports are signed within 24 hours. our secretaries save approximately 40 % transcription time, and we have become more flexible in the use of typists. the average recognition rate is around 95 %, with some doctors clearly achieving even better results. however, of even greater importance to the workflow is an optimal integration into our ris. a c d e f 208 conclusion: speech recognition has fully established itself in our hospital and is routinely used for practically all dictated reports. this has considerably increased the productivity of our typists and clearly reduced the turnaround time of reports. we are convinced that speech recognition will soon make its entry as state-of-theart technology in numerous other institutes. when the bladder was filled of contrast-material-enhanced urine, the patient in supine position was asked to urinate. during the micturition t1-weighted spoiled 3d-gradient-echo acquisitions on sagittal plane were performed (acq.time: 12 s). these acquisitions were post-processed with mip algorithm. 15 patients performed retrograde and micturating conventional cystourethrography in the month preceding mri. one patient was unable to perform the exam because of the inability to urinate in the supine position. results: we always obtained perfect evaluation of the male urethra with voiding mr-cystourethrography. the visualization of the urethra with mip reconstructed images was considered comparable to that obtained with conventional cystourethrography. the analysis of 3d sagittal scans allowed a better evaluation of the urethral strictures in comparison with conventional cystourethrography. we detected 10 cases of bladder neck obstruction, 12 cases of urethral stricture and 3 case of benign prostatic hypertrophy conclusions: voiding mr-cystourethrography demonstrates the morphology of the bladder neck and urethra during the micturition and can a substitute for standard retrograde and micturating cystourethrogram, avoiding radiation exposure to the gonads. patients underwent combined mri and 3d-mr spectroscopic imaging (mrsi) of the prostate after up to (n = 16) or more than (n = 20) 16 weeks of ht. pretherapeutic psa levels (11.8 ± 10.1 vs. 14.2 ± 10.0 ng/ml) and gleason sums (6.2 ± 1.2 vs. 6.4 ± 1.0) did not differ significantly. posttherapeutic psa was dichotomised as being up to or more than 0.20 ng/ml. ht of more than 16 weeks was significantly associated with psa up to 0.20 ng/ml (15/20 vs. 3/16 patients, p = 0.002, chi square test) and loss of citrate from the peripheral zone of the prostate (15/20 vs. 5/16 patients, p = 0.022). psa exceeding 0.20 ng/ml was associated with prevalence of citrate (12/18 vs. 4/18, p = 0.020). citrate was detected at mrsi in 4 patients with psa under 0.20 ng/ml, including 3 of 4 patients on monotherapy with lhrh agonists for more than 16 weeks. in conclusion, this study finds an association between psa decrease and loss of citrate from the peripheral zone of the prostate in patients on ht for locally confined pca. there is a hint of dissociation of psa loss and detectable citrate in patients on longer-term lhrh agonist monotherapy that warrants more extensive analysis. longitudinal follow-up with combined mri and 3d-mr spectroscopic imaging of patients on hormone therapy for locally confined prostate cancer u.g. functional assessment in non radicular low back pain patients with an ultrasound-based 3d-topometry-system (zebris®) and radiographic motion analysis of the lumbar spine correlated with the results of a self administered health status questionaire a. petrovitch, s.o.r. pfleiderer, t.u. schreiber, w.a. kaiser; jena/de purpose: non-radicular low back pain (lbp) is a leading cause for compensation in industrialised countries with high socioeconomic impact. in the past it was mostly described by structural deficiencies, but not by disturbance of functional spinal segments or the instantaneous axis of rotation. methods: 45 out-patients (age 22 -85 a; 22 males, 23 females) with suspected vertebral instability were included. general health and orthopedic status was evaluated at admittance. health status was evaluated using the self-administered sf-36 questionnaire, which includes eight scales of functional health. a self administered pain score was evaluated using the visual pain analogue scale (vas). the motion of the lumbar spine was analysed in lateral and ap projections using radiographs and in all three main axis of rotation with the topometric motion analysis system. results: compared to norm-based population scores for europe and north america, values are reduced below one standard deviation in almost all items using the sf-36-questionaire. the items body pain and physical function are decreased by two standard deviations (sd) and role physical has a score reduced by more than three sd. where heavy pain was reported, the correlation between disturbed physical and mental scores was high (r = 0.8950; p < 0.001), but no correlation to radiographic spondylolisthesis could be observed. conversely, a good correlation between reduced physical score (sf-36), pain and disturbed instantaneous axis of rotation was observed in 3d-topometry (r = 0.6820, p < 0.01). conclusions: this study supports a new concept in functional assessments of non-radicular lbp using ultrasound-based 3d-motion analysis. spinal pm msct-studies of 45 consecutive patients, assessed for non-radicular, multisegmental cervical and/or lumbar pain syndromes by myelography and pm ms-ct were reviewed for additional information when compared to the myelographic findings alone by two neuroradiologists. all pm msct studies had been performed on a four-slice ct scanner using the following parameters: slice thickness of 1 mm, reconstruction increment of 0.7 mm, field-of-view 15 (cervical)/20 (lumbar) cm. subsequently data postprocessing to multi-and curviplanar reconstructions was performed. in addition, the radiation exposure was assessed by calculating the effective dose values. results: msct yielded additional diagnostic information, termed as clinically significant in 60 % of the studies. due to the resulting voxel size of about 0.4 × 0.4 × 0.8 mm multiplanar imaging of the spinal pathology in all planes with excellent image quality was possible. typical image artefacts at the cervico-thoracic junction as well as due to metallic implants were significantly reduced. the effective dose amounted to 2.8 msv (cervical spine) and 6.2 msv (lumbar spine). conclusion: pm spinal ms-ct is a useful tool in assessing multisegmental spinal pathology in patients in whom mr imaging is either contraindicated or not compatible with the clinical findings. in terms of radiation exposure, careful restriction of the scan area to the clinically relevant segments seems to be more important than the type of helical ct, i.e. single-vs. multi-slice. results: there were five women and one men, mean age of 66 years. a diabetes mellitus was present in half cases. mean delay between vertebral collapse and the infectious syndrome was 12 days. staphylococcus aureus, e coli, salmonella enteritidis, were the identified pathogens. bone biopsy isolated the pathogen in two third of cases, and was the sole positive sample in one third of cases. a thoracic vertebra was involved in three cases, a lumbar one in three cases. lysis of the spongious bone associated with a soft tissue mass thicker than 8 mm was observed in five cases. two patients died from consequences of the disease. conclusion: we want to highligh a seemingly unusual entity to avoid a radiological diagnostic pitfall. calcified cervical intervertebral disc in children -radiological findings v. jevtic; ljubljana/si purpose: to describe radiographic, ct and mri features in a relatively rare entity of unknown etiology, calcified intervertebral disc in children (cidc). material & methods: 12 patients (7 males, 5 females, mean age 9 years) with clinical signs of limited movements, stiff neck, torticollis and pain were radiologically investigated. the patients were imaged using radiography, functional radiographic examination, ct and mri. plain films, ct and mri were analysed in a qualitative fashion. results: radiography demonstrated a calcified nucleus pulposus which was flattened, oval or round. in 10 patients more than one disc space was calcified. additional radiographic findings included widening or narrowing of the disc space and moderate flattening of the vertebral bodies. in 6 cases functional abnormalities were revealed at the level of disc calcifications. ct clearly demonstrated hyperdense disc calcifications with posterior disc protrusion in 4 cases and extrusion into the epidural space in one patient. calcifications were shown as signal void areas by mri. there were also discrete signal intensity changes of bone marrow below the endplates. conclusion: cidc may be diagnosed using plain radiography, ct or mri. the advantage of ct examination is in exact demonstration of clinically important protrusion or extrusion of the calcified nucleus pulposus. sacroiliitis in children with spondylarthropathy: use of dynamic mr imaging to detect the therapeutic efficacy of intraarticular corticosteroid injection t. fischer, b. hamm, m. bollow; berlin/de purpose: our aim was to prospectively study the therapeutic efficacy of ct-guided intraarticular corticosteroid instillation of inflamed sacroiliac joints (sijs) in children with juvenile spondylarthropathy (spa) and to evaluate the role of mri as a procedure for establishing the indication and the therapeutic follow-up. method/materials: a total of 69 ct-guided corticosteriod injections of the sijs were performed in 42 children with inflammatory back pain (ibp): 27 bilateral, 15 unilateral. forty milligrams of a crystalline longacting corticoid was instilled in each inflamed joint. all 42 patients underwent continuous clinical follow-up at 10 week intervals after corticosteroid injection to a maximum of 18 months. intensity of back pain before and after the intervention was graded on an visual analogue scale from 0 (no pain) to 10 (very severe pain). dynamic contrast-enhanced (gd-dtpa, 0.1 mmol/kg body weight) mri with quantitative determination of contrast enhancement was performed in all patients before the intervention and 8 ± 4 months after therapy. results: 37 of the 42 study patients (88.1 %) showed a statistically significant abatement of subjective back pain from 8.4 ± 1.4 to 3.3 ± 2.2 (p < 0.05) at 1.5 ± 1.0 weeks after therapy, and this improvement lasted for 12 ± 6 months. the percentage contrast enhancement at dynamic mri showed a reduction from 110.5 ± 52.3 % before to 53.4 ± 38.1 % after intervention (p < 0.01). conclusions: dynamic mri proved to be a reliable non-invasive tool for the assessment of inflammatory activity of sacroiliitis and the response to the therapy in patients with juvenile spa. congenital lesions of the lumbar spine: ct depiction and significance d. passomenos, g. mantzikopoulos, g. giannikouris, i. staikidou, c. pikoulas, s. ispanopoulou, c. dayiada; athens/gr purpose: congenital lesions of the bony skeleton are not uncommonly detected incidentally by plain films. moreover, posterior elements due to their complex anatomy and orientation are poorly visualized on plain films. in acute trauma setting, in order to exclude a fracture, further investigation without the problems of superimposition is needed. we retrospectively evaluated the files of 873 patients examined to our diagnostic department over a period of 9 months. patients ranged in age from 12 to 44 a. most of them presented with a history of minor recent trauma or had a vague intermittent back pain. cases of spinal cord lesions in association with bone dysplasias were excluded from the study. plain films were mostly suggestive of congenital lesions but further investigation with ct to ascertain the diagnosis was requested. scans consisted of consecutive 3 mm cuts through the questioned area of the spine. obtained scans were imaged at softtissue and bone windows. sagittal and coronal reformatted images were also obtained. we could locate a total of 18 cases of unilateral spondylolysis, butterfly vertebra, posterior limbus vertebra, hypoplastic or absent facets associated with hypoplastic arch, spina bifida and pseudo-arthrosis of transverse process. the lesions were mostly located at l5 -s1 level. purpose: to describe characteristics on mr imaging of radiation osteitis of the pelvis in patients who had received radiation therapy for gynaecological tumours. material and methods: 9 women (mean age: 67.5 years) with gynaecological tumours who developed radiation osteitis where examined with radiography, computed tomography and magnetic resonance imaging (mri). on a 1.5 t system we used plain t1-and t2-weighted sequences and contrast enhanced t1-weighted a c d e f 212 sequences with and without fat saturation. mri was performed at different distances between the end of radiation therapy and developing pain. mr images where correlated with the results of clinical examinations. results: depending on the time from radiation therapy, radiation osteitis showed different signal intensities. the acquired images suggest that signal changes in t2 weighted images as well as the different enhancement behaviour of radiation osteitis might be dependent on the time from radiation therapy. best visualisation of regions with even low contrast enhancement was achieved with fat-saturated sequences. computed tomography showed increased density in the affected regions corresponding to osteosclerosis. in all cases at least one iliosacral joint was affected with different topographies in sacral and iliac bone. conclusion: mri is helpful in detecting and characterizing orn and eases the demarcation from secondary manifestations of the known malignancy. changes in signal intensity, based on histopatholocical tissue changes, might make a chronological classification possible. the purpose of this on going study is to evaluate the usefulness of whole body mri in the diagnosis of the inflammatory myopathy seen in polymyositis and to assess the disease extent in affected patients. materials and methods: eight patients with laboratory, muscle biopsy and electromyographic evidence of probable or definite polymyositis were referred for imaging. an additional patient was referred for mr to identify a potential site for muscle biopsy. 16 coronal turbo stir images were taken in each of three or four body regions (tr/te/ti; 2400/40/160 ms). acquisition time per region was 3 minutes 30 seconds, with a total scan time of approximately 30 minutes. results: mean patient age was 43.5 years (32 to 57 years). one patient with "probable" polymyositis by conventional criteria had a normal scan. one patient with polymyositis had inflammation in a myofascial distribution in the gluteal region. two patients had florid symmetrical myopathy involving proximal upper and lower limb girdle muscles, psoas, intercostal muscles and neck flexors and extensors. in addition, mild involvement of the calf muscles was also seen. three patients had more patchy asymmetrical muscle involvement, but also demonstrated involvement of psoas, intercostal and neck muscles. conclusion: whole body mri gives a much more extensive assessment of muscle involvement in polymyositis than the conventional mr protocols used to image these conditions. extensive muscle involvement of psoas, intercostal, neck and distal limb muscle groups were diagnosed. these muscle groups are not imaged on standard sequence protocols. the posterior half of the lateral tibial plateau and the lateral half of the medial femoral condyle were statistically more frequently involved than their corresponding halves (p < 0.0001 for both parameters). the bare area of the medial, but not of the lateral tibial plateau is more frequently involved than the meniscus-covered area (p < 0.0001). the meniscuscovered area of the lateral tibial plateau was more frequently involved than that of the medial tibial plateau (p < 0.0001). results: mri allowed a good identification of the sites of osteochondral cylinder remotion ("donor" sites) and of the treated lesion sites at the 5 month mri. small ferromagnetic particles artifacts due to surgical instruments were often present, with limitation of diagnostic value, in particular the "gap" regions between cylinders and health tissue were not individuated. only the oldest two patients showed mild inflammatory signs (intraarticular fluid collection, synovial hypertrophy) at the 5 and 10 month mri. no case of donor site degeneration was seen at the 5 and 10 month mri. in all cases, the sites of treated lesions showed regularity of subchondral bone and the fillling-repair of donor sites at the 10 month mri. evaluation of the chondral portion was very difficult due to artifacts. conclusions: mri allows a good evaluation of knee chondral implant healing, especially of the subchondral bone repair and seems to be a good diagnostic tool, avoiding invasive examination. results: based on the statistical analysis of the ultrasonographic measurements, diagrams and tables were created. the study of these data concluded that: • articular cartilage thickness is the same in both knees. • articular cartilage of the knee is thicker in boys. • cartilage thickness reduces with age. • the rate of diminution is higher during the first six years of age and lower after the age of six years. • there is negative linear correlation between cartilage thickness and somatometric parameters. • body height is the somatometric parameter that has the strongest correlation with articular cartilage thickness. conclusion: equations, diagrams and tables of normal articular cartilage thickness of femoral condyles in children, measured with ultrasonography, represent a precise method for cartilage growth estimation. these equations, diagrams and tables afford an objective way to compare normal articular cartilage thickness with the thickness noted in various pathologic conditions affecting articular cartilage in children. opportunities for the use of high frequency ultrasound (10 -13 mhz) in the diagnosis of degenerative-dystrophic changes of the knee joint n. lordkipanidze, d. tatishvili, m. lortkipanidze; tbilisi/ge the purpose of study was to define diagnostic criteria for degenerative-dystrophic damage to the knee joint according to the stage of disease using high frequency ultrasound. the investigations were performed on the "siemens sonoline elegra" ultrasound system using siescape panoramic imaging with a 7.5 -13 mhz frequency linear transducer. a group of 956 patients, 10 -75 years of age, with complaints of knee joint pain were included in this study. 738 patients were diagnosed as having knee joint degenerative-dystrophic changes. the early stage is characterized by a normal or decreased hyaline cartilage thickness of the femoral condyle. ultrasound studies detected increased echogenity of the cartilage surface, existence of freely floating 0.4 -0.6 mm crystals in the joint cavity and suprapatellar synovial bursa. the same type of crystals, in addition to insignificant synovitis, were found in sportsmen and dancers who exercised vigorously. in the case of difficulties in examining the lateral patellar and medial inferiorlongitudinal surface the existence of crystals was revealed during its maximum displacement from the condyles of the femur. in severe cases, examination revealed marginal joint osteophytes, margin skipping of cartilage surface, discontinuous contour of the femoral condylar bony surface, narrowing or complete disappearance of joint space and the existence of hypertrophic synovial membrane and villi and baker's cysts. as a result, pan zoom mode is used to detect joint crystals, to study in details the structure of hyaline cartilage, fluid and to identify their minimal changes, which helps to diagnose degenerative-dystrophic changes of the knee joint. multislice spiral ct (somatom plus 4 volume zoom, siemens, germany) examination was performed after standard oral colonoscopy preparation and colonic distension with room air. images were obtained using 2.5 mm slice collimation; 3.0 mm slice thickness; 1.0 mm reconstruction interval; 17.5 mm/s table speed; kvp, 140; and mas 10. supine and prone acquisitions were obtained in all patients. dose exposure was calculated. images were directly reviewed on a dedicated workstation by two experienced gastrointestinal radiologists using a software with volume-rendering capabilities (vitrea 2.2, vital images, usa). conventional colonoscopy was performed on the same day in all patients and represented the standard of reference. results: all colorectal cancers were correctly identified at ct colonography (9/9, sensitivity 100 %). ct colonography also detected 12 of 14 polyps (sensitivity, 85.7 %). both false-negative findings were represented by lesions smaller than 5 mm. dose exposure (ctdi) never exceeded 1.37 mgy for each scan. conclusion: although studies on larger series are certainly needed, our preliminary experience demonstrates that ultra-low-dose scanning is a feasible and accurate option for multislice ct colonography. this technique allows to scan the patient in both supine and prone positions with a radiation exposure lower than that of a double contrast barium enema, which is of paramount importance to introduce this imaging modality in screening programs. results: of 264 cancers diagnosed in this cohort, 260 were detected by ct colonography. 3 were missed in our early experience with single slice spiral ct. 2 were flat cancers < 5 mm thick. 1 was a polypoid tumour hidden by residue in a poorly prepared patient. this was obvious on a repeat study with adequate preparation. one recently missed cancer was in a co-existent acute diverticulitis and was described as suspicious for malignancy only. there were 18 false positive diagnoses of cancer. all but 2 were cases of diverticulitis or ibd. in only 2 cases was no lesion found at laparotomy or repeated colonoscopy. 2.5 % of patients failed to complete their preparation or did not attend for scanning. this was no different to other complex ct examinations. 7 % of studies were sub-optimal (poor preparation, no iv access, could not lie prone etc). only 1 patient could not be scanned. conclusion: ct colonography is remarkably robust with a sensitivity of 98.5 % and a specificity of 98.4 % for the detection of colorectal cancer. is 1 mm collimation (effective slice width 1.25 mm) essential for multislice ct colonography? a.r. gillams, v. munikrishnan, w.r. lees; london/gb purpose: whilst the finest collimation possible with adequate signal to noise may seem desirable, fine collimation results in increased radiation dose and generates very large data sets. this increases expense, slows down analysis and 3d reconstruction times. we studied the impact of 1.25, 2.5 and 5 mm slice width on polyp detection and cancer staging. methods and materials: 55 symptomatic patients, 22 male, referred for ct colography ± virtual colonoscopy underwent multislice ct following standard bowel prep, bowel paralysis and rectal air insufflation. scans were performed with 1 mm collimation, effective slice width 1.25 mm, pitch 5, 0.5 s rotation time following iv contrast. retrospective reconstructions were performed at 1.25 mm, 3 mm and 5 mm. 1.5 and 2.5 mm overlap was used for the 3 and 5 mm data sets respectively. scans were analysed for the presence of lesions and any cancers detected staged. all patients had colonoscopic correlation and where cancer was detected the resected specimen was also included in the analysis. results: there were 23 cancers and 25 polyps. finer sections aided separate detection of small nodes but this did not impact staging. overall there was no difference in cancer staging between the three data sets. there was no difference in the number of polyps detected on the 1.25 and 3 mm data sets. small polyps were smeared out on the 5 mm data sets. conclusion: 2.5 mm slice width appears to be adequate for multislice colography. previous studies have shown no beneficial effect of using iv glucagons as a spasmolytic for ct colonography. studies of barium enema examinations, however, have shown that buscopan may be a more potent spasmolytic in the colon compared with glucagon. the use of buscopan in ct colonography has not been tested to date. the aim of this study was to assess the effect of iv buscopan on colonic distention and polyp detection when used as a muscle relaxant in ct colonography methods: 70 patients undergoing ct colonography were randomized to receive iv buscopan or no muscle relaxant prior to air insufflation and scanning. patients were scanned in both supine and prone positions using a multislice helical ct acquisition. for the purposes of reporting, the colon was subdivided into 6 different segments, yielding a total of 12 colonic segments per patient. the degree of luminal distention of each segment was scored on a scale from 1 to 4. the accuracy of ct colonography for polyp detection was based on findings at subsequent conventional colonoscopy. results: there was no significant difference in the degree of colonic distention achieved between the group receiving iv buscopan and those who did not. the addition of prone scanning was found to be the single most important factor in ensuring adequate visualization of the entire colon. there is no evidence to support the routine use of iv buscopan in ct colonography. mr was performed on a 1.5 t scanner by using gadolinium as a rectal enema. the 3d data set was post-processed on a workstation to obtain vdc and ssd images. 2 radiologists with knowledge of the colonoscopic findings compared coronal and rotated views. they were compared by consensus in terms of the visualization of the mass lesions and normal colonic segments. technical visibility and interpretation accuracy of the colonic lesions were rated on a score. coronal vdc was regarded superior to ssd for assessment in 11 of 17 patients, equal to ssd in 5 and worse than ssd in 1 case. rotation of vdc and ssd improved the assessement of the colon. rotated vdc was regarded superior to ssd in 4, equal in 11 and worse than ssd in in 2 of 17 cases. all mass lesions above 10 mm were equally well depicted with the vdc mode compared to ssd conclusions: vdc and ssd are useful as a first step and possibly online analysis tools and could possibly allow for an earlier finishing of the mr exam in case of poitive findings. vdc appears to be superior to ssd in excluding colorectal mass lesions at the slice position with the visually largest lymph node extension in plain sequences, dynamic mri was performed using a turboflash starting withj a bolus injection of 0.1 mmol/kg b.w. gd-dtpa. results: in a retrospective evaluation, lymph node staging using the contrast enhanced endorectal and body-coil mri studies was based on the following criteria: stage n0 designated failure to identify nodal structures with a diameter larger than 3 mm in the imaging volume including the perirectal space and the pelvic structures, and stage n1 designated visualization of four or less nodes larger than 3 mm in diameter. in our series eleven patients (n = 11) had histopathologically proven lymph node stage n1; all other patients (n = 12) were stage n0. we were able to depict the enlarged and involved lymph nodes in eight of eleven patients with stage n1. we staged correctly nine of twelve patients with stage n0 (sensitivity of 85 % and specificity of 72 %). conclusions: high-resolution contrast endorectal mri was excellent for depicting perirectal nodes larger than 3 mm in diameter. further studies are necessary to assess the architecture, geometry, and contrast-enhancement characteristics of lymph nodes to improve higher specificity. to investigate systemic and regional lv functional parameters including myocardial wall thickening in patients with symptomatic coronary artery disease and cabg. methods/materials: on a 1.5 t magnetom vision (siemens) 40 patients with angiographically proven cad underwent prospective evaluation of ejection fraction (ef) and regional myocardial function in 320 myocardial segments by cine mri (flash-2d, tr = 11 ms, te = 4.8 ms, flip 25°) at rest. consensus reading by two observers was used for the analysis of myocardial function. a phase-contrast flash-2d sequence (pixel 0.98 × 0.98, venc 250 cm/s) was applied for flow measurements in the ascending aorta in order to derive functional parameters such as lv ejection time frame (ät) and cardiac index. patients were re-examined 6 months after surgery. results: clinical symptoms improved in 35 of 40 patients after cabg. in patients with significantly reduced ef (n = 10) an improvement from 38.4 ± 10.3 % to 49.8 ± 15.3 % (p < 0.05) was found postoperatively. after cabg surgery functional improvement was observed in 45 of 53 myocardial segments (x of y patients) with severe hypokinesia (p < 0.03); mean increase of cardiac index was 15 % (from 2.26 -0.5 l/min/m to 2.65 -0.41 l/min/m, p < 0.02), mean decrease of ∆t was 10 % in patients with functional myocardial recovery (p < 0.05). in general, clinical improvement can be found 6 months after cabg surgery and corresponds to improvement of systemic and regional lv function. patients with persistent symptoms still presented with pathological findings. therefore, mri can be used as a tool to follow-up symptomatic patients after cabg. the following effective doses (male/female) were calculated for the different calcium scoring modalities: sequential msct prospectively ecg-triggered (3 msv/3.7 msv), spiral msct retrospectively triggered (3 to 5.2 msv/3.6 to 6.2 msv), ebt (1.0 msv/1.4 msv). effective doses associated with ct coronary angiography were: spiral msct retrospectively triggered (6.7 to 10.9 msv/8.1 to 13 msv), ebt (1.5 msv/1.8 msv). highest organ doses in all examinations were found for the female breast followed by the lungs and the oesophagus. conclusion: up to a 7-fold higher radiation dose is obtained in msct compared with ebct in coronary artery examinations. the high radiation exposure inherent in cardiac msct warrants careful analysis of the underlying clinical indication. bolus optimisation in multi-slice ct of the coronary arteries and assessment of diagnostic accuracy in comparison with cardiac catheter t.f. jakobs, c.r. becker, r. brüning, a. knez, c. thilo, m.f. reiser; munich/de objective: to determine optimal contrast concentrations and injection rates for detecting coronary stenoses with multi-slice ct (msct) angiography. materials and methods: 60 patients, 4 groups of 15 patients, underwent msct (somatom volumezoom, siemens) with different contrast protocols: (a) 300 mg iodine/ml at 2.5 ml/s; (b) 300 mg/ml at 3.5 ml/s; (c) 400 mg/ml at 2.5 ml/s; (d) 400 mg/ml at 3.5 ml/s (byk gulden, konstanz, germany). assessment of location and degree of coronary stenoses was compared with cardiac catheter. results: the faster injection rates resulted in higher enhancement compared with the lower injection rates at both iodine concentrations (210.9 ± 34.2 hu (a) versus 366.6 ± 84.2 hu (d)). diagnoses of significant stenoses obtained by msct were confirmed by coronary angiography in 37 out of 43 patients (86 %). among those with false negative results there were 3 patients in whom msct failed to determine significant stenoses in the coronary arteries. the diagnostic findings as described in msct were not consistent with angiography with regard to localisation and degree of stenoses: in 42 % of cases, the degree of the most severe stenosis was identical in msct and cardiac catheter. conclusion: superior coronary enhancement was achieved with higher iodine concentrations and flow rates. however, msct with any contrast protocol was unable to achieve the diagnostic level of coronary angiography in assessing location and degree of significant coronary stenoses. therefore further improvement of spatial and temporal resolution in msct-technique is required. coronary artery by-pass grafts: evaluation by retrospectively ecg-gated multislice spiral ct r. marano, m. zimarino, m.l. storto, r.l. patea, n. maddestra, l. bonomo; chieti/it purpose: to assess the potential value of multislice spiral ct (msct) using retrospective ecg-gating in patients who had undergone coronary artery by-pass grafting (cabg). retrospectively ecg-gated msct was performed in 61 asymptomatic patients (144 grafts) 147 ± 86 months after cardiac surgery. scanning parameters were: 4 × 2.5 mm collimation, 3 mm slice width, and 1.5 mm reconstruction increment. images were reconstructed during end diastole with an absolute or relative delay before the next r-wave and volume rendered images were obtained to display the grafts. visualization of the proximal, middle and distal segments of each graft was assessed. the presence of artifacts was recorded. results: 59 left internal mammary artery (lima) to left anterior descending artery (lad) and 85 non-lima grafts were studied. 3 non-lima grafts were shown to be occluded. the entire lima to lad and non-lima grafts could be visualized free of artifacts in 39/59 (66.1 %) and 19/82 (23.2 %) cases, respectively (p < 0.001). the most frequent causes of incomplete visualization were the presence of surgical clips (21.3 %) and motion artifacts (35.5 %) impairing distal anastomosis evaluation. conclusion: ecg-gated msct is a promising imaging technique for non-invasive evaluation of cabg, allowing a complete assessment of lima to lad grafts. current limitations are artifacts from surgical clips and irregular heart rates. isotropic sub-millimeter volume scanning of the heart with ecg-gated multislice spiral ct: first experience t. we investigated the performance of a new multislice ct system with simultaneous acquisition of up to 16 slices and sub-mm collimation (siemens, forchheim, germany) for ecg-gated cardiac imaging. ecg gated spiral data were acquired at pitch 3.5 -4 (pitch -feed/rot divided by one collimated slice width), providing continuous image data with up to 110 ms temporal resolution. spatial resolution, image quality and artifacts were evaluated with a simulation study of an anthropomorphic heart phantom for 0.8 mm, 1.0 mm and 1.5 mm slice width. the results were confirmed by scans of coronary specimens. scan times and radiation exposure for coronary cta protocols were evaluated. first clinical results are presented. results: with the investigated ct system a 120 mm heart volume can be covered in less then 20 s with sub-mm slices. sub-mm slice width allows for improved assessment of non-calcified coronary wall changes, heavy calcifications and instent lumen. radiation exposure for coronary ctas with sub-mm slice width is about 7 msv (male), which can be considerably reduced by ecg-gated dose modulation. a 16-slice platform can cover the heart with ecg-gated spiral acquisition with sub-mm slices within short breath-hold times. increased scan speed and isotropic resolution with voxel size >> 0.5 mm allow for substantially improved coronary imaging. a c d e f 218 results: biexponential relaxation was more pronounced in "black hole" lesions and homogeneous enhancing plaques while dwm, nawm and hypointense lesions presented biexponential behavior with a lower frequency. non-enhancing isointense lesions and normal white matter didn't reveal any biexponentional behavior. linear regression between monoexponential t2 relaxation time and mtr measurements demonstrated excellent correlation for dwm, very good correlation for "black hole" lesions, good correlation for isointense lesions, moderate correlation for hypointense lesions and non-significant correlation for homogeneous enhancing plaques, nawm and nwm. conclusion: biexponential behavior is more evident on plaques with high degree of demyelination and homogeneous enhancing lesions when using conventional sequences with long first echo time. a strong correlation between mtr and t2 values in regions where either inflammation or demyelination is present was found while when both pathological conditions coexist this linear relation is destroyed. method and materials: mri of 24 pediatric patients affected with definite ms (13 male and 11 female; mean age 15) and 20 with adem (7 male and 13 female; mean age 12) were retrospectively evaluated to identify differences in the morphology, location and post-contrast behavior of the demyelinating lesions at the onset of the disease. clinical and laboratory data were not used. plain t2 and t1weighted sequences were always available, flair in only 30 % of more recent cases; i.v. contrast injection was done in 18 adem and 21 ms patients. results: lesions in adem patients were multiple in all but 1 case and in 16/19 cases were more then 3; 10/20 cases infratentorial region was involved; gray matter involvement was present in 10/20 and thalamus was the most common involved (6/20); corpus callosum was involved in 2/20 cases; contrast enhancement was present in 16/18 cases; a "lumpy-bumpy" effect was never remarkable. conclusion and discussion: differentiation of ms and adem has an high prognostic significance. clinical and laboratory data may often overlap between the two demyelinating disorders. even though single mri findings can be non specific, the global evaluation of each patient leads to a differential diagnosis in more then 90 % of cases. results: mri of the brain revealed no abnormality in the 7 patients who had lower plasma fa levels both in the last 5 years and on the day of mri (mean 474.0 and 510.9 mmol/l respectively). however, the 3 patients who had demyelination changes detected on mri had average plasma fa levels in the last 5 years and on the day of mri of 768.6 and 1026.0 mmol/l respectively. no difference of iq between both subgroups were observed. conclusion: the low number of patients within the study group precludes evaluation of the statistical significance of the detected differences, but a trend toward correlation between a degree of metabolic compensation of the disease and a presence of brain lesions can be observed; no correlation was detected between the lesions and a degree of mental development. intracranial tuberculosis: mri evaluation and 1 year follow up i. tsitouridis, m. emmanouilidou, s. chondromatidou, f. goutsaridou, s. stratilati, p. papapostolou, a. morichovitou; thessaloniki/gr purpose: to present our experience in the mri diagnosis and follow up of patients with intracranial tuberculosis. materials and methods: 27 patients with intracranial tuberculosis were evaluated by mri. the examinations were performed on a 1 t, siemens expert plus scanner, using conventional se t1wi and t2wi. all the patients were conservatively treated and underwent clinical and mri examinations every two months for a year. results: 14 patients revealed basal leptomeningeal dissemination and meningeal enhacement and 4 of them also had a tuberculous abscess in this area. 7 patients had disseminated parenchymal tuberculosis and 3 of them had also and meningeal enhancement. one case had tuberculomas and aspergillomas closed together and this patient had a biopsy in the left parietal lobe. the other 5 patients also revealed spinal subarachnoid dissemination. there was no correlation between the mri findings and the clinical status at the early stages of he disease. conclusion: we believe that mri alone or in combination with the other clinical data clearly can detect and characterize this group of patients. differentiation of tuberculous from non-tuberculous meningitis using magnetization transfer mr imaging: a prospective study p. kamra, r.k. gupta, s. pradhan, k.n. prasad, r. kumar, s. chawla, s. jha; lucknow/in purpose: infectious meningitis presents similar features on mr imaging regardless of etiology. the purpose of this study was to characterize meningitis of different etiology using mt imaging. methods and materials: one hundred patients with meningitis on post-contrast mt imaging -65 tuberculous, 9 with viral, 9 with fungal, and 17 with pyogenic meningitis -were studied. the visibility of the meninges on pre-contrast mt imaging in different etiologic groups was studied and percentage difference between the mean signal intensity (si) of the meninges and the mean si of the surrounding t2 normal brain parenchyma was calculated. the mt ratio was also calculated from the thickened meninges in tuberculous meningitis. the mt ratio could not be calculated in other etiologic groups due to difficulty in the placement of pixel due to thin nature of the meninges and their location in the cerebral sulci. results: thickened meninges appeared hyperintense relative to surrounding brain parenchyma in the cisterns on pre-contrast mt-se images in all 65 patients with tuberculous meningitis. meninges were not visible on pre-contrast mt images in the non-tuberculous group. the percentage difference in the mean si of the meninges and the surrounding brain parenchyma was significantly higher (p < 0.05) in the tuberculous group (21.21 % ± 1.98) compared to that in the non-tuberculous group (5.55 % ± 1.01 viral, 3.76 % ± 2.39 fungal, 6.18 % ± 2.18 pyogenic) and explains this difference in visibility. the visibility of meninges on pre-contrast mt-se imaging is specific for tuberculous meningitis, and helps in its differentiation from other non-tuberculous meningitis. purpose: septo-optic dysplasia is a variable condition, characterized by developmental anomalies of midline structures, the optical pathways, and the hypothalamus/pituitary system. while visual and hormonal disturbances are well known in these patients, neurological and mental development has not yet been related to the morphological findings. patients and methods: 22 children, 12 female, 10 male, aged between 0 -13 years at first presentation underwent mri (0.5 -1.5 t superconducting systems, t1w and t2w sequences in 3 section planes, slice thickness 1.5 -5 mm. in 19 patients behavioural abnormalities and school performance could be analyzed with age appropriate tests. results: mri abnoralities consisted of a completely or partially missing septum pellucidum in 14 cases, anomalies of other midline structures (corpus callosum, fornix, other commisures) in 12, 3/14 mr scans revealed hypoplastic optical structures. anomalies of the hypothalamius/pituitary system were seen in 10, hemisperic lesions (mainly schizencephalic clefts) or infratentorial abnormalities occured in 10, and pathological formation of the hippocampus in 7/15 scans. marked develthe purpose of this presentation is to report on the prevalence of cerebrovascular complications in children with aids and investigate whether the mode of hiv infection plays a role in the development of this complication. 508 children (ages, 4 months to 17 years) with aids were periodically evaluated with pre-contrast ct scans. further evaluation with mri was perfomed for patients with either focal neurologic deficits or ct findings other than diffuse atrophy. in five patients mr angiograms and in one conventional angiography were also performed. eleven children were found to have vascular lesions. only one had focal neurologic symptoms at the time of diagnosis. six children were found to have 25 aneurysms. a seventh child had a surgical clip at the site a previously treated anerysm. eight patients were found to have 27 infarctions. in four of the patients with infarctions, fysiform aneurysms of the cerebral arteries were also identified. nine of the 11 patients in our study were infected by transplacental route or during blood transfusion in prematurely born infants. in this group of patients the diagnosis of cerebrovascular disease was made earlier (mean, 8.2 years) compared to the two patients that were infected later in life (mean, 14.9 years). there is increased prevalence of cerebrovascular disease in children infected by hiv. the risk is greater if the exposure to the virus took place prior to the 40 th week of gestation. this finding suggests that the immature vessels of the fetuses or the prematurely born children are more vulnerable. a quantitative study of mr imaging in vascular dementia l. wang; beijing/cn purpose: to identify the neuroimaging determinants which could predict the occurrence of the vascular dementia (vad). the findings of cranial mri were compared in 30 vad patients and 30 stroke without dementia (swd) patients by means of quantitative measurement of some indexes. the indexes of measurement included the cerebral white matter lesion (wml) area, the cerebral infarct area, the ratio of ventricle-to-brain (vbr) and the ratio between the areas of the corpus callosum and supratentorial brain in the midsagittal plane. discriminant analysis was used to search for the indexes which could contribute significantly to distinguishing the two groups. results: small cerebral vessel disease and multi-infarct were two major basal diseases of vad in this series. the wml areas, the left cortical infarct and vbr were significantly higher and the corpus collsum areas was significantly lower in the vad group than the swd group. the indexes that could significantly discriminate the two groups was: callosal atrophy, ventricle-to-brain ratio, white matter lesions area, left cortical infarct area, left parietal infarct area, total cortical infarct area. conclusions: callosal atrophy, lateral ventricle enlargement and extensive wml are important predictors of incidence of dementia in the small vessel disease; however, left cortical infarct, especially left parietal infarct, is important predictor of incidence of dementia in the multi-infarct group. biological markers of alzheimer's disease: diagnostic imaging and oxidative stress d. lupoi, r. squitti, a. orlacchio; rome/it purpose: a bulk of evidence indicates that oxidative stress mediated by redox transition metals plays a central role in the neurodegeneration of alzheimer's disease (ad). iron and copper are strongly concentrated within neuritic plaques and represents the hallmark of the ad brain. recent studies indicate that peripheral markers of oxidative stress in ad patients could be informative about the pathophysiology of this brain condition and suggested that elevated copper in serum may represent a peripheral marker for ad. we report a pilot study examining the relation between copper and oxidative parameters in serum and the lesions present in the ad brain. we performed retrospective subjective qualitative and quantitative analysis of the mr brain images of 53 subjects affected by ad and 30 without ad (healthy control group). on imaging, we noted the degree of atrophy and amount vascular lesions in both patients and controls and correlated these with oxidative stress parameters. the preliminary results indicate that oxidative stress, with higher copper levels, are related to atrophy of temporal lobe. vascular lesions and global atrophy do not correlate with copper and peroxides in serum. our evidence sustains copper as peripheral marker in ad to help in the early diagnosis. to determine whether diffusion weighted mri (dwi) contributes to the differential diagnosis of patients with parkinson's disease (pd) and the parkinsonian variants of multiple system atrophy (msa-p) and progressive supranuclear palsy (psp) methods and materials: conventional dual-echo fast spin echo and dwi scans were obtained from 12 msa-p, 13 pd, and 10 psp patients matched for age and disease duration. dwi was performed using echoplanar imaging with diffusionsensitizing gradients switched in slice direction and three different b-values (30, 300, 1100). regional apparent diffusion coefficients (radc) were determined in different brain regions including basal ganglia and pons. results: using the kruskal wallis test and post hoc testing with the mann whitney u test, significant differences in radcs of the putamen (0.85 vs. 0.71 s/mm 2 ; p < 0.001) and the caudate nucleus (0.81 vs. 0.72 s/mm 2 ; p = 0.007) were detected between patients with msa-p and pd. between psp and pd patients, significant differences in radcs were revealed in the putamen (0.87 vs 0.71 s/mm 2 ; p = 0.008) and in the globus pallidus (0.72 vs 0.65 s/mm 2 ; p = 0.006). no significant differences in radcs were obtained between patients with msa-p and psp. conclusion: the significant higher radcs in patients with msa-p (putamen, caudate nucleus) and psp (putamen, globus pallidus) compared to patients with pd may reflect a more advanced alteration of the cns tissue integrity due to neuronal loss and gliosis leading to increased random movement of water molecules. metabolic impairment of the brain in patients with apallic syndrome s. mirzaei, c. stepan, p. knoll, h. köhn, h. binder; vienna/at purpose: a reliable assessment of prognosis in acute/persistent vegetative state following cerebral anoxia is mandatory for clinical decisions concerning extended intensive care procedures. we evaluated five patients with apallic syndrome with [ 18 f]-2-deoxy-d-glucose (fdg) positron-emission-tomography (pet). pet images of the head were performed using a siemens ecat-art scanner (cti, knoxville). two 137 cs point sources were applied for attenuation correction and osemalgorithm for iterative reconstruction. regional cerebral metabolism in 12 cortical and subcortical regions was determined and compared to a normal control group. the global cerebral metabolism of glucose was markedly reduced in all patients. so far, a follow-up pet scan of the brain in one patient without clinical amelioration showed further decrease of cerebral glucose metabolism. in accordance with limited reports in the literature these results suggest that the extent of metabolic impairment may play an important role in order to assess the probability of clinical recovery from severe anoxic brain injury. methods and materials: a pioneer instance of a fully digital radiology department has been implemented at shanghai first hospital since aug. 2000, which has been composed of a dicom compliance pacs and a chinese ris developed inhouse. two phases were implemented for whole setup procedures. results: in initial phase started in oct.99, ct, mri, rf, dsa and a film digitizer connected to a central archiving system which involved a 300 gbyte raid and a round about 3 tbyte dvd jukebox, simultaneously a chinese ris was installed to implement the computerized management for routine workflow; full implementation of digital department was completed with three new modalities, a dr, a digital mammography and a digital radiofluoroscopy installed in aug. 2000, which realized full electronically archiving of images and initiated a filmless procedure. central and distributed image store management and auto-routing procedure employed to reduce network traffic and improved processing response of the system. soft copy image diagnosis and the computerized management of imaging workflow elevate workflow efficiency and improve patients passthrough obviously. the chinese version ris, which was developed based on the workflow and routine manage model of typical radiology department of china, has successfully transferred traditional film-based management into a revolutionary efficient and reliable digital management. conclusion: phases approach is a perfect way to achieve the fully digital radiology department in china and a specifically ris would play an important bridge role in a complex medical information system environment. possible pitfalls in the digitalisation of the radiologic image archive p.m.a. van ooijen, m. oudkerk; groningen/nl purpose: with the increase in the amount of data produced at radiology departments, the importance of digitalisation of the radiologic image archive also increases. when planning a picture archiving and communiations system (pacs), an overview of the possible pitfalls is crucial to judge the quality of the implementation plan. we present such an overview based on our experience with the digitalisation of a radiology department in the netherlands. methods and materials: according to our experience, seven pitfalls are present when implementing a pacs: (1) system acceptation by the radiologist; (2) emphasis on storage instead of retrieval performance; (3) reduction of data transfer capacity; (4) undersized digital storage capacity; (5) unpredictable radiologic workflow; (6) functionality archive media; (7) pseudo dicom 3.0 solutions. results: for a successful pacs, all pitfalls described above have to be eliminated. to achieve this, the everything on-line (eol) principle was developed based on the ground rule that all images have to be available to the radiologist fast at every workstation at all times (emphasis on retrieval). the eol pacs is a, windowsnt™ based, full dicom solution with a large (last months to years) raid-5 on-line archive (fast, standardized, scalable) and a large dvd-r on-line backup storage (non-erasable, standardize, scalable), eliminating dependency on workflow management, pre-fetching or auto-routing and increasing the ease of acceptation by radiologists. conclusion: a large number of pitfalls are present when digitising a radiologic image archive but with careful planning and by putting certain demands on the manufacturer, these pitfalls can be eliminated. this new technique is based on a regular 15″ tft-flatscreen monitor equipped with a special filter system. this configuration allows the display of objects from 8 different angles with a shift of one degree in between. of these 8 perspectives only two reach the eyes of a viewer at one time. different viewers in front of the screen obtain different perspectives resulting in a stereoscopic view for all viewers in front of the monitor. to demonstrate 3d data sets, we use a 69″ plasma display equipped with the "stereo viewing" panel. the stereoscopic view is used for still images and for movies, e.g. avi files. the described system was evaluated over a period of 6 months. results: panel-based stereo viewing is possible. without the addition of cumbersome and costly glasses, the technique can be used to provide a 3d rendition of complex 3d mri-and ct-data sets for large audiences. the system proved easy to use and was widely accepted by referring physicians as a tool for rapid data assessment. a selection of cases will be presented in this presentation. conclusion: "stereo viewing" without glasses proved to be feasible and became widely accepted at our department, especially for demonstration purposes. accessing 2d purpose: accessing medical images everywhere and everytime on mobile hardware is very important for both routine diagnostic and research. therefore, we developed an application for mobile devices, which are increasingly present like pencils. methods and materials: java mobile-informations-device-profile (midp) was selected for development. for data-transfer the http network protocol is used. the image data is available in the dicom file standard. there is no need of special filepreparation before file access. stereoscopic images were generated with our previously developed medical interactive stereo-3d visualisation tool. results: java was used because of the growing range of java-enabled hardware like mobile phones, personal-digital-assistants and tablet-pcs. the mid-profile was created especially for limited devices. our reference application is running on 16 bit color palm-organizers. image files can be accessed through wireless or wired connections. once the data is retrieved from a server, the images can be viewed, edited and saved. it is also possible to list and edit the dicom tags and make additional comments. precalculated 3d-data (e.g. from ct-datasets) based on chromatek visualisation can be displayed stereoscopic on color devices. summary: the goals of a mobile implementation is not the replacement of medical desktop workstations, but enlargement. the implementation includes methods for intelligent interaction and reduction of drawbacks of limited devices. because of using distributed standards and the standalone implementation, the application can easily be integrated into medical systems. creating his-based quality mangement: the nottwil experience h. hawighorst, t. mayer; nottwil/ch the swiss paraplegic center was founded in 1990 and is a modern level i trauma center for patients with all type of spine injuries. in this presentation we will discuss our road to success and the difficulties lying ahead to fully integrate a knowledgebased quality management to our institution. pacs was installed in 1998 and is productive with his and ris as a knowledge based information system since the end of 1999. radiological images and reports are distributed within the hospital by a webserver based intranet technology. for management purposes the model of efqm (european foundation for quality management) was choosen at the end of 1999 and aims at total quality management. although the pacs sytem is running quite well there are still problems to be solved. in the efqm model "processes" are the essential element. we adopted from the efqm matrix an audit matrix with 90 quality steps. the result of the first quality selfassessment has shown that knowledge-based quality has to be transparent and understandable to employees and has to be "lived" and continuously "taught". to increase and assure widespread access and acceptance of quality management we bring intranet technology-based information together with continuous education of employee. however, trained people with skills in modern technology and quality mangement are warranted in this type of modern infrastructure. new approach to picture communication in an outpatient environment f.x.j. fruehwald, e. steiner, m. obermayer; st. pölten/at purpose: while pacs inside hospitals is a widely used technology nowadays, the situation is much different outside hospitals. a new approach offers picture communication to the medical community outside hospitals. while hospitals solutions are "islands" with little communication to the outside world, the new system supports communication between all providers of medical services materials and methods: application provided pacs allows storage of image data in a professionally organised server farm. patients are provided with a chipcard containing the name, a unique serial number and a pin. all doctors authorised by the patient can access the server and load down all images they want using secured lines. results: technological requirements and guaranty of privacy of medical data are described. the system has been implemented in a part of austria. some 50 physicians up to now take part in this project. only normal amateur pc equipment is needed on the physician's side, adsl is recommended for download of dicom images; for use of jpeg images isdn standard would be sufficient. global access of the server is possible. conclusion: a combination of application provided pacs and a plastic card with a chip can transfer all advantages of hospital pacs into the extra hospital world. as storage costs and costs for telephone lines go down it is to be expected that this internet based system will replace traditional image communication per hardcopy and mail shortly. purpose: magnetic resonance imaging (mri) is limited by artifacts and image distortion in vessels after stenting. with a rigid active magnetic resonance imaging stent (amris) the stent lumen can be illuminated without causing artifacts, however, the use is limited due to the need for surgical placement. a new balloonexpandable stent design enables catheter implantation of the amris. the purpose of this study was to evaluate the imaging properties of this stent in a rabbit model using mr angiography (mra) and flow measurements. the amris was expanded with a balloon catheter in the abdominal aorta of five rabbits. flow measurements and mra before and after injection of an iron-oxide-based blood pool contrast agent were performed at 1.5 t. signal-to-noise ratios (snr) were calculated within and outside the stent lumen. results: placement of the expandable stent was feasible in all animals. snr outside as compared to within the stent increased significantly (p < 0.05) from 5.0 to 23.2 for plain, from 19.5 to 30.7 for contrast-enhanced mra, and from 5.8 to 13.9 for magnitude images of the flow measurements. flow volume curves within and distal to the stent were comparable. conclusion: mr imaging after interventional placement of the expandable amris is capable of illuminating the inner stent lumen. thus, follow-up after stent placement is feasible and it appears to be a useful tool for clinical follow-up and basic research on vessel alteration after stent placement. we retrospectively studied 37 procedures of mechanical thrombectomy of ptfe dialysis access grafts with the at-ptd performed in our vascular department. 28 dialysis accesses in 26 patients were included (nine had a double procedure). the delay between thrombosis and percutaneous thrombectomy was less than 48 hours. duration of the procedure, immediate technical results, primary patency and complication rates were analysed. the mean duration of the procedure was 137 minutes. a venous stenosis was associated with thrombosis in 90 % of cases. the technical success was 89.2 %. 31 % of successfully declotted access grafts presented with early recurrent thrombosis less than 3 months after the procedure: 45.5 % of them presented with residual stenosis at the end of the initial procedure and 45.5 % with residual clots. in this group, the mean primary patency was 30.5 days. three major and 4 minor complications were observed. conclusion: thrombectomy of dialysis access graft with the at-ptd is a safe and effective technique. the mean patency rate is superior to pulse-spray and the complication rate is lower. moreover, the procedure seems to be faster to perform than other techniques. results: indications for pta were ulceration in 40 limbs, rest pain in 26 limbs, gangrene in 4 limbs and bilateral intermittent claudication in a patient requiring total knee replacements. 24 limbs underwent one procedure, 12 underwent two and 8 underwent three. technical success was achieved in 67/72 (93 %), partial success in 4/72 (5.6 %) with 1 failure to achieve any improvement (1.4 %). 30 day mortality was 1/40 (2.5 %) from bronchopneumonia 17 days post bkpta. mean/ median follow up was 24 months (range 0 -48). clinical improvement (ulcer healing, reduced or absent pain) was seen in 34 patients (77 %). expected major and minor amputations were 2 (9 %) and 3 (14 %). there were no major complications requiring further radiological/surgical interventions or increased hospital stay. there was 1 minor groin haematoma. conclusion: bkpta is a safe, worthwhile procedure in carefully selected patients, although repeat procedures were required in almost half of the limbs treated. following appropriate inflow procedures we consider pta as a first line treatment for patients with distal critical ischaemia. (3) after previous sfa angioplasty, underwent pta with adjuvant pdt using 60 mg/kg of the photosensitiser 5-aminolaevulinic acid and 635 nm light at 50 j/cm 2 to pta site. at 6 months of follow up all patients were asymptomatic with no restenosis and no arterial complications. because of previous restenosis/re-occlusion these patients would be at a high risk of this complication again. results: these patients have now been followed up for 26 ± 3 months. patients were reviewed clinically and were offered duplex examination. six of the 7 patients remained asymptomatic. one patient has had repeat angioplasty. a further patient had mild, unlimiting claudication. three of the 4 patients who had duplex showed no restenosis. the 4 th patient (the only currently symptomatic one) had a significant stenosis (psvr = 3.7). there were no arterial complications such as aneurysm formation or occlusion at the treated sites. conclusions: pdt as an adjunct to pta is a safe and feasible procedure and appears effective in the long term. we have now started a randomised control trial to assess its potential for the treatment of restenosis. purpose: to present statistical data from a registry including patients after angioplasty or stenting of atheromatous peripheral lesions (essentially renal and lower limb arteries). methods and materials: angioplasty with or without stenting of an atheromatous peripheral lesion was the criteria for inclusion: 729 patients were included (540 men, mean-age 59.9 years) between may 1998 and dec. 1999, in 10 centers. cardiovascular risk factors, symptoms and atheromatous localization were analyzed with a descriptive method; the population with renal disease was compared with the one with lower limb disease. results: smoking (78.5 %), hypertension (58.7 %), and hypercholesterolemia (50.9 %) were the most frequent risk-factors. men were more frequently smokers than women (92.7 % and 37.8 % respectively). lower limb arteriopathy was more frequent in men than in women (80.9 % and 44.4 % respectively). vasculo-renal disease was more frequent in women than in men (46 % and 20.4 % respectively). smoking was much more frequent in the group with lower limb arteriopathy (90.3 %) than in the group with vasculo-renal disease (53.3 %). conclusion: this registry gives access to statistical data about a population of atheromatous patients treated for peripheral localization. long-term follow-up will allow us to evaluate the changes in the profiles of the patients and the morbidity and mortality in this population. results: all lesions with a maximum diameter of 5 cm were treated with a safety margin of 5 -10 mm around the lesion. lesions with a close relationship to the liver capsule, the gall bladder and major vessels were treated. in patients treated with litt for liver metastases from breast cancer the mean survival was 3.6 years (95 % ci 3.0 -4.2 years, median 3.5 years) after the first litt treatment and 4.6 years after the diagnosis of metastases, which was treated with litt (95 % confidence interval 3.9 -5.9 years, median survival 4.5 years , partial necrosis in the remaining 8 lesions (23.5 %); two of these tumors were > 5 cm. patients had no major complications except one hemorrage that required transfusion but resolved spontaneously. transient pain, nausea and fever were common minor symptoms that resolved within 2 -3 days. the median follow-up was 12 months. conclusion: rf ablation with the le veen probe is a safe, well tolerated and effective procedure for the treatment of unresectable liver tumors. enhanced gray scale ultrasonography with levovist and c 3 -mode of hepatocellular carcinoma treated with interstitial laser photocoagulation l. tarantino 1 , a. giorgio 2 , g. de stefano 2 , f. esposito 2 ; 1 torre del greco/it, 2 naples/it purpose: to evaluate c 3 -mode enhanced ultrasonography of hepatocellular carcinoma (hcc) treated with interstitial laser photocoagulation (ilp). method/materials: 8 patients with a single hcc (2.0 -5.5 cm) treated with ilp underwent helical ct and were also studied with c 3 -mode™ (esaote biomedica, genoa, italy) and an i.v. microbubbles contrast agent (levovist, shering, berlin, germany). after injection of levovist (4 g; 300 mg/ml), c 3 -mode™ scans were recorded at the times 20 s, 40 s, 60 s, 2 min, and 3 min. the results of c 3 -mode™ were compared with ct. results: after injection of levovist, c 3 -mode™ showed homogeneous enhancement (hyperechogenicity) of liver parenchyma at 20 s, 40 s, 60 s, 2 min, and 3 min. in 6 patients, with complete necrosis of hcc at ct, the lesions did not show any intralesional enhancement during c 3 -mode™ examination (complete agreement with ct). in one nodule, with enhancing intratumoral areas suggestive of viable tumor at ct, c 3 -mode™ showed hyperechogenicity in the same corresponding areas (agreement with ct). in the remaining patient, ct showed complete necrosis of the nodule. howewer, enhanced spots along the inferomedial margin of the lesion suggested parenchymal infiltration left untreated by ilp. c 3 -mode™ did not show enhancement in that area and a biopsy did not show malignancy. no relapse has been observed after 8 months. follow-up of the patient is in progress. results: all patients tolerated the procedure well under local anesthesia. the total procedure time was 90 minutes. all complications observed were minor and no further treatment was necessary. online mr thermometry allowed exact visualization of the extension of laser-induced changes and their relationship to the neighboring anatomy. lesions up to 2 cm in diameter could be efficiently treated with a single laser application; larger lesions were treated with dual, triple and quadruple simultaneous applications. in 97.5 % we achieved complete necrosis of the tumor and a 5 mm safety margin, resulting in complete destruction of the tumor without local recurrence. mean survival after the first laser treatment was 3.4 years (95 % confidence interval (ci) 2.5 -4.2 years) and 4.4 years (95 % ci: 3.6 -5.2 years) after the time of diagnoses of the hcc. conclusion: in hepatic involvement with oligonodular hepatocellular carcinoma, litt appears to be an effective therapeutic procedure. results: before treatment, intratumoral arterial-phase enhancement followed by a hypoechoic appearance in the portal venous and delayed phases was demonstrated by contrast us in 38 (90 %) of 42 hccs. after rf, all the 32 (84 %) of the 38 hccs that were found to be necrotic at spiral ct, failed to enhance using contrast us. by contrast, in the six hccs with residual viable tumor at spiral ct, intratumoral areas of persistent enhancement -corresponding to the enhancing areas at spiral ct -were identified using contrast us. these six nodules were retreated with rf, targeting residual tumor with contrast us guidance. conclusion: contrast-enhanced us, performed using c3-mode imaging, shows promise in assessing the therapeutic effect of rf thermal ablation in hcc. purpose: cytokine-based gene therapy has been shown to be highly efficient in stimulating an immune response leading to tumor rejection in transplanted tumors. woodchucks infected with woodchuck-hepatitis virus (whv) develop orthotopic hepatocellular carcinomas (hcc). the purpose of this study was to evaluate the efficacy of mr-guided injection of a therapeutic adenovirus vector into hccs of woodchucks and to monitor the course of the tumor non-invasively using mri. for mr imaging five woodchucks with known hepatocellular carcinomas were anesthesized using ketamine and xylazine. the animals were examined using standardized sequences on a 1.5 t whole-body scanner. under mr-guidance either adil-12/b7.1 or a control adenovirus were injected into selected tumor nodules. the animals underwent axial mr examinations of the liver immediately as well as 2, 4, 7 and 10 weeks following application of the therapeutic agent. finally all animals were sacrificed and the liver was referred to histopathology. results: mri of all animals was feasible. injection of adil-12/b7.1 caused a reduction of the tumor nodule volume in all animals. in contrast, tumor areas injected with the control vector showed increased tumor size. histopathologic examination of liver sections revealed necrosis and inflammatory infiltration in tumor nodules injected with adil-12/b7.1 whereas typical features of neoplastic hepatic cells were found in areas injected with the control vector. conclusion: objective monitoring of gene therapy strategies in vivo by means of high resolution mr imaging in small animals is possible. purpose: paediatric diagnostic examinations in ireland are currently under investigation, such that recommendations may be made for greater optimisation of practice. methods and materials: a questionnaire survey established which irish hospitals perform paediatric examinations. dose measurement, using a combination of tld and dap monitoring, is being conducted in a sample of these. in line with european recommendations, diagnostic reference levels are being established for examinations with high effective dose. an evaluation panel is using image assessment criteria derived from those of the european commission to assign objective image quality scores. correlation of dose and image quality allows proposals for optimal techniques for paediatric examinations. results: there is a wide spectrum of paediatric practise nation-wide, in terms of caseload, equipment used, and technique applied. this has significant impact on the range of patient dose for similar investigations, and on the diagnostic quality of the images produced. comprehensive analysis of image quality is difficult, and in paediatrics, is complicated by the fact that essential image details depend heavily on the clinical situation. an absolute image quality measure such that the lowest achievable dose for an examination may be specified is being sought. the formulation of a non-biased, representative sample of hospitals is fundamental to the validity of any dosimetric survey, but particularly one concerned with the establishment of national reference doses. optimisation demands that image quality is evaluated in clinical radiographs -in paediatrics this requires consideration of the clinical context of the request. does an absolute image quality measure exist? purpose: to investigate in a controlled patient study the potential of online tube current modulation in subsecond multi-slice spiral ct (msct) examinations of children to reduce dose without loss in image quality. method/materials: dose can be reduced for non-circular patient cross-sections without an increase in noise if tube current is reduced at those angular positions where the patient diameter and, consequently, attenuation is small. we investigated a pre-release product version of an online control for the tube current integrated in a somatom vz with improved technical performance. we evaluated image quality, noise and dose reduction for examinations with online tube current modulation in 50 msct of the thorax and the abdomen. we evaluated mas for tube current modulation and compared to the mas in standard protocols. image quality was rated as very good, good and poor in a consensus by three radiologists. noise was assessed in comparison to a control group and by phantom measurements. results: dose was reduced typically by 20 to 37 %, depending on the patient geometry and anatomical region (thorax 25 to 29 %, abdomen 20 to 37 %). in general, no loss of image quality was observed. measured noise did not change significantly. in some cases the noise pattern was improved. online tube current modulation is now used as a standard in multi-slice spiral ct at our institution. conclusions: dose in multi-slice spiral ct examinations of children can be reduced substantially in routine examinations by online tube current modulation without a loss of image quality. purpose: malformations of the corpus callosum (cc) may occur in many different syndromes. various forms have been observed with different degrees of structural abnormality. the purpose of this study is to review characteristic signs of callosal abnormality and try to find a correlation with the degree of clinical disability. material and methods: mri examinations were performed in patients with developmental delay. imaging included t1 and t2-weighted sequences in all cases. all patients had a thorough neuropaediatric clinical examination. the mri images were evaluated regarding the degree of callosal hypoplasia, presence of a fornix and hippocampus, hydrocephalus and concomitant further abnormalities. results: seven different forms of malformation of the corpus callosum were encountered. in particular the development of the fornix and hippocampus differed significantly as did the amount of clinical disability. as a hippocampal commissure is a prerequisite of normal hippocampal development, the size of the temporal lobes depended on the degree of this midline abnormality. patients without hippocampi were all severely disabled. the clinical disability of the patients presented here differed significantly, which may in part be due to the different extent of the midline cerebral malformation. the relevance of the concomitant aplasia of the limbic system has not been addressed in detail before in the literature. purpose: to evaluate the role of ct and ct angiography in the diagnosis and treatment of pulmonary cystic and adenomatoid malformations in the newborn and young children. methods and materials: nine children aged between 2 days and 5 months with respiratory failure and cystic pulmonary malformations underwent conventional ct and ct angiography. lung abnormalities were present on all the chest radiographs prior to ct. the abnormalities had varying appearances; 2 resembled pneumonia, 3 appeared as a mass and 4 as cysts. the ct acquisition protocol included sequential scanning with a 5 mm scan thickness and scan interval, which was followed by high resolution ct in all cases and ct angiography in two. all ct studies were performed under general anaesthesia. the final diagnosis was based on the surgical data and morphologic examination of resected lung tissue in all patients. results: morphologic investigation revealed different types of cystic adenomatoid malformation in 6 cases and persistent interstitial emphysema in association with other hallmarks of bronchopulmonary dysplasia in 3 cases. the following types of congenital cystic adenomatoid malformation were found: type i (4), type ii (1), type iii (1), and the ct data was in close relationship to the morphologic findings. in 3 cases ct showed the presence solitary or multiply lung cysts. conclusion: ct is a useful diagnostic tool for precise estimation of the extent and differential diagnosis of cystic pulmonary malformations in the newborn and young child with respiratory failure. ct angiography can provide important diagnostic information in the preoperative investigation of pulmonary and mediastinal vessels in these cases. we analysed 97 aubmt (46 boys, age 11.5 a; 51 girls, age 11.2 a), 35 (36 %) died and 83 albmt (33 girls, age 12 a; 50 boys, age 16 a), 29 (34.9 %) died. at least one plain radiograph and one ct were obtained before albmt and aubmt respectively. results: only 13 ct examinations in clinically complicated cases were peformed after albmt. pathological findings were found in 6/83 (7.2 %). 3/6 (50 %) later died because of infections. inflammatory pneumonia occured in 3 cases, mycotic infection in 2 cases and pneumonitis after chemotherapy was found in one case. graft versus host disease was the cause of death in 3/97 cases. 655 ct examinations of patients were performed after aubmt, mostly to exclude lung metastases and to follow up mediastinal lymph nodes. in 4/7 patients with respiratory symptoms parenchymal changes were found. we diagnosed 1 pneumonitis after chemotherapy, inflamatory pneumonia in 2 cases and mycotic infection in 2 cases. two patients had clinical symptoms with a negative ct. only 1/7 (12.5 %) died due to respiratory complications. conclusion: different imaging strategies for aubmt and albmt were used. the therapy of pulmonary complications is more complex with albmt, but there are frequently diagnosed with plain films. ct is used more frequently after aubmt in which pulmonary infections are rare and less serious. ct has a decisive role in bmt patients. chrispin-norman-score and bhalla-score of patients with cystic fibrosis: results: cn-scores varied between 2 and 24 in rx and mr. the mean cn-score was 12.6 ± 6.4 in rx and 12.8 ± 6.2 in mr. the cn-score was higher in rx in 10 patients and higher in mr in 15 patients. in 30.6 % the difference between the two scores was 0, in 88.9 % the difference was smaller than or equaled 2. high correlation was found between scoring with rx and mr with minor restrictions in differentiation of nodules and rings on mr. bhalla-scoring was possible in mr-imaging. conclusion: cn-scoring and bhalla-scoring of cf is possible with fast low-field mr. since scoring differences between rx and mr are not higher than interobserver differences in rx scoring, further research is strongly suggested to reduce radiation exposure in the long term follow-up of patients with cf, especially in children with minor pulmonary involvement. true-fisp lung mri at 0.2 t in pediatric oncology patients presenting with fuo g. schultz, c. laub, w. kenn, a. trusen, j. kühl, d. hahn; würzburg/de purpose: to compare conventional chest x-ray and mri in pediatric patients with a diagnosed cancer suffering from fever of unknown origin (fuo). materials and methods: 13 patients (aged 3 -22 years, mean age 8 years) had 21 chest x-rays and underwent mri in a 0.2 t mri unit (siemens magnetom open) using a phased array surface coil. the images were acquired in coronal and sagittal planes. for the mr investigation a trufi-sequence (tr = 6 ms, te = 3 ms, matrix 256, slice thickness 20 -40 mm) was used with an acquisition time for 10 slices of 20 s. results: although breathhold-sequences were not possible in all cases, it was possible to evaluate all investigations. with regard to pulmonary infiltration coincident findings were achieved in 15/21 cases. 2 out of 6 infiltrations could only be detected on the mr images and the extent of infiltration was better evaluated in 4 cases. additional mri-findings such as sinusitis, pericardial effusion and hepatosplenomegaly were detected. conclusions: true-fisp lung mri was found to be more sensitive than the conventional chest radiograph. additional important clinical information was also obtained with mri. underwent duplex ultrasound and digital subtraction angiography, followed by percutaneous treatment. duplex us was performed via trans-lumbar approach: ri derived from the interlobular arteries was obtained. pre-procedural mean ± sd values of ri and referral cut off values were calculated. patients were classified as cured/improved or not improved according to blood pressure values and changes in antihypertensive drugs before and after treatment. results: pre-procedure, mean ± sd ri values were different (p = 0.001) for atherosclerotic (0.63 ± 0.11) and fibrodysplastic (0.56 ± 0.10) stenoses, with no difference between cured/improved and not improved patients (0.59 ± 0.10 vs. 0.64 ± 0.12); no difference (anova p = 0.5) was found for medical therapy. in cured/ improved atherosclerotic patients (41/58, 70 %), ri was < 0.65 in 28 (57 % sonovue enhanced us measurement of altered renal haemodynamics in patients with liver metastases e. leen, j. macquarrie, w.g. angerson, p. horgan; glasgow/gb purpose: to assess sonovue enhanced ultrasound in the measurement of renal haemodynamics in patients with liver metastases. materials and methods: 10 healthy volunteers and 10 patients with proven liver metastases were studied; non-linear ultrasound imaging (m.i: 0.15 -0.20) of each kidney was performed continuously in a sagittal plane before and after bolus intravenous injection of 2 ml contrast medium (sonovue, bracco, milan). there was a minimum of 10 minutes delay between the examinations of either kidney to allow for contrast clearance from the previous injection. digital data acquisition over a period of 60 seconds was subsequently recorded for quantification analysis. timeintensity curves were derived from regions of interests placed over the kidneys. the contrast arrival times (at), peak amplitude (pa), time to peak (tp) & gradient (g) of the steepest portion of the curves for each kidney were measured. results: there was no significant difference in all the parameters between the contra-lateral kidneys for both controls and patients with liver metastases. there was no significant difference in the pa, at and tp indices between controls and metastases. in contrast the gradient values were significantly raised in those patients with liver metastases (metastases vs controls: 1.59 ± 0.47 vs 0.40 ± 0.22, p < 0.01); there was clear separation of the gradient values between the two groups. to study diagnostic possibilities of 3d-vusa in evaluation of main renal vessels. materials and methods: 71 consecutive patients were referred to 3d-vusa for assessment of major renal vessels: aortic aneurysm (5 pts), renal tumors (16 pts), suspicion of ras (22 pts), suspicion of upj obstruction (28 pts). 3d-vusa was performed on sonoline elegra (siemens) version 6.0 with power doppler and a special 3d program. postprocessing was performed using volume rendering data to obtain angiogramm-like virtual images. verification was made by conventional angiography (51 pts) and surgery (20 pts). sunday b results: 3d-vusa revealed 17/22 unilateral accessory ra, 2/3 bilateral accessory ra (sensitivity 75 %, specificity 95 %). upj obstruction was diagnosed by 3d vusa in 12 cases and was confirmed by conventional angiography and operation in 11 cases (sensitivity 81 %, specificity 71 %). ras was revealed in 4/22 patients referred to 3d-us study (sensitivity 50 %, specificity 62 %). 3d-vusa diagnosed 3 infrarenal aortic aneurysms. in the cases of renal tumors 3d-vusa helped to delineate normal and abnormal renal vasculature, thus providing necessary information for nephron-sparing surgery. conclusion: 3d-vusa is a useful, noninvasive new promising method for evaluation of main renal vessels. we suggested it especially in children and young adults, in patients with renal failure, allergy to iodinated contrast agents, or fear of ionizing radiation or arterial catheterization. high resolution 3d mr-angiography in renal arteries using sense this was related by measurement to the umbilicus and asis. results: on ct, the median (interquartile range) of the distances between the umbilicus and the ab, from the asis to the ab and from the umbilicus to the iv were −9.0 (28.8), 48 (16) and −24.9 (32) mm respectively. the mean angle of the umbilicus from the ab was 21.6° (range 14 -34°). on us, the mean distance from the iea to the midline was 36.2 mm (10 -48) and from the iea to the asis was 100 mm (80 -140). the relationship between the level of the asis and ab/iv is more consistent than the position of the umbilicus. primary-port trocar insertion at an angle of 34° and secondary-port insertion 15 mm from the midline is recommended. renal cyst ablation using mixture of n-butyl cyanoacrylate and iodized oil in patients with autosomal dominant polycystic kidney disease: a preliminary report j. kim 1 , s. kim 1 , m. moon 1 , h. lee 1 , j. sim 2 , s. kim 1 , c. ahn 1 ; 1 seoul/kr, 2 koyang/kr purpose: to assess the feasibility and effectiveness of renal cyst ablation using n-butyl cynoacrylate (nbca) in patients with autosomal dominant polycystic kidney disease (adpkd). materials and methods: during the past 14 months, 50 renal cysts in 14 patients were treated with percutaneous needle aspiration and intracystic injection of 1:2 mixture of nbca and iodised oil. clinical follow-up was done in all 14 patients for the period of 1 -12 months. subjective symptoms, blood pressure, and serum creatinine level before and after the procedure were compared. ct follow-up was done in 31 cysts in eight patients for the period of 3 -12 months. the procedure was considered successful at follow-up ct when the diameter of the cyst decreased more than 50 % after the procedure as compared to that before the procedure. results: after nbca therapy, symptom was improved in 12 of 14 patients (86 %) and cyst was disappeared or decreased more than 50 % in diameter after the procedure in 25 of 31 cysts (81 %). there were no significant changes in blood pressure and serum creatinine level after the procedure. there was no significant complication related to the procedure in any of the patients. conclusion: percutaneous needle aspiration with intracystic injection of mixture of nbca and iodised oil appears to be feasible and may be an effective modality in ablating renal cysts in patients with adpkd. purpose: stimulated acoustic emission effect shows marked lesional difference in uptake of the microbubble levovist in its liver specific phase. benign lesions showed high uptake, malignancies appeared as defects. a multicenter trial using a novel non-linear mode (adi, acuson, mountain view) offering greater sensitivity and spatial resolution. methods and materials: 67 patients with focal liver lesions characterised either by biopsy or serial/multimodality imaging have been studied. diagnoses were: metastases n = 34, hepatocellular carcinoma (hcc) n = 10; haemangioma n = 8 and benign non-haemangiomatous lesions (bnhl) n = 15, comprising focal nodular hyperplasia fnh; n = 5, focal fatty sparing n = 4, focal fat 1, adenoma n = 3, regenerating nodule: rgn n = 2. adi imaging of the lesion was performed without interval scanning after a delay of 5 minutes from bolus injection of levovist (2.5 g). liver-lesional uptake differences (llud: as %) were compared using a visual analogue score. comparisons were made using non-parametric comparisons (kruskal-wallis anova; mann-whitney 2-column comparisons with bonferroni corrections). results: highly significant differences (p ≥ 50 %), while fat/fatty sparing, rgn and fnh showed minimal differences (< 10 %). hccs (mean liver-lesion difference 67 %, range 0 -100 %) and haemangiomas (average 45 %, range 7 -80 %) showed overlap features. intergroup comparisons showed significant differences between bnhl and all other lesion types and between metastases and haemangiomas. conclusion: this simple test shows marked differences between lesion types. it is a very useful test for fatty change, fnh and rgn. non-haemangiomatous lesions can be separated from metastases with particularly high accuracy. the present of high-uptake of levovist at 5 minutes is strong evidence for benignity. b a c d e f 230 contrast-enhancement patterns of hepatic lesions at c3-mode intermittent us imaging d. cioni, r.a. lencioni, f. donati, l. crocetti, m. perri, c. franchini, c. bartolozzi; pisa/it purpose: to describe contrast enhancement patterns of focal hepatic lesions at c3-mode intermittent us imaging. materials and methods: a series of 99 hepatic lesions in 66 patients were examined. us examination was performed by using c3-mode intermittent imaging (technos, esaote biomedica) with 1.4 mechanical index after bolus injection of 2.5 g levovist (schering ag) at the concentration of 400 mg/ml. us images were acquired in arterial (15 -25 s), portal in-flow (40 -55 s), full portal (70 -85 s), and delayed (180 -200 s) phases. findings at contrast us studies were correlated lesion-by-lesion with those at spiral ct or dynamic mri. results: four distinct enhancement patterns were observed: (1) rapid enhancement in arterial phase, followed by either isoechoic (5/5 focal nodular hyperplasia, 1/1 hepatocellular adenoma, 1/6 haemangioma) or hypoechoic appearance (38/38 hepatocellular carcinomas) in portal-venous and delayed phases; (2) peripheral globular enhancement in arterial phase, with centripetal fill-in in portal-venous and delayed phases (5/6 haemangiomas); (3) rimlike enhancement in arterial phase, followed by hypoechoic appearance in portal-venous and delayed phases (9/25 metastases); and (4) no enhancement in arterial phase followed by either isoechoic (13/13 macroregenerative nodules) or hypoechoic appeareance (16/25 metastases) in portal-venous and delayed phases. the enhancement patterns shown at contrast us correlated with spiral ct or dynamic mri findings in 80 of 88 lesions (90 %). conclusion: c3-mode intermittent us imaging is an accurate tool to evaluate the contrast enhancement patterns of focal hepatic lesions. findings correlate well with those at spiral ct or dynamic mri. clinical study of a 3d virtual sonographic system to be used for remote diagnosis d. jeanbourquin 1 , t. le bivic 1 , r. larrue 2 , p. pineau 2 , j.-c. provost 2 ; 1 clamart/fr, 2 paris/fr objectives: virtualprobe system (iôdp, paris, france) allows to acquire sonographic images simultaneously with spatial position of the probe, in order to rebuilt exact 3d sonographic volumes. the system allows to rescan through the 3d volume in order to perform a complete but asynchronous sonographic examination. one possible application would be military medicine, because the expert is not present at the time and on the site where diagnosis has to be done. the objective was to evaluate the ability of the system to be used for remote medical diagnosis. the examinations from 40 patients were done on non moving organs, mainly on cervical and abdominal areas. examinations using conventional method were performed and later on compared to those realized using virtualprobe. all examinations were done by qualified radiologists. the image quality of the 2 methods were scored from 1 to 5 (poor to very good). moreover, the ability of the system to allow proper diagnosis was recorded. results: there was no difference between methods in image quality. for virtualprobe, diagnosis was adjudicated as "possible" in 33 cases (82.5 %), "possible with some difficulties" in 5 cases (12.5 %) and "not possible" in 2 cases (5 %) due to technical problems (electromagnetic interferences and patient with polypnea leading to the impossibility to do acquisition). conclusion: virtualprobe system is a powerful tool that would provide a significant improvement in remote medical diagnosis using ultrasonography. differentiation of neoplastic portal vein thrombus from vascular thrombus in cirrhotic patients using harmonic sonography and second generation contrast agents m. tonolini, v. osti, l. solbiati, p. marelli, v. kirn; busto arsizio/it purpose: assessment of neoplastic nature of intraportal thrombus is of crucial importance for staging and therapeutic choice in patients with hepatocellular carcinoma (hcc). we sought to assess the utility of grey-scale harmonic sonography using second generation contrast agents for differentiating between neoplastic and bland portal venous thrombus. materials and methods: 85 cirrhotic patients with solitary or multifocal hcc were evaluated for potential rf ablation therapy with triphasic helical ct, b-mode and color doppler us. contrast enhanced ultrasonography (ceus) was performed using low mechanical index (0.1 -0.2) and a second-generation contrast agent (sonovue, bracco). liver parenchyma and main portal branches were examined over arterial, portal, and delayed phases. results: in 10 patients (11.8 %) conventional us and helical ct identified thrombus within the portal trunk or main branches. arterial enhancement was depicted by ct in 7/10 (70 %) cases suggesting malignant nature. unenhanced color doppler detected arterial-type flow signals within the thrombus in 3 of 10 cases (30 %). with ceus, 8/10 (80 %) thrombus showed rapid and inhomogeneous enhancement in the arterial phase (p < 0.05, compared to unenhanced us). in the portal phase, the enhancement of these 8 thrombi decreased in proportion to the respective hccs, as contrast filled the patent portions of the vessel. in the remaining 2 cases, no arterial enhancement was detected and no malignant cells were found by us-guided fine-needle aspiration biopsy. conclusions: our study suggests that continuous-mode, contrast-enhanced harmonic sonography may serve as an easy and highly reliable modality for the characterization of portal thrombus in cirrhotic patients. specificity of contrast-enhanced harmonic sonography for characterization of solid, incidentally detected focal liver lesions l. solbiati, m. tonolini, l. cova, d. della chiesa, v. kirn; busto arsizio/it purpose: to assess the use of contrast-enhanced harmonic sonography (ceus) in the differential diagnosis of incidentally detected focal liver abnormalities. methods and materials: 460 patients underwent abdominal us for clinical questions unrelated to the liver. none of the patients had chronic hepatitis/cirrhosis nor history of malignancy. solid focal lesions were found in 49 patients (8.75 %). lesions with characteristic features of hemangioma were excluded. low mechanical index, continuous-mode ceus was performed using a second-generation contrast agent (sonovue, bracco). final diagnosis was established by means of helical ct, dynamic mri and/or fnab. results: in 14/14 focal nodular hyperplasias (fnh) and 13/13 atypical hemangiomas the typical enhancement pattern was detected. in 6 patients presenting multiple hyperechoic lesions, ceus showed enhancement analogous to that of the surrounding liver in all vascular phases, suggesting the diagnosis of focal fatty changes, subsequently confirmed with ct and fnab. in four patients with poorly enhancing lesions, ceus did not provide diagnostic findings and fnab was necessary to diagnose fibrotic hemangioma (1 patient), multiple tubercolous granulomas (1) and disseminated metastases form unknown origin (2). conclusions: for the characterization of most incidentally detected and sonographically indeterminate benign lesions (fnh, atypical hemangioma, focal fatty change) ceus (through the assessment of the enhancement behaviour over the different vascular phases) showed specificity equal to that of helical ct. ceus will probably alleviate the need for further investigation with helical ct studies and aspiration biopsies. o. catalano 1 , a. nunziata 2 , f. sandomenico 1 , a. siani 1 ; 1 pozzuoli/it, 2 naples/it purpose: to evaluate if ce-pd is helpful in the differential diagnosis of focal hepatic lesions detected by grey-scale ultrasound. methods and materials: in a 1-year period 98 consecutive patients where found to have previously unknown, non-cystic lesions on ultrasound examination (51 subjects showed 1 lesion, 29 2 -5 lesions, and 18 > 5 lesions). these lesions were evaluated with levovist-enhanced pd and were fitted into 9 categories (hepatocellular carcinoma, cholangiocellular carcinoma, adenoma, focal nodular hyperplasia, angioma, metastasis, dysplasic nodule, abscess, other). diagnostic confidence level was graded subjectively from 1 (possible) to 4 (certain). categorisation and diagnostic confidence scoring were repeated after ce-pd study. eight cases without confirmation were excluded. results: addiction of ce-pd study resulted in a change of category for 5 patients (5.6 %), all with a single lesion; this modification proved correct in all of them. excluding 48 subjects with a maximal scoring (level 4), there were 16 patients with increased confidence after ce-pd study, 2 with decreased confidence, and 24 with unmodified confidence after ce-pd; score change was never greater than 1 level. in the two most commonly encountered issues, suspected nodule in chronic liver disease and angioma vs. hypovascular metastasis, ce-pd imaging was rarely useful. conclusion: ce-pd increased the characterisation accuracy of ultrasound only in selected cases while it is not cost-effective if employed routinely. these patients can usually be predicted on a clinical-sonographic basis allowing selective ce-pd imaging to be performed. purpose: to define and quantify acoustic parameters in order to characterize liver histopathologic findings in patients presenting with chronic hepatitis type c using a commercially available ultrasound system. materials and methods: 78 patients with a chronic hepatitis type c were prospectively enrolled. cineloops from the liver and the spleen were acquired using an atl hdi 5000 unit (atl-philips, wa, usa). raw data were transferred to a pc for quantification with hdi lab, a software that eliminates the effects of the nonlinear b-mode map. two parameters were calculated using a linear time gain compensation: the liver and spleen attenuation coefficients (respectively lac and sac), and the signals of a region-of-interest (roi) located at 6 cm depth (mean and sd, linear units). all results were correlated to the results of the liver biopsy (knodell and metavir score). results: lac was higher than the sac in all cases. lac and the normalized ac (lac − sac) was significantly higher in cases of cirrhosis (p < 0.01). the signal intensity from the roi was not correlated to the histological findings. the standard deviation increased in cases of cirrhosis due to the heterogeneity of the echostructure. conclusion: quantitative ultrasonography is feasible in routine practice and can improve the stadification of cirrhosis due to chronic hepatitis type c. evaluation of reformatted image quality using a new 3d imaging tool for ultrasound multiplanar reconstruction m.j. o'neill, s.i. lee, j.f. simeone, p. mattos, j. haase, p.r. mueller; boston, ma/us purpose: virtualprobe® (iôdp, paris) is ultrasound acquisition and post processing software that uses an electromagnetic field to acquire positional data, allowing retrospective multiplanar 3d rescanning through a volume of tissue. the aim of this study was to compare image quality of the 2d movie clips used for volume rendering and the 3d reformatted images to that of conventional 2d images. methods and materials: 30 patients referred for exams of the kidney (9) and abdomen (21) were enrolled. each patient had a conventional ultrasound exam, followed by the virtualprobe. the static images, 2d movie clips, and 3d reformatted images were then graded by 2 radiologists on a 5 point scale (1 = best quality and 5 = worst). the difference between either the 2d clips or 3d reformats and the static images for right and left (28) kidney (58) liver (21), pancreas (21), cbd (21), spleen (20), gallbladder (18), and bladder (9) , for the static images, 2d clips, and 3d reformats. there was no significant difference in image quality for 2d movie clips or 3d reformats when compared to standard images. ratings when compared to the static images yielded p values ranging from 0.4 to 1.0 and 0.1 to 1.0 for 2d clips and 3d reformats. there is no significant difference in image quality between static ultrasound images, 2d movie clips, and reformatted multiplanar reconstructions when using the virtualprobe® post processing software. pim 3 minutes after iv injection of levovist (2 g, 300 mg/ml). pim examinations were analysed in consensus by two radiologists who assessed the number of lesions, the conspicuity of lesions on a scale 1 -4, and the smallest lesion diameter in comparison with baseline us. ct studies were performed using a multidetector ct scanner with 130 cm 3 of a non ionic contrast agent (400 mg i/ml) at a flow rate of 4 ml/s. scans were acquired at 35 scan delay for the hepatic arterial phase, 70 s scan delay for the portal venous phase and 120 s for the delayed phase, with a collimation of 4 × 2.5 mm and a slice thickness of 3 mm. all ct scans were evaluated in consensus by two experienced radiologists blinded to the results of us analysis. results: pim improved the conspicuity and the detection of lesions in comparison to baseline us (43 % increase) and to msct (13 % increase). in comparison with msct, the number of lesions detected with pim increased from 60 to 69; the improved detection rate was limited to lesions less than 5 mm in diameter and to non-cirrhotic patients. conclusions: pulse inversion mode may depict more lesions than msct although patients with very inhomogeneous liver parenchyma can represent a limit. performance of a digital flat-panel detector system in the detection of subtle rib fractures: a comparison with a conventional screen-film system and a phosphor-storage system at different levels of exposure k. ludwig, c. schuelke, h. lenzen, t.m. bernhardt, s. diederich, d. wormanns, p. brinckmann, w.l. heindel; münster/de purpose: to compare a digital flat-panel detector in the detection of subtle rib fractures with conventional screen-film radiography and phosphor-storage radiography at different levels of exposure. method/materials: subtle fractures were created in 100 of 200 porcine rib specimens. specimens were mounted into a basin filled with water to obtain absorption and scatter radiation conditions comparable to a human chest. imaging was performed using a flat-panel detector system, screen-film system and phosphor-storage system. exposure settings comparable to clinical imaging were applied (77 kvp, s = 400). additional imaging was performed with both digital imaging modalities at lower exposure doses: with the flat-panel detector images were acquired at exposure doses corresponding to speed-class 800, 1600 and 6400, with the phosphorstorage system to 800 and 1600. for each image the presence/absence of a rib fracture was assessed independently by three radiologists according to a five level confidence scale. roc-analysis was performed for a total of 5200 observations (600 for each imaging modality/exposure level). multivariate analysis was used to compare aucs. introduction: new digital imaging techniques offer the ability to adjust the radiation dose required to answer the clinical question. irrespective of the type of imaging technique, the lowest dose compatible with the required image quality should be used. material and methods: a comparative study was performed with three units for storage phosphor and a flat detector unit. image quality was evaluated by a contrast detail radiography phantom (nuclear associates: digirad). this was completed by further studies using phantoms containing anatomical structures. clinical images and doses were also evaluated by 5 european centres for radiology and medical physics that co-operate within the dimond-3 ec project. results: the images of the digirad phantom demonstrate differences in the image quality of storage phospor systems, but flat panel detector technology showed far the highest image quality. for the flat panel detector radiation dose can be decreased significantly in comparison to storage phosphor systems. using flat panel detectors all examinations can be performed with a maximum of halve the dose compared to storage phosphor systems, operated at a 400 speed class. further dose reduction by a factor of 4 is possible for specific examinations. conclusion: dose mangement with new digital imaging techniques can decrease radiation dose to the patient significantly. in a broad range dose and image quality can be optimized and adapted to the clinical question. performance of a digital flat-panel detector system in the detection of simulated rheumatoid erosions: a comparison with a conventional screenfilm system, a mammography-system and a phosphor-storage system at different levels of exposure k. ludwig, a. henschel, h. lenzen, t.m. bernhardt, d. wormanns, w.l. heindel; münster/de purpose: to compare a flat-panel detector system in the detection of simulated rheumatoid erosions with a screen-film system, mammography system and phosphor-storage system at different levels of exposure. method/materials: 320 artificial lesions (diameter 0.5 -1.2 mm, depth 1.5 mm) simulating erosions were created in 640 predefined regions in the mcp-and pipjoints of 20 monkey paw specimens. specimens were enclosed in containers with water for absorption/scatter conditions comparable to a human hand;imaging was performed at 44 kvp using a digital flat-panel detector system with exposure-doses corresponding to speed-class (s) 25, 100, 200, 400, 800, 1600, 3200 system, a phosphor-storage-system at (s) 200, 400, 800, 1600, a speed-class 200 screenfilm system and a mammography system. three radiologists independently evaluated each region for the presence/absence of a lesion according to a five level confidence scale. roc-analysis was performed for 16.224 observations (1248 for each imaging modality/exposure dose). multivariate analysis was used to compare aucs. in erosive lesions the flat-panel system is superior to conventional screen-film radiography and phosphor-storage radiography at clinical exposure settings. it offers the same diagnostic performance with a lower exposure. reference levels during interventional cardiology procedures: the european dimond experience v. neofotistou; athens/gr purpose: to present the european dimond approach in defining reference levels (rls) for radiation doses delivered to patients during interventional cardiology (ic) procedures, namely coronary angiography (ca) and percutaneous transluminal coronary angioplasty (ptca). rls have been suggested by the council directive of the european community 97/43/euratom as a means of optimising diagnostic exposures. method: during the dimond (digital imaging: measures for optimising radiological information content and dose) european research program patients' doses during ic procedures were measured. this was done in terms of dose-area product (dap), fluoroscopy time and total number of radiographic exposures. values were obtained in three participating european hospitals, using previously checked x-ray equipment and according to a commonly agreed protocol. moreover, a dap trigger level has been defined in order to prevent skin injuries since ic techniques are known to be associated with high radiation doses and thus deterministic effects may be observed. results: rls for dap equals 60 gycm 2 and 100 gycm 2 , for fluoroscopy time 6.5 min and 20 min and for number of frames 1000 and 1400 for ca and ptca respectively. dap trigger level for cardiac procedures, which should alert the fluoroscopist for probable skin injury, equals 300 gycm 2 . the proposed values, which should be considered only as interim rls, take no account of the complexity of particular case or patient's physical characteristics dimond rls are being updated with patient doses measurements taken in seven european countries and with degrees of tolerances assigned to complexity of procedure as well as the patient's size. optimized spectrum in direct digital mammography w.j.h. veldkamp, n. karssemeijer, r.e. van engen; nijmegen/nl purpose: the objective is to find the optimum target-filter and kilovoltage for varying simulated breast thicknesses when using a flat panel full field digital mammography detector (ge senograph 2000d). we use the cdmam phantom that was developed at our institute. this phantom consists of a matrix of squared cells with dots of varying size and contrast. each cell contains two dots, one in the center and one in a scientific sessions sunday b a c d e f 233 randomly selected corner. a computer program was used for automatic readout of the phantom recordings. the program uses the ideal observer model for detecting the dots. image quality is expressed by the contrast detail curve relating object size and contrast at some fixed detection threshold. to cover a range of exposure conditions and breast thicknesses a total of 288 recordings were evaluated. the glandular dose was kept constant for each simulated breast thickness while spectrum parameters were varied. results: results showed that for 7 cm perspex the rh-rh target-filter combination gave superior image quality compared to mo-rh and mo-mo. for 3 and 5 cm perspex the different target filter combinations gave comparable image quality. the results suggest that in full field digital mammography a rh-rh target-filter combination can be used for the whole range of breast thicknesses. an investigation of the observer variability in reading a contrast detail test object in digital mammography p. . images were printed on high resolution printers. a cdmam contrast detail phantom 3.2 (nijmegen, the netherlands) was placed on top of 4 cm of polymethyl methacryllate. images were read by a group of experienced observers within the dimond iii ec project. optimal viewing conditions in respect of viewing box brightness and ambient light level were used. image scores were analysed using a computer program which incorporated the rules for interpreting images. results and discussion: contrast-detail curves and image quality factors could be calculated for the different observers and images. observer variability was compared with theoretical predictions and some readings from conventional mammography images. image quality factors were low, meaning that low contrast differences and small objects could be distinguished. the variability of the readings was large, but tolerances were similar in all observers. therefore, we propose to also acquire typical cdmam images from digital mammography systems as part of an acceptance testing programme. first clinical experience of a digital slot-scanning-area detector for mammography t. francke 1 , j. egerström 2 , m. eklund 2 , l. ericsson 2 , t. kristoffersson 2 , v. peskov 1 , j. rantanen 2 , s. sokolov 1 , p. svedenhag 2 , s. thunberg 2 , c. ullberg 2 , n. weber 2 ; 1 stockholm/se, 2 danderyd/se purpose: to compare image quality and dose for a novel digital slot-scanning area detector vs. conventional analogue film-screen images. the design of the detector, photon counting and small detector width of 50 mm, results in a very high image quality (high resolution and high contrast) at a low dose. the avalanche gaseous photon counting technique, allows for virtually scatter free and noise free images, resulting in very high signalto-noise ratio. this new detector has been mounted on a commercially available mammographic unit (mammomat 3000, siemens). the digital images taken with the instrument are compared to analogue film images, where the beam quality (kvp and anode/filter combination) as well as projections has been kept the same to allow a true comparison. results: a full field mammographic digital detector, 19 × 24 cm, based on a slotscanning-area technique with photon counting gaseous detectors has been evaluated. the performance of the detector has been studied and compared to analogue film-screen system by imaging phantoms, breast specimens and patients. the results are very promising, compared to conventional film-screen images, regarding image quality and a significant dose reduction. conclusions: noise-free photon counting is a promising method for digital x-ray imaging, improving image quality as well as significant reducing the glandular dose to the patient. first considerations regarding an acceptance protocol for full field digital mammography equipment: validation in a multicenter setting f. rogge 1 , a.-k. carton 1 , h. bosmans 1 , e. vano 2 , p. torbica 3 , a. crevecoeur 4 , y. palmers 5 , k. faulkner 6 , g. marchal 1 ; 1 leuven/be, 2 madrid/es, 3 innsbruck/at, 4 liège/be, 5 genk/be, 6 newcastle upon tyne/gb purpose: the introduction of full field digital mammography equipment requires the development of acceptance testing protocols. we have reviewed the current european protocol for quality control in (conventional) mammography within the dimond-3 ec project and we propose a similar series of tests for digital systems. methods and materials: following tests had to be redefined: the assessment of the focal spot size, different tests of the automatic exposure control and tests of the detector including the grid. image quality was evaluated via phantom exposures and dqe measurements. the protocols were tested on 3 digital senographe dmr systems (ge) and on 1 digital fuji detector. results and conclusion: all the tests included in the revised acceptance protocol may be completed in under 4 hours. the performance of the three systems was very stable. the doses for standard exposures were variable between the different sites. this has an impact on image quality. since the dose setting for a digital detector is a parameter of the x-ray system only (independent of any filmscreen combination) that can be freely adjusted in the different centers, we propose to use a quite strict guidance regarding the standard dose settings. a difficult practical problem is the transfer of data in order to perform some evaluations offline. further cooperation with the manufacturer may be needed to make this type of testing feasible for hospital medical physicists. interventional radiology purpose: percutaneous ct guided biopsy is an accurate and safe procedure to evaluate indeterminate adrenal masses in oncologic patients. we sought to assess the clinical outcome in patients with negative percutaneous needle biopsies of focal adrenal lesions materials and methods: retrospective analysis of 225 oncologic patients (f:m, 138:87; age range 33 -87 years, mean age 66 years) who had undergone ct guided fna biopsies of an adrenal mass over a 5-year period were reviewed. the incidence of negative (for tumor) biopsy results were identified and assessed for subsequent evaluation of the biopsied lesion in these patients results: of the 225 biopsies, 41 (18 %) were negative for neoplasm. the primary neoplasm in these 41 patients included 32 lung cancers, 1 bladder, 1 prostate, 5 breast and 2 renal malignancies with the size of the adrenal lesion ranging from 2.8 -5 cm. of these 41 biopsies negative for tumor; 10 were identified as adenomas and the rest showed benign adrenal cortical cells or hyperplasia on cytopathology and histopathology. an experienced pathologist interpreted all specimens as sufficient for diagnosis. repeat biopsies were obtained in 13/41 (31 %) patients; whereas 2/41 (5 %) had the adrenal glands analyzed on post mortem examination. none of these 15 repeat evaluations yielded tumor conclusions: a negative or normal pathology result in a ct guided percutaneous adrenal biopsy can be regarded as a true negative evaluation in oncologic patients with no necessity to repeat the biopsy. a c d e f 234 materials and methods: in 54 patients (32 liver tumors and 22 different abdominal tumors) mr-guided biopsies or punctures were performed with a low field mri (0.2 t, magnetom open, siemens). for guidance of the needles, t1-weighted flash sequences (tr/te 100/9; 70°) were performed in all patients and an additional fisp-rotated-keyhole-sequence (tr/te 18/8; 90°) was also used. after positioning of the needle tip in the tumor, 82 biopsy specimens were acquired with 14 -16 g cutting needles (somatex®) during the interventional procedures. the visibility of the needles, the tumors and the abdominal vessels were evaluated. results: all interventional treatments were performed without vascular or organ injury. adequate specimens for histological interpretation were obtained in 47 cases (87.0 %). in 3 patients (5.6 %) the biopsy result was non-specific and in 4 patients (7.4 %) the lesion was missed. t1-weighted flash images were useful for confirming needle-tip placement during the biopsies or punctures. the use of free slice orientation facilitated the interventional procedure. the organs, tumors and vessels were easily determined. the fisp sequence resulted in equal or inferior results. conclusion: mr-guided abdominal interventions can be performed with acceptable safety and accuracy with low field systems. lesion and needle visibility are significantly affected by user-defined parameters which must be considered during procedure planning. materials and methods: over 4.3 years, 1120 biopsies were carried out under ct-fluoroscopic control (philips aveu and toshiba aquilion) in the lung (33.6 %), mediastinum (6.6 %), abdomen (26.6 %), pelvis (7.5 %), retroperitoneum (11.8 %) and varia (14 %). in 867 cases, the obtained material was sent to pathology. 88 % (761) provided material for cytology, 48 % (413) for histology. a pathologist was on-site and decided, by means of a quick staining procedure, whether further tissue removal was necessary. the primary tumour was known in 403 cases. the number of punctures, unsuccessful biopsies, positive and negative results (classified according to biopsying examiner and location), differences between histology and cytology and complications were analysed. results: on average, 1.6 punctures were performed to complete the procedure. 2 tissue samples for cytology were obtained in 181 cases (21 %). the overall sensitivity for cytology and histology was 97 % and 96 %, respectively; 93 % and 97 % with known primary; 99 % and 95 % with unknown primary. in 83 (0.1 %) and 26 (0.03 %) of cases, no diagnostic material was obtained with cytology and histology, respectively, although the on-site pathologist assumed that sufficient material was present. benign lesions were found in 163 cases (18.8 %), 45 biopsies were unsuccessful (5.2 %). one less experienced examiner yielded only 61 % sensitivity. overall, complications occurred in 43 patients (5 %). conclusions: ct-fluoroscopy-guided biopsy represents a safe and reliable technique with a high sensitivity for malignancy and minimal difference between cytology and histology. the examiners experience plays a decisive role in the diagnostic outcome. the device used (pin point*) is integrated into a multisclice ct (mx8000, *marconi medical systems). it uses a laser assisted proprietary articulated arm technology and displays corresponding multiplanar ct images as the computer assisted arm is manipulated along the patient's body. the system includes an intuitive virtual planning tool that allows simulation of the best instrument path from the entry point to the target area. 50 biopsies of masses in 50 patients were carried out. all biopsies were obtained using an 18 or 20 gauge high speed tru-cut biopsy gun. masses biopsied included lung (25), lymph nodes (8), bone (10) and pelvis (7). an average of 2.5 passes was performed. results: using this system interventions could be confidently planned and safely carried out even in difficult or risky areas in all 50 cases. however, due to respiratory motion there are some limitations, particularly with lung lesions. mean proce-dure time was 8 min ± 10 min. in 95 % of the cases biopsies were diagnostic. after central lung biopsy 1 of 4 patients with pneumothorax required a chest drainage. 2 cases with haemoptysis resolved with conservative treatment. conclusion: the evaluated simulation and virtual planning system is safe, quick and convenient for ct-guided biopsies with some limitations due to respiratory motion. it may also become a useful tool for additional ct-guided therapeutic procedures. evaluation of age-related risk profiles for pneumothorax in ct-guided percutaneous thoracic biopsies b. rapprich 1 , t. werba 1 , r. tomczak 2 , n. rilinger 1 ; 1 offenbach a. main/de, 2 bad friedrichshall/de purpose: in studies of patients undergoing percutaneous thoracic biopsies, the risk for pneumothorax has varied from 2 -61 %. our aim was to develop a risk profile for pneumothorax based on the severity of pneumothoraces and in correlation with age and the presence of emphysema. methods and materials: we retrospectively investigated outcomes of 133 patients with ct-guided thoracic biopsies using an 18 g coaxial cutting-needle with a high-speed-automatic system (biopty bard). pneumothorax was graded as: i minimal, local; ii < 1 cm; iii > 1 cm; iv chest tube required. emphysema was graded as: i discrete; ii moderate; iii extensive. results: 97.7 % of the biopsies in 133 patients were successful. the diagnostic sensitivity was 94 % and the incidence of pneumothorax was 30.1 % (grade i: 17.3 %; ii: 5.3 %; iii: 3.8 %; iv: 3.8 %). for younger patients the risk of severe pneumothorax (grade iii or iv) increased linearly. the degree of emphysema did not correlate with the incidence of pneumothorax. conclusion: the pneumothorax risk for elderly patients decreases in transthoracal ct guided automated high-speed cutting-needle biopsies. the incidence of severe, clinically relevant pneumothoraces increases linearly in younger patients. the linear correlation is caused by morphological and functional linear changes due to the regular aging of the lung. no correlation with pathological emphysema was found. purpose: the aim of this study was to examine the feasibility of percutaneous drainage of abdominal fluid collections using a mri-compatible drainage system. material and methods: in 6 patients drainage procedures were performed with mri-compatible drainage systems (somatex®) for the interventional treatment of abdominal fluid collections). for all procedures a low field mr-system (0.2 t, siemens) was used. the punctures were controlled using t1-weighted flash sequences (tr/te 100/9; 70°) and a fisp-rotated-keyhole-sequence (tr/te 18/8; 90°). after positioning of the catheter in the fluid collection, the topographic details were controlled with intracavitary injection of an aqueous gadolinium solution (dilution 1:200). results: all drainage catheters were successfully placed into the fluid collections under mr-guidance. the catheter position was easily visualized with the t1weighted flash sequences. using the fisp sequences the visibility of the catheters was good or moderate and also useful for mr-guidance. no procedure-related complications occurred. the mean time needed for the drainage procedure was 30 min ± 15 min. the fluid collections were drained for a mean of 12 days. the topic of the study presented here is the evaluation of the feasibility and acceptance of repeated ultrasound-guided lymph node puncture for vaccination. we performed 548 ultrasound-guided punctures of inguinal lymph nodes in 58 patients with proven malignant melanoma and biopsy confirmed metastases of the disease. we delivered a suspension containing antigen pulsed dentritic cells, under ultrasound view, directly into the lymph node's paracortical area. to visualize the procedure we used a high-resolution computed ultrasound system (sequoia 512) with a 13 mhz linear array probe. the tip of a 20 g needle was placed into the paracortical area of the node, and application of the suspension was performed under ultrasound view. results: normal-sized, morphologically unsuspicious lymph nodes were found in every patient during every procedure. major side effects were not observed; we merely noticed fever in 1 patient, painful swelling of the punctured lymph node in 3 patients, and newly occurring vitiligo in 10 patients. the immunological results of our therapy are still under evaluation. conclusion: ultrasound-guided intranodal vaccination is a reliable and reproducible technique to deliver antigen-pulsed dentritic cells into peripheral lymph nodes. the method is well accepted by patients. it could lead to changes in the therapeutical options of both malignant and infectious diseases. slowly-heparin-releasing drainage catheter: in vivo and in vitro assessment of clog-resistant effect j. han, k. lee, b.-i. choi, c. yoon, y. byun, h. moon; seoul/kr purpose: clogging of catheter is frequently encountered during various drainage procedures. we evaluated the effectiveness of a novel clog-resistant drainage catheter. we have recently developed slowly-heparin-releasing catheter by coating standard drainage catheter with the blend of amphiphilic heparin-derivative (heparin-deoxycholic acid) and polyurethane. in vitro fibrin formation test was performed by dipping heparin-coated catheter and non-coated catheter (as control) into fresh plasma for 60 minutes, and the results were interpreted using scanning electron microscopy. for in vivo assessment, eight pairs of coated and control catheters (8 french) were inserted into the peritoneal cavity in normal new zealand white rabbits (n = 8). applying a basic principle in flow dynamics (resistance = pressure/flow rate), intra-catheter pressure was measured at the plateau (pmax) during saline infusion in constant rate (0.1 ml/s) and pmax was followed up for 14 days to estimate the changes in effective caliber. results: on in vitro assessment, no fibrin formation was observed in heparincoated catheter compared to strong reaction in control catheter. on in vivo assessment, decrease in mean effective caliber was 1.7 % vs. 7.5 % (coated vs. control) at 3 rd day (p = 0.14, paired t test), 4.8 % vs. 12.5 % at 7 th day (p = 0.059), 6.5 % vs. palermo/it purpose: hepatic artery stenosis and thrombosis are common complications in liver transplant patients. digital subtraction angiography (dsa) has served as the gold standard to make this diagnosis. more recently, three dimensional helical computed tomographic arteriography (3d cta) with maximum intensity projection and shaded surface display techniques has been compared with dsa. the purpose of this study is to determine if 3d cta with volume rendering technique is a useful and accurate tool in the detection of vascular complications after liver transplantation. methods: 35 consecutive liver transplant patients underwent 3d cta with volume rendering technique. the standard of reference was dsa for 20 patients and imaging and clinical follow-up for 15 patients. two blinded reviewers evaluated the axial and 3d cta images in consensus. results: 3d cta with volume rendering technique detected 10 hepatic artery stenoses, six hepatic artery thromboses, two hepatic artery pseudoaneurysms, two splenic artery aneurysms, two portal vein stenoses, and four redundant hepatic arteries. in one case ct detected a moderate hepatic artery stenosis, while conventional angiography showed a normal artery. the sensitivity of ct for detecting vascular lesions was 100 %, specificity 89 % (8 of 9), accuracy 95 % (19 of 20), positive predictive value of 92 % (11 of 12), and negative predictive value of 100 % (8 of 8). conclusions: 3d cta is a useful and accurate noninvasive technique for detection of vascular complications in liver transplant patients. evaluation of an "all-in-one" multidetector-ct protocol for potential living liver donors t. schroeder, m. malagó, s. heistrüvers, s. nadalin, j. stattaus, j.f. debatin, s.g. rühm; essen/de purpose: to evaluate an "all-in-one" multidetector-ct-approach for evaluation of potential living related liver donors. materials & methods: 21 consecutive potential living donors of the right lobe of the liver (mean age 32 years) underwent three-phase, dual-enhancement multidetector-ct imaging to delineate biliary, vascular and parenchymal morphology. for display of the biliary system the first ct-image set was collected 25 minutes following the infusion of 100 ml of a biliary contrast agent (biliscopin). subsequently ct (slice thickness/collimation 1 mm, pitch 4 mm, table-speed 12 mm/s) was performed for display of the arterial as well as the portal and hepatic venous systems, following automated injection of 140 ml of an iodinated contrast agent (imeron 350). analysis was based on source images and multiplanar reformats. the hepatic parenchyma was assessed for the presence of pathologies and volumetry was based on the venous data set. results: all potential donors tolerated the exam well. the 'in-room' time for the exam ranged between 7 and 12 minutes. one hemangioma and one adenoma were identified. total liver volumes ranged between 1040 and 1716 ml. the underlying biliary and vascular anatomy was displayed at least to the second intrahepatic branch in all cases. anatomic variations were observed involving the biliary system (n = 16), the arterial system (n = 13), the portal system (n = 5) and the venous system (n = 6). conclusion: the outlined approach proved efficient and robust. all relevant pre-op data for potential living related liver donation was collected in one single diagnostic step. ischemic-type biliary lesions following liver transplantation: evaluation with mr cholangiography p. boraschi, r. gigoni, l. urbani, e. neri, f. filipponi, c. bartolozzi, f. falaschi; pisa/it purpose: to assess the diagnostic value of mr cholangiography (mrc) when evaluating ischemic-type biliary lesions (itbl) in the follow-up of liver transplant patients. we retrospectively reviewed mr imaging and mrc of sixteen liver transplanted patients (13 men, 3 women) with ischemic changes of the biliary tree. the mr examinations were performed on a 1.5 t unit (signa, ge medical system) with high performance gradients. after the acquisition of axial t1w and t2w sequences, mrc involved a coronal, non breath-hold, respiratorytriggered, fat-suppressed, two-dimensional, thin-slab, heavily t2w fast spin-echo sequence, and a coronal breath-hold, thick-slab, single-shot t2w sequence. ten patients underwent either surgical reconstruction of the biliary system (n = 4) or liver retransplantation (n = 6); the pathologic specimens were employed as standard of reference. the final diagnosis was obtained through direct cholangiography in the remaining cases. without knowledge of the surgical, pathological and cholangiographic findings two experienced observers evaluated in conference the mr images to determine the presence of biliary tract abnormalities. results: mrc demonstrated strictures involving the hepatic bifurcation and extrahepatic pre-anastomotic bile duct with concomitant thickening of the biliary wall in 13 patients; sludge or stones were present in 7 out of these patients. in the other 3 cases with circumscript extrahepatic lesion, mrc clearly showed intraductal sludge and/or biliary tract dilation above the non-anastomotic stricture, but direct cholangiography was more precise in determining the length of the stricture and grading the stenosis. we retrospectively reviewed doppler us images of the hv in 113 consecutive patients who underwent lrlt. doppler us was performed between 1 and 25 times (mean, 5.2 times) during 1 -433 days after lrlt. nineteen patients who were excluded for analysis of hv stenosis from various causes (early postoperative death, etc). patients who had more than 10 mmhg of pressure gradient between the hv and the inferior vena cava during the procedure of hv stenting were considered to have significant hv stenosis. the control group included patients with no evidence of hv stenosis at least 3 months after lrlt. spectral doppler us findings between the two groups were compared. results: five patients (4.4 %) had significant hv stenosis, and three of them showed persistent monophasic waves on doppler us whereas two patients showed monophasic waves on most of us examinations and a biphasic or a triphasic waves on 6-and 9-day follow-up. in control group (n = 89), 52 patients with persistent tri-or biphasic waves and 35 with mixed monophasic wave with tri-or biphasic wave according to the follow-up period of us examinations, and 2 showed persistent monophasic waves. conclusion: persistent monophasic waves on doppler us in the hepatic vein is a suggestive, but not a specific finding to be significant hv stenosis after lrlt. persistent triphasic waves on doppler us can confidently exclude significant stenosis. 3d ct angiography using multidetector row helical ct in the preoperative assessment of arterial supply to the liver g. brancatelli 1, 2 , m.p. federle 1 , v. kapoor 1 , d.a. geller 1 , j.j. fung 1 ; 1 pittsburgh, pa/us, 2 palermo/it purpose: to evaluate the usefulness of ct angiography (cta) with 3d reconstruction to detect the arterial supply to the liver using a multidetector row helical ct. methods and materials: eighteen patients had cta. of these, 17 had surgical correlation, including 9 who also underwent conventional arteriography. the remaining patient had conventional arteriography only. images were reviewed in cine mode on a pacs station with 3d volume rendered images. axial ct sections and volume rendered images were prospectively reviewed by two blinded readers jointly. results: all studies were technically satisfactory. ct angiographic findings were confirmed at surgery in 17/17 (100 %) patients (classical arterial anatomy, n = 11; replaced left hepatic artery (lha) off the left gastric artery (lga), replaced right hepatic artery (rha) off the superior mesenteric artery (sma) and accessory lha to segment iv off the common hepatic artery (cha), n = 1; replaced lha off the lga, n = 1; replaced cha off the aorta, n = 1; replaced lha off the lga and replaced rha off the sma, n = 1; rha, lha and gastroduodenal artery off common hepatic as a trifurcation, n = 1; rha off the coeliac trunk, accessory lha to segment iv off the cha, n = 1). findings at cta and conventional arteriography were concordant in 8/9 patients. in the single discordant case cta depicted a rha off the celiac trunk and an accessory lha to segment iv off the cha, but did not identify a lha off the lga. conclusion: cta is valuable in detecting the arterial supply to the liver allowing for precise surgical plannning. there are a number of sonographic features of posterior tibial tendinosis (ptt). one of these is an increase in posterior tibial tendon calibre. the aim of this study is to compare the posterior tibial tendon calibre in patients with ptt against a group of normal subjects by ultrasound. methods: patients with ptt were referred by the orthopaedic department for assessment of the posterior tibial tendon. healthy asymtomatic volunteers were taken as normal subjects. the posterior tibial tendon was examined by high frequency ultrasound (at least 7.5 mhz, usually 10 -12 mhz). the cross-sectional area was measured at three points along each tendon whilst keeping the probe at a right angle to the course of the tendon as it runs behind and under the medial malleolus and then forward on to its insertion at the navicular bone. the reference points were behind the medial malleolus, below the medial maleolus and just proximal to the tendon insertion. results: over a four year period, 44 patients with uni-or bilateral ptt were examined. the tendon calibre was compared with measurements obtained from 100 normal subjects from which the mean and standard deviation values were determined. it was shown that the vast majority of those with symptomatic ptt had values greater than 2 standard deviations above the mean normal value at each reference level. conclusion: patients with posterior tibial tendinosis demonstrate an appreciably larger tendon calibre than normal subjects. this is a very helpful sign in the diagnosis of posterior tibial tendinosis. kinematic ankle mri with a low field mri system g. dazzi, e. silvestri, a. iozzelli, f. magnaguagno, g. garlaschi; genova/it purpose: to test the usefulness of kinematic ankle mri performed with low field mri equipment. methods/materials: from january 1999 until february 2000 we examined 150 ankles using a 0.2 t mr system (artoscan, esaote). 25/150 patients (n = 4 synovial anterior impingement, n = 6 osseous posterior impingement, n = 15 lateral ankle sprains) underwent kinematic evaluation. we obtained the adequate range of motion by moving the chair with the foot in a fixed position, so that the leg passes from a semiflexed to the fully extended position. in this way, the ankle moves from 90° dorsiflexed to 135° plantarflexed position. kinematic examinations were performed on sagittal and/or axial planes using hse t1w sequences. results: we didn not identify significative findings in all cases of synovial anterior impingement. on the other hand, kinematic exams allowed a better evaluation of all patients with osseous posterior impingement. we directly visualized peroneal tendon instability in 3/15 cases of lateral ankle sprains. conclusions: kinematic ankle mri, performed with a low field unit, is a simple and quick technique in the study of some ankle pathologies. in particular, it seems to be very useful to evaluate the biomechanical alterations of osseous posterior impingement and to demonstrate the presence of peroneal tendon instability which is often unrecognized and misdiagnosed. purpose: the aim of this work was to assess mri diagnostic accuracy in detecting pathological conditions which lead to tibio-talar joint (ttj) impingement, using arthroscopy as the gold-standard. method and materials: 21 patients (aged 19 -35 years) clinically complaining of ankle unsteadiness and swelling entered this study; 20 out of 21 patients referred to a history of ankle sprain. mri examination was performed with both a 1.5 t whole-body (tse t2-w and se t1-w sequences) and a 0.2 t dedicated system (se t1 and t2-w sequences). in 12 cases i.v contrast material was administered followed by se t1-w sequences with fat saturation pulse. all the patients underwent arthroscopy. results: mri examination revealed the presence of ttj synovial impingement in 9 patients and in only 4 of them the presence of contrast enhancement revealed acute inflammatory stage; arthroscopy always detected a thickened synovial lining. in 3 patients mri examination showed the presence of tibio-peroneal tendon injury associated with synovial hypertrophy ("meniscoid syndrome"); in 1 of these cases contrast enhancement was evident. in 6 patients mri examination documented the presence of a bony impingement due to talus and tibial osteophyte; in these cases arthroscopy confirmed mri diagnosis. three patients had a completely negative mri examination, one of them showing a meniscoid syndrome on arthroscopy. conclusion: because of a good correspondence with arthroscopic findings we may consider mri very accurate in the diagnosis of different pathological conditions causing ttj impingement. mri is also able to detect extra-capsular causes of impingement. forty patients affected by tibio-talar pain and swelling were submitted to plain films and to mri using dedicated and whole body mri units. in 21 of them history of a previous inversion ankle sprain was present. in five cases intra-articular injection of paramagnetic contrast media (5 -10 ml of contrast medium obtained from the dilution of 0.6 ml of gd-dtpa in 250 ml of saline) was performed. ct scanning was performed in nine cases. all patients underwent surgery. in 36 of the 40 cases arthroscopy confirmed the mri findings. 25 examples of chondral disease were discovered by mri with differing degrees of severity (6 low, 11 mild, 8 severe grade). in 3 of 6 low grade conditions, arthroscopy could not reveal the damage of the deepest aspect of the cartilage and subchondral drilling was performed on the basis of mri findings. in nine patients arthroscopy confirmed ct and mri evidence of osteochondritis dessicans. in the other 4 cases mri and arthroscopy could not reveal any pathological condition. conclusion: on the basis of our experience, mr has to be considered the gold standard in the study of ttj cartilage allowing evaluation of its full thickness and of the subchondral bone. subjects and methods: 63 patients with recurrent lateral derangement of the ankle were studied with ct and mri. ct was performed with coronal acquisitions using a conventional equipment. mri was performed with a superconductive scanner, and coronal and sagittal t1 and t2*w images. in 24 cases (selected group) no signs of alteration of both internal and external collateral ligaments were demonstrable. in these patient analysis of the angle between long axis of the tibia and major axis of subtalar joint (ts angle) was calculated and the appearance of the articular space of subtalar joint was also evaluated. analogous measurement was done in a control group of asymptomatic patients results: in 13 cases ts angle appeared acute; in 7 of them mri demonstrated partial synostosis/synchondrosis of the subtalar joint. in 7 cases ts angle appeared highly obtuse and no signs of synchondrosis/synostosis were identifiable. in 4 cases no signs of alteration of the subtalar joint were demonstrable both at ct and mri. to analyse the normal mr anatomy of the intermetatarsal space, with emphasis in the description of the intermetatarsal bursae and neurovascular bundles, using mr imaging, mr bursography, as well anatomic and histologic correlation in cadavers. high resolution mr imaging of 32 intermetatarsal spaces derived from fresh human cadaveric feet was performed. the 4 intermetatarsal bursae were injected, and mr imaging were performed. t1-weighted and fat saturated t1-weighted spin echo sequences were performed in the 3 orthogonal planes. the intermetatarsal space anatomy was analysed. histologic examinations were performed. the intermetatarsal spaces were located in the forefoot, between two metatarsal heads, below and above the deep transverse metatarsal ligament (dtml) that divided them in two levels. the superior levels contained the synovial bursa, the interosseous muscles and tendons, and the collateral ligament complexes of the metatarsophalangeal joints, while the inferior levels contained lumbrical muscles and neurovascular bundles. one case presented a morton's neuroma. mr bursography improved the visualization of the structures of the superior level. the bursae extended distal to the dtml in the second and third spaces close to the neurovascular bundles and did not extend beyond the dtml in the first and fourth spaces. objective: plantar fibromatosis is an uncommon benign condition manifested by proliferation of fibrous tissue within the plantar fascia. as opposed to plantar fasciitis which affects the calcaneal insertion, plantar fibromatosis affects the mid-to forefoot region of the plantar fascia. methods: over a four year period, 10 patients (8 females; 2 males, average age 54.8 years) with clinically suspected plantar fibromatosis were examined by ultrasound 13 mhz (siemens sonoline) or 12 -5 mhz (atl hdi 5000) linear array transducers. results: plantarfibromatosis was seen as a discrete fusiform-shaped nodular thickening of the plantar fascia removed from the calcaneal insertion. of the 12 patients examined, 8 (66 %) had unilateral disease while 4 (33 %) had bilateral disease. of the 16 affected feet, a single site of fibromatosis was present in 9 (56 %) feet with two or more sites in 7 (44 %) feet. of the 25 discrete foci of fibromatosis, 22 (88 %) were hypoechoic to the plantar fascia and 3 (12 %) were isoechoic. the fascial margin was well-defined in 12 (48 %) and ill-defined in 13 (52 %). 2 of the 25 lesions (8 %) showed mild internal vascularity. no correlation was found between the ultrasound appearances and the chronicity of patients symptoms. 15 (60 %) of lesions were located in the midfoot while 10 (40 %) were located at the forefoot. 17 (68 %) were located medially in the fascia while 8 (32 %) were located centrally. conclusion: this is the first reported series detailing the ultrasound appearances of plantar fibromatosis. while the ultrasound appearances are variable, they are still characteristic enough to allow a specific diagnosis in all cases. purpose: spontaneous involution of lumbar disc herniation in patients treated with conservative therapy is reported in up to 70 % of cases. the aim of our study was to evaluate any eventually predictive signs on mr imaging of disc herniation involution. methods and material: 65 patients, affected by 72 lumbar disc herniations, entered a perspective study. mri examinations were performed on 1.5 t magnet, using sagittal and axial t1w se sequences before and after contrast administration, and fse t2w ones on the same scan planes. patient age, sex and level and size of disk herniation, clinical onset interval, type of herniation, t2-w signal intensity and pattern of contrast enhancement had been registered. all the patients, conservatively treated, underwent clinical and mri follow-up after 6 months: disc herniation size and contrast-enhancement variations were re-evaluated. results: mri follow-up showed herniation regression in 66 % cases. extruded disk with high signal intensity on t2w sequences regressed in 83 % of cases. the same percentage of regression was registered in enhancing cases. free fragments disappeared in all cases. rest in bed for at least 15 days resulted to be a significant factor for a favorable evolution of acute disk herniation. no relationship was found with side, size, level. conclusion: mri features seems to have a significant meaning in assessing spontaneous tendency on herniation involution, thus furnishing additional prognostic value. the role or mri and mra in diagnoses of cervical spondilotic myelopathy v.p. marchuk 1 , a. chernenko 2 ; 1 vitebsk/by, 2 minsk/by purpose: there are three important pathophysiologic factors in the development of cervical spondylotic myelopathy (csm): static and dynamic mechanical spinal cord compression, spinal cord ischemia. this study was performed to analyze the role of combination mri and mra in patients with csm. materials and methods: 121 pts were examined on a 1.0 t picker vista unit -18 healthy subjects, 50 pts had signs of discogenic radiculopathy and neuroreflected disorders (i), 53 pts had signs of cervical spondylotic myelopathy (ii). mra was carried out in coronal projection, oriented perpendicular to the direction of blood flow of ra (tr/te 40/12.5, 256 matrix, 2dft tof, mast, overlap 0.5 mm). mr investigation included standard protocol. the difference in groups were mainly obtained in the evaluation of the number of radicular arteries branches (ra) -more than 3 branches were visualized (+) or were not visualized (-); and spine cord compression (c) -present (+) or absent (-). combination (ra+ c-) for healthy group displayed in 100 %, for i group in 52.8 %, ii group in 16.73 %. combination (ra-c+) for i group 11.1 %, for ii group 40.47 %. the spinal cord damage and csm arising from inadequate blood passage in ra branches and spine compression were increased twofold in cases of combination (ra− c+). the mr technique allows these complications to be revealed simultaneously and serves as a basis for appropriate treatment. material & methods: 20 patients who suffered from radiation myelopathy were examined by mr. patients underwent radiotherapy with total dose of 40 -44 gy and irradiation was performed in two series, with one month time interval between them. radiotherapy was performed in patients with bronchial carcinoma (14 patients) and malignant lymphoma (6 patients). examinations were performed on 1.5 t mr imager using a surface coil. the protocol included t1w and t2w sagittal images, t1w and t2w axial images and images after application of gd dtpa. results: clinical signs of radiation myelopathy appeared 6 -18 months after radiotherapy. symptoms included weakness of lower limbs and paresthesia. mr examination revealed abnormally decreased signal on t1w images, increased signal on t2w images, focal contrast enhancement and spinal cord enlargement. cord enlargement was detected in 19 patients while in 1 patient spinal cord atrophy was found. radiation-induced abnormal high signal intensity was presented in cervical and thoracal vertebral bodies due to fatty replacement of bone marrow with sharp boundary corresponding to the radiation field. conclusion: mr is easy, safe and valuable imaging method in diagnosis and differential diagnosis of radiation myelopathy. then we performed contrast-enhanced sagittal t1-weighted scans after i.v. administration of gadolinium-dtpa (magnevist, schering, germany). when we recognized these features with mri, the exam was completed with axial scans using the same sequences. all the patients underwent lumbar puncture within 2 days of the mr examination. results: in 10 patients mri was positive. we detected diffuse sheet-like infiltration of the arachnoid membrane or neoplastic coating of the conus and cauda equina to nodular deposition throughout the subarachnoid space. the most sensitive acquisition was the contrast-enhanced se t1-weighted sequence. only 7 patients out of 10 had a positive lumbar puncture. in the follow-up during therapy, mri was considered more accurate in the evaluation of the pathological evolution of leptomeningeal involvement by hematopoietic neoplasms. conclusions: in our limited experience, mri was more sensitive in the detection of spinal epidural and leptomeningeal involvement by hemopoietic tumors. in patients with strong clinical suspicion of this involvement and negative lumbar puncture, mri should be performed. purpose: knowledge of the exact site and localisation of a csf fistula is important for planning surgical procedures and to prevent further complications. the purpose of this prospective study was to establish and to evaluate gd-dtpa enhanced mr cisternography in the detection of rhinobasal csf fistulae in patients with suspected csf rhinorrhea. materials and methods: 10 patients with suspected csf rhinorrhea were examined. clinical diagnoses were: 7 severe head/brain trauma, 1 meningocele, 1 hydrocephalus and 1 chronic sinusitis. mr cisternography included the following investigation steps: acquisition of non enhanced fat suppressed t1-weighted se scans of the skull base and the paranasal sinuses, lumbar puncture with administration of 1 ml gd-dtpa solute with 4 ml nacl and performance of mr cisternography with the same fat suppressed t1-weighted sequences as used initially. in 5 patients gd-dtpa enhanced mr cisternography detected a csf fistulae (2 sphenoidal and 3 ethmoidal). while 4 of these depicted leaks were confirmed surgically and sealed. in one case the csf fistula closed spontaneously. in another case, csf leakage after severe head injury was highly suspected clinically, but ceased prior to mr cisternography, which was unable to detect the temporary fistula. in the remaining 4 patients with serous rhinorrhea mr cisternography did not provide any evidence for csf fistulae. intrathecal gd-dtpa injection was well tolerated. conclusions: mr cisternography after intrathecal administration of gd-dtpa is a safe, promising and minimally invasive method for detection of csf fistulae. this mr investigation provides excellent depiction of csf spaces and pinpoints csf fistulae. the description of the complex 3d shape of the ventricular system is an important aspect for the typisation of the ventriculomegaly. materials and methods: pd and t2w 3d datasets were used for the segmentation of ventricular system. using the volume and surface data's a size independent shape descriptor number (edginess) was created. edginess number of 8 atrophic, 10 alzheimer and 7 nph patient's was compared 44 normal subjects database. results: upon statistical analysis the data for the control patient group showed a significant difference from those for the alzheimer's group (p < 0.003) and for the nph group (p < 0.003), but no significant difference from the atrophy group. with respect to the atrophy group a significant difference was ascertained both from the alzheimer's group (p < 0.002) and from the nph group (p < 0.000). significant difference was also ascertained between the alzheimer's group and the nph group (p < 0.001). discriminate analysis enables 100 % reliability to be achieved in distinguishing the nph group. conclusion: size-independent shape description provides the opportunity for the objective monitoring of hydrocephalus cases, with particular respect to those occurring in developing children. it also enables ventricular shape changes developing in individual hydrocephalus cases to be differentiated. a substantial aspect the procedure creates a new possibility in differential diagnostics for the determination and type classification of every condition involving ventriculomegaly. aim of the study was to examine the effect of three different types of meal on the function of proximal stomach in alcoholic cirrhotic patients by ultrasound. the proximal stomach of 12 normal volunteers and 15 alcoholic cirrhotic patients were examined by ultrasound. each subject received on consecutive days 500 ml meat soup, or 500 ml of two different semisolid meals: yogurt with potato flakes or sour cream with potato flakes, the latter contained 12 % fat. the proximal sagittal area and the frontal diameter were measured fasting and 5, 10, 15, 20, 30, and 120 min. after a meal and my multiplication of these two parameters approximate volume (av) was calculated. relaxation of the proximal stomach was characterized by the ratio of fasting avf to the actual av at different time points. results: compared with healthy controls, av/avf was significantly decreased (p < 0.05) after liquid and semisolid meal in cirrhotic patients (2.9 ± 0.3 vs. 5.3 ± 0.7 after liquid and 3 ± 0.3; 6.5 ± 1.5 after semisolid meal), while difference of this value was not observed after semisolid fatty meal between cirrhotic and healthy patients. the abdominal ct scans of 42 patients were retrospectively reviewed by 3 radiologists. eighteen patients had surgically proven internal hernias (2 paraduodenal, 16 transmesenteric, case group) while 24 had no evidence of internal hernia at surgery (comparison group). images were reviewed in a random and blinded fashion. individual and group performance was evaluated by roc analysis, and inter-observer agreement was measured by cronbach's coefficient alpha. individual ct signs relevant as predictors of transmesenteric hernia were identified by logistic regression and ranked by their odds ratio and p-values. the 2 paraduodenal hernias were diagnosed by all 3 readers. ct signs of paradoudenal hernias include: a sac-like mass of small bowel, encapsulation of small bowel, mass effect on the posterior wall of the stomach, left displacement of the main mesenteric trunk and mesenteric vessel abnormalities. we found poor inter-observer agreement in diagnosing transmesenteric hernia in the case group, but good to excellent interobserver agreement for some of the ct findings predictors of transmesenteric hernia, with a cronbach's coefficient alpha value ³ 0.8. logistic regression analysis suggests that clustering of small bowel loops, en-gorgement, stretching and crowding of the mesenteric vessels, right displacement of the main mesenteric trunk, and small bowel obstruction manifested as bowel dilatation with a transition point are associated with transmesenteric hernia. conclusion: ct may allow a diagnosis of internal hernia, although this diagnosis remains difficult, especially of transmesenteric hernia. provoked gastro-intestinal bleeding with tissue plasminogen activator -a useful diagnostic tool in patients with occult lower gi bleeding j.m. ryan, s. dumbleton, t. smith; durham, nc/us purpose: the purpose of this study was to assess the efficacy and safety of provocative mesenteric angiography with tpa, heparin and tolazoline in patients with occult lower gastrointestinal bleeding. materials: 17 provocative bleeding studies were performed on 16 patients for occult lgi bleeding including 9 women and 7 men, aged 44 -79 years. all patients had previous negative endoscopic and negative angiographic studies. to provoke bleeding we used a combination of intravenous heparin (range 3000 -10000 units), intra-arterial tolazoline (range 25 -100 mg) and intra-arterial tpa (range 10 -50 mg, mean 20.3 mg). results: 17 studies were performed in 16 patients leading to bleeding in 6 patients (37.5 %). 2 vascular abnormalities were diagnosed which did not bleed during provocation -an abnormality was identified in 8 of 16 patients (50 %). there were no procedural complications encountered. of 6 patients in whom bleeding was successfully provoked, 4 bleeds occurred in the large bowel, and 2 in the small bowel. 3 patients had embolization at the time of provoked bleeding. 5 of these 6 patients required no further therapy for lower gastrointestinal bleeding. 10 patients (including 2 with vascular abnormality) did not bleed during the provoked study with tpa. of 8 patients with normal study 5 patients rebled during followup. conclusion: intraarterial provocative mesenteric angiography with heparin, vasodilator, and tpa identified the site of bleeding in 37.5 % of patients in our study group, and contributed to treatment in 50 %. this small study indicates that the procedure appears to be safe. monday b methods and materials: ct films of 10 cases with internal hernia including 4 cases with paraduodenal hernia, 3 cases with transmesenteric hernia, 2 cases with transomental hernia and 1 case with foramen of winslow hernia were retrospectively reviewed. surgical proof was obtained in all cases and strangulation was found in 5 of the cases. results: prevalent ct findings found in internal hernia were cluster of small-bowel loops, crowding of mesenteric vessels, engorgement of the mesenteric vessels, evidence of small bowel obstruction, and closed loop. saclike mass was a helpful ct finding to diagnose internal hernia having hernia sac. mesenteric edema, bowel wall thickening, and ascites were frequently observed in cases with strangulation. in paraduodenal hernia, herniated bowel loops showed a sac like mass and were found posterior to either ascending or descending mesocolon. in a subtype of paraduodenal hernia and foramen of winslow hernia, herniated loops were found in the lessor sac. in transmesenteric and transomental hernias, herniated bowel loops were found lying adjacent to the abdominal wall displacing the colon centrally. conclusions: ct may allow the diagnosis of internal hernia based on the shape and anatomical location of the herniated bowel loops. the presence of strangulation can be assessed by the ct features of the bowel wall and mesentery. cross sectional imaging findings of juxtapapillary duodenal diverticulum c. balci, a. akinci, e. akun, c. duran; istanbul/tr objective: the purpose of this study was to evaluate the ct and mr imaging features of juxtapapillary diverticulum, correlating with ercp, duodenoscopy. we retrospectively evaluated ct (n = 6) and/or mri (n = 11) examinations of 12 patients who were diagnosed juxtapapillary diverticulum on ercp (n = 10) or endoscopy (n = 2) examinations as correlative diagnostic examination. mri was performed in a 1.5 t scanner, ct was performed with helical technique using thin sections. ct (n = 5) and/or mri (n = 9) were primary imaging modalities in 10 patients. size, location of the diverticula and imaging findings of associated biliopancreatic disease were assessed. results: diverticula were missed initially in three patients on ct (n = 1) and/or on mri (n = 3). size of the diverticula ranged between 1 -3 cm. imaging findings of the juxtapapillary diverticulum was characterized as outpouching of the duodenal wall towards pancreatic head (n = 5). on 5 patients papillary relation to diverticular wall was evaluated on mri. on ct, layering of oral contrast with air level was characteristic imaging feature. on mri t2-weighted true fisp and haste techniques demonstrated the air fluid level with hyperintense fluid and signal void air level above. associated imaging findings as dilated cbd (n = 5), cholecystitis (n = 2) cholecystolithiasis (n = 2), chronic pancreatitis (n = 6) and were visualized on both imaging modalities. conclusion: with a better recognition of juxtapapillary diverticulum on ct and mri, initial cause of biliopancreatic disease symptoms in patients with juxtapapillary diverticulum can be depicted by these modalities. results of screening ultrasound diagnosis of gastric and colonic cancer s. pimanov, a. sikora, c. vergasova, n. lud; vitebsk/by purpose: the problem of colonic cancer (cc) and gastric cancer (gc) diagnosis remains a difficult issue. a number of screening programs for cc diagnosis based on faecal occult blood tests and endoscopy are well-known. the objective of this study was to determine the possibilities of screening ultrasound examination for gastric cancer and colonic cancer. patients and methods: 29467 patients aged 25 -87 with various diseases were examined for cc and gc diagnosis. screening ultrasound examination for cc and gc was performed in all the patients of the hospital and ambulance station who were examined by conventional abdominal sonography. cc and gc had not been suspected before the examination. revealing of concentric hypoechogenic thickening of the stomach and bowel wall with increased central reflection (i.e. non-specific "pseudokidney symptom") was defined as a pathological criterion. bowel and stomach sonography lasted for about 3 minutes. results: the ultrasound examination resulted in revealing 54 cases of cc and 18 cases of gc. almost all patients with tumours were operated and in all cases the diagnosis was confirmed histologically. according tnm classification most of these patients had t2 -t3 stages of cancer. false negative results were analyzed using regional cancer register. conclusion: it seems quite possible to diagnose actively colonic and gastric cancer by means of screening ultrasound examinations. the aim of our study was to develop an examination protocol for esophagus virtual endoscopy, that in association to axial ct images allowed to evaluate malignant stenosis and diverticuli. methods and materials: virtual endoscopy of the esophagus was performed in 29 patients with esophageal wall pathology. esophageal distention was obtained by oral administration of effervescent granules and intramuscolar injection of 20 mg of scopolamine butylbromide. in all patients, spiral ct volume zoom examination (120/80/1 mm/1 mm/8 mm/0.5 s kv/mas/slice coll./slice width/feed per rot/rot. time) of the thorax and upper abdomen was performed within a single breath-hold, before and after i.v. administration of contrast media. real time endoscopy images were reconstructed using volume-rendering techniques with a dedicated workstation and specific software (vitrea 2.2, vital images). conventional esophageal endoscopy was performed in all cases and an additional bronchoscopy was executed. results: 5 diverticuli and 24 endoluminal stenotic lesions were founded. most of them were localized in the middle or lower thoracic esophagus and were displaied as a discontinuity of esophageal lumen. 3d ct imaging associated to axial images depicts esophageal tumoral extension, other mediastinal air filled structures, the gastroesophageal junction and shows the presence of diverticuli complications. conclusions: our protocol achieves excellent distention of the lumen both proximal and distal to the stenosis and allows a correct differentiation between malignant stenosis and tumor located into diverticular task. this technique allows to obtain additional informations in the stenosis that do not permitt the passage of an endoscope and comparing to barium studies excludes the risk of aspiration of contrast agent. in 15 patients with positive egr, hp was negative, while both were negative in one patient. there was highly significant difference between the hp and egr findings (p < 0.01), meaning that statistically there was no dependence between hp and egr. in all 52 patients, hp finding did not correlate with index values (r = 0.181, p > 0.05). index of egr in patients with positive hp was c = 16.7 ± 11.5 %, while in those with negative hp were x = 25.3 ± 9.8 %. there were significant differences (p < 0.05) in the values of index in relation to the presence of hp, meaning that it was lower in the patients with positive hp finding. however, when only patients with pathologic values of egr were considered (egr > 10 %), there were no significant differences (p > 0.05) in the values of index in relation to the presence (n = 19, x = 27.7 ± 9.6 %) or absence (n = 15, x = 27.0 ± 7.15 %) of hp. conclusion: there was no relationship between the presence of hp and egr. birmingham, al/us, 2 rome/it introduction: cardiovascular mri (cmri)can accurately assess lv systolic function. diastolic function assessment involves complex methodologies such as phase contrast imaging or myocardial tagging. our purpose was to define diastolic dysfunction (dd) with a routine cmri approach. methods: using a 1.5 t system (ge signa cv/i; ge medical systems, milwaukee, wi), lv volumes and mass were calculated on cine short axis sequences in 19 patients, 8 with risk factors for dd (lvh, hypertension, coronary disease, etc) and 11 (control group) without risk factors. post-processing was performed with mass analysis package (medis, leiden, the netherlands) studied variables were ventricular relaxation rate, lv mass index, ef, and end diastolic volume index. results: diastolic relaxation rate was calculated from a linear regression line fitted to the rate of lv volume change and was normalized using the body mass index. ef and lv mass index were calculated. using binary linear regression analysis, diastolic relaxation rate predicted patients with risk factors for dd with a 2 of 9.8 (p < 0.005), whereas lv mass index predicted dd with a 2 of 5.6 (p < 0.05). ef and end diastolic volumes were not significantly different between groups. normalized diastolic relaxation rate distinguished the two groups with 79 % accuracy, cardiac mass index with 74 %, and the combination of the two with 95 %, with 2 of 18 (p < 0.0001). conclusions: diastolic relaxation rate and lv mass index can be used to evaluate lv diastolic function as a component of every cmri study, using a simple cine sequence, without additional time or complex techniques not widely available. clinical usefulness of high dose dobutamine stress mri for the detection and cardiac tagging for the detection of myocardial ischemia d.y. kuijpers, k.y. ho; groningen/nl purpose: to evaluate the clinical value of high dose dobutamine stress mri (dsmri) for the detection of myocardial ischaemia by wall motion analysis using myocardial tagging. patients and methods: a consecutive group of 159 patients with known or suspected coronary artery disease, who stopped their anti-anginal medication 4 days before the examination, were examined with a cine breathhold using a standard 16 segment short axis model. seven patients could not tolerate the examination. patients were examined at rest and during increasing doses of dobutamine stress at 6-minute intervals up to 40 µg/kg/min. cine images were acquired during breathholds at 3 short axis levels, including myocardial tagging. the data were evaluated for the presence of ischaemia, which was defined as a new wall motion abnormality (hypokinesia, akinesia, dyskinesia) in at least 2 segments at 2 different levels. mr images were interpreted during the examination by two 2 experienced investigators. two datasets were not interpretable. results: average examination-time was 52 minutes without major complications. 54 patients who showed signs of ischemia, were examined with coronary angiography within 2 weeks. 51 patients showed significant coronary artery disease of whom 49 needed revascularisation. three patients showed false-positive mri results, while sensitivity for 50 % luminal narrowing was 94 %. in the 86 patients without ischaemia on mri, the cardiovascular occurence-free survival rate was 98 % (average follow-up period was 10 months). conclusion: high dose dsmri using myocardial tagging is a safe and clinically useful method for the detection of myocardial ischaemia. aim of this study was to investigate the capability of mr imaging as a noninvasive tool to follow up ventricular and valvular function, perivalvular flow and myocardial remodeling in patients after avr. methods: on a 1.5 t mr system 15 patients with aortic stenosis and 20 healthy volunteers were examined. cardiac output (co), ejection fraction (ef), enddiastolic volume (edv) and lv ejection time frame as a parameter of contractility (∆tlv) were determined using a velocity encoded 2d flash technique (tr 24 ms, te 5 ms) and cine sequence (tr 100 ms, treff. 10 ms, te 4.8 ms, flip 25°, temporal resolution 50 ms). hemodynamic parameters and end-diastolic myocardial wall thickness (emwt) were determined 1 ± 0.5 days pre/7 ± 2 days and 10 ± 3 months after implantation of a st. jude medical prostheses. invasive measurements (fick principle/thermodilution) and echocardiography served as reference standard. intra-and interobserver variability of two observers were calculated for mr measurements. results: for co a good correlation with invasive measurements was found using phase velocity mapping (r = 0.66, p < 0.0007). lv parameters normalized late postoperatively (∆t = 158 ± 20 ms/98 ± 20 ms, edmt = 18 ± 3 mm/11 ± 3 mm, pre/ 10 ± 3 months surgery, p < 0.001). differences between normal volunteers and patients were detected on a high level of significance (normal ∆t = 102 ± 24 ms, emwt = 9 ± 3 mm, p < 0.0001). for mr flow measurements interobserver variability was 2.5 ± 2.7 %, intraobserver variability was 1.7 ± 1.6 %. in patients with suspected postoperative complications after avr cardiac mri should be applied prior to hospitalization and invasive diagnostic procedures. cardiac systolic rotation and contraction before and after valve replacement for aortic stenosis -a magnetic resonance myocardial tagging study j.j.w. sandstede 1 , t. johnson 1 , m. beer 1 , k. harre 1 , t. pabst 1 , w. kenn 1 , w. völker 1 , s. neubauer 2 , d. hahn 1 ; 1 würzburg/de, 2 oxford/gb purpose: aortic stenosis leads to derangement of cardiac function and contraction mode due to chronic pressure overload that is relieved after surgical valve replacement (svr). this study aimed to determine the changes in left ventricular (lv) systolic wall function before and after svr using mr tagging, compared to age-matched healthy volunteers. monday b a c d e f 249 materials and methods: 12 patients with aortic stenosis were examined with an ecg-triggered 2d tagging sequence at 1.5 t before and 12 months after svr. lv function and mass were determined by cine mri. cardiac rotation at the apical, mid-ventricular, and basal level and overall torsion were evaluated. 8 healthy volunteers within the same age group served as a control. results: before surgery, all patients showed a significant increase of apical rotation and overall lv torsion, basal rotation was not significantly different compared to volunteers. apical rotation and torsion were negatively correlated with lv mass and end-diastolic volume. one year after surgery, basal rotation was reduced compared to controls. in comparison to pre-operative values, apical rotation also decreased but was still elevated, and this resulted in a normalization of lv torsion. conclusion: pressure overload before surgery is associated with an increase of systolic lv wringing motion, possibly serving as a compensatory mechanism. this mechanism declines with increasing lv hypertrophy and dilatation. svr for aortic stenosis leads to normalization of lv torsion one year after surgery. patients and methods: global and regional function was determined by cine mri in 30 patients 3 weeks after anterior mi. at the same time, 31 p-spectra were obtained from infarcted as well as non-infarcted adjacent myocardium using a 3d-csi technique (voxel size 25 ml each). pcr/atp ratios and signal to noise ratios (snr) were determined using amares. 6 months after revascularization mri and mrs were repeated. gold standard for viability was recovery of regional function after revascularization. healthy volunteers served as control group. results: two groups of patients (15/15; wall motion recovery versus persisting wall motion abnormalities) were formed according to follow-up mri. at study entry patients with non-viable segments had significant reductions of pcr/atp-ratios in non-infarcted and infarcted myocardium due to a significant reduction of pcr snr, whereas patients with viable segments showed that only in the infarcted areas (p < 0.05 each). no significant differences were detected concerning morphologic or functional parameters between both groups. control examination 6 months after revascularization revealed significant increases of energy metabolism and cardiac function for patients with viable myocardium (p < 0.05). conclusions: restoration of regional oxygen supply by revascularization therapy is connected with improvement of metabolism and function in patients with viable segments, whereas irreversible damage of infarcted tissue is connected with continuous depression of energy metabolism. time course of 23 na signal intensity after myocardial infarction in humans j.j.w. sandstede 1 , h. hillenbrand 1 , m. beer 1 , t. pabst 1 , w. machann 1 , w. völker 1 , w.r. bauer 1 , s. neubauer 2 , d. hahn 1 ; 1 würzburg/de, 2 oxford/gb purpose: elevated sodium (na) content in myocardial infarction (mi) can be imaged by increased na signal intensity ( 23 na si). experimental studies described the temporal changes of myocardial na content post-myocardial infarction. aim of our study was to determine the time course of 23 na si after mi in humans. materials and methods: 13 patients were examined 14 ± 3 days and 3 months after mi, 7 patients underwent an additional examination 4 ± 1 days after mi. double angulated short axis 23 na images of the heart were obtained in prone position using a 23 na surface coil and an ecg-triggered 3d-flash-sequence with 32 acquisitions. wall motion abnormalities were detected by cine mri. 23 na si of mi was expressed as percentual increase compared with the entire circumference of noninfarcted myocardium. results: all patients showed an area of elevated 23 na signal intensity correlating with wall motion abnormalities. 23 na si remained elevated between day 4 and day 14 in the 7 patients that were examined twice in the early stage after mi. all patients revealed a decrease of 23 na si until 3 months after mi. conclusion: 23 na si is elevated in acute mi and throughout infarct healing but decreases until 3 months after mi. this is in concordance with experimental studies, these studies showed the highest na content at day 1 with a decrease until day 90. correlation of 23 na si and myocardial viability in humans has to be determined in future studies. p-sloop-mrs. 15 healthy volunteers were included in the study. results: compared to matched volunteers, a significant decrease of absolute pcr concentration was observed in patients with ms (p < 0.05), whereas atp concentrations showed no significant changes. functional analysis by mri depicted depressed left ventricular (lv) ef in 3 patients. for ms patients with mitoxantrone treatment, an association between cumulative dose and ef could be detected (r = 0.59; p = 0.0189). however, ef, lv esv and lv esv were not statistically significant between the two groups of patients. mrs detected no association for ratios or absolute values and cumulative mitoxantrone dosage. the reduction in cardiac high-energy phosphates as well as lv ef in some patients points to a subclinical involvement of the heart in ms. treatment with a putative cardiotoxic drug like mitoxantrone seems, however, not to aggravate a possible pre-existing heart disease within the examined cumulative dose range up to 100 mg/m 2 . absolute concentrations of cardiac high-energy metabolites -relation to clinical severity m. beer 1 , h. köstler 1 , j.j.w. sandstede 1 , k. harre 1 , s. neubauer 2 , d. hahn 1 ; 1 würzburg/de, 2 oxford/gb purpose: cardiac high-energy metabolism is impaired in failing human myocardium, and this may contribute to contractile dysfunction. current technical improvements of cardiac mr-spectroscopy (mrs) allow for absolute quantification. we tested the correlation between clinical severity and metabolite concentrations. patients and methods: patients with hypertrophic (aortic valve stenosis, avd) and dilated cardiomyopathy (dcm) were studied (10 each). patients were graded according to nyha; lv volumes, mass and ef were determined by cine mri. 31 pspectra were obtained using a 3d-csi technique. pcr/atp ratios and absolute values (mmol/kg) were determined using amares and sloop. healthy agematched volunteers served as control group. results: for nyha classes 0 (vol), ii (7 avd, 1 dcm) and iii (3 avd, 9 dcm), pcr concentrations were 8.48 ± 1.42, 6.78 ± 1.11, and 4.23 ± 1.01, atp levels 5.93 ± 0.85, 5.03 ± 0.81, and 3.58 ± 0.64; and pcr/atp ratios were 1.59 ± 0.28, 1.36 ± 0.22, and 1.21 ± 0.30. pcr absolute concentrations showed the highest, atp intermediate and pcr/atp ratios lowest correlations with clinical and functional variables. conclusions: absolute concentrations seem to be more representative of the extent of energetic derangement in heart failure than established pcr/atp ratios. material and methods: high resolution mr imaging was performed on a 1.5 t unit (symphony quantum, siemens) using t1-and stir t2-weighted sequences via a dedicated wrist coil (total acquisition time 8 min) a mean of 6.5 days after initial radiographs in 50 patients with clinical suspicion of wrist fractures and normal plain or indistinct radiographs. initial radiographs were evaluated independently by two senior radiologists without knowledge of the mri findings. the resulting change in therapeutic strategy was clinically evaluated. results: in 29/52 wrists mri findings resulted in a change of diagnosis. there were false positive diagnoses on plain radiographs in 23 cases (46 %) and false negative diagnoses in 6 cases. mri allowed to detect additional injuries of soft tissue in 19 cases (38 %). in 19/52 wrists the period of immobilization could be shortened or ended. in 11/52 it needed to be prolonged and in 3/52 a surgical intervention was necessary. in 19 wrists mri had no therapeutic consequence. correspondingly, after mri examination the period of being unable to work was reduced in 15/50, prolonged in 7/50 and was not changed in 28/50 patients. axial images were not helpful regarding diagnostic accuracy. conclusion: mri of the wrist is recommended on the day of trauma if there is clinical suspicion and normal plain radiographs. accurate diagnosis by mri examination on the day of trauma may reduce economic costs due to shortened immobilization time. mri evaluation of the wrist using dynamic studies m. mastantuono, e. bassetti, g. simonelli, l. di giorgio, r. passariello; rome/it purpose: in some painful syndromes of the wrist the conventional mri imaging is not satisfactorily for diagnosis. we describe a new dynamic mri method, that is accurate and easy to repeat, for the study of carpal instability and wrist pain. materials and methods: we performed a dynamic study of the carpus in 27 healthy volunteers and on 38 selected patients which we chose from a group of 232 previously studied by static mri wrist examination. we used a dedicated magnet (artoscan, e-scan 0.2 t) that has revealed itself to be particularly useful for dynamic acquisitions. we standardized a technique of image acquisitions at different degrees of flexion both on the coronal plane in ulnar-radial deviation and in sagittal for palmar-dorsi-flexion. we used se and ge sequences obtaining sagittal and coronal scans with a slice thickness of 2 -3 mm. results: the dynamic study is superior in the evaluation of carpal instability and in the assesment of capsular and ligamentous lesions if compared to standard mri examinations. the kinematic evaluation of the images acquired in the different positions of movement allowed to document the pathologic articular kinetics. conclusions: in our experience the mr kinematic study provided information that permitted differentiation of the possible mechanisms responsible for chronic wrist pain. kinematic mri is a simple and low time-consuming method of study that permits an accurate assessment of carpal instability, easily demonstrating articular biomechanical alterations that may be difficult to diagnose on static conventional mr examination. in 23 patients we assessed direct mr-arthrography in comparison to multiportal wrist arthroscopy for the evaluation of extrinsic and intrinsic ligaments, the tfcc. we used a 1.5 t mr system (magnetom). after fluoroscopic-guided direct wrist arthrography into the mid-carpal and radiocarpal joint with a solution of ultravist and magnevist (1:200) we applied following sequences: (1) t1 tse (tr 500 ms, te 20 ms) 3 mm slice-thickness, coronal and sagittal plane, matrix 512, fov 120 mm. (2) 3d flash (tr 24 ms, te 11 ms, flip angle 50°) 1.5 mm slice-thickness, coronal and sagittal plane, matrix 256, fov 120 mm. between 1 and 14 weeks after mr-arthrography, all patients underwent diagnostic multiportal arthroscopy. for the evaluation of the scapholunate ligament and the lunotriquetral ligament we subdivided lesions in partial defects and complete tears. the mr-sign of a partial-ligament defect was the passage of gadolinium-contrast agent between the mid-carpal joint and the radiocarpal joint, but with intact ligament structures palmar or volar to the defect visible. complete tfcc-defects, recognized by passage of contrast-agent into the distal ulnoradial joint, were classified according to palmer. results: for complete defects there was a high correlation between mr-arthrography and diagnostic multiportal arthroscopy (sen: 91.7 %, spez: 97.9 %, ppv: 78.6 %, npv: 96.2 %). for partial defects the correlation was moderate (75.0 %; 98.0 %; 85.7 %; 94.8 %). conclusion: for the evaluation of complete defects of the intrinsic and extrinsic ligaments, the tfcc mr-arthrography and multiportal arthrography have nearly the same diagnostic power. for evaluation of partial defects arthroscopy is superior to mr-arthrography. after undergoing arthrography with a mixture of 1:200 diluted contrast medium (gadolinium-dtpa: imeprol) injected radiocarpally and midcarpally under fluoroscopic control, 65 patient suffering from ulnar-sided wrist pain were examined with a 1.5 t mr scanner. using computer-aided "navigator"technique, the 3d data sets were converted into a virtual arthroscopy. all these patiens underwent a conventional arthroscopy within 24 hours. imaging results were compared with the virtual findings. results: in 57 of the 65 cases virtual arthroscopy could be performed adequately, whereas in 8/65 the procedure was not successful due to excessive narrowing of the ulnocarpal compartment or artefacts caused by patients movement. among to determine morphologic changes of the median nerve in median nerve entrapment syndrome after surgical decompression using high resolution ultrasonography and to correlate with the clinical outcome. materials and methods: 25 carpal tunnels of patients (18 women, 7 men, mean age 66.7 years) with documented median nerve entrapment were examined with high resolution sonography before and at least 3 months after surgical decompression. a subgroup of 10 subjects was scanned before and after 3 months following surgery. we evaluated nerve ap diameter, the flexor carpi retinaculum, postoperative scar tissue and correlation with clinical outcome. results: 3 or more months after decompression the mean nerve diameter in the proximal canal is reduced from 2.46 mm to 2.09 (p = 0.05), in the distal canal from 2.32 to 1.98 (p = 0.0005). there was no significant difference in the subgroup examined within 3 months after decompression and in the relation proximal to distal nerve diameter pre-and postoperatively. the flexor retinaculum could be depicted clearly in all scans. the existence and extent of scar tissue and reduction of nerve diameter were found unreliable parameters regarding outcome. conclusion: analysed at least 3 months after surgical decompression the ap diameter of the median nerve is significantly smaller compared to preoperative values. this diameter reduction, however, as well as existence and extent of scar tissue does not always correlate with clinical outcome. the relation between nerve diameter in the proximal and distal canal does not seem to be a helpful parameter in the diagnosis of median nerve entrapment. ultrasonography of hand joints in rheumatoid arthritis y. khodjibekova, t. zasteba; tashkent/uz purpose: the aim of this investigation was to study typical sonographic signs of hand joints lesion in rheumatoid arthritis. materials and methods: 67 patients aged 20 to 55 years (15 males, 52 females) with rheumatoid arthritis affecting hand joints were investigated. the control group comprised 10 healthy individuals. in all patients diagnosis was established by clinical, laboratory and radiographic examinations. results: soft tissues, bone contours, ligaments, joint-forming surfaces, joint space and synovium were visualized on hand joints sonograms. the first stage of the disease was characterized by soft tissue thickening, increase of ligaments echogenity, effusion and increase of joint space. at the second stage of the disease soft tissues thickness decrease, slight increase of their echogenity, periosteum thickening, joint-forming surfaces destruction, narrowing of joint space to a c d e f 252 0.1 -0.2 cm were revealed on sonograms. at the third stage of the disease soft tissues were not visualized, bone contours were well-defined and deformed, periosteum was thickened, joint-forming surfaces were indistinguishable. conclusion: sonography is effective method for the diagnosis of hand joints lesion in rheumatoid arthritis, particularly in its early stages. preliminary experience with "extended field of view" (efv) ultrasonography in musculoskeletal disorders e. santacroce, c. avanzino, g. dazzi, l. raimondi, e. silvestri; genova/it purpose: to evaluate the usefulness of efv ultrasonography in the study of musculoskeletal system. materials and methods: forty subjects with musculoskeletal disorders were submitted to an efv ultrasound examination after a routine us evaluation. 20 shoulders with anterior-superior impingement, 4 wrists with carpal tunnel syndrome, 2 wrists with de quervain's disease, 8 ankles with achilles tendonitis and 8 patients with post-traumatic muscle injuries were considered. an atl hdi 5000 system equipped with a broadband 7 -14 mhz transducer with efv software was used. results: the efv evaluation improved the muscular and tendon anatomy demonstration and correctly showed the pathologic process extension in all cases. the larger field of view of this technique allowed more precise anatomic definition of muscles, tendons and peripheral nerves but did not provide further diagnostic information. not easy images acquisition, evaluation of small structures and convex bone surfaces are the main limits to this technique. purpose: this study was performed to establish the value of breathhold mr imaging in the diagnosis of acute appendicitis. materials and methods: over a 14-month period 138 consecutive patients, clinically suspected of having appendicitis all underwent an us study and a subsequent mri. the mri images were obtained with breathhold coronal and axial fast spin-echo t1, t2, and t2 fat suppression sequences with 5 mm thick slices. mri images were evaluated prospectively. appendiceal diameter, signs of periappendicitis, abscesses, fecaliths, free fluid, mesenteric lymphnodes, paralytic ileus, or the existence of an alternative diagnosis was noted. also the total duration of the mri study was noted. mri findings were correlated with surgical pathology in 62 patients and clinical follow-up in 76 patients. the mri findings of 63 patients were interpreted as positive for appendicitis (62 true positive, 1 false positive). mri findings showed no signs of appendicitis in 76 (true negative in all) and showed an alternative diagnosis in 36. sensitivity and specificity for detecting acute appendicitis were 100 % and 98 %. the median total duration of the mri study was 15 min. conclusion: fast spin echo t1, t2 and t2-fat-suppression breathhold mri imaging for the evaluation of patients with suspected appendicitis achieved a high accuracy in the detection or exclusion of appendicitis or an alternative diagnosis. the use of short imaging sequences minimized the impact on the routine mri program. in selected cases mri is a reliable, safe and quick tool that can be implemented in a community hospital. helical ct diagnosis of closed-loop obstruction and strangulation: how and when m. scaglione, f. pinto, a. pinto, f. lassandro, n. renda, e. de lutio, s. romano, l. romano; naples/it purpose: definite confirmation or exclusion closed-loop obtruction (clo) is one of the most difficult tasks the radiologist has to face in the clinical practice. the aim of this presentation is to focus on the impact of helical ct in the diagnosis of clo and strangulation. materials and methods: 120 cases of surgical proven clo diagnosed by helical ct were retrospectively reviewed. helical ct scans were performed after administration iv contrast material (120 ml, 50 s scan delay, 2.5 -3 ml/s rate), with initial 10 × 10 mm collimation and repeated 5 × 5 mm over the region of interest. the state-of-art ct signs were considered for the diagnosis. results: serrated beaks with poor or no contrast enhancement of the bowel walls, ascites or engorgement of the mesenteric vasculature are ct signs allowed the diagnosis of clo complicated by strangulation in 26/120 cases. u or c-sharped of dilated loops, radial distribution of the mesenteric vessels, beaks and whirls suggested clo in 94/120 cases, but did not help differentiate from strangulation in 17 cases. conclusions: clo is a dynamic entity which may regress or need laparotomy depending on the time and degree of rotation of the incarcerated loops. ct is a reliable imaging modality able to differentiate clo from strangulation, which is rarely simple and obvious. detection of ischemic changes in the bowel walls and/or attached mesentery on ct scans imply strangulation highlighting the need for laparotomy; if only signs of clo are detected, the existence and/or development of strangulation cannot be predicted. results: a diagnosis of strangulation was made in 30 patients at surgery. in the patients whose ct findings were mesenteric haziness and decreased conspicuousness of the mesenteric vessels with normal enhancement of the affected small bowel, diagnosis of viable ischemia was made at surgery. ct findings predicting strangulation were poor contrast enhancement of the bowel wall, haziness of mesentery, diffuse engorgement of mesenteric vessels and ascites. (p < 0.05). among these findings, poor contrast enhancement of bowel wall was the most significant one. in the patients with small bowel obstruction, poor contrast enhancement of the bowel wall, haziness of mesentery, diffuse engorgement of mesenteric vessels and ascites were useful ct findings for detecting and predicting strangulation. purpose: the aim of the study was to define the role of high resolution ultrasound in establishing the imaging diagnosis of the right iliac fossa pain syndrome (rifps). the retrospective study has included 25 patients, which were admitted in the emergency room presenting the clinical picture of acute rifps. paraclinic investigations were: abdominal high resolution us, blood and urinary testes. we compared the diagnosis emitted ultrasonographically with the one established by the surgeons in the theatre following the intervention. results: ultrasound examination has showed: 10 patients with inflammatory changes suggesting acute appendicitis (with a thickening of the appendic's wall greater than 6 mm and free peri-cecal liquid collection; mild small bowel loops distension with reduced motility at the right iliac fossa in 4 patients; 1 patient with suggestive terminal ileitis and mesenteric adenitis; 7 women with gynecological abnormalities (4 with big right ovarian cyst and 3 with ectopic right pregnancy) and douglas free of fluid collections; 3 patient with ureteral impacted stone and dilatation of the right ureter. conclusions: ultrasound examination used in emergency rooms offers reliable differential diagnosis data between inflammatory ceco-appendicular disease and renal or gynecological disfunction. the high resolution us diagnosis has a high sensitivity and specificity concerning the gynecological abnormalities. the diagnosis of acute appendicitis requires a carreful and several "in dynamic" examination. the diagnosis of acute appendicitis is not in most of the cases exclusively done by us, it necessitates very often a correlation with the clinical examination and laboratory tests. helical computed tomography diagnosis of gastrointestinal perforation in the elderly patient a. pinto, f. pinto, m. scaglione, f. lassandro, e. de lutio di castelguidone, l. romano; naples/it purpose: to determine the diagnostic value of helical ct in a consecutive series of elderly patients referred with clinically suspected gastrointestinal perforation. methods and materials: our series includes 48 consecutive elderly patients (mean age: 69 years old) presenting with acute abdominal symptoms suggestive of gastrointestinal perforation. all the patients were prospectively submitted to abdominal ct evaluation. as revealed on helical ct, the presence of free air was considered diagnostic of gastrointestinal perforation. other ct findings considered indirect of perforation were: intraperitoneal free fluid, thickening of bowel wall, streaky density within the mesentery, the "dirty fat" sign, and focal collection of extraluminal fecal matter. results: at surgery, the following sites of perforation were found: duodenum (38.8 %); stomach (30.6 %); ileum (8.1 %); sigmoid colon (8.1 %); rectum (6.1 %); jejunum (4 %); appendix (2 %), and trasverse colon (2 %). in our series, helical ct demonstrated the presence of free air in 95.9 % of cases, intraperitoneal free fluid in 81.6 %, and thickening of bowel wall in 48.9 %. streaky density within the mesentery was found in 1 patient. conclusion: ct is a reliable and accurate imaging method for assessing gastrointestinal perforation by providing excellent contrast resolution to depict presence of even small amounts of free air in the abdomen. this is particularly helpful when elderly patients series are concerned. a c d e f 254 materials and methods: 63 female patients with disorders of defecation-and/or micturition were examined. video-fluoroscopy was performed in a sitting position. the urinary bladder was filled with water-soluble contrast media. rectum and vagina were contrasted with bariumsulfate. dynamic-mri was performed with a 1.0 t scanner (magnetom expert, siemens erlangen) using an t2 weighted gradient echo sequence ("true fisp"). patients were asked to present with full urinary bladder at the time of examination. rectum and vagina were filled with ultrasound-gel. results: in 28 patients we found a anterior rectocele with a anterior extent between 3 and 11 cm in video-fluoroscopy. mri failed to visualise rectoceles in 4 cases. in 9 cases rectoceles lead to a displacement of the urethra thus causing a voiding deficiency of the urinary bladder. these findings could be depicted better in mri. 12 patients presented a cystocele shown by both modalities. in another 4 cases a enterocele could be detected. conclusions: mri is inferior to video-fluoroscopy for the detection and the estimation of the degree of anterior rectoceles. however mri is superior in assessment of the severity of displacement of the urinary bladder and the urethra. the extent of pelvic descent could more accurately be assessed by mri. due to the capability of mri of direct visualisation of the pelvic contents it is superior in demonstration of enteroceles. in 1997, the gradual implementation of the nation-wide mammographic breast cancer screening in the netherlands was completed. since then, 625000 screening examinations are being performed annually in the agegroup 50 -75 years, at an interval of two years. the medical performance of the various disciplines in the regional screening centres is assessed by means of regular site visits. at these site visits, first, the overall screening outcomes are evaluated. subsequently, screening and diagnostic mammograms of interval and screen-detected st. ii cancer cases are reviewed. results: despite the small size of the country, notable regional variations e.g. in the relative frequency of small tumours (t1) are observed, ranging from 21 % to 35 % at a national average of 27 %. from a not blinded review of > 2000 interval cancers, we found that in about half of the previous screening mammograms in some way abnormal signs were notable. in one fourth of the cases, with a range from 17 % to 40 %, significant lesions were found, that should have been referred for further examination. conclusion: this large regional variation in outcomes prompted us to carry out the so-called national optimisation study. the objective is to learn in what aspects screening performance may improve as to the earlier detection of relevant lesions. these aspects include; (1) double reading; (2) contribution of additional craniocaudal views; and (3) recall criteria for further assessment. the role of individual mcs shape and cluster shape in the interpretation of mammograms i. leichter 1 , r. lederman 1 , p. bamberger 1 , b. novak 1 , s. fields 1 , s.s. buchbinder 2 ; 1 jerusalem/il, 2 bronx, ny/us purpose: to evaluate the diagnostic role of computer extracted features reflecting the cluster shape compared to features reflecting the shape of individual microcalcifications, identified mammographically. material and methods: 286 cases of clustered mc's with proven pathology were obtained from three university hospitals and reviewed by experienced mammographers. quantitative features characterizing the finding were extracted by a cad system following digitization at 42 µm resolution. the shape factor and number of neighbors, according to delaunay and gabriel methods, were com-puted for each mc together with the eccentricity of the cluster. while shape is related to the individual mcs, the average number of neighbors and eccentricity reflect the cluster geometry. stepwise discriminant analysis (sda) determined the significance of the extracted features in predicting malignancy. the performance of a classifier based on these features was evaluated by roc analysis. results: sda assigned variability of shape the highest predictive power followed by average number of neighbors (delaunay) and average shape but excluded cluster eccentricity and number of neighbors (gabriel) from the model. a classification scheme assigned the variability of shape a weighting factor, about 2.4 times greater than that assigned to the number of neighbors and average shape. a scheme based on these three features yielded a roc curve with an az of 0.88, indicating a ppv of 77 % for 95 % sensitivity. conclusion: the variability of shape of individual mcs was found to have a higher impact in differentiating benign from malignant clusters than the average shape or features characterizing the cluster geometry. the efficacy of the independent double reading of mammograms with consensus has been established, but the observer variability between the readers must be supervised to determine the homogeneity of radiological criteria. objective: the k index has been proposed as a method to calculate the interobserver agreement that was not due to hazard. we use the k index regarding the classification of mammographic findings in the assessment of mammographic categories (weighted k). status of nuclear medicine in breast cancer imaging, staging and therapy e. piperkova 1 , a. grueva 2 , s. sergieva 1 ; 1 sofia/bg, 2 baltimore, md/us purpose: accurate staging in breast cancer depicting and averaging primary lesions, multifocal and spread of the disease and lymph nodes imaging by nuclear medicine (nm) effects surgery and treatment plans. current status, diagnostic importance, priorities and limitations of spet and pet modalities are analysed using different tumourtropic agents. materials and methods: evaluation of primary lesions, detection of regional and systematic metastatic disease and the assessment of treatment response are discussed through spet using 99 tc-mibi or 99 tc-anticea and pet using fes or fdg for two patients' groups in four trials targeted categories. in addition localisation of "hot spots" and tumour margins in radiodense breasts are introduced. mrm showed a significantly higher sensitivity, but its specificity was significantly lower than smm. in the subgroup of lesions equal or greater than 0 mm (n = 97) the figure of the sensitivity was higher (93.2 %), than the overall sensitivity of smm. using receiver operating characteristic (roc) analysis, between xmm and the combination of xmm and mrm we found no significant improvement, but the combination of xmm and smm yielded a significantly higher diagnostic accuracy than xmm alone. conclusion: both mrm and smm have adjunct value to xmm. mrm is to be preferred when high sensitivity and spatial resolution is essential, while smm is recommended as a complementary method in lesions larger than 1 cm. tc-mibi. the one, measured in ipsilateral and/or contralateral area divided the count density, measured within a region of interest. this value represents coefficient of tracer uptake (in suv). differences between count densities in early and delayed images reflected the washout of the tracer from the tumour and thus sensitivity to chemotherapy. mr-mammography included assessment of t1 and t2 weighted images with the use of flash-mode and gd-enhancement. results: statistically significant correlation coefficients (t/nt) were observed for evaluated regions of increased uptake of radiopharmaceuticals in primary lesions: mibi > 1.67 ± 0.21, fdg > 1.69 ± 0.25. these data were concordant with mr findings of primary breast tumours. in all cases p < 0.001. regional lymph nodes involvement in scintigraphy was assumed in cases of axillary region uptake > 1.36 ± 0.29 for pet and > 1.33 ± 0.28. parasternal lymph nodes were only detected fdg-pet in 15 pts. washout coefficients calculated using 99 tc-mibi data stipulated for chemotherapy choice in 32 consecutive pts. conclusion: mri-mammography, mammoscintigraphy and fdg-pet correlate in assessment of primary bc. the best tools for the staging and adequate planning of radiation and/or chemotherapy are mammoscintigraphy and fdg-pet. contrast enhanced digital mammography: phantom experiment and first clinical results c. marx 1 , m. facius 1 , s. muller 2 , a. rick 2 , k. benali 2 , w.a. kaiser 1 ; 1 jena/de, 2 buc/fr purpose: we evaluated on phantoms the capability of a full field digital mammography (ffdm) system to show lesion contrast enhancement after intravenous injection of iodine. acquisitions on patients have begun to validate the potential of this new application as an alternative to contrast enhanced mri of the breast. method/materials: using appropriate phantoms, we simulated the iodine diffusion in vessels and lesions to evaluate the threshold of detection of contrast uptake on ffdm images (senographe 2000d, ge medical systems). the injections consisted of 1 -3 cm 3 of 2 ml hexabrix 160 diluted in 60 ml of water, and were washed out using water. sequences of 5 -7 images were acquired on ffdm (45 -49 kv, mo/cu) and were analysed to quantify contrast uptakes. clinical use of contrast enhanced digital mammography (cedm) requires the uptake contrast to be visible for iodine concentration between 0.12 mg/cm 2 and 1.8 mg/cm 2 . results: detection thresholds, with and without structured noise, were 0.50 mg/cm 2 and 0.25 mg/cm 2 respectively. breast thickness has a low impact on uptake detection. spatial and temporal analysis showed delayed marginal contrast uptake and slow increase of contrast in the background. initial results on patients have demonstrated contrast uptake in malignant lesions. the shape of the uptake curves is influenced by the thickness of the breast under compression (4 -5 dan). conclusions: given these initial results, contrast enhanced digital mammography may be a fast and less expensive alternative to mri for breast lesion characterisation. mri studies were performed at 1.5 t using a modified volumetric interpolated breathhold examination (vibe) sequence before and after administration of gadolinium. all images were evaluated prospectively regarding lesion detection and characterization. mri findings were correlated with final diagnoses. retrospective grading (scores 1 -4 for "poor" -"excellent") was performed for: (1) general image quality and presence of artifacts (rated "negligible" -"severe"); (2) imaging quality of detected pulmonary lesions (conspicuity and contrast on pre-and postgadolinium images) results: 23 solid pulmonary lesions, 25 infiltrates and segmental atelectases, and 1 cyst were detected and prospectively correctly diagnosed. sizes ranged from 0.3 -10 cm. the mean grading scores for overall image quality and presence of artifacts were 3.3 (sd 0.7) and 1.8 (sd 0.7), respectively. conspicuity and contrast of pulmonary lesions received mean scores between 3.0 and 3.8 (sd 0. we observed a lower peak intensity of emphysematous regions. in 22 subjects with distractedly hypo-perfusion a hyper-perfused region was detected and this occurrence was interpreted as pulmonary circulation re-distribution. discussion: the low specificity was due to three positive cases observed in the control group. these perfusion defects were very well defined and there was total agreement between the three radiologists. in our experience, mr perfusion might be an effective alternative to perfusion scintigraphy in patients with pulmonary emphysema. after an informed consensus, 20 non-smoker subjects, without any present or past pulmonary pathologies, were studied by means of an ultra-fast gradient echo sequence after a gd-dtpa intravenous administration. the acquisitions were performed in coronal and sagittal planes, in supine and prone position, in breath holding. an ulterior acquisition was performed in only five cases immediately after 2 -3 minutes of physical exercise. results: all the examinations, reviewed according to a visual score by three independent observers, resulted fairly interpretable. the i/t curves, obtained in postprocessing evaluation, have the same trend in all cases and are correlated to the lung physiological criteria: the positional changes of the examined subjects confirm the gravity dependence of perfusion; the study performed immediately after physical exercise showed a reduction in the perfusion of the whole lung due to a transitory massive shift of blood mass from visceral to muscular compartment. the extremely short acquisition and post-processing time coupled with a simple feasibility, the ability to detect physiological perfusional changes, and the minimal invasiveness indicates a potential clinical use of mr in the evaluation of pulmonary perfusion defects. tl myocardial scintigraphy. results: echocardiography was normal in 20 cases, including 2 patients with cardiac-symptomatic sarcoidosis. mr images were normal only in cardiac-asymptomatic stage i or lofgren syndrome patients (n = 4). multiple organ cardiac-asymptomatic sarcoidosis (n = 17) displayed similar mr abnormalities to those observed in patients with cardiac symptoms (n = 5). focal myocardial thickness and/or intramyocardial increased signal on t2-weighted and/or intramyocardial increased signal on gadolinium-dtpa-enhanced t1-weighted images, representing granulomatous inflammation, were correlated with segmental perfusion defects on the thallium scan. available mr follow-up in 11 patients showed regression of gadolinium-dtpa uptake after corticosteroid therapy while progression was recorded in 2 patients without treatment. conclusion: mr imaging enables valuable detection and localisation of cardiac sarcoidosis. the occurrence of subclinical lesions in multiple organ sarcoidosis may legitimise the use of mr as a screening method to identify early patients requiring careful review and treatment. detection of regional wall motion abnormalities: tissue doppler echocardiography in comparison with magnetic resonance imaging d.e. kivelitz, a.c. borges, g. baumann, b. hamm; berlin/de purpose: echocardiography when combined with spectral and color flow doppler is well established as a safe, non-invasive, and versatile diagnostic modality for evaluation of left ventricular global and regional function. tissue velocity imaging is a new technique that measures myocardial motion by tracking myocardial velocities with color doppler myocardial imaging principles. the purpose of this study was to compare this new tool with magnetic resonance imaging. methods and materials: 30 patients with wall motion abnormalities underwent echocardiography (harmonic mode-octave) in comparison with tissue tracking (vivedfive, ge, vingmed ultrasound, horten norway, equiped with the echopac software package) which allows real-time acquisition of color doppler images and on-line as well as off-line analysis of time-velocities-integrals (tracking). magnetic resonance imaging (magnetom vision, siemens, erlangen, germany) was performed using stripe tagging. for regional wall motion analysis we used the 16 segment model. results: in 29/30 patients we analysed quantitative data from tagging and tracking. the concordance was 85 % and the best results were in septal, posterior and apical regions. conclusion: tissue tracking, compared with magnetic resonance imaging, is a reliable method for on-line quantification of global and regional systolic function of the left ventricle. fast assessment of abnormal valve function using mri a. meduri 1, 2 , r.m. razmi 2 , v.k. rathi 2 , l. natale 1 , g.m. pohost 2 ; 1 rome/it, 2 birmingham, al/us background: valvular diseases can be rapidly assessed by fast cine (fc) mri. signal void is related to the te and determines the severity. a short te may impair assessment and detection of valvular lesions. we hypothesize that a lower receiver bandwidth, a longer te, increases sensitivity and accuracy. methods: a total of 30 pts and 59 valves were evaluated with the predefined bandwidth of 31.2 khz (te = 4.7 ± 0.2 ms) and with the narrower bandwidth of 15.6 khz (te of 7.1 ± 0.4 ms). length, area and maximum width of signal void associated with every diseased valve were calculated. each area was graded as mild, moderate or severe and compared with echocardiography. results: lowering the bandwidth significantly increases signal void area (117 ± 124 vs. 71 ± 78 pixel, p < 0.0001), length (21 ± 15 vs. 16 ± 12 p < 0.001) and the width (5.8 ± 5.2 vs. 4.4 ± 4.0, p < 0.001), graded as mild, moderate, or severe for each te. longer te increases the severity graded in 22/49 (44.9 %) valves with signal void and diagnosed one abnormal valve not detected with the shorter te. in the 23 cases compared with echocardiography, the longer te showed a significantly better correlation (contingency coefficient 0.708, r = 0.657). conclusion: lowering the bandwidth allows longer tes, giving better correlation with echocardiography. we conclude that a short te leads to underestimation of the severity of the valvular lesion. accordingly, a longer te should be used routinely in every comprehensive cardiac mri study. three-dimensional blood flow in the heart: evaluation with mri g. reiter, u. reiter, r. rienmüller; graz/at purpose: evaluate a method of 3-dimensional determination of the intercardiac flow for early recognition of flow based cardiac dysfunction using magnetic resonance imaging (mri). materials and methods: using flow quantification via phase contrast methods (tr = 33 ms, te = 6.5 ms, flip angle 30°, slice thickness 8 mm, pixel size 2.25 mm × 1.64 mm and matrix 140 × 256) of mri (1.5 t field strength, 40 mt/m gradients) we measured and reconstructed discretized time-dependent 3-dimensional velocity fields of blood flow within the different intracardiac regions. at any time of the cardiac cycle calculated velocity fields were projected onto a corresponding cine-truefisp image (e.g. 4-chamber view). the protocol was designed on healthy volunteers. results: as result of reconstruction and projection we obtained a time series of truefisp images where in-plane velocities were displayed by vectors proportional to the in-plane velocity and through-plane velocities were color encoded. images can be displayed picture by picture as well as in cine mode. the presented method appears robust and sensitive in the 3-dimensional evaluation of the normal blood flow and promising to observe changes as possible causes of ventricle wall dysfunction. benchmarking non-rigid registration techniques for the quantitative analysis of myocardial function in tagged-mr imaging c. petitjean 1 , n. rougon 1 , p. cluzel 2 , f. preteux 1 , p.a. grenier 2 ; 1 evry/fr, 2 paris/fr purpose: in the framework of quantitative analysis of myocardial function our purpose was to assess the relevance of non-rigid registration techniques for estimating dense displacement fields and functional parameters from tagged-mri sequences of the heart without performing tag extraction. the study was conducted on 2d tagged-mr sequences under short axis incidence using various gradient echo/tagging sequences including fisp/dante and bffe/spamm. pixel-based, non-rigid registration techniques which deliver dense displacement fields over the whole image domain by establishing pointwise correspondences without requiring preliminary segmentation of heart walls nor tagging pattern have been evaluated. state-of-the-art methods have been tested for major registration criteria: (i) "demon" algorithms using an optical flow constraint with prior elastic smoothing; (ii) fluid registration methods governed by deformation laws from fluid mechanics; (iii) informational techniques maximising entropic measurements between successive images. in each case deformation modelling has been addressed by comparing functional measurements derived from non-parametric and parametric motion estimates. using hierarchical solvers for handling large deformations has also been investigated. results: demon and mutual information maximisation techniques allow accurate derivation of dense maps of functional parameters including deformation tensor eigenelements, local contraction/dilation and circumferential/radial strains. moreover, informational approaches are insensitive to tag fade out. b-spline modelling offers a good trade-off between measurement accuracy and modelling compactness. multiresolution processing allows us to account for large deformations. conclusions: following this assessment stage, novel non-rigid registration techniques are have now been developed that incorporate local image geometry information to constrain and accelerate the matching process. evaluation of palliative procedures in functional singular ventricle with mri f. weiss, c.r. habermann, c. lilje, k. sasse, j. weil, g.b. adam; hamburg/de purpose: to determine the value of mri in the postoperative evaluation of singular ventricle compared to echocardiography and cardiac catheterisation. methods/material: 19 patients (range: 4 month to 16 years) with functional singular ventricle who had undergone palliative corrective operations. 5 patients were treated without separation of circulation to improve pulmonary perfusion with blalock-taussig-shunts. 13 patients had cavopulmonary shunts, 10 of them total cavopulmonary anastomosis, 3 only partial separation with bidirectional glenn-anastomosis. 1 patient was treated with a central shunt. the results were compared to percutaneous echocardiography, cardiac catheterisation and operation reports regarding postoperative morphologic changes. detectability of thombotic material in the low-flow-system was evaluated. conclusions: 3d-rotational angiography allows for a more exact depiction of anatomical details important in planning surgical and interventional therapy of intracranial aneurysms than dsa. ra also identified more aneurysms. b a c d e f 258 incidence of old intracranial microbleeds in patients with acute intracranial hemorrhage m. alemany, r. raininko, a. stenborg, a. terent; uppsala/se purpose: previous publications have demonstrated, using blood sensitive t2*weighted (w) sequences, the presence of incidental foci of signal loss which have been confirmed histopathologically to represent hemosiderin deposition from earlier bleeds. their clinical significance is still debated. our purpose was to evaluate the occurrence of old microbleeds in patients having acute intracranial hemorrhages and correlate these findings with clinical data. methods and material: we studied 26 patients (mean age 65 years) with acute intracranial hemorrhages. 23 patients had spontaneous bleeds, 1 appeared after subclavian dilatation and 2 after coronary and lung thrombolysis, respectively. axial spin echo t1-w and t2-w, flair and gradient echo t2*-w images were obtained using a 1.5 t system. results: besides the acute hemorrhages, evidence of prior bleeds were found in 13/26 patients (50 %). 18/26 patients were hypertensive and 8/26 were normotensive. 10 of the 18 hypertensive patients (56 %) and 3 of the 8 normotensive ones (37 %) had evidence of old bleeds. other clinical data were also investigated (diabetes, abuse of alcohol or tobacco, anticoagulant treatment, etc) but no clear correlation with intracranial microbleeds was found. only the t2*-w sequences were able to detect these lesions. our results support the hypothesis of a correlation between hypertension and old intracranial microbleeds. the microbleeds may be the sign of a microangiopathy that could give a increased tendency for intraparenchymal bleeding. the detection of old microbleeds is, thus, of diagnostic importance. they may also help to predict risk for spontaneous rebleeding or bleeding complications after anticoagulant therapy. multislice angio-ct in the evaluation of cerebral aneurysms m. wintermark, m. chalaron, p. maeder, a. uske, p. schnyder, r. meuli, s. binaghi; lausanne/ch purpose: evaluation of the accuracy of multislice angio-ct in the detection of cerebral aneurysms, by comparison with conventional cerebral angiography methods and material: 50 consecutive patients, who successively underwent multislice cerebral angio-ct (1.25 mm-thick slice reconstructed every 1 mm, pitch 0.75, 140 kvp, 200 ma, timing determined with a bolus test) and conventional cerebral angiography, were prospectively identified in our department between july 1999 and august 2001. both examinations were reviewed independantly by two neuroradiologists, who were blinded to their initial interpretation and who did not perform the cerebral angiography. angio-ct axial slices were reviewed, as well as 2d mip and 3d ssd reconstructions. angio-ct and angiography data analysis was performed separately, but according the same systematic interpretation strategy. results: 49 cerebral aneurysms were diagnosed. sensitivity, specificity and accuracy of multislice angio-ct in the detection of cerebral aneurysms were 95 %, 100 % and 96 %, respectively. the impact of aneurysm location was determined. the ability of multislice angio-ct in the characterization of cerebral aneurysms was evaluated: size (slope 1.138, r = 0.79, p < 0.001), orientation (accuracy 91.2 %), thrombosis, calcification, origin of arteries, apical teat. conclusion: multislice angio-ct of the willis circle is a worthy tool in the detection and characterization of cerebral aneurysms. its ability to detect aneurysm partial thrombosis is higher than that of conventional cerebral angiography. angio-ct allows for efficient planning of cerebral angiography and affords useful information in the determination of the therapeutical strategy. monday b a c d e f 259 methods and materials: in a blinded, prospective study 50 patients with acute subarachnoid haemorrhage underwent both cta and dsa. spiral ct with 3d reconstruction was performed. 120 ml of intravenous contrast was administered at 4 ml/s. collimation of 1 mm. with a pitch of 2, and a reconstruction index of 0.5 was used. there were 32 females and 18 males entered into the study. the cta images were separately reviewed by two consultant neuroradiologists, who were blinded to the dsa findings. the ct angiograms were assessed for aneurysm size and location, in addition to adjacent vascular anatomy. the results were compared with dsa. results: from the initial group of 50 patients with sah, no aneurysm was evident on either cta or dsa in eleven. of the remaining 39 patients, 51 aneurysms of varying types were diagnosed. cta accurately diagnosed 48 of these (sensitivity 94 %). of the 3 intracranial aneurysms missed on cta all of these were under 3 mm in size. specificity of cta is 98 %. conclusion: cta would appear to be a safe and relatively reliable alternative to dsa in the management of acutely ruptured intra-cranial aneurysms. other advantages include speed, cost and its non-invasive nature. in addition it may be of benefit in the follow-up of known aneurysms. in view of these results we have since modified our protocol to improve sensitivity further. purpose: to evaluate the blood flow dynamics in patients with arterio-venous malformations (avms) before and after radio-therapy treatment. patients and methods: two different mr imaging techniques were used in a total of 25 patients. a non enhanced dynamic mra based on a blood bolus tagging technique and a new contrast enhanced projection mra (fluoroscopic mra/ mrdsa) based on a fast flash sequence were used to assess the angioarchitecture of the malformation as well as the hemodynamics, mainly based on a calculated shunt-time between feeding arteries and draining veins. the conventional tof-mra and conventional dsa served as an internal standard. mrdsa was performed with a bolus injection of 0.1 mmol/kg bw of gadodiamide (omniscan®, nycomed-amersham) at an infusion rate of 3 cm 3 /s and a time resolution of 400 ms per projection. images were assessed in regard to vessel detection and demarcation as well as the hemodynamic aspects of the malformation. results: both techniques were able to assess the angioarchitecture of the avm in all patients. the arterial feeder, the avm nidus and the venous drainage pattern could be clearly delineated. the time resolution of the non enhanced tagging technique was substantial better enabling a more precise assessment of the hemodynamics. discussion: mrdsa and dynamic non enhanced mra are able to assess both the avm angioarchitecture and the avm hemodynamics non invasively. the techniques are easy to implement and can be used for treatment planning. hemodynamic changes due to therapy (embolisation or radiosurgery) can be monitored. the role of transcranial doppler sonography (tcd), and somatosensory evoked potentials (sep), in the detection of vasospasm after subarachnoid hemorrhage a. fatourou, c. constantoyannis, e. solomou, p.a. dimopoulos; patras/gr purpose: to evaluate the correlation between blood flow velocity (bfv) and vasospasm in patients suffering from subarachnoid hemorrhage (sh). to detect any relationship between conduction time of somatosensory evoked potentials and vasospasm in the same group of patients. to assess the simultaneous use of tcd and sep in the detection of vasospasm. materials/methods: in our study, we included 105 patients with subarachnoid hemmorhage (sh), diagnosed with ct. six of them also underwent a lumbar spine puncture (lsp). all of them had digital subtracted angiography (dsa), for aneurysm localisation. the follow-up was performed using tcd and sep. the diagnosis of sh, in 99 patients was made with ct, and in the rest of them (6 patients), was made with lsp. dsa revealed an aneurysm in 85 patients, whilst there were no remarkable findings in 17 patients. the latter were reviewed again and an aneurysm was detected in one more patient. vasospasm appeared in 27 patients, whose bfv in the middle cerebral artery was 160.8 cm/s, and central conduction time (cct), was 6.05 ms. the remaining 78 patients without vasospasm, had bfv 95.37 cm/s and cct 5.81 ms. conclusion: statistical analysis showed that the prediction of vasospasm, with the correlation of the two modalities tcd and sep, allowed a proper successful classification in 93.3 %. using two additional parameters, the fisher classification, and the classification hunt-hess, the percentage of proper successful classification did not change significantly. clinical and neuropsychological outcomes in 35 patients presenting with a ruptured anterior communicating aneurysm: mid term follow-up b. jean, k. martin, m. gely-nargeot, a. bonafé; montpellier/fr purpose: rupture of an anterior communicating aneurysm (acoma) is associated with substantial cognitive and psychopathological dysfunction, disability in psychosocial activities and daily living. we report the clinical and neuropsychological outcome of 35 patients treated by embolization of an acoma; subgroup of our base of 61 acom aneurysm. material and method: from september 1998 to may 2001 we treated 61 ruptured acoma by coil embolization. at admission age, aneurysm description, initial clinical wfns score, fisher grade were collected. at discharge occlusion rate, glasgow outcome scale (gos) and complications were reported. we followed patients at 6 months, and 1 year with clinical evaluation and an angiographic control. out of 61 patients, we submitted 35 patients to an extensive range of tests: comprehensive batteries of neuropsychological and psychopathological tests, daily living scales. cognitive outcome was evaluated using global rating scale (mattis), and assessment for attention, executive functions, explicit, implicit memory and psychiatric associated disorders. results: we treated 61 patients using gdc coils. technical and clinical results are provided. we report our technical complications and complications due to sah evolution (symptomatic vasospasm, acute hydrocephalus). 35 patients were submitted to the battery of neuropsychological tests. the patient's performances were characterized by neuropsychological deficits, especially impairments in learning and explicit long term memory, associated with functional frontal dysfunction. conclusion: aneurysm morphological characteristics and occlusion rate do not influence early clinical evolution in ruptured aneurysm. patients submitted to a battery of neuropsychological tests showed neuropsychological deficits and frontal dysfunction on mid term follow-up. purpose: although preoperative embolization of meningioma is a helpful procedure to minimize bleeding and to facilitate resection, some meningiomas showing lack of vascularity are not suitable for embolization. the dsa itself would therefore be an unnecessary procedure. the goal of our study was to predict poorly vascularized meningiomas using time resolved mra (tr-mra). materials and methods: tr-mras were performed on a 1.5 t whole-body unit (vision, siemens, erlangen, germany) in 18 patients with meningioma using a snapshot flash optimized for 2d projection (tr/te 4.2/1.5 ms, slab thickness 45 mm). a standard dose of gd-dtpa was injected with an automatic injector (volume 15 ml at 3 ml/s). coronally directed tr-mra was obtained using single slice, 3 frames/s during 34 seconds without time-interval. tr-mra, dsa and embolization were done at the same day when possible. signal intensity (si) of meningiomas in tr-mra was graded as 0 if no si is detected. faint si was graded as +, good si as ++, and dense si as +++. grades of si on tr-mra of meningiomas and possibility of embolization were analyzed using x 2 -test. results: in 18 meningiomas, 7 graded as +++, 5 as ++, 3 as +, and 3 as 0 in tr-mra. embolization was done in all graded as +++ and ++. however, embolization could not be performed on grade + and 0 due to lack of vascularity from external carotid artery (p = 0.000). conclusion: tr-mra is an useful study to avoid unnecessary dsa in cases of meningiomas with lack of vascularity which would not be candidates for embolization. purpose: traditionally estimation of pancreatic exocrine function has been invasive e.g. duodenal intubation or non-specific. secretin mrcp can be used to calculate exocrine flow rates. we compared 29 patients with normal pancreatic morphology and 28 patients with chronic pancreatitis. materials and methods: following baseline ssfse, 0.1 ml/kg iv secretin was administered and the acquisition repeated every 2 minutes for 7 minutes. the receiver gain was held constant. flow rate = change in total signal intensity over time divided by the signal intensity of a voxel containing 100 % water. breath-hold axial t1w images and spiral ct were also performed as part of their work-up. 29 patients had a normal pancreas on ct and ercp, 28 had chronic pancreatitis of whom 8 had had surgery, pancreatoduodenectomy in 4 and a puestow procedure in 4. of the remainder, 15 had severe, 3 moderate and 2 mild chronic pancreatitis. results: mean flow rates in the normal group were 8 ml/min ± 2.6 and for patients with severe chronic pancreatitis 5.8 ± 2.6. this difference was significant (student t test p < 0.05). within the chronic pancreatitis group there were 5 patients with flow rates < 3 ml/min all with longstanding chronic calcific pancreatitis. significantly different smrcp flow rates were seen in normals as compared to patients with severe chronic pancreatitis. very low flow rates were seen in patients with long standing chronic calcific pancreatitis. materials and methods: 46 patients with suspected pancreatic lesion were studied in preoperative evaluation, including mri with vibe -a fast t1w sequence tailored for dynamic 3d studies -with gadolinium dtpa dynamically, t1w fse and t2w haste. the mri findings (as described in the reports) were analysed, scored and compared to those from surgery and pad. results: mri detected 45/46 lesions (one papillary tumour was missed). 17/26 neoplastic tumours were correctly characterized as malignant (sensitivity 65 %; specificity 35 %). vascular encasement (of portal, superior mesenteric vein/artery, celiac trunk, hepatic artery and/or splenic vein/artery) was correctly described in 7/8 cases (sensitivity 87 %; specificity 94 %; ppv 100 %; npv 97 %). nodular metastases were correctly characterized in 1/7 (sensitivity 14 %; specificity 86 %; ppv 20 %). lymph node enlargement (> 10 mm) was metastatic in 1/5. 0/2 liver metastases were found. the remaining 20 non-tumoral lesions were histopathologically classified as 19 inflammatory pseudotumours and 1 papillary fibrosis. (1) pancreatic lesions were accurately detected with mri/vibe. (2) the method cannot differentiate benign from malignant lesion. enlargement of lymph nodes was not correlated to lymph node metastases. (3) mri/vibe is an efficient tool to predict resectability in patients with pancreatic tumour. vascular encasement was well evaluated. small liver metastases (≤ 5 mm) were not detected. methods and materials: all available ct and mr/mrcp studies of 29 patients who underwent surgical resection were considered. the pathological exams revealed 11 ipmt with hyperplasia/low-grade dysplasia, 10 ipmt with moderate/ borderline dysplasia, 4 ipmt with high grade dysplasia/carcinoma in situ, and 4 ipmt with invasive carcinoma. 2 observers retrospectively reviewed all the images, searching for signs indicative of either benignity or malignancy. results: considering the criteria reported in literature, after complete evaluation of the lesions the assessment of malignancy was made in 13/29 pts after consensus, being correct in 11/13 (84.6 %) cases. the 2 false positive cases, regarding lesion histologically classified as low-grade dysplasia, the wrong diagnosis was related to their dimension (> 4 cm). in 7 false negative errors were made, concerning lesions lacking any sign indicative for malignancy (moderate/high grade dysplasia: 5; carcinoma in situ: 2). these results yielded a sensitivity, specificity, and accuracy of 61 %, 81 %, and 69 %, respectively. conclusion: (1) the assessment of malignancy is trustworthy, and warrants surgical resection. (2) invasive carcinomas are always recognisable, thanks to the wall thickening, and parietal proliferations. . additionally, t1-w contrast enhanced (ce), triphasic "volume interpolated breathheld examination" (vibe) was performed. in a control group of 45 pts. vibe was replaced by ce 2d-gre. two observers analysed data with regard to image quality, tumor conspicuity (roc), diagnostic accuracy and interobserver variability. results: 15/45 pts in the study-and 18/45 in the control-group had pancreatic ca. vibe revealed the best image quality in the study-group (3.6 ± 0.5) outperforming 2d-gre (2.5 ± 0.8) (p < 0.001). haste, t2-tse and mrcp also performed less well: 2.2 -2.9 (p < 0.001). roc-analysis (1/2. observer) showed that vibe (0.76/ 0.76) obtained higher values than haste (0.74/0.67), t2-tse (0.69/0.73) or mrcp (0.62/0.77). 2d-gre performed signif. worse than vibe (0.69; p < 0.05). best diagnostic capability was obtained by combination of all sequences in the study-(0.88/0.91) and the control-group (0.72/0.78). hence, sens. and specif. was higher in the study-(73 %/87 %) than in the control-group (58 %/75 %) (p < 0.01). interobsever variability ranged from moderate 0.4 (haste), good 0.6 (vibe; 2d gre) to very good 0.85 (combination of all sequences). purpose: to evaluate the use of mr perfusion imaging to monitor organ function of pancreas and kidney grafts after combined transplantation. methods and materials: a coronal fgre sequence was used to monitor the signal intensity of transplanted pancreas and kidney grafts, of psoas muscle and aorta before and during the first 6 min after bolus injection of 0.1 mmol gd/kg bw. a perfusion index as the percentage of maximum signal intensity in the organ relative to the maximum signal intensity in the aorta was calculated. in a prospective study 33 patients underwent a total of 77 examinations. mean follow-up after transplantation was 98 days (range 7 -486). perfusion index was used to judge function as good, fair or poor. results were correlated to clinical course and laboratory data. results: absolute values of perfusion index correlated with clinical course of organ function. in addition a strong correlation was found between the intraindividual course of the perfusion index and the clinical course during repeated measurements. the perfusion index can be used to monitor organ function after combined pancreas and kidney transplantation and is especially important in follow-up examinations to assess the intraindividual course of organ function. results: mean number of ct examinations per patient was 3.68, maximum 27 (in those with severe pancreatitis). mean number of series was 1.1. mean effective dose was 4.1 mgy, maximum (performed with incremental ct and high exposition parameters) was calculated to result in 18.44 msv. mean dose lenght product was 292 mgycm. risk for radiation-induced cancer could be estimated to be 0.0085 % per average examination, cumulating to 0.23 % in a patient with 27 ct examinations. as a worst case scenario, assuming that the dose per examination would have been the maximum found in this survey (18.44 msv), the radiation risk would be 2.5 %. conclusion: average number of examinations, cumulative dose and estimated radiation risk resulting from ct imaging in pancreatitis patients is moderate, especially in regard to the often severe course of the disease. however especially in young patients, examination parameters should be chosen with care, and mri should be taken into consideration. multidetector ct of isodense pancreatic adenocarcinoma: more there than meets the eye r.w. prokesch 1 , l.c. chow 2 , c.f. beaulieu 2 , r. bammer 2 , r.b. jeffrey jr. 2 ; 1 vienna/at, 2 stanford, ca/us purpose: to assess the frequency of isodense pancreatic adenocarcinoma with multidetector ct (mdct) and determine the value of secondary signs which aid in their detection. materials and methods: 53 patients with pancreatic adenocarcinoma underwent contrast-enhanced, biphasic mutidetector ct with curved planar reformations (cpr). tumors were initially deemed isodense or hypodense on the basis of visual inspection and then confirmed by calculation of mean attenuation differences between normal pancreatic parenchyma and tumor during the pancreatic phase. indirect signs of pancreatic tumor were tabulated in cases where an isodense tumor was identified. results: out of the 53 patients, six (11.3 %) had isodense tumors with a mean tumor-pancreas contrast of 9.25 ± 11.3 hu during the pancreatic phase and 4.15 ± 8.5 hu during the portal venous phase. ancillary signs of a pancreatic tumor included an interrupted pancreatic duct (n = 5), dilated biliary and pancreatic ducts (n = 1), atrophic distal pancreatic parenchyma (n = 3), and mass effect/convex contour abnormality (n = 3). mean tumor-pancreas contrast for the remaining 47 cases was 74.76 ± 35.61 hu during pancreatic phase. conclusion: isodense pancreatic tumors, even studied with high-resolution mdct, represent a significant percentage of pancreatic carcinomas. with no visible tumor-pancreas contrast, indirect signs such as mass effect, atrophic distal parenchyma and an interrupted duct sign are important indicators for presence of tumor. cpr of the pancreatic duct are particularly helpful in delineating the obstructed pancreatic ductal system. multislice helical ct with 2d and 3d multiplanar reconstructions using minimum intensity projection for assessment of the pancreatic ducts m. zins, n. bouzar, l. fontanelle, s. lenoir, c. strauss, r. palau; paris/fr to evaluate imaging quality of 2d and 3d multiplanar reconstructions with minimum intensity projection (minip) in assessment of the pancreatic ducts using multislice ct. methods and materials: 35 consecutive patients with potential disorders of the pancreas were scanned using multislice ct. the ct parameters were: 40 s scan delay for the pancreatic phase and 75 s scan delay for the portal venous phase. pancreatic phase images were used for 2d and 3d reconstructions with the following parameters: 1.25 mm slice thickness; interval of reconstruction: 0.6 mm; the 2d and 3d data sets were evaluated in oblique axial and oblique coronal planes, using minip. qualitative assessment of the multiplanar reconstructions included: (1) visibility and size of the main pancreatic duct (mpd), (2) visibility of the major papilla, (3) visibility and size of the duct of santorini, and (4) visibility and size of the branch ducts. the mpd was entirely visualized in 33 patients (94 %) including 15 with non dilated mpd. the major papilla was visualized in all patients. a non-dilated duct of santorini was visualized in 9 patients; a dilated duct of santorini was visualized in three patients with intraductal papillary mucinous tumors of the pancreas (ipmtp). non dilated branch ducts were visualized in two patients and dilated branch ducts were visualized in 18 patients. purpose: to assess main pulmonary artery dimensions in normal subjects and in patients with marfan's syndrome. materials and methods: 50 marfan patients (mean age 33 (10) years, 34 men, 16 women) and 15 matched control subjects (mean age 28 (4) years, 9 men, 6 women) underwent cardiac magnetic resonance imaging (mri). pulmonary artery dimensions were obtained on axial spin echo images at two different levels: 1) the level of the pulmonary artery root and 2) the level of the pulmonary artery bifurcation. results: upper limits of normal (mean + 2 sd) at the pulmonary root and at the pulmonary artery bifurcation were 34.8 mm and 28.0 mm, respectively. pulmonary artery dilatation was demonstrated in 37 (74 %, root) and 38 (76 %, bifurcation) of the 50 marfan patients. there was a good correlation between pulmonary and aortic root diameter in non-operated marfan patients (r = 0.76). dimensions of pulmonary root were larger (38.4 mm, range 28.3 -50.7 mm) than dimensions at the pulmonary bifurcation (30.7 mm, range 21.4 -38.5 mm, p < 0.001). marfan a c d e f 262 patients with aortic root replacement (n = 35, root 39.7 mm, bifurcation 31.7 mm) had significantly larger pulmonary artery dimensions than non-operated marfan patients (n = 15, root 35.5 mm, bifurcation 28.5 mm, p < 0.01). conclusions: in the majority of marfan patients the main pulmonary artery, particularly the pulmonary root, was dilated. a good correlation between pulmonary and aortic root diameter was demonstrated. pulmonary artery dimensions were significantly larger in marfan patients with aortic root replacement than in nonoperated marfan patients. methods and materials: selective pulmonary dsa was performed in 91 consecutive patients with ctph. six bolus injections of non-ionic contrast media were used (pa-, oblique and lateral projections of both pulmonary arteries, iomeprol, 25 ml, 13 ml/s). hemodynamics were obtained using swan-ganz catheters and classified in three groups depending on systolic pulmonary pressure (pasyst): group i: < 30 mmhg, ii: 30 to ≤ 60, and iii: > 60 mmhg). results: pasyst was 21.4 ± 2.2 (group i, n = 7), 49.8 ± 8.5 (ii, n = 18), and 87.0 ± 18.9 mmhg (iii, n = 66). pulmonary vascular resistance index (pvri) was 238 ± 103 (i), 703 ± 364 (ii), 1587 ± 569 dyne⋅s⋅m 2 ⋅cm −5 (iii), mean cardiac index (ci) was 3.2 (i), 2.8 (ii), and 2.3 l⋅min −1 ⋅m −2 (iii). pcw pressure was normal in all three groups indicating normal left heart function. contrast bolus injection caused only slightly increased pa pressure (dpasyst: 1.1 ± 1.1 (i), 2.9 ± 2.3 (ii), and 3.7 ± 3.2 mmhg (iii)). after completion of angiography right atrial pressure and pasyst were moderately increased (dra: 1.8 (i), 2.6 (ii), 3.0 mmhg (iii), dpasyst to determine the value of mri in the diagnosis of pulmonary embolism (pe) in patients unable to sustain apnoea, e.g. in acute pe. methods: a real time (rt) steady state free precession (ssfp, truefisp) sequence was adapted for the examination of the thoracic vasculature. 21 consecutive patients with suspected pulmonary embolism were prospectively examined with mri using a rt-truefisp sequence and contrast enhanced mr-angiography (mra). the clinical stages of suspected pe were as follows: chronic 4, mild 7, severe 6, massive 4. results: 71 % of the mra-sequences were diagnostic, excluding all patients with massive and some with severe pe. all 21 rt-sequences were diagnostic. all 125 lobar arteries and 85 % of the segmental arteries could be evaluated, segments 4/5 being the most difficult. for the rt-sequences, no patient preparation, ecg or breathing commands were needed. pe was diagnosed in 67 % of the patients by rt-mr. in 6 patients with pe, mra detected 9 additional thrombotic segments. two diseases mimicking pulmonary embolism could be diagnosed. in all remaining patients with clinically suspected severe and massive pulmonary embolism, thrombotic material could be visualized in the pulmonary arteries. chronic and acute pulmonary embolism could be differentiated, and the effect of thrombolytic therapy on thrombus size could be visualized. conclusion: rt-mri allowed the examination of any patient regardless of his clinical condition in 3 min and required no preparation. therefore, the range of indications for mri in patients with suspected pulmonary embolism is extended. the well established mra technique has advantages in patients able to sustain apnoea. a differentiated approach to pulmonary embolism and deep venous thrombosis using multi-slice ct j.e. wildberger 1 , a.h. mahnken 1 , a.m. sinha 1 , p. haage 1 , s. schaller 2 , r.w. günther 1 ; 1 aachen/de, 2 forchheim/de purpose: to establish a protocol for multi-slice ct (msct) examinations for clinically suspected pulmonary embolism (pe) using pulmonary ct-angiography and indirect ct-phlebography (ctp). methods and materials: from february 2000 to july 2001, 161 patients (92 male, 69 female; age: m = 55.2 a ± 18.1 a) with suspected pe were examined on a msct (somatom volume zoom; siemens, germany). after intravenous injection of 120 cm 3 of contrast-medium, thin collimation chest ct was performed. ctp was added if pe was present or previous examinations and clinical signs suggested deep venous thrombosis (dvt). the latter was performed using a 4 × 5 mm protocol (slice thickness 7 mm, reconstruction increment 6 mm). venous phase scanning was completed at the level of the popliteal fossa 3 minutes after contrastmedium injection. results: 62 patients in our series suffered from pe. 47 of these had additional deep venous thrombosis (78.3 %). the latter was ruled out in 13 patients, one patient with pe did not receive this additional examination protocol due to their poor clinical condition, one subsegmental pe was initially not detected. of the 99 patients without pe, 47 also received indirect ctp. in 10 cases dvt was proven, which was already known from previous examinations in 8 patients. only in 2/47 patients (4.3 %) was a previously undiagnosed dvt found, despite exclusion of pe. the examination protocol presented is suitable for clinical use in patients with suspected pe and offers detailed examination of the venous system. if dvt is not likely, additional ctp is not recommended if pe has been ruled out by msct. methods: patients with severe chronic ctph were evaluated using multislice ct and selective pulmonary dsa for operative treatment planning. ct findings and angiographic findings were correlated at the level of major arteries, interlobar arteries, segmental and subsegmental arteries. diagnostic criteria included patency or occlusion, thromboembolic deposits, webs, bands, and anatomical allocation of the respective findings. results: in 14 consecutive patients with severe ctph, ct and dsa findings of 994 pulmonary vessel segments from major to subsegmental arteries were separately analysed. using multislice ct 30 segments were insufficiently detected (25 subsegments, 5 segments) compared to 50 segments in dsa (37 subsegments, 11 segments, and 2 major arteries). predominantly segment iii and less often segment i arteries were insufficiently detected due to the position of the pigtail catheter. concerning inconspicuous vessles versus occlusion or any thromboembolic alterations, the diagnostic concordance of both methods overall was 67 %, was 79.4 % for segmental arteries and 63.6 % for subsegmental arteries. concerning patency versus complete occlusion diagnostic concordance overall was 82.4 %, was 88.6 % for segmental arteries and 77.1 % for subsegmental arteries. dsa was superior for detection of peripheral thromboembolic alterations. ct was superior for anatomical allocation. conclusion: multislice ct is suitable for diagnosis of ctph on segmental and subsegmental level. however, for planning of pulmonary thrombendarterectomy both modalities, multislice ct and selective pulmonary dsa, are still necessary for exact anatomical allocation and precise visualisation of thromboembolic findings. epidemiologic, clinical and morphologic criteria as listed below. (advanced disease was defined as hepatic insufficiency leading to olt within the subsequent 2 years). results: common and characteristic findings were as follows: 81 % of patients were women with the onset of disease (diagnosis) in middle age (mean, 50.7 years, range, 26 to 71 years). the average time from diagnosis to liver transplantation was 6.1 years (range, 0.5 to 20 years). ct findings in advanced pbc often resembled those seen in other forms of cirrhosis with a small heterogeneous liver, varices and splenomegaly. the liver in less advanced disease was usually enlarged or normal in size, with a smooth contour, little atrophy and lace-like fibrosis and regenerative nodules in nearly a third. even patients with less advanced disease frequently had varices (62 %) and ascites (24 %). prominent lymphadenopathy was seen in 88 % of all cases. hepatocellular carcinoma was found in only 4 patients, 2 of whom also had chronic hepatitis c. only two patients had recurrence of pbc following olt conclusion: pbc is an important cause of liver failure with distinctive clinical and ct findings that may allow confident diagnosis and management. we reviewed retrospectively the imaging studies of five patients (4 women; aged 16 -25 years) with liver nodules associated with a spontaneous intrahepatic portosystemic venous shunt. color-doppler ultrasoud (us), helical-ct and arteriography were performed in all patients and mri in 4 patients. nodules location, number, size, density or signal, homogeneity and pattern of vascularition were evaluated. hepatic vascularization, the morphologic type of the shunt and portal hypertension features were also analyzed. these findings were correlated to pathological results (transcutaneous biopsy of the nodules (n = 3); transplantation (n = 2)). results: sonography and angiography demonstrated a portohepatic venous shunt (persistent arantius ductus (n = 1), congenital absence of portal vein (n = 2), left portohepatic venous shunt (n = 1), left portoatrial shunt (n = 1)). hepatic arterialisation were observed in segment where no portal flow was seen and where hepatic nodules were present. the number of nodules in each patients was at least 3 with a size ranging from 1 to 12 cm. most lesions were heterogeneous, hypoechoic on us, hypodense on ct, hyperintense on t1, slightly hyperintense on t2 and enhanced slightly and heterogeneously on arterial phase after contrast injection. histological results showed nodular hyperplasia in the liver suggestive of focal nodular hyperplasia in all cases and adenoma in one case. conclusion: these findings emphasised the hypothesis that nodular transformation of the liver is probably due to the lack of portal blood flow and hepatic arterialisation and is usually of benign type. high resolution multislice spiral ct in liver metastasis: comparison of a high resolution vs a low resolution protocol f. fraioli, c. catalano, a. laghi, f. pediconi, a. napoli, r. brillo, m. danti, r. passariello; rome/it purpose: to evaluate the sensitivity and specificity of multislice spiral ct (msct) in the assessment of patients with suspected liver metastasis and to compare two different acquisition protocols. material and methods: 50 patients referred for different neoplasms underwent msct. all patients underwent intraoperative ultrasound or, in case of diagnosis of unresectability in the first examination, a follow up ct at three months. pre (4 × 2.5 mm collimation) and post-contrast (4 × 1 mm collimation, 1 mm and 5 mm reconstruction interval) acquisitions, during arterial and portal venous phases were performed after i.v. administration of 140 ml of c.a. at 4 ml/s. two observers blindly evaluated either 5 mm axial images or 1 mm axial and relative mprs, in terms of presence and number of lesions. results: ct correctly showed 123 (92 %) of the 133 liver lesions shown at intraoperative ultrasound in 42 patients. ct correctly evaluated all lesions greater than 2 cm in size. regarding lesions smaller than 2 cm in size ct evaluated as cyst 4 lesions shown at intraoperative ultrasound as metastasys. real time interaction 3d data set with 1 mm axial images, allowed to identify 24 subcapsular lesions. sensitivity, specificity and accuracy in detection of smaller lesions smaller than 1 cm was 98 %, 94 % and 97 % using 1 mm axial images and 89 %, 93 % and 90 % using 5 mm protocol. conclusion: high resolution msct with 3d data is a very accurate technique in the assessment of patients with liver metastases. the difference of images secretory and non-secretory carcinoid tumours using standard ct and functional techniques j.b. cwikla, j.r. buscombe, a.j. watkinson, m.e. caplin, a.j.w. hilson; london/gb functional and anatomical imaging modalities can underestimate presence or extent of disseminated carcinoid and should be used together. aim of study was to assess if there is any difference in imaging pictures between secretory and nonsecretory carcinoid and toconsider both techniques. overall 50 patients, all with confirmed carcinoid. there were 31 patients with primary disease. half of the patients had secreting tumours with carcinoid syndrome. ct and 111 in octreotide study was performed in each case, using standard imaging protocol. in non-function tumours ct was able detect disease within liver in rate of 0.53. 111 in octreotide was positive in all patients. different sites within abdomen and chest in patients with non-secretory tumours ct and functional imaging detected with rate as follows: pancreas 0.57/0.71, paraaortic nodes 0.7/0.8, gut and/or mesentery 0.67/ 0.83. other site of tumour spread: chest, pelvis, spleen or bone using ct was 0.25 and 111 in octreotide 0.92. those patients with secretory tumours had results as follows: liver deposits using ct in 0.96, 111 in octreotide 0.91. in this group of patients other sites of tumour deposits within abdomen and chest ct and functional imaging detected with rate as follows: pancreas 0.25/1, paraaortic nodes 0.79/ 0.93, gut and/or mesentery involvement both 0.61. other site of tumour spread like chest, pelvis, spleen or bone involvement using ct was 0.41 and 111 in octreotide 0.82. these results suggest that any imaging modality is perfect to detect carcinoid deposits, additionally there is a difference with deposits distribution of carcinoid in patients with secretory and non-secretory tumours. lymphoma therapy monitoring by multislice perfusion-ct w. römer, l. muresan, r. repp, a. taubald, h. greess, w.a. kalender, w.a. bautz; erlangen/de purpose: the high frequent acquisition of multislice ct data after contrast medium bolus injection allows quantification of tumor perfusion. it was our goal to assess therapy induced changes of tumor perfusion early after initiation of lymphoma treatment using dedicated software to calculate parametric images. method: dynamic msct was performed in 19 patients with lymphoma before and 7 days after initiation of chemotherapy. after automatic bolus injection of 80 ml contrast medium (flow 8 ml/s), two 10 mm-sections through the largest tumor region were scanned for 40 s (siemens somatom volume zoom). the arterial input function was derived from the largest arterial vessel in the field of view. perfusion indices were calculated using graphical analysis and displayed as parametric color coded images. results: at baseline, all lymphoma lesions were visible in perfusion images by an enhanced perfusion index (0.474 ml/min/ml). seven days after initiation of chemotherapy, tumor perfusion decreased by 46 % in high grade nhl and hodgkin's lymphoma, whereas in two patients with low grade nhl the perfusion index increased by 55 %. in contrast, 2d-tumor size only decreased by 19 % and 11 %, resp. conclusion: these results indicate that chemotherapy-induced changes of tumor perfusion may be assessed by perfusion msct and documented in parametric images. in highly responsive tumors like high grade nhl and hodgkin's lymphoma, therapy induced perfusion changes occur within the first 7 days after therapy and precede morphologic changes. we hypothesize that outcome of therapy may be predicted as early as 7 days after treatment. the effect of intravenous secretin administration on hepatic enhancement during ct examinations of the abdomen s.m. lyon, t. fotheringham, p. o'sullivan, m.f. given, m.j. lee; dublin/ie purpose: intravenous secretin increases blood flow to the pancreas in animals. in an associated study we found that iv secretin caused significantly increased enhancement of the portal venous (pv) system. this study investigated the effect of secretin on hepatic enhancement. methods: 32 patients (mean age 70; range 47 -88) were enrolled. triple phase helical ct of the abdomen was performed on successive days so that each patient acted as their own control. all patients had intra-abdominal malignancy and the study was approved by the hospital ethics committee. unenhanced and enhanced ct in the arterial phase and pv phase was performed without (day 1)and with (day 2) secretin (100 iu) given at t = 0 s (n = 10), t = 60 s (n = 5), t = 120 s (n = 5), t = 180 s (n = 4), t = 240 s (n = 4), t = 300 s (n = 3). percent enhancement of the liver was calculated using roi's obtained from studies with and without secretin. results: overall mean hepatic enhancement in the portal venous phase was 109 % without secretin and 117 % with secretin. the relative increase in hepatic enhancement after secretin when compared to hepatic enhancement without secretin was 13 % at t = 0, 16.6 % at t = 60 s, 24.6 % at t = 120 s, 18.9 % at t = 180, 3.1 % at t = 240 and 19.5 % at t = 300 s. pv/smv enhancement was significantly increased in all secretin studies (p < 0.05) when compared with non-secretin studies. conclusion: secretin administration causes an increase in hepatic enhancement which may lead to better lesion conspicuity. the optimal timing for secretin administration and its effect on lesion-liver contrast differences will be determined as more patients are recruited. study completion is expected in november 2001. imaging findings in extraosseous multiple myeloma m. patlas, i. hadas-halpern, c. reinus, e. libson; jerusalem/il purpose: extraosseous manifestations are rare and are found in less than 5 % of patients with multiple myeloma. the purpose of this study is to illustrate the imaging features of extraosseous myeloma and to heighten the awareness of this phenomenon. we retrospectively reviewed the radiological files of 200 myeloma patients. patients in whom the extraosseous masses were in contiguity with bony involvement were excluded from the study. results: seven of the 200 (3.5 %)myeloma patients had extraosseous masses. there were 2 men and 5 women and the age range was 48 -82 years old (mean age 60 years). ct was available in five patients, mammography in three cases, and ultrasound in one case. biopsy revealed the diagnosis of plasmacytoma in all cases. the gamut of findings included breast masses (three patients), supraclavicular lymph nodes (1 patient), pancreas and stomach (1 patient), adrenal and pleura (1 patient), thyroid cartilage (1 patient). more than one site was present in 2 of the 7 patients (adrenal and pleura; pancreas and stomach). soft tissue plasmacytomas presented as relatively well-defined masses of various sizes, and could not be differentiated from other malignant or benign lesions on the basis of the imaging findings alone. conclusions: exraosseous myeloma is very uncommon in multiple myeloma. radiologists should be aware of this occurence so that extensive unnecessary interventions can be avoided when extraosseous sites of disease are encountered. quality indicators in radiology management: a methodology development study p.e. varga 1 , e. belicza 1 , e. sík 2 , g. nagy 3 ; 1 budapest/hu, 2 szekszárd/hu, 3 zalaegerszeg/hu purpose: quality indicators are widely used in healthcare. though imaging is involved in almost all diagnostic procedure, few quality indicators are accepted in radiology. method: repeated x-ray examination data were collected in 3 hospitals. the 3-month multicenter study aimed to develop an indicator as well as to test the indicator development method itself, using common data sheets. in the 886 repeated examinations, the influence of different reasons of repetition was analysed. results: 21 causes were identified. inappropriate exposition or positioning were leading causes, in 71.6 % of the cases in hospital 1, 72.6 % in hospital 2 and 22.0 in hospital 3. failure of the equipment was the second cause: 25.0 %, 7.9 % and 0.1 %, respectively. low rates in hospital 3 can be attributed to the newly equipped digital x-ray department. in other words: hospital 1 and 2 pay the price of the lack of investment with repeated examinations. day-section has a higher influence than workload: though the majority of the examinations were carried out during normal hours, 23.7 % of the repetitions occur on night duty. nearly half of the technicians involved found the data sheet too detailed and they proposed to modify his for automatic registration. as repeated examination means increased risk for the patient and the institution, economical consequences will be demonstrated. conclusion: repeated x-ray examination proved to be an appropriate quality indicator, as it is profession-specific, relevant and convenient for benchmarking. data collection is easy and economic data can be linked. quality management can be based on reason analysis. materials and methods: of 59 patients who were referred for percutaneous drainage of hepatic abscess between 1995 and 2001, cases with incorrect diagnosis or without pre-procedural contrast-enhanced ct were excluded, and 78 abscesses in 47 patients (29 -79 years, m:f = 35:12) were included. 24 patients had the predisposing factor such as hepatocholedocholithiasis (n = 7), the history of biliary (n = 6) or gastrointestinal (n = 5) malignancy, or others. findings in dual-phase helical ct (n = 34) or single-phase ct (n = 13) were analyzed concerning the enhancement pattern of the abscess wall and adjacent parenchyma, and the presence of the thrombosis of intrahepatic vasculature. the abscess wall appeared as single layer of hyperdense ring in 38 lesions (48 %) or as double target (inner hyperdense ring and outer hypodense ring) in 32 lesions (41 %). there was thrombosis in the hepatic vein (n = 20) and/or portal vein (n = 18) noted in 30 cases (64 %). in cases with dual-phase ct, regional difference in parenchymal attenuation was noted in 28 cases (82 %), showing wedge-shaped hyperdense area surrounding the absecss in arterial phase (n = 24) or hypodense area peripheral to the abscess in portal phase (n = 11). of those cases with regional difference in parenchymal attenuation, 21 cases (75 %) had venous thrombosis (p = 0.07, fisher's exact test). the abscess wall has characteristic enhancement pattern on dynamic ct. the enhancement pattern of adjacent parenchyma is more complex, and it may be associated with the venous thrombosis. the liver is the most commonly damaged organ in children following blunt abdominal trauma. a conservative non-operative approach is now the recognised standard of care. computerised tomography (ct) is the primary imaging modality of choice. this conservative approach can result in bile duct damage remaining undetected for several days. we have evaluated the pre-emptive use of tbida hepatoscintigraphy, to detect biliary leakage prior to the patient becoming symptomatic. at birmingham children's hospital, all patients who have a history of trauma and clinical suspicion of abdominal injury undergo an abdominal ct. in those cases where there was liver fracture greater than 4.0 cm or involving the portahepatitis, a tbida study was performed. 21 patients underwent an abdominal ct abdomen. 7 patients had a significant liver injury, all with fluid in the peritoneum and additionally had a tbida study. in 2 patients the tbida demonstrated activity within the peritoneal cavity. intraoperative cholangiograms confirmed the biliary leaks that were surgically stented. both patients were asymptomatic with no evidence of a biliary peritonitis. the tbida in a third patient demonstrated a biloma that on follow-up ultrasound has shown to be shown to be the site of a portovenous fistula. all patients showed good recovery and returned to a normal lifestyle. tbida hepatoscintigraphy, when used pre-emptively, can detect biliary damage prior to the development of clinical symptoms. this early detection improves surgical outcome and reduces hospital stay. the investigation also allows the detection of other potential intrahepatic complications. b a c d e f 266 acute pancreatitis in childhood l. laufer, o. kleiner, g. greenberg, z. cohen, y. hertzanu; beer sheva/il purpose: acute pancreatitis in children is rare. the aim of this study was to demonstrate the spectrum of imaging findings in relation to the aetiology. materials and methods: 46 children aged 1 -18 a between 1984 and the year 2000 were diagnosed at our hospital with acute pancreatitis. the diagnosis was established using clinical data, us and ct examinations. a history of trauma was present in 22 children, 20 cases were considered to be idiopathic. the other cases were secondary to biliary stones, thalassemia, steroid treatment and chemotherapy. results: there is a considerable difference between traumatic and nontraumatic pancreatitis. the imaging in most cases of idiopathic pancreatitis was normal or minimal changes were showed. the children with pancreatic injury demonstrated a large range of imaging findings. laceration or fracture (13 cases), local or diffuse pancreatic enlargement (16), nonhomogenous structure (20), and pseudocyst formation (6). the tail was involved twice as frequently as the head. the study showed a large difference between the 2 groups. the contribution of imaging in diagnosis of idiopathic cases was minimal and follow-up was unnecessary. the imaging of posttraumatic pancreatitis demonstrates a large spectrum of pathology in the early examination and follow-up studies. when can balloon dilatation of esophageal strictures in children be considered successful? j. lisý jr., j. snajdauf, m. vyhnánek, s. tuma, j. neuwirth; prague/cz purpose: healing of a stricture by scar formation after balloon dilatation results in narrowing of the eosophageal lumen and reccurrence of dysphagia. consequently repeated dilatations are usually necessary. the authors tried to establish the delay after dilatation when the procedure could be considered successful and further dilatation or surgery was not indicated. methods and materials: eosophageal strictures in 49 children were treated by 189 balloon dilatations in total. 20 children had an anastomotic stricture after surgery for eosophageal atresia, 12 had a reflux stricture, 6 a tight cuff after nissen fundoplication causing achalasia, 6 a corrosive stricture, 4 congenital stenosis and 1 a stricture after radiation. dilatations were considered successful, when absence of dysphagia lasted for at least 1 year after dilatation and the patient hadn't undergone surgery. results: one procedure completely treated the stricture in 11 children (22 %). none of them had surgery. repeated procedures were neccessary in 38 patients (78 %). the delay between dilatations in the case of repeated procedures ranged from 1 week to 3 years. dilatation avoided surgery in 27 cases (56 %). only 6 of these patients had more than a 6 month delay between procedures. the remaining 11 children (22 %) required surgery after repeated unsuccessful dilatations. however in none was there a need for repeat dilatation later than 6 months following a previous procedure. conclusion: the authors conclude that a delay of 6 months after dilatation is the key time for evaluation of success rate of eosophageal balloon dilatation. crohn's disease in paediatric patients: mr imaging of the small bowel using peg solution as an oral contrast medium a. laghi, i. carbone, i. baeli, r. iannaccone, p. paolantonio, f. iafrate, c. catalano, r. passariello; rome/it purpose: the aim of this study was to evaluate mr findings of the small bowel using peg solution as an oral contrast medium in paediatric patients with suspected crohn's disease. subjects and methods: twelve patients with clinical and laboratory findings indicating possible crohn's disease underwent mr study of the small bowel. after an overnight fast, immediately before mr examination, a fixed amount of 10 ml/kg of weight of peg solution was orally administered. no antispasmodic drug or other drugs were given. mr study was performed using haste (tr/te/acq.t.: inf/90 ms/ 18 s) and trufisp (tr/te/acq.t.: 4.8 ms/2.3 ms/14 s) sequences obtained sequentially for up to 20 minutes, in axial and coronal planes. t1 weighted flash sequences (tr/te/acq.t.: 140 ms/5.3 ms/16 s) were acquired before and after dynamic contrast medium administration (0.1 mmol/kg of gd-dtpa). image were analysed by consensus by two experienced gastrointestinal radiologists. results: seven patients presented positive findings for crohn's disease. mr findings were represented by: wall thickening of the terminal ileal loop, with stricture in three cases. following contrast medium administration wall enhancement was observed in all the cases. conclusion: mr imaging of the small bowel after oral administration of peg solution is a reliable, reproducible, and safe imaging modality for the evaluation of crohn's disease. colonic duplication: clinical presentation and imaging features m.-j.g.j.g. grandsaerd, m.p. hartkamp, c. boetes, p. rieu, c. buonomo, c.e. van die, j.g. blickman; nijmegen/nl purpose: to make the imager and clinician aware that colonic duplication may present at birth, associated with other congenital anomalies or late, as an isolated finding. in the latter instance, the duplication almost always features connecting lumens. material and methods: we reviewed the clinical and radiological features of 9 cases of colonic duplication over the last 10 years. there were 7 girls and 2 boys. their age at presentation was either newborn (6, all girls) or between 4 and 11 years old (2 boys, 1 girl). all had contrast enemas, and 3 underwent abdominal ct. results: those that presented at birth had multiple associated congenital anomalies, including partial and complete vater associations (5, all girls), duplication of the bladder in 2, uterus and vagina in 2, as well as situs inversus totalis in 1 girl. the older presenting children all had long-standing symptoms of constipation and distended abdomens. all duplications had connecting lumens. conclusion: duplication of the colon is a rare congenital anomaly. this report illustrates that there are 2 peaks of presentation: perinatally and later in childhood. furthermore, in the former group multiple associated congenital anomalies are present in all (or almost all) cases. as opposed to other gi duplications, these colonic duplications displayed connecting lumens. renal parenchymal volume assessment with 3d ultrasound in paediatric uroradiology g.a. fritz, m. riccabona, e. ring; graz/at purpose: to prospectively investigate the accuracy of renal volume assessment using three-dimensional ultrasound (3dus) compared to the results of 2dus, ct/ mri, or scintigraphy in neonates, infants and children. methods and materials: 60 patients (mean age 9.81 ± 8.1 years) underwentadditional to conventional us and other conventional imaging as appropriate -3dus of the kidney for anatomical and volumetrical assessment. 3dus was performed with a voluson (kretztechnik/ge, austria/usa) or an external 3d-system (echotech/ge, germany/usa). volume calculations were performed in 2dus applying the ellipsoid equation v = (p/6) × l × w × ap, for 3dus using the system specific volumetric software; in ct/mri volume was calculated by planimetric analysis, and for scintigraphy the renal volume was quantified as relative renal volume. volume measurement focused on renal parenchyma, a dilated renal collecting system was subtracted. results: in 55/60 patients at least one 3dus acquisition/kidney was of diagnostic quality. 3dus volume measurements were accurate compared to ct/mri (± 5 %). 2dus volume estimates showed a larger variation and difference (± 10 %), particularly in kidneys with dilated collecting systems or scars, volumes differed significantly. there was a good correlation of relative renal volume in 3dus compared to scintigraphy in patients without acute pyelonephritis or other perfusion alterations. conclusion: 3dus is applicable to the paediatric genito-urinary tract. 3dus is a more accurate method than 2dus for assessment of (relative) renal parenchymal volume, particularly valuable in patients with hydronephrosis. 3dus improves sonographic potential and can be considered a useful adjunct to conventional imaging. pediatric excretory mr urography a. borthne, c. pierre-jerome, k. gjesdal, t. storaas; oslo/no purpose: normal-sized ureters are difficult to visualise in neonates and small children with the haste-technique (hydrography). an additional contrast-enhanced t1-weighted fast gradient echo (fge)sequence was used for improvement of the image quality. methods and materials: an experimental study with 3 pigs was first performed to validate the excretion-technique. we then studied 34 patients (17 neonates and 17 children) with the same technique. after injection of gadolinium and 5 mg of frusemide, contiguous coronal fge images were acquired with: matrix 163 × 512, tr 2.6 ms, flip angle 60, fov 260 mm, slice thickness 3.3 mm, gap 1.6 mm, nsa 6. 2-and 3-dimensional reconstructions of the entire genitourinary system were performed, followed by quantitative and qualitative image analysis. in all neonates the excretion technique proved better than hydrography; 79 % of the ureters were completely visualised. in children 4 patients with obstruction/reduced kidney function were better seen with hydrography. all the others were better or equally visualised with the excretion technique: complete assessment of the ureters were achieved in 74 % of the children. the mean diameters of the ureters in neonates were: 3 mm (proximal), 4 mm (middle) and 3 mm (distal segment); in children: 4 mm, 6 mm and 4 mm respectively. conclusion: excretory mr urography is better than the non-enhanced hastetechnique (hydrography) for the assessment of the entire excretory system in neonates and children, except for those patients with marked obstruction or reduced kidney function. grade one vesicoureteral reflux -an undergrading? k. darge 1 , g. roessling 2 , j. , with the intravesical application of microbubbles containing the us contrast medium levovist, were performed successively during one examination session. any grade i reflux detected on vcug was compared to the reflux grade of the respective vus. furthermore, in an in-vitro set-up simulating the urinary tract the possibility of passive ascension of microbubbles in the ureter was examined using a uv-spectrometer. results: grade i reflux was identified on vcug in 22 patients comprising of 23 kidney-ureter-units [kuus] . in 7 kuus the reflux was also grade i on vus. in the remaining 16 kuus microbubbles were detected in the renal pelvises, the grades of vur being 2 and 3 in 12 and 4 kuus, respectively. prior to the administration of the us contrast medium dilated ureters were seen in 13 kuus. the renal pelvis was dilated only in 2 cases. in the in-vitro set-up using the same us contrast medium, despite the absence of counter-flow no microbubbles were detected at the site corresponding to the renal pelvis. conclusion: microbubbles detected in the renal pelvis can only have been actively propagated by the reflux pressure and do not ascend passively up the ureter. 70 % of the grade i refluxes diagnosed in the vcug are actually grade ii or higher. review of imaging before and after surgery for posterior urethral valves n.p. power, k. mchugh, i. gordon, d. wilcox, p. duffy, p. ransley; london/gb purpose: to compare the imaging appearances on both micturating cystourethrography (mcug)and ultrasound (u/s)before and after surgery for posterior urethral valves (puv). to determine the clinical effectiveness of routine postsurgical mcug. materials and methods: the imaging findings of 43 boys, of whom 7 had two operations for puv were reviewed. mcug was performed before and after each operation making 100 mcug in total. features evaluated included the appearances of the bladder, posterior and anterior urethra, the presence of vesico-ureteric reflux (vur) and the contemporaneous u/s results. age at surgery and creatinine results were also noted. results: age at surgery ranged from 6 days to 5 years 9 months. 50 % were less than a month at surgery. vur was detected in 40 % of patients; most of these were unchanged post-operatively. the commonest bladder abnormality was trabeculation (82 %); 75 % were unchanged on follow-up. 50 % of patients had a small volume bladder. when the posterior urethra was visualised it was invariably dilated. 52 % of patients had an apparently narrow anterior urethra initially; most improved on follow-up. the commonest u/s findings were bilateral hydroureteronephrosis (62 %)and bladder wall thickening (42 %), although 4 % of pre-operative u/s were normal. most patients had little change in u/s features. 78 % had a fall in creatinine post-operatively. conclusion: a small number of boys with puv may have normal u/s appearances. imaging appearances on both mcug and u/s are frequently unchanged after puv resection. as patient management depends on several factors including renal function and cystoscopy findings, we question the clinical effectiveness of routine post-operative mcug. the transbrachial approach for sclerotherapy in paediatric varicoceles p. agresti, s. pieri, l. de medici, g. fiocca, a. calisti; rome/it introduction: percutaneous sclerotherapy has gained wide acceptance in the treatment of male and female varicocele. we introduced the percutaneous approach into the paediatric population, because it is minimally invasive, uses local anesthesia, is minimally traumatic and less expensive than a surgical option. we report our 10 year experience with the transbrachial approach. materials and method: from 1991 to 2000 we have done 425 procedures. inclusion criteria were positives at physical, doppler and ultrasound examination for varicocele type i, grade iii, and ii only if symptomatic. phlebography was done under local anesthesia, with a transbrachial approach. we first try to enter the right spermatic vein and then work on the left side. sclerotheraphy was done with tetra-decilsolfato (trombovar). follow up with clinical examination was done at 1 -6 -12 months and 6 -12 months with colour-doppler ultrasound. results: median age was 14.7 years. symptoms were present in only 3 % of boys. there were 78/425 bilateral varicoceles, 15 on the right and the remainder on the left. there were good clinical results with sclerosis in 95 % of the treated boys. discussion: percutaneous sclerotherapy of varicoceles is a safe, effective and less expensive option than surgical therapy, especially in the bilateral form, with a low complication rate. methods: 20 patients with fractures of the mandible underwent mri (gradient echo sequences before and after contrast administration). continuity of the nerve was evaluated by visual inspection, signal intensity was measured by region of interest in 4 different locations. the nerve could be evaluated in all 20 cases. the continuity or the disruption of the nerve detected on mri was confirmed by the surgical findings in all patients. there was no difference in the increase in signal intensity after contrast enhancement between patients with and without disruption of the nerve. some patients with neurological deficit without disruption of the nerve, showed a decrease of signal intensity distal the fracture. all the other patients without neurological deficit had an increase of signal intensity from proximal to distal. conclusion: it is possible to detect the disruption of the nerve by mri. the reason why the signal intensity in some patients decreases seems to be unclear. as we used gradient echo sequences, which in particular show blood flow effects, it might be possible to measure a reduced blood circulation in the perineurium distal the fracture by regions of interest. beside prevention of neurological deficits, this might be another argument for urgent surgical treatment. bmd measurements in the jaw from dental ct images. verification of the method and first applications in dental implantology a. beer, p. homolka, a. gahleitner, m. tschabitscher, r. nowotny, h. bergmann; vienna/at purpose: in implant dentistry, both bone quantity and quality, are of vital importance for preoperative planning. while bone quantity is well defined, different approaches on measuring bone quality exist. usually quite crude grading schemes are applied, that may not provide a quantitative measure for local bone quality exactly at the intended implantation site. a c d e f 268 methods and materials: a calibration standard with known concentrations of hydroxyapatite is scanned simultaneously with the patient using an adapted dental-ct technique. conversion of hounsfield numbers to bmd values is accomplished using a linear relationship. bmd is evaluated locally using full ct image resolution on reformatted views to evaluate possible implant sites. results: in a cadaver mandible pilot study a strong correlation (r 2 > 0.85) between bmd and the insertion torque of dental implants is demonstrated. therefore, bmd may serve as an estimate of achievable primary implant stability and thus, as a measure of bone quality. first clinical applications are going to be presented. conclusion: since a correlation with mechanical bone properties and accepted measures of primary implant anchorage has clearly been established, preoperatively determined bmd values of the jaw bone could help to assess possible implant sites to optimize primary stability and long term prognosis of the implants by guiding the surgeon through the choice of best suited implant site or implant type and preparation technique. periapical dental findings evaluated with coronal sinus ct c.r. krestan, p.l. peloschek, c. czerny, s. grampp, a. gahleitner; vienna/at purpose: to evaluate the frequency of chronic peripical periodontitis (cap) in teeth in the upper jaw using coronal sinus ct. methods: we reviewed 95 coronal sinus ct examinations (ct-secura, philips medical systems, best, the netherlands) from non-selected clinical patients. sinus ct was performed with the patient in the prone position with a collimation of 3 mm from the ventral border of the frontal sinus to the posterior edge of the sphenoid sinus. reconstruction was done using a high-resolution bone algorhythm. the frequency and size of hypodense periapical lesions was determined by two radiologists in a consensus reading. frequency and severity of artifacts from restoration dentistry and disease of the maxillary sinus was recorded. results: in 4 out of 95 patients (4.2 %) periapical disease (cap) could be dignosed. in 40 of these 95 patients metal artifacts reduced the image quality of the periapical region. the regions 16 and 26 were most affected by artifacts. there was no statistically significant difference between the site of periapical disease and concomitant sinus disease. conclusion: in up to 4 percent of non-selected patients, referred for sinus imaging, we found periapical dental disease on coronal standard ct. although coronal sinus ct is not the method of choice for evaluating dental disease, it is worth to pay attention to periapical disease. atypical non-odontical chronic jaw pain: findings on panoramic radiographs and dental-ct-scans correlated with histology and microbiology p.l. peloschek, d. turhani, f. watzinger, m. püregger, i. sulzbacher, j. sailer, c. czerny; vienna/at purpose: the aim of this study was to compare radiographic, histological and microbiological findings of patients with atypical non-odontical pain of the jaw. patients and methods: from 1998 to 2001 20 out-patients with jaw pain of uncertain origin were prospectively analysed by panoramic radiographs and ct following open biopsy. the axial ct scans (philips ct secura; 120 kv, 70 ma, scan time 2 seconds, slice thickness 1 mm, table index 1 mm, high resolution filter) were reformatted using dental-ct software (philips easyvision, dental reformatting package). usually no contrast enhancing media were given. inclusion criteria were long-term patient history with pain and/or swelling located in a tooth-free region and unclear conventional and panoramic radiographs. exclusion criteria were previous fractures, osteoradionecrosis and dental residuals. in this cohort, laboratory parameters were inconclusive. the bicortical bone-biopsies were classified following histological and microbiological findings. radiographic findings were correlated with the results of the histological and microbiological examinations. results: 20 patients could be included. no significant correlation between radiological and microbiological or histological findings was found. histological diagnosis included unspecific post-inflammatory changes, active osteomyelitis and healthy specimen. conclusion: the use of conventional radiographs, panoramic radiographs and dental-ct in the diagnosis of chronical atypical non-odontical pain of the jaw should be re-thought. if panoramic radiographs give no appropriate information in finding a focus in chronic pain of a tooth-free region, dental-ct will not give further information. maybe dynamic mri will resolve this diagnostic dilemma. appropriate studies are in progress. does a dose reduction by a factor of 27 affect the diagnostic value of multirow detector helical ct of the sinuses? d. tack, j. widelec, j.-m. bailly, c. delcour; charleroi/be purpose: to compare multiplanar reformations (mpr) and volume rendering technique (vrt) as well as virtual endoscopic views (ve) obtained from helical multirowdetector computed tomographic (mrdct) respectively with low-dose and standard-dose acquisitions in patients with sinusitis. method/materials: 50 consecutive patients with headache referred for a standard dose brain ct and in whom a sinusitis was found or had to be excluded had a second acquisition with a low dose technique (volume zoom, siemens). following parameters were used for the standard dose acquisition: collimation 4 × 1 mm, rotation time: 0.75 s, 140 kv, 150 mas, pitch: 0.875, ctdiw: 57.2 mgy, reconstruction width and increment 1.25 and 0.8 mm; low-dose acquisition: collimation 4 × 1 mm, rotation time: 0.5 s, 120 kv, 10 mas, pitch: 2, ctdiw: 2.04 mgy. coronal, axial and sagital 2 mm thick mpr and selected vrt and ve views were obtained from both native image sets and analysed on workstations by 3 radiologists who had to state the normal or abnormal appearence of 16 different anatomic regions. the effective dose was computer simulated. results: in 785 of of 800 regions of interest, no difference was found by all 3 readers. in the remaining 15 regions, 2 of 3 readers stated that low-dose and standard dose images were equivalent. computer simulated effective dose were respectively for standard-dose and low-dose mrdct of 1.72 and 0.063 msv. purpose: due to the complex anatomy of the facial bones ct examinations of fractures in at least two planes are required for reliable diagnosis and operative planning. however, in some cases examination can be performed in the axial plane only. therefore high quality mprs from axial ct-datasets have to be obtained. aim of this study was to analyse the influence of collimation, reconstructed slice thickness/increment, reconstruction-kernel, tube current and ultra high resolution (uhr) and non-uhr acquisition on detectability of facial fractures. methods and materials: a cadaver head with artificial blunt facial trauma was examined using a siemens somatom volume zoom unit (siemens, erlangen, germany). acquisition parameters were: collimation 2 × 0.5 vs 4 × 1 vs 4 × 2.5 mm, tube current 120 vs 90 vs 60 mas, uhr and non-uhr, reconstructed slice thickness/increment 0.5/0.3 vs 1.0/0.6 vs 3/1.5 mm. out of these volume datasets coronar and sagittal mprs were obtained with the following reformation parameters: slice thickness 0.5 -3 mm, overlapping 0.5 -3 mm. 6 fracture locations were scored blinded by 5 experienced radiologists. inter-observer variability was determined with the κ-test. differences in fracture detection of the respective algorithms were assessed with wilcoxon-and friedman-tests to p < 0.05. results: detectability of fractures was higher in 2 × 0.5 mm collimation (p = 0.001 to p < 0.0005). uhr is superior to non-uhr (p = 0.001). 120 mas exceeded 90 and 60 mas (p < 0.0005) in uhr and non-uhr, respectively. thin mprs (0.5/ 0.5 mm, 1/0.5 mm) are superior to thick mprs (p = 0.023 to p < 0.0005), whereas there is no significant difference between 0.5/0.5 mm and 1/0.5 mm (p = 0.317). conclusion: our data reliably prove that for subtle fractures thin mprs (0.5/0.5 mm, 1/0.5 mm) should be obtained out of thin slices (0.5 mm) with 120 mas in uhr. multi slice ct with 3d reconstruction in the maxillofacial diseases f.m. drudi, s. padula, a. righi, f. trippa, p. ricci, f. cascone, r. passariello; rome/it purpose: aim of our study was to demonstrate the utility of 3d-reconstruction and virtual endoscopy in the planning of surgical intervention and evaluation of treatment in maxillofacial diseases. materials and methods: thirteen patients (mean age 42; range 22 -67 years) underwent multi-slice ct examination (slice thickness 1 mm; scan time 2.8 seconds; rotation time 0.4 seconds; feed rotation 4 mm) using intravenous contrast agent, if necessary. volumetric data sets were post-processed with vitrea 2 (vital images, milwakee) volume rendering software. results: in 7 patients who presented keratocyst, 3d-reconstruction permitted an exact definition of volume and site of the cyst. also the trigeminal mandibular nerve branch pathway was clearly depicted. after surgery 3d-reconstruction showed a complete "restitutio ad integrum" of the bone. in 3 patients, who presented floor-ofmouth carcinoma, 3d-reconstruction was performed before treatment to evaluate the dimensions of the mass and to exclude bone involvement. after treatment the examination was repeated to evaluate response to therapy. one patient who had undergone numerous operations for bilateral cleft leap, was studied to plan further surgery and to control the outcome. in 2 patients who presented maxillary sinus osteoma, 3d-reconstruction evidenced tumor origin. virtual endoscopy showed the exact position of the neoplasia in relation to the maxillary sinus floor and permitted postsurgical evaluation of the maxillary sinus floor. conclusions: multi-slice ct with 3d-reconstruction and virtual endoscopy are useful tools in the evaluation of maxillofacial diseases before and after therapy. facial hemangiomas as anexternal manifestation of the segmental angiodysplasia: mri and mra diagnosis v. panov, a. ivanov, m. inaneishvily, a. nadtotchi; moscow/ru purpose: diagnosis of facial soft tissues angiodysplasia (fad) is not hard because of its well-known clinical symptoms. ultrasonography with color doppler mapping, invasive selective and super selective x-ray angiography are usually used for the evaluation of tumor volume, its syntopy, morphological structure variants and identification of main supplying vessels. the main task of this presentation is to the show possibilities of noninvasive mr-imaging (mri) and mr-angiography (mra) in fad diagnosis. methods & materials: 38 patients with different forms of fad were examined. all mri and mra examinations were obtained on a 1 t mri system harmony (siemens, germany) and were compared with noninvasive ultrasound and invasive x-ray angiographic data. results: in 7 patients mri has found the following arterial abnormalities: different forms of unclosed willis ring (4 cases); significant middle cerebral arteries asymmetry (4 cases); lateral choroid artery displacement (1 case). in 5 patients vascular malformations were found: intracranial arterial malformations in 4 patients, meningeal venous malformations in 1 case. the disadvantages of mri were: the long time of examination, the necessity of sedation in young patients (younger than 5 -8 years) and in patients with claustrophobia. conclusion: use of noninvasive mra made it possible to establish that in some cases fad was an external manifestation of a segmental angiodysplasia which could be diagnosed only by the combination of noninvasive ultrasound and invasive x-ray angiography. mri and mra allow to obtain the same information about fad as traditional methods but has additional advantages in diagnosis of such lesions due to opportunities for intracranial arterial and venous visualization. from ct through *.stl to rism: a few real steps in the future of craniofacial surgery a. nadtotchi, v. roginskij, o. topol'nitskij, a. evseev; moscow/ru purpose: the evaluation of ct-datasets allows the possibility of creation of realsize facial skeleton individual stereolitographic plastic models (rism). methods & materials: 20 children with severe diseases and abnormalities of facial skeleton were examined by ct (conventional or spiral): 6 patients had mandibular tumors, 4 patients had mandibular congenital deformations and 5 patients had postoperative defects, and 5 children had complex craniofacial syndroms. after ct examination, the ct-dataset was transformed into the specially produced computerized stereolitographic files (*.stl). stl-files were send to the computer operated stereolitographic device that finaly created the facial skeleton rism. the rism was used not only for diagnosis but as an aid for operation planning in each individual case. using the rism it was easier for surgeons to define the access and operation techniques and to choose the optimal localisation of osteotomy lines. the rism was used as the base for preoperative manufacturing of exactly anatomical endoprotheses. this application of rism-technology is very progressive because: (1) it allows an increase in both the quality of preparation of endoprothesis and in their organospecificity; (2) it allows a decrease in the duration of operation of 1.5 -2.0 hours. where it was necessary to enlarge the mandible with compression-distraction apparatus, rism allowed definition of construction and optimal position of compression-distraction devices. conclusion: rism will be used not only as diagnostic model, but as important and powerful aid in the different branches of cranio-facial surgery. that is why we are sure that the system "ct -*.stl -rism" is a real step in the future of surgery. purpose: investigate the utility of ct cystography in the study of bladder tumors. method and materials: 10 patients with bladder tumours, ranging from solitary polypoid lesion to multiple endoluminal lesions with diffuse alterations of mucosal surface, were studied with ct cystography and the results compared with conventional cystoscopy. radiologists were blinded to the results of cystoscopy. ct cystography was performed with one helical acquisition of 3 mm slices at pitch 1.5, with images reconstructed each 1 mm. in all patients, the bladder was inflated with room air via a foley catheter. the data were then downloaded to a workstation and reviewed, both on axial 2d and with 3d-intraluminal navigation. results: tumour lesions (12) of the 8 patients having localized lesions were recognized on the ct data. this included one small lesion less than 5 mm. in the two patients having diffuse bladder involvement, ct cystography was able to detect the major polypoid lesions, but also identify a diffuse irregularity of the bladder inner surface corresponding to the spread of the lesions over the entire mucosal surface. ct axial data also predicted the extra-serosal spread of the disease by contiguity to the inner part of the anterior abdominal wall, which was confirmed by open surgery the day after ct cystography. urologists found the 3d images very similar to their own cystoscopy images. conclusions: recognition of bladder wall tumours is feasible by means of ct cystography. lesions equal or bigger than 5 mm were shown. b a c d e f 270 three-dimensional volume and surface rendered ultrasound of the urinary bladder: early experience g. helweg, a. klauser, l. pallwein, a.h. schuster, g. feuchtner, a. stenzl, d. zur nedden, f. frauscher; innsbruck/at purpose: we evaluated the feasibility of three-dimensional (3d) surface and volume rendered ultrasonography (us) for detection and differentiation of urinary bladder lesions. methods and materials: fourteen patients suspicious for bladder tumours on two-dimensional (2d) us underwent 3d imaging of the bladder prior to cystoscopy and transurethral bladder biopsy. the suspicious areas on 2d us were evaluated using the perspectivetm 3d us (acuson, moutainview, ca). tumour volume was calculated using the built-in software. documentation was done on video and printouts. the us findings of 2d and 3d us were compared with endoscopic findings and the biopsy results. results: eight of 14 patients (57 %) had biopsy proven bladder cancers. in addition to conventional 2d us, the mean time for the assessment of 3d data sets was 2.5 minutes (range: 2.0 -4.0 min). 3d us allowed a better visualization of the inner contour, corresponding to the mucosal layer of the bladder. 3d surface and volume rendered us data sets, enabled the correct diagnose of a benign lesion in 5 of 6 patients, and of cancer in 7 of 8 patients. this revealed an overall accuracy of 85 % for differentiating benign from malignant lesions. the tumour volume was overestimated ≥ 20 % in 4 of 8 patients with cancer compared to cystoscopy measurements. conclusions: 3d volume and surface rendered us improves the differentiation between benign and malignant lesions of the urinary bladder, compared with conventional 2d us. this technique requires only a short additional examination time and does not put any burden on the patient. use of flair sequences for detection and local staging of bladder tumours with mri m. di girolamo 1 , a. roncacci 1 , g. brughitta 2 , d. fini 2 , s. cavalaglio 2 , v. david 1 ; 1 rome/it, 2 grottaferrata/it purpose: to increase the accuracy of mri in the detection and local staging of bladder tumours by using flair sequences. method and materials: 32 patients with bladder tumours detected by us underwent mri using 0.5 and 1.5 t superconductive magnet. we performed se t1weighted (tr: 500 ms, te: 30 ms), tse t2-weighted (tr: 2500 ms, te: 120 ms) and flair sequences (tr: 6000 ms, te: 150 ms, ti: 2000 ms, n.ex.: 4; acq.time: 7 min 30 s) on axial scans. the contrast to lesion ratio was evaluated in all sequences. all the patients underwent cystoscopy with transurethral biopsy and 14 had subsequent cystectomy. results: in comparison with other sequences, flair sequence was more sensitive in the detection of bladder neoplasms. this sequence demonstrates the hyperintense signal of bladder neoplasms from the filled bladder lumen with no signal. the sensitivity in the identification of bladder neoplasms was 100 % with flair sequences, 89.6 % with tse t2-weighted sequences and 86.2 % with se t1-weighted sequences. that was due to the higher signal to lesion ratio of the flair sequences in comparison with the others. in fact on flair sequences the mean value of contrast to lesion ratio of bladder neoplasm was 33.1 while on se t1-weighted sequences and tse t2-weighted sequences was respectively 15.2 and 29.2. flair sequences allowed the detection of small papillomas (less than 2 mm). tse t2-weighted sequences were more sensitive in the study of bladder wall infiltration. conclusions: flair sequences were more sensitive in the detection of bladder neoplasms, due to their higher contrast to lesion ratio and can be very helpful in the visualization of small papillomas, especially when multifocal. purpose: evaluation of the diagnostic performance of virtual mr-cystoscopy for the assessment of bladder tumours. materials and methods: 35 patients with bladder tumours were examined with a 1.5 t scanner, using a t2-weighted 3d-tse-sequence (tr = 2911 ms, te = 500 ms) with a voxel size of 1.1 × 1.0 × 1.5 mm 3 . in 10 patients the new "sensitivity-encoding"-technique (sense) was used, which allows a higher spatial resolution without increasing scanning time. the bladder-wall was divided into 6 re-gions, which were analysed separately for the presence of tumours by 3 radiologists without knowledge of the tumour location. findings of conventional cystoscopy and operation served as standard of reference. results: 39 of 43 tumours were detected by virtual cystoscopy with 6 false positive results, resulting in an overall sensitivity of 90 % and a specificity of 95 %. all tumours larger than 1 cm (21/21, sensitivity 100 %) and 17 of 22 tumours smaller than 1 cm (sensitivity 79 %) were detected. the tumours missed had a size of 5 mm or smaller. on the average, the time needed for virtual-endoscopic reconstruction was 15 minutes. with the new sense-technique, spatial resolution could be improved without increasing scan-time. limitations of virtual cystoscopy are the detection of flat lesions and the differentiation between neoplastic and inflammatory lesions. conclusion: virtual cystoscopy is a promising, completely non-invasive tool for the diagnosis and follow-up of bladder tumours. by using the new sense-technique, the spatial resolution can be further improved. mr virtual cystoscopy detection and staging of bladder lesions before performing conventional cystoscopy v. panebianco, r. iannaccone, i. sansoni, a. laghi, c. catalano, m. ciccariello, p. paolantonio, r. passariello; rome/it purpose: to identify and to stage bladder lesions with mr-cystoscopy combining axial and virtual images. methods and materials: 31 patients with suspected or known diagnosis of bladder tumour underwent mr cystoscopy. we used natural contrast (urine) for bladder distention, monitoring bladder filling with 3dflash sequence with i.v. c.m. (optimal results after 20 min). mri examinations were performed on a 1.5 t siemens vision plus mr imager. we obtained a 2d fse sequence on axial planes. for evaluation of bladder wall, we performed a t1 weighted gre sequence, with and without fat suppression, pre and post gd-dtpa (0.0025 mmol/kg) i.v. injection. a 3dspgre sequence was obtained for monitoring bladder filling and for virtual endoscopy analysis, prior to furosemide (1 cm 3 ) administration. real time endoscopic views were reconstructed using volume-rendering reconstrution algorithm (vitrea 2.2, vital images). results: image quality was considered optimal in all cases. a total of 24 lesions were detected and confirmed at biopsy. in 4 cases no lesions were evident at mri and at conventional cystoscopy. all lesions were evident on morphological t1 and t2 weighted images, with size ranging of 4 -20 mm. mr virtual cystocopy allowed detection of the same lesions than conventional cystoscopy, providing comparable images. however, endoscopic images did not show intramural and extravescical extension of the tumour, whereas these findings were easily appreciated on morphological t1 and t2 weighted images. conclusions: mr virtual cystoscopy optimises detection and staging of the bladder pathology by combining axial t1 and t2 weighted and ve images. three-dimensional visualization of pelvic lymph nodes in staging and treatment of urinary bladder cancer using high-resolution mri a. welmers 1 , b. schrier 1 , h. huisman 1 , j.r. fielding 2 , l. o'donnell 2 , w.m.l.l. deserno 1 , r. kikinis 2 , j.g. blickman 1 , j.o. barentsz 1 ; 1 nijmegen/nl, 2 boston, ma/us purpose: in this study we evaluated the possibilities of 3d modeling in lymph node visualization for surgical guidance during lymph node dissection (lnd) in bladder cancer using high resolution mr data. methods and materials: mri was performed on a 1.5 t mri using the 3d t1-w mp-rage sequence (tr 11.4, te 4.4, 1.4 mm isometric voxel-size) with a pelvic phased-array coil. an iv uspio contrast agent was used to enhance the visibility of the lymph nodes. bladder, iliac vessels, ureters, obturatory nerves and lymph nodes were manually segmented from the mr data, using the software "3d-slicer". from these segmentations 3d models were created. in total 25 patients with histology proven urinary bladder cancer were evaluated. in all cases lnd was performed. five patients had enlarged metastatic lymph nodes, which were all segmented. during lnd the 3d models were used as a guiding tool for removing lymph nodes. results: in all patients a 3d model was created successfully, showing iliac vessels, ureters, obturatory nerves and lymph nodes. the 3d models allowed accurate localization of normal and metastatic nodes in relation to the surrounding structures, which enabled the surgeons to find and remove more lymph nodes than without this technique. conclusions: this technique simplifies visualization of lymph nodes. this increases urologist awareness of the exact location of lymph nodes, which results in a higher yield of nodes at node dissection. long fov whole body 3d mri using continuous table motion s.j. riederer, d.g. kruger, p.j. rossman, r.c. grimm; rochester, mn/us purpose: current methods for imaging an extended longitudinal field of view (fov) in mri either use multiple fixed stations or rapid 2d axial imaging similar to single slice, helical ct. the purpose of this work was to develop a method for 3d mr imaging of an arbitrarily long fov using continuous table motion. methods and materials: a method was developed in which data are collected as the table is moved continuously through the mr scanner gantry. after fourier transformation along the readout direction, every echo is assigned to hybrid (x, ky, kz) space, with longitudinal (x) location determined by table position at the time of the echo. as the table moves, all desired phase encodings are measured periodically. the method was tested in phantom, animal, and human studies. table velocity ranged from 0.8 to 3.0 cm/s. the longitudinal fov for readout ranged from 15 to 30 cm, and the total fov was as large as 170 cm. results: complete 3d image sets were formed of objects up to ten times longer than the fov of the acquisition. correction for position at sub-pixel precision is critical to suppress ghosting artifacts. contrast-enhanced studies in pigs demonstrate the ability to follow the contrast bolus in peripheral runoff studies. results in humans suggest the feasibility of whole body imaging. conclusions: 3d mr acquisition during continuous table motion has been demonstrated. it offers potentially reduced acquisition time vs. fixed station 3d methods and improved snr vs. rapid serial 2d axial acquisition. spatial resolution in t1-weighted conventional se and tse sequences: phantom measurements and in vivo results c. fellner, f.a. fellner, j.-c. georgi, w.a. kalender; erlangen/de purpose: assessment of spatial resolution in t1-weighted tse sequences with different echo train lengths (etls) compared with an se sequence using phantom measurements and examination of healthy volunteers. materials and methods: t1-weighted tse sequences with different etls (3, 5, 9) and an se sequence with identical pixel size (0.8 mm) were evaluated with a custom-built resolution phantom offering resolution patterns from 0.1 mm to 1.5 mm in steps of 0.1 mm and in 25 healthy volunteers focusing on the cranial nerves. the resolution in the phantom images was assessed visually, and the standard deviation in an roi containing the 0.8 mm stack was evaluated. image quality and delineation of cranial nerves (ii, iii, v) of the in vivo measurements were assessed by an experienced radiologist blinded to the sequence technique. statistical evaluation of the visual evaluation was done using wilcoxon's test (p < 0.05). results: the visual evaluation of phantom images yielded identical results for the se and the tse sequences with short etls (3, 5); for an etl of 9 the spatial resolution was deteriorated. the quantitative evaluation, however, showed a continuous decrease of the standard deviation with increasing etl. image quality of in vivo images and delineation of cranial nerves was significantly superior in se images compared with tse images -even if a very short etl was applied. conclusion: qualitative as well as quantitative evaluation of spatial resolution and anatomical details correspondingly revealed disadvantageous results for t1weighted tse sequences with increasing etl. this result was even more pronounced in the in vivo examinations. deep brain stimulation during interventional mri: safety issues r. girnus, v. hesselmann, k. luyken, b. krug, g. nimtz, k. lackner; cologne/de purpose: to investigate safety aspects of linear conductive devices in interventional mri. materials and methods: the temperatures occuring in long wires placed in a 1.5 t mri (philips, gyroscan intera) were measured. the temperature increases (δt) at the tip of the electrode were determined using a mr-compatible opticalfiber-temperature system. the end of the wire was surrounded by 3 cm 2 of a 0.9% nacl solution. the length and the position of the wire were tested as parameters influencing the hf-induced increases in temperature. furthermore the influence of the sequence was taken into account. result: the temperature increase of the wire aligned parallel to the z-direction and symmetric to the isocentrum showed a significant dependence on the length. a resonance length of about 2 m could be observed, with a ät of 30°c at the tip located in the saline solution during a tse-sequence (sar = 3.9 w/kg). by moving the wire out of the isocentrum in x or y direction, the heating effect exceeded 100°c at the electrode tip. the ät fell below 2°c, if the wire length was different c d e f 272 from 2 m, the part of the wire inside the scanner bore was minimized and the wire was located in the center of the bore parallel to the z-direction. in general the ät can be reduced by applying gradient echo sequences with low flipangels. conclusion: under controlled conditions mentioned above it seems feasible to put a wire or stimulation electrode into an mr without risk of burning. liver iron overload: comparison of two methods in measuring liver r2* values. correlation with serum ferritin concetration (sfc) and liver iron concentration (lic) t.g. maris 1 , o. papakonstantinou 1 , e. chryssou 1 , v. ladis 2 , s. kostaridou 2 , n. papanikolaou 1 , p.k. prassopoulos 1 , n. gourtsoyiannis 1 ; 1 iraklion/gr, 2 athens/gr purpose: to compare liver r2* (r2* = 1/t2*) values obtained by means of quantitative mri (r2*-qmri) using two regression analysis models and correlate them with lic and sfc. materials and methods: liver r2* values were calculated in 10 thalassaemic patients, and 10 normal subjects on an 1.5 t mri system using a breathhold multislice-double-echo spoiled gre sequence with initial parameters: tr/te1/te2 160/ 2.7/5.3 ms. the sequence was repeated four times, each time altering inter-echo time spacing. t2* calculated image maps were post-proccessingly reconstructed using four different fitting methods (a, b, c, d) . methods (a) and (b) were based on a simple linear regression model applied to image pixel data. methods (c) and (d) were based on a weighted linear regression model on which pixel data were weighted according to background image random noise figures. results: differences of mean r2* values between patients and normal subjects were considered extremely significant (t = 19.25, p < 0.0001). r2* values correlated much closer with lic levels (r = 0.89, p < 0.005) when using weighted linear regression models (c) and (d) than when using normal regression ones (a) and (b) (r = 0.85, p < 0.005). r2* were moderately correlated to sfc values regardless the use of the regression model (r = 0.6, p < 0.05). r2* values were linearly correlated with lic [r2 × (s −1 ) = 4.94 + 93.94 lic (mg/g) −1 , r = 0.89, p < 0.005] conclusion: r2* when calculated using weighted regression methods on 1.5 t systems seem to be a valuable means for the evaluation of liver iron overload when lic does not exceed 8 mg/g (liver dry weight). improved mri-monitoring during rf-hyperthermia h. reinl 1 , m. peller 1 , m. hagmann 2 , r. issels 1 , m.f. reiser 1 ; 1 munich/de, 2 salt lake city, ut/us purpose: in a mri-hyperthermia hybrid-system t1 relaxation-time changes are investigated for monitoring hyperthermia of deeply seated tumors. a water-bolus is needed for power transmission into the patient body. the signal of this bolus limits image quality by signal compression and artifacts. this can be avoided by using d2o which would result in additional technical effort and high costs. the purpose of our study is to improve image quality, spatial and temporal resolution by using a paramagnetic suspension of magnetite instead. material and methods: all experiments were done on the hybrid-system which consists of a 0.2 t open mr-system and a hyperthermia system with a mr-compatible phased array applicator and an integrated mr receive-coil. the tested paramagnetic suspension was a commercially available ferrofluid (msg w11, ferrofluidics corp.), normally used for material separation. a polyamidacryl gelphantom mimicking the human body was used for heating experiments. results: we found ferrofluid in a low concentration as a useful substitute. in the 0.2 t system a concentration of 0.25 % showed optimum results. below 0.2 % the bolus is still slightly visible and above 0.3 % the mr system is no longer tuneable. no artifacts are induced in this concentration-range. conclusion: by using the new bolus-filling an extinction of the bolus artifacts and a significant improvement in snr, spatial and temporal resolution are possible. this method of signal extinction in mri may be adapted to other experimental demands where mr-invisible fluids are necessary. stereological estimations of liver volume from mr images m. mazonakis, j. damilakis, t.g. maris, p.k. prassopoulos, n. gourtsoyiannis; iraklion/gr purpose: to investigate the possibility of generating stereological estimations of liver volume from magnetic resonance (mr) images. methods and materials: 38 consecutive patients underwent 1.5 t abdominal mr imaging. two radiologists evaluated the mr images and found that the liver size appeared normal in 27 and increased in 11 cases. liver volume was estimated using the cavalieri method of modern design stereology in combination with point counting. the effect of the separation distance between test points of the grid in the efficiency of stereological estimations was examined. a systematic sampling of mr sections was performed to find the minimum number of sections needed to provide acceptable volume estimations. results: for both subgroups of patients with normal and increased liver size, it was found that 100 -150 test points counted on 7 -8 systematically sampled mr sections may provide reliable liver volume estimations with a coefficient of error (ce) of less than 5 %. the mean time required for the stereological measurements was approximately 10 min. the mean liver volume for the patients with normal and increased liver size was found to be 1477.7 ± 230.7 and 1944.7 ± 196.1 cm 3 , respectively. the proposed volumetric technique may provide efficient liver volume estimations from mr images in patients presenting both normal and increased liver size. improvement of diagnostic accuracy of pet imaging using a high performance in-line pet-ct system: preliminary results t.f. hany, h.c. steinert, g.w. goerres, a. buck, g.k. von schulthess; zürich/ch purpose: we describe the first application and optimisation of a novel in-line system combining a high performance clinical positron emission tomograph (pet) scanner and a fast multi-slice helical computer tomograph (ct) scanner in a single machine (pet-ct) for tumour staging. methods: we examined 53 patients with diagnosed or highly suspected malignancy. non-contrast-enhanced ct data with 4 different tube currents (10, 40, 80 and 120 ma) were acquired, followed by pet acquisition. step-wise image analysis was performed using pet images alone compared to co-registered pet-ct with increasing ct energies (pet-ct10, … pet-ct120). clinical or pathological staging was used as standard of reference for lesion-by-lesion as well as on patient based analysis. results: the following accuracy ratios for classifying tumour lesions were calculated: pet alone 91 %, pet-ct10 97 %, pet-ct40 97 %, pet-ct80 98 %, pet-ct120 98 % and a significant difference was found between pet alone and co-registered images (chi square p < 0.01). conclusion: pet-ct fusion in a combined scanner using non-enhanced lowdose ct with 80 ma is significantly increasing diagnostic accuracy regarding lesion classification, and by using the ct scan for transmission correction will reduce the acquisition time by 30 % when compared to pet imaging alone. transmission scanning for attenuation correction in cardiac spect studies: patient effective dose and radiogenic risk k. perisinakis, j. damilakis, n. gourtsoyiannis; iraklion/gr purpose: to determine patient effective dose and associated radiogenic risk from the transmission scanning performed during cardiac spect myocardial perfusion studies to correct scintigraphic images for attenuation and scatter effects. materials and methods: transmission scans were obtained using an optima nx ge system, which involved an l-shaped dual headed gamma camera equipped with transmission scan hardware. two flat scan boxes each containing a collimated rod source of gadolinium 153 were mounted on the gantry opposite each detector. a rando anthropomorphic phantom was used to determine radiation dose from transmission scanning in 14 organs and tissues using 352 thermoluminescent dosemeters. for each projection the resulting effective dose was calculated using the icrp 60 tissue weighting factors. radiation risk was determined using age and sex related radiation induced fatal cancer risk factors. results: the effective dose corresponding to a typical 5 s acquisition per transmission scan was 620 psv. the organs receiving the highest amount of radiation dose is the lung and the oesophagus. the average lifetime risk for fatal malignancy is 4.9 × 10 −8 for us and 3.9 × 10 −8 for uk population. conclusion: present data allow the accurate estimation of patient effective dose and associated radiation detriment risk from myocardial perfusion spect studies. purpose: assessment of three different rectal agents (water, ultrasound gel and methylcellulose) for their suitability for colorectal imaging in multislice ct material and methods: 115 patients with colorectal diseases underwent msct with varying rectal contrast agents in a prospective study. images were assessed by two independent ct-experienced radiologists. ct scans were analyzed for the following criteria: contrast of wall versus lumen (w/l), contrast of pathological wall versus lumen (p/l), distension of anal verge, distension of colon and artefacts (ar). a rating scale of 1 (no) to 5 (severe) was used. interobserver variability was assessed by kappa statistics. results: mean rating values of methylcellulose were higher in contrast of wall/ lumen (4.66 ± 0.6), pathological wall/lumen (4.73 ± 0.5) and least rate of artefacts (4.13 ± 0.7) than of water (w/l 4.36 ± 0.8; p/l 4.36 ± 0.7; ar 3.76 ± 0.9) and ultrasound gel (w/l 2.4 ± 0.96; p/l 2.55 ± 1.01; ar 1.76 ± 0.9). the distension of the anal verge was better in using ultrasound gel (4.5 ± 0.6) and methylcellulose (4.35 ± 0.7) than in water (2.82 ± 1.1). with water the best distension of colon (4.1 ± 1.1) could be obtained, it was nearly equal to methylcellulose (3.82 ± 0.8), but remarkable superior to ultrasound gel (1.5 ± 0.6). air artefacts only appeared in ultrasoundgel. an excellent interobserver correlation was found for the contrast of pathological wall versus lumen of methylcellulose (k = 0.81). a high rate of agreement between the criteria of both radilogists in final diagnosis could be achieved. conclusion: rectal filling with methylcellulose significantly improves diagnostic confidence in colorectal examinations. ease of application and lack of use suggest to use as a clinical routine. ct differentiation of colorectal mucinous and nonmucinous carcinoma e. ko, h. ha; seoul/kr purpose: to evaluate the ct findings which can help differentiate mucinous from nonmucinous colorectal carcinoma. ct scans of 86 patients with pathologically proven mucinous colorectal carcinoma during a 10-year period, were analyzed. as a control group, 105 consecutive patients with pathologically proven nonmucinous colorectal carcinoma in a 3-month period were included. retrospective review of ct was performed by two radiologists in consensus who were blind to the pathologic results. ct scans were analysed with regard to the site and length of involved segment and types of morphological features, bowel wall thickening and contrast enhancement patterns, degree of contrast enhancement in solid portion of the tumor. also evaluated were the presence of calcification, obstruction, lymphadenophathy, pericolic infiltration, local tumor extension, and distant metastasis. in heterogeneous masses, the extent of hypoattenuated areas within tumor was graded into three. statistical analyses were performed by using student t-test and pearson's ÷ 2 -test. results: as compared with nonmucinous carcinoma, mucinous carcinoma showed more severe (p = 0.026) and more eccentric (p = 0.025) bowel wall thickening. heterogeneous contrast enhancement was more common in mucinous carcinoma (p < 0.001). significant difference was noted in the extent of hypoattenuated areas within tumor (p < 0.001). the solid portion of mucinous carcinoma showed hypoattenuation while nonmucinous carcinoma showed hyperattenuation (p = 0.001). although statistical values were not obtained, the presence of intratumoral calcification was more frequent in mucinous carcinoma (21 % vs 5). conclusion: ct is very useful in the differentiation of mucinous from nonmucinous colonic adenocarcinoma. usefulness of the hydrogen peroxide enhancement in the diagnosis of the anal and ano-vaginal fistulas i. sudol-szopinska, w. jakubowski, m. szczepkowski, d. sarti; warsaw/pl purpose of the study was to assess the usefulness of contrast-enhanced anal endosonography (aes) with hydrogen peroxide in the diagnosis of the anal fistulas. method and material: a bruel & kjaer scanner with a 7.0 mhz transducer was used. after visualization of the fistula tract in non-contrast aes, hydrogen peroxide was introduced into the fistula tract through the external opening in 22 patients with different types of anal fistulas. results: both contrast-and non-contrast aes revealed 13 transsphincteric, 3 intersphincteric, 2 suprasphincteric and 4 ano-vaginal fistulas. simple tracts were found in 16 cases and complex in 6 cases in non-contrast aes. contrast-enhanced aes revealed 19 simple and 3 complex fistulas. 15 internal openings visible in non-contrast aes were confirmed in contrast-enhanced aes in 6 cases, which additionally found 11 more internal openings. in all cases, surgery confirmed the diagnoses of the contrast-enhanced aes. conclusion: contrast-enhanced aes appears to be superior to non-contrast aes in preoperative assessment of the anal and ano-vaginal fistulas and in locating of the internal openings. contrast-enhanced multislice ct colonography in the diagnosis and staging of colorectal cancer i. carbone, a. laghi, r. iannaccone, i. baeli, r. ferrari, f. mangiapane, f. iafrate, c. catalano, r. passariello; rome/it purpose: to evaluate the role of ct colonography (ctc) in patients with suspected colorectal cancer. methods and materials: forty-eight patients (21 females and 27 males; age range 41 -78) underwent conventional colonoscopy (cc) and ctc for suspected colorectal mass. multislice spiral ct (somatom plus 4 volume zoom, siemens, germany) examination of the abdomen and pelvis was performed after routine bowel preparation and colonic distention with room air. patients were scanned in prone and supine positions using the following parameters: slice collimation, 2.5 mm; slice thickness, 3.0 mm; reconstruction interval, 1 mm; mas, 80 (prone) and 120 (supine). 130 ml of contrast medium were administered i.v. during the supine acquisition with a 60 s delay time. images were subsequently downloaded and analysed on a dedicated workstation. surgical specimens were used as the standard of reference against which the findings of cc and ctc were compared. results: cc failed to visualize the entire colon in 27 patients due to occlusive neoplasms. ctc allowed whole-colon evaluation in all the cases and correctly detected and staged 43 out of 48 colorectal cancers. ten synchronous colonic lesions (8 adenomatous polyps, 2 carcinomas) were identified in 10 different patients at ctc. liver metastases were detected in 10 patients. conclusion: contrast-enhanced multislice ctc is a valuable tool for the preoperative staging of crc. this imaging modality is very useful for presurgical planning due to whole-colon evaluation even in the presence of stenosing lesions, as well as optimal assessment of bowel wall invasion, lymphoadenopathies, and hepatic parenchyma. detection of colorectal lesions with ct colonography: comparison with conventional colonoscopy in 165 patients i. carbone, a. laghi, r. iannaccone, i. baeli, r. ferrari, s. trenna, c. catalano, r. passariello; rome/it purpose: to compare the performance of ct colonography with that of conventional colonoscopy (cc) in a blinded, prospective study in 165 patients with suspected colorectal lesions. methods: 165 patients, all referred for cc, underwent preliminary ct colonography. after standard oral colonoscopy preparation and colonic distension with room air, ct colonography was performed either with a single-slice (somatom plus 4; siemens, erlangen, germany) or multislice (somatom plus 4 volume zoom, siemens, germany) scanner. imaging parameters for the single-slice scanner were: 3.0 mm slice collimation; 6.0 mm/s table speed; 0.75 s tube rotation; 2.0 mm reconstruction interval; 512 × 512 matrix; 120 mas; 130 kvp; and scan time 35 -47 s. imaging parameters for the multislice scanner were: 1.0 mm slice collimation; 8.0 mm/s table speed; 0.5 s tube rotation; 1.0 mm reconstruction interval; 80 mas; 120 kvp; and scan time 25 -32 s. ct images of all suspected lesions were analyzed on a workstation and subsequently compared to cc findings. results: there were 30 colorectal cancers and 37 polyps identified at cc. ct colonography correctly detected all cancers, as well as 11 of 12 polyps of 10 mm in diameter or larger (sensitivity, 92 %); 14 of 17 polyps between 6 and 9 mm (sensitivity, 82 %); and 4 of 8 polyps of 5 mm or smaller (sensitivity, 50 %). the per-patient sensitivity and specificity were 92 % and 97 %, respectively. conclusion: ct colonography has a diagnostic sensitivity similar to that of cc for the detection of colorectal lesions larger than 6 mm in diameter. colorectal polyps: improvement of detection with multi-slice ct colonoscopy j. wessling, r. fischbach, d. domagk, e. neumann, s. schierhorn, w.l. heindel; münster/de purpose: to compare the performance of virtual and conventional colonoscopy for the detection of colorectal polyps using a multi-slice spiral ct scanner (msct). material and methods: 48 patients (20 women, 28 men, mean age 61.5 years) with clinical indication for conventional colonoscopy were prospectively studied using a msct (somatom volume zoom, siemens, forchheim). examination was performed after standard oral colonoscopy preparation and colonic distension with room air and i.v. buscopan. images were obtained in prone and supine position using a detector configuration of 4 × 1 mm, a feed of 5 mm/rotation at 140 mas and 120 kv. slice thickness and reconstruction increment were 3 and 1.5 mm, respectively. ct data were assessed by 2 blinded radiologists on a vitrea workstation (vital images, usa) using a software with multiplanar and volume-rendering capabilities. results: 33 patients had normal findings on conventional colonoscopy. a total of 30 polyps and 2 carcinoma were identified in 15 patients. msct-colonoscopy detected all carcinomas and 23 polyps (77 %). 3 of 3 polyps were 10 mm or more (100 %), 6 of 7 polyps were 6 to 9 mm (86 %) and 14 of 20 were smaller 6 mm (70 %). there were 13 false positive findings for polyps (10 were smaller 6 mm) and no false positive finding of cancer. conclusions: compared to single-slice-ct, multi-slice ct colonoscopy increases the rate of detection of small colorectal polyps in particular. however, false positve results still remain a problem. does contrast enhancement contribute to ct colography? a.r. gillams, v. munikrishnan, w.r. lees; london/gb purpose: controversy persists over the usefulness of iv contrast in ct colography. enhancement in small lesions should facilitate detection particularly when there is adjacent fluid. we measured the attenuation values of polyps and cancers both before and after iv contrast. materials and methods: forty-nine patients, 32 male, mean age 57 (42 -80) were studied. all patients had routine bowel preparation, iv smooth muscle relaxant and rectal air insufflation. supine and prone imaging was performed using a multi-slice ct, collimation 1 mm, effective slice width 1.25 mm and pitch 1.2. the second acquisition was performed 30 s after pump injection of 100 -150 ml of iv contrast injected at 5 ml/s. all lesions were confirmed on colonoscopy. the attenuation values of polyps and cancers were measured both before and after iv contrast. results: eighteen cancers were detected and 28 polyps. mean polyp size was 12 mm (3 -25 mm). both cancers and polyps demonstrated enhancement following iv contrast enhancement but was more marked in polyps. the mean attenuation value in the cancers prior to contrast was 53 ± 16 and following contrast 105 ± 26. the mean attenuation value in the polyps prior to contrast was 62 ± 11 and following contrast was 113 ± 26. the mean increase for cancers was 39 and for polyps 51. conclusion: contrast enhancement is seen in both polyps and cancers but is more marked in polyps. enhancement could be used where there is diagnostic doubt on the pre-contrast imaging. colour doppler visualization of hemorrhoidary arteries during transrectal us a. sias, v. alvino, f. lecca, g. mallarini; cagliari/it purpose: the scope of this work is to evaluate the usefulness of color doppler transrectal us in the visualization of hemorrhoidal artery in patients undergoing non invasive surgery for hemorrhoids. material and methods: we have examined 25 patients undergoing doppler-guided hemorrhoidal artery ligation for the treatment of hemorrhoids with modified morinaga technique. discussion: new surgical less-invasive techniques of treatment of hemorrhoids are being developed. one of this techniques involves the use of a modified proctoscope for artery ligation. colour doppler during transrectal us was used to evaluate the position of terminal arteries originating from the superior rectal artery. we were able to confirm the arrangement of these terminal arteries at 1, 3, 5, 7, 9, 11 as seen in the lithotomy position. this was noted first by meintjes in 2000. conclusion: colour doppler transrectal us allowed a clear visualization of hemorrhoidal arteries in the fixed position described by meintjes. our study was the first to show the reliability of this classification. although useful, well tolerated, quick and easy to perform, we do not recommend routine use of colour doppler transrectal us in all patients undergoing treatment for hemorrhoids with modified morinaha technique. this examination can be useful in those with recurrent secondary hemorrhage, as it can help avoiding further bleeding problems. results: volunteers: using the corrections the mean difference between the volume of the 3 he-mri and the pft measured -74 ml (r = 0.9). patients: after the corrections the mean difference measured 616 ml (r = 0.96). functioning lung grafts contributed 66 ± 6 %, their corresponding native ipf lungs 34 ± 6 % to total ventilated volume. conclusion: 3 he-mri of the lung offers a new approach to regional determination of ventilated lung volume. the volunteers show good correlation and high consistence of the absolute values between 3 he-mri and pft. the patients with sltx show good correlation and the possibility to measure the individual contribution of the graft in comparison to the native lung. he-mri (300 ml hyperpolarized 3 he gas; flash 2d, tr/te 11/4.2 ms, fa < 10°, slice thickness 10 mm, pixel size 4.2 × 2.7 mm, coronal) were performed. hrct was evaluated for 3 main lesions: airway disease (bronchial wall thickening, air trapping), emphysema, and fibrosis. 3 he mri was assessed for three main ventilation defects. functional compromise was scored on a 4-point scale independently for hrct and 3 he-mri by two readers and compared to forced expiratory volume in 1 s (fev1) and residual volume (rv). results: 63 ventilation defects were depicted in total: 70 % in both, 18 % only on 3 he-mri and 12 % only on hrct. mean hrct score was 2.7, mean 3 he-mri score 2.5, mean fev1 was 60 %. there was no relevant correlation between hrct and fev1 (r = 0.3), but between 3 he-mri and fev1 (r = 0.7), exhibiting significant differences between scores 2 and 3 (p < 0.05) as well as 3 and 4 (p < 0.05). there was no relevant correlation between hrct and rv (r = 0.1), but for 3 he-mri (r = 0.6). conclusion: in comparison to paired in-and expiratory hrct, 3 he-mri has a higher sensitivity in the detection of ventilation defects and correlates better with lft. thus, functional information is predicted better using 3 he-mri. no single lung function test index correlates well with the severity of emphysema. the aim was to develop a composite pulmonary function score that best reflects the ct quantification of emphysema. material and methods: the hrct scans of 97 cases of emphysema were scored objectively using a density mask. the following standard pulmonary function tests (pft): dlco, kco, fev1, total lung capacity (tlc), residual volume (rv) were recorded. stepwise regression was used to identify the combination of pfts that best fitted the hrct score results: significant negative correlations were found between the hrct emphysema scores and dlco, kco and fev1 (r 2 = 0.39, r 2 = 0.36 and r 2 = 0.42 respectively) and positive correlations with tlc and rv (r 2 = 0.29 and r 2 = 0.37 respectively). a composite score representing the best fit combination of pfts against the ct emphysema score was: 24. purpose: this study evaluated the relationships between high resolution computed tomography (hrct) morphologic quantification of bronchiectasis and clinical and lung function parameters. materials and methods: 60 chinese with steady state bronchiectasis underwent thoracic hrct scan and full lung function tests. exacerbation frequency/year and 24 h sputum volume were determined. extent of bronchiectasis, bronchial wall thickening, and presence of small airway abnormalities and mosaic attenuation were evaluated in each lobe, including lingula. relationships between lung function, sputum volume, clinical exacerbation and hrct parameters were analysed. results: exacerbation frequency was associated with bronchial wall thickening (r = 0.32, p = 0.03); 24 h sputum volume with bronchial wall thickening, small airway abnormalities (r = 0.30, 0.39, p < 0.05), and fev11, fev1/fvc and fef25 -75(r = -0.33, -0.29, -0.32; p < 0.05). extent of bronchiectasis, bronchial wall thickening and mosaic attenuation were respectively related to fev11 (r = -0.43 to -0.60 p < 0.001), fef25 -75(r = -0.38 to -0.57; p < 0.001), fvc (r = -0.36 to -0.46, p < 0.01), and fev11/fvc (r = -0.31 to -0.49, p < 0.01). after multiple regression bronchial wall thickening remained a significant determinant of airflow obstruction, while small airway abnormalities remained associated with 24 h sputum volume. women in general had milder disease than men, but showed more hrct-functional correlations. conclusion: this study has established a link between morphologic hcrt parameters and clinical activity, and emphasised the role of bwt in bronchiectasis. there are gender differences in bronchiectasis with respect to disease severity and sensitivity to hrct evaluation. morphology and lung function in healthy smoking and non-smoking men: a 5-year follow-up study j.d. vikgren, m. boijsen, b. bake, u. tylén; gothenburg/se purpose: there is demand for a reliable method for early detection of smoking induced disease. healthy smokers can present with or without normal lung function. having abnormal lung function, the smokers present with airway obstruction and/or emphysema. a possible way to elucidate early smoking induced changes, bronchiolitis, could be analysis of e/i quotient. material and methods: our study was a follow-up study. subjects were recruited from the randomised epidemiological study "men born 1933 in göteborg". hrct and lung function tests were performed with a five-year interval. smokers were subdivided according to presence of emphysema or not at the beginning of the study. computer calculation of e/i quotient was performed, i.e. quotient between cross-sectional area and mean attenuation values in inspiration and expiration. visual quantitation of emphysema and air trapping was evaluated by consensus. results: at follow-up there was a significant increase of the e/i quotient for mean attenuation for smokers with and without emphysema, but also for non-smokers. e/i quotient for cross-sectional area showed a significant decrease at follow-up c d e f 276 only for smokers without emphysema. there was a significant progression in emphysema for smokers. analysis of the relation to lung function parameters as fev 1.0, fvc, co-uptake and n2-test are in progress. conclusion: there is a progress of emphysema with continued smoking. an increased e/i quotient has been interpreted as obstruction, but the fact that the e/i quotient increases in smokers as well as non-smokers requires further analysis. mediastinal lymphadenopathy in left heart failure: correlation of ct abnormalities with clinical and echocardiographic findings v. chabbert 1 , g. canevet 1 , g. philippe 1 , p. otal 1 , v. delannoy 2 , f.g. joffre 1 , m. rémy-jardin 1 ; 1 toulouse/fr, 2 lille/fr purpose: to evaluate the frequency of mediastinal lymphadenopathy due to left heart failure on computed tomography (ct) scans in correlation with clinical and echocardiographic findings. materials and methods: 31 consecutive patients (mean age, 69 years) with left heart failure in a subacute phase were included in a prospective study between september 2000 and august 2001. ct examinations (hrct and spiral ct scans) and transthoracic echocardiography were performed within 24 hours after presentation. ct follow-up were obtained within 8 days after initiation of medical treatment. results: at presentation, dyspnea was graded as type iv (39 %), iii (39 %), ii (19 %) and i (3 %). mean ejection fraction was 39 %. enlarged mediastinal lymph nodes were seen in 42 % of cases, heterogeneous in 23 %, with a hazy perilymphadenopathy fat in 38.5 % of cases. all patients had pleuroparenchymal abnormalities due to left heart failure. peribronchovascular thickening, septal thickening, fissures thickening, ground-glass attenuation, condensations, micronodules and pleural effusions were present respectively in 20 %, 71 %, 71 %, 74 %, 16 %, 16 % and 74 % of cases. after treatment, dyspnea was graded as type iii (16 %), ii (61 %) and i (23 %). lymphadenopathy decreased in size in 38.5 %, was stable in 38.5 %, disappeared in 23 %, and weas heterogeneous in 20 %, fat abnormalities disappeared in all cases. pleuroparenchymal abnormalities decreased in 74 %, disappeared in 19.5 % and were stable in 6.5 %. we examined 23 consecutive patients (138 lung lobes) referred for the assessment of possible airways disease using multislice ct. the thorax was scanned contiguously at 1 mm slice thickness and this was reconstructed at 1 mm slice thickness (lung windows utilising high spatial frequency algorithm) in the axial (10 mm apart), sagittal (4 per lung) and coronal (6) plane. pedal wheel reconstructions were also performed. axial images were assessed by 2 chest radiologists with and without the help of mpr at two separate occasions. the presence of bronchiectasis, emphysema and bronchiolitis in each lobe was documented on a confidence scale of 0 -3 (0 no disease, 3 definite disease). result: there was no significant difference (p = 0.280) in the mean confidence in the diagnosis of airways disease with the help of mpr [observer a (1.98 axial, 2.01 mpr); observer b (2.88 axial, 2.71 mpr)]. in addition, weighted kappa showed no improvement in inter-observer agreement (kappa = 0.566 for axial; kappa = 0.530 for mpr). isolated cases wherein mpr was beneficial were noted, particularly in patients with bronchiectasis (3 patients). due to the small number, this did not reach statistical significance. conclusion: our results did not demonstrate a significant increase in confidence in the diagnosis of airways disease. mpr was beneficial in a few selected cases of bronchiectasis. methods and materials: 40 consecutive patients were randomized into 2 groups of 20 patients each. group 1 underwent ssct with a standard protocol for the study of the airways and group 2 underwent msct with the following protocol: 4 × 1 mm slice collimation, pitch 7 (1.75 m), 1 mm slice width, 0.8 mm reconstruction increment. two radiologists evaluated by consensus the axial images and vb reconstructions in order to assess the degree of visualization of the bronchial tree according to a three point scale (grade 0, 1 and 2). results: on axial images, msct yielded better results in the evaluation of the segmental bronchi of the middle lobe (32 bronchi rated as grade 2 by msct vs 16 by ssct; p < 0.05), of the anterior segmental bronchus of the left upper lobe (19 rated as grade 2 by msct vs 10 by ssct; p < 0.05) and of inferior segmental bronchus of the lingula (18 rated as grade 2 by msct vs 8 by ssct; p < 0.05). evaluation of lobar and segmental bronchi was always possible when vb was obtained from msct data sets whereas 53/280 bronchi were scored 0 when vb was obtained from ssct. subsegmental bronchi could be better evaluated with msct than ssct either on axial images or vb (p < 0.05). conclusion: msct with 1 mm collimation significantly improves the visualization of segmental and subsegmental bronchi and is particularly useful for oblique oriented bronchi. methods: over a one year period 96 patients had by pct. 10 patients were directly examined by pct on admission day on icu. for this purpose a special interventional suite was prepared directly on icu. in this suite radiological modalities like radiography, sonography and portable angiography can be performed under intensive care monitoring and therapy. ct examinations are even possible by using pct in this special suite. on day of admission patients underwent extensive evaluation using modalities of this special interventional suite. results: in two cases a bedside ct procedure was performed the others were performed in the intervention suite on icu. in 80 % of the cases a final diagnosis could be determined by ct examination. in 40 % ct findings led to follow up evaluations by pct. even 40 % of ct examinations led to direct therapeutic consequences such as surgical intervention. 60 % of the ct indications were assessed as necessary or essential by an experienced icu physician. half of the follow up examinations had also direct therapeutic consequences. monday b results: using the sense technique the temporal resolution and spatial coverage could be increased from 12 slices per 1.7 s up to 20 slices per 1.4 s. as a consequence of the increase in k-space velocity using sense the typical susceptibility artifacts of epi sequences at the skull base were almost negligible. the s/n is strongly influenced by the specific coil arrangement and the actual number of profiles in k-space. for the applied double loop coil and a sense factor of two the s/n equals that of the standard scan (head coil) in superficial temporal regions and is reduced by a factor of 0.65 to 0.8 in central and occipital regions. however, the increased temporal resolution compensated for the decrease in s/n and the calculated parameter maps were always of good diagnostic quality. with a dedicated coil the sense technique allows substantial improvement in perfusion imaging. diffusion weighted mr imaging in the early diagnosis of periventricular leukomalacia a. bozzao, f. garaci, s. marziali, r. floris, g. simonetti; rome/it -presented by f. fasoli; rome/it purpose: the use of mr diffusion weighted imaging in detecting hypoxic-ischemic encephalopathy (hie) in neonates is still controversial. moreover few reports concern pre-term infants with possible periventricular leukomalacia (pvl). we examined the ability of this technique to detect cerebral changes of acute pvl. methods: fifteen mr examinations were performed in eleven preterm infants. imaging comprised conventional and diffusion-weighted (dw) sequences. conventional, dw sequences and apparent diffusion coefficient (adc) maps as well as us obtained in the acute phase were compared. all the neonates underwent us follow-up 6 and 12 months after delivery, those with suspect pvl also underwent mri follow-up at two months and one year. qualitative and quantitative evaluations were performed to assess the presence of dwi changes compatible with pvl. results: dwi showed signal hyperintensity associated with decreased adc values in 3 subjects (27 %); in these patients conventional mri sequences were interpreted as normal and us (performed at the same time) as doubtful in 2 and compatible with pvl in one. mri and us follow-up confirmed severe damage in all these patients. in one neonate hemorrhages involving the germinative matrix were identified at mri and us without signs of pvl. follow-up mri and us confirmed the absence of pvl 3 months later. in eight neonates mri was considered normal. in these subjects us follow-up confirmed no signs of pvl. apart from the well known image artefacts time consuming reconstruction periods often inhibit continuing data acquisition, particularly if sequences are used with more than one acquisition or with built-in postprocessing capabilities to automatically generate adc-maps. by using these sequences as the last sequence in the whole examination prior to the start of the subsequent examination of the next patient this time delay can be reduced. the aim of this prospective study was to find out if there is any diagnostically significant difference between acquisition of epi-dwi images before and after intravenous application of gd-dtpa. in 203 patients a epi-dwi sequence was used (tr/te: 4000/100, 19 slices, 6 mm slice thickness, 230 fov) both as the first (before i.v. cm) and the last sequence after cm. the mr indications were ischemic stroke, encephalitis, multiple sclerosis and brain tumor with and without disturbed blood brain barrier. the mri images were rated by two blinded, neuroradiologically experienced radiologists. results: intravenous cm had no influence on the diagnostic information of the images. there were no significant signal differences even in lesions with pronounced disturbances of the blood brain barrier. conclusion: it is possible to use epi-dwi after cm application without loss of clinical information. the proposed approach allows to reduce examination times. brain perfusion studies with trans cranial colour doppler using ultrasound contrast media g. salvaggio, g. caruso, t.v. bartolotta, a. scisca, g. caputo, r. lagalla, a.e. cardinale; palermo/it purpose: to evaluate the intracranial micro circulation using trans-cranial color doppler (tccd) with a contrast medium (levovist). material and methods: 25 patients, (age range: 41 -73 years; mean age 64 years) affected by mellitus diabetes were selected. 20 healty volunteers (mean age: 63 years) acted as control. the examinations were performed using an atl hdi 5000 ultrasound unit provided with a phased array 3.25 mhz probe. mechanical index was calibrated to high value in order to obtain microbubbles rupture under ultrasound beam exposition. after positioning of an operator defined region of interest, intensity/time curves related to the parenchymal micro circulation were plotted, and the areas under the curves were calculated. results: in all controls, the areas under the curve showed a mean value greater than 0.05 that we considered as cut-off value of normal perfusion. on the other hand, the diabetic patients showed a lower mean value, to indicate a micro circulation disease. conclusion: thanks to software improvements and ever more effective algorithms, contrast-enhanced tccd is able to provide information on brain perfusion non invasively and at low cost. purpose: to present our initial clinical experience with a one-piece design 8-channel neuro-array coil for mri of the brain. methods and materials: mri examinations of the brain were performed in 5 normal volunteers using an 8-channel parallel acquisition technique (pat) optimized neuro-array head coil (mri devices corporation, wisconsin, usa), and a standard circularly-polarized (cp) volume head coil. examinations were performed on a 1.5 t superconducting magnet (sonata, siemens ag, germany). signal-to-noise ratios were calculated and compared for the two coils in various anatomical locations including peripheral (cortex, subcortical white matter, etc.) and central (e.g. corpus callosum, sella, brainstem, etc.) parts of the brain. results: the 8-channel neuro-array coil provided excellent high-resolution imaging with anatomical coverage of the entire head. in the peripheral portions of the brain, snr was 50 -100 % superior to that obtained with a standard cp volume head coil. in the deeper parts of the brain snr was at least equally good. the neuro-array coil is pat optimized and allows the use of sense/smash type sequences with flexible phase encoding. conclusion: the 8-channel neuro-array head coil provided excellent high-resolution mri of the entire brain. snr was markedly improved, especially in the peripheral parts of the brain. the pat optimized imaging capablities can be used to decrease imaging time, improve spatial resolution, or a combination of both. genetic approach to ct appearance of brain ischemic stroke l. cyrylowski, a. ciechanowicz, a. fabian, i. goracy; szczecin/pl purpose: there is evidence that an allelic variation in the angiotensin converting enzyme (ace) gene may confer an increased risk of cardiovascular disease. the aim of our study was to evaluate the relationship between the ace insertion/deletion (i/d) polymorphism and the prevalence of brain ischemic stroke as well as between the polymorphism and ct type of ischemic stroke. materials and methods: the ace i/d genotype was identified by polymerase chain reaction in 46 patients (26 males and 20 females) with brain ischemic stroke, and in 100 controls (50 males and 50 females). to assess the polymorphism frequencies, statistical analysis was performed. results: the d/d polymorphism frequency was significantly higher in the stroke group than in the controls (32.6 % vs. 13 %; p < 0.01). the i/i and i/d polymorphism frequencies were similar in both groups (26.1 % vs. 30 %, and 41.3 % vs. 57 %, respectively; p > 0.05). conclusion: a positive association between the ace d/d allele and ischemic stroke was found in our study. the ace d/d allele may be an independent risk factor for the development of cerebrovascular disease. . the motorized c-arm provides fluoroscopic images during a 190° orbital rotation computing a 119 mm data cube. from these 3d data sets mpr reconstructions were obtained. all images were evaluated by four independent readers for the detection and extend of fracture lines. all fractures were classified according to the müller ao-classification. to confirm the results, the specimens were finally surgically dissected. results: 93 % of the fractures were detected with cr, 97 % with iso-c-3d and 100 % with ct. differences between cr and ct were significant (p = 0.046), not significant between iso-c-3d and ct (p = 0.157). with cr 27 % of the fractures were correctly classified, 96 % with iso-c-3d and 100 % with ct. there was again no significant difference between ct and iso-c-3d (p = 0.066), but between ct and cr (p < 0.001). the preliminary results suggest a remarkable efficient detection of tibial joint fractures with the iso-c-3d. the evaluation of fractures with the iso-c-3d is better than with cr alone and comparable to that of ct-scans. even if image quality is definitely inferior to ct, iso-c-3d may be useful in planning operative reconstructions and evaluating surgical results in orthopaedic surgery of the limbs. dynamic ultrasonography in evaluation of muscular trauma a.k. nath, r. bouras; muscat/om purpose: role of dynamic ultrasonography in muscular trauma. methods and materials: 50 male football players (aged 20 to 30 years) presenting with clinical muscular trauma in the thigh and calf region were evaluated in this study. dynamic ultrasonography of both the affected and contralateral normal region, with toshiba power vision 6000 ultrasound equipment using 7.5 mhz phased array linear transducer, in sagittal, coronal and angulated axis was performed, both without contraction and with contraction of the muscles. needle aspiration of suspected hematomas was performed for diagnosis and treatment. all muscles tears and hematomas were studied and followed up after 72 hours, until complete healing. results: 46 of the total 50 patients had muscle tears and/or hematomos in thigh and calf region. 4 pateints had no abnormality. 32 patients had clear-cut muscle tears appearing as echogenic retracted portions surrounded by hematomas ranging from highly reflective mass to complete echo poor areas were observed on follow up. the remaining 14 patients had partial tears. healed tears appeared as highly reflective scar tissue. (1) ultrasonography is very useful in diagnosis, management, and followup of muscle tears and hematomas. (2) dynamic ultrasonography is essential for diagnosis of partial tears. ultrasound and color doppler imaging of thrombosis of gemellary veins in patients with "tennis leg" lesion m. dahmane 1 , c. martinoli 1 , s. bianchi 2 , f. zandrino 3 , f. monetti 1 , a. beghello 1 , s. paltenghi 1 , l.e. derchi 1 ; 1 genova/it, 2 geneve/ch, 3 alessandria/it purpose: to assess with ultrasonography (us) and color doppler imaging (cd) the association between rupture of distal myotendineous junction of the medial gastrocnemius ("tennis leg" lesion) and thrombosis of gemellary veins. materials and methods: 32 consecutive patients with suspected "tennis leg" lesion were prospectively examined with 12 -5 mhz us and cd to confirm the diagnosis and evaluate the possible association with thrombosis of gemellary veins. the us study had to be extended to the most proximal portion of the leg, to image the veins up to the popliteal; both compression evaluation and a cd exam were obtained to confirm patency. results: 30/32 patients had typical "tennis leg" lesions; 1 had a ruptured baker cyst; 1 had proximal rupture of gastrocnemius muscle. an associated thrombosis of the gemellary veins was detected in 6 cases (18 %); none had extension to the popliteal vein. conclusions: presence of associated thrombosis of the gemellary veins has to be considered in patients with "tennis leg" lesion, and the us examination technique has to be changed accordingly. in this study, we report our experience regarding the usefulness of mri in the evaluation of traumatic and microtraumatic bone pathology. we performed mri examinations in 4324 patients with knee pain and a negative plain film examination where a post traumatic or non traumatic pathology at the level of the joints (knee, ankle, wrist, elbow and hip) was suspected. mri examinations were performed with a low field dedicated unit for the study of limbs (e-scan and artoscan esaote) and in some cases with an high field mri unit (vision plus siemens). we used se t1 and turbo-t2 sequences, ge and stir. in some patients we administered i.v. contrast media. in 964 cases we demonstrated the presence of post traumatic bone alterations or bone alterations not related to trauma that were not visible on conventional radiological examinations. in 112 the bone alteration was the most important finding. in 42 patients, a follow-up mri after 1 month allowed correlation between the evolution of the clinical symptoms and the changes in the appearance of the bone injury. in 75 patients, it was very useful to correlate the changes in the bone appearance with the clinical outcome. conclusions: in our experience mri has been very important in the evaluation of traumatic, post traumatic or non traumatic bone pathology and for a correct therapeutic assessment of the patient. purpose: to compare bone bruise patterns identified at mri incurred by impaction, distraction and shear injuries correlated with microtome sections and histopathology. methods: freshly harvested sheep cadaveric limbs were imaged on a 1.5 t philips mri intera scanner following exposure to impaction, distraction and shear forces. each limb was imaged using se t1 and stir sequences. following imaging, the cadaveric limb was sectioned using a microtome and pattern of trabecular damage correlated with identified bone bruise at mri. results: impaction forces produce poorly marginated globular bone bruises with extensive concertina type trabecular damage. distraction forces produce localised bone bruises in a linear pattern perpendicular to the axis of distraction with localised trabecular disruption, attenuation and stretching. shear injuries produce linear bone bruises obliquely oriented with localised linear disruption of trabeculae on microtome sections. conclusion: bone bruise patterns are dictated by mechanism. mri appearances reflect the underlying extent of trabecular damage at histopathology. to determine the diagnostic accuracy of contrast-enhanced, three-dimensional panoramic-table-mr angiography in the assessment of pelvic and peripheral arteries compared with conventional digital subtraction angiography as the standard of reference. in 169 patients with suspected peripheral arterial vascular disease, both conventional digital subtraction angiography and three-dimensional mr angiography using an automatic tracking technique were performed. in a prospective blinded analysis, each vascular segment (29 segments per patient) was evaluated for the presence of obstructive stenosis, graded as normal (0 -10 %), mild (10 -50 %), severe (50 -99 %), or occlusion (100 %). results: obstructive lesions were identified and graded correctly with mr angiography. overall sensitivity and specificity for the detection of hemodynamically significant disease (severe stenosis) on panoramic mr angiographic images were 93 % and 97.7 %, and for the detection of occlusive disease were 95 % and 99.8 %, respectively. the diagnostic accuracy of contrast-enhanced, three-dimensional panoramicpurpose: with 3d-mr-angiography gaining more acceptance for assessing the arterial system, the amount of data produced requires new tools for visualization of the datasets. recently, a new volume rendering method, "stereo viewing", has become available. the purpose of this study was to assess the potential diagnostic gain by "stereo viewing" in comparison to combined mip and mpr for various vascular territories. over an 8-month period 3d-mra was performed in 40 patients. mras were obtained of the carotid, pulmonary, renal and pelvic arterial systems. imaging was performed on a 1.5 t mr scanner (sonata®, siemens). image sets were analyzed on a workstation (virtuoso®, siemens, germany), firstly based on a combination of mip and mprs, and a second time based on mip, mprs and "stereo viewing". the data sets were analyzed using a 5-point confidence scale ranging from 'stenosis/occlusion definitely present' to 'stenosis/occlusion definitely not present'. in addition to the level of confidence, the time required to reach the diagnosis was documented. results: the addition of "stereo viewing" led to a significant increase in diagnostic confidence regarding the presence/absence of stenosis/occlusion in all anatomic regions, evidenced by a greater area under the roc curve (p < 0.05). "stereo viewing" prolonged the analysis process by an average of 10 %. conclusion: "stereo viewing" is an effective and accurate tool for assessing complex 3d-mra datasets as it provides more diagnostic confidence compared to the combination of common post-processing techniques (mip + mpr). the added time needed for "stereo viewing" results in enhanced diagnostic confidence. purpose: image quality of dsa of the hands is still superior to ce-mra due to the lower spatial resolution of ce-mra which is limited by the passage time of the contrast bolus through the arteries. the aim of this study was to demonstrate that temporary blood flow interruption with an inflated blood pressure cuff during the arterial first-pass can significantly increase imaging time and spatial resolution. materials and methods: 8 volunteers and 3 raynaud patients were examined with tac-cemra on a 1.5 t mr machine (philips intera). a blood pressure cuff was placed around the upper arm. after timing (bolustrac), 5 ml iv. gadolinium-dota was administered and tac-cemra was performed. after cuff inflation at 200 mmhg during the arterial phase, a 3d-gradient echo imaging sequence (tr 4.7 ms, te1.6, flip 35°, matrix 512 × 1024, fov 300, 0.7 mm-partitions) was acquired. slopes of histograms were measured perpendicular to the radial and one arch artery and cnr calculated. results were compared to a classic ce-mra study in all volunteers. results: compared to the classic first-pass mra with pixel dimensions of 1.17 × 0.59 mm, the use of tac-cemra allowed a significant increase in spatial resolution with voxels down to 0.59 × 0.29 mm. this gain did not impede the cnr which was not statistically significantly different ( a c d e f 282 materials and methods: 4 patients underwent pta of a single distal sfa stenosis. lesion length was < 1 cm. hr-mri (magnetom vision, siemens) was performed within 16 hours after the intervention using axial t1-w, fat-saturated contrast enhanced t1-w, t2-w and 3d-tof sequences. maximum matrix size was 320 × 512, minimum voxel size 0.49 × 0.49 × 2.0 mm. contrast enhanced mr angiography was employed for assignment of exact matching sites. ivus (3.5 f, 40 mhz) images were recorded with a standardized motorized pullback system (pullback speed 1.0 mm/s). quantitative analysis for each segment included minimum and maximum luminal diameter and cross sectional lumen area. morphologic analysis included the absence or presence and extent of dissection. results: precise pre-and post-pta assignment of 16 segments was successfully carried out according to our protocol. the lumen increase measured 100 % to 400 % with a remarkable agreement between ivus and hr-mri. post pta correlation for cross sectional lumen area (r = 0.90) was better compared to pre pta analysis (r = 0.80). hr-mri detected 7/7 ivus proven dissections while digital subtraction angiography failed to demonstrate 4/7 dissections. conclusion: our preliminary findings suggest that hr-mri has a high potential for non-invasive in-vivo assessment of quantitative and morphologic changes in atherosclerotic sfa lesions following angioplasty. the method for quantitatively determining contrast medium (cm) concentration by measuring the t2*-effect (brady, 1990 ) was adapted to t2w liver-mri. the cm used was an indium-doted spio. three groups of study animals (liver cirrhosis, hepatitis, fatty liver) and a control group were investigated (15 rats/group). se and gre imaging was performed (n = 6/group, 7.5 µmol/kg bw); 3 rats received no cm and 3 animals each 15 and 25 µmol/kg. t2-relaxation time of all livers were measured ex vivo by relaxometry, and cm concentrations were determined. q-values representing the phagocytosed cm were computed from the pre-and postcontrast si on both the se and gre images. spearman's correlation coefficient between cm concentrations and t2-relaxation rates was significant in the control group at 0.506 (p < 0.05). in the 3 study groups, pearson's correlation coefficient (pcc) between cm and t2-relaxation rates was significant, ranging from 0.627 -0.717 (p < 0.05) -a positive correlation between cm and t2-relaxation rates in all groups. pcc between q-values and cm concentrations was significant at 0.767 (se) and 0.587 (gre) (p < 0.05) -positive correlation between the cm and q-values. the mann-whitney test yielded a significant difference in the qse values between the liver cirrhosis and fatty liver groups compared with controls (p < 0.05). regarding qgre values, a significant difference was identified only for the fatty liver group versus controls (p < 0.05). the animal experiments suggest that quantitative determination of phagocytic capacity as a functional parameter using contrast-enhanced mri has a potential for differentiating diffuse liver disease from healthy livers. results: in the detection of focal liver lesions, unenhanced plus dynamic plus late phase enhanced mri was more accurate than unenhanced plus dynamic and than unenhanced plus late phase enhanced examinations, which were more accurate than unenhanced imaging. the accuracy and observer confidence in the characterization of focal liver lesions were higher when dynamic examination was considered. methods and materials: 45 patients were prospectively investigated using a 1.5 t magnetom (siemens symphony; philips acs nt). the sequence protocol included t2w tse and t1w se/gre scans using unenhanced and spio-enhanced studies (endorem: 15 µmol/kg bw). diagnostic criteria unenhanced were: homogeneous isointensity/mild hyperintensity (t2w); homogeneous iso-/mild hypointensity (t1w); scar detection. the uptake of the spio-particels was calculated comparing contrast-enhanced with unenhanced scans. results: the standard of reference was histopathology providing surgery (liver resection) or needle biopsy. as a second option gadolinium-enhanced mri was accepted within a timeframe of 6 month. in the resection group sensitivity was 95.2 % with a specificity of 95.8 %. signal intensity was homogeneous in t1-and t2w unenhanced sequences and similar to surrounding parenchyma in 37 out of 44 cases (group 1). in eight cases the lesion was heterogeneous hyperintense in t2w and hypointense in t1w scans unenhanced (group 2). group 1 documented a significant signal intensity loss using spio-enhanced t2w sequences compared with unenhanced prtocols. for group 2 a statistical significant decreased uptake of spio-particles was documented. histopathology revealed high degree of fibrotic changes (group2). using spio-enhanced mri detection and delineation of central scar tissue was increased compared to unenhanced mri. conclusion: spio-enhanced mri is an effective imaging tool for the diagnosis of fnh nodules providing morphological and functional details sufficient for characterization. purpose: capillary and cavernous hemangiomas represent the most frequent benign lesions of the liver; atypical features due to complications may simulate different lesions; the rare occurrence of other vascular histotypes makes the differential diagnosis even harder. the aim of our study was to describe their imaging features and discuss their differential diagnosis. we reviewed ct, mr images in 152 patients. ct protocol included: 5 mm collimation, pitch 1.5 injection of iodinated contrast medium in the arterial, porto-venous and delayed phases. mr protocol included 5 -8 mm slice thickness, t1, t2 weighted sequences and post-gd evaluation. we evaluated the morpho-structural appearance and the contrast enhancement of the lesions. the comparison between different imaging modalities, the dynamic of contrast enhancement, the follow-up, the bioptic and surgical specimens allowed for the correct diagnosis in all the cases. results: we identified the typical patterns of capillary hemangioma (50), cavernous hemangioma (65), giant hemangioma (10). in 5 case we demonstrated intratumoral hemorrhage, in 7 cases prevalent jaline and/or stromal components, in 6 cases calcifications. we also found 2 hemangioendotheliomas (1 single, 1 multiple), 4 hemangiosarcomas (2 showing extravisceral growth, 3 multinodular, 1 single), 3 kaposi's sarcomas (2 showing peri-portal infiltration, 1 multinodular). conclusions: ct and mr demonstrate an elective role in the identification and often in the characterization of vascular tumors of the liver in adults. the presence of complications is also well depicted. mr gives important information regarding the structure of the lesions and in particular of the hemorrhagic components. methods: 12 children (5 m/7 f, mean age 14.3 ± 2.1 a) suffering from marfan's syndrome were consecutively chosen from the department of pediatric genetics. bone ultrasound attenuation (bua) and speed of sound (sos) were calculated by sahara (hologic, usa). the standard-deviation-scores (sds) for both parameters were calculated using regional normative data (3299 children). and porosity index (pi) were estimated automatically from radiogrammetric measurements and bone texture analysis of the three middle metacarpal bones. for statistical analysis each case was pair-matched to a sex-and age-related healthy control. the mean bmd was 0.53 ± 0.04 g/cm 2 in the marfan group versus 0.53 ± 0.08 g/cm 2 in the control group. only pi showed a significant difference: 1.99 ± 1.14 versus 5.14 ± 2.22 (p < 0.05). conclusion: bmd was very similar in our patients with marfan syndrome compared to the reference population. statistically significant differences were only observed for the porosity index. data in the literature concerning osteoporosis in marfan patients is ambiguous. our findings may indicate a specific textural disturbance in the bones of marfan patients which does not result in overall altered bone density. there are potential limitations due to specific anatomic properties of the metacarpal bones in marfan syndrome. radiogrammetric based bone densitometry seems to be of promising clinical value in pediatric patients receiving x-rays of the wrist and hand routinely for determination of skeletal maturity. this new technology might be able to give additional information and reduce radiation exposure. gender-specific standard-deviation-scores (sds) were calculated using age, height and weight matched regional normative data (3299 healthy children). follow-up was performed in 9 children during bisphosphonate-treatment over a period of 2 years. results: 20 patients had oi type i, 6 had oi type iv. age-matched bua values were < −2 sd in 9/20 patients, < −1 sd in 6/20 patients and normal in the remaining children with type 1. 13/20 patients had sos values below −2 sd, 4/20 below −1 sd and 3 were within the normal range. no bua and sos-values below −2 sd were observed in type 4; and 2/6 patients had values below −1 sd. 1/6 patients had sos values < −1 sd, the others were within the normal range. mean bone values differences were significant: −1.82 sd/−0.10 sd (bua) and −2.34 sd/0.02 sd (sos). there was a strong correlation of bua and sos (r = 0.90, p < 0.01). 4/9 children showed a significant increase of bua and sos (more than 1 sd), 1/9 a slight increase in values during follow-up treatment, 4 had no change. in all treated cases fracture rates were significantly reduced. conclusion: ultrasound based bone densitometry may be of clinical value in children suffering from oi. oi type i causes severe disturbances of bone mineralization in contrast to type 4. ultrasound based bone densitometry of the os calcis measured on asthmatic children using regional normative data a. (sos)). bua/sos correlation was significant (r = 0.62; p < 0.01). conclusion: bone densitometry of the os calcis using ultrasound appears promising in detecting disturbances of bone mineralisation in children treated with low dose topical steroids. sos was more sensitive in detection of bone mineralisation in comparison to bua. girls seemed to be osteopenic more often. in contrast to steroid intake, asthma severity does not correlate significantly with bone mineralisation disturbances. the use of mri in the evaluation of paediatric wrist trauma k. johnson, a. page, f. haigh; birmingham/gb traumatic wrist injury in children is common but detection of fractures and other injuries can be difficult. we have evaluated the role of mr imaging in the assessment of paediatric wrist trauma. 99 children with a history of wrist trauma in whom the there was either a discrepancy in the clinical assessment and the plain radiographic findings or normal radiographs and persisting symptoms underwent an mri examination of the wrist. all mri examinations were performed within 2 weeks of the initial trauma, 76 % within 6 days. 101 mri examinations were performed (2 children has repeat examinations). 34 (34 %) patients with normal plain radiographs had fractures detected on mr imaging (59 % in the carpus and 41 % in the radius and ulna). in 20 patients there was a discrepancy between the plain radiographic findings and the clinical assessment and in 12 cases (60 %) mri detected further occult fractures and soft tissue injuries. no patient with a negative mri examination has represented with a complication of the initial injury, indicating that mri has a 100 % negative predictive value for wrist injuries. mr examination of the wrist in children significantly alters management. mr imaging detects radiographically and clinically occult fractures and soft tissue injuries. the technique is well tolerated by children. methods and materials: 21 patients (age 3 -16 years; m = 11, f = 10) suffering from juvenile aseptic osteonecrosis (legg-calvé-perthes disease), underwent mri in a 0.5 t mr-scanner (gyroscan t5 nt, philips, eindhoven, the netherlands) using a fat-suppressed stir sequence, t2-weighted turbo spin-echo and t1-weighted spin-echo sequences. postcontrast t1-weighted sequences were performed in each patient after administration of 0.1 mmol gadolinium/kg bodyweight (magnevist, schering, berlin, germany). all examinations were retrospectively assessed by two paediatric radiologists, evaluating the signal patterns of the femoral head and the metaphysis in each sequence in consensus. the mr features and the diagnostic accuracy were analyzed for the different sequences and compared to conventional x-ray. monday b results: based on the fat-suppressed and the contrast enhanced t1-weighted images, six different signal patterns were differentiated within the femoral head as well as three different signal patterns being identified within the metaphysis. combinations of separate signal patterns within one thigh were a common finding, representing different stages of necrosis and reparation. for the differentiation of viable and necrotic osseous fragments, the administration of contrast material was mandatory. the combination of fat-suppressed and contrast enhanced t1weighted images allows distinct staging of juvenile aseptic necrosis. a combination of these imaging modalities permits an efficient surveillance of the legg-calvé-perthes disease. the purpose: saethre-chotzen syndrome is an autosomal dominant syndrome with craniostenosis and syndactylies. the purpose was to evaluate the variability of anomalies on hand and feet radiographs of patients with genetically proven saethre-chotzen syndrome or muenke-type coronal synostosis. we evaluated radiographs of the hands in 31 patients, 25 with saethre-chotzen syndrome related to twist gene mutations and 6 with muenke-type mutation. x-rays of the feet were available in 27 cases. the age range was between 1 month and 36 years. radiographs were evaluated by 2 radiologists in respect of morphological anomalies. results: we found a bone age delay in 10/27 patients, whose epiphyses were not fused. a brachyphalangy was noted in 22/31 patients, clinodactyly in 18/31. partial syndactyly occured in 16 cases, involving the soft tissues of the 2 nd web space and additionally the 3 rd in 3 cases. 7/31 patients presented with partial carpal fusion, affecting the trapezoid and the trapezium in 5. coned epiphyses were present in 16/16 patients. other anomalies included a duplicated distal phalanx of the hallux (n = 9), a triangular deformity of the epiphyses of the distal phalanx of the hallux (n = 10), partial syndactyly (n = 11) and brachyphalangy (n = 10). conclusion: saethre-chotzen syndrome and muenke-type mutation have a variety of morphological anomalies of the hand and foot in which skeletal anomalies such as brachyphalangy and syndactyly are non-specific signs. different patterns of anomalies between both are a duplicated distal end and triangular shaped epiphysis of the hallux, which were only detected in patients with saethre-chotzen syndrome. purpose: saethre-chotzen syndrome (scs) and muenke-type mutation fgfr3 pro250arg (mtm) are both complex syndromes with skeletal anomalies such as craniosynostosis, syndactylism and cervical spine abnormalities. in this study we analysed the variable cervical spine abnormalities identified on radiographs for specific features in patients with genetically proven scs and mtm. methods and materials: cervical spine radiographs of 20 patients (11 female, 9 male; mean age 6 a) were reviewed by to 2 radiologists with experience of skeletal dysplasias. the patient population included 17 patients with scs and 3 patients with mtm. the appearance of the vertebral bodies, the posterior elements including the neural arch and the atlanto-axial joint were assessed. x-rays of the hands and feet were available in 10 patients. results: fusion of vertebral bodies and posterior elements were noted in 3 patients (level c2/3, c3/4 and c5/6). an isolated fusion of posterior elements occurred in 8 patients (level c 1/2 (n = 1), c2/3 (n = 7), c 4/5 (n = 1), c5/6 (n = 2)). 5/10 patients with cervical spine fusion additionally showed carpal and/or tarsal fusion. in 7/20 patients an enlarged vertebral space between c 1/2 was found. a hypoplastic neural arch was detected in 5 patients and a long spinous process at c7 in a single case. the atlanto-axial joint space had a mean distance of 3.4 mm (range 2 -9 mm). conclusion: scs and mtm display a great variety of cervical anomalies, however the radiological signs are morphologically non-specific. however, cervical vertebral fusion in these patients is often associated with carpal and/or tarsal fusions. ultrasound and mri in children with pyomyositis a. trusen, m. beissert, g. schutz, b. chittka, d. hahn; würzburg/de purpose: pyomyositis is an acute bacterial infection of the skeletal muscles, most often caused by staph. aureus. the purpose of our study was to evaluate the role of ultrasound and mri in the diagnosis of pyomyositis. material and methods: 11 children with myositis were evaluated. the areas involved included the pelvic region (n = 4), the shoulder (n = 4), the thigh (n = 1), the lower leg (n = 1) and the elbow region (n = 1). all patients were examined by ultrasound, 9 of them had mri. symptoms and signs included swelling, pain and inflammation. results: in 7/11 the correct diagnosis was made by ultrasound. in 4 cases, 3 involving the pelvic region the ultrasound diagnosis was initially incorrect. in one child where the diagnosis of a tumour was made both on ultrasound and mri, the diagnosis of a proliferative myositis was subsequently made by histology after ultrasound guided biopsy. the extent of myositis was determined better with mri than ultrasound. in the extremities an abscess was detected by ultrasound, the accompaniing osteomyelitis could only be detected with mri. conclusion: in cases of suspected myositis ultrasound is the primary imaging modality, however, it has a lower sensitivity in the pelvic region. mri is necessary to exclude osteomyelitis and often to determine the exent of inflammation. a c d e f 286 materials and methods: 4 healthy volunteers and 7 patients with tongue tumors underwent videofluoroscopy and real-time mri before and after tumor-resection, using a t1-ffe sequence (tr = 3.2, te = 0.9, fa = 10, slice thickness 1.5 cm) with 6 images per second. images were acquired in the midsagittal plane. swallowing of diluted magnevist-enteral solution, phonation of test words and defined testmovements of the tongue were evaluated. results were analysed by 2 radiologists in comparison to videofluoroscopy as the standard of reference concerning overall quality of the depiction of tongue-movement and deglutition (mri better, equally good or worse), and depiction of the stages of swallowing (from 0 = not recognisable to 3 = very good depiction). results: in all cases, the important stages of swallowing could be successfully depicted with real-time mri. however, quality of videofluoroscopy was considered to be better in all subjects. discrete pathologies like laryngeal penetration could only be seen on videofluoroscopy. depiction of tongue-movement was better with real-time mri in 13/18 cases and equally good in 5/18 cases. this was due to the better soft tissue contrast of mri and the lacking of artefacts from teeth and metall implants. conclusion: real-time mri can successfully depict the normal physiology of swallowing. for the analysis of dysphagia, quality is inferior to videofluoroscopy, while for the analysis of tongue movement-disorders, real-time mri is superior to videofluoroscopy. examinations were performed on a 1.5 t scanner (philips nt intera), equipped with sensitivity-encoding mri (sense) imaging software. sense shortens acquisition time by reducing the number of phase encoding steps, using the coil sensitivity as an encoding effect. 5 volunteers and 5 patients suffering from post-operative dysphagia were examined using a sagittal dynamic t1w 2d ffe sequence with 8 frames/s (tr/te 2.2/1.1 ms, 30°, slice 15 mm, matrix 144 × 256, fov 230 mm, 124 ms/image, sense reduction factor 2). water and yogurt (spiked with gadolinium 1:50) with a bolus size of 3 -15 ml were used as oral contrast agents. oral and pharyngeal swallowing phases were assessed. results: oral and pharyngeal transit, laryngeal closure, epiglottic tilting and pe sphincter opening upon swallowing could be visualized in all volunteers. boluses of yogurt ≥ 5 ml were found most useful. in 4 patients, residue and intra-or postdeglutitive aspiration and in 1 patient nasal regurgitation could be seen realtime. conclusion: mr fluoroscopic visualization of swallowing is possible using realtime 2d ffe imaging with sense. our initial experience indicates that functional swallowing abnormalities such as aspiration can be assessed with real-time mri. the leading symptoms were globus pharyngis or dysphagia, which could not be verified by means of endoscopy or ent-examination. in 40 % of the patiens reflux disease was indentified as underlying disease be means of ph-monitoring. 80 % showed reflux-associated motility disorders in videofluoroscopy. 82 % of them showed a dysfunction of the upper esophageal sphincter, which could not be found by other diagnostic tool. due to the resultant pressure elevation they showed constant/inconstant zenker's diverticula of pharyngeal pouches of different degree. in 85 % of those patients motility disorders of the oesophageal body were detected 6 -7 % of them sufferd from a delayed cleaning function of the oesophageal tube. in the remaining collective hypermotile disturbances like segmental not propulsive contractions or reflux-associated non specific motility disorders could be verified. the results of the study will be demonstrated by digital and videofluoroscopic recordings. evaluation of patients with dysphagia by modified barium swallow examination u. coskun, m. cigiltepe; ankara/tr purpose: to determine the perceived radiologic abnormalities of dysphagia with modified barium swallow examination. materials and methods: 250 patients with dysphagia were undergone modified barium swallow examination. utilization of a thickener abled us to determine the deglutition skill in different consistencies in anteroposterior, and lateral planes. results: the perceived radiologic pathologies are as follows. oral phase: 35 % of the patiens with bolus formation whereas 42 % with bolus transfer problems. pharyngeal phase: 85 % of patients revealed pulling in pyriform sinuses, 55 % had ventriculer residue 73.5 % problems with basal tongue retraction, 13.5 % had abnormal epiglottic tilt, 27 % delayed elevation of the pharynx and hyoid elevation problems. premature spill is seen in 25 % of them with stasis at the valleculae or pyriform sinuses, 15 % had aspiration and 7 % of them had backflow reflux. functional swallow refleks was delayed in 65 %. oesphageal phase: 15 % had upper oesophageal pathologies. 7 % had lower esophageal pathologies and 5 % had diffuse peristaltism disorder. conclusion: in our centre each study is tailored to the clinical history, the patients ability to undergo the examination, and the initial flouroscopic findings. according to the findings intervention techniques were establihed. those included positioning, alteration of the food texture, oral motor range of motion exercise. according to the results aspiration and aspiration related pneumonia free status was achieved. mealtime and videofluoroscopic fluids features affecting deglutitive events s. de giorgi, a. carniato; treviso/it a four years experience in dysphagic patients suggested that assessment of deglutition tested with videofluoroscopic fluids, doesn't closely enough reproduce deglutition with mealtime fluids. with this technique in fact only poor and approximate indications can be given to swallowing therapist concerning food to be used for rehabilitation. the aim is to give clinicians more precise and objective information about deglutition assessment. density and viscosity of videofluoroscopic fluids were measured and compared by means of a precision balance and a viscosimeter. videofluoroscopic fluids were more dense and viscous than mealtime food. different abilities to manage boluses in relation to their density and viscosity during each stage of swallowing were examined as well. the analysis of a recurrent aspiration pneumonia is difficult in newborns or children. besides the special requests of radioprotection the diminuished capacity of collaboration of small children is a considerable problem. therefore we use a dynamic recording unit with cine-fluoroscopy and with a videorecording system. the test-bolus consists of jotrolan (isovist r), which is a iso-osmolar, non ionic hydrosoluble preparation with a reduced pneumotoxicity. the taste is sugarlike. the analysis of the study should be done with the pediatrician or the paediatric ent-specialist in order to integrate the clinical findings with the radiologic pattern. the differentiation between an oral and a pharyngeal morphologic or functional swallowing disorder is of special therapeutic interest. in the analysis of the swallowing disorder the individual situation of the study has to be considered, since a rejection might be misinterpreted as a swallowing disorder of the first, the volontary phase. functional disorders as a complete or an incomplete paralysis of the velum or the pharynx, dysfunctions of the upper esophageal sphincter and alterations of the sensomotoric system can be differentiated with a high precision. the sensitive diagnostic tool allows to find an individual treatment plan in accordance to the therapy of castillo-morales, voita, pörnbacher or bobart for the single infant. patient examples will be shown and discussed. we studied up to now more than 10000 patients of which nearly 3500 had a neurologic disorder. only an adequate pretherapeutic work-up of the pathomechanism of an aspiration allows a correct therapeutic approach. the aim of the study is to assess the efficiency of the close cooperation of swallowing therapists and diagnostic radiologists, specially trained in the analysis of the pathomechanism of swallowing. the differentiation of the "pre-", "intra-" and "postdeglutitive" aspiration, which means aspiration before, during and after the triggering of swallowing reflex, turned out to have a great impact in the differential therapy of aspiration. moreover on the basis of dynamic imaging other important pathomechanisms of aspiration could be detected, which were the bases of the application of new therapeutic manoevers. by means of videofluoroscopy we examined patients before and after therapy. in 80 % of them a sufficient swallowing rehabilitation without aspiration could be achieved. videoflouroscopy shortened the time of training-hospitalisation, because the therapist could immediately center on the relevant exercises for swallowing rehabilitation. conclusion: dynamic evaluation of the neurologic impaired patient makes rehabilitation more efficient and shortens hospitalisation-time and costs. flat panel x-ray detector radiography: comparison with storage phosphor radiographs and conventional radiographs p. boehm, p. homolka, s. grampp, c. czerny, a. ba-ssalamah, h. imhof; vienna/at purpose: to compare images obtained with a flat-panel x-ray detector based on amorphous silicon technology with conventional screen film radiographs and storage phosphor radiographs using different exposure parameters to evaluate dose reduction and image quality in skeletal radiology. a digital x-ray detector (trixell, siemens, erlangen, germany) based on cesium iodide and amorphous silicon technology was used. state of the art screen film radiographs and storage phosphor radiographs (adc system, agfa) were compared with digital detector images obtained at doses equivalent to those obtained with system speed of 200 (hand: speed 50, femur and tibia: speed 100). in vitro human cadaver specimen (femur, tibia, head, lumbar/thoracic spine, hand) were embedded in a pmma tube filled with water. a conventional and storage phosphor radiograph and digital detector radiograph were made of each specimen by varying the exposure parameters (kv, mas). the resulting 228 images were evaluated independently by 3 radiologists using a subjective ranking (grade 1 -3) rating exposure, contrast resolution, spatial resolution and soft tissue presentation. from each group the best image was chosen and separately evaluated for comparison. results: radiation doses for digital detector images were equivalent or below the other methods giving the same or better diagnostic performance. the diagnostic performance of digital detector radiographs compared with conventional radiographs and storage phosphor radiographs suggests that this technology will be a useful tool in diagnostic imaging. comparison of a flat panel digital detector to screen-film by x-ray images of the hand t. pollack, h. pauls, k. köhler, r. friedberg, u. günl, f. stösslein; dresden/de purpose: to evaluate the image quality of hand images obtained with a new flat panel digital detector to those obtained with an extremity screen-film system. methods and materials: hand images were obtained on 50 patients presenting for a rheumatologic baseline or follow-up exam. the patients were imaged such that one hand, selected randomly, was imaged with a digital flat panel table system (general electric, xr/d, milwaukee, wi) and the other with an extremity 100-speed screen-film (sf) system (agfa, curix ht 1.000g plus). the dr images were printed using a laser printer. all images were obtained using the same x-ray tube and generator, without a grid, 100 cm source-to-detector distance, 50 kv, and 2.5 -3.2 mas (dependent on the patient acquired with matched techniques). five radiologists scored pairs of images dr vs. sf using a 5-point scale (−2 clearly worse to +2 clearly better). observers were asked to score the image quality of eight anatomical criteria. results: all anatomical structures were scored equal or higher with the flat panel system compared to screen-film. comparing the digital flat panel to screen-film, dr was graded statistically superior: by 3 of 5 readers for cortical structures, by 3 readers for trabecular structures and by 4 readers for border structures, soft tissues and overall image quality. none of the observers rated the sf statistically superior to dr for any category. the results demonstrate that the digital flat panel system with a 200 µm pixel size produced equal or superior hand images with respect to all anatomical criteria. cost-effective data recording device for mobile c-arm which has only analogue output: optimizing ordinary software of video-capturing and real time mpeg compression with limited funds a. sada, w. ikeda, e. nakagaki, k. hisazumi, i. imai, k. nakanishi; osaka/jp purpose: in our department, a mobile c-arm is used for routine digital subtraction angiography (dsa) because of limited funds. the purpose of our study is to find an adequate data saving device for this mobile c-arm which was equipped with only analogue output. materials and methods: a philips bv 312 mobile c-arm was used as dsa. all dsa images were obtained at five images per second and imaging matrix was 752 × 582. this machine has no facility for a data transport system. imaging data were generated by a video cassette recorder as an analogue output. a personal computer (macintosh powerbook g4) and mobile c-arm were connected through the analogue-digital converting and real time mpeg-1 compressing system (the pixela). from july 2001 to september 18 2001, 20 cases of dsa were performed (abdominal aortogram: 8, celiac arteriogram: 15, sma: 15, renal arteriogram: 6, common iliac arteriogram: 9, the others: 75). the compressed image qualities were evaluated. the amount of data and cost were estimated. results: compression was about 3.7 %. average compressed data per one-series of dsa was 3.2 mb. average data per patient was 20.6 mb. therefore, about 32 patients' data can be saved on 640 mb mo disks and two mo disks will be required per year in our department. conclusion: with limited funds, our device (using ordinary computer and the real time mpeg compression software) was useful for saving the imaging data of dsa using a mobile c-arm system which has only analogue output. hodgkin's disease -radiological procedures for determination of clinical stage l. todoric; belgrade/yu purpose: to assess the value of us, ct and lymphography in determination of the clinical stage of the hodgkin's disease and to evaluate the reliability of the techniques in identifying the spread of disease into infradiaphragmatic lymph nodes. methods: 100 patients with histologically confirmed diagnosis were examined using all three methods before the onset of treatment. the clinical stage of the disease was based on us and ct findings. lymphography was performed as the last diagnostic procedure. after this final staging took place. we compared and statistically analyzed us, ct, and lymphographic findings as well as the change of clinical stage after lymphography. results: lymphography did not show high aortic lymph nodes. us and ct did not show the changes in small or normal size nodes especially in pelvic region. statistically significant differences in alteration of the clinical stage, before and after lymphography, has been demonstrated in all stages. conclusion: lymphography enables a more accurate evaluation of lymph nodes in the pelvic and aortic region in comparison with us and ct and the assessment of the clinical stage resulting in an optimal therapeutic approach to hodgkin's disease. a c d e f 288 methods and materials: five patients with chronic low back pain and two volunteers underwent routine magnetic resonance imaging (mri) protocol for the lumbar spine. a 3-plane localizer sequence was taken with and without a standard supportive cushion. the angle of lumbar lordosis was calculated by two 'blinded', experienced radiologists from consensus measurements of the angles at the l5/ s1 and l1/l2 levels using a ruler line tool on a workstation. results: observations in the seven subjects who underwent lumbar spine imaging (mri) with and without the supportive cushion showed no change in the degree of lordosis; the mean angle with the supportive cushion was 46.7° (sd. 17.5) and 48.2° (sd. 17.6) without. the mean of the difference between the measurements for each subject was −0.14 (sd. 4.05). conclusion: as the use of supportive cushions produces no practical change in the lumbar lordosis, the decision to employ them should be made entirely with respect to patient comfort. the military radiographer: a profession in constant evolution e. martinello, a. giardino, m. pari, c. turchetti, c. ottonello, s. panica; rome/it diagnostic imaging in military medicine can be divided into two branches: clinical (in homeland and in field hospitals) and forensic. the clinical branch is performed in all clinical hospitals, while the forensic branch is performed both in clinical hospitals and in dedicated medical forensic military centers. in the clinical branch, field hospital radiological activity (fhra)is very specific and interesting; it is performed in the homeland (great disasters or accidents) and abroad (military operations, as peace-keeping/enforcing). fhra is influenced by three important factors: mass (high spatial-temporal concentration of injured personnel), environment (e.g.: tropical countries: infectious or climatic changes or unusual diseases, and injurious agents, ballistical or thermal. a special modular rx unit (8 parashutable packages) that can be easily and rapidly assembled and disassembled, and a us unit with 3.5 and 7.5 mhz probe are available in our field hospitals. the modular rx unit is composed of a "c" arm, tv unit with fluoroscopy, radiographic facilities and the ability to print on us type film. in the near future dedicated ct units, digital radiology devices and dry film processing units shall also be available. methods and material: over a two year period, 95 patients ranging from 5 to 80 years with or without an intraspinal component of the lesion were subjected to fnac. all were performed with 20/22 to gauge needle. two or three passes were made. us guided biopsy was performed with 5 -7 mhz linear probe with a free hand technique. ct was performed using a lead wire grid for accurate location. results: of these 45 (67.16 %) were benign and 22 (32.87 %) were malignant. 6 patients underwent ct guided fnac as us guided was negative. the success rate of us guided fnac was 33/45 (73.3 %) and that of ct guided 34/46 (73.9 %). a conclusive diagnosis could not be reached in 18 patients due to insufficient material caused by necrosis, clot or blood. conclusion: image guided fnac is an effective and safe procedure for evaluation of spinal and para spinal lesions for effective patient management. to evaluate the value of mri as an adjunct to clinical and sonographic findings for the prenatal diagnosis of fetal malformation as well as for the assessment of maternal disorders during pregnancy. methods: 77 women with complicated pregnancies (fetal pathologies n = 71, maternal pathologies n = 6, mean age of gestation 26.82 ± 6.88 weeks) were referred for mri. imaging was performed in a 1.5 t system (gems) using t2w ssfse sequences. images were analysed with regard to fetal and maternal abnormalities. findings were correlated with sonography, postnatal clinical and imaging findings and/or autopsy. results: most of the fetuses (n = 37) had isolated pathologies of the cns. in 7 cases complex malformation syndromes were present. the remaining pathologies included pulmonary (n = 6), gastrointestinal (n = 2) and other (n = 20) pathologies. mri was equal or even superior to sonography for diagnosing cerebral malformation. due to the small size, the lack of real time examination and the missing flow information, the diagnostic confidence of mri was lower for pathologies of the heart, abdominal organs and extremities. maternal disorders included anomalies of the uterus (n = 2), myoma (n = 2), 1 cervical carcinoma and 1 borderline ovarian tumour. purpose: aim of this work was to compare the new 3d mr-histerosalpingography with the x-ray conventional one in the evaluation of female infertility. method and materials: 15 infertile female patients (aging 29 -43 years, mean 35) were studied with a 1.5 t magnet unit (ge horizon 8.5) using a t2 weighted fse sequences on axial and coronal plane and a 3d fast spgr sequence (3d mra sequence) on coronal plane after injection of a diluted gadolinium solution into the uterine cavity via a balloon catheter. all the data were compared with conventional x-ray hysterosalpingography. the tomographic images provided a complete evaluation of the uterus and ovaries. the 3d mr technique provided the evidence of the uterine cavity and the patency of the fallopian tube with a complete concordance with x ray histerosalpingography. however the accuracy in detecting the fallopian tube calibre was considered inferior with mri than x-ray by two expert radiologists. two fallopian tube stenosis were missed at 3d mr-histerosalpingography. conclusion: 3d mr histerosalpingography may represent a real promising technique in the non-invasive evaluation of the infertile female. the main advantage is related to the lack of ionising radiation in these young females. up to date, in our experience, the mr technique does not have the same accuracy as x-ray in detecting the fallopian tube. improvement in spatial resolution probably have to be considered. the purpose of this study was to establish mr pelvimetric reference values in a large study taking into account the mode of delivery. intra-and interobserver errors and intra-individual variability of mr measurements were assessed in a complementary volunteer study. methods and materials: mr pelvimetric measurements of 781 women (28.9 ± 5.2 a) were reviewed and correlated to obstetric history in order to establish normative values. 2 subgroups were identified: (1) spontaneous deliveries, and (2) cases undergoing caesarean section or vacuum extraction due to fetalpelvic disproportion. in addition, mr pelvimetry was performed 5 times in 10 female volunteers (34.7 ± 6.0 a) on a 1.5 t system using t1w fspgr sequences. all measurements were then performed twice by 5 different observers to assess intra-and interobserver errors and intra-individual variability. results: mean obstetric conjugate measured 116.6 ± 10.8 mm, interspinous distance 106.6 ± 9.5 mm, intertuberous distance 114.8 ± 12.3 mm, transverse diameter 125 ± 9.8 mm and sagittal outlet 112.8 ± 11.0 mm. there were significantly different measurements in the 2 subgroups (p < 0.001), with wider measurements in the spontaneous delivery group. in the volunteer study intra-, interobserver and intra-individual reliabilities were accurate for obstetric conjugate (0.94 -0.96), interspinous distance (0.92 -0.95) and transverse diameter (0.95 -0.98), however they were poorer for intertuberous distance (0.64 -0.87) and sagittal outlet (0.66 -0.85). the normative values established in this study stratified for mode of delivery are likely to influence obstetrical decision making in the future. intertuberous distance and sagittal outlet presented the largest variabilities. obstetric decisionmakers would be justified in approaching this parameter with caution. a single-shot echo-planar diffusion mr sequence with 2 b-values (0 -500 s/mm 2 ) in the 3 planes of space (x, y, z) was implemented on a 1.5 t magnet and systematically added to a routine liver protocol including t1-, t2-and gadolinium-enhanced t1-weighted sequences in 66 patients. 52 fll were evaluated in 43 patients separated in 5 groups: metastases (n = 9); hepatocellular carcinomas (hcc, n = 9); benign hepatocellular lesions (bhl) including focal nodular hyperplasias and adenomas (n = 15); hemangiomas (n = 7); and biliary cysts (n = 3). the adcs were measured on the normal and the cirrhotic liver and on the fll. the results were then compared between the groups of patients. the liver parenchyma and the fll were found to be isotropic. the adc (× 10 −3 mm 2 /s) of the cirrhotic liver (1.37 ± 0.52) was lower than that of the normal liver (1.83 ± 0.36, p < 0.05). signal intensities of the focal lesions were rated by two radiologists as follows: hypointense, isointense, hyperintense, and markedly hyperintense. lesion-to-liver contrast-to-noise ratio (c/n) was measured for a quantitative assessment. results: on ferumoxides-enhanced fse images, 92 % of cysts were 'markedly hyperintense' and most of the other lesions were 'hyperintense', and the mean c/n of cysts was significantly higher than that of other focal lesions. t2*-weighted gre images showed most lesions with similar hyperintensities and the mean c/n was not significantly different each other. t1-weighted in-phase images showed all fnhs and hemangiomas, 29 (69 %) hccs and 8 (20 %) metastases as 'hyperintense'. on t1-weighted out-of-phase gre images, all hccs and metastasis except one were iso-or hypointense, while all of the fnhs and hemangiomas were hyperintense. ring enhancement was more commonly seen on the out-ofphase images than on the in-phase images. conclusions: addition of t1-weighted in-phase and out-of-phase gre images is helpful for characterizing focal lesions in ferumoxides-enhanced mr imaging. was acquired before and immediately following i.v. injection of 0.1 mmol/kg of gadodiamide, during arterial and portal-venous phases. in-phase and opposedphase images were calculated at the end of the sequence; subtraction was performed for each series of images on the main console. results: images of diagnostic quality were obtained in all the cases. nine metastases, 3 hemangiomas and 9 cysts were detected, all showing low signal intensity on unsubtracted and subtracted images. increase in lesion/liver contrast was observed on subtracted images (p < 0.05). three hepato-cellular carcinomas previously treated with chemioembolization showed high signal on in-phase images and low signal in opposed-phase images; after subtraction bright signal was observed with increase in liver/lesion contrast (p < 0.05). focal fatty areas showed bright signal on subtracted images. in two patients with diffuse liver steatosis, three metastases were missed in both opposed-phase and subtracted images, but they were visible as low signal intensity nodules in in-phase images. in-phase and opposed-phase images with electronic subtraction may help in identifying focal liver steatosis and increase lesion/liver contrast in case of fat-containing lesions. which is the optimal phase for the detection of hypervascular liver lesions with multislice helical ct? comparison beetween early and late arterial phase r. basilico, m. ricciardi, a. di credico, e. cucci, l. bonomo; chieti/it purpose: to compare early and late arterial phase imaging with multislice ct in the detection and conspicuity evaluation of hypervascular liver lesions. materials and methods: 50 patients with known hypervascular liver lesions (20 hccs, 15 metastases, 10 haemangiomas, 5 fnhs) were evaluated with double arterial phase ct. ct examinations were performed with multislice ct scanner using 4 × 2.5 mm collimation and 3 mm slice thickness during administration of 130 cm 3 of contrast agent (400 mg i/ml) at 4 cm 3 /s. after a test bolus, early and late arterial phase images were obtained serially during a single breath hold in a cranio-caudal direction, with interscan delay of 4.0 seconds and mean scanning time of 10.5 seconds for each phase. each set of images were evaluated in consensus by two blinded, experienced radiologists. they determined lesion detection rates, recorded lesion size and scored the conspicuity of lesions on a scale 1 -4. the mean scanning delay for the early arterial phase was 21.5 seconds (range 13 -28 seconds), whereas the mean delay for the late arterial phase was 36 seconds (range 27.5 -42.5 seconds). the number of lesions detected was 118 with early phase and 242 with late phase (p < 0.01). late arterial phase resulted in 51 % increase in detection rate versus early arterial phase. lesion conspicuity and diameter significantly increased on late arterial phase. the detection of hypervascular liver lesions did not significantly improved with early and late arterial phase evaluated in combination. conclusions: late arterial phase imaging (15 seconds after the peak enhancement in the aorta) significantly improves the detection of hypervascular liver lesions. a c d e f 292 material and methods: 24 consecutive patients underwent mri of the liver using a 1.5 t system with 30 mt/m gradients with phased array bodycoil. imaging protocol includes t2w tse with and without fatsaturation and breathhold t1w flash. seven t1w 3d flash datasets with parallel imaging (vibe with sense; tr/te/ matrix/slice thick./acq.t.: 6.21 ms/3.16 ms/256 × 192/4 mm/14 s) was performed as dynamic contrast study during infusion of gd-dtpa i.v. additional postcontrast breathhold t1w flash was acquired. results: images of diagnostic quality were obtained in all cases. normal findings were observed in 6, ecchinococcus cyst in one, liver metastases in 3, hemangiomas in 4 and hepatocellular carcinoma in 12 cases. dynamic contrast studies gives important additional informations about the perfusion of focal hepatic lesions. with a slice thickness of 4 mm in vibe sequence even in small hemangiomas typical contrast behaviours are seen. hepatocellular carcinomas are detected best in vibe sequence in early arterial phase compared with other sequences. conclusion: the vibe sequence with sense technique covers the whole liver within one breathhold. thus dynamic contrast studies in a slice thickness of 4 mm are possible and important perfusion informations of liver lesions are available in a high spatial resolution. we think that this mr technique is a very promisable tool for liver diagnostic. the value of mri in the diagnosis of hepatic tuberculoma f.h. yan, m.s. zeng, k.r. zhou; shanghai/cn purpose: to analyse the mri findings of hepatic tuberculoma, to discuss the value of mri in the diagnosis and differencial diagnosis. methods and materials: ten cases with hepatic tuberculoma underwent mr se sequence and fmpspgr sequence dynamic contrast scanning. results: mri findings of total 12 lesions in 10 cases appeared as: (1)se sequence: all lesions were hypointense on t1wi, 10 lesions were inhomogeneous hypointense on t2wi (central hypointense and peripheral hyperintense in 8 lesions and punctual hyperintense in the center in 2 lesions). the other 2 lesions showed as hyperintense. (2) fmpspgr dynamic contrast scanning: 10 lesions had no enhancement and 2 lesions had slight peripheral enhancement on the arterial phase, all lesions had various patterns of enhancement on the portal venous and delayed phase scanning, mainly peripheral enhancement and internal septal enhancement. conclusion: mri could reflect the pathological changing of hepatic tuberculoma and be of great value in the diagnosis and differencial diagnosis. comparative study of ctap and mndpdp enhanced mri of the liver in the pre-operative evaluation of colorectal metastases e.j. van der jagt, t. kok, m.j.h. slooff; groningen/nl purpose: to compare the sensitivity of ctap (computer tomography during arterial portography) with mndpdp enhanced mri in assessing the exact number of liver metastases before liver surgery. material and methods: in 30 patients evaluated for surgical treatment of metastases of colorectal carcinoma, we performed ctap and mri with mndpdp contrast medium (teslascan). peroperative ultrasonography performed jointly by surgeon and radiologist served as the gold standard. ctap and mri were evaluated by two experienced radiologists blinded to the results of the operative findings and the result of the other technique. results: in 18 patients at operation 37 metastases were found, and 1 focal nodular hyperplasia. ctap correctly showed 31 (81.6 %) and mndpdp enhanced mri 24 (65 %)of these lesions. of the missed meastases in mri 7 were smaller than 7 mm and 10 smaller than 1 cm. two were missed because of technical failure, two of three by interpretative failure were found in retrospect. ctap showed 13 lesions thought to be metastases not proven by surgery, whereas mri only scored 3 false positive findings. in the non operated group 6 patients underwent petscanning showing a total of 15 metastases in the liver. 13 of these were shown by ctap and 14 by mri. when this group of patients is added to the operated group, sensitivity for ctap rises to 83 % and for mri to 70 %. conclusion: mndpdp-enhanced mri is less sensitive than ctap (70 % versus 83 % of proven lesions) but showes less false positive lesions. = 1) , sle (n = 1), idiopathic (n = 1)), cystic acinar transformation (n = 3), oncocytic endocrine tumor (n = 1) and isolated polycystic disease (n = 1). we reviewed retrospectively the preoperative investigations (computed tomography, cholangio-mri, us-endoscopy, pancreatography) and correlated them to the histological results. results: ct and mri showed isolated abnormalities of the pancreatic ducts in 7 patients involving the main pancreatic duct (mpd) (n = 3) and the branch duct dilatation (n = 5). the mpd was normal (n = 4), dilated (n = 3) or stenosed (n = 1). the cystic lesions involved the head and/or uncinate process (n = 4), the body and/or tail (n = 3). the location was diffuse (n = 3) or multifocal (n = 1). the number of cystic lesions varied from 3 to 20 or more and the size was less than 10 mm. a solid tumor was demonstrated in one patient. correlation with us-endoscopy was good. none of the 8 patients were found to have mucous extrusion through the papilla. pancreatography was normal in 1 case, showed a communication between the cystic lesions and mpd in 2 cases or a stenosis in one case. ductal biopsies performed in 5 cases (eus-guided n = 3; transpapillary n = 2) revealed epithelial proliferation in 2 patients and were non-informative in 3. the pancreatic resection consisted with a pancreatico-duodenectomy in 6 patients and total pancreatectomy in 2. to compare mr cholangiography to multislice ct cholangiography without biliary contrast agent in the assessment of patients with biliary obstruction. methods and materials: 25 patients with clinical or biochemical signs of biliary obstruction were studied. mr cholangiography was performed with a 1.5 t unit, using respiratory-triggered three-dimensional fast-spin-echo and haste sequences; source images, maximum intensity projection, and multiplanar reformatted images were evaluated. ct cholangiography was performed using a multislice scanner, without biliary contrast agent, with intravenous injection of iodinated contrast material; axial, minimum intensity projection, and multiplanar reformatted images were evaluated. ct and mr findings were compared to ercp in 17 patients, ptc in 6, intraoperative cholangiography in 2. six patients underwent surgery or fine needle aspiration. results: ercp, ptc, surgery, and pathology demonstrated: 10 pancreatic, 2 gallbladder, 2 klatskin's, and 1 ampullary carcinomas; 1 bile duct obstruction due to enlarged hilar lymph nodes; 7 patients with choledocholithiasis; 1 chronic pancreatitis; 1 patient with negative findings. regarding site of obstruction, agreement was observed among ct, mr cholangiography and conventional cholangiography in all cases. concerning the cause of obstruction, the correct diagnosis was made in 23 patients by both mr and ct cholangiography. in two patients with choledocolithiasis, ct cholangiography was judged to be negative, but stones were correctly identified by mr cholangiography. conclusion: in the assessment of patients with biliary obstruction, multislice ct cholangiography can be considered a useful diagnostic tool alternative to mr cholangiography, which is still the non-invasive standard of reference in the evaluation of the biliary tract. mdct-ca was performed as part of a comprehensive preoperative assessment in 30 potential living liver donors (16 women, 14 men; mean age 31 years). for display of the biliary system, mdct of the liver (slice thickness/ collimation 1 mm, pitch 6 mm, table speed 12 mm/s) was performed 25 ± 5 minutes following intravenous administration of meglumine iodipamide (biliscopin). subsequent mdct angiography was added to depict the topographic relationship between biliary and vascular structures. mdct findings were correlated with intraoperative findings (n = 14). results: mdct-ca was diagnostic in all 30 patients. 21 of 30 patients presented with variations in biliary anatomy. these include drainage of liver segment four into right hepatic duct (n = 9), additional right/left segmental ducts draining into the common hepatic duct (n = 8) or the left hepatic duct (n = 4) and trifurcation at the upper confluence (n = 3). biliary-vascular topography was well depicted in all cases. intraoperative assessment confirmed the preoperative mdct-ca findings in all 14 cases. conclusion: variations in biliary anatomy appear to be the rule rather than the exception. mdct-ca represents a non-invasive means for accurately assessing biliary morphology. a continuous helical data set of the heart was acquired in 50 patients (group 1) using the standard protocol with constant tube current, and in 50 patients (group 2) using an alternative protocol with reduced radiation exposure during the systolic phase. the standard deviations (sd) of predefined regions of interest (rois) were determined as a measure of image noise and were tested for significant differences. results: there was no significant difference between group 1 and group 2 in respect of image noise. radiation exposure with and without tube current modulation was 1.0 msv and 1.9 msv, respectively (p < 0.0001) for males and 1.4 msv and 2.5 msv, respectively (p < 0.0001) for females. thus there was a mean dose reduction of 48 % for males and 45 % for females, respectively. conclusion: ecg-controlled tube current modulation allows significant dose reduction when performing retrospectively ecg gated msct of the heart. purpose: to analyse myocardial contrast dynamics and to calculate myocardial perfusion parameters using ecg-triggered multirow-detector computed tomography (mdct). methods and materials: 9 patients with a suspicion of or known cad underwent retrospectively ecg-gated mdct angiography of the coronary arteries. prior to cta data acquisition a prospectively ecg-triggered transaxial dynamic scan (4 × 5 mm) over 35 heart beats was applied to analyze myocardial enhancement patterns with subsequent assessment of perfusion parameters. contrast enhancement was provided by administration of 40 ml of iopromid 300 at a speed of 8 ml/s followed by a 50 ml saline flush. sequential image data was analyzed to calculate maximum left ventricular (lv) and myocardial signal intensity (si) increase and for maximum si upslope. all data were normalized to the lv input function. in addition quantitative measurements were performed using a fermi-function. coronary angiography was available in all patients. the lv si increase showed an amplitude of 244 ± 62 hu (136 -324 hu) and an up-slope of 39.7 ± 4.6 (34.0 -45.6). the range of si increase in myocardium was 31 ± 10 hu. within myocardial regions the normalized si increase and upslope were 0.13 ± 0.07 and 0.065 ± 0.022, respectively. in regions of impaired blood supply si amplitudes and si upslopes tended to be lower. quantitative flow calculations revealed values close to those within normal myocardium (0.73 ± 0.20 ml/g/min). the use of mdct scanners the assessment of myocardial contrast dynamics is possible. however, ventricular coverage so far is insufficient. with optimized contrast enhancement protocols the reliability may be even better. so far, the relatively low myocardial enhancement leads to a low snr. a c d e f 296 method/materials: in 30 children (22 male, 8 female, mean age 9.1 years) with suspected aortic isthmus stenosis or re-stenosis mr imaging was obtained using a 1.5 t body scanner (magnetom vision, siemens). an optimized 3d ge sequence with double-slab excitation (tr 12.3 ms, te 5.5 ms, slab thickness 12.5 mm) was used in a sagittal plane. in 14 children an additional ce mra was performed using a standard 3d ge sequence with short tr/te (~6 ms/~1 ms) after intravenous administration of gadolinium (0.1 mmol/kg). source images and maximum intensity projections (mip) were analyzed, evaluating blood-tissue contrast as well as size and focal stenoses of the aortic arch. results: in 21 of 30 an aortic coarctation could be found. using the double-slab technique, in 87 % the image quality was high and there was a low sensitivity to flow and breathing motion. there was a good blood-tissue contrast without the use of contrast agent. using a combined analysis of source images and mip diagnostic accuracy could be improved. conclusion: mr imaging represents an excellent tool for non-invasive examination of the cardiovascular system of children. the double slab method allows recording of a large 3d data set in an adequate measurement time especially in small infants, which were not able to hold their breath, and it is well suited for 3d reconstruction. evaluation of the tais stent in short de novo coronary lesions i.v. pershukov 1 , t.a. batyraliev 1 , a.n. samko 2 , z.a. niyazova-karben 1 , y. pya 1 , y.n. belenkov 2 ; 1 gaziantep/tr, 2 moscow/ru purpose: the tais is a new balloon-expandable, stainless steel, tubular stent. this study was designed to assess the safety and efficacy of this novel coronary stent and by indirect comparison to indicate equivalence with other formal stent studies. methods and materials: patients with angina and a single short (< 15 mm) de novo lesion in a native coronary artery of ≥ 2.75 mm diameter were included. a total of 588 patients were allocated in 2 centers. most patients (59 %) had stable angina, and 34 % of lesions were type b2 -c. clinical data was collected at sixand nine-month follow-up. in the first 308 patients angiography was routinely performed at six months. the remaining 280 patients were merely followed up clinically. results: no stent deployment failure occurred, as well as acute or subacute stent thrombosis. the primary end-point of the study, the six-month mace-rate was 12.3 %, which is similar to the calculated 15 % mace-rate in comparable reference studies. secondary end-points included among others restenosis at six months in the first population. the target vessel diameter was 3.13 ± 0.51 mm. minimal lumen diameter pre/post procedure and at follow-up was 0.81 ± 0.33, 2.97 ± 0.44, 2.21 ± 0.77 mm, respectively. the binary restenosis rate was 15.5 %. conclusion: the coronary tais stent is safe and effective as a primary device for the treatment of native coronary artery lesions in patients with stable or unstable angina pectoris. clinical and angiographic results are in the statistical range of equivalence with comparable studies with other current stents. the aim of this study is to asses if the bmi affects the amount of pulmonary atelectasis developing after general anaesthesia, and its effect on atelectasis evolution. material and methods: two groups of volunteers aged from 27 to 66 years old were prospectively randomised. they all underwent surgical celioscopy. 20 patients with a bmi over 35 kg/m 2 underwent a gastroplasty and 10 patients representing the control group (bmi under 30 kg/m 2 ) underwent a cystectomy. before induction of general anaesthesia, three ct sections of 7 mm, were acquired in expiration at the level of interventricular septum. immediately after surgery and 24 hours later, three ct sections were acquired at the same level. with a threshold of −1000 to +100 hounsfield units, the surface of pulmonary parenchyma was manually extracted from the ct sections. the amount of pulmonary atelectasis was determined with a −100 to +100 hu threshold. results: a statistically significant difference was observed in comparing the group with a bmi over 35 kg/m 2 and the control group in the development of pulmonary atelectasis (p = 0.0021) and in its evolution (24 h p = 0.0008). the bmi affects the amount of pulmonary atelectasis developing after general anaesthesia and its evolution at 24 hours. lymphomatoid granulomatosis: pulmonary abnormalities and correlation with pathology a. patsalides, g. atac, u. hegde, w. wilson, n. patronas; bethesda, md/us lymphomatoid granulomatosis (lyg) represents an angiodestructive lymphoproliferative disorder. immunosuppression is a major risk factor for the development of lyg and the lungs represent the most commonly affected organ. the purpose of our presentation is to report the pattern of respiratory tract involvement in lyg and assess evolution of these lesions after treatment. 22 patients, six females and 16 males, ranging in age from 26 to 73 years (mean, 48 years) were enrolled on a study on the diagnosis and treatment of lyg. the diagnosis was confirmed by lung biopsy in all patients. ct imaging was performed in all patients upon entering the protocol and follow up scans were performed after the initial evaluation in order to assess the effect of treatment. pulmonary involvement was evident in all patients. masses were identified in 19, alveolar and/or interstitial infiltrates in 20, and lymphadenopathy in five patients. pleural effusion was present in six and pleural thickening in one patient. eight patients were found to have pulmonary cavities. pathology studies showed infiltration of the pulmonary parenchyma by lymphoid cells with prominent perivascular distribution. granulomas with various degrees of ischemia and necrosis were also present. on follow up studies, partial or complete resolution of the pulmonary lesions was noted after treatment. the pattern of pulmonary involvement in patients with lyg is consistent with the pathological findings. the imaging findings are not specific. pulmonary biopsy is therefore essential for the establishment of an accurate diagnosis. imaging studies however are useful for evaluating the response to treatment. method: 13 patients with histologically diagnosed neoplasms underwent initial assessment with clinical examination, pulmonary function tests and high resolution ct. pulmonary clearance studies were carried out using using a proprietary nebulizer (amertec, uk) and baselines were obtained contemporaneously with pre-treatment hrct. investigations were repeated immediately after treatment and at one and four months. results were documented independently and compared to determine the presence, severity and timing of changes. results: eight patients were able to complete the study; one died and four were withdrawn on medical grounds. clearance was unaffected by treatment in only one patient, the rest showing a marked increase. in five patients clearance increased immediately post-treatment and occurred in both irradiated and contralateral lung. only 3 of 8 patients showed demonstrated late changes on hrct; there was no corresponding change in the contralateral lung on hrct. there was no correlation between radiation dose and alteration in lung clearance. the pilot study confirms that 99 tc dtpa pulmonary clearance studies are a highly sensitive method of detecting radiation pneumonitis and presumed contralateral sympathetic pneumonitis, and confirms that pulmonary radiation has a systemic in addition to local effect. optimization of the acquisition protocol m. rémy-jardin, a. amara, p. campistron, i. mastora, v. delannoy, j. rémy; lille/fr purpose: to evaluate the accuracy of 3 mm thick reconstructed sections in the diagnosis of bronchiectasis with msct. materials and methods: 40 consecutive patients suspected of bronchiectasis underwent msct of the entire thorax with a 4 × 1 mm collimation. from each data set, two series of images were systematically reconstructed with a high-spatial frequency algorithm: 1 mm (group 1) and 3 mm (group 2) thick scans, at 10 mm intervals. three observers independently analyzed the presence of bronchiectasis and associated abnormalities on group 1 and group 2 lung images. results: no significant difference between group 1 and group 2 was found in: (a) the detection of bronchiectasis [group 1: n = 24 (60 %); group 2: n = 23 (57.5 %); (p = 0.08)]; (b) the evaluation of the extent of bronchiectasis [focal: group 1; n = 10 (25 %) and group 2; n = 7 (17.5 %); (p = 0.39) and diffuse: n = 16 (40 %) in both groups]; (c) the characterisation of bronchiectasis [cylindrical: group 1: n = 24 (60 %); group 2: n = 21 (53 %); p = 0.08; varicose: group 1: n = 5 (12.5 %); group 2: n = 6 (15 %); p = 0.56; cystic (group 1: n = 2 (5 %); group 2: n = 2 (5 %)]. apart from the identification of abnormal bronchial wall thickening (group 2: n = 35; 87.5 % vs group 1: n = 31; 77.5 %; p < 0.05), recognition of associated abnormalities did not differ between the two groups. conclusion: a comparable accuracy of 3 mm and 1 mm thick reconstructed scans in the detection and characterization of bronchiectasis allows the recommendation of a 4 × 2.5 mm collimation with reconstruction of 3 mm thick scans in the screening of bronchiectasis, reducing the radiation dose of msct examinations by 20 %. purpose: for the development, optimization and validation of inhalation therapies it is important to develop a model that covers individual anatomical data, application process, deposition and uptake of applied medication. using cfd, velocities and deposition within the individually segmented tracheo-bronchial tree were simulated. material and methods: multislice ct datasets (n = 20) of the lung were segmented using a hybrid segmentation algorithm to detect the tracheo-bronchial-tree. this algorithm consists of: (a) 3d seeding process, (b) 2d bronchus finder (fuzzy-logicsystem), (c) 2d module to identify peripheral bronchi (template-matching). the influence of three reconstruction kernels on the segmentation process was inves-tigated. the hybrid system was compared to a merely threshold-based segmentation tool by visual assessment performed by two radiologists. the segmented images were used to reconstruct the 3d geometry of the tracheo-bronchial airways. this is meshed using an unstructured tetrahedral mesh. flow analysis and particle tracking model is carried out using cfd to simulate in-and expiratory breath velocities. results: due to the combination of the 3-step algorithm it is possible to segment down to the 8 th generation of bronchi semiautomatically. depending on the kernel used the following sensitivity ranges were obtained: 5 th generation 80 -90 %, 6 th 70 -80 % and 7 th 50 -60 %. calculation of the velocity during in-and expiration revealed a ratio of up to 2.4 (peripheral bronchi/trachea). conclusion: combining individual anatomical data derived from radiological images and a comprehensive model of the respiratory tract enables the simulation of distribution and deposition of inhaled drugs. support: ec (ist-1999-14004: "cophit"), british council b-0863 09:40 ct bronchography: assessment and validation of two approaches for 3d reconstruction c.i. fetita 1 , f. preteux 1 , c. beigelman-aubry 2 , p.a. grenier 2 ; 1 evry/fr, 2 paris/fr purpose: to validate and compare two reconstruction techniques leading to the 3d ct bronchography, by means of a scoring system established with respect to a reference anatomical bronchial tree. the study was conducted on volumetric helical data sets obtained from 20 patients with various chronic airway diseases. acquisitions were performed during breath holding following a full inspiration without any contrast agent. axial images were reconstructed with 1.25 mm thickness and 0.6 mm intervals. for each patient, the bronchial tree was reconstructed using 2 different techniques. the first one consists in a slice-by-slice segmentation of airway lumens followed by a 3d reconstruction using a topological propagation and filtering. the second one is fully-3d and relies on a diffusive-aggregative markovian modeling, which takes advantage of the structural and topological features of the airways. in both cases, the bronchial tree was visualized in a ct bronchogram mode, using a semi-transparent volume rendering technique. the images were assessed independently by 2 radiologists using a scoring system established on the basis of a reference bronchial tree defined up to the subsegmental level. results: the bronchial tree was reconstructed up to the 6 th order by both techniques without any significant difference (96 % accuracy and 97 % robustness). the fully 3d technique running twice faster, proved in addition the capability to reconstruct smaller bronchi distal to the 6 th order. conclusion: 3d bronchography obtained from multislice ct is an accurate technique to reconstruct the airways up to the 6 th -7 th order of division. . the results were compared to 50 patients, which were examined with a standard protocol (120 mas: g120). all other parameters were kept constant. subjective image quality was rated using a three point scale. objective criteria, based on signal-tonoise measurements, were assessed. results: image quality was sufficient in all cases. subjective gradings of image quality, based on soft tissue window settings, were 1.1 for the 120 mas protocol, 1.1 (g+10), 1.1 (g±0), 1.3 (g−10), and 1.2 (g−20), for the body weight adapted protocols. objective criteria showed mean standard deviation values of 5.7 hu for the 120 mas protocol. for the dose reduced protocols, values were calculated as 7.6 hu (g+10), 7.9 hu (g±0), 8.7 hu (g−10) and finally 9.1 hu (g−20). best correlation for the whole subgroup was achieved for the −10 protocol, with nearly constant noise related to the body weight in all patients. conclusions: by deriving mas values from body weight estimation, an individually adapted protocol for chest ct can be recommended. with an adaptation of the tube current time product (x mas = m − 10, m … body weight in kg), a well balanced examination, even in soft-tissue window settings, can be performed. therefore, for other types of ct scanners, analogous protocols may be adapted. highland heights, oh/us purpose: current ct liver perfusion methods typically involve limited (2 cm or less) z-axis coverage with the results displayed in the form of axial cross-sectional perfusion maps. we implemented a full-organ liver perfusion technique and explored the usefulness of providing full-organ volume-rendered perfusion maps. methods: ten ct liver perfusion studies were acquired (technique) for patients with hepatic masses using a series of 5 consecutive acquisitions of the liver during one breathold after the injection of a bolus of contrast (4 -5 ml/s). images of each slice location were acquired every 8.5 seconds. liver perfusion maps were produced using previously published techniques and displayed in both axial and volume rendered modes. results: multislice-spiral acquisitions with a pitch of 1.5 and a 0.5 s rotation enabled full coverage of the liver, portal vein and spleen, which were used as inputs for the perfusion calculation. both the axial and volume-rendered perfusion maps depicted characteristic perfusion patterns of various types of hepatic tumors. small tumors were depicted as area of hyperperfusion, while advanced tumors exhibited a ring of hypervascular tissue surrounding a necrotic core. perfusion values of normal liver tissue corresponded to expected physiological ranges. further investigation is warranted to understand the sampling rate required for clinically relevant quantitative measurements. conclusion: multislice ct scanners may enable full organ assessments of liver perfusion. volume rendering of perfusion images allows potentially superior assessment of perfusion abnormalities and might be used to predict the effectiveness of chemo-and thermoablation therapy. (ratios) were determined using amares. additionally, absolute values of phosphorous metabolites were determined using sloop and an concentration of 2.5 mmol for atp as internal standard, including corrections for inhomogenous b1-fields, t1 relaxation. 10 healthy volunteers and 10 patients with liver chirrosis were included. results: amares allowed relative quantification (metabolite ratios) in all volunteers, however, only in 7/10 patients, due to low signal to noise ratios. using, sloop as postprocessing method, all acquired 31 p-spectra had sufficient signal to noise ratios for all analyzed metabolites. in healthy liver parenchyma, absolute concentrations for pme, pi and pme were 2.3 ± 0.8, 1.5 ± 0.6 and 15 ± 6.2 mmol respectively. for patients pme and pi increased to 6.2 ± 3.8 and 1.8 ± 0.7, pde showed no significant changes (15.2 ± 7.2). conclusion: using sloop, significant changes of energy metabolism, which is a parameter for hepatic vitality, can be observed in patients with chronic liver disease. compared to conventional postprocessing packages, sloop allows for a robust and quantitative assessment. methods and materials: ct scans of 408 patients with 311 malignant (79 primary and 232 metastatic) and 97 benign changes were retrospectively rewieved over a 5-year period. there were 181 women and 227 men. the study protocol consisted of 5 and 8 mm slices of the liver area. images were obtained before and after intravenous injection of non-ionic contrast agent (iopromidum 623.40 mg/ml) in a standard dosage 2 cm 3 /kg, as a bolus. original films were rewieved and sought in favour of capsular retraction by two independent radiologists. the number, location, size, density of the tumor and presence of capsular retraction were evaluated. the final diagnosis of focal changes was based on histopathological findings. results: twelve of 408 patients (prevalence 2.9 %) revealed retraction of liver capsule, which was associated with adjacent hepatic tumor. all 12 tumors were proven pathologically to be malignant (4 hepatocellular carcinoma, 3 colorectal metastases, 1 stomach cancer metastasis, 1 epithelioid hemangioendothelioma, 1 prostate cancer metastasis, 1 breast cancer metastasis and 1 carcinoid). the occurrence of capsular retraction adjacent to the liver tumor in our study was a rarely observed but a specific sign (specificity 100 %) of a malignant process. purpose: virtualprobe® (iôdp, paris, france) is ultrasound acquisition and post processing software that uses an electromagnetic field to acquire positional data, allowing retrospective multiplanar 3d rescanning through a volume of tissue. the aim of this study is to assess the accuracy of measurements made from the reformatted images of normal structures. methods and materials: 30 patients referred for exams of the kidney (9) and abdomen (21) were enrolled. each patient had a conventional ultrasound exam, followed by the virtualprobe®. the average of 3 measurements of sagittal right (30) and left kidney (28), sagittal bladder (9), sagittal spleen (20), cbd (21), and gb wall (18) were recorded. the correlation of the measurements between both methods was caclulated. analysis of variance for measurements of structures < 1 cm (cbd, gb wall) was performed to assess for the intra-observer variability. the correlation coefficients between methods were 0.84, 0.90, 0.96, and 0.83 for the right and left kidney, bladder, and spleen. the correlation coefficients were 0.62 and 0.23 for the cbd and the gb wall. the correlation coefficient for cbd and gb was 0.56. the variance of measurements for the cbd and gb was 0.22 cm for conventional and 0.24 cm for virtualprobe®. although it exists a statistical difference between both methods for these two structures (p = 0.023), the absolute value of the measurement difference (0.02 cm) was less than the intraobserver variability of the conventional data alone (s.d. = 0.09 cm). to evaluate the possible role of multislice ct (msct) in the preoperative evaluation of patients candidate to laparoscopic splenectomy. material and methods: 32 patients underwent msct with 0.5 seconds gantry rotation time. pre (4 × 2.5 mm collimation) and post-contrast (4 × 1 mm collimation) acquisitions, during arterial and portal venous phases were performed after i.v. administration of 140 ml of non ionic contrast agent at 4 ml/s, with a delay time of respectively 22 and 60 seconds. real time interaction with the post-contrast 3d data set was performed on a dedicated workstation to determine total spleen volume, and to assess arterial and venous vascular anatomy. for volumetric determination an hand-trace editing was used to calculate spleen mass to select candidates for laparoscopic procedure. results: at surgery mean volume was 998 cm 3 . calculation based on ct provided a mean error of 8 %. in none of the patients undergoing laparoscopic splenectomy, a conversion in laparotomy was needed. five patients underwent laparotomic splenectomy because of spleen volume greater than 1200 cm 3 . in all cases optimal vascular detail was achieved. conclusion: high resolution msct afforded complete parenchymal, vascular, and volumetric preoperative evaluation of potential laparoscopic splenectomy. volumetric determination provided accurate and reproducible information. changing the imaging paradigm in ultrasound: can 3d technology improve productivity, decrease sonographer work-load and maintain study quality? m.j. o'neill, s.i. lee, j.f. simeone, g.j. harris, p.j. whelan, p.r. mueller; boston, ma/us purpose: virtualprobe® (iôdp, paris, france) is ultrasound acquisition and post processing software that uses an electromagnetic field to acquire positional data, allowing retrospective multiplanar 3d rescanning through a volume of tissue. the aim of this study was to assess the workflow impact for both sonographers and radiologists as well as overall image quality when conventional ultrasound examination was converted to an off-line interpretation model. methods and materials: 38 patients referred for exams of the kidney (9), thyroid (8) and abdomen (21) were enrolled. each patient had a conventional ultrasound exam, followed by the virtualprobe®. the 3d data were blindly reviewed. the time for conventional vs. 3d performance/review was compared for sonographer and radiologist. the diagnostic findings between both methods were compared. radiologist desire to rescan a patient was recorded on an ascending 5 point scale. the average scanning and image review/rescanning time for the sonographer was 14.2, 17.5, and 15.6 min during the conventional and 3.9, 7.0, and 3.8 min during the 3d for renal, abdomen and thyroid. the average review/ interpretation time for the radiologist was 1.3, 1.5, 1.6 min for the conventional and 1.3, 2.7, 3.0 min for 3d for renal, abdomen and thyroid. the desire to rescan averaged 3.4/5 and 1.2/5 for conventional and virtualprobe. all findings on conventional scans were observed on 3d. 2 findings were observed during the 3d only. conclusion: virtualprobe® allows for a 3 fold increase in sonographer efficiency while minimally increasing radiologist time. overall study quality was not different between both methods. predictive ultrasound factors of an adequate biliary drainage through an endoprosthesis in proximal biliary obstructions z. spirchez, m. tantau, b. diaconu, o. anton; cluj-napoca/ro purpose: to study the ultrasound performance in the evaluation of an internal biliary drainage through an endoscopically inserted endoprosthesis in proximal biliary obstructions. materials and methods: 32 patients (14 males, 18 females, mean age 56, range 41 -82) with proximal biliary obstruction due to hilar tumors, treated by biliary stenting using plastic, 7 -12 f, stents were studied. the efficacy of the drainage was assessed clinically and by biochemical parameters. ultrasonographically the size of the right and left hepatic ducts (rhd/lhd) and the intrahepatic bile ducts were noted before and after stenting. the presence and degree of aerobilia and the position of the stent (the proximal end above or below the stenosis) were noted after stenting. of pancreatic structures and abnormalities were evaluated using a three point grading scheme. furthermore the differentiation of cystic versus solid tumors was compared. results: in the detection of pancreatic lesions there was no statistically significant difference between both modalities (overall sensitivity 67 % with thi and 64 % with bm, specificity 100 % with thi and 97 % with bm). the differentiation between simple cystic, complicated cystic or solid tumors, is improved with thi. the visibility of the pancreas was not sufficient in 23 % because of technical problems (eg. meteorism). in patients with adequate visualisation of the pancreas the pancreatic duct could not be sufficiently delineated in 38 % with thi and 59 % with bm. conclusions: image contrast and delineation of the pancreas as well as diagnostic accuracy are improved with thi in comparison to conventional sonography. characterization of focal liver lesions by pulse inversion harmonic imaging (pihi) with levovist in patients with cirrhosis b. forgács 1 , e. quaia 2 , m. bertolotto 2 , l. crocè 2 , l. dalla palma 2 ; 1 budapest/hu, 2 trieste/it purpose: the aim of this study was to determine capabilities of pulse inversion harmonic imaging (pihi) with levovist in characterization of focal liver lesions in cirrhotic liver. methods and materials: 39 liver focal lesions in 25 consecutive cirrhotic patients identified by baseline ultrasound (us), were evaluated by color doppler (cd) and pihi. pihi was performed 30 seconds (vascular phase) and 3 -5 minutes (late phase) after levovist injection. helical ct (hct) (n = 15) or surgical/bioptic histologic findings (n = 10) were considered as reference procedures. results: 30 lesions classified as hepatocellular carcinoma (hcc) by reference procedures appeared hypoechoic (n = 19), isoechoic (n = 5) or hyperechoic (n = 6) on baseline us, with basket pattern (n = 10), vessels within tumor (n = 6), peripheral (n = 4) or no vascular pattern (n = 10) on cd. on pihi they appeared hyperechoic (n = 26) or isoechoic (n = 4) on vascular phase and prevalently hypoechoic (n = 22) or isoechoic (n = 6) and rarely hyperechoic (n = 2) on late phase. four (4) lesions classified as regenerative nodules by reference procedures appeared hypoechoic on baseline us, with peripheral (n = 1) or no vascular pattern (n = 3) on cd. on pihi they appeared hypoechoic (n = 3) or isoechoic (n = 1) on vascular phase, remaining prevalently hypoechoic (n = 3) or isoechoic (n = 1) on late phase. five (5) lesions classified as hemangioma by reference procedures appeared hyperechoic (n = 4) or hypoechoic (n = 1) on baseline us with few flow signal on cd. on pihi they revealed progressive fill-in or dot-like enhancement during vascular and late phase. conclusions: pihi with levovist had identified some typical enhancement pattern in focal liver lesions in cirrhotic patients. conclusions: mri has low sensitivity to identify small lymph nodes. when visible, mri with sinerem has high sensitivity to identify metastatic lymph nodes; the overall low specificity was due to a learning curve in the first cases. when objective data are combined with subjective impression of the radiologist results are quite satisfactory. to assess the performance of ms-325, a gd-based and albumin-bound contrast agent, for the differentiation of normal and tumor-bearing (vx2) lymph nodes of rabbits with interstitial mr lymphography. materials and methods: experiments were conducted on 4 mature male white new zealand rabbits. fully anesthetized, the animals underwent mr examination twice: prior to and three weeks following implantation of vx2-tumor cells to the left flank. for each session 1.0 ml of undiluted ms-325 was injected subcutaneously into both dorsal foot pads. 3d mr imaging was performed on a 1.5 t whole body scanner prior to as well as 5, 10, and 15 minutes post injection of the compound. contrast medium uptake in the individual lymph nodes and the lymph node size were determined. finally all animals were euthanized and lymph nodes were analyzed by histopathology. results: interstitial mr lymphography with ms-325 visualized lymphatic structures as well as popliteal and inguinal lymph nodes in all animals. vx2 tumours were well differentiated from surrounding tissues in all rabbits. maximum enhancement values were present 10 minutes following contrast medium injection in both normal and tumour-invaded lymph nodes. roi measurements in normal lymph nodes revealed statistically significant higher cnr values compared to tumourbearing lymph nodes. vastly reduced contrast medium uptake in tumour invaded lymph nodes permitted easy detection thereof. the size of normal and tumor-invaded nodes was not significantly different. in addition to providing a means for display of the normal lymphatic system, ms-325-enhanced mr lymphography allows for depiction of direct tumour invasion in lymph nodes. interstitial mr lymphography in rabbits: assessment of inflammatory and normal lymph nodes by different gadolinium-based contrast agents (dota, p760, p792) c.u. herborn, t.c. lauenstein, f.m. vogt, m. goyen, j.f. debatin, s.g. rühm; essen/de purpose: to assess three different gadolinium-based contrast medium compounds in order to distinguish normal from reactive inflammatory lymph nodes by interstitial mr lymphography in rabbits. materials and methods: experiments were conducted on 9, fully anesthetized mature white new zealand rabbits. in each set of three rabbits 1.0 ml of undiluted gd-dota, p760, or p792 (guerbet, france) was injected subcutaneously into the dorsal foot pads. whereas gd-dota is an extracellular, commercially available contrast medium agent, the latter are new macromolecular compounds, undergoing pre-clinical testing. mr examinations were performed three times in each rabbit prior to as well as 2 and 14 days following induction of inflammatory lymph node reaction by the application of freund's complete adjuvant. imaging was performed on a 1.5 t mr system using conventional 3d sequences. contrast uptake in the individual lymph nodes as well as the lymph node sizes were determined. results: interstitial mr lymphography visualized popliteal and inguinal lymph nodes with all evaluated contrast agents. maximal enhancement occurred 10 minutes after contrast medium injection for all three tested compounds. inflammatory lymph nodes revealed statistically significant higher cnr values compared to normal nodes (p < 0.05). average cnr values for the macromolecular contrast medium agents (p760, p792) and the extracellular compound (gd-dota) were not statistically different. furthermore, the size of inflammatory and normal nodes was not significantly different. tuesday b a c d e f 307 conclusion: all three contrast medium agents appear well suited for interstitial mr lymphography to visualize popliteal and inguinal lymph nodes in rabbits. determination of contrast medium uptake can aid in differentiating reactive inflammatory from normal lymph nodes. initial experience with mr-lymphography and employment of iron oxide contrast material for the detection of metastatic lymph node involvement in rectal cancer w. purpose: to evaluate mr-lymphography by employment of iron oxide contrast material (sinerem) in the preoperative evaluation of lymph node (ln) metastases of rectal cancer. method/materials: mr-lymphography of the pelvis was performed using plain and enhanced mr images after 24 to 36 hours after intravenous administration of superparamagnetic iron oxides at a dosage of 2.6 mg fe/kg b.w. conventional t1and t2-weighted spin-echo sequences as well as t2-weighted gradient echo sequences were performed. a total of 8 patients were examined. mri findings were correlated to histopathology in every case. results: a total of 108 ln in 8 patients were histopathologically evaluated and the findings correlated with mri. 7 ln metastases were detected histopathologically. mri was able to detect 6 of the 7 metastatic ln. the size of the analysed ln was approx. 5 mm in most of the cases. all malignant ln presented with a size between 10 and 25 mm. mri missed one ln metastasis with a size of 6 mm. 3 ln metastasis had a size between 6 -10 mm, 2 ln metastasis were 16 -20 mm in size, and 1 ln metastasis had a max. diameter of 25 mm. conclusions: mr-lymphography with employment of the new iron oxide contrast material is a promissing imaging modality for the detection of ln metastasis. studies with a large study population need to further evaluate the potential of this imaging modality. optical imaging of lymph nodes -a new technique for lymphography p. wunderbaldinger 1 , c. bremer 2 , u. mahmood 3 , l. josephson 3 ; 1 vienna/at, 2 münster/de, 3 charlestown, ma/us purpose: to validate the use of near infrared fluorescence imaging (nirf) using enzyme sensitive optical probes for lymph node detection. material and methods: an optical contrast probe that is activated by cystein proteases was used to visualize lymph nodes by nirf reflectance imaging. in order to quantitate the uptake of the optical probe in lymphatic tissue the biodistribution was assessed using the 111 in labeled optical probe. sixteen balb-c mice were injected either intravenously (i.v., n = 10) or subcutaneously (s.c., n = 6) with the nirf-probe (2 µmol gy/animal) and imaged 24 hours after injection. signal intensities and target-to-background ratios of various lymph nodes were measured by manual regions of interest (rois). additional signal intensity measurements were performed of excised lymph nodes (n = 21) from i.v. injected mice (24 hours after injection) and compared to excised lymph nodes (n = 8) of non-injected mice. the probe employed in this study was lymphotropic with about 3 -4 % accumulation in lymph nodes (3.4 ± 0.8 %id/g). lymph nodes showed a high fluorescence signal throughout the body after i.v. injection (96 ± 7.8 au) and/or regionally after s.c. injection (141 ± 11.5 au). the signal intensities of lymph nodes was significantly higher after s.c. probe administration compared to iv administration (p < 0.01), as was the target-to-background ratio after s.c. administration (6.6 ± 0.81 vs 4.8 ± 0.67; p < 0.05). measurements of the excised lymph nodes (after i.v. injection) confirmed a significant increase in lymph node fluorescence signal (26 ± 7.6 au vs. 146 ± 10.9 au; p < 0.0001). conclusion: detection and visualization of lymph nodes is feasible by nirf imaging using enzymatic activatable optical probes. ultrasmall superparamagnetic iron oxide particles (uspio) in magnetic resonance imaging (mri) of primary malignant lymphoma: are there changes in signal intensity of enlarged lymph nodes after contrast application? g. michna 1 , j. kromeier 1 , j. laubenberger 1 , g. paul 2 , m. langer 1 ; 1 freiburg/de, 2 bonn/de purpose: the aim of this study was to assess the potential value of mri with uspio-particles (g534-70, sinerem®) for the nodal staging in primary malignant lymphoma. according to several studies normal tissue in liver, spleen, and lymph nodes shows an uptake of uspio particles due to phagocytic activity of res-cells. material and methods: ten patients with histologically proven untreated primary malignant lymphoma were studied. pre-and post contrast injections of sinerem® mr-scans were obtained from 9 patients. the relative signal intensities of 23 lymph nodes with a size of more than 10 millimeters were measured. we compared (incl. sd) the delta of mean values of pre and post contrast signal intensities in t1-w and t2-w images. results: the diameter of lymph nodes ranges from 13 mm to 105 mm. in t1-w images the delta of mean values of pre-and post contrast signal intensities varied between 0.70 and 1.62. post contrast images showed no significant change in signal intensity. in t2-w images the delta of mean values of pre-and post contrast signal intensities varied between 0.60 and 1.20. there was no significant change in signal intensity in post contrast images. conclusion: there were no significant changes in signal intensity in post contrast t1-w and t2-w images in primary malignant lymphoma. this finding suggests that in these enlarged lymph nodes no active res-cells are present to phagocytise the uspio agent due to the malignant involvement. ionic and non-ionic iodinated contrast media induce neutrophil apoptosis through a caspase-dependent pathway n.f. fanning, b.j. manning, h.p. redmond, j.g. buckley; cork/ie purpose: iodinated contrast media (icm) can induce apoptosis (programmed cell death) in renal and myocardial cells. following intravascular injection, circulating immune cells are exposed to high concentrations of icm. as neutrophils constitutively undergo apoptosis, we hypothesised that icm may adversely affect neutrophil survival. our aim was, therefore, to investigate the effect of icm on neutrophil apoptosis. materials and methods: neutrophils were isolated from healthy subjects and cultured in vitro with ionic (diatrizoate and ioxaglate) and non-ionic (iohexol and iotrolan) icm. neutrophil apoptosis was quantified by annexin v flow cytometry, and caspase dependence determined using the caspase inhibitor zvad-fmk (100 µmol). results: data presented as percentage apoptosis ± s.e.m. iso-iodine concentrations (20 mg/ml) of ionic (diatrizoate 69.6 ± 2.9; ioxaglate 58.9 ± 2.0) and non-ionic (iohexol 57.3 ± 2.9; iotrolan 57.1 ± 2.6) icm significantly induced neutrophil apoptosis over control levels (47.7 ± 1.4, n = 10). ionic icm had a more significant (p < 0.01) apoptotic effect than non-ionic icm (p < 0.05). furthermore, icm reversed the anti-apoptotic effect of lipopolysaccharide (1000 ng/ml) treated neutrophils (23.0 ± 3.5 to 61.2 ± 5.3; n = 4; p < 0.05). iohexol induction of apoptosis is caspase dependent as zvad-fmk reversed its pro-apoptotic effects to control levels (75.7 ± 2.7 to 53.7 ± 1.1; p < 0.05). these results clearly demonstrate that icm promote apoptosis in unactivated and activated neutrophils by a caspase-mediated mechanism. a recent report suggests that icm can increase the incidence of local and systemic septic complications in patients with mild acute pancreatitis (carmona-sanchez r.; arch surg, 2000; 135:1280-4) . icm, through induction of neutrophil apoptosis, could have significant deleterious effects on host immune defence and resolution of an inflammatory response. effect of intravenous injection of iopromide on regional renal blood flow and medullary oxygen tension in diabetic rats f. palm, p.-o. carlsson, p. hansell, a. fasching, o. hellberg, a. nygren, p. liss; uppsala/se purpose: hemodynamic disturbances with subsequent renal medullary ischemia have been suggested as key mechanism in the pathogenesis of contrast media (cm)-induced nephropathy. increased risk of cm-induced renal failure is seen during diabetes mellitus with nephropathy. the present study investigated the effect of an a c d e f 308 injection of the cm iopromide (600 mg i/kg) on regional renal blood flow (cortical and outer medulla) and oxygen tension (outer medulla) in streptozotozin induced four-or nine-week-diabetic wistar furth rats. material and methods: oxygen tension was measured with modified clark-type microelectrodes and blood flow with laser-doppler flow probes. results: administration of cm decreased the outer medullary oxygen tension in non-diabetic animals by ∼ 35 %. this response was absent in diabetic animals. renal outer medullary blood flow of non-diabetic animals increased after cmadministration and remained elevated (∼ 25 %). in contrast, no change in outer medullary blood flow occurred in the diabetic animals. glucose infused non-diabetic animals responded similarly in medullary oxygen tension to normoglycemic animals, but similarly to diabetic animals in medullary blood flow, following cminjection. conclusion: we conclude that diabetic animals have an altered response in renal outer medullary blood flow and oxygen tension to cm compared to normoglycemic animals. however, in contrast to corresponding control rats, outer medullary oxygen tension did not decrease in diabetic animals, which suggests other mechanisms than hemodynamic changes to explain the increased renal failure frequency in this risk group for cm-induced nephropathy. doppler intensitometry: quantitative comparison of two ultrasound contrast agents in humans j.-m. correas 1 , v. dhalluin-venier 1 , l. bridal 1 , p. burns 2 , o. hélénon 1 ; 1 paris/fr, 2 toronto, on/ca purpose: to quantify the doppler signal enhancement following the injection of two different ultrasound contrast agents (uscas) in humans, levovist® (schering sa, germany) and optison® (fso69, mallinckrodt, usa). materials: 24 patients received 2 bolus injection of optison® (1, 2, 3, and 4 ml, randomized dose) and 1 injection of levovist® (2.5 g, 5 ml, 400 mg/ml). the continuous doppler signals from the radial artery were digitized to calculate mean duration of the enhancement, peak enhancement and area under the time-intensity curve (auc). in 3 patients, the doppler signals could not be analyzed due to wrist movement artifacts. results: the duration of the enhancement was respectively (mean ± standard deviation) 255 ± 50 s for the levovist® and 307 ± 93, 304 ± 78, 301 ± 85 and 386 ± 97 s for each dose of optison® (1, 2, 3, and 4 ml). peak enhancement was respectively 17.8 ± 5.1 db for the levovist® and 20.4 ± 3.4, 21.6 ± 3.4, 21.9 ± 2.8 and 22.3 ± 2.2 db for each dose of optison®. auc was respectively (linear units) 5009 for the levovist® and 6311, 10765, 13522 and 15854 for each dose of optison®. a linear relationship was found between the dose of optison® and the enhancement (r > 0.97). levovist® enhancement exhibited a larger variability between patients. purpose: this study was designed to validate the reliability of the ao comprehensive classification using routine radiographs to predict the intra-operative findings. a second goal of this study was to assess interobserver variability of this classification. the radiographs or computed radiographs (cr) of the thoracic and lumbar spines of 32 patients (18 male, 14 female) from jan 2000 to march 2001, were reviewed retrospectively by four separate observers, two experienced staff and two residents without knowledge of the operative findings. each fracture was categorized according to the ao comprehensive spinal fracture classification into type a, type b or type c injuries based on agreed well defined radio-logic criteria. this was compared to the intra-operative findings which assessed the integrity of the posterior ligament complex and mobility of the injured segments. the concordance of the radiologic classification and the intra-operative findings was 75 % (24/32) for orthopedic spine surgeon, 62 % (19/32) for orthopedic resident, 54 % (17/32) for skeletal radiology staff, and 66 % (22/32) for radiology resident. the mean correct designation of the fracture classification was 64.5 %. there were 28 % (9/32) of fractures categorized as type a injuries by 50 % or more of the observers which proved to be type b injuries at surgery. conclusion: the use of plain films or cr to categorize fractures of the thoracolumbar spine according to the ao classification was associated with a designation of 28 % of unstable b injuries as stable type a injuries. there is moderate interobserver variability. with suspected spine injury were evaluated using rx and spiral ct performed in admitting area. all patients received standard thoracic ct (5 mm/pitch 1.5) and abdominal ct (8 mm/pitch 1.5) according to an established trauma protocol including sagittal mpr reconstructions of suspicious vertebral bodies. rx and ct were independently evaluated by two blinded radiologists for detectability of fracture signs and classified in three groups (g1 -g3): definitely fractured (g1); non conclusive result (g2); definitely no fracture (g3). all suspected fractures were confirmed by an additional high resolution ct (2 mm -3 mm/pitch 1.5) and clinical follow up. results: in 21 patients (37 %) of the 56 patients a spine fracture could be depicted. 2 fractures were missed in rx, none in ct. 98 % of the ct reports and 89 % of the rx reports were classified correctly true positive (g1) or true negative (g3). 8.4 % of rx-reports were non conclusive (g2), but only 1 % in ct. in comparison ct versus rx sensitivity was 1/0.88, specificity 0.98/0.92, positive predictive value 0.93/0.92 and negative predictive value 1/0.97 conclusion: using an established standard ct protocol for chest and abdomen examination with slice thickness of 5 mm and 8 mm respectively all relevant spine fractures can be detected. these results suggest that rx of thoracic and lumbar spine is not mandatory in the admitting area, when thoracic and abdominal ct is performed. correlation between ct and clinical findings in patients with spine injuries -analysis of 193 cases t. turek, m. sasiadek; wroclaw/pl purpose: to analyze the correlation between ct appearances of spine injuries and clinical findings and thus to establish the clinical significance of the finding at ct. methods and materials: ct studies have been performed in 193 patients after spine injury. in most of them plain films of the spine were performed prior to ct. 27 patients had also mr. head ct was performed in 25 cases and chest ct in 18 patients. ct findings (the presence of fractures and facet joints injuries, number of involved vertebrae and spinal columns, narrowing of spinal canal, instability features, intervertebral disc lesions, normal study, etc.) have been compared statistically with clinical symptoms (pain, spinal medulla injury, radicular symptoms, disturbance of consciousness, etc.). results: there was statistically significant correlation found between clinical signs of spinal medulla injury and several ct symptoms (instability, spinal canal narrowing, number of affected vertebrae and columns, facet joint lesions). in patients with pain and no severe neurological signs there was positive correlation with a normal ct study. radicular symptoms have been associated with intervertebral disc lesions and in chronic cases with degenerative changes of the spine. consciousness disturbances have been negatively correlated with spine fractures, while positively with normal ct appearance of the spine and traumatic changes on head ct. conclusion: ct symptoms of spine injury are highly correlated with severity of the clinical and neurological findings, except for consciousness disturbances which are associated with simultaneous head injury. thus, ct is very helpful in establishing prognosis and treatment planning. the purpose of this study is to evaluate the efficiency and safety of self-expandable stent insertion in patients with acute colonic malignant obstruction before elective surgical resection. between march 1999 and march 2001, 24 patients (15 males and 9 females, mean age 74, range 41 -93) were included. all the patients were scored asa iii. colonic cancers were located between the rectosigmoid and the middle part of the descending colon. all patients had plain abdominal radiography and ct scan to demonstrate the complete obstruction of the colon and to localise the stenosis. immediate technical success was obtained in 23 of 24 patients (96 %). the mean time between stent insertion and surgery was 6 days (3 to 9). in 2 cases (8 %), stents were misplaced and did not covered the lesion which required the insertion of an other stent. in 2 (8 %)other cases, the stent was initially well positioned but migrated secondarily which required the insertion of a second stent in one and a surgery in a other one. colonic perforation occurred in 3 (12 %) patients. these 3 patients underwent surgery, one of them developed an abscess which required percutaneous drainage under radiological guidance, other (8 %) patients underwent ileostomia because of a missprepared colon by stent dysfunction (obstruction). there was no more morbidity (21 %) and no death (0 %) at the moment. self-expandable stent insertion is an efficient minimally invasive procedure that allows for single-stage surgery. however, this technique is quite difficult to perform and may be associated with some complications. sites of obstruction were antro-duodenum (n = 18), postoperative anastomotic site (n = 19; 12 gastroenterostomy, six esophagojejunostomy, and one duodenojejunostomy). all stents were covered with polyurethane. the size of the stent ranged from 15 -20 mm in diameter and 7 -20 cm in length. with fluoroscopic guidance, covered self-expandable metallic stents were placed. results: stent placement was technically successful in all patients without or with the gastrostomy (n = 3) and balloon dilatation (n = 3). after stent placement, symptoms improved in all but one patient, who had another stenosis at the proximal jejunum. during the follow-up of 2 -73 (mean 13) weeks, stent migration occurred in four patients (10.8 %) 1 -41 days after the procedure. those patients were treated successfully by means of placing a second covered metallic stent (n = 3) or endoscopic reposition (n = 1). recurred obstructive symptoms due to tumor overgrowth (n = 2) and mechanical failure of stent (n = 2) were noted. one of tumor overgrowth and both of the mechanical failure of stent were treated by means of coaxial placement of a second covered stent with good clinical result. conclusion: fluoroscopy-guided placement of covered self-expandable metallic stents can be considered as the primary choice for the palliation of malignant obstructions in those patients. the laparoscopically placed adjustable gastric band (lap-band™) has been popularised as a minimally invasive, adjustable and completely reversible surgical technique for the management of morbid obesity. we report our experience with particular emphasis on the radiological aspects of follow-up and patient results in terms of short-term weight loss and complications. methods: between may 1998 and december 2000 50 patients were treated (8 male/42 female) with a mean age of 37 years (range 30 -48 years). the technique of fluoroscopy guided band inflation is illustrated with particular emphasis on radiological lessons learned. a new method of measurement of pouch volume and the passage within the band is described. results: mean number of radiology-guided inflations per patient was 2.6 (range 1 -7). the volume used for inflation was noted to be critical, with 0.5 ml making the difference between complete obstruction and optimal band inflation. the mean hospital stay was 2.8 days (range 2 -10 days). 4 % had gastric pouch formation and 4 % had nonfatal pulmonary embolism. there was no mortality. the follow-up was up to 30 months. the mean bmi decreased from the pre-operative level of 43 kg/m 2 (range 38 -55 kg/m 2 ) to 34.5 kg/m 2 . the lap band is an effective procedure in the treatment of morbid obesity. initial weight loss is comparable with other open bariatric procedures but with the added benefit of a shorter hospital stay, less pain and a low frequency of complications. fluoroscopy guidance is useful in puncturing the subcutaneous valve and mandatory in assessing optimal band inflation. radiological percutaneous gastrostomy with ballon retained catheters in malignant upper digestive tract obstruction h.-p. dinkel, j. triller; berne/ch purpose: to assess success and feasibility of radiological percutaneous gastrostomy in malignant pharyngeal or esophageal obstruction where endoscopic passage was impossible. methods: we report a prospective series of 30 consecutive patients with esophageal and/or head and neck tumors who required artificial enteral feeding by means of gastrostomy. in all patients endoscopic passage was not possible or extremely difficult. in order to avoid surgical gastrostomy we performed a radiological gastrostomy using the following technique. first, the stomach was punctured under fluoroscopic guidance and gastropexy using 3 -4 cope-type t-fasteners was performed. then a balloon-type gastrostomy catheter was inserted using a peel-away sheath. results: pg was technically successful in all cases. the gastrostomy remained for 5 to 26 weeks. complications occurred in 10 % (2 minor, 1 major). one patient developed a peristomal leakage due to bowel atony and incomplete voiding of the stomach managed by insertion of a jejunal nutrition catheter through the gastrostomy tract whereafter the leakage subsided an the gastrostomy tract healed. one patient had minor suture infection and delayed gastric voiding. in one patient the early catheter dislocation and peritonitis occurred due to erroneous food injection into the balloon port. conclusion: radiological gastrostomy by means of ballon-retained catheters is a feasible and relative safe procedure. most complications can be managed conservatively or interventionally. care should be taken to avoid erroneous injection into the balloon port, especially within the first week of pg in order to avoid tube dislocation. to compare the diagnostic accuracies of sonography, scintigraphy in diagnosing ileocecal crohn's disease (cd) and assessing its activity compared to enteroclysis and final diagnosis. method: a retrospective analysis of the studies of 54 patients (30 females, 24 males, ages of 18 -71) with verified cd (operation: 8, biopsy: 50 cases). located to the ileocecal region was made. all patients had enteroclysis, sonography (4 -8 mhz receiving frequency with native tissue harmonic imaging, and measurement of the flow in the superior mesenteric artery (sma)) and 45 of them had 99 tc agab immunoscintigraphy with spect. the results were compared. results: overall sensitivity of enteroclysis, sonography and immunoscintigraphy was 100 %, 89 % and 71 %. in early crohn disease (12 cases) the sensitivities were 100 %, 75 % and 40 % respectively. in detecting active disease (determined by the presence of ulcerations or fistulas in enteroclysis) immunoscintigraphy had 70 % sensitivity, 33 % specificity. increased sma flow had 76 % sensitivity; 100 % specificity, while wall thickening (> 3 mm) had 92 % sensitivity; 33 % specificity. using a combined sonographic criteria (presence of destroyed wall stratification or detection of fistulas or abscesses or increased sma flow) 96 % sensitivity and 100 % specificity is obtained. surgical indications (fistulas or abscesses) were detected in 6/8 cases by both enteroclysis and sonography. conclusion: although the sensitivity of sonography in early cd is not sufficient for detecting suspected cd, for follow up in advanced cases sonography could replace enteroclysis. new combined sonographic criteria gives excellent correlation with enteroclysis detected activity. sensitivity for detecting abscesses might compensate for missed fistulas. crohn disease: evaluation of small and large bowel with combined ct enteroclysis and ct colonography a. cieszanowski, k. wojciechowski, r. pacho, b. pruszynski; warsaw/pl purpose: to evaluate the new method -combined ct enteroclysis and ct colonography -for the assessment of whole bowel in patients with crohn's disease. method and materials: 20 patients suspected of having crohn's disease underwent ct colonography after i.v contrast material injection. in 10 of them 1500 ml of fluid was administered by nasoenteric tube positioned in the duodenojejunal region (ct enteroclysis) and in another 10 patients water was given orally (1500 -2000 ml), beginning 30 -40 minutes before the examination. intestinal and extraintestinal abnormalities were evaluated. small bowel distention was assessed in 4 grade scale (good = 4, poor = 1). results were compared to enteroclysis, colonoscopy and intraoperative findings. results: in 15 patients with confirmed crohn's disease ct correctly identified all involved small bowel (n = 17) and colonic (n = 8) segments, although underestimated their length in 5 cases (20 %). mesenteric involvement was seen in 10 of 15 patients with crohn's disease (67 %), lymphadenopathy in 14 (93 %), perianal disease in 6 (40 %), abscess and fistula in 1 patient (7 %). the distention of small bowel was significantly better on ct enteroclysis (mean score 3.3) than on ct performed after oral fluid administration (mean score 2.7). conclusion: both techniques enabled simultaneous evaluation of small and large bowel during single examination and allowed identification of all involved bowel segments, although, visualization of small bowel was significantly better with the use of ct enteroclysis than after oral administration of fluid. material and methods: 50 patients affected by cd were examinated at 1.5 t, using fat and non fat-suppressed t2 w haste sequences after administration of a negative superparamagnetic oral contrast agent and t1w flash sequences, pre and post gd-dtpa injection. all patients underwent endoscopy, us, barium studies (gold standard), 7 had surgery. all mri data were blindly evaluated by two radiologists. the degree of strictures, the presence of small bowel dilation, adhesions, sinus tracts, fistulas, abscesses, biliary, pancreatic and renal abnormalities were evaluated. results: mri correctly detected 95 % of strictures (100/105), 100 % of adhesions (47), 85 % of fistulas (18/21), 100 % of abscesses (5), hydronephrosis (2), biliary, renal and pancreatic stones (5). in 6/50 patients (12 %) mri showed complications undetected by the gold-standard modalities. conclusions: mri is a promising method to assess main complications of cd. differentiation of inflammatory bowel diseases by hydro-mri k. schunk, s. reiter, a. kern, s. schadmand-fischer, t. orth; mainz/de purpose: to assess hydro-mri regarding the differentiation of inflammatory bowel diseases. after an oral bowel opacification using 1000 ml of a 2.5 % mannitol solution and a rectal bowel opacification using 250 -500 ml of an 0.9 % saline solution, axial and coronal breath hold sequences ± gd-dtpa (haste ("half-fourier acquisition single-shot turbospinecho") and dynamic flash ("fast low angle shot")) were acquired in 27 patients with inflammatory bowel disease. by mri findings, crohn's disease (cd; n = 15) and ulcerative colitis (uc; n = 12) should be differentiated. results: cd and uc showed significant differences regarding the number of affected bowel segments (2.3 ± 1.5 vs. 1.2 ± 0.5; p = 0.01), the incidence of nodular bowel wall thickening (1/15 vs. 8/12; p = 0.002), and the incidence of a blurred demarcation of the inflamed bowel wall against the surrounding mesenterial fat tissue (9/15 vs. 1/12); p = 0.007). there were no significant differences regarding the contrast enhancement of the inflamed bowel wall (+37.7 ± 28.3 % vs. results: before treatment unenhanced pd showed circumscribed hypervascularity of affected bowel loops, consistent with acute disease relapse, in 13/18 patients (72.2 %); in 5 patients the typical acute stage hypervascularity was demonstrated only with ce-pd (p < 0.05). in seven patients with complete clinical recovery no residual enhancement of the affected loop was found at post-treatment follow-up by either unenhanced or ce-pd. of the patients with clinical persistence of acute disease, 6 (54.5 %) showed typical hypervascularity on conventional unenhanced pd, 4 (36.3 %) had hypervascularity documented only on ce-pd (p < 0.05) and 1 (9.2 %)had no enhancement detected even after contrast administration. ce-pd had higher sensitivity (90.8 %) compared to conventional pd and 100 % specificity. purpose: to assess feasibility, safety, and effectiveness of percutaneous imageguided radio-frequency (rf) thermal ablation of the lung. the research project includes an experimental animal study and two clinical phases. in the animal study, 12 rabbits will undergo in vivo rf ablation of lung tissue. rabbits will be sacrificed and histologic analysis of the specimens will be performed to assess cell viability. the clinical part of the project includes two phases: (1) 10 patients with resectable cancerous nodules will undergo ct-guided rf ablation and subsequent pulmonary resection and pathology examination of surgical specimens; (2) 30 patients with unresectable lung tumors will undergo ct-guided rf treatment; in these cases the outcome of rf ablation will be assessed by follow-up ct studies performed 1 month after the procedure a c d e f 314 and at 3-month intervals thereafter. rf ablations are performed by using a 150 w generator (rita medical systems) and a 15 gauge, 9 hook expandable electrodeneedle. results: to date, 8 new zealand white rabbits underwent in vivo fluoroscopyguided rf of lung tissue. two rabbits were sacrificed immediately, one after 24 hours, two after 3 days, two after 2 weeks, and one after 1 month. on gross examination, round, sharply demarcated thermal lesions measuring 21.4 ± 2.1 mm in diameter were observed in all cases. histopatology analyses confirmed coagulation necrosis with no intervening viable cell. conclusion: findings of the animal study showed that rf ablation of pulmonary rabbit parenchima can be safely and effectively performed via a percutaneous, transthoracic approach, thus prompting the start of clinical studies. b-0922 10:40 2-component fibrin clue injection for needle tract obliteration during ctguided percutaneous cutting biopsy of lung lesions m.c. freund 1 , c. riedl-huter 1 , k.m. unsinn 1 , m. hackl 2 , t. schmid 1 , w.r. jaschke 1 ; 1 innsbruck/at, 2 natters/at purpose: pneumothorax is the most common complication of percutaneous lung biopsy. in order to reduce the incidence for pneumothorax a commercially available 2-component fibrin glue (tissucol® duo quick) was injected in the puncture tract during the withdrawal of the coaxial sheath at the end of the examination. methods and materials: in total 120 consecutive adult patients underwent ctguided percutaneous biopsy for histological evaluation of an intrapulmonary lesion utilizing a 17 -18 g coaxial cutting biopsy system. all lesions were surrounded by aerated lung parenchyma and were located within 0.5 -12.0 cm distance (mean, 3.3 cm) from the pleural surface. lesion size measured 0.8 -10.0 cm (mean, 3.6 cm), in total 1 -8 biopsy passes per lesion (mean, 3.6) were performed, and in 57/120 patients a perilesional hemorrhage 0.7 -4.5 cm diameter (mean, 1.9 cm) was observed. patients were assigned to undergo biopsy either without (group i) or with (group ii) the use of a 2-component fibrin glue. all patients were observed after biopsy; after 2 -4 hours a spiral-ct of the thorax and after approximately 24 hours a chest radiography was performed for pneumothorax detection. the rate of ct-proven pneumothorax resp. for chest tube insertion in group i was 40 % resp. 4 % and in group ii 10 % resp. 2 %. conclusion: the injection of a 2-component fibrin glue in the puncture tract during withdrawal of the coaxial sheath significantly reduces the incidence for pneumothorax as well as the rate for chest tube insertion. parietal extrapleural saline for the reduction of pneumothorax in percutaneous lung biopsies (plb) t. petsas, i. tsota, c.p. kalogeropoulou, m. karamesini, n. samaras, d. dougenis, i. dimopoulos; patras/gr purpose: in this study we evaluate the efficacy of extrapleural injection of normal saline at the initial procedural phase of percutaneous lung biopsy in order to prevent pneumothorax. methods: 66 patients underwent plb under ct guidance, for diagnosis of lung lesions. the patients were randomized in either group a or b. in 33 patients (group a) normal saline was injected beneath the parietal pleura just before the procedure. in the remaining 33 patients (group b) no saline was used. all biopsies were conducted under ct using a 19 g -22 g coaxial needle system. in group a, after local anesthetic infusion, the needle was advanced in the subpleural fat and 20 -30 ml of saline were injected extrapleurally, in order to create a bulge of pleura into the lung parenchyma, adjacent to the lesion. all patients had ct scan 15 min after, and plain chest radiogram after 4 hours after the procedure in order to evaluate the presence of pneumothorax. results: the procedure was well tolerated in group a. pneumothorax developed in 3 patients (9.1 %) in group a. in group b, pneumothorax occured in 7 patients (21.2 %) and in one instance drainage was required (3.03 %). the technique prolonged the duration of the procedure 9 -17 min in group a. conclusion: our results suggest that extrapleural injection of saline reduces plb induced pneumothorax. it is a supplementary technique, which can be used in patients who are prone to develop pneumothorax. application of a new specially designed guide stylet set in chest biopsies t. petsas, c.p. kalogeropoulou, i. tsota, d. karnabatidis, p. angele, d. siablis, i. demitrios; patras/gr purpose: we evaluate the efficacy of a specially designed guide-stylet for percutaneous chest procedures. in 50 patients, who underwent percutaneous procedures (lung biopsies n = 30, mediastinal n = 10, spinal and rib lesions n = 10), a new specially designed guide stylet set was used. the set is composed of a guide stylet and a 22 chiba needle. the guide stylet is made of stainless steel with a diameter of 0.41 mm (william cook europe a/s, bjaeverskov, denmark) the 22 g chiba needle is initially introduced in the thoracic wall and the guide stylet is advanced through the needle towards the lesion. when the stylet has been correctly directed, the needle is also advanced towards the same direction. the stylet serves either as a guide for the biopsy needle, or as an exchange wire in cases where a larger (core or tru-cut) needle is required for adequate sampling. the stylet can be curved before its insertion inside the 22 g needle in order to reach lesions which require redirection of the needle. for this purpose a torque device is used to point to the direction of the curved stylet results: the technique was easy to perform in all cases. five patients with lung biopsies developed pneumothorax (16.66 %). the stylet was advanced beyond the lesion in 4 cases, without clinical consequences and without this affecting the biopsy outcome. conclusions: our results suggest that the guide-stylet is a useful tool for percutaneous procedures, especially biopsies, in cases were the lesions to be reached, are difficult in approach. new technique for ct guided lung biopsy k. ishii 1 , y. wada 2 , j. kanekawa 2 , t. takahashi 2 ; 1 moriya/jp, 2 ibaraki/jp purpose: we establish both new device and a biopsy method to localize lesions in term of three-dimensions by ct in order to perform the biopsy of small nodular lesions in the lung field confidently, safely, and rapidly. material and method: we carried out ct guided lung biopsy in 20 cases of nodular lesions more than 5 mm in diameter. none of them contained calcifications. we simulated a targeting line by using a new device for ct guidance, "targ" developed by us. we then confirmed the right track of the guiding needle. the biopsy needle that we used was "pro-mag". the average time needed to complete the procedure was fifteen minutes. results: ten lesions were primary lung cancer. one of them was ground glass opacity lesion measuring 7 mm in diameter. this is what we call carcinoma of type a classified by noguchi. one case was lung metastasis from colon cancer (8 mm in diameter). conclusion: this technique enables us to obtain enough material by pinpointing and shooting peripheral lung lesions approximately 10 mm in diameter. we strongly believe that this technique contributes significantly to the progress of lung cancer treatment. ct guided percutaneous fine needle biopsy of small (≤ 15 mm) lung lesions in outpatients: safety and efficacy of the procedure compared to inpatients m. romano, m. gentile, m. midulla, m. salvatore; naples/it objective: compare safety and efficacy of ct guided fine needle biopsy (fnab) of small (≤ 15 mm) lung lesions in inpatients and outpatients. materials and methods: 100 consecutive inpatients (65 m, 35 f, mean age 56) and 100 consecutive outpatients (72 m, 28 f, mean age 50) who underwent ct guided fnab of small lung lesions at our institution from may 1999 to july 2001 were included. lesion size, thickness of aerated lung traversed, number of needle passes, presence of emphysema were recorded for the two patient groups. 22 g chiba needles and the roll-over technique (1 hour) were used for all patients; in the absence of significant pneumothorax at a subsequent expiratory chest roentgenogram, outpatients were allowed to go home and instructed to return in case of dyspnea or unusual symptoms. incidence of pneumothorax and other complications, need for tube insertion and percentage of diagnostic samples were noted for both groups. results: no statistical differences were observed in lesion size, thickness of aerated lung traversed, needle passes, presence of emphysema between the groups. we had 15 pneumothoraces in inpatients, two requiring a small caliber chest tube, and 12 in outpatients, all within 1 hour from the procedure, none requiring a tube. citology diagnosed a malignant lung neoplasm in 58 outpatients and 64 inpatients, absence of malignant cells in 33 and 25; the sample was inadequate in 9 and 11 respectively. all differences are nonsignificant. conclusion: ct guided fnab of small lung lesions in outpatients is a safe and reliable procedure, allowing significant decrease in hospitalization costs. tuesday b a c d e f 317 nant, 3 % adh. the highest rate of malignancy was seen in indication c (47 %) > a (32 %) > b (28 %) > e (20 %) > d (18 %). in the 71 % benign cases mrvb was able to avoid diagnostic surgery. conclusion: mrvb is a reliable tool, which allows to solve problems of mr-detected lesions. good training is a prerequisite. radiological or surgical port device implantation: a 4-year institutional analysis of procedure performance, quality of life and cost for breast cancer iv chemotherapy p.y.r. marcy sr. 1 , c. bailet 1 , n. magne 1 , j.c. machiavello 1 , j.c. gallard 2 ; 1 nice/fr, 2 caen/fr purpose: to evaluate the safety, efficacy, quality of life and cost of percutaneous radiologic arm port (pap) and surgical subclavian port (ssp) devices. this study involved a retrospective review of 200 port device implantation procedures (100 pap, 100 ssp) performed over a 4-year period, in breast cancer patients. parameters analyzed included technical success, procedure duration, complications, analysis of the quality of life and cost evaluation for both techniques. the success rate for port implantation was higher for pap than for ssp (96 % versus 91 %). pap was subsequently performed in 2 of ten patients in whom ssp procedure had failed; and ssp in 1 of the three pap failure cases. ssp and pap were performed without conscious sedation (i.e., local anesthesia only). mean implant duration time was 168/222 days, the overall complication rate (r/s) was 9 % versus 13 % (0.24 -0.4/1000 patient-days). mean implant duration time (r vs s), without any complication or death, was 193 d vs 233 d. median number of chemotherapy courses was 6 (r = s). 6 %, and 7 % respectively of the devices had to be removed prematurely. complication rate was 7 % and 9 %. febrile neutropenia cases occurred in 2 % of each file, without occurrence of any port infection. direct costs (r/s) were respectively 230.8 vs 219.1 • . conclusion: advantages of r over s include higher success rates, shorter procedure duration, higher cosmetic result despite a 5 % relative overcost for r placement. to study functional recovery after surgical damage to the supplementary motor area (sma). patients and methods: 6 patients were studied before and after resection of a medial frontal tumor, and compared to 7 healthy subjects. all of the patient group presented with an sma syndrome. fmri examinations (1.5 t) included functional axial eg-epi and anatomical images. tasks consisted of flexion/extension of the fingers and a complex digital sequence of both hands. data analysis was performed using spm99 software. results: in control subjects and in patients during movements of the hand ipsilateral to the tumor, activation was present in the contralateral hemisphere in the primary sensorimotor cortex, postsma, and both secondary sensory cortex. during complex movements, additional activation was present in the contralateral presma, anterior cingulum, ipsilateral primary sensory cortex, lateral premotor area, and both parietal lobules. before surgery, activation patterns were similar. however, during simple movements contralateral to the tumor, additional activation was present in the ipsilateral postsma and lateral premotor area. during complex movements, activation was also present in the ipsilateral presma and anterior cingulum. after resection of the sma, the presma and the anterior cingulum of the healthy hemisphere were also activated during simple movements. during complex movements, activation in the ipsilateral presma and lateral premotor area was stronger. these results suggest that there is a dysfunction of the sma ipsilateral to the tumor before surgery, and that the sma, anterior cingulum, and lateral premotor area in the healthy hemisphere are involved in the functional recovery following surgery. purpose: first experiences in comparing different methods for localization of brain function in the setting of neuronavigated guided surgery. maximum accuracy by using the same mri-3d-dataset for fmri and neuronavigation. material and methods: 12 patients suffering from intracerebral tumours in the central region performed a finger-tapping task of the contralateral hand in fmri. activated areas were superimposed on a 3d-ge-mri dataset including the surface fiducials for neuronavigated surgery. the coordinates of the voxel with highest statistical threshold was determined and compared with the coordinates of maximal response using intraoperative monopolar cortical stimulation. results: in all patients central sulcus and postcentral gyrus were identified by fmri. in 2 patients intraoperative stimulation was not possible. in 10 patients coordinates of maximum activation differed by 12 mm mean euclidean distance (stdev. 7 mm, range 2 to 28 mm). the distance was mainly dependent on the different approach of cortical stimulation to the surface of the brain and fmri activation in the depths of central sulcus (hand motor area). larger distances were due to a distorted morphology of central area from invading tumour. there was no influence of tumour histology, had motion during the fmri experiment or hemiparesis. conclusion: in the setting of neuronavigated guided surgery and intraoperative monitoring, fmri may help to guide the placement of a cortical electrode on the surface of the brain. maximum stimulation or activation points differ due to the approach, especially if morphology of the central area is distorded by tumour. this has to be considered in preoperative planning. 3d mr reconstruccion for neurosurgical planning f. matute, a. saiz ayala, j. arrazola garcía, j. jimenez del rio, c. saldaña; madrid/es purpose: we used three-dimensional reconstructed magnetic resonance images for planning the operations of 40 patients with intraxial brain tumors and vascular malformations. we studied the cases of these patients to determine the advantages and current limitations of our computer assisted surgical planning technique as it applies to the treatment of neurosurgical cases. we assessed the cortical surface-anatomy combining with vascular images using a single volumetric acquisition scanning technique from 3d spgr. in collaboration with neurosurgeons, we obtained tangential and oblique views, that simulates as properly as possible, the real surgical field. this technique, allow us not only to localize the lesion and define the tumor margins but to identify the superficial cortical veins related to the tumor. this multiplanar superficial venography will be used as a road map by the neurosurgeons at the moment of the craniotomy. in addition, a introperative electrical stimulation mapping was performed to assesses eloquent cortices. results: in each case neurosurgeons could easily reach the lesion with minimum risk because the combination of our multiplanar reconstruction model and intraoperative electrical mapping. conclusion: our technique is a easy and useful way of proper determining brain surface and venous anatomy over the tumor. this technique can be used to choose the best method of intervention, to minimize the surgical risk and to select the best surgical approach. intraoperative mri in a stereotactical operation unit: report on the first two cases v. hesselmann, r. girnus, u. von smekal, m. hoevels, b. krug, v. sturm, k. lackner; cologne/de purpose: to introduce practical issues for interventional procedures controlled by mri (gyroscan intera, philips, best, the netherlands) in a stereotactical operation unit. we report on a mri-controlled stereotactically guided catheter implantation for interstitial irradiation with iodine 125 seeds (case 1) in a patient with glioblastoma and the implantation of electrodes for deep brain stimulation (medtronics, minneapolis, usa) in a patient with parkinson's disease (case a c d e f 318 2). patients were placed on a mri-compatible operation table and fixed in a mricompatible stereotactic head frame (mrc-systems, heidelberg, germany). trajectory and target planning had been done prior to the intervention with a computerized stereotactic treatment planning system (fischer leibinger freiburg, frg). anatomical (t2-tse, t1-se), real-time mri and functional imaging (fmri) using a fingertapping paradigm was performed in both cases. in case 1 fmri was performed after placement of the head frame for localizing the motor hand area. in case 2 fmri was performed during deep brain stimulation of the subthalamic nucleus. results: in case 1 the trajectory for the catheter with 125 i seed was remodeled after fmri. performance on fmri for monitoring the effect of deep brain stimulation was poor in case 2, as the localizer of the stereotactical system caused severe distortions of epi-images. monitoring the placement of deep brain electrodes could easily be controlled mri with t2-weighted spin echo sequences. conclusion: intraoperative mri revealed decisive information during operation procedures such as brain shift, fmri and placement of catheters and electrodes. for fmri metallic materials are to be removed out of the scanner. neurovascular compression of the rostral medulla as a cause of essential hypertension? prospective mr study in hypertensive and normotensive subjects j. zizka 1 , j. ceral 1 , p. elias 1 , l. klzo 1 , m. solar 1 , j. tintera 2 ; 1 hradec kralove/cz, 2 prague/cz purpose: several experimental studies assigned vascular compression of the left rostral ventrolateral medulla (lrvm) as a possible cause of essential hypertension. published data concerning the mr imaging of the neurovascular compression of the medulla oblongata widely differ, particularly due to methodological incongruities. the aim of the study is to conduct a blinded prospective mr study of normotensive and hypertensive individuals. methods and materials: we examined 32 patients with severe essential hypertension (mean age 52 ± 9 years) and 40 normotensive subjects (mean age 53 ± 10 years). mr imaging protocol consisted of transverse and coronal t2 tse (slice thickness 3 mm), transverse 3d tof mra (0.8 mm) and 3d ciss (1 mm) sequences. the presence and degree of vascular compression at the lower brain stem and particularly at the lrvm were evaluated together with the conspicuity of the anatomical structures on different mr imaging sequences. results: among 32 hypertensive patients, 24 (75 %) showed neurovascular contact of the medulla at any location and 6 (19 %) at the lrvm. in the control group of 40 normotensive subjects, 32 (80 %) showed neurovascular contact of the medulla and 13 (32 %) of the lrvm. compared to t2 tse and 3d tof imaging sequences, 3d ciss offered better contrast resolution of neural and vascular structures and superior delineation of the outer vascular contours. conclusion: neurovascular compression of medulla oblongata is a frequent finding in both hypertensive and normotensive subjects. our results do not support the hypothesis of neurovascular compression at the lrvm as an etiological factor of essential hypertension. volume estimation of the fornix in patients with organic amnesias using co-axial mr images q.y. gong 1 , d. montaldi 1 , a.r. mayes 1 , j. aggleton 2 , j.r. hanley 3 , d. scutt 1 , n. roberts 1 ; 1 liverpool/gb, 2 cardiff/gb, 3 essex/gb purpose: the fornix is the principal tract that links the hippocampus with the midline diencephalon. the relative contribution of the fornix in human memory is debated and a reliable method is required for estimating the extent of fornix damage in patients with anterograde amnesias. this study aims to develop an efficient and unbiased approach for estimating the fornix volume on 3d mr images. subjects and methods: 12 healthy subjects and four patients with organic amnesia (one or other of the fornices were severed) were recruited. mr examinations were performed using a 1.5 t signa (general electric, milwaukee), and t1weighted images were obtained using a 3d spgr pulse sequence (tr/te 34/ 9 ms, flip angle 30°, slice thickness 1.6 mm). image analysis was performed using analyze tm (mayo foundation, rochester) and mri3dx (http://www.liv.ac.uk/mariarc/mri3dx). analysis algorithm using reformatted co-axial mr images was developed based on the pappus method of modern design stereology. results: the measurement reliability for fornix volume were obtained (cv = 3.61 %; r = 0.98). fornix volume in controls obtained was 0.46 ± 0.07 ml on the right and 0.46 ± 0.10 ml on the left. in three of four patients with radiological evidence of severance of either the left and/or right fornix, significant atrophy of the ipsilateral fornix was demonstrated, and ranged between 46.1 % and 22.3 %. the developed technique provides an efficient and mathematically unbiased approach for estimating the fornix volume on co-axial sections, and can be applied to assess the extent of fornix atrophy in patients with organic amnesia. voxel based morphometry in narcolepsy s.c.a. steens 1 , s. overeem 1 , c.d. good 2 , g.j. lammers 1 , m.a. van buchem 1 ; 1 leiden/nl, 2 london/gb purpose: recently, a close association between narcolepsy and hla-dqb1*0602 was found and linked to loss of hypocretin production by hypothalamic neurons, as suggested by lack of csf-hypocretin-1 levels. the aim of this study was to assess potential (autoimmune-based) hypothalamic degeneration using voxel-based morphometry. methods/materials: 15 narcoleptics and 15 age-and sex-matched controls were included. all patients were hla-dqb1*0602-positive, had typical findings during polysomnographic and multiple sleep latency testing, and had no csf-hypocretin-1. to optimize gray-white matter contrast, we used a 3d-t1 gradient-echo sequence with tr/te 26/12 ms, flip-angle 45°, 256 × 256 matrix, 100 slices of 1.5 mm and fov 250 mm. vbm was used for brain extraction, spatial linear and non-linear normalization, segmentation and smoothing. univariate analyses for gray and white matter were performed with statistical parametric mapping, employing the general linear model. regionally specific increases or decreases in gray or white matter between groups were assessed, with age, sex and global mean voxel values as confounders (p < 0.05, corrected for whole brain volume). because of our strong prior hypothesis for structural change in the hypothalamic region, we also assessed uncorrected data with a small volume correction for the hypothalamus (p < 0.001). results: no significant regional differences in gray and white matter could be detected between narcoleptics and controls, even with reduced thresholds and small volume corrections for the hypothalamus. conclusion: no evidence is found for structural changes in the hypothalamic region. either the hypothalamic changes are too subtle to be detected using vbm, or the hypocretin neurons remain intact but are not able to synthesize hypocretin. evaluation of requests for mri performed during 2 weeks in stockholm, sweden b. isberg, o. flodmark, l. zachrisson, h. jorulf, y. palmquist; stockholm/se over the last years the use of mri as a diagnostic tool has increased as the method has been recognised as the most efficient way to investigate a variety of clinical conditions. in stockholm the use of mri has rapidly increased to a level of today 40 mr examinations per 1000 inhabitants and year. a study was undertaken as an attempt to answer the question whether or not the indications for the mr study, were considered appropriate or not. method: all requests for 3205 mri studies performed during two weeks in the county of stockholm were collected and reviewed. material: the information on each request form was evaluated by one of four experts. two experts were clinicians two were radiologists. these experts were asked to evaluate whether the indications for study were considered appropriate or not. results: in the total material 43 % of the studies were thought to be indicated, 21 % probably indicated, 16 % were thought probably not to be indicated, while 17 % were clearly not indicated. in another 3 %, the material was inadequate and the indication was not possible to evaluate. there were clear differences between different groups of referring physicians in their pattern of using mri as a diagnostic tool. as an example, specialists in hospital practice had the highest proportion of indicated requests. the results of this study strongly supports the need for ongoing education and precise guidelines in the proper utilisation of mri as a diagnostic tool. standardized virtual endoscopic approach to the intracisternal course of the cranial nerves v -viii r. klingebiel, c. heine, r. lehmann; berlin/de purpose: standardization of a virtual endoscopic (ve) approach to the intracisternal course of cranial nerves (cns) v -viii. methods and material: magnetic resonance imaging (mri) of the basal cisterns was performed in 6 healthy volunteers on a 1.5 t unit, using a ciss sequence with an isotropic voxel size of 0.5 3 mm. data post processing (pp) was effected by means of direct volume rendering (vr), comprising the cn's complete intracisternal course as well as their root-entry-zone. subsequently, 12 patients with clinical signs of intracisternal pathology were investigated by standardized ve approach. the pp time was recorded and image quality and diagnostic value were rated by consensus reading of two neuroradiologists, using a five-point score (1 = insufficient, 5 = excellent). results: 2 -4 virtual endoscopic views were needed per cn for comprehensive intracisternal visualization (n. v = 4, n. vi = 2, n. vii/viii = 4). the pp time per cn varied between 7 -15 minutes. the average scores for image quality and diagnostic value amounted to 4.5 and 4.4, respectively. in 11/12 patients comprehensive ve cn imaging was achieved. in 4/11 patients variations of the ve views were required. different intracisternal pathologies were assessed by the ve approach such as neurovascular conflicts between the aica and the cns v, vi and viii at the rez level. conclusion: comprehensive intracisternal 3d visualization of the cns v -viii is possible within a routine imaging setting, provided direct volume rendering and standardized pp protocols are used. the value of the sagittal median nerve diameter in the diagnosis of median nerve entrapment o.j. sommer 1 , h. czembirek 2 , h. gruber 1 , p. kovacs 1 , m. stiskal 2 , f. kömürcü 2 ; tuesday b a c d e f 321 material and methods: 23 patients with suspected carotid artery stenosis were examined with mscta after bolus administration of 80 ml of nonionic contrast agent at 4 ml/s. before the acquisition, a test bolus of 16 ml of c.a. at 4 ml/s was performed. real time interactive 3d evaluation was performed on a dedicated workstation. the degree of stenosis and the morphology of the plaque (qualitative and quantitative) were evaluated. in all patients dsa was also performed and considered the standard of reference. results: excellent image quality was obtained in all cases, without venous filling. good correlation with dsa was achieved using the interactive 3d assessment. a perfect correlation between mscta and dsa regarding the degree of stenosis was seen in 42 carotids. in 3 carotids, with moderate stenosis at dsa, mscta showed a severe stenosis, due to the presence of calcification. the values of sensitivity, specificity and accuracy were respectively 96 %, 82 % and 91 %. regarding the morphology of the plaque, mscta correctly demonstrated all ulcerated plaques, also showing the presence, by means of quantitative assessment, of calcium, fibrous stroma and lipid. conclusion: mscta surpasses all the limitations of single slice spiral cta regarding venous overprojection and volume coverage. real time 3d interaction is necessary to correctly demonstrate the degree of stenosis. mscta appears to be particularly valid in the assessment of plaque morphology and therefore in treatment planning. carotid artery stenosis: accuracy of noninvasive imaging g. mansueto, m. d'onofrio, a. guarise, p. tamellini, c. procacci; verona/it purpose: this study prospectively compared contrast-enhanced magnetic resonance angiography (cemra) and doppler ultrasound (dopplerus) with digital substraction angiography (dsa) and endarterectomy findings to determinate the accuracy in assessing carotid artery stenosis. in this prospective study from january to may 2001, 32 patients underwent carotid endarterectomy, 21 studied by cemra, dopplerus and dsa and 11 with cemra and dopplerus. the degree of stenosis of 41 carotid arteries (21 patients) was analyzed with cemra and dopplerus and compared with dsa (reference standard) by using the spearman rank correlation coefficient (rs). in 9/32 patient eversion endarterectomy was performed; thus it was possible to compare cemra, dopplerus and dsa with the specimen measurement (reference standard). in 23/32 standard endarterectomies the presence of ulcers was documented to determinate the accuracy of noninvasive imaging. results: there was a significant correlation between cemra and dsa (rs = 0.81; p < 0.001) and between dopplerus and dsa (rs = 0.086; p < 0.001) for degree of stenosis. overestimation was the most frequent error, even in the specimen comparison. there was one false positive for cemra and dopplerus and one false negative for dsa, so the accuracy was the same at 89 %. ulcers were most frequently seen at cemra. conclusion: there was a significant correlation between cemra, dopplerus and dsa for estimating the degree of stenosis with the same accuracy by comparing with specimen measurements. ce mra was shown to be the best imaging modality to detect plaque ulceration. multislice spiral ct angiography vs. time resolved contrast enhanced mr angiography in the assessment of carotid artery stenosis f. pediconi, c. catalano, a. laghi, f. fraioli, a. napoli, m. danti, r. ferrari, r. passariello; rome/it purpose: to compare multislice ct angiography (mscta) with contrast enhanced mr angiography (mra) in patients with suspected carotid artery stenosis. material and methods: 23 patients with suspected carotid artery stenosis were examined with mscta and mra using a 1.5 t magnet. mscta was performed after bolus administration of 80 ml of c.a. at 4 ml/s. before the acquisition, a test bolus with 16 ml of c.a. at 4 ml/s was performed. ce-mra was performed using a multiphase sequence after bolus administration of 15 ml of gd-dtpa at 2 ml/s. a real time interactive 3d assessment of mscta images was performed in all cases, while mra images were assessed using a standard mip algorithm on the magnet console. the two techniques were compared for degree of stenosis and plaque morphology, using dsa as standard of reference. results: with both techniques images were diagnostic and free from artifact. no significant difference between the two techniques, regarding the degree of stenosis, was seen; the values of sensitivity, specificity and accuracy were respectively of 96, 100 and 97 % for both techniques. qualitative assessment allowed us to correctly demonstrate the morphology of the plaque in all cases with cta, while mra correctly demonstrated 10 of 12 ulcerated plaques. although multislice spiral ct encompasses most of the problems of spiral cta, contrast enhanced mra provides a simpler way to achieve comparable results, using well tolerated contrast agents and without ionizing radiation, regarding the degree of stenosis. nevertheless, mscta also appears accurate in the assessment of plaque morphology. power doppler screening for carotid artery stenosis in cardiac surgery patients v. beslagic, f. dalagija, z. merhemic; sarajevo/ba purpose: to assess the use of power doppler imaging as a screening tool for detecting carotid stenosis in the preoperative evaluation of cardiac surgery patients admitted at university clinical center sarajevo in an eighteen month period. material and methods: we surveyed 174 patients admitted for cardiac surgery. imaging methods were power doppler, duplex doppler, mra, dsa. a two phase study was performed. in the first, a prospective preoperative evaluation of 60 patients was performed using duplex doppler. during the second phase, prospective preoperative evaluation of 114 patients was performed using power doppler imaging. in patients with 50 % stenosis or more, duplex doppler was performed. imaging methods for further evaluation of 70 % and above stenosis, in both groups, were mra and intravenous dsa. results: stenosis of 60 % or more was found in 11 (19 %) patients in the first phase group and in 27 (24 %) of patients in the second phase group. stenosis of 70 % and above was found in 4 (7 %) patients in the first phase group, and in 12 (11 %) patients in the second phase group. adequate images were achieved in 89 % of the power doppler studies compared with 82 % in the duplex doppler studies. conclusion: power doppler, as a screening tool for carotid stenosis, is a low risk, fast, cost effective method with accurate results. using power doppler to screen patients and duplex doppler to evaluate significant carotid stenosis with possible further diagnostic evaluation with mra and dsa, an optimal imaging approach is achieved. cerebral hemodynamics in patients with vertebral artery hypoplasia comparing those with and without atherosclerotic lesions of carotid arteries s.g. mazur, i.i. glazovska, v.v. kuznetsov; kiev/ua purpose: comparison of brain hemodynamics in patients with vertebral artery hypoplasia (vah) comparing those with and without atherosclerotic lesions of the carotid arteries. methods and materials: we examined 102 patients, 51 males and 51 females, mean age 51 ± 15 years: (1) 58 patients without a history or signs of cerebrovascular diseases and without carotid stenosis: 31 with vah (1a) and 27 without vah (1b); (2) 44 patients with ischemic stroke caused by atherosclerotic lesions of the carotid arteries: 19 with vah (2a) and 25 without vah (2b). we used a sonography system "elegra" (siemens) to measure the vessel diameters, volume blood flow velocities (vf), total cerebral volume blood flow (tvf) -vf through both internal carotid arteries (vfica) + vf through both va (vfva). results: group 1a had lower vfva than 1b (p < 0.05), but there was no significant difference between tvf in these two groups. tvf in group 2a (0.36 ± 0.038 l/min) was lower compared with group 2b (0.51 ± 0.071 l/min, p < 0.001) resulting in a lower vfva in group 2a (0.028 ± 0.087 l/min and 0.12 ± 0.051 l/min respectively, p < 0.001). gropp 2b versus 2a patients had a higher severity of arterial narrowing. conclusions: patients with vah without stenotic lesions of the carotid arteries have brain hemodynamic compensation through the carotid arteries and contralateral vertebral artery. vah in patients with cerebral atherosclerosis evokes decompensation of cerebral hemodynamics and causes ischemic stroke with a lower grade of carotid stenosis than in patients without vah. purpose: the aim of this work was to retrospectively evaluate with mri, 45 patients affected by anterior knee pain without clinical symptoms of meniscal or ligamentous injuries. materials and methods: 45 patients with anterior knee pain entered this study. mr examination was performed using 0.2 t dedicated and 1.5 t whole body mr units. in 5 cases dedicated mr unit was performed to have kinematic evaluation of the knee at three different degrees of flexion. in 25 cases i.v. injection of contrast media was performed. all the patients underwent arthroscopy. results: in all the cases mri revealed a region of altered signal intensity in the superior aspect of the hoffa's body. arthroscopy revealed the presence of synovial thickening in 25 cases and enlargement of the patello-femoral synovial recess in 20 cases. in 14 cases of synovial thickening infusion mri showed in 8 cases contrast enhancement suggesting an acute stage of inflammation and in 5 cases no enhancement was found due to the presence of synovial fibrous tissue. in 9 cases of histologically proved villonodular synovitis se t2w sequences showed a region of non homogeneous high signal intensity because of the presence of spots of low signal intensity. in all the 5 patients showing synovial thickening of the hoffa's body apex, kinematic mr revealed impingement with the femoro-patellar joint. conclusion: our experience demonstrates that mri, eventually completed by kinematic study and/or infusion of contrast media, may be considered the method of choice in the evaluation of the synovial impingement of the knee. cystic degeneration of the lateral meniscus of the knee: mri evaluation before and after arthroscopic treatment using radiofrequency energy a. barile, a.v. giordano, m. caulo, m. sabatini, f. iannessi, g. bonanni, v. calvisi, c. masciocchi; l'aquila/it purpose: to assess by mri the potential benefit and efficacy of selective meniscectomy combined with radiofrequency ablation in cystic degeneration of the lateral meniscus treatment. materials and methods: forty-one patients entered this study. 18 patients underwent arthroscopic selective meniscectomy and 23 patients underwent arthroscopic selective meniscectomy and radiofrequency treatment (arthocare, sunnyvale, ca) of the meniscal remnant. all of them were submitted to mri and clinical evaluation three months later. in 9 cases mri examination was performed before and after the surgical treatment. mri examination was performed using a dedicated 0.2 t (artoscan esaote italy) and a 1.5 t superconductive unit (ge signa horizon usa) employing se t1-w, se t2-w and ge t2-w sequences in axial and longitudinal scan planes. in 3 cases arthro-rm was also performed. clinical evaluation included physical examination and a questionnaire. results: clinical evaluation did not show statistically significant discordance between the two groups. mri follow-up after 3 months demonstrated a very clear decrease of the degenerative spots inside the meniscal remnant in the group with combined treatment respect to the group treated only with selective meniscectomy. conclusion: in conclusion our experience considers mri the method of choice in the evaluation of post surgical treatment of degenerative cystic diseases of the lateral meniscus of the knee. bone-patellar tendon-bone (btpt) acl reconstruction of the knee: diagnostic imaging evaluation of failures compared to second-look arthroscopy a. barile, g. cerone, a.v. giordano, l. zugaro, a. catalucci, g. bonanni, v. calvisi, c. masciocchi; l'aquila/it purpose: to evaluate the capability of diagnostic imaging in cases of failed anterior cruciate ligament (acl) reconstruction. materials and methods: 16 patients submitted to acl surgical reconstruction with patellar tendon entered this study. all the patients were clinically suspected of acl reconstruction failures and had diffuse pain and/or joint swelling or instability. all of them underwent mri from 3 to 12 months after surgery. all patients underwent plain film and 11/16 ct. in all cases mr study was performed using dedicated 0.2 t or whole-body superconductive 1.5 t units; in 12 cases arthro-mri was also employed. results: in 5 patients enlargement of the graft related to the presence of significant synovial reaction were found. in 4 cases synovial reaction was exuberant (cyclops syndrome). in 3 patients the bone tunnels were not perfectly aligned and standard examination revealed the presence of osteophytosis of the intercondylar fossa. in 2 cases the bad positioning of the interference screws was found. in the last 2 cases mri documented a tear of the graft. in all the cases arthroscopic second look confirmed the mri diagnosis. conclusion: mr manifested very accurate evaluation of the acl autograft because of its high contrast resolution and multiplanarity. in our experience mri eventually completed with arthro-mri may be considered the method of choice in the evaluation of acl reconstruction failures. dynamic mri in the evaluation of femoro-patellar disorders m. mastantuono, e. bassetti, m. francone, m. valeo, r. passariello; rome/it purpose: alterations of femoro-patellar biomechanics in the young and sports practicing subjects may determine the development of early involutive process and painful conditions. in our experience we verified the potential offered by kinematic studies of the extensor complex on sagittal and axial planes and we developed an innovative method of study that permits a correct clinical assessment of in this particular problem. we used a 0.2 t dedicated magnet, dedicated to the study of limbs with an adapting device holding the knee at different angles of flexion. we obtained images in different positions of flexion-extention acquired with a se t1 and t2 and g.e. sequences slice thickness 2 -3 mm without gap. we studied 27 healthy volunteers and 39 patients with anterior pain or instability of knee joint of which was suspected of being femoro-patellar in origin. in 29 patients the correlations between cartilage and subchondral bone sufference and the cinemotion findings were significant. conclusion: our method differs from the other dynamic studies described in the literature in that it allows volume study and permits a clear evaluation of the dynamic relationship between rotule and troclear articular surfaces. postoperative meniscus: assessment with dual-detector spiral ct arthrography of the knee c. mutschler, b. vande berg, f.e. lecouvet, p. poilvache, j.e. dubuc, b. maldague, j. malghem; brussels/be purpose: to evaluate dual-detector spiral computed tomography (ct) arthrography of the knee in the assessment of the postoperative meniscus. materials and methods: two observers retrospectively determined in consensus the meniscal changes observed in 20 consecutive patients who have had partial meniscectomy (n = 23) and who underwent dual-detector spiral ct arthrography of that knee for recurrent symptoms before second-look arthroscopy. at ct arthrography, postoperative menisci were considered to be either stable (no tear or small partial tear) or unstable (meniscal separation, complete tear, large partial tear, displaced meniscal fragment). the sensitivity, specificity, and positive and negative predictive values for the detection of unstable meniscal tears among all postoperative menisci at spiral ct arthrography was determined with second-look knee arthroscopy as the standard. the sensitivity and specificity for the detection of unstable postoperative meniscal tears among all postoperative menisci were 85 % and 90 %, respectively, with positive and negative predictive values of 92 % and 82 %, respectively. conclusion: dual-detector spiral ct arthrography of the knee is an accurate method for detecting unstable meniscal tears among postoperative menisci. purpose: to analyze mr-pathology of the knee joint at different stages of osteoarthritis and to find out whether pain, stiffness and limited function assessed clinically correlate with the degree of pathology assessed on mr images and radiographs. material and methods: the study population consisted of 50 patients with varying degrees of osteoarthritis. osteoarthritis was graded clinically using the womac (western ontario and mcmaster university) score and on the basis of conventional radiographs using the standard kl (kellgren-lawrence) score. in addition mr imaging was performed at 1.5 t using a high-resolution fat-suppressed, spoiled gradient echo sequence, t2-weighted fat suppressed fast spin echo sequences and t1-weighted spin echo sequences. all images were analyzed by two readers concerning cartilage lesions, bone marrow edema and pathology of the ligaments and menisci. these findings were correlated with the clinical and the radiological score. results: 13/16 joints with a kl-score of 4 showed full thickness cartilage lesions and bone marrow edema. meniscal tears were found in all joints with kl-score 4. cruciate ligament pathology was found in 5/13 kl-score 3 and 9/16 kl-score 4 joints. the kl-score correlated well with the extent of mr-pathology. correlations between the extent of cartilage damage, bone marrow edema and the kl-score versus the womac-score were non-significant (p > 0.05). conclusion: a high percentage of meniscal and ligamentous pathology, bone marrow edema and severe cartilage lesions could be shown in advanced osteoarthritis. however, a significant correlation between clinical findings and the extent of mr-and x-ray pathology could not be demonstrated. purpose: evaluation of real-time mri in the assessment of velopharyngeal closure in comparison to videofluoroscopy. materials and methods: 1 healthy volunteer and 7 patients with suspected velopharyngeal insufficiency (age from 5 -19 years, mean 9 years) underwent videofluoroscopy and real-time mri, using a tse "zoom" sequence (tr = 170 ms, te = 21 ms, slice thickness 6 mm) with 6 images per second. images were acquired in the midsagittal, the coronal and axial plane at the level of maximal velopharyngeal closure during phonation of test words. results were analysed by 2 radiologists in comparison to videofluoroscopy as the standard of reference concerning overall quality of the depiction of the velopharyngeal isthmus and the pattern of velopharyngeal closure in all three image planes. results: in all cases, real-time mri could correctly depict the pattern of velopharyngeal closure in correspondence to videofluoroscopy: velopharyngeal insufficiency with wide open velopharyngeal portal (n = 2), with moderate open velopharyngeal portal (n = 1), close approximation of the velum (n = 1) and velum touching the dorsal phayryngeal wall (n = 3). in 3 cases, the coronal plane was not of diagnostic quality in mri due to motion-artefacts. in one case, mri showed an asymmetric movement of the pharyngeal walls which could not be seen in videofluoroscopy. conclusion: real-time mri can successfully analyse the pattern of velopharyngeal closure even in small children. being a non-invasive method, it avoids the radiation exposure of videofluoroscopy and the discomfort of nasoendoscopy. evaluation of the movements of the oro-pharyngeal cavity during phonation with different voice intensity using mri m. di girolamo, g. ruoppolo, e. iannicelli, m. mattei, a. carriero, v. david; rome/it purpose: the aim of this study was to evaluate with mri the movements of the different anatomical structures of the oro-pharyngeal cavity during the utterance of the fundamental vowels with different voice intensity. we have evaluated 30 volunteers using a 0.5 t mr superconductive unit (philips medical system). we performed turbo-field-echo sequence (tr: 12 ms; te: 6 ms; ti: 900 ms; n.ex.: 4; acq. time: 6 s) with midsagittal scan (slice thickness: 8 mm). the volunteers were asked to perform a prolonged emission of the fundamental vowels [a], [i], and [u] with normal voice intensity (50 db) and with loud voice (70 db). the voice intensity was measured with a phonometer before the mr acquisitions. on each midsagittal scan we measured the area of the mouth and pharyngeal lumen. results: in all the patients we accurately evaluated the movement and the activity of the lips, tongue, soft palate and the pharynx. comparing the utterance of loud voice to normal voice, we found an increase of the area of the mouth lumen for the vowels [a] and [u] and an increase of the area of pharyngeal lumen for the vowel [i]. the intensity of voice emission depends not only on subglottic air pressure and glottic rim dimension but also upon the oro-pharyngeal cavity volume. the three-dimensional ct study of the upper airway of obstructive sleep apnea syndrome: an oral appliance can change the volume of oro-and nasopharynx w. zhang; beijing/cn purpose: to evaluate the utility of the spiral ct and post processing with 3d remodelling to review the anatomical abnormalities and the changes of the upper airway of osas with or without an oral appliances in the mouth. method/materials: 15 osas patients who had ideal oral appliance therapy have undergone spiral ct with or without the oral appliances in the mouth. scan was obtained with 3 mm collimation at 1.0:1 pitch from nasopharynx to the level of the hyoid bone at end expiration. 3d remodeling, raysum and mpr were performed at the workstation. luminal area at naso-, oro-and hypopharyngeal levels, the distance of the posterior airway space and distance between the hyoid bone and mandibular plan were measured. results: oro-and nasopharyngeal areas were significant larger in patients with oral appliances than in patients without oral appliances, p < 0.05 (478.07 mm 2 ± 104.29 vs 374.86 mm 2 ± 135.72 and 175.50 mm 2 ± 80.30 vs 112.50 mm 2 ± 65.05). no differences of hypopharyngeal areas were found between patients with or without oral appliances, p > 0.2 (202.36 mm 2 ± 119.78 vs 250.43 mm 2 ± 103.78). the three dimensional spiral ct scanning had many advantages in the evaluation and measurment the upper airway in patients with osas, these results show the main therapeutic mechanism of oral appliance use is the volume change of the oro-and nasopharynx. static and dynamic evaluation with mri of larynx and oro-pharingeal cavity in professional opera singers m. di girolamo, g. ruoppolo, f. assael, m. minnetti, e. iannicelli, v. david; rome/it purpose: to assess the anatomical configuration of phonetic organs by mri in singers with different vocal range. methods and materials: 26 professional opera singers (7 tenors, 5 basses, 8 sopranos, 6 mezzosopranos) underwent mri, performing both static and dynamic studies. we performed tse t2-weighted axial scans at the level of larynx in order to evaluate the area of superior surface of vocal cord. in the dynamic study, the singers were asked to perform a prolonged vocalization at a confortable tonality of the foundamental vowels a. we performed a midsagittal turbo-field-echo scan (acq.time: 6 s) at the level of the oro-pharyngeal cavity measuring the area of the mouth and pharyngeal lumen. these data underwent statistical evaluation using the mann-whitney u-test. results: we determine the average size of the vocal cord (sopranos: 0.71 cm 2 ; mezzosopranos: 1.20 cm 2 ; tenors: 1.58 cm 2 ; basses: 2.88 cm 2 ) and of mouth and pharyngeal lumen (sopranos: 15.8 cm 2 ; mezzosopranos: 14.6 cm 2 ; tenors: 23.6 cm 2 ; basses: 32.2 cm 2 ). the differences in vocal cord size between sopranos and mezzosopranos (p: 0.0641) and between tenors and basses (p: 0.0833) are tendentially statistically significant. the variation in vocal tract size during the uttuesday b a c d e f 327 terance of the vowel a between tenors and basses is considered tendentially statistically significant (p: 0.0833) while the difference between sopranos and mezzosopranos is not statistically significant (p: 0.6434). we demonstrate a correlation between the vocal cord's surface and the vocal tract configuration and the vocal tessitura of a singer. long vocal cord and wide vocal tract are characteristic of singers with low-pitched voice types (bass, baritone, contralto, mezzosoprano) while short vocal cord and narrow vocal tract are characteristic of singers with high-pitched voice types (tenor, soprano). correlation between arnold chiari malformation and sleep apnea syndrome (sas) i. thomassin 1 , k. marsot-dupuch 1 , v. stahl 2 , f. bourquin 2 , f. parker 1 , p. lasjaunias 1 ; 1 le kremlin bicêtre/fr, 2 bobigny/fr purpose: to identify morphologic abnormalities on cervical mri exams among patients suffering from sleep apnea syndrome and arnold chiari malformation. materials and methods: 13 patients suffering from severe apnea syndrome (30/ mn) were referred for surgery of arnold chiari malformation. pre-and post-contrast sagittal and axial t1 w and t2w images of the brainstem and cervical cord were performed. were studied the cerebello-medullary cistern, the angle between posterior border of brainstem and cerebellum, location of cerebellar tonsilla, cervicooccipital junction and ventricular system. results: three brainstem abnormalities were detected (two isolated and one in a complex malformative syndrome). 9 patients have filling of cerebello-medullary cistern and a diminution of the angle between the posterior border of the brainstem and the cerebellum. anterior translation of cerebellar tonsils was noticed. discussion: many authors have studied obstructive sas which was partially explicated by laryngo-pharyngeal abnormalities. associated transient ischemic attacks are well known. our study suggested that abnormalities of brainstem may alter the function of respiratory nuclei and tracks and that brainstem abnormalities may be linked with sleep apnea syndrome. conclusion: sleep apnea syndrome may be associated with lesions of brainstem. further larger study should be done to prove a statistical correlation. however radiologists should look for posterior fossa abnormalities when exploring patients referred for sleep apnea syndrome. comparison of differently viscous iodinated and barium-containing contrast agents in the detection of pharyngeal perforation m. keberle, g. wittenberg, a. trusen, w. baumgartner, d. hahn; würzburg/de purpose: unlike in the investigation of esophageal perforation, the more radiopaque barium-suspensions are not as important as iodinated aqueous contrast agents for the detection of pharyngeal perforations. this study was performed to find out whether the highly different viscosities (of iodinated and barium-containing contrast agents with comparable radiopacities) are a reason for this. methods: viscosity, subjective difference in contrast, and ct-density of an iodinated aqueous (telebrix) and a 50 wt/vol% barium-containing contrast agent (micropaque) were determined. moreover, to exclude postoperative perforation, 104 patients were prospectively examined by pharyngography using both contrast media. pharyngographies of patients with perforation were later compared by two independent readers. all patients with perforation were followed up clinically to exclude complications due to barium-application. results: in-vitro comparison showed comparable radiopacity but the 50 wt/vol% barium-suspension was much more viscous than the iodinated contrast agent. in total, during pharyngography, 14 perforations were clearly delineated with the iodinated aqueous contrast agent. however, two of them were not detected with the barium-suspension. all the other perforations presented equally. conclusions: given a sufficient radiopacity, a low viscosity appears to be essential for a contrast agent to detect pharyngeal perforation. thus, we recommend the sole use of an iodinated contrast agent (if suspicion of aspiration as isoosmolar variant) for this purpose. percutaneous tracheostomy (pt) in the intensive care unit (icu) using ultrasound guidance t. geroukis, d. voultsinou, a. papachillea, v. kalpakidis, p. palladas; thessaloniki/gr purpose: to present the ultrasonographic investigation of anterior neck structures conducted prior to the performance of pt in the icu patients. to determine whether the ultrasonographic contribution could reduce the complication rate and improve the outcome of these patients. we studied 26 icu patients, with an average age of 58. the ultrasound investigation was performed with bedside portable equipment in the icu immediately prior to the tracheostomy, indicating the point of puncture and analyzing the relationships of the anatomic structures lying in the vicinity of the tracheostomy site. results: in 13 patients the thyroid isthmus was extending over the tr1-tr2 space and in 8 patients a considerable isthmus thickness was calculated. goiter was found in 7 patients whereas clinical examination indicated this in only in 3 patients. the clinical examination was unable to evaluate by palpation the guiding points in 6 patients. in all these cases the anatomical relations required were satisfactorily visualized ultrasonographically. complications included hemorrhage, pneumothorax and subcutaneous emphysema. the ultrasonographic results influenced the decision for surgical or transcutaneous tracheostomy or surgical management during the procedure in three cases but small complications were unavoidable. with increased practice and better evaluation of the ultrasound results, the radiologist can play a vital role in the management of the icu patient. possibilities of spiral ct in differential diagnosis of carotid chemodectomas g. results: chemodectomas were revealed in 23 pts, neurinomas in 8 pts and carotid arteries aneurysms in 11 pts. among 23 chemodectomas there were 19 carotid and 4 vagal tumours. the analysis of data revealed that chemodectomas were characterised with early (arterial phase) pronounced (up to 200 hu) contrast enhancement. sometimes a low density area can be seen in center of the lesion. neurinomas are characterized with less pronounced enhancement (up to 100 hu). "spots" and "stripes" of the contrasted vessels stand out against parenchyma in neurinomas. there was no significant difference (p < 0.01) of average density rates in arterial phase in chemodectomas (171.2 ± 45.8 hu) and in neurinomas (64 ± 26 hu). there was a simultaneous contrast enhancement both in aneurysm and in surrounding vessels. additional information valuable for differential diagnosis was not obtained in venous and delayed phases. simultaneous enhancement of tumor and carotid arteries gives the possibility of evaluat ing their relationship and the involvement of carotid arteries in pathological processes. conclusion: spiral ct with bolus contrast enhancement allows differentiation of tumors and other pathological masses of the carotid space and allows a 3d-image of the area of interest to be obtained for surgery planning. acute calcific retropharyngeal tendinitis m. tassart, c. le breton, f. bahlouli, n. szelei, j. bigot; paris/fr purpose: to improve early diagnosis of an under recognized cause of cervical pain and stiffness whose initial misdiagnosis can lead to parenteral administration of antibiotics or even open biopsy materials and methods: two patients (1 male, 33 a; 1 female: 47 a) were admitted to the hospital with dysphagia, severe neck discomfort and fever. lateral radiographs of the cervical spine were performed in 2 patients, computed tomography in 2 and mri in 1. using non-steroidal anti inflammatory medications (interruption of antibiotics), the two patients had complete resolution of the symptoms within one week results: the calcification of the prevertebral muscle was demonstrated by ct for 2 patients and identified on lateral radiography in one case only. the soft tissue swelling was seen both on ct and mri. conclusion: acute calcific tendinitis is an under recognized disease which can be initially misdiagnosed as retropharyngeal or nasopharyngeal abscess, leading to unecessary parenteral injection of antibiotics or even biopsy. the radiologist has an important role to ensure the definitive diagnosis: in our 2 cases, specific imaging led to the correct diagnosis. to test the hypothesis that the single testicular artery is low resistance, and two further arteries (cremasteric/differential) are high resistance, we examined the spermatic cord vessels in a cohort of healthy men. materials and methods: patients presenting for a scrotal us with normal testes and epididymis were recruited. the right and left spermatic cords were examined from the superior aspect of the testis to the external inguinal ring to locate the testicular, cremasteric and differential arteries. a 15l8w multifrequency (8 -13 mhz) linear array probe (acuson ca) identifed each artery as separate, allowing a spectral doppler waveform to be recorded. the resistive index (ri) from each artery was measured three times (right and left) and the mean calculated. the three arteries were labelled a (lowest ri) b and c (two higher ri). results: 51 patients (median age 39 a, range 18 -79 a) were examined. the ri's on the right were: a: 0.71 ± 0.05, b: 0.82 ± 0.05, c: 0.84 ± 0.04 and the left a: 0.70 ± 0.06, b: 0.84 ± 0.04, c: 0.83 ± 0.05. a paired t-test demonstrated a significant difference of the combined right and left measurements for avsb (p < 0.001) and avsc (p < 0.001) but not bvsc (p = 0.3). conclusion: although it is not possible to identify a named artery in the spermatic cord, consistently one artery has a significantly lower ri than the other two arteries. this finding may be useful as an adjuvant parameter in the assessment of scrotal pathology in particular with patients with spermatic cord torsion. age related changes in testicular perfusion and serum androgen levels o.j. sommer 1 , k. kharom 2 , t. zils 2 , h. czembirek 2 , h. pflüger 2 , e. plas 2 ; 1 innsbruck/at, 2 vienna/at purpose: to assess the peripheral vascular resistance of small testicular arteries in different age groups and to match these results with age and androgen levels. materials and methods: 94 testicular units of 47 healthy subjects were investigated. according to age, patients were divided into 5 groups (30 -39, 40 -49, 50 -59, 60 -69, > 70 a). using high resolution sonography (7 -13 mhz, elegra, siemens, erlangen) including power mode we measured resistive indices (ri) and pulsatility indices (pi) of centripetal testicular arteries of the lobuli testes excluding mediastinal arteries. androgen (testosterone, free testosterone, fsh, lh, sexual hormone binding globulin) levels were evaluated between 8 and 10 a.m. and correlated with age, ri and pi values. results: there was a significant difference of 0.58 to 0.67 in ri (p = 0.025) and 0.94 to 1.29 in pi (p = 0.0005) values between young and old men. with the exception of sexual hormone binding globulin (sbhg) (4.8 versus 2.5; p < 0.05) no significant correlation of androgens with age, ri or pi was shown. our study suggests a positive correlation of age with the peripheral resistance of small testicular arteries, i.e. an increase of peripheral resistance with increasing age. sbhg showed a positive correlation with age, ri and pi values. the other androgens do not seem to relate with ri and pi values of the aging male. consecutive patients referred for scrotal us were examined with a 15 l8w multifrequency (8 -13 mhz) linear array probe (acuson, ca). if a focal testicular lesion was identified, the abnormality was re-examined with colour doppler mode (7 -12 mhz). vascularity was classified into, (a) no intra lesional vessels, (b) surrounding but no intra lesional vessels, (c) intra lesional vessels present and subdivided into (1) vessels crossing (2) disordered vessels (3) complete infilling. us findings were correlated with histology or findings confirmed on follow up. results: over a 24 month period a total of 2032 patients were examined. 53 focal abnormalities in 44 patients were found. the distribution of vascular patterns was as follows: a: 9, b: 5, c1: 26, c2: 9, c3: 2. 27 primary testicular tumours (seminomas, teratomas) were detected, 26 showing a c1 (criss cross pattern), a single well differentiated teratoma showing no intra lesional vessels (a). nine patients demonstrated a c2 vascular pattern; 4 secondary tumours, 3 acute myeloid leukaemia, 1 chronic fibrosis and a single patient without histological diagnosis. the c1 pattern was present in 95 % of primary testicular tumours. the presence of the 'criss cross' vascular pattern allows confident diagnosis of primary testicular tumours, although not differentiating seminomas from teratomas. with the improvement in probe technology, vascularity of testicular tumours proves to be an important differentiating feature. varicocele and venous insufficiency in left low extremity s. deftereos, g. alexiadis, g. kafetzis, s. touloupidis, j. manavis; alexandroupolis/gr the aim of our study is to compare the rate of incidence of varicocele and venous insufficiency in left low extremity. the flow pattern of left common iliac, external iliac, common femoral and great saphenous veins were evaluated with colour doppler sonography (cds) in 32 patients (19 -22 years old) with clinically suspected left varicocele. the same veins were also evaluated with cds in 15 clinically healthy voluntaries (same age range). in 24 patients of the first group (32 patients with clinically suspected varicocele) when valsalva manouvre was performed with the patient in upright position, flow reversed for a period of one or more seconds in left common femoral vein. thus the diagnosis of venous insufficiency was made. in the second group (15 clinically normal males) normal findings were found in thirteen persons. in the remaining two young men the diagnosis of venous insufficiency were made. the cds of scrotum revealed varicocele in both of them. on the basis of these findings and also because of the anastomotic branches between the veins of scrotum and low extremity we believe that a cds evaluation of the flow pattern in left common iliac, left common femoral and great saphenous veins must be performed before surgical treatment of varicocele in order to avoid the possibility of varicocele recurrence. quantitative evaluation of scrotal veins by colour doppler us in healthy population a. cina, t. pirronti, r. foschi, g. restaino, g. oliva, a. pignatelli, d. ribatti; rome/it scrotal varicocele (sv) is a very common disease of the male population. presently, colour doppler ultrasonography (cdus) represents the most frequently adopted technique for confirming the clinical diagnosis of sv and for a treatment indication. despite for several years cdus has been clinically used in cases of sv, discriminating quantitative values are not reported in medical literature. this is at least partly due to the lack of studies of cdus patterns obtained from large populations of healthy subjects. the aim of this paper is to investigate the role of ecd in instrumental diagnosis of male varicocele, the implications in selecting the patients who require treatment, and to investigate the risk of sv overdiagnosis by adopting the qualitative criteria currently used. we prospectively examined by cdus a population of 150 healthy and symptomless subjects, with a negative clinical examination for varicocele, and a normal spermiogram. we found that the normal value range of the maximum diameter of scrotal veins (2.62 ± 0.53 mm) widely overlaps with the values currently accepted for a varicocele diagnosis (1.5 -3.0 mm). furthermore, a venous reflux, a criteria adopted also for the diagnosis of subclinical varicocele, was present in 53 % of the normal population. these data show that there is a risk of sv overdiagnosis by using cdus. the quantitative criteria for sv diagnosis should be re-examined. the patients group included 10 uvjs with grade i -ii and 5 uvjs with grade iii -iv of reflux. urethra-to-orifice distance (uod) and length of intravesical and submucosal parts of the ureter were measured. results: in normal cases ureteral orifices were situated on equal distances from urethra, the uod was 11.2 ± 2.8 mm (mean ± sd). the length of intravesical part of the ureter was 24.9 ± 6.6 mm and correlated with height (correlation coefficient 0.78), body surface area (0.73) and weight (0.66). the length of submucosal part of the ureter was 12.6 ± 3.1 mm and correlated with body surface area (0.85), weight (0.83) and height (0.82). the ratio between intravesical and submucosal parts of the ureter was 1.95 ± 0.3. there was no significant difference between the normal values and values of all 10 low-grade reflux uvjs. in 4 from 10 spontaneous resolution of the reflux during 1-year period was found. the grade iii -iv reflux orifices (5 uvjs) were situated farther from urethra than opposite normal orifices, the uod was 14.2 ± 2.5 mm. the intravesical part of the ureter was short (9 ± 2.1 mm) and submucosal part was absent in all cases. none high-grade reflux was resolved spontaneously. conclusion: ultrasonography is a valuable noninvasive method of examination of uvjs and may be useful in vesicoureteric reflux assessment. comparison of contrast-enhanced colour doppler targeted biopsy to conventional systematic biopsy: impact on prostate cancer detection f. frauscher, a. klauser, l. pallwein, a.h. schuster, h. volgger, g. helweg, d. zur nedden; innsbruck/at purpose: we investigated whether a limited biopsy approach with contrast-enhanced colour doppler ultrasound (cdus) targeted biopsy of the prostate could detect cancers as well as grey-scale us guided systematic biopsy with a larger number of biopsy cores. we examined 230 men (psa ≥ 1.25 ng/ml). two independent examiners evaluated each subject. one investigator performed contrastenhanced targeted biopsies (≤ 5) into hypervascular regions in the peripheral zone during intravenous infusion of levovist™. subsequently, a second examiner performed 10 systematic biopsies of the prostate. cancer detection rates for the two techniques were compared. results: cancer was detected in 69/230 subjects (30 %). cancer was detected in 56/230 subjects (24.4 %) by contrast-enhanced targeted biopsy, and in 51/230 patients (22.2 %) with systematic biopsy. cancer was detected with targeted biopsy alone in 17 subjects, and with systematic biopsy alone in 13 subjects. overall cancer detection rate was not significantly different for targeted and systematic biopsy (p = 0.53). the detection rate of targeted biopsy cores (118/1139) was significantly better than that of systematic biopsy cores (123/2300) (p < 0.001). targeted biopsy in a patient with cancer is 2.6 times more likely to detect prostate cancer than a systematic biopsy. conclusions: contrast-enhanced cdus targeted biopsy detected as many cancers as systematic biopsy with fewer than half the number of biopsy cores. although an increase in cancer detection rate is obtained by combining targeted and systematic techniques in this screening population, contrast-enhanced targeted biopsy alone is a reasonable approach to reduce the number of biopsy cores. intermittent contrast-enhanced ultrasonography for prostate cancer detection a. klauser, l. pallwein, w. horninger, f. frauscher, g. helweg, d. zur nedden; innsbruck/at purpose: we investigated the usefulness of intermittent contrast-enhanced ultrasonography (us) in the detection of prostate cancer. methods and materials: nineteen patients with an elevated prostate-specific antigen level (³ 2.5 ng/ml) or an abnormal digital rectal examination were enrolled in the study. we used an i.v. us contrast agent (levovist™). continuous greyscale, intermittent grey-scale, phase inversion grey-scale, and colour and power doppler us of the prostate were performed. sonographic findings were correlated with biopsy results. after us contrast agent administration we found significant enhancement on both grey-scale and doppler images (p < 0.01). in 3 isoechoic tumours we only detected focal enhancement using intermittent imaging. focal areas of enhancement were identified in only 1 patient (5 %) without cancer. conclusions: intermittent contrast-enhanced us of the prostate seems to be useful for selective enhancement of malignant prostatic tissue. therefore, this technique may be useful for targeted biopsies. power doppler sonography was more sensitive in detection of tumoral vessels than pd sonography and increased ppv from 81 % to 87 %, npv from 75 % to 82 %, sensitivity from 80 % to 90 %, specificity from 77 % to 86 %. conclusion: 3d pd trus examination is more informative than pd trus examination in detection prostate cancer. 3d pd trus examination can be used as a diagnostic tool in addition to complex examination of patients with suspected prostate cancer. trus cd and mri with contrast agent in the evaluation of local recurrence after radical prostatectomy f.m. drudi, s. petta, a. carbone, a. righi, f. trippa, p. ricci, r. passariello; rome/it purpose: aim of our study was to evaluate sensitivity of us cd and mri, both with contrast medium enhanced, in the detection of local recurrence of prostate cancer after radical prostatectomy and to evaluate the specificity of these techniques in distinguishing recurrent cancer from fibrosis. materials and methods: twelve patients (mean age 64.4; range 56 -73) presented with increasing psa values (> 0.4 ng/ml) in a variable period (mean time elapsed 3 years; range 3 months to 4 years). all patients underwent bone scintigraphy before and after treatment, mri (gadolinium dtpa i.v. 2 ml/s, 20 ml total. flash t1 fat sat 20 slice thickness 5 mm), grey scale trus, trus cd (levovist shu508) and trus guided multiple biopsy. presence of colour signal and mr signal after c.a. was considered sign of recurrence, absence of recurrence or fibrosis. the results were compared to biopsy showing a sensitivity of 100 % and a specificity of 100 % for cd, while mr showed a sensitivity of 100 % and a specificity of 80 %. cd showed colour signal after c.a. in all positive patients. mr showed local recurrence in 5 patients: 4 cases had been evidenced already at cd examination and confirmed by biopsy, while one was a false positive. scintigraphy detected distant bone metastases in 2 patients, one of which also presented local recurrence. conclusions: from this early experience we can say that trus cd with c.a. is a valid tool as compared to mr in the evaluation of local tumour recurrence in patients with rising serum levels of psa after radical prostatectomy. contrast media in mr, ct and dsa angiography mdct in emergency radiology: is a standardized chest and/or abdomen protocol sufficient for evaluation of thoracic and lumbar spine trauma? percutaneous image-guided radio-frequency thermal ablation of the lung bilateral inferior petrosal sinus sampling in cushing's syndrome; final solution? 16:20 multi detector ct in morphological assessment of pulmonary veins in patients with focal atrial fibrillation j. baqué, v. huart, a. azzarine, a. hakime, b. cauchemez, e. mousseaux; paris/fr purpose: to analyse the appearances of the pulmonary veins (pv) in patients with focal atrial fibrillation (faf) initiated by ectopic beats in the pv, compared to a control group. material and methods: the appearances of the pv were assessed in 10 patients with faf originating from the pulmonary veins (confirmed by electrophysiological study) and in 10 asymptomatic patients screened for coronary artery disease. the patients were paired by age and gender (age 50 ± 14 years). each patient underwent ecg-gated contrast-enhanced multi-detector ct (mdct) of the heart. the diameter of each of the four pv was calculated on 1 mm thick slices on axial and coronal oblique images and was measured at the ostium and at 5, 10 and 15 mm. both the mean and the maximal diameters were calculated for each vein. any anomalies or abnormalities of the heart and vessels were also described. results: the maximal diameters of proximal portions of the right superior (18.6 ± 3 vs 16.2 ± 2 mm; p < 0.05) and the left inferior (18.1 ± 2 vs 15.4 ± 2 mm; p < 0.05) pv were significantly dilated in faf patients compared to controls. the right inferior (19.9 ± 4 vs 17.4 ± 2 mm) and left superior veins (19.1 ± 3 vs 16.8 ± 2 mm) were not significantly different between the two groups. conclusion: on mdct images, the proximal portion of right superior and left inferior pv was significantly dilated in patients with faf initiated by ectopic pulmonary beats. accurate evaluation of the appearances of the pv gives valuable and complementary information before selective cannulation of each vein and percutaneous radiofrequency ablation procedure. evaluation of left atrium and pulmonary veins with mri and mra before and after circumferential radiofrequency ablation of pulmonary vein ostia for atrial fibrillation f. de cobelli, f. gugliotta, r. mellone, m. venturini, c. pappone, a. del maschio; milan/it purpose: the pulmonary veins (pvs) and surrounding ostial areas frequently house focal triggers or reentrant circuits critical to genesis of atrial fibrillation (af). a new anatomic treatment aimed at isolating each pvs from the left atrium (la) by circumferential radiofrequency (rf) lesions around their ostia has been developed. we evaluated the role of mri and mra in assessment of pvs and la before and after rf ablation. method and materials: 12 patients with resistant af underwent mri and mra before and the day after rf ablation. 8 patients underwent mr after 3 months. mr images were obtained with black-blood ecg-triggered breath-hold multishotfse sequences with double and triple inversion pulses (ir-msfse) (tr/te 2 × rr/ 40, etl = 32). mras were acquired with efgre 3d sequences (tr/te/ti/fa 5.4/ 1.6/30/30°) with gadolinium injection and reconstructed with mip and volume rendering. results: at the pretreatment mra, all four pvs were visualized in all patients. in four patients, the following anatomic variants were found: a common ostium of the left superior (ls) and inferior (li) pvs; a single ostium of the ls and lipvs; a posterior ostium of lipv; 3 separate right pvs ostia. at the post-treatment mri, high signal intensity was detected in the atrial wall around veins ostia due to oedema; in three patients a thin pericardial effusion was evident. at three months follow-up, the la volume was significantly decreased in patients who had sinus rhythm restoration; with mra, a left inferior pv stenosis was found. conclusion: mr is useful in evaluation of patients with af before and after rf ablation of pvs ostia. preoperative planning and intraoperative navigation with 3d-reconstructions and image guidance for robotically-assisted coronary artery bypass grafting t.c. mamisch 1 , g. zuend 2 , j. gruenenfelder 2 , s.p. hoerstrup 2 , f.a. jolesz 3 , r.m.m. seibel 1 , m. turina 2 , r. kikinis 3 ; 1 mülheim a. d. ruhr/de, 2 zürich/ch, 3 boston, ma/us objective: closed chest coronary artery bypass grafting with the use of a telemanipulator is still performed in very few numbers worldwide. preoperative planning and intraoperative navigation might be a helpful tool for increasing success rates of this procedure. the most promising accomplishments of image guidance in surgery are three-dimensional image-processing algorithms.methods: creation of 3d-visualization involves segmentation from acquired crosssectional images. in 15 patients cross-sectional images were obtained by ct and mr. images were digitally transferred via an internal high-speed to the surgical planning laboratory. we primarily used high-end computer workstations sparcand ultrasparc (sun microsystems, mountain view, ca), equipped with specially developed software, the 3d-slicer for registration, filtering of regions of interest, semi-automated segmentation and 3d-visualization. results: preoperative planning with identification of target vessels and assessment of wall quality, as well as the possibility of image-guided surgery can be obtained by the 3d-visualization of the acquired data-sets. together with the development of semi-automated segmentation, 3d rendering, integration of different image-modalities, intraoperative navigation and tracking can be provided for closed chest coronary artery bypass grafting. conclusion: 3d-image guidance in surgical procedures for preoperative planning in a non-invasive fashion, as well as intraoperative navigation and tracking of robotically-assisted instruments are very helpful in detecting complex coronary lesions and calcified vessels which facilitate closed chest coronary artery bypass procedures. patients with intramural vessels or severe calcification can be identified and the operative technique can be chosen adequately. subsecond spiral ct angiography for detection of small pulmonary thrombi: an experimental study k. li, y. li, x. du; beijing/cn purpose: to evaluate the diagnostic value of subsecond spiral ct pulmonary angiography (ctpa) to detect the small pulmonary thrombi (diameter 2.5 -3.5 mm) in canine models. methods: ctpa was performed as a control study in 23 dogs. pulmonary embolism was induced in the dogs by administation of autologous blood clots, after that ctpa and x-ray pulmonary angiography (xpa) were performed. the images were evaluated on a workstation by two radiologists and the image findings were compared with that of pathological dissections. results: 22 pulmonary embolism models were successfully made in this study and 110 thrombi were found during pulmonary artery dissection. the thrombi were same number as that injected and the all thrombi located in segment and subsegment of pulmonary arteries, of which 107 thrombi were in field of the view (fov). 90 thrombi were found with ctpa, whereas 82 thrombi with xpa. the sensitivity of the ctpa and xpa was 84.1 %, 76.6 %, respectively, and the positive predictive values were 93.8 % and 94.3 % respectively for the diagnosis of small pulmonary thrombi. conclusion: subsecond spiral ct angiography has a high diagnostic value for detection of small experimental pulmonary thrombi in dogs, and the result is superior to routine x-ray pulmonary angiography. diagnosis of acute pulmonary embolism with contrast-enhanced mr angiography: an experimental study k. li, y. li, x. du; beijing/cn purpose: to assess the diagnostic value of three-dimentional gadolinium-dtpa contrast-enhanced magnetic resonance angiography (3d cemra) in acute pulmonary embolism (pe). methods: seventeen dogs with acute pulmonary embolism induced by autologous blood clots were examined with 3d cemra using a fast spoiled gradient echo technique and with x-ray pulmonary angiography (xpa). the findings were compared with pathological dissection. results: the 3d cemra signs of acute pe were: total vessel occlusion (30/41), pulmonary perfusion defect (23/41), partial filling defect (3/41) and central filling defect (1/41) in the pulmonary artery. the sensitivity of 3d cemra was 82.9 %, specificity 98.2 %, whereas the sensitivity and specificity of xpa was 75.6 %, 97.9 %, respectively. conclusion: 3d cemra for the detection of acute pe demonstrated high sensitivity and specificity, but the technique needs to be confirmed by further clinical trials. cardiac imaging in infants with aortic isthmus stenosis: a comparison of contrast enhanced mra and a high-resolution 3d double slab technique u. kramer, f. dammann, j. breuer, l. sieverding, c.d. claussen; tübingen/de purpose: comparison of a three-dimensional gradient-echo (ge) sequence with interleaved double-slab excitation versus a contrast enhanced (ce) mra for the assessment of the great thoracic vessels in children with congenital heart disease.purpose: to assess applicability and diagnostic performance of a standardized multidetector row spiral ct (mdct)-trauma imaging protocol for evaluation of the thoracic and lumbar spine in patients with blunt or spinal trauma. material and methods: mdct (siemens somatom volumezoom, germany) was performed in 86 patients with a history of thoracoabdominal blunt or spinal trauma. all imaging was acquired using a collimation of 4 × 2.5 mm and a pitch of 6. based on this raw data set, the spine was targeted reconstructed using the following parameters: slice width 3 mm; reconstruction interval 1.5 mm. two readers separately assessed imaging quality of spinal structures for diagnostic purposes. in addition, both readers evaluated all patients for spinal fractures using five-point confidence scale (1 = fracture definitely absent, 2 = fracture probably absent, 3 = equivocal, 4 = fracture probably present, 5 = fracture definitely present). the number and level of fractures were categorized and correlated to thin section mdct and/or surgical findings. results: visibility of spinal anatomic details for diagnostic purposes was rated as excellent by reader 1/2 in 927/862 levels and good in 119/184 levels of 1046 spinal levels using a standardized trauma protocol. scoring on the confidence scale was 4.6 (± 0.8) in case of fractures and 1.1 (± 0.1) in case of no fractures, respectively. 20 of 21 spinal fractures (98 %) were correctly depicted by each reader. an anterior wedge fracture was missed by both readers. conclusion: evaluation of the thoracic and lumbar spine is possible with targeted image reconstruction based on standardized chest and/or abdomen mdct data sets. whole body spiral ct in trauma patients -part ii: spinal injuries j. von schlippenbach, t. albrecht, k.-j. wolf; berlin/de purpose: to assess the accuracy of a standardized "whole body" spiral-ct protocol in the initial work-up of spinal injuries in trauma patients and to compare spiral-ct with conventional radiography. methods: 46 trauma patients with potentially life threatening injuries underwent a spiral-ct of the skull base and neck (collimation/table speed/reconstruction interval: 3/5/3 mm), chest, abdomen and pelvis (5/7.5/5) immediately after resuscitation. additional dedicated axial and sagittal high-resolution reconstructions of the entire spine were performed from the data sets. 40 patients also had conventional radiographs of the spine. ct findings were compared with conventional radiographs and final diagnoses at discharge or death. results: image quality was adequate in 39/46 cts and 28/40 conventional spine series. in the remaining cases at least one area of the spine was not adequately imaged, in ct this was most often the thoracic spine. the final diagnoses included 8 cervical, 19 thoracic and 23 lumbar spine fractures; 7 fractures were instable. on ct, all but 1 thoracic and 3 lumbar spine fractures were diagnosed. none of the undetected fractures were instable. on conventional radiography, 1 cervical, 2 thoracic and 5 lumbar spine fractures were missed; again none of these were instable. conclusion: ct was superior to conventional radiography and allowed fast and accurate diagnoses of the vast majority of spinal fractures, and missed no instable fractures. in our experience, time consuming conventional spine radiography is dispensable with this approach in most cases. part i: b-0206 (ss 401) magnetic resonance imaging in traumatized intervertebral discs n.a. ghanem, p. uhrmeister, c.a. müller, c. altehoefer, m. markmiller, m. langer; freiburg/de purpose: evaluation of mri in trauma patients with traumatized adjacent discs of fractured vertebrae before dorsoventral stabilization material and methods: a prospective diagnostic study with 15 trauma patients (12 male, 3 female, mean age: 40 years, range: 17 -72) was performed on a 1.5 t magnetom. the preoperative mri using sagittal t1-w-se and t2-w-tse was compared to the gold standard being intraoperative discography which was carried out on both intervertebral dics adjacent to the fractured vertebrae within a time frame of 1.8 days (0 -3). beside signal alterations of adjoining intervertebral disc, morphological changes such as disc herniation and annular tears were evaluated in 30 adjacent discs. in 12/15 (80 %) patients and in 24/30 of the intervertebral adjacent discs, the results of both imaging findings were concordant. in 3 patients the adjoining discs were normal. concerning the positive concordant imaging findings, mri and discography both revealed traumatized adjacent dics in 6 cases. in 3 cases the upper adjacent disc was injured. among these 15 traumatized discs, 9 intraosseous herniations into the fractured vertebrae and 6 anuluar tears were depicted. in 3 patients the findings were discordant. in one case mri was false positive whereas discography as the gold standard demonstrated no lesion. in 2 cases mri failed to detect a disc injury. conclusion: mri as a noninvasive method may detect traumatized adjacent intervertebral dics, but mri is inferior compared with intraoperative discography although it does reveal additional preoperative information prior to dorsoventral stabilization. mri in traumatic lesions of cervical intervertebral disc b.w. raab, u. fischer, g. kernbach-wighton, k.s. saternus, e. grabbe; göttingen/de purpose: to demonstrate typical findings on mri in traumatic lesions of the intervertebral discs of the cervical spinal column. materials and methods: mri was evaluated in 2 groups of patients with traumatic changes of the cervical spine column including an injury of intervertebral discs. the study included 6 in-vivo examinations of patients and 8 postmortem examinations (neck specimen, c1 -t1 including the skull base) of human corpses after an acceleration trauma. disc lesions were verified intraoperatively in all patients or macroscopically by sections of the specimen. results: the variability of traumatic lesions of the intervertebral disks ranged from small detachments of the disc from the vertebral body to large ruptures of the entire disc. extensive lesions of the disks were correlated with other injuries such as fractures or ligamental trauma. mri depicted all lesions with extension to the entire disk due to morphologic changes in hr-sequences and/or signal alteration in inversion recovery and t2-wi sequences. most of the circumscribed disc detachments seen macroscopically were not detectable with mr imaging. conclusions: mri allows a reliable diagnosis of significant lesions of the cervical intervertebral discs after trauma. small detachments of the disc, however, will be missed. cervical spine injuries in elderly patients: does trauma mechanism and age influence the distribution, type and stability? f. lomoschitz 1, 2 , c.c. blackmore 2 , k.f. linnau 2 , s.k. mirza 2 , f.a. mann 2 ; 1 vienna/at, 2 seattle, wa/us purpose: the purpose of our study was to describe types and distribution of cervical spine injuries in consecutive elderly patients in regard to causative trauma mechanism and to patient age. materials and methods: the distribution and type of 225 cervical spine injuries in 149 consecutive subjects older than 65 years over a 5-year interval were retrospectively assessed. for each subject, initial imaging studies were reviewed and injuries were classified. the trauma mechanism (falls from standing or seated height vs. mechanisms consistent with higher energy) and initial clinical and neurological status were recorded. data were correlated according to patients' age (65 -75 a and > 75 a) and causative trauma mechanism. results: the majority of patients (64 %) had injuries to the upper cervical spine. multilevel injuries were frequent (40 %). the main causes for cervical spine injuries were motor vehicle crashes in "young elderly" (65 -75 a) (61 %) and falls from standing or seated height in "old elderly" (> 75 a) (40 %). fracture patterns at risk for neurologic deterioration were common (> 50 %), even in absence of acute myelopathy or radiculopathy. subjects older than 75 years, independent of causative mechanism, and patients who fell from standing height, independent of age, were more likely to have injuries of the upper cervical spine (p = 0.026 and p = 0.006, respectively). conclusion: injuries of the cervical spine in elderly patients tend to involve more than one level with consistent clinical instability. "old elderly" patients (> 75 years) and subjects who fall from standing height are more prone to injuries of the upper cervical spine. the fluid sign in acute vertebral compression fractures on mri a. baur, a. stäbler, r.h. dürr, m.f. reiser; munich/de purpose: to evaluate the occurrence of the linear fluid sign in acute osteoporotic and neoplastic vertebral compression fractures in magnetic resonance imaging (mri). methods and materials: the study group comprised 87 consecutive patients with a total of 107 acute vertebral compression fractures due to osteoporosis or neoplastic infiltration. the mri protocol included unenhanced t1-weighted spin echo (se) and short-tau inversion recovery sequences (stir) on a 1.5 t system. confirmation of diagnosis was made by surgery, follow-up mri examinations, clinical follow-up or unequivocal imaging findings. results: all fractures showed hypointensity on t1-weighted se images and hyperintensity on stir images, both in cases of osteoporosis (n = 65) and tumor (n = 41). in the fractured vertebral bodies the fluid sign appeared as a circumscribed lesion adjacent to the fractured end-plates, which exhibits signal intensities isointense to cerebrospinal fluid. the shape of the fluid sign was linear (n = 18), triangular (n = 5) or focal (n = 2). it was associated statistically significant with the osteoporotic cause of a fracture (n = 23, 35 %; chi square p < 0.001). the fluid sign occurred also in 2 cases of neoplastic compression fractures (5 %). at the site of the fluid sign histologic correlation demonstrated osteonecrosis, edema and fibrosis. the linear fluid sign represents areas of osteonecrosis with accumulation of fluid in acute vertebral compression fractures. it is highly indicative of osteoporosis, but may occur rarely in metastatic fractures. to compare the efficacy and stability of two different, "second generation", self-expandable, metallic, covered stents in patients with lower third malignant oesophageal strictures. material and methods: 53 patients with inoperable disease were randomised to receive either an ultraflex (n = 31) or flamingo (n = 22) covered oesophageal stent. all procedures were performed in the interventional radiology suite using fluoroscopic guidance. dysphagia before and after stent placement was scored on a 5-point scale and the incidence of early and late complications was compared between the two groups. the initial technical success rate was 100 % in both groups. improvement in the dysphagia score was demonstrated in both groups at both short and long-term follow-up (mean reduction of 2 points). no significant difference was seen in the improvement of dysphagia between the two groups. the early (migration, severe reflux and perforation) and late (haematemesis, tumour ingrowth) complication rates were similar in both groups. purpose: mnd is characterized by bulbar symptoms resulting in reduced respiratory function, diaphragmatic paralysis and weakening of respiratory muscles. nutrition is a prognostic factor for survival but surgical or percutaneous endoscopic gastrostomy is not well tolerated. rig can be safely deployed with severe respiratory compromise. we describe our experience using a modified technique, which allows safe percutaneous puncture of a high subcostal stomach. mnd patients requiring nutritional support were selected for a rig as a consequence of a sub-normal vital capacity. the standard procedure for rig insertion was adhered to, with use of four t-fastners to secure a gastropexy. to take account of the high subcostal site of the stomach, the procedure was modified, performed with lateral screening, allowing for constant visualization of the puncture needles, to confidently puncture the anterior stomach wall.results: this modified technique has been employed in 35 patients (20 male and 15 female, median age 62 years, range 31 -81 years) over a 36 month period. 28 standard radiological gastrostomy tubes were inserted, six were self retaining devices. the procedure was successful in 34 patients (97 %), 7 tubes were reinserted (20 %, all standard radiological tubes) over a variable period of time. the one failure was due to a high subcostal stomach in an obese patient. conclusion: diaphragmatic palsy presents a technical challenge for insertion of a rig in the conventional manner. using lateral screening a high success rate is achieved, and should be the method of choice for mnd patients with respiratory compromise. nineteen uncovered sems (diameters: 18 -22 mm, length: 60 -90 mm) were placed using fluoroscopic guidance in fifteen patients via a per-oral route using standard catheter and guidewire techniques. nine patients had pyloric obstruction. four had undergone gastric pull-up operations or partial oesophagogastrectomy for oesophageal or gastric carcinoma with pyloric dysfunction not responsive to balloon dilatation. five patients had inoperable oesophageal or gastric carcinoma involving the pylorus. six other patients had duodenal obstruction secondary to pancreatic carcinoma. in only three patients were two stents required to cover the obstruction. four patients with malignant obstructive jaundice required concurrent stenting of the common bile duct. results: all patients were able to consume an adequate diet after stent insertion. one stent migrated proximally into the fundus at day two in a patient with gastric carcinoma involving the pylorus. he presented five days later with perforation of the antrum at the tumour site which required emergency surgery. of the remaining patients (seven have died) none have experienced recurrent symptoms of gastric outflow obstruction over a mean follow-up period of fourteen weeks. conclusion: non-endoscopic placement of sems under fluoroscopic guidance is a safe and effective treatment for outflow obstruction secondary to pyloric and duodenal stenosis. it is particularly effective in the palliation of malignant disease, but also has a role on the treatment of pyloric dysfunction after gastric pull-up surgery. purpose: reference methods in diagnosis of crohn's disease are endoscopy and small bowel follow-through. involvement and activity of proximal segments of the small bowel is difficult to evaluate. our purpose was to develop a sensitive, easy to perform and minimal-invasive method for imaging small bowel without radiationexposure for mostly young patients. methods: 30 patients (18 female/12 male) with suspected or established crohn's disease were included. the patients were administered orally 1.5 l of a mannitolsolution (2.5 %) within 1 hour before imaging. a rectal mannitol-solution filling was also employed. butylscopolamin was administrated i.v. haste and fs-hastesequences and t1-bh-sequences were acquired before and after (fs-t1-bh) i.v. gd-dtpa administratio in transversal and coronal orientation. the images were analysed by three radiologist using a standardised protocol. in all cases a correlation with ultrasound-imaging was performed. results: alterations indicative of crohn's disease were noted in 21 patients. in these cases we detected wall thickening with an average of 7.1 mm and with a mean length of 11.5 cm. the signal-intensity-increase after contrastmedium-application of thickened bowel wall was 58 %. normal bowel-wall had an increase of signal-intensity after gd-dtpa of 38 %. 11 relevant stenoses (37 %), 2 abscesses (6 %) and 9 fistulas were visualized (31 %). in ultrasound imaging we detected 9 cases with a stenosis (31 %), 5 fistulous tracts (17 %) and 1 case (3 %) with an abscess. conclusion: mannitol-mri of small bowel in patients with suspected or established regional enteritis is a promising method for the diagnosic work-up and renders results superior to ultrasound imaging. inflammatory bowel disease in children: helical ct with water enema administration g. tognini 1 , f. ferrozzi 1, 2 , g. zuccoli 3 , a. patti 1 , p. bini 1 , p. pavone 1 ; 1 parma/it, 2 cremona/it, 3 reggio emilia/it purpose: the diagnosis of inflammatory bowel disease (ibd) in children, due to the non specificity of the clinical picture, is often difficult and delayed. the aim of our study was to assess the role of helical ct after water enema administration in the diagnosis and staging of ibd.materials and methods: 33 consecutive patients with ibd (19 ff, 14 mm) age range: 4 -15 years underwent spiral ct examination of the abdomen. the imaging protocol consisted of 5 mm collimation, pitch: 1.5, injection of iodinated contrast medium with high flow rates: 3 -3.5 ml/s. the lumen of the colon was filled with water (300 -1000 ml); oral administration of water was also performed in order to obtain gastric and duodenal distension. we evaluated: wall thickening, structure and enhancement of the involved segments, polypoid components, mesenteric fat involvement, adenopathies, extraparietal flogistic complications. 33/33 underwent endoscopic and bioptic confirmations: 23/33 were crohn's disease, 8 ulcerative colitis, 2 showed non specific features. results: wall thickening (26/33), increased contrast enhancement (23/33), endoluminal pseudopolyps (7/33), fibrofatty proliferation (9/33), edematous infiltration (6/33), mesenteric adenopathies (19/33), abscesses and flogistic complications (10/33). in 21/33 patients ct allowed for the correct differentiation between crohn's disease and ulcerative colitis. the morpho-structural evaluation which can be obtained by means of helical ct and water enema administration allow for an accurate study of the intra and extraluminal manifestations of the ibd. ct was found useful in the diagnosis but mainly in the follow-up of patients with ibd giving important differentiating criteria. ct signs of active crohn's disease and comparison with immunscintigraphy g. tóth, g. szentmártoni, t. györke, e.k. makó; budapest/hu purpose: this retrospective study compares the diagnostic yields of ct and immunscintigraphy in the assesment of activity in crohn's disease. we evaluated which ct signs are the best predictive signs of the activity in crohn's disease. we examined 126 patients with clinically suspected crohn's disease. we studied patients first with bifasic dinamic helical ct and 4 -7 days later with immunscintigraphy. ct studies were performed in a standard fashion: collimation 8 mm, feed 12 mm, reconstruction 5 mm. i.v. contrast administration flow 3.5 ml/s, volume 1.5 ml/kg, delay 40 s in a caudo-cranial direction. we were searching for bowel wall thickening, increased contrast enhancement of the bowel wall, mesenterial signs, fistulas and abscesses, and enlarged lymph nodes. ct results were correlated with immunscintigraphy. results: in cases where the affected loops showed thickened wall (4 -10 mm) increased contrast enhancement and sourranded by a fibrofatty proliferation, with increased vascularisation the immunscintigraphy was positive in 91 % of patients. when we saw fistulas, abscesses and a thickened bowel wall (10 mm or more), with increased vascularisation in mesentery with prominent enlarged lymph nodes the immunscintigraphy was always positive. conclusion: contrast enhanced spiral ct study is a goog tool in the assesment of the activity in crohn's disease. results: in 10 cases the embolization failed: no bronchial artery catheterized in the bleeding side (n = 6), pulmonary artery bleeding due to central excavated lung tumors (n = 2), right intercosto-bronchial trunk with a doubt about a spinal radicular artery (n = 1), unstable catheter position (n = 1) and technical problem (n = 1). among the 61 patients with at least one bronchial artery selectively catheterized (included 4 non-embolized), bronchial hypervascularisation was visualized in 58 associated with nonbronchial systemic hypervascularisation in 4 cases. the immediate control of bleeding was obtained in 72 %. long-term result was 61.4 %.complications were: acute but transient renal failure (n = 1), cerebral ischemia (n = 2) with one definitive deficit. conclusion: tumours are responsible of 12.3 % of massive hemoptysis and embolization is efficient. the bleeding is rarely due to nonbronchial arteries. stroke incidence is increased in comparison with other hemoptysis probably because of elderly patients. intraoperative transthoracic ultrasonography for the localization of hidden pulmonary nodules during thoracoscopy f. coppola, m. piolanti, f. gruppioni, s. papa, m.p. di simone, s. mattioli, g. gavelli; bologna/it purpose: the purpose of this study was the evaluation of intraoperative sonography in the detection of hidden pulmonary nodules during thoracoscopic resection. to perform intrathoracic ultrasonography an endosonographic linear probe with high-frequency transducer (7.5 -10 mhz) was employed. 40 patients, entered the study; 52 pulmonary nodules were preoperatively detected, 50 by spiral ct and 2 by pet. 10 sonographic examinations were performed during thoracotomic surgery and 30 examinations during thoracoscopy. the times needed to reach lung collapse and to localize the targets were recorded. complete lung collapse is essential to perform intraoperative sonography and can be accomplished by single controlateral lung intubation and ventilation for 45 minutes at least. the sonographic examination is quick, unless the patient is affected by obstructive disease (such as centrilobular emphysema): retained air in the parenchyma reduces the explorability. all but one preoperatively detected lesions and two further unknown lesions were localized by intraoperative sonography. there were no complications related to the procedure. conclusions: intraoperative sonography proved itself to be a reliable and satisfactory localization technique of lung nodules during thoracoscopy. in comparison with the other localization techniques it shows several advantages, such as the capability of revealing preoperative occult lesions and determining the surgical borders. the aim of this study was to assess the accuracy of wire-versus carbon-localization in slobb. a total of 1115 slobbs were performed from 01/94 until to 12/97 in 1068 female patients (age range, 22 -90 years) on a prone stereotactic unit (mammotest, fisher imaging, denver, co). in 1007 cases successful slobb was verified either by a malignant histopathological diagnosis or by immediate mammographic evaluation after surgery. in 582 (58 %) of these cases the lesion was localised with a wire, in 410 cases (41 %) carbon was used. both methods were used to localise the remaining 15 cases (1.4 %). a lesion was considered as missed when it could be still seen on mammography performed after surgery. results: ten out of 1007 cases (1 %) were missed at slobb. of these, 5 lesions had been localised by wire (5/582; miss-rate 0.9 %) and 5 lesions with carbon (5/410; miss-rate 1.2 %). there were no significant differences in miss-rates between wire-and carbon-localisation (p > 0.05). conclusion: both wire-and carbon-localisation are reliable and accurate in the localisation of non-palpable breast lesions undergoing slobb. considering the fact that wire-localisation is far more expensive than carbon-localisation the routine use of carbon should be considered. histological results of scnb and surgical biopsy were compared and scored for each needle size on a three point scale (1 = no agreement, 2 = partial agreement, 3 = complete agreement) to determine the optimal needle size for such lesions. results: there were 69 masses, 13 asymmetric densities, and 53 calcifications. a diagnosis of malignancy was found at surgery in 1/135 (0.7 %) [1 ductal carcinoma in situ]. the remaining 134 lesions revealed a benign histology. the 11 g needle (score = 3) scored better than both 14 g needles (score = 2.9). conclusion: based on the relative low rate of carcinomas scnb should not be performed routinely in probably benign lesions (bi-rads 3). mammographical short time follow-up seems to be more useful to confirm the benign nature of such lesions. if scnb will be performed 11 g needles seem to be advantageous. does the preoperative core-cut biopsy influence the appearance of local recurrence of breast cancer? u.g. aichinger, j. ammon, r.w.s. schulz-wendtland, i. kuchar, w.a. bautz; erlangen/de objective: retrospective study to evaluate if preoperative core-cut biopsy influences the incidence of local recurrence of breast cancer and metastasis -a phenomenon described after puncture biopsies of the pancreas and the prostate. material and methods: core-cut biopsy was performed on 150 patients with suspected breast cancer before undergoing surgery in the period 1992 -1993. the clinical outcome of 123 patients was analysed retrospectively over a period of seven years. 66 had undergone breast conservation therapy, 57 had had a mastectomy. adjuvant therapy was also included in the evaluation. results: local recurrence after breast conserving therapy (bct) was seen in 11 of 66 patients (17 %), and in 7 of 57 (12 %) after mastectomy (mrm). the rate of local relapse after radiotherapy (rt) was 8 of 43 (19 %) (bct) and 4 of 25 (16 %) (mrm) respectively. in the group without rt 3 of 23 (13 %) (bct) and 3 of 22 (9 %) (mrm) relapsed respectively. in two cases the biopsy site was not removed. one of those, not having had a rt, had a local recurrence. conclusion: according to the literature, breast cancer local recurrence rate is 1 -2 % per year. in our group recurrence rate reached 1.9 % totally per year and 2.1 % after bct being in agreement with international studies. no higher rate of local recurrence or metastasis was seen after core-cut biopsy. nevertheless the biopsy site should be removed in any case. multicenter evaluation of stereotactic vacuum biopsies of mammographically indeterminate or suspicious lesions the consensus was achieved based on the existing literature and on the experience of the participants using a consensus process as suggested by sackett. results: complete standard imaging work-up is the prerequisite before a decision for percutaneous breast biopsy is made. the following lesions are considered well-suited for vacuum biopsy: microcalcifications, small non-palpable masses with or without microcalcifications. the following indications may not be (as well) suited: architectural distortion (suspected radial scar) or lesions close to the skin. needle access (angulation of compression, stroke margin) must be exactly documented. acquisition of > 20 cores (11 g) shall be routinely attempted (goals: radiologic removal of lesions < 10 mm to increase diagnostic reliability, decrease of underestimates). documentation of scout, pre-, post-fire and post-biopsy images and another orthogonal view after biopsy are required. final diagnosis must consider imaging-histopathologic correlation, and for certain histopathologic entities the result on an interdisciplinary conference. standard documentation of the examination and of 6 months-follow-up is required. the closed architecture of 1.5 t whole body magnets makes it difficult to perform mr-guided biopsies at high-field strength. the aim of this study was to investigate the feasibility of mr-guided breast biopsy using a remote-controlled robotic system which assists the localisation of the target and runs inside the magnet. materials and methods: 13 patients with suspicious lesions (diameter 19 ± 11 mm) in mr-mammography were biopsied using the robotic system. after localisation of the lesion the robotic system positioned the troacar at the correct position. the troacar was inserted into the breast in front of the lesion. the specimen was taken in coaxial technique using a 13 g core needle biopsy gun. in case of malignant histology the patient underwent open surgery afterwards. the biopsy procedure inside the magnet was completely performed without interruption in all cases. operation proved the histological finding of breast cancer in 5 cases. one patient was diagnosed as atypical ductal hyperplasia by biopsy and turned out to have an invasive ductal carcinoma. 8 patients showed benign lesions and will be followed up. the current study demonstrated the feasibility of breast biopsies inside the magnet of a whole body scanner using a robotic system. one false negative case was due to tissue shift during the insertion of the troacar into the breast. first experiences with two patients show the procedure to be feasible. in future imaging, biopsy and therapy of breast lesions should be possible in one single patient session using this robotic system. to assess the feasibility of assessment of stent-graft patency by contrast-enhanced magnetic resonance angiography (ce-mra). materials and methods: 9 bifurcated abdominal aortic aneurysm (aaa) stentgrafts made of nitinol, elgiloy or stainless steel were investigated regarding their appearance on mr imaging. the stent-grafts were positioned in a phantom filled with aqueous gadolinium solution. coronal and axial three-dimensional gradient echo sequences were performed (tr 8.1 ms/te 1.3 ms, fa 40°). relative signal intensity reduction within the stent-grafts and the difference of the real stent-graft lumen as compared to the lumen measured on the mr images were calculated. results: the graft lumen was depicted in 6 prosthesis. the lumen of stainless steel stent-grafts showed a complete signal void. relative narrowing of the inner diameter on the mr images was less in the proximal part of the stent-grafts than in their legs. with a gadolinium dilution of 1:20 the artifical narrowing of the proximal lumen ranged from 7.1 % to 59.5 %, whereas in the stent-graft legs the visible lumen was diminished between 2.4 % to 71.8 %. only three stent-grafts presented with a lumen reduction on the mr images of less than 33 % along the whole prothesis length. conclusion: to differentiate between artifacts and stenoses, a knowledge of the degree of signal intensity reduction and artificial lumen narrowing within aaa stentgrafts is essential. stent-graft composition and the design of the stent-graft influence the artifact behaviour and lumen visibility as displayed on ce-mra. only a minority of the investigated stent-grafts is suitable for imaging by ce-mra. 28 patients with aaa undergoing endovascular stent grafting were included in the study. helical ct scanning was performed within one week following stent graft implantation with a scanning protocol of collimation 5 mm, pitch 1.0, and a 2 mm reconstruction interval. contrast enhancement was given to all patients with a total volume of 100 ml, flow rate of 2 ml/s and scan delay of 30 seconds. all patients received a zenith tm /aaa endovascular graft with uncovered supra renal struts of 2.5 cm length placed above the level of the renal arteries. vie images were created for each patient with analyze avw 1.0. the follow-up period ranged from 1 to 12 months (mean 6.9 ± 4.7 months). results: 4 of 28 coeliac arteries, 23 of 28 superior mesenteric arteries, 28 of 28 right renal arteries and 28 of 29 left renal arteries were covered by the stent struts to different extents. vie demonstrated the number of metal wires crossing the arterial ostia and the configurations of these stent struts relative to the arterial ostia such as partial or complete encroachment. follow up ct scanning showed that all of these aortic arterial branches were patent. conclusion: vie is a novel imaging technique to visualise the 3d intraluminal relationship of the aortic stent struts to the arterial ostia in patients with aaa following suprarenal stent grafting. the current system consists of a see-through, headmounted display, a tracking system, computer system and tracked surgical instruments. interaction with the system is provided through voice and speech. the system produces a computer-generated image overlaid onto the real world, using virtual "hanging windows" for information display eg. ct/mr scans, real-time fluoroscopy, vital signs, live video (endoscopy), step-by-step instructions, dictation/ communication screens, 3d models of anatomy and other information to assist the radiologist during a procedure. in addition, different pre-and post-stent 3d models of the aortic aneurysm from recent procedures can be brought up within the environment for comparison or as a reference. the user can also bring up patient-specific 3d reconstructions. results: this system provides assistance during aaa stent placement. all previous imaging series (ct-, mr-, and conventional angiography), stent planning data, 3d models of the aneurysm and monitoring of vital signs are shown on one screen (head mounted display) in "hanging windows" on request. the software provides a real-time surgical simulation system with integrated monitoring and information retrieval and a voice input/output subsystem. the system provides all the important information on one screen (head mounted display) and can be used to assist various tasks such as stent implantation procedures in the interventional radiological theater. a.m. grozaj, t. pfammatter, m. lachat, u. wolfensberger, p.r. hilfiker; zürich/ch purpose: to report midterm results of endovascular stent-grafting in patients with ruptured abdominal aortic aneurysm (raaa). materials & methods: 17 patients (3 women, 14 men; mean age 73 years) with raaa were treated with bifurcated endoprostheses. preinterventional assessement was performed with ct (n = 17), ultrasound (n = 5) and angiography (n = 1). all patients were a high operative risk. the procedure was performed under local (n = 12) or general anesthesia (n = 5). follow-up cta was performed after 1 day, 6 weeks, 3, 6, 12 months and annually. results: immediate technical success was achieved in 16 patients (94 %). one needed conversion to open surgery due to progressive hemodynamic instability. mean intervention time was 149 min (± 114), mean icu stay 2.6 days (± 0.85) and mean hospitalization 10 days (± 5). the 30 day mortality was 0 %. within 30 days one patient was treated with hemofiltration and three had reinterventions: replacement with homograft of an infected iliac-femoral extension sg; sg extension for retroperitoneal bleeding; embolization of the inferior mesenteric artery. in the mean follow-up period of 8 months two endovascular reinterventions were performed: sg implantation for graft disconnection; thrombolysis of a stent leg. one patient needed elective late conversion to open surgery after 14 months due to sg migration. aneurysmal diameter decreased in 58.8 %, increased in 5.8 % and remained unchanged in 35.3 % of patients. conclusion: endovascular treatment of raaa with sg implantation is feasible and safe. this technique seems to be a valuable alternative to emergency open surgery with its high mortality. emergency treatment of thoracic aorta diseases by endovascular stentgraft l. lovato, r. fattori, g. napoli, c. grazia, f. settepani, g. gavelli; bologna/it purpose: surgery of the thoracic aorta is characterized by high mortality and morbidity, especially if performed in an emergency. we report our experience in emergency endovascular treatment of the thoracic aorta. material and methods: from 1997, 58 patients underwent endovascular treatment of the thoracic aorta. seven (2 type b acute aortic dissections, 2 traumatic aortic ruptures, 1 penetrating aortic ulcer and 2 surgical prosthesis dehiscences) presented with clinical and/or imaging findings of impending aortic rupture and were treated as an emergency. before the procedure, spiral ct was used to define the lesion's anatomy. all procedures were performed in the operating theatre and monitored by a radiographic c-arm system and by echocardiography. results: stent-graft implant was successful in all patients. no death nor complication occured during the procedure. in 4 cases, immediately after stent-graft implant, surgical drainage of a hemothorax was performed. the average time of intensive care unit stay was 12 ± 8 hours, while hospital stay was 7 ± 5 days. in 6 patients a spiral ct follow-up showed complete aneurysmal exclusion; 1 case showed persisting leakage over 3 months and was converted to surgery. conclusion: endovascular stent treatment of thoracic aorta diseases could be a very effective option and an alternative to surgery, especially in an emergency. endovascular treatment of thoracic aortic aneurysms and dissections with the use of customized stent-grafts q. sénéchal, f. koskas, p. cluzel, j.-d. singland, e. kieffer, p.a. grenier; paris/fr purpose: to describe our experience with the use of a custom stent-grafts for the treatment of thoracic aortic aneurysms and dissection. patients and methods: from january 1996 to september 2001, 28 aneurysms and 11 dissections were selected to be treated using custom stent-grafts of different designs. custom stent-grafts were constructed with gianturco z stents sutured together and covered with polyester (twillweave, vascutek, innachinnan, scotland). endovascular treatment of aortic arch aneurysms combined with extraanatomic bypasses were used in 7 cases. elephant trunk in one step was used in three cases. endovascular bypasses were used as the second step of the elephant trunk technique in two cases. results: four patients (10 %) were converted to standard open repair. no leakage of the thoracic aneurysms was observed at follow-up. sealing of the primary tear in thoracic aortic dissections was successful in all cases. three patients died of myocardial infarction in the perioperative period. conclusion: custom stent-grafts in the endovascular treatment of thoracic aortic pathology achieve good results. endovascular treatment of aortic arch aneurysms combined with extra-anatomic bypasses provides a less invasive method of treatment of these complex lesions. longer follow-up is needed for the device. percutaneous treatment of thoracic aortic dissections and thoracic aortic aneurysms using commercially available stent-grafts f. fanelli, f. salvatori, m. rossi, g. marcelli, f. venditti, p. rossi; rome/it purpose: to report our preliminary experience in the treatment of thoracic aortic dissections and thoracic aortic aneurysms (taa) using endovascular stent-grafts. methods and materials: from november 2000, 16 patients were treated using a commercially available stent-graft: thoracic excluder (w.l. gore). twelve cases were performed in the angio-suite and 4 in the or under general or epidural anesthesia. taa: 6 patients. in two patients (12.5 %), with a short proximal neck, the origin of the left subclavian artery was covered by the stent-graft. dissection: 10 patients with type b dissection, 7 acute and 3 chronic. two cases were complicated by renal ischemia treated by renal stenting. the primary entry tear was located in 7 patients less than 2 cm from the origin of the left subclavian artery which was covered by the stent-graft. results: after a follow-up ranging from 2 to 10 months, all patients are in a good condition with no signs of paraplegia. taa: technical success with complete exclusion of the aneurysm was evident in all cases. dissection: 1 technical complication (6.25 %) was observed during stent-graft deployment of antegrade extension of the dissection into the ascending aorta which was surgically managed. in all cases progressive thrombosis of the false lumen developed. in 3 cases (18.7 %) an endoleak was detected: one, originating from the subclavian artery was treated by coil embolization; one sealed spontaneously after 6 months; the last one is under control. conclusion: endovascular techniques represent a new frontier in the treatment of thoracic dissection and taa, but further evaluations are mandatory to clearly understand its efficacy. the probability of location of breast mass margin in digitised mammograms f. sendra-portero, e. ristori-bogajo, e. nava-baro, m. martínez-morillo; málaga/es purpose: most of the computational problems in segmentation are originated by tortuous contours which are difficult to be perceives by either a computer segmentation program or a human observer. a method based on successive interactive segmentations of breast masses in digitised mammograms to plot the probability of location of the mass contour is introduced. materials and methods: 81 digitised mammograms including 94 masses with different type of margins were studied. the border of each mass was outlined with a digitising tablet, encompassing all densities considered as part of the mass, including spicules and tracts. two observers repeated the same procedure three times. the segmentations of the same image were split off between them 48 hours at least. a labelled image was obtained from the six binary images of each case, giving seven possible values per pixel, from 0 to 6. thus, the lines that delimit each value are considered "isoprobability lines", encompassing a probability equal to 1.00; 0.83; 0.67; 0.50; 0.33 and 0.17 to find the mass margin. results: when the margin is well defined the isoprobability lines are closed one each other, with a sharp transition from 1 to 0. in exchange, when the margin is illdefined obscured or speculated, the isoprobability lines spread out. in those combined type margins the uncertainly zones are clearly distinguished from well defined zones. conclusion: images obtained by this method can be used as a reference pattern to evaluate automatic or semi-automatic computer-aided segmentation systems of breast masses. results: mfe-vq employing 16, 25, and 36 cvs identified clusters that could be attributed to known suspicious regions in each case. the lesions could clearly be differentiated from surrounding tissue. in 7 patients, single clusters could be related to motion artifacts based on signal dynamics and cluster localization. in addition, a self-organized subclassification within the lesions could be achieved in up to 4 clusters w.r.t. fine-grained local differences in mri signal amplitude and dynamics. conclusions: mfe-vq by deterministic annealing is a useful strategy for the analysis of contrast-enhanced mri mammography time-series without time-consuming interactive contour tracing of regions of interest by human observers, thus enabling segmentation of suspicious lesions. in addition, a subclassification w.r.t. local differences of perfusion patterns inside suspicious regions can be achieved. in three dimensional medical imaging like ct or mri, knowledge based approaches foster the robustness and reliability of segmentation processes. a robust fully automatic segmentation is a desirable task to acquire objective and accurate results. a 3d surface model for the segmentation of parenchymal organs in ct-and mri-datasets has been developed. the necessary training set for the surface model is computed from semiautomatically generated triangulated surface meshes of the objects. the generated surface model is capable of learning the characteristic shape and gravalue information stored in the training set. the optimization is performed by iteratively moving the surface points of the model towards fitting image structures under the constraints of its grayvalue and shape information. two different 3d surface models have been developed: a milt model consisting of 10 training objects, and a kidney model generated from 7 left kidneys. the two models have been tested on 6 unknown milt-and also 6 unknown kidney-datasets. the total cover between the model and the organs varied between 70 % and 80 %, which is a respectable result in the face of the small training set. further the computing time of the model optimization lies in contrast to other approaches within a few minutes on a standard pc. to overcome the problems segmenting organic structures in 3ddatasets using arbitrary methods, a knowledge-based 3d surface model has been successfully introduced. the segmentation accuracy of the model can be actually improved by using a larger training set in future. use of the dicom file format for quantitative analysis of brain images m. larobina 1 , a. prinster 1 , m. quarantelli 1 , a. ciarmiello 1 , j.p. hornak 2 , b. alfano 1 ; 1 naples/it, 2 rochester, ny/us purpose: to review our experience using dicom format files to perform quantitative analysis of mr brain images. we use an algorithm that performs segmentation and volumetric measurement of normal and abnormal brain tissue. the method is based on calculations of relaxation rates of brain tissues from spin-echo images. the algorithm reads dicom format images, and requires repetition time, magnetic field strength, slice location, fov, and matrix size information from the dicom file header. we have applied the algorithm to studies performed on ge signa 1.0 t, ge signa 1.5 t, philips gyroscan nt 1.5 t, picker eclipse 1.5 t, and siemens magnetom 1.5 t. results: images generated by these scanners reveal that the manufacturers interpret dicom standard differently. in some cases, the file header reports fields with structure or content not always in accordance with the dicom standards. deviations in the dicom header usually do not render the file unreadable, but do hinder the use of the header information and the dicom format. the dicom format has the potential to become the format of choice for all the post-processing of mr images. unfortunately, the standard is too complex to easily discover if violations of the standard are present. we emphasize the need to have a way to know if a set of dicom files is totally compliant with the dicom standard. the use of images that are labeled dicom-compliant except for information reported in one field represents a non-negligible problem. multi-slice ct for visualization of pulmonary embolism using perfusion weighted color maps j. purpose: to evaluate the feasibility of a new technique for perfusion weighted colour display of lung parenchyma density derived from multi-slice ct (msct) data sets for visualization of pulmonary embolism (pe). methods and materials: imaging of patients with suspected pe was performed on a msct (somatom volume zoom; siemens, forchheim, germany) after intravenous application of 120 cm 3 of contrast-medium. based on thin collimation axial slices (slice thickness 1.25 mm, reconstruction increment 0.8 mm), a new image processing technique was deployed. automated 3d-segmentation of the lungs was performed followed by threshold based extraction of major airways and vascular structures. the filtered volume data were color encoded and finally overlayed onto the original ct-images. this color encoded display was presented in axial, coronal and sagittal plane orientation. in ten patients with excluded pe as well as in ten patients with proven pe the new technique was performed. results: in ten patients, considered negative regarding pe on msct, lung densitometry showed a homogeneous distribution of color encoded densities without circumscribed decreased or increased areas. in the patient group with proven pe, low density values on perfusion weighted colour maps were found distally to the occluded pulmonary arteries. conclusion: our initial experience indicates that lung densitometry with an optimized colour encoded display of the density distribution within the lung parenchyma may provide additional information in patients with suspected or proven pe. the evaluation of first-pass myocardial perfusion imaging in patients with coronary artery disease (cad) represents a complex issue in the field of cardiac mri. commercially available software allows placement of regions of interests (rois) into the myocardium and calculation of mean signal-intensity over time. however, small perfusion defects may be missed using this method due to the large area of rois. purpose of our study was to develop a pixel-based evaluation software for mr myocardial perfusion images. we chose a matlab based approach (matlab version 6.1). our software enables the user to register the images using a least-square-algorithm. images can be filtered with a median filter. maximum upslope and area-under-the-curve for the signal intensity are calculated for each pixel and shown graphically. myocardial perfusion measurements were performed in 10 patients with angiographically proven cad using a sr-truefisp-2d-sequence (tr 2.4 ms/te 1.2 ms). mr perfusion data were analysed with our software and compared to spect and angiography. results: data of 8 patients could be adequately analysed with the software developed. parameters upslope and area-under-the-curve in regions found to be malperfused by mri correlated well with angiographically detected coronary artery stenosis and hypoperfused areas detected by spect. main limitation of the method was incorrect registration of images, caused by cardiac arrhythmia and patient motion. conclusions: semi-automated pixel-based analysis of perfusion measurement is possible and the promising results of this analysis correlate with angiographic and spect findings. artefact free data acquisition and image registration are important and the limiting factor for pixel-based analysis. purpose: to evaluate clinical feasibility of spatial domain filtering as an alternative to additional image reconstruction using different kernels in chest ct. methods and materials: 40 adult patients with clinical suspicion of pulmonary embolism were examined utilizing multi-slice ct (somatom volume zoom, siemens, germany). two sets of images were reconstructed using lung (b50) and soft tissue (b30) kernels, respectively. additionaly, b50 images were filtered in the spatial domain, producing images largely equivalent to b30 images. diagnostic images were compared to the initially reconstructed b30 images. subjective image quality was rated using a three point scale (1 = excellent, 2 = fair, 3 = nondiagnostic). results: filtered images provided 10 central emboli, 19 segemental thrombi and 20 emboli on the subsegmental level in the 20 patients with proven pulmonary embolism. latter was excluded in the other 20 subjects. subjective gradings of image quality, based on soft tissue settings were comparable for all data sets. therefore, these filtered images provided exactly the same diagnostic accuracy for central, segmental and subsegmental pulmonary embolism compared to conventional soft tissue reconstructions. the new method presented has proven to be clinically feasible and should therefore be implemented in the clinical enviroment. online modifications of image sharpness and pixel noise in real time will potentially replace the need for multiple reconstructions using different kernels. volume rendering of portal liver vessels: correlation between 3d recostruction parameters and image quality g. luccichenti, f. cademartiri, p. pavone; parma/it purpose: aim of this work is to determine the influence of the scan, density values and opacity curves in three-dimensional reconstruction with volume rendering technique of portal liver vessels. methods and material: 22 patients with previous abdominal ct or us underwent spiral ct during the arterial and the portal phase with the following parameters: collimation 3 mm, feed 4.5 mm, pitch 1.5, increment 1 mm. images were sent to a workstation running on a nt platform equipped with vitrea 2.0 (vital images, usa) allowing 3d reconstructions in order to generate volume rendering of the liver vascular supply. density values of portal vessel (p) and liver (l) parenchyma were measured and correlated with 3d image quality and the parameters of three different opacity curves (oc) utilized to obtained them. results: better visualisation of arterial supply was obtained with non linear opacity curves. it was possible to clearly demostrate them up to the fifth generation. significative correlations were observed between curve parameters (c), liver and portal vessels densities ratios (c vs p and c vs l r = 0.67 and r = 0.82 respectively for linear oc and r = 0.82 and r = 0.84 for non linear oc). correlation between c and 3d image quality was r = 0.22 and r = 0.52 for linear and non linear oc respectively. p/l density ratio poorly correlate with 3d image quality r = 0.34. wilcoxon test was significant between the three opacity curves. conclusion: 3d image quality mainly depends on scan quality. density ratios are important to set the opacity curve parameters. direct volume rendering based interactive virtual colonoscopy d. jocha, j. koloszár; budapest/hu purpose: virtual colonoscopy is a non-invasive computerized medical examination method for examining the interior of the human colon, aiding the detection of polyps. nowadays systems for this purpose are slow and/or require special hardware and have many other problems making their usage difficult and limited. our purpose was to develop a system without these disadvantages. materials and methods: in our study we have examined the most popular approaches to the problems of high-speed rendering and navigation within the colon, and devised our own algorithms. our intent was to make them fast and reliable enough to be implementable on a consumer-end pc system, instead of state of the art high-end workstations, and to minimize off-line calculations. results: we present our idea of a real-time direct volume rendering based visualization technique combined with an on-line computer aided interactive navigation method for the examination of volume data constructed from ct scans. these algorithms have been implemented in our colon visualization program called colvis. the results are promising, the current implementation is close to the real-time requirements (∼ 2 seconds/frame). conclusion: according to our results virtual colonoscopy can be an everyday diagnostic method in the near future. results: acl and pcl avulsion fractures occurred with equal frequency. acl avulsion fractures occurred more commonly in adults than previously believed. about one half of acl avulsion fractures are partial, involving the anteromedial bundle only, one quarter are comminuted and one-half are extended. pcl avulsion fractures occur in an older age group than acl avulsion fractures. the majority are complete, half are comminuted (between the individual pcl bundles) and half are extended. when compared to anteroposterior and lateral radiographs, ct is helpful at delineating the fracture margins (for type i and ii fractures) and at delineating comminution and extent in pcl injuries. three-dimensional ct allows good perception of the fracture type and tibial bony defect as a prelude to operative reduction. this study leads to a better understanding regarding the relative freqeuncy and variablity of cruciate avulsion fractures and indicates those areas where ct is particularly helpful. dual-detector spiral ct arthrography of the knee: assessment of anterior cruciate ligament and associated meniscal tears b. vande berg, f.e. lecouvet, p. poilvache, j.e. dubuc, b. maldague, j. malghem; brussels/be purpose: to assess dual-detector spiral computed tomography (ct) arthrography of the knee in the evaluation of anterior cruciate ligament (acl) and associated meniscal tears. the acl and meniscal abnormalities in 125 consecutive patients who underwent dual-detector spiral ct arthrography of the knee were evaluated based on both initial interpretations and retrospective review of ct images and were compared with arthroscopic findings. the sensitivity and specificity of ct arthrography for the detection of acl tears and of meniscal lesions in aclabnormal knees were determined. results: the sensitivities and specificities for the detection of acl tears were 90 % and 96 %, respectively, at initial interpretation and 95 % and 99 %, respectively, at retrospective interpretation. the sensitivities and specificities for the detection of meniscal tears in acl-abnormal knees were 92 % and 88 %, respectively, at prospective initial interpretation and 96 % and 94 %, respectively, at retrospective interpretation. conclusion: dual-detector spiral ct arthrography of the knee is an accurate method for detecting acl and associated meniscal tears. 2d-tof unenhanced and 3d-spoiled-gre contrast-enhanced images were acquired. unmatched, randomized evaluation of images was performed on-site and by two off-site blinded reviewers. the change from unenhanced mra in total diagnostic quality (tdq) was evaluated for each patient using a five-point scale. evaluation was made also of the number of vascular lesions detected, confidence in lesion characterization and the ability to grade stenoses. a full safety assessment was performed. results: both off-site reviewers noted a significant improvement in tdq from preto post-contrast at all but the lowest dose. the increase appeared to plateau at 0.1 mmol/kg. the dose effect was significant for the on-site reviewers (p = 0.005) and off-site reviewer 2 (p < 0.001) but not for off-site reviewer 1 (p = 0.06). for all but the lowest dose group, gd-bopta increased (a) the number of patients with lesions detected and, for most patients, the number of lesions detected per patient; (b) confidence in lesion characterization; (c) the percentage of stenoses visualized clearly enough for grading (reviewers 1 and 2 graded 80 -95 % and 57 -80 % of stenoses, respectively). all doses were well tolerated. the overall incidence of adverse events was 9.6 %. conclusion: ce-mra of the pelvic arteries using gd-bopta is safe and significantly more effective than tof-mra. a dose of 0.1 mmol/kg appears the most suitable. purpose: the purpose of this study was to evaluate the feasibility of blood pool contrast-enhanced mra to visualize the arterial and venous vessel tree and to detect deep venous thrombosis (dvt) of the lower extremities. material and methods: nine consecutive patients with pulmonary embolism (mean age: 46 ± 9) were randomized to various doses of nc100150 (between 0.75 and 6 mg fe/kg b.w.). a t1w 3d-gre sequence (te: 2.0 ms, tr: 5.0 ms) was used. two observers blinded to the dose of contrast agent assessed image quality, contrast attenuation and appearance of thrombi.results: qualitative assessment of overall mra image quality and semiquantitative vessel scoring revealed good to excellent delineation of venous and arterial vessel segments independent of the dose of nc100150. however, quantitative roi analysis revealed a significantly higher s/n ratio in the high dose group compared to the mid and low dose groups of nc100150 (p < 0.01). between dose groups, s/n ratio was independent of vessel type (artery or vein) and vessel segment localization (proximal or distal). all seven venous thrombi (mean length 7.2 ± 0.95 cm) were characterized by a very low si, which was only 16.6 ± 7 % of the si in adjacent venous segments (p < 0.0001).conclusions: high quality mr angiograms of the lower extremities can be obtained using low concentrations of nc100150 in combination with a strong t1w 3d-gre sequence. the obvious delineation of venous thrombi suggest that this technique may be potentially used as a non-invasive "one-stop shopping" tool in the evaluation of thromboembolic disease. injection-associated pain in femoral arteriography: a european multicentre study comparing safety and efficacy of iodixanol and iomeprol c. manke 1 , f. cognet 2 , a. page 3 , j. pueyo 4 , n. batakis 5 ; 1 regensburg/de, 2 dijon/fr, 3 winchester/gb, 4 mallorca/es, 5 athens/gr purpose: to evaluate injection-associated pain, safety, and efficacy with the isoosmolar contrast medium iodixanol (visipaque 270 mg i/ml) compared with iomeprol (iomeron 300 mg i/ml) in femoral arteriography. materials and methods: a prospective, multicentre, double-blind, randomised, parallel-group clinical trial was performed in nine hospitals in europe. of the 352 patients evaluated, 176 received iodixanol and 176 received iomeprol during peripheral arteriography (automated stepping intra arterial dsa). the first injection was standardised (volume 80 ml, flow rate 10 ml/s), additional injections were performed according to needs. the injection-associated pain, safety and efficacy were evaluated. adverse events were recorded during the procedure and up to 72 hours after the examination. the iodixanol group reported statistically significant less injection-associated pain than the iomeprol group after first injection (7.4 % vs. 18.5 %; p = 0.002), and after all injections (10.9 % vs. 20.2 %; p = 0.02). no significant differences were found between the iodixanol group and the iomeprol group for frequency of contrast-related adverse events (1.7 % vs. 1.7 %). overall diagnostic utility was excellent/good for 86.8 % of the patients in the iodixanol group and 86.7 % in the iomeprol group (p = ns). in this trial iodixanol 270 mg i/ml caused significantly less injectionassociated pain during femoral arteriography than iomeprol 300 mg i/ml and was shown to be equally safe. despite lower iodine concentration, iodixanol provided similar diagnostic efficacy to iomeprol. optimizing vessel enhancement for cta of the pulmonary vasculature by contrast media dilution c.w. bader 1 , j.m. froehlich 1 , h.a. lohr 1 , j. sousa 2 , c.l. zollikofer 1 , k. wentz 1 ; 1 winterthur/ch, 2 wädenswil/ch purpose: to verify the hypothesis, that with a defined amount of 27 g iodine a higher injection rate of diluted contrast media (iobitridol) results in higher vessel enhancement in pulmonary cta methods and materials: after bolus timing, ctas were performed in 93 patients divided into 2 groups: group a with 48 patients (age 66 ± 17 a, 90 ml cm, 300 mg/ml concentration, flow 3 ml/s) and group b with 45 patients (age 66 ± 15 a, 108 ml cm, 250 mg/ml concentration, flow 4 ml/s). each cm application was followed by a saline flush of 30 ml. contrast enhancement of the pulmonary trunc, right and left main arteries and lower lobe arteries was measured. results: contrast enhancement of the pulmonary trunc was 342 ± 87 hu in group a and 382 ± 80 hu in group b, the right pulmonary artery 321 ± 86 and 352 ± 79 hu, the left pulmonary artery 311 ± 83 and 353 ± 78 hu. in the right lower lobe artery contrast enhancement was 309 ± 88 hu in group a and 335 ± 83 hu in group b, the left lower lobe artery 310 ± 88 and 342 ± 84 hu and the mean enlancement values of all measured pulmonary arteries was 319 ± 86 and 353 ± 82 hu. the effect on vascular enhancement was most significant (z-test, two sided p-values) in the pulmonary trunc (p = 0.002) followed by all measured pulmonary arteries (p = 0.05) and least remarkable in the lower lobe arteries. with an identical amount of 27 g iodine, the higher injection rate of diluted cm leads to a significant increase of vessel enhancement in cta of the pulmonary vasculature. with exact bolus timing this can be used to reduce the applied dose of iodine per patient. purpose: to evaluate prospectively diagnostic accuracy of 1 mol gadobutrol as a contrast agent for intraarterial x-ray digital subtraction angiography (dsa) in comparison to iodinated, non-ionic contrast media and 0.5 mol gadolinium-dtpa. methods: flush arteriograms (ascending, descending, abdominal aorta, iliac and femoral arteries) and selective angiograms (carotid, renal and visceral arteries) were obtained from bilateral femoral arterial access (5 f sheaths) in ten domestic pigs (70 kg body weight). digital subtracted angiograms were obtained during injecton of non-diluted 1 mol gadobutrol, 300 mg i/ml iopromide, or 0.5 mol gadopentetate. injection parameters (volume and velocity) were similar for all three contrast agents. in paired arteries, two different contrast media were used during the same angiographic run. diagnostic quality and accuracy of the angiograms were evaluated on a three-step scale by three independent blinded investigators. results: sufficient angiographic images were obtained in 90 % of cases using iodinated contrast material. gadobutrol achieved sufficient non-selective angiograms in 64 %. selective angiograms were sufficient in 98 % using iodinated contrast material, 90 % using 1 mol gadobutrol and 48 % using 0.5 mol gd-dtpa. adverse reactions to any of the used contrast agents were not noted. conclusion: 1 mol gadobutrol solution allows x-ray digital subtraction angiography with an diagnostic accuracy equivalent to 300 mg/ml iodinated contrast media, if selective injections are performed. flush aortograms are of inferior image quality to iodinated contrast material. 1m gadobutrol achieves significantly better image quality compared with 0.5 mol gadolimium solutions. high iodine concentration non ionic contrast agent. comparison with lower iodine concentration in peripheral multislice ct angiography c. catalano, a. laghi, r. brillo, f. fraioli, f. pediconi, a. napoli, i. reitano, r. passariello; rome/it purpose: multislice ct (msct) has already proved a very accurate technique in the assessment of different vascular pathologies. purpose of this study was to determine whether high iodine concentration non ionic contrast agent could improve vascular enhancement and vessel conspicuity. material and methods: 60 patients referred for msct angiography (mscta) of the aorta and peripheral arteries were included in the study. all examinations were performed with a msct using a fixed delay time of 28 seconds. in all patients a standard amount of 40 g of iodine was administered at 4 ml/s. all patients were randomly assigned to one of three following groups: group 1 consisting of 100 ml of 400 mg i/ml; group 2 consisting of 113 ml of 350 mg i/ml; group 3 consisting of 133 ml of 300 mg i/ml. rois were obtained at different. a qualitative assessment was also made by two observers, regarding image quality and vessel conspicuity. results: no significant difference was detected between the 350 and the 400 mg i/ml contrast agents at the level of the aorta, pelvic and thigh arteries; a 13 % difference was found between the 300 and 400 mg i/ml in the same districts. with the 400 mg i/ml a significant increase in vascular enhancement of respectively 16 and 21 % was seen in the popliteal and infrapopliteal arteries. conclusion: a significant improvement in contrast enhancement and vessel conspicuity can be achieved in mscta by means of high iodine concentration contrast agents. key: cord-009997-oecpqf1j authors: nan title: 2018 aspho abstracts date: 2018-03-31 journal: pediatr blood cancer doi: 10.1002/pbc.27057 sha: doc_id: 9997 cord_uid: oecpqf1j nan myelodysplastic syndrome (mds) and frequently arise in the context of inherited bone marrow failure (bmf) syndromes, such as shwachman diamond syndrome (sds). monosomy 7/del(7q) is associated with high grade mds and propensity to progress to acute myelogenous leukemia, a major cause of morbidity and mortality for patients with inherited bmf. development of non-transplant strategies to treat bone marrow failure without simultaneously stimulating outgrowth of malignant clones remains a major challenge. objectives: the aim of this study is to investigate the molecular consequences of del(7q) in the context of bmf with the goal of developing more effective treatments. design/method: to study the biological and molecular consequences of monosomy/del(7q) in bmf, induced pluripotent stem cells were generated from sds patients (sds-ipsc) . a deletion of the mds-associated region of the long arm of chromosome 7 was then introduced using a previously published modified cre-lox approach. results: the sds ipsc phenocopied bone marrow failure with slow proliferation and impaired hematopoietic differentiation. we next explored whether deletion of 7q conferred a relative fitness advantage within the context of bone marrow failure. proliferation of the sds-del(7q) ipscs was reduced below that of both the isogenic sds ipscs and normal controls without an increase in cell death. sds-del(7q) demonstrated reduced hematopoietic differentiation compared with isogenic sds cells. these data demonstrate that deletion of 7q fails to confer a relative growth advantage relative to isogenic sds ipscs and results in further impairment of hematopoiesis. to gain insight into the mechanisms of del7q-associated clonal evolution in sds, we performed rna sequencing (rnaseq) of sds+/-del(7q) ipsc. expression of tgf pathways and their downstream targets were reduced in sds-del(7q) ipscs compared to isogenic sds ipsc. single cell rnaseq analysis of primary sds bone marrow cells confirmed that the tgf pathway is hyperactivated in sds. western blot analysis showed increased phospho-smad2 levels in sds ipscs compared to sds-del(7q) and normal controls, while total levels of smad2 were unchanged. pharmacological targeting of tfg with small molecule inhibitors resulted in selective improvement of sds hematopoietic colony formation and myeloid differentiation without stimulating outgrowth of the isogenic sds-del(7q) cells or normal controls. these results demonstrate that del(7q) reverses the tgf pathway hyperactivation of sds. furthermore, inhibition of tgf selectively rescues hematopoiesis in sds but not in isogenic del7q cells, suggesting a potential strategy to treat bone marrow failure without stimulating del7q clonal outgrowth. background: standard therapy of medulloblastoma consists of treatment with alkylating agents and radiation after surgical resection. although a statistically significant increase in survival is reported with this regimen, 1/3rd recur and become resistant this class of agents ultimately leading to mortality. large numbers of somatic mutations were observed in recurrent medulloblastoma (rm) after alkylating agent and radiation treatment. high mutation rates in tumors can have twofold effect; 1) a large number of non-synonymous mutations that have no role as drivers can still cause functional tumor antigens increasing the neoantigen burden and immunogenicity. moreover, 2) such tumors can gain mutations in canonical or non-canonical dna repair pathways leading to a gain in the number of mutations as seen in case of glioblastoma, this can lead to even higher accelerated mutational rate. evidences suggest that high mutational load can cause higher neoantigen burden thereby making the tumor more susceptible to immune checkpoint inhibition. we propose that post therapy recurrent medulloblastoma gain mutational signature and immunophenotype of malignancies demonstrating clinical response to immune checkpoint therapy. objectives: 1) rm has molecular signatures identical to tumors with high immunogenicity and clinical response to immune check point inhibition. 2) rm has the immune inflammatory phenotype; harboring high percentage of tumor infiltrating lymphocytes (tils), macrophages and monocytes. design/method: to test our hypothesis, we downloaded the raw bam files of previously published data from international cancer genome consortium (icgc) . this set of about 30 matched primaries and recurrent medulloblastoma cases forms our discovery cohort. we have called somatic variants using the gatk pipeline by the broad institute. to validate our key findings, we have procured human medulloblastoma specimens and are conducting whole exome sequencing. the primary assays utilized to assess immunogenicity are immunohistochemical (ihc) staining of formalin fixed and embedded recurrent medulloblastoma tissue to identify tils, tumor associated macrophages and other markers. 300 mg/m2 had dlts of dyspnea (grade 4)/hypoxia (grade 3) but no dlts were observed in any other cohort. adverse events were generally mild to moderate, consistent with the safety profile observed in adults. across the desc cohorts, plasma concentrations were dose-proportional and steady state concentrations were lower on day 15 vs. day 1. mean systemic exposure in the 1200 mg/m2 cohort was ∼ 4-fold greater compared with the adult rp2d of 800 mg bid. a pk:pd relationship between tazemetostat exposure and h3k27me3 levels in peripheral blood monocytes and granulocytes was observed in the desc phase. consistent and significant post-dose reductions in h3k27me3 occurred at doses ≥900 mg/m2. further analysis of twelve patients treated at the rp2d confirmed that h3k27me3 inhibition was maximally inhibited. doses 520-900 mg/m2 showed confirmed objective responses (cr/pr) per recist/rano in patients with es (n = 1), chordoma (n = 2), and atrt (n = 1). background: previous studies established that the platelet/ fibrin(ogen) axis promotes metastatic potential by impeding the clearance of newly formed micrometastases by natural killer (nk) cells. however, multiple important questions remain, including the potential of fibrin(ogen) to promote metastasis through interactions with cells other than platelets (e.g., inflammatory cells), and the fundamental question of whether fibrin polymerization is required for metastasis. objectives: determine the role of fibrin polymerization and fibrin(ogen) engagement of integrins iib 3 and m 2 in metastasis. design/method: we performed experimental and spontaneous metastasis assays in immunocompetent mice carrying specific fibrinogen structure/function alterations. results: expression of a mutant fibrinogen lacking the binding motif for the leukocyte integrin m 2 (fib 390-396a) significantly decreased metastatic potential relative to wildtype fibrinogen, suggesting a role for fibrin(ogen)inflammatory cell interactions mediated by m 2 in metastasis. to directly determine the importance of thrombinmediated fibrin polymerization in metastasis, we analyzed metastatic potential in fibaek mice, which carry a form of fibrinogen essentially "locked" in the soluble state due to a mutation in the a chain thrombin cleavage site. metastatic potential in fibaek mice was diminished relative to control mice, speaking to the importance of thrombin-mediated fibrin polymerization in the metastatic process. however, the fibaek mice retained significant metastatic potential relative to complete fibrinogen deficiency, indicating that fibrinogen monomer retains significant prometastatic properties. in order to better define the role of fibrin(ogen)-platelet interactions in metastasis, we compared metastatic potential in control and fib δ5 mice, carrying a form of fibrinogen lacking the chain binding motif for the platelet integrin iib 3. surprisingly, this mutation had no impact on metastatic potential. together, these studies suggest fibrinogen plays a multifaceted role in metastasis. fibrin(ogen)-leukocyte interactions mediated by m 2 appear to have a role in metastasis. previous studies showed that macrophages promote the metastatic potential of circulating tumor cells, which may represent at least one important m 2 expressing cell type whose prometastatic behavior is influenced by fibrin(ogen) interactions. these studies show that thrombin-mediated fibrin polymerization promotes metastasis, but soluble fibrinogen retains some significant prometastatic capacity. surprisingly, loss of the fibrinogen chain iib 3 binding motif had no impact on metastasis. given the established importance of platelets in metastasis, these findings suggest that fibrin (ogen) is capable of platelet stabilization through mechanism(s) independent of this iib 3 binding motif. platelets may bind polymerized fibrin at other sites, and/or fibrin interactions with other matrix proteins capable of binding iib 3 are sufficient to support platelet functions required for metastasis. the role of platelets in hemostasis and thrombosis is well defined, but it is becoming increasingly evident that platelets also assist in host defense and inflammation. platelets participate in the innate immune system through direct antimicrobial activity and interactions with effector cells (chapman2012, garlanda2013, kapur 2016). in the adaptive immune system, platelets recruit and costimulate t-cells, and promote b-cell differentiation and antibody class switching (kapur2016, morrell2017). the question remains: which mechanisms influence platelet immune function and are they developmentally regulated? preliminary studies in the palis lab have revealed significant dif-ferences in embryonic versus adult platelet gene expression, including regulators of immune and inflammatory responses such as beta2-microglobulin (b2m) and major histocompatibility complex class i (mhc1). mhc1 is expressed on all cell surfaces except red blood cells and its molecular chaperone b2m is a marker of inflammation highly expressed in platelet alpha granules (zufferey2014). preliminary data from the morrell lab reveals a mass release of b2m during platelet activation, which drives monocyte differentiation to an inflammatory phenotype through tgfb receptor signaling. we therefore sought to determine whether developmental changes in platelet b2m expression mediate differences in platelet-mediated monocyte activation. with trilineage hematopoiesis with a predominance of early myeloid precursors, with full maturation. microarray, elane and sbds sequencing and deletion/duplication analyses were negative. immunologic evaluation was significant for agammaglobulinemia and an absence of memory (cd19+cd27+) b cells. a 207 gene primary immunodeficiency panel revealed two variants of unknown significance-c.1957g>a and c.2292g>t in dnmt3b; one previously reported in association with icf1. parental testing demonstrated parental heterozygosity. centromeric instability was confirmed in mitogen stimulated lymphocytes showing characteristic, multibranched chromosomes containing at least 3 arms of chromosome 1 and 16 joined near the centromere. decondensation of the 1qh and 16qh regions and triradial configuration of chromosome1 was noted, and a diagnosis of icf1 syndrome was made. the patient was started on monthly intravenous immunoglobulin (ivig). prophylaxis for pneumocystis jiroveci pneumonia and respiratory syncytial virus was initiated. a 10/10 matched sibling hsct is being planned. demonstrated the diagnosis of high grade osteosarcoma. the patient was started on multi-agent chemotherapy with planned a whole femur prosthesis at time of local control. 7 cases of osteosarcoma have been described in the literature in patients with nf1 (median age; 25 years, range 17-37 years) with slightly male predominance (4 cases). the femur was the most common site of involvement (5 cases). four patients died of metastatic disease despite surgery and multi-agent chemotherapy. conclusion: nf1 represents a major risk factor for development of malignancy and uncommonly osteosarcoma in adolescents and adults. we report a rare case of an extensive involvement of osteosarcoma of the left femur in a child with known diagnosis nf1. this presentation should alert the pediatric oncologists to monitor for bone tumors in patients with nf1 by physical exam and detailed medical history. hasbro children's hospital, providence, rhode island, united states background: dysautonomia is a paraneoplastic syndrome most commonly described in adult malignancies. despite current therapies aimed at symptoms management, it is often debilitating. we present a case of a 16-year-old girl who initially presented with autonomic dysfunction and was subsequently found to have hodgkin lymphoma. objectives: describe hodgkin lymphoma presenting with dysautonomia and discuss symptom management with rituximab design/method: case report a 16 year-old-girl presented with severe symptoms of orthostatic hypotension necessitating prone positioning to prevent syncopal episodes. additionally, she reported anhidrosis, xerostomia, urinary retention, and constipation. she had unmanageable peripheral neuropathic pain despite multiple analgesia medications. initially, it was suspected that her symptoms were caused by an atypical presentation of guillain-barre syndrome. she was treated with intravenous immunoglobulin g, without response. due to a suspicion of a paraneoplastic syndrome a positron emission test/cat scan (pet/ct) was performed and revealed widespread fdg-avid nodal and splenic disease. pathology from a thoracoscopic biopsy of a mediastinal lymph node demonstrated classical hodgkin lymphoma. she was classified as stage ivb. a paraneoplastic panel obtained during the first cycle of chemotherapy revealed elevated anti-amphiphysin antibodies and glutamic acid decarboxylase (gad) antibodies. therapy was initiated with abe-pc (doxorubicin, bleomycin, etoposide, prednisone, cyclophosphamide) ; vincristine was held given her significant neuropathy. due to persistence of autonomic symptoms following her first cycle and presence of antiamphiphysin and gad antibodies, rituximab was incorporated into her treatment. following two cycles abe-pc, she had a rapid early response by fdg-pet/ct. she completed an additional three cycles of abd-pc. end of therapy imaging demonstrated complete response with a single persistent mildly fdg-pet avid lymph node (deauville 2) and her antibodies were negative. she continues treatment of maintenance rituximab with significant improvement, but not resolution, of her orthostatic hypotension. at this time, the patient can ambulate with assistance. constipation and urinary retention have fully resolved and, her peripheral neuropathy, xerostomia, anhidrosis have improved. conclusion: this is rare case of a pediatric hodgkin lymphoma patient developing dysautonomia associated with antiamphiphysin and glutamic acid decarboxylase antibodies and subsequently managed with chemotherapy and rituximab. clinicians should be suspicious of a paraneoplastic syndrome when a neurologic disorder fails to improve with standard treatment. results: labs obtained at an outside hospital one month prior to presentation showed absolute neutrophil count (anc) 78 and hemoglobin 10.2 g/dl. she presented to our institution with 11 days of fever, hepatomegaly 1 cm below costal margin, a white plaque on her tongue, and circumferential perianal ulceration. labs were significant for anc 0 and hemoglobin 7.8 g/dl. anti-granulocyte antibody testing was positive. bone marrow biopsy showed arrest of neutrophil maturation. after initiation of filgrastim (2.7 mcg/kg/day), her anc increased to >500 and repeat bone marrow biopsy demonstrated left shifted myelopoiesis. biopsy of her oral lesion demonstrated invasive actinomyces prompting a prolonged course of antibiotics. biopsies of her oral and anal lesions were reported as myeloid sarcoma without mll rearrangement. chemotherapy was not initiated due to complete resolution of both lesions within 6 weeks of initiating filgrastim and appropriate antibiotic coverage. she has not developed any further lesions concerning for malignancy. testing for common genes associated with severe congenital neutropenia and autoimmune lymphoproliferative syndrome was negative. her immunoglobulin levels and the measurement of age-appropriate vaccine responses were normal. after her lymphocyte subpopulation analysis indicated a selective deficiency in cd8 positive t-lymphocytes (absolute cd8 cell count 185), the severe combined immunodeficiency panel from genedx showed compound heterozygous mutations in results: a male infant was born with a large thigh mass. the child was clinically well aside from restricted movement of affected leg. mri showed mass expanding into pelvis without other lesions. an interventional-radiology guided core biopsy of the mass was reported as high-grade spindle cell sarcoma without etv6 rearrangement. surgery was deferred because of concern that it would result in excessive morbidity. the mass was treated with vincristine and dactinomycin per infantile fibrosarcoma protocols. after 3 months of therapy, no significant change in size of the mass was noted on physical exam or imaging. repeat biopsy was obtained to confirm diagnosis and allow for expanded tumor testing. this biopsy showed triphasic distribution of adipose, fibrous and mesenchymal tissue consistent with fhi with rare sarcomatous foci. additional chemotherapy was deferred and the child was followed clinically. his tumor has remained approximately the same size and still unresectable. next generation sequencing of tumor utilizing panel based technology revealed braf-erc1 fusion consistent with braf activating mutation. this mutation was confirmed by fluorescent in situ hybridization (fish) probe for braf. braf and mek inhibitors have been pursued as treatments to decrease size of tumor and allow for resection. conclusion: braf mutations have been characterized in a variety of malignancies. inhibition of braf and downstream signaling components has produced promising results in a variety of patients. this is the first case report of a braf mutation in a fhi. although management of fhi is typically surgical, this does suggest a potential therapeutic target and may allow for improved surgical outcomes especially in cases where up-front surgery would result in unacceptable morbidity. genetic sequencing of fhi and other rare tumors is an important tool and has the potential to identify mutations amenable to targeted therapies. background: icf is a rare autosomal recessive disorder characterized by hypo-or agammaglobulinemia and often opportunistic infections suggesting t-cell dysfunction. it is further categorized into subtypes 1-4 based on mutations in dna methylation. mutations in the helicase-lymphoid specific (hells) gene, which is required for t-cell proliferation and participates in de novo dna methylation, are characteristic of icf type 4 (icf4). of approximately 70 reported cases of icf, less than 10 percent are characterized as icf4. while malignancy has been reported in icf1 (angiosarcoma, acute lymphoblastic leukemia), and icf2 (hodgkin lymphoma), here we describe the diagnosis and management of an icf4 patient with neuroblastoma and neutropenia, which has not been previously described. objectives: describe a novel phenotype and mutation of icf4 and its management to further expand our understanding of this disease. results: a 6 month ex-31 week premature male with bronchopulmonary disease and failure to thrive presented with acute respiratory failure in the setting of recent viral bronchiolitis with associated chronic diarrhea. he was subsequently diagnosed with multiple infections including pjp pneumonia, norovirus, parainfluenza, rhinovirus, and pseudemonal cellulitis. he presented with profound neutropenia and agammaglobulinemia with presence of b and t cells on lymphocyte phenotyping. ct revealed a paraspinal mass that was mibg-avid on further study, strongly suggesting neuroblastoma. bone marrow was normocellular and negative for malignancy, however revealed marked granulocytic hypoplasia and maturation arrest concerning for severe congenital or, less likely, immune-mediated neutropenia. metastatic workup was negative. whole exome sequencing revealed a homozygous variant of unknown significance (c. 668t>c) in the hells gene, portending a working diagnosis of icf4 syndrome. immunoglobulin supplementation, pentamidine prophylaxis, and g-csf were initiated. he was able discontinue g-csf after 4 months of treatment. his neuroblastoma, initially categorized as l1, met criteria for observation. however, followup mri revealed interval growth nearing the spinal canal. he underwent tumor resection, confirming mycn non-amplified, favorable histology neuroblastoma. after infectious prophylaxis and immunologic support were initiated, he incurred two other hospitalizations, the first for g-tube cellulitis and the second for parainfluenza respiratory illness. he now has stable neutrophil counts off g-csf and remains in remission from neuroblastoma. current plan is to proceed with bone marrow transplantation for immunodeficiency. conclusion: icf4 has not previously been described with neutropenia or neuroblastoma. this report not only describes a novel mutation and phenotype of icf4 and the management thereof, but also reveals the potential curative role of bone marrow transplantation in such disease. staten island university hospital -northwell health, staten island, new york, united states background: desmoid tumors are rare tumors that arise from highly differentiated fibroblasts. they occur in isolation or as part of the disease spectrum of familial adenomatous polyposis (fap) . fap mutations between codons 1445-1578 typically correlate with increased extraintestinal disease such as desmoid tumors and upper gastrointestinal polyps. we describe a patient with a large intra-abdominal desmoid tumor who is heterozygous for a c.8161c>t (p.arg2721cys) apc gene mutation. we are not aware of any other patients reported with this germline apc mutation presenting with a desmoid tumor. objectives: to discuss a novel apc mutation and the presentation of a rare case. design/method: review of clinical presentation, genetic analysis and management of a rare tumor. a 17-year-old female with no significant medical history presented with abdominal asymmetry and intermittent pain. she reported urinary urgency, shortness of breath, early satiety, decreased appetite and a 20-pound weight loss over the course of 7 months. ct scan of the abdomen demonstrated a 24 × 15cm abdominal tumor abutting the local organs but no presence of bowel obstruction. a biopsy revealed a spindle cell neoplasm favoring fibromatosis. there was no known family history of fap, colon cancer, or desmoid tumors. apc gene mutation analysis demonstrated a c.8161c>t (p.arg2721cys) heterozygous gene variant. due to size and location of the tumor, it was initially deemed unresectable. the patient was started on a course of monthly liposomal doxorubicin. she tolerated the initial cycles well and interval ct after 3 cycles of chemotherapy revealed a 40% decrease in tumor volume. variability exists in phenotypic presentation with regards to the location of the afp mutation locus. while fap mutations associated with desmoid tumors typically have changes in the 1445-1645 codon region, our patient presented with a heterozygous mutation resulting in a missense mutation at codon 2721. due to the change in polarity and size, the mutation is not considered to be of conservative nature. we are only aware of one other report of this mutation, which occurred in an individual with a personal and family history of colon cancer. we are not aware of any patients with desmoid tumors who also have this germline apc gene mutation. our case report highlights an apc gene mutation that is not well-described; we are not aware of any other cases of this mutation reported in patients with desmoid tumors. future evaluation and tracking of this mutation may lead to the determination of further clinical significance. background: over time, advanced care planning for location of death has been associated with increased deaths at home rather than in the hospital. in some cases, however, complex management and symptom control can prevent families from achieving their goal of keeping their child out of the hospital and at home at the end of life. ascites is a sequelae of many conditions including malignancy that might lead to significant morbidity. increasingly, interventional procedures are being utilized. peritoneovenous "denver" shunts are placed internally with one end in the peritoneal space and the other buried within a major vessel such as the svc. a one-way valve and pump buried under the skin allows the patient to pump fluid from the peritoneal to the vascular space. the shunt is used frequently in adults, but has not seen much use in pediatric oncology patients. objectives: to describe a case of a terminally ill patient with refractory wilms tumor with ivc involvement who received symptomatic relief with denver shunt placement. results: an 8-year-old female was diagnosed with relapsed, refractory, metastatic wilms tumor with pulmonary and hepatic involvement, with tumor extension to the hepatic veins and ivc. multiple chemotherapeutic regimens and palliative radiation to the ivc were administered, but her disease continued to progress, leading to pressure on the portal vein and portal hypertension. the resulting ascites was causing the patient significant pain and was difficult to manage. the patient's code status was changed to dnr/dni after discussion with her mother, who identified a desire to have the child die at home as comfortably as possible. a peritoneovenous shunt was placed in order to control the patient's pain and avoid frequent medical procedures and therapies. despite initial anxiety, the patient was able to utilize the pump and achieve significant improvement in her ascites and pain. she was able to spend the remaining six weeks of her life at home. ascites is a common phenomenon of end stage disease. peritoneovenous shunts are a treatment modality that may be considered to allow for pain control at the end of life for pediatric oncology patients with ascites. the procedure is relatively low risk, allows for self-control of the pump to maintain comfort, and is easy enough to use by the patient or family. background: extraneural metastases (enm) from pediatric glioblastoma multiforme (gbm) are rare, with an estimated frequency of 0.3%. etiologic factors include multiple neurosurgical procedures and sarcomatous dedifferentiation. their occurrence can seriously affect the patient's quality of life and survival. while enms have been well documented in adults, pediatric cases have not been previously summarized. a 15 year old male with a cerebral gbm developed extension of disease outside of the neuraxis approximately 18 months post initial presentation and at the time of disease progression. metastases included exracranial temporal lesions, cervical and mediastinal lymph nodes and s29 of s301 bilateral lung nodules. a large pleural-based soft tissue metastatic focus was identified on imaging when the patient presented with respiratory distress secondary to a right tension pneumothorax, which was recognized and managed promptly. we summarize the main reported cases in literature to better define risk factors for and evaluate the proposed mechanisms underlying these systemic metastases. design/method: we performed a literature review on the pubmed database using the terms gbm and enm. patients under 21 years of age who met the weiss criteria for the diagnosis of enm from primary cns tumors were included. results: our patient fulfilled two of the three weiss criteria with confirmed gbm at the primary site with all enm in the temporal soft tissue and cervical lymph nodes displaying histopathologic features similar to the primary cns tumor. the intrathoracic adenopathy and lung nodules detected upon chest imaging during workup for respiratory distress were assumed to represent additional metastatic foci. our literature review identified 22 pediatric patients with enm from gbm with a median age of 12 years (range 3.5 -21 years) and a slight female predominance (55% females vs. 45% males). the most common sites of metastases reported were pleura/lungs, bones, lymph nodes and liver. in 9 of 22 patients, metastases were associated with csf shunting. conclusion: pediatric oncologists should have an increased index of suspicion when caring for patients with gbm, particularly those who have undergone shunting procedures and present with systemic symptoms including bony pain, respiratory changes, transaminitis or cytopenias which should prompt timely investigation for enm. although enm of cns tumors carry very poor prognosis, their diagnosis has potential therapeutic importance because treatment of metastatic lesions may alleviate symptoms and improve the quality of life. additional studies may be warranted to evaluate the incidence of enm that can provide valuable insight into the pathogenesis and biology of high-grade gliomas. nicklaus children's hospital, miami, florida, united states background: sinusoidal obstruction syndrome (sos) has been reported in patients undergoing intensive chemotherapy and as a complication post-hematopoietic stem cell transplan-tation. sos may be complicated by portal hypertension, hepatorenal disease or multi-organ failure. however, despite treatment, there may be further potential complications that can be anticipated in patients with history sos. we report two patients with history of sos presented with post-procedural bleeding after gastric tube placement. we believe that their presentations may be associated to their previous diagnosis of sos. design/method: pubmed search was done with search for terminology including "sinusoidal obstruction syndrome" "defibrotide", and "bleeding". papers relevant to our cases were selected for literature review. results: case 1: a 4 year-old female with history of desmosplastic medulloblastoma status-post resection and intensive chemotherapy was diagnosed with sos one month after her second part of planned tandem transplant. she was managed with paracentesis and defibrotide. due to malnourishment, patient had a gastric tube placement 5 months after she completed therapy and had an episode of upper gastrointestinal bleeding postoperatively from the g tube site. case 2: similarly, a 4 year-old male diagnosed with anaplastic medulloblastoma status post resection and adjuvant multiagent chemotherapy. his treatment course was complicated with sos after the second cycle of induction chemotherapy which responded to 21-day course of defibrotide. likewise, the patient had a major bleeding event from the g-tube site approximately two months after sos diagnosis. defibrotide was discontinued in both cases before g-tube placement. both patients had no previous history of bleeding disorders or relevant family history. in addition, comprehensive laboratory evaluations were within normal limits before both procedures. in sos, there is blockage of fluid out of the liver that leads to congestion, ascites, ischemia of the liver, and post-sinusoidal portal hypertension. two related causes of sos should be considered as an explanation for g-tube bleeding. similar patients should have close monitoring postoperatively or if possible surgical intervention should be delayed until the sos process has been evolved. nicklaus children's hospital, miami, florida, united states background: the development of treatment related acute myeloid leukemia (t-aml) and myelodysplastic syndromes (t-mds) is a potential complication after cytotoxic chemotherapy or radiation therapy. the incidence of development of t-aml/t-mds varies from 1-20% depending on the treatment regimen used. cutaneous myeloid sarcoma (ms) is a common presentation of extramedullary leukemia and usually occurs in the setting of aml. we report a rare case of cutaneous ms in an adolescent female after successful treatment for ovarian yolk sac tumor (yst) stage i with bep (bleomycin, etoposide and cisplatin) therapy. the ms was managed only with biopsy and close observation. design/method: a pubmed search was conducted for queries including t-aml/t-mds, cytotoxic agents, cutaneous myeloid sarcoma, regression. relevant papers were selected for literature review. a 13 year-old female was diagnosed with a left ovarian yolk sac tumor, for which she underwent left salpingooophorectomy and successfully completed 4 cycles of bep over 4 months. during routine follow-up 8 months after initiation of treatment for ovarian yst, she was noted to have a small, non-tender, indurated nodule on the left side of her upper back approximately 1cm in diameter. punch biopsy of the skin nodule was performed and pathology was positive for cutaneous myeloid sarcoma. at the time of next follow-up less than one month later, the skin lesion had resolved. two subsequent bone marrow aspirates were performed one month apart and were negative for leukemic involvement or mds. examinations and work-up including whole body pet with ct scan were negative for evidence of disease. although cutaneous ms can be regarded as the herald of systemic myeloid disease rather than a localized process, our patient was monitored periodically with physical exam and laboratory evaluations. she remains free of disease more than four years after the presentation of cutaneous ms without any further treatment. spontaneous regression ms has been previously reported. the authors would like to stress that a conservative approach with close observation could be an option in cutaneous ms even with history of chemotherapy exposure. nesreen ali, iman sidhom, sonia soliman, sherine salem national cancer institute, cairouniversity, egypt children cancer hospital egypt, egypt background: acute leukemia is the commonest malignancy in childhood. the coincidental occurrence of leukemia with hemophilia is extremely rare. hemophilia is a congenital rare x linked bleeding disorder. the main complication of the two diseases is bleeding diathesis which may be lifethreatening due to many factors, deficiency of coagulation factors in hemophilic patients, thrombocytopenia from disease and chemotherapy in leukemic patients, certain cytotoxic drugs such as asparaginase which may result in coagulation disorders and infection which may lead to disseminated intravascular coagulation. objectives: reporting such a case is imperative to set up treatment guidelines for prevention of bleeding and to optimize the therapeutic approach for these patients. design/method: seventeen years old boy, presented to children cancer hospital egypt in june 2015 with pallor and multiple ecchymoses.he was diagnosed with precursor b acute lymphoblastic leukemia, cerebrospinal fluid (csf) was free, the chromosomal analysis revealed hypodiploidy 36, xy. he had moderate type of hemophilia a since birth, factor viii level was 1.5 % at time of diagnosis, coagulation profile revealed prolonged partial thromboplastin time 89 (normal 26-45), factor viii was low 1%, prothrombin concentration and prothrombin time were normal100% and 13 seconds, virology screening for hepatitis b core igg/igm, hbs ag, hiv and hc igg /igm were negative.the patient started induction total xv sjcrh protocol, factor viii 40 unit/kg was given at presentation before doing bone marrow aspiration(bma), csf and as a prophylactic before intramuscular asparaginase injection, intrathecal and bma. it was given immediately within 2 hours before the procedures and platelets transfusion was given regularly to maintain platelets count about 50,000. the minimal residual disease by flow cytometry was 0.81% and 0.11% at d15 and d42 induction. results: our patient received his induction and reintensification chemotherapy without any major bleeding event which reveals the success of our guidelines for the prevention of bleeding. he developed very early relapse at w7 maintenance by the same clone. he received salvage chemotherapy but didn't achieve remission and died out of disease and resistant clone. the development of leukemia on top of hemophilia is a major problem. bleeding complication during chemotherapy can be prevented by regular prophylactic factor viii and platelets concentrate transfusion with good supportive care. life threating bleeding complication may be correlated with the severity of hemophilia. we need to collect data about the biology of leukemic cells, complications, and cause of death to optimize care for these patients. background: mucoepidermoid carcinoma (mec) is a rare malignancy that arises from exocrine glands in the upper aerodigestive tract and tracheobronchial tree. conventionally, mec diagnosis is based on histology, with prognosis based on the extent of resection and detection of metastases. mec is characterized by a translocation of chromosomes 11q and 19p resulting in a fusion between the mect1 and maml2 genes, that occurs in 38-81% of cases. this fusion transcript has been recognized to have a favorable impact on disease features and prognosis of mec. however, recent studies indicate that high grade mec can have mect1-maml2 fusion positivity and multiple other genomic imbalances that have not been studied in much detail. owing to the rarity of mec tumors, more definitive data related to the clinical and prognostic significance of these molecular markers are limited. objectives: 1. identify the presence or absence of mect1-maml2 fusion in the tissue of our patient. 2. analyze the incidence of the fusion in 25 mec cases in children and young adults retrieved from the iowa cancer registry. 3. determine if fusion status correlates with clinical, pathological and outcome data in our cohort. design/method: we describe the case of a 12 year-old caucasian male who presented with recurrent pneumonia, persistent cough and radiographic evidence of right lobar collapse. bronchoscopy revealed an endobronchial lesion and the patient underwent right upper lobe sleeve resection. pathology report was consistent with low grade muco-epidermoid carcinoma. we retrieved 25 archived formalin-fixed paraffinembedded (ffpe) specimens of pediatric and young adult mec cases (ages 0-29) reported in iowa from 1973-2016 using the iowa cancer registry. testing for the mect1-maml2 fusion in the index case and 25 ffpe specimens will be done using a custom-designed laboratory validated next generation sequencing (ngs) assay with the ability to detect novel fusion partners. clinical, pathological and outcome data (age, sex, tumor site, tumor size, nodal metastases, clinical stage, histologic grade, treatment and follow up) will be analyzed to correlate with fusion status. the mect1-maml2 fusion tested positive in our index patient. we will obtain irb approval to test for the fusion in the 25 archived ffpe specimens and correlate clinical, pathological and outcome data. conclusion: mect1-maml2 fusion is a frequent event in mec that has prognostic and potential therapeutic applications in adults. the results of this study may enlighten the clinical management of mec in children and young adults. children 's mercy hospital, kansas city, missouri, united states background: mutations in the samd9 gene are associated with a rare syndrome comprising of myelodysplasia, infection, restriction of growth, adrenal hypoplasia, genital phenotypes and enteropathy (mirage syndrome). diagnosis is made through exome sequencing. in the largest reported case series, of eleven patients diagnosed with mirage syndrome, two developed loss of chromosome 7. given the potent growth restricting activity of samd9 mutants, the loss of chromosome 7 is considered the first documentation of adaptation by aneuploidy mechanisms in humans and led to myelodysplastic syndrome (mds), with deaths occurring from related complications at 2 and 5 years of age. objectives: to report a case of mirage syndrome with congenital thrombocytopenia progressing to bone marrow failure, managed uniquely with bone marrow transplantation. results: male born at 29 weeks gestation with prenatal diagnosis of iugr, two vessel cord, oligohydramnios was found to have ambiguous genitalia, adrenal insufficiency, partial panhypopituitarism and congenital thrombocytopenia with bone marrow showing absence of megakaryocytic precursors. severe thrombocytopenia was present from birth. bone marrow evaluation demonstrated a hypocellular marrow with markedly reduced megakaryocytic and myeloid precursors and no evidence of myelodysplasia. he required gastric tube placement for failure to thrive, had a laryngeal cleft repaired and developed focal segmental glomerulosclerosis. mpl gene testing for congenital amegakaryocytic thrombocytopenia was negative. testing for fanconi anemia, shwachman-diamond syndrome and dyskeratosis congenita was also negative. approximately 30% of cells had loss of heterozygosity on chromosome 7q. exome sequencing showed that he is heterozygous for a de novo gain of function variant, c.2471g>a (p.arg824gln), identified in the samd9 gene, confirmed by sanger sequencing and consistent with a diagnosis of mirage syndrome. at 6 years of age, he developed pancytopenia requiring frequent transfusions with platelets and packed red blood cells. he underwent a successful bone marrow transplant at 7 years of age without significant complications, and remains transfusion independent without cytopenias greater than 18 months from bone marrow transplantation. conclusion: it is imperative to pursue work up for persistent congenital thrombocytopenia in a stepwise multidisciplinary manner. to the best of our knowledge, this is the first case of mirage syndrome associated bone marrow failure treated with bone marrow transplant. due to the individual rarity of mirage syndrome and pediatric myelodysplastic syndrome, it is important to maintain an index of suspicion given their association and explore bone marrow transplant as a therapeutic option. results: the patient demonstrated disease regression, initially, and continued without disease progression for 36 months. the regimen has been well tolerated with only minimal side effects of dry skin (ctcae grade 1) and a transient episode of brief erythrodysesthesia (ctacae grade 2) that resolved spontaneously. the combination of sorafenib and capecitabine was effective and well tolerated in this adolescent patient with fl-hcc. our observations, although in a single patient, lend support for further testing of this novel oral chemotherapy regimen in patients with fl-hcc, a disease for which there is no effective standard chemotherapy approach. background: epstein-barr virus (ebv) is a ubiquitous virus associated with a broad range of malignancies due to its oncogenic potential. history of organ or bone marrow transplantation, immunosuppressive therapy, and primary or acquired immunodeficiency syndromes increases the risk of ebvassociated tumors. epstein-barr virus associated smooth muscle tumors (ebv-smt) are unique and rare neoplasms typically discovered in immunocompromised patients. most information related to pathogenesis and therapeutic options is limited to case reports and case series of adult patients. there are several gene expression pathways that ebv utilizes, the most notable of which is the mammalian target of rapamycin (mtor) pathway. the mtor pathway performs a key role through integrating various cell growth signals and factors to regulate protein synthesis and metabolism related to smooth muscle proliferation. sirolimus is an immune modulating therapy that targets the mtor pathway to block activation of lymphocytes. objectives: several case reports have demonstrated shortterm clinical remission of ebv-smt in adult patients with the use of sirolimus. we report the first case of long-term background: bilateral neuroblastoma is characterized as neuroblastoma arising in both adrenal glands, a rare presentation with little data on its genetic make-up. a two-monthold patient was diagnosed with bilateral neuroblastoma in our clinic. her risk assignment was based on biopsy of the left adrenal lesion, which showed mycn amplification, an unfavorable genetic marker. treatment regimen was intensified accordingly and after 5 courses of chemotherapy tumors were excised. patient went on to receive a stem cell transplant and immunotherapy. with no knowledge of genetic similarity between the two tumors it is unclear whether biopsy of the right lesion would have yielded similar results or whether bilateral biopsies are needed for risk assessment of bilateral neuroblastoma. objectives: utilize whole exome sequencing (wes) to characterize the genomic signature of bilateral adrenal neuroblastomas excised following chemotherapy treatment. design/method: paraffin-embedded samples from left (l) and right (r) tumors underwent wes at the broad institute. we analyzed resulting data including somatic variant calls, indel mutations, and copy number variants (cnvs) using ingenuity software to evaluate and compare differences between the two tumor samples. preliminary analysis of the data shows important descriptive information on the two tumor samples. out of 29 somatic mutations in the r tumor cells and 25 mutations in the l tumor cells, only two common somatic mutations were present. out of 40 cnv calls in the r tumor and 60 in the l tumor, 31 cnvs were common between the two tumors, or 73% of each tumor's cnv calls. there was a 14 fold higher frequency in gains versus losses. the median size of the common cnvs was 56,683 (range 220 to 3,323,064 bp). cancerrelated genes with increased copy numbers included transcription factors, receptors for signal transduction pathways, and histone methylation proteins. conclusion: preliminary analysis of the wes results of the two adrenal tumors show some genomic divergence. because the tumor tissue was exposed to chemotherapy prior to excision it is difficult to determine whether genomic divergence is a result of independently originated tumors or subsequent adaptation to chemotherapy of a clonal cell population. the high number of common cnvs in the two tumors points to a common cell of origin, however the low number of common somatic mutations does not fit that picture. a future study to help elucidate the question will be wes of the original biopsy tissue to provide information on tumor mutations prior to the effects of chemotherapy. baylor college of medicine, houston, texas, united states background: although there has been significant improvement in the overall survival rates of children with cancer many children will still die from their illness or complications secondary to treatment. research surrounding the deaths of children who succumb to their disease is warranted to ensure we are providing the best care possible for these patients. objectives: this case series aims to explore pediatric cancer deaths by focusing on perhaps the most extreme cases of high intensity end of life care. we explore those patients whom we know are dying or our very likely to die as evidence by their do not resuscitate (dnr) orders. in all of these cases despite the patients very grim prognosis, their great likelihood of death and limitations placed of resuscitation methods all patients continued end of life care in the pediatric intensive care unit (picu). the primary medical records of all children with a cancer diagnosis who died between february 1, 2011 and january 31, 2017 in the picu with a dnr order seven days or earlier prior to death. each medical history included disease-directed treatment history and response with particular attention to the events surrounding the terminal admission. results: eight patients met criteria for this study representing 1.9% of all cancer patients who died during this time period and 7.4% of those who died in the icu. the average time between dnr and death is 19.6 days (7 days -32 days). the average length of terminal admission was 43.5 days (1 day -153 days). the average time between diagnosis and dnr is 10.75 months (0 months -22 months). the average time between diagnosis and death is 11.25 months (0 months -23 months). conclusion: these cases highlight the journey that patients, families and providers endure leading up to death. medical care is complex, there are very few absolutes that are encountered when caring for patients and decisions around limiting or withdrawing medical care are made in a context of the prior journey. . these cases help to understand the complexity of death and how two seemingly opposite ideals can be congruent in the event of an anticipated death. most of these cases show the need for improved anticipatory guidance surrounding death and greater consideration for de-escalation of care when death is expected. the hospital for sick children, toronto, ontario, canada background: rhabdomyosarcoma (rms) is the most common soft tissue sarcoma in children, with embryonal (erms) and alveolar (arms) representing the most common subtypes. arms tumors are associated with inferior outcome when compared to erms, and they are characterized in about 80% of the cases by a t (2;13) or t(1;13) chromosomal translocation with creation of a pax3-foxo1 or pax7-foxo1 fusion gene, respectively. it is increasingly clear that the pax-foxo1 fusion status is an important poor prognostic factor, thus the histological classification tends to be replaced by the fusion status, particularly in terms of risk stratifica-tion in contrast to arms, there are no recurrent chromosome alterations in erms; however, there are multiple numerical chromosome changes that are frequent in these tumours: gain of chromosome 2,8, 12 and 13 have been found in 25 to 50 % of emrs karyotypes. moreover, erms tumors show frequently allelic loss, the 11.p15.5 chromosomal region being the most frequently involved. recently, novel gene fusions have been described also in erms tumours. these fusions involved mainly the ncoa2 and or the vggl2 genes. the rearrangement partners are variable, and include, i.e. pax 3 (2q35), srf (8q11) and tead 1 (11p15). objectives: to present a patient who died as a consequence of brain metastases while on therapy in the setting of an foxo1negative rms and the identification of a new translocation t(2;15)(q21;q22). design/method: case report and retrospective review of the literature. we report a case of pelvic embryonal rhabdomyosarcoma in a 3-month old boy. he was treated as per cog arst 0531 intermediate risk group, but unfortunately was found to have a large cerebellar tumour during the course of his chemotherapy treatment and he subsequently passed away. a novel translocation between chromosomes 2 and 15 was observed in 11 of 20 metaphase cells by g-band analysis in the autopsy sample of the brain lesion. breakpoints of the translocation were estimated to be at 2q21 and 15q22. there were no additional clonal chromosome abnormalities in the tumour cells. conclusion: erms tumors with fusion genes involved have been exclusively described in patients less than 12 months of age; they seem to be associated with spindle cell histology and, a favorable outcome. in our patient, a novel (2;15) translocation was found and clinically, the patient had a dismal outcome. further studies are indicated to inquire whether this finding is of significance in term of prognosis for these patients. children 's national medical center, washington, district of columbia, united states background: iatrogenic immunodeficiency-associated lymphoproliferative disorders (lpds) are a group of lymphoid s35 of s301 proliferations or lymphomas that are well known to be associated with an immunosuppressed state. these disorders most commonly occur following hematopoietic or solid organ transplantation (called post-transplant lymphoproliferative disorders or ptld), but cases have also been described during the treatment of autoimmune and rheumatologic disorders by immunosuppressive and immunomodulatory medications. these disorders are strongly associated with infection by the epstein-barr virus (ebv) as a result of impaired immune function in the immunosuppressed state. while this phenomenon has been well documented in autoimmune conditions, cases affecting pediatric patients while on antileukemia chemotherapy are lacking. background: atypical teratoid/rhabdoid tumor (at/rt) of the central nervous system (cns) in children younger than 3 years old has a prevalence of 1% to 2% and accounts for 1.6% of all pediatric cns tumors. only 15-30% of patients have leptomeningeal dissemination. rhabdomyosarcoma is the most common soft tissue tumor in childhood, but represent only 3-4% of all pediatric cancers. rarely, it can metastasize or even directly extend into the cns, but typically, cases of cns involvement arise either from parameningeal areas or other primary sites. primary spinal or meningeal rhabdomyosarcoma is extremely rare. objectives: our objective is to describe two unique cns malignancies presenting as rare, primary leptomeningeal disease. design/method: case 1 a 19-month-old female presented with vomiting, fatigue and listlessness, despite a normal head ct and brain mri. csf showed hypoglycorrhachia and mild pleocytosis. ceftriaxone was started, but she developed nuchal rigidity and cranial nerve vii palsy. repeat brain mri showed evolving leptomeningeal enhancement concerning for meningitis. she gradually developed worsening opisthotonus and ultimately a brain biopsy of the temporal lobe was consistent with at/rt. case 2 a 3-year-old male presented with new generalized tonic-clonic seizure activity and intermittent headaches with photophobia, phonophobia, and vomiting. brain mri was significant for enhancement of interpenducular and suprasellar cisterns extending to the optic nerves and chiasm most consistent with meningitis. neurosurgery ultimately placed a lumbar drain for hydrocephalus, and a tissue biopsy demonstrated primary meningeal rhabdomyosacroma. results: in case 1, our patient's temporal lobe biopsy demonstrated grade iv malignant tumor cells consistent with atypical teratoid/rhabdoid tumor. fish demonstrated a homozygous deletion of smarcb1 (22q11.23). she was started on chemotherapy per the dana farber at/rt protocol but ultimately was discharged home on hospice. in case 2, our patient's lumbar arachnoid biopsy demonstrated cellular tumor consistent with group iiia embryonal rhabdomyosarcoma. immunostaining was positive for cd99, desmin, myogenin, and myo-d1 with neural markers ema and gfap highlighting the meninges but without a neural component to the tumor. he completed craniospinal radiation to 36gy total with lumbar boost to 50.4gy total. he is currently receiving chemotherapy per arst0431 protocol. conclusion: these two cases are particularly instructive because of their similar initial presentations and neuroimaging, but with very different and unique diagnoses. university of iowa, iowa city, iowa, united states background: ebf1-pdgfrb fusion causes ph-like b-cell acute lymphoblastic leukemia (b-all), which has a philadelphia positive phenotype without the bcr-abl translocation. this is one of several mutations associated with ph-like b-all and leads to downstream overexpression of tyrosine kinase. ebf1-pdgfrb fusion accounts for about 8% of children with ph-like b-all. patients with ph-like b-all previously had poorer outcomes with conventional chemotherapy. the addition of tyrosine kinase inhibitors (tki), like imatinib, has improved the outcome for many patients predicted to have tki sensitive mutations. objectives: to review clinical characteristics and outcomes of two cases of ph-like b-all at the university of iowa stead family children's hospital and to compare these outcomes to similar cases reported in the literature. design/method: a retrospective chart review was performed for two cases of ph-like b-all diagnosed and treated at the university of iowa stead family children's hospital. results: both patients were males diagnosed at 8 years of age with high wbc count (110,700 and 347,200) and positive for ebf1-pdgfrb gene fusion. patient 1 (pt1) was cns 2b at presentation while patient 2 (pt2) was cns negative; neither had testicular involvement. both started treatment according to cog protocol aall1131. peripheral blasts cleared by induction day 22 for pt1 and induction day 14 for pt2. at end of induction, pt1 had m3 bone marrow and pt2 had m1 bone marrow but mrd 8%. dasatinib was started induction day 13 for pt1 and induction day 31 for pt2. pt1 was still not in remission at end of consolidation; bone marrow cell culture for tki resistance showed best response to dasatinib. pt1 proceeded to anti-cd19 car t-cell therapy followed by tbi-based matched unrelated donor bone marrow transplant. pt2 had negative mrd at the end of consolidation and continues chemotherapy according to aall1131, dasatinib arm. both patients are currently clinically well. our patients had the same tyrosine kinase gene fusion and similar initial clinical courses. while both patients had persistent disease at end of induction, pt1 had almost 80% blasts while pt2 had significant reduction of disease burden before starting tki. pt2 showed good response with the addition of dasatinib while pt1 did not. these findings suggest that response to conventional chemotherapy may potentiate the effect of tki and may predict overall outcome. there are likely additional factors which must be taken into account when determining response to tki for patients with ph-like b-all which have not yet been identified. background: medulloblastoma is the most common malignant brain tumor of childhood. classically, medulloblastoma presents as a well-defined mass lesion in the cerebellum, with a high rate of metastatic dissemination. primary leptomeningeal medulloblastoma (plmb) is an exceedingly rare type of medulloblastoma presentation with a dismal prognosis in which patients present with isolated leptomeningeal disease without an associated mass. to our knowledge, only three pediatric and three adult cases of plmb (ages 5 -30 years) have been reported, all of which died within 6 months of diagnosis. this is the first case of plmb to report a molecular classification. objectives: to report the case of a pediatric patient with plmb in which histopathologic and molecular characterization was performed and to describe the patient's treatment and clinical course. design/method: retrospective review of the patient's electronic medical record and review of the literature. a 9-year-old boy presented with headache, vomiting, diplopia, and fatigue. physical examination revealed upward gaze palsy, left-sided extremity and facial weakness, and ataxia. magnetic resonance imaging (mri) of the brain revealed diffuse cerebellar leptomeningeal enhancement and edema without an identifiable mass and moderate hydrocephalus. mri of the spine and cerebral spinal fluid analysis were normal. a diagnosis of cerebellitis was rendered, and the patient underwent placement of a ventriculoperitoneal shunt. an extensive infectious, neurologic, rheumatologic, and oncologic workup did not identify an etiology. empiric antibiotics, high-dose steroids, and intravenous immunoglobulin therapy yielded minimal improvement. two months later, repeat mri of the brain performed for declining mental status demonstrated progressive thickening of cerebellar leptomeningeal disease. a suboccipital craniectomy with decompression and cerebellar biopsy were performed. pathologic examination revealed a diagnosis of plmb, classic histology, non-wnt/non-shh, without gain/amplification of myc/mycn, and p53 wild type pattern. craniospinal radiation to 4140 cgy with a 1440 cgy boost to the posterior fossa was delivered with concurrent carboplatin/vincristine over six weeks. two months following chemoradiation, mri of s37 of s301 the brain demonstrates significantly reduced pathological leptomeningeal enhancement of the cerebellum, and the patient is awaiting initiation of systemic chemotherapy while recovering from a surgical wound infection. conclusion: plmb is extremely rare but should be considered in patients with cerebellitis and diffuse leptomeningeal involvement who are refractory to medical management or in whom an etiology has not been identified. cerebellar biopsy is recommended early to enable timely treatment and improved outcomes. molecular classification should be performed in cases of plmb to further characterize this disease, inform treatment decisions, and improve clinical outcomes. background: primary intracerebral osteosarcoma is extremely rare and limited to case reports. ptpn11 gain of function is associated with noonan syndrome, which has increased risk of multiple cancer types including brain tumors, but osteosarcoma has never been described. ptpn11 mutations have been reported in many cancers as both oncogenes and tumor suppressors, however no ptpn11 mutations have been described in osteosarcoma. pdgfr-a is a growth factor receptor whose activation is implicated in several malignancies. pdgfr-a and ptpn11 concurrent mutations are described in glioblastoma. there is no known link between holoprosencephaly, noonan syndrome, and osteosarcoma. we report a case of multifocal intracerebral osteosarcoma in a child with lobar holoprosencephaly and chronic subdural hemorrhage and discuss the genetic changes found in the tumor. design/method: a seven-year-old caucasian female, with a known diagnosis of lobar holoprosencephaly, chronic subdural hemorrhage and well controlled seizure disorder presented with status epilepticus shortly after completing antibiotic therapy for infection of subdural hematoma. mri showed diffuse dural thickening with mass lesions in the frontal lobe, temporal lobe, and the parasagittal region, the largest of which was contiguous with the subdural space but none of the lesions were associated with bone on mri or by direct neurosurgical visualization. tissue obtained for concern for recurrent infec-tion resulted in a diagnosis of high grade osteosarcoma. dna analysis was performed to help guide treatment choice. results: standard metastatic work-up was negative for skeletal primary tumor or metastatic lesions outside of the brain. she was treated with high dose methotrexate for two cycles per modified aost1331. despite maximal supportive care, she quickly developed rapid tumor growth as well as intratumoral hemorrhage with resultant herniation and death from respiratory failure just three months after diagnosis. tumor gene sequencing discovered three mutations with described roles in cancer: pdgfra d842>vr, kdm6a loss of exons 1-4, and ptpn11 a72v. conclusion: to our knowledge, primary multifocal extraosseus intracerebral osteosarcoma has not been previously described. despite known cns penetration of high dose methotrexate, this tumor proved resistant and aggressive. holoprosencephaly is associated with a multitude of known genetic drivers, but none are found in this case. furthermore, the genetic changes in this tumor are not typical for osteosarcoma. pdgfr-a over-expression is described in osteosarcoma, but is not clearly correlated with worse overall survival. further research is required to determine the role of ptpn11 in osteosarcoma. background: anaplastic lymphoma kinase (alk) encodes a receptor tyrosine kinase whose activation induces pathways associated with cell proliferation, angiogenesis, and cell survival. alk rearrangements are rare in neuroblastoma, while alk mutations and gene amplification occur more frequently. alk mutations have been found to be associated with increased alk protein expression that is associated with a worse prognosis. alk is commonly mutated in neuroblastoma at three hotspots (f1174, r1275, and f1245). the eml4-alk rearrangement has mostly been associated with lung adenocarcinomas, with only a few cases of non-lung cancers found. it has never been reported in neuroblastoma. multimodal therapy and to report the successful management of treatment related iron overload. results: a 10-year old male presented with abdominal swelling and ct showed a right kidney mass and bilateral lung nodules. he underwent right radical nephrectomy with lymph node sampling. pathology was reviewed centrally and revealed wilms tumor with diffuse anaplasia with rhabdomyosarcoma arising within the stromal component and 3 of 13 nodes positive. he received adjuvant intensive chemotherapy and radiation to the hemiabdomen and whole lungs. the 49-week chemotherapy regimen was vincristine, doxorubicin, cyclophosphamide (per cog arst0431) alternating with carboplatin and etoposide (per cog aren0321 revised uh-1). treatment was complicated by multiple episodes of fever and neutropenia and anorexia requiring g-tube placement. post-therapy, he had persistent neutropenia and thrombocytopenia without related complications. every 6 months for 3 evaluations he underwent a bone marrow which revealed normocellular marrow with maturing trilineage hematopoiesis. evaluation for a bone marrow failure syndrome was unrevealing. starting at 6 months into therapy and all posttherapy imaging showed splenomegaly. he received 29 units of packed red blood cells through the duration of therapy. he was diagnosed with iron overload based on serum ferritin and imaging, including t2*mri. he received therapeutic phlebotomy for 2 years with normalization of serum iron studies, t2* of the heart, and liver iron concentration. he is more than 6 years from completing therapy with no evidence of recurrent disease. asymptomatic cytopenias persist and he has no evidence of iron overload. conclusion: though a rare development, clonal sarcomatous transformation can occur in wilms tumor. our patient's tumor was successfully treated with intensive multimodal therapy targeting the diffusely anaplastic wilms and the rhabdomyosarcomatous component. treatment-related iron overload in a pediatric patient with a solid tumor was successfully treated with phlebotomy. consideration should be given to screen patients with solid tumors who receive multiple packed red cell transfusions for iron overload at the completion of cancer therapy. primary children's hospital, university of utah, salt lake city, utah, united states background: malignant solid tumors are less frequently encountered in infants. primitive myxoid mesenchymal tumors of infancy (pmmti) are a myofibroblastic malignancy and cases are rarely reported in the literature. cure is achieved in the majority of cases with surgical resection, however treatment for unresectable cases remains an enigma. recently published literature postulates that the newly discovered bcor duplication found in pmmti is tumorigenic via an epigenetic pathway. this molecular signature resembles that of clear cell sarcoma of the kidney (ccsk) and the growing number of bcor mutated sarcomas. a similar chemotherapeutic backbone and local control used for ccsk, has been proposed for the unresectable subset of pmmti. utilizing this approach a 19 month-old with relapsed disease has remained disease free for 12 months. however, given the rarity of this disease and the lack of published literature, there is no known standard of care treatment for unresectable and/or recurrent ppmti. we report a case of unresectable recurrent pmmti, a rare infant tumor, with less than 20 cases reported. design/method: medical record, radiological studies, pathology and literature was reviewed. results: our patient is a now 12 month-old female who presented with constipation and lower extremity weakness in the first weeks of life. an mri demonstrated a large lumbar epidural mass with spinal cord impingement. given prolonged (>14 days) neurological symptoms and location, emergent chemotherapy was initiated. biopsy showed a bcor positive, primitive myxoid mesenchymal tumor of infancy (pmmti). she was treated with ifosfamide, carboplatin and etoposide, and demonstrated clinical and radiographic response. we gave two additional cycles of cyclophosphamide, carboplatin and etoposide until surgical resection was feasible followed by two post-surgical cycles of chemotherapy. unfortunately, four month post-therapy mri demonstrated two new lesions; an unresectable paraspinal soft tissue mass and a left iliopsoas groove mass. given bcor association and reported successful therapy with vincristine, doxorubicin, cyclophosphamide alternating with ifosfamide and etoposide, we elected to incorporate vinca-alkaloid and anthracycline into her regimen. she is being treated with vdc/ie with plan for radiation consolidation. conclusion: pmmti is a locally aggressive tumor, for which surgical resection is curative. for those not amendable to resection, best care practices are still being determined. we report a case of pmmti initially responsive to chemotherapy, but not curative. this is the second case to conclusively demonstrate chemo-responsiveness. bcor mutation seems to be a common feature of this cancer; its role in the pathogenesis and as a target is an area of investigation. medical college of wisconsin, milwaukee, wisconsin, united states background: atypical teratoid/rhabdoid tumors (atrt) are central nervous system (cns) tumors that most commonly occur in very young children. there is no widely accepted standard of care for atrt patients, and while survival rates are improving they are historically poor. patients with metastatic disease to the spine at diagnosis have a worse prognosis, and for patients >3 years old, the presence of metastatic disease often results in the use of craniospinal radiation. the importance of correctly identifying metastatic disease at diagnosis aids in decision making and can have both prognostic and therapeutic implications. mr imaging at diagnosis is used to identify metastatic disease; however, here we present a case of diffuse leptomeningeal enhancement that spontaneously resolved after resection of a primary supratentorial atrt. objectives: to describe the resolution of diffuse leptomeningeal enhancement after resection of a primary atrt tumor in a 12-month-old prior to any adjuvant therapy. results: a 12-month-old male presented with a 2 month history of vomiting and weight loss, regression of gross motor developmental milestones, and left hemiparesis. a brain mri demonstrated a 7 × 5.8 × 5.7 cm solid and cystic right atrial mass with diffusion restriction and post-contrast enhancement. smooth diffuse enhancement was noted along the surface of the brainstem and within the interpeduncular fossa. a spine mri demonstrated diffuse circumferential post-contrast enhancement along the surface of the entire spinal cord. the patient underwent a successful near total surgical resection of the primary mass. pathology confirmed the loss of ini-1 staining in tumor cells, consistent with a diagnosis of atrt. no immediate adjuvant radiation or chemotherapy was given. repeat imaging was completed 15 days after resection. brain mr demonstrated expected post-operative changes within the surgical cavity without definitive residual mass or leptomeningeal enhancement. spine mr demonstrated complete resolution of the previously seen circumferential enhance-ment along the entire spinal cord. csf evaluation at that time was negative for tumor cells. after recovery from surgery, chemotherapy treatment was initiated. conclusion: leptomeningeal enhancement at the time of diagnosis of atrt has historically been considered clear evidence of metastatic disease. this case raises questions about the previously accepted etiology of these imaging changes and suggests that widespread leptomeningeal enhancement should be carefully interpreted in future patients with similar imaging findings. in this setting, clinicians should consider repeat imaging following primary surgical resection in order to provide appropriate prognostic information and inform therapeutic decisions. poster # 047 primary ewings sarcoma of cervical cord mimicking cauda equina syndrome sucharita bhaumik, joshua chan nyu winthrop hospital, mineola, new york, united states background: ewing's sarcoma (es) is a malignant primary bone tumor usually involving long bones. primary es of spine is quite uncommon (0.9%) and its location in the cervical spine is even more rare. cauda equina syndrome (ces) is symptoms due to damage to the bundle of nerves below the end of the spinal cord known as the cauda equina (low back pain, radiating shooting pain down the legs, paraplegia, and loss of bowel or bladder control). it often occurs with lesions of lumbosacral spine. treatment with high-dose steroids may provide pain relief and improved neurologic function (by reducing edema) while awaiting diagnostic studies objectives: to demonstrate an unusual clinical presentation and emergent management of cervical es presenting with ces like symptoms. : 15 year old male presented with a left sided posterior neck mass. soon after, he developed weakness of left arm, urinary and stool retention and inability to walk or bear weight in both legs. on physical exam a left tempero-occipital 6 × 4cm fixed, non-tender, non-fluctuant mass was noted as well as motor and sensory impairment of left upper extremity, bilateral spastic paraplegia and loss of sphincter control. mri cervical spine showed a left cervical tumor with moth eaten appearance involving the vertebral bodies of c2-c3, adjacent muscles, displacing vital structures of the neck and compressing the cervical spinal cord. the thoracic and lumbosacral spine had no disease involvement. due to rapidly worsening spinal cord compression he was emergently treated with high dose steroids. he gained back all function in his extremities and regained bowel and bladder control. this eliminated need for urgent neurosurgical intervention. results: biopsy of the neck mass showed small blue round cells consistent with es with ewsr1 gene rearrangement. staging work up revealed no additional metastatic involvement. he then initiated treatment for localized es with systemic chemotherapy and radiotherapy and has had excellent response to treatment so far. conclusion: this is the first known case of non metastatic primary cervical es mimicking ces where an acutely enlarging mass presented with rapidly progressive neurologic deficits due to compression of anterior spinothalamic tract. in these unusual presentations of ces without lumbodorsal involvement it is important to consider cervical lesions. early rapid steroid initiation should be considered while awaiting biopsy results to prevent worsening cord compression followed by es focused treatments. this increases the chance of a successful outcome. the initial improvement with steroids may confuse the tumor with being a lymphoma children 's mercy hospital, kansas city, missouri, united states background: von willebrand disease (vwd) is a relatively common bleeding disorder with a high degree of genotypic and phenotypic variation. bleeding is usually mucocutaneous but can be severe and include muscle and joint bleeds especially in type 3 vwd patients. most common bleeding management consists of desmopressin, anti-fibrinolytics, and/or plasma-derived antihemophilic factor/von willebrand factor (ahf/vwf) complex. a recombinant vwf has become available in the last few years. anaphylaxis and inhibitor development in vwd are rare. objectives: to describe the rare clinical manifestation of anaphylaxis to factor concentrate in a patient with severe type 1 vwd. results: a 13-year-old female with severe type 1 vwd [baseline vwag 10%, activity < 10%, factor viii (fviii) 26%] originally presented with heavy menstrual bleeding (hmb) leading to anemia requiring blood transfusion. she underwent placement of a levonorgestrel-releasing intrauterine device (lngiud) and began norethindrone. her hmb continued despite the lngiud and an increase in norethindrone dosing. plasma derived ahf/vwf complex was administered, which she had previously received. following the infusion, the patient developed anaphylaxis with hives, wheezing, tachycardia, and itching requiring 2 doses of diphenhydramine and 1 dose of hydrocortisone with resolution of symptoms. subsequently, she received recombinant vwf without incident. however, due to her low fviii level, she also required treatment with a full length recombinant fviii product. she again developed hives and itching after this infusion. she has since received recombinant vwf with recombinant fviii/fc fusion protein without further allergic reaction. there was no evidence of an inhibitor with her most recent post-infusion vwf level was 101%, factor viii 199%. conclusion: anaphylaxis to plasma derived factor products has been documented far less frequently within the vwd population compared to those with hemophilia and is typically seen in those with large gene deletions, usually with type 3 disease. therefore, similar type 1 vwd patients with severe disease may benefit from gene sequencing. it is unclear in this patient's case to which aspect of her treatment she is allergic, as she reacted to plasma-derived ahf/vwf and full length recombinant fviii, but not recombinant vwf or recombinant fviii/fc fusion protein. we hypothesize that she may be allergic to an epitope in the fviii b domain, or that the presence of fc fusion may have had a protective effect. further investigation including genetic analysis is planned. nodules. biopsies were consistent with neuroendocrine carcinoma, large cell type (g3). next generation sequencing revealed a khdrbs2-braf fusion. he received conventional cytotoxic chemotherapy regimens both with cisplatin/doxorubicin, capecitabine/temozolomide, and doxorubicin/etoposide, but achieved a minimal response followed by rapid disease progression, massive ascites, and renal failure secondary to bilateral ureteral obstruction. results: based on his prior genomic testing, therapy with single agent mek inhibitor (trametinib) was initiated. this produced a rapid, dramatic response with greatly reduced disease burden at all sites, resolution of ascites and return to completely normal activity within 2 months. this response lasted for approximately 6 months before the tumor again progressed. further therapy with an erk inhibitor was ineffective, and the patient expired from progressive disease. located on the chromosome 7q34, the braf oncogene, as part of the ras/mapk pathway, is involved in cellular proliferation, differentiation, migration, and apoptosis. braf mutations are recognized in a wide range of adult malignancies: thyroid cancers, non-small cell lung cancer, cholangiocarcinoma, ovarian cancers, and multiple myeloma. braf mutations have also been described in adult neuroendocrine carcinoma of the colon. trametinib is a highly specific inhibitor of mek1/mek2, a downstream mediator in the braf pathway. it has demonstrated activity in a number of tumors including advanced melanoma and gliomas. trametinib was chosen for this patient based on his atypical braf fusion. we believe this is the first documented case of its successful use in neuroendocrine carcinoma in the pediatric population. conclusion: this case demonstrates the presence of braf fusion in a case of pediatric neuroendocrine carcinoma and significant response to single agent mek inhibition in this context. this cases raises the question as to whether the combination of a targeted inhibitor, in addition to either conventional chemotherapy or other braf inhibitors, might offer a better approach to therapy than current treatment options. albany medical center, albany, new york, united states background: warm autoimmune hemolytic anemia (waiha) is characterized by autoantibody, and occasional complement binding of protein antigens, on the surface of red blood cells at temperatures ≥37 oc resulting in targeted destruction. we describe the case of a 17 year old male with a history of evan's syndrome, poor immune response to vaccines and lymphoid hyperplasia, presenting with altered mental status and severe anemia, found to have a warm igg pan agglutinin with evidence of both intra and extravascular hemolysis. his course was complicated by respiratory failure requiring intubation, pulmonary emboli, enterococcus bacteremia and hypertension. he received multiple transfusions with only transient increases in hemoglobin. the aiha was refractory to multiple rounds of treatment with high dose steroids, ivig, rituximab, cyclophosphamide, bortezomib, plasma exchange and mycophenolate mofetil (mmf). objectives: given the refractory nature of our patient's aiha the decision was made to trial eculizumab, a monoclonal antibody targeting c5 complement, preventing its cleavage and activation, and shown to be effective in treatment of atypical hemolytic uremic syndrome and hemolysis due to an igm cold agglutinin. prior to eculizumab infusion, ch50 and sc5b-9 assays were significantly elevated. design/method: the patient was given two doses of eculizimab 6 days apart. results: his hemoglobin steadily rose independent of red cell transfusions with a corresponding decrease in reticulocyte count, ldh and ch50 levels. the patient has remained stable with a normal hemoglobin (12-14 g/dl) on maintenance steroids and mmf. although we cannot definitively conclude that eculizumab directly caused his recovery, the clinical course post-eculizumab suggests this may be an efficacious treatment for aiha. genetic testing showed monoallelic frameshift mutation of the nfkb1 gene and monoallelic missense mutation of the dock2 gene. given the role of nfkb1 in both immunodeficiency and autoimmunity, it is thought that the patient's phenotype is due to nfkb1 haploinsufficiency and he is currently considering hematopoietic stem cell transplant. st. joseph's regional medical center, paterson, new jersey, united states background: heterozygous -thalassemia typically manifests as thalassemia minor, characterized by mild microcytic hypochromic anemia with minimal clinical ramifications. coinheritance of -globin gene triplication has been reported to exacerbate the clinical and hematological phenotype ofthalassemia trait, due to increase in the alpha/non-alpha-chain imbalance. reported phenotypes range from asymptomatic thalassemia minor to moderate thalassemia intermedia, usually diagnosed in adulthood without transfusion dependence. this combination has been described in mediterranean, european and asian populations, but rarely reported in hispanics. objectives: to report two cases of unusually severethalassemia intermedia in hispanic patients with heterozygosity for triplicated -globin gene and a (0)-thalassemia allele. results: case 1: sixteen-month-old male of mexican descent presented with persistent microcytic anemia and jaundice. peripheral smear showed nucleated rbcs with basophilic stippling and target cells. hemoglobin electrophoresis revealed: hba-79%, hbf-17%, hba2-4.3%. -globin gene testing revealed heterozygosity for (0) mutation (ivsi-i, g→a). given the unusually severe anemia, -gene testing was performed which showed -globin gene(anti 3.7) triplication ( / ). at four years, he had splenomegaly and bilateral maxillary prominence. head ct showed irregular contour of the parieto-occipital region due to medullary expansion. due to significant persistent anemia (6-8g/dl) and progressive bony deformities of the skull, patient began chronic transfusions at age eight after family declined splenectomy.case 2: fifteen-year-old female, of peruvian and honduran descent, presented for evaluation prior to cholecystectomy for gallstones and recurrent ruq pain. father had known thalassemia trait. her hb was 9.2 g/dl with hypochromia, microcytosis, and target cells. electrophoresis indicated -thalassemia trait (hba-94%, hba2-4.7%, hbf-1.3%), confirmed by gene testing (heterozygous for a (0) mutation in codon 39 c>t). given jaundice and gallstones, -globin gene analysis was ordered showing triplication ( / ). ruq pain resolved post-cholecystectomy, but she developed persistent painful splenomegaly. she began hydroxyurea to increase gamma-globin production and decrease excess alpha chains, but it was discontinued due to hematological toxicity. due to recurrent luq pain and progressive splenomegaly, she underwent laparoscopic splenectomy at age 22 with resolution of symptoms and improved hemoglobin. conclusion: -globin gene testing should be considered in -thalassemia carriers with an atypical clinical presentation including hispanic patients. the wide variability in the phenotypic expression of (anti 3.7) mutation andthalassemia trait suggest interplay of other genetic factors which remain undefined. the clinically significant presentation amongst certain subjects, as in our two cases, makes it imperative to identify these factors to aid in phenotype prediction and genetic counseling. ashley bonheur, shivakumar subramaniyam, jogarao vedula, sucharita bhaumik nyu winthrop hospital, mineola, new york, united states background: wilms tumor (wt) is one of the most common solid malignant neoplasms in children. a diverse range of genes and mechanisms are implicated in wt pathogenesis. predisposing syndromes result from a disruption of wt1 gene, crucial for renal and gonadal embryogenesis. another gene is wt2 gene locus at 11p15, an area of imprinting. the p53 tumor suppressor gene on chromosome 17p13.1 is seen in patients with anaplastic histology. in addition to these genes, whole and partial chromosome gains of 1q, 2, 7q, 8, 12, & 13 and losses of 1p, 7p, 16q, 22q, as well as loss of heterozygosity (loh) are commonly seen. some genetic markers appear to be predictive of outcome and are now incorporated into the assigning of risk-directed therapy. patients with loh at chromosome 1p and 16q are treated with more intensive chemotherapy, as they have been associated with increased risk of relapse and mortality. objectives: to describe a new complex translocation involving chromosome 2, 7, and 12 in a case of pediatric wt. design/method: a four-year old female presented with abdominal pain and emesis. on exam, patient had a firm and large abdominal mass. radiologic studies revealed a complex lobulated right renal mass. right radical nephrectomy was performed. histopathologic studies showed wt with triphasic histologic features with blastema predominance, invasion of the lymphovascular and perinephric adipose tissues, perinephric lymph node involvement and no anaplasia. chest ct scan showed bilateral lung metastases. tumor cytogenetics showed an abnormal karyotype, a complex translocation of 2, 7, and 12. the rearrangement occurred due to translocation between chromosomal bands 7q22 and 12q15, with an insertion of 7q22-32 on the 2q21 region. pcr based genotyping using microsatellite markers additionally identified loh for chromosome 1p36 and 16q22. the patient was treated for high risk stage iv wilms tumor with favorable histology and received intensive chemotherapy and radiation therapy to the flank and the lungs. she is now in remission 8 months after, with no evidence of recurrence on surveillance scans. complex translocations associated with wt have not been rigorously studied. a question for further study is whether there is any relationship between recurrence potential with a complex translocation compared to common chromosomal abnormalities. further knowledge of the molecular pathology and genetic changes in wt will help the development of new targeted therapies, as well as new biomarkers to aid diagnosis, risk stratification, and monitoring of treatment and relapse. results: a 4 week-old girl was referred for evaluation of an abnormal newborn screen. mother was a known carrier of hb khartoum trait while father was a known carrier of thalassemia trait. patient's hemoglobin quantification performed by capillary zone electrophoresis showed hbf 92%, hb variant 8%, and no detectable hba. the hb variant ran in the d zone, a pattern consistent with mother's hb. alkaline agarose gel electrophoresis banding pattern showed f/s. acid agarose gel electrophoresis pattern showed v/f. later testing revealed abnormal isopropanol stability with 3+ precipitation at 20 minutes. this electrophoresis pattern is consistent with the pattern previously reported of hb khartoum. clinically, the patient is a healthy, active child whom we have followed for two years. she has not had any significant anemia outside of her physiologic nadir. she has not had any hemolytic episodes, and her bilirubin levels have always been within the normal range conclusion: to the best of our knowledge, this is the only reported case of hb khartoum/ thalassemia. the proline to arginine substitution of hb khartoum introduces a charged group on the chain at the site of 1 1 contact. the resulting unstable 1 1 chains can dissociate into monomers and favor the formation of methemoglobin, leading to hemoglobin instability. we had wondered if this unstable hemoglobin might result in clinical hemolysis when challenged with oxidative stress, such as in periods of infection. however, in the two years we have followed this patient, she has never had a hemolytic episode. at two years of age, she has hbf 7.8%, hb khartoum 85.5%, and hba2 6.7%. whether hbf elevation is protective from oxidative stress remains to be determined as we continue to follow this child. university of puerto rico -medical science campus, san juan, puerto rico, united states background: gm1 gangliosidosis is a lysosomal disorder caused by -galactosidase deficiency due to mutations in the glb1 gene. it is a rare autosomal recessive neurodegenerative disorder with an incidence of about 1:100,000-1:200,000 live births worldwide. this neurological disorder has three clinical forms. gm1 type 1, or infantile form is characterized by psychomotor regression by the age of 6 months, visceromegaly (hepatosplenomegaly), macular cherry red spot, facial and skeletal abnormalities, seizures, and profound intellectual disability. we present a 4-year-old female with gm1 type 1 and acute lymphocytic leukemia (all). design/method: she was diagnosed with gm 1 type 1 at the 1st months of age and family history was remarkable for an older sister with gm 1 type 1. diagnostic studies reveal homozygous exon 7 of the glb1 gene for a sequence variant defined as c.622c>t, predicted to an amino acid substitution p.aarg208cs. results: patient presented to our hospital with petechiae in lower extremities, pallor and intermittent tracheal bleeding. physical examination shows a hemodynamically stable girl that is chronically ill dependent of mechanical ventilation, severe mental retardation and scatter petechiae at upper and lower extremities. laboratory workup revealed severe normocytic anemia (hgb: 5.7g/dl) with immature peripheral cells and thrombocytopenia (81 × 109/l). serum chemistry revealed increase ldh (695u/l), increase hepatic enzymes (ast: 63u/l), normal uric acid level. there was no evidence coagulopathy. chest x ray was unremarkable except for evidence of chronic pulmonary illness. abdominal sonogram hepatosplenomegaly. during hospitalization, bone marrow aspirate and biopsy was performed which was diagnostic of b cell acute lymphoblastic leukemia (all) with 26.5% lymphoblast and orderly myeloid/erythroid maturation. flow cytometry: 26% b lymphoblast with aberrant phenotype c/w b-acute lymphoblastic leukemia. karyotype revealed hyperdiploid female of favorable prognosis. cytogenetic by fish: hyperdiploid all with extra copies of runx1 and igh (no bcr-abl translocation). family was oriented about the new diagnosis and the dismal prognosis in conjunction to her primary condition. parents agree on no chemotherapy treatment for all with only supportive treatment. to this date, there is no evidence in literature that has previously described association of gm1 and leukemia. life expectancy of patient's primary condition is null therefore, correlation with leukemia might not be a coincidental finding. this patient opens the possibility of malignancy as part of gm1 type 1 thus, malignancy diagnosis should be considered as part of their medical lifetime course. university of south florida, tampa, florida, united states background: hematological manifestations related to hiv infection are not uncommon, with thrombocytopenia having an estimated prevalence of 5-15%. the pathophysiology is likely multifactorial. studies suggest that the primary mechanism may be immunologic resulting in accelerated platelet destruction. additional theories suggest that infection of megakaryocytes may also play a role causing inadequate platelet production. treatment of hiv-related thrombocytopenia is challenging. first-line treatments include initiation and optimization of antiretroviral therapies, immunoglobulin (ivig), and glucocorticoids. however, this approach is not effective in all patients and second line treatment options are less well studied, particularly in the pediatric population. objectives: we aim to present and discuss the case of a 13 year old patient with perinatally acquired hiv-1 infection and persistent thrombocytopenia who, after failing first line therapies, showed normalization of platelet count on the novel thrombopoietin receptor agonist, eltrombopag. design/method: a retrospective chart review of the case patient's medical record was conducted. additionally, a thorough literature review was performed on this topic including the pathophysiology of hiv related thrombocytopenia and its treatment modalities. the patient required monthly ivig infusions for about 1 year, but did not show a sustained response, often with platelet count dropping to less than 10,000 in between infusions. after initiation of 50 mg eltrombopag daily the patient showed a sustained increase in platelet count (range 32,000-88,000). during a brief 2 week lapse in eltrombopag treatment his platelet count dropped to 17,000. upon re-initiation of therapy his count increased to 84,000. the patient has remained asymptomatic, off of ivig for over one year, with undetectable hiv viral load and greater than 500 cd4 t cell counts. no side effects or grade 2 laboratory abnormalities were reported. conclusion: treatment of hiv-related thrombocytopenia can be challenging. first line therapies, including ivig and glucocorticoids, are not effective in all patients. several other treatment modalities have been utilized, including anti-d immunoglobulin, dapsone, danazol, interferon alfa, vincristine, thrombopoetic growth factors including romiplostim and eltrombopag, or splenectomy, but these are less well studied. this represents the first reported case of a pediatric patient with hiv who showed a positive response to eltrombopag with a sustained improvement in platelet count and no adverse effects from treatment. eltrombopag may be a safe alternative to first line therapies in those patients with hiv and refractory thrombocytopenia, however additional studies are needed. university of illinois college of medicine at peoria, peoria, illinois, united states background: achromobacter xylosoxidans is a gram negative rod with peritrichous flagella which causes rare opportunistic infections most commonly encountered by immunocompromised patients. it is primarily associated with uncomplicated bacteremia, cather-associated infections, and pneumonia. most reports of bacteremia associated with a. xylosoxidans are nosocomial, associated with neoplasm, and occurring mainly in adults. most reported infections with a. xylosoxidans in children are associated with cystic fibrosis. there are very few reported cases of septic shock from a. xylosoxidans bacteremia and pneumonia in the pediatric oncology population. objectives: to describe a rare case of a. xylosoxidans septic shock in a pediatric patient with relapsed neuroblastoma results: a 4-year old boy with history of stage iv highrisk neuroblastoma underwent standard frontline therapy with chemotherapy, hematopoietic stem cell transplant, radiation therapy, and immunotherapy, followed by a dfmo trial for maintenance. his 3-month follow-up scans demonstrated relapse and he was subsequently treated with additional chemotherapy, surgical resection, and mibg therapy, crizotinib for an eml4-alk fusion and finally ifosfamide, carboplatin and etoposide (ice). he developed neutropenic fevers and was started on cefepime, vancomycin and fluconazole. blood cultures were initially negative. on the 4th day of fever, his previously scheduled pet scan was performed during hospitalization and showed new pulmonary opacities. he did not have respiratory symptoms, but therapy was escalated to meropenem, vancomycin and amphotericin. emergent bronchoscopy was performed the same day, with all bacterial and fungal cultures remaining negative. overnight, he developed tachypnea and saturations in the upper 80s, requiring nasal cannula. ir-guided lung biopsy was performed the next day, a flexible bronchoscopy was done to remove blood clots in the airway, the patient was placed on a ventilator, femoral lines were placed, granulocytes ordered and pressors were started for deterioration to presumed septic shock. arterial and femoral lines were placed but patient continued to have hemodynamic instability on multiple pressors. the following day, blood and respiratory cultures returned positive for results: at 33 days after the start of iti, the inhibitor was <0.1 bu and continued undetectable 6 months after initiation of iti therapy. in this patient, iti with high-dose plasma-derived factor viii and von willebrand factor (vwf) complex was well tolerated and effective. genetic analysis confirmed a large factor viii gene duplication of exons 7 to 22. we believe our patient developed inhibitor so quickly (14 exposure days) due to the possibility of this mutation causing a frameshift that introduces a premature termination codon. this might be functionally similar to a deletion in the factor viii gene which poses the highest risk for inhibitor development in patients with severe hemophilia a. this variant has only been identified previously in two unrelated patients diagnosed with severe hemophilia a. this duplication is not listed in dbsnp variant database, nor observed in the general population database. our case proves the effectiveness of this method for patients with severe hemophilia a and an inhibitor. it also shows that more research is needed to identify patients at risk for inhibitor development. background: mercaptopurine (6-mp) is a prodrug that is a core component of maintenance chemotherapy for patients with a diagnosis of acute lymphoblastic leukemia (all). suppression of the neutrophil count is used to demonstrate adequate dosing of 6-mp during this phase of therapy. bone marrow suppression is mediated by the active metabolite 6-thioguanine (6-tgn), whereas the metabolite 6-methylmercaptopurine nucleotides (6-mmpn) has been shown to cause hepatotoxicity. allopurinol has been used infrequently in all maintenance therapy in the setting of skewed metabolism when adequate myelosuppression is difficult to achieve due to excessive hepatic toxicity. when given in combination with allopurinol a reduced dose of 6-mp may result in both increased 6-tgn levels and decreased 6-mmpn levels. objectives: describe the characteristics and clinical course of patients treated with allopurinol and reduced dose 6-mp during maintenance chemotherapy for all. we performed a retrospective chart review of patients at aflac cancer and blood disorders center of children's healthcare of atlanta with new diagnoses of b or t-cell all who received allopurinol during maintenance chemotherapy. we identified eleven patients with b-cell or tcell all who received allopurinol adjunctive therapy during maintenance chemotherapy at a single institution between 2014-2017. these 11 patients received adjunctive allopurinol for 2-120 weeks (median 52 weeks) with reduced 6-mp (25-65% of full dose). all ten patients with genetic testing for thiopurine s-methyltransferase (tpmt) had wildtype genotype associated with normal enzyme levels. indications for allopurinol use were most commonly unfavorable 6-mp metabolite levels, transaminitis (n = 8), pancreatitis (n = 3) and hyperbilirubinemia (n = 3). favorable metabolite shift was achieved in all patients. liver enzymes improved in 6 of 10 patients with transaminitis after initiation of allopurinol/reduced 6-mp. three patients who experienced pancreatitis during maintenance did not have recurrence after initiation of allopurinol (2 of these patients previously reported). six patients developed pancytopenia while on allopurinol, and two of those patients developed pancytopenia severe enough to require allopurinol cessation. four patients developed isolated anemia (hgb <11.0 g/dl) without thrombocytopenia or severe neutropenia. no patient has experienced a recurrence of leukemia. overall, treatment with allopurinol and reduced dose 6-mp was successful in producing a favorable 6-mp metabolite distribution and reducing toxicity. therapy was generally tolerated; however a major and notable side effect was pancytopenia, in two cases severe enough to stop allopurinol treatment. anemia may be more prominent with allopurinol usage. allopurinol effect is variable among individual patients despite normal tpmt genotypes. baylor college of medicine, houston, texas, united states background: congenital sideroblastic anemia, b-cell immunodeficiency, periodic fevers and developmental delay syndrome (sifd) is a rare inherited sideroblastic anemia syndrome, first described in 2013 with 12 clinically similar cases. genetic variations of trnt1 were identified as causative. objectives: to present an unusual presentation of a patient with sifd complicated by diagnosis of concomitant alpha thalassemia trait. design/method: retrospective chart review. a five month old male infant was referred to our hematology center for evaluation of elevated hemoglobin barts identified on newborn screen. despite numerous attempts, blood work was unable to be collected. at seven months of age he had microcytic anemia (hemoglobin 7.5 g/dl, mean corpuscular volume 44 fl) more severe than what would be expected with alpha thalassemia trait. no variant hemoglobin was identified with isoelectric focusing or high performance liquid chromatography. by nine months of age he developed growth failure, intermittent emesis with fevers, developmental delays (predominantly gross motor), hearing loss, a disproportionally large head and coarse, thinning hair. over the next ten months, he was seen by numerous specialists for seemingly unconnected problems including sensorineural hearing loss, elevated liver enzymes and growth hormone deficiency. alpha globin analysis revealed deletion of two alpha globin genes. at 20 months of age, he was admitted with one week of fevers, jaundice, and emesis. peripheral blood smear showed microcytic hypochromic anemia with marked anisopoikilocytosis including target cells, elliptocytes, tear drops, spherocytes, poikilocytes, marked polychromasia, and coarse basophilic stippling. given the inconsistency of his laboratory findings with the diagnosis of alpha thalassemia trait and clinical syndromic findings, bone marrow biopsy was performed which revealed rare ringed sideroblasts. one month later whole exome sequencing revealed trnt1 splicing variant c.1057-7c>g and novel missense variant c.1092a>t consistent with sifd. hemoglobin barts on newborn screen with moderate to severe microcytic anemia directed initial diagnostic work-up towards variant alpha thalassemia. as additional medical conditions developed the focus shifted to a unifying syndrome. compared to previously described cases, our patient was diagnosed at an older age, presented with anemia rather than episodes of febrile illnesses, and had rare sideroblasts on bone marrow examination. diagnosis in this case led to identification of the novel c.1092a>t variant in his sister who had similar, but milder, features. sifd is a rare disease with variable phenotypic severity making diagnosis challenging without high index of suspicion which is crucial for appropriate management. wiseman, blood, 2013 . chakraborty, blood, 2014 background: cholelithiasis is uncommon in childhood. cholelithiasis is known to occur more frequently in children with predispositions, including female sex, obesity, parenteral nutrition, previous abdominal surgery, use of oral contraceptives, family history of gallstones, chronic hemolytic anemias, hepatobiliary disease, or exposure to specific drugs. although there have been occasional case reports linking cholelithiasis to childhood leukemia or leukemia therapy, the prevalence and risk factors of cholelithiasis in patients with childhood leukemia remain unclear. objectives: to estimate the prevalence of cholelithiasis in patients diagnosed with childhood acute lymphoblastic leukemia (all), and to evaluate possible risk factors for the development of cholelithiasis in patients with childhood all. we performed a computer-assisted review of the electronic medical records of 503 patients diagnosed for b or t-cell all at children's healthcare of atlanta in the period from 2010 to 2016. patients with diagnoses of cholelithiasis, cholecystitis or who had a cholecystectomy were identified. possible risk factors of age, sex, bmi, history of abdominal surgery and parenteral nutrition use were abstracted. patients with underlying chronic hemolytic anemia or pre-existing gallbladder disease were excluded. results: seventeen cases of cholelithiasis and 2 cases of cholecystitis without documented cholelithiasis were identified. among patients with cholelithiasis, 8 were female. median age at diagnosis of cholelithiasis was 14.0 (range 2.7 -21.6) years. seven patients had no symptoms referable to cholelithiasis at the time of diagnosis. the median age of leukemia diagnosis among these patients was 12.1 (range 0.9 -18.8) years. the median interval from diagnosis of leukemia to gallbladder disease was 1.0 years. four patients had bmi over the 95th percentile for age. two patients had a prior history of intraabdominal surgery. no patient received oral contraceptive pills. six patients received parenteral nutrition for more than 30 days. there was no documented family history of cholelithiasis. seven patients did not receive any cholelithiasis directed therapy. two patients were managed with medical management only, 1 with endoscopic retrograde cholangiopancreatogram with stone extraction, and 7 with cholecystectomy. our study estimates the prevalence of cholelithiasis in childhood lymphoblastic leukemia to be 3.3%, higher than the reported prevalence in the general pediatric population of 0.13-0.22%. although our cohort size is small, it appears that all therapy and supportive care modalities associated with all are likely to play a larger role in the development of cholelithiasis than known predisposing factors in the general population. further studies are warranted. background: an uncommon side effect of intravenous immunoglobulin (ivig) administration is clinically apparent, sometimes severe hemolysis. we describe a severe case of coombs-positive hemolytic anemia secondary to ivig administration. ivig is a blood derivative manufactured from pools of 5,000 to 10,000 individual plasma donations. ivig is not abo-type restricted, so anti-a, anti-b and anti-a,b isoagglutinins are detectable. objectives: to describe a rare but serious type of transfusion reaction leading to gross hemolysis after ivig administration. results: a 16-year-old male with a past medical history of obstructive sleep apnea and obesity was admitted to the pediatric intensive care unit for adenoviral pneumonia and subsequent respiratory failure requiring mechanical ventilation. he had a complex hospital course with many complications including acute respiratory distress syndrome (ards), septic-shock, and coombs-positive hemolytic anemia. the patient was treated with commercial ivig (baxter/baxalta) 400-mg/kg daily for five days. he had two isolated episodes of severe hemolysis in relation to ivig administration requiring multiple transfusions of packed red blood cells (prbc). examination of pre-transfusion peripheral blood smear showed spherocytosis with rouleaux formation and large clumped rbc aggregates. the patient's blood type was classified as blood group a, rh-negative and his initial prbc transfusions were of this type. subsequently, the patient's coombs test was found to be positive using polyspecific and anti-igg typing sera. the patient's antibody screen against reagent group o screening cells was negative ruling out autoimmune hemolytic anemia. however, type specific anti-a antibodies were detected in his plasma as well as the acid eludate prepared from the coombs-positive red blood cells. it was concluded that the patient's hemolysis was due to anti-a antibodies presumed to arise from ivig. the patient's rbc transfusions were changed to o-negative blood and the hemolytic process resolved. the patient ultimately died due to complications of ards. although hemolysis is a known side effect of ivig, it is rarely considered when deciding to administer ivig. in addition, it has rarely been described in the pediatric population. ivig is used in the treatment of a growing number of medical conditions. due to the critical nature of many of these patients, hemolysis secondary to ivig may not be considered and continued blood transfusions with the patient's specific blood type may be used. it is crucial to remember that severe hemolysis can occur from ivig, and the importance of transfusing with blood group o, rh-negative blood when applicable. university of maryland medical center, children's hospital, baltimore, maryland, united states background: coagulopathy is a well-described complication of acute promyelocytic leukemia (apml), and remains a leading cause in induction failure. with treatment, coagulopathy associated with apml has been shown to rapidly improve. multiple organ dysfunction syndrome (mods) in apml, including acute respiratory distress syndrome (ards), has been associated with infection, traumatic injury, malignant infiltration, and cytokine release syndrome. when mechanical ventilation is no longer sufficient, extracorporeal membrane oxygenation (ecmo) can be considered; however, coagulopathy, severe end-organ damage, and malignancy are all relative contraindications to initiation of treatment. we report the case of a 17-year-old female presenting in respiratory failure, disseminated intravascular coagulopathy (dic), with intracranial hemorrhage, and mods, diagnosed with apml, successfully treated with ecmo therapy. design/method: retrospective case analysis and literature review. our patient, a 17-year-old female was admitted in respiratory failure and altered mental status, following a fall shortly prior to presentation. initial laboratory values were notable for pancytopenia, dic, and acute renal failure. a non-contrast head ct showed left temporal lobe intraparenchymal hemorrhage. she was diagnosed with apml by peripheral smear, later confirmed by fish for t(15:17), and was started immediately on high-risk induction chemotherapy as per cog protocol aaml1331, including all-trans retinoic acid, arsenic trioxide, idarubicin, and dexamethasone. cvvhd was required for acute renal failure. despite maximal respiratory support, she remained hypoxemic, with oxygenation index of 46, pao2/fio2 ratio of 70. ecmo was initiated 24 hours after start of induction, 48 hours after admission. coagulopathy resolved on day 6 of induction, ecmo was discontinued after 9 days, mechanical ventilation and cvvhd were stopped after 15 days and she continued to improve, eventually achieving remission with few neurologic side effects. despite relative contraindications to ecmo, this patient was successfully treated with ecmo without significant neurologic side effects. the correction of her coagulopathy was multifactorial: 1) restoration of adequate oxygen delivery via ecmo improving endothelial function; 2) successful organ support to allow sufficient response to induction chemotherapy with atra leading to the terminal differentiation of leukemic blasts; 3) complement and contact system activation through contact with ecmo circuitry. this case illustrates that ecmo can still be considered in patients despite coagulopathy and end organ damage. sinai hospital of baltimore, baltimore, maryland, united states background: primary polycythemia vera is an extremely rare diagnosis in the pediatric patient and is defined by a marked elevation of red blood cells due to erythropoietin-independent mechanisms. presentations of this disorder range from the asymptomatic person to severe thrombotic events, such as budd-chiari syndrome or cerebrovascular stroke. mutations in the jak2 gene are found in adult and pediatric patients with polycythemia vera; however, the jak2 v617f mutation is less commonly identified in pediatric patients. we describe an otherwise healthy 16-year-old female who presented with a significantly elevated total erythrocyte count, hemoglobin, and platelets, incidentally discovered upon routine annual blood work obtained by her pediatrician. design/method: this is a report and discussion of a rare case. demonstrated cellular marrow with trilineage hematopoiesis and no dysplasia. cytogenetics were not assessed. his hemoglobin and platelet count recovered but leukopenia and neutropenia persisted. follow-up evaluation at three months revealed fevers, ongoing cytopenias, a one-month of a nodular skin rash on the trunk and extremities resembling erythema nodosum, and hepatitis (peak alt and ast of 1,176 and 1,008, respectively). following clinical evaluation, a skin biopsy was performed and was remarkable for atypical lymphocytes within the subcutis with t-cell markers, a high ki-67, and positive tia-1, perforin, and -f1 immunoperoxidase stains. negative stains for cd56, cd30, and ebv were noted. these results are consistent with sptcl. additional evaluation did not support a diagnosis of hlh. a staging evaluation was performed. pet-ct showed widespread hypermetabolic subcutaneous activity in the legs, trunk and skull and diffuse marrow hyperplasia. bone marrow demonstrated involvement with precursor b-cell acute lymphoblastic leukemia, with a mll gene rearranagement. his skin biopsy was retrospectively stained with tdt, cd34, pax-5, cd79a, and cd20 with negative results, and a blood smear taken at the time of the skin biopsy did not demonstrate leukemic cells. conclusion: this is the first report of a patient with sptcl having a synchronous malignancy. the patient is doing well, currently in the maintenance phase of treatment for his all, and his skin disease has resolved on pet-ct. while it is possible that his presentation was a function of chance, the possibility of an underlying immune dysfunction or cancer predisposition warrants further investigation. cincinnati children's hospital medical center, cincinnati, ohio, united states background: hereditary xerocytosis (hx) is a rare red blood cell (rbc) dehydration disorder, characterized by variable hemolysis and propensity to iron overload. hx is often misdiagnosed as hereditary spherocytosis (hs). while splenectomy is curative for hs, it is relatively contraindicated in hx due to a substantial thromboembolism risk, signifying the importance of delineating these diseases. blood smear abnormalities are variable and often insufficient to make an accurate diagnosis. osmotic-gradient ektacytometry and genetic confirmation are critical in distinguishing these overlapping disorders. objectives: describe a family with hx, initially misdiagnosed as hs. discuss the importance of distinguishing these disorders and the utility of ektacytometry in making this distinction. design/method: a 13-year-old caucasian male was diagnosed with hs after presenting with prolonged neonatal jaundice starting on the first day of life. he described mild scleral icterus and history of intermittent jaundice and dark urine, without need for transfusions. his father, paternal uncle and paternal grandmother were all diagnosed with hs during childhood and underwent cholecystectomy. additionally, his father underwent splenectomy for abdominal pain. the child's blood counts revealed compensated anemia (hb 12.9 gm/dl) and reticulocytosis (arc 347 × 103/mcl) with increased mcv (96.6 fl) and mchc (38.2 gm/dl). blood smear showed increased polychromasia and poikilocytosis with rare spherocytes and few stomatocytes. while the child had normal ferritin, his father had iron overload (ferritin 800 ng/ml) despite no prior transfusions. osmotic-gradient ektacytometry profile of the child and father's rbcs showed a characteristic left-shifted, bell-shaped curve with decreased omin and ohyp, diagnostic of hx. the family is currently undergoing genetic studies. despite clinical similarities between hs and hx, distinguishing these diseases has significant management implications. hx is a disorder of rbc permeability, causing shortened rbc survival. stomatocytes on blood smear can raise suspicion for hx, but are insufficient to make an accurate diagnosis. identifying characteristic biomechanical membrane properties using osmotic-gradient ektacytometry is the gold standard for clinical diagnosis, which can then be confirmed by molecular studies. hs and hx can be easily and reliably distinguished using ektacytometry, as both disorders have very distinctive curves representing different rbc deformability patterns. after hx diagnosis was made, we counseled the family against splenectomy, as the risk of thromboembolism is significantly increased in hx compared to hs, and the father was diagnosed with iron overload. conclusion: hx is commonly misdiagnosed as hs. this case highlights the importance of making this distinction, and the utility of osmotic-gradient ektacytometry in reliably distinguishing these conditions. penn state health children's hospital, hershey, pennsylvania, united states background: relapsed acute myeloid leukemia (aml) presenting as an isolated central nervous system myeloid sarcoma (cns ms) is very rare and its treatment is not well-defined. thiotepa, vinorelbine, topotecan and clofarabine (tvtc) has been successful for re-induction therapy to induce remission prior to hematopoietic stem cell transplant (hsct). objectives: to describe our experience in utilizing tvtc therapy in two children with no extramedullary disease at initial diagnosis who presented with relapsed aml as intracranial myeloid sarcomas. results: case 1: 34 month-old female was diagnosed with flt3 negative aml and completed treatment per the children's oncology group (cog) aaml1031 study on the low risk arm without bortezomib. cerebral spinal fluid (csf) negative at diagnosis. fish testing positive for tcf3 gene deletion of unknown significance. mrd was undetectable after induction i and remained undetectable after each cycle. nine months off therapy, recurrent headaches prompted mri imaging which revealed two posterior fossa masses. csf and bone marrow testing were negative. stereotactic biopsy of the larger mass confirmed recurrence of aml. patient underwent two cycles of tvtc with a total of seven doses of intrathecal cytarabine with almost near resolution of the cns ms. completed cranial radiation and proceeded to allogeneic stem cell transplant with unrelated cord marrow donor and is disease free at approximately day +200.case 2: 5 year-old female diagnosed with flt3 and mll negative aml and completed treatment per cog aaml1031 study on the low risk arm without bortezomib. csf negative at diagnosis. mrd was undetectable after induction i and completed therapy without complications. two months off therapy, a retrospective analysis of her diagnostic bone marrow by the cytogenetic laboratory to test a new panel identifying novel 11q partners revealed a cryptic insertional 10:11(mllt10/mll(kmt2a) translocation. at four months off therapy, acute mental status changes prompted mri imaging which revealed two intracranial ms and lumbar spine involvement. resection of the larger lesion for symptomatic relief confirmed the mllt10/mll(kmt2a) fusion. csf positive for blasts and marrow negative for relapsed disease. patient completed two cycles of tvtc with a total of seven doses of it cytarabine with near resolution of cns disease (only 3 mm contrast enhancement in the medulla). she received craniospinal radiation and is awaiting improvement in her cardiac function before proceeding to hsct. conclusion: tvtc is a successful reinduction regimen for relapsed aml with cns ms prior to hsct. background: acute severe anemia can be a life-threatening medical condition. the differential is quite broad for possible etiologies of acute severe anemia, including autoimmune hemolytic anemia (aiha) and atypical hemolytic uremic syndrome (ahus). autoimmune hemolytic anemia is an antibody-mediated process that targets the protein antigens located on the surface of red blood cells. treatment options for aiha include corticosteroids, with up to 80% of patients being responsive, with some requiring splenectomy. atypical hemolytic uremic syndrome is a medical urgency, defined as the triad of microangiopathic hemolytic anemia, thrombocytopenia, and acute kidney injury. the etiology is usually due to genetic causes, or less commonly, due to autoantibodies or idiopathic reasons. prognosis is very poor. objectives: differentiating between autoimmune hemolytic anemia and atypical hemolytic uremic syndrome can be a time-sensitive diagnostic dilemma while the patient is in critical condition, but this important delineation can vastly alter therapeutic options. design/method: here we discuss two cases highlighting the diagnostic workup involved in differentiating between atypical hemolytic uremic syndrome and autoimmune hemolytic anemia. patient a is a 3-year-old male who presented in extremis with severe anemia, uremic encephalopathy, and severe acute renal injury requiring hemodialysis and multiple blood transfusions. patient b is a 10-month-old male, who also presented in extremis with respiratory failure secondary to adenovirus/rhinovirus/enterovirus, with acute progressive renal failure and microangiopathic hemolytic anemia, requiring hemodialysis and cardiorespiratory support. : patient a underwent a full hematologic and infectious disease workup. subsequent laboratory studies confirmed enteropathogenic e.coli (epec) in the patient's stool; blood cultures remained negative. renal biopsy results were consistent pigment nephropathy. bloodwork indicated positive direct coombs. patient a was ultimately treated with steroids 2mg/kg/day, with significant improvement. patient b also included a full hematologic work-up, including adamts13 activity and ahus genetic panel, as well as full infectious disease work-up. subsequent laboratory test-ing revealed blood cultures growing streptococcus pneumoniae, with adamts13 activity at 41% (adult ref range: >/ = 70%), and normal complement levels. imaging findings also supported diagnosis of ahus. the management of a critically ill patient with acute severe anemia requires a thorough hematologic and infectious disease work-up. while molecular and genetic are helpful in definitive diagnosis of ahus, the utility of such results is limited by time. overlapping clinical presentation of a patient in extremis due to acute severe hemolytic anemia with progressive renal failure presents a rather broad differential, with time-sensitive treatment and prognostic implications. the favorable response to steroids delineates aiha from hus. background: d-2-hydroxyglutaric aciduria (d-2-hga) is a rare metabolic disorder characterized by developmental delay, hypotonia, and bi-allelic mutations in d-2hydroxyglutarate dehydrogenase (d2hgdh) or isocitrate dehydrogenase 2 (idh2). metaphyseal chondromatosis with d-2-hydroxyglutaric aciduria (mc-hga) is a type of d-2-hga that has been previously reported in seven patients (omim 614875; pmid 24049096), three of whom had somatic mosaicism for r132 variants in isocitrate dehydrogenase 1 (idh1). we describe a 3-year-old boy with mc-hga who subsequently developed acute myeloid leukemia (aml) and was found to have a r132 variant in idh1 in a leukemic bone marrow sample. we report the first case of aml with this metabolic disorder. design/method: a 1-year-old hispanic boy presented with short stature, developmental delay, abnormal skin pigmentation, and unilateral congenital cataract. workup revealed multiple skeletal enchondromatosis and elevated urine d-2-hydroxyglutaric acid levels. he was diagnosed with mc-hga. no pathogenic variants in d2hgdh, idh1 and idh2 were identified in peripheral blood. germline testing with biopsies of skin lesions was declined by the family. two years later, he presented with streptococcal sepsis and pancytopenia. blasts were noted on peripheral smear. bone marrow morphology was consistent with acute myelomonocytic leukemia (∼23% blasts). chromosome analysis showed normal 46 xy, and molecular testing by pyrosequencing idh1 and idh2 revealed a r132c variant in idh1 (25% mosaicism). the patient is being treated as per the cog study aaml1031. end of induction i bone marrow aspirate was hemodiluted, but there was no obvious residual disease by flow cytometry (0.01-0.01% sensitivity) or morphology. the previously identified idh1 variant was no longer detectable (limit of detection <10%). although targeted therapy for aml with idh1 mutation is currently in phase i clinical trials in adults, there is no safety or efficacy data for using idh1 inhibitors in children. treatment with ivosidenib is therefore not currently an option for our patient. conclusion: this is the first case of aml reported with this rare metabolic disorder. somatic r132 variants in idh1 have been identified in three other mc-hga cases. this same mutation leads to the accumulation of d-2-hydroxyglutarate in gliomas and aml. without any confirmed germline mutation or somatic mosaicism testing of multiple specimen sources, we can only speculate that the patient has an underlying somatic idh1 mutation associated with mc-hga which subsequently led to leukemogenesis. we present the first case of this association, to increase index of suspicion for development of aml in children with metabolic disorders associated with variants in idh1. background: congenital combined deficiency of the vitamin k-dependent coagulating factors (vkcfd) is a rare heterogeneous autosomal recessive bleeding disorder. vkcfd is caused by mutations in the genes of either gamma-glutamyl carboxylase (ggcx) or vitamin k epoxide reductase complex (vkorc), which are responsible for the gammacarboxylation of vitamin k dependent proteins (vkdps) allowing for their activation. the clinical presentation ranges from no bleeding to intracranial hemorrhage. to date, vkcfd has been reported in few patients worldwide. objectives: we report a case of a girl with novel homozygous mutation of the ggcx gene, highlighting her clinical and biochemical characteristics with a review of the literature. a 3-month-old girl of consanguineous emirati parents, presented to our hospital with a history of bleeding from puncture site after receiving her second-month vaccine. that was associated with episodes of mild mucosal bleeding. review of systems was negative for jaundice, steatorrhea and failure to thrive and physical exam was unremarkable. investigations revealed markedly prolonged pt and aptt with high inr. fibrinogen, hemoglobin and platelets were always normal. activities of vitamin k-dependent factors including fii, fvii, fix, fx, protein c and s were all low. a measurement of proteins induced by vitamin k absence (pivka-ii) was done and came very high. this was associated with a mild elevation in liver enzymes but normal liver function test. the picture was supporting vitamin k deficiency, and as a result, she was started on oral vitamin k supplements of 1 mg/day. she responded partially to vitamin k and required higher doses to stabilize her inr. after excluding acquired causes and due to her requirement of high doses of vitamin k, a mutation in either ggcx or vkorc genes was suspected. genetic analysis was conducted for her which revealed a novel missense homozygous mutation in the ggcx gene (c.548a>t) confirming the diagnosis of combined deficiency of vitamin k-dependent clotting factors type 1. the asymptomatic parents were both heterozygous for the same mutation. results: she is currently stable on 10 mg/day of vitamin k supplements. conclusion: vkcfd is a rare bleeding disorder with an overall good prognosis due to the availability of several effective therapeutic options. the function of the mutated gene is unknown. our patient demonstrated a partial response to vitamin k supplements suggesting presence of a residual carboxylation capacity and a possible role of this gene in the enzymesubstrate interactions. university of alabama at birmingham, birmingham, alabama, united states s55 of s301 background: gata2 is a zinc finger transcription factor that plays a critical role in the regulation of hematopoiesis and lymphatic angiogenesis. mutations leading to gata2 deficiency (gd) have been linked to a variety of clinical conditions. patients with gd have a striking predisposition to develop myelodysplastic syndrome (mds), acute myeloid leukemia (aml), or chronic myelomonocytic leukemia (cmml). acute lymphoblastic leukemia (all) has not been associated with gd, although the association of bcell all and gd has been previously reported. objectives: to describe a unique association of gata2 deficiency and t-cell all in a young child. results: an 8-year-old female presented with a one-week history of fever and malaise. she had a significant past medical history of verruca plantaris and self-resolving leukopenia associated with febrile illnesses. significant family history included sister with neutropenia and human papilloma virus (hpv) infection, and mother with neutropenia, monocytopenia, atypical mycobacterial infections, and hpv infection. peripheral blood revealed hemoglobin 9.3 g/dl, hematocrit 26.7%, platelets 176,000/ul, and white blood cell 1,740/ul (neutrophils 122/ul, lymphocytes 1601/ul, monocytes 17/ul). patient underwent a bone marrow biopsy demonstrating lymphoblast infiltration. flow cytometry analysis demonstrated monoclonal lymphoid blast population that co-expressed cd117, cd34, cd13, nuclear tdt, cd2, however, lacked expression of cd33, cd10, cd3, cd19, hla-dr, or myeloperoxidase. findings were consistent with tcell all with aberrant myeloid markers. cytogenetics analysis revealed 45,xx,dic(21;22)(p11.2;p11.2). patient began treatment as per children's oncology group aall0434 and achieved remission at the end of induction. course of therapy was complicated by episodes of fever, reciprocating junctional tachycardia, asparaginase-associated thrombosis, viral meningitis, recurrent episodes of verruca plantaris, and resistant streptococcus pneumoniae or haemophilus parainfluenza infections causing chronic cough. later, she was also found to have low igm levels; after completion of therapy, she developed monocytopenia. lymphocyte subset panel revealed absent b cells, decreased number of natural killer (nk) cells, and cd4/cd8 inversion. further work-up included gata2 sequence analysis that showed heterozygous nonsense mutation (c.58c > t/c; reference nm_001145661) likely resulting in gata2 haploinsufficiency. patient continues to be in remission, is receiving monthly immunoglobulin replacement and is on azithromycin for atypical mycobacterial prophylaxis. surveillance bone marrow biopsies have shown no evidence of mds or leukemia, however, have demonstrated persistent hypocellularity. the possibility of undergoing an allogeneic bone marrow transplant is actively being discussed given its curative potential. clinicians should be aware that t-cell all may be associated with gata2 deficiency. cincinnati children's hospital medical center, cincinnati, ohio, united states background: treatment for severe hemophilia a is centered on factor viii (fviii) replacement therapy. development of an alloantibody (inhibitor) against fviii is a significant treatment complication occurring in as many as 25-30% of patients. high titer inhibitors render treatment with factor viii ineffective, necessitating the use of bypass agents that may not achieve hemostasis with the same efficacy. considering the substantial ramifications of inhibitor development on treatment, eradication of inhibitors is of great importance to achieve adequate hemostasis in this patient population. desensitization by immune tolerance induction (iti) is the primary method of inhibitor elimination. however, not all patients respond to iti. immunomodulation may be considered as the next line of therapy, although controversy remains in regards to agent selection and use. objectives: there is incomplete data on the use of immunomodulation therapy for inhibitor eradication in severe hemophilia a. we present a case of a pediatric patient with severe hemophilia a and high titer inhibitor who failed initial iti therapy to better illustrate potential treatment options for the future. design/method: a retrospective chart review was performed on a patient with severe hemophilia a at cincinnati children's hospital medical center. results: an 8-year-old caucasian male with severe hemophilia a secondary to intron 22 inversion, was initially diagnosed following extensive bleeding after circumcision at birth. he was identified as having an inhibitor (312 bethesda units (bu)) at 12 months of age after 15 exposure days of treatment. he failed multiple attempts of iti, with recombinant and plasma-derived (pd) fviii. he was advanced to immunomodulation therapy in combination with pdfviii, however demonstrated anaphylaxis to rituximab and ofatumumab. he underwent tolerization to rituximab, and received a six month course with a partial response (nadir of 0.56 bu). 12 months following last dose of rituximab, a rising inhibitor titer (7.44 bu) was found. mycophenolate mofetil (mmf) was initiated with subsequent inhibitor stabilization and a decreasing titer (1.48 bu) over the course of the following year. mmf has been well tolerated without major side effects or infection throughout therapy. conclusion: development of an inhibitor against fviii is a considerable complication in patients with severe hemophilia a. use of immunomodulatory therapies following iti failure remains controversial. mmf has not been well studied in this patient population. we report a case of a patient who is being successfully treated with mmf with minimal side effects. further prospective studies should be considered to further define the role of mmf immunomodulation therapy. background: down syndrome (ds) children with aml (ds aml) have higher cure rates than their non-ds counterparts. outcomes for refractory/relapsed cases, however, remain dismal. somatic mutations of the gene encoding the transcription factor gata1 in ds aml patients are responsible for the observed hypersensitivity of ds aml blasts to cytosine arabinoside (ara-c). in view of excellent survival rates (approaching 90%) of ds aml patients, the ongoing children's oncology group (cog) aaml1531 study seeks to determine the feasibility of treating standard risk (minimal residual disease/mrd negative) ds aml patients using a reduced dose (7-fold decrease) ara-c backbone. although results from japanese trials with this approach are promising, north american and european data are conflicting. although chromosome 7 rearrangements in ds aml do not appear to carry the same adverse prognostic significance as in non-ds aml, monosomy 7 in ds aml patients has been associated with a moderately worse outcome. isochromosome 7q, however, is rare and has only been reported in 3 previous cases of ds aml. objectives: to report our institutional experience of very early relapse involving 2 cases of ds aml patients treated per the reduced dose ara-c arm (3.8 g/m2) of the aaml1531 study. design/method: we hereby report the disease course and cytogenetics of the above 2 ds aml patients. : patient 1 is a 20 month old caucasian female who had gata1 mutation negative aml. patient 2 is a 3-year old caucasian male whose chromosomal analysis revealed isochromosome 7q (3 copies of the long arm of chromosome 7). both patients achieved negative mrd (<0.05%) after induction i chemotherapy with thioguanine, low-dose ara-c and daunorubicin and proceeded per the reduced dose ara-c arm of aaml1531. patient 1 relapsed immediately after completion of chemotherapy. salvage chemotherapy with mitoxantrone/high dose ara-c (hidac) failed to induce a second remission and the patient subsequently died of disease. patient 2 relapsed within 4 months from end of therapy. the patient underwent salvage chemotherapy utilizing a hidac backbone and remains in disease remission. the noted very early relapse following a reduced dose ara-c regimen in our 2 above ds aml children suggests that testing for gata 1 mutation and chromosome 7 rearrangements may play a useful role in the development of future risk-stratified treatment strategies for ds aml. university of rochester, rochester, new york, united states background: in developed countries in the 21st century, severe nutritional deficiency is not an often considered differential diagnosis of unexplained childhood anemia. aside from iron deficiency anemia, vitamin deficiency severe enough to impact hematopoiesis is uncommon in the general pediatric population. here we present the unique case of a 10-monthold infant who presented with intermittent emesis, failure to thrive (ftt), developmental delay, macrocytic anemia, and neutropenia which was initially concerning for a congenital bone marrow failure syndrome. instead, she was discovered to have an underlying, potentially familial deficiency of b12. objectives: 1. to describe the unique case of an infant with b12 deficiency. 2. to outline the importance of including b12 deficiency in the differential diagnosis of unexplained megaloblastic anemia in children. a 10-month-old exclusively breastfed infant presented for gastroenterology evaluation due to persistent emesis and poor weight gain over the course of 2 months. her history was notable for delayed developmental s57 of s301 milestones and hypoactivity. marked pallor prompted hematologic evaluation, which revealed concern for macrocytic anemia (hemoglobin 7.1 g/dl, mcv 107), reticulocytopenia (48.1 × 10^3/ l), and neutropenia (anc 0.4 × 10^9/l). an otherwise reassuring physical examination and laboratory evaluation was notable only for the discovery of an undetectable b12 level and marked hyperhomocysteinemia (162 mol/l). her hemoglobin (hgb) continued to decline (to 5.9 g/dl) over the first few days after presentation, and she required red blood cell (rbc) transfusion. within only a few days of initiation, daily cyanocobalamin injections resulted in a robust reticulocytosis response, improved hgb, immediate normalization in the neutrophil count, and resolution of hyperhomocysteinemia. additional history and laboratory evaluation from the patient's mother revealed a concurrent, asymptomatic maternal b12 deficiency as well as a history of a need for b12 supplementation in the maternal grandfather, raising concern for an inherited etiology. despite the rarity of vitamin-deficient hematologic abnormalities in the general pediatric population, b12 deficiency should be considered as a potential cause of an otherwise unexplained megaloblastic anemia, especially in the setting of concurrent ftt and neurodevelopmental delay. a detailed family history should be obtained in such cases and may have helped to prevent this patient's clinical sequelae had the deficiency been discovered sooner. our patient has experienced a favorable clinical response to b12 supplementation, attesting to the importance of vitamin b12 in early childhood growth and development. background: peg-asparaginase is universally utilized in the treatment of pediatric acute lymphoblastic leukemia (all). despite its high efficacy in this disease, it is associated with hypersensitivity and allergy in 10 -20% of patients. protracted anaphylaxis has been described in circumstances such as severe food allergy with ongoing allergen exposure; however, it has not yet been described in relation to peg-asparaginase. we describe the first reported case of protracted anaphylaxis after peg-asparaginase administration, provide guidance as to time course and management of protracted anaphylaxis, as well as evidence that erwinia asparaginase may be safely administered even in this high risk population. objectives: to provide guidance regarding the duration, course and management of protracted, severe anaphylaxis after peg-asparaginase therapy. a 15 year old male with very high risk all presented for consolidation therapy with peg-asparaginase (intramuscular) and vincristine. one hour after administration, he developed generalized hives and angioedema, for which he was given diphenhydramine. he then quickly developed progressive hives, angioedema, subjective throat and chest tightness, and wheezing. he was treated with diphenhydramine, epinephrine, albuterol, and methylprednisolone with resolution of symptoms. one hour later, symptoms recurred and the patient became hypotensive; he was retreated with methylprednisolone and epinephrine, and was transferred to the pediatric intensive care unit (picu). in the picu, he was placed on an epinephrine drip, and continued on methylprednisolone, diphenhydramine, cetirizine, albuterol, and ranitidine. the epinephrine drip was successfully discontinued after 48 hours, and his other medications were gradually weaned over the course of two weeks. of note, the patient did have st segment changes in his electrocardiogram during the first 48 hours of anaphylaxis. these were associated with normal ventricular function as per echocardiogram, and resolved within one week. this patient has subsequently tolerated multiple doses of erwinia asparaginase (intramuscular) without premedication. this patient was acutely managed in the pediatric intensive care unit with steroids, anti-histamines, and continuous infusion epinephrine. symptoms consistent with severe anaphylaxis including hives, angioedema, throat and chest tightness, wheezing, and hypotension persisted for a total of four days before finally resolving. he has thus far tolerated multiple doses of erwinia asparaginase without any symptoms of allergy, hypersensitivity, or anaphylaxis. protracted severe anaphylaxis after peg-asparaginase therapy can be successfully managed with multi-agent therapy, including antihistamines, steroids, and continuous infusion epinephrine. re-challenge with an alternate form of asparaginase may be tolerated, even in a patient with protracted anaphylaxis to peg-asparaginase. ucsf benioff children's hospital oakland, oakland, california, united states background: vincristine (vcr) is widely used in pediatric cancers. unlike most cytotoxic agents, hematopoietic toxicity is uncommon. vcr-induced anemia has been observed but its mechanism has not been well studied. vinca alkaloid-induced membrane changes were seen in early studies of hereditary spherocytosis (hs) and anecdotal cases suggest vcr may increase hemolysis in such patients. here we describe a case involving severe vcr-induced anemia in a patient with hs and an explanation as to the mechanism. objectives: to describe the mechanism of vcr-induced anemia in hs. design/method: case report. a 6 year-old female with hs was diagnosed with t-lymphoblastic lymphoma. she had required 2 packed red blood cell (prbc) transfusions as a neonate and thereafter had done well without episodes of acute hemolysis or aplasia. complete blood counts (cbc's) demonstrated a compensated hemolysis, and she did not require further transfusions until she commenced chemotherapy. by the start of maintenance she had received many more prbc transfusions than the average patient. intermittent drops in hemoglobin (hb) did not correlate with any particular agent, and she had stable, mild splenomegaly. a clear pattern emerged during maintenance. her hb was 8-9 g/dl at monthly clinic visits, when she received vcr, intermittent intrathecal methotrexate, and corticosteroids. within 3-4 days, her hb dropped to 5.8±0.6 g/dl, and reticulocyte count decreased from 13.4 to 4.3±0.7%. transfusion at day 4 corrected hb, and the reticulocytes and hb returned to baseline. white blood cell and platelet counts did not change after vcr. blood samples from pre, immediately post, and 4 days post vcr were analyzed and rbc characteristics and markers of hemolysis were not significantly different. ektacytometry showed identical curves, indicating no change in rbc deformability. in vitro incubation of patient blood samples with vcr also did not affect the osmotic deformability, confirming that a change in rbc rigidity was unlikely the reason for the drop in hb. these data indicate that a dysregulation of erythropoiesis was responsible for the anemia after vcr, rather than damage of peripheral rbc's. in most patients, maintenance therapy for lymphoblastic lymphoma does not cause severe anemia, likely because a temporary reduction in erythropoiesis in patients with a normal rbc survival and low reticulocyte count is not noticed. however, in a patient with decreased rbc survival and a brisk reticulocytosis, a disruption in rbc generation is more apparent. in conclusion, vcr administration to patients with an rbc disorder warrants close observation for potentially severe vcr-induced anemia. background: the addition of tyrosine kinase inhibitors (tki) to conventional chemotherapy has improved outcomes for pediatric patients with philadelphia chromosome-positive (ph+) acute lymphoblastic leukemia (all), however there remains an increased risk of relapse compared to other types of childhood all. typically, in relapsed disease the philadelphia chromosome persists and several mechanisms of resistance involving acquired mutations of the bcr-abl1 chimeric oncoprotein have been reported. objectives: describe a unique case of a pediatric patient with ph+ b-precursor all relapsing with b-precursor all without the philadelphia chromosome. results: an 8-year-old boy was diagnosed with ph+ bprecursor all with the presence of the t(9;22)/bcr-abl1 translocation by cytogenetics and fluorescence in situ hybridization (fish), respectively. additional abnormalities included gains of runx1 and loss of one copy of etv6. a remission bone marrow with negative minimal residual disease (mrd) was achieved at the end of induction with dasatinib and the esphall chemotherapy backbone. duration of tki therapy was two years post diagnosis. nearly one year after the completion of therapy, cytopenias prompted a bone marrow investigation. relapsed b-precursor all was established by immunophenotyping, however fish analysis did not identify the bcr-abl1 rearrangement. moreover, quantitative reverse transcriptase pcr was negative for the bcr-abl1 fusion transcript. again fish analysis of the bone marrow revealed multiple additional copies of runx1 and mono-allelic loss of etv6, similar to the initial diagnostic sample. the patient was re-induced per aall0232 anticipating a ph+ all relapse. however, with confirmation of the loss of the ph+ clone, tki therapy was not re-initiated. due to positive mrd of 3.5% at the end of re-induction therapy, the patient was salvaged with blinatumomab therapy and subsequently underwent an allogenic stem cell transplant with a sibling donor. conclusion: this is the first known report of a pediatric patient with ph+ b-precursor all who developed recurrent b-precursor all without the philadelphia chromosome. the persistent findings of gain of runx1 and loss of etv6 makes it unlikely that a second unrelated b-precursor all developed following successful treatment of the original disease. this case highlights the possibility of a genetically distinct subclone present at the onset of disease that shared abnormalities of runx1 and etv6 but did not contain the philadelphia chromosome. nevertheless, the subclone harbored leukemogenic potential in the absence bcr-abl1 expression. it is plausible that the predominant clone present at diagnosis was effectively treated with dasatinib and extinguished, but the bcr-abl1-negative clone persisted in the face of tki therapy. background: ligneous conjunctivitis is a rare form of pseudomembranous conjunctivitis that develops specifically in patients with type 1 plasminogen deficiency. lack of plasmin activity in those patients result in defective fibrinolysis and formation of fibrin-rich membranous material/ masses that develops on the palpebral conjunctiva as well as other sites in the body.current management involve surgical excision of the masses that is usually complicated by multiple recurrences. recently, use of topical plasminogen concentrates helped delaying recurrence, but currently, those concentrates are not commercially available. we report on a 7-year-old omani girl, with hypoplasminogenemia who required optimization of plasminogen level at the time of surgery to delay/ prevent recurrence. objectives: case report on the peri-operative use of ffp versus cryopricipitate transfusion as an alternative replacement of plasminogen during surgical excision of ligneous conjunctivitis. design/method: pharmacokinetic study was performed to assess plasminogen recovery after ffp (15 ml/kg) and precipitate (1 bag/5kg) transfusion results: plasminogen levels remained subnormal after either ffp or cryoprecipitate administration. with ffp, the maximum concentration reached was almost 50% of normal. although half-life of plasminogen is known to be 2-2.5 days, the patient seemed to have a high catabolic rate after receiv-ing cryoprecipitate, with plasminogen levels reaching basal levels within 4 hours. because of the better recovery profile with ffp, we opted to give ffp before and after surgery. peri-operative management included ffp transfusion at 20 ml/kg/12 hours one day before and for 3 days post operatively, followed by 10 ml/kg once daily from day 4-6, then 20 ml/kg on 7th post-operative day. topical treatment was initiated using antibiotic and steroids ed on the day of surgery, followed by heparin ed on the second day. on follow up, she used topical heparin, cyclosporine, prednisolone, and topical lubricant eye drops for variable duration. clinical picture remained stable for almost 1 year post operatively, when she started to develop recurrence of ligneous lesions again. background: ponatinib (inclusig®, ariad pharmaceutical) is a 3rd generation multi-targeted tyrosine kinase inhibitor (tki) approved for treatment of adults with chronic myeloid leukemia (cml) and philadelphia chromosomepositive acute lymphoblastic leukemia (ph+ all) resistant to or intolerant of other tkis. ponatinib has numerous drug-drug interactions and a black box warning for associated serious adverse vascular events and hepatotoxicity. for this reason, ponatinib use has been confined to specific high-risk populations. however, in patients who prove refractory to other therapies, the potential benefits of ponatinib may outweigh risks. to date, ponatinib has not been studied in the pediatric/adolescent and young adult (aya) population. furthermore, literature describing the use of ponatinib alone or in combination with other agents in pediatric oncology patients is scarce. objectives: to describe a single institutional experience using ponatinib in the pediatric patients with ph+ all. design/method: two cases of ponatinib use in pediatric ph+ patients resistant to other tkis were identified at our institution and are described. peripheral blood samples obtained from both patients identified bcr-abl1 p190 fusion transcripts and sanger sequencing was used to identify resistant mutations. results: our first case is a 15-year-old female who received upfront multi-agent chemotherapy plus dasatinib for ph+ all. relapse was confirmed on end-of-therapy bone marrow evaluation, thus bcr-abl mutation testing was performed and revealed a t315i mutation. ponatinib was initiated then discontinued after one week due to clinically significant fluid retention with peripheral edema and bilateral pleural/pericardial effusions. the second case is a lateadolescent female with ph+ all who relapsed 4-years after stem cell transplant (sct). following relapse, tki therapy included both imatinib and dasatinib. due to persistence of bcr-abl fusion transcript despite tki therapy she was switched to ponatinib. shortly following initiation of ponatinib she developed a diffuse, maculopapular rash, which persisted despite dose reduction, resulting in ultimate discontinuation of the drug. bcr-abl mutation testing identified f317l and f357v resistance-conferring mutations. to date, there is scant existing literature detailing the use of ponatinib in pediatric patients. appropriate dosing is undefined and side effect profile not well described, particularly when used concurrently with other chemotherapeutic agents. thus, this case series reporting the response to and toxicity of ponatinib in pediatric ph+ all patients has important clinical implications. additionally, this is the first report of a pediatric ph+ all patient with documented t315i mutation underscoring the importance of bcr-abl mutational testing, particularly at the time of relapse. cooper university hospital, camden, new jersey, united states background: myh9-related disorder is a rare autosomal dominant disease, encompassing several subtypes: may hegglin anomaly, epstein syndrome, fechtner's syndrome, and sebastian syndrome. heterozygous mutations are seen in the gene encoding non-muscle myosin heavy chain iia (nmmhc-iia) which is involved in cell motility as well as functions to maintain cellular shape and integrity. the presentation of myh9-rd is mainly characterized by macrothrombocytopenia, but various related expressions exist: nephritis often leading to renal failure, cataracts and sensorineural deafness (1). a 4-year-old girl with history of extensive dental caries, hyperactivity, and speech delay due to suspected hearing loss was incidentally found to have thrombocytopenia at the time of genetic evaluation. she did not have any bruising or excessive bleeding. she did not respond to observation, immunoglobulins, or steroid therapy. her platelet count remained persistently low (4-23 k/ul). she underwent extensive evaluation to rule out platelet disorder vs. coagulation defect. her peripheral smear showed enlarged platelets by giemsa stain but no inclusion bodies were noted in granulocytes. her platelet aggregation and platelet surface glycoprotein by flow cytometry were negative. her coagulation profile was also normal. objectives: this case report summarizes the complexity in diagnosing myh9-rd in a pediatric patient. design/method: since a unifying diagnosis for her clinical presentation was not apparent, whole exome sequencing (wes) was undertaken. results: wes revealed the r702c heterozygous pathogenic variant, located in exon 17 in the myh9 gene. myh9 gene alteration explained the patient's clinical features of macrothrombocytopenia and hearing loss. this mutation was paternally inherited, and her father demonstrates mosaicism. he was asymptomatic with normal platelet count but his morphology showed enlarged platelets with no inclusion bodies in granulocytes. when dealing with patients who have mild or no symptoms of bleeding diathesis but evidence of persistent macrothrombocytopenia, considering a platelet disorder belonging to myh9-rd can help delineate certain predisposing syndromes and guide clinical management. patients are likely to benefit from early genetic testing while receiving supportive therapy. wes can highlight syndromes and provide information on recurrence risk for families. the renal and hearing abnormalities are indistinguishable between epstein and fechtner's syndromes, but the pathogenic variants differ (2). the genotype-phenotype correlation implies that our patient may have either syndrome, although clinical features compatible with nephritis have yet to manifest. patients should be monitored closely for long-term progression of myh9 disease, and treatments should be initiated accordingly. we present an 11-year old female evaluated by genetics at birth due to prenatal microcephaly. chromosomes and microarray were normal. at age 3 she developed standard risk pre-b-cell acute lymphoblastic leukemia (all). she completed treatment in 2012 and has been doing well in the interim, remaining in complete clinical remission. during and after treatment she exhibited developmental delay and neurocognitive deficits. at age 11 her height and weight were at or below the 5th centile and head circumference was below the 2nd centile (approximately 6 standard deviations below the mean and corresponding to the 50th centile for a 9-month-old girl). bone age was appropriate. she had a distinctive triangular face with micrognathia and a pointed nose resembling a seckel-like syndrome. the patient also had clinodactyly of the 4th toes, zygodactylous triradius involving the 2nd and 3rd left toes, tendency to sydney line in the right palm and a radial loop in the left middle finger. the patient's unique clinical presentation prompted a more thorough genetic evaluation, which led to a novel finding we feel is clinically significant with regard to the development of malignancy. design/method: whole exome sequencing (wes) was performed on the patient as well as her biological parents (trio). a de novo heterozygous mutation in the gene pcdh17 with potential relation to the phenotype was discovered. this c.716dupa variant causes a frameshift starting with codon asparagine239, changing this amino acid to a lysine residue and creating a premature stop codon at position 34 of the new reading frame denoted p.asn239lysfsx34. this variant is predicted to cause loss of normal protein function via protein truncation or nonsense-mediated mrna decay. conclusion: pcdh17 is a member of the protocadherins family which is important in cell-to-cell adhesion and synaptic function in the central nervous system and is highly expressed in areas of the brain involved in higher cortical function and speech. aberrant expression of protocadherins has been associated with the development of malignancies in many organ systems. with regards to leukemia, the methylation status of this gene at diagnosis has been implicated in the prognosis of all and could be used as a biomarker to predict relapse. this patient's de novo mutation and clinical presentation are unique to what has been previously presented in the literature. we feel that this mutation is a clinically significant finding that may shed light on the role of this gene in the development of hematopoeitic malignancies. background: acquired hemophilia a (aha) is an uncommon and potentially life-threatening hemorrhagic disease characterized by sudden onset of bleeding in patients with neither personal nor family history of bleeding dyscrasia. it is usually seen in adults with autoimmune diseases, solid tumors, lymphoproliferative diseases, pregnancy or during the postpartum period; occurrence in the pediatric population has rarely been reported. we report a case of an otherwise healthy teenager who was found to have aha when he presented with acute onset of atraumatic soft tissue hematoma. results: a 13-year old male of middle eastern descent with history of congenital absence of the right external ear, but otherwise in good general health, presented to our emergency department with a three day history of progressive worsening of right lower leg pain, swelling, and paresthesia, without preceding history of trauma. evaluation by the pediatric orthopedics service documented significantly elevated compartment pressures, necessitating immediate four-compartment fasciotomy. pre-operative labs were significant for prolonged activated partial thromboplastin time (aptt) of 67.7 (23.4-38.9) seconds with normal prothrombin time (pt) and international normalized ratio (inr). ptt did not correct on mixing studies, suggesting the presence of a circulating anticoagulant. factors xii and xi were in the normal range; factor ix was elevated, 247 (60-150). factor viii level was 4% and fviii inhibitor level was 5.3 bethesda units (<0.8), confirming the diagnosis of aha. work up for autoimmune disease was negative. his bleeding and surgical hemostasis were managed with recombinant factor vii (novoseven) 90 mcg/kg every 3 hours for 24 hours post operatively, with gradual interval prolongation. factor viii antibody eradication was managed with prednisone 1 mg/kg/day. factor viii and inhibitor levels normalized by day 5 of hospitalization. recombinant factor vii was discontinued; steroids were gradually tapered and discontinued at discharge (hospital day 15). conclusion: acquired hemophilia is likely an underdiagnosed condition in pediatrics. while it is typically seen in adults with underlying autoimmune disease, solid tumors, lymphoproliferative disease, or during pregnancy or the postpartum period, pediatric cases may have no identifiable etiology. this case highlights the importance of considering this diagnosis in any patient with unexplained bleeding regardless of their age, so as to intervene early and prevent adverse consequences. university of oklahoma, oklahoma city, oklahoma, united states background: myeloid neoplasms associated with eosinophilia is a rare subtype of chronic leukemia characterized by clonal eosinophilia. the true incidence is unknown due to its rarity and possible classification as idiopathic hypereosinophilia syndrome. the most common chromosomal aberrations involve platelet-derived growth factor receptors (pdgfrs). we report one such rare case in a pediatric patient. most of the pediatric management of this entity is derived from adult case reports and case series. objectives: to describe a case of chronic leukemia presenting as eosinophilia results: a previously healthy 15 year old caucasian male presented with a several week history of migrating joint pain, splenomegaly, and abnormal blood counts with leukocytosis, thrombocytopenia and absolute eosinophilia. white blood cell differential showed myeloid precursors suggestive of chronic myeloid leukemia. bone marrow evaluation showed 10% blasts and 18% eosinophils. bcr-abl testing was negative, ruling out cml. fish analysis for eosinophilic clonality revealed deletion of chic2 gene, resulting in fip1l1/pdgfra fusion gene, diagnostic for myeloid neoplasm with eosinophilia associated with pdgfr abnormalities. treatment was started with tyrosine kinase inhibitor (tki), imatinib 100mg daily. within 3 months, fish analysis for fusion gene was negative. after approximately 18 months of daily imatinib, he was switched to maintenance dose of 200mg weekly. he is approximately 36 months since diagnosis and doing well on maintenance imatinib. in 2008, the who revised its classification of some chronic eosinophilic leukemias to myeloid and lymphoid neoplasms associated with eosinophilia and rearrangement of pdgfra, pdgfrb, fgfr1. the most common abnormality is the fip1l1/pdgfra fusion gene. other less common abnormalities include fusion genes kif5b-pdgfra and etv6-pdgfrb and point mutations in pdgfra22. some features of chronic eosinophilic leukemia include absolute eosinophilia, splenomegaly, elevated vitamin b12 and tryptase levels, and organ damage from eosinophil infiltrates and cytokine release. patients with rearrangements or mutations involving pdgfra are usually very responsive to imatinib. starting doses have not been well studied or established. experts recommend co-administration of corticosteroids during the first few days of imatinib therapy in patients with a history of cardiac involvement and/or elevated serum troponin levels to prevent myocardial necrosis, a rare complication of imatinib therapy in eosinophilic patients. fortunately our patient did not have cardiac involvement and to date has not exhibited signs of chronic tki toxicity. conclusion: myeloid neoplasms with eosinophilia constitute a rare form of chronic leukemias. they are often associated with pdgfr abnormalities and are usually very responsive to tyrosine kinase inhibitor therapy. walter reed national military medical center, bethesda, maryland, united states background: germline samd9l mutation is a rare cause of constitutional bone marrow failure with a unique propensity for clonal evolution to monosomy 7 and mds. objectives: previous case series have demonstrated diverse clinical outcomes in patients with a germline samd9l mutation. our case presents a novel samd9l mutation (p.val1551leu). additionally, the case highlights the challenges in clinical decision making for a patient with a gene mutation that is known for clonal evolution towards monosomy 7 with risk of progression to myeloid malignancy, but also known for self-correction through uniparental disomy or inactivating mutations which results in disease remission. design/method: a retrospective chart review and review of the literature was performed. dna was isolated from peripheral blood and used for whole exome sequencing. a peripheral blood sample from the patient's mother and father showed no samd9l mutation. skin biopsies of the patient and parents were evaluated for uniparental disomy or new mutations. to determine the pathogenicity of this novel mutation, the specific samd9l mutant dna was transfected into the 293human embryonic kidney cell line to assess its role in inhibiting cell proliferation. our patient presented at 8 months of age with pancytopenia and hypocellular bone marrow in the setting of s63 of s301 sepsis. he had evidence of dysfunctional immune activation with hemophagocytosis and elevated soluble il2 with simultaneous severe hypogammaglobulinemia. analysis of the peripheral blood showed no increase in chromosomal breakage, normal telomere length, and normal flow cytometry. gene testing for primary hemophagocytic lymphohistiocytosis and inherited bone marrow failure were negative. after the patient recovered from his presenting illness, a repeat bone marrow biopsy demonstrated improved cellularity with myelodysplasia and cytogenetics significant for monsomy 7.whole exome testing demonstrated a novel samd9l mutation. the patient continued to require intermittent ivig and failed to demonstrate appropriate leukocytosis with intermittent infections. on repeat bone marrow evaluation over the course of 9 months, the patient demonstrated no evidence of evolution towards self-correction and had a persistent monosomy 7 clone. the patient is scheduled to undergo a matched unrelated donor bone marrow transplant. our case highlights the unique clinical picture associated with constitutional marrow failure and clonal evolution secondary to a novel samd9l mutation which is thought to cause pancytopenia by inhibiting cellular proliferation and often results in the development of monosomy 7 which rescues hematopoiesis but with a risk for malignancy. background: notable labs developed a flow cytometricbased assay with a custom robotic platform to test fdaapproved drugs for anti-cancer activity against individual patient's tumor cells. this personalized assay is a potential method for identifying novel agents and drug combinations to treat aml patients who have failed standard therapies. objectives: to present the case of a teen who underwent successful treatment of relapsed aml post-sct with bortezomib, panobinostat, and dexamethasone-a regimen selected based upon results of notable lab testing. results: a 15-year-old male with m4-aml had an isolated bone marrow relapse 8 months after completion of scheduled therapy. at relapse, his aml was flt3-itd positive. he achieved a second remission with negative mrd and underwent matched sibling donor bmt after busulfan/cyclophosphamide conditioning. bma performed on day +180 was mrd positive (0.13%). repeat bma done on day +204 showed 5.7% mrd. he started sorafenib on day +212. he received donor lymphocyte infusion (dli) on day +246, then received 2 cycles of azacitadine (aza) followed by dli. marrow mrd by flow after sorafenib alone, sorafenib with dli, and sorafenib with aza/dli were 16%, 15.7%, and 0.16%, respectively. treatment was complicated by varicella meningitis, grade i skin agvhd, febrile neutropenia and c. difficile colitis, and metapneumovirus pneumonia. despite extremely low levels of leukemia (marrow mrd 0.16%), notable lab testing performed on the patient's leukemia cells from marrow collected after aza/dli/sorafenib revealed sensitivity of his leukemic blasts to a combination of bortezomib, panobinostat, and dexamethasone. because of prolonged cytopenias, multiple infectious complications, and persistently positive mrd, he discontinued aza/dli/sorafenib and on day +368 started bortezomib 1.3 mg/m2 iv on days 1, 4, 8, and 9; panobinostat 20 mg po on days 1, 3, 5, 8, 10, 12; and dexamethasone 20 mg po on days 1, 2, 4, 5, 8, 9, 11, and 12 . chemotherapy cycle 2 started 21 days later. he tolerated treatment without side effects and with resolution of rash and cytopenias. he achieved full donor chimerism, negative flt3-itd, and complete remission by morphology and flow after two cycles. notable lab testing is a powerful tool for evaluating the sensitivity of small populations of leukemic blasts to novel drug therapy. results from notable lab testing may serve as a useful guide for treatment selection after failure of standard aml therapy. this patient achieved morphologic and mrd remission post-sct with bortezomib, panobinostat, and dexamethasone-a regimen predicted to be efficacious based upon notable lab results. maria ahmad-nabi, christine knoll, sanjay shah, esteban gomez, lori wagner phoenix children's hospital, phoenix, arizona, united states background: development of inhibitors in patients with factor ix deficiency (fixd) is a well-recognized complication occurring in 1-3% of patients. within this subset a small percentage can develop anaphylaxis to factor. desensitization with cyclophosphamide, an alkylating agent used in the management of various oncologic malignancies, and reported for use in factor viii desensitization has been previously unreported for use in desensitization in patients with fixd. rituximab, an anti-cd 20 antibody, however has been used. objectives: to induce immune tolerance (it) in patients with inhibitors to factor ix with either novel or under reported methods using cyclophosphamide and/or rituximab. we report a case series of 2 patients at phoenix children's hospital with fixd who achieved it with cyclophosphamide and/or rituximab. results: patient one was a 14 year old male with severe fixd, who at the time of desensitization had inhibitor levels of 12 bu. he was desensitized with cyclophosphamide, then admitted for infusion of recombinant factor ix. he experienced a few minor symptoms of intolerance including an urticarial rash which was self-limited, and hemarthrosis of the right elbow on day 1 which responded to novo 7. he tolerated the remainder of his infusion without issues. he continued recombinant factor ix daily, and returned to clinic for monthly cyclophosphamide for 6 months. he did develop urticaria with hemarthrosis and spontaneous muscle bleeds which were tempered with zantac, zyrtec, solumedrol, and benadryl. he remained without a recurrence of inhibitors, however did have intermittent hemarthrosis of his ankles thereafter requiring prophylactic twice daily dosing recombinant factor ix. patient two was a 10 year old male with severe fixd and a family history of anaphylaxis to factor causing early death in all male relatives with the disease. he had never received factor ix and did not have a detectable inhibitor prior to desensitization. he successfully underwent desensitization to recombinant factor ix with rituximab in the icu, and returned to clinic for weekly infusions x 4. he experienced no adverse reactions concerning for anaphylaxis. he continued to tolerate factor ix products without evidence of intolerance, development of inhibitors, and continues on as prophylactic dosing of recombinant factor ix every other day. our experience at a single institution proves cyclophosphamide as a novel agent for inducing it in those with fixd and anaphylaxis. it also provides further evidence that rituximab can desensitize patients with severe fixd. differences include longer duration for cyclophosphamide therapy (6 months vs 1 month). background: cartilage-hair hypoplasia (chh) is an autosomal recessive chondrodysplasia associated with defective cell-mediated immunity caused by mutations in the ribonuclease mitochondrial rna processing (rmrp) gene. cancer incidence is 7-fold higher in patients with chh than in the general population, especially non-hodgkin lymphoma. the use of rituximab, an anti cd20 antibody, results in decreased host b-cell number and impaired humoral function for 6-9 months. the safety of rituximab in pediatric patients with cancer and immunodeficiency is not well documented. a diagnosis of underlying immunodeficiency may discourage physicians from using rituximab due to the risk of severe bacterial infection or viral re-activation. objectives: to report a case of burkitt lymphoma in a young adult female with chh and defective cellular immunity successfully treated with rituximab. results: an 18-year old amish female with disproportionate short stature presented to our center for management of stage iv biopsy proven burkitt lymphoma with myc rearrangement. she had presented a week earlier with cervical, occipital, and submandibular lymphadenopathy, splenomegaly; fevers, night sweats, and weight loss for 2-4 weeks. on exam, her height was three feet associated with brachydactyly, mild bowing of the legs, normal size head without frontal bossing, fine and sparse hair. she had normal intelligence. her pattern of dysmorphisms was suggestive of chh (genetic testing not performed at time of diagnosis). pet-ct scan showed stage iv disease with involvement of cervical lymph nodes, spleen, iliac bone and bone marrow. treatment with standardintensity fab/lmb therapy (group c) with the addition of rituximab was initiated. she had an incomplete response to cop (∼80% reduction of tumoral masses) but achieved complete remission after copadam1. her course was complicated with severe varicella zoster but she completed therapy and remains in complete disease remission for 24 months after treatment completion. genetic testing subsequently performed proved homozygosity for chh with a n.71a>g variant. she had no other opportunistic infections during or after therapy. conclusion: the use of rituximab was both safe and beneficial in our patient despite defective cell mediated immunity secondary to chh suggesting that rituximab may be safe to use in patients with cellular immune deficiencies. background: hemophilia a and b are bleeding disorders characterized by deficiency in factor viii or ix, respectively. spontaneous or provoked hemarthrosis is a known complication of hemophilia. repetitive episodes of hemarthrosis can lead to debilitating hemophilic arthropathy. lyme disease is a tick-born infection which is endemic to increasing parts of the united states. chronic lyme disease, the phase in which lyme arthritis typically develops, occurs months to years after initial infection and is characterized by swelling of one or more large joints generally in the absence of systemic symptoms. objectives: review cases of hemophilia a and b patients with episodes of provoked hemarthrosis refractory to intensive recombinant factor replacement therapy found to have concurrent lyme arthritis. design/method: we report two clinical cases and review relevant literature. results: first, we report a 12 year-old male with moderate hemophilia a with a provoked knee hemarthrosis which failed to improve despite 3 months of intense factor replacement therapy requiring multiple hospitalizations. factor replacement regimens included twice daily standard half-life recombinant factor viii products or daily to every other day extended half-life recombinant factor viii products with trough levels aimed as high as 50-80%. factor viii pk studies were obtained for dosing, to confirm adherence, and to evaluate for subclinical inhibitors (inhibitor testing was negative). given protracted symptoms additional workup for hemarthrosis was pursed. lyme titers were positive for (8)igg, though negative for igm. he was treated with 28 days of doxycycline during which time hemarthrosis greatly improved on examination and imaging, and he was able to recover function through physical therapy. second, we report a 6 year-old male with moderate hemophilia b who required multiple hospital admissions for a provoked knee hemarthro-sis with no improvement in symptoms despite weeks of daily or twice daily factor replacement with standard halflife recombinant factor ix products aiming for 100% correction. we performed inhibitor testing (which was negative) and pk studies to assess for non-detectable inhibitors, dosing and adherence. lyme testing was positive for (6)igg, though negative for igm. he was treated with amoxicillin for 28 days during which time hemarthrosis significantly improved on examination and imaging. diagnosis and follow-up imaging studies for both patients included mri and serial bedside ultrasounds performed as per uc san diego school of medicine mskus guidelines. background: relapse/refractory aml following allogeneic hematopoietic stem cell transplant (hsct) holds a high mortality rate. current relapse/refractory therapy modalities for younger patients may include re-induction with a clofarabinebased regimen followed by second allogeneic hsct. even for patients who undergo second hsct, the five-year survival rate is dismal. new therapies, including small molecule inhibitors, are being studied in the post-hsct relapse setting or those unfit for hsct with promising results. venetoclax is a small molecule inhibitor that has received breakthrough designation for aml treatment in elderly patients objectives: to report a young adult aml patient with relapse post hsct who was successfully re-induced with topotecan, vinorelbine, thiotepa, clofarabine (tvtc) and has sustained remission with venetoclax maintenance therapy. this approach appears to be unique in terms of reported literature. results: our patient is now a 23-year-old female noted to have mll rearranged aml at initial diagnosis when she was 21 years old. she underwent chemotherapy consisting of cytarabine/daunorubicin according to standard 7+3. due to persistent disease, she was re-induced with g-csf, clofarabine, and high-dose cytarabine (gclac) which put her in cr. her course was complicated by sepsis, colitis, gastrointestinal bleed, deep venous thrombosis, and transfusionassociated circulatory overload. given her co-morbidities, she received another cycle of clofarabine/cytarabine, and then proceeded to reduced intensity allogeneic hsct, according to bmt ctn 1101. the patient tolerated hsct well and experienced no transplant-related complications, including no acute or chronic gvhd. unfortunately, she relapsed about 10 month's post-hsct. initial salvage therapy consisted of another course of g-clac, but due to persistent disease the decision was made to re-induce her with topotecan, vinorelbine, thiotepa, and clofarabine (tvtc). during this time however, she was found to have extensive infection with a fusarium species requiring a course of anti-fungal therapy. bone marrow evaluation showed no residual disease with an mrd of <0.1%. once the absolute neutrophil count recovered, the patient was started on single-agent venetoclax for maintenance therapy, which has been well-tolerated. she remains in morphologic remission for over 8 months. we describe herein a young adult with multiply relapsed aml wherein tvtc re-induction, followed by maintenance with venetoclax were safely used in the post-hsct setting. venetoclax therapy in the relapsed aml setting warrants further study. background: vitamin b12 deficiency is uncommon in children in developed countries, especially in the absence of risk factors like malabsorption or inadequate dietary intake. it often presents with non-specific symptoms and signs and can elude diagnosis. the recognition and treatment of vitamin b12 deficiency is critical as it can lead to bone marrow failure as well as severe neurological and developmental problems in children. to increase index of suspicion of vitamin b12 deficiency anemia in children. we report a rare case of vita-min b12 deficiency anemia in a child who presented with a severe macrocytic anemia, with signs of hemolysis and concern of malignancy. design/method: an almost three-year-old previously healthy girl presented with a few day history of fever, emesis, fatigue and pallor. she had no dysmorphic features, hepatosplenomegaly or lymphadenopathy on exam, growth and development were normal. laboratory findings showed severe macrocytic anemia (hemoglobin 4.4 grams/dl; mcv 104.1 fl) with reticulocytopenia. signs of intravascular hemolysis were present with elevated lactate dehydrogenase (3,842 units/l) and haptoglobin below assay limit. immune-mediated hemolysis was ruled out. initial picture of a hemolytic anemia was compounded by other findings of moderate neutropenia, mild thrombocytopenia and peripheral smear showing occasional blasts. further workup was done with a broad differential diagnosis that included leukemias, hemolytic anemias, bone marrow failure syndromes, and specific deficiencies. results: workup revealed abnormally low vitamin b12 levels along with significantly elevated homocysteine and methylmalonic acid levels indicating functional vitamin b12 deficiency. bone marrow evaluation showed megaloblastic anemia and dyserythropoiesis consistent with vitamin b12 deficiency, and ruled out leukemia. vitamin b12 deficiency can cause a hemolytic anemia like picture secondary to intramedullary hemolysis due to ineffective erythropoiesis. myeloid precursors are also affected which can lead to neutropenia, thrombocytopenia, and abnormal peripheral blood cells. in our patient, initial symptomatic anemia was treated with blood transfusion, followed by intramuscular vitamin b12 injections with normalizing lab values. so far, workup for an etiology for vitamin b12 deficiency is negative except for an equivocal range of anti-parietal cell antibodies raising concerns for pernicious anemia; however it is rare in this age group. another rare condition is an inborn error of the cobalamin transporter. she is currently on oral vitamin b12 supplementation and further workup will be planned based on response. conclusion: this case highlights the importance of early consideration and thorough evaluation of vitamin b12 deficiency in children with unclear etiology of anemia, so that prompt treatment can be initiated. memorial hospital/ university of miami, miami, florida, united states background: despite great success in the treatment of acute lymphoblastic leukemia (all), the outcomes for patients with relapsed all remain poor. prognostic indicators include timing and site of relapse. blinatumomab, is the first agent in its class that simultaneously binds cd3-positive cytotoxic t cells to cd19-positive b cells resulting in lysis of malignant cells. however, mechanisms of leukemia resistance to blinatumomab are unclear. objectives: to describe a case with multiple sites of extramedullary (em) relapse during blinatumomab therapy. results: a 9-year-old hispanic male with philadelphia positive, cd19-positive b-precursor cell all refractory to chemotherapy, had failed a bone marrow (bm) and was placed on blinatumomab and imatinib. he achieved minimal residual disease (mrd)-negative systemic remission, but during his fifth cycle developed bilateral periorbital masses. biopsies confirmed cd19-negative isolated em relapsed disease, which was treated with radiation therapy (rt). there was notable resolution of em disease and he continued systemic therapy. subsequently, he presented with a painful left scapular swelling. imaging showed muscle and lung parenchymal em relapse with cd19-positivity confirmed on histology. he continued on blinatumomab with localized rt while awaiting car-t cell therapy. his bm mrd remained negative until he developed systemic mrd-positivity with cd19-positive blasts following the sixth cycle. primary resistance to blinatumomab is poorly understood. it is proposed that expansion of cd19-negative clones or downregulation of cd19 following blinatumomab may play a role. this was observed in our patient's periorbital relapse; but subsequent em and systemic relapses were cd19-positive, consistent with the co-existence of multiple clones in relapsed all. it has also been postulated that em relapse could be linked to the failure of blinatumomab or t cells to migrate to em sites of disease or drug inactivation by the microenvironment. the second em relapse in our patient, with cd19-positive disease suggests this as a possible mechanism of relapse. this was reported in patients with cd19 positive non-hodgkin lymphoma (nhl), and higher doses of blinatumomab however, have shown promising results in this population. despite blinatumomab's effectiveness in inducing remissions in patients with refractory/relapsed all, it appears to have limitations in patients with em disease. these may arise either from the multiclonality associated with relapsed all or due to the emergence of resistance to blinatumomab, including failure to migrate to em sites. background: cyclic neutropenia is a rare hereditary disorder, characterized by recurrent neutropenia, cycling at about 3 week intervals, with variable associated symptoms including oral ulcers and fever. there are 4 reported cases of cyclic neutropenia associated with chronic inflammation leading to development of reactive aa amyloidosis. one patient also presented with amyloid goiter. we report a new case of cyclic neutropenia with associated renal and thyroid amyloid. design/method: a 12-year-old female presented with a 1 month history of thyromegaly, and recurrent aphthous ulcers associated with fevers. laboratory workup showed severe neutropenia, anemia, azotemia, and abnormal thyroid function, with an absolute neutrophil count -0/ l, hemoglobin -9.0 g/dl, serum creatinine -1.89 mg/dl, and uric acid -9.0 mg/dl. thyroid stimulating hormone was elevated -12.5 iu/ml, and normal free t4. urinalysis showed 2+ protein, 2+ blood, and 5-10 urine red blood cells/hpf. chest radiograph showed mild narrowing of the trachea from thyroid compression. bone marrow biopsy showed a hypocellular marrow, with tri-lineage hematopoiesis, left shifted myeloid maturation with very rare mature neutrophils. both renal biopsy and thyroid fine needle aspiration revealed abundant amyloid. of note, her father had aa amyloidosis, resulting in end-stage renal disease (esrd) requiring hemodialysis, and recurrent aphthous ulcers. the family history suggested a familial predisposition. genetic testing revealed a pathogenic elane c.358 a>t gene mutation with autosomal dominant inheritance confirming the diagnosis of cyclic neutropenia. we treated our patient with daily granulocyte colony stimulating factor to reduce the burden of chronic inflammation induced by cyclic neutropenia, and to preserve renal and other end organ function affected by further amyloid deposition. results: proband with elane gene mutation positive cyclic neutropenia, amyloidosis of thyroid and kidney, with a positive paternal history of aa amyloidosis resulting in esrd. cyclic neutropenia may result in chronic inflammatory states leading to secondary amyloidosis. university of kentucky, lexington, kentucky, united states background: overall survival of burkitt lymphoma (bl), regardless of stage, is greater than 85% in the pediatric population when treated with multi-agent chemotherapy. adenovirus is a common, usually self-limited infection within the pediatric population; however, findings can vary within an immunocompromised host. hepatitis is a rare complication, with very few reports of radiologic findings in this patient population. we discuss a three year old male with history of bl who presented with clinical and radiographic evidence of relapse but was found to have adenovirus hepatitis. design/method: a case report of a patient with bl in complete remission after completion of standard of care chemotherapy, who presented with return of high fever, elevated ldh, transaminitis and hepatic lesions. we describe the hepatic imaging and pathology consistent with adenovirus hepatitis in this immunocompromised host. our patient presented at three years old with a six week history of worsening abdominal pain and fevers. he was found to have a right sided pleural effusion, multiple lesions of the liver, and diffuse abdominal lymphadenopathy; biopsy of lymph tissue was consistent with bl. he completed therapy per anhl1131 arm b and was in a complete remission at the end of planned therapy. one month after completion of therapy, he returned with high fever, abdominal pain and transaminitis, similar to his initial presentation. ct scan showed multiple hypodense discrete lesions throughout the liver and re-accumulation of right sided pleural effusion. ldh peaked at 3580 u/l (uln 370 u/l). uric acid remained within normal limits. bilirubin peaked at 4.0 mg/dl, conjugated 3.2mg/dl. liver biopsy was performed, showing smudgy nuclei with immunohistochemical staining positive for adenovirus. there was no evidence of lymphomatous involvement. resolution of hepatic lesions and transaminitis, with normalization of ldh and fever, occurred with symptomatic treatment alone. adenovirus is known to cause systemic disease in immunocompromised patients and rarely hepatitis. no pediatric patients with discrete hepatic lesions secondary to adenovirus have been reported in the literature. three cases of discrete hepatic lesions have been reported in adult immunocompromised patients, two with fatal fulminant liver failure and one who required cidofovir. this case demonstrates that a common pediatric viral infection can present with lesions concerning for metastatic disease in a pediatric lymphoma patient. prompt diagnosis is vital in the management of these patients when recurrent lymphoma is in the differential. background: heparin induced thrombocytopenia (hit) is an immunologic process in which antibodies bind a heparin complex and cause a paradoxical hypercoagulable state. ramifications of this process may include a multitude of thrombotic events and bleeding complications secondary to platelet consumption. in our patient, hit manifested as increased bruising, an acute decrease in platelet count, and continual clotting of her crrt circuit. hit, although rare in pediatrics, should be included in the differential for children with thrombocytopenia who have received heparin products. to present a unique case report of a critically ill pediatric patient who developed hit in the presence of multiorgan system failure and to discuss the challenges encountered with identification of an alternative anti-coagulant. results: a 12yo obese, caucasian female child presented to our facility with bilateral pulmonary emboli (of unclear etiology). initially, she was started on a continuous heparin infusion, but was transitioned to enoxaparin within 3 days without issue. five days after enoxaparin was initiated, the patient developed acute kidney injury (evidenced by increasing creatinine) attributable to her biventricular heart failure. due to her need for continuous renal replacement therapy (crrt), she was transitioned back to a continuous heparin infusion. whereas her initial platelet count on transition was normal, she developed severe thrombocytopenia (15,000ul) within 48 hours. due to intermediate risk but low suspicion for hit, pf4 antibodies were sent which were positive. after much discussion, she was transitioned to an argatroban infusion which was titrated according to ptt levels. within 48 hours, her platelet count normalized. at discharge, she was prescribed apixaban for anti-coagulant management. conclusion: hit is an uncommon presentation in the pediatric population. given its rarity, there is often a delay in diagnosis which increases risk of complications such as bleeding, stroke, and limb ischemia. even if the diagnosis is suspected or proven, there may be challenges in initiating alternative agents as limited data exists on pediatric options. as argatroban remains the treatment of choice for patients with hit, experience in pediatric patients is limited, and dosing recommendations have been extrapolated from adult studies. anecdotal data exists for use of bivalirudin in children, although studies, primarily, focus on use in specific cardiac cases. in our patient's case, choice was further complicated by renal failure. this case study highlights the need for further research regarding the identification of a secondary anti-coagulant agent for use in pediatric patients with hit. background: subcutaneous panniculitis-like t-cell lymphoma (sptl) is a rare form of non-hodgkin's lymphoma characterized by infiltration of cytotoxic t-cells into subcutaneous tissue. sptl occurs in both adults and children and can present in both patient populations as either alpha/beta or gamma/delta subtypes. patients with the gamma-delta phenotype have an overall poorer survival, although the exact etiology is unclear. interestingly, both subtypes of sptl can present with secondary hemophagocytic lymphohistiocytosis (hlh), and this is associated with a worse prognosis. currently, there are no standardized treatment protocols for sptl, and clinical management includes watchful waiting, corticosteroids/immunosuppression, chemotherapy, and stem cell transplant. the primary objective was to compare how two patients with the same diagnosis responded acutely to therapy. we performed a retrospective chart review of two pediatric patients at our institution who were diagnosed with alpha/beta sptl and secondary hlh. we examined each presentation, treatment course, and outcome. we then completed a brief review of the current literature describing treatment of and outcomes for sptl with secondary hlh. results: these two patients presented in a similar manner with signs and symptoms of hlh. each was then subse-quently diagnosed with alpha/beta sptl after biopsy of cutaneous nodules and each had diffuse disease, as measured by pet. however, they demonstrated vastly different acute responses to therapy. one patient was pre-treated with systemic glucocorticoids before receiving definitive chemotherapy and tolerated therapy well as an outpatient. the other patient started systemic chemotherapy without steroid pretreatment and developed severe cytokine storm characterized by hypotension, cardiac dysfunction, multi-organ failure and cytokine elevation. both patients achieved complete remission (cr) after treatment with chop chemotherapy and remain disease-free 12-24 months off therapy. in patients presenting with sptl and secondary hlh, we propose that initial treatment with antiinflammatory or anti-cytokine therapy can decrease, or even prevent, the possibility of life threatening cytokine release as a result of cytotoxic chemotherapy. background: congenital dyserythropoietic anemia type ii (cda ii) is a rare autosomal recessive disorder, rarely presenting in the neonatal period. iron overload often occurs as a late sequela of ineffective erythropoiesis and intramedullary hemolysis. objectives: to report the novel use of iron chelation in an infant with cda ii associated with severe iron overload. the patient is a 3-month-old, former 27-week infant with prenatal non-immune hydrops and transfusion-dependent fetal anemia who presented with persistent anemia, reticulocytopenia, hyperbilirubinemia, liver dysfunction, and hyperferritinemia. his initial ferritin was 4822.3 ng/ml, tibc 185 ug/dl, and transferrin 116 mg/dl. his bone marrow biopsy showed trilineage hematopoiesis and erythroid dyspoiesis characterized by binucleation of late-stage precursors. genetic testing revealed a compound heterozygous missense mutation and splice site mutation in the sec23b gene, confirming the diagnosis of cda ii. initial liver biopsy revealed mild portal fibrous expansion, and abundant hepatic iron deposition. his ferritin continued to increase, peaking at 21,114 ng/ml, along with liver enzymes peaking at an alanine aminotransferase (alt) of 505 u/l and aspartate aminotransferase (ast) of 776 u/l. ferriscan showed an elevated estimated liver concentration of 2.8 mg/g dry tissue. repeat liver biopsy 3 months later showed giant cell hepatitis with worsening mild portal fibrosis and hemosiderosis. additionally, tissue liver iron concentration was 4755 mcg/g dry weight. cardiac t2* mri revealed mild cardiac iron deposition. given his significant degree of iron overload, deferoxamine was used to reduce hemosiderosis and liver morbidity in preparation for bone marrow transplantation. the patient received deferoxamine 15 mg/kg/day iv x 5 days/week for three months, without any clinically significant adverse events. blood counts and hepatic and renal function were monitored weekly without any abnormalities. growth parameters and liver enzymes significantly improved while receiving chelation therapy. as a noninvasive, cost-effective method, serum ferritin levels were monitored monthly to gauge response to treatment. despite receiving blood transfusions every 3-4 weeks, serum ferritin decreased to 344 ng/ml and liver enzymes decreased to alt 29 u/l and ast 26 u/l prior to bone marrow transplantation. we report the use of deferoxamine in a patient with cda ii less than 2 years of age, for treatment of iron overload. our patient tolerated deferoxamine well without significant adverse events or organ toxicity. deferoxamine may be a well-tolerated method of reducing iron burden in young patients with iron-loading pathologies. background: low grade gliomas with kiaa-1549-braf fusions typically have a favorable prognosis with infrequent rates of high grade transformation, low rates of metastasis and even lower rates of extra cns metastasis. while highgrade transformation has been reported for tumors with braf v600e mutations and cdkn2a deletions, it has not been pre-viously reported in gliomas with kiaa-1549-braf fusions. while there are case reports of high-grade cns malignancies metastasizing through a ventriculo-peritoneal (vp) shunt, low-grade gliomas metastasizing in this manner are extremely rare. objectives: to describe a unique case of peritoneal tumor dissemination of a braf fusion positive high grade neuroepithelial tumor in a child with a vp shunt placed for multifocal braf fusion positive low grade astrocytomas results: an eight-year-old male was initially diagnosed with multifocal low-grade astrocytomas of the hypothalamus and c2-c4 spinal cord. initial testing revealed the kiaa-1549-braf fusion, but no cdkn2a or braf v600e mutation. initial surgical management included a vp shunt and resection of the cervical spinal lesion. he received vincristine and carboplatin, followed by transition to vinblastine given new thoracic metastatic lesions after 10 months of therapy. at 15 months after diagnosis, scans were concerning for diffuse leptomeningeal progressive disease and new intracranial lesions, necessitating craniospinal radiation. following a near cr, he presented 13 months later with acute onset of abdominal pain. a ct scan revealed peri-renal and perirectal soft tissue masses, confirmed by exploratory laparotomy to be peritoneal tumor dissemination of high grade neuroepithelial tumor. a kiaa1549-braf fusion was noted and confirmed by rt-pcr, identical to that seen in the original cns tumors. additional findings included deletion of chromosome 1p (without 19q loss) and heterozygous and homozygous deletion of cdkn2a found by fish. brisk mitotic activity justified a high-grade designation. salvage chemotherapy consisted of 4 cycles of ice with subsequent resolution of pet-avid disease and only minimal peri-nephric tissue remaining. given the favorable response, surgical resection and multiple tissue biopsies were performed which documented no residual active disease. the shunt was revised and he started trametinib for maintenance. we present a unique case of peritoneal dissemination of high grade neuroepitheial tumors with the same kiaa-1549-braf fusion as multifocal low grade astrocytomas in a child with a vp shunt. this raises suspicion for tumor metastasis and transformation to a higher grade malignancy versus two distinct diseases, which may be indicative of an underlying cancer predisposition. texas children's hospital, houston, texas, united states background: polycythemia is a common referral to hematology. it is important to evaluate for a high oxygen affinity hemoglobinopathy, ensuring appropriate testing is performed for early diagnosis and avoidance of additional tests and procedures. a 17 year old mexican female presented with an elevated hemoglobin and hematocrit, symptoms of plethora of her hands and feet, chest pain, palpitations, and fatigue. further confounding the picture, she also had significant menorrhagia and iron deficiency. she was diagnosed with the rare high oxygen affinity hemoglobin new mexico variant, only previously described once in the literature in a 4 year old black boy. objectives: the patient initially presented at age 14 with a hemoglobin of 16.7g/dl and a hematocrit of 52.4%. initial work up consisted of a hemoglobin electrophoresis which diagnosed sickle cell trait, a co-oximetry panel which was normal, and erythropoietin level of 7mu/ml, also normal. she was then lost to follow up and re-referred at age 17. she is a competitive basketball athlete, and at that time, she presented with a hemoglobin of 17.1g/dl, and hematocrit of 50%. erythropoietin level continued to be normal at 13mu/ml. design/method: cardiology was consulted regarding chest pain and palpitations with a normal evaluation. chest x-ray was also normal. a bone marrow aspirate and biopsy was performed with results significant for mild erythroid hyperplasia and mild reticulin fibrosis. jak 2 mutation, von hippel lindau, bpgm, and hereditary erythrocytosis mutations including phd2, hif2a, and epor mutation analysis were sent, all of which were normal. testing to mayo clinic for p50 rbc oxygen dissociation returned low at 19mmhg (24-30mmhg normal range) and subsequently a hemoglobin electrophoresis identified a hemoglobin variant leading to beta globin gene sequencing. results: patient found to be heterozygous for hemoglobin new mexico, with 41.9% hb new mexico and 54.5% hba, and 3.6% hba2. there was no evidence of hbs. when evaluating patients with polycythemia, maintaining a high index of suspicion for high affinity hemoglobinopathies may eliminate further unnecessary and invasive testing for patients. caution should be used when using hemoglobin electrophoresis testing since hb new mexico is known to migrate similarly to hbs on hplc with minimal change that may not be detected in regular laboratories. most high affinity hemoglobinopathies are reported to not have significant symptoms. in this case, our patient complains of fatigue, occasional palpitations and plethora of hands and feet. we will need to further follow this patient for possible attributable symptomatology. divya keerthy, simone chang, warren alperstein, patricia delgado, claudia rojas, ofelia alvarez, matteo trucco university of miami jackson memorial hospital, miami, florida, united states background: improved technology is enabling detection of previously unidentified translocations and mutations in otherwise unclassified sarcomas. one such mutation is the bcl-6 co-repressor -internal tandem duplication (bcor-itd) allowing for the new classification of bcor positive undifferentiated round cell sarcomas (urcs). this sarcoma has a similar appearance to clear cell sarcoma of the kidney (ccsk), potentially representing an extra-renal manifestation of this tumor, but their clinical pathologic features are not identical. objectives: this case highlights how recombinant polymerase chain reaction (rt-pcr) and bcor immunohistochemical staining can ease the diagnosis of this rare sarcoma. results: a 5 month-old female presented for right sided pre-septal cellulitis and a temporal subcutaneous mass. the detection of multiple other subcutaneous nodules on exam raised the concern for malignancy and she was admitted for evaluation. she had two subcutaneous masses on her abdomen, with more cutaneous masses on her legs, back, shoulder, cheek and submandibular areas. she lacked spontaneous lower limb movement and had bilateral clonus. imaging confirmed multiple masses throughout the body including paravertebral area from t3 to l2, bilateral adrenal glands, left kidney and muscles of upper and lower extremities. initial differential included neuroblastoma, infantile myofibromatosis, rhabdomyosarcoma or atypical presentation of a renal tumor. however, synaptophysin and chromogranin stains were negative. with standard immunohistochemistry, the tumor could be only broadly classified as "undifferentiated sarcoma" maintaining the diagnostic challenge. using rt-pcr in the setting of a morphologically primitive round cell neoplasm with strong bcor expression, two external institutes simultaneously diagnosed the tumor as bcor-urcs. the primary lesion is unknown but potentially may have arose from the kidney. bcor-urcs has a heterogeneous histology with tumor cells appearing monomorphic in nests of 6-10 cells separated by septa with uniform nuclei. there is frequently an "orphan annie eye" appearance and sparse cytoplasm to the cells. diagnosis cannot be made solely on evaluation of this nonspecific histology. rt-pcr uses the genetic abnormality in undifferentiated sarcomas to narrow the differential and bcor immunohistochemical staining provides further context. bcor has significant diagnostic value given its sensitivity and specificity in urcs. another potential marker includes ywhae-nutm2b fusions, which occur in smaller subset of cases, but requires further study. rt-pcr has helped further classify tumors leading to the diagnosis of a rare undifferentiated sarcoma with bcor overexpression. while this technology is beneficial, its availability is limited. if accessibility improves, earlier identification and treatment may be possible maximizing the chance for a positive outcome. background: hematohidrosis is a rare condition that mimics bleeding disorders. cases present with oozing blood tinged fluid from various sites like eyes, ears, nose, skin, etc. reported causes of this condition were stress or fear, physical activity, psychological disorders. the condition is self-limited and don't affect the general condition of the patients, but it may contributes to psychosocial problems and may increases their stress and anxiety. so this condition needs to be promptly treated. to test the response of this disease and the associated headache to propranolol treatment. design/method: our case female patient 11 years old 1st offspring of non consanguineous marriage, was admitted with recurrent episodes of oozing blood tinged fluid from eyes, ears and nose 2 months before admission, about 0.5-1 ml from each orifice, lasted 5-10 minutes and subsided spontaneously. it could involve the 3 sites simultaneously or 1-2 sites. the number of attacks was 3-4 times per day then gradually increased to 15-20 times per day. later on the patient developed a bleeding attack from umbilicus. these attacks were aggravated by stress and physical activity and decreased with rest and sleep. the condition was associated with severe headache involving the whole head, throbbing in nature of gradual onset, increased by physical activity and relieved by analgesics. the condition was not associated with vomiting, blurring or diminution of vision, ocular pain, eye discoloration. no earache, tinnitus or diminution of hearing. there was no other form of discharge from eyes, ears or nose. no history of ecchymotic patches, bleeding from other orifices or blood product transfusion. no history of trauma, drug intake, fever or rash. no symptoms of other system affection. past history of recurrent attacks of epistaxis and two operations were done that passed without remarkable bleeding. no similar condition in the family physical examination was free, no evidence of psychological problems. complete blood count, coagulation profile, platelets function, factor 13 and c.t brain were normal. oozing fluid from the patient was analyzed showed the same components as blood. results: our case started oral propranolol 0.5mg/kg/day based on its use in similar cases in literature. the frequency of attacks and headache reduced then stopped after 2 months of treatment and didn't recur after stoppage of propranolol. propranolol can treat this condition successfully. further investigations are needed to determine the link between this condition and severe headache our case was suffering from. background: wilms tumor is the most common renal solid tumors of childhood and is derived from primitive metanephric cells located in the kidney. primary extra-renal wilms tumors (erwt) are extremely rare, estimated to comprise 0.5-1% of all wilms tumors. despite similar histologic appearance intrarenal and erwts differ in embryologic tissues of origin. erwts arise from the more primitive mesonephric or pronephric origin and, therefore, can develop anywhere along the craniocaudal migration pathway of these primitive tissues, most often retroperitoneal, inguinal/genital, lumbosacral/pelvic and mediastinal. these tumors are typically staged and treated per national wilms tumor study (nwts) guidelines, and, by definition, are stage ii or greater due to location beyond the kidney borders. based on the cases reported in the literature, outcomes for erwt are comparable to renal wilms tumors with an 11% local recurrence rate and an 85% two-year event-free survival. we report the first case of a stage iii testicular extrarenal wilms tumor in an 8-month-old male with an intrabdominal undescended testis who underwent complete surgical excision followed by chemotherapy and inguinal radiation. results: a full term 8-month old male underwent orchipexy for an undescended left testicle. the testicle was noted to be grossly abnormal with a pea-sized thickened tissue adherent to the upper pole and a separate mass outside of the scrotum on the superior epididymis. both masses were removed, and s73 of s301 pathology demonstrated wilms tumor with favorable histology and negative margins. ct imaging of the chest, abdomen and pelvis were negative for a primary renal tumor, local residual disease, pathologic lymph node enlargement or distant metastases. the tumor was classified per nwts as stage iii due to tumor removal in multiple pieces. the patient completed dd-4a treatment with vincristine, doxorubicin and dactinomycin per aren0534 with 10 cgy left inguinal radiation. he is currently 15 months off therapy without clinical or radiographic evidence of recurrent disease. primary erwt is an extremely rare malignant neoplasm associated with challenges in diagnosis, staging and treatment. based on the 80 cases reported in the literature, outcomes are similar to that of intrarenal wilms tumor. there are four pediatric paratesticular wilms tumors reported in the literature and, to the best of our knowledge, this is the first case of stage iii testicular wilms tumor successfully treated with dd-4a chemotherapy and radiation. in erwt, nwts guidelines for staging and treatment should be applied with evaluation of both kidneys to exclude an intrarenal primary tumor. background: patient is a 20 yo f, with esrd secondary to atypical hus versus ttp, who presented with thrombotic microangiopathy, aki, thrombocytopenia and anemia after a living unrelated donor kidney transplant. patient initially had downtrending creatinine. on post-op day 2, hematology was consulted for an increasing ldh and drop in platelets. peripheral smear was notable for an absence of schistocytes. yet, biopsy of the kidney revealed microthrombi. the patient was diagnosed with a thrombotic microangiopathy. plasmapharesis was initiated on day #3, at which time ms r was noted to have significantly elevated creatinine. plasmapharesis did not yield any correction in labs and significant bruising developed. patient was started on eculizimab; plasmapharesis was stopped. shortly after, creatinine, anemia and thrombocytopenia corrected to levels at which she was discharged. overall, patient was found to have progressive anemia, thrombocytopenia, an increasing creatinine and ldh (600s) concerning for atypical hus, despite absence of schistocytes on peripheral smear. she responded well to eculizimab, with correction of hematologic changes during induction. she was discharged on eculizimab and continued to respond with normalizing platelet counts and hemoglobin. the differential in light of patient's thrombotic microangiopathy and thrombocytope-nia also included ttp. yet, adamts13 remained normal. dic was unlikely given normal fibrinogen level and d-dimer. objectives: presentations of atypical hus vs ttp. discuss eculizumab as a treatment of atypical hus. highlight atypical presentations of illness in transplant patients. results: despite absence of schistocytes by smear, pt was diagnosed with atypical hus based on presentation and after failing plasmapharesis, she responded well to eculizumab. though her presentation was abnormal, her response to this antibody that blocks the complement cascade suggests that she was experiencing a complement-mediated process. there are rare documented cases in the literature of atypical hus without schistocytes. hemolytic uremic syndrome (hus) is characterized by hemolytic anemia, thrombocytopenia and acute kidney injury. atypical hus is a diagnosis of exclusion, not due common etiologies such as shiga toxin. among atypical causes are complement-mediated forms, caused by an antibody to complement factor. in addition to plasmapharesis, renal transplant and supportive care, the mainstay of treatment for atypical hus is eculizumab (an antibody that blocks the complement terminal cascade). this case describes a patient unique in that, she was diagnosed with atypical hus without any schistocytes by smear. secondly, she responded to eculizumab, with unremarkable gene studies. finally, this case highlights that transplant patients often have unique presentations. nicklaus children's hospital, miami, florida, united states background: synovial sarcoma is a spindle cell tumor categorized as a soft tissue sarcoma. the chromosomal translocation t(x;18) leading to the ss18-ssx fusion protein is unique to this sarcoma. it is a slow growing tumor with common recurrences and often, at presentation, with evidence of metastatic disease. if resection is not feasible, then neoadjuvant with adjuvant chemotherapy is recommended. metastasis carries an unfavorable prognosis given synovial sarcoma historically does not respond well to chemotherapy. trabectedin is a well-tolerated alkylating agent currently indicated for the treatment of liposarcoma and leiomyosarcoma. we present a 17-year-old male with metastatic synovial sarcoma to the lungs that progressed and was refractory to chemotherapy. he was administered trabectedin as a form of palliative chemotherapy, with significant clinical and radiographic response. design/method: pubmed search was done with search for terminology including "synovial sarcoma" and "trabectedin". papers relevant to our case were selected for literature review. a 17-year-old male patient presented with a large right axillary mass. initial imaging showed a heterogeneous multiseptated mass invading the subscapularis and teres major muscles along with innumerable lung nodules. biopsy confirmed diagnosis of monophasic synovial sarcoma. the patient was started on protocol arst 0332 with ifosfomide, mesna, doxorubicin. he completed 4 cycles followed by radical resection and 33 sessions of radiation. due to progression of disease multiple chemotherapy regimens were tried including topotecan and cyclophosphamide, protocol advl 1522 with lorvotuzumab, and pazopanib. imaging of the chest continued to show significant progression of metastasis. the patient's clinical status deteriorated with worsening respiratory status, requiring 10l of oxygen therapy, and inability to ambulate. he was started on trabectedin 1.2mg/m2 for palliative care. after 2 cycles of treatment patient was no longer requiring oxygen and was ambulating without assistance. radiological imaging showed significant reduction in number and size of lung nodules. trabectedin is a recently approved alkylating agent for the management of sarcomas resistant to first line treatment. response in synovial sarcoma is scarcely documented in the pediatric population. epidemiology places the most common age group in the young adults and children. our case opens the doors to further consideration of the use of trabectedin in the pediatric patient with metastatic synovial sarcoma. background: gata1 is an x-linked gene that plays critical role in hematopoiesis. mutations of gata1 gene can be associated to various blood disorders including diamond blackfan anemia, cytopenia, congenital dyserythropoietc anemia and acute megakaryoblastic leukemia. we report a patient with macrocytic anemia and platelet dysfunction who carries a novel gata1 mutation that has not been reported. results: a now 28-month-old male with complex medical history including prematurity at 33 weeks, dysmorphic features, global developmental delay, hyperinsulinism, hypogonadotropic hypogonadism, growth hormone deficiency, micropenis, failure to thrive, patent ductus arteriosus status post ligation, and severe hypotonia, was referred to hematology at 16 months old for resolved, transient thrombocytopenia and macrocytic anemia since 1 month of age. chromosomal microarray showed chromosome deletion of 14q21.3, which is the rps29 gene. he doesn't have a family history of diamond blackfan anemia (dba), despite mom having the same rps29 mutation. he was then diagnosed with dba. his lab workup showed mild macrocytic anemia (hgb 9.1 g/dl, mcv 95fl), normal to inappropriately low reticulocyte count, normal white blood cell and platelet counts, hgf 0%, erythroid ada 1.39 eu/gm hgb (elevated). he has abnormal pfa-100, with prolonged closure time of both adp and epinephrine. he had low von willebrand antigen and ristocetin cofactor activity. he has severe pancreatic insufficiency. bone marrow biopsy showed normocellular marrow with trilineage hematopoietic maturation, without ringed sideroblasts. since mother has the same rps29 gene mutation, maternal labs were done and showed no evidence of macroytosis or anemia. the diagnosis of dba was questioned. whole exome sequencing did not identify any pathogenic sequence changes in the coding regions of rps29 gene, but detected a gata1 mutation r140w, which was reported variant of uncertain significance. his mother shares the same mutation and is asymptomatic, but she may not be affected since gata1 iis xlinked. his father doesn't harbor the gata1 mutation. conclusion: gata1 gene encodes zinc finger dna binding hematopoietic transcription factor, which is important during erythroid differentiation. gata1 mutation r140w has not been reported in literature and is a novel variant of gata1 mutation, which might be contributing to this patient's clinical picture. further studies are warranted to confirm gata1 mutation r140w to be a pathogenic sequence change. alexander boucher, tomoyuki mizuno, alexander vinks, greg tiao, stuart goldstein, james geller cincinnati children's hospital medical center, cincinnati, ohio, united states background: hepatoblastoma (hb), the most common pediatric primary hepatic malignancy, can be associated with specific congenital syndromes. recently, chronic kidney disease and genitourinary anomalies have been linked to hb. cisplatin is a key chemotherapeutic agent in treating hb but its renal clearance and toxicity profile can limit its use for those with end-stage renal disease (esrd). objectives: using an institutional case series, we present data using cisplatin for hb in dialysis-dependent esrd and define recommended dosing for future use. design/method: a chart review of patients with concurrent hb and esrd on dialysis treated with cisplatin at our institution was undertaken. demographic data, diagnostic history, tumor pathology, alpha fetoprotein (afp), hearing assessments, dosing schema, treatment outcomes, and therapyrelated toxicities were reviewed. total cisplatin levels were collected at 5 time points within 10 days after each infusion. free cisplatin levels were also collected for 2 infusions, as were dialysate cisplatin levels. pk parameters were generated using bayesian estimation with a published population pk model as a priori information. results: three patients meeting these criteria were identified. each had "low risk" (non-metastatic resectable) disease at presentation and underwent upfront resections. all had congenital renal anomalies with esrd prior to their hb diagnosis. all cisplatin infusions were given over 3 hours, followed 3 hours later by hemodialysis. patients 1 and 3 received cisplatin at 50% of children's oncology group's ahep0731 weight-based dosing (1.67 mg/kg). patient 2 received 50% of ahep0731 body surface area-based dosing (50 mg/m2) during cycle 1 but required a second dose reduction (25 mg/m2) for cycle 2 due to prolonged cisplatin exposure (total area under the curve 342 mg⋅h/l; average for all seven evaluable cycles 238 mg⋅h/l) and early sensorineural hearing loss at 2000-4000 hz. no other hearing loss in any patient was identified; mild toxicities also included grade 1-2 emesis and grade 1 neutropenia and thrombocytopenia. the median (range) of clearance, volume of distribution at steady-state, and elimination half-life at terminal phase for total platinum were 0.19 (0.15-0.31) l/hour/70 kg, 69.1 (59.0-105.7) l/70 kg and 155 (102-185) hours, respectively. patients 1 and 2 received 2 cycles with rapid afp normalization. patient 3 required an additional 2 cycles, for a likely second primary hb 1 year after initial therapy. cisplatin can be used successfully in pediatric patients with esrd on hemodialysis to treat hb with minimal morbidity using 50% standard mg/kg-based dosing (1.67 mg/kg), achieving pharmacologically appropriate cisplatin exposures. background: treatment for immune thrombocytopenia (itp) has been grouped into rescue and maintenance therapy and often is reserved for patients with bleeding, severe thrombocytopenia, or for improvement in quality of life. splenectomy is considered one of the more invasive but definitive treatments with success rates of 70-80%. treatment of itp can be more difficult in the setting of previous treatment with immune modulation or when the patient is immunocompromised and not a candidate for splenectomy. objectives: present an interesting case of a patient with an autoimmune disease that presented with severe thrombocytopenia, un-responsive to rescue therapy, and requiring emergent splenectomy in the setting of acute intracranial hemorrhage (ich). a 13 year old female with a history of juvenile dermatomyositis presented with a fine purpuric rash on her extremities, wet purpura, and a platelet count of 1k/ l. bone marrow evaluation at that time was consistent with itp. she was on cyclosporine and plaquenil for dermatomyositis. platelets failed to increase after three doses of intravenous immunoglobulin and high dose steroids. following a two week course of oral prednisone and eltrombopag, she presented with persistent severe thrombocytopenia of 1k/ l, anemia of 6.4 g/dl, and a lower gi bleed. she was started on amicar, novo-seven, rituximab, and given platelet transfusions with no improvement in bleeding. subsequently, she developed a subdural hematoma with midline shift. surgery performed an emergent open splenectomy with concurrent continuous platelet transfusion. results: she was monitored closely post operatively and, due to ich, transfused to maintain platelets greater than 100k/ l. by 1 week post-op she had normal platelet counts off transfusions. all medications were stopped within three days of discharge. she represented eight days later with abdominal pain and thrombocytosis and was found to have a portal vein, splenic vein and mesenteric vein thrombosis. she was started on lovenox therapy and admitted for monitoring due to her history of ich. it is unknown whether our patient's underlying immune dysregulation and history of treatment with immunosuppressive medications may have contributed to her unresponsiveness to multiple therapeutic agents. in addition, her significant bleeding did not allow us to fully evaluate her response to second tier therapy. this adds to the scarcity of literature of itp response in pediatric patients with autoimmune disease, and may support more aggressive therapy upfront in these patients. background: multivisceral organ transplantation involves concurrent transplantation of the stomach, pancreas, liver, and intestine with splenectomy, and has been classically used in the pediatric population for infants with intestinal failure from disorders affecting foregut integrity. while there is some data demonstrating its efficacy in adults with low-grade abdominal malignancies, it has not been traditionally used for hepatocellular carcinoma treatment. to describe a unique pediatric case of multivisceral organ transplantation as definitive therapy for refractory fibrolamellar hepatocellular carcinoma in an adolescent male. a 16 year old male presents with a history of fibrolamellar hepatocellular carcinoma, tumor invasion of the portal vein, severe portal hypertension complicated by bleeding esophageal varices and hypersplenism. he had two treatments with yttrium-90 radioembolization, without significant response. he completed six cycles of traditional chemotherapy in combination with sorafenib with resolution of petavidity, but minimal decrease in tumor size and continued portal hypertension. since his disease remained relatively stable for over 2 years, he was evaluated and listed for multivisceral organ transplantation. at approximately 2 years and 7 months after diagnosis, he underwent en bloc liver, pancreas, stomach, small bowel, and colon transplant with splenectomy. a single lymph node was positive for malignancy at the time of resection. in addition to expected post-transplant complications, he also developed skin only acute graft versus host disease at 2 weeks after transplant, treated successfully with a thymoglobulin course. he clinically improved and was back to his baseline activity level, on full oral feedings within 3 months post-transplantation. at three and six month post-transplantation, there is no concern for relapsed hepatocellular carcinoma on comprehensive imaging and evaluation. he is maintained on protocol immunosuppression and posttransplant support. we present the first known case of successful multivisceral organ transplantation in the treatment of refractory pediatric fibrolamellar hepatocellular carcinoma. background: hematohidrosis is a rare disorder that presents with spontaneous excretion of whole blood from intact skin or mucosa. diagnosis is based on clinical observation of the occurrence with the proven presence of erythrocytes and other blood components, without other abnormalities to account for the phenomenon. the existing literature is scarce and consists of primarily case studies. most reports describe bleeding from facial sites around the eyes, ears, and nose. the available literature suggests anxiety and physical or emotional stress reactions as the most common inciting events. little evidence exists regarding the ideal therapeutic approach, however propranolol has been used successfully to reduce bleeding frequency and severity in multiple case reports. a specific genetic etiology has not been elucidated, and no familial cases have previously been reported. we present a pair of half-siblings, both of whom presented with spontaneous cutaneous and mucosal bleeding before two years of age, and report on preliminary results of propranolol therapy. tanzania. at 20 months of age, he became ill and developed spontaneous bleeding from his ears, nose, and scalp. he continued to have frequent bleeding episodes, usually related to illness or physical distress. a bleeding diathesis work-up was unremarkable, however some episodes were severe enough to require transfusions. the patient was subsequently diagnosed with hiv and hepatitis b, presumably acquired via unscreened blood product transfusions. patient b is an infant female born to the same mother as patient a, with a different father. she was healthy until two months of age when she developed spontaneous bleeding from the hairline, eyelids, ears and genital/rectal area. bleeding episodes were nearly always associated with irritability and crying. extensive coagulation workup was unremarkable. results: propranolol therapy was started in both patients, titrated to a goal of 2 mg/kg/day. in both patients, the frequency and duration of bleeding episodes significantly improved. patient b continues to have milder occasional bleeding episodes from her eyes, ears and scalp but has significantly less discomfort and irritability during the episodes. conclusion: to our knowledge, there are no prior reports involving two related patients with hematohidrosis. this case series suggests that there may be a genetic predisposition which has yet to be identified. propranolol has shown effectiveness in reducing symptom frequency and severity. background: gliomas are the most common central nervous system tumors in children. they are classified into different grades based on genotype (idh, braf, tsc, etc.). lowgrade gliomas such as oligodendrogliomas, astrocytomas, and mixed oligoastrocytomas are classified as grades i and ii. of the molecular level alterations this case report focuses on the braf v600e mutation. braf is a member of the raf family of serine/threonine protein kinases and it plays an important role in cell survival, proliferation and terminal differentiation. objectives: here we discuss two cases where dabrafenib, a braf kinase inhibitor, was utilized in the management of gliomas. the cases focus on the use of dabrafenib late versus early in disease course. design/method: patient jl is a 20 year old female who was diagnosed with a low-grade glioneuronal tumor (c7-t1 with a metastatic lesion to the brain) in 2007. jl was treated with chemotherapy, radiation, and surgical resection. despite treatment, the patient's disease progressed. she developed lower extremity dysfunction, urinary incontinence, poor truncal control, and hydrocephalus. dabrafenib was started after the braf v600e mutation was confirmed. patient lg is a 12 year old female who presented in november 2016 with left facial and upper extremity weakness. ct and mri scans demonstrated a mixed solid and cystic lesion extending from the optic chiasm and hypothalamus to the right thalamus and posterior basal ganglia with additional involvement of the right cerebral peduncle. neurosurgical intervention was undertaken and dabrafenib was started after the braf v600e mutation was confirmed. results: patient jl's mri scans have demonstrated improvement of the spine with diminished areas of enhancement along thecal margins, decreased volume and enhancement within the trigeminal plate cistern and resolution of ependymal enhancement within the right ventricle. the patient's most recent mri exhibits no disease progression in head or spine. jl has shown improvement clinically since starting dabrafenib. patient lg has shown improvement in strength and recent mri of the brain has shown resolution of enhancement along surgical resection margins, decreased hyperintensity along the inferomedial aspect of the right basal ganglia and no new enhancements. conclusion: low grade gliomas can alter a person's quality of life and even lead to life threatening complications. often the standard chemotherapy, radiation and surgery don't prevent these complications. genetic analysis can help clinicians target therapy towards certain mutations such as braf v600e. dabrafenib has shown to decrease tumor burden, early utilization as therapy can help prevent morbidity and mortality. children's hospital of pittsburgh of upmc, pittsburgh, pennsylvania, united states background: copper is an essential cofactor in enzymatic reactions essential to proper hematologic, skeletal, neurologic and vascular function. copper requirements in children over the age of 4 are 15 mg/day, which is readily acquired in a typical diet. copper deficiency is known to occur in patients with the rare x-linked mutation and in older individuals with gastrointestinal bypass surgery; however, it is rarely reported in other conditions. objectives: to highlight individuals with autism spectrum disorders or developmental delay with a limited dietary repertoire are at risk for copper deficiency, thus a high index of suspicion must exist in order to diagnose the disorder. design/method: a 15 y/o boy with a prior diagnosis of global developmental delay and oral aversion presented with slowly progressive fatigue, weakness, gait instability, and weight loss. his longstanding feeding difficulties were refractory to intensive feeding programs. his daily diet consisted of 50-60oz of milk and 25-30 individual servings of butterscotch pudding (1680-1880calories/day, 0.7mg iron/day). initial complete blood count demonstrated white blood cell count of 3.3, absolute neutrophil count of 760, hemoglobin of 4.4, mean corpuscular volume of <50, reticulocyte count of 0.5, platelet count of 392. review of his peripheral blood smear revealed microcytic, hypochromic red cells without marked fragmentation, anisopoikilocytosis and ringed sideroblasts; there were no morphologic abnormalities of his leukocytes or platelets. iron studies demonstrated ferritin of 45, total iron binding capacity of 514, and 2% iron saturation. he had no evidence of b12, folate deficiency or blood loss. additional evaluation revealed a serum copper level of 6 (range 60-190), and cerulosplasmin of 2.1 (range 22-58). results: once a diagnosis of copper deficiency was made, the patient promptly began a course of parenteral copper repletion. he received iv copper 35mcg/kg/day x 3 days then weekly intravenous infusions. given his malnutrition, a gtube was placed to begin oral copper repletion and enteral nutrition. within 3 weeks his copper level improved as well as his blood counts. unfortunately, although his blood counts and copper levels normalized, his neurologic status remains below his old baseline although, he has made gains in his gross and fine motor abilities. conclusion: acquired copper deficiency in the pediatric population is a rare event but given the hematologic and neurologic consequences, prompt recognition and treatment is important. this patient's clinical course demonstrates the need to have a high index of suspicion of concomitant nutritional deficiencies other than those routinely evaluated such as iron, b12 and folate. background: lymphoepithelioma-like thymic carcinoma (lelc) is a rare, aggressive neoplasm with a high rate of invasion, metastasis and recurrence. there are no known curative therapies for metastatic lelc. we report the case of a 16-year-old male who presented with metastatic ebv positive lelc. sites of disease included a large primary anterior mediastinal mass and metastases to hilar lymph nodes, lungs and liver. he was initially treated with cisplatin and 5fluorouracil followed by mediastinal radiation. he had a partial response to therapy but his end of therapy scans showed disease progression in lungs, liver, and hilar, supraclavicular and axillary lymph nodes. objectives: molecularly targeted therapies tailored to the patient's genetic profile offer a novel approach to obtain improved survival outcomes. design/method: the patient enrolled on a precision medicine trial, nmtrc009: molecular-guided therapy for the treatment of patients with relapsed and refractory childhood cancer (nct02162732). in this study, tumor/normal whole exome sequencing and tumor rna sequencing were performed and a molecular report detailing the results of genomic and gene expression analysis was generated. a treatment plan was designed within a molecular tumor board comprising oncologists, pharmacists, genomicists, and molecular biologists with domain expertise. results: exome sequencing revealed 26 somatic coding point mutations and no structural mutations (focal copy number changes or translocations). candidate somatic driver mutations included tp53 s94x and r248w as well as kit n655k. both genes have been previously implicated in thymic carcinoma. rna expression analysis demonstrated aberrant activation of biological pathways, including overexpression of kit, hdac1, 2 and 9, tyms, and dhfr. the molecular tumor board selected the combination of pemetrexed (500 mg/m2) on day 1 of a 21 day cycle, imatinib (400 mg daily), and vorinostat (400 mg days 1-5, 8-12, and 15-19) . on day 8 of cycle 1, he was admitted with a herpes zoster infection and imatinib was discontinued in order to reduce risk of herpes zoster recurrence. imaging after 2 cycles showed a complete metabolic response on f-18 fdg pet and a partial response by ct size criteria. as of december 2017, the patient had received 15 cycles of pemetrexed and vorinostat. scans in december 2017 showed an increase in the size and metabolic activity of two right lower lobe pulmonary nodules. there were no new sites of disease and imatinib was re-started. background: systemic lupus erythematosus (sle) is a chronic autoimmune disease that affects multiple organ systems and is associated with many different autoantibodies. patients can present with vague constitutional symptoms including fever, rash, fatigue, and weight loss. some of the various hematologic manifestations of sle include anemia of chronic disease, leukopenia, autoimmune hemolytic anemia (aiha), and idiopathic thrombocytopenic purpura (itp). these can be the presenting signs of sle. evans syndrome (es), a disease characterized by itp and aiha, is a rare hematologic manifestation of sle. neurofibromatosis 1 (nf1) is a relatively common neurocutaneous disorder. these patients are at risk of developing benign and malignant tumors. its association with autoimmune disorders, including sle, remains rare. objectives: there are few cases in the literature that have patients with the combination of sle and nf1. this is the only case that has a patient with sle, nf1, and es. results: a 16-year-old caucasian female presents with two months of vaginal bleeding, weight loss and petechiae. her exam is remarkable for petechiae and café au lait macules. laboratory findings show severe anemia and thrombocytopenia. she receives blood and platelet transfusions during stabilization, and a bone marrow aspirate is performed to rule out a malignancy which is negative. based on the presence of thrombocytopenia and a positive coombs test, an autoimmune process such as es is considered. screening tests for sle reveal positive antinuclear and anti-double stranded dna antibodies as well as low complement. she receives intravenous immunoglobulin and methylprednisolone and eventually her vaginal bleeding slows and her counts recover. she begins sle therapy with hydroxychloroquine and azathioprine. due to the presence of café au lait macules on her exam, a genetics evaluation is performed and the patient is also diagnosed with nf1. to date, there are seven cases of sle with nf1 reported in the literature, only two of which are pediatric cases. there are no reports of the combination of sle, nf1, and es. conclusion: es is a rare hematologic manifestation of sle but can be the initial presentation of this disease. one large study estimates 2% of childhood-onset sle cases are observed to have es. screening for sle should be considered in all es patients even in the absence of typical clinical findings. association of nf1 and sle has been rarely described. whether this association reflects a causal relationship or is coincidental needs more investigation. (lube, ped blood & cancer, 2016) . university of california san diego, la jolla, california, united states background: high grade glioma (hgg) has poor outcomes in adults and children. extraneural metastases are very rare in hgg, and poorly characterized with only a few small case series in adults and only isolated case reports in pediatrics. no genomic data has previously been published for any children with hgg who develop extraneural metastases. objectives: our objective is to describe the natural history of two children with hgg and bony extraneural metastases, comparing their clinical characteristics as well as whole exome sequencing data for both tumors. this information would suggest similar patients should be monitored closely for extraneural metastasis and may benefit from more systemic therapy. design/method: we present a case series of two patients who presented with hgg and had development of bony metastases less than six months after initial diagnosis. both patients had molecular profiling with whole exome sequencing (wes). the first patient was an 11-year-old male with a tumor found in the left lateral ventricle invading into the fornices, hypothalamus, and left midbrain, who had subtotal resection. bony metastasis were found at 3.5 months after diagnosis, and he died 9 months after diagnosis. he initially received radiation, followed by nivolimuab. the second was a 12-year-old female with a tectal/pineal tumor and multiple spinal cord metastases, who had subtotal resection. she developed bony metastasis at 5.5 months after diagnosis and died 13 months after diagnosis. her histologic diagnosis was pineoblastoma, revised to hgg after whole exome sequencing. she received craniospinal radiation followed by chemotherapy per acns0332 (cisplatin, vincristine, and cyclophosphamide) for 2 cycles. when she failed to respond satisfactorily to this therapy, wes of tumor was performed and the findings were consistent with hgg. treatment was transitioned to temodar and lomustine after hgg diagnosis was given. she had ongoing progressive disease despite this therapy as well as trials of nivolumab, everolimus, and vorinostat. neither patient had extraneural metastasis at presentation. in both tumors, whole exome sequencing identified the h3f3a k27m mutation. both tumors also had additional known mutations associated with hgg but no other overlapping mutations. this case series represents the first description of the genetic alterations of pediatric hgg patients who developed extraneural metastases. while h3f3a k27m is a common mutation in pediatric midline hgg, especially dipg, and is associated with more aggressive disease, there has not been an association with extraneural metastasis prior to this series. background: deferiprone-induced agranulocytosis is a well -known albeit rare side effect of the drug. incidence of agranulocytosis varies from 0.5-3.6%, while milder neutropenia is reported in 8.5% of patients treated with deferiprone. deferasirox is unknown to cause such a complication. clinical trials and post marketing side effect monitoring studied possible correlations between different risk factors and development of agranulocytosis. unfortunately, no studies directly addressed a special risk in a community with background of ethnic neutropenia, like oman. objectives: to report on the incidence of neutropenia among omani children with b thalassemia using different iron chelators design/method: a retrospective study conducted on patients < 21 year-old with b thalassemia treated with different iron chelators. electronic patients records were reviewed to detect episodes of neutropenia either mild (anc 1.0-<1.5/cmm), moderate (anc 0.5-<1), severe < 0.5, or agranulocytosis anc = 0). data were collected including sex, age, personal or family history of ethnic neutropenia, iron chelating agent, infective complications, management and outcome. detailed clinical, laboratory ± radiological information were reported for patients who developed life-threatening agranulocytosis. among 179 young patients with b thalassemia, treated between 2007-2017 in squh, neutropenia, was reported in 78 patients (43.6%).severe neutropenia was encountered on 14 occasions in 11 patients (11/179: 6.1%) (8 on deferiprone including 5 episodes of agranulocytosis, 1 on defersirox, 1 on combined chelation, and 5 off chelation). moderate neutropenia was encountered in 29 patients (29/179: 16.2%), on 36 occasions: deferiprone (15), deferasirox (8), combined chelation (4), and 9 episodes off chelation. mild neutropenia was more prevalent, encountered in 59 patients (32.9%) on 124 occasions (30 on deferiprone, 44 on defersirox, 19 on combined chelation, and 31 off chelation) of 85 patients exposed to deferiprone, 35 patients had neutropenia (41%), higher than previously reported. deferiproneinduced agranulocytosis was encountered in 4 patients (4/85 = 4.7%). three of them had life threatening complications. one patient developed pneumonia complicated by rupture of pulmonary artery aneurysm-massive hemoptysis, who recovered fully after catheter embolization. the second had facial cellulitis and treatment with gcsf was complicated by frequent ventricular extrasystoles. the third had sepsis, disseminated herpes simplex and required admission to icu for inotropic support. in a community with background ethnic neutropenia, neutropenia is more common to be encountered among thalassemic patients, both on and off chelation therapy. careful monitoring of anc and rational choice/modification of chelating agents is required for optimal management of iron overload and to avoid life threatening complications. objectives: this case control study aimed to evaluate the systolic and diastolic cardiac function in 2 groups of children with ti: non transfused group and a group that received early regular blood transfusion comparing them to healthy controls. design/method: thirteen regularly transfused patients with ti with a mean age of 11.8+5.6 years were compared with eight patients who are non-transfused or minimally transfused (< 3 rbcs transfusion/year); mean age 11.8+9.4 years and 18 healthy controls with a mean age of 8.8 ± 3.9 years. clinical parameters and standard echocardiographic and tissue doppler imaging (tdi) were compared. results: young non-transfused ti patients had a statistically significant higher peak late diastolic velocity of the left ventricular inflow doppler, a mitral valve a wave duration over the pulmonary vein a wave duration ratio and the pulmonary s81 of s301 vein s/d velocities ratio compared to the transfused group with p values of 0.028, 0.01, 0.01 respectively. in addition, they have a lower e/a ratio of the mitral valve inflow and a larger left atrial to aortic diameter ratio compared to the control group with p values of 0.025 and 0.01 respectively. the diameters of the right and left outflow tract were significantly larger in the non transfused group with a trend to have a higher cardiac index compare to the transfused group. systolic function was similar in the 3 studied groups and none of the patients had evidence of pulmonary hypertension. young patients with ti who are receiving early regular blood transfusion have normal systolic function. diastolic function assessment revealed indicators of an abnormal relaxation of the left ventricle in the non transfused group which indicate diastolic dysfunction. the abnormalities affected multiple diastolic function parameters which give an indication that the changes are clinically significant. a statistically significant increase in the diameters of the outflow tracts are likely attributed to high cardiac output status in nontransfused ti patients as they had a trend to have a higher cardiac index. these findings support the early commencing of regular blood transfusion therapy for ti patients to prevent serious cardiac complications in adult life. background: in the 52-week sustain study, crizanlizumab 5.0 mg/kg significantly reduced the frequency of scpcs versus placebo (1.6 vs 3.0, p = 0.01) and increased the time to first on-treatment scpc (4.1 vs 1.4 months, p = 0.001) in patients with sickle cell disease (scd). to evaluate time to first scpc in sustain study subgroups and the likelihood of not experiencing scpc for the duration of the trial using post hoc analyses. design/method: sustain was a randomized, double-blind, placebo-controlled, phase 2 study (nct01895361). inclusion criteria were: scd patients aged 16-65 years; 2-10 scpcs in previous 12 months; concomitant hydroxyurea use permitted if ≥6 months and stable dose for ≥3 months. patients were randomized 1:1:1 to receive intravenous crizanlizumab 5.0 mg/kg, 2.5 mg/kg, or placebo. study treatments were administered on days 1 and 15, then every 4 weeks to week 50, with the final assessment at week 52. median time to first scpc after first dose was summarized for crizanlizumab 5.0 mg/kg or placebo in these subgroups: 2-4 or 5-10 scpcs in previous 12 months; scd genotype; and hydroxyurea use at baseline. hazard ratios (hrs) for crizanlizumab 5.0 mg/kg versus placebo were calculated based on cox regression analysis, with treatment as a covariate. descriptive statistics were used to summarize the frequency of patients who were scpc event-free for the duration of the study by prior scpc events, scd genotype, and hydroxyurea use at baseline. : 67 patients received crizanlizumab 5.0 mg/kg and 65 received placebo. there was a meaningful delay in time to first scpc with crizanlizumab 5.0 mg/kg versus placebo observed in the entire study population. the effect was present in both scpc subgroups, and the largest treatment difference was observed in hbss scd versus other genotypes (4.1 vs 1.1 months; hr: 0.50). in patients taking hydroxyurea who experienced 2-10 scpcs in the previous year, time to first onstudy scpc was longer with crizanlizumab 5.0 mg/kg versus placebo (2.4 vs 1.2 months; hr: 0.58). a greater proportion of patients treated with crizanlizumab 5.0 mg/kg were scpc event-free versus placebo in each of the analyzed subgroups. one third of patients who were taking hydroxyurea and treated with crizanlizumab 5.0 mg/kg were scpc event-free during the study versus 17.5% with placebo, possibly suggesting an additive effect. with crizanlizumab 5.0 mg/kg, there was a clinically meaningful delay in time to first scpc and an increased likelihood of being scpc-free versus placebo in all subgroups investigated. cincinnati children's hospital medical center, cincinnati, ohio, united states background: shwachman-diamond syndrome (sds) is an inherited marrow failure syndrome associated with increased risk of myelodysplasia (mds) and acute myeloid leukemia (aml). objectives: this multi-institutional retrospective study investigated clinical features, treatment, and outcomes of 38 sds patients who developed mds or aml by central pathology review. design/method: nine individuals presented with aml (4 male, 5 female), 5 mds-eb1/2 (3 males, 2 females, 23 with mds (11 male and 12 female), and one male with isolated persistent somatic tp53 mutation. one mds-eb1 and 1 mds patient progressed to aml. median age (years) at diagnosis of mds was 16 (range 0.5-30), mds-eb1/2 was 9 (range 0.7-20) and aml was 28.8 (range 5.5-47). complex cytogenetics were noted in 10/11 aml cases, with one having normal cytogenetics. complex clonal cytogenetic abnormalities were noted in 4 of 5 mds-eb1/eb2 patients and clonal abnormalities in 17 of 18 mds patients. follow up was available for 10 aml patients; 9 are deceased. 9 received chemotherapy with intent to proceed to hematopoietic stem cell transplant (hsct). four failed to achieve remission and died with disease without proceeding to transplant. one patient proceeded to hsct without prior chemotherapy. four of six transplanted subjects died with relapsed disease. treatment related mortality was largely infectious or gvhd. the sole surviving aml patient had normal cytogenetics, achieved remission with chemotherapy and underwent hscts with 3 separate stem cell infusions due to two primary graft failures. he remains alive in remission more than 4 years after diagnosis. of the 5 mds-eb1/2 patients, 4 underwent ric hsct, three of whom are alive, one died of infection. the fifth patient has stable disease on continued decitabine monotherapy for 4.75 years. of 19 mds patients with treatment data, 13 had upfront hsct therapy, 2 upfront chemotherapy and 4 had no therapy. three patients required ≥2 hscts all due to graft failure. follow up is available for 18, 11 of whom are deceased, 6 with relapsed disease. treatment related mortality was largely infectious or graft failure. one individual died of hepatic failure unrelated to mds. seven mds patients are alive in remission. in summary, prognosis is poor for patients with sds who develop aml due to resistant disease and treatment-related complications. better markers for risk stratification are needed to identify patients who would benefit from early transplant. novel therapeutic strategies are urgently needed to improve outcomes of sds patients with mds or aml. background: unlike primary myelofibrosis (pmf) in adults, which is associated with somatic mutations in jak2, mpl, or calr, myelofibrosis in children is rare and the underlying genetic mechanisms remain elusive. here we describe 3 families with autosomal recessive congenital macrothrombocytopenia with focal myelofibrosis (cmtfm) due to germline mutations in the megakaryocyte-specific immune receptor tyrosine-based inhibitory motif (itim) receptor g6b-b. objectives: to characterize the clinical phenotype, histological features and identify the causative gene for cmtfm. we performed affymetrix snp 6.0 genotyping on the index family to identify shared regions of homozygosity by descent. whole exome sequencing (ws) was performed on all three pedigrees to identify potentially causative mutations. we studied 6 affected children from 3 families, with macrothrombocytopenia, anemia, mild leukocytosis and a distinctive pattern of bone marrow (bm) fibrosis centered around clusters of atypical megakaryocytes. affected children had mild to moderate bleeding symptoms and required platelet and red cell transfusions. none showed evidence of extramedullary hematopoiesis, and all were negative for mutations in jak2, mpl, and calr. snp genotyping identified multiple statistically non-significant genomic loci, including the region of the major histocompatibility locus (mhc) on chromosome 6p (lod = 2.01). we focused on this region because affected individuals in two families shared a common homozygous human leukocyte antigen (hla) type and had congenital adrenal hyperplasia (cah) due to 21-hydroxylase (cyp21a2) mutation; the cyp21a2 and hla loci are located at 6p21.33 and 6p21.32-6p22.1. wes revealed homozygous frameshift mutations in the megakaryocyte and platelet inhibitory receptor g6b-b, encoded within the candidate linkage region. we identified two distinct g6b-b frameshift mutations (c.61_61+1dup; p.20fs and c.147inst; p.49fs) in 7 individuals within these three families. no other mutations that segregated with the phenotype were identified. to validate g6b-b as a potential disease-causing gene, we evaluated g6b-b expression in bm biopsy specimens from affected patient and control samples by immunohistochemical staining using a monoclonal antibody. g6b-b was strongly s83 of s301 and selectively expressed in megakaryocytes of control samples, but completely absent in clinically affected individuals. a murine knockout that lacks g6b-b has a strikingly similar phenotype with macrothrombocytopenia, myelofibrosis and aberrant platelet production and function, further affirming the causality of g6b-b mutations. we showed that autosomal recessive loss-offunction mutations in g6b-b cause cmtfm, uncovering the molecular basis of this rare disease. loss of g6b-b-dependent inhibition of megakaryocyte activation likely underlies the distinctive focal myelofibrotic phenotype and might be important in other forms of marrow fibrosis. cardinal glennon, saint louis, missouri, united states background: intrauterine transfusion is the method of choice for management of fetal anemia due to red blood cell alloimmunization. despite the decrease in prevalence of anemia due to rhesus d alloimmunization with prophylactic administration of anti-rhd immunoglobulin in rh d negative patients, maternal red red blood cell alloimmunization with other type of red blood cell antigens remains an important cause of fetal anemia. newborn who received intrauterine transfusion for hemolytic disease may have prolonged postnatal transfusion requirement. objectives: 1-to evaluate clinical outcome of fetuses and newborns who received intrauterine transfusions. 2-to determine the need of packed red blood cell transfusions until 6 months of age. we conducted a retrospective case series study of all intrauterine transfusions due to anemia secondary to red blood cell alloimmunization performed in our regional center ssm in st louis missouri, between april 2011 and january 2016. we evaluated the indications, diagnosis, gestational age, and frequency of intrauterine transfusions, along with the infant's gestational age at birth, duration of admission, timing of blood transfusion and monitoring of hemoglobin. results: 37 intrauterine transfusions were performed in 14 patients. the most common causes of alloimmunization were due to d antibodies (n = 7, 50%) and kell antibodies (n = 5, 35.7%). the median gestational age of the first intrauterine transfusion was 28.1 weeks, and the median pre-transfusion hemoglobin was 8.9 g/dl. the gestational age at the first intrauterine transfusions was found to be significantly correlated with the number of postnatal transfusions (r = 0.8. p = 0.001). the median gestational age at birth was found to be 35 weeks (28.6-36.9 weeks), with a hemoglobin of 13.1 (10.8-14.1). in our population, 6 patients (42%) received postnatal transfusions, of which 4 were during the first 3 weeks of life, and close monitoring follow up with a hematologist was established in 6 patients at their discharge from the nursery/nicu. one neonatal death occurred and severe morbidity due to severe anemia occurred in one infant. despite the continuing risk factor for persistent anemia, only 8 patients had follow up hemoglobin monitored by their primary care provider. conclusion: infants with anemia due to red blood cell alloimmunization treated with intrauterine transfusion should be monitored closely via regular complete blood count for persistent anemia due to suppression of fetal erythropoiesis. sebastian hesse, piotr grabowski, juri rappsilber, christoph klein dr. von hauner childen's hospital, lmu university hospital, munich, munich, germany background: neutrophil granulocytes are the most abundant leukocytes in the peripheral blood. validated diagnostic options for these cells are limited, leaving many patients with functional neutrophil defects without a defined diagnosis. objectives: here we evaluate proteomics as a new diagnostic tool to investigate defects of neutrophil granulocytes. we analyzed neutrophil granulocytes from 6 children with severe congenital neutropenia (scn) associated with elane mutations, 4 children with chronic granulomatous disease (cgd) with cyba (2) or cybb (2) mutations and 2 children with leukocyte adhesion deficiency (lad) due to itgb2 mutations. in addition we collected samples of children with genetically undetermined neutrophil defects. neutrophils from 68 healthy individuals served as controls. cells were isolated from fresh venous blood using negative selection (purity >99%). whole cell proteome analysis was done by data-independent acquisition. showed a correlation coefficient of ∼0.9. principal component analysis demonstrated unequivocal separation of the proteome of healthy and diseased cells. differential expression analysis showed minimal proteome aberrations in lad with deficiency in cell surface receptors and upregulation of alpl (total downregulated proteins: 7/ total upregulated proteins: 5). analysis of neutrophils from cgd patients also showed limited proteome aberration. cyba and cybb were both diminished independent of genotype, whereas protein clusters around a stat1/2 centered network were increased (total down: 11/ up: 23). neutrophils with elane mutations showed the gravest proteome disturbance (total down: 47/ up: 93) with an upregulated translational apparatus (srpdependent ribosomes and protein folding complexes) and increased mitochondrial proteins. proteins of each granule subset were dysregulated and metabolic pathways upregulated. a detailed analysis of the proteome from patients with genetically undefined diseases is currently ongoing. one patient with clinical phenotype of cgd was found to have no mutations of nadph oxidase members in whole exome sequencing but critically low levels of ncf1 on protein level. heterozygosity mapping showed autozytocity in the ncf1 region warranting current efforts to sequence promoters and intronic regions of the gene. mass spectrometry based proteomics promises exciting new insights into monogenic disease of neutrophil granulocytes and may offer new diagnostic options, in particular in synergy with genome sequencing. by virtue of our international care-for-rare alliance, open to new partners, we hope that our proteome focus may lead to better delineation of as yet unknown disease of neutrophil granulocytes. background: warm autoimmune hemolytic anemia (aiha) is an igg mediated disease. although it can be post-viral, it is often idiopathic and can also be a forme fruste for malignancy or an autoimmune disease. initial management includes steroids. it often relapses on steroid wean and can be refractory to the use of second line treatment such as rituximab. objectives: abatacept (ctla-4-ig fusion protein, ctla-4 mimetic) has been used to ameliorate autoimmune manifestation associated with ctla-4 haploinsufficiency. we used abatacept as a novel therapeutic agent to manage patients with refractory aiha. design/method: a retrospective case series of two patients at phoenix children's hospital with severe refractory aiha. results: patient 1, a previously healthy 12 year old female, presented with 8 weeks of icterus, fatigue, and hemoglobinuria. spleen was enlarged 8cm below the costal margin. laboratory evaluation demonstrated: hemoglobin 3.8 g/dl, mild leukopenia 3200/microliter, platelets 99,000/microliter, reticulocytosis 14.3%, positive direct coombs' test, mycoplasma igm and igg positive. bone marrow evaluation showed a hypercellular marrow. she continued to need packed red blood cell (prbc) transfusions despite receiving high dose steroids, ivig and rituximab from may-july 2017. in august, she started sirolimus decreasing her transfusion requirement. after starting abatacept (10mg/kg/dose bi-monthly for three doses and then monthly) in october, she maintained hemoglobin of 9-10 g/dl without transfusion. patient 2, a previously healthy 2 month old male, presented with one week of progressive fatigue, jaundice, and poor feeding. splenomegaly was absent. laboratory evaluation revealed hemoglobin 3.8g/dl, leukocytosis 20,200/microliter, platelets 324,000/microliter, reticulocytosis 16.1%, negative direct coombs' test, and non-specific reactivity on antibody screen. evaluation for inherited hemolytic anemia including a next generation sequencing panel was negative. further evaluation by blood bank showed 2+ positive coombs' for c3d due to a warm antibody. cold agglutinin disease was ruled out. bone marrow evaluation was normal. he received high dose ivig as a steroid sparing agent but continued to require prbc transfusions weekly. when prednisone did not seem to slow down hemolysis, treatment with abatacept was initiated and he has not required transfusions for two months. steroids are being weaned. we present successful treatment of two refractory aiha cases with abatacept. patient 1 is steroid and transfusion free and continues on monthly abatacept and sirolimus. patient 2 is also transfusion free and continues on a steroid taper. ctla-4 is crucial for suppressive function of treg cells. abatacept by binding to cd80/86 seems to enhance treg activity ameliorating autoimmune hemolysis. children's minnesota, minneapolis, minnesota, united states s85 of s301 background: transfusional iron overload is common in patients receiving chronic red cell transfusions. as a result, iron chelation is required to minimize toxicity from iron overload. chelation with a single agent can be inadequate at controlling or reducing iron burden. when combination therapy is required deferoxamine may be added to oral chelation. deferoxamine is generally given subcutaneous over 8-12 hours for 5-6 days a week at 25-60mg/kg/day. many patients struggle to remain compliant with this schedule which has prompted trials of intravenous high-dose (hd) deferoxamine. prior reports of short-term hd deferoxamine have shown minimal side effects however, prolonged use of hd deferoxamine has known toxicity. when compliance is a concern, our center has used hd deferoxamine infusions at 15mg/kg/hr x 48hours every 2 to 4 weeks. objectives: evaluate the safety and efficacy of hd deferoxamine at our institution to help guide future therapy. design/method: a retrospective review was completed of patients previously treated with hd deferoxamine between april 2011 and september 2017 at children's minnesota. final sample included 8 patients ages 3 to 14 years with underlying diagnosis of thalassemia (7) and diamond-blackfan anemia (1). deferoxamine infusions were given for 48 hours every 24-35 days with a mean length of treatment of 279 days. results: all patients were on combination therapy with deferasirox, however deferasirox was held during deferoxamine infusion. mean pre-deferoxamine liver iron concentration (lic) was 31.75mg/g and mean post lic was 12.11mg/g (p = 0.0008). ferritin mean pre-deferoxamine was 2677ng/ml compared with mean post 1594ng/ml (p = 0.0107). two patients had possible allergy, leading to deferoxamine discontinuation. one patient developed hives, eye swelling and cough while the other had emesis and cough. another patient experienced facial nerve palsy of unclear etiology, which did not recur with resumption of deferoxamine. no respiratory complications were seen. results showed significant decrease in iron burden following combination therapy with high dose deferoxamine and deferasirox. no significant pulmonary, liver, renal, vision, or hearing toxicities were observed. three patients reported reactions to deferoxamine infusions. however, one of these was able to successfully continue deferoxamine without further incident. short-term, hd deferoxamine was effective at reducing lic in combination with oral chelation but requires further evaluation to assess for potential increased risk of toxicity. short-term hd deferoxamine may be considered in the setting of poor compliance of subcutaneous administration or inadequate chelation with single agent therapy. further studies are needed to clarify ideal dosing, timing and risk of toxicity. background: immune thrombocytopenia (itp) is the most common cause of symptomatic thrombocytopenia in childhood but remains a diagnosis of exclusion warranting further evaluation if atypical findings are present. two male children (15 months and 3 years old) with newly diagnosed immune thrombocytopenia (itp) were found on initial evaluation to have persistent elevations of lactate dehydrogenase (ldh), alanine aminotransferase (alt), and aspartate aminotransferase (ast). these serum enzyme abnormalities cannot be attributed to itp. in the setting of thrombocytopenia, elevated transaminases and ldh create diagnostic complexity for the hematology/oncology provider as their elevation raises concern for malignancy, hemolytic disease, and other systemic diseases. to raise awareness about an unexpected pattern of duchenne muscular dystrophy in patients undergoing evaluation for itp. to expand the differential of a hematologist/oncologist when abnormal labs support a nonhematologic diagnosis design/method: this case-series of two patients with their clinical and laboratory findings were discovered with retrospective chart review. results: after a thorough evaluation for hemolytic anemias, liver disease and infectious etiologies was negative, bone marrow and liver biopsies were considered. eventually, both children were found to have severely elevated serum creatine kinase (ck). skeletal muscle has the highest concentration of ck of any tissue. thus, significant ck elevation is almost exclusively attributable to muscle injury and is the most sensitive and specific enzyme for diagnosis of muscle disease. referral to a neuromuscular specialist and further genetic testing confirmed the diagnosis of duchenne muscular dystrophy in both children allowing initiation of appropriate interventions. to date, there is no clear genetic predisposition to itp in patients with muscular dystrophy although further investigation may be needed. hematology/oncology providers should consider obtaining a serum ck to rule out muscle disease in any male child with unexplained elevations of serum ldh and/or aminotransferases, as it provides an easy and inexpensive, non-invasive approach to screening. additionally, clinical history and physical examination can aid in the diagnosis of muscular dystrophy, with gross motor delay, abnormal muscle bulk, gower's sign, and proximal muscle weakness all possible findings. objectives: to identify the range of cbcs in patients with ds without infections, hematologic or immune disorders and to create more accurate reference ranges for total white blood count; hemoglobin; hematocrit; mcv; platelet count and absolute neutrophils (anc), lymphocytes, monocytes, eosinophils, and basophils. design/method: a retrospective investigation of healthy pediatric patients with ds who received a cbc between 2011 and 2017 as part of their medical care at a single, large, pediatric teaching hospital. the study group consisted of 562 children with ds (male = 310, 55.2%; mean age = 2.10 years, sd = 3.17) at time of blood draw. initially 692 children were reviewed for possible participation in the study; however, 130 patients were excluded due to not meeting the study's inclusion criteria. descriptive statistics were performed on demographic and clinical characteristics. kruskal-wallis h tests, anova, and t-tests were run to determine the significant associations between independent means. results: a significant difference in absolute neutrophils between racial groups, f(2, 183.553) = 3.990, p = 0.020, was observed. there was an increase in anc from 2.5 +/-1.1 with african americans to 3.0 +/-1.6 in the other racial groups and to 2.9 +/-2.0 with caucasians. differences were also found in anc in hispanics/latinos versus non-hispanic/latinos. the results were higher in non-hispanics and latinos, a significant difference of -.584 (95% ci, -.791 to -.376), t(1255) = 2.572, p = 0.001. preliminary kruskal-wallis h tests run determined that there were significant differences between age groups for total white blood cell, hemoglobin, hematocrit, platelets, lymphocytes and anc. further studies are being run to evaluate in which age groups these differences lie and create reference ranges by age, race and sex. conclusion: among patients with ds, there are differences between racial groups and age groups. this data has been compared to previously established reference ranges for cbcs, but we are currently establishing healthy cbc controls which we will use to validate the reference ranges. these ranges will be published to help guide providers in workup and management of patients with ds. background: transfusion is a critical part of the care provided in the neonatal intensive care unit, but it is not without risks. low birth weight and premature infants can become anaemic from an immature haematopoietic system and frequent phlebotomy. these infants often receive multiple red blood cell transfusions. identifying infants more likely to require such intervention is important in ensuring the appropriate usage of this scarce resource. to determine whether birth weight, gestational age, gender, length of stay and mode of delivery can predict red cell concentrate (rcc) transfusion, units required, donor exposure and time to exposure. design/method: a retrospective chart review of all infants born below 32 weeks gestation and/or birth weight less than 1,500g who received a red blood cell transfusion between july 2009 and july 2012 in the cork university maternity hospital neonatal unit. results: 224 infants met the inclusion criteria, 105 (46.87%) received a rcc transfusion. our study showed lower gestational age (p<0.01) and lower birth weight (p<0.01) infants are more likely to be transfused. donor exposure increases with a lower birth weight (p = 0.016). multivariate analysis showed infants with a lower gestational age (or -0.019 per day; p<0.05); lower birth weight (or -0.002 per 1g; p<0.01) and a longer length of stay (or 0.016 per day; p<0.05) are more likely to receive a higher number of rcc transfusions. the time to first rcc transfusion is shorter in those with lower birth weight (or 0.013 per 1g; p<0.05) and lower gestational age (or 0.356 per day; p<0.01). gender and mode of delivery were not found to be predictors of red blood cell transfusion in this study. conclusion: low birth weight and premature infants are more likely to receive a rcc transfusion during admission to the neonatal unit. our study highlights predictors of rcc transfusion, donor exposure and time to transfusion. these can be used in identifying at risk infants, counselling parents and in anticipating transfusion requirements. emily southard, r. grant rowe, david williams, akiko shimamura, taizo nakano children's hospital colorado, aurora, colorado, united states background: the mecom locus encodes transcription factors that regulate hematopoietic stem cell self-renewal and maintenance. overexpression of mecom has been noted in 5-10% of acute myeloid leukemia, several solid tumors, and denotes a poor prognosis. mutations that reduce mecom expression or that disrupt protein function, however, have been implicated in the development of bone marrow failure (bmf) through undefined pathways. an association between mecom mutations and radioulnar synostosis with amegakaryocytic thrombocytopenia (rusat) syndrome has been reported, however further characterization of this phenotype has yet to be explored. to characterize the phenotypic spectrum of a cohort of pediatric patients with novel mecom mutations. we performed a retrospective review of five patients with mecom mutations who were referred to hematology at children's hospital colorado or boston children's hospital. clinical, laboratory, and genetic data was collected on subjects and available family members. results: four of 5 subjects were identified in infancy presenting with congenital cytopenias or physical dysmorphisms that prompted broad genetic screening. platforms for genetic detection included microarray, targeted genetic panels, and whole exome sequencing. three of 4 subjects with cytopenias presented with congenital thrombocytopenia, 1 of whom rapidly progressed to severe aplastic anemia. four of 5 subjects presented with congenital anomalies, 3 of whom demonstrated radioulnar synostosis. additional dysmorphic features identified include craniofacial (low set ears x1), cardiac (pda x1, vsd x1, aortic root dilation x1), pulmonary (pulmonary hypertension x1, arteriovenous malformations x1), and developmental delay. one subject presented at age 13 years with acute pancytopenia, hypocellular marrow, no dysmorphisms, and a mecom variant of unknown signif-icance. the identified mecom mutations include one 4.1 mb deletion involving several genes including mecom, one variant affecting a splice acceptor consensus sequence predicted to disrupt splicing, and three novel missense mutations, tyr949cys, arg950thr, and tyr1118cys, all of which were absent from public databases and were predicted in silico to be deleterious. we describe the phenotypic spectrum of 5 patients with novel mecom variants. a subset of patients lacked radio-ulnar synostosis and had presence of additional systemic anomalies, demonstrating a varied clinical phenotype that is not isolated to rusat syndrome. a centralized publically accessible database to share clinically annotated mecom variants, together with analysis by experts in mecom function would advance our understanding of the clinical interpretation of mecom variants. mecom should be considered in the differential diagnosis of bone marrow failure and we advocate for the inclusion of mecom in targeted sequencing panels. cairo university, cairo, egypt background: beta thalassemia is regarded as a serious public health problem in the mediterranean region, southeast asia, and the middle east. however, very few studies have been conducted to assess the quality of life (qol) among thalassemia major patients. objectives: to assess the quality of life among b-thalassemia major patients using short form (sf)-36 questionnaire and to determine the factors associated with their quality of life. design/method: a cross-sectional study was conducted among thalassemia major patients who were attending the hematology outpatient clinic at cairo university hospital, during the study period. data were collected between october 2016 and march 2017. the quality of life was assessed for patients aged ≥17 years. the mean age of the studied group was 18.32± 1.33 years. the majority (93.63%) had one monthly blood transfusion. the mean total score of sf-36 was 44.90±7.54. general health perception domain was the most affected domain with mean score, while vitality was the least affected one. there was no statistically significant difference between males and females regarding different quality domains except for vitality where the mean score was significantly higher in males than females (p = 0.05). age at onset of disease, and at first blood transfusion were the most documented factors positively correlated with the quality of life among the enrolled thalassemia patients. conclusion: the quality of life in thalassemia major patient was found to be compromised. all thalassemia patients should undergo assessment of the quality of life so that interventions focusing on the affected domains can be implemented. background: international adoption of children with special needs has become more prevalent in recent years leading to tremendous growth in the number of u.s. thalassemia patients adopted from foreign countries. currently 13% of the 1,119 thalassemia patients registered in the cooley's anemia foundation (caf) patient database have been adopted from foreign countries, primarily china. as this population continues to grow, further information is needed in order to provide these families with best supportive care. the primary goal of this study is to characterize the socio-demographics and health statuses of adopted children with thalassemia and their families. a secondary goal is to describe adoptive families' motivations, experiences, challenges, and support resources. design/method: a redcap survey was accessed by families of adopted children with thalassemia through the caf website and caf social media from january to august 2017. following a four-question screen, eligible subjects were directed to complete an adoption questionnaire. families who had at least one adopted child with thalassemia receiving care at a participating thalassemia treatment center or hematology office in the u.s. were considered eligible. descriptive statistics were analyzed using sas 9.4. respondents who were ineligible or who provided incomplete data were removed from the dataset prior to analysis. of 78 survey respondents, 67 qualified and completed the survey. these households had adopted a total of 74 children with thalassemia (33.8% male), most from china (93.2%), where they had been living in orphanages (73.0%). legal guardians identified primarily as christian (87.3%). the majority had completed post-secondary education (76.9%) with reported household incomes greater than $80,000 (76.1%). most adoptive families were connected to an adoption group or community including online groups, local support groups, and adoption networks (98.5%). commonly cited challenges were: 1) volume of frequent medical appointments, 2) insufficient support from their local care centers, and 3) financial burdens. the reality of care for the population of adopted patients with thalassemia in the u.s does not seem to match the expectations set by their providers. we are hopeful this data will be used to assist adoptive families navigating the complexities of thalassemia care. the findings suggest that this population would benefit from additional outreach, education, guidance, and advocacy resources -especially in the early stages of adoption and during initiation of post-adoption medical care. background: in many higher-income countries, thalassemia major has become a chronic disorder; many outcomes are different in emerging countries with more limited resources. most analyzes of health-related quality of life (qofl) in thalassemia have been conducted in high-income settings. objectives: to assess the impact of health status on qofl in thalassemia patients in an emerging country. we assessed qofl in 110 randomly-selected patients (72 thalassemia major; 33 with hemoglobin e thalassemia; five thalassemia intermedia) at the national thalassemia center in kurunegala, sri lanka where approximately 800 patients are managed. treatment is free, but compared to north america/europe, access to tertiary staff and other resources are limited. overall, control of body iron as estimated by serum ferritin concentration (mean± sem, 2906±267 g/l) was not optimal in many patients. to understand the impact of health status on qofl, we used the sf36v2 health survey, analyzing scores of physical function, pain, general health, social functioning, emotional and mental health, to generate overall physical and mental component scores. results: compared to reports from higher-income countries (american journal of hematology 2011; 86:92-5), physical function scores (mean±sd, 48.16±10.72) were similar in sri lankan patients; indeed, in three categories (physical role, social function, emotional role), sri lankan scores were slightly higher. by contrast, compared to scores from higherincome settings, those estimating bodily pain, general health, and mental health were significantly lower, resulting overall in a significantly lower physical component score in sri lankan patients. male sri lankan patients reported higher scores than females, and somewhat surprisingly, in four categories (physical function, physical role, social function and emotional role) reported higher scores than those obtained in higher-income settings. lower scores in physical functioning, leading to an overall lower physical component score, were recorded by females. patients with hemoglobin e thalassemia reported generally poorer qofl than those with thalassemia major. the lack of differences in qofl in patients with "high" and "low" hemoglobins was likely related to low pre-transfusion hbs (mean±sem, 8.31 ± 0.14 g/dl) in nearly all patients. these early data in a small cohort of thalassemia patients in an emerging setting suggest that in many patients bodily pain, reduced mental health, and poorer views of general health affect overall qofl. prospective studies in larger cohorts including evaluation of adequacy of transfusions and chelation therapy, complications, and overall accessibility of care may guide approaches to improve qofl in lower-income settings of thalassemia care. geetanjali bora, anand prakash dubey, tarun sekhri, mammen puliyel, aparna roy maulana azad medical college, new delhi, delhi, india background: in the last two decades, the presence of osteopenia has been described in optimally treated patients with transfusion dependent thalassemia, the pathogenesis of which seems to differ from osteopenia in non-transfused patients. the prevalence rate of low bone mineral density (bmd) in pediatric population is highly variable amongst studies done worldwide. furthermore, the role of metabolic and endocrine factors in determining bone mass in this population is not well understood. objectives: to assess bmd in subjects with transfusion dependent beta thalassemia by dual-energy-x rayabsorptiometry and find its co-relation with clinical, biochemical and hematological parameters. design/method: this is a comparative cross-sectional study and includes patients with transfusion dependent beta thalassemia between ages 6 to 16 years enrolled from a thalassemia day care center in the year 2012 -2013. at the time of enrollment age, sex, bmi z scores, pubertal staging, duration and type of chelation therapy were noted. enrolled subjects were scanned for bmd at lumbar spine l2-3 and left femoral neck using dexa scan. the bmd was expressed in mean values and z scores. age, bmi, ethnicity and gender matched historic controls were used to generate z scores. 5 ml of pre transfusion fasting venous blood samples were obtained to test for serum calcium, phosphate, alkaline phosphatase, pth, thyroid function panel, serum ferritin and serum igf-1 levels. mean values for pretransfusion hemoglobin and serum ferritin over last 12 months were calculated. results: total no of subjects 50, median age 11.6 years, male 32 (64%), female 18 (36%), ethnicity 100 % asian, bmi < 3rd centile 13 (26%), pre pubertal 50%, all receiving transfusion and chelation therapy. prevalence of low (z score < -1 sd) and very low (< -2.5 sd) bmd was 74%, 52 % at l1-l2 respectively and 66 %, 24% at left femoral neck respectively. there was trend of lower bmd z scores with advancing age. statistically significant co-relation (p value < 0.05) was found between low bmd and low mean pretransfusion hemoglobin, serum phosphate, igf -1 and vitamin d levels conclusion: a sizable proportion of children and adolescents with transfusion dependent thalassemia have suboptimal bone mineral density and this decline may start as early as 6-7 years of age despite being on transfusion regimen highlighting the importance of yearly dexa screening and optimization of pre-transfusion hemoglobin, vitamin d and igf 1 levels. vanderbilt university medical center, nashville, tennessee, united states background: it is well described that iron deficiency anemia (ida) can co-present with thrombocytosis or thrombocytopenia, though cases of thrombocytopenia are less frequent than thrombocytosis. prior reports of thrombocytopenia have included adult and pediatric patients with menorrhagia (1-2), menorrhagia due to uterine fibroids (3), or other gynecologic abnormalities (4). our cases highlight the pattern of ida, thrombocytopenia, and menorrhagia in the setting of significant menstrual clotting without observed gynecologic abnormalities in african-american adolescents. objectives: to describe the clinical course of three adolescent females with severe ida, menorrhagia, and thrombocytopenia. results: our cases included three female african-american patients ages 12-17 who presented with severe anemia and concurrent thrombocytopenia in the setting of menorrhagia. all three patients reported heavy and prolonged menstrual cycle bleeding with significant clots. two of the three were admitted for transfusions at presentation and noted to have significant menstrual bleeding with continued blood loss requiring additional transfusions until bleeding was controlled with estrogen therapy. these two patients were evaluated with pelvic ultrasounds revealing a prominent endometrium in both patients and hyperechoic material consistent with a clot in one patient. average hemoglobin on presentation was 4.3 gm/dl (2.8-6.5), average platelet count was 70,000/mcl (18,000-99,000), and average mcv was 63 (54-68). all had severe iron deficiency with an average ferritin of 4 ng/ml (2-7) subsequently treated with oral iron. one patient had a prior history of ida that required transfusion and had subsequent normalization of her complete blood count. two patients had subsequent thrombocytosis before normalization of their platelet counts. two patients received platelet transfusions: one due to recent neurosurgical intervention with a higher goal platelet count and the other to help control menstrual bleeding after a nadir platelet count of 9,000. a review of the clinical history and red cell indices pointed to ida and ongoing blood loss from menorrhagia as the reason for the bicytopenias. the thrombocytopenia in these cases may have been exacerbated by consumption of platelets in the significant clots all three patients reported. it is reasonable to treat with iron supplementation and supportive care which may include transfusions or management of menorrhagia with oral contraceptives or other hormonal methods. background: sickle cell disease is one of the most common inherited red blood cell disorders, yet many are not aware of their carrier status. the american college of obstetricians and gynecologists' guidelines recommend that pregnant women of african, mediterranean and southeast asian descent be screened for hemoglobinopathies with a cbc and hemoglobin electrophoresis1. however, adherence to this practice and frequency of improper screening with sickledex is unknown. proper screening and counseling can impact families' knowledge, allowing for establishing relationships with pediatric hematology providers earlier. objectives: we sought to assess prenatal hemoglobinopathy screening practice patterns and methods of obstetrics & gynecology (obgyn) and family medicine providers in the nyc regional area. design/method: a cross-sectional electronic survey was administered to obgyn and family medicine practitioners from four nyc institutions. questions focused on prenatal hemoglobinopathy screening practices using case scenarios with variations on parental trait status and ethnicities. chisquare analyses were used to compare the two provider groups on categorical variables. there were 98 total responses; 71 surveys were complete, of which 48 were obgyn and 23 family medicine providers. respondents were mainly from academic medical centers, with the majority being faculty (68% of the obgyns and 41% of family medicine). no significant difference was found in frequencies of screening patients with a positive family history of a hemoglobinopathy. when asked about screening practices for patients without a personal/family history of a hemoglobinopathy, 92% of obgyns versus 70% of family medicine providers "always" screened for hemoglobinpathies (p = 0.03). when analyzed by ethnic background, there were significant differences by group in screening patients of white (92% vs 70%), black (94% vs 74%), mediterranean (94% vs 74%), and asian descent (94% vs 70%) (p≤0.05 for all). however, in cases where the hemoglobinopathy carrier status of both parents was known, there was no difference in screening with a hemoglobin electrophoresis. furthermore, >20% of all respondents use sickledex for screening in the case scenarios. conclusion: this pilot survey highlights a difference in the methods and likelihood of prenatal hemoglobinopathy screening based on the type of prenatal care provider. screening differences can lead to variations in prenatal guidance, diagnostic procedures, informed decision-making and knowledge of families referred to pediatric hematology clinics. this is the first study analyzing prenatal screening for hemoglobinopathies in obgyn and family medicine. improving prenatal screening practices by collaborating with hematologists may decrease health care disparities and allow for earlier relationship building with pediatric hematology. 1. acog, opinion#691, 2017 poster # 220 hermansky-pudlak syndrome: spectrum in oman background: hermansky-pudlak syndrome (hps) is a rare autosomal recessive disorder, characterized by the triad of oculocutaneous albinism, a hemorrhagic diathesis resulting from storage pool-deficient platelets, and accumulation of ceroid/lipofuscin-like material in various tissues. before 2016, nine different types of hermansky-pudlak syndrome were identified, which can be distinguished by their signs and symptoms and underlying genetic cause. in 2016, a tenth type was defined based on mutations in the ap3d1 gene. hps type 2 is characterized in addition by severe neutropenia and recurrent sinopulmonary infection. the disease is more common in puerto rico, and this is the first report from oman. to describe the clinical, laboratory and genetic characteristics of hps sub-types in oman, including the first 2 cases of hps type 2. design/method: this is a retrospective study, including 7 cases with hps that had been suspected clinically and confirmed through genetic mutation analysis. clinical data included sex, age at presentation, initial clinical presentation (skin, eyes, development, neurological involvement, bleeding tendency, recurrent infections) and course of disease. laboratory data (complete blood counts, platelet and absolute neutrophil counts, coagulation screening, platelet function tests by platelet function analyzer, and platelet aggregation studies using different agonist had been recorded. pcr and next generation sequencing for genetic confirmation by testing mutations in hps1, ap3b1, hps3, hps4, hps5, hps6, dtnbp1,, bloc1s3, bloc1s6 genes had been done. results: seven omani cases with hps have been identified (4 males and 3 females). their age ranged between 0 (at birth) to 10 years. two patients had hps type 2, 1 patient had type 6, while the other 4 cases had hps type 3. no other sub-types were encountered in oman. all patients were products of consanguineous marriage. one patient had adrenal hge, while the others had mild hemorrhagic phenotype, characterized by recurrent bruising and mild epistaxis. laboratory testing confirmed variable platelet aggregation defects with different platelet agonists. all patients had characteristic hypopigmentation, iris transillumination, nystagmus, and foveal hypoplasia. both patients with hps type 2 had the same homozygous mutation in the ap3b1 gene (c.12_13delta), and presented with severe neutropenia. early diagnosis and initiation of gcsf on one of them improved outcome and prevented the development of complications. late diagnosis in the other patient resulted in the development of bronchiectasis as a result of recurrent sinopulmonary infections. background: sickle cell disease (scd), a genetic disorder characterized by defective sickle hemoglobin (hbs), triggers red blood cell sickling, hemolysis, vaso-occlusion, and inflammation. ischemic injury from scd starts in infancy and accumulates over a lifetime, causing pain, fatigue, and progressive end-organ damage that culminates in early mortality. voxelotor (gbt440) is an oral, once-daily therapy that modulates hemoglobin's oxygen affinity, thereby inhibiting hemoglobin polymerization. objectives: to assess the safety, pharmacokinetics, and efficacy of voxelotor in pediatric patients with scd. design/method: this ongoing study is being conducted in 2 parts: part a: a single dose of voxelotor 600 mg in pediatric and adolescent patients; part b: multiple doses of voxelotor 900 mg/d or 1500 mg/d for 24 weeks in adolescents. part b's primary objective is to assess the effect of voxelotor on modifying anemia. secondary objectives include measuring other markers of disease modification, such as hemolysis; daily scd symptoms, using a patient-reported outcome (pro) measure; and safety. results: as of november 6, 2017, 24 patients (10 females) had received voxelotor 900 mg and 12 patients (6 females) had received voxelotor for ≥16 weeks. the median age for the 12 patients was 13 years, 92% were receiving hydroxyurea (hu), and 41% had ≥1 painful crises in the past year. data for hemolysis measures are available for 11 patients who received voxelotor for 16 weeks. six of the 11 patients achieved a hemoglobin (hb) response of >1 g/dl increase. laboratory markers of hemolysis improved concordantly; the median reductions in reticulocytes and indirect bilirubin were 11% and 40%, respectively. ten of 12 patients showed reduction in total symptom scores (tss) at week 16, with a 94% median reduction in tss from baseline. there were no treatmentrelated serious adverse events (aes) or drug discontinuations due to aes. voxelotor 900 mg for 16 weeks in adolescents with scd, the majority receiving hu, demonstrated consistent, sustained efficacy on hb levels and measures of hemolysis; >50% of patients showed a >1 g/dl improvement in hb. improvement in tss in mildly symptomatic patients suggests that the pro is sensitive to treatment effect and supports use in the ongoing hope phase 3 study. voxelotor's reassuring safety profile is consistent with results in adults. these interim results support ongoing clinical evaluation of voxelotor as a potential disease-modifying therapy for adults and children with scd. supported by global blood therapeutics. background: acute kidney injury (aki) is a common complication in sickle cell disease (scd), and a potential risk factor for sickle nephropathy. aki is associated with acute decline in hemoglobin (hb) during vaso-occlusive pain crisis and acute chest syndrome (acs). it is unclear which pathologic factor plays a stronger role in aki development during hb drop: increase in free heme during vaso-occlusive events secondary to hemolysis or hb decline itself. objectives: to investigate if hb decline alone is associated with aki, we tested if the renal function of patients with scd worsened during parvovirus b19-induced transient aplastic crisis (tac), in the absence of accentuated hemolysis. design/method: with irb approval, a retrospective study of patients who had laboratory confirmed parvovirus-b19 was conducted. serum creatinine (scr), both during and within 12 months from the tac event, was collected. comparisons of the clinical and laboratory characteristics were analyzed using the wilcoxon test for continuous variables. aki was defined as an increase in scr by ≥0.3 mg/dl or a 50% increase in scr from baseline. to evaluate differences in change in hb on aki risk, changes in scr during tac were compared to those during pain crisis or acs admissions by fitting a generalized linear mixed model for binary outcome. a comparative sample of 149 acs events and 197 vaso-occlusive pain crisis were used to estimate rates of aki according to hb levels. results: three (9%) of the 34 patients with scd developed aki during tac. no association was identified between change in hb from baseline to tac event (p = 0.08). no cases of aki were identified until hb decreased <5.0 g/dl or the change in hb was ≥4.5 g/dl from baseline. next, we developed a model to evaluate the impact of change in hb from baseline for patients admitted with tac, pain crisis or acs on aki. with a 2 g/dl decrease in admission hb from baseline, patients with tac had a 3% probability of developing aki, while acute chest syndrome and pain crisis would have a 9% and 27% probability, respectively. our data suggest that aki is still prevalent during parvovirus b19-induced tac. however, the risk of aki during a tac event is 3 and 9 times lower than that from severe anemia induced by acute chest syndrome and vasoocclusive pain events, respectively. hemolysis-induced anemia during scd crisis appears to have a more significant role in the development of aki as compared to agenerative anemia. background: the natural history of hemoglobin e beta thalassemia (hbethal), the commonest form of severe beta thalassemia worldwide, has been examined in very few longterm studies. previously, we reported findings in 109 hbethal patients in sri lanka.1 objectives: to evaluate longterm requirements for transfusion and splenectomy, complications and death in hbethal patients. design/method: all available patients were reviewed 1-4 times annually over 12 years. results: 33 patients (30%) died, aged (mean ± sem) 29.3 ± 4.2 years; the (known) causes commonly included iron overload (9) and infection (12); 76 patients surviving patients are aged 33.4 ± 1.2 years. of 109 patients originally classified by severity (group 1 the mildest, and group 5 the most severe, phenotypes), 62 (57%) were assessed as mild (groups 1 and 2), of whom transfusions had been discontinued in 46. ultimately, 23/46 (50%) resumed transfusions, often following shifts to increasingly severe phenotypes including increasing intolerance to anemia. age at resumption of transfusions (following a transfusion-free interval of 14.9 ± 1.6 years) was 32.8 ± 2.7 years; in the more severe groups 4 and 5, regular transfusions were stopped in 27/33 patients and resumed in 22/27 (81%), at younger ages (19.9±1.8 years) and after shorter transfusion-free periods (10.1±1.4 years) than in "milder" patients. mid-parental height (mph) was ultimately achieved in 53%. 84 patients (77%) were splenectomized; updated analysis of responses to splenectomy (originally "group 3" patients), showed that splenectomy (at 9.0 ± 0.9 years) was followed by an extended, but impermanent, transfusion-free interval (11.1 ± 1.4 years); 50% patients resumed transfusions, usually related to exercise intolerance or poor growth. in groups 1 and 2, complications of anemia and ineffective erythropoiesis, including leg ulcers (in 38% and 50%) and gallstones (44% and 54%), were more frequent than in groups 4 and 5; fractures were observed (25-48%) across all groups, except for regularly-transfused group 5 patients (0%). pulmonary artery pressures >30 mm were recorded in 39% patients. evaluation of patients with hbethal requires observations over years, without which definition of patients as "mild" or "severe" may be misleading. while in many patients transfusions may be withheld or reduced in frequency, troublesome complications may surface with advancing age even in "milder" patients. although individual consideration of transfusion requirements is critical, the availability of effective chelation, where this can be provided without prohibitive cost, may alter the balance of risks and benefits of regular transfusions in hbethal. 1(premawardhena a. lancet 2005). background: social determinants of health (sdh) are environmental and socioeconomic factors, such as access to food and housing that affect health outcomes. pediatricians are increasingly screening for sdh as part of primary care visits, however less is known about screening for sdh in pediatric hematology. evidence suggests that sdh play a role in disease severity for children with scd, who face significant socio-economic and racial disparities. the goal of our quality improvement (qi) project was to increase the percentage of patients with scd who were connected to community resources for unmet social needs. design/method: we based our intervention on the successful implementation of wecare in our institution's pediatric primary care clinic. eligible patients were identified at the start of each clinic session. on arrival the parent was given a self-reported screening tool for six sdh (childcare, education, employment, food, utilities and housing). results were entered in the electronic health record by the physician or social worker who then printed a pre-existing resource list for patients with a positive screen. we used a series of plan-do-study-act (pdsa) cycles to study tests of change. we tracked process measures (percentage of patients screened, percentage of patients with an unmet social need who received a resource sheet), outcome measures (percentage of patients with an unmet social need who connected with a community resource) and balancing measures (staff, patient and provider satisfaction). run charts were reviewed weekly and then monthly to inform further tests of change. examples of pdsa cycles include who gave the paper survey to patients (social worker or physician versus medical assistant) and length of time between surveys (3 to 6 months). results: between august and december 2017 screening rates improved from 57% to 88%. of the patients screened, 67% report at least one unmet social need; of those 33% received a targeted list of community resources in the first month of the project, and 92% in the fifth month. finally, 44% of patients reached by phone had connected with a community resource within 2 weeks of the clinic visit. we have successfully implemented universal screening for sdh for patients with scd in our urban pediatric hematology clinic without requiring extra staff. next steps include further pdsa cycles to connect more patients to appropriate resources, and tracking improvement in health care utilization outcomes from addressing sdh in this vulnerable patient population. background: the clinical manifestations of sickle cell disease (scd), chronic hemolytic anemia, and vaso-occlusion occur as a direct result of sickle hemoglobin (hbs) polymerization. voxelotor (gbt440) is a first-in-class, oral, oncedaily investigational agent designed to modulate hemoglobin's oxygen affinity in a targeted approach to inhibit hbs polymerization. objectives: to examine the pharmacokinetics (pk), safety, and dosing of voxelotor in children (aged 6-11 years) and adolescents (aged 12-17 years) with scd from part a of the gbt440-007 study. design/method: gbt440-007 is an ongoing, open-label, phase 2a study in patients aged 6-17 years with scd (sickle cell anemia or sickle beta zero thalassemia). part a of this study (the focus of this abstract) is examining pk of singledose (600 mg) voxelotor. pk samples to measure whole blood and plasma voxelotor concentrations were collected up to 15 days following single-dose administration. separate population pk (ppk) models were developed to describe the concentration versus time profiles of voxelotor in whole blood and plasma using nonlinear mixed effects modeling (non-mem, version 7.3). ppk modeling and physiologically based pk (pbpk) modeling were used to simulate voxelotor pk parameters and support dose selection for future evaluation in younger children. : part a included 7 adolescents (4 females; median age 16 years [range 14-16]) and 6 children (3 females; median age 8.5 years [range 6-10]). mean weight was 52.8 kg (range 45-66 kg) and 21.1 kg (range 16-38 kg) in adolescents and children, respectively. voxelotor was well tolerated with no drugrelated grade ≥3 adverse events (ae) or serious aes. a 2compartment model with first-order absorption best described the pk of voxelotor (and was the same model structure used for adults with scd). voxelotor pk exposures in adolescents were comparable to those observed in adults, but higher exposures were observed in children. ppk and pbpk modeling support the use of a weight-based dosing strategy in younger children (aged <12 years) in future trials. adult voxelotor doses can be used in adolescents. however, based on higher pk exposures, a lower weight-based dosing strategy is recommended in children. ppk and pbpk modeling provides an innovative approach to minimize experimental dosing in children and accelerate dose selection of voxelotor in ongoing and future clinical studies. this abstract is supported by global blood therapeutics. background: hydroxyurea (hu) reduces rates of acute complications, and improves long term outcomes in patients with sickle cell disease (scd) and is now fda approved for children. through previous work we have increased the number of eligible patients on hu in our clinic, however accessing a compounding pharmacy remained a significant barrier to hu adherence for infants and children who cannot swallow capsules. objectives: the objective of our quality improvement project was to improve adherence to hu among pediatric patients with scd at our urban safety net hospital by addressing barriers to obtaining liquid hu. design/method: to begin we met with the leadership of our outpatient pharmacy which offers mail order delivery. however, like most retail pharmacies, they do not have the necessary protective equipment to compound liquid hu. through a series of discussions, we began a unique partnership with our institution's inpatient chemotherapy pharmacy who compounds the liquid hu and delivers it to the outpatient s95 of s301 pharmacy, who then dispenses liquid hu to families. using a series of plan-do-study-act (pdsa) cycles we tracked adherence by calculating the medication possession ratio (mpr), defined as the percentage of days in a given period of time that each patient had their medication on hand. the mpr for liquid hu mpr among enrolled patients was tracked by pharmacy staff and reviewed monthly. additional pdsa cycles included adding automatic refills and reminder calls by pharmacy staff and improving communication about delivery. we also tracked patient satisfaction. results: between march 2016 and december 2017, a total of thirty pediatric patients were enrolled in our program for on-site compounding and free mail order delivery of liquid hu. mpr for liquid hu is currently 93.8% among enrolled patients, significantly higher than the mpr of 60% reported in the literature, and has risen steadily since the beginning of the project. families are highly satisfied with the program, specifically appreciating the convenience of mail order delivery, saving on delivery fees, and reminder calls when refills were due. by compounding and dispensing liquid hu directly from our institution's outpatient pharmacy we have significantly improved adherence to this hu therapy in our high-risk population. next steps include analysis of change in clinical outcomes for patients enrolled in this program. as adherence to hydroxyurea is associated with decreased acute care utilization and cost, programs such as ours could play a crucial role in reducing the excessive costs and ed utilization among this patient population. background: experience with the iron-chelator deferasirox is reported widely in higher-income settings. by contrast, real-life experiences in emerging countries are infrequently reported. objectives: to evaluate, in a non-trial setting, the real-life response to deferasirox in an emerging country. design/method: in sri lanka's national thalassemia center which manages 800 patients without tertiary staff, quantitative evaluations of body iron or estimates of extra-hepatic iron, the records of 328 patients who began deferasirox in 2010/11 were retrospectively reviewed. results: baseline assessments (mean±sem) indicated substantial iron loading [serum ferritin (sf) 4,529±125 ug/l; serum alt 111±3.5 u/l (normal ≤ 40 u/l)]. deferasirox was introduced at low doses (21.2 ± 0.3 mg/kg/day); many patients started at <20 mg/kg and, after 12 months, doses remained ≤30 mg/kg/day in 60% patients. after 24 months, sf in 50% patients remained >2,500 ug/l; only by 48 months had (mean) sf declined to <2,500 ug/l (2475±344; p<0.001). similarly, mean alt normalized (to 35 ± 5 u/l) only by 60 months. death and complications were not systematically recorded by staff who had been charged, without provision of additional resources, with the introduction of this new drug in hundreds of patients. these results contrast to those in sri lanka's tertiary thalassemia center where, in 107 patients following the introduction of deferasirox 32 ± 0.1mg/kg/day, sf declined rapidly, even in relatively less ironloaded patients (from 3,231±278 to 2,153±218 g/l after 24 months; p = 0.0002). these findings underscore the importance, during the implementation of new drug regimens in lowerincome centers with marginal resources, for investments in methods to quantitate body iron burden, hands-on educational initiatives to guide day-to-day management by competent but non-expert staff, and data systems to record efficacy, effectiveness, toxicity and compliance. such investment is critical to optimising therapy and improving complications in thalassemia patients worldwide: even in sri lanka, where resources directed to thalassemia management are greater than in most of asia, results in the oldest living cohort (born 1980-1990) indicate under-treatment [elevated iron burdens (sf 3,565±323 ug/l) and high prevalences of diabetes (27%) and hypothyroidism (29%)]. even in a younger cohort (born 1990-2000) which has benefitted from improved treatments, the prevalence of many complications exceeds those reported from high-income settings. over the next decade, and two decades after the 2006 who declaration that the impact of thalassemia on global mortality and morbidity is underrecognized, increased investments by governmental and nongovernmental sources will be necessary to improve outcomes for asian patients with thalassemia. background: a major barrier to success in hydroxyurea (hu) treatment of patients with sickle cell disease (scd) is non-adherence. objectives: to optimize hu adherence in patients with scd. design/method: a care model was designed by the sickle cell (qi) team at children's hospital to improve hu adherence among scd patients. the original model included bimonthly family phone contact, monthly dispensing pharmacy phone contact and lab monitoring. adherence measures included obtaining hu from pharmacy monthly, completion of monthly labs, hb f percentage and mcv, and mtd achievement. from 6/2016 -6/2017, several pdsa cycles refined our care model. a one-year follow-up survey gathered feedback on the care model. the first-year data involved ∼ 30 patients. the biggest improvements resulted from making pharmacy calls before patient/family calls, shipping liquid hu to outlying patients, and tracking call time/content. the qi goal was 75 % hu adherence by 12/2017. the 33% baseline adherence rate increased to 80% by 12/2016, and has remained in that range. the completion rate of patient/parent phone calls increased from 33% the first month to 77% at six months. pharmacy prescription pick-up has increased from 50 % to 77% per month. lack of liquid hu availability was overcome by shipping the medication to the patient's home. parental hesitance to share information by phone, especially with qi team members with whom they had no established relationship, was overcome by having the longtime sickle cell nurse do many of the early calls. however, survey feedback showed families became comfortable with several clinic personnel calling. the calls gave families the opportunity to ask questions about their child and/or get additional information about scd. the calls also provided an opportunity for seasonal flu shot or tcd testing reminders. the surveys gave information on the optimal time of day to reach each family, providing individualization and further increasing the percentage of completed calls. two families surveyed said they no longer needed two calls a month because they were now able to remember to pick up hu, administer it, and get labs on their own. this qi project has not only improved hu adherence, but also fostered health education/counseling, increased patient/parent satisfaction, and enhanced service utilization. medical team member and patient/family comments demonstrate that it has helped build relationships and trust between families and the medical care system. based on survey feedback, we will further individualize care to increase adherence rate and sustain improvements. cincinnati children's hospital medical center, cincinnati, ohio, united states background: the thalassemias are a heterogeneous group of genetic blood disorders caused by mutations that decrease or eliminate the synthesis of the -and/or -globin subunits of hemoglobin. the phenotype of thalassemia depends on the interaction of the -and -globin gene clusters, because both loci determine the -/ -chain balance. for example, a -thalassemia phenotype can be more severe than expected when coinherited with -globin gene triplication (copy number gain), which exacerbates the -/ -globin imbalance. objectives: describe four individuals with an incorrect diagnosis of -thalassemia trait who were later properly diagnosed by comprehensive genetic testing to have -thalassemia intermedia caused by heterozygous -thalassemia mutations coinherited with triplicated -globin loci. design/method: sequence analysis of the -globin (hba1/hba2) and -globin (hbb) genes, and copy number variation analysis of the -and -globin gene clusters by multiplex ligand-dependent probe amplification. results: four unrelated individuals of northern european ancestry were evaluated for signs and symptoms not explained by a diagnosis of -thalassemia trait (previously made by a pediatric hematologist), including growth delay, splenomegaly, moderate anemia, marked elevation of hemoglobin f, thalassemic facies, reticulocytosis, and/or indirect hyperbilirubinemia. genetic testing revealed that all were heterozygous ( / 0) for the same, single -globin mutation [hbb.c.118c>t (p.q40*)] and also heterozygous for an -globin triplication ( / anti-3.7). their previous diagnoses of thalassemia trait had been made by complete blood counts, hemoglobin electrophoresis, and/or sequence analysis of the -globin genes only. these individuals' phenotypes ranged from moderate anemia only to multiple stigmata of thalassemia, demonstrating the phenotypic variation of a thalassemia genotype. correct diagnosis was made at an average age of 8.9 years. a trial of chronic transfusions was initiated for one patient for growth failure. all were educated about the potential for exacerbations of anemia, gallstones, osteoporosis, and iron overload (even without transfusions). parental genetic testing was recommended to assess reproductive risk, because inheritance of this complex genotype can be apparently autosomal dominant. conclusion: heterozygosity for a -thalassemia mutation does not necessarily indicate -thalassemia minor or "trait". when coinherited with -globin gene triplication, a symptomatic form of -thalassemia can occur. correct and timely diagnosis of thalassemia requires careful consideration of the degree of anemia and examination for organomegaly, bony changes, and jaundice. sequence analysis and copy number variation analysis of both the -and -globin gene clusters is key. hematologists need to be aware of this diagnostic possibility and how to test for it to prevent inaccurate or delayed diagnosis. background: the burden of healthcare costs for sickle cell disease (scd) is nationally estimated at over $488 billion. the major components of these costs are inpatient and emergency center (ec) visits, many of which are potentially avoidable. in several chronic conditions, a subset of patients account for most of the avoidable encounters. identifying these patients is the first step in targeted care delivery. objectives: to measure and analyze scd patient utilization patterns in the ec and inpatient at texas children's hospital (tch). we identified all individuals under 21 years old with any encounter at tch associated with an international classification of disease (icd)-9 or 10 code for scd, including hgb ss, hgb sc, and hgb s/beta thalassemia. for each patient, we identified all inpatient and ec encounters in the 365 days prior to their most recent encounter. finally, each encounter was classified as associated with pain, acute chest syndrome (acs), or "other" using an algorithm of discharge diagnosis codes and pharmaceutical delivery. the total number of scd-associated ec and inpatient encounters over the prior year was calculated for each patient. we stratified each patient according to their utilization patterns: low (0-1 encounters), intermediate (2-3 encounters), and high (≥4 encounters). we identified 952 unique patients with scd that had at least one encounter from july 2016 until june 2017. there were 1,100 scd-related encounters in the 365 days prior to their most recent encounter. most (74%, n = 701) patients exhibited low-utilization patterns and 18% (n = 174) were intermediate. finally, a small subset (8%, n = 77) demonstrated high-utilization patterns and accounted for 41% of all encounters. high-utilization was associated with older age and public payment mechanisms. pain encounters were predominantly in pre-adolescents and teenagers with high-and intermediate-utilization patterns. acs was most frequent in pre-teens and younger teens in the intermediate-utilization group. finally, the youngest-aged high and intermediate users presented for other reasons such as febrile episodes and splenic sequestration. our findings reflect national trends in that a significant portion of encounters are attributed to a small subset of patients exhibiting a high-or "super-" utilization pattern. at our institution, scd super-utilization is associated with older age and pain. we also identified a group of infants and toddlers with frequent encounters for fever. to comprehensively address this burden, it will be important to design interventions targeted toward age and specific medical needs. background: background: the rarity of diamond blackfan anemia (dba) has hindered describing the spectrum of disease, identifying predictive correlations, and guiding datadriven recommendations. long-term toxicities from steroid or transfusion therapy that start in childhood remain the major clinical problems in patients with dba who do not receive stem cell transplant. objectives: objective: to define the dba patient population at st. jude children's research hospital including treatment responses and toxicities to help inform recommendations on treatment and monitoring. design/method: method: medical records were reviewed for all patients with dba treated at st. jude between 1997 and 2017 for diagnostic testing, treatment types and regimens, and outcomes. two-sample t-test or wilcoxon rank sum test was used to compare continuous variables in two groups depending on the normality of the data tested by shapiro-wilk test. results: a total of 22 patients with dba were identified with a median age of 8.29 years (range 3 months -35 years) at last follow up. a ribosomal protein gene mutation was identified in 15/22 patients (68%) with an rps19 mutation 8/22 (36%). thirteen different congenital malformations were described in 9/22 patients (41%). fourteen of twenty (70%) patients treated with corticosteroids had an initial response and 3 of those achieved full remission. three patients became steroid-refractory and 2 were unable to wean to an acceptable dose. five of twenty patients continue on lower-dose steroids. five patients currently require no therapy. univariate analysis revealed no statistically significant genetic predictors of response or remission, however, 3/3 rpl11 patients responded to steroids with 2/3 (66%) in long-term remission. ten patients are maintained on chronic transfusions and 2 have undergone successful hematopoietic stem cell transplant. nineteen of 20 treated patients (95%) had a treatment-related toxicity. patients on steroids were more likely to have short stature than patients on transfusions or in remission (p = 0.005). severe bone mineral density deficit occurred in 4/20 (20%) patients, in 2 before age 7 years. eight patients had hepatic iron overload, in one documented by age 2 years. other severe toxicities included restrictive cardiomyopathy from iron overload, pathologic fracture, diabetes mellitus, and premature ovarian failure in one patient each. this genotypically and phenotypically heterogeneous dba cohort had a high rate of treatment-related toxicities, notably growth retardation, bone density loss, and hepatic iron overload even in very young children. these findings underscore the need for early standardized monitoring. background: patients with sickle cell disease (scd) face worsening morbidity and mortality between ages 18 and 30, when they must transition from pediatric to adult healthcare.(1) an effective curriculum addressing disease knowledge, educational and vocational skills, self-efficacy, and social supports is critical to a successful transition. traditional didactic approaches have not led to durable knowledge retention. (2) technology-based methods have been attempted, but the best educational approach remains unknown. objectives: 1. to understand how adolescent and young adult (aya) patients with scd view existing transition education. 2. to include patient preferences in improving our transition curriculum. we developed a qualitative survey to assess patient views of existing approaches for learning about scd and their opinions about preferred transition topics. thirty patients with scd aged 12 to 24 years old were recruited between january and december 2017. responses were managed using redcap electronic data tools hosted at the university of rochester.(3,4) qualitative and quantitative data analyses were performed, including independent t-testing to compare responses between age groups. results: approximately 68% of subjects were under 18 years of age, while 32% were 18 or older. seventy-one percent had a computer, and 93.5% had a cell phone, with most reporting daily use. subjects reported greatest satisfaction with learning from their doctor during clinic visits (83.9% agree or strongly agree) and websites on a cell phone (77.4% agree or strongly agree); the least popular methods were online chat rooms and microsoft® powerpoint presentations. satisfaction was similar across age groups. recommended transition topics were viewed positively, with subjects ranking highest understanding their bloodwork (87.1% agree or strongly agree) and understanding laws protecting students with chronic disease (93.6% agree or strongly agree). older subjects (18-24 years old) agreed more strongly with learning about opioid addiction and understanding differences between adult and pediatric doctors than did younger subjects (12-17 years old) (p < 0.05). this pilot study was successful in helping us to understand the educational needs of aya patients with scd. preliminary data underscore the importance of education provided by the pediatric hematologist. our results also suggest that the optimal use of technology-based methods requires further investigation and that tailoring transition education by age group may be useful. background: similar to patients with transfusion-dependent beta-thalassemias (tdt-beta), survivors of hemoglobin barts hydrops fetalis (homozygous alpha-0-thalassemia, tdtalpha) will require lifelong transfusions of erythrocytes. we have previously shown that a transfusion strategy that is based on the guidelines developed for tdt-beta (conventional transfusion) is suboptimal for these patients owing to the differences in the pathophysiology of anemia in the two conditions: in tdt-alpha, conventional transfusion strategy will lead to a gradual increase in non-functional hbh with subsequent tissue hypoxia and hemolysis. an aggressive transfusion strategy that was based on reduction of hbh and increase in "functional" hemoglobin level resulted in improvement of tissue oxygenation and reduction of hemolysis but was associated with significant increase in transfusional iron burden [amid et al, blood 2016] . objectives: to define the optimal chronic blood transfusion targets for hbh% and functional hemoglobin in patients with tdt-alpha. design/method: following research ethics board approval, longitudinal data of 6 patients with tdt-alpha (2 males, median age 11.5 (2.1-18.0) were retrospectively collected. variables of interest included total pre-transfusion hemoglobin, hbh%, and "functional" hemoglobin [measured as total hemoglobin x (1-hbh/100)]. outcome variables were lactate dehydrogenase (ldh, marker of hemolysis), and soluble transferrin receptor (str, marker of erythropoiesis). hemoglobin analysis was done using high-performance liquid chromatography and capillary zone electrophoresis. we examined the association of "functional" hemoglobin with str, and hbh% with ldh, using repeated-measures anova to adjust for the effect of multiple testing. we constructed receiver operating characteristic curve and calculated the area under the curve to define the best cut-off values for variables of interests. there was a strong association between functional hb and str, as well as hbh and ldh. the optimal cut-off for "functional" hemoglobin that was associated with str <2.0 mg/l was 98 g/l (auc = 0.94, sensitivity and specificity of 82.76% and 100% respectively). the optimal cut-off for hbh to supress ldh to <1000 u/l was 18% (auc = 0.94, sensitivity and specificity of 87.5% and 87% respectively). the optimal pre-transfusion hbh% for reduction of hemolysis was 18% and the optimal "functional" hemoglobin to adequately supress erythropoiesis was 98 g/l. to meet these hbh% and functional hb targets by simple blood transfusions, patients with tdt-alpha would require a hypertransfusion regimen with a minimum pre-transfusion total hb of 116 g/l and consequently high transfusional iron burden. an alternative approach using exchange transfusion to reduce hbh% and improve functional hemoglobin would be associated with less volume of transfusion and potentially better long-term outcome. hospital sacre coeur, milot, haiti background: initial results of work developing a pediatric sickle cell disease (scd) clinic at the hôpital sacré coeur (hsc) in milot, northern haiti were presented at aspho 2017. the purpose of this clinic is for a pediatrician with a special interest in scd to provide scd care, advising on trait and managing disease with penicillin prophylaxis (pcn) and hydroxyurea therapy (hu) for select patients. this clinic was started in collaboration with a us based hematologist and support from yale-new haven hospital. objectives: to describe the success and challenges of providing pcn and hu in the scd clinic at hsc through a review of patient records. design/method: since this clinic's inception, a database of patients, with basic clinical information has been kept and made accessible, through 'drop-box', to the us hematologist. the records of those that presented to the clinic were reviewed. the hemoglobin diagnosis was made either by clinical history and sickle cell prep or by hemoglobin electrophoresis through alpha laboratory, port-au-prince, haiti. results: ninety-nine individuals were seen in the first 2 years of the program. fifty-six underwent a hemoglobin electrophoresis. of these 99, 49 are ≤ 6 years old. thirty-two were started on pcn vk, of which 10/32 (31%) were ≤ 3 years old. eleven patients were started hu therapy. all patients on hu have shown progressive increases in hemoglobin. there have been no clinical complications of hu therapy. none of the patients taking hu have required hospitalization or transfusion in 2017. three patients (not on hu) were hospitalized in 2017 for complications of scd (osteomyelitis, pain). in 2016, with less than half the numbers in the program, there were 7 admissions for severe anemia, pain, stroke and splenic sequestration. with ongoing external support and a local reputation for excellence in sickle cell care, the clinic at hsc has been able to expand services and improve the health of a growing number of patients with scd. early data suggests that pcn and hu therapies are helping to reduce complications and improve quality of life. challenges to date have included lack of funding for transportation to clinics, for hospitalizations and to cover the cost of electrophoreses. at the same time as continuing providing excellent care and gathering data, it is crucial to explore opportunities for collaboration and cooperation in ways that will assure that the clinic can become independently sustainable while continuing to improve the quality of life for the individuals it serves. background: ykl-40 is an inflammatory glycoprotein expressed by infiltrating macrophages in various inflammatory conditions. it has been found to be elevated in patients with different pathological conditions like acute and chronic inflammations, increased remodeling of the extracellular matrix (ecm), development of fibrosis and cancer. several studies have found elevated ykl-40 concentrations in sera of patients with liver diseases such as hepatic fibrosis by hepatitis c virus. it has been suggested that ykl-40 concentrations reflect the degree of liver fibrosis. to evaluate serum ykl-40 levels in patients with -thalassemia and its relation to viral hepatitis, liver stiffness as assessed by transient elastography (fibroscan, fs) and hepatic iron concentration. design/method: a prospective study included 100 patients with -tm (43 males and 57 females) with mean age 13.8 ± 2.7 years (range: 5-18 years). serum ferritin level, liver enzymes (alt and ast), hbs ag, anti hcv ab and serum ykl-40 using elisa kit were evaluated. all patients were subjected to liver mri t2* to detect liver iron content by the sequence and transient elastography (fibroscan, fs) to assess degree of liver stiffness. results: mean fibroscan value was (10.99±11.5) kpa with a median 6.7 (range 1.3 to 47) kpa. 64 (64%) patients were categorized as f0-1 and 17 (17%) were stage f2-3, 19 (19%) patients had severe fibrosis. their median serum ferritin was 3100 ng∖ml, with 61 (61%) patients had values exceeding 2500 g/l. median cardiac t2* was 24.2 with 30 patients had values below 20 ms, and the median lic was 16.21 mg/g dw with 68 patients showed readings above 7 mg/g dw. nyl-40 was evaluated as a marker of inflammation and liver fibrosis and showed mean value 1505.1 (±960.9) pg/ml, and range from 500 to 3529 pg/ml. mean ykl-40 was significantly higher among males (p = 0.03), patients on chelation therapy (p = 0.002), patients on dfs (p≤0.001), in those with abnormal liver enzymes, splenectomised patients, patients with hbv sero-positivity, those with moderate elevation of t2* and patients with high grades of liver fibrosis (p<0.05). ykl-40 showed positive correlation with the rate of transfusion, lic, ferritin, alt and ast but negative correlation with weight, height and t2*. roc curve analysis revealed that the cutoff value of ykl-40 at 1500 pg/ml could differentiate -tm patients with and without viral hepatitis with 86.7% sensitivity and specificity of 91.4%, area under the curve (auc) 0.933, positive predictive value 81.2 and negative predictive value 94.1 (p<0.001). roc curve analysis revealed that the cutoff value of ykl-40 at 1600 pg/ml could detect -tm patients with liver cirrhosis with 93.4% sensitivity and specificity of 97.1%, area under the curve (auc) 0.972, positive predictive value 93.7 and negative predictive value 97.1 (p<0.001). conclusion: serum ykl-40 levels are elevated in patients with -thalassemia and can detect patients with active viral hepatitis and liver stiffness. background: the most common splenic complication in pediatric patients with sickle cell disease (scd) is acute splenic sequestration (ass), which has often been managed with splenectomy. although splenectomy has been a treatment of choice for years, long-term vascular complications have not been thoroughly evaluated. pulmonary hypertension (phtn) is a severe complication of scd. in adults with scd, phtn has been associated with a 40-month mortality rate of approximately 40%. it has been reported that splenectomized patients with hemolytic disorders are at even greater risk of phtn. several medications exist to treat phtn, but with few studies of their efficacy or toxicities in patients with scd. additionally, these patients are often treated with either chronic prbc transfusions or hydroxyurea (hu) to raise hemoglobin, reduce hemolysis, and prevent vaso-occlusive events. objectives: to evaluate effect of chronic prbc or hu vs. no intervention, on tricuspid regurgitant jet velocities (trv) in pediatric patients with scd and history of splenectomy. design/method: retrospective chart review of splenectomized patients with hbss followed at marian anderson center at st. christopher's hospital for children, philadelphia, between 1999 and 2017. we analyzed 73 trvs (16 hu, 40 prbc, and 17 from control group receiving neither treatment) from 35 patients (10 hu, 13 prbc, 12 neither). mean age at echo was 13.31 +/-5.1. data was analyzed with linear correlations and analysis of variance (anova), including the post hoc test of least significant difference (lsd) for all pairs of treatment groups. results: trv was not significantly correlated with age at time of assessment or with time between splenectomy and trv. univariate anova among groups yielded trv means of: 214.0 +/-36.0 cm/s (hu), 231.3 +/-28.1 (prbc), 231.3 +/-25.4 (neither). we found a notable difference as the mean of the hu group was almost 18 cm/s lower than the others, but no overall statistically significant association for any of the groups exists. however, when we performed post hoc tests to adjust for multiple comparisons and looked at all 3 pairings within the anova, we found that the lsd between the hu and the prbc groups was statistically significant (p = .051), and that a trend exists between the hu group and the neither treatment group (p = .095). our data suggests that treatment with hu is correlated with a reduction in trv in pediatric patients with scd who underwent splenectomy. given these promising results, we believe our data warrants further study with larger treatment groups. nancy olivieri, gaurav sharma, susmita nath, rajib de, tuphan kanti dolai, prakas kumar mandal, abhijit phukan, amir sabouhanian, robert yamashita, angela allen, david weatherall, prantar chakrabarti background: hemoglobin e thalassemia (hbethal), which accounts for 50% of all severe beta thalassemia worldwide, has an estimated prevalence of 1.4/10,000 in west bengal, from which little information about clinical findings has been reported. objectives: to document clinical and laboratory findings in patients with hbethal, ultimately to improve resources for clinical management. design/method: we reviewed records from: a database recording patient names; clinic charts; "special" charts containing additional details; and, in transfused patients, transfusion day-care records. additionally, because in india's public hospitals original lab/imaging reports are commonly retained at home, 20% of families were interviewed to provide additional information. we excluded records of patients aged <5 years and patients aged <30 years who had not been reviewed since 2014. results: while at least one visit had been recorded in 1,398 hbethal patients at nrs hospital, most patients are not regularly reviewed there. we examined 219 charts [84 (38%) aged ≥30 years; 135 (62%) aged 5-29 years; 61% male], representing approximately 70% of regularly-reviewed patients. most families (84.9%) reported monthly incomes (<5,000 indian rupees), below the monthly cost of living (70,000 rupees) in kolkata. mean (±sem) hemoglobin was 6.9±1.1 g/dl. 43% patients were receiving eight or more transfusions per year; from 2013, 40% had been treated with deferasirox, 26.5±8.5 mg/kg/day. iron control estimated by serum ferritin concentration (1357.2±1187 g/l) was highly variable. a total of 24% patients were splenectomized. a substantial obstacle to documenting complications was the lack of recording, in any of the five sources, of many relevant parameters: for example, the status of sexual maturation (normal, delayed, or absent) was documented in less than 60%, and measurements of fasting blood glucose in less than 50%, of records. where recorded, complication rates were high: delayed/abnormal sexual maturation was recorded in 15% patients aged >30 years; in the patients aged >30 years and those aged 5-29 years, respectively, hypothyroidism was recorded in 31% and 44%, and elevated serum alt in 30% and 35%. in most evaluable patients >30 years, height was measured between the 3rd-10th percentiles. cardiac findings, rarely documented, included pulmonary hypertension and reduced left ventricular ejection fractions in a few patients. despite dedicated attention to many aspects of thalassemia care, insufficient documentation limited a clear understanding of the current morbidity in hbethal patients. investment in personnel and technology will be critical to record relevant information, ultimately to improve clinical management, over the next decade. children's hospital of richmond at vcu health, richmond, virginia, united states background: sepsis is a common cause of death in children with sickle cell disease (scd). recommendations for care of fever in children with scd include immediate medical evaluation including blood culture and initiation of broad-spectrum antibiotic therapy. the increasing availability of pcr-based respiratory pathogen panels (rpp) provide the opportunity to rapidly identify viral causes of fever. the role for rpps in identifying the source of fever in children with scd and how it affects provider practice is not well studied. (1) to determine the epidemiology of respiratory virus-associated fever in children with scd and (2) to determine whether a positive rpp is associated with reduced risk of bacteremia in this population. this was a single-center, retrospective cohort study. we identified and reviewed the medical records of all children with scd seen in our emergency department (ed) with temperature ≥38.3oc at home or in the ed from january 1, 2016, through september 30, 2017, as well as, all febrile children for whom rpps were sent since the introduction of rpps april 2014. we reviewed the results of blood cultures, rpps, chest radiographs, and ed notes and discharge summaries to identify sources of infections. independent t test and chi-square analysis were used as appropriate to compare results using spss©. overall, the rate of bacteremia was 1%. there were no cases of bacteremia among children with positive rpps. 4% of children with negative rpps had true bacteremia. a positive rpp did not reduce the likelihood of bacteremia (p 0.11). patients with bacteremia had higher presenting temperatures than those without bacteremia (39.5oc vs 37.9oc, p 0.017). the most common rpp findings were rhinovirus/enterovirus (38%), human metapneumovirus (13%), and influenza a (10%). sending an rpp did not affect admission rate (29% and 26% respectively, p 0.70); however, likelihood of admission was lower in patients with positive rpps (21% vs 49%, or 0.27 [0.13-0.56], p 0.004). length of stay (los) was shorter in patients for whom an rpp was not sent (3.1 vs 4.5 days, p 0.036). as previously reported, bacteremia in febrile children with scd is very low, but remains a serious concern, particularly in the setting of high fever (>39oc). a positive rpp did not reduce the odds of bacteremia, but did have a sta-tistically significant impact on both admission rate and los. more work is needed to understand how rpp results impact provider decision-making and care for children with scd. cincinnati children's hospital medical center, cincinnati, ohio, united states background: diffuse myocardial fibrosis is a common, if not defining, feature of the heart in sickle cell anemia (sca) that is strongly associated with diastolic dysfunction. we found diffuse myocardial fibrosis in every patient in a sca cohort (n = 25) ranging in age from 6 to 61 years (niss 2017). the treatment and prevention of this complication of sca has not been studied before. objectives: because diffuse myocardial fibrosis must begin in early childhood, we hypothesized that early initiation and uninterrupted use of disease-modifying therapy for sca can prevent it. design/method: we use cardiac magnetic resonance imaging (cmr) to measure the myocardial extracellular volume fraction (ecv) to quantify diffuse myocardial fibrosis in individuals with sca who have been treated, uninterrupted, with hydroxyurea or chronic transfusion therapy since ≤4 years of age. two comparison groups were used: individuals with sca who have not been treated with disease-modifying therapy since ≤4 years of age (n = 25) and controls without sca (n = 16). results: we studied 7 individuals (3m/4f) with a mean age of 13.4 years (range 7 -24). mean age at the start of diseasemodifying therapy was 2.5 ± 0.4 years (range 1-4). only 1 had evidence of mild diffuse myocardial fibrosis (ecv 0.339); the other 6 had no detectable diffuse fibrosis (all had ecv <0.304, the upper limit of normal). mean ecv was 0.283 ± 0.012, which was significantly lower than the ecv of individuals with sca who have not received early uninterrupted therapy (0.441 ± 0.016; p = 0.009) and not statistically different from normal controls (0.257 ± 0.004; p = 0.898). none had macroscopic fibrosis by late gadolinium enhancement or evidence of myocardial hemosiderosis by t2* imaging. no patient had diastolic dysfunction by echocardiographic classification, right heart catheterization, or both. disease-modifying therapy for sca can prevent diffuse myocardial fibrosis, and possibly diastolic dysfunction, if started in early childhood. prospective trials of disease-modifying and anti-fibrotic therapy are planned to prevent diffuse myocardial fibrosis, which can be monitored noninvasively by cmr, and improve outcomes in sca. (niss, blood, 2017) . background: a statewide sickle cell surveillance system (sscss) was developed with the goal of determining the prevalence of sickle cell disease (scd) in indiana and the level of care that patients receive throughout the state. persons with scd are at high risk of infection, especially with encapsulated organisms, as well as at increased complications from influenza. utilizing sscss data, the relationship between vaccination status and mortality was explored. to determine if vaccination status is associated with mortality in persons with scd. the project was granted a waiver of consent by the st. vincent irb. death certificates were obtained to identify cause of death. deceased patients (cases) were matched by age, gender, and sickle genotype to living patients (controls). vaccination data were collected from the medical record and the children and hoosier immunization registry program (chirp) through the date of death for each case. cases and controls were assigned a point for completion of the pneumococcus, meningococcus and haemophilus influenza type b (hib) vaccine series and one point if the influenza vaccine was given within a year prior to death of the cases [max vaccine status score (vss): 4]. total points were compared between the cases and controls. two tailed t-tests to compare means of continuous data and wilcoxon signed-rank test to compare ordinal data. one thousand forty-eight individuals were included in the sscss. six hundred and seven (48.6%) were seen at one institution and included in this analysis (mean age = 21 years). thirty-three of the 607 (5.4%) were deceased at the time of analysis. six point one (6.1)% of controls and 12.1% of cases received a vss of 4. the mean vss for cases was 0.7±1.3 and 0.6±1.1 for controls. thirty point three (30.3) % of controls had a vss of one or more, compared to 27% of cases (p = 0.41). patients who died of infection [streptococ-cus (n = 1), pseudomonas (n = 1) and unidentified organisms (n = 4)] were not up to date on vaccination against encapsulated organisms, but two had received the influenza vaccine in the year prior to death. in this sample, mortality occurred exclusively among adult patients, which is consistent with current patterns in developed countries. among these adults, vss and mortality rates were not related. limitations to the study include small sample size and potential incompleteness of vaccine records. vaccination rates and other standard of care indicators should be explored in a larger cohort of patients to determine associations with mortality. background: sickle cell disease (scd) is a genetic disorder resulting in acute and chronic complications, including delayed puberty. delayed puberty can have adverse physical and psychosocial effects on affected children and families. there are no published reports from ghana on pubertal timing in children with scd. the aim of this cross-sectional study was to describe pubertal changes in children with scd at korle bu teaching hospital (kbth), accra, and compare these findings to those in a control group without scd. design/method: 178 children with scd and 174 children with hb aa, ages 8-19 years, were consecutively recruited and matched for age, sex and socioeconomic status. investigator-administered questionnaires were used to obtain demographic data for all participants and information on menarche (girls only). pubertal status was assessed by physical examination using tanner staging. testicular volumes were determined in boys using a prader orchidometer. body mass index (bmi) and socioeconomic status (ses) of participants were analyzed to determine if there were any associations with tanner stage. of the 178 with scd, 133 (74.7%) were hb ss and 45 (25.3%) hb sc. females comprised 51.1% (cases and controls). mean age at onset of breast development was significantly delayed in girls with scd (13.1 ± 1.9 years) compared to controls (10.8 ± 1.9 years) but there was no significant age difference at onset of pubic hair development. mean age at menarche was significantly delayed in girls with hb ss (14.0 ± 1.8 years) and hb sc (13.5 ± 1.5 years), compared to those with hb aa (12.5 ± 1.3 years). in boys, the mean ages at onset of puberty were significantly delayed in those with scd (13.6 ± 2.7 years, for genital development and 15.1 ± 2.2 years, for pubic hair development), compared to those without scd (11.3 ± 1.9 years and 11.4 ± 1.9 years, respectively). mean testicular volumes were significantly lower in cases compared to controls, across all age ranges (p<0.001). mean bmi in both cases and controls were similar at onset of breast development in girls. however, in boys with and without scd, mean bmi values were significantly different at pubertal onset. in univariate analysis, ses was not associated with tanner stage for both genital and breast development. mean ages at pubertal onset were significantly delayed in children with scd. longitudinal studies are needed to further characterize any associations with bmi and determine potentially modifiable risk factors affecting pubertal onset in scd. background: sickle-cell disease (scd) is a life-threatening genetic disorder associated with multiple chronic and acute complications. specific monitoring and treatment for children is a major part of the medical focus, but there remains a lack of real-world evidence of the disease burden and practice patterns among the pediatric scd population. objectives: to examine the clinical burden and management of scd among pediatric patients. design/method: a retrospective claims study was conducted using the medicaid analytic extracts database from 01jan2009-31dec2013. pediatric patients (aged <18 years) with scd were identified using icd-9-cm diagnosis codes (282.41-282.42, 282.60-282.69 ). the first observed scd diagnosis during the identification period was designated as the index date. patients were required to have continuous medical and pharmacy benefits for at least 6 months pre-and 12 months post-index period. patient data were assessed until the earliest occurrence of the following events: disenrollment, death, or the end of the study period. patient demographic and baseline clinical characteristics, clinical outcomes (mortality, incidence of pain crisis, complications), scd management, and healthcare utilization were examined. all variables were analyzed descriptively. results: a total of 12,388 patients met the study inclusion criteria, with a mean age of 7.7 years. most patients were black (59.9%) and had a charlson comorbidity index score of 0 (80.9%). mortality during follow-up was 0.1 in 100 personyears, and the event rate of pain crisis in the inpatient setting was 54.0 in 100 person-years. the three most common complications after pain crisis (highest rates in 100 person-years) were fever (31.9), infectious and parasitic diseases (27.7), and asthma (14.5). rates of life-threatening complications were also examined in 100 person-years, including acute chest syndrome (7.0), stroke (1.8), splenic sequestration (1.1), pulmonary hypertension (0.3), and pulmonary embolism (0.1). 83.9% of patients were prescribed antibiotics during the one-year post-index period. other frequent medications utilized among children were folic acid (39.2%), nonsteroidal anti-inflammatory drugs (37.4%), opioids (11.2%), and hydroxyurea (11.5%). 16.0% of patients had a blood transfusion within one year post-index date. patients had frequent health care utilizations in the inpatient (1 visit), emergency room (2 visits), office (7 visits), and pharmacy (11 visits) settings during the one-year follow-up period. pediatric scd patients are burdened with a high rate of complications including pain crisis. in addition, patients utilized a substantial amount of health care resources including outpatient office care and acute care visits. background: novel use of hydroxyurea in an african region with malaria (noharm, nct01976416) is a randomized controlled trial of hydroxyurea for very young children with sickle cell anemia living in uganda. during year 1, study participants received blinded study treatment of hydroxyurea or placebo; those receiving hydroxyurea had no increased risk of malaria, but had both laboratory and clinical benefits. during year 2, all study participants received openlabel hydroxyurea treatment. to assess the effects of open-label hydroxyurea treatment in a very young population of children with sickle s105 of s301 cell anemia living in uganda. study endpoints included the rates and severity of malaria infections, clinical sickle-related events, and laboratory effects. design/method: all children in the noharm trial were enrolled at mulago hospital sickle cell clinic in kampala uganda. during year 2, all children received open-label fixeddose hydroxyurea (20 mg/kg/day) for 12 months, after previously receiving either hydroxyurea or placebo for 12 months. results: a total of 198 children entered year 2 of the noharm trial and received fixed-dose hydroxyurea, including 107 males and 91 females, at an average age of 3.3 ± 0.9 years. among 99 children previously on placebo, there were 6 malaria events in 6 children, including 3 with severity grade ≥3, and three deaths (two acute chest syndrome, one sepsis). clinical adverse event rates dropped from 3.0 to 1.6 per patient year, and hospitalizations were reduced from 35 to 7. expected hematological benefits of increased hemoglobin, mcv, and fetal hemoglobin, along with decreased neutrophils and reticulocytes, were rapidly achieved. laboratory adverse events were infrequent at 0.2 events per patient-year, and only half of those were dose-limiting hematological toxicities. among 99 children previously on hydroxyurea, there were 7 malaria events in 5 children, including 2 with severity grade ≥3, and two deaths (one acute chest syndrome, one sepsis). clinical adverse event rates and hospitalizations were maintained at low rates, the hematological benefits of hydroxyurea continued throughout the extended treatment period, and dose-limiting toxicities remained infrequent. fixed-dose hydroxyurea treatment of young children with sickle cell anemia living in uganda is associated with no increased risk for malaria. clinical and laboratory benefits occur, including children previously on placebo who crossed-over to hydroxyurea treatment. future studies should focus on the optimal dosing and monitoring strategies, in an effort to determine the overall feasibility and safety of introducing hydroxyurea therapy across sub-saharan africa. background: acute chest syndrome (acs) is the second most common cause of hospitalization in patients with sickle cell disease and is a leading cause of morbidity and mortality. in mid-2009, an algorithm was implemented at cohen children's medical center to initiate transfusions within four hours of diagnosis of acs in order to improve patient outcomes. objectives: the aim of this project was to analyze the effect of early blood transfusion on the outcomes of patients with acs. we focused on the number of total transfusions, need for exchange transfusion, need for intensive care unit (icu) stay, and length of hospitalization. design/method: a retrospective chart review was completed on patients admitted to ccmc with a primary diagnosis of sickle cell disease and a secondary diagnosis of either acs or pneumonia during the years of 2006-2012. data from the three years directly prior to implementation of the algorithm was compared to data from the three years directly after implementation of the algorithm. a total of 118 patients were analyzed, of which 45 belonged to the pre-algorithm group and 73 to the postalgorithm group. patients from the post-algorithm group had a higher incidence of transfusions (78% with a mean transfusion number of 1.49 pre versus 86% with a mean of 1.83 post) as well as exchange transfusion (17% pre versus 27% post). the post-algorithm group had a shorter overall length of stay (mean of 6.0 days pre versus 5.0 days post). while the overall percentage of patients requiring an icu admission was similar in each group (27% pre versus 29% post), the post-protocol group had a lower likelihood of requiring an icu admission for reasons outside of line placement for exchange transfusion, most commonly for icu-level respiratory support (13% pre versus 4% post). despite a higher total number of transfusions, early recognition and transfusion for acs can lead to decreased lengths of hospitalization as well as decreased need for icu-level respiratory support. further studies comparing different center's clinical practice guidelines are necessary to improve the standard of care. background: novel use of hydroxyurea in an african region with malaria (noharm) was the first placebocontrolled randomized clinical trial of hydroxyurea in sub-saharan africa. in noharm, young children with sca received either hydroxyurea or placebo during year 1, followed by open-label hydroxyurea for all study participants during year 2. an ancillary noharm project was designed to determine if hydroxyurea treatment lowers transcranial doppler (tcd) velocities and possibly reduces stroke risk in this very young cohort. objectives: to perform tcd screening on the noharm cohort, measuring the time-averaged mean velocity (tamv) at the end of both year 1 and year 2. we hypothesized that the maximum tamv would be lower for noharm study participants receiving hydroxyurea compared to those receiving placebo, and that key clinical and laboratory parameters would also influence tcd velocities. design/method: all children enrolled in noharm were eligible to undergo tcd examination at two study time points: month 10-12 when they were completing the blinded treatment phase, and again at month 22-24 at the end of the open-label treatment phase. tcd measurements included tamv readings from the main intracranial arteries: middle cerebral artery, distal internal carotid artery, and bifurcation on tcd. all tcd examinations were scored and classified as normal (less than 170 cm/sec), conditional (170-199 cm/sec) or abnormal (greater than or equal to 200 cm/sec), with higher scores correlating to greater risk of stroke. results: at the end of year 1, 185 tcd exams were conducted of which 164 were suitable for analysis (81 hydroxyurea, 83 placebo). based on the maximum tamv, the median velocity was 138 cm/sec (iqr 120 -159) for children on hydroxyurea and 150 cm/sec (iqr 134 -168) on placebo, p = 0.0509. maximum tamv values had negative correlations with hemoglobin concentration (-0.47), fetal hemoglobin (-0.32), and oxygen saturation (-0.27); positive correlations were noted with age (0.27) and absolute neutrophil count (0.27). at the end of year 2, 187 tcd exams were conducted and all were suitable for analysis; the median velocity was 137 cm/sec on open-label hydroxyurea treatment, regardless of previous blinded treatment. all correlations with tamv were maintained except for age. conclusion: compared to placebo, hydroxyurea treatment for young children with sca living in uganda was associated with lower tcd velocities, which have been correlated in other studies with lower risk of primary stroke. tcd velocities were correlated with hematological and clinical parameters that can be improved by hydroxyurea therapy. children's hospital of richmond at virginia commonwealth university, richmond, virginia, united states background: acute chest syndrome (acs), defined by respiratory symptoms and a new pulmonary infiltrate, is a serious complication of sickle cell disease (scd). acs can occur during hospitalization for non-pulmonary conditions, such as a vaso-occlusive crisis or after surgery. nih clinical practice guidelines encourage incentive spirometry (is) which decreases the incidence of acs. it is additionally widely accepted that early, frequent ambulation in post-operative and pneumonia patients decreases the length of stay (los). to decrease acs events in children with scd at our children's hospital, we aimed for is use in 100% of ageappropriate pediatric sickle cell admissions. design/method: a multidisciplinary team examined inpatient acs prevention practices, including is, at children's hospital of richmond. key drivers were identified, including educational awareness of patients and healthcare staff, order placement, and documentation. we aimed for all scd patients ≥ 15 months of age hospitalized with any admission diagnosis to participate in is with the use of a traditional incentive spirometer or similar age-and ability-appropriate devices (e.g. positive expiratory pressure devices, bubbles, and pinwheels). we secondarily aimed to increase activity events, specifically ambulation and out of bed time. educational and outreach tools included patient informational brochure and incentive program, and staff informational sessions and reference materials at workstations. a disease-specific order set was implemented including desired is and activity orders. data were collected prospectively may through november 2017, during which 3 pdsa cycles were conducted. admissions during the corresponding months of the previous year were reviewed for comparison. independent t-test analysis was performed using graftpad prism 6 statistical analysis software. results: improvements reaching statistical significance included increase in is order placement from 44% to 89% of admissions (p < 0.01), and admissions with documented is use increased from 32% to 59% (p < 0.01). los decreased from a mean of 3.7 days to 2.7 days (p 0.02). post-admission development of acs also decreased from 12% to 4% of admissions, but did not reach statistical significance (p 0.18). there was an additional increase in appropriate activity order placement and documentation of activity events. conclusion: improving education and outreach to patients and staff, including implementation of a disease-specific order set, can improve is use and activity events. the decline seen in incidence of acs development during hospitalization, though not statistically significant, and the decreased los are encouraging, and efforts continue to improve on these trends. background: painful vaso-occlusive crises (voc) are a frequent and debilitating complication of sickle cell disease (scd) and are thought to occur due to progressive blockage of the microvasculature with rigid sickle shaped red blood cells. any trigger that decreases the microvascular blood flow (mbf) can promote entrapment of sickled cells in the microvasculature and progression to voc. exposure to cold wind and changes in weather are common triggers of voc and are associated with increased frequency of hospitalizations for pain in patients with scd. there is limited experimental data on the physiologic effects of these factors on peripheral perfusion in scd. to study the effect of graded thermal stimuli on the peripheral mbf in scd. design/method: 17 scd and 16 control (healthy or sickle trait) subjects aging 13 to 39 years were exposed to their individual threshold temperatures for heat and cold detection, heat and cold pain via tsa-ii thermode that was placed on the thenar eminence. mbf was measured on the contralateral thumb using photo-plethysmography (ppg). the vasoconstriction response within the complex ppg signal was detected using cross-correlation technique. mean mbf was derived from the ppg amplitude during each of these stimuli and compared to baseline mbf. cross correlation analysis showed that cold pain caused significant vasoconstriction response in 67% of the subjects, followed by heat pain (58%), cold detection (36%) and heat detection (18%).there was a significant drop in the mbf during cold pain (p <0.0001), heat pain (p <0.0001), heat detection (p = 0.0005) and cold detection (p = 0.02) when compared to baseline mbf, with cold pain causing the greatest drop in mbf. thermal sensitivity and mbf responses were comparable between scd and controls. conclusion: exposure to graded thermal stimuli causes a progressive drop in mbf with exposure to cold pain eliciting the strongest vasoconstriction response. vasoconstriction occurred in the contralateral hand at an average of 11 seconds after the stimuli, suggesting a neurally mediated mechanism. although there was no significant difference in vasoconstriction responses between scd and controls, the drop in mbf in patients with sickle cell disease can increase the likelihood of entrapment of the sickled red blood cells, leading to vaso-occlusion. these findings are consistent with extensive reports in literature that exposure to cold weather is associated with a higher frequency of voc. this suggests that neurally mediated vasoconstriction is likely an important factor in the pathophysiology behind cold exposure leading to voc in scd. background: vaso-occlusive crisis (voc) is a major cause of hospital admissions in children with sickle cell disease (scd). although the use of clinical biomarkers in voc has been studied, especially with regards to acute chest syndrome (acs), there is less data regarding overall voc severity prediction. in addition new biomarkers such as platelet to lymphocyte ratio (plr), neutrophil to lymphocyte ratio (nlr), and lymphocyte to monocyte ratio (lmr) have been little studied with regards to scd. objectives: to identify whether admission laboratory values, changes from well baseline laboratory values, and new biomarkers such as plr, nlr, and lmr could predict severity of vaso-occlusive crisis in children with sickle cell disease admitted with voc. design/method: this was a retrospective single center observational study of admissions of voc in children aged 1 -21 years with hbss or hbs-b0thal from september 2014 to november 2017 excluding those on hyper-transfusion protocol or having an admission diagnosis of acs. univariate analysis was done using student's t-test, mann-whitney non parametric test, or fischer's exact test as appropriate depending on the distribution between admission laboratory data of complete blood count (cbc), reticulocyte count, comprehensive metabolic panel, lactate dehydrogenase (ldh), change from well baseline cbc values within 6 months previously, plr, nlr, lmr, and the development of complicated voc. complicated voc was defined as the development of secondary acute chest syndrome, prolonged admission duration > 5 days (120 hours), requirement of blood transfusion, and readmission within 30 days. results: a total of 109 admissions were studied. fifty-nine (54.1%) were female. of the 109, 50 (45.9%) were complicated with no significant differences in sex (p 0.447) or age (p 0.435). univariate analysis revealed significant elevations in total bilirubin (p 0.017), ldh (p 0.010), and platelet count (p 0.019) in those with complicated voc. there is also significant difference in the percentage change of platelet count from baseline with greater decline in uncomplicated voc (p 0.014). there were no significant differences in plr (p 0.186), nlr (p 0.775), or lmr (p 0.445). conclusion: elevations in total bilirubin, ldh, and platelet count in admission laboratory values are associated with developing complicated voc. in addition, those with complicated voc present with significantly less decline in platelet count from baseline well cbc. plr, nlr, and lmr do not seem to be useful predictive biomarkers for severity of voc. background: sickle cell disease (scd) causes health problems of varying frequency and severity. the only validated biomarker for children with scd is transcranial doppler. if reliable predictors existed for scd severity, children with scd could be treated according to risk category. many patients with scd face psychosocial or economic hardships, but these factors have not been evaluated as risk markers for medical or functional severity of scd. objectives: the goal of this project was to develop and stratify a preliminary list of psychosocial risk factors for health outcomes that could be used as scd severity predictors. st. vincent institutional review board. a list of potential psychosocial risk factors for adverse health outcomes was compiled based on assessment materials utilized by the sickle safe program (indiana's hemoglobinopathy newborn screening follow-up program). this list of 39 items was distributed to child abuse prevention (12) and scd (17) experts, who ranked each item on a likert scale of 1 (least important) to 5 (most important). mean scores were calculated using spss version 24; 163 assessments were retrospectively analyzed to determine psychosocial risk factor frequency. risk factors occurring in ≥15% of homes were considered high frequency events. overall, there was high agreement among experts on the risk factors that were considered the most important predictors of severe scd outcomes. the risk factor with the highest frequency (92%) was eligibility for public assistance programs. fifteen risk factors were rated ≥4 by the experts. four (26.7%) were high frequency events occurring in ≥15% of homes: a child with hbss or hbs 0thalassemia not taking hydroxyurea (15%); parent report that they had treated a fever (>101®f) at home in the past 6 months (25%); tobacco use by someone in the household (23%); and the family reporting significant psychosocial stressors in the past year (30%). tobacco use in the home was significantly correlated with several other risk factors (smoking during pregnancy [r = 0.503], other health concerns in the child [r = 0.459], and child having health insurance [r = -0.459]), suggesting that it is part of a constellation of health risk. in general, the risk factors that were rated as most important for health outcomes occurred less frequently in the sample. this study represents important progress toward identifying a group of psychosocial risk factors for scd severity, which is a necessary first step for future investigation of empirical relationships between candidate risk factors and scd outcomes. unitversity of cartagena, cartagena, bolivar, colombia s109 of s301 background: sickle cell disease is an autosomal recessive disorder characterized by a mutation in the -globin chain, which produces hbs. acute and chronic complications as aplastic crisis, acute chest syndrome, priapism, stroke, leg ulcers and primary/secondary prevention of stroke can be treated with simple transfusion or exchange transfusion. the latter offers advantages as lower iron overload, post-treatment hbs goal control, lower viscosity and improved microvascular circulation. but it is not a widely-used option because is associated with technical difficulties. objectives: standardization of a new partial exchange transfusion protocol in a group of patients with sickle cell disease, within the framework of a chronic transfusion program. design/method: this is a prospective descriptive study, which included 25 patients under 18 years with sickle cell disease (20 hbss, 5 hbs-tal), with indication of partial exchange transfusion in a chronic transfusion program, according to the institutional protocol; patients who fulfilled the inclusion criteria were enrolled in the study between february 2016 and december 2017. a registry of the medical and technical complications was made in each of the procedures. a database was constructed in excel, and the graph-pad prism® version 6 oc software was used for statistical analysis. the sequence is as follows: isovolemic phlebotomy and transfusion of packed red cells. depending of the recent hemoglobin level (48 hrs), we do the phlebotomy there: hb:7-7.9: 10 cc/kg, hb: 8-8.9: 15 cc/kg, hb>9: 15 cc/kg; isovolemic solution (ns 0,9%) there: hb:7-7.9: 10 cc/kg, hb: 8-8.9: 15 cc/kg, hb>9: 15 cc/kg and packed red cell transfusion there: hb:7-7.9: 15 cc/kg, hb: 8-8.9: 15 cc/kg, hb>9: 10 cc/kg. the safety of this exchange transfusion protocol was analyzed in 25 patients with sickle cell disease (176 procedures). there were no differences in the sex distribution, and the median age was 8 years. 80% of the population was homozygous. the indication of transfusion was 52.27%(92/176) primary stroke prevention, 44.31%(78/176) secondary stroke prevention and 2.84%(5/176) was other reason. a low percentage of complications was found (7.3%); of which, those of medical origin (hypotension and nausea/vomiting) were only presented in 2.2% of the total procedures. the standardization of this protocol was safe and its use could be extended to other low-income centers that treat patients with sickle cell disease that need chronic transfusion program including patient with hemoglobin level until 7gr/dl. we suggest do studies for measure the security and efficacy of this protocol in patients with acute complications. background: clinical trials that aim to achieve pain reduction have challenges achieving clinical endpoints as pain has no quantifiable biomarkers and may be unrelated to scd. furthermore, the threshold of seeking medical care differs between patients and vocs that occur at home are missed. we present a non-interventional, longitudinal study to identify vocs in patients with scd. objectives: to examine the longitudinal relationship between pros and biomarkers in subjects with scd before, during, and after a self-reported voc event, in order to build a model of in-home and clinical voc and to collect longitudinal pros and biomarker data from subjects that span voc events in the home, clinic and the hospital. design/method: longitudinal measures of pain, fatigue, function, activity, and biomarkers from scd patients in steady state and voc were studied over a six month period. patients self-reported pain, fatigue, function, and medication use using a novel epro tool. voc was reported in real-time, triggering a mobile phlebotomy team. blood was collected sequentially after self-reported voc (at home or hospital). blood samples were drawn two days after resolution of voc, as reported by the patient. during non-voc periods, blood was drawn every 3 weeks to establish a baseline. biomarkers included leukocyte-platelet aggregates and circulating microparticles, cell and soluble adhesion molecules, cytokines, inflammatory mediators and coagulation factors. patients wore an actigraphy device to track sleep and activity and rest. results: twenty-seven of thirty-five patients experienced a total of 286 days with voc >4 hr, of which only 58 days resulted in healthcare utilization. voc days had significantly higher pain and fatigue scores. voc days were associated with significantly decreased functional scores, with significantly greater decreases during vocs requiring medical contact compared to at-home vocs. different activity profiles were identified for non-voc, at-home voc and medical contact voc days by actigraphy monitoring. at-home voc days exhibited increased daytime resting compared to non-voc days. medical contact vocs had decreased average and peak activity, and increased daytime resting compared to non-voc days. a sleep fragmentation index trended up for both at-home (16%) and medical contact voc days (18%). significant changes during voc days were observed in: c-reactive protein (54% increase), nucleated rbc (34% increase), monocyte-platelet aggregates (25% increase) and neutrophil-platelet aggregates (35% increase), interleukin-6 (112% increase), interleukin-10 (19% increase) and tnfalpha (14% increase). the identification and assessment of at-home vocs through use of epros, actigraphy and biomarkers is feasible as demonstrated by this innovative at-home study design. background: risk-stratifying sickle cell disease (scd) patients and demonstrating response to disease-modifying therapies is challenging due to the phenotypical heterogeneity of scd. a pathogenic role for procoagulant von willebrand factor (vwf) via excess vwf high molecular weight multimers (hmwm) has been proposed, with variable reports of increased vwf and hmwm in crisis vs. steady-state in adults, but less so for vwf in children with scd. moreover, vwf and multimers have not been studied in sickle trait. objectives: our pilot study evaluated the potential for vwf antigen (vwf:ag) and hmwm on densitometric tracings to serve as biomarkers for disease severity or treatment response in children and young adults with scd compared to sickle trait (hbas) siblings. design/method: we evaluated vwf:ag, vwf multimers and retrospective clinical data from 10 hbss, 3 hbsc and 5 hbas subjects at steady state. one hbsc subject also had a crisis sample. median scd age was 17 years (8.0-20.1 years). 46% were female. scd severity was judged by annual vasoocclusive and acute chest events, or stroke/elevated tcd. eight of 13 (6 hbss and 2 hbsc) took hydroxyurea. four hbss subjects had severe scd, all of whom were chronically transfused. results: mean vwf:ag (normal 50-160 iu/dl) was higher for hbss (175+/-17.4) and severe hbss (195+/-33.5) compared to hbsc (103+/-3.2, p = 0.049 and 0.044, respectively); however, lacked statistical significance when compared to hbas (152+/-34.5, p = 0.52 and 0.41, respectively). vwf:ag was elevated in 7/10 (70%) steady-state, including 3/4 (75%) with "severe" disease on chronic transfusion and 4/6 (67%) taking hydroxyurea, in 1 hbsc crisis but no hbsc 3/3 (100%) at baseline. vwf:ag was high in 2/5 (40%) hbas siblings. four (31%) had increased hmwm at baseline: 1 hbss/severe disease/chronic transfusion, 2 hbss/hydroxyurea and 1 hbsc untreated. hmwm were increased only during vaso-occlusive crisis in 1 hydroxyureatreated hbsc subject. no ultra-large hmwm were observed. in this preliminary study, in young scd subjects, vwf:ag trended higher in hbss vs. hbsc and in severe hbss participants at a single time-point, but serial evaluations at baseline, in crisis and with optimized diseasemodifying therapy are needed to determine the potential of vwf:ag and hmwm as biomarkers for severity or treatment response. surprisingly, vwf:ag was high in some sickle trait subjects. since hbas is associated with some health challenges such as increased thrombosis risk, further examination of vwf and endothelial dysfunction in sickle trait may provide novel insights into its role as a biomarker. background: the 2014 national heart lung & blood institute(nhlbi) guidelines for acute management of voe recommends rapid evaluation and treatment of pain, including administration of a parenteral opioid within 30-minutes of triage or 60-minutes from registration, pain reassessment & repeat opioid delivery within 15-30-minutes. inf use has been increasing in peds due to its rapid onset and ease of administration. objectives: to evaluate ped utilization of inf & its effect on intravenous (iv) opioid administration and pain control for the treatment of voe. design/method: a retrospective review of 250 emr was performed on children with scd±2years presenting to a ped with voe (pain scores 6 on a 0-10 scale) from jan-june 2017. variables studied were median time (iqr,95%ci) from ped arrival to first-parenteral-opioid-administration, time-to-first-iv-opioid, first & final pain score, disposition and readmission rate. time-to-first-iv-opioid was also compared to historical data (jan-dec2012,n = 231) prior to inf protocol initiation. . additionally, 15% patients received iv opioids within 60 minutes of ed arrival in the inf+iv opioid vs. 40% in the iv opioids alone group (p<0.01). no differences in 72-hour-returnrates were found in any of the groups, including inf alone group. conclusion: use of inf in the ped for voe is an excellent strategy to shorten time-to-first-parenteral-opioidadministration, improve pain scores & improve adherence to the nhlbi guidelines. however we had 2 distinct unexpected findings: (1) delays in iv opioid delivery after inf use & (2) inf alone appeared to provide sufficient pain control without iv opioids for disposition home in 17% of voe patients. whether the latter reflects insufficient pain management or that there is a milder subgroup for whom inf alone is sufficient, requires further investigation. this study illustrates our experience with a ped-based inf protocol in terms of unanticipated delays in iv opioids and also discharges after inf alone. efforts are underway to further improve use of inf in voe management. st. christopher's hospital for children, philadelphia, pennsylvania, united states background: folate supplementation is commonly included as standard management in patients with sickle cell disease. however, clear evidence supporting the clinical benefits of this practice is lacking. a single study demonstrated improvement on the occurrence of repeat dactylitis at a higher dose of folic acid. to compare clinical outcomes in pediatric patients with sickle cell disease treated with folate supplementation versus those who were not. design/method: this study was a retrospective chart review that included patients 3 to 23 years old with sickle cell disease type ss and s 0 followed at st. christopher's hospital for children. data collected included information about folate supplementation, red cell indices and the presence or absence of clinical outcomes including vaso-occlusive crisis requiring hospitalization in the last six months, acute chest syndrome, infections, asthma, sleep apnea, nephropathy, cerebral vascular disease, stroke and avascular necrosis. analysis of variance (anova) was used to evaluate mean differences between age, number of infections, number of voc events, hemoglobin, reticulocyte count, and mean corpuscular volumes. additionally, chi square analysis was implemented to evaluate differences in folate and non-folate groups for left ventricular remodeling (lvr), sickle cell nephropathy, asthma, obstructive sleep apnea (osa), nocturnal hypoxia, and avascular necrosis (avn). mean differences between the folate and non-folate groups were compared for patients on and off hydroxyurea therapy. one hundred and seven patients met inclusion criteria following review of clinical data. of the patients included in the study, 45 patients were found to be taking folate (42%), while 62 patients were not (58%). statistical analysis showed that there were no significant differences in the incidence of clinical outcomes between patients on folate versus those who were not on folate. of the patients who were not on hydroxyurea, hemoglobin levels were significantly higher in patients on folate versus those who were not (p = 0.053), but not significantly different for the patients on hydroxyurea. this study suggests that folate supplementation makes no significant impact on the red blood cell indices of anemia nor on the incidence of adverse clinical outcomes in children with sickle cell disease. however, a larger prospective study is needed to guide future considerations for folate supplementation in sickle cell patients in the clinical setting. background: tanzania ranks 3rd globally for the number of infants born annually with sickle cell disease (scd) but lacks a national newborn screening program. the prevalence of sickle cell trait (sct) and scd is highest in the northwestern regions around lake victoria served by bugando medical centre (bmc) a teaching and consultancy hospital in mwanza. bmc also houses the hiv early infant diagnosis (eid) laboratory that tests dried blood spots (dbs) from hivexposed infants. dbs can be tested for hiv and then retested for sickle cell trait and disease. to determine the prevalence of sickle trait and disease by region and district in northwestern tanzania using existing public health infrastructure. secondary objectives explored associations between sct, scd, malaria and hiv. design/method: the tanzania sickle surveillance study (ts3) is a prospective year-long cross-sectional study of hivexposed infants born in northwestern tanzania, whose dbs collected by the eid program are tested at bmc and available for further testing of sct and scd. samples from children ≤24 months of age were tested by isoelectric focusing (ief) and scored independently by two tanzanian staff as normal, sct, scd, variant, or uninterpretable. dbs samples scored as disease or variant were repeated. over the course of 9 months, 157 ief gels have been run. a total of 10,019 dbs samples have been scored, including 9,567 from children less than 24-months old. the overall prevalence of sct is 20.65% and the prevalence of scd is 0.99%, along with 0.10% hemoglobin variants. quality of the laboratory results is extremely high, with only 0.15% dbs samples yielding an uninterpretable result. geospatial mapping of the first 5,900 samples revealed a regional scd prevalence ranging from 0.3% up to 2.0% among the 9 regions served by bmc. the prevalence of sct and scd is very high in northwestern tanzania. geospatial mapping will identify high prevalence areas where targeted newborn screening can be started using existing public health infrastructure with minimal start-up cost and training. further data will enhance the accuracy of the map to the district level. background: pediatric patients with sickle cell disease (scd) could develop obstructive, restrictive or mixed abnormalities of pulmonary function (pf). several publications report progressive worsening of pf over time, which could lead to severe morbidity in adult patients with sickle cell disease. in adults with sickle cell anemia up to 20-30 % of mortality is related to lung disease. early intervention aimed at improvement of lung function could significantly decrease morbidity and possibly improve life expectancy. among disease modifying approaches commonly used in scd are hydroxyurea (hu) and chronic prbc transfusions. both interventions lead to increase of hemoglobin, decrease of hbs fraction, leading to decreased hemolysis. reports of effect of hu on pulmonary function are conflicting with some suggesting no effect and others proposing a slower decline of pulmonary function. the goal of our study is to evaluate effect of disease modifying therapies, like hu and chronic prbc on change of pulmonary function in pediatric patients with sickle cell disease. design/method: this study utilized a retrospective chart review of children with scd who had multiple pfts. we analyzed 286 pfts from 80 patients done during clinic visits. scd patients were divided into three treatment groups: hydroxyurea, chronic transfusions or neither. data was analyzed with linear correlations and analysis of variance (anova). comparison were made between the three groups specifically observing the changes in absolute numbers on pfts over time using the first and last pft the patient had. results: there were a total of 80 patients with multiple pfts (ranging from 2-7); control (40), hydroxyurea (23) and chronic transfusion (10). the mean changes of the control, and hydroxyurea for the pft parameters fev1 (-5.53 the chronic transfusion group demonstrated a small improvement in pfts over time for fev1 (0.300), fvc (1.300), fef25-75 (0.400), however there was a decline in fev1/fvc (-0.013). however, there was no statistically significant (p-value <0.005) in the difference in any pfts parameters between any of the groups. in children with scd there is a decline of pf parameters over time. although no significant differences were seen between the three groups it appears chronic transfusion may improve or limit the decline in pfts. larger studies need to be done to evaluate difference in pf decline in patients with scd patients. background: the use of mobile technology in health care has been a growing trend. patients with chronic diseases such as sickle cell disease (scd) require close monitoring to provide appropriate treatment recommendations and avoid complications. we conducted a feasibility study for patients with scd hospitalized for pain using our self-developed mobile application (tru-pain: technology resources to better understand pain) and a wearable activity tracker. subjective symptoms such as pain and objective data such as heart rate (hr) were measured. we aimed to 1) correlate nursing recordings with mobile technology recordings; 2) get feedback from patients about usability. design/method: we enrolled patients with scd >8 years old and <36 hours from admission for uncomplicated vasoocclusive crisis, excluding patients admitted to icu. patients were given an ipad and a wearable device. they were instructed to record in the application at least once per day and to keep the wearable on, removing only to charge. prior to discharge, patients completed a feasibility questionnaire. we enrolled 20 patients, 40% females, median age 17.5 (range 13 to 54) who were admitted for a median 5 days (range 2 to 8) for uncomplicated pain crisis. patients used the application throughout hospitalization and made one entry/day (range 0 to 2). pain scores recorded via tru-pain correlated well (r = 0.74, p<0.005) with pain scores recorded in emr. there was an average of 10,930 data points recorded per day, by the wearable, with a maximum of 54,693 data points/day. the median amount of hours of wearable data per day was 4.21 (maximum of 18.05). the hr recorded via the wearable correlated significantly with the hr recorded in emr (r = 0.69, p-value < 0.005). as for usability, 70% of patients indicated never having a problem with the technology, 90% found tru-pain 'very easy' or 'somewhat easy' to use, and 60% were 'very satisfied' with their participation in the study, indicating that it helped them track their pain. our pilot study during hospitalization shows strong potential for using tru-pain for patients with scd. pain data from application and hr from wearable correlated well to the emr data. according to the feedback received, our application was easy to use and helped patients track their pain. despite limitations of battery life, the use of wearable technology is feasible, providing additional data such as activity. we are optimistic that we can continue to improve our tru-pain system to help improve care in patients with scd. background: hydroxyurea, chronic blood transfusion, and bone marrow transplantation can reduce complications, and improve survival in sickle cell disease (scd), but are associated with a significant decisional dilemma because of the inherent risk-benefit tradeoffs, and the lack of comparative studies. these treatments are underutilized leading to avoidable morbidity and premature mortality. there is a need for tools to provide patients high-quality information about their treatment options, the associated risks, and benefits, help them clarify their values, and allow them to share in the process of informed medical decision making. objectives: to develop a health literacy sensitive, web-based, decision aid (ptda) to help patients with scd make informed choices about treatments, and to estimate in a randomized clinical trial the acceptability and effectiveness of the ptda in improving patient knowledge, involvement in decisionmaking and decision-making quality. design/method: we conducted qualitative interviews of scd patients, caregivers, stakeholders, and healthcare providers for a decisional needs assessment to identify decisional conflict, knowledge, expectations, values, support, resources, decision types, timing, stages, and learning, and personal clinical characteristics, and to guide the development of a ptda. transcripts were coded using qsr nvivo 10. stakeholders completed alpha and beta testing of ptda. we conducted a randomized clinical trial of adults, and of caregivers of pediatric patients to evaluate the comparative efficacy of the ptda, vs. standard of care. results: ptda (www.sickleoptions.org) was developed per decisional needs described by 223 stakeholders and finalized following alpha testing, and beta testing by 68 and 87 stakeholders respectively. in a randomized trial of 120 subjects considering various treatment options, qualitative interviews revealed a high level of usability, acceptability, and utility in education, values clarification, and preparedness for decision making of the ptda. a median 68% rated the acceptability of ptda as good or excellent and provided narrative comments endorsing the acceptability, ease of use, and utility in preparation for decision making. the ptda met international standards for content, development process, and efficacy with the exception of having a full range of positive and negative experiences in patient stories. compared to baseline ptda group had statistically significant improvement in preparedness for decision making (p = 0.005) and informed subscale of decisional conflict (p = 0.02) but not for decisional self-efficacy, knowledge, choice predisposition, or stages of decision-making. a ptda for patients with scd developed following extensive engagement of key stakeholders was found to be acceptable, useful, easy to use, to improve preparedness for decision making, and decrease decisional conflict. background: painful vaso-occlusive crisis (voc) accounts for the majority of emergency department (ed) visits and hos-pitalizations in sickle cell disease (scd). we are interested in studying mental stress and associated autonomic nervous system (ans) imbalance that cause vaso-constriction as possible triggers of scd pain. to this end, we developed a mobile phone application (app) to record daily pain frequency and intensity as clinical endpoints that might be predicted by ans parameters measured in the laboratory. in particular, we think that the aura may represent ans instability that precedes or even triggers change in blood flow and voc. objectives: to assess the feasibility of using an app to evaluate frequency and severity of voc and its potential association with mental stress and presence of aura. design/method: an app was developed for both ios and android systems to allow patients to track pain, stress, and aura. the idea was to create an app that was easy to use with the intent to only capture pain episodes, rather than detailed description of the pain. all scd patients were eligible and a parent version was available for younger children. de-identified data was automatically transferred to a hipaa compliant database via a cloud-based server interfaced to the main research project database. a feedback questionnaire was implemented after at least a month of utilization to assess usability. of the 51 scd patients enrolled, 39 participants utilized the app and 21 of the 23 participants that provided feedback indicated the app was easy to navigate. the mean pain scale was 6 out of 10 (standard deviation 1.97) for those that entered they had pain that day. although the mean stress level was 3 out of 10, there was a statistically significant correlation between increasing stress levels and increasing pain scores (p < 0.05). aura was reported by 26 patients, with 5 patients reporting more than 10 episodes. moreover, on days aura was present there was greater incidence that pain was present as well (p < 0.05). however, there was no statistically significant association between pain intensity and presence of an aura (p = 0.14). conclusion: consistent with prior research, reported pain intensity is significantly associated with reported stress intensity. although there was an association between presence of aura and pain, it did not seem to correlate with pain intensity. this uniquely designed app can monitor scd pain clinically and help understand the role of sickle dysautonomia in the genesis of scd pain. university of florida college of medicine, gainesville, florida, united states background: evidenced-based guidelines recommend the emergent evaluation of fever in children with sickle cell disease (scd). as the prevalence of bacteremia has decreased, outpatient management has become more common. however, fever can sometimes herald other complications of scd, such as acute chest syndrome, vaso-occlusive pain crisis, splenic sequestration, or aplastic crisis. institutional practices regarding fever management in scd remain variable, and little is known about the clinical outcomes of children hospitalized for uncomplicated fever. objectives: the primary objective was to determine the rate of bacteremia or scd-related complications per febrile episode in children with scd admitted to a single institution between january 2014 and june 2017 for uncomplicated fever. this was a retrospective cohort study of febrile patients up to 21 years of age with scd, any genotype, admitted to the university of florida during the defined study period. eligible patients were identified by a database search using admitting diagnosis codes for scd and fever based on the international classification of diseases 9th and 10th revisions. encounters were manually reviewed to confirm eligibility. patients were excluded if they had other indications for hospitalization apparent at the time of admission, such as an acute vaso-occlusive episode requiring parental narcotics, asthma exacerbation, or additional complications of scd. the database search identified 211 encounters, of which 83 were excluded based on confounding indications for hospitalization. sixty-three eligible patients accounted for 128 hospitalizations. the median age was 2 years (range 5 weeks-17 years); 60.2% were male. mean duration of hospitalization was 2.6 days (range 1-13 days). eight positive blood cultures were identified; six of these were classified as contaminants. bacteremia or the development of a scd-related complication was identified in 18 (14.06%) admissions. these included acute chest syndrome (n = 4), bacteremia (n = 2), splenic sequestration (n = 1), and red cell transfusion (n = 11). exploratory analyses of potential predictors of bacteremia or scd-related complications showed no association with the presenting white blood cell count or degree of fever (p = 0.36). of the patients classified as having a scd-related complication, 94% had hemoglobin ss disease and 78% had at least one prior documented complication. 64% of the patients transfused had at least one prior transfusion. conclusion: while improvements in preventative care have substantially lowered rates of bacteremia in children with scd, fever warrants careful evaluation for other acute scdrelated complications. providers should consider inpatient observation in select cases. additional studies are warranted to define subsets of patients suitable for outpatient fever management. background: children with sickle cell disease (scd) exhibit lower neurocognitive functioning than healthy peers, even in the absence of stroke. among the domains commonly affected, working memory (wm) seems particularly affected by disease processes and wm deficits have significant implications for academic achievement and disease selfmanagement. few interventions to improve working memory in pediatric scd have been evaluated. to determine the effects of cogmed, a homebased computerized wm training intervention, in children with scd using a randomized controlled trial design. design/method: participants (ages 7-16) with scd completed a baseline neuropsychological assessment and those with wm deficits were randomized to either begin cogmed immediately or enter an 8-week waitlist. cogmed is a homebased intervention completed on an ipad that consists of 12 increasingly challenging exercises targeting visual-spatial and verbal wm, practiced over 25 sessions. at the end of training, participants completed a post-intervention neuropsychological assessment, including tests of visual-spatial and verbal wm from the wechsler intelligence scale for children-fifth edition (wisc-v). results: ninety-one participants (m age = 10.43, sd = 2.93; 59% female; 69% hbss) enrolled in the study; 52% (n = 47) exhibited wm deficits and were randomized to either begin cogmed immediately or wait 5-8 weeks before starting cogmed. among those that have received the intervention and reached the end of their training period (n = 42), 27 participants (59%) completed at least 5 cogmed sessions, 19 (41%) finished at least 10 sessions, and 7 finished at least 20 sessions (15%). the mean number of completed cogmed sessions was 9.10 (sd = 7.77). paired samples t-tests revealed significant improvements on the working memory index (t[38] = -2.44, p = 0.020) and on the digit span (t[40] = -3.02, p = 0.004), and spatial span-backward (t[39] = -2.83, p = 0.007) subtests. improvements were especially pronounced for participants completing at least 10 sessions. partial correlations controlling for respective baseline scores indicated that the number of cogmed sessions completed was positively correlated with post-test scores on digit span (r = .38, p = .017) and spatial span-backward (r = 0.45, p = 0.004) subtests. among participants who completed at least 10 cogmed sessions, 77% scored in the average range or higher on the working memory index at the post-intervention assessment, compared to 58% at baseline. results support the efficacy of cogmed in producing significant improvements in wm. a dose-effect was observed such that participants who completed more cogmed sessions had greater improvements in wm. home-based cognitive training programs may ameliorate scd-related wm deficits but methods for motivating and supporting patients as they complete home-based interventions are needed to enhance adherence and effectiveness. background: sickle cell disease is associated with myriad complications that lead to significant morbidity and early mortality. hydroxyurea has been used successfully to reduce the incidence of these complications and has led to significant improvements in quality and duration of life. at children's minnesota we recommend hydroxyurea in all patients with hb ss/s 0 thalassemia as early as 5 months of age with a goal of starting all patients before 12 months of age. objectives: the purpose of this study was to evaluate the use of hydroxyurea therapy in young patients with sickle cell disease, with particular attention to those children less than one year of age. design/method: a retrospective chart review was conducted on patients less than 5 years of age with sickle cell disease who began hydroxyurea therapy between january 1, 2008 and december 31, 2016. the study population was divided into three cohorts based upon age at hydroxyurea initiation: cohort 1 (0-1 year), cohort 2 (1-2 years), and cohort 3 (2-5 years). outcomes included laboratory data, clinical events (hospitalization, dactylitis, pain crisis, transfusion, splenic sequestration, acute chest syndrome), and toxicity occurring in the first 2 years of life. results: a total of 65 patients were included in cohorts 1 (n = 35, mean age 7.2 months), 2 (n = 13, mean age 19.5 months), and 3 (n = 17, mean age 35.5 months). patients in cohort 1 had higher hemoglobin (p = 0.0003) and mcv (p = 0.0199) and lower absolute reticulocyte count (p = 0.0304) when compared to cohort 3. the wbc (p = 0.0007, <0.0001) and anc (p = 0.0364, 0.0025) were significantly lower compared to both older cohorts. however, no patient had therapy held because of neutropenia. the mean baseline hemoglobin f in cohort 1 was 31.5% compared to 19.7% and 16.5% in cohorts 2 and 3 respectively (p = 0.002, p<0.0001). the mean duration of therapy in cohort 1 was 31.3 months, compared to 57.6 months in cohort 2 (p = 0.018) and 29.1 months in cohort 3 (p = 0.401). during this time, hb f levels remained higher in cohort 1 (mean 29.9%) compared to cohorts 2 and 3 (mean 20.4%, p = 0.007 and mean 20.6%, p = 0.003). patients in cohort 1 experienced fewer hospitalizations (p = 0.0025), pain crises (p = 0.0618), and transfusions (p = 0.0426). there was no difference in toxicity between groups. hydroxyurea was used safely in infants 5 to 12 months of age and resulted in more robust hematologic responses and a decrease in sickle-related complications when compared with patients starting hydroxyurea later in life. children's national health system, washington, district of columbia, united states background: children with sickle cell disease (scd) have a significantly greater risk of silent or overt cerebral infarction than the general population. infarcts are associated with declines in cognitive functioning and academic achievement. while infarcts are reliably identified using mri, scans are expensive and occasionally necessitate sedation. moreover, mri's are not recommended for routine monitoring of cerebral infarcts. additional tools are needed for discriminating the presence of a cerebral infarct that are brief, noninvasive, inexpensive, and repeatable. objectives: to evaluate differences in performance on cogstate, a computerized neurocognitive assessment, in patients with scd with and without history of cerebral infarct. design/method: participants included 112 children with scd ages 7-16 (m = 10.61, sd = 2.91; 58% female; 70% s117 of s301 hbss) enrolled in a cognitive intervention trial. participants completed the cogstate pediatric battery, which measures processing speed, sustained attention, verbal learning, working memory, and executive functioning. history of silent or overt infarct was determined via health record review. participants also completed measures of intelligence (iq) and math fluency. results: participants' standard scores across most neurocognitive measures were lower than expected compared to the standardization sample (mean iq = 91.03, sd = 13.34). thirty percent of participants (n = 33) had a documented history of cerebral infarct. participants with a history of cerebral infarct scored lower on cogstate tasks measuring sustained attention (t[108] = 2.93, p = 0.004) and executive functioning (t[98] = 2.46, p = 0.016), as well as on a measure of math fluency (t[88] = 2.16, p = 0.033). receiver operating characteristic (roc) analyses demonstrated that the cogstate task measuring sustained attention was a fair discriminant of patients with and without a history of infarct (auc = 0.75, ci95 = 0.65-0.84, p = 0.0001), whereas iq score was not (auc = 0.58, ci95 = 0.46-0.71, p = 0.19). cogstate processing speed and sustained attention tasks fairly discriminated between patients with at least average or below average intelligence (auc = 0.77, ci95 = 0.67-0.86, p = 0.00001 and auc = 0.74, ci95 = 0.64-0.84, p = 0.0001, respectively). finally, the cogstate processing speed task was good at discriminating between at least average or below average math fluency (auc = 0.80, ci95 = 0.70-0.90, p<0.00001). multiple tasks in the cogstate pediatric battery appear to adequately identify patients with a history of cerebral infarcts. in addition, cogstate tasks appear to be fair predictors of impairments in iq and academic achievement outcomes. cogstate is inexpensive and can be easily administered in a medical setting with minimal training in approximately 20 minutes. results support the potential for cogstate to be used as a screening tool for medical and neuropsychological abnormalities in children with scd. st. christopher's hospital for children, philadelphia, pennsylvania, united states background: cardiovascular disease contributes to the morbidity and mortality of patients with sickle cell disease (scd). hydroxyurea therapy in scd has known clinical efficacy including improving anemia, decreasing episodes of vasoocclusive crisis and acute chest syndrome, and decreasing mortality. effect of hydroxyurea on cardiac function in children with scd is not well studied. an earlier study suggested the protective effect of hydroxyurea on left ventricular (lv) hypertrophy in scd. we hypothesized that hydroxyurea use would be associated with decreased lv remodeling and improved cardiac function. we aimed to evaluate the association between hydroxyurea use and lv remodeling and cardiac dysfunction in children with scd. design/method: we completed a retrospective study of patients with scd who were 10 to 22 years old, followed at st. christopher's hospital for children and had an echocardiogram completed in the past 18 months. data collected included gender, bmi, scd genotype, hydroxyurea use, chronic transfusion use, and 2d and doppler echocardiographic parameters. cardiac structure, geometry, systolic function, and diastolic function echocardiogram parameters were included. analysis of variance (anova) tests were performed to assess for statistical significance of differences in cardiac parameters between patients with and without hydroxyurea use. analysis of covariance (ancova) tests were performed to control for age. results: demographic and echocardiogram data was collected on all 93 patients who met inclusion criteria. of the 93 patients included, 31 (33%) were on hydroxyurea therapy. patients on hydroxyurea had significantly lower mean relative wall thickness (p = 0.026) and significantly higher mean peak early lv filling velocities (p = 0.032) and peak early lv filling/septal annuli early peak (e/ea) velocities (p = 0.002); however, only the e/ea velocities remained significant when controlling for age (p = 0.001). mean peak early lv filling velocities approached significance when controlling for age (p = 0.052). hydroxyurea therapy resulted in a significantly higher e/ea velocity, suggesting that these patients had worse diastolic function. it is possible that the patients initiated on hydroxyurea already had worse disease manifestations than those not on hydroxyurea, possibly accounting for the decreased diastolic function. when controlling for age, hydroxyurea use did not result in significant differences in cardiac structure parameters, systolic function parameters or cardiac geometry. prospective studies and larger sample size are needed to validate our findings, examine for additional statistically significant differences, and develop preventive strategies for cardiovascular disease in children with scd. background: acute chest syndrome (acs) is now the leading cause of death in children with sickle cell disease; mortality in the u.s. is reported to be 1-2% and is mostly due to respiratory failure. early transfusion improves clinical outcomes. although patients with concurrent asthma are considered at increased risk for poor outcomes, risk factors for respiratory failure in pediatric acs have not been well-defined. to determine whether specific epidemiological and clinical features of children hospitalized with acs are predictive of the need for mechanical ventilation. design/method: data from the kids' inpatient database were reviewed to identify patients age < 20 years with a discharge diagnosis of acs for the years 2003, 2006, 2009, and 2012 . outcomes were defined by the international classification of diseases, ninth revision, clinical modification code. data were weighted to estimate total annual hospitalizations according to hospital characteristics in the united states. trends in healthcare costs, length of hospital stay, transfusion, and mechanical ventilation use were analyzed using multivariable linear regression. in addition, multivariable logistic regression was used to ascertain specific clinical or epidemiologic factors associated with mechanical ventilation use after adjusting for patient and hospital characteristics. the total hospitalizations for acs were 5,018 in 2003; 6,058 in 2006; 6,072 in 2009; and 6,360 in 2012. reported use of mechanical ventilation ranged from 2.8% to 5.6% and was associated with non-black compared to black children (or, 1.53; 95%ci, 1.02 to 2.31) and the fall season (or, 1.36; 95%ci, 1.05 to 1.74), but not with age, preexisting asthma or hb-genotype. comorbidities of obesity (or, 3.35; 95%ci, 1.94 to 5.78), obstructive sleep apnea (or, 3.72; 95%ci, 2.23 to 6.20) and heart disease (or, 2.19; 95%ci, 1.47 to 3.27) were associated with mechanical ventilation use. the use of simple and exchange transfusion during all acs admissions ranged from 30.1% to 40.5% and 2.6% to 2.9%, respectively. among pediatric acs patients, those with obesity, obstructive sleep apnea or heart disease were at increased risk for respiratory failure and might benefit from early intervention (e.g., transfusion). surprisingly, asthma in children with acs does not appear to be a distinct risk factor for respiratory failure, and further studies are needed to clarify whether differences in treatment approach (e.g., addition of corticosteroids, bronchodilators) might impact on acs progression and/or severity even in high risk patients without asthma. objectives: to compare pulmonary functions between aa and k children with scd and to assess if a high hb f level contributes to better function. design/method: a cross sectional study was done on children with scd (hb ss disease) followed in comprehensive sickle cell programs. aa patients were followed at brookdale hospital, ny and k patients were followed in mubarak hospital, kuwait. children between the ages of 6 and 22 years who had pulmonary function tests (pft) done as a routine screening were enrolled. pft was done using spirometer and plethysmography. patients with congenital or anatomical lung abnormality, heart disease, pulmonary disease such as acute chest syndrome, acute asthma or pneumonia within 4 weeks were excluded. results: there were 74 children (37 in each group) with scd,. restrictive pattern on pft was seen in 18/37 (49%) of aa vs. 10/37 (27%) of k (p>0.05). obstructive pattern was seen in 6/37 (16%) of aa vs. 13/37 (35%) of the k group (p>0.05). in both groups, 13 children (35%) had normal pft. three/13 (15%) in the aa group had a hb f>20% as compared to 11/13 (85%) in the k group (p<0.01). abnormal pft was noted in 24/37 children (65%) in each group. hbf was >20% in 3/24 (13%) in the aa group vs. 15/24 (63%) in the s119 of s301 k group (p<0.01). in patients with abnormal pft, mean hbf was 10.4±8.4 in aa group, compared to 22.4±8 in k group (p<0.01). conclusion: abnormal pft is highly prevalent among children with scd in both groups. aa children are more likely to have restrictive disease and k to have an obstructive pattern. level of hbf did not seem to protect k patients from abnormalities on pft. this finding should emphasize the importance of performing pft as part of the initial evaluation of all children with scd. background: sickle cell disease (scd) is a life-threatening disease with varied clinical spectrum and severity leading to premature death. there is a lack of validated prognostic marker in scd. recent evidence suggests that inflammation and platelet adhesion plays a critical role in the pathophysiology of vaso-occlusion in scd. elevated mean platelet volume(mpv) values are associated with a higher degree of inflammation in many disease states but it's effect on sickle cell disease or it's severity is unknown. objectives: to analyze the role of mpv in predicting disease severity/mortality in pediatric patients with scd. design/method: this is a single center retrospective study and included patients with sickle cell disease between 6 months and 18 years of age during a 10-year period (2006) (2007) (2008) (2009) (2010) (2011) (2012) (2013) (2014) (2015) (2016) . demographic information, lab data and clinical information including acute chest syndrome (acs), priapism, transfusions, sepsis, pain crisis, avascular necrosis were collected. all laboratory data were collected in steady state with no crisis in the recent past 3 months. the disease severity score/probability of death was calculated using a validated model to predict risk of death in sickle cell disease (sebastiani et al. blood 2007) . pearson test was used to analyze correlation between mpv and probability of death. results: total no. of patients = 92; male 45 (48.9%); female 47(51.1%). median age is 6.0 years. all patients were of african-american origin. disease severity, hb ss -58(63%); hb sc -25(27.2%) and sickle-beta thalassemia 9(9.8%). patients on hydroxyurea has significantly lower mpv, p = 0.023 and this is independent of hb f levels. mpv has a significant positive correlation with the probability of death, p = 0.016 and correlation coefficient, r = 0.254. on subgroup analysis, the correlation is even more significant in the age group between 6 and 18 years, p = 0.004, r = 0.405. using linear regression model, with probability of death as a dependent variable and hydroxyurea, mpv as independent variables, mpv maintains a significant association with probability of death (p = 0.016). conclusion: mpv is an independent biomarker predicting disease severity and probability of death in pediatric patients with sickle cell disease. hydroxyurea a known disease ameliorating agent is associated with lower mpv values. this effect is independent of the levels of fetal hemoglobin and may be due to anti-inflammatory effect of hydroxyurea or effect on the platelets. background: major success with initial qi projects by the sickle cell care team at children's hospital has precipitated ongoing inclusion of the qi approach to many other aspects of patient care. objectives: to optimize scd patient care utilizing qi processes. design/method: success of the scd qi team's initial project on transcranial doppler studies (tcds) and a second more complex project on hydroxyurea (hu) adherence, led to additional projects on completion of key immunizations, rbc phenotyping, and vitamin d level testing. using similar processes and principles from the hu adherence project, plan-do-study-act (pdsa) cycles were used to conduct smallscale tests of change. patient chart prep sheets, created for bi-monthly pre-appointment chart prep meetings, were significantly modified to include these focused care qi objectives. because of difficulty with emr database capability, data collected from the emr was tracked in excel spreadsheets or other unique tracking vehicles for the various parameters. for example, due to the clinic's diffuse, geographically scattered population, many separate non-shared primary care emrs, and lack of a mandatory state immunization registry; immunization records needed to be retrieved from pcps, outlying hospitals, public health departments, and fqhcs, and added to the emr and excel database. starting in 12/2016, all such data was collected and updated monthly. in one year's time (2016 -2017) , the average immunization completion rate for seven key immunizations (pcv 13, pcv 23, hepatitis a, hepatitis b, meningococcal a, meningococcal b, and hpv) has increased by 20%. the biggest improvements were a 57% and 44% increase in completion for meningococcal a and meningococcal b, respectively. completion rate for rbc phenotyping rose from 34.8% to 74.4%. patients with at least one vitamin d lab test increased from 27.8% to 67.9%. since starting the tcd project in 2013, the percent of patients who have completed their annual tcd has gone from a baseline of 50% to a sustained value of > 80%. conclusion: these qi projects have not only increased adherence to national recommendations for care of scd patients, they have helped establish a scd clinic methodology to create and implement sustainable processes. having the focused care initiatives prominently displayed on the patients' chart prep sheet serve as a reminder to medical team members to check the status of that item. this methodology is currently being used to formulate additional qi projects on annual renal function parameters and specialty visits, such as annual eye and dental exams. background: dominican republic has a high burden of sickle cell disease, and 5-10% of children with homozygous hbss (sickle cell anemia, sca) will develop primary stroke. transcranial doppler (tcd) ultrasonography is an effective screening tool for primary stroke risk, but is not routinely available in dominican republic. hydroxyurea and blood transfusions are available, but no prospective screening and treatment program for stroke prevention has been implemented to date. (1) to screen a large cohort of children with sca living in dominican republic, using tcd to identify elevated stroke risk; (2) to determine the effects of treatments for stroke prevention (hydroxyurea for conditional velocities and transfusions for abnormal velocities). we hypothesized that both hydroxyurea and blood transfusions will decrease elevated tcd velocities and help prevent primary stroke. design/method: stroke avoidance for children with república dominicana (sacred, nct02769845) features a research partnership between cincinnati children's hospital and robert reid cabral children's hospital in dominican republic. the protocol, consent forms, and redcap database were prepared collaboratively and translated into spanish, and then irb approval was obtained at both institutions. in the initial prospective phase, children receive tcd screening over a 12-month period; those with conditional tcd velocities (maximum time-averaged velocity 170-199 cm/sec) receive fixed-dose hydroxyurea at 20 mg/kg/day, followed by dose escalation to maximum tolerated dose, while those with abnormal tcd velocities (≥200 cm/sec) receive monthly transfusions for stroke prevention. results: a total of 283 children were enrolled in sacred, with an average age of 8.7 ± 3.4 years. initial tcd screening revealed 200 (70.7%) normal, 63 (22.3%) conditional, 11 (3.9%) abnormal, and 9 (3.1%) inadequate velocities. among 48 children (25 males, 23 females, average age 6.8 ± 2.8 years) who initiated hydroxyurea at 20 mg/kg/day for conditional tcd velocities, 42 completed six months of treatment with expected hematological benefits including significant increases in hemoglobin concentration (7.5 to 8.5 g/dl) and fetal hemoglobin (15.8 to 28.4%). no clinical strokes have occurred in the treatment group. repeat tcd examination after 6-months of hydroxyurea treatment revealed 69% (29/42) with previous conditional velocities had normal tcd velocities. the prevalence of conditional tcd velocities in the dominican republic is high, indicating an elevated stroke risk among children with sca. hydroxyurea treatment is associated with improved hematological parameters, lower tcd velocities, and probable decreased stroke risk. sacred is an important prospective and collaborative research trial providing epidemiological data regarding tcd screening, stroke risk, and hydroxyurea effects among children with sca. background: red blood cell aggregation is a rheologic property that explains the shear-thinning behavior of blood. at lower shear rate blood flow, red cells tend to aggregate, s121 of s301 whereas in higher shear rate blood flow, these aggregates are dispersed. this property is especially important in the venous system, where low shear rate blood flow predominates. there is inconsistent data in the literature concerning aggregation and aggregability in sickle cell disease (scd). objectives: because the lorrca and myrenne instruments have been shown to be similarly effective methodologies in red cell aggregation measurements, we aimed to determine whether the measurement of aggregation indices in scd, by myrenne and by lorrca, is consistent in our lab. design/method: we measured aggregation in blood samples corrected to 40% hematocrit. aggregability was measured using 70kda dextran in the myrenne but not the lor-rca. aggregation index using lorrca was measured in 26 patients with scd and 22 healthy subjects enrolled in a study of blood flow between 2014 and 2017. aggregation and aggregability using the myrenne was measured in 67 patients with scd and 15 healthy subjects enrolled in a separate study of blood flow between 2008 and 2013. results: using lorrca, we found that aggregation index in patients with scd was less than that of healthy subjects (p<0.001). in the myrenne, aggregation at stasis was slightly higher in patients with scd compared to healthy subjects (p = 0.05) but aggregation at low shear rotation was not different. aggregability was higher in the patients with scd compared to healthy subjects at both stasis and low shear rotation (p<0.0001). red cell aggregation is an important determinant of low shear blood flow. deoxygenated venous blood is particularly important to low shear blood flow in patients with sickle cell disease. we found that two different aggregometers predict different aggregation results for scd. it is unclear why there is a systematic difference between the two methods, but there are some possibilities. first, the syllectogram in the lorrca is generated by the backscatter of light from the laser, while the myrenne measures transmitted light. second, the distance between the bob and cup in the lorrca is 300 microns, while the gap between plates in the myrenne is 50 microns, which might affect the disaggregation of red cells. further work is needed to understand the differences in red cell aggregation and aggregability when using these instruments, particularly when using aggregation as a predictor of blood flow and tissue perfusion. background: children with sickle cell disease (scd) are at risk of acute splenic sequestration crisis (assc). assc is a life-threatening complication characterized by splenomegaly, pain and severe anemia. assc most often occurs in young children with the most severe forms of scd and one-third of patients will have more than one episode. treatment is based primarily on expert opinion and includes blood transfusion and surgical splenectomy. objectives: we plan to assess the clinical practice patterns of physicians treating children with assc. design/method: a survey study was performed. the survey included six scenarios of severe scd with variation in age, hydroxyurea-use, and episode number of assc; questions focused on the acute and chronic management of assc. the survey was disseminated on three occasions over a six-month period, using an online survey tool, surveymonkey, to pediatric hematologist-oncologists participating in the american society of pediatric hematology-oncology hemoglobinopathy special interest group. the survey had a response rate of 43% (28/65). most respondents were recent graduates (61%; 17/28) practicing in academic urban centers with greater than 100 sickle-cell patients. seventy-nine percent (22/28) recommended hydroxyurea initiation in 9-12 m/o with severe scd. prophylactic penicillin after surgical splenectomy was continued by 93% (26/28) after 5 years. for the acute management of assc results did not vary despite patient age, hydroxyurea use, and the number of previous assc episodes. simple transfusion was preferred by 89% (25/28), with 54% (15/28) recommending slow transfusion and 36% (10/28) recommending routine simple transfusion. for the chronic management of assc, results varied based on patient age and the number of previous assc episodes. for a 12 m/o after the first episode, 36% (10/28) recommended observation and 32% (9/28) hydroxyurea initiation. for a 12 m/o with any prior episode of assc, 39% (11/28) recommended chronic transfusion therapy and 36% (10/28) surgical referral for splenectomy. for a 3 y/o after the first episode, 39% (11/28) recommended surgical splenectomy and 32% (9/28) increasing hydroxyurea dose. for a 3 y/o with any prior assc episode, 64% (18/28) recommended referral for surgical splenectomy. in this survey, we found most providers continue to recommend simple transfusions for assc and surgical splenectomy after two episodes. the majority of providers continue to delay referral for surgical splenectomy until age two, but earlier referral in children under two and use of chronic transfusion therapy were also reported. variability in chronic management highlights the need for further research of splenic sequestration. background: developing therapies for sickle cell disease (scd) is challenging in part because the accepted endpoint, vaso-occlusive crisis (voc), occurs infrequently, does not measure full disease burden, and is a measure of healthcare utilization. in phase 1/2 studies of patients with scd, voxelotor (gbt440) has demonstrated increased hemoglobin (hb) levels and reduced hemolysis and has been safe and welltolerated. voxelotor is being evaluated in the ongoing hope phase 3 trial. objectives: to report the innovative phase 2/3 hope trial design with novel primary and secondary outcomes to accelerate drug development. design/method: hope (nct03036813) is a phase 3, randomized, placebo-controlled, multicenter study of oral voxelotor in patients with scd (aged 12-65 years) with baseline hb 5.5-10.5 g/dl and 1-10 episodes of voc in the prior year. to accelerate clinical trials to support drug development, the study combines a phase 2 exploratory, dose-selection phase (group 1) with a pivotal phase (groups 2/3). patients in group 1 will be randomized 1:1:1 to voxelotor 900 or 1500 mg/day or placebo. analysis for dose selection will occur when the final patient has received 12 weeks of treatment. group 2 will continue enrollment with randomization 1:1:1 until dose selection based on analysis of the group 1 cohort. group 2 will allow for a seamless transition into group 3, which will randomize patients 1:1 to the selected dose or placebo. the final data analysis set will include group 2 patients who received placebo or the selected dose and all group 3 patients. the primary endpoint is an objective laboratory measure and surrogate of clinical benefit, increase in hb >1 g/dl, from baseline to 24 weeks based on voxelotor mechanism of action (inhibition of hb polymerization). this trial is the first to use a patient-reported outcome (pro), the 9-item sickle cell disease severity measure, as a secondary endpoint. this novel electronic pro, developed specifically for the hope study following fda guidance, will evaluate changes in scd symptom exacerbation and total symptom score from baseline to 24 weeks. additional secondary endpoints include measures of hemolysis, rates of voc, transfusions, and opioid use. the study was designed to enable selection of pro-defined symptom exacerbations or traditionally defined voc as the key secondary endpoint after the group 1 analysis. results: this study is ongoing. the hope trial, expected to complete enrollment by late 2018, will evaluate the efficacy and safety of voxelotor compared with placebo in patients with scd. supported by global blood therapeutics. background: inflammation, coagulation activation, oxidative stress and blood cell adhesion are elements of sickle cell disease (scd) pathophysiology. patients with scd have low levels of the omega-3 fatty docosahexaenoic acid (dha) and eicosatetraenoic acid (epa) in plasma and blood cell membranes. dha is a bioactive fatty acid with anti-inflammatory, anti-blood cell adhesion and anti-oxidant properties. altemi-atm is a novel dha ethyl ester formulation with a proprietary delivery platform (advanced lipid technology® (alt®)) that enhances oral dha bioavailability. the scot trial investigated the effects of altemiatm in children with scd. objectives: to demonstrate the effects of altemiatm on blood cell membrane omega-3 index and selected biomarkers of inflammation, coagulation, adhesion and haemolysis associated with scd. s123 of s301 design/method: children with scd, aged 5-17 years (n = 67), were enrolled. subjects were randomized to receive either placebo or one of three daily oral doses of altemiatm (12-26, 26-48 or 51-72 mg/kg/day dha) for two months. the effects of altemiatm on red blood cell (rbc), white blood cell and platelet membrane omega-3 fatty acids index (total dha + epa levels) were assessed after four weeks of treatment. the effects of altemiatm on markers of inflammation, adhesion, coagulation, and hemolysis were assessed after eight weeks of treatment. cell membrane dha and epa concentration was determined by using lc-ms/ms method. the percent changes from baseline on blood cell membrane omega-3 index and select scd biomarkers were compared between the three dose groups and placebo using a mixed-model repeatedmeasures (mmrm) analysis with baseline blood cell membrane omega-3 index, hydroxyurea use, and treatment as fixed effects and patient as a random effect. after four weeks of treatment, blood cell membrane dha and epa levels were significantly increased in all altemiatm doses (p<0.01). after eight weeks of treatment, significant reductions were observed in se-selectin (p = 0.0219), and d-dimer (p = 0.025) in patients exposed to altemiatm dose level 2 vs. placebo. hemoglobin was significantly increased at altemiatm dose level 1 versus placebo. plasma high-sensitivity c-reactive protein, lactate dehydrogenase, soluble vascular cell adhesion molecule-1 and white blood cell count showed improvement after 8 weeks of treatment in all three altemiatm doses levels but did not reach significance. conclusion: treatment with altemiatm enriches dha and epa in blood cell membranes of patients with scd and improves select sickle cell disease biomarkers of blood cell adhesion and thrombin generation. these findings provide insight into the mechanisms of action of altemiatm in sickle cell disease. brown university -hasbro children's hospital, providence, rhode island, united states background: despite clinical advances in the treatment of sickle cell disease (scd) in pediatric and young adult patients, pain remains a significant source of disease-related morbidity. physical therapy has been shown to be useful for the treatment of pain in children and young adults with various chronic illnesses of which pain is a significant component, however no data exists regarding potential benefits of physical therapy in pediatric and young adult patients with scd. objectives: to query healthcare providers and others involved in the care of pediatric and young adult scd patients regarding possible benefits of and barriers to physical therapy as a potential treatment modality. design/method: we conducted a web-based survey of healthcare providers within the new england pediatric sickle cell consortium (nepscc) in an attempt to identify potential benefits of and barriers to outpatient physical therapy in this patient population. results: nearly 92% of survey participants felt that physical therapy had the potential to be "somewhat beneficial" or "very beneficial" in pediatric and young adult patients with scd. a majority of physicians reported having referred patients with scd for physical therapy in the past. the most frequently identified perceived potential benefits included improved functional mobility, improvement of chronic pain symptoms, decreased use of opiates, improved mood symptoms, improved acute pain symptoms, and improved adherence with medications and clinic visits. significant perceived barriers identified included lack of transportation, time constraints, patient lack of understanding, and difficulty with insurance coverage. our study indicates that healthcare providers have an overwhelmingly positive view of the use of physical therapy in the management of pediatric and young adult patients with scd. significant barriers exist which need to be addressed. future research should focus on patient and parent perspectives regarding physical therapy, as well as a randomized controlled trial of a physical therapy intervention in this patient population. background: vitamin-d deficiency is fast becoming increasingly recognized in patients with sickle cell disease (scd). while it is estimated that these patients are five times more likely to develop vitamin-d deficiency, the exact clinical significance of this is largely unknown. given that this deficiency can be inexpensively and easily treated, our study sought to establish the prevalence of vitamin-d deficiency in our patient population and its relationship with disease severity. objectives: to estimate the prevalence of vitamin-d deficiency in patients with scd in our institution and to analyze their disease severity in relation to their vitamin-d level. design/method: through retrospective chart review we analyzed subjects that represent a cohort of patients followed at the adult and pediatric hematology services at university of miami with known diagnosis of scd that had a vitamin-d level drawn between january 01st, 2013 and august 31st, 2016. we conducted a cross-sectional study and recorded the first vitamin-d level during this period. patient demographics, medical and social history information were collected along with laboratory data. the number of admissions for vaso-occlusive crisis (voc) and acute chest syndrome within one year preceding the collection the vitamin-d level was also recorded. results: a total of 476 charts were reviewed, 279 adult charts and 207 pediatric charts. after exclusion, 119 patients were enrolled. subclinical vitamin-d deficiency is only evident on laboratory blood testing of vitamin-d (25-hydroxy) and according to this laboratory result patients were classified as sufficient (≥32 ng/ml), insufficient (<32 to 20 ng/ml) and deficient (<20 ng/ml). out of the 119 cases, 61.7% (74/119) were deficient, 21.7% (26/119) were insufficient and 15.8 % (19/119) were optimal. after statistical analysis two negative correlations were identified, increasing vitamin-d levels with decreasing white blood cell count (ci 95%-0.1931133 (-0.36057544, -0.01359017)and decreasing incidence voc (ci 95%-0.3149722 (-0.4684118, -0.1430889). conclusion: this study confirms that there is a significant prevalence of vitamin-d deficiency in patients with scd. furthermore, the results of this investigation proved that vitamin-d deficiency is associated with acute pain and leukocytosis in patients with scd. given the multitude of confounding factors that affect vitamin-d absorption and intake, multivariate analyses are required to truly further investigate this relationship. texas children's hospital, houston, texas, united states background: hemophagocytic lymphohistiocytosis (hlh) is a rare but life-threatening condition of hyper-inflammation that is characterized by splenomegaly, cytopenias, hyperferritinemia, hypertriglyceridemia, hemophagocytosis and coagulopathy. although timely diagnosis is imperative, it is often challenging as these individual signs and symptoms may occur in a variety of clinical conditions. to report a case of undiagnosed sickle cell anemia presenting with severe ebv viremia and associated hemophagocytic lymphohistiocytosis results: a 21-month-old previously healthy male presented with respiratory distress, increased fatigue, and a focal seizure following a two-week history of cough and lowgrade fevers. physical exam was consistent with hypovolemic shock and revealed significant splenomegaly. laboratory testing revealed severe hypoglycemia, acidosis and electrolyte disturbances including hyperkalemia, hyperphosphatemia, and hyperuricemia. labs showed a leukocytosis (wbc 53,000), severely low hemoglobin (1.9), and platelets of 56,000. coagulation testing revealed prolonged pt/inr and ptt, hypofibrinogenemia and a highly elevated d-dimer. additional workup was completed to determine etiology of acute presentation, given broad differential diagnosis. infectious studies were consistent with an acute ebv infection (plasma ebv pcr >550,000). elevated levels of soluble il-2 and ferritin completed 6/8 criteria for the diagnosis of hlh. bone marrow evaluation showed trilineage hematopoiesis with no abnormal blast population or hemophagocytosis. results from hemoglobin electrophoresis sent from the initial cbc sample were notable for hbs 72.5%, hbf 25.0%, and hba of 0%, confirming the diagnosis of sickle cell disease. the patient was started on hydroxyurea and penicillin and splenomegaly resolved. with supportive care, he demonstrated gradual improvement in symptoms and laboratory abnormalities, including normalization of soluble il-2, ferritin, cd163, il-18 levels, immunoglobulins, and declining ebv titers. nk cell function has remained abnormally low, not eliminating the possibility of acquired hlh despite spontaneous improvement. conclusion: splenic sequestration associated with sickle cell disease in combination with acute infectious mononucleosis could have explained many of the presenting symptoms including anemia, thrombocytopenia, and splenomegaly. however, it does not explain the unusually high ebv titer and degree of inflammation meeting diagnostic criteria for hlh, which raises concern for an underlying immunologic abnormality such as x-linked lymphoproliferative disorder (xlp). although testing for xlp was negative, he will require s125 of s301 continued monitoring in the future for signs of relapse. this case illustrates the complexity of diagnosing lymphohistiocytic disorders and the significant overlap in presentation between these disorders and other medical conditions. background: vaso-occlusive crisis (voc) is one of the most distressing occurrences in patients with sickle cell disease (scd). patient controlled analgesia (pca) is recommended by nih and expert opinions favor its early use. we aim to review the use of pca in patients with voc and to evaluate if its early use is associated with faster pain control and reduced length of stay (los). design/method: this retrospective single center study included all pediatric patients admitted and treated with pca for a severe voc from 2010 to 2016. "early" use was defined as start of pca within 48 hours of arrival in the emergency department (ed) and "late" use after 48 hours. time to reach adequate analgesia was defined as oucher, verbal scale or faces pain scale < 5/10 obtained twice consecutively in a 4-hours interval. time to reach adequate analgesia and los were compared between early-pca and late-pca groups. results: a total of 46 patients presented 87 episodes of voc treated with pca during the study. sixty-one episodes (70%) were treated with early-pca and 26 (30%) with late-pca. both groups were comparable in terms of age (13.2 vs 12.8 years old), gender (55.8% female vs 57.7%), hemoglobin phenotype (80.3% hbss vs 76.9%), but median pain score at admission was higher in early-pca than in late-pca (9/10 vs 7/10, median difference 1 (95% ci 0, 2). early-pca was associated with a median reduction in los of 3.15 days (95% ci 1.65, 4.82) (median early-pca los 6.4 vs late-pca 10.0 days). time to reach analgesia could be evaluated only in a subset of patients (20 in early-pca and 12 in late-pca group). although time to reach adequate analgesia tended to be shorter in the early-pca group, it was not statistically different: median102.9 hours vs 123.5 hours, difference of 30.4 (95% ci -4.0, 72.5). side effects were observed during 29 (33.3%) pca treatments (19/61 (31.2%) episodes in early-pca, 10/26 (38.5%) in late-pca group) among which 16 (18.6%) were significant adverse events. these were observed in 15 patients who required interventions: 2 desaturations requiring oxygen without intubation, 8 neurologic abnormalities (hallucinations, visual abnormalities, no stroke), 6 urinary retentions. conclusion: early use of pca for severe voc was associated with a reduced length of hospital stay despite that these patients had higher pain score on admission. prospective studies are needed to support these positive outcomes. background: acute chest syndrome is one of the leading causes of death in children with sickle cell disease1-2. while the cause of acute chest syndrome most commonly is not identified, fat embolism and infectious causes are believed to be most common. with an extremely high mortality rate, rapid identification and initiation of therapy is essential for survival. case presentation: we describe the case of an 18-year-old female with sickle cell sc disease who was admitted for vasoocclusive pain crisis and quickly progressed to multi-system organ failure due to fat embolism syndrome and parvovirus b19 infection objectives: the case highlights the presentation and diagnosis so other providers can optimize outcomes for those with this under-recognized syndrome design/method: her parvovirus studies returned after 7 days which showed: parvovirus b19 dna pcr detected; parvo igg 1.99 (positive > 1.1); and igm 12.98 (positive > 1.1). the patient experienced an approximately 2.5 g/dl drop in hemoglobin(8.7 to 6.0 g/dl/24 hrs) with progressive thrombocytopenia (from 269,000 to 54,000/ul) and a peripheral smear showed microcytic,normochromic red cells with nucleated rbcs and occasional nuclear budding, slight polychromasia, schistocytes, and polymorphic cells with toxic granules that suggested leukoerythroblastosis. she was emergently transferred to the regional quaternary care hospital for ongoing ecmo therapy where she experienced a change in her pupillary exam prompting a stat ct scan that showed severe, diffuse cerebral edema with transtentorial herniation. the decision was made to withdraw life-sustaining therapies and her family refused a post-mortem autopsy examination. fat embolism syndrome is a severe and uncommonly recognized complication of sickle cell disease, seen most commonly in those with a non-ss phenotype and previous mild disease course who present with severe, unrelenting vaso-occlusive pain episode and/or acute chest syndrome that progresses to respiratory distress with altered mental status and cutaneous changes. rapid identification and initiation of exchange transfusion therapy should be initiated with clinical suspicion because of the extremely high mortality rate. although previously considered rare, it needs to be considered in the differential diagnosis of more commonly encountered complications of sickle cell disease. background: patients with sickle cell disease (scd) experience vaso-occlusive crisis (voc), which results in extreme pain, often requiring opioids and admission. genetic and environmental factors affect the frequency and severity of these episodes. previous research has born conflicting evidence on whether environmental temperature is contributory. edmonton, alberta is the northern most city with a population over a million in north america. there is an increasing sickle cell population which is exposed to extreme winter conditions. this provides a suitable population and atmosphere to study the influence on cold external temperatures in scd. this study sought to identify if pediatric patients with scd, experience greater morbidity in cold external temperatures. board approved retrospective case control series. patients were identified through a clinical database, and emergency visit, phone call and admission data was collected over a fiveyear period. the average, minimum and change in temperature on day of presentation, 24 and 48 hours prior, was collected from the government of alberta, and was statistically analyzed using descriptive statistics, to determine the relation to vaso-occlusive events. results: one-hundred and eighteen patients were identified, and 258 voc events reviewed. the mean patient age was 6.6 years of age with a range from 0.3-17 years old. the female to male ratio was equivalent with 133 female (51.6%) and 125 male (48.4%) voc events. eight records (3%) had docu-mented cold exposures. the analysis between the temperature and the frequency of events did not yield significant correlation. average and minimum temperature on day of admission had the largest percentage of voc events occur at mild temperatures, from -4.99 to 20 • c and -4.99 to 5 respectively. change in temperature on day of admission, 24 and 48 hours had the largest percentage of voc events at a mild to moderate change in temperature of 10-15 degrees. data at 24 & 48 hours prior to admission showed similar results. secondary data analysis accounting for the lower proportion of extreme weather days in comparison to moderate temperate days showed no significant impact. there was no correlation of average, minimum or change in temperature on day of admission, 24 or 48 hours prior. multiple cofounding factors likely contribute to these results. as it was a retrospective study many confounding and precipitant factors may not be recorded or identified. a prospective study to better record specific cold exposure is warranted. children's national health system, washington, district of columbia, united states background: achieving optimal anticoagulation with unfractionated heparin (ufh) in pediatric patients receiving extracorporeal membrane oxygenation (ecmo) is often challenging due to antithrombin (at)-mediated heparin resistance (hr). intermittent at dosing during pediatric ecmo support does not maintain adequate at levels. continuous at infusion (cati) presents an alternative strategy to achieving consistent goal at levels and optimizing heparinization. however, cati during pediatric ecmo has not been adequately studied. objectives: to describe our center's experience with an ecmo cati protocol. design/method: in 2014, we modified our ecmo anticoagulation protocols to include ufh titration according to anti-factor xa (anti-fxa) levels and cati in patients with at-mediated hr. the cati rate was calculated using baseline and goal at levels while accounting for the circuit volume. cati was administered with ufh into the circuit via a s127 of s301 y-infusion set. at and anti-fxa levels were monitored every 6 hours. recombinant at (r-at) concentrate was used at our center until 2015 with subsequent transition to a plasmaderived at (pd-at) concentrate. due to the longer half-life of pd-at concentrate, the protocol was modified so cati is stopped once target at and anti-fxa levels are achieved. we conducted a retrospective study of all patients who received cati during ecmo support at our center. data are reported as median and interquartile range and compared using the mann-whitney u test. two-tailed p-value <0.05 was considered statistically significant. since 2014, 24 patients [13 males, age 1 month (0.03-8)] on ecmo support received 27 catis (12 rat, 15 pd-at) per our protocol (3 patients received 2 pd-at infusions during one ecmo run). the duration of cati was 48 hours (23-72). cati administration led to significant increases in at and anti-fxa levels from baseline of 43% (39-53) and 0.11 units/ml (0.08-0.22) to the first level within goal of 64% (55-83) and 0.39 units/ml (0.35-0.5), respectively (p<0.00001). the respective times to achieve goal at and anti-fxa levels were 9 hours (5-21) and 13 hours (6-23). the respective peak at and anti-fxa levels were 83% (70-99) and 0.53 units/ml (0.35-0.63). during cati, no patient required circuit change, 1 patient developed cannula thrombosis and 5 patients experienced non-fatal major bleeding. conclusion: cati in pediatric patients receiving ecmo support with close monitoring of at and anti-fxa levels was associated with significant rapid increase in at, optimization of heparin effect, and reduction in thrombotic complications without increase in major bleeding compared to prior reports. a prospective study of this at dosing strategy is warranted. children's hospital of orange county, orange, california, united states background: inherited factor xiii (f13) deficiency is a rare bleeding disorder with wide heterogeneity in clinical manifestations ranging from mild bruising, and mucosal and umbilical stump bleeding to spontaneous, severe intracranial bleeding. the bleeding phenotype is influenced not just by zygosity of the fxiii mutation alone, but also by co-inheritance of variants in other clotting protein genes that also play a major role in clot formation and stability. we present a series of three siblings found with f13a1 gene variant and platelet dysfunction linked to bleeding phenotype. design/method: retrospective chart review of the index case, coagulation studies and whole gene sequencing. the index patient presented at two years of age with a subdural hematoma after a fall, requiring emergent craniotomy. a week after initial evacuation, she re-bled, prompting an extensive work-up for potential bleeding disorders, including f13 activity, von willebrand profile, comprehensive fibrinolysis panel, pai-1 antigen level, platelet mapping thromboelastogram (plt-teg), and f13 genetic analysis. the patient's identical twin and older sibling, who had symptoms of bruising, underwent a similar evaluation. the index patient demonstrated consistently low f13 activity (31-49%), and platelet function testing revealed decreased response to adp agonists. the twin and older sibling had normal f13 levels, and only slightly decreased response to adp in platelet studies. whole gene analysis of f13 and 21 other genes on our next generation panel, revealed several intronic deletions in the index patient that were not shared by her siblings, which likely account for her decrease in circulating f13 levels. her symptoms have responded well to monthly treatment with factor 13 concentrate. all three children shared the f13 variant, pro564leu, previously described as a risk factor for intracranial hemorrhage. the f13 mutation, pro564leu, has been associated with intracranial hemorrhage in young women, but the presence of the variant alone may not be enough to cause a severe bleeding phenotype. family studies identified novel deletions in the index patient which may account for her decreased f13 levels, which would have been overlooked with standard sequencing. future studies, including evaluation of 'platelet' f13 levels, should be performed when platelet dysfunction is detected. further laboratory and clinical evaluation is required to delineate the long term implications of the interaction of even mild f13 deficiency if present with additional clotting disorders such as the platelet function defect in these siblings. background: acquired hemolytic anemia can occur due to mechanical shearing of red blood cells and is classically seen in patients with prosthetic heart valves. there are reports of this same traumatic effect with other repairs, including annuloplasty. following valvular procedures flow disturbances can exist across the valve that lead to shear stress and hemolysis. although von willebrand disease (vwd) is typically seen due to an inherited disorder in the pediatric population, flow disturbances in the setting of valve abnormalities can lead to acquired von willebrand syndrome (avws). von willebrand factor multimers become unfolded and elongated in the setting of shear stress resulting in increased susceptibility to cleavage by adamsts-13. specifically, loss of high molecular weight multimers (hmwms) can lead to a syndrome akin to type 2a vwd. objectives: to describe a case of mechanical hemolysis with acquired type 2a vwd design/method: a 3-month-old girl with history of hypoplastic left heart syndrome and severe tricuspid valve insufficiency underwent norwood procedure, blalok-taussig shunt placement and subsequently a bidirectional glenn and tricuspid valve annuloplasty. during the following month she requires weekly red blood cell (rbc) transfusions due to intermittent anemia. she also experienced bloody stools and dark urine. laboratory evaluation was notable for normocytic anemia, reticulocytosis, elevated lactate dehydrogenase, and low haptoglobin consistent with hemolytic process. immune-mediated hemolysis from transfusion reaction or presence of autoimmune or alloimmune antibodies testing was negative. to investigate gi bleeding, work up for vwd revealed normal vw activity and antigen but with loss of high molecular weight multimers consistent with acquired type 2a vwd. in consultation with cardiology, it was felt her tricuspid valve insufficiency jet could be leading to mechanical hemolysis and avws. a repeat echo showed persistent moderate tricuspid insufficiency but no other significant changes. due to the patient's continued need for weekly rbc transfusions she was subsequently trialed on pentoxifylline which is used in adult patients to decrease blood viscosity and increase erythrocyte flexibility in patients with mechanical hemolysis. her transfusion needs remained the same and the medication was discontinued after two weeks. she required one transfusion a week later but no transfusions since that time. although not commonly seen in pediatric patients, the diagnosis of mechanical hemolysis accompanied by avws should be pursued in a patient with congenital heart disease with significant anemia and/or bleeding. the work up in these patients is difficult as echocardiograms can be inconclusive thus an extensive hematologic evaluation is usually necessary. objectives: our aim was to assess incidence of and potential risk factors for central line-related dvt at our institution between 2011-2016. additionally, our goal was to analyze if that incidence differed between the three central line types and identification of line-specific risks. design/method: a retrospective chart review of 377 central line placements in pediatric patients at cleveland clinic between 2011-2016 was conducted. data included demographics, potential risk factors, line characteristics and any related thrombotic events. the study cohort consisted of 377 lines in 326 pediatric patients aged 1-18 years of age. there were 1.5 thrombi (95% ci 1.0-2.3) per 10,000 line days. statistically significant risk factors for thrombus include diagnosis group (liquid tumor highest rate of 16%, solid tumor lowest at 2%), type of line (picc 5%, broviac 29%, and mediport 4%), location of line, greater number of lines per patient, peg asparaginase (23% vs 4%), sepsis, and history of procoagulant state. line characteristics such as lumen size and number of lumens were not identified as a significant risk. there was a significantly higher rate of thrombus in 2016 than in the previous years when pooled (12% in 2016 vs 4.3% from 2011-2015, p = 0.020). the incidence of dvt in pediatric patients at our institution was highest with broviac lines, and significant risk factors in our patient population included liquid tumor, femoral vein location, peg asparaginase, sepsis, and history of a procoagulant state. the incidence of thrombi was highest in 2016, and therefore highlights the urgent need for improvement in nationwide hospital practices to minimize risk of thrombi formation and early detection in the higher-risk s129 of s301 populations. there is still much to be learned regarding the characteristics specific to different central lines, which would influence thrombi formation. nyu winthrop hospital, mineola, new york, united states background: pediatric immune thrombocytopenic purpura (itp) is an autoimmune disorder with platelet counts <100000 causing increased risk for significant hemorrhage. there is increased immunologic platelet destruction due to production of specific autoantibodies along with inhibition of platelet production. few randomized trials exist to guide management and ultimately each patient requires an individualized treatment plan. itp may be acute (diagnosis to 3 m) or chronic (> 12 months). one of the treatments of chronic itp is laparoscopic splenectomy (ls), which is very well tolerated. a rare complication of ls is splenosis, an autotransplantation or implantation of ectopic splenic tissue within the abdominal cavity or in any other unusual body compartment. splenosis is sometimes associated with relapsed itp due to preserved immune activity. the usual management of symptomatic splenosis is surgical resection. objectives: to describe medical management in a young patient with itp relapsed due to extensive unresectable splenosis following ls design/method: our patient was originally diagnosed at 2 years with itp and was treated with ls at 5 years of age for chronic severe thrombocytopenia and persistent bleeding not responding to first line therapies. she tolerated it well and had a complete response (cr) defined as a platelet count of >100000 measured on 2 occasions >7 days apart and absence of bleeding. she maintained a normal platelet count for twelve years after which she relapsed (loss of response after cr) with severe thrombocytopenia and hematuria necessitating high dose steroids. ct scans showed multiple wellcircumscribed soft tissue masses in the left lower quadrant adjacent to uterus and left ovary, involving left omentum and the anterior abdominal wall partly. findings were confirmed by damaged rbc nuclear scan to be splenosis. during laparoscopy the splenosis lesions were deemed too extensive and were not resected completely to avoid postoperative morbidity. she was started on sirolimus around the same time for treatment of her relapsed itp and steroids were weaned off. results: eight months since beginning sirolimus with therapeutic levels she remains in cr with no bleeding and has not required any steroids, immunoglobulins or anti d immunoglobulin. conclusion: sirolimus is a safe and effective steroid-sparing agent in treatment of chronic itp. this is the first instance of a patient with poorly resectable splenosis responding well to medications for itp. more data is needed regarding the longterm efficacy of such an intervention and whether it will eliminate the need for a second surgery in relapsed itp patients with extensive splenosis. background: storage pool disorders affecting platelets result in bleeding symptoms related to a deficiency or defect in alpha granules or delta granules. in delta-storage pool disorders (dspd,) there is a deficiency of the delta granules and their constituents, which results in the inability of platelets to properly activate as well as lack of proper constriction of blood vessels during bleeding episodes. amongst patients with dspd, females most commonly present with menorrhagia, while males tend to present with epistaxis and easy bruising. the international society on thrombosis and hemostasis (isth) developed a screening bleeding assessment tool (bat) for mild bleeding disorders, shown to be a validated tool in children. diagnosis of dspd is classically made with a platelet electron microscopy (pem) value <3.69 delta granules per platelet (dg/pl), but recently lower diagnostic thresholds of 2 dg/pl or even 1.2 dg/pl have been suggested. objectives: evaluate the correlation between pem and bleeding scores, and also examine various cut-off values used to diagnose and risk stratify patients with dspd. design/method: retrospective chart review of 96 pediatric patients followed by hematology with a diagnosis of dspd was performed. clinicians obtained bleeding scores for each patient as standard of care in the hemostasis clinic. quartile ranges were established to appropriate three stages of severity based upon bleeding scores. statistical analysis was performed using software r and exploratory data analysis to evaluate for a correlation. results: amongst all patients, the average bat score was 6.17 and pem was 2.37 dg/pl. the average bleeding score for pem between 3.69 dg/pl and 2 dg/pl was 6.17, while the average bleeding score for pem below 2 dg/pl was 4.65. the correlation coefficient between pem and bleeding scores is 0.30. using a threshold of 2 dg/pl, 31% of patients would have met diagnostic criteria. quartile ranges for the bleeding scores are as follows: 1st quartile was 2-4, 2nd quartile was 5-7, and 3rd quartile was >8. conclusion: patients with a more marked granule deficiency do not exhibit a more severe bleeding phenotype, suggesting proper platelet function is not solely determined by granule quantity in these patients. bleeding severity may be more appropriately assessed with bleeding scores rather than pem values, and using quartile ranges may aide in risk stratification and therapeutic interventions for dspd patients. further work remains to determine the optimal diagnostic threshold of pem dspd in pediatric populations. texas children's hospital, houston, texas, united states background: warfarin management has many challenging aspects including pharmacogenomics, food and drug interactions, lack of standardized dosing, patient compliance, tracking lab results from multiple lab locations, and the potential for significant bleeding or thrombotic complications. a literature review revealed limited data highlighting anticoagulation monitoring workflow and emr documentation and specifically, no data in the pediatric population. historically, the texas children's hospital cardiology and hematology centers were each documenting anticoagulation data within the epic tm system differently. epic's tm original design for anticoagulation documenting resulted in the necessity to duplicate documentation in order to see at-a-glance critical anticoagulation monitoring information. objectives: the objective of this project was to standardize inr documentation across departments to reduce the risk of patient safety events and improve workflow. design/method: a workgroup assembled consisting of nurses from the cardiology and hematology departments, along with staff members from the epic tm is support group. the workgroup identified current documentation practices, available epic tm tools, and brainstormed ideas to streamline and improve both documentation with the current epic tm tools. physician partners were identified in cardiology, hematology and coagulation laboratory to gain their input. a new anti-coag (ac) encounter was developed and first made available in an epic tm practice environment, then once approved, epic tm written education and training session were completed by both departments' staff. results: surveys were sent to 19 health care providers in the cardiology and hematology centers prior to the new ac encounter, and also to 27 health care providers six months after implementing the ac encounter. six responses were received for each survey. the pre-implementation survey showed the most problematic part of the documentation system for anticoagulation was no single place in the emr to find a complete anticoagulation picture. post ac encounter implementation survey results revealed more health care providers using the epic tm inr reminder pool, less time needed to compile a report of three months of anticoagulation information, less time needed to document individual encounters, less locations needed to document ac information and decreased amount of types of documentation used. standardized ac encounters improves workflow with less time needed to document and compile information, less types of documentation utilized and easier access to patients ac information. next steps include retrospective review of patients' inr time in therapeutic range to determine if there was an impact on patient compliance and continue to evaluate and modify the ac encounter to enhance user friendliness. caitlin tydings, jennifer meldau, christine guelcher, carole hennessey, eena kapoor, michael guerrera, yaser diab s131 of s301 children's national health system, washington, district of columbia, united states background: venous anatomic abnormalities (vaas) are considered a risk factor for developing deep vein thromboses (dvts) that occur as a result of significant alterations in venous blood flow. identification of predisposing vaas can be challenging. hence, diagnosis can be delayed or overlooked especially in pediatric patients. dvts in children or adolescents with predisposing vaas have been only described in sporadic case reports and small case series. objectives: to describe characteristics and outcomes of dvts in pediatric patients with underlying vaa treated at our center. design/method: we conducted a retrospective chart review of all pediatric patients with objectively confirmed extremity dvt treated at our institution over a 6-year period from 2011 to 2017 and identified all patients with underlying vaas. patients were managed according to standardized institutional protocols based on published guidelines. post-thrombotic syndrome (pts) was assessed at our center using the manco-johnson instrument. relevant data were collected and summarized using descriptive statistics. during the study period, 20 of 227 pediatric patients (9%) [14 females, median age 17 years (range 11-20)] diagnosed with extremity dvt at our center were found to have an underlying vaa. vaas included may-thurner anomaly (13 patients), venous thoracic outlet obstruction (5 patients) and inferior vena cava (ivc) atresia (2 patients). additional provoking factors were identified in 14 patients at time of presentation. dvt locations included upper extremity veins (5 patients), lower extremity veins (9 patients) and lower extremity veins and ivc (6 patients). the majority of dvts [17 patients, (85%)] were completely occlusive. high risk thrombophilia (defined as inherited deficiency of antithrombin, protein c, or protein s, or antiphospholipid antibody syndrome) was present in 6 patients (30%). all patients were treated with therapeutic anticoagulation with 6 patients continuing indefinite anticoagulation. endovascular interventions were performed in 18 patients and included percutaneous pharmacomechanical thrombectomy and/or catheter-directed thrombolysis (15 patients), balloon angioplasty (11 patients) and stent angioplasty (9 patients). surgical interventions included thoracic decompressive surgery (5 patients) and surgical thrombectomy (1 patient vvas represent an important risk factor for developing extensive extremity dvt in adolescents. this special population is at risk for short-term and long-term com-plications. early identification and correction of vaas may improve outcomes. however, multicenter, prospective studies are needed for developing optimal evidence-based treatment approaches. alexander glaros, roland chu, sureyya savasan, meera chitlur, madhvi rajpurkar, yaddanapudi ravindranath children's hospital of michigan, detroit, michigan, united states background: acute budd-chiari syndrome (bcs) is a rare thrombotic emergency in children, and etiologies/treatment are less well-defined than in adults. in adults, a systematic approach including anticoagulation, relief of venous obstruction, and treatment of the underlying cause has proven successful. more recently treatment has tilted towards aggressive surgical interventions, which carry significant risk and are often not feasible. objectives: review our experience with three different patients with bcs and suggest a mechanistic based approach to treatment. the records of three patients with bcs were reviewed and their presentations, etiologies, treatment, and outcomes were reported. results: patient a was a 17-year-old female with paroxysmal nocturnal hemoglobinuria who presented with recurrent worsening abdominal pain over several months. narrowing of inferior vena cava (ivc) and hepatic veins was noted on imaging. liver transplant was not considered surgically feasible. she was treated with eculizumab, steroids, and anticoagulation with restoration of hepatic venous flow in 4 weeks. patient b was a 14-year-old male with several weeks of right upper quadrant pain, fatigue, and pre-syncopal episodes, with a history of blunt abdominal trauma from football scrimmage 4 weeks earlier. he was found to have near complete occlusion of the ivc and hepatic veins. liver transplant was not considered feasible. he was successfully treated with anticoagulation alone. patient c was a 3-yearold male with acute myeloid leukemia in induction cycle 2 who developed severe pancytopenia; typhlitis was diagnosed and managed medically. days later he acutely decompensated, arrested, and was placed on extra corporeal membrane oxygenation, and imaging showed complete occlusion of the portal vein, hepatic veins, and ivc to the level of the atrium, with bilateral pulmonary emboli. emergency liver transplant or catheter based interventions was deemed not feasible. treatment with eculizumab was considered for presumed inflammation induced complement activation (c3 59mg/dl [normal 77-171]; ch50 was 12u/ml [normal 42-91]) as a trigger for thrombosis, but the patient progressed quickly and died before it could be initiated. our experience with bcs shows that invasive interventional options and liver transplant may not be feasible in most patients for multiple reasons. rapid diagnosis and aggressive etiology-based medical management are paramount to successful treatment of this rare complication. eculizumab may be considered in treating bcs with complement activation not only due to innate disorders, but also secondary to acute inflammation when proper laboratory evidence is present. background: platelet aggregation studies are the gold standard for the diagnosis of platelet function defects during the evaluation of a patient with bleeding problems. the platelet aggregation test measures how well platelets clot in response to different concentrations of epinephrine, adenosine diphosphate (adp), collagen, arachidonic acid and ristocetin. because platelet function defects are often under-recognized and under-diagnosed in the pediatric patient, the true incidence is unknown. we report our experience in the diagnosis of platelet defects at our institution over a 5-year period in order to add some clarity to the limited pediatric data available. objectives: our primary objective is to document correlations/trends between less well-known platelet function abnormalities and clinically significant bleeding at our institution over a 5-year period. design/method: after appropriate irb approval obtained, we performed a retrospective chart review of all children who had platelet aggregation testing done from 2011 to 2015. data collected included demographics (age, sex, race), personal and family history of bleeding, screening for coagulation defects and platelet aggregation test results. symptoms examined in our data were limited to epistaxis and heavy menstrual periods. for each of these symptoms, results were further analyzed to those with abnormal responses to adp and epinephrine. patients with existing bleeding diagnoses and those with incomplete medical records were excluded. we identified 159 patients. of the patients with epistaxis, 70% had abnormal platelet aggregation testing while only 36% of those with heavy menstrual periods had abnormal results. within our population, abnormal platelet function assay (pfa-100) results or race did not appear to correlate with abnormal platelet aggregation testing. in the cases of epistaxis, sex was also noncontributory. our preliminary results suggest that platelet aggregation testing was more useful in predicting platelet defects in those with a clinical bleeding history of epistaxis as opposed to heavy menstrual periods. for other presenting symptoms, platelet aggregation testing did not offer diagnostic benefit. abnormal response to adp in the platelet aggregation test was the most common finding in our population; the clinical significance of which is not well understood. going forward, we plan to document whether abnormal results correlated significantly with the subsequent final diagnoses of our patients. background: decision making for severe hemophilia a in previously untreated patients (pups) has recently become a significant ethical debate. recombinant factor viii (rfviii) products previously were recommended to avoid transmission of blood borne pathogens associated with plasma-derived fviii (pdfviii) products. however, the increased incidence of fviii alloantibody inhibitors with rfviii products compared to pdfviii products has challenged this former standard of care. despite the support of the medical and scientific advisory council, recommendations considering pdfviii products for a pup remains controversial. design/method: we used a modified utilitarian approach involving clinical, public health, and research ethics. shared decision making permeates the framework to maximize understanding, minimize bias, respect informed consent or dissent, and provide care that aligns with patient and family values when medically and practically feasible. the framework has three tiers. first, it evaluates whether resources are scarce or abundant for equitable resource allocation. if fviii products are scarce, we s133 of s301 recommend developing a central supply for emergency use and then evaluating the needs of the severe hemophilia a patients. prioritization of who receives the factor products would be decided by a designated team based on the availability of the factor products and clinical scenarios, with no preference given to those on research trials. however, if resources are abundant, treatment for acute bleeding and standard of care prophylaxis measures, including primary prophylaxis, could continue. the second tier accounts for whether there is a new infectious epidemic or concern where a pathogen cannot be eliminated. if there is, healthcare and public health workers may limit the use of pdfviii products. if not, pdfviii and rfviii products are to be equally considered. the third tier evaluates whether the clinical scenario is emergent or not. if there is acute, emergent bleeding, the immediately available resource should be used, along with bypassing and/or adjuvant resources as needed until the bleeding has resolved or improved. to align with patient and family preferences, attempts to have both pdfviii and rfviii products available at similar costs in institutions would be ideal. this ethical framework endeavors to balance autonomy, beneficence, nonmaleficence and justice in helping guide discussions among providers, pups with severe hemophilia a, and their families. disclaimer: findings and conclusions are those of the author(s) and do not necessarily represent the official position of the centers for disease control and prevention, emory university, or children's healthcare of atlanta. background: von willebrand disease (vwd) is a common bleeding disorder which affects up to 1% of the population without gender predilection. bleeding associated with this condition results from a deficiency or abnormality in von willebrand factor interfering with formation of primary hemostasis. ehlers-danlos syndrome (eds) is a group of rare inherited connective tissue disorders which may have an associated bleeding manifestation without abnormalities in coagulation testing. bleeding symptoms reported in eds result from capillary and tissue fragility. joint hypermobility syndrome (jhs) is an inherited condition which is nearly indistinguishable from eds iii. reports of coinheritance of vwd and eds or jhs are infrequent. the objective of this retrospective study was to review patients with coexisting vwd and eds or jhs at the indiana hemophilia and thrombosis center in order to describe the type and severity of bleeding symptoms, physical examination findings, and pertinent laboratory data. design/method: the electronic medical record database of the indiana hemophilia and thrombosis center was queried for patients with a diagnosis of vwd and one of the following descriptors: hypermobility syndrome, hypermobility, hypermobile joints, or ehlers-danlos syndrome. the records of identified patients were reviewed for demographics, type and severity of bleeding symptoms, beighton scores (bs), vwd antigen, ristocetin cofactor, factor viii levels, vwd multimer pattern, vwd subtype, genetic testing for eds, and family history of eds. results: a total of 6 patients with dual diagnoses of vwd and eds and 21 patients with vwd and hypermobility were identified with this query. two patients had completed genetic testing for eds, and one had a col1a1 gene mutation identified. significant bleeding symptoms in the vwd and eds group included hematuria and postoperative hemorrhage. two of these patients had delayed wound healing postoperatively. seven of the 19 patients identified to have type i vwd and jhs had moderately severe and somewhat unusual bleeding episodes reported including hematuria, hematemesis, and hemoptysis; 4 of these patients had significant perioperative bleeding. females composed 83% of the vwd and eds group and 76% of the vwd and jhs group. conclusion: coinheritance of vwd and eds is an uncommon phenomenon. patients with vwd and eds or jhs may have atypical and moderately severe bleeding, especially with procedural intervention. incorporation of bs into the assessment of patients with bleeding disorders is useful to identify potential inherited collagen disorders, as diagnosis of these conditions may impact clinical management. in the year-long phase ii study (ro1fd003712), 11/12 khe patients responded. patients were followed for 5 years after study completion, collecting data on growth and development, complications of therapy, unexpected toxicities, and need for continuing sirolimus. objectives: after study therapy treatment of one year, objectives include: 1. assess long term toxicity over the 4-5 year period after study therapy completion 2. assess unexpected toxicity 3. assess overall condition of the patient 4. assess need for restart or continuation of sirolimus therapy design/method: prospective follow-up of patients with a diagnosis of khe from 2 institutions. inclusion criteria: follow-up for 4-5 years post-study. results: follow-up included data at 5 year (n = 5) and 4-4.5 year (n = 4) time points. average age at the start of treatment was 12 months. 9 of 12 patients were available for follow up. four patients are no longer on sirolimus: one patient completed study therapy and remains off treatment (ot) (7 years), 1 required 2 years of treatment and is now 2.5 years ot and 2 required an additional treatment course prior to successful discontinuation now 17 and 22 months ot. of the 5 patients still on sirolimus, all restarted medication for symptoms of pain, swelling and/or edema interfering with quality of life and have made an average of 2.5 attempts to discontinue sirolimus. no patient had reoccurrence of kmp. all patients had improvement in clinical and radiologic appearance of khe but all have residual lesions noted on imaging and/or clinical exam. no unexpected toxicity, growth delay, developmental issues or other long term toxicity of sirolimus was noted. conclusion: this is the first prospective data on long-term follow up of khe patients treated with sirolimus. although numbers are small, sirolimus is well tolerated; however, over half the patients were still on medication at 4-5 year follow up. this stresses the need for continued long term follow up in these young patients and investigation of the mechanism of sirolimus effect. nationwide children's hospital, columbus, ohio, united states background: recent studies have identified that adult persons with hemophilia (pwh) have a higher prevalence of hypertension and renal disease than the general population. while hematuria is a known complication of hemophilia a and b (ha, hb), its long-term impact on pwh is not currently known. by annually screening our patients with urinalysis, our pediatric center identified that just under half of our patients demonstrated hematuria over a four-year period. motivated by a desire to identify early markers of hypertension and renal disease, we sought to determine if this finding is reflected in the pediatric hemophilia population as a whole. objectives: establish the population-wide prevalence of hematuria in pediatric pwh. design/method: we used the pediatric health information system (phis) database, which contains clinical and resource utilization data for inpatients from 45 hospitals nationwide, to analyze the prevalence of hematuria, hypertension, renal disease and related diagnosis codes in pediatric pwh who were admitted from january 2010 to september 2015. results: during the five-year period, 2,197 unique pediatric pwh accounted for 4,802 admissions. while the majority of admissions were for bleeding or infectious concerns, 96 (4.4%) patients had an affiliated admission code for hematuria. for admissions as a whole, the median age was 7 years with 12% of those admitted being infants, 32% toddlers, 27% children, 28% adolescents, 2% older than 21. we identified 83% of admissions were for ha with the remaining 17% were for hb. there were 1254 (26%) admits in which a bypassing agent was administered. the median length of stay for persons with hematuria was 2 days compared to 3 days for nonhematuria/other bleeding. there were 120 (2.5%) admissions with hypertension reported; though, only 3 patients received an antihypertensive medication during that admission. additionally, only 31 (0.6%) admissions reported a diagnosis code of renal disease. our study demonstrated that pediatric pwh are experiencing hematuria. in general, only patients with persistent hematuria require hospital admission so we suspect this data underrepresents the numbers of pwh experiencing hematuria that is managed in the outpatient setting. we also suspect that hypertension is grossly underreported and undertreated in pediatric pwh. additionally, there are a low number of patients experiencing renal disease requiring hospital admission among this cohort. given that there is little research into the long-term impact of hematuria in hemophilia, we feel these findings support the need for further vigilance of our pediatric pwh. background: gla and gsd can aggressively destroy bone, with significant impact on morbidity and mortality. the mtor inhibitor, sirolimus has been shown to be effective in the treatment of these diseases. based on the addition of mtor inhibition to bisphosphonate therapy in metastatic cancer therapy, regimens have been used for refractory or high risk gla and gsd but there is heterogeneity of diagnosis, and variability of drug regimens and assessment of effectiveness. objectives: 1. assess the variability of clinical features of gla and gsd 2. assess the heterogeneity of diagnosis 3. assess drug regimens and response assessment across multiple institutions design/method: we conducted a retrospective review from 5 institutions of 19 cases of gla and gsd treated with sirolimus and a bisphosphonate for at least 2 months with assessment of clinical features, treatment protocols, response regimens and side effects. results: patients included gla (n = 8) and gsd (n = 11). the average age at diagnosis was 10 years. clinical features included effusions: gla (n = 4), soft tissue lymphatic malformations: gla (n = 3), gsd (n = 1), multiple splenic lesions: gla (n = 3), and soft tissue swelling at the site of bony lesion: gsd (n = 3). the presenting symptom in 17 patients was pain with 2 patients (gla) presenting with shortness of breath. fracture was noted in 5 patients: gla (1), gsd (4). diagnostic and/or response imaging included mri, ct, bone scan, skeletal survey and dexa scan. treatment consisted of: initial sirolimus use with the addition of bisphosphonate secondary to worsening disease (n = 4), initial therapy with other agents (interferon, chemotherapeutic agents, radiation) and change to sirolimus and bisphosphonate secondary to toxicity (n = 6), sirolimus and bisphosphonates (n = 7) and sirolimus, bisphosphonates and interferon (n = 2). seventeen patients had stable disease and 8 patients had improvement of disease. sirolimus protocol was standard; however, bisphosphonate protocol varied in dosing and frequency. side effects were tolerable and expected with no grade iii or iv toxicity. sirolimus and bisphosphonates are a safe and effective therapy for gsd and gla. a consistent medication regimen, redefined response and an improved radiologic classification will be important for the development of a prospective clinical trial. background: hemophilia a is a bleeding disorder from the deficiency of clotting factor viii. the most significant sequelae of hemophilia a is the tendency to develop hemarthrosis that incites joint destruction. the prevalence of overweight and obesity has been increasing in the general and hemophilia population and leads to several morbidities including arthropathy. this is a particular concern for hemophilia a as arthropathy is a consequence of joint bleeding. objectives: the purpose of this study was to detect the relation between body mass index (bmi) and joint health endpoints in a pediatric hemophilia population. design/method: participants in this study included 64 patients from the hemostasis and thrombosis center at children's hospital los angeles. participants were pre-screened and approached for this study during routine follow-up appointments. patients aged 4-18 years old who have been diagnosed with hemophilia a, including mild, moderate, and severe, qualified for the study. informed consent was obtained from the patients or parents before enrollment. joint health was objectively measured by physical therapists from children's hospital los angeles using the hemophilia joint health score (hjhs). an hjhs total score is calculated by assessing: swelling, duration of swelling, muscle atrophy, crepitus on motion, flexion loss, extension loss, joint pain, and muscle strength in 6 major joints. subjective data was also obtained by patients recording their annual bleed rate within the past year. of the 64 patients, 28 (44%) were normal weight, 12 (19%) overweight, and 24 (38%) obese. we used chi-square analysis to compare joint scores across bmi classifications (chi square = 2.87, df = 2, p-value = 0.24). although, this did not approach statistical significance, the average hjhs score in patients who had a hjhs >0 shows an increasing trend among bmi classifications: 6.19 in normal bmi patients, 6.75 in overweight bmi patients, and 7.00 in obese bmi patients. the average number of annual bleeds in those with positive values show: 8 in normal bmi patients, 5 in overweight bmi patients, and 12 in obese bmi patients. although a positive effect of adiposity was found in the joints of hemophilia a pediatric patients, the effect shows there was not enough evidence to conclude a difference. future studies are needed to address whether obesity has an effect on hemophilia and to determine whether overweight/obesity can lead to further complications in hemophilic joints. background: stagnant blood flow in slow-flow vascular malformations (vm), particularly in their venous components, can lead to localized intravascular coagulation (lic) that is characterized by elevated d-dimer levels, low fibrinogen and decreased platelet count this coagulation derangement can lead to localized thrombosis or bleeding which can result in pain, functional limitations, and possible progression to disseminated intravascular coagulopathy (dic). the treatment of vm and their associated coagulopathy has proven difficult. patients with complex vm are frequently managed with sirolimus, an mtor inhibitor, and have clinical benefits, including reduction of pain and improvement in functional impairment. it is possible that some of these improvements from sirolimus could be secondary to improvement in the coexisting lic. objectives: this study assessed the use of sirolimus to manage the coagulopathy seen in slow-flow vm. design/method: we reviewed charts of patients with vm who are followed in the vascular anomalies center at arkansas children's hospital and were started on sirolimus. efficacy was objectively assessed through improvement of ddimer, fibrinogen and platelet count. three sets of lab values (pre-sirolimus, 1-3 months post-sirolimus, and most recent) were obtained for each patient when available. we identified a total of 35 patients who had been prescribed sirolimus. eighteen were excluded based on underlying condition other than slow-flow vascular malformation and 1 for inadequate medical records. a total of 16 patients (13 combined vascular, 3 venous) were included in the study. all 16 had elevated d-dimer levels (mean 4.64 mcg/ml feu, median 2.99 mcg/ml feu, range (0.83-14.65)) prior to treatment. two patients had an associated low fibrinogen (below 175 mg/dl), indicating severe lic. with treatment, 14 (87.5%) patients showed an overall decrease in d-dimer levels with an average decrease of 1.52 mcg/ml feu between pre-and post-sirolimus labs, and an average decrease of 1.03 mcg/ml feu between pre-sirolimus and most recent values. the two patients with low fibrinogen prior to treatment showed a decrease in d-dimer levels (mean decrease of 7.845 mcg/ml feu) and an increase and normalization in fibrinogen (mean increase 83.95 mg/dl) after beginning sirolimus. no patient had thrombocytopenia. we report that treatment with sirolimus was effective in improving coagulopathy associated with slowflow vm as evidenced by decreased d-dimer levels and increased fibrinogen and/or platelets. long-term use of this medication in this population may decrease the bleeding and thrombotic complications that these patients experience, especially following invasive vascular procedures. background: safety and efficacy of bay 94-9027, a sitespecifically pegylated b-domain-deleted recombinant factor viii, in previously treated adolescents and adults aged 12-65 years with severe hemophilia a was demonstrated in the phase 2/3 protect viii study and ongoing extension. objectives: this subanalysis examines the efficacy and safety of bay 94-9027 in adolescents in protect viii and the ongoing extension study (data cutoff, january 2015). design/method: in protect viii, 134 patients (including 12 adolescents) received bay 94-9027 on demand or as prophylaxis for 36 weeks. prophylaxis regimens for weeks 10-36 were twice-weekly (30-40 iu/kg), every-5-days (45-60 iu/kg), or once-weekly (60 iu/kg) infusions based on bleeding during a 10-week run-in period of 25 iu/kg twice-weekly prophylaxis. patients continued their prophylaxis regimens in the extension or changed regimens at any time. results: twelve patients aged 12-17 years were included in the protect viii intent-to-treat population; 1 s137 of s301 additional patient discontinued after 1 dose (included in safety population). for 11 patients receiving prophylaxis before study enrollment, median (range) number of total and joint bleeds in the 12 months before study entry was 8.0 (0-15) and 6.0 (0-10), respectively. ten patients (83.3%) had target joints at baseline (median [range],1 [0-4] per patient). during weeks 10-36 of protect viii for the entire time patients remained on their designated prophylaxis dosing frequency, the median (quartile [q]1; q3) annualized bleeding rate (abr) for patients receiving twice-weekly (n = 3), every-5-days (n = 6), and once-weekly prophylaxis (n = 3) was 0 (0; 2.0), 1.1 (0; 8.2), and 18.4 (0; 19.3), respectively (overall prophylaxis [n = 12], 1.0 [0.0; 10.1]). two patients switched from once-weekly to twice-weekly (n = 1) or every-5-days prophylaxis (n = 1), and number of bleeds decreased from 2 to 1 in one patient and 6 to 4 in the other. all 12 patients from the main study continued in the extension; mean abr in the extension was 3.2 and varied by dosing regimen (twice weekly [n = 3], 3.2; every 5 days [n = 5], 5.2; once weekly [n = 2], 0.9). two patients changed from every-5-days to once-weekly prophylaxis during extension (mean abr, 0.6). one patient had a nonneutralizing antibody to bay 94-9027 at baseline; end-of-study titers were negative. no patient developed anti-peg antibodies or factor viii inhibitors or experienced a serious adverse event related to bay 94-9027 during the main study or extension. in previously treated adolescents with severe hemophilia a, bay 94-9027 prophylaxis was effective in prevention of bleeds, with less bleeding overall versus prestudy, and was generally well tolerated. funded by bayer. cincinnati children's hospital medical center, cincinnati, ohio, united states background: vascular malformations (vms) consist of a heterogeneous group of congenital disorders characterized by the abnormal development of blood and/or lymphatic vessels, which cause a broad spectrum of clinical manifestations. although considered benign, vms are frequently associated with cutaneous complications that can cause significant morbidity such as nodular overgrowth, skin thickening, pruritus, oozing or bleeding of lymphatic blebs and secondary infection. oral sirolimus has shown to be effective in the treatment of complicated vascular malformations but has known side effects and need for frequent laboratory monitoring. currently, there are limited studies on the use of topical sirolimus for the treatment of cutaneous manifestations of vascular malformations. objectives: to evaluate the efficacy and safety of topical sirolimus in vms with cutaneous complications and propose indications for use. design/method: this is a retrospective review of medical records of patients with vascular malformations treated with topical sirolimus from january 2012 to december 2017. response was determined by subjective and objective improvement. results: twenty-four patients, 16 (66%) females and 8 (33%) males, with vascular malformations and cutaneous manifestations were treated with topical sirolimus. age ranged from 4-27 years. indications for treatment were: blebs (79%, n = 19) causing either leaking, bleeding, pain, pruritus, swelling or recurrent infection; nodular overgrowth 8% (n = 2); pyogenic granuloma 4% (n = 1); bleeding 4% (n = 1) and cosmetic 4% (n = 1). treatment course ranged from 1-18 months. no major side effects were reported. one patient reported burning and itching sensation. regarding clinical response: 83% (n = 20) patients had improvement in cutaneous lesions; 12% (n = 3) had a stable lesions; and 4% (n = 1) stopped treatment due to side effects. for prior/concomitant treatment: 83% (n = 20) had prior surgery, laser or sclerotherapy; 37% (n = 9) had concomitant oral sirolimus. of the 15 patients not receiving concomitant systemic sirolimus, only 13% (n = 2/15) had been on oral sirolimus. of these patients, 80% (n = 12/15) had a very good response to topical treatment. : topical sirolimus appears to be beneficial and well-tolerated with a minimal side effect profile for the treatment of cutaneous manifestations of vascular malformations as a single agent or as adjuvant therapy with systemic sirolimus when symptoms are not adequately controlled. further studies are needed to prospectively analyze efficacy and safety of topical sirolimus in this patient population. objectives: to evaluate the safety and efficacy of long-term romiplostim in children with itp. design/method: all patients received weekly sc romiplostim from 1-10 g/kg to target platelet counts of 50-200 × 10(9)/l. median (min-max) treatment for the 65 patients was 135 (5-363) weeks for a total of 182 patient-years, or 2.8 years per patient. at baseline, median (min-max) age was 11 (3-18) years; 56% were female; 9.1% had prior splenectomy. median (min-max) average weekly dose was 4.8 (0.1-10.0) g/kg, including escalation to a stable dose; 20 patients started on 1 g/kg. reasons for discontinuing romiplostim (n = 28, 42%) included consent withdrawn (n = 10), required other therapy (n = 6), and ae (n = 2) (asthenia, headache, dehydration, and vomiting in one patient and anxiety in the other; none treatment related). fifty four serious aes occurred in 19 patients but were treatment related in one (concurrent grade 4 thrombocytopenia, grade 3 epistaxis, and grade 2 anemia). anti-romiplostim neutralizing antibodies were detected in one patient who discontinued to receive other therapy; antibodies were absent on retesting. from week 2 on, median platelet counts remained >50 × 10(9)/l; median platelet counts were >100 × 10(9)/l from weeks 24-260. nearly all (94%, 61/65) patients had ≥1 platelet response (platelet counts ≥50 × 10(9)/l, excluding ≤4 weeks after rescue medication). most (72%, 47/65) patients had a platelet response ≥75% of the time and 58% (38/65) did ≥90% of the time. sixty (92%) patients (or caregivers) self-administered romiplostim. fifteen (23%) patients had treatment-free periods of platelet counts ≥50 × 10(9)/l for ≥24 weeks (ie, remission); these patients (9 girls, 6 boys) had had itp for a median (min-max) of 3.5 (1.3-13) years, none had prior splenectomy, and had received romiplostim for 2.1 (0.7-6) years. all 15 had platelet counts >100 × 10(9)/l for ≥3 months and 12/15 for ≥6 months; the median (min-max) duration of being ≥100 × 10(9)/l was 42 (13-109) weeks. of baseline characteristics such as sex, platelet counts, itp duration, and number of past itp treatments (1, 2, 3, >3), only age <6 years was predictive of developing treatment-free periods ≥24 weeks (p = 0.0035). in this seven-year open-label extension, >90% of children with itp achieved a platelet response and romiplostim was well tolerated. importantly, 23% of patients were able to discontinue all itp medications for ≥6 months. funded by amgen inc. background: sirolimus is an immunosuppressive drug that is widely used in solid organ and bone marrow transplantation, and more recently for the treatment of vascular and lymphatic anomalies. sirolimus has been associated with decreased immunity in the transplant setting in patients that have received other immunosuppressive drugs or were immunosuppressed from previous chemotherapy. the effects of sirolimus on the immune system in chemotherapy naïve children who have not received other immunosuppressive agents are not well understood, and there is variability in the approach to fever and pcp prophylaxis. to understand the effects of sirolimus on the immune system of patients with non-complicated vascular or lymphatic anomalies by evaluating anc, alc prior to and after sirolimus therapy. design/method: multi-institutional retrospective review was done to include patients with non-complicated vascular or lymphatic anomalies. those with effusions/ascites, multiorgan involvement, or history of vascular-anomaly-related infections prior to treatment were excluded. results: twenty patients with kaposiform hemangioendothelioma (n = 6), generalized lymphatic anomaly (n = 2), cloves syndrome (1), and simple vascular malformation (n = 11) were included. age at initiation of sirolimus treatment ranged from 0.5 -20 years. male to female ratio was 9:11. sirolimus was initiated due to extensive disease, lack of response to steroids or bisphosphonates, pain, dment, lymphatic drainage, and prevention of ongoing overgrowth. prior to the start of sirolimus (sir-0) the mean anc was 3850 and alc was 2875. the target level of sirolimus varied by indication and patient, and ranged from 6 to 10. after the 1st steady state level, 1 month after sirolimus (sir-1) the mean anc decreased to 2951 and alc was 2793. at 3 months after sirolimus (sir-3) the mean anc was 3108 and alc was 2874. the first sirolimus levels (sir-1) mean was 11.3; and sir-3 level was 7.8. nine patients were placed on pcp prophylaxis at the start of sirolimus. none of these patients had an infectious complication while on sirolimus at a median f/u of 13 months. one patient had mild neutropenia (anc >500) which normalized after discontinuation of pjp prophylaxis. conclusion: in this small cohort of patients we found that the anc and alc level in patients with non-complicated vascular or lymphatic anomalies at sir-0 was not different from the sir-1 or sir-3. prospective studies that specifically track anc, alc, igg, and lymphocyte function should be conducted to better understand the effects of sirolimus in the immune system. this data will allow for uniform recommendations regarding prophylaxis and management of febrile episodes. background: acute infections and the associated systemic inflammation can increase the risk of venous thromboembolism (vte) and in certain well-defined clinical scenarios may be the primary trigger of vte in pediatric patients. pediatric data on vte in the setting of acute infection are sparse. objectives: to describe characteristics and outcomes of vte in pediatric patients with acute infections. we conducted a retrospective chart review of all pediatric patients with objectively confirmed vte treated at our institution since 2011 and identified all patients in whom an acute infection was identified as a vte trigger. patients were managed according to standardized institutional protocols based on published guidelines. relevant demographic, clinical and laboratory data were collected and summarized using descriptive statistics. since 2011, acute infection was identified as a trigger in 147 of 429 vtes (34%) diagnosed at our center. the median age at time of vte diagnosis in this group was 2.3 years (interquartile range 0.3-16). males were more commonly affected than females, representing 56% of cases. neonatal vte events accounted for 14% of cases. sepsis was the most common acute infection to be identified as a vte trigger [59/147 cases (40%)]. most vte events (80%) associated with acute infections were considered hospital-associated vtes. at time of vte diagnosis, 61% of patients were critically ill. extensive vte (defined as completely occlusive thrombosis involving >1 venous segment) occurred in 16% of patients. acute infection was deemed to be the primary trigger for vte in 30/147 patients (20%). infection-associated vtes in this cohort included cerebral sinus venous thrombosis due to sinus or cns infection (13 patients, 43%), septic throm-bophlebitis (11 patients, 37%), lemierre's or lemierre's-like syndrome (4 patients, 13%) and osteomyelitis-associated deep vein thrombosis (2 patients, 7%). systemic anticoagulation was prescribed in 124/147 patients (84%). anticoagulationrelated major bleeding occurred in 10/124 patients (8%). vte complications included vte recurrence (16 patients, 10%), vte progression (1 patient), acute pulmonary embolism (2 patients) and arterial ischemic stroke (2 patients). our study indicates that acute infection is a common risk factor for pediatric vte, especially in critically ill children, and can be the primary trigger in a significant proportion of vte cases associated with acute infections. anticoagulation appeared to be overall safe in this population and was associated with low rates of serious vte-related acute complications. however, our study also suggests that this population may be at increased risk for vte recurrence and anticoagulation-related major bleeding. background: epithelioid hemangiomas (eh) are rare benign vascular tumors that occur in soft tissues and bone and present between the third and sixth decades of life. a subset (29%) of eh harbor fos rearrangement. eh has been described in children, but little is known about the long-term outcomes of pediatric eh. the main objective is to obtain data to be used for improved understanding of this rare disease in order to provide standardization of care and development of future research studies. board-approved retrospective review of clinical, pathologic, and radiographic characteristics, and treatment outcomes in 11 patients diagnosed with eh between 1999 and 2017. results: eight patients were male; mean age at diagnosis was 14.8 years (range: 6-23). lesions involved the lower extremities (n = 5), cranium (n = 3), pelvis (n = 2), and spine (n = 1). multifocal disease was identified in five patients. the most common presentations involved significant localized pain and neurologic symptoms: headache, cranial nerve injury, loss of consciousness. radiographic studies identified variable features, such as multifocal lytic bony lesions with sclerotic margins, enhancing soft tissue component, and surrounding inflammatory edema. histologically, all specimens were composed of vascular channels lined by epithelioid endothelial cells without significant cytologic atypia; solid cellular areas (n = 2). endothelial cells were positive for cd31 and egr, and negative for camta1. fos rearrangement was assessed in only one specimen and detected. mean follow-up time was 545 days (range: 23-2642). patients were treated with surgical resection, intravascular embolization, bisphosphonates, propranolol, interferon, and sirolimus. one patient treated with interferon and one with sirolimus exhibited partial response for mean follow-up of 1566.5 days. although eh is a benign neoplasm, it is difficult to manage without standard protocols and portends considerable morbidity. our findings suggest medical management, particularly sirolimus, may benefit these patients; however, long-term follow-up is needed in treated children. novel fos inhibitors are in development and may benefit patients with fos rearrangement. penn state health children's hospital, hershey, pennsylvania, united states background: central venous catheters (cvc) are often required in critical care settings in order to provide a secure point of access for life sustaining care. clinical studies identify cvc presence as the single most important risk factor for deep vein thrombosis (dvt) in children. venous thromboembolic event (vte) incidence rates in critically ill children with a cvc range from 0.3-18% and 0.06-32.5 per 1000 catheter days depending on the population studied. per institutional protocol, the penn state health children's hospital picu (hershey, pa) utilizes a low dose continuous infusion of unfractionated heparin (ldufh) at 10 units/kg/hr as prophylaxis against cvc-related vte and to maintain line patency. the efficacy of this approach has never been evaluated. to determine if ldufh for prophylaxis results in lower incidence of cvc-related vte, catheter dysfunction and central line associated blood stream infection (clabsi) without increasing morbidities. to determine if the incidence of catheter related vte is lower than historical published data, a retrospective chart review was conducted utilizing the institutional electronic medical record for all patients in 2015, aged 0-17.99 years, who had a cvc during a picu admission. secondary objectives such as the incidence of catheter dysfunction, clabsi, and any associated bleeding complications are also being analyzed. results: interim data analysis revealed 478 cvcs (400 nontunneled cvc, 18 totally implantable devices, 19 tunneled lines, 41 peripherally inserted central catheters [picc] ) in 374 total patients with a median age of 1.9 years. overall vte incidence was 1.88% (9/478) with 7 vtes associated with non-tunneled cvc and 2 with piccs. sixty one percent of non-tunneled cvcs received ldufh and 85% (6/7) of the patients with vtes associated with non-tunneled cvcs did receive ldufh prophylaxis. vte incidence rate of nontunneled cvcs with ldufh was 2.5% (6/243) and 2.56 per 1000 picu catheter days. the only other vte events identified within our study cohort were in the picc group where two patients experienced vte, one of which was receiving ldufh. clabsi incidence was 1.2% (4 non-tunneled cvc, 1 tunnel cvc, 1 picc). no major bleeding complications were associated with ldufh. preliminary data demonstrates ldufh is efficacious in preventing cvc-related vte in comparison to published reports. further analysis will compare another similar sized and acuity level picu which does not practice the same method. background: fibroadipose vascular anomaly (fava) is a rare, challenging disorder associated with pik3ca mutations. fava often causes painful replacement of muscle and soft tissues with fibrotic and adipose tissue and is associated with ectatic draining veins. treatments for focal lesions are surgical excision, cryoablation or sclerotherapy and the role of medical therapy is unclear. some fava lesions are too extensive or directly involve neurovascular structure, resulting in refractory pain. objectives: to retrospectively evaluate the efficacy of sirolimus in patient with residual symptoms after procedural therapies for fava design/method: retrospective review of individual 7 cases from 6 institutions of fava refractory to other therapies treated with sirolimus for at least 3 months. cases were s141 of s301 identified by polling member of the aspho vascular anomalies special interest group. results: all seven patients report improvement on sirolimus therapy. all patients had received prior procedures, including sclerotherapy (6 patients), cryoablation (2 patients) and/or resection (3 patients). mean age at sirolimus initiation was 16y (range 6-29y). mean length of therapy is 18.4 months (range 3-29 months). six patients were treated with bid dosing and one adult received daily dosing. goals of sirolimus were improvement in pain or musculoskeletal dysfunction. pain and function improved in all patients, including discontinuation of narcotic use and resumption of participation in sports. time to symptom improvement ranged from 1-4 weeks. in four patients for whom dose was lowered, pain recurred in all four and responded to restarting or increasing sirolimus dose. while all patients do not have pre-and postsirolimus imaging, decrease in fava lesion size is seen in cases with available imaging. sirolimus side effects are similar to prior reports, most commonly mouth sores, elevated lipids and acne. we report the first known data supporting a role of sirolimus in refractory fava cases. sirolimus is welltolerated and initial improvement is rapid, within 4 weeks of initiation. whether sirolimus has a role in upfront therapy to reduce lesion size prior to procedures deserves further study. objectives: to assess platelet responses in children with itp receiving romiplostim. design/method: eligible children had itp for ≥6 months, ≥1 prior therapy, and screening platelet counts ≤30 × 10(9)/l or uncontrolled bleeding. weekly dosing was from 1-10 g/kg to target platelet counts of 50-200 × 10(9)/l. bone marrow biopsies were evaluated in europe at baseline and after 1 or 2 years (cohorts 1 and 2). as of mar 2017, 203 patients received ≥1 dose. at baseline, median (min-max) age was 10 (1-17) years, itp duration was 1.8 (0.5-13.8) years, and platelet count was 14 (2-265) × 10(9)/l; 10 patients (5%) had had prior splenectomy. the median (q1, q3) % time with a platelet response (platelet count ≥50 × 10(9)/l, no rescue medications past 4 weeks) in months 0-6 was 50% (17%, 83%) (primary endpoint). over the course of the study, 88% (179/203) of patients had a platelet response. four patients maintained platelet counts ≥50 × 10(9)/l with no itp medications for ≥24 weeks. median (min-max) treatment duration was 53 (8-119) weeks for 226 patient-years in total. median (min-max) average weekly romiplostim dose over the course of the study was 6.9 (0.2-9.5) g/kg; the median dose was 9 g/kg at 1 year (n = 106) and 10 g/kg at 2 years (n = 17). most (63%) patients initiated self-administration. sixty-four patients (31%) discontinued treatment, most frequently for lack of efficacy (n = 38), patient request (n = 7), and adverse event (ae) (n = 7). fortyone (20%) patients had serious aes (saes) including epistaxis (5%) and decreased platelet count (3%). five patients had treatment-related saes: 2 headaches, 2 abdominal pain, and 1 each of presyncope and neutralizing antibodies (ab). there were 6 cases of neutralizing ab to romiplostim (of 201 patients tested), but none to tpo; 5/6 had continued elevated platelet counts and in 2/6 cases ab were not found on retesting. for cohort 1, of 30 patients with baseline bone marrow biopsies, 27 had evaluable on-study biopsies scheduled for 1 year; 1 patient had an increase from grade 0 to 2. there were no findings of collagen or abnormalities. in this interim datacut of a romiplostim openlabel study in children with itp, 88% of children had a platelet response. overall, the median dose was 6.9 g/kg; the median romiplostim dose over time reached 10 g/kg. no new safety signals were observed over 226 patient-years. funded by amgen inc. background: hepatic hemangiomas are benign vascular tumors without a medical home, managed by multiple specialties. the diagnosis has been assigned historically to various vascular lesions affecting the liver with completely different clinical presentations, resulting in difficult standardized management. objectives: the consensus steering committee identified an acute need of clear definitions and evaluation guidelines using the updated international society for the study of vascular anomalies (issva) classification. the goal was to formulate recommendations that will be adopted by all specialties involved in the care of children with hepatic hemangiomas. design/method: we used a rigorous, transparent consensus protocol, with input from multiple pediatric experts in vascular anomalies from hematology-oncology, surgery, pathology, radiology and gastroenterology. in the first section, we precisely define the subtypes of hepatic hemangiomas seen in children (congenital and infantile) using clinical course, histology and radiologic characteristics. inclusion and exclusion limits to the diagnosis are noted. the following two sections describe these subtypes in further detail, including complications to be considered during monitoring and respectively recommended screening evaluations. conclusion: while institutional variations may exist for specific clinical details, a clear understanding of the diagnosis of hepatic hemangiomas affecting the pediatric population and the possible complications that require screening during the monitoring period should be standard. as patients with hepatic hemangiomas are managed by different medical and surgical specialties, a multidisciplinary consensus based on current literature, on the data extracted from the liver hemangioma registry and on expert opinion was required and was accomplished by this manuscript. objectives: to investigate the association between routine prophylaxis with bay 81-8973 and bleeding outcomes after adjusting for key patient and pharmacokinetic (pk) characteristics. design/method: the leopold kids study evaluated safety and efficacy of bay 81-8973 prophylaxis in 51 previously treated boys aged ≤12 years with severe hemophilia a. patients received bay 81-8973 25-50 iu/kg 2x/wk (n = 21) or >2x/wk (n = 30) and were followed up for 6-8 months. prophylaxis dose and frequency were assigned by investigators. pk parameters, including area under the curve (auc), half-life, and clearance, were derived from a population pk model and reflect predicted pk values with a 50-iu/kg dose. patient characteristics were compared between the 2x/wk and >2x/wk groups using wilcoxon rank sum or chi-square tests. negative binomial regression was used to model the association between prophylaxis frequency and annualized bleeding rate (abr) for total bleeds, first without adjustment and then adjusting for age, pk parameters, and bleed history. results: mean ± sd age for patients in this analysis was 6.4±3.0 years. patients receiving prophylaxis 2x/wk had more bleeding episodes in the 12 months before study entry (mean ± sd, 13.0±16.6 [median, 6.0] for 2x/wk vs 4.3±5.7 [1.0] for >2x/wk; p = 0.027) and were more likely to have been treated on demand (38% vs 10%; p = 0.035). pk parameters were similar between the 2x/wk and >2x/wk groups. without adjustments, abr during the study was 12% higher in the 2x/wk group compared with the >2x/wk group (rate ratio [rr], 1.12; 95% ci, 0.44-2.90; p = 0.81). abr was 36% lower in the 2x/wk group (rr, 0.64; 95% ci, 0.24-1.70; p = 0.37) after adjusting for age, auc, and number of bleeds in the prior 12 months. conclusion: abr was numerically lower but not significantly different between the 2x/wk and >2x/wk groups after adjusting for age and pk parameters. these findings suggest that even among patient groups that are homogeneous with respect to age, pk, and bleed history, further individualization of bay 81-8973 prophylaxis based on other characteristics may help reduce bleeding episodes even at a lower treatment frequency. larger real-world studies are needed to verify these findings. funded by bayer. stanford, palo alto, california, united states s143 of s301 background: vascular malformations may be of lymphatic, arterial, venous or capillary endothelial origin. they may be simple or complex, with complex malformations being a combination soft tissue and skeletal overgrowth. although likely present at birth, these malformations often become symptomatic with puberty or infection, and range from little or no clinical impact to life threatening symptoms. in malformations primarily of venous origin, pain may be significant and hypothesized to be caused by phlebolith development (intra-malformation thrombi), inflammation, consumptive coagulopathy, vascular engorgement, and endothelial proliferation. anti-angiogenic and anti-platelet therapies have been reported to relieve pain. however, the use of anticoagulation for pain is not well described. objectives: to report clinical features and outcomes of patients with vascular malformations of venous origin treated with anticoagulation for pain. we performed a retrospective review of patients with vascular malformations followed by the hematology service between january 2010 and december 2017 who were treated for pain with anticoagulation. pain relief was determined both by wong-baker pain scales and patient report. clinical data were extracted from electronic medical records. we identified five patients with venous malformations (vm) who had received anticoagulation for pain. four patients were female and median age was 8 years old (range 4 to 29 years old) at time of initiation of anticoagulation. all five patients had vm of the extremity, two with vm of the lower extremity, and three patients had vm of the upper extremity. two patients had concomitant coagulopathy and demonstrated decreased d-dimer after initiation of anticoagulation. four patients received enoxaparin, and one adult patient received rivaroxaban. all patients reported improvement in pain after administration of anticoagulation. one patient exhibited mild epistaxis and bruising at the injection site. there was no significant bleeding or other complications. pain is a significant complication in patients with venous malformations. our case series suggests that anticoagulation is a safe and effective therapy for pain relief in this population. further investigation is indicated to compare the effect of anticoagulation to other therapeutic interventions such sclerotherapy, surgery, and sirolimus in the treatment of pain associated with venous malformation. maria ahmad-nabi, christine knoll, sanjay shah, lucia mirea phoenix children's hospital, phoenix, arizona, united states background: estimates of the incidence of dvt in patients with osteomyelitis range widely from 5%-30%, however risk factors and outcomes of dvt in this cohort have not been thoroughly established. objectives: this study aims to estimate the incidence of dvt in patients with osteomyelitis, and to assess risk factors and outcomes of dvt in this cohort. design/method: after irb approval, a retrospective chart review was conducted for patients aged 0-18 years seen at phoenix children's hospital between 2012-2016 with icd 9/10 codes for osteomyelitis. exclusion criteria included chronic recurrent multifocal osteomyelitis, and chronic dvt. demographics, clinical factors and outcomes were compared between osteomyelitis patients with and without dvt using the fisher-exact and wilcoxon-rank sum tests, as appropriate for the data distribution. results: a total of 179 study subjects with osteomyelitis had a mean (standard deviation) age of 8.4 (5.7) years. dvt was present in 14 (8% of 179) patients, and 4 (28%), 5 (36%) and 5 (36%) patients received anticoagulation for < 6, 6-12 and ≥12 weeks, respectively. patients with vs without dvt were more likely to be male (86% vs 59%; p-value = 0.05), and had significantly higher rates of bacteremia (64% vs 24%; p-value = 0.003). rates of central lines were comparable between dvt and non-dvt patients (71% vs 68%; p-value = 1.00); however patients with dvt vs without dvt had significantly longer mean length of stay (18 vs 9 days; p-value <0.0001) and higher rates of icu admission (71% vs 16%; p-value <0.0001). the incidence of dvt among osteomyelitis pediatric patients was estimated at 8%, with risk increased by male sex and bacteremia. patients with dvt had significantly higher rates of icu admission and longer length of hospital stay. many of these patients had standard practice management of their dvt with 6-12 weeks of anticoagulation. our data highlights the need for recognition of high risk patients, and the need for future efforts targeting dvt prophylaxis. baylor college of medicine, houston, texas, united states background: lymphatic malformations (lm) frequently occur in the head and neck and can often be disfiguring and even life-threatening. management options include observation, surgery, sclerotherapy, and sirolimus. the optimal sequence of therapeutic interventions has not been determined due to the lack of comparative clinical trials or established guidelines. thus, prenatal planning with a multidisciplinary team is beneficial. we present a case series of ten children with head and neck lms evaluated in 2017 at our multidisciplinary vascular anomalies center. a chart review was performed to assess treatment modalities and recent trends. results: seven of 10 patients (70%) with head and neck lms were diagnosed prenatally. six patients required an ex utero intrapartum treatment procedure. all patients were started on sirolimus at a median age of 12.5 months (range 12 days -18 years). four patients most recently started on sirolimus were less than 3 months of age at the time of initiation. six patients underwent partial excision of lm during the first year of life; none of whom received sirolimus prior to surgery. sirolimus was discontinued in one patient given chronic clostridium difficile infections, and non-compliance in another patient. five patients received sclerotherapy. tracheostomy was necessary in six patients; one patient was de-cannulated after 7 months on sirolimus. all patients have had radiographic and clinical improvement of lm with varying treatment modalities. current clinical observations show improved response with sirolimus and demonstrate tolerability of sirolimus at a young age. conclusion: treatment of pediatric head and neck lms is challenging and a multidisciplinary approach is necessary. as the majority of patients are diagnosed prenatally, prenatal planning and discussion of potential use of sirolimus is beneficial. availability of vascular anomalies experts in the prenatal/neonatal period offers the best management results, and early initiation of sirolimus should be considered for complex lesions. long-term follow up is warranted to investigate the efficacy and timing of treatment options. yale school of medicine, new haven, connecticut, united states background: to mitigate transfusion of pathogencontaminated platelets, amotosalen, a synthetic psoralen compound, is added to sdp components. exposure to uv-a light activates amotosalen and crosslinks dna/rna base pairs, preventing replication of a broad spectrum of viral, bacterial, and other pathogens that may contaminate platelets. pr-sdps were fda approved for clinical use with no age restrictions in 2014. we initiated use of pr-sdps in november of 2016 for all patients. we retrospectively analyzed usage of pr-sdp vs conventional (non-pr) platelets (cp) in neonatal and pediatric patients with thrombocytopenia to compare hemostatic efficacy and the incidence of transfusion reactions (tr) for these products, after one year of a dual platelet inventory. design/method: since pr-sdp were fda-licensed, no irb approval was required; pr-sdp and cp were both considered standard of care. we evaluated transfusions for all pediatric patients age 0-18 years who received any platelet transfusion between november 2016 and november 2017. we determined the volume (mean ml ± 1sd) of each type of platelet component transfused, the number of platelet transfusion episodes, and reported trs based on cdc hemovigilance guidelines. a subgroup analysis was performed for thrombocytopenic neonates (0-4 months). results: patients 0-18 years who received only cps (n = 46) received a total of 8,030 ml of platelets (175 ± 151 ml/patient) over 62 transfusions (1.3 ± 0.6 episodes/patient). for comparison, in 38 patients who received only pr-sdp, a total of 4,350 ml of platelets (115 ± 107 ml/patient, p = 0.04) were infused over 61 transfusions (1.6 ± 0.9 episodes/patient, p = 0.12). for neonates (0-4 months, n = 26) who received only cps, 2,195 ml of cps (84 ± 105 ml/ patient) were transfused over 36 episodes (1.4 ± 0.6 episodes/patient). for comparison, those who received only pr-sdp (n = 27), received 1,613 ml of pr-sdp (60 ± 41 ml/patient, p = 0.27), transfused over 48 episodes (1.8 ± 0.9 episodes/patient, p = 0.08). for all recipients 0-18 years (n = 162), including additional patients who received both cp and pr-sdp, there were three reported allergic trs over 757 transfusion episodes, while no allergic reactions were reported with 537 pr-sdp transfusions. one febrile tr was reported to cp transfusion, while three were reported for pr-sdp. in conclusion, pr-sdps, in our pediatric population age 0-18 years, were comparable to cp products in regards to volume and episodes of platelet transfusions, and incidence/type of transfusion reactions. pr-sdp were safe and effective for use in this pediatric patient population. background: vascular anomalies are classified as either vascular tumors or vascular malformations. fibro-adipose vascular anomaly (fava) is a newly described entity which presents with distinct clinical, radiographic and histopathologic findings. we present a case in which the diagnosis of fava was complicated by a persistent low platelet count secondary to immune thrombocytopenia (itp). to describe a challenging diagnosis of a novel vascular anomaly (fava) complicated by severe thrombocytopenia. a 17 year old male presented to hospital with bruising and left thigh pain related to a remote sports injury. blood work revealed a platelet count of 9 × 109/l, but with an otherwise normal complete blood count. the following were also normal: aptt and fibrinogen; d dimer levels were slightly increased. he was treated with one dose of ivig (0.8 mg/kg) for presumed itp and responded well with his platelet count increasing to 118 × 109/l. he returned to hospital 3 weeks later with recurrent thrombocytopenia and worsening leg pain. an ultrasound of the left thigh revealed a 7.7cm x 4.0cm x 2.9cm lesion within the vastus medialis. the diagnosis of an intramuscular hematoma secondary to persistent thrombocytopenia was made. the patient presented with multiple episodes of thrombocytopenia over the next several months. his itp did not respond to oral prednisone (150 mg/day for 4 days). he continued to have short-lived responses to ivig requiring infusions every other week as his platelet count would fall below 10 × 109/l. his leg pain progressed, restricting him to a wheelchair. further imaging by mri brought into question the diagnosis of a hematoma and a biopsy of the thigh lesion was performed. the results were consistent with a diagnosis of fava; this was subsequently excised. conclusion: this is a unique case where a vascular anomaly was misdiagnosed as a hematoma due to a patient's persistent thrombocytopenia and history of an injury. fava is a newer entity which, unlike other vascular anomalies, has not been linked to thrombocytopenia or a localized consumptive coagulopathy. after excision of the fava, the patient's chronic pain, and mobility resolved, though his itp persisted. objectives: this preliminary, exploratory analysis of realworld administrative data was conducted to determine units dispensed and factor replacement product-related direct expenditures associated with a currently marketed shl or ehl rfix product. design/method: de-identified claims data from the commercially available truven health marketscan® research u.s. claims database were used to identify direct expenditures and number of international units (ius) dispensed for all patients aged 0-17 years with a diagnosis code of icd-9 286.0/icd-10 d66 who used nonacog alfa or eftrenonacog alfa during the study period (june 1, 2014 to july 31, 2017). reference weight measurements from the centers for disease control and prevention national center for health statistics' (cdc nchs) anthropometric data were used to estimate product dispensation on an iu per kg basis. the nonacog alfa and eftrenonacog groups comprised 37 and 11 patients, respectively. the median [iqr] age in the two groups was 8.0 [9.0] and 13.0 [4.0] years, respectively. while 10 of the 11 patients in the eftrenonacog alfa group had >1 calendar quarter of available data, only 23 of the 37 patients in the nonacog alfa group had >1 available quarter. the median rfix product dispensation per quarter was 29,074ius (iqr, 13, 967 ius) in the nonacog alfa group and 62,268ius (iqr, 18, 882 ius) in the eftrenonacog alfa group. incorporating attributed weight values, the median rfix product iu dispensation per kg per week was 97.39 iu/kg/wk (iqr, 31.92 iu/kg/wk-153.92 iu/kg/wk) in the nonacog alfa group, and 96.27 iu/kg/wk (iqr, 53.05-154.03 iu/kg/wk) in the eftrenonacog alfa group. applying 2016 wac prices (eftrenonacog alfa = $2.97/iu; nonacog alfa = $1.37/iu), the calculated estimates of $/kg/week were $133 and $286 in the nonacog alfa and eftranonacog alfa groups, respectively. conclusion: preliminary real-world data derived from a large u.s. claims database revealed differences in product dispensation and factor product-related expenditures among pediatric patients with any severity of hemophilia b to whom an shl or ehl rfix product was prescribed. refinements of these data, potentially to exclude instances of sporadic usage, may shed light on real-world dispensation of rfix products among pediatric hemophilia b patients. background: vascular malformations can be classified as simple (including capillary, venous, lymphatic, arteriovenous), combined, malformations of major named vessels or associated with other anomalies. multiple modalities including laser treatments, sclerotherapy, embolization, surgery and pharmacological intervention (with mtor inhibitors like sirolimus) have been used for treatment of vascular malformations. these interventions have been used alone or in combination with varied outcomes. we present our institution's experience with a multimodal approach to simple and combined vascular malformations. design/method: we performed a retrospective chart review of patients with vascular malformations who were referred to our center for an interventional radiology evaluation from june 2015 -july 2017. we included 22 patients (age at presentation:4 months -25 years), referred initially for interventional radiology procedures (irp) for vascular malformations. all patients had symptoms of pain and/or swelling/deformity. diagnosis of was based on vascular imaging (doppler ultrasound, mri/a/v). nine patients had venous malformations (vm), five had macrocystic lymphatic malformations (lm), six had lymphatic-venous malformations (lvm), and two arteriovenous malformations (avm). 19 patients initially underwent interventional radiology procedures. all the vm patients responded to sclerotherapy alone. three patients with lm responded to sclerotherapy alone, remainder required surgical intervention. one avm patient responded well to embolization, the other needed surgical resection after embolization. four lvm patients underwent irp with minimal improvement in symptoms (3-8 procedures attempted), surgical resection was attempted in 3 patients with poor response and 5 patients were started on sirolimus (0.8mg/m2/dose twice a day). all lvm patients started on sirolimus have responded well (decreased pain and swelling); time to initial symptom response ranged from 2 weeks -1 month from starting medication. in this case series, patients with simple vm responded well to sclerotherapy alone, avm and lm patients needed irp and/or surgery for complete response. complex lvm did not respond well to surgery or irp; 83.3% had improvement in clinical symptoms with addition of sirolimus to the treatment regimen. response to various modalities of treatment varied based on the type of vascular malformation. a multidisciplinary approach to management of vascular malformations is essential to provide multimodal therapeutic options for rapid symptom relief and improve the quality of life of these fragile patients, especially those with complex malformations. background: von willebrand disease (vwd) is the most common bleeding disorder in humans, affecting ∼1% of the united states' population. desmopressin (ddavp) is a longacting vasopressin analog that induces vasoconstriction and release of vwf. ddavp is used in patients with vwd and as a surgical prophylaxis, but carries anti-diuretic properties. to avoid electrolyte imbalance and hyponatremia, fluid restrictions are recommended in the 24 hours post-ddavp administration. objectives: this study sought to examine perioperative practices and outcomes following ddavp administration and a fluid restriction protocol in a population of pediatric patients with von willebrand disease. design/method: a retrospective chart review was conducted for patients with von willebrand disease who underwent surgical procedures at children's hospital of pittsburgh of upmc between january 1, 2015 and december 31, 2016. patient age, sex, weight, diagnosis, surgical procedure, total fluids administered, and post-operative sodium level were recorded. the primary outcomes noted were the proportion of patients exceeding 50% of the recommended fluid consumption for the 12-and 24-hour periods post-ddavp s147 of s301 administration, as defined by local guidelines. secondary outcomes were the presence of any bleeding requiring an er visit or readmission or hyponatremic seizures within 72 hours of ddavp administration. results: data was compiled for 42 patients (23 females, 19 males). the mean age was 11.19 years (sd 5.13 years), median age was 12 years (range 3 to 19 years). procedures included dental (13), otolaryngology (9), orthopedics (7), gastrointestinal (5), plastics (3), neurosurgery (1), ophthalmology (1), dermatology (1), general surgery (1) and gynecology (1). 30% of patients exceeded 50% of the fluid volume recommended for the first 12-hour period post-ddavp administration while still in the surgical setting. no patients exceeded 50% of the fluid volume recommended for the total 24-hour period post-ddavp administration. post-operative sodium levels were obtained in only 7 of 42 patients. no patients returned to the er or were admitted for bleeding in the 72 hours post-ddavp administration. no patients returned to the er or were admitted for hyponatremia or seizures in the 72 hours post-ddavp administration. maintenance of a fluid restriction protocol effectively deterred negative outcomes in this cohort. however, a significant fluid volume was administered in nearly a third of patients despite the restrictions. given the risk of hyponatremia, and limited compliance with fluid restrictions, postoperative sodium levels should be recorded in following ddavp administration to assess the possibility of a hyponatremia and to reinforce the importance of fluid restrictions and their communication. results: a male fetus required in utero insertion of a pleuroamniotic shunt for bilateral pleural effusions diagnosed antenatally by ultrasound. shortly after delivery at term, he developed respiratory distress and was found to have reaccumulation of the pleural effusions. blood work on day 1 of life showed a platelet count of 157,000/ l, which then decreased precipitously. he demonstrated schistocytes on blood-smear, signs of consumptive coagulopathy with hypofibrinogenemia and high d-dimers, and compensatory reticulocytosis. he required multiple transfusions and admissions to the intensive care unit for respiratory support. investigations ruled out congenital ttp, neonatal alloimmune thrombocytopenia, and noonan syndrome. given high clinical suspicion for an underlying vascular lesion causing kmp, a full body mri without contrast was undertaken. this showed a focal area of suspicious signal intensity in the upper paraspinal musculature. an ultrasound and mri with contrast demonstrated an extensive infiltrative vascular lesion involving the paraspinal musculature, prevertebral space, posterior extrapleural space, mediastinum, and neck. the child was commenced on prednisone (2mg/kg/day) and rapamycin (0.9 mg/m2 twice/day). there was no clinical or laboratory improvement after one month. a biopsy was performed which confirmed khe. in the second month of rapamycin therapy, the platelet count gradually normalized and the patient was discharged from hospital at 3.5-months of life. prednisone was weaned off at 4.5 months of life. a repeat mri at 7 months showed significant reduction in the khe. he is now almost 2 years into therapy and doing well. conclusion: this is a unique case of khe with kmp that initially presented with extensive and recurrent pleural and pericardial effusions. this case demonstrates the importance of suspecting an underlying vascular malformation in the presence of kmp. our patient had a delayed but overall good response to rapamycin. further studies investigating duration of rapamycin therapy is key for the optimal management of these patients. rosa diaz, donald mahoney, lakshmi srivaths, donald yee texas children's hospital, houston, texas, united states background: since von willebrand disease (vwd) is the most common inherited bleeding disorder, it must co-exist with other less common bleeding disorders in some dually affected patients. however, reports of combined deficiencies in factor viii (fviii) and von willebrand factor (vwf) are rare. objectives: to study the prevalence and bleeding phenotype of combined deficiencies of fviii and vwf in males with hemophilia a in a hemophilia treatment center. design/method: we retrospectively reviewed the electronic medical records of 99 males with hemophilia a followed at our institution during the past 10 years. the primary and secondary outcomes for the study were (1) the prevalence of combined fviii and vwf deficiencies and (2) the bleeding phenotype of these patients. we identified vwf deficiencies in 9% (n = 9) of the patients with hemophilia a. most (n = 6, 67%) patients were tested for vwf deficiency as part of the initial hemostatic evaluation, but one-third were tested due to clinical concern for inadequate response to fviii concentrate. the median duration of follow up was 9.5 years (range 3.4 to 17.2). patients were referred to our clinic at a median age of 12 months (range 0 to 6 years) for evaluation of easy bruising (n = 4, 45%), mucosal (n = 3, 33%) and surgical bleeding (n = 2, 22%). primary diagnoses included 4 with severe, 3 moderate and 2 mild discrepant hemophilia a. secondary diagnoses included 6 with low vwf activity, 2 type 1 vwd and 1 with type 2 unclassified. patients experienced episodes of musculoskeletal (n = 7, 78%), mucocutaneous (n = 6, 67%) and cns bleeding (n = 1, 11%). a total of 8 patients received factor prophylaxis. half of the patients were initially treated with fviii concentrates but subsequently changed to combined fviii/vwf products due to the frequency of breakthrough bleeding despite good compliance. all patients are on combined fviii/vwf products at the time of this review. a total of 7 (78%) of this cohort developed chronic joint disease manifest as decreased range of motion and/or abnormal mri findings. combined deficiencies of fviii and vwf were present in 9% of our center's hemophilia patients. these patients exhibited a severe bleeding phenotype as evidenced by the high frequency of hemarthrosis, need for prophylaxis and high prevalence of chronic joint disease. while the optimal treatment strategy remains to be elucidated, early recognition of a combined deficiency may have important clinical implications, particularly in patients who demonstrate a suboptimal response to fviii concentrate alone. background: childhood neutropenia is heterogeneous and may be congenital or acquired. cerebral cavernous malformation 3 (ccm3) is a neurovascular malformation disorder where lesions consist of low flow, dilated capillary endothelial channels with increased permeability, predisposing to hemorrhage and thrombosis. programmed cell death protein 10 (pdcd10) activity has been implicated in glia and neuron migration, and recently linked to the dysregulation of the actin and microtubule cytoskeleton, thereby affecting cellular morphology and migration. variants of pdcd10 encoding pdcd10 have been associated with ccm3. ccm3 causes a greater and earlier disease burden than other ccms, with 26% presenting younger than 10 years. some patients have associated extra-neuronal manifestations, suggesting that pdcd10 plays a role in other tissues. we describe a patient with significant blood cytopenias associated with ccm3. design/method: retrospective chart review to obtain patient data. results: an 8-month old female presented with seizure and was found to have multiple intracranial cystic lesions and abscesses due to s. pneumonia serotype 33f. during her treatment, she developed anemia (hemoglobin 7.6-8.7 g/dl), thrombocytopenia (platelets 73,000-128,000 cells/l), and profound neutropenia (absolute neutrophil counts of zero). initial bone marrow evaluation revealed a normocellular marrow but with marked granulocytic hypoplasia and 38% hematogones on flow cytometry. florescent in situ hybridization excluded cytogenetic changes characteristic of myelodysplastic syndrome. further evaluation included testing for neutrophil antibodies, chromosome breakage, and telomere length and results were normal. whole exome sequencing excluded mutations affecting congenital neutropenia genes, but detected a de novo pdcd10 variant (c.474+5g>a), thereby diagnosing ccm3. the neutropenia has responded well to granulocyte colony stimulation factor (gcsf), which is still needed at 26 months of age. moreover, the thrombocytopenia has progressed, requiring periodic platelet transfusions. over time, the bone marrow hematogone population has decreased to 8% at 20 months of age, though the granulocytic hypoplasia persists. conclusion: our case describes the first patient with neutropenia and thrombocytopenia associated with ccm3. we hypothesize the pdcd10 variant is the etiology of bone marrow dysfunction due to its role in actin and microtubule cytoskeleton formation, akin to the pathophysiology of xlinked neutropenia. supportive features of an underlying genetic cause of marrow dysfunction include the persistence of cytopenias beyond infection resolution as well as presence of hematogones. hematogones were previously reported to occur in patients with other congenital neutropenia disorders, indicating they could be a feature of congenital neutropenia and may be reactive to surrounding cell apoptosis. further testing of pdcd10 role in hematopoiesis should be explored. background: 10-15% of adult women will suffer from heavy menstrual bleeding (hmb) during their lifetime. 90% of women with inherited bleeding disorders suffer from hmb. there is a paucity of data about hmb among adolescents and young adults (aya), a population in which hmb may have large social and educational effects. objectives: to study the social and academic implications of hmb in an aya population. design/method: this is a questionnaire based survey conducted in a medium-sized city in california. we recruited females 14-24 years of age from one high school and from local university. the questionnaire was set up in research electronic data capture (redcap) at our institute which allowed us to obtain objective data about the respondents' menstrual cycles. a link was sent to the high school students via their online portal schoolloop and to the university students via social media and word of mouth. data was collected over 12 weeks from may 2017 to august 2017. we received 145 replies, some were not complete. using regression analysis, data was analyzed from 115 respondents in the age group of 18-24 (with a mean age of 19) years. we developed a composite score for hmb based on factors including saturation levels, number of pads, duration of bleeding, soaking of a pad within two hours, passage of clots, size and number of clots, and gushing sensation. we conducted statistical analysis of the drivers and implications of hmb based on the composite score. results indicate that having a relative with hmb, having other bleeding problems, and having anemia are drivers of higher hmb score. the results also indicate that hmb adversely affects quality of life as measured by participation in sports, social activities, after-school activities, tiredness, absenteeism, and gpa. hmb is also associated with increased rates of anemia and use of anti-depressants. hmb-driven anemia further adversely affects gpa. under-represented minorities are more likely to have a higher hmb score, as well as an increased adverse effect of hmb on gpa. the results suggest that the social costs of hmb are pervasive in the aya population, and especially pronounced among minorities. a relative with hmb is a significant driver of heavy menstrual bleeding. a hemostatic screen should be included when assessing the aya population with hmb. johns hopkins all children 's hospital, st. petersburg, florida, united states background: propranolol is a non-cardioselective beta blocker medication frequently prescribed for hemangiomas and hyperthyroidism. propranolol inhibits types i and ii iodothyronine deiodinases, enzymes that convert bioinactive thyroxine (t4) into bioactive triiodothyronine (t3). hypothyroidism is a well-recognized complication of diffuse hepatic hemangiomas that produce type iii deiodinase, an enzyme that converts t4 into bioinactive reverse t3 and t3 into diiodothyronine. thyroxine is typically selected for replacement in this population, even though doses up to 60% above physiologic may be necessary. we hypothesized that low dose, nearly physiologic t3 would be safer and equally effective because it bypasses propranolol's impact on the pituitarythyroid axis. we report an infant with diffuse hepatic hemangiomatosis and acquired hypothyroidism successfully treated with propranolol, prednisone, and triiodothyronine. design/method: a 7mo healthy female presented with abdominal distension, poor oral intake, and hepatomegaly. mri confirmed diffuse hepatic hemangiomatosis, the largest lesion measuring 4.4 cm by 3.9 cm. thyrotropin (tsh) was elevated at 47.9 (reference range* 0.5-6 mcgiu/ml), total t3# 165 (rr 60-300 ng/dl), and total t4^18.8 (rr 6-14 mcg/dl). treatment was started with prednisone (2 mg/kg/day) for three weeks, propranolol (3 mg/kg/day) and t3 (0.64mcg/kg/day). the t3 dose was slowly titrated to a maximum of 1.72 mcg/kg/day. thyroid hormone levels rapidly improved on t3 replacement. after two weeks, the tsh was 14.4, tt3 92, and tt4 16.5. after eight months, the tsh was 2.9, tt3 161, and tt4 10.1. at twelve months, the tsh dropped to 0.6, tt3 294, and tt4 3.7, suggesting decreased tumor production of type iii iodothyronine deiodinase. liver mri confirmed fewer hemangiomas, largest being 1.3 cm by 1.6 cm. the patient's t3 dose was reduced. both propranolol and t3 were discontinued after twenty-four months of treatment. one year off all therapy, this child has normal growth and development, only two <1.3cm hepatic hemangiomas and no evidence of hypothyroidism (tsh 2.2; tt3 153; tt4 6.4). conclusion: t3 at near physiologic doses corrects the consumptive hypothyroidism associated with diffuse hepatic hemangiomas. t3 replacement is preferable to thyroxine due to its lower risk of rebound hyperthyroidism as the hemangiomas involute and type iii deiodinase production declines. there are two prior case reports describing t3 use without t4, one employing propranolol and the other utilizing steroids for hemangioma management. this is the first case report with long term follow-up of a child treated with multimodal therapy including propranolol, prednisone, and triiodothyronine. *rr = reference range; #tt3 = total t3;^tt4 = total t4 background: multifocal lymphangioendotheliomatosis with thrombocytopenia (mlt) is a rare congenital disorder first described in 2004 that is characterized by multiple vascular abnormalities commonly involving the skin and gastrointestinal tract as well as consumptive coagulopathy often resulting in gi bleeding in infancy(1). to describe an unusual presentation and successful management of mlt in a neonate. design/method: baby h was born at full term after a pregnancy complicated by maternal sinus venous thrombosis requiring anticoagulation beginning at 28 weeks. at birth, she was diagnosed with multiple hemangiomas based on clinical exam. at two weeks of age, she developed melena and hematemesis. cbc revealed platelet count of 70 and she was referred to the ed. abdominal ultrasound was concerning for abnormal hepatic waveform; cxr showed multiple pulmonary nodules. workup revealed no other lesions and no further hematologic abnormalities. biopsy of presumed hemangioma ultimately revealed a smooth muscle-lined vascular proliferation without glut-1 immunoreactivity, consistent with mlt. her early course was complicated by an acute hemodynamically significant gi bleed; esophagogastroduodenoscopy identified six bleeding vascular malformations within the stomach that were injected with epinephrine and sclerosed with successful hemostasis. she received multiple prbc and platelet transfusions. central access was obtained and she was started on oral sirolimus based on previous reports of successful use in management of vascular malformations given its antiangiogenic and immunosuppressive effects (2). she has tolerated it well with no evidence of toxicity and has achieved a partial response with stable of hemoglobin >8 and platelet count >90. cutaneous lesions have diminished in intensity and she has had no further signs of gi bleeding. she receives pentamidine for pcp prophylaxis. she continues to have appropriate growth and development. we describe here an unusual presentation of an already rare disease. while cutaneous and gi lesions are typical of mlt, pulmonary involvement is not well-described in the literature. early identification of tissue-based diagnosis enabled timely stabilization and treatment of the patient. five months later, she continues to tolerate sirolimus and has shown significant response with diminished coloration of cutaneous lesions, stable blood counts, and no further bleeding. mlt is a relatively newly-recognized disorder with significant phenotypic variability. given that bleeding secondary to a kasabach-merritt-type consumptive thrombocytopenia is the major cause of morbidity and mortality in the first year of life in children with mlt, it is essential to recognize the diagnosis and initiate appropriate treatment as early as possible. 1north, arch background: patients with generalized joint hypermobility (jhm) may experience easy bruising or bleeding given the association between these symptoms and abnormalities in collagen, a required component of primary hemostasis. heavy menstrual bleeding (hmb) is a common initial presentation for females with underlying hemostatic defects and may be the sole manifestation of a bleeding disorder. however, limited reports describe jhm as a cause of hmb, leading to under recognition. objectives: to describe the clinical characteristics and management of young women presenting with hmb in the setting of jhm. design/method: this study utilized our hmb research registry. we included subjects 11-18 years, seen in the nationwide children's young women's hematology clinic between february 2014 and november 2017 with both hmb and jhm. medical records were retrospectively reviewed for history of presentation, menorrhagia impact questionnaire (miq): a validated quality-of-life tool for females with hmb, medication profiles and relevant laboratory studies. results: twenty-five patients met inclusion criteria (median age 15 years, range 11-18) with an average beighton score of 6.2 (range 4 to 9). participants presented an average of 3.2 years (range 5 months to 6 years) after menarche despite 76% of patients reporting heavy to very heavy menses since menarche. according to the miq responses, most participants expressed hmb-associated limitations in physical activities (84%), social activities (68%), and work or school activities (64%). of the participants, 92% reported bleeding symptoms in addition to hmb, most commonly easy bruising (56%), epistaxis (48%) and cutaneous bleeding (44%). forty percent of young women presented with anemia due to chronic blood loss. results of hemostatic testing were unremarkable, with the exception of one patient who was also found to have type 1 von willebrand disease. additionally, 44% of females reported arthralgia, with knees and ankles the most commonly affected joints. at time of presentation, 32% of participants reported failure of initial therapies and most patients (88%) were managed long-term with oral hormone therapy. in a small population of young women found to have jhm who initially presented with hmb, patients were likely to have prior bleeding symptoms as well as substantial delays from menarche to timing of presentation at our young women's hematology clinic despite limitations in activities of daily life. greater awareness of the associations between bleeding symptoms and jhm, despite typically normal hemostatic laboratory results, is necessary so that patients can more easily be identified and receive appropriate therapy. the objective is to determine the impact of cl care practices involving the home environment on ambulatory clabsi rates. design/method: information for the pi was collected through a comprehensive survey that was completed annually by the ccbdn member hospitals. responses to the questions about cl care practices involving the home environment were selected from the pi for 2015. ambulatory clabsi rates and ambulatory total bloodstream infection (bsi) rates were obtained from another ccbdn database. the proportion of hospitals that did or did not employ a particular cl care practice was tallied. the mean ambulatory clabsi rate and mean ambulatory total bsi rate of the hospitals that did or did not employ a particular cl care practice were compared using generalized linear model techniques assuming an underlying negative binomial distribution. results: twenty-five hospitals submitted responses to the 8 questions about cl care practices involving the home environment. one hospital was excluded for lack of bsi data. sixty-three percent of the hospitals programmatically educated parents about all aspects of the cl care bundle. the mean ambulatory clabsi rate for the hospitals that educated parents was significantly lower than that of the hospitals that did not (0.20 infections/1000 cl days vs. 0.30 infections/1000 cl days; p = 0.02). the mean ambulatory total bsi rate was also significantly lower (0.35 infections/1000 cl days vs. 0.53 infections/1000 cl days; p = 0.01). the mean ambulatory clabsi rates and mean ambulatory total bsi rates were not significantly different for the other 7 cl care practices. conclusion: an analysis of cl care practices involving the home environment reveals that parental education of all aspects of the cl care bundle is associated with a lower ambulatory clabsi rate and lower ambulatory total bsi rate. this finding highlights the importance of systematically teaching family members the proper method of handling cl. background: children undergoing chemotherapy are at a high risk for developing nausea. dr. amy baxter in collaboration with pediatric oncology patients and nurses, developed and validated a pictorial nausea rating scale for children aged 7-18 years, called the baxter retching faces (barf) nausea scale. staff nurses at a large, academic, pediatric hospital located within washington, d.c., have identified variability in nursing assessment and documentation of chemotherapy induced nausea and vomiting (cinv) in pediatric oncology patients. the purpose of this quality improvement project was to utilize the barf scale to standardize assessment and documentation of nausea in pediatric oncology patients receiving chemotherapy. the primary aims of this project were to: assess feasibility of the barf scale in clinical practice; increase nursing knowledge about cinv through education sessions; increase documentation of nausea assessments through the use of the scale. the secondary aim of this project was to: increase the recognition of nausea through the use of a standardized assessment tool. design/method: the pdsa model was used to guide the design and implementation plan. in the first phase of the project data was collected to identify the prevalence of nausea in patients admitted for chemotherapy in the prior three months. education sessions discussing cinv and the utilization of the barf scale were conducted. pre and post assessment of nurses' knowledge of cinv and documentation were assessed. in the second phase the barf scale was implemented into practice. nurses were asked to utilize the barf scale to assess and document nausea scores in patients, aged 7 to 18 years, receiving chemotherapy. at the end of the implementation period nurses were surveyed about the feasibility of the scale. post data was collected to identify the prevalence of nausea documented in the electronic health record. this project was undertaken as a quality improvement initiative at children's national and it does not constitute as human subjects research. as such it was not under the oversight of the institutional review board. results: all data has been collected; however complete data analysis will be conducted in the upcoming weeks. background: sickle cell disease (scd) is the most common inherited blood disorder in the united states (us); however, there are few quality measurements to evaluate scd practice. in 2014, the nhlbi published guidelines that include two key interventions for children with sickle cell anemia (sca): the use of transcranial doppler (tcd) screening for stroke prevention and hydroxyurea (hu) to prevent scd pain crisis. we conducted a national survey of scd management sent to providers in over 20 institutions in the us to better assess knowledge of the guidelines and barriers to hu counseling and tcd screening guideline implementation. it was hypothesized that the barriers to tcd screening are different than barriers to hu counseling and prescribing. a 33-question anonymous survey was sent to 49 providers by mail (follow-up by email). survey themes included nhlbi guidelines knowledge and comfort with understanding and implementing both tcd screening and hu use. the response rate was 59% (29/49) however one survey was incomplete. thus, 28 were analyzed in the final data set. all of the respondents are in active practice, 96% s153 of s301 in academics and all care for children with scd. the majority of providers (96%) felt "very" or "extremely" confident in their knowledge of tcd screening and interpretation. similarly, 100% of providers felt "very" or "extremely" familiar with hu dosing and management. for tcd screening, 36% of providers estimated their screening rates were >90% and 64% providers felt their annual screening rates were 75-90%. the two biggest barriers to tcd screening noted by providers (of moderate to extreme significance) included: lack of support staff (36%) and lack of time during a patient visit (26%). regarding hu prescribing practices, 71% of providers offered hu to at least 90% of children with sca over nine months of age. the biggest barrier to hu prescribing noted by 46% of providers was concerns about patient adherence or access to the medication. only 7% providers felt that lack of support staff was a moderately significant barrier to hu prescribing. the pediatric scd providers surveyed all have access to the nhlbi guidelines. despite widespread guideline knowledge, there are different barriers for tcd screening versus hu prescribing, which prevent optimal implementation. as a result, although both recommendations are from the same nhlbi guideline, they likely will require different implementation strategies (systems-based interventions for tcd screening; interventions to improve patient adherence for hu counseling) to improve outcomes. background: invasive fungal disease (ifd) is a major cause of mortality and morbidity among pediatric immunocompromised patients such as those who receive chemotherapy or hematopoietic stem cell transplantation. the current diagnostic 'gold standard' of ifd remains culture of infected tissue obtained by biopsy. noninvasive biomarker testing for galactomannan or 1,3-beta-d-glucan (bg) can have low sensitivity and does not provide species-level identification. nextgeneration sequencing (ngs) of cell-free plasma is a promis-ing noninvasive approach to providing species-level identification of ifd via a blood test and can further guide specific treatment. objectives: describe the incidence of positivity for fungal specific pathogens on ngs analysis in a high-risk immunocompromised pediatric population and correlate results with other 'standard' infectious studies if performed. design/method: immunocompromised pediatric patients with suspected ifd were enrolled and plasma was collected at time of enrollment. ngs was performed on extracted dna in cell-free plasma (karius, redwood city, ca). after removing human reads, remaining sequences were aligned to a curated database including 1251 pathogens. organisms present at a significance-level above a predefined threshold were reported. results: twenty-seven samples from 33 enrolled patients have been processed thus far. of these 27 subjects, 14 were enrolled for prolonged febrile neutropenia (≥96 hours) despite broad-spectrum antibiotics, 5 for recrudescent febrile neutropenia, 5 for abnormal imaging, and 3 with other findings. after evaluation of routine studies performed, 4 patients met criteria for proven ifd, 2 for probable ifd, and 9 for possible ifd using eortc/msg guidelines. the ngs plasma test identified the same pathogen as cultured from infected tissue or blood in 100% (4/4) of the proven cases. in the probable cases, pneumocystis jirovecii was identified in a patient with a positive bg (389 pg/ml) and pneumonia. among the possible cases, toxoplasma gondii was detected in a patient with prolonged febrile neutropenia and lung imaging suggestive of ifd. additionally, candida glabrata was isolated in a patient with prolonged febrile neutropenia but no other criteria for ifd. numerous pathogens were also identified that could explain the above clinical parameters, including hsv1, cmv, vzv, hhv6, ebv, bk polyoma virus, and ureaplasma parvum. the cell-free plasma ngs test can detect invasive fungal infections from blood. the test identified fungi from proven ifd, detected pathogens in both probable and possible ifd cases, and is a useful diagnostic tool in the evaluation of ifd. supplies and sample shipment and processing supported by karius, inc. baylor college of medicine, texas children's hospital, houston, texas, united states background: practicing medicine is a lifelong learning process. as noted in the institute of medicine's seminal report, 'to err is human,' adverse outcomes do not typically result from individual recklessness; rather, they result from faulty systems, processes, or conditions that provide an environment conducive to making a mistake, or failing to prevent one. learning to systematically review errors and translate lessons learned into quality improvement (qi) initiatives is a critical component of practice-based learning and improvement for practitioners at all career levels. objectives: to develop a methodical, self-reflective and nonthreatening approach to incident analysis and translation of lessons learned into qi initiatives. design/method: we used a validated, structured case audit approach, modified from szostek et al: 1) review all documentation relating to the case and identify all health care providers involved; 2) interview stakeholders, including those who directly provided and supported care; 3) use a qi tool to conduct a root-cause analysis; 4) identify a systems issue that contributed to the outcome; and 5) propose systems-level interventions and prioritize initiatives based on effort-yield projections. results: pdsa cycle 1: plan: establish a committee to 1) identify potential cases, 2) triage cases for conference presentation, 3) determine timing and frequency of conferences, 4) develop a training manual, 5) record identified qi initiatives. do: we established a quarterly section-wide meeting to which all members of the pediatric hematology/oncology service are invited, including administrative and nursing leadership. we developed a training manual and structured presentation template. prioritized cases were discussed in advance during multidisciplinary case review sessions, and presented by senior fellows who were instructed to focus discussion on potential opportunities for qi. study: we identified 23 cases, 10 meeting criteria for mmi presentation. qi initiatives identified from this conference resulted in a number of systemic practice changes; however, we encountered challenges to sustaining these changes over time. act: objectives for the next pdsa cycle are to 1) establish a method for tracking the adherence to recommended changes in practice, 2) maximize sustainability by integrating qi initiatives into institutional qi leadership and practice standardization committees. we have successfully implemented an mmi conference that meets 5 out of 6 institute of medicine quality domains: safety, effectiveness, patient-centeredness, timeliness, and efficiency. a standardized, consistent approach to mmi presentations that includes identification of contributing factors and specific qi implications has the potential for improving both provider education and patient care/safety. johns hopkins university, baltimore, maryland, united states background: receiving a cancer diagnosis is a life-changing event for patients and caregivers, although little is known about the experience. while some oncologists receive dedicated training in delivering this bad news, the initial conversation is often with a primary pediatrician, and these providers often feel they do not receive adequate training in the communication of a cancer diagnosis. objectives: our objectives were two-fold: first, to better define the experiences of caregivers/patients when told of a cancer diagnosis, and to query how caregivers/patients believe providers can improve the disclosure of this bad news. secondly, to assess what, if any, training primary pediatricians received in this skill, and to assess how comfortable providers in various settings and stages of training are with communicating cancer diagnoses. design/method: from november 2016-2017, semistructured, in-depth interviews were conducted with pediatric oncology patients and caregivers of patients (n = 6) diagnosed in the past year regarding their experiences receiving the diagnosis at our institution. in addition, pediatric residents (n = 6), outpatient pediatric primary care physicians and pediatric emergency medicine physicians (n = 6) were interviewed regarding their experiences delivering cancer diagnoses. interviews were analyzed following principles of thematic analysis. interviewers with patients and caregivers had two common themes: 1) all emphasized their wish for direct and thorough information; 2) both patients and caregivers emphasized the gratitude they felt for physicians who gave them hope by emphasizing the good prognosis of their child's cancer. lack of training in this area, as well as lack of comfort delivering this news was common will all providers. additionally, providers report variable approaches to giving bad news, including 1) whether to tell caregivers separately or tell the child and parents together, and 2) whether to give favorable prognostic information. additionally, attending physicians also differed significantly in their approaches to teaching residents. while some believed residents should give the news to gain experience, others felt that this is not appropriate if residents are inexperienced. only one resident reported ever receiving feedback on his communication skills in this type of discussion. conclusion: we plan to build on these interviews to develop a national survey of patients, caregivers, and providers to better understand the issues surrounding this discussion. we will use the findings to develop a communication curriculum for pediatric residents, focusing on the discussions that occur in the outpatient setting by primary pediatricians. background: human papilloma virus (hpv), common in both females and males, is responsible for pathologies ranging from benign genital warts to cervical and penile cancer. hpv strains 16 and 18 are responsible for 21,000 malignancies each year in the united states, and one third of them arise in men. pharmaceutical companies have now developed a vaccine that will help prevent the virus-associated malignancies. the cdc initially recommended that females ages 11-26 years receive the vaccine series, then starting in 2011 they expanded the eligibility to males ages 11-21 years. despite being widely available and highly publicized, only 40% of eligible females receive the full vaccine series. objectives: this study aims to assess the knowledge of hpv, the attitudes towards the hpv vaccine, and identify barriers preventing its full utilization. once identified, we aim to overcome the barrier(s) in order to improve vaccination rates in eligible adolescents. we distributed a standardized questionnaire to the parents of eligible female and male patients in our pediatric hematology-oncology clinic. it assessed the parents' knowledge of hpv and the vaccine, their views of the vaccine, and reasons why they may oppose it. results: approximately 80% of parents claim they have been educated about hpv, mostly by their primary care physician. however, 35% did not know what disorders hpv caused; 35% felt the vaccine should not be added to the typical vaccine schedule; 25% of parents do not intend to vaccinate their child. of those that opposed the vaccine, one-third were concerned about potential side effects and nearly 35% feel they do not have enough information. additionally, 25% of parents are not aware that the vaccine is available at their child's doctor and only 30% of parents have discussed the hpv vaccine with their child's doctor. the largest barrier to the utilization of the hpv vaccine that we have identified appears to be lack of educa-tion. as a result, we have begun distributing the cdc's hpv and vaccine patient guide to our patients' families as an intervention. we are currently in the process of re-administering our survey to these families after implementing the intervention to assess its success in increasing both knowledge and utilization of the hpv vaccine. cancer institute, chennai, chennai, tamilnadu, india background: rasburicase is a recombinant urate oxidase enzyme approved for use in tumor lysis syndrome (tls) and it acts by reducing serum uric acid levels. using rasburicase at the recommended dose of 0.2mg/kg/day for 5 days is expensive and it is not known whether this extended schedule is clinically beneficial compared to a single fixed dose of 1.5 mg. the aim of the present study was to evaluate the efficacy of single dose rasburicase 1.5 mg in prevention and management of tls. design/method: rasburicase is available as single use 1.5 mg vial. at our institution a single dose of rasburicase 1.5 mg irrespective of bodyweight has been used in adults and in children a dose of 0.15 mg/kg (maximum 1.5 mg) has been used since 2012 for prevention and management of tls and subsequent doses are given based on biochemical response and clinical condition. we retrospectively analysed the case records of patients who had received rasburicase from january 2012 to january 2017. the study included 186 patients with hematological malignancies who received rasburicase. children accounted for 56.4% (n = 105) patients and males comprised 73% (n = 135). rasburicase was used prophylactically in 59 (31.7%) patients, for laboratory tls in 76 patients (40.8%) and for clinical tls in 51 (27.4%) patients. single fixed dose rasburicase prevented laboratory/clinical tls in 87% of the prophylactic group and prevented clinical tls in 72% of the laboratory tls group. none of the patients in prophylactic and laboratory tls group developed clinical tls. however, majority of the patients with clinical tls required more than one dose rasburicase. single dose of 1.5 mg (1 vial) rasburicase is efficient in preventing and managing laboratory tls and is economically viable in resource constrained settings. nicole wood, lauren amos, nicholas clark, chris klockau, karen lewing, alan gamis children's mercy kansas city, kansas city, missouri, united states background: medication reconciliation for newly diagnosed oncology patients is complicated and cumbersome. these patients are often admitted on no medications, and leave on multiple. chemotherapy and supportive medications are crucial. despite numerous individuals overseeing this process, prescribing errors or omissions still occur. when reviewing the literature, improvement occurs when there is an interprofessional and standardized process to medication reconciliation. objectives: this project's aim was to improve the accuracy of the discharge medication reconciliation process from 74% to 90% from february 2017-august 2017. the process measure was the percentage of patients discharged with an accurate checklist. additional time for staff spent in completing the checklist and avoiding an increased error rate by changing the prescribing process were followed as balancing measures. we created a discharge medication checklist which included a list of required home medications prescribed by the resident, ideally 24 hours prior to discharge. it required fellow or attending review and pharmacy to review the list and educate the family. checklists were collected monthly and reviewed against the electronic medical record (emr) for accuracy. results: six pdsa cycles were completed. there were 2 errors during the data collection time frame. in pdsa cycle 1, a patient received acetaminophen for pain control which is avoided at home. in addition, this patient received diphenhydramine instead of ondansetron, which is preferred as an antiemetic. in pdsa cycle 4, a patient with a pending diagnosis was sent home with acetaminophen. of note, this patient did not have a checklist completed upon discharge. this project provides a novel and important method to standardize the discharge medication reconciliation process in a complex patient population. it clarifies which types of medications these patients need, provides pharmacy teaching to families which was not done previously, and prescribes discharge medications to families sooner. after the first medication reconciliation error, the checklist was revised. no further errors were made following revision, with the exception of one patient without a completed checklist at dis-charge. our accuracy rate increased from 74% at baseline to 92% following implementation. we are in the process of making the checklist electronic and accessible in the emr. in the interim between the end of data collection and implementation into the emr, a leukemia patient was sent home without an epinephrine pen, further demonstrating the importance of this standardized discharge process. for this reason, we have re-instituted the checklist until the electronic version is available. background: survivors of pediatric cancer are at risk of losing pre-existing protective antibodies to vaccine preventable diseases. in a prior study, 35% of children < 7 years lost humoral immunity to measles as a result of chemotherapy induced alterations in immune system. measles in recipients of immunosuppressive chemotherapy has mortality rates up to 50%. because of volitional vaccine refusal, there has been a dramatic increase in measles infection from 63 cases in 2010 to 677 in 2014, including several statewide outbreaks. small pediatric oncology practices frequently share floor/clinic space with the general pediatric patients putting them at risk for measles since virulence starts 48 hours prior to symptoms. there is no standard protocol for revaccinating post-chemotherapy patients. to assess measles risk based on serial humoral immune status in a cohort of pediatric oncology patients receiving intensive chemotherapy design/method: patients < 21 years age with known vaccination status receiving intensive chemotherapy between july 2015-june 2017 at our institution's pediatric oncology practice were included in this prospective study. serial measles igg antibodies were measured at diagnosis, 6 months and 12 months after initiation of chemotherapy using elisa. measles immunity was defined per lab standards. a comparison of pre-chemotherapy and serial post-chemotherapy immunization titers was made for all patients by diagnosis. the study population consisted of 31 children (17 male); 8 patients had all, 7 non-hodgkin lymphoma, 11 sarcoma and 5 other solid tumors. two patients (6.4%), both unvaccinated had non-protective measles antibody levels at s157 of s301 baseline. of the remaining 29 patients, 13.7% patients (2 leukemia, 1 lymphoma and 1 sarcoma) lost protective antibody titers at 6 months after initiation of chemotherapy and 27.5% (4 leukemia, 1 lymphoma and 3 sarcoma) at 12 months after initiation of therapy. 60% of the remaining 21 patients who retained measles antibody titers within protective range at 12 months also demonstrated a steady decline in antibody titers at 6 and 12 months from therapy initiation. the loss of protective measles humoral immunity occurred significantly more often in patients with leukemia compared to other malignancies. oncology patients in our practice undergoing intensive chemotherapy demonstrated progressive waning of protective measles igg titers. our data suggests that it should be standard practice to check all patients for measles humoral immunity prior to starting chemotherapy and at completion. larger studies need to be performed to establish guidelines for revaccinating post-chemotherapy pediatric patients, an intervention that is easily applicable and of low cost. background: the accurate determination of glomerular filtration rate (gfr) is important to screen for acute kidney injury, to dose chemo-therapy, and to identify risk for chronic kidney disease.being correlated with inulin clearance, measured gfr by iohexol plasma disappearance (igfr) is a new gold standard for measurement of gfr in pediatric cohort studies. igfr is based on the clearance of an exogenous marker and is unaffected by endogenous compounds or a patient's muscle mass. we compared igfr with 24-hour urine creatinine clearance (24crcl) and gfr estimating equations using serum creatinine (scr) and serum cystatin c (cystc) in pediatric patients with cancer. we recruited participants who were ages 6 to 16 yrs, continent of urine, and diagnosed with a malignancy in the past 5 years. eligible subjects had stable kidney function for at least two weeks prior to the assessment of igfr. consented subjects had baseline assessments including height, weight and vital signs. blood samples were obtained for serum chemistry, and time zero iohexol. igfr determined by 5ml iohexol solution infused over 1-2 minutes followed by 10ml of sterile saline. blood was drawn at 10, 30, 120 and 300 minutes.at the same time of igfr, the 24crcl was collected. igfr was calculated using a two-compartment model and area under the curve. we compared igfr to published gfr equations (schwartz et al, kidney int 2012). results: ten subjects (7 female/3male) agreed to participate. the distribution of diagnoses for the subjects: all = 6, lymphoma = 1, brain tumors = 2 and hepatocellular carcinoma = 1. six patients were off therapy. the lower gfrs are noted in patients who had malignancies other than leukemia, likely due to the use of cisplatin based therapy. the average igfr was 85ml/min/1.73m^2 whereas 24crcl was 155.8 ml/min/1.73m^2; demonstrating the 24crcl overestimates gfr compared to igfr. comparing igfr to univariate equations using scr, cystc, and the multivariate equation with both, the univariate cystc equation correlated well with igfr; the others overestimated igfr. we found that 24crcl overestimated igfr. the univariate cystc equation better correlated to igfr than equations with scr. the poor performance of scr based methods to assess gfr might be due to decreased muscle mass and inadequate nutritional status. creatinine-based determinations of gfr alone, may not be accurate in this population. further study is needed to determine if igfr should be a standard of care to assess gfr in children with cancer particularly who are receiving nephrotoxic medications and incontinent of urine. background: pediatric oncology patients undergoing chemotherapy through indwelling venous catheters are at increased risk for severe sepsis especially when neutropenic due to chemotherapy. rapid triage and early recognition are essential because delayed initiation of antibiotics and fluids in these patients or delayed transfer to higher level of care after initial stabilization is associated with poor clinical outcome. our pediatric oncology out-patient clinic is designated as an article 28 unit whereby the providers can initiate and give treatment such as intravenous fluid, antibiotics, chemotherapy and blood products. objectives: global aim-optimize management of early sepsis and decreased morbidity, mortality and hospital length of stay in the high risk pediatric oncology patients. smart aim-improve timely management with initiation of fluids and antibiotics and transfer of septic patients to higher levels of care by 10% in 6 months in above patients design/method: multidisciplinary team with physicians and nurses was created. retropective chart review of sepsis patients treated at the clinic from april 2016 to october 2016 was done using an audit sheet to identify the barriers in the delivery of care. three patients were identified and data analyzed prior to intervention; two were analyzed post interventions. a key driver diagram was created by the group to drive intervention. a process map was designed to identify the different steps in the care of these patients to pinpoint areas needing improvement. different timed data points were used starting from time of arrival to clinic, time to antibiotics and fluids and time to transfer to higher level of care. rapid pdsa cycles were done to improve the processes and delivery of care. run charts were created. there was an improvement close to the goal of 10 % for all data points used. pdsa cycles for improvement included conducting frequent mock codes with appropriate feedback real time coaching and process planning with nursing staff. we partnered with pharmacy for close loop communication with clinic staff and we improved communication between physicans at different levels. conclusion: sepsis in neutropenic pediatric oncology patients is deadly and can be reversed with timely management at different levels. given the promising results of the above project, we want re-inforcement of the processes to be a part of the daily practice of first line clinical staff. eventually we will extend the principles learnt in management and triage of sepsis to other outpatient emergencies chemotherapy related anaphylaxis background: chemotherapy-induced nausea and vomiting (cinv) is a common side effect in children receiving antineoplastic chemotherapy. recommended prophylactic antiemetic medications are based on the classification of chemotherapy emetogenicity. however, despite appropriate use of these antiemetic agents, some patients will still experience nausea and/or vomiting. children's oncology group clinical practice guidelines recommend the addition of olanzapine to prophylactic regimens for management of breakthrough cinv. objectives: our pediatric hematology oncology center implemented a quality improvement (qi) project aimed to increase the use of olanzapine in pediatric cancer patients 7 years of age and older receiving moderately or highly emetogenic chemotherapy and experiencing breakthrough cinv over a 3 month period. design/method: this qi project was conducted utilizing plan-do-study-act (pdsa) cycles. for the first pdsa cycle, baseline data was collected through chart review to determine the rate of olanzapine use for breakthrough cinv over a 6 month period from july 2016 to december 2016. breakthrough cinv was defined as use of 2 or more doses of antiemetic agents other than those given for cinv prophylaxis. guidelines for treatment of breakthrough cinv were reviewed with pediatric hematology/oncology attending physicians and fellows. flyers were created that listed chemotherapy regimens considered moderately and highly emetogenic. if a patient experienced breakthrough cinv, a flyer was to be placed in the patient's roadmap binder to signal olanzapine should be added to the next chemotherapy block. data was collected over a 1 month period in september 2017 following this first intervention. the second pdsa cycle consisted of didactic education and training of pediatric oncology nurses as well as pediatric residents regarding the addition of olanzapine for breakthrough cinv. rates of olanzapine use were then collected from october 2017 through november 2017. results: olanzapine use increased from 3.8% at baseline to 58.3% after the first pdsa cycle ( 2 = 14.666, p = 0.000). after the second pdsa cycle, olanzapine use increased another 14.1% to 72.4% ( 2 = 0.777, p = 0.378). the administration of olanzapine was successfully increased by modifying patients' roadmaps after patients experienced breakthrough cinv as well as with education and training of pediatric oncology staff, fellows, residents, and nurses. background: venous thromboembolism (vte) is increasingly affecting children. according to an administrative database study, there was a 70% increase in the incidence of vte among children admitted to free-standing children's hospitals in the united states from 2001 to 2007. risk factors for hospital-acquired vte are well-known and well-studied in adults, with evidence-based preventative measures available. similar guidelines are lacking for children. objectives: there is an ongoing national-initiative to develop and institute methods for screening and preventing hospitalacquired vte in children. in 01/2014, nationwide children's hospital instituted an electronic screening form required for all patients admitted ≥24 hours. patients were scored and riskstratified based on eight risk-categories. a summated score was used to determine the vte risk level, and used to make prophylaxis recommendations for patients ≥18 years; as well as patients ≥14 years who were admitted to an intensive care (icu), surgical, or trauma unit. the purpose of this irb exempt, quality improvement initiative was to retrospectively review our experience with this risk-stratification tool. results: 262 hospital-acquired vte events occurred in 232 unique subjects. median age at vte diagnosis was 2 years. only 69 (26%) vte occurred in children ≥14 years of age. 237 (91%) vte were deep vein thrombosis (dvt), and 16 (6.1%) involved pulmonary embolism. vte was most common in subspecialty units including the pediatric and cardiac icus 87 (33.2%); neonatal icu, 43 (16.4%); and hematologyoncology, 31 (11.8%). 184 (70%) vte were associated with central venous catheters (cvc) and 144 events (55%) were associated with altered mobility. congenital heart disease/heart failure was the most common chronic medical condition associated with vte (69 (26.3%) events); whereas infection and trauma/surgery were the most common acute medical conditions associated with vte (137 (52.3%) and 89 (34%) events, respectively). during 249 (95%) events, subjects scored a summated score ≥3. in summary, in this single institution, prospectively maintained database, cvc remains the most common risk factor for vte, followed by cardiac disease, infection and trauma/surgery. most subjects who developed vte scored high (score ≥ 3) on our screening tool. only a small proportion of vte occurred in patients older than 14 years and thus eligible for thromboprophylaxis. our results indicate that future vte prevention endeavors should include these age groups in addition to exploring more aggressive prophylactic modalities including pharmacological prophylaxis. background: pediatric fellows are required to have active engagement in quality improvement (qi) activities, and yet a national acgme review found most trainees had "limited knowledge of qi methods" and "limited participation in interprofessional qi teams". the twenty fellows in our pediatric hematology/oncology training program identified blood culture utilization as their qi priority. our institution recently introduced a hospital-wide decision algorithm to guide providers regarding when to obtain blood cultures. there is often a low threshold to obtain blood cultures in immunocompromised pediatric oncology patients, but these are often low-yield or result in falsepositives. our fellows spearheaded a project to implement the algorithm in the inpatient pediatric oncology population and improve the proportion of appropriately drawn blood cultures. we investigated how appropriately the algorithm was being utilized on the inpatient pediatric oncology floor prior to and after several educational steps aimed at disseminating the algorithm to members of the care team. our primary endpoint was to quantify the proportion of culture episodes drawn "inappropriately", with a goal of reducing inappropriate episodes to ≤10%. the algorithm was initially introduced to the nursing staff and residents covering the twenty-bed inpatient unit in september 2016. qi project planning took place with upper level fellows in january 2017. fellows and faculty received intensive training on the algorithm in july-august 2017. we then conducted a retrospective chart review of blood culture episodes drawn between august 2016 and november 2017. upper level fellows scored ∼500 culture episodes as to whether the decision to culture and number of cultures drawn were "appropriate" or "inappropriate", and catalogued the indications for culture episodes and if applicable, why the episode was found to be inappropriate. additionally, fellows discussed inappropriate culture episodes with the team onservice, to provide direct feedback on where the algorithm failed. results: between august -december 2016 on average 337 cultures/1000 patient-days were drawn. forty-nine percent of culture episodes were inappropriate. from january -october 2017, following targeted education on the algorithm, the rate of blood cultures drawn decreased to 263 cultures/1000 patient-days. the average proportion of inappropriate culture episodes fell to 16.7%, representing a 66% decrease in inappropriate culture utilization. correct application of a decision algorithm for blood culture utilization can reduce total cultures drawn on an inpatient pediatric oncology unit. fellow-led education of the multi-disciplinary team decreases the rate of inappropriate culture episodes as well as provides active engagement in qi. background: inadequate understanding of sickle cell disease (scd) is common and can affect patients' compliance and therefore their morbidity and mortality, especially after transition to adult care. optimal clinical care for scd includes disease education, which can be difficult given the breadth of possible topics and limited time in clinic. it is unclear how best to provide personalized, efficient education for adolescents with scd. this quality improvement (qi) study aimed to implement a questionnaire-based system to improve patients' knowledge of their scd and documentation of education by the nurse or physician. the study objective was to improve provider documentation and patient knowledge about their scd by identifying patients' gaps in comprehension. by january 2017, the study aimed to increase education documentation from 50% to 75%. by april 2017, the study aimed to increase use of a smart phrase for education documentation from 0% to 50%. by june 2018, the study aimed to increase patients' knowledge about their disease by 20%. design/method: twenty-one scd patients enrolled on an irb approved qi study, with twenty active patients. our comprehensive team generated a questionnaire with knowledgebased questions for two age groups: 12-14 and 15-18 years old. at each comprehensive visit, a questionnaire was distributed, with at least 3-month intervals. the provider scored questionnaires and reviewed two educational topics, with wrong answers taking priority. plan-do-study-act (pdsa) cycles included pdsa#1: patients completed questionnaire. pdsa#2: a smart phrase addressing questionnaire topics was created and shared with providers. pdsa#3: patients received education handouts during clinic education. documentation in clinic notes was the process measure and questionnaire scores was the outcome measure. results: pdsa#1 is complete, pdsa#2 has four patients remaining, and pdsa#3 is ongoing. due to variable visit frequency, there are multiple concurrent cycles. after pdsa#1, free text documentation was completed an average of 61% over the course of 3 months. after pdsa #2 documentation increased to 100% within 3 months and questionnaire scores increased from an average of 59% to 78%. of the questions that patients got wrong on their first visit, they were significantly more likely to improve on retesting if the topic was taught to them than if it was not addressed (72% vs. 33%, p = 0.04). we are currently completing pdsa#3 and collection of post pdsa#3 data. questionnaire-based scd education coupled with standardized smart phrases improves patients' scd knowledge and documentation by providers. further improvement in knowledge is expected with the addition of handouts. background: exposure to suffering can have a profound impact on the wellness of caregivers, often referred to as the "cost of caring". this cost is especially high in pediatric hematology/oncology. repeated exposure to suffering has the potential to negatively impact resilience and increases the risk of burnout, thus impacting quality of care and patient satisfaction. we have developed a peer support team utilizing the critical incident stress management (cism) model. this model has been successfully used in other professions that frequently face traumatic events such as fire fighters, police and emergency medical technicians. the h.o.p.e.s. team (helping our peers endure stress) consists of 18 volunteer multidisciplinary staff members who have received training to provide both group and peer support following any 'critical incident' that may impact one or more staff members. we hypothesize that implementation of the h.o.p.e.s. team will improve staff resilience, decrease overall rates of burnout and improve compassion satisfaction. s161 of s301 design/method: we are using both empiric metrics and anecdotal reports to assess the impact of the h.o.p.e.s. team. prior to the activation of the team, all pediatric hematology/oncology clinical staff members were surveyed using validated tools to assess their levels of resilience, burnout, secondary trauma and compassion satisfaction (proqolv5 and brief resilience scale). they were also asked to rate the number of times they had experienced critical incidents, as well as their perceived level of distress after dealing with traumatic events. after the h.o.p.e.s. team has been functional for 6 months, we will send the same survey to staff members to measure changes, paying special attention to resilience and rates of burnout and compassion satisfaction. results: enthusiasm for development of the team has been high. 18 of 19 people approached to volunteer their time to participate in the multidisciplinary team agreed, including attending physicians, fellows, nurses, nurse practitioners, child life specialists, social workers, clergy and psychologists. all volunteers participated in a 3-day training conducted by an instructor from the international critical incident stress foundation. engagement in the first staff survey has been high, with 91 of 150 responding to date. data collection is ongoing. clinical staff in pediatric hematology/oncology may be particularly vulnerable to burnout and decreased resilience by repeatedly witnessing suffering and trauma. peer support interventions following critical incidents may lead to increased resilience and compassion satisfaction while decreasing rates of burnout. enthusiasm for the development of a peer support team has been high. background: monthly blood transfusions are an indicated therapy for pediatric patients with sickle cell disease with certain complications. maximizing transfusion efficiency in a busy infusion clinic requires: ensuring that appropriate blood units are available in the hospital blood bank; laboratory specimens are obtained from patients in advance; and coordination of clinic appointment and nursing availability. we sought to improve clinic efficiency through identifying ways to better communicate with patients/families regarding upcoming laboratory and transfusion appointments, and to assess the efficacy of implementing a web-based personalized text reminder (pinger.com). we measured the baseline frequency with which transfusion appointments were missed by families, moved to later within the week, or delayed due to late labs. a convenience sample of patients receiving monthly transfusions received a questionnaire about patient/parent preferences for appointment reminders and barriers to keeping appointments. those patients/parents who did not opt-out of an additional text reminder received personalized texts from their care team reminding them of lab and transfusion appointments. rates of missed/moved/delayed appointments were compared between the group receiving the additional text messages and the group only receiving standard, hospitalgenerated appointment reminders (telephone call). results: forty-one families (45 patients) responded to the survey, capturing information on 63% of patients receiving chronic transfusion therapy. thirteen families (32%) declined the additional text reminders. families reported a preference for text reminders (66%), more often than email (49%) or telephone (37%), and 80% of families wanted to receive reminders for both transfusion and laboratory appointments. the majority (43%) of families reported competing work/life priorities as the reason for missed/late appointments. other families noted transportation/travel (29%), fear/illness/pain (21%), and lack of reminders (21%) as the reason for missed appointments. at baseline (twelve weeks), 3.7% of appointments were missed on a weekly basis (range 0-3 of 20 available per week), 10.4% were moved, and 5% of appointments were delayed. during our intervention period (twelve weeks), 7% were missed, 9.2% were moved, and 8.7% were delayed (combined, both groups). there was no difference in missed (7.0% texted vs 7.1% standard), moved (8.0% texted vs 10.0% standard) or delayed (8.0% text vs 9.3% standard) appointments. though families at our center reported a preference for a text-based reminder, personalized text reminders for appointments did not improve clinic efficiency as measured by missed, moved or delayed transfusion appointments. there was no improvement in appointment adherence in the group receiving personalized texts in addition to standard hospital reminders. university of utah, salt lake city, utah, united states background: childhood cancer outcomes have improved significantly, in large part due to multi-institution collaborative clinical trials run by the children's oncology group (cog). approximately half of eligible children with cancer will enroll on a therapeutic trial, but little is known about the factors affecting caregiver decision-making regarding enrollment or how well the required elements of informed consent are conveyed during the consent process. objectives: 1. assess coverage of ten of the required elements of informed consent for cog therapeutic trials. 2. describe factors affecting caregiver decision-making regarding therapeutic trial enrollment. we surveyed families of children who were offered enrollment onto a phase 3 cog therapeutic study for an initial cancer diagnosis in the previous 18 months. fisher's exact or wilcoxon rank-sum tests were utilized to compare demographic and other motivating factors related to enrollment decision-making. results: seventy participants were surveyed. regarding 10 of the basic required elements of informed consent, 96% knew the trial involved research, 99% knew consent was required, 76% knew the enrollment length for the trial, 97% knew they could continue care independent of enrollment, 73% knew who to contact with questions, 71% knew there were options besides enrollment, 83% knew they could withdraw at any time, 93% knew the information was confidential, 34% knew there were risks associated with the trial, and 46% knew there were benefits. of all participants, 84% (n = 59/70) enrolled onto a therapeutic study. among enrollees, 37% (n = 22/59) of the primary caregivers had completed college compared to 18% (n = 2/11) of those not enrolled (p = 0.3). when asked about factors impacting their decision, 69% (n = 41/59) of those enrolled said they felt there were no risks or did not know if there were risks associated with the study compared to 45% (n = 5/11) of those choosing not to enroll (p = 0.17). of those enrolled, 61% (n = 36/59) reported the physician recommendation "somewhat" or "strongly" affected their decision to enroll compared to 0% (n = 0/11) of those not enrolling (p = 0.0001). of those who enrolled, 17% (n = 10/59) reported feeling pressured to enroll while 45% (n = 5/11) of those not enrolled reported pressure (p = 0.05). of enrollees, 10% (n = 6/59) reported they did not have enough time to decide compared to 36% (n = 4/11) of those not enrolled (p = 0.03). failure to convey all 10 required elements of informed consent highlights possible deficiencies in the consent process for cog therapeutic trials. caregivers' perception of being pressured and lack of time to make an informed decision may impact clinical trial enrollment. background: abnormal uterine bleeding (aub) is a frequent adolescent gynecologic complaint. however, limited research exists to guide management, and acute care varies. we sought to improve emergency care for adolescents with aub by developing a clinical effectiveness guideline (ceg) and assessing its impact on quality of care. design/method: a stakeholder engagement group consisting of members from the departments of hematology/oncology, adolescent medicine, general pediatrics, and emergency medicine designed a ceg algorithm for emergency aub management. pediatric residents received ceg training and their knowledge and attitudes were assessed using pre and post intervention surveys. icd-9 and 10 codes identified electronic health record data for patients presenting to the pediatric emergency department (ed) for aub 6 months before and after ceg implementation. pre-pubertal patients and those with vaginal bleeding from trauma were excluded. a weighted, 20-point scoring system consisting of prioritized aspects of history, laboratory studies and management was developed to quantify the quality of care provided. t-test, chi square test, wilcoxon rank sum test, and a run chart were used for analysis. of the 91 patients identified, 62 met inclusion criteria. there were 37% of patients currently using some form of contraception, while 12.9% had bleeding related to a current or recent pregnancy. median aub quality care scores were 14 pre-and 16 post-intervention (p = 0.064). run chart data showed no shifts or trends (overall median score, 14-points). both pre and post-implementation, points were deducted most frequently for not assessing personal/family clotting disorder history and inappropriate use/dosing of oral contraceptives. we successfully designed and implemented a ceg and educational intervention for aub management in a pediatric ed. these data suggest our ceg may be an effective tool to improve emergency aub care for adolescents, though additional cycles are needed. background: high-dose methotrexate (hd-mtx) is a common chemotherapy administered inpatient at most centers. its administration is particularly susceptible to error due to the need for frequent drug levels with resulting changes in supportive care. errors can prolong patient stay and cause patient harm. objectives: global aim-to reduce the length of stay (los) of hd-mtx admissions. smart aims-to increase the percentage of patients whose pre-hydration fluids are started by 10am from 0% to 20% by 1/31/18, and to increase the percentage of patients who receive hd-mtx by 5pm from 43% to 100% by 6/30/18. we used rapid process improvement methods to target earlier methotrexate administration. a key driver of prolonged los was hypothesized to be drug levels returning overnight rather than in the day time due to delayed hd-mtx start. changes implemented have included scheduling hd-mtx patients as the first patients of the day for their exam in clinic and scheduling labs to pass for hd-mtx on the day prior to admission. there are ongoing pdsa cycles to change the location of pre-hydration start from the inpatient room to the clinic exam room in order to meet hd-mtx administration time goals. we are piloting two different education materials to improve patient experience. one explains hd-mtx levels in a red/yellow/green stoplight format and the other reminds patients how to prepare for the admission. other interventions regarding how we test urine ph and safety checks in the ordering process for history of delayed clearance are in the planning stage. the project is ongoing, but as of 12/12/17, we start methotrexate by 5pm 50% of the time which is improved from a baseline of 43%. when the project was started, pre-hydration was never started before 10am. now, fluids are started by 10am 40% of the time. pdsa cycles are ongoing and we have yet to sustain reductions in los, but some months have shown decreased los by as much as 19 hours from baseline measurements. rapid cycle improvement can be utilized to decrease los hd-mtx admissions. this has important financial implications as well as the potential to reduce secondary harm from unnecessary time in the hospital. pediatric cancer centers should schedule hd-mtx admissions first thing in the morning so that data regarding kidney injury and drug clearance can be interpreted by the day team and children are not cleared for discharge in the middle of the night. background: education and training for interdisciplinary pediatric oncology providers requires training in principles of palliative and end-of-life (eol) care. the experiences of bereaved parents can inform and enhance palliative care educational curricula in uniquely powerful and valuable ways. the objective of this study is to present an innovative palliative care educational program for oncology providers facilitated by trained bereaved parents who serve as volunteer educators in local and national palliative care educational forums and to describe how incorporation of bereaved parents in these educational forums affects participant comfort with communication and management of children at the eol. design/method: survey tools were adapted to determine how bereaved parent educators affected participant experiences in 3 different educational forums: institutional seminars on pediatric palliative and eol care, role-play based communication training sessions, and an international symposium on pediatric palliative oncology. pre-and post-session surveys with incorporation of retrospective pre-program assessment item to control for response shift were used in the evaluation of institutional seminars and communication training sessions. results from feedback surveys sent to all attendees were used to appraise the participants experience in the international oncology symposium. results: involvement of trained parent educators across diverse, interdisciplinary educational forums improved attendee comfort in communicating with, and caring for, patients and families with serious illness. importantly, parent educators also derive benefit from educational with interdisciplinary clinicians. integration of bereaved parents into palliative and eol care education is an innovative and effective model that benefits both interdisciplinary clinicians and bereaved parents. background: poorly controlled chemotherapy-induced nausea and vomiting (cinv) significantly impairs patients' quality of life and contributes to ongoing medical costs through increased length of stay in the hospital or readmissions and outpatient visits for control of nausea, vomiting or dehydration. lack of adherence to national evidenced-based guidelines that dictate antiemetic prescribing for variably emetogenic chemotherapy leaves patients vulnerable to increased cinv and its ensuing complications. objectives: to review our institution's antiemetic prescribing practices and their consistency with the antiemesis guidelines from the national comprehensive cancer network (nccn) and children's oncology group (cog)-endorsed supportive care guidelines and to further develop tools to increase adherence to these national-based guidelines to improve control of cinv. we performed a retrospective chart review of inpatient chemotherapy encounters. we evaluated emetogenicty of chemotherapy (high, medium, low), initial antiemetic regimen ordered, number of as needed medications required and adherence to national evidenced based guidelines tailored to each level of emetogenicity in the prescription of antiemetics. results: fifty-five total inpatient chemotherapy encounters were reviewed over 8 months. eighteen of these encounters were considered to have been highly emetogenic chemotherapy (hec) with the remaining 37 of these considered to be moderately emetogenic. only 9 out of 18 hec encounters completely included all guideline-recommended agents. there was a demonstrable lack of consistency across providers with dosing of aprepitant and most as needed medications. there was significant variation in order of first, second and third line anti-emetics ordered -with lorazepam and promethazine being used most frequently. with an aim of improving antiemetic prescribing practices for our patients, we are currently rebuilding chemotherapy treatment plans in our electronic medical record to incorporate antiemetic drug order sets that follow evidenced-based guidelines for variably emetogenic chemotherapy. this will be used in conjunction with an education initiative about best practices in supportive care for all prescribers of antiemetics. review of our department's recent inpatient chemotherapy encounters show we are falling short in following nationally recommended standards for appropriate antiemetic coverage during chemotherapy. identification of these deficiencies allows for implementation of quality initiatives to improve prescriber adherence to evidenced-based guidelines for better control of cinv. background: there are currently no consensus guidelines for the management of pediatric oncology patients presenting with fever without neutropenia. historically, these patients had been treated similarly to neutropenic patients with empiric antibiotics. while there has been a shift towards reducing unnecessary empiric treatment, there has been limited research into the outcomes associated with withholding empiric iv antibiotics in this patient population. we assessed the safety and efficacy of our institution's current protocol of observing well-appearing patients who present with fever without neutropenia and compared the outcomes of the patients who did and did not receive empiric iv antibiotics. design/method: this was a prospective, single-institution cohort study. patients were included if they were currently undergoing chemotherapy for an oncologic diagnosis and presented initially as an outpatient with fever and nonneutropenia (defined as anc ≥ 500 cells/mm3). for each episode we recorded lab and blood culture results, signs and symptoms of initial presentation, and clinical outcomes, including antibiotic administration and hospital admission. results: a total of 242 episodes of well-appearing patients with fever without neutropenia were identified. compliance with the institutional protocol was high; 81.8% of patients were observed without receiving empiric iv antibiotics. the majority of patients were discharged home and there were no serious complications or infectious deaths. the incidence of positive blood cultures was low (3.7% including several likely contaminants), despite the presence of central venous catheters in the majority (84.7%) of patients. there were no significant differences in age, oncologic diagnosis, central s165 of s301 line access, anc value, or incidence of bacteremia between patients who did and did not receive empiric iv antibiotics. patients who were admitted to the hospital were significantly more likely to have received iv antibiotics (p <0.001) despite documentation of a reassuring exam. however, admitted patients who initially received iv antibiotics were just as likely to discharge within 48 hours compared to patients who were observed. we propose that empiric iv antibiotic administration in febrile, non-neutropenic, otherwise well-appearing patients is unnecessary. our study demonstrated no adverse consequences of observation and no significant differences in clinical outcomes between patients who did and did not receive iv antibiotics aside from rate of hospitalization. this supports the practice of observation without empiric antibiotics for such patients. background: children with hepatoblastoma (hb) undergo repetitive computed tomography (ct) scans to determine response to treatment and assess for relapse. this imaging exposes children to radiation, anesthesia, and imposes financial and emotional burden. objectives: review our institutional experience to determine if afp measurements are sufficient to assess response to treatment and detect relapse. we conducted a retrospective chart review of all patients diagnosed with hb at our institution between 1978-2017. data collected included serum afp, total number and type of imaging studies during and post treatment, and how relapse or progressive disease was detected. results: thirty-one patients were diagnosed with afp positive hb. during therapy, 173 ct scans were performed: 118 to assess for response to therapy or surgical planning (average 4 scans/patient) and 55 due to concern for progression with rising afp. off therapy, 213 surveillance ct scans were performed (average of 5.3 scans/patient) and 72 (33%) included the chest in patients with no lung metastasis at diagnosis. relapsed patients averaged 12.5 surveillance scans, 6.5 of which were done before relapse was noted on imaging. there were no cases of radiographic evidence of relapse without a prior increase in afp. during treatment, response to therapy based on imaging correlated with a decline in afp in all patients, arguing that repetitive scans are not needed in this setting unless required for surgical planning. only 3 of 213 scans performed during off therapy surveillance displayed evidence of relapse, all of which were preceded by rise in afp. our study represents the largest cohort of hb patients. prior studies suggest similar results, but included fewer patients, lower stage of disease and less than 10 years of surveillance monitoring. at our institution, the cost of a ct c/a/p is $15,169 with reimbursement varying from 30-50%. in comparison, the cost of an afp measurement is $101.50. many scans also require anesthesia and result in emotional toil for families concerned about this procedure as well as the results. thus, afp demonstrates greater sensitivity, with significant cost savings and decreased emotional burden, and should be used for monitoring both during and off therapy, replacing routine serial imaging. background: we observed that our practice of drawing daily blood cultures in hospitalized patients with fever and neutropenia was wasteful; it resulted in excessive negative cultures that did not add to patient care. the smart aim of this quality improvement project was to reduce the number of negative blood cultures drawn on hospitalized patients with fever and neutropenia by 25% in 6 months. design/method: after reviewing published evidence suggesting drawing daily blood cultures in febrile neutropenic patients was unnecessary, a new blood culture guideline was implemented: cultures were drawn at presentation for fever with neutropenia and, if negative at 24 hours, repeat cultures were not drawn except for clinical change, new fever after being afebrile >24 hours, or antimicrobials were being changed/broadened. to impact key drivers, we educated staff and changed blood culture order sets to require providers to select a reason for ordering the culture and to eliminate a nursing order to draw daily cultures with fever. we compared the number of blood cultures drawn per 1000 central linedays (/1000-cld) and the proportion of positive versus negative cultures pre-guideline (july 2015-may 2016) and postguideline (june 2016-december 2016). we calculated the cost savings from reducing cultures. to assess patient safety, potential septic events without a corresponding positive blood culture were reviewed. data were analyzed by service (oncology and stem cell transplant). a chi-square test was used to compare rates. in stem cell transplant patients, pre vs. postguideline, there were 492 vs. 258 total cultures drawn/1000-cld; 25 vs. 21 positive (16% decrease, p = 0.404) and 467 vs. 237 negative cultures/1000-cld (51% decrease, p<0.0000001). in oncology patients, pre vs. post-guideline, there were 266 vs. 181 total cultures drawn/1000-cld; 17 vs. 13 positive (24% decrease, p = 0.024) and 249 vs. 168 negative cultures/1000-cld (32% decrease, p<0.0000001). the decreased positive culture rate among oncology patients may be due to decreased culture contaminants and/or the effect of a concurrent initiative to decrease clabsi in that group. there were 2 safety concerns; however, chart review concluded that the guideline did not lead to missed infections in these patients. for the first 6 months of the guideline, the total cost savings in blood cultures was $31,454.31. the implementation of our new blood culture guideline successfully led to a substantial reduction in the collection of negative cultures and a cost savings without compromising the detection of bacteremia in hospitalized pediatric patients with fever and neutropenia. background: there are various evidence-based guidelines for treatment of adult cancers, such as the nccn guidelines. previously, care was standardized for most new diagnosis pediatric cancer patients through enrollment on a clinical trial. with decreasing clinical trial availability and enrollment and few, if any, evidence-based guidelines for pediatric cancer, care standardization is challenging for pediatric cancers. objectives: to assess consistency of care, as determined by plan of treatment by diagnosis, for pediatric patients receiving chemotherapy for newly diagnosed cancer at a single center. design/method: patients with a new cancer diagnosis at a large, tertiary care pediatric oncology center in calendar year 2016 were identified through reports from the chemotherapy order entry (coe) system. reports included diagnosis (recorded through standardized options) and the plan of treatment. chart review was used to exclude patients who started treatment elsewhere and patients being treated for relapse, to clarify diagnosis if the standardized options in coe were unclear, and to clarify treatment plan if needed. data was entered and analyzed in a redcap database. specific diagnoses were clustered into higher level disease groups and the distribution of treatment plans for patients within each was determined. this project was deemed exempt from irb approval for human subject research as a qualifying quality improvement project. of the 324 patients with a first chemotherapy order in 2016, 142 were excluded due to one or more reasons: stem cell transplant (62), transfer of care (54), relapse (25), and other (9). an additional 61 patients were excluded because <5 patients/year/diagnosis. there was no cns tumor disease group with >5 patients. thus, 121 patients with hematologic malignancies or non-cns solid tumors are the focus of this analysis. for patients with intermediate risk rhabdomyosarcoma, the plan of treatment was the standard arm of a cog protocol, arst0531 for 3 patients and arst 1431 for 1 subsequent patient after protocol activation. for all other diseases including lymphoblastic leukemia/lymphoma (excluding infants), classical hodgkin lymphoma, aml (excluding trisomy 21 and apml), stage iii/iv burkitt lymphoma/diffuse large b-cell lymphoma, posttransplant lymphoproliferative disease, wilms tumor, rhabdomyosarcoma, ewings sarcoma, osteosarcoma, neuroblastoma, and retinoblastoma, only one treatment plan per risk category was used. conclusion: this analysis demonstrates highly consistent chemotherapy treatment at a single center for patients with hematologic malignancies and non-cns solid tumors. next steps include exploring strategies to group diagnoses for cns tumors and assessing the quality of evidence supporting the treatments given. background: rapid initiation of empiric antibiotics in patients with fever and neutropenia has been shown to reduce morbidity and mortality. current practice guidelines call for the initiation of antibiotics in these patients within sixty minutes and time-to-antibiotic (tta) has been suggested as a quality-of-care measure. many institutions, including our own, face barriers to meeting this time limit. objectives: utilizing a quality improvement model, determine barriers and implement an intervention to reduce the time-to-antibiotics for pediatric febrile patients with suspected neutropenia who present to the emergency department (ed) at our institution. we have identified and implemented an intervention utilizing the plan-do-study-act model for quality improvement. a twelve-month retrospective review was conducted to evaluate the efficacy of the current practice algorithm at our large, academic tertiary-care hospital. subjects identified were pediatric oncology patients undergoing active chemotherapy who presented to the ed with febrile neutropenia. we identified two specific barriers, triage level assignments and delay in ordering antibiotics. to address these barriers, we have created a wallet sized "fever card" that patients were instructed to show upon arrive to the ed. in collaboration with the ed staff, efforts were also made to educate all pediatric staff on the use of the fever card. post-intervention data collection is currently underway and pre-and post-intervention antibiotic delivery times will be compared. the pre-intervention cohort consisted of thirty-three encounters with a mean time-to-antibiotic delivery of 135 minutes, or seventy-five minutes greater than the accepted standard of care. only one patient received antibiotics within sixty minutes of arrival. post-intervention data collection is currently underway. since identifying two barriers to meeting the standard of care at our institution, we have implemented a quality improvement measure that empowers patient families to direct appropriate triage in the ed as well as simplifying the treatment protocol for ed providers. we expect to identify an improvement in time-to-antibiotics from the pre-intervention to the post-intervention period. background: sickle cell disease (scd) is a genetic disorder in which sickle hemoglobin (hbs) triggers multiple downstream effects, including red cell sickling, hemolysis, vaso-occlusion, and inflammation. scd, a lifelong disease initiated at birth with injury that accumulates over time, causes significant end-organ damage and clinical complications that are undertreated and associated with early death. homozygous mutation (hbss) causes the severe form of scd. individuals with scd are at increased risk of infection, stroke, and retinopathy. clinical guidelines for pediatric patients with scd recommend prophylactic penicillin use (ages 2-5), annual screening for stroke with transcranial doppler (tcd) imaging (ages 2-16), and annual ophthalmology exams to assess for retinopathy (ages ≥10). there are limited real-world data on implementation of these nhlbi-based recommendations. objectives: to describe utilization of penicillin, tcd screening, and ophthalmology care in children with hbss disease. medicaid administrative claims databases were used to identify us patients aged 2-16 years at first indication of hbss recorded in each calendar year from 2009 to 2014. patients were required to have medical and pharmacy benefits for the calendar year in which they were identified and for 12 months prior to their first recorded hbss indication. prior year utilization of penicillin, tcds, and ophthalmologist visits was measured for each annual cohort. annual cohorts included 347-438 commercial (mean age 9.5 years, 52% female) and 1024-1557 medicaid (mean age 8.3 years, 48% female) patients with hbss disease. fewer than half of all patients had received a tcd scan in the previous year, with similar rates seen across all age groups for both payers. ophthalmologist visits increased as patients aged, and while patients aged 12-16 years had the highest proportion with an ophthalmologist visit in both payer populations, the overall implementation remained low. in contrast to the low use of tcd and ophthalmology visits, penicillin use was highest in the 1-5 year age group: >80% use in any given year for both payers. conclusion: although our data demonstrated high penicillin use in the 1-5 year age group, consistent with guidelines there is an opportunity to improve implementation of other guidelines-based recommended screening. for example, tcd screening can identify children at risk of scd-related stroke in order to initiate preventive therapies. further research to understand potential barriers to proper screening and to evaluate strategies to improve awareness, adherence, and implementation of recommended screenings in children with scd is warranted. supported by global blood therapeutics. background: childhood cancer therapy has improved where there are many long-term survivors. while psychosocial difficulties in pediatric cancer survivors are recognized, the prevalence of these problems at initial survivorship presentation is unclear. objectives: to examine the prevalence of overall internalizing symptoms (e.g., depression/anxiety) in pediatric cancer survivors presenting to a survivorship clinic and to examine how this is mitigated by receiving psychological services and by evidence of parental depression/anxiety. design/method: pediatric cancer survivors attending their first visit at the reach for survivorship clinic at vanderbilt (ages 3-18) were included. survivors' parents (93% female) completed the child behavior checklist (cbcl), beck depression inventory-ii, and beck anxiety inventory. survivors >12 years completed a self-report. the wilcoxon rank-sum and pearson's 2 test were used for univariate analyses. the effect size and 95% confidence intervals (ci) estimated from the multivariable linear regressions were reported. results: 142 childhood cancer survivors a median of 12 years old and 3.3 years off therapy were included. thirty one survivors (22%) showed at least borderline clinical internalizing problems (t score >60) on the cbcl, but only 8 of these patients (26%) reported receiving psychological services. nine other survivors with normal t score ≤60 also reported receiving psychological services. parental depressive and anxiety symptoms were correlated to the parental report of survivor overall internalizing symptoms (spearman = 0.415, p = <0.001 and = 0.476, p = <0.001 respectively), however they were not correlated to survivor selfreports. furthermore, parents with mild to severe depressive symptoms or mild to severe anxiety symptoms were more likely to rate their child as having higher overall internalizing symptoms (p = 0.001; p = 0.008, respectively). multivariable linear regression showed that when adjusted for age, gender, cancer diagnosis and time off treatment, reported utilization of psychological services ( = 8.58, 95% ci [3.54, 13.62],p = 0.001), and parent depressive symptoms ( = 0.43, [.22, .65 ],p<0.001) were significantly associated with child overall internalizing symptoms. in an otherwise identical alternate model substituting parental anxiety for parental depression, parental anxiety was also a significant risk factor ( = 0.70, [.38, 1.03], p<0.001). alternatively, parent anxiety/depressive symptoms were not significantly associated with child self-report of internalizing symptoms. childhood cancer survivors have an elevated prevalence of experiencing internalizing symptoms but seldom report receiving psychological services. childhood cancer survivors' parents with anxious/depressed symptoms are more likely to rate their children as having more internalizing problems, compared to patient self-reports. ongoing longitudinal analyses will help clarify the best timing for potential interventions. background: life expectancy for adults with sickle cell disease (scd) has remained unchanged over the past 30 years despite improvements in pediatric scd survival. at greatest risk are the adolescents and young adults (ayas) transitioning from pediatric to adult care. allen county ranks 3rd in scd incidence among the 92 counties in indiana, and has 2 board certified pediatric hematologist-oncologists. when children "age out" of the pediatric system, there are few providers knowledgeable about managing adults with scd in the region. a novel partnership between hematologists and the family medicine residency program in allen county was initiated to educate family medicine residents (fps) about scd, hydroxyurea (hu), and management of scd-related complications with the goal to increase the number of knowledgeable providers to care for adults with scd. to determine the effectiveness of online learning modules in educating fps about hu, best practices for aya scd care and transition. three online learning modules about scd (comprehensive care of ayas with scd, hu, best practices in aya transition) were developed and cme-accredited. electronic pre-and post-tests were distributed to 32 fps with five questions for each module covering: contraception; screening tests; hu indications, dosing and monitoring; developmental milestones and scd knowledge assessments. the st vincent irb reviewed the protocol and granted a waiver of consent. results: twenty-six fps (81%) completed the pre-and posttests. over two-thirds correctly identified the clinical benefits of hu on both assessments. knowledge about the rationale for hu therapy increased after the completion of the hu module (30% correct on pre-test vs. 62% on post-test, p = 0.009). the proportion of correct responses increased for all comprehensive aya scd care post-test questions, but only the leading cause of death and the priapism-related questions reached statistical significance (15% vs. 35%, p = 0.048; 0% vs. 23%, p = 0.003, respectively). the proportion of correct responses for 2 of the transition-focused questions was unchanged (89% for both), while the proportion of correct post-test responses on the self-care assessment question significantly increased (0% vs. 12%, p = 0.04). after module completion, fps were able to correctly identify common scd complications and why hu is an effective treatment for individuals with scd. the best practices of transition clinic module may need modification to improve physician understanding of the intricacies in establishing and maintaining a scd transition clinic. overall, online training is effective at educating fps and could be used to increase the number of providers knowledgeable about scd care. background: survival rates for pediatric hodgkin lymphoma (hl) exceed 95% with contemporary therapy. studies of pediatric hl survivors treated in the 1970s-1990s have shown increased risk for treatment-related chronic health conditions. risk-adapted therapy, including tailored radiotherapy, has been developed to reduce long-term morbidity while maintaining excellent survival. little is known about chronic conditions associated with contemporary therapy presenting during the first 5 years from therapy completion (early outcomes). objectives: to analyze survival and early outcomes of pediatric hl patients treated with contemporary therapy. we conducted a retrospective review of hl patients diagnosed <21 years of age at our institution from 2010-2014. three-year overall (os) and event-free (efs) survival were calculated with kaplan meier statistics using sas 9.4. results of standardized screening for targeted toxicities that developed between 2 -5 years from therapy completion were identified and graded per ctcae criteria. censoring occurred at date of death, 5 years from therapy completion, or december 31, 2016. data from the last collection point were used for prevalence calculations in cases with multiple evaluations. we identified 83 patients (51% male; 43% non-hispanic white; mean age at diagnosis 13.6 ± 3.7 years) with a median time since therapy completion of 3.3 years (range 0.1-5.0). initial treatment included: 56 (67%) chemotherapy only and 27 (32%) multimodality treatment. all patients received anthracyclines (median dose 200mg/m2) and 96% received alkylating agents (median cyclophosphamide equivalent dose [ced] 3600mg/m2). the 3-year os was 99% with an efs of 90% (90% chemotherapy only, 91% multimodality treatment; p = 0.76). patients with relapsed/refractory disease received salvage treatment including chemotherapy only (n = 1), multimodality therapy (n = 1), or multimodality treatment including stem cell transplant (autologous n = 4; autologous+allogeneic n = 1). no patients developed thyroid dysfunction, cardiac dysfunction, subsequent neoplasm, or male gonadal dysfunction during the study period. pulmonary dysfunction was limited to ctcae grade 1. anti-mullerian hormone (amh) below the normal range was found in 10/11 pubertal females who received ced ≥7000mg/m2 compared to 0/12 females who received ced <7000mg/m2. two of the females with low amh also had follicle stimulating hormone >30iu/ml. this study is the first to evaluate early outcomes in pediatric hl survivors. the results indicate contemporary chemotherapy and a lower rate of radiotherapy utilization lead to excellent 3-year survival rates with minimal early toxicities. females exposed to ced ≥7000mg/m2 are at increased risk for gonadal dysfunction and should be prioritized for fertility preservation approaches prior to initiation of cancer therapy. background: cancer is one of the leading disease-related causes of death among individuals aged <20 years in the united states. recent evaluations of national trends of pediatric cancer used data from before 2010, or covered ≤28% of the us population. objectives: this study describes pediatric cancer incidence rates and trends by using the most recent and comprehensive cancer registry data available in the us. design/method: data from us cancer statistics were used to evaluate cancer incidence rates and trends among individuals aged <20 years during 2001-2014. data were from 48 states and covered 98% of the us population. we assessed trends by calculating average annual percent change (aapc) in rates using joinpoint regression. rates and trends were stratified by sex, age, race/ethnicity, us census region, county-based economic status, and county-based rural/urban classification, and cancer type, as grouped by the international classification of childhood cancer (iccc). we identified 196,200 cases of pediatric cancer during 2001-2014. the overall cancer incidence rate was 173.0 per 1 million; incidence rates were highest for leukemia (45.6), brain tumors (30.8), and lymphoma (26.0). rates were highest among males, aged 0-4 years, non-hispanic whites, the northeast us census region, the top 25% of counties by economic status, and metropolitan counties. the overall pediatric cancer incidence rate increased (aapc = 0.7, 95% ci, 0.5-0.8) during 2001-2014 and contained no joinpoints. rates increased in each stratum of sex, age, race/ethnicity (except non-hispanic american indian/alaska native), region, economic status, and rural/urban classification. rates were stable for most individual cancer types, but increased for non-hodgkin lymphomas except burkitt lymphoma (iccc group ii(b), aapc = 1.2, 95% ci, 0.4-2.0), central nervous system neoplasms (group iii, aapc = 0.4, 95% ci, 0.1-0.8), renal tumors (group vi, aapc = 0.6, 95% ci, 0.1-1.1), hepatic tumors (group vii, aapc = 2.5, 95% ci, 1.0-4.0), and thyroid carcinomas (group xi(b), aapc = 4.8, 95% ci, 4.2-5.5). rates of malignant melanoma decreased (group xi(d), aapc = -2.6, 95% ci, -4.7--0.4). this study documents increased rates of pediatric cancer during 2001-2014, in each of the demographic variables examined. increased overall rates of hepatic cancer and decreased rates of melanoma are novel findings using data since 2010. next steps in addressing changing rates could include investigation of diagnostic and reporting standards, host biologic factors, environmental exposures, or potential interventions for reducing cancer risk. increasing pediatric cancer incidence rates may necessitate changes related to treatment and survivorship care capacity. background: while childhood cancer treatment modalities have improved, the delayed effects of cancer treatment continue to compromise the quality of life in survivors. metabolic syndrome (ms) is diagnosed based on the presence of three of the following findings -obesity, dyslipidemia, hypertension and insulin resistance per the world health organization (who) criteria. the increased risk of ms among childhood cancer survivors was first reported in the 1990's and is known to increase the incidence of cardiovascular disease in these individuals. objectives: assess the frequency of ms in childhood cancer survivors at our institution. . we conducted a retrospective chart review on pediatric cancer survivors, 4 -18 years of age, who had been treated at sri ramachandra medical institute and research foundation between august 2015 and august 2017. patients who received at least one year of treatment with s171 of s301 chemotherapy and/or radiation and surgery were included. medical history, family history of diabetes, cardiovascular diseases, and hypercholesterolemia, tanner staging, weight for height (<5y per who criteria), bmi (>5y per indian academy of pediatrics iap), blood pressure (nhlbi criteria), fasting blood sugar levels and lipid profile were obtained from the charts. statistical analysis of the data was done using ibm spss statistical software (version 22). results: 97 patients were studied, 63.9% were male. 22.68% were under 5 years of age, 38.14% between 6-10 years and 39.18% above 11 years. leukemia survivors comprised 39.18% of the sample and non-leukemic's were 60.82%. 51.5% were treated with chemotherapy alone, 19.5% with radiotherapy and chemotherapy, and 28.8% underwent surgery with radiotherapy and chemotherapy. hypertension was found in 19.5% of the study group, dyslipidemia in 68%, impaired fasting blood glucose in 4.12% and 36.08 % were found to be obese. 10% of the study group was diagnosed with ms based on who criteria. conclusion: 10 % of our study population was found to have ms per who criteria. individual metabolic complications were detected in 68% of the population. acute lymphoblastic leukemia (all) survivors appeared to be at high risk in our population. ms has been known to increase cardiovascular complications in cancer survivors. a multidisciplinary team approach to management of these patients is important to closely monitor and manage the long-term complications related to ms such as type 2 diabetes and atherosclerosis. such an approach is essential to decrease long term morbidity and mortality from ms in this vulnerable population. background: the 5-year survival rate for childhood cancer exceeds 80%. however, up to 38% of these children require admission to the pediatric intensive care unit (picu) within three years of diagnosis. these children account for approximately 10% of all picu deaths, with mortality being higher for those post-hematopoietic stem cell transplant (hsct). national guidelines recommend that providers share informa-tion regarding prognosis and treatment options within the first 48 hours of icu admission. these prognostic goals of care conversations (pgocc) are critical to the care of children with malignancies, a subpopulation at risk for increased mortality. to determine the frequency of pgocc as well as describe differences in patient characteristics and critical care therapies by pgocc status. design/method: a retrospective cohort study was conducted using the university of michigan virtual picu system database. picu admissions lasting longer than 24 hours for patients ages 0 to 25 years between july 1, 2011 and june 30, 2016 with an oncologic diagnosis and/or hsct were identified. data on pgocc, patient demographics, diagnoses, picu interventions, and outcomes were recorded and compared between children with pgocc and those without using chi square test for categorical variables and kruskal-wallis test for continuous data. of 128 picu admissions, 53% were male; the mean age was 10.5 years. the leading diagnoses were acute lymphoblastic leukemia (46%), acute myeloid leukemia (14%), lymphoma (14%), neuroblastoma (5%), and brain tumors (5%), and 43% of patients were post-hsct. pgocc was documented in 35 (27%) patients. in comparison with patients who did not have a pgocc, children with a pgocc were more likely to be readmitted to the picu (45% vs. 15%, p <0.01) and more likely to have had relapse of disease (41% vs. 18%, p<0.01). patients with a pgocc had higher severity of illness scores (p = 0.02), higher use of non-invasive (22.9% vs. 8.6%, p = 0.04) and invasive conventional ventilation (68.6% vs. 23.7%, p<0.01), and high frequency ventilation (25.7% vs. 4.3%, p <0.01). also, patients with pgocc were more likely to receive continuous renal replacement therapy (37.1% vs. 5.4%, p<0.01), arterial catheterization (54.3% vs. 23.7%, p<0.01), and cardiopulmonary resuscitation (22.9% vs.1.1%, p<0.01). in only 1 in 3 critically ill children with hematologic-oncologic disease is pgocc held. children with pgocc were sicker and received more critical care interventions. future research is needed to evaluate the content of pgocc. background: central nervous system (cns) tumors and autism spectrum disorder (asd) represent significant disease cohorts in the pediatric population. asd diagnoses in children have a prevalence of 2%, 1 in every 88 children in the united states. additionally, more than 4,000 cns tumors are reported in children age 0 to 19 years in the united states with brain tumors being the most common solid tumor and the leading cause of death among all childhood cancers. the genetic etiology of autism and cns tumors is complex. specific gene alterations present in certain cancers have similarly been described and suspected to play a role in asd subtypes. targeted therapy panels, like foundation one (fo), have been beneficial in guiding treatment for some cancers based on distinct gene alterations. given the genetic overlap, the potential for therapeutic benefit and crossover from such actionable gene target panels merit further exploration in asd and cns tumors. we aim to identify and describe genetic alterations with known actionable targets in cancer therapy from fo as potential diagnostic, therapeutic and research targets for neurodevelopmental diseases. we plan to discuss the common genetic alterations between our cancers and neurodevelopmental diseases described in the literature. fo data was extracted and compared to the literature. each reported gene alteration from fo plus the keywords "autism", "psych" were used on pubmed to search for a suspected association if any with a neurodevelopmental disorder. results: twenty-one patients representing a cohort of six unique (astrocytoma-five, ependymoma-six, gbm-four, glioma-three, nerve sheath tumor-one, etmr-two) cns tumors were investigated. fo produced eighty total with sixty unique gene alterations. thirty-one (52%) of these yielded at least one published, suspected association to a neurodevelopmental disorder. the most common gene alterations were tp53-four, cdkn2a/b-five and braf-four. the main functional categories were cellular: proliferation, structure, differentiation and degradation; chromatin modeling; histone transcriptional modification; dna methylation and repair; strna; and neural signaling. sixty unique gene alterations were found in our cns tumor set using foundation one. thirty-one (52%) of these discrete alterations paired with at least one description in the literature as having been similarly altered in an asd subtype. many of these alterations have actionable targeted therapies presented through foundation one for our cns tumors and may be a relevant guide in the future of targeted therapy and research in asd subtypes. monoclonal antibody therapy usage is associated with significantly improved survival in b-cell nhl aya patients. although the usage has increased in the aya population from 2006 to 2013, the magnitude of the increase is low. factors that affect the use of mab include race and insurance s173 of s301 type. further research is warranted to identify why privately insured patients are less likely to receive these drugs. background: prevention of chemotherapy-induced nausea and vomiting (cinv) remains a challenge despite advances in pharmacotherapy and the development of cinv clinical practice guidelines by the pediatric oncology group of ontario (pogo) that have been endorsed by the children's oncology group. achieving control of cinv in pediatrics further is complicated by the difficulty young children have vocalizing their symptoms. use of a validated nausea-assessment tool in conjunction with improved adherence to evidence-based guidelines may result in better quantification of symptoms and reduction of both nausea severity and vomiting frequency for pediatric patients undergoing chemotherapy. the pediatric nausea assessment tool (penat) has been validated for children ages 4-18, and its integration into clinical practice may help optimize cinv control. objectives: this single-institution study sought to improve control of cinv in patients admitted for chemotherapy by standardizing the antiemetic regimens prescribed by all providers according to an institutional cinv algorithm developed from the pogo guidelines. we hypothesized that treatment using a standardized guideline would improve cinv control in patients admitted for chemotherapy. a baseline cohort of 70 admissions for chemotherapy completed penat assessments and cinv diaries prior to receiving chemotherapy, four times daily during each admission, and daily for 7 days following completion of chemotherapy from may 1, 2013 to january 31, 2014. providers then were provided an institutional cinv treatment algorithm based on the pogo guidelines and received education at departmental meetings on appropriate implementation of this algorithm. a second cohort of 78 admissions completed penat assessments and cinv diaries in a similar fashion from july 1, 2014 to december 31, 2016. results: complete control of vomiting markedly improved following cinv guideline implementation (72% vs 52%, p <.0001) with treatment failure also significantly reduced (6% vs 23%, p <.0001). after controlling for the degree of emetogenicity of chemotherapy received, a patient was 3.33 times more likely to vomit prior to guideline implementation (or 3.33, ci 1.96-5.56). there was no difference in nausea control, even after adjusting for the emetogenicity of chemotherapy. conclusion: control of chemotherapy-induced vomiting (civ) improved following widespread implementation of an institutional cinv treatment algorithm at a single institution. the severity of nausea reported remained unchanged which may reflect the difficulty of assessing nausea or an inadequate sample size. future research may focus on cinv treatment management through the use of guidelines specifically for breakthrough cinv and delayed cinv. background: aspho's professional development committee (pdc) recognized pediatric hematologists-oncologists (phos) serving in the united states (us) military have unique professional development needs that may not be addressed by aspho or a similar professional society. these individuals may also encounter challenges when transitioning to a civilian career. however, barriers to professional development have not been systematically characterized. the objectives were to characterize the number of phos with current or prior military service (mphos) and to identify any unmet professional development needs. design/method: a working group consisting of pdc members and both senior and early career mphos was formed. initial comments were solicited by email from known mphos regarding potential gaps in professional development and interest in working with aspho to improve support of mphos. a survey was developed and piloted with four members of the advisory group, questions were revised based on their feedback, and a final version was distributed via the aspho website and online community forum. targeted emails were sent to mphos identified through aspho and military databases. eligibility to complete the survey included 1) completion of a fellowship in pediatric hematologyoncology, and 2) current or prior service as an active duty military provider. quantitative and qualitative information were collected, including demographic data and perceived barriers to professional development. responses were summarized using descriptive statistics. results: sixty-five mphos were identified and 34 surveys were completed for a 52% response rate. respondents were engaged in a variety of professional activities; 64% were male, 52% were serving active duty commitments, and 32% felt there were professional development gaps. areas of concern were categorized into nine themes with the most concerning being 1) limited civilian knowledge of mpho practices (76% of participants), 2) inability to attend professional society meetings (60%), and 3 possibility of deployment (56%). participants expressed a desire for educational products to meet their specific needs and for networking opportunities with civilian colleagues. qualitative analyses identified concerns about low patient numbers and practice size. a subset of mphos perceive significant gaps in professional development. additional research is needed to better define areas for intervention, but many of the concerns align with those of similarly sized civilian programs and may be addressed through professional society networking opportunities, such as an aspho special interest group. background: infertility is an established cause of distress and has a negative impact on quality of life among childhood cancer survivors. the american society of clinical oncology has established guidelines on fertility counseling for individuals of reproductive age diagnosed with cancer, with the goal of improving reproductive and psychosocial outcomes. studies have shown that instituting a fertility team that can provide counseling and discuss fertility preservation (fp) options results in improved patient satisfaction in patients with cancer. objectives: the goal of this study was to examine predictors of referrals to the multidisciplinary fertility team, and documented fp interventions among these patients. design/method: an irb-approved retrospective medical record review was performed at a large pediatric academic center. all patients with new cancer diagnoses receiving chemotherapy were included from january 2015 (when the fertility team was established) to present. a standardized abstraction form was used to collect information about: age at diagnosis, gender, cancer type, whether a fertility consult was placed, and documented fp interventions. data were summarized descriptively and comparisons were made using nonparametric statistical methods. results: 265 patients met inclusion criteria, of which 152 (57%) were male. cancer types were as follows: 126 leukemia/lymphoma, 51 cns tumors, 44 sarcomas, 37 embryonal tumors, and 7 langerhan's cell histiocytosis (lch). the mean age was 8.2 years, (range <1-31 years). overall, 27% of all patients had a consultation with the fertility team. patients were significantly less likely to have a fertility consult if they were younger (p<0.001). further, there were differences in the consultation rate between diagnoses, with 53% of sarcoma patients completing a consult, compared to 31% of those with cns tumors, 41% of those with embryonal tumor, 44% of those with leukemia/lymphoma and none of the patients with lch. our findings show that many children, adolescents, and young adults newly diagnosed with cancer are still not receiving fertility counseling despite: 1) an expanding body of literature supporting the need to provide this counseling, 2) guidelines published by several organizations recommending discussions about infertility risk and fp options, and 3) presence of a multidisciplinary fertility team. specific strategies need to be developed to improve access for younger children, and for disease groups in whom fertility consults are underutilized, such as youth with cns tumors, embryonal tumors, and leukemia/lymphoma. background: socioeconomic status (ses) has on impact on overall survival in the pediatric oncology population. unfortunately, data are insufficiently detailed to explain the mechanism behind this phenomenon. how parents handle the health management demands placed on them at the time of a child's cancer diagnosis may represent a point of differentiation in health outcomes. objectives: determine the association between socioeconomic factors, cancer literacy, and parents' understanding of home emergency management and their responses to instances of pain, nausea, and fever. in a prospective observational study of parents whose children were newly diagnosed with cancer, we obtained demographic information and, using a validated instrument, (dumenci, 2014) we evaluated cancer literacy. we tested understanding of the education parents received about home emergency management with a 6-item multiple-choice vignette-based questionnaire focused on actions needed in home scenarios. we then followed parents' actual behavior through periodic phone calls assessing instances of nausea, pain, and fever and their responses to these episodes. results: preliminary analysis of 24 participants showed an average score of 4 on the 6-item parental understanding questionnaire (range 0-6). variables associated with increased score were college-level education by 1.2 points (95% ci [.3 to 2.1]), private insurance by 0.9 points [.13 to 1.7] and adequate cancer literacy by 1.2 points [.2 to 2.2]. actual behavior reported by families indicated that married parents and those with income above $75,000 were less likely to treat instances of pain by 51% (95% ci [28 to 72]) and 43% [6.6 to 79], respectively. white parents, those with college-level education, and those with adequate cancer literacy were less likely to treat instances of nausea by 31% [6 to 57], 29% [5 to 53] and 29% [5 to 53], respectively. no associations were found between socioeconomic markers and parental responses to instances of fever. our findings suggest an association between demographic and socioeconomic markers and improved parental understanding of home emergency management. paradoxically, the same markers show a decrease in treatment response to pain and nausea. larger prospective studies are needed to link this behavior pattern to health outcomes, and help inform the extent of ses impact on home emergency management. emory university/children's heathcare of atlanta, atlanta, georgia, united states background: cardiovascular disease is a leading cause of morbidity and mortality in childhood cancer survivors (ccs). previous research showed wide practice variation in referral patterns to cardiology from the survivor clinic and in recommendations from cardiologists about the need for further testing or exercise restrictions. to develop a cardio-oncology algorithm in order to standardize referrals to cardiology and provide guidelines for cardiologists evaluating pediatric ccs. design/method: survivorship and cardiology experts developed a weighted scoring system for pediatric ccs who received cardiotoxic therapy based on time since treatment and risk factors identified by the children's oncology group (cog) and american heart association (aha). the cardiooncology algorithm assigned a score of 1-21. the score range was categorized to guide cardiology referral: screening echo only (1-3), consider cardiology referral (4-6), recommend cardiology referral (7-9), and regular cardiology follow-up (≥10). the algorithm also provides recommendations to cardiologists for screening and exercise modifications based on the score. after establishment of the algorithm, a convenience sample of institutional survivor clinic patient charts were retrospectively reviewed from the first month of each quarter from april 2015-march 2016 to validate the algorithm, evaluate referral patterns to cardiology, and assess cardiology recommendations. the retrospective chart review evaluated 243 patients (51% male; 61% non-hispanic white; 46% leukemia survivors; median age at diagnosis 4.0 years [range 0-19.7]; median time off-therapy 7.2 years [range 2.3-18.2]). 230 patients (95%) received anthracyclines (median dose 154mg/m2, range 30-512) and 73 (30%) received cardiac radiation. assigned cardio-oncology scores resulted in: 35% echo only, 47% consider cardiology referral, 16% recommend cardiology referral, and 3% regular cardiology followup. when evaluating detection rates of late effects by cardiooncology score, 12 survivors (5%) had an abnormal echo: 1/83 echo only, 4/115 consider referral, 4/38 recommend referral, and 3/6 regular cardiology follow-up. assessing referral patterns prior to initiation of the algorithm revealed forty-two survivors (17%) referred to cardiology: 8/83 echo only, 16/115 consider referral, 14/38 recommend referral, and 4/6 regular cardiology follow-up. of the 37 patients seen by a cardiologist at our institution, 4 had further diagnostic testing ordered (i.e., stress test) and 7 received exercise restrictions. a cardio-oncology algorithm and guidelines will standardize cardiac care for survivors by assigning a score to guide referral and cardiology practice after referral. prospective clinical use has begun and review will occur in one year to determine changes in detection rates of cardiac late effects, referrals, and recommendations from cardiologists. oregon health and science university, portland, oregon, united states background: delirium affects 10-30% of patients (pts) in pediatric intensive care units (picu) and is associated with increased length of stay, decreased attention in school, and post-traumatic stress disorder. the diagnostic and statistical manual of mental disorders (dsm v) defines delirium as a "disturbance of consciousness […] with reduced ability to focus, sustain or shift attention" due to an underlying medical condition. despite the medical complexity of the hospitalized pho population, there are no published prospective studies looking at delirium in these pts. hypothesizing that delirium is under recognized in the pho population, we designed a year-long prospective study using a validated screening tool to determine the frequency of delirium in hospitalized pho pts and to identify associated clinical factors. design/method: baseline frequency of pts with symptoms suggestive of delirium was determined through retrospective chart review using a data mining program of electronic medical records (emr). for the prospective study, pho and picu nurses were trained to use the cornell assessment for pediatric delirium and to record scores within the emr on all pho pts once every 12-hour shift. predetermined demographic and clinical variables were entered daily into a red-cap database on all hospitalized pho pts. results: baseline frequency of delirium, without active screening, was determined to be 4.5% of hospitalized pho pts. in the first 6 months of the prospective study, 405 consecutive admissions occurred among 152 unique pho pts: 347 oncology, 30 hematology, and 23 stem cell transplant pts. 25 pts had at least 1 positive delirium screen, for a prevalence per admission of 6.2%. statistically significant variables associated with delirium, at p < 0.0002 by univariate logistical regression, included prolonged length of stay, pt location (picu vs pho unit), and fever. adjusting for length of stay, administration of benzodiazepines and opiates were also significantly associated with delirium, p = 0.048 and 0.044, respectively. on average, nurses completed delirium screening in 70% of each pts' 12-hour shifts. study accrual ends in jan 2018 and final data analyses will be reported in the abstract presentation. conclusion: delirium does occur in the pho hospitalized population and screening by trained nursing staff is feasible. pts at highest risk appear to be pts with prolonged hospital stays, picu admissions, or frequent use of benzodiazepines/opioids. routine screening should improve our recognition of delirium and allow us to promptly intervene, or prevent delirium in an effort to avoid potential acute and long term consequences. background: with high survival rates for children and adolescents with hodgkin lymphoma (hl), treatment regimens are now designed to maximize cure while decreasing risk of long-term health outcomes associated with chemotherapy and radiation therapy. within contemporary treatment regimens, the comparison of toxicities experienced by patients receiving chemotherapy plus radiotherapy (crt) versus only chemotherapy (co) has not been studied extensively. objectives: this study examines select self-reported adverse health outcomes in survivors of contemporarily-treated pediatric hl to better understand the balance between efficacy and toxicity associated with chemotherapy and radiation therapy. (cog) ahod0031 that evaluated a response-based treatment paradigm in pediatric hl. patient who received initial chemotherapy were randomized based on early response to continued chemotherapy, chemotherapy plus radiotherapy or augmented chemotherapy plus radiotherapy. patients completed self-report questionnaires on health problems at 0, 1, 3, and 5 years following therapy. we examined selected patient-reported pulmonary, gastrointestinal (gi), cardiac and endocrine outcomes. kaplan-meier survival curves were used to determine probability of survival without the selected adverse health outcome. log-rank tests were used to compare the co versus the crt group. results: a total of 1,051 enrolled patients, 251 patients in the co group and 800 patients in the crt group, completed 2,134 questionnaires at a median of 1.3 years after s177 of s301 completion of therapy (q1, q3: 0.6, 3.3) which were analyzed. the cumulative 10-year incidence of endocrine dysfunction was significantly greater in the crt group versus those in the co group (17% versus 6%; p<0.001), driven by the incidence of hypothyroidism (11% versus 2%; p<0.001). there were no significant differences in cardiac (7% versus 9%; p = 0.226), pulmonary (11% versus 10% p = 0.068), and gastrointestinal dysfunction (20% versus 17%; p = 0.317) between the co and crt patients. conclusion: this study demonstrates low cumulative incidence overall of organ dysfunction early post completion of contemporary therapy for hl. the addition of radiation therapy significantly increased risk for hypothyroidism, but with no higher risk noted for cardiac, pulmonary or gi dysfunction. limitations include self-report status, potential selection bias, and relatively short latency period following end of therapy. longer follow-up is needed to determine more delayed risks for organ dysfunction in order to best define the balance between therapeutic efficacy and long-term adverse health outcomes related to chemotherapy and/or radiation therapy. background: identification of an organism via bronchoalveolar lavage (bal) or respiratory tract biopsy (rtb) has historically been considered the gold standard for diagnosis of invasive fungal infection (ifi); however, data previously published by our group showed that these procedures infrequently lead to a change in management in children with an oncological diagnosis or undergoing hematopoietic stem cell transplant (hsct). there is also a paucity of data on the cost of ifi in this population. to compare the costs of work-up and management of pulmonary ifi diagnosed based on ct scan alone versus ct scan or chest x-ray prompting a bal or rtb. design/method: we collected cost data on patients at ann & robert h. lurie children's hospital of chicago undergoing chemotherapy or within 6 months of hsct who were suspected of having an ifi between 2007 and 2012. in order to include sufficient time to account for post-procedure compli-cations but avoid including costs unrelated to ifi, data were included for 14 days from the day of their diagnostic scan or procedure. cost data was available for 76 of the 101 patients previously studied. thirty-six of these patients were diagnosed with suspected ifi based on ct only and 40 patients underwent bal or rtb. when evaluating specific costs, inpatient beds costs were higher in the bal and rtb group (median $1,555 versus $1,255, p = 0.01), yet there was only a trend towards higher costs for antifungal agents (median $1,635 versus $1,089, p = 0.26) and respiratory support (median $257 versus $0, p = 0.14). many of the initial ct scans were not captured in the 14-day evaluation period for the bal or rtb group based on the study design; however, even when accounting for ct scans up to a week prior these procedures, the total cost of ct scans was higher in the ct only group (median $963 versus $635, p = 0.0002), as they had more scans. despite this, total costs were significantly higher for patients who underwent bal or rtb versus ct scan only (median $14,087 versus $5,900, p <0.0001). combined with our previous data that bal and rtb infrequently leads to a change in management in children with an oncological diagnosis or undergoing hsct suspected to have an ifi, the significantly higher costs associated with these procedures makes these invasive diagnostic techniques even less desirable. batra, pediatr blood cancer, 2015. background: while infants >12 months of age with acute lymphoblastic leukemia (all) have a poor prognosis, infants with acute myeloid leukemia (aml) fare better despite more intensive therapy. there are limited data on this difference, particularly differences in supportive care requirements during induction therapy for infants. objectives: to compare induction mortality and resource utilization in infants relative to non-infants aged <10 years, separately for all and aml. design/method: we used previously established cohorts of children treated for new onset all or aml at children's hospitals in the us contributing to the pediatric health information system. patients with down syndrome were excluded. follow-up started on the first day of induction chemotherapy and continued until the earliest of: 35 days after commencement of chemotherapy, start of the subsequent course, or death. high acuity of presentation, defined as icu requirements involving 2 or more organ systems within the first 72 hours following initial admission were compared using log binomial regression. 35-day inpatient mortality was compared using cox regression. resource utilization rates (days of use per 100 inpatient days) were compared using poisson regression. results: a total of 10359 all (405 infants, 9954 non-infants) and 871 aml (189 infants, 682 non-infants) were included in the analyses. infants were more likely to present with high acuity compared to non-infants for both all (12% and 1%, rr = 12.2, 95% ci:8.6, 17.5; p<0.0001) and aml (6% vs 3%; rr = 2.0, 95% ci: 0.96, 4.3; p = 0.06). infants with all had higher inpatient mortality compared to non-infants even after accounting for differences in acuity of presentation (2.7% vs 0.5%, adjusted hr = 2.7 95% ci: 1.2, 6.1; p = 0.015). in contrast, inpatient mortality was more similar for infants and noninfants with aml (3.2% vs 2.1%, adjusted hr = 1.2 95% ci: 0.3, 3.9; p = 0.73) and comparable to rates among infants with all. infants with all and aml had higher rates of utilization of fresh frozen plasma, cryoprecipitate, diuretics, supplemental oxygen, and ventilation relative to non-infants. infants with all also had higher rates of total parenteral nutrition, ecmo, and patient controlled analgesics compared to noninfants. infants with all experienced significantly higher induction mortality compared to noninfants, a difference not entirely explained by acuity at presentation. differences in ru among infants may reflect higher presentation acuity and greater treatment related toxicity. further work is needed to elucidate the contribution of treatment related toxicity to early mortality in infants with all. background: fever in a child with cancer is a medical emergency due to the significant risk of a serious bacterial infection. many attempts have been made to risk stratify these patients. the respiratory pathogen panel (rpp) is a panel of polymerase chain reaction tests that identify seventeen common respiratory viruses and three bacterial infections. samples are taken via nasopharyngeal swab. rpps are frequently sent, but we do not have data to determine whether a positive result can lead to stratification to a lower risk of bacterial infection. (1) to determine the epidemiology of respiratory virus-associated fever in pediatric oncology patients (2) to determine whether a positive rpp is associated with reduced risk of bacteremia in this population. this was a single-center, retrospective cohort study. we identified and reviewed the medical records of all pediatric oncology patients seen in our emergency department (ed) with fever from the introduction of the rpp in april 2014 to september 30, 2017. we reviewed the results of blood cultures, rpp, chest radiographs, and discharge summaries to identify sources of infection. we also identified the patients' cancer diagnosis, age, absolute neutrophil count (anc), and absolute lymphocyte count (alc). results: 107 positive rpps were found among pediatric oncology patients who presented to the ed with fever. the most common positive rpp findings were rhinovirus/enterovirus (rev) (45%), parainfluenza (14%), influenza (11%), coronavirus (11%), and polyviral (10%). among patients with a positive rpp, 4% had bacteremia compared to 12% bacteremia among all pediatric oncology patients with fever (or 0.42 [0.18-0.99], p 0.048). all cases of bacteremia were associated with rev. there was no bacteremia identified in patients with rpps positive for other viruses (or 0.0596 [0.0037-0.9715], p 0.048). rev positivity did not confer a lower risk of bacteremia than rpp negative patients ], p 0.97). anc (p = 0.87) and alc (p = 0.89) less than 500, and number of patients with severe neutropenia (p = 0.27) were not statistically different between the rev and non-rev positive rpp groups. rpps positive for viruses other than rev reduced the likelihood of bacteremia in febrile pediatric oncology patients in the ed setting. patients with bacteremia may have concurrent infection with rev. a larger study is warranted to determine if positive rpp results can inform clinical management of a child with febrile neutropenia. emily mueller, anneli cochrane, seethal jacob, aaron carroll s179 of s301 background: the usage of mobile health (mhealth), which refers to the application of mobile or wireless communication technologies to health and healthcare, has grown exponentially in recent years. mhealth tools have been used by caregivers of other vulnerable populations, but little has been focused on caregivers of children with cancer. objectives: to conduct a survey to understand the mobile technology usage, barriers, and desired mhealth tools by caregivers of children with cancer. we conducted a mailed cross-sectional paper survey of caregivers of all children who were diagnosed with cancer at riley hospital for children between june, 2015 and june, 2017. the survey contained 13 questions, both fixed and open-ended, in both english and spanish. up to three rounds of surveys were sent to those who did not respond. of the 121 respondents, they were primarily parents (93.2%), median age was 40.7 years (range 23-63), and most were white (78.5%) and non-hispanic/latino (87.1%). the top three annual household income brackets included $50,000 to $74,999 (21.2%), $25,000 to $49,999 (20.3%) and under $25,000 (17.8%). the majority had an education: 35.6% college graduates, 22% graduate degree, and 18.6% high school education or ged. nearly all respondents owned a smart phone (99.2%) and 61.2% owned a tablet. the majority used an ios operating system (62.8%), while 49.6% reported use of a device with an android operating system. all caregivers reported use of at least one mobile website/app regularly for their personal use. while 35.5% of respondents reported no barriers to mobile technology use, the top barrier selected was "data limitations" (21.5%). overall, 84.5% wanted at least one medical managementrelated website/app: medical knowledge (58.7%), healthcare symptom tracking/management (47.1%), and medication reminders (43%). healthcare system-related desires were high, as 59.5% wanted access to their child's medical record and 56.2% wanted a website/app to facilitate better communication with medical providers. there were no significant associations between socioeconomic status (income or education) with barriers or types of websites/apps desired by caregivers. since the vast majority of caregivers use mobile technology with minimal barriers, future research should focus on designing an mhealth tool to address the medical management needs by caregivers of children with cancer. by supporting caregivers through this type of mhealth tool, it could positively impact patient clinical outcomes through greater adherence to medications and treatment protocols. background: in children with fever and neutropenia, early initiation of targeted antibiotic therapy improves outcomes, yet there are no standards for choice of empiric antibiotics. in 2013 our institution implemented an early empiric ceftriaxone (eec) protocol to reduce time to antibiotic administration in febrile hematology-oncology patients who are potentially neutropenic when the absolute neutrophil count is not yet know. ceftriaxone is given immediately after obtaining blood for culture and lab studies. in patients found to be neutropenic, ceftriaxone is discontinued and cefepime is initiated. the purpose of this retrospective study was to evaluate our eec protocol in neutropenic patients by assessing ceftriaxone sensitivity of positive blood cultures and comparing rates of adverse outcomes with a cohort of patients treated prior to implementation of the protocol. we are now conducting a prospective study to more thoroughly investigate antibiotic sensitivities of organisms isolated from blood cultures of neutropenic patients. design/method: hematology-oncology patients with at least one positive blood culture between january 2011 and december 2013 were identified. patient demographics, neutrophil count, antibiotic treatment, isolated organisms and sensitivities, and adverse outcomes (increased respiratory support, hypotension requiring intervention, and icu admission) were obtained by retrospective chart review. fisher exact test was used to compare dichotomous variables between patient groups. we are now prospectively identifying febrile neutropenic patients with positive blood cultures and performing antibiotic sensitivity testing to several antibiotics commonly used as empiric therapy for febrile neutropenia. results: retrospectively, we identified 58 neutropenic patients with a total of 127 bacterial isolates from blood cultures. of organisms isolated, 47 were tested for sensitivity to ceftriaxone and 23 (49%) were not sensitive, 6/18 (33%) of gram-positive cultures and 18/29 (62%) of gram-negative cultures. ten of 16 (63%) eec patients had an adverse outcome versus 13/26 (50 %) of non-eec patients (p = 0.277). notably, 31% of eec patients required icu admission versus 4% of non-eec patients (p = 0.049). thus far our data obtained prospectively is revealing similar rates of ceftriaxone resistance with 9/19 cultures not sensitive to ceftriaxone (47%, ci 24.9%-71.1%). in our retrospective study, no statistically significant difference was seen in overall adverse outcome rate between the two cohorts, though icu admission rates were significantly higher in eec patients. ceftriaxone resistance rates were high in tested isolates, which is further supported by preliminary data from our ongoing prospective study. given these data, eec may not be effective at improving outcomes in febrile neutropenic pediatric hematology-oncology patients. background: approximately 1 in 5 children diagnosed with cancer will die of their disease, despite advances in treatment. results: two focus groups of six parents each met in june 2017. the parents were predominantly female (11 female, 1 male) and had lost their children an average of 2.8 years prior (range 1-5.3 years). two parents were in the same family. nearly all patients were offered palliative care (10/11), all were offered hospice and most died at home (9 at home, 2 in the icu). parent discussion uncovered six broad themes: beneficial provider qualities, optimal communication, helpful systematic supports, struggles to feel like a good parent, struggles with a loss of control and unmet needs. parents appreciated providers who were consistent, reliable and honest. parents desired communication that was sensitive to the needs of the patient and family with a balance of hope and realism. parents appreciated the tangible supports pro-vided by social work and the emotional support of child life both for the patient and their siblings. some parents struggled to define and advocate for their child's quality of life, especially when it led to disagreeing with the medical team. several parents expressed frustration with unfamiliar caregivers in the hospital, especially trainees. they expressed a strong desire for more anticipatory guidance about the end of life including how to discuss it with their children. they also wished for a cancer-specific support group for bereaved parents. conclusion: bereaved parents of pediatric oncology patients in our focus groups appreciated consistent, reliable providers who communicated with a balance of realism and hope. they appreciated the tangible and emotional support they received and wanted more anticipatory guidance at the end of their child's life. these results can help guide clinical care, especially in communities without strong palliative care support. further research is needed to develop interventions to improve end of life care. background: clinical trials involving human subjects depend on informed consent (ic) to ensure ethical protections for participants. parents of children with cancer often lack full understanding of the basic elements of ic for clinical trials. additionally, the stress of their child's cancer diagnosis may affect their decision-making capabilities. this is especially problematic as these children rely on parents to fully comprehend clinical trials and weigh their benefits and risks. physician communication is critical for effective family-centered care. the acgme mandates that training programs teach and assess trainees' communication skills. however, there are currently no published curricula aimed at training pediatric hematology/oncology fellows to deliver ic effectively for cancer clinical trials. to develop and pilot-test a simulation-based curriculum to enhance communication skills of pediatric s181 of s301 hematology/oncology fellows in the delivery of ic for cancer clinical trials. we developed, tested, and implemented the curriculum from 2016 to 2017 in two phases. in phase-1, we reviewed literature on simulation-based curricula and completed a needs assessment to create a clinical scenario and full curriculum using standardized patients. using miller's pyramid model, fellows' assessments included: immediate de-brief, surveys to assess pre/post confidence and knowledge of the basic ic elements ("knows" and "knows how"), and 360-degree summative assessments compiled from fellow self-assessments, faculty, and standardized patients ("shows how"). after initial testing and refinements done with 1 fellow, in phase-2, we implemented the curriculum with our 8 fellows. likert scale (1 strongly disagree-5 strongly agree) and basic p values are reported. results: fellows gave high mean ratings for training relevance (4.7) and standardized patients' preparedness (5). almost all (4.9) reported they have used the knowledge gained in their clinical practice. increase in self-reported confidence (pre/post) was noted in all domains: general -describing possible benefits of the clinical trial 3.5/5 vs.4.1/5 (p = 0.025), risks and potential side effects 3.5/5 vs.4.3/5 (p = 0.004), and explaining alternatives 3.1/5 vs.3.6/5 (p = 0.016); research -discussing purpose of the clinical trial 3.1/5 vs.3.7/5 (p = 0.006), and randomization 3.3/5 vs.4.0/5 (p = 0.046); and family-centered -addressing emotions during ic 3.6/5 vs.4.5/5 (p = 0.004), and delivering bad news 3.1/5 vs.3.6/5 (p = 0.016). summative evaluation mean ratings for all fellows were 4.5 (range 4.1-4.9). our novel simulated-based ic curriculum, significantly increased fellows' self-reported confidence and skills during ic delivery. importantly, our ic curriculum addressed not just research-related content but also management of parental emotional needs during the ic discussion. next phase includes kirkpatrick model program evaluation and dissemination across other training programs in our institution. national kaohsiung normal university, kaohsiung, taiwan, province of china background: taiwan's childhood cancer foundation reported in 2016 that the 5-year survival rate of childhood cancer was 75%. as a result, many childhood cancer survivors were back in school after treatment. however, childhood cancer survivors' educational outcomes suffered because of their long-term absence from school and late effects of cancer and cancer treatment. a few school reentry protocols have been developed by the nursing professionals in taiwan to facilitate students' return to school but remained experimental in nature and hardly accessible. parents, students, and teachers were left to their own devices to make individual school reentry plans. objectives: this study aimed to examine and uncover the commonalities among three middle school students' successful school reentry experiences from their teachers' perspectives and to analyze the factors contributing to their success. design/method: this is a qualitative interview study. indepth semi-structured interviews were conducted with three middle school teachers in december 2017 about their perceptions, observations, and experiences working with adolescent childhood cancer survivors. the students were two boys with leukemia and one girl with bone cancer. they were diagnosed in the first year of middle school when they were 12-13 years old and returned to school for the third and the final year. these students met the following criteria for successful school reentry: regular school attendance, average/above average academic performance, friendship maintenance, and high school diploma. the theme -bring the class to the hospital was found to be the key to the adolescents' successful return to school. without a prescribed school reentry protocol and in the face of limited bedside education services, the homeroom teachers, as links between school, home, and hospital, brought the class to their hospitalized students. they doubled as bedside teachers conducting lessons at the hospital or students' homes, became friends with the parents, witnessed firsthand the students' pain and triumph during treatment, brought the students back to school for visits and celebrations, delivered the classmates' wishes and news to the students, encouraged and welcomed classmates' visits to the hospital, and, together with parents and other teachers, developed flexible school reentry schedules for the students. this on-going study demonstrated the critical roles and functions of homeroom teachers in successfully bringing the students back to school during and/or after cancer treatment. further analysis will be focused on how and why these three homeroom teachers were able to carry out this unexpected task on top of their already full workload. jennifer kesselheim, shicheng weng, victoria allen, collaborative group fellowship program directors dana-farber/boston children's cancer and blood disorders center, boston, massachusetts, united states background: a novel, 4-module, case-based curriculum entitled "humanism and professionalism for pediatric hematology-oncology" (hp-pho) aims to foster pho fellows' reflection on grief and loss, competing demands of fellowship, difficult relationships with patients and families, and physician well-being and burnout. in small group facilitated sessions, fellows work to identify coping strategies and explore how the challenges of fellowship influence both their own doctoring and the patient experience. objectives: to administer the hp-pho curriculum in a prospective, cluster-randomized trial, measuring whether exposure to this educational intervention, compared to standard conditions, fosters humanism and professionalism and improves satisfaction with training. design/method: pho fellowship programs (n = 20) were cluster-randomized to deliver usual training in humanism and professionalism (control) or the novel curriculum (intervention) during the 2016-2017 academic year. the primary outcome measure was the pediatric hematology-oncology self-assessment in humanism (phosah). secondary measures included a 5-point satisfaction scale, the maslach burnout inventory (mbi), the patient-provider orientation scale, and the empowerment at work scale. participating fellows were pre-tested in summer 2016 and post-tested in spring 2017. a change score was calculated for each study instrument. we compared each outcome between arms using mixed effect models adjusted for pre-test score as a fixed effect and site as a random effect. results: randomization yielded 59 intervention and 41 control fellows. the two arms did not significantly differ in distribution of fellow age, gender, or post-graduate year. the 9 intervention sites successfully administered 33 of 36 (92%) modules. change scores on the phosah were not significantly different between the control and intervention arms (adjusted mean difference = 0.5; 95% confidence interval [ci] -1.0, 2.0; p = 0.5). compared to the control arm, fellows' exposed to the curriculum gave significantly higher ratings on several items within the satisfaction scale including satisfaction with their training on "physician burnout" (adjusted mean difference = 0.8; 95% ci 0.4, 1.2; p<0.001), "physician depression" (adjusted mean difference = 0.9; 95% ci 0.4, 1.4; p<0.001), "balancing professional duties and personal life" (adjusted mean difference = 0.7; 95% ci 0.3, 1.1; p = 0.002), and "humanism overall" (adjusted mean difference = 0.4; 95% ci 0.03, 0.9; p = 0.03). change scores on other secondary measures were not significantly different between study arms. conclusion: exposure to the hp-pho curriculum did not alter fellows' self-assessed humanism and professionalism. however, the curriculum proved feasible to administer and intervention fellows expressed higher levels of satisfaction in their humanism training, indicating the curriculum's positive impact both for fellows and their learning environment. background: recent work has documented significant levels of unmet needs among adolescents and young adults with cancer, particularly psychosocial challenges during the transition to adulthood, (e.g., abrupt disruption to school and social life, and social isolation). given that adolescents and young adults drive mobile app use, a mobile-phone may be an ideal way to deliver a psychosocial intervention to adolescents and young adults with cancer. to use a patient-centered approach to inform a mobile-based mindfulness and social support intervention for adolescent and young adult patients with cancer. design/method: participants were ten aya with sarcoma (50% female; 50% adolescents); parents of the five adolescents, and six healthcare providers (n = 21). formative research involved three steps: (1) in-depth interviews were conducted with ten aya with sarcoma; parents of the five adolescents, and six healthcare providers (n = 21). (2) adaptations were made to an existing mindfulness app which offers a program for youth. modifications included creating a 4-week "mindfulness for resilience in illness" program, with 28 relaxation exercises, and the addition of videos featuring two sarcoma survivors as program hosts. content was informed by the mindfulness curriculum for adolescents, learning to breathe. (3) a private facebook usability group was organized to (i) elicit beliefs about the mindfulness app and potential future enhancements, and (ii) promote social support. results of the in-depth interviews revealed themes around adolescents' functioning and coping, including body image concerns; recurrence-related anxiety; anger over loss; and being overwhelmed by medical information. themes from the interviews were incorporated into a demonstration version of the mobile app. a patient-centered approach is widely recommended in the development of mobile-based health behavior change interventions and may be a useful way to inform development of a mobile-based mindfulness and social support intervention for adolescents and young adults with cancer. background: medical trainees consistently report suboptimal instruction and poor self-confidence in communication skills. despite these deficits, few training programs provide comprehensive pediatric-specific communication education, particularly in the provision of "bad news." an in-depth survey to examine the historical experience and communication needs of pediatric fellows was conducted at a large academic pediatric center as the first step towards the development of a comprehensive communication curriculum. to determine the previous educational and clinical experiences of pediatric subspecialty fellows, assess their levels of comfort in the context of various communication topics, and query potential modalities and topics for future communication training. design/method: the needs assessment survey was developed using previously developed and validated questions and review of the literature. the survey was reviewed by internal and external pediatric oncology and palliative experts and pre-tested with a subset of trainees to enhance content validity. results: thirty-two out of a total of 38 fellows completed the survey (84% completion rate), of which 81% were pediatric hematology-oncology or subspecialty fellows. most fellows had participated in previous teaching sessions (97%), including those involving role play or simulation (75%). however, few fellows had received feedback from senior clinicians on their communication skills (31% of fellows had received feedback ≤ 3times). on a scale of 1-x, with 1 indicating "not well prepared," the mean score for 12 of 23 communication items was <3. fellows felt least prepared to lead discussions around informed consent for experimental therapies, end of life care, and autopsy. fellows indicated that didactic educational sessions and additional coursework were less useful strategies for improving their communication skills, whereas small group role play sessions with faculty and/or bereaved parent educators were most useful. fellows' overall communication preparedness score was not correlated with post-graduate year but was positively associated with the number of times they previously had delivered bad news to patients and families. fellows requested additional training on many topics, with greatest interest in learning skills to optimize communication with an angry patient or family. additional topic requests included placing limitations on resuscitation, withdrawing/withholding further therapy, and ageappropriate inclusion of patients in difficult discussions. despite self-report of prior communication skills training, pediatric subspecialty fellows felt underprepared to participate in difficult discussions with patients and families. learners identified role-playing and coaching with real-time feedback from other physicians and bereaved parents as more useful training strategies as compared to didactic sessions. background: when children die of cancer, parents must adjust to their child's absence amidst the lingering turmoil of what preceded their death: witnessing their child undergo painful treatments, making difficult decisions, and anticipating a devastating loss, all the while hoping for a recovery. adjustment to a child's death, as depicted by current bereavement literature, necessitates making meaning of one's loss. professional care staff can help parents make sense of their child's illness, and in turn, of their own parental experience during treatment. however, the extent to which relationships with professional care team members influence parents' ability to make sense of, and successfully cope with, their loss has not been examined. objectives: to examine how bereaved parents' interactions with their deceased child's pediatric oncology professional care team have impacted their grief symptoms design/method: to better understand how interactions with professional care staff relate to parents' grief outcomes, we conducted a mixed-methods study examining staff impact on parental grief. thirty participants whose children died of cancer one to three years ago completed an in-depth interview and psychometrically validated surveys measuring meaningmaking, depression, and grief symptoms. results: correlational analyses of the measures found that an increase in meaning making was associated with lower depressive and grief symptoms. a content analysis of the interviews found that many participants regarded staff "like family," had on-going relationships with staff after their child died, and described various ways staff interactions during treatment and after the child's death helped them make sense of their loss. in particular, participants described how interactions with staff have helped them find benefits in their loss and learn to create a new relationship with their child despite their physical absence. quantifying the interview data and statistically analyzing it along with the measures found that participants' increased frequency of describing staff's positive impact on their grief correlated with higher meaning-making scores and lower grief symptom scores. our study found that bereaved parents who lost their children to cancer were articulate in sharing their experiences of staff engagement and communication during treatment, offering numerous examples of how staff aided them in making meaning of their loss that were reliably associated with their subsequent grief. we hope the results of this mixed methods research encourage further study of the importance of staff interaction with families during the critical period of their children's care, and the lasting impact this can have regardless of the treatment outcome. memorial sloan kettering cancer center, new york, new york, united states background: although resiliency has been recognized as necessary for healthcare professionals, trainees feel unprepared for the emotional challenges inherent in caring for sick and dying patients. compounded by long hours, challenging work environments, and lack of formal training on handling emotionally difficult situations, many institutions are recognizing the need for interventions to reduce trainee distress. the goals of this fellow-led quality improvement initiative were: 1) to determine whether there is a need for emotional support amongst pediatric hematology and oncology fellows, 2) to provide formal resiliency and debriefing sessions, and 3) to measure feasibility, acceptability and effectiveness of implemented curriculum. design/method: an anonymous survey to determine need for resiliency and debriefing sessions following a traumatic event was distributed to 24 active pediatric hematology & oncology fellows at memorial sloan kettering cancer center in january 2017. once need was established, an intervention consisting of a formal curriculum was developed and initiated in june 2017, involving: 1) scheduled and ad hoc debriefing sessions in response to traumatic events (including patient death, codes, interpersonal conflicts, end-of-life care); led by a psychiatrist and social worker with fellows and a pediatric oncologist mentor in attendance, and 2) a resiliency didactic curriculum, led by a palliative medicine specialist, focused on skills such as contesting cognitive distortions and mindfulness. the effectiveness of these sessions will be measured using follow-up anonymous surveys at 6 months (currently underway) and 12 months post-initiation of intervention. the initial survey demonstrated most trainees (19/24) were present at 3 or more deaths during their training, while less than half of respondents had attended a post-event debriefing session. 85% of respondents felt there was not sufficient emotional support from the institution for physicians caring for dying patients. a separate pre-intervention survey found all respondents (14/14) expressed a need for regular debriefings, and nearly all anticipated that they would benefit from such debriefings. concerns identified by trainees that would preclude participation in the curriculum included preference to deal with emotional situations privately and time constraints. trainees identified a need for formal debriefings and resiliency skill development. the program was easily implemented, and is both feasible and acceptable with good attendance. feedback received at the 6-month mark will determine deficits and possible improvements to the curriculum. the 12-month survey will measure effectiveness of the program and whether it should be continued. background: acute kidney injury (aki) is a common but under-recognized complication among patients with leukemia. it is associated with prolonged hospital stays, increased mortality, progression to chronic kidney disease, and delays or changes in cancer therapy which may affect a patient's prognosis. however, data on aki in pediatric patients with cancer is still lacking overall. we investigated the incidence of aki in patients who were newly diagnosed with all at our center from january 2009 to september 2017. we performed a retrospective chart review of all patients who were newly diagnosed with all from neonate to 18 years in our facility. we determined the incidence of aki in our population using the kidney disease: improving global outcomes (kdigo) diagnostic criteria. we also assessed for nephrotoxic exposures, nci all risk stratification and risk of aki, and tumor lysis syndrome (tls). we identified 62 patients diagnosed during the study period who met inclusion criteria. median follow-up time was 29.5 months (range 3.6-60.3). the cohort was predominantly male (54.8%) and hispanic (93.5%). our analysis showed 51.6% had aki by kdigo criteria (29% grade 1, 14.5% grade 2, and 8% grade 3), 62.5% had aki on presentation, and 75% had multiple aki episodes during the study period. older age and longer length of hospitalization were associated with aki (p = 0.019 and p = 0.009, respectively). there was no association between aki and nci all risk classification, contrast exposure, hyponatremia, elevated white blood cell count, uric acid levels, antimicrobial therapy, or diuretic use in this study. conclusion: aki was a common finding in our study population. the majority had grade 1 aki by kdigo criteria. however, aki was associated with older age and a longer length of stay. further study is needed to determine the short-and long-term impact of aki on pediatric patients with all. st. jude children's research hospital, memphis, tennessee, united states background: in some regions, the availability of trained pediatric oncologists is a limiting barrier for the care of children with cancer. in 2003, the unidad nacional de oncología pediátrica (unop) and the universidad francisco marroquín school of medicine in guatemala established a pediatric hematology/oncology fellowship program sponsored by st jude children's research hospital to provide central america and the caribbean with well-trained specialists. a systematic analysis of the impact of fellowship programs in pediatric oncology has never been done, especially in the context of a regional education program. objectives: this study sought to analyze the impact of the unop fellowship program based on the regional number of providers, pediatric cancer centers and patient volume. in addition, it sought to characterize the jobs and scientific output of the graduates. the impact will be evaluated in the context of a cost analysis. to define the volume of providers, pediatric cancer centers and patients, the directors of pediatric cancer centers in central america were sent an online survey to obtain these data. all the centers contacted maintain an updated hospital-based patient registry. in addition, the 22 graduates of the fellowship program were also sent an online survey, asking about their job at graduation, current role and scientific productivity. the cost analysis will include assessment of direct costs including salaries and stipends for away rotations, as well as the indirect costs of faculty time spent teaching. since the establishment of the unop fellowship program, the region has more providers for pediatric cancer (p<0.05) and centers treat a larger volume of patients (p<0.05). two new centers have opened with graduates of the program. all but one graduate practice pediatric oncology (21/22) and the majority do it in their country of origin (19/21). no graduate practices outside of this region. almost half of the graduates (44%) hold a leadership role at their institution. the majority of their time is spent in the public sector (>95%). the majority of graduates participate in clinical research (61%) and have participated in the creation or implementation of therapeutic protocols (67%). on average, the graduates have published 2 peer-reviewed articles since completion of training. the unop fellowship program has had a favorable impact on pediatric cancer care in the region, contributing to the capacity to treat a larger volume of patients. graduates practice pediatric oncology in the region in the public sector, frequently hold leadership roles and are scientifically productive. background: abandonment of treatment is a major cause of treatment failure and poor survival in children with cancer in low-and middle-income countries. the incidence of abandonment in peru has not been reported. objectives: the aim of this study was to examine the prevalence and associated factors of treatment abandonment in pediatric patients with cancer of peru. we retrospectively reviewed the sociodemographic and clinical data of children referred between january 2012 and december 2014 to the two main tertiary centers for childhood cancer, located in lima, peru. definition of treatment abandonment was used from the siop (international society of paediatric oncology) podc (paediatric oncology in developing countries) abandonment of treatment working group recommendation. results: data of 1135 children diagnosed with malignant solid tumors and lymphomas were analyzed, of which 209 (18.4%) abandoned treatment. univariate logistic regression analysis showed significant higher abandonment rates in children living outside the capital city, lima (p<0.001); prolonged travel time to a tertiary center (> 5 hours; or 2.75, p = 0.002); living in a rural setting (or 3.44; p<0.001) and lack of parental formal job (or 4.39; p = 0.001). according to cancer diagnosis, children with retinoblastoma were more likely to abandon compared with other solid tumors. in multivariate regression analyses, rural origin and lack of formal parental employment were independently predictive of abandonment. conclusion: treatment abandonment prevalence in our country is high and closely related to socio-demographical factors. treatment outcomes could be substantially improved by strategies that help prevent abandonment of therapy based on these results. st. jude children's research hospital, memphis, tennessee, united states background: to improve the quality of a pediatric hematology/oncology fellowship program, a systematic assessment must be performed that can evaluate its current state and identify areas of opportunity, as well as modifications over time. unfortunately, widely agreed-upon metrics of quality for pediatric hematology/oncology fellowship programs currently do not exist. this is particularly important in this field due to the global shortage of specialists. for this reason, an assessment instrument that is applicable throughout the world must be created. objectives: the st. jude global education program assessment tool (epat) is a novel instrument that seeks to evaluate pediatric hematology/oncology fellowship programs around the world in systematic and objective way. epat will help determine key performance indexes that are relevant for quality education in pediatric hematology/oncology fellowship programs and establish the framework for improvement. design/method: firstly, key domains to be evaluated for program assessment were identified a priori based on the continuum of pediatric hematology/oncology fellowship programs in the context of geography and educational structure. subsequently, questions were formulated to evaluate these key domains, seeking to assess elements involved in ensuring competence in clinical practice, academic productivity and regional impact. due to the novelty of this tool and the lack of defined metrics of quality, epat relies on expert opinion in a two-step process: internally in the department of global pediatric medicine at st. jude children's research hospital and, subsequently, from a panel of experts in global pediatric oncology and medical education from around the world. ten key domains were identified to evaluate all aspects relevant to training programs around the world, regardless of educational and geographic context. questions have been created to assess these domains and, to make epat quantitative, these have assigned weights with a value reflective of their relative importance. this grading system allows for a score in each key domain, permitting monitoring of changes over time. epat is currently at the stage of external expert review, and subsequently will be piloted in five fellowship programs around the world to provide different geographical and patient care contexts for its validation. once epat is finalized, it will be distributed to pediatric hematology/oncology fellowship programs around the world to be applied. epat proposes a novel strategy to assess training programs in a systematic way that includes all aspects relevant for a training program in a global context. this tool will help guide improvements in pediatric hematology/oncology fellowship programs and assure a well-trained workforce. background: with the improvement in pediatric oncology patient survival and outcomes in the past several decades, monitoring for recurrence and long-term effects of therapy has become even more important. the utilization of personalized treatment summaries and survivorship care plans (scps) is one way to communicate this information with patients and families. the american college of surgeons commission on cancer (coc) created a standard regarding provision of scps to 50% of eligible patients by december 31, 2017 as a metric for accreditation of all cancer centers. the standard applies to all patients with stage i, ii, and iii cancer diagnoses and requires creation of the scp within one year of diagnosis or six months of completing treatment. during implementation at our pediatric cancer center, we identified barriers to use of the guidelines in the childhood cancer setting. objectives: define eligibility for an scp for pediatric oncology patients to include all patients with curative intent and to deliver scps within six months of finishing therapy. design/method: using chart review and a cancer center registry query, we identified childhood cancer patients potentially eligible for an scp by collecting stage, goal of therapy, and dates of treatment. all patients with curative intent were deemed eligible for an scp regardless of stage i-iv. patients being followed in the oncology clinic for posttreatment surveillance and care were included even if they had received an scp in the survivorship program or were greater than six months off therapy at time of implementation. as expected in the pediatric oncology population, acute lymphoblastic leukemia (all) was the most common diagnosis comprising 31.5% of patients. all is stratified into risk groups instead of surgical staging categories, and treatment duration is greater than one year, unlike many adult-onset malignancies. these differences required interpretation of the guidelines to apply to our pediatric population for all and other pediatric diagnoses with non-surgically based staging. our pediatric oncology clinic has to date provided scps to 141 of 277 eligible patients by adapting the guidelines to focus on patients with curative intent to receive an scp by six months off therapy. cancer staging guidelines and goals for curative intent as well as lengths of treatment vary between the pediatric and adult populations. the coc guidelines require adaptation for optimal applicability to the pediatric oncology population. background: education in communication for fellows in fields that require difficult discussions with families are few in nature. adult learning pedagogies such as role play are under-utilized in medical education, and have been shown to be as effective as traditional teaching methods such as lecture. an 8-module course for fellows in hematology/oncology, hospice and palliative medicine, radiation oncology, and pediatric hematology/oncology was implemented in january/february 2017. 12 fellows participated in the program. topics covered including fundamentals of communication, coping and spirituality, delivery of bad news, communicating with families, sexual dysfunction during treatment, palliative care/death and dying, and burnout. objectives: overall goal of this course is to foster holistic physicians who views their patients as people with cancer, not cancer patients, and physicians that can communicate effectively with their patients throughout the disease continuum. by the end of the course, learners should be able to practice the fundamental principles of good communication. design/method: fellows initially participated in a pre-course osce to establish baseline skills. osce was facilitated by the center for learning and innovation at northwell, and included actors portraying a pediatric patient and family member to whom the fellow had to break bad news. two months later, the course was carried out over the span of eight weeks and included didactic sessions followed by 45 minutes of role play scenarios. five of the eight modules included role play, with faculty members serving as simulated patients. after the course, a second breaking bad news osce was held. both osces were filmed, and feedback was given by the on-site actors. additionally, faculty members were given access to the videos in an on-line format and were given an evaluation tool to assess the fellows' performance pre-and post-intervention. fellows were given subjective surveys pre-and post-course as well. results: subjective data from participants showed a noticeable increase in comfort level in all areas on the pre-and post-course survey. data obtained from osce videos showed improvement in communication skills as assessed by sps and faculty members using a new evaluation tool developed by faculty. initial first-run data shows that this course is successful in improving communication skills as well as increasing fellows' comfort level across several domains of communication. future directions for our course include improving and validating our assessment tool, expanding our topic base to include more aya and pediatric scenarios, faculty development for improved role play, and investigating impact on practice after course completion. background: acute lymphoblastic leukemia (all) is the most common form of childhood cancer with approximately 2900 children diagnosed each year. survival rates have improved significantly over the past several years. children with all are at risk for developing musculoskeletal complications during and after completion of treatment, which can contribute to impaired activity, elevated body mass index (bmi), and risk for complications. interventions involving physical activity could improve musculoskeletal strength as well as overall health in these children. the aims of this study are to examine the feasibility of a directed physical activity program for children with newly diagnosed all during the initial intensive phase of therapy and to evaluate the overall health and quality of life of children participating in the directed physical activity program. design/method: all subjects will receive education materials about the importance and safety of physical activity and a nutrition handout. all subjects will also participate in the directed physical activity program under the supervision of a trained physical therapist for at least 40 minutes every week for 12 weeks. the program will entail four stations including a cardiovascular, balance/proprioception, strength and flexibility, and coordination and cardio. feasibility will be assessed by tracking the participation rate throughout the study period. other assessments will be made at study entry, at the end of 12 weeks of physical activity initiative and 3 months after completion of the intervention. assessments include overall strength and flexibility, weight, height, bmi, blood pressure and performance scores. descriptive statistics will be used for this study. results: a total of 10 patients, 3 male and 7 female, enrolled in the study over a 9.5 month period. patient ages ranged from 5-16 years. half of the patients enrolled have completed the 12 week program and all 5 patients had stability or improvement of their physical functioning scores. further data collection and analysis is ongoing. patients in the early intensive phase of all therapy are at risk for complications that can affect their physical functioning. a directed physical activity protocol may improve their overall physical functioning. patients may not need specific physical therapy; however a directed physical activity program appears to be beneficial for these patients. the main roadblocks to successful completion of the program were difficulty with scheduling, strain on the parents and patient from treatment, unplanned admissions for fever, as well as nausea and fatigue at time of visit. albany medical center, albany, new york, united states background: communication skills are a core competency highlighted by the acgme. increasing resident confidence in delivering difficult news has been shown to lead to more s189 of s301 effective communication. currently, the majority of residency programs lack formal training in communication skills. our objective was to demonstrate feasibility and efficacy of integrating a standardized-patient based training program for communication skills into the curriculum of pediatric residents design/method: to date, 10 pediatric and 4 medicine/pediatric residents have participated in the program during the intern year. the program consists of three, two-hour long sessions, in which each resident is given several opportunities to act out case scenarios with a standardized patient. scenarios included informing a parent of their child's new cancer diagnosis and disclosure of a positive hiv test to a teenager. residents received post hoc peer to peer, and preceptor to learner feedback. pre and post-program surveys were completed by residents. results: following course completion residents reported an increase in confidence in multiple areas of communication including giving a difficult diagnosis (p<0.05), discussing a poor prognosis (p<0.02), responding to different patient/family member emotional responses i.e. crying or anger (p<0.01), and organizing vital information to be relayed (p<0.01). in conclusion, communication skills training of pediatric residents is feasible and provides a platform for developing valuable skills not taught elsewhere within the curriculum. background: for children with cancer, transitioning back to school during or after treatment can be challenging. literature supports the need for school re-entry programs to ease this transition. however, these programs vary widely among pediatric cancer institutions with little data addressing their program components. data from this study provides information on current school re-entry programs across these institutions. objectives: one objective of this study was to assess for correlation between the presence of a school re-entry program and other factors, such as geographic location and institution size. a second objective was to establish a list of differences between institutions' school re-entry program components. finally, we aimed to describe current school reentry practices, as well as program benefits and perceived areas for improvement. states with membership in the children's oncology group were offered enrollment in this study. a member of each institution was invited to participate in a survey established by the research team. this person was closely associated with the institution's school re-entry practices. each interview queried institution demographics, as well as program components (e.g., participants, target audience, resources). comment was also collected on program benefits and potential for improvements. analysis of transcripts was performed using pearson's correlation to assess for relationships between institution size, geographic location, and program presence. grounded theory was used for analysis of benefits and improvements. results: thirty-nine of forty-one pediatric institutions who were offered enrollment participated in this study. twentynine institutions (76%) indicated the presence of a school reentry program, and ten (24%) stated they had none. no correlation was found between institution size and the presence of a school re-entry program (p = 0.627, ns). there was also no correlation found between institution location and the presence of a school re-entry program (p = 0.921, ns). a major theme surrounding the benefits of having a program included education for the returning student's peers. for those with programs, perceived improvements included increasing staffing and the ability to offer more services. the results do not support the hypothesis that the presence of a school re-entry program is influenced by the size and geographic location of the treating institution. however, data seem to suggest that available staffing may influence the presence of a program. future studies are needed to address other potential influences, as well as to take an evidence-based approach to determine the effectiveness of the interventions present in these programs. cohen children's medical center/ zucker school of medicine at hofstra-northwell, new hyde park, new york, united states background: genetics/genomics is evolving at an extremely rapid pace. current advances lead to individual algorithms toward disease treatment for each disease with multiple branch points. fellows learn only a fraction of the knowledge and there is no formal approach to teaching critical analysis of information and application algorithms toward disease. additionally, as knowledge evolves extremely rapidly, any approach must teach self-acquisition and application of evolving discoveries. objectives: to create, implement and evaluate a novel curriculum for genetics/genomics targeted toward pediatric hematology/oncology fellows design/method: the curriculum includes four components: 1) genetic and genomic medical knowledge, with one initial team-based learning session and weekly online multiple choice questions; 2) essential pathways, which will teach molecular pathways common in oncogenesis and relevant to targeted therapy in microteaching sessions with using auditory, visual and tactile learning; 3) knowledge acquisition and clinical judgment, to allow learners to gain experience into researching data available, then developing and prioritizing potential treatment plans using problem-based learning sessions in which they will stage a patient, research treatment options, prioritize and present findings; and 4) synthesis to demonstrate independent ability to research and recommend therapy through an independent project in which the learner, given a case, will present the case and research findings, genetics/genomics, molecular pathways and make recommendations for therapy in molecular tumor board for faculty and fellows. to evaluate, we plan to recruit 12 to 16 institutions, match for size of programs and implement in half and evaluate 2nd and 3rd year fellows in both groups by mcq exam and satisfaction surveys. the creation of a multi-module, adult-learning based curriculum for genetics and genomics in pediatric oncology is feasible. implementation and evaluation are necessary to demonstrate efficacy. background: neuroblastoma is the most common extracranial solid tumor in children. chimeric anti-gd2 antibody ch14.18 (dinutuximab) therapy has improved the survival of children with newly diagnosed high-risk, neuroblastoma patients as well at the time of first relapse/progression. acute neuropathic pain is a well-documented side effect of dinutuximab administration. however, additional adverse effects including sensorimotor neuropathy, ocular symptoms, and behavioral changes have been described. the incidence and severity of these effects are currently not well-documented in pediatric patients. with improved long term survival of patients receiving this modality, it is important to look for the potential late effects of dinutuximab. objectives: to determine the incidence and severity of neurologic, ophthalmologic, or behavioral changes after dinutuximab administration at our institution. we performed a retrospective chart review using our electronic medical record. we included all patients with high-risk neuroblastoma between the ages of 1 and 21 years at our institution diagnosed between 1997 and 2017 who received dinutuximab. patients with history of opsoclonus-myoclonus syndrome or gross sensorimotor neuropathy prior to receiving dinutuximab were excluded. we examined clinical documentation for subjective reports and objective exam findings of neurologic, ophthalmologic, or behavioral changes. we also looked for referrals made to neurology, ophthalmology, physical medicine & rehabilitation (pm&r), and psychology. : twenty-two patients met inclusion criteria. at the time of chart review, 15 patients were alive and 7 were deceased. eighteen patients received dinutuximab per anbl0032; 5 patients received dinutuximab per anbl1221. of these 22 patients, 11 patients reported symptoms of interest and 5 reported multiple symptoms. six patients reported symptoms that began at least 12 months after completing dinutuximab. nine patients had objective findings on exam, including decreased deep tendon reflexes, abnormal pupils, and nearsightedness. for 10 patients, 15 referrals were made to ophthalmology, pm&r for neuropsychologic testing, or neurology. two patients who reported symptoms of interest were not referred to a specialist. conclusion: neurologic, ophthalmologic, and behavioral symptoms were commonly reported and demonstrated on exam among pediatric patients with high-risk neuroblastoma who received dinutuximab. it is important to identify these effects so that appropriate specialist referrals can be placed for adequate management of these changes. we recognize that these symptoms may not be solely due to dinutuximab as these patients receive other agents including opioids, so a prospective trial is needed to further evaluate the long-term effects of dinutuximab and to determine how best to screen for these effects. akron children's hospital, akron, ohio, united states background: pediatric cancer is the leading cause of diseaserelated death in children in the united states (u.s.). in 2014, over fifteen thousand children were diagnosed with cancer in the u.s. this population is at high risk for malnutrition due to the multimodal therapies they receive: surgery, chemotherapy, radiation therapy, antibody therapy, and/or bone marrow transplant. adverse effects of these therapies include taste changes, loss of appetite, diarrhea, vomiting, and/or mucositis, making it difficult for the children to be able to consume adequate amounts of nutrition during therapy. there is no "gold standard" measurement tool for identifying patients at risk for malnutrition. nutritional status is not frequently evaluated as a component of clinical trials. assessment of anthropometric measurements (weight, height, z-scores) at diagnosis, as well as over the duration of treatment, can assist in the early identification of malnutrition. the incidence and prevalence of malnutrition in this population is unknown at akron children's hospital. the purpose of this study is to describe the nutritional status and provision of nutritional support therapies in pediatric patients during their first year post new oncologic diagnosis. objectives: identify the incidence and prevalence of malnutrition across oncologic diagnostic categories over the first twelve months post diagnosis. we performed a retrospective records review of all patients newly diagnosed with cancer in 2015 at akron children's hospital. demographic and anthropometric data was collected at time of diagnosis and nutritional status categorized by z score. anthropometric and nutrition support data was then collected every two months for the first year after diagnosis along with incidence of unplanned inpatient admissions. results: a total of 65 patients were included in the analysis, with 6.2% malnourished at time of diagnosis; 12.3% developed malnutrition the first year. patients with solid tumors represented 50% of patients with pre-existing or acquired malnutrition. overall, 47% of patients received at least one nutritional support modality. patients with pre-existing or acquired malnutrition had a non-significant increase in unplanned admissions (p = 0.1196). our study demonstrated that patients with solid tumors were found to be at increased risk of pre-existing and acquired malnutrition, followed by leukemias, and experienced higher incidence of unplanned admissions in the time period observed. prospective, multi-center replication of this study, including detailed collection of nutrition therapies is recommended to guide development of diagnosis specific nutrition support guidelines. background: pediatric and young adult oncology patients treated with intense chemotherapy have a high incidence of transfusional iron overload. iron deposition can lead to heart failure/arrhythmias, liver abnormalities, endocrine dysfunction, ineffective erythropoiesis, and increased cancer and mortality risk. however, there is a paucity of data regarding recommendations for management of transfusional iron overload in these cancer survivors. consequently, long-term complications of transfusional iron overload specific to these patients have not been assessed. objectives: to assess screening and phlebotomy-based treatment algorithms for this population. design/method: a retrospective chart review of pediatric and young adults who completed oncology management, had iron overload, and initiated phlebotomy treatment was conducted. tiered screening occurred in patients that received at least 5 packed red blood cell (prbc) transfusions. patients were recommended for evaluation and possible phlebotomy if: (1) liver iron concentration (lic) >5 mg of iron/gram dry weight liver tissue by ferriscan and/or (2) cardiac mri t2* < 20 ms. during phlebotomy, iron status was assessed quarterly and phlebotomy discontinued with lic <5 or normalization of ferritin/imaging lic verification. descriptive statistics were employed to report the characteristics of the study population. spearman correlations were utilized to describe associations between transfusions, lic, ferritin, iron saturation and number of phlebotomy sessions. results: twenty five survivors underwent phlebotomy. the mean age was 11.6 years (sd 6.1) and 10 (40%) were female. oncologic diagnoses: all (36%), aml (8%), nhl (12%), ewing sarcoma (16%), osteosarcoma (4%), neuroblastoma (12%) and cns (12%). patients received a median of 25.0 (iqr 17 -34) transfusions. median number of phlebotomy sessions was 6 (iqr 4-8) over 0.36 years (iqr 0.28 -0.59). prior to phlebotomy, median lic was 7.5 mg/g (iqr 5.6-9.0) and ferritin was 1110.0 ng/ml (iqr 700 -2030) . no patients demonstrated abnormal cardiac t2* mri (n = 18). 23 (92%) patients completed phlebotomy. one discontinued due to poor vascular access. no patients developed iron deficiency. lic was reduced by a median of 2.4 mg/g (iqr 1.1 -3.6) and ferritin by 586 ng/ml . correlation between number of transfusions and phlebotomy sessions was poor (r2 = 0.017). conclusion: management guidelines are lacking for transfusional iron overload in pediatric and young adult survivors of cancer. we demonstrate a phlebotomy algorithm that is effective and tolerated. correlation between number of transfusions received and phlebotomy treatments was poor, necessitating serial assessments. using this management algorithm, prospective studies can evaluate the effect of iron removal on iron overload complications in this patient population. penn state children's hospital, hershey, pennsylvania, united states background: cancer therapy leads to an impaired immune system that takes time to recover. it is important to ensure that these survivors have adequate immunity to prevent common yet potentially severe childhood illnesses. no validated guidelines currently exist for surveillance testing or re-immunization in this population. retrospective analysis involving a small cohort of pediatric cancer patients treated at penn state children's hospital showed 46% of patients screened for varicella immunity after therapy completion did not have adequate disease titers. to determine the proportion of pediatric cancer survivors who have lost humoral immunity to previously received vaccines; to determine the rate of response to single dose boosters or full vaccine series in seronegative subjects after one booster. design/method: pediatric cancer survivors treated at the children's hospital who are at least 12 months from completion of cancer therapy are prospectively tested for antibody levels to hepatitis b, tetanus, varicella, measles, and 6 strains of pneumococcus (4, 6b, 9v, 18c, 19f, and 23f). samples are analyzed by the cdc for measles and varicella avidity. seronegative subjects by commercial studies, are eligible to receive booster vaccines. titers are rechecked at least 6 weeks after boosters to re-evaluate immunity; if still seronegative, subjects will receive the entire vaccine series. titers are finally tested at least 6 weeks after the final dose of the vaccine series. immunity analyzed after therapy, after boosters, and after vaccine series. results: of 37 pediatric cancers survivors who completed therapy, 78% were non-immune to hepatitis b, 92% nonimmune to >50% of pneumococcal strains tested, 24% nonimmune to measles, 54% non-immune to varicella, and 2% non-immune to tetanus. 1 of 13 subjects who received mmr vaccine after therapy and prior to study enrollment did not have protective antibodies to measles. of the 15 subjects who received varicella vaccine after end of therapy and prior to study enrollment, 6 did not maintain protective antibody levels. cdc results for measles and varicella are pending, as well as repeat studies after vaccine boosters and series. conclusion: a significant percentage of pediatric cancer survivors do not retain immunity to hepatitis b, pneumococcus, measles, and varicella. after one booster, a high percentage of subjects did not develop protective immunity to varicella. only 1 subject did not have immunity to tetanus, which is consistent with the high immunogenicity of tetanus toxoid. formal guidelines are needed to protect this population from vaccine-preventable illness post-therapy. children's hospital of richmond at virginia commonwealth university health system, richmond, virginia, united states background: childhood cancer survivors are at risk for being overweight. diet and physical exercise are important in maintaining a healthy lifestyle and weight; however, it has been reported that cancer survivors are less active than their peers. one reason for this may be that there are no clearly established risk-based exercise recommendations for cancer survivors. another reason may be that providers tend to focus s193 of s301 recommendations for exercise more towards patients who are overweight. objectives: to describe changes in physical fitness of childhood cancer survivors who exercise. design/method: 'moving forward' is a wellness and physical fitness program that the center for care beyond the cure at chor offers in partnership with the ask childhood cancer foundation and the ymca. the program is available for any childhood cancer survivor between 8y and 18y age, being seen at our center. survivors define their fitness or wellness goals and then work with a trainer once a week (at least) for 30 min sessions throughout the year to achieve these goals. baseline and ongoing measurements for core strength, endurance, overall strength and balance were collected. the average of each of the parameters of all participants were compared from the beginning to the end of the program. over the year, there was a 30% increase in endurance as measured by the average of the miles walked in 6 minutes, 40% increase in core strength as measured by the average number of sit-ups in 30 secs, an 80% and 44% increase in overall strength as measured by the average weight lifted by leg press and the average weight lifted by chest press, and a 10% increase in balance as measured by the average number of seconds balancing on a single leg. in addition, each child had actually gained weight in the process with an approximately 10% increase in the average of the weights of all children. there are benefits to regular exercise beyond weight control, and improvements in physical fitness can be seen even without weight loss. regular physical exercise results in improved physical fitness and should be universally advocated to all patients. determining insulin resistance, measuring changes in fatigue and wellness perception following exercise are future directions that we intend to explore. dana-farber cancer institute, boston, massachusetts, united states background: improvements in adolescent and young adult cancer patient (aya) survival rates and quality of life outcomes have lagged behind those of children and older adults, highlighting a need for research targeting this unique population. current literature supports the value of strong ayaclinician communication, notably in facilitating therapeutic alliance, however little is known about aya communication priorities during cancer care and barriers to optimal ayaclinician communication. objectives: to explore aya and oncology clinician communication priorities and to identify barriers and facilitators to aya-oncology clinician communication. design/method: semi-structured interviews were held with 21 aya cancer patients and survivors (ages 15-25 years) from a single large academic institution and 22 oncology clinicians (physicians and nurse practitioners) from 7 academic institutions in the northeastern united states. interviews were conducted in english by phone or in person. all interviews were audio-recorded and transcribed verbatim. analyses were aided by nvivo11 software. ayas identified a wide range of topics as important to discuss with clinicians. the most frequently identified topics were 1) side effects of treatment (with an emphasis on physical appearance and function, n = 16), 2) social issues (including friendship, family, and school, n = 13), 3) looking ahead to the future (n = 12), and 4) sexual & reproductive health (including future fertility, contraception, and romantic relationships, n = 8). clinicians prioritized 1) cancer treatment and side effects (n = 17), 2) emotional and psychological health (n = 11), and 3) sexual and reproductive health with a focus on fertility risk and fertility preservation (n = 8). aya reported facilitators to good communication including an open and long-established relationship with the clinician (n = 16) and clinician engagement in age-appropriate and patient-directed conversations (n = 7). barriers included parental presence during visits (n = 7). clinicians reported barriers including 1) clinician discomfort (not feeling wellequipped to discuss psychosocial topics such as sexual health, spirituality, and relationships with peers, n = 13), 2) presence of parents/family (n = 12), and 3) perceived patient discomfort discussing specific topics (such as sexual health, n = 10). clinicians acknowledged the need for collaborative efforts with additional team members (i.e. nurses, psychosocial providers) to assist in meeting aya communication needs. conclusion: aya and clinician-reported communication priorities are largely aligned. however, ayas emphasize some topics, such as social function, appearance, and sexual health that are not highly prioritized by clinicians, which may result in gaps in care for ayas in treatment and in survivorship. these data identify opportunities for intervention, including clinician education, patient and family education, clinic-based intervention, and systems-based changes that can be developed and tested. background: primary care physicians (pcps) cite lack of knowledge and inadequate communication with the oncology team as major barriers to providing recommended surveillance for late effects of treatment to childhood cancer survivors. a standardized telephone handoff to pcps posttherapy is a potential strategy to increase survivorship care by pcps through interactive communication. to determine the feasibility of a structured telephone communication using the situation, background, assessment, and recommendation (sbar) communication tool delivered by a trained oncology nurse to increase pcp knowledge and willingness to provide survivorship care. design/method: from 12/12/16 to 1/23/17, a registered nurse expert in childhood cancer survivorship attempted to contact by telephone the pcps of the 30 most recent patients attending yale's childhood cancer survivorship clinic that were <18 years old, english-speaking, and ≥2 years posttreatment. all pcps had been previously sent an individualized survivorship care plan (scp) that listed the patient's previous treatment history and recommended surveillance tests. upon successful contact and after confirming receipt of the scp, the nurse explained the definition of late effects, description of patient's diagnosis and treatment history, and associated potential late complications and schedule of recommended surveillance tests. the pcp was also asked about his/her ability and willingness to provide needed surveillance for late effects in the future. overall, 26 of 30 pcps were successfully contacted with a median of 1 phone call (range: 1-3) that lasted a median of 6 minutes (range: 3-10) after a median of 1 business day (range: 0-18). no pcps ended the call mid-conversation. all 26 pcps were receptive and expressed appreciation for the call. twenty-five of 26 (96%) pcps expressed an understand-ing of the material discussed and endorsed belief in their ability and willingness to provide late effects surveillance for their patients. no pcps questioned discussing their patient's care with a nurse versus a physician. interactive, structured communications between nurses and pcps by telephone are feasible and are associated with high-levels of pcp confidence in providing survivorship care. background: childhood cancer (cc) admissions account for 5% of non-newborn pediatric hospitalizations. these hospitalizations are longer and more expensive than other hospitalizations. admission payer (medicaid or commercial) reflects both health policy and sociodemographic status. the objective of this study was to determine if length of stay (los) or cost of cc admissions differed by payer. we used the 2012 kids inpatient database, a sampling of all pediatric hospital discharges in the united states. analysis for this study was limited to admissions containing a cancer diagnosis in any discharge icd-9 codes. admissions were further subcategorized by discharge codes according to diagnosis (leukemia, lymphoma, solid tumor and brain tumor) and reason for admission (chemotherapy, procedure, infection, non-infectious toxicity or "other"). charges were converted to costs using cost-to-charge ratios. multivariable linear regression models were performed to control for age, gender, race, reason for admission, and diagnosis. results: there were 105,752 weighted admissions for children with a cancer diagnosis in 2012. of these admissions, 40.5% had medicaid, 50.6% had commercial insurance, and less than 1% had other payers. the mean los for medicaid admissions was 7.37 days (95% ci 7.2-7.5), compared with 6.33 days (95% ci 6.2-6.4) for commercial insurance. surgical admissions accounted for the largest difference in length of stay with medicaid admissions being 2.77 days longer than those covered by commercial insurance (11.19 days vs 8.42 days), however, the difference was significantly different for all reasons for admission. in multivariable analysis admissions associated with commercial insurance were 6% shorter s195 of s301 (p<0.001), accounting for approximately one hospital day, than admissions associated with medicaid after controlling for other variables including race. the mean overall cost for medicaid admissions was $23,464 (95% ci 22840-24088), compared with $21,849 (95% ci 21343-22356) for commercial insurance. in the multivariable model, cost was collinear with race. conclusion: los and cost of admissions associated with medicaid differed from those associate with commercial payers. medicaid admissions were 6% longer on average than commercial insurance, accounting for a difference in length of stay of approximately one day although the difference varied with the reason for hospitalization (chemotherapy, surgical procedure, infection, other toxicity, other). costs of admissions were not independent of race. further investigation into potential explanations for this difference including differential access to home care needs, outpatient reimbursement differences, social indications for prolonged hospitalization, and provider biases, is warranted. background: pediatric cancer is a major cause of morbidity and mortality among children surpassed only by accidents. despite improved outcomes in high income countries (hic) survival rates remain poor in the developing word. there are various diagnostic and therapeutic limitations contributing significantly for the survival gap. the main objective of the study is to to evaluate the outcomes of pediatric cancer in armenia and identify diagnostic and therapeutic limitations in the country. we conducted a retrospective study among 97 (≤18 years old) children with cancer (solid tumors and hematological malignancies), who were diagnosed and treated at the clinic of chemotherapy of muratsan hospital complex of yerevan state medical university between 2008 and 2016. those patients, who didn't receive chemotherapy for any reason were not included in the study cohort. epidemiological, social, medical information was collected through the patient charts review. this included patient age at diagnosis, sex, place of residence (city vs village), the educational level and employment status of parents, type of cancer, stage, presentation of symptoms, first medical specialty consulted and the time consulted, initial work-up, the type of treatment received, information on the diagnosis/treatment received abroad. results: at our clinic during the mentioned period of time the majority of patients presented with hematologic malignancies-71%. 77 (74.6%) patients had information on diagnosis delay. average delay in diagnosis was about 42 days. in 33% of cases the first contact with "healthcare system" was through pediatrician, and in 20% with surgeon. out of 19 relapsed patients 10 received salvage treatment in armenia and 4 abroad. from those who stayed for treatment in armenia 4 patients survived. majority of relapsed patients had acute lymphoblastic leukemia. from 35 leukemia patients immunophenotyping and cytogenetics were available for 26 (74.3%) patients; the majority of missing cases were between 2008 and 2012, when these diagnostic modalities were not available or affordable in the country. 43 (45%) patients received part of diagnosis and/or treatment abroad. the most frequent reason for going abroad was bone marrow transplantation, otherwise none available in armenia. out of 97 patients 22 were lost to follow-up, 15 patients had a fatal outcome. 60 patients were in remission at a median follow up of 3.57 years. conclusion: unavailability of cancer registry and several essential diagnostic/treatment modalities, luck of multidisciplinary care and palliative support, high rate of out-of-pocket expenses were among the main challenges of pediatric cancer care in armenia. background: adverse drug reactions (adrs) are increasingly recognized as important and sometimes irreversible complications of cancer treatment. anthracyclines and cisplatin are effective chemotherapeutic agents, but their use can be limited by cardiotoxicity (anthracyclines) and ototoxicity (cisplatin) in up to 60% of patients. genetic variants that can be used to predict who is most at risk of developing these adrs have been discovered and replicated. objectives: to create pharmacogenetic risk prediction models for anthracycline and cisplatin toxicities and discuss results with oncologists to facilitate incorporation into treatment decision-making when appropriate. design/method: risk prediction models were developed from the linear regression of strongly-predictive genomic variants (odds ratios ≥ 3) discovered and replicated in at least three patient populations. these models were used to assess an individual patient's genomic risk of developing cardiotoxicity from anthracyclines or hearing loss from cisplatin. risk results were returned to oncologists showing where the specific patient's genetic risk of toxicity lies on a continuum between the lowest and highest risk groups across all studied patients using a multi-gene model. interviews were conducted with patients, families, and oncologists to determine how results were valued and utilized. results: 227 patients have been genotyped and had their genetic risk results returned to their oncologists. the first 140 patients have been characterized to determine the impact these test results have had on their clinical care. results were described as being useful in decision-making by patients and/or oncologists in 100% of cases. additionally, for patients in the most extreme risk groups (highest and lowest risk), a change in treatment plan was ordered 30% of the time for cisplatin patients and 35% of the time for anthracycline patients. this included increased cardiac and audiological monitoring, the addition of a protective agent, or choosing an alternative treatment protocol if the risk outweighed the benefits of remaining on the current treatment plan. in interviews, patients indicated that they felt more involved in decision making, and felt reassured by understanding their genetic risk of toxicities. genetic risk prediction models for anthracycline cardiotoxicity and cisplatin ototoxicity were highly utilized by patients and oncologists in decision-making. results were found to be an important tool for informing patients of the risk of adrs during cancer treatment, and resulted in patients and their families feeling more involved in decision-making. background: childhood cancer survivors are at increased risk of developing executive dysfunction, and low socioe-conomic status (ses) has been identified as one of the mediators of executive functioning. previous studies have used traditional measures of ses, such as parents' education level, family annual income and occupation. but more recently, area based socioeconomic measures like block group poverty status are deemed to be more useful in monitoring of social inequalities in health in the united states. block groups are statistical divisions of census tracts and generally contain between 600 and 3,000 people. the current study aims to understand the association of block group poverty status (percentage of households in family's block group of residence living below the federal poverty level) with executive functioning among cancer survivor children. design/method: we used a retrospective cohort of 67 childhood cancer survivors. relevant information was collected from the medical record, administrative data sets and parent-filled surveys. address information was geocoded using arcgis 10.2 to obtain data on the block group poverty status. a priori cut-points were set to represent block groups with families living below poverty level at 0%, 0.1% to 9.9%, and ≥10.0%. executive functioning were assessed through a parent-rated instrument, the behavior rating inventory of executive functions (brief). multiple linear regressions were used to determine the relationship between block group poverty status and the brief scores. results: data was examined from 67 families of childhood cancer survivors, ranging in age from 6 to 18 years. in this sample, 32.8% families reported an annual income <$60,000, 32.8% reported income between $60,000 and $100,000 while 34.3% reported annual income ≥$100,000. primary care giver of 85.1% of cancer survivors had more than more high school education, and 31.3%, 41.8% and 26.9%, of families were living in a block groups with 0%, 0.1-9.9% and ≥10% poor households respectively. block group poverty level was not significantly associated with annual income levels (spearman's rho = 0.14, p = 0.25), or parental education level (spearman's rho = -0.02, p = 0.84). in a step-wise multiple linear regression, there was no statistically significant association seen between block group poverty status and executive functioning after adjusting for co-variables in the final model. future prospective study with a bigger sample size, longer follow up period and more robust measures of the executive functioning like a clinician administered test are needed to understand the effect of block group poverty status on executive functioning. to d100 completion was 45.5 days (range 21-63). all parents strongly agreed/agreed that d100 was helpful and would recommend d100 participation to another family. ten parents (100%) reported time spent on d100 was "just right." no parent felt more worried due to the intervention, though 1 parent found d100 participation stressful. this interim analysis suggests that parents have a favorable d100 experience and recommend the intervention. to date, <20% of enrolled parents fail to participate. d100 shows promise as an acceptable interdisciplinary communication intervention targeted to the early treatment period for childhood cancer. children 's hospital and research center oakland, oakland, california, united states background: screening echocardiograms are recommended by children's oncology group (cog) guidelines to assess for anthracycline-induced left ventricular (lv) systolic dysfunction. the yield of screening echocardiograms during chemotherapy and in the immediate post-therapy period is uncertain. objectives: to assess the incidence of lv dysfunction detected by screening echocardiograms during chemotherapy and in the immediate post-therapy period, defined as 0-24 months off-therapy. design/method: children diagnosed with cancer between january 2013-march 2016 who received anthracycline chemotherapy were identified. echocardiograms were performed as per protocol, institutional and cog guidelines, and were reviewed retrospectively. lv dysfunction was defined as fractional shortening (fs) <28% or ejection fraction (ef) <55% (1) results: in this cohort (n = 195, median age 6 years), the most common diagnosis was all (54.8%), followed by aml (9.7%). of 357 echocardiograms, 224 (62.7%) were performed during treatment and 133 in the immediate posttreatment period. thirty-eight (19.3%) patients had a >10% decrease in fs compared to their pre-treatment echocardiograms. none of these patients required any treatment modification or cardiac medications. only 1 patient (0.5%) had echocardiogram-proven lv dysfunction discovered on a screening echocardiogram during her treatment course. she eventually died due to multi-organ failure following septic shock. this patient was receiving treatment for aml and had received 300 mg/m2 of doxorubicin-equivalent anthracyclines at the time of the abnormal echocardiogram. one patient with metastatic ewing sarcoma had borderline lv dysfunction with a fs of 30% detected a month before completion of therapy. she had received 375mg/m2 of doxorubicin equivalent anthracyclines at the time of the abnormal echocardiogram. she did not require any therapy modification or additional cardiac medications. serial echocardiograms done on this patient have shown stable ventricular function. no off-therapy screening echocardiograms identified lv dysfunction. in our experience, the yield of echocardiograms to detect anthracycline-related cardiac dysfunction during treatment and in the immediate post-therapy period is very low. one patient developed lv dysfunction during treatment and one had borderline fs, while no lv dysfunction was identified within 24 months of completing chemotherapy. though fs decreased in 19% of patients, none required intervention. further study is needed to optimize the use of echocardiography screening in children treated with anthracyclines. references: 1. landier w et al. jco 2012. background: platinum-based chemotherapy increases the risk of sensorineural hearing loss in children with cancer. little is known about the impact of hearing loss on cognitive and emotional functioning in survivors. to determine the association of severe/profound hearing loss after platinum-based chemotherapy with 1) cognitive impairment and 2) emotional distress (i.e. anxiety and/or depression). cross-sectional study of all patients attending yale's childhood cancer survivorship clinic ≥2 years off therapy for cancer diagnosed at <21 years and treated with cisplatin and/or carboplatin, but with no history of cns tumor, cranial radiation, congenital hearing loss, or developmental delay. hearing loss severity and hearing aid data were abstracted from audiograms and detailed clinical history. cognitive impairment was defined as behavior rating inventory of executive function t score ≥65, assessment by neuropsychologist, and/or history of special education. emotional distress was determined by brief symptom inventory t score ≥63 (global or two subscales) or behavioral and emotional screening system t score ≥61, psychologist interview, and/or history of psychotropic medication/psychotherapy. the most recent available patient data were used. logistic regression with sas software, version 9.4 was performed. results: overall, 37 patients (57% female, 78% white) met eligibility criteria with a median age of 9.0 years (iqr = 12.1) at diagnosis and 22.3 years at evaluation (iqr = 10.4) after a diagnosis of sarcoma (36%), neuroblastoma (32%), or other (32%) for which 84% received cisplatin and 30% received carboplatin. fifteen patients (41%) had severe/profound hearing loss in at least one ear. patients with severe/profound hearing loss had a significantly increased risk of cognitive impairment (or = 5.14; 95% ci = 1.17-22.69), but not emotional distress, compared to patients without severe/profound hearing loss. there was no significant association between age at diagnosis, current age, time since diagnosis, sex, race, ethnicity, or diagnosis with either cognitive impairment or emotional distress. similarly, there was no significant interaction between 1) age at diagnosis and hearing loss or 2) sex and hearing loss with either cognitive impairment or emotional distress. ten of the 15 (67%) patients with severe/profound hearing loss in at least one ear were recommended hearing aids, of which 3 (30%) reported compliance most of the time. we conclude that severe/profound hearing loss is significantly associated with cognitive impairment, but not emotional distress, in childhood cancer survivors. our data supports the need for interventions to improve hearing in these patients, including compliance with hearing aids. background: who grade 3 anaplastic astrocytoma is a high grade glioma dependent on vascular endothelial s199 of s301 growth factor (vegf) mediated angiogenesis for its growth and infiltration. bevacizumab is a recombinant humanized monoclonal antibody which binds vegf-a and inhibits angiogenesis. common adverse effects of bevacizumab are hypertension, proteinuria, thrombosis and bleeding. while animal model based studies have shown that bevacizumab may impair ovarian function the effects of bevacizumab therapy on human fertility are not clear. since the physiology of pregnancy involves neovascularization/angiogenesis it is recommended that conception be avoided for at least 6 months following exposure to bevacizumab. to describe the course of a young adult who became pregnant after receiving bevacizumab and radiation therapy for treatment of an anaplastic astrocytoma. a 20 year old woman diagnosed with a localized hemispheric who 3 anaplastic astrocytoma was treated with chemotherapy and radiation (temozolomide/59.4 gy) followed by 12 cycles of bi-weekly bevacizumab/temozolomide. patient opted not to pursue fertility preservation prior to initiation treatment. she experienced bevacizumab-associated proteinuria and hypertension during treatment but received all protocol mandated doses (cumulative doses: bevacizumab = 240 mg/kg; temozolomide = 15.78 gm/m2). she had a spontaneous unassisted pregnancy 18 months after completing treatment. her pregnancy was uneventful and she was normotensive throughout. fetal ultrasonography at 16, 20, 27, 33 weeks revealed no abnormality of the brain, heart, great vessels, kidney, extremities, placenta and umbilical cord. at 39 weeks she delivered a female infant via cesarean section (birth weight: 3890 grams, apgars: 95 and 1010) excessive post-partum hemorrhage was not reported. placenta was bi-lobed and weighed 604 g. histological analysis revealed normal placental villous development and maturation and two small infarcts. conclusion: exposure to bevacizumab in our patient had no detrimental effect on fertility and on placental/fetal vascular development. we hope this report will add to the existing data on the effects of bevacizumab therapy on fertility. children's healthcare of atlanta, emory university school of medicine, atlanta, georgia, united states background: reports of malnutrition incidence and prevalence in young cancer patients are variable and not well established. previous research suggests children, especially less than 3 years old, treated with intensive cancer-directed therapy are at higher risk for malnutrition. however, no standardized assessment has been used to evaluate risk in this population. objectives: we aim to assess the trends of weight-for-age for patients following cancer diagnosis. this study will be the first to use a standardized measure of treatment intensity (intensity treatment rating scale, itr-2) and will assist in targeting interventions for identification and treatment of malnutrition. design/method: this observational, retrospective study obtained data through the center's pediatric cancer registry and electronic medical record. patients were classified by tumor type (brain or non-brain tumor) and treatment intensity (itr-2). itr-2 incorporates diagnosis, chemotherapy, radiation, and surgery, beginning with lowest intensity (1) to highest intensity (4). inclusion criteria included new cancer diagnosis 2007-2015 at less than 3 years old, with weight obtained and available within 2 days of therapy start date. incomplete data, alternate growth charts, or treatment intensity of 1, were excluded. weight was obtained at start of therapy and through 2 years after treatment initiation (approximately 750 days) and converted to z-scores adjusted for age and sex. weight trajectories were modeled using generalized linear mixed models with subject-specific random intercepts and spline functions. separate functions were constructed for subgroups of interest (tumor type and itr). results: there were 402 patients included: 53 patients with brain tumors (13.2%) and 349 with non-brain tumors (86.8%). of included patients, 165 had treatment intensity of 2 (41.0%), 192 of 3 (47.8%) and 45 of 4 (11.2%). over the observation period, 34,593 valid weights were recorded. at initiation of treatment, no difference existed between z-score by tumor type (p = 0.880) or by intensity (2 vs. 3, p = 0.879; 2 vs. 4, p = 0.665; 3 vs. 4, p = 0.558). tumor type did not affect z-score through the follow up period. z-scores were higher for intensity rating 2 vs. 3 and 2 vs. 4 (p = <0.001 and p = 0.015 respectively) at 240 days after the start of treatment and persisted through 720 days (p = 0.003 and p<0.001 respectively). higher treatment intensity is associated with decline in z-score and failure to return to baseline. future directions include further analysis on specific risk factors and timing of weight loss, longer-term follow-up of weight trends, and targeted interventions for identification, prevention, and treatment of malnutrition. objectives: asses the pt requirements for bleeding episodes in a prospective cohort of pcp using a <10 × 10e9 threshold compared to a <20 × 10e9/l threshold in a historical cohort. we collected pt data in all pcps treated at our center between january/2013 through december/2017. diagnosis, prescription for pt (prophylaxis vs bleeding disorder), plt count and transfused units were assessed for each pt. pcps treated from january/2013 through june 2015 received prophylactic pt with a <20 × 10e9 threshold (cohort a), and pts treated from july/2015 through december/2017 received prophylactic pt with a <10 × 10e9 threshold. pts done for procedures and pts with concomitant hemorrhagic pathology were excluded. we compared the number of pts prescribed as prophylaxis vs bleeding episode between cohorts. data analyzed: graphpad prims 6.0®. statistical analysis: percentages with confidence interval (ci); t-student test (parametric variables) and mann-whitney test (nonparametric variables). statistical significance: p<0.05. we reviewed 2093 pts (871 in cohort a, 1222 cohort b) in 209 patients. 62% had acute leukemia, 33% received and auto or allo hsct. diagnoses and the proportion of patients undergoing hsct was comparable in both cohorts. the average number of pts per patient was 8,54 in cohort a and 8,24 in cohort b (p = ns), but a significant difference was found when hsct patients were excluded from this comparison (7,34 pt per patient in cohort a vs 6,07 in cohort b, p = 0,005), which resulted in an estimated 16,4% reduction in pts prescription. furthermore 61 (7,1%) pts were prescribed for bleeding episodes in cohort a versus 99 (8,2%) in cohort b (p = ns). patients receiving hsct in the entire group ver-sus those not receiving hsct had similar pt requirements for bleeding episodes (10% vs 8,5% p = ns) conclusion: a <10 × 10e9 plt count threshold for prophylactic pts is safe in pcp in chemotherapy and hsct. it can result in a significant reduction in pt usage. key words: platelets, transfusions, prophylaxis, cancer, childhood. ucsf benioff children's hospital oakland, oakland, california, united states background: transition of care for adolescent and young adult (aya) survivors of childhood cancer from pediatric to adult-oriented long-term follow-up (ltfu) is complex. loss to follow-up is common, and little is known about the success rates among different models. the survivors of childhood cancer program (sccp) at ucsf benioff children's hospital oakland employs a community-based model for transitional care. our multidisciplinary team provides aya survivors a comprehensive treatment summary and recommendations, then facilitates transition to primary care or adult oncology ltfu programs. evaluate the success rate for transition of care among aya survivors of childhood cancer in our ltfu program, and identify barriers to successful transition. design/method: aya patients seen from november 2010 to august 2017 in the sccp with intent to transition were asked by email or telephone if they had followed up with their designated provider. the primary outcome was successful transition, defined as establishing care within 18 months of their visit. patients were also asked about barriers to transition and to rate the new provider's familiarity with their cancer history and ltfu needs. results: transition was intended for 88 patients. eightyseven were contacted and 43 responded. of these, 29 (67%) successfully transitioned, while 14 (33%) were lost to followup. ages ranged from 19 to 48 years, at 2 to 32 years since completion of therapy. ten (34%) transitioned to a primary care provider, 20 (69%) to an adult oncology ltfu program, and 1 (3%) to a pediatrician. patients rated their new provider's knowledge above average (3.76) on a 5-point scale from poor (1) to excellent (5). survivors lost to follow up indicated the following barriers to transition: loss/change of insurance (3), inability to find a provider (1), too busy/forgot (4), problems with transportation (1), concerns about cost/copay (2), and s201 of s301 other (4). twelve patients requested further assistance with transition. conclusion: two-thirds of responding patients successfully transitioned. more work is needed to overcome various barriers to transition for one third of aya survivors. albany medical center, albany, new york, united states background: the transition from active treatment, to offtherapy follow-up, is a stressful event for parents of children with cancer. the psychosocial needs of parents after therapy have received limited attention in the united states with only 3 published quantitative studies, the largest with 35 parents. we have secured funding for and recruited a transition care coordinator (tcc) to investigate this further. objectives: our objective is to assess and screen parents at the end of their child's treatment, and to develop interventions to support parents during this time and thereafter. design/method: after informed consent, a standardized questionnaire, the psychosocial assessment tool (pat 2.0), was administered to parents at end of therapy (t1), 6 months later (t2) and 1 year later (t3). the tcc provided "universal" intervention to all families with an end of therapy binder containing a treatment summary, follow-up roadmaps, information on late effects, and survivor scholarships. based on their pat2.0 scores, some parents were provided intervention specific to symptoms (targeted intervention for scores 1-1.99) or referred to a behavioral health specialist through the clinic social worker for counseling (for scores >2). results: analysis of pat1 data showed that 45% of parents (n = 45) scored in the targeted or clinical ranges; 19% of parents scored in those ranges at pat2. significant gender differences were revealed with the mean score for men of 0.7 and for women of 1.13. this was confirmed by showing statistical significance (p = 0.017) when analysis was conducted for only a subgroup of data composed of couples (n = 24). analysis of pat2 data by couples (n = 10) showed the mean score for men was 0.64 and for women was 0.93 (p = 0.12). gender differences were most apparent in caregiver stress reaction questions that focused on ptsd symptoms. when the subgroup of couples' scores (n = 24) for caregiver stress reaction at pat1 was analyzed, there was a significant difference (p = 0.005) in caregiver stress reaction with a mean of 0.08 for men versus 0.3 for women. [note: subcategory scores range from 0 to 1]. this study was initiated in october 2013 using a tcc and the pat2.0 screening tool. the results suggest greater stress on mothers after therapy, with a substantial proportion of parents having symptoms of ptsd after therapy. background: hodgkin lymphoma (hl) is a common childhood cancer characterized by an inflammatory microenvironment. chemotherapy and radiation may exacerbate this inflammation and contribute to the development of late effects (pneumonitis or pulmonary fibrosis). in a heterogeneous cohort of childhood cancer survivors exposed to pulmonarytoxic therapy, no association between pro-inflammatory cytokines and late pulmonary dysfunction was observed. our objective was to test this association in a relatively uniform cohort of survivors of hl, given the well-recognized proinflammatory background of this disease. objectives: to characterize off-therapy pulmonary function in survivors of hl treated with contemporary therapy, and to investigate its association with persistent systemic inflammation. design/method: blood samples, clinical data, and pulmonary function tests were obtained from survivors of hl ≥6 months off therapy. lung function score (lfs), a validated method for assessing degree of pulmonary dysfunction on a scale of i to iv, was determined from diffusion capacity and forced expiratory volume in one second (fev1). for a control group, blood samples from patients with benign, noninflammatory hematologic conditions were used. plasma concentrations of 50 inflammatory cytokines were measured on a luminex platform (emd millipore). associations between clinical features or cytokine levels and lfs i (normal) vs. ii-iv were evaluated using logistic regression or wilcoxon rank sum tests, respectively. results: of 77 survivors (mean age at diagnosis: 14 years, range: 3-18; mean time off therapy: 3.3 years, range: 0.5-24), 70% were categorized as lfs ii (mild dysfunction), 8% as lfs iii (moderate dysfunction), and no survivors as lfs iv (severe dysfunction). higher lfs was associated with female sex (p = 0.01) but not other demographic, disease, or treatment factors. forty-eight survivors had blood samples collected at a mean age of 18.5 years (range: 10-32) with a mean time since treatment completion of 3.8 years (range: 0.6-6.1). of 31 controls, the mean age at time of blood collection was 12 years (range: 4-17). survivors did not have significantly elevated cytokine levels compared to controls. female survivors of hl ≥6 months off therapy are at increased risk of pulmonary dysfunction. neither evidence for pulmonary dysfunction, as measured by lfs, nor duration of time off therapy were related to systemic inflammation in this study. pulmonary function deterioration and clinical pulmonary symptoms are rarely observed immediately following therapy but increase over time. future studies may consider exploring the contribution of systemic inflammation to pulmonary late effects in survivors farther off therapy, when risk for this late effect is greater. background: thyroid carcinoma is a very rare tumor in pediatrics, accounting for 1.5-3% of childhood carcinomas in the united states and europe. we aim to detect the risk of second malignancies among pediatric thyroid cancer survivors. the cohort analysis consisted of pediatric cancer patients aged less than 20 years diagnosed with a primary thyroid cancer and identified by site code icd-0-3: c739, reported to a seer 9 database between 1973 and 2013. they were followed up by death or the end of the study period (december 31, 2013) . out of 1769 patients diagnosed primarily with thyroid carcinoma, there were 42 patients who had 45 incidences of subsequent malignancies. the mean age of patients at initial diagnosis of thyroid cancer was 16 years. females (90.5%) had significantly higher incidence of second malignancies (sm) than males (9.5%). the overall standardized incidence ratio (sir) of sm in thyroid pediatric patients was higher than expected (sir = 1.48). some specific sites showed significantly higher incidences: salivary gland (sir = 33.95), gum and other mouth (sir = 24.53) and kidney (sir = 5.72). the overall risk of sm in patients received radioactive iodine was higher than expected (sir = 4.41). the cumulative inci-dence of sms from the initial diagnosis of thyroid cancer was calculated with the survival methodology of competing risk, death treated as a competing event. cumulative incidence of sm was 2.7% [95 % ci (1.62, 3.83 %)] at 25 years and substantially expanded after 15 years, reaching 11.92% [95 % ci (4.9, 18.8%)] at 40 years. the cumulative incidence of each tumor type at 40 years was 0.452% [95 % ci (0.139, 0.765 %)] for breast cancer, 0.28% [95 % ci (0.034, 0.53 %)] for salivary gland, 0.22% [95 % ci (0.00034, 0.448 %)] for each one of kidney and cervix uteri and 0.169% [95 % ci (0, 0.361 %)] for each one of ovary and melanoma of the skin. cumulative incidence of sm was stratified based on race, gender and radiotherapy exposure, but there was no statistical difference in each of them. conclusion: race, gender, histological subtypes, and radioactive iodine may play an important role as prognostic factors for developing sm among pediatric thyroid cancer survivors. identification of underlying mechanisms that raise the risk of sm is important for both treatment and follow-up strategy. background: the ethical practice of informed consent requires it be both voluntary and understood by the research participant. in pediatric oncology, parents must undergo informed consent to enroll their child with cancer into clinical trials, but often it can be difficult to understand especially for parents with low english proficiency. previous research has shown that parents of children with cancer have difficulty understanding voluntariness, and that parental satisfaction with informed consent does not always correlate with adequate comprehension. objectives: to examine socio-demographic and contextual correlates of comprehension of informed consent, voluntariness, and satisfaction in parents who consented to participation of their child in a cancer clinical trial. we focused on characterizing differences between non-hispanics and hispanics, the fastest growing ethnic group in the u.s. design/method: parents/guardians (n = 121) of children aged 0-17 years with newly diagnosed cancer, who had consented to participation of their child in a clinical trial for cancer treatment at rady children's hospital-san diego were s203 of s301 prospectively recruited. parents completed questionnaires assessing comprehension, voluntariness, satisfaction, health literacy, socio-demographics, and acculturation level, if hispanic. comprehension was surveyed at baseline and longitudinally at 3 months. comprehension, voluntariness and satisfaction outcomes were analyzed by socio-demographics, health literacy, and acculturation level using logistic regression. results: of the 121 participants surveyed, 61 (50.4%) were hispanic and 60 (49.6%) were non-hispanic. we found that higher health literacy was associated with greater objective comprehension (p<0.001), voluntariness (p<0.001), socioeconomic status (p<0.001), and acculturation (p<0.001). hispanics reported lower objective comprehension (p = 0.025), voluntariness (p = 0.029), health literacy (p<0.001) and ses (p = 0.015) compared to non-hispanics. spanish-speakers reported lower voluntariness (p = 0.016), health literacy (p<0.001), and acculturation (p<0.001) compared to englishspeakers. at the 3-month follow-up, comprehension in hispanics significantly improved (p = 0.012) compared to their baseline comprehension. satisfaction was moderately high across all subgroups and was not significantly impacted by socio-demographics, health literacy, or acculturation. in this study, with equivalent numbers of hispanic and non-hispanic participants, we found that hispanic and spanish-speaking parents of children with newly diagnosed cancer had inadequate informed consent comprehension, voluntariness and health literacy despite high satisfaction. our study suggests that hispanics and individuals with limited english proficiency are not making truly informed decisions for their child with cancer. to ensure the ethical practice of research in pediatric oncology, the informed consent and decision-making process must be improved with culturally and linguistically interventions for these underserved populations. memorial sloan kettering cancer center, new york, new york, united states background: pediatric oncology patients undergo repeated bone marrow aspirations and biopsies (bma/bx). these potentially painful procedures can exacerbate anxiety and distress. standard practice at memorial sloan kettering (msk) department of pediatrics is to use propofol, which has amnestic but no analgesic properties. we sought to evaluate whether the addition of local anesthetic would improve patient experience with bma/bx. the purpose of reppair: reducing procedural pain and improving recovery of quality of life (qol) (nct02924324) is to evaluate the efficacy of local anesthesia with ropivacaine in reducing procedural pain and improving post-procedure qol in pediatric neuroblastoma patients undergoing bma/bx with general anesthesia. reppair is a prospective, randomized, crossover clinical trial that opened for enrollment october 2016. eligible patients were 3 -18 years old with neuroblastoma. participants were observed on trial for two sequential bm procedures; one procedure with intervention a: propofol alone (pa), and the other with intervention b: propofol plus ropivacaine (p+r). participants were randomized to intervention sequence ab or ba and were blinded to the order of interventions. participants and recovery room (rr) nurses, who were also blinded, followed a standardized postprocedure pain management algorithm. the primary endpoint was percentage of participants requiring opioid analgesia in the 24 hours post-procedure. secondary endpoints included total opioid in 24 hours, non-opioid analgesia use, pain scores, time to first opioid, and short-term qol. qol was assessed by a parent-proxy metric that evaluated pain interference with sleep, physical, emotional, and social recovery. as of january 2018, 105 patients were assessed for eligibility and 56 patients were randomized (47 have completed both procedures). for the primary endpoint, a slightly higher proportion of participants required opioid for pa than p+r (24% versus 21%, p = 0.6). pain scores in the rr were significantly higher for pa than p+r (median [25th, 75th percentile]: 2 [0,4] versus 0 [0,2], p = 0.004). there were no statistically significant differences in total opioid or non-opioid analgesia, 6-and 24-hour pain scores, median time to first opioid, or pain interference scores. there were no adverse events. conclusion: preliminary findings of the reppair trial suggest that local anesthesia does not reduce the need for opioid analgesia or improve short-term qol in pediatric patients undergoing bma/bx with general anesthesia. local anesthesia did improve pain scores in the immediate recovery period. final results of this study will help establish evidence-based guidelines and optimize the experience of pediatric patients with bone marrow procedures at our center. background: children with advanced cancer experience a range of symptoms throughout treatment or at end of life, some of which are poorly controlled. minimizing suffering, including effective symptom management, in children with advanced cancer is a central value for pediatric oncology clinicians. patient-reported outcomes have been used in symptomrelated research in pediatric oncology patients; however the majority of literature specific to symptoms during palliative care and end of life for children and adolescents with advanced cancer is based primarily upon medical record reviews and to a lesser extent, patient self-report. the purpose of this study was to prospectively describe symptom frequency, severity, and level of distress in children/adolescents with advanced cancer using patient selfreport and parent proxy. design/method: a prospective cohort design was used for this study. five pediatric oncology institutions from across the united states participated. children and adolescents were eligible to participate if they were 7-18 years of age, englishspeaking, and had a diagnosis of advanced cancer, defined as a 2-week history of progressive, recurrent, or non-responsive disease or a decision not to pursue curative-focused therapy. a modified version of the memorial symptom assessment scale (msas) was used to measure symptom frequency, severity, and level of distress and was administered to child/parent dyads electronically via smartphones every two weeks. information regarding disease status and cancer treatment was collected concurrently. data was analyzed using descriptive statistics and univariate logistic regression analysis. results: a total of 47 children and adolescents and 47 parents participated in the study. the median age of child participants was 13 years, with half being male. the median age of parents was 46 years. the child participants had a variety of primary diagnosis, including: leukemia/lymphoma (n = 11, 23%), solid tumor (n = 21, 45%), and brain tumor (n = 15, 32%). the most frequently reported symptoms by children with advanced cancer and parents were pain (n = 195/562, 34.70%), lack of energy (n = 186/561, 33.16%), and nausea (n = 156/560, 27.86%). presence of disease (p = <0.0001), recent disease progression (p = 0.0002), and receiving cancer therapy (p = 0.0004) were significant factors on the presence of pain. high intensity cancer therapy was a significant factor on pain frequency (p = 0.0445) and level of distress (p = 0.0224). it is feasible to collect data prospectively in children with advanced cancer regarding symptom frequency, severity, and level distress. clinicians' increased understanding of the symptom experience may promote communication with children and adolescents and timely intervention. more research is needed to understand symptom clusters in children with advanced cancer. vanderbilt children's hospital, nashville, tennessee, united states background: febrile neutropenia (fn) is a frequent occurrence in children undergoing chemotherapy. though guidelines recommend adding a second antibiotic to broad-spectrum antipseudomonal coverage in specific scenarios, augmenting empiric therapy with a second antibiotic is common practice. additional empiric antibiotic (aea) use increases the risk of antibiotic toxicity and future antimicrobial resistance. data clarifying the indications for aea are limited in pediatric patients. objectives: to identify risk factors for gram-positive (gp) and gram-negative (gn) bacteremia in patients presenting with fn to determine situations in which aea use is warranted. design/method: a retrospective chart review was conducted of pediatric severe fn with absolute neutrophil count <500/ l occurring at a single institution between 2006 and 2013. potential a priori risk factors based on clinical reasons for antibiotic expansion were chills, hypotension, mucositis, skin or soft tissue infections (sstis), recent administration of highdose cytarabine (hdac), and a diagnosis of acute myeloid leukemia (aml). potential factors for gn bacteremia were chills, hypotension, mucositis, and abdominal pain. the association between each potential risk factor and gp or gn s205 of s301 bacteremia was identified. logistic regression was used for multi-variable analysis. the review yielded 701 episodes. gp bacteremia was isolated in 75 cases (10.7%) and gn bacteremia in 37 episodes (5.3%). in multivariable analysis, hypotension (or 3.5 (95% ci 1.7, 7.2), p = 0.001) and sstis (or 3.1 (1.1, 8.7) , p = 0.036) were independently associated with increased risk of gp bacteremia, while mucositis (p = 0.376), recent administration of hdac (p = 0.34) and chills (p = 0.161) were not. ten patients with aml didn't receive hdac, thus the association between aml and gp bacteremia could not be reliably estimated. hypotension (or 4.9 (2.2, 11.0), p<0.001) and chills (or 5.0 (2.5, 10.1), p<0.001) were independently associated with a higher risk of gn bacteremia, while mucositis (p = 0.196) and abdominal pain (p = 0.509) were not. of the 37 gn infections, 6 (16%) were resistant to cefepime, the empiric agent of choice at our institution. patients with fn with sstis, hypotension, or recent hdac had increased risk of gp bacteremia indicating potential benefit of empiric vancomycin in these settings, while mucositis and chills were not associated with gp bacteremia. hypotension and chills were associated with gn bacteremia, potentially warranting empiric antibiotic expansion, while mucositis and abdominal pain were not. identifying specific indications for aea use in pediatric severe fn use may improve antimicrobial utilization, decrease unnecessary antibiotic use, and improve patient outcomes. background: for children/young adults with incurable high grade gliomas (hggs), like diffuse intrinsic pontine glioma (dipg) or glioblastoma multiforme (gbm), oncologists endeavor to align therapy with patient/family goals of care, but may be influenced by providers' preferences or limited resources. ethical challenges can arise around the perceived purpose, risks and benefits of therapy options, provider conflicts of interest, access to care, deciding decisional priority between patients and families, and conflicts around end-oflife care. objectives: evaluate factors that play into longitudinal decision making for children and young adults with hggs, their families and oncologists using a qualitative approach with ethnographic elements. design/method: eligible patients were aged 0-21 with dipg, gbm, or secondary hgg. patient exclusions included: non-english speaking, in state custody, death prior to diagnosis, seen by oncology once, or an oncologist declined participation. key decision making visits (e.g. mri reviews) were serially audio-recorded, along with subsequent 1:1 semistructured interviews with patients and/or parents about the decision making process. field notes from clinician meetings, chart notes, and oncologist questionnaires were obtained. discussions and interviews were transcribed and independently coded by three investigators. inter-rater reliability was assessed during code book development. discrepancies were discussed until consensus met. constant comparison analysis with maxqda software continued until thematic saturation. results: twenty-two of 34 eligible patients were approached; 15 agreed to participate. one withdrew upon transferring care. mean age was 9.9 years (sd 5.9); 71% male, 50% caucasian, 29% african american, 14% hispanic, and 7% asian. four encounters, (2.5 hours), were recorded on average per patient. parent/patient interview themes included: 1) hope (for a cure, prolonged life, and quality of life), 2) importance of physician recommendations, 3) importance of support systems (family, community, social media), 4) food (as cancer etiology, intervention) 5) finances (personal, research funding), 6) communication (with medical providers, family, community), 7) death, and 8) god (beliefs, prayer, existential questions). oncologists desired prolonged quality of life, while patients/families transitioned to that hope from hope for a cure. decisions made in the setting of hggs are multi-factorial, ultimately reflecting the competing values of decision makers. optimism about treatment efficacy is held in tension with poor prognosis, allowing for functional hope. acknowledging patients' and families' shifting hopes allows for changes in goals of care and shared decision making. future work is needed to 1) develop preference tools for pediatric patients and families to inform medical providers and 2) provide training in communication and shared decision making with oncologists. emory university, atlanta, georgia, united states background: bone marrow transplantation (bmt) is a potentially curative but underutilized treatment for scd. our previous work has shown that there is variation in physician philosophy and practice in considering bmt as a treatment option for patients with scd, and physicians may not discuss this with patients and families as a potential treatment option. in a randomized clinical trial to test the effectiveness of a decision aid for disease modifying therapies for sickle cell disease, adult patients with scd as well as caregivers of adult/pediatric patients were interviewed about how they seek or have sought information related to scd, made decisions about treatments for scd, and identified a treatment option they were interested in learning more about using the decision aid tool. we performed a secondary analysis of these baseline data to understand patient information needs and attitudes regarding bmt as a treatment option for scd. the goals of this analyses was to understand patient and caregivers' attitudes and perceived information needs regarding bmt as a treatment option for scd. we performed an analysis of baseline interviews from caregivers of patients with scd or adult patients from a randomized control trial for a decision aid tool for scd. 13 of the 38 interviews belonged to caregivers of patients with scd. in addition to reviewing interviews for discussion of bmt, we interrogated for mention of terms such as 'bone marrow transplant' or 'cure' or 'stem cell transplant'. interviews were coded using nvivo10 and analyzed for emerging themes. results: of the 98 baseline interviews, 38 interviews met selection criteria. thirteen of the 38 interviews were with caregivers of pediatric patients, and the remainder were with adult patients, including young adult patients with scd. the majority of participants want to learn about bmt or curative options. in many participants, this was expressed despite knowledge that they were not a likely candidate for transplant. desired information about bmt included eligibility, benefits, risks, long-term effects, quality of life and financial aspects related to bmt. of the patients who discussed how they learnt about bmt, approximately half mentioned that their healthcare provider had not previously mentioned this to them. we then examined knowledge of bmt and attitudes with demographic and clinical variables. patients and caregivers of pediatric patients with scd want to learn about bmt as a treatment option. healthcare providers should consider discussing bmt with their patients with scd. natasha frederick, anna revette, alexis michaud, jennifer mack, sharon bober dana-farber cancer institute, boston, massachusetts, united states background: adolescents and young adults (ayas) consistently identify the need for improved patient-clinician communication on sexual and reproductive health (srh) issues. however, oncology clinicians do not routinely integrate srh conversations with ayas through disease treatment and survivorship. little is known about why these conversations do not take place. objectives: explore aya perceptions of and receptiveness to srh communication with oncology clinicians and to identify barriers and facilitators to these conversations. design/method: semi-structured interviews were held with 21 aya cancer patients and survivors (ages 15-25 years, 6 men, 15 women). twelve participants were on active treatment and 9 were within 2 years of treatment completion. interviews were conducted in english by phone or in person. the interview transcript underwent pre-testing with ayas. all interviews were audio-recorded and transcribed verbatim. transcripts were analyzed and summarized by two trained qualitative researchers according to standard comprehensive thematic qualitative analysis methods. analyses were aided by nvivo11 software. results: ayas perceived existing srh communication between ayas and oncology providers as inadequate. all ayas reported a need for improved srh communication with oncology providers, and three key areas of need emerged: 1) general education; 2) addressing specific srh issues experienced during treatment and survivorship; and 3) understanding the long-term impact of cancer and treatment on srh. ayas felt that current srh discussions are limited and too narrow in scope and scale. ayas reported that most srh conversations focus exclusively on fertility (n = 17), usually taking place at the start of treatment. other additional yet limited communication reported was about sexual activity (n = 7), contraception (n = 7), sexual function (n = 1). no ayas reported conversations about potential treatment complications related to sexuality other than infertility. key barriers to srh conversations include patient discomfort initiating conversation (n = 14) and presence of family members (n = 10), with additional reported barriers including perceived provider discomfort (n = 4), lack of rapport with provider (n = 4), and age/gender differences (n = 4). ayas felt that s207 of s301 communication tools such as handouts, brochures, and websites would be helpful facilitators to direct communication from the oncology clinician, and wanted conversations to start before treatment initiation and to continue through treatment and survivorship conclusion: ayas identify a key role for pediatric oncology providers in srh care from diagnosis through survivorship, however multiple barriers interfere with discussions about srh on a regular basis. identified barriers suggest that future efforts should focus on provider education and training in srh and srh-related communication in order to optimize care provided to this unique patient population. background: peripherally inserted central venous catheters (picc) provide secure vascular access in pediatric patients for the delivery of necessary therapies. the ease of placement in the inpatient and outpatient settings has expanded their utilization. however, recent data analyses show a significant increase in venous thromboembolism (vte) risk with the use of picc lines. with its rising use, modifiable risk factors need to be understood for preventative measures. objectives: in this study we aim to understand patient and catheter specific characteristics in relation to the development of vte. design/method: with irb approval, a retrospective interrogation of the electronic medical record and a picc database, at rainbow babies and children's hospital, was completed. the study cohort contained patients < 18 years of age who had a picc line placed between january of 2004 and december of 2016. data collected included indication for line placement, line dwell time, location of insertion including blood vessel and extremity, number of attempts at line placement, lumen size and indwelling line length. in addition, we collected number of days to vte formation, associated symptoms and location of vte. chi-squared analyses and fischer's exact test were used where appropriate for statistical analysis. we analyzed 3729(1098 neonatal) newly placed picc lines. fifty line-associated vte events were found, for an incidence of 1.3%. all vte occurred with the placement of the first picc line. intravenous therapies were the most common reason for line placement. no statistical significance was found between various indications for placement. the most common symptom of vte manifestation was extremity swelling, follow by extremity pain. right extremity picc was found to have a higher incidence of vte. larger catheter lumen sizes (> 4 french) had a higher incidence of vte. we found a mean time of 20.07 days to vte detection. we were unable to find any clinical, patient or line specific factors leading to increased vte formation after statistical analysis. special consideration should be given to the duration of picc line use as this may reduce the incidence and comorbities associated with vte. there is still much to be understood about catheter associated vte formation as our analyses indicates the need for prospective data collection on a larger scale in hopes to create guidelines related to catheter use in pediatrics. background: the decision to transfuse a patient is a complex one and is never based solely on a number; however, certain hemoglobin or platelet count thresholds have been proposed in aiding physicians make transfusion decisions. in our hospital, the thresholds for packed red blood cell (prbc) and platelet transfusion in pediatric oncology patients are hemoglobin levels below 8.0 g/dl and platelet counts below 20,000/mm3 (< 35,000 for brain tumors), respectively. recently, these thresholds have been questioned and we were asked whether we could safely lower the thresholds to < 7.0 g/dl of hemoglobin and < 10,000 /mm3 platelet count objectives: to investigate platelet and hemoglobin transfusion thresholds for oncology patients at children hospital of michigan design/method: retrospective chart review over a 6-month period, examining platelet and hemoglobin pretransfusion levels for each prbc and platelet transfusion given to oncology patients results: over the course of 6 months, 60 eligible oncology patients (median age 6 years) received 584 transfusions (233 prbc transfusions and 351 platelet transfusions). the mean pretransfusion hemoglobin level was 7.6 ± 1.0 g/dl (range 2.3-11.9) (n = 233) for total prbc transfusions and this was not different among disease categories (p = 0.146). patients who had anemia symptoms and signs (n = 190) had a slightly lower hemoglobin level compared to those who did not (n = 43): 7.5 ± 1.0 vs 7.8 ± 0.9 g/dl (p = 0.058). the mean pretransfusion platelet count was 24,570 ± 15,151 /mm3 (range 2,000 -104,000) for total platelet transfusions (n = 351); 32,800 ± 14,586 /mm3 in patients with brain tumors (n = 84); 20,610 ± 15,270 in patients with leukemia (n = 119); and 23,090 ± 13,628 in patients with solid tumors (n = 148). the mean pretransfusion platelet count was significantly higher in transfusions for brain tumors compared to that in the other disease groups (p<0.001 for both). the mean pretransfusion platelet count was not different among those patients who had bleeding/bruising symptoms (25,150 ± 17,898, n = 115) versus those who did not (24,290 ± 13,648, n = 236) (p = 0.620). the bleeding/bruising rate was slightly but insignificantly higher in those who had platelet counts <10,000 vs those who had ≥ 10,000 (38.2% vs 32.2%, p = 0.564). since most patients develop symptoms of anemia at hemoglobin above 7 g/dl and about 1/3 of patients develop bleeding/bruising symptoms at platelet counts above 20,000 /mm3, our current policy so far reflects a safe threshold for transfusion, and further lowering of the thresholds should be investigated in prospective studies. background: renal impairment is an important complication of childhood cancer and its treatment. serum creatinine level is frequently used as a screening test to monitor renal function; however, patients can have significantly decreased glomerular filtration rate (gfr) with normal serum creatinine. to determine the prevalence of chronic kidney disease (ckd) among children with cancer diagnosis, based on calculated gfr. to compare the difference between using serum creatinine value alone versus gfr in detecting ckd. design/method: retrospective review of medical records of 150 patients, age 1-18 years, diagnosed between 1/2011-12/2016 with solid tumors were analyzed. serum creatinine and calculated gfr using schwartz formula were recorded. ckd as classified by the foundation of kidney disease and outcome quality initiative was used: ckd stage 2: gfr (60 to 89 ml/min per 1.73 m2) ckd stage 3: gfr (30 to 59 ml/min per 1.73 m2) statistical analysis using spss software v.23. chi-squared test for proportions within group, and pearson chi-squared and fisher exact tests for statistical differences between groups. p-value <0.05 was considered to indicate significance results: out of the 150 records reviewed, 81 (54%) were males and 69 (46%) females, with mean age of 9.2±5.6 years. 37 (24.6%) patients received one or more of nephrotoxic chemotherapy drugs; cisplatinum, carboplatinum, or ifosphamide mainly in the non-wilms solid tumors group (94.5%) compared to (5.5%) in the wilms tumor (wt) group. based on calculated gfr (by schwartz formula) ckd stage 2/or 3 was diagnosed in 66 (44%) patients with overwhelming majority (98%) were in the mild stage 2 ckd, only 3 (4.5%) of those patients had abnormally high serum creatinine levels (p = 0.006). 56.7% of patients who received nephrotoxic chemotherapy developed ckd, compared to 39.4% in those who did not receive it, (p = 0.01). despite that only 2/18 (11%) of wt group patients received nephrotoxic chemotherapy, yet this group had higher percentage of ckd (83.3 %) compared to non-wt group (34.8%) p = 0.02. significantly lower mean gfr 73.8±10 was noticed in the wt group compared to 99.8±29 in non-wt group (p = 0.001) conclusion: high prevalence of mild ckd was found among solid tumor patients. using serum creatinine alone as measure of renal function significantly under estimates renal impairment in those patients. early identification of ckd is easily achieved by using calculated gfr, which can helps providers and care givers to avoid potential nephrotoxic antibiotics, contrast media, nsaids and dehydration that may further deteriorate renal function the university of texas southwestern medical center, dallas, texas, united states background: children with down syndrome (ds) have increased risk of developing leukemia. pediatric patients with ds-associated acute lymphoblastic leukemia (ds-all) are known to have significant toxicities with reinduction chemotherapy and historically poor outcomes with stem cell transplant (sct). anti-cd19 chimeric antigen receptor (car) t-cell therapy, tisagenlecleucel, demonstrated high rates of durable complete remission (cr) and a manageable safety profile in children with r/r b-cell acute lymphoblastic leukemia (b-all). objectives: characterize the efficacy and safety of tisagenlecleucel in pediatric/young adults with ds-all. design/method: pooled data from 2 single-arm, multicenter, phase 2 trials of tisagenlecleucel in pediatric/young-adult patients with r/r b-all (eliana, nct02435849; ensign, nct02228096) were analyzed. eight patients with ds-all were enrolled (data cutoff: eliana, 23 november 2016; ensign, 1 february 2016). seven were infused with tisagenlecleucel; 1 patient died from all progression and intracranial hemorrhage before infusion. no manufacturing issues occurred during production. 5/7 infused patients were male, 2/7 had prior sct (age range, 6-16 years). 6/7 patients achieved cr or cr with incomplete blood count recovery (cri) by day (d) 28 (cr+cri, 86%); 1 died before d28 and was not evaluable. analysis of minimal residual disease was negative in bone marrow in responding patients. two patients had cd19negative relapses at 5 and 8 months. ongoing remissions in 4 patients without relapse ranged from 2 to 11 months. the safety profile (n = 7) appears similar to that in patients without ds in the same trials (n = 90). grade (g) 3/4 cytokine release syndrome occurred in 43% (3/7) of patients with ds and in 44% without ds. rates of other g3/4 adverse events of special interest did not appear to favor a consistent trend between patients with/without ds (febrile neutropenia: 43% vs 36%; neurological events: 14% vs 11%; tumor lysis syndrome: 14% vs 2%). g3/4 infections were not observed in patients with ds (0% vs 23%). one patient died after infusion due to intracranial parenchymal hemorrhage on d15 associated with ongoing coagulopathy. time and extent of tisagenlecleucel expansion and long-term persistence were similar between groups. conclusion: this is the first analysis of car t-cell therapy in pediatric patients with r/r b-all and ds. these data suggest that toxicities appear similar to those in patients with b-all without ds, remission rates in ds-all are high, and longterm outcomes with sustained persistence appear promising. further exploration of tisagenlecleucel as an alternative to sct in children with r/r ds-all is warranted. sponsored by novartis. background: hispanic adolescence and young adults are twice as likely to develop acute lymphoblastic leukemia (all) with high risk features as non-hispanic whites. they also have poor prognosis and 39% higher death rate. b-all with crlf2 overexpression caused by genetic alteration of the cytokine receptor, crlf2 is five times more common in this subgroup. approximately 80% of crlf2 b-all cases also have ikzf1 genetic alterations. ikaros is involved in transcriptional regulation of several important genes involved in leukemogenesis. overexpressed casein kinase ii (ck2) impairs functions of ikaros. objectives: understand the molecular mechanisms that regulate crlf2 expression in crlf2 b-all. here we present evidence that ikaros-mediated repression of crlf2 transcription in b-all in hispanic children is regulated by ck2. design/method: primary b-all patient samples from hispanic children were used. ikaros retroviral transduction, ikaros shrna transfection, real time-pcr, luciferace assay, quantitative chromatin immunoprecipitation (qchip) coupled with the next-generation sequencing (chip-seq), cytotoxicity assay and western blot. results: ikaros binding to promoter of crlf2 was confirmed using quantitative chip. functional experiments such as overexpression of ikaros in b-all primary cells results in transcriptional repression of crlf2 whereas ikaros silencing using shrna resulted in increased transcription. these results suggest that ikaros negatively regulates crlf2 expression. molecular inhibition of ck2 with shrna targeting the ck2 catalytic subunit, as well as pharmacological targeting of ck2 with cx4945 resulted in transcriptional repression of crlf2. ck2 inhibition was associated with increased ikaros dnabinding to the promoter of crlf2. however, the ability of cx4945 to repress crlf2 is lost or severely reduced, in cells with shrna silencing of ikaros, as compared to cells with intact ikaros. moreover, similar results were noted following treatment with cx4945 in leukemia cells obtained from high risk b-all patients with deletion of one ikzf1 allele. ikaros binds poorly to promoters of crlf2 gene in these cells. treatment with cx4945 restores ikaros dnabinding to the promoters of crlf2, which is associated with its strong repression. serial qchip analysis of the epigenetic signature at the crlf2 promoter showed that increased ikaros binding to the crlf2 promoter, following ck2 inhibition, is associated with enrichment for the h3k9me3 histone modification, which is a marker of repressive chromatin. results demonstrate that crlf2 expression is epigenetically regulated by the ck2-ikaros axis .cx4945 show antileukemic effect via restoration of ikaros tumor suppressor function, resulting in crlf2 repression suggesting advantage of using ck2 inhibitors as potential therapeutic approach in crlf2 altered b-all. results: hypodiploid all (modal chromosome number <44 and/or di <0.81) was identified in 131 patients (1.6% of all patients; 0.9% of nci standard risk (sr) and 2.9% of nci high risk (hr)), who were removed from frontline protocol therapy post-induction. overall 5-year efs and os were 52.1%±4.9% and 58.9%±4.8%. transplant status was retrospectively available for 113/131 (86%), 61 of whom underwent hsct in cr1. five-year efs with hsct was 57.4%±7.0% vs. 47.8%±7.5% without (p = 0.48). 5-year os with and without hsct was 66.2%±6.6% vs. 53.8%±7.6% (p = 0.34). when corrected for the median time to hsct (137 days), there were no significant differences in 5-year efs or os rates with and without hsct: 53.1%±7.3% and 64.2%±6.9% vs. 48.8%±7.8% and 53.8%±7.8%. no nci risk group or mrd subset benefitted significantly from cr1 hsct. sr patients (n = 42) had 5-year efs and os of 68.8±10.3% and 77.3%±9.2% with hsct (n = 27) vs. 57.1%±13.2% and 64.3%±12.8% without. hr patients (n = 71) had 5-year efs and os of 48.3%±9.0% and 57.6%±8.8% with hsct (n = 34) vs. 44.4%±9.2% and 49.9%±9.4% without. for those with end-induction mrd <0.01% (n = 74), 5-year efs and os were 66.3%±7.9% and 79.5%±6.7% with hsct (n = 39) vs. 60.3%±9.2% and 66.7%±8.8% without. end-induction mrd-positive patients (n = 30) fared poorly with both 5year efs and os of 29.4%±14.3% with hsct (n = 18) vs. 16.7%±10.8% and 22.2%±13.9% without. multivariate regression analysis including nci risk group, mrd, and cr1 hsct, showed only mrd negativity was significantly associated with efs (hr 0.256, p<0.0001) and os (hr 0.216, p<0.0001). patients with hypodiploid all fare poorly, particularly those with end-induction mrd ≥0.01%. while cr1 hsct is a standard treatment approach, it does not confer significant benefit. we were unable to assess bridging therapy prior to hsct, and comparator groups are small. taken together, however, new strategies are urgently needed for these patients. background: ras-pathway mutations are known to play a pivotal role in a significant proportion of myeloid malignancies, including upwards of 20% of pediatric aml cases. ras-pathway mutations in myeloid malignancy commonly co-occur with mutations of epigenetic regulators, suggesting cooperative leukemogenesis. among the epigenetic modifiers most frequently mutated in myeloid malignancy are regulators of dna methylation. this indicates that the alteration of dna methylation contributes to leukemogenesis. the ten-eleven translocation 2 (tet2) is an epigenetic regulator that plays an important role in regulation of dna methylation through its action of hydroxylation of 5-methylcytosine, which ultimately leads to passive de-methylation of dna cytosines. in myeloid malignancy, loss of function tet2 mutation is one of the most frequently co-occurring lesions in ras mutated malignancy. how specifically the altered methylation patterns in ras-pathway driven diseases promotes leukemogenesis is unclear. objectives: we hypothesize in mice with a ras-pathway mutation, that when an epigenetic modifier co-occurs, such as loss of function of tet2, this primes stem cells and/or early differentiating progenitors for transformation by preventing the repression of stem cell self-renewal genes, inhibiting differentiation, enhancing ras signaling and leading to leukemogenesis. we have generated a novel murine model with constitutive deletion of tet2 (tet2-/-) combined with an inducible activating krasg12d mutation (krasg12d/wt). mice have been tracked for evidence of hematologic malignancies and compared to mice with corresponding single genetic lesions. cooperative leukemogenesis will be demonstrated by decreased latency to disease onset, impact on malignancy lineage, in addition to investigating mechanistically through which pathways leukemogenesis may be promoted. results: krasg12d/wt/ tet2-/-mice demonstrate statistically significant differences in peripheral white blood cell count, hemoglobin, and platelet levels as early as 4-weeks post ras-pathway activation. peripheral cell lineage analysis demonstrates early skewing toward myeloid differentiation and marked splenomegaly in mice harboring both genetic lesions compared to wild type or mice with single genetic lesions. phospho-flow cytometric analysis reveals increased perk and ps6 activation in krasg12d/wt/ tet2-/-sca-1 enriched bone marrow cells compared to either genetic lesion alone. our study utilizing a murine model to examine how in ras-pathway mutations the addition of a co-occurring epigenetic lesion demonstrates that these lesions appear to cooperate to promote early myeloid differentiation with attendant changes in signaling pathways. this exploration to elucidate the mechanics of ras-pathway mediated disease lay the foundation for identification of patients who may benefit from existing therapies, such as dmtis, or identify new signaling targets for therapeutic exploration. background: the humoral immunogenicity of car19, a chimeric antigen receptor (car) with a murine scfv domain developed for treatment with tisagenlecleucel in relapsed/refractory (r/r) pediatric/young-adult acute lymphoblastic leukemia (all), was evaluated in 2 studies. little is known about the presence/impact of preexisting/treatmentinduced anti-murine car19 (mcar19) antibodies in patients treated with car therapy. objectives: patients from eliana (nct02435849; n = 68) and ensign (nct02228096; n = 29) were evaluated before and after tisagenlecleucel infusion to determine the impact of anti-mcar19 antibodies on cellular kinetics, efficacy, and safety. design/method: anti-mcar19 antibodies were determined by flow cytometry and reported as median fluorescence intensity. assay validation included evaluation of the interferences of intravenous immunoglobulin (ivig) treatment with the anti-mcar19 antibody assay. impact of preexisting and treatment-induced immunogenicity on cellular kinetics, efficacy, and safety was determined. treatment-induced immunogenicity was defined by a positive increase in anti-mcar19 antibody levels over baseline and was assessed by calculating the fold-change between preexisting (ie, baseline) and postinfusion levels. results: 90% of patients displayed preexisting anti-mcar19 antibodies; a similar incidence was detected in healthy volunteer samples during method validation. 35% of patients developed treatment-induced anti-mcar19 antibodies. no relationship was identified between tisagenlecleucel expansion (auc0-28d) and preexisting/treatment-induced anti-mcar19 antibodies (r2<0.001 and r2 = 0.006, respectively); similar results were seen for cmax. presence of treatment-induced anti-mcar19 antibodies did not appear to impact transgene persistence or response. kaplan-meier estimates showed that preexisting/treatment-induced anti-mcar19 antibodies did not appear to impact duration of response or event-free survival. strip plots showed consistent levels of preexisting/treatment-induced anti-mcar19 antibodies across patients with safety events, including cytokine release syndrome, neutropenia, thrombocytopenia, and neurological events. there was no apparent relationship between treatment-induced anti-mcar19 antibodies and b-cell recovery categories (≤3months, >3 and ≤6months, >6months, and ongoing sustained aplasia). no association existed between time of b-cell recovery and presence of treatment-induced anti-mcar19 antibodies. b-cell aplasia requiring ivig occurred following tisagenlecleucel in the majority of patients. the tisagenlecleucel concentration-time profiles in patients with treatment-induced anti-mcar19 antibodies were categorized by time following ivig administration. time of ivig administration had no impact on in vivo transgene expansion and persistence. we report the first comprehensive assessment of the impact of anti-mcar19 antibodies on clinical endpoints with car therapy. pediatric/young-adult patients with r/r all had a high frequency of baseline anti-mcar19 antibodies, and preexisting/treatment-induced anti-mcar19 antibodies did not impact the cellular kinetics, safety, and efficacy of tisagenlecleucel. cell-mediated immunity studies are ongoing. sponsored by novartis. background: adoptive immunotherapy, using cd123 engager (cd123-eng) t-cells, has shown success in preclinical studies, recognizing and killing acute myeloid leukemia (aml) blasts in vitro and in vivo. cd123-eng t-cells secrete bispecific molecules that recognize cd3 (t-cells) and cd123 (aml blasts), and are able to direct transduced t-cells and recruit bystander t-cells to kill cd123-positive blasts. however, cd123-engs do not provide costimulation and have not shown the capability for sequential killing of targets in vitro. we are seeking to improve the expansion, persistence and sequential killing capabilities of cd123-engs by genetically modifying these cells with an inducible costimulatory molecule, which can be activated by a chemical inducer of dimerization (cid). we generated a retroviral vector encoding cd123-eng and the inducible costimulatory molecule myd88.cd40 linked by a 2a sequence (cd123-eng.2a.imc). cd123-eng and cd123-eng.imc t-cells were generated by retroviral transduction, and their effector function was compared with and without cid. we used flow cytometric analysis to assess transduction efficiency, chromium release assays to evaluate cytolytic activity, and elisa to determine cytokine production. we successfully generated cd123-eng.imc tcells and achieved a mean initial transduction efficiency of 63% that was maintained above 50% throughout our study period. cd123-eng.imc t-cells +/-cid and cd123-eng t-cells readily killed cd123-positive aml blasts (molm13 and kg1a) in cytotoxicity assays when compared to the cd123-negative control (k562). in co-culture assays, cd123-eng.imc t-cells secreted increased il-2 and ifn-gamma in the presence of cid and cd123-positive targets (kg1a and molm13) when compared to co-culture with cd123-positive targets in the absence of cid. in addition, cd123-eng.imc t-cells displayed enhanced sequential killing capabilities and ifn-gamma secretion when stimulated weekly with cid and tumor cells at a 1:1 ratio when compared to cd123-eng t-cells. conclusion: cd123-eng.imc t-cells are able to recognize and kill cd123-positive aml blasts in an antigen dependent manner. cd123-eng.imc t-cells have improved effector function in the presence of cid as judged by cytokine production and their ability to sequentially kill cd123-positive target cells. thus, inducible myd88 and cd40 costimulation is a promising strategy to improve the effector function of cd123-eng t-cells, and warrants further active exploration in preclinical studies. background: eliana (nct02435849; n = 75) is a pivotal multicenter study testing the efficacy of tisagenlecleucel, anti-cd19 car-t, in children/young adults with r/r b-all. tocilizumab (toci) has been used for management of moderate/severe (grade 3/4) crs in ≈38% of patients treated with tisagenlecleucel at equivalent doses used in approved nononcological pediatric indications (<30kg received 12mg/kg; ≥30kg received 8mg/kg [800mg max dose]).(1) crs onset, as graded by the penn grading scale, generally occurred at a median of 3 days (range, 1-22) after infusion, requiring administration of 1-3 toci doses in some patients via a protocol-specific treatment algorithm. toci is a humanized monoclonal antibody that inhibits il-6 receptor (il-6r) signaling. the pharmacokinetics (pk) and pharmacodynamics (pd) of toci in pediatric patients with b-all with carassociated crs have not previously been described. objectives: characterize toci pk/pd for crs management following tisagenlecleucel infusion and describe its impact on cellular kinetics. design/method: toci pk and levels of soluble il-6r (sil-6r) were determined from serum and quantified using validated assays. maximum toci concentration (cmax) was derived using noncompartmental methods. sil-6r, proinflammatory cytokines, and crs resolution time were characterized to describe toci pd. summary statistics and graphical analyses of tisagenlecleucel exposure by number of doses were performed to describe the impact of toci on tisagenlecleucel kinetics in patients responding to tisagenlecleucel infusion. : 28/58 patients with crs received the first toci dose at a median of 5 days (range, 1-18) after crs onset. seventeen patients received 1 dose (range, 6.9-12 mg/kg); 8 received 2 doses (8-12 mg/kg); 3 received 3 doses (8-12 mg/kg), per the crs treatment algorithm. first-dose mean cmax (sd) was ≈111(30.6) g/ml; second dose, ≈265(376) g/ml. individual patient pd concentration-time profiles showed increased sil-6r levels after the first toci dose which remained elevated following the second dose. following toci administration, median time to crs resolution (including fever resolution) was 5 days (range, 2-29). crs onset coincided with tisagenlecleucel expansion, followed by a peak in serum cytokines, including il-6. the geometric mean auc0-28day and cmax of tisagenlecleucel transgene (by pcr) were 358% and 216% higher in tisagenlecleucel-responding toci-treated patients. conclusion: crs symptoms resolved within a median of 5 days after toci administration. toci levels achieved in patients with b-all were similar to reported pediatric nononcological indications (tocilizumab label) and resulted in concentration/time-dependent sil-6r increases. transgene continued to expand and persist following toci administration. these data support treatment with toci for crs management. (1) buechner, eha, 2017. sponsored by novartis. background: in acute myeloid leukemia (aml), mesenchymal stem and stromal cells (mscs) in the bone marrow microenvironment contribute to extrinsically mediated chemo-resistance and are therefore important potential therapeutic targets. the study of patient-derived mscs is at a competitive disadvantage, however, because traditional means of isolating mscs from a bone marrow aspirate interferes with isolating the more highly prioritized leukemic cells. many opportunities to study mscs are therefore missed. objectives: to develop a novel method of isolating mscs using the otherwise discarded portion of a bone marrow aspirate, thereby de-coupling the isolation of primary mscs from the isolation of leukemia cells. design/method: aml patient bone marrow aspirates were obtained prospectively from the children's oncology group. healthy patient marrow was purchased. experimental mscs were isolated from the bottom-most layer (rbc-layer) produced by density-gradient separation of a bone marrow aspirate, which is typically discarded. control mscs were isolated from the buffy coat (mnc layer). non-adherent cells were removed after 72 hours, and adherent cells were cultured at 5% co2 with mem-alpha containing 20% fbs. growth curves were obtained by seeding 6-well plates with 10,000 cells per well. cells were stained using oil red o to observe adipocyte differentiation. results: rbc-layer mscs grow successfully following overnight shipment of the aspirate. identical to mnc-layer mscs, rbc-layer mscs exhibit a fibroblastic morphology and are adherent to plastic. rbc-layer mscs persist in culture up to 14 passages before senescence. they exhibit a slower growth curve relative to mnc-layer mscs, but their overall doubling time is similar at approximately 120 hours. surprisingly, mscs from the rbc-layer exhibit adipocyte differentiation on stimulation, revealing their stem-cell like qualities. we present a method of isolating mscs from the discarded portion of a bone marrow aspirate that does not interfere with the isolation of leukemia cells from the same patient. this portion of the aspirate can be shipped, or can sit for at least 24 hours, without sacrificing its mscs. rbclayer mscs are nearly identical to mscs obtained conventionally. perhaps most importantly, rbc-layer mscs retain a stem-cell like capacity, showing them to be a highly valuable cell population in aml research. future plans include investigating potential selective enrichment of stem-cell mscs in the rbc-layer, which could explain the unexpected difference in growth kinetics. aml researchers now have the opportunity to study this exciting component of the bone marrow microenvironment without sacrificing valuable leukemic cells in the process. background: neutropenia is one of the most frequent side effect of chemotherapy associated with an increase in the risk of infection, especially in the cases when the depth and duration of neutropenia are extended. some genes, as variations of darc, gsdma and cxcl2 are known to influence white blood cell and neutrophil counts. our previous study conducted in children with acute lymphoblastic leukemia (all), showed that polymorphisms in these genes might play a role in the onset of chemotherapy complications during consolidation and maintenance treatment. objectives: in order to support our previous finding, we have expanded the study to the induction period in a cohort of 233 all children treated at the sainte-justine university health center between july 1995 and july 2005. design/method: previous associated single nucleotide polymorphisms (snps) in darc, gsdma and cxcl2 genes were analyzed for an association with the complications occurring during induction including the duration of low neutrophil count (pnn) and low absolute phagocyte count (apc), proven infections and delay between induction and consolidation phases. results: significant effect was found for all studied polymorphims. minor alleles of darc rs3027012, cxcl2 rs1680408 and gsdma rs3859192 were all associated with higher risk of complications during induction treatment, whereas that of darc rs12075 (particularly gg genotype) had a protective effect. the gg genotype of rs12075 was associated with a lower risk of post-induction delay (p = 0.02 or = 0.1, 95%ci 0.02-1.0), less frequent febrile episodes (p = 0.02) and lower number of days with apc/pnn count reduction (p = 0.008 for apc<0.5 and p = 0.02 for pnn<0.5). in contrast, the minor t allele of another darc polymorphism (rs 3027012), was associated with longer apc/pnn count reduction (p = 0.01 for apc<0.5 and p = 0.02 for pnn <0.5), as it was the tt genotype of gsdma rs3859192 (p = 0.02 for apc<0.5 and p = 0.04 for pnn<0.5). the patients with the gsdma rs3859192 had also a higher risk of documented febrile episodes (p = 0.04 or = 2.4 95%ci 1-5.5). the aa genotype of rs1680408 cxcl2 was associated with a higher risk of post-induction delay due to infection (p = 0.04, or = 3.4, 95% ci 1.1-11.5). conclusion: this complementary study confirmed our previous results, showing overall that variations in darc, gsdma and cxcl2 genes influence the onset of chemotherapy complications in pediatric all, regardless of treatment phases. these polymorphisms might be useful pharmacogenetics markers possibly guiding an adjustment of chemotherapy intensity. background: pediatric acute myeloid leukemia (aml) has a poor survival rate of about 70% and there is an urgent need for newer targeted therapies. car t-cell based therapies are effective against all but similar therapies against aml are still under development. recent clinical trials have highlighted the concerns about toxicity and therapy related deaths from car t-cells. antigen selection is the key factor determining the specificity, efficacy and toxicity of car t-cells. while contemporary adoptive t-cell therapies use monoclonal antibodies against tumor associated antigens we employed the naturally occurring flt3 ligand (fl) to target aml cells expressing flt3 receptors. flt3 receptor is expressed on multipotent and myelomonocytic progenitors as well as myeloid leukemia cells. to generate fl containing chimeric tlymphocytes designated flcar t-cells and to evaluate their efficacy against aml cells. design/method: flcar was constructed by fusing the coding sequences of the human fl, cd28 costimulatory domain, and cd3-zeta chain (intracellular region) in series. it was then cloned into the phiv-egfp lentiviral vector for expression in cell lines and primary t cells obtained from healthy donors. the empty phiv-egfp vector was used as a negative control. flcar was expressed on both cd4+ and cd8+ t-lymphocytes, confirmed by western blot. cell cytoxicity was evaluated by co-culturing flcar t-cells and aml cells followed by flow cytometric analyses. cytokine production was assessed by analyzing expression of interleukin-2 using quantitative rt-pcr. results: flcar t-cells were generated from cd4+ jurkat and cd8+ tk-1 cell lines with up to 70% lentiviral transduction efficiency. the efficiency for primary t cells was lower (5-10%). flcar was expressed as a ∼42 kda protein in cells and was partially phosphorylated on tyrosine. the expression of flcar on lymphocytes lead to increased basal il-2 expression in the cells. this was further augmented (by > 5 folds) upon co-incubating flcar t-cells with flt3expressing target cells. jurkat cells, tk-1 cells and primary human t cells expressing flcar suppressed the growth of flt3-expressing aml cell lines and primary aml cells in vitro. notably, flcar t-cells generated from healthy donors caused strong inhibition of aml cells even at a lower transduction efficiency. in vivo experiments using nsg-sgm mice xenografted with human aml cells are underway. our data demonstrate that flcar can be effectively expressed on t-lymphocytes and mediate potent cytotoxicity against flt3-expressing aml cells in vitro. being a completely human derived chimeric protein, it represents a promising candidate for further therapeutic development. holly pacenta, kelly sullivan, ahwan pandey, kelly maloney, joaquin espinosa children's hospital colorado, denver, colorado, united states background: individuals with down syndrome (ds) have a 20-fold higher risk of developing acute lymphoblastic leukemia (all) than the typical population. there are several important differences between all in individuals with ds (ds-all) and all in individuals without ds (nds-all): first, patients with ds-all have a lower percentage of favorable cytogenetic features compared to nds-all. second, patients with ds-all are more likely to have activating mutations in jak2, crlf2 overexpression, and ikzf1 deletions. despite these clear genotypic differences, this knowledge has not yet been exploited for therapeutic purposes in ds-all. when outcomes for ds-all are compared to nds-all with similar cytogenetic features, the survival rates are similar. however, individuals with ds-all have an increased risk of treatment-related mortality (trm). current therapy for ds-all is similar to that for nds-all, with the exception of small changes to decrease toxicities that are more prevalent in ds-all. it was recently identified that interferon signaling is constitutively activated in healthy individuals with t21. we hypothesize that aberrant interferon signaling could play a role in the unique leukemias observed in ds patients. objectives: to identify differences in gene expression and intracellular signaling cascades that are unique to individuals with ds-all, relative to both nds-all and healthy individuals with ds that can be exploited for therapeutic use. design/method: bone marrow samples were obtained from ds-all patients and matched nds-all patients based on clinical characteristics and genetic features. rna sequencing of these samples was performed and a total of 19 samples were used for the transcriptome analysis (6 ds-all vs. 13 nds-all). the differential expression data was generated by deseq2 and analyzed using ingenuity pathway analysis. the analysis revealed that the chromosome 21 genes that have been implicated in leukemogenesis are not differentially expressed in the ds-all samples, relative to nds-all. an inflammatory signature was identified, which included interferon gamma as an upstream regulator with predicted activation in ds-all. this finding is consistent with prior observations from healthy individuals with ds. other examples of results with potentially actionable targets include the upregulation of several genes in the ras pathway and genes involved in histone methylation. the increased interferon signaling seen in healthy individuals with ds was also identified in ds-all. this may contribute to the development of mutations in inflammatory pathways such as jak2 and crlf2 in ds-all. targeting these common pathways with small molecule inhibitors may have a therapeutic benefit in ds-all. cincinnati children's hospital medical center, cincinnati, ohio, united states background: next-generation sequencing (ngs) guides precision medicine approaches in oncology using therapies targeting molecular alterations found within an individual cancer. increased availability of ngs coupled with a proliferation of targeted drugs in development heightens the need for reliable pre-clinical animal models. here we report a patientderived xenograft (pdx) system with integrated molecular profiling for pre-clinical testing of conventional cytotoxic and novel targeted agents. objectives: to utilize ngs from patients with pediatric leukemia to guide rational pre-clinical trials in pdx leukemia avatars, and to determine pdx mice tolerance of and response to cytotoxic and targeted therapies. pediatric acute lymphoblastic leukemia (all) samples were obtained in adherence to an irb-approved protocol and xenografted into nod/rag/interleukin-2 (il-2)rg (nrg) mice. ngs was performed clinically using the foundationone® heme panel. a de novo all sample bearing mutations involving jak2, crlf2, ntrk3, cdkn2a/b, ptpn11 and wt1 was used for pre-clinical testing. thirty-seven nrg mice were transplanted with 2 million patient cells/mouse via iv injection. standard 4-drug induction chemotherapy was administered consisting of vincristine, dexamethasone, pegaspargase, and daunorubicin [vxpd, n = 6 mice], in comparison to vehicle control [n = 8]. parallel pdx cohorts were treated with single agent targeted therapies based on ngs findings, including ruxolitinib [n = 7], crizotinib [n = 8] and loxo-101 [n = 8]. the four-week treatment period began on day +30 from transplant after confirmation of engraftment. following completion of therapy, residual disease burden was analyzed by flow cytometry (hcd19+, mcd45-cells) in the bone marrow [bm] . to date, pdx models have been established using over thirty ngs-profiled pediatric all samples, including six samples bearing philadelphia (ph) chromosome or phlike mutations. pre-clinical testing was performed in a repreconclusion: ngs reveals concomitant mutations in ph-like all that may represent additional targets for therapy, or predict tyrosine kinase inhibitor (tki) resistance. we show that all xenograft nrg mice can tolerate a 4-week multi-agent cytotoxic chemotherapy induction regimen, as well as rational targeted agents, and serve as a robust pre-clinical model for precision medicine trials. background: osteonecrosis is a well-characterized all therapeutic toxicity attributed to glucocorticoids, asparaginase, and methotrexate that disproportionately affects adolescents. in ccg-1961, alternate-week dexamethasone during double delayed intensification (di) reduced osteonecrosis vs continuous dexamethasone with single di in rapid early responders (rer) ≥10y. to compare efs and os between hr-all patients with vs without osteonecrosis. design/method: hr-all patients 1-30y on aall0232 (2004-11) received cog augmented therapy with a 2 × 2 randomization to: (1) induction dexamethasone (10 mg/m2 d1-14) vs prednisone (60 mg/m2 d1-28), and (2) interim maintenance (im) high-dose methotrexate (hdm) vs escalating-dose methotrexate/pegaspargase (ema). rer received single, and slow early responders (ser) double, im/di. initially, all received monthly dexamethasone maintenance pulses, patients ≥13y received di alternate-week dexamethasone, and patients ≤12y received di continuous s217 of s301 dexamethasone. there were 2 osteonecrosis-related amendments: after 10/2006 all patients ≥10y received di alternateweek dexamethasone; after 6/2008 all patients ≥10y were assigned to induction prednisone, and all patients received di alternate-week dexamethasone and maintenance prednisone pulses. results: osteonecrosis was confirmed in 315/2817 patients. the 5y cumulative incidence (ci) was 12.7% overall and increased with age: 1-9y 2.6%, 10-12y 15.3% (alternateweek dexamethasone 10.2% vs continuous dexamethasone 23.5%; p<0.0001), ≥13y 19.7% (p<0.0001). among randomized rer patients ≥10y, ci differed by glucocorticoid (dexamethasone 25.0% vs prednisone 15.0%; p = 0.0003) but not methotrexate assignment (hdm 18.8% vs ema 21.5%; p = 0.7). among randomized ser patients ≥10y, ci was 18.9% with no difference by regimen. results were similar for patients ≥13y. in the entire study population, patients with osteonecrosis had superior 5y efs (89.0% vs 76.1%; p<0.0001) and os (95.8% vs 85.9%; p<0.0001) than those without osteonecrosis. 5y efs was significantly higher among randomized patients ≥10y with vs without osteonecrosis (88.5% vs 72.9%; p<0.0001); this finding was present in different age ranges (≥10y, ≥13y, ≥16y) and rer/ser subsets within each, especially in the ≥10y rer (92.6% vs 81.8%; p = 0.0004) and ser (74.0% vs 43.7%; p<0.0001) cohorts. across groups, asparaginase allergy was significantly associated with reduced osteonecrosis risk (≥10y: hr 0.43; p = 0.0013). patients who develop osteonecrosis have significantly increased efs and os, suggesting host differences that increase sensitivity to develop osteonecrosis and render all cells more chemo-responsive. pennsylvania state university, hershey, pennsylvania, united states background: cdc42 (cell division cycle protein 42) belongs to rho family of small gtpases in ras-oncogene superfamily. pro-oncogenic role of overexpressed cdc42 in ras driven solid tumors are well known. however, role of cdc42 in leukemia is yet to be established. ikzf1 encodes ikaros protein which has important role in regulation of lymphoid development and tumor suppression in leukemia. casein kinase ii (ck2) oncogene is overexpressed in leukemia. ck2 impairs ikaros function which can be restored by using ck2 inhibitors. objectives: to investigate role of cdc42 in leukemia and regulation of cdc42 by ikaros and ck2 in b-cell acute lymphoblastic leukemia (b-all). shrna transfection, real time-pcr, luciferace assay, quantitative chromatin immunoprecipitation (qchip) coupled with the next-generation sequencing (chip-seq), cytotoxicity assay and western blot. results: cdc42 is identified as one of the ikaros target genes by analysis of genome-wide dna binding of ikaros using chip-seq and qchip in b-all primary cells. expression of cdc42 was also noted to be higher in all patient samples compared to normal bone marrow. functional experiments showed that ikaros overexpression via retroviral transduction results in transcriptional repression of cdc42. ikaros silencing using shrna resulted in increased expression of cdc42. these data suggest that ikaros negatively regulates transcription and expression of cdc42. ck2 directly phosphorylates ikaros and impairs its function as transcription factor. we noted that molecular inhibition of ck2 via sirna as well as treatment with specific ck2 inhibitor, cx4945 also decreases expression of cdc42. treatment with cx4945 of primary b-all with ikaros haploinsufficiency restores ikaros binding to cdc42 promoter and represses cdc42 expression. however, this effect is evident only in presence of ikaros. treatment with cx4945 in ikaros silenced (ikaros shrna) cells showed no change in expression of cdc42. these results emphasizes the importance of ikaros in regulating cdc42 expression. furthermore, we analyzed the changes in epigenetic signature at the cdc42 promoter following treatment with cx4945. results show that loss of histone marker of open chromatin (h3k9ac) and increased histone marker for repressive chromatin (h3k27me3), at the cdc42 promoter. these data suggest that ikaros transcriptionally represses cdc42 via chromatin remodeling. a specific cdc42 inhibitor, ml141 showed cytotoxic effects on primary b-all cells. conclusion: cdc42 may have important role in hematologic malignancies. expression of cdc42 in b cell all is regulated by ikaros and ck2. these results suggest that targeting cdc42 could be a potential therapeutic strategy in leukemia. caitlyn duffy, laura hall, justin godown, koyama tatsuki, scott borinstein monroe carell jr. children's hospital at vanderbilt, nashville, tennessee, united states background: systemic corticosteroids are widely used as treatment of acute lymphoblastic leukemia (all) and lymphoblastic lymphoma. there are anecdotal reports of bradycardia in pediatric patients receiving corticosteroids, but a more extensive analysis of this effect is needed. objectives: the aim of this study was to describe the incidence, severity, and timing of steroid-induced bradycardia and document any adverse events associated with bradycardia. design/method: we performed a retrospective review of all newly diagnosed patients at our center (2010-2016) with all/lymphoblastic lymphoma who received corticosteroids (dexamethasone 3-5mg/m 2 /dose or prednisone 30mg/m 2 /dose) during induction chemotherapy. patients were excluded if they had a pre-existing cardiac abnormality or if they received prior corticosteroids. the average 24 hour heart rate (hr) was assessed for the period prior to initiating steroid therapy and for the 24 hour period surrounding the nadir following steroid administration. the degree and time of steroid induced bradycardia was assessed. adverse patient events and concomitant medication use was documented to identify other contributing factors to bradycardia. a total of 153 children (80 females, 73 males, 16 months-27 years) were included in the analysis with 159 demonstrating a decrease in mean hr following steroid administration. median hr decrease was 22.9 beats per minute (quartiles 12.5-32) from prior to initiating steroids to surrounding nadir. sixty one percent developed bradycardia less than or equal to the 1st percentile for their age range. nadir occurred 7 doses (range 5-10) into treatment, which corresponded to 79 hours (55-109) after initiation of therapy. of 94 patients who experienced bradycardia, 78% were associated with dexamethasone rather than prednisone. hr nadir was not associated with other vital sign abnormalities. after completion of induction chemotherapy, 87% of patients had documented resolution of bradycardia with hr greater than the 5th percentile for age. it was observed that the children who continued to have relatively low hr were often younger (20 months-5 years old). examination of nadir hr during subsequent hospitalizations in which steroids were not being administered (excluding hr during procedural sedation) did not demonstrate a significant incidence of bradycardia. concomitant opioid, beta-blocker, or other medication exposure did not contribute to the incidence of bradycardia. corticosteroid-induced bradycardia is extremely common in children, teenagers, and young adults with all receiving induction chemotherapy. bradycardia was not associated with clinical adverse events and resolved after completion of corticosteroid treatment. therefore, further cardiac assessment may not be warranted in the presence of bradycardia suspected to be secondary to steroid administration. baylor college of medicine, houston, texas, united states background: survival in newly diagnosed pediatric acute myeloid leukemia (aml) is approximately 65%; however survival falls dramatically if a patient relapses. currently, approximately one-third of patients with pediatric aml relapse on standard chemotherapy regimens. aml cells are exposed to proteotoxic stress at baseline due to their rapid and inefficient metabolism; proteotoxic stress increases after chemotherapy due to accumulation of reactive oxygen species resulting in misfolded proteins. this leads to activation of cell stress pathways, such as the unfolded protein response (upr) in the endoplasmic reticulum. because an activated upr can make cells more sensitive to proteotoxic stress, we hypothesize that upr activation correlates with response to chemotherapy. objectives: determine the status of upr in pediatric aml and its correlation with chemosensitivity; design/method: peripheral blood samples from pediatric patients with aml were collected at the start of induction chemotherapy, 6-10 hours (h) and 24 h post initiation of systemic chemotherapy. tumor cells were sorted from peripheral blood mononuclear cells. expression of upr proteins was determined by chemiluminescence using an automated capillary electrophoresis system. clinical correlations were performed using an annotated database. we measured five upr proteins: grp78 (glucose regulated protein 78kda), phospho-eif2 , inositol-requiring enzyme 1 (ire1) and activating transcription factor (atf6). patients with aml had 2-5 times higher expression of upr proteins (except atf6) at baseline than normal controls. grp78-the key upr driver-had the highest level of protein expression in myeloid blasts. there was a wide variability in the level of baseline upr expression. eight out of 38 samples expressed >5 fold increase in grp78 above those with the lowest grp78 levels. similarly, 7 and 9 patients respectively, had a >5 fold increase in peif2 and ire1, compared to patients with low basal expression of these upr proteins. in our limited sample set, there was a trend towards lower overall survival (os) and event-free survival in patients with low baseline grp78 and ire1. conclusion: upr has a variable expression at baseline in pediatric aml, with a trend towards lower os in patients with a low basal grp78 and low ire1 expression, suggesting less chemosensitivity in this subgroup. conversely, it is possible that blasts with an upregulated upr prior to chemotherapy manage proteotoxic stress less effectively, having faster apoptosis and hence a better response to chemotherapy in patients with a high basal upr. we are currently expanding our findings in a larger cohort of patients enrolled in the children's oncology group aaml1031 protocol. background: children with newly diagnosed acute lymphoblastic leukemia (all) undergo chest x-ray (cxr) evaluation during initial diagnostic workup to ensure safe airway management. however, to our knowledge, no systematic assessment of cxr findings has been reported. objectives: to evaluate cxr findings at diagnosis of all and their associations with clinical characteristics. we reviewed the cxr findings at diagnosis of all in patients treated on the total xv and xvi protocols at st. jude children's research hospital. findings were evaluated for associations with clinical characteristics at presentation, and the clinical management of mediastinal masses was reviewed. mediastinal masses were seen in 107 (10.8%) of 990 patients evaluated and were more common in older patients (mean age, 8.51 years) than in younger patients (mean age, 7.14 years) (p = 0.005), in males than in females (p = 0.017), and in patients with t-all than in those with b-all (p<0.001). also associated with mediastinal masses were a higher white blood cell count (wbc) at diagnosis (mean, 107.02 × 109/l) (vs. a lower wbc; mean, 36.65 × 109/l) (p<0.001), cns involvement (vs. no involvement) (p = 0.028), and standard/high-risk disease (vs. low-risk disease) (p<0.001). other cxr findings included pulmonary opacity (160 patients [16.2%]), bronchial/perihilar thickening (187 patients [18.9%]), cardiomegaly (68 patients [6.9%]), and osteopenia/fracture/periosteal lesions (132 patients [13.3%]). pulmonary opacity was more common in younger patients (mean age, 6.51 years) than in older patients (mean age, 7.44 years) (p = 0.023) and in those with t-all (vs. b-all) (p = 0.010). bronchial/perihilar thickening, cardiomegaly, and osteopenia/fracture/periosteal lesions were also more common in younger patients than in older ones (p<0.001, p = 0.002, and p<0.001, respectively) and in those with low-risk disease (versus standard/high-risk disease) (p<0.001, p = 0.001, and p = 0.005, respectively). of the 107 patients with a mediastinal mass on cxr, 56 underwent a confirmatory chest ct scan, and 48 (85.7%) were confirmed to have a mediastinal mass. notably, 23 patients (41.1%) had airway compression, and compression of venous structures was identified in 18 of 48 patients (37.5%) who received iv contrast. the clinical course was evaluated for 107 patients with mediastinal masses detected by cxr. fifty patients (46.7%) required icu admission (mean stay, 3.0 days). general anesthesia was used for only 52 patients (48.6%), and 68 patients (63.6%) had a less invasive peripherally inserted central catheter. no deaths occurred in the acute phase. conclusion: cxr at the time of all diagnosis can detect various intrathoracic lesions and is helpful in planning initial diagnostic workup and management. background: mertk is a receptor tyrosine kinase that is aberrantly expressed in 80% of pediatric primary aml samples. mertk inhibition with the small molecule tyrosine kinase inhibitor (tki) mrx-2843 decreases tumor burden and prolongs survival in aml xenografts. while treatment with mrx-2843 reduces leukemia in the peripheral blood, it is less effective in the bone marrow, suggesting a role for the marrow microenvironment in therapeutic resistance. the jak/stat pathway has been implicated as a mediator of bone marrow derived resistance to tkis and inhibitors of this pathway are in clinical development for the treatment of aml. to determine the role of the bone marrow stromal niche in mediating resistance to mertk inhibition and to evaluate the efficacy of combined mertk and jak/stat inhibition. design/method: aml cell lines were cultured with or without the hs27 stromal cell line or hs27 conditioned medium, then treated with mrx-2843 +/-the jak/stat inhibitor ruxolitinib, or control. induction of apoptosis and cell cycle arrest in aml cells was measured by flow cytometry. expression of h2ax and total and phosphorylated stat5 were determined by immunoblot. results: co-culture with stromal cells significantly reduced aml cell death and g2/m phase arrest in response to treatment with 200nm mrx-2843 compared to no co-culture (cell death: 31.9% versus 61.2%, p<0.05; g2/m arrest: 8.9% versus 14.8%, p<0.01). g2/m arrest was accompanied by an increase in h2ax expression which was similarly abrogated in co-culture. conditioned medium did not provide protection from mrx-2843 induced apoptosis, g2/m arrest, or h2ax induction. mrx-2843 inhibited stat5 phosphorylation but direct co-culture and conditioned medium potently increased basal stat5 phosphorylation which was not inhibited by mrx-2843. to determine whether the observed induction of stat5 phosphorylation was functionally relevant, cocultures were treated with both mrx-2843 and ruxolitinib. while ruxolitinib potently inhibited the phosphorylation of stat5 in the presence of co-culture, combination treatment did not overcome stromal mediated protection from mrx-2843 induced apoptosis. similarly, the addition of exogenous gm-csf induced stat5 phosphorylation but did not yield protection from mrx-2843 functional effects in the absence of co-culture. together these data support a model whereby direct cell-cell contact with stromal cells in the bone marrow niche protects leukemia cells from mrx-2843 induced apoptosis, cell cycle alterations, and dna damage. while co-culture potently induces phosphorylation of stat5 in leukemia cells, this is neither necessary nor sufficient for stromal-cell mediated protection from mertk inhibition and combined treatment with jak/stat inhibitors is unlikely to be therapeutically efficacious. background: mercaptopurine (6-mp) is an immunosuppressive thiopurine drug that is a key component of acute lymphoblastic leukemia (all) treatment. 6-mp is metabolized into 6-thioguanine (6-tgn), which is responsible for anti-leukemic effects, as well as 6-methylmercaptopurine nucleotides (6-mmpn/6-mmp), which are associated with hepatotoxicity. some patients preferentially metabolize 6-mp to 6-mmpn/6-mmp, increasing their risk for hepatotoxicity and potentially reducing anti-leukemic effects. hepatotoxicity can cause interruptions or delays in therapy that may jeopardize cure rates. allopurinol has been increasingly used in patients with inflammatory bowel disease (ibd) to shunt 6-mp metabolism toward 6-tgn and away from 6-mmpn to minimize hepatotoxicity and preserve therapeutic effects. objectives: this retrospective chart review expands upon our previously published case series of three patients with all in whom allopurinol was successfully used to redirect 6-mp metabolism. twelve additional patients have subsequently received allopurinol and 6-mp combination therapy at texas children's hospital. data from this larger patient sample, with longer follow up, is being analyzed to increase knowledge of the effectiveness and longitudinal effects of adding allopurinol to 6-mp to reduce risk of hepatotoxicity. design/method: data were abstracted from the electronic medical records of 15 patients with all treated at texas children's hospital from 2012 to present, who had been found to have evidence of altered 6-mp metabolism and in whom allopurinol was added to 6-mp therapy due to concern for risk or recurrence of hepatotoxicity. metabolite levels, 6-mp dose, and alanine transaminase (alt) prior to initiation of allopurinol and approximately 8 weeks later were compared. wilcoxon signed-rank test was applied for statistical analysis. : after the addition of allopurinol, patients experienced a significant decrease in mean levels of 6-mmpn (p = 0.0007), correlating with a significant decrease in mean alt (p = 0.004). with the initiation of allopurinol, the mean 6-mp dose was decreased from 84 to 32 mg/m2/day over an 8-week period. mean 6-tgn levels increased (p = 0.14). in follow up beyond 8 weeks, no patients had further holds in 6-mp due to hepatotoxicity. addition of allopurinol appears to shift metabolism from 6-mmpn toward 6-tgn, with increases in mean 6-tgn levels despite a decrease in mean 6-mp dose. this may limit negative side effects, thus resulting in fewer gaps in therapy and possible improved outcomes. further analysis of 6-mp dose titration and effects on anc over time as well as effects on overall survival is ongoing. prospective background: alterations in epigenetic patterning are a fundamental feature in acute myeloid leukemia (aml). treatment with dna methyltransferase inhibitors (dnmti) yields responses in aml, but the molecular mechanisms underlying this effect are poorly understood. in prior work, we demonstrated induction of genes involved in the pirna rna (piwi) silencing pathway as a common gene feature of 4 aml cell lines treated with decitabine. the piwi pathway is an rna silencing system, distinct from classical small rna transcriptional silencing, responsible for transposon-silencing in gametogenesis; emerging data suggest a role for this system in somatic cells. based on these data, we postulate that piwi induction plays a crucial role in aml recovery following demethylation and that disruption of this pathway would modulate response and/or recovery from decitabine treatment. to assess the effect contribution of the pirna pathway response following dnmti treatment in aml. design/method: to choose target genes in the pirna pathway for disruption, molm13 cells were first treated with escalating doses of decitabine. using quantitative rt-pcr, the dose-dependent expression of several pirna-associated genes were analyzed. two genes, mael and piwil2, were selected for disruption experiments based on preliminary data suggesting decitabine dose-dependent responses. molm13 cells were transduced with shrna targeting these genes using a lentivirus delivery system with selection in puromycin. knockdown efficiency was assessed by rt-qpcr. to determine how gene disruption affected cell growth, knockdown cells were treated with decitabine 20nm. proliferation was assessed by celltiter glo assay following decitabine treatment. clonogenic potential was assessed by colony forming assays of transduced cells after treatment with decitabine at 5nm and 10nm. results: following decitabine exposure in molm13, there was a markedly increased expression of mael and piwil2 compared to untreated cells (2363:1 and 41:1, respectively) . thus, these were the candidate genes chosen for disruption. of 4 mael shrna constructs, two resulted in a 25% relative expression of mael compared to controls. of the 3 piwil2 shrna constructs, the best knockdown showed 75% relative expression. there were no significant differences in proliferation or clonogenicity of stably selected mael or piwil2 knock-down molm13 cells following decitabine treatment. using gene knockdown procedures, mael and piwl2 do not appear to have a marked effect on growth and response to decitabine treatment in molm13. however, these results may be limited by inefficient knockdown using shrna targeting methods. further work using a cas9/crispr based inactivation of these genes is ongoing. children cancer hospital cairo, egypt background: hypodiploidy <44 chromosomes is very uncommon and have particularly poor outcomes in childhood acute lymphoblastic leukemia (all). it is subdivided into: near-haploid (24-31chromosomes), lowhypodiploid (32-39chromosomes) and high-hypodiploid (40-43chromosomes). to determine if minimal residual disease (mrd) can identify a group of patients with better prognosis in the hypodploid population who can be treated with intensive chemotherapy alone. design/method: a retrospective study that included all patients under age of 18 diagnosed as hypodiploid b-precursor all during the period between january 2008-december 2015 and treated at children's cancer hospital egypt on sjcrh total study-xv for ir/hr all. sixteen patients had <44 chromosomes (9 nearhaploid and 7 low-hypodiploid), constituting 1% of all pediatric patients with b-precursor all during the study period. patients with near-haploid all had a median age of 6 years (range 2-17), initial leukocyte count (wbc) median of 7.5 × 109/l (range 1.3-86.6), 4 (44.4%) were males and 5/9 (55.6%) had hr-nci criteria. four patients (44.4%) are alive in complete remission(cr) (range 25-48 months, median 30), one died in induction and 4 (44.4%) had hematological relapse (range 6.8-33 months, median 15). patients with low-hypodiploid all had significantly older age (median 15 years, range 13-17), median wbc 4.3 × 109/l (range 3.5-13.5), 5/7 (71.4%) were males. one patient (14.3%) is alive in cr, one died in induction, one failed to achieve cr post-induction and 4 patients(57%) had hematological relapse (range 3.9-5.6 months, median 4.8). mrd<0.01% by flow-cytometry on day-15 and end of induction was achieved in 5/9 (55.6%) and 6/8 patients(75%) with near-haploid, compared with 1/6 (16.7%) and 3/6 patients(50%) with low-hypodiploid; respectively (p = 0.287, p = 0.58;respectively). allogeneic transplantation was performed during initial remission only in 2 mrd negative patients (one relapsed and one is in cr) and in the patient with induction failure (relapsed post-transplant). five of the total six patients who had negative mrd on day-15 and end of induction are alive in cr (4/5 with chemotherapy alone). all 3 patients with negative mrd at end of induction but with mrd levels≥0.01% on day-15 (range 0.02-0.33%) relapsed as well as all 4 patients with detectable mrd at the end of induction. the difference in relapse was statistically significant in relation to negative-mrd on day-15 (p = 0.005), but not at end of induction(p = 0.105). conclusion: children with hypodiploid all and negative mrd on day-15 of induction are highly curable with intensive chemotherapy alone, while patients with negative mrd at the end of induction and detectable mrd on day-15 had dismal outcome. background: overall survival in pediatric acute myeloid leukemia (aml) has plateaued between 60-70%, with death during induction chemotherapy seen in 4-11% of patients. respiratory complications contribute to morbidity and mortality in pediatric aml induction, however the incidence, patterns, and predictors of respiratory adverse events (aes) during this period are unknown. to estimate the incidence of respiratory aes during induction therapy for de novo pediatric aml, to characterize and grade these respiratory aes, and to identify predictors of respiratory ae development. we conducted a retrospective longitudinal study from presentation to day 42 in institutional de novo pediatric aml patients (≤ 21 years) between march 2009 and december 2016. outcomes included any nci ctcae grade 2-5 respiratory ae or death from another cause. demographic, disease, and treatment-related data were abstracted. the most specific, best-fitting ctcae category and grade for each ae was determined. descriptive statistics, survival analysis, multivariable logistic regression analysis, and time-toevent distributions were performed (sas v9.4, cary, nc) . among 113 eligible patients, 54.0% (n = 61) experienced 69 discrete respiratory aes. incidence of grade 3-5 aes was 46.0% (n = 52). a bimodal time-to-event distribution demonstrated peaks at treatment days 0 and 14. induction death occurred in 4.4% (n = 5) including 3 deaths from respiratory failure associated with disseminated fungal disease. in univariate analysis, those experiencing aes differed significantly in regards to older age at diagnosis (p<0.0001), higher initial wbc (p = 0.012), higher initial peripheral blast percentage (p = 0.002), coagulopathy at diagnosis (pt (p = 0.004), d-dimer (p = 0.002)), fluid overload status (p<0.0001), occurrence of infection (p = 0.01), and occurrence of tumor lysis syndrome (tls) (p = 0.016). patients with hyperleukocytosis (p = 0.005), fluid overload (p<0.0001), and fab m3 morphology (p = 0.0016) each had a significantly decreased probability of completing the follow up period without experiencing a respiratory ae. on multivariable analysis, fluid overload (aor 45.2 [95% ci: 5.4-376.0) and older age (aor 1.10 [95% ci: 1.01-1.20) were significantly associated with ae occurrence when gender, hyperleukocytosis, tls, and infection status were held constant. we describe a high incidence of respiratory aes during pediatric aml induction. fluid overload and older age at diagnosis are independently associated with ae development when controlling for other proposed risk factors. interventions focused on conservative fluid management and offset of fluid overload should be explored in newly diagnosed pediatric aml in an effort to reduce respiratory complications during induction. overall, all survival rates are outstanding and have continued to improve with risk-adapted therapy. the most striking improvement occurred in t-all where 5-year os rates now exceed 90% and parallel b-all. survival improvements, however, have not been observed uniformly across all subgroups. while the gap in outcome differences narrowed among blacks, outcomes for hispanics have remained static. further, no improvements in survival were observed in infants or ayas and new treatment approaches have been implemented for these populations. background: acute myeloid leukemia (aml) accounts for approximately 18% of new childhood leukemia cases. chest x-ray (cxr) is performed in all newly diagnosed aml cases to evaluate the safety of airway management for anesthesia during diagnostic procedures; however, cxr results in pediatric patients with aml have not been described. objectives: the primary objective was to evaluate cxr findings at diagnosis in patients with aml. the secondary objectives included assessing associations between cxr findings and clinical characteristics, with the overall goal of aiding in the evaluation of the use of cxrs as an initial diagnostic study in pediatric patients with aml. design/method: cxr findings and clinical characteristics were evaluated in patients with newly diagnosed aml who were enrolled in one of three protocols at st. jude children's research hospital (aml97, aml02, and aml08). the findings were categorized based on radiologic reports. further, the associations of these findings and clinical characteristics were evaluated. we evaluated cxr findings in a total of 302 patients: 85 from aml97; 101 from aml02; and 116 from aml08. common cxr findings were pulmonary opacity (n = 51, 16.9%), bronchial/perihilar thickening (n = 38, 12.6%), splenomegaly (n = 38, 12.6%), mediastinal mass and lymph nodes (n = 27, 8.9%), pleural effusion/thickening (n = 17, 5.6%), demineralization/fracture/periosteal lesions (n = 10, 3.3%), scoliosis (n = 10, 3.3%), and granulomatous disease (n = 7, 2.3%). three cxr findings were associated with younger age at diagnosis: pulmonary opacity (median age, 4.5 years in patients with positive findings vs. 10.1 years in those with negative findings, p<0.01), bronchial/perihilar thickening (median age, 2.7 years vs. 10.3 years, p<0.01), and demineralization/fracture/periosteal lesions (median age; 2.7 years vs. 9.3 years, p = 0.04). two cxr findings were associated with older age at diagnosis: scoliosis (median age, 16.5 years vs. 9.0 years, p<0.01) and granulomatous disease (median age, 15.1 years vs. 9.1 years, p = 0.02). higher white blood cell counts (wbcs) at diagnosis were associated with cxrs showing pulmonary opacity (median wbc; 33.7 × 10^9/l vs. 14.8 × 10^9/l, p = 0.01) or splenomegaly (median wbc; 36.4 × 10^9/l vs. 15.2 × 10^9/l, p = 0.02). french-american-british (fab) m4/m5 subtypes were more frequently associated with pulmonary opacity compared with others (p<0.01). we did not find significant differences between female and male patients. conclusion: cxr in patients with newly diagnosed aml showed a variety of thoracic, abdominal, and bony lesions that are important for the initial evaluation and management. pulmonary opacity was the most common finding and was frequently seen in patients who were younger or had higher wbcs at diagnosis or fab m4/m5. background: children diagnosed with acute lymphoblastic leukemia (all) require a central venous catheter (cvc) to administer chemotherapy safely. both external and internal cvcs carry risks of complications including thrombosis, infection, and possible replacement. internal catheters, such as a port, are generally used for the majority of patients for the duration of treatment since therapy lasts for several years. many institutions place a port at the time of diagnosis. other institutions prefer to start induction therapy via placement of a peripherally inserted central catheter (picc) and defer port placement until the completion of induction therapy due to concerns of increased risk of infectious complications with port placement. objectives: to compare rates of common cvc associated complications by type of cvc placed at start of induction therapy in children treated for newly diagnosed all at the jimmy everest center (jec) at the university of oklahoma health sciences center. design/method: a retrospective chart review analyzed data from newly diagnosed all patients treated at the jec between 2010-2017. data was collected on complications including thrombosis, bacteremia, insertion site infection, cvc malfunction and need for removal. data collection began at the start of induction and was completed at the end of induction therapy. statistical analysis used a univariate and multivariate logistic regression model to compare complication rates between those who had a port versus those who had a picc placed at start of induction. results: data was collected on 128 patients. fifty-six patients had a port placed at start of therapy while 72 had a picc placed. fourteen percent of patients had a cvc associated complication. univariate analysis showed no statistically significant difference in rates of cvc associated complications between the groups (port 16%, picc 12.5% p = 0.564). the rates of hospitalization for cvc associated complications were similar between both groups (port 14%, picc 11% p = 0.590). rates of cvc removal were also similar between both groups (port 4%, picc 4% p = 0.863). multivariate model that included baseline patient characteristics including type of all, patient body surface area, gender, ethnicity and age continued to demonstrate no significant difference in cvc associated complications between both groups. conclusion: this single institution study showed that there was no significant difference in cvc associated complications between port and picc line placement at the start of childhood all induction therapy. port placement can be considered as a safe option at the start of induction therapy. complete remission [cr] or cr with incomplete blood count recovery [cri]) within treatment cycles 1-4. interim data are reported (nct02538965). results: seventeen patients were enrolled and received ≥1 dose of lenalidomide; median age was 12 years (range 5-18); 7 patients were female. patients received median 5 prior regimens (range 2-13). nine patients had previously undergone bone marrow transplantation (bmt). four patients had relapsed aml and 13 were refractory to immediate prior treatment. median duration of study treatment was 4 weeks (range 1-12); patients completed a median of 1 treatment cycle (range 0-3). all patients were evaluable for primary outcome; 1 achieved morphologic cri after 2 cycles (no patients achieved cr). the responder was a 13-year-old male with history of r/r aml after first-and second-line treatment, bmt, and salvage chemotherapy. at baseline, he had a complex cytogenetic karyotype (monoallelic −21q22.12, −3q, −4q13.3, −8p12) with no identifiable molecular mutation; he was also positive for del(5q) (−5q11, −5q23). his post-treatment karyotype showed no abnormalities. sixteen patients experienced treatment failure; 12 due to resistant disease, 3 of indeterminate cause, and 1 had treatment failure before a post-baseline assessment was performed. all patients experienced ≥1 grade 3-4 treatment-emergent adverse event (teae). the most commonly reported were thrombocytopenia (n = 10), anemia (n = 7), febrile neutropenia (n = 7), and hypokalemia (n = 7). fifteen patients experienced ≥1 teae related to lenalidomide. all patients discontinued treatment; 3 remain in follow-up. the study is now closed to enrollment. ten patients died on study: 3 during treatment, 7 during follow-up. all deaths were attributed to aml or complications due to aml. conclusion: third-line lenalidomide monotherapy was associated with clinical response in 1 of 17 pediatric patients with r/r aml; however, treatment exposure was limited. safety data are consistent with the known profile of lenalidomide. lenalidomide was not an efficacious treatment for r/r pediatric aml. funding: celgene corporation, summit, nj, usa. cook children's medical center, fort worth, texas, united states background: it is well documented that pediatric patients with acute lymphoblastic leukemia (all) often experience significant weight gain during induction therapy and later struggle with obesity. however, some patients experience unintended weight loss during induction therapy; since this issue is not well reported, it often goes undertreated. although malnutrition is reported to be associated with decreased survival, increased risk of infection, and loss of lean body mass, there remains a scarcity of in-depth analysis of prevalence and risk factors that contribute to this problem. our study attempts to address this critical yet unmet need. objectives: our aim was to identify the clinical risk factors and outcomes associated with weight loss during induction therapy for pediatric all. design/method: this was a retrospective chart review of patients between 2 and 20 years of age diagnosed with all at cook children's medical center from 4/1/14 to 3/31/17. for each patient, we collected height, weight, age, body mass index (bmi) z-scores at diagnosis and end of induction therapy, risk stratification, and whether consolidation was delayed. patients with a bmi >85th percentile at diagnosis were categorized as being overweight or obese. using logistic regression analyses, we examined which variables predicted whether the patient had an increase or decrease in bmi z-score throughout induction. a critical alpha level of 0.05 indicated statistical significance. results: ninety-six patients met our inclusion criteria. of these, 40% experienced a decrease in bmi during induction therapy. compared to patients whose bmi increased during induction, patients with a decrease in bmi were more likely to be overweight or obese at diagnosis (55% vs. 22%; p<0.001), to be ≥10 years of age (53% vs. 16%; p<0.0001), to have a high-or very-high-risk stratification (87% vs. 31%; p<0.0001), and to experience a delay in the start of consolidation therapy (47% vs. 21%; p<0.01). conclusion: this research highlights a risk not previously identified in the literature that may impact outcomes. patients treated on high-or very-high-risk protocols, who are overweight or obese at diagnosis, and who are ≥10 years of age at diagnosis should be monitored closely for weight loss during induction therapy. patients who experience weight loss should receive prompt intervention. it is our hope that this information can be used for future prospective studies and to help develop evidence-based guidelines. background: 17p abnormalities have been observed in some patients with hematologic malignancies. loss of p53 function as a tumor suppressor gene in the chromosome 17 plays an important role for development of leukemia. these patients usually have poor outcome due to the chemotherapy and are associated with poor prognosis. objectives: this study aimed to identify frequency of 17p abnormalities between iranian children and adult patients with aml (acute myeloid leukemia) malignancy. design/method: the 17p abnormalities were analyzed via bone marrow karyotyping and fish method in 669 acute myeloid leukemia patients. in this study, 17p abnormalities were observed in 52 (8%) patients out of 669 diagnosed cases. a significant strong correlation between 17p abnormalities and other high risk factors (poor risk cytogenetic) were observed. from 52 patients with aml malignancy (17p abnormalities), 45 (86%) patients have complex karyotype, 35 (67%) patients monosomal karyotype and 34 (65%) patients have monosomal karyotype accompanied with a complex karyotype. overall, 17p abnormalities are independent risk factor in acute myeloid leukemia and evaluation of these abnormalities by fish or other complementary techniques prior to treatment, might help for better risk stratification of high risk aml patients. background: hepatotoxicity in treatment of acute lymphoblastic leukemia (all) is well studied and transiently affects most patients receiving antimetabolite therapy. rarely, patients develop liver injury severe or prolonged enough to undergo a liver biopsy. little is known about how these patients differ from patients that develop transient hepatotoxicity. we sought to describe disease and treatment characteristics for all patients that developed hepatotoxicity severe enough to undergo liver biopsy. we also looked for pre-dictive factors for liver biopsy, including signs of early hepatic injury from the initial treatment protocol. design/method: pathology reports of all patients from the liver biopsy database at children's healthcare of atlanta were collected. controls were matched 2:1 for age, all subtype, and treatment protocol. demographics, treatment protocols, and overall outcomes were collected through the electronic health record. hepatic lab results for transaminases, coagulation, and albumin were collected for induction, consolidation, interim maintenance, delayed intensification, and maintenance. results: sixteen patients diagnosed between 2003-2013 (median age at diagnosis 10 years, range 1-16; 50% male; 75% pre-b all) were included in the case series. the median time from diagnosis to liver biopsy was 1.5 years (range 1-11). eight patients (50%) were in maintenance at the time of biopsy; none had active disease. eight (50%) were postbone marrow transplant. biopsy results included: steatosis (3), acute inflammatory/infectious (3), liver infiltration (1), fibrosis (6) and graft-vs-host disease (gvhd) (2). six patients were deceased; 5-year all-cause mortality from diagnosis was 31%. thiopurine methyltransferase (tpmt) status was known in 44% cases and 80% controls. all cases had intermediate or wildtype status, which did not differ from controls (p > 0.05). patients requiring liver biopsy did not have evidence of acute hepatotoxicity (ast/alt > 10× normal values) during their initial treatment protocol. hepatotoxicity requiring liver biopsy is a rare outcome of all treatment. these patients had elevated rates of relapse, bmt, and 5-year all-cause mortality, suggestive of a more severe disease process. however, it is difficult to sort out the temporality of relapse, bmt, and hepatoxicity requiring biopsy in this limited sample. additionally, patients with bmt preceding liver biopsy have other confounding factors that makes them difficult to include in the analysis. finally, our limited descriptive data show no notable correlation between early hepatotoxicity and later indication for liver biopsy. future cohort or case-control studies with larger sample sizes are required to further explore early predictive factors for severe hepatotoxicity requiring liver biopsy. nathan gossai, joanna perkins, michael richards, yoav messinger, bruce bostrom background: the majority of chemotherapeutic agents used to treat hodgkin lymphoma are teratogenic. pregnancy screening prior to the start of chemotherapy is supported by clinical guidelines and baseline testing is a standard component in therapeutic trials. there is limited data available on the incidence of pregnancy screening prior to the start of hodgkin therapy but previous studies suggest that pregnancy screening, especially at pediatric institutions, is not consistently completed. objectives: the objective of this study is to evaluate the incidence of pregnancy screening and contraceptive counseling prior to the start of therapy in females diagnosed with hodgkin lymphoma. design/method: a retrospective chart review was performed for all female patients newly diagnosed with hodgkin lymphoma from 2000 to 2015 at the hospital for sick children in toronto, ontario. all patients who were intended to receive multi-agent chemotherapy were included, regardless of age. data collected included demographic and disease information, chemotherapy regimen and enrollment on clinical trial. all pregnancy testing within two weeks prior to the start of therapy was captured, as well as type of pregnancy test performed, documentation of menstrual status, contraceptive counseling and contraceptive provision. univariate and multivariate analyses were used to describe factors influencing the incidence of pregnancy testing. results: a total of 122 female patients with newly diagnosed hodgkin lymphoma between the ages of 5 and 17 years were identified. sixty patients (49%) had pregnancy testing done prior to the start of therapy. testing modalities included serum and urine screens as well as quantitative beta-hcg measures. older age (p = 0.0016), documentation of menstrual status at diagnosis (p = 0.019) and diagnosis between 2008 and 2015 (p = 0.004) were associated with higher incidence of screening. enrollment on a therapeutic trial was not associated with a higher incidence of screening (p = 0.374). contraceptive counseling was documented for 19 patients (16%) and 11 patients (9%) were prescribed contraceptive medications during therapy. pre-chemotherapy pregnancy testing was completed on 49% of females with newly diagnosed hodgkin lymphoma. improvement is required and interventions, including clarification of institutional standards, modification of chemotherapy order sets and staff education, are planned. (rao et al., cancer, 2016) . university of louisville, louisville, kentucky, united states background: granulocytic sarcomas (also known as chloromas or leukemia cutis) were first described by a. burns in 1811. they are solid tumors comprised of immature granulocytic cells and represent extramedullary manifestations of underlying leukemia. chloromas are most commonly associated with acute myeloid leukemia. they may arise in other myeloproliferative disorders but are rarely seen in b or t cell acute lymphoblastic leukemia (all). objectives: although patients with all rarely have chloromas, it should remain on the differential for patients with unusual swelling or masses. design/method: we present a case series of two patients from our institution diagnosed with b cell all who had a chloroma as the presenting symptom. the first patient is a 4yo who presented to his primary provider with nasal congestion and a one-week history of bilateral eye swelling and was referred to an allergist when the symptoms did not resolve with anti-histamines. his review of systems was otherwise negative. he was referred urgently to ent two months later for a 3 × 3cm mass palpated along the medial border of the left eye. an mri showed a left facial mass surrounding the zygoma and extending into the anterior inferior left orbit. biopsy revealed b cell acute lymphoblastic lymphoma, and bone marrow aspirate and biopsy confirmed the diagnosis as b cell all. the second patient is a 10yo who presented to his primary doctor for rapid growth of a scalp nodule that had been present for about 2 months. he was referred to dermatology and treated for a supposed kerion from tinea capitis. the lesion continued to grow and became more irritated with this treatment. punch biopsy revealed a complicated phenotype of lymphoblastic lymphoma. however, after a lymph node biopsy and bone marrow aspirate and biopsy, the diagnosis was confirmed as b all. his only other positive point on review of systems was a questionably pathologic 20-pound weight loss and an area of matted cervical lymph nodes. for both of our patients, the chloromas completely disappeared during induction therapy. it is worth noting that both of these patients presented with the chloroma as the only symptom of the underlying leukemia. this led to initial misdiagnosis and delay in identifying their leukemia. therefore, while it is very rare for a patient with b all to present with a chloroma, our experience shows that all should be on the differential for patients presenting with unusual swelling or masses. background: hodgkin lymphoma (hl) is a lymphoproliferative neoplasm that commonly presents with history of adenopathy and a predictable pattern of disease involvement with or without systemic symptoms of fever and/or weight loss. in the hands of an experienced oncologist the diagnosis of hl is usually not a challenge. occasionally a diagnostic challenge is presented by a patient who has an atypical presentation which is suggestive of an alternative diagnosis. we describe a case series of patients diagnosed with hl whose initial clinical presentations lead to a diagnosis different form hl. honduras, nicaragua and the united states. results: six pediatric oncology centers from the american continent conducted a retrospective review of patients diagnosed with hl since 2010. patients that had an initial presentation not suggestive of hl or who were initially diagnosed with a disease other that hl were included for a total of 25 patients. argentina n = 8, guatemala n = 7, honduras n = 1, nicaragua n = 2, united states n = 7. five patients were female and 20 male. patient's ages ranged from 2 to 18 years. most patients (n = 19) were older than 11 years. three patients (15%) presented with non-immune cytopenias without overt lymphadenopathy, of those one had active hemophagocytic syndrome. five patients (20%) were suspected to have localized solid tumors: ewing sarcoma n = 2, rhabdomyosarcoma n = 1, hepatocellular carcinoma n = 1, and soft tissue tumor of the cheek n = 1. two (8%) metastatic solid malignancy as they presented with disseminated pulmonary nodules. five (20%) with autoimmune disorders: hashimoto thyroiditis n = 1, autoimmune hemolytic anemia n = 1, nephrotic syndrome n = 3. ten (40%) with chronic infectious processes: brucella n = 1, tonsillar abscess n = 1, splenic abscess n = 1, and tuberculosis (tb) n = 7. patients with suspected tuberculosis were diagnosed outside of the united states. six of 7 patients were ultimately diagnosed as having both tb and hl. seventeen patients had ann-arbor stage iii or iv, seven patient had stage ii with either b symptoms or bulky disease. patients were treated with various chemotherapy regimens according to the treating center: abvd, abve-pc oepa-copdac, avpc, beacopp. two patients had recurrent disease, one died of disease progression and one died from causes not related to hl conclusion: a small proportion of hl patients have atypical or unusual presentations. hl should be included in the differential diagnosis of solid tumors, autoimmune disorders, infections or cytopenias. the most common atypical presentation is an infectious process. background: acute lymphoblastic leukemia (all) represents the largest group of pediatric malignancies. the high cure rate of childhood all represents one of the most remarkable success stories in the war on cancer. in a lower middle income country (lmic) like the philippines, we reviewed the five year survival in a tertiary referral center. objectives: this retrospective cohort study aims to determine the survival of children 1-18 years old with all treated at a tertiary referral center for childhood cancer in the philippines from january 2012 to december 2016. design/method: this is a retrospective cohort study that reviewed medical charts of newly diagnosed all ages 1 to 18 years old from january 2012 to december 2016. a total of 435 subjects were included in the study. the 5 year overall survival (os) and event free survival (efs) were 65.3% and 62.8%, respectively. the 5 year os for standard risk all was 68.8% and for high risk patients was 50%. the 5 year os for the patients on remission was 83.7% and for those who relapsed was 21.1%. univariate and multivariate by cox proportional hazards regression revealed wbc count at diagnosis, risk classification, immunophenotyping, and development of relapse showed significant prognostic impact for mortality. age and gender were reported with no prognostic significance. the 5-year os and efs were lower compared to developed countries but are comparable with other lmics. the prognostic factors for relapse and mortality were compatible with the literature. overall, the adopted treatment protocols for childhood all in this institution showed acceptable results. relapse has a significant prognostic impact for mortality. development of accessibility to care, increase awareness, early detection and resources at hand should be achieved. improvement in the follow up protocol to prevent delays in the treatment, patient education to prevent non-compliance and psychosocial support, to developed better supportive care, and expand facilities should be given emphasis to further improve survival and prevent relapse. objectives: here, we seek to further characterize this entity by describing the pathologic and clinical features of 4 pediatric cases of burkitt-like lymphoma with 11q aberration. we collected pathologic and clinical data from the medical record on all pediatric high grade b-cell lymphoma (hgbcl) cases diagnosed at our institution over a 5-year period (2012-2017) . for those cases classified as neither burkitt lymphoma nor diffuse large b-cell lymphoma (dlbcl), fish for myc, bcl-2 and bcl-6, as well as array comparative genomic hybridization (acgh), were performed. we identified 38 cases of hgbcl, including 5 cases of burkitt lymphoma presenting as purely leukemic phase. of the hgbcl cases, 20 had burkitt lymphoma as defined by myc rearrangements, and 13 had dlbcl. collectively, the majority of these 33 patients had primary disease outside of the head/neck, and most patients presented with advanced stage (iii-iv) disease. of the 5 remaining cases, 11q aberration was identified in 4 cases using acgh. all 4 cases histologically and immunophenotypically resembled burkitt lymphoma but lacked myc rearrangement, instead showing proximal gains in 11q13-q23 and telomeric losses in 11q24.1qter. all 4 cases involved primary disease in the cervical lymph node and/or tonsil. three of these cases were localized (stage ii), and the fourth case involved a few metabolically active but non-enlarged lymph nodes in the chest and abdomen (stage iii). all 4 patients achieved complete remission with standard therapy for mature b-cell lymphoma, and were alive with no clinical evidence of disease at a median follow-up of 23 months. although the number is small, our results suggest that the majority of non-burkitt, non-dlbcl cases of pediatric hgbcl carry 11q aberrations. in addition, patients with 11q aberrations appear to be more likely to present with lower stage disease, thus requiring less intensive therapy, and also tend to have primary disease in the head/neck. these findings further support the classification of burkitt-like lymphoma with 11q aberration as a distinct pathologic and clinical entity, and we propose that all pediatric non-burkitt, non-dlbcl cases of hgbcl regularly undergo further workup for possible 11q aberrations. marie claire milady auguste, joseph bernard st damien hospital, port-au-prince, port-au-prince, haiti background: hodgkin lymphoma (hl) and non-hodgkin lymphoma (nhl) account for 7% of cancers in the united states pediatric population (1, 2). in central america and the caribbean, they are in second position among all types of pediatric cancers (3). a previous study on pediatric cancers in haiti showed that the lymphomas were in fifth place after the leukemias, wilms tumor, retinoblastoma and the sarcomas (4). the main objective of this study is to present the epidemiological profile of lymphomas managed at a haitian pediatric hospital. design/method: this is a retrospective study conducted on the cases of lymphoma diagnosed and managed at st damien hospital from january 2006 to december 2016. key variables such as age, gender, stage at diagnosis, histopathological types and outcome were collected to present the characteristics of this retrospective cohort. of the 407 cases of cancer diagnosed during the study period, 23 (5.7%) had the diagnosis of lymphoma. the sex ratio was 2.8 (17 males for 6 females) and the average age was 8.9 years [0-19 years]. there were 11 cases of hl (47.8%) and 12 cases of nhl (52.2%). 69.6% of the patients were diagnosed at stages iii and iv. among the hl cases, 6 (54.5%) were nodular sclerosis lymphoma, 3 (27.3%) with mixed cellularity and 2 (18.2%) with lymphocytic predominance. for the nhl cases, 4 (36.4%) were burkitt's lymphoma and 3 (27.3%) lymphoblastic t-cell lymphoma. among the 12 patients for who immunohistochemistry was found, the 4 cases of hl were cd30-positive and 6 out of 8 cases of nhl were cd20-negative. only 1 patient was hiv-positive, and 4 patients had a confirmed exposure to epstein-barr virus. 8 patients (34.8%) were lost to follow-up, 7 (30.4%) were in remission, 3 (13 %) relapsed, 2 (8.7%) were still in treatment and 3 (13%) were deceased. university of chicago, chicago, illinois, united states background: due to the adoption of risk-adapted therapy, pediatric and adolescent acute lymphoblastic leukemia (all) is associated with high cure rates. despite excellent outcomes in most children, patients with certain blast cytogenetic features do not fare as well. furthermore, african american, native american, and hispanic patients have worse outcomes than caucasian patients. while the outcome discrepancies are certainly multifactorial, and blast cytogenetics are related to age, it remains unclear whether ethnicity and blast cytogenetics correlate. the diverse patient population at the university of chicago provides an opportunity to evaluate for such a correlation. objectives: to describe cytogenetic findings in a racially and ethnically diverse population of patients of all age groups diagnosed with all at university of chicago from 2006 to 2016 and determine if there is a correlation between race/ethnicity and blast cytogenetics. results: a total of 191 newly diagnosed patients with all between the ages of 1-100 from 2006-2016 were included in this study. of those, 167 patients (87.4%) had b-all, 22 had t-all (11.5%), one had early t-cell precursor all and one had mixed phenotype all (b/t). caucasians accounted for 46% of patients, african americans (aa) 22%, hispanics 24.6%, asians 5.24%, and 2% were of other races. age distribution had a bimodal pattern, with a peak in incidence at 5 and another at 58 years of age, consistent with published data. cytogenetic categories included: t(12;21)(p13;q22), 11q23 rearrangements (kmt2a), iamp21, t(1;19)(q23;p13.1), t(9;22) (q34;q11), hypodiploidy, hyperdiploidy and double trisomy of chromosomes 4 and 10. aa and hispanic patients with b-all presented more frequently between the ages of 10-18 years compared to caucasians (p = 0.002 and 0.02, respectively). in aa patients, t(1;19) (q23;p13.3) was overrepresented (p = 0.04 when compared to caucasians), and was mainly observed in patients between 10-18 years. caucasian patients were more likely than non-caucasians to have hyperdiploidy (p = 0.04), especially in patients aged 1-9 years. the rate of t(1;19)(q23;p13.2) was significantly higher in aa patients in our cohort, in particular in patients between the ages of 10-18 years. hyperdiploidy was more likely in caucasians aged 1-9 years. these findings may suggest that varying blast cytogenetics could contribute to outcome differences between races. ahmed elgammal, yasser elborai, mohamed fawzy, asmaa salama, eman d el-desouky, lobna shalaby national cancer institute, cairo, cairo, egypt background: hodgkin lymphoma (hl) in children is one of the malignancies that have a high chance of cure. stage iv hl remains a challenge for getting good clinical outcome as in other stages. many treatment protocols used to give combination chemotherapy while combined modality treatment is the mainstay in other treatment protocols. objectives: we aimed in to assess the outcome using consolidation radiotherapy to chemotherapy (combined modality treatment) versus combination chemotherapy alone in treatment of stage iv hl. design/method: we included patients with stage iv hl and whose data were retrieved from the medical records of the pediatric oncology department, national cancer institute, cairo university, egypt from 2005 till june 2013 and were followed till august 2015. treatment was either to give 8 cycles of abvd (adriamycin, bleomycin, vinblastine, dacarbazine) only or to give 6 cycles of abvd followed by consolidation radiotherapy. the study included 22 cases; 17 were males and 5 were females. mean age was 10.66 years ranging from 4 to 17 years. the histopathology subtype was nodular sclerosis in the majority of cases (15 cases) followed by mixed cellularity (6 cases) then only one case of lymphocyte rich. nine cases were initially bulky while 13 cases were not. constitutional manifestations were present in 10 cases while it was absent in 12 cases. bone marrow was involved in only 4 cases. radiotherapy was given after completion of chemotherapy to 10 cases while 12 cases received chemotherapy only. the 5-year overall survival for patients who received radiotherapy was superior to those who received chemotherapy alone; 100% versus 45.8% respectively with statistical significance (p = 0.02). the 5-year progression free survival was also higher with radiotherapy than others; 90% versus 44.4% (p = 0.095). patients with stage iv hl who received consolidation radiotherapy apparently had a better outcome than those who received chemotherapy only. this suggests that radiotherapy contributes significantly with chemotherapy to the cure rate for those patients. the feinstein institute for medical research, manhasset, new york, united states background: microrna (mirnas) are short non-coding rnas that play a decisive role in cancer biology, including leukemia. exosomes are microvesicles (30-100 nm) produced by most cells in biological fluids. exosomes represent the fingerprint of the parental tumor and are loaded with bioactive markers such as mirnas, which may regulate tumor growth. exosomal cargo can be transferred into target cells changing their biological properties. our study investigates a functional role for exosomal mir-181a in pediatric acute lymphoid leukemia (p-all). objectives: 1/ to demonstrate that p-all exosomes induce cell proliferation2/ to confirm that exosome-induced cell proliferation is disease-stage specific 3/ to analyze exosomal mir-181a expression profiles in p-all4/ to authenticate that inhibition of exosomal mir-181a reduces leukemia proliferation design/method: exosomes were isolated by ultracentrifugation from healthy donors (hd) & p-all serum and conditioned medium (cm) of sup-b15, jm1, and cl-01 (control) human cell lines. cell lines were exposed to different sources of leukemia-derived exosomes in a paracrine or autocrine fashion for 24hrs in triplicates. proliferation was assessed by microscopic cell counting and confirmed by gene expression for proliferation, pro-survival and pro-apoptotic genes. mirna profiling was performed with the human cancer pathway finder microarray (qiagen). silencing of exosomal mir181a was carried out by a mir-181a inhibitor (qiagen), utilizing exo-fecttm exosome transfection reagent (sbi, system biosciences). further, exosomal mir-181a silencing was confirmed by q-pcr. cellular uptake of texred-sirna (sbi, system biosciences) was confirmed by flow cytometry. transfer of exosomal mir181a to the target cells was evaluated by q-pcr. we elucidated that cm-derived exosomes from sup-b15 and jm1 cell lines induce cell proliferation in sup-b15, jm1 (autocrine and paracrine) and cl-01 cells (paracrine) (p<0.01). serum p-all exosomes promote paracrine cell proliferation in all cell lines compared to hdderived exosomes (p<0.0001). heatmap analysis of mirna profiles of leukemia exosomes (all cell lines and p-all) identified mir-181a significantly upregulated in leukemia exosomes compared to controls. mir-181a was also upregulated in all cell lines after exposure to leukemia exosomes that induced proliferation. moreover, exosomal mir-181a inhibition reduces leukemic proliferation in pediatric all. our data suggest that all exosomes induce cell proliferation of leukemic cell lines in both paracrine and autocrine fashion. exosomes regulate these phenomena in a highly orchestrated way, by transfer of functional exosomal mirnas such as mir-181a. the results of this study suggest s233 of s301 that exosomal mir-181a inhibition can act as a novel way for growth-suppression of pediatric leukemia. results: a total of 199 disease sites were detected at pet/ct, while 172 sites were detected at contrast-enhanced ct and bone marrow biopsy (bmb). pet/ct showed improved detection of nodal lesions (p <0.0001) (kappa value = 0.633), extranodal lesions (p <0.0001) (kappa value = 0.632) and bone marrow (p <0.0001) (kappa value = 0.728) compared to contrast enhanced ct and bmb. pet/ct had upstaged 15 cases (16%) and down-staged 4 cases (4.3%) (p <0.001) (kappa value = 0.649). among the upstaged 15 cases, 10 patients (10.9%) were upstaged from stage ii to iii, based on residual in pet/ct not seen in contrast enhanced ct after abdominal mass excision. four patients (4.3%) were upstaged from stage iii to iv based on bone marrow uptake in fdg-pet without positivity in bma or bmb.regarding response assessment, sensitivity was 60% for pet and 80% for contrastenhanced ct (p = 0.56). specificity was 100% for pet and 65% for ct (p< 0.0001). positive predictive value for pet was 100%, while was 12% for ct scan (p< 0.0001). negative predictive value for both pet and ct was 98% (p = 0.82). five patients had 2nd biopsy to confirm viability of the residual lesions, 4 lesions were negative in pathological examination (all of them were metabolic negative in pet/ct; deauville score below 4). one lesion was positive in pathological examination (was positive in pet/ct; deauville score of 4). conclusion: pet/ct detected additional sites compared with contrast-enhanced ct and resulted in changing stage of disease. pet scan is significantly more specific than ct in the management of children with burkitt lymphoma. background: deep sequencing of the immunoglobulin heavy chain (igh) locus indicates that each b all is composed of innumerable subclones. in many cases, subclones exhibit differing phenotypic qualities. however, it remains unclear whether subclones demonstrate distinct tissue distribution within a patient. objectives: 1. to quantify the extent of clonal heterogeneity in diagnostic b all specimens; 2. to identify variability in clonal composition between bone marrow (bm) and peripheral blood (pb) disease sites. design/method: igh sequencing was performed on purified dna from 10 pairs of matched bm and pb patient specimens. multiplex pcr was used to globally amplify the igh locus; next generation sequencing (ngs) was performed using illu-mina® miseq. index clones (defined as ≥ 5% of all sequence reads in a specimen) and their subclone progeny (defined by 6 shared nucleotide bases immediately upstream of a common jh, or 6n_jx) were identified using igblast-determined vh and jh alignments (http://www.ncbi.nlm.nih.gov/igblast/) and an established in-house computational pipeline. results: up to 3 index clones per specimen were discovered in 16 of the 20 samples. in the remaining 4 (2 bm/pb pairs), 1 pair did not reveal a clonal igh and was eliminated from analysis; in the other, clone frequency did not reach the 5% index threshold, but predominant clonal precursors were inferred by the prevalence of their subclone progeny. subclone counts ranged from 2 to 2,619 per index clone. a combined 2,900 subclones derived from 11 pb index clones were observed; in contrast, 12 bm index clones gave rise to only 400 subclones. subclone heterogeneity was observed between all paired specimens. in 6 bm/pb pairs, index clones existed in equivalent proportions between disease sites. in contrast, 1 bm/pb pair demonstrated 2 high-frequency index clones in the bm (32.6% & 12.5%) with limited representation of these clones in the pb (0.6% & 1.4%, respectively); in this case, the most prevalent clone in the pb (10.8%) matched the least frequent index clone in the bm (5.0%). similarly, another pair showed a predominant index clone in the pb (5.8%) which was below index threshold (3.6%) in the bm. in 2 paired patient specimens, index clone predominance was discovered to be overtly distinct between bm and pb. among all pairs, the extent of subclone progeny derived from each index clone showed marked variability, with far higher subclone frequency in the pb than in the bm. our data indicate that b all clonal composition differs between disease sites. valley children's healthcare, madera, california, united states background: tuberculosis (tb) presenting with hodgkin lymphoma (hl) is rare. their coexistence could lead to delay in diagnosis of both tb and hodgkin lymphoma due to the similarities in signs and symptoms of presentation. most cases have been reported in the adult literature. we describe a case series of 11 children that were suspected to have tb and were found to have coexisting tb and hl. results: a retrospective review of hl patients in guatemala and argentina over 6 six years, uncovered 11 patients with simultaneous diagnosis of tb and hl. eight patients were from guatemala (incidence of 4.5%) and 3 from argentina (incidence of 2.5%). there were 4 females and 7 males. age ranged from 4 -17 years (mean 10.5 years, media 9 years). nine patients were suspected to have tb at presentation by the referring physician. two patients were found to have tb at the time of relapse through routine tissue culture. initial systemic symptoms included fever (n = 5), weight loss (n = 2), and night sweats (n = 2). six patients had a second systemic symptom in addition to fever. time for referral to oncology center ranged from 2 weeks to 5 months. nine patients were diagnosed with tb and hl through a tissue cultures and 1 with serum quantiferon. one patient was found to have hl without tb. two patients had no systemic symptoms and the diagnosis of tb came to light through routine tissue culture. five patients had stage iiib and ivb, two stage iia and one iib at diagnosis. hl treatment was given according to the insti-tutional standards depending on stage and risk with abvd, oepa/copdac +/-radiation therapy, and ice for relapse. five patients started anti tb treatment (isoniazid, rifampin, pyrazinamide +/-ethambutol for 2 months followed by isoniazid and rifampin for 30-52 weeks) simultaneously with chemotherapy, and three others after completing 2 cycles. the two relapsed patients started tb treatment after 2 cycles of chemotherapy. seven patients are alive and have been followed for 5 months -6 years. one patient died during therapy, another died for causes not related to tb or hl and one is currently receiving treatment. conclusion: tuberculosis can coexist with hl. in areas were the prevalence of tb is high, microbiology investigations of biopsy specimen should be strongly considered. therapy for tb can be given simultaneously with chemotherapy. coexistence of tb and hl does not appear to affect outcomes. the children's hospital affiliated to the capital institute of pediatrics, united states background: the pi3k/akt signaling pathway plays a central role in cell growth, proliferation and survival in physiological conditions. this signal pathway is considered to be an innovative targeted therapy of cancer, and its abnormal activation has been proved to be related to t-cell acute lymphoblastic leukemia (t-all). despite improved treatment strategies, such as multi-drug combination, high-dose chemotherapy and all kinds of application and popularization of hematopoietic stem cell transplantation, children with drug resistance or relapse t-all are still rather worse and its overall outcome and prognosis are much poorer than the more common b-lineage all. objectives: to explore the relationship between the pi3k/akt pathway and the pediatric t-all, so as to probe the exact molecular mechanisms of t-all and provide more directions for its treatment. design/method: 7 cases of new or recurrent acute t lymphocyte leukemia children with clinical information were collected in the children's hospital affiliated to the capital institute of pediatrics from dec.2015 to oct.2017, with 7 age and gender matched healty children as control (all was informed consent). the expressions of key genes in pi3k pathway were s235 of s301 analyzed by western blot rt-pcr analysis, the pi3k enzyme activities were detected by elisa,and the ccrf -cem's proliferation and its apoptosis were tested by mtt and flow cytometry technology on t-all cell lines ccrf-cem in different treatment group. the results of t-all children in clinical showed that pi3k protein and gene expression level were higher apparent than the control group (p<0.05), and pi3k enzyme activity increased as well (p<0.05); pi3k inhibitor ly294002 made a significant inhibition of cell proliferation and promoted cell apoptosis. ly294002 also enhanced the effectiveness of clinical commonly used chemotherapeutic drug dnr. in combination ly294002 and dnr treatment group cell viability dramatically declined, apoptosis and the apoptosis relation protein casepase3 expression in t-all patients was obviously higher than the control and the single drug group; pi3k/akt signaling pathway related proteins and gene expression level, pi3k, akt, gsk3 transcription in ccrf-cem were significantly higher than the control (p< 0.05), while pten transcription was significantly lower than the control (p<0.05). the abnormal activation of pi3k/akt signaling pathway might play an important role in pediatric t-all patients, especially in the cell proliferation or apoptosis. the results might provide new train of thought and direction in targeted suppress this signal pathway or in combination with other chemotherapy drugs therapy in looking for the more effective and less cytotoxic treatment of pediatric t-all. cleveland clinic children's hospital, cleveland, ohio, united states background: non-hodgkin lymphomas (nhls) are a heterogeneous group of lymphoproliferative diseases which comprise 7% of all childhood malignancies. nhls can be divided in to b cell lymphomas and t cell/natural killer (nk) cell lymphomas depending on immunophenotype, molecular biology, and clinical response to treatment. although nk/t cell lymphomas occurring in childhood and adolescence comprise a small portion of all lymphomas, they present many diagnostic and therapeutic challenges. the role of angiogenesis in lymphoma pathogenesis is becoming more evident. high molecular weight kininogen (hk) is a central compo-nent of the kallikrein-kinin system. it has been previously reported that cleaved hk (hka) induces apoptosis of proliferating endothelial cells and inhibits angiogenesis in matrigel plug and corneal angiogenesis models. however, the role of endogenous kininogen in regulation of angiogenesis is in tumor microenvironment is unknown. objectives: to elaborate the role of hk in lymphoma angiogenesis, we used a murine t-cell lymphoma model and compared angiogenesis and tumor growth between wild-type and kininogen deficient (mkng1-/-) mice. we also evaluated the effect of hka on lymphoma cell proliferation. design/method: el-4 murine t-cell lymphoma cells (5 × 10^5) were implanted into wild-type and mkng1-/-mice. tumor size was measured using calipers and tumor volume was calculated using the formula volume = length × width^2 × 0.52. seventeen days after cell implantation, tumors were harvested and processed by immunoblotting and immunofluorescent staining. cell proliferation assays (mts) were performed to investigate any possible inhibitory effect of hka on el-4 cell growth, with human umbilical vein endothelial cells (huvec) were used as a positive control. results: el-4 lymphomas grew more rapidly and to larger sizes in mkng1-/-mice compared to wild-type mice, with significant differences apparent by day 11 after tumor implantation (p<0.01). by day 17, the volume of tumors in mkng1-/-mice was approximately 1.4-fold larger than in wild-type mice (mean volume ± standard deviation; 2120 ± 536 vs. 1485 ± 272 mm3, respectively, p<0.01). mts assays showed that hka does not directly inhibit the proliferation of el-4 cells in vitro, though it does significantly impair the viability of ecs studied simultaneously. conclusion: these findings suggest that hk is an important endogenous regulator of angiogenesis and tumor growth in this t-cell lymphoma model, and suggests that hka specifically modulates endothelial proliferation in tumor microenvironment. further work is needed to understand the mechanisms underlying these findings and provide future anti-angiogenic approaches to increase the therapeutic options for patients with nhl. bruce bostrom, jack knudson, nathan gossai, joanna perkins, michael richards, jawhar rawwas, susan sencer, julie chu, nancy mcallister, yoav messinger children's minnesota, minneapolis, minnesota, united states background: osteonecrosis causes significant pain and morbidity in older patients treated for acute lymphoblastic leukemia. besides altering the schedule of dexamethasone in delayed intensification there is no other intervention known to reduce the incidence of symptomatic osteonecrosis. pamidronate has been shown to reduce bone pain from osteonecrosis but not to prevent joint collapse when advanced. objectives: to compare the incidence of symptomatic osteonecrosis in patients who received prophylactic pamidronate compared with concurrent controls. to describe any increase in side effects from the use of pamidronate. design/method: patients age 10 to 28 years at time of all diagnosis were given intravenous pamidronate monthly for one year at the discretion of the primary oncologist starting in the first year of therapy. concurrent controls were patients age 10 to 28 who did not receive pamidronate. all patients were treated according to the concurrent cog protocols and received intermittent dexamethasone during delayed intensification. patients with bcr-abl all were excluded as the use of imatinib may increase the risk of osteonecrosis. imaging was only done if osteonecrosis was suspect based on clinical symptoms. patients were censored at the time of relapse. data were analyzed as of 1/1/2018. this retrospective study was approved by the children's minnesota irb. of the 62 patients evaluated 58% were male and 42% female, 74% had b-cell and 26% t-cell. the median followup is 2.4 years with a range of 0.3 to 7 years. pamidronate was given to 23 patients with 2 developing symptomatic osteonecrosis. there were 39 concurrent controls with 14 developing osteonecrosis. there was no significant difference in the leukemia lineage, gender distribution or body mass index (bmi) at diagnosis between groups. for all patients the median bmi was 22 with a range of 15 to 47. the age at diagnosis was significantly higher in the pamidronate group with a median of 18.6 years vs. 15.7 in the controls (p = 0.014). by kaplan-meier analyses the incidence of symptomatic osteonecrosis was significantly lower in the pamidronate group at 14% vs. 43% in controls. the log-rank p-value was 0.049 and the breslow p-value, which is more sensitive to early events, was 0.039. there were no untoward side-effects from pamidronate. pamidronate infusions significantly reduced the incidence of symptomatic osteonecrosis in patients over the age of 10 compared to concurrent controls who did not receive pamidronate. arahana awasthi, dina edani, janet ayello, christian klein, mitchell cairo new york medical college, valhalla, new york, united states background: mature b-nhl, including bl and pmbl express cd20+/cd79b+ and have an excellent prognosis, however, subset of patients relapse secondary to chemoimmunotherapy resistant disease and have a dismal prognosis (≤ 20% 5 yr. efs, cairo et al. blood. 2007; gerrard/cairo et al., blood, 2013 , goldman/cairo et al. leukemia, 2013 . pv has been demonstrated to possess significant preclinical activity against indolent cd79b+nhl (polson et al. can. res.2009 ). we previously observed that obinutuzumab (anti-cd20 mab) significantly enhanced cell death and increased overall survival against bl (awasthi/cairo et al., bjh 2015) in xenografted nsg mice. however, additive/synergistic effects of pv with obinutuzumab against mature pmbl/bl are unknown. to determine the efficacy of the pv or obinutuzumab/rtx alone or in combination against pmbl and rituximab (rtx) sensitive/resistant bl cell lines. design/method: raji4rh (provided by m. barth, md, roswell park cancer institute) and raji/ karpas1106p (atcc, usa) were cultured in rpmi. tumor cells were incubated with pv, and/or anti-cd79b, mmae (generously supplied by genentech inc.) with obinutuzumab /rituximab (100ug/ml) for 4 hr with nk cells at 10:1 e: t ratio and cytotoxicity was determined by delfia cytotoxicity assay. six to 8 week old female nsg (nod.cg-prkdcscid il2rgtm1wjl/szj), were divided into 5 groups: pbs, isotype control, pv, anticd79b mab and mmae (5mg/kg). mice were xenografted with intravenous injections of luc+ bl and pmbl cells and tumor burden was monitored by ivis spectrum system. results: os of mice receiving pv alone was significantly increased compared to anticd79b ab or isotype control in raji (35.5 vs.17 vs.19.5 our preliminary data indicates that pv significantly increased survival in bl and pmbl nsg xenografts compared to anti-cd79b ab alone. furthermore, pv in combination with obinutuzumab significantly enhances in-vitro cytotoxicity in bl and pmbl compared to obinutuzumab or pv alone. results: maximal grades (g)1/2, 3, and 4 crs occurred in 36, 19, and 24 patients, respectively. median lowest fibrinogen levels were 3.5, 3.3, and 1.2g/l in patients with maximal g1-2, 3, and 4 crs, respectively. 3%, 11%, and 25% of patients with maximal g1-2, 3, and 4 crs had lowest reported fibrinogen levels of ≥1 to <1.5g/l. eight patients (all with g4 crs) had very low fibrinogen levels (<1g/l), which occurred before (n = 1) or during (n = 6) maximal crs grade or at time of improvement (n = 1). no patients with maximal g1-3 crs had <1g/l fibrinogen levels. at the onset of <1g/l fibrinogen levels, 1 patient had concurrent g3, and 7 had g0-2 increased international normalized ratio and activated partial thromboplastin. cryoprecipitate was the primary treatment in the us, and fibrinogen concentrate (fc) guidelines for tisagenlecleucel-associated coagulopathy were developed for other countries because administration of fresh frozen plasma can be problematic. fc was available at 7/25 sites for 20 infused patients: 3/7 (g4 crs) and 0/8 (g1-3 crs). cryoprecipitate was available at 18/25 sites for 77 infused patients: 12/17 (g4 crs), 2/15 (g3 crs), and 0/32 (g1-2 crs). risk of bleeding increases in pediatric patients with comorbid thrombocytopenia and anticoagulant treatments. 5/8 patients had g3/4 decreased platelets within 1 day of <1g/l fibrinogen levels. 1 fatal case of intraparenchymal cranial hemorrhage occurred during resolving crs with g3 hypofibrinogenemia, ongoing thrombocytopenia, and continuous veno-venous hemofiltration with citrate. hypofibrinogenemia was observed more frequently in patients with higher crs grades during/when crs was improving or resolving. fc and cryoprecipitate treatment guidelines were developed. frequent monitoring and fibrinogen replacement are needed in patients with g3/4 crs. sponsored by novartis. its prolonged cns half-life, may allow a reduction in the number of intrathecal injections. objectives: to safely reduce the burden of therapy by reducing the number of it injections and reducing the total dose of doxorubicin with the addition of liposomal cytarabine and rituximab. design/method: patients (3-31 years) with cd20+ b-nhl with fab group b good risk (=stage i/ii and stage iii with ldh < 2xuln), fab group b intermediate risk (=stage iii ldh ≥2xuln and stage iv {bm blasts < 25%}) and fab group c high risk were eligible. patients received fab backbone therapy with the addition of six rituximab (375mg/m2) doses; two doses prior to each of two induction courses and one dose prior to each of two consolidation courses. cumulative doxorubicin was reduced from 120 to 50 mg/m2 in gr patients. after systemic methotrexate clearance, patients received age based dosing of it liposomal cytarabine. it injections were reduced from nine to five. the primary outcome is safety and toxic deaths among 40 evaluable patients with an estimated 3-year survival above 90%, monitored by an independent dsmb. results: to date, 32 evaluable patients, 25 fab group b and 7 group c (6 cns positive), median age 12 years (range 3-23), 20 males, 16 burkitt/16 dlbcl with 18 gr, 7 ir and 7 hr have enrolled. there has been one grade 3 anaphylactic reaction to rituximab and one grade 3 facial nerve palsy. no other serious adverse events were attributable to protocol therapy. there has been 1 death from progressive disease and 1 relapse at a median follow up of 30 months. efs and os are 94% and 97%, respectively. our initial results show excellent efs and os, consistent with published standard of care outcomes, with the addition of rituximab and intrathecal liposomal cytarabine despite the reductions in therapy. further enrollment is ongoing and continued long term outcomes are needed to confirm early results. future randomized studies are needed to examine both short term (mucositis, infections, hospitalization days) and long term (late cardiac toxicity) endpoints. 1. goldman etal, leukemia, 2013 2. cairo etal, jco 2012 st. jude children's research hospital, memphis, tennessee, united states background: bereaved parents identify significant spiritual needs around time of death and throughout their bereavement journeys. spirituality has been identified as a primary means by which bereaved parents can find meaning in their losses, and this ability to find meaning is associated with lower maladaptive grief symptoms. the use of spiritual coping strategies has been associated with improved coping and mental health outcomes among bereaved parents. objectives: to better understand how bereaved parents' experiences with spirituality throughout bereavement effects objective measures of grief, depression, and meaning-making. design/method: thirty participants whose children died of progressive cancer or related complications one to three years prior to participation completed an in-depth semi-structured telephone interview about their experiences with grief. participants were prompted to describe the impact of their spirituality on their bereavement processes. additionally, participants completed surveys related to grief (prolonged grief disorder questionnaire, pg-13), depression (beck depression inventory, bdi), and meaning-making (integration of stressful life experiences scale, isles). results were analyzed using a mixed methods approach including semantic content analysis of qualitative content and kruskal-wallis h test and post-hoc analyses of quantitative data. results: correlation analyses demonstrated significant differences between participants with positive and negative spiritual experiences of bereavement. participants with negative experiences of bereavement had a statistically significant increase in scores on the pg-13 compared to those with positive spiritual experiences signifying greater symptoms of prolonged grief. participants with negative spiritual experiences with grief had significantly lower scores on the isles, suggesting a lesser degree of adaptive integration of their losses. there were no significant differences in depression scores between groups. conclusion: bereaved parents that have a negative spiritual experience of bereavement are at increased risk for prolonged grief symptoms and are less likely to find meaning in their children's deaths than bereaved parents that describe a positive spiritual experience of bereavement. providers should consider exploration of spiritual beliefs and provision of spiritual care for parents of children facing life-limiting illnesses during treatment and bereavement. background: langerhans cell histiocytosis (lch) is an inflammatory myeloid neoplasia characterized by frequent relapse, with treatment failure associated with higher risk of death and neurodegenerative disease (lch-nd). activating somatic mutations in mapk pathway genes have been identified in almost all cases, with braf-v600e in approximately 60% of lesions. targeted therapies have been successful in treating other refractory cancers with braf v600e mutations (such as melanoma). given the central role of mapk pathway activation in lch, mapk pathway inhibition may be an effective therapeutic strategy for children with lch. objectives: the purpose of this study was to report the efficacy and toxicity profile of a retrospective cohort of patients with lch treated with mapk pathway inhibitors. design/method: medical records from 12 pediatric patients with lch (systemic and/or lch-associated neurodegeneration) who were treated with a mapk pathway inhibitor were retrospectively reviewed from five institutions. all patients had failed at least one prior systemic therapy and had a proven mapk pathway mutation. results: all patients in this series were less than 21 years old (median = 10.1 years; range: 2-20 years) with a median of three prior treatments (range: 1-9). at the time of initial mapk inhibitor use, nine of the 12 patients had lch-nd diagnosed clinically and/or by radiographic imaging; the remaining three patients had systemic disease. patients were treated for a median of 9 months (range: 1-20 months) with various reasons for discontinuation. three patients received combination mapk inhibitor therapies and three patients received other concurrent lch-directed therapies. four of the twelve patients had a grade 3 or 4 toxicity reported and three of these patients required dose reduction in order to be able to successfully resume therapy. overall survival was 92% with median 20 month follow-up (range: 1-42 months) with only one patient achieving transient complete response. the remaining ten patients had partial response or stable disease and four of these patients developed progressive disease while on therapy. conclusion: mapk pathway inhibitors may be a relatively safe salvage therapy for refractory systemic lch and lch-nd but the efficacy and durability of this strategy remains to be defined. combination with cytotoxic chemotherapies may be required in order to eradicate the disease-causing cell. future prospective trials of mapk pathway inhibitors for patients with refractory lch are needed in order to directly compare their efficacy and toxicity relative to other current salvage strategies. cincinnati children's hospital medical center, cincinnati, ohio, united states background: medication adherence during maintenance therapy has been shown to have a direct relationship with disease relapse in pediatric leukemia. previous research determined that patients who are ≤ 95% adherent to 6mercaptopurine (6mp) have a greater risk for relapse. the primary aim of the present study is to examine the relationship between metabolite profiles of 6mp with behavioral adherence rates obtained via electronic monitoring at 5, 10, and 30 days. it is hypothesized that patients demonstrating low levels of thioguanine (tgn) and methylated mercaptopurine (mmp) will have lower behavioral adherence rates prior to the blood draw. design/method: in a multisite, prospective study of 139 patients ages 7-19 years diagnosed with acute lymphoblastic leukemia (all) or lymphoblastic lymphoma (lbl), 6mp adherence was measured across 15 months of maintenance therapy using behavioral adherence (electronic monitoring) and pharmacological (metabolites) measures of 6mp. 6mp is metabolized into mmp and tgn. cluster analysis was used to generate three mutually-exclusive profiles of 6mp adherence. behavioral adherence rates were calculated for 5, 10, and 30 days prior to the blood draw. results: this study identified three metabolite profiles of 6mp across 15 months. previous research indicated that low levels of both metabolites suggest nonadherence to medication. low levels of one metabolite with high levels of another metabolite indicate adherence to 6mp. in this study, 51.2% of the low tgn-low mmp group had 5-day behavioral adherence rates ≥ 95% (mean = 100%); 48.8% had adherence rates < 84% (mean = 48.5%). in the high tgn-low mmp group, 77.6% had a mean 5-day adherence of 100%; 22.4% had adherence rates < 84% (mean = 32.9%). the low tgn-high mmp group had 74% of patients with a mean 5-day adherence level of 100%; 26% had adherence rates < 84% (m = 54.6%). at 10 and 30-days, 62 to 66% of patients in the low tgn-low mmp group had adherence rates < 95%. conclusion: these findings suggest that electronic monitoring and metabolite concentrations can be used to monitor 6mp medication adherence during maintenance therapy. it is notable that there is a sub-sample of pediatric patients who are identified as being nonadherent to 6mp based on electronic monitoring, however, metabolite levels indicate adherence to 6mp. similarly, a sub-sample of patients were identified as being adherent based on electronic monitoring, but metabolite profiles indicated sub-therapeutic levels of 6mp. our findings underscore the clinical significance of using both objective measures of medication adherence to inform clinical decision making. cincinnati children's hospital medical center, cincinnati, ohio, united states background: hemophagocytic lymphohistiocytosis (hlh) is a life-threatening hyperinflammatory syndrome characterized by non-remitting fevers, rash, hepatosplenomegaly, cytopenias, liver dysfunction and coagulopathy, and can include central nervous system involvement. several genetic diseases cause hlh by impairing normal lymphocyte or macrophage function. the hlh panel at the cincinnati children's genetics laboratories includes 14 genes associated with hlh and other lymphoproliferative diseases, including the genes that cause primary hlh (prf1, unc13d, stxbp2, stx11, rab27a), x-linked lymphoproliferative diseases (sh2d1a, xiap), itk deficiency (itk), hermansky-pudlak syndrome types 2 and 9 (ap3b1 and bloc1s6), chediak-higashi syndrome (lyst), cd27 deficiency (cd27), xmen syndrome (magt1) and lysinuric protein intolerance (slc7a7). deletion/duplication analysis is available as a reflex test for all 14 genes, as copy number variations (cnvs) are not directly assessed by sequencing. objectives: the prevalence of cnvs among large groups of patients with hlh in north america is unknown. we assessed the frequency of cnvs in the genes on the hlh panel through a retrospective review of 522 orders for deletion/duplication analysis performed after next-generation or sanger sequencing: 397 orders for all 14 genes on the panel, and 125 orders of 1-5 genes from the panel. deletion/duplication analysis was performed on a custom 4 × 180k microarray annotated against ncbi build 37 (ucsc hg19, march 2006). deletion/duplication analysis resulted in a confirmatory diagnosis in 11 of 522 cases (2.1%). pathogenic or likely pathogenic cnvs were most common in the three x-linked genes: sh2d1a (3 deletions), xiap (3 deletions, 1 duplication), and magt1 (3 deletions). hemizygous deletions in xlinked genes in male patients were typically suspected after amplification failure during previous sequencing. of the autosomal recessive genes, pathogenic cnvs were observed once in each of three genes: rab27a (heterozygous), lyst (heterozygous), and stxbp2 (homozygous). in the two heterozygous cases, a second change was not identified by sequencing, so deletion/duplication analysis did not offer a confirmatory diagnosis. in 25 patients, deletion/duplication analysis was performed after a pathogenic or likely pathogenic variant was identified in an autosomal recessive gene during sequencing; however, in no case was a second mutation uncovered by cnv analysis. we recommend that deletion/duplication analysis be routinely performed in all male patients with hlh who lack a genetic diagnosis after sequencing of hlh-associated genes, especially if any regions failed to amplify. deletion/duplication analysis may be performed in female patients after sequencing if a genetic form of hlh is highly suspected, but the yield is expected to be low. cleveland clinic children's hospital, cleveland, ohio, united states background: the development of post-transplant neoplasia, typically from lymphoproliferative disease (ptld), is a severe complication in transplant recipients and affects approximately 12% of pediatric solid organ recipients. rates of lymphoma in adult heart transplantation patients are comparatively low, at less two percent at ten years. there are few published reports of the long-term outcomes of neoplasia after pediatric heart transplantation. we aimed to identify the subsequent malignancies that occurred in pediatric heart transplantation patients in a large single institution, and describe their treatment and subsequent clinical course. we performed a retrospective chart review of all pediatric heart transplant recipients followed at the cleveland clinic children's hospital from january 1985 to october 2012. we excluded patients who died within 30 days of heart transplantation. we reviewed in depth the history and clinical course of subjects who developed neoplasms. results: between 1985 and 2012, 101 patients underwent heart transplantation and survived at least 30 days post transplantation. nine patients (8.9%) developed a subsequent malignancy. in this case series, the median age at heart transplant was 3 years old and the median time to develop neoplasia was 88.6 months. primary neoplasia included monomorphic ptld (3), polymorphic ptld (1), burkitt lymphoma (2), hodgkin's lymphoma (1), plasmacytoma-like lymphoma (1) and epstein-barr virus-associated smooth muscle tumor (ebv-smt) (1). one patient with hodgkin lymphoma subsequently developed monomorphic ptld, one patient with polymorphic ptld subsequently developed ebv-smt and later, an undifferentiated gastric cancer. one patient with monomorphic ptld developed an ebv-smt. evidence of epstein-barr virus was present in six of nine patients at diagnosis of first malignancy. four of nine patients received reduction in immunosuppression as a primary intervention for the initial malignancy, with two complete responses (cr), one partial response, and one with progressive disease. five patients were treated with chemotherapy, with four cr and one with progressive disease. three patients died of malignancy (recurrent ebv-smt, undifferentiated gastric cancer, and monomorphic ptld post-hodgkin disease) and two patients died of other transplant related complications. conclusion: secondary malignancies represent a significant disease burden to survivors of cardiac transplantation. as expected, much of the malignancy burden is driven by ebv. despite aggressive histology, many malignancies can be successfully cured in this setting with a multidisciplinary approach. stanford university school of medicine, palo alto, california, united states background: current treatment of langerhans cell histiocytosis (lch) is based on extent of organ system involvement and if high risk systems are affected. gastrointestinal (gi) involvement is diagnosed in about 2% of lch patients, and classically presents in children under 2 years of age with malabsorption, failure to thrive, bloody diarrhea and anemia. although the gi system is considered standard risk, a mortality rate over 50% occurring within 2 years of diagnosis has been reported. this study was performed due to this discrepancy and the limited number of published cases. objectives: to review the clinical course and outcomes of patients diagnosed with gi lch. design/method: a retrospective chart review of patients with histologically confirmed gi lch diagnosed in the last 15 years identified from the bass center histiocytosis clinical database was performed. two other pediatric hematology/oncology centers (ucsf benioff children's hospital oakland and san francisco) were queried for additional cases. results: four patients with biopsy proven gi lch [3 subjects (2.9%) from 105 database records and l from center queries] were identified. failure to thrive, hypoalbuminemia, bloody diarrhea and rash were the most common presenting symptoms. lch of the skin was found in all patients. risk organ systems were involved in 2 patients. of note, 2 subjects were of african racial background. the median age at diagnosis was 3.5 months (1.5 months to 16 years), mean albumin 2.2 g/dl (1.2 -2.9 g/dl), mean esr of 56 mm/hr (37 -78 mm/hr). all patients initially received combination therapy per lchiii protocol (vinblastine, prednisone, and 6 mercaptopurine). two patients had recurrent disease and received second line therapy (cytarabine, 2cda, and local radiation therapy). all patients are alive without active disease at last follow-up (8 to 107 months after completion of therapy). a systematic approach to evaluate gi involvement should be performed in children diagnosed with lch. from our experience, combination chemotherapy for patients with lch involving the gi tract is an effective intervention for active disease. cincinnati children's hospital medical center, cincinnati, ohio, united states background: bhatia indicated that rates of 6mp adherence ≥ 95% have better clinical outcomes. those with adherence rates ≤ 95% have an increased risk for disease relapse. the present study investigated patterns of 6mp medication adherence using group-based trajectory modeling in a large sample of pediatric patients. to describe patterns of behavioral adherence during the maintenance phase of therapy for a cohort of pediatric patients ages 7-19 years who were diagnosed with acute lymphoblastic leukemia or lymphoblastic lymphoma (n = 139). previous research has documented the relationship between optimal levels of medication adherence with positive health outcomes. it was hypothesized that three groups would be identified: optimal adherence, deteriorating adherence, and chronic nonadherence. it was hypothesized that patients in the optimal adherence group would have adherence rates ≥ 95%. those with poor adherence would have adherence rates ≤ 95%. design/method: the present study was a longitudinal, multisite study investigating adherence to 6-mercaptopurine in a pediatric cohort of patients using electronic monitoring devices. daily adherence rates (electronic monitoring of 6mp) were examined across 15-months. health outcomes were measured at quarterly intervals through medical chart reviews. results: unconditional growth curve modeling indicated that the mean percentage of behavioral adherence was 84.4% at baseline and declined to 75.2% at 15-months. three trajectories of 6mp behavioral adherence were identified: 1) optimal adherence (67% of patients): averaging 95% behavioral adherence across 15 months; 2) moderate adherence (20%): relatively stable nonadherence with rates of 67% across 15 months; and, 3) chronically nonadherent (13%): adherence decreased from 63% to 30%. with respect to patterns of medication adherence and relationship to clinically-relevant health outcomes, there were no significant differences in health outcomes between patients in the adherent versus nonadherent trajectories, including mean absolute neutrophil counts (anc), risk for infection as measured by anc, healthcare utilization, or risk for disease relapse. although longitudinal patterns of 6mp behavioral adherence were not related to health outcomes, it is notable that only 67% of the current sample had adherence rates ≥ 95%. in fact, 33% of the current sample demonstrated adherence rates ≤ 95%. our findings are important for development of future adherence promotion studies in pediatric cancer. our findings underscore the relative significance of tailoring adherence promotion interventions to subgroups of patients, including those with problematic patterns of adherence. patients who demonstrate adequate levels of adherence could still benefit from less intensive, preventative interventions to sustain and improve adherence. sophie gatineau-sailliant, pascale grimard, marie-claude miron, guy grimard, anne-sophie carret, jean-marie leclerc chu sainte-justine, montreal, quebec, canada background: vertebral involvement in langerhans cell histiocytosis (lch) is still a subject of interest, due to its low frequency and the absence of management's guidelines. objectives: to provide additional information on presentation, treatment and morbidity of pediatric lch vertebral lesions, we report cases of 11 children with vertebral lesion of biopsy-proven lch, between january 1st 2000 and december 31st 2015, at sainte-justine university health center (montreal, quebec, canada). we conducted a retrospective study by reviewing charts and imaging of vertebral lch in a population of 11 children (median age of 8.25 years at lch diagnosis), followed for a median duration of 34 months. symptoms at presentation, treatment modalities and morbidities were collected. results: vertebral lesions were present at lch diagnosis in 9 of 11 cases. they were usually diagnosed secondary to back pain in 10 of 11 cases and were asymptomatic in only one case. despite an epidural extension in 6 of 11 cases, no child developed neurological symptoms. lesions frequently involved vertebral body (10 of 11 cases) and were rarely unstable (2 of 11 cases). out of 29 vertebral lesions, most of them had a dorsal localization (15 of 29 lesions) and 8 of 11 patients had lch in multiple vertebrae. at diagnosis, median vertebral height loss was 37.5% compared to 25% at last imaging control. most used imaging modalities were pet-scan and plain x-rays. treatments were diverse and consisted in chemotherapy in all children but three and bisphosphonates in only 3 cases. radiation therapy was not used in any patient. six out 11 patients did benefit of an orthosis. a lch recurrence was observed in 6 patients and involved vertebrae in 4 cases. one patient with treatment-resistant lch disease had 5 relapses, and required multiple lines of treatment. all children were alive and disease-free at their last follow-up, 10 patients having radiological vertebral sequelae and only 3 had clinical sequelae. our study is consistent with the epidemiological data described in larger cohorts of children with vertebral lesions of lch and the favorable prognosis associated with such lesions. nevertheless, aggressive treatment and long term follow-up seemed to be essential as recurrences are s243 of s301 not rare and spontaneous bone regeneration often incomplete. plain x-rays appears to be a good follow-up tool for vertebral lesions as it allows reliable measures, less exposure to radiation at lower cost. national cancer institue, giza, giza, egypt background: acute lymphoblastic leukemia (all) is the most common type of childhood cancer and also the most complicated in the treatment, so it requires many interventions for both treatment and to alleviate suffer form side effects. pancreatitis is one of the toxicities, which is more common in all as it appears in about 16% of the patients. it occurs in many drug combinations which induce pre-pancreatitis and even direct destruction of pancreatic tissues. pancreatitis can be induced by many drugs used in the treatment such as chemotherapeutic agents or supportive treatment. lasparaginase is the backbone drug of the treatment of all in which 6 to 9 doses are required to achieve complete remission status in the induction phase of treatment and 12 to 19 doses in the maintenance phase.it is an enzyme that destructs the l-asparagine amino acid into aspartic acid and ammonia thus deplete the asparagine from the extracellular matrix . many drugs are investigated for their effect on treatment of induced pancreatitis such as interleukin-10, nsaid as antiinflammatory, glycerin tri nitrates as improvement of microcirculation, tnf-alpha antibody, paf inhibitor as specific anti-inflammatory and low molecular weight heparin .none of the drugs was investigated for their ability to prevent the occurrence of pancreatitis. objectives: this study was designed to evaluate the protective effect of enoxaparin and diclofenac against l-asparaginase induced pancreatitis design/method: acute pancreatitis was induced in rats by intra-muscular injection of l-asparaginase (1000 i.u/kg) given daily for five days. enoxaparin was given subcutaneous (100 i.u/kg) and diclofenac was given intra-peritoneal (2 mg/kg) daily for five days. then, markers of pancreatic injury, lipids, immune cell infiltration and oxidative stress were analyzed with histo-pathological examination of the pancreatic tissue results: during acute pancreatitis, oxidative stress markers were significantly changed as indicated by reduced tis-sue glutathione and increased malondialdehyde levels. this was accompanied with significant increase in immune cells infiltration as indicated by high levels of myeloperoxidase and pro-inflammatory cytokine tnf-alpha. triglyceride only showed increase level. treatment with enoxaparin and/or diclofenac restored levels of biochemical markers including serum alpha-amylase, reduced glutathione, malondialdehyde, pro-inflammatory cytokine tnf-alpha, myeloperoxidase and triglyceride. histological injuries of pancreatic tissues as vacuolation and necrosis of epithelial lining pancreatic acini, inflammatory cells infiltration and focal pancreatic hemorrhage were also reduced by treatment with enoxaparin and/or diclofenac. the present study emphasizes the potential protective effect of enoxaparin and diclofenac against l-asparaginase induced pancreatitis background: rosai dorfman disease (rdd), or sinus histiocytosis with massive lymphadenopathy (shml), is a rare condition of immune dysregulation of unknown etiology arising from the massive accumulation of non-langerhans type histiocytic cells inside lymph nodes. the disease classically presents as bulky, painless lymphadenopathy often associated with infection showing distension of lymph node sinuses by abundant histiocytic cells (cd1a(-), s-100(+)/cd68(+)). in some cases, the disease can be self-limiting, but in cases with a prolonged chronic course of exacerbations and remissions, those with extranodal involvement, or disease that threatens vitals structures, treatment may be necessary. there is no treatment consensus. to describe a case of life-threatening, unresectable, recurrent rdd successfully treated with langerhans cell histiocytosis (lch) 2009-inspired therapy. design/method: we compared this case to the current literature on chemotherapeutic treatments for rdd. we searched pubmed, ovid, and google scholar for similar cases. we believe this to be the first reported case of using lch therapy to successfully treat rdd. an 8-year-old male presented to an outside hospital with two years of massive neck swelling causing torticollis. biopsy confirmed rdd. he was intermittently treated with courses of antibiotics with partial response. surgical removal of the affected lymph nodes was unsuccessful due to proximity to the spinal cord. two years later, the patient presented to our institution. he was initially treated with prednisone with a fast tapering dose, but after a second relapse the decision was made to try chemotherapy following the lch-2009 protocol of weekly vinblastine (6 mg/m2), 6-mp (75 mg/m2), and high dose steroid bursts. he experienced two additional relapses off therapy at ages 12 and 14 years old, including cmv(+) associated septic shock and cytokine storm requiring rapid response, picu admission, and ionotropic support. this last episode was treated with a more prolonged induction and maintenance therapy. an extended and slowly tapered maintenance therapy regimen of 2.5 years of daily 6-mp, monthly vinblastine and steroids with a slowly tapered dose during his fourth remission has resulted in 38-months of continuous complete remission-the longest stretch of his life. no similar cases were found. literature search demonstrated no consensus regarding the most effective treatment of rdd, with no previous cases being successfully treated following lch chemotherapy protocols. we hypothesize that the multi-agent relatively mild lch-2009 therapy mitigates the immune dysregulation of rdd. this case suggests that lch-2009 therapy can be used to treat cases of rdd that is not amendable to surgery or observation. nicklaus children's hospital, miami, florida, united states background: central venous catheters (cvc) are necessary in the management of patients with malignancies, especially children. patients with acute leukemia (al) have higher rates of central line associated complications such as bloodstream infections compared with other malignancies. objectives: to examine the choice of placement of cvc and the differences in outcome between peripherally inserted central catheters (picc) and ports in patients with leukemia during induction. design/method: retrospective chart review of patients with newly diagnosed leukemia at nicklaus children's hospital between 2010 and 2016. results: ninety four patients with a new diagnosis of leukemia undergoing induction chemotherapy were identified. the average age was 6.9 years. overall, 51 (54.3%) patients had a port placed and 43 (45.7%) had a picc placed. the decision for picc or port was subjective and physician based. the main outcome measures were local inflammation/infection, bacteremia, thrombophlebitis, blocked catheter and premature removal. the most common complication was bacteremia (12. 8%). in a multiple logistic regression analysis for predicting whether patients had at least one complication, results showed that having at least one complication is 3.4 times the odds in patients with aml compared to patients with all (p = 0.032). when comparing picc vs. ports, patients with picc had more frequent episodes of blocked catheters (23.3%) and premature removal (20.9%) compared to the patients with ports (2.0% and 0.0%) (p = 0.002 and p = 0.001 respectively) during induction. local inflammation, bacteremia and thrombophlebitis were not statistically different (p = 1.0, p = 0.54 and p = 2.4 respectively). the most common place for port placement was the right subclavian vein (55%). there was no significant association between port location and having at least one complication (p = 0.112). acute lymphocytic leukemia subgroup analysis: fourteen patients (61%) in the picc group had at least one complication and 9 (39%) in the port group but that was not statistically significant (p = 0.128). our series showed a higher incidence of blocked catheters and premature removals with picc compared to ports in patients with leukemia during induction. the choice of placement of picc vs port was subjective and physician based. patients with all, despite receiving steroids and asparaginase during induction, did not show a statistically significant increase risk in thrombosis or infection but larger numbers may be needed in future studies. university of california, san francisco, san francisco, california, united states background: hemophagocytic lymphohistiocytosis (hlh) is classically a disorder of young children meeting systemic hyperinflammation criteria. presentation in late adolescence is uncommon. furthermore, though cns signs occur in 30-70% of cases, initial isolated neurologic presentation is rare, frequently resembling encephalitis or demyelinating disorders. these cns signs can be isolated or precede systemic disease, delaying hlh diagnosis. hlh declaring in adolescence with predominant psychiatric features has not been well documented. objectives: to describe a case of cns hlh presenting with neuropsychiatric features in absence of classic hlh criteria. design/method: retrospective review of clinical, radiologic, histologic, immunophenotypic, and molecular features of a patient with cns hlh. a 19-year-old female presented with acute-onset headaches following nine months of progressive anxiety, short-term memory loss, emotional lability, perceptual disturbances, and hypomania. brain mri demonstrated numerous enhancing t2 hyperintense supratentorial and infratentorial white matter lesions in the left thalamus and caudate head. brain biopsy showed histiocyte-rich inflammation and associated demyelination. extensive evaluation including universal microbial pcr failed to reveal underlying infection or malignancy. past medical history was notable for presumptive pulmonary sarcoidosis diagnosed 14 months prior with progressive respiratory failure with associated granulomatous pulmonary nodules which responded to systemic immunosuppression. at presentation of her neuropsychiatric symptoms, she had normal sil-2r, ferritin, fibrinogen, and triglycerides. there was no pancytopenia, coagulopathy, bone marrow hemophagocytosis, fevers, or splenomegaly. given the possibility of partial immune suppression of systemic symptoms and the prominent neurologic symptoms, hlh screening labs were sent and notable for decreased natural killer and cytotoxic t lymphocyte function, normal granzyme expression and cd107a mobilization, and absent perforin expression. genetic testing confirmed compound heterozygous mutations in prf1 (c.227g>a, c.626a>c) and familial hlh type 1. she was treated with low-dose dexamethasone and intrathecal chemotherapy per hlh-94. due to lack of evidence of systemic inflammation, vp-16 and high-dose steroids were held. within one week of initiating therapy, she had decreased anxiety and improved cognition, with sustained, incremental neuropsychiatric improvement with additional intrathecal treatments. she tolerated dexamethasone tapering without symptom flare. mri also demonstrated parenchymal lesion improvement. for definitive treatment, she underwent unrelated allogeneic hematopoietic cell transplantation and remains at neurologic baseline as of eight months post-transplant with ongoing imaging improvement. conclusion: this case of familial hlh with compound heterozygous perforin mutations in an adolescent with isolated neuropsychiatric symptoms illustrates that cns hlh may be an underrecognized phenomenon in absence of systemic signs. standard hlh therapy may effectively reverse these symptoms with associated radiologic responses. rush university children's hospital, chicago, illinois, united states background: posterior reversible encephalopathy syndrome (pres), a recognized complication of pediatric leukemia treatment has been reported in up to 5% patients in various series. hypertension, chemotherapy and cortical spreading depression have been implicated in the pathophysiology. due to the combinations used, it is difficult to identify the offending drug, several have been implicated. since delay of chemotherapeutic treatment in children with high risk leukemia is unfavorable, it is important to recognize the characteristic radiologic findings, manage appropriately and reintroduce the treatment as soon as possible. pharmacoethnicity is now recognized as an important factor for variation in neurotoxicity in children with all. ethnic differences in reported pres events in pediatric patients with all has not been well described in literature. to describe the factors associated with pres in a cohort of high risk pediatric all patients at a single institution. design/method: a total of 12 children with an average age of 9 years (1-20 years) diagnosed with all between 2013-2017 were retrospectively reviewed for the occurrence of pres. various demographic factors, therapy received, clinical features, radiology related findings and management were reviewed. a search for all published articles on pres in leukemia was conducted using pubmed databases. results: five (42%) children (average age 8.5 years) developed pres during days 10-29 of induction. 80% of the patients that developed and 45% of those that did not develop pres were hispanic. all the patients that developed pres and 43% of those that did not were diagnosed with high risk all. all patients received vincristine, 80% received daunomycin and intrathecal methotrexate and 20% received asparaginase in the 1 week prior to the event. mri findings confirmed pres in all 5 patients with no evidence of methotrexate related leukoencephalopathy or leukemia. at the time of pres all patients were in remission based on mrd and spinal fluid cytology. two-thirds of the patients had seizures and hypertension at the time of the event with no prior history of either. all patients had complete recovery of normal mental status after resolution of pres. a higher incidence of pres than previously reported was noted in our series. hispanic ethnicity, high-risk all and exposure to vincristine, daunomycin and intrathecal methotrexate in induction were associated with pres in our cohort. a new association that emerged was that of hispanic ethnicity with pres .larger studies to understand the importance of pharmacoethnicity in pres may help in individualization of chemotherapy based on ethnic differences. children's hospital of illinois, peoria, illinois, united states background: hyper ige syndrome is a primary immunodeficiency characterized by susceptibility to skin and lung infections as well as increased propensity for malignancy. hemophagocytic lymphohistiocytosis (hlh) is a syndrome characterized by overwhelming activation of t lymphocytes and macrophages occurring as either primary hlh caused by genetic abnormalities or secondary hlh associated with infectious, malignant, metabolic, or immunodeficiency causes. we describe the first case to our knowledge of hlh in a patient with hyper ige syndrome. to describe a case of hlh in a pediatric patient with hyper ige syndrome. results: a 7-year old caucasian male with known autosomal dominant hyper ige syndrome (stat3 mutation) was transferred to the pediatric intensive care unit secondary to concern for septic shock. the patient had persistent slow bleeding from oral lesions and central catheter sites despite the addition of aminocaproic acid and recombinant factor viia. he also required numerous blood product transfusions sec-ondary to anemia and thrombocytopenia. clinical suspicion was high for hlh and the patient met criteria for diagnosis of hlh with the following: ferritin > 40,000 ng/ml, triglycerides 264 mg/dl, decreased nk cell function with the sample only containing 1% nk cells, elevated soluble il-2 receptor at 4215 u/ml, splenomegaly, and fever. infectious workup was remarkable for a positive ebv qpcr with 80,700 copies/ml suggestive of ebv driven secondary hlh. familial hlh testing was unable to be completed. therapy was initiated based upon the hlh-94 study. the addition of ruxolitinib and anakinra were considered but the patient declined rapidly prior to treatment. ct of the head was concerning for a stroke with signs of edema and increased intracranial pressure likely leading to the development of symptoms consistent with brain stem herniation. the decision was then made to withdraw care. conclusion: to our knowledge, this is the first report of hlh in a patient with hyper ige syndrome. diagnosing hlh requires a high index of suspicion in critically ill patients, and prompt initiation of therapy is essential. this challenging case of hlh in a patient with hyper ige syndrome highlights the diagnostic challenge, variable presentation, and need for effective therapy in this vulnerable patient population. background: adolescents and young adults (ayas) with cancer are at risk for psycho-social as well as physical symptom burden during cancer therapy. the purpose of this study is to explore psychological and physical symptoms endorsed by aya while receiving therapy for cancer design/method: surveys were given in both inpatient and outpatient settings during cancer therapy. symptom screening in pediatrics tool (sspedi) and memorial symptom assessment scale (msas). symptoms severity was rated by teens on a 5 point likert scale. spss 22, used for statistical analysis. results: : a total of 39 aya on cancer therapy (age range 13-19.9 years) 35% female, 65% male, 43.6% acute leukemia, 48.7% solid tumors, and 7.7% diagnosis was not reported. 78% of aya on cancer therapy reported at least 1 or more symptoms, 45% reported >3 symptoms cluster. of the physical symptoms that were reported as most distressing to the teens, mouth sores and headaches were the top causes. of the physical symptoms that were most frequently endorsed; fatigue was on the top (58%), followed by change in appetite 45 %, vomiting 43%, and pain 40%., the least was bowel habit changes. aya rated sadness as the most frequent psychological symptom 38%, followed by feeling angry 32%, and scared 30%. statistically significant difference was noticed based on gender difference with more females reported symptoms (p = 0.01), while type of cancer (acute leukemia versus solid tumors) was not statistically different. conclusion: aya with cancer reported multiple physical and psychological symptoms with significant distress. females seem to report more symptoms compared to males. screening aya for cancer therapy related symptoms is feasible during routine visits and adds important information about the aya well-being. background: sinus histiocytosis with massive lymphadenopathy (shml), also known as rosai-dorfman disease, is a rare histiocytic proliferative disorder of unknown etiology. many treatment modalities have been employed; however, no uniform guidelines exist. objectives: literature review of treatment options for shml. design/method: chart review was performed on pediatric patients diagnosed with shml at the children's hospital at montefiore between 2010 and 2012 after irb approval. inclusion criteria included children between the ages of 0 and 21 years with shml. exclusion criteria included children with cutaneous shml. four cases of shml seen at montefiore are described. a comprehensive review of the literature identified 102 additional cases published between 1978 and 2018. manuscripts that did not include the treatment modality or outcome were excluded. results: many of the 106 patients with shml responded to observation alone. of 106 patients, 46 patients were observed, with 35 (76%) having resolution of disease, five having stable disease, and five being lost to follow-up. one patient received subsequent systemic therapy. surgical management was con-ducted upfront in 29 patients. of those, 18 (62%) had resolution of disease, one had stable disease, and one had recurrence with no further therapy noted. of the remaining nine patients, 77% were successfully treated with systemic therapy, consisting of either steroids (5) or steroids and chemotherapy (4). systemic therapy was used as first-line therapy in 31 patients. steroids alone or in conjunction with chemotherapy resulted in resolution of disease in 12/15 and 7/11 patients (19/26, 73%), respectively, with four patients having stable and three with progressive disease. chemotherapy without steroids resulted in resolution of or stable disease in 3/5 patients. radiation was ineffective. conclusion: shml is a rare disease with no published guidelines for treatment. from the results of the cases and a detailed review of the literature, it can be suggested that observation may be considered as first line management in patients providing there are no significant symptoms. for patients who are symptomatic or have significant progression, surgery may be considered. in patients with recurrence or refractory disease, steroids and/or chemotherapy may be used. the presence of nodal or extra-nodal disease did not seem to have a significant impact on the course of treatment. given the rarity of the disease, it is difficult to conduct a randomized control trial. further work, involving collaboration between centers and cooperation with the international rare histiocytic disorders registry would be helpful. boston children's hospital, boston, massechusettes, united states background: increasing census and intensified work compression on the inpatient oncology service at our institution was identified as leading to resident dissatisfaction, impaired resident learning and decreased perceived quality of patient care. objectives: to evaluate the impact of a redesign of a pediatric inpatient hematologic malignancy (ihm) service on resident perceptions of the educational value of the rotation and safety of patient care. design/method: during the 2016-2017 academic year, we initiated a bundled intervention on the ihm service. modifications included 1) decreased patient volume: the ihm service was divided into two teams, utilizing an extra attending -a teaching service consisting of residents and fellows and a team comprised of nurse practitioners. 2) intentional patient team assignment: patients were deliberately assigned to a care team based on educational opportunities and provider skill sets. 3) intentional attending faculty selection: attending faculty with deeper clinical and teaching experience were selected to supervise on the teaching team. 4) increased weekend staffing. after completing the service, junior residents completed an electronic survey to evaluate their perceptions of the educational value of the rotation, as well as their ability to deliver safe care while on the rotation. fisher's exact tests were used to compare responses from residents in 2017 who experienced the redesign to residents in 2016, whose experience results: survey completion rates were 70% (28/40) in 2016 and 57% (29/51) in 2017. intervention residents were significantly more likely than comparison group residents to choose the answers "very good" or "excellent" to describe both the overall quality of the rotation (76% intervention vs. 25% comparison, p<0.001) and the educational experience on rounds (52% intervention vs. 7% comparison, p<0.001). intervention residents also reported caring for fewer average primary patients daily on weekdays as compared to comparison residents (4.8 vs 8.7 patients, p<0.0002, 95% ci -5.14 to -2.64). furthermore, intervention residents were more likely than comparison residents to "agree" or "strongly agree" that they could provide safe patient care on weekend days (79% intervention vs. 14% comparison, p<0.001) and on nights (69% intervention vs. 25% comparison, p<0.01) while on the oncology service. a redesign initiative of an oncology service with the development of a new teaching service led to improved resident perceptions of the educational value of the rotation and ability to provide safe care to patients. this approach could be useful to other services and institutions to promote similar outcomes in resident education and patient care. background: alk-positive histiocytosis is a rare histiocytic proliferative disorder that has been reported in three infants presenting primarily with hepatosplenomegaly, anemia, and thrombocytopenia. given the rarity of this disease, there are no standard treatment algorithms for this diagnosis and the disease course and outcomes remain largely unknown. the published series describes treatment ranging from monitoring alone to multi-drug chemotherapy regimens. there was ulti-mately resolution of presenting symptoms in all three cases despite varying treatment strategies. objectives: to report a newly diagnosed case of alkpositive histiocytosis that was treated with a novel approach using cytarabine monotherapy. results: a full term male infant presented at birth with difficulty feeding and hyperbilirubinemia. over the first few weeks of his life, he subsequently developed thrombocytopenia, transaminitis, and profound hypoalbuminemia. by six weeks of life, he was experiencing significant abdominal ascites requiring repeat paracenteses, massive hepatosplenomegaly, respiratory distress secondary to abdominal distension, anemia, and coagulopathy. he underwent numerous diagnostic tests, including a liver biopsy followed by a bone marrow biopsy that showed alk-positive histiocytic infiltrates in both sites. treatment was initiated with cytarabine 170 mg/kg/day x 5 days, repeating every 4 weeks. throughout his course of five cycles of treatment, he experienced intermittent fevers and mild nausea with no other adverse events. by the end of five cycles, his hepatosplenomegaly resolved, his blood counts normalized, he demonstrated weight gain on oral feeds, and his liver enzymes normalized. he is currently 12 months post completion of therapy and remains well with a normal physical exam and laboratory values. conclusion: treatment of alk-positive histiocytosis with lose dose cytarabine resulted in complete resolution of our patient's symptoms with minimal treatment related adverse effects, and few long-term treatment related risks. given the rarity of the diagnosis, the reporting of effective novel treatment options is important for future patient care. background: adult patients with melanoma or lung cancer harboring braf v600e have benefitted from the development and subsequent approval of specific braf inhibitors. as such, delineating the subset of similarly targetable pediatric oncology patients may spur development and rational use of these inhibitors in children. importantly, other point mutations and fusions of braf may also be targetable in s249 of s301 children analogous to recent emerging data in adult cancer patients. objectives: to define the genomic landscape of known and novel braf alterations and raf1 fusions in pediatric malignancies and report index cases with clinical response to braf or mek inhibitors. design/method: dna was extracted from 40 microns of ffpe sections of 3,633 tumors from pediatric (<21 years of age) oncology patients, and cgp was performed on hybridization-captured, adaptor ligation based libraries to a mean coverage depth of 579x for up to 315 cancer-related genes plus 37 introns from 14 genes frequently rearranged in cancer. genomic alterations (ga) included base substitutions, indels, copy number alterations and fusions/rearrangements. a total of 221 (6.1%) braf-altered pediatric malignancies were identified. 172 (77.8%) harbored a single kinaseactivating braf short variant, indel, or fusion. an alteration resulting in reduced braf kinase activity was identified in 8 (3.6%) tumors while 7 (3.2%) tumors harbored multiple braf alterations, 3 of which contained at least a single activating short variant. the remaining 34 tumors (15.4%) contained functionally uncharacterized variants. kinaseactivating braf alterations were identified in diverse tumor spectra comprised of brain tumors (75.3%; 18 subtypes), carcinomas (10.6%; 6 subtypes, with melanoma constituting 50% of cases), hematological malignancies (8.8%; 5 subtypes), sarcomas (2.9%; 3 subtypes), and extracranial embryonal tumors (2.4%; 2 subtypes). seventy-two (32.6% of braf-altered cases) braf fusions were identified, 64 (88.9%) of which were kiaa1549-braf; 2 involved the novel fusion partners: stard3nl and khdrbs2. seven (0.2%) raf1 fusionpositive cases, predominantly brain tumors (5), were identified; 2 involved the novel fusion partners: tmf1 and sox6. index cases of response to therapy of intracranial tumors will be presented. we describe a population of pediatric patients with targetable braf alterations predominantly enriched in primary intracranial tumors, but spanning diverse solid tumor types and hematologic malignancies. we additionally report a cohort of raf1 fusion-positive patients. an index case and multiple previous reports suggest raf or mek inhibitors may benefit pediatric patients with either intracranial or extracranial disease, and development of such drugs in pediatric indications is strongly warranted. background: diffuse midline gliomas (dmg) with h3k27m mutation, including diffuse intrinsic pontine glioma (dipg), are the leading cause of brain tumor-related deaths in children. there are no effective therapeutic strategies and the median survival remains dismal. genomic studies have identified a recurrent mutation in the majority of dmgs involving a lysine to methionine substitution (k27m) in histones 3.1 and 3.3, resulting in changes in the epigenetic landscape that dysregulate gene expression and promote gliomagenesis. panobinostat, a multiple histone deacetylase (hdac) inhibitor, was found to be one of the most effective agents against dipg patient-derived cell cultures and xenograft models in previous studies and is presently in clinical trial for dipg. hdac inhibition with panobinostat may also exhibit activity against h3k27m+ diffuse midline gliomas of the thalamus and spinal cord. to evaluate the effect of panobinostat as a single agent against patient-derived thalamic and spinal cord h3k27m+ diffuse midline glioma cell cultures and in an orthotopic xenograft murine model of h3k27m+ spinal cord glioma. design/method: patient-derived thalamic and spinal cord h3k27m+ diffuse midline glioma cell cultures were treated with single agent panobinostat at a range of concentrations. cell viability was evaluated using the celltiter-glo assay. panobinostat was systemically administered to orthotopic xenograft murine models of luciferase-expressing spinal cord h3k27m+ diffuse midline glioma. response to panobinostat was evaluated with ivis in vivo imaging. results: hdac inhibition with panobinostat significantly decreases cell proliferation with an ic50 of 30 nm and 41 nm in the spinal cord and thalamic glioma patient-derived cell cultures respectively. panobinostat slowed tumor growth in murine models of spinal cord glioma by 1.5-fold in the brain (p = 0.0219, n = 5) and 2-fold in the spinal cord (p = 0.0176, n = 5) when compared to vehicle controls after 1 week of administration. panobinostat is in clinical trials for dipg. this study suggests that hdac inhibition with panobinostat may also be beneficial for patients with thalamic and spinal cord diffuse midline glioma h3k27m mutants. background: brain tumors are the most common solid tumor of childhood and the leading cause of childhood cancer deaths. while medulloblastoma is the most common malignant brain tumor of childhood with a 5-year survival 70-80%, children with high-grade gliomas (hggs) such as glioblastoma multiforme (gbm) fare much worse with a 5-year survival of 15-35%. implicated in this poor outcome is the presence of treatment resistant brain tumor stem-like cells. gbm stem-like cells (gscs) have been implicated in tumor growth, treatment resistance and patient relapse, making them a key therapeutic priority. antipsychotic drugs (apds) have been used for decades in various psychiatric clinical settings and are associated with a lower incidence of cancer, including malignant brain tumors. currently, atypical apds are being evaluated for their potential to alleviate cancer and treatment induced side effects. furthermore these drugs may have direct anti-tumor effects, potentially via inhibition of dopamine d2 receptors (drd2). objectives: determine the anti-cancer effects of atypical apds on gbm stem-like cells design/method: the anti-cancer effects of apds (quetiapine and risperidone) were evaluated on gbm stem-like cell lines developed in our laboratory (glio 3 and 38) and the group 3 medulloblastoma cell line hdmbo3. cell proliferation/viability was determined using trypan blue exclusion and mts assays. the effect of apds on cancer stem cell self-renewal was determined by neurosphere assay. receptor expression and apds effect on cell cycle proteins were examined by western blot analysis. results: western blot analysis of gscs and hdmbo3 demonstrated robust drd2 expression indicating a viable therapeutic target. both apds induced dose dependent cell death of all cell lines tested. treatment with only 2um of either apd for 10 days significantly reduced cell proliferation by 60% (hdmbo3) and 50-90% (gscs). consistent with these findings, we observed an increase in cell cycle inhibitors p21 and p27. furthermore at day 10 both apds induced a robust increase in gsc death, approximately 60% compared to only 10% in non-treated controls. lastly, 1um apds significantly reduced gsc neurosphere formation compared to untreated controls by up to 35% suggesting inhibition of gbm stem cell self-renewal. our data indicates that clinically relevant concentrations (low micromolar) of these apds induce anticancer effects in both gscs, which are enriched with tumor initiation/propagation properties, and in the group 3 (myc amplified) medulloblastoma cell line. these apds represent strong candidates as potential adjuvant therapies for the treatment of these brain tumors. background: while the poor prognosis for high risk neuroblastoma (hrnb) underscores the need for new treatment strategies, the elucidation of specific biologic subsets of neuroblastoma suggests a way to improve disease management. the identification of agents that target specific molecular pathways associated with the development or progression of diseases holds promise. dfmo, an inhibitor of odc, has been shown to decrease lin28 and mycn and target cancer stem cells in preclinical studies. currently 14% of patients undergoing immunotherapy relapse. dfmo is in studies to prevent relapse after immunotherapy and may be helpful during immunotherapy as well. the hypotheses for this study were that: 1) the incorporation of a targeted therapy, selected based upon upfront tumor genomic interrogation, into standard induction chemotherapy for hrnb is safe, feasible and may increase the pr/cr/vgpr response rate at the end of induction therapy; and 2) the addition of dfmo as maintenance during immunotherapy is safe and feasible and may decrease the relapse rate for hrnb. a multicenter feasibility pilot trial in subjects with newly diagnosed hrnb within the beat childhood cancer consortium. at diagnosis, patients' tumors underwent dna exome and rna sequencing which were analyzed within a molecular tumor board to identify the single best drug of 6 targeted agents to be added to cycles 3-6 of induction chemotherapy. after consolidation with asct and radiation, the patients received dfmo along with standard dinutuximab and retinoic acid and dfmo for 2 years after immunotherapy. patients were evaluated for additional toxicities with the addition of targeted agents and dfmo in addition to induction response. results: the pilot study of 20 eligible patients has shown this process to be feasible. all 20 patients have completed induction portions of the study. the combination of targeted agent with chemotherapy was shown to be safe without any unexpected toxicities. delays between induction cycles were < 2 weeks and related to surgery, infection, or thrombocytopenia. the induction response demonstrated 88% cr/vgpr/pr rate, which suggests improvement over historical 80%. in addition, 15 patients were eligible for the combination of dfmo with dinutuximab and retinoic acid was well tolerated and safe without additional toxicities due to dfmo. the pilot study of 20 patients has shown the process of genomic sequencing and addition of a targeted agent to upfront chemotherapy and addition of dfmo to dinutuximab and retinoic acid maintenance therapy in newly diagnosed hrnb patients and is feasible and safe without any unexpected toxicities. background: identifying sub-populations of medulloblastoma tumors with stem cell-like properties holds promise for reducing disease recurrence, but there is no known unifying marker of medulloblastoma cancer stem cells. the granulocyte stimulating factor receptor (gcsf-r or cd114) is well understood in the context of hematopoiesis, but its role in solid tumor pathogenesis is less clear. neuroblastoma and melanoma subpopulations expressing gcsf-r have cancer stem cell properties of chemoresistance and increased tumorigenicity, and are enriched in tumors after chemotherapy. gcsf-r activation leads to signaling through the jak-stat pathway, suggesting a potential therapeutic target. we hypothesized that a subpopulation of medulloblastoma cells would express the gcsf-r and that this subpopulation would demonstrate chemoresistance and response to inhibitors of the jak/stat pathway. objectives: our objective was to identify a subpopulation of medulloblastoma cells expressing the gcsf-r and determine their relative growth rates, tumorigenicity, and responses to chemotherapy and jak/stat inhibition. design/method: medulloblastoma cell lines were sorted via flow cytometry for gcsf-r surface expression. subpopulations of gcsf-r-positive and -negative medulloblastoma cells were then monitored for growth by continuous live cell imaging. responses to chemotherapy were measured in subpopulations of gcsf-r-positive and -negative medulloblastoma cells using continuous live cell imaging to measure percent cell confluence and cell viability assays. ic50 values were calculated for each cell line and each agent. parental medulloblastoma cell lines and isolated gcsf-r-positive and -negative subpopulations were also treated with the jak1/2 inhibitor ruxolitinib and growth rates, viability, and ic50 values were calculated. results: gcsf-r surface expression was identified on 0.2-1.3% of medulloblastoma cell lines. isolated gcsf-r positive cells demonstrate a slower growth rate compared to gcsf-rnegative or parental unsorted medulloblastoma cells. gcsf-r positive cells are more resistant in vitro to vincristine, etoposide, and carboplatin, when compared to the gcsf-r negative population and an unsorted population of the same cell line. ruxolitinib is cytotoxic to medulloblastoma cells in vitro, with higher ic50 values noted in gcsf-r positive cells compared to unsorted and gcsf-r negative cells. we show that a subpopulation of gcsf-r positive cells are present in multiple medulloblastoma cell lines via flow cytometry, and that isolated gcsf-r-positive cells have a slower growth rate than gcsf-r-negative or unsorted populations. we also show that ruxolitinib has in vitro activity against medulloblastoma cell lines. we propose that jak inhibition may represent an adjunct therapy targeting overall tumor burden and specifically targeting the gcsf-r-positive subpopulation of medulloblastoma cells that may drive tumor recurrence. we investigated the efficacy of intensified adjuvant chemotherapy in osteosarcoma patients. design/method: we retrospectively analyzed the medical records of 48 children with osteosarcoma treated at asan medical center between 2006 and 2015. all patients received a 3-drug induction consisting of 2 cycles of cisplatin and doxorubicin along with 4 cycles of methotrexate (map), and proceeded to surgical resection. adjuvant ct was map or map with the additional ifosfamide and etoposide (mapie), and mapie was mainly considered for poor responders (tumor necrosis below 90%) or patients with metastases. results: among 48 patients, 6 patients had metastases at diagnosis. surgery was conducted in 43 patients who responded to induction ct, and 17 showed over 90% tumor necrosis. among 43 patients who proceeded to adjuvant ct, 19 and 24 patients received to map and mapie protocols. with a median follow-up of 73 months, the 5-year overall survival (os) and event-free survival (efs) rates of all patients were 80% and 46.7%. of those 43 patients, 16 patients recurred, and 5 of them died of disease progression. relapsed patients received salvage ct and/or surgery, and 2 were rescued after autologous stem cell transplantation (sct). three patients developed treatment-related acute myeloid leukemia, and they are alive after allogeneic sct. according to the response to neoadjuvant ct, the os rates of good responders (n = 18) and poor responders (n = 30) were 100% and 68.1% (p = 0.011), and efs rates were 63.8% and 41.7% (p = 0.084). of the 30 poor responders, 9 patients received map as adjuvant ct, and the other 21 received mapie. the os rates of map and mapie group were 68.6% and 70.3% (p = 0.568), and efs rates were 30.0% and 48.3% (p = 0.247), respectively. when patients were classified into three groups: 1. localized disease & necrosis ≥ 90% (n = 17), 2. localized disease & necrosis < 90% (n = 24), 3. metastatic disease (n = 6), survival rates were in the order of group 1>2>3 (os = 100%:81.8%:16.7%, efs = 67.6%:43.6%:0%). in each group, intensified adjuvant ct by mapie did not improve survival outcomes. conclusion: initial metastatic disease and poor histological response to neoadjuvant ct were major risk factors for poor survival in osteosarcoma patients. we found that adding ifosfamide and etoposide to map did not improve survival outcomes of patients with adverse risk factors. more effective adjuvant therapy for these patients is needed. background: circulating cell-free dna (cfdna) that shed from tumors into circulation have been used for noninvasive molecular profiling in adult cancers but little is known about its utility in pediatric cancers. pediatric patients with metastatic and refractory solid tumors are known to have poor survival rates, and a key challenge in their management is obtaining biopsy samples especially at times when disease is widely spread or the patient is physically unfit for sampling. the development of a noninvasive profiling strategy is critical for optimizing molecularly guided therapy and assessing response to treatment. in this study, we want to determine the utility of cfdna to noninvasively analyze the molecular profiles of pediatric solid tumors such as neuroblastoma (nb), osteosarcoma (os), and wilms tumor (wt). design/method: tumor, plasma, and matched controls were collected from patients with nb, wt, and os, at diagnosis or time of disease progression. cfdna was extracted from the plasma and analyzed through multiple methodologies including a targeted next generation sequencing panels and shallow whole genome sequencing (swgs). results: fifteen nb patients, 10 os patients, and 2 wt patients had tumor molecular profiles known from different targeted next-generation sequencing platforms. in the cfdna of 7/15 nb patients, somatic mutations and copy number alterations previously reported in the tumors were detected, including recurrent nb drivers such as mycn amplification, alk, and atrx mutations. mutations not detected in the original tumor were also found in 6/15 nb patients including nras, mll2, arid1b, some of which are potentially actionable. in os, mutations known from the tumor were found in the cfdna of 5 of 10 patients, including atrx and notch3 mutations, as well as copy number alterations such as cdk4 amplification, which has targetable therapeutics available. of the two wt patients analyzed, cfdna revealed the same mutations as tumor in one patient, however in a cohort of patients where tumor was not available, cfdna revealed recurrent driver mutations such as amer1, dicer1. it is feasible to noninvasively identify somatic mutations and copy number alterations in cfdna of patients with pediatric solid tumors. establishing a platform using cfdna to identify molecular profiles of these tumors can serve as a powerful tool for guiding treatment and monitoring response to treatment. background: despite multi-modality therapy, the prognosis for patients with metastatic osteosarcoma remains poor necessitating development of novel targeted therapies. immunotherapy can be exploited to target osteosarcoma with exquisite specificity but remains limited by insufficient tumor specific targets. objectives: to overcome the dearth in tumor specific antigens, we have explored the use of tumor derived mrna (representing a tumor specific transcriptome) for development of personalized nanoparticle vaccines. design/method: rna-nanoparticles (rna-nps) can be amplified from limited amounts of biopsied tissue for induction of tumor specific t cells against osteosarcoma. since local vaccination strategies are mired by poor overall immunogenicity, we assessed the feasibility, immunogenicity and antitumor activity of intravenously administered rna-nps (tumor mrna complexed to dotap nanoliposomes) in pre-clinical murine and canine tumor models. we identified a clinically translatable np formulation for the delivery of rna to antigen presenting cells (apcs) that induces in vivo gene expression and preserves rna stability over time. tumor derived rna-nps induced antigen specific t cell immunity and mediated anti-tumor efficacy in several pre-clinical solid tumor models (i.e. b16f10, kr158b). when administered intravenously, rna-nps increased expression of co-stimulatory molecules (i.e. cd80, cd86, cd40, ccr7) and pd-l1 on cd11c+ cells throughout reticuloendothelial organs (i.e. spleen, liver, bone marrow) and within the tumor microenvironment; this phenotype was strictly dependent on type i interferon. targeted inhibition of type i interferon signaling (via infar1 mabs) abrogated anti-tumor efficacy mediated by rna-nps. we enhanced the immunogenicity of this platform by simply combining mrnas encoding for immunomodulatory molecules (i.e. hcv-pamps, gm-csf) or by combining rna-nps with immune checkpoint inhibitors. addition of checkpoint inhibitors (pd-l1 mabs) to rna-nps increased tumor infiltrating lymphocytes, and intratumoral mhc class i/ii expression, and mediated synergistic anti-tumor activity in settings where pd-1 or pd-l1 inhibition alone did not confer therapeutic benefit. we then explored the feasibility of rna-nps in a large animal osteosarcoma model. in ongoing studies for canines with osteosarcomas, we have shown that sufficient amounts of rna can be extracted, amplified, and manufactured into personalized rna-np vaccines. conclusion: rna-nps reprogram systemic immunity and mediate anti-tumor activity providing near immediate immune induction without the complexity of cellular immunotherapy. the immune correlate of preclinical response to rna-nps is hallmarked by interferon dependent pd-l1 expression on activated apcs (cd11c+ mhcii+ cd86+ cells). based on these findings, we are exploring the preclinical safety, efficacy and immunologic effects of rna-nps targeting canine osteosarcoma before first in-human evaluation. background: ewing sarcoma is an aggressive bone tumor affecting mainly adolescent and young adults. treatments are based on compressed schedule chemotherapy combined with local control (surgery and/or radiation). prognosis is poorer for patients with metastatic disease, older age and central primaries. survival when disease recurs within two years of diagnosis is <10%. the ews-fli1 fusion gene t(11; 22) (q24; q12) has been well characterized as a dominant ews driver-gene. the most common variation is ews exon 7 with fli1 exon 6 (60% of fusion positive patients). we designed a novel pbi-shrna tm ews/fli1 type 1 lpx which has demonstrated, safety and efficacy in animal model (rao et all). the pbi-shrna strategy silences target gene expression by concurrently inducing translational repression and p-body sequestration as well as post-transcriptional mrna cleavage. to determine the safety and maximum tolerated dose of intravenous administration of pbi-shrna tm ews/fli1 type 1 lipoplex in patients advanced ews. design/method: phase i study 3 × 3 escalation cohort. testing pbi-shrna tm ews/fli1 type 1 lpx (starting iv dose of 0.04 mg/kg) on patients (≥ age 8) with advanced ewing's sarcoma, all with a type 1 translocation. intravenous infusion was given twice a week for 4 weeks with the following escalation schema: 50% → 33% → 25% → 25% → 25%. required kps >80% and adequate organ function. cytokines induction pre and post-infusion was analyzed (il-12, il-6, tnf-alpha, il1ra). first cohort of patients has been enrolled (ages between 17-35 years). three relapsed patients had >3 lines of therapy and 1 patient had refractory disease, 3 patients received a complete cycle of pbi-shrna tm ews/fli1 type 1 lpx with twice a week infusions. a total of 69 doses were given. the most prominent related toxicity has been hematological, 1 patient developed transient g3 neutropenia, another patient developed g3 anemia that required prbc transfusion, and of note this patient had significant bone and bone marrow involvement. one patient only received two lpx infusions; she developed a fatal rsv pneumonia. other reported grade 2 toxicity includes fatigue and headache. evaluable patients (n3) had stable disease between 4 and 12 months before progression. one patient had sustained response for 12 month before progression, two patients are still alive. our preliminary experience supports the safety and potential efficacy of pbi-shrna tm ews/fli1 type 1 lpx as novel treatment for advanced ews with limited toxicity. il-6 increase correlates with higher bi-shrnai ews/fli1 lpx infusion rate and clinical symptoms. further clinical testing is indicated. background: as more children with cns malignancies (bt) are surviving, the late effects of the therapies they receive are better described. studies show that radiation therapy is particularly harmful to neurocognitive functioning, specifically processing speed, working memory, and attention span. these deficits have negative effects on quality of life, especially in academic and professional settings. a large proportion of s255 of s301 adult survivors of bt are unable to reach adult milestones such as living on their own, holding a steady job, and getting married. proton beam radiation therapy (pbrt), is touted for the potential to have fewer and less severe side effects than traditional photon radiation therapy (xrt). because of the properties of protons, the amount of damaging energy released in non-target healthy tissue is reduced when compared to xrt. although a study comparing iq testing between pbrt and xrt found no difference between the two therapies, no studies have compared the specific neurocognitive domains. it would be valuable to evaluate full neurocognitive testing scores (nct) since the specific domains, particularly processing speed (psi), appear to be most vulnerable to radiation therapy. objectives: our primary aim was to assess differences in psi for patients with bt who underwent pbrt versus xrt. a secondary aim was to assess differences in iq (fsiq) and working memory (wmi). we retrospectively evaluated all patients treated for bt at the jimmy everest cancer center within the past 20 years who received rt and had nct post radiation. we examined the full nct results for both subsets of participants to evaluate differences in the specific domains of processing speed, working memory, and iq by measuring percentiles scored in these domains. objectives: we report our experience on imaging children with mm treated uniformly on an institutional melanoma trial. we retrospectively reviewed the clinical and imaging findings of patients with ajcc stage iic-iv cutaneous mm treated on our institutional mel06 protocol. brain mri/ct, pet/ct, ct chest, abdomen, and pelvis (ctcap) were performed at diagnosis in all patients. on treatment, stratum a patients (peg-interferon; ajcc iic, iiia, iiib) (n = 16) had the same imaging repeated every 6 months; stratum b1 (peg-interferon and temozolomide; unresectable measurable disease metastatic, or recurrent) (n = 2) had pet scans every 2 months and brain imaging every 4 months; those in stratum b2 (peg-interferon and temozolomide; unresectable non-measurable, metastatic, or recurrent) (n = 3) had the same imaging performed every 4 months. off therapy all patients continued same imaging every 6 months for 3 years. results: there were 21 patients (11 female; median age 14 years). eleven had spitzoid and 10 conventional melanoma. primary sites included head/neck (n = 6), trunk (n = 7), and extremities (n = 8). patients with spitzoid melanoma had 236 imaging studies (86 pet, 81 ctcap, 11 ct chest, 10 ct brain, and 48 mri brain) with a median of 8, 7, 0, 4 and 0 studies/patient respectively. median cost per patient was $32,718. thirteen studies (5.8%) showed suspicious lesions with 28 additional scans and 2 diagnostic biopsies of which one only was positive stratum a with tert promoter mutation and died from disease). for conventional mm, 162 studies (61 pet, 57 ctcap, 8 ct chest, 7 ct brain, and 29 mri brain) were performed with a median of 7, 6.5, 0, 1, 3 studies/patient respectively. median cost per patient was $23,420. twenty (14%) showed suspicious lesions with 19 additional scans and 6 diagnostic biopsies; four were positive (two at diagnosis); both died of disease; the other two recurred locoregionally and were detected clinically; both are alive and disease free; one patient had diffuse metastases and died shortly after enrollment. after a median follow up of 6.3 years (range 0.4-9.2) 17 patients are alive and disease free. children with spitzoid melanoma should have minimal imaging at diagnosis and follow-up given the low risk of recurrence and low yield and high cost of aggressive imaging protocols. patients with conventional mm should be imaged according to the adult guidelines. nationwide children's hospital, columbus, ohio, united states background: the role of infections in the long term outcome of patients with bone tumors is controversial. two retrospective studies have shown increased survival in osteosarcoma patients who had a post-operative wound infection, while another showed no changes in overall survival. to determine the relationship between wound infections and/or bloodstream infection (bsi) on survival in pediatric and young adult patients with osteosarcoma and ewing sarcoma treated at a tertiary children's hospital. design/method: a retrospective chart review was performed for patients with diagnosis of osteosarcoma or ewing sarcoma from 2006-2016. patients received standard chemotherapy regimens for their disease type and stage. local control included surgical resection and/or radiation therapy. presence of infection was determined by bsi or wound cultures while receiving treatment for primary tumor. the median age of 85 patients was 14 (range 2-46 years) at diagnosis. 53% had a diagnosis of osteosarcoma and 47% had ewing sarcoma. of these, 46% of patients developed an infection during treatment; 25% had bsi, 26% had wound infections, and 5% had both. patients with bsi had a 5 year os of 63.3%, compared to 81% in those without bsi (p = 0.0015). those with both bsi and wound infections had the poorest overall survival of 50%, compared to 80.8% for patients without any infection. patients with wound infections alone had a 5 year os of 80.2%, compared to 75% of patients without a wound infection. our analysis revealed decreased os in patients with bsi; however, this could be due to other confounding factors in the presence of bsi. those with bsi or bsi and wound infections had the poorest survival. wound infections without bsi were associated with a slight increase in survival; however, this study was limited by the number of patients that had local wound infections. with the use of newer surgical techniques, availability of antimicrobials and routine use of prophylactic antibiotics, the incidence of infections while undergoing treatment is low. however, the importance of this clinical observation indicates a likely enhanced immune system associated with infection, supporting the role of immunotherapy for treatment of these aggressive tumors. background: hypoalbuminemia is a well-recognized effect of cancer and other chronic illnesses and is often regarded as a marker of malnutrition. in adults, hypoalbuminemia has been associated with adverse outcomes in patients with cancers of the lung, pelvis, head and neck, gastrointestinal tract, and bone marrow, as well as in some pediatric patients with ewing sarcoma and hodgkin lymphoma. hypoalbuminemia has not been well studied in children with cancer. to determine the incidence of hypoalbuminemia (using age-specific references) in children with cancer receiving chemotherapy at baseline (prior to starting chemotherapy) and to determine whether hypoalbuminemia is associated with inferior 5-year overall survival. design/method: we performed a single institution, irbapproved, retrospective review of pediatric oncology patients diagnosed between 1998 and 2012. five-year survival was estimated using the kaplan-meier method; groups were compared using cox regression. we identified 863 pediatric patients with a first diagnosis of cancer, brain tumor, or other condition possibly requiring chemotherapy. of these 863 patients, 204 were excluded for reasons including not receiving chemotherapy and missing data, leaving 659 patients who had a serum albumin level within 60 days prior to starting chemotherapy. the mean age was 8.1 years (sd 5.8 years); 62% were male; 92% were non-hispanic. the most common diagnosis was acute lymphoblastic leukemia (201 of 659; 31%). one hundred thirty nine of 659 (21%) had hypoalbuminemia prior to starting chemotherapy. there was no statistically significant difference in 5-year overall survival between those with and without hypoalbuminemia (78% vs. 82%, respectively; hazard ratio 1.27, 95% c.i. 0.85 -1.90). conclusion: hypoalbuminemia at baseline in pediatric oncology patients requiring chemotherapy is common (one in five), and was not associated with inferior 5-year overall survival in this cohort. leptomeningeal metastases at diagnosis. standard treatment for completely resected, non-anaplastic supratentorial ependymomas is close observation. treatment for anaplastic or incompletely resected non-anaplastic ependymomas is maximal safe surgical resection followed by focal radiation. however, up to 50% of localized ependymomas recur. the role of chemotherapy in treating ependymomas is under investigation. extraneural metastases of anaplastic ependymomas have rarely been reported and the outcome is dismal. objectives: to report extraneural cervical node metastases of a non-anaplastic ependymoma and successful treatment with surgical resection, radiation, and systemic chemotherapy. design/method: retrospective review of patient medical records, including radiographic imaging and tumor tissue pathology, and comprehensive literature review. results: a previously healthy 3-year-old girl underwent gross total resection (gtr) of an isolated right parietal lobe ependymoma (who grade ii). at age 4 years, magnetic resonance imaging (mri) revealed an isolated localized recurrence. she underwent gtr followed by observation. at age 6 years, she again experienced isolated localized recurrence and underwent gtr followed by 59.4 gy focal conformal photon radiation. at each recurrence, pathology revealed a non-anaplastic ependymoma, and cerebral spinal fluid (csf) cytopathology and spine mri were negative. at age 10 years, she developed an enlarged right posterior cervical chain lymph node. subsequent mri revealed a large rim-enhancing, t2 hyperintense lymph node and multiple abnormally enhancing regional nodes consistent with metastases. biopsy revealed a non-anaplastic ependymoma. mri of the brain and spine, computed tomography of the chest, abdomen, and pelvis, and csf and marrow evaluations were unremarkable. chemotherapy according to acns0831 was initiated. mri after course 3 demonstrated significant node size reduction. she underwent right neck node dissection. only one right level ii lymph node showed metastases. she was treated with 59.4 gy irradiation to the neck and 3 additional courses of chemotherapy. she remains in remission 24 months and 17 months after diagnosis of metastatic disease and end of therapy, respectively. literature review reveals rare reports of extraneural metastatic disease of anaplastic ependymomas to bone, lung, or liver, and only 2 involving lymph nodes, all associated with a poor outcome despite multimodal therapy. to our knowledge, this is the first report of extraneural metastases of a non-anaplastic ependymoma. extraneural metastases should be considered in children previously treated for non-anaplastic ependymomas who experience systemic symptoms, even in absence of cns relapse. multimodal treatment offers potential long-term disease control with acceptable toxicity. arun gurunathan, joel sorger, andrew trout, joseph pressey, rajaram nagarajan, brian turpin cincinnati children's hospital medical center, cincinnati, ohio, united states background: pigmented villonodular synovitis (pvns) is a benign neoplasm of the synovium. standard treatment is surgery, but post-operative recurrence rate is as high as 60%. radiation therapy can be used for local control, but is associated with late effects. while pvns is rarely fatal, aggressive disease and/or extensive surgery can result in substantial functional impairment. colony stimulating factor-1 (csf1) overexpression, often due to chromosomal translocation involving csf1, drives pvns through recruitment of synovial-like mononuclear cells expressing the csf1-receptor. tyrosine kinase inhibitors such as imatinib are active against the csf1-receptor, and have shown benefit in the post-surgical relapse setting. however, questions remain regarding the broader application of imatinib and regarding optimal response assessment. to present three patients with pvns, each with different clinical scenarios, who demonstrate clinical response to imatinib monitored by changes in metabolic activity (maximum suv) on pet/ct. results: three patients with pvns demonstrate pet/ct response to imatinib, guiding management of their challenging clinical scenarios. patient 1 is a 20 year-old female with left hip pvns and high grade articular cartilage loss, with decrease in metabolic activity (suvmax 8.3 to 4.7 in 3 months) on neoadjuvant imatinib, enabling total hip replacement surgery planning. patient 2 is a 16 year-old female with left knee pvns with recurrences after synovectomies, spared subsequent surgical control attempts after clinical improvement correlating with pet/ct response to imatinib (suvmax 10.2 to 4.3 in 2 months). patient 3 is a 27 year-old male with right knee pvns that recurred after total knee replacement, now with clinical improvement correlating with pet/ct response to imatinib (suvmax 11.2 to 5.2 in 3 months). all patients would have been characterized as stable disease by response evaluation criteria in solid tumors (recist). in each of these patients, imatinib has been tolerated well, with no therapy interruptions and absent or easily managed side effects (one patient takes dronabinol for decreased appetite, one patient takes prn immodium for diarrhea). all patients are currently still taking imatinib, with therapy length ranging from five to eleven months. in our series of three patients with pvns, imatinib shows promise for disease management in neoadjuvant and adjuvant settings with a tolerable side effect profile. imatinib should be considered in the treatment of pvns to spare surgical and radiotherapy related morbidity, and treatment effect can be monitored by pet/ct. background: metastatic rhabdomyosarcoma (rms) carries a poor prognosis with three-year event free survival rates ranging between 20%-69% (depending on oberlin risk factors) due to the lack of significantly effective breakthroughs in the recent past. there is an urgent and unmet need for new treatment strategies against this disease. metastatic rms cell lines exhibit increased expression of the erm family membrane-cytoskeleton linker protein ezrin. knockdown of ezrin expression using sirnas decreases the metastatic potential of these cells, whereas forced expression of ezrin results in increased degree of metastasis. the activity of ezrin is controlled by its phosphorylation at the threonine 567 (thr567) residue at the c-terminus of the protein, suggesting that alteration of ezrin phosphorylation may control rms growth and metastasis. our goal was to determine if pharmacological inhibition of thr567 phosphorylation in ezrin affects the growth, survival and metastasis in rms in vitro as well as in vivo. design/method: rms cell lines representative of the alveolar and embryonal histological subtypes were used. rms cells were treated with a small molecule inhibitor of ezrin, nsc668394, which specifically dephosphorylates ezrin at the thr567 residue. baseline expression of ezrin and perm levels as well as the effect of nsc668394 on perm levels in the rms cell lines was determined by western blotting of cell lysates. viability of cells was assessed by trypan blue exclusion, and morphology visualized by bright field microscopy. the extent of apoptosis was detected by imaging caspase 3/7 activation using fluorescent microscopy. motility of rms cells was examined by performing a wound-healing assay. subcutaneous and orthotopic xenografts were established in nsg mice using rd cells (embryonal rms). mice harbor-ing xenografts were treated with intraperitoneal injections of nsc668394 or dmso. results: ezrin is constitutively phosphorylated at the thr567 residue in a majority of the rms cell lines examined. nsc668394 dephosphorylates ezrin at the thr567 residue in these cell lines. treatment with nsc668394 inhibits growth, induces apoptosis and inhibits the migration of rms cell lines in vitro. further, treatment of nsg mice bearing subcutaneous or orthotopic embryonal rhabdomyosarcoma xenografts with nsc668394 significantly impedes tumor progression without any obvious adverse effects. our findings suggest that dephosphorylation of ezrin at the threonine 567 residue may have the potential to be a novel therapeutic strategy for rms patients. all india institute of medical sciences, new delhi, new delhi, delhi, india background: the role of laparoscopy in the management of pediatric intra-abdominal solid tumors is yet to be established. the safety of laparoscopic management of pediatric intra-abdominal tumors is still questionable. we study the results of the initial case series of pediatric intraabdominal tumors managed laparoscopically at our institute from july 2013 onwards. design/method: total 11 children (8-males, 3 females) who presented to us with pediatric intra-abdominal tumors were included. the tumors included wilms tumor (n = 7), neuroblastoma(n = 2), adrenal cortical tumor(n = 1), ovarian teratoma(n = 1).children were between 10months -7years and 4 received neo-adjuvant chemotherapy. a 4-port laparoscopic nephrectomy and lymph node sampling for wilms tumor and adrenalectomy for adrenal tumors was performed. the tumors were removed in-toto with no rupture (except in one). specimens were retrieved through a lumbar incision (n = 8) or an inguinal incision(n = 1). all the children are under regular follow up. two children with wilms tumor had recurrence. the neuroblastoma child underwent open surgery for recurrence later. conclusion: laparoscopy/laparoscopic assisted removal of pediatric intra abdominal tumor is a feasible and safe option. it has the advantage of less postoperative pain, shorter hospital stay and a better cosmetic result. proper patient selection, port placement and laparoscopic experience are contributory. background: targeting of proteins and cell surface antigens specific to cancer cells with monoclonal antibodies has proven to be an effective form of treatment in many forms of cancer. gd2 is a cell surface disialoganglioside that is expressed on the cell surface of some normal tissues including nerve cells, melanocytes, and mesenchymal stromal cells and is overexpressed in some pediatric cancers like neuroblastoma and osteosarcoma. dinutuiximab is a chimeric monoclonal antibody that is fda approved for the treatment of patients with high risk neuroblastoma and under investigation for the treatment of relapsed osteosarcoma. little is known about the patterns of gd2 expression in other pediatric malignancies. objectives: we sought to describe the patterns of gd2 expression in the following pediatric sarcomas: synovial sarcoma, rhabdomyosarcoma and ewing sarcoma. design/method: synovial sarcoma (n = 44), rhabdomyosarcoma (n = 35) and ewing's sarcomas (n = 12) formalin fixed, paraffin embedded cores were obtained from the seattle children's research institute tissue microarray (tma) biorepository. tma blocks consisting of melanoma cores stained with and without gd2 antibody were used as positive and negative controls, respectively. slides were incubated with anti-ganglioside gd2 antibody clone 2q594 (ab68456 from abcam) diluted 1:50 in 10% normal goat serum and 5% bsa in tbs overnight at 4˚c. the negative control of human melanoma section was incubated in 10% normal goat serum and 5% bsa in tbs without primary antibody. the expression of gd2 was indicated by characteristic brown diaminobenzidine staining. the intensity and location of tissue staining were assessed and compared to positive and negative controls. staining was considered positive (+++) if the intensity of the staining was consistent with that of the positive control with 67-100% of cells staining positive. classification of intermediate gd2 expression (++) was assigned to slides in which 34-66% of cells stained positive. slides were classified as sporadic staining (+) if 1-33% of cells stained positive. tissue was considered (-) if there was complete absence of staining, similar to the negative control. objectives: to evaluate the clinical presentation, management and treatment outcomes of children with malignant germ cell tumor at our institute design/method: a prospective study was conducted from june 1994 to dec 2016 in the department of pediatric surgery in a tertiary care institute in a developing country. all patients were evaluated for local disease and metastatic disease by imaging and tumor markers. risk stratified chemotherapy was used with low risk tumor receiving no chemotherapy, intermediate risk: 4 courses of peb chemotherapy and high risk: 4 courses of peb + 2 courses of pe. upfront resection of the primary or the residual disease after neoadjuvant chemotherapy if feasible was performed. follow up was done with monthly tumor markers for 6 months and imaging studies every 3-6 months for initial 3 years. five year overall survival and disease free survival was calculated. results: during the study we treated 152 children who formed the study group. of these 83 (55%) were gonadal (45;30% testicular and 30;25% ovarian) and the remaining 69 (45%) were extragonadal with sacrococcygeal (sct) being the most common site 48 (31%). one hundred and thirteen children (75%) presented to us primarily while the remaining 39 had received treatment elsewhere. stage 3 or stage 4 disease at presentation was present in 104 (68%) children. recurrence was noted in 50 (33%) patients. respectively. patients with testicular mgct and children with age 2-5 years and males had significantly poor rfs rates. conclusion: patients with mgct should be staged correctly and adjuvant chemotherapy is advisable to all patients except stage i endermal sinus tumor of testis. awareness regarding the same is still lacking in our country. meticulous follow up is needed as more than 30% of will recur. cure rates are dismal in children with recurrent mgct especially those who are not chemotherapy naïve. nemours children's specialty care, jacksonville, florida, united states background: radiotherapy for pediatric head and neck tumors often results in mucositis, limiting oral intake and compromising patients' nutritional status. this may be reduced through the improved conformality offered by proton therapy. despite widespread use of enteral tube feeding through a percutaneous gastrostomy (peg) or nasogastric tube (ngt), there is little data available regarding overall incidence of ngt/peg placement and perspectives of pediatric patients and caregivers. objectives: to (a) estimate the need for ngt/peg support and (b) characterize patient and caregiver perceptions surrounding enteral feeding in children with head and neck tumors undergoing proton therapy. design/method: dependent on development stage, patient (n = 16) or parents (n = 6) filled out a series of customized surveys according to a prospective irb approved study. seventythree percent of patients also received concurrent chemotherapy. questions addressed their current feeding route and perception, for example, "what aspect(s) of tube feedings are beneficial to you?" and "what aspect(s) of tube feeding worry or scare you?" fifty-five surveys were distributed before and after radiation, and with any change in feeding route. results: at the start of proton therapy, 1 patient had a ngt and 8 patients had peg. of these, 8 patients (36%) had a ngt/peg in place exclusively for the administration of medication; only 1 patient (4%) needed a ngt/peg for nutrition. in those patients without ngt/peg, 46% would "consider" enteral feeds. in patients without ngt/peg, the most commonly cited benefit was "maximizing my nutrition" (67%) and the most common negative aspect was "fear" of tube placement (100% of patients). all sub-populations (32% of patients) cited change in appearance as a negative aspect. in patients without ngt/peg at the start of proton therapy, 46% of patients/caregivers felt enteral feeding to be "unnecessary," and 83% of these patients would not "consider" ngt/peg even if their "physician advised it." over the course of proton therapy, the patients/caregivers who deemed enteral feeding "unnecessary" decreased from 46% to 18%. at completion of treatment, 7 patients (32%) were using a ngt/peg tube for nutritional support but only one (4%) patient relied exclusively on their enteral feeds. two patients (without ngt/peg) (9%) required parenteral support. our data does not support prophylactic placement of ngt/peg in of children with head and neck tumors undergoing proton therapy. ongoing research is needed to identify which patients will need ngt or peg to supplement their diet. in this cohort, anticipatory counseling should focus on pain, cosmesis, and utility. children's national medical center, washington, district of columbia, united states background: ovarian sex cord-stromal tumors (osct) are rare neoplasms that typically present with signs/symptoms of an adnexal mass and signs of hormonal production1 approximately 20% of ovarian sex cord-stromal tumors in children are sertoli-leydig cell tumors (slct) with median age of presentation 25 years overall.1 to our knowledge the youngest reported case in the literature describes a 9-month old female in china with a slct that was treated with oophorectomy alone.2 some studies have found an association in families between pleuopulmonary blastoma and osct with a germline mutation leading to dicer1 syndrome, which has been associated with a younger age at diagnosis.3,4 objectives: to describe an unusual case presentation of slct in an infant results: 3-month old, twin female, ex-32 week premature infant presented to the emergency department on multiple occasions for abdominal distention and feeding intolerance initially thought to be related to previous omphalocele repair and umbilical hernia. an ultrasound demonstrated an 8 × 6 cm mass arising from the right ovary with large volume ascites. she required admission to the intensive care unit due to s261 of s301 respiratory distress from her significant ascites. serum tumor marker including hcg, afp and ldh were negative. patient underwent right oophorectomy with tumor capsule noted to be open at time of surgery. further imaging post operatively demonstrated no other sites of disease. the patient was classified as figo stage ic due to the presence of her significant abdominal ascites that was presumed to be malignant pre-operative tumor rupture.5 the pathological diagnosis was challenging and eventually resulted as a mixed germ cell sex cord stromal tumor with pattern of sertoli cell tumor with neuroendocrine differentiation. based on the staging of figo ic with pre-operative rupture, the decision was made to treat with a standard platinum based regimen as there is a higher incidence of relapse in stage ic patients when compared to ia treated with observation alone.6 our patient tolerated four cycles of chemotherapy well and end of therapy scans showed no evidence of disease. interestingly, her dicer mutation genetics performed by ion torrent tm next generation sequencing was negative in germline and tumor studies. to our knowledge, our patient is the youngest described with slct. she will continue to be followed with serial imaging alone as she had no evidence of elevated tumor markers at diagnosis.6,7 due to young age and unusual diagnosis, she was referred to cancer genetics team. background: approximately 12% of patients with wilms tumor (wt) have metastatic disease at diagnosis and often have a grave prognosis. limited cell lines are available for the study of metastatic wt and long-term passaged cell lines do not always recapitulate the human condition. focal adhesion kinase (fak) is a non-receptor tyrosine kinase that controls cellular pathways involved in the tumorigenesis of pediatric renal tumors. using a novel patient-derived xenograft (pdx) model from a patient's primary wt (coa 25) and matched isogenic metastatic wt (coa 42), we previously demonstrated that fak is expressed and its inhibition led to decreased tumorigenicity of both the primary and metastatic pdxs. kinomic profiling is an innovative, high-throughput method used to investigate kinase signaling to identify potential therapeutic targets. to date, the kinomic profile of primary and metastatic wt has not been examined. objectives: investigate baseline kinomic differences between primary and metastatic wt and evaluate kinases upstream and downstream of fak as potential targetable therapies. design/method: cells from coa 25 and coa 42 were treated with pf-573,228 (pf), a small molecule fak inhibitor. protein from cell lysates of treated and untreated coa 25 and coa 42 were combined with kinase buffer, atp, and fluorescently labeled antibodies and loaded into a phosphotyrosine kinase or serine-threonine kinase pam-chip® per the uab kinome core protocol. phosphopeptide substrate analysis with the pamstation®12 kinomics workstation (pamgene® international), pamchip® protocol using evolve2 software, and bionavigator v. 6.0 were used to analyze kinases upstream and downstream of fak. the primary wt had increased epha8, ror1 sgk307 and decreased pdgfrb relative to the paired metastatic wt at baseline. treatment with pf increased ron, pdgfrb, p70s6kb, mak, camk2g, vacamkl, camk2d, ck1a1 and pskh1 in the primary wt. treatment with pf decreased tnk1, lmr1, cck4, epha5, pdk1, sgk196, lkb1 and increased pskh1 in the paired metastatic wt. primary wt displayed a different kinomic profile compared to metastatic wt in a matched isogenic pdx model. these data reveal that alternative therapies to specifically target metastases are needed. furthermore, fak inhibition resulted in diverse kinomic alterations between primary and metastatic wt. inhibitors targeting many of these pathways, such as pdgfrb inhibitors, are currently available and potentially could be combined with fak inhibitors in the treatment of wt. the results of the current study indicate that kinases upstream and downstream of fak in primary and metastatic wt warrant further investigation. background: use of high-dose methotrexate (hd-mtx, 12 g/m^2) is a mainstay of standard therapy for pediatric osteosarcoma (os) in north america. in pediatric os, there is a narrow therapeutic window for hd-mtx, with decreased tumor response rate with mtx concentrations <1000 m and decreased survival due to severe toxicity with concentrations >1500 m. risk factors for hd-mtx toxicity have been defined in adults, including body mass index (bmi) and male gender, but such studies have not been conducted in children. we sought to examine the relationship between mtx levels and toxicities during hd-mtx infusion for pedi-atric os, thereby identifying risk factors for increased toxicity and providing a framework for therapeutic drug monitoring. design/method: this retrospective chart review included patients treated at texas children's hospital with hd-mtx as first-line therapy for os from 2009-2015. data abstracted from electronic records included patient characteristics, bmi and body surface area (bsa), baseline and post-treatment laboratory values, mtx levels 4 and 24 hours after dose given (4h, 24h), hour mtx cleared (mtx <0.1 um), grade 3/4 mucositis, myleosuppression, persistent lft elevation (ctace v4.0), and % tumor necrosis. correlation between 4h mtx level and other covariates was summarized using descriptive statistics. we reviewed 128 hd-mtx infusions corresponding to 12 patients. bmi was found to significantly impact 4h mtx level (p<0.05). female gender was also significantly associated with higher 4h mtx level (p<0.001). percent necrosis (available in 9 patients) was associated with 4h mtx levels at near-statistical significance (p = 0.07). 4h mtx level was not found to contribute to toxicities or associate significantly with mtx clearance. analysis in a larger cohort is ongoing. we have identified at least one patient factor (bmi) that significantly impacts 4h mtx levels and is of potential use for future modeling, as current models incorporate bsa only. our findings concord with studies in adult os in that bmi significantly impacts 4h mtx level but diverge in that female gender is associated with higher 4h levels. importantly, these data support targeting 4h mtx levels to ensure that minimum concentration for adequate tumor necrosis is reached. these results do not suggest that monitoring 4h levels would prevent toxicities, thus necessitating further characterization of any intrinsic patient factors that associate with toxicity. overall, our definition of the clinical factors that associate with 4h mtx levels contributes to a framework for therapeutic drug monitoring in pediatric os. children 's mercy hospital kansas city, kansas city, missouri, united states background: post consolidation immunotherapy with dinutuximab, aldesleukin (il-2), granulocyte macrophage colony stimulating factor (gmcsf) and isotretinoin is standard of care for children with high risk neuroblastoma. dinutuximab is combined in 5 alternating cycles with s263 of s301 gmcsf or il2, followed by a 6th cycle with isotretinoin alone. il-2 is administered as a 96hour continuous infusion on days 0-4 at 3miu/m2/day followed by a higher infusion dose, 4.5miu/m2/day, in combination with dinutuximab on days 7-10 of cycles 2 and 4. the 3miu/m2/day dose may be administered inpatient or in the ambulatory setting. objectives: to retrospectively compare the incidence of inpatient and outpatient side effects and complications associated with low dose (3miu) il2 to provide the tolerability data necessary to evaluate these venues for future administration options. design/method: this study was a descriptive, singlecentered definitive study utilizing a retrospective convenience sample population of children with high risk neuroblastoma who received low dose il2 either as an inpatient or an outpatient without exclusion from may 2012 to june 2017. subjects were identified by a tumor registry query post irb approval. electronic and paper medical records were reviewed for the dates and location of the infusions, the home health company used if applicable and all documentation regarding clinical status, side effects and toxicity. demographics was limited to age and gender. results: infusion venue was chosen by provider preference. twenty-six infusions, 9 inpatient and 17 outpatient via 3 separate home health companies were all administered in entirety and without interruption. there were 10 males and 4 females ranging from 2-7 years of age. two children received a single outpatient infusion due to intolerance of il2 when combined with dinutuximab and 2 received therapy in both settings. fever, 3 inpatient and 1 outpatient was the only common side effect. no source of infection was ever identified. there was one incidence of diarrhea and one patient with pruritus in both the outpatient and inpatient settings respectively. no planned outpatient infusions required subsequent admission however the outpatient fever did necessitate an er evaluation. conclusion: low dose il 2 can successfully be administered outpatient. the medication has minimal side effects with fever occurring in 15%, none of which were associated with infection. no outpatient infusion required a subsequent admission. no patients who received cycle 2 infusions outpatient opted to receive the next cycle inpatient. baylor college of medicine, houston, texas, united states background: metastatic ewing sarcoma (es) has an extremely poor overall survival, necessitating investigations into molecular mechanisms to identify novel targets and develop new therapies. we previously performed an in vivo study, using our mouse model, designed to provide insights into transcriptomic and proteomic signatures for metastatic es to identify potential therapeutic targets. comparing profiles of primary tumors to corresponding metastatic lesions, we identified aberrant expression of integrin ß3 (itgb3) and downstream activation of integrin-linked kinase (ilk) in metastatic lesions compared to primary tumors, implicating this pathway as a key regulator in the ability of es to establish and enhance metastasis. our hypothesis is that upregulation of itgb3 and its downstream signaling events play a key role in es metastasis and are viable therapeutic targets. objectives: to investigate the role of itgb3 and its downstream signaling pathways in driving the establishment and enhancement of metastasis in es and to investigate this pathway as a potential therapeutic target. to investigate the role of itgb3 and ilk in es metastasis, we used sirna to knock down itgb3 and ilk expression in established es cell lines and then performed functional assays in vitro, including cell proliferation and invasion/migration assays. we also tested inhibition of this itgb3 signaling pathway using available small molecule inhibitors targeting itgb3, ilk and the downstream target ap-1, using cilengitide, compound 22 and sr11302, respectively. we are currently using these small molecule inhibitors as treatment in vivo and assessing rates of metastatic tumor formation. we generated stable itgb3 and ilk overexpression and knockdown cell lines, which we are using for similar in vitro and in vivo investigations. knockdown of itgb3 and ilk in our sirna cell lines resulted in decreased cell proliferation and decreased invasion and migration compared to controls. we also found significantly decreased cell proliferation using each of the small molecule inhibitors in vitro. our preliminary studies using compound 22 in vivo established a safety profile and dose escalation is underway to assess the effectiveness of inhibiting es metastasis. these results support our hypothesis that itgb3 and its downstream signaling events play a key role in the ability of es to establish metastatic foci and may serve as a potential therapeutic target. we continue to investigate this pathway in vitro. we are also using our small molecule inhibitors and itgb3 and ilk overexpression and knockdown approaches to study these effects on metastatic tumor development in vivo using our mouse model. background: neuroblastoma (nbl) is characterized by phenotypic heterogeneity. outcome is excellent for patients with low-(lr) and intermediate-risk (ir) disease, whereas only 50% of high-risk (hr) patients will survive. 5-hydroxymethylcytosine (5hmc) is an epigenetic marker of active gene transcription, and 5hmc profiles are prognostic in many types of adult cancers. we hypothesized that 5hmc profiles will serve as robust biomarkers in children with nbl tumors, refining current risk stratification. objectives: analyze genome-wide 5hmc in nbl tumors and correlate 5hmc deposition with chromosomal copy number and gene expression. design/method: 5hmc was quantified by nano-hmc-seal-seq from the dna extracted from 15 hr, 11 ir and 27 lr nbl tumors. read counts and clinical data were analyzed with deseq to identify genes with differential 5hmc patterns between risk groups. chromosomal copy number was assessed by chromosomal microarray analysis (cma) in a subset of samples (3lr and 9hr). expression of genes located on chromosome 1p was evaluated using publically available microarrays (e-mtab-1781) of 171 hr nbl tumors with known 1p loh status. results: globally, lr tumors had more 5hmc peaks (140,062) than ir (102,398, p = 0.36) tumors, or hr tumors (79,727, p = 0.01). 1,049 genes had different patterns of 5hmc deposition in hr versus lr tumors. 315 (30%) of these genes mapped to chromosome 1p and had decreased 5hmc in hr versus lr tumors (padj <0.05). in the cma analysis 1p deletion was detected in 5 of the 9 tumors tested. in the tumors with 1p loss, 322 genes that map to 1p showed decreased 5hmc deposition compared to the 4 hr tumors without 1p loss (p<0.05). further, compared to the tumors without 1p loss, the expression of 188 of the 322 1p genes was decreased (p<1 × 10-5), including chd5, camta1, and arid1a, known and proposed tumor suppressor genes in nbl. conclusion: different patterns of 5hmc accumulation are associated with neuroblastoma risk classification. nano-hmc-seal-seq is sensitive to copy number variations and has the potential to identify these changes in patient tumors. our results suggest that 5hmc deposition contributes to the silencing of tumor suppressor genes in 1p and may also regulate the transcription of other genes that drive tumor phenotype. background: metastatic osteosarcoma has a 5-year survival rate of 15-40%. pulmonary metastases remain a major treatment challenge in osteosarcoma. current treatment with conventional chemotherapy shows inadequate activity towards metastases and has toxic systemic side effects. chloroquine is a widely used anti-malarial drug and has been shown to have promising anti-cancer and anti-metastatic activity. polymeric drugs have been shown to have multiple advantages over their small molecular parent drugs, including enhancing the therapeutic efficacy, an improved pharmacokinetics profile and decreased systemic toxicity. we hypothesized that by developing chloroquine into a polymeric drug and combining it with conventional chemotherapy it will improve the treatment of metastatic osteosarcoma. objectives: to identify the optimal combination of polymeric chloroquine (pcq) with conventional chemotherapy active in osteosarcoma as a new means of treating metastatic disease in a murine osteosarcoma model. we synthesized and developed pcq and evaluated its anti-invasive activity using an osteosarcoma cell migration and invasion assay. we evaluated the efficacy of cell killing using combination drug therapies with pcq and a panel of conventional chemotherapy agents (doxorubicin, docetaxel, cisplatin and paclitaxel) using celltiter blue cell viability assay. to develop the murine osteosarcoma model, we intravenously injected luciferase-expressing human osteosarcoma cells 143b into nsg mice. we administered the drug combination that showed the strongest in vitro synergy to the mice and evaluated their anti-cancer and anti-metastatic effects in vivo. tumor growth and suppression were evaluated using whole body bioluminescence imaging. results: we successfully synthesized pcq that contains 16.7% chloroquine with a molecular weight of 18.9 kd. pcq was also found to decrease the toxicity of the parent chloroquine. pcq showed strong inhibition of osteosarcoma cell migration with 51% inhibition compared to 13% by chloroquine. we screened the combination drug therapies and found the combination of pcq and doxorubicin to show the strongest synergism. the pcq/doxorubicin combination is currently being evaluated in the murine model. combination drug therapy using pcq and doxorubicin showed synergistic cell killing and inhibition of cell migration in vitro. the combination represents a promising treatment strategy for pulmonary metastatic osteosarcoma. emory university/children's healthcare of atlanta, atlanta, georgia, united states background: survival for relapsed high-risk neuroblastoma (rnb) is < 5%, underscoring the critical need for novel therapies. rnbs have increased ras/raf/mapk mutations and increased yes-associated protein (yap) transcriptional activity. yap is a transcriptional co-activator that binds with tea-domain (tead) transcription factors to regulate cellular proliferation, self-renewal, and survival. we found that shrna inhibition of yap decreases nb cell proliferation and sensitizes ras-mutated nbs to mek inhibitors, supporting yap as a tractable therapeutic target. verteporfin (vp), a photodynamic drug used for macular degeneration, is the only drug found to inhibit yap expression or yap:tead binding to kill tumor-derived cells. peptide 17 is a 17mer yap peptidomimetic that also disrupts yap:tead interactions. we sought to determine whether these compounds are potent in nb via yap direct effects. design/method: yap expressing (nlf, sk-n-as) or yap null (ngp, lan5, sk-n-as-shyap) human-derived nbs were incubated with vp, with and without direct light exposure, or with peptide 17. celltiter-glo and immunoblots were used to assess for cell death and yap-downstream protein expression, respectively. results: without direct light exposure, vp inhibits yap expression at nm dosing, yet no nb cell death was observed at equal or higher concentrations. egfr and erk1/2 were inhibited along with yap, confirming yap/ras pathway coregulation. when vp was exposed to direct incandescent light for 30 minutes, > 80% nb cell death occurred in all nbs tested, even those lacking yap. peptide 17 caused no cell death or yap inhibition up to 75 um. neuroblastomas are resistant to vp at doses sufficient to inhibit yap expression. in macular degeneration, light-activated vp produces reactive oxygen species, which we hypothesize is the off target mechanism killing nbs independent of yap. given the off target effects and the need for light activation, vp is not an ideal preclinical or clinical yap inhibitor. accordingly, peptide 17 has poor cell permeability and low tead affinity, leading to its lack of efficacy. given the relevance of yap in rnb and other cancers, we are chemically optimizing a yap peptidomimetic with enhanced permeability, nuclear localization, and tead affinity to create a bonafide yap inhibitor for preclinical and clinical application. kayeleigh higgerson, aaron sugalski, rajiv rajani, josefine heim-hall, jaclyn hung, anne-marie langevin ut health san antonio, san antonio, texas, united states background: osteosarcoma is the most common bone malignancy in children, adolescents, and young adults. most study cohorts have 10 to 15% hispanic patients that encompass many different hispanic backgrounds. the university of texas health science center at san antonio (uthscsa) sarcoma team serves a latino population that is predominantly mexican american, thus providing a unique opportunity for evaluation this population. this study expands on previous data collected from january 2000 to december 2010 from the same institution, providing increased insight into outcomes of mexican american children, adolescents, and young adults with osteosarcoma. objectives: to further understanding of osteosarcoma in latino children, adolescents and young adults. design/method: a retrospective analysis of demographics, tumor characteristics, response to treatment, and survival outcome of all localized osteosarcoma of the extremity patients below 30 years of age diagnosed and treated by the uthscsa sarcoma team between january 2000 and june 2017 was performed. results: in our original cohort from january 2000 to december 2010, we observed a significantly decreased 5-year eventfree survival (efs) in patients diagnosed before age 12 (preadolescent) relative to patients diagnosed between ages 12 and 29 (11% vs. 57%, p<0.001). patients had a 5-year overall survival (os) and event-free survival of 65% and 48% respectively. in our expanded cohort from january 2000 to june 2017 we evaluated sixty-six patients with a median age of 14 (range, 2 to 28 y) with localized high-grade osteosarcoma of the extremity. the expanded cohort was 68% mexican american, with a median follow-up of 59 months (range, 5 to 192). the analysis of our expanded cohort is ongoing and we postulate that the findings will hold true, as we increase the cohort size and length of follow-up. conclusion: analysis of our previous cohort, predominantly of mexican american ethnicity, showed that preadolescent patients had an increased rate of relapse when compared with previous large studies. we also showed a trend towards decreased efs for the entire cohort. we hypothesize that we will further validate these findings with this expanded cohort and this will support further investigation into potential causes of poor outcome in this vulnerable latino population. background: neuroblastoma in infants has the potential to regress or mature spontaneously. growing literature showed that some cases subjected to initial observation didn't show inferior outcome compared to actively treated similar categories. objectives: we investigated whether early active treatment can be safely avoided/deferred in selected favorable cases at the children's cancer hospital-egypt (cche). design/method: patients enrolled on the watch and see strategy (w&s) at cche had small primary tumor; inss stage 1-2, uncomplicated stage 4s or stage 3 infants (< 365 days). tissue biopsy was not mandatory for infants below 6 months of age with localized adrenal mass (stage 1-2). on progression, immediate intervention took place according to stage and risk of disease after biological characterization. results: thirty four nbl patients were enrolled on w&s strategy; m/f:2.4/1. eighteen patients had stage 4s disease, 12 patients had stage 1-2 and 4 were stage 3. primary adrenal site was reported in 29 patients (85.3%), 21 patients (61.77%) had small mass measuring ≤5 cm in its largest diameter. the 5-year os & efs were 88.2±8.8% and 72.5±9%, respectively, with 43 months median follow-up (range: 1-106 months). spontaneous total/near total resolution of mass occurred in 16/34 patients (47%). median time to eliciting regression was 1.7 months (range: 0.4-14.7 months), and 20.7 months (range: 7-63 months) till complete resolution. only 8/34 patients (23.5%) witnessed progression (2 local, 2 distant and 4 combined local and distant progression); median time to progression was 8 months (range: 1-32 months) with 2/8 deaths after starting chemotherapy. watch and see strategy is a safe approach in localized and uncomplicated stage 4s neuroblastoma. progressive cases could be rescued. baylor college of medicine, houston, texas, united states background: ga-68 dotatate binds to somatostatin receptor 2 expressed in neuroendocrine tumors (nets). it was approved by fda in 2016 for use with pet/ct scan for localization of somatostatin receptor positive nets in adult and pediatric patients. pediatric approval was based mainly on extrapolation of data from adults. objectives: to describe the use of ga-68 dotatate pet/ct scan in children with neuroendocrine tumors and compare with other imaging modalities. design/method: patients with nets enrolled in texas children's rare tumor registry between february and october 2017 were reviewed and those patients who underwent ga-68 scan were included. results: four patients with nets underwent ga-68 scans without any adverse reactions. first patient was a 15-yearold female with small bowel net with multiple liver metastases. mri abdomen and fdg pet at diagnosis showed s267 of s301 multiple liver metastases but could not identify the primary lesion. ga-68 scan was able to accurately identify the enlarged lymph nodes in the small bowel and was better than fdg pet in delineating the liver metastases. second patient was a 13-year-old female with recurrent small bowel net with liver, lung and paraspinal metastases. the lesions were initially detected by ct scan. octreotide scan failed to show any uptake in the identified lesions while ga-68 was taken up by the liver lesions, lung lesions >1 cm in size and the paraspinal lesion. third patient is an 8year-old male with pancreatic net with peripancreatic lymphadenopathy, multiple liver metastases and cardiophrenic lymph node involvement. the primary lesion in the pancreas could not be identified by ct scan, ct angiogram, mibg scan, or octreotide scan. in addition, there was uncertainty about involvement of the enlarged cardiophrenic lymph node. in addition to clearly identifying the primary lesion, ga-68 scan was able to detect multiple peripancreatic lymph nodes not detected by other scans and revealed uptake in the cardiophrenic lymph node confirming its involvement by the tumor. fourth patient is a 15-year-old female with malignant abdominal paraganglioma with solitary lung metastasis. both mibg scan and ga-68 scan were able to identify the primary lesion. ga-68 scan was performed after the lung metastasis was removed and thus its ability to detect it could not be confirmed. background: neuroblastoma is the most common extracranial solid tumor of childhood, with overall survival for high-risk patients (hrnbl) near 50%. the outcomes of hrnbl have improved with high dose chemotherapy followed by autologous stem cell rescue (abmt). data about factors influencing the rate of hematopoietic recovery following abmt in hrnbl is lacking in the literature. our objective was to identify factors influencing the rate of hematopoietic recovery following abmt in hrnbl. design/method: this was a retrospective chart review of 55 patients with hrnbl treated at texas children's hospital from 2006 to 2016. neutrophil engraftment was considered the first of three consecutive days with post-transplant neutrophil count greater than 500 cells/ul. red blood cell and platelet engraftment were considered at a hemoglobin greater than 8g/dl and platelets greater than 20,000/ul three days after the last transfusion. race and conditioning regimen were analyzed using one-way anova; amount of infused cells was analyzed using pearson correlation coefficients; chemotherapy delay and bone marrow (bm) involvement after cycle 2 of induction chemotherapy were analyzed using independent sample t-tests. the study included 32 males and 23 females with a median age at diagnosis of 2.5 years. thirtyeight patients were caucasian, 6 african-american, 5 hispanic, 2 asian, and 4 did not have race documented. the mean dose of infused cd34+ cells was 3.36 × 10^8 cells/kg. forty-five patients received conditioning therapy with carboplatin/etoposide/melphalan (cem), 8 received busulfan/melphalan (bu/mel), and 2 received thiotepa/cyclophosphamide (thiotepa/cpm). the conditioning regimen administered was significant (p = 0.037) for time to engraftment of neutrophils, with bu/mel at 16.6 days, cem at 12.1 days, and thiotepa/cpm at 10 days. a delay of chemotherapy during induction (n = 25) was significant (p = 0.001) for time to platelet engraftment of greater than 75,000/ul and trended towards significance (p = 0.088) for time to neutrophil engraftment. bm involvement at diagnosis and after cycle 2 of induction was not significant for time to engraftment. dose of stem cells infused was the only variable significant for hemoglobin engraftment. background: osteosarcoma (os) is the most prevalent aggressive primary malignancy of the bone affecting children and young adults. approximately 10% to 20% of patients have metastatic disease at initial presentation, and 61% of those patients have isolated pulmonary metastases. although overall survival in patients with os has improved with advances in therapy, there have been no significant improvements in survival outcome in patients with metastatic disease. recent studies suggest that tumor-associated vascular cell adhesion molecule 1 (tvcam-1 or cd106) plays a critical role in the metastatic progression of various tumors. indirect evidence from these studies suggest that vcam-1/ 4 1 integrin signaling promotes tumor survival and metastatic progression by changing the tumor niche and associated immune response. to determine if interfering vcam-1/ 4 1 signaling between pulmonary metastatic osteosarcoma (pos) and macrophages (macs) by down-regulating vcam-1, depleting macs or blocking vcam-1/ 4 1 signaling will reduce pos and improve overall disease-free survival. design/method: we used a pair of spontaneous, high-grade murine os cell lines from balb/c mouse (h-2d), k7 and k7m2 (derived from in vivo k7 metastasis). we used lentiviral shrnas to knockdown vcam-1 mrna and protein expression in k7m2 (vcam-1kd). we introduced luciferase into k7, k7m2 and various k7m2 shrna cell lines to follow lung metastasis by bioluminescence (bli). we depleted macs by intranasal administration of liposomal clodronate formulation. we tested the ability of k7 and k7m2 supernatants to polarize m0 macs into m1 or m2 phenotype in vitro. we also administered anti-4 monoclonal antibody (anti-4 mab) intranasally to assess the outcome of functional blockade of vcam-1/ 4 1 signaling. results: k7m2 over-expressed vcam-1 compared to k7. mac depletion in k7m2-bearing animals exhibited reduced pos. weekly administration of anti-4 mab resulted in 80% tumor-free rescue among mice with established k7m2 pos. interestingly, supernatant from k7m2 but not k7 preferentially induced m2-like macs, suggesting a novel integrin-mediated mechanism of m2 differentiation. validation data with additional os cell lines will be presented. despite aggressive multimodal therapy, overall outcome for patients with pos remains dismal at 25-30%. for this reason, novel and directed therapy approaches are desperately needed. molecular targeted approaches for therapy are challenging, due to the complex genetic heterogeneity of os. immune-modifying therapy is a promising new alternative approach for pos. university of chicago, chicago, illinois, united states background: only half of all patients diagnosed with high-risk neuroblastoma achieve long-term survival. 123imetaiodobenzylguanidine (mibg) scans are routinely used to evaluate disease at diagnosis and following treatment, and the extent of disease is quantified using the curie scoring system. a previous study by yanik et al., has shown that for high-risk patients with mycn non-ampliified tumors, scores less than versus greater than 2 following 6 cycles chemotherapy are associated of superior survival, whereas scores less than versus greater than 0 were prognostic in patients with mycn-amplified tumors. however, the prognostic significance of specific sites of metastatic disease at diagnosis is not known. to determine if site of metastatic disease determined by 123i-metaiodobenzylguanidine (mibg) imaging in high-risk patients at the time of diagnosis was associated with outcome design/method: we performed a retrospective chart review of high-risk neuroblastoma patients treated at comer children's hospital and lurie children's hospital in chicago between 2006 and 2017 with positive mibg scans at the time of diagnosis. we collected imaging data as well as other clinical data including bone marrow status. sites of disease were defined as curie regions with any positive value. kaplan-meier analysis was performed to evaluate the association with disease sites and survival. pearson correlation coefficients were calculated to compare bone marrow disease to sites of positivity on mibg scan. the cohort consisted of 49 high-risk patients. 31 had skull disease, and 30 had pelvic disease. the presence of mibg positive disease in the skull and in the pelvis trended toward worse efs. efs at 3 years for patients with disease in the skull at diagnosis was 52 ± 10% and for patients without skull disease was 78 ± 10 % (p = 0.16). efs at 3 years for patients with and without pelvic disease was 49 ± 10% and 80 ± 9% (p = 0.10). consistent with prior data, we found that the presence of bone marrow disease was associated with worse survival with 3 year efs of 47 ± 10% and 88 ± 8% with and without marrow disease at diagnosis (p = 0.02). there is the highest correlation between pelvic disease on mibg scan and bone marrow disease with pearson coefficient 0.79. pelvic disease noted on mibg scan likely reflects underlying bone marrow disease. in patients with high-risk neuroblastoma, skull disease and pelvic disease on mibg scan at diagnosis may predict worse event free survival. background: osteosarcoma is one of the deadliest cancers in the pediatric population with little progress in morbidity and recurrence rates since the 1980's. oncolytic herpes simplex-1 virus (ohsv) is an attenuated virus that has shown encouraging results against certain solid tumors. programmed cell death protein (pd)-1-mediated t cell suppression via engagement of its ligand, pd-l1, is also of particular interest due to recent successes in selected cancers, especially those with high genetic mutational loads. most pediatric cancers do not have a wide variety of mutations; however, osteosarcoma has a chaotic genome, prone to genetic mutations. it has been shown through numerous other studies that pd-1 inhibition alone is not sufficient to result in statistically significant tumor growth delays in osteosarcoma models and patients. we hypothesize the addition of ohsv therapy as an immunologic stimulus to pd-1 inhibition is efficacious for osteosarcoma. (1) to determine whether ohsv therapy enhances response to pd-1 inhibition in immunocompetent murine models of osteosarcoma and (2) to quantify and characterize the anti-tumor t-cells infiltration after treatment with ohsv and pd-1 inhibition individually and in combination. we utilized an immunocompetent transplantable murine model using a cell line derived from a spontaneous metastatic osteosarcoma (k7m2, balb/c background). we transplanted established tumor wedges subcutaneously and monitored tumor volume by caliper measurement. once tumors reached 200-400mm3, we administered intratumoral injections of hsv1716 (1 × 108 plaque-forming units) every other day for a total of 3 injections. we then gave intraperitoneal injections of 250ug anti-pd-1 or control antibody twice weekly, up to 4 weeks, starting from the last dose of virus treatment. we monitored tumor growth via calipers twice weekly until tumors reached 2500mm3 or 2cm diameter. we quantified and characterized innate and adaptive immune cell infiltrates in tumors using flow analysis. we found significantly prolonged survival with our combination therapy group compared to all other groups. we found that anti-pd-1 by itself had little impact on t cell recruitment while the combination group had higher influx of cd8+ cells with a reduced amount of t-regulatory cells (cd4+foxp3+cd25+). we also found an increase in cd44+ effector memory cells. osteosarcoma is a deadly cancer with therapeutics remaining unchanged for the last 30 years. here, we describe prolonged murine survival after treatment with combination of pd-1 inhibition and ohsv injection. the combination treatment changed the microenvironment to be more inflammatory. our data support further preclinical and clinical studies. background: neuroblastoma is the second most common cause of cancer related death in children. treatment for high-risk neuroblastoma has improved significantly over the past twenty years, however cure rates remain below 50%. immunotherapy has emerged as an effective therapy for neuroblastoma, however new modalities and targets are needed to improve outcomes. objectives: our lab has developed a chimeric antigen receptor (car) that targets b7-h3 (cd276), an immune checkpoint molecule overexpressed on many cancers, including neuroblastoma. we hypothesized that b7-h3 would be a good target for car based immunotherapy for neuroblastoma. design/method: neuroblastoma tissue microarrays of primary patient samples were screened for b7-h3 expression by immunohistochemistry and cell lines were screened using flow cytometry. b7-h3 car t cells were tested in vitro by measuring tumor cell killing and cytokine production after coculture with tumor cell lines and in vivo in an orthotopic model of neuroblastoma. results: b7-h3 expression was detected by ihc on 82% of the 186 screened neuroblastoma patient samples. b7-h3 was expressed at high levels (2+ or 3+) in more than half of these samples (56%). almost all cell lines screened were homogeneously positive for b7-h3 by flow cytometry. retrovirally transduced b7-h3.4-1bb. car t cells were cocultured with three b7-h3 positive neuroblastoma cell lines (sk-n-be2, kcnr, and chla255) and robust tumor cell killing was demonstrated using an incucyte assay. supernatant from the co-cultures was harvested after 24 hours and both interferon gamma and il-2 production were detected by elisa.in an orthotopic subrenal capsule xenograft model of neuroblastoma, mice treated with b7-h3 car t cells show significant reductions in tumor growth and prolonged survival compared to those treated with untransduced control t cells. however, the treatment is not always curative.b7-h3 car t cells express high levels of exhaustion markers (pd1, tim3, and lag3) when compared to cd19 car controls. in order to overcome inhibition from exhaustion, b7-h3 car t cells were co-cultured with neuroblastoma cell lines and pd-1 blocking antibody. nivolumab significantly increased the production of il-2 and interferon-gamma by b7-h3 car t cells. further studies are underway to determine if b7-h3 car t cell activity is enhanced in vivo by treating animals with pd-1 blockade along with car t cells. conclusion: b7-h3 is expressed on a majority of neuroblastoma samples and appears to be a promising candidate for car t cell therapy. b7-h3 car t cells demonstrate activity against neuroblastoma xenografts that may be enhanced by the addition of pd1 inhibitors. helen devos children's hospital, michigan state university, grand rapids, michigan, united states background: osteosarcoma is the most common bone tumor in children. it is often metastatic at diagnosis and in this scenario less than 30% of children survive. polyamines, small molecules found in all cells, are involved in many cell processes including cell cycle regulation, immune modulation, cell signaling and apoptosis. they are also involved in tumor development, invasion and metastasis. in neuroblastoma, inhibition of the polyamine biosynthesis pathway with odc inhibitor alpha-difluoromethylornithine (dfmo) results in decreased cell proliferation and differentiation. these finding have led to multiple phase i and phase 2 ii multicenter clinical trials in pediatric neuroblastoma patients. dfmo is an attractive drug as it is oral, well-tolerated, can be given for prolonged periods and is already used in pediatric patients. the polyamine pathway has not been evaluated in osteosarcoma. objectives: evaluate effect of inhibition of polyamine biosynthesis with dfmo on osteosarcoma proliferation and cell differentiation. design/method: up to three osteosarcoma cell lines were used: mg-63, u-2 os and saos-2. cells were exposed to 5 mm dfmo for 6 days with replacement of media and dfmo on day 3. intracellular polyamine levels were measured by high performance liquid chromatography (hplc). cell numbers were obtained with a hemocytometer using trypan blue. flow cytometry cell cycle distribution (facs) and propidium iodide were used to evaluate for cell cycle arrest. the protein expression of several osteosarcoma differentiation markers was measured by sds-page and western blot using differentiation specific antibodies. a bioluminescent cell viability assay was used to measure cell recovery over several days after dfmo was removed and replaced with standard media. results: dfmo exposure resulted in significantly decreased cell proliferation in all cell lines. after treatment, intracellular spermidine levels were nearly eliminated in all cells. cell cycle arrest at g2 was observed in u-2 os. cell differentiation was most pronounced in mg-63 and u-2 os cells as determined by increased osteopontin levels. remarkably, cell proliferation continued to be suppressed for several days after removal of dfmo. conclusion: based on our findings dfmo is a promising new adjunct to the current osteosarcoma therapy for high risk patients. it is a well-tolerated oral drug that is currently in phase ii clinical trials in pediatric neuroblastoma patients as a maintenance therapy. the same type of regimen may also improve outcomes in metastatic or recurrent osteosarcoma patients for whom there have been essentially no medical advances in the last 30 years. background: recent studies demonstrate that lower levels of the ews-fli1 fusion oncoprotein are associated with enhanced metastatic capability in ewing sarcoma. the nf-kb transcription factor is a critical mediator of cxcr4 and cxcr7 -driven metastasis in multiple cancers, and increased cxcr4 and cxcr7 expression have each been associated with increased metastasis and poor prognosis in ewing sarcoma. we thus sought to investigate the impact of ews-fli1 on cxcr4/cxcr7-dependent nf-kb signaling in ewing sarcoma. objectives: the goals of this study are 1) to determine the impact of cxcr4/cxcr7 signaling on metastasis-associated nf-kb target gene expression in ewing sarcoma and then 2) to investigate how the ews-fli1 fusion oncoprotein modulates this response . design/method: we utilized multiple ewing sarcoma cells lines including a673, chla9, chla10, tc32 and tc71. cxcr4/cxcr7 cell surface expression was determined by flow cytometry. ews-fli1 level was modulated using sirna and expression levels were confirmed by western blot and rt-pcr. p65 dna binding was measured via elisa. nf-kb target gene expression was assessed via rt-pcr. results: consistent with ihc analysis of primary and metastatic patient tumor samples, the paired primary and metastatic ewing sarcoma cell lines chla9 and chla10 showed dramatic differences in cxcr4 and cxcr7 expression, with the metastatic chla10 line demonstrating much higher expression of both receptors. other cell lines (nonpaired) showed variable cxcr4/cxcr7 expression. genetic knock-out of cxcr4 lead to significant decrease in expression of both cxcl12/sdf-1 and il-6, two nf-kb transcriptional targets known to play a key role in tumor metastasis. knock-out of cxcr4 did not alter endogenous ews-fli1 mrna levels. conversely, lowering the level of ews-fli1 using sirna lead to enhanced nf-kb signaling, indicated by an increase in p65 dna binding. consistent with this observation, treating ewing cell lines with ews-fli1 sirna also resulted in significantly increased nf-kb target gene expression compared to control cells and target gene expression was then further enhanced upon cxcr4/cxcr7 receptor stimulation with the receptor ligand cxcl12/sdf-1. our findings indicate that the ews-fli1 oncoprotein negatively modulates cxcr4/cxcr7-dependent nf-kb signaling. this suggests that ews-fli1 low, cxcr4/cxcr7 high cells, which are associated with enhanced metastasis and poor prognosis, would be anticipated to exhibit enhanced expression of key nf-kb target genes. importantly, the nf-kb pathway is a druggable target that could potentially serve as an "achilles heel" in this subset of high risk tumors. current work is evaluating nf-kb inhibition as an approach to treating metastatic and refractory ewing sarcoma. background: acute graft versus host disease (agvhd) is a major cause of morbidity and mortality following allogeneic bone marrow transplant (bmt) in pediatric patients. gastrointestinal (gi) agvhd is the most serious manifestation. recently, decreased paneth cell (pc) in a predominantly adult cohort was shown to correlate with agvhd clinical grading and response to treatment. we aim to demonstrate the relationship between pc counts and gi agvhd stage and response to therapy. design/method: charts of patients who underwent endoscopy following bmt between 2004-2014 were reviewed. for repeated biopsies during the course of agvhd, only the first was included for analysis. one pathologist retrospectively reviewed the biopsies and counted pcs in 3 high powered fields; the average pc count was analyzed. twenty-six percent of biopsies were reviewed by a second blinded pathologist. statistical associations between pc counts and day 28 (d28) response, agvhd stage, and other study covariates of interest were gauged using general linear regression. agreement in pathologist pc counts was quantified by intraclass correlation (icc). the research was approved by the children's healthcare of atlanta irb. results: seventy-eight biopsies were included in the analysis. mean age at transplant was 10.5 years ± 5.8 (range: 2 months -20 years). most patients underwent transplant for hematologic malignancies (63, 74%). the majority of transplants used a matched unrelated donor graft -including cords (59, 69%) and myeloablative conditioning regimens (71, 82%) -52% received total body irradiation. of these, 64% were diagnosed clinically with gi agvhd (stage 1, 42%; stage 2, 14%; stage 3, 22%; stage 4, 22%). icc showed good agreement (0.833) between the pathologists. mean pc was 16.8 for patients with no gut agvhd, 21.3 for stage 1, 22.9 for stage 2, 9.4 for stage 3 and 5.9 for stage 4 (p = 0.001). on multivariate analysis pc was strongly associated with gi agvhd stage (p<0.001) after controlling for age, preparative regimen intensity, and diagnosis (malignant vs. non-malignant). mean pc counts were significantly lower in patients with no response to steroid therapy at d28 (complete response (mean 17.8) vs. persistent disease (4.2) vs. partial response (4.5) (p = 0.001)). patients diagnosed with gi agvhd with pc counts less than 10 had a higher risk of mortality (hr 3.1, 95% ci: 1.17, 8.09; p = 0.023). lower pc count correlated with stage 4 gi agvhd, refractory disease at d28, and mortality. incorporating pc count in pathology review during gi agvhd work-up may help in agvhd risk stratification. background: there have been increasing discussions pressuring health care teams and institutions for potentially bearing the cost of clostridium difficile infections (cdi) as a health care-associated infection in the recent years. the pediatric oncology patient population, though small, accounts for significant portion of all cdi with 10-15-fold increased risk. hematopoietic stem cell transplant (hsct) recipients constitute a unique subset with distinct risk factors, such as severe immune deficiency state and graft versus host disease (gvhd). although there is ample data on cdi in adult hsct recipients, reports on pediatric experience are limited. objectives: to evaluate the incidence and patterns of cdi among pediatric hematology, oncology and hsct inpatients at our institution. a retrospective review of all clostridium difficile (cd) stool tests performed using toxin enzyme immunoassay and later, polymerase chain reaction targeting toxin genes between 2007 and 2017 in a large, urban academic children's hospital was performed. the data were analyzed for hematology, oncology, hsct inpatient population and all the other cases separately and statistical comparisons were performed. results: a total of 5271 samples were submitted to the microbiology laboratory for cd testing during the study period. while hematology patients constituted 1.7%, oncology 5.9%, hsct 2.0% and others 90.4% of the cases on whom cd testing was done; per patient average test number was 2.0, 2.8, 6.2, and 1.5, respectively. of all the cd tests per-formed, 15.6% were positive. test positivity was higher in hsct (47.6%) and oncology (42.4%) cases tested compared with hematology (21.2%) and other cases (17.1%) with statistical significance (p<0.001). overall recurrence rate was 4.3%; hsct patients had the highest recurrence with a rate of 27% followed by oncology (13.6%), hematology (7.7%) and other (3.2%) cases, again reaching statistical significance (p<0.001). again, hsct patients had the highest average number of recurrences at 3.1 (2-6) followed by oncology 2.8 (2-10), general 2.52 (2-6) and hematology 2.25 (2-3) groups. there was no seasonal variability in the incidence of cdi among populations analyzed. prolonged hospital stay/antibiotic use and persistent diarrhea due to gvhd are the likely reasons for higher rate of cd testing in hsct as a result of increased monitoring and thus might have even caused underrepresentation of positive cd test frequency. higher incidence and frequencies of recurrence underscores the inevitable nature of cdi in hsct population as a consequence of the current therapies and may lead to future radical treatment approaches like fecal implantation. background: viral infections remain a challenge to treat post hct in children, and significantly contribute to morbidity and mortality. virus specific t cells (vsts) have shown tremendous clinical efficacy in treating viral infections post-hct, with minimal toxicity and long term efficacy. we have used donor-derived vsts in individual patients, however not all donors are agreeable to the process, and numerous patients may benefit from vsts who do not have an identified donor/have other disease indications objectives: we sought to actively build a third-party vst bank, for "off the shelf" use in eligible patients. design/method: vsts targeting cmv, adenovirus and ebv were manufactured using one of 2 techniques. initially ebv transformed b cells were genetically modified with an ad5f35pp65 vector and used as antigen presenting cells (apc) to stimulate and expand ebv, ad and cmvpp65 specific t cells. more recently, vsts were expanded using s273 of s301 apc pulsed with commercially available peptide pools (pep-mixes) to expand ebv/cmv/ad specific t cells. products were entered into the "bank" via two mechanisms: a) left over products from our "donor-derived" protocol when patients no longer required vsts or were not at risk of developing viral infections, or b) by targeting regular blood donors based on their hla typing to ensure an appropriate mix of high frequency hla types for optimal patient matching and antigen presentation based on current knowledge of antigen presentation. results: a total of 30 products are currently in the thirdparty vst bank ready for use. twenty seven of these are from our donor derived protocol, and three from targeted donors. all vst products met safety and in vitro efficacy testing. thirteen vst infusions have been given to 7 patients. eleven infusions have been given for cmv and two for adenovirus. five out of seven patients responded to thirdparty vst infusions, with a median of 2 vst infusions per patient (range 1-4). the median hla matching was 2 out of 10 per patient (range 1 to 4) no patients experienced adverse reactions, gvhd or other toxicity related to the vst infusion. a third-party vst bank is feasible and produces clinically appropriate vsts for use in patients with viral infections. hla typing and matching of vst products is essential to reduce toxicity and promote appropriate antigen presentation and expansion of vsts in vivo. further work is underway to further characterize the vsts using epitope mapping to better define the hla restriction and immunogenicity of each vst product. akron children's hospital, akron, ohio, united states background: acute graft-versus-host disease (agvhd) is a well-known complication of hematopoietic stem cell transplant (hsct) and a major cause of post-transplant related morbidity and mortality. first line therapy of agvhd involves corticosteroids and calcineurin inhibition. in patients with severe refractory gvhd, mortality can reach up to 90%. currently, there is no standard of care for the treatment of steroid refractory agvhd. many centers have looked at the use of antibody mediated control of agvhd to competitively inhibit the inflammatory cascade. basiliximab, a chimeric monoclonal antibody against the t-cell il-2 receptor, has been used in adults with steroid refractory agvhd. patients receiving this medication have demonstrated complete and partial responses to therapy with minimal toxicities. objectives: report the successful use of basiliximab in the treatment of agvhd in a 2-year-old following matched unrelated (mud) hsct. design/method: a 2-year-old male underwent mud transplant for high risk aml with monosomy 7. conditioning regimen included busulfan, fludarabine and equine atg. his clinical course was complicated by fever, mucositis and agvhd (stage 3 skin; stage 1 gi-biopsy proven). gvhd prophylaxis included tacrolimus and methotrexate, however with progressive skin rash, diarrhea, and early satiety, gvhd treatment with corticosteroids was initiated. as the patient continued to have worsening symptoms, basiliximab therapy was started. the patient received 2 doses (10mg) iv basiliximab on two consecutive days and then received weekly therapy for a total of 4 doses leading to initial improvement. the patient further developed acute on chronic gvhd on day +100, and subsequently received a second course of basiliximab. after initial administration of basiliximab, the patient had near complete resolution of symptoms. however, with a small wean in his tacrolimus dose, the patient experienced another skin gvhd flare prompting the second basiliximab course. the patient was subsequently weaned off all immunosuppression by day +376. the only acute complication the patient experienced while receiving basiliximab was right toe paronychia and asymptomatic low ebv titer. the patient is currently off all immunosuppression at the time of report without evidence of cgvhd. conclusion: this single case report, in a young pediatric patient, demonstrates the use of basiliximab may be a safe and efficacious treatment for pediatric patients with agvhd. university of california, san diego, la jolla, california, united states background: clinical outcomes after allogeneic hematopoietic stem cell transplantation (hsct) depend on restoration of t lymphocyte populations. association between recovery of cd4+foxp3+ regulatory t cells (tregs) and protection from chronic graft versus host disease (cgvhd) has been described in adult hsct. in adults, t cell recovery is driven by expansion of donor t cells and treg reconstitution is hypothesized to result from peripheral conversion. restoration of t cells in pediatric patients has a larger contribution from thymopoiesis, however, the relationship between thymopoiesis and treg recovery is undefined. objectives: we hypothesized that effective thymopoiesis is important for restoration of treg populations and protection from cgvhd in pediatric hsct patients. design/method: we performed longitudinal flow cytometry of peripheral blood t cells from 17 pediatric hsct patients and 9 age-matched healthy donors. laboratory data were correlated with clinical outcomes to evaluate impact. recovery of tregs occurred in 11/17 (64.7%) patients by post-transplant day 90. day 90 treg frequency in patients that developed cgvhd (1.7 ± 1.1% of cd4+ t cells) was reduced compared to cgvhd-free patients (3.2 ± 0.7%). failure to restore tregs to >2.0% of cd4+ cells by day 90 was associated with increased risk of cgvhd in the first year post-hsct (rr = 7.3, p = 0.05). a majority (60.8 ± 11.9%) of tregs from patients recovering the peripheral treg compartment expressed helios, a marker of thymic-derived tregs; only 21.5 ± 11.4% of tregs expressed helios in patients failing to restore adequate tregs. this prompted examining the relationship between defects in thymopoiesis and inability to restore tregs. we evaluated thymic function by flow cytometry quantification of cd45ra+cd31+ptk7+ recent thymic emigrant (rte) cd4+ cells (confirmed by qpcr for trec content). most (13/17, 76.5%) hsct patients had detectable rtes by day 30 post-hsct. thymic production of rtes was persistently absent in patients that developed cgvhd (<10/10^4 cd4+ cells in 5/5 patients), compared to cgvhd-free patients (7/12 patients >10 rte/10^4 cd4+ cells by day 30, average 22.3 ± 7.1/10^4 cd4+ cells). post-hsct thymic activity as measured by rte enumeration correlated with treg restoration; 6/8 (75%) rte+ patients restored tregs, compared to 3/9 (33%) of rte-patients. conclusion: failure to restore tregs after allogeneic hsct results in increased risk for cgvhd. in pediatric patients thymic generation of new t cells is an important contributor to restoration of the treg compartment. this data supports further investigation into mechanisms impairing post-hsct thymopoiesis and suggests peripheral blood tregs may be a prognostic biomarker for cgvhd. background: haploidentical stem cell transplantation (haplo sct) is riddled with unique challenges. objectives: we present our experience in the use of haplo sct with post-transplant cyclophosphamide (ptcy) and the adaptations required for each disorder for optimal outcome. design/method: we performed a retrospective study at the pediatric blood and marrow transplant unit, apollo cancer institutes, chennai, india. children up to 18 years of age, diagnosed to have benign disorders and underwent haplo sct with ptcy from 2002 to july 2017 were included. results: ptcy was used in 36 i.e. 73% haplo transplants for children with benign disorders. the underlying conditions included fanconi anemia 10, severe aplastic anemia 6, mds 1, jmml 1, hemoglobinopathy 3, prca 1, xld 1 and primary immunedeficiency disorders (pid) 13. source of stem cells was peripheral blood in 58%, bone marrow in 41%. conditioning included fludarabine with treosulphan or cyclophosphamide for pids and aplastic anemia respectively. neutrophil engraftment by day+16-21 with a durable graft was noted in 75% transplants with graft versus host disease in 20%, cmv reactivation in 35%. mortality rate was 45% with 2 infants less than 6 months of age developing severe fatal cytokine release syndrome. the median follow up is 1 year with 3 years being the longest. no significant late effects have been noted with chronic skin gvhd in 3 children. survival rate was superior among children with pids with survival of 70% in this group. haplo sct with ptcy is a feasible and costeffective option for cure in children with life-threatening benign disorders with no compatible family or matched unrelated donor. careful patient selection, reducing cyclophosphamide related free radical toxicity with the use of n acetylcysteine, limiting t cell numbers by capping cd34 at 5 × 106/kg, post-transplant viral monitoring protocols are required to reduce morbidity and mortality. we have been working on universal access to care for children from s275 of s301 all socioeconomic background and incorporating innovations to reduce the cost of hsct without compromising outcomes. haploidentical hsct using tcr / depletion costs 18000 usd as compared to ptcy priced at 25 usd. children with severe aplastic anemia and pids can be transplanted using reduced intensity conditioning and ptcy. in hemoglobinopathies, pretransplant immunosuppression is required to prevent graft rejection. graft versus host disease remains the main cause of mortality in children with fanconi anemia. mortality in infants less than 6 months after ptcy has been high, tcr / depletion would be superior in this cohort. cincinnati children's hospital medical center, cincinnati, ohio, united states background: fanconi anemia (fa) is a congenital bone marrow failure syndrome with hsct the only curative option for associated bone marrow failure. patients with fa undergoing hsct may experience increased toxicity related to either their underlying disease, or the effects of medications, resulting in the inability to tolerate prophylactic medications or sideeffects from anti-microbial therapy. objectives: we postulated that increased cd34 cell dose would be associated with a rapid immune reconstitution and therefore early withdrawal of anti-infective prophylactic medications. design/method: patients with fa transplanted at cchmc from an unrelated donor had peripheral blood stem cell grafts collected and cd34 selection performed. where possible, patients had serial measurements of their immune system performed at varying intervals post hsct. we defined immune reconstitution as normalization of lymphocyte subsets-cd3, cd4, cd8 and cd19 cells, as well as a normal response to mitogen stimulation including phytohemagglutinin, concanavalin a and pokeweed. the first measurement of either normal cell number or mitogen response was recorded for each patient. results: a total of 35 patients underwent hsct for fa at cchmc between 2012 and 2017. patient demographics included a median age of 8 years at hsct, the vast majority of patients having a fully matched or one anti-gen mismatched donor, and the majority of patients transplanted for bone marrow failure. there was a statistically significantly decreased time post-transplant to immune cell recovery in patients receiving >20 × 106/kg cd34 cells (median 25.7) compared to those receiving <20 × 106/kg cd34 cells (median 11.9). the median time to normalization of cd3 count was 224 days (cd34 count >20/kg) versus 371 days (cd34 count <20/kg), cd4 count 211 days (cd34 count >20/kg) versus 489 days (cd34 count <20/kg), cd8 count 193 days (cd34 count >20/kg) versus 344 days (cd34 count <20/kg) and cd19 count 93 days (cd34 count >20/kg) versus 109 days (cd34 count <20/kg). time to normalization of mitogen response was decreased posttransplant in those patients receiving increased cd34 cell dose at time of transplant, though this was not significant, reflecting low number of patients with evaluable responses. no patients in either group experienced gvhd or graft failure. patients with fa who are transplanted with higher cd34 cell doses have quicker immune reconstitution than those who receive lower cell doses. along with benefit to patients including less risk of infection and early termination of immune-prophylaxis medications, this supports the use of high dose cd34 selected grafts in this vulnerable population. background: parvovirus b19 (pvb19) infection after transplantation was first reported in 1986. since then, numerous cases of pvb19 infections after hematopoietic stem cell transplantation (hsct) and solid organ transplantation (sot) have been reported. most report anemia as the predominant clinical manifestation. however, pvb19 has been associated with pancytopenia, hepatitis, myocarditis, and allograft rejection. we present a patient with acute lymphoblastic leukemia who developed bone pain and pancytopenia following hsct in the setting of pvb19 infection. to describe an unusual presentation of pvb19 in a patient with acute lymphoblastic leukemia following hsct. design/method: a search of the english-language medical literature was performed using pubmed and medline databases. a review of the patient's medical history was performed. a 7 year old male with relapsed b-cell all and history of "fifth disease" in infancy presented four months after hsct with focal left arm pain and difficulties fully extending the arm. bone mri showed enhancement of the medullary space centered within incomplete transverse cortical fracture interpreted as pathologic fracture due to neoplastic involvement of the ulna with no history of inciting injury. subsequently, peripheral blood counts decreased from low normal values to wbc 1.9 k/microl, anc 310/microl, plt 57k/microl, and hemoglobin 8.6 g/dl. the patient's chimerism remained 100% donor. a bone marrow biopsy and aspirate were performed to assess for recurrent leukemia given persistence of bone pain and developing pancytopenia. marrow findings included morphologic cytopathic effects with erythroid precursors and strong parvovirus staining with no signs of red cell aplasia or recurrent b-cell disease by morphology or flow cytometry. pvb19 was detected in blood by pcr and immunoglobulins with resolution of cytopenia and bone pain. this case highlights an unusual constellation of symptoms following hsct in a child with all. unexplained bone pain and medullary infiltrates with pancytopenia suggestive of recurrent leukemia were likely triggered by pvb19 infection. the question remains if he had reactivation of pvb19, a primary infection by a new strain, or the virus was aquired through stem cells. bone biopsy could not be justified in light of clinical improvement. so far, bone lesions have only been described with congenital pvb19 infection. pvb19 appears to be uncommon after hsct, with a review of literature yielding 15 pediatric cases. however, it may be underestimated due to lack of routine screening. our patient's presentation supports that evaluating for pvb19 may be warranted in hsct patients presenting with symptoms suggestive of relapsed leukemia. background: cardiac injury may occur during hematopoietic stem cell transplant (hsct) in pediatric patients and can be asymptomatic for many years. recommendations for screening are available for patients who received anthracyclines or chest irradiation, but no guidelines exist for unexposed longterm survivors. we sought to define the prevalence of echocardiographic abnormalities in long-term survivors of pediatric hsct and determine the need for screening in asymptomatic patients. design/method: we analyzed echocardiograms performed on long-term survivors (≥ five years) who underwent hsct at cincinnati children's hospital between 1982 and 2006. we analyzed echocardiograms for left ventricular ejection fraction (ef), end-diastolic dimension (lvedd), septal thickness, posterior wall thickness, and global longitudinal strain (gls). we normalized linear measurements for age and patient body surface area. we included for further analysis patients who had echocardiogram obtained for routine surveillance. results: a total of 389 patients underwent hsct and were alive more than 5 years after transplant in 2017, with 114 having an echocardiogram obtained ≥ five years postinfusion. those with an echocardiogram were transplanted more recently (median 2003 vs. 1998 ). however, no difference between screened and unscreened individuals was noted for age at transplant, sex, transplant indication, anthracycline exposure, chest irradiation, or cyclophosphamide based preparative regimen. indications for echocardiograms included: cardiac symptoms 5 (4.4%), congenital cardiac anomalies 8 (7.0%), hypertension 2 (1.8%), known cardiac or pulmonary disease 2 (1.8%), routine post-hsct surveillance 95 (83.3%), and unknown 2 (1.8%). the mean time post-hsct was 11.7 years. among routine surveillance echocardiograms, the mean ef z-score was -0.97. mean lvedd zscore was -0.94, mean septal thickness z-score -1.00, mean posterior wall thickness z-score -0.98, and mean gls -21.96%. for patients that had echocardiogram performed for routine surveillance, 77/95 patients (82.1%) had ef measured, and 10/77 (13.0%) had ef z-scores ≤ -2.0 (abnormally low). patients exposed to anthracyclines had a mean z-score ef of -1.19 vs. unexposed patients -0.50 (p = 0.003). among individuals who received neither anthracyclines nor tbi only 1/31 (3.2%) was found to have an abnormal ef, 51.4% (z-score -2.73) or gls (-14.28%). only one patient who had a normal ejection fraction (z-score -0.39, ef 61.7%) had an abnormal gls, -15.9% (normal ≤ -16.0). long-term survivors of pediatric hsct who are asymptomatic and did not receive radiation or anthracyclines likely do not require surveillance echocardiograms, unless indicated by clinical symptoms. patients exposed to anthracyclines or tbi require close echocardiographic s277 of s301 screening and clinical monitoring for the development of cardiac complications. duke children's hospital, durham, north carolina, united states background: children undergoing pediatric blood and marrow transplants (pbmt) experience significant symptom distress. mobile health (mhealth) technologies can be leveraged to collect and monitor patient generated health data, and subsequently enhance our understanding of pbmt symptom clusters, patterns, and trajectories. better understanding of symptom complexity can foster development of precision health strategies to improve patient outcomes. however, limited research exists in integrating mhealth technology into pbmt management. we aimed to explore the feasibility, acceptability, and usability of using a pbmt specific mobile application to collect and monitor symptoms and wearable technology (apple watch) to measure objective data such as heart rate (hr) and activity. design/method: an exploratory mixed method design began in october 2017 to monitor pbmt symptoms for 20 patients using real-time data from: 1) a self-developed mhealth application (app) to collect subjective symptom data; and 2) apple watch to collect physiologic measures such as heart rate and number of daily steps. data is collected pre-transplant through 90 days. acceptability will be assessed through satisfaction surveys at study completion. we have enrolled 4 patients to date who are all currently using the app and watch. patients' average frequency of daily charting in the app 80%. the wearable average daily recorded measurements are 144 for hr and 29 for step count. most common symptoms recorded within the app include fatigue and pain. we have noted trends in data including a decrease in activity following transplant and gvhd and an increase following engraftment. patients have stated "the app is helpful to keep track of how my pain is doing day to day" and "i try to take more steps each day than the day before". patients often remove the watch for charging, then forget to put it back on, but consistently put it on upon reminder. finally, parents often were required to make app entries with patients too sick to record. we continue to enroll patients with enthusiasm from both patients and parents to use mhealth during pbmt. preliminary findings suggest feasibility of using the mhealth devices is strongly correlated to the patient's post-transplant stage and is facilitated by caregiver participation with device management (charging devices, reminders to wear watch and record in app). patients reported satisfaction and ease of use with devices, but found it difficult to keep up with charging and charting. these findings indicate using mobile devices may be useful methods to collect patient generated health data. cincinnati children's hospital medical center, cincinnati, ohio, united states background: bacterial bloodstream infections (bsi) are a common complication following hematopoietic stem cell transplantation (hsct) in both pediatric and adult populations, and are associated with poor outcomes. there is limited data describing the outcomes and characteristics of patients who develop three or more bsi after hsct. objectives: to describe the characteristics and outcomes of pediatric patients who develop three or more blood stream infections in the first-year post hsct. design/method: we performed a retrospective chart review of 373 consecutive patients who underwent hsct at our institution from 2011 through 2016 to compile this case series. data were collected through the first year post-hsct including: patient demographics, underlying disease and therapy characteristics; and transplant complications such as thrombotic microangiopathy (tma), graft versus host disease (gvhd) and overall survival. bsis were classified according to current center of disease control guidelines. results: of 373 patients, 18 (5%) developed 3 or more bsi in the first-year post transplant (total bsi cases = 77 including all patients). of the 18 cases, the majority underwent allogeneic hsct (n = 17/18; 94%). most cases were from unrelated donor (n = 15/18, 83%). more than half of patients had grade 2-4 gvhd (n = 11/18, 61%). sixteen (89%) had tma. of these 16 cases, tma preceded the first bsi in n = 10/16 (62%). the majority of bsis were classified as central line-associated bloodstream infections (clabsis, n = 37/77, 48%), followed by mucosal barrier injury laboratory-confirmed bloodstream infections (n = 29/77, 38%) and secondary bsi (n = 11/77, 14%). the majority of isolated organisms (45%) were associated with mucosal barrier injury pathogens. one-year overall survival in the cohort was 44% (n = 8/18). pediatric patients undergoing hsct who develop 3 or more bsis in the first-year post transplant demonstrated an increased rate of tma compared to the overall institutional incidence of roughly 30%. tma diagnosis preceded the first bsi in over half of patients, suggesting that tma may predispose to recurrent bsi. improved strategies for early detection and treatment of tma as well as prevention of clabsis may help reduce the number of bsis ultimately leading to decreased morbidity and mortality in this patient population. background: in neutropenic pediatric patients, infection remains a significant cause of morbidity and mortality. while granulocyte transfusions have been utilized for decades to treat infections, including in the pediatric population, the efficacy of this intervention remains poorly described. previous guidelines have primarily utilized information from adult populations. furthermore, recruitment of donors typically involves friends or relatives of the patient with periodic involvement of community donors. the use of a readily available local donor population to improve availability has yet to be well described. as the immunocompromised population is particularly susceptible to worsening infection and clinical deterioration, the ability to rapidly harvest and deliver granulocytes warrants further investigation. to investigate the efficacy, safety, and outcomes of severely immunocompromised patients receiving granulocyte transfusions from a local altruistic granulocyte program in a pediatric tertiary care center. design/method: a retrospective review was performed to evaluate the context for receiving a transfusion as well as primary outcomes including infection clearance, survival to discharge, and overall mortality. the indiana blood bank assisted with timing the interval from initial order placement to onset of first granulocyte infusion. results: among the patient population reviewed, 22 patients received 23 separate granulocyte regimens. ages ranged from 0-18 years with a mean neutrophil count of 77 at time of first transfusion. indications for transfusions included bacteremia (n = 11), fungal pneumonia (n = 6), and fungemia (n = 5). primary outcomes included clearing infection (70%) and surviving to discharge (57%). the median time from initial order placement to infusion was 46 hours, although there was no significant difference between responders who cleared the infection and non-responders who did not. however, additional investigation found that ward patients had a 75% chance of surviving to discharge while patients in the icu at time of initial transfusion had a 36% chance of survival to discharge. the readily available granulocyte transfusion program allows patients to quickly receive therapy in neutropenic settings. this is beneficial for patients as transfusion prior to clinical decompensation correlates with increased likelihood of infection clearance, and subsequently improved mortality. further investigation is needed, likely as a prospective study, to better explore circumstances that are beneficial for granulocyte transfusions. background: donor lymphocyte infusions (dli) are composed of immune cells to treat relapse after hematopoietic cell transplantation (hct). to date, data regarding its efficacy is limited in pediatric populations. furthermore, while outcomes related to cd3 content have been characterized, to our knowledge, the relationship between outcomes and other cellular content in dli has never been reported. objectives: determine whether the primary hematological malignancy, presence/absence of graft-versus-host disease s279 of s301 (gvhd), and unique phenotypic content of each dli impact overall survival (os) in pediatric patients with hematological malignancies. design/method: irb-approved, retrospective study investigating all consecutive dlis given to patients at the children's hospital of wisconsin. analyses were conducted using mann-whitney, fisher's exact, and chi-square. from 1980 from -2016 patients ≤20 years old with hematologic malignancies [myeloid (aml/ mds/cml/jmml),n = 23; lymphoid (all),n = 7] underwent 55 dlis (72%% ≥2 dlis). the median time between hct and dli was 0.6 (range, 0.1-5.8) years. there were significant differences between the lymphoid and myeloid groups, respectively, in regard to median age at hct (14.7 vs 7.5 yrs, p = 0.022) and at first dli (20 vs 8 years, p = 0.006). ultimately, there were no statistically significant differences in gvhd or os in products with either higher or lower cd3, cd4, cd8, cd56, or cd19 cellular content. however, the median cd3/kg content was more than double in the patients who developed gvhd as compared to patients who exhibited no gvhd after dli (29.99 × 106 vs 10.03 × 106, p = 0.346). patients receiving one dli had a 6-year os of 21 ± 9% vs those receiving 2+ dli of 52 ± 16% (p = 0.012). with a median follow-up of 0.74 (range, 0.04-16.61) years, the 6 year estimated os of patients in the lymphoid group was higher at 71 ± 17% vs 22 ±9% in the myeloid group, although not significant (p = 0.11). our results indicate a survival benefit when using dli in a subset of patients who relapse after hct. unlike adult studies demonstrating little effect of dli in lymphoid diseases, many children with all achieved durable remission. while our analysis did not demonstrate that dli cellular content had a statistically significant effect on gvhd or os, it is possible that differences could be found if a larger population and more targeted cell doses were studied. more data will be needed to further define these relationships and identify patients who stand to benefit most. cincinnati children's hospital medical center, cincinnati, ohio, united states background: many arabic speaking muslim parents of children requiring bone marrow transplantation (bmt) receive medical care in the united states. providers may not understand the impact of islamic parents' religious beliefs and practices on their health care experience. objectives: to explore how islamic parents used religion in decision making and to understand the impact of their religious beliefs and practices on their overall health care experience. design/method: we used grounded theory, an inductive method gathering data from interviews and analyzing text, to identify core themes. ten caregivers of bmt children from middle eastern countries were interviewed by an arabicspeaking provider; interviews were coded by an interdisciplinary team. we identified 5 key themes: 1. patience is a core belief in islam. patience results from the acceptance of allah's will. behaviors showing patience include praying rather than questioning and crying. 2. al qur'an provides comfort, healing, and protection. families listen to recitations of al qur'an in the patient's room because they feel that this practice not only comforts them but promotes healing as well. for some, certain portions of the qur'an were especially meaningful such as surat al-baqara, which explains that while we may think something is bad for us, allah will know it is good for us. 3. religious care in the medical center helped families feel respected. religious care in the medical center included interactions with chaplains, who were understood to be "religion experts," and provision of space for prayer and religious resources. 4. seeking religious consultation. religious consultation from imams or religious scholars (muftis or sheikhs) provides interpretations of the qur'an applied to the family's specific situation helps families make difficult decisions and follow allah's plan. 5. muslim beliefs guided decision making; muslim practices brought comfort, strength, and peace. drawn from the parents' understanding of islam. parents who addressed this topic said they would only do what islam allowed. they did indicate that most aspects of healthcare were understood to be allowed within islam. additionally, muslim practices of prayer, reading/listening to qur'an, and giving alms all provided comfort, strength and peace. we identified several recurring themes through our interviews that allowed us to understand how families use their muslim faith to deal with their children's illnesses and how it influences their decision making. we believe this better understanding will allow for more informed conversations about patients' health care and decision making, and shows respect for religious beliefs and practices. nemours/dupont hospital for children, wilmington, delaware, united states background: virtually all children will be infected with human herpesvirus 6 (hhv-6) by the age of two. hhv-6 reactivation after stem cell transplantation causes multiorgan toxicities, including encephalitis, with inflammation and destruction of the temporal lobes and hippocampi, memory loss, and seizures. catatonia is characterized by posturing, immobility, mutism, and autonomic instability, and it's associated with various psychiatric and medical conditions. we describe a patient with hhv-6 encephalitis and unusual neurologic sequelae, including cognitive and neurobehavioral dysfunction and catatonia, which may impact our understanding of the pathophysiology of hhv-6 reactivation encephalitis. objectives: describe a case of hhv6 encephalitis with practice implications for stem cell transplantation. results: our patient was diagnosed with acute myeloid leukemia at age 14. within 2 years, he relapsed and received two stem cell transplants. on the 29th day after his second transplant, he developed hyponatremia and refractory seizures. brain mri showed edema in the medial right temporal lobe with linear ischemic change. eeg showed diffuse encephalopathy. cerebrospinal fluid (csf) demonstrated 5 white blood cells, 2 red blood cells, and hhv-6 by pcr. his prophylactic antiviral was switched to foscarnet and ganciclovir. repeat mri showed abnormal signals in bilateral medial temporal lobes and the right insula. three months later he developed episodes of diaphoresis, hypothermia, agitation, mutism, and unusual posturing, recurring almost daily, recognized as catatonia. mri showed improvement of the abnormalities in the bilateral medial temporal lobes and hippocampi. eegs showed diffuse slowing. after 4 months of antiviral therapy, csf was negative for hhv-6. over the ensuing 3 years, he had numerous episodes of diaphoresis, hypertension, hypothermia, pruritis, confusion, agitation, cogwheel rigidity, and bizarre posturing. dopamine blocking agents did not help. clonazepam helped reduce their frequency, and hot showers helped break acute episodes. further mris showed generalized cortical volume loss. he suffered from depression and severely impaired sleep and cognitive function. we describe a novel, debilitating outcome of hhv6 encephalitis which may provide diagnostic considerations as we continue to improve our understanding of the breadth of possible neurologic sequelae in transplant patients. hhv-6 is understood to infect and destroy the temporal lobes and hippocampi, but our patient's autonomic dysfunction indicate involvement of the hypothalamus and basal ganglia. antidopaminergic agents may worsen catatonia, and they were not effective for our patient. treatment of catatonia includes benzodiazepines; electroconvulsive therapy was not attempted in this case but may also be useful. background: epstein-barr virus (ebv)-related posttransplant lymphoproliferative disorder (ptld) is a lifethreatening complication in patients following hematopoietic stem cell transplantation, with a frequency estimated at 3.2% and a cumulative incidence of mortality estimated as high as 31%. studies of ebv have hypothesized that the tonsils are critical for propagating this infection, as tonsillar epithelial cells have been shown to be the site of primary viral infection and continued viral shedding; however, to date no studies have been performed assessing the role of tonsillectomy in patients with ebv ptld. objectives: identify patients with localized ebv ptld treated with tonsillectomy to identify prognostic factors that may be able to help guide future treatment decisions. design/method: patients treated at memorial sloan kettering cancer center who had received hematopoietic stem cell transplantation and had billing codes for both ebv and tonsillectomy were eligible for inclusion in this study. a retrospective chart review was performed, assessing patient demographics, transplant characteristics, laboratory values, tonsillar pathology, and clinical course. any patient who did not have unilateral or bilateral tonsillectomy performed or who had non-localized disease (defined as disease involvement outside of the oropharynx and neck) was subsequently immunodeficiency; 17% (n = 17/100) fanconi anemia (fa); 17% (n = 17/100) hemoglobinopathy; 12% (n = 12/100) non-fa marrow failure and 3% (n = 3/100) a metabolic disorder. seventy one percent (n = 71/100) had normal amh for age pre-transplant, 29% (n = 29/100) had low amh for age pre-transplant; of these, 37% (n = 11/29) had an oncologic diagnosis; 37% (n = 11/29) had fa; 10% (n = 3/29) had previously treated hlh; 6% (n = 2/29) had non-fa marrow failure; one had a metabolic disorder and one a hemoglobinopathy. of the 33 patients with post-transplant amh measurement 72% (n = 24/33) had low levels. of the 25 patients with previously normal pre-transplant amh 52% (n = 13/25) underwent myeloablative conditioning (mac) regimen with a 100% (n = 13/13) having low amh levels post-transplant compared to 48 %(n = 12/25) who underwent reduced intensity conditioning (ric) regimen with 25% (n = 3/12) having low amh levels post-transplant (p 0.0002). fifteen percent (n = 5/33) had low levels pre-transplant and underwent mac regimen with 100% (n = 5/5) remaining low; 80% of these patients (n = 4/5) had fa. nine percent (n = 3/33) had low levels and underwent a ric regimen with 100% (n = 3/3) of amh levels remaining low; 66% (n = 2/3) of these patients had hlh treated prior to transplant. conclusion: amh levels can be used for detection of premature ovarian failure and fertility counseling. there is a higher risk of premature ovarian failure with mac regimens and prior chemotherapy vs ric regimens. follow up of this cohort will provide more information to understand the effects of hsct in ovarian function and the usefulness of amh as a predictor of fertility potential. background: there are no proven strategies to prevent blood stream infections (bsi) secondary to oral mucosal barrier injury after hematopoietic stem cell transplant (hsct). additionally, we recently reported progressive gingivitis and dental plaque accumulation in hsct recipients despite our current oral standard of care (three times daily oral rinse). xylitol is a non-fermentable sugar alcohol that reduces dental caries, plaque accumulation, and oral disease progression by inhibiting bacterial growth. we hypothesized that the addition of xylitol to standard oral care will decrease dental plaque accumulation, gingivitis and bacteremia from oral flora. objectives: identify a clinically effective strategy to improve oral health and prevent bsi secondary to bacterial translocation through the oral mucosa in patients undergoing hsct. we are conducting a prospective randomized control study to test our hypothesis. those in the intervention arm receive our current standard of care (three times daily oral rinse) in addition to daily xylitol wipes; controls receive oral standard of care alone. oral exams are performed at baseline and weekly for the first 28 days post hsct. metagenomic shotgun sequencing (mss) of gingival samples is performed at all time points to evaluate microbiome diversity and pathogenic bacterial load. finally, we performed whole genome sequencing of pathogenic bacterial isolates causing bacteremia to assess for genetic relatedness to corresponding strains present within the patient's oral microbiome preceding the infection. : preliminary interim analysis of 21 patients demonstrates improved oral health in patients receiving xylitol (n = 10) over those receiving standard of care (n = 11), measured by the oral hygiene index (p = 0.03) and gingivitis index (p = 0.02). in the nine patients having complete oral mss analysis, xylitol appeared to be associated with decreased streptococcus mitis/oralis domination in the oral microbiome. finally, patients receiving xylitol had no incidence of streptococcus mitis/oralis bacteremia through the first 21 days compared to three patients (27%) in standard of care arm. interestingly, streptococcus mitis/oralis comprised 70% of the oral microbiome in one child who subsequently developed a streptococcus mitis/oralis bsi. we expect to complete this study in the next 4 months (n = 50). the addition of xylitol to oral standard care appears to decrease dental plaque and gingivitis in patients undergoing hsct. xylitol may also impede streptococcus mitis/oralis dominance in the oral microbiome with potential reduction in blood stream infections. (range:4-159 days). twenty-one mdli (49%) were administered because of lymphopenia, fourteen of them (33%) in patients with concomitant viral/opportunistic infections. mixed chimerism/graft failure was the motive of 37% of the mdli (n = 16) and six (14%) were administered to accelerate immune reconstitution. all infusions were well tolerated without appearance or worsening of gvhd. an increase in t-cell counts was observed following six mdli (28.57%), although it was a transitory response (3-8 weeks) in five cases. viral/opportunistic infections were controlled in five cases (35.71%), requiring a median of 2 mdli to achieve this response. none of the mdli administered in cases of mixed chimerism/graft failure were effective in reverting this situation. our preliminary data suggests that mdli, is a safe adoptive immunotherapy strategy even with high dose of t-cells without infusion side effects or gvhd complications. some efficacy has been observed in patients with lymphopenia and opportunistic infections, with no positive results in patients with mixed chimerism/graft failure, up to date. however, to determine the real efficacy of this strategy, prospective studies are required. jun zhao, kristen beebe, lucia mirea, alexandra walsh, shane lipskind, alexander, ngwube phoenix children's hospital, phoenix, arizona, united states background: male adolescents undergoing myeloablative hematopoietic stem cell transplantation (hsct) develop infertility with impaired spermatogenesis with reported rates ranging from 17% to 80%. in nonmalignant diseases, myeloablative regimens have been replaced with reduced intensity conditioning (ric) with the hopes of better survival rate, less organ toxicity and improved quality of life. despite the increased use of ric regimens for hsct, the effects of ric on fertility remain unknown. objectives: to assess fertility following ric hsct in young adult males. we assessed gonadal function and semen characteristics in adolescent males (>14 years) who received a single ric hsct at phoenix children's hospital for nonmalignant diseases during 2006-2016. male patients who were a minimum of 1 year from ric hsct and had postpubertal development at tanner stage iii or above were eligible for this study. gonadal status was assessed by measuring fsh, lh, testosterone, and inhibin b levels, and semen anal-yses assessed fertility indicators (semen volume, sperm concentration, motility, viability, forward progression, morphology, and total count). results: hormone levels and semen analysis have been obtained for 3 patients thus far. the median time between transplant and semen analysis was 4 years. post hsct, 2 (67%) patients showed abnormally elevated lh levels, but fsh, testosterone (total and free), and inhibin b levels were within normal range for all patients. sperm morphology and viability testing were not able to be performed due to low concentrations and volumes. as a result, the total motile sperm count, the most useful estimate for fertile potential, is essentially 0 for all 3 patients. conclusion: recruitment is ongoing, but so far our limited results suggest that ric hsct may have detrimental longterm effects on male fertility. a multi-institutional trial may be appropriate due to small patient numbers at each institution. we are currently exploring options to expand to other centers. further consideration is warranted regarding decisions made by providers, ways to improve anticipatory counseling provided to patients and their families prior to transplant, and how to augment the preventive care of these patients in longterm follow-up. currently all male patients being considered for ric transplant should be counseled to sperm bank prior to transplant. background: a previous systematic literature review identified all published studies of defibrotide treatment for patients of all ages with vod/sos. to assess day+100 survival for defibrotidetreated pediatric patients (≤18 or ≤16 years, per study) all patients exhibited infectious complications with at least 1 viral infection. four patients also had bacterial infections. of note, no patient developed evidence of fungal infections. conclusion: early institution of ecp in patients with high risk acute gvhd (grade 3-4) was very effective at treating agvhd, allowed for an aggressive steroid taper and contributed to excellent overall survival rates (83%). infectious complications were primarily viral and bacterial, with no fungal infections in this very high risk population. background: vod/sos is a life-threatening complication of hsct conditioning. vod/sos with multi-organ dysfunction (mod) may be associated with >80% mortality. defibrotide is approved to treat hepatic vod/sos with renal/pulmonary dysfunction post-hsct in the us and severe hepatic vod/sos post-hsct patients aged >1 month in the eu. there are few published data on survival of neuroblastoma patients with vod/sos post-hsct. objectives: to report day+100 survival and safety post hoc for patients with neuroblastoma and vod/sos post-hsct in the defibrotide t-ind trial. design/method: vod/sos was diagnosed by baltimore or modified seattle criteria or biopsy, with/without mod, after hsct or chemotherapy. defibrotide treatment (25 mg/kg/day) was recommended for ≥21 days. this post hoc analysis is based on 1154 adult and pediatric patients receiving ≥1 dose of defibrotide, including 571 with mod. results: among 111 patients with neuroblastoma, 106 developed vod/sos after hsct. for these post-hsct patients, 60.4% were male and 39.6% were female, median age was 3 years (range 1-17 years): 7.6% aged 0-23 months, 90.6% 2-11 years, 0.9% 12-16 years, and 1 patient >16 years. day+100 survival data were available for 105/106 of these neuroblastoma patients (43 with mod and 62 without mod); 103 had autologous and 2 had allogeneic transplants. kaplan-meier estimated day+100 survival for the neuroblastoma group was 87.2% (95% confidence interval [ci] , 79.0%-92.4%). for the mod and no mod subgroups, kaplan-meier estimated day+100 survival was 78.4% (95% ci, 62.6%-88.2%) and 93.5% (95% ci, 83.6%-97.5%), respectively. in the overall t-ind hsct population aged ≤16 years (n = 570) and pediatric autologous hsct subgroup (n = 127), kaplan-meier estimated day+100 survival was 67.9% and 87.1%, respectively. treatment emergent adverse events (teaes) occurred in 45.3% (n = 48/106), with serious teaes in 23.6% (25/106; most common: multi-organ failure, 4.7% [5/106]). teaes lead to treatment discontinuation in 17.0% (n = 18; most common: pulmonary hemorrhage, n = 3); death occurred in 10.4% (n = 11; >2%: multi-organ failure, 4.7%; vod/sos, 2.8%). treatment-related adverse events, as assessed by investigators, occurred in 17.0% (n = 18; most common: pulmonary hemorrhage, 2.8%). this post hoc analysis found kaplan-meier estimated day+100 survival of 87.2% in patients with neuroblastoma and vod/sos post-hsct, which was consistent with outcomes in pediatric patients after autologous hsct. the safety profile of defibrotide in neuroblastoma patients was consistent with the overall hsct population in this study and other defibrotide studies in pediatric patients. cincinnati children's hospital medical center, cincinnati, ohio, united states background: blood stream infections occur in nearly 30% of patients undergoing hematopoietic stem cell transplant (hsct) and fever is often the first symptom. timely administration of antibiotics is associated with improved outcomes, thus, early recognition of fever is paramount. current standard of care (soc) includes episodic monitoring of temperature in hospitalized patients, which may delay fever detection. therefore, continuous real-time body temperature measurement may detect fever prior to the current soc. temptraq is a food and drug administration cleared class ii medical device and consists of a soft, comfortable, disposable patch that results: of 100 patients, 98 were started on a pca in the 30 days post hct. 65% were male with median age of 11y. 46% had all, and 37% aml. matched related donors were used in 21% and 79% received tbi. pca was initiated median d+2. oral mucositis alone was the most common indication (80%). a majority of patients were started on hydromorphone (79%); 20% started on morphine and 1% started on fentanyl. 49% started on continuous infusion. pca was used for a median of 20 days (range 4-144 days). median pain score was highest d+3 of pca use, however, there was inconsistency in charting of numerical pain scores. on d+3, 12 patients had insufficient data to determine efficacy of pain control; of the remaining 86 patients, 24% had good pain control while 60% had moderate and 15% had poor pain control using our devised scale. the most common toxicity observed was respiratory depression (∼30%), however, etiology was often multifactorial and not due to opiates alone. analysis is ongoing to assess variables predicting pca use as well as efficacy of pain control and correlation between current reporting scales and patient perception. conclusion: pca use is common in pediatric hct yet pain control remains inadequate. there's a need for better evaluation of pca management, especially uniform assessment of pain, thereby improving quality of life post hct. children's national health system, washington, district of columbia, united states background: actinomycosis is a rare invasive anaerobic gram-positive bacterial disease caused by actinomyces spp. that may colonize the oropathynx, gastrointestinal tract and urogenitial tract and can lead to abscesses. respiratory tract actinomycosis is characterized by pulmonary cavities, nodules, consolidations and pleural effusions. although actinomyces are nearly always sensitive to penicillin they are frequently resistant to cephalosporins and variable sensitives to fluoroquinolones. although rare in children, immunosuppressed patients are at increased risk for actinomycosis. to describe a case of next-generation sequencing identification of actinomycosis. a 13-year-old male with a history of very high risk b-cell acute lymphoblastic leukemia who was 5 months status post a 7/8 matched unrelated donor bone marrow transplant complicated by prolonged fevers, persistent weight loss, and splenic lesions, treated with posaconazole and levofloxacin developed fever and cough in the setting of neutropenia. blood cultures demonstrated staphylococcus epidermidis. ct showed micronodules and effusion not consistent with s. epi, prompting bronchoscopy. all bacterial cultures were negative. patient was prescribed a three-week course of vancomycin with rapid improvement. design/method: 16s next generation sequencing (ngs) from bronchoalveolar levage sample was performed at the university of washington laboratory results: ngs assay from bronchoalveolar lavage showed major abundance of actinomyces most closely related to meyeri or oodontolyticus. demonstrated actinomyces. the patient was started on a six month course of amoxicillin with continued clinical improvement. in retrospect, the splenic nodules that were presumed fungal disease were likely actinomycosis, partially treated with levofloxacin. this case highlights the potential utility of ngs in the diagnosis of rare diseases in immunocompromised patients. actinomycosis was only demonstrated through ngs and led to a change in treatment regimen and durable clinical improvement. because actinomyces often mimics malignancy, tuberculosis or nocardiosis, the use of this novel test both targeted appropriate therapy and reduced the exposure to unnecessary medications to treat the differential diagnosis. finally, we highlight that actinomyces should be considered in patients who present with unexplained fevers, weight loss, and night sweats. haneen shalabi, cynthia delbrook, maryalice stetler-stevenson, constance yuan, bonnie yates, terry j. fry, nirali n. shah center for cancer research, national cancer institute, national institute of health, bethesda, maryland, united states background: car-t therapy, while effective, may not be durable for all, and antigen negative escape is a growing problem. hct, in relapsed/refractory all, can be curative, particularly for those in an mrd negative remission. we demonstrated that cd19 directed car-t therapy effectively rendered patients into mrd negative remissions (by flow cytometry) and the leukemia free survival post-hct was high 1 . in pastorek, jesssica bruce, michael a. pulsipher, chloe anthias, peter bader, andre willasch, jennifer sees, jennifer hoag, wendy pelletier, brent logan, pintip chitphakdithai, lori wiener university of pittsburgh, pittsburgh, pennsylvania, united states background: more than 4,500 pediatric hscts are performed in north american and europe each year. the ethics of exposing a healthy child to donation procedures which have some risks and no direct medical benefits continue to be a topic of debate. pediatric donors may experience psychological distress and poorer quality-of-life during and after donation compared to healthy controls. although there are fact/jacie requirements related to the management of pediatric donors, it is unclear what standardized practices exist for psychosocial assessment/management of this group. objectives: to describe transplant center practices for psychosocial evaluation/ management of pediatric donors (<18 years) and to examine differences in practices by location (cibmtr/ebmt) and number of harvests (volume). design/method: data were collected via a single crosssectional survey distributed electronically to cibmtr and ebmt centers between 9/18/17 and 11/20/17. : 55/98 (56%) of cibmtr and 85/147 (58%) of ebmt centers completed the survey. most centers had written eligibility guidelines for pediatric donors (91%). most also had a process for ensuring that donors were freely assenting to donate (78%), managed by a transplant physician (61%). a single physician often jointly managed donor/recipient care (44%). half of centers had a pediatric donor advocate (51%), who was most often a physician (38%) or social worker (16%). cost was the largest barrier to having a donor advocate (82%). most centers performed psychosocial screening of donors (69%) but rarely declined donors based on psychosocial concerns (13%). less than half of centers provided post-donation psychosocial follow-up (41%). comparisons by center location indicated that ebmt centers were more likely to have a physician doing joint donor/recipient care (60% vs. 23%; p = .001), less likely to have a psychosocial assessment policy (53% vs. 79%; p = .011), less likely to have a donor advocate (37% vs. 69%; p = .002), but marginally more likely to do post-donation psychosocial follow-up (49% vs. 31%; p = .063). large volume centers were more likely to have a psychosocial assessment policy than their medium/smaller counterparts (69% vs. 23%, 27%; p = .003) â€"there were no other differences on key psychosocial management variables by volume. although most centers have written guidelines for pediatric donor eligibility and mechanisms for ensuring assent, substantial numbers of donors do not undergo psychosocial assessment, are jointly managed with the recipient by a single physician without an assigned donor advocate, and do not receive psychosocial follow-up. the field would benefit from guideline development for the psychosocial management of pediatric donors. background: germline mutations in samd9 and samd9l genes cause mirage (myelodysplasia, infection, restriction of growth, adrenal hypoplasia, genital phenotypes and enteropathy) and ataxia-pancytopenia syndromes, respectively, and are associated with chromosome 7 deletions, mds and bone marrow failure (bmf). there are limited data on outcomes of hct in these patients. to describe outcomes of allogeneic hct in patients with hematologic disorders associated with samd9/samd9l mutations. results: seven patients underwent allogeneic hct for primary mds (n = 5), congenital amegakaryocytic thrombocytopenia (camt)(n = 1), and dyskeratosis congenita (n = 1). retrospective exome sequencing revealed gain-of-function mutations in samd9 (n = 4) or samd9l (n = 3) genes. constitutional mosaic monosomy 7 was present in 6 cases. two samd9 patients had features of mirage syndrome. unusual findings of panhypopituitarism, laryngeal cleft, and glomerulosclerosis were noted in one case. in another case with a samd9 mutation hypospadias & bifid scrotum were the only findings. the remaining patients had no phenotypic abnormalities. median age at hct was 5y (range: 1.4 -12.8). patients received transplants from bone marrow (matched unrelated (n = 3) & hla identical sibling (n = 2)), or unrelated cord blood (ucb) (n = 2). five mds patients received myeloablative s295 of s301 conditioning (busulfan-based (n = 3) or tbi-based (n = 2)); 2 patients (mds (n = 1); camt (n = 1)) received reducedintensity conditioning (ric) (fludarabine, cyclophosphamide, with ratg or alemtuzumab). syndrome-related comorbidities (diarrhea, infections, malnutrition, electrolyte imbalance, lung disease and hypoxia) were present in both patients with mirage syndrome. one patient with a familial samd9l mutation, mds and morbid obesity failed to engraft following ric double ucbt. she died one year later from refractory aml. all other patients achieved neutrophil and platelet engraftment, at a median (range) of 15 (12-19) and 16 (12-31) days, respectively. posttransplant complications included severe hypertension (n = 1), pericardial effusions (n = 2), veno-occlusive disease of liver (n = 1), and recurrent aspiration pneumonias (n = 1). one patient developed grade iii agvhd which resolved with treatment. one patient developed mild skin cgvhd and suffers from chronic lung disease. all surviving patients had resolution of hematological disorder and sustained peripheral blood donor chimerism (98-100%). overall survival was 86% with a median follow-up of 3 years (range: 1.1 -14.7 y). patients with hematological disorders associated with germline samd9 /samd9l mutations tolerated transplant conditioning without unusual, or unexpectedly severe toxicities. allogeneic hct led to successful resolution of mds or bmf, with excellent overall survival. more data is needed to refine transplant approaches in samd9/samd9l patients with significant comorbidities, and develop guidelines for their long-term follow-up. shyamli singla, tiffany simms-waldrip, andrew y. koh, victor m. aquino background: steroid-refractory acute graft versus host disease (agvhd) is a potentially fatal complication of allogeneic hematopoietic stem cell transplantation (hsct). basiliximab (anti-il2-r monoclonal antibody) as a single agent or in combination infliximab (anti-tnf-monoclonal antibody) has demonstrated efficacy in adult cohorts with steroid-refractory agvhd, but has not been well studied in the pediatric population. we adopted the use of basiliximab and infliximab as our institutional standard of care for steroid-refractory agvhd in pediatric hsct patients. to determine the response and survival of hsct children who received basiliximab and infliximab for the treatment of steroid-refractory agvhd. design/method: we retrospectively reviewed children who received basiliximab and infliximab for steroid-refractory agvhd refractory between september 2011 and december 2017. complete response (cr) was defined as resolution of all clinical signs of agvhd. partial response (pr) was defined as at least one grade reduction in one target organ (e.g. skin, gut or liver) without increased grade in another target organ. no response was defined as either no improvement or progressive worsening of agvhd in at least one organ. baseline demographics, transplant details, laboratory findings, and treatment outcomes were also evaluated. results: of the 214 evaluable hsct patients, 15 children (median age 11 yrs, range 9 mo-19 yrs) with steroid-refractory agvhd received combination monoclonal antibody (mab) therapy. the median time from the start of steroid therapy to initiation of mab was 13 days. the overall glucksberg grade of agvhd at the time of initiating mab therapy was grade i (n = 1, 6.7%) ii (n = 3; 20%), iii (n = 8; 53%) or iv (n = 3; 20%). the overall response rate was 53%, with 3 (20%) patients achieving cr, 5 (33.3%) patients achieving pr, and 7 (46.7 %) patients with no response at 30 days following the start of mab therapy. the median overall survival was 613, 292, and 84 days for patients who exhibited cr, pr, and no response, respectively. the overall survival at 1 year following start of mab therapy was 40%. background: the role of high dose chemotherapy (hdc) and autologous stem cell rescue (ascr) in patients with high risk (advanced metastatic or relapsed) soft tissue sarcomas is controversial. despite multimodal chemotherapy, radiotherapy, and local control measure advancements, prognosis of patients with advanced metastatic or unresectable and relapsed sarcomas remains poor, with less than 10% 5 years disease free survival. objectives: to determine if consolidation with myeloablative hdc and ascr improves relapse free (rfs) and overall survival (os) outcomes in a high risk patient subgroup. we performed retrospective review of all high risk soft tissue sarcoma patients who underwent hdc and ascr at the children's hospital at montefiore, bronx, ny between october 2014 and january 2018. the protocol was approved by albert einstein college of medicine institutional review board. results: 7 patients (4 primary metastatic high risk disease, 3 relapsed or recurrent disease) received hdc with ascr. primary diagnoses were rhabdomyosarcoma (rms) (n = 2, alveolar histology), primary site nasopharynx (n = 1) and lower extremity (n = 1). ewing's sarcoma (ews) (n = 5), axial site (pelvic) in 3 patients (60%). median age 12 years (range 6-35 years), 5 (71%) were male. all patients were in complete metabolic remission before transplant. median pre transplant comorbidity index was 3 (range 0-4). 5 patients (2 rms and 3 ews) received conditioning with carboplatin, etoposide and melphalan. remaining 2 patients with ews received conditioning with busulfan, melphalan and topotecan. all patients received peripheral blood mobilized hematopoietic stem cell transplantation. stem cell mobilization achieved with high dose filgrastim in all patients except one who required addition of plerixafor. median cd34+/kg s297 of s301 recipient body weight cell dose infused was 6.34 × 10^6 (range 2.72-12.03 × 10^6). median times to neutrophil and platelet (>20,000/â l) engraftment were 9 (range 8-13) and 49 (20-76) days respectively. 2 patients (28%) developed bk viuria (one with grade iii hemorrhagic cystitis); 3 (43%) developed cmv viremia; and one patient (14%) had asymptomatic ebv viremia. there was no graft failure, sinusoidal obstruction syndrome or transplant related mortality. median follow up post-transplant was 452 days (range 155-1141 days). 3 year probability of os and rfs were 80% and 50% respectively. hdc with ascr is a promising therapeutic strategy to consolidate remission and improve survival in select high risk soft tissue sarcoma patient subgroups. prospective clinical trials will inform the impact of disease status prior to hdc and ascr on outcome, optimal conditioning and long term relapse free and overall survival. background: absence of minimal residual disease is paramount for cure of pediatric acute lymphoblastic leukemia (all). the testis may harbor occult leukemia and this disease may result in treatment failure. objectives: the purpose of this study was to assess the longterm outcomes of boys with or without testicular leukemia pre-hematopoietic stem cell transplantation (hsct). design/method: retrospective analysis of 16 boys with high-risk de novo (2 with hypodiploidy all) or recurrent/refractory all was conducted. flow cytometry of bone marrow mononuclear cells was used to determine remission status. testicular evaluations were performed by physical examination and wedge biopsy pre-hsct. the median age at time of transplant was 12.3 years. all patients were in remission by flow cytometry of bone marrow mononuclear cells at the time of transplant and none had evidence of clinically apparent testicular disease. testicular leukemia was detected in 1 patient and he underwent bilateral orchiectomy. he developed acute graft versus host disease (gvhd) of the duodenum and sigmoid colon which resolved, and the leukemia remains in second complete remission and he is free of hsct-related morbidity 33.6 months post-hsct. of the 15 patients without testicular leukemia 4 died a median of 8.2 months (range, 2.5 to 12.5) post-hsct (2 with adenovirus infection and 1 each with thrombotic microangiopathy and aspergillus pneumonia); 6 experienced infection (staphylococcus species, corynebacterium, enterococcus, klebsiella, citrobacter, e. coli, epstein barr virus, adenovirus, bk virus, human herpesvirus-6, candida albicans, fusarium, aspergillus, yeast, and other fungus); 11 experienced gvhd (8 of the gi tract, 6 of the skin, 5 of the liver, 3 of the eyes, 2 of the mouth, and 1 of the lungs); and 1 developed a second neoplasia (right lower leg leiomyosarcoma). one patient developed bone marrow minimal residual disease (2.7% phenotypically abnormal cells detected 9 months after 6/6 matched sibling hsct). reinduction therapy comprised 5 weekly doses of rituxan, 2 courses of blinatumomab and 2 donor lymphocyte infusions with il-2. two subsequent bone marrow evaluations were minimal residual disease negative. thirteen months post-hsct residual disease recurred (0.012%) and he will receive inotumumab. overall median survival post-transplant of the 16 boys is 32.1 months (range, 2.5 to 75.3) and of the 12 surviving boys is 37.3 months (range, 11 to 75.3). conclusion: testicular biopsy can detect occult leukemia pre-hsct. testicular leukemia pre-hsct does not appear to increase the risk of subsequent relapse or other hsct-related adverse events compared to those without it. yaya chu, nang kham su, sarah alter, emily k. jeng, peter r. rhode, mathew barth, dean a. lee, hing c. wong, mitchell s. cairo new york medical college, valhalla, new york, united states background: rituximab has been widely used in frontline treatment of b-nhl including burkitt lymphoma (bl), however, some patients retreated with rituximab relapse, which limit patient treatment options. novel therapies are desperately needed for relapsed/refractory b-nhl patients. several strategies for overcoming rituximab-resistance are currently being evaluated, including engineering immune cells with chimeric antigen receptors (car), as well as second-generation anti-cd20 antibodies. nature killer (nk) cells play important roles in the rejection of tumors. however, nk therapy is limited by small numbers of active nk cells in unmodified peripheral blood, lack of tumor targeting specificity, and multiple mechanisms of tumor escape of nk cell immunosurveillance. our group has successfully expanded functional and active peripheral blood nk cells (expbnk). 2b8t2m was generated by fusing alt-803, an il-15 superagonist, to four single-chains of rituximab. 2b8t2m displayed tri-specific binding activity through its recognition of the cd20 molecule on tumor cells, activated nk cells to enhance adcc, and induced apoptosis of b-lymphoma cells. objectives: to examine if 2b8t2m significantly enhances the cytotoxicity of expbnk against rituximab-sensitive and -resistant bl cells. design/method: expbnks were expanded with lethally irradiated k562-mbil21-41bbl and isolated using miltenyi nk cell isolation kit. alt-803 and 2b8t2m were generously provided by altor bioscience. nk receptors expression and cytotoxicity were examined as we previous described. ifng and granzyme b levels were examined by elisa assays. equal doses of rituximab, alt-803, rituximab+alt-803, obinutuzumab (obinu) were used for comparison. igg was used as controls. anti-cd20 car expbnk cells were generated as we previously described by mrna electroporation. rituximab-sensitive raji andresistant bl cells raji-2r and raji-4rh, were used as target cells. results: 2b8t2m significantly enhanced expbnk cytotoxicity against rituximab-sensitive raji cells, rituximab-resistant raji-2r cells and resistant raji-4rh cells compared to the controls igg, rituximab, alt-803, rituximab+alt-803, obinu (p<0.001, e:t = 1:1). furthermore, we confirmed the enhanced cytotoxicity by measuring ifn-g and granzyme b production. 2b8t2m significantly enhanced ifn-g and granzyme b production from expbnk against raji, raji-2r and raji-4rh compared to igg (p<0.001), rituximab (p<0.001), alt-803 (p<0.001), rituximab+alt-803 (p<0.001), and obinutuzumab (p<0.001). when compared to anti-cd20 car expbnk cells, 2b8t2m + expbnk had the similar cytotoxicity against raji, raji-2r and raji-4rh as anti-cd20 car expbnk cells did (p>0.05). conclusion: 2b8t2m significantly enhanced expbnk activating receptor expression and in vitro cytotoxicity against rituximab-sensitive and -resistant bl cells. the in vivo functions of 2b8t2m with expbnk against rituximab-sensitive and -resistant bl cells using humanized nsg models are under investigation. background: cardiac dysfunction, including left ventricular systolic dysfunction (lvsd), is a known complication in stem cell transplant (sct) survivors. while detection of lvsd by echocardiography is important in this population, there has been minimal research to determine if subclinical cardiac dysfunction exists in sct patients. cardiopulmonary exercise testing (cpet) is a valuable tool to assess cardiac function, and to determine how the heart responds to the stress of exercise. no studies have been performed to determine if sct patients with normal lvsd on standard echocardiography may have abnormal cpet. to determine the feasibility of cpet, as well as additional echocardiographic parameters, to detect dysfunction in sct patients with a normal ejection fraction on echocardiogram. design/method: we performed a cross-sectional analysis of sct survivors who were at least 3 years post sct, 8 years of age or older and with an ejection fraction > 50% (low end of normal range) on echocardiogram. we assessed the exercise capacity of all patients with cpet, and sub-clinical cardiac dysfunction through tissue doppler and strain analysis from the echocardiogram. results: seven patients (6 male) have qualified and completed this study so far with an average age of 12.2±3.4 years. the median time from transplant is 4.4±0.8 years. all seven patients had a normal ejection fraction, however four patients had abnormalities on their cpet. these abnormalities included abnormal predicted peak oxygen consumption (vo2) (61%±9.8, normal > 70%) (the best predictor of functional capacity), predicted oxygen pulse (62%±10.1, normal > 70%) (measure of cardiac stroke volume) and ventilatory efficiency (ve/vco2 slope) (39±7.6, normal < 30). submaximal exercise data, used when patients are unable to complete a maximal effort test, demonstrated low-normal predicted vo2 at anaerobic threshold (45.8%±7.2%, normal >45% of was 19.4 days while patients who received autologous infusions had a mean number of days to engraftment of 13.3. engraftment after hsct needs to be prompt to minimize duration of neutropenia and maximize survival rates 6 . our data demonstrates that the infusion of hematopoietic stem cell products with a syringe or iv pump is an effective method of delivery for stem cell products and does not delay the time to engraftment. the median days to neutrophil engraftment was 14.5 days. this is comparable to data from the nmdp, which reports engraftment occurs within 14-20 days. the main limitation to this study was its small sample size due to the number of transplants done at our center. however, it does provide evidence to support that infusion of stem cell products via pump mechanism is a safe alternative to the infusion by gravity method in the process of the hematopoietic stem cell administration. johns hopkins all children 's hospital, st. petersburg, florida, united states background: leukemic relapse remains the most common cause of treatment failure after allogeneic hematopoietic cell transplant (allohct) for myeloid malignancies. most children who relapse post-allohct will die of their disease, making interventions to minimize this risk a high priority. objectives: to evaluate the safety and efficacy of posttransplant azacitidine for relapse prevention in children undergoing allohct for myeloid malignancy. design/method: we retrospectively reviewed the charts of children undergoing allohct for myeloid malignancies between february 2015 and november 2016 at johns hopkins all children's hospital. results: during the study period, 18 children (ages 2 to 20 years, median 12) underwent allohct for myeloid malignancies: de novo acute myeloid leukemia (aml), 11; mixed phenotype acute leukemia, 2; treatment-related aml, 2; juvenile myelomonocytic leukemia with aml transformation, 2; and myelodysplasia/aml, 1. thirteen were in first complete remission, 5 were in cr2 or greater. most patients (13/18) received fludarabine/melphalan/thiotepa conditioning; 11 received hla-identical related or unrelated donors, and 7 received haploidentical bone marrow grafts with post-transplant cyclophosphamide. three patients never received planned azacitidine (2 early relapse; 1 early trm), leaving 15 evaluable patients. azacitidine (32mg/m 2 /dose for 5 days, in 28-day cycles for up to 9 cycles) was started at a median of 66 days post-transplant (range 42-118). two-thirds (10/15) of patients received eight or more cycles. of five patients who stopped therapy early, only one was due to toxicity; other reasons included severe gvhd (1), parental preference (1), and relapse (2). cycle delays occurred in 9 patients, with a median 2 cycles delayed per patient, mostly for mild myelosuppression with early cycles. no patient required blood product transfusion during therapy, but g-csf was used in three patients to maintain anc>500/ l. dose-modifications were made in 3 patients (renal tubular acidosis, acute kidney injury, and myelosuppression). there were 3 relapses (20%), two of which occurred in patients in cr2, for a relapse incidence of 9% in patients in cr1, with a median follow-up of 20 months (range 12.5 to 28). no patients who received azacitidine died of transplant-related mortality. conclusion: administration of azacitidine in children undergoing allohct for myeloid malignancies is safe and feasible, with most patients successfully receiving all planned cycles. toxicity was acceptable and there was no trm or secondary graft failure. despite the limitations of a small cohort, relapse incidence-particularly in patients transplanted in cr1suggests a potential benefit in disease control that warrants investigation in follow-up studies. background: despite significant improvements in the success rate of hematopoietic cell transplantation (hct), graft failure remains an important complication in patients transplanted for severe aplastic anemia (saa). second allogeneic hct can salvage patients, but 5-year overall survival (os) rates have been reported as low as 60% 1 . objectives: identify patients who developed dropping donor chimerism, graft rejection, and/or graft failure after first hct for saa, necessitating additional hcts or cellular boosts (defined as stem cell products infused without preceding chemotherapy), and evaluate treatment-related complications and os. with vod/sos with and without multi-organ dysfunction (mod) pubmed and embase databases were searched for "defibrotide and retrospective chart reviews; excluded publication types were: case reports (<10 cases); meta-analyses; reviews; animal, modeling, pharmacokinetic, chromatography, and adult-only studies; guidelines; articles; and letters. resulting reports were screened for exclusion criteria. full-text articles were then reviewed for eligibility. study characteristics of selected publications were summarized, and publications were categorized by patients' mod status. when necessary, additional data tables were requested. a random effects model was used for pooling data for efficacy. interstudy heterogeneity was assessed with cochran's q-test. percentage of total variation across studies due to heterogeneity (i2) was evaluated we quantified ∼4300 proteins in each sample. reproducibility for one donor at 3 different time points children 's minnesota, minneapolis, minnesota, united states background: pediatric and young adult hodgkin lymphoma (hl) has five-year survival rates >90%. chemotherapy required to achieve this rate is associated with a lifetime risk of cardiac deaths, second malignancies, pulmonary disease and infertility. as effective salvage therapy exists, outcomes may be improved by de-intensifying initial therapy to lessen toxicity.objectives: we piloted a regimen in low and intermediate risk hl patients using agents without known association to significant late effects. this retrospective chart review was approved by children's minnesota irb.design/method: the bvg(p) regimen incorporated bortezomib (1.3 mg/m2 day 1,4,8,11); vinorelbine (25 mg/m2 day 1,8); gemcitabine (1000 mg/m2 day 1,8) every 21 days and prednisone (20 mg/m2/dose bid x 11 days). we treated 5 newly diagnosed patients, ages 10-18 years, with non-bulk stage iia (n = 4) or iib (n = 1) hl. two patients received bvg and 3 received bvgp with the addition of prednisone.results: newly diagnosed patients were all pet negative after the first or second cycle and remained pet negative at end of therapy, 4 cycles. nausea was well controlled with 5-ht3 antagonists and scopolamine. pegfilgrastim was not necessary due to the high absolute neutrophil count nadir [median 1.16 and minimum 0.56 × 109/l]. there were no episodes of febrile neutropenia, infection or transfusion need. no patients experienced alopecia. one patient developed sensory neuropathy after the eighth dose of bortezomib that was controlled with gabapentin and a switch to subcutaneous bortezomib administration. of the five newly diagnosed patients, four remain in remission at 227, 270, 557, 1191 days; 1 relapsed at previous disease sites at 861 days and subsequently achieved remission with bvgp with the addition of brentuximab. this series provides early evidence to stimulate expansion of this pilot experience and subsequent multiinstitutional study leading to a randomized trial of bvgp and current chemotherapy for low and intermediate hl. st jude affiliate clinic at st francis hospital, tulsa, oklahoma, united states background: symptoms suggestive of morning hypoglycemia has been noticed in children receiving all chemotherapy. only few small studies looked at this therapy related complication. factors increase risk of hypoglycemia in all patients include accelerated starvation, steroid induced adrenal suppression, mercaptopurine therapy and prolonged fasting for procedures.objectives: to study the prevalence and risk factors for hypoglycemia during all therapy design/method: medical records of of children (up to 18 years old) treated for all between 2011-2016 (86 patients) were studied for evidence of morning hypoglycemia defined as blood sugar (bs) < 60 mg/dl. statistical mean differences between the subgroups were analyzed with spss using a nonparametric mann-whitney u test.results: fifty two percent (52%) of patients developed hypoglycemia during all treatment, with an average of 2.2 episodes/patient. 59% were males and 41% females. almost 2/3 (65%) of patients with hypoglycemia were in maintenance phase of therapy. 34% of hypoglycemic episodes occurred in 10% of patients. majority of hypoglycemic episodes (78.2%) occurred on the day of procedure when patients were fasting overnight. 48.9% of hypoglycemic episodes occurred in children ≤3 years, with 75.8% in ≤6 years. patients who developed hypoglycemia were significantly younger (mean age at time of diagnosis of all was 4.93 ± 3.69 at the hypoglycemia group versus the non-hypoglycemia (7.27 ± 4.98) p<0.05. no statistically significant difference was found regarding sex, or tpmt genotype. 6% of hypoglycemic children-all <3years of age-presented with life threatening hypoglycemia symptoms including seizure and loss of consciousness. this study showed high prevalence of hypoglycemia during childhood all therapy. younger age, especially ≤ 3 years, is associated with higher risk of hypoglycemia as well as life-threatening episodes. to decrease fasting hypoglycemia during therapy for childhood all, we recommend that children under the age of 6 years receive bed time snack high in proteins and complex carbohydrates, and to get them up early the day of procedure to take clear sugary drink. hospital for sick children, toronto, ontario, canada ann & robert h. lurie children's hospital of chicago, chicago, illinois, united states background: childhood brain tumors are the most common solid malignancy and the leading cause of cancer-related mortality in children. the most aggressive type of pediatric central nervous system (cns) tumors is diffuse intrinsic pontine glioma (dipg). despite decades of clinical trials, there has been no substantial improvement with respect to therapeutic outcomes with most children eventually succumbing to the disease. research on adult high-grade gliomas has shown a targetable pathway through the inflammationinduced expression of indoleamine 2,3 dioxygenase 1 (ido1) and its recognized ability to suppress the anti-tumor immune response. a limited understanding into the role of ido1 in pediatric central nervous system tumors serves as the foundation of this research project. furthermore, the integration of nanotechnology is a fundamental step for the investigation and targeting of ido1. spherical nucleic acids (snas) composed of nanoparticles have been shown to transverse cellular membranes, exhibit stability in physiological environments, escape from degradation, and create precise targeting in brain tumors.objectives: the purpose of our project is to delineate the role of ido1 in pediatric dipg, and develop small inhibitory (si)rna oligonucleotides and snas aimed at therapeutically inhibiting the gene expression of immunosuppressive ido1. our specific aims are to: (1) confirm the gene expression ido1 in different human dipg cell lines; (2) generate and characterize sirna oligonucleotides targeting human ido1 in vitro; and (3) generate and characterize gold nanoparticles for targeted inhibition of ido1.design/method: unique patient-derived dipg cell lines were grown in culture, stimulated with increasing concentrations of the proinflammatory cytokine, ifn , and analyzed for mrna levels. sirna specific to ido1 was transfected into cells. sna generation is in progress.results: ido1 is expressed in multiple human pediatric dipg cell lines. sirna targeting ido1 among exons 9 and 10 results in a significant decrease in overall ido1 expression by dipg cells. sna generation for targeting ido1 with improved penetration & stability is ongoing, with preliminary results demonstrating a robust ability to inhibit ido1 expression. the grim prognosis of children with dipg, the lack of effective therapies, and the expression of ido1 by human dipg cells emphasize the importance of developing the treatment capability to inhibit ido1 gene expression, as a excluded from this study. the remaining patients were analyzed using descriptive statistics.results: a total of 17 patients meeting inclusion criteria were identified. of these, 4 patients (23.5%) received tonsillectomy alone, 1 (5.9%) underwent tonsillectomy and decreased immunosuppression, 6 (35.3%) received tonsillectomy and rituximab, and another 6 (35.3%) received tonsillectomy with additional therapy (including ebv-specific cytotoxic tlymphocytes, donor leukocyte infusion, and chemotherapy). of the 5 patients who received tonsillectomy with or without a decrease in immunosuppression, all were diagnosed with high-grade lymphoma and achieved clinical remission following tonsillectomy with no evidence of relapse to date. on further analysis looking at ptld risk factors, all patients were under 50 years of age, all received t-cell depleted grafts, and none had significant graft-versus-host disease (gvhd) at the time of ptld diagnosis. we have identified a population of patients with localized ebv ptld that achieved clinical remission with no evidence of recurrence following tonsillectomy, suggesting that tonsillectomy alone may be an adequate treatment for localized ebv ptld in a specific subgroup of patients. further analysis is needed to identify characteristics of this subgroup to determine which patients would be most likely to respond to this treatment. university of rochester, rochester, new york, united states background: malignant central nervous system (cns) tumors in young children have a poor prognosis and pose a significant therapeutic challenge. consolidation therapy with carboplatin and thiotepa was piloted in ccg-99703, cog acns0333, and cog acns0334 with the goals of intensifying therapy and omitting or delaying radiation.objectives: to document outcomes for patients undergoing carboplatin/thiotepa consolidation with autologous stem cell rescue (ascr) and to demonstrate the feasibility and toxicity of this regimen.design/method: patients up to 3 years old (median age: 12 months) with malignant cns tumors treated at the university of rochester from 2012-2017 with at least one cycle of carboplatin (17 mg/kg/day x 2 days) and thiotepa (10 mg/kg x 2 days) followed by peripheral blood ascr were included in retrospective analysis. data were recorded on time to engraftment (defined by absolute neutrophil count (anc) recovery to > 0.5 × 10^9/l), length of hospitalization, toxicity with each consolidation cycle, progression free survival (pfs) and overall survival (os). stem cell harvest data were also collected.results: eleven patients with malignant cns tumors (6 atypical teratoid/rhabdoid tumor, 3 primitive neuroectodermal tumor, 1 glioblastoma multiforme, and 1 pineoblastoma) received a total of 30 cycles of carboplatin/thiotepa. of these, 9 underwent stem cell harvest at our institution, with complications limited to procedure-related hypotension for 1 patient with known autonomic instability, and catheter-associated deep vein thrombosis (dvt) for 1 patient. four patients were in complete remission (cr) 1/status-post gross total resection, 1 was in cr2, and 6 had residual tumor at the time of consolidation. nine patients received 3 planned consolidation cycles, 1 patient 2 (of 2) planned cycles, and 1 patient 1 of an anticipated 3 cycles thus far. average time to engraftment for these 30 cycles was 10.2 (+/-1.4) days, with a mean hospital length of stay of 16 (+/-3.2) days. fever occurred in 17 of 30 cycles (57%); infectious toxicity included documented bacterial infection in 2 cases (enterococcus faecalis bacteremia in 1, klebsiella pneumoniae in 1). there were no regimenrelated deaths. with a mean follow-up of 23 months, 2 survivors have not yet completed all therapies, and 5 patients have relapsed (4 have died of disease). of the 7 survivors, 4 have been disease-free for >12 months. background: autologous hematopoietic stem cell transplantation (auto-hsct) has resulted in improved survival for patients with high-risk neuroblastoma. treatment intensification is however associated with greater complications. data on early infectious complications in low-and-middle income countries are limited.objectives: to review the early infectious complications following auto-hsct in patients with high-risk neuroblastoma.design/method: a retrospective chart review of pediatric patients with high-risk neuroblastoma who underwent auto-hsct at the american university of beirut medical center between 2003 and 2017 was conducted. infectious complications during the first 100 days post-transplant were reviewed.results: forty-three patients (27 males and 16 females) with a median age at diagnosis of 4.35 years [range: 0.5-13.9] years underwent auto-hsct during the above-mentioned period. conditioning regimen consisted of melphalan, etoposide and carboplatin. all patients received antiviral and antifungal prophylaxis. median time for neutrophil engraftment was 10 days [range: 8-19]. bacteremia and clostridium difficile infections occurred in 16 (37%) and 12 (28 %) patients respectively. seven (16%) patients developed enterocolitis diagnosed by imaging, 4 were adenovirus induced. cmv viremia was diagnosed in 7 (16%) patients, 5 of whom required treatment. varicella zoster reactivation, parvovirus viremia, toxoplasmosis encephalitis, bk virus cystitis (2 patients) and central nervous system ebv related post-transplant lymphoproliferative disorder were diagnosed in 6 different patients. there was no invasive fungal infection. sixteen (37%) patients have died, 6 of whom died in the early post-transplant period, 1 due to disease progression and 5 (11.6%) due to infectious complications. among the 5 patients who died due to infection, 1 developed toxoplasmosis encephalitis, 4 developed severe enterocolitis, 2 of which were adenovirus related. the mean igg level within one week post-transplant was lower in patients with clinically significant viral infection compared to others (4 vs 5.6 mg/dl, p: 0.08). the mean igg level at the time of clinically significant bacterial infection was lower in infected patients compared to others (4.4 vs 6.3 mg/dl, p: 0.03). neither absolute lymphocyte count nor absolute neutrophil count at day 20 post-transplant affected the incidence of clinically significant infections. our results show that the rate of infections during the early post auto-hsct period is higher than what has been described in developed countries and has a significant impact on mortality. prevention, early detection and improvement in the treatment is required to improve outcome. university of miami, miami, florida, united states background: allogeneic hematopoietic stem cell transplantation (allo-hsct) is a curative treatment for many malignant and non-malignant (bone marrow failure, immunodeficiency, or metabolic diseases) in pediatrics. despite advances in medicine, graft-versus-host-disease (gvhd) remains a significant cause of non-relapsed morbidity and mortality, specifically in those with malignant diseases.objectives: to highlight the complexity to acute gvhd management and seldom-described treatment approach. a 7 year male with a history of high risk acute myeloid leukemia (aml) due to failed induction therapy. he received a matched (10/10) unrelated donor hsctmarrow product-conditioned with busulfan, fludarabine, and anti-thymoglobulin (atg). his post-transplant course was complicated by hhv-6 viremia, pres (prompting a change from prograf to cyclosporine), mucositis, and grade iii acute gvhd (skin s3, gut s2, liver s0) around post transplant day 101, which later morphed to ocular involvement by d+120. he was started on 2 mg/kg steroids with good response but flared up with each attempt to taper steroid dose. a course of rituximab and later atg were tried without success in weaning off steroids. switching cyclosporine to sirolimus did not provide any additional benefit either. extracorporeal photopheresis (ecp) was started 3 times a week. he initially responded well, yet was not able to wean off steroids. in addition, he developed a flare when ecp session was reduced to 2 days per week. ecp was therefore increased to 5 days per week, which appeared to stabilize skin lesions. a trial of weekly methotrexate was attempted to wean off steroids and photopheresis, which provided no response. finally, a trial of bortezomib on days 1, 4, 8, and 11 of a 21 day cycle as published in a case series of multiple myeloma patients who developed post hsct gvhd. skin lesions improved remarkably however dose had to be reduced due to related pancytopenia. given the response to therapy, he was continued on a weekly dose of bortezomib, receiving a total 8 doses, which has permitted the slow taper of prednisone that has since been discontinued without a major flare. he however is currently maintained on ecp 3 times per week, which is now been slowly withdrawn.conclusion: management of acute gvhd in pediatric patients after hsct can be challenging with no definite options for those who fail steroids or become steroid dependent after initial response. in these situations, bortezomib could be a valid therapeutic option. background: neuroblastoma (nbl) is the second most common solid tumor in children and despite recent treatment advances, overall survival for high risk nbl remains <50%. the addition of immunotherapy has improved survival and includes anti-gd2 antibody therapy. the success of antibody therapy in neuroblastoma is primarily due to natural killer (nk) cell mediated antibody dependent cellular cytotoxicity. we previously demonstrated that nk cells from patients with high risk nbl can be successfully isolated and expanded to large numbers and exhibit potent anti-tumor effects against nbl (1). thus, infusions of autologous expanded nk cells in high risk nbl in combination with anti-gd2 antibody are being studied in clinical trials. toll-like receptors (tlr) present on the surface of leukocytes are responsible for pathogen recognition, and activation of these receptors stimulate the production of cytokines that critically link innate and adaptive immune responses. the tlr3 agonist, poly(ic) is a synthetic analog of dsrna that has previously been shown to directly stimulate cytokine production and improve cytotoxicity in primary nk cells through activation of genes regulated by interferon-response elements (ire) (2). we hypothesized that ex vivo activation of tlr pathways in nk cells during our normal 14-day expansion using k562 feeder cells expressing membrane bound il-21 would enhance their function.design/method: nk cells were isolated from peripheral blood mononuclear cells and expanded with our previously described expansion protocol in media containing il-2 and 50 ug/ml poly(ic) (3). at the end of the 14-day expansion, nk cells expanded with poly(ic) were compared to controls using a calcein cytotoxicity assay to measure cytotoxicity against high risk neuroblastoma and cytometric bead array to measure cytokine production. : surprisingly, the addition of poly(ic) during nk cell expansion did not improve proliferation, cytokine production or cytotoxicity compared to our standard expansion method. rnaseq demonstrated that our standard expansion method results in a modest decrease in tlr3 expression at the transcriptional level, but significant upregulation of several ireregulated genes. we conclude that either our standard approach interferes with tlr signaling or saturates the innate immune response pathway such that co-stimulation with poly ic does not produce an additive effect. we are performing expression analysis on nk cells receiving poly(ic) during expansion to further explore this hypothesis. background: gonadal dysfunction leading to infertility is a complication after hematopoietic stem cell transplant (hsct). anti-mã¼llerian hormone (amh) is a marker of ovarian reserve; it is not controlled by gonadotropins and has minimal inter-cycle variations, therefore, it can be used as a marker of ovarian reserve and aid in fertility counseling.objectives: assess ovarian reserve in hsct patients utilizing amh levels. background: tgf beta is an immune suppressive cytokine frequently elevated in the tumor microenvironment causing tumor immune evasion. acute tgf beta treatment potently inhibits nk cell cytotoxicity, cytokine secretion, and proliferation. however, tumor infiltrating nk cells receive chronic inhibitory tgf beta signals in conjunction with activating signals from tumor cells. objectives: to this end, we hypothesized that long-term tgf beta-cultured nk cells would induce functional and phenotypical changes on nk cells that differ from short-term tgf beta treatment.design/method: to explore this, primary human nk cells were cultured with the leukemia cell line, k562, alone or with exogenous tgf beta for 2 weeks. : surprisingly, nk cells cultured in tgf beta proliferated faster, and upon challenge with a variety of cell line targets they secreted much greater quantities of ifnî 3 (5-to 282-fold increase against 8/8 cell lines) and tnf (3-to 33-fold increase against 7/8 cell lines). further, the high cytokine secretion induced in these nk cells was no longer inhibited by adding additional tgf beta. degranulation was also increased (2/3 cell lines), however cytotoxicity was not enhanced in a 4-hour cytotoxicity assay. after resting in il-2, the cytokine hypersecretion of tgf betacultured nk cells was maintained for several weeks suggesting this functional change might involve cellular reprogramming. we investigated the mechanism behind these functional changes and profiled 92 genes involved in tgf beta signaling. we found significant reduction of smad3 transcription which corresponded to a striking decrease in smad3 chromatin accessibility. we also found significantly increased smad6 and decreased tgfbr3 expression. phenotypic analysis revealed that tgf beta also induced remodeling of the nk receptor repertoire with decreased nkp30, cd16, and klrg1 and upregulation of trail. the functional consequences of these tgf beta-induced changes on in vitro and in vivo nk cell function are currently under investigation. background: the use of t-cell depleted grafts in haploidentical stem cell transplantation (hsct) has been associated with a delay in early t-cell recovery which increases the risk of viral infections, relapse or graft rejection. conventional donor lymphocyte infusion (dli) after hsct transplantation is effective but conditioned because of a high prevalence of gvhd. the infusion of selected lymphocyte subpopulations with low aloreactivity is emerging as an effective strategy to rectify this issue. the depletion of cd45ra+ naive lymphocytes, preserving cd45ro+ memory t-cells, could provide a safe source of functional lymphocytes with anti-infection, antileukemic and anti-rejection properties, and lower rates of adverse effects. our objective is to present data of patients that have received cd45ro+ memory t-cells dli (mdli) and assess its safety and outcome. we present data of mdli performed after hsct in cases of mixed chimerism, persistent lymphopenia, viral/opportunistic infections or as a strategy to accelerate immune reconstitution.results: fifteen patients with diagnosis of all (n = 6), aml (n = 3), mds (n = 1), saa (n = 3), sideroblastic anemia (n = 1) and cgd (n = 1), received mdli after hsct. a total of forty-three mdli were infused. the median dose of cd45ro+ memory t-cells infused was 5.00 × 107/kg (range:4.8 × 104-4.25 × 108/kg), with a median dose of cd45ra+ naive t-cells of 3.90 × 102/kg (range:0-1.3 × 104/kg). the mdli were infused at a median of seventy-seven days after hsct (range:14-407 days), with a median interval between mdli of thirty-four days results: eight published studies reported survival outcomes for pediatric vod/sos patients (n = 1036), across all defibrotide doses. estimated day+100 survival (95% confidence interval) was 60% (53%-67%). for vod/sos with mod, 4 studies were identified (n = 402) with pooled estimated day+100 survival of 57% (52%-61%). only one openlabel expanded-access study, the treatment-ind, reported outcomes separately for pediatric vod/sos patients without mod (n = 289 patients aged ≤16 years). the day+100 kaplan-meier estimated survival for those patients was 78% (72%-82%). safety results were not pooled due to differences in reporting methodology; however, study results were consistent with the safety profile of the phase 3 historicallycontrolled trial in vod/sos patients with mod (43% pediatric), in which 101/102 defibrotide-treated patients and all 32 controls experienced ≥1 ae. hypotension was the most frequent ae (39%, defibrotide; 50%, controls); common hemorrhagic aes (ie, pulmonary alveolar and gastrointestinal hemorrhage) occurred in 64% of defibrotide-treated patients and 75% of controls. in this pooled analysis of studies with defibrotide-treated pediatric patients with vod/sos, estimated day +100 survival was 60% (without mod, 78%; with mod, 57%). safety results in individual studies were generally consistent with the known safety profile of defibrotide. taken together, these results show a largely consistent defibrotide treatment effect in pediatric patients treated with defibrotide for vod/sos, with or without mod. results: six patients met inclusion/exclusion criteria. all patients were started on ecp while concurrently receiving 1.5 to 2 mg/kg steroid therapy for agvhd plus a calcineurin inhibitor. patients had initiation of ecp within a maximum of 2 weeks from initial diagnosis of agvhd (range 3-12 days). patients had grade 2-4 agvhd (3/6 patients with grade 4) with skin, liver, and gi gvhd represented. patients received ei-ecp 2-3 times per week for the first 6 weeks and then had ei-ecp frequency tapered based on initial response.after 6 weeks of therapy 1 patient had a decrease in overall gvhd grade by 1 grade. all patients were able to have steroids tapered, with doses decreased by an average of 62% (33% -100% decrease).at 12 weeks of therapy, one patient with grade 4 agvhd died of mof associated with infections. three patients had complete resolution of agvhd and 2 patients decreased by 1 grade. steroid doses were decreased by an average of 91% (69% -100% decrease). continuously measures axillary temperature and wirelessly transmits real time-time data. the primary aim of the study was to evaluate the feasibility, safety and tolerability of continuous temperature monitoring in hsct patients using temptraq. we are performing a prospective observational study of pediatric patients (1-12 years of age) undergoing hsct at cincinnati children's hospital in cincinnati, ohio. enrolled patients wore a temptraq patch for 5 days. a 1-10 rating scale survey was completed by the parent/guardian at the end of the study to determine tolerability, ease of use, satisfaction and desire for future use in the inpatient and outpatient setting. temperature data from the temptraq patch was compared to the standard episodic temperature monitoring to determine detection of febrile episodes. seven of ten patients have completed screening. we anticipate completion of the study in early february. the temptraq patch was well tolerated by study subjects (mean tolerability rating of 8.7/10). one patient developed skin breakdown at the site of the temptraq patch attributed to recent thiotepa. the patch was easy to apply with an easy of application rating of 9.7/10. parents were overall satisfied (rating 8.4/10) and would like to use the temptraq patches in future hospitalizations (rating 8.4/10) and at home (rating 8.9/10). temptraq patch identified fever (≥ 100.4 • f) in 4 patients. the fever was never detected by episodic monitoring (soc) in 2 patients and significantly delayed in the other 2 patients (>12 hours). temptraq was well tolerated in pediatric hsct patients. timely fever detection was improved in temptraq over the current soc. background: serotherapy is commonly used in patients undergoing hematopoietic stem cell transplant (hsct) to reduce the incidences of engraftment failure and graft versus host disease. however, one well-known side effect is fever. as children undergoing hsct have compromised immune defenses, fever may also be an early indicator of bloodstream infection, which would warrant prompt use of broad-spectrum antibiotics. in a subset of patients with serotherapy-associated fever, antibiotics, which may induce antibiotic resistance and increase costs, may be unnecessary. we aimed to determine the incidence and characteristics of serotherapy-related fever, as well as the likelihood of concomitant bacteremia, in our institutional experience. a 5-year retrospective chart review was conducted of pediatric patients who received serotherapy as part of hsct conditioning at the university of minnesota. one-hundred sixty eight consecutive hsct patients who received serotherapy -either atg (n = 99) or alentuzumab (n = 69) -were identified. the median age at hsct was 6-years (range, 0.4-18 years). a total of 133 patients (79 %) developed fever while on serotherapy (atg = 79, alentuzumab = 54). one-hundred sixteen patients presented fever following the first infusion, and the median onset of fever was 7 hours after commencing infusion (range, 0.1-22 hours). fever resolved at a median 8 hours (range, 1-48 hours). one hundred and fourteen patients (98%) underwent blood cultures. only seven patient were not started on (6%) empiric antibiotics, while 14% (n = 17) were on antibiotic treatment prior to serotherapy for previously known or suspected infections. nine patients (7% of febrile patients, 4% of all patients) had positive blood cultures (atg = 6; alentuzumab = 3). no infection-associated deaths were observed.conclusion: while fever is common during serotherapy conditioning in children undergoing sct, episodes of concomitant bloodstream infection are rare. ongoing analysis identified potential risk factors for bacteremia as recent history of infection, first episode of fever following second or subsequent infusions, and previous central line placement. further analysis is being conducted to identify subgroups of patients for whom close monitoring alone may be safe. background: hsct is potentially curative for caya with high-risk leukemias; however, most lack an hla-matched 2018 aspho abstracts related donor. the risk of gvhd is increased with unrelated (urd) or partially matched related (pmrd) donors. selective t-cell depletion based on the elimination of t cells carrying and chains of the t-cell receptor may greatly reduce the gvhd risks, while allowing the maintenance of mature donor-derived alloreactive nk cells and / (+) t cells, which may augment the anti-leukemia effect.objectives: this is a prospective study of caya with acute leukemia who underwent hsct with mmrd or urds and tcr / /cd19 depletion. outcomes included engraftment, toxicities, viral reactivation, and relapse.design/method: this study included 36 caya with acute leukemia transplanted between october 2014 and may 2017. all received a myeloablative preparative regimen with targeted busulfan (n = 15) or tbi (1200 cgy/6 fractions) (n = 21), with thiotepa (10 mg/kg) and cyclophosphamide (120 mg/kg). atg (3 mg/kg x 3) was given to those receiving haploidentical grafts and to the first 17 who received urd grafts. immune suppression was not given post-hsct. the stem cell source was mobilized peripheral blood stem cells (pscs), which then underwent tcr / /cd19 depletion utilizing the clinimacs device under gmp conditions in the chop cellular immunotherapy lab.results: median age was 11 (range 1.3-21.7). diagnoses included all (9-b-cell, 3-t-cell) and aml (24; 3-secondary aml). urd were used for 28; 13 were 10/10 allele matched and 15 were 9/10 matched. haploidentical donors were used for 8. median cd34(+) dose -10.1 × 106, / (+) cd3(+) cells -5.63 × 106, and b cells -8.95 × 104. all patients achieved an anc at a median of d+13 (8-30), and 94% had platelet engraftment at median d+17 (12-40). nine patients (25%) developed acute gvhd (all skin, grades i-iv). five developed chronic gvhd (skin, gut, lung): limited in 4, extensive in 1. viral reactivations included: adenovirus (5, 14%), bk virus (8, 22%), cmv (10, 28%), and hhv6 (2, 6%). nine (25%) patients relapsed at a median of 147 days (range 57-625) post-hsct, including 7 aml patients (29.2%) and 2 all patients (16.7%). transplant-related mortality was 14%; causes included sepsis (6) and ards (2). os was 72%; efs was 58% (gvhd-free efs 39%, lfs 61%). hsct with tcr / /cd19 depletion demonstrates excellent engraftment kinetics with limited gvhd without immune suppression. elimination of post-hsct immunosuppression may offer an excellent platform to augment anti-leukemic immune therapy or to enhance immune reconstitution. background: hematopoietic cell transplantation (hct) is the only curative treatment available for patients with sickle cell disease (scd). low bone mineral density (bmd) has been described in scd, but little is known about the impact of curative hct on this outcome. to determine the prevalence of low bmd and variables associated with low bmd in scd patients after hct. we conducted a retrospective chart review of scd patients who underwent hct at children's healthcare of atlanta (choa) between 12/1993 and 12/2016 and survived ≥1 year post-hct. transplant characteristics, post-hct dual-energy x-ray absorptiometry (dexa) scan results, vitamin d levels, graft-versus-host-disease (gvhd) status, and fsh levels were reviewed. for patients 2-20 years of age, height corrected z-scores were calculated using a nihvalidated calculator, with t-scores used for older patients. bmd was categorized as low if between -1 and -2 sd below the mean and clinically significantly low if >-2 sd, in accordance with the children's oncology group long-term follow-up guidelines. vitamin d levels <20 ng/mol were considered deficient, and fsh levels >40miu/ml suggestive of premature ovarian failure. fisher's exact test was used to compare variables in those with normal versus abnormal dexa scan results, with p<0.05 considered significant.results: hct was performed on 71 patients with scd, with 67 surviving ≥1 year post-hct. dexa scans were obtained in 40 patients (55% female), with mean time from hct to dexa scan being 4 years (1.3-11.2 years) and mean age at time of dexa 13.1 years (6.1-22.3 years). patients with and without dexa scans did not differ by sex, donor source, age at transplant, or vitamin d status. low bmd was noted in 10 patients (25.0%), with these patients more likely to be >13 years (pubertal; 90.0 versus 40.0%, p = 0.009). acute gvhd was more common in patients with low bmd (50.0 versus 16.7%), but not statistically significant (p = 0.085). clinically significant low bmd was noted in 3 patients (7.5% of those with dexa scans). these patients were older (16.2 years at testing), were more likely to be male (66.6%), and all had acute and chronic gvhd, while none had evidence of gonadal failure.conclusion: clinically significant low bmd is uncommon after hsct for scd. patients at risk for low bmd include older patients and likely those with gvhd. this preliminary data suggests routine dexas may not be indicated for all patients who undergo hct for scd, but further data is needed. background: causes of renal dysfunction after hematopoietic cell transplantation (hct) include damage from radiation, nephrotoxic medications, graft vs. host disease (gvhd), hepatorenal syndrome, viral infections, or transplant associated microangiopathy. we sought to investigate the incidence of, and risk factors for, acute kidney injury in pediatric hct patients and associated risk with mortality.design/method: data from patients who underwent hct between 2013 and 2016 at a single institution were sequentially retrospectively captured on irb approved protocol. acute kidney injury (aki) was defined at multiple time points post-hct using the standardized criteria: kidney disease: improving global outcomes (kdigo). interval differences between values were analyzed using wilcoxon rank sum testing and categorical variables were analyzed using chi-square analysis.results: ninety-eight patients were included in the study: allogeneic (n = 96) and autologous (n = 2), mean age 8.7 years, of whom 50% were african american, 3% asian, 21% caucasian, 13% latino, and 13% mixed race. forty-seven percent of patients developed aki within the first 2 years of hct. increased risk for aki was associated with a lower pre-transplant creatinine level (p = 0.001), abnormal pretransplant bun (p = 0.019) and an unrelated donor (p = 0.022) while preparative regimen intensity, race, or primary disease were not. twenty-six percent of patients developed aki within 30 days of hct. of those with aki, 41% were exposed to either cidofovir, aminoglycosides, and/or ambisome for at least 5 days versus 18% without aki and 74% were exposed to vancomycin compared to 49% without aki. evaluating outcomes at 1 year after hct, of those with stage 1 aki: 10% had reduced gfr and 37% died, while 14% had reduced gfr and 43% had died for patients with aki stage 2 or 3. the absence of aki by day 30 was associated with 24% reduced gfr and 8% death at 1-year after hct. overall, those with aki at any time in the first year post-hct had a 3.7 fold increased risk of death compared to those without. for patients who required renal replacement therapy (rrt, n = 8), the risk of death was 19.5 fold greater compared to those who did not. in the 25% of patients who survived rrt, both recovered renal function within 2 years.conclusion: acute kidney injury is common after pediatric hct, and may be associated with low creatinine, abnormal bun, unrelated donor pre-hct, and renal toxic medications. early-onset aki post hct is associated with an increased risk of mortality. these data should be validated in a larger prospective study but may offer opportunities to intervene and enhance outcomes. background: myeloablative hematopoietic stem cell transplant (hct) for pediatric malignant disease is associated with significant morbidity with 90% patients experiencing mucositis. patient controlled analgesia (pca) utilizing opioids is an effective strategy for pain management. we sought to describe and analyze pca use in d+30 days post myeloablative hct for malignancies at lurie children's hospital of chicago from 2010-17.design/method: utilizing retrospective chart review, pca details were collected: indication, initiation day, pca duration, team managing pca (anesthesia or palliative), medication and dose in morphine equivalents, and pca toxicities. efficacy of pca was evaluated on pca day + 3, +7, +14, +21 using demands %, maximum pain score (rflacc, faces, vas) and subjective patient, parent and/or pain team perception of pain control. we devised a scale based on the above to designate pain control as good, moderate or poor. variables being analyzed include recipient age, sex, donor type, source, diagnosis, tbi use, gvhd/trm. this analysis, we analyze the depth of remission, car-t persistence, and post-transplant gvhd on our phase i anti-cd22 car-t protocol (nct02315612) to better understand the role of car-t in the peri-hct setting.design/method: children and young adults with relapsed/refractory cd22+ all treated on our phase i anti-cd22 car-t protocol were analyzed. mrd was assessed by flow cytometry (fc) in all, with pcr-based mrd analysis using igh or tcr testing assessed in select patients. hcts were performed at each patient's local institution based on standard of care and included varying conditioning regimens, donor types, stem cell source, and gvhd prophylaxis.results: on our cd22 car trial, 36 patients were treated, the majority of patients (n = 29) having relapsed following a prior hct. 23/36 patients (64%) attained a cr, 18 of whom were mrd negative by fc. concurrent pcr based mrd analysis available in 8 patients demonstrated that all patients achieved pcr based negativity. in 6, this was simultaneous with the 1 month mrd negative fc, and in 2, pcr negativity was achieved over time (fc remained negative). 4 patients proceeded to hct at a median time of 70 days (range: 54-117 days) post-car-t, which was a first hct in 2. these two patients remain in an mrd negative cr, 1 year post-car-t. no patients developed acute or chronic gvhd. car persistence was seen in 3 patients who had detectable car-t cells on the pre-hct marrow suggesting the possibility of ongoing anti-leukemia surveillance prior to initiation of the conditioning regimen.conclusion: by inducing pcr negativity, car-t therapy may have a synergistic role with hct to improve leukemia free survival, prior to emergence of antigen negative leukemia, without an increased risk of gvhd. while the sample size is small, car-t therapy may offer an effective bridge to hct, particularly for those who are pcr negative, and those who have not had a previous transplant. given the underlying risk of hct related trm, pre-hct car may potentially allow for hct conditioning de-intensification as it may not be needed to eradicate residual disease.1 lee dw, ash abstract 218, 2016 background: post-transplant lymphoproliferative disease (ptld) is a complication after solid organ transplantation (sot) that is frequently due to epstein -barr virus (ebv) as a decrease in ebv-specific t cell immunity due to immune suppression allows for uncontrolled proliferation of ebv-infected b cells. outcomes for ptld are suboptimal with relapse rates approaching 50%. however, ebv-infected b cells in ptld express the ebv antigens lmp1 and lmp2 that can be targeted with immune therapy.objectives: we hypothesize that third party "off the shelf" lmp-specific t cell products may improve outcomes and decrease associated co-morbidities for patients with ptld by not only target the lymphoproliferating ebv-infected b cells but also restoring ebv-specific immunity.design/method: lmp-specific t cells (lmp-tcs) are manufactured from eligible donors with a broad range of hla types in our gmp facility to be used in a children's oncology group (cog) trial (anhl1522) for patients with ptld after sot. lmp-tc products are manufactured from healthy donors using autologous monocytes and lymphoblastoid cell lines (lcl) transduced with an adenoviral vector expressing δlmp1 and lmp2 as antigen presenting cells. lmp-tc products undergo comprehensive characterization by ifn-elispot assay to determine lmpspecific epitopes, class i and/or ii response, and hla restriction to guide selection of lmp-tc product for each patient.results: thus far, 27 lmp-tc products have been manufactured. lmp-tcs were active against lmp2 (mean: 158 sfu/1 × 10^5 cells; range: 1-800), lmp1 (31; 0-355), and lcl (105; 0-424) as determined by ifn-elispot assay. at the time of cryopreservation, the lmp-tc products comprised a mean of 36% cd8+ t-cells, 45% cd4+ t-cells, and 8% nk cells. no b cells or monocytes were detected in the final products. thus far, we have identified 3 novel lmp epitopes (lmp1 specific: n = 1; lmp2 specific: n = 2). approximately 80% of the lmp-tc products have lmp-specific activity through multiple hla alleles, and 67% have a mixed class i and class ii response. conclusion: thus, lmp-specific t cell products can be expanded from healthy donors to creat a third party bank, and identifying epitopes and hla alleles with lmp activity will facilitate selecting the most appropriate product for patients. while lmp-specific t cells have previously demonstrated safety and efficacy in phase i studies, anhl1522 is the first trial using cellular therapy within a cooperative group setting. children's cancer hospital at the university of texas md anderson cancer center, houston, texas, united states background: in 2017, the united states food and drug administration (fda) approved the first chimeric antigen receptor t cell (car-t) therapy; tisagenlecleucel. this cd19-directed genetically modified autologous t cell immunotherapy has shown response rates of almost 90% among children and young adults with b-cell precursor acute lymphoblastic leukemia (all) that are refractory or in second or later relapse. cytokine release syndrome (crs) and car-t cell related encephalopathy syndrome (cres) are well described toxicities associated with car-t therapy. crs is a systemic inflammatory response and is typically characterized by fever, hypoxia, tachycardia, hypotension and multi-organ toxicity. cres may occur concurrently or following crs, or without any associated crs symptoms and is characterized by encephalopathy, delirium, seizures and rarely cerebral edema. almost half of patients who receive tisagenlecleucel may require pediatric intensive care unit (picu) support. crs and cres are generally reversible but may be associated with fatal outcomes. pediatric specific management guidelines, comprehensive training of multidisciplinary staff, effective communication and phased infrastructure ensure that adequate resources are available to facilitate early diagnosis and appropriate management of pediatric patients with crs and cres and allow for optimal patient outcomes and accreditation by the foundation for accreditation of cellular therapy (fact).objectives: develop a comprehensive program to ensure safe administration of immune effector cell (iec) therapy to pediatric patients.design/method: an inter-disciplinary pediatric cartox (car t cell therapy associated toxicity) committee consisting of cell therapy and picu physicians, neurologists, fellows, nursing leadership, advanced practice practitioners, pharmacists, registered nurses and social workers was created to monitor patient toxicity and establish specific clinical guidelines and diagnostic and treatments algorithms for pediatric patients receiving iec therapy. educational modules were developed as (i) live in-services and (ii) an online module with a competency based assessment. electronic medical record (emr) order sets and documentation and warning systems were also developed by the committee. the pediatric cartox committee developed a diagnostic and treatment algorithm for patients receiving iec therapy. emr orders and flowsheets were developed to support adherence to the algorithm. inter-disciplinary staff training and competency assessments were closely tracked. almost 97% of identified staff have completed training and achieved competency including, pediatric cell therapy staff, emergency center, picu, outpatient clinic/triage, neurology and sub-specialty staff and nocturnalists.conclusion: an inter-disciplinary approach can assist in institutional readiness for an iec program, promote quality assurance and perhaps fact iec accreditation. future directions include a program for ongoing staff competency assessments. predicted peak vo2) and abnormal oxygen uptake efficiency slope at the anaerobic threshold (1359.3±297.8.9, normal 1790±310). additionally, on echocardiogram three patients had evidence of diastolic dysfunction as evidenced by an elevated e/a ratio (1.9±0.4) on tissue doppler. three patients demonstrated depressed longitudinal peak systolic strain (-17.7±2.8), indicating dysfunction not captured by ejection fraction. in this feasibility study, sct patients without evidence of lvsd on standard measures by resting echocardiogram can demonstrate abnormal exercise capacity. additionally, they can demonstrate systolic and diastolic dysfunction by measures not always included in standard echocardiography. these data suggest the need for a more thorough screening of survivors, and will be further validated as additional patients are recruited for this study. background: in hematopoietic transplantation, the t lymphocytes of the inoculum play a determining role in promoting hematopoiesis, transferring immunity to pathogens and acting as mediators of the graft-versus-leukemia effect (gvl). however, they are also responsible for graft-versus-host disease (gvhd), the main cause of post-transplant morbidity and mortality. the depletion of cd45 ra lymphocytes, by eliminating naive t lymphocytes from the inoculum, aims to conserve the gvl without producing gvhd.design/method: since april 2016, 14 patients (8 boys and 6 girls), with a median age of 8 years, have undergone an allogeneic hematopoietic transplant from an hla donor identical with cd45 ra/cd19 depletion. the indication for transplant was: acute lymphoblastic leukemia (4), acute myeloblastic leukemia (4), myelodysplasia (5) and medullary aplasia (1). the donor was familiar in 4 cases and unrelated in 10. the conditioning regimen was with fludarabine, busulfan and thiotepa. the median of cd34 + cells infused was 6.82 × 10 6 / kg. on the day 0, +15 and +30 a programmed infusion of 1 × 106 / kg lymphocytes cd45ra-was performed.results: all the patients grafted with a median leukocyte (> 0.5 × 109 / l) and platelet (> 20 × 109 / l) engraftment time of 15 and 10 days, respectively. only one patient has developed acute gvhd grade i and no patient has developed chronic gvhd. immune reconstitution was early and rapid in all t cell subsets no patient has relapsed so far and only 1 patient with myelodysplasia has developed an aml. she has received a 2nd transplant and has died of relapse. there was no case of toxic mortality. the event-free survival (sle) was 90 â± 10% with a median follow-up of 10 months. at present, 13 patients are alive, out of immunosuppressive treatment and doing well. allogeneic transplantation with cd45 lymphocytes ra depletion resulted on very encouraging results, with a very low incidence of acute and chronic gvhd, but preserving the gvl effect by infusing cd45 ra-donor lymphocytes. miami children's health system, miami, florida, united states background: hematopoietic stem cell transplantation (hsct) using autologous or allogeneic progenitor cells is a potentially curative treatment for patients with high-risk malignancies and nonmalignant conditions. the american society for blood and marrow transplantation developed a task force to establish consensus guidelines for defining patient care in hsct and advocated for further studies to delineate safe procedural steps as an increasing amount of hsct are being offered to patients. there is limited evidence to support engraftment in recipients who receive their infusions via iv or syringe pump. we present novel data from patients who achieved neutrophil engraftment following hsct by a pump mechanism.objectives: to provide evidence supporting the use of pump (intravenous or syringe) infusion method in hematopoietic stem cell transplantations.design/method: a retrospective review was completed for 114 patients who underwent hsct between 2003 and 2012. inclusion criteria included patients who had received hematopoietic stem cell transplants between 2003 and 2012 and who were ages 6 months to 21 years old. the main outcome measure was days to neutrophil engraftment (defined as the first of three consecutive days with an anc > 5 × 10 9 /l).results: among 114 patients who received infusion of hematopoietic stem cell products via pump mechanism, 63 patients (55.3%) received autologous products and 51 (44.7%) received stem cells from allogeneic donors. neutrophil engraftment (anc > 5 × 10 9 /l) occurred in a median of 14.5 days after stem cell infusion. the mean number of days to engraftment for patients who received allogeneic infusions s301 of s301 design/method: a retrospective chart review was performed at the children's hospital of wisconsin. statistical analyses included kaplan-meier estimate for os, mann-whitney test for comparing outcomes between subjects, and descriptive analyses.results: from 2005-2016, 14 patients with a median age of 7.5 (4.3-23.0) years at 1 st hct were identified. patients were conditioned with cy/atg (n = 3), cy/flu/atg (n = 6), or cy/flu/atg/tbi (n = 5) and received marrow (n = 13) or cord blood (n = 1) with median cd34/kg dose of 6.82 (1.88-10.90) ×10 6 . two patients developed grade i acute graftversus-host disease (gvhd); none developed chronic gvhd. due to dropping chimerism, graft rejection, or graft failure, 2 nd hct (n = 9) or boost (n = 5) was offered. the median cd3 chimerism prior to hct/boost was 53 (0-100)%. median time between 1 st hct and 2 nd hct or boost was 134 days (42 days-5.1 years). in 9 patients receiving 2 nd hct, 5 used the same donor, of which 3 used the same stem cell source (marrow) and 2 switched to peripheral blood stem cells (pbsc). in 4 patients who switched donors, 3 used pbsc and 1 used cord blood. most patients receiving 2nd hct underwent a uniform conditioning regimen of cy200/flu150/equine atg/8 gy tli (n = 5) or cy120/flu120/rabbit atg/2 gy tbi (n = 3); one received cy/atg. acute and chronic gvhd (limited seen in 83%) developed in 50% and 43% of patients, respectively. four patients required 18 additional boosts and 1 additional hct. after final intervention, cd3 and whole-blood chimerism at last follow-up was between 95-100% (n = 9) and 90-100% (n = 5), respectively. with a median follow-up of 8.6 (3.8-12.8) years, 13 of 14 patients are alive with an estimated 10-year os of 92.3 ± 0.07%, having performance status ≥90% (n = 12) or 80% (n = 1). one patient developed chronic extensive gvhd and died of fungal infection 2.1 years after 2 nd hct. our single-center experience demonstrates excellent ability to salvage patients who develop graft failure after initial hct. transplant-related complications such as gvhd and infections remain significant concerns. key: cord-006849-vgjz74ts authors: nan title: 27th international congress of the european association for endoscopic surgery (eaes) sevilla, spain, 12–15 june 2019 date: 2019-09-13 journal: surg endosc doi: 10.1007/s00464-019-07109-x sha: doc_id: 6849 cord_uid: vgjz74ts nan laparoscopic cholecystectomy is one of the most commonly performed operations worldwide. bile duct injury (bdi) is a rare but very serious complication of the procedure, with a significant impact on quality of life and overall survival. the high frequency of bdi with laparoscopic cholecystectomy was first considered to be a consequence of the initial learning curve of the surgeon, but it later became clear that the primary cause of bdi is misinterpretation of biliary anatomy. intraoperative cholangiography (ioc) has been advised by many authors as the technique reduces the risk of bdi. however, the procedure has inherent limitations and is therefore reserved for select cases. fluorescent cholangiography using indocyanine green(icg) is a novel approach, which offers real-time intraoperative imaging of the biliary anatomy. a comparative study was contacted by administering icg intravenously or intrabiliary during the operation. forty patients scheduled to undergo an elective lap. cholecystectomy were randomly divided in two groups: in group a icg was administered in a dose 2.5 mg in 2 ml solution intravenously 1 hour before surgery. in group b icg was injected intrabiliary in a 0.025 mg/ml solution mixed with the patient's bile. also, we observed and analysed the following parameters, liver function, b.m.i, asa score and possible complications, before and after operation. results: group a. intravenous icg was administered in 20 patients. there was no any reaction and the extrahepatic biliary anatomy was identified well. there was no bdi or any complication related to the procedure. group b. icg was injected intrabiliary in 20 patients during the laparoscopic procedure. in all but one patient the extrahepatic biliary tree was delineated very well. in one patient part of icg solution was injected into the gallbladder wall and this resulted in a partially confusing image. there was no bdi and no postoperative complication conclusions: fluorescence cholangiography can be used during laparoscopic cholecystectomy to obtain fluorescence images of the bile ducts following intrabiliary injection during the operation orintravenous injection 1 h before the procedure. the later technique is more easy to perform and does not require catheterization of the biliary tree. endoscopia digestiva chirurgica, policlinico universitario ''a. gemelli'', rome, italy; 2 ihu, strasbourg, france; 3 camma group, icube, university of strasbourg, cnrs, ihu strasbourg, strasbourg, france; 4 ircad, strasbourg, france; 5 digestive and endocrine surgery, nouvel hopital civil, university of strasbourg, strasbourg, france; 6 digestive and endocrine surgery, ihu-strasbourg, strasbourg, france aim: surgical societies are united in promoting the critical view of safety(cvs) during laparoscopic cholecystectomy(lc). nonetheless, reports have shown a discrepancy between the operative reports and the correct application of cvs, which may explain the stability of bile duct injury rates. therefore, surgeons and computer scientists at our institution are developing a machine-learning algorithm to automatize cvs assessment. however, the lack of a consistent cvs video assessment framework limits the ability to generate data to train the artificial intelligence. here we describe and test a method for cvs evaluation in videos. method: between march and july 2016, 100 consecutive videos of lc performed at nouvel hospital civil(strasbourg, france) were recorded. two independent reviewers assessed the achievement of cvs in the 60 s video sequences preceding clipping of cystic duct and artery. in addition to the 'doublet view' method, a 'binary' video evaluation method was tested: each of the 3 criteria composing the cvs(2 structures entering the gallbladder, clearance of the hepatocystic triangle and lower part of the cystic plate) was classified as achieved or not. if the 3 criteria were met, then the cvs was considered achieved. inter-rater agreement for cvs and for each of the 3 criteria was evaluated. results: twenty-two videos(12 fundus first and 5 partial lc, and 5 broken videos) were excluded from the cvs analysis. cvs elements were assessable in all but one 60 s videos sequences(98.72%). after mediation, cvs was achieved in 32/78(41.03%) of lc. the cystic plate was identified in only 52.56% of videos. inter-rater agreement using the doublet view vs. the binary method was as follows: 83.33%(? = 0.54) vs. 88.46%(? = 0.75) for cvs achievement, 66.66%(? = 0.48) vs. 93.59%(? = 0.79) for the 2 structures, 65.38%(? = 0.45) vs. 82.05%(? = 0.62) for the hepatocystic triangle and 61.53%(? = 0.36) vs. 88.46%(? = 0.77) for the cystic plate ( fig. 1) . conclusions: reliable cvs assessment is crucial to generate consistent data for machine-learning algorithms aiming at decreasing bile duct injury after cholecystectomy. our binary cvs video assessment method showed higher inter-rater reliability than the doublet view, originally described for assessment of photos. further studies are on going to validate the cvs assessment in videos and support our initial results. surg endosc (2019) the vital role of surgeries in healthcare requires a constant attention for improvement. surgical process modeling is an innovative and rather recently introduced approach for tackling the issues in nowadays complex surgeries, involving complex logistics, much technology, and large teams. surgical process modeling allows for evaluating the introduction of new technologies and tools prior to the actual development and is beneficial in optimization of the treatment planning and treatment performance in operating room. in this study, we first discuss the concepts associated with surgical process modeling, aiming to clarify them and to promote their use in future studies. next, we apply these concepts to analyze the procedure of challenging interventions, minimally invasive liver treatment (milt) methods, with the ultimate goal of improving and optimizing the treatment procedure. the procedure model of current treatment activities and planning of various milt methods and the associated techniques, are analyzed and combined into a generic procedure model of milt, which provides a firm foundation for qualitative and quantitative analysis of different milt procedures. the generic procedure model is validated by data from erasmus medical center (rotterdam, the netherlands) and oslo university hospital (oslo, norway) . the proposed procedure model is designed to be a basis for improvement of the procedure and to determine how and where the new technologies can be best, effectively and efficiently, employed in the clinical practices prior to and/or during actual development of the new technologies for milt. as a conclusion, the current work illuminates the importance of surgical process modeling for improving different aspects of treatment procedures and provides an overview of various modeling strategies that can be used to establish surgical process models. the generic procedure model of various milt methods, including laparoscopic liver resection, laparoscopic liver ablation and percutaneous ablation, is introduced and validated which is a basis for introduction of the optimized procedure model of milt objective: to determine the most appropriate time to start total laparoscopic living donor right hepatectomy (tldrh) based on the experience with laparoscopic liver resection (llr). summary background data accumulation of experience in llr is essential before starting tldrh to ensure donor safety. methods: we retrospectively reviewed data of 567 and 78 consecutive patients who underwent llr and donor hepatectomy, respectively, between 2003 and 2017. operative outcomes of laparoscopic major hepatectomy (lmh) were compared between two periods based on tldrh introduction (phase i 2003 -2009 vs phase ii 2010 . learning curve of llr was evaluated using the cumulative sum (cusum) method to determine the optimal time of tldrh introduction. conclusion: accumulating an experience of at least 73 lmh cases is needed in low-volume lt centers before starting tldrh to ensure donor safety. introduction: the number of surgical adverse events is still too high. an important number of these adverse events occur within the operating room (or) and are in fact preventable. in order to reduce adverse events in the or, we simply need to know what went well and what can be done better. the aim of this study was to analyze and debrief a predefined selection of surgical procedures, with the use of an operating room 'black box', to identify commonly observed safety threats and resilience support events. methods: in the period 2017-2018, 35 predefined gastro-intestinal laparoscopic cases were recorded by the or black box'. the postoperative surgical team assessment record (star) questionnaire was used. the recordings were analyzed by specifically trained raters, using the systems engineering initiative for patient safety (seips) model of work system and patient safety to identify relevant safety threat and resilience support events. qualitative data analysis was used to identify the most commonly discussed events during the team debriefings. results: in only 26.5% (n = 65) of times or team members, when asked direct following surgery, indicated that they had noticed aberrations (n = 234) during the case. a mean number of 52.5 (sd 15.0) relevant positive and negative events (e.i. aberrations) per surgical procedure were identified using the black box performance report. on average, 11.5 (sd 4.2) of events identified by the black box were rated as safety threats. most events discussed during the team debriefings were related to communication. conclusion: these results once again highlighting the importance of clear and closed-loop communication in the operating room. theatre staff underestimated the number of aberrations occurring in the or, when asked to retrieve from memory. postoperative structured team debriefing may be important for resolving incorrect assumptions between operating team members to avoid future unnecessary miscommunication. background: the eaes has recently published an intraoperative adverse event classification to assist the direct measurement and routine reporting of minimal access surgery interventions. we aimed to explore the clinically validity and reliability of the classification. methods: a prospective evaluation utilising case videos and clinical data from a completed multi-centre laparoscopic total mesorectal excision surgery randomised controlled trial was performed (isrctn59485808). enacted adverse events identified with the observational clinical human reliability analysis technique were graded with the eaes classification by two blinded, independent assessors. test-retest reliability was explored using grades previously applied during the development of the classification with intraclass correlation co-efficients calculated. clinical validity was assessed using 30-day morbidity events, the clavien-dindo classification and the highest eaes grade per case. results: 77 laparoscopic cases (419 h of surgery) contained 1393 error events which were all successfully categorised. excellent inter-rater and test-retest reliability was seen (icc 0.957, 95% ci 0.952-0.961, p \ 0.001 and icc 0.893, 95% ci 0.88-0.904, p \ 0.001 respectively. 61% of patients experienced post-operative morbidity (median 1 event, range [0] [1] [2] [3] [4] [5] . labelling analysed cases by their highest eaes classification grade gave 53% grade 2, 43% grade 3 and 4% grade 4 procedures. 51% of grade 2 cases developed a morbidity event, but this significantly increased in grade 3 and 4 operations (70% and 100%, p = 0.043). the number of complications and highest recorded clavien-dindo grade increased with each additional grade (1.05 ± 1.3 vs. 1.48 ± 1.3 vs. 2.33 ± 0.6, p = 0.145 and median 1 vs. 2 vs. 3, p = 0.023 respectively). anastomotic leak and re-operation were correctly captured by the allocated eaes grade (2.5% vs. 3.3% vs. 100%, p \ 0.001 and 5% vs. 0% vs. 66%, p \ 0.001 respectively). there was a significant rise in length of stay observed with increasing eaes grade (median 6 vs. 7 vs. 61 days, p \ 0.001). conclusion: in the context of major laparoscopic surgery, the eaes intraoperative adverse classification is seen to be a clinically valid and reliable assessment method. psychological medicine, nuhs, singapore, singapore aims: neurobiological feedback in surgical training could translate to better educational outcomes such as measures of learning curve. the variation in brain activation of medical students when performing laparoscopic tasks before and after a training workshop is not properly studied before and we planned to do this using functional near infrared spectroscopy (fnirs) which is a non-invasive optical brain imaging tool that measures cortical oxygenation change which is used as a marker of pre-frontal cortex activity (pfca). methods: this randomised controlled trial examined the pfc activity differences in two groups of novice medical students during the acquisition of 4 basic laparoscopic tasks. 'trained-group' had standerdised oneto-one training on the tasks, while the 'untrained-group' had no prior trainining and was just shown a video of the tasks. the pfca was measured pre and post intervention using a portable fnirs device. primary outcome was the difference in the pfca pre and post intervention. secondary outcomes were the differences in pfca between the 4 tasks and between the sexes. results: 16 trained and 16 untrained medical students with an equal sex distribution and a comparable age distribution were invovlved in the study. all students were right handed. trained group had a significantly attenuated pfca in the 'precision-cutting' (p = 0.011) and 'suture-insertion' (p = 0.025) tasks compared to the untrained group. subgroup analysis based on sex revealed significant attenuation in pfca in trained females compared to untrained females across 3 of the 4 laparoscopic tasks: 'pegstransfer' (p = 0.013), 'precision-cutting' (p = 0.034), 'suture-insertion' (p = 0.03). no significant pfca attenuation was found in male students who underwent training compared to untrained males. conclusion: a standardised laparoscopic training workshop promoted greater pfca attenuation in female medical students compared to males. this suggests that female and male students respond differently to the same instructional approach. these results may have implications for surgical training and education such as a greater focus on one to one surgical training for female students and use of pfca attenuation as a form of neurobiological feedback as a measure of learning curve in surgical training. robot assisted versus laparoscopic advanced suturing learning curve e. leijte 1 , i. de blaauw 2 , c. rosman 1 , s.m.b.i. botden 2 1 surgery, radboudumc, nijmegen, the netherlands; 2 pediatric surgery, radboudumc, nijmegen, the netherlands aims: compared to conventional laparoscopy, robot assisted surgery is expected to have most potential in difficult areas and demanding technical skills as minimally invasive suturing. this study was performed to identify the differences in the learning curves of laparoscopic versus robot assisted advanced suturing method: novice participants, with the knowledge of basic surgical procedures, were recruited and performed three suturing tasks on the eosim laparoscopic augmented reality simulator or the robotix robot assisted virtual reality simulator. each participant performed an intracorporeal suturing, tilted plane needle transfer and anastomosis needle transfer task. to complete the learning curve, all tasks were repeated for maximal twenty repetitions or until a plateau was reached three consecutive times. clinical relevant and comparable parameters regarding time (seconds), movements and safety were recorded. intracorporeal suturing was used to visualize and compare the learning curves between the groups. results: forty-six participants completed the learning curve, of which 16 laparoscopically and 30 robot assisted. when comparing the suture time, the plateau was reached much faster in the robot assisted group (7-9 repetitions) than the laparoscopic group (10) (11) (12) repetitions) as shown in figure 1 . there was a significant difference in 'time per suture', during the whole learning curve with median values of 637 versus 251 (first knot), 450 versus 147 (fifth) and 186 and 115 (eighteenth), all with a p \ 0.05. however, the parameter 'adequate surgical knot' was reached earlier in the laparoscopic group than in the robot assisted group. first: 69% versus 60%, fifth: 100% versus 70%, and eighteenth: 100% versus 83%. when assessing the 'needle out of view' parameter, the robot assisted group scored a median of 0.3 and 0.0 s during the first, respectively eighteenth knot, and the laparoscopic participants had their instruments out of view for 41 and 17 s during the first respectively eighteenth knot. conclusion: the learning curve of minimally invasive suturing can be reduced with the use of robot assisted surgery, with a specific reduction in operation time. the rate of adequate knots seemed to remain lower in robot assisted surgery, although this could be due to the virtual reality aspect of the simulator. introduction: endoscopic sleeve gastroplasty (esg) is a novel promising bariatric endoscopy treatment. gastric volume reduction and delayed gastric emptying are the mechanisms driving weight loss. however, little is known about the factors influencing the effectiveness of weight loss overtime. the present study aims at evaluating the correlation between endoscopic suture appearance and excess weight loss (ewl%) at 6 and 12 months follow up. patients and methods: all patients who underwent follow-up endoscopy at 6 and 12 months after esg were included. esgs were classified in 3 groups according to endoscopic appearance of the gastric sutures: optimal (group 1) when all stitches were in place and tights; suboptimal (group 2) when one or more stiches were displaced; loose (group 3) when all the sutures were completely disrupted. bmi at enrollment and ewl% at 6 and 12 months were recorded and compared to the endoscopic appearance. results: a total of 53 patients were included in the analysis. at 6 months, 25 (47.2%) patients had an optimal esg, 24 (45.3%) had a suboptimal sleeve and 4 (7.5%) had complete sutures failure. bmi at enrollment and ewl% were respectively 37.7 ± 4.2 and 36.6 ± 21.3% for group 1, 43.6 ± 6.7 and 22.77 ± 18.7% for group 2 and 50.7 ± 14.4 and 7.8% ± 16.5% for group 3. twenty five patients had 12 months egds: 5(20%) presented an intact esg and were classified in group 1, 15 (60%) in group 2 and 5 (20%) in group 3. twelve months ewl% was respectively 47.6 ± 9.1%, 31.3 ± 29.3 and 12 ± 14.4%. initial bmi significantly correlated with suture status at both 6 (rho -0.528; p \ 0.001) and 12 months (rho -0.423; p = 0.035) follow-up. furthermore, the sutures' appearance itself correlated with ewl% at both time points (rho ?0.416; p = 0.002 and rho 0.439; p = 0.028 respectively). conclusion: our preliminary results show that the aspect of the endoscopic suture has a significantly impact on ewl% at 6 and 12 months after esg. furthermore, bmi at enrollment seems to predict endoscopic suture duration overtime. larger studies and longer follow-up are needed to further validate our preliminary findings. background and aim: endoscopic sleeve gastroplasty(esg) is a relatively novel endoscopic procedure that reduces the gastric lumen with proven less complications and less 6 months weight loss compared to laparoscopic sleeve gastroplasty (lsg) . at present there are no studies investigating the role of multidisciplinary approach in esg. the aims of the present study were to evaluate the role of multidisciplinary assessment(ma) prior esg, weight loss outcomes, quality of live improvements and adverse events. material and methods: from may 2016 to may 2018 all patients that underwent esg were retrospectively evaluated from a prospective database. until september 2017 before esg only psychiatric evaluation was requested, while after this date we adopted the guidelines of the italian society for obesity surgery and all patients were evaluated on a multidisciplinary fashion prior esg. the multidisciplinary team was composed by:gastroenterologist, surgeon, psychiatrist, endocrinologist and dietitian. patients were divided in two groups:group 1 were patients with esg before ma and group 2 were patients with esg after ma. we compared this two groups in terms of weight loss outcomes, quality of live improvements and adverse events. quality of live was measured with the bariatric analysis and reporting outcome system(baros).all procedures were done with the apollo overstitch suturing system(apollo endosurgery) and a double channel gastroscope olympus 2tgif-160(olympus japan).all procedures were done in general anesthesia and with insufflation of co2. all patients had ambulatory visit t 1, 3 and 6 months after esg and weight loss outcomes were measured in terms of excess weight loss (%ewl),the total body weight loss (%tbwl) and baros scale were assessed. statistical analysis was done with chi-square test and \ 0.05 value was considered significant. results: 31 patients were identified (20 female; mean age 45. 4, range 23-73) . mean bmi at inclusion was 41.6(range 31.6-62.4). mean %ewl and %tbwl at 6 months was 37.1 and 16.7 respectively (table 1) .non procedure related complications were observed. comparing the two groups there was significant(p \ 0.05) difference in terms of %ewl and %tbwl (table 2) ,with better results in group 2. there was also a significant improvement in the baros scale in the patients in group 2. conclusions: ma before esg has a fundamental role in terms of better procedure outcomes for both weight loss and quality of live in obese patients. 2 gastroenterology, hadassah medical center, jerusalem, israel, israel aims: the over-the-scope clip (ovesco) is a novel endoscopic tool that enables non-surgical management of gastrointestinal defects. the aim of this study was to report our experience with ovesco for patients with staple line leaks following laparoscopic sleeve gastrectomy (lsg). methods: a prospectively maintained irb-approved institutional database was queried for all patients treated with ovesco for staple line leaks following lsg from 2010 to 2018. primary outcome was complete resolution of leak following ovesco as defined by return to complete oral nutrition and no evidence of leak on imaging. secondary outcome was the number of additional endoscopic or surgical procedures needed following ovesco. results: twenty-five patients (12 males, 13 females) were treated with ovesco for staple line leaks following lsg. the median age was 35 years (range 18-62), and mean body mass index was 44 kg/m 2 . nine patients (35%) were referred from an outside hospital. the median time from index operation to leak diagnosis and from leak diagnosis to ovesco was 18 days (range 2-118), and 6 days (range 1-120), respectively. all patients had upper staple-line leaks near the gastroesophageal junction. initial treatment included antibiotics-6 patients; computed tomography guided drainage and antibiotics-7 patients; and laparoscopic drainage-12 patients. ovesco led to final resolution of leak in 8 patients (33%) within 70 days of clip deployment (range 41-136). leaks which persisted following ovesco were eventually resolved with a combination of ovesco and stent-5 patients (21%), total gastrectomy and esophago-jejunostomy-10 patients (42%), and endoscopic suturing-1 patient (4%). one mortality was noted in a patient who suffered multiorgan failure. the number of additional endoscopic sessions ranged from 1 to 10 (median 2). no procedure related complications were noted. all patients were treated with total parenteral nutrition and the total length of stay was 49 days (range 13-127). conclusions: despite its low success rate, ovesco should be part of the bariatric surgeon's non-surgical armamentarium in treating staple line leaks following lsg. r. bademci 1 , r. vilallonga 2 , p. alberti 2 , r. renato 2 , c. yuhamy 2 , s.s. cordero 2 , l. posadas 2 1 general surgery, istanbul medipol üniversitesi, istanbul, turkey; 2 bariatric surgery, vall d'hebron, barcelona, spain background: in cases of morbid obesity, treatment is generally applied as either a surgical or endoscopic approach. the number of primary obesity surgery endolumenal (pose) procedures is increasing but the reliability and effectiveness is unclear as yet. the aim of this study was to present a series of cases that required revision surgery due to pose failure and to reveal possible alternative surgeries. materials and methods: a retrospective comparison was made of the data of obese patients with pose failure and conversion to surgical procedures between 2016 and 2018 in respect of operation, medical illness and bmi results. results: the patients comprised 60% females, 40% males with a mean age of 44.8 ± 12.4 years and mean follow-up period of 12.6 ± 8.3 months. on average, patients lost 24.1 ± 8.9 kg, with an average excess weight loss of 47.6%. conclusion: no firm conclusions can be drawn from such a small group. although sg seems to be a safe procedure and should be considered as the first technique to be applied following pose failure, it is possible to perform gastric bypass on patients with this endoscopic precursor. introduction: the population of post bariatric surgery patients is rapidly increasing worldwide. due to the altered anatomy post roux-en-y gastric bypass (rygb), conventional endoscopic management for choledocholithiasis is challenging. these patients are now commonly managed by means of a laparoscopic assisted ercp. although effective, this requires significant resource utilization and potential morbidity related to the need for surgical intervention. we present our preliminary experience with a purely percutaneous management of choledocholithiasis in bariatric patients post-rygb. methods: a retrospective single center review identified five patients with choledocholithiasis after bariatric rygb who underwent percutaneous cbd access and treatment by interventional radiology. four patients underwent percutaneous transhepatic cbd access while one patient underwent percutaneous trans-cholecystic cbd access. in three of the five patients conscious sedation alone was sufficient to perform the procedure. results: all patients had radiologically confirmed choledocholithiasis and were clinically symptomatic prior to intervention. the biliary tree was successfully accessed percutaneously and cleared in all five patients. in the four patients where a percutaneous transhepatic access was utilized, three patients required only fluoroscopic balloon sphincterplasty and sweep of the cbd to clear the ductal stones, while the fourth required percutaneous cholangioscopy assisted lithotripsy for clearance. in the fifth patient with non-dilated intrahepatic bile ducts a trans-cholecystistic approach into the cbd was utilized with percutaneous cholangioscopic assistance to clear the ductal stones. all procedures were completed successfully with no post procedure complications. conclusion: percutaneous clearance of cbd stones in bariatric patients presents a minimally invasive alternative to current surgical practice. the use of conscious sedation and the purely percutaneous approach may potentially reduce morbidity and resource utilization for this increasingly common clinical scenario. laparoscopic narbona-arnau procedure to control the gerd after lsg-3 years results of a prospective study i.c. hutopila, c. copaescu background: after the laparoscopic sleeve gastrectomy (lsg) alone or associated with calibration of the esophageal hiatus, for some patients the reflux symptoms worsen postoperatively due to development of a hiatal hernia (hh) or due to the recurrence of the hh previously repaired. for these situations, when the conservative treatment fails, are proposed some surgical solutions, one of them cardiopexy with teres ligament-narbona arnau. objective: is to establish a standardized laparoscopic technique for cardiopexy using the teres ligament (narbona arnau technique) and to analyze the procedure's outcomes. methods: the study was performed in a bariatric and metabolic center of excellence-ponderas academic hospital. all the patients undergoing narbona arnau procedure to control gerd after lsg since 2014 were included and prospectively analyzed. the selection criteria included lsg patients, presenting hh and symptomatic gerd. preoperative investigations were upper gastrointestinal endoscopy, radiological contrast study, ph-metry, computed tomography with oral contrast. results: 28 patients were included into the study. gerd and hh were preoperatively documented in all the cases. one patient was excluded after 2 years of follow up after being converted to a laparoscopic roux-en-y gastric bypass, for intense relux symptoms. no incidents during surgery. for 8 cases laparoscopic narbona arnau technique was performed concurrent with re-sleeve gastrectomy and gastric curvature plication. without postoperative complications. postoperative follow-up at 6 months, 1, 2 and 3 years, the percentage of patients without gerd symptoms and free of treatment with ppis was 64,28%, 82,14%, 71,42%, respectively 66.66%. at 3 years postoperatively the upper gi endoscopy showed remission/ improvement of the degree of esophagitis for 17 patients. for the same period of follow-up, the ph-metry highlighted a normal value of demeester score for 62.96% o patients (all the patients had preoperatively high de meester scores). no objective signs of hiatal hernia recurrence at imagistic investigations and upper gastrointestinal endoscopy were encountered. conclusions: complete preoperative evaluation is mandatory for choosing the optimal intervention. laparoscopic narbona arnau technique after lsg is proved to be a good option for the treatment of symptomic gerd, but further studies with high-volume patients are necessary. introduction: the aim of this study was to investigate the influence of baseline glycated hemoglobin level (hba1c) level in bariatric patients on postoperative outcomes. we found scarce of clinical data regarding influence of baseline hba1c on bariatric surgeries postoperative morbidity and readmission what was inspiration to conduct this multicenter retrospective study. methods and procedures: retrospective cohort study analyzed patients who underwent laparoscopic: sleeve gastrectomy (sg), roux-en-y gastric bypass (rygb) or mini-gastric bypass (mgb) for morbid obesity in seven referral bariatric centers. patients were divided into groups depending on preoperative hba 1c : hba 1c \ 5.7%; 5.7-6.4% and c 6.5%. primary endpoints: influence of hba 1c level on perioperative (30-days) and postoperative (12-months) morbidity rates, operation time, length of hospital stay (los) and readmission rate. results: study group included 2125, 68% females and 32% males. median age was 43 (35-52) years. median hba1c was 5.7 (5.3-6.1). hba1c \ 5.7% was present in 49% patients, hba1c5.7-6.4% in 35%, and hba1c c 6.5% in 16%. percentage of male patients increased in groups from 26% in hba 1c \ 5.7% to 47% in hba 1c c 6.5% significantly. same tendency through groups we observed in case of bmi and age. uncontrolled diabetes (hba 1c c 6.5%) was present in 8.7% patients, while 7.62% patients were not on antidiabetic medications despite having hba 1c c 6.5%. median operative time in patients was significantly longer than in hba1c \ 5.7% and hba1c 5.7-6.4%. 30-days morbidity rate was 5.27% and did not differ groups significantly, as 12-months morbidity rate (excl. 30-days) of 2.02% . los did not differ groups significantly. patients having hba1c in range of 5.7-6.4% and with hba1c c 6.5% did not have significantly increased odds for perioperative morbidity, 12-months postoperative morbidity as compared with those with hba1c \ 5.7%. patients with hba1c c 6.5% had increased or for prolonged los as compared to those with hba1c \ 5.7% (or 1.45; 95% ci 1.07-1.97). hba1c did not influence or for readmissions. patients with baseline hba 1c c 8% had significantly increased chances for hospital readmission (or 3.53, 95% ci 1.35-9.21). conclusion: baseline level of hba1c did not influence chance for perioperative morbidity, 12-months postoperative morbidity and prolonged los. patients with hba1c c 8% have increased chance for hospital readmissions. surg endosc (2019) 33:s485-s781 introduction: surgical resection is crucial for curative treatment of rectal cancer. through improvements in treatment and minimally invasive techniques, 5-year survival improved to over 60% of patients. the most recently introduced surgical technique is robotic-assisted surgery (ras). ras and conventional laparoscopy (cl) seem equally effective in terms oncological control. however, ras possibly provides further advantages e.g. 3d vision or the endowrist function, which have the potential to maximize the precision of surgery and thus has benefits for functional outcomes such as sexual function as well continence. therefore, the aim of this systematic review and meta-analysis was to compare functional outcomes of cl and ras for rectal cancer. materials and methods: this review was done according to the prisma and amstar guidelines andregistered with prosper-o(crd42018104519). the search was planned with the pico criteria and conducted on medline (via pubmed), web of science and central. two independent reviewers first screened titles and abstracts and then eligible full-texts. inclusion criteria were original studies, comparative studies for cl vs. ras for rectal cancer as well as reporting of functional outcomes. quality assessment was done with the newcastle-ottawa-scale for non-randomized studies and the cochrane tool to assess risk of bias for randomized trials. results: the search retrieved 9603 hits, of which 51 studies with 26225 patients met inclusion criteria. preliminary results yielded a lower rate of urinary retention for ras (odds ratio (or)[95%-confidence interval (ci)] 0.64 [0.45, 0.91] ) while there were no differences for ileus (or[ci]: 0.90 [0.77, 1.04] ). erectile function (iief) showed no differences after 3 (mean difference (md)[ci] 0.80 [-1.63, 3.21] , 6 (md[ci] 1.60 [-0.69, 3.89] ) and 12 months (md[ci] 1.11 [-1.70, 3.93] ). in terms of urinary problems (ipss) there were no differences 3 postoperative (md[ci] -0.96 [-2.16, 0. 23]) and 6 month postoperative md[ci] -0.92 [-1.96, 0.11] ), but advantages for the cl group after 12 months md[ci] -1.05 [-1.89, -0.21] ). discussion: ras and cl seem to provide similar functional outcomes after rectal cancer surgery. however, the results need to be interpreted carefully as none of the studies had any functional outcome defined as primary endpoint. future studies should evaluate both surgical approaches in terms of functional outcomes and should be appropriately powered. methods: from april 2014 to november 2018, 252 laparoscopic right colectomy with intracorporeal anastomosis were performed in our surgical department. all patients in both groups were perioperatively managed using an eras pathway. seventy-two patients had the enterotomy closed with a single layer running suture of filbloc tm (assut europe). these patients were matched with 72 patients who underwent intracorporeal right colectomy with enterotomy closed with a 'hybrid' double layer technique (first layer interrupted stitches in maxon tm 3-0 (covidien), second layer using a running suture in pds tm .intraoperative variables, anastomotic leak rate, morbidity and mortality rates were analyzed. results: the two groups were homogeneous with respect to demographics, body mass index (bmi), american surgical association score (asa) as well as for tumor stage. in the barbed group, median operating time was 121.5 min vs 140.7 min in the hybrid group (p = 0.02). anastomotic leak occurred in 5 (6.7%) patients in the hybrid vs 2 (2.7%) patients in the barbed group (p = 0.24) all patients required a reoperation. intraoperative findings at shows in 2 (0.4%) cases in the hybrid group a leak at the enterotomy closure, while an intact staler access was observed in both patients in the barbed group. no difference was observed with respect to non-infectious complications between the two groups (p = 0.55). patients in the hybrid group experienced a longer hospital stay when compared to the barbed group (p = 0.03). a re-admission occurred in the hybrid due an intraabdominal collection, while no re-admission was observed in the barbed group. no patient died in the postoperative period. conclusion: our results shows that the use of knotless barbed suture for enterotomy closure after laparoscopic intracorporeal right colectomy is safe, reproducible and associated with shorter operative time. aims: the accurate measurement and staging of rectal cancer, in particular the distal margin of low rectal tumours, is of paramount importance to optimise oncological surgical resection whilst preserving function. it is well recognised that the lower the tumour, the greater the technical challenges, operative time and the possibility of a temporary or permanent stoma. accurate localisation of the tumour is also essential to assist the multi-disciplinary team when considering neo-adjuvant chemoradiotherapy (crtx). the objective was to compare tumour height as reported on magnetic resonance imaging (mri) with endoscopic measurement. methods: a retrospective analysis of rectal tumour heights on pre-operative endoscopy and mri in patients undergoing radical colorectal surgery with curative intent over 3 years from january 2015. rectal tumours were identified as within 15 cm of the anal verge (av). all mri measurements were reported by one of two specialist gastrointestinal radiologists. measurements were taken from the lowermost point of the tumour to the av. endoscopic measurements were as recorded by 11 endoscopists including 2 rectal surgeons, 4 general surgeons, 4 gastroenterologists and a clinical nurse specialist endoscopist. results: records of eighty one patients with histologically confirmed rectal adenocarcinoma were reviewed. median age was 64 years (35 to 93). twenty three patients had 2 or more endoscopies. on mri the median tumour height from the av was 10.75 cm (3.5-18 cm) . on endoscopy the median tumour height was 23 cm (1-45 cm) . on comparing endoscopy with mri, the median difference was 12 cm (0-24 cm) . for over a third of patients (36%) tumours were lower on mri than endoscopy, median difference 12.25 cm (0.5-24 cm) . only rectal surgeons documented tumour height in relation to the rectal folds. the majority of the repeat endoscopies were performed by surgeons to locate tumours more accurately pre-surgery. on no occasion was it documented whether the tumour had been measured during insertion or withdrawal of the endoscope. conclusions: precise localisation of rectal tumours is imperative to plan complex surgery and give informed counsel to patients. this study demonstrates the urgent need for a standardised protocol for all endoscopists to use while recording the distal extent of rectal tumours. objectives: the aim of the present rct was to compare the incidence of genitourinary (gu) dysfunction after elective laparoscopic low anterior rectal resection and total mesorectal excision (lar ? tme) with high or low ligation (ll) of the inferior mesenteric artery (ima). secondary aims included the incidence of anastomotic leakage and oncological outcomes. background: the criterion standard surgical approach for rectal cancer is lar ? tme. the level of artery ligation remains an issue related to functional outcome, anastomotic leak rate, and oncological adequacy. retrospective studies failed to provide strong evidence in favor of one particular vascular approach and the specific impact on gu function is poorly understood. methods: between june 2014 and december 2016, patients who underwent elective laparoscopic lar ? tme in 6 italian nonacademic hospitals were randomized to high ligation (hl) or ll of ima after meeting the inclusion criteria. gu function was evaluated using a standardized survey and uroflowmetric examination. the trial was registered under the clinicaltrials.gov identifier nct02153801. results: a total of 214 patients were randomized to hl (n 111) or ll (n 103). gu function was impaired in both groups after surgery. ll group reported better continence and less obstructive urinary symptoms and improved quality of life at 9 months postoperative. sexual function was better in the ll group compared to hl group at 9 months. urinated volume, maximum urinary flow, and flow time were significantly (p \ 0.05) in favour of the ll group at 1 and 9 months from surgery. ultrasound measured post void residual volume and average urinary flow were significantly (p \ 0.05) better in the ll group at 9 months postoperatively. time of flow worsened in both groups at 9 months compared to baseline. there was no difference in anastomotic leak rate (8.1% hl vs 6.7% ll). there were no differences in terms of blood loss, surgica l times, postoperative complications, and initial oncological outcomes between groups. conclusions: ll of the ima in lar ? tme results in better gu function preservation without affecting initial oncological outcomes. hl does not seem to increase the anastomotic leak rate. introduction: robotic single-site cholecystectomy (rssc) has been known to have some advantages such as reducing stress of the surgeon compared to single incision laparoscopic cholecystectomy (silc). however, there are few studies comparing the perioperative outcomes of these two operative methods. patient and methods: between march 2014 and february 2018, 145 rssc and 268 silc were performed for benign gallbladder disease in our center. propensity score matching was performed to control variables including sex, age, body mass indes (bmi), diagnosis, american society of anesthesiologist (asa) score and 145 cohorts were selected among the silc group through 1:1 matching. the perioperative data of these 290 patients were analyzed retrospectively. the diagnosis was classified into acute cholecystitis, chronic cholecystitis, and gallbladder polyp. results: patient demographics between the two groups were evenly matched. total operation time including docking time was slightly longer in rssc group (48.1 min vs. 42.6 min, p \ 0.001), but real working time except the docking or set-up was shorter in rssc group (19.2 min vs. 23.5 min, p \ 0.001). conversion to additional robotic arm or additional port was frequent in silc group (0 vs. 5 cases, p = 0.03). intraoperative bile spillage rate (13.8% vs. 11.7%, p = 0.725) and postoperative hospital stay (1.8 days vs. 1.7 days, p = 0.091) were comparable in both group. conclusion: both surgical procedures performed safely. but the rssc demonstrated the better performance of the operation with shorter working time and the advantage of overcoming unexpected difficulties during the surgery with low conversion rate compared to silc. even though laparoscopic cholecystectomy(lc) is the gold standard procedure for cholelithiasis, patients are still suffering from various causes of pain. one of main causes is high pressure by pneumoperitoneum which makes peritoneal stretching and diaphragmatic irritation. however, there are few well-designed studies for evaluating pneumoperitoneum. therefore, we conducted a study to compare the postoperative pain after lc at serial different pressure methods. a prospective randomised double blind study was done in 147 patients with benign gallbladder disease. they were divided into 3 groups. each 49 patients underwent lc with different pneumoperitoneum method; group a: far-low (6-8 mmhg), goup b: low (9-11 mmhg) and group c: standard pressure (12-14 mmhg). three groups were compared for pain intensity, duration, analgesic requirement and complications. post-operative pain score was significantly least in far-low pressure group as compared to low or standard pressure group during late periods (12, 24 h). but, there were no pain score difference between far-low and low groups during early period (1, 2, 4, 8 h) even though scores of standard group were significant higher than those of low group. number of patients requiring rescue analgesic doses and intraoperative complications were not significantly different among 3 groups. this study demonstrates reducing the pressure of pneumoperitoneum results in reduction in intensity of post-operative pain. this study also shows that low pressure technique is safe with comparable rate of intraoperative complications. however, in immediate postoperative period, there is limitaton of pain relief after low pressure surgery. therefore, there may need new alternatives for pain. background and aim: anatomical hepatectomy with the glissonian approach is widely accepted as an important technique to ensure surgical safety and curability of the carcinoma. however, the histomorphological structure of the hepatic connective tissue is not sufficiently understood by surgeons. this study aimed to clarify the hepatic connective tissue structure using modern tissue imaging and analytical techniques. materials and methods: in total 5000 stained thin slices were loaded onto the computer and were reconstructed as 3dimages and analyzed. results: when the liver capsule enters the liver at the hepatic hilum, it becomes a sheath which envelops the portal pedicle. the hepatocytes in a row that constitute the periportal limiting plate at the edge of the hepatic lobule are firmly supported by the framework of the reticular fiber. the hepatic lobule and the portal area are in contact via the periportal space of mall. the framework of the limiting plate plays a role of a capsule of hepatic lobule (proper hepatic capsule) on the side in contact with the portal area. the binding site between the hepatic capsule and proper hepatic capsule (ppbs) is loose binding and is a layer that is easy to apply to surgical procedures. in order to enter between the liver capsule which became the sheath of the portal pedicle and the proper hepatic capsule at the hepatic hilum, the liver capsule must be dissected to reach the surface of the proper hepatic capsule. then, on the one hand, the portal pedicle is firmly gripped and pulled, on the other hand, the hepatic parenchyma covered by the proper hepatic capsule is pushed to expand between the portal pedicle and the liver parenchyma. at this time, the portal area (glisson's sheath) branched from the sheath of the portal pedicle into the gap of the hepatic lobule breaks like a string. with this dissecting plane, dissecting layer can reach to the next branch of the portal pedicle without entering into the portal pedicle or liver parenchyma. conclusion: understanding the connective tissue constituting the liver and conducting surgery turns the laparoscopic systematic hepatectomy into a standardized procedure. background: postoperative pancreatic fistula (popf) is the primary contributor to morbidity after distal pancreatectomy (dp). to date, no techniques used for the transection and closure of the pancreatic stump showed a clear superiority over the others. this study aimed to compare the rate of popf after pancreatic transection conducted with the reinforced stapler (rs) and ultrasonic dissector (ud) following dp. method: consecutive patients underwent dp from 2014 to 2017 were retrospectively reviewed. we included dps where pancreatic transection was performed by rs or ud and excluded dps extended to the pancreas head. to overcome the absence of randomization, we conducted a propensity matching analysis according to risk factors for popf. results: overall, 200 patients met the inclusion criteria. the rs was employed in 108 patients and ud in 92 cases. after the one-to-one propensity matching, 92 patients were selected from each group. the matched rs and ud cohort have no differences in baselines characteristics except for the mini-invasive approach, that was more common in the ud group (34% vs. 51%, p = 0.025). overall, 48 patients (26%) developed a popf, 46 a grade b (25%) and 2 (1%) a grade c. in the rs group the rate of popf was 12% (n = 11) and the ud group 38% (n = 35) with a p \ 0.001. conclusion: the results of this study suggest that the use of rs for pancreatic transection, reduces the risk of postoperative pancreatic fistula. a randomized trial is needed to confirm these preliminary data. aim: this study compares clinical and cost outcomes of robot-assisted single port and open longitudinal pancreaticojejunostomy (rlpj and olpj) for chronic pancreatitis. single incision mis needs more manual skills than conventional multiport operation. the advantage of better operation course is 3d vision and dedicate instrument. this paper aims to evaluate the feasibility and safety of the robot-assisted single incision with single port platform for chronic pancreatitis. materials and methods: clinical and cost data were retrospectively compared between open and ralpj. we collected 21 patients since july, 2015 to september, 2018. the patient was supinely placed in reverse trendelenburg position. the assistant surgeon was located between patient's legs. under general anesthesia a trans-umbilical 4.0 cm skin incision was made. a single incision advanced access platform with lagis port, glove portò (nelis, s. korea) and gelpoint combined with the da vinci si and xi surgical system (intuitive surgical, sunnyvale, ca, usa) pure or plus one was performed. the three arms, no. 1, no. 2, and da vinci scope, were in dwelled through the glove portò. pneumoperitoneum of 12 mmhg was established through the port. a rigid 30-degree up scope was used during operation. results: twenty-one patients underwent lpj: 5 open and 16 ralpj. no robot-assisted cases converted to open were noted. patients undergoing ralpj had less intraoperative blood loss, a shorter surgical length of stay, less postoperative pain and lower medication costs. operation supply cost was higher in the ralpj group. no obvious difference in hospitalization cost was found. conclusions: versus the open approach, ralpj performed for chronic pancreatitis shortens hospitalization, less postoperative pain and reduces medication costs; hospitalization costs are equivalent. a higher operative cost for ralpj is mitigated by a shorter hospitalization and less pain control. robotassisted puestow procedure using single port platform is feasible and safe method. the total procedures by da vinci robotic system are safe and easily performed in highly selected patients. 2 general surgery, hospital universitario infanta sofia, madrid, spain; 3 general surgery, hospìtal quirón la luz, madrid, spain aims: the concomitant presence of abdominal wall midline hernias and diastasis recti is frequent. diastasis recti might be a risk factor not only for having but for recurrence of midline hernias. most open surgical procedures not consider the treatment of both pathologies, nor laparoscopic most spread out approaches. the author presents a novel endoscopic, extraperitoneal and retromuscular hernioplasty technique and its preliminary results. methods: a serie of 15 patients is presented. a ct abdominal wall study is performed preoperatively. they all presented abdominal wall midline hernias in presence of a [ 3.5 cm concomitant diastasis recti. there were 8 females and 8 males. a totally endoscopic, extraperitoneal and retromuscular repair was performed, that included a midline anatomic restoration, tension-free hernia gap closure, omphaloplasty and skin treatment, if needed in every case. the tension-free massive-meshed hernioplasty included a bilateral totally endoscopic posterior components separation when needed. no drainages were used. all procedures included a bladder catheterization. results: all patient were dispatched within a period under 48 h. no reoperations were needed in postoperative period. postoperative pain was measured by an eva scale. 85% of the patients have no pain medication after 24-48 h dispatching from hospital. 25% of the patients have a skin suffusion or hematoma. a male patient presented a temporary abdominal asymmetry due to a unilateral posterior component added to his technique. the mean following-up is to 6 months (1-12 months) . no recurrence was observed. conclusions: preliminary results demonstrate this new approach to be a safe, feasible and a reproductible procedure. the 'terra' novel technique could provide of a new minimally invasive approach to abdominal wall midline hernias repair in the presence of a diastasis recti. only time and new results can predict the spreading out of this 'third way'. results: this study comprised 15 males and 12 females. mean age was 62 years (range 33-82 years) and mean body mass index was 30. gh and mh were found intraoperatively in 22 and 5 cases respectively. mean operative time for all hernias (gh/mh) was 122 min (range 70-240 min); 113 min for gh (range 70-155 min); and 169 min for mh (range 105-240 min). in 51.8% of cases, hernia operative measurement was larger than preoperative size, especially in cases of incisional hernias (64.2%). in 29.6% of cases, laparoscopy found additional abdominal wall defects previously undetected by physical examination and by us-and/or ct-scan. a composite mesh and a non-composite mesh (up to 30 cm in size) were used in 96.3% and 3.7% of cases respectively. the ethicon securestrap?? absorbable fixation device straps for sm fixation were employed in 77.8% of cases. mean length of hospital stay was 2.8 days. mean follow-up time was 33 months (range 1-109 months). in our study, there was one early (\ 30 days) postoperative seroma (3.7%), plus one late, small (2 cm) symptomless recurrence, but neither needed reoperation. conclusion: the sutureless sm technique facilitates intra-abdominal introduction, as well as the handling and fixation of large/very large meshes. this new approach is safe and fast, even in cases of gh/mh repair. aims: any ventral hernia (vh) combined with rectus muscle separation (rms) must be repaired along with repairing the rms, otherwise there is a high risk for hernia recurrence. open rms repair is vast and traumatic surgery and laparoscopy is not effective. at 2015 a new era of repairing abdominal wall hernia by assisted endoscopy started with wolfgang reinhold's milos procedure. these procedures are somewhat complexed and real reconstruction of the linea alba (la) was limited, which done better by ferdinand koeckerling's elar technique. we perfected the elar technique to be fully endoscopic with wide mesh fusing to the muscles immediately by fibrin glue: extended endoscopic hernia & linea alba reconstruction glue (eehlarglue), achieving a low traumatic mis for vh and rms with excellent surgical and cosmetic results. methods: our eehlarglue is a totally endoscopic based technique used since 2017. penetrating with optiview trocar and co2 pressure to the anterior rectus sheet (ars) level is followed by an extensive endoscopic dissection of the sub-cutaneous fat tissue from the ars. three trocars are inserted at the supra-pubic line enabling the dissection up to the xiphoid and costal margins laterally. any hernia sac is dissected, and the content reduced back to the abdominal cavity. relaxing incisions of the ars are performed longitudinally in the lateral aspect. the la is reconstructed by running two layers of non-absorbable sutures from xiphoid to pubis. a light mesh 30x15 cm is applied over the repair and the mesh is fused immediately to the muscles by fibrin glue. results: 25 patients underwent the eehlarglue with follow up of 24 months. all had significant rms of 5-10 9 14-26 cm combined with primary or recurrent vh. recovery was smooth with 1-3 days of simple analgesics and return to regular activity within 4-10 days. no one had recurrent vh, but two males had limited rms and two early cases seroma formation. conclusions: our eehlarglue enables endoscopic vh repair and la reconstruction with extrastrength received by immediate mesh fusion to muscles with fibrin glue. thus, achieving low traumatic mis, easy recovering and very effective results-a perfect solution for patients with vh combined with rms. results: twelve blinded prospective rcts were used. when compared to tep repair, tapp repair has comparable seroma formation rates (chi 2 = 7.94; (p = 0.02); ci -4.31, 0.55; i 2 = 75%) and post-op pain at 24 h (chi 2 = 30.28; (p = 0.00001); ci -0.31, 0.06; i 2 = 87%). however, tep repair is associated with a significantly shorter operative time (chi 2 = 502.95; (p = 0.00001);ci 0.24, 0.48; i 2 = 98%), post-op pain at 1 hour (chi 2 = 11.26; (p = 0.004); 0.05, 0.30; i 2 = 82%) and shorter hospital stay (chi 2 = 455.14; (p = 0.00001); ci 0.72, 1.07; i 2 = 99%). conclusion: tep is significantly better than tapp repair with regards to operative time, post-op pain at 1 h and hospital stay. there is no significant difference with regards to post-op pain at 24 h and seroma formation. background: primary hyperhidrosis (ph) is a neurological condition characterized by excessive sweating most often of the face, palms or axillae . palmar hyperhidrosis is treated through sympathetic chain clipping or transection .we aiming to compare the efficacy and results obtained with both techniques. patients and methods: sixty four patients underwent of 128 sympathetic procedures from march 2013 to february 2017. the patients were categorized into two groups: right sided transection sympathectomy and left sided clipping . patients were evaluated to compare the rates of success, satisfaction, compensatory sweating and recurrence either with transection or clipping of the t3 andt4 ganglion .mean follow up was 15 ? _7 months. results: sixty four patients 24 males and 40 females undergoing electro-coagulation sympathectomy on the right side and clipping on the left side. with mean age was 15 years (range 13 to 18 years). all patients had balanced demographic data . no statistical difference between the two groups according rate of success. compensatory sweating was observed in 28 patients (43.75%) overall with 4 cases of severe unsatisfied compensatory sweating. recurrence was reported in one case with transection and 2 cases in clipping. satisfaction was occurred in 63 cases in transection group and 61 cases in clipping group .pnumothorax was occurred in 2 cases in transection group compared to one case in clipping. no gustatory sweating and over dryness were reported in both groups. conclusion: both thoracoscopic sympathetic transection and clipping of t3t4 ganglion are safe and effective procedure in palmar hyperhidosis treatment. with no differences regarding recurrence rate,satisfaction and incidence compensatory sweating. keywords: thoracoscopic sympathectomy,palmar hyperhidrosis, clipping, compensatory hyperhidrosis. introduction: primary ventral hernias and ventral incisional hernias pose a challenge for surgeons throughout the ages. even though minimally invasive surgery and hernia repair have evolved rapidly, there is no standardized method that adequately decreases postoperative complications. hybrid hernia repair is a surgical repair, which has not been adopted widely. it combines both a laparoscopic and open component allowing sac excision, primary defect repair as well as laparoscopic mesh insertion. aims: to evaluate the short-term and long-term outcomes of hernia recurrence for patients undergoing hybrid ventral repair (hvr) for the treatment of primary and incisional ventral hernias. methods: between october-2012 and june-2013, hybrid vhr was performed in 24-patients at st mary's hospital, imperial college london. the medical records of these patients were reviewed retrospectively for demographics, comorbidities, prior surgeries, body mass index (bmi), hernial defects, hybrid technique used; mesh selection, operative time, complications and recurrences over a 5-year follow-up. results: twenty-four patients who underwent hybrid vhr were included with surgery performed by two surgeons. the mean age is 48-years with a mean bmi of 33.1 kg/m 2 . 88% had incisional hernias and 12% had primary hernias. the number of hernia defects ranged from 1 to 4, with the average mesh size used was 15x17 cm. extensive adhesionolysis was performed in 58% of patients. 30-day postoperative complications; 2 patients developed post-operative seroma, paralytic ileus in 1, pain control in 1 and urinary retention in 1 patient. there were no conversions to open procedures. the mean length of hospital stay was 2-days. none of the patients developed chronic pain and only one recurrence over the 5-year follow-up period. conclusions: the hybrid technique for vhr is safe and feasible, and has important benefits over an open or purely laparoscopic approach, including a low rate of seroma formation, chronic pain and fiveyear hernia recurrence. future investigation may include randomized controlled trials, to fully evaluate the benefits of hybrid vhr, with careful assessment of patient-centred end-points including quality of life and postoperative pain. surgery, medical faculty-university of tetove, tetove, macedonia; 2 general medicine, medical faculty-university of tetove, tetove, macedonia; 3 anestesiology, medical faculty-university of tetove, tetove, macedonia; 4 surgery, clinical hospital-tetove, tetove, macedonia laparoscopic cholecystectomy is widely used operative technique and it's characterized with less postoperative hospitalization and side effects. duration of the hospitalization after laparoscopic surgery depends on several factors of which pain and physical weakness are the most important. dexamethasone is well known; not only for its anti inflammatory effects but at the same time for analgesic and antiemetic effects, although the mechanism of this effects are not clarified yet. objectives: the aim of our study is the evaluation of analgesic effect of dexamethasone on reducing postoperative pain after laparoscopic surgery. patients and methods: in this study, 200 patients aged 25 -74 years old undergoing laparoscopic surgery, were classified into two groups, 100 patients in each group. the first group were treated with a intravenous injection of 8 mg dexamethasone preoperatively and another dose the next day after operation. the second group received a intravenous injection of normal saline. we evaluated the dose of consumed analgesics and antiemetic's drug during the first 24 h in both groups. results: according to our experience results the total dose of tramadol in a postoperative period in dexamethasone receiving group was smaller than in normal saline group. measure of postoperative pain was assessed using the paper-based vas scale. our result shows that the intensity of post operative pain in a period during first 36 h, after surgery in a group of patients treated with dexamethasone was lower compared with the group of patients treated with normal saline. nausea and vomiting during the first 36 h was significantly lower in the dexamethasone group than in the normal saline group. 2 surgery, hospital quiron sagrado corazon, sevilla, spain; 3 surgery, hospital virgen macarena, sevilla, spain; 4 surgery, hospital virgen del rocio sevilla, sevilla, spain aims: closing the defect (cd) during laparoscopic ventral hernia repair (lvhr) could be related to a reduction of seroma formation or bulging (hernia mesh) compared to conventional lvhr. but tension of the midline may contribute for some authors to a higher incidence of pain, recurrence in medium size defects and suggest to perform a component separation (cs) for restoring the midline in medium-large defects.we have developed a new technique for restoring the midline in medium ventral hernias (lira technique) and weanalyzed our results in terms of pain and recurrence compared to our conventional cd series (ccd). methods: we conducted a prospective controlled study of lvhr with ccd from january 2014 to december 2016 and a prospective controlled study performing lira technique from january 2015 to january 2017. we analyzed and compared both techniques in medium size defects (4-8 cms) in terms of postoperative pain (1, 7 days, 1, 3 months and 1 year) using a visual analogue scale (vas), bulging (return to prior distance among rectus muscles with the mesh in the sac in ct that didn't need surgical treatment)and recurrence (by physical examination and tomography). results: ccd was performed in 42 patients (mean age was 58.10 ± 13.15 years old and mean bmi was 33.11 ± 6.61 kg/m 2 ) and lira technique in 12 patients (mean age was 56.5 ± 10.5 years old and mean bmi was 30.12 ± 5.30 kg/m 2 ). the mean average follow-up in both series was 1 year. mean average vas in ccd was 5.35 ± 2.49 (1 day), 2.01 ± 2.13 (7 days) 0.62 ± 1.45 (1 month) 0.10 ± 0.43 (3 months ) and 0 at 1 year. in lira series vas was 3.9 ± (24 h) 1.08 ± 1.78 (7 days), 0.08 ± 0.28 (1 month), 0 (3 months) and 0 (1 year) . there are 6 cases of bulging in ccd series and 1 recurrence. bulging and recurrence were absent in lira series. conclusions: lira technique might be a safe procedure in medium size defects for restoring the midline in lvhr, and could be related to a lower pain rate compared to ccd with no recurrence or bulging. surg endosc (2019) 33:s485-s781 background: the desire of pediatric surgeon to reduce incision related morbidity and pain while achieving good cosmetic results has recently led to the introduction of single incision pediatric endo-surgery [sipes] and needlescopic surgery. intracorporeal suturing and knot tying during sipes remains challenging. the aim of this study is to introduce a novel and simple technique for intracorporeal suturing of the pediatric inguinal hernia after needlescopic disconnection of hernia sac using just needles rather than laparoscopic instruments. it is an imitation of the principles of sewing machine. methods: the first author discussed the idea of the technique with the co-authors and a demonstration was done on a silicon pad before application of the technique on children with congenital inguinal hernia [cih] for peritoneum closure after needlescopic disconnection of the hernia sac. the main outcome measurements were; feasibility of the technique, knot quality, suture placement accuracy, performance and suturing time and recurrence rate. results: the sutures were snugly applied to the ridges of silicon pad with good approximation and the knot was firmly tightened in all experiments. after applying and mastering the technique on a silicon pad, we shifted to use it on 373 children with 491 hernia defect. all operations were completed by the needlescopic technique without the need for insertion of any laparoscopic instruments. the time required for suturing of the peritoneum around internal inguinal ring [iir] and knot tying, decreased considerably from 5 min 27 s in the first operation to less than 3 min after the fifth operation and stabilized at approximately 2 minute 30 s. no major intraoperative complication and no recurrence. the primary end-point was to compare clinical outcome as well as cost effectiveness study between both groups. results: a total of 148 patients were enrolled (70 of them underwent tapp and 78 olr). drop out occurred in 5 cases (2 of tapp and 3 of olr group). patient characteristics were statistically similar between the 2 groups. tapp procedure had less early post-operative pain (p = 0.037), a shorter length of stay (p = 0.031) and less postoperative complications (p = 0.002) when compared with the olr approach. a slightly higher recurrence rate in the tapp group was found. additionally, there is a trend towards a higher postoperative quality of life and less chronic pain in the tapp group. conclusions: tapp procedure for bilateral inguinal hernia effectively reduces early postoperative pain, hospital stay and postoperative complications. cannizzaro hospital, catania, italy aim: the purpose of this study was to evaluate the long-term results in terms of safety and efficacy of a new technique to repair incisional ventral hernias with a self-gripping mesh, after a mean follow-up period of 15 months. methods: a retrospective, single-centre study was performed from june 2016 to june 2018. all patients undergoing elective incisional ventral hernia repair were included. hernias were diagnosed based on clinical examination at the outpatient clinic. in case of doubtful diagnosis, ct-scan was used to confirm the diagnosis. the component separation technique and, when needed, tar were performed. the self-gripping mesh was placed in sublay position (overlap 5 cm) with the self-gripping surface face down. in all cases drainage tubes were placed in retromuscular and supraaponeurotic position. the following characteristics were collected: age, sex, body mass index (bmi), smoking, comorbidities, number of previous surgical operations, defect size (ehs classification), mesh size, postoperative complications, duration of follow-up. all patients were interviewed by telephone every six months. when patients complained recurrence or other symptoms, visits were organized and when there was the doubt of recurrence a ct-scan was performed. results: a total of 40 patients were included in this study, 21 males, mean age was 59 years. 83% of patients had bmi [ 25, smokers and diabetics were respectively 28% and 9%. the mean defect size was 115 cm 2 . component separation technique was associated with tar in 6 patients. in 11 cases the size of mesh was 20 9 15 cm, while in 7 patients the size of mesh was 30 9 15 cm and in 11 cases this was 15 9 15 cm. in the other patients the mesh sizes were tailored to defect dimensions. subcutaneous seromas occurred in 7 patients, they were treated conservatively in 5 cases and with percutaneous punction in 2 cases. long-term follow-up demonstrated recurrences in one case, while in another one ct-scan revealed a bulging. no cases of mesh infection, pain or sensation of mesh. conclusions: this study with a mean follow-up period of 15 months demonstrated that the use of self-gripping mesh in sublay position is safe and effective to treat incisional ventral hernias. aim: morgagni hernias present technical challenges. the laparoscopic approach was described at first in 1992, however, as they are uncommon in adult life and, little data exist on the optimal method of surgical management. this study purpose was to analyse a method for laparoscopic repair of morgagni giant hernias using laparoscopic primary closure. methods: this case series describes a method of laparoscopic morgagni hernia repair using primary closure. in all patients a laparoscopic transabdominal approach was used. the content of the hernia was reduced into the abdomen and the diaphragmatic defect was closed with a running laparoscopic suture using a self-fixating suture. clips were placed at the edges of the suture to secure the pledged sutures to both the anterior and posterior fascia. demographic data as age, gender and bmi were collected. operative data (operative time, rate of conversion, blood loss) and post-operative data (short and long term complications, length of hospital stay, need of readmission and reoperation) were recorded. results: retrospectively collected data about 9 patients were analysed. there were 1 (11.1%) male and 8 (88.8%) females. the median bmi was 29.14 ± 5.2 kg/m 2 . median operative time was 80 ± 25 min. there were no intraoperative complications nor conversion to open surgery. patients began a fluid diet on the first post-operative day and were discharged after a median hospital stay of 3 ± 1.87 days. in a median follow up of 36 months we did not observe any recurrences. conclusions: transabdominal laparoscopic approach with primary closure of the diaphragmatic defect is a viable approach for repair of morgagni hernia. in our experience, the use of laparoscopic transabdominal suture fixed to the fascia allowed the closure of the defect laparoscopically with minimal tension on the repairs. can we predict the success of the laparoscopic approach in the adhesive small bowel obstruction? c. tellez marques, e. sebastian valverde, e. membrilla fernandez, l. grande posa, i. poves prim general surgery, parc de salut mar-hospital del mar, barcelona, spain aims: the laparoscopic approach in the acute adhesive small bowel obstruction and internal hernias (asbo) has shown superior to laparotomy in terms of morbidity and hospital stay. especially, in patients who present simple adhesions or internal hernias. according to this, the aim of the study is to determine those preoperative factors associated with simple adhesions and internal hernias, and consequently, improve the success of the laparoscopic approach in asbo methods: a retrospective study of patients who underwent urgent surgery for asbo was conducted from january 2007 to may 2016. we compare preoperative variables between single adhesions and internal hernias vs complex adhesions. a p value \ 0.05 was considered statistically significant. results: we analysed 262 patients who underwent surgery for asbo, 78 (30%) by laparoscopy and 184 (70%) by laparotomy. conversion rate in laparoscopy was 38.5%. 49.2% of patients presented a single adhesion or internal hernia; and 50.8% were considered complex adhesions. sex and age did not correlate with the type of adhesions. previous surgery (p \ 0.001), number of previous surgeries (p \ 0.001), asa (p \ 0.001) and previous abdominal wall mesh (p = 0.002) were significantly associated with complex adhesions. laparoscopy as the only surgical history was significantly associated with simple adhesions (p = 0.033). only appendectomy (p = 0.139) or supramesocolic (p = 0.076) previous surgeries tended to present single adhesions but it did not reach statistical significance. the need for intestinal resection was not related to the type of adhesions (p = 0.743). there was a significant correlation between the findings in the ct (computed tomography) and the type of adhesion found (p = 0.001). signs of ischaemia on ct were related to the need for intestinal resection (p \ 0.001). in the multivariate analysis, the number of previous surgeries, asa and ct scan findings were identified as independent factors related to the type of adhesion. conclusions: according to our study, a lower number of previous surgeries, asa i-ii and internal hernia in the ct scan are associated with single adhesions and internal hernias. patient selection is a key factor for the success of laparoscopic approach in asbo. aims: there aims of this study were: (i) to compare england with the united states in the utilisation of minimal access surgery (mas) and in-hospital mortality from four common abdominal surgical emergencies (appendicitis, incarcerated or strangulated abdominal hernia, small or large bowel perforation and peptic ulcer perforation). (ii) within england to evaluate the influence of mas upon in-hospital and long-term mortality. methods: between 2006 and 2012, the rate of mas and in-hospital mortality for four abdominal surgical emergencies were compared between the united states and england. univariate and multivariate analyses were performed to adjust for underlying differences in baseline patient demographics. results: 132,364 admissions in england for four abdominal surgical emergencies were compared to an estimated 1,811,136 admissions in the united states. after adjustment for patient demographics, mas was used less commonly england for three conditions; appendicitis (odds ratio (or) 0.30, 95% ci 0.30-0.31), abdominal hernia (or 0.18, ) and small or large bowel perforation (or 0.48, ). in-hospital mortality in multivariate analysis, was increased in england compared to the united states for three conditions; abdominal hernia (or 1.91, 95% ci 1.81-2.01), small or large bowel perforation (or 2.33, ) and peptic ulcer perforation (or 2.02, 95% ci 1.91-2.14). in england, after adjustment for patient demographics, open surgery was associated with increased in-hospital mortality for three conditions; abdominal hernia (or 1.80, 95% ci 1.26-2.71), small or large bowel perforation (or 1.59, 95% ci 1.37-1.87) and peptic ulcer perforation (or 2.31, . similarly open surgery was associated with increased long-term mortality for three conditions; abdominal hernia (hr 1.32, 95% ci 1. 15-1.52) , small or large bowel perforation (hr 1.30, 95% ci 1.18-1.43) and peptic ulcer perforation (hr 1.69, 95% ci 1.50-1.89). conclusions: minimal access surgery was used less commonly and inhospital mortality was increased in england compared to the united states for common abdominal surgical conditions. given the benefits of mas shown in this large study, strategies to enhance adoption of mas in emergency conditions in england need to be optimised and include appropriate patient selection and improved surgeon mas training and experience. surg endosc (2019) 33:s485-s781 background: in the treatment of inguinal hernias, there is little hard evidence concerning the economic reimbursement in the diagnosis-related-group (drg) era. factors that affect whether a hospital may earn or lose financially depending on open or laparoscopic approach is still underexplored. the aim of this study is to provide a reliable analysis of in-hospital costs and reimbursements in inguinal hernia surgery. methods: this retrospective study analysed the 1-year experience in inguinal hernia repair in patients undergoing open lichtenstein (ol), laparoscopic totally extraperitoneal unilateral (utep) or bilateral (btep) hernia repair. demographics, results, costs and drg-based reimbursements were recorded and analysed. results: during the study period, 39 patients underwent ol, 82 patients utep and 16 patients btep. the average total cost amounted to 4126 eur in ol, 5134 eur in utep and 7082 eur in btep groups (p \ 0.001*). the hospital reimbursement amounted to 5486 eur, 5252 eur and 6555 eur in the ol, utep and btep groups respectively (p \ 0.001*). finally, the mean hospital earnings were 1360 eur, 118 eur and -527 eur for each patient in ol, utep and btep respectively (p \ 0.001*). conclusions: in-hospital costs were higher in utep and btep as compared to ol. the drg-based reimbursement provided adequate compensation for patients with unilateral inguinal hernia, whereas hospital earnings were profitable in ol group only, and led an overall financial loss in the btep group. surgeons should be conscious that clinical advantages of the laparoscopic approach are not adequately compensated for, from an economic point of view. aims: umbilical hernias are common anatomical defects in swine which become a suitable model for surgical training and research in the field of surgical meshes. the aim of this study was to develop a surgical protocol for a successful laparoscopic implantation of stem cell-coated surgical meshes. methods: 9 large white pigs, weighing 25-68 kg and with congenital abdominal hernia were anesthetized for the surgical procedures. non absorbable polypropylene surgical meshes were coated with fibrin glue (fg) (control group) or with fg admixed with porcine bone marrowderived mesenchymal stem cells (fg/bm-mscs). approximation of hernia's borders was performed by intracorporeal suture. the meshes were carefully rolled inside the trocar for laparoscopic implantation. the surgical implantation was performed by laparoscopy using helicoidal staples. laparoscopic inspections and biopsies of the tissue surrounding the mesh were performed at 7, and 30 days post-implantation. at day 30, the animals were euthanized and macroscopically evaluated. ultrasonography was used at day 0, 7, and 30 to evaluate the size of the hernia. the biopsies were then processed for the histological analysis. results: ultrasonography demonstrated that the mean size of umbilical hernias before mesh implantation was 2.49 ± 0.99 cm. a decrease in hernia mean size was observed at day 7 and 30. the laparoscopic procedures allowed a successful mesh implantation in all animals. in most of cases, the implantation site did not show excessive inflammation or tissue adhesions. but one animal showed hernia maintenance. one animal had peritoneal and implant-site infection. foreign body reaction was noted in the histological analysis, although no significant difference was found between the control, and bm-msc group. conclusions: the anatomical similarities between humans and pigs in umbilical hernias make this animal model useful to: i) improve minimally invasive surgical procedures for hernia treatment; ii) evaluate new surgical meshes, and iii) introducing stem cell therapy to hernia surgical repair. the laparoscopic approach is efficient and safe for the implantation of stem cellcoated meshes. gene and protein expression analysis are required to evaluate the molecular changes between the conventional and the stem cell surgical approach. aims: fluorescence angiography with indocyanine green (icg) is used as a marker in the assessment of tissue perfusion, being more frequently used in colorectal procedures. this technology has shown to be a good technique to reduce complications related to vascular supply to the anastomosis. in esophagogastric procedures blood supply to the gastric pouch, jejunum and esophagus could be evaluated by icg fluorescence imaging. it could be also used in bariatric surgery to evaluated the anastomoses, during gastric bypass, and blood supply to the gastroesophageal junction and the angle of his during sleeve gastrectomy. methods: we have collected data during 8 gastric resection due to adenocarcinoma and 53 bariatric procedures that were performed by the same surgeon, using icg fluorescence to evaluate blood supply. the icg was infused before performing the anastomosis in order to evaluate the need to change the transaction line (tl). we analyzed those cases in which the tl was changed and the number of leaks in those cases that we changed this line. results: all the 61 cases were performed by laparoscopic approach: 5 subtotal gastrectomy (sg), 3 total gastrectomy (tg), 26 gastric sleeve (gs) and 27 gastric bypass. there were no changes regarding the tl before performing the anastomosis in any of the four types of procedures (sg, tg, gs, gb). in the analyzed data there is 1 anastomotic leak in one sg procedure (1.6%). conclusions: icg fluorescence angiography could be helpful in assessing blood supply during gastrointestinal anastomosis, although we have not find an influence in the results during bariatric and gastric procedures. however, we do not have the sufficient evidence to determine the value of this technology in this entities, being needed more volume and data to improve the significance of the results. aims: hyperspectral imaging (hsi) combines a spectrometer with a camera to analyze the tissues' optical properties in a broad wavelength range, without the need for a contrast agent. it provides extensive real-time information about tissue physiology, including oxygen saturation (sto2). fluorescence-based enhanced reality (fler) is a software solution providing a dynamic, quantitative analysis of the signal evolution of a systemically administered fluorophore, during fluorescence angiography (fa) . the aim of this study was to compare the performance of hsi and fler to assess bowel perfusion, in a porcine, non-survival model of bowel ischemia. methods: in 6 pigs, an ischemic small bowel segment was created and imaged after 1 hour of ischemia. the imaging modalities were applied sequentially to the same area.hsi was performed first, to acquire the sto2 spectra, by means of the tivita tm system (diaspective vision, pepelow, germany), which provides a spectral range of 500-1000 nm and a 5 nm resolution. subsequently, fa was performed using a nir-capable laparoscopic camera (d-light p, karl storz, germany), after intravenous injection of 0.2 mg/kg of indocyanine green (icg; infracyanine, serb, paris, france). the fluorescence flow was recorded during 40 s, then the slope of the fluorescence flow was analyzed using a proprietary software to obtain a virtual perfusion cartography. the virtual cartography was overlaid onto real-time images to obtain the enhanced reality effect. ten adjacent regions of interest (rois) were selected from hsi datasets and were superimposed to fler-generated cartographies using a custom plug-in software function, allowing for a quantitative comparison of both imaging modalities. hsi was repeated after icg injection. results: the r 2 correlation coefficient between hsi-sto2 and the fler slope was 0.79. at control hsi after icg injection, the correlation coefficient dropped significantly (r 2 0.45). the interference of icg on hsi imaging was clearly identified in the spectral curves. conclusion: sto2 given by hsi provided results comparable to those obtained with fler in our bowel ischemia model, without the need to inject a contrast agent. icg interferes with hsi datasets, disrupting sto2 values. surgical treatment is one of the most effective options for treatment of giant hiatal hernia. laparoscopic approach became is a 'gold standard' over the time demonstrating all advantages of minimally invasive techniques over the open procedures. however the utility of robotic operations still remains controversial. aim of the study: evaluate the initial experience of robotic fundoplication in compare to laparoscopic procedures. materials and methods: since the january till the december of 2017 thirty operations were operated on. mean age was 57.2 (44-76), among them 12 (65%) were female and 6 (35%) were males. mean bmi was 29.4 (24. 1-41.0) . laparoscopic procedures were performed in 8 patients (1st group), robotic procedures with davinci system were performed in 10 patients of the second group. nissen fundoplication modified was performed in 14 patients, toupet fundoplication was used for 4 patients. results: the median operative time in laparoscopic group was 150 min, in robotic group-131,2 min. there were no statistical differences between two groups (p = 0.93). blood loss was minimal in both groups. mean postoperative hospital stay was 4.08 days (2-7 days) in the 1st group and 3,6 days (2-6 days) in the second. there were no statistical differences between two groups (p = 0.19). postoperative course was uneventful in all patients of both groups. surgical stress response is associated with systemic inflammatory syndrome, sepsis, multiorgan dysfunction syndrome. robotic assisted surgery has been introduced to overcome the limitations of conventional laparoscopy. this technique has potential advantages over laparoscopy, such as increased dexterity, three-dimensional view, and a magnified view of the operative field. these advantages could result in limited intra-abdominal trauma and hence in attenuated surgical stress response over conventional laparoscopy. aims: this study aimed to synthesize data on the effect of robot assisted surgery on surgical stress response. methods: electronic databases were searched with the search terms 'surgical stress', 'stress response', 'oxidative stress', 'robotic assisted surgery', 'c-reactive protein', 'interleukin 6', 'interleukin 10','cortisol',;'oxidative stress markers', 'antioxidants', 'antioxidant status', 'mda', 'glutathione', 'cortisol', 'acute phase response' up to and including march 2018. results: one hundred forty studies were identified and their title and abstract were reviewed. one randomized controlled trial, six non randomized comparative studies, one experimental study and one case report met inclusion criteria. data were discordant. one prospective trial concluded that cortisol and il-6 were lower in laparoscopic assisted distal gastrectomy compared with robot assisted distal gastrectomy in another study comparing robotic assisted laparoscopic radical prostatectomy with open radical prostatectomy based on plasma measurements of il-6, il-1a and c-reactive protein, it was demonstrated that robotic assisted laparoscopic radical prostatectomy induces lower tissue trauma than open radical prostatectomy. in another study, it was reported reduced expression of genes associated with surgical stress response in patients treated with robotically assisted radical prostatectomy compared with patients treated with open prostatectomy. the case report concerned a case of polymyalgia rheumatic after robotic assisted laparoscopic prostatectomy. the experimental trial demonstrated that cortisol and substance p were significantly higher with open thoracic approach versus robot assisted thoracoscopic oesophageal surgery. conclusion: further research is needed to elucidate the effect of robotic surgery on surgical stress, based on a well standardized protocol for the measurement of surgical stress response. purpose: tissue compression is essential to prepare the tissue for proper staple formation. this study evaluates the risk factors of compression injury on the circular stapling line in vitro. methods: to reproduce the artificial bowel wall, a collagen plate was prepared by mixing collagen extracted from porcine with glycerin. artificial collagen plates with 4 mm and 6 mm in the thickness were made for dry and healthy condition and immersed plates in the tap water for 10 min to make wet and edematous condition. circular stapler (cdh25a, ethicon, usa) was applied in the collagen plates (dry and wet condition) and optimal compressions. compression line was evaluated for compression injury score. risk factors for excessive compressions and unacceptable injury were analyzed. results: in the dry condition, optimal compression didn't cause unacceptable injury. in the wet condition, excessive compressions were occurred in 47.1% with optimal approximation. unacceptable injury was significantly different in proper and excessive compression cases as 18.8% and 5.6%, respectively. on the univariate analysis, thickness (6 mm), wet condition, proximal side, maximal compression, and excessive compression were associated with unacceptable injury. on the multivariate analysis using logistic regression model, excessive compression was significant independent factor to cause tissue injury (p \ 0.001) and this significance was also proved in the optimal compression group (p = 0.021). background: minimal invasive appendectomy gained much popularity due to its better cosmoses, early recovery and less wound site infections. single incision laparoscopic appendectomy (sila) has many disadvantages such as, long operative time, bad ergonomics, surgical site infections, high conversion rate and port site hernia. needlescopic appendectomy (na) using mediflexò facial closure needle expected to be more superior over sila. here in we compare our results of needlescopic appendectomy with single-incision one. material and methods: one hundred and twenty patients with acute non complicated appendicitis were randomly assigned to na and sila 60 children for each group during the period between january 2015 to october 2018. the main outcome measurements included, demographics, operative time, intraoperative complication, conversion rate, post-operative hospital stay, surgical site infection, port site hernia and cosmetic results. results: a total of 120 children underwent appendectomy. there were 60 children who underwent na and 60 children who underwent sila. there were no difference in age (11.5 vs 11.98 years, p = 0.35), weight (42.98 vs 43.46 kg, p = 0.76) and hospital stay (1.51 vs 1.55 days, p = 0.92) between the two groups. there were no intraoperative complication during the two surgical approaches. operative time for na group is significantly shorter than single incision group (20.7 vs 38.2 min, p = 0.0001). no single case of conversion in na group and 18 cases needed conversion in sila group. seven cases of sila showed surgical site infection. 2 cases of sila group presented with port site hernia. the na group was superior as regard ergonomics. the two groups showed equal excellent cosmetic results. conclusion: needles scopic appendectomy and sila are comparable as regard cosmetic results and hospital stay. na proved to be safe, applicable, repetitive and superior over sila as regard better ergonomics, less operative time, absence of surgical site infection and port site hernia. aims: to objectively analyze the surgical performance and surgeon's ergonomics in the use of a novel flexible laparoscopic instrument during intracorporeal suture, and compare it with the use of a conventional laparoscopic needle holder. methods: three experienced laparoscopic surgeons performed five laparoscopic sutures on an organic tissue using the novel flexible instrument (flexdexò) and five sutures using a conventional needle holder with axial handle. the new device is based on a mechanical design with no electrical components, which transfers the surgeon's hand, wrist, and arm movements to the instrument tip in an intuitive manner. the use of the instruments was organized in a random fashion. prior to the study, participants conducted a 15-minute training session with the new flexible instrument. execution time and quality of the suture were assessed for each repetition. besides, flexion and radioulnar deviation of the wrist were recorded using an electrogoniometer (biopac systems, inc.) attached to the surgeon's hand and forearm. the intensity of the forearm's muscle activation was also analyzed by means of a myo armband (thalmic labs). results: surgeons required more time to perform the intracorporeal suture using the novel laparoscopic instrument (87.8 ± 23.333 s vs. 56.467 ± 8.733 s; p \ 0.001), but the quality of the suture was similar with both instruments. the wrist flexion (9.976 ± 7.513°vs 15.440 ± 4.049°; p \ 0.01) and wrist ulnar deviation (21.565 ± 5.19°vs 27.401 ± 3.19°; p \ 0.01) were significantly lower when using the flexible instrument. during the suturing tasks, the use of flexdexò instrument led to a higher muscular activation of the flexor (32.614 ± 3.437 vs 25.23 ± 3.076 rms; p \ 0.001) and extensor (23.341 ± 1.869 vs 20.017 ± 1.307 rms; p \ 0.001) muscle groups of the forearm. conclusions: the presented novel instrument allows surgeons to perform robotic-like laparoscopic suturing. we believe that with a longer training period surgeons could potentially reduce surgical times with this device. the preliminary results of this study suggest that the use of this new instrument provides a quality of the suture similar to that obtained with a conventional laparoscopic needle holder and an ergonomically more adequate wrist posture. aims: the intraoperative real-time evaluation of tissue perfusion is one key element for successful visceral surgery. traditionally, tissue evaluation is performed visually by surgeons. newer devices for objective quantification have in majority been based on the application of the fluorescent dye indocyanin green (icg). a novel method derived from geographic research is hyperspectral imaging (hsi). the aim of this study was the evaluation of hsi as a promising method for the evaluation of tissue perfusion and its implementation in the evaluation of the gastric conduit during esophagectomy in a porcine model. methods: the hsi camera records a 3 dimensional data cube from a 2 dimensional surgical situs obtaining wavelengths between 500 and 1000 nm. the absorption at different wavelengths is tissue-specific and influenced by the amount of oxygenated haemoglobin and other pigments. a software calculates 4 different indices in real-time including oxygen saturation. a porcine model (n = 24) is used for esophagectomy with gastric conduit formation. ischemia is induced artificially by magnets simulating staplers. different shapes of the gastric conduit and anastomosis formation are evaluated for perfusion metrics in order to obtain recommendations for the optimal formation of esophagogastrostomy. conclusion: hsi is a promising method for intraoperative evaluation of tissue perfusion that does not require application or injection of any agents. the preliminary results in this study showed that the gastric conduit receives its main blood supply from the gastroepiploic arteries and not via the mucosa. further results from the current evaluations enable formation of an optimized gastric tube and esophagogastrostomy in esophagectomy. surg endosc (2019) pediatric surgery, al azhar university, giza, egypt; 2 pediatric surgery, beni suef university, beni suef, egypt background: varicocele is one of the most common causes of infertility. many surgical interventions are used for varicocele ligation including open and conventional laparoscopic multiport or single incision techniques. the aim of the study is to present a new needlescopic lymphatic sparing varicocele ligation using mediflexò facial closure needle and 14 gauge vascular access cannula. material and methods: twenty-two male children with bilateral varicocele of grade ii-iii. all children were counseled by clinical examination, doppler ultrasonography, abdominal ultrasonography, and routine laboratory investigations. testicular lymphatics were delineated by subcutaneous injection of 1/2 cm 3 methylene blue in anterior wall of the scrotum 20 min prior to surgery. the testicular vessels (both vein and artery) were ligated one cm above the deep inguinal ring using two mediflex needles with preservation of lympatics. the main outcome measurements included; operative time, hospitalization, testicular atrophy, hydrocele formation, recurrence of varicocele and intra or postoperative complication. results: a total of twenty-two male children with grade ii-iii varicocele subjected to needlescopic lymphatic sparing technique. twenty one were bilateral. 15 background and aims: even if the clinical outcomes of robotic rectal resections are under investigation, the related robotic costs have not yet been well addressed, and the differences between the robotic rectal resection costs and the laparoscopic approach are still not well known. we have therefore performed a prospective comparative study of robotic rectal resections (rrr) and laparoscopic rectal resections (lrr) performed at our centre with the aim to evaluate the cost-effective outcomes of robotic versus laparoscopic surgery. study design: this is an observational, comparative prospective non-randomized study which includes patients that underwent laparoscopic and robotic rectal resection reaching a minimum of 6 months of follow up from february 2014 to march 2018, at the sanchinarro university hospital, madrid. an independent company performed the financial analysis and fixed costs were excluded. outcome parameters included surgical and post-operative costs, quality adjusted life years (qaly), and incremental cost per qaly gained or the incremental cost effectiveness ratio (icer). the primary end-point was to compare clinical outcome as well as cost effectiveness study between both groups. results: a total of 86 rrr and 112 lrr were included. the mean operative time was significantly lower in the lrr approach (336 versus 283 min; p = 0.001). the main pre-operative data, overall morbidity, hospital stay and oncological outcomes were similar in both groups, except for the readmission rate (rrr: 5.8%, lrr: 11.6%;p = 0.001).the mean operative costs were higher for rrr (4285.16 versus 3506.11€; p = 0.04); however, the mean overall costs were similar (7279.31€ for rrr and 6879.8€ for the llr; p = 0.44). mean qalys at 1 year for rrr group (0.5624) was higher than that associated with lrr (0.5066) (p = 0.018). at a willingness-to-pay threshold of 20,000 € and 30,000 €, there was a 61.18% and 64.09% probability that rrr group was cost-effective relative to lrr approach. conclusion: this study provides data of cost-effectiveness differences between rrr and lrr approach showing a benefit for the rrr aim: the efforts were aimed to the introduction of novel surgical technologies to overcome the intrinsic anatomical and technical constraints of rectal surgery. this was the case of the introduction into the clinical practice of laparoscopy and later on of robotic surgery for rectal surgery. however, whether robotic surgery is actually superior to laparoscopy is still debated. the aim of this study was to compare 3d laparoscopy and robotic surgery for rectal cancer on technical and oncological outcomes. methods: this was a single-center, prospective, randomized controlled trial. all patients more than 18 years of age undergoing elective surgery for rectal cancer situated from 5 to 10 cm from the anal verge were included. patients undergoing abdominal perineal amputation and/or with t4 and/or m1 tumours were excluded. patients were randomized before surgery into two arms: arms a (3d laparoscopy) and arm b (robotic), and gave their consensus to the study. demographic data, data regarding the tumour, operative and post-operative data were collected. patients with a follow up shorter than 24 months were excluded as well. results: twenty patients were enrolled in arm a and 20 in arm b in the period time of one year. patients' population of the 2 arms was homogeneous as concerns demographic characteristics and stage of the disease. robot-assisted rectal resection results in comparable operative time (125.70 vs 170 min; p = 0.068). the conversion rate was significantly lower for arm b (2 vs 0 p = 0.0). postoperative morbidity was comparable between groups. hospital stay was comparable but time required to resolve post-operative ileus was shorter in arm b (2.5 vs 1.2 days, p = 0.048). overall survival and disease-free survival were comparable between arms (98.6% vs 98.3%, p = 0.989, and 97.4% vs 97.6%, p = 0.856, respectively) conclusions: 3d laparoscopy and robotic surgery are two viable options for rectal surgery. robotic surgery can add some in terms of post-operative outcomes and ergonomics. aim: currently, robotic surgery for rectal cancer is a surgical operation that is being performed worldwide. we also introduced robotic surgery in 2015. however, after robotic surgery, we observed a rise in creatinine kinase (ck), which is unlikely to happen in other surgeries. we studied the postoperative complications of rectal cancer patients who underwent either robotic surgery or laparoscopy during the same period of time. methods: from january 2016 to november 2018, 23 patients underwent surgery using robotassisted rectal resection (da vinci si 20 cases and xi 3 cases) and 33 patients underwent laparoscopic rectal resection. in this study, abdominoperineal resection, intersphincteric resection, and lateral lymph node dissection were excluded. result: the operation time for the robotic surgery group was significantly longer than that for the laparoscopic group (424 min vs. 305 min; p \ 0.001). the ck value of the robotic surgery group on 1pod was significantly higher than that of the laparoscopic group (525 iu/l vs. 160 iu/l; p \ 0.001). in addition, one case of compartment syndrome was observed in the laparoscopic group. there were no significant differences in age, body mass index, intraoperative bleeding, tumor invasion depth, urination disorder, or postoperative hospital stay. in robotic surgery, it is considered that the increase in ck value is caused by the extended operation time, contact of the patient's cart with the left thigh of the patient, and the extra force applied to the abdominal wall caused by the displacement of the remote center. conclusion: in robotic surgery, it is suggested that the measurement of postoperative ck value is important. therefore, an attempt to shorten the operation time and paying attention to the surgical field are necessary to improve the outcomes. aims: anastomotic leak remains as one of the most important and life threatening post-operative complications in colorectal surgery. this complication has important consequences, both acute and long term, longer hospital stay, re-intervention, and increased morbidity and mortality. among all different circumstances that have been related to this entity, blood supply is an important factor that might have influence. fluorescence with indocyanine-green (icg) is used as a marker in the assessment of tissue perfusion in colorectal surgery which might reduce the numbers of leaks. methods: a multicenter analysis of the experience of 5 centers in spain is collected in order to assess the value of icg in colorectal anastomosis. 379 colorectal procedures were performed using icg to evaluate vascular supply in the anastomosis. icg was infused before performing the anastomosis analyzing the number of cases in which the transection line (tl) was changed. we also analyzed the number of leaks in those cases that we changed this line. results: out of the 379 cases performed, 15 cases were performed by open surgery, 319 by laparoscopy, 35 by single-port and 10 with transanal total mesorectal excision(tatme). the following procedures were performed: 94 right colonic resection(rc), 9 splenic flexure partial resection(sf), 149 left colonic resection(lc), 3 subtotal colectomy(sc), 2 total colectomy(tc), 6 hartman reversal surgery(hr), 63 low anterior resection with partial mesorectal-escision(lar) and 47 ultra low anterior resection with total mesorectal-escision(ular). leak rate(lr) was 6.59% (3.19%rc, 5.36%lc, 33.33%sc, 11.11%lar, 11 .32%ular). overall lr was 4.3% in colonic surgery and 11.2% in rectal surgery. the tl was changed due to icg in 12.13% of the cases (4.25%rc, 11.1%sf, 16 .77%lc, 50% tc, 7.93% lar, 18.86% ular), being 11.9% in colonic resection and 12.9% in rectal resection. the relation between leaks and the cases in which the tl was changed, were 20% (33.3%rc, 25%lc, 33.3%ular). conclusion: icg fluorescence may play a role in anastomotic tissue perfusion assessment. the lr after colorectal surgery might decrease using icg to detect the proper tl before to perform the anastomosis. however, we do not have the sufficient evidence to determine that the changing transaction line can lead to avoid leaks. surg endosc (2019) aims: to analyse the value of postoperative day 2 crp as an early predictor of safe discharge in robotic rectal cancer surgery. methods: a retrospective analysis was performed, including patients who had undergone robotic total mesorectal excision (tme) in a single centre over a 4-year period (may 2013 -september 2017 . patients who had a permanent stoma (abdominperineal resections or hartmann's procedure) were exluded from the study, leaving 144 patients for further analysis. as the los is currently used as a performance tool in assessing outcomes in colorectal surgery (with a cut-off established at 5 days), we compared the crp values in these 2 groups. results: fourty one percent of patients were discharged home within 5 days. they had an earlier peak of crp on postoperative day (pod) 2 (median 94. 5, 80) . the group of patients that were discharge home after 5 days (59%) had a crp peak on pod 3 (median 151, 168). on pod 3, the group of patients that went home within 5 days had a lower crp (83-70-vs. 151-168-) compared to the group of patients that were discharge after 5 days, p = 0.001). conclusions: a crp peak on pod 2 in robotic tme can predict an early and safe discharge (los within 5 days). background: purposelateral pelvic lymph node dissection (lpnd) is suggested to treat suspected lymph node metastasis in pelvic side-wall in patients with rectal cancer who underwent preoperative chemoradiotherapy (crt). however, technical difficulties make it possible that lateral pelvic lymph nodes (lpns) are not dissected completely and, thus, remained in the narrow pelvis. near-infrared fluorescence imaging (fi)-guided surgery is expected to help visualization and complete excision of nonvisible lymph nodes during cancer surgery. this study aimed to evaluate the efficacy of fi using indocyamine green (icg) to identify lpns during robotic lpnd. methods: 31 rectal cancer patients who were suspected lpn metastasis and had received preoperative crt were prospectively enrolled. icg in a dose of 2.5 mg was injected around tumor preoperatively. all procedures were performed with a totally robotic approach. after completing lpnd, fi was checked again for identifying remained lpns and resecting them completely. results: the lpns were successfully detected in 25 (80.6%) of the 31 patients. however, after accounting for eight cases, having finished adjusting icg injection, the lpns were successfully detected in 22 (95.7%) of 23 patients. the fi-guided lpnd group (n = 25) showed similar mean operative time for unilateral pelvic dissection and complication rate, compared to patients who underwent conventional robotic lpnd (n = 62). however, the mean number of unilateral harvested lpns was 10.2 in the fi-guided lpnd group, which was greater than the mean of 6.6 in the conventional group. lpn metastasis was identified in 40% of the fi-guided lpnd group, which was higher than that of the conventional group, 31.7%. conclusion: fi-guided lpnd identifies lymph nodes in pelvic side-wall with great reliability. this contributes to increased number of lpns yield compared to conventional robotic lpnd. this technique should be considered to dissect them completely by preventing subsequent missing of nonvisible lpns. aims: to compare the medium-term oncological outcomes of laparoscopic total mesorectal excision (l-tme) vs. robotic total mesorectal excision (r-tme) for rectal cancer. methods: a retrospective analysis was performed including patients who underwent l-tme or r-tme resection between 2011-2017. patients with disease stage iv at diagnosis or r1 resection were excluded. 680 patients were initially included, and 136 cases of r-tme were matched based on age, gender, stage and time of follow-up with an equal number of patientswho underwent l-tme. we compared 3-year disease free survival (dfs) and overall survival (os). in adittion, a multivariate analysis was performed in order to idenfity independent prognostic factors for 3-year dfs and os. results: pathological outcomes were similar between groups. however, major complications were lower in the robotic group (13.2% vs. 22.8%, p = 0.04), highlighting the anastomotic leakage rate, which was 7.4% in the r-tme vs. 16.9% in the l-tme group (p = 0.01). overall, the 3-year dfs rate was 69% in the laparoscopic group and 84% in the robotic group (p = 0.02). the 3-year os rate was 70% in the l-tme groups and 97% in the r-tme group (p = 0.000). for disease stage iii, 3-year dfs was significantly higher in the r-tme group. os was also significantly superior in the robotic group for every stage, reaching 86% in the stage iii. in the multivariate analysis, r-tme was a significant positive prognostic factor for distant metastasis (or 0.2 95%ci 0.1, 0.6, p = 0.001) and os (or 0.2 95%ci 0.07, 0.4, p = 0.000). conclusions: r-tme for rectal cancer can achieve better oncological outcomes compared to l-tme, especially in stage iii rectal cancers. the robotic approach has demonstrated to be a significant positive prognostic factor for local recurrence and overall survival, due to the better postoperative outcomes. however, a longer follow-up period is needed to confirm the oncologic findings. university hospital for visceral surgery, university of oldenburg, oldenburg, germany; 2 bremen spatial cognition center, university of bremen, bremen, germany aims: in clinical settings, realistic assessment of one's own abilities can enhance performance and promote patient safety, especially in surgical residents, who inevitably have to acquire skills during real surgery. this study thus implemented the global assessment of laparoscopic skills (goals) questionnaire with the aim to explore divergences between resident self-evaluation and specialist's evaluation on laparoscopic performance, as a first step to implement the goals questionnaire as a tool for constructive and objective feedback. methods: between july and october 2018, seven residents from the university hospital for visceral surgery at the pius-hospital oldenburg participated in this study. at the end of every laparoscopic operation where the resident acted as the primary surgeon, the resident and the supervising surgeon independently evaluated the resident's operative performance using the goals questionnaire. the five dimensions evaluated were depth perception, bimanual dexterity, efficiency, tissue handling and autonomy. a cumulative goals-score (with 25 being the highest possible score) was calculated for n = 46 laparoscopic operations. resident's year of training, the level of case difficulty and the type of laparoscopic procedure performed was also analysed. results: residents overestimated their laparoscopic abilities in 64.4% of the operations (goals-scores: residents: median = 16, mean = 16.51; specialists: median = 15, mean = 14.60; p \ 0.001). residents in the first three years of surgical training were more likely to overestimate their performance (residents: median = 16.5, mean = 16.82; specialists: median = 13, mean = 13.14; p \ 0.001) than those with more than three years of surgical experience (residents: median = 16, mean = 16.22; specialists: median = 15, mean = 16.00; p = 0.613). goals score differences did not depend on case difficulty and laparoscopic procedure. conclusions: surgical residents tend to overestimate their intraoperative laparoscopic performance when compared to specialist evaluation. overestimation was found to depend on one's own laparoscopic experience and seem to disappear with gained expertise. these results signify the importance of individually adapted training and the greater need for objective feedback for surgical residents. this approach could in return increase the skill acquisition rate of the resident and in return contribute towards enhancing patient safety. introduction: the delivery of safe surgical care is dependent of various, complex and interrelated factors. substantial data exist regarding the impact of training in human factor skills on surgical outcomes. however, except for the standardized time-out process, the best way to go about improving these skills remains unclear. the aim of this study was to gain more insights in the theatre staff's perception of human factors and their importance on surgical outcome in the operating theatre. methods: the surgical team assessment record (star) questionnaire was used to study the role of human factors, such as communication, situational awareness and organization, contributing to surgical team performance. the self-assessment questionnaire was filled out by the theatre staff, directly after the surgical procedure. conditional logistic regression was used to identify the impact of the role in the operating theatre on the yes versus no answers. results: some 507 questionnaires were completed. the theatre staff rated their team's performance with a median of 4 (iqr 0.0, 5-point likert scale). the surgical fellows (n = 76) rated their personal factors significantly lower compared to the rest of the operating team (median 3 versus 4, p-value \ 0.0001). the staff surgeon (n = 119) indicated significantly more often that there were many distractions (51.3%, yes n = 61) and noticed aberrations (60.5%, yes n = 72) during the surgical procedure (pvalue \ 0.0001) when compared to the rest of the operating team. most aberrations reported by the surgeons were related to technical performance. conclusions: human factors play an important role in the surgical environment. situational awareness may be less developed in members of operating teams, compared to the surgeon of that team. further work is needed to elucidate the impact of human factor skills on team performance. a team-based approach to safety interventions is recommended. future studies should determine what type of aberrations and distractions are most relevant and valuable to embark on with team training. dept. of digestive surgery, school of medicine, tokushima university, tokushima, japan; 2 dept. of digestive surgery, tokushima university, tokushima, japan background: the qualitative evaluation for laparoscopic training of medical students was performed using rubric evaluation, and weak points in conjunction with the lack of anatomical knowledge were derived. to conquer these weak points, virtual reality (vr) ? augmented reality (ar) training for understanding of regional anatomy was investigated. materials and methods: one hundred and six students in 5 th grade of tokushima univ. participated basic laparoscopic task training (gummy band ligation, beads transfer, delivery of beads, gauze excision) with training box and sham laparoscopic cholecystectomy with virtual simulator. rubric evaluation, as qualitative evaluation, which includes the evaluation standards for each maneuver were performed before and after basic task training and sham operation. the group which self-evaluation was higher in a rubric evaluation was investigated. the 3d image of vessels and bile duct obtained from mdct of real patient was projected in reality space with microsoft hololens. training of ar image using hololens was performed for understanding of regional anatomy. after training of regional anatomy with hololens, sham laparoscopic cholecystectomy was performed again, and quality of procedure was evaluated by rubric. anatomical questions were. results: rubric evaluation in basic task training showed no difference between self-evaluation and evaluation by tutor before and after practice. in sham laparoscopic cholecystectomy, several students showed higher score than tutor, especially in part of extension of operation field by elevation of the gall bladder, exposure of triangle of calot, and exposure of cystic duct. after ar training, all students showed high score in questions related regional anatomy during operation. especially, rubric evaluation of students who showed high self-evaluation in sham operation showed same score with tutor. conclusions: as rubric evaluation showed weak points of detailed parts of maneuver, and vr ? ar was useful for understanding details of regional anatomy for laparoscopic training. background: the eaes has recently published an intraoperative adverse event classification to aid reporting of minimally access surgery events. this includes capture of non-consequential errors. we aimed to investigate the clinical impact of these apparent 'near miss' events. methods: case videos and clinical data from a completed multi-centre laparoscopic total mesorectal excision randomised controlled trial was utilised (isrctn59485808). the eaes classification was applied by two blinded assessors to all enacted adverse events identified on video analysis using the observational clinical human reliability analysis technique. the total number of grade 1 (non-consequential) errors were compared with the number and nature of 30 day morbidity events (graded with the clavien-dindo system) and length of stay. results: 77 cases (419 h of surgery) contained 1377 error events of which 809 (58.8%) were classified as eaes grade 1 (median 10 per case, interquartile range 7-13, range 1-28). there were significantly more inconsequential errors recorded in patients that developed any early morbidity event than those who had an uneventful post-operative recovery (median 8.5 (iqr 6-12) vs. 11 (9-14), p = 0.005). a stepwise increase in the sum of eaes grade 1 errors is seen for each additional 30 day morbidity event reported (8.5 vs. 11 vs. 11 vs. 12, p = 0.047) and the highest clavien-dindo grade experienced (9 vs. 10 vs. 11 vs. 12. p = 0.067). positive correlation is observed between the sum of eaes grade a errors and length of post-operative stay (r s = 0.36, p = 0.001). conclusion: in the context of major laparoscopic surgery, near misses are commonplace and correlate with surgical outcomes. this may represent a novel surrogate assessment method for intraoperative performance. aims: diagnostic laparoscopy (dl) is an under-utilised procedure that can replace non-therapeutic exploratory laparotomies in many contexts. to date, no validated education programme for dl exists. this study seeks to evaluate the feasibility, acceptability and face, content, construct validity of the laplat curriculum (laparoscopic learning for abdominal trauma; a simulationbased curriculum for trauma dl). this is in addition to the development of a novel 3d-printed bench-top model for abdominal inspection. methods: this prospective and observational pilot study involved 39 novice medical students and junior doctors. surgeons from the uk and international (n = 8) were involved in a two stage delphi-process to determine the components of the training course which were used to formulate a final curriculum. in the absence of an adequate model for abdominal inspection, a novel 3dprinted abdominal inspection model was designed and produced. after an introductory familiarisation session as well as pre-course cognitive lectures, the novices performed 6 tasks on a virtual reality and bench-top simulator with 5 repetitions of each in a half-day session. outcome measures for construct validity were total time to complete task, accuracy, percentage of horizon maintained and economy of movement. face and content validity as well as acceptability was evaluated by a qualitative and quantitative survey. results: face, content and construct validity as well as acceptability was established. face validity was demonstrated in all components of the course (including pre-course cognitive content and technical tasks) in addition to content validity. all also met an acceptability threshold of 3/5 on a 5-point likert scale. one-way anova tests demonstrated construct validity in all tasks (p \ 0.0002) with learning curves in reducing time observed. using a performance improvement metric, one-way anova tests showed similar rates of improvement per participant between most tasks (p [ 0.05). the course was rated overall mean 8.86/10 (± 1.05). conclusion: this pilot study has demonstrated the feasibility, acceptability and face, content and construct validity of the laplat curriculum as well of the novel 3d-printed abdominal inspection model. randomised controlled trials are needed to establish higher-quality evidence, as part of a wider curriculum with transfer needed to the clinical environment. surgery, regional institute of gastroenterology and hepatology, cluj-napoca, romania; 2 anesthesiology-surgical propedeutics, university of agricultural sciences and veterinary medicine, cluj-napoca, romania; 3 radiology, regional institute of gastroenterology and hepatology, cluj-napoca, romania; 4 urology, training and research center, prof. dr. sergiu duca, cluj-napoca, romania; 5 general surgery, training and research center, prof. dr. sergiu duca, cluj-napoca, romania aims: to evaluate the benefits of systematical use of ex vivoliver model and ct imaging in the planning process for swine laparoscopic liver resections done by residents during training programs. methods: twenty four general surgery residents were equally divided into two groups: first one which performed laparoscopic liver resections without planning stage and the second one which systematically used anatomical data from a swine liver model and interactive ct scans 3d reconstructions. the planning stage included an interactive tutorial for establishing the strategy for the next resection followed by performing open liver dissection and the same resection on an ex vivoswine model. a total of twelve models were used during this step. afterwards, laparoscopic procedures were performed on sixteen anesthetized domestic pigs, two swine for every team, composed of three residents. both groups were part of a dedicated and continuous training program and used the same 'step by step' protocol for resections. results: the average time for imagistic planning was 36.7 min and for open dissection and resection was 57.9 min. all teams successfully completed the interventions and followed the standardized protocol without trainers' interventions and with no conversions. the second group obtained better results regarding the time needed for completion and blood loss. also, when the planning stage was applied the resection was more accurate and less functional parenchyma was removed. the 'warming up' by adding the imagistic and anatomical data to the core protocol offer more clarity before laparoscopic liver resections. this also makes an upgrade for our 'step by step' protocol and provides sufficient data to admit this planning stage as mandatory for laparoscopic liver resection on swine during a training program. introduction: submucosal tunnel endoscopic resections (ster) had been increasingly performed for treatment of gastric subepithelial tumors. one of the limitations for ster is the risk of incomplete tumor resection due to close dissection and bridging of tumor capsule. endoscopic full thickness resection (eftr) allowed complete resection of the tumor with margins to prevent recurrence. this study aimed to review the techniques and outcomes of eftr for treatment of gastric subepithelial tumors. method: patients who received endoscopic resection for gastric subepithelial tumors were recruited. the gastric subepithelial tumors were considered eligible for endoscopic resection with size \ 40 mm. all patients received preoperative assessments including eus and ct scan to define the extend of tumors and the proportion of extra and intralumenal components. all the procedures were performed under general anesthesia with co2 insufflation. eftr started after injection with mucosal incision up to 50% of tumor circumference, followed by submucosal dissection to identify tumor margin. further dissection was performed using esd devices. after adequate exposure of lateral margins, incision into muscularis propria was performed to achieve full thickness resection. luminal defects were closed by either clips, clip-loop crown method or overstitch suturing. results: from 2012 to 2018, 10 patients received eftr for gastric subepithelial tumors. the mean age was 60.6 years, and 4 were male. the gist were located at greater curvature (4), cardia (3) , lesser curve (2) and antrum (1) . the mean size was 20.5 mm (10-50 mm) . most of the eftr were performed in operation theatre while two were done at endoscopy. the mean hospital stay was 4.5 days, and mean operative time was 98 min (34-180 mins). there was no conversion to laparoscopy. closure of luminal defect were performed mostly with clips (5), followed by overstitch (4) and clip and loop crown closure (1) . most patients resumed full diet on day 3, and all the pathologies confirmed gist tumors with clear resection margins. conclusion: endoscopic full thickness resection is technically feasible and safe procedure for treatment of gastric gist. future research should focus on refining the techniques of eftr and closure of the defect. next generation endoscopic intervention (project engine), osaka university, suita, japan; 2 gastroenterological surgery, osaka university, suita, japan; 3 research & development, 3-d matrix, ltd., chiyoda-ku, tokyo, japan; 4 research & development, fuso pharmaceutical industries, ltd., cyuou-ku, osaka, japan background: hemostatic peptides have received increased attention. self-assembling peptides (tdms) comprise synthetic amphipathic peptides that immediately react to changes in ph and/or inorganic salts to transform into a gelatinous state. since tdms do not carry a risk of infection, their clinical application as new hemostatic agent is expected to increase. the first generation of these peptides (tdm-621) is currently used as a hemostatic agent in europe. however, tdm-621 exhibits slow gel-formation and low retention capabilities on tissue surfaces. the second generation (tdm-623) was therefore developed to encourage faster gel-formation and better tissuesealing capabilities, and we subsequently verified its usefulness and increased performance relative to tdm-621 in preclinical open surgery. aim: the aim of this study was to verify the efficacy of tdm-623 in terms of its hemostatic effect in endoscopic surgery. materials and methods: evaluation of the hemostatic effect in endoscopic surgery (animal study) was performed using eight female (35 kg) pigs in spine position. following systemic heparinization, we established a bleeding model by utilizing flexible endoscopic grasping forceps on the anterior wall of the stomach and duodenum. in the hemostasis method, an endoscope with a distal hood was brought into contact with the bleeding point, and 1 ml tdm-623 was applied to the wound. after tdm-623 gelation, the endoscope was removed, and the acute hemostatic effect (after 2 min) was confirmed. histologic evaluation was subsequently performed on resected specimens. results: in the endoscopic bleeding model, 17 of the 23 cases (73.9%) showed complete hemostatic effects on the anterior wall of the stomach, whereas on the anterior wall of the duodenum, 18 of 20 cases (80%) showed complete hemostatic effects. moreover, none of the gels were displaced from the anterior walls of the stomach and duodenum, and histologic evaluation confirmed no infiltration of inflammatory cells. the new self-assembling peptide (tdm-623) displayed improved hemostatic effects relative to the previous generation (tdm-621) in endoscopic surgery. tdm-623 had potential usefulness for upper gastrointestinal bleeding. our future work will assess its usefulness for laparoscopic surgery. objective: indocyanine green (icg) is a dye used in medicine since the mid-1950 s for different applications in ophthalmology, cardiology and hepatobiliary surgery; thanks to its selective hepatic uptake and biliary excretion, it can be used to evaluate hepatic function in patients scheduled for hepatic resection surgery. the aim of this study is to evaluate the efficacy and the feasibility of icg guided surgery in the intra-operative localization of liver tumors, comparing the pre-operative radiological aspect, the intra-operative visualization and the post-operative histopathological features of the tumors. materials and methods: icg was intravenously injected for a routine liver function test (limonò) in 58 patients who underwent hepatic resection surgery for primitive and secondary liver tumors in the period between november 2016 and september 2018. for each patient was performed an intraoperative visualization of the stain both in vivo and ex vivo, using a nearinfrared imaging system. all the images were recorded. results: a correct differentiation between liver parenchyma and tumor area was obtained in 89.1% of cases. five patients were not evaluable due to widespread uptake or complete absence of uptake; it was probably the first cases enrolled in the study for which we were not able to set doses and timing of administration of icg. in patients in which the method had been feasible, we observed a prevalence of nodular pattern in patients with hepatocellular carcinoma (63%) and a predominance of rim pattern in both cholangiocarcinoma (80%) and metastasis (83%). furthermore, in patients with hccs well-intermediate differentiated (g1-g2) was found predominantly a nodular pattern (82.9%), whereas in poorly differentiated ones was prevalent a rim appearance (60%). regarding radiological correlations, the only one patient who presented an atypical radiological feature in pre-operative evaluation, showed a lesion with no icg captation in intra-operative visualization. conclusions: icg fluorescence imaging is a safe, minimally invasive and quite inexpensive method, that can be easily administered for routine evaluation of pre-operative liver function. it can be a useful support tool in the intra-operative detection of liver tumors, especially in laparoscopic surgery where it is not possible to directly touch the tissue. surgery, bundang cha medical center, seongnam-si, korea; 2 surgery, severance hospital, seoul, korea; 3 surgery, nhimc ilsan hospital, ilsan, korea; 4 surgery, seoul national university bundang hospital, seongnam, korea; 5 surgery, asan medical center, seoul, korea backgrounds & aims: robotic surgical system had been widely accepted in various surgical field with the expectations of overcoming the limitation of laparoscopic surgery. however, robotic liver resection had not generalized, so far. thus, this study aimed to evaluate the feasibility and safety of robotic major liver resection by prospective multicenter study. methods: from july2017 to december 2018, five surgeons who were novice in robotic liver resection but experienced a lot in open and laparoscopic liver resection in five tertiary hospitals performed 46 cases of robotic major anatomical liver resection. perioperative patient's clinical data and surgical data were prospectively collected. results: 22 cases of left hemihepatectomy, 1 case of extended left hemihepatectomy, 14 cases of right hemihepatectomy, 2 cases of right anterior sectionectomy, 6 cases of right posterior sectionectomy, and one cases of central bisectionectomy were performed. the most common indications were hepatocellular carcinoma for 21 cases following intrahepatic cholangiocellular carcinomas for 7 cases, liver metastases for 3 cases, sarcoma for 1 case, intraductal papillary neoplasms for 2 cases, mucinous cystic neoplasm for 1 case, hemangioma for 1 case, and intrahepatic duct stones for 10 cases. surgical resection margins for all tumor cases were negative. total average operation time was 378.58 ± 124.31 min and estimated intraoperative blood loss was 276.67 ± 397.41 ml (minimal to 2600 ml). in terms of severe surgical complication, there were 3 cases of postoperative fluid collection treated with drainage and one case of bile leakage treated with percutaneous trans-hepatic biliary drainage. only one case out of 46 cases was converted to the conventional open left hemihepatectomy because of bleeding. conclusions: in this study, robotic anatomic major liver resection might be safely performed even by robotic beginners but advanced open and laparoscopic liver surgeons. surgical technique: with the patient at 30°on right lateral decubitus, access is gained through the path of the percutaneous drainage catheter after opening of the aponeuroses of the oblique and transverse muscles of the abdomen. a 15 mm laparoscopic trocar is inserted and a cavity is created with pneumoretroperitoneum at 15 mmhg. it is accessed with an optic of 0°and 5 mm, and the work space is extended with aspiration and hydrodissection. with 5 mm grippers, the necrotic material is removed, washed and drained. a two light silicone probe is left, one light for drainage and another one for washing. results: the mean age was 52. background: minimally invasive surgery has achieved worldwide acceptance in various fields, however, pancreatic surgery remains one of the most challenging abdominal procedures. in fact, the indication for robotic surgery in pancreatic disease has been controversial. the present study aimed to assess the safety and feasibility of robotic pancreatic resection. methods: we retrospectively reviewed our experience of robotic pancreatic resection done in sanchinarro university hospital. clinicopathologic characteristics, and perioperative and postoperative outcomes were recorded and analyzed. aim: this work aims to study the contact pressure between the moving capsule and a synthetic small intestine in order to provide design guidance for prototyping the self-propelled capsule robot for small-bowel endoscopy. method: since small-bowel peristalsis consists of peristaltic contraction and wave distension, the contacts between the capsule and the small intestine are multimodal. we consider three contact cases for the capsule robot. case 1: the capsule moves on a flat small intestinal surface; case 2: the capsule moves in a collapsed intestine with a flat surface support; and case 3: the capsule moves in a surrounded small intestine. by considering these three contact cases, experimental testing and finite element analysis (fea) were conducted by measuring the contact pressure between the small intestine and the capsule. introduction: traditional laparoscopic instruments have limited degrees of freedom and are not ergonomic. this results in severe limitations in performing complex, and even simple tasks in surgery, limiting many surgeons from performing a variety of minimally invasive procedures. handx tm is a hand-held, electromechanical smart instrument with robot-like features. the instrument is composed of a sophisticated user interface that enables unrestricted hand movement, and a novel, motor driven articulating tool that is controlled by the interface. the instrument is 5.5 mm in diameter, lightweight, and can be easily moved between laparoscopic trocars and perform complex motions in the surgical field. after the regulatory process was completed we have tested the device clinically through a structured, approved, clinical trial. materials and methods: after irb approval 30 patients were recruited to the trial. we have included a variety of procedures that require suturing and complex tissue manipulation. two experiences surgeons performed all procedures. after completing each procedure the surgeons completed a detailed standard usability (sus) questionnaire. results: 30 procedures were completed successfully without complications or device malfunction. there were 15 female and 15 male patients with an average bmi of 27. procedures performed were 6 right hemicolectomis with intra-corporeal anastomosis, 3 paraesophageal hernia repairs and fundoplication, 3 diagnostic laparoscopies, 2 tapp procedures, 10 ventral hernias with fascial suturing, and 6 laparoscopic cholecystectomies. the average performance score was 84.70/100. the results suggest that the handx device is safe and easy to use and may offer a simple solution for enhancing minimal invasive surgery capabilities and possibly reduce conversion rates while maintaining current standard surgery flow.the handx could potentially extend the surgeon's abilities to access hard to reach anatomy and perform complex maneuvers and present a cost-effective alternative to large console-based robotic systems. objective: endoscopic submucosal dissection (esd) has become widely accepted treatment for rectum neuroendocrine neoplasm. the aim of this study is to evaluate the safety and efficacy of esd with dental floss-assisted suspension traction for rectal neuroendocrine neoplasm. methods: we retrospectively reviewed the medical records of the patients, who underwent esd for rectum neuroendocrine neoplasm at endoscopy center of zhongshan hospital, fudan university. the data of operation time, r0 resection and adverse events were collected analyzed.in dfs-esd group: after the mucosa was partly incised along the marker dots, the next step was to construct traction device, similar to others in esd, with dental floss and hemoclip. the dental floss was tied to any arm of the metallic clip. the hemoclip was attached onto the incised mucosa, another hemoclip was attached onto normal mucosa opposite to the lesion in the same way. the submucosa was clearly exposed with the traction of dental floss and the resection could proceed. results: 37 patients were enrolled in the study. there were 17 patients treated by esd with dental floss-assisted suspension traction and 20 patients treated by conventional esd. the average tumor size was (0.74 ± 0.2)cm in both group. the operation time was 17.9 ± 6.6 min in conventional esd group and (14.7 ± 3.3) min in dfs-esd group (t = 1.776, p = 0.084). according to pathological grading about rectal neuroendocrine neoplasm, there were 17 grade 1 (g1) and 3 grade 2 (g2) in conventional esd group while 13 grade 1 (g1) and 4 grade 2 (g2) in dfs-esd group (?2 = 0.436, p = 0.509). among 37 cases in this study, all the basal resection margins were negative, the en blot resection rate was 100% and the curative resection rate was 100%. however, pathological results showed tumor tissue close to the burning margin in 5 cases of conventional esd group and in 2 cases of dfs-esd group (?2 = 0.364, p = 0.546). conclusions: esd with dental floss-assisted suspension traction for rectum neuroendocrine neoplasm can assist exposing tumor borders, provide good vision during the procedure and offer clearer anatomic structure, so as to simplify operation, reduce operation time and ensure the negative basal margin. it is especially suitable to be promoted in primary hospitals. surg endosc (2019) aims: force feedback and assessment provides detailed insight into tissue manipulation skills. the aim of this study is to evaluate learning curves for basic laparoscopic skills based of force and motion learning curve patterns. morevover, we aimed to detect the favourable time span for this curriculum for each individual trainee. methods: in this prospective cohort study, first year surgical residents participated in a three week at home training course. a mobile box training was equipped with forcesense system for objective force, motion and time based assessment. the system provides seventeen unique metrics. the training goal was set by the mean score of proficient laparoscopic surgeons. each repetition was captured and made available for analyses. continuous force feedback was provided during training. curve fitting was used to estimate the learning curve plateau and the number of repetitions needed to approach the plateau phase and to reach proficiency level. finally, a comparisson between novices and experts was executed. results: a total of 2007 attempts, executed by 20 residents were captured and analyzed. significant improvement of motion analysis parameters (e.g. path length and time) was observed for all training tasks, except for the fifth tasks. tissue manipulation skills (i.e. maximum and mean applied force) significantly improved by training tasks 2, 3 and 6. learning curve analysis revealed various shapes and lengths of the individual learning curves. a large range in learning curve plateaus was found between trainees and between tasks. each trainee managed to accomplish the preset goals within three weeks. conclusion: force-and motion based assessment provides insight into both tissue manipulation and instrument handling skills. when combined in learning curve analysis, these parameters effectively show progression towards proficiency for each individual trainee over time. we emphasize the variation in learning curves between trainees. therefore, we recommend individually tailored courses provided with objective force-and motion-based learning curve tracking. aims: the posterior retroperitoneoscopic adrenal access represents a challenge in orientation and working space creation.the aim of this experimental acute study was to evaluate the impact of computer-assisted quantitative fluorescence imaging on adrenal gland identification and perfusion assessment in the posterior retroperitoneoscopic approach. methods: six pigs underwent synchronous (n = 5) or sequential (n = 1) bilateral posterior retroperitoneoscopic adrenalectomy (pra, n = 12). fluorescence imaging was obtained via intravenous administration of 3 ml of indocyanine green (icg) using two near-infrared camera systems. fluorescence-based visualization of adrenal glands before vascular division (n = 4), after main vascular pedicle ligation (negative control, n = 1) or after adrenal division (n = 7) was followed by completion adrenalectomy. one of the animals had undergone icg injection 3 h previously, during another study. the dynamic evolution of fluorescence signal intensity over time was recorded and analyzed using a proprietary software. the computed color-coded perfusion cartography was superimposed onto real-time images obtained by corresponding left (l) and right (r) camera systems. the slope of fluorescence signal intensity evolution over time in the regions of interest (roi) served to assess adrenal perfusion by means of quantitative fluorescence signal analysis. results: in the retroperitoneum, the adrenal glands were promptly highlighted after primary intravenous icg administration or showed an increase in fluorescence signal intensity upon reinjection (both glands in a recovery pig and one gland in the sequential approach). after left adrenal main vascular pedicle ligation, the gland displayed low perfusion (blue; rois a1-a2 in figure 1 ), while a weak fluorescence signal after completion adrenalectomy suggests perfusion via collateral vessels. with intact vascular supply, the caudal segment of the right adrenal (a3) gland showed a significantly higher perfusion rate (red) than the ischemic cranial segment (a4). quantitative analysis of logarithmic fluorescence intensity showed a statistically significant difference between perfused and ischemic zones (p = 0.005) allowing to assess gland vascularity. kidneys (k) and adrenal glands showed distinct perfusion curves ( figure 1 ). conclusions: prior to dissection, fluorescence imaging allows to easily discriminate the adrenal gland from surrounding retroperitoneal structures. during adrenal gland surgery, icg injection complemented by a computer-assisted quantitative analysis helps to distinguish between wellperfused and low-perfused segments. giant adrenal tumors:technical considerations and surgical outcome a. giordano, g. alemanno, c. bergamini, p. prosperi, v. iacopini, a. dibella, a. valeri sod chirurgia d'urgenza, aou careggi, firenze, italy objectives: giant adrenal tumors are tumors with size more than 6 cm. these are rare cancer associated with malignancy in 25% of cases. the size of these tumors is an important topic in literature because of their higher probability of malignancy and possible technical limitations of laparoscopic approach. we report our center's experience on laparoscopic adrenalectomy. materials and methods: in the last ten years we performed about 242 adrenalectomies for benign and malignant adrenal tumors. 45 of these were giant tumors. the medium size was 9.9 cm (7-22 cm). 23 tumors were on the left adrenal gland and 22 on the right. there were 20 women and 25 men, the average age was 55 (21-81 years). 29 of these cancers were laparoscopically removed and 16 with open approach. 2 cases of open conversion. results: betweenn the 29 tumors laparoscopically removed we recorded 6 cases of carcinoma, 2 endothelial cysts, 6 adenomas (3 with aldosterone and 2 with cortisol hypersecretion), 2 myelolipomas, 10 pheochromocytomas and 3 metastases from lung carcinoma. the surgical outcomes in these patients were optimal in terms of good pain control and hospital stay (median 3 days). the average time of the intervention was 110 min with very low blood less (90 ml). no postoperative complications were recorded. the removal of the adrenal gland necessitated 3 or 4 trocars. in the dissection and resection phases we always used radiofrequency scalpel. the follow up after 12 and 24 months didn't show local recurrences. conclusions: laparoscopic adrenalectomy offers significant advantages over the open approach. the size of these tumors is still at the center of debate for the choice of the technique. the tumor size is only a predictive parameter of possible malignancy. the laparoscopic approach is a safe and feasible method in terms of surgical and oncological outcomes also for the giant adrenal tumors, only if performed by expert surgeons and in high-volume centers. vascular or adjacent organs infiltration is a contraindication to the laparoscopic approach. aims: adrenal gland size greater than 6 cm is considered a contraindication to laparoscopic adrenalectomy (la). aim of the present case-control study is to compare the surgical outcomes in patients undergoing la for adrenal gland measuring = 6 cm versus = 5.9 cm in diameter. methods: from january 1994 to august 2018, 552 las were performed in the two authors' centers which follow an identical treatment protocol. eighty-one patients with an adrenal gland size = 6 cm (intervention group) were included in the study. based on body mass index (bmi) class [ 40 kg/m 2 ) , lesion side (right or left), surgical technique (anterior transperitoneal for right and left-sided lesions, anterior transperitoneal submesocolic for left-sided lesions) and lesion type (conn-cushing, pheocromocytoma, primary adrenal cancer or metastases, other type of lesion), 81 patients with an adrenal gland lesion measuring = 5.9 cm in diameter were included (control group) and paired to the intervention group. results: comparing the intervention and control groups, statistically significant differences were observed in mean lesion size ( conclusions: the only significant difference between the two groups was the operative time which was longer in the intervention group. conversion and complication rates were also higher in the intervention group but the difference was not statistically significant. based on the present data, adrenal gland size measuring more than 6 cm in diameter is not a contraindication to a laparoscopic approach. ; and orthopaedics and urologists for the remaining 6.6%.the costs from these claims, differed from 2 to 13% of the total damage burden per year. the review of medical charts of claims related to laparoscopic gynaecologic surgery showed that 82% of claims were filed for visceral and/or vascular injuries (40% bowel injuries, 20% ureter). 38% of the injuries were entry-related. a delay in diagnosing injuries was the primary reason for financial compensation. conclusion: evaluating and learning from complications and claims will improve medical health care. in contrast to overall trends and developments considering medical claims, claims concerning laparoscopic surgery decreased, possible due to a rising learning curve. considering laparoscopic surgery, extra caution is required at moment of entry and the early recognising complications and at pre-operative counselling from patients. the aim of the study was to determine indications and contraindications for laparoscopic splenectomy in abdominal trauma patients and to analyze results of the operations. patients and methods: the study involved 112 patients with spleen injury grade iii who were admitted in our institute in the years of 2013-2018. the patients were divided on two groups. laparoscopic splenectomy was performed in 62 patients (group i) and 'traditional' splenectomy was carried out in 50 patients (group ii). there was no difference in the demographic data and trauma severity between the two groups.non-invasive investigations, such as laboratory investigations, serial abdominal ultrasound examinations (us), x-ray in multiple views and computed tomography (ct) had been performed before the decision about necessity of an operation was made. results: patients after laparoscopic operations had better recovering conditions compare to patients with the same injury after 'traditional' splenectomy. neither surgery related complications no mortalities were registered in both groups. laparoscopic splenectomy was more timeconsuming operation than 'traditional' splenectomy. we suggest that as experience of laparoscopic splenectomy is gained the operation time will be reduced. conclusion: laparoscopic splenectomy is a safe feasible operation in patients with spleen injury. the operation is indicated in patients with spleen laceration more than 3 cm of parenchymal depth with moderate continuing bleeding or expanding hematoma and contraindicated in patients with hemodynamic instability and high bleeding rate (more than 500 ml/h on serial us examinations). the isolated hydatid disease of the spleen is a quite rare condition, liver and lungs being the most common locations. the treatment requires usually splenectomy, open or laparoscopic. there are few reports in the literature describing a spleen-preserving type of surgery. we present a case of a female patient, 51 y.o., with a large cystic lesion of the spleen, 11 cm in diameter. lab tests and ct scan confirmed that is a hydatid cyst. after albendazole treatment and vaccination the patient was referred to us for surgical treatment. the procedure was performed under general anesthesia and laparoscopic approach was performed with the intention to preserve the spleen. after the cyst was identified and adhesiolysis was done, the area was isolated from the rest of the abdominal cavity with sponges with a betadine solution in order to prevent contamination. a needle aspiration of the cyst allowed the evacuation of 550 ml of purulent content, an indicator of a dead cyst. betadine solution was injected into the lesion. laparoscopic excision of the cyst was performed using advanced electrocoagulation devices and the spleen removal was not deemed necessary. two drainage tubes were placed in the remnant cavity. an abdominal ultrasound was performed in the third postoperative day and no collections were identified. the postoperative outcome was uneventful; the patient was discharged in the 6 th postoperative day. the conclusion is that in selected cases, with the cyst located in the anterior part of the spleen, with proper equipment and experienced laparoscopic teams, the cyst can be successfully treated without splenectomy. deep neuromuscular block was induced with rocuronium 1.2 mg/kg. in group1, forty patients were enrolled for reversal of profound neuromuscular block during thyroid surgery (sugammadex 2 mg/kg, after identification of vagus nerve). in group 2, thirty-five patients were enrolled profound neuromuscular block during thyroid surgery(without reversal of nmbd). tof-watch acceleromyograph was recorded in response to adductor pollicis muscle for ulnar nerve stimulation in patients with both groups; recovery was defined as a train-of-four (tof) ratio = 0.9.to prevent laryngeal nerve injury during the surgical procedures, all patients were neurophysiologically detected using ionm. results: the total duration of surgery was higher in group 2 than group 1(63.7 ± 5.6, 82.5 ± 6.1;p \ 0.001). the mean time to recovery of the tof ratio to 0.9 was higher in group 2 than group 1(22.3 ± 2.6, 74.3 ± 5.0; p \ 0.001). the mean duration of vagus reverse (v1:3,5milisecond) was higher in group 2 than in group1(21.3 ± 1.7, 42.9 ± 5.1; p \ 0.001). no significant difference was found between left and right v1-v2 and r1-r2 values in group 1 following nerve monitoring, whereas in group 2, a significant difference was found between left v1-v2, left r1-r2 and right v1-v2 values ( introduction: oeosphagogastric oncology trials have often lacked robust methods of monitoring and surgical quality assurance (sqa), leading to difficulty in interpretation of trial results. this study aims to assess expert opinion regarding challenges to sqa in oncology trials and potential mitigating strategies. method: a purposive international cohort of 71 expert stakeholders with experience in oncology trials were recruited including: 35 surgeons; 17 oncologists; 10 trial methodologists, and; 9 trial managers. semi-structured interviews were thematically analysed using grounded theory. spss was utilised to assess differences between trial stakeholders' opinions. results: 389 emergent themes were identified and 74 consensus themes emerged on qualitative analysis of stakeholder responses. key consensus challenges to implementation of sqa in oncology trials included: insufficient resources; limitations of surgical volume in centre selection; differing oncological beliefs and resistance to change adoption; overly prescriptive protocols and standardisation contributing to difficulty in surgeon recruitment; and cultural factors leading to difficulties in providing and receiving feedback. seminal consensus mitigating strategies to overcome challenges to sqa in oncology trials included: trial centre selection according to case volume (n = 31, 44%); requirement for specific centre attributes for inclusion in trials including specialist centre designation and participation in national audit (n = 29, 41%); consideration for surgeons learning curve in surgeon selection (n = 33, 46%); flexible standardisation of trial operating (n = 22, 31%); operation manual utilisation to aid standardisation of surgical interventions (n = 34, 48%); case monitoring using video (n = 22, 31%) or photographs (n = 11, 16%); direct intraoperative observation by an expert (n = 15, 21%), and; histopathological assessment of resected specimens (n = 10, 14%). other methods of monitoring surgical quality advocated included: recording post-operative outcomes; lymph node yield; case report forms; and real time data monitoring (n = 32, 45%). oncologists were significantly more likely to state the importance of standardisation of surgery in oncology trials (p \ 0.05), and trial methodologists significantly more likely to advocate consideration of surgeons' learning curve in surgeon selection (p \ 0.05). conclusion: surveying international expert stakeholder opinion revealed a wide variety of perceived challenges across all domains of surgical quality assurance. proposed mitigating solutions require consensus opinion to formulate a framework to aid design of sqa measures within future oncology trials. research group did not register a single case of ega leakage while 2 patients in control group (? \ 0,05). had the leakage which was stopped by means of 'endovac' system. there were 2 cases of esophagus postoperative strictures which developed 3 months after the surgery in the research group which was less than in the control group which saw 6 cases of strictures of ega (? \ 0,05). 6 months after surgery, the number of post-operative strictures increased in both groups, but was lower in the research group and amounted to 4 cases in the research group and 11 cases in the control group (? \ 0,05). there were 5 cases of esophagus postoperative strictures which developed 12 months after the surgery in the research group which was less than in the control group which saw 13 cases of strictures of ega (? \ 0,05). neither of the groups had any cases of post-operative mortality. purpose: to investigate the prognostic effects and risk factors of the omission and delay of postoperative chemotherapy of ii/iii gastric cancer (gc), with the goal of providing a reference for interventions of related departments. methods: the clinicopathological data of 1520 patients undergoing radical gastrectomy for ii/iii gc were collected and retrospectively analyzed. we defined the chemotherapy delayed until more than 60 days after radical gastrectomy and the complete omission of chemotherapy as unacceptable chemotherapy initiation (uac group), while the chemotherapy conducted within 60 days of radical gastrectomy was defined as acceptable chemotherapy initiation (ac group). the survival between the two groups was compared, and the trends and risk factors of uac were analyzed. results: the total number of patients who underwent totally laparoscopic distal gastrectomy with uncut roux-en-y and delta shaped billroth-i anastomosis was 244 and 214, respectively. the mean reconstruction time was longer in uncut roux-en-y than in delta shaped billroth-i, (30.5 ± 14.5 vs. 13.6 ± 10.3 min, p \ 0.001). the uncut roux-en-y was used more cartridge than delta shaped billroth-i anastomosis (6.9 ± 1.2 vs. 6.2 ± 1.0, p \ 0.001). however there was no significant differences in operation time, estimate blood loss, number of retrieved lymph node and postoperative course between reconstruction methods. postoperative complications more than clavien-dindo grade iiia occurred in 22 cases (4.8%) of postoperative early complications and 14 cases (3.1%) of late complications. the endoscopic findings showed excellent short and long-term outcomes in terms of very low incidence of bile reflux and reflux-induced remnant gastritis in uncut roux-en-y compared with delta shaped billroth-i anastomosis. conclusions: uncut roux-en-y gastrojejunostomy was a useful reconstruction method with totally laparoscopic distal gastrectomy for cancer, especially for diverting enteral contents from the remnant stomach and preventing remnant gastritis. therefore, it is recommended for young patients with early stage disease who have a long time to live after distal gastrectomy for cancer. operative technique: the seromuscular layer above the tumor is dissected, while the mucosa is kept unbroken. when seromuscular layer is dissected all around the tumor, the full layer is lifted, and the mucosa is stretched. the mucosa is then transected with a stapling device to execute fullthickness resection of the specimen. finally, the seromuscular defect is repaired by hand-sewn suture. results: since december 2015, clean-net has been performed in 57 patients with gastric smts. all tumors were resected en-blocwithout rupture. the average operation time ranged from 50 to 220 min with an average of 101.7 min. the postoperative course was uneventful. microscopically the surgical margin was tumor-negative (r0 resection) in all cases. the margin width was small with an average of 5.4 mm ± 2.5. conclusions: clean-net is a useful option in the laparoscopic surgical treatment of gastric smt, when excessive sacrifice of the healthy gastric wall surrounding the endophytic tumor should be avoided. background: the type of fundoplication-complete or partial is still controversial for the surgical treatment of gerd. laparoscopic toupet (270 0 wrap) fundoplication has less post op dysphagia and gas bloating compared to nissen fundoplication (360 0 wrap) and is advised to be the procedure of choice when esophageal manometry findings are abnormal, however it is considered by some less effective and more difficult to perform. the aim of this research was to determine in the functionality and efficacy of the different types of fundoplication. methods: explanted pigs stomachs weighing 45-60 kg were studied. two different studies of the les were performed: distensibility and failure point (occurrence of reflux according to volume added to the stomach). for both studies we first disrupted the lower esophageal sphincter using a rigiflex tm dilating balloon. we then performed three different fundoplications-nissen, toupet, dor and measured the distensibility of the egj after each fundoplication. the failure point was determined following each fundoplication type. results: we used 12 pig stomachs for the distensibility study and 11 pig stomachs for the failure point study. there was no statistically significant difference between the nissen and toupet fundoplications when distensibility was measured, however the egj was more distensible following dor fundoplication (p = 0.008 for nissen, 0.016 for toupet). when the failure point was measured, nissen fundoplication was significantly more effective than toupet, and toupet was significantly more effective than dor (p = 0.016,p = 0.017 respectively) conclusions: we studied the differences between the mechanical effects on the egj following three different fundoplications, encompassing 360 0 , 270 0 , and 180 0 of the esophagus. we demonstrated that there is a significant difference between dor fundoplication and nissen/toupet when distensibility was measured. there was no difference in the distensibility of the egj following a 360 0 or 270 0 wrap. there was, however a significant difference of effectiveness between all three fundoplications. these findings suggest that the 360 0 and 270 0 fundoplications have similar functionality while the 360 0 wrap mechanically prevents possible reflux and support proponents of toupet fundoplication rather than nissen due to the similar functional results while decreasing the post op dysphagia and gas bloating complications. surg endosc (2019) aim: to describe patients undergoing surgical treatment of incident gastro-oesophageal reflux disease and the use of anti-reflux treatment in a danish population-based cohort. methods: all adult danes 2000-2015 undergoing upper endoscopy and receiving a diagnosis of gerd within 90 days were identified. patients with previously diagnosed gerd, peptic ulcer-disease, barrett's oesophagus or cancer of the gastrointestinal tract were excluded. in this study, only patients undergoing anti-reflux surgery within two years of gerd-diagnosis were subsequently included. age, sex, charlson comorbidity index (cci), anti-reflux surgery (primary and re-operative) and endoscopic dilatation were identified using the danish national patient registry. mortality was identified using the national civil registry. pharmacological treatment of gerd (proton pump inhibitors, h \ su2 \/su-blockers and other prescription anti-reflux drugs) as well as use of nonsteroid anti-inflammatory drugs (nsaid) and anti-thrombotic treatment were identified using thethe danish national prescription registry. all data was linked on an individual level using the unique identification number that all danish citizen are assigned to at birth or first immigration. results: a total of 674 first-time fundoplications were performed, hereof 98.1% performed laparoscopically (n = 661) and 1.9% performed using open technique (n = 13). at one-year followup, 4.9% (n = 33) had undergone endoscopic dilatation and 2.1% (n = 14) had undergone reoperation. the 90-day mortality was \ 0.5%. patients had a median age of 46 years (18-80 years) and were predominately male (57.9%-n = 390). a total of 93.9% had cci 0 (n = 633). diagnoses were gerd with esophagitis (66.9%-n = 451), gerd without esophagitis (31.5%, n = 212) and gerd without specification (1.6%, n = 11). before initial endoscopy, 91,7% (n = 618) used at least one type of anti-reflux drug, dropping to 32.2% (n = 217) in the year after anti-reflux surgery. however, even when censoring patients with barrett's esophagus or peptic ulcer disease after initial endoscopy and patients undergoing concomitant treatment with nsaids or antithrombotic drugs, 27.7% still used at least one type of anti-reflux drug after surgery. conclusion: in this population-based study, anti-reflux surgery was safe and lowered the use of pharmacological treatment. however, even when adjusting for competing reasons for use of antireflux drugs, 27.7% used at least one type of anti-reflux drug one year after surgery. the new approach to perform nissen fundiplication m. paranyak, v. grubnyk surgery, odessa national medical university, odessa, ukraine nearly 10% of patients who undergo laparoscopic anti-reflux surgery at long-term follow-up need for surgical reintervention mostly because of hiatal hernia (hh) recurrence, wrap migration or disruption. purpose: the aim of our prospective study was to evaluate and compare several technics of wrap fixation and determine whether modified nissen fundoplication(mnf) reduce failure rate in the long term follow up. materials and methods: this was a prospective, randomized, controlled trial. from november 2012 to october 2014 one hundred and thirty-eight gerd patients who underwent anti-reflux surgery were divided into two groups. excluded criteria for our study ware diagnosed hiatal hernia (hh) type iii. in the i group which include 87 patients we performed the following manipulations: nf was supplemented with suturing wrap to the diaphragmatic crura (52 patients) on each side using two non-absorbable stitches. such technique permit us to create more symmetrical wrap. in case of weak conditions of crura or short esophagus (35 patients) fundoplication wrap was sutured to the body of stomach using two non-absorbable stitches on each side. control group (51 patients) underwent classic nissen fundoplication (nf) without wrap fixation. all patients were assessed before and after surgery using validated symptoms and quality of life (gerd-hrql) questionnaires, 24-h impedance-ph monitoring and barium-swallow. results: baseline characteristics were similar between groups. there were no conversion to open procedure or mortality. mean hospitalization was 2.7 days ± 1.4 days. at 41,6 months (range 18--57) of followup, the overall rate of complications after mnf was 1,14% (1 hh reccurence) and nf 7,84% (3 hh reccurence, 1slipped wrap). patient in mnf group show significant improvement in gerd-hrql score, from 19.3 ± 13.2 (preoperatively) to 4.3 ± 3.9 (postoperatively) (p? \ ?0.001). complete ppi independence was achieved in 91%. in the ii group of patients mean gerd-hrql score decline from 18.7 ± 11.9 (preoperatively) to 9.3 ± 7.7 (postoperatively), postoperative ppi treatment was necessary in 29%. conclusions: according to our study mnf minimized risk of slipped wrap and intrathoracic migration of the wrap and can make positive impact on reducing the failure rate of laparoscopic anti-reflux surgery. aims: comparative evidence across laparoscopic antireflux procedures does not exist. aim of this project was to identify direct comparative evidence between laparoscopic antireflux procedures and synthesize evidence using network meta-analytical methods. methods: the databases of medline, amed, central, opengrey were interrogated. pairwise meta-analyses for each pair of interventions using a random-effects model and network metaanalysis in stata was performed using the mvmetacommand and self-programmed stata routines. differences between direct and indirect evidence were explored by comparing direct and indirect estimates though computing the inconsistency factor within each closed loop of evidence. the ranking probabilities for all treatments of being at each possible rank for each intervention were computed using the mvmetacommand in stata. a hierarchy of the competing interventions was obtained using rankograms. quality of evidence was assessed using grade-nma and the cinema application. results: forty-three publications reporting on 32 randomized trials and some 1892 patients were identified. the network of treatments formed a closed loop between 270°, 360°and anterior 180°; and star network between 360°and other treatments; and between anterior 180°and other treatments. laparoscopic 360°, 270°, anterior 180°and anterior 90°were equally effective in the control of heartburn and this was supported by low quality of evidence according to grade-nma. the odds for dysphagia were lower for anterior 90°(high quality evidence), anterior 120°( moderate quality evidence), 270°(moderate quality evidence) and proton-pump inhibitors (moderate quality evidence) compared to 360°. the odds for gas-bloat were lower for 270°and anterior 90°compared to 360°(low quality evidence). the odds for regurgitation, morbidity and reoperation were similar across treatments, albeit these were associated with very low quality evidence. anterior 120°had a 49% probability of being the best treatment in terms of dysphagia. conclusion: under consideration of treatment effect estimates, evidence quality as assessed with grade-nma and other parameters, anterior 90°, anterior 120°and 270°should be preferred over 360°. further research needs to focus on the comparison between 90°and 120°/270°. aims: we have recently demonstrated that the tension of crural closure can be reliably measured intraoperatively (alsgbi conference december 2018). the aims of this study were to further characterise tension at the diaphragmatic hiatus from our prospective pilot study of 72 patients. methods: a prospective analysis was performed of patients undergoing laparoscopic hiatal hernia repair between april 2017 and december 2018. 72 patients underwent crural tension measurement intra-operatively. 24 patients had a pre-operative ct scan of the abdomen within one-year of surgery. hiatal surface area (hsa) was measured intraoperatively and a sauter-fh50 universal digital force gauge was used to measure the tension of crural closure during cruroplasty. outcome measures included the mean tension of the crural closure and the presence of muscle splitting during the cruroplasty. results: for all patients, the mean crural tension measurement was 2.93 n and the mean hsa was 543 mm 2 . pre-operative ct was positively correlated with post-dissection intra-operative hsa (r = 0.5402, p = 0.0064), however, strength of association was weak (r 2 = 0.2918) and ct consistently overestimated the size of hiatal defect intra-operatively (mean of differences 404 mm 2 , p = 0.0016). crural tension was positively correlated with age (r = 0.3321, p = 0.0044), hiatal height (r = 0.6023, p \ 0.0001), hiatal width (r = 0.766, p \ 0.0001) and hsa (r = 0.7753, p \ 0.0001). crural tension was correlated to the hiatal width to height ratio to assess the shape of defect and there was positive correlation (r = 0.4072, p = 0.0004). tension was calculated for the posterior and anterior halves of the suture cruroplasty. anterior tension was significantly higher when compared to posterior tension (3.26 n vs 2.59 n, p \ 0.0001) . 16 patients had evidence of muscle splitting during the cruroplasty. the group with muscle splitting were significantly older (66 vs 53, p = 0.0029), had larger hsa (910 mm 2 vs 347 mm 2 , p \ 0.0001) and higher crural tension (5.69 n vs 2. 14 n, p \ 0.0001). the lowest observed mean crural closure tension causing muscle splitting was 3.52 n. conclusion: there is now a possibility to optimise this operation with objective measures 100 years after it was first described. initial findings suggest that crural closure up to * 4 n could be the permissible tension threshold for suture cruroplasty and higher tension may benefit from the use of mesh reinforcement. background: endoscopic submucosal dissection (esd) and endoscopic full thickness resection (eftr) are advanced endoscopic techniques which can be time consuming using traditional endoscopic instruments. a new endosurgery platform, designed by fortimedix surgical, was developed featuring flexible articulating instruments to use in combination with a standard flexible endoscope. the platform is intended to perform endoscopic cutting, dissecting, and hemostasis. aim: evaluate feasibility of the platform in the upper gi-tract. project description: the platform was tested in a dry esophageal model as well as a second series with a porcine esophagus and stomach. the system has an external docking station affixed to the operative table to stabilize both flexible instruments for the right and left hand of the surgeon. at the tip of the endoscope, a cap containing instrument lumens is attached to allow advancing and removing the flexible instruments. the endoscope with the cap and instrument lumens attached is advanced via an overtube with outer diameter 18.5 mm. in the first series, flexibility and range of motion of the endeffectors was assessed. additionally, the ability to advance the instruments to the intraluminal target area from the docking station and along the scope was evaluated. in the second series, the functional capabilities of the system and instruments were evaluated in a porcine model. preliminary results: : in the dry model, the platform was adequately deployed to the target then range of motion was tested as well as cutting and grasping gastric wall with instrumetn triangulation achieved. the grasping forceps provided enough force to pull the mucosal wall and expose the dissection plane. in the pig model, the distal esophagus and stomach could successfully be accessed and platform deployed. esd was performed using newly designed flexible articulating scissors, dissection-hook, and graspers with good triangulation and sufficient grasping force with traction/counter-traction. the new fortimedix surgical endo-surgery platform applied to a standard flexible endoscope is feasible to perform esd. future studies are planned to determine learning curve and compare it to traditional endoscopic instruments. background: in laparoscopic surgery, we usually observe the organs in the same direction to avoid a mirror-image situation. therefore, we are unable to recognize how far the dissection has proceeded on the other side of the target organs or lesions, especially when the plane of dissection is under the mesentery or organs. this becomes a problem not to understand how far the dissection has progressed and how much more dissection is needed. aim: to solve this problem, we developed a laparoscopic device with tip illumination. project description: the device is configured by the long and narrow part made of polycarbonate resin and a battery-powered light-emitting diode to illuminate the tip by shining light through the polycarbonate resin. during the surgery, the tip of the device is inserted into the deepest part of the dissection area, and the transmitted light indicates how far the dissection has progressed. the tip of the device has a prism structure and light is emitted in a direction perpendicular to its axis. tip position can thus be more clearly identified even with insertion in the same direction as the laparoscopic view. to verify the utility of this instrument, laparoscopic surgeries were performed in a porcine model and cadavers. preliminary results: we performed some laparoscopic surgery such as the medial-to-lateral approach to the white line of the left side of the descending colon for sigmoidectomy, dissection of the posterior surface of the pancreas to the upper edge of the pancreatic body or splenic artery for distal pancreatectomy, and the separation of the anterior surface of the inferior vena cava from the liver to the area between the right and middle hepatic vein for right hepatectomy. we quickly and easily identified the deepest part of the dissection area even if identification had been difficult using other techniques such as placing gauze in the deepest position, inserting forceps into the dissection area or simply depending on the experience of the operator. background: recent advancements within surgery have seen artificial intelligence transform traditional approaches. robotic assistive devices have demonstrated particular success, as safe and cost effective, and are widely supported via industry and local government as a step closer to the future standard of practice. an example of seamless and touchless robotic assistive technology is based on touchless and interactive eye tracker glasses worn by the surgical team thereby enabling the team to perform wider surgical tasks, more efficiently and reduced human error. we introduce a perceptually-enabled, smart operating room (smart-or) based on a novel real-time framework for theatre-wide 3d gaze localisation in a mobile fashion. this framework enables dynamic gaze based user interaction with a robotic scrub nurse to facilitate meaningful practical integration of human and technology intra-opertively. aims: we tested participant acceptability of a novel robotic scrub nurse during simulated surgery. project description: surgeons performed segmental resection of pig colon and handsewn end-to-end anastomosis while wearing eye-tracking glasses to select surgical instruments on a screen. the robotic scrub nurse(rn) picked up and transferred the instrument to the surgeon. the study compared human nurse(hn) vs rn. gaze-screen interaction was based on a 3d gaze framework we developed with synergy of conventional wearable eye-tracking, motion capture system and fixed in space rgb-d cameras for real-time 3d reconstruction of the environment. nasa-tlx and van der laan's technology acceptance questionnaires were collected and analysed using anova. preliminary results: overall, 7 teams of surgeons(st) and scrub nurses(sn) participated. nasa tlx feedback for st and sn revealed no significant difference between in mental, physical or temporal demand. importantly, st and sn reported no significant difference in task overall performance. st reported more significant frustration with rn vs hn. van der laan's scores showed positive usefulness and satisfaction scores in using the rn platform. overall, all outcomes were more positive by sn vs rn. conclusions: this is the first platform of its kind. overall, quantitative and qualitative feedback was positive. the source of frustration has been understood and we believe it can be improved by appropriately modifying robot behaviour. importantly,there was no difference on perception of performance. background: endoscopic tumor resections in the gi tract may be facilitated by more advanced instruments for dissecting and suturing. we have focused on developing an endoscopic suturing technique using a standard flexible pediatric endoscope with new, flexible instruments allowing for complex end-effector movements. aim: perform flexible endoscopic suturing using a standard flexible scope in the gi tract project description: a standard flexible pediatric endoscope and a standard gastroscope were used for testing the new technique. via an overtube, the endoscope and newly designed fortimedix surgical flexible instruments (needle holder; grasper) with a diameter of 5 mm were inserted into the esophagus. suture training was performed in an experimental setting in a box in the dry lab and porcine model . the flexible needle holder was advanced into the esophagus next to the scope, and a suture of the esophageal wall was performed, followed by extracorporeal knot-tying with 3 knots. the test series consisted of training with both resident trainees and surgeons to evaluate the learning curve. each participant performed sutures on the box model and in the pig-esophagus. feasibility, duration of the different steps, and handling problems were documented. preliminary results: test series 01 (box training on esophago-gastric explant) with prototype 01 showed good feasibility. suturing was possible in 9 out of 10 attempts. median duration for single bite: 6 min (5-30); knot-tying: 5 min (2) (3) (4) (5) (6) (7) (8) . test series 02 (training in pig-model) with prototype 02 showed improved feasibility with better flexibility of instrument shaft: median duration of double bite: 8 min (7-15); knottying: 2 min (1) (2) (3) (4) (5) , overall duration intraluminal esophageal double bite suture and closing with 3 knots: median duration: 13 min (12-20). the new flexible endosuture instruments seem feasible to use and perform dependable intraluminal sutures. the training period and learning curve is short and the objective is to apply this system clinically for closure of perforations and fistulas. school of mechanical and aerospace engineering, nanyang technological university, singapore, singapore; 2 general surgery, national university hospital, singapore, singapore; 3 gastroenterology, national university hospital, singapore, singapore; 4 surgery, chinese university of hong kong, hong kong, hong kong background: ideally, endoscopic suturing should mimic surgical closure as the latter is stronger than most endoscopic closure devices. however, endoscopic suturing is challenging due to the confined endoluminal space and lack of dexterity of current endoscopic instruments. we have developed a novel robotic suturing device to overcome these problems. aim: this animal study aims to demonstrate the feasibility of this device in closing perforations. method: the trial was conducted on an anaesthetized live pig. a double-channel colonoscope was first inserted into the rectum. following saline lift, a 10 mm submucosal incision was created in the rectum to simulate a perforation. the robotic suturing device and grasper were inserted into the two colonoscope channels, allowing the endoscope to remain in position for tool exchanges or needle reloading. both the effectors were intuitively tele-operated by the user via a robotic master console. this robotic suturing device manipulated a curved, double-point needle (with a 10 cm 3-0 vicryl suture) to penetrate tissues at desired orientations. the needle could be switched between both jaws of the device through a locking mechanism. this facilitated passing the needle through tissues to form stitches or through suture loops to form surgical knots. the articulated joints and five degrees of freedom allowed dexterous steering to reach targets and triangulation with other tools in a confined space. the robotic grasper facilitated handling of tissue and suture. result: a total of four running stitches were performed and secured with a surgical knot by passing the needle through suture loops. the suture was cut and the needle was removed by the robotic grasper through the channel. 11 min and 4 min were required to stitch and tie the knot respectively. there was no complication. conclusion: our novel endoscopic robotic device can suture perforations resulting from complex endoscopic procedures. as our suturing method is similar to laparoscopic and robotic suturing, closure using our device is expected to be as strong as a surgical through-and-through closure. when developed further, this device can be used to close full-thickness resection sites and orifices in transluminal endoscopic surgery. modelling a collaborative robot with the ieee 11073 sdc standard for combined focused ultrasound and radiation therapy j. berger, m. unger, l. landgraf, a. melzer medical faculty, university hospital leipzig, innovation center computer assisted surgery, leipzig, germany background: surgical robotics require a smooth integration into the operating room (or) . for this propose the ieee 11073 sdc(service-oriented device connectivity) standard has been developed in the or.net project. in preparation for a combined focused ultrasound and radiation therapy (fus-rt) we have shown concepts and evaluations to position ultrasound and interventional devices with collaborative kuka arms. however, the safe and intraoperative cooperation with multiple different or-devices (e.g. an irradiation unit) requires a more sophisticated exchange of the robot's information and functionality. aim: to realize a safe clinical integration, the aim of this work is to implement and evaluate a dynamic connection between the kuka robots and other devices using the vendor-independent sdc communication standard. project description: a kuka lbr iiwa 7 r800 robot (kuka ag, germany) was modeled inside the sdc standard for medical device communication. the interconnection with other devices was implemented and evaluated on a mobile platform to position a clarius l7 wireless ultrasound transducer (clarius mobile health corp, canada). all necessary information of the robot was represented in the medical device description of the sdc standard to be shared via network. for each joint of the robot arm the position, torque, stiffness, damping, velocity and functional-states were represented, resulting in a total of 42 parameters. the software was implemented in c ?? on a standard pc accessing the kuka controller cabinet with ros (robot operating system) via ethernet. the accessibility of each parameter, as well as activation commands for planning and movement were tested with an sdc-consumer application. preliminary results: the sdc-provider functionality of the robot was successfully implemented, allowing for dynamic changes of the robot state during interventions. all appliances (sdc standard compatible) in the robots network can react to state changes and send movement and planning commands to the robot via activations. after testing, 100% of the 42 defined parameters are safely accessible. implementing the medical device communication for the kuka robot enables its integration into any networked operation room that supports the sdc standard. it is, therefore, ready to be set up and evaluated for the application of fus-rt in a clinical environment. background: assessment of perfusion of the left colon with fluorescence during anterior resections for cancer changes surgical decisions in up to 19% of cases. use of fluorescence has been shown to be associated with lower leak rates, and improved short-and long-term outcomes with reduced costs. given the high incidence of colorectal cancer, fluorescence-guided perfusion assessment could be of great importance in contemporary surgical practice. however, there is currently no standardisation of this technique which represents a significant limitation to widespread adoption. aim: to standardise fluorescence-guided perfusion assessment in rectal anterior resection through a computer vision algorithm. project description: videos were collected by a single surgeon in a referral centre for colorectal cancer treatment. perfusion assessment was used before proximal colon division to identify the best location for transection. a bolus of indocyanine green was injected intravenously and a near-infrared camera used to assess perfusion through fluorescence. photographs of fluorescent imaging of the colon were analysed using a non-supervised learning algorithm called 'k-means clustering'. the first step was to digitally subtract all background pixels, leaving only the area of interest of the colon. this area was then subsegmented into 2 'clusters' corresponding to perfused and nonperfused areas. a mathematical model was applied based on the 2 sub-clusters centres to select the area for transection with optimal perfusion of the proximal colon. preliminary results: representative images of proximal colon under perfusion assessment were presented to 8 expert surgeons. the optimal point for transection was selected based on their clinical judgement on previously delimited areas indicated by random letters. this was compared with the results from the automated segmentation using the algorithm ( fig. 1 ). the area identified for section by the algorithm included the area selected by the expert surgeons in 87.5-100% of test cases. these results need to be further validated due to high risk of overfitting. next steps include the collection of multicentre data with a standardised fluorescence perfusion assessment. after robust training, the algorithm will be validated on real-time clinical data to ensure improved outcomes for patients, which is our ultimate goal. background: endoscopic submucosal dissection (esd) is a flexible endoscopic technique that allows for an en bloc removal of lesions of the gastrointestinal (gi) tract. these procedures are typically time consuming due to the difficult control of the tools, and they often require around 95 min for removing lesions, that can reach 3-4 cm in diameter. the probability of intestinal perforation exceeds 18% and the hemorrhage risk ranges from 3.5% to 15.5%. a flexible robotic endoscope may offer a solution to overcome these limitations, by improving the degrees of freedom (dof) and operational efficiency. aim: within this clinical panorama, the aim of this project is presenting the development of a novel miniaturized robotic device to be coupled to the tip of a traditional endoscope for the surgical dissection of gi neoplasms. project description: the robotic platform consists of the miniaturized robot, the actuator housing (hereafter called external platform), the control unit and the master console (i.e.,two geomagic touch phantom) to allow the user driving and control (figure 1a ). during the operation, one surgeon stands close to the patient to maneuver the endoscope for exploring the gi tract and reaching the target area. another surgeon operates the miniaturized robot through the master console, carrying out the surgical procedure. the robot has been designed to be coupled to the tip of traditional flexible endoscopes of 14.5 mm in diameter. it exploits the flexibility of the endoscope for navigation through the intestine and integrates two-active robotic arms (i.e.,cautery and gripper) extending the dofs, and thus enhancing the efficiency during complex tasks such as manipulation and surgical tissue dissection. furthermore, the endoscope provides the optical system for visual feedback and one working channels for conventional instruments. preliminary results: firstly, a mock-up that faithfully reproduces the miniaturized robot has been realized using a 3d printer machine (projet mjp 3600, 3d system, inc.) to verify the feasibility of the design solution. after verifying the potentiality of the 3d printed prototype, a final device, with the same features (i.e.,dof and geometry) of the 3d printed prototype, has been designed, fabricated and assembled ( figure 1b ). background: virtual and augmented reality has been widely used in many fields mainly for entertainment purposes. we think that it could be beneficial to use augmented reality in medical practice. aim: the aim of this study was to evaluate usefulness of 3d holographic images of patients anatomy displayed using augmented reality goggles during endovascular aortic repair (evar). project description: one of the major challenges during endovascular procedures is working on two dimentional x-ray images of three dimentional vascular anatomy. using 3d holograms of patients anatomy could be beneficial during the evar procedure and could make the orientation in vascular anatomy easier for surgeon. we performed two endovascular aortic repairs with the assists of microsoft hololens -smart glasses using augmented reality. we used carna life application created by polish company medapp. it was one of the first use of holograms during vascular procedures in the world (second and third stent-graft implantation using holographic imaging in the world). results: two patients with abdominal aortic aneurysms, 79-years old male and 74-years old female, were operated on. holograms of patient's anatomy made from preoperative angio ct scans by polish company medapp were displayed during the procedures using microsoft hololens. holograms could be displayed in any place and configuration using augmented reality, which means that the images did not interfere with the surgeon's field of vision. microsoft hololens use voice commends which permits the surgeon staying sterile. stent-graft implantations were successful. both patients were discharged three days after the procedure and the hospitalization was uneventful. seeing precise patient's vascular anatomy reconstructions in three dimention certainly helped us to navigate in a vascular tree. we believe that in the future this technology would enable to reduce the operation time and need for radiation. background: interaction with electronically controlled operating room (or) systems embedded in modern surgical environments is everyday practice for surgeons performing minimally invasive surgery (mis). while there is a non-sterile operating nurse available in the or, capable of interacting with these systems upon request by the surgeon, this indirect control is mostly slow, prone for error and disrupting surgical workflow. facing an unanticipated and unwanted outcome may cause distress emotions. distress emotions are undesirable when performing surgery, since they may impact available cognitive workload. furthermore, they may result in negative communication, hampering or-team empowerment and effective leadership. both factors are known to negatively influence quality and safety in the or. aim: the aim of the tedtrial is to investigate what setup best enables surgeons to interact with the endoscopic operating room setup during surgical procedures. as a result, disruptions of workflow, delays and errors may be reduced. outcome parameters will be objectified using medical data recorder (mdr) derived output and biometric analysis using hexoskinó. subjective evaluation of outcome parameters is done using questionnaires. project description: the tedcubeó system is a plug-and-play device enabling wearable sensors to act as a wireless alternative for a regular computer mouse, therefore enabling direct hands-free and sterile control of the or. the study is an observational trial with three different arms: intervention group 1) direct interaction by surgeon with or environment using tedcubeó and myo tm armband, intervention group 2) direct interaction of surgeon with or environment using tedcubeó and plantronicsó wireless microphone headset. the third arm is the control group using indirect interaction of surgeon with or environment using third-person computer interaction. main endpoint of study is the number of workflow disruptions due to the operation of laparoscopic or equipment. secondary endpoints are error rate, delay, team communication, subjectively reported frustration and satisfaction with the system and objectively measured stress as symptom of frustration and anger as distress emotions. preliminary results: primary and secondary endpoints of study are compared among groups. it is anticipated that reduction of miscommunication, error and delay may result in a reduction of distress emotions. trial start is expected q1 2019. anticipating the automated intraoperative tissue recognition: intraoperative tissue classification using hyperspectral imaging and machine background: iatrogenic injuries may occur despite a sound expertise in surgical anatomy. hyperspectral imaging (hsi) is an emerging optical method, combining the use of a camera system with a spectrometer. hsi analyzes optical properties of tissues and acquires 3d data sets with two spatial dimensions (x, y) and one spectral dimension (?). the data sets contain information about tissue physiology, composition, and perfusion. those spectral features coupled with machine learning algorithms might allow for automatic tissue recognition. aim: assessing the ability of an hsi-based machine learning to discriminate the hyperspectral features of different tissues during neck and abdominal surgical procedures. methods and procedures: fourteen pigs underwent laparotomy (n = 6) or neck dissection (n = 8). twenty data sets were acquired in vivo from abdominal organs and 20 from neck structures by means of a customized hyperspectral camera (diaspective vision, germany). different anatomical structures were manually outlined by a surgeon using an image manipulation software (gimp). each pixel contained a hyperspectral curve and each curve was composed of 100 bands (from 500 to 1000 nm with a 5 nm resolution). the curves were normalized using the standard normal variate method. a logistic regression machine learning (ml) algorithm was used to train the model to discriminate tissues, based on the hsi spectral features. the efficacy of the prediction model was tested using the k-fold (k = 10) cross-validation. results: a large number of tissue-related hyperspectral curves could be extracted (4675 thyroid, 9417 vagal nerve, 48546 fatty tissue, 30486 cartilage, 16001 carotid artery, 81567 muscle, 5149 carotid vein, 7148 portal vein, 22973 biliary tract, 73940 gallbladder, 1874 hepatic artery, 16712 pancreas, 2412 duodenum, 34313 abdominal adipose tissue). the algorithm used 4 min to 'learn' all data sets, and prediction was provided as an immediate output. overall, prediction accuracy was 92 and 89% for neck and abdominal structures respectively. in particular, biliary ducts could be identified with a 93% accuracy and the vagal nerve with an 89% accuracy (see figure 1 for details). background: a gaze-controlled robotic endoscope is innovative technology with myriad potential applications in the rapidly advancing field of flexible endoscopy. improvements to the current flexible device to allow examination of the gastrointestinal tract whilst minimising procedural discomfort and complications are desirable. aim: to use a gaze contingent framework to manipulate a flexible endoscope through a simulated upper gastrointestinal tract (ugit) model. description: a flexible gastroscope (karl storz 13801 pks) was attached to a ur5 6 axis robotic arm (universal robots), mounted onto a rail and placed on top of a surgical table. two cogwheel shaped dials were 3d printed and placed onto the up/down and left/right wheels on the head of the gastroscope ( figure 1 ). robotization of these controls was achieved by using two motors (dynamixel rx-24f) to steer the distal tip. this system allows users to operate a robotised flexible endoscope using gaze control. gaze interaction with the screen was based on a 3d gaze framework we developed with the synergy of conventional wearable eye-tracking, motion capture system and fixed in space rgb-d cameras for 3d reconstruction of the environment. users are able to control endoscope movements without handling the device. the distal tip of the gastroscope was controlled using eye gaze technology. the ur5 robot was used to enable shaft rotation (initiated by fixed head movements) and linear movements were triggered using a joystick handle (up for forward movement, down for endoscope withdrawal). pause and retroflexion of the endoscope are achieved by moving the joystick left and right respectively. users were asked to navigate an endoscope through an ugit model (chamberlain group) simulating a diagnostic gastroscopy using gaze control and targeting ten points scattered through the stomach. results: four expert endoscopists and one novice used gaze control to successfully navigate a gastroscope through a simulated ugit. all were able to intubate the oesophagus and accurately locate ten targets placed in the fundus, body, antrum and pylorus of the stomach. conclusion: gaze control endoscopy is a feasible concept. it allows ergonomic, user-friendly and intuitive control whilst maintaining the benefits of a flexible endoscope. background: image-guided needle biopsies and histopathological evaluation are the gold standard for the diagnosis of liver neoplasms. most often, however, these are reserved for suspicious, but not diagnostic, situations. radiomic may help to characterize tumor biology by correlating imaging features with relevant tumor-biology information. features derived from radiomic analysis may provide complementary information to support clinical decisions, especially in situations where tissue analysis cannot be performed or is inconclusive. aim: the goal of our technology is to exploit computational capabilities for image analysis in order to identify radiomic features useful for characterizing liver lesions and to identify relevant information related to patient prognosis. project description: 17 patients derived from an internal database and 12 patients randomly extracted from the cancer archive liver dataset were included in this study. 56 lesions were extracted from those volumes using expert annotations (31 secondary vs 25 primary; 34 well differentiated vs 22 non-well differentiated). lesions were then split into training and testing sets. first order statistical features were computed and a lasso regression step was performed to reduce the number of features. both logistic regression and random forest models were built using cross-validation to predict the target classes on the test set. preliminary results: only 2 features namely the energy and the volume of the lesion were sufficient, when combined in either model, to predict the differentiation grade on the test set with an f1-score of 0.74(± 0.07). we are currently working on the addition of higher order statistical features to the analysis in order to differentiate primary from metastatic tumors and identify complementary features that may assist clinical decisions in patients with inconclusive hepatic lesions. objective of the technology or deviceideally, the use of medical simulators could provide trainees with initial background information about indications for procedures, endoscopic technique, and early hands-on training experience that could shorten the initial critical learning curve. rationale for using ex vivo models is that in the beginning of the learning curve, the most important issue is having an initial exposure to the basic movements and maneuvers. our objective of is to create a stomach model from renewable polymer, which would closely simulate normal human stomach with gastric pathology for endoscopic diagnostic or interventional skill acquisition/evaluation. description of the technology and method of its use or application stomach model is based in several steps; the first one is in the in-silicodesign of the overall shape, after that we 3d print the positive two halves of it. the interior detail is obtained shaping the 3d printer parts with ceramic putty. once concluded, this elaborated part will serve as a template in order to build injection bleeding moulds. in the injection bleeding moulding a mesh is placed between layers in order to provide structural attachment points as stiches or several pathological models that will be incorporated after the casting process. we have developed for these instance polyp moulds, fistulae structures in order to attach endoscopic clamps. the two halves are closed once the pathological models are placed inside via a thermic-fusing and stitching creating a leak proof stomach model. preliminary results if available: our models were evaluated by 8 international experts in ircar/ihu france in interventional endoscopy course and were favorable accepting for next trails in these prestigious institutions. conclusions: future directionsa new endoscopic training model of stomach was made and will be evaluated and validated for feasibility in mastering diagnostic and interventional endoscopic skills. clinical trials will be necessary to compare the ability of the simulator to perform training compared with traditional methods of training in endoscopic procedures. background: endoscopes are the eye of surgeons in minimally invasive surgery (mis). conventional endoscopes are mostly chopstick-like and are steered by the assistant. this limits the field of view and results in issues such as endoscope-instrument fencing, surgeon-assistant coordination. existing robotic endoscope holder enables solo-surgery, however endoscope remains blocking the instrument movement and impairs the operational safety. flexible endoscope such as the endoeye provides angulation at the tip and could enlarge the field of view. however, its steering the view is much more complex compared to the rigid endoscope. aim: to provide an intuitive robotic flexible endoscope with enhanced safety. project description: in this work, we present a robotic flexible endoscope for mis with enhanced safety. in the proof-of-concept system, it contains a flexible endoscope module and a robot manipulator. the endoscope contains a proximal rigid shaft and a distal flexible bending section. it is installed onto the patient side manipulator (psm) of the da vinci research kit (dvrk). visual servoing is adopted to achieve autonomous instruments tracking. during the tracking process, movements of the manipulator as well as the endoscope are minimized to save space for the operation and avoid instrument-endoscope fencing. the endoscope could also be controlled by the surgeon. a foot pedal is used to switch between the tracking-mode and control-mode. preliminary results: a prototype was developed and tested experimentally. in tracking a volume of 200*200*100 mm 3 , the spaces required by the flexible endoscope are 15.55% (inside the trocar) and 9.83% (outside the trocar) of that occupied by the rigid endoscope. evaluation with the fls tasks involved 10 subjects. all of the participants completed the tasks under the tracking-mode without failure. in the ex-vivo test with porcine stomach, the endoscope successfully guided the detection, dissection and knotting autonomously. background: fluorescence imaging allows to visualize deep-seated anatomical structures, using a deeper tissue penetration of near-infrared (nir) compared to visible light. the most commonly used fluorescent substance, indocyanine green (icg), is not naturally excreted by the urinary system and requires retrograde stent placement and injection. lighted catheters have been proposed to help visualise the ureter. fluorescent dye-coated ureteral catheters could well represent a more effective and less expensive solution. icg is unsuitable for coating materials. aim: to develop a stable fluorescent coating for catheters to be used intraoperatively, working in the same nir window as icg, to facilitate its use with clinically available systems. project description: the coating was developed based on poly(methyl methacrylate) (pmma), a biocompatible polymer, and on specifically designed fluorescent dyes exhibiting icg-like optical properties. three nir dyes (substances a, b, and c) were tested in order to find the optimal one, in terms of fluorescence signal intensity, and were compared to icg in a polymer form and to an icg-based reference card (green balance tm ). the fluorescent coating was applied onto 3 common ureteral stent materials: hydrophilic-coated ultrathaneò, silicone-coated latex, and pvc. the coating process involved 3 cycles of immersion into the respective dyes blended in pmma polymer (icg, substances a, b, and c), followed by a drying phase. the various tubes were partly inserted into a porcine ureter, next to the icg-based reference card. images were taken in white light and nir modes using the d-light p camera system (karl storz), at a fixed camera-to-target distance. the fluorescence signal intensity was measured for the different regions of interest (each material/coating combination inside and outside of the ureter, reference card) using proprietary software and normalised against the reference card. preliminary results: the signal intensity was significantly higher for all new substances as compared to icg. substance a showed the strongest fluorescence signal intensity among the tested coatings in all tested conditions and materials and was identified as the ideal candidate to undergo further evaluation and in vivo testing. background: endoscopic resection(er) of early gastric cancers provides tremendous patient advantages. however, post-resection findings of deeper sub-mucosal(sm) and/or lympho-vascular invasion can necessitate a second, surgical intervention. we propose that pre-resection evaluation of the submucosal architecture under the tumour can provide critical information for staging and operative planning. we evaluate three techniques to assess the submucosal architecture underlying the gastric mucosa in a pig model. aim: to evaluate three needle-based methods of evaluating the sm before er. project description: 6 acute pigs were used. a simulation of sub-mucosal tumours (endoscopically and eus visible bleb) by injecting the sm with 20 cc of undyed nac. a linear eus was use for all procedures. the tumours were marked and labelled according to geography. methodology: after creating the tumours, anterior lesions were evaluated using the following 19g needle-based modalities: confocal microscopy(cm) using the through-the-needle cellvizio (mauna-kea) system; mini-biopsy(mb) using the micro-biopsy forceps moray (us endoscopy) and fine-needle biopsy(fnb). results: 18 cm examinations were video recorded in all a positions. submucosal vascular visualisation was possible in all cases, excellent in 17/18. mb was performed in 18 lesions with a total of 2 biopsies obtained from each lesion (total = 36). fnb was performed once in the anterior lesions and twice in the posterior lesions with different needle brands. therefore, there was a total of 54 biopsies collected. 2 passes were performed in each biopsy (total = 108). each pass constituted 20-25 insertion/withdrawal movements combined with fanning, slow pull technique, no suction and suction (10-20 cc air negative pressure) to collect the material. all material were sent to an animal anatomo-pathologist blinded to the acquisition method. mean time of confocal examination was 15 min 8sec (6'02' '-30'59'') . mbtook a mean time of 5 min and fnb was a mean of 10 min for each biopsy. cm identified different patterns of vessels in relation to the probe position (superficial/reticular, middle cross-roads or deep/longitudinal). conclusion: eus-fnb, cm and mb are three potential methods to assess the sub-mucosal space underlying the gastric mucosa. cm offered the most architectural information but required more time to perform. these method's may have a role in better staging patients for appropriate er. background: the overall and disease-free survival of patients with rectal cancer is dependant on its staging, and adequate selection of the treatment strategy. mri has a proven efficacy in rectal cancer local staging and recognition of the adverse prognostic features. however, it can be difficult to utilise it as a navigation tool for surgeons, as it represents a complex three-dimensional pelvic space with a series of individual two-dimensional images. 3d image reconstruction has been successfully adopted in other surgical fields to overcome these limitations. aim: our primary aim is to develop a bespoke automated generation of patient-specific 3d pelvic models, which will improve surgical planning and navigation, patient interaction and surgical education. true-size, rotatable 3d models will offer a more realistic three-dimensional representation of the surgical space and its complex relationships, allowing for a more confident surgical rehearsal and potentially better utilisation of minimally invasive techniques in rectal cancer management. our secondary aim is to develop a large multipurpose database of the 3d models of male and female pelvis in health and in the disease. project description: our multidisciplinary team consists of colorectal surgeons, radiologists specialising in pelvic mri imaging and computer scientists. virtual 3d pelvic models are generated based on standard 2d dicom mri images routinely used for rectal cancer staging, which guarantees the high fidelity of cancer delineation. segmentation of the pelvic anatomy is performed with the use of itk-snap, an open-access, multi-platform software. machine learning technology is then employed to automate the 3d model generation, making it time-efficient, allowing for its clinical application. preliminary results: in the initial stage, using the manual segmentation, we have created ten models of normal male and female pelvic anatomy. a good inter-rater agreement level was found, which proves reproducibility of the approach applied. various machine learning algorithms are being explored to fully automate the process of 3d model generation, which will allow for their use in clinical practice and in development of the 3d colorectal database. the technology will be further implemented in creation of dynamic models of functional pelvic floor disorders. 4 surgery, toho university omori medical center, tokyo, japan; 5 surgery, neuchâtel hospital, neuchâ tel, switzerland background: laparoscopic gastrojejunostomies are time-consuming and require a specific training. alternatively, sutureless anastomosis can be achieved by means of endoscopically delivered magnetic rings. objective of the study: assessing the feasibility and reproducibility of an endo-laparoscopic gastrojejunostomy technique, using magnets coated with a fluorescent biocompatible polymer. methods and procedures: four pigs (2 acute, 2 survival models) and one cadaver were included in this study. the anastomotic device was composed of two magnetic rings (25x8x6 mm; attraction force 30 newton), each one attached to a 75 cm long thread. the distal ring was inserted endoscopically into the first duodenum, and the extremity of the thread was clipped to the gastric mucosa. twenty-four hours later, a two-port laparoscopy (12 mm, 5 mm) was performed, using a near-infrared (nir) laparoscope (d-light-p; karl storz). the magnet's position in the jejunum was detected thanks to the transluminal fluorescence of the dye. magnetic interaction with the metallic tip of the laparoscopic grasper allowed to catch the ring and bring the bowel loop to the future anastomotic site on the gastric wall. simultaneously, the proximal magnet was delivered to the gastroesophageal junction using a flexible endoscope. the magnet was carefully advanced into the stomach allowing precise connection with the distal ring. in one cadaver the procedure was repeated. the sole variation was that, in order to reach the second jejunal loop, the distal magnet was placed using a gastroscope inserted through a transgastric port. in two acute animals, the distal magnetic ring was introduced into the jejunum via an enterotomy. the anastomotic procedure (from the distal magnet detection via fluorescence to the magnetic connection using a hybrid approach) was reiterated 40 times. survival animals were followedup for 10 days and underwent control endoscopies and ct-scans. results: the procedure was easy to standardize and reproducible, with a mean anastomotic procedure time of 2.62 ± 1.42 min. there were no technical problems and magnetic connection could be precisely directed in all cases, at both the anterior and posterior gastric wall. no complications occurred during the survival period and the anastomoses were patent by day 5. transluminal fluorescence allowed for a rapid detection of the magnet. colorectal cancer is the fourth most common cancer in high-income countries counting [ 700.000 deaths worldwide. survival rate reaches 94% in case of early diagnosis, falling down to 11% in case of advanced stage. conventional colonoscopy screening is limited by invasiveness, pain and often need of sedation. wireless capsule endoscopy enables inspection without discomfort, but passive locomotion often leads to incomplete and/or false negative results. the european endoo project (grant agreement 688592) aims to develop a novel system that overcomes most of the drawbacks of conventional colonoscopy, maintaining accurate and reliable diagnosis and therapy. the system is composed of an active robotic platform that magnetically drives a soft-tethered capsule; magnetic guidance is achieved through the magnetic localization of the capsule in combination with a closed-loop control that maintains an optimal and safe link between the capsule and the magnetic end-effector. a stereoscopic camera is integrated in the capsule for enhanced diagnosis though 3d reconstruction and automated detection of lesions/pathologies. the different modules of the endoo medical platform are illustrated in the figures. the robotic guidance systemconsists of an anthropomorphic manipulator that controls the capsule through an external permanent magnet. the robot, positioned on a dedicated trolley, is equipped with sensors for performing safe human-robot collaboration. the medical workstationincorporates: screens, buttons and pedals for visualization and command initiation, a joystick for system teleoperation and a back-end for fluidic control and data communication. the soft-tethered capsuleembeds an internal permanent magnet, magnetic sensors, an accelerometer, white and infrared illumination and an hd stereoscopic vision system with two wide-angle customized optics. a controller serves as the main control unitfor performing real-time communication and closed-loop control of the robot, localization system, capsule and physician commands. the synergistic cooperation of academic, industrial and clinical partners within the project allowed to develop and validate the system in in-vitro \/i [ , exvivoand preliminary cadaver sessions, performing comparisons with state-ofthe-art commercial colonoscopes. in conclusion, the endoo medical platform provides: reduced procedural pressures, user-friendly procedures, similar functionalities and performances of commercial devices, comparable procedural times and considerably lower costs with a new painless approach. background: this study is aimed at the comparison of the process of manual and robotic-assisted positioning of the electrode performing radiofrequency ablation with the usage of multifunctional robot-assisted surgical platform. under the control of the surgical navigation system. the main hypothesis of this experiment was that the use of a collaborative manipulator will allow to position the active part of the electrode relative to the center of the tumor more accurately and from the first attempt. we also check the stability of the electrode's velocity during insertion and consider some advantages in ergonomics using the robotic manipulator. methods: sphere-shaped tumor phantoms measuring 8 mm in diameter were filled with contrast and inserted in cow livers. 10 livers were used for the robotic experiment and an equal quantity for manual. the livers were encased in silicone phantoms. analysis of ct data gave the opportunity to find the entry and the target point for each tumor phantom. this data was loaded into the surgical navigation system that was used to track and record the position of the rf-electrode during the operation for further analysis. results: standard deviation of points from the programmed linear trajectory totaled in the average 0.3 mm for the robotic experiment and 2.33 mm for the manual operation with a maximum deviation of 0.55 mm and 7.99 mm respectively. standard deviation from the target point was 2.69 mm for the collaborative method and 2.49 mm for manual method. the average velocity was 2.97 mm/s for the manipulator and 3.12 mm/s for the manual method, but the standard deviation of the velocity relative to the value of the average velocity was 0.66 mm/s and 3.05 mm/s respectively.thus, in two criteria out of three, the manipulator is superior to the surgeon, and equality is established in one. surgeons also noticed advantages in ergonomics performing the procedure using the manipulator. conclusions: this experiment was produced as part of the work on the developing of the robotic multifunctional surgical complex. we can confirm the potential advantages of using robotic manipulators for minimally invasive surgery in case of collaborative practice for cancer treatment. surg endosc (2019) background and aims: laparoscopy has reduced tactile feedback compared to open surgery. in neuropsychological literature there is increasing evidence that visual and haptic information converge to form a mental representation of an object. through the combination of these inputs, this representation is believed to be more refined and robust. we investigated whether tactile exploration of a lifelike anatomical object before executing a laparoscopic action on this object in a laparoscopic box trainer improves performance of this action. description: a randomized prospective cohort study with two groups (a ? b) of ten laparoscopically naïve medical students was conducted. we compared the groups for baseline characteristics and performance, using a basic laparoscopic task (post and sleeve). to investigate the effect of haptic exploration, students performed ten repetitions of a laparoscopic needle action on a lifelike silicone caecum model (applied medical, rancho santa margerita, usa). group a did a pre-test visual exploration of the model. in group b manual exploration of the anatomical model was added to the visual exploration before executing the task. the box trainer was equipped with the forcesense tm (medishield, delft, the netherlands) system for skill assessment using objective force, motion and time parameters. results: baseline characteristics and-laparoscopic performance were comparable (p [ 0, 05) . performances of 200 trials on the anatomical model were captured and parameter outcomes were compared between groups. significantly less force (maximal force, maximal impulse, mean force and force volume) was exerted by the 'touch' group (p \ 0.000) (fig. 1 ). this group also completed the task with less distance travelled by the instruments (p \ 0,003). there was no significant difference in time needed to complete the task (p = 0,695). conclusion: this study showed that, when performing a laparoscopic task on an anatomical model, pre-task haptic exploration of the model results in the use of significantly less force and less movement. adding haptic exploration to a laparoscopic training curriculum could therefore result in more efficient and more refined learning of laparoscopic actions. this, in turn, could lead to better, quicker and safer performance of laparoscopic operations. . esophagogastroscopy was performed before gabe and 1-week post-procedure assessing gastric abnormalities. weight and fasting plasma ghrelin were obtained at baseline, 1-, 3-, 6-and 12-months post-index procedure. after 6 months, the sham group was unblinded and received gabe. both gabe and sham crossover to gabe groups were followed for 12 months and received lifestyle therapy (behavioral-diet education). preliminary results: gabe was successful in all patients with no serious complications. significant, progressive weight loss was observed at 6 and maintained at 12 months. ghrelin in gabe group decreased by 22% (67.91 pg/ml) compared to baseline and 12 months levels. weight-loss was approximately 6.5% greater in the gabe group versus sham at 6 months ( table 1) . itt = intent-to-treat, pp = per-protocol analysis preformed using independent-sample t-test and à paired-sample t-test conclusions: gabe using eles is safe, accompanied by significant and so far maintainable weight loss. gabe using the eles demonstrated a reduction in ghrelin levels. aims: transanal total mesorectal excision (tatme) is the latest colorectal approach that continues to be in the spotlight. this study aims to describe the technique in depth by identifying and understanding technical advantages, errors and adverse events. methods: detailed video analysis using observational clinical human reliability analysis (ochra) was completed on 100 clinical tatme cases performed by 27 international surgeons. error frequency and error pathways leading to adverse events were described. tatme expert surgeons were interviewed and engaged in a workshop to elicit error-reducing mechanisms. results: overall technical errors and adverse events per procedure on average occurred 49 ± 32.9 (range 6--194) and 9 ± 6.1 (range 1-45) times respectively. inadequate insufflation and poor camera optics were the most frequent set-up problems. instrument handling errors consisted most commonly of excessive grasper movement during the pursestring phase (321 times total), inappropriate force applied (79 times) with the energy device during the rectotomy, inappropriate force with the grasper (74 times) and excessive movement with the energy device (117 times) during tme dissection. incorrect dissection planes were created during tme dissection mostly due to insufficient retraction (127 times) which didn't allow adequate exposure of the tissue planes. the most frequently occurring consequence was bleeding (mean: 6 times per procedure). rectal perforation (7 cases), vaginal wall injury (4 cases), and prostatic injury (7 cases) were also recorded. adverse events regularly occurred as a result of poor set-up/exposure, inappropriate retraction and/or instrument movement and incorrect plane surgery. error-reducing mechanisms and 'technical tips' describe specific steps and actions, both set-up/equipmentrelated and technique-related, that aim to prevent errors from occurring and avoid adverse consequences. ochra and individual feedback with error-reducing mechanisms developed by this study have been implemented into the national training programme for tatme. conclusion: tatme is an advanced complex procedure during which technical errors and their consequences are not infrequent. tatme requires knowledge of anatomy 'bottom-up', familiarity with its specialised equipment and technical skill working in a narrow space. appropriate structured training and mentorship are therefore recommended. surg endosc (2019) objective: insufficient vascular supply is one of the main causes of anastomotic leak in colorectal surgery. icg has been shown to provide information on tissue perfusion, identifying a well-perfused location for colonic and rectal transections and thus possibly reducing the leak rate. objective of this study is to evaluate the usefulness of intraoperative assessment of anastomotic perfusion using intraoperative indocyanine-green dye (icg) angiography in patients undergoing left-sided colon or rectal resection with colorectal anastomosis. methods: this randomized trial involved 252 patients undergoing laparoscopic left-sided colon and rectal resection randomized 1:1 to intraoperative icg or to subjective visual evaluation of the bowel perfusion without icg (clinicaltrials.gov nct02662946). the primary aim was to assess whether icg angiography could lead to a reduction in anastomotic leak rate. secondary outcomes were possible changes in the surgical strategy and postoperative morbidity. results: after randomization, 12 patients were excluded. accordingly, 240 patients were included in the analysis; 118 in the study group, and 122 in the control group. icg angiography showed insufficient perfusion of the colic stump, which led to extended bowel resection, in 13 cases (11%). an anastomotic leak developed in 11 patients (9%) in the control group and in 6 patients (5%) in the study group (p = n.s.). conclusion: intraoperative icg fluorescent angiography can effectively assess vascularization of the colic stump and anastomosis in patients undergoing colorectal resection. this method led to further proximal bowel resection in 13 cases, however its role in reducing anastomotic leak rate should be studied in further research. endoscopic sleeve gastroplasty (esg) is a promising endoscopic bariatric procedure carried out with the application of transmural sutures resulting in a gastric reduction and gastric shortening. sutures are placed in u shape fashion, from the incisura to the fundus, which is preserved, using an over the endoscope suturing platform (overstitch, apollo endosurgery, austin, texas, usa). the choice of right lankmarks for suturing the gastric wall is extremely important for the efficacy and safety of the procedure. flexible endoscopy suffers from little anatomical reference points. correct spatial relation to precisely target the insertion of the helix device used for retraction and correct orientation of the full thickhness tissue bite require a good undrestanding of the anatomy of the stomach and sourrounding organs including vascular structures that could be inadvertently injured (left lobe of the liver, gallbladder, spleen, short gastric vessels, pancreas, transverse colon). surgeons by training can 'see' the anatomy beyond the gastric wall and undrestand whether they work in a safe layer or whether an underlying structure should be spared. this video illustrates all the potential risks realted with a wrong chioce of endoscopic landmarks when performing esg with respect to gastric and abdominal anatomy. introduction: central bisectionectomy, anterior sectionectomy, and posterior sectionectomy are technically demanding procedures in minimally invasive approach because of difficult expoure and extensive parenchymal transection planes. with limited robotic instruments including absence of cusa, these procedures have been rarely perfomed by robotic approach. method: consecutive robotic central bisectionectomy, anterior sectionectomy, and posterior sectionectomy were performed. patients were all males and were 67, 71, and 41-years-old, respectively. pathologic diagnoses were all hepatocellular carcinomas of each 4.4, 4.2, and 3.2 cm diameter. operative settings were identical for the three kinds of procedure. the patients were placed in supine with a reverse trendelenburg and right side elevation. umbilical 12-mm camera port, three 8-mm ports and additional 12-mm assistant port were used. glissonian approach and icg fluorescence image clearly demarcated the resection planes. parenchymal transection was performed using the maryland bipolar dissector and harmonic scalpel. the rubber band self-retraction method and third arm of robot system helped for stable and excellent exposure of surgical planes result: there were no conversions to laparoscopic or open surgery. the operative time was 320, 330, and 290 min and estimated intraoperative blood loss was 200, 330, and 250 ml. the pathologic surgical margin was 2.5, 0.5, and 3.6 cm. the length of stay after surgery was 7, 8, and 6 days and there were no postoperative complications. conclusion: robotic central bisectionectomy, anterior sectionectomy, and posterior sectionectomy are still demanding procedures with long operative time. however, these procedures could be performed safely in regard to short-term perioperative outcomes. robot surgical system provided several benefits for anatomical hepatectomies including a stable and excellent operative field and clear surgical planes. suprapubic hernias (less than 5 cm above the pubic arch in the midline) require important anatomical knowledge because of complexity of their repair and low incidence, by approximately 2% of all hernias. the problem to repair this type of hernias is that inferior margin of the defect is very close to pubic symphysis, consequently, mesh overlap is often inadequate. treatment of suprapubic hernias is controversial because of limited evidence in the literatura. this video shows the case of a 40-year-old female patient with suprapubic hernia with a defect of 3x3 cm. we performed a laparoscopic repair with a bilateral peritoneal flap of the groin region (as it is perfromed during tapp) for proper view of the pubic symphysis, cooper's ligaments, epigastric and major vessels, nerves and meticulous dissection the space of retzius. the defect was repaired by reconstructing the middle line with a running sutures. subsequently, titanium helical tacks were used to fix the mesh to the pubis and cooper and following the double-crown technique having special attention when fixing the mesh near to inguinal chanal, due to the possibility of causing chronic pain. the peritoneal flap was fixed over the mesh with abdsorbable fixation devices and seal with fibrin glue. laparoscopic repair of suprapubic hernias can be considered as the first option in treatment, because it endeavors to join the advantages of a minimally invasive approach and it is associated to low recurrence. the main advantages are that allows a proper visualization the anatomy and a proper fixation of the mesh. background and aim: thoracoscopic esophagectomy has been performed for two decades and becomes widely spread. we evaluate our cases who undergone the thoracoscopic esophagectomy and consider the future prospective of this operation.transient recurrent laryngeal nerve palsy after lymphadenectomy in this surgery is not rare and induces not only hoarseness but also aspiration or pneumoniae. new method to avoid this complication is desired. patients and methods: 702 patients who received thoracoscopic esophagectomy in our institute from march 1995 to october 2017 were enrolled and studied retrospectively. operative indication is an all of the clinically resectable cases including with a neoadjuvant treatment or definitive chemoradiotherapy before surgery. overall survival rate of the patients with thoracoscopic approach and with thoracotomy until 2001 was analyzed. long term outcome of the patients with thoracoscopic esophagectomy was compared to the result from comprehensive registry of esophageal cancer in japan. short term results of the perioperative parameters were analyzed between left lateral decubitus position and prone position.we had introduced intraoperative nerve monitoring system for prone esophagectomy from 2014. results: there was no significant differences of the survival rate between thoracoscopic group and thoracotomy group based on pathological stage. 5 year survival without neoadjuvant treatment was 88.9% (pstagei), 71.5%(pstageiia), 68.1%(pstageiib), 40.9%(pstageiii), respectively.5 year survival rate of cstageii and iii with neoadjuvant chemotherapy was 65.7% and 5 year survival rate of the salvage esophagectomy after failure of definitive chemoradiotherapy was 31.4%. every outcomes are as good as any reported results in esophagectomy. in the comparison of the lateral position with the prone position, total blood loss was significantly lower in prone position. inflammatory response after surgery was improved more rapidly in prone group, therefore, prone position is recommended as a minimally invasive procedure for thoracoscopic esophagectomy. transient recurrent laryngeal nerve palsy was observed 30% of patients. conclusion: thoracoscopic esophagectomy will develop further as a standard operation for esophageal cancer. nerve monitoring is useful for detecting recurrent nerve and avoiding nerve injury. background: laparoscopic total mesorectal excision (tme), in a wide female pelvis is usually technically easier than in a narrow male pelvis. however, this is not always the case, as the uterus and adnexae may obscure the views and hinder safe dissection, especially in obese patients. techniques such as graspers through additional ports or suspension with sutures through the broad ligament may potentially cause injury or need additional ports/assistants. aim: we present a novel technique using a self-retaining gynaecological uterine manipulator to improve access during deep pelvic laparoscopic surgery in female patients. technical tip: the operation is commenced in the standard manner for a laparoscopic rectal excision. once pelvic dissection is commenced, whenever it is felt that uterine retraction would be advantageous (depending on the level of the rectal tumour, size of the uterus and ovaries, obesity etc.) a self-retaining uterine manipulator (as shown in the video) is used. the tip of this disposable device is introduced into the uterus after dilatation of the uterine cervix. once the balloon at the tip has been inflated, the instrument is secure and hence there is no need for active manipulation by an assistant. the shaft can be rotated to allow anteversion/retroversion of the uterus to varying degrees as required to aid dissection. as the video depicts clearly, it acts as a self-retaining retractor for the uterus and is removed at the end of the operation. though the procedure is being demonstrated by a gynaecologist in the video, the instrument is quite easy to insert and some of our colorectal team have been trained as well. conclusion: the self-retaining uterine manipulator is an efficient tool for uterine retraction in laparoscopic rectal surgery and we have been using it routinely in tme in females for the past 8 years, with no complications. this was previously published as a technical tip in the journal of minimal access surgerybut has never been submitted for peer review as a video. the authors present a video of two clinical cases treated by trans-axillary endoscopic approach. methods: a 74 years-old male and a 73-year-old male presented with intermittent dysphagia and frequent reflux (class ii of lahey). one had a history of recurrent respiratory infections. the disease was characterized by oesophagogastroscopy (egd) and oesophagogram. trans-axillary approach with areolar port. step-by-step as follows: (i) dissection anteriorly to the pectoralis major muscle (ii) isolation of the anterior border of sternocleidomastoid muscle (iii) omohyoid muscle's isolation (iv) identification of the thyroid's upper pole (v) zd isolation (vi) myotomy of the cricopharyngeal muscle (vii) zd's resection with stapler and its withdrawn with sac. results: both cases progressed without complications. complete local recovery was verified in both cases one month after the procedure. conclusion: this technique seems feasible and reproducible, allowing zd diverticulectomy with a better cosmetic result and perhaps lower surgical site infections (ssi). in the authors' knowledge, this approach to dz has never been published. background: gastric leak occurs in 1-6% of patients who undergo roux-en y gastric bypass (rygb) for morbid obesity. the pathophysiology may be related to gastric ischemia, fistula, or ulcer.gastric leak is a severe complication of gastric bypass (gbp) that is associated with significant morbidity and mortality. fistula may have several clinical impacts, depending on patientrelated factors, fistula characteristics, onset time, and therapy proposal. abdominal drainage, gastrostomy, and revisional surgery constitute the traditional approaches to dehiscence and fistula closure, with variable results. methods: we present a video of a clinical case of 44-year-old lady with body mass index of 45 kg/m 2 who underwent roux-en-y gastric bypass and 48 h later presentedtaquicardia and right cuadrantum pain. the ctscan inform a apical leak at the gastric pouch level. the video shows the relevant aspects of a revisional surgery and the key points to drain the fistula and close de defect laparoscopically. results: after 6 monts, the patient achieved succesful results, defined as a stabel clinical situation with image evidence of gastric fistula remision. conclusions: gastric bypass (gbp) is one of the most efficient bariatric interventions in morbidly obese patients. the most severe risk of this procedure seems to be the staple line leak, and the management of this complication can be very arduous. without any guidelines it is very difficult to determine the right procedure addressing the staple line leak after gbp. laparoscopic sleeve gastrectomy (lsg) has become the most commonly performed operation worldwide as a primary bariatric/metabolic procedure. however, conversion to other surgical procedures such as roux-en-y gastric bypass (rygb) or one anastomosis gastric bypass (oagb) have been described as treatment options for inadequate weight loss after lsg and unresolved co-morbidities or complications such as leak, stricture, and severe gastroesophageal reflux disease (gerd). we present two clinical cases of weight regain and severe gerd and dysphagia, which account for the main indications to reversal of lsg to either oagb or rygb. aims: we show in the video the surgical technique that we perform by laparoscopic aproach, in order to construct a roux-en-y polipropilene banded gastric bypass lrygb-b. methods: we are performing this procedures within a prospective randomized trial that is design to compare the long term results of lrygb-b versus the standard laparoscopic roux-en-y gastric bypass.the video shows our technique in a case of a 46 years old female with a bmi of 46 kg/m2. first we create a vertical gastric pouch of about 25-30 ml, and a polypropylene mesh (10x65 mm) is placed 20-30 mm proximal to the anastomosis around the gastric pouch, with the help of a laparoscopic band retractor. after that a 150 cm roux-en-y limb is constructed in an antegastric antecolic fashion, been the lenght of the biliary limb 100 cm. a 25 mm gastroyeyunal anastomosis is performed with a linear stapler, and the enterotomy and gastrostomy are closed with a 3/0 barbed running sutures. jejunojejunostomy anastomosis is constructed in similar fashion, but with a lenght of 30-45 mm. the petersen space and the mesenteric defect are closed with polipropilene 0/0 sutures. results: 31 patients has been operated following this technique, and there has been no complications related to the polipropilene band. (the ramdomized prospective trial is still ongoing). conclusions:the video shows a reproductible easy way to perform a lrygb-b using a polipropilene mesh. introduction: a 23-year old female patient presented at our clinic two years after initial rouxen-y gastric bypass. she had had a preoperative bmi of 31,5 and had a significant weight loss which resulted in a bmi of 21,4 at two years postoperatively. she currently suffered from severe dumping with glycaemia levels dropping to 30 mg/dl. pharmacological treatment with metformine, sandostatine and acarbose did not yield any results. on top of these problems she felt less restriction, could eat large portions and had gained 9 kg in the last three months. objective: the usual approach for severe dumping-related hypoglycemia would be to undo the gastric bypass. this patient however was extremely anxious to regain weight, so we sought other options. we assumed that by adding more restriction and slowing down the emptying of the gastric pouch we could alleviate some-if not all-of the dumping related symptoms and prevent further weight regain. methods: in this video we present the banding of a gastric pouch for severe dumping after rouxen-y gastric bypass. results: although unconventional, the banding of the pouch yielded excellent results. the slower pouch emptying and reduced portions resulted in a near complete remission of all symptoms. as an additional benefit we found a slight weight loss of four kilograms six weeks postoperatively. conclusion: the usual treatment of severe dumping-related hypoglycemia would be an undo of the gastric bypass. in this case however the patient was extremely anxious to regain weight, being very pleased with the results her gastric bypass had yielded. in agreement with both the patient and treating endocrinologist we attempted a different approach. the slower pouch emptying and increased restriction offered another way to alleviate the dumping and deep hypoglycemia while concomitantly resulting in weight maintenance. aim: the aim of this video is to present a novel surgical technique to avoid stent migration after endoscopic placement in patients with leakage subsequent to laparoscopic sleeve gastrectomy (lsg) . methods: this video shows the case of a patient (bmi 46,6 kg/m2) who developed an upper gastric leakage 2 days after lsg. a ct scan showed a small leakage at the eg junction complicated by intra-abdominal abscess. a ct guided percutaneous drainage of the abscess was performed. a stent placement was attempted endoscopically three times and failed for migration. we decided to place laparoscopically a non adjustable gastric ring (nagr) around the stomach, in order to avoid stent migration.first of all the stent is replaced endoscopically in order to cover the fistula tract. the patient is placed in a half sitting position and the pneumoperitoneum was obtained using a veress needle in left subcostal space. a 4 port technique is used as in standard laparoscopic sleeve gastrectomy.the procedure starts with the mobilization of adhesions, the fistula is identified in the upper part of the tubule.the gastric tubule is isolated and the lesser omentum is opened. the blunt needle at the tip of the ring is passed retrogastrically, a tourniquet can be useful is the positioning turn out to be difficult. the nagr is then closed over the gastric tubule containing the stent. a drain is finally placed. results: the stent was removed after 4 weeks. a gastrointestinal ct scan with oral contrast showed a complete resolution of leakage. after 6 months the patient was in a good condition with bmi 29,4 kg/m 2 . the stent was endoscopically removed after 4 weeks. a gastrointestinal ct scan with oral contrast showed a complete resolution of the leakage. after 6 months the patient was in a good condition with bmi 29,4 kg/m 2 . conclusions: this new technique is feasible and effective, as shown in this video; however the nagr can lead to complications, so a strict follow up is needed and if any complication appears, should be considered to remove laparoscopically the ring. introduction: in this case, we will discuss the case of a 72 year old male patient who underwent a laparoscopic cruraplasty and gastric plication resulting in a weight loss of 12 kg. other medical history reported insulin-dependent diabetes, reflux esophagitis and sleeping apnea with cpap. two years after gastric plication the patient presented with passage problems, gastro-esophageal reflux and epigastric pain. to this end a swallow test was performed revealing a large fundus with a restricted passage of contrast. due to the persistent complaints and the abnormal findings on barium swallow a surgical re-intervention was needed. objectives: despite the current bmi of 27 and the age of the patient, conversion from a gastric plication to a roux-en-y gastric bypass was performed. several other surgical options were considered, including an undo of the gastric plication or a dilatation with a resizing of the fundus. methods: in the video we describe the laparoscopic approach for a conversion of a gastric plication to a roux-en-y gastric bypass. results: at 6 months follow-up the patient showed a weight loss of 8 kg and the resolution of his earlier symptoms. the patient had a normal oral intake without any gastro-esophageal reflux or epigastric pain. conclusion: after a gastric plication, partial loosening of the sutures and stenosis are both wellknown complications. as presented in the video, it is apparent that a laparoscopic undoing of gastric plication is not as straightforward as it seems. firm adhesions between folds can compromise the procedure and inhibit a complete separation of the tissues. we believe that in these cases the best surgical approach is to convert to a roux-en-y gastric bypass. laparoscopic sleeve gastrectomy (lsg) is a relatively new surgical approach in the weight loss surgeon's armamentarium. in literature there is a consensus about the importance of mobilizing completely the gastric fundus before transection. the resg (revised sleeve gastrectomyresleeve) may be a valid option for failure of primary lsg. we focused the attention on the consequences that can have an incomplete resection of gastric fundus during an operation of sleeve gastrectomy and how they can be solved by the repetition of this procedure. a sleeve gastrectomy was performed in an obese 34-year-old woman (bmi = 40). three days after the operation, an upper gi x-ray with gastrografin did not show any abnormalities. three months after the surgical procedure, the woman referred frequent episodes of vomiting and a significant weight loss (42 kilos). an upper gi x-ray with gastrografin demonstrated the presence of multiple communicating cavities of the gastric fundus. the esophagogastroduodenoscopy (egd) showed that the gastric tube close to the esophagogastric junction was separated from a recess (2-3 cm in diameter) by an incomplete septum. a severe hypokalemia and consequent ecg abnormalities were treated with intravenous infusion of potassium. then, we performed a laparoscopic operation. the gastric tube was completely released along the suture line of the previous operation and, especially, the posterior surface of the upper part until the left crus of diaphragm became evident. under the guide of the bougie, the recess was removed. results: the clinical course was regular, and the patient was discharged on third post-operative day after an upper gi x-ray with gastrografin which demonstrated the absence of leakage and a normal gastric tube. after 1 year, the patient was very satisfied with the operation. conclusions: the complete mobilization of the gastric fundus allows to see clearly which part should be resected to obtain an adequate gastric tube and facilitate a correct placement of the stapler. in our experience, in patients with a residual fundus, an upper gi x-ray with gastrografin and an egd are needed to exclude the presence of stenosis. then, a resleeve gastrectomy is an efficient and safe procedure to treat this post-lsg complication. weight regain is one of the main problems in bariatric surgery. we have many surgical option but when we evaluate patients with long follow up and bmi of superobese patient before the first surgery, the weight recidivism can arrive up to 50-70% at 5 years.in most cases the first surgery is a restrictive procedure, and in many cases sleeve gastrectomy.here we present a case of weight regain after laparotomic super-magenstrasse (that we consider like a sleeve gastrectomy except for remnant removal) with a big incisional hernia. after a complete multidisciplinary re-evaluation we decided to perform an oagb (one anastomosis gastric bypass) but in this case we decided to create a functional exclusion to the duodenal transit by positioning a minimizer ring. this solution is effective in food diversion and guarantee gastric and duodenal endoscopic exploration in case of need. we think that this technique can represent an option to take in account for selected cases. at the end of bariatric procedure we perform a laparoscopic repair of incisional hernia with mesh in the hope to avoid future surgery and post operative small intestine herniation. patient rejected additional bariatric procedures and in fact she has gained 10 kg two years later (bmi 39.14). conclusions: lagb gastric erosion is uncommon (1.46-3%) . intraoperative (such as perigastric approach) and patient related factors (smoking, alcohol…) have been described as risk factors. the most frequent clinical presentation is weight loss failure; band and port issues (such as infection) are also frequent. erosion is infrequent to present as an acute event (\ 5%: peritonitis, abscess…) or asymptomatically (\ 1%). diagnosis is mostly performed under upper endoscopy. the most common therapeutic technique is removal of the band (by endoscopy or surgery), repair of the stomach, if needed, and band replacement (at least three months later). some authors have performed immediate replacement but the incidence of recurrent erosion seems to be higher. other options are lagb removal alone or conversion to different bariatric procedure. for endoscopic removal, it has been advised to wait until the band buckle is in the stomach and is sometimes very difficult. replacement of the band is not associated with weight regain. she reports 5 years of evolution presenting moderate intensity heartburn that was exacerbated during the night as well as submit occasional rejurgutation. the intensity of the symptoms is attenuated by maintaining a diet without irritants and improving feeding times. denies hematochezia, unintentional reduction of weight, dysphagia or early satiety. the patient has suffered from obesity since childhood, after pregnancy she had progressive weight gain and difficulty in controlling blood sugar, so she is scheduled a gastric bypass roux-en-y . preoperative endoscopy was performed, evidencing submucosal tumor in the gastroesophageal junction at 37 of the dentary arch, approximately 3 cm in diameter. an endoscopic ultrasound was performed, demonstrating subepithelial lesion of the gastroesophageal junction, hypoechoic, with well-defined borders, pseudobilobulated, 2.4 cm x1.3 cm, and dependent on the external muscular layer. a fine needle aspiration is performed in which spindle cells are identified, leiomyoma is likely diagnosed. it is programmed for laparoscopic resection of submucosal gastric tumor, gastric bypass and laparoscopic cholecystectomy. a tumor at the level of the gastro esophageal junction of approximately 2.5 cm is identified in the surgery, which can be resected by laparoscopy without complications. the patient is discharged after 2 days of postoperative stay. the final histopathological result: leiomyoma of 3.3 cm with free edges. cd4 (-) gog1(-) caldesmon (?)s100 (?). background: fifty percent of patients who have undergone gastric bypass, posterior reversal and sleeve gastrectomy and finally complete hiatoplasty presents symptomatic gastroesophageal reflux disease. surgical reinforcement of the lower esophageal sphincter is necessary to prevent acid reflux. here, we describe ligamentum teres cardiopexy, a surgical technique that reinforces the lower esophageal sphincter and restores its competence with a new valve, in patients with previous conversion of sleeve gastrectomy to gastric bypass and hiatal hernia repair. methods: we present the surgical techhnique performed to a patient with initial gastric bypass who underwent sleeve gasterctomy for hipoglycemias and hiatoplastia for severe gerd. persistent gerd requested to undergo ligamentum teres cardiopexy. in this procedure, the ligamentum teres is released from its umbilical connection and the hernia reduced by manual traction, freeing the last 3-5 cm of esophagus in the abdomen. the distal ligamentum teres is fixed with one stitch to the apex of the angle of his, one at the gastroesophageal junction, and one joining the gastric fundus to the esophagus. the remainder of the ligamentum teres is fixed over itself with four to six stitches, forming a necktie cardiopexy. the procedure concludes with diaphragmatic crus closure. results: after 3 months, the patient achieved successful results, defined as resolution of gerd, no protonpump inhibitor (ppi) use, and manometry measurement over 12 mmhg after surgery. conclusions: ligamentum teres cardiopexy combined with closure of the gastric crus is a late alternative treatment for gastroesophageal reflux disease in patients with previous sleeve gastrectomy and hiatal hernia. general surgery, ponderas academic hospital, bucharest, romania introduction: as metabolic surgery techniques evolve during the years, we have to face more and more patients with complications ands uboptimal results after the older/initial procedures. vertical banded gastroplasty(vbg) is one of those procedures that gain momentum during the initial experience in bariatric surgery, but has proven to have dissapointing results and a lot of complications, nowadays surgeons having to deal with difficult revisional operations. aim in this video: we want to present from our experience the difficulties encountered during the revisional surgery, rouxen y gastric bypass (rygbp)aftervbg, and the tips and tricks that will make this a safer and easier procedure. objective: after thorough preoperative assessment and a review of the literature multiple treatment options were considered. the procedure of choice ended up being a laparoscopic adjustable gastric banding, with the objective to achieve optimal weight loss with the lowest risk for complications. methods: in this video we present the placement of an adjustable gastric banding in a patient with a cirrhotic liver and portal hypertension and the possible pitfalls. results: postoperatively there were no complications and patient had a satisfying weight loss both 6 months and 1 year postoperatively. in a short review of the literature we've found that bariatric surgery is feasible in patients with portal hypertension as long as the patient is not decompensated or has bleeding varices. conclusion: cirrhosis and portal hypertension are no absolute contraindication for banding, sleeve or rny gastric bypass as long as the patient is not decompensated or has bleeding varices. the type of surgery is dependent on patient and surgeon-related factors. the aim should be to achieve optimal weight loss with the lowest possible surgical risk in this type of patients. surg endosc (2019) 33:s485-s781 introduction: in this case, we will discuss on a 54 year old female patient who had undergone a laparoscopic nissen fundoplication 5 years ago due to gerd grade b. because of morbid obesity a n-sleeve gastrectomy was performed 1 year ago resulting in a weight loss of 12 kg. at presentation she had regained all the lost weight, resulting in a bmi of 42,8. the patient history also reported insulin-dependent diabetes and obstructive sleep apnea with cpap. gastroscopy was performed showing a large residual fundus but no esophagitis. on the subsequent upper gi series a relatively wide sleeve with an intact nissen-collar was detected. objectives: a laparoscopic conversion to a roux-en-y gastric bypass was performed. other potential surgical treatment options are a sadi procedure or a sleeve gastrectomy with transit bipartition (santoro procedure). methods: in the video we describe the laparoscopic approach for a conversion of a n-sleeve to a roux-en-y gastric bypass. results: at 4 month follow-up the patient presented with a weight loss of 12 kg. the patient had good restriction on oral intake and did not have any reflux-related symptoms or complaints. conclusion: conversion from a n-sleeve to a roux-en-y gastric bypass is a challenging procedure. the largest pitfall during the creation of the gastric pouch is to staple a double fold of the nissen fundoplication. we believe that in these rare cases of weight regain after n-sleeve, the best surgical approach is to convert to a roux-en-y gastric bypass. four years later, in 2010, a laparoscopic conversion to roux-en-y gastric bypass was performed because of weight regain. she now presents with satisfactory and stable weight loss over the last few years. she was recently diagnosed with a brca-1 mutation for which she underwent a bilateral ovarectomy and mastectomy. the patient's brother was also diagnosed with this mutation and died of pancreatic cancer at the age of 39. genetic counseling advised a twoyearly follow-up because of an increased risk up to 10% of developing pancreatic cancer. control gastroscopy showed a normal esophagus and gastric pouch. control ct scan revealed hypertrophic stomach creases in the excluded stomach. these results prompted a laparoscopy-assisted gastroscopy of the excluded stomach which uncovered hypertrophic stomach glands and intestinal metaplasia on biopsy. methods: in this video we demonstrate the laparoscopic approach for complex revisional bariatric surgery. conversion from rny gastric bypass to a sleeve gastrectomy in a patient who already underwent a vbg. the focus of the video is on a manual gastro-gastrostomy with partial gastrectomy of the fundus and part of the stomach where the old vbg-band was placed. results: after 1,5 months follow-up the patient had no complaints and a stable weight. upper gi series shows a normal passage of contrast through the sleeve gastrectomy. conclusion: endoscopic surveillance of the remnant stomach and echo-endoscopy of the pancreas is no longer possible after rny gastric bypass. in cases where the need for such a surveillance arises after a rny bypass a patient-tailored approach is necessary. in our patient a laparoscopic conversion from a rny gastric bypass to a sleeve gastrectomy was performed. this approach keeps the patient's wish for weight loss intact while enabling further surveillance through natural-orifice endoscopy. a 47-year-old morbidly obese japanese woman with a body mass index of 41 kg/m 2 suddenly complained of swallowing difficulty 4 months after laparoscopic roux en y gastric bypass surgery with retro-colic roux limb route. an internal hernia of the defect of the transverse mesocolon was suspected by computed tomography, and emergency intervention was performed. the surgery revealed no internal hernia. however, strong inflammation and adhesion were observed between the transverse mesocolon and the retrocolicroux limb. in addition, the roux limb on the oral side of the adhesion site was dilated and bent.the adhesion between the transverse mesocolon and the flexed roux limb was dissected, linearized and re-fixedby suturing to the transverse mesocolon. however, since the difficulty of oral intake persisted re-do surgery was performed again. after resecting the roux limb involved in the severe inflammation, a 'new' roux limb was lifted to the cephalad via the ante-colic route. finally, the gastric pouch and roux limb were re-anastomosed with 3-0 absorbable sutures in an interrupted full thickness single layer manner. in the present case, we experienced difficulty with both adhesiolysis and determining the accurate target line to resect at the 'old' gastrojejunostomy. however, blocking the blood flow of the 'old' roux limb facilitated the accurate recognition of the target line. esofagogástrica, cirugía general y ap digestivo, hospital regional universitario de málaga, malaga, spain; 2 hepatobiliopancreática, hospital regional universitario de málaga, malaga, spain introduction: marginal ulcer is one a serious complications after a bariatric gastric bypass. tobacco, non-steroidal anti-inflammatory drugs (nsaids) and helicobacter pylori (hp) infection are known risk factors. methods: we present a 29-year-old women operated 3 years before of bariatric surgery with a gastrojejunal (gy) bypass technique due to intraoperative dehiscence of the staple line after attempting a vertical gastrectomy (sleeve). she has persistent vomiting and epigastralgia from 3 months after the intervention, affecting his quality of life. upper gastrointestinal endoscopy (uge) was performed, describing an ulcer in the gy anastomosis. she started hp eradication treatment, treatment with proton pump inhibitors (ppis), tobacco and nsaids were discontinued, but she had slight improvement. after 6 months the uge was made again, which show peptic esophagitis and 2 marginal ulcers. the plasma gastrin level was normal. due to the persistence of symptoms despite conservative treatment, we decided reoperation by laparoscopy. we found herniated bowel in petersen space, which were reduced and the space was closed. we proceeded to truncal vagotomy. the gy anastomosis was resected ( fig. 1 ) and performed again. finally, we perform antrectomy. the pathological anatomy showed ulceration. she was diacharged home on the 5th postoperative day without any complications. results: a marginal ulcer after bariatric surgery appears in the jejunal mucosa of the g-y anastomosis. the symptoms are epigastric pain, nausea and vomiting. acid, tobacco, nsaids and hp infection has an important role in their development \ sup [ . \/sup [ the first treatment is medical, discarding out the risk factors, but if it is not effective, it will be surgical, resecting the previous anastomosis. the usefulness of vagotomy is debatable, but the percentage of success increases. in our case, we perform antrectomy to avoid retained antrum syndrome. the hernia through petersen space is a cause of intestinal obstruction and abdominal pain as the case presents. although we believe that the symptoms were mainly caused by the marginal ulcer, the internal hernia was probably a symptomatic cause. conclusion: the treatment of a marginal ulcer is medical, eliminating the risk factors, but if it is not effective, the surgery is indicated. results: bowel's measurements and confection of the gastric pouch are identical in both cases. in the first case, intestinal anastomosis is performed in the inframesocolic compartment once small bowel has been divided. in the second case, such union is made next to the gastrojejunal anastomosis with the bowel uncut, making the section once no leakage has been found conclusions: laparoscopic roux-en-y gastric bypass is currently considered one of the technique of choice in the surgical treatment of morbid obesity. there are variations and alternatives for its realization. to know them can allow to individualize the technique to each type of patient. we present a clinical case of a 47 year old female. she had a vertical banded gastroplasty procedure (in another clinic) 9 years ago with an initial weight loss of 30 kg in a period of 2 months. she was seen at our clinic because she was suffering from dysphagia to solids and general diffuse abdominal pain for the last month. at physical exam we found a bmi of 39 and nothing else called our attention. we did an upper gi endoscopy and egd transit; we concluded that a gastric bypass would offer her the best results. therefore, we converted her vertical banded gastroplasty into a gastric bypass laparoscopically. she had an uneventful postoperative period and was discharged home without complications. aims: sadis emerged as a modification of biliopancreatic diversion with duodeno-ileal switch (bpdds) in which after sleeve gastrectomy (sg), the duodenum is anastomosed to an ileal loop in a billroth-ii fashion. sadis has promising outcomes for weight loss and comorbidity resolution in morbidly obese patients avoiding the high morbidity of biliopancreatic diversion with duodenal switch. clinical case: 50-year-old patient, subjected to bariatric surgery two years ago, including a sleeve gastrectomy (sg). despite this operation and dietary and hygienic modifications, the patient gained weight in recent months, reaching a bmi of 56 kg/m2 and an overweight of 78 kg. an endoscopy was carried out on her, which provided evidence of a gastric remnant of moderate size with flexible tissue, normal peristalsis, and fast disposal speed. the case was discussed in a joint session, leading to the decision to apply revision surgery. the decision was taken to apply sadis, a novel technique that had never been used before in andalucia. the rate of weight re-gain after the use of classical techniques such as sleeve gastrectomy (sg) or the roux-en-y gastric bypass (rybg) is considerable high. revision surgery due to weight re-gain is necessary in many of these cases. sadis emerged as a simplified alternative to the use of bpdds as revision surgery following a gv due to weight re-gain with good short-term results, in terms of both weight control and comorbidity control. since only one anastomosis needs to be applied, chirurgical time diminishes, as well as the rate of surgery-related complications. moreover, it could be used, through laparoscopy, for patients who have undergone previous, complex abdominal surgery. conclusion: sadis showed a promising short-term weight loss outcome and comorbidity resolution rate but long-term data are missing and there is currently a high level of technical variability. on the other hand, further studies are required to measure its cost-effectiveness compared to the currently popular bariatric procedures, sg and rygb. aims: the lps sleeve gastrectomy is the most common bariatric surgery technique because it has a low surgical complexity and acceptable weight loss results. however, 5-11% of patients present with an insufficient weight loss, weight regnances, reflux or dysphagia. in these cases, it is recommended to perform a second bariatric surgery to combine a component of malabsorption such as gastric bypass or duodenal switch. the video describes the technique of a laparoscopic biliopancreatic diversion with duodenal switch with a previous laparoscopic sleeve. the objective is to describe the safety of the technique and the subsequent success of it. methods: a 41-year-old female patient presented morbid obesity with a bmi of 49 after performing a laparoscopic sleeve gastrectomy in 2010. initially, she presented a percentage of excess weight loss of 62%, reaching a bmi of 33 after two years of follow-up. after this, she suffered a reganancia of all the weight lost despite diet and exercise, presenting a bmi 49. a study was made with tegd where no complications of the previous surgery or symptoms of gastroesophagical reflux or dysphagia were observed. the lps duodenal switch is proposed in the obesity unit committee in 2016, without immediate postsurgical complications. the patient presented a favorable postoperative period and was discharged three days postoperatively. results: at the present time, the patient has achieved a 98% excess weight loss and has a bmi of 26.5. presents good oral tolerance with 3 stools a day without urgency. it doesn't present protein deficioncies. vitamin deficiencies are orally supplemented. the lps duodenal switch is a technique that can be performed after a sleeve gastrectomy safely in cases of insufficient weight loss or weight reganancia. the patients presented a greater weight loss after the duodenal switch than after the gastric bypass, observing a lost of excess weight of 74% compared to 64%. the differences being statistically significant. weight regain after gastric bypass is a challenging problem. a number of revisional surgical options have been reported. this is a case of a 48 year-old woman 10 years after lrygb. her initial bmi was 67, lowest after surgery-28, at presentation-48. the video shows a robotassisted laparoscopic conversion of rygb to loop duodenal switch. the roux limb is transected and dissected to the gastrojejunostomy. the gastrojejunostomy is resected and the gastric pouch is recreated over a bougie. the gastric blood suply is confirmed with icg. a gastro-gastrostomy is created to restore gastric continuity and a sleeve gastrectomy is performed. the duodenum is devided and a duodeno-ileostomy is created 300 cm from the ileocecal valve. the remaining roux limb is resected. the patient recovered uneventfully. conversion of rygb to loop duodenal switch requires creation of as little as two anastomoses, in comparison to standard ds, which requires four. it is a safe option for patients with weight regain after lrygb. methods: irb approval and informed consent have been obtained. a dissection is conducted to separate the descending mesocolon of the gerota's plan from the medial aspect to the peritoneal lining to the left parietal gutter. the peritoneal layer is incised parallel to the vessel and close to the colonic wall. the dissection is continued anteriorly up to reach the resected parietal gutter. a passage into the mesentery of the upper rectum is created for the allocation of the stapler and the dissection of the rectum. these maneuvers permit to straighten the mesentery simplifying the identification and cutting of the sigmoid arteries. a caudal-to-cranial dissection of the mesentery is performed from the sectioned rectum to the proximal descending colon by a sealed envelope device. it can be very useful to mobilize the colon in any direction: laterally, medially, or upward. the dissection is performed along the course of the vessel up to the proximal colon, with progressive sectioning of the sigmoid arterial branches. the specimen is extracted by a pfannenstiel incision. the anastomosis is performed transanally with a circular stapler according to knight-griffin technique. results: we performed a laparoscopic segmental colectomy using this approach for 21 patients with benign sigmoid lesions: 13 diverticulitis, 3 flat polypoid lesions (no lift-up sign), and 5 bowel endometriosis. the mean operative time and blood loss were 161.4 ± 15.7 min and 50 ± 40 ml, respectively. there were not a single conversion to open surgery and no any leakage or stricture. only 2 cases of intraluminal bleeding and 1 case of wound infection (treated conservatively) were observed. conclusion: we consider this approach to be safe and useful for segmental colectomy to be performed sectioning the sigmoid artery close to the colonic wall. aims: to show a clinical case with a video of a patient was operated for colon cancer in hepatic angle by a single suprapubic incision (ssilrh). methods: a 44-year-old male assessed for abdominal pain and weight loss. on physical examination: a painful mass was detected in the upper right quadrant. the colonoscopy revealed an ulcerated lesion in the hepatic angle and the biopsy revealed a moderately differentiated adenocarcinoma. in the abdominal ct a mass of 3 x 4 cm was observed (figure). the patient was operated with ssilrh technique, as shown in the attached video. results: the patient was placed in the supine position and with the legs separated. the surgeon is placed between the patient's legs. a transverse incision of the skin was made in the middle line of 3.5 cm to 1 cm above the pubis. the underlying fascia was divided transversely, the rectus abdominal muscle was exposed, a purse-string suture placed in the fascia. an 11 mm reusable trocar was inserted for the chamber, a 6 mm reusable flexible trocar was placed at the 9 o'clock position and another trocar was placed at the 3 o'clock position. the ileocecal valve was released from the peritoneal parietal foil, as well as the mesocolon right by a lateral to medial approach to the second portion of the duodenum. the hepatic angle was also dissected from lateral to medial. for the anastomosis, the 11 mm trocar was replaced with a 13 mm trocar and a stapler was placed. a 5 mm 30°chamber was inserted through the 6 mm flexible trocar. the small intestine was divided as well as the proximal transverse colon with endogia. an intracorporeal ileocolic anastomosis was performed. the piece was removed through the suprapubic incision. he was discharged after 5 days without complications. the histological studies confirmed a differentiated adenocarcinoma of 8x7x6 cm. the surgical margins were free, without infiltrated lymph nodes (0/26) with stage pt3n0. the ssilrh technique allows a complete resection of the mesocolon and complies with the oncological principles. they can present with abdominal pain, nausea, acute abdomen, symptoms of intestinal obstruction or asymptomatic with incidental diagnosis. their diagnosis can be difficult. the objective is to demonstrate the safety and efficacy of the laparoscopic approach in this infrequent pathology. material and methods: we present a video of the surgical intervention of a 32-year-old patient, with functional dyspepsia, with a casual diagnosis of a pseudocystic mass of the right colon after performing a ct scan: giant diverticulum of the hepatic colon angle with fecaloid content inside it under tension the patient goes to the emergency room for acute abdominal pain, pending colonoscopy, antibiotic treatment is established, and a laparoscopic approach is decided upon after the patient's evolution. results: intervention: complete laparoscopic approach, 4 trocars. large size tumor in the right colon, diverticular in appearance, with stony content inside, with locoregional adenopathies, oncological radical right hemicolectomy, manual intracorporeal anastomosis, correct postoperative, hospital discharge. on the 4th day. definitive pathological anatomy: giant diverticula on areas of intense mucosal ulceration, free edges. conclusion: the laparoscopic approach of the symptomatic diverticula of the right colon is safe and effective. introduction: minimally invasive transanal surgery (tamis) is a surgical technique whose established indications are the complete exeresis of rectal polyps that are not resectable endoscopically or early rectal neoplasms with good prognosis criteria. transanal devices with gel platform facilitate dissection in this field. however, one of the drawbacks of this approach is the oscillation of the right nerve, which hinders dissection and prolongs the surgical time. material and methods: we present the case of a patient with a central depression neoformation, located 8 cm from the anal margin in the posterior aspect of the rectum in a male patient. the lesion occupies 25% of the circumference and was considered unresectable endoscopically. the endoscopic biopsies showed a tubulovillous adenoma with moderate dysplasia. results: an exeresis of full thickness of the rectal wall is performed, with subsequent suture of the defect. we show in the video the use of a glove interposed in the pneumoperitoneum gum to maintain the stability of the neumorectum and the technique of dissection and suture, as well as the stability of the neumorectum with this technique throughout the procedure. the use of a glove as a reservoir to stabilize the nemorectum is an economical and easy-to-use method that can safely replace extra devices. aims: endometriosis is a gynecologic disorder defined by the presence of endometrial glands and stroma outside the uterine cavity. deep infiltrating endometriosis (die) invades 5 mm to the retroperitoneum of the pelvic sidewalls, the rectovaginal septum, or the muscularis of the bowel, bladder or ureters. the rectum is being the most common bowel site of involvement. for symptomatic die, medical therapy should always be the first-line treatment. therefore, a minimally invasive approach using laparoscopy is considered the gold standard option and challenging aiming at complete disease excision. also, there are several advantages of natural orifice specimen extraction when compared with abdominal incision that may directly impact the postoperative results of these young patients. methods: we report a case of a 36-year-old female with a 12-month history of chronic pelvic pain, dyschezia and rectal bleeding. these symptoms were refractory to hormonal, antispasmodic and opioid therapy. magnetic resonance imaging reported a nodule 2 x 2 cm invading the rectal wall 10 cm to the dentate lane. we performed a laparoscopy and we found the nodule at the uterine posterior wall invading the rectal anterior wall. the nodule was invading into the rectum in a large area so we proceeded with segmental resection and added hysterectomy and salpinguectomy because it was the preference of the patient. the anastomosis was created intracorporeally and the specimen was removed through the vagina performing in this way a totally laparoscopic procedure with natural orifice specimen extraction. results: the total operative time was 3 h, the postoperative stay was uneventful and the patient was discharged on day four. the pathological report showed an endometrioma 4 9 4 cm length predominantly involving colonic muscularis propria. conclusion: laparoscopic surgery is a safe and feasible approach for the surgical management of deep infiltrating endometriosis of the rectum and the gold standard for female young patients that often need multiple surgeries. in addition natural orifice specimen extraction avoids potential complications of abdominal incisions. week-day surgery, university, sapienza, ospedale sant'andrea, rome, italy; 2 urology, clinica mater dei, rome, italy aims: we describe a case of a patient affected by a mass in the left kidney and a diverticular stenosis of the sigma. methods: a 65 years old woman complained abdominal pain in the left flank of the abdomen and in the left iliac fossa radiated to the hypogastrium, with fever and no passing flatus. contrast enhanced computer tomography scan (ct-scan) showed a 7 cm mass of the superior pole in the left kidney and a colonic diverticulitis with thickness of the wall and a microperforation of the sigma. she underwent to medical therapy with resolution of the diverticulitis. after 4 weeks a laparoscopic nefrectomy and sigmoidectomy was planned. patient was positioned on the right flank. this position was kept for both the procedures. we performed four trocar accesses along the left subcostal region and a periombelical incision for the specimen extraction. results: post-operative course was uneventful. patient was discharged in 7 post-operative day. istopathological exam showed a renal cell carcinoma confined to kidney with no positive lymph nodes and a diverticular stenosis of the sigma. laparoscopy allowed to perform two fine procedures in a critical situation using few trocar incisions and obtaining good results. background: hartmann procedure consists in a sigmoidectomy followed by a terminal colostomy. stoma is associated with complications and suboptimal quality of life, so the restoration of colonic continuity should be at least considered in any case. open restoration has been associated with significant morbidity and mortality. many authors have described the advantages of laparoscopic hartmann reversal. we want to go a step further showing our experience using a combined laparoscopic and transanal approach in an attempt to improve the surgical technique in a patient with 5 previous abdominal surgeries and a rectovaginal fistulae. methods: the transanal and laparoscopic team work simultaneously. by the abdominal approach a pericolostomic incision is made, the distal affected colon is resected and a purse string suture is performed around the anvil of the eea 31 mm single-use stapler with 4.8 mm staples (autosuture, covidien). a 12 mm umbilical trocar is located for a 30°camera and a gelport laparoscopic system (applied medical) with two 12 mm trocars is introduced through the colostomy wound. hard pelvic adhesiolysis was performed and splenic flexure was also mobilized.the gelpoint path transanal access platform (applied medical) is introduced through the anal canal with three trocars in a triangle position. the proximal rectum and mesorectum are dissected until the peritoneal reflexion. the previous stapler line with the resected tissue is then exteriorized throught the anus. the distal rectum is prepared with a circumferential purse string suture. the vaginal defect was sutured transanally. the proximal colon and the anvil are extracted through the rectal stump and connected to the circular stapler, performing an end-to-end anastomosis. results: the total operative time was 5 h. the postoperative stay was uneventful and the patient was discharged on day 5. conclusions: as in patients with rectal cancer, dissection of the stump in hartmann reversal procedure may be better and associated with shorter operative time. as with any new surgical procedure, it is probably too early to draw conclusions but nowadays transanal combined with laparoscopic approach seems to be a safe and feasible technique to perform a hartmann reversal, especially in challenging cases. intravenous and endoluminal contrast enhanced ct revealed the presence of a large retroperitoneal fluid and gas collection, due to diverticular perforation, extended from pelvis to iliac bifurcation, involving the left urether. no hydrosoluble contrast media leakage or massive pnuemoperitoneum were present. after an initial conservative treatment without significant improvement an emergency laparoscopic left colectomy with primary anastomosis and laparoscopic retroperitoneal collection drainage was performed. the laparoscopic approach was very challenging due to the obesity of the patient and the presence of the abscess. the patient was discharged on pod 12 after requiring re-intervention for dehiscence of the left iliac mini-laparotomy on pod 7. conclusion: diverticular perforation in obese patients adds a further challenge to its laparoscopic treatment and deserves an aggressive surgical approach since its outbreak. although intracorporeal anastomosis has been demonstrated to be safe and effective after right colectomy, limited data are available about its efficacy after left colectomy for colon cancer located in splenic flexure. there are few studies comparing patients who underwent laparoscopic left colectomy with intracorporeal anastomosis or with extracorporeal anastomosis. anyway literature shows that there is no significant difference between intracorporeal anastomosis and extracorporeal anastomosis about oncological result. as for right hemicolectomy, intracorporeal anastomosis seems to show a trend towards a faster recovery after surgery due to the shorter time to flatus and lower post-operative pain expressed in the mean vas scale. laparoscopic left colectomy with intracorporeal anastomosis is associated with a lower rate of post-operative complications as for right colectomy. literature results could suggest that a complete laparoscopic approach could be considered a safe method to perform laparoscopic left colectomy with the advantage of a guaranteed faster recovery after surgery. as usual further randomized clinical trials are needed to obtain a more definitive conclusion. we show a video of a 58 years old patient with a pure splenic flexure colon cancer who underwent to a laparoscopic left hemicolectomy with intracorporeal anastomosis. case presentation: here we describe a case of a 81 year old asthmatic and hypertensive lady with an asa score of iii who presented to emergency after a right knee replacement with a four day history of lower abdominal pain. she was septic upon arrival to the resuscitation roomimmediately prompting the hospital's local septic management protocol. a ct scan of her abdomen showed a rectosigmoid perforation with free intra-abdominal air and fluid. the patient underwent laparoscopic hartmann's procedure within 4 h of admission. after an uneventful postoperative recovery the patient was discharged home after a total of 4 days of hospitalisation. she was followed up at surgical outpatients with no adverse events over the course of the subsequent months. conclusion: this case exhibits the feasibility of laparoscopic hartmann's procedure as a surgical modality for hinchey stage iv diverticulitis. the positive outcome supports the claim that for experienced surgeons laparoscopic hartmann's procedure remains a safe and viable option for elderly comorbid patients in the emergency setting. introduction: mesenteric cysts are a very infrequent pathology, they usually present an anodyne clinic, and their diagnosis is reached casually. objectives: to demonstrate the safety and efficacy of the laparoscopic approach, in cases with intra-abdominal cysts of benign etiology, using material with mini-instruments, reducing surgical aggression, maintaining its safety and efficacy.material and method: clinical case: a 23-year-old man with no personal history of interest. in the last two months he presented episodes of pain in the right hypochondrium, exploration without findings, us-ct scan: a cystic tumor of 6 cm. in hepatic colon angle compatible with uncomplicated benign mesenteric cyst, tumor markers and normal colonoscopy. evidence of interest is exposed. given the evolution it is decided tto. elective surgical. result: intervention: laparoscopic approach, 4 trocars, two of 3.5 mm, optics of 5 mm 30°, benign cystic tumor, with colloid content of more than 7 cm. of diameter in antimesenteric border of colon, which is not possible to separate, mobilization and resection is carried out by endo-gia, including a portion of the colonic wall, appendectomy, extraction in a pocket. good postoperative course, alt to 2nd day. definitive ap: mesenteric cyst, absence of malignancy. the laparoscopic approach is a valid and effective alternative in cases of benign intra-abdominal cystic pathology, the use of mini instruments reduces surgical aggression, favoring the recovery of the patient. male, 70 yr, wuth doblue post-operative coloanal stenosi and 1 women, with ultralow rectal neoplatis stenosis (4 cm from anla verge). both patients were discharge ater 3 days from prosthesis positionins without pain and complications. the first patient, with protection ileostomy, showed fecal incontinence before the operation and was performed prosthesis positioning because rectal losses of infected material and fever. fecal incontinence was showed also after procedure but he had not fever. second patient, 93 yr, with ultralow rectal tumor, after prosthesis positioning was submitted to radiotherapy and she decided for not to be operated and she survives after 6 months in ful well-being. conclusion: endoscopic prosthesis positioning is a consolidated procedure for treatment of bowel obstruction. this study demonstrated that this procedure is safe and this kind of prosthesis is suitable for correct positioning. results: we present a case of a 67 years old man with faecal occult blood test positivity that was diagnosed by colonoscopy of a villous lesion at 9 cm of anal verge. biopsies were taken showing a tubulovillous adenoma with high grade dysplasia. a rectal mri was done showing the lesion fixed to the postero-lateral left side of the lumen at 9 cm of anal verge. no pathological lymph nodes were reported. extension study was negative. the case was presented in multidisciplinary committee agreeing in local excision. in october 2018 the procedure was done without incidents. the patient was placed in lithotomic position finding a lesion occupying of the lumen. resection was done without incidents and posterior suture with 2 continuous barbed sutures. he presented an uneventful recovery being the patient discharged in 3 rd postoperative day. definitive pathological findings showed a ptis with negative margins. after three months of followup the patient remains with good functional results and waiting for the first endoscopic revision. conclusions: tamis is a safe and feasible technique with low morbidity that gives us an alternative for early rectal cancer or big rectal lesions much less invasive than techniques used until now. complete mesocolon excision and d3 lymphadenectomy are two fundamental points in the oncological surgery of right colon cancer. most of the adenopathic recurrences of colon neoplasia in tumors located in the hepatic angle and the ascending colon are located near the head of the pancreas and the vascular axis of the superior mesenteric vein due to an alleged incomplete dissection. we present a case of right colon neoplasia where we performed a laparoscopic right hemicolectomy associated with a d3 lymphadenectomy. we use medial to lateral dissection of the mesocolon focused on the dissection of the superior mesenteric vein with the identification of ileocolic vascularization, right colic vessels and henle's trunk. this approach is safe and facilitates a correct resection of the mesocolon, which is approached following the embryological plans and a vascular ligature near the bifurcation. the performance of an extended lymphadenectomy allows a wider resection of the mesocolon and the excision of a greater number of lymph nodes, all of which can contribute to a greater survival. the efficacy of pc treatment is related with a properly preoperative imaging diagnosis of the disease, but the poor sensitivity for identifying small peritoneal metastasis are the major obstacle to achieve a complete resection and that leads to peritoneal recurrence. imageguided surgery using icg, could represent an advance in the detection of small peritoneal nodules. there are only a few clinical studies that have analyzed the role of icg for the staging of pc, specially from ccr, and nearly in all of them the selected approach were exploratory laparotomy. this study presents a laparoscopy case, as a non-invasive way of cs in selected patients with limited pc. a new category, tis, was created for low-grade appendiceal mucinous neoplasms (lamns) that invade or push into the muscularis propia by ajcc cancer staging 8th ed. management of these tumors depends on stage and histology. traditionally, laparotomy was the most recommended approach, however, if laparoscopy is safe, it could be used. the laparoscopic appendectomy should be done with 'not touch' technique and a radical approach has been recently proposed for its treatment. the laparoscopic radical appendectomy should start by exploring complete abdominal cavity. grasping of appendix should not be done. complete resection of mesoappendix is obligated. cequectomy with stapled endogia is necessary. the specimen must be extracted in an endobag. methods: we report a case of a 64 year-old female patient with a personal history of three caesarean sections. this patient was studied due to chronic abdominal pain. a computerized axial tomography was performed, showing an appendix increased in size and a thick wall. the colonoscopy evidence a lesion that protrudes from appendiceal base which is biopsied. results: a laparoscopic way was used and large and width appendiceal was viewed (10x2 cm). furthermore, a rounded right anexial tumor was also found. a radical not touch laparoscopic appendectomy with stapled cequectomy was done. the intraoperative study was mucinous appendiceal tumor without serose affection. the final result was ptisnx (lamn) without resection margins affected. after 48 h of admission, the patient is discharged without incidents. conclusion(s): minimally invasive surgery in lamns is possible if it is performed with enough experience, following specific rules and tips to manage this tumors. a correct follow-up should be carried out using tumor markers and computer tomography (ct). introduction: resection of both benign and malignant colovesical fistulae can be particularly challenging and carry with it specific surgical considerations. often there is a large inflammatory mass sat within a narrow pelvis, limiting specimen mobility and consequently access to dissection plains. additionally, with the underlying inflammatory process, the ureters may be displaced anatomically and be at risk of injury. aim: to demonstrate a streamlined and reproducible approach to the laparoscopic management of both benign and malignant colovesical fistula, with specific emphasis on the different modalities for bladder repair. method: the following method portrays an overall technique which is adapted dependant on the clinical scenario and specific intra-operative findings: approach to abdominal cavity in standard fashion.identification of right ureter.poster-medial mobilisation of the mass to facilitate delivery out of the pelvis followed by visualisation of the left ureter on the medial and lateral sides before division of the fistula.division of the fistula in benign disease or resection of the bladder dome in malignant disease.transverse laparoscopically sympathetic suprapubic skin incision.vertical incision through linea alba to deliver bulky specimen.intra/extracorporeal repair of bladder dome. results: all of the considered cases were successfully completed with a laparoscopic approach, irrespective of the malignant status of the disease in question. conclusion: both benign and malignant colovesical fistula disease can make the laparoscopic approach to resection challenging, especially when encountering a bulky mass in a narrow male pelvis. the stepwise and streamlined approach considered here can help facilitate successful and safe laparoscopic completion without the necessity to convert to open. background: primary neoplasms of the retrorectal space are very rare. they are located in anatomically difficult area to be addressed, hence a complete evaluation of the lesion is required to determine the extent of resection and the appropriate surgical approach, which include posterior, abdominal and combined abdominoperineal, depending on the characteristics of the lesion. objective: to show a combined laparoscopic abdominoperineal approach of retrorectal tumor. method: we present a video of a combined laparoscopic abdominoperineal resection of a lowlying retrorectal tumor in a 73-year-old female without prior abdominal surgery. conclusion: retrorectal tumors are infrequent. their anatomical location can make difficult the surgical approach. preoperative imaging can provide useful information for surgical planning. in the recent years, minimally invasive surgical approach has been proposed. laparoscopic approach is feasible and safe, but it is important to select adequately the patients. background: adult intussusception is a rare clinical event representing only 1-5% of all bowel obstruction cases and 5% of all intussusceptions and the occurrence of adult intussusception due to colonic cancer is even more rare. aim: we present this case of malignant colo-colic intussusception and literature review to increase the awareness of the incidence of colocolic intussusception due to colonic cancer. case report and literature review: our patient is a 70 years old female was admitted to our hospital due to central abdominal pain, cea level of 4, she was further investigated with ct scan of the abdomen and pelvis which raised the suspicion of mid transverse colon intussusception due to large polypoid lesion. she was further assessed with urgent colonoscopy which confirmed mid transverse colon tumour with biopsies confirmed adenocarcinoma. laparoscopic extended right hemicolectomy with lymph node dissection was performed. upon laparoscopic exploration it was found that the colocolic intussusception was evident as described on the ct scan and as clearly shown on the video. histologically, the transverse colon carcinoma was a moderately differentiated adenocarcinoma, with no lymph node involvement '0 out 15 lymph nodes', tnm staging of pt3 pn0 pm0 and r0 resection. intussusceptions of the colon in adult are frequently found in the ileocecal portion or sigmoidal colon but rarely in the transverse colon. only two cases of adult intussusception of the transverse colon caused by colonic cancer have been reported. overall 12 cases on literature review reported showing colo-colic intussusception due to colonic malignancy. conclusion: colo-colic intussusception due to colorectal cancer is a rare clinical event, however it should be included in the differential diagnosis of colonic obstruction. laparoscopic surgery is safe in malignant colocolic intussusception. aims: single-incision laparoscopic colectomy (silc) aims to achieve better cosmetic outcomes, less pain, and faster recovery compared to multi-port laparoscopic colectomy, but it also has several limitations, especially the technical difficulties. we report our experience with singleincision robotic right hemicolectomy via video presentation. methods: we arranged robotic-assisted single-incision right hemicolectomy for a 78-year-old female patient with ascending colon tumor. the operation was performed with gloveport singleport device and a three-arm da vinci robotic surgical system through a small midline umbilical incision. colectomy was proceeded by a medial-to-lateral approach along with one or two accessory instruments for maintaining sufficient bowel traction or surgical field exposure. after vessel ligation, complete colon mobilization and right side omentum division, the robotic arms were undocked to perform anastomosis extracorporeally. results: the operation was performed successfully without drainage tube placement. the total operative time was 193 min. the bowel movement returned on post-operative day 5,and the patient tolerated normal soft diet on post-operative day 7. she was hospitalized for 8 days after operation. the pathology report revealed colon adenocarcinoma (t1n0m0, tumor size 1.8 cm), and 19 lymph nodes were harvested. conclusions: single-incision robotic colectomy (sirc) approach seems feasible and safe in treatment of ascending colon cancer. this surgical option provides less pain and wound scar for the patient. moreover, it also achieves further benefits for the surgical procedures compared to silc. reasons being, first, it has better instruments flexibility and precision with endo-wrist, as well as less instruments clashing. second, the improved camera stability achieved through the use of the robotic arm is unattainable through manual hand-controlled methods. third, roboticassisted approach gives us an ergonomic environment, which enables the operator to control the arms while sitting by the console, and also to reassign them whenever they cross each other or block the surgical view. in spite of the advantages above, we still need to sincerely consider each patient's situation for proper management. recently, indocyanine green (icg) fluorescence has been introduced in laparoscopic colorectal surgery to provide detailed anatomical information.the aim of our study is the application of icg imaging during laparoscopic colorectal resections: to identify sentinel lymph node, for studying its prognostic value on nodal status, to facilitate vascular dissection when vascular anatomy of the tumor site is unclear and to assess anastomotic perfusion to reduce the risk of anastomotic leak. after tumor identification 5 ml of icg solution (0.3 mg/kg) is subserosal peritumoral injected. a full hd image1 s camera, switching to nir mode, in about 10 min displays fluorescence: the sln is identified and the sln biopsy (slnb) is performed.when tumor is in difficult site, as hepatic or splenic flexure, 5 ml of icg solution (0,3 mg/kg) is intravenous injected. in about 30-50 s a real-time angiography of tumor area is obtained; on this guide, vascular dissection and pedicle ligation is performed.after anastomosis, another 5 ml of icg solution is injected to confirm anastomotic perfusion. if there is an ischemic area, a new anastomosis is performed. from november 2016, 70 patients were enrolled: 22 left colectomy, 38 right colectomy, 2 transverse resections, and 8 resections of splenic flexure. in ten cases, intraoperative angiography led to the identification of vascular anatomy. in two cases the anastomotic perfusion wasn't good and the surgical strategy was changed. four postoperative complications occurred, of which one anastomotic leak, due to a mechanical problem. from november 2017, 40 patients were enrolled to perform the slnb: 23 right colectomy, 11 left colectomy, 1 transverse resection and 5 splenic flexure resections. the sln was identified in 37 cases. 17 cases were found to be n0 to the conventional examination and were subjected to ultrastaging. icg-enhanced fluorescence imaging is a safe, cheap and effective tool to increase visualization during surgery. it's recommended to reduce the incidence of anastomotic leak, to facilitate the assessment of vascularization in order to perform oncological resections, and to perform the slnb to study its clinical role on nodal status and for the sln ultrastaging in order to identify the micrometastases. background: surgical emptying of lateral pelvic lymph nodes (llnd) is a strategy used differently when compared the approaches to rectal cancer in the west and eastern countries. there is evidence that = 5 mm lymph nodes in lateral compartment should be removed, even in the setting of neoadjuvant chemoradiation. minimally invasive surgery with nerve-sparing technique and sharp dissection with minimal bleeding may help overcome the significant complexity of the procedure that may have been a technical obstacle to implementation in the past. the standardization of the technique may help implementation with shorter learning curves and excellent surgical outcomes. methods: a 56-year-old male with distal rectal cancer underwent neoadjuvant crt for a mrt3cn2m0 mremvi ? mrcrm ? disease. there was one left obturator node of 7 mm prior to crt. following 12 weeks of crt completion, the patient underwent tatme for the primary disease followed by left lateral node dissection by laparoscopy. results: the present video illustrates the most relevant surgical steps to perform lateral node dissection. the procedure has been didactically divided into 7 steps. the left ureter is identified and retracted using a vessel loop (step 1). identification of the common iliac vein and dissection with subsequent identification of psoas and internal obturator muscles (step 2). identification and dissection of accessory vessels. ( step 3) identification of obturator nerve and obturator vessels (step 4). blunt dissection of obturator nerve (step 5). identification and ligation of obturatory vessels. (step 6) umbilical artery is skeletonized to allow identification and clearance of fatty tissue along superior vesical arteries, internal iiliac artery/vein, inferior vesical artery and internal pudendal artery (step 7). postoperative course was uneventful. conclusion: standardization of lateral-node dissection for rectal cancer has paramount importance. laparoscopic lateral-node dissection for rectal cancer provides optimal anatomical view and allows safe dissection of the nodes of interest. aims: the aim of this video is to describe our technique using fluorescence to assess the lymph flow to ensure a complete mesocolic excision and central vascular ligation in order to provide expertise to contribute to the standardization of this new tool. methods: laparoscopic right colectomy with total excision of the mesocolon was proposed in all cases. for the detection of lymph flow, we injected indocyanine green dye (1 milliliter of 25 milligrams dye dilution in 10 milliliter of distilled water) into the subserosal to submucosal layer around the tumor at 1 point with a 21-gauge injection laparoscopically after trocar insertion, and observed the lymph flow using a near-infrared system (visera elite ii, olympus) after injection. we also performed a total mesocolic excision with central vascular ligation in the region where the lymph flow was fluorescently observed. results: 7 (100%) patients were included. no intraoperative or postoperative complications presented. no adverse effects were reported due to the infusion of indocyanine green. the lymph flow was visualized intraoperatively in a satisfactory way helping the surgeon in decision making to determine an appropriate separation line of the mesentery. the section line of the mesocolon was modified in 1 (14%) case based on the findings obtained by fluorescence. the mean operative time was 160 (42) min. the morphometric laboratory data of the specimens to audit the correct complete mesocolic excision were satisfactory according to the oncological standards. conclusion: fluorescence lymphography during colorectal surgery was feasible and reproducible with a minimum of added complexity. fluorescence-guided surgery may be a helpful technique for determining an appropriate total mesocolic excision in colon neoplasms. aims: this video shows our technique for complete mesocolic excision (cme) during right colectomy for cancer. methods: in this video, a 62 years old patient underwent a laparoscopic right colectomy with cme for a cancer of the ascending colon diagnosed with a colonoscopy performed after positivity to fecal occult blood test (fobt). after ct scan staging we obtained 3d printed models to clarify patient's vascular anatomy. patient was placed in supine position, 4 trocars were inserted in left quadrants as for standard right colectomy. cme is performed by sharp dissection between the visceral fascia that covers the posterior lay of the mesocolon and the parietal fascia that covers the retroperitoneum (toldt's fascia). the ileo-colic vessels are used as landmark to identify the right anterior surface of the superior mesenteric vessels. with a caudo-cranial approach, the mesocolon is sharply dissected and the root of tributaries venous is ligated, up to the inferior margin of the pancreas. the gastro-colic trunk is dissected out with ligation of the right colic vein, while the gastroepiploic vein is preserved (harvesting the sixth group lymph node). the pancreas-duodenum fascial plane is entered and all the lymphoid tissue around the vessel surface is harvested. procedure is completed with ileo-transverse intracorporeal stapled anastomosis. results: in our experience, between april 2017 and december 2018, 46 laparoscopic right hemicolectomies with cme were performed. we had no major intraoperative vascular lesions. no patients needed intraoperative blood transfusion. compared to our series of standard right colectomies we did not notice any significant difference in post-operative complications. the follow-up is too short to demonstrate if the cme approach has a better oncological outcome compared to standard right colectomy. conclusions: laparoscopic cme is feasible, although it requires a higher expertise level of surgical know-how. the quality of evidence is limited and does not consistently support the superiority of cme as compared to standard right colectomy. better data are needed before cme can be recommended as the standard of care for colon cancer resections. h. bando gastroenterological surgery, ishikawa prefectural central hospital, kanazawa, japan aim: in case of right-sided transverse colon cancers, it is necessary to dissect the lymph nodes around the root o f the middle colic vessels. but in this area there are dangerous organs, for example : pancreatic head, duodenum, and gastrocolic trunk. it is the point of our technique that we resect the accessory right colic vein and middle colic vein, and then dissect pancreas head and duodenum at early step of the operation. method: we perform the operation by five trocars. the first step is to transect the great omentum, and confirm the lower edge of pancreas.there are much adhesion between mesocolon of transverse colon and stomach, great omentum. it is very important to dissect the adhesion accurately. secondly, the mesocolon is incised at lower edge of pancreas. it is possible to detect the lower edge of pancreas in obese people. the anterior surface of superior mesenteric vein is exposed. the accessory right colic and middle colic vein are resected. and then front face of surgical trunk, pancreas, and duodenum is dissected caudally as possible. the superior mesentery artery is resected below the mesocolon after flip up of transverse colon. this approach is safe and feasible, because the dangerous organs are handled by direct vision. by that, extraction of intestine is easy from small incision. afer flip up of transverse colon, the mesenteric of ileum is incised. the root of ileocecal vessels is exposed and these are resected. the peritoneum of the front of superior mesenteric artery is incised, and the lymph nodes around the surgical trunk are dissected. this dissected area is easily connected with the one done beforehand. uniquely we resect the mesocolon and major omentum from the root of dissected vessels to resected side of transverse colon. and then right-side colon is dissected medial approach. conclusion: we dissect the dangerous organs in advance. that prevent major injury of them. background: good visualisation of the operative field is a fundamental requirement for safe laparoscopic colorectal surgery. over the past 25 years of the senior author's experience, camera systems have evolved from single to three chip, high definition (hd) and most recently, the 4 k system. in parallel, the rest of the infrastructure such as cables, processors, monitors etc. have also undergone improvements, resulting in improved image quality. aim/methods: we present a video of a case of laparoscopic total mesorectal excision (tme), performed with strict adherence to our previously published 'stepwise approach to laparoscopic colorectal surgery' which places particular emphasis on safety aspects. tme was performed in a 54 year old male patient with history of previous abdominal as well as robotic prostatic surgery. the procedure was filmed with all components including the camera head, cables, processing unit, screens as well as the recording/mixing decks being 4 k. multiple external 4 k cameras were also used. live transmission to a remote audience as part of our masterclass was achieved using appropriate bandwidth and projection on to 4 k screens. results: feedback from the operating team as well as from the live audience was that the image quality was far superior to hd systems. the 4 k system accorded a degree of clarity well beyond usual expectations. the depth of field also appeared to be different initially, but within a few minutes of starting the procedure and acclimatisation, the effects were appreciable. the clarity of the image which showed the fine details of the dissection planes and anatomical landmarks as well as the vibrancy of the vasculature gave a distinct three-dimensional effect to the picture. this excellent visualisation added one more layer of safety and complemented our stepwise approach for a successful procedure. conclusion: the laparoscopic 4 k system, in our practice, proved to bea beneficial visualisation tool to enhance the accuracy of dissection. vital structures appeared to be more vivid and clearer with dissection planes being more easily apparent. in our opinion the laparoscopic 4 k system when combined with a systematic approach enhances safety, especially in complex laparoscopic colorectal surgery. accumulating evidence suggests that laparoscopic surgery for colon cancer has feasibility and efficacy equal to or over conventional laparotomy. for cases with pasthistory of laparotomy, especially history of colon resection, however, there is almost no evidence for laparoscopic recolectomy for metachronous colon cancer. since 2016, we have been used submucosal local injection of indocyanine green (icg) around primary colorectal cancer by using intraoperative endoscopy, and complete mescolic excision (cme) have been convincingly carried out, which was clarified by completely resected icg positive area. although evidence on the oncological efficacy of icg guided surgery has not yet been clarified, since it can be easily judged whether cme is performed clearly, it is considered that icg guided surgery for primary colon cancer is useful for education. recently, we are applying this to ensure convincing cme for patients with colorectal cancer who had a history of colic resection. the representative case is as follows. a 60-year-old female was diagnosed as advanced sigmoid colon cancer, and laparoscopic sigmoidectomy with high tie of the inferior mesenteric artery was performed 10 years ago. then she was diagnosed as the metachronous descending colon cancer. the feeding artery of the new tumor should be the left colic artery, however, the left colic artery was already resected and genuine feeding artery was not identified by preoperative examination. by injecting icg into submucosa endoscopically during operation, it was clearly observed that the lymphatic flow from the tumor was directed to the inlet portion of the inferior mesenteric vein (imv). re-cme was performed by ligating the inlet of imv. intraoperative icg was also useful for clarifying the borderline for adhesion detachment of pastoperation between the mesentery and retroperitoneum (figure) . interestingly, icg flow in the mesentery direct to of the anus side was disrupted clearly at the past anastomotic site. we believe that laparoscopic surgery under icg guidance is potential useful tool that can confirm evidence to date more intuitively in real time. further studies, ideally randomized controlled trials, are required for define the oncological usefulness of icg guided surgery for re-do colectomy. the operation movie will be presented at the meeting. background: laparoscopic lateral pelvic node dissection (llpnd) is a minimally invasive alternative to open surgical therapy for advanced low rectal cancer patients. in this video, we demonstrate the technique of llpnd for rectal cancer patients with suspicion of lln metastases after neoadjuvant chemo-radiation. methods: the principle of this approach is en bloc resection with bilateral peritoneum. the peritoneum is incised lateral to the ureter following the line between external and internal iliac vessels. in the next step, llpnd dissection of the regional lymph node and high ligation of inferior mesenteric vessels were performed. a contralateral llpnd was performed in the same manner as a mirrored technique. after extracting the specimen, an end-to-end double-stapled circular anastomosis was performed. results: the procedure was done safely without any complications.the surgical duration was 245 mins, and the blood loss was 50 ml. the number of harvested lateral pelvic lymph nodes was 15. the tnm stage was ypt4an2m0. conclusion: this approach enables extended resection during lymph node dissection, allowing autonomic nerve preservation. it is maybe a helpful approach in the treatment of locally advanced rectal cancer with a lateral lymph node metastasis. aims: the aim is to present an inspection method where the anastomosis vascularity is testing simultaneously using the indocyanine green fluorescent angiography intraluminal and intraperitoneal. methods: sixty-five year old female patient underwent standard laparoscopic-assisted low anterior rectal resection for rectal carcinoma. the proximal end of the bowel and the stump of the distal rectum were checked using near-infrared fluorescence imaging with d-light camera. after making sure of adequate perfusion of the bowel, the end-to-end stapled anastomosis was performed under the laparoscopic visualisation. the d-port proctoscope was inserted into the anus. the second icg injection was administered. the perfusion of the anastomosis in transabdominal way and viability of the mucosa in transanal way was evaluated with two d-light cameras simultaneously. the anastomosis was determined 4 cm from the anal verge. an air-water leak and tension of the bowel tests were performed. after evaluation of anastomosis viability with fluorescence imaging, after negative air-water leak and tensions testing, the decision was made by surgeon not to perform preventive ileostomy. results: the patient had no complains for the first three days postoperatively. nevertheless, crp level was growing and was 69.6 mg/l on the second postoperative day, and 103.5 mg/l on the 4th postoperative day. the patient complained of the pain in the right iliac area and below symphysis on the 4th postoperative day. the abdominal and pelvis computed tomography scan with oral contrast was performed which denied our thoughts about the anastomotic leakage. intravenous cefuroxime and metronidazole antibiotics were prescribed. the crp level was 16.3 mg/l on the 10 th postoperative day. the patient was discharged on the 11 th postoperative day without preventive ileostomy. conclusion: using the original, standardized colorectal anastomosis inspection method we can determine which patient doesn't need the preventive ileostomy after low colorectal anastomosis. the 2 important causes of anastomotic leak are local ischemia and staple line defect. the purpose of this study was to investigate the combination of methods aimed to reduce the risk of anastomotic leak after anterior resections for rectal cancer. methods: we retrospectively analyzed perioperative outcomes of the first 30 patients, who underwent modified laparoscopic anterior resection with partial mesorectal excision for rectal cancer without preventive stomy. operative technique was modified and included routine preservation of the left colic artery (fig1)(aimed to improve anastomotic blood supply), manual suture invagination of the 'dog ears' (fig2) (aimed to reduce the risk of staple line defects), transperineal pelvic drainage and pelvic peritoneum reconstruction (aimed to reduce the risk of reoperation in case of leakage). anastomotic leak rate, reoperation rate, left colic artery preservation rate, additional operative time (time required for left colic artery preservation, 'dog ears' invagination and pelvic peritoneum reconstruction), blood loss, morbidity and mortality were analyzed. results: 1 (3.3%) patient developed an asymptomatic leakage, which was managed conservatively. there was no postoperative mortality and no reoperations. median additional operative time was 56 min for the first 15 procedures and 41 min for the last 15 procedures. left colic artery preservation was successful in 26 (86.7%) patients. median blood loss was 35 ml. conclusions: additional techniques used in our modification of laparoscopic anterior resection are safe and may lead to improved perioperative outcomes. however, they are associated with increased operative time, which may be reduced with a better learning curve. introduction: parastomal hernias are a significant cause of post abdominal ostomy morbidity with an overall life-time incidence exceeding 80%. the complications can range from a bulge resulting in stoma bag leakage, to life threatening bowel obstruction. the prevent-trial sought to determine if prophylactic utilisation of polypropylene mesh would decrease the incidence of parastomal hernias, with initial results demonstrating that it was safe to use in permanent end stomas. aim: to demonstrate a reproducible and streamlined technique for laparoscopic parastomal hernia repair with intraperitoneal funnel mesh, and assess the outcomes with the clavien-dindo (cd) classification tool. method: 10 parastomal hernia repairs (7 colostomy, 3 ileostomy) were considered, with the following approach adopted for each: swab sutured in stoma orifice to prevent wound contamination.sharp dissection of the stoma using parachute technique.stoma end refreshed followed by change of gloves and instruments.lateral stay sutures placed to tighten sheath later on.pneumoperitoneum temporarily created to assess/divide adhesions.funnel mesh placed in-situ, orientated in the optimal intraabdominal position, and sutured to the peri-colic fat to prevent slip.medial suture placed to narrow the sheath further.pneumoperitoneum re-created and mesh fixed in place with double crown laparoscopic tacks.redundant portion of end stoma excised and stoma formed. results: at median follow up of 12 months: no recurrence.no reported symptoms of pain or decreased stoma functionality.one superficial wound infection treated with drainage at bedside (cd = grade 1) conclusion: laparoscopic parastomal hernia repair with intraperitoneal funnel mesh for permanent end stomas yielded good outcomes in our patient cohort. a streamlined and reproducible approach ensures that the technique can be adopted for both prophylactic, primary and recurrent repair. parastomal hernias are common and can be associated with significant morbidity. when taking this into account, in conjunction with the recommendations of the initial results of the prevent-trial, one may consider prophylactic utilisation of a mesh in patients receiving a permanent end stoma. general surgery, rambam medical center, haifa, israel 29 year old, female patient referred to our institution with common bile duct stricture, caused by iatrogenic injury during laparoscopic cholecystectomy. during last year, patient suffered from recurrent episodes of ascending cholangitis. recently, she underwent ercp and severe stricture of middle cbd was diagnosed. plastic stent was inserted through the cbd. mrcp also showed severe stricture of cbd with dilatation of biliary tree, proximal to the stricture. due to severe and resistant (did not resolved by recurrent dilatation) structure of middle cbd, she was referred to operation. patient underwent da vinci robot-assisted excision of the cbd stricture, hepaticojejunostomy and extracorporeal jejunojejunostomy of roux-an-y limb. total operating time was 320 min. day three after operation patient started regular diet and was discharged home on day four. final pathology has shoved part of cbd with severe inflammation. aims: extrahepatic biliary duct resection for the treatment of bismuth i and ii stage klatskin tumor is the standard surgical technique [1] . methods: a 85 years old patient present at emergency room (er) with right upper abdominal pain with an elevation of the inflammatory markers at the blood exams and fever. the patient was submitted to a computer tomography (ct) that shows a tumor involving the lower tract of the principal bile duct. an endoscopic retrograde cholangio pancreatography (ercp) with biopsy (intraductal papillary neoplasm of the bile duct,ipnb with high-grade dysplasia) and stent placement was performed. considering the good general conditions of the patient and an absence of vascular and nodal invasion at the preoperative imaging, a minimally invasive surgical resection of the biliary tract with cholecystectomy was performed. results: a four port laparoscopic biliary tract resection with cholecystectomy was performed with lymphadenectomy of the hepatic hilum. no vascular or liver infiltration was found. the hepatic hilum was completely skeletonized. the resection of the biliary duct was performed with adequate free margin. a biliary reconstruction with roux-en-y technique was performed and a fully laparoscopic hepatico-jejunal anastomosis was done. and abdominal retro anastomotic drain was placed. the operative time was 350 min. the postoperative course was complicated by a low rate biliary leakage that was treated conservatively. the patient was discharged at 25 post operative day in good general conditions. the histological examination revealed a moderately differentiated in situ cholangiocarcinoma of the principal bile duct with the involving of the cystic duct with free resection margin (pt1bn0r0). conclusions: laparoscopic resection of the biliary tract is a challenging procedure that allows, in expert hands, to achieve in selected cases negative pathological margin, complete linfonode retrieval and entero-biliary bypass. injury to the extrahepatic bile duct during bile duct or hepatic surgery can be reduced by better real-time visualization. recently, indocyanine green (icg) fluorescence imaging has been used in laparoscopic hepatobiliary surgery. we applied icg fluorescence imaging in patient with huge hepatic cyst which severely deviated extrahepatic bile duct. the patient had received laparoscopic cholecystectomy and huge hepatic cyst stuck firmly with peri-hepatic structures including bile duct. icg fluorescence imaging correctly identified the common hepatic duct and remnant cystic duct and allowed for more meticulous and easier dissection. therefore, icg fluorescence imaging may guide a safe and accurate dissection and excision in hepatobiliary surgery. results: total patients who underwent ercp were 2,321 and 3.2 percent (75 cases) had a first failed ercp and 13 of then were unsuccesfull in the second intent of ercp. intrahospitalary stay was more than 7 days in the 11 percent, in the 89.2 percent was 4 to 7 days, with and average of 6 days. conclusions: before, during or after lcbde, ercp remains the gold standard for manegement of choledocolitiasis confirmed by clinics, laboratory and imagenology. lcbde is a very good option that requires experience and specific skills, and especialized equipment. in 9 years the rate of sucess in our hospital was 95.3% and there were no posoperatory complications such as: biliar peritonitis, pancreatitis or liver abscess. aims: easier intraoperative recognition of the biliary anatomy may be accomplished by using near-infrared (nir) fluorescence imaging after an injection of indocyanine green (icg). neither radiological support nor additional intervention such as opening the cystic or common bile duct is required, making it an easy and real-time technique to use during surgery. the aim of this video is to describe our experience in fluorescence-guided cholangiography in different clinical situations. methods: intravenous injection of icg is used to illuminate extrahepatic biliary anatomy. however, the simultaneous enhacement of liver parenchyma can disturb the visualization of clinical details. the key is in the used dose of icg, the route of administration and the time since its infusion. in the first case, a scheduled cholecystectomy is shown in which a dose (1 ml of 25 mg dye dilution in 10 ml of distilled water) administered intravenously 3 h before the intervention was used. the second case shows an urgent cholecystectomy in which the dose (30 ml of 25 mg dye dilution in 1000 ml of distilled water) was administered intragallbladder during surgery. all patients underwent laparoscopic cholecystectomy with traditional four-port technique. all procedures were performed using a 30-degree 10 mm laparoscope with nir imaging capability (visera elite ii, olympus). results: there were no intraoperative or postoperative complications. there was no increase in operative time due to the use of icg. in the first case, a clear identification of the cystic duct and the main bile duct was obtained thanks to the biliary excretion of the icg and the intravenous clearance. in the second case, the identification of the cystic duct, the main bile duct and the cystic artery occurred due to the intravesicular absorption of icg. conclusion: fluorescence-guided cholecystectomy clarifies the dissection plane. it can be considered to increase the safety of laparoscopic cholecystectomy. being aware of the doses, times and possible routes of administration is basic to universalize the technique and give it utility in different scenarios. introduction: mirizzi syndrome type 2 is an uncommon cause of obstructive jaundice caused by an inflammatory response to an impacted gallstone in hartmann's pouch or the cystic duct with a resultant cholecystocholedochal fistula. the obstructive biochemical changes can be caused by direct extrinsic compression from the impacted gall stone or from the fibrosis caused by advanced chronic cholecystitis, or for the established fistula. objective: we present a case of a mirizzi type 2 syndrome with choledocholithiasis which was solved by laparoscopy approach. material and methods: a 28-year-old female patient with no past medical history. the history of present illness begans with the presence of icteric dye since the last 3 days; she received symptomatic treatment with poor improvement. a liver and biliary tract ultrasound was performed with report of a 12 mm coledochus, 5 mm wall gallbladder. then an endoscopic retrograde clolangiopancreatography was performed with successful endoscopic sphincterotomy and removal of gallstones. but the patient jaundice persisted after the procedure. the patient underwent cholecystectomy and laparoscopic common bile duct exploration, where the findings were a mirizzi type 2 according to the csendez classification, chronic cholecistitis and choledocholithiasis. results: in this laparoscopic approach we performed a partial cholecystectomy, bile duct exploration with removal of residual gallstones. the closure of the choledocotomy was performed with simple knots using vycril 3.0. a subhepatic drainage was left. the patient showed adequate clinical evolution. after 4 days the patient was discharged. conclusions: it is important to properly identify the anatomy at the time of surgery to avoid injury of the common bile duct. operative treatment of mirizzi syndrome type 2 includes either laparoscopic or open subtotal cholecystectomy or placement of a t-tube or choledocoplasty. near-infrared fluorescent cholangiography (nirf-c) is an innovative intra-operative imaging technique that allows a real-time enhanced visualization of the extrahepatic biliary tree by fluorescence. thanks to the development of laparoscopes/endoscopes with light sources emitting infrared frequencies, it is possible to visualize anatomical structures (vessels, ureters, bile ducts, etc.) through the luminous intensity of substances (fluorescein, blue of methylene, indocyanine green) which are injected into the patient. this technology may be considered as an important teaching tool for laparoscopic surgery, especially for young surgeons in their surgical learning curve and it could lead to reduce the risk of iatrogenic bile duct injuries during laparoscopic cholecystectomy. the following video is characterized by a series of intra-operative images of biliary anatomy by fluorescence, having an important educational interest, while also detecting anatomical variations of the cystic duct. a. umezawa, minimally invasive surgery center, yotsuya medical cube, tokyo, japan aims: laparoscopic cholecystectomy(lap-c) for cholecystolithiasis has become standard. however, serious bile duct injury has been reported as a complication. repeated colic and chronic inflammation in cholecystolithiasis lead to the so-called difficult gallbladder conditions, such as dense fibrosis and scarring of the tissue. dissection of calot's triangle includes the risk of bile duct injury. critical view of safety (cvs) is the most well-known land mark for safe cholecystectomy. in the revised tokyo guidelines 2018 (tg 18), important land marks and bailout procedures had been proposed. those are for the difficult gallbladder which are not able to achieve cvs. methods land marks: baseline of segment4 of the liver and sulcus rouvier should be confirmed. the gallbladder wall itself is also useful landmark. bailout procedure: when the dissection of calot's triangle is considered impossible, bailout procedures should be considered. subtotal cholecystectomy which leave the neck is one of option. the fundus first technique is another approach. however, because fundus first technique has a possibility of leading to serious bile duct injury, it should stop by the neck. in this video, first case shows the importance of landmarks from near miss cases of misidentified injuries. second case shows bailout procedure, subtotal cholecystectomy with fundus first technique. result: in the atrophic gallbladder (case 1, near miss), it is liable to misidentify the junction of common bile duct as the gallbladder neck. the neck and common hepatic duct were lifted together easily. with confirming the landmark, misidentification was corrected and bile duct injury was avoided.in the case2, since the calot's triangle was obscured due to repeated cholecystitis, dissection of gallbladder was performed from the bottom to the neck, and was excised with the cervical portion remained. the remaining neck was reconstituted.in each case, intraoperative cholangiography was performed, and it was confirmed that there was no bile duct injury. without postoperative complications, those patients were discharged pod 2 as usual lap-c. conclusion: during lap-c for difficult gallbladder, the most annoying part is bile duct injury. confirming landmarks and switching bailout procedures can be contributory to avoid bile duct injury and to achieve safe lap-c. aims: choledocholithiasis is an important cause of morbidity and is present in about 18% of patients submitted a cholecystectomy. his treatment should be done in the same operative time, avoiding the morbidity and hospitalization time and costs of multiple procedures.the transcystic approach is preferable to prevent morbidity associated to choledochotomy.large stones can preclude this procedure. the use of laser lithotripsy to stone fragmentation is an option to provide transcystic extraction. methods: we present a video of laparoscopic transcystic common bile duct (cbd) exploration for choledocholithiasis. results: female patient, 65 years old with a previous hospitalization for acute cholangitis with choledocholitiasis.submitted to laparoscopic cholecystectomy with intraoperative cholangiography that showed the presence of stone in distal cbd with 1 cm size. the use of holmium laser lithotripsy made the stone fragmentation and provided his extraction by transcystic route using a basket.the patient was discharged at 4 th postoperative day, with no complications. conclusion: the use of laser lithotripsy for large cbd stones is safe and effective, making possible the transcystic approach and preventing the choledochotomy morbidity. surg endosc (2019) 33:s485-s781 gallbladder adenocarcinoma is rare and extremely aggressive. its' incidence is higher in elder females and its progression is rapid and silent with a dismal prognosis if diagnosed at advanced stages. we present the case of a 77 years-old female with dyspeptic complaints. the abdominal ultrasound revealed a 2 cm solid lesion of the gallbladder suspect for malignancy. the ct confirmed the presence of a vegetant mass on the free border of the gallbladder fundus with 28x13 mm. we performed a radical cholecystectomy with lymphadenectomy and liver bed excision. the post-operative period was complicated with a urinary tract infection, with full recovery after antimicrobial treatment. the histological sample revealed an adenocarcinoma of the gallbladder (t1bn0m0) and the patient remains asymptomatic and tumour free 9 months after the surgery. gallbladder cancer treatment depends of the stage and clinical presentation of the disease. complete surgical excision is the only curative treatment and should include a limited hepatectomy and portal pedicle lymphadenectomy. laparoscopic surgery might be an option in early stages, although it is challenging and requires both expertise in hepato-biliary and laparoscopic surgery. seen at the emergency room for a two month history of abdominal pain associated with jaundice. she is evaluated by the surgical team and diagnosed with acute cholecystitis and moderate risk for choledocholithiasis. the initial surgical plan was cholecystectomy with intraoperative cholangiogram. during surgery, firm adhesions are found from the gallbladder to omentum. friable tissue with edema and easy bleeding. difficulty is encountered during the dissection of calots'triangle. an intraoperative cholangiogram is done through hartmans'pouch without identifying correctly the biliary tract. therefore, an endoscopic retrograde cholangiopancreatography (ercp) is done to visualize the correct anatomy. during the ercp, a stenotic common hepatic duct is found and no stones are visualized. a biliary endoprosthesis is placed. she is discharged asymptomatic. a month later, the patient is back in the emergency room with abdominal pain. after an abdominal ct scan, we found that the endoprosthesis had migrated to the 4 th portion of the duodenum. a second ercp is done and this time we found a big stone (1.5-2 cm) aims: when training in the residency you watch your teacher perform laparoscopic cholecystectomy with ease, and even yourself perform several steps. but as a young surgeon, when confronted with a patient with acute cholecystitis, you're filled with emotions, and you do not know where to start the gallbladder dissection. the aim of this presentation is to show to young surgeons that you can, and must achieve, critical view of safety when performing laparoscopic cholecystectomy for acute cholecystitis. methods: we present the case of a 42 years old female patient, bmi of 36.3, who presented with a grade ii (moderate) acute cholecystitis. following tokyo guidelines, we initiated antibiotics and general supportive care, but without clinical improvement. the patient was proposed for laparoscopic cholecystectomy. results: at initial exploration we identified a 20 cm long gallbladder, with a thick wall, difficult to manipulate. we opted for an anterograde cholecystectomy, in our opinion the best option in acute cholecystitis. the dissection was started with hook electrocautery and then continued with a combination of blunt dissection with the aspirator and with the hook. when reaching the pedicle, blunt dissection was used in order to appreciate the anatomy of the cystic duct and cystic artery. after correct identification of these structures they ware clipped and cut. a drainage tub was then placed, and the abdomen deflated. conclusion(s): as a young surgeon, when dealing with acute you must maintain your calm, and try to achieve critical view of safety before transecting the cystic duct and cystic artery. this can be achieved with a combination of blunt and sharp dissection, keeping your camera clean and with a good collaboration with the assisting surgeon. conclusions: here, an easy and reproducible method is described for future macroscopic analysis by the surgeon following a cholecystectomy. in addition, we depict several frequent macroscopic abnormalities in order to provide surgical colleagues with some cases of abnormal macroscopic gallbladders. the left hepatectomy is a demanding and difficult procedure, still limited to reference centers. the caudal approach and exposure of the middle hepatic vein is a reliable way to achieve a safely and reproductible left hepatectomy. with this technique, exposing the middle hepatic vein, we believe that we can perform a safe and feasible laparoscopic left hepatectomy increasing the quality of this hepatectomy. we present a 47-year-old woman with an intrahepatic and common bile ductlithiasiswhich was previously submitted to an ercp. with an unsolved intrahepatic lithiasis the patient was proposed to alaparoscopic left hepatectomy. the minimally invasive approach for alpps in a patient with a large hepatocellular carcinoma in a liver with severe steatosis is shown. during the first stage a partial alpps is performed. pve is performed in postoperative day one. after 15 days from the first stage both liver volume and function (by hida scan) are re-assessed. right hepatectomy (second stage of alpps) is then conducted by laparoscopic aproach. hepato-bilio-pancreatic, centro hospitalar são joão, porto, portugal a 68 year old woman with a previous history of anxiety and catheter ablation to treat heart arrhythmias, was studied for for multiple pancreatic cysts incidentally discovered on a routine ultrasound. an mri was performed showing multiple cystic tumors throughout the pancreas, the largest of which was 15 mm. this led to a suspicion of multi-focal, side-branch intraductal papillary mucinous neoplasm (ipmn), with minimal dilatation of the main pancreatic duct. an echo endoscopy was subsequently performed indicating probable multifocal ipmn. a fna was carried out during this procedure, with aspiration of cystic content which was sent for cea analysis and cytology. cytology was compatible with mucinous neoplasm with mild atypia and cea 98 u/ml. a splenic preserving total laparoscopic pancreatoduodenectomy was proposed. the procedure was uneventful and the patient was discharged on the 5 th post-operative day. pathology revealeded a 19 mm ipmn, with severe dysplasia and 3 foci of microinvasive ductal adenocarcinoma of 1 mm-pt1n0r0. indocyanine green immunofluorescence guided laparoscopic partial hepatectomy y. tai obtaining negative tumor margin during laparoscopic hepatectomy has always been a very challenging topic for surgeons in that the surgeons are not able to palpate the tumor during laparoscopic surgery. although intraabdominal echo is available, but it demands great experiences and skills. with the guidance of icg immunofluorescence, surgeons can avoid failure of not obtaining enough negative margins nor resect too much healthy liver. icg is often used to estimate the liver function prior to hepatectomy traditionally. it binds to plasma protein and has a peak absorbance at 780 nm and emits fluorescence with a wavelength of approximately 800 nm. icg is preferentially retained in or around biliary malignancies due to impaired biliary excretion of hepatocytes in the affected area. we performed icg immunofluorescence guided laparoscopic partial hepatectomy on a 57 years old male who suffers from hcc located at segment 5 and 6. icg was injected 3 days prior to the operation day. while evaluation of liver is performed, it also allowed us to use a high-end laparoscopic camera system equipped with integrated filters for detection of near-infrared fluorescence. during the surgery, we were able to clearly locate the borders of malignancies through the use of integrated filters combine with icg injection. the pathology study also confirmed that the adequate tumor free margin ([ 0.5 cm) were obtained in both tumors and the patient's condition was stable as well. icg immunofluorescence guidance enables surgeons to obtain optimum result in tumor resection through laparoscopic surgery. it also has the ability to detect bile leakage. with the use of icg immuofluorescence, surgeons will have higher chances to achieve adequate negative margins. background: parenchymal sparing hepatic resection has the advantage of preserving valuable tissue in chemotherapy-treated livers, assuring an adequate future remnant volume without compromising long-term survival. moreover, the laparoscopic approach offers the decreased postoperative morbidity of minimally invasive surgery. whenever technically feasible, this kind of procedure should be considered a suitable alternative to the classic major hepatectomy for the treatment of multiple colorectal liver metastases. methods: 69-year old male with a previous history of laparoscopic sigmoidectomy in november 2014 for a pt2n0m0 sigmoid adenocarcinoma. a control scanner three years later showed liver metastases in segments v, viii, ii and caudate lobe. after chemotherapy (xelox), control mri and pet scans showed a good response. he was proposed for a laparoscopic parenchymal-sparing liver resection. results: total operative time was 3 h and 45 min with no intraoperative complications. patient presented a right atelectasis as the only postoperative complication and was resolved with respiratory therapy. he was discharged in 4 days. pathology report showed that lesions on segment v and viii had no viable tumor (100% fibrosis) and lesions on segment ii and caudate lobe had moderately differentiated adenocarcinoma. margins were free in all the lesions. after a 6 month follow up, the patient has no recurrence and normal liver function tests. conclusion: minimally invasive liver resection is possible in patients with multiple bilobar liver metastases and allows to perform parenchymalsparing surgery safely. difficult localization of lesions such as the caudate lobe are not a contraindication for this type of surgery. laparoscopic approach for perihilar cholangiocarcinoma is still poorly reported in the literature due to technical challenges secondary to the combination of major hepatectomy, lymphadenectomy and biliary confluence resection. despite this, in selected cases it can be a good option to provide a short term benefit to patients. the video reports the case of a perihilar cholangiocarcinoma with involvement of left bile duct and therefore requiring left hepatectomy. komagome hospital, bunkyo-ku,tokyo, japan aims: segmentectomy is an anatomic liver resection, in which the tertiary branches of the glissonean pedicles are selectively transected. however, the branching pattern of the tertiary branches varies depending on the case, particularly in segment 7 (s7) and segment 8 (s8). the extrahepatic approach to the glissonean pedicle from the hepatic hilum is very difficult depending on the branching pattern. furthermore, the distance of exposing the secondary branches that are to be preserved becomes longer, and there is an increased risk of biliary leakage and delayed biliary stricture due to excessive traction in laparoscopic surgery. therefore, laparoscopic s7 and s8 segmentectomy are considered technically difficult. we standardized the intrahepatic glissonean pedicle approach for laparoscopic s7 and s8 segmentectomy. methods: we standardized the intrahepatic glissonean pedicle approach for laparoscopic s7 and s8 segmentectomy. we identify the targeted glissonean pedicle intrahepatically after the parenchymal transection along the major hepatic vein or its branch running on the intersegmental plane, referring to the preoperative simulation by 3d imaging. (a)s7 segmentectomy; after the mobilization of the right lobe, the glissonean pedicles of s7 (g7) can be approached from the dorsal side by transecting the parenchyma between the ivc and the right hepatic vein. after the division of the g7, the parenchyma is transected along the demarcation line and the rhv from the root side to the peripheral side. (b)s8 segmentectomy; first, the parenchyma is transected along the middle hepatic vein (mhv) from the root side to the peripheral. g8 is typically detected on the right dorsal side of the mhv. after the division of the g8, the liver parenchyma is transected along the demarcation line and the rhv from the root side to the peripheral side. results: we have experienced 11 cases of laparoscopic s7 segmentectomy and 26 cases of laparoscopic s8 segmentectomy. conclusion: our approach to the g7 and the g8 is safe and very useful. laparoscopic anatomical segmentectomy of right anterior section is technically demanding because it is difficult to dissect the deep tertiary branches of right anterior portal pedicle (rapp). we present three cases of laparoscopic anatomical segmentectomy using the extrafascial and transfissural approach: 1) anatomical resection of segment 5, 2) anatomical resection of the ventral area 3) anatomical resection of segment 8 dorsal area. the extrafascial and transfissural approach means that the liver parenchyma along the fissure lines is opened, then the surgeon can confirm the glissonean pedicles and territory directly. the extrafascial and transfissural approach in laparoscopic anatomical segmentectomy of right anterior section is feasible and effective because this technique can easily be approached to the deep tertiary branches of rapp. repeated liver resection has significant role in patients with recurrent hepatocellular carcinoma (hcc) in several situations. laparoscopic redo surgery is becoming safer along with advance in surgical technique. we have performed laparoscopic re-resection for limited intrahepatic hcc recurrence. the aim of the present study was to investigate its significance comparing with first laparoscopic liver resections. subjects: patients with limited intrahepatic hcc recurrence after open hepatectomy underwent laparoscopic liver re-resection (n = 12). methods: adhesion between abdominal wall and visceral organs was carefully divided, after the first laparoscopic port was safely inserted. adhesion between diaphragm and liver surface or between previous liver cut surface and colon or duodenum was also minimally dissected. approach to the glisson's pedicles at the hepatic hilum was often difficult due to previous surgical procedure, thus pringle's maneuver was generally applied. dissection of hepatic parenchyma approaching to the target glisson's branch was often preceded under the ultrasound-guidance. liver resection was performed using lcs, biclamp, and cusa using intermittent block of the hepatic inflow. operation time, intraoperative bleeding, morbidity, mortality, and postoperative hospital stay were compared with those in patients who underwent first laparoscopic liver resection during the same period (n = 20). results: operation time was significantly longer in the re-resection group, possibly due to the adhesiolysis. meanwhile, no significant difference was detected in intraoperative bleeding, morbidity, mortality and postoperative hospital stay between the first and the redo surgeries. methods: the donor was a 32-year-old gentleman who decided to donate part of his liver to his wife suffering from viral liver cirrhosis and hepatocellular carcinoma. his bmi was 20.3 kg/m 2 and the preoperatively estimated donor's right liver volume was 836 ml, representing 63.6% of his entire liver. with the recipient's weight of 57 kg, the graft to recipient weight ratio (grwr) was 1.6%. the liver had classic hilar anatomy except that the right posterior intrahepatic duct seperately joined to the left main hepatic duct. after isolation and clamping of right hepatic artery and portal vein, indocyanine green of 2.5 mg was injected intravenously. results: the total operation time was 370 min and the estimated blood loss was 150 ml without transfusion. indocyanine green fluorescence image clearly demonstrated the anatomical demarcation between the lobes and visualized the running of the biliary tree. his postoperative course was uneventful and discharged postoperative day 7. conclusion: real-time indocyanine green fluorescence image may be particularly helpful to delineate anatomical surgical plane and to determine the appropriate division point of hepatic duct during laparoscopic living donor hepatectomy. surg endosc (2019) the correct management of intraoperative volemic status is essential in laparoscopic liver resection in order to control bleeding and to perform even complex procedures with a good profile of safety. central venous pressure is not really reliable in laparoscopy, due to presence of the pneumoperitoneum and patient position. monitoring of haemodynamic parameters via vigileo system is a minimally invasive method to control stroke volume variation, cardiac output, cardiac index and oxygen delivery in order to optimize the anaesthesiological management by controlling venous bleeding and avoiding tissutal ischemia. introduction: non-hydatid liver cysts represent a heterogeneous group of disorders that differ in their etiology, prevalence and clinical manifestations.within them, the simple hepatic cyst is the most frequent.the majority of simple cysts are an incidental finding during the performance of an imaging test for another unrelated cause and few of them are symptomatic or are associated with complications, and surgery is not necessary in most of them. described various therapeutic approaches so far there is no consensus about the optimal treatment of simple symptomatic, complicated or growth-showing liver cysts during its follow-up. currently the laparoscopic approach is widely used for the management of cysts hepatic, with results similar to open surgery but with the advantages of laparoscopy. objectives: to demonstrate the safety and efficacy of the laparoscopic approach in the approximation of complicated simple hepatic cysts.material and method: clinical case: a 68-year-old female patient with a history of: giant hiatus hernia intervention with laparoscopic nissen, fibromyalgia, previous ischemic colitis. hospital admission due to pneumonia and right pleural effusion with us: simple cyst 64 x90 x99 mm in segment v hepatic, with dilatation of biliary radicals adjacent to the cyst, distended gallbladder with irregular walls in the hepatic side. ct: cystic lesion in segment iv-v of the liver, which has increased in size, with small microabcesses adjacencies to the lesion, thickening of the gallbladder wall, to assess cholecystitis. antibiotic treatment is established with good evolution, deciding surgery. results: intervention: complete laparoscopic approach, 4 trocars, edematous cholecystitis, large retroyuxta vesicular cyst,with thickened walls with serous content. cholecystectomy maintaining the cyst wall, puncturing and taking samples for cytology and biochemistry of the contents, resection of the cyst wall, partial flare of its internal surface, negative intraoperative biopsy, epipoplasty, with drainage placement.correct postoperative course.pathological anatomy: simple biliary cyst with negative cytology, ck7?, ck20-, calretina-. conclusion: the treatment of choice of complicated simple hepatic cysts is laparoscopic.we recommend performing an intraoperative biopsy of all resected liver cysts to confirm its nature,we propose cyst enucleation as the best surgical treatment. objective: the objective of the following case is to present a patient with symptomatic polycystic liver disease, which was solved by laparoscopy approach and the management of its complications. material and methods: the case reported is about a 62 years old female patient with abdominal pain in upper right quadrant associated to asthenia, adynamia and hyporexia. ct scan reported heterogeneous liver with multiple ovoid images with regular edges defined which the biggest one measure 102x99x137 mm with volume of 723 cc on segment 2 and 3, which comprises stomach, and the other one in segment 8 with a volume of 1453 cc and others small sized located in segment 6, 7 and 4b. results: in this laparoscopic approach, we performed a cyst unroofing of the two biggest cysts as well as cholecystectomy because of firm and lax adhesions. the patient evolved with fever in the 5 th day postsurgical day and biliary leaking in a volume of 270 cc in 24 hrs. an ercp (endoscopic retrograde cholangiopancreatography) was asked for that was carried out by finding leak at the intrahepatic biliary duct therefore; esphinterotomy with placement of plastic endoprotesis was performed. the patient evolved without complication and was discharged at the 10 th day. conclusions: only symptomatic polycystic liver disease needs to be treated. the choice of treatment is not yet standardized, for voluminous cysts the unroofing ideally by laparoscopy is the gold standard and the ercp is the elected treatment when the biliary leak appears as a complication. introduction: laparoscopic liver resection (llr) for tumors located in the posterosuperior segments of the liver (segments (s) 7 or 8) is a challenging procedure. especially, llr for s7 is difficult because the access of instruments is limited, bleeding control is not feasible, major llr is sometimes required, and obtaining sufficient resection margin is not easy. to overcome this obstacles, we performed llr in s7 with a lateral approach using intercostal trocars. to obtain competent resection margin, llr through right hepatic vein (rhv) first approach was performed for 1.8 cm mass located near the rhv in a 58 year old female. case: after full mobilization of right liver including all short hepatic veins and caudate lobe, rotate the whole liver completely to the left side to approach to the root of rhv. one intercostal trocar was inserted to access the lesion. parenchymal transection started from the confluence of hepatic vein and then, followed along rhv with ligating several small branches from rhv. resection margin was demarcated after localization using laparoscopic ultrasonography. after completion of parenchymal dissection using cusa and ultrasonic shears, hemostatic agents were applied and drain was inserted. operation time and estimated blood loss were 120 mins and 400 ml. the patient was discharged without any complication on postoperative day 7. final pathological assessment confirmed clear resection margin (safety margin : 1.5 cm). conclusion: laparoscopic s7 segmentectomy with hepatic vein first approach technique is safe and recommended to obtain better resection margin. aims: simple liver cysts are the most common cystic lesions of the liver. most are diagnosed casually in image tests such as ultrasound or computerized tomography, most of which are asymptomatic and do not require treatment. in symptomatic patients (abdominal distension with palpable mass, abdominal pain, dyspnea, jaundice, etc.) the clinical manifestations are usually due to the growth of the cysts or the compression of neighboring structures. liver function tests are usually not altered. intracystic complications occur in less than 5% of cases and malignancy is exceptional. in this video, we present the case of a symptomatic patient with polycystic liver disease including a large size hepatic cyst. material and methods: 65-year-old woman with a personal history of arterial hypertension, saos, partial hysterectomy due to endometrial cancer, who was referred to our department complaining of supraumbilical pain and abdominal distension with palpable mases. abdominal ultrasound showed cholelithiasis and multiple simple hepatic cysts. in ct scan, multiple hepatic cysts were found, the largest one of about 20 cm of larger diameter. echinococcus granulosus serology test was negative. there was also no evidence of cancer disease in pet scan. results: a laparoscopic approach was performed with four trocars, three of 5 mm and a hasson trocar inserted thought a umbilical small incisional hernia. aspiration and wide unroofing of the large size cyst and smaller accessible ones was done. the patient also underwent cholecystectomy with intraoperative cholangiography and umbilical eventroplasty. the patient recovered uneventfully and is asymptomatic one year after surgery. conclusion: simple liver cysts rarely require treatment. in some cases, especially in large, complicated and symptomatic simple liver cysts, surgery is indicated. laparoscopic fenestration treatment is the best choice. aims: liver resection is the preferable initial treatment option for solitary or limited multifocal hepatocellular carcinomas. surgical indications for laparoscopic liver resection (llr) are the most important consideration, like liver function, tumor size (diameter less than 5 cm) and location (easy technical access like in the left lateral section or on the surface of the inferior region). partial liver resection or left lateral sectionectomy are the typical procedures for such tumors and are considered the best way to begin llr. with accumulating experience and technical advancement, llr has been performed for tumors larger than 5 cm and for others locations. some requirements to perform llr are to have experience in liver surgery and laparoscopic also, adequate technology and intraoperative ultrasound. methods: a 69-year-old male smoker, ex-parenteral drug users with chronic hcv liver disease child-a stage. he is diagnosed with a single lesion of 7 cm in segment iii of the liver, biopsied twice without conclusive diagnosis and with a three-phase ct suggestive of hepatocarcinoma li-rads 4 with data of portal hypertension (pht) and mild ascites. after the study is commented on tumor committee deciding surgical intervention. results: a laparoscopic resection of segment iii was performed with 5 trocars. liver is explored by intraoperative laparoscopic ultrasound. vascular control was performed using the pringle technique. liver transection was done with sonostar until identification of intraparenchymal segment iii vascularization, which is sectioned with endogia (45 mm) with seamguard. after the resection, we perform hemostasis control with electrocoagulation and hemostatic material. intraoperative bleeding of 300 ml. favorable postoperative evolution, high on the 5th postoperative day. ap: 7 cm trabecular hepatocarcinoma moderately differentiated pt1b, r0 resection. conclusions: llr allows major liver resections with low morbidity and mortality and the advantages of laparoscopic surgery. an efficient learning curve can be achieved by a parallel evolution of procedures and indications (according to modified bclc staging system and treatment strategy). studies suggest that llr results in less blood loss, shorter postoperative hospital stays, lower abdominal wall trauma and lower incidences of ascites accumulation and postoperative liver failure. with respect to oncological considerations, tumor margins are adequately maintained during llr. v. drakopoulos, s. voulgaris, i. iliadis, k. botsakis, p. trakosari, v. vougas 1st department of surgery and transplantation unit, district general hospital of athens « evangelismos » , athens, greece introduction: laparoscopic surgery is gaining acceptance in the treatment of liver metastasis. laparoscopic treatment of liver metastasis often presents technical difficulties and requires an extensive learning curve. material-method: we present the case of a 62 year old woman presented with a liver metastasis in section 3 of the liver. the patient had been submitted to a laparoscopic low posterior resection in february 2018. patient underwent laparoscopic left lateral hepatectomy, with the use of three trocars (umbilical 10 mm, and two in the midclavicular line bilaterally.) left lateral hepatectomy was conducted with the use of a linear stapler. the postoperative period was uncomplicated and the patient remains in good condition three months after surgery. conclusion: laparoscopic approach seems to be safe for treatment of liver metastasis, offering better surgical field view and less postoperative complications. 5 year survival rate after laparoscopic hepatectomy is compared to the open approach. general surgery, chang gung memorial hospital kaohsiung division, kaohsiung, taiwan purpose: laparoscopic hepatectomy is a quickly growing method for liver tumor because of modern technology. but for the ihd thrombosis, it is still technique dependent. the video was tried to share our experience for special case. material and method: one 68 y/o female patient suffered from fever episode and image show s56 3 cm hcc with right anterior ihd obstruction r/o tumor thrombosis, hilum ln enlargement, double right portal vein, hilum adhesion with duodenum, no ascites . lab data : no-b, no-c child a, afp 1199, icg clearance rate 4.5%, plt 174000 . heart, lung function exam normal. the laparoscopic right total hepatectomy and hilum ln dissection was conducted. results: laparoscopic approached was performed. the hilum ln dissection was done with vessel and bile duct isolation. hilum ln frozen show negative malignancy. hemi-vessel control was done with resecting the vessel. right hepatectomy was done with preserving middle hepatic vein. the right anterior and posterior ihd was opened and tumor thrombosis was removed from right anterior ihd carefully. the stump of ihd was closed by suture separately. the total op time was 630 min with 345 cc blood loss. post op minimsl bile leakage was found in the drain at day 6. the patient discharged at day 14 with drain. conclusions: laparoscopic hepatectomy may be a feasible method for hcc even with ihd tumor thrombosis. surg endosc (2019) introduction: the progressive laparoscopic learning in gastric surgery and the great development of instruments and laparoscopic material that facilitates the realization of advanced procedures, has led to an increase in the use of laparoscopy in the treatment of gastric cancer. material and methods: we present the case of a 75-year-old man without amc with a history of ischemic heart disease who enters our surgery department for cholangitis secondary to choledocholithiasis. ercp is requested during his admission that describes a gastric lesion from which a biopsy is taken, making it impossible to access vater papilla to perform sphincterotomy and lithiasis extraction due to the existence of duodenal diverticula. the result of pathological anatomy of the gastric lesion was compatible with adenocarcinoma. negative extension study. the clinical case is presented in a committee of multidisciplinary tumors and it is decided to perform surgical intervention of both pathologies. a subtotal gastrectomy was performed with a roux-en-y reconstruction. surgical time of 300 min. choledochotomy was performed with lithiasis extraction, as well as intraoperative exploration of the bile duct and main conduits by means of a choledochoscope. results: income of 9 days, with a clavien ii. the definitive pathological anatomy was an ai stage with a total of 22 isolated nodes without evidence of neoplasia in any of them, therefore it does not require adjuvant treatment. the patient is asymptomatic, with nutritional supplementation with follow-up in ccee of surgery. conclusions: in our case, there were no serious postoperative complications when performing gastric resection and bile duct exploration with drainage of the same. from the oncological point of view, the number of lymph nodes extracted and the surgical margins are similar to those obtained in patients in whom we perform open surgery; therefore, although it is a single clinical case, laparoscopy in expert surgeons is a safe and effective technique. the puestow procedure was initially proposed to alleviate the pain in patients with chronic pancreatitis and dilated wirsung duct. its objective is to provide an efficient drainage of the pancreatic fluids and, in the meantime, to preserve the pancreatic tissue and minimize the risk of endocrine and exocrine pancreatic insufficiency. aims: to describe the particular technical aspects and the efficacy of totally laparoscopic puestow procedure in patients with cystic duodenal dystrophy. methods: a 37 years old patient presenting diffuse epigastric pain, vomiting and weight loss was diagnosed at endoscopic ultrasound and biopsy with cystic duodenal dystrophy. a conservative treatment was decided with octreotide and opioids. however, due to the persistence of symptoms surgery was performed. results: due to the association of a dilated wirsung duct, the patient was submitted to a puestow procedure. the surgical procedure was completed in a minimally invasive manner; after dissecting the anterior surface of the pancreas an intraoperative ultrasound was performed in order to identify the wirsung duct. therefore, the pancreatic parenchyma was transected along the wirsung duct, a totally laparoscopic pancreato-jejunostomy on roux en y limb being performed. the early postoperative outcome was uneventful, the patient being discharged in the sixth postoperative day. at one month and six months follow up the need for opioid treatment significantly diminished. a kinking of the enteral anastomosis required a laparoscopic intervention one year after with a very good evolution after. conclusions: totally laparoscopic puestow procedure seems to be a safe and efficient method in order to treat symptomatic patients with cystic duodenal dystrophy in whom a dilated wirsung duct is present. aims: the approach to the intraductal papillary mucinous neoplasm (ipmn) is various, from a radiological follow-up with magnetic resonance (rm) to the surgical treatment with a pancreatic resection [1] . the surgical approach is various and depends on the localization of the lesion and on the surgical skills [2] . methods: a 67 years old patient was admitted at the chi possy-saint germain-en-laye with an acute pancreatitis. at the ecoendoscopy was found a pancreatic cystic at the junction of the pancreatic body and tail with a wirusng diameter of 5 mm. a second episode of acute pancreatitis occurred a few months later. after that episode the patient was submitted to a computer tomography (ct) that found a cystic lesion of 2 cm with an increasing dilatation of the wirsung duct. the serum ca19-9 was 452 ui/ml. a laparoscopic sils distal pancreatectomy with spleen conservation was performed. results: a trans-umbilical incision was performed with the positioning of the gelpoint sils platform with the placement of 3 trocars. a distal pancreatectomy with a spleen preservation and without a standard linfadenectomy was performed. the pancreatic stump was closed with an endo-gia 60 mm with seamguard device. any drain was placed. the post-operative course was uneventfull. a ct scan was performed in …. post-operative day which didn't show collections. the patient was discharged in -…… post'operative day. the histological examination shows an ipmn with low grade dysplasia. no invasive carcinomatoses cells were found. the distal pancreatic sils resection with spleen conservation is a feasible and safe technique that combine all the advantages of the minimally invasive laparoscopic approach with the esthetic advantages of the sils approach. pancreato-duodenectomy is a complex surgery, requiring several anastomoses to reconstruct the digestive tract. due to its technical complexity, the laparoscopic approach is not yet the goldstandard and there remains some controversy about its oncological safety. worldwide experience is limited, and its safety and effectiveness are yet under evaluation.we present the clinical case of a 70 years-old woman with a prior history of epilepsy. she was studied due to painless obstructive jaundice and a 2 cm pancreatic head tumour was diagnosed on imaging, causing cbd and wirsung channels' dilatation. the tumour was considered locally resectable and she was proposed for a radical pancreato-duodenectomy.we present the main steps of the surgery including the oncological resection with lymphatic basin clearance and totally laparoscopic reconstruction.the post-operative was uneventful, and the histologic sample revealed a ductal adenocarcinoma (t2) with an r0 resection and 0/30 lymph nodes invaded. although technically demanding, laparoscopic pancreato-duodenectomy is safe and effective requiring teams with experience both in pancreato-biliary and laparoscopic surgery. chronic pancreatitis is characterized by a progressive pancreatic fibrosis with loss of endocrine and exocrine function. one of its main symptoms is debilitating pain. surgical drainage of a dilated pancreatic duct is an option to consider in cases of refractory pain. longitudinal pancreato-jejunostomy allows an effective decompression of the pancreatic channel and a significant improvement in the quality of life. we present the clinical case of a 56 years-old lady with a prior history of gallstones. she was treated for an acute pancreatitis in may 2018, followed by recurrent relapses of pain and enzymatic elevation. she required opioid use for partial pain control and a significant 20 kg decrease on body weight due to 'fear of eating'. the endo-ultrasonography and the mri revealed a chronic pancreatitis with an 8 mm wirsung duct with ductal stones and an atrophic body and tail. we proposed a laparoscopic longitudinal pancreato-jejunostomy. the surgery was performed with 4 trocars, with the surgeon on the right side of the patient. we performed a trans-mesocolic 6 cm pancreato-jejunostomy. the post-operative was uneventful, and the patient was discharged on the 8th post-operative day, asymptomatic. laparoscopic longitudinal pancreato-jejunostomy, although effective is a technically demanding surgery but brings the benefits of a minimally invasive approach. background: preservation of spleen in distal pancreatectomy is also useful from the maintenance of platelets and the prevention of overwhelming post splenectomy infection. we have performed laparoscopic spleen preservation distal pancreatectomy: lspdp to benign and low-grade tumors of the pancreatic body tail. the aim of this study was to report our surgical experience with the method of svp: splenic vessel preservation and wt: warshaw technique of lspdp, describe our techniques with videos. method: there are three points of our surgical technique. 1, precede pancreatic dissection, improve the mobility of the pancreas. 2, confirming the courses of splenic artery and classified them into two major types. 3, preserving the left gastro-epiploic vessels and short gastric vessels.the postoperative cases of lspdp which performed from april 2012 to september 2018 was retrospectively studied. result: of 19 consecutive patients were performed lspdp at our institute, 12 were svp and 7 were wt. ages, gender and bmi were similar for two groups. there were no significant differences in operative time, blood loss and length of stay after surgery. comparing pathological finings, wt was associated with a slightly large tumor lesion (median 31 mm vs. 12.5, p = 0.08). among the median observation period of 27 months, splenic infarction was observed in 1 case in svp and 2 cases in wt. however, they were focal splenic infarctions, they did not need surgery or drainage. there were no cases in which late onset of splenic artery occlusion or esophageal / gastric varices. conculusion: after performing lspd, the function of the spleen was good in all cases. both svp and wt were safe and feasible procedures. this is the case of a 61-years-old lady presenting with recurrent abdominal intractable pain she has been suffering from for the last 7 years. msct revealed pancreatic calcifications from 1 mm to 5-8 mm and dilatation of the main pancreatic duct in the body of the pancreas up to 4 mm. the patient underwent laparoscopic local resection of the head of the pancreas combined with longitudinal roux-en-y pancreaticojejunostomy-a technique known as frey's procedure. it is recognized as an effective therapeutic option for the surgical treatment of patients with persistent pain caused by chronic pancreatitis.after performing the posterior wall of the pancreaticojejunal anastomosis we've faced an intraoperative complication such as volvulus of the roux limb causing serious ischemia of the limb. we were forced to remove all previous sutures in order to untwist the roux limb, thereafter the pancreaticojejunostomy was started anew.the purpose of this video is to demonstrate that frey's procedure can be performed in a minimally invasive fashion, which provides all the well-known advantages of this approach. we demonstrate that even such serious intraoperative complication as volvulus of the roux limb can be managed without conversion. our center has an experience of over 30 laparoscopic frey's procedures, however this is the first case where we encountered with such complication and we believe this is an experience worth sharing.yet we would like to underline that this approach should be used by highly skilled minimally invasive surgeons experienced in intracorporeal suturing which is the most challenging stage in frey's procedure. v. tomulescu, i. hutopila, c. copaescu spleen preserving distal pancreatectomy (spdp) is commonly applied in patients with benign or low-grade malignant tumors in the body and tail of the pancreas. two surgical techniques for spdp have been described. the first technique was described by kimura (spleen preserving distal pancreatectomy with splenic vessel preservation-spdp-svp) and preserves the main splenic artery and vein and excises the tail of the pancreas and those small, short vascular connections to the body;the second technique was described by warshaw and involves resection of the splenic vein and artery before distal pancreatectomy, and conservation of theshort spleno-colic and gastric vessels to keep normal blood flow for the spleen (spleen-preserving distal pancreatectomy with splenic vessel resection-spdp-svr). we present the case of a 50 years old female with 40/50 mm tumor of the pancreatic tail on ultrasonography. ct scan confirmed the tumor and endoscopic ultrasonography with fna have shown a solid pseudopapillary tumor. due to the low grade malignancy we have decided to perform a laparoscopic spleen preserving distal pancreatectomy with splenic vessels preservation (lspdp-svp). for lspdp-svp the difficulty is related with the splenic vessels dissection and manipulation. primary dissection and control of main trunk of splenic artery and vein will help to quickly control bleeding during vascular rupture in small vessels dissection. optimal stapling of any tissue requires an adequate tissue compression time to allow elongation of the tissue being compressed, smooth firing of the instrument, consistent staple line formation balanced against the risk of increased tissue tearing and excessive tensile strength. this is why, for pancreatic division, we prefer choosing a cartridge loaded with higher staplers. the pancreatic stump transection line is evaluated for bleeding and when it is needed, hemostatic clips are applied. histology report confirmed a solid pseudopapillary tumor t3nomxl0v0r0 at this moment with 12 month good follow up. in conclusion lspdp-svp is safe, reproductible and demonstrated very good outcomes when certain indications are respected. surg endosc (2019) aim: advances in minimally invasive surgery has permitted to perform complex techniques by this approach, being the laparoscopic duodenopancreatectomy (lpd) one of these. the aim of this communication is to present a surgical technique video for a complete laparoscopic pd, showing the most important steps of the resective and reconstructive phase, with the anastomosis realized completely by laparoscopy. methods: a surgical technique video is presented showing the main steps for the lpd and a complete laparoscopic reconstruction with an hepaticojejunostomy, duct-to-mucosa pancreatic-jejunostomy and a gastrojejunostomy. results: an 82 years old woman with past medial history of arteria hypertension, dyslipidemia, type ii diabetes mellitus and a breast cancer treated in 2009 with lumpectomy and axillary lymphadenectomy plus radiotherapy, recently diagnosed of and adenocarcinoma of the head of the pancreas. the ct scan showed a neoplasia localized in the head of the pancreas without extension to other organs. a laparoscopic pd was indicated after a multidisciplinary committee evaluation. a supraumibical hasson trocar was used for the pneumoperitoneum, three 12 mm trocars and two 5 mm trocars were used. lpd was performed. the resective phase was done following the conventional steps of the open whipple procedure and for the reconstructive phase, a child limb was used for a termino-lateral hepatico-jejunostomy with an absorbable 4/0 monofilament; a duct-to-mucosa pancreatic-jejunostomy with an absorbable 5/0 monofilament and finally a latero-lateral mechanical gastro-jejunostomy was performed. surgical time was 480 min. postoperative course without complications and the patient was discharged on the 7th postoperative day. definitive anatomopathological exam: intraductal tubulopapilar neoplasia, 16x16x13 mm, with wide high grade epithelial dysplasia. free margins. ptisn0 (0/12). conclusion: laparoscopic pd is a feasible procedure with a high technical requirement which should be performed in specialized centres with high experience in hepatobiliary surgery and in advanced laparoscopic procedures, because of its high morbidity and mortality. conclusions: robotic assistance in whipple may overcome limitations of laparoscopy and offer a minimaly invasive approach to this procedure potentially resulting in lower blood loss and less morbidity. we need further prospective randomized trials in order to determine the exact role of robotics in pancreatic surgery. aims: distal pancreatectomy is the standard curative treatment for symptomatic benign, premalignant, and malignant disease of the pancreatic body and tail. the most obvious benefits of a laparoscopic approach to distal pancreatectomy include earlier recovery and shorter hospital stay. spleen-preserving distal pancreatectomy should be attempted in case of benign disease. laparoscopic spleen-preserving distal pancreatectomy (lspdp) is expected to be less invasive than laparoscopic distal pancreatectomy with splenectomy. however, there are few reports regarding the details of the procedure for lspdp, and its safety remains unclear. this study aimed to evaluate the feasibility and safety of lspdp. methods: retrospective analysis of surgery treatment of 48 patients was made. lspdp was conducted in the period from 2014 to 2017 in the department of laparoscopy surgery of state institution o.shalimov national institute of surgery and transplantology. the average age was 45 :1 3.4 years, the body mass index (bmi) was 28.7 ± 1. results: laparoscopic distal pancreatectomys was performed in 100% of cases, were attempted in 36 female and 12 male patients. postoperative pathological examinations revealed 17 cases of serous cystadenoma in the body and tail of the pancreas, 2 case of serous oligocystic adenoma, 20 case of mucinous cystadenoma, 3 case of neuroendocrine tumor (insulinoma), and 6 case of solidpseudopapillary neoplasm. complications related to the surgery were like acute pancreatitis with 3-fold increase normal plasma amylase confirmed by ct-7 cases, fluid collection-4 cases, pancreatic fistula (grade a)-3 cases. the operation time was 195.6 min, (range 157-250 min) blood loss of 50.1 g (range 0-110 g), mean hospital stay was 6.8 days (range 5-11 days). conversion to laparotomy was in 1 case. mortality was 0. conclusion: laparoscopic spleen-preserving distal pancreatectomy is minimally invasive, safe, and feasible for the management of benign pancreatic tail tumors, with the advantages of earlier recovery and less morbidity from complications. aims: a pancreatic pseudocyst is an encapsulated, mature fluid collection occurring withing the pancreas that have a well-defined wall minimal or no necrosis secondary to pancreatic injury and mediated by the enzimatic and inflammatory disruption of pancreatic tissue. it is a common complication of acute and chronic pancreatitis. we present the case of a pancreatic pseudocyst located within the body of the pancreas due to recurrent necrotic pancreatitis. the objective of this video is to show the minimally invasive surgical approach of this entity. methods: a 47-year-old man without medical history was admitted to hospital in the digestive service on 3 times for acute necrotizing pancreatitis. after study in which is evidenced cholelithiasis and pseudocyst in pancreatic body of 6 cm maximum diameter and formation of two peripancreatic collections without signs of superinfection, cholecystectomy is indicated. magnetic control cholangiography was performed after surgery and it showed an increase in the size of the pancreatic pseudocyst, suspecting wirsung's duct disruption. therefore, endoscopic retrograde cholangiopancreatography (ercp) was performed by placing a plastic pancreatic prosthesis and performing a sphincterotomy. after hospital discharge, the patient is re-admitted due to recurrent abdominal pain without analytical alteration. tc abdominal observed an increase in the pseudocyst from 6 to 8 cm. this case was discussed in a multidisciplinary committee and surgical intervention was decided. results: laparoscopic approach is decided and four trocars were placed. initially, a gastrostomy was performed with liquid outlet. an aspiration of the liquid and quistogastrostomy with 45 mm endogia was made. the patient progresses favorably, being high on the tenth postoperative day, without complications. conclusions: almost every pancreatic pseudocyst improves spontaneously and needs no specific treatment. draining is indicated when secondary symptoms to compression, complications or rapidly enlarging are found. depending on the complexity of the pseudocyst, its communication with wirsung's duct and the existence of ductal injury, it may perform a percutaneous, endoscopic or surgical drainage. the goal of pancreatic debridement is to excise all dead and devitalized pancreatic and peripancreatic tissue while preserving viable functioning pancreas, controlling resultant pancreatic fistulas, and limiting extraneous organ damage. only the surgical procedure is definitive. case: a 29y old male presents with intermittent low retrosternal pain and progressive dyspnea with exercise since a couple of months. cardiac investigation was negative and gastroscopy showed a grade b esophagitis. he was treated medically but with only partial response. on a thoraco-abdominal cat-scan the diagnosis of a left sided bochdaleks' hernia was made. the hernia includes the left kidney (with blood vessels and ureter), transverse colon and small intestine which are positioned in the left lower thoracic cavity with the left lung considerably compressed. method: given the clear correlation between the patients' complaints and these anatomical findings, he was referred to our service of abdominal surgery. we performed a laparoscopy with the patient in lithotomy position and the surgeon between the legs. the patient was tilted to his right side. mobilization of the spleen was necessary to gain maximal access to the hernia. we were able to reduce all the herniated content, freed the margins of the defect, reduced the hernia sac and repositioned the kidney intra-abdominally. the defect was manually closed with non-resolvable stitches and covered with a mesh which was secured with tackers. result: postoperatively the patient recovered well with adequate pain relief and pulmonary support. he could leave the hospital after 6 days. control cat-scan on day 5 postoperatively shows an intact lining of the diaphragm with normal positioning of the intra-abdominal organs. on follow-up 6 weeks after surgery the patient had regained normal activities and was symptom free. conclusion: a symptomatic left sided bochdaleks' hernia in adults with an ectopic intrathoracic kidney is extremely rare. we hereby state that, during a laparoscopic repair, the kidney can also be safely reduced, which has almost never been described in literature yet, enhancing pulmonary recovery, improving access for mesh placement and thus diminishing recurrence rate. aims: large incisional hernias repair involves an actual problem for surgeons to face. anterior component separation has been an important method allowing to close the fascia defects without tension while also having underlay mesh reinforcement.therefore, we present a case of incisional hernia reparation performing endoscopic anterior component separation with advantages compared with open approach. method: we present the case of a 31-year-old woman, bmi 40 kg/m 2 , with previous laparoscopic gastric sleeve and posterior reintervention using open approach. the patient presented a 10 cm size incisional hernia m3w3. a ct scan was performed, confirming a midline incisional hernia containing colon, with an herniary defect of 11 cm. full minimal invasive abdominal wall repair was proposed. a 2 cm size incision was made in left iliac region to reach the aponeurosis of external oblique muscle. we placed a balloon trocar and subcutaneous pneumo-dissection with 8 mmhg pressure was performed; then, we placed a 5 mm trocar in left lumbar space. the aponeurosis of external oblique muscle was incised and anterior component separation from inguinal to subcostal area was achieved. an extensive intermuscular dissection was performed to achieve complete midline closure. we performed the same procedure on the right side. then, with laparoscopic approach using v-loc n°0 suture, we completely closed the midline. eventually, we placed a 30x15 cm ptfe-c mesh fixed with a double crown of tackers and fibrin glue. results: postoperatory course was uneventful and the patient was discharged 24 h after surgery without any remarkable event during his postoperative stay. the patient has been followed up for 12 months without any complication or recurrence in ct scan, confirming the correct minimally invasive reconstruction of the abdominal wall. conclusions: trends in abdominal wall reconstruction and complex-hernia repairs have advanced rapidly in recent years. the goal is to perform a complete abdominal wall repair with no tension in midline incisional hernias. endoscopic anterior component separation and laparoscopic eventroplasty with closure of the defect, leads to a complete wall reconstruction without tension and avoids drawbacks due to primary close defect in those patients with herniary defects wider than 10 cm. aims: endoscopic technique is a valid and safe approach for the treatment of abdominal wall defects. to combine the advantages of complete endoscopic extraperitoneal surgery with those of sublay mesh repair we propose totally endoscopic sublay anterior repair (tesar), a safe and feasible approach for the treatment of ventral and incisional midline hernias. methods: from may to september 2018 12 patients were referred to our unit for clinical and radiological diagnosis of midline ventral or incisional hernia and selected for tesar. exclusion criteria were: complicated ventral or incisional hernia (i.e. incarcerated hernia), maximum defect width [ 5 cm, contraindications to general anesthesia. the procedure consisted of suprapubic access with 3 trocars, complete endoscopic pre-aponeurotic dissection, isolation and reduction of the hernial sac, bilateral incision of the medial rims of recti aponeurosis and dissection of retromuscular plane to create the retromuscular space, sublay non-absorbable mesh positioning and anterior aponeurosis reconstruction. one drain was always placed in the retromuscular space and one drain in the subcutaneous space. results: all procedures were completed with endoscopic approach, with no conversion to laparoscopy or open surgery. no intraoperative complications were registered. total mean operative time was 148 ± 18.5 min. no post-operative major complications were registered. only one subcutaneous seroma was registered (8.3%), and treated conservatively. the mean postoperative stay was 3.6 ± 0.6 days. at post-discharge clinical checkups drains were checked and removed when indicated. no wound complications nor recurrence were registered to date. cosmetic and functional results were successful in all patients. conclusions: tesar is a safe and feasible technique for the extra-peritoneal sublay repair of ventral hernias with totally endoscopic approach. it provides accurate hernia repair with good outcomes in terms of resolution of symptoms and post-operative complications. r. mizuno, m. kondo backgrounds: abdominal incisional hernia is found in more than 10% after abdominal surgery, and risk factors such as wound infection, obesity, elderly, high abdominal pressure are pointed out. laparoscopic hernia repair using intraperitoneal onlay mesh (standard ipom) is becoming widespread in japan since the insurance release in 2012, and our hospital is actively working on it. recently, ipom plus procedure which also carries out fascia suture in addition to laparoscopic mesh placement has been introduced. aims: we report the clinical results of laparoscopic abdominal incisional hernia repair in our hospital. methods: we performed hernia repairs using a mesh for 36 cases from january 2014 to september 2018. of these, 21 cases were standard ipom and 15 cases were ipom plus. there was no significant difference in the patient background such as gender, age, bmi, etc, and in the intraoperative findings such as hernia orifice diameters and adhesions. surgical time, postoperative hospital stay, and the rate of complications such as seroma, mesh bulging, postoperative pain, hernia recurrence were compared and examined between the two groups. results: as a result, in ipom plus group, the operation time was longer and the incidence rate of postoperative pain was higher, but the incidence of mesh bulging was significantly lower. also, in some cases since 2018, the ' u reverse stitch method ' is used as an ingenuity of fascia suture in ipom plus. conclusions: laparoscopic abdominal incisional hernia repair has the advantage of being able to reliably confirm the hernia orifice from the intraperitoneal side?it is excellent in the identification of the fragile part of the abdominal wall and in the visibility of the restoration range. with regard to the ipom plus procedure which has been introduced in the last few years, although the operation time is extended, it has usefulness such as reduction of mesh bulging. from the viewpoint of cosmetic surgery, usage of ipom plus will increase in the future. introduction: incisional hernia is one of the most common complications after abdominal surgery. several methods have been introduced, and yet, there is no consensus on the best method of repair. we present a novel method for hernia repair which uses the retromuscular sublay mesh repair through a single incision at the pubic area to improve cosmesis. methods: medical records of patients who underwent single-port retrorectal incisional hernia repair from may 2018 to december 2018 were reviewed. patients were placed in supine position and a 3 cm incision was made in the pubic area below the panty line. a flap is made upwards until the defect is found and bilateral rectus sheathes are dissected. a mesh is then placed between the posterior rectus sheath and the muscle. results: a total of 30 patients with midline incisional hernia underwent single-port retro-rectal incisional hernia repair. mean age was 59.0 ± 12.5 years with an average bmi of 23.4 ± 2.7. all the patients had midline hernia defect with an average of 3.4 ± 2.2 cm. mean operation time was 59.6 ± 30.1 min and estimate blood loss was 32.6 ± 36.5 ml. there was no postoperative complication, and 27 (90%) patients were discharged on the day of surgery. conclusion: the single-port retrorectal incisional hernia repair is safe and effective while providing good cosmesis to selected patients with incisional hernia. aims: closing hernia defect during laparoscopic hernia repair is a vast extended technique nowadays. however, this technique is associated with mesh placemnt intraabdominally in contact by the abdominal content. nowadays there is a trend to recontruct the midline and to avoid a mesh intraabdominally in those cases suitable for it, as a new step forward of minimally invasive abdominal wall reconstruction. laparoscopic sublay approach with retromuscular placement of a mesh without mechanical fixation after reconstruction the linea alba migth be considered an option in primary hernias of the midline. methods: we present a case of a 47 year old male with an umbilcal hernia of 4 centimeter in diameter associated with rectus diastasis. a laparoscopic approach was performed, using one 12 and two 5 millimeter trocars placed on the left flank. the first step was to open the lateral side of the posterior fascia of the left rectus muscles, dissecting the retromuscular plane until we reach the linea alba getting into the preperitoneal space where the sac was diseected preserving the integrity of the peritoneum. the contralateral posterior fascia was also dissected all the way to the semilunaris line. the midline was closed, including th hernia defect, using a running double loop suture (maxon-loopò). a self gripping mesh (progripò) is placed in the retromuscular space in a sublay position (21 cm long, 9 cm wide). last, we close the fascia of the left rectus muscle using a barbed suture (v-locò). results: surgical time was 80 min, being discharged of the hospital on postoperative day 1. pain was controlled with conventional analgesia and no postoperative complications, nor seroma was detected. conclusions: sublay approach for ventral hernia can provide a midline reconstruction, reestablishing abdominal function and avoiding the use of intraabdominal meshes and traumatic fixation, decreasing postoperative complications and pain. aims: lumbar hernia is one of the rare cases that most surgeons are not exposed to. hence the diagnosis can be easily missed. this is often related to previous surgery as lumbotomies or primary in the superior lumbar triangle. this leads to delay in the treatment causing increased morbidity. we report a case of adquired lumbar hernia in a middle-aged woman repaired by laparoscopic approach. methods: a 60 years old woman with surgical history of a myelomeningocele surgery by posterior approach over 40 years ago, a laparoscopic left nephrectomy 2 years ago with a left colostomy due to a left colon injury during this procedure. a hartmann reversal by laparoscopic approach 6 months later. patient showed a large lumbar mass over 6 cms in the left lumbar region and a large scar near to spinal cord. it was soft in consistency, reducible and expansible on coughing and straining with defined borders. computerized tomography showed a large defect in the superior lumbar fascia over 6 cms in the grynfeltt-lesshaft triangle with the left colon inside. results: patient was placed in a full lateral decubitus position. in order to optimize exposure, a lumbar roll was placed under the lumbar region. a capnoperitoneum (12-15 mmhg) was built up. one 11 mm and two 5 mm trocars were used and positioned in the left mid axillary line. a 30 optic was used. adhesions were removed and toldt fascia was opened in order to expose the hernia defect bounded by quadrates lumborum, erector spinae muscles, 12 rib and serratus. hernia content was carefully extracted from the sac using a ligasure maryland (covidien medtronic-usa). hernia defect was measured and an intraperitoneal mesh (dinamesh-ipom feg textiltechnik mbh, aachen, germany) was positioned and sutured by tackers to the margins included the bone. patient was discharged in 48 h with a low pain rate and without complications. there is not recurrence in 10 months follow-up. conclusion: laparoscopy might be a safe and feasible approach for repairing lumbar hernias, either primary or adquired, with a low rate of pain and complications s582 surg endosc (2019) after pneumoperitoneum is done, three 5 mm trocars are placed on the left flank. the defect is delimited by drawing it over the skin of the patient with aid of an intramuscular needle and intraabdominal vision. posterior fascia is opened longitudinally at its medial edge and the retromuscular space is dissected. the arcuate line of douglas and the epigastric vessels are identified. from this point, transversus abdominis fascia is sectioned cranially 1 cm medial to the semilunar line, preserving the neuro-vascular pedicles that reach the rectus abdominis laterally. at supraumbilical level, transversus abdominis fibers advance behind rectus abdominis, so they need to be sectioned to access to the space below the ribs. lateral dissection of this space enables a tensionfree closure at midline. once the procedure is repeated on the contralateral side using two 5 mm and one 12 mm trocars on the right flank, a continuous suture of the posterior fascia is performed with a barbed suture. the anterior fascia is closed with a slowly-absorbable monofilament loop-type suture. finally, a double-layer polypropylene mesh is placed at retromuscular level without any suture and fibrin glue is applied. results: the patient was discharged 24 hous after surgery. no recurrence has been presented to the moment. conclusions: the section of the aponeurotic plane from the arcuate line of douglas enables a more accurate dissection of the retrotransversus plane without sectioning its fibers except for its cranial end, preserving the innervation and vascularization of the abdominal wall. this technical modification aims to simplify a complex laparoscopic procedure allowing its estandarization. aims: the authors present a video with their standardized laparoscopic ventral hernia intraperitoneal mesh (ipom) hernioplasty procedure but introducing a novel laparoscopic technique for tension releasing while hernia gap closure and midline anatomical restoration. methods: a 64 years old male patient with a bmi 31 presents a symptomatic ventral hernia recurrence after a sigma colic cancer open surgery. a ct scan study showed a 5 cm transverse diameter midline ventral hernia. a laparoscopic ipom hernia repair procedure is performed using 5 mm instruments and a 10 mm camera. when checking tension while midline restoration suturing, we decide to add a tension-releasing maneuver: a totally laparoscopic transverse abdomini muscle release (taltar). this maneuver allow right rectus posterior sheath to advance some distance to the midline, in order to provide a tension-free midline closure. a double-faced ready-to visceral contact mesh is now placed and fixed. case and technical details are shown in the video. results: the patient was discharged from hospital within a period of 5 h with a 4 rate in a eva acute pain visual scale. in a 2 year follow-up, there has no been an anatomical or clinical recurrence. no chronic pain, anatomical recurrence, lateral asymmetry, umbilical or abdominal wall complications have been reported with this technique. conclusions: depending on the patient characteristics, anatomical hernia factors and surgeon mini invasive experience, a taltar maneuver could be a safe and feasible option for releasing tension when midline anatomical laparoscopic closure. more studies are needed in order to standardized this approach. aims: when primary ventral hernia and simultaneous diastasis recti are diagnosed, there is no consensus among the international surgical community on the surgical treatment regarding indications or surgical technique. however, if diastasis recti is symptomatic of or is associated with midline hernias, the corrective surgery of both pathologies at the same time could be the most recommended option. when we only correct the herniary defect, we risk performing a reparation on an anatomically weak tissue, so the rate of hernia recurrence may increase. we propose a minimally invasive access using totally endoscopic retromuscular hernioplasty. by developing this technique, several advantages are provided, such as no peritoneal opening without intraabdominal access, no mesh fixation needed and simultaneous solving of both pathologies. method: we present the case of a 50-year-old man, with bmi 35 kg/m 2 and no previous medical history complaining of ventral hernia with associated recti diastasis. a 4 cm size umbilical hernia was diagnosed with a 5 cm size supraumbilical diastasis recti associated. full endoscopy retromuscular hernioplasty was proposed. a 2 cm size incision was made in left hypocondrium, openned the anterior rectus sheath and retracted the rectus muscle. we placed a balloon trocar and open the homolateral retromuscular space after placing two 5 mm trocars in left lumbar space and epigastric position. we crossed-over the linea alba and achieve contralateral retromuscular space. after this step, the hernia sac was reduced and we extended the dissection 5 cm caudal to the hernia ring. both medial posterior rectus sheaths were sutured with running barbed suture n°0 and a 20x20 cm size light-weight, big pore, polipropilene mesh was placed in retromuscular space and unrolled properly with enough overlap. a drain was placed and the anterior rectus sheath incision was closed. results: the patient was discharged 24 h after surgery without remarkable events during his postoperative stay. he has been followed up for 8 months remaining asymptomatic. conclusions: totally endoscopic retromuscular ventral hernia repair in men with umbilical hernia and diastasis recti associated, is feasible and reproducible procedure with several advantages compared to traditional laparoscopic ipom in terms of pain and mesh position. aims: parastomal hernia (ph) is one of the most frequent long-term complications of stoma formation, occurring in 35%-50% of patients. surgical treatment for parastomal hernia is the only cure but a fairly difficult field with a recurrence rate ranging from 24% to 54% of cases. due to its advantages, the number of laparoscopic mesh repairs for parastomal hernia has gradually increased over the past decade. according to this common complication, we report a case of laparoscopic reparation of ph using the sugarbaker technique. method: we present the case of a 65-year-old patient with surgical antecedent of laparoscopic low anterior resection due to rectal cancer, presenting in postoperative period an anastomosis leakage with severe peritonitis was identified and a laparotomy with end colostomy was performed. the postoperative course was uneventful. during the follow-up the patient showed a 6 centimetres size paraestomal hernia, being a m3w2 incisional hernia confirmed with ct scan.the patient underwent full laparoscopic hernia repair, performing a sugarbaker technique, exposing parastomal hernia completely to measure the hernia ring size (6 centimetres) and the midline associated defect (5 centimetres). a 26x36 cm size ptfe-c was selected to allow a 5-cm overlap over two defects. results: using this approach, the bowel loop was pushed into the abdominal wall and appropriate place between the mesh edge and the abdominal wall is left to allow the bowel loop to pass through. postoperatory course was uneventful and the patient was discharged 48 h after surgery without any remarkable event during his postoperative stay. he has been followed up for 18 months without realizing any clinical signs or alterations in ct scan. compared with traditional open surgical repairs, laparoscopic repair has certain advantages including its safe operation, postoperative rapid recovery, fewer complications, and lower recurrence rate. however, it still faces challenges regarding parastomal hernia treatment, and there is a need to improve existing surgical techniques. aims: nowadays, the principal disadvantages of laparoscopic approach in hernia repair are the use of intraabdominal meshes and traumatic fixation. first, intraabdominal meshes involve the contact of the prosthesis with the intestinal loops with the consequent risk of adhesion and fistula. also, using helicoidal sutures in prosthetic fixation produces adhesions to the tackers and a non-negligible incidence of chronic pain. when it comes to lead to better results, placing the mesh in retromuscular space avoids the drawback of contact with the loops, and using self-fixation meshes may decrease the rate of acute and chronic pain. accordind to this facts, we present a case of laparoscopic ventral hernia repair with transabdominal retromuscular mesh placement without traumatic fixation. methods: we present a 50-year-old patient with a 7 cm diameter hernia showed in preoperative ct scan, m3w2, with diastasis recti associated. the patient underwent laparoscopic surgery using transabdominal retromuscular route. one 11 mm and two 5 mm trocar were placed in left flank. the posterior rectus sheath on the left side is opened starting 5 cms far from the left egde of the defect. once the retromuscular space is dissected, the hernia ring is dissected and the hernia sac reduced, we continue with the dissection in retromuscular space on the side. craniocaudal dissection is achieved 5 cm distal to the defect margins. the hernia defect with the anterior rectus sheath and the diastasis recti were closed using v-loc running suture. self-adhesive mesh was subsequently placed. the mesh should be overlap 5 cm from the margins of the defect, covering the defect widely, with grips facing upwards. finally, we closed the posterior rectus sheath with peritoneum on the left side with v-loc running suture. results: the postoperative course was uneventful and the patient was discharged 24 h after the surgery. after 18 months of follow-up no clinical or radiological recurrence was showed. conclusions: the combination of laparoscopic approach, retromuscular mesh placement and the use of self-fixation meshes, seems to be an actual useful solution, combining the advantages of each item and avoiding the use of intraabdominal meshes and helicoidal sutures. aims: laparoscopic ventral hernia repair has clear advantages over open repair, including less post-operative pain and earlier return to normal activity. however, a prolonged surgeon learning curve is necessary to perform this technique effectively. robot assistance may improve outcomes of minimally invasive ventral hernia repair with improved three-dimensional visualization and enhanced dexterity with articulating instrumentation. we report a case of robotic rives-stoppa epigastric hernia repair in order to demonstrate the feasibility of the robotic approach. methods & results: a 58-year-old man came to our attention for the presence of a palpable mass in the epigastric region. the abdominal ct scan showed the presence of an epigastric hernia with herniation of omental content, and the presence of diastasis recti. the patient was then submitted to a rives-stoppa robotic hernia repair under general anesthesia. the da vinci-si surgical system (intuitive surgical inc., sunnyvale, ca, usa) was brought into position over the head of the patient and docked after placement of the ports. three trocars were placed in the hypogastric region along the transtubercular line. a fourth trocar was placed in the left iliac fossa and used by the assistant. the operation started with an extended adhesiolysis and hernia reduction. then, the retromuscolar dissection began by incising the posterior sheath starting from 4 cm above the pubic symphysis. an extended dissection of the rives space was performed to create a correct housing for the mesh. the hernia defect and the diastasis recti were closed using a 1-0 absorbable barbed suture. a phasix st tm mesh (bard inc./davol inc., warwick, ri) was positioned in the retromuscular plane, and was anchored with absorbable sutures and glue. the midline incision was closed using a 2-0 absorbable barbed suture. the operative time was 250 minute. the postoperative period was uneventful, and the patient was discharged home on the second post-operative day. conclusions: robotic rives-stoppa ventral hernia repair is feasible, safe, and effective when a standardized approach is performed. whether robotics may improve the outcomes of minimally invasive ventral hernia repairs, including lower recurrence rates, decreased post-operative pain, or shorter surgeons' learning curve, will require careful prospective investigation. aims: the authors present a video with a left chronic bochdaleck hernia classical hernioplasty repair but performing a mini invasive thoracoscopic approach and 3 mm instruments. methods: a 73 years old female patient come to hospital due to chronic left dorsolumbar pain. a ct scan study showed a chronic left diaphragmatic bochdaleck hernia. a lateral right decubitus thoracoscopic repair is performed using 3 mm instruments and a 5 mm camera. case and technical details are shown in the video. results: the patient was discharged from hospital within a period of 48 h with no pain and a clean chest x-ray. in a 2 year time follow-up, not an anatomical or clinical recurrence has been reported. neither chronic pain or respiratory complications happened, with in this period of time. conclusions: depending on the patient characteristics, anatomical factors and surgeon mini invasive experience, left bochdaleck hernia mini invasive thoracoscopic hernioplasty repair using 3 mm instruments could be a safe and feasible option. more studies are needed in order to standardized this approach. surg endosc (2019) abdominal wall surgery has expanded exponentially in the last decade. many techniques have been developed, mainly in minimally invasive surgery. laparoscopic ventral and incisional hernia repair (lvihr) has become a common procedure because of its feasibility and safety but unfortunately, it is not free of complications. chronic postoperative pain and bleeding are frequent complications, prolonging hospital stay and altering quality of life of the patients. absorbable or non-absorbable tacks are the usual method of mesh fixation and sometimes combined with transfascial sutures to secure the mesh. these 2 mechanical fixations pierce the abdominal wall causing nerve or vessel injuries. some studies showed no differences between absorbable tacks, non-absorbable tacks or transfascial sutures concerning postoperative remarkably high pain. some authors consider that a non-penetrating fixation of the mesh getting an effective mesh-abdominal wall interface will reduce significantly the postoperative pain after a laparoscopic ventral hernia repair. tissue glues are used in different medical treatments and also have been used successfully for extra peritoneal mesh fixation in laparoscopic inguinal hernia repair, open ventral hernia repair but not so in laparoscopic ventral hernia repair in spite of good results published in the literature. cyanoacrylate and its derivatives are 'synthetic glues' and classified as medical devices with stronger adherent properties than fibrin glues. experimental studies have reported good results compared with suture fixationand also tissue toxicity doesn't lead to an increased foreign body reaction. some authors have studied the use of cyanoacrylate in laparoscopic inguinal hernia repair but unfortunately, clinical trial reports in ventral and incisional hernia repair were not found in the literature because the lacking of experimental studies that guarantee the safety of intra-abdominal mesh fixation and the interaction of the glue with the intra-abdominal tissue. our group developed an experimental study demonstrating the feasibility, safety and effectiveness of the cyanoacrylate using for intraperitoneal mesh fixation and after this conclusion, started a clinical study. this video shows the methodology for laparoscopic mesh fixation with only glue in our first cases. aims: small epigastric hernias, associated or not with the rectus abdominis diastasis, and small umbilical hernias are common in middle-aged women, particularly with past history of pregnancy. the aim of this video is to illustrate a new extraperitoneal approach to these clinical situations. methods: patients between the ages of 40 and 60 years old, with epigastric hernia orifice up to 2 cm, with or without associated umbilical hernia (up to 2 cm), were chosen for this procedure. the surgery begins with a vertical umbilical incision for the umbilical hernia's correction, and dissection of the pre-aponeurotic plane. two 3 mm trocars (mini-laparoscopy instruments) are introduced at both flanks to enlarge the pre-aponeurotic plane towards the xiphoid appendix. in this way epigastric hernial defects are isolated. the surgery proceeds with defect suturing with braded suture, midline invagination and mesh placement if necessary. results: all patients had an eventful post-operative period and were discharged home at postoperative day 1. the aesthetic and functional results are optimal conclusion: for selected cases with high aesthetic motivation this technique seems to be feasible and with optimal cosmetic results. this technique allows the mesh placement both in-lay and onlay, protecting it from surgical site infections often present at the classical approac bochdalek hernia is a rare entity in adults. fewer than 200 have been reported in medical literature, the majority of which were incidentally diagnosed. as such, the optimal repair of a symptomatic hernia is unknown. we present a case of adult bochdalek hernia repair. methods: a 30-year-old obese male patient with a 2 years of chronic dry cough and left lung opacity in chest x-ray. a large posterior and lateral bochdalek hernia with herniation of intestinal loops and fat to the left hemithorax was seen in chest and upper abdominal ct scan. the hernia extended to mid-thorax, caused significant atelectasis of left lung. eighteen months later, due to appearance of chest and abdominal pain following a recent motor vehicle accident, a repeat chest ct was done and a slight enlargement of the hernia was shown. results: the patient was operated laparoscopically, positioned in a semi-right lateral decubitus with double lung intubation. a large left posterior and lateral diaphragmatic hernia which contained transverse and descending colon with omental fat was seen. they were pulled in to the intraperitoneal space carefully. the defect was measured to be 10*8 cm. it was reduced to 7*7 cm by suturing with a non-absorbable 0 v-loc suture . advancing the camera to the thoracic cavity showed the left lung to be severely atelectatic. after selective recruitment lung was well expanded. a symbotex composite 20 9 25 cm mesh was fixed to the defect area by suturs and laparoscopic tacker. the operation and post-operative course were uneventful. chest x-ray demonstrated the bowel below the diaphragm. the patient was discharged on pod 3. at 8-month follow-up, chest x-ray was normal. objective: to demonstrate the safety and efficacy of the standardized laparoscopic approach in the treatment of large parastomal hernia. currently, this approach is recognized as the one of choice in parastomal hernia pathology, being controversial which is the best technique of choice: keyhole vs sugarbaker. material and method: clinical case: a 76-year-old woman with a history of laparoscopic abdominoperineal amputation due to rectal neoplasia (pt2n0), a year ago, with symptomatic parastomal hernia with incarceration episodes and inflamation changes in the stomal orifice.tac: large hernia parastomal with intestinal content inside. surgical treatment is decided. result intervention: complete laparoscopic approach, right lateral partial decubitus, 4 trocars, dissection of the hernia defect and reduction of the content, partial mobilization of the pre-stomal colon, with bleeding at the level of the vascular origin, requiring careful hemostasis to avoid ischemia of the colostomy, herniorrhaphy with stitches with extracorporeal knotting, placement of polypropylene/pvdf mesh,fixed with irreabsorbable tackers with administration of biological glue at the edges of the mesh. correct postoperative, discharge at the 3rd day. asymptomatic and without hernia recurrence at one year of follow-up. conclusions: the technique of sugarbaker using a laparoscopic approach is a safe and effective alternative in the treatment of parstomal hernias. objetives: laparoscopic ventral hernia repair provides advantages in term of low infection rates and postoperatory stay when is compared with open repair. trends in laparoscopic abdominal wall surgery is to complete defect closure without tension in midline. closing the defect in ventral hernias wider than 8-9 cms creates high tension in midline and postoperatory pain. it's proposed different techniques to solve this drawback. laparoscopic posterior component separation makes the defects closure easier with no tension and placing the mesh extraperitoneally. methods: 65 years old woman with previous total hysterectomy, a m3m4w3 midline incisional hernia was clinically diagnosed and confirmed with ct scan. full laparoscopic abdominal wall repair with defect closure was proposed. 3 trocars in left side were placed and posterior rectus sheath right side in the defect margin is freed. once the lateral edge of the rectus sheath is reached, the posterior rectus sheath is incised, dividing the posterior aponeurotic sheath of the internal oblique muscle. this allows access to the plane between the internal oblique and the transversus abdominis muscles. it's is made the same steps in the left side with 3 trocar on the right flank. the posterior rectus sheath both side is reapproximated in the midline and 20 9 20 cms polipropilene mesh is placed and unfolded properly. it's fixed using cyanocrilate glue. one drain is left in retromuscular position and 10 mm trocar wounds are sutured. results: postoperatory course was uneventful. hospital stay 24 h. the drain was removed in day 3 after surgery. after 9 months follow-up no complication or recurrence were identified. methods: this video will show the evidence of gangrenous jejunal segment due to superior mesenteric vein thrombosis in a patient with history of breast ca on hormonal treatment.in this video, the gangrenous segment was resected and primary anastomosis was done using endogia 60 mm. results: a second look after 48 h revealed to be negative for any further ischemic bowel. conclusion: therefore, laparoscopy in acute abdomen is diagnostic and for treatment. introduction: gastric pseudo-volvulation is a rare entity of paraesophageal hernia that is characterized by migration of the stomach into the posterior mediastinum. this clinical-radiological picture has severe complications so in certain cases should be operated urgently. another small group of patients are asymptomatic, although the current literature recommends their regulated surgical intervention. we present a gastric pseudo-volvulation in the mediastinum, with a laparoscopic approach, showing that by systematizing the surgery, it is possible to perform this type of intervention with relative ease and safety material and methods: we present a video of an urgent laparoscopic approach in a female patient of 80 years with a personal history of hypertension, smoking and dyslipidemia. with a hiatus hernia diagnosed more than ten years ago. he went to the emergency department due to significant symptoms of heartburn and reflux, as well as incoerctable vomiting and difficulty feeding one week of evolution. a simple abdomen and postero-anterior chest radiograph was performed, showing a paraesophageal hiatus hernia with almost the entire stomach included in the mediastinum. a thoraco-abdominal axial tomography corroborated giant hiatus hernia with pseudovolvulation and incarceration data. urgent intervention was decided by laparoscopic approach in which hiatus hernia reduction and esophageal abdominalization were performed. closure of pillars and reinforcement with bioabsorbable mesh. gastric and gastropexy toupet of anterior face to anterior peritoneum of abdominal wall. results: the patient had a post-operative 48 h without incident, discharged with a crushed diet. the follow-up and evolution has been acceptable without notable complications. conclusion: the laparoscopic approach, in extreme cases of paraesophageal hiatus hernia with incarceration of the stomach and pseudovolvulation of it, is a correct, safe and effective alternative in experienced groups. surg endosc (2019) case report of incarcerated hiatal hernia. 30 years old female was admited to the hospital due to severe chest pain and vomiting for about six h. physical examination and lab test showed no abberations. chest xray revaled incarcerated stomach above the diaphragm. she was rushed to the or. laporoscopic approach was used, the stomach was removed from the chest and nissen fundoplication was performed. day after surgery patient was asymptomatic, got full oral diet. she was discharged on postoperative day two, without a need of any analgetics. gastroduodenoscopy was performed 6 weeks after surgery and showed proper image of oesophagus, stomach and duodenum, neither signs of hiatal hernia nor inflamation were present. laparoscopic approach is good way to treat incarcerated hiatal hernias and is related with shorter lenght of stay, lesser postoperative pain and better patient comfort. and it should be procedure of choice in this kind of cases. she was operated open technique using a 2 cm long incision in right iliac fossa and the appendix was phlegmonous. the patient began feeling bad from the second day postoperative having temperature over 38°c, pain and increasing crp. the general condition worsened the next day when the temperature went up till 39.5°c, extreme generalized pain and crp:343. the ct abdomen control indicates signs for generalized peritonitis and rises the suspicion for a forgotten large gauze. the patient is operated using laparoscopy technique: identifying and taking out the foreign body, doing adhesiolises, extensive lavage and in the end inserting one drain in douglas. the video is presenting what king of special graspers can be used but also tips and tricks when speaking about identifying the anatomy but also dissection in acute and inflamed environment. postoperatively the patient began to feel better and in the 5 th day was released home. conclusion: this case illustrates that even after open surgery, laparoscopy is a viable solution with the condition that there is available experience in minimally invasive surgery. introduction: foreign bodies can enter inside the human body by different mechanisms such as ingestion, aspiration, trauma or in some cases due to medical procedures. they are potentially life-threatening events, the diagnosis could be challenging and its management depends on their location. case report: a 64-year-old male was referred to our hospital due to chronic abdominal pain. he had cholelithiasis, medical history of acute pericarditis and past surgical history of left adrenalectomy, left nephrectomy, distal pancreatectomy and colon resection due to an adrenal adenocarcinoma (stage t4n0m0).abdominal radiograph showed a foreign body in the left lower quadrant of the abdomen, as an incidental finding. this was not detected in ct scans during ten years of oncology follow-up. ct scan revealed an extraintestinal metallic curved object in the right lower quadrant. this finding was not related to any surgical intervention or trauma. diagnostic laparoscopy was performed: the foreign body seemed to be a guidewire, it was included into the omentum and almost stuck to the abdominal wall. the guidewire was reached and carefully extracted through a 10 mm trocar without any evidence of intra-abdominal organ injury. then an elective cholecystectomy was also performed due to his medical history of symptomatic cholelithiasis.the procedure lasted 60 min. the hospital discharge was on the third postoperative day and no complication was registered. conclusion: is extremely rare to discover a guidewire that had migrated into the peritoneal space without abdominal injuries.this case report demonstrates the technical feasibility, safety and minimal postoperative morbidity associated with minimal invasive laparoscopic removal. aims: the authors present a video with their standardized laparoscopic groin hernia transabdominal preperitoneal hernioplasty (tap) procedure but using 3 mm instruments and 5 mm camera approach. methods: a 45 years old male patient with a bmi 30 presents a symptomatic bilateral groin hernia for 5 months. us study showed an indirect bilateral inguinal hernia. a laparoscopic tap hernia repair procedure is performed using 3 mm instruments and a 5 mm camera. a selfgripping mesh preperitoneal hernioplasty and peritoneal flap barbed-sutured hermetic closure was performed. case and technical details are shown in the video. results: the patient was discharged from hospital within a period of 4 h with a 2 rate in a eva acute pain visual scale. in a 2 year follow-up, there has no been an anatomical or clinical recurrence. no chronic pain, anatomical recurrence, umbilical or abdominal wall complications have been reported with in this period of time. conclusions: depending on the patient characteristics, anatomical factors and surgeon mini invasive experience, a laparoscopic bilateral hernia repair using 3 mm instruments, could be a safe and feasible option. more studies are needed in order to standardized this approach. results: during tapp approach a direct hernia relapse was identified, the previous mesh was included on preperitoneal space and some non-absorbable sutures to inguinal ligament were identified. stitches and nearly total mesh removal (only the part surrounding cord elements was left in place) were performed. 15x15 heavyweight polypropylene mesh was employed fixed with gubran2ò and the flap was closed with running sutures. patient was discharged uneventfully the same day. seven months later he did not need analgesics and had no physical impairment. conclusions: post inguinal hernia repair chronic pain can be severe and disabling, and is becoming more prevalent. the origin is complex and meshes and sutures could play a role. the management is multimodal and demanding. for refractory patients, surgery may be an option. laparoscopic, open and mixed approaches have been employed. they usually combine mesh removal and substitution (often in different planes) and groin nerve therapies. nowadays, triple neurectomy seems to be the most effective treatment (more than 90% pain relief). generally, removal of mesh alone does not lead to lasting pain relief or has worse outcomes compared with associated neurectomy. introduction: mesh repair of inguinal hernia is sometimes followed by adverse effects such as mesh migration, chronic groin pain or recurrence. removal of the mesh is necessary in selected cases. we affront this cases by tapp intervention. methods: we present a video with two intreventions of inguinal recurrent hernia by laparoscopy (tapp). we remar the points to decide explant the mesh or not to explant. the conditions to decide the explant were the proximity to the main vessels in inguinal area (espigastric and femoral vessels) and the plication of the mesh. results: and conclusion as we show in the video, the explant of the mesh is only conditioned by the plicature of the mesh for its migration and recurrence, accompanied usually with pain. we don't remove any time the mesh or the plug if it is in the triangle of doom with firm adhesions to the main vessels. we cover the previous mesh with a new ligthweigth 3d mesh and closing at the end the preitoneum over the new reparation. introduction: tep technique isn't a controversial area in surgical practice for inguinal hernias anymore, but a fully accepted method. the use of general anesthesia has been the mainstay of laparoscopic hernia repair, but epidural anesthesia is not a contradiction to properly selected patients. material-method: the approach of the extraperitoneal area achieved without use of a dilation balloon, but via the indroduction of the camera and the dissection of the regional structures.3 trocars ports were used: a 10 mm trocar through the umbilicus for the camera, exactly as in sils (single incision laparoscopic surgery), another one 5 mm is placed in the midline between the umbilicus and pubis, the last 5 mm trocar is placed in the midclavicular line ipsilateral with the hernia. the key for every operation was the tension free technique with placement and fixation of a mesh 10x5 cm. in 20/25 cases the mesh was placed with tacks on the inside of the inferior epigastric artery-vein complex. all patients were dismissed from the hospital in 24 h, no drain was placed and no major postoperative complications took place. conclusion: tep is a demanding technique with serious learning curve. the use of a dilation balloon for insertion in the extraperitoneal area is not prerequisite. tep is an appropriate method both for first appearing and recurrent inguinal hernias. epiduralanesthesia instead of general anesthesia is no a contradiction for properly selected patients. aims: the aim of this study was to investigate the effects of preperitoneal carbon-dioxide (co 2 ) insufflation during tapp (transabdominal preperitoneal) repair. materials and methods: 20 male patients with inguinal hernia were include in our study. we obtain laparoscopic access at the umbilicus and introduce 10 mm port. two 5 mm working ports are placed lateral. diagnostic laparoscopy of the entire abdomen is necessary to rule out other pathology or contraindications for surgery. using aspiration needle we insuflate carbon-dioxide (14 mmhg) preperitoneal at the level of anterior superior iliac spine while decrease abdominal gas pressure to 8 mmhg. same procedure is made lateral to the umbilical artery. results: we found that preperitoneal carbon-dioxide (co 2 ) insufflation during tapp facilitate the future parietalisation and even can reduce operating time in future improvements of the technique. there were no intraoperative complications related to this procedure. we did not found any potential risk of the technique when is use by trained surgeons. aims: laparoscopic inguinal hernia repairs (lihr) are performed more and more frequently because they offer some advantages; however, we cannot forget their specific complications. lihr are associated sometimes with peritoneal tears that can lead to bowel obstruction. we present two cases of bowel obstruction related to peritoneal defects post tapp procedure and review peritoneal closure, bowel obstruction and options to repair defects. a 79 year-old male was scheduled for tapp due to bilateral relapse. two 10x15 tio2mesh tm fixed with securestrapò, employed also for peritoneal flap closure, were employed. three days later he was readmitted with bowel obstruction with ct suggesting 'adhesions'. a 56 year-old male had bilateral tapp in another centre. seven days later he presented with bowel obstruction. ct showed metallic tackers and suggested 'adhesions' results: first case: after four days of conservative treatment failure, a revisional laparoscopy showed ileum herniation through a peritoneal defect and firm adhesions to the mesh. bowel was labouriously separated and the peritoneal defect closed with two running sutures. he was discharged on the 7 \ sup [ th \/sup [ postoperative day and three years later he is asymptomatic. second: after two days of conservative treatment failure, on laparoscopy, ileum was filmy adhered to polipropilene mesh through a big defect on flap closure. defect was closed with interrupted sutures. as tears persisted, an omental flap was created to cover the area. patient was discharged on the 5th day and continues asymptomatic three years later. conclusions: lihr bowel obstructions can be divided in adhesive disease and herniation. herniation can be early (through peritoneal defects) or late (trocar site). international guidelines recommends a thorough closure of peritoneal incision or bigger tears (grade b). the closure can be achieved with staples, tacks, running suture, or glue. these last two methods are more time-consuming but less painful. running suture seems to be the best, due to its low costs, tightness and low pain but sometimes can be technically difficult. low intra-abdominal pressures (= 8 mmhg) facilitate suturing. when a herniation appears, careful bowel management is needed and running sutures are recommended. if tears persist, an omental flap can be useful. aims: application of a single port robotic platform to perform an entirely transanal tatme/ tata. methods: the following video demonstrates how a totally transanal proctosigmoidectomy is performed using a novel, single port (sp) robotic platform was used to carry out a totally transanal proctosigmoidectomy, single port robotic tatme/tata. a 38-year-old female patient with a clinical t3n1b rectal cancer at the 3 cm level, status post neoadjuvant chemoradiotherapy (5580 cgy, xeloda) is presented. shown here is the open transanal dissection followed by docking of the sp robot, implementation of the single port instruments (fenestrated bipolar forceps, cadier, scissors, camera, clip applier) through a gelpoint path to complete a totally transanal proctosigmoidectomy including transanal tatme, ima/imv transection, splenic flexure release, and left colonic mobilization, loop ileostomy, and handsewn coloanal anastomosis. results: blood loss was 100 cc. pathology demonstrated a moderately differentiated, rectal adenocarcinoma. the total mesorectal excision was complete (grade 3), margins were negative, and all 17 lymph nodes were negative for metastatic carcinoma. the patient was discharged on postoperative day 4 after an uncomplicated hospital course. there was no postoperative morbidity or mortality. conclusions: application of the single port robot to transanal tatme/tata (sprtatme) is presented here. while much work remains to be done to validate the sp robot's safety, this first demonstration of a totally transanal tatme/tata establishes its feasibility and utility. this single port platform stands to greatly expand the application of natural orifice transluminal endoscopic surgery (notes). as shown, the sp robot offers more than sufficient visualization, technical control, and adequate reach to perform such an operation. we present an exciting new avenue by which to complete operations in an entirely transanal fashion, which are classically performed via a combined transanal and transabdominal approach. methods: this video shows the utilization of a new robotic platform to perform transanal endoluminal microsurgery, rtem. presented here is a 53 year old woman with a recurrent rectal adenoma at the 6 cm level, status post a previous tem resection in october 2017. demonstrated is the utilization of the sp robot through a gelpoint path in order to perform a partial fullthickness and full-thickness resection. the robot is introduced through a 25 mm in diameter cannula via a four-channel face-plate. the instruments' two-jointed mobility at the elbows and wrists as well as the novel navigation system are well demonstrated. the docking of the sp robot, utilization of the dissecting devices, and closure of the defect is shown. results: sprtem was performed with a blood loss of 5 cc, and the patient was discharged on postoperative day 1. there was no postoperative morbidity, mortality, or moderate/severe pain. pathology showed tubular adenoma with low-grade dysplasia in a non-fragmented specimen with negative margins circumferentially. conclusion: initial experience using the sp robot for rtem is demonstrated here. the robot provides wonderful visualization and operative control to the surgeon. articulation of the robot's wrists and arms have the potential to facilitate technical aspects of the procedure. rtem stands as an exciting development in the field of transanal endoluminal surgery. introduction: the application of robotic approach in the esophageal surgical field is in its first phase. the microsuturing and microdissection capabilites of the robotic system can potentially overcome the traditional limitation of the laparoscopic surgery thus enhancing the indications of minimally invasive surgery. methods: we have performed a retrospective analysis of our prospectively maintained database that included 16 patients who underwent robotic-assisted esophagectomy for malignant disease between 2014 and 2017. results: ten out of sixteen patients had squamous cell carcinoma meanwhile six had adenocarcinoma. ten mckeown's and six ivor lewis were performed. the mean operative time was 525 min (332-688) and the median blood loss was 155 ml (70-220). no patients required conversion nor intraoperative transfusion. the morbidity rate was 3/16 (18.7%) : a transitory laryngeal nerve paresis, a pneumotorax and pneumonia. the mean hospital stay was 8 (range 7-23) days. an r0 resection rate of 93.7% was achieved with a mean lymph node yield of 16 (13-21). the 1-year disease free survival was 82.8%, wheres the the 1-year overall survival was 88.5%. conclusions: robotic assisted minimally invasive esophagectomy (ramie) is safe and feasible, it offers promising results while preserving a good oncology adequacy. this video shows our technique for the treatment of an esophageal diverticolum using a robotic left sided transthoracic approach, followed by a heller myotomy and dor fundoplication using a transabdominal approach. our case is a 75 year old male, who suffered from severe dysphagia, halitosis and gastric reflux who on endoscopic and radiological investigations was found to have low grade and a 3 cm wide esophageal diverticulum, 7 cm from the lower esophageal sphincter. initially conservative management was attempted, however following poor compliance and the persistance of symptoms after 1 year of therapy, surgical intervention was indicated. the operation was performed using the minimally invasive robotic system of the davinci siò, starting with the thorax time. the patient is positioned in left side decubitus. the camera-trocar is insert in the thorax via the fifth intercostal space the, two 8 mm and one 12 mm robotic trocars are added. the lung is liberated from pleural adhesions and the esophagus is then prepared exposing the diverticulum which is successfully removed with an endo-giaò. the esophageal muscle fibers, near the suture line is reinforced with separated vicryl stitches and the resected piece is extracted via endo-bag. a 16fr thoracic drainage tube is then placed and the trocar accesses repaired. the patient is the put in supine position with a 15°anti-trendelemburg angle. three robotic trocars (two 8 mm and one 12 mm) are placed and the robot docking is made from the patient left shoulder. the lesser omentum is divided to visualize and prepare the gastric-esophageal junction (gej) sparing the vagus nerve. the heller myotomy is then performed for 4 cm over the gej and 3 cm under it. the mucosal integrity is assured via laparoscopic and contemporary gastroscopic view. the gastric fundus is attached to the distal esophagus completing the dor fundoplication. post-operative care comprehends the removal of the thoracic drainage during the first post-operative day, the pain management and the progressive realimentation. the hospitalized period lasts 6 day and the patient was dismissed without complications occurred. the uniportal video assisted lung lobectomies gained popularity all over the world during the last 10 years. the technique is safely applied for peripheral pulmonary lesions, under 6 cm, but more and more complex cases are being approached while the indications continue to evolve. our aim is to present the particular aspects of this technique in an 11-year-old female patient with a giant bullous lesion located in the lower lobe of the right lung. the preoperative work-up for this case is presented and commented. a multidisciplinary surgical team consisting of thoracic and pediatric surgeons was involved. a single 3.5 cm length incision in the fourth intercostal space was used for the access. due to the fact that the lesion involved almost the entire lobe and the margins were very close to the hilum, we have decided and performed a right lower lobectomy. dissection and stapling were quite difficult. all the anatomical structures had small dimensions, forcing us to perform an 'artery first approach' in a very narrow space. no complications during or after surgery were encountered. the patient was discharged after four days and she went to school on the sixth day. histopathological examination showed that the lesion was a type 1 ccam (congenital cystic adenomatoid malformation). conclussion: the uniportal video assisted lung lobectomy was safety applied for a giant bullous lesion of the right lung. aim: dunbar syndrome, celiac trunk (ct) compression syndrome, caused by median arcuateligament is a rarely diagnosed disease because of its nonspecific symptoms, which cause adelay in the correct diagnosis. the aim of the study was to demonstrate the usefulness andadvantages of laparoscopic approach in the treatment of dunbar syndrome. methods: we performed 3 laparoscopic release of ct in the department of general, minimallyinvasive and elderly surgery in olsztyn in 2018. all of three patients suffered from severepain of abdominal cavity before the surgery. results: in two cases, there were a complete remission of the symptoms. in one case, there was animprovement. all patients reported relief of symptoms in the first days after the operation.there were no postoperative complications. conclusions: the laparoscopic treatment of dunbar seems to be safe and feasible procedure. thelaparoscopic surgery alone can often eliminate discomfort, while angioplasty and stentimplantation are no longer necessary. introduction: the advances in robotic surgery have permitted the application of such technology to various surgical fields, one of the last of these being hernia surgery. we present a case video of the treatment of a dual-hernia using a robotic retromuscular ventral hernia repair(rrvhr) using the davinci siò robotic system. the case report demonstrates the evolution of the trans-abdominal robotic umbilical prosthetic (tarup) in that it utilises a 'double docking' technique to allow the positioning of a large retromuscular mesh. methodology: our patient is a 50-year-old male who presented with chronic epigastric pain. the abdominal ct confirmed two abdominal wall hernias; an epigastric and supra-umbilical hernia with visceral contents and wall defect diameter of 6 cm and 2.5 cm, respectively. using the minimally invasive robotic system of the davinci siò we adapted the well known retromuscular mesh technique. the operation was initially intraperitoneal with access to the retromuscular preperitoneale space using a right sided longitudinal incision.(as per standard tarup technique). we proceed with the dissection of the retro-muscular space until the left lateral edges of the rectus sheath, creating a preperitoneal space for the placement of a specifically modified ultrapro polypro-leneò 25x22 cm mesh. following this we repositioned the davinci siò in a symmetrical manner, with ports placed in the retromuscular space. the mesh is positioned and the peritneum subsequently closed with a v-lock sutureò. finally we opted for a negative pressure jackson-pratt drain, inserted preperitoneally. results: the patient was discharged on the 2nd post-operative day without complication follow up continued until 12 months post operatively during which the patient remained asymptomatic, without signs for hernia recurrance . conclusion: the technique highlighted in our video demonstrates the utility of the robotic system in hernia repair. specifically the approach proved a success as it facilites the placement of the mesh totally extra-peritoneally with closure of the posteriore sheath without tension. the added advantages are that the port-sites are distant from the mesh thus reducing infective risk. additionally this technique allows the treatment of large peritoneal defects. surg endosc (2019) aim: to analyse the performance of a robotic fellow during a robotic total mesorectal excision (tme) at the end of the fellowship, and subsequently compare it with their mentor. methods: the fellow is exposed to 2 robotic colorectal lists per week. during the fellowship, assessment of performance is recorded in a structured proforma covering aspects of autonomy, tissue handling and dissection. at the end of the fellowship, areview of cases performed by the fellow and the mentor was carried out in a blindly manner (video footage). results: robotic tme training was divided into modules in order of complexity and the trainee had to achieve sequential proficiency in each module, before progression. docking of davinci robotic system. inferior mesenteric artery exposure and ligation, development of medial to lateral plane and inferior mesenteric vein division. left colonic and splenic flexure mobilization. pancreas identification. rectal dissection (tme). qualitative assessments were recorded by the mentor; the fellow was 'able to perform with verbal help' most of the steps from early on. by the end of the fellowship, all steps were performed in a similar manner in terms of quality and oncological integrity when compared with the mentor. conclusions: at completion ofan advanced robotic colorectal fellowship, high quality trainees can perform every step of the tme dissection in a similar manner with the trainer, when assessed blindly, without compromising oncological integrity. aims: to find safe and simple method in robotic rectal low anterior resection with low tie arterial ligation and lymph node dissection around the root of inferior mesenteric artery. methods: we performed robotic rectal low anterior resection (rlar) by davinci si system in eight patients with rectal cancer. we applied low tie arterial ligation, just caudally to the origin of the left colic artery in all cases. during the procedure, we used tilepro function of davinci si system which enabled to display two other visual informations through external inputs under the normal 3-dimensional surgeon console view. preoperative 3d-ct vessel branching simulation video and intra-operative real time ultra sound navigation view were displayed simultaneously under normal operative camera view in the surgeon console. results: left colic artery preservation was completely done in all 8 cases. the mean time to find and expose the left colic artery from the first incision in sigmoid mesentery was 5 min, which was drastically shorter than conventional method. this method needed lesser mobilization of inferior mesenteric artery (ima), and may be less invasive to autonomic nerve around the root of ima which is very important for ejaculation function. conclusion: robotic rectal low anterior resection with low tie arterial ligation was performed safely and in short time, using tilepro intra-operative navigation method. preoperative 3d-ct vessel branching simulation video and intra-operative real time ultra sound navigation view were very useful in the procedure. we present the method in video. nerve sparing tme and pelvic neuroanatomy for colorectal surgeons p. tejedor, f. sagias, j.s. khan aim: to describe the critical points in which the pelvic nerves can be damaged during a total mesorectal excision (tme) for rectal cancer and the benefits of robotic surgery for identifying these points. methods: there are 4 critical points regarding pelvic neuroanatomy: superior hypogastric plexus (shp): located in front of l5-s1. the ganglionic sympathetic fibres form the right and left sympathetic trunk, travel along the anterior surface of the aorta and coalesce in the shp at the level of the inferior mesenteric artery (ima). superior hypogastric nerves: they take an anterolateral course into the pelvis. there is an avascular 'holy plane' around the rectum between these two nerves. inferior hypogastric plexus (ihp): lies over the posterolateral pelvis, almost parallel to the internal iliac arteries. this can be identified at the lower end of the rectum. neurovascular bundles(of walsh): in front of the denonvillier's fascia, at 2 and 10 o'clock position. they are responsible for erectile function. results: lack of knowledge or identification of key structures at these 4 points can lead to increased risk of nerve damage and translate into poor functional outcomes. the ima is dissected up to the origin from aorta and here the shp can be seen. care is taken to avoid any damage to these structures. the tme plane is found at the back of ima as the inner most dissectible layer between mesorectum pelvic fascia. right and left superior hypogastric nerves are identified. dissection is carried out posteriorly, laterally and anteriorly. ihp is identified at the lower third of the rectum, when the dissection is about to reach the pelvic floor. care should be taken in not to go too far lateral and damage this plexus. in the anterior dissection, plane is carried in front of the denonvilliers' fascia. the neurovascular bundles can be seen at 2 and 10 o'clock position and the surgeon has to be careful to stay inside that plane in order to avoid damage. conclusions: the precise dissection in robotic surgery results in minimal tissue damage and better visualization and preservation of the pelvic nerves. aims: to describe and evaluate new contributions and eventual advantages of icg fluorescence to perform an icg guided bilateral pelvic lymph node dissection in a patient who underwent low-anterior-resection for rectal carcinoma. we also present the basic steps to avoid ileostomy during rectal surgery in which icg and ghost ileostomy play an important role. methods: a 68-year-old male patient was referred to our hospital due to abdominal pain and significant changes in usual bowel habits.colonoscopy showed a no obstructing 5 cm middle rectal mass, which was reported as an adenocarcinoma.ct scan and mri revealed a 63 9 52 mm polyp in the anterior rectal wall which was located 7 cm from the anal verge. it was involving mucosa and sub-mucosa with muscularis propia invasion. no pathological lymphadenopathies or hepatic metastatic disease were found (stage t2n0).a laparoscopic ultra-low-anterior resection plus icg lateral lymphadenectomy with total mesorectal excision was performed. a complete splenic flexure mobilization was performed to achieve a safe tension-free anastomosis. transection line of the proximal rectum was checked after icg intravenous injection. icg was injected around the tumor by inserting an anoscope, just before the surgery. after the dissection of the rectum, lateral lymphadenectomy was performed assisted by icg. an end-to-side anastomosis was made. and a vascular loop was passed around the terminal ileum to create a ghost ileostomy.the procedure lasted 120 min. reactive protein c was monitored to identify an initial leak. the patient was discharge in postoperative day 7 and no complication was detected. results: pathological exam reported a rectal adenocarcinoma. pelvic lymphadenectomy results were: 2 negative nodes, 2 negative nodes and 10 negative nodes from right lymph node dissection, left lymph node dissection and rectosigmoid resection specimen respectively. no metastatic disease was found (stage t1n0m0). conclusions: in our experience, icg fluorescence imaging system offers important contributions to rectal surgery furthermore than evaluating vascular supply to the anastomosis. lymphatic mapping of the lateral lymph nodes and avoiding ileostomy could be a potential important use in the future. larger studies and more specific evaluations are needed to confirm its role in colorectal surgery and to find its limitations. background: robotic surgery for colorectal cancer is an emerging technique. potential benefits as compared to conventional laparoscopic surgery have been demonstrated. innovative robotic technologies have helped surgeons overcome many technical difficulties of conventional laparoscopic surgery such as hand-eye coordination, a two-dimensional view, and a restricted range of motion. robotic-assisted surgery was established as a new approach to minimally invasive surgery, overcoming these limitations. the following video shows a total robotic sigmoidectomy step by step on the basis of ourexperience. intervention: a 52-year-old male patient with no previous medical historyand a colon adenocarcinoma, 22 cm from the anal verge, no distant metastases. it was decided to perform a robotic sigmoidectomy. target anatomywas located andwe proceededto the exposure of the mesenteric vessels from medial to lateral. a cautery wasused to open the peritoneum,up to the origin of the inferior mesenteric artery, and caudally past the sacral promontory.the vessels weretransected by ligasuretm. we performedthe complete release of the colon taking care to avoid injury to retroperitoneal structures. we usedligasuretm to section the mesocolon in order to prepare the transection of the proximal colon. indocyanine green was used to check the correct vascularization. an endogia tristapletm was used to divide the colon. subsequently, we sectioned the rectumand extracted the specimen through itwith no need to make any auxiliary incisions. we introduced the anvil of the suture device to perform the anastomosis. we sectionedand close the rectum with an endogia tristapletm. finally we opened the proximal colon to introduce the anvil,making a pursestring to fix it and create a side to end anastomosis. outcome: the surgery took 110 min. the patient started oral intake 6 h after surgery and left the hospital on the 3rd postoperative day. pathological examination ruled out a colon adenocarcinoma pt1n0. conclusion: total robotic sigmoidectomy is safe and feasible and can be a procedure of choice to achieve a good surgical qualityand avoid assistance incisions in patients with colon cancer. surg endosc (2019) with more and more data now advocating wait and watch policy for these patients which require close radiological and endoscopic follow-up but unfortunately around 30% of them have regrowth of tumour which will require surgical intervention. the use of robot for cancer resections is becoming more frequent especially in narrow spaces like in an obese male pelvis. the reason being better 3-dimensional views, more angulation of the instruments and exclusion of tremors, which in turn leads to better dissection and preservation of hypogastric nerves. in this video, we present a robotic low anterior resection for rectal re-growth in an obese 55-years old male patient. he was offered neoadjuvant chemoradiotherapy after discussion in mdt. he had an complete response with chemoradiotherapy and was decided to offer him watch and wait regime. unfortunately, he developed rectal re-growth in the first year of his follow up. imaging showed t2 lesion with no distant metastasis and was later confirmed on histology as well. after mdt discussion he was offered robotic low anterior resection. the video starts by showing the clinicopathological features of patient including his radiological and endoscopic images. robotic port sites are shown. the edited video starts with rectal dissection after ligation of inferior mesenteric artery and vein with emphasis on narrow pelvis and preservation of hypogastric nerves, seminal vesicles and intact presacral fascia. postoperative histology was ypt2no and patient was discharged home after 3 days with no postoperative complications. background: minimally invasive surgery for colon resection has improved patient outcome, however a minilaparotomy still is necessary to extract the specimen. this report describes a new approach that combine laparoscopic parellel overlap stapling left colectomy with natural orifice specimen extraction surgery, with the aim to minimize abdominal wall trauma. method: laparoscopic left colectomy for malignant diesease was performed using a standard five-port technique. after releasing the left colon via laparoscopy, divide the proximal and distal of specimen with 60-echelon, and put distal sigmoid colon and proximal transverse colon together. open sigmoid colon 6 cm apart from distal margin, and incise transverse colon at proximal margin. take transverse colon and sigmoid colon side-to-side anastomosis via 60-echelon. incise posterior vaginal fornix to get into the abdominal cavity and extract specimen through vaginal. outcome parameters such as complications, conversions, operative time, postoperative recovery, and postoperative pain were prospectively recorded in a database. results: surgery was performed for 17 patients with left-colonic carcinoma. no perioperative complications or conversions occurred. the median operating time was 157 min. the median visual analogue scale score of postoperative pain was 1, and 2 of 17 patients needed analgesia on postoperative day 1. the median postoperative hospital stay was 6 days. for malignancies, tissue margins were oncologically adequate, the averge number of harvested lymph nodes were 16.9. the 4-week follow-up period was uneventful. conclusion: the described technique, a combination of laparoscopic parellel overlap stapling and natural orifice surgery, has the potential to avoid incision-related morbidity of the minilaparotomy in laparoscopic left colon resections. background: open surgical skills training has been well established over centuries, however, there are some significant differences in laparoscopic surgical skills training. it is an obvious advantage that the trainee and the trainer have the same view; however, some of the hurdles include the differences in tactile feedback, hand eye co-ordination, spatial awareness, depth perception and maximizing assistance. aim: we present a video highlighting some of the key challenges faced in laparoscopic colorectal surgical training, show-casing our systematic, structured approach. our approach: we have developed a structured approach starting with junior surgical trainees and progressing through to consultant level as per the levels below: level 1: attend courses/ workshops level 2: master camera work level 3: contra-lateral assisting level 4: intermediate level trainee-start operating with trainer scrubbed. the trainer is an additional member of the scrub team and stands on the same side as the trainee (does not replace any assistant) level 5: advanced level trainee-gradual progression from level 4. trainer un-scrubbed but standing next to the monitor throughout the procedure. level 6: trainer in theatre but out of sight of the trainee, with little interference level 7: progression to trainer-once proficiency is achieved at level 5/6, the trainee is trained to become a trainer, for the junior and intermediate level trainees. within each level the complexity of the procedure increases as the trainee progresses through the level. junior trainees (years 1-3 of surgical training) are taken through levels 1-3, intermediate (middle years of training) level 4 or 5 and advanced (last 2-3 years) up to levels 7. this way of training allows multiple members of the team to be trained simultaneously in every case. each operating list is preceded by team briefings where the role of every member of the team is clearly identified and followed by individual and collective feedback. conclusion: this training ladder proved very successful through the years. the feedback from trainees at all stages has been consistently positive. several trainees who have progressed to independent consultant practice, in the uk and abroad, are adopting this approach in their practice. introduction: despite the potential microsuturing capabilities of the robotic surgery, most of the esofago-jejunostomy after robotic total gastrectomy are still performed extracorporeal or through mechanical staplers. this can increase the cost of the procedure, the risk related to a improper functioning of the stapler. methods: we reviewed our prospectively maintained database analyzing patients from april 2015 to september 2017, who underwent robotic total gastrectomy with hand-sewn esophagojejunostomy for gastric cancer. results: a total of 18 patients were included in the study. the mean estimated blood loss was 140 ml (60-257). the overall operative time was 365 min (277-421). length of hospital stay was 6 days (5) (6) (7) (8) (9) (10) (11) (12) (13) . no conversion was necessary nor anastomotic leakage occurred. the morbidity rate was 2/18 (11.1%) and included a subhepatic abscess and wound infection trough pfannenstiel incision. a r0 resection rate was achieved in all cases. the mean of lymph node yield was 32 (14-39). the 1-year disease free survival was 74%, the 1-year overall survival 82.3%. the robotic-assisted hand-sewn esophago-jejunostomy is a safe and no time-consuming technique. it avoids the complication related to the stapler firing and it offers cosmetic benefit to the patient in terms of extraction site. introduction: colorectal endoscopic submucosal dissection (esd) is increasingly practiced for treatment of early colorectal neoplasia. however, colorectal esd is difficult to perform due to lack of retraction as well as instability especially over hepatic flexure. dilumen eip is an external flexible sheath introduced during colonoscopy to stabilize environment for esd. this video demonstrated the use of dilumen eip for performance of colonic esd at the ascending colon method and results: this is a 60 years old lady who received screening colonoscopy and found a 20 mm lateral spreading tumor (lst) type 0 iia lesion at ascending colon distal to ileocecal valve. under general anesthesia, patient received colonic esd using dilumen eip. due to significant looping, the dilumen device was introduced with the techniques of double balloon enteroscopy. after identification of the lst, the balloon in the front would be deployed to the proximal to the lesion while both balloons would be insufflated and created a stable environment. the esd procedure started after submucosal injection with normal saline in mix with indigocarmine, epinephrine and hyaluronate. mucosal incision was performed over the anal side of the lesion, and after adequate submucosal dissection, clips were applied to attach the mucosal flap to the sleeve of proximal balloon and achieved retraction. the submucosa was adequately exposed for dissection using dual knife jet. this enhanced submucosal dissection especially at one area with significant fibrosis. after the procedure, complete closure of the mucosal defect was performed by clips and assisted by the front balloon. the pathology confirmed intramucosal adenocarcinoma with clear resection margins. discussion: the dilumen eip device stabilized the environment within the colon with the double balloon and provide adequate retraction for performance of colorectal esd. surgery, kobe city medical center general hospital, kobe, japan background: robotic surgery has been widely spread all over the world, but robotic gastrectomy is not common and difficult because of complex anatomy and wide-ranging operation fields. in addition, it had been performed only under a few high-volume centers for reasons of the limitation of national health insurance in japan, which means medical expenses not covered by insurance. the situation was changed from this april, so we started robotic gastrectomy to reduce complications more rather than laparoscopic gastrectomy. we report results and aim to present the methods in detail using da vinci si surgical system. methods: we place five trocars, one is umbilical endoscopy port, and other four ports are placed at the reverse trapezoid, almost fan-shaped. using the arm number 3, the organ can be lifted up so that sharp lymphadenectomy is able to be done by almost a scissor as the arm number 1 while applying the countertraction by the arm number 2. in order to achieve a clear and bloodless lymphnode dissection while maintaining the oncological safety, we think not only the ultrasonic coagulating scissor but also the electrocautery of the scissor is very essential in robotic surgery. less postoperative complication such as pancreatic fistula or pancreatitis might be derived from robotic surgery because we can avoid pressing the pancreas during the suprapancreatic dissection of lymph nodes. the billroth i reconstruction can be performed using da vinci endowrist stapler under stable and inflexible surgical fields without needing help of surgical assistant. results: from october 2017 to december 2018, 25 patients with gastric cancer were operated robotic gastrectomy, included 3 total gastrectomy. there was no conversion to open surgery and no conversion to other procedures derived from intraoperative complications, and the overall operation time is gradually decreasing from the 14 th case. we are now on the way of learning curve shortening operation time, but robotic gastrectomy is no less safer and adequate than laparoscopic surgery. we will show our robotic procedures including lymphadenectomy around subpyloric and suprapancreatic area, and reconstruction with several important points in our video purpose: this report describes the benefits and drawbacks in the use of a novel articulating device (artisential), which has a multi-degree wrist freedom like the davinci endowrist, in performing complete single-port d2 lymph node dissection (lnd) in single-incision distal gastrectomy (sidg). methods: the artisential was used in performing sidg with d2 lnd for patients with advanced gastric cancer. all operations were performed by a single surgeon using a threedimensional camera and a passive scope holder in place of a scopist. the artisential was used mainly in the 4sb and suprapancreatic lnd, an area that is relatively far from the single port. in certain cases when the pancreas needed to be pushed down, such as obese male patients, the intraabdominal organ retractor was used to lift the tissue and the artisential to push the pancreas. operative results and short-term outcome were analyzed. results: twelve patients underwent the procedure without any intraoperative events, conversion to conventional laparoscopy, or surgery-related complications including postoperative pancreatic fistula. all patients underwent single port d2 lnd by complete exposure of the portal and splenic vein. mean operation time was 181.9 ± 42.5 mins. and mean number of retrieved lymph nodes was 61.8 ± 11.4. the artisential was found to be useful in grasping the tissues behind the pancreas and the major arteries throughout most of the lnd. the articulating motion also allowed the narrow single-port field of view to be clearly seen without the instrument body obstructing the camera. conclusion: the use of artisential in sidg appears feasible and reproducible, and is mandatory in performing a complete d2 lnd in sidg. the video shows a case of laterally spreading tumour of the rectum with preoperative benign histology, paris classification 0-is g (granular type), ut0n0 eus stage, kudo type iv, nice type 2. the neoplasm measured 6 x 7 cm, and extended from 6 to 12 cm from the anal verge, mainly located on the posterior wall. according to our local policy the indication was a transanal full-thickness excision. this was performed with the medrobotics flexò robotic system, used here for the first time outside the united states.the system technology utilizes an articulated multi-linked scope that can be steered along non-linear, circuitous paths in a way that is not possible with traditional, straight scopes. the maneuverability of the scope is derived from its numerous mechanical linkages with concentric mechanisms. this enables surgeons to perform minimally-invasive procedures in places that were previously difficult, or impossible, to reach. with the flexò robotic system, surgeons can operate through a single access site and direct the scope to the surgical target. once positioned, the scope can become rigid, forming a stable surgical platform from which the surgeon can pass flexible surgical instruments. the system includes on-board 3d hd visualization. the flexò robotic system contains two working channels to accept a number of different surgical and interventional instruments including monopolar and bipolar electrodes, scissors and graspers for tissue manipulation.the video shows the introduction of the dedicated rectoscope, the connection of the flexible robot, and the way to operate the device performing a full-thickness excision, including suturing of the rectal defect by means of two running sutures by a v-lock 3/0 thread. while illustrating the technique the authors will comment pros and cons of the use of the device. background: hepatobiliary procedures using a minimally invasive approachare demanding, especially in major hepatectomies. the use of da vinci surgical system allows to overcome some of the kinematics limitations of the direct manual laparoscopy maintaining the potential advantages of a minimally invasive approach . we herein present a case of left hepatectomy and local lymphadenectomy for hepatocellular carcinoma, carried out with the use of the da vinci xi. methodology: a 72-years old man with a long-lasting hbv chronic infection and ct scan and mri finding of a 4-cm solid neoplasia of the left hepatic lobe and gallbladder stones, was operated with the da vinci xi platform. the patient was placed in a supine position, with 15°anti-trendelenburg inclination. the trocars were positioned according with the intuitive indication for the upper quadrants surgery. results: the procedure was successfully completed in 360 min.at first, an intraoperative us scan with the use of tile-pro technology was done to determinate the tumor extension. the hepatic parenchyma transaction and the local lymphadenectomy were performed with monopolar scissors and bipolar grasps. the left hepatic vein section was performed with an endoscopic vascular stapler. there were no surgical complications or need for conversion to laparoscopy or laparotomy. the post-operative course was uneventful and the patient was discharged 5 days after surgery. conclusion: the da vinci xi can facilitate some technically demanding procedures and ultimately widen the range of application of minimally invasive surgery such as hepatic surgery. besides the well-known advantages provided by robotic surgery on 3d imaging, increased range of motion and augmented surgical dexterity, one of the most interesting and innovative features of robotic technology is the digitalization of the operative view; furthermore the tile-pro multiinput display allows the surgeon a 3d view of the operative field along with the ultrasound exam for a precise understanding of anatomy and vascularity and of tumor location. during the last few years, robotic surgery as well, as the latest innovation of minimally invasive procedures, takes its position in this particular field with the benefits of overcoming the limitations of conventional laparoscopy. our aim is to demonstrate the advantages of robotic surgery in procedures of hepatectomies, on occasion of a robotic hepatectomy performed by our team. methods: we present video fragments of a robotic left lateral hepatectomy procedure in an elderly female patient with a symptomatic gigantic haemangioma of the left hepatic lobe. we emphasize on the technical aspects and the advantages that the surgeon gains applying the robotic techniques in such procedures. results: the procedure was completed with minimal blood loss and the patient presented an uncomplicated post-operative course, with discharge on the third postoperative day, minimal need of analgesics and full recovery. conclusions: the excellent three-dimensional and high quality visualization that the robotic system offers, combined with the flexibility and the accuracy of the robotic instruments (especially on suturing), provide to the surgeon an important aid, in order to avoid serious complications, such as intraoperative bleeding and post-operative bile leaks. the restriction of the limitations of conventional laparoscopy is far more beneficial and promising for the evolution and the future of minimal invasive liver surgery. aims: the new da vinci xi surgical cart allows multi-quadrant and complex surgical interventions in a minimally invasive fashion. we present a case of robotic appleby left pancreatectomy using this platform and its specific operating bed. methods: a 73-years old woman with ct scan finding of a 30-mm hypo-vascular neoplasm of the pancreas body underwent surgery with the use of the new da vinci xi with four arms upper quadrants trocar' disposition. results: the procedure was successfully completed in 285 min. the pancreatic body was mobilized in order to expose the portal-mesenteric axis. the gland was transected using a robotic endo-stapler as well as the splenic vein. after evaluating the patency of collateral circles with intra-operative ultrasound, the common hepatic artery and the celiac artery were transected. then we increased the right tilted position and the neoplasia was detached from the gastric body by a tangential gastric resection using the robotic endo-stapler. finally, the operation was accomplished with the transection of the posterior attachment of the spleen and the pancreatic tail. no conversion or intra-operative complications were recorded. the post-operative course was uneventful and the patient was discharged 6 days after surgery. the da vinci xi with its specific tools helps in performing challenging procedures such as appleby operation for locally advanced pancreatic cancer. in our experience, the robotic endo-stapler permits the operating surgeon to directly control the transaction phase whereas the specific operating bed allows to perform minimally invasive multi-quadrant surgery and to obtain a better exposition of the operating field. results: the whipple procedure was successfully completed in 570 min. thanks to the dvtm the patient's position changed during the intervention to improve the exposure, with the instruments left inside the abdomen and without undocking the robot. the dissection of the pancreatic head from the portal vein and the section of the retroportal lamina were performed with the use of the endowrist vessel sealer device. a personal modified end-to-side pancreatojejunostomy was carried out, with 5/0 prolene and gore-tex double layer suture. no intra-operative complications occurred and no conversions to laparoscopy or laparotomy were required. the postoperative course was uneventful. conclusions: the use of the new fully wristed vessel sealer extend makes easier difficult maneuvers such as the fine dissection of the pancreatic head from the portal vein and the section of the retroportal lamina, enabling an optimized approach for vessels sealing and cutting and tissue bundles. moreover, the dvtm allows patient's movements without undocking the system or removing instruments from the abdomen, enhancing the surgical workflow. background: necrotizing pancreatitis is a devastating illness which can develop in up to 20% of patients who suffer from pancreatitis. it carries great morbidity with an associated mortality rate between 8 to 39%. many of these patients require drainage of fluid collections to treat sequela related to pain, per-os tolerance, and source control of sepsis if infected. the step-up approach to treatment of this disease has trended towards minimally invasive techniques, considering the morbidity of open debridement. as such, many centers have implemented the use of transgastric debridement via endoscopic cystogastrostomy. this technique, while effective in draining fluid and particulate necrotic tissue, has difficulty in resection of large necrotic tissue, due to instrument and anatomic limitations. current endoscopic accessories designed for polypectomy or foreign body extraction, for example, are not optimal for performing necrosectomy. to overcome this obstacle, additional access sites can be utilized to assist debridement. we describe the first laparoscopic assisted transgastric endoscopic necrosectomy through a percutaneous gastrostomy in a 59 year old male with infected pancreatic necrosis secondary to biliary pancreatitis. aim: to investigate the feasibility of utilizing gastrostomy access to assist in debridement during endoscopic necrosectomy. methods: the patient previously underwent an open necrosectomy and gastrostomy tube placement for acute emphysematous pancreatitis. post-operatively, there was a persistent and enlarging 12 cm infected walled-off necrosis (won). therefore, endoscopic cystogastrostomy was performed using a lumen-apposing metal stent. results: frank pus was evacuated. initial endoscopic necrosectomy was technically challenging due to the large volume of solid necrotic tissue. repeat endoscopic debridement utilized a surgical laparoscopic grasper via the gastrostomy site to aide solid debris extraction (video). this allowed for complete necrosectomy and resolution of the won. the patient did well and was discharged subsequently. conclusion: this is another emerging minimally invasive technique in the step-up approach for debridement and drainage of won. the use of the gastrostomy as a utility port for accessory instruments not only enhanced the technical aspects of the procedure but increased its efficacy as well. further experience is needed to validate the utility and reproducibility of this technique. objective: the presentation of the minimally invasive surgical approach for pancreatic necrosectomy guided by videoretroperitoneoscopy or var (video assisted retroperitoneoscopic), established in our center, as one of the option of the step-up approach treatment for acute necrotizing pancreatitis (anp) methods: the placement of the patient on the operating table should be in decubitus, with right lateral inclination, at 20-30°on the horizontal surface. the pancreatic cell is approached using the drainage catheter previously placed by radiological control (ultrasound or ct) as a guide, which will allow access to the cavity with safety. an incision of 3-5 cm is made around the previously placed catheter, crossing the subcutaneous cellular tissue and muscular fascias, dissolving the musculature. it continues in a blunt dissection, until a loss of resistance is appreciated which generally coincides with the outflow of necrotic or purulent material. once the retroperitoneal cell is accessed, a 15 mm trocar is placed and a pneumoretroperitoneum is performed. the 15-mm trocar allows the joint use of a 5 mm and 0°optic and the surgical material that allows debridement and cleaning. the aspiration and hydrodissection of the necrotic material, and the extraction of the solid component of the necrosis are proceeded. once the collection is drained and the necrotic material removed, a wash and drain system is placed, like a 3-way foley type probe. conclusions: in conclusion, the var is an alternative surgical technique, valid and reproducible in the treatment of anp, which offers comparable results and even superior, in some series, to those of open surgery, with satisfactory results in terms of morbidity and postoperative mortality. aim: lung subsegmentectomy is suitable for small and deep, non-palpable lung nodules. since it is difficult to intraoperatively detect the arteries, veins and bronchi of the subsegment, as well as the intersubsegmental borders, complete video-assisted thoracic surgery (vats) for lung subsegmentectomy is challenging. we use preoperative three dimensional ct to detect the arteries, veins and bronchi of the subsegment before conducting complete vats subsegmentectomy, and perform intraoperative bronchoscopy to detect the bronchi and intersubsegmental borders. i would like to describe our experience of complete vats combined subsegmentectomy for a non-palpable lung nodule. methods and results: the patient was a 67-year-old woman. during health screening, a small groundglass opacity was observed in her right lung on chest ct. the nodule was 15 mm in diameter and was located in s 2b (horizontal subsegment of the posterior segment) near s 3 (the anterior segment). we preoperatively diagnosed the lesion as well-differentiated adenocarcinoma, and planned combined subsegmentectomy for s 2b and s3 a (lateral subsegment of the anterior segment) of the right upper pulmonary lobe. before the operation, the locations of vessels were confirmed by three-dimensional ct angiography. video-assisted thoracoscopic surgery was performed using four ports: two 1 cm ports in the 8th intercostal space in the post-axillary line and in the angulus inferior scapulae line for the operator, a 4 cm port in the 4th intercostal space in the mid-axillary line for the assistant, and a 1 cm port for the camera in the 6th intercostal space in the mid-axillary line. the 4 cm port was also used for removal of the resected specimen. intraoperative bronchoscopy was used for detecting the subsegmental bronchi. she was diagnosed with primary lung cancer (adenocarcinoma in situ, nonmucinous) postoperatively. the tumor was pathologically graded as tisn0m0. no tumor recurrence has been noted in follow-up of twenty two months. conclusions: the combination of preoperative three-dimensional ct angiography, intraoperative bronchoscopy and complete video-assisted thoracoscopic surgery can be used for performing lung combined subsegmentectomy. aims: minimally invasive surgery is increasingly widespread for the diagnosis and treatment of abdominal pathology. laparoscopy is a diagnostic resource for those cases in which mass biopsy is not approachable through image-guided puncture, and is often therapeutic in the same act. it avoids the morbidity and mortality associated with laparotomy, favoring the early treatment of malignant processes. methods: we present a case of a 71 year old male who was incidentally diagnosed with an oval-shaped pelvic mass in the right lateral wall of the pelvis, adjacent to the vascular bundle of the right external iliac at its origin(5 9 3 9 5 centimeter), without sign of infiltration of surrounding structures. no other pathological findings on the abdominal computerized tomography and magnetic resonance imaging were found. due to its localization, it was not accessible to percutaneous biopsy. the first diagnostic impression was a benign tumor of the nerve sheath (schwannoma), without being able to rule out other diagnostic possibilities. to provide a definitive diagnosis the patient was subjected to an elective laparoscopic resection of the tumor. surgical procedure was performed using a 12 millimiter and two 5 millimeter, umbilicus for the optical system and operative on hypogastrium and left iliac fossa respectively. acleavage plan between the tumorand rightiliac vesselswas found. the exeresis of the masswas achieved, and it was extracted using an endo-bagò through the umbilical port site. a drain was put in the surgical bed. results: the patient had a short, uneventful post-operative course, being discharged on postoperative day 1. pathological examination revealed a lymphatic node with metastasis of poorly differentiated carcinoma, with suspected urothelial lineage. cystoscopy was performed with the finding of a 1 centimeter lesion on the right ureteral orifice with calcifications on the surface. biopsies were taken, confirming the bladder origin of the tumor. conclusions: both diagnostic and therapeutic laparoscopy is useful on pelvic masses because of the direct vision into this narrow anatomical space, especially in obese patients, providinga detailed view that makes easier to isolate and spear the anatomical structures surrounding the tumor, minimizing the risk of tumor rupture and bleeding. surg endosc (2019) aim: indocyanine green (icg)-enhanced fluorescence has been introduced initially in laparoscopic surgery to provide detailed anatomical information during laparoscopic cholecystectomy and to evaluate vascular supply to garantee correct anastomotic perfussion in order to reduce the risk of anastomotic leak. the uses of icg are increasing, specially in hepatic and oncological surgery in order to identify centinel lymph node and lymphatic mapping.we propose the use of icg imaging during complex laparoscopic colorectal resection in cases presenting ureter obstruction, to prevent iatrogenic ureteral injury. methods: we present a case of a 42 year old female previously diagnosed of pelvic endometriosis with severe pain and symptoms related with episodes of pseudo-occlusion .a colonoscopy was performed finding sigmoid cancer in an area of endometriosis in a narrow colon with difficulties to perform a complete colonoscopy that could be related to the process of pseudo-occlusion. the biopsy was informed as an adenocarcinoma.the ct-scan showed a dilatated left ureter in an area next to the sigmoid colon.we propose a preoperative strategy with a bilateral double j stent insertion, finding a ureter obstruction caused by the endometriosis.icg was injected through the ureteral catheter, guiding us during the surgery to avoid a iatrogenic ureteral injury. results: a laparoscopic left colectomy was performed. the icg allows us to follow the ureter during the surgery, disecting the colon properly from the area attached to the ureter. the prestenotic area of the ureter was marked dilatated up to two centimeters allowing the icg to identify it from the anatomic structures of the areas and guarateeing that there was not spill of icg out of the ureter avoiding a postoperative leak of urine. conclussions: when tumors, or another entities like endometriosis, produce a ureteral occlusion, icg could be injected through a j stent, allowing us to identify and to avoid an injury.icg fluorescence imaging is a safe, cheap, and effective tool to increase visualization during surgery, offering additional information of the anatomy in colorectal surgery. in this video we are going to show three cases of the robotic treatment of splenic artery aneurism and the evolution of the technology that we relied on for the preoperative planning and intraoperative navigation. our preoperative evaluation evolved from a tridimensional virtual reconstruction with augmented reality to patient specific anatomical 3d printed models, initially made of rigid materials and afterwards made of malleable materials, in order to reproduce hollow anatomical structures such as vessels, feasible to simulate the planned surgical plan. the choice of a robotic approach, in selected cases, allowed to restore the continuity of the splenic artery after the exclusion or excision of the aneurism, in order to preserve the spleen. aims: tumor-induced osteomalacia (tio) is a rare paraneoplastic syndrome in which patients presents bone pain, fractures and muscle weakness caused by the fibroblast growth factor 23 (fgf-23), a phosphate and vitamin d-regulating hormone. in tio, fgf-23 is secreted by mesenchymal tumors that are usually benign but small and difficult to locate. when medical treatment is unsuccessful, surgical treatment is indicated and conclusive.this video shows our technique for tio surgical treatment guided by indocyanine green (icg) fluorescent angiography. methods: the patient is an 81-years-old woman with tio confirmed by blood sampling of fgf-23, gallium-68 pet/ct scan and abdominal ct scan which identified a highly vascularized 8 mm nodule in the mesentery along the ileo-colic vascular axis.the patient was scheduled for a diagnostic laparoscopy with tio removal.the patient was placed in supine position. three trocars were introduced in the left quadrants. identified the last ileal loop, following ileo-colic vessels, a small mesenteric bulge was found. the icg fluorescent angiography confirmed the localization of the ipervascularised nodule and helped to define its edges. the nodule was removed through monopolar energy and the hemostasis was optimized through bipolar energy. the specimen was extracted through an endobag using one of the trocar access. results: the postoperative course was uneventful and the patient was discharged on postoperative day 4. histopathological examination showed an extrasurrenalic paraganglioma. conclusion: tio are often difficult to locate for surgical removal. icg fluorescent angiography allows to facilitate tio localization and removal. the minimally invasive technique decreases perioperative morbidity and mortality. laparoscopic removal guided by icg angiography should be considered when tio needs to be removed and is difficult to locate. aim: this video shows our technique to perform laparoscopic resection of a voluminous left paraaortic paraganglioma. methods: the patient is a 16-years-old man with a recent medical history offever, lumbar pain and haematuria.abdomen ct scan, performed during admission at emergency department, revealed a 8 x 7 cm left paraaortic retroperitoneal mass with pseudo-aneurysm. after procedure of angiographic embolization (with spermatic artery sparing), the patient was scheduled for a laparoscopic resection of paraaortic tumor. the patient was placed in the right flank position. three trocars (10 mm) in the abdominal midline and one trocar in left hypocondrium were placed. at initial examination of the abdominal cavity, voluminous left paraaortic mass arising in the contest of left mesocolon was found, dislocating posteriorly kidney vessels. the parietal peritoneum was divided and the paraaortic lesion was dissected on the aortic plane from medial to lateral and from down to up, preserving the inferior mesenteric vessels; the mobilization was carried on to splenic vein. the vessels, supplying the mass and arising directly from aorta, was isolated and taped with vascular clips. on the inferior margin of the lesion a large vessel, probably connected with previously embolized pseudoaneurysm, was dissected with vascular linear stapler. the mobilization was completed through difficult dissection from aortic plane and mesocolic posterior surface. the colonic perfusion was verified with fluorescence angiography. specimen was extracted through an endobag.a drain was left in pelvis. postoperative day 4.histopathological examination showed a morphological and immunoistochemical pattern for benign paraganglioma. conclusion: laparoscopic resection of paraaortic paragangliomas is feasible by skilled surgeon. the minimally invasive technique decreases perioperative morbidity and mortality. careful preoperative planning and surgeon's experience with vascular dissection and visceral mobilization are mandatory for a good outcome. aims: posterior retroperitoneal endoscopic approach has been considered for many years as a very complex and unsafe surgical technique. often attributed to a difficult location and visualization of retroperitoneal structures. in addition, surgeons were forced to work in a small and easily altered space due to discontinuous flow with constant changes of the retroperitoneal vision. lately this approach is emerging thanks to technological advances, mainly better visualization laparoscopic cameras and high definition screens, as well as continuous flow insufflators of co 2 , maintaining stable and smoke-free cavity uninterruptedly. methods: it shows a management of a potentially serious complication and the reproducibility of the technique through the retroperitoneal approach. results: to operate with high pressure of neumoretroperitoneum allows to contain the hemorrhage and to value with relative serenity and security, the best surgical option to repair said injury being laborious due to the reduced workspace. conclusions: the posterior or retroperitoneal approach is feasible, safe and fast. although the possibility of injuring the vena cava in right adrenalectomy remains one of the most serious and feared complications. as shown in the video, posterior retroperitoneal endoscopic approach allows repair of vascular injury correctly and safely. methods: four patients undergoing adrenalectomy, two of them with right adrenal pathology and two left. minimally invasive access, endoscopic approach, is exposed in all of them. results: in the first two surgeries, right gland is shown. initially, transabdominal approach, which requires mobilization and separation of the liver to access the retroperitoneal space and subsequent proceed to adrenal extirpation. later, right retroperitoneal approach is observed, with a meticulous sealing of the adrenal vein prior to complete the dissection of the gland, despite the small cavity created by co2. in the second part, both left adrenal approaches are exposed. transabdominal pathway is necessary to mobilize left colon and spleen to access a narrow space above the upper edge of the pancreas to locate adrenal gland. this is very different in posterior adrenal approach. conclusions: posterior or retroperitoneal approach is feasible and safe, allowing access to adrenal glands, located in retroperitoneal space, without across peritoneal cavity and its disadvantages. colon and small intestine mobilization is not necessary, with a lower rate of intestinal lesions and postoperative ileus. in the same way, liver or spleen mobilization is avoided. aims: when performing a laparoscopic adrenalectomy, especially in the setting of pheochromocytoma, one of the most important steps is to gain control of the adrenal vein early on in the procedure before great manipulation of the adrenal gland. we present the case of a 78 year old female with episodic headaches and tachycardia and severe uncontrolled hypertension, found to have elevated plasma and urine metanephrines with ct scan localizing a 1.2 cm right sided adrenal nodule. the patient was prepared preoperatively with phenoxybenzamine until mildly orthostatic with dry mucous membranes and was taken for laparoscopic right adrenalectomy. methods: after positioning our patient in left lateral decubitus, ports were placed inferior to the costal margin. the right lobe of the liver was mobilized and retracted cephalad and the ivc was exposed. careful and meticulous dissection was carried up the ivc, however no main adrenal vein was encountered. the adrenal gland was then dissected circumferentially and was removed in an endoscopic retrieval bag. there was no difficulty in hemostasis and the patient was deemed to be hemostatic prior to withdrawal of the ports and extubation. results: our patient had no issues with hemodynamic stability and her blood pressure was within normal ranges during and following the case. her hemoglobin was stable postoperatively with 11.1 immediately post op and 9.9 on discharge. her pre-op hemoglobin was 11.7. conclusions: our video demonstrates a right adrenal gland that was congenitally missing a main adrenal vein. it is very possible that small venous branches were taken with dissection however we believe this report to be important to note in the literature for surgeons performing adrenalectomy. surg endosc (2019) aims: adrenal cysts are the most frequently identified adrenal cysts, although they are a rare entity. typically they are presented by abdominal pain or palpable mass, but nowadays, cystic lesions of the adrenal gland are more often discovered incidentally by radiologic studies. adrenal cysts have an extensive differential diagnoses, which makes a difficult definitive diagnosis and a difficulty in later management. the management of an adrenal cyst can be summarized in three fundamental pillars: discard the functional status of the cyst, evaluation of eventual malignancy by images, and avoid possible complications (hemorrhage, infection), especially in large cysts . methods: clinical case: a 45-year-old male patient, with no history, studied for nonspecific pain in the right hypochondrium, without other accompanying symptoms. an abdominal ultrasound was performed, a cystic lesion in hcd without being able to identify the origin was seen. complementary explorations of interest are shown (ct), the biochemical study discards functionality of the lesion, negative serology for hydatidosis. the minimally invasive approach is the gold standard in the surgical treatment of adrenal pathology, so a laparoscopic approach is proposed for this patient. aims: endometriosis is a high incidence disease (approximately 10% of women) with a large impact on women's quality of life and fertility. endometriosis nodules surgical treatment is necessary every time there is evidence of active disease. the aim of this video is to present a minimally invasive technique for the resection of an endometriosis nodule from the abdominal wall. methods: a 41-years-old woman, with past history of endometriosis and a c-section, presents at the office with a palpable nodule at the rectus abdominis left lateral border, close to the umbilical scar. she had complaints of exuberant catamenial pain and magnetic resonance imaging (mri) showed a 33 mm nodule compatible with endometriosis depot. this technique uses 3 trocars (1 9 10 ? 2 9 5 mm) placed at the pfannenstiel scar. stepby-step as follows: (i) dissection of the pre-aponeurotic plane and isolation of the lesion (ii) lesion excision and its removal with sac (iii) closure of the aponeurotic defect braded suture. results: the post-operative period was uneventful and the patient was discharged home at post-operative day one. the aesthetic result was excellent and the patient was asymptomatic one month after the procedure. conclusion: endometriosis of the abdominal wall is related to previous c-section, is a rare event (incidence 0.1-0.4%) and usually located in the subcutaneous fat underlying the scar. the presence of nodules in the depth of the muscle is much uncommon and particularly in this clinical case, the nodule was located 8 cm cephalad from the previous pfannenstiel scar. this technique seems easy and reproducible in the authors' opinio. aims: general surgeons often face gynecological pathological findings, either along with other abdominal pathology, or as primitive cases that need laparoscopic expertise. with this particular presentation, our goal is to demonstrate the essential laparoscopic skills and the basic operative strategy that a general surgeon should be familiar with, in order to manage such cases. the presentation is made on occasion of a woman with multiple uterine fibromatosis of the pelvis, who was treated by our team. methods: we present video fragments of the laparoscopic excisional procedure for multiple uterine fibromyomatosis of the pelvis, highlighting the proper strategy in order to conclude the operation effectively and uneventfully, in a minimally invasive fashion. results: patients with multiple, large or other complex forms of uterine or pelvic fibromas can effectively be treated with a minimally invasive approach, with minimal blood loss, very fast recovery and minimal postoperative pain and complications. 2% of pregnancies require emergency surgery for a non obstetric indication, including acute appendicitis, cholecystitis, adnexal torsion, choledoco-lytiasis, hernias, intestinal obstructions, oncologic pathology or other less frequent indications. laparoscopic approach is the preffered surgical option for the patologies presented above. aims: to present the technical particularities and to analyze the outcomes of the emergency operations in pregnant women operated in hospital. method: a retrospective study including all the pregnant women operated in our hospital between 2015-2018 was performed. the preoperative workup and the surgical indication was discussed by a multidisciplinary medical team. the anesthesic and the obstetrical risk and their management was evaluated and specifically planned for each patient. the intraoperative and post-operative outcomes were recorded. results: 12 patients with gestational age between 16 weeks and 32 weeks who underwent emergency laparoscopic procedures were included in the study. out of the 12 cases we have performed 5 appedectomies, 3 cholecystectomies, 4 adnexal torsions. with a 75 min mean operating time, we had no major intraoperative complications; the technical challenges are presented and discussed. the hospital stay was 1,5 days (1-3 days). no major complications were associated with the laparoscopic approach in these cohort. one pre-term labour in a 31 weeks gestational patient was post-operatively encountered. conclusion: laparoscopic surgery can be the first option for pregnant woman with non obstetrical surgical emergencies; challenges in diagnostic, management and surgical techniques of the multidisciplinary team are expected. the objective of this presentation is to demonstrate step by step the technique to the oncologic surgeon and gynaecologist in training, including some tips and pitfalls. this is a laparoscopic transperitoneal approach in a woman with advanced cervical cancer (figo ib2) that will be treated with exclusive radio-chemotherapy. the purpose of the laparoscopic lumbo-aortic lymph node staging is to define the irradiation field. in this indication false negative in pet ct ranges from 12 to 22% (depending of the existence of pelvic fixation or not). the limits of this lymphadenectomy are: both ureters as the lateral limit of the dissection, iliac bifurcation as the caudal limit and renal veins as the cranial one. since the tumour is cervical and not ovarian, both ovarian veins are not resected. in the pathologic report, 25 lymph nodes were examined free of cancer spread. the patient have had a radio-chemotherapy with restriction of the irradiation field on the pelvis. lymphocele is a frequent complication that only sometimes needs treatment ranging from dietary changing to percutaneous drainage. if conversion to laparotomy for bleeding this technique loose its benefice but this is a rare complication. this technique is feasible and safe but requires advanced laparoscopic skills. objectives: although extremely rare, isolated splenic metastases are being increasingly diagnosed due to the improvement of imaging, survival times, and surveillance of oncologic patients. this video alerts to the growing diagnostic dilemma with primary lesions of the spleen, particularly in patients with history of cancer, and reviews the laparoscopic splenectomy 'step-by-step'. case-report: 58-year-old male patient diagnosed with rectal cancer (g2adenocarcinoma at 4 cm of the anal verge) after a colonoscopy for rectal bleeding. thoracic and abdominal ctscan and pelvicmri, showed a ct3n1 lesion, without distant metastases, except for a 15 mm suspicious splenic lesion. cea-12.2 ng/ml. after neoadjuvant therapy, a complete response was verified at the 8th week post-crt with a stable splenic lesion, and a 'watch-and-wait' program was initiated with no evidence of disease at the 3rd month. pet-ctscan did not show active metabolic features, despite an increase in the splenic lesion. in mdt, elective laparoscopic splenectomy was proposed and afterwards performed uneventfully. with the patient in semi-right lateral tilt, we approached the spleen inferiorly by dividing the splenocolic ligament. then we continued upwards, dividing the gastrosplenic ligament and exposing the splenic hilum, which was then carefully dissected, clipped and divided. finally the splenorenal ligament was divided and the spleen was extracted within an endobag, through a small pfannenstiel incision. pathologic report revealed a splenic lymphangioma. the patient is currently under a 'watch and wait' protocol surveillance with no signs of regrowth or relapse disease after 1 year and 3 months of follow-up. conclusion: one out of five colorectal carcinomas are metastatic at their presentation. isolated metastases to sites other than liver, lung or axial skeleton, are extremely rare, but can be found in the spleen. although the rare splenic secondary involvement is usually associated with breast, lung, melanoma, and gynecologic malignancies, if we consider solitary splenic metastases, colorectal and ovarian carcinomas are important sources. also, imaging including percutaneous biopsy, is frequently insufficient to clarify the nature of splenic lesions. for all these reasons, the decision-making process about this issue can be a true challenge, and will probably end up with laparoscopic splenectomy. therefore, surgeons must be familiarized with a standardized technique. sarcoidosis is a multisystem disease of unknown etiology characterized by the formation of noncaseating granulomas. sarcoidosis should be considered in the differential diagnosis of lymphoid disease. indications for diagnostic splenectomy includes a suspicion of a neoplasic process. the less invasive laparoscopic approach is the gold standard. case report: a 64-year-old female was referred to a general surgery department to complete a study to rule out lymphoid neoplasia. followed by hematology for cytopenias. biopsy of bone marrow and adenopathies were negative for lymphoid process. patient presented ct with multiple solid (8-10 mm) lesions in spleen, in thorax showed no pathological changes. laparoscopic splenectomy was performed. access with optical trocar, in mammary line. 3 triangle 5-mm trocars after pneumo under vision. section with ligasure of gastroesplenic ligament with short vessels and phrenic-splenic ligament. identification and preservation of pancreatic tail. section of splenic vessels at hilar level (branches) with ligasure. lower pole release. release of posterior part with gerota and diaphragm. incision by aid helps in bag without fragmenting. review of hemostasis, extraction of trocars under direct vision. intraoperative findings: spleen with normal external appearance, not megalic. postoperative evolution: satisfactory. first hours without incidents and with analytical control without anemization. tolerance and mobilization starts without incidents. the histopathology report shows granulomas formed by epithelioid histiocytes with the presence of multinucleated giant cells of the foreign body type, in some perisinusoidal granulomas the giant cells with the presence of asteroid bodies in their interior. the material has been revised with the extension of special studies. conclusion epithelioid granulomatosis, non-necrotizing, which suggests sarcoidosis. the procedure lasted 180 min. the hospital discharge was on the next postoperative day and no complication was registered. conclusion: splenectomy can be performed in a classic way, but at present the less invasive laparoscopic approach is the gold standard. indications for splenectomy include splenic tumours of unknown origin, suspicion of a neoplastic process, and splenomegaly. sarcoidosis should be considered in the differential diagnosis for lymphoid disease. postoperative pathological examination confirms the diagnosis. week-day surgery, university, sapienza, ospedale sant'andrea, rome, italy aims: we describe an interesting case of a female patient affected by a suspected echinococcus granulosus large cyst of the spleen. methods: a 42 years old woman complained abdominal pain and a sense of gravity in the upper left abdominal quadrant. computed tomography scan(ct-scan) showed a 13 centimetre (cm) cyst of the spleen with thickness of the wall and contrast enhancement uptake referred to an echinococcus granulosus cyst. the sierological blood test assessment, antigens and antybody markes, for echinococcus granulosus infection was negative. a laparoscopic procedure was planned. the patient was positioned on the right flank, four trocars were inserted along the left subcostal region of the abdomen: one 12 millimetre (mm) trocar for camera, one 10 mm for the assistant, and two of 5 mm for instruments. a periombelical minilaparotomy was performed for the specimen extraction. results: post-operative course was uneventful. patient was discharged in third post-operative day. istopathological exam showed a simple epithelial cyst of the spleen. conclusions: laparoscopy is safe and feaseable in case of large cyst of spleen in condition of unclear nature of the cyst. laparoscopy permits to explore the abdominal cavity and to assess the cyst characteristics in a lack overlap between the radiological exam and blood test examination. surg endosc (2019) we describe laparoscopic splenectomy for recurrent splenic cyst after laparoscopic marsupialization and partial resection of splenic cyst. the patient was a 31-year-old woman with abdominal discomfort and with a 24-cm palpable mass in the left upper and inferior quadrant. she undergone 9 years ago in another country a laparoscopic operation for splenic cyst. abdominal computer tomography revealed a cystic lesion of the spleen with concomitant huge splenomegaly. serology and oncological marker were negative. we performed laparoscopic splenectomy for the recurrent splenic cyst. the operation took 180 min. histologic examination of the resected spleen revealed a chronic hematoma. the patient had no abdominal symptoms during 12 months of follow-up. postoperative long term follow-up and examination by ultrasound or computed tomography is required after surgical treatment for splenic cyst to exclude the possibility of recurrence after spleen-preserving surgery. hand-assisted surgery is a recognized technique that combines the advantages of laparoscopic approach with the tactile feedback of the laparotomic one. it proved beneficial especially for the treatment of megaspleens due to lymphoma localization, thanks to safer handling of splenic vessels, major bleeding control and more effective detachment of superior splenic pole from the diaphragmatic dome. here we show an hand-assisted splenectomy for megaspleen reaching the omolateral anterosuperior iliac spine due to lymphoproliferative disease, in which the hand, inserted through a right subcostal minilaparotomy, was very useful during the dissecting manoeuvres, the splenic artery recognition and ligation and the isolation of the superior pole of the spleen from the gastric fundus and diaphragm. in any case of huge spleens, the specimen bagging is very difficult to perform in a pure laparoscopic way, not to mention the inexistence of capable endobag; besides, a minilaparotomy would be necessary for the spleen extraction. hand-assisted approach allow to overcome this not underestimable technical difficulty, reducing operative time with similar aesthetic and functional results to that of laparoscopic approach. aim: the evolution of technology and its application to the minimally invasive surgery of the thyroid gland offers new surgical techniques, like the transaxillary approach. this new procedure is still being implemented in our environment and has recently begun to be incorporated into our surgical practice. the objective of this case is to explain step by step how to carry out a right transaxillary endoscopic thyroidectomy and emphasize in the most relevant tips to take into account. also, current indications and limitations of this technique will be addressed. methods: a 49-year-old woman is referred for evaluation of a right thyroid nodule without any associated symptomatology. the blood test shows normal thyroid profile. cervical ultrasound is performed identifying a 3.5 cm single right nodule with well-defined edges and presence of peripheral vascularization. no other nodules are identified. fine needle aspiracion (fna) of the nodule describes a bethesda iii. after evaluation, a right transaxillary endoscopic thyroidectomy was performed. results: dissection begins in the subcutaneous plane above the pectoralis major muscle until identification of the sternocleidomastoid muscle. dissection continues towards the prethyroid muscles in order to perform a lateral approach of the thyroid gland. section of the upper pole allows better exposure of the recurrent laryngeal nerve (rln) which is being monitored intermittenly. identification and preservation of the parathyroid glands is the next step. surgery is completed with the section of the inferior pole of the thyroid along with the istmus. the postoperative period was uneventful and patient was discharged at 24 h after surgery. final pathology revealed a 3 cm nodule without malignancy. conclusion: surgical treatment of the thyroid gland by transaxillary approach may be indicated in previously selected patients with benign pathology, offering the advantages from minimally invasive techniques (shorter recovery time, shorter incision length, etc.). further research is required to make a better assessment of the minimally invasive approaches in thyroid surgery. we present the video of a thoracoscopic esophageal leiomyomaenucleation. it has been widely demonstratedthe advantages of theminimally invasive approach in surgery. esophageal thoracoscopic surgery has been suggested as an alternative to open procedures, presenting less surgical trauma, lower risk of bleeding, less postoperative pain, lower wound infection and lower pulmonary morbidity, showing similar oncologic outcomes. although leiomyomas are the most commonof benign tumors of the esophagus, they are relatively rare, presenting an incidence of 10-40 per 10.000 autopsy series. in our case, the patient was diagnosed of leiomyoma located at the medium third of the esophagus. he referred a history of 6 months of dysphagia for solid and liquids and retrosternal pain. the complementary studies were esophagoscopy, esophagography, ct and endoscopic ultrasonography. the patient was operated by a thoracoscopy approach using 3 ports. it was completed the enucleation of the tumor following the closure of the muscular layer. methylene blue test confirmed no leaks. the patient was discharged on third day postoperative developing no incidences. pathology report: leiomyoma 6 cm size, actin and desmin positive; s-100, cd 34 and cd 117 negative. we want to demonstrate the advantages of a minimally invasive approach in this kind of pathology. aims: this video shows our technique to perform thoracoscopic enucleation of large esophageal leiomyoma. methods: the patient is a 53-years-old woman with a six months history of progressively worsening dysphagia. chest ct scan revealed a 6 cm lesion of middle esophagus with extrinsic compression of mucosa and no increased fdg uptake on fdg-pet scan. barium swallow study showed a lateral deviation of thoracic esophagus due to extrinsic compression. endoscopic ultrasound confirmed the suspicion of esophageal leiomyoma. patient was scheduled for a thoracoscopic enucleation of esophageal tumor. she was placed in prone position and one-lung ventilation was employed. three trocars were placed in intercostals spaces on right hemithorax. azygos vein was identified and transected between vascular clips. esophagus was circumpherentially isolated from mediastinal structures. after myotomy, the lesion was dissected from submucosal-mucosal layer. since air leak test excluded injury of internal layer, muscular layer was closed with a continuous suture. the specimen was extracted through an endobag. a drain was left in place. results: the postoperative course was uneventful and the patient was discharged on postoperative day 7. final pathological examination confirmed esophageal leiomyoma. conclusion: thoracoscopic surgery in prone position allows removal of large esophageal tumor with several advantages. the minimally invasive technique decreases perioperative morbidity and mortality. introduction: spontaneous esophageal perforation is life threatening disease and requires emergent surgical treatment. recently, the efficacy of minimally-invasive surgery such as laparoscopic and thoracoscopic surgery for esophageal perforation has been reported. we report a novel technique of minimallyinvasive abdominal and left thoracic approach (malta) for spontaneous esophageal perforation. case presentation: 64-year-old male, who had been under hemodialysis due to iga nephropathy, complained of chest pain after vomiting several times. since the ct scan showed left hydropneumothorax and pneumomediastinum, and the gastrografin study demonstrated extravasation from left side of esophagus, we diagnosed him with the spontaneous esophageal perforation and planed emergent surgery. the patient was placed in the reverse trendelenburg position, and the legs were split, with the left side of the upper body lifted in order to perform thoracoscopy and laparoscopy simultaneously. first, we explored the thoracic cavity through a 12 mm port in the left 8th intercostal space and added other 3 ports. we identified the rupture site 30 mm in size on the left wall of the lower esophagus and sutured the mucosa and the muscle layer with a running suture respectively. we covered the perforation section with pericardium fat and irrigated the cavity with physiological saline. then transferred to the abdominal cavity, no contamination was found in the abdominal cavity. a feeding tube was inserted into stomach through the round ligament of the liver and the operation was completed. the total operative time was 173 min and the amount of intraoperative bleeding was 1300 ml including pleural effusion. postoperatively, the patient experienced left empyema pleurae but no other severe complications and was discharged on postoperative day 25. conclusion: we experienced a rare case of spontaneous esophageal perforation of a patient under hemodialysis. malta is an effective procedure for emergent esophageal operation because of great visual field of the chest and abdominal cavity without expanding contamination. introduction: digestive caustic injury is associated with high morbidity and mortality with stenosis in the long term. surgical treatment involves resection of the esophagus and reconstruction with the stomach, colon or jejunum. coloplasty provides several advantages but its vascularization is complex and involves 3 anastomosis. classically, vascular assessment was achieved by palpation through laparotomy and color evaluation. indocyanine green (icg) allows a minimally invasive intraoperative angiography in real time. methods: a 43-year-old female with medical history of caustic ingestion and subsequent esophagogastric stenosis, carrier of feeding jejunostomy.1. thoracoscopy (prone position): dissection of the esophagus from the hiatus to the upper thoracic inlet.2. laparoscopy: patient in the supine position, placement of five trocars. total non-oncological gastrectomy, post-pyloric section of the duodenum and omentectomy were completed. mobilization of the righ, transverse and descending colon. measurement of the transverse colon with a tape (distance from the neck and the esophageal hiatus). individualization of the righ, middle (with its branches) and left colic arteries and placement of clamps at the right colic, right branch of the middle colic and left colic arteries. 3 cc of icg were injected allowing for an assessment of the colon vascularization. section of the right branch of the middle colic artery. proximal section of the ascending and distal colon near the splenic angle, preserving the marginal arch. silk point to join the staple line of the descending colon and the pylorys. side-to-side mechanical antiperistaltic anastomosis between the distal endo of the coloplasty and the jejunum. finally an anastomosis between the ascending and descending side-to-side mechanical anastomosis using an assistance incision in the left flank was performed.3. cervical dissection: extraction of the surgical especimen under laparoscopic control. vascular assessment with icg is performed before and after the side-to-side anastomosis is performed. results: there were no intraoperative complications. the patient was discharged on postoperative day 11. discussion: we describe the first case of total minimally invasive colonic interposition with icg assessment of the vascularization. this technique, although technically demanding, avoids the drawbacks of the open surgery and allows for a precise assessment of the vascularization of the graft. surg endosc (2019) introduction: large pedunculated fibrovascular polyps are uncommon, mostly benign, intraluminal massess, usually located in the upper esophageal tract. most frequent reported clinical manifestation is dysphagia, followed by regurgitation, chest pain and intestinal bleeding. ct scan, and mri are the key in the diagnostic work-up revealing a sausage-shaped intraluminal mass. endoscopy with ultrasonography and biopsy add important information for the diagnosis and pedicle location. surgical excision is deemed due to potentially life-threating complication related to airway obstruction. the most frequent polyp resection is performed through cervical esophagotomy or by direct esophagectomy. however, this approach is related to a high morbidity and mortality rate. in the last years, few excisions have been reported by a endoscopical approach with a lower post operative complication. material and methods: this video shows the surgical steps of a trans-oral endoscopic surgical resection of a giant (23 cm) pedunculated polyp in a 43 year old man. the procedure was performed under general anesthesia. a flexible endoscope probe was used and the distal end of the polyp was extracted through the oral cavity with a loop. the endo-gia stapler was used to cut the base of polyp and finally removed. the anatomo-pathological study confirmed the diagnostic of a fibrovascular polyp with no evidence of malignancy. results and conclusions: the patient had an uneventful recovery with no recurrency at 3 years of follow up. this minimally invasive approach is a safe and feasible procedure to treat large esophageal fibrovascular polyps avoiding the complications related to more aggresive procedure. introduction: leiomyomas are the most common mesenchymal tumors affecting the esophagus and they usually grow in the mid to distal third of it. they tend to be asymptomatic, but sometimes they can grow to enormous size and produce dysphagia. case report: 61-year-old male asymptomatic patient was referred to our hospital due to an incidental finding. ct scan revealed a 41 x 35 mm rounded submucosal tumor on the dorsal side of the lower third of the esophagus. upper gastrointestinal endoscopy revealed a cystic lesion in the lower esophagus 37 cm from the incisor teeth, with normal overlying mucosa. an endoscopic-ultrasound-guided fine-needle-aspiration of the mass was performed, which was reported as a likely leiomyoma.conservative treatment was performed, no growth was detected during eleven years of follow-up. but it became symptomatic, the patient complained of progressive dysphagia caused by compression so surgical resection was decided.laparoscopic enucleation of esophageal leiomyoma was performed. the tumor was reached by transhiatal dissection. a careful dissection of the mass was performed, preserving the vagal branches. an intraoperative endoscopy was performed to verify the integrity of esophageal mucosa and that the tumor was completely resected. the muscular layer was sutured after enucleation using absorbable suture material and the hiatus was closed with non-absorbable suture material. a dor fundoplication was also performed. a swallow test with a water-soluble contrast was obtained on postoperative day one. no pathological findings were found so the patient was asked to drink.histopathological exam revealed a tumor measuring 70 mm 9 33 mm 9 17 mm consistent with leiomyoma.the procedure lasted 160 min. the hospital discharge was on the third postoperative day and no complication was registered. conclusion: surgical excision is the mainstay of treatment and is recommended for symptomatic leiomyomas and those greater than 5 cm. this case report demonstrates the technical feasibility, safety and minimal postoperative morbidity associated with minimal invasive esophageal surgery. introduction: total esophagectomy by means of minimally invasive surgery has proven to be a valid and effective alternative for performing this procedure. however, this procedure is not implemented in most centers. objective: demonstrate the technique of a total esophagectomy by endoscopic surgery for a benign esophageal stenosis. material and methods: clinical case: a 75-year-old female patient diagnosed with double esophageal peptic stenosis, treated on several occasions with endoscopic dilation by digestive, showing in the last endoscopy: severe esophagitis with stenosis impassable to 22 cms. additional tests of interest are exposed. resolved: intervention: right thoracoscopy in prone position, dissection and complete mobilization of the thoracic esophagus, section of the azygos vein, pleural drainage. laparoscopic time, 5 trocars, gastrolysis respecting the right gastroepiploic vessels, broad kocher until the cava is identified, vascular section of the vessels left gastric, full mobilization of the stomach, subxiphoid minilaparotomy, beginning of the cervical time with dissection of the cervical esophagus, section and fixation of this to a tube, externalization of the piece by abdominal route, creation of the gastric tubular with successive loads of gia, ascending posterior mediastinal plasty with manual esophago-tubular anastomosis, with placement of drainages and feeding jejunostomy. right operative with radiological control with gastrografin on the 6th day, discharge from hospital on the 11th day. asymptomatic one year after surgery, with radiological control without alterations. conclusions: the approach of esophageal peptic stenosis with minimally invasive surgery is safe and effective, adding the advantages inherent to this type of technique. (figs. 1, 2) , showing a cystic lesion in the gastric submucosa with a well defined, medial and superior to the lesser curvature of the stomach with exophytic growth. it causes extrinsic compression of the cardia in the gastric body. within the differential diagnosis are gastric duplication cysts or gastrointestinal stromal tumor. a biopsy was taken, discarding the presence of neoplastic cells. finally, a study of digestive transit showed extrinsic compression at the cardial level, which causes difficulty in passing contrast. a laparoscopic approach was performed beginning with the dissection of the abdominal esophagus. the presence of a cystic lesion on the anterior face of the abdominal esophagus was identified (figs. 3, 4) . we proceeded to the complete resection of cyst. the surgery was completed with 180°f undoplication anterior dor. the patient went home on the 3rd day without incident. results: duplication cysts are congenital malformations of the gastrointestinal tract contiguous with the esophagus, which can communicate with the esophageal lumen. most are diagnosed in childhood, but when it is diagnosed in adults, they used to be symptomatics. it is more frequent in men. although the pathogenic mechanism is unknown, it is caused by an anomaly during embryonic development. they are located in the thoracic esophagus, at the level of the lower and posterior mediastinum and, less frequently, in the abdominal esophagus, as in our case. they can give digestive symptoms(epigastralgia, vomiting) or respiratory symptoms. the diagnosis is made with eda, ct, and ecoendoscopy of choice, although it may be incidental. the treatment of choice in symptomatic patients is complete resection or cystic enucleation. in asymptomatic surgical is not defined, because it can cause complications, and, malignization due to degeneration is very infrequent. conclusion: the most of duplication cysts are diagnosed in childhood, although it's more frequent in adults to be symptomatic. surgical treatment can cure this disease. however, the choice between these becomes difficult in young patients, where the low incidence does not allow get series of long patients and decisions must be based on results achieved in adults. objetivos: to demonstrate the safety and efficacy of the laparoscopic approach in this infrequent pathology, pointing out the importance of having standardized the procedure to achieve better results. material and methods: case report: a 19-year-old man with progressive dysphagia until almost complete afagia, with clinical, endoscopic, radiological and manometric diagnosis,compatible with typical primary achalasia. chagas negative serology,we show the complementary studies of interest.dilatation is not performed, preoperative symptomatic treatment with calcium channel inhibitors. intervention: laparoscopic approach, 5 trocars, aberrant left hepatic artery with signs of severe esophagitis,opening of the gastroesplenic-hepatic ligament, no retroesophageal window, dissection of the hiatus and inferior mediastinal, preservation and mobilization of the left hepatic artery and the anterior vagus,meticulous disection of the cardia,standardized myotomy: first proximal 8 cms. with adequate simultaneous traction of both edges of the myotomy, then distal myotomy including 2-3 cm, including selectively the distal oblique fibers of les, tutorization with fouché and methylene blue to confirm good step and absence of leakage, dor-type funduplication, 4 pts on each side, fixed to both pillars, hiatalmediastinal drainage. egd on the 1st day of normal po, dischargeat 3rd day, asymptomatic and with normal radiological control at 1 year of age. conclusions: laparoscopic mh should be the first therapeutic option, in patients with primary achalasia, even in young patients. the length of myotomy, especially distal to ueg is one of the most important aspects of surgery, most authors (pellegrini) recommend that the myotomy extend 1-2 cm in the stomach, even up to 3 cm below the ueg to achieve an effective disruption of the eei.the standardization of the procedure is fundamental to increase safety and effectiveness in these more complex cases. aims: the surgical treatment of giant hiatal hernias is a complex and demanding procedure, not only in terms of performing the operation in a minimally invasive abdominal fashion by avoiding thoracic approaches, but also concerning the management of large hiatal defects which contribute to high recurrence rates. our aim is to present our surgical technique for the reconstruction of such hiatal hernias, exploiting the benefits of the robotic approach and also to highlight the technical aspects of non-absorbable mesh placement in order to bridge effectively the hiatal defects. methods: we present video fragments from a procedures selected from a series of cases of robotic reconstruction of giant hiatal hernias performed by our team, in which a non-absorbable meshes were utilized to restore the hiatal gap. we emphasize on the clear benefits of robotic surgery in these cases and on the strategy of how to avoid high recurrence rates. results: all of our patients, who underwent reconstruction of giant hiatal hernias with this particular technique, experienced very good early post-operative results, very short hospital stay and no recurrence in a 12-month follow-up. conclusions: the robotic approach for the treatment of large hiatal hernias offers great advantages to both surgeons and patients, by eliminating the restrictions of conventional laparoscopic surgery, minimizing intra-operative incidents and post-operative complications. large hiatal defects are very effectively closed with the use of advanced suturing techniques and non-absorbable meshes in a tension-free bridging fashion. aims: mckeown esophagectomy is commonly used for invasive esophageal carcinoma. as the morbidity and mortality rates for esophagectomy are persistently high, minimally invasive esophagectomy in prone position is expected to reduce respiratory postoperative complications. there is still limited experience for the use of minimally invasive approaches in patients undergoing surgery after neoadjuvant chemoradiation and many concerns about the feasibility, safety, and oncological outcomes of these procedures are still present. methods: we present the case of a 55-year-old female with a middle third esophageal squamous cell carcinoma, who received neoadjuvant chemoradiation. she underwent laparoscopic and thoracoscopic (prone position) mckeown esophagectomy with hand-sewn esophagogastric anastomosis through a left lateral cervical incision. results: the operation was completed successfully, with no conversion to open surgery. the operative time was 6 h with minimal blood loss and the patient was fed on day 5 and discharged on day 7 post-op. r0 resection was achieved and the number of total harvested lymph nodes was 44 (3 positive nodes, n2). conclusions: minimally invasive mckeown esophagectomy in patients with esophageal cancer and prior chemoradiation is feasible and safe procedure with acceptable oncological outcomes. results: preliminary results demonstrated that minimally invasive ivor-lewis esophagectomy procedure, provided of a better postoperative pain control and less respiratory complications. in order to standarise our procedure, the video shows how three different types of esophagogastric anastomosis are performed, depending on the patient characteristics, anatomical factors and safety and comfort for the surgeon: manual termino-terminal, mechanical termino-terminal and mechanical latero-lateral. conclusions: in our way to standardization, we are still looking for the best type of anastomosis, even though, we find out that, manually performed anastomosis are easier to performed, when the section in esophagus is lower, involving medium and inferior third. in the other hand, mechanical termino-terminal anastomosis seemed to be an ideal option for upper sections. more studies are needed in order to standardized one anastomosis, for all cases. because esophagectomy with radical lymphadenectomy is highly invasive, thoracoscopic esophagectomy (te) is attracting attention as a less invasive procedure. we first performed te with the left decubitus position in 1996. in 2009 we developed a hybrid of the prone and left lateral decubitus positions for te, and a total of 470 patients underwent te with a hybrid position . we introduced te with a hybrid position for the following three reasons: (1) mobilization and lymphadenectomy around the middle and lower esophagus are easier in the prone position. thanks to artificial pneumothorax and the gravity, the middle and lower mediastinum are opened, and which give us good surgical field. (2) lymphadenectomy along the left recurrent laryngeal nerve (rln) is more reliable and precise when performed in the left lateral decubitus position. we can dissect lymph node around the rln higher position in the upper mediastinum. (3) unexpected events requiring conversion to thoracotomy (e.g., massive bleeding, injury of other organs, dense intrathoracic adhesion, resection of adjacent organs) are easier to deal with in the left lateral decubitus position. the patient is fixed on the operating table with the semi-prone position and we can easily change patient positions from the left lateral decubitus position to the prone position and vice versa using rotation system of the operation table. the upper mediastinal procedure including lymphadenectomy along the right and left rln is performed with the patient in the left lateral decubitus position, while the middle and lower mediastinal procedures are performed with the patient in the prone position with artificial pneumothorax (7 mmhg). theabdominal procedures wereperformed by hand-assisted laparoscopic surgery (hals) and gastric tube reconstruction through aposterior mediastinal route was performed as a standard surgical procedure in our institution. the magnifying effect of thoracoscope enables us to perform more precise surgery and preserve nerve and vessels, and a hybrid position is thought to be feasible and effective methods. ivor lewis esophago-gastrectomy is a standard procedure for the treatment of distal esophageal cancer. among the years, the surgical community standardized the mininvasive abdominal phase. the thoracic phase is much more complex because usually all surgeons get in trouble in the phase of esophago-gastric anastomosis. in fact, is still very difficult and tricky to perform a mechanical circular anastomosis due to problems with the correct handling of the circular stapler through the minitoracotomy and is also difficult to place the anvyl in the proximal esophagus. the linear anastomosis (side-to-side) is a little bit easier but not so effective as the circular anastomosis in terms of leak rate. we think that robotic approach with its endowrist can allow us to overcome these limits and that a tailored double layer hand sewn esophago-gastric anastomosis could be the right choice. we treated 4 patients with this approach and they were all uneventful in the post operative period except for a case of chylothorax we treated successfully with lipiodol injection in inguinal lymphnodes. we need more cases to analyze the technique in terms of leak rate and major complications but we think this is a promising and cost-effective procedure for robotic approach. aim: anastomotic leakage is one of the most dreaded complication after esophagectomy. indocyanine-green near-infrared angiography (nir-icga) intraoperative use has been recently introduced for visceral perfusion evaluation. in this video we present our technique for gastric conduit fashioning according to the nir-icga blood supply evaluation in a total minimallyinvasive ivor-lewis esophagectomy. methods: a 48 years-old man affected by a siewert 1 adenocarcinoma (ct3, n2, m0) underwent a preoperative neoadjuvant treatment according to cross protocol. at restaging ct-scan no more pathologic nodes were evident (ct3, n0, m0). the patient was submitted to a total minimally-invasive ivor-lewis esophagectomy. surgical procedure: after pneumoperitoneum induction and 4 trocars insertion, the lesser omentum was opened and a lymphadenectomy at stations 12a, 8, 7, 9 and 11 performed. the esophagus was dissected at diaphragmatic hiatus with lymphadenectomy at station 1, 2 and 111. the larger omentum was opened along the right gastroepiploic arcade, that was preserved, the short gastric vessels divided and gastric fundus mobilized. by evaluating the presence of an intense fluorescence at nir-icga, a tailored partial tubulization of the stomach was performed with multiple linear stapler firing. a right thoracoscopy was performed through 4 trocars. the azygos vein ligated and divided. the mediastinal pleura was opened and the esophagus was dissected entirely with an en-bloc excision of nodes at stations 110, 112 and 108. nodes at stations 105, 106, 107 and 109 were removed separately. the esophagus was sectioned above the azygos vein level and a purse-string fashioned. the cardia and the gastric tube were pulled up and a minithoracotomy performed. a new nir-icga was repeated to verify the good blood supply and tailor the site of anastomosis on a well perfused area. the stomach was opened and a circular stapler inserted. after the end-to-side esophago-gastric anastomosis fashioning, the tubulization was completed by 2 linear stapler firing and the specimen removed. results: the post-operative course was uneventful and the pathologic examination revealed a cardial adenocarcinoma (ypt2,n0, r0). conclusions: nir-icga is an interesting and easy-to use tool for surgeons. nevertheless in literature is still not clear which is the best parameter to measure the blood supply. large studied are needed. aim: uses and application of indocyanine green (icg) fluorescence in the field of surgery are growing exponentially. the safety and feasibility of its usage has been proven in several areas and various pathologies of surgery and surgeons are starting to incorporate it into their common practice. however, there are still several aspects to define regarding this technology. we present different uses of icg in the specific area of esophageal cancer. methods: we used icg fluorescence at different moments of a two-field minimally invasive esophagectomy. first of all, peritumoral injection of icg may offer a lymphatic mapping, both in the abdominal phase of the surgery and the thoracic one, improving lymph node dissection by allowing a more targeted and less morbid approach that includes all relevant nodal stations. at the moment of the gastric section, intravenous injection provides assessment of gastric conduit perfusion, therefore optimizing the construction of the graft to avoid the inclusion of poorly perfused areas that may increase the risk of leak of the anastomosis. besides that, the esophagogastric anastomosis can be tested in the thoracic phase of the operation in order to check an adequate perfusion and prevent further complications. results: we consider that icg fluorescence is a promising technology that could be easily introduced in the surgical routine of the esophageal surgeon as an instrument to assess the anastomosis perfusion. icg is also feasible in detecting lymph node drainage from the esophagus, although its technique of application needs to be defined. conclusions: icg fluorescence has opened a new world of possibilities in all the different surgical specialties. its use in the esophagectomy is safe, simple and feasible. in a near future, its application to esophageal cancer surgery could improve survival by predicting and preventing anastomotic leak and guiding in a tailored lymphadenectomy. further research is needed to demonstrate these promising applications. introduction: the oesophagectomy is currently still mandatory in the curative treatment of the malignant oesphagic pathology. this procedure is defined by important morbidity and mortality. the minimally invasive approach aims to reduce the complications without repercussion on the oncological outcomes, however it's not exempt from them being a demanding surgical technique like it is. aim: we present the video of three complications after a three-stage oesophagectomy (mckeown-like) with the thoracic stage via thoracoscopy and the minimally invasive surgical solution for both of them. methods: all three cases represent a three-stage oesophagectomy for malignant esophageal pathology. the first one was a 50-year-old male who suffered an intraoperative left main bronchus injury. the second case was a 62-year-old male with no intraoperative complications whatsoever. nonetheless, on the second postoperative day, milky drainage started to appear through the thoracic tube. the third and final case represents an intraoperative hemorrhage, which is the most common complication of this kind of surgery. results: the first case was diagnosed and treated intraoperatively with the use of an adhesive matrix. during the postoperative period the patient showed no further complications. the second case was a chylothorax, diagnosed on the second postoperative day. it was treated initially with conservative measures. due to bad evolution, he underwent surgery on the tenth postoperative day. we can see how we ligated the stump of the thoracic duct in the original surgery and then how we repaired the unexpected leak. after the second surgery, the patient was discharged on the sixth day. the last patient was also diagnosed and treated intraoperatively successfully, with no repercussion whatsoever in the postoperative time. conclusions: the minimally invasive surgery has many advantages in the upper gastrointestinal field. it is a demanding technique, so it is important to be able to treat the complications that may arise with this approach. surg endosc (2019) aims: the use of icg fluorescence is incrising in surgery, mainly as a test of vascular supply in colonic anastomoses. during the last years, other potential uses have been described, such as the identification of the sentinel lymph node and lymphatic mapping in oncological surgery. these advances could allow a better staging in order to decide the most appropriate treatment to each patient. gastric cancer is one of the fields where this could play a key role in the near future. we present a case of a patient who underwent a laparoscopic total gastrectomy with icg-guided d2 lymphadenectomy, where a personalized lymphatic mapping was performed. methods: a 37-year-old male patient underwent gastroscopy for gastric discomfort, and a gastric carcinoma was detected at the greater curvature of gastric body. endoscopic biopsy was informed as diffuse type gastric adenocarcinoma. the preoperative staging was completed with echoendoscopy and ct-scan (t1bn0m0). we decided to perform a laparoscopic total gastrectomy with icg-guided lymphadenectomy. the preoperative day, a gastroscopy was performed to inject 0.75 mg of icg in four submucosal areas around the tumor. results: intraoperatively, the lymphatic mapping marked by icg was checked, allowing the identification of the territory of drainage of the tumor to lymph nodes at the lesser curvature, the greater curvature and the splenic artery. a d2 lymphadenectomy and a total laparoscopic gastrectomy with roux-en-y reconstruction was performed. during the lymphadenectomy, we were able to observe marked lymph nodes in territory 11, and also observed that the paraaortic lymph node behind the celiac trunk did not become green and the lymphadenectomy at this area was not continued. the patient presented no postoperative complications, and was discharged on the seventh postoperative day. the histological results showed a diffuse type gastric adenocarcinoma pt2n1 and 26 isolated lymph nodes, being one of them possitive (corresponding to the adenopathy marked at the greater curvature). conclusions: lymphatic icg-mapping in gastric cancer is a potential revolutionary advance that could ensure a correct lymphadenectomy, avoiding lymph node understaging. it is necessary to continue carrying out studies that will allow developing protocols to define appropriate lymphadenectomy based on icg-mapping. introduction: petersen's hernia is one of severe postoperative complication after gastrectomy, which may result in massive resection of small intestine. it is considered an essential proscedure to close the petersen's defect for all cases after such reconstruction after gastrectomy as roux-en y method. we report a case of petersen's hernia after radical gastrectomy, which was repaired laparoscopically. patient: the patient was 59-year-old male, who underwent laparoscopic distal gastrectomy for gastric cancer (d2 lymph node dissection followed by roux-en-y reconstruction) two years ago. the closure of petersen's defect was not performed in the initial operation. he was aware of abdominal pain and visited emergency unit in our hospital. abdominal ct scan showed internal hernia of petersen's hernia. surgical procedure: in laparoscopic examination, dilation of small intestinal and mastoid ascites was observed. massive small intestine including y-limb entered into petersen's defect from left to right side. we carefully pulled through the small intestine and confirmed absence of ischemic change in the whole small intestine. then the petersen's defect was closed by continuous suturing with 3-0 non-absorbable barbed suture. results: the operation time was 95 min and the estimated blood loss was 10 ml. oral intake was started from the next day of the operation. there was no postoperative complication. the patient was discharged on the 10th postoperative day. conclusion: we could safely perform laparoscopic repair for petersen's hernia. regarding technical points in the procedure, it is important to judge the direction of the small intestine into the petersen's defect, to manage the dilated small intestine gently, and to close the petersen's defect by laparoscopic suturing. introduction: in this case we present a 52-year old male with a history of morbid obesity, sleep apnea and psychiatric affliction including alcohol and nicotine abuse. in 2009 he underwent a laparoscopic roux-en-y gastric bypass. the results were satisfactory, with no complications post-surgery, and a steady weight loss over time (pre: 162 kg, post: 125 kg). in november 2017, he presented with complaints of dysphagia and weight loss (12 kg in 3 months). laryngoscopic examination by the otorhinolaryngologist was negative. he was referred to gastro-enterology for gastroscopy. biopsies showed a mildly differentiated adenocarcinoma of the gastro-esophageal junction with submucosal invasion. objective: after negative staging assessment, multiple treatment options were considered. the route of choice ended up being a laparoscopic radical gastrectomy with esophago-jejunostomy, with the objective to achieve optimal oncological results. methods: the procedure is demonstrated in this video. the gastric pouch as well as the remnant stomach, greater and lesser omentum were resected laparoscopically. due to the invasion of the carcinoma into the distal esophagus, a segment of the esophagus was resected as well. following anatomopathological examination on frozen section, the resection margins were reported malignancy free. results: postoperatively, there were no complications. ct scan with contrast showed no signs of leakage. anatomopathological examination confirmed the tumor to be a mildly invasive and poorly differentiated adenocarcinoma with local signet-ring cell differentiation (pt1bn0). there was no need for adjuvant therapy. oral intake was sound. conclusion: adenocarcinomas of the gastric pouch are rarely seen following gastric bypass. this patient presented with complaints of dysphagia, and an adenocarcinoma was diagnosed. consequently, the patient had a total gastrectomy at our hospital. the surgery was performed laparoscopically, and was executed with success. to conclude, it is feasible to treat adenocarcinomas after gastric bypass laparoscopically via total gastrectomy and omentectomy. 80 year old, female patient presented with upper abdominal discomfort and microcitic anemia. an ulcerative lesion was found on gastroscopy examination in body of the stomach (near the grate curvature). biopsy was done and pathology result showed poorly differentiated adenocarcinoma. chest computed tomography (ct) was without any significant findings. abdominal ct showed the lesion in stomach without enlargement of regional lymph nodes. her blood laboratory examinations were within normal limits, including serum cea. patient underwent laparoscopic total gastrectomy with modified d2 lymphadenectomy and roux-en-y esophagojejunostomy. total operating time (ort) was 218 min. three days after operation, patient has developed none st elevated mi and respiratory failure. she was intubated. on day 6 after operation she was extubated, on day 9 patient started regular diet and was discharged home on day 13. final pathology result confirmed poorly differentiated adenocarcinoma of the stomach. this video shows our favourite technique for laparoscopic d2 subtotal gastrectomy. we usually perform the procedure with 4 or 5 trocars; after the coloepiploic detachment we perform the gastric transection first! this manoeuvre provides a perfect view for the lymphadenectomy. at the end of our dissection we transect the duodenum with seamguard reinforcement. before going on with the reconstructive phase, we prepare the roux en 'y' with double loop technique, usually without dividing the mesentery. then we remove the specimen through a periumbilical 3-4 cm minilaparotomy; we think it's important anyway to check margins and distance from the tumor before going on with the reconstructive phase. from the same minilaparotomy we retrieve the prepared limb for roux en y and we perform a side to side mechanical linear anastomosis outside.then we proceed with performing the anastomosis between the gastric pouch and the alimentary limb by laparoscopy. we like very much this technique for the increased exposition of tissues during lymphadenectomy. laparoscopic roux en 'y' d2 surg endosc (2019) a body-tc was performed in which axillary, mediastinal adenopathies and images suggestive of hepatic metastases were identified. the biopsy confirms a gastrointestinal stromal tumor. the case discussed in a multidisciplinary committee and the pet-ct study was completed, subcardial gist t4n1m0 was diagnosed. neoadyuvance was decided with imatinib for one month and surgery was performed using a laparoscopic approach. the approach was performed with 5 trocars (11 mm supraumbilical, two 12 mm subcostal left and right, 5 mm subxifoid and 5 mm left flank). gastrectomy was performed with d1 lymphadenectomy following the oncological principles of subcardial tumors. the piece was removed in a bag by extending the 11 mm port to mini-laparotomy. esophagogastric anastomosis was performed by hand assisted circular mechanical suture. methylene blue test was carried out. no nasogastric tube left, but drainage tutoring the esophagogastric anastomosis was left. results: the postoperative evolution was favorable. oral tolerance without incidents at fourth postoperative day. the patient was discharged without incidences on the seventh postoperative day. the pathological study of the piece was reported as subcardial gastrointestinal stromal tumor 3 cm with respected surgical margins and 11 lymph nodes free of malignancy, postoperative diagnosis of t2n0m0. one month after surgery, the patient has adequate oral tolerance. she does not report gastroesophageal reflux and at 6 months remains asymptomatic and with good evolution. conclusions: laparoscopic proximal gastrectomy is a technique that is not currently used but can be performed through a laparoscopic approach. it is a safe technique with good clinical and oncological results, especially in the early gastric cancer and gastrointestinal stromal tumors. however, long-term studies are necessary. laparoscopic gastrectomy is a perfectly safe option nowadays for the treatment of gastric cancer. every year the percentage of the laparoscopic approach is rising not only in the east but also in the west. we present a case of a 44 year old female patient with a gastric tumor of the antrum-g3 adenocarcinoma with a ct2n0m0 staging. we perform a subtotal laparoscopic gastrectomy with a d2 lymphadenectomy and roux-en-y anastomosis. the patient begin clear liquids on the first post operative day and was discharged on the 5th. the final anatomopathological result of the specimen was a adenocarcinoma (g3)-pt1n0. there were 37 nodes resected all negative. the case was discussed in multidisciplinary team and was decided for clinical follow up with no further treatments. the patient was evaluated one month after surgery with no complaints and will continue the follow up. upper gi surgery, university of verona, verona, italy laparoscopic endoscopic cooperative surgery is an option in medium size submucosal cancers invading the muscular layer, mainly in border area were wedge resections are nor feasible.in this video we report a case of prepiloric gist treated with news technique (nonexposed endoscopic wall-inversion surgery).we think that this technique is feasible and safe and should be considered a valid option with a view to preserving the organ. aim: laparoscopic wedge resection or partial resection is a safe and feasible stomach preserving approach to gastric submucosal tumors (smt) such as gastrointestinal tumors (gist), and it has been widely performed recently. however, it should not be applied to the tumors at cardia in order to avoid stenosis or disruption of anti-reflux mechanism. we have introduced percutaneous endoscopic intragastric surgery (peigs) for smt at cardia since 2013 to preserve function of cardia. we will report the tips, techniques, and clinical result of our peigs. methods: from september 2013 to august 2018, seven patients with smt at cardia underwent peigs in our hospital. we insert the 12 mm port at umbilicus and investigate the abdominal cavity at first. then the incision is extended to 2.5 cm and lap-protector tm is equipped with the site to perform mini-laparotomy. using peroralendoscopy, a stomach was insufflatedand incision is made at an anterior wall of gastric body under direct vision. additional lap-protector tm is placed into the stomach so that the stomach is fixed on the abdominal wall. it enables us to keep direct access to gastric lumen and stable operative field. ez access tm is attatched on lap-protector tm , and intragastric operation is started. subsequently, two trocars are inserted using funada's gastropexy instrument. tumor is dissected by using energy devices, avoiding injury of capsule of the tumor. the defect of the gastric wall is closed by intragastric suturing. we should take particular care not to damage egj during the suturing, inserting peroral endoscopy in and out. results: the mean operation time was 145(117-149) min and the amount of intraoperative bleeding was 5.0(3.0-7.5) ml. the maximum diameter of tumors was 30(15-30) mm. one case was low risk gist and otherwise were leiomyoma. the postoperative course was uneventful in all cases, without leakage or stenosis. total hospital stay was 9(8.5-9) days. no patient had symptoms of esophagitis. conclusions: peigs for smt at gastric cardia is a feasible and safe approach, preserving function of cardia. our procedure achieves great stability and excellent visualization during the operation, which may have led to the fine surgical results. laparoscopic lymphadenectomyin gastric cancer is considered a feasible and safe procedure. data on the compliance of lymphadenectomy in the various lymph node stations is not yet well understood; moreover it is not clear if there are particular conditions relate to the patients impairing the oncological results. this video reports the use of the icg for the lymph node dissection of station number 6 in a case of obese patient and a case of a cirrhotic patient. fist patient, m.a., was a 67 year old man with distal cancer ct2n0 and a 32 bmi. second patient, t.d., was a 56 year old man with distal cancer ct2n0 and a alcoholic cirrhosis child b7. in both cases, intraoperative endoscopy was performed 20 to 30 min before the onset of lymph node dissection. 0.1 mg of icg was injected into the submucosal layer in 4 quadrants of the primary tumor. a laparoscopic subtotal gastrectomy was conduced with d2 lymphadenectomy. lymph note navigation were analyzed by novadaqò detector. using navigation system we removed the n6 basin. in both cases dissection were effective and pancreatic surface were easily detectable. number of lymph nodes retrieved was 8 in the case of obese patient and 3 in the case of cirrhotic patient. pathological tnm were pt3n0 (0/50 n ?) in the first case and pt3n1 (2/40 n ?) in the second. no n ? metastases were detected in n6 station for both cases. no pancreatic fistula was recorded. icg lymph node navigation system should be considered a valid support for the surgeon for completion of a correct lymphadenectomy in surgical challenging cases. aims: morgagni hernia is the rarest of congenital diaphragmatic hernias (2-3%). its presentation is rare in adults and its finding is usually incidental. it was first described by giovanni b. morgagni in 1769. it is located in the anterior region of the diaphragm. it is caused by a congenital defect in the fusion of the transverse septum of the diaphragm and the costal arches. the need for surgery depends on the presentation, it is recommended early repair before the development of complications. classically, the surgical approach was thoracotomy or laparotomy. currently, the tendency is to use a minimally invasive approach, which has shown good results, lower morbidity and faster recovery. the need to repair the defect with a mesh is controversial, recommended when it is not possible to close the defect without tension. the objective of this video is to demonstrate the safety and efficacy of the laparoscopic approach for the repair of this type of hernia, as well as the different types of mesh that can be used. aims: the treatment of the non-metastatic gastro intestinal stromal tumour (gist) is the surgical resection [1] . the duodenal gastro-intestinal stromal tumour (gist) is a relatively rare clinical entity. from all the resected gist, only 5% are duodenal [2] . the clinical presentation could vary from the most common acute gastro intestinal (gi) bleeding, chronic anaemia, but also acute abdomen caused by tumour rupture and intestinal obstruction. methods: a 69 years old patient present at the emergency department of the chi poissy-st germain-en-laye (paris, france) with acute gastrointestinal bleeding. at the laboratory exams the haemoglobin was 9.1 g/ dl. the patient perform a computer tomography (ct) which shows two hyper vascularised lesion at the 4th duodenum; this lesions has an intra and extraluminare growing. the ct scan didn't show any other abdominal lesions. the patient were submitted to a minimally invasive surgical operation with the multiport laparoscopic technique. results: the resection of the 3th and 4th duodenum and of the first 5 centimetre of jejunum was performed with a four trocar laparoscopic technique. a latero-lateral duodeno-jejunal mechanical anastomosis was performed. the operative time was 90 min. the patient start with oral alimentation on the third post-operative day after a ct scan with oral contrast that was negative for anastomotic dehiscence and collections. the post-operative course was globally uneventful and the patient was discharged at fifth post-operative day without complications. the histological examination shows a low risk gist, cd117 positive and with a ki-67 inferior of 2% (classification tnm 7th edition pt1 aims: gastric volvulus are a rare condition that sometimes represent a diagnostic challenge for surgeons. here we present the video of a recent case of a gastric volvulus in our area that was treated with a minimal invasive approach. methods: we report the case of a 58-year-old woman who was admitted in the emergency room (er) with epigastric transfixing pain and impossibility to vomit that had started 8 h prior to the admission. the physical exam showed good vital signs, and her abdomen was soft, with a tendency to tenderness with palpation in the epigastrium without guarding or rigidity. her lab tests were normal and the conventional radiology showed a double gastric bubble. we run an urgent computed tomography scan (ct scan) and a upper gastrointestinal (gi) endoscopy that showed a big type ii hiatal hernia that was complicated with a gastric volvulus. results: first, a nasogastric (ng) tube was placed for decompression of the stomach at the time when the endoscopy was made. the patient experienced a great improvement of the pain with that initial measure and remained stable. after almost a day of appropriate resuscitation, she underwent urgent surgery: we performed a hernia reduction, resection of the hernia sac, hiatal closure and a gastropexy and nissen fundoplication. the patient suffered no complications in the immediate postoperative time and was discharged after six days. conclusion: gastric volvulus are an uncommon emergency that we need to keep in mind. a simple abdomen x-ray can be very helpful, given that the double gastric bubble sign is a typical sign of this condition. it's always mandatory to perform an upper gi endoscopy in order to get to the diagnose and place a ng tube promptly. the surgery can be safely delayed in stable patients with no signs of ischemia, and a laparoscopic approach is associated with a shorter hospital stay and good long-term outcomes in this kind of patients. aims: during laparoscopic treatment of hiatal hernias the dissection can be complicated, but even more so the closure of the pillars, especially in giant hiatus hernias with a large defect. the use of prosthesis is controversial due to the lack of long-term studies and the possibility of secondary complications. the aim of this video is to demonstrate the safety of mesh hiatoplasty in hiatus hernia surgery. methods: we present the case of a 78-year-old woman with hypertension, hypothyroidism and right hemicolectomy for neoplasia 18 years ago. the patient presented with malnutrition, with a weight loss of 15 kg in the last months. a gastroscopy was performed in which a large hiatus hernia, that caused gastric volvulation, was shown. the upper gastrointestinal oral contrast study revealed esophageal tertiary waves and good passage to the gastric chamber, with an organoaxial volvulation of the stomach that was completely included in the thoracic cavity. results: through a five trocar laparoscopic approach, a large paraesophageal type iv hiatal hernia (7 9 6 cm hiatal orifice) with complete herniation of the stomach and greater omentum to the mediastinum was observed. after reduction of the hernia content, complete dissection with partial resection of the sac was performed. an extended mediastinal dissection of the esophagus, with descent of the esophagogastric junction until achieving an abdominal esophagus of 3-4 cm, was carried out. after posterior and anterior phrenorrhaphy with nonabsorbable sutures, dislacement of the right pillar without diagragmatic opening was evidenced. it was decided to reinforce the hiatorraphy using a c shape composite mesh fixed with nonabsorbable sutures. the procedure was completed with a nissen-type fundoplication. postoperative course was uneventful and the patient remains without hernia recurrence 9 months after the intervention. conclusion: prosthetic reinforcement in hiatal hernia repair can be a very useful resource in large hiatal defects in which a stress-free hiatus closure cannot be achieved. however, its use must be individualized according to the characteristics of the patient, the quality of the tissues involved and the result of simple hiatorraphy. aims: heller myotomy is an advanced laparoscopic surgical technique for the treatment of achalasia, a rare disease in which long time is needed to achieve the learning curve. surgical simulation, using animal models with an anatomy similar to humans, could help improving surgeon performance in a shorter time. the aim of our video is to show an ex-vivo and in-vivo animal model for heller myotomy training. methods: a cadaveric porcine model was developed using a tissue block including the esophagus and the stomach, without the diaphragm, mounted in a physical laparoscopic simulator. training procedures were also performed in an in vivo porcine model. experiments were carried out in the ' jesús usón' minimally invasive surgery centre in cáceres. results: the surgical technique is described step by step, first in the esophagus-stomach ex-vivo model and later in the live animal model. conclusion: surgical simulation using cadaveric an live animals offers a realistic representation, allows training in a safe environment, and can be very useful for advanced laparoscopic training in low incidence pathologies. introduction: esophagic perforation is one of the least frequent complications after laparoscopic nissen fundoplication, but it remains one of the most dreaded because of its morbidity and mortality rates and its technically difficult reparation. aims: to present how the authors dealt with an iatrogenic esophagus perforation post laparoscopic nissen fundoplication. methods: the authors report the clinical case of a 65-year-old woman who underwent a laparoscopic nissen fundoplication because of a symptomatic large hiatus hernia in a different hospital. the second postoperative day and after resuming oral intake, she presented respiratory and hemodynamic instability. she needed a chest tube that drained purulent content. the patient was referred to our hospital for clinical management. an urgent ct scan with oral contrast was performed without showing any leakage. results: in spite of the results, as the patient was unstable, she underwent an emergent diagnostic laparoscopy. it was found a small anterior esophagus perforation with right mediastinic collection. a running suture of the perforation was carried out and the nissen fundoplication was converted to a dör fundoplication. the operative time was 120 min. she went to the intensive care unit for ten days. five days after the surgery, she was given methylene blue with no exteriorization through the drainages. as postoperative morbidity, she suffered from a right pneumonia and a thoracic collection that was treated by thoracic surgeons. the patient was finally discharged on the 64th postoperative day. she did well at home. she attended follow-ups without clinical reflux or any other particular condition. conclusions: esophagic perforation is a life-threatening complication that can be managed laparoscopically if it is detected soon after surgery and an expertise is available. surgical treatment of achalasia fails in 10-20% of patients. the most frequent responsible cause is a previous incomplete myotomy, followed by fibrosis and aspects related with antireflux procedure. revisional surgery can represent a greater difficulty and a challenge. in this video we show 3 revisional surgeries after heller's myotomy with dor fundoplication for achalasia. all cases presented a recurrence of the symptomatology and a revisional surgery was proposed. surgeries were characterized by the presence of a herniation of the previous fundoplication, fibrosis around the prior myotomy and/or the formation of a pseudodiverticulum. we show the steps followed and the aspects to consider during the dissection. these cases demonstrate that laparoscopic reoperation for achalasia is feasible, even after open surgery. aims: upside-down stomach (uds) is a rare type of large paraoesophageal hernia, characterized by migration of the entire or large parts of the stomach into the posterior mediastinum. uds is associated with severe complications like strangulation or volvulus development, possibly leading to acute gastric outlet obstruction and incarceration. surgical repair is the only curative treatment option and therefore recommended for these patients. standard procedure includes a hiatoplasty followed by an anti-reflux procedure. in a variety of studies, the use of mesh proved to be superior with respect to reduction of anatomical recurrences. methods: a 78-year old woman presented to us with reflux symptoms, dysphagia, dyspnea and tachyarrhythmias. she reported a weight loss of 14 kg in the last 6 months. ct scan and esophagogastroscopy showed a large paraoesophageal hernia, measuring approximately 10 cm, with intrathoracic uds. results: we performed a laparoscopic hernia repair with dissection of the hernia sac from the posterior mediastinum, tension-free intrabdominal reposition of stomach and distal esophagus and hiatoplasty with biologic mesh (tutomesh tm ) augmentation. finally, a toupet fundoplication was performed to recreate the antireflux valve. in consequence of pronounced adhesions, a lesion of the muscularis of the distal esophagus occurred during surgery. the esophageal mucosa was unaffected. we treated the lesion laparoscopically with a simple interrupted suture (vicryl tm 3-0). an intraoperative patent blue v leak test did not identify any leaks. the recovery was uneventful. the patient was discharged on day 12 after surgery and was free of symptoms in her follow-ups. conclusions: patients with large hiatal hernias and uds can be treated successfully and effectively with laparoscopic mesh repair. intraoperative complications can be handled laparoscopically in a safe manner. iatoplasty followed by nissen fundoplication represent the gold standard treatment of hiatal hernia; however it has been reported high hernia recurrence rate, especially in case of giant hiatal defects. in order to reduce recurrence rate, various techniques of hiatoplasty reinforcement have been implemented, such as prosthetic materials apposition. however, in literature have been reported various mesh complications such as esophageal and proximal stomach erosion and late esophageal perforation after ischemia, especially in case of synthetic non absorbable materials.in this video we are going to show the repair of a huge hiatal hernia by hiatoplasty and positioning of an absorbable biosynthetic 'bio a' mesh which is replaced by connective soft tissue over six months, therefore decresing complications and recurrence rate.as usual, we start with the mobilization of gastric fundus and isolation of diaphragmatic pillars by sectioning the aderences between them and herniated viscera. we proceed then with intrabdominal esophagus mobilization and higher mediastinal dissection in order to obtain an adequate esophageal lenght. after the exposition of the hiatus, we approximate the pillars with some non absorbable stitches and we reinforce the hiatus positioning a 'u' shaped bio a mesh over the esophagus, simply fixed to crura with single stitches. then we go on performing nissen fundoplication.the use of this prosthetic material appears to be cost-effective; first series in literature show very low complication rate and less recurrences of hiatal hernia than hiatoplasty without reinforcement. this video demonstrates the technique of laparoscopic identification and complete dissection of the sac of a totally intrathoracic stomach. identification of the sac is performed centrally by scoring the peritoneum overlying the arch of the diaphragmatic hiatus. the inferior edge is retracted and series of blunt dissection is undertaken. once the areolar tissue of the avascular plan is visualized; a raytec sponge is placed and advanced cephalad to expose the extra-saccular space. this raytec is kept in place to allow carbon dioxide to infiltrate and further delineate the anatomy. we then proceed with dissection at the left crus and right crus. complete reduction of the stomach can be achieved without grasping it. this can be performed by applying caudal retraction on the sac. this maneuver exposes the plane outside the sac. this space is divided into two compartments (right and left) separated by a septum which indicates the proximal extent of the sac. this plane is avascular and blunt dissection can easily free the hernia sac from the mediastinal structures and the pleura. this was followed by excision of the sac and hiatal repair which is reinforced with bioabsorbable mesh. the proximal short gastric vessels were then divided and a standard toupet fundoplication was performed. v257-upper gi-reflux-achalasia introduction-objectives: the mixed giant hiatus hernias with paraesophageal component are hernias of difficult surgical correction, the laparoscopic approach of these implies a greater experience of the surgical team, given the complexity involved in its management, being the recurrence a complication that neither the use of meshes in this surgery has been able to avoid. in very high-risk patients, the gastric anterior pexy (boerema) may be an alternative to treat or alleviate the symptoms of these large hiatal hernias, although the frequency of recurrence with this technique is very high. material and methods. objective: the objective of the following case is to present a patient with type-1 hiatal hernia, barrett's esophagus without dysplasia and situs inversus. method: a laparoscopic partial fundoplication was performed on a 47-year-old male patient with a history of situs inversus totalis, who was seen in our general surgery service presenting a clinical history of retrosternal pain, heartburn and regurgitation. an endoscopy was performed, which reported hiatal hernia type 1 and incompetence of lower esophageal sphincter, with squamocolumnar junction biopsies with report of barrett's esophagus without dysplasia. results: surgical time was programmed, for toupet type fundoplication; there were lax adhesions from omentum to wall, the lax hiatus and already known situs inversus. partial funcuplication was performed, with the usual technique adapted for structural anatomical abnormality, postoperative course without complications, oral initiation at the next day, drainage penrose type was set draining just a little serohematic liquid, diet was progressed and patient was discharged on the third postoperative day without complications. conclusion: situs inversus is the mirror image of situs solitus, which presents subdivision in situs inversus totalis, which is the most usual form, characterized by the mirror location of the intraabdominal and thoracic organs including the heart; in the case presented, the patient was referred with situs inversus and barrett's esophagus, performing laparoscopic fundoplication. the gold standard of surgical management is laparoscopic in benign esophageal pathology. gastroesophageal reflux disease (gerd) is a condition that reduces the quality of life and can causedisorders associated with acid reflux, such as bronchial asthma, barrett's esophagus and esophagealadenocarcinoma. gerd is often caused by existing of hiatal hernia. in rare instances gerd is associatedwith type iv hiatal hernias in which the part of stomach and other organs migrate into mediastinum.nowadays this condition can cause problems for some surgeons.patient was a 64-year-old man. he was diagnosed with hiatal hernia in 1992. the condition had beenhaving asymptomatic course until 2003. patient takes omeprazole 20 mg for 15 years. he startedexperiencing chest pains when inhaled and dyspnoea in june 2018. co-morbidities were: arterialhypertension, chronic obstructive pulmonary disease (copd) and obesity (body mass index was 43.9 kg/m 2 ). the posterior mediastinum contained the part of stomach, large bowel and small bowelaccording to chest roentgenography. sizes of esophageal hiatus were 145 9 98 mm. in our clinical centerwas performed laparoscopic removal of hernia, cruroraphy, mesh repair of the esophageal hiatus andnissen fundoplication in 2018 july. during the surgery stomach, the part of small intestine, greatomentum and transverse colon were relocated into abdominal cavity. after cruroraphy, repair of theesophageal hiatus with prolene mesh was performed. the patient was in intensive care during 9 h.total enteral feeding was initiated on second day. patients had been discharged within 5 days aftersurgery. patient was re-examined by a surgeon in september 2018, there were no signs of a reccurence.this case report shows an efficiency and feasibility of the laparoscopic approach to the treatment gerdassotiated with a large defect in the phrenoesophageal membrane, allowing other organs, such as colon,great omentum and small intestine to enter the hernia sac. aims: the authors present a video with their standardized laparoscopic hiatal hernia repair and anti-reflux nissen procedure but using 3 mm instruments and 5 mm camera approach. methods: a 42 years old female patient with a bmi 29 presents a symptomatic gastro esophageal reflux disease (gerd) for 20 years. manometry and ph-metry showed a lack of esophageal motor disorders and a severe acid pattern with a 96.35 demeester score. panendoscopy study showed a 3 cm hiatal hernia and a los angeles-grade 2 esophagitis. she decided not to go with ppi treatment anymore. a laparoscopic hiatal hernia repair and standardized nissen procedure is performed using 3 mm instruments and a 5 mm camera. case and technical details are shown in the video. results: the patient was discharged from hospital within a period of 6 h with a 3 rate in a eva acute pain visual scale. in a 2 year follow-up, there has no been an anatomical or clinical recurrence. no chronic dysphagia, anatomical recurrence or abdominal wall complications have been reported with in this period of time. conclusions: depending on the patient characteristics, anatomical factors and surgeon mini invasive experience, hiatal hernia and anti-reflux mini invasive standardized repair using 3 mm instruments, could be a safe and feasible option. more studies are needed in order to standardized this approach. background and aims: parastomal herniation a very frequent complication in stoma patients. in isolated parastomal hernias (type i or iii)* a laparoscopic sugarbaker repair with intraperitoneal mesh is our preferred technique. if a concomitant incisional hernia is present (type ii or iii)* we currently opt for a retromuscular mesh repair as described by pauli. we adopted a minimal invasive approach using the robotic platform. methods: we performed a robot-assisted laparoscopic pauli repair for a wide incisional henria needing component separation and a small parastomal hernia (type ii)*. a non-slit retromuscular mesh was placed after a bilateral tar (transversus abdominus release) and lateralization of the colon. results: the operation was performed robot-assisted laparoscopically with 2x3 trocars without the need to convert to an open procedure. the procedure lasted 300 min. the patient was discharged from the hospital on post-operative day three. one month after the repair our patient presented with a parastomal skin infection for which she received surgical cleaning and wound dressing. ct scan three months postoperative shows good positioning of the mesh with a reinforced abdominal wall. conclusions: the modified sugarbaker repair in parastomal herniation is feasible following a pauli approach (retromuscular mesh positioning) completely laparoscopic, albeit robotically assisted. short-term follow up is promising. long-term postoperative follow-up in these patients is needed. methods: case presentation results: a 67-year-old caucasian female patient was admitted on emergency due to a progressive alteration of her physical condition and weigh loss, caused by intermitent and intense epigastric pain and vomisments. symptomes occurred several years prior to admittance, but used to be mild and rare. during the last months, the described episodes became more intense, lasted longer and occurred more frequently. percutaneous ultrasound raised the suspicion, while thoraco-abdominal ct revealed an enormous intrathoracic morgagni hernia and gastric volvulus inside the hernial sack. after a careful preoperative preparation (restoring of the nutritional and hydric inballances, amelioration of respiratory parameters), laproscopy confirmed the diagnosis; we gently reintegrated the herniated organs from the thoracic hernia into the abdominal cavity (small bowel, large omentum, transverse-doloco-colon, and thisted stomach); a laparoscopic exploration of the hernial cavity was followed by a thorough hemostasis. do to patient's frailty, we decided to leave the hernial sack in situ. surgical direct repair of the defect technique was done by using extracorporeally tied separate sutures through separate skin incisions. the postoperative outcome was completelly uneventful; patient was discharged on postoperative day 5. barium contrast at 3 mounths followup showed a slight esophageal diskynesia, but normal gastroduodenal passage; due to aerocolia, the normal position of the transverse colon could be confirmed aswell; no signs of reccurrence where detected. conclusions: although very rare, a morgagni hernia should be suspected and included in the differential diagnosis of patinets with dispeptic syndrome and epigastric/thoracic symptomes. thoraco-abdominal ctscanning is the imagistic technique of choice. laparoscopic approach became the gold standard, being far mora addvantageous as compared to laparotomy or thoracoscopy. direct suture with extracorporeally separate sutures through separate skin incisions was chosen for being less time consuming; for the same resons, the hernial sack was left in situ, with no consequences so far. aims: the giant fibrovascular polyp is one of the rarest benign lesions of the oesophagus. the most common locations of origin are the upper oesophagus or crico-pharyngeal region. the lesion is more common in elderly population, particularly men. symptoms include dysphagia, odynophagia. management options include surgical resection or endoscopic removal with endoloop. we aim to demonstrate the optimal management of these rare lesions using an endoscopic approach. method: we demonstrated the management of 75-year old patient with a giant oesophageal polyp, excised by minimally invasive endoscopic resection. the patient was placed in supine position and tracheal intubation was performed under general anaesthetic before an endoscopic approach was taken. the oesophago-duodenoscopy visualised a cresenteric shaped lumen due to an intraluminal mass occupying two thirds of the oesophageal diameter. the procedure was a multidisciplinary approach with the upper gi surgical and gastroenterology consultants. the polyp stalk was located in the oesophagus at the level of t2 and an endoloop was manipulated to surround the polyp. the polyp was then separated from the stalk by cauterisation and resected from the patient. the stalk was then injected with adrenaline to prevent haemorrhage. results: the excised specimen was a 15 cm polyp with stalk originating from the t2-t3 level. histology confirmed diagnostic suspicions of a benign pedunculated fibrovascular polyp. the polyp was covered by non-keratinising squamous epithelium with a discoloured tip demonstrating ulceration. there was no evidence of dysplasia or neoplastic process. the video shows a case of laterally spreading tumour of the rectum with preoperative benign histology, paris classification 0-is g (granular type), ut0n0 eus stage, kudo type iv, nice type 2. the neoplasm measured 6 x 7 cm, and extended from 6 to 12 cm from the anal verge, mainly located on the posterior wall. according to our local policy the indication was a transanal full-thickness excision. this was performed with the medrobotics flexò robotic system, used here for the first time outside the united states. the system technology utilizes an articulated multi-linked scope that can be steered along nonlinear, circuitous paths in a way that is not possible with traditional, straight scopes. the maneuverability of the scope is derived from its numerous mechanical linkages with concentric mechanisms. this enables surgeons to perform minimally-invasive procedures in places that were previously difficult, or impossible, to reach. with the flexò robotic system, surgeons can operate through a single access site and direct the scope to the surgical target. once positioned, the scope can become rigid, forming a stable surgical platform from which the surgeon can pass flexible surgical instruments. the system includes on-board 3d hd visualization. the flexò robotic system contains two working channels to accept a number of different surgical and interventional instruments including monopolar and bipolar electrodes, scissors and graspers for tissue manipulation. the video shows the introduction of the dedicated rectoscope, the connection of the flexible robot, and the way to operate the device performing a full-thickness excision, including suturing of the rectal defect by means of two running sutures by a v-lock 3/0 thread. while illustrating the technique the authors will comment pros and cons of the use of the device. surg endosc (2019) the video shows the use of a barbed suture of novel concept. this first prototype thread developed together with assut europe (roma, italy) is characterised by a bidirectional 3/0 barbed suture, of 24 cm length overall, with two needles 22 mm in diameter, and circumference. in order to fix the thread to the tissue, on the exact midline of the thread a small (2 mm) ball of the same material of the thread is fused with heat. this button as the entire thread is made of polydioxanone, a monofilament material for long-term absorption, self-retaining. this small advancement offera a consistent advancement in endorectal surgery helping in making transverse wound closures as easy as never before. the first stitch is placed on the transverse midline of the rectal wall defect, this way approximating proximal and distal edges. the button keeps the thread under tension allowing the completion of a running suture towards one of the two lateral ends of the would. when the first end is reached the needle is cut and the other needle is grabbed in order to perform the other half of the running suture keeping the right tension on the thread, with no risk of lumen stenosis. the two lateral ends of the suture are self-blocked passing them through the last stitch. no need for clips, knotting or buttonholes to pass through. while illustrating the technique the authors will comment pros and cons of the use of the device. background: the usefulness of robotic surgery has been largely reported; however, there are not enough reports on gist's treatment. the aim of this study is to report a single center experience on gastric gist's robotic resection. gastrointestinal stromal tumor (gists) are the most common mesenchymal tumors (overall incidence 1-3% of all gastrointestinal malignant tumor). they are most frequently located into the stomach. complete surgical resection still remains crucial for patients with gists. in cases of difficult localization of tumor (e.g. posterior wall, his angle) and bigger tumor (more than 5 cm in diameter), there still exist apparent difficulty and limitation to conduct laparoscopic resection. robotic assistance provides wide movements of its arms and was recognized particularly useful in case of difficult tumor localization, especially for those positioned at the posterior side of the stomach wall or around the lesser curvature. methods: six consecutive patients were analyzed focusing on safety (conversion/complications rate; hospital stay), oncological (margin resection, recurrence rate) and feasibility (operative time, technical tip and tricks) profile of robotic approach. results: the mean operative time was 173 ± 39 min, the mean hospital stay 3 ± 1 days. conversion rate was nihil. no intra and post-operative (mean follow-up 12 months) complications were registered. in all cases, the resections were classified as r0. conclusions: our experience supports the usefulness of robotic system in case of gist located at anatomically difficult gastric portion, such as lesser curvature or fundus close to gej, confirming the excellent oncological outcomes (100% r0) and the encouraging safety profile (0%). regarding the operative time our data are similar or better as compared to those reported by the previous literatures and didn't differ by the most recent published data for laparoscopic gastric resection. the anatomical hand-sewn reconstruction performed by precise hand-sewn suture instead of the usage of mechanical staplers represents a real great advantages of robotic resection. in our series, no patients suffered from stenosis or leakage after operation. background: we describe the use of a different suture from those historically used in the elaboration of a widely spread surgical technique such as the nissen fundoplication, for the treatment of pathological gastroesophageal reflux or symptomatic hiatal hernias. in our unit we have implemented the use of 2/0 irreabsorbable barbed suture to close the diaphragmatic pillars and the 360°fundoplication with the same continues suture. aim: the objetive of the use of the irreabsorbable barbed suture in the nissen fundoplication is to shorten the surgical times, which would achieve benefits for the patient and the institution, increasing the number of ambulant patients and the number of patients to be operated the same surgical session. objective: the goal of the present study was to demonstrate that intraoperative icg fluorescent imaging is a safe technique that can be used in laparoscopy establishing the exact location of the lymphocele and reducing intraoperative risks. method: fifty milligrams of icg dissolved in 20 ml of saline solution was injected via percutaneous drainage placed into the lymphocele to decompress transplanted kidneys 2 weeks before a laparoscopic lymphocele marsupialization procedure. results: during the first exploratory laparoscopy, in the flank and right iliac fossa, near the 2 renal grafts, fluorescence was identified in 3 raised areas that were the internal side of the lymphocele lobes. the lymphocele wall was dissected and 300 ml of serous fluid was aspirated after puncturing. a 5 cm breach was then made in the cyst wall using the ultracision harmonic scalpel (ethicon us). afterwards, a pedicle of the omentum in the lymphocele core was interfered with and fixed by 2 stitches. conclusions: laparoscopic surgery seems to be the preferred surgical option for the treatment of primary symptomatic lymphocele after kidney transplantation. intraoperative icg fluorescent imaging is a safe technique to establish the exact location of the lymphocele and reduces the risk of damaging urinary structures during surgery. conclusions: this method proved safe and risk-free, easily reproducible and without the need for a different toolkit than the one of a modern operating theatre. the preliminary analysis shows a strong correlation between the perfusional data so far obtained and the early outcome of the graft. thus opening the way to further analysis aimed to a future better management of post-operative immunosuppressant and support therapy. these results are quite encouraging, even if our study is at an initial stage. conclusions: results show a persistent dread across specialities regarding ai. rather than be seen as threat, ai should be embraced by clinicians as it will ease the ever-increasing daily workload faced. this will enable clinicians to focus their skills on patient centred activities, interventional procedures and development. despite current regulatory hurdles, ai implementation in medicine is unavoidable. this coming revolution presents a unique opportunity for endoscopist and radiologist to refocus their expertise in novel areas. project description: from february to july 2017 a three-armed proof of concept study was conducted at three hospitals, in three groups of patients; recurrent ventral hernia, aortic aneurysm, and healthy controls. patients were measured once at the outpatient clinic using an electronic nose based on three metal oxide sensors. measurement data were compressed to low-dimensional vectors using a tucker 3 like algorithm, and used to train an artificial neural network (ann) to provide a classification between patients (?1) and healthy controls (-1). preliminary resultsa total of 64 patients (hernia n = 29, aneurysm n = 35) and 37 controls were included in the study. based on receiver operating curve (roc) analysis, the ann could differentiate between recurrent hernia patients and controls with the following details: area under the curve (auc) 0.74, sensitivity 0.79, specificity 0.65. aortic aneurysm patients and healthy controls could be differentiated with an auc of 0.84, sensitivity of 0.83, and specificity of 0.81. the aeonoseò enose can reliably distinguish patients with weak collagen (recurrent hernia and aortic aneurysm patients) from healthy controls. validation of these results in a prospective cohort study is required before clinical application of the device. background: laparoscopic and endoscopic cooperative surgery (lecs) has been performed gastric submucosal tumor (smt) or duodenal tumor. although minimally invasive surgery using thoracoscopy has been the usual approach for esophageal smt, the treatment method combined thoracoscopy and endoscopy has not been established. in addition, submucosal endoscopic tumor resection (set) for esophageal smt was reported using the technique of submucosal tunnel. aim and project description: we planned to resect large esophageal smt located in the upper or middle thoracic esophagus by a combined endoscopic and thoracoscopic approach. because set is only recommended for tumors up to 40 mm in size owing to the limited submucosal space available and the left thoracic approach is restricted by the aortic arch and the trachea. preliminary results (case presentation): a 47-year-old woman was diagnosed with a benign schwannoma of length 60 mm originated from either the submucosal or the muscular layer of the middle thoracic esophagus by endoscopic ultrasonography, enhanced computed tomography, and ultrasound-guided fine-needle aspiration biopsy. since the tumor had increased in the 5 years and she had a symptom of dysphagia, we planned to resect it by a combined endoscopic and thoracoscopic approach. on endoscopy in the supine position, a submucosal tunnel was created 40 mm proximal to the cranial edge of the tumor, and its only oral end was dissected from the mucosal and muscular layers. this was followed by the resection of the entire tumor by left-sided thoracoscopic procedure in the prone position. endoscopic mucosal closure was achieved by using clips. no postoperative complications were observed. large benign esophageal tumors can be safely excised with minimally invasive surgery by using a combination of endoscopy and thoracoscopy. background: haemorrhage remains a major cause of morbidity and death in all surgical specialties. in laparoscopic surgery. relatively small amounts of blood can obscure the view of the operative field and increase the risk of injury to surrounding structures. excessive bleeding often leads to longer hospital stays, increased healthcare service utilisation, and higher healthcare costs, among other negative consequences. aim: the aim of this study was to analyse the feasibility of purastatò, a new synthetic haemostatic device, made of self-assembling peptides in laparoscopic colorectal surgery. project description: this was a prospective observational non-randomised study. consecutive patients undergoing laparoscopic colorectal surgery were enrolled. informed consent was obtained from all patients inclusion criteria was the need employ a secondary method of haemostasis when traditional methods such as conventional pressure or utilization of energy devices to control the bleeding were either insufficient or not recommended/ appropriate due to proximity to ureter, pelvic/sacral veins and other important structure. preliminary results: twenty patients were enrolled (12 males (60%) and 8 (40%) females). mean age was 61 years (± 2,4 years). all patients were undergoing elective laparoscopic colorectal cancer surgery (4 right hemicolectomy, 5 sigmoid colectomy, 11 anterior resection). we utilised 3 mls of purastatò in all patients. the mean area of application was 5, 35 cm 2 (± 2.25 cm 2 ) with the amount of purastatò needed per centimetre being 0.56 mls. the mean time to apply the product was 40 secs (± 17 s), whereas the mean time to achieve haemostasis was 17, 5 secs (± 3.5 s). there were no post operative complications in this cohort of 20 patients. mean operative time overall was 185 min (± 45.2 min). none of the patients experienced delayed post-operative bleeding and the mean hospital stay was 5 days (± 3.4). in conclusion, according to the purpose of this preliminary study, we have demonstrated that purastatò can be easily used in laparoscopic surgery and it is a safe, effective haemostatic agent. this is a feasibility study and additional controlled studies would be useful in the future. during last three years the laparoscopic method of surgery in the presence of common bile duct stones was carried out. after performance of intraoperative cholangiography and visualization of stones in the common bile duct laparoscopic, choledochotomy and bile duct stones extraction was undertaken in 56 patients, using flexible choledochoscopy control. in all patients with gallbladder stones was then performed laparoscopic cholecystectomy. results: laparoendoscopic intervention on common bile duct was successfully performed in 48 patients (85.7%) and the operation was completed by common bile duct drainage by kehr. in 8 patients due to technical difficulties conversion to open surgery was carried out. postoperative morbidity in the form of bile leakage were diagnosed in 9 patients (16.1%). in three cases they stopped spontaneously in 5-6 days after the operation. 6 patients were operated on repeatedly and additional suturing on choledocholithiasis was carried out. postoperative mortality was 2.4%. the death of the patient of 92 years was caused by acute cardiovascular failure. institute for image guided surgery, ihu-strasbourg, strasbourg, france; 2 hepato-digestif, nouvel hôpital civil, strasbourg, france; 3 image guided surgery, nouvel hôpital civil, strasbourg, france; 4 gastroenterology, chu-besancon, besancon, france; 5 gastroenterology, chu-lyon, lyon, france; 6 gastroenterology, clinic de trocadero, paris, france background: eus is difficult to learn and has a steep learning curve. therapeutic eus (teus) is even more so. simulators, ex-vivo models and phantoms are the most common current teaching modalities but are felt by many to be unsatisfactory for high-level training. aim: we designed a training curriculum for teus that uses high-fidelity animal models and present a validation study performed by 4 teus experts. project description: 3 different simulated pathologies were created in each of 9 acute pigs. 4 teus experts performed 15 therapeutic procedures in two or more animals over two days. each intervention was evaluated simultaneously using a structured survey by an non-expert observer. data included demographics and procedure details as well as likert-scale evaluation of the quality, realism and education utility of the simulations. global evaluation of the experience was captured from the experts as written comments. all data was consurrently registered and subsequently analysed by two blinded surgical educators. methodology: three types of models were created using surgical access: 1-tumors (injection of 4 types of hydrogel), 2-retro-gastric collections (5-7 cm long intestinal loops filled with oatmeal, oil-water and gel), 3-obstructions (bile duct and ureteral ligations 2 days prior to experience). gastric, pancreatic and liver tumor models were used for fna and fnb practice. retrogastric fluid collections and choledochal/ureteral obstructions were used for cyst gastrostomy, hepaticogastrostomy, gallbladder drainage and kidney drainage. results: experts age: 45-63, median intervention time 22 min , total of 60 interventions evaluated, overall quality of experience: 37 (68%) ranked 8-10 (excellent), 14 (27%) from 7-4 (good), 3 (5%) from 1-3 (poor), 54/60 procedures were successfully completed. models were rated good to excellent quality (7-10) in 42 (70%), poor quality in 8 (13%). for 17% (10) of the interventions the model was considered not good enough to be repeated (solid retrogastric tumor and peripheral hepatic lesion). conclusion: high-fidelity live animal models with simulated pathologies are considered to be excellent training tools by experts and may provide a better learning experience for teus. surg endosc (2019) in our short videos, we present scenarios in which this technology helped: to distinguish a significantly dilated cystic duct from the cbd, to identify an anterior cystic artery in the contest of acute inflammation, to identify a luksha duct, to exclude a leak after endoloops positioning on cystic duct. intra-operative augmented visualisation of biliary anatomy with indocyanine green cholangiography is an essential technology tool with the potential to extend the 72 hour window of safety for emergency cholecystectomies, with significant logistics benefits. introduction: endoscopic resection of subcardial polyps has its limitations; especially when it is necessary to dry out the entire gastric wall. uniportal intragastric surgery is a good alternative for the exeresis of subcardial premalignant lesions with gastric preservation. patient and method: we present a video with two cases. technique: we perform a laparoscopy to explore the entire abdominal cavity, then we open a 1.5 cm hole in the great curvature; a 2 cm incision is made in left hypochondrium and the uniportal device is placed inside de stomach. we inject serum in the submucosa with a endoscopic needle. when submucosa is completely separated from muscular lay; a submucosal exeresis can be made; but when there is not a complete separation after injection, then we perform a entire wall resection with a 1 cm circular margin. if a complete wall resection is made, then we close the defect with a barbed suture. results: case 1: 45 years old male with a 1,5 cm subcardial polyp, preoperative biopsy was informed as severe dysplasia. in the laparoscopy we saw an unknown lesion in the great curvature that looked like a gist. we placed the uniportal device intragastric and proceed to the submucosal serum injection. as the submucosal lay was completely separated from muscular, then we performed a submucosal exeresis. we close the gastrotomy and made the resection of the great curvature lesion with endostapler. the pathological analysis confirmed the severe dysplasia in subcardial lesion and gist in the great curvature lesion. patient was discharged with no complications after 2 days. case 2: 58 years old male with a 2 cm subcardial polyp. preoperative ecoendoscopy suggested a muscular layer infiltration but only severe dysplasia was found in the previous biospsy. laparoscopy did not found more lesions, and uniportal intragastric device was placed. a complete wall resection was made, and the defect was closed with manual barbed suture. pathologyst confirmed severe dysplasia and unaffected margin. patient was discharged with no complications after 4 days. conclusion: uniportal intragastric surgery is feasible and safe and may be useful for subcardial premalignant lesions when endoscopic resection is very difficult or not feasible. introduction: the role of icg in bariatric surgery is still unclear. knowing the lack of perfusion in the gastric pouch could be of great interest in revisional surgeries; but the question remains: is the current icg technology reliable enough to make intraoperative decisions in bariatric surgery? methods: we have carried out a check of tissue perfusion with icg fluorescence in several cases of primary and revisional bariatric surgery. a solution of 0,1 mg/kg was injected intravenously and icg fluorescence was performed. we looked for the correct staining of the entire gastric pouch and the intestinal loop trying to rule out areas of tissue ischemia. results: the 15 cases in which the test was performed showed a minimal delay of 10-15 s between the intestinal loop stain and the pouch. a correct staining was observed in all but one case shown in the video. is the case of a 46 years-old male patient who was operated 8 years earlier in another center; at that time he underwent a sleeve gastrectomy. we evaluated the patient for persistent gastroesofhageal reflux of 5 years of evolution with esophagitis. we offered revisional surgery to perform gastric bypass and hiatal closure. fundus was dilated so a funduplasty was performed instead of using endostappler in the vertical side of the pouch. manual anastomosis gastric bypass was performed. when the icg test was performed, a corner of the pouch does not stain green (an area of 1,5 cm) . so the decision was to resect that part and redo the anastomosis or wait and see. it was decided not to resect and the patient was discharged two days later with no complications and good outcome with a 12 months follow up. conclusion: icg fluorescence may be useful in bariatric surgery in the future but more evidence is needed of its usefulness in making intraoperative decisions. background: lymph node status is one of the key prognostic factors in patients with colorectal cancer, and remains the most important selection criteria for adjuvant chemotherapy. it is believed that at least 30% of node negative patients will suffer disease recurrence within the first 5 years after surgery. this may be due to understaging of lymph node status. sentinel lymph node mapping is widely used for staging of breast cancer and melanoma, with injection of colloid tc99 and isosulfan blue (ib). however, indocyanine green (icg) fluorescence guidance is a new technical approach to this issue, with promising results for detection of aberrant lymphatic drainage outside of the planned resection. the icg lymphography has the advantage of offering a good visualization of the lymphatic channels but there are problems in order to identify the lymphatic nodes. aim: the objective of the experimental study is to investigate the possibility to detect the sentinel lymph nodes after the injection of different solutions with indocyanine green in the subserosal colonic layer in the pig. project description: twelve female large white pigs were operated with laparosocpic approach and spies optic filter (karl storz, germany). indocyanine green was injected in the subserosa of the colonic wall (1 ml at 2 points). lymphatic flow was observed at 1-3-5-10-15 and 20 min, searching for the migration of the icg by the lymphatic channels and its introduction in the sentinel nodes. preliminary results. the identification of the sentinel nodes is very difficult with the solution of icg-sterile water. with this technique we can see the lympjatic channels but not the lymphatic nodes. the adition of 5% human albumin as a transporter of the icg is very helpful for the correct identifiaction of the lymphatic channels at 5-10-15 min and the correct visualization of the lymphatic nodes at 20 min after the bowel injection. addition of other transporters like dextran solutions may be helpful too but the time to the correct visualization is longer. there was significant difference among the three groups as regards postoperative les and postoperative ph metery.the incidence of persistent dysphagia was significantly higher in the group i. postoperative gerd symptoms were significantly higher in group iii (23.3%. p \ 0.0001). recurrent achalasia was significantly higher in group i (11 patients 15.9%, 8 patients in group ii (7.1%) and nil in group iii (p \ 0.02). in conclusion: longer myotomy on the gastric side ([ 2.5 cm) ensures complete division of the les with better outcomes in term of resolution of dysphagia but may be associated with higher postoperative gerd. therefore, a myotomy length of 1.5 to 2.5 cm on the gastric side provides a balance between relieve of dysphagia and development of postoperative gerd. c/t scan of his abdomen revealed a large groin hernia with signs of small bowel obstruction and collapsed distal bowel. emergency theatre was organised for this patient with anaesthetic assessment prior to his surgery. initial plan of local exploration with possibility of small resection was changed once he was under full anaesthetic with muscle relaxation. his abdominal girth provided an opportunity to utilise laparoscopic intervention as an initial approach. laparoscopy with 0 degree lens revealed moderately distended loops of small bowel and a large omental mass along with a loop of small bowel incarcerated in right direct inguinal hernia site. background: robotically assisted surgery is a rapidly developing modality of minimally invasive surgery with proven advantages in the management of cancer. despite its increasing prevalence, there is still an ongoing debate regarding its future role in colorectal surgery. while the prospective randomised multi-centre studies provide research evidence for its potential efficacy, an assessment of its effectiveness and realistic outcomes in everyday clinical practice can add an important perspective to this discussion. the international robotic colorectal registry will allow to compile and pool the international robotic colorectal experience. aims: the aim of the international robotic colorectal registry is to monitor the safety and outcomes, as well as the quality of specimen of robotically assisted colorectal surgery for malignant and benign diseases of the colon and rectum. the primary endpoint is a composite oncological failure. the secondary endpoints include anastomotic leak, resection margin involvement, conversion rate, operative time, post-operative 30-day morbidity and mortality, long term oncological outcomes, quality of life, functional outcomes and cost-effectiveness. project description: the international robotic colorectal registry is a multicentre web-based, online secure database. the registry has been awarded an ethical approval by a relevant national committee. all surgeons performing robotic or robotically-assisted surgery are invited to participate. the data collected includes patient demographics, cancer characteristics, operative details, histology of the specimen, wound healing, post-operative therapy, readmission, quality of life and functional (bowel, urinary and sexual) outcomes. all the sensitive patient information is encrypted before its introduction into the database. preliminary results: so far, twenty robotic colorectal centres have joined the international robotic colorectal registry. the preliminary results will be published once 600 patients have been enrolled. univariate and multivariate analyses will be performed to identify possible risk factors for poor outcome.the possibility to record open, laparoscopic or other minimally invasive colorectal procedures will facilitate comparison of the outcomes of the robotically assisted surgery and other modalities. the registry will also allow each surgeon enrolled to monitor their skill progression and outcomes over the time. results will be published in surgical literature and presented internationally. background: gastric outlet obstruction (goo) due to benign strictures is an uncommon surgical entity today. this paucity relates to the decrease in its aetiological factors in the modern era as well as to advances in both prevention and medical as well as endoscopic treatments of such condition. the most common of causes relating to peptic ulcer disease, has been subdued for decades with quality acid control medications. on the other hand advances in gastroscopic dilatations skimmed even more the frequency of these cases from arriving to surgical intervention. aim: this presentation gives an update on the standing of this pathology and its surgical management today. it will also shed a light on our early experience in this condition at the royal hospital of muscat in oman. project description: a case series of all patients with goo, who were surgically managed between 2010 and 2015 results: there were a total of 16 patients, 10 males and 6 females. the cause of obstruction was peptic ulcer disease in 10, corrosive injury in 2, iatrogenic perforation in 1 and idiopathic hypertrophic stenosis in 2 . emergency presentation was seen in 4. management included jaboulay pylorpolasty in 2, resection in 10 (distal gastrectomy in 9, total gastrectomy in 1) or a bypass (gastrojejunostomy) in 4. in 14 of the above, the procedure was done by laparoscopy. post operatively, temporary gastric paresis delayed recovery in 5, however all symptoms resolved in 15. there were no recurrences at minimum of 2 years of follow up. in spite of advances in medications and gastroscopy interventions, we still seem to identify this condition within our population. although infrequent, they demand awareness from surgeons since they could be managed successfully, especially laparoscopically, with minimal morbidities and early recovery. the introduction of advanced laparoscopy to the unit's setup in recent years, made such option feasible with satisfactory and durable outcomes. background: gists of the upper gi are found mainly in the stomach (60-70% of cases) and small intestine (30%). duodenal gists however, comprise a smaller subset with a frequency of 6 to 21%. the optimal surgical procedure for duodenal gist is still evolving. since wide margins and extensive lymphadenectomy are not required, restrain from more radical resections in this area would be a valid option. aim: this is a video case report of a patient with a gist involving the third part of the duodenum treated by laparoscopic lateral duodenectomy and end-side roux-en-y duodenojejunostomy case report: 55 years lady presented with recurrent mid abdominal postprandial pain with anorexia, nausea and occasional vomiting an ultrasound showed well defined hypoechoic mass of 3 9 2.5 9 2.2 cm at the right para-aortic region . ct scan defined the mass as retroperitoneal, intimately related to the pancreas uncinate process and the third part of duodenum with no clear cleavage line between them. an mri endorsed the diagnosis of gist of the duodenum. she was operated upon through a laparoscopic lateral duodenectomy including the gist at the third part of the duodenum. a frozen section confirmed the clear margins . reconstruction was done by a roux-en-y duodenojejunostomy with the alimentary limb taken 30 cm from the dj flexure. she had an uneventful post operative recovery and was discharged well. the histology confirmed a low grade gist tumour hence no further treatment was needed. at follow up six months later, she was doing well and gaining weight. conclusion: complex anatomy of the pancreatico-duodenal area makes conserving the duodenum for tumours rather than a major resection a challenging option. in our case however, with the disease in the third part being of a moderate size, a lateral duodenal wall resection including the mass was possible rather than a segmental resection. this procedure could be an ideal choice for benign, moderate sized tumours in the third and fourth part of the duodenum. background: during laparoscopic colectomy, laparoscopic lymph node dissection and extracorporeal intestinal anastomosis is commonly performed. an umbilical incision of 4-6 cm and wide-range mobilization of the intestinal tract is required for extracorporeal anastomosis. previously, we introduced intracorporeal overlap anastomosis in june 2017 as a minimally invasive treatment. here, we report its short-term outcomes. aim: we retrospectively compared the surgical outcomes of 21 cases of extracorporeal anastomosis and 8 cases of intracorporeal anastomosis, all of which were performed between june 2017 to may 2018. procedures: after lymph node dissection and sufficient mobilization of the intestinal tract, the proximal and distal intestines were resected perpendicularly to the intestinal tract with a 60-mm linear stapler. the anastomosis was performed after the specimen was extracted from an umbilical incision. the opposite sides of the mesenteric margin 3 cm from the staple line of the one intestinal tract, and 7 cm from the staple line of the other intestinal tract, were marked, and then the respective intestinal tract was positioned to join the opposite mesenteric sides together. an insertion hole was made in the intestinal tract at the marked site. side-to-side anastomosis with a linear stapler was performed, and then the insertion hole was closed with a linear stapler after several temporary sutures. preliminary results: in the extracorporeal anastomosis group, the mean operation time, blood loss, and post-operative days were 270 min, 127 ml, and 13.2 days, respectively. furthermore, there were three intraoperative cases of bleeding (14.3%), and two postoperative cases of lymphorrhea (9.5%) that occurred. however, in the intracorporeal overlap anastomosis group, the mean operation time, blood loss, and post-operative days were 284 min, 75 ml, and 12.5 days, respectively. additionally, there were no cases of intraoperative complications, and only one postoperative case of lymphorrhea (12.5%). conclusion: intracorporeal overlap anastomosis in laparoscopic colectomy is safe and feasible, and can be used as a minimally invasive treatment. nowadays 3d-printing it's not a new technology any more but with an exponential developing. there are beliefs that in 2027 10% of everything that will be produced will be 3d-printed. in medical field this technology knows the same exponential developing. first used in orthopedics and maxilo-facial surgery now 3d-printind is used in many other fields for different reasons, like preoperative training models, surgical special instruments, in medical education, etc.. liver surgery is in continuous developing and this is the reason why we need experimental liver model for training and testing. a best liver experimental model should heave liver consistency, to be flexible, to heave the same ultrasound feedback, to be cheap and easy to be reproduced. this is why we developed a liver experimental model made of gelatin by a simple recipe, using a 3dprinted mold, created after a human liver ct-scan. first was made the segmentation of the liver. after segmentation we create the 3d virtual liver model and the negative image of the liver, which was used for creation of the 2 pieces of the liver mold, with connections between them and a hole on the top to pour the gelatin solution. (1) ethical concerns on learning and training with real patients and substitutives such as animals, and (2) reconciling time devoted to learning with clinical practice, considering the european work time directives. simulation in medical education is and has been the preferred route to address both pedagogical needs. virtual simulation has proven to be a valid tool for training; however, current systems restrict usage to tasks and modules offered, without possibility of personalization. we present the minimally invasive surgery simulator scenario editor (mis-sim) an environment where users can create, edit and run virtual reality tasks designed for medical training. the environment features an editor allowing users to develop learning tasks, defining its learning objectives and task goals in an easy way. a first proof of concept has been implemented for surgical training and training activities (demostrators and short courses) have been carried out in three european sites: spain, the netherlands and hungary. during training activities, 10 different exercises have been created and uploaded to the contents' database. trained technical skills include handeye and bimanual coordination, instrument handling and pulling. preliminary results with 30 users have shown mis-sim training potential, although some functionalities should be made easier. personalization has been highlighted as the key added value of mis-sim with respect to the current competitions in the market: the ability for target users to use virtual reality based learning tools while remaining in complete control of the learning process. mis-sim aspires to break the barrier between vr and medical education by empowering users to create their own tasks. with mis-sim teachers/course creators and learners (healthcare professionals & future healthcare professionals) will benefit from an innovative tool to (1) create personalised medical learning contents tailored to preferred learning styles, allowing the creation of individualize learning paths; (2) improve the efficiency of training by focusing on the training needs of the learners and (3) share and sell vr-based didactic contents. c. tiu 1 , p. sánchez-gonzález 2 , m. chmarra 3 , d. gutiérrez 4 , c. guzmán-garcía 5 , l. sánchez-peralta 6 , g. wéber 7 , f. sánchez-margallo 8 , b. pagador 9 , j. dankelman 10 aims: currently surgical training is largely based on the improvement of technology enhanced learning solutions. the progress of engineering and the diversification of training facilities outside the operating theater results in an even greater contribution of technology in the future. the main reasons to encourage these changes are increased efficiency of simulators and directly increased patient's safety. the goal assumed by the easier project is to develop multi-skill, online platforms for minimally invasive surgical (mis) procedures-based on common pedagogical principles with reference value in a multinational space. the platform will allow the connection of external assets (such as simulators) to centralize all training data from residents. this work presents the milestones of the project during its first year of life. methods: the consortium's activity started with a knowledge elicitation process organizing brainstorms and workshops including experts in mis and interventional techniques, from spain, romania and hungary. this experience led to the formulation of a questionnaire that was implemented online and sent via email to surgeons and residents from the participating countries. results: accumulated experience was used to define the pedagogical needs of the platform. the pedagogical needs form the starting point for defining the technical requirements and specifications. based on them, the design of the platform has been achieved, including its architecture and communication protocol between external assets design, facilitated by the use of state of art educational standards. discussions and conclusions: next steps include the implementation of the easier platform, as well as the definition of cases studies selected by the clinical partners in spain, romania and hungary to solve applications of the platform dedicated to cholecystectomy, lumbar puncture and arthroscopy. a pedagogical model, built by the experience of the consortium, is being used to guide instructional design of the course. finally, results will be validated in a multi-center validation study.the easier project will create a training platform with reference value for european surgery. the structure of the consortium, based on the confluence between collectives with clinical, technological and pedagogical experience, will generate a complex learning tool in surgery embodying technology-based training systems with clinical experience. background: the treatment of groin hernia is an important part of our daily surgical activity. aim: we proposed to evaluate outcomes of the laparoscopic trans abdominal pre peritoneal treatment (tapp) of the groin hernia. project description : one hundred and fifty patients who underwent a tapp for a groin hernia were included in a retrospective study between january 2014 and november 2018. results: the gender ratio was 5. the average age was 57,4 years. twenty percent of patients had a history of abdominal surgery. the operative indication was a unilateral hernia in 25% of cases, associated with an umbilical hernia in 40% of cases, a recurrent groin hernia in 30% of cases and a bilateral inguinal hernia in 45% of cases. the conversion rate was 1.33%. the hernias were classified according to the ehs classification in l3 type in 31% of cases, l2 in 24% of cases, l1 in 19% of cases, m2 19%, l2 r in 20% of cases and f1r in 15% of cases. a contralateral inguinal hernia was discovered in 15% of patients. a polypropylene mesh 15x15 cm was fixed by a stapling in 59% of cases and by a suture in 41% of the cases. the average operation time was 55 min. the hospital stay average was 0,7 day. an antalgic treatment was prescribed in 15% of patients. the average time to return to normal physical activity was 5 days. a postoperative seroma was noted in 14% of patients. no cases of mesh suppuration were noted. chronic pain was noted in two patients. no recurrence was noted with an average follow-up of 25 months. conclusion: laparoscopic treatment of the groin hernia by tapp had good results concerning the postoperative pain, early recovery of physical activity and aesthetic damage. a larger setback is needed in our study to evaluate the recidivism rate. background: surgeon's training in ultrasound is viewed and understood differently in different parts of the world. if in united states the need for surgeons' training was accepted and taken over by the american college of surgeons, in europe the practice is completely different from one country to another, from one city to another, from one department to another within the same premises hospital. in some european countries, surgeons currently use ultrasound for diagnosis-especially in urgency, for follow-up, intraoperative, or as guidance for many surgical gestures. during this time, access to ultrasound of other surgical specialties-gynecology, urology, ophthalmology-is considered natural. material and method: once the decision to initiate an ultrasound course for surgeons was taken, a team of experts with technical or clinical expertise in ultrasound was organized. at the initiative of the technology commission, the courses were to be organized at the eaes congresses or others communication events endorsed by eaes. starting from the importance of each ultrasound application in surgery, it was decided to develop different modules to solve different training needs. at this time, the course offered at seville covers the capitols like abdominal ultrasound, guided punctures and trauma. a module dedicated to intraoperative ultrasound is under construction and will be available in november 2019. the course has a skill abilities dominant character, two thirds of it being thought of as a hands-on application on stationary, classical ultrasounds with large screens and also on small size wireless actual devices. results: after his debut in frankfurt in 2017, the course was resumed in london and in bucharest, twice. in this process, new modules and better teamwork skills have been developed. the participants' satisfaction quizzes, coming from all continents, were really encouraging. for the intraoperative ultrasound module the team approach is unique. students will have the opportunity to practice on live animals both laparoscopic and open abdominal procedures conclusions: the ultrasound for surgeons course initiated by eaeas was received with interest. the team will seek to inspect the real needs of training surgeons in this field and will complement and diversify the current platform surg endosc (2019) preliminary results: a total of 26 procedures (3-12, ± 5.2) were carried out in 5 patients. the indications included acute (2 leaks following esophageal resection, 1 rupture of the strictured anastomosis following pneumatic dilatation) and 2 chronic conditions (esophagopleurobronchial and gastropleurobronchial fistulas following the resection of esophageal diverticulum and sleeve gastrectomy). the initiation of the therapy was in 13, 18 and 1 day in case of acute conditions, and after 2 years of the duration of the unsuccessful therapy in 2 chronic cases. the successful closure was observed in 2 patients, 1 patient passed from mods and ards. in 1 case, the initiation of evac was provided as a combined surgical and endoscopic intervention (ct proven distant intraabdominal abscesses). in 2 chronic cases, 1 was discontinued due to the haemophagocytic syndrome of unknown etiology, in the second one, success in reduction of the lesion and symptomatology with long term duration was observed following just 3 applications of evac, despite minimal remanent leakage. the success is to our experience linked to early initiation of the therapy and presumes complex intensive care. the future investigation should specify the timing including preemptive use of evac and the combination of evac with other endoscopic, interventional and surgical therapeutic modalities. the aim of this feasible study is to investigate complete robotic esophagectomy with total mediastinal lymph node dissection (retm) only by the robotic arms. methods: the patient is placed hemi-prone position with one lung ventilation by blocking balloon tube under general anesthesia. the robotic trocar for 1st arm of da vinci xi surgical system is placed in the 10th intercostal space (ics) on the scapular line, the trocar of 2nd arm is placed in the 7th ics on the posterior axillary line, 3rd arm trocar is placed in the 5th ics on the middle axillary line, 4th robotic arm trocar is placed 3rd ics on the middle axillary line, and assistant trocar only for taking in and out of gauze is placed in the 8th ics on the middle axillary line. on the upper mediastinal lymph node dissection, robotic camera exchanges from 2nd to 3rd robotic arm to close and identify anatomical structures. esophagectomy with lymph node dissection starts from middle and lower mediastinum to upper mediastinum including along bilateral recurrent laryngeal nerves. all procedure perform under close-up view along the robotic enhanced anatomy to preserve organ functions. background: complete stenosis of the duodenal lumen secondary to a surgical suture in the treatment of a duodenal ulcer is a rare complication. the usual surgical resolution corresponds to a gastrojejunostomy associated or not, to an antrectomy with vagotomy, as a treatment for the peptic disease. the endoscopic resolution of this complication requires the use of complex maneuvers and specific therapeutic instruments. aim: to describe the endoscopic resolution of iatrogenic occlusion after raffia of perforated duodenal ulcer. description: a 43-year-old man was admitted to the emergency service for four days of pain and abdominal distension associated with abundant retention vomiting. performed ten days ago of a perforated duodenal ulcer, in which manual raffia was performed in two planes and drainage. abdomen and pelvis ct showed great distension and diffuse thickening of the gastric wall. the endoscopy showed abundant gastric retention content, pylorus, and bulb edema, and complete closure of the duodenal lumen, secondary to suture material; it was possible to count three suture threads. with a tipped papillotome and electrocautery, all the suture threads were sectioned, identifying a filiform opening through which a hydrophilic guide is inserted under fluoroscopy until it is sure to overcome the stenosis; we dilated the trajectory with a dilator of 10 mm in diameter and 4 cm in length. with a contrast medium, we observed an adequate trajectory and installed a partially covered duodenal metal stent (hanaro stent) of 14 cm in length by 20 mm in diameter in order to sustain the dilation. he was sent to home with inhibitors of the proton pump. after two weeks, the stent was removed, without complications. he was controlled two weeks after withdrawal, and, with pharmacotherapy, the patient was asymptomatic, making a normal life. conclusion: in this case, the result was positive. satisfactory results can prevent major surgery, which reduces the risk and possible complications. a new range of non-invasive medical tools with a remarkable improvement on the existing market. a manual laparoscopy, with the important novelty of having a bending head with a high degree of movement. this head can get multiple spatial positions to work in surgery and is very easy to use, with the same scissors thimble who controls it, so its performance and learning is very simple and intuitive. the tools can be easily reusable and they can be cleaned and sterilized by ordinary methods, very ergonomic and lightweight . the generic type models we initially have developed are focused in general surgery, but gradually we will develop new applications and different heads for specific medical conditions such as arthroscopy, laryngoscopy, otolaryngology, ophthalmology, orthopedics . its operation is simple and functional, simply moving the scissors thimbles, where they have a dual role, combining the head tilt and the action of opening and closing of this is achieved.the design of this tool allows us to work with some degrees of unparalleled freedom from the existing tools. our instruments replicate the movements of the robot with a simple handheld mechanical instrument, our philosophy is to position our instruments in between a long empty field between the surgeon and the robot. the tip of our instruments are providing the surgeons with angulations impossible to reach with the traditional instruments unless applying huge movements from the hands of the surgeon. we consider that this devices will have a very fast acceptance from the market as this robotic type movements can be managed by the surgeon through the traditional 5 mm trocars, without the need to change to a new surgical technique, just with the traditional method and a very brief training. background: diverticula of the middle thoracic esophagus are infrequent, its etiology may be secondary to traction or pulsion mechanisms. when the etiology is a mechanism of pulsion, they are associated with esophageal motor disorders and its prevalence is estimated between 0.02% and 0.77% of the population . they are rarely symptomatic and the diagnostic is usually incidental. the most common symptoms are episodes of food impaction, chest pain or bronchoaspiration.diverticulectomy and esophageal myomectomy by minimally invasive approach is the treatment of choice in those with large size or associated symptoms. aim: to describe a clinical case of esophageal diverticulum solved by minimally invasive surgery approach. clinical case description: a 74-year-old patient with a history of epilepsy and hypothyroidism consulted for atypical chest pain and dysphagia to liquids and solids. a study with esophagogastroduodenoscopy was performed: 27 cm from the dental arch, a large wide-mouth diverticulum was identified. we complete the study with an esophagram with barium: voluminous diverticulum in the right lateral face of the middle esophageal and a thoracic ct scan showing esophageal diverticulum located in the carina, from 5.6x4.5 cm to 13 cm from the esophagogastric junction. due to the suspicion of associated motor disorder, high resolution manometry was performed showing a significant motor disorder with alteration of peristalsis and exit obstruction with incomplete relaxation of the inferior sphincter and superior hypertonic sphincter. preliminary results: the patient underwent surgery: diverticulectomy and complete esophageal myotomy by thoracoscopy minimall invasive approach. the patient evolved favorably and was discharged after 5 days with a previus control esophagram without pathological findings. currently, it remains asymptomatic 6 months after surgery. , rectus muscles are re-approximated from xiphoid to pubis using laparoscopic running self-locking, pds sutures to restore anatomy and physiologic function of the abdominal wall. unlike the standard access to the abdominal cavity executed with 3 lateral access, the lap-t technique is performed through 3 sopra-pubic aesthetic approaches, using one 3 mm and one 5 mm bariatric (45 cm) instruments laterally, and one 8 mm camera in the middle.the entire procedure is performed in gas-less laparoscopy, with laryngeal mask and intra-peritoneal liquid anesthesia. the repair is consolidated placing an intra-peritoneal semi-absorbable mesh. preliminary results: in all cases abdominal functioning was successfully restored; no higher pain related to the continuous laparoscopic suturing has been reported compared to bridge ipom laparoscopic repair, while allowing for a more physiologic outcome and a stronger repair. the use of miniaturized instruments allowed for minimal tissue trauma and accurate surgical gestures; the tiny trocar sites did not require skin suturing and might reduce the risk of trocar hernias. no intra operative bleeding, no seroma formation, chronic pain, nor mesh infection have been recorded. 98% follow up at 24 months, 89% at 36 months with no recurrences observed. the lap-t technique allowed for a sound and anatomic reconstruction, reduced trauma, faster recovery and more satisfactory aesthetic results. surg endosc (2019) background: anastomotic leakage is a serious complication, associated with significant morbidity and mortality. one possible cause of anastomotic leakage is insufficient vascular supply. markers of sufficient perfusion include pink color of the bowel wall, visible peristalsis, palpable pulsations and bleeding from the marginal arteries. these signs are subjective and may be misinterpreted even by experienced surgeons. aim: the assessment of bowel perfusion with the use of indocyanine-green fluorescence angiography might be helpful in decreasing the number of anastomotic leaks. project description: we report a case report of a middle-aged patient without significant medical history who was treated by transanal total mesorectal excision (tatme) for rectal carcinoma. the patient underwent neoadjuvant treatment with radiochemotherapy. during the surgical procedure, indocyanine-green fluorescence angiography showed adequate perfusion of the bowel. the postoperative phase was uneventful and the patient was discharged home on the 9th postoperative day. preliminary results: indocyanine-green fluorescence angiography is a safe, cost-effective and feasible tool for assessment of tissue perfusion during colorectal resections. background: to properly learn how to perform a laparoscopic suture, along with safe tissue handling, applying an appropriate magnitude of the force on the tissue is essential. for this reason, it is fundamental to investigate and validate if training with real-time visual force feedback improves the suturing performance of laparoscopic novice surgeons. capturing all of the forces applied in laparoscopic in surgery in an unobtrusive way has been difficult in the past. sensor has supplied a novel force-sensing film (forcefilm) that can detect all of the forces applied with laparoscopic instruments without changing the surgical workflow or operation of the instruments. aim: to evaluate the effect of visual force feedback on surgical performance, applied force and surgeon's ergonomics during training of laparoscopic suturing using the sensor technology (sensor medical laboratories ltd.). methods: twenty novice laparoscopic surgeons participate in this study. they perform a laparoscopic suture on an ex vivo stomach tissue from a pig. participants are assigned, in a random fashion, to either group that receives visual force feedback (a) or the control group (b) without visual force feedback. five training trials (t1-t5) are carried out in order to assess the learning curve. in addition, an evaluation pretest (t0) and posttest (t6), without visual force feedback but recording the force applied, will be performed after the training trials. the applied force on the tissue and visual force feedback of each instrument are provided by means of the sensor technology. it accurately measures the forces exerted on the tissue from the instrument tip and wirelessly communicates the force information to the surgeon via visual force-feedback. during each trial, several parameters are evaluated such as execution time, applied force, surgical performance, and mental and physical workload. preliminary results: laparoscopic training using visual force feedback leads to an improvement of suturing skills with a reduction of the applied force and therefore providing a potentially positive effect on patient outcomes and surgeon's ergonomics. background: hiatal hernia is a frequent disorder, characterized by a protrusion of any abdominal structure other than the esophagus into the thoracic cavity through a widening of the diaphragmatic hiatus. current anatomic classification is mainly based on the location of the gastroesophageal junction and the presence of a true hernial sac, differentiating sliding from paraesophageal hernias. there is no solid evidence to support an association between gastric carcinogenesis and peh. however, chronic reflux is considered as one of the strongest risk factors of developing adenocarcinoma of the esophagus and proximal stomach. aim: herein, we report a case of an 83-year-old caucasian female with dysphagia, regurgitation and heartburn accompanied by an iron deficiency anemia, a remarkable total body weight loss and recurrent lower respiratory tract infections due to microaspirations. subsequent work-up with ct, upper endoscopy and barium esophagram confirmed the presence of synchronous distal gastric adenocarcinoma and a giant paraesophageal hernia with complete intrathoracic stomach. after mdt discussion and keeping in mind the patient's age and comorbidity, a 3d laparoscopic distal gastrectomy with a synchronous hernia reduction with posterior cruropexy was scheduled. project description: the patient was placed in a supine position, five thoracoscopic ports were introduced, and a diagnostic laparoscopy of the abdominal cavity was performed. the stomach was identified through the dilated hiatus into the left thorax. the hernia sac was dissected away from mediastinal structures, then excised to untwist the stomach. after reduction of the stomach to abdominal cavity, a total d1 ? gastrectomy with a roux-en-y reconstruction was performed. maintenance of optimal vision during minimally invasive surgery is crucial to maintaining operative awareness, efficiency and safety. hampered vision is commonly caused by laparoscopic lens fogging (llf) and lens condensation which has prompted the development of various antifogging fluids and warming devices. numerous tricks have been proposed to overcome this issue, such as heating the scope into a sterile thermos flask filled with hot water, or using one of the commercially available antifogging solutions. however, whether one method is superior to another remains elusive. as most surgeons know, none of these tips are totally efficient, as they don't treat the cause: the temperature difference. taking into account this need, we have developed ehs (endoscopy heater system), a thermoadjustable system by microcontroller, which is implemented in the manufacturing process of the rigid endoscope focused on laparoscopy. the technology enables the self-modulation of the temperature of the endoscope within the different conditions during the surgery, avoiding the 100% of laparoscopic fogging. with the adoption of ehs surgeons get a clear field of vision avoiding continues repetitions of extraction and insertion of the endoscope in the body during the intervention. in this way the risks of the patients are reduced with a more efficient and shorter duration procedure. ehs also represents an alternative that meets sustainability criteria by reducing energy costs and eliminating much of the waste currently generated by this procedure. therefore, this innovation will disrupt the laparoscopic device market by enhancing safety and effectiveness without introducing new components that could complicate surgical procedures. case report: we presented the case of a 63 year old women with chronic coloenteric fistula. conservative treatment was unsuccessful. the orifice was then closed with two subsequent clips, and the patient recovered well. to our knowledge, this is the first successful case of coloenteric fistula treatment with ovesco discussion: ovesco system is a technique that enables the closure of gastrointestinal defects (perforation sites, leaks, fistulas) . after the system application, the patient can be treated at home as was the case with our patient. a successful closure of the leak or fistula is possible when no extraluminal abscess is present. in our case, we had a cavity (previous sinus or abscess) that drained into the small bowel, thereby forming the coloenteric fistula. this allowed us to succeed with a fistula closure, as the cavity could drain into the small bowel conclusions: looking through the reports, one notes that the success rate of the otsc system procedure for insufficiency of anastomosis or colorectal fistula was 57-100%, but only nine successful reports of chronic colorectal fistula were found). a 100% success rate is reported if the clip is placed within a week of occurrence of the leak . on considering the financial side, clips could reduce costs and time of hospitalization and avoid patients having to undergo a surgical repair . the major advantage of ovesco clips seems to be their ability to grasp more tissue compared to the standard clips and their strong grip on the wound margins because of their sharpened teeth. the drawback of the clips in fistula sealing is their incomplete grasp when the tissue is fibrotic. most authors agree that ovesco is not very appropriate for fistulas larger than 12-15 mm. inguinal hernia repair is one of the most performed interventions in minimally invasive surgery. in this opportunity we report a new technique through the use of innovative devices such as the robotic clamp and magnetic deviceswith this technique and thanks to the magnetized devices and the robotic clamp we have demonstrated to reduce the surgical time between 10-20 min as well as to optimize the ergonomics of the surgeon.we explain the technique with a demostrative video and exposition of the devices that are necessary for make it.with this new technique we get a greater capacity of mabiobra for dissection of the peritoneum and later a greater facility for the suture of the same in the repair of the inguinal hernia. a motorized and computerized laparoscopic tool that can be customized to the specific surgeon and procedure a. szold aim: surgeons have different levels of skill and use instruments for different tasks, but laparoscopic instrument are commonly simple mechanical instruments that allow limited degrees of motion, and the same instruments are used regardless of the surgeon or the task. robotized articulating instruments so far have added degrees of freedom, but perform in a standard way for all users and procedures. technology: human xtensions has developed a \ u[hand-held \/u [ motorized smart laparoscopic instrument, that was recently introduced in human procedures. the device has several features that enable to customize it to the user and procedure. the degrees of freedom can be reduced from 7 to 5, the scale of rotation motion has 3 options that can control both speed and range of rotation, a feature especially useful for the variable types of suturing tasks. results: the variable features were tested in different procedures requiring suturing and grasping. the combination of all optional settings made the instrument customizable to the different skill levels of the surgeons. as such, it enabled to control the complexity of the device and take the surgeon through the learning curve until full control of all features was achieved. in addition, the combination of different controls was used for performing specific tasks requiring different levels of maneuverability. in september 2016, the results of a bomss survey regarding the routine use of pre-operative bariatric surgery were published. they found that 10% of units surveyed considered routine preoperative ogd completely unnecessary. as part of newly launching bariatric services in a single isolated centre we protocoled that all bariatric patients had to undergo pre-operative ogd, including a clo test, and reviewed if the ogd findings had influenced our surgical choice of operation and any necessary treatment before surgery. all patients embarking on the bariatric programme since its launch in jan 2017 to sept 2018 were included and had an ogd. the results of these ogds and all the clo tests were reviewed. these ogds were all performed by a single consultant to minimise any potential subjective differences. of the 45 patients, 7 (16%) tested clo positive of which 3 had normal findings on ogd. 9 patients had a hiatus hernia, 5 gastritis, 8 oesophagitis, 12 gastritis and oesophagitis, 9 had other findings e.g. ulcers, polyps' or nodules. the 7 positive clo patients underwent eradication of h pylori. studies have shown that this is a treatable and preventable cause of gastritis/ gastric cancers and potential surgical complications causing prolonged hospital stay in 22% of patients. knowing about the presence of a hiatus hernia prior to surgery also contributed to the surgical planning, including allowing time for the concurrent correction of the hiatus hernia in the operation. all patients with demonstrable oesophagitis (44%) had their operative choice changed to roux en y gastric bypass thus aiming to prevent post-operative reflux which would have been exacerbated had they undergone a sleeve gastrectomy instead. carrying out a pre-operative ogd had a significant impact in operative choice and additional treatment before surgery and therefore should be advised in all patients. general surgery department, ahievran university, kirsehir, turkey the majority of fatalities worldwide in people under the age of 35 years are caused by trauma 1 . blunt mechanisms account for 78.9 to 95.6%of injuries [2] [3] [4] [5] ,with the abdomen being affected in 6.0 to 14.9% of all traumatic injuries. this case contribute to the literature: a patient with sleeve gastrectomy has distorted anatomy at duodenogastric junction, if has bat,her/his small bowel perforation(sbp) will occur on more distal segment. this a unique case before unpublished. 33 years old female who had sleeve gastrectomy 3 years ago presented to emergency department sustained blunt abdominal trauma (bat). when she arrived pyschical exam (pe) revealed an abdominal guarding, tenderness, normal vital signs but those increased 8 h later. wbc values also increased 8 h later. hb was normal.fast showed in 3 cm thickness fluid early in douglas pauch (dp), 50 mm in supravesical, 33 mm diameter in dp 4 h later. abdominal ct: 37 mm diameter fluid in interloop, dp free air at 5th h from the accident. a diagnostic laparoscopy(dl) was done with diagnossed acute abdomen.there were a sbr-located 60 cm from treitz, intraperioneal fibrin deposits and fluid-repaired with a primary suture.the patient discharged on5 days without any event. repeat ct scans are recommended for patients with initial suspected bowel injury. we could not do this; cause ct exam could taken in rush hours only but we did repeatly pe that peritoneal iritation signs increased,resulted a dl,surgical therapy. according to the literature; dl may be a good treatment option in these patients, to reduce morbidity or mortality, time to surgery has been emphasized. long interval between presentation and surgery was found to be associated with complications. very few reports of isolated jejunal transection following blunt abdominal trauma have been published in literature. the literature mentioned; the patients with sbp are hemodinamically stable on arrival to the hospital like our case are, a rupture of the jejunum was seen just distal to the duodenal-jejunal flexure but there were a perforation 60 cm below treitz ligament and caused me to think the patient had sleeve gastrectomy and some brid around gastric and duodenal proximal jejunal part of intestines and also caused a new descended treitz ligament. normally external forces across to spine produce a blast effect on small bowel between treitz and ileocolic ligament. introduction: sasi bypass is a novel metabolic/bariatric surgery operation based on minigastric bypass and santoro's operation.it can be offered for patients with weight regain after sleeve gastrectomy. sleeve gastrectomy (sg)is a commonly performed bariatric procedure.weight regain following sg is a significant issue.yet,the understanding of this phenomenon is still unclear.rates of regain ranged from 5.7% at 2 years to 75.6% at 6 years.sasi bypass was an option for some candidates having sg done 2 years back and failed to achieve the required weight loss or having weight regain.in sasi bypass, resleeve gastrectomy of the dilated gastric pouch is done followed by a side to side gastro-ileal anastomosis. the aim of this study is to report the clinical results and the outcomes of sasi bypass as a therapeutic option for patients with weight regain after sg methods: we conducted a retrospective study for 25 morbidly obese patients having history of sg done more than 2 years back and failed to achieve and/or to maintain the required bmi. exclusion criteria:patients with recent history of laparotomy(less than 12 months). procedure was done at sidra hospital in kuwait from november 2016 to november 2018. using 5 ports, resleeve gastrectomy was performed over36 fr bougie tube starting 6 cm above the pylorus then gastro-ileal anastomosis (side to side)was performed 6 cm above the pyloric ring to an ileal loop counted 250 cm from the ileocaecal valve. data was collected from the patients including:weight loss progress,laboratory full results. discussion and results: during the study period:25 morbidly obese patients with a mean bmi of 44 ± 6 kg/m 2 were evaluated. -%ewl(excess weight loss)reached 85% at one year. -diabetes was cured in the 2 known diabetic patients (type2)within 6 months,and the one known type 1 diabetic patient had better control and less insulin daily doses(results were guided by glycated haemoglobin results every 3 months). follow up laboratory results were normal in 88% of patients (all were kept on regular vitamins and proteins supplementation)-one patient had postoperative leak(day1)from the anastomotic line that was treated conservatively. conclusion: sasi bypass is a promising operation that offers a good weight loss for morbidly obese patients having weight regain after sg conclusions: our study demonstrates a good agreement between the degree of liver steatosis and monocytes fat accumulation as well as between plin2 levels in liver and circulating monocytes. this suggests that ectopic fat deposition is a generalized feature of insulin resistance in obesity. sg reverses monocyte fat accumulation and restores insulin signalling, which correlates well with insulin sensitivity. moreover, circulating mmp9 levels significantly dropped after sg suggesting that the state of generalized inflammation characterizing obesity normalizes. her stomach stapled,a foreign tube like body was seen on cut surface of the stomach.the foreign body seen in dissected stomach wall is the tube is in placed a gastric banding insuflation tube.a laparatomy was made and the tube is extracted her stomach sutured primarily,nasogastric decompression,peritoneal drainage was made.her peritoneum was drained.she has a septic condition, leave in icu for a long period.her general status being well and discharged from hospital in 50 days.we learn after the operation not before;she had a gastric adjustable banding and extraction the gastric band, but the tube of gastric band is not removed. alkhaffaf et al present a case of fistulation of the lagb tubing into the jejunum a review of the published data to identify the salient learning points with this and similar rare complications fistulation from lagb tubing is a rare complication that tends to follow removal of an infected port. the clinical presentation is nonspecific, rendering the preoperative diagnosis difficult. the tube and band can be removed laparoscopically, with closure of the small bowel fistula site. securing the tubing to the abdominal wall fascia after intentional detachment from the port might reduce the incidence of this complication.katherine j et al report a late and rare complication of a small bowel obstruction in a 52-year-old woman from an lagb placed for 2 years. although not a common complication, one that could easily see the safety record of lagb patients tarnished if this small subgroup of patients is not acted upon promptly by emergency departments' unfamiliar lagb surgery. in our case we already made esophagogastroduodenoscopy before operation, ofcourse take past medical history from the patient.the patient hide past operation (gastric banding and removing band and port but leaving insuflation tube). ). there was no difference in the two groups regarding follow-up rate. basic demographics were the same, and other long-term results were similar between the groups. regression models for both post-op complications and failure as defined by baros score did not show that gender is a risk factor. discussion and conclusions: in our study, revisional sleeve surgery were similar. we did not see any significant difference in post-op complications, success of the operation as defined by baros, or subjective feeling of the patients. we do believe that gender-specific outcomes should be taken into consideration in optimizing patient selection and preoperative patient counseling, and that in the case of a sleeve post a band gender is not a risk factor for complication or failure of the procedure. objective: the internal hernia is a rare but a potentially fatal complication of laparoscopic roux-en-y gastric bypass (lrygb). the aims of this study are: (1) to determine the impact of mesenteric defects closure on the incidence of internal hernia after lrygb; (2) to determine the symptoms, characteristics and management of internal hernias after lrygb. the median interval between lrygb and reoperation was 53 months in group a and 26 months in group b. the median percentage of excess weight loss (%ewl) was 61% vs 67%, respectively (p = 0.79). the median percentage of total weight loss (%twl) was 39% vs 37%, respectively (p = ns). 14 patients, 70% (5 in group a), were admitted to the emergency room with acute abdomen pain. a ct scan was performed in 8 patients, 40%, and showed signs of occlusion in all cases. the most common symptoms were abdominal pain and vomiting. the surgery was performed using laparoscopy in 8 patients, 40%, and using laparotomy or conversion in 12 patients, 60%. conclusions: the closure of mesenteric defects during lrygb is recommended because it is associated with a significant reduction in the incidence of internal hernia. our study intends to analyze the long term results of 112 sleeve gastrectomies performed by 3d laparoscopic approach. materials and methods: a prospective cohort study was conducted to perform gastric sleeve for morbid abesity. all surgeries were performed by the same surgeon over a period of two years. the operating surgeon is a senior most laparoscopic surgeon with vast experience in laparoscopic surgery. during two years period, 112 cases were operated using 3d laparoscopy system. scientific calculation was done using spss release 18.0 windows software. results: 112 patients, 74 female (66%) and 39 male (43%), with median age of 42.3 ± 12.6 (15-70) the excess weight lost (ewl) was 68% in the first year, 72% in the second, 73% in the third, 71% in the fourth, 70% for the fith year, 68% for the sixth and 67% for the seventh. postoperative complications were 3 stenosis of the sleeve always located in the incisura and treated with endoscopic dilatation except one that required conversion to oagb. three leakages, all of them reoperated with drainage and introducing prosthesis by endoscopy in the same act. we have never had a postoperative bleeding of the sleeve. conclusions: 3d gastric sleeve laparoscopy is a safe and feasible technique for morbid obesity and related pathologies. the ewl is correct in long time. complications are rare but is necessary to have a good level of suspicious in order to a rapid solution. the worst complication is the leak of the sleeve. the oversewn of the gastric section is a good technique to avoid this complication. surg endosc (2019) aims: leak is one of the common complications of laparoscopic sleeve gastrectomy that result prolongation of hospital stay, morbidity and even mortality. methods: i report new approach for the treatment of 17 leaks presented to me post laparoscopic sleeve gastrectomy with laparoscopic roux en y bypass to the leak site at the level of gastroesophageal area. this new approach is possible and feasible, and avoids stenting due to high failure rate, prolonged hospitalization and saves life of patients. results: all leaks healed 7 days from surgery due to well vascularized small intestinal patch, except for 2 leaks that healed after 2 weeks of conservative treatment. aims: analyse the effect of one anastomosis (mini) gastric bypass (mgb/oagb) in the treatment of gastro-esophageal reflux in patients previously submitted to laparoscopic sleeve gastrectomy (sg). methods: a retrospective analysis was performed on the data of patients who underwent mgb/ oagb after a previous sg at policlinico san marco, italy, from january 2014 to june 2017. a total of 40 patients, 36 female and 6 males (85% f/15% m) underwent mgb/oagb after sg, due to the development of significant gastro-esophageal reflux disease (gerd), refractory to proton pump inhibitors (ppi), detected with the gerd questionnaire (gerd-q) and esophagogastroduodenoscopy (egds). in three patients (5%) a weight regain was also observed (mean bmi 41.3 kg/m 2 , range 39.3 kg/m 2 -42.5 kg/m 2 ). mean patients age was 40.6 (35-60 years old). before sg none of the patients had declared symptoms of gerd or was subjected to a therapy with ppi, preoperative egds did not show signs of esophagitis. mean bmi of the 37 patients who developed gerd without weight regain was 31.4 kg/m 2 (28 kg/m 2 -33.7 kg/m 2 ) at the time of surgery, with a medium ewl% of 51% (68.3-42.5%). patients were treated unsuccessfully with ppi for at least six months before programming revisional surgery. mean gerd-q score was 12. results: after mgb/oagb, with a mean follow up of 19 months (24-15 months), mean bmi was 28.5 kg/m 2 and gerd-q score was 5. however, five patients out of 40 (13%) developed an anastomotic ulcer or a grade c esophagitis. we did not observe any post-operative immediate complication nor any death. conclusion: mgb/oagb is a simple, effective and safe surgical procedure for patients who underwent a previous sg and who developed gerd, with satisfactory results in the short and medium post-operative time, even if there is still concern regarding the complications linked to biliary reflux. v.s. kyosev aims: laparoscopic adjustable gastric band (lagb) was one of the common techniques in bariatric surgery worldwide. the advantages included the possibility of regulation, ease of placement, acceptable weight loss and low rate of perioperative complications. a late complication of lagb is penetration of the gatric band through the gastric wall and migration into the lumen of the stomach. hereby, we present three cases of gastric band migration following lagb. methods: from 2013 to 2017 we observed 3 cases of gastric band migration in between 5 and 7 years after lagb placement. the patients were hospitalized in surgical department complaining of sudden sharp epigastric pain, nausea and vomiting, with symptoms onset in the last few days. all patients underwent abdominal ultrasound examination, x-ray investigation of the abdomen with oral contrast administration, fibrogastroscopy. in 2 cases the imaging studies revealed gastric band migration into the stomach's lumen and in 1 case-obstruction of the jejunum by the gastric band. all patients underwent laparoscopic surgery. results: two of the patients underwent gastrotomy, extraction of the gastric band and roux-and y-gatric bypass. the patient with jejunal obstruction underwent laparoscopic enterotomy, extraction of the gastric band and cholecystectomy due to concomitant cholecystitis. two of the patients had no additional perioperative complications and were discharged at the 5th postoperative day. one patient developed fever, left pleural effusion and partial insufficiency of the gastrointestinal anastomosis in the early postoperative period without the need of surgical treatment. the patient was discharged on 20th postoperative day. all patients were prescribed a diet and monthly blood test of ion balance. conclusions: lagb was one of the most common treatment methods due to the epidemic spread of morbid obesity in western countries. detailed knowledge on possible lagb complications is essential for the treatment of these patients. the diagnosis of lagb complications is often delayed due to its relative rarity and nonspecific clinical manifestations, but in most of the cases it requires emergency surgery for management of life-threatening conditions. results: there was conversion in 2 patients (short mesentery of the small intestine). such postoperative complication like anastomotic leak in 1 patient (2.7%) and staple line bleeding in 1 patient (2.7%), which was managed laparoscopically. compensation for type 2 diabetes was achieved in 9 (50%) patients, improvement was recorded in 7 (38.9%), dyslipidemia in 4 (23.5%) and 7 (41.1%) patients, arterial hypertension in 16 (55.1%) and 9 (31%) patients respectively, what led to metabolic syndrome resolution in 11 (55%) patients. the liquid is allowed to take after 1 day. average postoperative hospitalization-4.1 ± 1.9 days. %ewl for 48 months 69%. conclusions: laparoscopic mini gastric bypass is an effective method of surgical correction of body weight and metabolic disorders in patients with morbid obesity and allows to receive an adequate and stable correction of arterial hypertension, lipid and carbohydrate metabolism, which are components of a metabolic syndrome. introduction: over time laparoscopic sleeve gastrectomy lsg has become the most popular bariatric operation worldwide. a critical step during lsg is ensuring sleeve-size consistency. gastrisail device (gastric positioning system) is a three in one surgical device replacing the standard bougie used in lsg for the application of suction, decompression and to serve as a sizing guide for gastric sleeve creation. the aim of this study is to evaluate the possible merits of gastrisail device in lsg over the standard laparoscopic sleeve gastrectomy. methods: a prospective study of 40 patients randomly divided into two groups: group a composed of twenty patients who undergo lsg with the use of gastrisail and group b composed of twenty patients who undergo lsg with the standard bougie without the use of gastrisail comparing both according to operative time, consistent sleeve formation, delineation and visualization, intraoperative and post-operative complication rates, the lenght of hospital stay,gastric pouch design and percentage of excess weight loss (%ewl). results: regarding intraoperative time, the mean time was 72.0 ± 13.58 and 79.0 ± 11.74 for group a and b respectively,while no patients in group b had consistent sleeve formation,12 patients (60%) had consistent sleeve formation. delineation and visualization were accomplished in 100% of group a patients, was not accomplished at all in group b patients. the alignment of the stomach was reached in 12 patients in group a but no patients at all in group b, the mean of hospital stay was 2.20 ± 0. 42 and 2.40 ± 0.84 for group a and b respectively, the smaller tube design illustrated by gastrograffin x-ray at 3rd post-operative day was accomplished in 8 patients (80%) and 2 patients (20%) in group a and b respectively. there was no significant difference in %ewl in both groups. conclusion: the use of gastrisail device is superior to the standard lsg in consistent sleeve formation, visualization, delineation and good alignment and accomplishment of a small tube design while no significant difference in %ewl. bariatric surgery has spread all over the world. since japan has few patients with morbid obesity compared with western countries, it has been implemented only in limited facilities. however, bariatric surgery in japan is rapidly spreading recently, and many facilities are about to install bariatric surgery. effects of bariatric surgery are known to last for a long time, but some cases require reoperation which is called revision surgery due to late complications or rebound. because of thick subcutaneous and visceral fat, open surgeries are not even always a good solution to make surgery easier in morbid obese patients and all procedures must be completed laparoscopically. therefore, especially in revision surgery, the incidence of complications tends to be increased. as the number of bariatric cases to be increased in japan, cases requiring revision surgery is likely to increase. in revision surgery, it is necessary to select the procedure according to patient condition, and it is necessary to familiar well with those procedures. we will present cases that underwent revision surgery in our department and show the clinical outcome. we have done four revision surgeries after sleeve gastrectomy so far. operative indications are 2 mid-gastric stenosis and 2 rebounding disease. for stenosis cases, we performed roux-en y gastric bypass with distal stomach resection, and for rebounding cases, we performed re-sleeve gastrectomy with duodenal-jejunal bypass. average interval from initial operation to revision surgery is 69 months in rebounding cases, and 9 months in stenosis cases. duration of operation was 269 min in average, and mean estimated blood loss was 18 ml. no postoperative mortality was observed. in rebounding cases, excess bmi loss at 1 year after surgery was 40.9% in average, and both cases achieve diabetes remission at 1 year. one cases of mid-gastric stenosis required a nutritional support with formula diet temporally. in particular after sleeve gastrectomy, revising to roux-en y gastric bypass, re-sleeve gastrectomy, and adding the duodenal-jejunal bypass will be the main techniques. along with an increase of bariatric surgery in japan, it is necessary to acquire sufficient knowledge and skills to carry out revision surgery. methods: we present the case of a 45 year old woman who underwent lsg after lagb removal and lgcp. the patient underwent preoperative endoscopy and barium swallow, with no sign of stomach perforation or erosion. we emphasize that the patient, had undergone three operations of gastric band placement, gastric band removal and gastric plication before sleeve gastrectomy. however, a successful lsg was achieved. results: no severe postoperative complications were mentioned. conclusion: weight loss in the first year was 70% of the excess weight.sleeve gastrectomy after gastric band removal and gastric plication, for morbid obesity seems to be safe and efficient, especially in casesof absence of gastric erosion. surg endosc (2019) department of surgery, 19 patients were observed with serious septic complications many years after gastric banding operation. we detected a female dominance (16 female, 3 male) in patients with a mean age of 41.6 years. the leading symptoms were: dysphagia, upper abdominal tenderness and pain, spontaneous fistula formation, fever, masked septic signs, bowel and urinary obstruction. patients underwent video-endoscopy, chest and abdominal ct (computed tomography), fistulography and cystoscopy. results: in still morbid obese patients, laparoscopic procedures were performed with a conversion rate of 50%: atypic gastric and cardia resection in 4 cases, gastric suture in 9 cases, small bowel resection and suture in 4-4 cases. in one case, fistulectomy, abscess evacuation and combined urinary bladder suture and drainage were carried out. the duration of the surgeries were over 2 h with minimal blood loss (\ 200 ml). the foreign bodies were completely removed in every case. intraoperative complication was not occurred. early physiotherapy were promoted, oral feeding were gradually built up from the 2th postoperativ day depending on the type of the operation. early postoperative complications included recurrent fistula formation (n = 2) and wound infection (n = 11). all the fistulas were closed after conservative treatment. average hospital stay was 8 days, regular check-ups were held on the 3rd, 6th and 12th months of follow up. conclusion: gastric banding is the most common, routine and safe technique for the treatment of morbid obesity. the development of late, severe septic complications draws attention to the crucial importance of follow up. the surgical management of these patients is recommended in specialized centers in regard to difficult operative conditions and atypic treatment options. aims: single anastomosis duodeno-ileal bypass with sleeve gastrectomy (sadi-s) has been proposed as an alternative to biliopancreatic diversion with duodenal switch (bpd-ds) in order to maintain the outcome of the original procedure simplifying the technical complexity and to avoid potential complications. moreover, it potentially represents the more natural second step bariatric procedure after sleeve gastrectomy (sg). we aimed to report the initial experience with sadi-s of our high volume bariatric center. methods: retrospective analysis of patients who underwent bariatric procedure between july 2016 and november 2018 was conducted. the primary aim was the evaluation of the safety of sadi-s, defined as the rate of postoperative complications. the secondary endpoint was the bariatric efficacy of the procedure, defined as percentage excess weight loss (%ewl). results: among 813 patients who underwent bariatric procedures at our institution 36 (4.4%) patients were scheduled for sadi-s. all patients had multiple comorbidities. initial indication for sadi-s was failed sg in 8 patients (median pre-sg bmi 52.1 kg/m \ sup [ 2\/sup [ ; median 39 months after initial operation respectively) and primary procedure in 28 patients (median pre-operative bmi 56.5 kg/m 2 ). the surgical procedure was accomplished with robotic-assisted approach in 4 cases (median operative time 198 min) and with laparoscopic 4 trocars standard approach in the remaining 32 cases (median operative time 130 min). the duodeno-ileal anastomosis was fashioned using a double layer hand-sewn running sutures. no patients showed early post-operative complications, the median postoperative stay was 3 days. at a mean follow up of 12 months the median %ewl was 66.1. to date no patients experienced surgical. one patient develop wernicke encephalopathy 6 months after surgery, but he was non-compliant to multivitamin supplementation. conclusions: at least in a high volume bariatric center sadi-s, both as second step after sg and as primary surgical option, seems to be a safe and effective bariatric metabolic procedure based on solid physiopathologic principles. on the other hand, longer follow-up is necessary to support the use of this procedure as a better alternative to bpd-ds. m.r. elkeleny 1 , a. abo khozima 2 1 git and bariatric surgery, faculty of medicine, alexandria university, alexandria, egypt; 2 git surgery department, faculty of medicine,alexandria university, alexandria, egypt four bariatric cases 1. female patient with intragastric balloon, minor leak from the balloon leading to ballon migration to the jejunum;hance, small bowel obstruction occured. emergency diagnostic laparoscopy was done, enterotomy and extraction of the balloon, direct repair of enterotomy and balloon extraction through 10 mm port site. 2. male patient presented after 5 days of lsg with small bowel obstruction due to entrapment of small bowel loop through one of the port sites;therefor, emergency laparoscopy was done with reduction of the herniated segment and closure of the port site. 3. female patient presented with stricture of the ogj after re-sleeve gastrectomy managed by balloon dilatation which recur after 2 weeks .she was managed by expandable metallic stent for 6 weeks with good response and the stent was removed.4.38-year-old male patient presented with sever peripheral neuropathy following 5 months after sleeve gastrectomy, and the patient was getting worse; thus, he used wheel chair. he has been making good progress on vitamin b complex injections. the aim of our study was to compare histopathological findings of gastric specimens to preoperative clinical symptoms and to conclude about the need for ugi endoscopy as a routine prior to surgery. methods: the last two years, 44 morbid obese patients were selected to undergo laparoscopic sleeve gastrectomy (lsg) in our institution. for the needs of our study, all of them had ugi endoscopy and were reviewed for upper gi symptoms. histopathological reports obtained according to our protocol, after surgery. results: gastric histology from specimens revealed: no findings in 16/44 patients (36.4%), gastritis in 19/44 patients (43.2%) and focuses of incomplete intestinal metaplasia without dysplasia in 8/44 patients(18.1%). finally, two minor leiomyomas with low cellular proliferation rate were fully excised in a patient's specimen. there was no inconsistency between preoperative symptoms and gastric histology, while leiomyomas found were no reported to ugi endoscopy due to size. conclusions: some of the patients with clinical features of food intolerance, gastroesophageal reflux disease, and peptic ulcer disease had finally findings in histopathology of their stomachs. history of helicobacter pylori infection implements a raised incidence of mucosa pathology as well. because only one case revealed carrying significant pathology (leiomyomas), we consider that is safe to proceed with surgery in an otherwise asymptomatic patient based on his previous medical records and blood tests. aims: splenic abscess following laparoscopic sleeve gastrectomy (lsg) is a rarely seen complication. the aim of our study was to present a case of splenic abscess in a morbid obese patient who underwent lsg. as the main concern in these cases is leakage from the staple line, we present our diagnostic and treatment approach. methods: a 42-year-old, female morbid obese patient (bmi 56.6 kg/m 2 ), without any predisposing risk factors, underwent elective lsg in our department. following an uneventful course, she was discharged at the 2 nd postoperative day. however, at the 20 th postoperative day, she readmitted to our unit with high temperature of 38.4 o c, left upper quadrant tenderness and leukocytosis. contrast computed tomography (ct) revealed an abscess at the upper pole of the spleen 4,5 cm in maximum diameter, without leakage from the staple line. results: the patient was treated with broad-spectrum antibiotics and radiological percutaneous drainage of the abscess. although there was a partial clinical improvement, a week later, a new ct scan revealed the continuous presence of the abscess. despite the stable general condition of the patient a laparoscopic splenectomy was performed and a gradual recovery was followed. the presence of splenic abscess without splenic trauma or leakage from the gastric staple line, is an extremely rare complication and only a few cases have been previously reported. the cause has not yet clarified, but the proposed mechanism involves infarction of the spleen, due to vascular compromise and subsequent infection. most of the reported splenic abscesses were diagnosed during the late postoperative period. in our report we present a case of early onset, hence highlighting the need of clinical awareness for early diagnosis and treatment. introduction: obese surgical patients with obstructive sleep apnea (osa) have a higher risk of peri-and postoperative desaturations and subsequent morbidity and mortality. currently, the best perioperative management of patients without known osa remains unclear. although routine osa screening has been advocated, sleep studies are costly and time consuming. we hypothesized that bariatric patients can be safely monitored on a surgical ward by continuous postoperative pulse oximetry without preoperative screening for osa. objectives: to evaluate outcomes of continuous postoperative pulse oximetry without preoperative osa-screening, and to compare the results to outcomes of patients with osa and continuous positive airway pressure (cpap) treatment. methods: all patients who underwent bariatric surgery between 2011 and 2017 were included in this single-center retrospective cohort study. all patients were postoperatively monitored with continuous pulse oximetry on the surgical ward. patients with less than two documented saturation measurements were excluded. patient files were reviewed for osa diagnosis, cpap usage and perioperative details. primary outcomes were 30-day complication rates, intensive care unit admissions due to cardiopulmonary causes and postoperative desaturations of spo 2 \ 90%. secondary outcomes were icu admissions following all causes, length of stay and rates of reoperation and readmission. results: in total, 5203 patients were included. 675 patients (13%) were preoperatively diagnosed with osa, 511 (9.8%) were cpap users. complications occurred in 7.2% of patients without osa and in 9.6% with osa(p = 0.028). desaturations were documented in 1.4% and 4% (p \ 0.001), respectively. in both groups, 1 patient was admitted postoperatively to the icu for cardiopulmonary causes that could be related to osa (p = 0.119). both recovered without further complications. icu admissions, regardless of cause, occurred in 0.42% of patients without osa and in 1.18% with osa(p \ 0.001). no significant difference between groups was observed in complications based on clavien dindo classification, length of stay, reoperation-and readmissions-rates. conclusions: these findings suggest that continuous postoperative pulse oximetry without preoperative osa-screening is a safe perioperative management strategy for bariatric surgical patients. future studies are needed to assess cost-effectiveness of pulse oximetry vs. routine preoperative osa-screening in a prospective clinical setting. background: the pathology of colon is one of the most pressing and socially significant problems of modern health care, because it leads to reduction of the working population employed in manufacturing, in some cases to disability and reduced quality of life. mini invasive surgery of the colon has a great advantage: speed recovery, shorter hospital stay and better cosmetic results, the quickest return of patients to work. as a result, mini invasive endovideosurgery is firmly established in clinical practice of coloproctology. objective: the choice of optimal surgical method for treatment of colostasis, achievement of favorable outcomes of treatment. introduction: laparoscopic roux-en-y gastric bypass (rygb) is one of the most important bariatric surgical procedures performed worldwide and it can produce an important loss of weight with reversal of metabolic disorders like diabetes and dyslipidemia. even though it has good results, some complications occur after gastric bypass. a rare but serious complication of rygb is the so-called postprandial hyperinsulinemic hypoglycemia. its prevalence has been estimated less than 1% of cases and its pathophysiology remains unclear. methods: the aim is to present a case series of reversal surgery in patients with severe hiperinsulinemic hypoglycemia after rygbp in the hospital general universitari de la vall d'hebron. unit of endocrine-metabolic and bariatric surgery (eac-bs center of excellence for bariatric and metabolic surgery by ifso). it is a retrospective analysis of a prospective database same surgical team. we present in this study, the main features of those patients. results: between 2011 and 2018, 13 patients underwent a laparoscopic reversal procedure to normal anatomy and age mean was 57 year (22 years to 70 years). mean preoperative body mass index (bmi) was 31.2 kg/m 2 (range 28-39.4 kg/m 2 ) and 10 were women. all patients presented hypoglycemia symptoms 5 years after and the longest was 15 years after the procedure. the first step of the standard approach was a laparoscopic reversal to normal anatomy with resection of the alimentary rygb limb in 7 cases. a concomitant sleeve-like gastrectomy (sg) was added. four patients presented postoperative complications: gastrogastric anastomosis leak (1) introduction: laparoscopic sleeve gastrectomy is the most performed bariatric procedure, but complications might interfere with patient's long-term evolution based on its compliance and tolerance, surgical attitude and unpredictable evolution. materials: we present the case of a female obese patient, with type ii diabetes mellitus and blood hypertension, with multiple, sequential bariatric minimally-invasive interventions: sleeve gastrectomy in 2012 complicated by postoperative acute gastric dilation and mediogastric stenosis, reoperated for viscerolysis and cholecystectomy, with endoscopic gastric dilations, initially converted to functional one anastomosis gastric bypass (200 cm limb), with a non-adjustable gastric ring positioned instead of stapled division. the last operation was complicated 12 months after by persistent biliary gastro-esophageal reflux, chronic abdominal pain, and gas bloat syndrome. in 2018 the patient underwent conversion to laparoscopic r-en-y gastric bypass, with gastro-enteral anastomosis resection, band removal and viscerolysis. results: conversion to r-en-y was complicated by biliary leakage post-viscerolysis, treated with laparoscopic approach in the 9 \ sup [ th \/sup [ po day. after multiple surgical and endoscopic interventions, the patient presents short-term favorable outcomes, with no reflux or abdominal pain, with further weight loss and diabetes improvement. conclusion: bariatric surgery has unpredictable evolution in same cases, and conversion to r-en-y seems to be the best solution. lgcp is widely used in developing countries due to its lower cost and good results. material and methods: we performed in our department 120 lgcp for morbid obesity. excess weight loss (%ewl) was 55% at 6 month after surgery and 65% at one year. in 12 cases revision surgery was needed for different complications and in 22 cases for inadequate weight loss or weight regain after 18 month follow up. in 8 cases we performed sleeve gastrectomy (in 3 cases after taking down the plication) and in 14 cases we performed a re-plication in one row. results: the rate of revision surgery was 28% overall and 18% for inadequate weight loss (excess weight loss \ 50%) or weight regain. major complications occurred only in one patient (leak with abscess) but it was solved by laparoscopy. minor complications as vomiting and nausea appeared in 5 patients (22%) and were solved with medication. after one year follow up %ewl in these cases was 85%. conclusions: revision surgery after lgcp is possible. a new plication or sg was the option in our series with good results. further studies are needed to evaluate the use of lgcp in the armamentarium of bariatric surgery. background: roux-en-y gastric bypass (rygb) is one of the most commonly performed bariatric procedures around the world.however, rygb it sometimes carries the risk of rarebut serious long-term complications such as malnutrition and liver failure. we report a case of laparoscopic reversal of rygb. methods: in march 2017, a laparoscopic rygb was performed for a 53-year-old female without comorbidities and with a bmi of 54 kg/m 2 . all laboratory test results at the preoperative evaluation were within the normal range. abdominal ultrasound revealed moderate hepatic steatosis and oral endoscopy a hiatal hernia with grade b esophagitis. one year later, patient experienced an important weight loss of 75 kg (from 155 to 80 kg) with a bmi of 28 kg/m 2 . however, patient presented general weakness, abdominal pain, ascitis lower extremitiy edema, anemia, progressive caloric and protein malnutrition, vitamin (a, d), mineral (copper) and folic acid deficiencies, nonalcoholic steatohepatitis (nash) and liver function was progressive worsening. results: a laparoscopic reversal of gastric bypass was performed. the operation was successfully performed via laparoscopy. operating time was 70 min. postoperative was uneventful and patient discharge home at day 6. hepatic biopsy revealed nash with steatohepatitis of 80% (fibrosis f2-3/4). eight months after reversal of gastric bypass, patient has improved her clinical situation (no asthenia), maintains of weight (80 kg) and has improved her nutritional status and liver function parameters. conclusion: laparoscopic reversal of rygb is technically feasible and might be performed safely after thorough preoperative evaluation in carefully selected patients with malnutrition and liver failure. conclusion: laparoscopic sleeve gastrectomy it's a safety obesity procedure before major abdominal hernia repair. it's a minimally invasively technique with an absence of anastomoses. these factors prevent fewer complications, without using the small bowel, and skin problems and allow resolution of obesity-associated co-morbidities. body weight loss after surgery may be an opportunity to repair the severe loss of domain incisional hernia. bibliography borbély, y., zerkowski, j., altmeier, j., eschenburg, a., kröll, d. and nett, p. general surgery, benhazi medical center, benghazi, libia, 2 general surgery, royal bahrain hospital, manama, bahrain obesity is a worldwide epidemic with an increasing incidence trends and as a consequence obesity related health problems become priority to healthcare authorities in all the countries. laparoscopic gastric plication is an emergent restrictive procedure which claimed to be low cost because they do not need staplers and carries less complications as compared to laparoscopic sleeve gastrectomy. we present here a 37 years female who was operated for morbid obesity four months back where she underwent laparoscopic gastric plication with no immediate post operative complication and her wight loss was adequate. two days before presentation to our emergency department she started to complains of sever attacks or upper abdominal pain and vomiting.clinical examination was unremarkable apart of abdominal tenderness in left upper abdomen. all blood routine were normal and all inflammatory markers were within normal range.ct abdomen showed large cystic lesion around the greater gastric curvature containing fluid and raised possibility of collection. patient was admitted to hospital, in despite of medical treatment her pain persists and necessitate immediate laparoscopic exploration. gastro-gastric hernia at the greater curvature through loosen ethibond suture that was used to plicate the stomach in the previous surgery. we released the suture to liberate the strangulated stomach which is not gangrenous. re-plication was not possible because of the extensive gastric wall edema and as preoperative discussion with the patient she refused conversion to sleeve gastrectomy no intervention was done. post surgery patient was free of symptoms and tolerating oral diet and discharged home on third post operative day with no complications. gastro-gastric herniation could progress to gastric wall gangrene which will result in high morbidity and even mortality. high index of suspicion is required to diagnose the condition . preoperative patient counseling is important to explore the surgical options if deemed necessary to convert to another bariatric procedure. k. chouillard, a. d'alessandro, l. chahine background: bariatric surgery is the best available, long-term treatment for morbid obesity. currently, laparoscopic sleeve gastrectomy (sg) is the most commonly performed bariatric procedure in france. despite its safety and efficacy, long-term complications of sg are not rare including gastro-esophageal reflux disease (gerfd), twisting, stenosis, insufficient weight loss, and weight regain. the goal of this study was to analyze the pattern and short-term results of surgical revision in patients with sg. methods: revisional bariatric surgery, regardless of its motivation, was always a multidisciplinary decision after clinical, biological, endoscopic, and radiological assessment. patients who had revisional surgery after sg were retrospectively identified and subsequently divided in 4 subgroups according to preoperative body mass index ( we aim to present the management and the particular aspects of the surgical technique in a gastrobronchial fistula after gastric sleeve . the mean time between intervention and diagnosis is 6.7-7.2 months. methods: between 2011 and 2018, 4253 laparoscopic gastric sleeve resections were performed in our bariatric center. we had one case of gastrobronchial fistula associated with an inferior lobe abscess of the left lung, diagnosed 3 months after the gastric sleeve. the patient was subject for medical treatment for 24 h, than a laparoscopic intervention was performed in order to drain the lung abscess and the gastric fistula and to place a feeding jejunostomy. 2.5 months after this intervention (5.5 months after gastric sleeve) a laparoscopic roux-en-y fistulojejunostomy was performed. the evolution was monitorized with blood tests, upper gi contrast series and ct scans. results: the surgical drainage of the lung abscess, along with the antibiotherapy, controlled the infection and allowed the lung cavity to reduce in size, and thus the drainage tubes introduced in the thorax through the diaphragmatic orifice were retracted progressively. also, the feeding jejunostomy allowed a proper nutrition for the patient with a good recovery. however, 2.5 months after the drainage intervention, the gastric fistula was not healed, and a decision to interrupt the communication with the lung cavity was made, by creating a laparoscopic fistulojejunostomy. after this, the evolution was favorable, with the healing of the lung cavity, oral feeding was permitted and the jejunostomy was suppressed. conclusions: the treatment of the gastrobronchial fistula is complex (medical, endoscopic or surgical), phased and long lasting until healing. surgery was our initial choice for treatment due to the existence of the lung abscess, which needed to be drained. key words: gastrobronchial fistula, lung abscess, laparoscopy, fistulojejunostomy s.i. filip, i. hutopila, c. copaescu introduction: leakage remains one of the most dreadful complications in metabolic surgery. the main cause of leakage is poor tissue oxygenation due to inadequate vascular perfusion. the study of intraoperative tissue perfusion in real time due to icg enhanced fluorescence could provide valuable information for the surgeon in order to prevent postoperative fistula. aim: to present our experience in using icg enhanced fluorescence in laparoscopic bariatric surgery material and method: in 30 cases of gastric sleeve, 12 cases of gastric bypass and in 10 cases of revisional surgery or redo cases we used intraoperative icg mediated fluorescence to assure the optimal vascularization of the involved tissues. in our video we present intraoperative aspects before and after using icg in different cases. results: in all cases of primary gastric sleeve and gastric bypass with intraoperative use of icg we did not encounter inadequate perfusion. in one case of redo gastric bypass after failed vertical banded gastroplasty for morbid obesity despite intraoperative laparoscopic normal aspect of the gastro-jejunal anastomosis, icg mediated fluorescence allowed to identify an unexpected ischemic anastomosis and we could prevent consecutive postoperative leakage. discussion: presented cases are discussed and result with referral to literature is made. conclusion: intraoperative use of icg is a valuable tool in assessing the perfusion of the tissues and provide essential information for the surgeon in order to avoid postoperative leakage. , including 1270 patients, hemostasis with clips has been performed in all cases. however, among these cases nine patients required reoperation for early postoperative bleeding. in five cases a bleeding source from the stapled line was identified while in 4 cases no identifiable source was found. during the second period (2015 to present) 2967 patients were submitted to bariatric surgery and hemostasis was performed by over sewing with a running suture. among these cases reoperation for postoperative bleeding was needed in 13 cases (0.4%), but no bleeding from the staple line being encountered (0%). the difference has statistical significance. no significant complications related to the use of this type of reinforcement were encountered. conclusions: over sewing the gastric stapled line in bariatric surgery is superior to hemostatic clip application in preventing the postoperative bleeding from the stapled line postoperative bleeding. a protocol of active search of the bleeders during the bariatric procedure should be implemented and respected in all the cases. gastroenterological surgery, saitama medical university international medical center, hidaka-shi, saitama, japan intestinal endometriosis is a rare disease which is associated with about 10 to 30% of patients with endometriosis, and it is favorable to the rectum and sigmoid colon. here we report 5 cases (shown in the table) underwent laparoscopic resection for intestinal endometriosis. there were no postoperative complications in all cases, and all patient was discharged on 5-8 \ sup [ th \/sup [ postoperative day. before the operation, 2 of 5 patients were diagnosing intestinal endometriosis, and it was difficult to preoperatively diagnose. among them, the symptoms at the time of menstruation were clear was one case. in case of submucosal tumor, preoperative diagnosis seems difficult. additional image examination at menstruation may be useful for diagnosis. d2 dissection was performed for case 1, 2, 4 because malignant disease could not be denied as a preoperative diagnosis. 2 of them were strongly doubted endometriosis in surgical findings. in intestinal endometriosis surgery, pelvic adhesions and fibrosis are often advanced. in the sigmoidectomy, the average operation time was 152 min and the blood loss was 10 ml. in the rectal resection, the average operation time was 282 min and the blood loss was 17 ml. in case 1 and 5, pelvic adhesion was severe, residual rectum could not be straightened, and side to side anastomosis was performed. in intestinal endometriosis surgery, intestinal anastomosis method should be considered flexibly. conclusion: laparoscopic surgery for intestinal endometriosis was safe, but technically difficult because of fibrosis and adhesion. it is important to accurately diagnose from clinical symptoms and image also intraoperative findings. anastomotic method should be decided according to the case. aim: the aim of the study was to identify and highlight some of the complications one can encounter in bariatric surgery-specific-sleeve gastrectomy and discuss the therapeutic options one has at his disposal. methods: the study was retrospective. we identified a number of 260 patients which had a sleeve gastrectomy done in our clinic for a 2 year period. of these 10 had important surgical complications encountered during the surgery or in postoperative care. results: the group included 260 patients, with an average bmi of [ 40 kg / m 2 . average hospital stay was 7 days, with an average of 4.5 days which increased to 30 days when fistulas were encountered. the most frequent surgical complications were bleeding from the gastric suture (6) and gastric fistula (4 cases). other complications encountered were wound hematoma. surgery was required in 4 of the 6 cases of bleeding and 3 of the fistula cases required reintervention. one case was resolved with endoscopic stenting. conclusions: laparoscopic gastrectomy is considered a safe procedure with good results for the patient. although complications are rare they pose a series of technical difficulties for the surgeon due to the weight of the patient and frequent comorbidities which come with obesity. a thorough understanding of the symptoms and good follow-up ensures the best results. aims: to achieve additional weight loss or to resolve band-related problems, a laparoscopic adjustable gastric banding (lagb) can be converted to a laparoscopic roux-en-y gastric bypass (rygb). there is limited data on the feasibility and safety of routinely performing a single-step conversion. we assessed the efficacy of this revisional approach in a large cohort of patients operated in a high-volume bariatric institution. to the best of our knowledge this series represents the largest single-center study on conversion from lagb to rygb methods: between october 2004 and december 2017, a total of 1383 patients who underwent lagb removal with rygb were identified from a prospectively collected database. in all cases, a single-stage conversion procedure was planned. the feasibility of this approach and peri-operative outcomes of these patients were evaluated and analyzed. results: a single-step approach was successfully achieved in 920 (86.5%) of the 1383 patients. during the study period, there was a significant increase in performing the conversion from lagb to rygb single-staged. no mortality or anastomotic leakage was observed in both groups. only 49 patients (3.6%) had a 30-d complication: most commonly hemorrhage (n? = ?23/49), with no significant difference between the groups. conclusion: converting a lagb to rygb can be performed with a very low morbidity and zero-mortality in a high-volume revisional bariatric center. with increasing experience and full standardization of the conversion, the vast majority of operations can be performed as a single-stage procedure. only a migrated band remains a formal contraindication for a one-step approach. surg endosc (2019) . six months after surgery the mean hrql score, was 2 (0-6) in 5 patients underwent to lsg and 0.6 (0-2) in 3 patients underwent lgb. twelve months after surgery the mean postoperative questionnaire score was 6 (0-12) in 2 patients who underwent lsg. at ph-manometry the mean percentage time of acid reflux in orthostatism was 7.3 (range 6-8.6) and in clinostatism 5.3 (range 0.3-10.4). the mean demeester score at the distal electrode was 33.1 (13.7-52.5). conclusions: in asymptomatic patients, complete gerd evaluation before bariatric surgery allows better selection of surgical procedure, to reduce the postoperative occurrence of severe or de novo gerd. postoperative gerd evaluation provides useful data regarding the impact of lsg on gastroesophageal reflux. a larger patient sample size is required. aims: vertical calibrated gastrectomy (usually know as gastric sleeve) as unique technique gives better results than the roux y bypass in terms of improvement of anthropometric measures, reduces comorbidities and has a lower rate of postsurgical complications, with an improvement of quality of life. material and methods: an observational, longitudinal, retrospective and comparative study with 95 patients, aged 18-65 years,during a period of 3 years. everyone must comply with the protocol of the unit. demographics of the population and the anthropometric data will be measured in the presurgical consultation, the month and the year after the surgery: weight, height, bmi, weight loss percentage,bmi percentage and percentage of excess weight lost. we took data on the cardiovascular risk by the framingham score. the quality of life is measured by baros scale. mayor comorbidities are hypertension, diabetes, dyslipidemia. complications will be measured in absolute frequencies. for de statistical study, we apply type t student or chi square being statistically significant p equal to or less than 0.05. results: there was not statistically significant difference between the 2 techniques of surgery month (p = 0, 83), but they were evident to the year of the same (p 0.003). not gender or age differences were apparent. mayor complications did not appear in gastrectomy (no leaks), highlighting the number of bleeds with this surgical technique. the bypass there were two leaks. there was no statistically significant difference in cardiovascular risk (p = 0, 07) between the two techniques. there was a more significant decrease in number of comorbidities in gastrectomy against the bypass, with a total disappearance of patients with dyslipidemia. there were no statistically significant differences in baros score, although it was higher in gastrectomy. conclusions:-the vertical gastrectomy as unique technique can be considered superior in the short term, as well as safe, according to the aec quality parameter. we think it will be necessary to continue their studies into the medium-long term. aims: analyze the impact of different bariatric surgeries technics in carbohydrate metabolism and pancreatic beta cell population of none obese adult wistar rats. methods: we used twenty healthy not obese adult wistar rats divided in five groups randomly assigned. each with n = 4. the control groups were divided into fasting control (f) and sham (surgical control). the surgical groups were separated into vertical gastrectomy (gs), 50% resection of the middle small bowel (ri50) and gastric bypass (gb). in each group was assessment: beta cell mass modifications, pancreatic islets histomorphometry, proliferation, apoptosis and neogenesis in beta-cell pancreatic population; intraperitoneal glucose test tolerance, body weight and food intake. statistical analysis as evaluated using mann whitney test. results: the malabsorptive and restrictive group have a significantly smaller increase weight than the control groups. the intraperitoneal tolerance glucose test reports incremental glucose area under curve (auc) was significantly higher in the malabsorptive group and lower in the restrictive group compare to the control groups during the second (p \ 0.01) and third (p \ 0.05) month of the study. the beta-cell mass was significantly higher in the ri50 group compared with control groups respectively. there was a significantly increased number of beta-cell per pancreatic insulin positive area in gs and gb. proliferation was significantly increased in ri50 and gb group, and significantly decreased in sg compared. there was no significantly difference during apoptosis assessment among surgical and control groups. in neogenesis differences between groups were assessed qualitatively by the presence pdx -1 expression, being higher in rygb. the endocrine pancreas in our model is altered by the anatomical and functional conditions arising from surgical techniques. carbohydrate metabolism conditions are affected by temporary adaptive processes due to surgical alternatives. there is a hyperplasia and hypertrophy of the beta cells in surgeries with a malabsorptive component, as well as greater neogenesis. these results could explain part of the existing relationship between the enteropancreatic axis and the existing incretins. m. buza, c. copaescu introduction: nowadays, we have high volumes of obese patients for whom surgery is the answer, but unfortunately the psychological evaluation has no standard recomandation in preoperative evaluation of bariatric patients. it is argued that surgery success, in addition to the operation itself, relies on behavioral changes and that one of the goals of the preoperative assessment is to prepare the patient for the postoperative period, aiming to optimize surgical results. aim: although no formal standard exists in the literature, there is growing recognition of the important elements to be addressed and the appropriate means for collecting the necessary data to determine psychological readiness for these procedures. methods: information regarding the components of the clinical interview and the specific measures used for psychological testing are discussed. given the limited data on predicting success after surgery, determining psychological contraindications for surgery is addressed. additionally, the multiple functions served by the psychologist during this assessment procedure are highlighted along with the value of this procedure in the patients' preparation for surgery as well as the postoperative follow-up. in our center of excelence for bariatric and metabolic surgery (coe) we introduced since 2013 a mandatory pre-and postoperative psychological evaluation for all patients addressing the metabolic program. results: psychological evaluation of patients before bariatric surgery is a critical step, not only to identify contraindications for surgery, but also-and more so-to better understand their motivation, readiness, behavioral challenges, and emotional factors that may impact their coping and adjustment through surgery and the associated lifestyle changes. postoperative follow-up is necessary. the psychological evaluation of the patient undergoing bariatric surgery is an invaluable piece of the larger pre-and post-surgical assessment, aiming better results in the short and long term after bariatric surgery. introduction: a mesenteric cyst is defined as a benign abdominal tumors that is located in the mesentery of the gastrointestinal tract, identified in * 1 of 100,000 hospital admissions. mesenteric chylous cysts are rare pathologic entities that often present with unspecific symptoms. the preoperative diagnosis requires all the common abdominal imaging techniques. usually the correct diagnosis may be made only at the operation stage or during the histological examination. all mesenteric cyst should be resected in order to avoid their complications, complete surgical resection is recommended and curative in the majority of cases with a low risk of local recurrence. the laparoscopic approach is the gold standard in the treatment of intraabdominal mesenteric chylous cyst. laparoscopic resection provides less pain, shorter hospital stay, and early recovery for the patient. case report: we report a case of 28-year-old saudi woman who presented to our clinic complaining of upper abdominal pain and mass in the epigastrium for one week, no history of nausea, vomiting, or recent changes in bowel habits. her medical and family histories were clear and she had never had any abdominal interventions. abdominal palpation revealed a smooth-surfaced mass palpable in the left upper quadrant, ultrasonography and with computed tomography of the abdomen revealed an approximately 93 9 72 9 66 mm unilocular cyst closely related to the mesentery in the left side of upper abdomen not related to the pancreas .the cyst was excised by laparoscopy complete surgical excision to avoid recurrence within healthy borders, it is contained milky white fluid. the histopathological findings were chronic inflamed mesenteric cyst. a review of the literature considering this rare entity was also performed to evaluate our treatment strategy. conclusion: mesenteric chylous cysts represent a diagnostic challenge and they should be considered when a physician encounters an intraabdominal mass. usually the correct diagnosis may be made only at the operation stage or during the histological examination. the treatment of choice is the complete surgical excision that can be safely performed by laparoscopy. surg endosc (2019) background: diverticulum of appendix is relatively rare, and appendiceal diverticulitis was reported to have a higher risk of perforation than appendicitis. in the us and europe, because of the high risk of perforation, preventive appendectomy is recommended to appendiceal diverticulosis, even if the patient has no abdominal pain. methods: we retrospectively reviewed the records of 672 post-operative patients, who were diagnosed appendicitis or appendiceal diverticulitis on the pathological findings in our institution from january 2012 to october 2018. all patients were performed computed tomography (ct) before operation. 652 patients underwent laparoscopic surgery, including appendectomy, cecal resection, ileocecal resection and right hemicolectomy, while 20 patients underwent open surgery. total of 12 cases of appendiceal diverticulitis were analyzed in our study. result: 11 patients had abdominal pain before surgery. 4 patients were diagnosed appendiceal diverticulitis by preoperative ct. all patients underwent laparoscopic surgery (10 appendectomy, 1 cecal resection, and 1 ileocecal resection). on the pathological findings, perforation of appendix was found in 5 patients and the pseudo type of diverticula with no muscle layer was found in all patients. 660 patients with appendicitis were treated surgically during the same period. among them, a perforation of appendix was found in 78 cases. the perforation rate was 11.8%. on the other hand, the perforation rate of appendiceal diverticulitis was 58.3% in our study. conclusion: the perforation rate of appendiceal diverticulitis was higher than of appendicitis in our study. for the examination of the treatment strategy, including preventive appendectomy, the accumulation of more cases will be expected. case presentation: a 59-year-old man was referred to our hospital with right lower quadrant abdominal pain for 2 days. his fever was 38.4°c. his white blood cell count was 30,200/ ll, and c-reactive protein level was 8.3 mg/dl. ct revealed multiple diverticula of cecum and appendix. micro-abscess and free air were found around appendix. we diagnosed this case as appendiceal diverticulitis and laparoscopic appendectomy was performed. a perforation was found in resected appendix. microscopic study revealed a pseudo-diverticulum. the inflammation of appendix was stronger in serous membrane side than in mucosa side. this finding accorded with appendiceal diverticulitis. introduction: in order to reduce the abdominal trauma and the length of scar incisions (also during laparoscopic surgery) many approaches during the last decade has been proposed, such as single access laparoscopic surgery (sals). the aim of our paper was to update the data of our previous paper with a greater cohort of patients and a longer follow-up, also showing the single access laparoscopic left colectomy (salc) technique in particular with inferior mesenteric artery preservation imap (valdoni's technique). materials and methods: we made a retrospective analysis from october 2009 and october 2016 of all patients who underwent a sals approach for colorectal disease in the department of general and mininvasive surgery of san camillo hospital of trento. statistical analysis was performed using ibm spss statistics 23. continuous data were expressed as mean ± standard deviation (sd). categorical data were expressed as absolute number and percentage. the results are presented as 2-tailed values with statistical significance if p values \ 0.05 results: from october 2009 until october 2016, 72 salc for colorectal surgery were performed in our unit. of this 72, 58 were for left colectomy. in 12 cases we performed an imap. the salc with imap were performed only in case of benign disease. the mean operative time was 149.74 ± 27.93. only one intraoperative complication were recorded, that was a splenic capsule tear, resolved with apposition of fibrillar haemostats. according to clavien dindo classification there were in particular 2 grade ii complications, a bleeding solved with blood transfusion and one pancreatitis solved with medical therapy; 2 grade iiia complications that was anastomotic bleeding solved endoscopically (the two complications raised in patients with imap) and 2iiib complications due to anastomotic leakage which needed reoperation. the mean length of incision was 3.64 ± 0.86 cm. logistic regression did not show any correlation between imap and any complications. conclusion: in conclusion, salc is a safe but very challenging technique which need a longer learning curve than the conventional laparoscopic one. in laparoscopic colectomy, also, imap seems to be safe and effective without correlation with post-operative complications also if performed in single access laparoscopic approach. aims: to describe an infrequent anatomical variation that can give rise to diagnostic and therapeutic difficulties. methods: patient with ivermark syndrome (situs ambiguus and polysplenia) with acute appendicitis and bibliographic review results: a 41-year-old male who consulted for flank and right hypochondrium pain of 18 h of evolution, associated with nausea without vomiting, no fever noir other symptoms. to the physical examination good general condition. painful to palpation selectively on the flank and right hypochondrium, with involuntary defense and positive decompression at this level. the signs of rovsing and psoas were negatives. in the analytical performed leukocytes of 17,000 with neutrophils in 82% and rpc (reactive protein c) in 22 mg/l. abdominal ct (computed tomograph): cecum and the ilio-cecal valve were visualized at the subhepatic level with tubular structure on the side and seemed to correspond to the cecal appendix which is increased in size (12 mm), with findings suggestive of acute appendicitis. sigma and descending colon located in right hemiabdomen. second per duodenal portion located anterior to the superior mesenteric artery. superior mesenteric vein located to the left of the superior mesenteric artery, rotating around it, (radiological signs compatible with intestinal malrotation). no free fluid collections nor pneumoperitoneum. laparoscopic appendectomy on phlegmonous acute appendicitis without incidents. correct post-operative course, being discharged at 48 h; the pathological anatomy was reported as acute appendicitis in phlegmonous. conclusions: ivermark syndrome is a genetic alteration with a multifactorial inheritance pattern, characterized by an alteration in the situation of the mesenteric vessels, which leads to abnormal rotation of the intestine during the embryonic period and alteration of the situation of different intra-abdominal organs, without a specific pattern that is pathognomonic, is associated with congenital heart anomalies between 50 and 90%. reaching adulthood only between 5 and 10% of them. a case of acute appendicitis is presented in a patient with this anomaly, which can lead to diagnostic and therapeutic difficulties due to the anatomical variations involved. abdominal tomography is the image method that provides the best performance for the diagnosis of acute pathologies in this type of patients. background: the clinical manifestations which occur in relation to decompression during scuba diving are variable. mild symptoms have often been reported in gastrointestinal tract. this is one of the severe cases with gastrointestinal barotrauma. ischemic colitis caused by air embolism very rare, therefore it is to be reported and discussed. case presentation: a 58-year-old man visited our emergency room with diffuse abdominal pain and bloody diarrhea 2 days ago. the patient was a skilled diver who took seafood through diving for 30 years. two days before presenting, the patient had severe abdominal pain just after diving for 2 h at a depth of 30 meters. he was immediately transferred to a local hospital for hyperbaric oxygen therapy, but there was no improvement with the symptom. abdomen ct angiography showed terminal ileal, ascending, sigmoid colonic and rectal decreased enhancement with wall thickening. sigmoidoscopy showed diffuse huge ulcerative lesions and ischemic changes on mid rectum and sigmoid colon. emergent subtotal colectomy and temporary loop ileostomy were done, and pathologic findings revealed diffuse mural infarct with serosal abscess formation in whole colon and transmural infarct in terminal ileum. conclusion: surgical approach could be one of the treatment options, though it depends on severity of the symptoms and the patients' conditions. colonic lipomas are extremely uncommon benign tumours, with an incidence ranging between 0.035% and 4.4%. although they are most frequently asymptomatic, when colonic lipomas are [ 2?cm, they may present symptoms such as constipation, abdominal pain or rectal bleeding. most colonic lipomas typically occur in middle aged women and are located in the ascending colon and the caecum, while occurrence in other parts of the colon and rectum is rare. in this case report, we describe a lipoma that caused descendent bowel intussusception. a 55-year-old male presented with longstanding history of constipation. personal history of interest included active smoker, hypertension, hypercholesterolemia, psoriasis with joint affectation and reiter syndrome. he had had no previous surgery. he attended the emergency services on 17th july 2018 with a two-day bowel obstruction, without fever or nausea, being attended by our surgical emergency unit. he had been assessed during the previous months by gastroenterology, with a colonoscopy that showed a 4 cm submucosal lesion that partially occluded descendent bowel, with inconclusive biopsy. an abdominal contrast-enhanced computed tomography (ct) was performed, confirming a welldefined mass located in splenic flexure of descendent bowel, conditioning a large bowel intussusception, nevertheless with no obstructive acute signs. the surgery was scheduled a few weeks later, performing a laparoscopic segmental resection with primary anastomosis including oncologic margins. the patient evolved satisfactorily in the postoperative period and was discharged six days after the surgery without any complications. likewise, he was monitored on a regular basis at our outpatient department and was free of symptoms at the 1-month follow-up visit. the histological analysis revealed a 5 cm ulcerated lipoma affecting 60% of bowel circumference. the molecular study, using fluorescent in situ hybridation (fish) showed no mdm2 gene amplification. laparoscopic segmental resection of the large bowel is a safe and feasible technique for the treatment of large bowel intussusception caused by a colonic lipoma. the complete removal of the lipoma will condition the prognosis. furthermore, in the future, endoscopic surgery using colonoscopy could be employed when having a certain preoperative diagnosis of lipoma. surg endosc (2019) introduction: acute appendicitis is one of the most common abdominal surgical emergency, the diagnosis of which mostly relies on conventional methods such as physical examination and blood tests. the use of ultrasonography and ct abdomen aids in more precise diagnosis especially in patients with atypical presentation or in elderly. aim: this study aims to evaluate the ability of the neutrophil/lymphocyte ratio (nlr), platelet/lymphocyte ratio (plr) and mean platelet volume (mpv) in predicting the diagnosis of acute appendicitis. methods: retrospective analysis of prospectivly maintained data of all patients (98) admitted with acute appendicitis to the emergency department at a tertiary hospital in the middle east between january 2016 till september 2016. medical records and database of patients,who had appendicectomy for clinically and radiologically proven appendicitis, were reviewed. the retrieved data included patient's demographic and laboratory values of white blood cells (wbc), neutrophil (n), lymphocyte (l), and platelet (p) along with their ratios for comparison. results: spss 23 version was used for tabulating the data. the recommended cutoff value of the nlr, plr and mpv in predicting the diagnosis of acute appendicitis was decided by using receiver operating characteristic (roc) curve analyses. at least for nlr, the confidence interval (ci) was 0.47 which is 47 percentage of the positive values, since the confidence limit was between 35 to 58%. our results showed that the laboratory parameters were fairly significant since the confidence interval was 0.47 in predicting the diagnosis in our population. conclusion: although appendicitis is a clinical diagnosis but laboratory parameters specially nlr, plr and mpv can be used as an adjunct in the diagnosis of acute appendicitis. literature is scarce concerning the validity of such parameters in our part of the world and prospective randomized controlled trials are needed to prove the efficacy of such rationale. objective: tumors of the cecal appendix represent a subset of colonic neoplasms whose early diagnosis is a real clinical challenge. correspond to 0.5% of all gastrointestinal tumors and their prognosis depends on the type of injury, being the most frequent variety the carcinoid type. appendix involvement in endometriosis is rare, accounting for 3% of all endometriosis cases, and sometimes mimicking cecal tumors. methods: a 43-year-old woman with a history of hypothyroidism due to autoimmune thyroiditis and atrophic gastritis with gastric neuroendocrine tumors resected by endoscopy that in the digestive unit reviews, tac with double contrast was requested, showing a lobulated lesion in the cecum adjacent to the ileocecal valve, with contrast enhancement of approximately 27 9 21 9 20 mm, suggestive of tumor. the colonoscopy evidenced a protruding appendicular osteum with inflammatory aspect that was biopsied. the pathological anatomy of the biopsy reports chronic congestive colitis with edema of the own blade and minimal acute activity, with moderate local eosinophilia.the case was presented in the multidisciplinary oncology committee and it is decided, due to the patient's background, to perform surgery on the lesion. laparoscopic right hemicolectomy was performed, with extracorporeal latero-lateral mechanical anastomosis with endogia signiaò 60 mm. results: the patient evolves favorably, with good oral tolerance and depositional habit. she is sent home at the sixth postoperative day. the pathological anatomy reports tumor injury in the appendicular ostium compatible with endometriosis at the base of the cecal appendix implantation, ruling out malignant tumor pathology. conclusions: gastrointestinal tract endometriosis represents 3-15% of cases, being most frequently located in the rectal-sigmoid region. appendix involvement in endometriosis is rare, accounting 2-3% of all endometriosis cases and presents a preoperative diagnostic challenge, because sometimes mimicking a carcinoid cecal tumor. in our case, due to the patient's history, we assumed that the cecal lesion was a carcinoid tumor, so we performed a laparoscopic right colectomy, but if we had known that it was an endometriosis, we could have performed an appendectomy, although in both cases the laparoscopic approach gives us some benefits compared to the open approach aims: the natural history and predictive factors associated with chronic anastomotic complications have not been clearly studied. the aim of this study was to evaluated the predictive factors related to chronic anastomotic complications methods: from january 2010 to december 2016, a total of 53 patients who underwent anastomotic leakage were enrolled in this study. all patients underwent anterior resection with or without defunctioning stoma due to colorectal cancer. the patients received follow-up by clinical examination and abdominopelvic computed tomography (ct). they underwent a follow-up ct every 6 months for the first 1 year and then every 12 months for the next 2 years after that. complicated group (cg) underwent chronic anastomotic complications. normal group (ng) didn't underwent chronic anastomotic complications like stricture, fistula, chronic sinus, etc. results: there were no significant differences in gender, age, preoperative chemoradiotherapy and operation type between two groups. low rectum lesion and defunctioning stoma at the time of primary surgery were more frequent in cg (p = 0.013, 0.021). there were no significant differences in type of anastomotic leakage, international leakage grade and ct findings at the time of diagnosis of anastomotic leakage. however, abnormal ct findings at the time of 6 month were more frequent in cg group (p \ 0.0001). in multivariate analysis, abnormal ct finding at the 6th months was only significant factor related to chronic anastomotic complications. conclusions: abnormal ct findings at the 6th month associated with prediction of chronic anastomotic complications. aims: acute appendicitis is the most common cause of acute abdomen requiring surgical intervention in the world. nowadays, standard treatment of acute appendicitis involves a surgical approach, eitherlaparoscopic or open.the purpose of the present study is to evaluate the safety of a discharge within less than 24 h after performing appendectomy as a result of an uncomplicated acute appendicitis. conclusions: patients who undergo appendectomy (open or laparoscopic) for acute uncomplicated appendicitis, without surgical incidents and an adequate social/family network, can be discharged in less than 24 h without a higher risk of post-operative complications or readmissions than patients with longer postoperative stays. it will be necessary to conduct more prospective studies with higher level of evidence that could corroborate our results. aims: median arcuate ligament syndrome (mals), also known as the celiac axis compression syndrome, is a rare condition caused by to the compression of the celiac trunk and the nerves located in this area (celiac plexus) by the median arcuate ligament. it is believed that mals is caused by the median arcuate ligament compression of the celiac plexus nerves over the celiac trunk, but another probably cause may be the lack of blood flow to the organs supplied by the celiac artery, however, this theory is controversial. the first clinical sign of mals is the apparition of postprandial abdominal pain in the upper abdomen. this typical pain forces patients to avoid eating, which can lead to loss weight (often more than 20 pounds). other associated symptoms may include nausea, diarrhea, vomiting and delayed gastric emptying (a delay in food moving from the stomach into the small intestine). in relation to this uncommon condition, we present a clinical case of laparoscopic management of mals. methods: we present a 23-year-old patient with complaints of recurrent epigastric pain, postprandial vomiting and loss weight. blood tests and gastroscopy were performed to help ruling out more common causes of his symptoms, such as gastroesophageal reflux disease (gerd), gastritis or gastroparesis. as a part of the differential diagnosis, mals was suspected and a mesenteric doppler ultrasound was ordered to check blood flow through the celiac trunk and evaluate a possible compression of the celiac plexus. also, an angio-ct scan was also performed to confirm the diagnosis. once the mals was diagnosed, we decided to perform a laparoscopic approach as definitive surgical procedure. results: the patient was discharged 48 h after surgery with no remarkable events during his postoperative stay. he has been followed up during 6 months, remaining asymptomatic. conclusions: laparoscopic approach in mals offers a superior visualization during the surgery and involves lower morbidity in compare to open approach, which makes it an optimal treatment for this condition. aim: pilonidal sinus is a common disease with annoying and often painful symptoms. traditional surgical techniques for its treatment are characterized by either intense postoperative pain and prolonged wound-healing periods (wide resection, marsupialization) or unsatisfying aesthetic results (advancement or rhomboid flaps). 'endoscopic pilonidal sinus treatment' (epsit) is a new minimally invasive technique which utilises the meinero scope, primarily designed for the endoscopic treatment of complex perianal fistulas in a technique known as vaaft. we present our experience and outcomes in three treatment centers in northern greece. methods: between july 2015 and november 2018 we treated 61 patients with pilonidal sinus using the epsit technique. the mean age of patients was 30, and 85% of them were male. 4 patients were treated in the acute phase with the presence of pilonidal abscess. all operations were performed by two laparoendoscopic surgeons specifically trained in the technique. most patients were treated on a day-case basis. postoperative wound care included daily tract irrigation with 10 ml of saline for a total of 10 days. results: there were no immediate postoperative complications. medium postoperative pain was 2.8 on a vas scale. 91% of patients were discharged on the same day, 4 patients remained in hospital for one day mainly due to social reasons. return to daily activities was immediate. in a maximum follow-up of 24 months we observed 5 recurrences. conclusions: epsit is a promising minimally invasive technique for the treatment of pilonidal sinus. what makes it mostly attractive is the minimal amount of postoperative pain, the excellent cosmetic result and the fast recovery with return to daily activities. introduction: isolated acute chylous peritonitis is a rare event. when presented as an acute abdomen warranting surgical intervention, it is often difficult to determine the cause pre-operatively. here, we report a case of acute chylous peritonitis due to meckel's diverticulitis presented with the clinical features suggestive of acute appendicitis. presentation of the case: a 32-year-old female presented with abdominal pain and clinical features consistent with acute appendicitis underwent diagnostic laparoscopy. she was found to have four-quadrant chylous peritonitis and ileus caused by an inflamed meckel's diverticulum adhered underneath a loop of small bowel and mesentery leaking chyle. after uneventful postoperative recovery, she was discharged at post-operative day two with oral antibiotics and was advised to take a low-fat diet. aims: perforated diverticulitis with purulent peritonitis (hinchey iii) has traditionally been treated with surgery including colon resection and stoma (hartmann procedure) with considerable postoperative morbidity and mortality. laparoscopic lavage has been suggested as a less invasive surgical treatment. methods: a 78-year-old woman with a 10-day history of abdominal discomfort exacerbed during the last 48 h. ct scan showed neumoperitoneum accompanied by free fluid and a 6 cm collection adjacent to descending colon showing diverticula suggestive of covert perforation. after 48 h of non-response to medical treatment, associated with the impossibility of percutaneous drainage through interposition of intestinal loops, colon and lumbar vessels, urgent surgical intervention is decided. results: laparoscopic lavage of all 4 quadrants was performed with saline, 3 l or more, of body temperature, until clear fluid was returned. two non-suction j-pratt drains were placed. intravenous antibiotics were continued for a minimum of 72 h, then oral antibiotics were continued for 1 week. oral fluids were commenced on the first postoperative day and solids were subsequently introduced, depending on clinical progress. conclusion: laparoscopic management is reasonable alternative to the traditional open resection for hinchey grade ii-iii perforated diverticulitis with generalized peritonitis. this approach has a low mortality rate despite patient co-morbidity and disease severity. benefits include stoma avoidance and minimal wound infection. subsequent elective resection is probably unnecessary and readmission in the medium term is uncommon. background: constipation and fecal incontinence are common annoying complications after pull through procedures for hirschsprung disease (hsd). many causes could be the etiology of these problems. perineal descent syndrome could be the major hidden cause of these complications. the aim of this study is to evaluate the role of perineal descent syndrome in the development of post pull through constipation and fecal incontinence in addition to evaluate the role of laparoscopic rectopexy for treatment of these problems. \ b[patient and methods: \/b [ 380 patients treated with pull through for hsd over the period of five years. 62 out of the 380 patients presented with constipation and fecal incontinence. 23 patients with constipation and 39 patients with fecal incontinence. rectal exam, anorectal manomety, defecography, contrast enema, rectal biopsy, emg, proctoscopy and endorectal ultrasound were performed to all patients. patients with stricture, missed aganglionic segment, injured internal anal sphincter, and loss of the sensory mucosa above the dentate line were excluded from the study. anterior wall rectopexy was performed for anterior wall rectocele. posterior wall rectocele was treated by retro rectal mesh rectopexy. emg is repeated 7 weeks and 7 months after surgery. outcome measurements included constipation, fecal incontinence and pudendal nerve latency. results: 62 cases of post pull through constipation and fecal incontinence. 23 patients with constipation and 39 patients with fecal incontinence.7 patients with stricture, 3 patients with missed aganglionic segment,2 patients with loss of anal sensory sensation and 2 patients with injured anal sphincter were excluded from the study. defecography showed 40 patients with anterior rectocele (22 males and 18 females) and 8 patients with posterior rectocele (2 males and 6 females). the patients mean age 8.93 ± 2.4 years . emg showed prolonged pudendal nerve conduction in all cases. anterior wall and retro rectal rectopexy were performed laparoscopically without complications. constipation was resolved in all patients after surgery. all patients showed fully control in defecation. pudendal nerve latency decreased in all patients. conclusion: perineal descent syndrome proved to be a major hidden cause of post pull-through constipation and fecal incontinence. laparoscopic rectopexy showed a good solution of these complications. cystic lymphangioma is a rare entity. the surgical indication is determined by the size and symptomatology, and consists of the complete exeresis of the tumor. the laparoscopic approach is feasible in these cases, allowing a broad visualization of the anatomy, accessibility to the retroperitoneum in the context of a minimally invasive approach and a better recovery of the patient, without providing an increase in morbidity compared to the conventional. in this way we defend as a technique of choice laparoscopic surgery against these rare tumors for the general surgeon in the abdominal cavity, betting on a minimally invasive surgery. aims: laparoscopicposterior sutured rectopexy is one of the accepted treatment options for fullthickness rectal prolapse. recently, reduced port surgery(rps) has beenan emerging concept that, compared with conventional multiple port surgery (mps), yields reduced postoperative pain and improved cosmesis. the aim of the study is to evaluate the feasibility and safety of rps for fullthickness rectal prolapse. methods: rps was performed by single-incision plus one puncture, using internal organ retractor(ior) to secure operative field. straining one ior by 3-4 strings in 3-4 directions makes it possible to retract the internal organs three-dimensionally. this multi-directional flexible retraction could secure good operative field. from 2012 to 2018, 32 patients (rps: 22 cases, mrs: 10 cases) underwent laparoscopicposterior suture rectopexyfor total rectal prolapse. shortterm outcomes were compared between the two procedures. results: there was no significant difference between rps and mps in median operative time (175 vs 167.4 min, respectively, p [ 0.05). the median blood loss volume was not significantly different between rps and mps groups (7.7 vs 8.0 ml, p \ 0.05). the duration of median hospital stay after surgery was not significantly different between two groups (12.9 vs 13 days, respectively, p [ 0.05). the frequency of complications after surgery were not different between them. conclusions: reduced port lap-rectopexy can be a good therapeutic option for total rectal prolapse. a prospective, randomized, controlled trial should be conducted to confirm the superiority of this procedure over mps. the piccolo project proposes a new compact, hybrid and multimodal photonics endoscope based on optical coherence tomography (oct) and multi-photon tomography (mpt) combined with novel red-flag fluorescence technology for in vivo diagnosis and clinical decision support. for its development it includes different phases of validation. within this framework, the present study has as main objective: to characterize a model of rat colonic hyperplasia, which will be used for the development and validation of the previously mentioned endoscopic technology. secondary objectives: procure the reproducibility of the model chosen and determine the optimal time, after induction of the model. material and methods: 12 animals (rattus norvegicus), wistar, males and females \ 1-yearold, randomly distributed. group 1 (n = 2): by laparotomy, a non-resorbable suture (silk 4/0), not stenosing, is placed through the wall of the colon. group 2 (n = 2): by endoscopy, a 0.3 mm long segment of a polymeric catheter is inserted, which is fixed to the wall of the colon by means of a suture. group 3 (n = 2): by means of endoscopy, a self-expanding and uncoated metallic stent are placed in the colon. group 4 (n = 2): a superficial laser resection of the colonic mucosa is performed by endoscopy. group 5 (n = 4): as an extension of the most optimal model. weekly, the animals were anesthetized again to perform a colonoscopy, which determined the degree of mucosal growth in descending colon and colonic biopsies were extracted weekly (4 weeks). results: group 1. growth around the sutures after the second follow-up, diagnosed as hyperplastic polyps after a histopathological analysis. aim: the role of laparoscopy in the management of generalized appendicular peritonitis is controversial. this is due mainly to the lack of scientific data. through this study and a laborious bibliography research, we proposed to report our experience in terms of postoperative results, in the laparoscopic treatment of generalized appendicular peritonitis and to try to identify the risk factors associated with the occurrence of global morbidity and conclude on the feasibility of this technique in its treatment. methods: we conducted a retrospective study including all cases of generalized appendicular peritonitis managed laparoscopically, in the general surgery department of charles nicolle hospital between january 2006 and december 2016. results: we identified 93 patients. the mean age was 31.7 years. one fifth of the cases required a midline conversion (20.4%). the mean operative time was 146.6 ± 36,7 min. the overall morbidity rate was 15% including 7 surgical complications. there were no deaths. in uni-variate analysis, comorbidity, crp [ 200 mg /l, operative time exceeding 170 min and midline conversion were significantly associated with postoperative morbidity. co-morbidity, diabetes, asa score [ 2, delay of consultation [ 3 days, intra-abdominal abscess and operative time exceeding 170 min were significantly associated with medical complications. the univariate analysis also revealed that crp [ 200 mg /l and midline conversion were predictive of surgical complications.the multivariate analysis identified the midline conversion as the only independent factor significantly associated with post operative morbidity (odds ratio = 6.57, 95% confidence interval [1.28-33.7] ). conclusion: based on our results, it appears reasonable to continue the laparoscopic management of diffuse appendicular peritonitis. however, enhance this technique is basic in order to reduce midline conversion rate and to shorten operative time, which can lead to post operative complications. aims: currently, acute appendicitis is the most common surgical emergency. laparoscopic appendectomy is the usual procedure to treat acute appendicitis. the aim of this study is to evaluate the safety of electrocoagulation in the treatment of mesoappendix in laparoscopic appendectomy. methods: we have retrospectively studied a prospective database of operated patients of appendecectomy in emergency surgery unit. we have reviewed laparoscopic appendectomies from june 1st, 2014 to december 31st, 2017. the mesoappendix was electrocoagulated in every laparoscopic appendectomy. the statistical analyses has been done with spss 24.0 version. results: our group consists of 294 patients of which 59.2% were male and 40.8% were female. the average age was 37.94 years with a standard deviation of 18.14% and p75 was 51.5 years. the most common total stay was 1 day (100 patients). the usual post-operative stay was one day (144). we classified the diagnosis in complicated apendicitis (82 patients) and no complicated apendicitis (198 patients). the conversion rate was 3.1% (9). the main surgical complications were: surgical wound infection (1.4%); intraabdominal abscess (6.8%); and bleeding (1%). only one of the patients that suffered bleeding had complicated appendicitis. the medical complications were catheter sepsis (0.7%); respiratory infection (0.3%); cardiologicals (0,3%); and paralytic ileus (4.1%). the treatment of mesoappendix with electrocoagulation is safe and effective since the complications rate is very low. even so, it would be necessary to conduct more prospectives randomized studies in order to get enough evidence about the treatment of mesoappendix with monopolar electrocoagulation. introduction: the difficulty of resection of the rectum is determined by its anatomical relationships, intimately in contact with the bladder, seminal vesicles, prostate and urethra in the case of the male, vagina in the woman and nerve structures that will give defecatory, genital and urinary functionality. this structure creates a big impediment due to problems of visualization and difficult dissection, in such a way that conventional surgical techniques instigates a series of complications derived from this difficulty. we propose a new approach in rectal surgery in patients with inflammatory bowel disease. material and methods: a 49-year-old man with a history of ulcerative colitis developed a severe acute outbreak refractory to treatment. a total laparoscopic colectomy with a terminal ileostomy was performed in 2016. in 2018 he was notified for reconstruction. we evidenced a rectal stump of about 10 cm with signs of inflammatory disease at the mucosal level. a transanal proctectomy was performed with confection of 'j-pouch' and ileoanal anastomosis about 4 cm from the anal margin by laparoscopy. the postoperative courses favorably, being discharged on the sixth day. currently in follow-up in digestive and general surgery, he is asymptomatic and he has an optimum level of quality of life valued by the sf-36 12 weeks after the intervention. conclusions: our service introduces the transanal approach to the performance of proctectomy in cases of inflammatory disease, a technique that provides clear advantages by improving visualization and the identification of anatomical structures. in this way, a safe dissection of the pelvis is achieved, adjusted to the serosa of the rectum, with preservation of the mesorectum and the hypogastric plexus, and with the consequent improvement of the genital and urinary function. the result is an equally safe surgery, which implies little increase in operative time and with better and shorter postoperative recovery.the conservation of the pelvic innervation avoids disorders of ejaculation, vaginal lubrication and bladder and rectal motility. the transanal approach for the performance of proctectomy provides benefits in terms of the preservation of the hypogastric plexus, minimizing the anatomical difficulties involved in rectal surgery and maintaining urinary and sexual function. aims: to evaluate the feasibility and outcomes of laparoscopic appendicectomies in both simple and complicated appendicitis, given the increasing trend towards a laparoscopic approach in the last four decades for the treatment of acute appendicitis. we present data from a district general hospital over a 7-year period. methods: we retrospectively analysed a single consultant's continually updated database of laparoscopic appendicectomies between 01/03/2012 and 15/12/2018 (82 months). patient demographics, investigations, intraoperative findings and postoperative outcomes were recorded and analysed. complicated appendicitis was defined as the formation of appendiceal mass or abscess with or without perforation and peritonitis. results: 81 cases of laparoscopic appendicectomies were identified during the specified period. the median patient age was 30 (range 10-89 years). true positive rates for uss and ct were 33% and 84%, respectively. the rate of negative appendicectomies was 14%. transanal minimally invasive surgery (tamis) has been used for the treatment of rectal neoplasms such us benign polyps and early rectal cancer. when the tumour is located in the upper rectum or close to the rectosigmoid junction, this approach may be technically dificcult.we present a video of a tamis resection of a large polyp located 20 cm from the anal verge. after properative examination and ct and mri were performed, the patient was prepared for surgery, and a trasnanal minimally invasive surgery was proposed.resection of the polyp was performed with the aim of an endogia and conventional laparoscopic materials. total resection of the polyp with free margin was possible. the postoperative pathology report confirmed a high grade displasia villo-tubular adenoma with a lesion free margin. tamis resection of tumours located above the rectosigmoid junction may be a safe and feasible technique in selected patients. aims: pelvic organ prolapse (pop) is a very relevant problem for women's quality of life and has a prevalence of about 5% defined by symptoms and up to 50% when established by physical examination. nowadays, sacrorectopexy for posterior pop and sacrocolpopexy for apical pop are considered the gold standard techniques. recently, we have seen that laparoscopic lateral suspension is a feasible procedure for apical pop, obtaining a success rate higher than 90% at one year. these results are similar to what we can achieve with sacrocolpopexy. methods: we herein present the case of a 70-year-old woman with apical and posterior pop, this was provoking an important impact on her quality of life, with obstructive defecation (needing digitations) and urinary incontinence. we proposed sacrorectopexy for her posterior pop and laparoscopic lateral suspension for her apical pop. in the video we can see how we perform a ventral mesh sacrorectopexy, following d'hoore technique; and a laparoscopic lateral suspension with preperitoneal dissection, following the technique described by the team headed by dubuisson and veit-rubin. we used 4 laparoscopic ports (12, 5, 2.9 and 2.5 mm). results: patient was discharged home on the second postoperative day and has not had any sign of recurrence or extrusion after more than two years of follow-up. in addition, she has not suffered lower urinary tract symptoms, constipation or pain. conclusions: we present a case in which we have carried out a laparoscopic lateral suspension instead of a sacrocolpopexy for an apical pop, obtaining good short-term and long-term results. we consider it is very soon to assess this technique's efficacy and it has to be validated in studies with larger source of patients. nevertheless, we think this procedure might become an excellent alternative to sacrocolpopexy for apical pop. aims: laparoscopy is a minimally invasive approach with low morbidity. the aim is to show the usefulness of the laparoscopic approach for massive intra-abdominal abscesses, which it is controversial. we report three patients who underwent emergency laparoscopy for peritonitis or massive intra-abdominal abscesses not amenable to percutaneous approach that were suspected to be caused by acute diverticulitis. methods: all patients had diagnosis of acute diverticulitis (hinchey ii-iii grade) with pelvic abscesses situated between sigma and bladder or diffuse peritonitis. the patients with hinchey ii grade had failed conservative management with antibiotics. they underwent emergency laparoscopy under general anaesthesia, with three abdominal ports. intra-abdominal abscess cavities were exposed and the purulent exudate was sampled and aspirated. copious irrigation was performed under direct vision and thorough examination without other findings. the procedure was completed laparoscopically in all cases. results: all patients had favourable evolution. one of them had a properly drained faecal fistula which changed to a purulent fistula on the twentieth postoperative day. this patient underwent laparoscopic left colectomy three months later because he had have a new episode of acute diverticulitis. other two cases showed very good clinical evolution, without evidence of fistula in postoperative period and they were complete asymptomatic one month later. conclusion: in our experience laparoscopic drainage is a feasible, safe, and effective for the treatment of pelvic abscesses and diffuse peritonitis secondary to acute diverticulitis. n. pinheiro, a. ziegler introduction: solitary rectal ulcer syndrome (susr) is characterized as a rare disease whose pathophysiology remains uncertain. it was first described in 1829 by cruveilhier and his clinicopathological feature was reported in 1969 by mandigan and morson, where he is associated with defective disorders, internal rectal prolapse, and psychological changes. according to works about 26% of the patients are asymptomatic. when symptomatic the diagnosis can be made through physical examination, clinical history and, often, confirmed by endoscopy with biopsies. treatment depends on the severity of the symptoms and the existence of associated rectal prolapse. according to the literature, conventional surgical options include local excision, rectal mucosectomy, retopexy, and segmental colonic resection. rolato: a 28-year-old male complaining of anal bleeding at bowel movements 10 years ago. he performed, several times, conservative treatment, but without improvement. he sought proctological care and underwent colonoscopy, in which he showed an ulcerated lesion on the anterior wall of the distal rectum. new investigation with videodefecogram revealed colorectal intussusception with associated mucosal prolapse, being considered the factor causing the ulcer. elected by the sacropromontofixação. evoluiu with improvement of anal bleeding, mucorrhea and anal discomfort. after a proctological examination, which was normal, a control colonoscopy performed after 5 months of surgery revealed rectal mucosa, with residual scarring and disappearance of the submucosal nodule present in the initial examination. reassessed after 12 months, the patient is asymptomatic. conclusion: rectal solitary ulcer whose causal factor was a colorectal prolapse (intussusception) with mucosal exteriorization through the anal canal, which was individually treated with sacropromontofixation. j.p. mali, p.j. mentula, a.k. leppäniemi, v.j. sallinen approximately 15-20% of patients diagnosed with colonic diverticulitis have an intra-abdominal abscess as a complication. abscess diameter of 3-6 cm is generally accepted as a cut-off determining the choice of treatment between antibiotics alone and percutaneous drainage. the aim of this study was to analyze the treatment choices and outcomes of patients with diverticular abscesses. this was a retrospective cohort study which was conducted in helsinki university hospital, an academic teaching hospital functioning as secondary and tertiary referral center. patients with computer tomography-verified acute left-side colonic diverticulitis with intra-abdominal abscess were collected from a database containing all patients treated for colonic diverticulitis in our institution during 2006-2013. altogether, 241 suitable patients were included in analyses. those treated primarily with percutaneous drainage or antibiotics alone (29 and 150 patients, respectively) were further compared in regards to treatment results. the main measured outcomes were need of emergency surgery and 30-day mortality. abscesses under 40 mm were mostly treated with antibiotics alone with high success rate (93 out of 107, 87%). in abscesses over 40 mm, the use of emergency surgery increased and use of antibiotics alone decreased with increasing abscess size, but the proportion of successful drainage remained at 13-18% regardless of abscess size (figure 1 ). there were no differences in failure rate, 30-day mortality, need of emergency surgery, permanent stoma, recurrence, or length of stay in patients treated with percutaneous drainage versus antibiotics alone, even when groups were adjusted for potential confounders. white blood cell count = 15.0 * 10 9 /l, abscess diameter = 50 mm, and corticosteroid medication were independent risk factors for failure of treatment with antibiotics alone. patients without these risk factor had 95% and patients with one risk factor had 78% success with antibiotics alone. percutaneous drainage as treatment for large abscess does not seem to be superior to treatment with only antibiotics. majority of patients with abscesses over 60 mm in diameter undergo surgery as primary intervention. introduction: even today, 'chronic appendicitis' is a clinical term that is not widely accepted nor well documented amongst the medical community. its etiology is the presence of a mass (e.g. fecal mass, hyperplasia of lymphatic tissue, etc.) that continuously and partially obstructs appendix lumen. it is presented as a low intensity, intermittent, with exacerbations and remissions, abdominal pain that is located at the right iliac region. the pain lasts up to several months and it is usually underestimated by the patient. its diagnosis is based on imaging examination. appendectomy is the treatment of choice for chronic appendicitis. the operation is challenging for the surgeon who has to cope with an intensively inflamed area around the appendix without the ease of access to that area. purpose: to present our laparoscopic approach to a chronic appendicitis case and to review the literature. case report: a 56-year-old woman is hospitalized due to chronic appendicitis. the patient was treated conservatively with the use of intravenous antibiotics in two separate hospital admissions dated 2 and 4 months back respectively. eight weeks after the last exacerbation, she underwent a laparoscopic appendectomy. results: even though the procedure was planned six months after the first episode, the laparoscopy revealed a severe inflammation of the appendix, which was extended to the caecum and the surrounding preperitoneal tissues. although the difficultness of the operation it was completed successfully laparoscopically. the histological examination confirmed without any doubt the existence of 'chronic appendicitis'. the patient was discharged uneventfully the third postoperative day. conclusions: chronic appendicitis is an existing clinical entity that the surgeon may come through during his career. in the hands of experienced laparoscopic surgeon, the laparoscopic approach is feasible and safe. introduction: ventriculo-peritoneal shunting (vps) used in the treatment for hydrocephalus is associated with several complications.the exact cause of such extrusion is not known. visceral perforation is an unusual but serious complication with consequeces such as peritonitis, meningitis or encephalitis. management involves prompt removal of shunt, intravenous antibiotics, an adequate recovery gap so that cerebrospinal fluid culture is sterile and then followed by shunt replacement on opposite side. aim: multidisciplinary approach of extrusion of vps through anus by laparoscopic and external ventricular drainage. case exposure: a 49-year-old woman had a vps inserted 11 year ago after excision of gangliocytoma due to lhermitte-duclos disease. she was admitted in the emergency department without symptos after trans-anal protrusion of vps catheter. the neurological and abdominal evaluation was normal. laboratory tests did not reveal disorders and abdominal ct-scan suggested perforation, itshowed the insertion of the end of the catheter in sigma, without pneumoperitoneum or intraabdominal free fluid. cranial ct-scan did no describe sings of hydrocephalus. the patient underwent an emergencysurgical intervention. first of all, antibiotic therapy was initiated and neurosurgery's team was performed an external ventricular drain and they disconnected the proximal catheter side. after that, an exploratory laparoscopy was performed. it revealed a microperforation and collection beside to an appendix' base due to the proximity with the catheter. additionally, the catheter was freed from adhesions at the point of entry into the colon and after careful dissectionwe release the vps from colon with a 1.5 cm transmural trajectory at the sigmoid level. no free fluid was seen and rest of the bowel appeared normal. the distal end was removed through the anus and the proximal end through a laparoscopic port. we performed a laparoscopic segmental cecum resection and an extracorporeal colo-colonic anastomosis was performed for a mini-pfannestiel laparotomy of assistance. there were no complications in the postoperative period, being discharge on the 5th day. conclusion: the multidisciplinary approach and the laparoscopic support in the diagnosis and treatment of patients with colon perforation caused bay vps catheter is a feasible and safe option in third level centers. background: acute appendicitis continues to be the most common source of complicated intraabdominal infection worldwide. the high incidence of postoperative complications and dissatisfaction with the results of treatment in cases of complicated appendicitis and peritonitis gave the reason for conducting this study. aim: to evaluate the effect of different laparoscopic trocars position in case of laparoscopic appendectomy for diffuse appendicular peritonitis for the incidence of postoperative complications methods: the results of laparoscopic treatment of 116 patients with acute appendicitis complicated by diffuse peritonitis were analyzed. the first group consisted of 37 (32%) patients operated by triangulation access (type 1 trocar placement according sages guidelines for laparoscopic appendectomy (sages qla). the second group consisted of 79 (68%) patients operated by sectorisation access (type 4 sages qla). postoperative complications were classified by clavien-dindo classification. results: the duration of the operation for the analyzed groups was 91.1 ± 29.9 vs 84.5 ± 24.9 min. there were no deaths among this group of patients. the incidence of postoperative complications for both group was 36.2%. postoperative complications in the triangulation and sectorisation group were 43% and 21.6% respectively (p 0.043). clavien-dindo iiib complications were noted in 4.3% (n-5) patients and presented with intra-abdominal abscesses (iaa). all patients with iaa were operated in sectorisation group. conclusion: sectorisation trocar placement increases the incidence of intra-abdominal complications for laparoscopic appendectomy for diffuse appendicular peritonitis. introduction: the diverticular disease of the colon is a chronic entity with a variety of abdominal symptoms that can present with recurrent episodes of acute diverticulitis (ad). the prevalence of diverticulosis is not influenced by gender and increases with age, which, according to the increase in life expectancy, explains the accumulation of cases in western countries. the classic diagnostic-therapeutic algorithm of the disease is it has been based on the hinchey classification, the use of antibiotics and the intervention of hartmann (ih) at the acute time and elective colectomy in the multirecurrent cases. the use of laparoscopy with washing and drainage is actualymore extended in cases with peritonitis. objectives: to demonstrate the safety and efficacy of the laparoscopic approach, in cases with diverticular disease complicated by severe inflammatory plastron with 'covered' perforation, with several recurrent episodes. material and method: case report: a 46-year-old man with ap-diverticulitis 10 years ago with complete resolution and normal control colonoscopy. he presents in the last two months three compatible episodes of acute diverticulitis, exploration with plastron-mass in hypogastrium without defense, tac-marked thickening of a segment of 10 cms. of medium sigma, collection not drainable in mesosigma, of 3 cm, which loses the plane of cleavage with loops of thin neighbors with a linear tract that suggests fistulization. evidence of interest is exposed. given the evolution, it is decided surgical elective treatment. result intervention: preoperative ureteral double catheterization, laparoscopic approach, is exposed by video, rectosigmoid resection by diverticular plastron, with negative io biopsy, mechanical colorectal anastomosis. good postoperative course, discaharge at 5th day. defini-tive ap: perforated diverticulitis, absence of malignancy. the laparoscopic approach is a valid and effective alternative in cases of complex and severe diverticular disease. aim: tamis resection has been described for the treatment of rectal neoplasms, wether benign or early malignant tumours. since tamis appearance, many different indications have been reported.we aim to show an special indication as seen in this video of a tamis resolution of a rectal stenosis non treatable by endoscopy. method: we present a video of a female patient, previously treated for a large rectal adenoma treated by trasnanal apporach, with a postoperative sepsis which required lateral colostomy and trasanal drainage. after surgery, the patient suffered from a rectal stenosis which couldn' t be solved by endoscopy, so the patient was sent back for a surgical treatment.we decided to performed a trasnanal apporach by tamis and a long and circunferiential stenosis around 6 cm from the anal verge was seen.we performed a rectotomy by electrocautery in the posterior rectal wall until the perirectal fat was seen and the stenosis was passed. a dilatation with a foley catether was also performed. results: postoperative course was uneventful and after 6 months she was prepared for colostomy closure with no complications and remains asymptomatic nowadays. conclusion: tamis approach of rectal stenosis may be a safe and feasible technique in selected cases if conservative treatments fail. iatrogenic endoscopic colon perforation it is a severe, but rare complication of colonoscopy. the incidence of this complication is estimated to be 0.016-0.8% for diagnostic colonoscopies and 0.02-8% for therapeutic colonoscopies. the management of these complications depends on the size of the lesion,the time elapsed between the lesions were produced and diagnostic of the lesions and associated pathology. the treatment can be consevative,endoscopic or surgical(clasic/ laparoscopic) in our sevice in last 10 years we treated 5 cases with iatrogenic colon perforation after diagnostic colonoscopies. all lesions were at sigma level. one case was admission in our service at 3 days after a diagnostic colonoscopy.the pacient was operated clasic,in emergency,we found a fecaloid peritonitis,a perforation at sigma level.we made a colostomy, lavage, drainage but the pacient died after 4 days. in 4 cases we made the operation at maximum 2 h after the lesion was diagnosticated by the endoscopist(directly visualisation).we didn't made radiologic investigation.the pacients were operated laparoscopic,we made suture,lavage,drainage. evolutions of the pacients were good. conclusion: iatrogenic colonic perfortion are rare,but severe complication. laparoscopic surgery can be a choice in treatment of this complication introduction: complicated diverticulitis with fistula is responsible for about 20% of surgical procedures in diverticular disease and is commonly found in patients with diverticulitis of the sigmoid colon. colovesical fistulas are the most frequent (65%), with highest incidence in males. only a third of these patients have a history of diverticulitis. in most cases, treatment is surgical, and colectomy is performed, whether or not in association with vesical recession. case report: 61 year old male with pneumaturia and fecaluria for the preceding 4 months. the colonoscopy identified a diverticulitis of the sigmoid colon and the subsequent pelvic mri suggested a colovesical fistula. the cystoscopy was not able to identify any fistulous opening, but a double j catheter was placed in the left ureter, as surgical treatment had been proposed. a subsequently abdominal pain motivated a preoperative ctscan which revealed a pneumoretroperitoneum and a fluid collection near the left ureteral tract. the multidisciplinary team on the case decided to perform a percutaneous nephrostomy, followed by an exploratory laparoscopy. the fistula tract was identified and a laparoscopic sigmoidectomy with partial cystectomy was performed, as well as a ureterorenoscopy (with double j replacement). there were no intra or postoperative complications, and the patologic repport had no signs of malignancy. video of the surgical procedure is presented. conclusion: a laparoscopic approach to complicated diverticulitis with colovesical fistula is safe and effective when performed by experienced colorectal surgeons. introduction: diverticular disease is characterized by its high prevalence, being one of the most frequent causes for hospital admission when it comes to gastrointestinal pathology. even though it is more frequent in older patients, there has been an increase in incidence amongst lower age groups. the approach to the disease has also suffered changes in the last few years, showcasing a tendency for less invasive options, deferring elective surgery to later in the course of the disease. this study examines the therapeutic approach to diverticular disease in our hospital. methods: retrospective analysis of demographic data, therapeutic options and surgical outcomes in patients admitted for diverticular disease between january2015 and june2018. results: 154patients(n = 154)were included in the study:75(49%)were male and79 (51%) were female, with an average age of 61 years. 135patients(88%) underwent medical treatment, with surgery reserved for the remaining 19 patients, 11 of which were emergencies, with the other8 being elective(5%).about89% of patients were only admitted once,9%were admitted twice and2% had3or more episodes. for the single-admission group, the most common treatment was medical(93%of cases), as was the case for the group with3or more episodes(in which 58%of cases were subjected to medical treatment). in the patient group with2episodes,53%were submitted for surgery, most of which elective.as far as the surgically operated group is concerned, no statistically significant differences were found with regards to patient sex. age, however, was significantly greater for the group that underwent emergency surgery vs that submitted to elective (65.2 years vs 45.2 years,p \ 0.001).the most common procedure overall was colic recession, with hartmann's operation standing out as the most frequent for the emergency surgery group. length of hospital stay was again higher for the emergency group (vs elective;14 vs 5,p \ 0.001),as well as the morbidity rate. no statistically significant differences were found with regards to mortality rate. conclusion: knowledge of the natural history of diverticular disease led to changes in the approach to treatment, with a tendency to adopt a less aggressive therapeutic. despite controversy around aspects such as selection of patients for elective surgery, among others, it is key to the approach to diverticular disease that existing recommendations are taken into account, treatment is individualized and outcomes are closely monitored. surg endosc (2019) aims: the objective of this analysis is to establish if there is differences after the procedure of laparoscopy appendicectomy comparing the use of endoloop (el) vs. endostapler (es) in complicated and non-complicated acute appendicitis. methods: we performed a retrospective analysis of a prospective database of 499 patients from february 2012 to june 2018. we divided the patients in two groups: depending on that the procedure of the appendicectomy was with endoloop or endostapler. the groups were created selecting 229 patients in order to be homogeneous as to perforation appendix rate, thus a propensity score was performed for sex, age and perforation rate. an univariant analysis was carried out in regard to the differences in the use of el vs es in the apparition of abdominal complication, as well as hemorrhage, ileo, surgical wound infection, collection, reintervention or hospital readmission.qualitative variables were expressed in terms of absolute frequencies and percentages and mean values and standard deviation were used to express quantitative variables. introduction: intramural haematomas can develop anywhere within any the gastrointestinal tract3. these are most frequently associated with blunt trauma above the level of the sigmoid colon and very rarely occur in the rectum1. spontaneous, non-traumatic haematomas are a rare clinical condition usually secondary to haematological blood disorders or anticoagulant therapy2. case summary: a 56-year old gentleman presented to the emergency department with a 2 day history of worsening lower abdominal pain and bloody stool. he presented twice within the previous week with worsening, generalised abdominal pain. the patient had been taking regular aspirin and clopidogrel following insertion of coronary artery stents. on clinical examination, he was guarding with a distended, generally tender lower abdomen but all observations were stable, afebrile. an initial computer tomography of the abdomen reported pneumoperitoneum with haemorrhagic ascites; a differential diagnosis being perforated sigmoid colon with a large localised haematoma. the patient underwent an emergency laparotomy and hartmann's procedure (appendicectomy, sigmoid colostomy and rectal stump). he recovered well with no significant post-operative complications. histology reported the rectal perforation macroscopically associated with an opened haematoma and no evidence of malignancy. the appendix shows reactive appendicitis with serousal inflammation background: ulcerative colitis (uc) is one of the risk factor of developing sporadic colorectal cancer. approximately 15% of uc patients develop an acute attack of severe colitis, and 30% of these patients require colectomy. one third of the patients will not respond to steroid therapy. thus, a long-term follow-up has been recommended. case report: we reported a single case of completed 5 years follow of colorectal cancer related ulcerative colitis on 54 years old female patient undergoing emergency operation (2 staged total colectomy and j-pouch ileo-rectal anastomosis) after 1 year no responsed of medical treatment before, presenting with bloody diarrhea and anemia. there was no post operative complication reported. pathologic finding was early adeno carcinoma, closed follow up was done each year and for another five years later, no progression of the disease was found in this period and the patients has good quality of life after this procedures. is becoming a standard and feasible surgical method worldwide. 20% of patients with crohn's disease (cd) and 80% patients with ulcerative colitis (uc) will require an operation during their life. over the last decade, there have been many studies documenting the safety and feasibility of the laparoscopic approach for ibd in well-selected patients. methods: patients with a cd with the tight stenosis in the distal ileum and/or ileo-colon or various colon and rectum stenosis, patients with uc with ineffective medical therapy, steroid dependence or dysplasia underwent the lcs. from 2009 to 2018, 247 ileocolic resections, 63 hemicolectomies, 74 subtotal colectomies and 35 restorative proctocolectomies with ileopouchanal anastomosis were performed either totally laparoscopically or laparoscopically assisted (n = 419).the average time of the procedure was 105 min (55-295 min), average blood loss 125 ml (0-350 ml) and the conversion to laparotomy was in 8.2%. average return time of the bowel function was 3.5 days (2-9 days) and the average hospital stay was 7.1 days (6-11 days). complications occurred in 24 patients (5.7%). 3 cases of the early ileus due to adhesions, 2 cases of the anastomotic bleeding threated conservatively, 1 case of the instrumental perforation of the small bowel, 7 cases of the incisional hernia in minilaparotomy and 11 wound infections occurred. conclusion: in well-selected patients with ibd, thanks to superior short-and long-term outcomes, the laparoscopic approach should be considered a safe and effective method when performed by experienced surgeons. supported by mo1012. aim: over 80% of patients with crohn's disease (cd) will require a surgical resection within 10 years of their diagnosis and one quarter will have another resection for disease recurrence. laparoscopy should by preferred approach in surgery in cd due to reduced morbidity, faster recovery time, shorter hospital stay and reduction in adhesions and hernial formation. methods: patients with cd with the tight stenosis in the distal ileum and/or ileo-colon or various colon stenosis were indicated for the laparoscopy. from january 2009 to november 2018 we performed 246 ileocolic resections, 63 hemicolectomies and 72 subtotal colectomies either totally laparoscopically or laparoscopically assisted. the average time of the procedure was 92 min (55-240 min). the average return time of the bowel function was 3.5 days (2-9 days) and the hospital stay was from 6 to 10 days. complications occurred in 14 patients (3.7%) . in 3 cases early ileus developed due to adhesions, in 1 case was anastomotic bleeding threated conservatively, the incisional hernia in minilaparotomy occurred in 6 cases and 4 wound infections occurred. conclusion: minimally invasive surgery is becoming a gold standard in cd. it is safe and feasible in well-selected patients thanks to short-and long-term outcomes. laparoscopic approach for recurrent disease is still in debate. supported by mo1012. aim: the aim of the study was to observe when laparoscopy is avoided when treating surgical complications of crohn disease. methods: we did a retrospective study which included all of the patients diagnosed and operated in our clinic for complications of crohn disease during a period of 3 years. results: we identified a number of 62 patients operated for complications of crohn disease. of these 15 were operated by minimally invasive procedures. we observed that laparoscopy was avoided in the case of intestinal fistulas (p = 0,02). also when sepsis associated the surgical complication-laparoscopy was avoided (p = 0,01). age under 43 years represented another factor to avoid laparoscopy (p = 0,04). conclusions: although laparoscopy offers numerous advantages careful selection of the patients is of utmost importance so the safety of the procedure can be ensured. retroperitoneal sarcoma represents approximately 12-15% of all sarcomas and less than 0.5% of all neoplasia. radiotherapy and chemotherapy still do not represent valid therapeutic alternatives; therefore radical surgery remains the only valid option. complete surgical resection is the only potential curative treatment modality for retroperitoneal sarcomas. the ability of complete resection of a retroperitoneal sarcoma with tumor grading remains the most important predictor of local recurrence and disease-specific survival. hypoglycemia is a rare but potentially lifethreatening presentation of soft tissue tumors the etiology of hypoglycemia may be difficult to diagnose, assays for insulin-like activity (ila) were found to be high in the extract of tumor tissue, while insulin was not detected in significant concentration neither in the same extract nor in his serum. the most likely mechanism of hypoglycemia appears to be production of insulin like substance and increased utilization of glucose by the tumor. laparoscopic surgery represents an alternative technique for radical resection of such tumors rather than traditional surgery. only few cases of retroperitoneal tumors resected laparoscopically were reported in the literature. we report a rare case of 53 years old male presented to ed unconscious due to hypoglycemia.he was resuscitated and admitted for further investigations. hypoglycemic attack recurred again during the same evening of admission. initial investigations were within normal except for serum glucose 35 mg/dl (2.0 mmol/l). his tsh, glucagon & cortisol levels were within normal, insulin and c-peptide levels were undetectable. only hypokalemia (2.3 meq/l). he tested negative for the anti-insulin antibodies. his abdominal ultrasound as well as his ct scans showed the presence of a large retroperitoneal tumor (15 cm 9 12 cm 9 7 cm) with a heterogeneous contrast effect. a glucose supplement was required to maintain the plasma glucose level within normal limits during which complete resection of the tumor which was performed laparoscopically. diagnosis of such hypoglycemia inducing retroperitoneal fibrosarcoma represents great challenge especially when patients presents only with hypoglycemia and no other abdominal symptoms, management using minimal invasive technique to resect and remove such tumors from the retroperitoneal region shows superiority in recovery and limitation of complications when done by experienced surgeons. solitary fibrous tumor (sft) is a rare fibroblastic mesenchymal neoplasm, tipically arising from the pleura, less frequently from other anatomic sites. sft is an indolent neoplasm, but it have been described cases of greater aggressiveness in terms of local recurrences and more rarelly of distant metastases. among the various extrapleural sites, intrabdominal, retroperitoneal localization is the most common site, followed by the pelvis soft tissues and parenchymatous organs. the most common clinical finding of intraabdominal localization is a palpable mass, and the pain is the most frequently associated symptom. the diagnosis is performed by imaging, but the histological as well as immunohistochemistry characterization of the lesion is the latest goal. furthermore, histological features are used to attempt to identify the patient with a hight risk of malignant evolution of the tumor. the gold standard treatment is surgical approach, meanwhile there are no evidences about the efficacy of any adjuvant treatment. we present the case of a 62-year-old man affected by symptomatic tfs arising from mesosigma treated by surgical radical excision. finally, we propose a review of the literature of last decade. background: laparoscopic right hemicolectomy involves making an additional incision to remove the specimen and perform the anastomosis. recently, natural orifice specimen extraction surgery (noses) has been reported as an alternative approach without any additional incisions or extensions, may lead to better outcomes compared to conventional laparoscopic right hemicolectomy. in this video, we aimed to evaluate the safety and feasibility of noses for laparoscopic right hemicolectomy. methods: we describe the technique with transvaginal specimen extraction and d3 lymph node dissection in laparoscopic right hemicolectomy by this video. we performed intracorporeal anastomosis combined with a transvaginal route of specimen extraction after medial-to-lateral mobilization. transverse transvaginal posterior colpotomy was performed under aid with visualization. the specimen was pulled into the sterilized plastic bag, passed transvaginally. the vaginal incision was then closed with a running suture. results: the operation time was 230 min and the hospital stay was 6 days. an excellent postoperative recovery was demonstrated and has shown future potential for less incision. the pathologic tnm stage is t3n0m0. conclusions: this video has shown that laparoscopic right hemicolectomy with the noses technique is feasible and safe for selected cases. the long-term benefits of this procedure need to be more evaluated. recently, indocyanine green (icg) fluorescence has been introduced in laparoscopic colorectal surgery to provide detailed anatomical information.the aim of our study is the application of icg imaging during laparoscopic colorectal resections: to identify the sentinel lymph node (sln) to search micrometastases that can be missed with the conventional pathological exam, and to assess anastomotic perfusion to reduce the risk of anastomotic leak. after tumor identification 5 ml of icg solution (0.3 mg/kg) is subserosal peritumoral injected. a full hd image1 s camera, switching to nir mode, in about 10 min displays fluorescence: the sln is identified and the sln biopsy (slnb) is performed.after the transection 5 ml of icg solution is injected to confirm the stumps perfusion. if there is an ischemic area, a new resection is performed.after the anastomosis is performed, another bolus of icg is intravenous injected to confirm the anastomotic perfusion.when the sentinel node is negative for cancer metastases by conventional histological examination, ultrastaging is performed by serial sections. when no micrometastases are identified on these sections, immunohistochemical techniques are applied. from november 2016, 70 patients were enrolled: 22 left colectomy, 38 right colectomy, 2 transverse resections, and 8 splenic flexure resections. in two cases, one left colectomy and one right colectomy, the anastomotic perfusion wasn't good and the surgical strategy was changed. four postoperative complications occurred, of which one anastomotic leak, due to a mechanical problem. from november 2017, 40 patients were enrolled to perform the slnb: 23 right colectomy, 11 left colectomy, 1 transverse resection and 5 splenic flexure resections. the sln was identified in 37 cases. 17 cases were found to be n0 to the conventional examination and were subjected to ultrastaging. the serial sections showed micrometastases in two cases. in the other cases the immunohistochemistry was performed but the exam is still in progress. icg-enhanced fluorescence imaging is a safe, cheap and effective tool to increase visualization during surgery. it's recommended to assess the anastomotic perfusion in order to reduce the incidence of anastomotic leak, and to perform the slnb for the sln ultrastaging in order to identify micrometastases. methods: for the last 3 years, tem was performed on 28 patients' with early rectal cancer. there were 19 women and nine men, age 68 to 87. localization of tumors was 4-12 cm from anus. mean size of tumors was 3.8 cm. full thickness excision was performed in all patient with suturing of mucosa. during follow-up in three patients' metastasis in lymph nodes of mesorectum were detected. all of these patients were re-operated: laparoscopic colectomy with total mesorectal excision (tme) was done. for the last year in 9 patients with early stage rectal cancer we used indocyanine green (icg) with fluorescent imaging for mapping sentinel lymph node. icg was injected in four quadrants to submucosa around the tumor. during the laparoscopy, sln was detected and removed with morphological examination. results: among nine patients in 8 patients, sln was negative. tem was performed in these patients with good results. after 10-12 months no recurrence or metastasis were detected in these patients. in two patients with positive sn laparoscopic tme was performed with low colorectal anastomosis. anastomotic complication was occurred in one patient. conclusion: tem procedure is highly effective in selected group of patients with early rectal cancer. mapping and examination of sln can clarify indication for the tem in the patients with early rectal cancer. purpose: laparoscopic surgery for colorectal cancer provides better short-term benefits and similar long-term outcomes compared with conventional open surgery. unlike minimally invasive surgery, natural orifice specimen extraction (nose) can provide additional advantages by reducing morbidity and postoperative pain related to the surgical extraction site. this study aimed to evaluate the efficacy and safety of a nose procedure using needlescopic instruments for colon cancer surgery. methods: between november 2013 and february 2018, 6 patients underwent laparoscopic nose using needlescopic instruments. the first port for the camera was placed at the umbilicus. a 5-mm or 12-mm port was inserted in the right lower quadrant. a 3-mm or 5-mm port was inserted in the right upper quadrant. individual needlescopic forceps for the assistant were inserted into left upper and lower quadrant ports. thus, a total of 5 ports were placed. the superior rectal artery and inferior mesenteric vein were ligated with clips, and colonic mobilization was performed using a medial to lateral approach. after rectal stump irrigation, the distal rectum was transected using an endoscopic linear stapler. the proximal colon and associated mesentery were transected. after the rectal stump was opened, a wound retractor was pulled through the anus and inserted in the rectal lumen. the resected specimen was transanally extracted through this route. an anvil was intracorporeally attached to the proximal colon, and the open rectal stump was reclosed using an endoscopic linear stapler; colorectal anastomosis was then performed using a double-stapling technique. results: of the 6 patients, 4 were male and 2 were female, with a median age of 71 years (44-76 years). median body mass index was 21.8. the tumor site was in the sigmoid colon in 4 patients and rectosigmoid colon in 2 patients. median operative time was 309 min and blood loss was 13 ml. there was no conversion to open surgery. no postoperative complication was observed. median postoperative hospital stay was 8 days (7-12 days). conclusions: nose surgery using needlescopic forceps is an easily performed type of reducedport surgery with a conventional port arrangement. this procedure is feasible for the selected patients. introduction: splenic flexure colon cancer accompanying obstruction is usually managed stent insertion as a bridge to surgery and left hemicolectomy, or subtotal colectomy. however, stent insertion can fail more often than in sigmoid colon because it requires longer colonoscopic approach in the circumstance of impossible bowel preperation. although subtotal colectomy has advantage in the aspect that it is 1-stage treatment, it needs open surgery in most cases, right colon has to be sacrificed without oncologic neccesity, and preoperative staging and evaluation can be insufficient. despite colostomy is reluctant procedure when considering quality of life, in splenic flexure colon cancer obstruction, we can obtain prompt stabilization of patient state, suffient time to preoperative staging and evaluation, and also we can achieve minimally invasive surgery by using colostomy site as mini-laparotomy and close colostomy before discharge. colostomy site, tumor location, and minilaparotomy site for next radical surgery have to be considered comprehensively before making colostomy incision. colostomy site has to be appropriate as mini-laparitomy site for feasibility of laparoscopic left hemicolectomy and the colostomy has to be included in the specimen with caution to prevent unneccessary lengthening of the specimen. we experienced 3 cases which were treated succefully in this strategy and report them. result: temperary loop transverse colostomy and laparoscopic left hemicolectomy via colostomy site in splenic flexure colon cancer obstruction has advantage of quick stabilization of patient's status, suffient preoperative staging and evaluation, achieving minimally invasive surgery, and also rapid colostomy closure before discharge. our tatme procedure for locally advanced low rectal cancer following chemoradiotherapy y. nakamoto 1 , r. okamoto 1 , f. kimura 1 , h. yanagi 1 , t. nakajima 1 , h. yoshie 2 , n. yamanaka 1 1 surgery, meiwa hospital, nishinomiya, japan, 2 surgery, yoshie clinic, itami, japan background: short-course chemoradiotherapy using hyper-fractionation method (scrt; 25 gy/ 10 fraction/5 days ? s-1 or xeloda) is performed to secure circumferential resection margin (crm) due to tumor shrinkage, reduction of cancer cells with viability, reduction of radiation hazard for resectable locally advanced lower rectal cancer (more t3 or n1). the patient underwent radical surgery after one month of scrt. for more locally advanced lower rectal cancer (t4 or n2), induction chemotherapy is performed before scrt. for patients with poor efficacy of chemotherapy, we also do normal 25 fraction 45 gy radiotherapy. methods: we introduced tatme from last august, and 18 cases were performed so far. in all cases temporary stoma has been constructed, and intersphincter resection (isr) is based on partial isr avoiding total isr considering postoperative anal function. if possible, colonic j-pouch is added, and pelvic floor repair may be added for esr cases and older people. at first one team preceded with the anal operation and shifted to the abdominal procedure, now it is done with two teams with the advantage of getting good visual field from both sides when there is difficulty identifying the right dissecting layer. tatme is very useful in cases such as large tumor, obesity, and narrow pelvis. furthermore, when it is difficult to identify the dissecting layer by scarring after crt, it is more possible to control the crm/drm of cancer. results: 14 cases of isr, 3 case of apr, 1 case of tpe were performed, and in 10 of these cases lateral lymph node dissection was also performed (one side 5, both sides 5). postoperative complications were 2 anastomotic leakage, 4 pelvic floor infection, 2 perineum infection, and 1 bowel obstruction. conclusions: tatme for locally advanced lower rectal cancer is useful even after chemotherapy and scrt. background: although many studies have demonstrated similar perioperative outcomes for single-incision laparoscopic surgery (sils) and conventional laparoscopic surgery (cls) for colon cancer, few have directly compared the costs of them. we aimed to compare costs between sils and cls for colon cancer. methods: we analyzed the clinical outcomes and overall hospital costs of patients who underwent laparoscopic surgery for colon cancer from july 2009 to september 2014 at severance hospital; 288 were used for analysis after propensity score matching. the total hospital charge, including fees for the operation, anesthesia, preoperative diagnosis, and postoperative management was analyzed. results: the total hospital charges were similar in both groups ($8770.40 vs. $8352.80, p = 0.099). however, the patients' total hospital bill was higher in the sils group than in the cls group ($4184.82 vs. $3735.00, p \ 0.001) mainly due to the difference of the cost of access devices. there was no difference in the additional costs associated with readmission due to late complications between the two groups ($2383.08 vs. $2288.33, p = 0.662). conclusions: sils for colon cancer yielded similar costs as well as perioperative and long-term outcomes compared with cls. therefore, sils can be considered a reasonable treatment option for colon cancer for selective patients. aims: technology improvements in medicine allow the development of new minimally invasive approaches. despite every single advantage of these new devices they also can cause technical problems and difficulties for the surgical team. well known from last few years-laparoscopic assisted transanal total mesorectal excision for distal rectal cancer is perfect example for a quite new procedure, based on the combination of forgotten old surgical principles and technology advances. the aim of the study is to analyze the rate of technical problems during the procedure and to measure the impact of them on the operative time. methods: we conducted prospective observational study related to technical problems during the procedure. for the period between september 2017 and november 2018 in the department of endoscopic endocrine surgery and coloproctolgy at military medical academy-sofia have been performed 25 laparoscopic assisted transanal total mesorectal excisions. we used standard local preoperative work up and postoperative care protocols. we defined technical problem as intraoperative event different from complication leading to delay in operative time. every technical problem during the procedure was recorded and time for resolving the problem was measured in seconds. results: overall technical problems occurred in 11 of the cases. most of them were related to the insufficient smoke evacuation during the 6 cases. the second most common technical problem were the excessive rectal stump spasms during the procedure-this complication occurred in 3 of the patients. mean delay of the procedure related to technical problems is 21 min. in our series we experienced only one intraoperative complication which was specimen perforation during the dissection. three complications occurred in postoperative period-two urinary retentions and one perianastomotic abscess, without need of reoperation. conclusion: technical problems during the procedure can be source of delay in operative time. correct use of devices in operating room is the key to reduce technical issues. technical problems can increase the rate of intraoperative near miss events and complications during the transanal total mesorectal excision. surg endosc (2019) aims: anastomotic leak after rectal cancer surgery constitutes a severe complication associated with poorer oncologic outcome and quality of life. preoperative assessment of the risk for anastomotic leak is a key component of surgical planning, including the opportunity of creating a defunctioning stoma. methods: studies on rectal cancer surgery published between 2000 and 2015 were systematically reviewed according to the preferred reporting items for systematic reviews and meta-analyses of individual participant data (prisma-ipd) guidelines. with the aim to generate a score for anastomotic leak, all available per-operative covariates were used as independent factors in a logistic regression model with anastomotic leak as dependent variable. a receiver operating characteristic curve (roc) analysis was generated. we selected as threshold the value that allowed a missing rate of anastomotic leak \ 2%. the predictive power of the previously selected cut-off was validated in an independent set of patients. results: twenty-six centers provided individual data on 9735 patients. with a threshold value of the roc corresponding to 0.0791 in the training set, the area under the roc curve (auc) was 0.585 (p \ 0.0001). sensitivity and specificity of the model's probability [ 0.0791 to identify anastomotic leak were 79.1% and 32.9%, respectively. accuracy of the threshold value was confirmed in the validation set with 77.8% of sensitivity and 35.2% specificity. conclusions: we trust that, with further refinement using prospective data, this nomogram based on preoperative risk factors may assist surgeons in decision making. the score is now available online (http://www.real-score.org). in 7 (12.5%) cases laparoscopic interventions were performed in patients with diverticular colon disease. in the group of patients with colorectal cancer localization of the tumor in the right parts was observed in 27 (36%) patients, in the left-in 30 (39%), in the rectum-19 (25%). results: in the adenocarcinoma of the sigmoid colon, performed a left laparoscopic hemicolectomy (19 cases) and resection of the sigmoid colon (11). was executed high clipping and intersection of the lower mesenteric vessels, aorto-iliac lymphatic dissection. in the standard scope, lymph node dissection was performed with removal and testing of not less than 12 epi-, para-and mesocolical lymph nodes (max 21). the average length of the laparoscopic stage is 125 ± 22 min. laparoscopic right hemicolectomy (27 cases) was performed in accordance with the principles of cvl (central vascular ligation) and cme (complete mesocolic excision). intracorporal ileotransversoanastomosis was formed by a semimanual method with endogia universal and v-lock suture material. the average length of the laparoscopic stage was 125 ± 25 min, the open phase was 56 ± 14. in the tumor of the lower and middle ampullary parts of the rectum (19 cases) after neoadjuvant chemoradiotherapy, was executed a laparoscopic total mesorectumectomy. conclusions: the use of minimally invasive technologies in colorectal surgery provides a complete revising of the abdominal organs, adequate scope of resection and lymph nodes dissection in surgical interventions. background: it is thought that complete mesocolic excision (cme) improves the oncologic outcomes for colon cancer. but, precise mesenteric mobilization from retroperitoneum and safe ligations at the origins of central vessels are considered to be technically difficult in single port surgery(sps). to resolve this problem, we utilize retro-mesenteric medial approach for right side colon cancer. herein, we introduce this technique and assess its outcomes. operative procedure: the multi-trocar platform is placed in the umbilical site. 3d laparosopy is inserted from one of this channels. the surgeon manipulates instruments via the other 2 channels. 1st step: right colonic mesentery is mobilized medial to lateral from the head of the pancreas and retroperitoneum along the embryonic plane. 2nd step: the origins of ileocolic and right colic vessels are divided and central lymph node dissection is achieved. 3rd step: hepatic flexure is taken down from cranial. and right lateral attachment is dissected away and cme is achieved. 4th step: specimen is extracted and anastomosis is performed using a functional end to end anastomosis extracorporealy. results: from april 2009 to december 2018, 125 consecutive patients underwent sps-cme with right side colon cancer. there were 52 in stage i, 32 in stage ii, 30 in stage iii and 11 in stage iv. the mean operative time was 207 min. the mean estimated blood loss was 42 ml. there was no conversion to open surgery. additional port was placed in 4 patients (3.2%). intraoperative bleeding was occurred in 1 patient. anastomotic leakage was observed in 1 patient (0.8%), intestinal obstruction 1(0.8%) and wound infection in 3(2.4%). conclusion: these results suggest that retro-mesenteric medial approach in single port surgery with right side colon cancer is useful and safe technique. aims: this multicenter, randomized controlled trial (simple trial) aimed to investigate the quality of life (qol) and patient satisfaction of single port laparoscopic surgery (spls) for colon cancer, compared with multiport laparoscopic surgery (mpls). methods: patients with histologically diagnosed adenocarcinoma in cecum, ascending and sigmoid colon were eligible for this trial. eligible patients were randomly assigned to the spls or mpls group at a ratio of 1:1. qol was measured with the eortc qlq-c30 third edition (korean version) preoperatively and postoperatively at month 1, 3, 6 and 12. in addition, patient satisfaction was surveyed with a five-point questionnaire at postoperative 12 month. to exclude the impact of adjuvant chemotherapy on qol, subgroup analysis for patients with or without adjuvant chemotherapy were carried out. (clincaltrials.gov identifier: nct01480128) results: total 359 patients were randomly allocated into the spls group (n = 179) and mpls group (n = 180). in total patients, global health status and five functional scale steadily increased and nine symptom scales also gradually improved over time. but, nausea/ vomiting and appetite loss temporally deteriorated at postoperative 3 month. pain score was significantly worse in the mpls group (11.6 in the spls group vs. 17.6 in the mpls, p = 0.002) at postoperative 1 month and appetite loss score was significantly worse in the spls group (19.9 vs 13.5, p = 0.017) at postoperative 3 month. except for that domains, all the other items of qol between groups were not different until postoperative 12 months. patient satisfaction was significantly higher regarding the operation (p = 0.025) and the abdominal wound (p = 0.025) in the spls group. in patients without adjuvant chemotherapy, some items of qol (global health status, physical functioning, role functioning, emotional functioning, fatigue and pain) were significantly better in the spls group at postoperative 1 month. since postoperative 3 month, all of qol domains (except pain score) were similar between groups. conclusion: although postoperative pain was temporarily better in the spls, most of qol domain were similar between the spls and the mpls group until postoperative 12 month. in patients without adjuvant chemotherapy, spls showed better outcomes in some of functional scales and symptom scores at postoperative 1 month. coloproctological surgery, juntendo university, tokyo, japan; 2 gastroenterological surgery, juntendo university, tokyo, japan introduction: laparoscopic surgery causes less postoperative pain compared with pain after laparotomic surgery, and its low invasiveness should be considered for pain control. we have previously controlled postoperative pain by epidural anesthesia. in this study we compared postoperative multimodal analgesia centering on acetaminophen in patients who underwent laparoscopic colorectal cancer surgery with the conventional method. subjects: the subjects were 39 patients who underwent laparoscopic colorectal cancer surgery between january 2018 and june 2018. surgery was performed under epidural anesthesia in 24 patients and multimodal analgesia in 15: periodic acetaminophen administration ? transverse abdominis plane (tap) block in 6, periodic acetaminophen administration ? local anesthesia of the wound in 2, and periodic acetaminophen administration ? intravenous patient-controlled analgesia (ivpca) in 7. the operating roomoccupying time, postoperative pain (nrs), frequency of taking analgesics as needed, and postoperative nausea were investigated for 3 days after surgery and the duration of urethral catheter placement and postoperative intestinal movement were investigated in the epidural anesthesia and multimodal analgesia groups. results: while the time from entering the operating room to initiation of surgery was significantly shorter, the time from completion of surgery to leaving the room was significantly longer in the multimodal analgesia group. there was no difference in the operating room-occupying time. the frequency of postoperative pain was significantly lower in the multimodal analgesia group on postoperative day (pod) 2. the frequency of taking analgesics as needed was significantly lower in the multimodal analgesia group on pod1, 2, and 3. no significant difference was noted in the duration (number of days) of urethral catheter placement or postoperative nausea between the 2 groups. regarding postoperative intestinal movement, discharge of gas occurred significantly earlier in the epidural anesthesia group. the total number of incidents of complications in the epidural anesthesia group was 12. discussion: in laparoscopic colorectal cancer surgery, the effect of multimodal analgesia centering on periodic administration of acetaminophen without epidural anesthesia for postoperative analgesia was sufficient compared with the effectiveness of epidural anesthesia. this approach to analgesia may be useful because none of the potential complications of epidural anesthesia occur. surg endosc (2019) in the last years the application of new technologies like 3d vision or virtual reality have provided to surgeons the possibility of establish a preoperative surgical plan of each surgery and of each patient. these advances are specially useful in minimally invasive colorectal surgery due to the variability in location, anatomical relationship with other organs and vascular variants of these type of surgeries. the aim of our work is to built a digital 3-dimensional virtual model of the colorectal ct scan imagen of patients with colorectal cancer. the virtual models are obtained from the preoperative ct scan. the ct scans that we use to this work are general electric healthcare revolution gsiò and siemens somatom perspective 64ò and the size of each image is 1 mm. a medical software let us build a reconstruction of colorectal digital images where a radiologist has marked the exact image of the tumor so we obtain a 3d reconstruction which can provide an enhanced understanding of crucial anatomical details like the exact location of the tumor and the relationship with other organs and structures of the patient which can be selectively displayed or hidden. this information has an important applicability into clinical practice since it lets surgeons estimate the colorectal anatomy, tumor size and relationships, providing key landmarks to choose the most appropiate surgery, the best trocar location and a safer dissection specially in some cases whose location can change the kind of surgery radically. we present some cases where virtual models were crucial for the preoperative and intraoperative surgical plan, showing the potential interest of these 3d reconstructions in colorectal surgery. in conclusion the ct scan colorrectal image reconstruction can provide an enhanced understanding of crucial anatomical details of the colon and tumor location and relations which could contribute to choose the best surgical option and to improve safety in colorectal surgery. background: anastomotic leakage (al) after colorectal procedures are a common surgical experience and represents a significant burden both for patients and surgeons. the incidence of al has been reported to vary between 0.5% to up to 21%, with rates for the colon and rectum of 3-7% and 13-18%, respectively. they, not only add to potential postoperative patient morbidities and to overall costs of postoperative patient care, but also are considered a quality indicator in colorectal surgery. aim: we aimed to evaluate the clinical burden associated with anastomotic leaks following colorectal surgery. methods: we conducted a retrospective analysis of 641 colorectal patients who underwent conventional or laparoscopic colorectal surgery for colorectal cancer (crc), from january 1st, 2013 to december 31st, 2016 in a single colorectal centre (centro hospitalar de leiria). patient demographics, intraoperative and postoperative aspects were collected and analysed. all statistical analysis will be conducted using stata software (statacorp lp). results: in our cohort of 641 pts, 35 developed a clinical al (5.46%), mostly males (90%), with an average age of 71 ± 10.57. male gender and conversion were independent risk factors. the group with al had a higher lohs (25.2 days vs, 6.59-p \ 0.0001). 6 out of 35 al have been detected after the discharge. the mean diagnostic day was the eighth, and mode estimated at day 5. when compared with a control group, wcc, eosinophils and crp were statistically significant different in al group, at day 3 and 5. conclusion: in the present study, no statistically significant risk factors for al in crc surgery were detected, except for male gender and conversion. clinical methods and biomarkers were useful for early diagnosis. technology combined with experience and common sense may be the embodiment of the clinical method. conclusions: our regional screening program has significantly improved early diagnosis and quickened surgical treatment of crc. thanks to this, we obtained an earlier stage at diagnosis, a less invasive surgical approach, and a lower rate of complications and emergency surgery need were obtained also with an improvement in both os and dfs. introduction: surgeons are increasingly being faced with the problem of treating elderly colon cancer patients. we evaluated the outcome of silc in patients of over 80 years with colon cancer with a propensity score matched comparison to assess its perioperative and long-term oncological outcomes. methods: this retrospective cohort study analyzed our experience with silc for colon cancer over 5 years. eighty-seven patients of over 80 years with colon cancer who electively underwent silc were included in this study (elderly group). eighty-seven patients were then chosen out of a collective of 257 patients less than 80 years old in a propensity score matched design (younger group). short-term clinical outcomes in both groups were compared and verified its long-term oncological outcome. results: american society of anesthesiologists score and post-operative complication rate were significantly higher in elderly group. however, the other short-term clinical outcomes including post-operative hospital stay were equivalent in two groups. the rates of 5-year cancer specific survival were 78.0% in elderly group and 70.9% in younger group, respectively, and the 5-year overall survival rates were 64.6% and 66.8%, respectively. no significant differences were seen between two groups. conclusions: our initial experiences suggested the oncological and clinical safety of silc in patients of over 80 years with colon cancer. however, further studies are needed to demonstrate the advantages of this procedure compared to conventional laparoscopic colectomy. aim: some clinical trials have reported the safety and efficacy of laparoscopic colectomy for colon cancer. on the other hand, transverse colon cancer was excluded in these trials because of the difficulty of laparoscopic colectomy for transverse colon cancer. in this presentation, we report the tips for laparoscopic colectomy for transverse colon cancer. tips: in our department, 87 transverse colon cancers has been resected by laparoscopically so far. to complete cvl and cme, lymph nodes around middle colic artery should be resected, however many important structure, duodenum, pancreas, superior mesenteric vein (smv) and so on, may be obstacles. this is most difficult point for this surgery. our surgery is as follows. mobilization of ileum and ascending mesocolon from caudal sideconfirm duodenum and pancreasexpose smv and ligation root of ileocecal artery and veindissect lymph nodes around smv and ligation of middle colic artery and accessary right colic veinconfirm pancreas from caudate side of transverse mesocolon and incise the peritoneum along the caudal side of the pancreasdissect lymph nodes sufficiently by dissection from both side of transverse mesocolonmost important point. to dissect lymph nodes safely, confirmation from both side of transverse mesocolon is necessary and dissection should be performed along important structure, smv, pancreas and so on. introduction: we have developed and previously reported single-incision plus one port laparoscopic anterior resection of the rectum (sils ? 1-ar) as a reduced port surgery in which we can utilize the incision for drainage as an additional access route for laparoscopic procedures including the transection the lower rectum. a consecutive experience from its introduction of sils ? 1-ar for rectal cancer is reviewed, and its 5-year oncological outcomes are evaluated retrospectively. methods: one hundred and forty-one patients (53 female) with a mean age of 67.6 years adopted the sils ? 1 procedure for rectal cancer. a lap protector (lp) was inserted through a 2.5 cm transumbilical incision; an ez-access was mounted to the lp and three 5-mm ports were placed. a 12-mm port was inserted in the right lower quadrant. results: one hundred and thirty-six patients (96.5%) completed with sila ? 1-ar. the tumor locations in the rectosigmoid, rectum above the peritoneal reflection (ra), and rectum below (rb) were 44, 63 and 29, respectively. the median follow-up interval was 42 months. aims: colovesical fistulae came from inflammatory disease or cancer and do have a significant morbidity. the most common location is the sigmoid colon and the most common aetiology is diverticulitis. the treatment of choice is a surgical procedure. the aim was studying compare laparoscopic approach in patients diagnosed by benign (diverticulitis) and malignant (colon adenocarcinoma) colovesical fistulae. methods: from january 2001 to march 2005 all characteristics of surgical patients with diverticular and colon adenocarcinoma colovesical fistulae were reviewed. patient details (sex, age, symptoms, diagnosis, medical history and anaesthetic risk), surgical approach, hospital stay and complications were recorded. both groups were compared with significance level set at p \ 0.05. results: nine laparoscopic (71%) and 4 open approaches (29%) in diverticular colovesical fistulae were performed, with a conversion rate of 33%. the procedure done was sigmoidectomy. there were also performed 3 laparoscopic (14%) and 16 open approaches (72%) in colon adenocarcinoma colovesical fistulae. the procedures done were sigmoidectomy, pelvic exenteration, left colectomy, low anterior resection and loop colostomy. comparison between the two groups didn't show significant differences in characteristics but did show significant differences regarding the approach, with more cases performed by open approach in colon adenocarcinoma colovesical fistulae (p = 0.03). conversion rate didn't show significant differences. patients diagnosed for malignant colovesical fistulae had more complications, 15 cases (68%), 10 (45%) i-ii and 5 (23%) iii-iv-v according to clavien dindo classification, manifesting significant differences (p = 0.03). laparoscopic approach didn't show significant differences regarding complications. conclusions: generally, surgical approach with colonic resection and partial or total cystectomy is the treatment of choice in colovesical fistulae, although vesical resection can be avoided if it is suspected benign aetiology. whenever laparoscopic approach is performed by experienced surgeons, is feasible in colovesical fistulae and the morbidity and mortality numbers are acceptable. laparoscopic approach allows the advantages of a minimally invasive treatment but implies clinical trials to stablish stronger evidence. aims: laparoscopic right hemicolectomy became the standard of care for treating cecum, ascending and proximal transverse colon cancer in many center. most centers use multiport laparoscopic colectomy with extracorporeal resection and anastomosis (mce). single-incision laparoscopic colectomy with intracorporeal resection and extracorporeal (sci) remains controversial. the aim of the present study is to compare these two techniques using propensity matching analysis. methods: this study analyzed 171 patients who underwent laparoscopic right hemicolectomy including 119 mce surgeries and 52 sci surgeries from december 2015 to december 2017. short-term outcomes were recorded. postoperative pain was evaluated using a visual analogue scale (vas) and postoperative analgesic use as outcome measure. results: the length of skin incision in the sci group was significantly shorter than in the mce group: median (range) 3 (2-10) cm verses 4 (3-8) cm (p \ 0.0001). the vas score after surgery was significantly less in srhi than in mrhe. significantly fewer patients required analgesia after srhi after surgery. there were no significant differences in operative time, intraoperative blood loss, the number of lymph nodes removed and postoperative courses between the groups. the cost effectiveness was significantly cheaper in srhi than in mrhe. conclusions: sci for right colon cancer is safe and technically feasible. sci reduces the length of skin incision and postoperative pain compared with conventional mce. aim: this study was designed to clarify the utility of laparoscopic surgery for advanced lower rectal cancer after neoadjuvant chemoradiotherapy (ncrt). patients and methods: we investigated 3-year disease-free survival rate, operative outcomes and recurrence risk factor in 73 patients with lower rectal cancer (ct2-4, n0-2) who underwent laparoscopic surgery after ncrt from 2010 to december 2017 in kitasato university hospital. results: of 73 patients, 43 patients underwent low anterior resection (lar), 4 patients underwent intersphincteric resection (isr) and 27 abdominoperineal resection (apr). there were 7 anastomotic leakage, and 1 urinary disorder and 2 sexual dysfunction. ypcr rate was 24.7%, but 15 patients (20.5%) had recurrence (7 liver,7 lung and 2 lymph node and 1local recurrence; there is some overlapping). ypt4 and lymph node metastasis were detected as a recurrent risk factor. the 3-year relapse-free survival rate (rfs) was 79.5% and the 3-year overall survival rate (os) was 92%. conclusion: in this examination, ypt4 and lymph node metastasis were risk factor for recurrence. the operative outcomes, 3-year rfs and the 3-year os are relatively good results. we will conduct further follow-up, and it is necessary to investigate a long term prognosis. laparoscopic surgery is warranted for rectal cancer after ncrt. surg endosc (2019) introduction: synchronous colorectal neoplasia presents an incidence ranges from 2% and 7%. classically its surgical treatment consisted in the realisation of a subtotal colectomy (stc), however, several authors have proposed that in certain occasions the realisation of two segmental resections with two anastomoses was not accompanied by an increased risk of anastomotic failure. the objective of this study was to compare the feasibility and safety of the laparoscopic approach of synchronous colorectal neoplasia using two different techniques: stc versus two segmental resections with two anastomoses. methods: we retrospectively reviewed the clinical data of patients over 18 years of age who underwent colorectal surgery between 1998 and 2018 at a single center. we included patients with a synchronous colorectal neoplasia who underwent laparoscopic surgery, either stc or double resection (dr). results: a total of 24 patients met the inclusion criteria. mainly males (86%) with an average age of 75 years, with a scale of the american association of anesthesiologists superior to ii in 53% and with an average body mass index of 29 kg / m2. the mean operative time was 251 min in the dr and 281 min in the stc, the stc resulted in a higher conversion rate (23% vs 11%) and intraoperative bleeding (39% vs 22%), in addition to a postoperative period with more complications, only 15% of the patients undergoing stc didn't present any complication while 67% of the patients with a dr didn't present any complication. 38% of the stc presented anastomotic failure and only 11% of the dr. the mean hospital stay was 8 days in the dr and 18.5 in the stc. in the dr, an average of 47 cm of colon was resected with an average of 24.8 lymph nodes, while in the stc, 127 cm of colon was resected with an average of 24.2 resected nodes. conclusions: the double resection with two anastomosis is a less aggressive surgery, with fewer complications and a shorter hospital stay, providing similar oncological results. there were no differences in morbidity, re-operations or hospital stay. regarding tumor stage there were no differences between the three groups. as for the resected nodes, we found a mean of 21 in stc, 16 in lc and 14 sr with no statistical difference. there were no differences in the affected nodes among groups. in our patients we didn't find differences in the recurrences rate or in the distant metastases rate.the average follow-up was 76 months (range: 30-114), with no differences in overall survival. conclusion: segmental resection of splenic flexure neoplasias is safe and feasible, with no differences in morbidity or in the oncological outcomes compared with more aggressive surgeries. introduction: the evaluation of perfusion in colorectal anastomosis is still a field of study and progress for the development of new modalities that allow reducing the ratio of dehiscence or anastomotic leakage (al) in said surgery. our objective with this work is to highlight the utility of indocyanine green (icg) in the said evaluation after colo-rectal surgery. methods: we present a series of 85 cases of colorectal surgery (benign and malignant disease) intervened in the period between 2014 and 2018. the population sample has been homogenized according to age criteria, risk factors and comorbidity. a retrospective database has been developed with the spss v.22 software for the evaluation of the results obtained. the primary outcome measure was al rate with at least 1 month of follow-up. results: a significant reduction in the incidence of al was observed in patients who underwent colo-rectal surgery (p = 0.005). low al rates were shown in rectal cancer surgery (p = 0.02). there was no significant decrease in the al rate when colorectal procedures for benign and malignant disease were combined. conclusions: the use of the image by fluorescence with indocyanine green is a safe, reproducible and relatively simple method with which to evaluate the perfusion of the colorectal anastomosis as well as reduce the rate of anastomotic leak in the postoperative period. large well-designed randomized control trials are needed to provide evidence for its routine use in colorectal surgery. introduction: currently colonoscopy is the gold standard investigation for colonic evaluation. although caecal intubation is one of its quality indicators, it is not attained in up to 20% of cases. this remains a significant concern. limited data are available on the follow-up of patients with incomplete colonoscopy. aims: to assess colonoscopy completion rate, the reasons for incomplete colonoscopy, and the methods used to complete colonic evaluations after incomplete colonoscopy. methods: we performed a retrospective study of incomplete colonoscopies in our unit over a one year period (2017) these results compare favorably with published data. few statistically significant differences between groups suggest varying modalities of treatment broadly result in similar qol. this data highlights a need for well-delivered support programmes for specific issues, for example stoma care and sexual dysfunction. future studies will need to include a baseline questionnaire to truly measure the impact of surgery and measure quality in an increasingly elderly and comorbid population. splenic flexure cancer (sfc), comprising the tumours raised in the distal transverse colon and proximal descendingcolon, accountfor 2 to5%of all surgically treated colorectal cancers.in cme forsfc, dissection of both the transverse and descending mesocolon must be considered. however, the use of laparoscopic surgery as a curative treatment for sfc, has never been investigated in adequate controlled trials, because of difficulty in deciding on the appropriate operative procedure, as well as technical difficulties with laparoscopic lymph node dissection. the aim of this multicenter study is to evaluate the oncologic effectiveness of laparoscopic segmental resection with cme with for cancer located at the splenic flexure. we performed a retrospective analysis of all cases of sfc treated with a laparoscopic segmental resection with cme in five different institution. intra and post operative were evaluated. 112 patientes were evaluated, the mean operative time was 155.17 ± 48.54 min. a total of 6 (5.4%) conversions occurred, 2 due to splenic artery lesion, one for difficult adesyolisis and three due to locally advanced tumour. recurrence was observed in 13 (11.6%) patients. there was a significant association between disease stage and recurrence (p \ 0.001) with a higher proportion of stage iv patients in the recurrence group (46.1% vs 7.1%). at 30 days follow-up no mortalitywere recorded.during a median follow-up of 43 months (range 12-149), 13 deaths occurred (all of them for disease progression). keplan mayer curves showed a compareble suvival with other colo-rectal cancer. in conclusion, laparoscopic segmental resection with cme and cvl seems to be an oncologically safe and effective procedure for treatment of sfc. it may be regarded as the standard surgical method for elective management of this disease. in the future, more tailored patient-and tumor-specific segmental resection might be achieved with the use of routine lymph node road mapping. it is very important to establish a minimum number of lymph nodes to analyse for a correct staging. it has been established as 12. the treatment of colorectal cancer is essentially surgical. the review of the medical literature indicates that laparoscopic colorectal surgery is a safe procedure that has not found significant differences in the survival rate from open surgery. aim: the aim of our study is to compare the outcomes of laparoscopic and open resection for colorectal cancer surgery evaluating lymph node assessment. methods: the patients were collected in our hospital during the period from 1/11/2017 to 1/12/ 2018 and the number of lymph nodes obtained in lymphadenectomy has been studied comparing the laparoscopic and laparotomy approaches. results: 81 interventions were performed. 55 were laparotomic, 20 were laparoscopic and 5 converted laparoscopic (fig 1) . the average number of nodes found in these interventions was 15, 36. nowadays, the recommendations to obtain a proper lymphadenectomy is to find more than 12 lymph nodes. analysing our procedures, 61 surgeries had obtained a good lymphadenectomy. according to the approach, 62,3% of the interventions (38) are laparotomy, 31,2% (19) are laparoscopic procedures and 6,5% (4) are by reconverted laparotomy (figure 2 ). the average number of lymph nodes isolated was similar. laparotomy approach found 16,45 nodes while 13,5 nodes were found in laparoscopy. converted laparoscopy found 12,2 ( figure 3 ). conclusion: the treatment of colorectal cancer is essentially surgical. today, there are a lot of studies that support that laparoscopic surgery has a survival rate similar to laparotomy surgery. according to our study, the data collected indicates that the number of isolated lymph nodes in both approaches is very similar. to sump up, laparoscopic colorectal surgery is safe and has demonstrated oncological adequacy comparable to open approach and better short-term outcomes due to a less invasive approach. background: laparoscopic low anterior resection highlights the advantages of laparoscopic surgery (better surgical field, less bloodloss, less postoperativepain, better cosmeticresult). defunctioning ileostomy prevents anastomotic leakage in low rectal cancers, butincreases morbidity, degrades thequality of life and requires a second surgery for its closure. method: in the last 24 months we performed 8 laparoscopic low anterior resections for rectal cancer, whithout performing any protectiveileostomy, afterchecking the anastomosis intraoperatively(5 men, 6 women. average age: 65 years). the typical placement of trocars included one supraumbilical 5 mm trocar, two right sided 10 mm trocars in the midclavicular line, one 5 mm in the left midclavicular line and one 5 mm trocar in the suprapubic midline which is also used for specimen removal, after a 2 cm transverse extension of the incision. we present themain stages of the procedure (dissection andmesorectal excision, division of the rectum with linear stapler using the 'chinese hat-parnex' technique, creation of an end-to-end intracorporeal anastomosisusing circular stapler under direct laparoscopic vision). results: no major postoperative complication was observed. the mean operative time was 250 min (180-300) and free surgical margins were achieved. in one case a conversion to open surgery occured. the average length of hospital stay was 8 days (7-9). conclusions: the laparoscopic approach facilitates access to the middle and lower rectum, total mesorectal excision and avoidance of ileostomy if possible. it is a demanding operation with extended learning curve, and requires adequate experience in laparoscopic surgery and colorectal surgical oncology. background: in colorectal cancer, local excision is an attractive treatment option, but additional resection is considered when lymph node metastasis(lnm) is expected at high rate. in lower rectal cancer, advanced surgery techniques are required, so it is often difficult to make judgments. the aim of the current study is to assess the reliability of laparoscopic surgery for submucosally invasive rectal adenocarcinoma (pt1) analyzing short-term outcomes and long-term survival. method: this cohort study analyzed 217 patients who underwent laparoscopic rectal resection for submucosally invasive rectal adenocarcinoma (pt1). conversion rate and functional and oncologic outcomes were analyzed. data on long-term results and survival were evaluated. result: surgical procedure was low anterior resection / intersphincteric resection / abdominoperineal resection: 190/23/4, and conversion to open surgery was needed for 6 (2.8%) patients. sphincter-preserving procedures were performed in 204 (97.2%) patients. there were no perioperative mortalities and positive resection margin. the mean length of hospital stay was 10.5 days. complications beyond clavien-dindo grade iii occurred in 14 (6.4%) patients,the anastomotic leakage rate was 3.6% (8/217). the positive lymph node metastasis rate was 12.9% (28/217). high tumor budding (p = 0.006), lymphatic invasion (p \ 0.0001), and mucinous /poor histological differentiation (p = 0.01) were significantly associated with lymph node metastasis on univariate analysis. on multivariate analysis, only lymphatic invasion was associated with lymph node metastasis (p \ 0.001).the median follow-up time was 50 months (range, 6-151 months), recurrence free survival rates was 96.3% (209/217). conculusion: the outcomes of this study suggest that laparoscopic surgery can be used for safe and radical resection of submucosally invasive rectal adenocarcinoma (pt1)?and the absence of lymphatic invasion, budding, and mucinous /poor histological differentiation are each associated with low risk of lnm. risk stratification models integrating these factors need to be investigated further. conclusions: this study highlights the complex nature of sarcopenia, as well as its common incidence. minimally invasive surgery had a higher incidence of sarcopenia than that of open surgery when both were performed within an enhanced recovery setting. despite colorectal patients being a typically well-nourished cohort at low risk of complications, there may well be benefit from interventional strategies such as perioperative immunonutrition or pre-habilitation to reduce the incidence of this poor prognostic indicator. backgrounds: urinary dysfunction is frequently observed after rectal resection and justifies urinary drainage. the concept of enhanced recovery after surgery (eras) has been widely spread from the early 2000 s. however, the optimal duration of postoperative urinary drainage is unknown. aims: the aim of this study was to comprehend short-term outcome of early removal of urinary catheter after robotic rectal surgery (rrs). patients and methods: (patients) the data of 44 consecutive patients who underwent rrs at two hospitals between april 2015 and november 2017 were retrospectively reviewed. the main indication of rrs was the patients who need rectal mobilization with autonomic nerve preservation regardless of benign or malignant disease. perioperative management: none of the patients received epidural anesthesia for postoperative analgesia. our basic principle was to remove urinary catheter on postoperative day (pod) 1. after removal of urinary catheter, trans-urethral catheterization (tuc) was performed in the following situations:1) no autonomous urination over 6 h after removal 2) the decrease in urine volume (\ 150 ml/6hr) 3) the appearance of subjective symptoms like abdominal distension. when tuc was required even once, residual urine volume was measured with ultrasonic examination device since then. results: twenty seven male and 17 female were included. the median age of patients and bmi were 67 years old and 22.7 kg/m2, respectively. the surgical procedures included anterior resection (n = 33), intersphincteric resection (n = 4), abdominoperineal resection (n = 5), hartmann's procedure (n = 1), and total coloproctectomy (n = 1). only one patient received lateral pelvic lymph node dissection. urinary catheter was removed on pod1 in 40 cases (90.9%), on pod2 in 4 cases (9.1%). although tuc was needed in three cases (6.8%) immediately after removal, tuc was no longer needed within three days in all three patients. late dysuria was observed in two cases (4.5%), and bladder overdistension was suspected in these two cases. conclusions: our study showed that urinary catheter could be safely removed on pod1 after rrs. however, careful follow-up observation to avoid bladder overdistension is essential after removal. introduction: intersphincterian low rectal resection is a valid alternative to lower rectal cancers located at about 4-7 cm from the anus. methods: we present 19 cases from our personal experience for tumors localized 4-7 cm from the anus. 13 of them required preoperative radiochemotherapy. in 12 cases, abdominal surgery was performed laparoscopic, 7 having the surgical specimen extracted transanal. lone star device was used for the perineal procedure in all cases. 6 cases required a manually, separate wires anastomosis; the others 13 cases benefited from mechanical anastomosis performed endoanal with 29-31 mm circular stapler. we performed complete mesorectum excision in all cases, ligation at the origin of inferior mesenteric artery, complete mobilization of left splenic flexure and lateral protective ileostomy. all pacients underwent inspection rectoscopy before transit reintegration, and 16 cases were reintegrated over a period of 3-12 weeks, except for 3 cases which developed a colo-anal fistula, that closed under conservative treatment over a period of 3-9 months. results: there were no postoperative anal incontinence. in one case, a relative anal stenosis occured, which required endoscopic dilation. there was 1 case of tumor recurrence and required abdominoperineal resection. conclusion: literature data sustain a 3-4/1 ratio for very low rectal resection versus rectum amputation. the limit resection under the tumor is accepted as 0.5 cm. very good functional results by considering oncological principles, is a sustainable argument for choosing this kind of procedure as an alternative of rectum amputation. in the few studies conducted on crcs, the reported rate of sln micro-metastases is up to 20-30%. the aim of this ongoing prospective study is to assess the predictability of the ex-vivo nirf sln mapping and of the research of micrometastases in nnd crc patients to propose adjuvant chemotherapy. materials and methods: fifty-eight patients undergoing standard oncological crc laparoscopic resection have been prospectively enrolled in two centre. as previously described by the authors, the intact surgical specimen was extracted and opened longitudinally and 1 ml of indocyanine green (icg; 5 mg/ml) was injected submucosally at four corners around the tumor in order to identify the lymphatic pathway and the slns. each sln presenting as negative at conventional histological analysis, was further investigated with ultrastaging techniques including serial sectioning and additional immunohistochemistry, in order to detect the presence of micrometastases. results: thirty patients were n ? , and 28 were nnd. overall, a total of 1085 lymph nodes were retrieved. a total of 117 sln were identified (mean 2.01 per case) and 54 of those were nnd. after ultrastaging investigations, 4 micrometastatic cases were found in nnd patients. the patients were so upstaged to n1. sln located deeper in the mesenteric and mesorectal fat could easily be identified by nirf (even after nchrt). conclusions: in our preliminary series, the ex-vivo nirf sln mapping rightly predicts the status of loco-regional nodes, as confirmed by the histological investigations. the micrometastases' identification let selected patients to undergo the adjuvant treatment with the aim to reduce the risk of recurrence. (3/13) in lateral node positive group and 18.8% (3/16) in lateral node negative group. four of 6 local recurrence were lateral lymph node recurrence. two patients recurred the other lateral side of previous lpl, then they were laparoscopically resected and no recurrence (52, 58 months). two patients recurred the same side after lpl were not curable because of liver metastasis and extensive invasion to the common iliac vessels. conclusion: selective lpl for rectal cancer was safe and good local control for lateral lymph node positive patients. also curable local recurrence resection was possible for non-treated lateral lymph node recurrence. intestinal malrotation is an embriologic anomaly generally discovered in the first months of life due to bowel obstruction. adult presentation is rare and its association with colon cancer is far more rare. we report a case of a 70 years old man affected by asymptomatic intestinal malrotation incidentally found during an abdominal computed tomography (ct) performed for retroperitoneal colonic perforation in a patient with an endoscopically diagnosed aenocarcinoma of the caecum and a large polyp of the descending colon. preoperative vascular anatomic study allowed us to plan a laparoscopic approach safely also with adequate lymphoadenectomy. the abdominal cavity was entered throught a right flank 12 mm optical trocar on the transverse umbilical line. three additional 5 mm trocars were placed in right iliac fossa, right and left hypocondrium respectively. exploratory laparoscopy confirmed midgut malrotation and a fresh flogistic area at the descending colon perforation site. caecum and ascending colon were on midline and attached due to adhesions to sacral promontory. ileocolic artery (ica), middle colic artery (mca) and ima were selectively ligated but not at their origins due to aberrant anatomy. laparoscopic subtotal colectomy with intracorporeal stapled ileosigmoid anastomosis were carried out (endogia 45 mm, double layer 3/0 polyglicolic acid suturing of the breech). the anisoperistaltic nature of the anastomosis is due to the disposition of the mesenterium which did not allow an isoperistalting orientation of the two resected stumps. the specimen was extracted throught a pfannestiel incision. the postoperative course was complicated by intestinal obstruction conservatively treated with slow bowel function's restoration. the patient was discharged from the hospital in 15th postoperative day. unexpectedly specimen histology revealed two villous adenomas with high grade dysplasia. 17 lymphnodes were retrieved from the specimen (ptisn0). to date our case is the only fully laparoscopic colonic resection reported in literature in malrotation as well as the first intracorporeal stapled ileo-sigmoid anastomosis for such disease. the median hospital stay was 6 days. in-hospital mortality was nil. the overall morbidity was 20%. the median length of follow-up was 23 months. conclusions: our preliminary results suggest that robotic-assisted surgery for colorectal cancer can be carried out safely and according to oncological principles. robotic surgery is advantageous for both surgeons (in that it facilitates dissection in a narrow pelvis) and patients (in that it affords a very good quality of life via the preservation of sexual and urinary function in the vast majority of patients and it has low morbidity and good midterm oncological outcomes). in rectal cancer surgery, the robotic approach is a promising alternative and is expected to overcome the low penetration rate of laparoscopy in this field. aims: postoperative inflammation have been reported as one of the independent prognostic factors in several types of malignancies.the aim of this study is to clarify the impact of laparoscopic approach on postoperative inflammatory status after surgery for colorectal cancer, and to analyze the association between postoperative inflammation and prognosis in patients with colorectal cancer. methods: a total of 636 patients with stage l-lll colorectal cancer (crc) who underwent curative surgery were retrospectively analyzed. the maximum crp value measured between the times of surgical resection and discharge was defined as 'max crp'. the optimal cut-off value of max crp that best predicts rfs was determined to be 10 mg/dl by the minimum p-value approach. methods: trainees working in this firm were responsible for data collection. patients who underwent emergency surgery during the calendar year of 2018 had the following details collected-the presence or absence of a complication in the 30-day post-operative period, the type of complication and description of complication along with the grade of the complication (see fig. 1.) . patients who underwent intermediate to major surgery were followed up at outpatients and were specifically asked for the occurrence of complications from the point of discharge up until the outpatient appointment. with one centralised national hospital-the people who were discharged and subsequently experienced considerable or major complications invariably represented back to hospital via the a&e department. results: a total of 148 emergency surgeries were performed by this surgical firm in 2018, 63% of these being done laparoscopically. of these 148 cases-29 patients experienced post-operative complications within the first 30 days after their procedure. this equated to a complication rate of 19.59%. the most common complications were abdominal pain, nausea & vomiting, and wound infection. there were 8 complications for each of these 3 categories. post-operative bleeding occurred in 5 cases with fistulas or leak of an anastomosis occurring in 3 cases. death of a patient occurred in 3 instances once as a result of post-operative bleeding from the site of anastomosis after a whipple's procedure, the 2nd occurred subsequent to post-operative bleeding from a peptic ulcer and in the 3rd case occurred in an instance of faecal peritonitis as a result of anastomotic failure after a roux-en-y bypass for a patient with pancreatic malignancy. conclusion: the davien-clindo classification proved to be simple, efficient and useful in analysing post-operative outcomes. the results indicate that despite the emergency setting & elderly cohort of patients-minimally invasive surgery proved to be a safe and viable option. conclusions: in this prospective study, we observed greater rates of detection of adenomas among endoscopists. screening colonoscopy on symptomatic and/or high risk group for crc is valuable in early detection and the prevention of crc. large sample size and long period of screening colonoscopy was needed. limitation of our study was the small sample size and no use of high detention endoscopy. results: the mean intraoperative blood loss volume was significantly less in the lap group than in the open group (735 vs. 4447 ml, respectively, p \ 0.01). the mean operative time was not significantly different between the lap group and the open group (738 vs 679 min, respectively, p = 0.276). the incidence of severe postoperative complication (grade 3 or higher in the clavien-dindo classification) was lower in the lap group (4/17 (24%) vs 16/35 (46%), respectively). the mean postoperative hospital stay was significantly shorter in the lap group than that in the open group (39 vs. 454 days, respectively, p = 0.022). conclusions: lap-tpe can be a safe and feasible procedure. background: amyloid light chain (al) amyloidosis is a rare protein deposition disorder with an incidence ranging between 3-8 cases per million people. it can present insidiously with localized or multisystem symptoms and usually occurs later in life. prognosis is poor as al typically presents at an advanced stage. intestinal pseudo-obstruction is a rarely reported complication of al amyloidosis. here we report a case of al amyloidosis which was identified during surgery for intestinal pseudo-obstruction. case presentation: a 56 year old male presented to the emergency department with a 4 month history of abdominal pain and distension, as well as marked swelling of his lower limbs. this had worsened in the previous 2 weeks and he had developed intermittent diarrhoea. ct showed ileitis with marked dilation of the proximal small bowel. laparatomy revealed small bowel that was grossly distended that rapidly developed multiple petechiae and subsequent haematomas upon handling. two days later a repeat laparotomy was performed and 3.45 m of ishaemic small bowel was resected. histology showed amyloid deposition with positive congo red staining. subsequent cardiac events led to an echo being performed that showed concentric left ventricular hypertrophy attributed to amyloid deposition within the myocardium. free serum light chain ratio was sent and confirmed the diagnosis of al amyloidosis. he has recently been started on a treatment regimen consisting of cyclophosphamide and dexamethasone. discussion: systemic al amyloidosis frequently involves the gastrointestinal tract, typically presenting with chronic diarrhoea and associated malabsorption. only 1 case presenting with pseudo-obstruction has been reported in the literature. al amyloidosis presents insidiously with non-specific symptoms depending on which organs are affected. treatment aims to prevent further deposition of protein within the organs. prognosis is determined by the organs that are affected and the extent of protein deposition within them. cardiac involvement holds the worst prognosis ultimately causing sudden cardiac death. the mainstays of management are early identification and treatment implementation to prevent protein build up and subsequent organ failure. conclusion: a diagnosis of amyloidosis should be considered in patients with intestinal pseudo-obstruction to expedite the diagnosis of al amyloidosis and improve survival. aim: in the management of locally advanced rectal cancer (larc), the achievement of a complete total mesorectal excision (tme) with clear resection margins was demonstrated to be the main predictor of overall and disease-free survival. predicting surgical difficulty in larc patients may be of particular importance to choose the best surgical approach. this study proposes a mri-based score to identify preoperatively larc patients with a high risk of having a difficult surgery. methods: this is a retrospective study based on the european mri and rectal cancer surgery (eumarcs) database, including patients with mid-low larc who were treated with neoadjuvant chemoradiation therapy and laparoscopic tme with primary anastomosis. data on pre-treatment and restaging through magnetic resonance imaging were available for all patients. surgical difficulty was defined as high or low grade taking in to account operative (e.g. duration of surgery), and postoperative factors (e.g. hospital stay). score accuracy was evaluated by estimating sensitivity, specificity and area under the receiver operating characteristics curve (aroc). results: seventeen (12.5%) of 136 larc patients were graded as high surgical difficulty. the eumarcs score was developed using the following significant predictors of surgical difficulty: bmi [ 30, interspinous distance \ 96.4 mm, ymrtstage = t3b, and male sex. the score ranged from 0 to 10. the cut-off score to best differentiate patients with a high probability of difficult surgery was = 3 points. this cut-off value showed the best balance in sensitivity and specificity. the eumarcs score demonstrated high accuracy (aroc: 0.0802) conclusions: the eumarcs score was found to be sensitive and specific in predicting surgical difficulty in larc patients who were candidate for laparoscopic tme. the score has the advantage of considering patient and cancer related characteristics that can be all assessed preoperatively and it can be useful in the decision making process. this score has not yet been externally validated. background: recently published two non-inferiority randomised control trials has raised questions on laparoscopic surgery for rectal cancer, showing lower quality pathological specimens to those achieved using an open technique. locally advanced rectal cancers add to the level of difficulty for laparoscopy approach. our study was aimed to assess feasibility of laparoscopic rectal surgery, comparing short term outcomes, quality of surgical specimen, morbidity and mortality, between propensity score match groups of locally advanced and early rectal cancers. methods: prospectively acquired data from consecutive patients undergoing laparoscopic surgery for rectal cancer at the minimally invasive colorectal unit in united kingdom between 2006 and 2014. locally advanced rectal tumours were identified as t3b or t4 with pre-operative mri scans. all the patients were operated by the same team and the procedures were performed laparoscopically. 1:1 propensity score matching was performed to create a perfect match in terms of tumour height. results: total of 369 laparoscopic rectal resections were performed during the study period, out of which 87 patients had locally advanced (la) disease and were propensity-score matched for tumour height with non-locally advanced (nla) patients. median operative time was higher for the la surgery group (270 min vs 250 min p = 0.024). however, conversion to open surgery (p = 0.621), readmission (p = 0.295), re-operation (p = 0.747), clinical anastomotic leak (p = 0.589) and 30-day mortality rates (p = 0.497) were all equivalent between the two groups. r0 resection was achieved in 89% of la group as compare to 94% of nla group (p = 0.177). conclusion: this study demonstrate that standardised approach to laparoscopy is safe and feasible in locally advanced rectal cancers. comparable post-operative short-term clinical and pathological outcomes were seen between la and nla groups. aims: the application of colorectal cancer screening programs, has showed a decrease in recurrence and mortality. for this reason, these programs are being implemented at a national level in the different spanish regions, as has happened in our community.to present the initial short-term results on the morbidity of the immediate postoperative period to 90 days of colon cancer, mortality and hospital stay after the implementation of a screening program in our center. methods: a retrospective study was performed. 73 patients aged between 60 and 69 years were included in the study, diagnosed with colon cancer. they underwent minimally invasive surgery, in most cases, with any type of colonic resection, from january 2010 to december 2017. all patients were diagnosed, conventionally or through a screening program, the latter according to the plan implemented in our community. the sample was divided into two groups of patients according to the way of being diagnosed (group si screening = 25 patients, group no screening = 48 patients) and they were compared according different variables: dependent factors of the patient, factor of type colon cancer, factors of colon cancer resection and follow-up. results: both groups were comparable in all study variables. regarding the variables included in the follow-up, no statistically significant differences were found in terms of postoperative mortality-clavien-dindo v. however we found differences statistically significant in postoperative morbidity (p = 0.006) and in its classification according to clavien dindo i-iv (p = 0.018). the complications analyzed independently, such as anastomotic dehiscence (p = 0.023) or postoperative ileus (p = 0.033), have also presented significant differences, unlike surgical wound infection (p = 0.115). conclusion: at our center, the application of the screening program has not influenced in the initial stage of colon cancer or its surgical approach. however, we have found a lower overall morbidity rate and minor complications, justified by a lower incidence of anastomotic dehiscence and postoperative ileus. background: colorectal carcinoma is one of the most common malignancies. surgery is the only definitive method to achieve cure for this illness and can be performed via an open or a laparoscopic approach. the pros and cons of each approach have been discussed extensively, with the oncologic efficiency of the laparoscopic approach being one of the leading topics. objective: the aim of this study was to establish oncological non-inferiority of the laparoscopic approach to colorectal cancer. primary outcome measure was defined as number of harvested lymph nodes. secondary outcome measures were medium-term disease free and overall survival as well as length of hospital stay, time to oral feeding and short-and long-term complication rate. methods: this was a single center retrospective chart review. all consecutive patients who underwent colon or rectal resection due to colorectal carcinoma at hadassah medical center between the years 2014-2017 were included. patients who were operated on for recurrent disease or who had metastatic disease at the time of surgery were excluded. patients were divided into three groups according to the surgical approach: laparoscopic, open or converted. medium-term oncological outcomes were the same for all groups. time to oral feeding, length of hospital stay, short-and long-term complication rate were all significantly improved in the laparoscopic group. conclusions: we were unable to prove non-inferiority of the laparoscopic approach regarding the number of harvested lymph nodes. however, all surgical approaches yielded a high number of harvested lymph nodes which is most probably oncologically sufficient, as reflected by the non-existent difference in medium-term oncological follow up. this study supports previous studies showing the superiority of the laparoscopic approach regarding short term recovery and overall complications rates. aims: two non-inferiority randomised control trials have questioned the utility of laparoscopic surgery for rectal cancer by failing to prove that pathological markers of high quality surgery are equivalent to those achieved by open technique. we intend to present short and long-term postoperative outcomes from the largest single surgeon series of consecutive patients undergoing laparoscopic tme for rectal cancer. we describe the standardised laparoscopic technique developed by the principal surgeon, and the short-term outcomes from three surgeons who were trained in and subsequently adopted the same approach. methods: prospectively acquired data from consecutive patients undergoing surgery for rectal cancer by the principal surgeon (ap) at the minimally invasive colorectal unit in portsmouth between 2006 and 2014 were analysed along with data acquired between 2010 and 2017 from surgeons (tq,nf,ah) at three further international centres. end-points were overall and diseasefree survival at 5 years, and early post-operative clinical and pathological outcomes. results: 263 consecutive patients underwent laparoscopic tme surgery by the principal surgeon (ap). at 5 years overall survival was 82.9% (dukes' a = 94.4%; b = 81.6%; c = 73.7%); disease-free survival was 84.0% (dukes' a = 93.3%; b = 86.8%; c = 72.6%). post-operative length of stay, lymph node harvest, mean operating time, rate of conversion, incomplete resection, major morbidity and 30 day mortality were not significantly different between the principal surgeon and those he had trained when subsequently in independent practices. conclusion: laparoscopic tme produces excellent long-term survival outcomes for patients with rectal cancer. a standardised approach has the potential to improve outcomes by setting bench-marks for surgical quality, and providing a step-by-step method for surgical training. results: analysis of association of tumor location (sigmoid, right or left colon), operation time, blood loss, extraction site, type of surgical sutures used for wound closure with postoperative complications or specimen quality either did not show significant correlation or could not be conducted due to data nature. unexpectedly, a significant difference was demonstrated between two surgical teams in terms of hernias. majority of cases-44 (64.7%) were performed by surgeon 1 (s1), surgeon 2 (s2) operated on 22 (35.3%) patients, nevertheless minilaparotomy closure was usually performed by junior members of the team. conversion rate was 4.5% for s1 and 18.2% for s2 (p = 0.089). operation time and blood loss were smaller in s1 group compared to s2 (153.6 ± 62.5 min vs 179.3 ± 55.2 min, p = 0.037 and 59.7 ± 45.7 ml vs 100.0 ± 74.0 ml, p = 0.027 respectively). specimen quality and early postoperative complications did not differ. postoperative hernia rate was 2.3% for s1 and 22.7% for s2 (p = 0,013). both surgeons used the same specimen extraction sites and materials for wound closure. hernias were more frequent after vertical minilaparotomy-25% (1 of 4 patients), and in converted patients 33,3% (2 of 6 patients), compared to 5, 5% (3 of 56) in transverse minilaparotomy group. there was no association of hernias and wound infections. conclusions: our study demonstrates, that besides consultant dependent surgical surrogates, steps which are often performed by other members of surgical team (such as wound closure) may contribute to complication rate as well. more thorough supervision of wound closure may be needed. aims: laparoscopic complete mesocolic excision (cme) right hemicolectomy is considered a demanding procedure and it is actually adopted in few centers from the west. the aim of the present study is to analyze the safety of laparoscopic cme right hemicolectomy and to compare its short-term results with standard right hemicolectomy in a single western center. methods: prospectively collected data from 56 patients who underwent laparoscopic cme right hemicolectomy between june 2014 and november 2017 were retrospectively analyzed (cme group) and compared with data from 49 patients submitted to standard laparoscopic right hemicolectomy between april 2013 and november 2017 (s group). results: no differences were observed between the cme and the standard right hemicolectomy groups in terms of clinical characteristics. in the cme group, 39.3% of patients were = 75 years old, 28.6% of patients were asa class 3, 46.4% of patients had = 2 comorbidities, 30.4% of patients had bmi [ 28 and 14.3% of patients had = 2 previous abdominal surgeries. no differences were observed in terms of duration of surgery (215 ± 59 min vs. 208 ± 58 min; p = 0.573) and intraoperative complications (5.4% vs. 4.1%; p = 0.759) between cme and s groups; mean blood loss was lower in the cme group (50.5 ± 45.9 ml vs 75.7 ± 62.6 ml, p = 0.029). the percentage of overall (42.9% vs. 46.9%; p = 0.412) and severe (clavien-dindo = 3) complications (8.9% vs. 8.2%; p = 0.875), redo surgery (3.6% vs. 8.2%; p = 0.414) and readmission (3.6% vs. 6.1%; p = 0.662) was comparable between cme group and s group. a significant difference was observed in the length of specimen (329 ± 79 mm vs. 270 ± 98 mm; p \ 0.001) as well as in the length of proximal (159 ± 96 mm vs.121 ± 70 mm; p = 0.028) and distal margins (134 ± 64 mm vs.110 ± 61 mm; p = 0.05) in favor of the cme group. the number of lymph nodes harvested was slightly higher in the cme group (21.9 ± 9.6 vs. 25.7 ± 10.2; p = 0.055) as it was for the percentage of cases with less than 12 retrieved lymph nodes (8.2% vs. 1.8%; p = 0.143), although these differences did not reach statistical significance. conclusions: this study represents one of the few western experiences demonstrating the safety of laparoscopic cme right hemicolectomy. cme technique showed good short-term results and better quality specimens when compared with the standard procedure. aim and background: peritoneal dissemination of colorectal cancer (pc) makes the complete resection of cancer lesions impossible. in such cases, multidisciplinary therapy is essential with mainly chemotherapy. preoperative diagnosis of pc is usually uncertain by ct or mri image. for diagnosis of pc needs surgical materials with laparotomy. but the laparotomy and resection of pc with general anesthesia tends to make impossible for immediate chemotherapy. less invasive diagnosis of pc is necessary and expected.endocytoscopy (ec) makes the histological diagnosis with precise images gained by high magnification (x 520). as a preliminary examination, ec diagnosis for resected specimens of pc were evaluated. methods: two cases of pc diagnosed in operation were evaluated. under general anesthesia, laparotomy was conducted. peritoneal dissemination lesions obviously diagnosed as pc were resected. immediately the lesions were stained by methylene blue solution for 120 to180 s. ec observation was done according ec classification1) and ecv classification2). results: in two cases, ec observation was successfully done. images of dilated surface microvessels of a nonhomogeneous caliber or arrangement were observed in nbi ec corresponding to ec-v3. histopathological diagnosis of resected specimens was metastatic colorectal carcinoma in peritoneum in both cases. conclusions: histological diagnosis for pc is gained by ec with resected specimen. as the result of this investigation, ec examination via camera port in laparoscopic operation might be possible for diagnosis for pc of colorectal cancer in vivo. aims: the aim of this presentation is to demonstrate and analyze surgical complications, arising during laparoscopic colorectal resections for cancer and to analyze the reasons of adverse events. methods: we demonstrate videos from our surgeries, where different types of complications occurred and share our classification of types of mistakes, that may lead to intraoperative complications and ways to prevent them. results: we divide mistakes in laparoscopic colorectal resections into two large groups-'false strategy' and 'dangerous techniques'. the first includes poor diagnosis, too extensive or insufficient extent of surgery and improper enthusiasm in using platforms. prevention of first type mistakes is in thorough training and peer-review of each consultant practice. second type of mistakes includes two subtypes : 'faulty habits'-use of unsafe techniques (blind port insertion, poor vascular exposure prior to clipping, not obtaining 'critical views', unsafe use of energy and stapling devices etc.) and 'failure in a certain case'-when despite correct general approach a complication occurred (misinterpretation of fascial layers or vessels). prevention of 'faulty habits' lies in supervised training in high volume colorectal departments including dedicated surgical devices training. to avoid 'failure in a certain case' standardization of surgical procedure is essential, as the most efficient way to prevent this type of mistake is 'pattern recognition'ability of a surgeon to compare the picture he sees during a procedure with a 'standard' view, he used to have during previously performed standard surgeries-this is apparentely impossible when every procedure is done differently. regular reviews of own surgeries recording and other surgeons' procedures may also fascilitate pattern formation. in case a complication occurres we use the four step course of action: preservation of the view, temporary control, decision on conversion, permanent control. conclusion: as popularity of laparoscopic colorectal resections is growing rapidly the number of intraoperative compliactions is increasing as well. we demonstrate videos of complications and our approach to classification of possible mistakes. systematic aproach to reasons, underlying certain mistakes helps to produce a strategy to reduce intraoperative complication rate. introduction: the drains placement inside the abdominal cavity has traditionally been carried out to evacuate hematic remains or postoperative collections. there is no scientific evidence of the prophylactic use of drainage in elective colorectal cancer (ccr) surgery to avoid anastomotic complications or other complications. however, it is traditionally used. when the anastomotic leak is produced, it is generally agreed that drainage system should be used for therapeutic purposes. aims: the aim of this study is to evaluate the effectiveness of the use of prophylactic drainage in elective surgery of ccr. we would check if they avoided the appearance of complications, and if they are useful when the anastomotic leak appears. methods and results: we analyzed the data collected in our hospital from 1/11/17 to 12/12/18. we studied the number and type of interventions in which prophylactic drainages were placed, the appearance of anastomotic complications and if these drains were effective. 93 interventions were performed during this period of time. 72% of these procedures had used prophylactic drainage (67 interventions). this percentage was up to 100% in patients who have performed a left colon surgery as a sigmoidectomy or rectal procedure. during this period, there were 10 cases of anastomotic leakage. in all of them had been placed drainage but only 3 of them were effective. conclusions: we have seen that prophylactic drainage is a common practice independently of the location of the anastomosis. the last multimodal rehabilitation guidelines recommended the nonuse of drains systematically above the peritoneal reflection with a high level of scientific evidence. they cause discomfort to the patient and delay early mobilization. however, it may be useful to use drains in the first 24 h of a pelvic floor procedure. there is not enough evidence to show sistematic drainage after colorectal anastomosis prevents complications of the anastomosis or other complications. aims: colonic cancers of the splenic flexure is uncommon and associated with poor prognosis. several studies were published aimed to identify the optimal surgical option for the best oncological outcomes. however, whether an extended colectomy or a segmental resection is required is still controversial. the aim of this study is to analyse the outcome of the two different approaches through the experience of a single centre. materials and methods: retrospective data of consecutive patients with diagnosis of colonic cancer situated at the splenic flexure of our department between 2004 and 2017 were analysed. based on type of surgical procedure, patients were enrolled in arm a (segmental resection) and arm b (extended resection). arm a patients were treated with segmental resections with a wide mobilisation of the transverse and descending colon and ligation of the left colic artery, sparing the middle colic artery and the inferior mesenteric artery. functional lateral to lateral anastomosis was performed extracorporeally. arm b patients were treated with more extended colectomies, both associated with central vascular ligation. results: out of 200 patients included, 141 were allocated in arm a and 59 in arm b. patients' population of the 2 arms was homogeneous as concerns demographic characteristics and stage of the disease. operative time was comparable (108,9 min vs 119 min, p = 0,332). the length of the specimen was significantly shorter in arms a (15, 7 vs 32, 1, p = 0, 0351) . the number of harvested lymphnodes did not differ between the two groups (12,5 vs 17 p = 0,167)postoperative short term complications was comparable in both arms (17 vs 1, p = 0,692). no postoperative mortality was observed. overall 5-year survival and disease free survival rates were similar in arm a and b (81.3% vs 83.05%, p = 0,321 and 78,6% vs 80,5%, p = 0,534). hospital stay was similar in the two groups (p = 0,99). conclusions: despite a shorter length of surgical specimen after limited resections, postoperative complications, lymph node harvest, and survival were comparable in both.in our opinion the extracorporeal anastomosis is functional to both the achievement of a cleaner operative field and a better control of the resection margins. incidence of neuroendocrine tumours in the rectal area has increased in recent years.before the onset of minimally invasive colorectal surgery, these lesion had to be treated by a more radical technique when not suitable for endoscopic resection.selection of the cases is mandatory in order to achieve good results not only surgical, but also oncological. we present our series of 3 neuroendocrine tumoirs treated by tamis approach, including technical aspects, deffect closure techniques and data regarding pathological findings.all cases were low grade carcinoid tumours. resection with free margin was obtained in all cases. defect closure was performed in all cases. the tumours were settled 9,10 and 15 cm form the anal verge. postoperative course was uneventful, ann no adyuvant therapy was needed.tamis apporach for rectal neuroendocrine tumours is a safe and feasible technique. proper selection of the cases is mandatory in order to achieve good results. surg endosc (2019) aim: to assess the safety and efficacy of single layer of barbed vs double layer 'hybrid' (interrupted and running) suture for the closure of anastomotic stapler access enterotomy after laparoscopic right colectomy with intracorporeal anastomosis. methods: from april 2014 to november 2018, 252 laparoscopic right colectomy with intracorporeal anastomosis were performed in our surgical department. all patients in both groups were perioperatively managed using an eras pathway. seventy-two patients had the enterotomy closed with a single layer running suture of filbloc tm (assut europe). these patients were matched with 72 patients who underwent intracorporeal right colectomy with enterotomy closed with a 'hybrid' double layer technique (first layer interrupted stitches in maxon tm 3-0 (covidien), second layer using a running suture in pds tm 3-0 (ethicon). intraoperative variables, anastomotic leak rate, morbidity and mortality rates were analyzed. results: the two groups were homogeneous with respect to demographics, body mass index (bmi), american surgical association score (asa) as well as for tumor stage. in the barbed group, median operating time was 121.5 min vs 140.7 min in the hybrid group (p = 0.02). anastomotic leak occurred in 5 (6.7%) patients in the hybrid vs 2 (2.7%) patients in the barbed group (p = 0.24). all patients required a reoperation. intraoperative findings show in 2 (0.4%) cases in the hybrid group a leak at the enterotomy closure, while an intact staler access was observed in both patients in the barbed group. no difference was observed with respect to noninfectious complications between the two groups (p = 0.55). patients in the hybrid group experienced a longer hospital stay when compared to the barbed group (p = 0.03). a re-admission occurred in the hybrid due an intraabdominal collection, while no re-admission was observed in the barbed group. no patient died in the postoperative period. aims: lymph node status is one of the key prognostic factors in patients with colorectal cancer, and remains the most important selection criteria for adjuvant chemotherapy. it is believed that at least 30% of node negative patients will suffer disease recurrence within the first 5 years after surgery. this may be due to understaging lymph node status. sentinel lymph node mapping is widely used for staging of breast cancer and melanoma, with injection of colloid tc99 and isosulfan blue (ib). however, indocyanine green (icg) fluorescence guidance is a new technical approach to this issue, with promising results as it is not influenced by body mass index or lymphatic invasion. intraoperative fluorescence icg navigation also aims for detection of aberrant lymphatic drainage outside the planned resection. the icg lymphography has the advantage of offering a good visualization of the lymphatic channels but there are problems to identify the lymphatic nodes. our objective with this study is to rate the use of the intraoperative lymphogram in cases of elective colorectal surgery to evaluate if there were changes in the surgical attitude regarding the performance of lymphadenectomy. methods: indocyanine green was injected into the submucosal layer around the tumor at 2 points with?a 23-gauge localized injection before lymph node dissection and the lymph flow was observed at 1, 3 and 5 min after injection, using a near-infrared camera system. in addition, a complete mesocolic excision with central vascular ligation guided the region where the lymph flow was observed to be fluorescent. the following table summarizes the 10 procedures carried out as well as the lymphadenectomy performed before and after the use of icg. in brief, after the application of intraoperative icg it was observed that in 20% of patients additional lymph nodes were obtained after the expansion of the surgical plan, moreover 10% affected lymph nodes were spotted after the expansion of the surgical plan. conclusions: intraoperative real-time visualization of the lymph flow using indocyanine green fluorescence imaging during laparoscopic colon cancer surgery is feasible and a helpful technique for lymph node mapping which may lead to intraoperative changes in lymphadenectomy. tamis resection of rectal tumours has proven to be a sefe and feasible technique, specially for lesion located in the mid and low rectum.when the tumour is located in the upper rectum, and specially near the colorectal junction, tamis resection may be more difficult, not only due to technical aspects, but also due to the risk of a free perforation, specially when a full thickness resection is performed.we present our results of 6 tamis resections of lesions located around the colorectal junction. four resections where performed with the aim of an endostpaler in order to achieve full resection without the risk of a free colonic perforation.in 3 cases, an abdominal combined laparoscopic exploration was made, in order to help and assure proper resection of the lesion as well as avoiding intraoperative complications.distance from the anal verge ranged from 12 to 20 cm.postoperative course was uneventful in all cases, and a complete specimen resection was obtained in all cases.tamis resection of tumours located in the rectosigmoid junction may be a safe and feasible technique in selected patients. methods: between january 2015 to april 2018, 83 patients with diagnosis of right colon adenocarcinomas underwent right hemicolectomies. the data was analysed for patients demographic, histology, type of surgical approach, intraoperative details (length of surgical procedure, blood loss, blood transfusion, conversion rate) and short-term post-operative outcomes including complications. introduction: postoperative ischemic colitis is a life-threatening vascular gastrointestinal condition, that mainly occurs after cardiovascular surgery. we present a surprising case following a laparoscopic rectum resection. case report: a 77-year-old diabetic patient with upper rectal adenocarcinoma undergoing laparoscopic anterior rectal resection (partial mesorectum excision) and mechanical anastomosis following chemotherapy / radiotherapy. after 48 h postsurgery he presented abdominal pain, distension and fever. on adominal computed tomography (ct) scan (contrast enema) no anastomotic leakage (al) finfings were revealed. neither digital palpation nor proctosigmoidoscopy (3th day) showed al signs. the patient clinical situation improve with conservative treatment (antibiotics, digestive rest …), c-reactive protein levels decreased and the blood cultures were negative. on the 11th day he was discharged presenting semiliquid stools. eight days later he needed hospital readmission: air and feculent/purulent discharge from the previos abdominal drainage orifice. ct scan: no evidence of dehiscense found although rectum and sigmoid colon distention and an image of a 'large fecaloma' were observable. on the 4 th day of hospitalization he expulsed a large malodorous segment of tissue with necrotic asppearance (image) through the anus with surprising histologic features: 'complete-thickness necrotic colonic wall'. further rectosigmoidoscopy: complete anastomosis, signs of ischemic colitis proximate to the anastomosis and a fistulous orifice. surprisingly, the patient progressed favorably, being discharged the 12th day for ambulatory control with a low debit enterocutaneous fistula. histopathological diagnosis: ypt3 n0 m0. follow up: the fistula discharge quantity increased maintaining diarrheal stools through anus along with persistent anemia and malnutrition. a exploratory laparotomy was schedule. fistulous tract towards a small stenotic segment of colon inmediately proximal to the colorectal anastomosis was identify and resected. finally a terminal colostomy was performed. subsequent postoperative without incidents. currently the patient is asymptomatic. comments: it seems indisputable that a colon segment, proximal to the anastomosis, was necrosed and expelled through a colorectal anastomosis. the mechanism seems inexplicable to us. it is even more disconcerting that there was no disruption of the anastomosis. objectives: fluorescence-guided surgery has emerged as a new imaging modality to improve the detection of liver and lymph node metastasis in colorectal cancer. in right-sided colon cancer, the standard lymphadenectomy should reach the ileocolic vessels and the right branch of the middle colic vessels. the purpose of this study is to perform an objective estimation of lymphatic drainage and metastatic lymphonodes in right-sided colon carcinoma through indocyanine green (icg) lymphography. methods: patients with right-sided colon adenocarcinoma were included, excluding those in stage iv, t4 and those who underwent urgent surgery. 2 cc of icg peritumoral were injected using a peripheral intravenous catheter at the beginning of the intervention. the lymphatic drainage mapping of the tumor was identified. lymphadenectomy of the ileocolic vessels and right branch of the middle colic vessels was performed extending it to the left branch and origin of middle colic vessels if it was shown in the mapping. results: 16 patients were included. the average age was 58. in 10 patients the tumor was located in the ascending colon and in 6 patients in the hepatic angle. in 11 patients, the mapping showed lymphatic drainage to ileocolic vessels and right branch of the middle colic vessels. in 5 patients (31%) it showed drainage to the left branch and origin of the middle colic artery, therefore extended lymphadenectomy was performed at that level. in 14 patients, the postoperative period was uneventful. 1 patient presented infection of the surgical wound and another patient developed a 6 cm perianastomotic collection treated with percutaneous drainage. the anatomopathological report showed nodal metastasis in 4 of the 5 patients (80%) in whom lymphatic drainage was observed in the territory of the middle colic vessels with icg. these patients presented the tumor in the hepatic angle. therefore, 4 of the 16 patients with right-sided colon carcinoma (25%) presented nodal metastasis in the territory of the middle colic vessels. conclusions: fluorescent lymphography may improve the results of lymphadenectomy in colon cancer. in patients with tumors of the hepatic angle, lymphadenectomy extended to the left branch and origin of middle colic vessels, could be an adequate alternative. introduction: over the last decade, the common principles of surgical treatment in colon surgery are central vascular ligation (cvl) and complete mesocolic excision (cme). however, the superior mesenteric vessels anatomy, while performing the right colectomy is characterized by wide variability, which can lead to complications, especially during minimally invasive surgical intervention. objective. the purpose of this study is describing vascular variations around the superior mesenteric artery and vein-middle colic, right colic and ileocolic vessels, henle trunk in the laparoscopic right colectomy. materials and methods: the study was held in the 'dobrobut' clinic and o. o. bohomolets national medical university, department of general surgery (kyiv, ukraine) during the 2016-2018 period. 24 patients were included to the study, 13 females (45.8%), 11 males (54.2%) in the average age of 71,4 ± 9,8 years. all the patients underwent the laparoscopic right colectomy (cme ? cvl) with d3 lymph node dissection. recorded video materials from each laparoscopic right colectomy were analyzed during the study. results: ileocolic vessels were the most stable. there were typical anatomical position in all cases. 58.3% of cases, ileocolic vein was identified anteriorly to the ileocolic artery, while 41.7% being posteriorly. right colic vein was absent in 29.1% of cases. right colic vein drainage was to henle trunk and inferior mesenteric vein in 62.5% and 37.5% respectively. the right colic artery was present in 75% of patients, it's origin was superior mesenteric artery in 94.4% and 5.6% the middle colic artery. the middle colic vein was present and drained to superior mesenteric vein in 100% of cases. same as the middle colic artery with the superior mesenteric artery origin. henle trunk was present in 91.7%, gastro-pancreato-colic trunk in 45.5% of cases gastro-pancreatic trunk in 40.9%, gastro-colic in 13.6%. conclusions: knowing the options of surgical vessels anatomy, while performing the right colectomy, altogether with surgeons preparation, using the ct-scan data can reduce the risk of iatrogenic damage and complications risks. introduction: the enhanced recovery after surgery (eras) protocol was designed to accelerate convalescence, reduce morbidity and shorten the length of hospital stay (los). one of its major interventions is balanced perioperative fluid therapy. the impact of this single intervention on short-term outcomes is widely discuss. aim: the aim of this study was to assess the impact of perioperative fluid therapy on short-term outcomes. material and methods: the analysis included consecutive prospectively registered patients operated laparoscopically for colorectal cancer between november 2012 and january 2018. patients were divided into two groups: balanced (= 2500 ml) or unbalanced ([ 2500 ml) perioperative fluid therapy. all patients were treated according to eras protocol. study outcomes were: recovery parameters, morbidity rate, los, 30-day readmission rate. results: group 1 consisted of 361 and group 2 of 80 patients. there were no statistically significant differences between the groups in terms of demographic and operative parameters. morbidity was lower in group 1 (27.4% vs 38.8%, p = 0.044). patients in group 1 were discharged home earlier than in group 2 (4 vs 5 days, p \ 0.001). moreover, we observed differences in recovery parameters between the groups: tolerance of an oral diet on the 1st postoperative day (76% vs. 59%, p = 0.002) and patient mobilization on the day of surgery (90% vs. 78%, p = 0.005). 30-day readmission rate was lower in group 1 (7.8% vs. 15%, p = 0.041). conclusion: a balanced perioperative fluid therapy on the day of surgery may be associated with faster convalescence, lower morbidity rate, shorter los and lower 30-day readmission rate. methods: a retrospective analysis was performed including patients who underwent lcs or ocs for cancer treated as emergency in a single centre between 2014 and 2018. patients who underwent palliative surgery were excluded. lcs were 1:1 propensity score-matched based on pposum and stage of disease with ocs. short-term outcomes included oncological quality, length of hospital stay (los) and postoperative mortality. for long-term outcomes, 3-year overall and disease free survival (os and dfs) rates were analyzed. results: during the study period, a total of 406 emergency colorectal resections were performed. of them, 25% (n = 101) were coloniccancers. 38 lcs were matched to an equal number of ocs.median age was 71 (21) years and 62% were females. median follow-up was 18 (22) months. the majority of resections were right hemicolectomies (47%), followed by sigmoid resections (36%) and subtotal colectomies (17%). operative time (188 (90) background: total mesorectal excision (tme) offers the best reported rates for local recurrence and survival in patients with rectal cancer. our series from a single high-volume center, assessed the feasibility, safety and long-term oncologic adequacy of laparoscopic total mesorectal excision methods: we reviewed the prospective database of 266 consecutive unselected patients undergoing laparoscopic tme for rectal cancer between 1995 and 2009 at the department of general surgery, onze-lieve-vrouwziekenhuis hospital (olv), campus aalst, belgium. the objective of the present study was to evaluate the effectiveness of laparoscopic tme, with an emphasis on perioperative variables and long-term oncological outcomes. results: 266 pts with mid and distal rectal cancer up to 10 cm from the anal verge had laparoscopic tme resection. 161 patients (60.5%) underwent a sphincter-preserving surgery and the remaining 105 patients (39.5%) had an abdominoperineal resection. end-to-end anastomoses: 68 pts (42%), j-colonic pouch: 92 pts (58% introduction: the rica clinical pathway (intensified recovery in abdominal surgery), also called surgical multimodal rehabilitation, is the application of a series of perioperative measures and strategies in those patients who are going to undergo a surgical procedure with the objective of reducing secondary stress to the surgical intervention. in this way, we achieve a better recovery of the patient and significantly reduce complications and morbidity. objective: s to analyze, through our database of patients undergoing crc, the percentage of postoperative ileuses and the following quality indicators: the postsurgical hospital stay, the anastomotic leak, and the infection of the surgical site. to check if the implantation of the rica pathway has meant an improvement in our postoperative hospital stay and with that, a lower sanitary cost. methods and results: we analyzed the data collected from those patients who underwent ccr in our hospital between 01/11/2017 and 12/12/18, during which time we implemented the rica clinical pathway. the average hospital stay was 8 days. of the 78 patients, 8.97% presented anastomotic leak, 12.82% infection of the surgical wound and 19.23% paralytic ileus. we have verified how the average hospital stay increases with the appearance of anastomotic leak (18.86 days), infection of the surgical wound (16.10 days) and paralytic ileus (16.80 days). when we divided this 12-month period into two halves to see the impact of the implantation of the clinical pathway, we obtained the following results: the post-surgical hospital stay in the period from 01/11/2017 to 05/01/2018 was 8.33. the stay from 05/01/2018 to 12/12/2018 was 5.33. the implantation of the rica clinical pathway is providing us with important advantages in our clinical practice, with greater postoperative comfort and an improvement in our quality indicators, such as the decrease in the average hospital stay of our patients. on the other hand, after starting its implementation we have encountered the resistance to change clinical habits and the one that requires a multidisciplinary participation, so adherence to this is being progressive, and requires periodic audits to reinforce and consolidate our achievements, and identify our points of improvement. however, tem has not yet achieved widespread use. recently, transanal minimally invasive surgery (tamis) using single-port surgery devices has been reported. initially facilitated by existing single-port surgery devices, two platforms for transanal access, the gelpoint ò path (applied medical, rancho santa margarita, ca, usa) and the sils tm port. the gelpoint ò path is the only platform to be specifically designed for tamis y tatme. objetive: in the present study, usesa gelpoint ò path was performed in 35 patients with lower rectal neplasms. results: complete full-thickness excision was performed in all cases of tamis and free margins over rectal cancer. on two cases no neoplasm was visualizad. the patient characteristics, operative techniques and operative outcomes were evaluated. the mean age of the patients was 63.0 years (range 48-76). the mean operating time were 186 min (range 55-110). 23 patients was selsted for tatme, 10 for tamis and two patients for evaluation and biopsy if was necesary. additional transabdominal rectal resection was not performed, and adjuvant chemoradiotherapy was performed in all cases. tamis using a gelpoint ò path was revealed to be easy and safe to perform. although only a small number of cases were treated, and the operation was demonstrated to be sufficiently feasible. conclusion: gelpoint path is a good tool for colorectal surgery in tatme, tamis and evalluation of anastomoses or de novo lesions introduction: several improvements in rectal cancer treatment, in the last decades, resulted in a markedly increased survival. nevertheless, surgery remains the prevalent treatment and 60 to 90% of operated patients experience some kind of functional abnormalities. as nowadays we acknowledge the importance to focus not only on survival rates but also on quality of life, we craved for a precise, reproducible, simple, clear and user-friendly tool for evaluating bowel function in rectal cancer patients after sphincter saving operation. therefore, we performed a thorough translation with cultural adaptation of the patient reported outcome tool, low anterior resection syndrome (lars) score, to the portuguese language (lars-pt) and population. methods: according to the current international recommendations, we designed this study encompassing three main phases: (i) cultural and linguistic validation to european portuguese; (ii) feasibility and reliability tests of the version obtained in the previous phase; and (iii) validity tests to produce a final version. the questionnaire was completed by 154 patients from six portuguese colorectal cancer units, and 58 completed it twice. results: the portuguese version of lars score showed high construct validity. regarding the test-retest, the global intraclass correlation showed very strong test-retest reliability. looking at all five items, only items 3 and 5 presented a moderate correlation. lars score was able to discriminate symptoms showing worse quality of life in patients submitted to preoperative radio and chemotherapy. conclusion: lars questionnaire has been properly translated into european portuguese, demonstrating high construct validity and reliability. this is a precise, reproducible, simple, clear and user-friendly tool for evaluating bowel function in rectal cancer patients after sphincter saving operation. therefore, his sistematic use should be implemented. oesophagectomy is the mainstay of curative treatment for oesophageal cancer and post-oesophagectomy diaphragmatic hernia (podh) represents a potentially life-threatening surgical complication characterized by an underestimated occurrence rate and unknown related risk factors. this study analyses the experience of two tertiary designated centers in order to evaluate key elements concerning development and treatment of podh. a cohort of consecutive patients affected by a clinically resectable oesophageal cancer (any t, any n and m0) underwent ivor-lewis oesophagectomy between march 1997 and april 2017 according to three different approaches: totally open incision procedure (oilo), hybrid (hilo) and totally mininvasive to esophagectomy (milo). all population was retrospectively observed in the context of a postoperative calendarised follow-up in order to record the incidence and postrepair results of podh. 414 patients underwent ivor-lewis oesophagectomy for cancer and 22 (5.3%) developed podh within a median follow-up period of 16 months (6-177). surgical repair was generally applied by the mean of laparoscopic cruroplasty (77%) with a conversion rate of 24%. postoperative morbidity did not include early recurrences but exclusively cardio-pulmonary complications (5 patients) with one case of respiratory failure leading to death. the discharge was reached after a median hospital stay of 6 days (2-95) while 3 recurrences (14%) occurred over a median followup period of 10.1 months. a wide univariate analysis identified statistically significant associations between podh occurrence and the administration of preoperative chemoradiotherapy, the complete pathological response (cpr) and a lymph node harvest (lnh) larger than 33 stations (p-value of 0.016, 0.001 and 0.024 respectively). the strong influence of an extended lnh was confirmed by the multivariable analyses (0.026) along with cpr which should however be considered as longer survival-related bias. the minimally invasive surgery and the neoadjuvant chemoradiotherapy represent a considerable part of multimodal treatment for oesophageal cancer presenting a not statistically significant association with podh development while a lnh including more than 33 nodes resulted to be an independent risk factor mirroring the extent of surgical demolition in oesophagectomy. l. barbulescu aim: to asses the safety and effectiveness of robotic total meso-rectal excision vs laparoscopic total meso-rectal excision and to analyse the primary outcomes. methods: the operative, post-operative and oncological outcomes were evaluated to assess the effectiveness of both techniques of tme. in our center were performed 30 robotic rectal resections and 48 laparoscopic resections from january 2018 to present. results: the rtme was associated with longer operation time, early bowel movements, lower risk of conversion and shorter hospitalization. the statistical equivalence was seen between rtme and ltme for non-oncological variables like blood loss, morbidity and reintervention risk. the oncological variables such as number of harvested nodes and positive circumferential resection margin risk were also comparable in both groups. the length of distal resection margins was similar in both groups. conclusion: rtme in patients with rectal cancer was associated with a lower rate of conversion and less incidence of urinary retention. the operative time in rtme was significantly longer than in ltme. the initial oncological and function outcomes of rtme seem to be equivalent with ltme. c. athanasiou aims: two randomized controlled trials failed to show non-inferiority of the laparoscopic total mesorectal excision (ltme) compared to open. ltme becomes particularly challenging in low rectal cancers and in narrow pelves. many surgeons report that robotic tme (rtme) may be beneficial in that setting. our aim was to systematically review the literature and compare the pathologic outcomes of open, laparoscopic and robotic tme for rectal cancer methods: medline, embase, scopus, cochrane library and web of knowledge databases were searched for randomized controlled trials (rct) reporting patholologic outcomes of open, laparoscopic or robotic tme with no language restriction. our primary outcome was quality of tme on macroscopic assessment of the specimen. secondary outcomes included positive circumferential resection margin, distance to radial margin, number of lymph nodes and positive radial margin. the included studies were quality assessed and the jadad score was reported. the grade approach was used to rate the certainty of each network estimate. results: fourteen rcts were included in our study. seven rcts compared the otme to the ltme, six compared the ltme and rtme and one study the otme to the rtme. no statistical significant difference was found in quality of tme when the the ltme was compared to the otme or = 1.36 (0.99, 1,85) or the rtme or = 1.33 (0.82, 2.16) . no difference was found in pcrm for the laparoscopic or = 1.23(0.90, 1.69) or the robotic approach or = 0.87 (0.44, 1.75) when compared to open. distance to radial margin and number or lymph nodes didn't differ between the groups. conclusions: no significant advantage on pathologic specimen quality has been found with the robotic approach. the ltme doesn't seem to compromise the quality of the specimen. h. samura 1 , j. arakaki 2 , k. sugata 2 , y. hori 2 , y. nagamine 2 , f. kohagura 2 , h. motonari 2 , s. kameyama 2 , t. ishimine 2 1 division of digestive and general surgery, urasoe general hospital, okinawa, japan; 2 department of surgery, urasoe general hospital, okinawa, japan colorectal cancer often invade adjacent organs and it is known that prognosis improves with resection of the involved organ. we report our experience of invaded adjacent organ resection, which include seminal vesicle, uterine and bilateral appendages, posterior wall of the vagina and bladder wall. method: although the range of resection is predicted by image study preoperatively, at the time of operation, it was decided by palpation with a forceps. each operation is evaluated by operation time, blood loss, blood transfusion volume, postoperative complication, postoperative hospital stay, and short term prognosis. result: resection cases of seminal vesicle, posterior vaginal wall, uterine and bilateral appendages and bladder wall were 5, 4, 4 and 1, respectively. the results are shown in the order of seminal vesicle / vaginal posterior wall / uterine / bladder. median age was 70, 67, 54 and 74 years old. the median operation time was 541, 630, 623, 249 min, the median blood loss was 580, 340, 310, 10 ml, and only one case of uterine and bilateral appendages resection required the blood transfusion. the average postoperative hospital stay was 40, 38, 45, 15 days. nine cases have postoperative complication, that include delayed wound healing, anastomotic leakage and rectovesical fistula, postoperative ileus, chyle ascites and neurogenic blodder. all of those were improved with conservative treatment. the mean hospital stay in complication cases was 48 days (38-88) and 19 (14-29) days without complications. the median observation period was 773 days (166-2166), and there was no local recurrence. all of the case of stage iv were dead. there was no local recurrence and all patient without stage iv are alive, it seems that the resection range was sufficient. conclusion: even with adjacent organ invasion colorectal cancer, it was possible to determine the resection line by palpation with laparoscopic forceps manipulation, and possible to resect margin free of cancer. laparoscopic low rectal resection with/without diverting ileostomy p. ihnát, m. tesar, p. ostruszka, p. gunková, p. vávra background: the construction of diverting ileostomy (di) is recommended to avoid septic complications of anastomotic leakage. the aim of our study was to assess the benefits and risks of di constructed during laparoscopic low anterior resection (lar). methods: retrospective clinical cohort study was conducted in university hospital ostrava, czech republic. all patients undergoing laparoscopic lar with tme because of rectal cancer within a 6-year study period were assessed for study eligibility. results: a total of 151 patients (73 patients without di, 78 patients with di) after laparoscopic lar were enrolled into the study and underwent analysis. both study subgroups were comparable in terms of demographic and clinical features. postoperative 30-day morbidity was significantly lower in patients without di (23.3% vs. 42.3%, p = 0.013). anastomotic leakage frequency was higher in patients without di (9.6% vs. 2.5%, p = 0.090); surgical intervention was necessary in 6.8% of patients without di. stoma-related complications were noted in 53.8% of patients with di; some patients had more than one complication. surgical intervention because of stoma-related complications was needed in 9 patients (11.5%). distinctive complications of di laparoscopic construction (small bowel obstruction due to di semi-rotation around its longitudinal axis) was noted in 3 patients (3.8%). mean stoma period (interval between lar and di reversal) was more than 10 months in our study; only 19.2% of patients were reversed without delay (= 4 months). postoperative morbidity after di reversal was 16.6%; re-laparotomy was needed in 2.5% of patients. conclusions: despite benefits of di in protecting low rectal anastomosis, ileostomy construction remains fraught with many stoma-related complications and long stoma periods associated with significantly decreased quality of life. aims: single port laparoscopic is a minimally invasive surgical technique that joint the cosmetic advantages with the well recognized benefits of the standard laparoscopic approach [1] . we describe a laparoscopic single port hartmann reversal in a patient by the use of the umbilical colostomy site for surgical access [2] . methods: a 42 years old patient was submitted to a laparoscopic single port hartmann procedure with an trans-umbilical colostomy for a recurrent sigmoid volvulus that was treated at the beginning by endoscopic de-rotation. after three months the patient was reevaluated for a hartmann reversal with a laparoscopic single port technique. after routine skin preparation and laparoscopic setup, the colostomy is mobilized from its mucocutaneous border, and the anvil of a circular stapler is secured to the distal lumen. by the use of a gelpoint system with 3 trocars, the intra-abdominal adhesiolisis in performed. the splenic flexure is mobilized to achieve a sufficient mobilization of the left colon that allows the fashion of a tension free anastomosis. the rectal stump is mobilized to the mid rectum, starting from the posterior mesorectal fascia around to the anterior rectal wall. a tension-free colorectal anastomosis is secured with a standard circular 31 mm stapling device inserted transanally. the colostomy wound is closed. the operative time was 60 min. results: the postoperative course was uneventful, the patient was discharged at forth postoperative day, oral intake started on postoperative day three. conclusions: single port laparoscopic hartmann reversal thought the umbilical stoma site is a minimally invasive surgical option that is safe in selected patients and offer the best cosmetic results. [ the progressive evolution of surgical techniques and oncologic protocols on rectal cancer disease facilitates surgeons to challenge the skills for anus preservation in low rectal cancer surgery. the laparoscopic surgery is already one of the best ways to reach the pelvic floor and to try procedures, which were previously difficult to apply through open surgery. the anastomotic leakage has particularly high occurrence if the anastomosis is performed in the anal or distal rectum area. it is evident that although the fecal diversion does not decrease post operatory mortality, it significantly reduce the risk of anastomotic leak and the risk of a second major surgery when the leak occur. diverting stomas are low-risk procedures from a technical point of view, but they potentially expose the patients to postoperative morbidity, impacting the patients' quality of life. it is not easy to decide whether the fecal diversion is needed or not. this decision must be made on a case to case basis, trying to apply the stomas only when they are really needed. we report our initial experience by living a transmesenterial cotton loop around the pre terminal ileum which extremities are turned out usually through the lateral trocar wound in laparoscopy or by applying a dedicated mini incision in open surgery. the purpose is to perform (in case of suspected fistula), a mini invasive diverting procedure, by widening the loop wound and by pulling up the ileum in a lateral loop ileostomy. we applied this procedure to 12 consecutive patients with low colorectal anastomosis and in two of them we performed a lateral loop ileostomy with good results. we believe this can be an alternative that needs to be standardized. purpose: sarcoidosis is a chronic, multisystem inflammatory disorder with unknown aetiology characterised by noncaseating granulomas within involved organs. gallbladder involvement in sarcoidosis is extremely rare and literature review revealed only 7 reported cases to date. in this paper, we present a case of gallbladder associated sarcoidosis. method: a 67-year-old lady was known to the clinic for regular surveillance of liver steatosis and incidental gallbladder polyps. the largest polyp was 4 mm at presentation in 2008 and has grown to 7 mm in 2017. in view of worsening symptoms of biliary colic and growing polyps, a laparoscopic cholecystectomy was performed. results: laparoscopic cholecystectomy was unremarkable and specimens of the gallbladder and lymph nodes were sent for histology. histological examination revealed chronic cholecystitis with polypoid cholesterolosis of the gallbladder and noncaseating granulomata within a lymph node, which strongly suggest sarcoidosis. conclusion: in conclusion, we report a case of incidental finding of gallbladder sarcoidosis over the course of treatment of biliary colic and symptomatic gallbladder polyps. therefore, the definitive treatment for patients with symptomatic gallbladder sarcoidosis is a cholecystectomy. the surgical management of cholelithiasis can be associated with significant morbidities. despite the relatively low incidence of bile duct injuries during laparoscopic cholecystectomy, the total number is large due to the high frequency of the operation. the subtotal cholecystectomy with its variants is a well known bailout strategy to the surgical community. however, there is no agreement on when and how to perform these procedures. indeed, the majority of surgeons will adopt these solutions when there is a struggle to identify the critical view of safety. this struggle results increases the risk of injuries. we hypothesize that a primary intent gall bladder lithotomy and disconnection (glad) when the dissection of the gb pedicle is anticipated difficult dissection is a safe and feasible strategic option. methods: out 347 patients elevtively admitted to aberdeen univesity hospital with gall stone disease between march 2017 and november 2017, 75 consecutive patients were operated with glad procedure based on intraoperative criteria. the primary outcome was the operative time. secondary outcomes were length of hospital stay, the criteria to do this procedure will be explained, the outcomes will be listed. indocyanine green is a molecule that becomes fluorescent when excited struck with light of a specific wavelength in the infrared spectrum (nir-infrared), allowing the visualization of anatomical structures in which it has accumulated. the aim of the study is the application of icg enhanced fluorescence in laparoscopic cholecystectomy in order to identify the anatomy of the biliary tract, to reduce the risk of iatrogenic lesions and the conversion rate. the study involves laparoscopic cholecystectomy for cholecystitis and gallstones of main biliary tract. the evening before the surgery, a vial of icg (25 mg) diluted in 100 ml of saline solution was intravenous injected. during the procedure, after opening the calot triangle, switching to the nir mode on the camera, the anatomy of the biliary tract and in particular of the main biliary tract is visualized. the cystic duct and cystic artery are isolated, their section between clips is cut and the cholecystectomy is performed. from january 2018 11 patients were enrolled: 9 cases of acute cholecystitis, 2 cases of gallstones of main biliary tract, undergoing preoperative ercp. in 8 cases of cholecystitis, the angiography allowed the visualization of the main biliary tract. in one case, an abnormal course of the cystic duct was identified. in two cases of gallstones of common bile duct, it favoured the visualization of the biliary tract anatomy. all cases were completed with laparoscopic technique. there were no intra-and post-operative complications. icg-enhanced fluorescence is a safe, effective, cheap and rapid tool that can also be applied in small hospitals with no need for training. its use does not extend the time of surgery and allows the visualization of the anatomy of the biliary tract, especially in situations where it can be altered by reducing the conversion rate and potentially the risk of iatrogenic lesions of the main biliary tract. case presentation: patient is a 22 year old female with no significant past medical or surgical history presented to the emergency department with a 2 day history of worsening sharp right upper quadrant pain with associated nausea, vomiting, and po intolerance. the pain started a few months prior, however it was self-limited with diet modifications. an ultrasound demonstrated a contracted gallbladder with a 15 mm gallbladder wall. white blood cell count was within normal limits and total bilirubin was slightly elevated to 1.8 mg/dl. no palpable mass was noted on physical exam. an mr cholangiopancreatography was performed which demonstrated a dilated gallbladder measuring 11.5 x 2.5 cm, a severely thickened gallbladder with a small intramural collection and multiple gallstones. the patient proceeded with a laparoscopic cholecystectomy. intraoperatively, the omentum was densely adhered to the gallbladder and needle decompression of the gallbladder was unsuccessful due to the wall thickness. the gallbladder was subsequently removed without any complications. patient's remaining hospital course was uncomplicated. surgical pathology returned demonstrating acute on chronic cholecystitis. discussion: cholecystomegaly or 'giant gallbladder' disease is a rare pathology encountered in the surgical world. there have been few reported cases, most of which occurred in the elderly ([ 65 years). kuznetsov et al. defined an enlarged gallbladder to have a volume of 200-300 cc and a giant gallbladder as exceeding 1500 cc (the average weight of the liver). the etiology remains unknown, however certain factors exist to allow the gallbladder to reach this size without life-threatening sequela. preoperative imaging, such as mr cholangiopancreatography, is important to differentiate biliary pathology and delineate anatomy. removal of the gallbladder is recommended to prevent the development of complications like cholangitis or bowel obstruction. the cause of cholecystomegaly still remains uncertain and warrants further research. the management and treatment remains similar to acute cholecystitis. aims: mini-laparoscopic cholecysectomy (mlc) is considered to be the best variant of minimizing surgical trauma and improving cosmesis in laparoscopic cholecystectomy. the most challenging techniqual step of mlc is clipping the cystic duct. it may be impossible or unsafe when diameter of cystic duct exceeds 3 mm, which is common in severe chronic colecystitis or acure cholecystits. there is very limited data in the literature about the use of mlc in acute cholecystits. the aim of study was to access the first results of new technique of mlc. methods: five women with the mean age of 39 years (32-48) underwent mlc. the 1st 10-mm troacar was inserted in the umbilicus and used for the camera and removal of the gallbladder. the 2nd 5-mm troacar was inserted in subxyphoidal area and used for the main working instruments, including medium-large polymer clip-applier (hem-o-lok type). the 3rd and 4th 3-mm troacars were placed in right subcostal area and used for mini-graspers (karl storz). in initial 4 procedures we used conventional 5-mm clip-applier with adopted medium-large titanium clips. to improve safety, we aplied 5-mm hem-o-lok type clip-applier for the last patient with acute cholecystitis. in this case the diameter of cystic duct was 3,5 mm. the clipping was performed successfully. the 3-mm drain was placed via subcostal troacar incision. also, in this case we applied original technique of removal of the bladder using wound retraction instrument (karl storz). results: in all the cases there were no intra-or postoperative complications. the mean duration of procedures was 120 min (100-180 min). the postoperative stay was 2 days in every patient. the patients estimated their pain on postop day 2 as 'almost absent' and cosmethic results 1 mo postop as 'exellent'. conclusions: 1. new technique of mlc alowed to perform the clipping of cystic duct safely, which is essential in acute calculous cholecystitis. was conducted in department of surgery lumhs jamshoro. all the patients having age = 18 year of age, either gender presented with history of abdominal pain, nausea and vomiting and were diagnosed as cholelithiasis included in the study and were planned either for mini-laparoscopic cholecystectomy and conventional laparoscopic cholecystectomy were explored for outcome while the patients with empyema gallbladder, gangrene, mucocele gallbladder and adhesions were excluded from the study. results: during one year study period, total five hundred patients were diagnosed as cholelithiasis with means age 53.21 ± 6.83 (sd). of five hundred, 127 (25.4%) were underwent for mini-laparoscopic cholecystectomy with 15 (11.8%) were males and 112 (88.1%) were females. the outcome were measured as postoperative pain (vas) 1.61 ± 0.92, size of wound (umbilical 10 mm, epigastrium 5 mm and subcostal 2 mm), excellent cosmetic results, mean ± sd for hospital stay (hrs) and operative time (minutes) was 12.86 ± 5.73 and 30.83 ± 10.85, early return to work 115 (90.5%), minor oozing 07 (5.5%), port size hernia 2 (1.5%). remaining 373 (74.6%) were underwent for conventional laparoscopic cholecystectomy with 38 (10.1%) were males and 335 (89.8%) were females. the outcome were measured as postoperative pain (vas) 3.53 ± 1.95, size of wound (umbilical 10 mm, epigastrium 10 mm and subcostal 5 mm), mean ± sd for hospital stay (hrs) and operative time (minutes) was 49.95 ± 8.95 and 30.83 ± 7.72, early return to work 310 (83.1%), port size hernia 10 (2.6%) along with zero (0%) mortality. conclusion: it has been concluded that mini-laparoscopic cholecystectomy is superior and feasible than conventional laparoscopic cholecystectomy and has decreased early postoperative incisional pain, avoided late incisional discomfort and safe procedure with nearly scarless wounds with superior cosmetic effect especially for young female patients. objective: to determine the outcome of immediate versus late laparoscopic cholecystectomy in acute cholecystitis at tertiary care hospital hyderabad / jamshoro sindh pakistan patients and methods: the descriptive case series study of one year (2016 -2017) was conducted in department of surgery lumhs jamshoro. all the patients having age = 18 year of age, either gender presented with history of abdominal pain, nausea and vomiting and were diagnosed as acute cholecystitis (cholillthiasis) included in the study and were planned for laparoscopic cholecystectomy and were explored for outcome as immediate (within 48 h) and late components ([ 6 weeks). the frequency and percentage was calculated for categorical variables and mean ± sd was calculated for numerical variables. as this was descriptive case series so there was no any statistical test of significance was applied. results: during one year study period, total one hundred patients were diagnosed as acute cholecystitis with means age 55.72 ± 8.95 (sd). of one hundred, 80% were females and 20% were males. the immediate outcome reported as tissue fragile 10%, pancreatitis 2%, slipage of ligature of cystic duct 5%, empyema gallbladder 5%, mucocele 15% and gangrenous gallbladder 2% while the late outcome reported as adhesions 70%, cholecystoduodenal fistula and mirizzi syndrome 1% and 6%, gallstone ileus 2%, perforated gallbladder 8% and cholidochiolithiasis 20% while the mean ± sd for hospital stay (days) in immediate as 1.51 ± 0.32 while in late outcome (days) during acute cholecystitis 4.50 ± 0.55 and after surgery (6 weeks later) as 2.85 ± 1.21 respectively. conclusion: it has been concluded that early lc for acute cholecystitis with cholelithiasis is safe, low cost and feasible intervention and offering the additional benefit of shorter hospital stay and reduce the economical burden. surg endosc (2019) 33:s485-s781 general surgery, chang gung memorial hospital kaohsiung division, kaohsiung, taiwan background: the treatment of common bile duct (cbd) stones is challenging while unclear hepatic hilum anatomy especial experience of previous laparotomy. a minimally-invasive approach choledocholithotomy is feasible, but can be difficult and converted for the unclear anatomy of the biliary tree. near-infrared (nir) cholangiography by systemic administration of indocyanine green (icg) can enhance the visualization of the biliary tree anatomy but is limited by the high intensity of background fluorescence signal coming from the liver. nir fluorescence cholecysto-cholangiography by direct biliary tree administration of the icg can enhance the biliary tree without background noise signal. we created the nir cholangiography via different route according to patient situation : systemic circulation or biliary tree injection to see the feasibility of those application. material and method: ten patients who suffered from obstructive jaundice due to cbd stone and 5 patients received percutaneous biliary tree drainage as first treatment and 2 patients received endoscopic biliary tree drainage. those patients received laparoscopic choledocholithotomy as definite treatment after acute infection phase. 5 patients received biliary tree icg injection via drain tube and 5 patients by systemic injection. visualization and fluorescence patterns around cbd was recorded. results: in our series, one patient received previous gastrectomy and 4 patients had previous biliary tree surgery. background: laparoscopic cholecystectomy (lc) has become the gold standard for the treatment of gallstone disease. multiple studies have confirmed its safety, lc at index admission is still not widely practiced in ireland. we present our experience in performing index cholecystectomy at cuh after the start of acute care surgery program in may 2017. aim: the aim of this study is to determine the safety of laparoscopic cholecystectomy at index admission, complications,re-admissions, and los. methods: electronic records, theatre records and imaging reports were searched to enroll all patients who underwent lc for gallstone disease at index admission from may17 to october18. patient demographics, indication for surgery, postoperative complications, readmission and conversion rate were recorded.in addition timings of mrcp and ercp, imaging findings, and los were also noted. results: a total of 117 patients underwent lc during the study period. median age was 47 years (18-79). male to female ratio was 1: 1.78. 75(64%) patients had acute cholecystitis, 12 (10%)had acute biliary pancreatitis, 10 (8.5%)biliary colic and 9(7.6%) had cholecystitis with signs of cbd obstruction. 7(5.9%)patients had obstructive jaundice and one with adenomyomatosis.50 patients (42%) had preop mrcp while 23 (19%) underwent pre-op ercp. all except 3 patients undergoing ercp had preprocedure mrcp.2 patients had pre-op cholangiograms. in terms of complications, 2(1.7%) patients had bile leak and one(0.85%) had re-operation. one patient had the post-op hematoma which was drained percutaneously, one patient had procedure abandoned because of bradycardia upon induction of anesthesia. there was no common bile duct injury, no conversion to open and no 30 days mortality was reported. the average length of hospital stay has been 6 days. (2to18 days). conclusions: laparoscopic cholecystectomy at index admission for cholecystitis, choledocholithiasis, and biliary pancreatitis, has been a safe and feasible treatment option in our hospital. a safe practice can be ensured by adherence to a care pathway and a multidisciplinary, consultant-led service. index cholecystectomy service can be provided safely across the country to prevent diseaserelated morbidity and multiple re-admissions in patients awaiting interval surgery. when to use the two-stage surgery to treat choledocholithiasis: the size aims: the treatment of choledocholithiasis has been provided by various of studies worldwide. the most common accepted minimal invasive treatment was two-stage treatment using endoscopic retrograde cholangiopancreatography before or after laparoscopic cholecystectomy(ercp ? lc), and one-stage treatment with laparoscopic exploration of the common bile duct(lcbde). in fact, despite several large studies have been published in recent years, the debate for the ideal treatment of choledocholithiasis is way from being concluded. we aim to find the proper treatment option for the patients with variable sizes of choledocholithiasis. methods: we retrospectively analyzed 136 patients who underwent treatments for cholidocholithiasis in our institute between january 1, 2011 and july 31, 2016. the patients who received either ercp and lc in the same admission, and the patient who received lcbde, irrespective of trans-cystic(ltcbde), or choledochotomy(lcd), were included. the data was analyzed with chi-square test and mann-whitney u test. results: the stone size of the ercp ? lc group is significantly smaller than the lcbde group. we further analyzed the ercp failure case, and the group of stone size [=9.5 mm has a significantly higher rate of procedure failure. the failure rate is increasing with the stone size. conclusions: both the treatment of lcbde and ercp ? lc have similar safety and success rate, and the rate of residual stone was also similar in both group. however, the failure rate for ercp is significantly increased when stone size is larger than 9.5 mm in this study. aims: the xanthogranulomatous cholecystitis (xc) is a rare entity that can cause doubt in the choice of surgical treatment, because of differential diagnosis with gallbladder carcinoma (gc). methods: a 70-year-old patient presented acute abdominal pain in the right upper quadrant, nausea and low-grade fever with signs of peritonitis. he had elevated pcr, leukocytosis with neutrophilia. abdominal ultrasound showed an acute xanthogranulomatous cholecystitis. a laparoscopic cholecystectomy was decided but it was converted to open surgery due to the difficulty in the dissection, with fundus embedded in the hepatic bed and intraoperative finding of hilar adenopathic conglomerate .the postoperative period was torpid, with abdominal pain, jaundice, elevated bilirubin and enzymes of cholestasis. postoperative abdominal tomography showed injury in the iv segment of the liver suggestive of neoplasia. metastatic adenopathic conglomerate at the hepatic hilum caused extrinsic biliary obstruction with hepatic failure later so an internal-external drain was placed in the bile duct. the patient was died a week later. the pathological anatomy reported a stage four of gc. results: xc is a rare, non-neoplastic, inflammatory and destructive entity of the gallbladder wall, considered a variant of chronic lithiasic cholecystitis. it may be due to extravasation of bile or ulceration of the mucosa, causing an inflammatory reaction and fibrosis, with xanthomatous cells. the prevalence is 1 to 2% in the resected gallbladders. it is more frequent in 60-70 years oldfemales. its clinical presentation does not have specific characteristics that differ from cholelithiasis, except for the weight loss. radiologically it is characterized by nodular thickening and increased attenuation of the vesicular wall with signs of cholecystitis, indistinguishable from a vc. the xanthogranulomatous inflammatory foci infiltrate the hepatic parenchyma, having an invasive behavior; hence, it mimics a neoplastic disease. the confusion in diagnostic and the risk of gc (up to 10%) makes treatment contentious. conclusions: the xc can simulate an advanced gc that sometimes makes us wonder if we should perform a radical surgical treatment; when presented in an emergency situation, our therapeutic decision can focus on solving the acute problem and be conditioned by the patient's general condition. single port transumbilical laparoscopic surgery (sptls) is a techinque that has been around for about 18 years. although the enthusiasm for this type of surgery seems to have diminished in recent years it is expected to rise considering the recent development of sophisticated devices for its execution . we report retrospectively our 8 year experience with 253 procedures performed by sptls technique. in a private practice setting in mexico city. procedures include cholecystectomy (107), appendectomy (69), inguinal hernia tapp and tep (26), hiatus and esophageal (15) , sleeve gastrectomy (2), colon (6), gyn (28) . 4 different access platforms were employed. we explain our selection criteria for the application of the technique and describe the evolution of the instruments employed during the past 8 years, from laparoscopic conventional to curved and bendable; regular scopes to extra long telescopes with different angles. or time, top bleeding, conversion rate, the need to employ an extra trocar, complications, pathology reports, scheduled or urgent kind of surgery and length of hospital stay were recorded from the beggining; patients variables such as bmi, asa status, tep risk, satisfaction with the procedure and other were recorded . we describe the evolution of our technique, and our learning curve with cholecystectomies. we compare our group of sptls transvaginal assisted laparoscopic hysterectomy (tvalh) patients vs tvalh multiport patients. we explain the feasibilty, and efficiency of the procedure in our hands compared to other series. background: in japan, the severity of acute cholecystitis(ac) is assessed by the severity classification of the tokyo guidelines 2018 (tg18). the value of c-reactive protein (crp) is not included in the severity classification criteria. the first line treatment, according to tg18, for mild (grade i) to moderate (grade 2) ac is laparoscopic cholecystectomy, but laparoscopic surgery may not be feasible in some cases due to adhesion or local inflammation of the gall bladder. aim: the aim of this study is to assess the effect of crp on the open conversion rate in laparoscopic cholecystectomy for acute cholecystitis.method: we conducted a retrospective study. 41 patients who were diagnosed with ac and treated with emergent laparoscopic cholecystectomy between june 2017 and may 2018 in our institution are included. we set the cutoff value for crp at 20 mg/dl and compared the open conversion rate. secondary endpoints are amount of bleeding, operation time, post-operative course (peak in body temperature and inflammatory markers) and the frequency of complications according to the clavien-dindo classification. results: 10 out of 41 patients had a crp value greater than or equal to 20 mg/dl. the median crp values for the crp \ 20 group and crp = 20 group were 4.4 and 23.1, respectively. the open conversion rate of the crp = 20 group was significantly higher than that of the crp \ 20 group (3/10, 1/31, p = 0.01). the most common reason for these conversions was local adhesion (3/4) . there were no differences in the amount of bleeding, operation time, post-operative course, and frequency of complications with clavien-dindo grade ii or higher. background: reports about clinical value of fluorescent cholangiography using indocyanine green (icg) during single-incision laparoscopic cholecystectomy (silc) were increasing. we report clinical value and pitfalls of fluorescent cholangiography during silc for the patients with the infraportal type of the right posterior bile duct. methods: our silc procedure utilized the sils-port with an additional 5-mm forceps through the umbilical incision. before silc, 1 ml of icg (2.5 mg) was administrated by intravenous injection. for fluorescent cholangiography, icg fluorescent laparoscope system was used. results: we performed fluorescent cholangiography during silc in 13 patients with the infraportal type of the right posterior bile duct. all procedures were completed successfully. the interval from the injection of icg to the first obtained fluorescent cholangiography before the dissection of calot's triangle ranged from 40 to 60 min. detectability of infraportal type of the right posterior bile duct before dissection in claot's triangle was 23.1% (n = 3) and that during dissection in calot's triangle was 53.8% (n = 7). the infraportal type of the right posterior bile duct could be identified under fluorescent cholangiography only when it joined into the common hepatic duct. conclusions: utilization of fluorescent cholangiography can lead silc to safe even for the patients with the infraportal type of the right posterior bile duct. its benefit is emphasized when the infraportal type of the right posterior bile duct joins into the common hepatic duct. aims: due to the development of laparoscopic surgery and the progress made in surgical treatment ofhydrocephalus, surgeons may come across patients with ventriculoperitoneal (vp) shunt, as candidates for laparoscopic procedures. according to this fact, we report a case of an unusual complication of laparoscopy surgery that can appear in this kind of patients. methods: we present a case of a 66-year-old man with medical history of normotensive hydrocephalus with vp shunt, that came to the emergency room complaining of abdominal pain and fever since two days. blood test showed an elevation of infection parameters and inflammatory markers, and the ultrasound study revealed an emphysematous cholecystitis. therefore, we decide to carry out an emergency laparoscopic cholecistectomy. the patient did not present any adverse event during the surgery or the immediate postoperative period, being discharged the third postoperative day and evaluated ambulatory one month after the surgery with no complications. two months after surgery, the patient returned to the emergency room presenting alteration in consciousness and fever. results: during the study of the pacient, an abdominal ct was performed, showing a complete section of the vp shunt in the subcutaneus space of the upper abdominal wall and intraperitoneal migration of the remaining catheter. the patient was transferred to neurosurgery to carry out an emergent replacement of the ventriculoperitoneal shunt. after surgery and intravenous antibiotic treatment, the patient evolved favourably and was discharged a few days later. conclusions: the rate of serious complications associated with a laparoscopic approach is overall low and up to 50% of them occur during the abdominal access for camera or port placement and may not be recognized until postoperative period. vp shunts should not be a contraindication for laparoscopic surgery. however, laparoscopy approach must be carry out with good anesthetic and monitoring facilities and taking several previous considerations, such as verifying the proper functioning of the vp shunt, identifying the path of the catheter within the abdominal wall to avoid inadvertent damage to the catheter during trocar placement and ensuring that the intraperitoneal portion of the catheter is not twisted or obstructed prior to decompression of the abdomen. surg endosc (2019) introduction: since advantages of robotic surgery is being more emphasized, robotic cholecystectomy (rc) cases are increasing. ajou group had introduced a method called which technique places the trocars transversally on the bikini line and it makes cosmesis and pain beneficial. however, rc with low incision port has several limitations. therefore, we changed port placement which may be a one of safe tehniques for rc. method: this study retrospectively reviewed data for patients who received rc with port changing method (rcpc, n = 33) and rc with low incision port (rcli, n = 81) from february 2016-february 2017 and surgical variables were analyzed. results: patients in both groups had similar demographic features and indications for surgery. the rcpc group required no conversions to conventional robotic surgery and no additional operation, whereas the rcli group had one incisional hernia (1.2%) and two bowel perforation (2.4%) cases. length of stay (4.29 ± 0.72 vs. 5.13 ± 0.93 days, respectively; p = 0.123) did not significantly differ between the rcpc and scli groups. however, the rcpc group had shorter operative time (71.30 ± 48.88 vs. 74.70 ± 30.16 min; p = 0.772) than the rcli group, although the parameters mentioned above were not statistically significant. conclusion: robotic cholecystectomy with bikini line incision has some limitations even though it has cosmetic benefits. whereas robotic surgery with changing port method is one of safe and feasible procedures for performing robotic cholecystectomy. also nothing more to say that it gains cosmesis effect and escapes complications. mini surgery, odessa medical university, odessa, ukraine the aim of the study was to optimize the diagnostic and therapeutic tactics for yatrogenic injuries of the extrahepatic bile ducts. methods: 15 patients were examined. typical manifestations were jaundice, cholangitis, biliary peritonitis, external biliary fistula, subhepatic abscess.cholecystectomy main cause of damage.a visual, manual and x-ray examination of the hepato-choledochus and cholangioscopy were performed. ultrasound, endoscopic retrograde cholangiopancreatography, fistuloholangiography or percutaneous transhepatic cholangiography play a leading role in diagnosing. the results: high damage to the bile duct was detected in 53.3% of patients, low-in 46.7%.percutaneous transhepatic drainage under ultrasound control was performed in 66.7% of patients.emergency laparotomy, sanation of the abdominal cavity and external drainage of the bile ducts were performed with bile peritonitis. recovery operations produced 60.0% of patients. reconstructive interventions were performed in 40.0% of patients after 6-8 weeks after the first stage. the covery operations were successful in 66.7% of patients. 33.3% of the sick had complications in the form of biloma. a scar stricture formed in 33.3% of patients after 4-6 months. 1 patient underwent recanalization of the stricture zone with a dilatation balloon through interchangeable transhepatic drainage. balloon dilatation was performed retrogradely through the large duodenal papilla in 2 patients. deaths in the postoperative period was not observed. conclusions: the surgical team should be strengthened by an experienced surgeon when intraoperative diagnosis of yatrogenic damage to the bile ducts.the operation should be completed by external drainage of the bile duct and the abdominal cavity in the absence of an experienced specialist.recovery operations are shown only with lateral injury of the ducts.the patient must be sent to a specialized institution for radical surgical treatment after stabilization of his general condition. aim of the study sub-hepatic bile collections, biloma and hematoma are rare complications and we present our experience in treatment this complications. material and methods: from 750 laparoscopic cholecystectomy performed in our clinic, three patients (two women and one men) to whom it was performed laparoscopic cholecystectomy, came back two weeks later after they were released from the hospital because of epigastric discomfort, fever and nausea. results: clinical examination after rehospitalization showed tenderness in the epigastrium and right subcostal region. in all patients were measured high levels of leukocytosis and crp . an ultrasound examination of the abdomen revealed a large hypoechoic collection in the sub hepatic space, after the abdominal ct scan was performed, the density of the collection did not indicate the presence of blood in two patients. percutaneous drainage of the collection in both patients was realized under us guidance and 8-10 fr catheter was inserted in the sub hepatic region. in the first patient 800 cc of bile-stained liquid, and in the second patient 650 cc of biliary liquid was drained. in a third patient 16 h after surgery signs of significant hypotension and limited tenderness at the right subcostal region occurred. a complete blood count (cbc) showed a decrease in the level of haemoglobin to 10.4 g%. ultrasound examination revealed a fluid collection in the sub hepatic space, which is also confirmed by computed tomography. laparotomy was performed and the large sub hepatic hematoma was evacuated. after that the 18 fr abdominal drain was inserted into the sub hepatic space. the postoperative course of all three patients was not complicated. conclusion: sub hepatic biloma and hematoma are rare complications of laparoscopic cholecystectomy, while early diagnosis followed by percutaneous drainage or open laparotomy is the only way to resolve these complications. (3), hemoperitoneum 3.4% (1) . the average number of days of hospitalization was 7.6 days. there was no mortality at 30 days. conclusion: in the emergency setting the rendezvous technique has an adequate success rate of cannulation and clearence of the bile duct, an acceptable surgical time, few complications, these being more frequent in those patients with inflammation of the gallbladder and without associated mortality at 30 days. there is a need for controlled randomized studies with a greater number of patients recruited and follow-up to determine the usefulness of this technique. intraoperative cholangiography could serve as a fundamental solution to avoid the bile duct injury during laparoscopic cholecystectomy. however, it is difficult to identify the cystic duct to which the contrast catheter should be inserted in cases with high degrees of adhesion around the calot's triangle. in these cases, it is not possible to conduct cholangiography from the cystic duct. for these types of cases, intraoperative cholecystography may serve as an option. however, since the bladder is a bag-like organ that expands when liquids are entered, directly inserting a contrast dye into the bladder would make the bladder itself expand, which makes it impossible for to maintain enough pressure in the contrast dye to flow into the cystic duct, extrahepatic bile duct, and intrahepatic bile duct. also, since it is difficult to control leakage of the contrast dye from the catheter insertion site, it is not possible to obtain enough images to sufficiently understand the anatomical characteristics of the bile duct in many cases. therefore, cholecystography is not generally recognized as a method to be used during surgery. in our facility, we insert the contrast catheter through the bladder after stretching the gallbladder neck as much as possible, hold the gallbladder neck with a removable intestinal clamp, and then apply the contrast dye to the bile duct. through this method, it is possible to insert enough contrast dye into the cystic duct, extrahepatic bile duct, and intrahepatic bile duct to understand the anatomical characteristics of the bile duct, allowing us to obtain appropriate images of the biliary tract. because this method uses equipment that is highly versatile, we believe that it is inexpensive and convenient. during this presentation, we will also conduct a case presentation of the methods of bladder contrasting that we utilize in our facility during laparoscopic cholecystectomy. introduction: retrieval of a thick walled gallbladder during a difficult laparoscopic cholecystectomy (lc) for an acute or chronic calculous cholecystitis can be exasperating. it increases operative time and often necessitates enlargement of 10 mm port to deliver the specimen. the 'in-situ cholecystotomy', which we wish to call the 'delhi maneuver' is very helpful in improving the ergonomics of specimen retrieval, saves time and conserves cosmesis. patients & methods: one hundred and ten patients of acute or chronic calculous cholecystitis were placed randomly in 2 groups. a disposable transparent plastic bag was used in all cases to retrieve the gallbladder specimen through the 10-12 mm port using a rampley's sponge holding forceps. retrieval was done using conventional technique in 60 patients (group b). the delhi maneuver was used in the remaining 50 patients (group a). it involved cutting the gall bladder inside the plastic bag in a certain fashion, delivering the gallstones in the bag, and removal of gallbladder preceding the stones. the retrieval time, number of insertions of sponge holder, any rupture of plastic bag as well as the number of cases needing port enlargement were noted. results: the average time taken by delhi maneuver (group a) was 9 min as compared to was 14 min by conventional method (group b). the number of insertions of sponge holder ranged from 3-11 in group a (mean 5) and 5-18 in group b (mean 13). four patients needed port enlargement in group a (8%) while 17 patients needed enlargement in group b (28.3%). there were 2 incidences of bag rupture in group a (4%) and 3 in group b (5%). the delhi maneuver improved the ease and speed of specimen extraction at laparoscopic cholecystectomy for thick walled gallbladders. it also decreased the need for port enlargement for specimen retrieval. the bile duct injuries are a very complex desease to confront, the inciian managment is to clasificate the injury and to identifie the mechamism of the injury. it's important for the optimal heal of the patient to have a multidisciplinary approach including internal medicine, surgery, endoscopy and interventional radiology specialists. the laparoscopic cholecystectomy responsible for 80%-85% of them.this is a retrospective study on the incidence, classification and management of bile duct injuries in a private sector hospital in monterrey nl. mexico. in this study, 17 bile duct injuries were identified in 10 years of experience in a single center. were categorized using the strasberg classification. variables were evaluated such as type of injury, mechanism of injury, hospital stay, if the surgery was scheduled or of emergency, the moment in which the surgeon evidenced the injury, the way in which the surgeon became aware of the injury performed. the type of management that was given to this lesion was also studied and the days of intrahospital stay and the number of reinterventions or procedures performed were compared.the average age of the patients was 53 years, 10 patients belonged to the female sex, although there were lesions of all kinds in this work, there was a greater incidence in strasberg type a lesions, which represented 41% of the lesions. the most common diagnosis presented was cholecystolithiasis. in 7 surgeries the evidence and repair of the bile duct was in the same intervention aims: bile leak is a rare but recognised complication after laparoscopic cholecystectomy. this usually occurs after a difficult procedure complicated by adhesions, unusual anatomy or if the surgeon is inexperienced or unfamiliar with the anatomy. this video aims to demonstrate the laparoscopic diagnosis and treatment of this complication particularly for surgical trainees. methods: we report a case of significant bile leak occurring soon after a straightforward laparoscopic cholecystectomy due to very short cystic duct (cd). the procedure was carried out uneventfully but the cd was clipped flush with the bile duct. the patient was discharged on the day of surgery feeling well but readmitted with abdominal pain 48 h later. results: after readmission the patient underwent a ct demonstrating only a small amount of fluid suggestive of a small collection. she was treated conservatively but suddenly deteriorated and a repeat ct confirmed significant intraperitoneal fluid. a diagnostic laparoscopy was carried out urgently confirming a cd stump bile leak where the clips had sloughed off causing the leak. two litres of bile was aspirated with copious irrigation and a latex t-tube inserted into the cbd. patient made a full and rapid recovery. conclusions: this is a rare complication and learning opportunities for trainees are therefore infrequent. this video demonstrates a successful laparoscopic approach to management of postoperative bile leak showing t-tube insertion technique and highlighting the need for careful cd closure techniques during laparoscopic cholecystectomy when the duct is very short. about 10-15% of bile duct stones could not be extracted using conventional endoscopic techniques (baloon, sphincterotomy). there is lower success rate in elderly patients; among the biggest challenges are intrahepatic stones, size of stone is large, etc. aims: to present the case of a recurrent intrahepatic lithiasis and its management using spyglass choledochoscopy.to expose, other cases and the main outcome and complications of other difficult cases of bile duct stones that solvedusing this choledochoscope vs. the traditional one and the beneffits. we present a case of 85 years old male who presented with cholangitis caused by an intrahepatic stone that required multiple sessions of endoscopic retrograde cholangiopancreatography with spyglass for clearance. one year later, he presented again with cholangitis, that required another session of spyglass lithotripsy and cholecistectomy. conclusions: besides ercp, there are different approaches to treat difficult bile duct stones, as transhepatic percutaneous drainage, surgical techniques, or other endoscopic techniques (doubleballoon, enteroscopy). ercp and sphincterotomy are the first step of endoscopic treatment with more than 90% of success rate, and a low mortality and morbility rate; other steps include some lithotripsy techniques, or the use of biliary stent as a bridge before definite treatment. spyglass is a visualization & intervention system used when common ercp has been unsuccessful, and it is first line for better and direct image of biliary ducts, with 12°range of motion, with multiple advantages like the concomitant use of lithotripsy devices. aims: the number of elderly people has increased, because of the strong association between age and gallstone disease, both prevalence and incidence of this disease are increasing. this presentation aims to review our current management options of octogenerian patients with acute cholecystitis. methods: we retrospectively analyzed 173 octogenerian patients who were admitted to the our hospital with the diagnosis of acute cholecystitis between january 2013 and october 2018. the patients were initially allocated to four different treatment groups as follows: immediate surgery, delayed surgery, medical treatment and cholecystostomy. differences in the outcomes between the treatment groups were evaluated. results: there were 67 males (38.8%) and 106 females (61.2%) with a mean age of 85.7 years (range 80-90 years). the patients had different co-morbid diseases, especially hypertension (65, 37.5%) cardiovascular disease (43, 24.8%) and diabetes mellitus ( methods: a retrospective observational study where were analyzed patients older than 75 years who underwent urgent surgery for ac who fulfilled an indication for surgery according to tokyo guidelines 2018. the type of cholecystitis, stay and postoperative complications, the type of intervention, the conversion rate, the need for reoperation and re-admissions in patients older than 75 years were analyzed and compared with those of patients operated on for cholecystitis younger than 75 years. outcomes: a total of 289 patients were registered, 55 older than 75 years (19%) and 234 younger (81%). in 128 cases, cholecystitis were complicated (44.3%), 34 cases older than 75 years (26.56%) and in 94 cases younger than 75 years (73.44%). the approach was laparoscopic in 89% of the cases older than 75 years, with a conversion rate of 10.2%, not finding statistically significant differences with younger than 75 years (91% laparoscopies with 4.2% of conversions). 18% of patients older than 75 years had some type of postoperative complication, not finding statistically significant differences in patient younger than 75 years (17%); being the most frequent complication the intrabdomintal abscess (3.66% of patients [ 75 years, and 4.27% of those \ 75 years = '' span = '' [ being not statistically significant with 95% ci. any patient older than 75 years required re-entry after discharge, compared to 8 patients younger than 75 years who were re-entered, not being statistically significant; and any patient older than 75 years required reintervention, while it was necessary to reoperate 3 patients younger than 75 years (1%), being not statistically significant. mortality was very low, finding 1 case in older than 75 years (1.8%) and 1 case in younger (0.4%), not obtaining statistically significant differences. the postoperative stay in patients younger than 75 years of age has a median of 3 days and in older than 75 years a median of 4 days, not finding statistically significant differences with 95% ci conclusions: laparoscopic cholecystectomy is safe and effective in the treatment of elderly patients with (ac), there being no differences with younger patients. introduction: significant bile leak is an uncommon but serious complication of laparoscopic cholecystectomy. our study aims to evaluate the efficacy of relaparoscopy in treating symptomatic bile leak and biloma formation. material and methods: 125 patients presenting with postoperative bile leak after different operations on extrahepatic biliary tree from january 1993 to december 2018 were reviewed retrospectively (in total, 23,590 laparoscopic surgical interventions were performed for the period under study). the sites of bile leaks were the cystic duct stump in thirty seven patients, the bile ducts of luschka in fifty two, liver beds in 16 cases after hepatectomy, in 13 had small injury of cbd, and seven patients with tubular stenosis of the common bile duct. results: three main approaches of mini-invasive treatment of bile leakage was used: (1) percutaneous puncture with or without drain under ct-scan or ultrasound guidance in 45 patients; (2) endoscopic management in 50 patients (in 35 patients (70.0%) were managed with ercp alone and fifteen (30.0%) were treated with a percutaneous intervention followed by ercp. endobiliary stent placement was performed after es in 23 patients and without es in twenty seven patients (3) relaparoscopy has been performed in 30 patients, in cases of biliary peritonitis. conclusions: relaparoscopy was the ultimate method of treating postoperative complications of laparoscopic surgery in 94.3% of patients. in general, this method, as well as laparoscopic intervention, is highly effective in the diagnosis and correction of postoperative complications, with minimal surgical trauma for the patient, with great therapeutic effect and subsequent rapid social rehabilitation of patients. introduction: laparoscopic operations have already become routine, even for pancreatoduodenectomy for periampular cancer. for unresectable cases, endoscopic bibliary stenting or hepaticojejunostomy are usually used. these methods are quite expensive and may be accompanied by complications. materials and methods: laparoscopic cholecystogastroanastomosis was performed in 72 patients with unresectable periampullary cancer. there were 34 females and 38 men and average age was 72,6. the indications for surgery in all patients was unresectable periampullary cancer and biliary hypertension with preserved patency of the cystic duct. the level of bilirubinemia ranged from 89 to 520 lmol/l (the average level was 179,8 lmol/l). we used 3-port technique. optical trocar was placed in the right iliac region, one 10 mm above the navel and one 5 mm in the right hypochondrium after punction gallblaber and aspiration of bile, we cut the apex of the gallbladder and gastric antrum up to 2.5 cm and performed cholecystogastroanastomosis with barbed-suture v-loc. results: we had not conversion to open surgery. the average operation time was 37 min. postoperative stay was average 4 days and on median follow-up of 12 month. post-operatively, there were no major morbidity and nil mortality. we had 2 cases of leakage of bile through drainage for up to 3-5 days, which spontaneously stopped. all patients showed a decrease in the level of bilirubinemia. 12 patients were later radical operated (pancreatoduodenectomy), while they did not have such phenomena as cholangitis, pancreatitis, inflammation of the hepatoduodenal ligament elements, which we often observe after endoscopic biliary stenting. conclusions: laparoscopic cholecystogastroanastomosis is safe, effective and feasible for patients with periampular cancer and obstructive jaundice. aims: surgeons with the expertise and resources to perform laparoscopic common bile duct exploration often prefer the 'one stage approach' over endoscopic retrograde cholangio-pancreatography (ercp) for the management of common bile duct (cbd) stones. this case series aims to evaluate the effectiveness of lcbde in a single benign upper gastrointestinal (gi) unit. methods: all patients with suspected and confirmed pre-operatively cbd stones who underwent a lcbde between january 2015 and october 2018 were included. lcbde was performed on the basis of pre-operative suspicion of cbd stone confirmed by intra-operative imaging. results: 187 patients with confirmed choledocolithiasis had lcbde during this time period. the indications for lcbde were deranged liver function tests, dilated cbd or confirmed stones on preoperative imaging. median age was 63 (range 19-91), 67% of whom were female. 36% of patients had confirmed cbd stones pre-op. 70% of cases were performed as emergencies and conversion rate to open was 6.5%. choledocotomy was performed in 60% of cases. in 17% of these t-tube was left in situ. transcystic approach was used in the remaining 40%. despite positive intraoperative imaging no stones were found on cbd exploration in 11 cases (6%). in 3 patients stones were unable to be cleared with lcbde. the overall morbidity was 20%. 11% of patients had gallstone related complications. overall mortality was 1% (due to bile leak). 19/187 patients required re-intervention with re-look laparoscopy (n = 6) or ercp (n = 13). 3 patients re-presented within 3 months with cbd stones. overall median length of stay was 5 days. conclusions: our case series demonstrates that lcbde is an effective and safe treatment for choledocolithiasis in both the elective and emergency settings. complication rates are comparable with therapeutic ercp (10% specific complications) followed by laparascopic cholecystectomy (10% 30 day morbidity). the variability in anatomic location of subvesical bile ducts puts them in danger during hepato-biliary operations. its prevalence varies between 3% and 10%. the origin and drainage of these ducts were limited mainly to the right lobe of the liver, but great variation could be seen. some authors think of them as small bile ducts that drain directly into the body of the gallbladder; others consider them to be networks of miniscule bile ducts between the liver capsule and the gallbladder. recent studies suggest that clinically relevant bile leaks complicate approximately 0.4-1.2% of cholecystectomies. injury to a subvesical duct is one of the most common causes of cholecystectomy associated bile leak and occurs as often as major bile duct injuries and leaks from the cystic duct stump. indeed, recent studies suggest that about 27% of clinically relevant bile leaks are caused by inadvertent injury to a subvesical bile duct. there are four types of subvesical bile ducts, including (1) superficial variations of segmental and sectorial bile ducts, (2) superficial or intercommunicating accessory bile ducts, (3) hepaticocholecystic ducts, and (4) aberrant bile ducts.we present a case of 73 year old patient who developed a coleperitoneum after a routine daycase colecystectomy due to the inadvertent injury of a hepatocholecystic duct. a superior comprehension of ductal anatomy is essential in preventing and managing operative injury to the subvesical ducts, although some times is unavoidable. nowadays, the diagnosis of liver cancer is primarily radiological, as recommended by the principal international societies. in doubtful cases or due to the clinician needs, diagnostic evaluations can eventually be completed with a liver biopsy. the goal is to perform the examination, or the examinations, that guarantee the most elevated sensibility and specificity levels being as little invasive as possible. nevertheless, even using the best radiological tools, the diagnosis is not certain, due both to device limitations and radiology experience. recently, various diagnostic algorithms have been proposed, relating with contrast enhancement characteristics, different radiological techniques, blood examinations and cross evaluations from different radiologists. one of the most recent algorithm purposed is liver imaging reporting and data system (li-rads), that evaluates ct and mri imaging to classify hepatic lesions in different diagnostic categories, in order to perform a better and more precise diagnosis of hcc or other liver benign or malignant lesion. through a retrospective study, we evaluated and compared preoperative imaging and post-operative histological reports. results reveal that li-rads routine use increases hcc diagnosis up to 95%. background: we previously developed a modified difficulty scoring system (dss-ihd) of laparoscopic liver resection (llr) for patients with intrahepatic duct (ihd) stone. we validated dss-ihd in patients who underwent llr for hepatolithiasis. methods: dss-ihd was based on the extent of liver resection (2 to 4), stone location (1 to 5),atrophy of liver parenchyma (0 to 1), ductal stricture \ 1 cm from the bifurcation (0 to 1), and combined choledochoscopic examination for remnant ihd (0 to 1). results: the dss-ihd ranged from 3 to 12 and divided to 3-level groups of low group (score 3 * 5; n = 26), intermediate group ( objective: improving the surgical treatment of patients with cholangiogenic abscesses of the liver through the application of minimally invasive technologies. material and method: in the presented study presented results of treatment of 49 patients with biliary liver abscesses. surgical interventions for hepatic abscesses were performed simultaneously with the elimination of the primary pathological process of the biliary system, which caused the occurrence of cholangitis, or in the near future (up to 3 days) after biliary drainage drainage. among 49 patients with biliary liver abscesses, treated with minimally invasive methods, 29 revealed abscesses of the right hepatic lobe, 15-abscesses of the left hepatic lobe, 5-abscesses and right and left hepatic lobes. single abscesses were detected in 39 patients, and in 10-two or more abscesses. in terms of liver abscesses, more than 3 cm were detected in 43 patients, more than 5 cm in 6 patients. drainage of the biliary tract was carried out endoscopically transpapillary and (if the endoscopic approach was unsuccessful) with transcutaneous transhepatic approach. results: drainage under ultrasound guidance was performed on 21 patients with solitary and 7 patients with two or more cholangiogenic abscesses of the liver. laparoscopic interventions were performed on 21 patients. among the patients operated on using minimally invasive technologies, 7 occurred complications (14.3%). 1 patient died due to the development of biliary sepsis (2.0%). conclusion: percutaneous drainage of liver abscesses under ultrasound control is appropriate not only for single abscesses, but also for their larger number, which has many advantages over other interventions. it was proved possibility of simultaneous drainage of liver abscess and bile duct. percutaneous drainage of the liver abscess, drainage of the biliary tract and laparoscopic surgical intervention are complementary aspects in the treatment of liver abscesses of biliary origin. after laparoscopy residual calculus can be removed endoscopically in more favorable conditions after stabilization of the patient's condition is achieved and the infection-associated disorders are eliminated. in case of localization of abscesses in the marginal segments of the liver, laparoscopic atypical resection of the liver with an abscess is most desirable. general surgery, rambam medical center, haifa, israel background: recently robotic surgery has emerged as one of the most promising surgical advances. despite its worldwide acceptance in many different surgical specialties, the use of robotic assistance in the field of hepatobiliary (hbp) surgery remains relatively unexplored. our study presents single institution's initial experience of robotic assisted surgery for treatment of benign hepatobiliary pathologies. methods: a retrospective analysis of a prospectively maintained database on clinical outcomes was performed for 26 consecutive patients that underwent robotic assisted surgery for benign hbp disease at rambam medical center during 2013-2015. results: there were 26 robotic assisted surgical procedures performed for benign hbp pathologies during the study period. there were 3 anatomical robotic liver resections for symptomatic hemangiomas, 9 cases of giant liver cyst, 5 robotic assisted surgery for type i choledochal cyst, 2 case of benign (iatrogenic) common bile duct (cbd) stricture, 3 cases of robotic (cbd) exploration due to large intra choledochal stones and 6 cases of cholecystectomy for cholelithiasis. the median postoperative hospital stays for all procedures were 3.5 days (range 1-6 days). general morbidity (minor) was 2%. there was no mortality in our series. conclusion: robotic surgery is feasible and can be safely performed in patients with different benign hbp pathologies. further evaluation with clinical trials is required to validate it's real benefits. most liver cysts are asymptomatic and tend to have a benign clinical course. however, symptomatic or complicated liver cysts sometimes require surgical intervention. needle aspiration is safe and can be the lease invasive procedure, this procedure is however associated with a high failure rate and rapid recurrence. surgical approach is the crucial and provides definitive treatment for such cysts. thirteen cases were nominated from shonan kamakura general hospital between january 2015 and december 2018. mean age and body mass index (bmi) were 67.8 and 20.8, respectively. all patients have had any complaint such as upper abdominal pain, dyspnea, and fever. two cases were clinically diagnosed as the infectious cyst and serum crp was elevated before surgery. additional cholecystectomy was planned for one case of chronic cholecystitis with gallbladder stones. all cases were prompted the reduced port surgery (rps) and 4 cases were performed rps with trans-vaginal approach (hybrid notes) and 4 case was chosen in single port surgery. cyst unroofing was performed for all cases. mean operation time and blood loss of all cases were 122.3 min. and 62.7 ml, respectively. no surgical complication has been occurred in all cases, an infectious cyst case was however required additional drainage for infectious control after surgery. although statistic difference was not shown, fewer blood loss and shorter hospital stay was seen in non-infectious cases, compared to laparotomy cases. mean hospital stay after surgery of whole cases, non-infectious cases, infectious cases was 5.5, 2.5, 22.5 days, respectively . no recurrence of any symptom was shown in any cases in observation period (10-1392 days) . laparoscopic unroofing is the definitive treatment for the complicated or symptomatic liver cyst. however, for the infectious cyst, infection control such as intensive drainage and/or administration of antibiotic before surgery may be needed to avoid additional treatment, leading to longer hospital stay. laparoscopic unroofing of liver cyst can be the first choice for symptomatic or complicated liver cyst. also, reduced port surgery can be nominated to achieve less invasiveness. introducction: laparoscopic liver resection (llr) has been increasing since it was first reported in 1991. three international expert consensus conferences on llr surgery were held in louisville, ky, usa, in 2008 , morioka, japan in 2014 and southampton, uk, in 2017 . while most initial minimally invasive liver resections were typically done for benign lesions in anterior o left segments, llr is currently being applied for major anatomic resections, malignancy, cirrhosis and liver donor hepatectomy. clinical case report: this is a 78-year-old male patient with a history of hta and liver cirrhosis due to hepatitis b virus. hepatocarcinoma is diagnosed in liver segment vi with a size of 3 cm . in the digestive study the patient presents a child a stage, meld \ 9, without signs of portal hypertension. complete analytical with normal afp and cea 19.9 markers. after presentation of the patient in a multidisciplinary committee and being a stadium according to the early bclc classification, laparoscopic surgery with segment vi resection was decided. discussion: laparoscopic liver resection is becoming widely accepted for the treatment of hepatocellular carcinoma. liver resection is a first-line option in very early and early-stage disease. many meta-analysis have shown that llr is better than open liver resection in terms of short-term outcomes for patients with child-pugh a cirrhosis, solitary tumors, and minor resections. in the long-term setting, the results demonstrate that a minimally invasive approach is comparable to an open approach in terms of overall. in conclusion, the current evidence conclude than llrs for hcc are safe and may be considered a standard practice in specific settings. results: there were 6 women (43%) and 6 men (57%). the age of patients ranged from 43 to 82 years. the patients underwent complex examination including abdominal ultrasound, esophagogastroduodenoscopy, and some of them underwent ct (computed tomography). all patients in the first stage were performed antegrade external drainage of biliary tracts with x-rays of the biliary tracts, and specifying the level and extent of the block.total 28 miniinvasive interventions were hold. two patients in connection with the uncoupling of equity ducts were performed antegrade bilobar stenting with preliminary split external bile release.there were complications after carried out interventions in 10 cases, which were associated with dislocation of holangiostomic drainage in 5 patients (35.7%); with acute cholecystitis in 1 patient (7.1%); with hydrothorax in 2 patients (14.2%); perihepatic biloma in 1 case (7.1%).1 patient (7.1%) had a recurrence of obstructive jaundice due to germination of endobiliary stent in the late period after stenting. lethal outcome appeared in 1 patient. conclusions: ultrasound examination allows us to determine the level of obstruction of the biliary tract, to substantiate the tactical position in the application of mini-invasive technologies. antegrade miniinvasive technologies in the treatment of tumor lesions of the proximal bile ducts allow timely and effectively stop biliary hypertension and to determine further treatment strategy. acknowledgements this study was supported by the russian science foundation under project ? 18-15-00201. background: repeat hepatectomy is an effective treatment, with long-term surgical outcomes for recurrent hcc and colorectal liver metastasis(crlm). however, the efficacy of a minimally invasive surgical approach for recurrent liver tumor is not yet confirmed. the purpose of this study is to examine the efficacy of laparoscopic repeat hepatectomy(lrh) compared with open repeat hepatectomy(orh) for recurrent liver tumor. we retrospectively analyzed the clinicopathological features and short-term surgical outcomes between lrh and orh. methods: from 2006 to 2018, 158 patients with liver cancer underwent repeat hepatectomy. of those patients, 113 patients underwent partial hepatectomy, 37 patients were undergone laparoscopically, and 76 patients underwent open hepatectomy. we compared the clinicopathological and surgical parameters in the lrh group with those in the orh group. results: there were no significant differences in patients' gender, age, viral infection status, child-pugh classification, tumor size, tumor number, and tumor location in the two groups. the operative times were similar, but blood loss was significantly lower in lrh group (68 vs. 310 ml, p \ 0.001). the postoperative hospital stay was significantly shorter in the lrh group (9.0 vs. 11.5 days, p = 0.016). postoperative complications(cd = 3a) were observed only in the orh group, with a complication rate of 9.2%. conclusions: we demonstrate that lrh reduces blood loss and postoperative complications compared with orh. lrh might be a feasible and effective procedure for the selected patients. background: the liver is the most common site of metastatic disease with up 40-50% of all cancers having the potentiality for sending liver metastasis during the disease. consequently, increasing value for surgical resection of hepatic deposits of different types of cancers, the need for accurate evaluation of the extent of hepatic metastasis was established for choosing the most suitable patients for surgery and in planning the extent of hepatic resection. the aim of this work is to evaluate the role of intra-operative ultrasound in the detection of hepatic deposits in intra-abdominal malignancies with special emphasis on its accuracy, sensitivity, specificity. patients and method: this study was carried out on thirty patients who were admitted to the gastrointestinal surgery unit, main alexandria university hospital with intra-abdominal malignancies for whom elective open surgical intervention was recommended in the period from 1st of september 2017 till the 31th of march 2018. results: in the present study consisted of 17 males (56.7%) and 13 females (43.3%). their mean age at admission was 52.77 ± 9.12 years. six of the included patients (20%) were found to have hepatic lesions by using ious including the four cases (13.3%) already detected by preoperative imaging. two cases (6.67%) were newly discovered in the operative room by using ious. conclusion: the current study has proved that ious demonstrates superior lesion detection over the various non-invasive preoperative imaging modalities causing significant impact on change of the planned surgical strategy laparoscopic approach to the liver has become an integral part of surgery. two consecutive international consensus meeting recommends major hepatectomy has been on the expert hands. tumors located in the right posterior section are considered to be difficult for laparoscopic resection. patients and methods: since 2005, until 2017, cnuhh has been performing 260 laparoscopic hepatectomies including 67 major hepatectomies. among 67 major ones, there are 36 rh, 13 lh, 16 rps, 2 ch, and 1 as. we analyze data on patient demographics, tumor characteristics, operative date, and posterior outcome retrospectively. results: during 2014-2017, 16 laparoscopic rps were performed. the diagnosis were hcc in 13 and crlm in 3 patients. median operative time was 405 min, and median blood loss was 850 ml. no blood transfusion was occurred. median tumor size was 38 mm, and median resection margin was 12.3 mm. six of the 16 patients (38%) were cirrhotic on pathology. there was no conversion and was no postoperative mortality. median hospital stay was 11.6 days. conclusion: laparoscopic rps is known challenging procecedure. strict preoperative planning and operative procedure is mandatory. even though it should be performed by the experienced hands both on hepatic surgery and laparoscopic skill, it can be an good option for treatment of the tumor locating over right posterior section. purpose: previously we developed a new sponge (named endoractor) as an organ retraction device in laparoscopic surgery in 2009 and have reported that it is useful in various surgical procedures including rectal surgery we confirmed that it is also useful in laparoscopic radiofrequency ablation of the liver in terms of pulling and protecting organ, so we report it materials and methods: a case is an 82-year-old female with liver cirrhosis. she had primary hepatocellular carcinoma in s8 lesion with a diameter of 1.8 cm very close to the inferior vena cava and middle hepatic vein root and in s3 lesion with a diameter of 2.0 cm we thought she could not put up with hepatic resection because of her poor hepatic reserve capacity. and we could not expect treatment effect by embolization therapy since contrast effect was poor. so we decided to select ablation therapy in the puncture and ablation of the s8 tumor, since there was concern about the thermal damage of the middle hepatic vein and the cooling effect by the inferior vena cava, we would dissect the right coronary mesentery sufficiently and pull the liver apart from the inferior vena cava and the middle hepatic vein as much as possible using our endoractor also, in the puncture and ablation of the s3 tumor, it was feared that the stomach would be thermally damaged, so we would place endoclactor between the liver and the stomach to protect the stomach results: when ablating the s8 tumor, we could pull the liver securely without slipping, so we did not cause thermal damage to the middle hepatic vein. and there was no cooling effect by the inferior vena cava, so we could obtain sufficient cautery margin. in ablation of s3 tumor, we were able to puncture by stabilizing the lateral segment of the liver on our endoractor, and avoid thermal damage of the stomach conclusion: it seems possible to perform safe and reliable puncture and ablation by using our endoractor as well in laparoscopic radiofrequency ablation surg endosc (2019) surgical reinterventions in patients with complicated hepatic hydatid cysts usually occur as a result of diagnostic or technical failures during the initial procedure. according to recent studies, the most common complication after liver hydatid cyst surgery is local sepsis at the residual cavity and long-term biliary leak. we report the case of a 21-year-old male with a history of liver hydatid disease four years before the current episode, admitted in our surgical department for intense upper right quadrant pain. abdominal ultrasonography, ct and mri scans revealed three cysts in the gastrosplenic ligament, in liver segments vii-viii, and ii-iii respectively, sized between 4 and 8 cm. the intraoperative aspect during laparoscopy was strongly suggestive for liver hydatid disease. laparoscopic fenestration with tunneling for the hepatic cyst in segment viii, partial cystectomy in the left liver lobe and ideal cystectomy in the gastrosplenic ligament were performed. postoperatively, the patient displayed a constant biliary drainage output of 500-600 ml from the cavity remnant in the segment viii. conservative therapy for external biliary fistula and concomitant treatment with albendazole for 3 months were initiated. evolution was slowly favorable with decreased biliary drainage to 200 ml two months after surgery and complete symptom resolution five months after hospital discharge. aims: this study aimed to evaluate the effectiveness of fluorescence imaging with indocyanine green (icg) during laparoscopic deroofing of hepatic cysts. methods: this was a single-center, case-control study. we included 14 patients who underwent laparoscopic deroofing between november 2008 and october 2018. imaging with and without icg fluorescence was performed in 10 (icg group) and 4 (non-icg group) patients, respectively. icg was intravenously administered between 15 min and 6.5 h before surgery. we performed a standard laparoscopic procedure. we detected a thin bile duct on the hepatic cyst on using intraoperative icg fluorescence imaging. we adjusted the resection line of the cyst wall and ligated the bile duct at the point at which it crossed the resection line. data on age, sex, cyst size, resected cyst size, operative time, estimated blood loss, post-operative hospital stay, complications, and recurrence were compared between the groups. results: the mean cyst size was 139 ± 30.9 and 138 ± 32.5 mm, the mean resected cyst size was 139 ± 51.1 and 86 ± 39.9 mm, and the mean operative time was 95.8 ± 30.8 and 152 ± 72.8 min in the icg and non-icg groups, respectively. using icg fluorescence imaging, the bile duct was detected on the cyst wall in 4 patients (40%). all surgeries were completed laparoscopically, and no post-operative complications occurred in either group. recurrence of the hepatic cyst occurred in one patient (25%) of the non-icg group. conclusions: fluorescence imaging with icg is used widely in hepatobiliary surgery for intraoperative identification of biliary and vascular anatomies. this method does not require complicated techniques or instruments. icg fluorescence imaging may facilitate the prevention of intra-or post-operative complications, such as biliary leakage, in laparoscopic surgery. in this study, icg fluorescence imaging was found to be effective in detecting the bile duct on the cyst wall intraoperatively, allowing for wider resection of the cyst and avoiding inadvertent injury. our study suggests that wider resection of the cyst wall might prevent recurrence of hepatic and that icg fluorescence imaging could ensure procedural safety. abdominal ct showed: large hepatic cyst (18x17,8x22 cm size), with no malignity signs, that occupies practically the whole right liver, causing subsegmentary atelectasis of the middle lobe, superior and inferior cava vein compression, and displacement of right kidney, pancreas and right atrial. due to breath involvement, a percutaneous drainage is performed achieving clinical improvement and reduction of the size of the injury. the patient was released but a cyst superinfection occurred; once this problem was solved, the drainage was removed. results: in light of the complication, surgical treatment was decided, which confirmed the large cyst located in right posterior hepatic segments with tight diaphragmatic adhesions. we carried out the cyst evacuation and a wide laparoscopic resection of the cyst walls, until the posterior area of the cava vein, combining supra and infrahepatic access. the patient was released on the sixth postoperative day and continues asymptomatic. conclusions: simple cysts can be approached in a no surgical way (punction-aspiration with/ without sclerosing products injections) or in a surgical way (cyst wall fenestrations, cystectomy or liver resections). a conservative treatment will obtain symptomatic relief but with a high risk of recurring. recurrence is the main drawback of unroofing. cystectomy is the better option but may be too complicated depending on the cyst's location. to our patient, we carried out a wide laparoscopic unroofing (even though its posterior localization) to minimize recurrence possibilities. in conclusion, laparoscopic resection of the cyst wall is a simple and effective approach in symptomatic or complicated cases. background: single-incision laparoscopic surgery or laparoendoscopic single-site surgery is emerging as an alternative to conventional multiple-incision laparoscopic surgery. it has a potential benefit of less postoperative pain and faster recovery compared with conventional multiple-incision laparoscopic surgery. single-incision laparoscopic hepatectomy (silh) has been reported in only a few small series and the majority were minor resections. case report: a 54 y/o male patient is a case of chronic viral hepatitis b and early cirrhosis of liver. two atypical hepatocellular carcinomas (up to 2.4 cm in diameter) located at the junctions of segments 6 & 7 and segments 5 & 6 were impressed by liver magnetic resonance imaging (mri). we performed single-incision laparoscopic anatomical hepatic resection of the right posterior section via a 5-cm transverse incision on the right middle abdominal wall. inflow control was carried out with an extra-glissonian approach before parenchymal transection. the glissonean pedicles of segments 6 and 7 were divided by linear staplers respectively as well as a major branch of the right hepatic vein in segment 7. the operative time was 580 min and the estimated blood loss was 150 ml. the pathologic examination revealed two foci of hepatocyte dysplasia with a safe margin of 4 cm. the patient was discharged eight days after the surgery uneventfully. conclusion: single-incision laparoscopic anatomical right posterior sectionectomy is feasible and safe by experienced laparoscopic surgeons. it provides a fast recovery but needs a long operative time. the mortality in the patient with liver cirrhosis is very high. the aim of this work was to decrease mortality and morbidity by using endoscopic local heamostasis and laparoscopic operations, in the patients with bleeding from cirrhosis by variceal bleeding. methods and material: we observed 692 patients with cirrhosis complicated by variceal bleeding during 12 years. there were 260 patients with child phue a, 279 ones with child phue b, 153 ones with child phue c. all the patients were performed prolonged endoscopic heamostasis with conservative therapy. the main methods that we used were the ligation in 345 cases, sealing in 50 cases, sclerotherapy in 158 cases. in 18 cases we couldn't stop the bleeding with band ligation method and introduce the danis stents into esophagus and stopped the bleeding successfully. to prevent the re-bleeding we performed the laparoscopic dissection the abdominal part of esophagus with suturing the venous vessels, coagulations and dissection of short gastric vessels between stomach and spleen, clipping the left gastric artery and vein in the 67 patients. in 29 patients we performed laparoscopical suturing the variceal veins by introducing the laparoscopic trocars into the stomach. in 35 cases with varices vien of stomach, with non-effective local endoscopic heamostasis we performed laparoscopic resection the fundal part of stomach. results: endoscopic local heamostasis were successful (in 85%) in 588 cases. the relapse of bleeding were in 85 patients. 25 patients died. there was no mortality after laparoscopic operations. there were 7 cases for trocar wounds infection, 3 cases of subphrenic abscess. goals: the advance of laparoscopic surgery also includes the more complex procedures of abdominal surgery such as those affecting the liver and pancreas. there are multiple indications that laparoscopy has in hepatobiliopancreatic surgery, both in benign and malignant pathologies. material and methods: we present the video of a 78-year-old male patient with a history of right hemicolectomy due to disease-free intestinal lymphoma who, in the control analysis by his attending physician, detects the elevation of tumor markers. an extension study was started showing a hepatic lesion in the caudate lobe with a pathological anatomy suggestive of hepatocarcinoma and an adenopathy suspicious for malignancy adjacent to the right renal vein. the clinical case is presented in a multidisciplinary tumor committee and it is decided to perform surgery. a laparoscopic caudate lobe resection was performed, previously performing intraoperative ultrasound and a lymphadenectomy of the portal territory, vena cava and exeresis of adenopathy of the right renal vein. introduction: major vascular complications during laparoscopic surgery occur approximately in one in 1000 cases, but mortality rate can reach 8-17%. most major vascular injuries lead to conversion to laparotomy but successful laparoscopic repair is also possible. simulation training improves laparoscopic performance and possibly reduces surgeons mental strain. materials & methods: during two editions of advanced laparoscopic training course 12 participants had a task to control a major vessel damage (damage). before the task an educational video explaining the methods of obtaining haemostasis was shown. the algorithm of the 'damage' task was as follows: without previous preparation a 1 cm injury of a major vessel was done with l-hook electrocautery. after the injury participants were free to control the damage the way they wanted. heart rate of the participants was measured with an ear electrode. measurements were carried out 3 times-before the injury, immediately after, and afterwards obtaining vessel control. after participants were interviewed for their feelings after the 'damage' task. results: there were 12 vessel injuries in 10 animals. one animal died during the 'damage' task 20 min after desuflation due to relapse of bleeding. there was no conversion to open procedure. temporary vessel control was obtained with different methods. all participants used vicryl 2.0 or pds ii 3.0 suture for final hemostatic purposes. heart rate of the participants before injury were 52-85 ± 3.33 bpm, immediately after the injury it rose to 75-120 ± 4.31 bpm, and after obtaining vessel control were in the range 50-100 ± 4.83 bpm. a statistically significant difference was found between the ratio of the first and second hr measurement (p = 0.01, t = -9.727), and second compared to the third (p = 0.02, t = 4.177) measurement. participants judged their experience on a 5-point scale (1was not helpful at all; 5-was extremely educative). the educational value of the task received 5 points in 11 cases and 3 points in one case. conclusion: participants feel stress during major vessel bleeding even in animal model, and this stress can result in a serious intraoperative mental strain and significantly increase heart rate. participants found the 'damage' task very useful for their daily practice. the aim of study was to improve the results of treatment of patients with hepatic echinococcal cysts by using of argon plasma coagulation. methods: the analysis of treatment results of 66 patients was put into the basis of this study. it was 12 (18.2%) men and 54 (81.8%) women in total. an average age of them was 47.7 ± 15.9 years. the main difference between groups was a way of liver parenchyma coagulation in order to make reliable hemostasis. in main group the final stage of surgical intervention on liver was argon plasma coagulation. it was performed to 45 (68.2%) patients. alternatively, monopolar coagulation was performed to 21 (31.8%) patients (comparison group). results: in main group in the 86.6% cases pericystectomy was conducted. the resecting surgeries was performed to 13.4% cases. in comparison group was conducted in 28.6% cases. in early postoperative period in main group the complications were observed in 4.4% of cases. the same parameter was 4.8% in comparison group. it led to relaparomies. the forming of external biliary fistulas was observed in 2 (4.4%) patients in main group and in 3 (14.3%) patients in comparison group. however, all the fistulas have closed spontaneously on 7th-10th day in both groups. hernias of abdominal wall and peritoneal adhesions that manifested by intestinal obstruction of different degree were considered as complications of late postoperative period. these values were 0% and 4.4% in main group versus 19% and 14.3% in comparison group, respectively. the resection of hepatic echinococcal cysts with further application of argon plasma coagulation on the cyst bed was accompanied by complications quantity decrease in patients that underwent surgery in early as well as in late postoperative period. in this case more positive dynamics of functional liver values improvements was observed. aims: indocyanine green (icg) fluorescence imaging has been reported as a reliable and safe navigation tool in laparoscopic hepatectomy. however, the factors affecting the sensitivity of tumor detection with icg fluorescence imaging is relatively unclear. the aim of the present study is to analyze the factors of successful icg fluorescence in laparoscopic hepatectomy. methods: this is a retrospective single-center study. this study population consisted of 80 laparoscopic hepatectomies from january 2018 to november 2018 undertaken at kurashiki central hospital. we excluded patients whose tumors were located more than 10 mm from the liver surface, those who did not receive icg fluorescence imaging, and those who were not injected with icg dye (0.5 mg/kg) intravenously within 7 days of surgery. the pinpoint endoscopic fluorescence imaging system was used to detect the tumor location. we evaluated the relationship between successful fluorescence and the timing of injecting icg before operation, tumor size, icg r15, liver damage and bmi. results: following exclusion, 15 patients were eligible for analysis. among the 16 tumors resected, icg fluorescence imaging detected 9 tumors (56.3%), including 6 hepatocellular carcinomas and 3 liver metastases. icg fluorescence imaging detected all 9 tumors in the patients injected with icg 2 to 5 days before hepatectomies . icg fluorescence imaging detected all 9 tumors which were more than 10 mm in diameter. there was no relationship between indocyanine green fluorescence with icg r15, liver damage and bmi. conclusions: the injection of icg 2 to 5 days before operation and a tumor size of more than 10 mm can be factors in successful fluorescence in laparoscopic hepatectomy. introduction: cysts in the liver have a wide variety of aetiologies. it is important to characterize the cystic lesion before treating it. the simple cyst has a low prevalence and is more frequent in women. fenestration is a useful option for the treatment of simple cysts in selected patients. case presentation: a 40-year-old woman was referred to our hospital with a one-year history of intermittent, right upper quadrant pain, with no other associated symptoms. computed tomography and magnetic resonance imaging showed a large cyst (14,4 x 13,2 cm) in the right of the liver. the cyst presented lobulated morphology, smooth edges and well delimited. there were other smaller cysts in the left lobe. hepatic function in blood analysis was normal. biomarkers, tumor markers and hepatitis virus markers were negative. outpatient follow-up and symptomatic treatment of pain was decided. after six months of follow-up, the pain persisted, so surgical treatment was proposed. a laparoscopic fenestration was performed, widely resecting the free wall of the cyst. there was no evidence of a connection to the bile duct. there were no complications. on 3 days she was discharged. discussion: some giant hepatics cysts become symptomatic due to mass effect. persistence of pain is an indication of surgical treatment. laparoscopic fenestration is an alternative for the management of simple hepatic cysts. aim: laparoscopic liver resection for malignant pathology such as colorectal cancer metastases has been a matter of discussion for several groups in the last years. it has been proposed as a safe and feasible treatment but subjects like short and long term outcomes and oncologic results have not been adequately assessed. methods: we performed an observacional retrospective study of patients undergoing laparoscopic liver resection for colorectal metastases in our center. from november 2007 to november 2018 a total of 113 patients underwent laparoscopic liver resection. data for resection margin, hepatic and extrahepatic recurrence and both disease free survival and overal survival were collected. patients were discussed in a multidisciplinary group with oncologist, radioterapic oncologist and surgeons. the surgical procedures were perfomed by the same team in all the cases to minimize bias. results: a total of 9 patients (7.9%) were non resectable at the time of surgery.the mean overall survival was 19 months with a maximum of 132 months. we got a mean of disease free survival in our patients of 11.7 months. the hepatic recurrence was 28%, most of them in high risk patients, and from this group 67.74% underwent a new liver resection. major complications took place in 9 patients (7.96%) two biliar leaks, one bowel perforation, two hepatic failure, one evisceration and three respiratory insufficiency needing urgent surgery in three of the cases. mean hospital stay was 5.84 days. a mean of 2 days of this stay were in an intensive care unit. conclusions: laparoscopic liver resection for colorectal liver metastases could be a feasible technique when perfomed by trained surgeons. it improves the postoperatory recovery with a reduction of hospital stay and less postoperatory pain without increasing the development of major complications or mortality in the first 30 days after surgery. we got good oncological results that have been improving with the experience acquisition of the surgical team. aged 29 to 71 underwent surgery for cirrhosis with massive refractory ascites child c (9-10), without obvious signs of hepatic encephalopathy. major etiological factors were: viral hepatitis c (47 patients (48.0%)), b (29 patients (29.6%)), b ? d (17 patients (17.3%)), toxicity (5 patients (5,1%) ). to prevent possible bleeding at the first stage, endoscopic filling of esophageal varices with fibrin glue was performed in 81 patients (82.7%). after testing the effectiveness of varices filling, in the following 5-7 days decompression surgery of thoracic lymphatic duct was performed under local anesthesia to improve lymphatic drainage from liver and abdominal organs. simultaneously, laparoscopic sanitation of abdominal cavity was performed, with complete evacuation of ascites fluid, rinsing and drainage. fractional post-surgery rinsing was repeated daily for 3-5 days towards removing peritoneum edema and improving its absorptive properties. results evaluation was performed 3, 6 and 12 months after surgery, based on criteria of liver reserves and ascites volume. results: post-surgery mortality from liver failure was 5.1% (5 patients) . 7 other patients died of the same cause the following 3-6 months. annual survival rate was 87.6%. complete ascites regression over 3-12 months after surgery was noted in 53 patients (55.8%), significant regression and stabilization in 25 (25.6%), moderate regression with need for periodic decompressive laparocentesis in 8 cases. in all patients, functional liver reserves and life quality significantly improved. conclusions: the use of the given technique of refractory ascites correction, in patients with depleted liver cirrhosis, by laparoscopic sanitation with post-surgery fractional rinsing of abdominal cavity, with simultaneous decompression of thoracic lymphatic duct showed very high efficiency and deserves establishment as a clinical practice. t. urade, hepato-biliary-pancreatic surgery, kobe university, kobe, japan aim: anatomical liver resections guided by a demarcation line after portal staining or inflow clamping of the target territory were established as essential methods for the curative treatment of hepatocellular carcinoma (hcc) and then subsequently applied to other malignancies. however, laparoscopic anatomical liver resection (lalr) is much more difficult to reproduce these procedures and to confirm demarcation of the hepatic segment visually on the monitor. recently, laparoscopic fluorescence imaging system has been used as a tool for real-time intraoperative navigation in llr. the aim of this study is to demonstrate how to perform lalr using indocyanine green (icg) fluorescence imaging. methods: three patients underwent pure lalr using icg fluorescence imaging. the following operative procedures were performed: 1 partial liver resection for hcc, 1 segmentectomy for liver metastasis and right anterior sectionectomy for hcc. in all patients, preoperative 3d simulation images from dynamic ct were reconstructed using a 3d workstation to decide on cutting points of the glissonean branches. after mobilization of the liver, intraoperative ultrasonography was performed to identify the location of the tumor and glissonean pedicles corresponding to the tumor-bearing hepatic region. we dissected or transected the hepatic parenchyma to encircle the glissonean pedicles. after clamping or closure of them, 2.5 mg of icg was injected intravenously to identify the boundaries of the hepatic segments under near-infrared light. parenchymal transection was started according to the demarcation on the liver surface. the lateral aspect of the parenchymal transection was carried out based on the demarcation between non-fluorescing and fluorescing liver parenchyma as far as possible. results: in all the 3 cases, demarcation lines on the liver surface could be visualized clearly after injection of icg. in addition, boundaries of cone units, segments and sections could be recognized to some extent because the tumor-bearing hepatic region became non-fluorescing parenchyma during parenchymal transection. these procedures were completed successfully, and the postoperative courses were almost uneventful. aim: sintrahepatic cholangiocarcinoma is the second most common primary liver cancer after hepatocellular carcinoma (hcc). although the laparoscopic approach of these tumours is not frequent due to its complexity, it is performed increasingly by hepatic surgeons.traditionally, the abdominal surgery in cirrhotic patients has been reserved to selected cases secondary to the high rate of complications. the advance on the treatment of the hcc on liver cirrhosis and the higher safety when performed by laparoscopic approach has encourage some surgeons to extend surgery to child b-c or portal hypertension patients. methods: we present a male of 56 years old, diagnosed in 2010 of liver cirrhosis accompanied with portal hypertension. on mri in 2012 was found a solid lesion of 25 mm located on segment ii hepatic. biopsy confirmed the diagnostic of intrahepatic cholangiocarcinoma. after a liver function evaluation (child c, meld 17), an hepatic chemoembolization was performed. sequentially ct scans indicated a complete radiologic response. after 6 years of follow up, mri showed a recurrence of 25 mm between segment ii and iii of the liver.on multidisciplinary committee liver resection was decided due to suitable liver function and low aggressiveness of the tumour. a laparoscopic left lobe liver resection was performed. sonastarò and ligasure tm were used to perform the liver transection and endo gia tm for portal and hepatic veins sections. the surgery develop was complicated due to trend to bleeding that finally was achieve through cauterization. results: early after the surgery, the patient presented a haematic debt through the drain of 900 cc accompanied of hypotension, therefore an emergent surgery was indicated. an exploratory laparoscopy was performed finding hemoperitoneum and diffuse bleeding of the liver surface that was controlled. the patient had a proper recovery and was discharged on the 11 th day post-surgery. the analysis of the specimen showed a 6.5 cm cholangiocarcinoma with a 0.4 cm margin of resection. conclusion: there is an augmented risk of complications on liver resection of cirrhotic patients with portal hypertension. the laparoscopic approach allows to reduce potential complications, despite bleeding continuous to jeopardize this surgery, this option could be proposed on selected patients. introduction: accessory spleen itself is found in approximately 7% to 15% of the population. most (80%) are located near the splenic hilum but intrapancreatic accessory spleens (ipas) are the second most frequent location (16.8%) of accessory spleens. in adults, ipas are clinically silent. they may become clinically important because of their radiographic similar appearence of cancer. intrapancreatic accessory spleen is a rare cause of pancreatic pseudotumors and is located in the pancreatic tail in approximately 1% to 2%. ipas can be difficult to differentiate radiologically from hypervascular pancreatic tumors such as pancreatic endocrine neoplasms because theycan share a similar enhancement pattern. as a result, most of the reported cases of ipas have been diagnosedonly after distal pancreatectomy was completed. material and methods: we present the case of a 55-year-old male patient with a history of large vessel vasculitis followed-up for rheumatology, which showed a pancreatic nodule in a control ct so he was referred to digestive for study. an echoendoscopy was performed. it showed, at the level of the tail, in the third distal, a lesion of 16x12 mm, hypoechoic, with rounded morphology and well-defined edges that can not be biopsied given the absence of adequate window for the realization of fine needle aspiration biopsy (fnab). based on these radiographic findings, the differential diagnosis included a pancreatic endocrine tumor. due to the high suspicion of malignancy and the absence of biopsy, he was referred to general surgery for scheduled surgery. a laparoscopic corporocaudal pancreatectomy was performed without incidents and the definitive histology showed an intrapancreatic accessory spleen in the pancreatic tail that excluded the presence of cancer. conclusion: intrapanceratic accesory spleen is a challenging diagnosis to make and it should be included in the differential diagnosis of pancreatic neoplasm. its early identification precludes surgical resection. however, the preoperative diagnosis of ipasmay be difficult, and distal pancreatectomy is a safe and relatively simple operation, most of the reported cases of ipas being diagnosed correctly only after surgery there are various options for treating pps. this paper describes our tailored and methodological approach to laparoscopic drainage of pancreatic pseudocysts based on an anatomical classification. methods: we adopted the laparoscopic approach in 28 patients who had pps requiring surgical drainage. the laparoscopic method had been decided according to preoperative computed tomography (ct) and intraoperative findings. the results shown represent median (range). the aim of this work was to decrease mortality and morbidity in patients with combined trauma. methods and material: for 5 years 667 patients were brought to our clinic with combined trauma. everybody was performed ct and ultrasound examination. 286 patients were performed open laparatomic operation due to massive liver rupture, spleen rupture and massive trauma of bowels, pancreas and kidney with massive bleeding. in 106 circumstances we didn't found the trauma of the abdominal organs and the massive abdominal bleeding after ct observation. those patients were cured conservatively. in 275 circumstances with combined trauma after ct examination we performed laparoscopic operation. in 97 circumstances from the 275 patients, who we started laparoscopic operation in, we conversed to laparotomy, due to massive liver rupture, and trauma spleen and hollow organs. in those 112 circumstances we performed urgent laparotomies with suture ligation of bleeding points, suturing of liver and hollow organs and drainage of abdomen cavity. results: we performed laparoscopic operation in 178 patients. in 107 circumstances with trauma of liver we performed laparoscopic electro coagulation and argon-plasma coagulation. in 66 circumstances with trauma of liver we performed electro coagulation with packing the omenture to its surface. in 5 circumstances with trauma of spleen we performed argon plasma coagulation and used fibrin glue. after laparotomic operations mortality were in 35 circumstances, morbidity were in 87 patients. after laparoscopic operation mortality were in 5 circumstances of severe combined trauma with multiple abdominal trauma and morbidity in 11 patients. conclusion: laparoscopic operations in patients with combined trauma decrease mortality and morbility. aims: in laparoscopic distal pancreatectomy, getting away liver and stomach from the surface of the pancreas is sometimes difficult. when we separate the pancreatic body from the retroperitoneum, we must not injure the pancreas to prevent breaking a tumor. when we cut the dorsal side of the spleen from the retroperitoneum, we rarely cut into the spleen accidentally. based on our experiences, we gradually explored a set of procedural operation steps to resolve these problems. our three-step maneuver simplifies the procedure and improves the efficiency and safety of laparoscopic distal pancreatectomy. methods: as the first step, to get away the liver we sutured the round ligament of liver and crus of the diaphragm using 3-0 pds and the both ends were tugged form the outside of the body through both side of the xiphoid process. and the stomach was hung from the outside using two nylon thread like a bridge, so we could see the surface of the pancreas body with a good view. the second step was a rolling up maneuver of the pancreas. when we separate the pancreatic body and tail from the retroperitoneum, we rolled the pancreas with gauze for use in laparoscopic surgery and lifted the gauze up in only one assistant's forceps. then we could find the correct line for dissection clearly. the last step was a hanging maneuver of the spleen. when we cut the dorsal side of the spleen from the retroperitoneum, we hanged the hilum of spleen with cotton tape. with this technique we could find easily the correct line to dissect. results: the operation time was 4 h and 7 min and the estimated blood loss was a little. we did not injure the tumor or spleen in this operation. the patient recovered uneventfully after short hospitalization. conclusion: our three-step maneuver can be effective to perform laparoscopic distal pancreatectomy. about 10-20% of patients with pancreatic collections will develop walled off necrosis, with an associated 8-39% mortality. there are multiple options for intervention and drainage, usually the outcomes after endoscopic drainage are related with the nature of the collections. aims: to evaluate and present the rol of endoscopy in pseudocyst and walled off necrosis treatment, and favorable outcomes. methods and results: we present a case of a 48 years old male, who presented biliary pancreatitis treated with cholecystectomy and transoperative cholangiogram 6 weeks ago. he continued with persistent abdominal pain; his ct scan showed a big walled off necrosis; he was taken to surgery for an endoscopy-assisted laparoscopic cystogastrostomy with necrosectomy, he was discharged 14 days po. conclusions: the step-up management of walled off necrosis has proven to be a better option than conventional surgical or endoscopical techniques alone; by reducing complications and mortality vs conventional necrosectomy. the use of endoscopic treatments reduce the pro-inflamatory response. drainage of walled off necrosis can be done by a transpapilar or transmural endoscopic apporach each one with its own advantages. some authors avoid the use of endoscopy in walled off necrosis because of a higher rate of complications, re-interventions and a greater lenght hospital stay. in our experience, we have achieved excellent results with this combined technique. nearest and longpatients underwent chemotherapy after electroporation procedure. 90 day mortality was 4.3% (n = 1) in electroporation group. it was found that erreversible electroporation improved local recurrence-free survival (12 and 6 months, respectively, p = 0.01) and distant recurrence free survival (15 and 8 months, respectively, p = 0.03) . overall survival was 18 and 11 months, respectively (p = 0.03). conclusion: irreversible electroporation of locally advanced pancreatic cancer is safe. four month chemotherapy followed by surgical procedure is associated with good local response and better overall survival compared with chemotherapy alone. these data will be validated in further multicenter study. introduction: pancreatic pseudocysts are the most frequent complication of acute or chronic pancreatitis. usually asymptomatic, they can be managed conservative or, in case of complications, by several methods, endoscopic, percutaneous or by surgery. material and method: we present the case of a 41 years old patient known with an episode of acute pancreatitis five years ago, who was hospitalised now for an upper gastrointestinal bleeding with hematemesis. the upper endoscopy showed a subcardial bulking with an erosion of the posterior gastric wall, with signs of recent bleeding, managed by clipping. patient work-up showed a 12 cm pancreatic pseudocyst at endoscopic ultrasound. taking into consideration the history of the patient, the size and the complication of the cyst, the patient was proposed for a drainage intervention. results: a minimally invasive approach was decided. using ultrasonography guidance, a posterior gastrotomy was performed with the cystotome, establishing the comunication with the pancreatic pseudocyst. dilatation of the path with 8 mm cre baloon, with partial evacuation of turbid liquid. the drainage consisted in 2 pigtail 10 fr plastic stents. the patient was discharged the following day in a good health condition.the endoscopic ultrasound control at 3 weeks showed complete resolution of the pancreatic cyst and was followed by stent removal. the endoscopic drainage of the pancreatic pseudocyst represents the first treatment option as an alternative to the surgical intervention, being minimally invasive, with low risk and fast recovery. clinical case report: a 69-year-old man was admitted to the hospital with a diagnosis of severe acute pancreatitis and multi-organ failure. during the first month patient has in uci and non invasive procedures were attempted: enteral feeding by a nasoduodenal tube was started and antibiotics were administered to control sepsis. on day 30, percutaneous drainage was performed for large retroperitoneal abscess. on 67 days, endoscopic transgastric necrosectomy was performed and the left collection was resolved. due to the multi-organ failure persistence and the evidence of size increase of the right retroperitoneal collection, a vard was decided.the right collection was accessed following the previously pigtail catheter. a 12 mm trocar was placed to create retro-pneumoperitoneum with a pressure between 6-8 mmhg. a trocar of 5 mmhg was placed, purulent content was aspirated and a debridement was performed. irrigation and aspirate was performed with normal saline and povidone-iodine solution. drainage was used to perform washes with physiological saline and urokinase.on 146 days, the ct confirmed collection resolution. on 190 days he was discharged. after 8 months, the patient is in good clinical condition. discussion: drainage of the retroperitoneal abscesses via laparotomy is highly invasive and risky. vard enables radical necrosectomy and drainage less invasively. in this patient, the complete resolution of the right collection is obtained with retroperitoneal debridement without complications. we conclude that careful retroperitoneal necrosectomy is a valid alternative for the management of right collections. aims: in this study we analyze laparoscopic approach for hepatocellular carcinoma in order to clarify iwe can take advantage in some outcomes as complications, postoperative recovery or long-term survival outcomes. methods: a retrospective case consecutive study has been taken analyzing: age, sex, body max index, comorbidity, surgical extension and tumor size. the outcomes analyzed were: operation time, intraoperative blood loss, blood transfusion, postoperative morbidity and mortality, intensive care stay, hospital stay, tumor size, r0 resection, conversion rate, early reintervention, disease-free survival rate, overall survival rate results: in this study 15 patients were analyzed 12 males and 3 females with ages between 54 and 73 years (mean age 62) and diverse comorbidities: arterial high pressure (7/15; 46%), diabetes (2/15; 13,3%) ; dislipemy (5/15; 33,3%) , hepatophaty measured as liver cirrhosis (14/15; 93,3%). all of them underwent laparoscopic liver surgery, in 9 cases non-anatomical resection was performed while in the other 6 a segmentectomy was performed. in 12 cases the laparoscopic was strict, in 3 and assistance incision was needed. operative time was 120-525 min (mean: 282 min). blood loss mean was 1,2 g/dl and only 2 intraoperative transfusion were needed. massive blood loss was reported in 1 case. postoperative medical complications were observed: hepatic failure and renal insufficiency and in 1 case we observed a postoperative hemorrhage that needed an urgent reintervention. the mean of intensive care stay was 1 day and hospital stay was 4.93 days. about oncological outcomes r0 resection was achieve in 9/15 (60%), r1 in 6/15(40%). at 3 years 9/15 cases were free disease, 3 dead by progression of disease and 2 dead by other causes. aim: the purpose of this study is to analyze our initial experience with laparoscopic duodenopancreatic resection. introduction: laparoscopic procedures have advanced to represent the new gold standard in many surgical fields. laparoscopic pancreatoduodenectomy and laparoscopic distal pancreatectomy(ldp) are advocated to improved perioperative outcomes, including decreased blood loss, shorter length of stay, reduced postoperative pain and expedited time to functional recovery. however, the indication to minimally invasive approach for pancreatic surgery is often benign or low grade malignances. material and method. the steps of ldp procedures are similar to the open procedure. we perform destructive part of procedure totally laparoscopically and we prefer to do reconstructive part of procedure using hand-assisted techniques. for the period 2014-2017, we have been perform 76 pd, 24(32%) we have done with laparoscopic approach. 6(31%) of patients were operated totally laparoscopic and 18(69%) of patients were operated by handassisted techniques. results: a significantly higher conversion rate was encountered when lc was done 2-6 weeks after es, as compared to 1 week after ercp. it is estimated that pancreatitis after ercp affects roughly three to 10 percent of patients and many endoscopists quote a post-ercp pancreatitis rate of 3-5%. however, 10-15% is probably a more realistic answer for the majority of ercp endoscopists. wise endoscopists inform their patients that there is a spectrum of post ercp pancreatitis severity, from mild ([ 95% of cases) to severe (1-5% of cases). in mild forms, pancreatitis after ercp may resolve itself. conclusion: endoscopic retrograde cholangiopancreatography is a procedure used to diagnose and treat disorders involving the pancreatic and bile ducts. acute pancreatitis is the most common and feared complication of endoscopic retrograde cholangiopancreatography. the assumption is that the duration of the laparoscopic method is longer, but on the other hand the patient have better wound healing and fewer possibility of developing postoperative hernia . the postoperative period is much more simple due to the significantly shorter hospitalization and the faster recovery, and according to patients the level of pain is much smaller as well. however the oncology results are the same. introduction: spiegel hernias are a rare, representing only between 0.1% and 2% of all abdominal wall hernias. due to its location, below the spiegel line, its diagnosis requires a high index of suspicion. the physical examination only detects 50% of the spiegel hernias and, in many occasions, imaging tests are necessary for the diagnosis. goals: our objective is to describe the case of an urgent laparoscopic repair of a case of high grade bowel obstruction secondary to a spiegel hernia. material and methods: we present the case of a 75-year-old male patient with no medical history that comes to the emergency department of our center due to an eight hour evolution of abdominal discomfort associated with nausea without vomiting or other symptoms. the patient was afebrile and hemodynamically stable at all time. on physical examination, the abdomen is soft and depressible, painful on the left flank where a tumor compatible with spiegel's hernia is palpable. in the blood count there is no leukocytosis nor alteration of inflammatory parameters. an abdominal computed tomography (ct) scan was requested from the emergency department which demonstrated a high-grade small bowel obstruction caused by an entrapped loop of distal jejunum conditioned by a left-sided spiegel hernia. given the situation, an informed consent was obtained, and the patient was taken to the operating room for emergency laparoscopic repair. we performed a laparoscopic hernioplasty with ventralpatch mesh between oblique major and transverse and primary closure of defect in continuous suture. after this, the evolution of the patient is favorable, with good oral tolerance and re-establishment of intestinal transit, being able to be discharged 48 h after surgery. the spiegel hernia is a rare entity that requires a high index of suspicion for its diagnosis. despite the limited evidence published in the literature on the laparoscopic repair of incarcerated spiegel hernias, the studies published so far suggest that the laparoscopic repair is a valid alternative to the classic approach when it is performed by a well-trained laparoscopic surgeon. introduction: repair of lateral abdominal wall hernias (both primary and incisional) can be challenging due to the complexity of anatomy, issues with fixation and the low incidence of such cases. a good understanding of abdominal wall and retroperitoneal anatomy, coupled with proficient laparoscopic technique is essential for successful repair via the minimally invasive approach. methods: a retrospective review of a prospectively maintained database was performed to identify patients with lateral abdominal wall hernias who underwent laparoscopic repair from january 2015 to july 2018. results: 11 patients with 12 hernias were identified (6 primary, 6 incisional). mean patient age was 60 (range 22-81) and mean bmi was 27.1 kg/m 2 (range 18. 2-34.6 ). according to ehs classification, the incisional hernia defects were located at subcostal (l1, n = 1), flank (l2, n = 3), iliac (l3, n = 1) and lumbar (l4, n = 1) regions. background: it is commonly admitted that laparoscopic surgery has the advantage of abdominal wall preservation. however, the increased use of laparoscopy has resulted in certain complications specifically associated with the laparoscopic approach, such as trocar-site incisional hernia. until today, it is not finally clarified 'patient-dependent' factors contributing to the occurrence of postoperative hernia after laparoscopic abdominal surgery. methods: between 1996 and 2017, 256 patients were operated due to trocar-site incisional hernia in one surgical centre. 'the patient-depending' factors which caused postoperative trocar site incisional hernia data was collected and retrospectivily analysed. results: port site incisional hernia occurred in 98% (250 patients) after the use of trocars with 10 mm or larger diameter. the presence of metabolic syndrome was the decisive factor in the development of postoperative incisional hernia in 62% (159 patients). in 15% (38 patients) the postoperative hernia occurred on the background of a long cough symptoms caused by chronic obstructive pulmonary diseases. the cause of postoperative hernia in 13% (33 patients) of patients was the condition of lifting a one-time severity or heavy physical work. in 10% (26 patients) of postoperative patients hernia developed due to prolonged constipation of chronic inflammatory colon diseases. conclusions: thus, when the aponeurosis of the trocars is adequately closed, the reason of the occurrence of postoperative hernias was caused by patient-dependent factors which increase intra-abdominal pressure. for this method, small midline incision 3 cm in length 5-6 cm away from hernia orifice was carried out initially. dissection of intraperitoneal adhesion was carried out by sils with sils device. subsequently after closure of initial laparotomy unilateral anterior rectus sheath was incised from the same incision and dissection of retro-rectus space up to preperitoneal space was done under laparoscopic vision. dissecting the other side was carried out by same fashion. initial dissection of linea alba could be done by open surgery from initial incision. further dissection of linea alba, retro-rectus space, and hernia orifice was carried out by sils. defect closure of anterior and posterior rectus sheath using barbed suture was also done by sils and self-grip mesh was inserted. additional trocar to assist retro-rectus dissection, defect closure, and decompression of intraperitoneal cavity was inserted as required. aims: the laparo-endocsopic approach of inguinal hernia contiue to bring many clarifications concerning inter-parieto-peritoneal space of this region through in vivo exploration, obtained by magnification by means of specific optic intrumentation. our study aimed to revalue the in vivo fascias, to establish their embryological correspondences and to reunite the variable nomenclature existing in the classical anatomy of this region. these observations find their applicability in tapp and tep hernia procedures, as the old anatomical descriptions are no longer operative. methods: we have tried to identify the structures that delimit the anatomical regions of retzius and bogros in 20 recording of tapp procedures performed on men, on the right side, for small indirect hernias on patintes with clear view of the structures. additional, a review of literature on this subject has been performed through a search in the detabases according to the following keywords: bogros space, retzius space, preperitoneal approach, urogenital fascia. results: retzius and bogros are the medial and lateral compartments of the inter-parietalperitoneal space, located between the transversal fascia and the parietal peritoneum. these narrow, virtual spaces are best highlighted today with the help of insufflation techniques during laparo-endoscopic procedures. a competent and careful dissection confirms a 'deep and superficial' stratification, highlighting embryonic relics derived from the uro-genital fascia: urinaryprevesical fascia and spermatic fascia. in addition, the real retzius space is located previously and the real bogros space is located behind this strcuture. the confluence area of the two spaces is a critical point of laparo-endoscopic dissection, its non-recognition may 'wander' the dissection. conclusions: literature data in this topic reflects a certain terminological confusion using general terms such as 'preperitoneal tissue' or 'arreolar tissue' to denote what we consider to be the urogenital fascia or its prologations. the data obtained were synthesized in several drawings and diagrams very useful in training surgeons to use tapp / tep techniques. aim: spigelian hernia containing epiploic appendage is really rare entity. in this paper, we present a very rare case of spigelian hernia involving epiploic appendage performed laparoscopic hernia repair. case report: a 60-year-old woman presented to the emergency department with sudden onset abdominal pain in the left lower quadrant. on physical examination, she had a small, palpable tender mass in the left lower abdominal quadrant. temperature and white blood cell count were normal. an inflamed epiploic appendage with an oval shape, a fatty core, and a central thin hyperdense line in the hernia sac was detected on abdominal computed tomography. its intraabdominal relationship with the normal wall of the sigmoid colon was well appreciated (figure 1a, 1b) . diagnostic laparoscopy was performed. (figure 2 ) adhesions between the sac and epiploic appendage are released using sharp dissection. a peritoneal flap is then created (figure 3 ). laparoscopic tapp repair was used without closing the defect (figure 4) . the patient was discharged on 3th days uneventfully. aims: morgagni's hernia is an in infrequent, congenital, anterior or retrosternal diaphragmatic defect. the right side is the most frequently affected, up to 90% of cases. it represents between 2 and 5% of congenital diaphragmatic hernias. in childhood, they usually attend asymptomatically or with respiratory symptoms. up to 5% are diagnosed in adulthood, incidentally or after gastrointestinal obstruction debut. the treatment is surgery, which can be by laparoscopic or open approach.we present a case of laparoscopic approach with intra-abdominal mesh placement of giant morgagni's hernia diagnosed in senile age. methods: 84-year-old woman with a history of advanced alzheimer's dementia, partially dependent in daily life activities and institutionalized who consulted for intermittent episodes of oral diet intolerance associated with vomits of one month of evolution. abdominal examination was anodine. chest radiograph revealed a right lower lung field mass with fluid collected. thoracoabdominal scan showed small bilateral pleural effusion and large, right anterolateral morgagni's hernia, which contains dilated segment of transverse colon and greater omentum . results: laparoscopic approach was performed. hernia was reduced and hernia sac was removed. the defect was repaired with a dual-component (absorbable and non absorbable) mesh anchored with intracorporeal suture. patient recovered and was discharged 4 days after surgery. conclusion: laparoscopic approach for morgagni's hernia reapir is secure and offers the advantages of less post-opertive pain, faster recovery and short postopatory stay. introduction: recently, laparoscopic operations for ileus are increasing. we have undergone laparoscopic operation to adhesive ileus with umbilicar incision at the beginning. the umbilicar incision at the beginning makes it possible to secure the laparoscopic field by peeling the adhesion under direct view, and makes it easy to repair damage to the intestinal tract. surgical procedure: at first, the umbilicus 3-4 cm incision was made and peeled the adhesion as much as possible under direct vision. secondly, ez access was set and inserted one 12 mm port, therefore laparoscopic operation was performed with 2 or 3 pieces of 5 mm ports. when the repair or resection of small intestinal due to damage is necessary, it is pulled out through the ez access. objective: to investigate the possibility of problems of laparoscopic ileus operation to adhesion ileus by umbilicar incision at the beginning. introduction: small bowel obstruction (sbo) during pregnancy is a rare condition with an incidence of 0.001-0.003% and in around 70% of cases it is most caused by adhesions from previous abdominal surgery. other diagnosis, such as, hernias, malignancy, volvulus or intussusception are extremely rare. when sbo occurs in pregnancy, it carries a significant risk to mother and fetus. its diagnosis of can be difficult to make as symptoms are often attributed mistakenly to the pregnancy. goals: a case report of congenital bowel obstruction during the second trimester of pregnancy handled by laparoscopy. material and methods: we report the case of a 38 year old woman with a history of chronic lung disease, pregnant because in vitro fertilization (17 ? 3 weeks) who attended the emergency department with abdominal pain and bloating accompanied by nausea and vomiting for two days. on physical examination she showed a distended, soft, depressible and painful abdomen without peritonism. laboratory tests were normal. a nasogastric tube was placed with generous output fecaloid intestinal contents. abdominal ultrasound by expert radiologists in abdomen showed a moderate amount of free abdominal fluid with normal uterus moderate and sbo to the ileum because of intestinal adhesion. this results were confirmed with an magnetic resonance imaging (mri). results: the patient was operated by laparoscopic approach with three trocars. the main problem was discovered. we founded a congenital adhesion which conditionated the obstructive syndrome. postoperative recovery was uneventful and the patient was discharged 48 h after surgery. conclusion: the non-obstetrical acute abdomen in pregnant patient is a reality that occurs in one of every 500 pregnancies. its diagnosis in more difficult than in nonpregnant patients requiring or high index of suspicion. the laparoscopic approach of acute abdomen during pregnancy is a valid and safe option, even in the early hours after diagnosis of bowel obstruction when it is performed by a well-trained laparoscopic surgeon. aim: intestinal malrotation (im) without midgut volvulus in adults is a rare clinical entity, which is the result of an incomplete rotation of the small bowel during embryogenesis, due to the nonlysis of the ladd bands. these ligaments spread between the duodenum and caecum and do not allow the gastrointestinal tract to take its normal position into the peritoneal cavity. im appears in 1 to 300-500 newborns and is usually asymptomatic. diagnosis is usually made in the first month, and presents with findings of an acute abdomen, small bowel ileus and volvulus. im in adults is a rare entity. most of the times it is asymptomatic, but it can cause chronic abdominal discomfort and constipation. we present the laparoscopic management of an adult patient with intestinal malrotation. methods: our patient, a 22 year old female, presented to the emergency room with a 3-month history of abdominal pain and nausea. all blood tests were normal. an abdominal mri showed intestinal malrotation without volvulus. due to persisting symptoms, she underwent a diagnostic laparoscopy with complete lysis of the ladd bands. the only unusual finding was a slight oedema of the duodenum. results: her symptoms settled postoperatively and she was discharged on the 2 nd postoperative day. since her discharge, she has not developed any similar abdominal pains or complaints. conclusions: symptomatic intestinal malrotation in adults is an unusual clinical entity, but it is definitely one of the differential diagnoses we need to consider in case of chronic abdominal symptoms. the management consists of the division of the ladd bands, and this procedure can be performed safely with laparoscopy. many small intestinal obstructions are due to adhesions after laparotomy, but small bowel obstructions without history of open surgery is relatively few. in diagnostic imaging such as preoperative ct examination, the cause is diagnosed to some extent, but details are sometimes unknown unless operative observation is actually made. in many institutions, laparoscopic surgery is also actively introduced into the operation to relieve bowel obstruction, and its effectiveness is beginning to be recognized. we examined the usefulness of laparoscopic surgery for patients with small bowel obstruction without history of laparotomy from experience in our hospital. aim: from december 2000 to october 2018, we searched cases of laparoscopic surgery for a small bowel obstruction without previous laparotomy at our hospital, and clinical findings, surgical results, and postoperative course were examined. results: there were ten cases. eight men and two women. the median age was 57 years (15-90 yrs.) . reasons for intestinal obstruction were adhesions 5 cases, internal hernia 3 cases, persimmon stones 1 case, small intestine tumor 1 case. four cases of adhesions were emergency surgery. there were 7 cases of emergency surgery and 3 waiting surgery. five laparoscopic operations were completed and five cases during laparotomy transition. the median surgical operation time was 103 min (75-302 min), and the median bleeding amount was 10 g (5-230 g). there was no fatal case after operation, only one complications of ileus. the median length of hospital stay was 14 days (10-29 days) . conclusion: laparoscopic surgery for intestinal obstruction with no history of laparotomy was thought to be a safe and effective procedure. although the transition to laparotomy would be higher in case of emergency, but there was no case of large incisional laparotomy. conclusions: laparoscopic surgery for sbo reduces postoperative complications and contributes to shortening the postoperative hospital stay and to decreasing the rate of recurrences, although it is a retrospective study, which is a safe and a useful approach. furthermore, first episode of sbo without previous operation seems to be an appropriate indication for laparoscopic surgery. background: postoperative adhesion after abdominal surgery may cause intestinal obstruction, chronic pain, or female infertility, which constitutes the major problems after surgery. adhesion formation are reported to be reduced by laparoscopic surgery and the use of anti-adhesion barriers. seprafilm composed of sodium hyaluronate carboxymethylcellulose bioresorbable membrane has been widely used to date, especially in open surgery. the characteristics of seprafilm, which is easily stick when wet, conversely brittle when dry cause it difficult to deliver into the abdominal cavity via the small incision in laparoscopic surgery. therefore, seprafilm is not much used in laparoscopic surgery. although various methods of insertion of seprafilm have been reported, some need special devices, or some acquire skill. methods: we adopted the pre-moistening technique for the replacement of seprafilm in 210 consecutive cases of laparoscopic gastrointestinal surgery. a sheet of seprafilm was cut into 4 equal pieces. to soften the sheets, one of the pieces was placed on a folded wet gauze until it became naturally curled then it was reversed, and the same procedure was repeated. softened sheet is easily to deliver into the abdominal cavity via a small incision by pushing with digital finger. moistened sheet expands naturally in the abdominal cavity. one or two pieces were needed to cover the incision. this process took only a few minutes. results: in all cases, the sheets were successfully introduced into the abdomen and spread widely enough to cover the incision. there have been no adverse effects, no postoperative complications, or gastrointestinal obstruction due to adhesion in the observation period of median two years. conclusions: short term outcomes were good after applying this technique. however, to record the incidents of intestinal obstruction and chronic pain, over 10 years observation is indispensable. long term follow-up studies are required to clarify the usefulness of the anti-adhesive barrier in gastrointestinal surgery. b. east, 3rd department of surgery, motol faculty hospital, prague, czech republic aim: since 1994 when the ipom acronym was used for the first time our views at intraperitoneal mesh positioning has changed several times. despite growing evidence on its possible long term consequences it is still preferred method at some centres for large number of patients. the aim of this study is to point out the pitfalls of this method but also show that ipom is a good technique but only for highly selected cohort of patients. methods: this is a review of the literature focusing on the indications and complications of ipom pointing out controversies among the published articles over last two decades. some mesh material characteristics are being discussed as they are basic for understanding this complex and highly sensitive issue. results: a wide range on indications of ipom from little umbilical to large incisional hernias is advocated by many. however, some opinion leaders promoting this technique as universal and ideal for everyone just few years ago are advising to avoid it if possible lately. a necessary overlap has also been questioned recently. despite improving anti-adhesion barriers and methods of fixation in may 2017 a surgical mesh has become classified as risk class iii by the eu parliament and council on medical devices hoping to prevent physiomesh like incidents in the future. the need for post market registries and long term follow up is obvious. conclusion: us as surgeons implant a mesh in our patients and therefore we should be aware of its possible long term effects. no mesh on the market has a long term safety evidence especially in the intraperitoneal space. ipom is a good technique but possess a significant risk of long life complications and therefore should be spared only for those unfit for other methods of repair, patients with too high mesh infection risk, obese or older patients. introduction: acute appendicitis in elderly patients is relatively uncommon and could represent an underlying neoplasm. hence patients over the age of 40 are often referred for a follow-up colonoscopy after management of acute appendicitis. the current routine use of computed tomography (ct) scans in the evaluation of suspected acute appendicitis in elderly patients prior to surgery coupled with intra-operative findings at laparoscopy question the role of follow-up colonoscopy for these patients. aims: to determine the role and optimal timing of colonoscopy in early detection of colorectal neoplasia after treatment of acute appendicitis in elderly patients. methods: all patients aged 40 years and above with confirmed appendicitis admitted to our hospital during the period 1/1/15 to 30/9/17were included. follow-up colonoscopy, diagnosis of colorectal neoplasia and its location in this patient cohort was evaluated. results: number of people aged 40 and above in olol who had appendectomies from the dates 1/1/15 to 30/9/17 = 184. out of them 44/184 (24%) had full colonoscopy within 2 years of the appendectomy.of them 25 of the 44 colonoscopies done were maleand 19 were females. 30/44 (68%) of these colonoscopies were completely normal.1 colonoscopy identified colorectal carcinoma in ascending colon (2.3%). other pathologies identified included: benign polyp 3 (7%), polyp with low grade dysplasia 4 (9%) and others 6 (13.6%) (lymphocytic colitis, ulcerative colitis, medication related ulceration, diverticulosis, melanosis coli, haemorrhoids). conclusions: in elderly patients above 40 years of age: there may be an increased risk of colorectal cancer after acute appendicitis. only 24% of this patient cohort underwent colonoscopy after appendectomy. the current recommendations suggest the need for follow-up colonoscopy in elderly patients post acute appendicitis. further studies are needed to decide whether routine colonoscopy is indicated after acute appendicitis patients over 40 years. introduction: it is generally accepted that the main aetiology of appendicitis is obstruction due to appendicoliths in adults and lymphoid hyperplasia in children. in contrast, incidental appendicoliths have been reported to occur in up to 32% of the asymptomatic population. controversy still exists regarding the association of appendicolith and appendicitis. is the appendicolith a causative factor or merely an incidental finding? aims: to determine the association between the presence of appendicolith and acute appendicitis (perforated or non-perforated) vs healthy appendix. methods: we collected the data retrospectively from the electronic records of all appendicectomies performed between january 2012 and december 2016 in our institution. data collected included: age, sex, appendix histology and the presence of appendicolith. interval or incidental appendicectomies were excluded from this study. we analysed the data using spss software version 2010. results: during the study period 2348 appendectomies were performed (males: 1137, females: 1211, age range: 2-89 years). 1794 cases were histologically confirmed cases of acute appendicitis and of these, 61 were perforated. a normal appendix was identified in 288 cases. the remaining 266 cases were due to chronic appendicitis, sub-acute appendicitis, lymphoid hyperplasia, parasitic infestation, and neoplasm. appendicolith was found in 43 cases, of which 33 were found in a normal appendix and 10 were found in an inflamed appendix. out of the 33 cases of appendicolith with normal appendix: 23 cases were aged between 1 and 20 years old, 9 cases were aged between 21 and 40 years old and 1 case was aged between 40 and 60 years old. out of 10 cases of appendicolith with acute appendicitis, 7 cases were aged between 1 and 20 years old, 2 cases were aged between 21 and 40 years old and 1 case was aged over 41. conclusions: appendicolith may merely be an incidental finding and is not the primary cause of appendicitis. no significant correlation between gangrenous/perforated appendicitis and the presence of appendicolith. contrary to popular belief appendicoliths are more common in paediatric appendicitis than in adult cases. further research is recommended. over the last 20 years, patient satisfaction surveys have gained increased popularity. nowadays, respect for patients' needs is central to our health care system. hospitals use patient satisfaction surveys to assess quality of care. many hospitals routinely survey patient satisfaction but relatively little data has been published. our acute surgical assessment unit operates from 8am to 6 pm monday to friday and in its first year saw 2079 surgical patients, of whom 1308 were discharged and 771 were admitted to the hospital for further management. aims: to assess the levels of satisfaction of patients attending asau at our lady of lourdes hospital. methods: a random sample of patients seen in the asau was surveyed to determine their level of satisfaction and the experience they had whilst attending asau. a novel self-reported patient satisfaction questionnaire was developed and used to assess patients' opinion regarding the treatment they received, the doctor's explanation of their condition, the waiting time and the service in asau. also the questionnaire encouraged patients to suggest improvements to the service. aim: sintestinal obstruction is a very common cause of presentation to an emergency department. the most common cause in patients with prior abdominal surgery are adhesions, but the list of differential diagnosis is large. internal hernia is a very rare cause of obstruction, with a reported incidence of between 0.2 and 0.9%. the herniation related with broad ligament defects is even more uncommon. methods: we report the case of a 63-years-old woman with antecedents of liver transplant, tubal ligation and appendectomy. the patient was admitted refering abdominal pain in the epigastrium of 24 h duration, accompanied by nausea and vomiting. on physical examination, abdomen was depressible, tender in the right low quadrant, without evidence of peritoneal irritation. laboratory studies were normal except for an elevated leukocyte count with a left shift. computed tomography (ct) revealed dilated small bowel loops with a transition point in right lower quadrant. radiological diagnosis was intestinal obstruction, with fibrous adhesion as the most probably aetiology. management was conservative at the beginning, with intravenous hydration, nasogastric tube and administration of gastrografin (diatrizoate) without a good response. results: at 24 h, an exploratory laparoscopy was perform, finding dilatation of small bowel loops and a 3 cm defect in the right broad ligament in which a segment of ileum was herniated. ileal segment was liberated without evidence of ischemia. the hernial defect was closed by laparoscopy with simple silk stitches. the postoperative course was excellent, tolerating oral feeding next morning. the patient was discharged 72 h after surgery. conclusions: internal hernias of the broad ligament are an extremely rare cause of intestinal obstruction, but must be added to the differential diagnosis for female patients due to the risk of intestinal strangulation and perforation. even if clinical and radiological diagnose is difficult, ct is the best tool to delineate the cause and location of the obstruction. laparoscopy allows reduction of the hernia and closure of the defect with minimal invasiveness. because of that, the laparoscopic approach of bowel obstruction should be considered as the first choice if there is the suspicion of an internal hernia, without signs of necrosis or perforation. the laparoscopic approach is a safe and effective tool in the management of postoperative complications. it is well tolerated in critically ill patients and avoids respiratory and wound related morbidity associated with laparotomy. it also reduces diagnostic delay and a considerable number of unnecessary laparotomies, with a high resolution rate and minimal morbidity. it thus represents a valid and necessary alternative in surgeon's armamentarium. in the management algorithm of our institution we always choose the laparoscopic technique as the fisrt tool in case a reoperation is necessary. , small bowel obstruction (11.20% vs 9.09%), and colorectal cancer obstruction (9.09% vs 8.23%) was found higher for acs unit group, and also progressively higher during the last years. conclusion: according to our study, laparoscopic approach in abdominal emergencies shows an upward trend, and surgeons from acs units seem to have higher rates of laparoscopy than general surgeons in emergency procedures. background: incarcerated and strangulated hernias present a major problem in emergency medicine. there is scarce data about the role of laparoscopy in the management of these patients. laparoscopic repair offers the benefits of the ability to survey the incarcerated organ and to evaluate its viability, apart from the obvious advantages of laparoscopic surgery. the use of mesh repair in these emergent operations is also a major concern, due to the un-sterile conditions in which they are performed. objective: to evaluate the safety and short-term efficacy of laparoscopic emergent repair of incarcerated hernias. methods: retrospective review of prospectively collected data of all the patients who underwent emergent laparoscopy due to an incarcerated hernia between november 2017 and october 2018. results: during the study period, 13 patients underwent emergent laparoscopy due to incarcerated hernias (5 females, 8 males). 10 had incarcerated inguinal hernias, and 3 had incarcerated umbilical hernias. mean age was 63.3. all inguinal hernias were repaired in the tapp approach, and using an absorbable mesh. all umbilical hernias were repaired using the ipom approach. 7 patients had bowel obstruction, 5 had incarcerated omentum, and one patient had incarcerated urinary bladder. 3 patients underwent resection of an ischemic organ (1 bowel, 1 urinary bladder, 1 omentum). mean hospital los was 2.6 days. during the follow up period there were no mortalities, and no recurrences. one patient had a wound infection that resolved with antibiotics. conclusion: laparoscopic emergent repair of incarcerated hernias is a safe and feasible approach. further studies with longer follow up time need to be conducted, in order to evaluate the added benefit of the laparoscopic approach. gibraltar is a small overseas british territory with a residential population of approximately 30,000 inhabitants, that increases up to 50,000 daily due to incoming tourists and cross-frontier workers. as a geographically isolated center we have to provide a varied service including emergency surgery, and elective operating such as colectomies, gastrectomy's etc. one of the challenges faced is the limited stock of red blood cell (rbc) units within gibraltar and reliance on platelets (plt) from across the border from spain. given the immanent brexit we need to prepare for the challenges we will face in these times of political and distribution uncertainty. a prospective audit of all blood use within gibraltar was carried out over 4 months. the number and type of units requested, the number of units given, the speciality, location and indication for requests was recorded. introduction: the use of laparoscopic surgery in abdominal emergencies, such as in trauma, has had a slow acceptance. the advantages with this approach include less postoperative pain, faster recovery, quicker return to everyday activities, and fewer complications. we have collected the cases and indications of laparoscopy in abdominal trauma in the main hospitals in the andalusian capitals and compared with the national registry material and methods: a total of 25 patients who underwent laparoscopic surgery in the main hospitals of seville, cordoba, malaga, cadiz, huelva, jaen, granada and almeria were analyzed. they have been compared with the 567 traumas archived nationally by the spanish association of surgeons taking into account age, sex, score of the american society of anesthesiologists, hemodynamic stability and mechanism of injury. the intra and postoperative variables were compared between groups. results: at the national level, the main cause of abdominal trauma were traffic accidents, therefore, it was the patients who had a greater number of laparoscopies (35.3%), followed by stab wounds (9, 03%) and run over (11.2%). in our series, the average age of the patients is 41 years and 68% are male. only eco-fast was performed in 45% of the patients, being positive in 15.9% of the cases. as they were stable patients, in 95% of the cases a tac was possible. in our data, 60% of the laparoscopies were performed for therapeutic purposes as well as being diagnostic, thus avoiding a posterior laparotomy. conclusion: slaparoscopic surgery for abdominal trauma, either blunt or penetrating, is safe and technically feasible in hemodynamically stable patients. we found that laparoscopic surgery was associated with shorter operative time, lower estimated blood loss and faster return to normal diet. based on our findings we establish the indications of laparoscopy in these patients aims: submucosal aneurysm of small intestine is extremely rare, but its rapture can be lifethreatening. due to the unstable hemodynamics and unknown site of bleeding, emergency laparotomy has been widely performed for the rupture. we will present case reports and show the strategy for minimally invasive treatment for ruptured aneurysm. methods: we experienced two cases of ruptured submucosal aneurysm resected by laparoscopic surgery. case 1 is a 16-year-old male who was taken to our er with massive hematochezia. ct showed arterial bleeding in the small intestine and angiography revealed bleeding from the ilial artery. selective embolization using gelatin sponge and micro coil was performed and hemostasis was obtained. video capsule endoscopy found the hemispheric elevated lesion with protrusion at the top in the ileum. using balloon assisted enteroscopy, the site of aneurysm was marked with injecting india ink, which allows surgeons to accurately and easily identify the part of small intestine with aneurysm. subsequently, a single incisional laparoscopic assisted partial ileectomy was performed for the purpose of definitive diagnosis and preventing re-bleeding. the ileum with aneurysm was easily identified in laparoscopic exploration owing to the marking, and it was taken out from the incision to perform resection. case 2 is a 21-year-old female who was transferred to our emergency department with sudden onset of massive melena. ct and angiography were perfomed, and bleeding from the 3 rd jejunal artery were confirmed. subsequently, therapeutic embolization was performed in the same way as case 1. enteroscopy revealed submucosal elevation similar to case1 in the jejunum. we carried out endoscopic tattooing, followed by single incisional laparoscopic assisted partial jejunectomy. results: the operative time in case 1 and case 2 were 130 min and 68 min, respectively, and the amount of blood loss was both 5 ml. the postoperative course was uneventful in both cases. case 1 was discharged on the postoperative day 7, and case 2 was on postoperative day 6. conclusions: our experience indicates that ruptured submucosal aneurysm of the small intestine can be effectively managed by a laparoscopic surgery with combination of therapeutic embolization and enteroscopic evaluation, which is safe and minimally invasive. background: laparoscopic bilateral inguinal hernia repair may be completed with one large selffixating mesh crossing the midline in front of the bladder. no studies have investigated in detail whether preperitoneal mesh placement induces temporary or more lasting urinary symptoms. methods: urinary and hernia related symptoms were evaluated preoperatively and postoperatively at 1, 3 and 12 months in 100 patients using the iciq-mluts questionnaire and eurahs-qol score. results: voiding symptoms and bother scores were unchanged at 1 or 3 months, but there was significant improvement at 12 months compared with preoperative findings (symptoms p \ 0.001; bother score p \ 0.01). incontinence symptoms improved at 1 month (p \ 0.05) but not at 3 or 12 months, with a bother score significantly improved at 1 month (p \ 0.01) and 12 months (p \ 0.01). diurnal and nocturnal frequency did not change significantly postoperatively, but 12 months nocturnal bother score was decreased (p \ 0.05). eurahs-qol scores showed significant improvement in all 3 domains for all measurements compared to previous measurements. postoperative symptoms were improved at 12 months, compared with preoperative pain scores (-6.1), restriction of activity (-10.1) and cosmetic scores (-4.7) these findings were statistically significantly (p \ 0.001). at 12 months, there were no patients with severe discomfort (score = 5) for any of 3 domains. no recurrences were diagnosed with 95% clinical follow-up at 12 months. conclusion: placing a large preperitoneal self-fixating mesh for bilateral groin hernia repair did not cause new urinary symptoms and demonstrated significant improvement in voiding symptoms at 12 months. incontinence and nocturnal bother score were significantly improved. introduction: tep/tapp hernia repair is an increasingly widely used surgical methods for minimally invasive treatment of inguinal hernia. tep advantages to tapp are noincision of the parietal peritoneal sheet, therefore no need for its recovery-sewing or sticking at the end of the procedure, and no need for attachment of the prosthetic mesh to the structures of the anterior abdominal wall, which results in a reduction in the financial cost of operation.various types of meshes with different characteristics are used, depending on the surgeon's preferences.the aim of this study is to highlight mesh-related postoperative complications, which can be serious and life-threatening. material and methods: a retrospective cohort study of 68 cases of unilateral or bilateral tep and tapp hernia repair performed at the university hospital for the period 2016-2018 with a study of early and late postoperative complications potentially causally related to the implanted prosthetic mesh and methods of their treatment. results: for a 3-year period 22 tapp (12 bilateral) and 46 tep (33 bilateral) have been performed. three complications (clavien-dindo iva, ivb and v) were found, of which 2 were early postoperative (up to 20 pod)-one in tapp-5pod small bowel adhesive ileus due to suture dehyscense of the peritoneal sheet and adhesion of a bowel loop to the surface of polypropylene mesh.one in tep-2pod-a large preperitoneal hematoma with haemorrhagic shock at 86 years old female in anticoagulant therapy-an open revision of the preperitoneal space and definitive haemostasis; followed in 12 pod established bladder lesion from erosion from the edge of self-locking polypropylene mesh. suture and drainage performed, but the patient died of decompensation of concomitant diseases. a late complication-11 months after bilateral tep-erosion of soft polypropylene mesh of sigma (probable undetectable lesion of the peritoneum) with faecal peritonitis-hartmann procedure with laparostoma followed by restitution but persistent chroniosepsis with established abscess in retzii. 24 months after-revision with abscess incision and extraction of infected meshes. discussion: use of biologic meshes is quite expensive, however synthetic non-resorbable meshes implanted in preperitoneal layout is a prerequisite for specific severe postoperative complications. inguinal hernia repair is one of the most performed procedure all over the world, with more than 20 million procedures performed each year, it represents one of the top three most performed procedures. the lichtenstein procedure is one of the first procedures that a young trainee in general surgery learn, not only for its reproducibility and for the great numbers of procedures that could be done in each department, but also because during inguinal hernia repair the trainee learn a lot of skills which are the basis of major surgical interventions. the surgeon's performance for any procedure could be evaluated by way of established learning curves that can predict the minimum number of procedures required to reach the same intra and post-operative outcomes as an experienced surgeon performing the same technique. the aim of our multicentre study was to analyse how many cases are required to stabilize operating time (ot) and intra and post-operative complication rates over the course of the learning curve period for a lichtenstein procedure. from january 2014 to december 2018 all lichtenstein procedures from four different institutions were recorded in a prospective maintained computer database. the results of the first 100 consecutive procedures performed by three different trainees (group a; group b; group c) were compared with the same numbers of procedures by two senior surgeons of the same institutions (group e, group f). cusum analysis was performed to evaluate the achieving of learning curve. no differences in terms of biometric and hernia type were recorded between the five groups. cusum analysis showed that the trainees achieve the learning curve between the 37-41 procedures. no intra or post-opertive complications were recorded during the training period.in conclusion after our analysis we found that at least 40 procedures are needed for the trainees to achieve the learning curve for lichtenstein procedures. background: since its first description in the 1990 s, the total extraperitoneal (tep) technique has established itself as a popular endoscopic method for the repair of inguinal hernias. the tep repair is generally viewed as a technically-demanding procedure requiring adequate experience to minimize and handle complications. in this case report, we describe an uncommon complication of urethral injury, which was successfully repaired laparoscopically. case report: mr r is a 25 year old gentleman with no significant past medical history who presents to the department of general surgery, tan tock seng hospital, with a two-month history of a reducible right inguinal hernia, associated with some tenderness. an ultrasonography confirmed the diagnosis of a fat-containing indirect right inguinal hernia. in view of persistent pain, mr r was counseled for a laparoscopic repair of his right inguinal hernia. as mr r was able to empty his bladder just prior to surgery, no urinary indwelling catheter (idc) was inserted. an infra-umbilical incision was made to access the posterior rectus sheath and a balloon was used to bluntly dissect the pre-peritoneal plane. on inspection of the operating field, persistent pooling of blood was noted in the retropubic space. careful inspection revealed a defect in a tubular structure just inferior to the bladder neck. an idc was inserted, which confirmed a 1.5 cm defect in the pre-prostatic urethra. decision was made for primary repair using absorbable sutures in two layers. the bladder was subsequently filled via the idc, which did not reveal any leak. we then completed the right inguinal hernia repair using a mesh. mr r made an uneventful recovery and was discharged on post-operative day 1 with instructions to keep the idc in-situ for two weeks. the idc was removed after two weeks and a micturating cystourethrogram was performed, which showed no filling defects along the urethra and no contrast leaks. discussion: though uncommon, urethral injuries can be a complication of laparoscopic tep repair. the key to managing these complications is in the early identification of such injuries intra-operatively. with early recognition and careful assessment, such complications can be managed laparoscopically with minimal post-operative morbidity. aim: the purpose of this study is to report surgical technique and outcome of hybrid tapp procedure (a combination of tapp and ipom) for inguinal hernia patients complicated with preperitoneal space adhesion. methods: hybrid tapp procedure is applied if peritoneal dissection or closure of the peritoneum is difficult due to severe adhesion. the peritoneum should be dissected as much as possible. for the site where adequate dissection was achieved, the collagen mesh is placed outside the peritoneum. in the part where dissection was difficult it is placed inside the peritoneal cavity. in order to prevent mesh migration, the mesh should be directly fixed to the cooper's ligament with a tacker. for this purpose, the peritoneum around the cooper's ligament must be well-dissected, even if it is strongly adhered, so that the ligament can be exposed. the crucial points in the hybrid tapp procedure are fixation of the mesh and prevention of the bowel herniation into the preperitoneal space. at the site where peritoneal dissection is possible, the mesh is directly fixed on the fascia using a tacker. if it is difficult, the mesh is placed in the peritoneal cavity and fixed over the peritoneum. if there is a risk of migration along with peritoneum, transcutaneous full-thickness fixation can be performed using non-absorbable sutures. the preperitoneal space should be closed tightly as soon as possible in order to prevent the bowel herniation into the preperitoneal space. at closure of the preperitoneal space, the peritoneum is fixed on the collagen mesh using non-absorbable sutures. objective: show a tapp approach using a self-fixating mesh(15x10 cm. progrip tm laparoscopic self-fixating mesh, medtronic) with bipolar peritoneal defect sealing, avoiding the use of tackers and performing an easy and sutureless peritoneal closure. material and methods: 62 years old male, asa ii, medical history of beta-latacm allergy, high blood pressure, dyslipidemia and bilateral knee surgery. diagnosed of bilateral inguinal hernia at consultation due to inguinal disconfort. surgical site infection prophylaxis with iv vancomycin. balanced general anesthesia. supine decubitus position with shoulder supporting to allow a forced trendelemburg. 30 degree optical device with 3 trocars disposition: one 11 mm umbilical trocar and 2 5 mm trocar in both flanks, same distance and height to umbilical trocar. peritoneal opening and flap creation with monopolar energy, blunt maneuvers and pneumoperitoneum dissection. anatomical landmarks identification(cooper's ligament, epigastric and iliac vessels, hernia defect and spermatic cord elements). reduction of hernia sac content(pseudosac in this case, direct hernia) and complete peritoneal dissection to achive a correct mesh placing. mesh is folded in 3 parts(one inferior part, two superior parts) in vertical axis outside the abdomen to facilitate the posterior intraabdominal maneuvers. introduction: into abdominal cavity with grasping forceps and correct unfolding mesh assesment: medially(pubic bone), caudal(cooper's ligament) cranial(more than 5 cm of hernia defect/ deep inguinal ring) and lateral(anterior superior iliac spine). finally, we use a bipolar forceps to close de peritoneal defect. in order to facilitate this step, its necessary to decrease pneumoperitoneum pressure and to use the grasping forceps to bring together both peritoneal flap edges prior to bipolar energy sealing. results: 60 min. surgical procedure. 24 h hospital discharge, no complications. routine outpatient follow up(week, month, 3 months and 6 month later) with an epididymitis episode 2 months after surgery(treated with oral ciprofloxacin). conclusions:-this procedure is an easy implementation technique once the intraabdominal mesh unfolding procedure control is reached.-the use of a self-fixating mesh avoid the use of tackers and its potential disadvantages(e.g. increasing postoperative pain).-bipolar peritoneal sealing offers a quick, easy, cheap and safe peritoneal closure, avoiding the contact of the mesh with the viscera in the same manner. results: we performed 53 procedures within 42 patients. the average age was 54 years. twenty six percent of hernias were bilateral, 11,3% were inguinoscrotal and 56% in the right side. the median asa score was 1. the conversion rate was 3,7%. the average duration of the procedure was 88,21 min 34 min. overall morbidity was 19%. there were 5 seromas (9,4%) . on 2-year follow-up, one recurrence (1,8%) was found and chronic postoperative pain in one case . we had no mortality. in the univariate analysis, male sex, inguinoscrotal hernias, hernias classified as nyhus 3a were significantly associated with overall postoperative morbidity. a chronic obstructive pulmonary disease was the only variable significantly associated with the occurrence of medical complications. conclusion: given these results, the tapp technique is a good alternative in the treatment of groin hernias. however, enhancing this approach is essential to reduce the operating time and the postoperative outcomes. introduction: studies have emphasized the impact of a strong safety culture on patient outcomes. consequently, many interventions focus on improving the safety culture, of which teamwork and safety climate are important ingredients. it is known that differences in culture and safety attitudes may also impact teamwork. implementations of safety interventions, such as a ' black box', are dependent upon these differences. the aim of this study was to assess the safety culture at the operating theatre complex, along with the theatre staff's attitude towards a specific quality improvement intervention, a black box in the operating room as a tool for structured team debriefing. methods: the validated dutch version of the hospital survey on patient safety culture was administered to all healthcare professionals working in the operating room complex at one academic medical centre. this survey was supplemented with 10 questions regarding the use of a 'black box', a medical data recorder in the operating room, to measure the staff's attitude towards this quality improvement tool and its potential contribution to patient safety. aims: the aim of the study was to compare two methods of treatment of dunbar syndrome: thelaparoscopic release of median arcuate ligament alone and the hybrid method consisting ofsurgery and percutaneous stent implantation to celiac trunk. methods: we performed 6 laparoscopic release of ct in the department of general, mini-mallyinvasive and elderly surgery in olsztyn in 2016-2018. all of patients suffered from severepain of abdominal cavity before the surgery. three patients underwent doppler percutaneousangioplasty of the ct with stent implantation one month after the laparoscopy. results: all patients reported relief of symptoms in the first days after the operation. in two cases fromboth groups, there were a complete remission of the symptoms. in one case respectively,there was an improvement. there were no postoperative complications. the results of both methods do not show the differences therefore the surgery alone seems tobe a safe and feasible procedure. it increases the comfort of the patient and brings theopportunity for normal functioning. the method of wedge resection of lungs in patients with limited forms of chemo-resistant pulmonary tuberculosis is developed. in order to evaluate the efficacy, 80 patients underwent surgery (the main group). for comparison, the data on similar operations in 100 patients, made according to the traditional method (with the help of a cardboard weaving machine yo-60) were selected. compared the duration of the stage of resection itself, the frequency of need for additional hemostasis of the parenchyma sutures, the degree of deformation of the pulmonary tissue in the seam area, the frequency of postoperative complications and reoperations, the duration of postoperative inpatient treatment. the developed method, in comparison with the traditional one, has the following advantages: simultaneously leak proofness and hemostasis with minimal electrothermal damage to tissues are provided and there is no need for additional hemostasis, there are no negative effects of manual stitching of parenchyma of lung with abandonment of foreign material, a significant reduction in the duration of wedge resection of the lung from 27.5 to 9.2 min, a decrease in the number of postoperative pulmonary-pleural complications is achieved by 96.4% and caused by them reoperations-by 99.1%, shortening the duration of postoperative inpatient period of treatment from 20.7 to 14.5 days. introduction/aims: laparoscopy is a diagnostic and therapeutic resource that is largely used in elective gastrointestinal surgery due to its well-known advantages over the classic open approach. nevertheless, there is still some discussion about its application in emergency surgery. our aim is to analize the use of the laparoscopic approach by the members of the surgical emergency unit from our medical center. methods: a descriptive research based on the data of 12920 patients who required emergency surgery, that was performed by the members of the surgical emergency unit of a spanish hospital between november 2000 and may 2018, was conducted. these data were analyzed according the pathology that motivated the surgical procedure and the chosen form of surgical approach (open versus laparoscopic). results: out of the 12920 patients in whom emergency surgery was performed, 9712 suffered from a pathology that actually allowed the laparoscopic treatment. laparoscopy was used in 38.8% of these patients. according to pathology, the most common were acute appendicitis and cholecystitis, in which the laparoscopic approach was used, respectively, in 56% and 62% of the cases. regarding other less frequent pathologies, such as gastroduodenal perforation, bowel obstruction, diverticulitis and pancreatitis, laparoscopy had a less significant role. according to the year, a general tendency to increase the use of the laparoscopic approach was found, most notably in the cases of acute appendicitis and cholecystitis (with rates above 90% in 2018). conclusions: despite our positive results in the terms of the implementation of the laparoscopic approach in emergency surgery, there is still room for improvement, especially in regards of the less common pathologies. furtheremore, additional studies are needed in order to identify the factors that have had an effect, in favour or detriment, in the development of emergency laparoscopy in our center. aims: laparoscopic surgery, which produces small scars, has become widespread. when performing surgery through small laparoscopic incisions, a surgeon manipulates tools inserted into the abdomen through ports. for minimally invasive accurate procedure, the port as the pivot point should be stabilized on the abdominal wall. however, these laparoscopic incisions are loaded while manipulation because it is difficult for the port to be fixed on. thus, it is necessary for the patient friendly manipulation to be fixed the port mechanically. we developed a new pivot restraint device (prd) attached to a trocar for guiding the tool. the purpose of this study is to evaluate both of reducing the operating time and the load of the port with the prd experimentally. methods: the prd uses gimbal mechanism for two rotating axes and a linear guide mechanism for the insertion axis though into the forceps. in the experiment, the left hand forceps with or without the prd and the right hand forceps without the prd were set on the training box. the box had a measuring system created with a pressure sensitive sensor for the continuous force (resolution 0.1 n, 30fps) applied to abdominal wall fulcrum. the experiment task was performed as following three steps. (1) the surgeon lifted the 225 g weight for 5 s at the initial position using the right hand forceps. (2) the weight was transferred from the right hand forceps to the left hand forceps, and held for 5 s. (3) the weight was moved to the predetermined position, held for 5 s, and returned to the initial position. the surgeons were five endoscopic specialists and five non-specialists. the operating time and the time ratio exceeded 1 n for the left hand forceps were measured. two grouped datasets with or without the prd were compared using two-sided t-test. results: the prd was associated with both of reducing the operating time (33.2 s vs. 38.2 s; p \ 0.01), and the load of the port (13.3% vs. 58.0%; p \ 0.01) at the statistical analysis. conclusion: the prd could be used for reducing the operating time and the load of the port in minimally invasive accurate procedure. background: pathophysiological changes during laparoscopic surgery and positive pressure pneumoperitoneum (pp) may include (beside cardiovascular changes) elevated intra-thoracic as well as intracranial pressures. however, the possibility of physiological and functional cerebral impairment under pp is still debated. aim: to study the effects of pp on brain activity during different modes of anesthesia and ventilation during laparoscopic cholecystectomy (lc). patients and methods: thirty patients undergoing elective lc were divided to those who were ventilated by intermittent positive pressure ventilation (ippv, 16 pt.) and by high frequency jet ventilation (hfjv, 16 pt.). in those under hfjv we used total intravenous anesthesia (tiva). in those under ippv we either used inhalational anesthesia or tiva. intra-ocular pressures were detected in both eyes, trans-cranial doppler was used to measure the changes in flow of the middle cerebral artery, and cerebral oxygenation (o2 saturation) was measured too. each parameter was detected during anesthesia before surgery, several times during surgery under pp and after co2 evacuation. a novel computerized signal analysis by a continuous recording through a single electrode was done to explore cerebral cognitive activity during surgery. results: all surgeries went uneventful and without complications, pp was set to 14 mmhg, and each patient was positioned in a 15 degree anti-trendelenburg posture. cerebral perfusion and oxygenation were not changed significantly during pp. intra-ocular pressures decreased during anesthesia and increased during pp, but to a lesser extent under tiva. however, pressures during pp did not exceed pre-surgical values. we did not observe changes in cognitive brain activity during pp, although enhanced cerebral activity was seen under hfjv. conclusions: increased intra-abdominal pressure during laparoscopic surgery was not accompanied by decreased cerebral functions, maybe due to cerebral circulatory auto-regulation. changes in cerebral cognitive functions under hfjv might be explained either by the different cerebral effects of tiva in comparison to inhalational anesthesia, or due to dissimilar hemodynamic changes during hfjv. aims: gallstone ileus (gi) is a rare complication of cholelithiasis and accounts for 0.1-5% of small bowel obstructions. intermittent and non-specific presentation often results in late diagnosis. the triad of rigler is pathognomonic (pneumobilia, small bowel obstruction and ectopic gallstones), so an image test is usually mandatory in order to assure the diagnose. our aim is to expose our experience regarding this topic to show that a minimally invasive approach is feasible in selected cases. methods: since january 2016 we treated 12 cases of gi, 5 of whom (42%) underwent laparoscopic surgery. in all cases a ct was made to reach diagnosis. enterolithotomy alone is our preferred procedure for the resolution of this pathology. here we present a descriptive analysis of our data in those cases where a laparoscopic treatment was attempted. epidemiological variables, surgical technique, postoperative complications, days until hospital discharge, recurrence, etc. has been collected. results: 80% of patients were female(4) and 20% male (1). mean age was 68. size of gallstones varied from 20 to 34 mm and ct located them all in the ileum. two conversions to open surgery were made (40%), in one case because the gallstone could not be found and in the other case due to the need of an intestinal resection. in two cases (40%) la aparoscopic-assisted surgery was performed using a pfannestiel incision for the gallstone extraction and enterorrhaphy. only one case was total laparoscopic approach (20%). two cases needed an intestinal resection and anastomosis, one of them was complicated with a leak that needed reintervention. there were two cases of recurrence during the follow-up time. hospital stay varied from 4 to 27 days, mean of 10 days. conclusion: the widespread use of ct facilitates early diagnosis with high sensitivity detecting rigler's triad. a totally laparoscopic procedure might be ideal for patients specially with solitary stones even though a laparoscopic-assisted approach is an easier technique for surgeons with less experience in laparoscopic surgery. although experience in minimally invasive surgical treatment of gi is still developing, it may be recommended in selected cases and experienced hands. introduction: most of surgical interventions in hospitals in the world, where laparoscope is used, it is common that the vision inside the human body is constantly interrupted by fogging in laparoscope tip. the laparoscope fogging is caused by the difference of temperatures between the optic tip and the abdominal cavity. material and method: we replaces the traditional laparoscope for the ehs (endoscope heater system) with resistance between the internal and external tube that maintains the temperature of laparoscope at (30-50°celsius) without modifying the external architecture of traditional laparoscope. results: ehs does not generates any waste like other anti-fog systems, like liquids, plastics covers or electric heater. reduces intervention time, can keep same instruments or accessories for the intervention. all of the above means a saving of resources with have a positive environmental impact. conclusions: the discomfort transmitted by surgeons about the fogging in laparoscopy tip make success of the product and it will replace the current laparoscope which is fogged. aim: synchronous locally-advanced low rectal cancer and prostate adenocarcinoma represent a rare condition and a challenging situation for colorectal surgeons and urologists. the simultaneous resection of both adenocarcinomas after long-course chemoradiation therapy combines two major surgical procedures associated with a potentially increased postoperative morbidity. in the other hand, simultaneous resections minimize the risk of difficult dissections, which are expected if the two procedures are scheduled sequentially. in the past decade, robotic-assisted minimally-invasive surgical techniques have been increasingly used to treat both rectal and prostatic malignancies. especially in case of prostatic malignancy, the robotic approach is considered the treatment of choice because it is associated with significantly lower blood loss and transfusion rate, and much greater functional outcomes compared to laparoscopy. methods: we present the case of a 66-year-old male patient (bmi: 30.6) diagnosed with a histologically proven locally-advanced rectal adenocarcinoma (ct3an0) located at 5 cm from the anal verge and concurrent histologically proven prostatic adenocarcinoma [gleason score of 8 (4 ? 4)] located in the postero-basal right lobe. the preoperative total-body computed tomography (ct) scan showed no evidence of metastatic disease. after discussion in a multidisciplinary meeting, the patient received a long-course neoadjuvant chemoradiation therapy (ncrt). at the restaging positron emission tomography / magnetic resonance imaging (pet-mri), the rectal lesion was classified as ymrt0n0. preoperatively, the surgical difficulty was assessed as high, based on the calculation of the eumarcs score (equal to 6/10). moreover, due to the high-risk status of the prostate cancer (gleason 8), it was decided not to preserve the neuro-vescular bundles during the radical prostatectomy. results: the patient was operated on after 12 weeks from completion of ncrt by using the da vinci robot system si with a single docking approach, as previously described, in order to address both cancers. conclusions: this video shows the main surgical steps of the simultaneous robotic resection of the low rectal adenocarcinoma first, of the prostatic carcinoma then, and the mechanical colo-anal anastomosis followed by drain positioning and ileostomy. this video demonstrates the perioperative safety and feasibility of the minimally invasive robotic approach in case of extended and challenging oncologic resections. general surgery, rambam medical center, haifa, israel 75 year old, male patient presented with melena, without abdominal pain, nausea or vomiting. patient underwent colonoscopy and tumor was found in ascending colon (near the hepatic flexure). biopsy from the tumor has showed moderately differentiated adenocarcinoma. his blood laboratory examinations were within normal limits except of hgb level-11.0. cea and cea19-9 were normal. abdominal computed tomography was normal . patient underwent da vinci robot-assisted right hemicolectomy with extracorporeal anastomosis. total operating time was 150 min. three days after operation patient started regular diet and was discharged home on day four. final pathology result confirmed diagnosis of moderately differentiated adenocarcinoma. introduction: one of the goals of colorectal surgery is to decrease the number of leaks once an anastomosis has been performed. this life-threating entity after elective surgery has been related to the clinical history of the patients, the location of the tumor and to technical reasons, specially due to tension in the anastomosis or to lack of vascularization. tension could be identified during surgery, while vascular supply is evaluated by the surgeons based on a subjective analysis of the color of the colon/ileum. fluorescence tries to make these subjective parameter more objective in order to avoid an anastomosis with lack of vascularization, decreasing the numbers of leaks related to this factor. patients and method: the study presents a quasi-experimental analysis made from january 2009 to october 2017 in two hundred and eighty-five patients who underwent elective colerectal surgery, performing either a colo-rectal, ileo-rectal or intracorporeal ileo-colic anastomosis. vascular supply was eveluated using indocianyne green (icg) in one hundred and forty-five patients, while one hundred and forty subjects were operated in a previous period without using this technology, being considered the control group. the number of time that the attitude changed and the number of leaks were collected. results: out of the 285 cases performed, 80 were right colectomies (rc), 162 left colectomies (lc) and 43 rectal excision (re). in 20% the transection line was changed (2, 8% in rc, 11, 1% in lc and 6, 3% in rr) . in comparison with the control group, the icg group had a significantly less indicence of anastomotic leak compared to the control group (2,8% vs. 8,6%, p = 0,04), lower rate of terminal stoma after reoperation (0,7% vs. 5,7%, p = 0,018), a shorter length of hospital stay (4 days vs. 5 days, p = 0,02 respectively), and a low morbidity and mortality. conclusions: the rate of leaks after colorectal surgery decrease using icg to detect the proper transsection line before to perform the anastomosis in comparison with control group. these findings might influence in the final results although it is necessary in the future to find a system that provides greater objectivity by quantifying icg. aims: anastomotic leaks continue being one of the most important complications when a colorectal surgery is performed. this complication is usually related to the level and type of resection, the patient clinical history and surgical technique, where tension and vascular supply are the most important. indocyanine green (icg) fluorescence angiography seems to be helpful in order to evaluate the vascularization at the resection margins. methods: we have collected data on 187 colorectal procedures that were performed by the same surgeon using icg fluorescence angiography to evaluate vascular supply to the anastomosis. in order to asses in which of the different type of colorectal procedure has more value to be used, we analyzed the type of surgical procedure, the percentage change in the resection margin and the number of anastomotic leaks (al). results: all of the 187 cases were performed by laparoscopic approach: 77 left colonic resection (lc), 66 right colonic resection (rc), 9 splenic flexure partial resection (sf), 15 low anterior resection with partial mesorectal escision (lar), 19 ultra low anterior resection with total mesorectal escision (ular) and 1 total colectomy (tc). there was a change of transection line (ctl) in 21 lc (27,2%), 4 rc (6%), 1 sf (11,1%) and 10 (28,5%) in rectal anastomosis (lar, ular and tc). as far as al we found: lc 1 (1,2%), rc 2 (3%) and 2,8% in rectal procedures. lc, sf and rectal procedure showed more ctl and less al, while rc showed less ctl and more al. conclusion: icg fluorescence angiography as an additional tool to try to reduce the anastomtic leak rate seems to have more value in the procedures that involve the left colon and the rectum, since that is where we have observed the greatest number of ctl, this could be explained by the riolan's arcade and the variability of the vascular anatomy. however, it seems that this is a line of research should continue developing with longer and larger studies, so in that way we can have more significant results. retrorectal tumors ara rare and often found incidentally. the majority of retrorectal tumours are benign, but they have potential for malignant transformation and therefore should be resected when found. a case of a 44-year-old female patient with a retrorectal tumor is showed. the tumor was found incidentally on ct scan of the abdomen for evaluation of non specific right side abdominal pain. a mri was also performed and imaging was informed as a probably congenital retrorectal tumor (tailgut cyst) there was no evidence of involvement or invasion of other structures the tumor was palpable at rectal examination. a transanal minimally invasive surgery (tamis) approach was proposed. preoperative preparation was done with a full mechanical and oral antibiotic bowel preparation. preoperative parenteral antibiotics werw administred. under general anesthesia, lithotomy position. the contour of the tumor is not visible due to the small size. palpation of tumor and placement of clips to lolocate was done. placement of gel point path and rectal insufflation. a longitudinal incision was made to the posterior left side of rectal wall. the insufflation of the perirectal extraperitoneal space allowe for excellent exposure of the tumor. the tumor was disected with ligasure. then the tumor was extracted transanally.the proctotomy was closed in a single layer with reabsorbible monofilament continuous suture (pds). no complications after the procedure. the patient was discharged at 2 days. discusion: traditionally, the retrorectal tumors have been resected using a posterior parasacrococcygeal approach, an abdominal approach or a combined abdominal and posterior approach. with the advent of minimally invasive surgery, laparoscopyc approach has been described too. however, tamis approach is feasible, with low pain, morbidity, fester recovery and excellent cosmetic (no scare) results. it can be accomplished using standard laparoscopic equipment, with transanal access. we think that perhaps it could be the gold standar approach for this tumors. aimes: robotic-assisted laparoscopic surgery (rals) is a promising advanced technology that can overcome the inherent limitations of conventional laparoscopic surgery (cls). its advantage includes free-moving multijoint forceps, a motion scaling function, high-quality three-dimensional imaging, and stable camera work by an operator. this study aimed to clarify the short-term outcomes of rals for rectal tumors. methods: this study group comprised 25 patients who underwent rals for rectal tumors (cancer in 24 patients and gastrointestinal stromal tumor in 1 patient), excluding ones with distant metastasis from november 2016 through december 2018. the clinicopathological findings and short-term outcomes in rectal tumors were analyzed. results: the median operative time was 372 min (309-682). the median console time was 207 min with a median blood loss was 5 ml (5-394). conversion rate was 0.0% (0 / 25). the median postoperative hospital stay was 11 days (6-17). 2 patients (8.0%) had postoperative complications. 9 patients (36.0%) had lymph nodes metastases. the mean harvested lymph node was 17.6. the r0 resection rate was 96% (24 / 25). conclusions: these results suggest that rals for rectal tumors is safe and feasible, and the perioperative outcomes are acceptable. introduction: anastomotic healing defects are a feared complication which might have a fatal impact on the patient. fundamental conditions for proper anastomotic healing include sufficient blood supply. fluorescent angiography using indocyanine green in the spectrum of near infrared light facilitates the monitoring of tissue perfusion during a surgery. aim: a presentation of the results of our non-randomized study in which we assessed prospectively obtained data from a perioperative assessment of anastomosis perfusion by fluorescent angiography using indocyanine green during robotic rectal cancer surgery. method: thirty patients with rectal cancer, who underwent a robotic resection with primary anastomosis, were consecutively included in the study between april 1, 2017 and june 21, 2018. the study included patients facing a least invasive surgery with a guaranteed payment by a health insurance company. during the surgery, we monitored and assessed the quality of the perfusion of the resection line of the sigmoid colon and subsequent anastomosis by means of fluorescent angiography using indocyanine green in the spectrum of near infrared light. the data were obtained prospectively and subsequently analyzed. results: between april 1, 2017 and june 21, 2018, we consecutively included 30 rectal cancer patients in the project: 16 men and 14 women. monitoring of the perfusion of the resection line and anastomosis was successful in all cases and perfusion quality was satisfactory across the sample. perfusion insufficiency requiring a change in the resection line level or anastomosis adjustments was not detected with any patient. in two cases (6.7%) of tme, we gave up the planned protective ileostomy owing to quality perfusion of the anastomosis. one patient (3.3%) suffered from defective anastomosis healing without clinical symptomatology (type a). we found no technical complications related to fluorescent angiography or undesirable effects due to the application of indocyanine green. conclusion: even though we did not register insufficient perfusion in our sample and hence we did not have to change the resection line level or adjust the anastomosis, we may state that fluorescent angiography performed by an experienced colorectal surgeon may potentially reduce the frequency of complications linked to defective anastomosis healing.supported by mo 1012 aims: the aim of our study is to demonstrate whether robotic surgery has any influence on the reduction of complications in the aged population undergoing rectal cancer. methods: we performed a retrospective analysis of a prospective database of 151 patients who underwent robotic surgery for rectal cancer. we divided our population in 3 groups: under 65 year old, between 65 and 80 year old and above 80 year old. we recorded complications in each group intra and post procedure. qualitative variables were expressed in terms of absolute frequencies and percentages and mean values and standard deviation were used to express quantitative variables. the analysis of data was applying fisher's exact test or chi-squared test for qualitative variables and variance analysis or student'-t test for quantitative variables. statistically significant values of p \ 0.05 underwent multivariate logistic regression analysis. results: the present study included 151 patients (94 males).seventy seven patients were under 65 year old, 73 patients were between 66 and 80 year old and 11 patients were above 80 year old. the analysis showed conversion rates of 10.38%, 13.69%, 27.27%, and complication rate of 23.4%, 23.8%, and 27.3% in each group. univariate analysis showed no differences between the three groups. nevertheless, there were statistical differences from bmi, asa and neoadjuvant therapy. in multivariant analysis only neoadjuvant therapy was significant. conclusions: robotic approach do not decrease complications in elderly population. introduction: it has been described the advantages of total transanal mesorectal excision (tatme), with better visualization and access to the lower rectum. we use this access whith the gel point path device, to repair a rectovaginal fistula with stenosis of low rectal anastomosis in two patients, that would be difficult by conventional abdominal approach method: we show our surgical technique for repair a rectovaginal fistula with stenosis of low rectal anastomosis in two female patients operated due to rectal neoplasia. one of the patients underwent prior chemo-radiotheratpy. rectoscopy and image test was performed at the patients prior the intervention. no recurrence signs are recorded at mri.we describe the operation technique: a new anterior rectal resection was performed with a combined transanal (gel point path) and abdominal minimally invasive approach. redo anastomosis whith eea 31 stappler was performed, vaginal repair and epiploplasty. the intervention was especially laborious due to the fibrous tissue. pathology: fistulous path without tumor infiltration in the two patients. at two months, a opaque enema show permeability and absence of leaks in the two patients. the ileostomy was closed at three months. discusion: we believe that transanal access through the gel point path can be a good option for rectovaginal fistula and stenosis of low rectal anastomosis, allowing a better visualization and acces, and making more easy a very difficult intervention. introduction: tamis or transanal minimally invasive surgery for polyp resection has increased fame for several situations in which adenomas with or without dysplasia cannot be removed with conventional colonoscopy. in this video we show the step by step technique performed with the da vinci xi system. material and methods: in this video we show the setting and the location of the patient-side cart and the arms to perform the resection of polyps in different patients and how to develope the procedure. results: after placing the patient-side cart the arms are connected to 3 ports and the camera, double fenestrated grasper and scissors are connected to the arms through a transanal gel-port device. a line is described around the polyp with monopolar energy to determine the place of the dissection. the scissor is exchanged by a robotic harmonic wrist instrument and the complete dissection is performed. the wound is closed using a robotic needle holder and a suture. results: transanal robotic surgery could be safely performed after a standardized technique is stablished. aims: robotic rectal cancer surgery has demonstrated to obtain at least the same results than laparoscopic surgery. however, robotic surgery is associated with high rates of costs, specially when conversion to opened surgery occurs. the goal of this study is to create a predictor nomogram of conversions for robotic rectal cancer surgery. methods: we performed a retrospective analysis of a prospective database of patients who underwent robotic surgery for rectal cancer from october 2008 to november 2017. we performed a bivariant analysis and detected the variables which were related with the conversion: body mass index (bmi) and the t. we divided the patients of the population in two groups depends on obesity (bmi of kg/m2) and on t (t1-2/t3-4). we registered conversions in each group calculating the pretest risk. we performed likelihood index (lr ?/-) for under and above 30 kg/m2 of bmi, adding in a second step the lr of t; obtaining the prediction index for four groups by using a standardize nomogram. results: the present study included 194 patients (128 males). 143 were under bmi of 30 kg/m2 and 51 above. regarding t, 54 were with a tumor of t1-2 and 150 with t3-4. the analysis showed a conversion rate of the statistical sample of 14%. univariant analysis showed significative differences in the bmi (p = 0.005) and t (p = 0.022). a nomogram was performed; as regards the bmi, the positive likelihood index in the group of bmi [ 30 a prediction index of conversion of 50% (lr ? 4,95) and in bmi \ 30 the prediction index of conversion is 5% (lr-0,52). adding the t group data, for bmi [ 30 and t1-2 the conversion prediction rate is 3.5% (lr-1,2); for bmi [ 30 and t3-4 the conversion prediction is 92% (lr ? 5,6). bmi \ 30 and t1-2 the conversion prediction is 2% (lr-1,2); imc \ 30 and t3-4, the conversion prediction is 30%. conclusion: a standardize nomogram with the variable bmi and t facilitates the selection of patients for robotic surgery in rectal cancer avoiding conversion to open surgery. background: 3d-laparoscopy is proven to improve performance in dry laboratory settings, especially for novice surgeons due to better depth perception. however, the benefits for experienced laparoscopic surgeons are still discussed. aim: the aim of this study is to compare the results of right hemicolectomy (rc) using a conventional (2d hd) laparoscopic system with rc performed using a 3d laparoscopic system in terms of duration, complications and results. material and methods: from all laparoscopic right hemicolectomies performed in our clinic we selected all procedures performed by the same team of 2 consultant surgeons using the same technique and divided them in 2 groups. the study group comprised of all patients operated using our 3d einstein vision 2.0 system; all other patients which were operated using our standard wolf hd laparoscopy system comprised the control group. all patients were retrospectively analyzed in terms of patients characteristic, or time, duration of operation, intra-and postoperative complications, length of hospitalization, pain score, necessity of analgesics and number of lymph nodes retrived. risk factors for complications (bmi, smoker, diabetes, copd, bph) were also registered. results: there were 54 patients included in the study group, while the control group comprised of 98 patients. mean operation time in the study group was 123.3 min in the study group, while mean or time was 157.4 min. mean operation time in the control group was 128.1 min, while mean or time 145.4 min. one reintervention was noted in the control group and two in the the study group; no conversion to open surgery was noted. there were no significant differences regarding patient characteristics, pain score, wound complications, hernia rate, length of hospitalization or number of lymph nodes removed. conclusions: there were no significant differences regarding the outcome of rc using 3d laparoscopy; total or time was significantly higher in the study group due to the time needed to set up the 3d-laparoscopy unit. this is biased by the fact that the 3d system needs to be set up manually while the conventional hd system is integrated in the or. also, there was no significant difference in complication rate. background/purpose: robotic approach can be a treatment option for patients with pelvic recurrence after primary resection for rectal cancer. however, data regarding patient selection, complication rates, and oncologic outcomes are rarely reported. we aimed to present initial experience and to evaluate feasibility, safety, and oncologic outcomes of robotic salvage surgery for recurrent rectal cancer. methods: ten patients who underwent robotic salvage surgery for local recurrence at the anastomotic site, lateral pelvic side-wall, or lateral pelvic lymph nodes (lpns) were retrospectively evaluated from a prospectively maintained database. results: two patients underwent pelvic mass excision with en bloc resection of anastomosis and redo-anastomosis, and eight patients underwent lateral pelvic lymph node dissection (lpnd) for lpn metastasis; one of these eight patient underwent additional en bloc resection of anastomosis. all patients achieved r0 resection. the median operation time was 165 min and the median estimated blood loss was 50 ml. there were no conversions. as for intraoperative complications, one patient experienced ureter injury during lpnd because the metastatic lpn was closely abutting to the ureter. the median hospital stay was 7 days. in six patients who underwent lpnd, the median number of harvested lymph nodes was 7 (range 2-13) and the median number of metastatic lymph nodes was 1 (range 0-2). with median follow-up 26 months, one patient developed lung and pelvic recurrence at 36 months after salvage operation and seven patients remained in disease-free state at the last follow-up. conclusion: initial experience of robotic salvage surgery for pelvic recurrence in rectal cancer indicated that it is safe and feasible. therefore, the robotic approach can be considered as a treatment option for the treatment of local recurrence in selected patients. introduction: there is uncertainty regarding the effects of simulated patient death. several reports showed increased cognitive load and poorer learning outcomes, and others increased performance without causing stress to learners. we have not found any report studying the impact of animal death in the simulation lab. methods: this was an observational cohort study to assess the emotional and cognitive load of surgeons who experienced animal death in the simulation lab. seventy-four faculty and residents from different surgical specialties training minimally invasive surgery participated in the study. one cohort consisted of surgeons whose animal died during surgery, and the other by those whose animal survived. emotions were assessed using the scale for mood assessment and cognitive load with nasa task load index. results: twenty percent of participants experienced mortality while training anti-reflux surgery (11 cases) and other procedures (3 cases). causes of death included intraoperative pneumothorax (n = 10), hemorrhage (n = 1), and cardiac dysrhythmias (n = 3). participants exposed to animal death had higher levels of sadness and anxiety, and lower levels of happiness (p [ 0.05). cognitive load was slightly higher in the exposed cohort (p [ 0.05). conclusions: these findings suggest that mortality in the animal lab do not have a significant effect on cognitive workload and emotions of surgeons training complex laparoscopic procedures. introduction: the visuospatial profiles of expert laparoscopic surgeons remain unaccounted in the current literature for as the influence of visuospatial ability on laparoscopic learning has mainly been investigated in medical students or novice surgeons and using simulators as means of performance measurement. such knowledge is critical, as without understanding how clinical experience may impact visuospatial processes in surgeons, we hinder our efforts to utilize the available knowledge to support surgical education for the future. this study is aiming to explore the development and influence of visuospatial processes on intraoperative laparoscopic learning. method: the study reports the interim baseline results from the ongoing longitudinal study throughout a 2-year period of training on laparoscopic surgery. data from 35 surgeons including 17 residents undergoing training were captured and compared to 18 specialists who are working in departments of general and visceral surgery at two large hospitals. the mean experience of the surgical residents was 4 years. the mean laparoscopic experience among the senior surgeons is 17 years, with each surgeon performing an average of 6 laparoscopic procedures per week. visuospatial ability was tested using mental rotation test (mrt), guay visualization of views tests (gvvt), spatial perspective taking and spatial orientation test (ptost) and pictorial surface orientation (picsor). spearman correlation coefficient was used in this study with a p-value of significance at \ 0.05. results: senior surgeons have an overall good visuospatial profile, in the sense that they performed close to optimum on all measurement scales. the spearman rho revealed a significant correlation between scores on gvvt and picsor (r = 0.607, p = 0.012) and between ptost and picsor (r = -.686, p = 0.003). a significant correlation between years of laparoscopic experience and ptost score was also observed (r = 0.587, p = 0.035). when comparing residents and senior surgeons, no significant difference on the mrt was observed (m = 10.2, sd = 4.33), nor between baseline scores of senior surgeons and resident surgeons on all tests. conclusion: the results of this study carry important clinical and theoretical implications, as the results hint towards the idea that intraoperative laparoscopic experience lends little to no influence over the development of visuospatial ability. learning models and laparoscopic technical skills, how to adapt each case to improve objectives: according to da. kolb learning is the result of how people perceive and then process what they have perceived. the aim of this study is to identify the personal characteristics of learning in of the participants in a course of laparoscopic technical skills according to the styles described by kolb. methods: between june 2016 and november 2017, 35 participants performed a 50 h course distributed over five consecutive days performing laparoscopic manual intestinal anastomosis in endotrainer. they all filled in kolb's learning style test adapted to spanish. the anastomoses were performed in 'ex-vivo' swine intestines. in each anastomosis we evaluated the quality at the end and execution time. the test and quality variables were analyzed through statistical studies. results: in our study, 69% of the participants were women and 31% wew men. 49%were staff surgeons and 58% were resident. the median age among residents was 29 years and among the staff 39 years. the most frequent learning model in the sample studied was converging (31%). the predominant model among women was assimilating (37%), which, however, represented only 8% in men. in men, converging model was predominant (39%). among the staff, the most frequent model was diverging (35%). adaptation style prevailed among residents (39%), being rare among the staff (12%). the mean time of the anastomosis was 74 min for both the adapter model and the assimilator, 68 min, for the convergent and divergent models. the quality of the anastomosis performed by each participant was 80% for the adapter model, 37% for the assimilator model, 42% for the convergent model and 45% for the divergent model. the predominant style in our study was convergent. among women, the most frequent model was assimilator wheras in men it was the least frequent. in the residents, the most frequent model was adapter however, it was very rare in adjuncts. among residents we do not find divergent styles. the highest quality of the anastomosis was achieved by those who worked with an assimilating style. knowing previously the training style we can individualize the teaching methodology in order to improve competences. aims: assess whether laparoscopic appendicectomies (la) are a superior option to open appendicectomies (oa). specifically, comparing the time taken, complication rates and whether it is more appropriate to perform an la overnight, as opposed to oa. finally, to find out how a range of outcomes differs between different grades of surgeon. methods: an information request was sent to the clinical coding department to derive patient identification numbers for all appendicectomies over a ten-month period (180 total surgeries). these numbers were then inputted into the hospital information system where the electronic operation note is present, and specific outcomes were derived and analysed. results: 68% of operations were oa and 32% were la. mean la times for consultants, sas and spr were 88.4, 78 and 92 min respectively and oa 63, 57 and 59 min respectively. their respective conversion rates were 27%, 16% and 0%. oa had a complication rate of 16.3%, la was 10.2%. conclusion: oa are performed more than la. spr doctors had the slowest completion times for la but the lowest conversion rates. sas doctors had the fastest completion times for la and oa but higher conversion. la takes longer than oa but has lower complication rates; key factors when performing at night. key statement: laparoscopic appendicectomies require more surgeon-hours and have the potential to be converted to open, however the rates of complications and serious complications are significantly lower. background: paper based resources have been the standard sources for information for centuries. however, more and more people (patients and staff alike) are looking online for information. while the internet often provides excellent resources, there is often conflicting and confusing material of doubtful veracity. trainee staff and patients/carers should be able to access reliable resources whenever and wherever they are. the aim of this project was to create a high-quality resource fulfilling these needs. aim: we present a video demonstrating our integrated colorectal education website ( http://www.colorectaleducation.com/). our approach: high quality health care provision requires highly trained staff as well as wellinformed patients. information resources for these two groups are usually accessible from different repositories. our integrated website provides a common platform for all those involved in colorectal surgery, to use, learn and reflect on. users are directed to separate sections for patients and colorectal professionals. multiple disclaimers prevent patients accidentally stumbling across clinical/ operative information, whilst providing access to those who wish to do so. trainees struggle with balancing their educational needs with their service commitments. this website gives them the opportunity to view detailed operative training videos on the go. many of videos are chapter based allowing them to stop and re-start with ease. modules are also available for nurses providing them access to relevant educational material. the modular design of the website allows us to build upon it with more topics planned to be added over the next eighteen months. the resource also has detailed chapterised videos for patients due to undergo various colorectal procedures. all have been approved by a multi-professional panel including patients and are designed to provide information, offer support and to allay any anxiety. videos with the care pathway and previous patients' experiences are accessible on demand. conclusion: on demand information has now become the norm with the use of smart phones/ tablets. this website provides patients, surgical trainees and other healthcare professionals access to information and education in a clear and reliable format anywhere in the world. colorectal education, on demand and just a click away! objective: in the last decade the growing interest in robotic surgery is evident as shown by several published articles. the aim of the present study is to evaluate the main outcome of a single center experience and to describe the organizational system we have progressively established in our center in order to improve the development of robotic program in all surgical area. materials and methods: we report a case series of patients who underwent robot-assisted surgery at sanchinarro university hospital since the beginning of the program (october 2010) until november 2018 main patient demographic characteristics, type of surgery, peri and postoperative data and follow-up were evaluated. results: a total of 326 robotic procedures were performed for a total of 323 patients. the prevalence of malignant disease was 86%. a total of 72 pancreatic surgery were performes; 22 liver resections (mean operating time: 190 min); 33 gastrectomy (mean operating time 310 min); 18 esophagectomy (mean operating time: 490 min); 152 colorectal resections (100 rectal resections, 23 sigmoidectomy 19 hemicolectomies right, 10 left colectomy) (mean operating time: 220 min); 6 nissen procedures (mean operating time: 130 min), 2 esofagheous myomectomy for achalasia (operating time: 90 min); 3 adrenalectomy (mean operating time: 240 min); three biliary surgery for benign desease, 2 splenectomy. eight partial resection of the duodenum, one yeyunal resection, one mesenteric cyst resection and 3 retroperitoneal tumor have been performed. conversion rate was 6%, total morbidity have been 17%. there has been no peri and postoperative mortality up to 30 days after surgery. the average hospital stay and intensive care were respectively16 days (range 6-45 days) and 1.9 days (range 0-12 days). conclusions: the organizational model defined in our center is facilitating the constant and progressive development of the robotic program. a broad and flexible availability of the robotic system, a progressive increase of young surgeons joining this technology as well as the institutional and departmental economical effort are the points with which the robotic system may increase its development in a surgical department. aims: endoscopic surgery has been widespread in the field of general surgery. however, in japan, there is no standard program for endoscopic surgery training, and its competency has not been considered for the acquisition of board certified surgeon. the purpose of this survey was to investigate the current situation of endoscopic surgery training and autonomy of young surgeons for endoscopic surgery in japan. methods: the survey was planned to target general surgery members of the japan society for endoscopic surgery (jses) who was post graduate year 10 or less. after approval by the ethics committee of jses, the request for the participating in survey was mailed to 2296 object members. questionnaire responses were available in print or online media. the contents of the questionnaire consisted of 19 items, about the conditions of endoscopic surgical training, experienced case number, and the self-assessment of autonomy from 1 to 4 point by zwisch scale in 9 specific procedures of endoscopic surgery. results: the total response rate was 28.5% (645/2296). sixty five answers were excluded due to inadequate response and 580 answers were analyzed. of the questionnaire respondents, 87% were male and 13% were female. the ratio of board certified surgeon was 67%. although 87% of the teaching hospitals had simulators for basic training of endoscopic surgery and 94% of the respondents practiced basic skill of endoscopic surgery, only 34% teaching hospitals had specific training programs for endoscopic surgery. the surgeons who operated 20 cases of laparoscopic appendectomy and inguinal hernia repair and 50 cases of laparoscopic cholecystectomy, right hemicolectomy and sigmoidectomy, felt confident to perform each procedure independently. regarding with laparoscopic rectal resection and gastrectomy, even though the surgeons who had 50 cases of experience, they didn't had confidence to perform those procedures independently. conclusions: this study is the first national survey to investigate the status of endoscopic surgery training in japan and the autonomy of young surgeons for endoscopic surgery. in order to develop a training system for not only basic skills but also advanced procedures of endoscopic surgery, cooperation of each teaching hospital, academic surgical society, medical specialty board is necessary. currently there is a debate about what is the most optimal work schedule for residents of general surgery, it is important to respect the free time of residents to avoid burnout, however it is also important have enough exposition to clinical cases that allow a satisfactory development in the clinical practice. this becomes even more important when we talk about the learning of surgical skills. this is where the laparoscopic simulation industry opens a large area of opportunity, for a reasonable price it is possible to practice basic laparoscopic skills without compromising patient safety. this is a pilot study that was carried out during the period from january 2018 to june 2018, in a public hospital in monterrey, nl, mexico, the composition between the execution of the standardized exercises of the fls (fundamental laparoscopic surgery) in an endoscopic simulator was performed to 20 residents of general surgery (from first to fifth year) 24 hrs before being on call vs these same residents post call. a series of questions was asked to each resident in each measurement, so in this way they answered the same questions twice, then a comparison of the results of both questionnaires was made. the results of the exercises were assessed and rated by the same person using the criteria established in the fls for the scores of each exercise and for the final grade. an average age of 27 years was obtained, measurements were taken of 20 residents of which 16 are male and 4 female. on average, the residents before be on call performed the exercises with 7 h of having slept while the post call performed the exercises with 2.15 h of having slept, the residents before be on call had on average 10.9 h without sleep while the post call had 25 h without sleep. the average number of hours worked per week is 111 h, measured by the time in and out of the hospital. in this study, conclusive results were obtained regarding the null relationship of sleep deprivation with the performance of laparoscopic skills in surgical residents. aim: 'precision cutting' is one of skills tasks of the fundamentals of laparoscopic surgery (fls) program, which is cutting a circle on a piece of gauze under laparoscope and assessed by completing time (maximum time limit: 300 s). there is no definition of quality of the final product. the aim of this study is to develop an assessment tool of laparoscopic precision cutting and test its reliability. method: an assessment tool of laparoscopic precision cutting was developed with four items based on completion, degree of deformation, degree of being pulled, and overall appearance of the final product of laparoscopic precision cutting by experts' meetings. the scale of each item was 5 points likert scale. a descriptive sheet with a legend and a text description for each scale (fig) was attached for assessors' reference. for our high school entry medical students, they gained hands-on experiences of laparoscopic skills first time by attending a 1-hour course at minimally invasive surgery training center, national taiwan university hospital (ntuh). we invited students to participate this study after this training. we collected participants' final products of ' precision cutting' station and assessed them by using this assessment tool. this study was proved by institutional review board, ntuh (irb no:201512051rinb). results: 35 students were enrolled between february 2016 to june 2016. two non-medical assessors and a senior surgeon were invited to assess the products. the mean score and cronbach' s alpha value of each item were as followed: completion 2.2 ± 0.9, 0.91; degree of deformation 2.11 ± 0.9, 0.96; degree of being pulled 3.1 ± 1.1, 0.85; and overall appearance 2.6 ± 0.9, 0.95. conclusions: in summary, we successfully developed an assessment tool for laparoscopic 'precision cutting' and showed its reliability. the tool could provide qualitative descriptions for objective feedbacks. validating this tool in a large scale is undergoing. purpose: to evaluate whether the participants who experienced this scenario could recall an interventional scenario for testing trainees' situational awareness and intra-operative decision making when they participated this training again. methods: we designed an iodm training course for junior surgical trainees and nurses by using live pigs since sep 2016. in the first simulation, we created an interventional scenario and then provided an educational session. a researcher disconnected the ekg monitor on purpose for creating a scenario that the pig would lose vital signs when the team nearly finished a diagnostic laparoscopy. if the team did not aware the situation after 1.5 min, a researcher would remind the team (fig). we used a new developed assessment tool of iodm and an assessment tool for nontechnical skills for surgeons (notss) for self-evaluations and objective assessments. we also discussed with them about their reactions while encountering this interventional scenario. results: between sep 2017 to june 2018, 14 teams participated this training and experienced this interventional scenario. fourteen 2 nd year surgical trainees have experienced it before. only one participant (7%) recalled it and made a quick decision while encountering this interventional scenario again. the results of iodm assessment and notss did not show statistical difference comparing their self-assessments in the first and second year. based on the analysis of the discussions, most of them remembered this this interventional scenario and reminded themselves to react it properly before the simulation. however, when they were the primary surgeon of diagnostic laparoscopy, they focused on performing this procedure and tutoring their junior trainee. they had no capacity in their brain to notice the change of vital signs. in addition, although they increased their situation awareness in clinical settings after the 1st time iodm training, they did not show this ability in the simulation. conclusions: recalling of an interventional scenario for testing situational awareness of surgical trainees was very poor (1/14, 7%) among the 2nd year surgical trainees. qualitative analysis of discussions showed their brain capacities were occupied by performing new procedures and tutoring others. how to enhance trainees' situational awareness should be addressed. aims: a well-designed learning curve is essential to measure the progress of surgical abilities. learning curves are very important to test the skills of trainees. however, there are still no welldefined criteria for developing good learning curves. as a result, many authors use subjective evaluation criteria. the purpose of this review is to analyse this field of surgical education and to identify the key criteria for good learning curves. methods: learning curves were investigated in the field of laparoscopic and robotic minimally invasive surgery. surgery of appendectomy, cholecystectomy, cholectomy, inguinal hernia repair and gastrectomy were considered. the type of surgery, the year of publication, the design of the study, the surgeon's experience (resident, young or senior), the surgical technique, the number of patients involved in the study and the suggested learning curve by the different studies were taken into account. in the selection of articles, more importance was given to those based on the activity of young surgeons or residents. results: the literature analysis showed conflicting results. the different learning curves for the same surgery may be due to the different evaluation criteria considered. only a few studies investigate the learning curves of young surgeons and residents. conclusions: the data available in the literature on learning curves are contradictory. several factors need to be evaluated in order to create more accurate learning curves. we suggest the introduction of checklists with a score for each parameter to be examined, in order to develop more objective and standardized learning curves. aim: the uk training programme for transanal total mesorectal excision (tatme) has completed its first round of training. the study aim was to design a reporting platform that provided trainees with video-assisted feedback in a clear, concise and useful manner to support their training. methods: an established method of video analysis called observational clinical human reliability analysis (ochra) was used to assess the surgical performance of the trainees during their clinical tatme cases. a reporting form for the ochra results was designed identifying areas of difficulties in each procedure and providing error reduction mechanisms. this was piloted during the national training programme for tatme in the uk. results: the ochra reporting form underwent three modifications before the content and format was agreed upon. the final version is divided into three sections: a. case details, b. ochra findings, and c. suggested error-reducing mechanisms. for part b the tatme procedure was divided into four phases of the operation: 1. pursestring, 2. rectotomy, 3. tme dissection, and 4. connected phase when the abdominal and transanal teams work together synchronously. for each phase, ochra findings described the most frequently occurring technical inaccuracies/errors, number of consequential errors/adverse events and the most frequent and serious consequences encountered. suggested error-reducing mechanisms in part c were developed and established by an expert workshop and individual interviews with international surgeons experienced in tatme.trainee and mentor feedback stated that the reporting form had a clear format, easy to follow and understand. the error-reducing mechanisms were particularly useful and allowed the trainee to focus on improving specific technical aspects in their subsequent cases. conclusion: video analysis using ochra can provide a wealth of information on surgical performance, especially for trainees at the start of their learning curve. as an exploratory study, validation of the reporting platform is required; however, its potential to offer detailed, individualised feedback to enhance training is promising. laparoscopic pelvic surgery training program-using a new concept 3d-printed versatile pelvi-trainer r.c. elisei 1 , f. graur 2 , c. popa 2 , e. mois 2 , l. furcea 2 , n. al hajjar 2 1 general surgery, bistrita emergency county hospital, bistrita, romania; 2 general surgery, regional institute of gastroenterology and hepathology ,,prof. o. fodor,,, cluj-napoca, romania pelvic laparoscopic surgery (rectal, urological, or gynecological laparoscopic surgery) is an advanced surgery which require advanced skills, not easy to acquire. there are a lot of training programs for advanced laparoscopic skills but many of them are not affordable for most of surgery residents in eastern europe, where the training programs are far behind from those in western europe. because of that those training programs need to be improved and optimized. in the european union we want equal and high skilled surgeons. this is why we designed a new concept of pelvi-trainer, a versatile one in order to offer the residents the possibility to achieve advanced laparoscopic skills like perfect coordination, precise movements, ability to cut and suture after a well defined route, all of them in the pelvis tight space. we 3d-printed this pelvitrainer which has multiple characteristics: cheap and easy to produce, easy to be used, versatile because offer the possibility to achieve the skills named above, and many others, but also to train on real ex vivo animal rectum (suine model). we also believe that with a proper training a medical student and a young surgery resident are able to achieve the same skills like experienced surgery residents or specialists. in order to demonstrate that we need a study to compare the time to perform 4 or more exercises in this new concept pelvi-trainer by the medical students, young and experienced residents and surgery specialists. what we want to achieve with this training program project is to have more and more skilled surgeons in advanced laparoscopy and an equal laparoscopic surgery training all over the country, close to the level of training in the western europe. also we want this training program to make a standardization of the pelvic laparoscopic surgery training first in our country and then in other countries if possible. aims: the objective of this systematic review is to provide an evidence-based overview of the different components of laparoscopic training curricula, emphasizing the value of objective forcebased assessment and how this in implemented in modern laparoscopic training. methods: bibliographic databases of pubmed and embase were searched till april 2018 to identify studies reporting on evidence-based laparoscopic skills training. abstracts of retrieved studies were reviewed by two authors independently and those meeting the inclusion criteria were selected for full-text review. results: the search yielded a total of 2010 individual records. a total of 96 articles were included. the articles were divided into nine different categories, which include 'metrics', 'benchmark criteria', 'measurement systems', 'timetable', 'training modalities', 'camera settings', 'training tasks', 'serious gaming', and 'competition'. a descriptive analysis of the data is provided. motion analysis parameters, such and path length and time are frequently validated and used for assessment. the results of validation studies on tissue manipulation parameters, such as maximum force and mean force show proved their discriminating power between different levels of proficiency. however, implementation of these metrics remain restrained. conclusions: numerous studies on laparoscopic skills training have been conducted over the years. nevertheless, no consensus is reached towards the use of objective assessment tools. although the value of validated metrics is described well, implementation of objective metrics is limited. we recommend to consider objective force-and motion metrics for feedback and assessment during laparoscopic skills training. surgery, regional institute of gastroenterology and hepatology, cluj-napoca, romania; 2 anesthesiology, university of agricultural sciences and veterinary medicine, cluj-napoca, romania; 3 radiology, regional institute of gastroenterology and hepatology, cluj-napoca, romania aims: the aim of the study was to create a new easy learning method of swine liver anatomy for residents in training. based on human liver surgical anatomy we put 'face to face' the similar structures and also the differences using ex vivo porcine models and ct reconstructions from live pigs. methods: having in mind the human liver anatomy, in the first stage we used data obtained from dissection of twelve porcine liver models to create an anatomical pattern, which summarized the most important surgical information. in the second stage, anatomical data obtained from ct scans of twelve living anesthetized pigs were analyzed. the ct reconstructions and volumetry data were added to the gross anatomy pattern to create a more complex learning module. results: the residents established the most frequent description of swine liver anatomy by putting together the information from ex vivo model dissection. the liver parenchyma is divided into four main anatomic lobes: left lateral, left medial, right medial and right lateral. all those lobes are connected only in the posterior part, which allows a very good separation between them by deep fissures. just as in humans, we found eight distinct segments with independent vascularization and biliary drainage. portal vein has a specific 's' shape; in most cases hepatic artery was found like a trifurcation and extrahepatic biliary tree has a very thin wall. in the right hemi-liver, the inferior vena cava passes through the liver parenchyma. most frequent, we found five hepatic veins which are running completely intraparenchymal. the imagistic data offered a very useful 3d reconstruction with anatomical positions of the vascular-biliary tree and liver segmentation and gave us the possibility to create practical scenarios for resections. perhaps the most important information was to discover and see the section plan and to calculate the volume of the remaining liver after resection. conclusions: the anatomical-imagistic pattern based on \ i[ex vivo \/i [ model disections combined with imagistic data offers a unique mindset before intervention. the concept 'human \ i[vs \/i [ swine' to create an easy method of learning for residents in training can be applied to swine liver anatomy. the learning of surgery is traditionally based on the behaviourist model . goals are set, standards of care fixed, with regular assessments of the level achieved. the teacher exercises control over the student, imposing rules and models, supported by 'reinforcing' actions (reward or punishment). the theory of skinner's program of education, from 1954, is reflected in surgical learning. it foresees a gradual progression by level of difficulty, following a transmission-imitation model . these theories seem currently outdated to face the new challenges of medicine and surgery and to keep up with technological developments. bruner, one of the theorists of the constructivist model, proposed in 1990 a method of collaborative learning between those who teach and those who learn. the goal of the method was to improve strategic problem solving. the comparison between various perspectives (between teacher and student), allowed the learner to better absorb knowledge and improve critical thinking. in 2008 kapur published on the theory of 'productive failure'. this model makes the error of a single person useful for all his colleagues, privileges the practice of theoretical knowledge, contextualised learning as opposed to abstract learning, and 'guided' practice compared to a 'guided' theory. bruner and kapur's systems favour creativity, critical analysis of a problems origin, and the practical use of knowledge. they represent a hypothesis of learning, based on constructive discussion and a continuos 'give-take' feedback system. in order to put these new models into practice in the clinical context, one may hypothesise and propose the adoption of a formal discussion of clinical cases that are complicated or difficult. thereby making the theoretical lessons more collaborative, intuitive and inclusive. in the surgical field, one could adapt such a concept to surgery simulation, virtual reality and anatomical models. aim: large hiatal hernias have a surgical indication when the patients suffering disabling symptoms such as anaemia, dyspnea, chest pain, gastric reflux. several studies showed that in the case of large hernias the placement of a prosthesis was safe and could protect against recurrence. mini-invasive surgery is the preferred approach for hiatal hernia repair and anti-reflux procedure and the toupet fundoplication has been shown to be the best surgical technique for the hiatal hernias repair.the laparoscopic approach is currently the surgical gold standard but is burdened by technical difficulties especially in the case of large hiatal hernias. the robotic system is designed to overcome some technical difficulties of laparoscopy and the studies available in literature report the safety and effectiveness of the robotic approach in complex hiatal hernias repair. methods: we present the case of a grade iv hiatal hernia treated with a robotic approach in a 73 years old woman (bmi: 31 kg/m 2 ). the medical history consisted of a road accident with a probable mechanism of deceleration, three years before. the patient had been suffering from dyspnea for three years. due to the recent discovery of an anaemia, the patient was subjected to an endoscopic examination with the identification of a voluminous grade iv hiatal hernia. a subsequent computed tomography (ct) scan showed also the partial herniation of the transverse colon. results: the patient underwent to surgery by using the da vinci robot system siò (intuitive surgical, sunnyvale, usa) with a single docking approach. the surgery consisted in the liberation of the hernial sac, the placement of a goretex prosthesis and the packaging of a toupet fundoplicatio. the surgery was performed without complication. conclusions: the robotic approach in the hiatal hernia surgery seems to be a valid alternative to laparoscopy, especially in complex cases. the surgical ability in robotic surgery is of paramount importance. general thoracic surgery, kawasaki municipal hospital, tokyo, japan aim: video-assisted thoracoscopic surgery (vats) with carbon dioxide (co 2 ) for mediastinal surgery is known to improve the visualization of medaistinal space. we report our experiences with two cases that underwent vats thymectomy using co 2 insufflation under the one-lung ventilation general anesthesia by double lumen tube. methods: the instruments that were used for vats thymectomy were only the 5-mm 30-degree rigid thoracoscope, maryland jaw energy device, cotton made-dissectors, and straight endoscopic grasping forceps. they were used through sealed ports designed for laparoscopic surgery. lowpressure co 2 insufflation set at 8 mmhg were used for compression of surround tissue of mediastinal tumor during the releasing procedure. results: the patients were an 81-year-old male and a 54-year-old female. thoracoscope with the 8 mmhg co 2 insufflation provides excellent visualization of the medaistinal space and operation could be done smoothly without any hemodynamic compromise. their pathological diagnoses were thymic cancer and thymoma, type b1. the operative times were 115 min and 66 min. the postoperative courses were uneventful and the patients were discharged on day 10th and 3 rd . conclusion: we have just begun to routinely use co 2 insufflation for mediastinal tomorectomy and present our early experiences of successful vats thymectomy by utilizing co \ su2 \/su insufflation. aims: this retrospective study aims to evaluate the feasibility of single-incision thoracoscopic surgery (sits) for primary spontaneous pneumothorax (psp), using a novel multichannel port (x gateò). methods: between october 2015 and november 2018, ten patients who underwent sits using x gateò. nine patients were male and 1 was female, with mean age of 22.6 ± 8.7 years old. a 2.5 cm incision is placed in the middle axillary line on the 4th or 5th intercostal space, depending on the lesions. postoperative outcomes of these patients were compared with those of 33 patients with psp who underwent conventional three-port video-assisted thoracic surgery (vats). results: there were no conversions from sits to vats. mean operative time of sits group was significantly shorter than that of three-port vats group (55.4 ± 14.3 min vs 79.8 ± 26.0 min, p = 0.003). mean number of staplers used in surgery was 2.5 (1) (2) (3) (4) in sits group and 3 (1) (2) (3) (4) (5) in vats group (p = 0.698). mean duration of postoperative drainage was also shorter in sits group (1.0 ± 0 days vs 1.3 ± 0.6 days, p = 0.05). no recurrence and wound infection were observed in sits group. conclusion: sits using x gateò is feasible when performed for selected patients with psp. x gateò provides good visualization of intrapleural space and esthetic outcomes, as well as a superb maneuverability by decreasing mutual interference of surgical instruments. although conventional three-port vats for psp is well established, sits using x gateò can be a permissible alternative. further examinations are required to evaluate efficacy of sits using x gateò. aims: haemorrhage remains a leading cause of potentially preventable death in trauma. in particular non-compressible torso haemorrhage is approximated to cause 60-70% of mortality in civilian trauma patients with otherwise survivable injuries and 80% in war setting. we performed a literature review to assess the potential for using endovascular stenting in traumatic venous injuries and explore the evidence of their efficacy and safety with different venous injury patterns. methods: systematic online search of pubmed performed using key words'endovascular stent', 'venous injury', trauma, penetrating, blunt, abdominal and pelvic. inclusion criteria included all studies that explored the use of endovascular stents following traumatic abdominopelvic venous injuries. english language studies were used. results were presented according to prisma guidelines. results: of the 112 studies generated by the search,there were only four case reports in the literature documenting the use of endovascular stents in traumatic venous injuries dating back to 1997 and most recently 2009. the four cases included three retrohepatic ivc injuries, two secondary to blunt trauma and one penetrating; whilst the final case a blunt injury at the ilio-caval bifurcation. all four cases reported successful deployment of stents via the femoral or internal jugular veins, with subsequent resolution of haemorrhage. length of time taken for stent insertion ranged from 9 to 52 min. three of four patients made full recoveries and discharged from hospital, with one patient subsequently dying of a brain injury independent of the successful venous stent insertion. no complications were reported at up to 8 months follow up in remaining cases including stent leak, stenosis or migration. conclusion: endovascular venous stents have been used successfully in managing complex abdominopelvic traumatic venous injuries. in particular retrohepatic venous injuries refractory to hepatic packing and vessel embolization, which are not amenable to direct surgical repair due to anatomical location. however before endovascular stenting can be added to the arsenal of interventional radiologists for abdomino-pelvic trauma, further development of stents custom made for venous injuries as well as prospective studies examining their long term safety and outcomes is needed. tracheal papilloma is a rare neoplasm growing from the tracheal or bronchial epithelium and has no specific clinical presentations. this is a 40-year-old female who complained of progressive dyspnea for about 2 months. physical examination was unremarkable and the there was no abnormal finding by the chest plain film. chest computed tomography was arranged and revealed a mass lesion located at the tracheal lumen with more than 80% luminal obstruction. we used fiberoptic bronchoscopy to evaluate the airway and found a mass lesion with pedicle originated from the posterior tracheal wall. cryotherapy was considered for the tumor mass removing to establish a patent airway. the pathologic report revealed tracheal papillomatosis without any malignant component. dyspnea was immediately improved and the patient chose closely observation after the bronchoscopic cryotherapy. aims: recent advances in laparoscopic surgery, both in techniques and instrumentation material, have led to the emergence of innovative technological fields, among which robotic surgery stands out.one of the handicaps of this surgery is its high cost as well as the long learning curve. in this stage a new tool arises, the flexdex semi robotic arm, which combines the precision and the range of movements of robotic surgery with the greater availability, simplicity of use and learning of conventional laparoscopic surgery.the objective of this study is to evaluate the efficacy and safety of the flexdex device in different laparoscopic procedures. methods: flexdex's is a three-axis gimbal technological device integrated in a conventional laparoscopic instrument that translates the surgeon's hand, wrist, and arm movements from outside the patient into corresponding movements of an end-effector inside the patient's body.the greater accessibility provided by the flexdex allows the surgeon to perform sutures in areas of difficult access where mobility with conventional laparoscopic instruments is not optimal. the comfort of the surgeon remains fundamental in any type of surgery, even more when we are in anatomical locations with complex access, especially for the realization of sutures. here is where surgical innovation instruments such as flexdex provides ergonomic comfort for the surgeon and improves the patient's safety, especially in high-risk situations, such as when performing anastomosis. results: we present a prospective series of 10 laparoscopic procedures carried out by the same surgical team being the initial experience in our environment in the use of the flexdex semi robotic arm for the realization of complex anatomical sutures.this is a case series of 10 patients to whom different surgical techniques requiring manual suture have been performed. these being 2 tapp procedures, 6 nissen-type fundoplicature and 2 reinforcements of colorectal anastomosis. it is important to note that in none of the cases complications were recorded conclusions: flexdex can provide an excellent alternative to the robotic systems in complex surgical procedures, offering surgeons the precision and control they desire while maintaining the balance of cost, outcome and patient benefit. background: a new single-port device (fsis-flexible-single-incision-surgery) is presented. this new platform has three working channels, two for rigid instruments and one for the flexible endoscope. the channel for flexible instruments offers a pneumatic sealing to avoid the air's leak of the cavity (abdomen, rectum, vagina) . in this study the preclinical data are shown testing the feasibility and safety for laparo-endoscopic instruments. methods: experimental evaluation of feasibility and safety in two stages. in the first stage a working channel with pneumatic sealing was tested in simulators to use a flexible endoscope. in the second stage (animal model) the single incision device that makes possible to use laparoscopic instruments and flexible endoscopes was tested. the measured variables were: time of the procedure, co2 employed, adverse intraoperative events, grip's losing, losing of pneumatic sealing, feasibility and safety of the procedure for the surgeon. results: the hysterectomy and double adnexectomy was done with a median time of 7.1 min. the median of the co2 consumption was 32.5 litres. only in one case (16.6%) the surgeon had problems with the abdominal navigation of the endoscope that was easily solved. the grip's lose wasn't a major problem. the median size of the skin incision was 5.4 cm. the median surgeon' score for the feasibility was 10 and for the safety was 9.6. conclusions: the surgeons considered that the use of the device was very feasible and safe. the fsis-device is a universal platform for single-incision-surgery for surgeons and gastroenterologists and for abdominal, rectal and vaginal access. aim: despite the near-infrared fluorescence (nirf) via the intravenous administration of indocyanine green (icg) improves the visualisation of the cystic duct (cd) and the extrahepatic biliary tract (ebt), the back fluorescence of the liver reduces the signal-to-noise ratio.we have modified the technique of nirf cholecystocholangiography with intragallbladder icg injection by using the arrow-karlan tm balloon cholangiography catheter instead of the purse string at the gallbladder's fundus. this procedure allows a high rate of visualisation of the ebt, with few cases of icg leakage.aim: of this study is to confirm the feasibility of this different technique and to analyse the icg spillage from the gallbladder and to identify the ebt. methods: we enrolled nine patients undergoing laparoscopic cholecystectomy for cholelithiasis. the gallbladder was perforated with the cholangiogram catheter, the balloon inflated with 0.5 ml of saline and tightened. the bile was drained and the icg bolus injected. a titanium clip was the placed on the catheter strict closely to the gallbladder in order to prevent the catheter dislocation. results: the cd and the ebt were visible before dissection in 6/9 and 8/9 patients respectively. after dissection the cd was visible in all the patients and the ebt again in 8/9 patients. there was only one icg spillage due to a tardive positioning of the clip. in a case of inflamed gallbladder this technique helped in the identification of the dissection plane. conclusions: our preliminary results of this ongoing study confirm the feasibility of this different approach as a possible alternative to the purse string and a good visualisation of ebt. introduction: robotic-assisted surgery is a promising technique for overcoming the limitations of laparoscopic surgery, especially with regards to complex and advanced surgical procedures. here, we describe the establishment and implementation of our robotic upper gastrointestinal (gi) and hepato-pancreato-biliary (hpb) surgery program within our center of excellence for minimally invasive surgery as well as the first-year results. method: robotic-assisted surgery was performed using the davinci xi surgical system tm and performed by two surgeons specialized in minimally invasive surgery (db and tk). our robotic surgery program of upper gi and hpb surgery was established in three steps: (1) first, surgical procedures with easier degree of difficulty were performed robotically, including cholecystectomy, minor gastric resections and fundoplications. (2) then, pancreatic distal resections, enucleations, adrenalectomies and atypical liver resections were robotically performed, as procedures with moderate degree of difficulty. (3) finally, advanced and highly complex procedures were performed, including right hemihepatectomy, complex pancreatic head resections (including portal vein resections), total gastrectomy and esophagectomy. data collected from july 2017 till july 2018 were retrospectively analyzed with regard to conversion rate, morbidity (clavien dindo grade £3) and mortality. results: within the first year, a total of 66 robotic assisted upper gi and hpb resections were performed. the first step of establishing our robotic surgical program included eight procedures. here, conversion rate, morbidity and mortality were 0%. within the second step of establishment 31 procedures were performed. conversion rate, morbidity and mortality were 27%, 10% and 0%. the last step included 27 of advanced and highly complex procedures. these procedures resulted in a conversion rate of 48%, 30% morbidity and 0% mortality. conclusion: our stepwise approach enables a safe implementation of a robotic surgical program for upper gi and hpb surgery with low morbidity and no mortality even for highly complex procedures. however, highly complex procedures required a high conversion rate, which might be caused by the early stage of experience. the standard surgical procedure of choledochal cyst is a complete excision of the cyst with rouxen-y hepaticojejunostomy and laparoscopic surgery had been increasingly used. this is still a challenging way to perform anastomosis due to the small diameter of bile duct and the possibility of bile leak or stricture. robotic system can overcome the shortcomings of laparoscopy with providing three-dimensional view, magnification, and articulated instruments. from jan 2014 to dec 2017, 22 patients underwent robotic cyst excision and hepaticojejunostomy by single surgeon. we reviewed the clinical data and compared with laparoscopic outcomes of early (from 2009 to 2011) and late (from 2014 to 2017) group, retrospectively. patients of robotic series were all female with mean age 35.3 years and bmi 23.7. the mean size of cyst was 3.2 9 5.0 cm, and todani type ia 10, ic 6 and iva 6, respectively. total 5 trocars were used with 3 robotic working arm and 1 assist and 1 camera. the mean operative time 248.5 ± 52.9 min, and it was similar with late laparoscopic group (236 ± 62.9 min) and significantly shorter than early group (395 ± 85.9 min).there were no open conversion in robotic and late laparoscopic group, however, the early laparoscopic group involved 35% of conversion rates. the hospital length was 7 ± 3.8 days in robotic group, and it was similar with late group (7 ± 3.5) and more shorter than early group (9.3 ± 6.8). in robotic series, postoperative complications occurred 3 patients. one case included cholangitis which was resolved after conservative treatment. bile leakage was developed in 1 patient, and treated with drain that inserted intraoperatively. last cases showed incisional hernia at postoperative 4 months, and was corrected by laparoscopic herniorrahphy. complications (n = 7) in late laparoscopic group included hepaticojejunostomy stricture and stone, bleeding of jejunal branch, portal vein thromobosis, acute pancreatitis, and adhesive ileus. there were no mortaility case in any groups.robotic surgery of choledochal cyst is a safe and feasible option with short-term results that are comparable to laparoscopic approach. general surgery, sanchinarro university hospital, madrid, spain background: the incidental detection of benign to low-grade malignant small pancreatic neoplasms increased in the last decades. the surgical management of these patients is still under debate. the aim of this paper is to evaluate the safety and feasibility of robotic enucleations. methods: we retrospectively reviewed our prospectively databases from november 2018. demographics, pathological characteristics, perioperative outcome, and medium-term follow-up of patients who underwent robotic pancreatic enucleations were collected. results: 18 patients were included. the mean age of the patients was 61 years (48-74). the median body mass index was 26 (24-29). ten lesions were located in the pancreatic head, 4 in the pancreatic body, 4 in the pancreatic tail. operative time was 250 min (range 114-356), no intraoperative transfusion were needed and in one patient conversion to open approach was needed. in three patients grade b pancreatic fistula occurred. the mean postoperative stay was 8,4 days. conclusions: robotic enucleation is a feasible and safe approach, with low incidence of morbidity. the results of surgical treatment of patients with pulmonary tuberculosis were evaluated depending on the prevalence of the tuberculosis process and the type of surgical intervention used. according to the results of the questionnaire, 556 people operated on pulmonary tuberculosis in the period from 1 to 9 years ago, the frequency of cases of tuberculosis reactivation, the complicated course of the remote postoperative period, as well as the mortality and causes of lethal outcomes were assessed. it was found that after sublobular resection and lobectomy, treatment failure was noted at 3.2%, relapse of tuberculosis-2.2%, pleural empyema-1.1%, bronchial fistula-0.8%, cardiovascular insufficiency-in 1.3% operated. the mortality rate was 3.2% with a total clinical efficacy of 96.0%. after combined resection and bylobectomy, treatment failure was noted at 8.9%, relapse of tuberculosis-15.0%, pleural empyema-12.0%, bronchial fistulae-6.3%, cardiovascular failure-5.0% operated. the mortality rate was 12.6% with a total clinical efficacy of 87.4%. after pneumonectomy, treatment failure was noted at 5.6%, relapse of tuberculosis-5.6%, pleural empyema-3.8%, bronchial fistulae-3.8%, cardiovascular failure-3.8% operated. the mortality rate was 10.0% with a total clinical efficacy of 90.0%. robotic reduced-port splenectomy using single-site platform j.h. lee background: in the era of minimal invasive surgery, single incision laparoscopic splenectomy can offer some advantages compared to conventional laparoscopic splenectomy. but it requires expertise in minimally invasive techniques due to technical difficulties. the da vinci robotic reduced-port splenectomy using single-site platform permits greater freedom of movement and higher levels of accuracy than previous laparoscopic surgery through two small incisions. methods: we performed a retrospective review of all patients who underwent robotic reduced-port splenectomy using single-site platform at our institution between january,2015 and november,2018. one 3 cm periumbilical incision was made for glove port insertion and the other incision was made at left side of abdomen for additional 8 mm port insertion.the surgical technique is much same as open procedure. short gastric artery was ligated, firstly. splenic artery and vein were ligated individually. during the surgery, any stapling device was not used. vessel sealer was used for hemostasis and mobilization of spleen. a specimen was removed through umbilical port site within lap-bag. result: eight patients (6 female and 2 male) with median age of 33.5 years underwent robotic reducedport splenectomy using single-site platform (one case with combined robotic cholecystectomy for gall bladder stones without additional trocar). the indications were; hematological disease (n = 3), splenic mass (benign n = 4, malignant n = 1). preoperatively measured spleen size was ranged 5.5 cm to 16 cm (mean 11 cm). there were no intraoperative complications and open conversion. mean operative time was 132 min. (range 74-206 min) including docking (mean 19 min) and console time (mean 62 min) mean blood loss was under 10 ml. mean hospital stay was 5.2 days after surgery. one patient underwent oral anticoagulation therapy only for portal vein thromobisis without any symptoms, and thromobisis was resolved at 1 month follow-up ct scan. there were no clavien-dindo class iii or above postoperative complication. conclusions: robotic reduced-port splenectomy using single-site platform seems to be feasible and effective. it seems to overcome certain limits of previous robotic or conventional single-site laparoscopic splenectomy and single-site only robotic splenectomy. we think 8 mm additional port allows to use endo-wrist da vinci instruments such as vessel sealer which enhances dissection efficiency andsafety of procedures. aims: inguinal lymph node dissection carries an important risk of post-operative complications, mainly related with wound complications and long term lymphedema. the minimally invasive approach aims to reduce the morbidity of this procedure, avoiding the traditional groin incision but still allowing a full access to the lymph node basin. the authors aimed to describe their videoassisted inguinal lymph node dissection (vilnd) cases, comparing the surgical outcomes with a sample of open inguinal lymph node dissection (oilnd) cases. methods: we performed a retrospective descriptive study that compared the data from patients submitted to vilnd since 2017 (the year in which this technique was first performed in our institution) with the patients submitted to oilnd in 2015 and 2016. gynaecologic and urologic malignancies were excluded. the statistical analysis was performed using spssv25ó, with a p value \ 0.05 indicating statistical significance. results: a total of 62 cases of inguinal lymph node dissection were analysed, 33.9% of which vilnd (none of them requiring conversion to the open approach). melanoma was the primary tumour in 87% of patients. the vilnd and oilnd groups had no statistically significant difference between them regarding age, body mass index, smoking status or the reason for lymph node dissection-clinically detected lymph node vs. positive sentinel node biopsy. the mean of isolated lymph nodes in the vilnd (7.71) and oilnd (9.63) groups was also not statistically different (p = 0.109). there was no difference in the rate of post-operative seroma, wound dehiscence or lymphedema. the rate of surgical site infections was higher in the oilnd group-34% vs. 9.5% during post-operative hospital admission (p = 0.045); 29.3% vs. 4.8% after discharge (p = 0.036). conclusions: in our population of patients we conclude that the main advantage of the videoassisted approach regarding surgical morbidity lies in the reduction of the infection rate, as the published literature also confirms. the equivalent number of lymph nodes retrieved in both groups points toward the oncological safety of the minimally invasive procedure, that we hope to study further in the future after a longer follow up period. objectives: to evaluate the clinical feasibility of tumor localization technique with radio-frequency identification (rfid) clip marker methods: we developed the proto-type rfid integrated endoscopic clip (rfid-clip) and probe to detect it on serosa surface during the laparoscopic surgery. a pig weighing 40 kg was used as the specimen for the in-vivo test. endoscopist performed the application of the rfid-clip on porcine gastric mucosa. after then, the surgeon tried to find the location of rfid-clip using the detection probe and marked with the electrocautery. after the gastrectomy with 3 cm margin (each to proximal and distal), we confirmed the prediction of rfid-clip location and accuracy of resection. results: rfid-clip location was detected and recorded on the exact site of clip application. detection range was very short and we confirmed there are almost no differences between actual clip location and our prediction. this result might arise from using the low-frequency rfid tag to increase the accuracy through reduction of the range. however, some rfid-clip were not detected because of the issue of clipping trouble, not rfid tag. conclusions: this is a basic study to evaluate the clinical usefulness and feasibility of the new localizing technique. we confirmed the possibilities of this system and it could be the helpful option to provide the information of exact location for the minimally invasive surgery or early gastrointestinal tumors. background: the advantages of laparoscopic posterior retroperitoneal adrenalectomy (lpra) have been described in the literature. the aim of this study was to compare the clinical outcomes of lpra and robotic posterior retroperitoneal adrenalectomy (rpra) and determine the differences that could affect the outcomes. methods: we retrospectively analyzed 253 adrenalectomy cases at asan medical center from 2014 to 2017. there were 190 lpra and 63 rpra cases, and their clinicopathological features and surgical outcomes were compared. results: in lpra, there was a positive relationship between operation time and male gender, early period of experience, adrenal tumor size, and pheochromocytoma. in rpra, adrenal tumor size and pheochromocytoma were the only factors affecting the operation time. when the adrenal tumor size was = 5.5 cm, the operation time of lpra was shorter than that of rpra (p = 0.001). when the tumor size was [ 5.5 cm, there was no significant difference in the operation time of lpra and rpra (p = 0.102). conclusions: rpra is a feasible and technically safe approach for benign adrenal diseases. the use of rpra could benefit patients with large tumors and provide comfort by overcoming the factors contributing to a longer operation time in the laparoscopic technique. methods: twenty years experience at the american university of beirut medical center for laparoscopic adrenalectomy. a total of 65 cases were done laparoscopically with no conversion and minimal complication. the average operative time is 40 mins.the video will show the various steps used for lap redo (lt) adrenalectomy for a 15 cm pheochromocytoma using the lateral position and through 3 trocars. attempt to remove the pheochromocytoma in iraque was complicated by cardiac arrest treated successfully and patient referred to the american university of beirut medical center. results: patient had smooth postoperative course following laparoscopic adrenalectomy and patient discharged 3 days later with no complications. conclusions: even large adrenal masses can be completed laparoscopically in advanced experienced centers in laparoscopy. surg endosc (2019) aims: the adrenocortical of uncertain malignancy neoplasm is a spectrum of classification for adrenal tumors whose histopathological diagnosis is uncertain. clinical case: we present a 65 year old patient with constitutional syndrome and severe hypercortisolism and hypokalemia reason why she was admitted to icu for episodes of ventricular fibrillation. no other medical history of interest except refractory hypertension to treatment. the tc showed a left adrenal mass of 6.5 9 4.5 9 5 cm with microcalcifications, areas of necrosis and hemorrhage, no infiltrating, without disease to distance. the surgery was a laparoscopic left adrenalectomy with no evidence of infiltration and no lymph nodes. the histopathology lesion presented a dense proliferation cellular of cortical type, with incomplete fibrous, without vascular or capsular invasion, with a 30% ki67; positivity vimentin and cd56. all epithelial markers, were negative. all this leads to the diagnosis of a neoplasm of uncertain malignancy potential adrenocortical. during the postoperative period, the patient presents a crisis of adrenal insufficiency that was treated with intravenous replenishment corticoidea and later orally with good clinical response. discussion: the adrenal carcinoma has a low incidence (0.1%), incidence peak around the 50 years, the most frequent is the mixed secretory. they are 2-5% of the adrenal incidentalomas. it is usually presented to the diagnosis as a locally advanced tumor with metastases (to liver, lung, retroperitoneal ganglia and bone). may present clinically due to hormonal hyperproduction; or be non-functioning tumors. the adrenal carcinoma poses a great difficulty at the time of the diagnosis pathological, and includes as differential diagnosis to other abdominal tumors. the distinction between corticoadrenal adenoma and adrenal carcinoma is sometimes difficult, so it has been defined a spectrum of intermediate category called adrenocortical neoplasm of intermediate or uncertain malignancy. it is obtained with the weiss criteria, being necessary at least 3 of them for confirm the diagnosis of adrenal carcinoma. this category has a low risk of local recurrence or metastasis, but it needs a narrow follow-up. conclusion: adrenal carcinoma of uncertain malignancy implies a new category in those tumors of difficult classification. aims: multiple endocrine neoplasia type 2 (men2) is an autosomal dominant disorder with an estimated prevalence of 1 per 30,000 in the general population. among patients suspected to have a pheochromocytoma, the diagnosis is rarely confirmed and only 10% is presented bilaterally. we present bilateral laparoscopic adrenalectomy in patients with men2. method: a 77-year-old woman with a family history of medullary thyroid cancer and breast cancer. personal history: hypertension, medullary thyroid cancer, breast cancer, laparoscopic cholecystectomy. appendectomy. after a study by endocrinology and suspicion of bilateral pheochromocytoma, discussing the case in a multidisciplinary committee, bilateral adrenalectomy was decided by laparoscopic approach. selective alpha-1-adrenergic blocking agent (doxazosin) were utilized before surgery. under general anesthesia left adrenalectomy was performed first in right lateral decubitus position. 15 mmhg pneumoperitoneum was started with the verres needle and 3 trocars (11 mm umbilical, 5 mm subxifoid and 12 mm left subcostal).once dissection was completed the gland was placed in a plastic bag and extracted through one of the trocars incisions, then the position of the patient was changed to left lateral decubitus for the right adrenal approach. another right subcostal 5 mm trocar was used. adhesiolysis of previous cholecystectomy was performed to right adrenal approach. adrenal veins were divided between metallic clips.no drainage was employed. results: the procedures were successfully performed without conversion. surgical time was 150 min and hospital stay was 2 days. had a clinical reversion with control of blood pressure monitored by endocrinology conclusions: currently, the laparoscopic approach is the technique of choice for the management of adrenal pathology.lateral decubitus transperitoneal approach is the procedure of choice in most cases. bilateral laparoscopic synchronous adrenalectomy is feasible and safe with good results as in our patient. traditionally the treatment of hyperparathyroidism for patients with familial hyperparathyroidism was subtotal parathyroidectomy or total parathyroidectomy and auto transplantation. in the era of minimally invasive parathyroidectomy, the removal of only abnormal glands guided by preoperative localizing studies has been suggested. aims: this systematic review aimed to investigate the role of focused minimally invasive parathyroidectomy in the treatment of patients with familial hyperparathyroidism. methods: electronic databases were searched with the search terms 'men i', 'familial hyperparathyroidism', 'men2a','hyperparathyroidism-jaw tumor syndrome', 'parathyroidectomy', 'minimally invasive ', for the time period up to and including december 2018. full publications, including clinical trials randomized or not, retrospective studies, case series, case reports that provided relevant data met inclusion criteria. results: thirty five possibly relevant studies were identified. abstracts were reviewed and fifteen articles were excluded. twenty studies, that met inclusion criteria were retrieved in full text and included in the systematic review, including three retrospective cohort studies i.e. two presenting data on meni associated hyperparathyroidism and the third study on familial hyperparathyroidism and seventeen small case series or case reports. the two retrospective studies on meni hyperparathyroidism included 125 patients treated either with focused minimally invasive parathyroidectomy or with the conventional approach. these studies presented conflicting data with one supporting and the other negating the focused minimally invasive parathyroidectomy due to the failure of localization studies to identify enlarged parathyroid glands in a great number of patients. conclusion: undoubtedly, the idea of minimally invasive parathyroidectomy in patients with hereditary and familial hyperparathyroidism is interesting. this idea is especially challenging in the case of meni. existing data suggest that focused mimimally invasive parathyroidectomy is feasible under the condition of exact preoperative localization studies. the main advantage of this approach is the minimization of the risk of postoperative hypoparathyroidism. however, data are limited and further research is needed before valid conclusions can be drawn on the suitability of this approach. objective: resection of pheochromocytomas is a challenging procedure due to hemodynamic lability, tumor vascularity and malignant potential.given the technical challenges for resection of large pheochromocytomas, there were hesitations about using the laparoscopic approach for these tumors during the first decade of laparoscopic surgery. however, improvement in imaging modalities,better pharmacological preparation,advances in anaesthesia and laparoscopic surgery rendered laparoscopic surgery for pheochromocytomas safe and efficient. our aim was to evaluate surgical outcomes in 86 patients with pheochromocytoma and to validate the role of laparoscopic surgery in the treatment of these tumors. design: a total of 85 procedures for pheochromocytoma were performed between january 1998-september 2018. the preoperative diagnosis, operative details, complications, length of hospital stay, morbidity and follow up were retrieved from the hospital records of 668 patients who underwent 686 adrenalectomies for benign and malignant adrenal tumors in the same period. preoperative localization was established in all patients with computerized tomography (ct) or magnetic resonance imaging (mri), while iodine -123-metaiodobenzyguanidine(mibg) scan was reserved for ambiguous cases where paraganglioma or metastatic disease was suspected. endocrinological evaluation and complete adrenal dynamic testing were performed to determine whether the tumor was functional or not. results: eighty-seven tumors were removed from 85 patients. one patient with meniia underwent bilateral resection of pheochromocytomas in two stages. tumor size in laparoscopic procedures ranged from 1.2 cm to 11.0 cm (mean 5.87 cm). forty-three patients had benign disease, 41 potentially malignant (based on pass), 1 malignant with metastasis. eight were in the context of a familial syndrome. sixty -eight patients underwent laparoscopic adrenalectomy, 8 patients had open approach from the start for recurrent pheochromocytoma or large benign tumor, 1 patient had open approach due to inoperable malignant pheochromocytoma and 10 patients had conversions from laparoscopic to open procedure. nine patients received sodium nitroprusside intraoperatively to treat hypertension. one patient developed pulmonary embolism, and succumbed 1 month later. there were no recurrences for the benign tumors during the follow-up period. conclusions: laparoscopic resection of pheochromocytomas despite its increased level of difficulty compared to that of other adrenal tumors, is a safe and effective procedure. aim: the concept 'large' in transperitoneal lateral laparosopic adrenalectomy (tlla) has been evolving along time, ranging from 5 to 8-10 cm depending on different authors. on the other hand, some authors discourage laparoscopic surgery in larger tumors due to the increased risk of malignancy in those larger than 5-6 cm, referring to malignancy in 1 out of 3 or 4 cases. paragangliomas are rare tumors originated in extra-adrenal chromaffin cells, with an incidence of 2-8 cases per million inhabitants. they can appear in any location between neck and pelvis. sympathetic paragangliomas are usually functional and catecholamines producers. we present a movie of surgical intervention of a 22-year-old patient who, in study for refractory hypertension, presented paraganglioma producing norepinephrine, whose approach was performed laparoscopically. 22-year-old woman studied by nephrology for refractory hypertension. on physical examination, only obesity standed out. in blood exams, levels of normetanephrine were observed in plasma of 1950 pg/ml and aldosterone 832 pg/ml. abdominal scintigraphy was performed in which there was no evidence of increased activity at adrenal level. abdominal ct shows retroperitoneal extra-adrenal tumor of inter-aortocava location immediately below renal vessels with dimensions of 3.6 9 2.1 9 6 cm. after preparation, she was operated. laparoscopic access was performed under exhaustive monitoring. an heterogeneous, polylobulated tumor of 6 cm, located interaortocava, intimately adhered to left renal vascular pedicle, was observed. a cattell-braash and kocher maneuver was performed, with exposure of inferior cava and aorta to iliac bifurcation. complete tumor excision was performed after clipping arterial and venous tributary branches. after the operation, the pacient presented favorable evolution being discharge on the second postoperative day with good control of blood pressure levels. laparoscopic approach of retroperitoneal paragangliomas is a safe technique, which allows minimally invasive access, with consequent improvement in postoperative results. the exact location of lesions and their relationships with surrounding structures, as well as their functional behavior, are very important when considering the best therapeutic strategy for these patients. we present the case of a 50-year-old obese male patient referred for adrenalectomy after being diagnosed with left adrenal incidentaloma. abdominal mri showed a 4.7/4.1/3.9 left adrenal mass with normal hormonal levels. after preoperative workup, the patient underwent standard laparoscopic adrenalectomy. the lateral to medial dissection and mobilization of the spleen and pancreatic tail was difficult due to the abundance of peritoneal and pararenal fat. the anatomy was peculiar: the bulky pancreatic tail was located well inferior to the splenic hilum and was visible throughout the intervention and the spleen was quite elongated-long axis = 15 cm. the exposure of the adrenal gland was therefore cumbersome. the operating time was 128 min and blood loss 170 ml. the abdominal drainage was maintained for 48 h. before discharge the patient underwent a control abdominal us examination that only showed a thin line of left pleural fluid. the patient was readmitted 6 days after discharge for chest pain, fever (38.9°c) and malaise with no abdominal signs. the emergency ct scan diagnosed left basal pneumonia with minimal pleural effusion and a 7/1 cm fluid collection between the spleen and diaphragm while the blood test showed leukocytosis. the patient was treated for pneumonia with an apparent clinical benefit for three days and lowered white cell count but his condition worsened during the forth day. repeat abdominal us demonstrated that the abdominal collection increased in size therefore the patient underwent emergency surgery. during laparoscopic exploration, the collection was unveiled as being pancreatic juice (more than 7 times the normal serum levels of lipase and amylase). after thorough lavage, two drainage tubes were positioned in the left subphrenic space. the postoperative course was uneventful under antibiotic treatment for pneumonia and pancreatic antisecretory medication. the patient was discharged after 7 days with minimal pancreatic drainage and the drainage tube was extracted after 5 more days. the aim of the study was to develop the algorithm and the choice of the method of endoscopic treatment of a combined pathology of uterine leiomyoma and adenomyosis depending on the reproductive plans. methods: the study involved 60 patients with a combined pathology of uterine leiomyoma and adenomyosis. indications for conservative myomectomy were: the size of the uterus is more than 13 weeks. pregnancy; multiple leuomatous nodes and adenomyotic foci up to 5 cm in size; hemorrhagic and pain syndromes, anemia, compression of the adjacent organs; suspected node malfunction; submucous leiomyoma deforming the uterine cavity with foci of adenomyosis; subserous, cervical isthus nodes and foci of adenomyosis; the presence of endometrial hyperplasia, tumors of uterine appendages; growth rate of uterine leiomyoma more than 4 weeks pregnancy for the year; the growth of uterine leiomyoma on the background of drug treatment; infertility associated with leiomyoma and uterine adenomyosis.the laparoscopic myomectomy of the subserous node on the 'leg' with a size of more than 6 cm and nodes of more than 8 cm of intramural location is shown with an interest in preserving the organ.the hysterectomy is indicated for women after 43 years of age who insist on hysterectomy, with a combination of uterine leiomyoma with atypical endometrial hyperplasia. results: the conservative myomectomy and removal of adenomyotic foci were performed in 24 (40.5%) patients: from hysteroscopic access-4, vaginal access-3, laparoscopic access-13, abdominal access-5 in the presence of reproductive plans.the hysteroscopic myomectomy was performed in 8 (21.1%) patients, hysterectomy in 30 (78.9%) patients: from laparoscopic access-23, from vaginal access-3, from abdominal access-4 in the absence of reproductive plans. conclusions: the choice of surgical treatment of uterine leiomyoma and adenomyosis depends on the reproductive plans of the woman and the severity of the lesion.the laparoscopic method of treating a combined pathology of uterine leiomyoma and adenomyosis in the presence and absence of reproductive plans is a priority for women. surgery, policlinico ,,paolo giaccone,,, palermo, italy background: breast cancer in females represents the most frequent neoplasm in all age groups. the risk of getting breast cancer (mc) increases with age. the brca1 and the brca2 genes (tumor-suppressor genes, autosomal dominant transmission at high penetrance) alone justify from 30% to 70% of cases of hereditary breast cancer. methods: from 1 january 2011 to 1 june 2017 we have analyzed 18 patients with brca mutation. all 18 patients had in common a genetic mutation of brca1 or brca2 tumor suppressor genes. results: the frequency of germline mutation on brca1 (9 patients: 50%) was identical to brca2 gene (9 patients: 50%). 13 of the analyzed patients were women (72.2% of patients) 9 brca1 and 4 brca2, and 5 men (27.8%) all with brca2 mutation. conclusions: prophylactic surgery must be seen as a way to put the patient in the condition to implement the most appropriate treatment. further studies will be necessary to support the validity of prophylactic surgery in patients with mutations in brca1 and brca2 genes. introduction: laparoscopic hysterectomy is a safe surgical technique for removing the uterus with or without including the ovaries and fallopian tubes. laparoscopic surgery of endometrial cancer is a safe method, with the mean time of recovery being two days only. material-method: the case of a 55 yr old woman with metrorrhagia and anaemia (ht 24,5%) due to adenocarcinoma of the endometrius is presented. the patient underwent a laparoscopic hysterectomy and oophorectomy. 4 trocar ports were used during the procedure (a 10 mm transumbilical port, similar to the port used in single incision laparoscopic operations, two 5 mm ports at the level of the anterior superior iliac spines, and a 10 mm port in the middle of the imaginary line between the pubic symphisis and the umbilicus). the uterine vessels and the uterine ligaments were ligated and dissected by using a thermal energy source. the patient's postoperavite course was uneventful. the patient continues to be in good condition, 6 months post-surgery. conclusion: laparoscopic hysterectomy seems to be a safe method for addressing endometrial cancer, as it offers the surgeon a better surgical field, is tissue friendly and causes fewer postoperative complications. it is considered to be a less traumatic operative method, as due to zooming in the picture there is greater accuracy in handling the tissue, and blood loss is minimal. m. shahin background: hysterectomy is one of the most frequently performed surgical procedure. though there are three approaches in hysterectomy (open, vaginal and laparoscopic), still there are controversies regarding the optimal route for performing it. methods: this prospective comparative study included 42 obese patients subjected for panhysterectomy as a treatment. the forty-two patients were allocated into two groups: group (a) subjected to laparoscopic pan-hysterectomy, group (b) subjected to open pan-hysterectomy. results: there was significant difference between the two groups regarding mean operative time, blood loss, analgesic requirements and hospital stay, while no significant difference regarding intra-operative complications. conclusions: laparoscopic hysterectomy in obese patients has emerged as a viable, safe and better alternative to open hysterectomy amongst appropriately trained surgeons. general: endometriosis in the inguinal region is rare. the usual presentation is that of a woman in the reproductive age group. it accounts for 0.3-0.6% of patients affected by endometriosis. the groin swelling is usually slow growing, painful with exacerbations during menses. the incidence of inguinal endometriosis on the right side is 90-94% as compared to the left. aim: to present our laparoscopic approach for the treatment of the diagnostic dilemma. case presentation: a 40-year-old woman presented with a palpable mass in the right groin. the swelling was associated with a dull aching pain. the patient was suffering from increasing pain over the swelling during menstruation. she had undergone cesarean section some years ago and the scar had healed by primary intention. mri scan revealed a nodular hypoechoic lesion at the level of the internal inguinal ring with the absence of vascular flow around the lesion. results: since inguinal endometriosis was in the differential diagnosis and it may be associated with pelvic or intraperitoneal endometriosis, a laparoscopic approach was decided. the procedure was successfully completed laparoscopically following the transabdominal preperitoneal approach. the endometriosis was found, after dissecting the internal inguinal ring, firmly adhered to the round ligament. it was excised en bloc with the round ligament. a preperitoneal polypropylene mesh was inserted to protect for future inguinal hernias due to extensive dissection at the level of the internal inguinal ring. no intraperitoneal endometriosis was appreciated. histopathology revealed endometriosis of the round ligament. the patient was uneventfully discharged the next day. on follow up the patient was asymptomatic. conclusions: round ligament endometriosis is a rare entity. it is a disease of specific interest to the physician. it can be confused with an inguinal hernia and thereby pose a diagnostic dilemma. we recommend considering endometriosis in the differential diagnosis of groin swellings in women. the transabdominal preperitoneal approach is feasible and safe in the hands of an advanced laparoscopic surgeon. introduction: sentinel node biopsy is the newest accepted method for surgical staging of early stage endometrial and cervical cancer. aim: to evaluate the role of the technique of indocyanine green (icg) identification of the sentinel lymph nodes in cases of early endometrial cancer. material and method: five patients with early endometrial and cervical cancer were introduced in a prospective study. icg was locally injected during the laparoscopic exploration. novadac pinpoint near to red technology was used. guided biopsies were performed into the marked sentinel nodes and histological results were evaluated. results: sentinel lymph nodes were easily identified by using icg and near-infrared technology. technical details are described. no associated complication was encountered. conclusion: sln mapping using icg in uterine cancers is demonstrated as an effective and safe procedure. laparascopic extraction of an intraperitoneal gossypiboma following c/s and a retroperitoneal gossypiboma following pyeloplasty n. ozlem general surgery department, ahievran university, kirsehir, turkey gossypibomas are forgatten foreign bodies,iatrogenic.their symptoms are different where they are. they extracted with laparotomy in the past but now we can some article mentioned their extraction was made with laparoscopy. case 1: 33 y o female has abdominal pain after c/s for 2.5 years. a gossypiboma was extracted with laparoscopy above umblicus.a superficial surgical site infection existed,drained,subsided. case 2: 46yo m had a pyleoplasty operation 8 years ago.a gossypiboma was extracted with retroperitonescopy,no postoperative event. basibuyuk et al reported retroperionescopic extraction of a gossypiboma from single port in first time.althoug every effort taken the incidence of foreign body detected in the body is about 0.03-0.1%.they are most frequently localized in the intraabdominal cavity followed by tracheobronchial area,pleural cavity,pararenal area,vagina,spinal chord, neck, femur,breast,bladder,pancreas,and they may cause local irritation,and infection.tactile sense is absent in laparoscopy. all radiologic examinations(usg ct pet mri etc) be used to detect.we used usg ct.in the end laparoscopy make the diagnosis and remove gossypibomas in our cases with less postoperative pain and cosmosis. justo et al the computerized tomography (ct) scan is the most useful method for diagnosis; however, sometimes the preoperative diagnosis remains uncertain even after the imaging exam. in that case, laparoscopy arises as a valuable diagnostic tool, as well as a prompt treatment option. concerning gossypiboma, prevention is preferred rather than treatment. notwithstanding, there is no highly reliable prevention system. counting sponges is a method based on staff communication during the surgery with only 77% sensibility. routine surgical postoperative x-ray (spox) constitutes an early detection system, but the need to incorporate a radiopaque marker and to expose the whole surgical field to maximize its efficacy limits its use. more recently, electronic dispositives based on barcode detection and other technological adjuncts for counting sponges are being developed. none of these prevention systems are reliable when used alone. our education and research clinic was a state hospital before. no surgeon followed above instruction.but now we use all. multiple procedures and surgical teams, long operations and non-elective operations are the evidenced risk factors.c/s operation was learned full opened of ostium of cervix of the patient. urology, japan, nagoya, japan aims: some scoring systems have been suggested to standardize the renal tumor characteristics. among them, renal score is widely used in partial nephrectomy. whereas diameter-axis-polar (dap) score was developed to be more significantly related with postoperative renal function. our study compared dap score with renal score in robotic partial nephrectomy (rpn) outcomes. methods: records of patients who underwent rpn at nagoya daini red cross hospital between april 2016 to october 2018 were analyzed retrospectively. those include three oncocytomas. accordingly, we calculated the estimated glomerular filtration rate (egfr) just before rpn and 1 month postoperatively in 51 patients. we compared two nephrometry scores with warm ischemic time and change in egfr. results: in our institution, four surgeons performed rpn. according to dap score, 14 patients were high, 19 were middle and 18 were low. according to renal score, 1 were high, 26 were middle and 24 were low. the median warm ischemic time was 20 min (11-35). the median egfr decreased from 67.9 (23. 2-127.3) to 57.8 (10.7-116.9 ) ml/min/1.73 m 3 . there were no significant differences in warm ischemic time and percentage change in egfr between renal score groups (p = 0.38 and 0.87) but significant differences between dap score groups (p \ 0.05 and p \ 0.05). univariate and multivariate analyses were used to identify factors influencing postoperative renal function. that confirmed that dap score was independent poor predictors of change in egfr after rpn. conclusions: dap score is simpler estimate system than renal score. our study suggested that dap score is a useful scoring system for preoperative evaluation of renal tumor for rpn. further investigation is needed to better understand preoperative dap score. aims: retroperitoneal primary tumors comprise a great variety of neoplasm with different histological typologies, with insidious clinical symptoms and little specificity in most cases. its diagnosis is established through imaging tests and anatomopathological study is needed so complete surgical resection is the treatment of choice. the aim of the video is to demonstrate the safety and efficacy of the minimally invasive approach in patients with retroperitoneal lesions. methods: a 66-year-old female patient who, in the course of an abdominal pain at the right iliac fossa suspected of possible acute appendicitis, is diagnosed with a right retroperitoneal tumor, compatible with primary neurogenic tumor on a ct. radiographic imaging is a key component of the evaluation of a patient with a retroperitoneal mass, a ct scan is necessary to evaluate the primary site as well as to rule out metastatic disease. after complete biochemical study, nonfunctioning tumor is determined. the study is completed with mri where the lesion is located below the right kidney, in front of the right psoas muscle and lateral to the inferior vena cava, and without contact with these structures. ??it is in intimate contact with the ovarian vein. the complementary tests and iconography of interest of the case are exposed. surgical intervention is proposed with a laparoscopic approach. results: full minimally invasive approach in left lateral decubitus position: 4 trocars-lateral laparoscopic transabdominal approach. laparoscopic liberation of the right colon, kocher maneuver until the inferior vena cava is visualized, identification of a tumor of approximately 5 cm in the right infrarenal region, lateral to the right ureter, which includes the gonadal vessels. resection of the tumor in block with margins previous dissection and clipping of the proximal and distal gonadal vessels with ligasureò. the patient presented a successful postoperative recovery, being discharged 24 h after the intervention. definitive result of the specimen: leiomyosarcoma, grade 2 of the fnclcc with negative margin. the laparoscopic approach is a safe and effective technique in the approximation of retroperitoneal tumors, a radical oncological criterion is always needed with correct margins of resection especially in those of uncertain etiology. we started endoscopic thyroidectomy using the lifting method in 2001 and have developed single incision endoscopic thyroidectomy (siet) via chest (c-) or axillary incision (a-) by our original retractor since 2007. we created a new approach in 2010. recently, we have applied this method to parathyroid surgery. in this study, we present our method and results in parathyroid surgery with regard to surgical outcome and patients' complaints. method: endoscopic parathyroidectomy of c-siet was performed in 6 patients with hyperparathyroidism (primary 4, secondary 2) in new approach (mean age 69, male 1 female 5). single parathyroid adenoma was diagnosed using ultrasonic device, preoperatively. the patient is placed in a supine position with the neck extended. 30 mm vertical incision is made in anterior chest. flexible endoscope (olympus co. japan) is used through 5 mm trocar detached the retractor. in new approach, the parathyroid and thyroid are exposed through the avascular space between sternal head and clavicular head of sternocleidomastoid muscle. both of the skin and sternal head are lifted up by our original retractor (takasago medical co. japan). parathyroid adenoma behind the thyroid is resected using an ultrasonic scalpel. i would like to present our c-siet procedure. results: no scars in the neck were left in all cases. benign and hemi lateral parathyroid adenoma sized from 8 mm to 25 mm (mean:16.5 mm) were operated. mean operation time is 123 min. in new approach. there was no complication. parathyroid hormone levels decreased in all patients immediately after operation. conclusion: it is a little possible to make recurrent nerve palsy in this approach. new approach is useful to operate and make the working space wider without stress to find out of parathyroid adenoma. our original retractor can be introduced easily in most hospital, because it is not so expensive. most of women satisfied cosmetic results because of hidden scars. objectives: radiofrequency ablation (rfa) is a novel and developing technique for the treatment of parathyroid hyperplasia/adenoma in the context of secondary hyperparathyroidism (hpt) to chronic kidney disease (ckd) and there is little literature on the subject. the purpose of this study is to determine its usefulness by contributing a case carried out in our hospital. methods: we selected a case of secondary htp in a patient of 62 years old with ckd who presented a parathyroid adenoma detected clearly by ultrasound scanning. the patient was dismissed for surgery due to high surgical risk due to his comorbidities. rfa of a right inferior parathiroid adenoma was performed. intact parathyroid hormone (ipth) was measured before arf and 10 min after de procedure, calcium and phosphorus were measured the day after. the treatment was considered effective if ipth levels decreased at least 50% 10 min after rfa and calcium levels decreased the day after. results: ipth level before rfa was 1985 pg/ml. ipth level after 10 min of rfa was 835 pg/ ml, this meant a 58% reduction (normal values 15-65 pg/ml). calcium levels were from 10.2 at the baseline to 8.6 the day after (normal values 8.5-10.5 mg/dl) and phosphorus from 4.5 to 5.4 mg/dl (normal values 2.5-4.5 mg/dl). the patient presented dysphonia as a complication that improved with corticosteroid therapy. we are currently waiting for the next analytical controls at 3, 6 and 12 months after the proceidure. conclusions: rfa of parathiroid adenomas for treating secondary hpt in patients with ckd is feasible in selected patients. this treatment may reduce the morbidity that surgery supposes, it is developed in an outpatient regime avoiding hospital admission and this contributes to a reduction of health costs. however, a longer follow-up is necessary to verify the good results in our case. splenectomy is one of the treatment strategy for advanced portal hypertension due to liver cirrhosis. after splenectomy, thrombocytopenia is dramatically ameliorated, and liver function parameters have also been improved in several clinical settings. however, the mechanism underlying such a phenomenon remains unclear. the aims of the present study was to analyze histological changes of the liver after splenectomy in human, and to speculate the underlying mechanism. subjects and methods: cirrhotic patients with hepatocellular carcinoma (hcc) who had undergone laparoscopic splenectomy prior (4 weeks-52 months) to hepatic resection were analyzed (n = 15). non-tumorous liver specimens obtained at hepatectomy were histologically investigated. liver tissues from cirrhotic hcc patients who underwent only hepatectomy were used as controls (n = 15). results: after splenectomy, significant leukocytosis, especially increase in monocytes, was observed in addition to thrombocytosis. in the non-cancerous liver tissues, many round-shaped cd68-positive macrophages accumulated after splenectomy, while this phenomenon was merely observed in patients without splenectomy. the macrophages were cd163 ? (m2 marker) and cd14 -cd16 ? , suggesting their anti-fibrotic population. the accumulated macrophages existed around fibrous scar as well as ck19 ? epcam ? cells spreading out from the ductular reactions (dr). as a result, the number of ki67-positive hepatocytes significantly increased after splenectomy. the amount of platelets detected in the liver did not change even after splenectomy. finally, remarked attenuation of the established liver fibrosis was detected after relatively long duration. the accumulated macrophages expressed metalloproteinase (mmp)-1 and fibroblast growth factor (fgf)-7, suggesting these molecules may possibly participate in resolution of established fibrosis and hepatocyte proliferation. conclusion: splenectomy in cirrhotic patients with portal hypertension ameliorate liver fibrosis, and stimulate liver regeneration. the mechanism possibly include hepatic accumulation of anti-fibrotic cd163-positive macrophages and stimulation of dr-derived ck19 ? epcam ? progenitor-like cells. in patients with advanced splenic fibrosis, splenectomy could be a feasible therapeutic modality. the paper tries to establish the role and the opportunity of using laparoscopy in regard with abdominal contusions, as well as its indications or contraindications, combined in a therapeutic algorithm. we analyzed two groups of patients with abdominal contusions divided over two 5-year periods, 2008-2012 (51 patients) and 2013-2017 (60 patients) respectively. we have separated the two periods because starting from 2013 we have established a strategy for dealing with cases of abdominal contusions where we included diagnostic and / or therapeutic laparoscopy and nonoperative management. the investigation was done by fast echography, ct scan, simple abdominal radiography, peritoneal lavage puncture, and sometimes arteriography. in the second period we determined the diagnostic and therapeutic laparoscopy indications: suspicion of hollow or parenchymal organ injury, or mesentery injury, the presence of hemoperitoneum or fluid in the peritoneal cavity in a stable patient without major hemorrhage, apparent with unique injuries, without immediate vital risk and without other associated severe trauma. we have associated in this last period the nonoperative management for patients with grade 1 and 2 lesions of parenchymal organs that do not have fluid in the peritoneum, or only a very discreet quantity. in the first period, all 51 patients were treated by classic surgery, resulting in 4 unnecessary laparotomies where no visceral lesions were revealed. in the second period, we applied non-operative management to 8 patients out of 60, 2 patients with grade 1 and 2 splenic injuries, and 6 patients with grade 1 and 2 hepatic lesions. diagnostic laparoscopy was performed in 5 cases, in 2 of them without evidence of lesions, and in 3 other cases of grade 1 lesions no therapeutic action was required. therapeutic laparoscopy was required for one case of splenectomy and one of hepatorrhaphy. diagnostic laparoscopy is useful in abdominal contusions, if certain indications are followed and in selected patients. in our study, with the introduction of modern therapeutic strategies, unnecessary laparotomies were completely avoided, some lesions being even treated by laparoscopy. the new algorithm introduced allowed 23% of patients to avoid laparotomy. aims: about 150 cases of splenic hamartoma have been described in the literature since it was first described by rokitansky in 1861, it is a rare benign tumor. it is usually a casual finding in laparotomies or autopsies. they are usually asymptomatic, but there are few symptomatic splenic hamartomas and they can be associated with haematological alterations, being in some cases associated with spontaneous splenic rupture and acute abdomen, two thirds of them have multiple tumors. there are no specific data that allow the preoperative diagnosis of this entity, which is performed after the anatomopathological study of the surgical specimen, which must be extracted entirely, this together with the size of the spleen makes the laparoscopic approach difficult. the aim of this video is to demonstrate the surgical technique of a complete laparoscopic approach for this type of lesions, without the need for assistance laparotomies (handport). methods: clinical case: a 44-year-old man admitted to internal medicine due to fever and left lumbar pain. additional explorations of interest are discussed, including: thrombopenia of probable peripheral origin secondary hypersplenism (fna of bone marrow), ct: splenomegaly with 4 splenic masses, which deform the splenic contour, compatible with atypical hemangiomas, without being able to discard other vascular splenic tumors. results: complete semi-laparoscopic approach, 4 trocars, multilobulated splenomegaly (19x16 cm.), mechanical vascular section, complete bag extraction after minilaparotomy on the left flank. the patient presented a successful postoperative recovery, being discharged on the 4th po day. abdominal ultrasound at 1st week with portal vein thrombosis, which resolves after treatment with heparin. definitive result of the specimen: multiple splenic hamartoma. asymptomatic one year after surgery. the laparoscopic approach is a valid and effective alternative to splenic benign tumor lesions. the size does not contraindicate this type of approach, although the complete extraction of the spleen is recommended for its pathologic study. we recommend eco-doppler control per week, given the risk of portal thrombosis with an existing laparoscopic post-splenectomy. objectives: splenic cysts are a rare entity, currently described between 800-1000 cases in literature. a female patient's case is hereby presented, giant splenic cyst treated by conservative laparoscopic surgery obtaining good results. method: 30 years old female, without any relevant medical history, examined after abdominal pain on the left hypochondriac region, nausea, postprandial swelling and mass sensation. after exploration the presence of such mass was ratified, the rest of exploration found no relevant findings, no record of previous traumatism nor any other relevant incidence. diagnosis was made through ultrasound and computerized tomography, the existence of a big splenic cyst is confirmed, 19 cm by 14 cm, on the superior section of the spleen, negative results after parasitism test, normal haemogram, coagulation and biochemistry levels. patient was intervened using laparoscopic surgery, performing the deroofing technique on the cyst (two liters of orangey amber serous liquid that was sent for analysis) as well as extirpation of superior wall of the cyst, which was sent to pathological anatomy, a saline solution was used to cleanse the cavity, omentum and drainage were then set in place. results: patient evolved satisfactorily, hospital discharge and drainage withdrawal after 48 h. regular check-ups, after 12 and 24 months, patient presents no symptoms nor recurrence. pathological anatomy confirmed primary splenic cyst and the extracted liquid as cystic. conclusion: splenic cysts are primary (25%) or secondary (75%). diagnosis is performed through imagery tests, cat scan the being standard test used. regarding her treatment there is no clear consensus, due to the fact that up to a few years ago, complete splenectomy was the recommended treatment, techniques with preservation of the spleen are currently being widely recommended through laparoscopy in literature. among the conservative techniques percutaneous aspiration, with or without the injection of a sclerosing agent, partial splenectomy, marsupialisation, cystectomy, decapsulation, unroofing or fenestration can be found. the main issue is recurrence rates. few cases of primary giant splenic cysts treated by laparoscopic decapsulation can be found in literature, this treatment being simple and quick to perform, resenting a recurrence rate lower than other techniques such as aspiration and marsupialization. introduction: technology's progress and its application in the minimally invasive surgery of the thyroid gland offers us new surgical approache's like the transaxillary approach. this new technic still unusual in our environment and has recently begun to be incorporated into our surgical practice. the objective of this case is to explain step by step how to carry out a right transaxillary thyroidectomy and emphasize in the most relevant tips to take into account. also we going to review the main limitations we observed so far. statement of the case: we present the case of a 49-year-old woman referred for evaluation of a left thyroid nodule without associated symptomatology. the blood test shows normal thyroid profile. cervical ultrasound is performed identifying a 3.5 cm single right nodule with welldefined edges and presence of peripheral vascularization . no other nodules are identified. fna of the nodule describes a bethesda iii. after evaluation we decide to perform a left transaxillary thyroidectomy. discussion: surgical treatment of the thyroid gland by transaxillary approach may be indicated in previously selected patients, offering the advantages from minimally invasive techniques (shorter recovery time, shorter incision length, etc.). surely, more evidence and experiencie is required to make a better assessment of minimally invasive approaches in thyroid surgery. surgery, taipi city hospital, yan-ming branch., taipei, taiwan; 2 surgery, taipei city hospital, taipei, taiwan the first endoscopic thyroidectomy was performed in 1997 using a cervical approach. since then, various remote-access method, have been developed for thyroid surgery to avoid scarring of the neck. trans axillary approach(taa),bilateral axillo-breast approach(baba),and retroauricular approach(raa) are common in use. the main benefit of these procedure is that there are no visible scar that is one of the drawbacks of conventional kocher's incision. however,these methods require more dissection and longer operation time than conventional thyroidectomy transoral thyroidectomy(tovet) is a new approach and has become popular in recent years, however,most surgeons peformed a single procedure because of the limited patients and the learning periods sine 2017,more than 100 cases were performed,patients received endoscopic thyroidectomy(et) procedure at our hospital. we compare the surgical procedure of bilateral axillo-breast approach(baba) with transoral vestiblar approach(tovet) in our hospital both performed by one single surgeon .the surgen has expended eaqual amounts of time with these two procedures. the patient seletion process,operation time, operation procedure and approach,learnig experience, consmetic effect,onaologic consideration and surgical outcome were discussed yhroughly. presenting a case of a thyroid metastasis from an ovarian carcinoma, we conducted a review of the literature without finding similar reported cases. case: a 43-year-old woman consults for progressive asthenia, weight loss and ascites. abdominal ct finds a conglomerate in the pelvis involving the ovaries and peritoneal implants, the largest up to 10 cm. an omental epigastric lesion biopsy and paracentesis is performed resulting in adenocarcinoma and omental metastasis from ovarian neoplasm, associated with ca125 of 4553. patient starts neoadjuvant therapy with carboplatin-paclitaxel. in image controls there is a favorable response. three months later, intervention was carried out; laparotomy hysterectomy ? double anexectomy ? omentectomy ? appendectomy ? pelvic and paraaortic lymphadenectomy.the anatomopathological study shows a low-differentiated endometrioid carcinoma, omentum infiltration and absence of metastatic lymphatic involvement. while getting the maintenance treatment with bevacizumab the patient presented symptoms of arthritis and hypercalcemia was detected (11.4) with pth 268. a gammagraphy was performed and an increased uptake area was detected in the lower pole of rtl, suggestive of a parathyroid adenoma. we initially proposed the possibility of performing radiofrequency ablation but in a previous thyroid ultrasound we visualize 3 nodular lesions in rtl compatible with adenoma and a mass in the superior mediastinum that seems to correspond the area of greatest uptake in the gammagraphy so finally the procedure is dismissed and surgery is proposed. during the intervention we found a hard consistency nodule in the inferior pole rtl and lymphadenopathies of hard consistency in right vi area that are sent for intraoperative anatomopathological study with the result of adenocarcinoma metastasis without identifying origin. a total thyroidectomy, parathyroidectomy and central ganglion drainage is performed with the result of a parathyroid adenoma, lymphatic invasion of ovarian-grade latent carcinoma and extensive vascular permeation by carcinoma of the thyroid. the patient maintains oncological treatment with carboplatin-caelix. in the last follow-up, the pth and calcemia remains normal. conclussion: although some cases of neoplasic thyroid involvement associated with struma ovarii have been published, no cases similar to the one described are found, neither in our experience, which is why it is an exceptional case. the aim of the study was to evaluate the effectiveness of the use of embolization of the splenic artery in order to prevent portal bleeding. methods: the study included 96 patients, who had esophageal varices bleeding, which developed as a result of decompensated cirrhosis of the liver of various etiologies of classes b and c according to child-pugh. patients were divided into 2 groups. the main group included 71 (73.95%) patients who underwent endoscopic ligating of bleeding varix and in order to prevent recurrence of bleedingembolization of the splenic artery with gianturco coils. the comparison group consisted of 25 (26.05%) patients who received only drug therapy. to assess the effectiveness of the treatment, the patient's condition was monitored for 6 months. results: the average age of patients in the comparison group was 56.8 ± 4.4 years. using only drug therapy, we stopped bleeding in 54 (76.1%) patients. in all cases, at the end of treatment, we received an improvement in clinical and laboratory parameters. 17 (23.9%) patients died. the duration of treatment was 10.1 ± 2.4 days. the average age of patients in main group was 55.2 ± 5.6 years. performing endoscopic ligation of bleeding varices, we stopped bleeding in 23 (92.0%) patients. in all cases, at the end of treatment, we received an improvement in clinical and laboratory parameters. 2 (8.0%) patients died. the duration of treatment was 6.5 ± 2.7 days. a statistical analysis of mortality and duration of treatment revealed a significant difference (p \ 0.01) between the groups in both indicators. after splenic artery embolization in all cases managed to achieve a reduction in blood flow of 60-80%. after 6 months among 54 patients in the comparison group, bleeding relapse occurred in 12 (22.2%) cases. in the main group, this indicator was 8.7% (2 patients). the indicator in the main group was significantly (p \ 0.01) different from the same indicator in the comparison group. conclusion: performing embolization of the splenic artery in patients after endoscopic hemostasis of variceal bleeding allows to reduce the pressure in the portal system, which in turn leads to a decrease in the frequency of bleeding recurrences. thoracoscopic esophagectomy for aortoesophageal fistula y. ebihara, t. shichinohe, y. kurashima, s. murakami, surgery ii, hokkaido university, sapporo, japan background: aortoesophageal fistula (aef) is an uncommon but one of highly fatal conditions. there are surgical, endoscopic and interventional radiological treatment options, however, definitive treatment is the surgical intervention. video-assisted thoracoscopic surgery (vats) has been gradually accepted as a substitution for thoracotomy to reduce the invasiveness of the surgery as radical surgery for esophageal cancer. we aimed to evaluate a feasibility of vatsesophagectomy (vats-e) for aef in this study. introduction: achalasia is the most common motility disorder of the esophagus. heller's cardiomyotomy associated with a antireflux technique is the treatment of choice in patients with this disease; however, a small group of patients could present a recurrence of the symptoms being necesary a new surgery, what is an important challenge for most of the surgeons. we report the case of recurrence after a laparoscopic miotomy and dor fundoplication as a paradigm for the appropiate management in this kind of patients. methods: a 63 years old female, who underwent a previous miotomy and a dor fundoplication in 2011 due to an achalasia.six years after surgery, the patient showed epigastric pain and dysphagia. the study of the patient was performed with: barium swalow, phmetry, manometry, ct-scan and mri showing a recurrence of her disease.the patient was transfered to our center where she underwent a new surgery.the key points of the new surgery includes the next steps: dissection of the previous adhesions, dissection of the dor's partial fundoplication, avoid dissection of the anterior esophageal wall at the leve lof the hiatus (the area of previous myotomy) in order to avoid perforation of the esophagus, lateral and posterior dissection of the distal esophagus, lateral myotomy at the rigth wall of the esophagus and a toupet's funduplicatury. all of thisis procedures are done under intraoperative endoscopy in order to confirm a good passage to the estmach and to identify a perforationic supervision. results: following theseis steps several patients have been operated in our center with excellent results. in all of these cases, including the patiente presented previously, the symptoms have dissapeared. conclusions: achalasia is a rare motility disorder of the esophagus, being recurrences an important challenge for surgeons. a great proper therapeutic strategy using the different diagnostic exams and the supervison by a group of experts in this kind of entity are the basis in order to obtain good results in these situations. aims: re-do fundoplication is usually performed for recurrent reflux symptoms due to wrap failure or recurrent hiatus hernia. conversely, persistent dysphagia may occur early due to tight wrap/crural repair which should be avoided by good surgical technique. a small group of patients however may suffer progressive dysphagia due to weakening motility (especially in older patients), fibrosis of the wrap or a combination of the two. this video demonstrates the successful treatment of this problem with a laparoscopic conversion from nissen to posterior toupet fundoplication. a 72 year old man underwent an uncomplicated laparoscopic nissen fundoplication in 2015 with complete resolution of reflux symptoms. he re-presented 2 years later, still free of reflux but suffering progressive dysphagia and troublesome regurgitation. investigations demonstrated intact wrap and no mechanical obstruction, but confirmed low-amplitude peristalsis. a trial endoscopic dilatation improved symptoms for 11 days before recurrence, suggesting likely wrap fibrosis (which would reduce elasticity and impede passage of food bolus), justifying consideration for a conversion from nissen to toupet. results: this video demonstrates the expected adhesions between fundoplication and inferior surface of left lobe liver, mobilisation and division of the nissen fundoplication, and reconstitution of a posterior toupet fundoplication. the patient made a good recovery and was discharged the following day. three-and six-month follow-up confirmed complete resolution of symptoms with no recurrence of reflux. conclusion: laparoscopic re-do surgery for late-onset progressive dysphagia is a safe and viable option. patients must be thoroughly investigated and carefully selected for an appropriately tailored procedure. they should also be advised of the increased risks associated with re-do surgery. the anatomy can be unpredictably distorted by variable adhesions and this operation should therefore only be performed by laparoscopic surgeons experienced in both primary and re-do fundoplication. methods: i report unusual iatrogenic injury of cervical esophagus that resulted with complete resection post total thyroidectomy for papillary ca of thyroid patient presented 4 days post surgery to our center. the video will show the steps used to treat this unusual complication by neck exploration, laparoscopic trans hiatal esophagectomy with creation of gastric tube with preservation of the right gastroepiploic artery and the neck anastomosis between the cervical esophagus and stomach. were open and 13 minimally invasive esophagectomies. of the 27 patients, 10 were for squamous cell carcinoma, 13 were adenocarcinoma and 3 were of other histological diagnosis such as gastrointestinal stromal tumor and schwannoma. the median length of stay for patients who underwent minimally invasive esophagectomies was 9 days (9 to 120 days) while the median length of stay for patients who underwent open esophagectomies was 15 days (9 to 45 days). the minimally invasive group had a shorter icu stay of 1 day. for 30 day morbidity, the minimally invasive esophagectomy group had 2 patients who encountered anastomotic leaks, 1 with post operative pneumonia while the open esophagectomy group had 1 patient with anastomotic leak, 1 patient with post operative stricture and 1 patient with delayed gastric emptying. there were 2 mortalities in the minimally invasive group while there were no mortalities in the open group. conclusion: our data show that patients who underwent minimally invasive esophagectomies had a shorter duration of hospitalization with similar perioperative morbidity rates. minimally invasive esophagectomy is a viable surgical option for a select group of patients. aims: there has been an increasing tendency towards minimally invasive surgery for esophageal cancer. our aim was to evaluate the results of the thoracoscopic approach (ta) and compare them with the ones of open approach (oa) at our institution. methods: retrospective review of all patients who underwent esophagectomy due to esophageal cancer (adenocarcinoma or squamous cell) between 2013 and 2017 were included. patients with siewert iii tumors and those who didn't need a thoracic approach were excluded. results: during the study period were performed 83 esophagectomies, 23 through ta. in 43.5% of these, the abdominal stage was done by laparoscopy. when comparing ta versus oa, there were no statistically significant differences in the baseline characteristics of the two groups (mean age, median body mass index, ecog performance status, asa score, smoking status, diabetes mellitus, pulmonary disease, histologic type, clinical staging and neoadjuvant chemo and radiotherapy). regarding outcomes, there were no significant differences in need of intraoperative transfusion, median intraoperative blood loss, operative time and length of stay. although not significant, in ta group there was a tendency for higher overall morbidity (69.6% versus 58.3%, p = 0.347); major morbidity-ctcae 3-5 (56.5% versus 38.3%, p = 0.135); anastomotic leak (34.8% versus 16.7%, p = 0.084) and re-intervention rate (17.4% versus 15%, p = 0.748). on the other hand, in ta group there was a tendency (although not significant) towards lower rate of respiratory complications (17.4% versus 33.3%, p = 0.152), lower rate of r1 margins (4.3% versus 13.3%, p = 0.433) and higher median of lymph nodes removed (22 versus 18, p = 0.083). conclusions: in our series, outcomes of ta were similar to oa, with a tendency towards lower respiratory complications, lower rate of r1 margins and higher number of lymph nodes removed in ta group. the impact of these findings in survival remains to be seen. the tendency towards higher morbidity may be related to the learning curve, since this were the first cases performed at our center. background: esophagectomy is a surgical procedureburdened by a high morbidity rate. the effect of minimally invasive (mi) approach on elderly patients is still not clear. aim: of this study was to analyze the impact of mi approach on post-operative course according to the patient age. methods: a consecutive series of 692 patients underwent to elective oncological esophagectomy between 1997 and 2017. all data were entered into a prospective database. patients submitted to 3-flield or trans-hiatal esophagectomywere excluded andonly ivor-lewisopen, hybrid or totally minimally invasive esophagectomywere. patients were stratified according to age in 3 groups:group a(= 50 years) 53 patients, group b ([ 51 and \ 70 years)269 and group c (were = 71 years)126.clinical and pathological factors influencing surgical outcome were evaluated. complications were classified according to clavien-dindo (cd). results: as expected outcomes worsened with patients age(cd = 3b: 7.5% group a, 13% group b and 21% group c. p = 0.001), mortality (0% group a, 3% group b and 5.5% group c. p = 0.035) and length of stay (10 days group a, 11 days group b and 13 days group c. p = 0.001).a statistically significant higher incidence of anastomosticleaks was observed among patients submitted to totally mi esophagectomy in group c vs a and b that were respectively 12,5%, 0% and 7%. major respiratory complications were not statistically different among these 3 three sub-group. conclusions: old age has a significant impact on outcomes afteresophagectomy. in this subset of patients a mi approachcould also increasepostoperative morbidity. elderly patients should be carefully selected before to be submitted to mi esophagectomy. introduction: esophagectomy is a major surgical procedure with morbidity and mortality related to the patient's condition, stage of the disease, complementary treatments, and surgical experience. minimally invasive esophagectomy (mie) may lead to a reduction in perioperative morbidity and mortality with very good quality of life. material and method: we present the experience of the center of excellence in esophageal surgery regarding totally mie through thoracolaparoscopic modified mckeown three-stage approach followed by esophageal reconstruction by gastric intrathoracic pull-up and cervical esophagogastric anastomosis used for the treatment of thoracic esophageal cancer. results: in the last 4 years, mie was performed initial, in our clinic with extracorporeal preparation of the gastric conduit with reduced lung complications and hospital stay. we introduced the totally minimally invasive esophagectomy with laparoscopic-assisted feeding jejunostomy using a 3d high definition camera. operative times were: thoracic-120 min, abdominal-130 min and cervical-50 min with a total of 300 min. the augmented 3d high definition image provided an excellent visual field, that allowed an accurate identification of dissection plans and extensive periesophageal and perigastric lymphadenectomy. the short-term outcomes of the totally minimally invasive esophagectomy procedure were very encouraging with early feeding on jejunostomy and the control of cervical anastomosis was usually performed in the 5th day postoperative and the patients were discharged in the 9th day postoperative without any symptomatology. at the first and third-month follow-up was not reported any major complications. the long-term oncological results are being evaluated. conclusions: the totally minimally invasive approach using advanced technology of endoscopic surgery allowed for these patients a simple postoperative evolution, no major complications, and a good recovery after an extensive surgery. the solid experience in open esophageal surgery of the upper gastrointestinal surgeons provides a fast learning curve of complex minimally invasive surgical procedures with reduced perioperative morbidity. long-term follow-up should confirm the results from the literature regarding the survival, which is expected to be for these patients at least equivalent with outcomes after open esophagectomy. introduction: esophageal fistulas, benign or malignant, represent a real challenge for the surgeons and gastroenterologists, regarding the treatment and the outcome. in these cases, endoscopic treatment is the first line approach, being less invasive and sometimes avoiding the need for surgery. this includes clips, stents, glue and even suture. material and method: we have analyzed 9 esophageal fistulas in patients with benign or malignant pathology, diagnosed and treated in the first 6 months of 2018. the management of this complication included a self-expandable esophageal metallic stent. we have evaluated the diagnosis, the surgical intervention, the timing until the development of the leak, the localization and management of the fistula. results: 5 were postoperative leaks and 4 spontaneous esophageal fistulas. the localization was cervical in one case, thoracic in 5 cases and abdominal in 3 cases. for the postoperative fistulas, in 4 patients the treatment included at least one surgical reintervention with lavage and drainage, beside the insertion of an esophageal metallic stent. in the other cases, endoscopic treatment and antibiotic therapy was enough. in 2 cases, the stent migrated needing repositioning. 30 days mortality was 22%, both patients from postoperative group. conclusions: esophageal fistulas represent a severe complication, usually in patients already immunocompromised. endoscopic management, including self expandable esophageal metallic stent, can be the main approach, by stopping the contamination and by permitting the early per oral feeding. disadvantages include the possibility of migration and the need of removal after 6-8 weeks. methods: five hundreds and one patients with esophageal cancer who underwent mie from 2010 to 2016 at our department were eligible. we considered the risk factors of complications of pneumonia, anastomotic leakage, and hoarseness after surgery, and the risk factors of difficulty of surgery. results: the risk factors of postoperative complications in univariate analysis were more than 75 years old (odds ratio: 2.1, p = 0.01), more than ii in asa-ps (odds: 3.1, p \ 0.01), more than 300 g of bleeding (odds: 2.1, p = 0.01), more than 450 min. of operation time (odds: 2.2, p \ 0.01), and colon reconstruction (odds: 3.2, p = 0.02). the one in multivatiate analysis was more than ii in asa-ps (odds: 3.2, p = 0.01). the risk factors of much bleeding were colon reconstruction (odds: 6.5, p \ 0.01), and more than 50 of lymph node dissection (odds: 1.5, p = 0.05). the risk factors of long operation time without cervical lymph node dissection were neo-adjuvant therapy (odds: 8.1, p \ 0.01), more than 60 of lymph node dissection (odds: 3.0, p = 0.01), and colon reconstruction (odds: 8.1, p \ 0.01). the ones with cervical lymph node dissection were more than pstage iii (odds: 2.4, p \ 0.01) and more than 60 of lymph node dissection (odds: 2.8, p = 0.03). conclusions: considering those risk factors, we should perform perioperative management more carefully. method: sa 74-year-old man with a tobacco and alcoholic habit was suspended for years, under treatment for arterial hypertension, who consults for a logical dysphagia of 4 months of evolution. he is diagnosed of stenosing esophageal distal third epidermoid carcinoma txn1m0. it is decided to place a prosthesis that is effective and subsequent neoadjuvant qt-rt, after 6 weeks of its completion the surgery is performed. results: the surgery is performed in 2 times, initially by laparoscopy. the esophageal hiatus and the greater curvature are dissected preserving the right gastroepiploic, and lymphadenectomy of the celiac trunk with pedicle section of the left gastric. gastric plasty is performed with a section of lesser curvature towards fundus. it is continued by thoracoscopy. a section of the azygos vein is performed, dissection of the esophageal middle and lower third and lymphadenectomy. gastric plasty is promoted, proximal esophagus section and latero-lateral intrathoracic gastro-oesophageal anastomosis. the anatomopathological study reports ypt3 and pn2 with 4/33 adenopathies, and disease-free surgical margins. he was discharged without complications on the 12th day and did not require re-entry. conclusions: ivor-lewis endoscopic surgery is safe and meets oncological criteria in selected patients with distal esophageal neoplasia and performed by an experienced esophagogastric unit. background: the rates of thoracoscopic esophagectomy performed in the prone and left lateral decubitus positions are similar in japan. we retrospectively reviewed short term outcomes of thoracoscopic esophagectomy for esophageal cancer performed in the left lateral decubitus position under artificial pneumothorax by co2 insufflation in a single institution. this study aimed to evaluate the feasibility of applying this procedure. methods: between july 2013 and december 2017, 124 patients with esophageal cancer underwent thoracoscopic esophagectomy in the left lateral decubitus position under artificial pneumothorax by co2 insufflation. the thoracic procedure is performed as follows:the lymph nodes around the right recurrent laryngeal nerve are dissected. on the cranial side, the lymph node dissection is advanced to the level of the inferior thyroid artery. then, the assistant rotates the trachea toward the ventral side, and the lymph nodes around the left recurrent laryngeal nerve are dissected. the middle and inferior mediastinal lymph nodes are dissected including supradiaphragmatic lymph nodes and the dorsal lymph nodes around the thoracic descending aorta. then, the esophagus is transected using an automatic suture device. finally, the tracheal bifurcation area lymph nodes are dissected. we retrospectively analyzed these patients. results: the completion rate of thoracoscopic esophagectomy was 92.0%, and the procedure was converted to thoracotomy in five patients, due to hemorrhage,severe adhesion. the mean intrathoracic operative time, intrathoracic blood loss, and number of dissected mediastinal lymph nodes were 210.5 min, 120.5 ml, and 23.0, respectively. postoperative complications included pneumonia (13.7%), anastomotic leakage (16.9%), and recurrent nerve paralysis (16.1%). postoperative (30d) mortality was 2/124 (1.6%) due to ards and nomi, respectively. conclusions: standardization of the procedure for thoracoscopic esophagectomy in the left lateral decubitus position under artificial pneumothorax by co2 insufflation, with a standardized clinical pathway for perioperative care led to favorable surgical outcomes. introduction: recently thoracoscopic surgery has become widespread even in chest procedure in thoracic esophageal cancer surgery. as an advantage of minimally invasive esophagectomy, it is possible to perform sophisticated procedures due to its magnified visual effects. on the other hand, short-term perioperative safety and oncological safety are still unclear. in cases where abnormal anatomy or comorbidity in the thoracic cavity is observed, it is thought that it is necessary to carry out thoracic surgery which ensures safety while keeping in mind the transition to transthoracic surgery. here, we report on esophageal resection of the thoracic esophageal cancer accompanied by a 20 mm saccular aneurysm inside the aortic arch. patient: a 67-year-old man visited a nearby doctor with a chief complaint of discomfort during swallowing. upper gastrointestinal endoscopy examined middle cervical esophageal cancer and received referral to our hospital. ct revealed a 20 mm saccular aneurysm inside the descending aorta in contact with the thoracic esophagus. preoperative diagnosis was middle thoracic esophageal cancer; 0-iic ct1bn0m0 stageia (uicc 8th). we performed thoracoscopic esophagectomy and lymph node dissection as curative surgery. the anterior surface of the aorta was exposed from the lower mediastinum and descended ascendingly, reaching the lower end of the saccular anus at the head level of the lower pulmonary vein. peeling off the esophagus dorsal side along the margin of the saccular sac and performing esophageal resection. conclusion: we reported thoracoscopic esophageal resection for thoracic esophageal cancer with chest descending aortic saccular aneurysm. thoracoscopic surgery, which can fully exploit close magnification effect, seemed to be useful for anatomically disqualified cases. introduction: anastomotic leakage from oesophagojejunal (oj) anastomosis after total gastrectomy is associated with a high morbidity and mortality rate. leakage rates reported vary between 3?% and 11?% but lack of consensus in management. in the past, it often required surgical intervention or radiologically abscess drainage that will keep patients fasted with external drain for a long duration. recently, variable endoscopic options-oesophageal stents, clips, fibrin glue and endoluminal vacuum therapy had been introduced with variable outcomes. here, we presented a case of oj anastomotic leak management with combination innovative endoluminal and radiologically technique to insert double pig-tailed catheter. aim: to introduce the feasibility of double pig-tailed catheter for drainage and management of oj anastomosis leak. a 70 year old man presented with two months history of dysphagia. upper endoscopy (ogd) showed suspicious cardio-oesophageal lesion. histology biopsy confirmed with adenocarcinoma. ct-scan of thorax, abdomen and pelvic showed irregular thickening at cardiooesophageal junction with regional lymphadenopathy. no distant metastases. he underwent uneventful d2 total gastrectomy. on 5th post-operative day, patient had spike fever and newly developed atrial fibrillation. urgent ct-thorax, abdomen and pelvis with oral omnipaque. it showed lower mediastinal gas-containing fluid adjacent to oj anastomosis within the left retrocrural space suspicious for leak. ogd evaluation showed pin-hole oj leak. guidewire inserted via endoscopy into left retrocural space under radiologically guidance. double pig-tail 7fr 5 cm subsequently inserted via seldinger approach over guide wire. the proximal end of pig-tail pushed into left retrocural space and distal end positioned into efferent jejunal limb with crocodile jaw through endoscope. diluted contrast injected and passed down to efferent limb with minimal leak. outcome: after double pig-tail insertion, patient started on clear feed on 1st day post-insertion. one week later, he was started on full feed. repeat upper endoscopy and stent removal done two weeks later. contrast injection showed small blind ended sinus tract from anastomosis toward left pleural space without obvious leak. conclusion: radio-endoscopic is a novel minimally invasive technique that allows insertion of double pig-tailed internal drainage to control oj anastomosis leak. it allows early enteral nutritional feeding and avoid external drainage. background: the number of gastric cancer (gc) survivors, especially long-term survivors, is increasing. how best to evaluate the diseasespecific survival (dss) of gc survivors over time is unclear. we aimed to assess changes in the conditional survival of patients with gc after curative intend gastrectomy and the evolution of the impact of well-known risk factors. methods: clinicopathological data from 22,265 patients who underwent curative intend resection for gc at four specialized centres (three in china and one in italy) and from the surveillance, epidemiology, and end results (seer) database were retrospectively analysed. changes in the patients' 3-year conditional disease-specific survival (cs3) were analysed. we used time-dependent cox regression to analyse which variables had long-term effects on dss and devised an accurate, dynamic dss predictive model based on the length of survival. results: the median follow-up time was 74 months, and disease-specific death occurred in 9,927 cases (44.6%). the dss of the patients after surgery was dynamic, and most of the disease-specific deaths occurred within the first 3 years after surgery. based on 1-, 2-, 3-, 4-and 5-year survivorships, the cs3 of the population increased gradually from 62% to 68.1%, 77.3%, 83.7%, 87.6%, and 90.6%, respectively. subgroup analysis showed that the cs3 of patients who had poor prognostic factors initially demonstrated the greatest increase in postoperative survival time (e.g., n3b: 26.6%-84.1%, ?57.5% vs. n0: 84.1%-93.3%, ?9.2%). time-dependent cox regression analysis showed the following predictor variables constantly affecting dss: age, the number of examined lymph nodes, t stage, n stage and site (p all \ 0.05, 5 years after gastrectomy). the influence of prognostic factors on dss and cs3 changed dramatically over time. based on data from several large global centres, we developed an effective model for predicting the dss of gc patients based on the length of survival time. this model can provide personalized long-term follow-up strategies for patients. methods: we retrospectively analyzed clinicopathological data for 253 rgc patients who underwent radical gastrectomy from 6 centers. the prognosis prediction performances of the ajcc7th and ajcc8th tnm staging systems and the trm staging system for rgc patients were evaluated. web-based prediction models based on independent prognostic factors were developed to predict the survival of the rgc patients. external validation was performed using a cohort of 49 chinese patients. result: the mean number of retrieved lymph nodes was 16.1, and in 54.2% of patients, the number was = 15. the predictive abilities of the ajcc8th and trm staging systems were no better than those of the ajcc7th staging system (c-index: ajcc7th vs. ajcc8th vs. trm, 0.743 vs. 0.732 vs. 0.744; p [ 0.05). within each staging system, the survival of the two adjacent stages was not well discriminated (p [ 0.05). multivariate analysis showed that age, tumor size, t stage and n stage were independent prognostic factors for overall survival (os), disease-specific survival (dss) and disease-specific survival (dfs). based on the above variables, we developed 3 web-based prediction models, the huang os model, the huang dss model and the huang dfs model, which were superior to the ajcc7th staging system in their discriminatory ability (cindex), predictive homogeneity (likelihood ratio chi-square), predictive accuracy (aic, bic), and model stability (time-dependent roc curves). the stratified analysis showed that regardless of whether more or fewer than 15 lymph nodes were retrieved, the predictive performances of the web-based prediction models were still better than those of the other three staging systems. a decision curve analysis showed that the huang model provided better net benefits than the other three staging systems. external validation showed predictable accuracies of 0.780, 0.822 and 0.700, respectively, in predicting os, dss and dfs. conclusion: the ajcc tnm staging system and the trm staging system did not enable good distinction among the rgc patients. we have developed and validated visual web-based prediction models that are superior to these staging systems. objective: to perform competing risk analysis and evaluate cancer-and noncancer-specific mortality in patients with gastric cancer after radical surgery. methods: a total of 5051 patients from our department (as training set) and a total of 7123 patients from the surveillance, epidemiology, and end results (seer) database (as validation set) were enrolled in the study. the cumulative incidence of cancer and noncancer-specific mortality was determined by univariate and multivariate competing risk analysis. results: the five-year cancer-and noncancer-specific cumulative incidence of death (cid) in the training set were 36.9% and 2.5%, respectively, which were significantly lower than that in the validation set (48.2% and 8.6%, respectively). multivariable analysis showed that age, tumor site, tumor size and ptnm stage were independent predictors of gastric cancer-specific mortality and overall survival, whereas age was an independent predictor of gastric noncancer-specific mortality. noncancer-specific cid surpassed cancer-specific cid for ptnm stage i patients after approximately 8 years of surgery, but never for stage ii and iii patients. moreover, for stage i patients, the time point when noncancer-specific cid surpassed cancer-specific cid become earlier as age increasing, with only 3.5 years after surgery for patients more than 74 years of age. conclusions: age is an independent predictor of gastric cancer-and noncancer specific mortality and overall survival for patients after radical surgery. for patients with stage i gastric cancer, noncancer-specific mortality is a significant competing event, with an increasing impact as age increases. aim: of the study was to analyse the possibility of function preserving gastrectomy based on the sentinel lymph node (sln) concept. methods: during last 5 years in two clinics odessa national medical university we used mapping procedures in the 25 patients with early gastric cancer. there were 11 men and 14 women, age 52 to 85 years, mean age 56.8 ± 8.2 years. blue dye was injected into 4 quadrants of the submucosal layer surrounding the primary lesion using an endoscopic puncture needle in 16 patients. blue lymphatic vessels and blue-stained lymph nodes can be identified by laparoscopy within 15 min. of the blue dye injection. we used 0.5% indocyanine green in 9 patients, which we injected by intraoperative endoscopy. new technology indocyanine green (icg) fluorescent imaging was used for sln mapping in this 9 patients. results: amany 16 patients, in which we used blue dye for mapping sln, positive sln was in 5 patients, negative-in 11 patients. in all 16 patients distal gastrectomy (dg) was performed with d2 lymphdissection. from 11 patients with negative sln in 3 patients metastasis in other lymph nodes were detected.among 9 patients in whom we used icg fluorescent mapping positive sln were detected in 2 patients. laparoscopic-assisted distal gastrectomy with d2 lymph node dissection was performed in these patients. in 7 patients with negative sln partial wedge resection was performed in 2 patients, segmental pylorus preserving gastrectomy was performed in 5 patients. during follow-up period from 3 to 24 months no recurrences or metastasis were detected in these group of patients. qol in this group of patients was much better, than in patients with conventional distal gastrectomy. conclusions: icg fluorescent method is highly effective for detection of sln. in the patients with early gastric cancer function preserving gastrectomy based on sln navigation may be promising strategy to achieve better results. laparoscopic procedure taking advantage of robotic gastrectomy for gastric cancer to prevent pancreatic fistula gastrointestinal surgery and surgical oncology, ehime university, toon-city, japan backgrounds and aims: analysis of japanese national clinical database (ncd) showed that laparoscopic gastrectomy(lg) had rather increased pancreatic fistula (pf) compared with open gastrectomy. on the other hand, last year, multicenter collaborative research result of robotic gastric cancer surgery(rg)was shown that the complications including pf were significantly decreased as compared with lg. in this study, we have employed a new easy to use device in lg to minimize pf during suprapancreatic lymph nodes dissection requiring pancreatic retraction and compared with conventional lg and rg. materials and methods: internal organ retractor (aesculapò) to grasp the gastropancreatic fold and the suprapancreatic peritoneum to imitate davinci's forceps was guided with a thread outside the body. 104 patients(jan.2016 * nov.2018) were divided into three groups as follows, group lg-1(n = 40), lg using the standard devices, group lg-2(n = 40), lg using organ retractor, group rg (n = 24). amylase value in drain(d-amylase) and the volume in drainage, intraoperative bleeding, postoperative hospital stay, incidence of cd (] grade iii) were compared among three groups. results: data are indicated as lg-1/lg-2/rg(mean ± sd), respectively. on the day and third day after surgery, d-amylase were 1203 ± 260/645 ± 148/608 ± 285 and 383 ± 228/ 323 ± 136,176 ± 98(iu/l). d-amylase was significantly lower in lg-2 and rg group than in lg-1 the day after surgery. the operation time was significantly longer in rg, 318 ± 38/ 290 ± 64/396 ± 47 (min). bleeding volume and hospital stay did not differ among 3 groups. pancreatic fistula (cd ] grade iii)was observed only in lg-1 group at 5(%) . discussion: pf(grade]cdiii), which may lead to mortality, occurred in lg-1 group. a significant elevation of d-amylase on the 1st postoperative day was prevented in lg-2 just like rg, which seemed to lead to prevent pf afterwards. the multijoint forceps is known to be an advantage of rg but it cannot be reproduced by lg using a linear forceps. however, another advantage such as vertical grasping and lifting of the gastropancreatic fold at rest could be mimicked by lg using this device, which seemed to enable a safe lymph node dissection and lead to reduce the pancreatic damage. conclusion: this inexpensive and easy to use method taking the advantage of rg seems to reduce surgeon's fatigue and tissue damage(pf). the study presents comparison of perioperative outcome between different surgical approaches for gastric adenocarcinoma (ac). methods: retrospective cohort of 85 patients that underwent gastrectomy for (ac) at rambam hospital during 2012-2016. patients data was collected based on demographic characteristics, bmi, operating room time (ort), number of lymph nodes (ln), length of hospitalization (loh), and perioperative complications. results: study population included 55 patients after total gastrectomies, 10 of them robotic and 30 partial gastrectomies, 12 of them robotic. age, gender and bmi were similar between patients who underwent any type of procedures. median length of hospitalization (loh) for robotic total gastrectomy was 4.5 days and it was significantly shorter than both laparoscopic total gastrectomy (ltg) 7.0 days (p = 0.003) and open total gastrectomy (otg) 9.0 days (p \ 0.001). similar significant differences in (loh) between the groups were observed among patients who underwent partial gastrectomy, but the comparison between robotic and laparoscopic procedures was limited due to small numbers of (lpg). median(ort) was significantly longer among robotic gastrectomies compared to open, the difference was 64 min in total gastrectomy group and 145 min in partial gastrectomy group (p \ 0.001 for both differences), but the difference in(ort) between laparoscopic and robotic procedures were smaller and non-significant. the number of dissected (ln) was similar between the 3 procedures in total gasrectomies. in partial gastrectomies, the number of dissected (ln) was even higher among both laparoscopic and robotic gastrectomies compared to open (p \ 0.001).) conclusions: robotic total and partial gastrectomies for gastric (ac) are associated with oncologically adequate lymphadenectomy and faster patient recovery, but longer ort. objectives: during esophagojejunostomy using a circular stapler after latg, placement of the anvil head via the transabdominal approach proved difficult. the authors report on a method modified for laparoscopy-assisted, esophagojejunostomy performed by placing the pretilted anvil head(orvil) via the transoral approach. methods: between january 2013 and november 2018, esophagojejunostomy was performed using orvil in 99 patients after latg. the anesthesiologist introduced the anvil while observing its passage through the pharynx. during the anastomosis, we kept the jejunum fixed in position with a silicone band lig-a-loops, thereby preventing the intestine from slipping off the shaft of the stapler. results: esophagojejunostomy using the orvil was achieved successfully in all patients. no other complications, such as hypopharyngeal perforation and/or esophageal mucosal injury, occurred during passage. the postoperative complications of anastomosis were leakage in two patients and stenosis in 5 patients, in whom mild relief was achieved using a bougie. conclusions: esophagojejunostomy using the orvil is a simple and safe technique. gastrointestinal tract surgery, fukushima medical university, fukushima-shi, japan; 3 surgery, ohara general hospital, fukushima-shi, japan background: juvenile polyposis of the stomach is a very rare disease, and its malignant potential has been reported previously and total gastrectomy has been recommended as a standard treatment. recently, the usefulness of laparoscopic surgery for this case has been reported, however this type of surgery is thought that maintaining the surgical space is difficult because of distended and thickening stomach. case presentation: eight years ago, a 64-year-old woman who had no family history of gastrointestinal polyposis had been diagnosed with gastric polyposis and polyp-related anemia and received twice endoscopic submucosal dissection to early gastric cancer in another hospital. she had received an annual upper gastrointestinal endoscopy and she had taken iron supplements for anemia caused from the occasional bleeding from the polyps. however, the number of the polyps had increased over time. because she had a loss of appetite, she admitted to our hospital. enhanced computed tomography showed gastric wall thickening and multiple gastric polyps without lymphadenopathy or distant metastasis. colonoscopy showed no specific findings. she was diagnosed as the juvenile polyposis of the stomach, and she received laparoscopic total gastrectomy with roux-en y esophagojejunostomy. in operative findings, although there were the excessive distention and congestion of the stomach, standard laparoscopic surgery could be performed. the resected specimen revealed multiple variously sized polyps throughout the stomach except for lesser curvature and fundus and the histopathological examination revealed that all polyps were hyperplastic polyps without containing cancer. she was discharged on postoperative day 10. we successfully performed laparoscopic surgery to treat a rare case of juvenile gastric polyposis. introduction: we report a novel technique for combined use of laparo and thoracoscopy for faradvanced adenocarcinoma of esophagogastric junction (aeg). case presentation: a 50's years old man presented with far-advanced aeg. an esophagogastroduodenoscopy revealed a type 2 lesion with the entire circumference around esophagogastric junction (egj). contrast radiography revealed a severe stenosis in the egj and wall irregularity from egj to cardia. computed tomography revealed a stenosis of egj, suspected invasion into the left side diaphragm and some lymph nodes metastases at the abdomen. we diagnosed siewert type ii aeg (ct4an1m0, cstage iiia : japanese classification of gastric carcinoma ver.14). surgical technique :the patient was placed in the reverse-trendelenburg position with the left upper body lifted and legs spread, under general anesthesia. the tumor was huge, exposed from the serous membrane and invaded the left crus. first we performed from laparoscopic proximal gastrectomy using five ports. then, three ports were added in the 8th, 9th, and 11th intercostal spaces with the patient in the same body position, and performed thoracoscopic lower esophagectomy under artificial pneumothorax with intrathoracic pressure of 8-10 mmhg, which allows the ventilation of both lungs. the lower esophagus was resected under the thoracoscopic view to ensure an adequate margin. following this resection, intrathoracic esophagojejunostomy was performed by using the laparo-and thoracoscopic techniques. the operative time was 439 min, and the blood loss was 15 g. he was discharged on the 15th day after the operation without any postoperative morbidity. the histopathological diagnosis was pt4bn3am1, p1, pstage iv. after adjuvant chemotherapy with capecitabine and oxaliplatin, ramcilumab monotherapy is undertaken now. ct revealed solitary lung metastasis in 24 months after the operation. conclusion: malta for locally advanced aeg invading the surroundings could be performed safely. introduction: despite being the pioneer in laparoscopic surgery, europe did not have similar surgical experience compared to east asia due to decreased exposure to gastric cancer. several studies on minimally invasive gastrectomy for gastric cancer have been conducted in europe. however, some of them did not analyse total gastrectomy as a distinct entity combining both distal and total gastrectomies; moreover, most of them do not provide data on full five-year follow up for each patient. baltic countries stand in between east and west in terms of gastric cancer incidence: incidence rate per 100,000 is 10.6 in united kingdom, 26.3 in lithuania and 85.3 in japan. this exposure to gastric cancer provides unique opportunity to investigate the role of laparoscopic gastrectomy. therefore, a case-control study was designed to evaluate laparoscopic (ltg) versus open total gastrectomy (otg), comparing short-term surgical and long-term oncologic outcomes. surgery, jeju national university, school of medicine, jeju, korea; 2 surgery, chosun university, school of medicine, gwangju, korea objective: although mcv (mean corpuscular volume) levels are known to be associated with the prognosis of various diseases, few study investigated mcv as prognostic factor after gastric cancer surgery. the aim of this study is to address the prognostic value of mcv in gastric cancer who underwent curative gastric cancer surgery. methods: 286 patients (june 2009-december 2015) with stage i, ii, and iii cancer were consecutively included in this study. all patients underwent curative gastric cancer surgery including subtotal gastrectomy or total gastrectomy. overall survival (os), disease-free survival (dfs) and postoperative complications rate were compared between mcv [ 94 group and = 93 group. results: of all patients, the mean mcv was 89 fl (normal range, 80 to 100 fl). the dfs was significantly higher in the high-mcv ([ 94) than low-mcv group(= 93) (p \ 0.05) group. there was no significant difference in postoperative complications when compared with clavien-dindo scale. the survival rate of the high mcv group was higher but there was no significant difference. conclusions: mcv may be a predictive factor after gastric cancer surgery. unlike previous studies, patients with low mcv group showed lower dfs. more research is needed on the significance of mcv in variety of disease. methods: and materials. for 6 years we observed 11 cases with gist of stomach and duodenum. seven patients were brought to clinic with the bleeding and two patients were brought to clinic with vomiting and compensate stenosis. in all circumstances we done the ct, mrt and endoscopic examinations of stomach and duodenum with biopsy . in two circumstances we performed endoscopic operation. in one circumstance we successfully take off the gist from the duodenum endoscopically. during the operation we use the endoscopic instruments. in another circumstances,after endoscopic excision the tumor appear the bleeding which was stopped by endoscopic local heamostasis, by putting clipps on the vessels. in 9 circumstances the tumors were in stomach. in 4 circumstances we performed laparoscopic wedge resection the tumors by staplers. in 3 circumstances when the tumor was very big and situated in the fundus of stomach, we performed laparoscopic resection of the fundal part of stomach by using laparoscopic staplers and 'liga sure' sealing. in 2 circumstance we took off the tumor by putting laparoscopic trocars inside the stomach for instruments and for visualization tumor. after excision the tumor and took it of the stomach we sutured the holes in the stomach. we have no mortality after laparoscopic operation. there were no malignisation in all 9 circumstances. we have 3 cases morbidity. in 2 circumstance the bleeding from the stomach that was stopped endoscopically. in 1 circumstance there was wound infection. the aim of the study to decrease the morbidity in the patients with perforated ulcers of the stomach and duodenum. we observed 107 patients with perforated ulcers of stomach and duodenum. women were 45, men were 62. average age about 45 years. 91patients had perforation ulcer of stomach and duodenum. 26 patients had perforations with bleeding. all patients were divided in two groups. the first groups 59 patient operated laporocopically, in the second group 48 patients operated traditionally. results: there were no mortality in the group that operated laparoscopically. in the group that were operated traditionally one patient died after rebleeding. the average stay in hospital in the group that were operated laporoscopically about 2 days. in the groups with traditional operations, were about 8 days. the morbidity in the first group were in 5 cases. pneumonia in 2 cases, suppuration of the troacar points were in 3 cases. in the second group pneumonia were in 3 cases, suppuration of the operation wound were in 5 cases, subdiaphragmatic abscess was in 1 cases. conclusion: laporoscopic operation in during treatment decrease the mortality, morbidity and hospital staying in the patients the perforated ulcer of stomach and duodenum . of the 32 patients of the third group 22 (68.75%) were operated about ulcer rebleeding in the hospital, and 10 (31.25%)-about the profuse bleeding ulcer. noonr patient had recurrent bleeding. the average treatment time for patients in group 2 was 12.5 ± 3.2 days. conclusions: the development of hemorrhagic shock in patients with peptic ulcer bleeding significantly increases the risk of rebleeding and mortality. the application of endoscopic hemostasis allows to reduce the risk of rebleeding and mortality compared with conservative antiulcer therapy. surgical treatment can achieve reliable hemostasis, but accompanied by higher mortality and longer duration of hospital treatment. tan tock seng hospital is second largest hospital in singapore. it is affiliated to two medical schools in singapore and it is a training hospital for both undergraduates and postgraduates. minimally invasive surgery for both benign and malignant diseases of upper gastrointestinal tract becomes more and more popular nowadays. in our department, all the residents have to view the step by step instructional videos of mininally invasive surgeries before they can assist in the cases or perform on their own under the supervision of consultant surgeons. the viewing of the instructional videos help them with better understanding of the procedures. the viewing of videos help them with the importance of steps, standardization of steps. with the help of instructional video, they can not only assist better in the surgery but also reduce the learning curve when they start doing the procedure themselves after the graduation from the residency programme. this is the step by step instructional video of laparoscopic repair of perforated duodena ulcer for surgeons-in-training rotated to our department. in general duplication cysts are rare developmental congenital disorders of the gi tract. three morphological criteria should be met in order to confirm the pathological diagnosis: 1. they should be attached to the stomach's wall and should be the continuation of it, 2. at least one of the muscle layers of the stomach's wall should be included and 3.it should have normal gastric mucosa. the treatment is either enucleation or partial gastrectomy. aim: present our minimally invasive approach to a rare prepyloric submucosal cystic lesion causing gastric outlet obstruction. case report: a 27-year-old female with vomiting, weight loss and in bad general condition was diagnosed after a full work-up (blood tests, endoscopies, eus, ct and mri) with a submucosal cystic tumor. this cyst first was thought to be a duplication cyst. since the patient was young, our intention was to offer the least invasive surgical technique in order to spare gastrectomy and billroth anastomosis. results: the procedure was completed laparoscopically with enucleation of the cyst through a gastrotomy on the anterior wall of the stomach. after the enucleation of the cyst the gastric mucosa was sutured back and then the gastrotomy was closed with continuous sutures. the result of the pathological report confirmed a rare case of a heterotopic pancreatic cystic lesion. the postoperative course of the patient was uneventful and was discharged with instruction for her diet the 4 th postoperative day. the patient 3 months post-operative has no symptoms. conclusion: in such benign conditions and especially in young patients, gastrectomies could be avoided if possible and give their place to less invasive approaches in order to reduce lifelong risks and morbidity. trangastric enucleation of the cyst although a demanding approach is safe and could be considered as a 'gentler' technique with reduced morbidity. background: pancreatoduodenectomy is considered to be very invasive for early superficial duodenal tumors (sdts), which have a lower risk of lymph node metastasis. partial duodenal resection with endoscopic submucosal dissection for sdts is an attractive technique but it is associated with a high risk of complications. the full-thickness resection of the duodenum wall including laparoscopic and endoscopic cooperative surgery has risk of spreading tumor cells and digestive juices into the abdominal cavity. we have developed novel technique for sdts to decrease the risk of exposure to abdominal cavity of tumor cells and digestive juices, called nonexposed duodenum laparoscopic and endoscopic cooperative surgery (neo-dlecs). aim: the aim of this study is to evaluate the feasibility and safety of neo-dlecs for sdts. surgical procedure: the attachment of the transverse mesocolon was freed from the head of the pancreas and retroperitoneal tissues under laparoscopy. the duodenum and the head of the pancreas were mobilized from the retroperitoneum using the kocher maneuver. a standard esd was performed for the sdt using endoscope. the serosa of the esd ulcer bed was reinforced using the laparoscopic hand-sewn suturing technique in the seromuscular layer around the resected area. after completing the procedure, the endoscope was inserted and passed over the resected area to confirm that there was no stenosis or leakage. methods: ten consecutive patients with sdt underwent neo-dlecs in our institute between march 2015 and march 2017. the clinicopathological features of the patients and surgical outcomes were prospectively collected and retrospectively analyzed. results: pathological diagnosis was adenocarcinoma for six patients, adenoma for three patients, and neuroendocrine tumor grade 1 for one patient. the median tumor size was 36 (20-54) mm. the median operative time was 227.5 (180-390) min. the median blood loss was 0 (0-175) g. there were no conversions to open surgery in this series. intraoperative perforation was found in two cases during the esd procedure. however, all perforations were closed and reinforced using hand-sewn sutures. no postoperative complications were above grade 2 in the clavien-dindo classification system. conclusions: neo-dlecs is safe and feasible and can be an option for surgical sdt resection. aims: wilkie's syndrome is caused by the entrapment of the 3 rd part of the duodenum between the aorta and the superior mesenteric artery (sma). surgery is indicated for chronic cases and failure of conservative management, being reported a laparoscopic duodenojejunostomy as a minimally invasive option. methods: all cases treated by laparoscopic duodenojejunostomy in our centre because of chronic wilkie's syndrome were recorded. results: 3 females and 1 male underwent a laparoscopic duodenojejunostomy, with a mean age of 32 years (range 19-47). all patients presented abdominal pain, and weight loss was identified in most of them. a reduced aortomesenteric angle measured by ct scan was the key for the diagnosis (mean angle 22.5 degrees, range 21-24). conventional laparoscopic approach was performed in two patients, the other two patients underwent a sils port approach. mean time of surgery was 62.5 min (range 35-100) and length of stay was 5 days (range 2-13). after a mean follow-up of 47.5 months (range 11-69), 3 patients improved their symptoms. conclusions: surgery is the mainstay in complicated or refractory cases of sma. laparoscopic duodenojejunostomy has the advantages of the laparoscopic approach (including rapid recovery time, reduced post-operative pain and shorter hospital stay) and it is feasible, safe and effective. in mexico in 2013, gastric cancer represented the 3rd cause of death; it may manifest in a variety of histologic, anatomic, and genetic patterns, which influences the surgical approach. until now gastrectomy with curative intent is the only treatment that offers potential cure in gastric cancer. in recent years, laparoscopy has emerged as an important modality in the surgical management. in multiple trials no significant difference in recurrence, long-term survival and disease-free survival was observed when compared to the standard open gastrectomy. we present the case of a 62 year old man. with a smoking history of 30 pack years, suspended 12 years earlier. he presented unspecific upper gastrointestinal symptoms; an upper endoscopy was made observing a suspicious depressed lesion of 3 cm located in the greater curvature between the body and the antrum, the biopsy resulted in a poorly diferentiated signet-ring cell carcinoma of the stomach. an endoscopic ultrasound and a thoracoabdominal ct scan showed no evidence of enlarged adenopaties or metastatic disease. initially a diagnostic laparoscopy was made, there was no evidence of carcinomatosis, nor free intraperitoneal fluid; so the greater omentum was dissected towards the splenic and hepatic flexure; a d2 lymph node dissection was performed, and a subtotal gastrectomy with reconstruction of roux en y was done; intraoperative endoscopy was done to identify the lesion, so adequate margins could be obtained. the patient had a good post operative evolution and was discharged home at 4th day tolerating oral intake. minimally invasive techniques have proved equivalency of oncologic results when compared to the conventional approach; these techniques are becoming the preferred approach in the treatment of well-selected patients with gastric cancer and have a role in definitive staging, curative resection, and lymphadenectomy. appropriate selection of patients and optimal technical approach are paramount for good outcomes. most data of laparoscopic gastrectomy come from eastern countries, where the prevalence is higher; however western experience is growing along with evolution and development in surgical instruments and new technology. wilkie syndrome is a rare cause of high intestinal obstruction, resulting from the compression of the duodenum between the abdominal aorta and the superior mesenteric artery. the main symptoms are nausea and vomiting, weight loss, early satiety, abdominal distension and epigastric pain. historically, the barium study and arteriography were the diagnostic tests used; more recently the angiotac has shown greater sensitivity. the diagnostic criteria are: dilated duodenum, duodenal compression by the superior mesenteric artery and aortomesenteric angle less than 20 degrees. patients with an acute condition usually respond to conservative treatment (decompression, correction of hydroelectrolyte alterations, nutritional support…). however, those with chronic symptoms usually require surgery preferably with laparoscopic approaches of duodenojejunostomy or the strong's procedure. the strong procedure mobilizes the duodenum by dividing the ligament of treitz. once the duodenal-jejunal junction is mobilized, the duodenum is positioned to the right of the superior mesenteric artery and it is preferred because it provides less morbidity due of the maintaining of the integrity of the gastrointestinal tract, but it has a failure rate of 25%. gastrojejunostomy allows gastric decompression, but does not relieve duodenal compression, so digestive symptoms may persist, leading to the appearance of a blind loop syndrome or recurrent peptic ulcers. on the other hand, the duodenojejunostomy, which according to some series may be the procedure of choice, may obtain a success rate higher than 90%. we advocate to initiate the surgical approach with the strong procedure and if it fails to perform to a duodenojejunostomy. during this procedure, gastro-esophageal reflux was evaluated and assigned to severe, moderate and slight category. if the reflux was observed slightly up to cervical esophagus, the case was assigned to moderate category. if the reflux was observed intensely up to cervical esophagus, the position was returned to head high position for the safety and the case was assigned to severe category. the anti-reflux surgery was considered in the moderate and severe categories. results: we have performed laparoscopic nissen procedure in 95 cases. the outcome was assessed by reflux test performed on 4-5 postoperative day, and the results showed the reflux was disappeared in every cases. median follow-up period of this study was 56 months (3-110 months) . in 11 cases (11.6%) ppi was restarted before 6 months after the anti-reflux surgery. in 25 cases (26.3%) ppi was restarted after the anti-reflux surgery during the whole follow-up period of this study. the bmi of the patients had no relationship to the needed restart of ppi. to evaluate the degree of esophagitis objectively before and after the anti-reflux surgery we designed 'the esophagitis score'. in this scoring method, a number from 0-5 was assigned according to the degree of esophagitis along with the la classification. the results of the study have shown that the reflux esophagitis was improved obviously after the anti-reflux surgery even in the ppi restarted group (p \ 0.001). discussion: to extract the gerd patients who really need anti-reflux surgery is important. reflux test is feasible because of its convenience and visual effects for the patients. the results of the laparoscopic nissen fundoplication were good. background: laparoscopic paraesophageal hernia repair with fundoplication has become more and more popular nowadays due to less morbdity and mortality with shorter length of hospital stay. discussion: tan tock seng hospital is the second largest hospital in singapore. it is affiliated to two medical schools in singapore and it is a training hospital for both undergraduates and postgraduates. in our department, all the residents have to view the step by step instructional videos of mininally invasive surgeries before they can assist in the cases or perform on their own under the supervision of consultant surgeons. the viewing of the instructional videos help them understand the procedures better. the videos can also help them recognize the important steps and standardized safe approach. with the help of instructional video, they can not only assist better in the surgery but also reduce the learning curve when they start performing the procedure themselves during their training period. this is the step by step instructional video of laparoscopic paraesophageal hernia repair with fundoplication for surgeons-in-training who are posted to our department. conclusion: the step by step instructional video on laparoscopic paraesophageal hernia repair with fundoplication can help the surgeons in training reduce their learning curve and improve their surgical skills so that they can perform the procedure safely. the human immunodeficiency virus (hiv) is a neurotropic virus. there have been reports of patients with hiv who have esophageal motility problems, sometimes associated with opportunistic infections. the absence of contractility is defined as a major motility disorder according to the chicago v 3.0 classification, which is characterized by normal esophagogastric union relaxation and 100% peristalsis failure. we present the case of a 56-year-old male patient with a history of acquired immunodeficiency on treatment with efavirenz, emtricitabine and tenofovir. he presented progressive dysphagia, gastroesophageal reflux and pyrosis of 4 months of evolution. physical examination showed no alterations. upper endoscopy is done reporting a normal esophagus and diffuse chronic gastritis. the esophagogram reported inadequate esophageal motility with contrast stasis and a delayed emptying. the esophageal manometry reported an upper esophageal sphincter with high resting pressure. the middle and distal esophagus showed absence of peristalsis with a pan-esophageal pressurization pattern. the lower esophageal sphincter presented normal resting pressure and borderline relaxation (41%). the integrated relaxation pressure was less than 15 mmhg. the diagnostic impression was absence of contractility (chicago classification v 3.0).medical management was initiated with inhibitors of the proton pump, isosorbide dinitrate and injections of botulinum toxin without success. it was decided to program the patient for a heller myotomy with toupet fundoplication. a trans-surgical endoscopy revealed a complete myotomy with no leakage or obstruction. the patient went home on the second postoperative day tolerating a solid diet.heller myotomy by laparoscopy with partial fundoplication is safe in the treatment of patients with hiv and esophageal motility disorders, reporting a mortality of 0.1%. the effect of endoscopic treatments prior to surgery is controversy aims: epiphrenic diverticulum represents an infrequent entity and it is usually associated with esophageal motility disorders, such as achalasia, distal esophageal spasm, nutcracker esophagus or hypertensive lower esophageal sphincter. nowadays, epiphrenic diverticulectomy, esophageal myotomy and partial fundoplication is the gold standard technique; although it supposes a challenging procedure and it may provoke lots of complications. approach for diverticulectomy usually depends on the distance from the upper border of the diverticulum's neck to gastroesophageal junction, considering that thoracoscopy should be carried out when this distance is more than 5 cm. methods: we presentthecase of a 57-year-old male patient, with a bodymass index of 30anda medical history of diabetes, smoking and alcoholism. his symptoms were mainly regurgitation and dysphagia. upper endoscopy showed esophageal dilatation and the presence of a diverticulum with its neck 2 cm over the gastroesophageal junction. ct scan confirmed these findings and manometry showed achalasia. in the video we can see how we perform a laparoscopic diverticulectomy with esophageal myotomy and dor fundoplication. results: patient was discharged home on the second postoperative day with no complication. after more than two years of follow-up, he has not suffered regurgitation, heartburn, dysphagia or chest pain. conclusions: we present a case with an epiphrenic diverticulum secondary to achalasia in which we performed a laparoscopic diverticulectomy, esophageal myotomy and dor fundoplication. some authors suggest that the correction of the underlying motility disorder is the key in the management of these patients and they do not recommend concomitant diverticulectomy for all cases. however, we consider that the complete procedure, adding diverticulectomy, supposes the gold standard and it is feasible to perform for teams which are skilled in esophageal and gastric laparoscopic surgery, despite its high morbidity rates. purpose: a laparoscopic wedge resection for a gastric submucosal tumor closed to gastroesophageal junction or involved to gastroesophageal junction is technically challenging and more aggressive compared with tumors in other sites of the stomach. a gastroesophageal reflux disease would be more prevalent after laparoscopic wedge resection of a gastric submucosal tumor in gastroesophageal junction because of the destruction to low esophageal sphincter. we hypothesized that a prophylactic anti-reflux surgery after this surgery would be less prevalent the gastroesophageal reflux disease (gerd) and more improve the quality of life of the patients. the aim of this study is to analyze our experience with prophylactic anti-reflux surgery after laparoscopic wedge resection for a gastric submucosal tumor of gastroesophageal junction materials and methods: we retrospectively collected data from 51 patients who diagnosed with submucosal tumor of near the gastroesophageal junction underwent laparoscopic wedge resection between january 2000 and december 2017. the patients were divided into 2 groups according to operation with prophylactic anti-reflux surgery (group a) and without one (group b). results: there were no difference in the frequency of the preoperative gerd symptoms between the 2 groups, whereas postoperative gerd symptoms and postoperative use of acid suppressive medications were more frequent in the group b (p = 0.032, p = 0.036). however, there were no differences in the follow-up endoscopic findings in terms of reflux esophagitis and hill's grade between the 2 groups. in group a, postoperative mean low esophageal sphincter (les) pressure was 22.0 ± 13.0. the les pressure was dropped until 15 mmhg in the only one patient. however, there was no reflux symptom in this patient. conclusions: the prophylactic anti-reflux surgery after laparoscopic gastric wedge resection of gastroesophageal junction is an effective method of prevent gastroesophageal reflux symptoms. background: the most critical obstacle is a pancreatic leakage(pl). the most cause of pl might be an activation of pancreatic juice by the mixing of pancreatic juice and intestinal fluid because of the anastomosis technique, the difference of anastomosis between pancreatic duct and caliber of jejunum, and the topple of jejunal mucosa. aim: in this study, we devised the new anastomotic method of pancreato-jejunostomy, so called ' pancreatic stent sliding guide' (pssg) method using a pancreatic duct stent. we would like to demonstrate its method and results. (operative procedure) the 10cases of hybrid laparoscopic pancreatico-duodenectomies (pd) were done by shuriken-shaped umbilicoplasty with pssg. the pancreatic duct stent, which is fit for a diameter of pancreatic duct, is used for the direct puncture without any incineration. the aims of direct puncture are both the avoidance of the enlargement of anastomotic opening and disturbance of blood flow. the contralateral of anastomotic opening is also punctured and the stent is pulled out of the jejunum. the 6-0 pds with the needles at both ends is used for anastomotic thread. firstly, the eversion anastomosis of posterior wall is done by sliding the needle on the stent. and then the anastomosis of anterior wall is done by the same way. the stent of contralateral side is cut and the hole is closed. materials and methods: the 10 cased of pancreato-jejunostomy by pssg method were done by february 2019. the average of patient's age was 72 y.o. the disease of patients were pancreatic cancer (n = 4), bile duct cancer (n = 5), and papilla vater cancer(n = 1). the pancreatic leakage by the isgpf were grade 0:10,a:0,b:0,c:0 respectively. in the same periods, we underwent the more ten cases of open pd by pssg method. the pl were only one case of grade a and there were none of clinical pl. conclusion: our new device of pancreato-jejunostomy by pssg might be very effective for the decrease of pl from the view point of machanisms of pl even for laparoscopic pd. year old, male patient presented with upper abdominal discomfort and pain, without nausea, vomiting or weight loss. an sub mucosal lesion was found on endoscopy examination in first part of the duodenum. endoscopic ultrasound has showed 2.5 cm sub mucosal lesion in first part of duodenum (anterior wall and close to pylorus). cytology examination from the lesion has showed neuroendocrine tumor. computed tomography of abdomen and chest were normal. his blood laboratory examinations were within normal limits. patient underwent da vinci robotic partial gastrectomy with intra corporeal billroth ii gastrojejunostomy. total operating time (ort) was 255 min. three day after operation patient started regular diet and was discharged home on day fife. final pathology report confirmed diagnosis of carcinoid tumor with ki67 less than 1%. surg endosc (2019) 33:s485-s781 p426-robotics & new techniques-education integrated education for colorectal disease-a digital solution for a digital age united kingdom aims: surgical plume has problem in poor visibility of the operative field, inclusion of harmful chemical substances, and biological risk. it is desirable that plume should be removed appropriately to minimize these risks. we assessed whether these problems can be solved by using commercialized evacuator semi-quantification of residual chemicals in the abdominal cavity: was performed using industrial smoke tester by aspirating the intra-abdominal plume onto filter papers and digitizing the stains. (3) detection of dna in the exhausted gas from the evacuator: the hepa filter, which was interposed at the inlet or outlet of the evacuator, was analyzed using pcr method to detect any dna derived from porcine tissues. results: (1) laparoscopic visualization: judgement score were 2.2 vs. 1.0 for ec and 3.8 vs. 1.8 for us (evacuator: on vs. off, both p \ 0.0001), indicating the visualization was significantly better in the use of the evacuator on both devices general surgery, royo villanova hospital general surgery minimally invasive surgery centre, jesús usón minimally invasive surgery centre methods: i report my experience at the american university of beirut medical center for laparoscopic adrenalectomy 65 cases, 35 left adrenalectomy and 30 cases for right adrenalectomy. three out of the series are large adrenal of 15 cm, and all of these were completed laparoscopically.the video will show the steps of this procedure.a large rt. adrenal mass measuring 15 cm, wt.750gm was removed laparoscopically using 4 trocar techniques. the lateral position facilitated the exposure and ease of dissection. the mass was removed by extending one of the trocar site with muscle splitting using endocatch 15 mm. results: patient was discharged home 3 days after surgery. the operative time was 1 hour. pathology revealed carcinoma with no involvement of the capsule or vascular invasion 163 patients (male: n = 39; female: n = 124) underwent minimally invasive adrenalectomy (tp: n = 135; rp: n = 28) at our institute. mean patient age was 53.8 years (21-82 years). besides comparing operative (intraoperative blood loss, previous abdominal surgeries, conversion rate, operative time, tumor size) and perioperative factors (time of hospitalization, time to oral intake, histology, postoperative complications) in each group, perioperative outcomes of a learning curve (lc)-the first 28 procedures in both groups-was also analyzed in terms of tumor size, significantly larger lesions were removed with tp (tp: 48.18 ± 22.8 mm vs rp: 34.8 ± 11.2 mm; p = 0.028). the number of asa (american society of anesthesiologists) ii patients were significantly higher in the tp group while there were significantly more asa iii patients in the rp group conversions 237) showed no significant difference. the analysis of lc showed a significant difference in previous abdominal surgeries min vs rp: 134.5 ± 12.4 min; p = 0.023] all favoring the tp approach. conclusion: both methods proved to be feasible and safe in terms of minimally invasive adrenalectomy. based on our own experience the tp approach resulted in improved operative time and conversion rates to demonstrate the safety and efficacy of the laparoscopic approach in the treatment of large splenomegaly. currently, this approach is recognized as the one of choice in benign splenic pathology, being controversial in the face of a massive splenomegaly or neoplastic pathology. material and method: clinical case: a 38-year-old man followed in the dept. of internal medicine for a hepatosplenomegaly of probable lymphoproliferative origin. additional explorations of interest are provided. result: intervention: complete laparoscopic approach, right lateral partial decubitus, massive splenomegaly, ? 23 cm, splenuncle of 3-4 cm that is resected, section of short vessels, dissection of the splenic hilum, vascular section with endogias, splenectomy with full extraction in a pocket through reduced laparotomy in the left flank for anatomopathological study the aim of this video is to demonstrate the safety and efficacy of the laparoscopic approach in the treatment of large splenomegaly. currently, this approach is recognized as the one of choice in benign splenic pathology, being controversial in the case of a massive splenomegaly or neoplastic pathology it can transform into adenocarcinoma. patients and methods: between 2001 and 2008 we performed laparoscopic nissen fundoplication (lars) in 254 cases of gerd. in 78 cases of gerd patients be was proved by endoscopy and histological examination. the demeester score was higher (18.9 versus 41.9, p \ 0.001), and bile re?ux was measured more frequently among the be patients on the other hand during the 8.5 years long endoscopic follow up early barrett carcinoma developed in 2 patients, 38.5 months after the lars. both patients underwent a limited surgical resection of the distal esophagus and esophagogastric junction, regional lymphadenectomy, and reconstruction by interposition of an isoperistaltic jejunal segment. there were no complication. histological examination was shown pt1n0 stage disease in both cases. oncological follow up was 82 months long (6.8y) and both patients are still disease free. conclusions: although lars can affect regression in a part of be patients, progression to adenenocarcinoma can also occur. endoscopic surveillance is important in the case of be to recognize early cancer, to perform limited surgical resection with low morbidity and long overall-and disease free survival gastric cancer development a nomogram for predicting the conditional probability of survival after d2 lymphadenectomy for gastric cancer this study aimed to devise a nomogram to predict the conditional probability of cancer-specific survival (cpcs) in gastric cancer (gc) patients after gastrectomy with d2 lymphadenectomy. methods: clinicopathological data for 2,596 gc patients who underwent d2 lymphadenectomy in a large-volume eastern institution (the training cohort) were analysed. cancer-specific survival (css) was predicted using cox regression models. a conditional survival nomogram was constructed to predict cpcs at 3 and 5 years post-gastrectomy. two external validations were performed using a cohort of 2,198 chinese patients and a cohort of 504 italian patients. results: in the training cohort, the 5-year cpcs was 59.2% immediately post-gastrectomy and increased to 68.8%, 79.7%, 88.8% and 95.1% at 1, 2, 3 and 4 years post-gastrectomy, respectively. multivariate cox regression analyses showed that age; tumour site, size and invasion depth; numbers of examined and metastatic lymph nodes; and surgical margins were independent prognostic factors of cancer-specific survival (all p \ 0.05) and formed the nomogram predictor variables. internal validation showed that the conditional nomogram exhibited good discrimination ability at 3 and 5 years post-gastrectomy (concordance index, 0.794 and 0.789, respectively) gastric cancer does non-compliance in lymph node dissection affect oncological efficacy in gastric cancer patients undergoing radical gastrectomy? univariate and multivariate analyses revealed that non-compliance was an independent risk factor for os. logistic regression analysis demonstrated that the extent of gastrectomy, primary tumour site, history of intraperitoneal surgery, bmi and open gastrectomy were independent preoperative predictive factors for non-compliance. cox analysis demonstrated that age, pt, pn, and the extent of gastrectomy independently affected os in patients with noncomplaint lymphadenectomy. however, os was significantly better in the compliant group than in the non-compliant group regardless of the recommendation for chemotherapy. stratified analysis demonstrated that os was significantly better in chemotherapy patients than in patients without chemotherapy and stage ii patients (pt1n2/n3m0 and pt3n0m0) in whom chemotherapy was not recommended. conclusion: non-compliance is an independent risk factor after radical gastrectomy for gc we prospectively collected and retrospectively analysed the medical records of 398 patients with proximal gc who underwent lspsd. the data were split 75/25, with one group used for model development and the other for validation testing. results: of the 398 patients enrolled in this study, 174 (43.7%) required laparoscopic haemostasis treatment. a multivariate analysis determined the following preoperative adverse risk factors for the model group: gender, preoperative n stage, and terminal branches of the splenic artery (spa), and we developed a scoring system based on these findings. each of these factors contributed 1 point to the risk score. the intraoperative laparoscopy hemostasis rates were 11.5, 33.6, 58.5, and 73.5% for the low-, intermediate-, high-, and extremely high-risk categories, respectively. there were statistically significant differences among groups (p \ 0.001). with the increase in risk, both blood loss volume (blv) and operative time (min) of lspsd increased significantly (p \ 0.001).the area under the receiver operating characteristic curve for the score of intraoperative laparoscopic haemostasis was 0.700. the observed and predicted incidence rates for intraoperative laparoscopic haemostasis were parallel in the validation set. conclusions: this simple we compared the survival of src patients with that of tubular adenocarcinoma patients according to bmi. results: the 5-year survival of src was significantly worse than that of wmd (p \ 0.001) but superior to that of pd (p \ 0.001). bmi-stratified analysis showed that in the high-bmi group, the prognosis of src was similar to that of wmd (p [ 0.05) and better than that of pd (p \ 0.001). in normal-bmi patients, src had a worse prognosis than wmd (p \ 0.001) but a more favorable prognosis than pd (p \ 0.001). src among low-bmi patients displayed much poorer survival than did both wmd (p \ 0.001) and pd (p = 0.005). multivariate analysis indicated that the risk of death was lowest for src patients with a high bmi and highest for src patients with a low bmi baseline characteristics were compared in a 35-patient rspshl cohort and a 608-patient lspshl cohort. one-to-four propensity score matching was performed to determine between-group differences. result: in total, 175 patients were matched, including 35 patients who underwent rspshl and 140 who underwent lspshl. no significant differences in baseline characteristics were observed between these groups after matching. significant differences in total operative time, estimated blood loss (ebl), splenic hilar blood loss (shbl), splenic hilar dissection time (shdt), and splenic trunk dissection time were detected between these groups (all p \ 0.05). furthermore, no significant differences were evident between rspshl and lspshl in the overall noncompliance rate of lymph node (ln) dissection (62 the highest body temperature within 1 week after operation was used to establish diagnostic thresholds for high body temperature and low body temperature, which was obtained by x-tile software. the study used cox regression to analyze the influence of high body temperature on 5-year dfs. results: a total of 1396 patients were included in the analysis. the diagnostic threshold for high body temperature was defined as 38°c; 370 patients with a high postoperative body temperature were allocated to the high temperature group (htg), while another 1026 patients were allocated to the low temperature group (ltg) cao department of gastric surgery, fujian medical university union hospital, fuzhou, china background: laparoscopic surgery for remnant gastric cancer third step: baring of the right side of the esophagus. fourth step: exposure of left gastroepiploic vessels and lns dissection in the splenic hilar area. fifth step: baring of the left side of the esophagus. the above procedure was performed for 45 rgc patients with stage ct1-4an0/? disease. results: there was no conversion to open surgery. mean operation time was 195.0 ± 52.5 min, mean blood loss was 104.3 ± 90.4 ml, and mean times to first flatus p526-upper gi-gastric cancer a novel prognosis prediction model after gastrectomy for remnant gastric cancer: development and validation using international multicenter databases fuzhou, china; 2 department of gastrointestinal surgery the model calibration was accurate in predicting 5-year survival. dca showed that the model has a greater benefit. the results were also confirmed by bootstrap internal validation. in external validation, c-statistics and dca showed good prognostic performance in patient datasets from 2 participating institutions. moreover, we verified reliability of the model in an analysis of patients with different eln counts p527-upper gi-gastric cancer a novel abdominal negative pressure lavage-drainage system for anastomotic leakage after r0 resection for gastric cancer while risk of gastric cancer for ppi users was higher than non-ppi users when duration between 1-3 year, = 1 year, = 3 year and = 5 year. the risk of gastric cancer when duration = 5 year(rr = 2.03)and duration = 3 year(rr = 1.95)are higher than risk of gastric cancer when duration between 1-3 year (rr = 1.74). according to location subgroups meta-analysis,risk of non-cardiac gastric cancer for ppi users higher than non-ppi users conclusion: based on a systematic review with meta-analysis, we found the correlation between long-term use of ppi and the risk of gastric cancer and long-term use of ppi may increase the risk of non-cardiac gastric cancer when duration = 1 year p534-upper gi-gastric cancer age-adjusted charlson comorbidity index (acci) is a significant factor for predicting survival results: there were 1476 patients included in the analysis. the high-acci and low-acci groups had significant differences in preoperative abdominal surgery history, asa grade, tumor size, tumor stage, histologic type, age and comorbidity (all p \ 0.05). the incidence of postoperative complications was 17.9% in the high-acci group and was significantly higher than that in the low-acci group (p = 0.001). the overall survival rate (os) and cancer-specific survival (css) rate in the low-acci group were both higher than those in the high-acci group (p \ 0.05). univariate and multivariate analyses showed that the acci was an independent risk factor for os and css (p \ 0.05). furthermore, a combination of the tnm staging system and acci showed a trend toward higher prognostic value and higher auc for os and css than the tnm staging system alone (p \ 0.05). conclusions: the acci was an we aimed to investigate the clinicopathological features and prognosis of patients with mgc and the impact of postoperative adjuvant chemotherapy on long-term survival. methods: the clinical and pathological data of patients diagnosed with gastric adenocarcinoma and undergoing radical gastrectomy from stratified analysis showed that, in advanced gastric cancer (agc), the 5-year os rates of mgc without adjuvant chemotherapy and sgc without adjuvant chemotherapy were 34.0% and 46.1%, respectively, with a statistically significant difference (p = 0.025). the 5-year os rates of advanced mgc after adjuvant chemotherapy and of advanced sgc after adjuvant chemotherapy were 48.0% and 53.3%, respectively, and the difference was not statistically significant (p = 0.292). the 5-year os rate of advanced mgc after adjuvant chemotherapy was significantly higher than that of patients without adjuvant chemotherapy (48.0% vs. 34.0%, p = 0.026). conclusions: mgc is a poor prognostic factor after radical gastrectomy for gastric cancer background: whether the tumor-node-metastasis (tnm) staging system is suitable for patients with node-negative gc is still controversial. the modified staging system established by rpa showed good prognostic performance in a variety of cancers. the application of rpa has not been reported in the prognostic prediction of gc. methods: node-negative gc patients who underwent radical resection at fujian medical university union hospital (n = 862) and sun yat-sen university cancer center (n = 311) with an at least 5-year follow-up information were selected as the training set. rpa was used to develop a modified staging system. patients from the surveillance, epidemiology, and end results databases (n = 1415) were selected as the external validation set. results: the 5-year overall survival (os) rates of patients with 8th ajcc-tnm stage ia-iiia in the training set were ia 95%, ib 87%, iia 78%, iib 76% and iiia 73%. multivariate analysis (mva) showed that larger tumor size, older age, and deeper depth of invasion were independent risk factors for os in patients with node-negative gc (all p \ 0.05). patients were reclassified into rpa i, rpa ii, rpa iii, and rpa iv stage based on rpa, the 5-year os rates were 96%, 87%, 81%, and 64%, respectively, with significantly difference (p \ 0.05). two-step mva showed that the rpa staging system was an independent predictor for os (p \ 0.05) were retrospectively collected. patients were classified into two groups according to bmi of \ 25 kg/m 2 (332 patients; high bmi group) and = 25 kg/ m 2 (108 patients; low bmi group). for these 440 patients, clinicopathological variables were analyzed using propensity score matching to mitigate the selection bias: sex, age, asa physical states, clinical stage, laparoscopy-assisted total gastrectomy (latg) or totally laparoscopic total gastrectomy (tltg), d2 lymph node dissection, combined resection of other organs, method of anastomosis, jejunal pouch reconstruction. the surgical results and postoperative outcomes were compared and examined between the two groups. results: a total of 152 patients were matched for the analysis. contrary to our expectations, there were no differences in the surgical results about operative time and estimated blood loss (low bmi 336.3 ± 72.0 min, high bmi 354.5 ± 85.3 min; p = 0.479, low bmi 144.2 ± 300.8 g, high bmi 112.6 ± 155.8 g; p = 0.695, respectively). furthermore, there was no significant difference in postoperative outcome of complication (clavian-dindo [ iiia) and the length of postoperative hospital stays (low bmi 13 cases, high bmi 10 cases baiocchi general surgery, university of brescia-spedali civili, brescia, italy background and aim: recently indocyanine green (icg) was introduced in clinical practice as a fluorescent tracer. the use of icg for sentinel lymph node (ln) mapping was investigated in lots of fields such as breast methods: we conduced a single center prospective trial. we included patients with gastric cancer candidate to surgery. icg was injected intraoperative or the day before surgery, via submucosal or subserosal. total or subtotal gastrectomy was performed open, laparoscopic or video-assisted access. during gastric cancer standard lymphadenectomy we studied lymphatic flow and ln bright in vivo and ex vivo japan introduction: in japan, the number of elderly patients with gastric cancer has been increasing in correlation with the increase in average age of the population. the aim of this study is to assess the safety and efficacy of laparoscopic gastrectomy for cancer in elderly patients compared with the short-term outcome in the nonelderly. method: we reviewed 231 patients who underwent laparoscopic gastrectomy (dital gastrectomy,proximal gastrectomy,total gastrectomy)between 021).the incidence of advanced cancer(stageiior more)was higher in elderly patients there were no significant differences in the operating time,blood loss and postoperative hospital stay. there were no significant differences in the incidence of postoperative morbidity. conclusion: in elderly patients, there was a tendency of reduction surgery being selected according to individual condition, but there was no significant difference in the short-term outcome.hence,we conclude that laparoscopic gastrectomy is indicated even in elderly patients. p548-upper gi-gastric cancer improved technique of vacuum therapy and carried out ltg . a patient factor (the gender, the age and bmi), an operation factor (operation time, the bleeding amount, lymph node dissection and conjurer), a coincidence related complication (clavien dindo classification, sutural insufficiency of grade more than 2, anastomotic stricture, anastomotic region bleeding and reflux esophagitis) and the post-operatively length of stay were considered . result: cs crowd met 98 cases (85.2%) and ls cluster (14.8%) 17 cases. 70 years old of age medians (38-84), men and women were 93 examples (83.4%), 22 examples (16.6%) and bmi median 22.5 (16.2-31.1) by a patient factor, and a significant difference didn't admit by two groups for 13 days, the post-operatively average length of stay was 11 days by ls group by cs group. conclusion: operation time was short for a coincidence by linear stapler more than a coincidence by circular stapler in comparison of an esophagoenterostomy way in ltg on the day before the operation, we endoscopically clipped several points located 2 cm proximal to the tumor edge to cover about half of the tumor. after lymph node dissection, we incised the stomach with an endoscopic linear stapling device,including the previously placed clips. reconstruction was performed in all patients who underwent billroth i or roux-en-y procedures. result: no complications were observed during pre-operative endoscopic clipping or intraoperatively p558-upper gi-gastric cancer small intestinal tumors after laparoscopic surgery in our hospital small intestinal tumors are rarely observed, accounting for about 3-6% (malignant cases: 1-2%) of all gastrointestinal tumors. therefore, occasionally, their diagnoses can be difficult. however, recently, capsule and balloon endoscopes have been widely employed were examined regarding patient backgrounds, diagnostic methods, pathological findings, postoperative courses, and prognoses. results: the subjects consisted of 15 males and 5 females, with a mean age of 63 years. their chief complaints were black stools the median distance from the treitz ligament or bauhin valve was 50 cm (2-200) postoperative complications were abdominal abscess (2 cases; 10.0%) and surgical site infection (ssi), hemorrhage, and paralytic ileus (1 case each; 5.0%). pathological diagnoses were lymphoma metastatic small intestinal tumor (2 cases; 10.0%), and granuloma, lipoma, peutz-jeghers polyp, clear cell sarcoma, malignant mesothelioma, and ectopic pancreas most patients were diagnosed in bleeding, complicated by anemia and black stools. however, as most tumors were relatively close to the treitz ligament and bauhin valve, almost a half could be diagnosed with a small intestine endoscope before surgery patients were classified as popf and no-popf according to their grade b or c popf status. popf was diagnosed according to international study group of pancreatic fistula (isgpf) criteria or clinical findings. patient characteristics, intraoperative parameters, electrosurgical device type, pathological findings, and early postoperative outcomes were compared. electrosurgical devices were classified asthunderbeat (tb) or laparosonic coagulating shears (lcs) based on energy sources. results: eighteen patients developed grade b or c popf. among them, 12 (66.7%) and 6 (33.3%) were diagnosed with popf according to isgpf criteria and clinical findings 011), operation time (p = 0.03) and electrosurgical device type (p = 0.005) were significant risk factors for popf following lag 017) and tb device (or, 6.80; 95% ci 002) were independent risk factors for popf following lag. conclusions: operation time and tb use significantly affect the risk of popf and should be considered in future clinical studies. p560-upper gi-gastric cancer feasibility and nutritional benefits of double flap with no-knife stapler reconstruction after laparoscopic proximal gastrectomy for gastric cancer were analyzed. receiver operating characteristic curves were generated, and by calculating the areas under the curve(auc) and the c-index, the discriminative ability of crps during different periods were compared, including pre-crp, postoperative days 1, 3, 5 and postoperative maximum crp (post-crp max ). a decision curve analysis was performed to evaluate the clinical utility. result: ultimately, 401 patients were included this study and the median follow-up time was 29 (3-41) months. for postoperative recurrence, the auc and c-index of pre-crp were 0.692 and 0.678, respectively, significantly higher than the other crps, all p \ 0.05. among = ''''''the = '''' post-crps = '''' post-crp = '''' sub = similar findings were observed for overall survival. conclusion: both pre-crp and post-crp max , cheap and easily obtained, are independent predictors of recurrence for gc. act significantly prolonged the rfs for stage ii/iii gc patients with high-prep p566-upper gi-gastric cancer robot-assisted gastroduodenal surgery: a single center experience robot-assisted gastroduodenal surgery (ras) was introduced to overcome the technical limitations of conventional laparoscopy. it provides a 3d-amplified view to the surgeons and an increased ability to control the operative field by manipulating optics, as well as enhanced mobility and precision of instruments. the aim of the present study is to evaluate the main outcome of a single center experience in gastroduodenal robotic surgery. materials and methods: we report a case series of patients who underwent robot-assisted gastroduodenal surgery at sanchinarro university hospital between conclusions: robot-assisted gastroduodenal surgery is a safe and feasible technique in experienced centers with advanced robotic skills. in the literature, there are only few reports of robotic assisted gastroduodenal resection. further studies are necessary to better confirme our results. p567-upper gi-gastric cancer atypical methods: retrospective review of ogd reports before and after the introduction of the new guidelines. inclusion criteria: all elective ogds. exclusion criteria: emergency ogds and elective therapeutic ogds. data recorded: patient demographics, endoscopist, indication, number of photos, anatomical site photographed, pathology identified and whether pathology photographed or not. results: 1099 ogds reviewed, 790 before the guidelines (group 1) and 309 afterwards (group 2). the most common indication was reflux 166 (21%) in group 1 and anaemia 67 (22%) in group 2 clinical utility of systematic pre treatment staging laparoscopic exploration methods: all locally advanced gastric adenocarcinoma managed in surgical oncological unit between 1st january and 30th november were prospectively enrolled in the study. in the absence of emergency surgery or preoperative contraindications, all patients with curative intent underwent either preoperative chemotherapy followed by surgical exploration in the intent of curative gastrectomy (g)or systematic pretreatment laparoscopic exploration (l) benkabbou surgical department the patient background (age, gender, bmi) and c-stage of the preoperative factor were matched using propensity score matching method, and the surgical results were compared and examined. results: thirty rg groups matched rag 30 cases. the operation time (rag / lg) was significantly longer in the rag group as 309.2 ± 47.9 min / 220.6 ± 55.2 min (p \ 0.05). amount of blood loss was not significantly different each other; 10 ml / 9 ml (p = 0.693). pathologically t4a case was involved in 4 cases in rag and 5 cases in lg. the extent of lymph node dissection (d1 ? / d2) was 23/7 cases in both groups conclusions: rag in our clinical experiences can be safely introduced and short-term results are comparable to those of lg. verification of superiority of robotic surgery including long-term results seems to influence the future of robotic surgery conclusions: totally laparoscopic gastrectomy is feasible method in terms of surgical outcomes. furthermore, totally laparoscopic total gastrectomy is not technically difficult in advanced gastric cancer such as early gastric cancer and safety method. key words: gastrectomy, reconstruction, laparoscopic surgery, stomach neoplasm aims: meckel's diverticulum (md) is one of the most common congenital anomalies of the small intestine caused by an obliteration defect of omphalomesenteric duct. the objective of this study was to review surgical treatment and clinical outcomes of md, and evaluate the safety and feasibility of minimal invasive surgery (mis) in md. methods: we performed a retrospective analysis of medical record for patients who underwent meckel's diverticulectomy at six hallym-university-affiliated hospitals between 18 d), as well as the average of drainage stay. patients who underwent laparoscopic repair required significantly less parenteral analgesics than the open group.the mean postoperative stay was significantly shorter for laparoscopic group (mean, 5.48 d) than the open one.morbidity of medical and surgical complication was higher in open groups (23 vs 2). the most common complication in both groups was medical complication.more case of pneumonia was occurred in open groups compared to laparoscopic groups methods: a retrospective study using our prospective database was designed to analyse all the resected md in our centre. epidemiological data, clinical setting, diagnostic test and histological results were reported. results: md was resected in 112 patients, 80 males and 32 females, with a mean age of 13.00 years (3.25-59.50). in 35 cases, a laparoscopic approach was chosen. eighty-seven percent of the patients had a presurgical imaging test (ultrasounds, ct-scan or meckel's scan) background: perforated peptic ulcer (ppu) is a substantial health problem with significant postoperative morbidity up to 63% and mortality up to 40% worldwide. aims: this study aimed to estimate the sensitivity scoring systems for prognosis morbidity of patients operated for ppu with diffuse peritonitis. methods: a total of 153 patients were underwent emergency repair for ppu with diffuse peritonitis in pirogov russian national research medical university's surgical clinics during 2014-2016 years. different scoring systems used to predict outcome in ppu patients were identified: boey score, peptic ulcer perforation (pulp) score, asa, mannheim peritonitis index (mpi), world society of emergency surgery sepsis severity score (wses score). to quantify the strength of the concatenation of prognostic score and morbidity we use odds ratio (or) with 95% ci 05), respectively. pulp score and asa score have good prognostic value in relation to morbidity, but less than boey, mpi and wses sss. patients with pulp [ 7 had or 27 with 95% ci of p596-upper gi-gastroduodenal diseases gastrostomy tube placed by laparoscopy as a new therapeutic option for continuous intestinal infusion treatment with levodopa/ carbidopa we present 20 year outcomes of our initial consecutive patient cohort. methods: patients were identified in a prospectively maintained irb-approved database (1993-1998). post-operative eckardt scores and a 5-point validated system questionnaires were obtained via telephone interviews one patient required reoperation for failed myotomy. the mean eckardt score at 20 years was 0.81(± 0.21), with all fourteen patients having an eckardt score \ 3. all patients reported significant improvement in their quality of life. classic gerd symptoms (heartburn and regurgitation) were present in 3 (21.4%) patients. proton-pump inhibitors are being used by 35% of with patients with excellent symptom control. seven patients returned for a repeat egd (median 18.3yrs) with 5 patients having normal anatomy and 2 having la grade a esophagitis (1 patient on ppi). barrett's esophagus was not detected. conclusion: long-term results from our early experience with lhm are excellent and durable with only one patient requiring re-intervention in 20 years until recently the esophagectomy was the only choice in treatment of patients with end-stage achalasia. developing of minimally invasive techniques such as a laparoscopic heller miotomy and peroral endoscopic myotomy (poem) allowed to use them as a treatment options. aim: to present an experience of treatment of patents with end-stage cardiac achalasia. materials and methods: since 07.2013 till the 12 laparoscopic heller myotomy was performed in 3, and esophagectomies were performed in 3 patients with failed previously myotomy made in other clinics. gastric tube was used to replace the esophagus in patients underwent esophagectomy after skeletization of crura posteriorly to esophagus, two separated rectangular patches of parietene progrip mesh (covidien) measuring 1x2.5-3 cm were attached to the posterior surfaces of the crura. the patches were fixated themselves due to special hooks. than continious twodirections suture was placed through both crura along with the patches using self-gripping v-loc 2-0 suture (covidien). the same suture was used for construction of nissen fundoplication wrap 3.5 cm long. aditional anchoring stich through the wrap and esophageal wall was placed using ti-cron 2-0 suture (covidien). 3d laparoscopy was used while suturing using richard wolf epic system. results: all the procedures were performed successfully. there were no cases of bleeding from the suturing points either from the crura and the fundus wall. there were no crural dehiscence while suturing, even if the distance between crura was more than 4 cm. the mean duration of suturing facilitated by 3d laparoscopy was 15 min (range, 12-20 min) for crural repair, and 10 min (range, 8-25 min) for fundoplication. there were no excessive postoperative pain in all the patients. there were no disphagia 1 month postop in every patient. conclusions: 1. the new technique of posterior buttress of crural repair using small patches of parietene progrip mesh and v-loc suture showed feasibility and safety. 2. the use of 3d in such case most commonly manifested symptoms are cough, sore throat, hoarseness, dysphonia, globus and only 40% patients with lpr have typical gerd symptoms. also ppi therapy are less effective in patients with lpr in comparison with patients which have typical features of gerd. purpose: to compare the outcomes between surgical treatment and conservative therapy in patients with laryngopharyngeal reflux. materials and methods: for the period chesarev faculty surgery #1, federal state autonomous educational institution of higher education i.m. sechen, moscow, russia p614-upper gi-reflux-achalasia a case of a primary parahiatal hernia associated with a type i hiatal hernia emergency county hospital parahiatal hernia is a rare disease that occurs when an abdominal organ protrudes through an opening adjacent to an anatomically intact esophageal hiatus. the herniated organ is usually the stomach, although cases of omental and colonic herniation exist we report the case of a 60-year-old woman which accused epigastric pain, starting 2 years prior, pseudo-angina, heartburn and bloating. based on imagistic findings the patient was diagnosed with a parahiatal hernia and an associated type i hiatal hernia. patient underwent surgery and a 7 cm diameter defect in the diaphragm lateral to the left crus was discovered, through which 40-50% of the stomach had herniated. the hiatal orifice was slightly enlarged but anatomically intact, with an associated small sliding hiatal hernia. we performed closure of the defect, hiatoplasty and a floppy-nissen fundoplication pneumatic dilation with 30 mm balloon was performed under general anesthesia. radiological contrast control and endoscopy reevaluation revealed a perforation just above the squamo-columnar junction. a minimally invasive approach was decided. an fully covered esophageal stent was inserted. radiological control after 2 days reveals left pleurisy and migration of the stent. the same day was performed an endoscopic repositioning of the stent with clip fixation. left pleural puncture was performed and clear fluid was extracted. the condition of the patient got worse and she was transferred on icu (08.07). we performed left pleurostomy and initial exploratory laparoscopy-no intraperitoneal lesions. due to difficult transhiatal access to the inferior mediastinum the surgery was converted to open-perisophageal mediastinal abscess was found, evacuated and drainage and jejunostomy were performed. after a week, the patient presented progressive altered condition, febrile syndrome. thoraco-abdominal ct-scan showed left pleural effusions. left pleurostomy was performed, with extraction of fetid fluid. continuous lavage was instituted. on 1 st of august, the pleurostomy tube drained gastric content, and the clinical examination revealed signs of generalized peritonitis. laparotomy was performed with lavage, drainage and posterior decompression gastrostomy. results: postoperative evolution was favorable, with the suppression of pleural drainage in 13.08 and discharge in 29.08 with alimentation exclusive on jejunostomy. one month later, she had normal clinical and radiological examination evaluation of efficacy was performed with reflux symptom index (rsi) specific for extraesophageal symptoms, subjective satisfaction and occurrence of dysphagia and gas-bloat syndrome. a rsi score [ 12 was considered as pathological. results: rsi significantly decreased after surgery (14and msa as compared with total fundoplication; 83,3% of patients were satisfied with surgery: a comparison between techniques showed superiority of msa objective: to demonstrate the efficacy of hiatorraphy without the use of meshes in thegiant paraesophageal hiatus hernia, as well as the standardization of our technique, with thetechnical steps that we make successively. material and method: clinical cases: 68-year-old man,with symptomatic hiatal hernia with progressive intolerance and dysnea. egd: the stomach rotated in a giant hiatal hernia.gastroscopy not completed due to endoscope loop formation within giant hiatal hernia with gastric volvulation. ct: large hiatal hernia,combined volvulation (axial axial mesenteric organ), the stomach in a right subpulmonary situation. results: intervention: laparoscopic approach.hh of large paraesophageal size,double organoaxial-and-mesenteric volvular component,gastric walls very thickened and adhered to the mediastinum.reduction of all content and the sac,is adhered to the pleura, extended med-iastinal esophageal disection, up to vein pulmonary and get enough abdominal esophagus and rule out the presence of an short esophagus,posterior-anterior and left tutorized modified hiatorraphy with stitches in ''u'' with non-absorbable suture on teflon reinforcement patches.nissen fixed to both pillars, intramediastinal drainage.egd at the 1st day with esophageal stenosis due to inflamation of the nissen, resolved with medical treatment. dischage at 5 th day.asymptomatic and without radiological recurrence after 10 months of follow-up. conclusions: in giant and paraesophageal hiatus hernias, modified primary hiatorraphy together with mediastinal esophageal dissection extended can be an effective and safe alternative, and can be advised as a technical gesture prior to a collis nissen and-or placement of a hiatal-hiatoplasty mesh united states of america aim/background: prescribed opioids for pain control have been implicated as major contributors to addiction through their illicit use. efforts to reduce opioid prescriptions and measure their impact on outcomes are novel. we analyzed how patient outcomes are affected with reduced opioid prescriptions following laparoscopic foregut surgery narcr: 89%), length of hospital stay (narcs: 1.60 days vs. narcr: 1.62 days), 30-day readmission rates (narcs: 1% vs. narcr: 4%) and perioperative complication rates. additionally, no significant qol outcome differences between the groups were reported at one month postoperatively. conclusion: our study supports reducing opioid prescriptions as a strategy to counter illicit drug use and addiction 50 patients who underwent paraesophageal hernia repair at a tertiary referral center were analyzed retrospectively. demographic data, asa classification, characteristics of peh, onset of symptom, dysphagia severity score, characteristics of fundoplication (partial vs. total; laparotomy vs. laparoscopy; emergency vs. elective) and surgical outcome (length of stay, complication and 30-day mortality) were recorded and reviewed. results: 50 patients were included; 88% were female (mean age of 76.8 years old and mean body mass index of 21.5). mean onset of symptom was 2.0 weeks after peh repair, dysphagia severity scores were changed 1.8 from 3.7. conclusion: in our series, the dysphagia severity scores reduced after surgery upper gi surgery, the catholic university of korea mary's hospital, incheon city, korea p634-upper gi-gastric cancer general surgery biopsy from the mass has showed poorly differentiated signet ring cell adenocarcinoma. chest computed tomography revealed 38 mm thoracic aortic aneurism. abdominal computed tomography showed 43 mm infra renal aortic aneurism and no evidence of metastatic disease general surgery 70 year old, female patient presented with upper abdominal pain, weight loss (10 kg during last three month), without nausea or vomiting biopsy was done and pathology result showed intestinal type, her2-negative adenocarcinoma of the stomach. chest and abdominal computed tomography (ct) were normal. endoscopic ultrasound (eus) revealed 3 cm lesion with invasion to the muscularis propria (mp) she was treated by neo adjuvant chemotherapy (3 cycles carboplatine ? 5fu). patient underwent laparoscopic partial gastrectomy with modified d2 lymphadenectomy and billroth ii gastrojejunostomy. total operating time (ort) was 320 min. three day after operation patient started regular diet and was discharged home on day fife. final pathology result confirmed intestinal type, modified differentiated adenocarcinoma of the stomach economou 1st surgical department 1 general, visceral and transplant surgery, section minimally invasive surgery, heidelberg university hospital, heidelberg, germany; 2 department of surgery, iuliu hatieganu university, cluj-napoca, romania; 3 general and visceral surgery, klinikum mittelbaden, baden-baden, germany 1 surgery, toyonaka municipal hospital, toyonaka city, osaka, japan; 2 gastroenterological surgery, osaka university, osaka, japan; 3 next generation endoscopic intervention, osaka university, osaka, japan aims: uncomplicated healing of anastomoses in colorectal surgery is the basis for early adjuvant oncology therapy. the basis for proper healing is good blood flow. we use by robotic surgery foor control the firefly by intuitive. since january 2018, icg has used for blood flow in laparoscopic bowel surgery for the d-light system of storz. method: use of icg wants to accurately determine the resection line for free colon operations based on good blood circulation. we use icg pulse in two batches and color detection using d light from storz to verify blood flow. the first dose is given after the skeletalisation of the intestines intraabdominally and the second after the colic anastomosis to verify its vitality. results: in the period under review we performed 85 laparoscopic operations on the free colon, 82% of the operations were elective. we had 5.88% leakage across the set, however, in the subset of elective operations, we had only a leak of 0.142%. conclusion: in an unselected set of colorectal operations, leakage was 5.88%, but only 0.142 for elective operations. in our group there was a clear effect of using icg in elective laparoscopic resections with an intracorporal anastomosis, the effect was not shown in others, probably due to leakage were factors other than blood flow. objective: right hemicoloctomy (rhce) is the first choice in treating the right colon cancer. complete mesocolic excision with extended lymph node dissection at the roots of superior mesenteric artery (sma) branches enables removal of all lymphatic tissue and prevents local recurrence. previously variability of sma branches was demonstrated. the aim of presented study was to compare the distribution of sma branches in two ethnically different cohorts methods: preoperativect scans with vascular 3d reconstruction were assessed in 100 patients (28-93 years) from russia and 95 patients (24-88 years) from turkey with right colon cancer operated in 2015-2018. the distribution of ileocolic artery (ica), right colic artery (rca) and middle colic artery (mca) was investigated. results: ica and mca could be found on ct scans in all patients, whereas rca had significantly different distribution between patient cohorts: it was visible in 93 (98%) of turkish patients and only in 32 (32%) of russian patients (p = 0.001). conclusion: these results suggest that there might be ethnical differences in sma branches distribution. in turkish patients all named sma branches ate visible on ct scans in 98%, whereas in russian patients only in 32%. the majority of patients from russia don't have rca. ica and mca could be found in all patients regardless ethnicity. knowing the variant of sma branching before the operation can help plan extended lymph node dissection. the national training programme in laparoscopic colorectal surgery (s-micras-lapserb) in serbia was set up to introduce standardized and structured training in laparoscopic colorectal surgery. method: an assessment based structured training programme (lapserb) started in 2015. series of hands on supervised workshops were conducted for four different hospitals using the structured training by single trainer. this study aims at retrospective analysis of prospectively collected data for patients undergoing colorectal resections. we look at short-term clinical and pathological outcome of patients within laparoscopic colorectal resections performed in national training program. results: during the period november 2015 until november 2018, laparoscopic colorectal resection was performed in 746 (426 male and 320 female) patients. mean age of patients was 65.6 (21-88). the most common indication was colorectal cancer (645 patients, 86.4%), 80 (10.7%) patients were operated due to the colorectal polyps not suitable for endoscopic resection and 21(2.8%) was operated due to ibd. there were 174 (23.3%) right colonic, 557 (74.6%) left colonic /tme and 13 (1.7%) other resections. average number of lymph node harvested in patients with colorectal carcinoma was 16.5 . there were 6/645 (0.9%) r1 resections mean duration of hospital stay was 6.5 days (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) (12) (13) (14) (15) (16) (17) (18) . postoperative complications were encountered in 103 /746 patients (13.8%). overall, mortality rate was 1.2% (9/ 746). conclusions: this study demonstrates successful and safe adoption of laparoscopic technique for colorectal resections. short term clinical and pathological outcomes are compared to published data and shows wider adoption at the national level. standardization of operative technique and structured training remains the key in success. introduction: femal adnexal tumor of probable wolffian origin (fatwo) was first described in 1973. it is a tumor of mesonephiris wolffian duct origin. fatwo is rare tumor which is usualle benign. in the literature has been reported 71 cases and only 8 cases of recurrent disease. next rare tumor in pelvic localisation is sex cord-gonadal stromal tumor of sertoli cells. methods: we present case report of women who presented metastatic fatwo with duplicity of sertoli tumor. results: 60-year old women underwent 15 years ago exstirpation of tumor in the left broad ligament. histologically there was rare benign fatwo. this year was indicated adnexectomy at gynecology department. during the operation was done bilateral adnexectomy and discovered tumor of anterior wall on upper rectum. microscopic examination showed sertoli tumor on the left ovary. afterward we completed next examinations. colonoscopy without any abnormality. on ct scan was tumor 7 cm without contact to rectum wall, without distant metastasis. the same was described on rectal ultrasonography-normal wall of rectum, tumor probably from uterus. at diagnostic laparoscopy was tumor mass 7 cm, with necrosis arising from anterior wall of the rectum. next small metastasis on pelvic peritoneum. we performed debulking of this big tumor and metastasectomy, there was no infiltration to muscularis propria of the rectum. patient did not have any postoperativ complications. microscopic examination of the rectal tumor and small peritoneal metastasis showed metastatic fatwo. after 6 weeks she underwent laparoscopic second look operation. there were small metastasis on pelvis peritoneum. we removed two biggest metastasis and the rest was destroyed wit j plazma. microscopic examination showed in this metastasis sertoli tumor. conclusion: our patient has metastatic fatwo and sertoli tumor. fatwo is so rare, that in the literaure is not enough information for observation or adjuvant therapy. in one case was described imatinib mesylae (gleevec) therapy with good results. surgeons must be ready to meet new diagnosis. bochdalek hernia is a type of congenital diaphragmatic hernia. in most cases, it is diagnosed during the neonatal period. we present a case of laparoscopically treated congenital bochdalek hernia that led to jejunal strangulation in an adult . case: an fifty eight year old obese(bmi = 38.3) female admitted for gradually worsening right flank pain, vomiting and respiratory distress for one day. there was no trauma history to chest or abdomen. the past medical history were old cva, well controlled hypertension and dm. she was hemodynamically stable. her right flank was very tender. there was no abdominal distension. initial cbc tests showed leukocytosis (15,200/ul) , but electrolytes were normal. chest pa revealed right side diaphragmatic hernia. there was poorly enhanced, herniated small bowel in the right hemithorax on chest ct scan. the patient was taken for emergency operation. on laparoscopy, the normal liver was displaced leftward because of herniated bowel. there was incarcerated jejunum and omentum which could not be reduced. so we widened a 3 cm sized posterolateral diaphragmatic defect first, and then we could reduce the strangulated jejunum(45 cm in length) and omentum. there was no hernial sac. the defect was closed with 2-o prolene. finally, the strangulated jejunum was resected and anastomosed extracorporeally. the hospital progress of the patient was not eventful. on post-operative day 4, the patient was allowed soft diet. the patient was discharged on post-operative day 8 without any complication. conclusion: congenital diaphragmatic hernia is an uncommon condition in adults, but you should keep in mind the diaphragmatic hernia as a cause of intestinal obstruction and respiratory distress in an adult. prompt surgical intervention is required to a favorable outcome. laparoscopic repair of bochdalek hernia is a good management option. aims: intestinal obstruction is one of the most frequent abdominal conditions in the emergency department (ed). up to 93% of patients having undergone a laparotomy will have an episode throughout their lives, of which 60% up to 70% will respond to conservative management. the laparoscopic approach is widely accepted and supported by the studies published up todate. it is recommended in patients with suspected single band, who have less than one previous laparotomy and less than 24 h of clinical evolution. our objective is to validate in our experience that these premises are the appropriate ones in the election of candidates for a minimally invasive approach. methods: we present a series of 26 cases admitted with symptoms compatible with adhesive intestinal obstruction in the ed of a third level hospital during 16 months. all patients underwent abdominal ct to rule out the possible causes of obstruction. emergency surgery was indicated because of failure of a conservative medical treatment or for the findings of the complementary tests. results: a initial laparoscopic approach was performed in the 26 patients, with a conversion rate of 38% of the cases (resection and anastomosis was required in 7 patients, due to loop suffering or intestinal tumor not seen in the ct). among the patients who required laparotomy, 80% had more han 24 h of clinical evolution before de surgery and 20% had free fluid in the tc. as surgical complications: 5 intestinal perforations were produced secondary to the manipulation. there was 3 recurrences of obstruction in the following 3 months. conclusion: the laparoscopic approach is feasible in selected cases and experienced hands. acording to our results it is recommended to perform it in only in patients with less than 24 h evolution and with a single band image in the ct without free fluid. the intestine should be explored avoiding the manipulation of the most extensive loops to prevent complications and keep in mind the possible conversion to laparotomy in case of complications. aim: the aim of the study was to evaluate whether physiologic and operative severity score for the enumeration of mortality and morbidity (possum) is useful to predict the risk of complications in patients older than 80 years. methods: we performed a retrospective study of 13 patients older than 80 years old diagnosed with acute abdomen who were admitted to the department of general, minimally invasive and elderly surgery in olsztyn between may and october 2017. results: the most common disagnosis was ileus. the mortality rate in surgery department was 31%.after relocation to the intensive care unit, the overall mortality rate was 53.9%. the patients who died a short time after surgery had mortality rates greater than 95% and morbidity rates greater than 60% according to possum. conclusions: this study shows that possum seems to be a valuable scale to predict the risk of death after surgery in older patients. patients with higher mortality and morbidity scores should be very carefully selected for surgery. aims: diaphragmatic hernia in adulthood is rare. the most common causes are blunt and penetrating trauma. we present an intraoperative video of the laparoscopic repair of an adult onset, non-traumatic, diaphragmatic hernia in a patient with splenomegaly. method: a 66 year old woman was referred to upper gastrointestinal surgery with epigastric burning and pain in the left side of her chest, radiating to the left shoulder, for one year. there was no recent or distant history of trauma. she has a past medical history of treated hepatitis c, cirrhotic liver disease, splenomegaly, thrombocytopenia and iron deficiency anaemia. gastroscopy was interpreted as a fundal diverticulum. ct abdomen/pelvis with intravenous (iv) contrast showed this to be a left diaphragmatic defect with herniated stomach causing a volvulus, which lay immediately above an enlarged spleen. a ct three years prior to this showed no diaphragmatic hernia. the patient had some symptomatic relief with a proton pump inhibitor and oral antacids, however due to her persistent symptoms surgery was undertaken. the patient had laparoscopic repair of the diaphragmatic hernia. ports were as follows: 10 mm umbilical, 12 mm left upper quadrant, 5 mm right upper quadrant, 5 mm left iliac fossa. a left posterior diaphragmatic defect was found, just above the enlarged spleen, containing the incarcerated fundus of the stomach. the hernia was reduced by gradual dissection of the sac. a 15 9 15 cm nonabsorbable polypropylene mesh (proceed) was used to cover the defect a 4 cm margin. this was tacked in place with protack. a single 16 french robinson drain was left in situ. results: the procedure was uncomplicated. oral diet was introduced on post-operative day 1 and the drain was removed and patient discharged on day 4. there were no post-operative complications. conclusions: the video shows an effective dissection of a left sided diaphragmatic hernia and mesh repair, overcoming multiple technical challenges secondary to splenomegaly and portal hypertension. aims: creating laparoscopic anastomosis is a challenging surgical skill with high clinical relevance. to assure efficient training and enhanced learning curves, constructive and objective feedback is essential. currently there is no appropriate instrument to assess the surgical performance while creating laparoscopic anastomosis. the aim of this study is to develop and validate the anastomosis-objective structured assessment of technical skill (a-osats) score. methods: to obtain an international expert consensus for a procedure specific checklist (psc) for laparoscopic anastomosis, a modified delphi survey with an integrated analytic hierarchy process is currently being performed. each a-osats sub step is assigned a specific weight to determine its importance to the final outcome of the anastomosis. to validate the a-osats score, a laparoscopic side-to-side small bowl anastomosis with a linear stapler and hand-sewn closure of the enterotomy was chosen and is performed by surgeons with varying degrees of laparoscopic experience on a live porcine model. all performances are recorded and rated twice using the a-osats by two blinded experts. results: the final a-osats score includes a weighted psc developed by the modified delphi survey and the already validated global rating scale of previously published osats scores. four key steps (bowel placement, creation of enterotomies, stapling, closure of enterotomy) and sub steps, as well as their definitions, were established during the delphi survey. to validate the a-osats, 16 surgeons (4 experts, 9 intermediates, 3 novices) have participated in the study so far. preliminary results showed significant differences between all three levels of laparoscopic experience (novices: 73.6 ± 8.9; intermediates: 89.1 ± 8.7, experts: 110.2 ± 5.6; p \ 0.001) for the overall a-osats score as well as the psc itself (novices: 52.0 ± 7.8, intermediates: 63.4 ± 6.2, experts: 76.5 ± 4.6; p = 0.001). conclusions: the a-osats is a weighted score that objectively assesses surgical skill during the creation of laparoscopic anastomosis. preliminary results confirm construct validity of the proposed score. furthermore, by offering the possibility to differentiate single aspects during the procedure, the a-osats allows focused feedback to enhance one's performance. minor changes in weights are expected after the last round of the delphi survey. interand intrarater reliability will be assessed after final inclusion of all participants.aims: to apply augmented reality technology from three-dimensional colon models as preoperative planning method in colorectal surgery. method: from three-dimensional anatomical models of the colon we have developed holograms of augmented reality. the models were obtained from ct images (siemens somatom perspective 64ò) with abdominal image cuts with 1 mm thick. the recovery of the images was in dicom format and the processing to achieve the three-dimensional reconstruction was performed with the programs osirixò and horosò, which made a complete segmentation of the colon surface, and a modification of the image density. in this way models 3d were obtained of the isolated colon, and in relationship with the bone structure. the application colon 3d ar was designed (increased hyper experience-visualizer with slam technology) creating a hologram of augmented reality to scale 1:1 from each three dimensional model to make a projection of it on the abdomen of the patient by modifying the position in height of the reconstruction, using the bone pelvis as anatomic reference point to calibrate the placement of the hologram. results: in the preliminary phase (from october to december 2018) holograms of augmented reality were developed in 6 patients with colorectal cancer (right colon, left colon, transverse colon and rectum) to complement the radiological reconstruction with the virtual model. in the application phase (from january 2019) the holograms developed are going to be applied as a method to improve preoperative study. conclusions: three dimensional reconstruction of the tumor in the preoperative plan of colorrectal surgery combined with hyperreality technology allows to develop models of augmented reality in order to improve colon anatomy knowledge and to plan the surgical technique.aims: laparoscopic adrenalectomy has become the standard of care for most adrenal masses. we report a case of laparoscopic adrenalectomy for left adrenal adenoma. methods: we present the case of a 72-year-old caucasian female patient with an asymptomatic, left-sided adenoma, that was incidentally detected during abdominal ultrasound. no headaches, palpitations, tachycardia, tremor, dizziness or vomiting were reported. pre-operative blood tests confirmed that the tumor was a non-secreting one and a ct-scan revealed a 2.9 9 2.2 cm left adrenal mass. laparoscopic surgical excision was proposed. the patient was placed in semilateral right-sided decubitus position. four trocars (1 epigastric-10 mm & 3 subcostals-10 mm & 2 5 mm) were used, without the use of a liver retractor. the adrenal vessels were clipped not only with the standard laparoscopic clips, but also with the hem-o-lok ligation system. results: the operation lasted for 2 h with minimal blood loss. the patient's post-operative course was uneventful and she was finally discharged four days post-operatively. histology report ensured that it was adenoma of the adrenal cortex. aims: since the first laparoscopic adrenalectomy in 1992 (gagner), the laparoscopic lateral transabdominal approach has proved to be the one of choice. it provides an easy anatomical orientation, overall the technique is similar to other traditional laparoscopic procedures. on the other hand, the posterior retroperitoneoscopic adrenalectomy (pra), described in 1995 (waltz), has proven to be a safe technique and effective for the surgical management of several adrenal pathologies. the advantages include direct access to the adrenal gland, without the need for visceral mobilization or lysis of adhesions from previous abdominal operations and the ability to perform a bilateral adrenalectomy without repositioning the patient. currently there is controversy about which is the approach of choice, having to take into account the learning curve necessary for the retroperitoneal approach and the reduced number of patients with adrenal pathology subsidiary of surgical management. the objetive is to demonstrate the safety and efficacy of the standardized laparoscopic approach of the left adrenal gland with 3 trocars for selected cases. methods: clinical case: 43-year-old man, resistant hypertension despite concurrent use of three antihypertensive agents, with biochemical and radiological diagnosis of left adrenal adenoma with primary hyperaldosteronism. demonstrative video of the technical steps in a standardized way that we propose for laparoscopic left adrenalectomy only using 3 trocars. results: full laparoscopic surgical approach in right lateral decubitus position: 3 trocars-lateral transabdominal approach. steps: 1. laparoscopic liberation of the splenic flexure of the colon for the colo-spleen-pancreato-gastric en block mobilization until identification of the left pillar, 2. dissection of the medial border of the gland, identification of left renal and diaphragmatic vein, as well as the adrenal vein which is dissected and clipped, 3. dissection of the lateral edge of the adrenal gland, 4. lower pole dissection of the gland completing the resection with ligasureò. the patient presented a successful postoperative recovery, being discharged 24 h after the intervention. asymptomatic, the patient does not need antihypertensive drugs at 1 year follow-up. conclusion(s): the standardization of the procedure allows reducing the number of trocars, maintaining the safety and effectiveness of the minimally invasive approach. aims: cortical-sparing adrenalectomy is a suitable treatment for hereditary and sporadic bilateral pheochromocytoma, in cases of low risk of malignancy, to reduce the possibility of adrenal insufficiency assuming the chance of local recurrence. the aim of the study is to analyze the functional results of partial adrenalectomy by retroperitoneal endoscopic approach in singleadrenal patients or patients requiring bilateral adrenalectomy. methods: prospective study between january 2015 and october 2017 including pheochromocytoma patients diagnosed with low risk of malignant mutations. all patients agreed to be included in the study. experienced endocrine surgeons who have been trained in minimally invasive endocrine surgery performed the procedure using the same surgical technique. demographic variables and clinical characteristics were collected, subsequently carrying out the descriptive analysis of the data. results: a total of eight patients were registered, five associated with men type 2 syndrome and three in the context of vhl syndrome. retroperitoneoscopic resection was performed without laparoscopic or open conversion and no postoperative complications; the average hospital stay was 2.2 days. preservation of the functional cortex without corticosteroids was achieved in 7 (87.5%) of out 8 cases with a follow-up of 37.5 ± 4 months. today, these seven patients have a preserved adrenal function without hormone replacement. conclusions: cortical-sparing adrenalectomy by the retroperitoneal endoscopic approach, in expert hands, is safe and feasible for the treatment of hereditary and sporadic pheochromocytoma in a context of low malignancy, making it possible to avoid the need for corticoid replacement in most cases. biomedical sciences, university of west attica, athens, greece partial adrenalectomy has been suggested for patients benign adrenal tumors especially in the case of hereditary syndromes, like multiple endocrine neoplasia type 2, von hippel-lindau disease and neurofibromatosis type i. aims: this systematic review aimed to investigate the role of partial adrenalectomy in the treatment of hereditary pheochromocytoma. methods: electronic databases were searched with the search terms 'men ii', 'von hippel lindau', 'neurofibromatosis', 'laparoscopic partial adrenalectomy', 'robotic assisted partial adrenalectomy' for the time period up to and including december 2018. full publications, including clinical trials randomized or not, retrospective studies, case series, case reports that provided relevant data met inclusion criteria results: thirty five possibly relevant studies were identified. abstracts were reviewed and fourteen articles were excluded as they were review articles or articles presenting data on open partial adrenalectomy. twenty one studies, that met inclusion criteria were retrieved in full text and included in the systematic review. eight studies presented data on partial adrenalectomy in patients with von hippel lindau including two case series with median follow up ranging from 5 to 7.2 years and six case reports. thirteen studies presented data on partial adrenalectomy in patients with men ii, including two case series and eleven case reports. recurrence rate was estimated at about 10% for pheochromocytoma. overall steroid dependence rate was estimated at 90%. conclusion: minimally invasive partial adrenalectomy is a therapeutic option especially in patients with heritable pheochromocytoma, given that tumors are often bilateral, tumors are commonly benign and severe morbidity and mortality may be associated with life-long steroid replacement therapy such as the possibly lethal addisonian crisis . however, data are limited, follow up is not standardized and not appropriately reported and rcts are difficult to be done due to the rarity of the disease. a multinational registry on the short term and long term outcomes of partial adrenalectomy in hereditary pheochromocytoma would be a significant source of knowledge. results: patients were operated on after an average of 31 months with complaints. in both groups, the leading symptoms were severe dysphagia and severe regurgitation. no intraoperative complication was detected. in the transoral group, one patient had to be reoperated on for bleeding, another patient developed pneumonia in the transcervical group. the average duration of the surgeries (42.5 vs. 98 min, p \ 0,001), the time to oral feeding (2.9 vs. 4.6 days, p \ 0,001) and the mean hospital stay (7.3 vs. 9.7 days, p \ 0,001) were significantly shorter in the transoral group than the transcervical group. 15 patients were completely symptomless postoperatively. after transcervical treatment, complaints were developed in 2 cases (moderate dysphagia and hoarseness). after transoral surgery, recurrent symptoms were observed in 6 patients, 4 had to be reoperated transcervically due to severe regurgitation. conclusion: transoral stapler diverticulostomy is a fast procedure and offers short hospital stay especially in comorbid, aged patients and intermedium diverticulum size. in the long term, some of the patients may require reintervention due to persistent regurgitation. the transcervical approach has higher perioperative morbidity, which can be performed in patients with less than 3 cm or large diverticulum size. aims: complex hiatal hernias, either implicating large hiatal defects or concerning cases of recurrence, often need apart from the primary closure of the hiatal gap, the re-enforcement of the crura with the use of meshes. our aim is to demonstrate the surgical technique for the on-lay placement of the absorbable mesh (phasix tm st mesh /bard) in challenging cases, presenting both the laparoscopic and the robotic approach. methods: we present video fragments from procedures of laparoscopic and robotic reconstruction of complex hiatal hernias, performed by our team, in which an absorbable mesh was utilized in an on-lay fashion. results: patients having undergone a minimally invasive surgical approach (laparoscopic or robotic) for the treatment of complex hiatal hernias with the use of an absorbable mesh, had an uneventful post-operative course and very short hospital stay and recovery time. the 6-month follow up revealed no recurrences or late complications. conclusions: treating complex cases of hiatal hernias with a minimally invasive approach can be proven quite challenging, with high recurrences and possible complications rate. a proper surgical technique, either laparoscopic or better (based in our primary experience) robotic, by experienced surgical teams and the use of meshes with the right strategy, minimizes the complications, offers all the benefits of minimally invasive surgery and reduces the recurrence rates. aims: several flexible endoscopic techniques for symptomatic zenker's diverticulum have been developed during the last decade. thulium laser has limited tissue penetration and may decrease the risk of perforation. this study reports the first use of thulium laser through flexible endoscopy for cricopharyngeal (cp) myotomy. aims were safety and efficacy of flexible endoscopic thulium laser myotomy and quality of life (qol) changes after treatment. methods: a retrospective review of a prospectively collected database of 19 patients who underwent thulium laser septum division for symptomatic zenker's diverticulum was done. demographic data, presenting symptoms, diverticulum characteristics, and intraoperative data were analyzed. functional outcome swallowing scale (foss) and m.d. anderson dysphagia inventory (mdadi) questionnaires were administered to determine severity of dysphagia and its effect on qol, both preoperatively and during follow-up visits. all the operations were carried out under general anesthesia. a continuous laser configuration and an emissionpower of 9 w was used in non-contact mode. once the mucosa was opened, the fibers of the cricopharyngeal muscle were divided until the buccopharyngeal fascia was visibile. results: between march 2017 and september 2018, 19 patients (12 males) underwent flexible endoscopic cp myotomy with thulium laser. mean age was 72 ± 10.6, mostly males (68.4%). seven patients (36.8%) presented with recurrent diverticulum after previous transoral or open treatment. mean diverticulum size was 2.5 ± 0.8 cm. preoperative main symptoms were dysphagia (94.7%), regurgitation (68.4%), and cough (47.3%). foss score was = 2 in 12 patients (66.7%). mean mdadi global and composite score were 47.8 ± 25.8 and 59.7 ± 9.4. complete division of the septum was achieved in all patients. mean hospital stay was 2.83 ± 1.62 days. there was only one perforation treated conservatively. no 90-days mortality was observed. at median follow-up of 7 months, foss was = 2 in 1 (5.6%) patient and mdadi global and composite score were 90.0 ± 12.4 and 89.5 ± 7.7. all main symptoms were significantly reduced and qol significantly increased. conclusions: flexible endoscopic approach with thulium laser is a safe and effective treatment option for zenker's diverticulum either as a primary treatment or as a rescue therapy. objective: this study sought to explore prognostic factors for patients with borrmann type iv gastric cancer and to establish a predictive model for survival benefit of postoperative adjuvant chemotherapy in such patients. method: this study reviewed the clinical data of patients who underwent curative surgery at fujian medical university union hospital from 2006 to 2014 for borrmann type iv gastric cancer using a prospective database. cox regression analyses were performed to identify prognostic factors that formed the basis for a nomogram and risk groups. establishment of risk groups to identify patients with borrmann type iv gastric cancer who would benefit from adjuvant chemotherapy. results: 265 patients who underwent r0 resection were included in this study.multivariate analysis showed that bmi, tumour differentiation, pt stage, pn stage, and asa score were independent prognostic factors. patients in the act-group had longer os than patients in the sagroup, although the p-value for this difference was marginally above the threshold for statistical significance (23.8% vs. 10.9%, p = 0.057). stratified analysis showed that there was no significant difference in os between the act-group and the sa-group for each ajcc stage (stage ii: 40.6% vs. 29.8%, p = 0.44; stage iii: 21.4% vs. 9.7%, p = 0.056).a nomogram was established based on these independent risk factors, and nomogram scores were used to divide all patients into a high-risk group (score [ 16), an intermediate-risk group (8 \ score = 16) and a low-risk group (score = 8).further stratified analysis based on ajcc stage showed that the 3-year survival rate was higher in the adjuvant chemotherapy group than in the surgery alone group for low-and intermediate-risk patients in each ajcc stage, while high-risk patients in stage iii did not significantly differ. objective: this study sought to explore the prognostic factors for smoking patients with gastric cancer and to establish a predictive model for the survival benefit of postoperative adjuvant chemotherapy in such patients. methods: we studied 2081 patients who were diagnosed from september 2009 to september 2014 at union hospital of fujian medical university. cox regression analyses were performed to identify prognostic factors. the kaplan-meier method was used to assess the effect of smoking history on the benefit of adjuvant chemotherapy after gastric cancer surgery. a decision tree algorithm was used to identify smoking patients who benefited from postoperative adjuvant chemotherapy. results: the median follow-up time for the whole group was 42.5 months, and the average age of all the included patients was 61.5 years.multivariate analysis showed that age (p \ 0.001), bmi (p \ 0.001), degree of tumor cell differentiation (p \ 0.01), and ajcc stage (p \ 0.001) were independent risk factors for the prognosis of smoking patients. based on these independent risk factors, a decision tree model for the benefit of adjuvant chemotherapy for smokers with gastric cancer was established, and the smoking patients were divided into the low-risk patients 78 .7%), medium-risk patients (3year os, 51.3%) and high-risk patients (3year os, 28.4%) (p \ 0.001). conclusion: cigarette smoking may reduce the efficacy of adjuvant chemotherapy after gastric cancer surgery. our decision tree model is simple and effective for identifying smokers who would benefit from adjuvant chemotherapy. objective: our study investigated the effect of lymph node (ln) noncompliance on the longterm prognosis of patients after laparoscopic total gastrectomy (ltg) and explored the risk factors of ln noncompliance. methods: the clinicopathological data of gastric cancer (gc) patients who underwent ltg with d2 lymphadenectomy from june 2007 to december 2014 were prospectively collected and retrospectively analyzed. the effects of ln noncompliance on the long-term prognosis of patients with gc after ltg were explored. results: the overall ln noncompliance rate was 51.9%. ln noncompliance was significantly correlated with age, bmi, asa score, tumor size, macroscopic tumor type and tnm staging (p values \ 0.05). the survival rate of patients after ltg with ln compliance was significantly superior to that of patients with ln noncompliance (p = 0.013). the stratified analysis of tnm stage indicated that there was no difference between the os of stage i patients with ln compliance and those with ln noncompliance; os of stage ii/iii patients with ln compliance was significantly better than that of those with ln noncompliance. cox regression analyses showed that ln noncompliance was an independent risk factor for os. logistic regression analysis showed that high bmi ([ 25 kg/m 2 ) was an independent risk factor for preoperative prediction of ln noncompliance in cstage ii/iii patients. compared with patients with a low bmi (bmi \ 25 kg/m 2 ), those with a high bmi were more likely to show ln noncompliance during surgery, especially during the dissections of #6, #8a and #12a ln stations. conclusion: ln noncompliance was an independent risk factor for poor prognosis in patients with advanced gastric cancer (agc) after ltg. patients with high bmi were more likely to have ln noncompliance, especially during the dissections of #6, #8a and #12a ln stations. ln tracing was recommended for these patients to reduce the rate of ln noncompliance. aim: to study the differences in pathology, survival, and recurrence between special remnant gastric cancer (srgc) and nonspecial rgc (nrgc). method: a total of 366 rgc patients were analyzed in 7 hospitals in china from january 2003 to july 2015.we compared the 3-year overall survival (os) disease-free survival (dfs) rates and used two-step regression explore the influence of the rgc categories on patient outcomes. results: all of the patients divided into srgc group (group s) (n = 200) and nrgc group (group n) (n = 166). the r0 resection rate and lymph node (ln) dissection number of group s were significantly higher than group n (p \ 0.05). the difference in 3-year os was not significant (p = 0.282), but the 3-year dfs of group s was worse than group n (p = 0.042). twostep multivariate analyses showed nrgc was an independent risk factor for poor dfs. of the 225 patients who had undergone r0 resection, 74 patients (32.89%),suffered recurrence, and the recurrence rate of group s was significantly higher than group n (p = 0.039), moreover, the ln recurrence rate of group s was significantly higher than group n (p = 0.027). cox regression analysis showed that age, ca199 level, n stage and category of rgc were independent risk factors for rgc recurrence. conclusion: srgc has a higher r0 resection rate and ln dissection number than nrgc, but among patients who had undergone radical gastrectomy, srgc patients had worse dfs and a higher tendency for ln recurrence; thus, they should be treated differently in the clinic. objective: the aim of this study was to report our institution's experience with a novel abdominal negative pressure lavage-drainage system (anplds) for anastomotic leakage (al) after radical gastrectomy (rg) for gastric cancer (gc). background: al is a severe complication associated with high morbidity and mortality after rg for gc. the optimal creation of drainage in al patients after rg remains controversial. methods: the study enrolled 4173 patients who underwent r0 resection for gc at our institution between 2009 and 2016. anplds was routinely used for patients with al after january 2014. al rates and postoperative outcome were compared before and after the anplds therapy. we used multivariate analyses to evaluate clinicopathological and perioperative factors for associations with al and failure-to-rescue (ftr) after al. results: al occurred in 83 patients (83/4173, 2%), leading to 7 deaths. the al rate was similar before (2009-2013, period 1) and after (2014-2016, period 2) the implementation of anplds (1.7% vs 2.3%, p = 0.121). age and malnourished were independently associated with al. the ftr rate and abdominal bleeding rate after al occurred were respectively 8.4% and 9.6% for the entire period, but compared with period 1, it significantly decreased at period 2 (16.2% vs 2.2%, p = 0.041; 18.9% vs 2.2%, p = 0.020, respectively). what's more, only anplds therapy was an independent protective factor for ftr after al. conclusion: our experience demonstrates that anplds is feasible and cost-effective for the management of al after rg for gc. objective: to apply the principles of the 'metro-ticket' paradigm to develop a novel tnm staging system (ntnm) for gastric cancer (gc). background: the 'metro-ticket' prognostic tool for hepatocellular carcinoma has been proven to predict outcome, but a similar concept has not been investigated for gc. methods: the ntnm considered the distance from the origin on a cartesian plane incorporating the pn (x-axis) and pt (y-axis) stages. gc patients undergoing radical resection at fujian medical university union hospital (fmuuh) (n = 4267) were included. the ntnm was validated using 2 external cohorts from the sun yat-sen university cancer center (sysucc) (n = 1800) and surveillance, epidemiology, and end results (seer) (n = 3227) databases. results: ntnm classes with the same distance from the origin have same stage; the stage increases with this distance. among all patients, 48.0% (n = 2049) were restaged in the ntnm compared with the 7th edition of the ajcc-tnm classification; 26.2% (n = 1116) were downstaged in the ntnm compared with the 8th edition. the ntnm provides significant survival differences between stages (all p \ 0.001). the survival difference between stages ib and iia was especially large for the ntnm (p \ 0.001) compared to the 7th and 8th editions (p = 0.073). the concordance index and hazard ratio increased successively with the ntnm stage. similar findings were observed in both external cohorts. conclusion: compared with the ajcc-tnm classification, the 'metro-ticket' ntnm for gc is easier to remember and provides some improvements; therefore, the ntnm may be considered for adoption in future editions of the ajcc-tnm classification. objective: to investigate the prognostic value of complete blood count (cbc)-based biomarkers for patients with resectable gastric cancer (gc). methods: patients with gc who underwent curative resection between december 2008 to december 2013 were included. estimated area under the curve (auc) and multivariate cox regression models were used to identify the best cbc-based biomarker. time-dependent receiver operating characteristics (t-roc) analysis was used to compare the prognostic impact. results: based on multivariate analysis, the lymphocyte-monocyte ratio (lmr) and hemoglobin (hb) level were the independent prognostic factors (both p \ 0.05). based on the lmr and hb level, we established the cbc-based inflammatory score (cbcs). higher cbcs was associated with older age, female sex, higher american society of anesthesiologists (asa) score, proximal tumor location, larger tumor size, later stage and vascular involvement (all p \ 0.05). univariate analyses showed that higher cbcs was also associated with poorer overall survival (os), which was consistent in each stage (all p \ 0.05). multivariate analysis revealed that the cbcs was a significant independent biomarker (p \ 0.05). furthermore, t-roc curve of the cbcs was superior to that of the prognostic nutritional index (pni), systemic immune-inflammation index (sii), modified glasgow prognostic score (mgps) and c-reactive protein/albumin ratio (crp/ alb) throughout the observation period. conclusion: preoperative lmr and hb were optimal cbc-based biomarkers for predicting os in gc patients after curative resection. based on the lmr and hb, we developed a novel and easily obtainable prognostic score called the cbcs, which may improve the prediction of clinical outcomes. purpose: the aim of this study was to evaluate the prognostic value of the eighth ajcc tnm staging classification for patients with gastric cancer who had already survived for 5 years. patients and methods: patients who underwent radical gastrectomy at a large eastern center were considered. the prognostic value of staging systems were assessed and compared. additional external validation was performed using a dataset from the surveillance, epidemiology, and end result (seer) database. results: the 5-year overall survival (os) rate for patients in the training set was 59.4%. with the prolongation of the survival time after surgery, the 5-year os improved significantly (p \ 0.05). however, there were no significant differences in survival curves among patients who have survived 5 years after surgery. the auc and c2 of the eighth ajcc classification for predicting of 5-year os decreased gradually after surgery and appeared stable after 5 years. for patients who survived 5 years after surgery, we constructed a new tnm staging system (ntnm) according to the survival curves of t stage and n stage. a 2-step multivariate analysis showed that ntnm, age and sex were independent prognostic factors. the ntnm demonstrated superior prognostic stratification, with higher c-statistic and likelihood ratio chi-square scores and lower aic values than those of the ajcc classification. similar results were observed in the external validation set. conclusion: the ntnm predicted an additional survival more accurately than did the ajcc classification for patients who have survived 5 years after surgery; this may guide decisions regarding surveillance. objective: to investigate the relationship between preoperative sarcopenia and systemic inflammation and evaluate the prognostic impact of these factors on patients with resectable gastric cancer (gc). methods: patients with gc who underwent radical gastrectomy between december 2009 and december 2013 were included. a multivariate cox regression analysis was performed to identify the prognostic factors. a novel prognostic score (slmr) was developed based on preoperative sarcopenia and the lymphocyte-monocyte ratio (lmr), and its prognostic value was evaluated. results: in total, 1167 patients with resectable gc were included in the study. on multivariate analysis, preoperative sarcopenia and the lmr were shown to be independent prognostic factors (both p \ 0.001). a low lmr was an independent predictor from sarcopenia (p \ 0.001). based on preoperative sarcopenia and the lmr, we established the slmr. an elevated slmr was associated with older age, higher asa scores, larger tumor size, advanced stages and vascular invasion (all p \ 0.05). multivariate analysis revealed that the slmr was a significant independent predictor (p \ 0.001). we incorporated the slmr into a prognostic model that included tumor size and tnm stage and generated a nomogram, which accurately predicted 3-and 5-year survival for gc patients. objective: to explore whether adjuvant chemotherapy is still needed in patients aged less than 50 years with pt1n0-3 and pt2/3n0 gastric cancer. methods: multi-center cohort data of patients with gastric cancer who underwent radical gastrectomy were analyzed. kaplan-meier curves and cox regression were used to analyze the relationships between chemotherapy and prognosis. additionally, nomograms to predict the benefit of chemotherapy were established. results: in total, 1,432 patients with pt1n0-3 and pt2/3n0 gastric cancer were included. 217 patients (15.2%) were aged \ 50 years. the 5-year overall survival (os) was not significantly different between the \ 50 years of age group and = 50 years of age group (92.6% vs. 90.4%, respectively; p = 0.249). lymph node (ln) metastases (hr 5.054; p = 0.002) and ln dissection number \ 15 (hr 6.944; p \ 0.001) were independent risk factors for the os of patients aged \ 50 years. adjuvant chemotherapy did not improve the 5-year os for patients aged \ 50 years with pt1n0-3 and pt2/3n0 gastric cancer (p = 0.218). however, chemotherapy showed a significant benefit (p = 0.042) when there were ln metastases and/or ln dissection number was \ 15. two nomograms were constructed, and the calculated difference was the potential benefit of adjuvant chemotherapy for the patients aged \ 50 years. conclusions: ln metastases and ln dissection number \ 15 were independent prognostic risk factors of patients aged \ 50 years with pt1n0-3 and pt2/3n0 gastric cancer. patients with these risk factors may benefit from the addition of adjuvant chemotherapy. objective: the choice of reconstruction after distal gastrectomy remains controversial. we have performed roux-en-y (r-y) method after laparoscopic distal gastrectomy(ldg) as a standard since 2008, but we have performed billroth ii (b-ii) method in an increasing number of cases, depending on the patient. we retrospectively investigated the outcomes of patients with b-ii method after laparoscopic distal gastrectomy in our hospital. methods: patients who underwent b-ii and r-y reconstruction after ldg from january 2008 to december 2015 were included. the patient characteristics, surgical outcomes, and postoperative outcomes between the 2 procedures were retrospectively analyzed. we also compared extend of gastritis on endoscopy and loss of body weight after surgery at 1 year. results: b-ii / r-y :110/307. b-ii was selected in the elderly patients with poor asa-ps (p \ 0.001). in surgical outcomes, operative time was shorter for b-ii than r-y (p \ 0.001), and blood loss was also smaller (p = 0.023). in postoperative outcomes, there were significant differences in complications (?grade3) (b-ii vs. r-y: 0.9 vs. 6.8%, p = 0.013) and length of stay (b-ii vs. r-y: median 10.5 vs. 14-day, p \ 0.001). there was significant difference in presence of gastritis between b-ii (35.4%) and r-y (11.0%) (p \ 0.001), but no significant difference in loss of body weight (p = 0.105). conclusion: b-ii reconstruction may be an adequate procedure for high-risk cases because of its shorter operative time and the absence of severe complications. background: numerous studies have shown that the short-term efficacy of three-dimensional (3d) laparoscopic radical gastrectomy (lg) is comparable to that of two-dimensional (2d)-lg. whether 3d-lg affects the recurrence pattern after surgery has not been investigated. using data from a prospective clinical trial, the present study compares the recurrence patterns between 2d-lg and 3d-lg. methods: from january 2015 to april 2016, a total of 419 patients were recruited for the clinical trial (nct02327481). the recurrence types, the first recurrence time and recurrence-free survival (rfs) were compared between the two groups. multivariate analyses of factors associated with rfs were performed to identify whether 3d-lg affects the recurrence patterns. results: ultimately, 401 patients were analyzed (197 in the 2d-lg group and 204 in the 3d-lg group), and there were no differences in the clinicopathological data between the two groups. distant metastasis was the most common type of recurrence. there were no significant differences between the two groups in the recurrence types, the first recurrence time or rfs (all p [ 0.05). according to the 7th american joint committee on cancer tumor-node-metastasis (tnm) staging system, both groups were stratified into pathological (p) i, ii, and iii stages. the stratified analysis showed that there were no statistically significant differences in rfs between the 2d group and the 3d group among patients in each subgroup (all p [ 0.05). the multivariate analysis of rfs showed that pathological tnm (ptnm) stage and lymphovascular invasion were independent risk factors (all p \ 0.05). the multivariate analysis of post-recurrence survival (prs) showed that adjuvant chemotherapy was an independent protective factor (p = 0.043). conclusions: distant metastasis was the most common type of recurrence after lg. the postoperative recurrence patterns, rfs and prs after 3d-lg were similar to those after 2d-lg. purpose: the aim of this study is to evaluate the efficacy of delta-shaped anastomosis compared to circular stapler anastomosis in laparoscopic distal gastrectomy with billroth i reconstruction (ladg-bi). method: this is a single-center randomized controlled study. eligibility criteria included histologically proven gastric adenocarcinoma in the lower third of the stomach, clinical stage i tumor. patients were preoperatively randomized to circular stapler anastomosis or delta-shaped anastomosis. the primary endpoint is the number of analgesics use during 3 days after surgery. we compared the surgical outcomes of the two groups. postoperative qol was evaluated using the postgastrectomy syndrome assessment scale-45. this trial was registered at the umin clinical trials registry as umin000016496. results: between december 2016 and september 2018, 39 patients (delta-shaped anastomosis 18, circular stapler anastomosis 21) were enrolled. there was no difference in the number of analgesics use during 3 day after surgery (median 9: delta-shaped anastomosis vs. 7: circular stapler anastomosis, p = 0.91). there was no difference in the overall proportion with in-hospital grade ii-iiib surgical complications (11%: delta-shaped anastomosis, 14%: circular stapler anastomosis). there was no operation-related death in either arm. regarding postoperative qol evaluated 1 month after surgery, diarrhea subscale was significantly worse in delta-shaped anastomosis than in circular stapler anastomosis. conclusion: we did not demonstrate the advantage of delta-shaped anastomosis in terms of postoperative pain. since delta-shaped anastomosis tended to cause postoperative abdominal symptoms related to diarrhea, we should carefully apply the delta-shaped anastomosis to ladg. introduction: the use of a three-dimensional(3d) camera for laparoscopic surgery has been reported in literature. however, there are only few comparative studies demonstrating its benefits, and no reports on the application of 3d vision to single-incision laparoscopic surgery. this study aims to compare 3d vision to the previous two-dimensional(2d) system in solo single-incision laparoscopic distal gastrectomy(sidg). methods: medical charts of 179 gastric cancer patients who underwent solo sidg from february 2014 to december 2017 were retrospectively reviewed. patients were grouped into either 2d group or 3d group depending on the type of camera used. all the operations were performed by a single surgeon using a flexible camera(olympus, japan), fixed onto a passive scope holder without the use of a scopist or an assistant. operative data, postoperative outcome, and early complication were analyzed. results: ninety had their operations under 2d vision and 89 used the 3d scope. in both groups, there was no difference in age, body mass index, staging, and other demographic or histopathologic criteria. operative time was significantly faster in the 3d group(115.6 ± 34.0 vs. 129.4 ± 38.5 mins., p = 0.012) and ebl was also less(20.7 ± 30.0 vs. 35.1 ± 56.0 ml, p = 0.034). patients in the 3d group started small fluid diet faster(2.5 ± 0.9 vs. 3.0 ± 1.1 postoperative days, p = 0.006), and were discharged faster(4.4 ± 1.7 vs. 5.2 ± 3.1 postoperative days, p = 0.024). early complication was also less in the 3d group(2.2% vs. 6.7%) but there was no statistical significance(p = 0.140). conclusion: the use of the 3d camera improves operative outcome and hospital stay in patients undergoing solo sidg. the frequency of anastomotic leakage after gastrectomyreaches 7-8%. at the same time, mortality in this group of patients reaches 30%, and the use of aggressive methods of surgical treatment for the treatment of anastomotic leakage increases the mortality rate from 20 to 64%. since 2006, vacuum-assisted closure has been used to treat anastomotic leakage of various localizations. the essence of this method is based on the creating a local negative pressure, which is transmitted to the drip cavity through a special porous spongy system. the negative pressure created in the closed cavity, allows you to remove exudate, helps to reduce tissue swelling, improvesmicrocirculation, which in turn contributes to the development of granulations and wound healing with separation of the fistulous course. failures in using the method of vacuum therapy in anastomotic leakage are associated with the great difficulty of delivering a polyurethane sponge with a drainage tube to the leakage zone. in this regard, we have developed an improved method of endoscopic local vacuum therapy, in which the delivery of a polyurethane sponge was carried out with the help of a thread through a pharyngeal ring, a leakage zone and brought out through a drainage tube. this technique has been successfully used in the treatment of four patients with anastomotic leakage after operations on the upper part of the digestive tract. for complete healing of the cavity of the leakage and defect of the organ wall, it took 6, 9, 10 and 5 sessions of replacing the vac system, respectively (average 7.5 ± 2.4). there were no complications during the endoscopic local vacuum therapy. when the control endoscopic studies after 3 months after the completion of the treatment at the site of defects of the seams of the anastomoses formed tender scar tissue without signs of narrowing of the organ. aims: enhanced recovery after surgery pathways are safe and effective for patients undergoing gastrectomy. this study aimed to identify perioperative factors influencing the adherence to the protocol, the postoperative course, and the consequent length of stay. methods: between 2014 and 2017, 201 patients were referred to our institution for gastric cancer. among these, 21 patients underwent atypical gastric resection and were excluded from this analysis. 187 were assigned to either total or distal gastrectomy and represent the study population. all patients were managed with a standardised perioperative pathway according to eras principles. according to data from the literature and based on our clinical experience, patients with optimal adherence to eras protocol may fit the criteria for discharge within ninth postoperative day, that was considered our ideal threshold for hospital discharge. data were retrospectively collected and analysed from a prospectively maintained database. statistical analyses were performed using spss version 24 for macintosh. the v 2 test, with a significance level of 0.05, was used to investigate the association between the outcome and perioperative categorical variables. when parametric assumptions were met, student's two-tailed t-test was used to compare the means of continuous variables; otherwise, the mann-whitney test was performed. a significance level of 0.05 was chosen. logistic binary regression with a backward selection procedure and selection criteria of p-value \ 0.05 were exploited to determine significant predictors. results: 44 preoperative, intraoperative and early postoperative variables were considered. among all, multivariate regression analysis revealed that incomplete preoperative immunonutrition, failure to extubate the patient at the end of surgery, intraoperative crystalloids infusions [ 2150 ml and blood transfusion [ 268 ml, surgery duration [ 195 min, and failure to mobilise patients within 24 h from surgery were associated with delayed discharge. the logistic regression model was statistically significant (p \ 0.001) and correctly classified 73.6% of cases. sensitivity and specificity were 74.1% and 73.2%, respectively. conclusions: results seem to be clinically rational and focus the attention on the importance of some perioperative clinical issues for the management of postoperative course. these variables could be considered as clinical goals to be reached in order to get an early discharge. objectives: the purpose of this study is to confirm the safety of laparoscopic gastrectomy with intraperitoneal cisplatin administration as a treatment for advanced gastric cancer with potential for peritoneal seeding. methods: from july 2014 to august 2018, 56 patients with advanced gastric cancer who underwent ip chemotherapy after diagnostic laparoscopy were retrospectively studied. all patients underwent laparoscopic gastrectomy with ip chemotherapy or ip chemotherapy alone after a diagnostic laparoscopy. gastrectomy was performed for palliative purposes even with seeding. results: the average age of the patients was 56 years. eight patients (14.3%) had preop chemotherapy. curative resection (r0) was performed in 31 patients (55.4%). in diagnostic laparoscopy, cytology was performed in 38 patients (67.9%) and cy1 was 10 (26.3%). peritoneal metastasis was detected in 35 patients (62.5%). of the total cohort, the 2 year os rate was 54.5% and the median survival time was 19 months. in the case of stage iiib and below, the 2-year os rate was 83%, but it was 42% in stage iiic-iv group. when the r0 resection group and the r1-2 resection group were compared, the 2-year os rates were 70.7% and 26.7%, respectively. hematological toxicity such as neutropenia was not seen in all patients. the mean hospital stay was 8.2 days and adjuvant chemotherapy was performed in 35 patients (62.5%). background: radical proximal gastrectomy (pg) and lymph nodes dissection are indicated for selected gastric cancers at the upper third of the stomach. with the advent of laparoscopic surgeries, more and more pg were performed by laparoscopic apporaches. in the past 5 years, our team has accomplished and reported the oncological outcome of laparoscopic distal gastrectomies in 100 cases of clinical stage i gastric cancer in taiwan. through the evolution of surgical trechniques and team work, we have cruised the learning curve of laparoscopic gastrectomy and reconstruction. materials and methods: in this report,we would like to present our surgical experience of laparoscopic proximal gastrectomy for gastric cancer patients. from 2005 to 2018,192 pateints with gastric cancer underwent laparoscopic gastrectomies by the same surgical team at the national taiwan university. among them,six consecutive pateints (male:female = 3:3) with gastric adenocarcinoma of the upper stomach underwent laparoscopic pg in 2018. the demographics, dissection, reconstruction methods and peri-operative outcome are presented. all six patients tolerated the procedure well, onepatient had mild anastomotic stenosis and improved with one session of endoscopic dilatation. one patient needed temporary proton pump inhibitor for controlloing acid reflux. four of the 6 patients were pathological stage i, and the rest two pateint were stage iia and iiia disease. there was no tumor recurrence until now. summary: laparoscopic proximal gastrectomy is technically safe for treating upper third gastric cancers. the long term oncological outcome deserve further observation. introduction: open gastrectomy (og) has long been the preferred surgical approach worldwide for treatment of gastric cancer (gc). nowadays, several randomized, prospective trials have confirmed improvements in postoperative outcomes for laparoscopic gastrectomy (lg) compared to open procedures, with similar oncologic outcomes. however, most part of these studies comes from the eastern countries. material and methods: a prospective non randomized study was conducted with all patients operated of gc at ramón y cajal university hospital from january 2015 to december 2017. over 96 patients enrolled, 47 patients underwent lg and 49 og. textbook outcome was defined as the percentage of patients who underwent a complete tumour resection with at least 15 lymph nodes in the resected specimen and an uneventful postoperative course, without hospital readmission. results: a textbook outcome was achieved in 51.04% of patients operated of gc. the outcome parameter 'no severe postoperative complication' had the greatest negative impact on the textbook outcome. a statistically higher number of patients with early cancer (40% vs. 16.3%) and subtotal gastrectomy (57.5% vs. 34.7%) were found in the laparoscopic group. no statistically differences were found between open and laparoscopic approach regarding operating time, rate of microscopic margin positivity, hospital stay, number of retrieved lymph nodes, complications, reinterventions, mortality and readmissions. no statistical differences in textbook outcome were found between both groups (57.14% vs. 45%; p = 0.25). conclusions: laparoscopic gastrectomy for treatment of gastric cancer seems to be safe and feasible with similar textbook outcomes compared to open gastrectomy. introduction: laparoscopic surgery has been increasing for treatment of gastric cancer. however, standardization of this minimally invasive approach has not been reached yet because of its technical difficulties and the concern about oncological safety. the aim of the study was to analyze the outcomes of our learning curve in this complex surgical technique. material and methods: the first consecutive 100 cases of laparoscopic gastrectomy (lg) performed at our hospital from november 2008 to february 2018 were enrolled. patients were divided into two groups based on the period they were operated. training phase (tp) was considered between 2008 and 2014 (46 cases) and more-developed phase (mdp) between 2015 and 2018 (54 cases). conversion, lymphadenectomy and retrieved lymph nodes (ln), hospital length of stay, mean operative time, complications, reintervention and mortality rates were compared between the two phases of learning curve. results: the number of retrieved ln was higher in the mdp (17 ± 8,6 vs. 23,3 ± 10,4; p = 0,004). furthermore, we have also found less complications (47,8% vs. 27,8%; p = 0,038), a decreased reintervention rate (15,2% vs. 1,85%; p = 0,023) and overall mortality (8,7% vs. 0%; p = 0,003) in the mdp. there were no significant differences in conversion rate, mean operative time, and hospital length of stay between phases. conclusion: although we consider that our learning curve is not completed yet because the average of monitored parameters have not reached a steady state, the improvement on surgical parameters and postoperative course in the last two years have showed our results are near to the best results published in the literature. aims: lymph node (ln) dissection proves to be essential for oncological gastrectomy, given that the presence of ln metastases is very high, even for early gastric cancer (4.9% for t1a and 21.4% for t1b). this way, d2 dissection for advanced gastric cancer and d1 ? for early gastric cancer are the gold standard procedures. some teams are using indocyanine green (icg) lymphography to improve their ln dissections, claiming that this technique facilitates the harvesting of small fluorescent ln that, otherwise, would be difficult to identify by conventional laparoscopic methods. methods: we herein present the case of a 60-year-old man with a t1b distal gastric cancer. endoscopic ultrasound discarded the presence of metastatic ln and ct scan showed no distant metastases. icg was administrated endoscopically the day before the surgery, an amount of 6 mg was injected along the submucosal layer around the tumour. in the video we can see how we perform a laparoscopic distal gastrectomy with d1 ? ln dissection and roux-en-y reconstruction. icg lymphography helped us to complete our expected ln harvesting, especially for groups 6 (infrapyloric) and 7 (left gastric artery). thanks to this technique, we could resect ln that we might have obviate during a usual laparoscopic procedure. results: patient was discharged home on the sixth postoperative day without complications and with adequate oral tolerance. conclusions: we present a case in which we have performed a laparoscopic distal gastrectomy with d1 ? dissection and roux-en-y reconstruction. we used icg lymphography to help us to improve our ln harvesting. although it is soon to assess if this technique may increase the number of retrieved ln and in which stations might be more useful, we consider this is a harmless method that may help gastric teams to complete their expected ln dissections. introduction: gastrointestinal stromal tumor (gist) represents around 0.1% to 3% of gastrointestinal neoplasms, with the mesenchymal tumor being more frequent than the digestive one.the gist can be produced from the esophagus to the anus, at any point, being the stomach of (39 to 60%) and the small intestine (30 to 42%) more frequent sites.it is characterized by the expression of the tyrosine kinase growth factor receptor,cd117,differentiating it from other mesenchymal tumors,which do not express it.it is accepted that its origin corresponds to the interstitial cells of ramón y cajal,which act as a pacemaker for intestinal motility.they are very heterogeneous tumors, which vary in size,morphology and biological behavior,being neoplasms with uncertain malignant potential.the incidence is between the fourth and sixth decades,being the distribution by gender similar. clinical case: female patient of 70 years,who goes to the general surgery service,as interconsultation,after a veda,by dyspepsia.it is reported stomach:ceiling mucosa without alterations,at the level of the greater curvature is seen a tumor of 5 cm,hard to the touch with the biopsy forceps,slightly irregular covered with mucosa of normal appearance. computed tomography: stomach body:rounded image of nodular aspect which does not present heterogeneous enhancement after administration intravenous iodine contrast extending to peritoneal region, measures 44 x33x32 mm liver:hypodense image without heterogeneous enhancement adjacent to this,a 10 mm rounded image that is suggested to be studied with nmr. gadolinium nmr liver hypodense image with well-defined limits without heterogeneous enhancement of cystic aspect. gastric roof,heterogeneous formation,which enhances with gadolinium 37mmx38m-mx40 mm,having to discard a gist. surgical technique laparoscopic partial gastrectomy. pathological anatomy and immunohistochemistry 1.5 cm injury with net edges.uncertain malignant fusocellular nodule, cd117 ??? actin-dog1 ??? s100-no mitosis or invasion of the mucosa is observed. conclusion: a case of stomach gist is presented,which,the main symptom was dyspepsia,being the clinical presentation very variable,in relation to the place in which it is located. there is fletcher criteria for the risk of malignancy,this being less than 1.5 cm,very low risk,less than 2 cm, the patient evolved favorably,without surgical complications.aims: to present the surgical procedure of resection of the lesser gastric curvature and its pedicle with laparoscopic surgery, fulfilling oncological criteria, carried out in the general surgery service of the hospital of torrecárdenas. methods: an 85-year-old man with prostate cancer treated with complete hormonal block and epoc, who consults for rectal bleeding of 1 week of evolution. it is diagnosed of gist in gastric lesser curvature, 9 x 8 x 11 cm, very vascularized and infiltrates the wall producing marked imprint on the fundus. it is tributary of left gastric artery. precise blood transfusion and presents hemodynamic stability, is decided surgical resection scheduled. results: the surgery is performed by laparoscopy, with a tumor of approximately 10 cm, which is dependent on the lesser curvature. the esophageal hiatus and the lesser curvature are dissected with section of the left gastric pedicle. atypical gastrectomy of the lesser curvature including gist, making a gastric sleeve dependent on the greater curvature. the anatomopathological study reports pt4 pn0 with 22 lymph nodes without adenopathies, and disease-free surgical margins. he was discharged without complications on the 6th day and did not require re-entry. conclusions: the laparoscopy surgery for atypical gastrectomy of lesser curvature is safe and meets oncological criteria in selected patients and performed by an experienced esophagogastric unit. aims: to present the surgical procedure of total gastrectomy with d2 lymphadenectomy with laparoscopic surgery, fulfilling oncological criteria, carried out in the general surgery service of the hospital of torrecárdenas. methods: a 35-year-old male with a tobacco habit who consults due to epigastric pain and constitutional syndrome of 6 months of evolution. it is diagnosed of gastric adenocarcinoma t3n2m0. neoadjuvant qt is decided, after 4 weeks of its completion, scheduled surgery is performed. results: the surgery is performed by laparoscopy, showing a stenosing tumor in at gastric antrum of approximately 8 cm. dissection of the greater curvature with section of the right gastroepiploic at its birth and duodenal section is performed. dissection of the lesser curvature with d2 lymphadenectomy, section of the pedicle of the left gastric and the distal esophagus. the transit is restored with latero-lateral esophageal-jejunal anastomosis and jejunojejunostomy. the anatomopathological study reports ypt4a and pn2 with 3/36 adenopathies, and disease-free surgical margins. he was discharged without complications on the 7th day and did not require reentry. conclusions: the laparoscopy surgery for total gastrectomy with complete d2 lymphadenectomy is safe and meets oncological criteria in selected patients and performed by an experienced esophagogastric unit. background: in gastric cancer surgery, to secure surgical margin, it is necessary to accurately judge the position of the tumor. however, with conventional marking clips, it is difficult to identify the exact location of the tumor during laparoscopic surgery. purpose: we investigate whether icg (indocyanine green) fluorescence navigation method is effective and safe for determination of cutting line in laparoscopic gastrectomy. patients and methods: 428 subjects underwent laparoscopic gastrectomy (including robot-assisted surgery) based on the icg method for gastric cancer in the period from april 2017 to december 2018. the day before surgery, icg diluted 50 times (0.2 ml of reagent ? 9.8 ml of distilled water) was injected at 1 cm from the tumor edge and 0.5 ml at the four submucosal layers around. then clip to the same part. gastrectomy based on standard surgery is performed, and the position of the tumor and spread of icg are confirmed by icg fluorescence navigation during operation, and a cutting line is determined. the extent of icg from the tumor is again measured with the excised specimen and compared with the pathological margin. results: among the patients who underwent intraoperative pathological examination, they were negative in all cases except one. the spread of icg was 2.5 cm on average, and considering the marking position (1 cm) from the tumor edge, securing of 3.5 cm or more was possible. the operation time was 230.0 ± 92.7 min and the estimated bleeding loss was 24.6 ± 120.9 ml. conclusion: laparoscopic gastrectomy with icg method can evaluate tumor position and spread easily and in real time during operation and it was effective for determining the cutting line in laparoscopic gastrectomy. epstein-barr virus (ebv) has been known as one of causal virus of gastric cancer. ebv-related gastric cancer considered to be about 10% of the entire gastric cancer, and it is rare that ebvrelated gastric cancer has multiple lesions. the patient was 60 years old female. she was diagnosed with upper gastrointestinal endoscopy with lesion in the lower major stomach body, lower anterior wall of the stomach body, rear wall in the middle part of the stomach, rear wall in the middle part of the stomach, and lesser curvature of the stomach angle, as a result of biopsy, adenocarcinoma was observed from the former four. the patient underwent a robot-assisted total gastrectomy. adding a newly found lesion, the histopathological diagnosis was pt1b in the lower major stomach body, pt1b in the lower anterior wall of the stomach body, pt1b on rear wall in the middle part of the stomach, pt1b on rear wall in the middle part of the stomach, and pt1a in lesser stomach body, pn0, pstageia. pathological examination results showed that the four lesions were positive for tumor cells in eber in situ hybridization and were considered to be ebv-related gastric cancers. she was discharged on the 12th day after the operation without any postoperative morbidities.there has been no sign of recurrence without postoperative therapy for 12 months. results: a 35-year-old female with no medical history of interest or allergies to medications, who consulted for palpable mass at mesogastric level to the left of the midline associated with abdominal pain of 3-6 months of evolution, without concomitants or relationship with the intake, valsalva or physical efforts, without change in the depositional habit or toxic syndrome. the abdominal ct (computed tomography) revealed a cystic mass in jejunum mesentery, defined edges, about 6 cm in diameter and that does not capture contrast; likewise, there is no ascites, retroperitoneal adenopathies or other intra-abdominal or pelvic masses, radiology recommends completing the study with abdominal mri (magnetic resonance imaging) that informs of possible lymphangioma at the level of the jejune mesentery. surgical exeresis was decided, which was carried out by laparoscopic approach, with emptying of the lesion and enucleation of the lesion without incidents, the postoperative evolution was favorable being discharged at 48 h. the pathological anatomy reported fibro-adipose tissue with presence of lymphatic dilatations associated with a cystic lesion without epithelial lining, with serous fluid and abundant macrophagic reaction compatible with mesenteric lymphangioma. conclusions: the mesenteric cyst is a rare pathology with an incidence ranging from 1 / 27,000 to 1 / 250,000, predominating in the fourth decade of life. it is defined as any cystic lesion in the mesentery, and is subdivided according to its origin into lymphatic, mesothelial, urogenital, dermoid, and enteric and pseudocysts. most of the time they are asymptomatic although they can (as in our case) present with abdominal pain and even produce complications such as intestinal obstruction, volvulus, intracystic hemorrhage, infection, rupture, and even malignant transformation. for the diagnosis, the palpation can be of great help, showing mass of well-defined limits and partially mobile. the imaging test of choice is abdominal ultrasound / abdominal ct, supplemented by magnetic resonance imaging. the recommended treatment is surgical exeresis, considering laparoscopy as the first option; if it is complete, it can be considered as a curative treatment. purpose: gastrostomy(og) is an alternative method for nutrition support, especial for the patients with oral-esophagus route obstruction or dysfunction. the most operation were conducted by young surgeon or residents. laparoscopic gastrostomy(lg) was a new coming procedure and the skillful suture techniques were needed. the most the residents can't be qualified for this operation. we designed the method for laparoscopic gastrostomy to provide the traning opportunity of suture skill training and guarantee the patient's safety. material and method: laparoscopic gastrostomy procedure was done with two 5 mm trocar. the lower body of stomach was chose. four point around gastrostomy wound were chose for subcutaneous fixation. the straight needle with 2-0 prolene was inserted into peritoneal cavity from upper point, then punctured the sero-muscular layer of stomach. the needle was retrieved out from the same point by guidance of 18 gauge needle. the same way was used for other three points. one purse string around gastrostomy was created by one hand suture method and fastened by köckerling knot tier after insertion of 20 fr foley tube. finally, the peritonization was finished by hand tie externally and knot were keep in subcutaneous layer material-method: we present the case of a 85 year old woman who presented with melena, hematemesis, anemia (ht 12.5%) and being haemodynamically unstable. after the stabilization of the patient, a gastroscopic examination followed, where it revealed a tumor of the fundus (adenocarcinoma). the patient was submitted to laparoscopic total gastrectomy and oesophagojejunal anastomosis, omega type (o), and intestinal anastomosis braun, with the usage of 3 trocars (umbilical 10 mm as inserted in laparoscopic surgery of a single incision, and two 12 mm in the midclavicular line bilaterally). the oesophagojejunal anastomosis was conducted with the use of a linear stapler for the posterior wall and the convergence of the anterior wall with laparoscopic sutures in two layers. patient remains in well condition, 6 months after the operation. conclusion: laparoscopic approach seems to be safe for treatment of gastric cancer of the fundus and of the gastroesophangeal junction, as it offers better surgical field view and less postoperative complications. the restoration of the continuity of the gastrointestinal tube with anastomosis of w type is considered safe alternative to the classic roux-en-y anastomosis. git and bariatric surgery, faculty of medicine, alexandria university, alexandria, egypt; 2 git surgery, faculty of medicine, alexandria, egypt background: superior mesenteric artery syndrome is best described as compression of the third part of duodenum by the superior mesenteric artery, resulting in obstruction. the study of this rare medical condition was carried out since decades yet remain obscure. this study aimed to analyze different clinical presentations, diagnostic modalities, treatment approaches and outcomes, as well as to emphasize the importance of long term follow up. methods: thirty-five superior mesenteric artery syndrome cases were collected retrospectively from a facebook group called 'superior mesenteric artery syndrome awareness & support'. a questionnaire was designed using google form to obtain the demographics, presenting symptoms, risk factors and co-morbidities, investigations, means of treatment and the outcomes. data was entered into microsoft office excel for statistical analysis. results: the median age at diagnosis was 22 years. the median body mass index was 20.8 kg/ m 2 ;. the median time interval from symptom onset to initial diagnosis was 22 months. the major presenting symptoms were abdominal pain (82.86%), nausea (77.14%), and vomiting (65.71%). abdominal computed tomography scan with contrast (82.86%) was commonly used for confirmation of diagnosis. thirteen cases (37.14%) were congenital. thirty patients (85.71%) had received treatment. the overall management success was only 13.33%. surgical management (34.29%) was the most used regimen. conclusion: diagnosis of superior mesenteric artery syndrome is established after a thorough assessment of the clinical presentations and confirmation with suitable imaging modalities. the choice of treatment should be dependent on the causes and severity as different patients respond differently to therapy. recurrence is possible in all patients thus a long-term follow up is required. aims: in the last hundred years much has been written on peptic ulcer disease and the treatment options for one of its most common complications: perforation. laparoscopic repair of perforated peptic ulcer has been gaining popularity in recent years. treatment for perforated ulcer can be performed laparoscopically in 85% of cases, making it possible to avoid a median laparotomy which can lead to wound infection and late eventration. methods: a 77-year-old male presented to emergency room with a three-hour history of progressively worsening epigastric pain and nausea. physical examination revealed rebound tenderness compatible with an acute abdomen. a ct scan showed: important pneumoperitoneum unable to define the drilling point; distended stomach with plenty of fluid inside and dense content fundus / body suggestive of active arterial bleeding . results: the patient was emergently taken to the operating room for diagnostic laparoscopy . perforation shown in greater gastric curvature associated blood remnants. gastrotomy for clot removal is done without observing active bleeding. the gastrotomy was repaired using standard stitches. all exudate was aspirated and the peritoneal cavity was irrigated with warm saline solution the patient had an uncomplicated post-operative course. jp drain was removed and he was discharged one week after surgery. conclusion: the role of laparoscopic surgery in emergencies is well documented. laparoscopic approach is indicated in any case of suspected gastroduodenal perforation and seems to offer the same advantages as for the vast majority of laparoscopic procedures. laparoscopic surgery may therefore have a real place in the treatment of perforated peptic ulcer. the aim: of our study was to evaluate of effectiveness of local injection of platelet-rich plasma for treatment of peptic ulcer bleeding with hemorrhagic shock in experiment. methods: the study was performed on 60 wistar rats according to local and international rules for working with experimental animals. the average weight of animals was 183 ± 16 grams. in all animals our modification of type 2 acetic acid ulcer (susumu okabe, 2005) was modeled. we randomly divide all animals in 3 groups. 20 rats with only modeled ulcer were included in group 1. 20 rats with modeled ulcer and hemorrhagic shock after 3-3.5 ml blood sampling were included in group 2. in group 3 we included 20 rats with modeled ulcer and hemorrhagic shock and performed local injection of platelet-rich plasma (local periulcelar injection of 0.1 ml of autologous platelet-rich plasma). on 1st, 7th and 14th day measurement of the ulcers square and morphological study were performed. results: the data we have received demonstrate a tendency of decrease of ulcers' square in all groups with time flow. we also compared sizes of ulcerative defects in all groups at every point of the study. on the 1 st day of investigation there were no differences (p [ 0.05) between ulcers' square in all groups. on the 7 th day we found out more rapid decrease of size in group 3 (p [ 0.05). however, this tendency had no statistical significance. on the 14th day difference was larger and it was statistically significant this time (p \ 0.01). also the better ability to stimulate the activity of fibroblasts and revascularization in the young connective tissue with improving oxygenation in the ulcers and enhancing of cell proliferation, differentiation and accelerating of maturation of connective tissue and healing of ulcers was demonstrated in group 3. conclusion: platelet rich plasma reduces inflammatory response and stimulates proliferation of gastric epithelial cells on 7 th day with the restoration of secretory activity and epithelialization of ulcers in 71.4% of experimental animals on 14 th day, the activation of the fibroblastic reaction during the all experiment and decreasing of ulcers' square. h. fujii, depat. of surgery, japanese red cross fukui hospital, fukui, japan introduction: in conjunction with charmant, a local eyeglass frame manufacturer, we developed novel devices called the fj (free jaw) clip to grasp organs in the abdominal cavity and the f (free) loop plus to pull thread extracorporeally from within the abdominal cavity. product summary: the fj clip is used to grasp organs in the abdominal cavity, a stainless steel, removable forceps for use in laparoscopic surgery. it provides a strong grip but rarely crushes organ tissue. the clip comes in two sizes, one for use in a 5-mm port and the other for use in a 12-mm port, and in two lengths, 29.4 mm and 35.6 mm, respectively. to pull out thread tied to the fj clip, we developed the f loop plus, which is a 21g by 90-mm-long special stainless needle with f0.1-mm niti alloy thread which is used pull suture threads from inside the abdominal cavity to outside the body. case: we performed 9 cases of reduced port laparoscopic and endoscopic cooperative surgery (lecs). we performed reduced port surgery (rps) by making a 1.5-cm incision at the umbilicus, inserting 2 trocars (12 mm and 5 mm), and inserting another trocar (5 mm) at the left side of the abdomen. we expanded the left hepatic lobe with a 12-mm fj clip for penrose drain placement, grasped the front wall of the gastric body with a 12-mm fj clip, applying traction toward the legs to pull up the tissues around the tumor, and resected all layers of the tumor via oral endoscopic submucosal dissection technique. the resected area was closed with a suturing device or interrupted sutures in the abdominal cavity. a 75 year-old female was admitted to the emergency department with complaints of abdominal cramping pain, back pain and diarrhea for one day. she also had fever, ever up to 39°. in these two weeks, she felt occasionally epigastric pain. her past medical history included hypertension. on physical examination, she was conscious and alert. abdominal examination revealed diffuse tenderness and knocking pain over right flank. laboratory tests indicated an degraded white cell count of 2890/cumm with 22% band forms, c-reactive protein of 25 mg/dl and abdominal liver function tests (alanine aminotransferase: 149 u/l, alkaline phosphatase: 249 u/l, gammaglutamyl transferase: 175 u/l) without hyperbilirubinemia. abdominal x-ray showed paralytic ileus. our presumptive diagnosis was acute peritonitis, based on the patient's symptoms. empirical antibiotics were administered immediately, and a computed tomography (ct) imaging study was performed. the ct scan showed a stick like foreign body noted between ventral side of pylorus and smv lumen, about 1.5 cm in length and associated with perifocal infiltration and segmental smv thrombus formation. (fig. 1) however, there is no obvious pneumoperitoneum and no evident ascites is associated. an emergency exploratory laparotomy was performed, revealing stomach perforation at posterior wall with a 3 cm fish bone thourgh pancreas into smv. localized inflammation and fibrosis were identified without obvious fluid accumulation( fig. 2 -4) . removal of fish bone and simple closure of stomach perforation were performed. blood cultures revealed bacteroides thetaiotaomicron. three weeks later, she received a follow-up ct scan which showed smv obliteration with chronic pylephlebitis. aim: here we present a case report about the endoscopic treatment for iatrogenic gastric perforation secondary to a chest tube insertion. methods: a case report of a 24-year-old male with history of a road traffic accident. described injuries were severe brain injury with gcs \ 8 at pre-hospital care arrival, thoracic injury with several rib fractures on the left hemithorax and hypoventilation on the left side. prior to hospital transfer a chest drain was inserted on the left side, and the patient was intubated. results: at hospital admission, the patient was hemodynamically stable and connected to a mechanical ventilator. thoracic exam showed persistent hypoventilation on the left chest. no other abdominal or pelvic injuries were found in the physical exam. a frontal chest x-ray revealed pneumothorax and the chest tube was not viewable. a further ct scan showed the chest drain placed in the abdominal cavity, into the stomach, besides a subdural hematoma, comminuted pelvic fracture of the pubic rami and a left sacroiliac fracture. during the first 24 h in the icu, neurological worsening was observed, and a new cranial ct revealed enlargement of the subdural hematoma, for what the patient underwent decompressive craniectomy, with improvement thereafter. following a five-day period of stabilization after surgery, the patient was evolving satisfactorily, and the removal of the intragastric chest drain was considered. endoscopy was performed to confirm the placement of the drain, and it was removed under direct vision. approximately twenty five centimeters of the catheter were visualized in the gastric lumen, and then successfully removed. the patient recovered well and was discharged from icu to medical hospital ward after fourteen days, and a week later he was discharged home. conclusion: endoscopic management for gastric perforation after a chest drain insertion may result effective and can prevent open surgery morbidity. aims: intestinal infusion treatment with levodopa/carbidopa (duodopa) is a therapeutic option concerning the advanced parkinson disease cases with no response to the conventional treatment. the drug requires carrying out a gastrostomy either by percutaneous endoscopy way, or by laparoscopy -if the first one is not possible-. later, a duodenum-yeyunum tube is placed in order to infuse the duodopa gel continuously by a portable bomb. in this report, we explain the laparoscopic gastrostomy technique. method: sin this report, we include two patients with advanced parkinson disease: the first one is a 61 year-old female patient suffering from an important gait disorder; and the second one is a 71 year-old male patient with uncontrolled motor fluctuations. in both cases, a percutaneous endoscopic gastrostomy was proposed, but neither was feasible because of the non-traslumination between the gastric and the abdominal wall. under general anesthesia, neumoperitoneum by veress needle was performed. three main trocars and one accessory were placed. at the level of the gastric antrum, a 1 cm incision was conducted to insert a gastrostomy tube, to be the guide for the drug infusion catheter. next, the gastrostomy is fixed to the abdominal wall by the stamm technique, externalizing the catheter through the accessory trocar in the medial line. results: on the first post-operative day, a duodenum-yeyunum tube is placed by endoscopic control through the gastric device. both patients got well satisfactorily, and no complications were described; and they develop a total normal life within the limitations of their underlying disease. conclusions: the duodopa intestinal infusion shows a significative improvement for the advanced parkinson disease symptoms, compared with oral medication; appreciating positive results referring to life quality. when the catheter placement by endoscopy way does not seem posible, gastrostomy by laparoscopy constitutes a valuable surgical option for the treatment of this kind of patients. peptic perforated ulcus (ppu) is a common surgical emergency and laparoscopic repair has been introduced as an alternative to open repair. it has shown good results and allows closure and peritoneal lavage, just like the open repair does but with the advantages of a minimally invasive surgery. the objective is to report the outcome of laparoscopic ppu in our hospital. methods: from january 2015 to october 2018, 16 patients with a clinical diagnosis of ppu were assigned to undergo laparoscopic repair. this retrospective study included all husm patients who underwent laparoscopic ppu repair by emergency surgeons. minimum follow-up of 3 months is carried out. results: of the 16 patients in this series, 70% were men and 30% were women, between 15 and 80 years of age at the time of surgery, average of 48 years. the time between the manifestation of symptoms and surgery was [ to 24 h in 70% of patients. in 6 patients there was a history of previous ulcer or non-steroidal anti-inflammatories intake and up to 50% were smokers. a ct scan was performed in all cases to reach the diagnosis primary closure with simple suture plus omental patch was the elected technic (90%). the approach was performed with 3 trocars in 44%, 4 trocars in 50% and 5 in 1 case. 13 cases (81%) were gastric ulcer, 2 duodenal cases (13%) and in one case no perforation was found. the conversion rate was 19%, in two cases due to technical difficulty and in the other case because the level of the perforation was not found. the median postoperative stay was 7 days although there were 2 cases with intrabdominal complications. there was an exitus due to a metastasic pulmonary neoplasia diagnosed in the immediate postoperative period. there were no cases of recurrence in the follow-up time. conclusion: in most centers, including ours, the rate of laparoscopic management has gradually increased along with the improvement of technical skills. improvements in the outcome of laparoscopic ppu repair are to be expected with more experience surgeon and a good selection of the cases. general surgery, jzu hospital ,,sveti vracevi,, bijeljina, bosnia-herzegovina introduction: diverticulum is an outpouching of a hollow organ. gastric diverticulum is rare form od this disease. incidence of detection varies depending on investigation method. it has been reported in 0.02% cases of autopsies, 0.04% cases of gastroduodenal roentgenographies with contrast, and 0.01-0.11% cases of upper endoscopies.small diverticula are usually asimptomatic, but bigger diverticula can cause variable symptoms such as abdominal pain, feeling of epigastric fullness right after meal, feeling of discomfort in upper parts of abdomen, and severe 'foetor ex ore' .diagnosis is usually established in procedures such as gastroduodenal roentgenographies with contrast, upper endoscopies and abdominal ct scan. case report: a 57-year-old woman came to our hospital because of feeling of discomfort and mild pain in upper abdomen that lasted for last year. diagnosis is established after ct scan of abdomen and upper endoscopy procedure. initially she has been prescribed conservative therapy (proton pump inhibitors). since the symptoms persisted, laparoscopic resection of the gastric divertuculum was performed using endogia stapler. considering the feeling of discomfort and abdominal pain dissapeared, the patient was discharged from hospital on the fourth postoperative day. conclusion: asymptomatic gastric diverticula doesn't require treatment. since gastric diverticulum can have complications such as bleeding, perforation and neoplasia, patient without symptoms should be monitored. initial therapy for symptomatic diverticula is conservative therapy (proton pump inhibitors). if conserative therapy doesn't procude expected results, laparoscopic resection of the diverticulum should be considered. introduction: the acute perforation of a gastric ulcer is a serious entity that requires urgent surgical treatment in most of the occasions, it is increasingly accepted that the approach of choice is laparoscopic, depending, above all, on the time of evolution of the process. objectives: to demonstrate the safety and efficacy of the laparoscopic approach in the perforation of a pyloric peptic ulcer, even in cases of severe peritonitis, by means of a standardized procedure, insisting on the sequential thorough washing of the cavity.material and methods: we present a video of the surgical intervention of a patient with acute abdomen, with a history of nsaid ingestion, exploration and ct-analysis compatible with perforation of hollow viscus, probably of gastric origin. results: intervention: complete laparoscopic approach, 4 trocars. severe biliopurunitic peritonitis, by pyloric perforation 'acute', liquid culture, suture of the perforation, epipoplasty, sequential thorough washing of the cavity with physiological saline and placement of drainages.correct postoperative period, discharge from the hospital on the 7th day after completing antibiotic treatment. endoscopy and helycobacter test are performed on an outpatient basis with normal results. conclusion: the laparoscopic approach is safe and effective in acute and complicated gastric ulcer disease, even in cases of severe peritonitis. surgical procedure: the clean-net procedure involves the selective dissection of both the serosa and muscle layer using a laparoscopic monopolar endoscopic scissor. the preserved mucosal layer provides a mechanical barrier between the gastric lumen and peritoneal cavity that aids in the prevention of peritoneal cavity contamination with gastric contents. tumors are observed with an upper gastrointestinal endoscope with the injection of indocyanine green (icg) into peri-tumoral submucosal layers at 4 points. selective seromuscular dissection is performed using a laparoscopic electrocautery monopolar scissor. the mucosa surrounding the gist is then resected using a endoscopic mechanical stapler to prevent exposure of the gastric lumen to the peritoneal cavity and peritoneal tumor cell seeding. results: there were 5 males and 1 female, and the average age was 65 years. the operation time was 186 min, the average bleeding volume was 14.6 ml, the postoperative hospital stay was 7.8 days. the mean tumor diameter was 32.3 mm, the final histopathological diagnosis was 5 gist, 1 schwannoma. there were no postoperative complications of clavien-dindo classification 2 or more. conclusion: clean-net was found to be safe and useful for the treatment of gastric smt with ulceration. year outcomes: laparoscopic heller myotomy stands the test of time aims: laparoscopic cardiomyotomy leads to excellent relief of dysphagia in 95% of patients and avoids thoracotomy or laparotomy. methods: we present a video illustration of the procedure that was modified at the american university of beirut medical center. so far, 129 patients underwent laparoscopic cardiomyotomy, age range of 14 to 76 years, with 56 males and 73 females. most of them have had previous balloon dilatation. results: all cases were successfully completed laparoscopically without complications. followup of 2 months to 15 years revealed excellent results with complete resolution of symptoms and no need for further medications. this will result in minimal post-operative pain and very short recovery period and is associated with low complication rate. conclusion: cardiomyotomy for achalasia is ideal for laparoscopic approach. magnification allows for precise division of muscle fibers. the new technique of hydro dissection and enseal for division of esophageal muscle allows for completion of the procedure without injury of the mucosa. therefore, adequate release of the obstructing segment followed by anti reflux procedure toupet will lead to excellent results with minimal morbidity and no mortality. aims: laparoscopic repair of huge hiatus hernia methods: twenty two cases of huge hiatus hernia presented to the american university of beirut medical center. patients underwent through 5 trocars in the upper abdomen reduction of the hernial sac from the chest. special care was taken in the dissection of the mediastinum to keep the thoracic fascia and pleura intact. the defect was sutured primarily by 0-ethibond sutures reinforced by onlay prolene mesh u-shaped was fixed at the rt. and lt. crus and a floppy nissen fundoplication performed . results: the video presentation includes the technical aspects and the method of reducing and repair of huge hiatus hernia.aim: nowadays, there is little experience in the world of applying robotic surgical system (rss) in treatment of patients with hiatal hernia (hh) and reflux-esophagitis (re). the aim of study was to determine the possibility and feasibility of using rss in treatment of patients with hh. materials and methods: a total of 41 patients underwent robot-assisted hh repair without mesh, followed by fundoplication with our original method (360°full symmetric wrap). the clinical and technical analysis did not reveal any advantages over similar laparoscopic procedures, so we abandoned the use of rss for hh type i, and these 4 patients were excluded. there were 32(86%) patients with hh type iii and 5(14%) type iv. the surgeries were performed by experienced robotic upper gastrointestinal surgeon and conducted with the davinci si surgical system (intuitive surgical, sunnyvale, ca). results: average operation time was 118 ± 37 (62-173) min. the respondents' mean age was 56.2 ± 10.9 years (range 29-68) and bmi was 30.8 ± 7.1 (range 17.1-44.3) cm/kg 2 . average blood loss was 20 ± 9 (5-70) ml. average hospital stay was 5 ± 1.3 (1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) (12) (13) (14) (15) days. the average follow-up time was 14 ± 3.6 (6-24) months. postoperative x-ray imaging and upper gi endoscopy was conducted in all 37 (100%) patients. there was no hh recurrence diagnosed. we did not observe a relapse of hh or clinical manifestations of re in the early (less than 30 days) and long-term (more than 6 months) postoperative periods. conclusion: we can conclude that robot-assisted surgery is safe, appropriate and justified in patients with hh type iii and iv. all procedures performed to the patients with giant hh revealed clear technical advantages of rss over similar laparoscopic operations: an enlarged 3d hd image, bendable instruments with endowrist technology allowed for precise dissection of tissues (hernial sac, cicatricial adhesions) in a narrow anatomical space-posterior mediastinum without damage to pleura, pericardium and vagus nerves. we believe that use of rss in treatment of patients with reflux esophagitis and/or hh type i is unjustified, due to the lack of proven advantages over laparoscopy. introduction: the presence of major anatomical obstacles -such as massive caudate lobe-in the confined operative field of laparoscopic hiatal hernia repair (lhhr) poses significant challenge to the foregut surgeon. aim: to provide a safe alternative for lhhr using a laparoendoscopic approach. method: this patient is a 60 year old female, with bmi of 32.2. her past medical history includes diabetes, hypertension and hyperlipidemia. she had gerd for 20 years. her egd showed 5 x 4 cm hiatal hernia and class b esophagitis. manometry showed ineffective esophageal motility. we used the classic five ports approach for lhhr. we found a massive caudate lobe which was comparable to the size of an already enlarged left lobe of the liver. the operative strategies: terminating the procedure proceeding with the standard approach and taking the risk of bleeding from the caudate lobe itself or the inferior vena cava (ivc) with possible catastrophic outcome. using the laparoendoscopic approach. the following three steps facilitated the performance of safe and effective surgery. additional liver retractor this improved exposure and minimized manipulation of the caudate lobe. extracorporeal sliding arthroscopic knots (esak) esak are similar to the knots used in endoloop. they are tied extracorporeally and require a single insertion of the knot pusher as they do not unravel. transoral incisionless fundoplication (tif) we performed tif to avoid a limited operative field and to prevent excessive tissue manipulations associated with laparoscopic fundoplication. tif also preserves the angle of his and produces partial fundoplication which has less side effects of dysphagia and gas bloat syndrome. results: the operative time was 98 min (lhhr 78 min and tif 20 min). there were no complications. patient discontinued omeprazole which she used daily for 20 years. at 6 months follow up, her gerd related quality of life (hrql) and gerd symptom (gerss) scores were (30 vs 5) and (40 vs 8). conclusion: the laparoendoscopic repair of hiatal hernia in the presence of anatomical obstacles is safe and effective. longer follow up is needed to assess the durability of this repair. gastroesophageal reflux disease (gerd) is a condition that reduces the quality of life and can causedisorders associated with acid reflux, such as bronchial asthma, barrett's esophagus and esophagealadenocarcinoma. gerd is often caused by existing of hiatal hernia. nowadays, some surgeons haddifficulties with the laparoscopic approach to treatment of recurrent hiatal hernias.patient was a 30-year-old man. he requested medical assistance with dysphagia, nausea after eatingand heartburn getting worse in a horizontal position. conservative treatment was not effective.transthoracic nissen fundoplication was performed in 2017. the main complaints of the patientpersisted during the postoperative period. the upper half of stomach and s-like curved esophagus werelocated in the mediastinum according to multislice computed tomography of the thorax in 2018 august.in our clinical center was performed laparoscopic cruroraphy, cardiomyotomy and nissen fundoplicationin 2018 november. during the surgery the normal anatomical position of stomach has been restored, s-like curve of esophagus has been removed; a gastric cuff (collis-nissen) has been created and anteriorand posterior cruroraphy has been performed. the patient was in intensive care during 8 h. anasogastric tube feeding was continued during the first 48 h. passage of the contrast through theesophagogastric junction was free within 72 h after surgery. patients had been discharged within 5 days after surgery.this case report shows that at the current stage of surgery laparoscopic approach can be useful not onlyfor treatment of primary hiatal hernias-but also for treatment of recurrent ones. aims: laparoscopic heller myotomy procedure, completed with an anti-reflux procedure is technically demanding. we report a case of laparoscopic heller myotomy followed by a dor anterior fundoplication. methods: this is the case of a 57-year-old caucasian woman with gradual dysphagia for solids and liquids, accompanied by severe regurgitation and chest pain. an initial diagnosis of achalasia was made in 2010, with the use of manometry and barium swallow. endoscopic dilatations were attempted pre-operatively with no clinical improvement. decision was made to perform a laparoscopic heller myotomy, combined with a standard dor anterior fundoplication. a 4-ports operation took place (one intra-umbilical 10 mm trocar-single incision laparoscopic surgery (sils) technique, two 5-mm subcostal trocars, and one another 10 mm subcostal trocar for the use of liver retractor). the operation lasted 2 h and 15 min. results: no post-operative complications were noted. the post-operative swallow test showed improvement of the esophageal patency. the patient started a liquid diet three days later and was discharged six days post-operatively. two months later the patient presented no complications. conclusions: heller's myotomy has demonstrated good long-term results in the treatment of esophageal achalasia and the laparoscopic approach has been well established in the last two decades. it is a very demanding operation to perform and the disease is relatively rare, making the learning curve difficult to achieve. aims: achalasia is a type of motor disorder of the esophagus due to degeneration of ganglion cells in the myenteric plexus, leading to failure of relaxation of the lower esophageal sphincter, accompanied by a loss of peristalsis in the distal esophagus. the association of a long-term achalasia and a large size hiatus hernia is an infrequent entity. among the therapeutic options is medical treatment, endoscopic treatment and surgical treatment associated with an antireflux procedure. the laparoscopic approach being the more indicated due to its better results in terms of morbidity, mortality and recurrences. the aim of the video is to show the effectiveness and safety of the laparoscopic approach in this infrequent pathology, pointing out the importance of performing a standardized procedure. methods: 73-year-old male patient, with personal history of chronic ischemic heart disease and obesity, diagnosed with long-term achalasia with moderate dilatation of the esophagus associated with giant hiatus hernia. the complementary explorations and iconography of interest are exposed. results: intervention: complete endoscopic approach, 5 trocars. reduction of hernial content into the abdominal cavity, dissection of the hernial sac and esophageal lipoma. extended mediastinal esophageal dissection. complete resection of both the sac and lipoma, respecting the posterior vagus. heller's myotomy of 10 cm, including 3 cm distal to the ueg, perforation of 3 mm of the mucosa at the ueg level, suture and blue methylene verification of the sealing. hiatorraphy and dor-type anterior fundoplication as antireflux technique. correct postoperative, with egd control on the 3rd po day and discharge on the 6th. asymptomatic at 24 months after surgery. conclusion(s): for achalasia laparoscopic heller myotomy with a partial fundoplication should be the treatment of choice in patients who are at low surgical risk. the length of the myotomy, especially distal to ueg is one of the most important aspects of the surgery, to achieve an effective disruption of the les. the presence of a giant hiatus hernia makes the procedure difficult, increasing the risk of complications, such as perforation. standardization is essential to increase safety and efficacy in these complex cases. purpose: there is evidence that the application of mesh-reinforced hiatal repair has resulted in a significant reduction in recurrence rates in comparison with primary suture repair, at least in short-term follow-up. however, and instead of this, the standard of care for repairing large paraesophageal hiatal hernias (lphh) remains controversial because no clear guidelines are given regarding indications, mesh type, shape and position. the aim of this study is to evaluate our short-term outcomes in management of lphh with a biosynthetic monofilament polypropylene mesh surrounded by a high-purity and adherent titanium dioxide surface coating to enhance the biocompatibility (tio 2 mesh tm ). methods: a retrospective study was conducted on our institution between december 2014 and october 2018. data were collected on 27 patients with lphh greater than 5 cm in which a laparoscopic repair was carried on by primary suture and additional reinforcement with a tio 2 mesh tm . clinical and radiological recurrences, dysphagia and mesh-related complications were investigated. results: there were 17 females and 10 males with a mean age of 73 years (range, 63-79 years). all operations were completed laparoscopically. median postoperative stay was 3 days. after a mean follow-up of 16 months, 3 patients developed clinical recurrence of reflux symptoms (11.1%) and 2 radiological recurrences (7.4%). there were no mesh-related complications. conclusions: the use of tio 2 mesh tm for laparoscopic repair of lphh is suited and with a reasonably low recurrence rate in this short-term study. additional long-term studies with enormous numbers carried out for years will be necessary to affirm whether this mesh is convenient in the prevention of recurrences and mesh related complications. background: surgery for refractory gastroesophageal reflux disease (gerd) has a satisfactory outcome, however sometimes fundoplication fails and redo surgery is required. several publications have investigated the feasibility of performing reoperative fundoplications using laparoscopic techniques. the aim of this study was to describe our experience in laparoscopic redo fundoplications in the last 4 years. material and methods: we retrospectively reviewed 26 consecutive patients who required laparoscopic redo fundoplication from january 2014 to august 2018.the indications were recurrent symptoms of gastroesophageal reflux disease (gerd) (15.4%), recurrent symptomatic paraesophageal hernia (42.3%), dysphagia (30.8%) and acute volvulus (11.5%). results: all redo fundoplications (basically toupet 69.2% and nissen 26.9%) were completed laparoscopically. the mean operative time was 120 min (range, 100-136.25 min). a mesh was placed in 31% of cases. intraoperative and postoperative complication rates were 23.1% and 3.8% respectively. the mean hospital stay was 4 days (range, 3-5 days). one patient (3.8%) from the laparoscopic group required a third operation-one for acute recurrent paraesophageal herniation of the redo wrap one month after surgery, which was repair laparoscopically again. symptomatic outcome was successful in 84.6% without any kind of proton bomb inhibitors therapy. conclusion: laparoscopic redo fundoplication is technically feasible and clinically effective with a reasonable low rate of postoperative complications p620-upper gi-reflux-achalasia objectives: in recent years, balloon dilatation (bd) for diseases requiring correction of the impaired patency of the sphincter zones of the esophagogastroduodenal region has become widespread. purpose: to assess the effectiveness of the use of the balloon dilatation in patients with impaired sphincter zones of the esophagogastroduodenal region. materials and methods: in the institute department of surgery for the period from 2006 to 2018, bd was performed in 245 patients. 210 of them diagnosed with achalasia of cardia (ac): 17-1 stage, 86-2 stage, 62-3 stage, 45-4 stage. 7 patients diagnosed with pylorospasm, 7 patients had compensated stenosis and 21 patients had subcompensated ulcerative pyloroduodenal stenosis. there were 87 males, 158 females, average age (45.3 ± 5.2). bd was performed under endoscopic and / or x-ray control by 'boston scientific' balloons with a diameter of 18-20 mm, 35 mm and 40 mm, a course of 3-6 sessions with an interval of 1-3 days and a cylinder exposure of 3-6 min. evaluation of bd was performed using esophagogastroscopy, balloon manometry and x-ray passage of barium. results: in the course of the study, the existing indications were refined and new indications were developed for performing an endoscopic bd in pyloroduodenal stenosis and in ac. in patients with stage 1-2 ac, a positive result was noted in 94.3% of cases already after the first session of bd. recurrences of ac after bd for up to 5 years were established in 49 (23.3%) patients: at stage 1-in 12.2%, at stage 2-in 16.3%, at stage 3-in 24.5% and at stage 4-in 47.0%. repeated bd courses in case of ac recurrence in 29 (13.8%) cases turned out to be ineffective. recurrence of pyloroduodenal subcompensated stenosis was diagnosed in 2.8% of cases in the period of 24 months after performing bd. conclusions: bd is an effective method for correcting the permeability of the sphincter zones caused by the pathology of the esophagogastroduodenal region. keywords: balloon dilatation, achalasia of cardia, pylorospasm, ulcerative pyloroduodenal stenosis, recurrences. introduction: the reoperation in antireflux surgery significantly increases morbidity and mortality up to 75-85%, reaching rates of 42% in patients undergoing 3 or more surgeries. the advantages of laparoscopic surgery used in this surgical technique have amplified its acceptance and use, resembling its results in terms of feasibility, safety and efficacy of laparoscopic surgery to open surgery.objective: :evaluate the currently literature about antireflux surgery reintervention, focusing on the main indications of re-intervention, type of approach and morbidity and mortality of laparoscopic antireflux surgery. material and methods: a literature search was conducted in two electronic databases, med-line and embase. the search was limited to the period 2009 to 2016. terms were used in relation to the procedure or intervention and the underlying disease. we chose observational studies (cohort, cases and controls and series of cases), where the main indication for antireflux surgery would have been gastroesophageal reflux disease. results: a total of 19 studies were selected, most of them were case series (57.9%), cohort studies (31%) and case-control studies (10.5%). a total of 1940 patients. the main indications were anatomical faults, of these failures, recurrent hiatus hernia and sliding occupy the highest percentage, while physiological failures, failure in esophageal and gastric motility occur more frequently. the main type of approach was laparoscopic in 85%, the conversion rate was 5.3% and the open approach was reserved for complex cases with more than one re-intervention 12.9%, for abdomen 8.6% and chest 3.5%, this last for cases with high esophageal lesions that can not be repaired via trans-abdominal.the main complications were injuries to hollow viscera, such as: esophagus and stomach among others. these complications are related to the complexity of the procedure. mortality has remained low up to 0.05%, however, the cause of death was due to medical complications and not related to the procedure. conclusions: this systematic review on reoperation in reflux surgery has confirmed that morbidity after reoperation surgery is higher than after primary surgery and reoperation indications increase with the use of new technologies (manometry) and the laparoscopic approach continues on the rise, with great adaptation to its use and improvement in results. aims: eras protocol is not commonly used in acute emergency procedures. elective lc is commonly performed as one day surgery, while in an emergency setting of acute cholecystitis, the in hospital stay averages 4, 5 days. the aim of this trial is the application of eras protocol in patients with acute cholecystitis, undergoing laparoscopic cholecystectomy. methods: a randomized prospective trial was conducted in first surgical department of sismanogleion g.h.a. the study included 96 patients, who were admitted with acute cholecystitis and underwent lc into 24 h from their admission. preoperatively, they all received crystalloid isotonic solutions and antibiotics. 5.3% were submitted to ercp, preoperatively, due to choledocholithiasis. the postoperative care included early mobilization into 2 h after surgery, early fluid intake (into 4 h) and early liquid food intake (into 6 h). they all received systematically antibiotics, analgesics and antiemetic on demand. asa score was not an exclusion criterion. results: conversion to open procedure was necessary in 6.5% of patients, whom were excluded from the study. all the rest were discharged into 24 h from the surgery with the guidance to receive oral antibiotics for 3 more days. readmission was necessary for 2 patients, one week after the operation. the first one presented with bile leak and submitted to ercp with stent placement and percutaneous drainage of the intrabdominal collection. the second one presented with choledocholithiasis and underwent ercp with balloon catheterization. conclusion: it is commonly accepted that eras protocol in elective procedure enhances the postoperative recovery while reduces the in hospital stay and cost. in emergency condition eras cannot be applicated preoperatively. however, a modified post surgery application seems to have advantages equal to those observed in elective procedures. aim: laparoscopic cholecystectomy is the gold standard for the treatment of symptomatic cholelithiasis. administration of one single dose of chemoprophylaxis before an elective laparoscopic cholecystectomy is a broadly accepted practice. however, its value is currently questioned, especially in low risk patients. method: this study was conducted in a high volume surgical department. one hundred and twelve patients submitted to elective laparoscopic cholecystectomy were included in this research. a written consent was acquired after thorough patient briefing. half the patients that underwent surgical operation received one dose of antibiotics 30 min prior to the incision and the other half did not receive any chemoprophylaxis. results: the age ranges from 16 to 81 years old. commonest concomitant diseases were arterial hypertension, type ll diabetes, hypothyroidism and respiratory deficiency. approximately 30% of patients were smokers and 11% were obese (bmi [ 30). the duration of the operations was between 20 and 85 min. intra-operative gallbladder rupture was observed in 36 patients (rate 32%). all the patients were discharged the first post-operative day and their monitoring continued for 30 more days. in the chemoprophylaxis group, no surgical site infection or other major complication was observed. from the group that did not receive any antibiotics, one patient developed surgical site infection and specifically infection of the surgical port in the epigastrium, which was treated with drainage of the abscess and oral antibiotics administration. no other complications were recorded. conclusion: our study concluded no statistically significant difference between the two patient groups, which depicts that chemoprophylaxis may not be necessary in elective cholecystectomy operations. on the contrary, antibiotics increase the cost of hospital stay and are often accompanied by multiple mild or severe side effects. publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. key: cord-015354-yknwveyz authors: nan title: abstracts_poster presentations date: 2007-09-18 journal: eur j nucl med mol imaging doi: 10.1007/s00259-007-0544-9 sha: doc_id: 15354 cord_uid: yknwveyz nan t am and t 1/2rv increasing. and vice versa in patients with t vm and t 1/2rv decreasing residual pulmonary hypertension was diagnosed. it may be explained on the one hand by residual imbalance in vascular tonus regulation, on the other hand by morphological changing in vascular wall. in inoperable patients (because of high risk of postoperative acute right ventricle failure) t am and t 1/2rv decreasing predominated. in inoperable patients and in children with residual pulmonary hypertension we discovered mottled lung perfusion pattern that pointed either to local or diffuse circulatory disturbances. the expression of these symptoms was directly proportional to pulmonary artery pressure. conclusion. the performing of perfusion lung scintigraphy and first pass radionuclide angiography with vasodilatators allows estimating right ventricle function and pulmonary microcirculation. it may be used for predicting of postoperative right ventricle function and pulmonary artery pressure normalization. one of the main goals of whole body scintigraphy with radioactive iodine, performed after total thyroidectomy for differentiated thyroid carcinoma of follicular origin (dtcfo), is to quantify the residual tissue left, thus identifying the patients who need to be reoperated. to avoid the stunning effect, one may administer a low activity of 131i (e.g., 11, 1 mbq) or use other radiopharmaceuticals, in particular the 123i. aim to compare scintigraphic imaging and cervical uptake of 123i and 99mtc in patients submitted to total thyroidectomy for dtcfo, in order to evaluate the suitability of 99mtc for the identification of patients whose volume of residual thyroid tissue constitutes an indication for a second surgical intervention. materials and methods prospective study from 2005/08/04 to 2006/10/18 in 45 patients submitted to total thyroidectomy for dtcfo: 30 female and 15 male, aged 16-85 years (mean 51,16 ± 18,71 years). after withdrawal of levothyroxine, we obtained scintigraphic images and determined the cervical uptake of 123i 24 hours after oral administration of 11 mbq (300 μci) of the radionuclide. then, we proceeded to the i.v. administration of 296 mbq (8 mci) of 99mtc, and, 20 minutes later, acquired scintigraphic images and calculated the cervical uptake of the radionuclide. we used a siemens e-cam dcr dual head gamma camera, with medium-energy and low-energy high-resolution collimators for 123i and 99mtc respectively. images of the activities to be administered as well as of the patient`s cervical region in anterior projection were acquired at 30 cm from the detector. results all of the patients presented cervical uptake of 123i ranging from 0,21 to 37,2%, mean 6,17 ± 9,21. in 16 patients, who presented a very low or absent cervical uptake of 99mtc , a median 123i uptake of 1,1% (0,21-1,69%) was found. in 29 patients the cervical uptake of both radionuclides had a median value of 10,89 ±9,19 for 123i and 0,83 ± 0,62 for 99mtc, with an high correlation (r2 = 0,76). all the patients with a cervical uptake of 123i exceeding 12% presented a 99mtc cervical uptake above 1%. conclusions a high correlation was found between the cervical uptake of 99mtc and 123i in patients submitted to total thyroidectomy for dtcfo. cervical scintigraphy with 99mtc was shown to be useful in the identification of patients requiring repeat surgery for voluminous residual thyroid tissue. imaging a breast cancer with tc99m mdp scintigraphy s. i. mihajlovska, 1954 , n. kosturski, 1944 ; clinical hospital, bitola, the former yugoslav republic of macedonia. the aim of the study was to assess the value of tc99m mdp scintimammography in the detection of breast carcinoma. fifty six patients (30-71 years, mean 49) were included into the study. there were 35 patients with diagnosed malignant lesions, 12 patients with mastectomy and 9 normal patients. all women were injected with 555-74mbq of tc99m mdp and double phase (15 min. and 2 h.) breast imaging was made. whole body scans and lateral views of both breast were obtained in prone position with elevated arms. focal accumulation of mdp uptake in tumor localization was considered positive. results: a clear uptake of tc99m mdp was evident in 25 of 28 malignant lesions individuated (sensitivity 94.5 , specificity 100 %). no false positive results were observed. 11 out 12 patients presenting lymph node metastases (sensitivity 93.7 %). radioactivity accumulations were detected on contralateral nonoperated gland in two of 12 patients who had masteclomy . for detection malignancy mammography, ultrasonography and biopsy were performed but they were negative. definitive diagnosis were made base on the histopathologic results and showed malignant lesions. our study suggests that scintimammography with tc99m mdp seems to be a highly sensitive and specific method in the differentiation of breast lesions. this method can be added to routine presurgical bone scintigraphy as a diagnostic tool. the aim of this study was to evaluate the results of early and late lymphoscintigraphy scan using medium sized particles of labeled human serum albumin (hsa) and to compare the results of preoperative imaging and intraoperative probe detector technique in localization and detection of slns in melanoma patients. material and methods: study enrolled 17 patients (9 male and 8 female, mean age 55 ±12 yr) with malignant skin melanoma. the localizations of the skin lesion were as follows: trunk 6, upper extremities 4, limbs 6 and head 1. the patients were given a total of 0.3 ml (37-74 mbq) 99mtc-hsa with the particle size of 200-600 nm (sentiscint-mediradopharma, hungary) in four to six small portions, intradermally, around the melanoma or on both sides of the scar after the making diagnostic excision. dynamic lymphoscintigraphy was performed immediately after the tracer was injected, followed by early and late (12-18h) static scintigraphy. at the time of the surgery, blue dye was injected around the tumor at two to four sites, 10 minutes before surgery. during the surgery, a gamma probe (europrobe, france) was used to localize sentinel lymph nodes. results: a total of 25 slns were detected in 19 lymphatic basins in 17 patients on dynamic, early static and late lymphoscintigraphy. ten patients were found to have 1 sln, in 6 patients 2slns were detected, while in one patient 3slns were detected in one lyphatic basin. no additional sln was detected on late static scintigraphy 18h after labelinig, and all slns localized preoperatively were found during the operation by collimated gamma probe detector, even 24h after labeling. vital blue dye failed to color 5 sln in 3 patients, and 2slns in patient in whom 3 slns were found by lymphoscintigraphy. seven out of 17 patients had metastatic spreading in the lyphatic basins. the slns were positive in all patients with metastatic disease and were the only site of metastases in 6 out of 7 patients. conclusion: the results of our study suggest that the use of medium sized colloidal particles should be preferred in a melanoma patient because slns could be detected early after radiopharmaceutical application but with prolonged selective concentration in the sln, giving the surgeon enough time to make a surgery plan either for the same day or for the day after lymphoscintigraphy. the results demonstrated lymphatic mapping using lymphoscintigraphy as highly accurate method for staging melanoma patients. conclusion: in our study, there was a significant correlation between the pattern of brain glucose metabolism and regional myocardial mibg uptake. in particular, decreased cardiac mibg uptake in inferior wall tends to correlate with hypometabolism in subcortical nucleus. key words: mibg, heart, spect, fdg, brain, pet the treatment options for patients with follicular lymphoma have substantially improved recently, due to the development of radioinmunotherapy, which combines radiation and antibodies. the most important example is 90y-ibritumomab tiuxetan (zevalin®), which is specially indicated in relapsed and/or refractory follicular b-cell non-hodgkin lymphoma (nhl). aim: show our experience in the use of zevalin® in those patients with follicular lymphoma, whose previous treatments have failed. material and methods: since april 2005 until february 2007 we have treated 17 patients (7 women and 10 men) with ages between 24 and 79 years old. all patients had to follow these criteria: follicular lymphoma, previous treatment with rituximab, platelet counts 100x109/l and bone marrow involvement 25%. the administered dose was 14.8mbq/kg if platelet counts 150x109/l, and of 11.1 mbq/kg if 150x109/l. 15 days post-treatment, the weekly clinical and analitical survey was done, until haematological recovery was confirmed. the evaluation of the therapeutic response was done after three months. results: from the 17 patients studied, 2 died (11.8%), 1 because of the progression of the disease, the other due to heart failure. 4 had not yet been evaluated (23.5%) and from the remaining 11, 8 had a complete response (47.1%), 2 had a partial response (11.8%) and 1 had a stabilized status (5.9%). toxicities were primarily haematologic and reversible, with non extrahaematologic toxicity observed. conclusions: based on our experience, the treatment of nhl with zevalin® is useful and secure, due to the minimal secondary effects. the use in early stages of the follicular lymphoma could improve the therapeutical results. aim: to evaluate the usefulness of 99mtc-ciprofloxacin scintigraphy (cp) in patients with hip or knee arthroplasty and suspect of infection. material and methods: fifteen patients (9 women, 6 men) with a mean age of 71±10 years and clinical symptoms, haematological and/or 99mtc-hmpao leukocyte scan suggestive of prosthetic infection were included. cp was performed at 1h, 4h and 24h alter intravenous injection of 370 mbq of 99mtc-ciprofloxacin. anterior and posterior views centred in the affected joint were performed in all patients. a conventional bone scan, 99mtc-hmpao leukocyte scan and 99mtc-colloid scan were performed in all cases. the final diagnostic of arthroplasty infection was established by positive microbiologic analysis, macroscopic evidence of purulent material, or after visualization of more than 5 neutrophils in the periprosthetic tissue. results: diagnosis of arthroplasty infection was established in 9/15 cases (coagulase-negative staphylococcus (4), aureus staphylococcus (2), e. coli (1) and polymicrobial agents in the remaining 2 cases). cp was able to correctly diagnose all cases of infection. cp images at 60' postinjection showed 2 false positive cases, and at 24h 1 false negative case was found. in one patient with knee prosthetic loosening without infection and intense inflammatory changes, cp was positive and then considered as a false positive case. on the other hand, 99mtc-hmpao leukocyte scan was non-diagnostic in 2/9 cases of infection.conclusions: cp is useful in the diagnosis of arthroplasty infection of the hip and knee. cp images obtained at 4h alter injection are recommended. presence of synovitis may cause false positive images with cp in knee prostheses. surgical removal of pgs is a difficult procedure especially when their localization is deeper than expected. the aim of the study was to evaluate the number of deeply situated pgs in relation to their right or left positioning. materials and methods. in this retrospective study 415 consecutive patients who had a positive scan (350 with primary and 65 with secondary hyperparathyroidism) were included. a double phase sestamibi technique followed by a pertechnetate scan was used. early right and left 30 degree oblique images were routinely obtained in order to evaluate the depth of the pgs. findings were classified in to two groups based on the degree of change of the relative position of pgs and the thyroid gland (tg) in the oblique compared with the anterior image. group i included pgs where the relative position of the pg and tg in the anterior an oblique images remained the same or changed only slightly. those pgs were characterized as not deeply located. group ii included pgs that in oblique images the pg to tg distance was significantly increased and were characterized as deeply situated. the localization of the pgs was confirmed by the available surgical data. results a total of 565 pgs were identified (65 upper right, 115 upper left, 202 lower right and 183 lower left). group i included 58/65 upper right, 95/115 upper left, 163/202 lower right and 170/183 lower left (486 of the total 565 pgs). group ii included 7/65 upper right, 20/115 upper left, 39/202 lower right and 13/183 lower left (79 of the total 565 pgs). upper left and lower right pgs were significantly more frequently located at a significant depth compared with the upper right and lower left sites (p<0.05 and p<0.01 respectively). conclusion these results indicate that upper left and especially lower right pgs are more frequently deeply located; information which is useful for the procedure of surgical removal, mainly when preoperative imaging has not been performed. in recent years, picture archiving and communication systems (pacs) and electronic transfer of radiological images using the dicom file standard has become more widely employed in diagnostic radiology. it seems to be likely that nuclear medicine will be integrated within such systems. on the other hand, many departments possess older equipment without digital output facilities. there is an increasing tendency to display and archive evaluated images ('save-screens', printouts) on non-dedicated, inexpensive systems using file formats capable of data compression. this was the reason for examining the value of the jpeg format in this pilot study. fifty scanned planar bitmap images of the most frequent scintigraphic examinations (thyroid, bone, myocardium, lungs, and kidneys) were compared with jpeg format at different data compressions by two blinded observers. the visualization of details, e.g. pathologic findings, is described for all these images as the visual appearance of the images and the storage capacity required. relevant loss of clinical information did not occur up to compression factors of 0.75. a major decrease of subjective image quality was seen at compression factors > 0.90. compared to bitmap files, the use of these factors reduced the storage capacity required by 98% at a (jpeg-related) compression factor of 0.50, and 99% at a compression factor of 0.90. compared to the gif format, a reduction by 4.0-5.7 could be achieved. use of the jpeg format can therefore be recommended to save costs of image transfer or archiving of standard planar scans for nuclear medical evaluation. the evaluation of genotoxic effect of gamma radiation in nuclear medicine workers to be used [1] . material and methods: in a previous work we recorded the personal whole-body dose values received by the workers over a period covering the starting of a pet unit (october, 2004) and the subsequent years until march, 2006 [1] . then, we reported a substantial increase (167%) of the whole-body dose received by the technologists which was then related to the initial increasing number of pet exams. following a clear evidence of this initial increase of whole-body dose to be related with the technologists contact with the patient during preparation to exam, a wholebody lead shielding, with a thickness higher than the tenth-value-layer (tvl) for 511 kev photons, was implemented for protection during patient handling and exam preparation. all the dosimetric measurements considered in this work were executed by the same personal dosimeter provider (nrpb, uk) . results: after shielding started to be used by the technologists during pet patient handling, we observed a clear reduction of whole-body doses back to levels close to the ones observed before the pet implementation. conclusion: the increased dose received by the technologists before shielding implementation can now be even more clearly related with the time needed to handle the pet patient at the exam and with the higher exposition rate constant of f-18 when compared with other isotopes used in nuclear medicine (namely tc-99m). in conclusion, we can say that whole-body shielding is an affective way to reduce doses to the technologists during this stage of pet procedures. besides shielding during patient preparation image acquisition, a remote control similar to the ones existing in a common gamma-camera could be also useful in the reduction of the doses. [1] j.a.m. santos et al. impact of fdg-pet in the occupational whole-body dose received by several professional groups in a nuclear medicine department, annual congress of the eanm, athens, 2006 (oral presentation, 198) aim: the dose administered to the hands of nuclear technologists working with petnuclides is a problem of concern ever since the introduction of pet as a routine examination in nuclear medicine. the dose to the hands can be monitored using ring tld's. the aim of this study is to determine the accuracy and detection limits of extremity dosimetry using ring tld's. material and methods: two types of tld's with different thicknesses, 0,0036 and 0,015 inch respectively, were used. the tld's were exposed to ionising radiation using a 137cs source. the tld's were exposed to various doses under several angles. the use of 12 sets of tld's, each consisting of 1 thick and 1 thin tld, averaged out the effects of single tld's. to improve statistics each exposure was repeated 3 times. a perspex rod with a diameter of 20mm was used to simulate a human finger. after each exposure the tld's were read out using a harshaw 6600. uncertainty analysis was used to determine detection limits and uncertainty intervals for both types of tld's. results: analysis of the measured data shows that within the uncertainty intervals the measured dose matches the exposed dose. no significant angle dependence is found. the relative error in the measured dose is larger at smaller doses. this effect occurres in both types of tld's. the effect was more pronounced in the thin tld, yielding a higher detection limit for the thin tld then for the thick tld. the detection limits for the thin and thick tld are 180 μ sv and 34 μ sv respectively. the main contribution to the uncertainty at low doses is the effect that manipulating a tld induces an artificial dose during tld read out. this effect probably scales with the volume/surface ratio of the tld and the amount of manipulation, needed to get the tld out of the ring, into the tld reader. conclusion: due to its high detection limit, is the thin tld, in contrast with the thick tld, not suitable to be used for extremity dose monitoring in nuclear medicine. the detection limit of both tld's can be improved by reducing the amount of manipulation, needed to put the tld in the tld reader, and to improve the protection against mechanical impacts. both can be achieved by improving the construction of the ring. new experiments are conducted using an improved design of the ring. aim: despite international recommendations about the use of the si units system [1] determined in 1978 by the cipm (comité international des poids et mesures), non-si units in radiation physics and other fields of science are still in use today and included in scientific publications. some of these, such as the roentgen (r), rad, rem and curie (ci) are called traditional units and still temporarily acceptable by the si system although its use has been discouraged and a cessation has already been proposed for the year 2000 by the cirrpc. in nuclear medicine, these units have also been thoroughly used through the years. nevertheless, si units are slowly taking their place in the current clinical nuclear medicine practice and there is a general tendency for homogeneity towards its universal acceptance. however special care should be taken in this process. discussion: although the rad, rem and roentgen have already been almost universally replaced by their si units, the curie is still widely used in parallel with the bequerel (bq). the consequences, although minimal, can not be disregarded. activity values tend still to be written as integer multiples of the milicurie (ex. 5 mci, 20 mci) in most of the nuclear medicine literature, even if a conversion is provided, resulting in awkward values of activity expressed in si units, altering the number of precision digits, as seen in the above example, and leading to erroneous appreciation of measurement errors. for example when writing "3 mci", it is implicit an error of 0.5 mci (17%) while writing "3.0 mci", an error of 0.05 mci (1.7%) is assumed. on the other hand, when writing "111 mbq" instead of "3 mci", we assume an error of 0.5 mbq, i.e. 0.45% (which is much less than the actual precision of a clinical purpose activimeter). conclusion: supplementary effort, besides simple conversion of traditional units into si should be pursued. significant digits number and the errors associated with them should be considered. the calculation of other important nuclear medicine physical quantities, such as the suv in pet or activity per body mass, should also be written and thinked primarily in si and optionally converted to traditional units and not vice-versa (ex. 0.1 gbq/kg -3 mci/kg; 120 mbq/kg -3.24 mci/kg). [ ecnc, in 2007 guidelines for radionuclide imaging of cardiac function will be published by the same institutions. methods and results: 22 authors from several different european countries are collaborating and have written a draft of the new guidelines including the following sections: 1) radiopharmaceuticals and dosimetry, 2) acquisition of radionuclide ventriculography (first pass and planar and tomographic equilibrium ventriculography) as well as gated perfusion imaging, 3) right ventricular ef, 4) left ventricular (lv) ef, 5) lv volumes, 6) lv diastolic function, 7) lv regional function, 8) physics and software, 9) reference values, and 10) clinical indications. discussion and conclusion: the paramount principle is to write evidencebased guidelines, referring to original, peer-reviewed papers from international journals. however, such evidence is not always available. in lack of evidence for the best choice of performance of a procedure or indication, we emphasize the lack of evidence by expressions like "there is general consensus" or "most centres use" etc. the guidelines will be published in the ejnm with direct links from eanm, ecnc, and esc, and they will be regularly updated. influence of radiation source geometry on determination of 111in and 90y activity of radiofarmaceuticals p. kolenc peitl, p. tomše, a. so an, m. krošelj, t. gmeiner stopar; university medical centre ljubljana, ljubljana, slovenia. aim: measuring of the radioactivity of radiopharmaceuticals before injection to patient is essential in nuclear medicine. measurements are performed by use of a dosecalibrator. to assure accurate readings quality control checks are performed and proper calibration factors used. calibration factors are not only dependent on the type of the radionuclide but also on a number of other factors, including nature of the container and volume of the solution in it. the aim of our study was therefore estimation of the impact of these factors on radioactivity readings for 90y and 111in in four different dose-calibrators before implementing radiotherapy with 90y based radiopharmaceutical into routine use. material and methods: 90ycl3 and 111incl3 solutions were gravimetrically dispensed in seven different containers (3, 10 and 20 ml vials and 1, 2, 5 and 10 ml syringes). in each container several dilutions of the parent solutions were performed. mass, activity and time for each source geometry were recorded for all dose-calibrators (two vdc-405, capintec and ptw). measurements were background, time and mass corrected. aliquotes of both parent solutions were calibrated in national metrology laboratory, vienna, austria (bev). from our measurements and results from bev correction factors (cf) and volume correction curves were determined. results: 111in: accurate results with ±5% precision for all source geometries in all vials were obtained using manufacturersupplied cf in both vdc-405 and capintec calibrators. for ptw the uniform cf (0,75) was determined for all geometries in all types of vials. the uniform cf for each type of syringe was determined in each dose-calibrator: readings have to be reduced for up to 20% for vdc-405 and up to 30% for capintec and ptw, depending on syringe. 90y: the uniform cf for each type of syringe was determined in each dosecalibrator: readings have to be reduced for up to 10% for vdc-405, 20% for ptw and 30% for capintec. in the vials the volume correction curves have to be used to increase readings for up to 20% in 15% in capintec and to reduce readings 10 to 20% in ptw. conclusion: our results show that manufacturer-supplied cf without ckecking the influence of radiation source geometry cannot be blindly trusted. ignoring this fact measurements can lead to errors reaching 30% in preparation and dispensing of 111in and 90y radiopharmaceuticals. aim: bone grafting is essential modality for reconstruction of congenital and acquired bone defects. our aim was to determine the viability of bone grafts by three phase bone scintigraphy with histopathological confirmation. method: two different grafting methods in 12 new zealand rabbits were evaluated; autogenous bone grafting and demineralisation bone matrix (dbm) method, which has been developed to improve incorporation and formation of new bones. one centimeter square sized bone defects were made on the parietal bones of rabbits. the acquired bone defects on the left side were replaced by grafting the healthy parietal region from the right and the bone defects on the right side were replaced by using dbm grafts. at the second week; as early stage and in the sixth and twelfth weeks as late stages of the graft operation, dynamic three phase bone scans were performed. the rabbits had intravenous bolus injection of 20 mci (185 mbq) tc-99m hdp under anesthesia and the images were acquired with a pinhole collimator. early and late stages of bilateral parietal regions were visually and quantitatively assessed with equal pixel region of interests (roi). visual assessments were scored from 0 to 3 (zero as no uptake, 1 as mild, 2 as moderate and 3 as highest uptake). results: osteoblastic radioactivity uptake ratios were evaluated from 1 to 3 in all grafts and histopathologically those grafts were viable. perfusion and blood pool images were similar in both bone grafts in all rabbits at all stages. in the quantitative assessment right parietal to occipital roi and left parietal to occipital ratios were as follows; at the second week dbm 0.70±0,12, autogenous bone graft 0,76±0,16 (p= 0,08); at the sixth week dbm 0.66±0,85, autogenous bone graft 0, 62±0,65 (p=0,38) and at the twelfth week dbm 0.68±0,16, autogenous bone graft 0, 64±0,14( p=0,24) . in all phases of bone scintigraphy there was no visual or quantitative difference in statistically by between 2 grafting methods statistically (p<0.05). conclusion: the determination of graft viability by three phase bone scintigraphy in both dbm and autogenous bone graft method is an in-vivo, sufficient, useful and cost-effective imaging modality. p01 -monday, oct. 15, 2007, 2: aim: it is widely accepted that myocardial perfusion spect should be acquired with ecg-gating. with this technique additional information about the pump function of the left ventricle is gained. the purpose of this study was to evaluate the relationship between left ventricular stress and rest ejection fraction (ef) in myocardial perfusion spect and to analyse possible influencing factors. material and methods: in this study 50 consecutive patients from our outpatient clinic with a 2-day stress/rest protocol were enclosed. the patients consisted of 7 women and 43 men, with a mean age ± s.d. of 63.2 ± 10.3 years. in 45 patients a coronary heart illness was known. the stress was induced ergometric by bicycling in all patients. the spect acquisition was carried out 60 min after i.v-injection of tc-99m-mibi (stress-study) or after 90 min (rest-study) with a double headed gamma camera e.cam (siemens). the reconstructed slices of the short heart axis were used for fully automatic determination of the left ventricular ejection fraction and assessment of semiquantitative segmental pathology scores through the software 4dm-spect (university of michigan). results: the matched ef-values of the stress and rest study showed a small, but significant difference in the paired t-test (p = 0.04). the average value for the stress ef (55.5%) lay about 2.5 percent points below the value of the rest ef (58.0%). in a regression analysis the decrease of the ef ( ef) between the stress and the rest study showed no dependency with age (p = 0.68), the summed stress pathology score (sss) (p = 0.46) or the summed rest pathology score (srs) (p = 0.27). however a significant increasing of the ef was found with the summed pathology difference scores (sds) (p = 0.02) and a growing rest ef (p = 0.03). conclusion: the stress ef was found to be significant lower then the rest ef. this indicates a stress induced injury of the heart still influencing the ef at the post stress acquisition time of the spect. higher ef values correlated positively with stress-induced ischemia, according to the sds score. in contrast a perfusion abnormality alone in rest (high srs score) or stress (high sss value) had no significant influence to the ef. the additional information gained with gated myocardial perfusion spect can contribute to the assessment of stress-induced stunning of the myocardial pump function. aim: in many institutions, the first line imaging modality for suspected pulmonary embolism is lung scintigraphy. the value of adding ventilation imaging and single photon emission computed tomography (spect) to the perfusion study is controversial. the prospective acute pulmonary embolism 1 (ape 1) trial is planned to include 500 patients suspected of pulmonary embolism. the aim is to determine if ventilation imaging and spect, as an adjunct to planar perfusion imaging, improves the interpretation of lung scintigraphy. this is a report from an initial pilot study. consecutive patients clinically suspected of pulmonary embolism entered the study. within four hours we performed scintigraphic examinations and, if abnormal, pulmonary angiography which was considered the gold standard. readings were done by expert physicians blinded to clinical data and other imaging modalities except the chest x-ray. results: of the 17 patients who entered the pilot study, two had normal scintigrams and in one case logistics failed. the results presented are from the remaining 14 patients, of whom six had pulmonary embolism and eight did not. planar perfusion images correctly identified five patients with pulmonary embolism and five patients without, but failed to identify one patient with and three patients without pulmonary embolism. perfusion spect and combined perfusion and ventilation imaging (both planar and spect) correctly identified all patients with pulmonary embolism and four patients without, but failed to identify four patients without pulmonary embolism. in the table below, the corresponding sensitivities and specificities are presented. conclusion: the ape 1 pilot study showed no clear benefit from either ventilation imaging or spect, suggesting that planar perfusion imaging alone may be sufficient in suspected pulmonary embolism. however, the number of patients in the pilot study was small and definitive conclusions cannot be drawn until the results from the ape 1 trial become available. the aim of the study was to compare myocardial blood flow (mbf) and coronary flow reserve (cfr) measured by positron emission tomography (pet) and the severity of coronary artery stenosis on coronary angiography. methods: we studied 67 patients with angiographically proven coronary heart disease (chd) with dynamic [13n]ammonia pet imaging at rest and after dipyridamole. mbf was calculated by firstpass extraction method. the coronary flow reserve (cfr) was defined as the ratio between the stress and the rest mbf. results: mbf at rest did not differ between the patients with coronary atherosclerosis and the controls (70,56±15,7 ml/min/100g vs 74,2±14,6 ml/min/100g ns) with the exception of infarct-related regions where mbf at rest was significantly low (44,8±15,7 ml/min/100g, p<0,01). during hyperemia mbf significantly decreased in the regions supplied by diseased coronary vessels in the patients (99,57±32,1 ml/min/100g. vs 202,1±15,4 ml/min/100g., p<0,001). it was revealed a significant correlation between mbf during hyperemia and coronary artery stenosis degree (r= -0,79; p90% stenosis showed an attenuated response to dipyridamole (cfr = 1, 14±0, 18) . cfr was significantly low in regions supplied by arteries without significant stenoses in the patients vs the controls (2,2±0,54 vs 2,9±0,2; p<0,001) due to an influence of coronary heart disease risk factors: myocardial hypertrophy, smoking, diabetes mellitus. conclusion: [13n]-ammonia pet imaging provides the valuable information about functional severity of coronary atherosclerosis. cfr impairment in regions without significant stenosis can be explained by an influence of coronary heart disease risk factors. silent ischemia elicited on resting post-nitrate gated-spect by a coronary steal mechanism is associated with short term outcomes in prior myocardial infarction g. carboni, t. castiello; univ. campus bio-medico, roma, italy. the value of post-nitrate cardiac gated spect (g-spect) in patients (pts) with prior myocardial (m) infarction (i) is still uncertain .thirty-six such pts ,mean age 74+-10 years , 56% males , were thus studied by g-spect , at rest , after sublingual administration of 5 mg isosorbide dinitrate (n) and at controlled conditions ( baseline ) . methods: in all pts , g-spect , (63 % with thallium , 37 with % mibi ) , was carried out on a dual-head gamma camera and ejection fraction (ef), extent and reversibility (r) of abnormal defects (ads) were analyzed with cedars-qgs-cequal softwares. extent of ads after n administration was calculated as a percentage (%) of total lv pixels ( p ) and r as a % of the ads . the ads were considered significant when > than 10% p and concordant with regional hypokinesia on echocardiograpy . all pts were followed-up for cardiovascular events (ce) . results: overall pts , only 9 showed partial r of ads . on a cox regression model (chi-square = 6 , p < 0.01) , only r ( b = 1.4 , p < 0.01 ) was associated with the hazard of ce ( in 3 pts cardiac death , in 6 pts major ce ) but not with age, ef, cad , prior cabg or ptca , ( p = ns for all ) . results did not change when data were adjusted for risk factors. on kaplan-meier curves , pts with r showed also lower event-free survival probability versus those without r ( 11% versus 63% at a 24 months follow-up ) , log-rank test: p < 0.0007 , hazard ratio = 0.2 , 95% ci = 0.006 to 0.6 ) . conclusions: in 25% ( 9/36) of pts under study , resting post-n g-spect elicited partial r of ads ( residual m ischemia in prior mi ) in absence of any increase in m demand. a n-induced " coronary steal " from low flow coronary territories (infarct-related coronary artery) to non ischemic territories cannot be thus excluded . such a paradoxical effect occurs silently and may identify m instability , predict short-term outcomes and imply concern for n chronic therapy in prior mi . the aim of this study was to compare the results of ejection fraction (ef) values and volumetric data derived from gated myocardial perfusion spect( g-spect) using both qgs (siemens icon) and 4d-mspect(4d) algorithms and to determine normal limits in patients with normal cardiac perfusion and function. methods: one hundred and sixty-six consecutive patients (59 men, m, 107 female, fm, 53 ±10 years old) referred for the evaluation of suspected coronary heart disease ( chd) using g-spect were included in the study. inclusion criteria: having normal cardiac perfusion and function; exclusion criteria: previous chd, left bundle branch block, ischemia finding, q or qs pattern in ecg and severe arrhythmia at rest .modified bruce protocol was performed in stress test. ef%, end-diastolic (edv;ml) and end-systolic volumes (esv; ml) and stress/ rest left ventricular cavity dilatation index (cdi) were calculated. results: the mean values of overall ef, edv and esv in s and r were as follows. qgs: r-ef%=64. . in volume comparison, although there was high correlation (r=0.85-93) between the methods , the mean differences were significantly different (p<0.001). conclusion: ejection fraction limits in normal patients obtained in this study were in concordance with those of previously reported in the literature. ef values derived from 4d were significantly higher than those of qgs both in s and r g-spect and the methods do not prove to be interchangeable for ef calculation in normal patients. key words: left ventricular ejection fraction, gated perfusion spect, normal limits aim: generator-produced rubidium-82 (82rb) is of interest for centers lacking access to a cylotron. quantitation of myocardial blood flow (mbf) has been performed with 82rb using compartment-based models. however, reproducibility of such mbf quantitation with 82rb is not known precisely. material and methods: fourteen individuals (mean age 47±19y range 21-75y; 4w, 10m; including 10 volunteers and 4 patients with angiographically proved cad) underwent dynamic pet imaging studies (21 frames) at rest and during adenosine stress (0.14mg/kg/min for 6 min) after injection of 1100mbq of 82rb (discovery ls, gems). after waiting period of 30min, the rest-adenosine stress sequence was repeated. mbf was determined using a 1-compartment model including a correction for flow-dependent extraction fraction of 82rb (pmod 2.80 analysis software, www.pmod.ch). myocardial flow reserve (mfr) was defined by the ratio of stress/rest mbf. for comparison, paired t-test and bland-altman plots were used. results: there was no difference in hemodynamic parameters between baseline and repeat measurements (rate-pressure product: 7.42e3±0.20e3 vs. 7.34e3±0.17e3 mmhg/min, p=0.70). one volunteer refused to undergo adenosine stress because of side effects. there was no significant difference between baseline and repeat studies regarding mbf at rest (0.84±0.18 vs. 0.87±0.19 ml/min/ml, p=0.45), during adenosine stress (2.50±0.84 vs. 2.43±0.99 ml/min/ml, p=0.49) or in mfr (3.07±0.79 vs. 2.80±0.81, p=0.14). the correlations between baseline and repeat studies were also excellent (rest: r2=0.97 y=1.02·x; adenosine: r2=0.98 y=0.98·x; mfr: r2=0.96 y=0.90·x) . finally, overall agreement was very good on bland-altman plots with 26 out of 27 measurement pairs (96%) being within reference range for difference, without any systematic difference (p=0.72). conclusion: these results demonstrate an excellent reproducibility of myocardial blood flow measurements with 82rb at rest and under adenosine challenge. aim: diabetic patients develop coronary artery disease (cad) more frequently and have a higher incidence myocardial infarction (mi) .cad is also an important cause of mortality in patients with diabetes. its early detection is fundamental to improve medical treatment. the aim of this work is to describe single-photon emission computed tomography myocardial perfusion imaging (spect mpi) findings in patients with diabetes mellitus type 2 (dmii) with atypical chest pain and analyze whether the presence of others risk factors are reliable predictors of positive scyntigraphy. materials & methods: authors interviewed all patients with dmii that underwent spect myocardial-perfusion with 99mtcmibi from december 2006 to march 2007 that had read and accepted informed consent. method of inducing stress was infusion of dipyridamole in 68.3% cases and exercise loading in the others (31.7%). ejection fraction (ef) was assessed by ecg-gated technique. patients that had reported previous heart infarction with or without revascularization intervention were excluded. results: authors interviewed 41 diabetic patients who underwent spect mpi during this period. 68.3% were women, ages ranging from 40 to 76 years old (mean value=59.8). it was found perfusion abnormalities in 15 patients (36.6%); 14 exams showed reversible defects and 1 of them had irreversible lesion. 40% of the abnormal exams showed only one lesion; 40% showed two compromised walls and 20% showed 3 walls affected. ejection fraction ranged from 35 to 75% (median=58). concerning to risk factors, 33 patients (80.5%) affirmed being sedentary, 25 patients (61%) were overweight, 10 patients (24.4%) were smokers, 17 patients (41,5%) had hyperlipidemia and 23 patients (56,1%) reported positive family history of cvd. authors also assessed whether the presence of risk factors would be correlated to a positive exam. no statistical correlation was individually significant: smoking (p=0,130) and sedentatariness (p=0,687) both analized with exact fisher' test; and overweight (p=0,923), hyperlipidemia (p=0,067), and positive family history (p=0,702) , assessed with qui-square test. conclusion: frequency of perfusion abnormalities in diabetic patients with atypical chest pain was high (36.6%).this data suggests that occult cad is common among asymptomatic and poorly symptomatic patients with diabetes. perfusions abnormalities in these patients by means of spect mpi could provide incremental information about silent cad. individualy, risk factors for cad had not statiscaly significant correlation with a positive spect mpi in this study, probably due to the small population surveyed. early primary percutaneous coronary intervention (pci) is a very effective technique in the treatment of the acute myocardial infarction (ami), since it allows the recanalization of the affected coronary vessel. objective: the aim of the study was to evaluate the extension of saved myocardium defined as the difference of perfusion score pre and post pci. patients and methods: 13 patients with ami and st segment elevation were studied prospectively (3 women, mean-age: 63.6 ± 14.1 years) . two gated-spect detections were acquired after 99mtc-mibi injection in all cases. the first injection before pci and the other after it (15.22 ± 9.02 days), following the habitual methodology. the initial acquisition was carried out at the exit of the catheterization lab in 12 patients (70.83 ± 13.01 minutes) and after seven hours of stay in the coronary unit in 1 patient. the quantitative automatic valuation of the 17 segments was performed by the software qps (cedars). pre and post pci (sss, srs) score, the difference of the score (sds) and the percentage of extension (ss%, sr% and sd%) was evaluated. according to the coronary angiography the dilated arteries were 10 left anterior descending arteries (lad) and 3 right coronary arteries (rc). in 12 patients the revascularization was angiographycally effective. results: in 2 patients there was not significant difference between pre and post spect quantification (1 not effective revascularization and 1 with large ami). in the rest of patients salvaged myocardium is showed. sss shows the pre-dilatation deffect, srs shows the residual deffect (ami) and sds shows the saved myocardium. conclusions: the myocardial perfusion quantification by gated-spect allows a precise valuation of the saved myocardium by primary pci in the ami. side effects in 3723 patients undergoing myocardial perfusion imaging in one centre. medicine, aarhus university hospital, skejby, aarhus, denmark. aim: to analyse the frequency of side effects in stress myocardial perfusion imaging (mpi) related to gender, age, referral diagnosis and type of stress. material and methods: we included 3723 consecutive patients referred for mpi in the period june 2003 -december 2006 (3½ years). bicycle stress was first choice (14%). patients who could not perform the test or were treated with betablockade were stressed with adenosine in combination with a minor work load when possible (55%) otherwiseand in case of left bundle branch block -adenosine was injected at rest (23%). dobutamine was used in patients with severe chronic obstructive lung disease or atrioventricular block (8%). results: the investigation included 1836 men and 1887 women aged 5 to 95 years (mean of 62 years). the women were on average 1.3 years older. the patients suffered from ischemic heart disease (ihd) (32%) or were suspect to ihd (67%). side effects: only164 patients (4.4%) had side effects. the most frequent side effects were: atrioventricular blockade (1.9%), bronchospasme (0.8%) and "other unspecified side effects" (1%). rare side effects were arrhythmias (0.35%), ami/unstable angina (0.30%) and syncope (0.24%). no patients died. uncomplicated angina and well-known subjective symptoms to pharmacological stress and work load were not registered. patients stressed with bicycle had seldom side effects (1.3%), whereas frequency was about 5% after adenosine and dobutamine stress but with differences in type of side effects. there was a higher prevalence of side effects in women (57 vs. 43%), especially for ami /unstable angina (91%) and other unspecified side effects (67%). only syncope was more frequent among men (78%). the frequency of side effects increased with age from 1.9% in the thirties to 6.3 % in the eighties. patients referred with known or suspected ihd had the same frequency of side effects. conclusion: during a 3½ year period 3723 patients were examined with stress mpi. no one died and only 4.4% had side effects apart from angina and wellknown subjective symptoms to pharmacological stress and work load. less than 1% had arrhythmias, ami /unstable angina or syncope. the prevalence was higher during pharmacologic stress than work load. the prevalence was more frequent in women and increased with age. cardiovascular disease is the leading cause of death among patients with type 2 diabetes, myocardial ischemia being frequently silent. coronary artery disease detection is challenging in women due to a variety of factors. aim our purpose is twofold: to investigate the association of silent ischemia and diabetes in women; and determine the sensitivity of myocardial perfusion gated spect in these patients. material and methods poststress and resting gated spect was performed in 60 women (39 with type 2 diabetes and 21 nondiabetic) with suspected coronary artery disease. 28 of the diabetic patients underwent coronary angiography within 3.7 months. mean age was 67.5 years. a 2-day stress/rest protocol was used with 99mtctetrofosmin and pharmacologic stress (adenosine:56, dobutamine:4). perfusion analysis was semiquantitative based on a 20 segment model determining the summed stress store (sss) and the summed difference score (sds). the sss<4 was defined as a normal scan, sss: 4 to 13 as moderate and sss>13 as severe ischemia, respectively. the sds < 2 was considered no ischemia, sds: 2 to 7 moderate and sds>7 severe ischemia, respectively. poststress lvef was considered normal if > 45%. results p<0.05 sds detected ischemia more frequently is diabetic versus nondiabetic patients. results of coronary angiography were positive with good vessel-territory correspondence in 26 patients. two patients had false negative myocardial gated spect yielding a sensitivity of 92.8%. clinical presentation, age (65 vs 67.8), stress agent and risk factores (arterial hypertension, dyslipemia and smoking) were not different between nondiabetic and diabetic patients. there is no statistically significant difference between both groups in age variable. conclusion female patients with type 2 diabetes present more severe ischemia than nondiabetic patients of similar conditions and clearly benefit from early coronary angiography. diabetes is considered a coronary artery disease (cad) risk equivalent with the evidence of an increased mortality rate in diabetic patients. cad is often silent and when it becomes clinically manifest it is in an advanced state. however, there is a wide variation in prevalence of cad in diabetes, possibly related to the presence of additional risk factors. aim of the study was to prospectively assess the usefulness of myocardial perfusion spect (mps) in asymptomatic diabetic patients and occult cad in comparison with traditional risk factors. methodology: among 402 patients, 105 pts with diabetes mellitus (7 type i; 98 type ii) and high likelihood of cad underwent rest-stress mps with 99mtc-tetrofosmin and a 20-segments scoring model was used for spect analysis. a summed stress score (sss) >4 indicated abnormal mps, sss 4-8 a mild, sss >8-13 a moderate and sss >13 a severe perfusion defect. multiple risk factors and clinical predictors like duration of diabetes, presence of peripheral vascular disease, dyslipidemia, hypertension, active smoke, family history of cad or diabetes and body mass index, were analysed. results: according to the spect results, patients were classified in: group a (56 pts with normal mps), and group b (12 pts with reversible, 23 pts with mixed, 14 with fixed perfusion defects). moderate or large stress defects occurred in 13 and 17 pts, respectively. the analysis of the presence of cad risk factors or the association of two of these was not statistically significant (table 1) . conclusion: mps is effecting in detect occult cad and silent myocardial infarction in asymptomatic patients with diabetes mellitus while the usual risk factor analysis or the association of 2 or more of these, are inadequate to predict the presence of cad in this population. effects of cardiac resynchronization therapy: evaluation by first-pass radionuclide angiography and multiple gated equilibrium blood pool scintigraphy s. minin, v. chernov, e. makarova, g. savenkova, y. lishmanov; institute of cardiology, tomsk, russian federation. background: cardiac resynchronization therapy (crt) reduces symptoms and improves left ventricular function in many patients with heart failure due to left ventricular systolic dysfunction and cardiac dyssynchrony. but changes of pulmonary and central haemodynamics after crt are not clear. aim: to evaluate of chronic crt effect on pulmonary and central haemodynamics as well as on left ventricular ejection fraction (lvef) in patients with severe heart failure. material and methods: the study involved 15 patients (m/f: 11/4, mean age: 52+4.9 years). we studied scheduled for implantation of a crt device based on conventional criteria (nyha class iii or iv, lvef <35%, left bundle-branch block and qrs duration >120 ms). two patients had ischemic and 10 patients had idiopathic dilated cardiomyopathy. first-pass radionuclide angiography (fpra) and multiple gated equilibrium blood pool scintigraphy (muga) were performed before and 1 month after crt. results: our data show a significant clinical benefit of crt (nyha class change from 3.3+0.6 to 2.1+0.7; p=0.01). we found significant increase in cardiac output from 3.7±1.2 to 4.3±1.1 ml/min (p=0.004), stroke volume from 52.1±18.8 to 64.4±17.6 ml (p=0.02), cardiac index from 1.9±0.6 to 2.2±0.5 ml/min/m2 (p=0.009) and stroke index from 26.8±9.8 to 32.1±9.9 ml/m2 (p=0.03). also increase in lvef from 26.6±8.3 to 31.9±8.3% (p=0.02) was shown. all patients after crt had improvement in pulmonary haemodynamics: the time of radionuclide bolus transit thought arterial section of lung (tam) and time of radionuclide bolus transit from right to left ventricles (tlung) decrease from 7.95±3.3 to 6.25±2.5 sec (p=0.01) and from 16.9±6.45 to 13.8±5.6 sec (p=0.01), respectively. conclusion: our results suggest that crt improved of pulmonary and central haemodynamics as well as of left ventricular contractility in patients with severe heart failure. fpra and muga are useful methods fore monitoring of crt effect. aim the aim of this study was to investigate whether early myocardial tetrofosmin imaging (t1, 15 min after injection) provided additional information in detecting coronary artery disease with respect to standard delayed scan (t2, 45-60 min). one-hundred and twenty patients (100 male, 20 female, mean age 61+/-10 yrs, range 23-83) with anginal symptoms underwent single or two-day stress-rest tetrofosmin gated spect. in all conditions, t1 an t2 were obtained after stress and at rest with the same gamma cameras and using the same acquisition parameters. combines myocardial perfusion/function analysis was performed on a 20segment model using qps/qgs software (cedar sinai). coronary angiography was obtained within one month in all patients and stenosis > 50% at quantitative analysis was considered significant. results among clinical and nuclear variables, univariate predictors of coronary artery disease included: gender; previous myocardial infarction; previous ptca/cabg; t1 and t2 summed stress, rest and difference scores, t1 and t2 post-stress and rest wall motion scores; t1 and t2 post-stress and rest ef, t1 and t2 ef. multivariate logistic analysis of the most predictive and not correlated variables revealed previous myocardial infarction, t1 summed difference score and t1 ef as the most important predictors of significant coronary artery disease (p<0.001). according to roc curves analysis, the optimal cut-off to identify coronary artery disease was 2 for t1 summed difference score providing a global diagnostic accuracy of 0.81 (sensitivity: 0.75; specificity: 0.77). moreover, roc analysis showed that a reduction in t1 ef after stress >2% was the optimal cut-off to identify patients with coronary artery disease (sensitivity: 0.80; specificity: 0.77; accuracy: 0.84). the combination of t1 summed difference score and t1 ef resulted in a significant increase in the global chi-square for prediction of significant coronary artery disease (30.82 vs 67.90; p<0.001). conclusions our data suggested that early 15 minutes tetrofosmin gated spect is superior to standard delayed 45-60 minutes imaging providing indexes of both perfusion and function highly predictive of coronary artery disease. serum levels of crp, creatine kinase (ck), creatine kinase mb fraction (ck-mb) and troponin i of 560 patients with acs of high-risk, were measured on admission and every 6 hours for 48 hours. patients were evaluated with stress/rest 99mtc-tetrofosmin gspect before discharge or up to one month after acs. patients have been divided in group 1. acute st elevation myocardial infarction (stemi) without history of prior myocardial infarction (pmi) (18,8%), 2. stemi and pmi (2,6%), 3. non-st-elevation acute myocardial infarction (nstemi) without pmi (18,8%), 4. nstemi and pmi (11,8%), 5. unstable angina (ua) without pmi (28,9%) 6. ua and pmi (19, 1%) . infarct size was measured by myocardial perfusion defects in spect ("bull eye"); lvefr by gated spect and the left ventricular dysfunction in stress was evaluated by the ratio of ventricular volume stress/rest >1,2 or when the stress lvef was significantly lower than the lvef at rest (more than 5 percent). results: the serum levels of crp on admission were similar in all 6 groups. the pcpr, ck, ck-mb and troponin i levels were significantly related to infarct size determined by spect in all the groups, except in the patients with ua without pmi. the pcrp levels were significantly related to mn size (p = 0,0001), with a tendency to more infarct zone in the patients with pmi. higher pcrp (> 3mg/l) were related to infarct zone > 18% of left ventricular myocardium (p=0,001). pcrp levels were not related to myocardial ischemia in either groups (p=0,55). the maximum cpr levels were found in patients with lower lvefr (p=0,008). left ventricular dysfunction was not related to pcrp levels (p=0,67). conclusion: the high levels of c reactive protein are related to extension of myocardial necrosis and low left ventricular ejection fraction at rest, determined by gated spect irrespective of clinical form of acute coronary syndrome, but they are not related with stress-induced systolic left ventricular dysfunction of ischemic origin. the aim of the study was to assess (1) diagnostic accuracy of myocardial perfusion spect (mps) with low-dose ct attenuation correction (ac), and (2) the risk of concomitant correction artifacts (ca). methods: ac has been clinically validated in 95 patients with coronary artery disease (cad) verified by coronarography (group a). ca were studied in 25 patients with normal mps finding (group b). in both groups, gated stress mps has been performed with 99mtc-tetrofosmin using hybrid dual-head gamma camera with low-dose ct (ge infinia-hawkeye). rest mps was performed only in the group a. for data processing, 4d-mspect programme was used. ac was applied using ct attenuation maps. in both groups of patients, perfusion defects were compared in emission scans with and without ac. quality of spect/ct registration was assessed visually. results: in the group a without ac, perfusion defects on inferior wall were found in 57 of 95 patients. with ac, 9/57 (16%) of these defects completely disappeared. in comparison with coronarography, specificity of findings in the territory of the right coronary artery (acd) increased by 13% from 84 to 97%. in the group b without ac, no perfusion defect was found in any of 25 patients. with ac, perfusion defects appeared in the anterior wall and in the apex in 16/25 (64%) patients. in these patients, apparent spect/ct misregistration was found. in 9/25 patients without perfusion defects on ac scans, spect/ct registration was good. conclusions: considering perfusion defects in the teritory of acd, ac improved specificity of mps. in this area, no correction artifacts were found in any patient. in the anterior wall and in the apex, high frequency of correction artifacts reduced the value of ac unless the reality of the perfusion defect was supported by registration of emission and transmission scans. in order to optimise the diagnostic accuracy of ac mps, simultaneous assessment of emission scans with and without ac and inspection of the fused spect/ct images remains necessary. background: wbr is an iterative method for resolution recovery. it is designed to simultaneously suppress noise and improve image resolution and is optimised for short gated cardiac perfusion acquisitions. we have demonstrated in previous studies that the wbr technology applied to cardiac perfusion scans doesn't influence functional and perfusion parameters. considering that transient ischaemic dilation (tid) is believed to be also an important parameter for cad severity, the aim of this study is to compare the tid indexes obtained from the two reconstruction spect methods (fbp/wbr). methods: 100 patients (pts) were studied: 29 women and 71 men. mean age: 62±11 years old. 51 with past ami. after pharmacological stress test, pts went through a double stress spect acquisition. the first acquisition used 30 views, 40s/view with 2 detectors at 90º and images were reconstructed by fbp. the second acquisition used 60 views, 10 s/view, and images were treated by wbr. the 200 studies were analysed and processed with cedars-sinai software. perfusion scores (sss and sds) and functional parameters (lvef, edv, esv, sms, sts) were obtained. tid index resulted from the ungated lv stress and rest volumes ratio (usv and urv). we considered abnormal values of tid index >= 1.25.for statistical analysis, we used paired student t-test to compare fbp and wbr tid indexes. we also determined the correlation coefficient (cc) between tid and lvef, edv, esv, scores and ungated volumes) results: global paired t test for wbr and fbp tid indexes showed p<0.05. there were only 7/100 high tid for wbr and 5/100 for fbp. from these high tid, only one had a normal perfusion scan. the others had necrotic and ischaemic lesions. although 67 pts had perfusion scans showing cad lesions, only 6 (9%) showed a high tid index on fbp and 5 (7%) on wbr. conclusions: this study showed that tid index determination isn't influenced by the reconstruction method (fbp/wbr). in neither techniques (fbp or wbr), did tid index show a good correlation to lvef, edv, esv, to the ungated volumes or to any score (sss, sds, sms, sts).the low incidence of significant tid in patients with known cad is also of concern. p19 scintigraphic and hemodynamic pattern of diabetic patients with and without cardiac autonomic neuropathy undergoing adenosine stress myocardial perfusion scintigraphy p. keinrath 1 , f. gürel 2 , r. weitgasser 2 , c. pirich 1 ; 1 nuklearmedizin und endokrinologie, salzburg, austria, 2 innere medizin i, salzburg, austria. myocardial perfusion scintigraphy (mps) is recommend for cardiac risk assessment in diabetic patients. in many countries, however, there is no agreement on diabetic patient selection for mps. recent studies have demonstrated an attenuated heart rate response in diabetics during dypirdamole mps (lee et al. j nucl. cardiol. 2001) representing a subgroup with presumably increased cardiac risk. methods: we aimed to investigate whether this effect could be also found in adenosine stress mps in diabetics with or without cardiac autonomic neuropathy (can). can was diagnosed by the vagus 2000 programme ( beat to beat variation, valsalva test, 30:15 ratio and orthostasis test). 67 patients with a mean age of 65 ± 2 years with diabetes underwent adenosine stress mps (42 pts without and 25 pts with can). patients were asymptomatic or had episodes of atypical chest pain, but a negative physical exercise test. results: mean ejection fraction was 59 ± 13 % in can positive and 61% ± 12 in group can negative subjects. mps was classified as abnormal in 12% ( 5 patients) without can and in 24% (6 patients) with np, respectively (n.s.) mean stress defect scores were 4 ± 5 in patients with can and 2 ± 4 in patients without can (n.s.) . baseline heart rate (can negative pts: 73 ± 13, can positive pts 69 ± 12) and maximum heart rate (can negative pts: 91± 16, can positive pts 86 ± 14) as well as absolute or relative heart rate increase were not different in can negative or positive diabetics, either. conclusion: in this study in diabetics hemodynamic to response adenosine was not different between patients with and without can. there was not difference in scintigraphic outcome between subjects with or without can, either. our data suggest that the presence or absence of can does not yield information on cardiac risk stratification comparable to the well validated information given by scintigraphic parameters, alone. purpose of study: a reverse redistribution (rr) pattern is described with technetium (tc-99m) myocardial perfusion stress (mps) imaging. the aim of this study was to determine if there was an angiographic correlation of the finding of a rr pattern on tc-99-m mps imaging. method: we reviewed 2923 consecutive tc-99 m tetrofosmin spect stress studies over a 5 year period. 111 patients (3.8%) were found to have a rr pattern, of which 36 patients had undergone coronary angiography within 12 months. correlation was sought between rr pattern and location of angiographic stenoses, the effect of reversible perfusion defect (rd) or a fixed defect (fd) in addition to rr pattern on angiographic findings was also determined. results: of 111 patients, rr pattern occurred anterior in 32, lateral in 6, inferior in 46 with 27 having rr in more than 1 territory. of the patients who had angiography 16/36 (44%) had normal coronary angiograms, 5/36 had 1 vessel disease (vd), 8/36 had 2vd and 7/36 had 3vd. of the 36 studies 7 patients had rr pattern involving more than one coronary territory. stenosis location correlated poorly with rr pattern (lad/anterior 5/10, cx/lateral 3/9, and rca/inferior 11/22). in 7 cases, there was a rr pattern without rd or fd, of which 4 cases had normal angiographic findings,1 had angiographic disease not correlating with the rr pattern and 2 had angiographic disease correlating with the rr pattern. in 12 cases, there was a rr pattern together with rd or fd but normal angiography. in the remaining 17 cases (47%), there was angiographic disease with evidence of rr pattern with rd and/ or a fd as well but correlation with coronary territory was poor (as given above). conclusion: (1) rr pattern alone should not be used to make a decision to proceed to angiography. (2) rr pattern does not reliably correlate with the location of significant coronary artery stenosis (3) rr pattern in addition to rd or fd does not influence angiographic findings. correlation of myocardial perfusion single photon emission computed tomography with coronary artery calcium score in coronary artery disease -an indian perspective. s. simon, i. muthukrishnan, p. nagwani, h. r. kulkarni; apollo hospitals, chennai, india. objectives: the consequences of atherosclerosis can be detected by coronary artery calcium score (cacs) and stress induced myocardial ischemia on myocardial perfusion single photon emission computed tomography (mps). we assessed the relationship between stress induced myocardial ischemia on mps and magnitude by 64 slice computed tomography (ct) in patients undergoing both tests. methods: our study included 77 patients with no earlier history of coronary artery disease (cad) of both sexes ( males 63, females 14) in age group of 34-69 years. our patients were referred by cardiologists after they underwent cacs. of these 45 patients (58%) presented with symptoms which included chest pain (non anginal, anginal, atypical) presence or absence of shortness of breath, and rest (42%) were asymptomatic. for each patient coronary risk factors were noted. all these patients underwent cacs and rest and stress mps one day protocol with tc99m sestamibi within 7 days. according to the cacs patients were divided into groups a ( 0-100 cacs ), group b (100 and above cacs ), group c ( group a with symptoms), group d (group b with symptoms). results: myocardial perfusion study was positive for inducible ischemia in 28% in group a ( n=47), 67% in group b (n=30), 34% in group c ( n=32), 85% in group d (n=13). from these we observe that the incidence of ischemic mps is more with increasing cacs (p=0.02), in patients with symptoms (p=0.003) which are statistically significant. and also it is noted that more frequency of inducible ischemia in patients who presented with symptoms irrespective of cacs who are at short term risk. in negative mps cacs may be useful in long term risk stratification in finding out subclinical atherosclerosis. conclusion: the general perception is that the cacs is a good tool for long term risk stratification but it may be applicable to those patients with no significant risk factors. when there are risk factors mps is a better indicator for risk stratification for cad irrespective of cacs. further studies incorporating prognostic follow up is required. objective: peripheral arterial disease (pad) is frequently associated with significant coronary artery disease (cad) and cardiovascular morbidity/mortality. however, there is a paucity of studies disclosing the prevalence of cad by stress tc99m sestamibi myocardial perfusion imaging tomography (spect) and the effects of atherogenic risk factors (arf) on abnormal myocardial perfusion. we thus investigated the prevalence of silent cad and the impact of other arf in hypertensive (ht) patients (pts) with pad vs those without pad and no known cad. material and methods: we investigated 993 treated ht pts without known cad; 476 men, 517 women aged 66.3 ±10.1 years. all pts underwent stress and rest dipyridamole stress spect imaging that were analysed blindly by 2 experienced observers. other arf were also evaluated. it is important to note that, of these 993 pts, 398 or 40.1% had type 2 diabetes mellitus. results: we found that pad was present in 307 pts or 30.9% of our studied population. moreover, overall silent myocardial ischemia was observed by spect in 205 (20.7%) of the ht pts. of note, the frequency of silent cad increased from 20.7% to 30.3% in pts with pad (p=0.009;rr:1.46). analysis of arf indicated that pts with pad were more closely associated with male gender (p<0.0001), hypercholesterolemia (p=0.009) and smoking (p<0.0001) as compared with pts without pad. most importantly, silent cad was further increased in ht pts with pad affected by type 2 diabetes mellitus (dm) (p<0.0001;rr:1.90). indeed, the prevalence of silent cad increased from 20.7% in ht pts to 39.4% in ht pts with dm plus pad. conclusion: in this large scale population of high risk treated ht pts, the prevalence of silent myocardial ischemia is significantly greater in ht pts with pad. furthermore, the prevalence of silent cad increased significantly in dm pts. these findings should be clinically relevant in order to select ht pts who are the most suitable candidates for silent cad who require intensive medical or surgical intervention. objectives: coronary artery disease (cad) is a major complication of type 2 diabetes mellitus. because cad is often asymptomatic and the disease can be controlled through screening programs, myocardial perfusion scintigraphy may be the best practical way to accomplish this on a larger scale. the aim of our study was to screen the silent coronary artery disease in type 2 diabetic patients by perfusion myocardial scintigraphy. we also analyzed the risk factors that might be related to cad in type 2 diabetes mellitus (t2dm) patients with no classical cardiac ischemic symptoms. methods: gated single-photon emission computed tomography was performed using a same day stress/rest protocol with tc-99m sestamibi. we screened a total of 75 patients: 38 diabetic patients without evidence of cad and 37 diabetic patients with evidence of cad . gender, patients' age, known diabetes duration, smoking status, hba1c, the presence of who-metabolic syndrome defined hypertension and level of cholesterol and triglycerides were examined in order to access relationship to cad in diabetic patients. results: a semi-quantitative visual interpretation was made using short axis, horizontal, and vertical long axis myocardial tomograms and a five grade (0-4) scoring system in 20-segmental model. a study was judged abnormal if the sum of stress scores (sss) was 4. two groups of patients were compared: group a (38 patients) without clinical evidence of cardiac disease and group b (37 patients) with clinical evidence of cardiac disease. compared with group b patients (we excluded patients with combination of reversible and fixed defects), group a patients tended to have fewer perfusion reversible changes by visual analysis (t-4,817, p< 0,001), as well as by sss test (p= 0.001). correlation coefficient has been sign among visual analysis and sum stress scores (c = 0.510) . thirty-eight asymptomatic patients with normal resting ecg (group a) were examined by stress/rest myocardial perfusion scinigraphy with tc-99m sestamibi. fifteen patients (39%) considered to have positive test or significant myocardial ischemia. twenty-three showed no significant ischemic lesion (p <0.007). diabetes duration of 7.9 years was associated with silent cad (ci: 1.96;5.05), tryglicerides and hba1c were significantly associated with asymptomatic cad as well. (p<0.05 and p< 0.02). conclusions: a considerable proportion of t2dm patients have silent cad (39%). the patients with diabetes duration seven years and more should be screened routinely for the presence of cad as well as the patients with high level of hba1c. m. l. de rimini 1 , m. catalano 1 , s. comenale pinto 2 , r. ancona 2 , p. caso 2 , r. merenda 2 , a. scalzone 2 , p. muto 1 ; 1 nuclear medicine aorn monaldi, naples, italy, 2 non invasive cardiology, aorn monaldi, naples, italy. diastolic function (df) abnormalities can be an early sign of cardiomyopathy in diabetic (dm) patients (pts) with no coronary artery disease (cad) or systolic (sy) left ventricular (lv) dysfunction. echocardiography (echo) with doppler measurements of transmitral and transtricuspidal flow and myocardial (m) tissue doppler (dti), strain (s) and strain rate (sr) can evaluate df. aim: to evaluate early d dysfunction in dm pts without documented cad. methods: we studied 30 male pts: 15 non-dm and 15 dm, mean age: 54±7. selection criteria were: no history of cad or hypertension and normal perfusion at stress/rest (str/r) m-gspect (sss/sds 4). qgs quantified lv sy (ef; rwm; rwt) and d (pfr/edvs; ttpf) f. echo system seven ge, equipped with tvi function, calculated lv/rv sy and df, pulmonary artery wedge pressure (pcwp), by e/ea and left and right atrial (la/ra) peak sy tissue s and sr in 4 and 2 chambers view, at the level of the apical segment of the septal, lateral, anterior and inferior la walls, and ra free wall. pulsed doppler and dti studied early (e) and late (a) d wave velocity, ratio e/a, deceleration time (dect); l-r isovolumic relaxation time (ivrt) and pulsed doppler of pulmonary vein flow. results: at echo: significantly higher prevalence of abnormal d mitral (ratio e/a=0,83 vs 1,2) and tricuspidal (ratio e/a=0,85 vs 1,4) flow patterns and a longer mitral valve dect (245 versus 195 msec) was observed in dm vs non-dm pts. although no differences were found in la/ra diameters and volumes, the m atrial s and sr were found to be significantly (p=0,002) lower for atrial septum, ra free wall and la anterior wall in dm pts in respect of controls. no differences were found in dm and non-dm pts for sy function: ef=60% vs 64%, ivrt (91 vs 90 msec), propagation velocity of transmitral flow during early ventricular filling (vp=78,93 vs 80,12 cm/sec) and pcwp (11, 87 vs 10, 21 mmhg) . similarly at gspect: str/r pfr/edvs mean value = 2.8/2.34 in dm and 3.6/3.14 in non-dm pts (p=0,002); rest tpfr was longer in dm pts (203 ± 45ms) than in non-dm pts (172 ± 23ms), with preserved sy function (lvef= 60 ±5% / 57±5%) in all pts. conclusions: gspect can assess str/r df; impaired pfr/edvs, tpfr, la/ra s and sr in dm pts with no hypertension or cad and preserved lv-sy function can suggest an earlier functional effect of a specific dm cardiomyopathy independently of cad. würzburg, würzburg, germany, 2 st. antonius ziekenhuis, nieuwegein, the netherlands, 3 objectives: for quantitative comparison of myocardial perfusion spect scans (mps), the 17-segment model conventionally used for clinical analysis has an undesirably low resolution, resulting in numerical obfuscation of extreme differences in small areas. the objective of this study was to establish a segment model that allows for detailed quantitative comparisons of mps and compare this to the 17segment model. methods: a 68-segment model was defined by quartering each segment of the 17-segment model. both models were applied to 6 tl-201 and 6 tc-99m repeated phantom mps, 20 repeated tl-201 and 20 repeated tc-99m-sestamibi patient mps from an ethical board-approved study. mean segmental counts-per-pixel values for the 17-and 68-segment model were calculated based on 460 data-points extracted from mps using the munichheart software. for each segment the difference between repeated scans was calculated. spiral profiles for the difference per segment between scans were then generated. results: tl-201: the overall variation between repeated phantom mps was 2.3% (95% ci: -0.7 to 5.4 %) for the 17 segment model. for the 68-segment model this was 4.5% (95% ci: 0.4 to 8.6%). for patient scans overall variation was -5.0 % (95% ci: -4.0 to -6.0%) for the 17-segment model and -6.1% (95% ci: -7.3 to -4.8%) for the 68-segment model. tc-99m: the overall variation between repeated phantom mps was 0.9 % (95% ci: -1.6 to 3.3%) for the 17 segment model. for the 68-segment model this was 2.9% (95% ci: -2.2 to 6.4%). for patient scans overall variation was -1.6% (95% ci: -4.3 to 1.0 %) for the 17 segment model and -5.2% (95% ci: -6.4 to -4.1%). spiral profiles: comparing the spiral profiles for the 17-and 68-segment model showed that the 68-segment model showed higher extreme deviations than the 17-segment model. regions of variability could be identified in more detail than in the 17 segment model. conclusion: the 68-segment model allows for more detailed analysis of differences than the 17-segment model when comparing mps quantitatively. research support: supported financially by tyco healthcare. würzburg, würzburg, germany, 2 st. antonius ziekenhuis, nieuwegein, the netherlands, 3 utrecht university, utrecht, the netherlands, 4 tyco healthcare b.v., petten, the netherlands, 5 umc utrecht, utrecht, the netherlands. objectives: simultaneous acquisition of a tl-201 rest myocardial perfusion spect (mps) and a tc-99m-sestamibi labelled stress mps is a much sought-after procedure in nuclear cardiology. before this procedure can be applied clinically, tl-201 rest-mps before and after an exercise test need to be compared for equality. for interpretation of this comparison, the normal variation between two repeated mps needs to be known. the objective of this study was establishing a normal range for the variation between repeated rest tl-201 and repeated stress tc-99m-sestamibi mps. methods: ethical board approval was obtained. in 20 patients repeated tl-201 rest-mps and in 20 patients repeated post-stress tc-99m-sestamibi mps was performed. also 6 repeated anthropomorphic thorax phantom mps were obtained for both isotopes. quantitative analysis of mean counts-per-pixel for each segment in a 17segment model was done using the munichheart program. subsequently, statistical methods were used to calculate a normal range of variation. visual analysis was performed by 2 independent observers scoring each of the repeated 17 segments for each patient on a scale of 0-4. results: tl-201: the overall variation between repeated phantom mps was 2.3% (95% confidence interval (ci): -0.7 to 5.4 %). for patient scans this was -5.0 % (95% ci: -4.0 to -6.0). observer 1 scored 6.4% of segments differently between repeated scans; observer 2 did so in 8.8% of segments. the observers disagreed in 3.7% of segments. the differences were not clinically significant. tc-99m: the overall variation between repeated phantom mps was 0.9 % (95% ci: -1.6 to 3.3%). for patient scans this was -1.6% (95% ci: -4.3 to 1.0 %). observer 1 scored 2.9% of segments differently between repeated scans; observer 2 did so in 3.2% of segments. the observers disagreed in 3.1% of segments. the differences were not clinically significant. overall: the mean difference per segment for repeated phantom spect scans did not differ significantly between the tl-201 and tc-99m tests (paired t-test, p=0.24) , and were significantly correlated (pearsons' r = 0.70, p = 0.002). the mean difference per segment for repeated patient spect scans differed significantly between the tl-201 and tc-99m patients (paired t-test, p=0.025) conclusion: on average, tl-201 and tc-99m-sestamibi mps show only minor variation when repeated; a normal range of variation between scans was calculated. the difference between tl-201 phantom-and patient-mps indicates a biological source of variation in patients. research support: supported financially by tyco healthcare aim: to study the prevalence of ischemic heart disease (ihd) in patients with diabetes mellitus who are asymptomatic for ihd with myocardial perfusion study (mps) . materials and methods: this retrospective study included 62 patients known for diabetes mellitus of more than 5 years duration of both sexes with or without additional risk factors for ihd but without any clinical evidence of ihd. patients were selected from the group referred by the cardiologists for myocardial perfusion single photon emission computed tomography (spect). patients with known ihd were not included in this study. age matched asymptomatic non-diabetics [n = 21] without risk factors for ihd were evaluated with myocardial perfusion spect as controls. these patients were subjected to a rest and stress technitium-99m sestamibi myocardial perfusion spect. the images were interpreted as fixed perfusion defects, inducible ischemia or both. twenty-two patients with inducible ischemia underwent coronary angiography. these results were correlated with glycosylated hemoglobin {hba1c}; duration of diabetes; and presence of additional risk factors for ihd -hypertension [bp>140/90], hyperlipidemia [total cholesterol > 240 mg/dl, ldl > 160 mg/dl, hdl < 35 mg/dl], obesity [body mass index > 25 kg/ sq. m], smoking, and a family history of premature ihd. results: significant perfusion abnormalities were found in 45 out of the 62 patients [75 %] and 3 out of the 21 [14%] controls. hence cad was 5 [relative ratio] times more prevalent in diabetics than in controls. in 45 patients, the extent of myocardial ischemia or perfusion defects increased with duration of diabetes and with poor glycemic control [elevated hba1c] statistically significant with [p = 0.04]. nine out of 22 patients [41%] who underwent angiography had significant perfusion abnormalities in mps but without significant coronary stenoses [< 70%]. the correlation of mps with coronary angiogram showed a sensitivity and specificity of 100% and 59% respectively. conclusion: due to autonomic dysfunction in diabetes mellitus, chest pain is uncommon in spite of the underlying "silent" myocardial ischemia, warranting a thorough cardiac evaluation. mps is a sensitive modality for screening of subclinical ihd in diabetics. . perfusion of 73.1%, 76.9% and 72.7% in the segments with severe, moderate and mild perfusion defects respectively. pre-operative rest mps showed 409/720 hypo-perfused segments with 74 (18.1%) segments with severely decreased perfusion, 161 (39.4%) segments with moderately and 174 (42.45%) with mildly decreased perfusion. after revascularization, perfusion in these segments was improved in 39.2%, 82.6% and 91.95% respectively. there was no change in 60.8% of segments with severely decreased perfusion. conclusion: the positive effect of cabg surgery in the area of severely hypoperfused segments on rest mps was not observed in more than in 60% of segments. segments with severely decreased perfusion showed fixed defects normally associated with myocardial infarction. however the significant improvement in myocardial perfusion after cabg was demonstrated in segments of moderate and mild perfusion defects. myocardial perfusion scintigraphy with tc99m sestamibi provides useful information for assessment of coronary artery bypass surgery and prognosis of revascularization in patients with ischemic heart disease. the role of captopril renal scintigraphy for the qualification to the pta of the stenosed renal artery. m. kostkiewicz 1 , t. przewlocki 1 , d. rzeznik 2 , w. szot 1 , a. kablak-ziembicka 1 , w. jarosz 1 , w. tracz 1 ; 1 john pauil ii hospital, dept of nuclear medicine, krakow, poland, 2 john pauil ii hospital, dept of nulcear medicine, krakow, poland. stenosis of renal artery is the most common cause of secondary hypertension and renal insufficiency. renal perfusion imaging (rpi) with ace inhibitors is well acknowledged study in diagnosis of these diseases. percutaneous transluminal angioplasty (pta) of stenosed arteries is currently one of methods of treatment in this group of patients, however, there are no effective methods of noninvasive control in those subjects and indications for pta still remain unclear. methods the group of patient studied comprised of 24 people (14 males and 10 females, mean age 61.04_+ 8, 72) with ischemic heart disease, referred for pta, in whom angiography revealed stenosis of one or both renal arteries. all the patients had rpi with ace inhibitors performed with 2-days protocol with minimum 48 hours between the first and second study -initially and 3 months after pta. the values of gfr, time to peak of renographic curve (tmax), renal perfusion images, value of renal inflow and shape of renographic curves were analyzed. two independent observers were evaluating data in aim to refer the patient for pta. 3-grade scale was used: 1 -stenosis not significant or normal images, 2 -borderline stenosis, 3 -significant stenosis. the data obtained were compared with ultrasonographic studies. rpi was repeated after 3 months to evaluate late outcome of treatment and probability of recurrent stenosis. results. in studied group of patients left renal artery stenosis was found in 13 pts, right in 9 pts and bilateral in 2 pts. pta proved to be successfully performed in all those pts. in 2 pts recurrent stenosis was found and subsequent pta was performed. in 2 pts, despite successful pta, no improvement in renal function was found in control study. those pts had low gfr values (below 20 ml/min.) together with nephrectomic type of renographic curve. scintigraphic image was consistent with angiographic localization of renal artery stenosis. in 2 pts, despite the presence of significant stenosis the scintigraphic images were normal. conclusions rpi with ace inhibitor is substantially efficient study in referring pts for pta and evaluation of late results. in case of severely impaired renal function the rpi should be the reason for postponing the pta. kbn 2po5bo1528 aim: coronary revascularisation is effective in many patients with stable angina pectoris. however, in some patients symptoms may persist or even progress, probably because of persisting regional hypoperfusion. we examined the rates of unchanged or worsened perfusion two years after coronary revascularisation. material and methods: a prospective series of 139 patients (30 females) with a mean age of 60.3 ± 8.0 years underwent coronary revascularisation for stable angina pectoris. myocardial perfusion scintigraphy (mps) was performed before angiography and two years later. the decision of invasive management was based exclusively upon patient history and angiographic findings since the result of mps was kept secret. the mps studies were reviewed to determine if a change, e.g., from a reversible to a mixed defect or from a mixed to a fixed defect was due to improvement (i.e., smaller defect) or deterioration (i.e., larger defect or decreased reversibility at unchanged defect size). results: before revascularisation, the rates of normal perfusion or of reversible, mixed, or fixed defects were 17% (24/139), 53% (74/139), 23% (32/139), and 6% (9/139), respectively. two years following revascularisation, improvement in perfusion was noted in 0% (0/24), 77% (57/74), 38% (12/32), and 0% (0/9) of these groups, respectively, summing up to improvement in 50% of the entire study population (69/139). perfusion remained unchanged in 41% (57/139) corresponding to 79% (19/24), 19% (14/74), 47% (15/32), and 100% (9/9) of patients with initially normal perfusion, or reversible, mixed, or fixed defects, respectively. in the remaining 9% (13/139) of patients there was a worsening of perfusion. worsening of perfusion was deemed serious in only 3 of the 13 patients with a worsened perfusion. conclusion: two years following revascularisation, the relationship between improvement, no change, or a deterioration in myocardial perfusion was in stable angina pectoris patients approximately 5:4:1. serious deterioration was a seldom event. improvement was noted exclusively in the patients with reversible or fixed perfusion defects suggesting that preoperative mps might potentially improve the overall result of coronary revascularisation by straining off patients with normal perfusion or fixed perfusion defects. f. marranzano 1 , m. caruso 1 , c. privitera 1 , g. privitera 1 , g. rapisarda 2 , a. la rosa 2 , s. gusmano 2 ; 1 dip. immagini az.osp.un. ove, catania, italy, 2 uoc cardiologia az.osp.un. ove, catania, italy. aim to determine the clinical features of myocardial perfusion imaging in a novel heart syndrome with transient left ventricular apical ballooning( ab) , but without coronary artery stenosis, that mimics acute myocardial infarction. several case studies of ab, so called takotsubo cardiomyopathy ( tm), have been reported. tm is characterized by angina-like precordial pain and st-segment elevation and limited release of cardiac enzymes. sometimes appears with dyspnea or syncope. the catheterization procedure shows normal coronary arteries, and apical dyskinesia is observed on contrast ventriculography. the incidence of this syndrome is not clear but it develops predominantly in elderly women. case report we present the case of a 78 year-old woman arrived to the emergency department of our institution 1 hour after emotional stress ; symptoms began with angina and dyspnea at rest . the electrocardiogram on admission showed small progression of the first vector and stsegment elevation in leads v1 to v6, with a moderate increase in levels of cardiac serum markers (ck , ck-mb, and troponin i ). on physical examination, she had a pulse of 70 beats/min and her blood pressure was 130/80 mm hg. two-dimensional echocardiography showed left ventricular dilatation with preserved systolic function in the basal segments; the midventricular segments and the apical segments were dyskinetic. the diagnosis of acute anterior myocardial infarction was established, and thrombolysis was performed by use of recombinant tissue plasminogen activator. partial signs of reperfusion were observed , with reduction of st-segment elevation. four hours after the initial symptoms appeared acute rest-sestamibi myocardial perfusion g -spect was perfomed. results acute rest-g-spect showed perfusion defects on the septal, anterior, and apical walls . by use of gated spect, it was possible to assess myocardial dyskinesia of the anterior wall and apex. coronary artery study revelead no significant stenosis of main epicardial vessels . one month later a stress-rest g-spect study ( two days maximal exercise protocols) showed no perfusion defects, and the wall motion abnormalities had disappeared, with completely normal heart function. conclusion we report a case of severe, reversible myocardial perfusion defects and left ventricular wall motion dysfunction , seen on gated spect , compatible with tm , in patient with normal coronary angiograms and dyskinesia on contrast ventriculography.g-spect is therefore a useful method for the diagnosis and follow-up of tm because it is a noninvasive imaging technique that shows the complete reversibility of this entity. clinical utility of myocardial stress-rest perfusion scintigraphy with adenosine in elderly patients with diabetes mellitus. g. p. gerasimou, t. aggelopoulou, a. revela, e. dedousi, g. liaros, e. papanastasiou, a. siountas, k. psarrakos, s. chatzimiltiadis, s. gavriilidis, a. psarrakou; ahepa university hospital, thessaloniki, greece. coronary artery disease (cad) in elderly patients with diabetes mellitus (dm) is often characterized by occult or absent symptoms. these patients are not able to achieve an acceptable level of ergometric exercise. this study has as purpose to assess the diagnostic value of stress/rest radionuclide myocardial perfusion scintigraphy (rms) with adenosine (adn) in patients with dm, older than 60 years, with a low clinical prevalence of cad. materials and methods: fifty-six patients (18 females) with dm (mean age 67.6+6.8), with equivocal symptoms of cad are enrolled in the study. all patients underwent pharmacological intervention with adn at a dose of 140μg/kg/min in 6min under ecg inspection and 260mbq of tc99m-tetrofosmin (tf) were injected at the 3rd min of adn infusion and stress study was taking place 20min post tf injection. four hours after pharmacological test, rest study was performed 30min post iv injection of 740mbq of tf. coronary angiography (ca) has been performed to all patients. results: the left ventricle of the patients was divided into 9 segments (apex and apical plus basal segment of the anterior, lateral, inferior wall and interventricular septum). a segment was considered as abnormal, if the counts revealed were less than 75% compared to the data of normal population. in ca, a stenosis was considered significant when it exceeded 60% of a vessel's lumen or accordingly to the fraction flow reserve. in 12 of the patients stress/rest radionuclide tf test has been considered within normal limits. in these patients ca revealed a stenosis of the coronary vessels in one of the patients, in one of the coronary vessels. in the remaining 44 patients, reversible myocardial ischemia has been mentioned to 60 out of a total of 396 segments, whilst findings compatible with myocardial infarction have been reported to 2 of these patients, numbering 3 additional segments of the left ventricle. ca has been considered as abnormal in 40 of these patients, with total occlusion of the coronary arteries in both patients with myocardial infarction as mentioned to rms. according to these results, the sensitivity of rms has been considered as high as 97.5%, whilst specificity was at the level of 73.3%. conclusions: in elderly patients with dm, presenting silent myocardial ischemia, rms with adn challenge, is a sensitive tool in the diagnosis of cad. purpose: some authors reported that a reduced i-123 bmipp uptake in the myocardium in patients with hcm, and the reduction of i-123 bmipp related to the myocardial abnormalities. we hypothesized that the abnormality of fatty acid uptake and metabolism may occur before it can be visually recognized on spect images in patients with hcm. a distribution volume (vd) of i-123 bmipp could be useful for detecting such abnormality of myocardial fatty acid metabolism. the purpose of this study was to investigate vd of i-123 bmipp in myocardium through a compartment model analysis in patients with hcm. methods: twenty-eight normal controls and 30 patients with hcm were studied. i-123 bmipp and tc-99m tetrofosmin spect were performed. according to the literaturere, the uptake of tc-99m tetrofosmin and i-123 bmipp are preserved in very early phase of hcm. in moderately advanced phase of hcm, the uptake of i-123 bmipp is reduced, but the uptake of tc-99m tetrofosmin is preserved. in severely advanced phase, the uptake of tc-99m tetrofosmin is also reduced. based on these results, we defined early hcm as normal uptake of tc-99m tetrofosmin and i-123 bmipp, moderately advanced hcm as normal uptake of tc-99m tetrofosmin and decreased uptake of i-123 bmipp, and severely advanced hcm as decreased tc-99m tetrofosmin and i-123 bmipp. moreover, all the myocardium was divided into 13 segments. finally, these 390 segments of hcm were categorized into early, moderately and severely advanced hcm segments. by using the timeactivity curves, we analyzed bmipp pharmacokinetics through a 2-compartment model. we defined k1 and k2 as influx and outflux rate constant between blood and reversible component, k3 as specific uptake rate constant between reversible and irreversible compartments. additionally, we calculated k1/k2 as vd. results: the results were summarized in the table. the vd of i-123 bmipp was gradually decreased with progression of hcm, and there was statistically significant difference between normal and each hcm group (p < 0.005 in each group). conclusion: vd of i-123 bmipp might be useful index to evaluate the progression of hcm. however, uptake of i-123 bmipp was not reduced in early hcm group at least with visual qualitative approach. these results indicated that a mathematical compartment model analysis might be useful to detect subtle change of fatty acid metabolism in patients with hcm, and not only for identification of hcm in very early stage, but also for evaluation of the progression of hcm. aim: 99mtc-sestamibi (mibi) shows good retention in normal myocardium after the initial uptake. but, the washout is sometimes observed in ischemic hearts. these suggest the possibility that the washout rate of mibi would be a useful indicator of myocardial damages or dysfunction. this experimental study evaluated the mibi washout by hypoxic myocardial damage using electrically paced isolated rat hearts. methods: isolated rat hearts were electrically paced at 300 beat/min and were perfused with oxygen-saturated krebs-henseleit solution of constant flow of 6ml/min. heart rate and left ventricular pressure (lvp) were measured. after mibi (15 to 25 mbq) was infused for 5 minutes, mibi washout was observed in the following two groups: the control group that was continuously perfused with oxygen saturated solution for 60 minutes and the hypoxic group that was perfused with oxygensaturated solution for 30min followed by nitrogen-saturated solution including glucose. cases of irreversibly damaged hearts were excluded. radioactivity in the heart was continuously measured using a gamma camera equipped with pin-hole collimator. mibi washout rate was evaluated by the slope of time-activity curve (tac) for roi of whole heart. results: the mean mibi uptake in the isolated heart was 10.5±1.6 %/added dose. in the control group, mibi showed good retention with a very gentle slope of tac (-0.17±0.08%/min). in the hypoxic group, the slope of tac was significantly increased (-1.37±0.57%/min). under hypoxic condition, lvp was reduced first, and then the diastolic pressure (dp) was elevated. the change of tac slope simultaneously occurred with the rise of dp, not at the initiation of the hypoxic condition. carbonyl cyanide-m-chloro phenylhydrazone (cccp), a mitochondrial uncoupler, induced similar increase of the slope of tac under the same condition, suggesting that the mibi washout induced by the reversible hypoxic damage observed here was implicated in mitochondrial function. conclusion: the myocardial washout rate of mibi can be a useful marker of myocardial viability. aim: initial clinical studies have shown that bone marrow progenitor cells had beneficial effect on the healing process after myocardial infarction. the aim of the present study was to evaluate the effects of intracoronary infused bone marrow derived progenitor cells (cd34+) on regional myocardial viability and perfusion by [18f]fdg pet and [99mtc]mibi spect in patients with first episode of acute myocardial infarction. materials and methods: 7 patients were treated by percutaneous revascularisation and stenting of the occluded artery; 6 left anterior descending (lad), 1 right coronary artery (rca). all patients received intracoronary infusion of autologous cd34+ bone marrow stem cells 12±1 days after the revascularisation. all patients underwent fdg-pet and mibi-spect before transplantation and 6 months afterwards during follow-up. for quantitative evaluation of myocardial [18f]fdg and [99mtc]mibi uptake a ventricular segmentation scheme (16 segments) was applied. mean signal intensities (msi) of the segments assigned to the lad/rca distribution were callculated for each patient. results: pet studies showed a highly significant increase of the msi in the infarct area from 56.6±11.8% to 72.2±13% (p=0.007). no statistically significant differences were found in myocardial [99mtc]mibi uptake before (52.8±10.3%) and after (59.0±15.9%) stem cell translpantation(p=0.152) conclusion: our results indicate that local intracoronary cd34+ progenitor cell therapy results in a significant increase in myocardial viability of the infarct zone. aim in patients with previous myocardial infarction, the relationship among viability, ischemia, volume overload and systolic dysfunction is still unclear. methods we studied 90 patients (age 64±10 yrs, 75 male) with previous myocardial infarction (27 anterior, 45 inferior, 18 lateral). all patients underwent a single day rest postnitrate/stress tetrofosmin g-spect study. g-spect analysis was performed using qgs/qps protocols. viability was scored according to a summed rest score (srs) <3 (mostly viable), 7-4 (partially viable), and >8 (mostly necrotic). in each category, summed difference score (sds) provided the presence (sds>4, group 1) or the absence (group 2) of myocardial ischemia. results according to srs, 38 patients showed mostly viable, 22 partially viable and 30 mostly necrotic myocardium. in patients with mostly viable myocardium, mean resting lvef resulted lower in g1 than in g2 patients (50±8% vs 58±10%, p<0.01) and significantly changed following exercise only in g1 (from 50±8% to 48±7%, p=0.02). mean resting edv was higher in g1 than in g2 (p<0.02) and did not change following exercise in both groups (p=ns). delta sms (resting sms -exercise sms) resulted significantly lower in g1 than in g2 patients (-4.4±3.8 vs -0.9±5.0, p<0.001) , suggesting the presence of exercise induced regional stunning. in patients with partially viable myocardium, mean resting lvef was lower in g1 than in g2 patients (39±5% vs 46±4%, p<0.005) and significantly changed following exercise only in the presence of myocardial ischemia (g1, from 39±5% to 36±5%, p=0.05). mean resting edv was higher in g1 than in g2 patients (p<0.01) and did not change following exercise in both groups (p=ns). again, delta sms resulted significantly lower in g1 than in g2 patients (-4 .8±7.2 vs 3.7±4.0, p<0.01). in patients with mostly necrotic myocardium, mean resting lvef resulted similar between g1 and g2 (36±11% vs 30±9%, p=ns) and did not change following exercise (p=ns). similarly, mean resting edvs were 159±40 ml and 188±58 ml (p=ns) in g1 and g2 patients and did not change following exercise (p=ns). delta sms resulted similar between g1 and g2 patients (-0.6±5.4 vs -3.9±7.6, p=ns) . conclusions in patients with previous mi, ef decreases and edv increases proportionally to the amount of scarred myocardium. at any level of tissue viability, transient ischemia has an additional role in determining the degree of resting systolic dysfunction and volume overload. repetitive episodes of ischemia during daily activity could modulate the extension of scar and the time course of lv dysfunction. several studies have indicated that contrast-enhanced magnetic resonance imaging (cmr) enables the visualization of infarction and reperfusion.so far there are only a few reports comparing cmr with spect early after ami.the aim was to compare tl-201 rest(r)-redistribution(rd) perfusion spect results with cmr in patients early after ami. methods:twenty-nine patients (21 males,8 females;62±11 yrs) with recent ami were studied.within 6 days after ami, the patients were performed tl-201 r-rd perfusion spect using 4 mci activity.cmr was carried out 5-20 minutes after 0,15 mmol/kg of iv.gadobutrol injection.myocardial perfusion and contrast enhancement was analyzed using a 17 segment model.myocardial perfusion was scored in tl-201 spect as follows:0=normal (70%-100% maximal myocardial activity(mma), 1= 69-50% mma, 2= 49-30% mma ,3=29-10% mma and 4=<10% mma ;myocardial contrast enhancement on cmr images was graded as:0=no contrast enhancement, 1=hyperenhancement of 0-25% of the wall thickness(wt) 2=hyperenhancement of 26-50 % of the wt, 3=hyperenhancement of 51-75 % of wt and 4=hyperenhancement of 76-100 % of wt.in cmr the existence of microvascular obstruction(mo) was also evaluated.total segment scores(tss) in r,rd and cmr for each patient were calculated by summing of 17 segment score values. results:the mean tts values were calculated as: r-tss=15±10.8,rd-tss=14.2±10.9 and cmr-tss=22.5± 10.6.the mean differences between r-rd tl-201 and cmr were significant(p=0.000); cmr-tss values > r and rd-tts in 23/29 patients. in 24/29 patients, mo was observed.in 2/24 patients with mo, perfusion was normal in r-rd tl-201 (r and rd-tts=0, cmr-tss= 19).in 2/ 5 patients without mo,r-rd tl-201 perfusion findings were normal (r and rd-tts= 0; cmr-tts=3 and 4),1/5 patients had r-tts =o, rd-tts= 2 and cmr-tts=14.in the analysis of a total of 493 segments, poor agreement was found between cmr versus r and rd results (kappa=0.24 ve 0.27).according to coronary artery territories the agreement between the segments were: lad: cmr -r, rd (kappa= 0.26 and 0.30), rca:cmr-r,rd (kappa=0. 15 and 0.17), lcx: cmr-r, rd (kappa= 0.28 and 0.28). conclusion:a poor segmental agreement was observed between cmr and tl-201 r-rd study. the segments in rca territory showed the worst agreement comparing to lad and lcx. cmr detected infarcted areas larger in 80% of patients. this was compatible with related literature including histopathology. possible explanations for overestimation in cmr, early after ami include an altered washout characteristics of the contrast medium in the ischemically injured but viable myocardium. follow up studies after revascularization are needed to obtain reliable results in identifying accurate viable and necrotic tissues. in patients with previous myocardial infarction evaluation of myocardial viability and global left ventricular ejection fraction (ef) may provide clinically useful diagnostic and prognostic information. gated spect imaging allows simultaneous assessment of myocardial viability (according to extent of perfusion defect and preserved wall thickening) and function (left ventricular ef). the aim of the study was to compare myocardial perfusion and global ef in patients with previous myocardial infarction (mi) before and after angioplasty. materials and methods: study group consisted of 25 patients (mean age 53±8 year, 21 male) with previous myocardial infarction (before 3.6±6 months) and single vessel coronary artery disease (17 lad, 4 lcx and 4 rca). all patients underwent coronary angioplasty and stenting of infarct related coronary artery. to evaluate myocardial perfusion and function we performed rest ecg gated mibi acquisition after nitroglycerin administration. left ventricular ef was calculated from gated spect data by commercially available software 4d-mspect. myocardial perfusion abnormalities were expressed as defect extent in per cent of entire left ventricle. myocardial region was considered as viable when systolic wall thickening was present and mibi uptake was 50% of peak myocardial activity. perfusion and function were evaluated before and 3-13 months after stenting. results: according to myocardial perfusion and preserved systolic wall thickening the patients were divided in two groups: group i consisted of 16 patients with viable segments after mi and group ii of 9 patients with non-viable segments. the mean left ventricular ef in group i was higher than in group ii (60±9% vs. 39±7%, p<0.05) and perfusion abnormalities were grater in group ii than in group i (41±13% vs. 25±15%, p<0.05). after successful angioplasty and stent implantation in group i global lvef slightly increased (60±9vs 63± 9%, p>0.05) and perfusion abnormalities significantly decreased (25±15% vs. 18±14%, p<0.05). on the contrary, in group ii there was no significant improvement of lvef (39±7% vs. 43±8%, p>0.05). perfusion abnormalities were larger after angioplasty, although without statistically significance (4l±13% vs. 42±11%, p>0.05 age 65.4 ± 8 years submitted for evaluation of viability with 99mtc-sestamibi using rest-nitrate protocol with gspect and rnv. eighteen pts. had repeated studies at six months for assessment of therapy, so a total of 47 pairs of studies were obtained. gated spect was performed between 45 and 75 min after administration of 99mtcsestamibi (14 mbq/k) at rest, using 8 frames per cardiac cycle, 2x zoom factor and no beat rejection. rnv was performed 48 hours later with labeled rbcs in left anterior oblique projection, 16 frames per cardiac cycle, 2x zoom factor, and 20% window beat rejection. patients with complete arrhythmia or with ectopic beats >20% of total beats were not included for analysis. edv, esv and lvef were determined using the qgs (cedars-sinai) software package for gspect aim coronary artery disease (cad) shows higher incidence in diabetics than in nondiabetic population and is more advanced at diagnosis. the prognosis of cad is less favorable in patients with diabetes than in nondiabetics. postinfarction mortality is higher in diabetics. the available data suggest that occult cad is a comon finding among asymptomatic diabetics. stress/rest myocardial perfusion imaging (mpi) could be a useful, noninvasive procedure with diagnostic and prognostic roles. methods study population of 306 patients, 122 of them presented diabetes mellitus. clinical follow-up of 11-20months, for confirmed cardiac deaths, non-fatal myocardial infarction and others adverse cardiac events (ace) mpi was performed after administration of 740 mbq tc99m-tetrofosmine in stress and 925 mbq in rest (2 day protocol). some patients also underwent radionuclide ventriculography and coronary angiography. the obtained images were categorized as normal or abnormal: reversible, fixed or mixed myocardial perfusion defects, severity and anatomic location (right, descending and circumflex coronary artery). results aim: due to the aging of population and high frequency of obesity, the prevalence of type ii diabetes mellitus (dm) is increasing rapidly in western nations and the associated coronary artery disease (cad) is nowadays the leading cause of death in diabetic subjects. the purpose of this study was to evaluate the long-term prognostic value of gated-spect myocardial perfusion imaging (gmpi) for the occurrence of cardiovascular events in patients with dm. materials and methods: a cohort of 184 consecutive patients (76 women and 108 men, mean age 64±7 years), with at least a five-year history of dm were enrolled in this study. the population was clinically classified according to history of cad and chest pain into high-(n=78) and low-risk (n=106) groups. all subjects underwent clinically indicated rest/stress tc-99m sestamibi gmpi with physical exercise (n=117) or dipyridamole (n=67). to determine the prognostic value of gmpi the first endpoint was major acute cardiac events (cardiac death or non-fatal myocardial infarction) and the second endpoint was the revascularization rate. patients data were analysed using both kaplan-meier event-free survival curves and cox multivariate analyses. results: follow-up was completed in all patients with a median period of 2.8 years (1.9-3.5 ). the prevalence of abnormal gmpi was 56% (n=103) with reversible defects occurring in 35% (n=64), fixed defects in 6% (n=11) and mixed defects in 15% (n=28). patients with a normal gmpi had neither cardiac death, nor myocardial infarction, independently of a history of cad or chest pain. among the independent predictors of cardiac death and myocardial infarction, the strongest was abnormal gmpi (p<0.0001), followed by history of cad (hazard ratio (hr)=15.9; p=0.0001) and inability to exercise (hr=7.7; p=0.02). patients with normal gmpi had a revascularisation rate of 2.5% during the follow-up period, significantly lower than subjects with abnormal gmpi (21.1%). compared to normal gmpi, cardiovascular events increased 6.1 fold for reversible defects, 9.3 fold for fixed defects and 22.6 fold for the association of both defects. conclusion: dm patients with normal gmpi seem to have an excellent prognosis independently of history of cad. on the opposite, an abnormal gmpi led to a more than 6-fold increase in cardiovascular events. this study outlines the additional value of gmpi in predicting cardiovascular events and risk-stratifying dm patients even if larger prospective trials are mandatory to confirm these findings and to assess their potential impact in clinical settings. the detection of myocardial ischemia in patients with preexisting left bundle branch block (lbbb) remains problematic. myocardial perfusion scintigraphy (mps) with dipyridamole is the preferred non-invasive diagnostic modality for this group of patients. materials and methods: seventy six patients with preexisting lbbb underwent sestamibi perfusion imaging with dipyridamole infusion protocol (0.56 mg/kg). stress and rest spect studies were acquired using single head ecam (siemens) and double head toshiba gca-7200a gamma cameras. images were interpreted by consensus of two experienced observers and classified as, low risk group (normal mps, small reversible/small fixed defect) and high-risk group (a large severe fixed or reversible defect and dilated lv cavity). 76 patients with mean age of 53±10 years (range=39-72 years) were included in the study. these patients were followed up for 24 months ± 8 months and occurrences of hard cardiac events (mi or cardiac death) were asked by telephones. results: out of 76 patients 52 had low-risk scans (68%) and 24 had high-risk scans (32%). in low risk group cardiac deaths were observed in 1/52 (1.9%) and non-fatal mis were seen in 2/52 (3.8%). in high-risk scans, 5 suffered cardiac death (20.8%) and non-fatal mis in 3 (12.5%). over all survival rate was 98.1% in the low-risk group compared with 79.16% in the high-risk group with a significant difference (p=0.0338). conversely, the negative predictive value of a normal myocardial perfusion scintigraphy for the occurrence of death was 100%. conclusion: myocardial perfusion imaging with dipyridamole stress provides important prognostic information in patients with left bundle-branch block, which is incremental to clinical assessment. aim; revascularisation of occluded coronary arteries and bypass grafts with insertion of drug coated and non drug coated [bare metal] stents has become the preferred choice of treatment in recent years for patients with multivessel coronary artery disease [cad] .our aim was to evaluate the role of gated spect [gspect] in patients who underwent multivessel ptca /stents. materials and methods: we evaluated 41 patients[32 males,9 females, mean age 53yrs] referred with chest pain 6-24 months after ptca/stent procedure in multiple coronary vessels including bypass grafts.all patients underwent two day stress/rest technetium-99m-tetrofosmin myocardial perfusion gated spect [gspect] [2] [3] [4] [5] [6] .coronary angiography showed instent restenosis in 7 patients and progressive cad in 5 patients with patent stents.9 patients were treated with redo ptca/stent and 3 had cabg .no myocardial event was seen at 10-12 months follow-up. 9[22%] patients were considered normal [sds 0-1] .coronary angiography showed partial instent restenosis in 3 of these patients. no adverse myocardial events were seen in these patients at 10-12 months followup. 5[12%] patients had fixed defects and event free follow-up .conclusion:our study shows that technetium-99m-tetrofosmin myocardial perfusion gspect can be used as a powerful prognostic tool in patients who were treated with multivessel ptca/ stents aim: extension and severity of myocardial scar may condition short and long term efficacy of autologous stem cell treatment. methods: five male patients (mean age 56 â± 3 yrs) with previous myocardial infarction, multivessel coronary artery disease underwent 10 to 23 intramyocardial 0,1 ml injections of autologous stem cell in scarred myocardium concomitant with off-pump coronary artery bypass grafting. after open heart surgery, stem area was mapped on a 3d heart model by a cardiologist and a cardiac surgeon and transferred to the 20-segment model used for scintigraphic analysis. delivery area was chosen according to: 1) dominance of scar; 2) akinesis; 3) ungraftability of the tributary coronary artery. 99mtc tetrofosmin gated spect (370 mbq, 64 views in a 180 degrees orbit, double head gamma camera) was performed at rest before, 10 weeks and four years after treatment with the same camera and acquisition parameters. severity of scar was quantified as number of standard deviations below matched normals according to qps protocol (ge health care) in 20 segments. in the same segments regional wall thickening was quantified by qgs protocol (ge health care). results: ten weeks after the implantation, gated spect showed an improved regional perfusion in stem area in 2 patients in whom the reduction of scar was 32% and 61%, respectively. one patient showed a further reduction of 10% after four years. 3 patients who did not improve regional perfusion both at short and long term follow-up showed a more extensive scar area and an impairment in regional wall motion before surgery. conclusion: in patients with previous myocardial infarction and multivessel coronary artery disease undergoing stem cell treatment in ungraftable areas, reperfusion was higher in those segments with more viability and less akinesis. results observed at 10 weeks were confirmed by gated spect at long term follow-up. gated spect appears to be an optimal tool to assess short-and long term effect of stem cell treatment on regional blood flow and function. background: there is a lack of validation and standardization of acquisition parameters for myocardial 123i-metaiodobenzylguanidine (mibg). this lack of standardization hampers large scale implementation of 123i-mibg parameters in chronic heart failure (chf). methods and results: in a retrospective multi-center study 123i-mibg planar scintigrams obtained on 290 chf patients (82% male; 58% dilated cardiomyopathy; nyha>i) were reanalyzed to determine the late heart-tomediastinum ratio (h/m). there was a large variation in acquisition parameters. multivariate forward stepwise regression showed that a significant proportion (31%, p<0.001) of the variation in late h/m could be explained by a model containing patient related variables and acquisition parameters. left ventricular ejection fraction (p<0.001), type of collimation (p<0.001), acquisition duration (p=0.001), nyha class (p=0.028) and age (p=0.034) were independent predictors of late h/m. conclusions: acquisitions parameters are independent contributors to semi-quantitative measurements of cardiac 123i-mibg uptake. improved standardization of cardiac 123i-mibg imaging parameters would contribute to increased clinical applicability for this procedure. objectives: for investigating the effects of suppression of myocardial sympathetic innervation on the myocardial adrenergic activity and norepinephrine transporter (net) density, the study undertaken 123i -metaiodobenzyl guanidine (mibg) myocardial imaging and and myocardial net immunohistochemistry in sprague-dawley (sd) rats following surgical sympathectomy (sx) at superior cervical ganglia. methods: twelve 12-wk-old male sd rats were included in this study, 4 rats were subjected to right-sided surgical sx (rsx group), 4 rats were subjected to left-sided surgical sx (lsx), and another 4 rats were subjects to sham operation for control (c group) . all rats were undertaken myocardial imaging within 48 hours following operation. 123i-mibg myocardial images were performed for the early and delayed imaging using a gamma camera (picker prism 1000 xp) equipped with a 2-mm pinhole collimator. the heart-to-mediastinum count ratios (h/m) of the 15-min initial imaging and the 4-h delayed imaging were determined, then the myocardial washout rate (mwo) was determined for being a marker of uptake-1 activity. following 123i-mibg myocardial imaging, the rats were sacrificed and the isolated hearts were collected for net immunohistochemistry. results: the results demonstrated the early mibg h/m of rsx rats were lower than that of control rats (h/m: 1.91+0.15 in rsx; 2.96+0.15 in control rats, p < 0.05), whereas h/m in lsx rats were similar to control rats (h/m: 2.59+0.19 in lsx; p= ns vs. control rats). the mwo of control rats were higher than that of sx rats; whereas the lsx rats were higher than that of rsx rats (control rats: 0.67+0.10, vs. rsx: 0.29+0.08; p < 0.01; lsx 0.46+0.05,p < 0.05 vs. control rats). the myocardial net immunohistochemistry revealed the density in rsx rats were higher than in lsx rats, whereas the net density in lsx were higher than that of control rats. conclusion: based on the above findings, we suggest myocardial sympathetic dennervation will develop following right-sided sympathectomy, which will accompanied by compensated uptake-1 system on presynaptic nerve endings of postganglionic neuron, demonstrated by lowered mwo and increased net density. role of i123-mibg cardiac scintigraphy in differential diagnosis between alzheimer's and lewy bodies dementia e. m. covelli, p. sullo, g. mazzarella, m. salzillo, g. vitale, g. belfiore; s. anna e s. sebastiano hospital, caserta, italy. purpose: lewy bodies are abnormal structures in the mid-brain: microscopic protein deposits found in nerve cells that disrupt the brain's normal functioning. lewy body disease (lbd) is the second cause of dementia in older adults caused by abnormal structures in the brain. lbd diagnosis can be difficult because many of the symptoms are similar to alzheimer's disease (ad), and cerebral perfusive tomography is always non conclusive. i123-metaiodobenzylguanidine (i123-mibg) is a radioiodinated analogue of noradrenaline. i123-mibg scintigraphy is a non-invasive and safe diagnostic tool to assess and evaluate cardiac sympathetic innervation. the aim of this study is to evaluate the cardiac sympathetic innervation by i123-mibg scintigraphy in patients with clinically demential symptoms and inconclusive tc99m-ecd perfusive tomography in order to help the differential diagnosis between lbd and ad. methods: fourteen patients (9f, 5m; mean age 67±16 years) with suggestive dementia symptoms underwent cerebral tc99m-ecd tomography and cardiac i123-mibg scintigraphy. cerebral perfusive tomography was performed one hour after tc99m-ecd (740 mbq) injection and qualitative analysis was used for diagnosis. cardiac i123-mibg scintigraphy was carried out in all patients within one week and planar scintigraphic images were acquired 4 hours after i123-mibg (111 mbq e.v.) administration. semiquantitative analysis was also performed calculating delayed (4 hours) heart to mediastinum count-ratio (h/m) by drawing regions of interest (rois) over the upper mediastinum and whole heart to confirm diagnosis. results: all patients submitted to cerebral tc99m-ecd tomography presented severely reduced tracer uptake suggestive to dementia but we observed a different cardiac innervation pattern between ad and lbd patients. in fact, cardiac i123-mibg scintigraphy showed normal uptake (delayed h/m: 1.92±0.16) in eight patients diagnosed as having ad and abnormal reduced cardiac tracer accumulation (delayed h/m: 1.27±0.22, p<0.05) in remaining six lbd patients. conclusions: a significant decrease of cardiac mibg accumulation indicating a relevant degeneration of myocardial sympathetic neurons in lbd patients was detected. therefore, these preliminary data suggest that cardiac i123-mibg scintigraphy may be useful in the differential diagnosis between ad and lbd especially when cerebral tc99m-ecd tomography is not conclusive and it can be considered a suitable and helpful tool in the management of patients with dementia syndromes. a new iterative reconstruction algorithm (wbr™) has been recently proposed for cardiac spect. the wbr™ technology, based on accurate modelling of the emission-detection process, was designed to reduce noise improving lesion detectability without affecting the image resolution. few data exist on the comparison between filtered back-projection (fbp) and this new algorithm in a clinical setting. aim. the aim of this study was to compare the performance of fbp and wbr™ in the clinical arena. methods. a group of 18 pts, with different cardiac pathology, scheduled for a stress-rest spect were studied. a two-day 99mtc-sestamibi protocol was used. all pts performed standard ecg-gated spect acquisitions with a dual-head@90° camera, with a time/frame of 20 sec. immediately after the conclusion of the acquisition, a second ecg-gated acquisition was performed at half-time/frame (10sec). standard-time spect was reconstructed with a conventional fbp (butterworth, 0.4, 10); half-time spect was reconstructed with wbr™. tracer uptake was blinded evaluated by two experienced observers in 17 segments with a 4point scoring system (from 0=normal to 4=absent). discrepancies were resolved by consensus. summed stress scores (sss) and summed rest scores (srs) were calculated. lv ef were automatically calculated with qgs. results. no significant differences were observed in sss and srs between half-time wbr™ spect (21.5 and 21.0, respectively) and standard-time fbp spect (22.1, and 20.7, respectively, ns) . lv ef on rest acquisitions was also comparable (43.6% on half-time spect vs 44.2% on standard-time spect, ns). lv ef on post-stress studies in half-time spect (40.3%) was lower than standard-time spect (46.7%), although not statistically significant. conclusions. visual analysis of half-time/frame spect reconstructed with the new algorithm wbr™, was comparable to that of a standard time/frame spect acquisition reconstructed with conventional fbp. differences in the time elapsed from the end of the stress test and the spect acquisition could be involved to explain the differences of lvef between the two post-stress studies. results from the present study do not necessarily apply to spect studies employing an reduced activity of injected tracer, and further studies are needed. aim: present devices used for gated spect mpi may be incapable to identify the r wave as a proper triggering signal in patients with a pacemaker, mainly with dualchamber stimulation. the aim of our study was to assess in how many such patients the use of r wave fail and to test the usefulness of pulse wave as an alternative. material and methods: we evaluated a group of 22 pts with pacemaker referred to our department for stress mpi. there were 11 m and 11 f, mean age 71 y (52-82). two data sets were acquired at rest, the first set synchronized with r wave and the second set with pulse wave. cequaltm and qgstm software were used for processing. we compared ejection fraction (ef), end-diastolic and end-systolic volumes (edv, esv). paired t-test and correlation were used for comparison. results: we were unable to get good data in 3/22 (13.6%) pts using synchronization with the r wave. in all of them the data synchronized with the pulse wave were acceptable for processing. in the whole group, the mean ef, edv and esv calculated using the r wave for triggering were 0.50 (0.21-0.75), 79 (43-155) and 39 (14-95) respectively, using the pulse wave 0.49 (0.16-0.73), 89 (49-156) and 46 (15-89) respectively, p=0.485 for ef, p=0.004 for edv and p=0.002 for esv. correlation for ef was 0.363 (p=0.096), for edv 0.884 and for esv 0.921 (p = 0.000 for both correlations). conclusion: there is a significant number of pts with pacemaker in whom the use of the r wave does not allow to evaluate parameters of the heart function (13.6% in our group). we believe that the use of the pulse wave is the only alternative in such pts. quantitative data correlate highly with the data calculated with ecg trigger. the relation between helicobacter pylori infection and cardiac syndrome x;a novel study objectives: cardiac syndrome x (csx) is characterized by an angina pectoris and/or presence of positive none-invasive test (exercise tolerance test or myocardial perfusion scan) accompanied with normal coronary angiogram. several mechanisms such as ischemia, inflammation and endothelial dysfunction have been suggested. this study was carried out to assess the possible role of helicobacter pylori (hp) in this syndrome. methods: hp infection was distinguished by urea breath test (ubt) in patients with csx, and compared with two sex-and age-matched control groups. ubt classified as; negative, intermediate, positive for h. pylori. statistical analysis was carried out using anova and t tests. a p-values of 0.05 or less were considered to be significant. results: each group consisted of 30 patients with a mean age of 53.30 ± 5.90 [sd] years, 55.80 ± 8.49 years, and 51.80 ± 8.72 years in csx, cad and healthy control respectively. fifty percent (15) of csx patients had positive result, while none of two control groups had the same results (p-value= 0.005). the negative and intermediate results were not statistically significant in three groups. conclusion: with respect to the high occurrence of hp infection and likely contributory effect of inflammation in subjects with csx, potential role of hp infection in the pathogenesis of csx is proposed. however well planned clinical trials are required to validate this initial result. the interpretation of medical images by inexperienced physicians would theoretically be improved with a second opinion of a more experienced colleague or by a decision support system. in the present study we evaluate the performance and interobserver variability between inexperienced as well as experienced physicians and a decision support system regarding classification of myocardial infarction and ischemia. method: seven physicians, all specialists in nuclear medicine but with varying experience, participated and were compared with the care decision support system. each of the physicians interpreted 98 patients with gated myocardial perfusion scintigraphy (mps) first a preliminary interpretation was made without the advice from the decision support system. the image was then processed by the computer and within seconds the physician received the advice from the decision support system and the interpretation and report was finalized. result: the sensitivity regarding interpretation of ischemia increased with 6 % (p<0.001) for the whole group with the help of a decision support system, both for inexperienced, 8% (p<0.001) and experienced physicians, 4% (p=0.006). the increase in sensitivity was larger in the anterior and inferior areas of the heart. conclusion: in the present study a second opinion from a decision support system increased the precision of physicians interpreting nuclear images, both for inexperienced as well as experienced physicians. a decision support system based on artificial intelligence is always available and can give advice regarding presence of infarction or reversible ischemia with the same precision as an experienced physician. a new iterative reconstruction algorithm (wbr™) has been recently proposed for cardiac spect. the wbr™ technology, based on accurate modelling of the emission-detection process, was designed to reduce noise improving lesion detectability without affecting the image resolution. few data exist on the comparison between filtered back-projection (fbp) and this new algorithm. aim. the aim of this study was to compare the performance of fbp and wbr™. methods. an antropomorphic phantom was acquired with a dual head@90° camera, equipped with a lehr collimator. a solution of 99mtco4-was used to fill the different regions of the phantom: 2 mbq for both right ventricles and heart cavity. two different activities were used to fill the heart wall: 20.3 mbq (comparable to the activity usually obtained in clinical setting; standard dose) and 10.1 mbq (half-dose). a cold lesion was simulated in anterior, septal, posterior, and lateral region with a 5 cubic cm cold disk inserted in the cardiac wall. for each wall activity and the different lesions, two sets of acquisitions were recorded: one at 20sec/frames (standard time) and one at 10sec/frame (half time). each spect was reconstructed with conventional fbp (butterworth, 0.4, 10) and with wbr™; a circular roi was drawn on the short-axis slice better displaying the lesion. an activity-vs-angular position histogram (circumferential profile) was obtained and the fwhm was calculated for each lesion. results. the average fwhm in half-time/standard dose (59.2 degrees) and halfdose/standard time (55.3 degrees) wbr™ spect were comparable to that of standard time/standard dose fbp spect (60.2 degrees). however, the fwhm in half time/half dose wbr™ spect (71.1 degrees) was worst than standard time/standard dose fbp spect. conclusions. the new iterative reconstruction algorithm wbr™ compared well in respect to conventional fbp spect, allowing half-time or halfactivity studies. however, further studies are needed to verify the potential clinical application of this method. fanbeam reconstruction using an iterative algorithm including 3d-collimator modell s280 o. s. grosser 1 , t. prautzsch 2 , g. ebel 2 , m. seemann 1 , j. ricke 1 ; 1 radiology und nuclear medicine, universitaetsklinikum magdeburg, magdeburg, germany, 2 scivis, goettingen, germany. aim: fanbeam geometry improves resolution and sensitivity imaging small volumes and small field-of-views. reconstruction of volume data from fanbeam projections is usually performed using filtered back-projection algorithm (fbp). this procedure considers the imaging geometry, but attenuation and collimator characteristics are ignored. to improve imaging quality we performed reconstruction using an 3d-itertiv reconstruction algorithm for fanbeam geometry. the algorithm incorporates the distance and location dependent point spread function of the collimator and attenuation of the object. material and methods: examinations were performed using an e.cam variable (siemens medical solutions) gamma camera with fanbeam collimators. for this system the location dependent point spread function for different distances to the collimator front and for different positions orthogonal to the focus line were estimated. a 3d-system model is derived. it is used for iterative reconstruction with gma (geometric mean algorithm). we performed spect with a jaszcsak-phantom with different count rates (high/low) and different numbers of projection angles (n=120, 60 and 30). data were reconstructed using a clinical established fbp including chang's attenuation correction and with an iterative algorithm using a contour based attenuation correction. furthermore the reconstructed data were examined for image quality and artifacts. spect homogeneity and resolution of solid spheres with different diameters were estimated. additionally line profiles, resolution and contrast were examined. results: the visual image quality of gma reconstructed data is significant improved compared to images reconstructed by fbp. in addition iterative reconstructed images show an better signal-noise-ratio snr (gma: 9.9; fbp: 6.3; p=0.05) and a significant higher contrast in small solid spheres. fbp shows typical extra corporal artefacts. these artefacts are not to notice in images reconstructed with gma. conclusion: utilization of iterative fanbeam reconstruction including a 3d-collimator model results compared to standard fbp to an improved image quality, significant higher snr and an increased contrast. using the iterative algorithm is connected with an acceptable time involved. the main obstacle of fbp is the noise otherwise it is the best technique of tomographic reconstruction. determining the best filter and the proper degree of smoothing can help to ensure the most accurate diagnosis. unfortunately there have been significant discrepancies in selection of proper filter and adjustment of the filter parameters to individual cases. the purpose of this study was to define an optimal parameter for the tomographic reconstruction procedure in routine single photon emission tomography (spect) studies. in this study hoffman brain phantom is modified in such a way that only software capability is evaluated. the phantom is composed of several independent slice that can be imaged individually (planar) or in 3-d composition (spect). method and materials: the designed phantom was filled with water containing 99mtc. dual head mediso gamma camera spect system, equipped lehr and legp parallel hole collimators was used. energy window was set at ±20% of photo peak. planar image of the slices were acquired separately at 0-10 cm from the collimator face collecting 107 counts. tomographic image was performed using the phantom in 3d position. a total of 128 projection images with 128×128 matrix were acquired over 360°. the time per view was 10 and 20 sec. planar images were used as reference ideal image for each corresponding reconstructed slice images. all the spect images were reconstructed using 6800 different filtering conditions. the quality of reconstructed images was evaluated by comparing the reconstructed images with the reference image using the universal image quality index (uiqi). results: at all count density no significant difference observed between metz and wiener (), however the difference between these two and other filters was quite significant (p<0.001). the optimum filtering condition was significantly related to the count density (signal to noise ration) of the data. the results of this study are summarized the tabel-1. finally, all of the acquisition studies regardless of counts or collimator, that the mean of uiqi was the most for wiener filter in comparison with the other filters. discussion: the data from this study suggests that the hanning and hamming are the weakest of the seven filter types tested. this is due to response of hanning and hamming filters at the low frequencies. based on the results of this study, wiener filter provided best image quality. aim: gated myocardial perfusion scintigraphy is an efficient tool to simultaneously assess myocardial perfusion, wall motion, left ventricular volumes and ejection fraction (lvef). filtered back projection (fbp) is often used for tomographic reconstruction, as this method can efficiently determine the transaxial slices. in a previous study we have investigated the effects of the applied smoothing filters on the measured volumes and ejection fractions. it turned out that the smaller volumes were underestimated, also resulting in an overestimation of the lvef for small hearts. iterative reconstruction techniques like osem perform better in low signal-to-noise ratio studies. so, we can apply filters with a higher cut-off frequency, which in turn may result in better estimates of the smaller volumes. in this study we have investigated the differences in measured volumes after fbp and osem reconstruction. methods: 44 studies (ex/re) from 29 patients were selected. all studies were reconstructed with fbp using an order 9 butterworth filter with fixed cut-off frequency equal to 0.27. the first 22 studies were also reconstructed using osem. by increasing the cut-off frequency of the filter from 0.18 to 0.30, a single frequency for all 22 studies was selected above which the lvef was not changing anymore. in a former study this method was also applied to select the optimum cut-off frequency for fbp reconstructed studies. next all studies were reconstructed using both, fbp and osem, each method with their optimum cut-off frequency. a standard software package (germano) was used to determine the left ventricular volumes. fbp and osem results were compared on a study by study basis. results: the optimum cutoff frequency for osem turned out to be equal to 0.24 (0.26 for fbp). the comparisons of the volume measurements as well as the lvef are shown in the table. a good correlation was found between the two reconstruction methods. both, esv and edv volumes determined after osem turned out to be somewhat larger than those calculated from the fbp reconstructed studies, especially for the smaller lv volumes. lvef in turn, was found to be lower for osem compared to fbp with differences ranging from -4% to +12%. aim: erdheim-chester disease (ecd) is a rare multisystem, non-langerhans form of histiocytosis of unknown origin. it involves multiple organs and typically causes symmetrical osteosclerosis of the long bones. we describe 2 patients with histologically proven ecd whose pet/ct showed vascular lesions. materiel and methods: case 1 is a 52-year-old man operated for aortic regurgitation with a bicuspid aortic valve. spumous histiocytes were found in samples collected during surgery. a thoraco-abdominal ct showed an infiltration of main thoracic and abdominal arteries, and a perisplenic and perirenal fibrosis. bone scintigraphy showed symmetrical increased uptake of the long bones. case 2 is a 41-year-old woman who had a history of weight loss and a severe biologic inflammation. a thoraco-abdominal ct scan revealed infiltration of the mediastinum, subrenal abdominal aorta and the superior mesenteric artery. bone scintigraphy did not reveal any abnormalities. the 2 patients underwent a 18f-fdg pet/ct for evaluation of the extent of the disease. results: case 1: fdg pet imaging showed a marked hypermetabolism within the vascular lesions seen on the ct scan, with a more important fdg activity on the thoracic vascular lesions. there was no abnormal fdg uptake on the long bones. on the other hand, increased fdg uptake was observed on two dorsal vertebrae which was proved to be an extra-medullary meningioma. pet imaging failed to depict perirenal and perisplenic fibrosis. case 2: fdg pet showed only 3 hypermetabolic foci: one on the level of the left pulmonary artery and the 2 others of the superior mesenteric artery and the subrenal abdominal aorta. there was no abnormal fdg uptake on the skeleton. conclusion: fdg pet can detect extra skeletal lesions such as vascular involvement. in our cases, skeletal lesions were not depicted. this could be explained by effective treatment, since fdg pet was performed under chemotherapy. in ecd, fdg pet may be used for evaluation of the extent of the disease and the assessment of the response to therapy, but more further studies are needed. the prevalence of coronary steal in dipyridamoleinduced myocardial perfusion scintigraphy: the philippine heart center experience r. b. matias; philippine heart center, quezon city, philippines. to determine the prevalence of coronary steal in patients undergoing dipyridamoleinduced myocardial perfusion scan (mps) in the nuclear medicine division of phc to identify the subsequent mps abnormality in patients who developed coronary steal during dipyridamole induction. to determine if there is an association between mps abnormality and coronary steal. coronary steal is caused by redistribution of flow away from collateral-dependent myocardium following coronary vasodilatation. although coronary steal has been well described in canine studies, there are more limited observations of the absolute magnitude of coronary steal in humans and its relationship to clinical signs of myocardial ischemia. there is controversy whether chest pain and ecg changes with coronary vasodilation represent true myocardial ischemia because of coronary steal. dipyridamole (dipy) is often used as an alternative to exercise in the detection of coronary artery disease by radionuclide techniques that produce selective vasodilatation of normal coronary arteries, predominantly in the small, resistance vessels of the coronary bed. method: 795 patients from january 1, 2003 to december 31, 2006 who developed chest pain with respective ecg changes after induction of dipy during mps procedure were included in the study. ecg changes include st segment depression or elevation of > 1mv in 1 or more leads. perfusion abnormalities include evidence of inducible ischemia (mild, moderate or severe), fibrosis or scar and infarcts. normal perfusion scan pertains to those with no definite evidence of ischemia and defects which are due to soft tissue attenuation. a. hughes; royal preston hospital, preston, united kingdom. aim gated spect is a well established technique that allows simultaneous assessment of the perfusion and function of the left ventricle (lv). both global and regional lv function can be assessed using this technique and analysis of regional wall motion and thickening can help to identify viable myocardium and eliminate attenuation artefacts. most centres use an acquisition protocol that divides the cardiac cycle into 8 frames. temporal resolution can be improved by using 16 frames per cycle, but there will be a loss in the signal-to-noise ratio if the duration of the study is not increased. the aim of this study was to compare regional wall motion and thickening scores derived from gated spect using 8 and 16 frames per cycle. thirty-four female patients with normal perfusion and function were imaged on a philips forte jetstream gamma camera. gated datasets with 8 and 16 frames per cycle were acquired simultaneously one hour after treadmill exercise. all data were filtered using a 2-dimensional butterworth filter and reconstructed using filtered backprojection. regional wall motion and thickening scores were computed for a 20-segment model of the lv using the cedars-sinai qgs software. results wall thickening scores for the 16-frame datasets were consistently higher by 15-20% throughout the myocardium. additionally, there was a significant increase in circumferential variation in thickening in the mid and distal portions of the lv, with the anterior and antero-lateral segments exhibiting the largest differences. wall motion scores were ~12% higher for the 16-frame data except in the septal wall, where the scores were comparable. comparing motion and thickening scores of patients with known functional defects with data from the normal patient group did not reveal an increased sensitivity of one technique over the other. conclusion the acquisition and processing of gated spect studies using 16 frames per cycle is feasible on modern imaging systems. although there is an increase in temporal resolution over data acquired using 8 frames per cycle, resulting in differences to the normal ranges, there does not appear to be an improvement in the detection of functional abnormalities. aim: brain natriuretic peptide (bnp) is a neuro-hormone representing a marker of heart impairment. female patients undergoing radiotherapy for left breast cancer may develop cardiac impairment. to evaluate this potential heart damage, bnp was measured in women treated by left breast radiotherapy. methods: twenty-four women with left breast carcinoma undergoing breast conservative surgery and radiotherapy (single dose 2 gy; total dose 50 gy followed by boost of 10 gy on tumour bed) underwent bnp measurement, echocardiography and electrocardiogram at baseline (1 week before treatment) and 1 (2nd evaluation), 6 (3rd evaluation) and 12 (4th evaluation) months after radiotherapy. four patients were also evaluated 24 months after radiotherapy, because the study is still in progress. aim: the aim of the study was to compare lv dyssynchrony assessment by gated myocardial perfusion spect (gmps) and tissue doppler imaging (tdi). background: recently, it has been demonstrated that left ventricular (lv) dyssynchrony is an important predictor of response to cardiac resynchronization therapy (crt); dyssynchrony is predominantly assessed by tdi with echocardiography. information on lv dyssynchrony can also be provided by gmps with phase analysis of regional lv maximal count changes throughout the cardiac cycle which tracks the onset of lv thickening. methods: in 75 patients with heart failure, depressed lv function and wide qrs complex, gmps and 2d echocardiography, including tdi, were performed as part of clinical screening for eligibility for crt. clinical status was evaluated using nyha classification, 6-minute walk distance and quality-of-life score. different parameters (histogram bandwidth, phase standard deviation (sd), histogram skewness and histogram kurtosis) of lv dyssynchrony were assessed from gmps and compared with lv dyssynchrony on tdi using pearson's correlation analyses. results: histogram bandwidth and phase sd correlated well with lv dyssynchrony assessed with tdi (r=0.89, p<0.0001 and r=0.80, p<0.0001 respectively). histogram skewness and kurtosis correlated less well with lv dyssynchrony on tdi (r=-0.52, p<0.0001 and r=-0.45, p<0.0001 respectively). conclusion: lv dyssynchrony assessed from gmps correlated well with dyssynchrony assessed by tdi; histogram bandwidth and phase sd showed the best correlation with lv dyssynchrony on tdi. these parameters appear most optimal for assessment of lv dyssynchrony with gmps. outcome studies after crt are needed to further validate the use of gmps for assessment of lv dyssynchrony. aim. using radionuclide methods to study the correlation between the disturbances of central hemodynamics and the renal functional activity in patients with heart failure. material and methods. thirty seven patients (median age was 52,43 ± 1,29 years) with coronary artery disease (cad) and heart failure (hf) of nyha class ii or iii were examined using radionuclide renoscintigraphy and radiocardiopulmonography. parameters of cardio-pulmonary hemodynamics and renal function were estimated. results. we observed the damage of most of cardio-pulmonary hemodynamics parameters in all patients. that indicated the reduction of contractive activity of the left and right heart ventricles with pulmonary hypertension development. the disturbances of renal function were note in 73% of pts with hf and included the decrease of glomerular filtration rate and/or the increase of parenchymal clearance of 99mtc-dtpa. using multiple linear regression analysis significant positive correlations were detected of the damages of renal filtration and evacuatory parameters with the decrease of cardiac minute volume, cardiac index and efficiency factor of circulation. therefore the decrease of cardiac output is one of the basic factors of renal dysfunction pathogenesis in patients with hf. furthermore were detected significant negative correlations between the disturbance of pulmonary circulation and the decrease of glomerular filtration rate. conclusion. the radionuclide methods are available for the evaluation of influence of hemodynamics disturbances on renal function in pts with hf. aim to explain our experience with gbps, the obtained measurements of right and left ventricular ejection fraction (rvef and lvef) from gbps and corresponding values determined by equilibrium imaging, due to erv is the standard technique used to evaluate ejection fraction. to assess the reproducibility and reliability, the advantages and limitations of both thechniques. materials and methods 31 patients underwent gbps and erv. there were 26 females and 5 males, with a range age between 39 to 84 years, who had risk of cardiotoxicity induced by chemotherapy (this is the most frequent indication to evaluate fvef), except the younger patient, who presented congenital cardiopathy, and the two older men, who presented cardiac failure. imaging was performed 10 min after administration of 925 mbq 99m tclabelled blood cells, acquiring spect with ecg gating. next a planar image was acquired, about 30 min after injection. the data were processed using qube algorithm on a segami workstation by a physician specialist in nuclear medicine and processed again to assess intraobserver reproducibility. a second operator reconstructed and processed the same studies, to assess interobserver reproducibility. bland-altman analysis was applied. results the mean of lvef's values obtained with gbps was 73.10, versus 66.03 from erv. for rvef was 53.10 with gbps and 55.41 with erv. the intraobserver reproducibility of lvef and rvef was higher for erv than gbps in both observers (in the best of cases, the limits of agreement ±2sd calculated using bland-altman analysis were -0.13±7.1 for gbps vs. 0.03±3.32 for erv from lvef, and 0.71±9.12 for gbps vs. 0.26±3.46 for erv from rvef). the interobserver reproducibility presented less differences between both techniques. lvef and rvef obtained from gbps were compared with those from erv using bland-altman analysis. the mean difference was 7.07 with ds 4.46 from lvef and -1.76 with ds 7.31 from rvef. processing of data obtained with erv for rvef was unsuccessful in 4 patients, in this cases gbps was very useful to estimate rvef. conclusions gbps presented a intra-inter-observer reproducibility slightly lower than erv. this technique provides values of lvef higher than erv (approximately 7%), but rvef's values were very similar to obtained with erv. in cases that rvef is especially difficult to estimate with erv, gbps is very usefull. aim: the aim of the study was to identify myocardial viability by 99mtc-tetrofosmine (rest and nitrate) in patients with ischemic left ventricular aneurysm. material and methods: the study involved 15 patients (men) aged 41 -63 with stable angina of the ii-iv nyha classes, chronic left ventricular aneurysm, all of them had a history of 1-3 previous transmural myocardial infarction. all patients before operation were underwent 99mtc-tetrofosmine myocardial spect according to protocol "nitrate-test (10 mg of sublingual isosorbide dinitrate) -rest". all patients underwent coronary artery bypass surgery (abs) and aneurysmectomy by dore. after operation patients in 4 weeks were underwent 99mtc-tetrofosmine myocardial spect only rest. analyse was performed by dividing the left ventricle into 16 segments for spect. result: 240 segments of left ventricle were analyzed on 99mtc-tetrofosmine spect. after 99mtc-tetrofosmine nitrate-test the amount of aperfusion sectors decreased in 11% in comparison with rest. after the surgery, we found that the amount of aperfusion segments was 13%; the amount of normal perfusion segments was 63%. we analyzed 90 perfusion scans and 1080 myocardium segments for assessment size of the perfusion defect. average the perfusion defect before operation in 99mtc-tetrofosmine spect rest was 37.4±12.9%. after 99mtc-tetrofosmine nitrate-test it decreased to 25,3±13,7% (p<0.05). after the surgery it was 23.1±10.5%. we found significant difference in intensity of accumulation 99mtc-tetrofosmine in the perfusion defect on rest and nitrate-test (p<0.05). conclusions: 99mtc-tetrofosmine spect by protocol rest -nitrate -rest is useful techniques for the identification of viable myocardium and to predict functional recovery after revascularisation in patients with ischemic left ventricular aneurysm. diagnostic value of gated spect myocardial perfusion imaging using thallium-201 in patients with latent coronary artery disease h. shi, y. gu, w. liu, w. zhu; zhongshan hospital, fudan university, shanghai, china. aims: to investigate the diagnostic value of spect myocardial perfusion imaging using thallium-201 for the patient likelihood of latent coronary artery disease. materials and methods: fifty-two asymptomatic aircrews with positive results of exercise treadmill test underwent dipyridamole pharmaceutical stress and rest spect myocardial perfusion imaging using thallium-201. patients with myocardial perfusion imaging positive findings accepted coronary artery angiography. patients with myocardial perfusion imaging negative findings were followed up till five years. results: twenty-four patients showed positive results in myocardial perfusion imaging and twenty two of them detected coronary artery stenoses with more than 50% luminal narrowing by coronary artery angiography and two of them were negative results in coronary artery angiography. twenty eight patients showed normal in myocardial perfusion imaging and no cardiac events happened in the following five years after myocardial perfusion imaging performed. conclusion: spect myocardial perfusion imaging using thallium-201 is very useful method for detecting latent coronary artery disease, especially for negative predictive value. and its diagnostic accuracy is much higher than exercise treadmill test. association of left ventricular functional parameters measured by gated single photon emission tomography and by two-dimensional echocardiography c. groselj, 19481 , b. simonic, 19731 , b. groselj, 19832 ; 1 university medical center, ljubljana, slovenia, 2 medical faculty, ljubljana, slovenia. introduction lvef, edv and esv are good clinical indicators of left ventricular function and volumes, routinely measured by echocardiography (echoc). in former decade the emory cardiac tool box (ectb) was developed, a toll for assessing left ventricular function and volumes from gated spect myocardial perfusion scintigraphy (gspect). gspect myocardial function assessment provides an important incremental information. aim of the study the aim of the present study was to validate the accuracy of the ectb in assessing lvef, edv and esv from gspect using echoc as a reference values. patients and methods 44 consecutive patients, 29 males and 15 females; mean age 63+/-12 y, range 39 -87 y, with suspected or known coronary artery disease were examined using 99mtc-mibi gspect (8 gates/cardiac cycle) 60 min after tracer injection at stress. the gspet data were reconstructed using an automatic algorithm employing filtered back projection (fbp) and further analyzed by emory cardiac (ec) toolbox. all patients underwent two-dimensional (2d) m-mode echoc in the same diagnostic evaluation. the results of both methods were compared. aim to determine if an average residual activity could be assumed for stress and rest myoview administrations. method an audit of residual activity in the syringe following myoview administrations for myocardial perfusion imaging was conducted at guy's and st thomas' (gstt) and the royal free hospital (rfh). residual activities for both stress and rest administrations were measured. myoview was administered using 2ml terumo syringes and 2ml braun injekt syringes at gstt, and 3ml bd luer-lok syringes and a y-tap extension set at rfh. stress activities were administered via a 3-way tap (gstt) and y-tap extension set (rfh). rest activities were directly injected into a vein. results at gstt 40 residuals for rest studies and 43 residuals for stress studies were collected using terumo syringes. 13 residuals for stress studies were collected during a trial of braun injekt syringes. at the rfh 26 residuals for stress studies and 13 residuals for rest studies were collected. the residual activities from gstt, using the terumo and injekt syringes follow a normal distribution for both stress and rest administrations, and there was no dependence of residual activity on time of injection. there was a statistically significant difference in residuals between technologists for stress injections but not rest injections. the mean stress residual using terumo syringes (86.26mbq), is significantly higher (p = <0.001) than the mean rest residual of 53.90mbq. the mean stress residual for braun injekt syringes of 28.62mbq was significantly lower than the mean for terumo syringes of 86.26mbq (p=<0.001). the mean stress residual using the y-tap extension of 65.89mbq was significantly lower than the stress administration with terumo syringes (p=0.041). there was no significant difference between the rest and stress residual activities at the rfh (p=0.409). conclusion: the significant difference between stress and rest residual activities was attributed to increased difficulty flushing the syringe during the stressing procedure, compared to direct injection. the significant difference between the stress residuals using the terumo and y-tap extension set but not between the rest residuals demonstrates that the stressing method using a y-tap extension reduces the residual activity and is not due to technologist working practices. due to the overall large variation of residuals assuming a single average residual activity may not be good practice. however, residual activities were significantly reduced using the injekt syringes and the y-tap extension set. using injekt syringes would reduce the residual of rest injections as well as stress injections. the value of radionuclide methods in patients with suspicious chronic myocarditis. , 7 -complained about chest pain and dyspnea, 12 had myocardial conduction disorders. echocardiography showed abnormalities at 28 patients: hypokinesia (total or local) at al cases, mitral valve prolapse -in 6 cases. abnormalities of laboratory indexes were found at 5 patients (increasing of erythrocyte sedimentation rate, levels of ast and kfk). all patients underwent spect with 99mtc-hmpao-leucocytes at 20 hours post injection, following by gated-spect with 99mtc-mibi at the rest condition. both scintigrams were then combined, using fusion display application, to define more exactly the localization of 99mtc-hmpao-leucocytes uptake in the heart. the presence, character and magnitude of perfusion defects, ejection fraction (ef) of left ventricle (lv), motion and thickening extent were also estimated. results: perfusion defects were detected at 31 cases, with average size -10,3±3,57% (max -16%), which localized in ventricular septum, anterior or inferior wall of the lv. (7). the viability of labelled stem cells was tested by flow cytometry with propidium iodure (facscan® becton dickinson™). the proliferation capacity was tested by cell culture on specific media (rpmi-based cell media). after determination of optimal dose, we made an intramyocardial injection of labelled stem cells on a healthy rabbit. a spect scintigraphy was then performed with static acquisitions at 24 and 48h after injection. results: the labelling efficiency was good for all samples with an average rate of 67% (52-85%). the viability was 91.6% of living cells (no significant difference with control groups). the labelling with 1.85 mbq did not interfere on the proliferation whereas the higher activities, 3.7 or 7.4 mbq, stopped proliferation. the lowest dose does not disturb the viability and proliferation of stem cells and allows spect scintigraphy until at least 48h after intramyocardial injection of labelled stem cells on animal. conclusion: the labelling of rabbit bone marrow stem cells was successfully performed with indium-111 oxine. thus, we can follow stem cell therapy by spect scintigraphy without affecting cell viability or proliferation. the usefulness of an 18f-fdg pet/ct image obtained at 2 hours after intravenous 18f-fdg injection in detecting aortic 18f-fdg uptake compared to that obtained at 1 hour after injection aim: atherosclerosis is an immune inflammatory disease. increased macrophage metabolism is seen in active atherosclerotic plaque inflammation. 18f-fdg concentrates in those lesions and many studies have reported clinically and experimentally regarding the 18f-fdg images of atherosclerotic plaque inflammation. most of the studies used pet or pet/ct images obtained at about 1 hour after intravenous 18f-fdg injection (as an early image), but to our knowledge there have been no reports using pet or pet/ct images obtained at 2 hours after injection (as a delayed image). therefore we investigated the usefulness of the delayed pet/ct images in detecting aortic 18f-fdg uptake comparing with the early images. forty-one patients were participated in this study who were referred for tumor staging or seeking recurrence or metastatic lesions using fdg-pet/ct. we reviewed the early and delayed images visually for the presence of aortic 18f-fdg uptake. aortic 18f-fdg uptake was evaluated visually by dividing into the following 5 sections: (1) ascending aorta, (2) aortic arch, (3) thoracic descending aorta, (4) upper abdominal aorta and (5) lower abdominal aorta. we also examined the degree of aortic blood-pool 18f-fdg activity. results: the delayed image showed decreased blood-pool 18f-fdg activity in all lesions of the aorta. the number of aortic 18f-fdg uptake seen in the early image, the number of uptakes seen in the delayed image and the number of obtained clear visualizations in the delayed image of each section were as follows: (1); 30, 31 and 18, (2) ; 27, 28 and 13, (3); 15, 15 and 9, (4); 4, 4 and 3, (5); 3, 2 and 2, respectively. conclusion: this presentation illustrates the change in the aortic 18f-fdg uptake over time and the usefulness of delayed pet/ct images. about half of the aortic 18f-fdg uptake lesions in the delayed image showed clear visualization compared to the early image. the reasons were thought to be not only decreasing the blood-pool 18f-fdg activity but also increasing the aortic 18f-fdg uptake itself in the delayed image. aim: to measure the equivalent doses of radiation to medical staff performing 13nh3 myocardial perfusion pet scan. methods: the study was conducted in 2006 during 17 pet examinations. nine examinations were performed on patients with severe ischaemic heart disease and consisted of two pet scans (one rest and one dipyridamole pharmacological stress scan), and eight examinations were performed on asymptomatic hiv patients and consisted of three pet scans (one rest, one cold pressor stress and one dipyridamole pharmacological stress scan). an electronic dosimeter was placed on the chest, and highly sensitive thermoluminescent dosimeters (tld) were placed on the right index finger and the right wrist of the two technologists and the physician, performing the examinations. when examinations consisted of two scans (2s), the primary technologist (t1) withdrew 13nh3 from the production facility and performed injection of the tracer into the patient. the second technologist (t2) nursed and observed the patient during the whole scan, and the physician (p) monitored and observed the patient during the pharmacologic stress. when examinations consisted of three scans (3s), the roles were the same, but the physician additionally held the left leg of the patient in 0ºc water and coached the patient through the cold pressor testing. results: when performing two scans, the mean equivalent doses to the index finger were 387 μsv, 5 μsv and 5 μsv, and the mean equivalent doses to the wrist were 91 μsv, 3 μsv and 1 μsv for t1, t2 and p respectively. when performing three scans, the mean equivalent doses to the index finger were 453 μsv, 3 μsv and 7 μsv, and the mean equivalent doses to the wrist were 138 μsv, 0 μsv and 0 μsv for t1, t2 and p respectively. the mean equivalent doses to the chest when performing two scans measured by electronic dosimeter were 10±0.6 μsv for t1 (p=0.026 vs. 3s and p<0.001 vs. b2 and p), 4±0.5 μsv for t2 (p=0.01 vs. p) and 2±0.4 μsv for p and when performing three scans, 13±0.8 μsv, 3±0.4 μsv and 4±0.4 μsv for t1, t2 and p respectively. conclusion: mean equivalent dose is less than 1 ‰ of the current one year dose limit for the most exposed member of the medical staff when performing a myocardial perfusion examination with three 13nh3 pet scans. equivalent dose is dependant on work function and scan regimen as well as patient morbidity. the role of 18f -fdg pet in the diagnosis of large vessel vasculitis purpose: physiological accumulation of fdg into salivary glands often causes false positive findings in diagnosing head and neck lesions. it has been reported that some amount of radioactivity were excreted into saliva, therefore gargling before pet scanning has been investigated for improving the image quality in this region, however the actual efficacy of it is still unknown. in this study, we assessed the efficacy of lemon stimulation for encourage secretion of radioactivity in saliva to obtain images with higher quality. methods and materials: thirty normal subjects were examined fdg pet before and after lemon stimulus. region of interests of salivary glands, oral cavity and soft tissue were determined according to anatomical margins of them using fusion image with ct, and suvs were measured. radioactivities in saliva before and after lemon stimulation were also measured by a curiemeter. results: the suvs of salivary glands were shown in table 1( pg: parotid gland, smg: submandibular gland, slg: sublingual gland ). there were no significant differences between before and after lemon stimulation. in addition, radioactivity in saliva after lemon stimulation was 3.64+/-4.83 microci in 10ml of gargling water which was as low level of radioactivity as that of background (0.360+/-0.476 microci/ml). conclusions: although low level of radioactivity was present in saliva after injection of fdg, excretion of it was not influenced by lemon stimulation in normal subjects. therefore, alternative imaging methods need to be developed for reduction of physiological accumulation of fdg into salivary glands and for improving image quality in the area of oral cavity. aim. diffusion weighted mr imaging is a technique allowing to grade non-invasively the tumour cellularity, basing on the principle that molecules in living tissues routinely undergo random (brownian) motion. adc (apparent diffusion coefficient) is a value describing microscopic water diffusibility in presence of factors restricting diffusion within tissue (cell membranes, viscosity). our aim was to investigate the existence of a relationship between metabolic activity as measured by 18fdg pet and water diffusivity as evaluated by apparent diffusion coefficients (adc) in brain tumours. methods. gadolinium-enhanced fast spoiled gradient echo (gd-fspgr), diffusion weighted magnetic resonance imaging (dwi) with adc maps and 18fdg pet were performed in 13 patients (2 glioblastoma multiforme, 1 astrocytoma, 10 brain metastases) with 16 tumour lesions. adc and 18fdg pet images were coregistered with enhanced fspgr images to identify tumour sites. spherical 3d tumour and contralateral control region of interest (rois) of the same geometric parameters were drawn on fspgr, adc and pet images, using gd-fspgr as target for statistical parametric mapping with fused localization of adc and pet (by using mricro). pet and adc ratios of the tumour and control roi were obtained and linear regression analysis was carried out. results. a significant correlation was not shown between pet and adc ratios in all lesions studied; plotting ratios, if pet values were greater than 2.5, adc data were below 4, while if adc indices were greater than 4, pet ratios were below 2.5. a significant correlation (r2 = 0.5506, p = 0.0350) was found between pet and adc findings in 8 lesions, having pet and adc ratios lower than 4. conclusions. our data, although preliminary, show that a relationship might exist if pet and adc present low ratios. this could be due to the fact that in high cellularity areas, structures and cell membranes could increase impedence to water diffusion, causing decreased adc values and increased 18fdg uptake, while areas with low cellularity, i.e. necrotic areas, present increased adc and reduced 18fdg uptake. aim: according to literature, 18f-fluoroethyl-l-tyrosine (fet) was found to be a new valuable pet tracer to image brain tumors. particularly, fet uptake was higher in recurrent gliomas than in radiation injuries, whereas ct and mri showed a limited specificity in differentiating between post-therapeutic unspecific changes and neoplastic lesions. in this study we evaluated the contribution of fet pet/ct in the diagnosis of tumor recurrence in patients with gliomas undergoing multimodal treatment or radiosurgery. methods: the study included 24 patients with glioma (primary grading: 17=who grade iv, 5= grade iii, 2= grade ii) who showed neuroradiological findings suspected for tumor relapse after multimodal treatment (20 patients) and gliasite radiation therapy using radioactive iodine 125-i-iotrex (4 patients). brain pet/ct scans (discovery ls pet/ct scanner, ge healthcare, milwaukee, wi, usa) were performed 30 min after injection of 160-360 mbq of 18ffluoroethyl-l-tyrosine (iason labormedizin gesmbh & co. kg graz-seisberg, austria) using 3d mode acquisitions in 20/24 cases and 2d acquisitions in 4/24 the fet uptake in the most active part of the lesion was quantified by the standardized uptake value (suvmax) and lesion-to-brain ratio (suvmax/bg). brain lesions with a suvmax/bg of at least 1.5 were interpreted as probable recurrent disease. previously undergone breast cancer surgery and sentinel node biopsy and, when indicated, axilla lymphadenectomy, were enrolled. a sct scan was already performed in these patients when they came to our institution for pet/ct scanning. we compared sites and number of sct-diagnosed relapses with pet/ct results. results. in 10/50 patients (pts) (20%) sct scanning showed relapses not observed by pet/ct; in 6 of these pts metastases observed in sct scans were located in liver or lungs. in other 4 pts metastases sites were axillary or mediastinal lymph node chains. in 7/50 pts (14%) pet/ct results were coparable to sct ones. 8/50 pts (16%) had negative sct scanning, while pet/ct revealed widespread bone or lymph nodes metastases. finally in 25/50 pts (50%) pet scans showed unclear meaning high metabolic activity bone and lymph nodes areas; while in the same pts sct imaging revealed different sites of relapses as in lungs. conclusion. pet/ct seems to have higher sensitivity and positive predictive value than sct in detecting lymph node and bone relapses; sct appears more reliable than pet/ct to reveal lung or liver metastases. comparison of 99m aim. breast carcinoma express the na+/i-symporter and may -albeit not a routine procedure -be imaged with 123iodide (123i) and 99mtechnetium-pertechnetate (99mtco4-) scintigraphy. objective of our prospective study was the comparison of 99mtco4--and 123i-spect with fdg-pet in patients suspicious for breast cancer. methods and patients. twenty-nine untreated patients suspicious for breast carcinoma were prospectively examined with thorax spect with 99mtco4-(n=19) or 123i (n=10), respectively, and fdg-pet (n=29) prior to biopsy. tumor-to-background ratios (tbr) were calculated for spect findings. mean and maximum suv were calculated for pet findings. findings were compared in an intra-individual lesion-tolesion analysis. results. in 28/29 patients, malignancy was verified with histopathology. in imaging the primary tumor, sensitivities of 99mtco4--spect, 123i-spect and fdg-pet were 63%, 67% and 89%, respectively. tbr mean was 2.3±0.9 in 99mtco4--spect and 2.7±1.1 in 123i-spect. in fdg-pet, mean tumor suv was 4.1±4 and maximum tumor suv was 5.4±5.1. in contrast to fdg-pet, 99mtco4--spect was not sufficient in imaging nodal and distant metastases in the thorax, and 123i-spect failed in imaging lymph node infiltrations. distant metastases were not present in patients of the 123i group, and the value of 123i-spect was not evaluated. conclusion. in contrast to fdg-pet, 99mtco4--and 123i-spect are not sufficient in imaging breast carcinoma in clinical practice. showed an overall accuracy of 94%, with sensitivity and specificity of 97% and 71% respectively. conversely, dual-time point pet-ct showed an overall accuracy of 83%, for lesions with an suvmax 2.5 and/or with a positive suvmax, with sensitivity and specificity of 80% and 100%, respectively vs 66%, 60% (both, p<0.001) and 100% (p=n.s.) of single-time point pet-ct. in addition, on pet-ct, malignant lesions showed an increase in fdg uptake between time point 1 and 2, with a %suv of 12±25. conversely, benign lesions showed either no change or a decrease in suvmax between time point 1 and 2, with a % suv max of 20±8 (p < 0.001). discussion. mri shows higher sensitivity compared to pet-ct in disclosing breast malignancy. dual-time point improves pet-ct accuracy in patients with suspicious breast malignancy over single point pet-ct. on pet-ct examination there is increasing uptake of fdg over time in breast tumor, conversely, benign lesions show a decrease in fdg uptake over time. these changes in suvs over time might be considered a reliable parameter that can be used to differentiate benign from malignant lesions of the breast, on pet-ct examination. aim : to evaluate the significance of early and late delayed image in the lesion that suv is over 2.5. material and methods : 96 cases suspected malignancy obtained three-phase (64±10min, 110±12, 232±24 after fdg injection) pet/ct scan. the maximum suv value in three phase were recorded as suv1,suv2,suv3. retention index of each lesion in two delayed phase were calculated according to the following formula: ri1=(suv2-suv1)/suv1*100%.ri2=(suv3-suv1)/suv1*100%. the diagnostic value of two delayed images was compared through roc curve. the most proper cut-off value of ri in two different delayed phases was established. results : 160/200 lesions were malignancy, 40/200 lesions were benign, that were proven by pathology, clinical, laboratory and radiological examination. suv1 in each lesion was over 2.5. ri1,ri2 in malignancy were 12.6%±16.0%,11.1%±21.4%, the correlation coefficient was 0.65(p=0.0001). ri1,ri2 in benign lesion were 10.0%±28.6%,8.7%±4.3%, the correlation coefficient was 0.60(p=0.0001). through analysis of roc curve, the area under roc curve in early delayed image was 0.62 ±0.05(null hypothesis: true area = 0.5, p<0.05), when ri =1%, the maximum youden's index was 0.219, the diagnostic sensitivity, specificity and accuracy was 81.9%,40.0%,73.5%. the area under roc curve in late delayed image was 0.57 ±0.06 (null hypothesis: true area = 0.5,p>0.05), that suggest late delayed image has no diagnostic value. conclusions : the retention index of two delayed phase in benign and malignant lesion have good relativity. the diagnostic value of early delayed image is higher than late delayed image. when ri was 1% in early delayed image, it has maximum diagnostic efficiency. the aim of the study is to evaluate the use of pet-ct for detection of mediastinal lymph node (mln) metastases from preoperatory staging of non small cell lung cancer in order to avoid mediastinoscopy before surgery. material and method we studied 84 patients (p), 5 out of them were women, between 44-83 years old (medium of 66 years). we used a ge discovery ls equipment to realize the pet-ct studies after the administration of 370 mbq of 18f-fdg and multislide ct without iv contrast. we analized histologically the primary tumour and mediastinal lymph nodes in all patients by means of mediastinoscopy or thoracotomy. we determined tumour staging and the standard uptake value (suv) of the tumour and mediastinal lymph nodes with activity above vascular pool. results primary tumour location: hilium 14p, right lower lobe 15 p, left lower lobe 5, lingula 2p, medium lobe 2p, right upper lobe 21 and left upper lobe 25. hystological analyse of primary tumour: adenoesquamous carcinoma 43 p, adenocarcinoma 26 p, large cell carcinoma 8 p , bronchioloalveolar 1 p and others 5 p. differentiation grades: indiferentiated 3,1%, low 37,5%, moderate 33%, high 6,3% and non valuable 15%. suv t 1 = 7,78 (17-3,2) ; suv t2 = 11,4 (25-3); suv t3 = 13,6(19-10); suv t4 = 16,3 (24-11). staging: ia 12 p; ib 34 p; iia 3 p; s iib 18 p; iiia 12 p, iiib 4 p and iv 1 p. detection of mediastinal metastases: sensitivity: 0.71, specificity: 0.93, ppv: 0.66; npv: 0.94 and diagnostic accuracy: 0.89. the false-positive pet-ct scan were 2 carcinoma abcessed, 1 fibrohistiocitosis and 2 inespecific adenitis . false negative scan in 3 p with subcarinal mediastinal station afectation milimetric nodal size. the hight npv of pet-ct can avoid mediastinoscopy. but it must be considered that a positive or negative pet-ct does not assess or exclude malignancy in mediastinal nodes. aim: pet is a useful technique in the staging of non small-cell lung cancer (nsclc). although there is a wide experience with fdg-pet and ct, the introduction of pet/ct deserves to investigate its role in the context of diagnostic ct as a routine technique for nsclc staging. the aim of this study was to compare the contribution of fdg-pet/ct and diagnostic ct in the staging of nsclc. material and methods: sixty-six patients with nsclc, 52 male and 14 female were studied, (average age of 62 years). all patients underwent a fdg-pet/ct and a ct, in 1-month interval. the findings of both techniques were compared, and the final diagnosis was made by histological findings, clinical follow up, and response to therapy. results: fdg-pet/ct and ct findings were concordant in 16 of the 66 patients (24%). in 15 of them, the same lesions were identified. in 50 of the 66 patients (76%), the results disagreed. thus, in 34 of the 50 discordant patients (66%), the fdg-pet/ct showed a greater involvement than ct, related to the extension of lymph node involvement in 23 patients (2 false positives) and to the number of metastasis in 15 (2 false positives). in 13 of the 50 discordant patients, the fdg-pet/ct showed a smaller involvement than ct: less lymph nodes in 7 (10%) and less metastasis in 6 (9%). therefore, in 1/50 patients fdg-pet/ct and ct showed differences in location of the involved lymph node region. staging was modified by fdg-pet/ct in 41/66 (61%): it was increased in 28 (42%) (3 false positives) and diminished in 13 (19%). in 21 patients (31%), fdg-pet/ct modified the therapeutic setting, avoiding surgery in 15 (22%), discarding adrenal metastasis in 3 (4.5%), and diminishing the lymph node extension in 3 (4,5%) patients. objective: diffusion-weighted mri is known to provide images seemingly similar to those of fdg-pet. in the present study, we examined and compared lung cancer cases using fdg-pet/ct and dwibs (diffusion-weighted mri) on the same day. [subjects] we examined 21 lesions that were confirmed to be lung cancer with lymph node metastasis based on biopsies in addition to one pulmonary hamartoma lesion in 13 patients who underwent follow-ups longer than 6 months. the mean lesion size was 20.8±9.4 mm (range: 10-45 mm). materials and methods: after 5-hour fasting, fdg was intravenously injected at a dose of 3.7 mbq/kg and then its distribution was analyzed using discovery st elite system (ge) one hour later. dwibs was performed to the consented patients, immediately prior to pet analysis, by taking images (slice thickness = 6 mm, b-factor = 1000) with a single shot epi method using a 8-ch body array coil with signa excite 1.5t (ge). both images were visually evaluated. the tracer accumulation in the liver and the signals in the spinal cord were considered to be positive for pet, dwibs, respectively. results: twenty (95.2%) of the 21 malignant lesions were positive on fdg-pet/ct, whereas 19 lesions (90.5%) were positive on dwibs. there were no significant differences between the two modalities (p = 0.565). the benign pulmonary hamartoma was negative on pet, but positive on dwibs. pulmonary adenocarcinoma (12.6 mm) in the right upper lobe showed false-negative findings on pet, but ct scanning of this node indicated suspicious pulmonary adenocarcinoma. in addition, left pulmonary hilar lymph node metastasis (15 mm) associated with left upper lobe cancer and pulmonary adenocarcinoma (12 mm) in the right upper lobe showed false-negative findings on dwibs. conclusion: both pet and dwibs detected malignant lesions almost the same level. however, dwibs is less efficient in differentiating malignant lesions from benign lesions because dwibs showed benign lesions such as pulmonary hamartoma as positive. by-lesion analysis. the vertebrae were the most frequently involved bones (23/70 = 32.8%), followed by ribs (16/70 = 22.8%), and pelvic bones (15/70 = 21.4%). suv values of the metastatic foci range from 2.1 to 26.1 (mean 6.3; median 5.5). the ct patterns were classified into four groups: osteolytic (21/70 = 30.0%); osteoblastic (18/70 = 25.7%), mixed (17/70 = 24.3%) and invisible type (13/70 = 18.6%). osteolytic and invisible skeletal metastases showed higher value of fdg uptake than osteoblastic (the difference were statistically significant, p < 0.0001) and mixed lesions (the difference were statistically borderline, p = 0.0615). conclusion: our preliminary data shows that [18f]fdg-pet/ct provides a powerful combination of functional and morphologic information allowing an accurate characterization of bone metastases in lung cancer in terms of both metabolism and structural changes. , suvmax, and suvmean were calculated for each adrenal lesion. moreover, fdg adrenal uptake was compared with radioactivity of aorta, liver, and spleen by calculating the adrenal lesion-to-aorta, the adrenal lesion-toliver, and the adrenal lesion-to-spleen suv ratio. standard of reference for confirming the definitive nature of the adrenal lesions was either histophatology or clinical/imaging follow-up data. the value of [18f]fdg-pet/ct imaging was assessed by using independent t tests and receiving operating characteristic analysis (roc). results: of the 29 lesions, 8 turned out to be malignant based on subsequent growth (n = 6) or histophatology (n = 2), while 21 were benign based on stability for 6 months (n =19) or histopathologic analysis (n = 2). there was a statistically significant difference in hu and suv between benign and malignant masses (p < 0.0001), while the difference in size was not statistically significant (p = 0.09). the cutoff values derived from roc analysis for best discriminating malignant from benign lesions were as follows: suvmax of 4.6 (auc = 1.00, sensitivity = 100%, specificity = 100%, ppv = 100%, and npv of 100%), hu of 21 (auc = 0.976, sensitivity = 100%, specificity = 90.5%, ppv = 77.8%,and npv of 100%), and a adrenal lesion-liver suv ratio of 2.2 (auc = 1.00, sensitivity = 100%, specificity = 100%, ppv = 100%,and npv of 100% purpose: positron emission tomography (pet) is a radioisotope imaging method for obtaining information of organs and metabolisms within the human body. one of the most important criteria for quality-pet images is a high contrast value. injection doses and scan durations have important effects on the contrast of pet images, especially for the overweight patients. in this study, we have investigated the impact of injection doses and scan durations on the spatial resolution of the pet images within the lung lesions with diameters 0.6, 1.0, 1.6 and 2.4 cm consecutively. material and method: for the study, a whole body phantom was designed considering a standard adult human body of average weight of 100 kg. the lung-lesions were filled with different an activity-concentration as 4, 8 and 16 times more than that of lung-tissue background. seventy-two transaxial pet images were acquired with combinations of 3, 4, 5, 6, 7, 8 mbq/kg injected doses and 2, 3, 4, 5 min/bed scan durations using a siemens biograph hi-res pet/ct. results: it was found that the visibility and contrast value of lung lesions increased with the increasing of injection doses and scan duration. two minutes scan duration for a bed position is not sufficient to localize a lesion with 0.6 cm diameter with all injection doses. apart from this, all scan durations and injection doses used in this study are sufficient to detect the lesion of 2.4 cm diameter. conclusion: we concluded that minimum contrast value for the visibility of a lung tumor pet image is 3 and 5 min/bed scan duration and 8 mbq/kg injection dose are sufficient to detect the lung lesion used in this study. objective: pulmonary nodules associated with low or absent flourodeoxyglucose (fdg) tracer activity on fdg pet can generally be managed conservatively after consideration of multiple clinical parameters and risk factors. in some instances, patients with such pulmonary nodules have hilar and mediastinal lymph nodes with definite abnormal fdg uptake, confounding study interpretation and patient management. we hypothesized that a high level of fdg uptake in hilar or mediastinal lymph nodes, in the setting of a pulmonary nodule with low or absent fdg uptake, is due to benign inflammatory processes. methods: a total of 1520 pet-ct reports were reviewed and twenty-seven studies with discordant pulmonary nodule and hilar or mediastinal lymph node metabolism were identified. discordance was defined by an suv ratio of lymph nodes to nodule of greater than 2.0. the suv (standardized uptake) values (average values, not corrected for lean body mass, and measured at 90-120 minutes post fdg administration) were calculated from filtered back projection images, and ratios were then calculated based on those suv values. a retrospective chart review was performed on the cases that met the study criteria and the follow-up (biopsy or follow up imaging) was documented. patients with a known diagnosis of malignancy or sarcoidosis were not included in the study. results: the suv values for the nodules ranged from 0.6-3.2, with a mean of 1.8. the suv values for the lymph nodes ranged from 4.3-9.3, with a mean of 6.8. in 6 of twenty-seven patients biopsy found histologic findings of necrotizing granulomas or histoplasmosis. in 12 of the twenty-seven patients, follow-up imaging revealed the hilar or mediastinal lymph nodes had decreased in size or remained stable. the remaining nine patients have yet to be followed up. conclusion: in patients undergoing fdg pet for evaluation of a pulmonary nodule, a nodule with low or absent glucose metabolism can likely be managed conservatively, even when there is definite associated abnormal glucose metabolism in hilar or mediastinal lymph nodes. 18f-fdg uptake of n2 lymph nodes and primary tumor on pet: clinical significance in stage iiia n2 non-small-cell lung cancer purpose: this study evaluated the potential role of 18f-fluoro-2-deoxy-glucose (fdg) uptake by primary tumors and n2 nodes on positron emission tomography (pet) in patients with stage iiia n2 non-small-cell lung cancer (nsclc). experimental design: we analyzed pet scans of 57 nsclc patients who received surgical resection and proved pathologically to have stage iiia n2 disease between january 2000 and april 2005. on each patient's pet scan, fdg uptake by the primary tumor and n2 nodes were evaluated using the maximum standardized uptake value (suv). the highest suv of the n2 nodes in each patient was used for analysis. the suv of the node was affected by histology (p = 0.012). whereas a different survival outcome was not observed according to the suv of the primary tumor (p = 0.875), the suv of the node ( median vs. > median) was associated with survival (p = 0.034). patients with a low ratio of the node suv to the primary tumor suv ( median) showed better survival than those with a high suv ratio (> median) (p = 0.024). in the multivariate analysis, the t stage (p = 0.002) and ratio of the node suv to the primary tumor suv (p = 0.045), adjusted for the size of the n2 node ( 1 cm vs. > 1 cm), remained significant prognostic factors. conclusion: these results suggest that fdg uptake by the n2 node, especially relative to the uptake by the primary tumor, may predict survival of patients with stage iiia n2 nsclc. accuracy of dual-phase fdg pet for diagnosis of pulmonary nodule with initial suv less than 2.5 c. chen, b. lee, w. yao, p. wu, c. chu, n. chiu; national cheng kung university medical center, tainan, taiwan. aim: 18f-fdg pet is a very useful tool for the evaluation of pulmonary lesions with high sensitivity and specificity when using cutoff standard uptake value (suv) of 2.5. however, false results may occur, such as in bronchioalveolar carcinoma or inflammatory foci. studies indicated the usefulness of delayed pet images to improve accuracy. our study aimed to clarify the efficiency of delayed pet in pulmonary nodules with initial suv less than 2.5. material and methods: we collected dualphase fdg pet studies, imaging at 1hr and 2 hr post-injection, that showed pulmonary lesions with initial suv less than 2.5. those with final pathological reports were recruited for further analysis. we analyzed the difference in suvs, retention index (ri) (%) (ie. subtracting the 1 hr suv from the 2 hr suv and dividing by the 1 hr suv), and rate of further increase of suv between benign and malignant pulmonary lesions. results: totally 24 lesions, in 20 patients, were recruited. ten, including nine of granulomatous inflammation, were benign and 14 were malignant. for the benign lesions, the average suv on 1 hr and 2 hr images were 1.79 (range: 1.1 to 2.3) and 1.97 (range: 1.0 to 2.4), respectively. for the malignant lesions, the average suv on 1 hr and 2 hr images were 1.55 (range: 0.8 to 2.3) and 1.77 (range: 0.9 to 3.4), respectively. further increases of suv on delayed 2 hr images were observed in 7 of the 10 benign (70.0%) and 9 of the 14 malignant lesions (64.3%). no significant differences in suv, ri, rate of further increase of suv were found between the benign and malignant pulmonary lesions. conclusion: further increases of fdg uptake on delayed pet images occur not only in malignant lesions but also in benign lesions, such as granulomatous inflammation. therefore, delayed fdg pet is not useful for differentiating benign and malignant pulmonary nodules with initial suv less than 2.5, especially in the epidemic area of granulomatous diseases. irmet spa, torino, italy, 2 università di torino, dipartimento di scienze cliniche e biologiche, aso s. luigi, orbassano, torino, italy. introduction. the role of fdg pet/ct in the management of patients with non small cell lung cancer has been widely investigated in the recent years and its usefulness has been proved in the initial diagnosis, staging, restaging in case of suspected recurrence and radiotherapy planning. our aim was to evaluate the accuracy of pet/ct with fdg in the preoperative mediastinal nodal staging of nsclc with histological results as gold standard. materials and methods. 60 patients (37 men, 23 women, mean age 65) with early clinical stage nsclc were included. all of them were preoperatively studied with clinical evaluation, whole body c.e. ct, whole body fdg-pet/ct, fibrobronchoscopy. all patients underwent surgery. pet mediastinal nodal findings were compared with histo-pathological ones; these latter were used as the reference standard. statistical evaluation was performed on per-nodal-station. sensitivity, specificity, positive and negative predictive value and accuracy of pet were calculated. results. pet correctly classified 314 out of the 339 lymph nodes histologically evaluated, with an accuracy of 92.6%. in particular, pet correctly evidenced 11 malignant nodes out of 31, and 303 non malignant nodes out of 308. so, sensitivity and specificity resulted 35.5% and 98.4%, respectively. in the remaining 25 nodes, we had 5 false positive (all reactive hyperplasia) and 20 false negative nodes (in all cases, the node diameter was inferior to 18x13mm), with positive and negative predictive value of 68.8% and 93.8%, respectively. conclusions. our study, in concordance with the literature data, demonstrate that fdg-pet/ct has high specificity, but low sensitivity in mediastinal nodal staging. in patients with non small cell lung cancer (nsclc), pre-operative assessment with fdg pet/ct provides accurate tnm staging resulting in improved management plans. assessment of the visceral pleura is important since visceral pleural disease changes tumour staging from t1 to t2, hence from stage ia to ib, which reduces post operative 5 year survival from 80 to 60%. although orthogonal planes are available, attention is often focused on the axial and coronal planes when pet/ct data is analysed. the aim of the study was to assess the impact of additionally reviewing images in the sagittal plane to assess visceral pleural involvement. method 59 consecutive patients who had pet/ct for nsclc staging were reviewed. we assessed the effect of analysis of the sagittal plane in determining extension of the tumour onto interlobar fissures, and so by implication involvement of visceral pleura. results pet/ct identified 13 patients with t2 disease. in 6, t2 disease was diagnosed by size criteria, or extension onto the fissure on axial pet /ct. 7/59 patients (11.9%) were upstaged from t1 to t2 by diagnosis of extension onto the fissure not diagnosed prior to sagittal plane review. in 1 patient multiple lumbar vertebral collapses due to osteoporosis was diagnosed on sagittal plane images. conclusion review of the sagittal plane on pet/ct images especially when the primary tumour is in the vicinity of an interlobar fissure can improve accuracy of t staging, and thus provide important prognostic information. background: accurate staging of small-cell lung cancer (sclc) is critical for patient treatment and prognosis. the most common staging system adopted from the veterans affairs research service lung group includes two stages, limited-stage disease is defined as tumor confined to one hemithorax and the regional lymph nodes, whereas extensive-stage disease is defined as disease beyond these bounds. patients with limited-stage disease are offered combination chemotherapy and concurrent thoracic radiation therapy. patients with extensive-stage disease are offered combination chemotherapy without thoracic irradiation. [18f]fluoro-2-deoxy-d-glucose (fdg) positron emission tomography (pet) scan is widely used for the staging evaluation of non small cell lung cancer, however, its use in small cell lung cancer (sclc) remains investigational. the aim of this study was to evaluate fdg pet for sclc staging and to determine the impact of pet on treatment planning. patients and methods: from february 2005 to march 2007, we prospectively performed pretreatment fdg-pet on 29 patients, with sclc who also underwent a conventional staging. tumor-nodemetastasis system staging was assigned for each patient, with and without pet information and modification of treatment planning was assessed. results: fdg-pet demonstrated findings consistent with extensive-stage sclc in fifteen of 29 patients. fdg-pet correctly upstaged nine (31%) of 29 patients to extensive-stage disease. pet correctly identified tumor in each sclc mass (primary or nodal) that was suspected on computed tomography (ct) imaging, thus giving a lesion-based sensitivity relative to ct of 100%. pet identified unsuspected bone metastasis for eleven patients, hepatic lesions for 7 patients and 5 in others sites. fdg-pet correctly downstaged one (3%) of 29 patients to limited-stage disease who had a adrenal mass in ct and negative in pet confirmed by histology. treatment was modified for ten patients (34 %), 9 patients underwent only chemotherapy and one had both chemo and radiotherapy.conclusion: fdg-pet has high sensitivity for sclc and appears to be of value for initial staging and treatment planning. aim: non small cell lung cancer (nsclc) is the leading cause of cancer mortality in both females and males. some studies have linked tumor glucose metabolism as evidenced by f-18 fdg pet to survival but these study populations were heterogeneous. we aimed to assess whether tumor glucose metabolism is related to tumor size, disease stage and tumor histology in patients treated with radiation therapy and curative intent. material and methods: 87 patients (71 males and 16 females, mean age: 67 years) underwent 3d conformal radiation therapy. all patients underwent pre-treatment staging with f-18 fdg pet (pet-ct) and were evaluated by the assessment of tumor size in two dimensions, maximum suv (suvmax), and tumor histology. eighty-one patients were clinically staged by tnm (t1 n = 19, t2 n = 37, t3 n = 20 and t4 n = 5). in 77 out of 87 patients the tumor was histologically analysed (squamous cell carcinomas = 48, adenocarcinomas = 18, large cell carcinomas = 4, non-small-cell-lung-cancer = 7). results: in non-parametric analysis tumor metabolism as measured by suvmax was associated with tumor stage( r = 0.507, p < 0.01). suvmax was related to 2-d tumor size in patients with nsclc (r = 0.440, p < 0.05). this relation was stronger in patients with adenocarcinoma (r = 0.603, p < 0.05) than in patients with squamous cell cancer (r = 0.403, p < 0.05). multivariate analysis indicated that up to 20 % of suv variability could be explained by tumor size. conclusion: in nsclc some relation exists between disease stage, primary tumor size and suvmax as an indicator of glucose metabolism. however, it is notable that tumor histology has substantial impact on these relations. correlation between staging 18fdg-pet, some cell cycle markers and survival in lung cancer. a. sanchez-salmon 1 , i. aim: a great part of the patients with lung cancer have spread disease at the diagnosis. 18fdg positron emission tomography (18fdg-pet) is recommended for staging these patients in order to avoid unnecessary surgery in advanced disease. we report the evaluation of the relation between the suvmax (" standardized uptake value ") of the pet, cell cycle markers and the patients' survival in lung cancer patients. material and methods: there were 85 patients (76 men and 9 women) studied, with an average of 65 years old and a range of 39-87 years old. in the histological evaluation 41 cases were squamous, 26 adenocarcinoma (including 7 bronquioloalveolar), 10 undifferentiated, 5 oat cell, and 3 neuroendocrine tumours. five patients were in stage ia, 15 in ib, 1 in iia, 10 in iib, 13 in iia, 20 in iiib and 21 in iv. the follow-up ranged between 1 and 92 months. the inmunohistochemical study was realized by 2 blocks of tissue microarrays using the envision (dako) system. results: an association between the suv and the negativity for the d3 cyclin (p=0.022 and p16 (p=0.035) was found. there is also a positive correlation between the suv and the index of proliferation (mib-1) as well as between the suv and the 1a inducible factor inducible by hypoxia (hif-1a) expression but both of them did not reach significance. the of the suv maximum values associated with the age and with the squamous histology. there was found no correlation of the suv neither with the tnm nor with the survival. conclusions: 1. 18fdg-pet is very useful method for staging lung cancer. 2. 18fdg-pet is associated with different biological characteristics of the tumours 3. in our experience, it does not seem to be a good survival marker . background: the diagnostic and therapeutic management of different lung nodules in a single patient is challenging. the nature can be benign, as hamartoma, or malignant, as primary cancer or metastases. despite a high number of researchers and proposal for diagnostic work-up have been published accurate differentiation of benign from malignant lesions remains unsolved. aim of our study is to assess whatever integration of morphologic and metabolic imaging can help in the differential diagnosis between malignant and benign lung nodules in patients bearing multiple lung nodules. aim: 18f-fdg pet is widely accepted for evaluating patients with lymphoma; the role of pet in paediatric patients is still debated. aim of our study was to assess the usefulness of 18f-fdg pet imaging in paediatric hodgkin (hd) and non-hodgkin (nhl) lymphoma. materials and methods: 19 paediatric subjects (11males, 8 females; mean age 12years, range 5-12 years) with malignant lymphoma (9hd, 10nhl) were enrolled in the study. 18f-fdg pet was performed following standard procedures (5,3mbq/kg of fdg were injected iv in the 6hours fastened patient, image acquisition was performed after one hour uptake). overall 45 pet scans were carried out, 7 at lymphoma presentation and 38 during follow-up. pet results were compared with conventional imaging (ci) information (mr and/or ct) and with clinical followup; in all cases at least one contemporary imaging method was available, as well as 10 months follow-up. results: out of 45 scans, pet findings were consistent with clinical follow-up and other ci data in 43 cases (15 true positive, 28 true negative results) with an overall sensibility and sensitivity of 100% and 93% respectively. the remaining two cases resulted falsely positive, and in one subject this was due to prominent thymic uptake. considering all scans, pet was more accurate then conventional imaging in the assessment of children with lymphoma, identifying active disease in 2 ci negative scans and in 4 ci inconclusive cases and excluding the presence of lymphoma in 3 ci inconclusive and 1 ci positive scans. conclusions: our data show the usefulness of 18f-fdg pet to accurately evaluate children with lymphoma. the presence of hyperplastic thymus in one case may have accounted for inaccurate pet reading, although in other 6 cases prominent thymic uptake did not affect pet reporting. a recent report has emphasized the number of false positive pet findings in children: our data do not support this observation. nonetheless particular care has to be paid when reporting pet scans carried out in paediatric patients. purpose: in this retrospective study we aimed to assess the clinical impact of pet/ct imaging on staging and management of both hodgkin disease (hd) and nonhodgkin lymphoma (nhl). the results are also compared with the ct imaging findings. materials and methods: a total of 30 patients with newly diagnosed lymphoma were included in the study. there were 20 hds and 10 nhls. the age range was 16-78 with a mean age 38.4 years. each patient was undergone whole body pet/ct examination with low dose ct acquisition by administrating only oral contrast in addition to establish full diagnostic ct examinations of cervical, chest and abdominopelvic regions. pet/ct scanning from the skull base to the upper thigh was performed using a dedicated pet/ct scanner (siemens biograph 6 hi-rez lso), only when the patient's blood glucose level did not exceed 150 mg/dl. the interval of pet/ct and ct was 3 weeks at maximum. the findings suggesting for disease involvement obtained from the both modalities were recorded on a data sheet according to their topographic localization. the diagnostic certainty of two modalities was made according to clinician's final decision mainly based on clinical follow-up status of the patients. results: a total of 113 disease sites in 30 patients were recorded according to final clinical decision. of these, 107 sites were revealed by pet/ct, but only 80 were shown by ct. two modalities were agreed in 74 sites. thirtythree sites were demonstrated only by pet/ct, which caused upstaging in 8 (27%) patients. whereas ct found 6 sites despite of negative pet/ct, which did not caused upstaging of the disease in any patient. in 6 of the 8 patients in whom pet/ct upstaged disease, treatment strategy was changed to the more aggressive protocols. conclusion: fdg pet/ct has a very important contribution in the initial staging of lymphomas, by changing the treatment strategy in a considerable percentage of the patients. according to our opinion ct appears to have a minimal role in initial staging beyond of pet/ct scanning and can be omitted in routine clinical settings. high negative predictive value of midtreatment fdg-pet/ct in response assessment of malignant lymphoma. aim 18f-fdg-positron emission tomography/computed tomography (pet/ct) is currently used in staging/restaging and in the definitive evaluation of response to therapy of hodgkin disease (hd) and aggressive non-hodgkin lymphoma (nhl). in fact, this functional imaging modality allows an accurate evaluation of disease extension as well as a metabolic characterisation of residual masses after chemo and/or radiotherapy. the use of 18f-fdg pet/ct for response assessment during treatment is still under debate: midtreatment scan seems to be predictive of final response to therapy, however its role and prognostic value remains to be proved. in our study we evaluated the predictive value of interim pet/ct scan in patients with hd and aggressive nhl, compared to the final therapy response. materials and methods 87 consecutive patients (43 male, 44 female; mean age±sd: 44±13 ys) were staged by 18f-fdg-pet/ct (pet-1), whole body ct and bone marrow biopsy for hd (n=53) and aggressive nhl (n=34). all of them underwent interim pet/ct (pet-2) after 2-4 cycles of chemotherapy, and final restaging with whole body ct and pet scan (pet-3) at the end of the treatment. results hd: 40 out of 53 patients had a negative pet-2 scan. at the end of the treatment, 38 of them (95%) presented complete response, while 2, partial response. the remaining 13 patients were positive at pet-2. at the end of the treatment, 6 (46%) of them were in complete response, while 7 (54%) had partial response. nhl: 23 out of 34 patients had a negative pet-2 scan. at the end of the treatment, all of them had complete response. the remaining 11 patients presented a positive pet-2 scan. at the end of the treatment, 4 (36%) of them were in complete response, while 7 (64%) had partial response. conclusions our data confirm that interim pet/ct scan has a very high negative predictive value, both in hd and aggressive nhl (95% and 100%, respectively). further studies are needed to demonstrate how this information can affect patient management and patient outcome. aim we performed a systematic review of the literature to analyze positron emission tomography with 18f-fluorodeoxiglucose (fdg-pet) as a diagnostic tool in the evaluation of lymphomas response to chemotherapy or immunotherapy in terms of diagnostic accuracy and clinical usefulness. methods and material bibliographic search was performed between july-august 2006, with a date limit consensus established in 1999. we used medline, embase and cancergov, as bibliographic primary fonts adopting in each case the most convenient searching strategy, adopting free vocabulary to specific thesaurus. cochrane library and other health technology agencies data bases were also reviewed. the methodology quality assessment of every article was determined by the quadas questionnaire. the software tools use to manage all extracted data were reference manager 10.0, spss 13.0 and epidat 3.1. results the number of primary article localized was 407. two independent reviewers performed screening of all references, and the final number of articles selected to be analyzed was 10. despite of the differences among equipment, no difference in patient's preparation and studies acquisition were found. all studies consider visual qualitative analysis as part of the evaluation, and only four did semiquantitative analysis using standard uptake value (suv). six of ten studies performed fdg-pet scans in hodgkin lymphoma at the end of the treatment. global results of sensitivity, specificity, positive predictive value, negative predictive value and accuracy correspond 90.0% [95%ci, , 73.1-74.1] . work in progress to evaluate the possibility of develops meta-analyses of diagnostic test. conclusion despite of the small number of studies and the heterogeneity of the different population, it is important to emphasized the global results of negative predictive value of the fdg-pet in both hodgkin and non-hodgkin lymphomas and also at the different early and late response evaluation. study supported by the quality plan of the spanish national health service. 28 months after fdg-pet) despite of additional therapy. two patients were noted as false-positive. in four patients only slightly increased fdg uptake was observed (equivocal findings). conclusions: fdg pet enables reliable prognosis in short and long-term follow-up of patients with hd and nhl , especially in patients without pathological uptake of fdg. false positive fdg uptake seems to be a problem. no one of our 15 fdg negative patients relapsed. our results show that fdg negative patients usually have good prognosis and stay in complete remission for a long time. therefore, results of pet are predictive of immediate success of therapy as well as of disease-free survival. negative pet scan is an important contribution in the management of these patients due to its prognostic value and may reassure patients and their doctors that disease is not active. the bone lesions (bl) in hodgkin's disease (hd) are rare (1 to 4%) in the initial staging but have to be detected for a more aggressive treatment. bl are explored mainly by the invasive unilateral bone marrow biopsy (bmb), insufficient compared with the bilateral one. the aim of this study is to evaluate the agreement between bone positive fdg-pet, bone ct and mri for rachis bl detection in hd, before and during chemotherapy. material and methods: 4 patients (mean age 28 ± 6 years, 2 men) with hd histologically proven and with fdg-avid lesions in the bone were analysed. only one suffered from lumbar pain. all underwent unilateral bmb, bone ct, and then mri of axial skeleton at the time of first staging. all those imaging exams were repeated for early interim evaluation (after 4 cycles of chemotherapy) and 1 month after the end of treatment (after 8 cycles). each lesion was defined by its localization, the intensity of its signal: t1, t2 on mri, bone destruction with ct by a neuroradiologist, fdg uptake with maximum standardized uptake value by a nuclear physician. results: the bmb was positive only in 2 cases. a total of 37 lesions were visualized on initial staging fdg-pet (average suvmax 3,1±1,7) and 32 on mri. on bone ct, only 4 of 32 lesions were detected. for 6 of 37 lesions, fdg-pet presented a vertebra hypofixation corresponding to a massive infiltration on mri. the localization of bl on fdg-pet and mri was well correlated except for patient4 (kappa=0,89 ; 0,58 ; 0,70 ; 0,21 respectively for patients 1 to 4). indeed for this patient, a mismatch was noted between a homogeneous intense uptake of the thoracic rachis without pathological signal on mri at the same level. we concluded to a falsepositive fdg-pet by bone marrow hyperplasia. at mid and end of treatment, the fdg-pet became relatively normal whereas mri showed healing pattern on several vertebrae. on the follow-up, one patient recurred on mediastinal lymph node without bl. conclusion: fdg-pet and mri were the most accurate imaging modalities for bl in this context, complementary, especially in the whole spine assessment. fdg-pet allowed a better wholebody analysis and was enough sensitive to detect bl, including vertebra hypofixation. during treatment, bone fdg-pet became negative earlier than mri. the mri remained more precise for the small bl individualization. objective: because of anatomic changes after operation, detecting recurrent tumor is difficult in post-operative stomach cancer patients, especially in patients with paucity of intra-abdominal fat tissues. this study aimed to compare fdg pet/ct and enhanced ct in the detection of recurrent tumor according to body mass index (bmi) and anatomic regions. materials and methods: total of 77 patients who had pet/ct and enhanced ct within 1 month of each other, and diagnosed with recurrence were included. 17 cases were pathologically confirmed and 60 diagnosed clinically. we classified the patients into 4 groups according to the bmi (kg/m2): group i <18.5; group ii 18.5 ~ 22.9; group iii 23.0 ~ 24.9; and group iv >25.0. we compared pet/ct and enhanced ct findings by the anatomical sites: anastomosis site or stump; lymph node (ln); seeding nodules; bowel wall; and solid organ. result: five patients had only extraperitoneal lesions, and one had diffuse ascites without a focal lesion. 3 cases were false negative in both pet/ct and enhanced ct. excluding these 9 cases, we compared the findings of pet/ct and enhanced ct. in group i (n=23), pet/ct found 25 ln lesions, 21 seeding nodules and 2 foci of bowel wall thickening, while ct found 20 ln lesions, 17 seeding nodules, 11 foci of bowel wall thickening. in group ii (n=34), 54 ln lesions, and 23 seeding nodules were discovered on pet/ct. and 40 ln lesions, 11 seeding nodules, and 7 foci of bowel wall thickening were detected. conclusions: fdg pet/ct may be more useful than enhanced ct in detection of metastatic lymph nodes and seeding nodules in patients with low bmi (groups i and ii). however in cases with seeding metastasis presenting as bowel wall thickening, enhanced ct could be more useful. aim: gastrointestinal tumors can be detected incidentally by fdg-pet. even though measurement of standard uptake value (suv) has been proposed to determine the nature of these tumors, the method has been criticized. because dual-time point fdg imaging was reported to increase accuracy of fdg pet, we conducted this study to analyze the use of suv and delayed fdg imaging in the evaluation of gastrointestinal tumors. material and methods: gastrointestinal tumors with dual-time point fdg imaging were collected. images were acquired at 1 hr and 2 hr post-injection. those with final pathological results were enrolled. we recorded the 1 hr and 2 hr suv of the lesions for further analysis. results: there were ten benign and fourteen malignant gastrointestinal lesions enrolled in this study. average 1 hr and 2 hr suv of the benign lesions were 3.72 (sd: 1.11) and 4.18 (sd: 1.52), respectively. average 1 hr and 2 hr suv of the malignant lesions were 6.19 (sd: 1.95) and 7.62 (sd: 2.35), respectively. for differentiation of benign and malignant lesions, best accuracy (accuracy: 0.71, sensitivity: 0.71, specificity: 0.70) could be obtained by using criteria of initial suv higher than 4 and further increase of delayed suv higher than 10%. conclusion: delayed imaging can improve the accuracy of fdg-pet in differentiating benign and malignant gastrointestinal lesions. however, the accuracy is not high. evaluation of liver metastases from colo-rectal cancer after chemotherapy: fdg pet seems not to improve ct sensitivity m. rodari, c. carnaghi, c. tronconi, l. rimassa, f. r. lutman, g. ciocia, a. chiti; istituto clinico humanitas, rozzano -milano, italy. aim: neoadjuvant chemotherapy has been successfully used to treat patients with colorectal liver metastases. selection of those patients who can benefit from surgical resection after chemotherapy still poses a significant clinical problem. fdg pet is a useful tool in the assessment of liver metastases from colo-rectal cancer, but few data are available on its sensitivity after chemotherapy. we aimed to assess fdg pet and ct in the pre surgical evaluation of patients bearing liver metastases. materials and methods: data from patients with liver metastases from colo-rectal cancer treated with chemotherapy, evaluated with fdg pet and contrast enhanced ct scan at the end of treatment were retrospectively reviewed. nineteen patients (12 males, 7 females; median age 61 years; range 41-79) were evaluated. chemotherapy regimens were: folfox (14 patients), folfiri (3 patients), other (2 patients). median time between end of chemotherapy and ct was 3.4 weeks, between end of chemotherapy and pet 5.9 weeks and between end of chemotherapy and surgery 9.9 weeks. all patients underwent surgery and had pathological confirmation of liver lesions. nine patients underwent segmentectomy, 2 wedge resection, 5 right hepatectomy and 3 explorative laparotomy with liver biopsies. results: data from 19 patients were evaluated and 65 liver lesions were confirmed by pathology. results on a perlesion basis shown a sensitivity of 62% for pet and 70% for ct. a complete agreement between pet or ct and histology was documented in 5 and 3 patients, respectively. pet sensitivity increases for lesions larger than 1 cm (74% vs 18%). conclusions: our results suggest that pet and ct scan have sub-optimal sensitivity in the evaluation of colo-rectal liver lesions after neo-adjuvant chemotherapy, particularly for lesions <1 cm. the combined use of the two imaging techniques seems not to significantly increase the sensitivity of ct alone. introduction: the basic of pet/ct by use of 18f-fluorodeoxyglucose (fdg) is significantly increased glucose metabolism in the malignant neoplasm cells. the fdg metabolism depends on many factors such as: histopathology and presence of other factors which increase fdg metabolism. knowledge about the fdg metabolism in the stomach cancer cells' is not clear and some types of cancer are not avid in this type of diagnostics. aim: the evaluation of the fdg metabolism of pathological lesions in gastric cancer patients according to its histopatological type. material & methods: retrospective analysis of the pet/ct results of 55 patients (16 women, 39 men, mean age 58,3) suffered from stomach cancer. the study population consists of 20 patients with the primary stomach cancer and 35 patients with confirmed recurrence. there were 35 tubular adenocarcinoma, 16 mucinous adenocarcinoma and 19 low differentiated stomach cancers. pet/ct studies were performed on the biograph lso 60 min after iv. of 5 mbq/kg fdg. standard uptake value -suv was calculated. pet/ct results and mean values of suv were calculated for the each histopathological type of stomach cancer. results: lesions with pathological increase of fdg metabolism were fund in 29 patients (82,8%) with tubular adenocarcinoma, (mean suv 10,3± 6,1), 4 (25%) patients with mucinous adenocarcinoma (mean suv 4,1±1,8) and 16 (84,2%) patients with low differenciated stomach cancer (mean suv 11,2 ± 5,1) false negative results were found in 12 patients with mucionous adenocarcinoma, 5 with tubular adenocarcinoma ( low differenciated -g3) and 4 with low differentiated cancer. conclusions: 1. higher differentiated tubular adenocarcinomas and low differentiated stomach cancers are characterized by the highest fdg metabolism. 2. mucinous adenocarcinomas is characterized by the low level of fdg metabolism. 3. histopatological type of stomach cancer must be taken into consideration during setting of indication to the pet/ct study. polyps: a feasibility study p. mainenti 1 , b. salvatore 2 , c. sirignano 1 , t. de falco 3 , a. speranza 1 , g. fiumara 3 , f. ricci 3 , l. evangelista 3 , l. pace 3 , m. salvatore 3 ; 1 ibb-cnr, naples, italy, 2 aou "federico ii", naples, italy, 3 department of diagnostic imaging, university "federico ii", naples, italy. aim: to evaluate: 1) the feasibility of pet/ct colonography (pet/ctc) in patients with colo-rectal polyps; 2) the impact of metabolic information on ctc findings and the added value of morphologic to functional information in the characterization of focal colorectal uptakes. materials and methods: ten patients with colo-rectal polyps underwent pet/ctc previous colo-rectal air insufflation and just after therapeutic conventional colonoscopy (cc). a radiologist and a nuclear medicine physician analysed the pet/ctc images. the grade of overlapping of morphologic and metabolic information in the colon-rectum was evaluated. sensitivity and specificity for colo-rectal polyps of pet, ct and pet/ct were calculated. results: 17 polypoid lesions were identified at cc: 6 < 5 mm, 6 between 6 and 9 mm, 5 > 10 mm (4 hyperplastic polyps, 11 tubular adenomas, 1 adenocarcinoma and 1 submucosal lipoma). the overlapping of morphologic and metabolic information was excellent in 17 scans, good in 2 and moderate in 1. pet/ctc showed a sensitivity of 91% for lesions > 6 mm and a specificity of 100%. the metabolic information did not allow to disclose any further polyp missed on ctc. the morphologic information permitted to classify correctly all 8 focal radiotracer uptakes. conclusions: pet/ctc is a feasible study. adding a colonographic protocol to pet/ct images seems to allow characterizing correctly all colo-rectal focal radiotracer uptakes. the metabolic information does not seems to increase the accuracy of ctc. aim. metastases of colon cancer are often diagnosed in an advanced stage. in patients with this kind of neoplasm, pet with [f-18] fluorodeoxyglucose (fdg) is more sensitive and specific than the ct for detection of metastases. the cea level is used for monitoring the cancer but without anatomical localization of the lesions. the aim of this study was the retrospective assessment of the value of the pet/ct and ct in the diagnostics of the group of patients with an increased cea level. material & methods in the time between march 2003 and april 2005, 326 studies were made to diagnose colon cancer . we selected 32 patients referred to the pet-ct study with an increased cea marker level who were being diagnosed for colon cancer with complete information about ct with contrast media. pet studies were made by using the siemens biograf lso scanner according to typical pet protocol. we compared the results of the particular methods of diagnostics, performing patient to patient analysis. results: in 4 cases (14,1%)pet/ct and ct gave consistent results. there was 3 patients (9,38%)with negative results of pet/ct and ct . there were 5 negative pet/ct results ( 15,63%) and 29 ct negative results(90,63%). in 26 patients pet/ct positive results(81,25%) corresponded with the negative ct results. in 2 patients (6,25%)ct positive results corresponded with the negative pet/ct results. mean cea level in this group of patients was 28,84 ng/ml. conclusion: pet/ct was found to be the more valuable than ct tool for detecting colon cancer metastases in the group of patients with increased level of cea, additionally giving exact information about their localization. there is a need to conduct a prospective study to assess the value of the pet/ct in the diagnostics of colon cancer in connection with histopathology. introduction. although the fdg-pet is indispensable in the follow-up of colo-rectal carcinoma (crc) when recurrence suspicion exists (elevation of markers and/or findings in structural image), is not defined the role that can suppose its inclusion in the systematic follow-up of these patients. the aim of this work is to analyze the impact that can suppose the incorporation of the fdg-pet in the systematic management of crc patients without suspicion of tumour recurrence. population and methods. from a cohort of 43 patients with crc, a total of 32 (mean age 66,83 +/-14,2 years; 14 rectum, 9 sigma, 9 colon) were followed-up during two years by simultaneous use of fdg-pet and structural image (mainly us and ct) evaluated in blinded conditions. results. fdg-pet was considered negative in 25/32 patients, without findings in the structural image. in 7/32 (21,8%) cases fdg-pet showed not suspected tumour recurrence, without findings in the structural images in 4 of them (4/7/32; 57%/0,12%). dissemination of was determined as hepatic metastases (3), pulmonary metastases (2), retroperitoneal lymph node (2) and mesenteric implants (2) . that is, fdg-pet showed unsuspected tumour disease in 21,8% of patients, 57% of them free of significant structural changes. conclusions. even though the little number of patients, our series suggests that the inclusion of the fdg-pet in the systematic follow-up of the treated crc patients can improve their clinical management. aim. primary carcinoma of the gallbladder is a rare malignancy which is very difficult to diagnose and characterizes an extremely poor prognosis,. using fdg pet/ct we can obtain functional and morphological images of the entire body the aim of the study is a retrospective evaluation of pet/ct in patients with gallbladder carcinoma incidentally detected during cholecystectomy. material and methods. between march 2003 and december 2006 pet/ct was performed on 13 patients (10 women, 3 men; age 55,9 yrs ) with gallbladder carcinoma detected incidentally after cholecystectomy. the pet/ct was performed with a biograph lso 60 minutes after an intravenous administration of 5 mbq/kg fdg. results. pet/ct scanning presented lesions of increased fdg metabolisms in 10 patients. in 6 patients liver metastases, 5 hilus of the liver , 3 site of the gallbladder removal, 3 postoperative scar metastases, 3 metastases in lymph nodes of the abdominal cavity, 3 lymph nodes of the retroperitoneal space metastases, 1 omentum metastases were found. all were true positive. there were true negative results in the remaining 3 patients. conclusions. 1. pet/ct by fdg is a useful method in gallbladder cancer patient diagnostics. 2. pet/ct enables the diagnostics of the residual tumors, recurrence and distant metastases of the gallbladder carcinoma.. background it is known that f-18 fdg pet has a low sensitivity in the detection of hepatocellular carcinoma (hcc). we prospectively compared c-11 acetate pet results to those of f-18 fdg pet in patients with hccs. methods we prospectively analysed four patients (m:f=3:1, age range:48-64) with histopathologically or clinically confirmed hccs underwent c-11 acetate pet and f-18 fdg pet. whole body c-11 acetate pet was performed 10 min after injection of 555 mbq of c-11 acetate. f-18 fdg pet was done within 2 day before or after c-11 acetate pet. results a total of 22 hcc lesions were confirmed histopathologically or clinically. f-18 fdg pet detected only 8 lesions of them whereas c-11 acetate pet detected 12 lesions. two false positive lesions were found on both pets, respectively. conclusion although the number of patients was very small, c-11 acetate pet may be complementary to f-18 fdg pet and useful in imaging of hcc. further studies including more patients are needed. comparison of hepatic fdg uptake between japanese people with and without metabolic syndrome objectives: liver demonstrates heterogeneous fdg uptake pattern and sometimes shows abnormally increased uptake even though there is no malignant tissue. recently, fdg uptake in liver was correlated with fasting plasma glucose, reported. over the past 2 decades, there has been a dramatic increase in the number of subjects with the metabolic syndrome in japan as well as in western countries. the international diabetes federation defines metabolic syndrome as the presence of central obesity plus any two of the following three factors (fasting plasma glucose, lipid deviation and blood pressure). therefore, we evaluated the significance of hepatic fdg uptake associated with metabolic syndrome and hepatic enzymes. methods: sixty one patients (40 men and 21 women; age range, 28-80 years; mean age, 54.8 years) underwent whole-body fdg-pet imaging for cancer screening. patients with sever hepatic disease had been excluded. all patients were instructed to fast for at least 5 h before the intravenous injection of fdg. pet image was obtained 1 hour after injection of 3.7mbq/kg of f-18 fdg with pet camera. the fdg uptake in liver was analyzed semiquantitativly using roi on transaxial image at umbilical level and we compared mean standardized uptake value (suv) between normal and metabolic syndrome group, based on waist circumference, raised triglyceride level, reduced hdl cholesterol, raised blood pressure, and raised fasting plasma glucose. we also evaluated effects of fasting plasma glucose and hepatic enzymes, i.e., aspirate aminotransferase (ast), alanine aminotransferase (alt) and -glutamyl trasopeptidase ( -gt) on hepatic fdg uptake. results: the average of hepatic suv in abnormal groups of blood glucose level, lipid deviation and blood pressure was significantly higher than that of normal group, respectively (blood glucose level; 2.25±0.22 vs 2.06±0.36 (p<0.05), lipid deviation; 2.21±0.37 vs 2.00±0.29 (p<0.01), and blood pressure; 2.17±0.32 vs 2.00±0.35 (p<0.05). there was much more significantly high hepatic fdg uptake in metabolic syndrome group than normal group (2.30±0.30 vs 1.99±0.33, p<0.0001). on the other, hepatic fdg uptake of abnormal ast, alt and -gt groups showed no significant difference from normal groups. conclusions: there was significantly high hepatic fdg uptake in metabolic syndrome group than normal group. this result suggests that we need careful interpretation of the liver in a case of metabolic syndrome. aim: contrast materials with high iodine concentration have been found to improve parenchymal enhancement on ct imaging. however, intravenous contrast materials (cm) may cause artifacts on pet/ct when using the ct data for pet attenuation correction. the aim of this retrospective clinical study was to assess the feasibility to use a highly concentrated contrast material (hccm) containing 400 mg iodine/ml in pet/ct imaging. intravascular and parenchymal enhancement, potential ct and pet artifacts, and the accuracy of pet tracer quantification were assessed and compared to a lower concentrated cm containing 300 mg iodine/ml (lccm). material and methods: 60 whole-body fdg-pet/ct-scans of oncologic patients were investigated: 30 patients each with hypervascularized and non-hypervascularized tumors underwent fdg-pet/ct with either an application of hccm or lccm. ct enhancement (hounsfield units) and tracer uptake (maximal standardized uptake value, suvmax) were measured at 16 defined positions in different vessels and parenchyma. the quality of ct enhancement, the extent of potential ct and pet artifacts as well as the quality of tumor delineation were defined on a 4-point-scale. the influence of pet artifacts on clinical interpretation was defined. mann-whitney-wilcoxon-test was performed to evaluate statistically significant differences (p<0.05). results: in patients with hypervascularized tumors, hccm led to significantly higher ct enhancement in 11/16 positions compared with lccm. in patients with nonhypervascularized tumors, hccm provided significantly higher ct enhancement in 6/16 positions. no significant differences using hccm and lccm were found both for hypervascularized as for non hypervascularized tumors with regard to the quality of ct artifacts, to the suvmax, to the quality of pet artifacts, the quality of tumor delineation on ct, and the quality of tumor delineation on pet. no statistically significant difference was detected between hccm or lccm concerning the influence of pet artifacts on clinical image interpretation. conclusion: hccm leads to a stronger contrast enhancement on ct images than lccm without causing more artifacts on ct or pet. the application of hccm is feasible in hybrid pet/ct and should be considered in patients with hypervascularized tumors. aim: is to determine the clinical utility of 18-fdg pet/ct in follow-up of patients with malignant melanoma. materials and methods: we studied 68 patients in followup after surgery, having ajcc stage iii melanoma and contrast-enhanced computed tomography (ct) total body negative. in all patients a whole body (legs included) pet/ct scan was performed after an intravenous injection of 444-518 mbq of 18f-fdg in normoglucemia conditions. images were evaluated by 2 nuclear physicians. results: of the 68 pet/ct scans 24 showed 56 sites of active disease: 26 limph nodes (10 axillary, 2 parasternal, 2 supraclavicular, 6 external iliac, 4 bronchopulmonary, 2 paratracheal), 2 suprarenal gland, 2 bone, 22 subcutaneous and 4 skin. all pet/ct findings were confirmed by histology or clinical evolution; pet/ct caused changes of treatments. conclusion: in our study pet/ct is superior to ct scan in detecting lymph nodes, skin and subcutaneous metastases. as everybody knows: the early detection of resecable melanoma metastases with early treatment decreases the risk of recurrence and increases survival. aim. to value pet/ct scanning sensibility and specificity compared with those of standard ct (sct) in staging lymph nodes, liver, bone and other organs metastases in patients (pts) with malignant melanoma (mm). patients and methods. between september 2006 and march 2007, 17 pts, age 31-62 years, mean 44, were enrolled. all pts were previously submitted to surgery to remove mm, sentinel node and, when indicated, other regional lymph nodes. a sct scan was already performed in these pts when they came to our institution for pet/ct scanning. we compared sites and number of sct-diagnosed relapses with pet/ct results. results. in 1/17 (6%) pts sct scanning showed a cerebellar relapse not observed by pet/ct. in 9/17 (53%) pts pet/ct results were comparable to sct ones; 1 of these pts had a lung relapse, 7 hadn't metastases, 1 had an ovarian mass which was described as an ovarian cyst by sct, while pet/ct wasn't able to define it as malignant or benignant lesion. 5/17 (29%) pts had negative sct scanning, while pet/ct revealed bone or lymph nodes metastases; in 1 of these pts there were widespread metastases. finally in 2/17 (12%) pts pet scans showed high metabolic activity lymph nodes, while in the same pts sct imaging revealed different sites of relapses, above all liver. conclusion. pet/ct and sct seem to have, in staging or restaging of mm, the same sensibility in discovering lung metastases, while pet/ct sensibility is higher than sct one relative to bone or lymph nodes relapses. pet/ct sensibility appears lower in detecting liver involvement. sct shows more specificity than pet/ct in describing cerebellar and ovarian lesions. aim: ovarian cancer is the leading cause of death as concerns gynecological cancer in the western countries. the difficulty in the detection of recurrence and the bad prognosis of the disease is well known. this study was designed to determine the value of 18 fdg pet/ct compared to mri and ct, in the evaluation of recurrence disease. material-methods: 30 patients went through 18 fdg pet/ct examinations (siemens biograph lso) from june 2004 -march 2007. the injected radioactivity dose for all scans was between 340 -410 mbq (9-11 mci). all of them had ovarian cancer and underwent the pet/ct for restaging. mean age was 53.6 ±12.2 years. in women with ovarian cancer, 26 were subjected to ct scans (group a) and 8 to mri (group b) for disease reevaluation just before pet/ct evaluation. results: 20/30 patients had positive pet/ct scan (suv 4.9 ± 2.3), 13/26 patients had positive ct while 7/8 had positive mri. group a: 7/26 patients (26,9%) had match findings in pet/ct and ct scans (6 cases negative results and 1 case positive result) pet/ct scan outbalanced ct in 9/26 patient cases (34.6%) -(mainly in extra pelvic disease). in 7 cases with negative ct, pet/ct was positive (26.9%). in 1/3 patients with negative pet/ct, ct was positive and 2 of them had non diagnostic ct. group b: in 2/8 patients (25%) we had match findings in pet/ct and mri as well. in 1/8 patients (12.5%) we had mri (+) and pet/ct (-) while another one had mri (-) and pet/ct (+). the critical point is that in 4/8 patients with mri (+) and pet/ct (+), pet/ct outbalanced mri (mainly in extra pelvic disease).in 8 patients with tumor markers, 6 of them had elevated serum ca 125 and 2 had normal ca 125 levels. in 5/6 women with elevated serum ca 125 pet/ct was observed (+) and in 1/6 pet/ct was (-). in the 2 cases with normal ca 125 level we found pet/ct (+). conclusion: according to the results of this study pet/ct scan presents a plain superiority in effectiveness over the ct scan. 18-fdg pet/ct may detect recurrent ovarian cancer more accurate than mri. also 18-fdg pet/ct is a very promising technique compared to raising levels of tumor markers. introduction: only sporadic data support the use of labelled-choline as oncological probe to monitor the pca response to treatment in patients. aim: to evaluate early modifications of 18f-methyl-choline (18f-ch) uptake in an animal model of prostate cancer (lncap xenograft on balb-c nude mice). material and methods: hormonosensitive prostate cancer xenografts were obtained in the back legs of athymic nude mice by subcutaneous injection of 6-10 lncap cells suspended in a solution of rpmi 1640 medium and matrigel®. animals were kept in appropriate facilities until tumour size reached 0.5-1 ml. mice were then treated twice a week by intra-peritoneal administration of docetaxel (8mg/kg). sequential 18f-ch animal pet acquisitions (105_to_120 min after ip injection) were performed basically and in the course of treatment of eight mice, to observe tumour metabolic changes after 2-3 cures and 5 cures of docetaxel. because some animals died after the fifth cure of docetaxel, not enough data were available to perform further statistical analysis. results: tumor xenograft volumes continued to rise during the first cures of chemotherapy but tumour growth significantly slowed down afterwards. before tumour growth stabilization, 18f-choline pet revealed a decrease in tumour metabolism characterized by a significant fall (p=0.016) of both suvmean (-43%) and suvmax (-46%) in comparison with initial values. a transitory stabilization of tracer amount in tumours (%id/ml) was also noted. nevertheless, this observation was restricted to the induction phase, while later pet studies (after 5 or more cures) demonstrated a slight increase of semi-quantitative parameters in parallel to a tumor size regrowth, suggesting a docetaxel failure in the tumour proliferation control. conclusion: these preliminary data show that docetaxel treatment inducted a rapid decrease of semiquantitative index of 18f-choline uptake in lncap xenograft tumours. nevertheless, these observations are limited in time due to the suboptimal control of tumour growth by chemotherapy in these small animal series. purpose: we studied dynamic pelvic imaging followed by whole body 18ffluorocholine pet/ct imaging for the assessment of salvage radiotherapy in prostate cancer patients presenting either biochemical recurrence or suspicion of residual disease. methods: we evaluated 40 patients with a persistent >0,1ng/ml or elevating psa (median 3.41; range 0.23-37.7), 20 after radical prostatectomy combined or not with radiotherapy and 20 after radiotherapy commonly with additional hormonotherapy. systematically all patients underwent early dynamic pelvic imaging within the first 10 minutes after intravenous injection of 300mbq 18f-fluorocholine, followed by total body pet/ct scan (siemens sensation 16 or 64). late pelvic imaging after 40 minutes was performed in 23 patients. fused pet/ct images were interpreted visually by 2 observers. correlation was made with other imaging modalities including endorectal mri (19 patients) and bone scintigraphy (18 patients). first results: overall, 30 of the 40 patients showed positive pet/ct for local or distant recurrence, 2 were equivocal and 8 negative. when classified according to site, 22 were positive for local recurrence, 6 equivocal and 12 negative. loco-regional lymph nodes were positive or equivocal in 5 patients. of the 9 patients with positive pet/ct findings for distant sites, 3 were positive for lymph node, 5 for bone and 2 for adrenal metastases. when classified according to psa levels, 3 patients were equivocal and 4 negative in range 1ng/ml, 2 positive and 4 negatives in range >1 to 2ng/ml, and 25 positive and 2 ambiguous in range >2ng/ml. subsequently 16 patients underwent salvage radiotherapy with the radiation field centred according to pet/ct findings as well as other imaging modalities. conclusion: dynamic and late 18ffluorocholine pet/ct imaging was advantageous in assessing loco-regional recurrence of prostate cancer. 25/27 patients with psa >2ng/ml had positive pet/ct findings. consequently, salvage radiotherapy field could be better defined. further evaluation of the accuracy of this technique in the detection of recurrence using quantitative criteria as well as long term follow-up is underway. aim: pet/ct using 18f-choline (fch) was found to be valuable in the detection of prostate cancer recurrence even at lower psa levels. we evaluated the possible use of fch pet/ct in early re-staging of prostate cancer relapse with regard to the degree of glandular differentiation of the primary prostate tumor [gleason score(gs)]. methods: 147 patients who had well/moderately differentiated primary prostate tumors (gs </=7) and were at low-risk for recurrence, and 92 more patients who had poorly differentiated primary prostate cancer (gs>7) and were at high-risk for recurrence underwent a whole body pet/ct scan at > 60 min after injection of 4.0 mbq/kg of fch (iason labormedizin gesmbh & co. kg graz-seisberg, austria) because of rising psa (> 0.1 ng/ml) after initial therapy (prostatectomy n= 145, radiotherapy n= 45, hormone therapy alone n= 49). 44(48%) patients with gs>7 and 33(20%) patients with gs </=7 were under adjuvant hormonal therapy at the time of examination. focal high uptake of fch was rated (visual interpretation) as probable recurrent disease. corresponding images of ct from pet/ct (discovery ls pet/ct scanner, ge healthcare, milwaukee, wi, usa) were also used to achieve the diagnosis. results: prostate cancer recurrence was confirmed in all but one fch positive case in the clinical course. no fch negative patient had prostate cancer relapse from the clinically available data during a 6 month follow-up . fch pet/ct detected recurrent disease in 69/92(75%) high-risk patients (local recurrences n=17, distant recurrences n=52) and in 72/147(49%) low-risk patients (local recurrences n=24, distant recurrences n=48). among them, 37 high-risk patients and 17 low-risk patients were under hormonal therapy. median psa in fch positive cases was 7.35 and 8.77 ng/ml for high-risk and low-risk patients respectively; median psa in fch negative cases was 0.74 and 0.76 ng/ml for high-risk and low-risk, respectively. fch pet/ct obtained true positive findings even at lower psa levels (< 4.01 ng/ml) in many (24/47) cases with gs>7 (median psa 0.9 ng/ml, range 0.11-3.49) but in only few (14/82) cases with gs</=7 (median psa 2.5 ng/ml, range 0.3-4.0). 15(35%) high-risk patients as well as 15(26%) low-risk patients developed recurrence in the first years after therapy. all recurrences (local n=7, distant n=23) were identified by fch pet/ct, and for 21 patients pet/ct was the only test showing recurrent disease. conclusion: fch pet/ct is proven as feasible in early detection of prostate cancer relapse, especially in those with poorly differentiated primary prostate cancer. introduction: retroperitoneal (rp) lymph nodes represent the regional lymphatic drainage in germinative testicular tumors. these lymph nodes often remain enlarged even following chemotherapy (cht), while the histopathological findings in resected lymph nodes consist of fibrotic tissue (48%), teratoma (37%), or other viable tumor cells (15%). aim: evaluation of the benefit of 18f-fdg pet in prediction of the viability of the rp masses via comparison of pet positive or pet negative findings in patients following curative cht plus rp residue resection. patients and methods: from september 2003 through june 2006 (33 months) a total of 501 pet scans were performed in 482 patients with germinative testicular tumors. the presented study group includes 18 patients after cht, in which the rp masses were resected within an average of 90 days following the pet scan. the patient age ranged from 18 to 39 years (average 27.6 years, median 26.8). the tumors included 3 seminomas and 15 non-seminomas. results: the pet scan results subdivided the rp masses into pet positive (n = 5, activity of the lesion higher than the referential activity of the liver), and pet negative (n = 13). in the pet positive subgroup the resection confirmed persisting tumor tissue in 3 cases, while false pet positive results were recorded in 2 patients with inflammatory changes within fibrosis (in both seminoma and nonseminoma). fibrotic changes were correctly detected via pet in 2 patients with seminomas. the negative pet scans in 11 patients with non-seminoma proved problematic due to eventual histopathological findings of teratocarcinoma micrometastases (1x), mature teratoma (4x) as well as fibrotic changes (6x). conclusion: in case of seminomas the fibrotic residual masses were detected correctly. we have recorded false pet positivity due to inflammatory changes in fibrotic tissue in various histological tumor types. our data suggest limited capability of pet to differentiate residual fibrotic masses from mature teratoma in case of nonseminomas (both findings can appear as pet negative). support: iga mzcr grant nr 8342-3/2005. aim: the incidence of testicular cancer has increased three-fold over the last decades, with the highest incidence being in european countries. a relatively new method 18fdg pet/ct, might be useful to overcome the diagnostic problems in re-staging testicular carcinoma. this study was designed to determine the value of 18fdg pet/ct compared to mri and ct, in the evaluation of recurrence disease and postchemotherapy residual mass in testicular carcinoma. material -methods: we examined 39 patients who underwent whole-body pet/ct (siemens biograph lso) scans with 2-deoxy -2-[f8f]fluoro-d-glucose (fdg). the injected radioactivity dose for all scans was between 340-410 mbq (9-11mci). all of the patients had history of testicular carcinoma and underwent the pet/ct for re-staging. mean age 29,5 ± 6,8 years. in men with testicular carcinoma, 37 were subjected to ct scans (group a) and 10 to mri (group b) for disease reevaluation just before pet/ct reevaluation. results: 16/39 patients had positive pet/ct scan (suv 7,6 ± 7,4), 24/37 patients had positive ct while 6/10 had positive mri. group a: 13/37 patients (35,1%) had match findings in pet/ct and ct scans (11 cases negative results and 2 cases positive results). in 12 cases with positive ct, pet was negative (32,4%) while in 2 cases with negative ct, pet was positive (5,4%). in 10/37 patients we had mismatch findings between pet/ct and ct (in 6 patients, pet/ct scan outbalanced ct, while in 4 cases we had the opposite result). group b: in 3/10 patients (30%) match findings observed between mri and pet/ct scan (2 cases negative results and 1 case positive result). 3/10 patients (30%) had mri (+) and pet/ct (-) while 2/10 patients (20%) had mri (-) and pet/ct (+). in 2/10 patients (20%) with mri (+) and pet/ct (+), pet/ct outbalanced mri. in 21 men with tumor markers, 10 of them had elevated blood levels. 6/10 patients with abnormal tumor markers had positive pet/ct scan, while 4/10 patients had negative pet/ct (all cases with elevated afp levels). on the other hand in 11 patients with normal tumor markers 9 of them had negative pet/ct and 2 positive pet/ct scan. conclusion: these preliminary results demonstrate that 18fdg pet/ct was superior to conventional techniques in restaging patients with testicular carcinoma. 18fdg pet/ct was a sensitive and reliable modality for detection of residual viable tumor in these patients. aim: primary extragonadal germ cell tumors (exgcts) account for nearly 5% of all gcts and are characterized by a poor prognosis. radical post-chemotherapy surgery of residual masses represents the standard of care. in case of residual viable tumor or teratoma, complete resection may be curative. however, when only necrosis is found, patients will be exposed to surgery-related morbidity and mortality without any survival benefit. no reliable factors predictive of the presence of viable tumor or teratoma in residual masses are available yet. fdg-pet has been successfully used for staging primary gonadal gct, but its role in the management of residual masses form gcts has not yet defined. we aimed to assess fdg-pet as a tool to detect residual tumor after chemotherapy. materials and methods: we evaluated 6 consecutive patients with exgcts (mean age 39 years, range 29-62), who underwent residual surgery following standard platinum and etoposide based chemotherapy. four patients had primary mediastinal location, 2 peritoneal. four patients had a non seminomatous tumor, 2 had seminoma. three patients were metastatic at the time of first diagnosis. four out of 6 patients were classified as poor prognosis (pp) according to the igcccg. the 2 patients with good prognosis (gp) had 3 cycles of chemotherapy, the others had 4 cycles.. all patients had fdg-pet, following standard procedures, at the end of chemotherapy and before undergoing residual surgery. fdg-pet results were compared with pathological findings. results: after chemo the four pp patients were classified as in partial response, the 2 gp as complete response. the mean tumor shrinkage on ct was 54%. a correlation between fdg-pet and pathological finding was found in all cases: two patients with positive pet had viable tumor in postsurgical specimen, while 4 patients with negative pet had necrosis or fibrosis. conclusion: following chemotherapy for exgcts, complete surgery of residual masses remains the recommended standard of care since it may be curative in an approximately half of patients with residual viable tumor or teratoma. among other clinical factors a positive fdg-pet might help to identify patients at higher risk for residual disease. in these patients, complete surgery may be suggested even in centimetric residual disease. fdg-pet may also help to address surgery to active lesions in patients with thoracic and abdominal disease. introduction and aim: multiple myeloma (mm), malignant b cell and plasma cell disorder, involves the skeleton in more than 60% at diagnosis. conventional and radionuclide methods are routinely used to evaluate these lesions. recently, fdg pet/ct has been introduced to the field. in this study, our aim was evaluate the accuracy of fdg pet in detecting myeloma lesions and its influence on patient's management comparing with clinical, radiological and bone scintigraphic findings. materials and methods: 34 pts (10f, 24 m) were evaluated; group i had 26 patients (8f, 18m; aged 32-83 years) with mm, group ii had 4 pts (1f, 3m; aged 35-72 years) with solitary plasmocytoma and group iii had 4 patients (1f, 3m; aged 37-60 years) with monoclonal gammopathy. mean follow up period was 18,1±17,6 months. in group i, 2 pts were referred for evaluation of extent of disease before bone marrow transplantation (bmt) and 1 pt referred for assesment of bmt response, 7 pts had pain and referred for assesment of the extent of disease, and other pts with no complaints referred for follow up. in group 2 and 3, pet/ct was performed to evaluate the extention of disease. the results of whole body bone scintigraphy (wbs), radiographs, and mri or ct imaging modalities as well as the clinical course at the same period were used to compare with fdg pet/ct results. results: the results are summarized in this table. conclusion: pet/ct scan is helpful to evaluate mm pts. it appears to be more sensitive than other radiologic and scintigraphic examination for the detection of lytic bone lesions. however, it may not be sufficient for detection and differentiation of small lesions and diffuse marrow involvement. in this study, 2/34 pts had negative pet/ct and positive bone lesions. it was thought that the combination of pet/ct and other radiological and scintigraphical examination might be more succesfull than pet alone. since pet investigation was performed mostly during active disease evaluation of its impact on survival, response was not avalaible. it is also important to emphasize the disadvantages of pet/ct in myeloma treatment, steroid related hyperglycemia, early vertebrate operations the frequently performed cause false positivity. however, we took precautions to delay imaging untill 3 months following surgery and avoding imaging during glucose intolerance. pet/ct has the applicability to whole body imaging which is hard to apply to mri and results with better resolution compared to whole body mri. , lymphoma (n=8),hepatoma(n=5), prostatic carcinoma(n=5), gastric cancer(n=4),esophageal carcinoma(n=3), multiple myeloma (n=3), thyroid cancer (n=2), osteosarcoma (n=2), renal carcinoma (n=1),unknown primary origin (n=2);11 nonmalignant cases ingcluding:osteoporosis(n=7),bone tuberculosis(n=2), inflammation (n=1), hyperparathyroidism (n=1).in 51 of 58 malignant cases 18f-fdg pet/ct showed tracer accumulations corresponding to etiologic diagnosis .the sensitivity of 18f-fdg pet/ct was 51/58(87.9%).the false negative rate of 18f-fdg pet/ct was 7/58(12.1%).in 4 0f 11 nonmalignant cases 18f-fdg pet/ct showed abnormal tracer accumulations . the specificity was 7/11(63.6%).the false positive rate of 18f-fdg pet/ct was 4/11(36.4%). conclusion: whole body 18f-fdg pet/ct is a valuable tool in etiologic diagnosis of suspected bd,the diagnostic accuracy could be more improved combinding with ct ,mri appearance and clinical informations. aim: the aim of this retrospective study was to evaluate the potential additional diagnostic role of 18f-fdg pet/ct imaging for the detection of unknown primary origing cancer (cup). materials and methods: the study population consisted of 61 consecutive patients (37 men, mean age: 61 ± 6.8 years old) with suspected cup, tumoral markers abnormalities and/or paraneoplasic syndromes. an 18f-fdg pet/ct was performed in all patients population. all acquired images were assesed by a nuclear medicine with experience in pet and pet/ct and a radiologist physician. results: the initial evaluation of patients showed two differents findings: 1. patients with macroscopic lesions: presence of masses and lymphoadenophatiesmostly supraclavicular -in 25 patients (41%) and liver and bone metastases in 10 patients (16%). 2. patients without macroscopic lesions: high serum levels of tumour markers in 16 patients (26%) and paraneoplasic syndromes in 5 cases (8%). pet-ct results were: normal test in 11 patients, non-specific features in 10 patients and hypermetabolic lesions sugestive of malignancy (suv > 3) in 40 patients. primary tumor was sugested in 36 patients and re-stage of neoplasm was performed in 83%. pet/ct was abnormal in all patients of the group with macroscopic lesions, except in one case. in the second group, pet/ct was suggested of malignancy in only of 38% of patients. conclusion: pet/ct identified primary tumour in 68% of patients with suspected cup, showing a better accuracy than other imaging techniques. in our study the diagnostic accuracy of pet/ct was higher than previously described in literature (24-40%). however, the main limitation of this technique is the low ability to detect metastatic occult primary tumors in patients without macroscopic lesions. objectives: to provide accurate preoperative localization of parathyroid adenomas (pa) and to facilitate minimally invasive surgical approach to pa, as opposed to open cervicotomy and bilateral neck exploration. methods: for the same patients spect and mri scans were acquired with fiducial skin markers (fsms) placed on patient's thorax and neck. spect scans were obtained using: (i) 1 mci of tc-99m pertechnetate; (ii) 15 min. and (iii) 120 min. after administration of 30 mci of tc-99m sestamibi. mri was acquired with a 3t magnet using t2-weighted spin-echo sequences. a deformable finite element model (fem) has been implemented for accurate nonrigid registration and fusion of spect and mri images. in this model fsms are used to sample 3d image deformation between spect and mri. in this method the intermodality displacements of the corresponding fsms observed in spect and mri are determined, then fem is used to distribute the fsms displacements linearly over the entire volume, followed by creation of a warped mr image registered with the spect image and by mri and spect volume fusion. a commercial ansys fem software was used for fem calculations along with our own programs for 3d image warping and fusion. results: we verified correct anatomical intermodal registration of the fused spect/mri images using organs with known high uptake of radiopharmaceuticals. the target registration error not exceeded 4 mm. conclusions: our nonrigid registration and fusion method allowed creation of a detailed anatomic map of the neck and thorax from mri accurately combined with a functional 3d map from spect for improved preoperative localization of the parathyroid adenomas. aim: we describe our experience with 68ga-dotatoc pet imaging in neuroendocrine and neuroectodermal tumours as compared to 111in-octreotide, 123i-mibg and cross sectional imaging over a two year period. material and method: thirty-three patients (13f, 20m) with a variety of neuroendocrine and neuroectodermal tumours underwent 68ga-dotatoc pet imaging. the mean administered activity was 150mbq. the number of lesions, intensity of uptake and overall quality of the images were compared with 111octreotide or 123mibg (performed within 3 months in 80% of cases) and radiological investigations such as ct, mri and angiography (performed within 3 months in 77% of cases). results: five patients (15%) had additional lesions on the 68ga-dotatoc scan compared with other nuclear medicine imaging. in two of these patients the 68ga-dotatoc scan showed the lesions more clearly than the 111in-octreotide scan due to better resolution. in 4/33 (12%) patients, 111in-octreotide or 123i-mibg demonstrated more lesions than the 68ga-dotatoc scan. of these cases, 3/5 were in patients with benign phaeochromocytomas. in 6/33 (18%) patients all scintigraphic tests were negative when radiological investigations including angiography demonstrated lesions. conclusion: 68ga-dotatoc pet has an emerging role in detecting a wide range of neuroendocrine and neuroectodermal tumours. it shows better resolution and demonstrates extra lesions compared to 111in-octreotide and 123i-mibg. in has lower sensitivity than 123i-mibg for benign phaeochromocytoma but higher sensitivity in malignant neuroectodermal tumours. the multi-modality approach remains essential as 18% of these tumours were only detected with anatomical imaging. the increasing use of pet-ct should improve the sensitivity of this technique. breast cancer is the most frequent tumour in women. it would be very useful to identify patients responders to neo-adjuvant treatment from not responders. aim: the aim of this study was to systematically review the literature regarding the value of fdg-pet and pet-ct in the assesment of treatement respond after neo-adjuvant theraphy. materials and methods: systematic review of the literature, searching relevant studies in medline and cancerlit. for the selection of the studies we applied inclusion and exclusion criteria that had been previously set. two independent reviewers assessed the methodological quality of each selected study (flynn criteria) and the eficacy diagnostic level (fryback). most relevant data and statistic results were obtained from each study. results: 63 studies were found in the primary search. after aplying inclusion and exclusion criteria, four studies were selected. in three of these four studies the metodological quality was modarately low (c group) ; all the studies were in level ii of diagnostic eficacy. with a statistical analysis , 0.91 sensitivity, 0.5 specificity and 0.85 accuracy were obtained. most of the authors agree in the necessity of perform some pet studies during neoadjuvant treatment. most authors also agree that it would be suitable to use a semicuantitative analysis using "standardized uptake value" (suv) from assessment the response. the threshold value for differentiation responders and no-responders is different depending on the study. conclusions: recent studies suggest that fdg-pet may identify patients responders to neo-adjuvant therapy earlier then other conventional imaging modalities. it is still not clear when to perform pet studies or which is the appropriate threshold value for differentiation responders and not-responders. finally, further prospective investigations on a larger number of patients need to be performed. objectives: paragangliomas are usually slowly growing, somatostatin receptor (sstr)-expressing, benign tumours of the head and neck region. however, they can also be locally invasive and cause bone destruction and dysfunction of cranial nerves. up to 10 % of paragangliomas are malignant and may metastasize, leading to distant lesions. therefore, accurate whole body tumour screening is important. the aim of this study was to assess the accuracy in detection of sstr-positive lesions derived from paragangliomas by 68ga-dota-tyr3-octreotide (dota-toc) pet/ct or 68ga-dota-toc pet/mri fusion. methods/patients: in this study, the clinical value of sstr imaging with 68ga-dota-toc pet was assessed in 9 patients (4 male and 5 female, age ranged from 27 to 74). seven patients underwent whole body imaging with 68ga-dota-toc pet, and in 2 patients cerebral 68ga-dota-toc pet imaging was done. each patient received 150 mbq 68ga-dota-toc, images were obtained 60-90 minutes post i.v.-injection. combination of morphologic and functional imaging was done by pet/ct or pet/mri, providing more accurate information in staging and restaging. the interpretation of ct and pet scans was done independently. results: of the 9 investigated patients with paragangliomas 2 patients showed true-negative and 7 true-positive results. all known lesions were also shown by pet. additionally 3 unknown bone lesions were detected in a patient with metastatic disease. because of the high sstr-expression in one patient with local recurrence of invasive paraganglioma, treatment with the sstr-analog 177lu-dota-tate was initiated, since no other therapeutic options were available. over one year six therapeutic cycles with an overall dose of 32,7 gbq were performed, without severe side effects. in the follow up one year after first treatment by 68ga-dota-toc pet/ct, minor response was observed. conclusion: 68ga-dota-toc pet provides accurate information concerning extension and localisation of paraganglioma lesions for initial diagnosis, for selection and for follow up after radionuclide-peptidetherapy. furthermore, our data indicate that whole body imaging with 68ga-dota-toc pet might be useful to delineate distant and small metastases of paragangliomas. . fourteen patients had more than one fdopa-pet examination (between 2 to 6). forty examinations were performed without combined ct and 36 (since july 2004) with combined ct. the impact of fdopa pet was evaluated, on a per-patient basis, thanks to a questionnaire filled in by the referring physician and the pertinence of the induced decisions was assessed thanks to the follow-up data. results: -carcinoid tumour of the small bowel: 22 of 23 patients were evaluable. an impact of fdopa-pet was reported in 11 of them (rate: 50%), corresponding to an adequate decision in all patients (major therapeutic changes in 5 patients, minor therapeutic changes in 4 patients and orientation of biopsies or complementary imaging in 2 patients). among the 40 examinations performed in these 22 patients, 6 examinations were true-negative (tn), 33 were true-positive (tp) and only one was false-negative (fn) (residual tumour measuring 3 mm, responsible for clinical symptoms). -non-carcinoid digestive tumours: 21 of 29 patients were evaluable. an impact of fdopa-pet was reported in 4 of them (rate 19%), corresponding to an adequate decision in 2 patients (decision of surgery and decision of medical therapy) and a non-pertinent decision in 2 patients (inappropriate cancellation of surgery and futile complementary exploration of a questionable focus of fdopa uptake). the 22 examinations performed in these 21 patients corresponded to 6 tp, 4 tn, 1 fp and 11 fn results. conclusion: the overall rate of change in patient management was 35%, with a significant difference between the rate in carcinoid and in non-carcinoid tumours (50% vs. 19%, p < 0.04). fdopa-pet appeared to be a major tool for the management of carcinoid digestive tumours with excellent diagnostic performances and induced pertinent changes in the management of patients at a rate similar to that of fdg-pet in other malignancies. background: fdg pet has a role to evaluate the response to molecular targeting therapy with imatinib mesyilate against gastrointestinal stromal tumor. metabolic response assessed by fdg pet is earlier than morphological changes determined by ct or mri. the assessment of early response to the molecular targeting therapy has a clinical significance in terms of evaluating effectiveness and determining alternative therapy based on the possibility of ineffectiveness in the early stage of the expensive therapy. purpose: we have conducted preliminary study of fdg pet to assess early response to the chemotherapy with gefitinib to non-small cell lung cancer (nsclc). materials and methods: four patients with advanced nsclc who have measurable lesion and epidermal growth factor receptor mutation, and were scheduled for gefitinib therapy were evaluated. the study was approved by the institutional review board and all the patients gave informed consent. fdg pet was done prior to, 2 days and 4-6 weeks after the commencement of the therapy. pet was performed after injection of 5-6 mbq/kg fdg by 2d acquisition using a dedicated whole-body pet scanner (set2400w, shimadzu, japan). transmission data was acquired simultaneously with emission data using the external source. uptake of fdg in the tumor was evaluated by the semiquantitative evaluation using standardized uptake value (suv). outcome of patients was correlated with the changes in the size of the tumor and the suv. results: conventional response evaluation with ct revealed that two of four patients showed partial response (pr) and the others showed stable disease (sd) with minor response. progression free survival (pfs) of the two pr patients was 12.9 and 12.5 months. pfs of two patients with sd was 14.9 and 4.5 months. fdg pet showed decrease in fdg uptake (58.1% and 47.2% of initial study) in sd patients as well as in pr patients. conclusion: fdg pet could represent early response to gefitinib and have a role to estimate prognosis even in patients with sd which is evaluated by conventional ct. aim: dynamic pet studies with 18f-fdg were performed in patients with advanced non-small cell lung cancer (nsclc) who received palliative chemotherapy to evaluate the impact of full kinetic analysis and assess its value with regard to short ot long survival. methods: the evaluation includes 42 metastatic lesions in 14 patients with nsclc. all patients received a combined chemotherapeutic protocol consisting of vinorelbin and oxaliplatin. the survival data served as reference for the pet data. all patients were examined prior to onset of chemotherapy and on day 15-21 after onset of the first cycle. the following parameters were retrieved from the dynamic pet studies: suv, fractal dimension (fd), two compartment model with computation of k1, k2, k3, k4 (unit: 1/min), the fractional blood volume (vb) and the fdg-influx according to patlak was calculated using the formula (k1 x k3) / (k2 + k3). we used a two group classification, namely a short and long term survival group based on the median survival time (193 days) as a cutoff. a support vector machines (svm) analysis was used for classification of the two a priori defined groups. results: the observed survival times varied from 40 to 392 days with a median survival time of 193 days. most kinetic parameters demonstrated only small changes, mostly declining after one cycle. the change in all kinetic parameters did not correlate to the survival based classification.the change in suv was significant between the first and second study (p=0.006) but without an impact on the prediction of short ot long survival. svm based analysis revealed the highest correct classification rate (ccr) between short and long survival for the combination of suv and influx of the first study and suv, influx, k2, k4 of the second study with a ccr of 95.2 %. conclusion: the results demonstrate, that a full kinetic analysis of the 18f-fdg kinetics in nsclc is helpful for the classification into short or long survival and may be used to identify those patients who may benefit from this palliative chemotherapeutic protocol. aim: (a) to evaluate the efficacy of fdg pet in the early prediction of chemotherapy effect on human testicular cancer xenografts; (b) to determine the optimal delay between chemotherapy administration and fdg imaging. material and methods: animal model eight 4 week-old male nude rats bearing subcutaneous human embryonal carcinoma xenografts (n=6 per animal) were treated with a single dose of cisplatin. a control animal received saline serum. pet imaging sa-pet imaging (phillips mosaic system) was performed 3.5 hours after injection of 15-45 mbq of fdg in the tail vein. fdg uptake was evaluated with tumour/background ratio (t/b ratio). animals were imaged at day 0 (baseline examination), day 2, day 4 and day 7. immunochemistry at each point, 2 rats were sacrificed for immunochemistry studies which comprised cell proliferation (cyclin a), apoptosis (cleaved caspase 3), and macrophagic infiltrate (anti-cd 68). whole slice quantification (pixit® software) was used for comparison with sa-pet data. results: sa-pet imaging fdg uptake in rats who received cisplatin showed a biphasic evolution: initially, a peak was observed at day 2, with t/b ratios (10.21 +/-1.87) higher than those observed at day 0 (7.25+/-1.63), p<0.0001. secondly, a decrease was seen from day 2 to day 4, although t/b ratios at day 4 were still higher than those at day 0. the decrease of fdg uptake became statistically significant at day 7 (p<0.0001). in the untreated rat images, tumours demonstrated an increase of fdg uptake at day 2 (far lower than that observed in treated animals) then remained stable. immunochemistry a significant increase of apoptosis was observed at day 4 (29.4 +/-24.3; p=0.012) and day 7 (23.8 +/-13.8; p=0.001) in comparison with day 0 (11.8 +/-8.9). a transient increase in cell proliferation was observed at day 4 (72.8 +/-24.9 ; p=0.003) in comparison with day 0 (39.2 +/-26.3), and was followed by a decrease at day 7 (16 +/-14.5 ; p=0.008). macrophage infiltrate, a well known cause of false positive findings, remained low when 18 fdg uptake was increased after chemotherapy. conclusion: fdg pet may be useful in the early evaluation of treatment in patients with testicular cancer. a very early increased fdg uptake precedes a transient increase in cell proliferation but does not reveal refractory disease. additional studies investigating the effect of chemotherapy type, dose and schedule are currently underway in our laboratory. purpose. the purpose of this study was to analyze the diagnostic accuracy of pet and pet/ct in the evaluation of treatment response, both analyzing early response to treatment (ert) after a few cycles of chemotherapy, and after having completed the treatment (ahct), in patients with hodgkin disease (hd) and non-hodgkin lymphomas (nhl). methods. we performed a systematic review of the literature, searching medline and embase databases for studies published until december 2006. we included articles that evaluated pet and pet/ct in patients with lymphoma after treatment (ert and ahct). the eligibility was based in articles with sufficient data for calculate parameters of diagnostic accuracy, with separated analysis in hd and nhl. we calculated values of sensitivity (se), specificity (sp), positive probability rate (ppr) and diagnostic odds ratio (dor). results. we selected 28 studies for analysis. the diagnostic parameters for ert in pet and pet/ct in patients with hd were: se of 0.813 ( recent studies have demonstrated the effective use of imatinib mesylate for the unresectable, metastatic or recurrent gist. the aim of this study was to evaluate the role of 18f fdg pet/ct in gist patients treated with imatinib mesylate. material and methods: eight consecutive patients with gist proven by surgery (3 stomach, 2 small bowel, 1 small bowel and peritoneum, and 2 rectum) underwent thirteen 18f fdg pet/ct imaging after the start of imatinib mesylate therapy (400 mg/day or greater if disease progression). patients were overnight fasting and had normal blood glucose levels. pet/ct was acquired 69-90 minutes after the intravenous injection of 370-555 mbq of 18f fdg. iterative reconstruction algorithms were applied and pet images were corrected for attenuation on the basis of ct data. a visual analysis of images was performed. standardized uptake value (suv) was calculated for each lesion. in the 3 patients who underwent serial fdg pet/ct imaging, the therapy response was assessed according to the recist criteria for ct and eortc recommendations for pet. results were confirmed by clinical follow-up, radiographic findings or histological analysis. results: five patients were therapy-responders. the response was complete in 3, 2 of them had abdominal lymph nodes and the other, peritoneal implants. the remaining 2 patients had a partial response showing persistent fdg uptake in lung (1) and in liver metastases and lymph nodes (1). this latter patient showed a complete response increasing the imatinib mesylate dosage to 600 mg/day. one patient had a disease progression showing new hepatic lesions on fdg pet/ct; a partial response was documented (a decrease of suv in two liver lesions) after a left hepatectomy and an increase of dosage to 800 mg/day. two patients were no-responders. one patient had an unresectable pelvic gist and the other multiple peritoneal implants. both patients died in a 2-6 months period after fdg pet/ct. conclusion: tumor response to imatinib mesylate should be assessed by fdg pet/ct. fdg pet/ct imaging identified the degree of therapy response with a clinical impact on the management of patients with gist. of 3 doses that mimics maximum tolerated dose (mtd) used clinically. the body weight of each mouse and the size of tumor implants were monitored throughout the experiment. the mice were scanned with 18f-fdg on days 7, 10, 14, 17 and 21 post tumor inoculation using high-sensitivity projection imaging (ppis-4800, hamamatsu) with 18f-fdg for monitoring the anti-tumor effect of ctx. the results of ppis imaging was compared to those of micropet imaging (r4, concorde). result: ctx treatment resulted in growth inhibition of the ct-26 tumor and a decreased of the body weight of the mice as compared to the untreated controls. both the highsensitivity projection and micropet 18f-fdg imaging modality are equally effective in monitoring the ctx-induced tumor growth changes. conclusion: our results demonstrated that ppis imaging modality is as effective as micropet in the monitoring of the tumor response to ctx chemotherapy. these results suggest that the high-throughout screening imaging system may be employed for evaluating new anticancer drug using murine tumor models. aim: aim of the study was to evaluate the usefulness of 18ffdg-pet/ct in patients (pts) with lower rectal cancer treated with neoadjuvant chemo-radiotherapy (crt). fifty-five pts were enrolled in the study. all patients had known rectal cancer located within 5 cm from the anal verge. the pts characteristics were: 30 men, 25 women, mean age 65 (35-81). stage: 4 pts (ut2n-m0), 17 pts (ut3n-m0), 20 pts (ut3n+m0), 8 pts (ut3nxm0), 3 pts (ut4n0m0), 3 pts (ut4nxm0). chemotherapy consisted of a weekly schedule of oxaliplatin (oxa) and 5-fluorouracil (5fu) or 5fu alone. radiotherapy started the same day as cht and was delivered up to a dose of 50.4 gy in daily fractions of 1.8 gy. rectal surgery was performed 6-8 weeks after the end of neoadjuvant treatment. fdg-pet/ct was performed at staging and 6-7 weeks after the end of crt. pathological examination of surgical specimens included the tumor regression grade (trg) evaluation according to mandard. pts were followed up for 6 -36 months. suvmax pre and post crt was measured in the site of the primary lesion. results: twenty-nine pts were considered as complete pathological responders (group 1: 10 trg1 -19 trg2). twenty-six pts were classified as pathological non responders (group2: 19 trg3 -7 trg 4). the mean suvmax decrease compared to the baseline was 82% (range -42% to -100%) in group1 and 80% in group2 (range -49% to -100%). the mean value of suvmax post crt in group 1 and 2 was respectively 2 and 2.7. in group 1 pre therapy suvmax mean value was 9.5, while in group 2 was 13.6. interestingly, pts with trg 4 showed a pre therapy suvmax mean value of 26 while pts with trg 1 showed a pre therapy suvmax mean value of 11 (p < 0.05). conclusion: in our series of patients no correlation was found between metabolic response (suvmax decrement) and pathological response (trg). however a correlation was found between pre-therapy suvmax value and pathological response (trg1 vs trg4). aim: to evaluate the fdg metabolism in patients (pts.) with high risk soft-tissue sarcomas receiving an induction or neoadjuvant chemotherapy. the treatment effect was assessed with regard to the prediction of therapy outcome. methods: the ongoing evaluation includes 25 patients with high grade soft-tissue sarcoma with different histologies. 14 pts. received an induction chemotherapy consisting of adriamycin 75 mg/m2/day 1 and ifosfamide 1500 mg/m2/day 1-4 (ai-g regimen, six cycles) prior to peripheral blood stem cell transplantation, and 11 pts. were treated with pre-operative chemotherapy consisting of etoposide 125 mg/m2/day 1+4, ifosfamide 1500 mg/m2/day 1-4 and doxorubicin 50 mg/m2/day 1 (eia regimen, 4 cycles). pts. were examined prior to onset of therapy and after completion of the first cycle of ai-g and after two cycles of eia chemotherapy, respectively. the restaging data of 20 patients (13 pts with ai-g and 7 patients with eia treatment) served for reference. restaging was performed using ct and/or mri after six cycles of ai-g or four cycles of eia chemotherapy. results: restaging data are available in 20 pts. according to recist criteria, clinical outcome was as follows: 1 pt. showed no evidence of disease (ned), 6 partial remissions (pr), 5 stable diseases (sd), and 8 pts. progressive disease (pd). due to the small number of pts., we dichotomized the data in pts. with ned/pr (n = 7) and pts. with sd/pd (n = 13). median suv prior therapy was 4.0 suv in comparison to 3.6 suv after chemotherapy. median influx was 0.034 prior to chemotherapy in comparison to 0.036 following therapy. most kinetic parameters showed only small changes, only vb declined after one cycle. we used discriminant analysisto classify the patients into responders and non-responders. da revealed a correct classification rate of 85 % using all kinetic data of the baseline study and 91 % using all kinetic data of the second study. conclusions: on the basis of these results, kinetic fdg data are helpful for the prediction of chemo-sensitivity in patients with high risk sarcomas. 18f-fdg pet/ct monitoring of tumor response to chemotherapy: does 18f-fdg imaging can be used as a chemosensitivity testing method? s. song, g. huang; renji hospital, shanghai jiaotong university, shanghai, china. aim: the aim of this study was to determine if fdg-pet/ct can be used as an in vivo individual chemosensitivity testing method, especially in those who underwent chemotherapy at the begining. material and methods: fourteen vx2 xenografts bearing new zealand rabbits with total of 27 tumors in axillary fossa close to anterior wall were randomly divided into control group(n=4) and cisplatin chemotherapy group(n=10). the tumors were 15-20mm in size. in treatment group fdg-pet/ct images were obtained before administration cddp(pett1),during treatment (40min after administration cddp pett2),1d(pett3),7d(pett4) and 14d(pett5) after chemotherapy. in control group fdg-pet/ct were obtained every 3 days from the first imaging to 40days of total 6 pet/ct imaging since the rabbit were inoculation vx2 tumor. results: mean suvmax ( 55-60min after injection )of the control group were increased steadily, which were 6.25±2.92 (petc1), 9.97±0.91(petc2), 10.47±1.31 (petc3), 9.02±2.40(petc4), 9.39±1.57(petc5) and 11.36±1.41(petc6) respectively. in cddp treatment group, according to the degree of suvmax decrease on pett1 and pett2, we divided the xenografts into a responder group (partial response + stable disease, n = 6) and a nonresponder group (progressive disease, n = 4). we use the (pett1-pett2)/ pett1 degree>25% as the criteria of response. the retention index and t/m ratios showed marked changes at the time point of pett2 in the responder group, although the tumors did not show any significant change in volume at that time. paraffin section stained with haematoxylin and eosin of sections showed that the number of viable tumor cells in the responder group decreased at 7 days, and peaked at 14 days. necrotic cells and fibrotic tissue were observed after cddp treatment of 7and 14days. the decrease of fdg uptake in responder group on pett2 was an early marker that the individual was sensitive to cddp, and correlated well to 14days pathology results. in non-responder group there were no significant changes in pathology results compared with control group. conclusions: early evaluation by fdg-pet/ct, especially during cddp administration is useful. the decrease of fdg uptake was an in vivo biomarker to predict later pathology result. the study included 38 patients diagnosed and treated of nmlc. fdg-pet/ct was done 4 and 6 weeks after chemoteraphy and/or radioteraphy respectively. pre-treatment staging was done with the addition of fdg-pet/ct in 18 patients, and only by ct in 20. the images were evaluated by visual and semiquantitative analysis and the results were compared with ct findings. final diagnosis was based on the information obtained from clinical records. a good therapeutic response (gr) was achieved in 23 patients, no changes (nc) in 5, and progression of the disease (pr) in 10. results: fdg-pet/ct and ct findings agreed in 12 of the 38 patients (32%) and disagreed in 26 (68%), 16 with gr, 1 with nc and 9 with pr. in 14 of the 26, fdg-pet/ct revealed more lesions than ct (5 in gr, 1 in nc and 8 in pr), showing a more extensive nodal disease in 8, extra-nodal metastatic disease in 5 and local growth in one. in 3 of the 26 patients with discordant findings (11%), all with gr, fdg-pet/ct rule out tumoral disease suspected by ct findings. in 12 patients ct studies were non-diagnostic (9 with gr and 3 with pr), and in 3 of them fdg-pet/ct rule out disease, in 4 confirm it. overall, fdg-pet/ct was definitive to establish the final diagnosis in 11 of the 23 with gr (48%), in one of the 5 with nc, and in 9 of the 10 with pr (90%). interestingly, regarding the employment of pet/ct at staging, of the 18 in whom it was applied, 15 showed gr; however of the 20 in whom staging was based only in ct, only 8 showed gr unlike 10 who showed pr. conclusion: the results demonstrate the value of fdg-pet/ct and confirm that it must be included in the assessment of the response of treatment of nmlc. in addition to clarify non-diagnostic ct scans, revealed a considerable number of unsuspected tumoral lesions. moreover, when fdg-pet/ct is employed for the initial staging a better therapeutic response is obtained. . 26 males and 4 females. they were of post solid organ transplantation namely heart (n=12), lung (n=1), liver (n=14), and kidney(n=3) that were performed from september 1989 until october 2005. they were for staging purposes (n=13), and as follow up assessment( n=17), post therapy. the biopsy procedure and tissue samples were obtained prior to the pet ct scan. the results of a total 50 pet ct were compared with conventional imaging (us, ct, mr), both of which imaging were done about the same time. results: 29 cases were confirmed ptld by histopathological diagnosis. 9 patients developed ptld early(less than 12 months)and 20 patients developed late (12 months and later) after transplant. the mean time to onset is 60.6 months. ptld histological subtypes revealed malignant lymphoma,(ml) in 20 cases, polymorphic lymphoproliferative disorder (pld) in 6 cases, multiple myeloma (mm) in 2 cases. in 1 patient, diagnostic histology type was not available. 9 cases involved only the lymph nodes and 20 cases involved extranodal. in 46/50 examination, pet ct and conventional imaging were concordant. in comparison to conventional imaging, the pet ct study results showed lower sensitivity (76.9 % vs 80%) but similar specificity(100% vs 100%). the overall accuracy of pet in diagnosis and follow-up is almost similar to conventional imaging ( 86.4 % vs 87 %). conclusion: this study suggest pet ct is an accurate diagnostic tool in staging and follow-up of ptld patients. however, reconfirmation with histology of all positive findings remains mandatory. it is also a useful modality in patients with impaired renal function as a result of chronic immunosuppressive treatment. as no contrast medium is necessary, contrast related nephrotoxicity in ptld patients is avoided. further study is recommended before implementing pet ct as a routine diagnostic tool in suspected cases of ptld following solid organ transplantation. keywords: aim: 18f-fdg pet is increasingly used in radiotherapy planning. the aim of this study was to evaluate from a retrospective study the feasibility of using 18f-fdg pet/ct to detect and delineate the target volumes in advanced nsclc. this implementation into radiation treatment planning has required strong collaboration between radiation oncologists and nuclear physicians. patients and methods: from april 2005 and october 2006, were enrolled for radical radiation therapy staging 17 patients with unresectable nsclc (13 males and 4 females; mean age 61.2 years), performance status >70% (karnofsky), 12 squamous cell carcinoma, 4 adenocarcinoma and 1 large cell carcinoma, stage iii (n=12), stage iv (n=5). whole body pet/ct (biograph sensation 16 siemens) was performed after 60 min from the injection i.v. of 370 mbq 18f-fdg, followed by pet/tc scan of the roi on bed for radiotherapy. gtvs were determinated and based on the pet data. results: after fdg pet/tc, 14 out of 17 pts were judged to be potentially eligible for curative treatment; 13 out of 14 pts underwent concurrent chemotherapy, 2 out of 14 pts performed successive surgery (in one of these a focal thyroid uptake of fdg were investigated and malignant lesion were demonstrated by cytological analysis -papillary cancer-). 3 out of 17 pts fdg pet/tc detected distant metastases (controlateral lung, adrenal and bone); in this pts was given palliative therapy. mean rate of radiation was 63gy (50-74). gtv was changed in all pts (decreased in 8 pts and increased in 6 pts). 10 out of 14 pts had mild toxic effects (6 oesophagitis, 3 cough, 3 dyspnoea); 3 out of 14 pts moderate toxic effects (1 oesophagitis, 2 dyspnoea). all pts were followed for at least 6 months; 8 pts presented relapse (2 with local and 6 with distant recurrences), 2 pts were in stable disease and 3 pts were in complete remission (median time of 14 months: range 6-20). one patient died post-treatment. conclusion: our data, even if obtained in a short number of pts, seems to confirm that fdg pet/tc could add information to precisely identify the gtv in advanced nsclc so as to obtain a better local control of disease. the technique of tumor contour definition by fdg pet/ct lead to substantially different volumes, especially in pts with necrotic or colliquative areas in the tumor mass. as we know from literature pet significantly altered the gtv or ctv in 44%, therefore all patients underwent a whole-body pet scan after a ct scan. the ct images provided morphological volumetric information, and in a second step, the corresponding pet images were overlaid to define the effective target volume. the images were exported off-line via an internal network to an rt simulator. we consider definitive follow-up after two years from treatment or in case of patient death's. the dose range is 40÷66 gy, with a mean of 50,3 gy. five patients have a negative pet, so the rt field was the whole mediastinal area to prevent prospective micro metastases. in all the others cases we have considered the pet area as the gtv for rt. results: nine patient were excluded from the study owing to change in the disease stage subsequent to the pet/ct study, 2 sclc and 7 nsclc. among the remaining 67 patients, we have definitive follow-up for 44 pz (66%) and temporary follow-up for the others . we verified 10 (15%) not evident disease, 34 (51%) sistemic progression or diffused metastases, 13 (19%) stationary disease and 10 (15%) with relapses in the rt field or in the neighboring. conclusion: fdg-pet is a highly sensitive imaging modality that offers better visualisation of local and locoregional tumour extension. this study lead to the conclusion that the use of pet/ct in radiotherapy planning allows a better patient management and gives comforting results about relapses in field. the assessment of the radioimmunotheraphy with it is important to assess the therapeutic response in refractory or relapsing lymphoma patients before progression of disease. therefore, we intended to find out the optimal timing for assessing the treatment response of the 131i-rituximab in patients with refractory nhl using 18f-fdg-pet/ct (pet). methods: twenty-eight patients with nhl (dlbl in 10, mcl in 6, mzbcl in 3, fl in 3, malt in 1) refractory to previous chemotherapy (5 to 22 cycle, median: 9 cycle) were enrolled. pet was performed at pretreatment, and 5 days, 30 days, and 60-90 days after 131i-rituximab. we compared pre and post-treatment pet with 5 parameters; mean suv, maximum suv (suvmax), volume of interest (voi) of lesions, total metabolic volume volsum) and adjusted metabolic volume (suv*volsum). we correlated the decrement (%) of individual pet parameters calculated by roc curves with the clinical assessment of the treatment of 3 months after 131i-rituximab. results: clinical assessments for the 131i-rituximab were cr in 2, pr in 3, sd in 8 and pd in 10. area under the curve of the calculated decrements of each pet at 5, 30, and 60-90 days after 131i-rituximab were 0.667, 0.838 and 0.780 for suvmax, and 0.633, 0.853 and 0.800 for suv*volsum. there were statistically significant differences in the pet parameter decrements on 30 days after 131i-rituximab (p<0.05). moreover, there was tendency of disease progression in the 60~90 days pet parameters. conclusion: the assessment for the treatment of 131i-rituximab in patients with refractory nhl using pet was recommended at 30 days after treatment. second dose of 131irituximab was recommend within 60~90 days before progression of disease. aim: ct images provides additional anatomical information for pet/ct study. however, the role of contrast medium in pet/ct is still controversy. in this study, we demonstrate the results and our experience by using ct contrast medium enhancement in fdg pet/ct examination. material and methods: between dec. 2005 and apr. 2007, 802 fdg pet/ct studies were performed on 730 patients. patients whose images had either insufficient anatomic information or equivocal findings in fdg pet/ct were included in the study. subsequently we performed delayed imaging without and with intravenous contrast medium. the impact of contrast medium was assigned a value on a 5-point probability scale. results: during this period, 142 fdg pet/ct delayed studies with contrast medium enhancement in 138 patients were recruited for the study. among these scans with contrast medium enhancement, malignancy of the digestive system (70/142, 49%) is the most frequently required for this procedure, especially in colorectal cancer (40/70, 57%). in fact, contrast medium technique was useful for delineating the boundary of tumor and its surround tissues, evaluating vascular invasion of the tumor, and determining the vascularity of suspected lesions. there was mild adverse effect occurred in 1 patients with skin rash and 2 patients with extravasating contrast medium. conclusion: an additional imaging with contrast medium enhancement in fdg pet/ct study may provide useful information in cases with insufficient anatomic information or equivocal findings. the relatively side effect for contrast medium is acceptable in this study. introduction: the accumulation in the stomach and colon often pesters nuclear medicine physicians with the interpretation as to whether " normal or not " because 18f-fdg frequently accumulates not only in the abnormal lesion like malignant tumor but also in the normal stomach and intestines. the purpose of this study is to assess the ability of scopolamine butylbromide that inhibits the periatalsis to reduce the physiologic uptakes in the stomach and colon. methods: we studied 148 people who had a checkup for cancer using pet/ct. all people are less than fifty years old and mean age was 41.3±6.03 (25 to 49). fifty-four people were female and ninety-four people were male. we administered an intravenous drip injection of isotonic sodium chloride solution including scopolamine butylbromide of 20mg to 66 people in this study for 30 minutes. the drip was started at five minutes before the injection of 18f-fdg. we categorized the degree of 18f-fdg uptake in the stomach and along the colon into four grades according to the following scale: grade 0: no visible uptake; grade 1: lower than in the liver; grade 2: similar to the liver; grade 3: higher than in the liver. also, we measured suv in the stomach (circle roi, 10mm in diameter) and counted the number of nodular uptakes in the colon that is higher than in the liver per man. results: the mean grade of stomach in the injection group (1.11±0.75sd) was significantly lower than that in the non-injection group (1.94±0.91sd) (p<0.0001). also, the mean grade of colon in the injection group (0.88±0.83sd) was significantly lower than that in the non-injection group (1.26±0.91sd) (p=0.010). the suv in the stomach averaged 2.68±0.70sd in the injection group, and 3.26±0.75 in the non drip injection group. the averaged suv in the drip injection group was significantly lower than that in the non drip injection group (p<0.0001).the number of nodular uptakes in the colon (0.15±0.40sd) in the injection group was lower than that in the noninjection group (0.37±0.96sd), but the significant difference was not found (p=0.066). conclusion: our results indicate that the intravenous drip injection of scopolamine butylbromide can reduce the physiologic uptake in the gastrointestinal tract, especially in the stomach. aim: to detect malignant tumors pet images are usually obtained about 1 hour after intravenous administration of fdg, but fdg uptake by malignancies is often greater in delayed scans than in early scans. we investigated malignancies that were only detected on delayed scans and showed no fdg uptake on early scans. materials: two pet specialists judged the fdg-pet images of 48 lesions in 46 patients (33 men and 13 women with a mean age of 64.8 ± 10.6 years), which showed no uptake on early scans and abnormal uptake on delayed scans. these lesions were shown to be malignant by histology in 13 cases, by follow up in 21 cases, and by other methods in 14 cases. methods: pet images were obtained from 50 to 70 minutes (early scans) and from 110 to 130 minutes (delayed scans) after administration of fdg following 5 hours of fasting. the roi was set on the sites of abnormal fdg uptake on delayed scans and the corresponding area on early scans, after which the suv max of each roi and the rate of increase were calculated. results: the 48 lesions included 13 metastatic liver tumors, 6 metastatic lung tumors, 6 metastatic mediastinal lymph nodes, 9 abdominal lymph nodes, 4 prostate cancers, 2 cases of peritoneal dissemination, 2 primary lung cancers, 2 bladder cancers, 1 esophageal cancer, 1 mesothelioma, 1 hepatoma, and 1 cholangioma. the suv max values for the early scans and delayed scans were 2.54 ± 0.42 and 3.23 ± 0.64, respectively, while the rate of increase was 28.2 ± 5.4. discussion: among the 48 lesions, the most common was metastatic liver tumors, presumably because fdg uptake by these lesions increased over time and normal liver uptake decreased. the second most frequent diagnosis was metastatic mediastinal lymph nodes, also presumably because fdg uptake by these lesions increased over time and mediastinal background uptake decreased. four prostate cancers and 2 bladder cancers were detected on delayed scans because bladder uptake was markedly decreased on these scans. the other lesions were too small for abnormal uptake to be detected on early scans. conclusion: examination of a delayed scan is extremely useful for detecting malignant tumors that do not show fdg uptake on the early scan, especially lesions surrounded by high background activity, such as those in the liver, mediastinum and bladder. fdg uptake in cold and heat treated mcf-7 cells, comparison with cell viability, apoptosis, and tumor marker changes c. zhang, x. sun, j. liu, p. liu, g. huang; renji hospital, shanghai jiaotong university, shanghai, china. aim: to investigate the fdg uptake changes in cold and hyperthermia therapy and its correlation with cell viability, apoptosis and tumor marker changes. material and methods : an in vitro cultured breast adenocarcinoma cell line, mcf-7, was divided into 5 groups. hyperthermia group: cell was treated in 43degree centigrade 30 min. hypothermia group: cell was treated in 0degree centigrade 30 min. hypo-and hyperthermia group: cell was treated in 0 degree centigrade 30 min and 43 degree centigrade 30 min. chemotherapy group: cell was treated with 21 microgram cisplatin for 6 hours. and control group: cell was untreated. the levels 18f-labelled fdg uptake, a 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazoliumbromide viability assay, flow cytometry assay and tumor markers (ca153,ca125) were detected at 24 hour and 48 hour. results : the change of 18f-fdg uptake is early than tumor marker (which came out at the 48h) under our study conditions. in treated mcf-7 cells, the levels of 18f-labelled fdg uptake were significantly lower than control group. the levels of 18f-fdg uptake depression were well correlated with cell viability and apoptosis data. conclusions : fdg uptake is sensitive and well correlated with cell viability and apoptosis assay, and can be used for early response monitoring in hypoand hyperthermia therapy. purpose: to prospectively analyse the relevance of pet/ct in the clinical management (benign disease/malignancy, initial staging, re-staging) of the primary pleural malignancy (ppm). methods: 23 consecutive patients (33-76 y.o., median 57 y.o.; 18 m, 5 f) with pleural disease were included. all of them underwent a wholebody pet/ct investigation (discovery ls, ge healthcare) with standard dose (0.125mbq fdg/kg). 30 studies were reviewed. pet/ct findings were assessed according to the tnm international mesothelioma interest group clasification. the clinical indications were: suspected ppm (group a: n=6); initial staging of primary malignant mesothelioma (pmm) (group b: n=12); re-staging following therapy (group c: n=11) and assessment of recurrence (group d: n=1). for clinical management and to establish prognosis the following subgroups were compared: t1-t3 vs t4, n0-n1 vs n2-n3 y m0 vs m1. imaging findings were correlated with surgical and histopathologic staging in all patients. results: in group a (n=6) malignancy was excluded in 4/6 patients and confirmed in 2/6 cases, thus avoiding multiple invasive procedures and speeding up diagnosis. in group b (n=12) pmm was staged as: epithelioid (n=8), sarcomatoid (n=2) y (n=2) was unknown. it was located on the right-sided (n=9) and left-sided (n=3) pleura. eight studies diagnosed irresectable disease: t4 (toracic wall/mediastinum infiltration) in 4/8 ; n2 (mediastinal adenopathy) in 2/8 and m1 in 2/8. globally pet/ct diagnosed 6/11 patients (54%) with extensive disease significantly modifying their clinical management. in group c 11 studies were performed to assess response to therapy: chemotherapy (n=8): 3/8 with stable disease and 3/8 with disease progression, 1/8 with partial response and 1/8 had no previous study for comparison; surgery (n=2): 1 to assess incomplete surgery (decortication) showed residual disease and 1 without evidence of recurrence; surgery and chemotherapy (n=1) without evidence of recurrence. pet/ct showed unknown metastasis in two patients and a synchronic unknown malignancy (synchronic squamous cell carcinoma in the contralateral lung) which was confirmed by pathology. conclusions: pet/ct is a non-invasive multimodality imaging technique with significant relevance in the clinical management of the primary pleural malignancy. estimation of optimal kinetic model and prediction of pathological diagnosis of anterior mediastinal tumor using 11c-acetate dynamic pet study aim: recent studies indicated that 11c-acetate (ac) may be a complementary tracer in pet imaging of thymomas. but, kinetics of ac in tumor tissue is not completely elucidated, and it is unknown which kinetic model (km) is most optimal. the aim of this study is to evaluate which km is most optimal for analyzing ac dynamics in thymoma tissue, and whether dynamic ac-pet study can predict pathological diagnosis of mediastinal tumors using this "most optimal" km. methods: dynamic ac-pet studies were performed for suspected thymic tumor with anterior mediastinal mass on chest ct scan. (in addition, static ac-pet scans and fdg-pet studies were also performed just after dynamic ac-pet studies.) we assumed candidates of four kms as follows: we analyzed 10 datasets of cases diagnosed pathologically (3 thymomas of type a/ab, 4 thymomas of type b2/c, and 3 thymic cysts) from august 2005 until december 2006, applying to these (a)-(d) kms, and calculated akaike informational criterion (aic) of each km, and determined which km is most optimal, based on values of aic. furthermore, we analyzed 10 datasets again using this "most optimal" km, and estimated parameters, and compared with pathological diagnoses. results: aics of (a) 2c-2p km became smallest in all 10 datasets, and it seemed to be "most optimal" among 4 kms. using 2c-2p km, we estimated rate constants (k1, k2) and blood volume and calculated metabolic rate (mr) defined as k1/k2 in 3 thymomas of who type a/ab, mrs were more than 1.0 (k1>k2), and in the remaining 7 tumors, mrs were less than 1.0 (k1 < k2). 7 cases with thymomas (type a/ab/b2/c) were successfully detected by static ac-pet scan, but 2 cases among 7 thymomas were false negative by fdg-pet. 3 cases with thymic cysts demonstrated neither ac nor fdg uptake. conclusion: this study indicated that 2c-2p km may be "most optimal" for pharmacokinetic analysis of ac in anterior mediastinal tumors, and mr obtained by dynamic ac-pet studymay be useful for discriminating between type a/ab thymomas and thymic cysts, or type a/ab thymomas and more aggressive histology, as well as static ac-pet scan. objective: a potential false-positive fdg pet interpretation in oncologic imaging is fdg-uptake in brown adipose tissue. the purpose of this exhibit is to demonstrate the characteristic as well as the atypical locations and appearance of hypermetabolic brown adipose tissue in the neck, thorax, and abdomen. methods: twenty-one patients (16 female, 5 male; age range, 8-64 year-old) with brown adipose tissue on pet/ct studies were documented out of approximately 500 scans. lesions were defined as brown adipose tissue by increased fdg metabolism corresponding to fat density tissue on ct scan. results: there were two cases of hibernoma, two cases of lipomatous hypertrophy of the interatrial septum and the reminder seventeen cases of brown fat were identified in neck, supraclavicular, superior mediastinal, perinephric and retroperitoneal regions. hibernoma is a benign neoplasm presenting as a focal lipomatous mass indistinguishable by conventional imaging from a lipoma with increased fdg metabolic activity of brown adipose tissue. lipomatous hypertrophy of the interatrial septum is characterized by excessive deposition of fatty tissue in the interatrial septum. the typical appearance of brown fat in the neck appeared as bilateral curvilinear areas of fdg activity with extension into the supraclavicular regions. mediastinal fat demonstrated focal activity in the mediastinum and mapped to the adipose tissue surrounding the large vessels. perinephric fat illustrated curvilinear or focal activity corresponding to the perinephric adipose tissue surrounding the upper pole of the kidneys. retroperitoneal fat demonstrated focal activity mapped to adipose tissue. conclusion: hypermetabolic brown adipose tissue can be misinterpreted as adenopathy or malignant mass in the setting of known primary malignancy. knowledge of this potential pitfall and precise localization with ct are important in preventing misinterpretation as malignancy. male), 2528 consecutive fdg whole-body scans were obtained with a pet/ct scanner. scanning was performed using the discovery ls pet/ct scanner (general electric medical systems). patients were fasted at least 6 h before the pet acquisition. intravenous injection of 55.5mbq/kg of 18f-fdg was followed by a tracer uptake phase of about 60 min, during which the patients sat in a quiet room without talking. imaging parameters were as follows for an acquisition at 5-7 bed positions: 140 kv, 120mas, 0.8s per ct rotation, a pitch of 6, a table speed of 22.5 mm/s, 722.5mm coverage, and a 31.9s acquisition time. all pet/ct scans were examined retrospectively by 1 observer on an interactive display using fusion software (xeleris; general electric medical systems). results: twenty-five patients (7 male and 18 female) of the 2528 scans (0.99%) demonstrated brown fat uptake. the incidence rate was 2.20% in scans of female patients and 0.42% in scans of male patients. patients with brown fat uptake were younger than patients without (35.3±13y vs.53.6±14y, p<0.01). although there was no significant difference in bmi between patients with brown fat uptake, they tended to be thinner (bmi, 20.4±2 vs. 23.2±5, p>0.05). bmi was 19.6±2 for male patients and 20.8±2 for female patients with brown fat uptake (p>0.05). when comparing the monthly incidence rate from april to october, the incidence was highest from november to march in the whole group of patients (1.68% vs. 0.48%, p<0.01). conclusions: fdg uptake in brown fat occurs particularly in female, younger patients and those with lower bmi values. the incidence of brown fat is clearly increased during the cooler period of the year. aim:the aim of the study was to evaluate the feasibility as well as the agreement between tl-201 and tc-99m mibi in brain spect for the differentiation of brain lymphoma and toxoplasma encephalitis -a distinction which is not always possible by routine ct or mri. methods:we studied 21 female patients with acquired immunodeficiency syndrome during a 13-month period who had intracranial lesions on ct or mri. dual isotope tl-201 and tc-99m mibi brain spect was performed in order to obtain simultaneous acquisition. we calculated uptake ratios by drawing roi around each lesion as well as in the opposite side. we compared our findings with pathologic data and clinical follow up. results:of the 21 patients studied, 12 had intense focal uptake in the lesion(s). 11/12 had either biopsy -or autopsy-proven lymphoma (11 true positive). one patient with purulent infection had focal uptake (1 false positive). 9 patients with negative scans had toxoplasma encephalitis on clinical follow up (9 true negative). tl-201 and tc-99m mibi spect tally with each otherwith mibi slightly prevailing -as far as it concerns the lesion-to-normal tissue uptake ratios which were higher for sestamibi compared with those of tl-201. conclusions:1. patients with aids having intracranial mass on ct or mri may benefit from tl-201 or tc-99m mibi spect in order to distinguish lymphoma and toxoplasmosis. 2. tl-201 and tc-99m mibi may give similar results. meningiomas account for about 30% of all intracranial tumors. although grade i meningiomas have a benign clinical course, malignant ones are associated with 50-80% recurrence rate and less than 2 years median survival. evaluation of their proliferation rate is useful for assessing their biological behavior, with implications in patient prognosis. spect by various radiotracers can metabolically characterize intracranial tumors. we evaluated whether 99mtc-tetrofosmin (tf) uptake in meningiomas correlates with cellular proliferative activity and with tumor grade. materials & methods: 15 consecutive cases with diagnosed meningioma (4 males, 11 females; mean age 62.3 years) were enrolled. brain spect by tf had been performed within a week prior to surgical excision. in the excised tumor specimens we assessed the ki-67 index by the mib-1 immunostaining method, reflecting cellular proliferation and aggressiveness. tf uptake was assessed visually and semiquantitatively, by calculating the lesion-to-normal (l/n) uptake ratio. pearson bivariate correlation analysis was performed between the level of tracer uptake (as expressed by the l/n ratio) and ki-67 expression and tumor grade. statistical significance was set at p < 0.05. results: 12/15 patients were diagnosed with typical benign meningiomas and 3/15 had malignant meningiomas. intensity of tf uptake in the region corresponding to the ct/mri findings ranged from faint to profound. a significant correlation was found between both tf uptake and tumor grade (r = 0.834, p < 0.001) and between tf uptake and ki-67 expression (r = 0.702, p = 0.004). conclusion: this pilot study implies that tf brain spect could prove useful in differentiating benign from malignant meningiomas and is a potential indicator of their proliferative activity. comparison of brain spect with tc99m-mibi and ctscan in discriminating of radiation necrosis and brain tumor recurrence s. dabiri oskouie 1 , m. amiri 2 ; 1 tabriz university of medical scienses, tabriz, iran (islamic republic of), 2 babol university of medical scienses, babol, iran (islamic republic of). aim: tc99m-mibi has been proposed for use as an imaging agent for various tumors, including brain neoplastic lesions. in spite of many advances in diagnosis and therapy, brain tumors still represent a serious challenge for clinicians. after radiotherapy, deterioreting clinical status can be due to either radiation necrosis or recurrent tumor. computed tomography and magnetic resonance imaging offer imperfect discrimination of radiation necrosis and tumor recurrence. the aim of this study is to compare tc99m-mibi scan and ct-scan results in this group of patients. material and methods: twenty six patients (14 male, 12 female, mean age of 37 years) with primary brain tumors and deterioration of clinical status after radiotherapy were enrolled in this study. tc99m-mibi brain spect was performed 10 minutes and 3 hours after iv injection of 740 mbq (20mci) tc99m-mibi. images were obtained with adac dual head camera. transverse, coronal, and sagital views were reconstructed. images were visually assessed. results: focal tc99m-mibi was observed in 14 patients. eight of these patients expired within 6 months. biopsy of 3 patients in this group confirmed tumor recurrence. ct-scan was positive in 7 patients and the rest had equivocal or negative results. of 12 patients with negative tc99m-mibi scan, only 2 patients died during 6 months follow-up. six of these patients had positive, five had equivocal and one had negative ct-scan. ct-scan results didn't correlate with survival rate. conclusion: patients with negative mibi scan showed higher 6 months survival rate ( 83.3% ) compared to patients with positive mibi scan ( 42.8% ). focal uptake on tc99m-mibi scan is probably due to recurrent tumor. it can be concluded that brain spect with tc99m-mibi is a useful method for discriminating radiation necrosis from tumor recurrence in patients following brain radiotherapy. aim: the differentiation between tumor recurrence and radiation necrosis remains a challenge. these entities have discrete treatment options and prognosis. radiation necrosis can occur between 6 months to few years after irradiation, i.e. the same period during which recurrence is most frequent. in many cases morphologic brain imaging by ct/mri is unable to distinguish between these two pathological entities. although glioma cell line studies substantiated a plausible imaging superiority of 99mtc-tetrofosmin (tf) over other tumor-seeking radiopharmaceuticals, little has been reported on its in vivo imaging properties.we sought to evaluate the usefulness of tf brain tomography in distinguishing glioma recurrence from radiation necrosis. materials & methods: 11 brain tumor patients (7 males, 4 females; mean age 50.1 years) were prospectivelly enrolled in the study. the initial diagnosis had been glioblastoma multiforme (4 cases), anaplastic astrocytoma (1), anaplastic oligodendroglioma (3), grade ii astrocytoma (2), and low-grade oligodendroglioma (1) . all patients had been operated upon and then received adjuvant external-beam radiotherapy (total dose 60 gy; no residual tumor on ct/mri), while 8 of them also received temozolomide-based adjuvant chemotherapy. in all cases neurologic symptomatology relapsed in a mean period of 25 months, arousing suspicion of tumor recurrence. ct/mri could not differentiate between recurrence and post-irradiation necrosis, so tf spect was performed. the level of tracer uptake (as expressed by the lesion-to-normal brain [l/n] uptake ratio) was compared between radionecrosis and recurrence by the two-sided mann whitney u non-parametric test. statistical significance was set at p < 0.05. results: in 8/11 cases an abnormally increased tracer uptake appeared in the region that ct and/or mri indicated as suspicious; in half recurrence was confirmed histologically after surgery, while in the other 4 by growth of the lesion over a 6-month follow-up period and clinical deterioration. the remaining 3/11 patients had faint uptake in the suspicious region, compatible with radiation injury; these lesions remained morphologically unaltered over a mean 12month follow-up period, with no clinical deterioration in patient's condition, a course most likely favoring the diagnosis of radiation injury. statistical analysis verified that tumor recurrence had significantly higher tf uptake, as compared to radionecrosis (p = 0.014). conclusion: metabolic brain imaging by tf could offer useful information in the workup of treated brain tumors, where radiomorphologic (ct/mri) findings are inconclusive between recurrence and radionecrosis. aim: distinquishing neoplastic from nonneoplastic intracerebral hemorrhage (ich) constitutes a common challenging problem since on standard neuroradiologic imaging neoplasms can be hidden behind an intracerebral hematoma, while some hemorrhagic nonneoplastic lesions may mimic neoplasms. ct and mri cannot always distinguish between neoplastic and nonneoplastic hemorrhage due to considerable overlap of findings. in contrast to neoplastic ichs, nonneoplastic ones display faint radiotracer uptake and only several days (>7) after the onset of the episode. accurate diagnosis is therefore critical in providing optimal patient care. we evaluated the usefulness of brain spect by the tumor-seeking tracer 99mtc-tetrofosmin (tf) in diagnosing hemorrhagic brain tumors among patients with nontraumatic intracerebral hematomas. materials & methods: ten patients (3 males, 7 females; mean age 64.0 years) diagnosed with spontaneous intracerebral hematoma on ct/mri were prospectively enrolled in the study. all underwent tf brain spect within a mean period of 3 days after onset of symptoms. imaging was performed early (10 min) post-injection. surgery was performed in 4/10 within a week; in the remaining 6/10 the diagnosis was based on a 'wait-and-see' policy of clinical and morphologic (ct/mri) follow-up. results: faint or absent tf uptake in the region corresponding to the ct/mri findings was found in 9 cases, while only 1 displayed significant tracer accumulation. the latter patient and 3 of those with negative spect underwent surgery, which revealed an underlying tumor (glioblastoma) solely in the patient with positive spect. the 6 hemorrhage cases lacking tf uptake that were not operated upon demonstrated a diminution in the lesion size on ct/mri follow-up and clinical improvement, thus considered as representing non-neoplastic intracerebral hematomas. conclusion: tf could prove useful in the early noninvasive assessment of nontraumatic brain hematomas, allowing differentiation between neoplastic and nonneoplastic intraparenchymal cerebral hemorrhage. # investigation of pediatric brain tumours using combined 111indium-octreotide /99mtechnetium-dtpa brain scintigraphy g. dabasi 1 , i. szilvási 2 , p. hauser 3 , m. garami 3 , d. schuler 3 , a. doros 1 , j. járay 1 ; 1 semmelweis university transplantational and surgical clinic, budapest, hungary, 2 semmelweis university department of nuclear medicine, budapest, hungary, 3 semmelweis univ. 2 .dept. of pediatrics, budapest, hungary. brain tumours are the most frequent pediatric solid tumours.some of them (especially medulloblastomas) express somatostatin receptors (ssr). in-111-octreotide scintigraphy (os) can visualize ssr expression of various types of tumours. increased octreotide uptake might be non-specific due to impaired blood-brain-barrier (bbb). conventional brain scintigraphy (bs) with 99mtc-dtpa assess integrity of the bbb. aim of our study was to evaluate os for differential diagnosis of pediatric brain tumours using a double-tracer technique. patients and methods: 56 children with brain tumours were studied. 31 patients had medulloblastoma, 25 patients had different types of brain tumours: glioblastoma, ependymoma, astrocytoma, primitive neuroectodermal tumour (pnet) and cerebral metastasis of ewing sarcoma. diagnosis was based on histopathology and conventional radiological investigations. all patients underwent cs using tc-99m-dtpa and os with in-111-octreotide on the next day.tumour to background ratios (t/bg) were measured at 60 minutes of the dtpa and at 24 hr of the octreotide scans. t/bg on os was compared to t/bg on bs. only tumours with t/bg on os higher than on bs were defined as ssr positive. results. 27 cases (48,2%) were ssr positive:16 medulloblastomas, 4 ependymomas, 4 astrocytomas, 3 glioblastomas. 29 patients had lower t/bg on os than on bs. in this group 19 (33,9%) patients had no uptake of octreotide in the tumour region defined by dtpa scan. diagnoses of these tumours were: 1 astrocytoma, 3 ependymomas and 12 medulloblastomas and in 3 pnet . in 10 (16,9%) patients moderate uptake of octreotide was seen, but t/bg on os was lower than t/bg on bs. diagnoses were:1 glioblastoma, 1 astrocytoma, 2 ependymomas, 1 metastasis of ewing sarcoma, 3 medulloblatomas and 2 pnet. conclusions: os has not proved to be useful for differental diagnosis of pediatric brain tumours. ssr expression defined by higher t/bg ratio on os than on bs is not specific for medulloblastoma. in our opinion somatostatin analogue and/or targeted radiation therapy is indicated only in patients with specific octreotide uptake, i.e. with higher t/bg on os than on bs. this combined scintigraphic approach can be used to evaluate therapy of pediatric brain tumours with ssr expression. although magnetic resonance imaging (mri) is an excellent tool to diagnose brain tumors, the functional information is limited. on the other hand 99mtc-mibi brain spect is considered a useful tool in the management of brain tumors. aim: 99mtc-mibi tumor uptake is related to histological grading, cellular proliferation index and prognosis. our aim was to evaluate 99mtc-mibi brain spect and mri studies efficacy in the differential diagnosis between recurrence of malignant gliomas and glioblastomas and the local modification after radiotherapy. material and methods: eight patients with suspected recurrence after surgical removal of a glioma (2 low grade and 6 high grade), 6-12 months before study and treated with radiotherapy were investigated. for brain spect -740mbq of 99mtc-mibi were i.v. injected to each patient 15 minutes before image acquisition by a dual-head gamma camera. gd-dtpa enhanced t1 and t2 weighted mri studies were carried out in every patient within 3 days before 99mtc-mibi spect. the ratio between the tumor roi on a slice with maximum uptake and a mirrored control roi was calculated and if >2 it was considered pathological. results: spect and mri studies well correlated being both positive for recurrence in 5 patients as confirmed by biopsy, while both negative in 2 patients, considered as having radiation effects (evaluate by clinical follow up). one patient with negative spect was operated being severely symptomatic and the biopsy was positive for low grade tumor. combined sensitivity was 83,3%, specifity 100%, npv 66% and ppv 100% conclusion: 99mtc-mibi brain spect and mri studies provide high specifity of detection of relapses of gliomas and glioblastomas and also the most adequate anatomic depiction of extent of tumor process. clinical follow up of these patients is underway to assess correlation of metabolic response to clinical response. aim: the aim of this study was to assess the incremental diagnostic value of 131i spect/ct fusion imaging compared with conventional 131i planar scintigraphy in patients with thyroid carcinoma. materials and methods: seventy-nine patients with thyroid carcinoma underwent 131i spect/ct and 131i planar imaging 3-7 days after administration of either a therapeutic dose (n=64) or a diagnostic dose of 131i (n= 15). reconstruction of fusion images were performed by using external markers placed at 3 locations on each patient's skin to mark the same geometric plane and combining spect and ct images on a workstation. without knowing the clinical information of the patients, 2 nuclear medicine physicians interpreted first 131i planar images and then 131i spect/ct fusion images. 131i spect/ct fusion imaging was considered to have an incremental diagnostic value when it demonstrated different but precise localisation from the 131i planar scintigraphy. results: as compared with the conventional 131i planar scintigraphy, 131i spect/ct fusion imaging had an overall incremental diagnostic value in 34.2% (27/79) of patients, with more lesions detected in 55.6% (15/27) of patients. the undetected activity at the thyroid bed was demonstrated in 7.6% (6/79) of patients, 5 of whom had markedly elevated serum thyroglobulin level. the percentage of the detection of unsuspected lung metastases, bone metastases, and lymph node metastases were 1.3% (1/79), 1.3% (1/79), and 7.6% (6/79) of patients. the previously considered lymph node metastases were excluded in 7.6% (6/79) of patients. conclusion: 131i spect/ct fusion imaging had an incremental diagnostic value over conventional 131i planar scintigraphy in patients with thyroid carcinoma for precise localisation of lesions and improved interpretation, which led to more appropriate patient management. optimal time for 131i post-treatment whole body scan: comparison between 2-day scan and 7-day scan after treatment c. somboonporn, k. roysri; nuclear medicine division, department of radiology, faculty of medicine, khon kaen university, khon kaen, thailand. objective: 131i post-treatment whole body scan (wbs) is a widely accepted test in identifying the presence of thyroid remnant and the extent of functioning metastases in well-differentiated thyroid carcinoma (wdtc) patients. sensitivity in detecting lesions depends on image quality and the amount of 131i taken up by the lesions. although the scan is conventionally performed 4-7 days after 131i administration, optimal scanning time, however, that gives the best detection rate has not been well established. therefore, we compare the sensitivity of lesion detection between the scan performed on the day of discharge from the hospital (day-2 scan) and that performed 7 days after treatment (day-7 scan) on the same patient basis. material and method: 131i post-treatment wbs was prospectively studied in 37 patients (28 female and 9 male, mean age 44.7 + 14.2 years) treated with high-dose 131i therapy from november 2006 until january 2007 in our nuclear medicine division. both day-2 scan and day-7 scan were performed in every patient and the scans were interpreted by two nuclear medicine physicians with consensus. the number, location and grading of uptake (0 = no abnormal uptake, 1 = minimally increased but abnormal uptake, 2 = clearly seen abnormal uptake) by each lesion were compared between the two types of scan. results: three patients were negative by both scan types, whereas 34 patients had at least one lesion seen in either day-2 or day-7 scan. the two scans were concordant in terms of the number of lesion detection in 52 from the overall detected 65 lesions (80%). day-7 scan found 11 lesions (7 in the neck, 3 in the lung, 1 in the mediastinum) not visualized in day-2 scan. day-2 scan revealed 2 lesions not seen in day-7 scan of 2 patients; both of them were in the mediastinum. eleven lesions in 9 patients having abnormal uptake had increase in uptake grade in day-7 scan compared with day-2 scan. two patients with elevated serum thyroglobulin disclosed a cervical lesion that had not been seen in both pre-treatment scan and day-2 scan. two patients showed more metastatic lesions in bone and mediastinum in day-7 scan which were not seen in day-2 scan. conclusion: 131i post-treatment wbs performed 7 days after treatment is better than the scan performed 2 days after treatment because it yields higher lesion detection rate. hence, it provides more accurate staging, risk stratification and better management plan in wdtc patients. value of post-treatment 131i spect/low dose ct on the management of patients with thyroid cancer k. taborska, k. michalova, p. racek, p. vlcek; clinic of nuclear medicine and endocrinology, the 2 ndmedical school of charles university and faculty hospital motol, prague, czech republic. accurate assessment of inconclusive foci on whole body 131i scan after radioiodine therapy is important for treatment planning. due to lack of anatomic landmarks it is not always to evaluate correct site involvement or sometimes distinguish metastatic spread from physiologic uptake without further examination such as ultrasound, ct or mri. aim of our work was to analyse usefulness of 131i spect/low dose ct after radioiodine therapy when unexpected or new unknown areas with accumulation of 131i were found on post-treatment whole body scans. material and methods: 19 patients (15 females, 5 males, age 20-83 years) with thyroid cancer at various stage of their disease were examined between august 2006 and march 2007. planar scintigrams were performed with sophy dstxi (ge ) within four to six days after administration of 3,7-7,4 gbq 131i, spect/low dose ct examination was acquired with symbia t (siemens) at the same or next day. results: precise localization was obtained in all evaluated regions. spect/low dose ct images improved characterization of equivocal foci of 131i uptake as definitely benign in 2 patients. additional morphologic imaging was recommended in 2 patients, 2 patients were admitted to surgery due to solitary neck lymph nodes involvement and 1 patients to ovarectomy due to 131i uptake (teratom was histologically proven). in 12 patients subsequent radioiodine therapy was scheduled with tailoring of the administered dosage according to skeletal, lung or nodes involvement. conclusion: results of the post-treatment spect/low dose ct scans were finally implemented into the management of all patients, 17 patients were spared further examination and findings in 2 patients helped to direct additional follow-up. spect/low dose ct examination was found to be a valuable tool in management patients with thyroid cancer. v. valotasiou, s. gerali, c. zerva; "alexandra" university hospital, athens, greece. introduction: diffuse liver uptake (dlu) seen on 131i wbs of patients with operated thyroid cancer, represents liver metabolism of iodoproteins and may indicate either functional thyroid remnants, recurrence of the tumor or functioning metastases. aim: the aim of our study was to evaluate the frequency and clinical significance of dlu on 131i wbs in patients with thyroid cancer in the presence and absence of thyroid visualization (tv). materials-methods: we studied 244 patients (45 men, 199 women) with operated thyroid cancer (164 papillary, 19 follicular, 56 mixed papillaryfollicular, 5 hürthle), mean age 53.47 years (age range:22-86 years). two hundred thirty-three out of 244 patients (group a) underwent post therapy wbs 4-15 days (mean 10.3 days) after the administration of 30-200 mci of 131i (mean 99.86 mci), while 63/244 patients (group b) had diagnostic wbs. dlu was graded by two nuclear medicine physicians from 0-3 (0=no uptake, 1=faint uptake, 2=moderate uptake and 3=intense uptake). results: group a: 203/233 patients had tv (group a1) and 30/233 patients (group a2) had no tv. in group a1, 189/203 patients had dlu (11/189 had visible metastases on wbs) and 14/203 patients had no dlu (1/14 patient had visible metastases). in group a2, 27/30 patients (group a2a) had dlu and 3/30 patients (group a2b) had no dlu. group a2a: 9/27 patients had visible metastases on wbs (6/9 had dlu grade=3) and thyroxin-free thyroglobulin (tg) levels 2-455 ng/ml. the other 18/27 patients had thyroxin-free thyroglobulin (tg) levels 1.6-44 ng/ml, findings which raised the suspicion of hidden metastases in these patients. group a2b: thyroxin-free tg was 0-1.4 ng/ml. group b: 61/63 patients had tv (group b1) and 2/63 (group b2) had no tv. in group b1, 8/61 patients had dlu (1/8 had visible metastases on wbs with dlu grade=3) and 53/61 had no dlu (1/53 had visible metastases on wbs). in group b2, 1/2 patient had dlu and 1/2 had no dlu. conclusion: dlu in the presence of tv may be due to functioning thyroid remnant although the possibility of recurrence or functioning metastases can not be excluded. nevertheless, dlu in the absence of tv on delayed post therapy wbs, may indicate hidden metastases and therefore could offer additional information in the management of patients with thyroid cancer. aim: to evaluate the role of the parathyroid hormone (pth) assay in patients with primary hyperparathyroidism (phpt). material and methods: we studied 82 patients, mean age 57 years, clinical and biochemical diagnosis of phpt, surgical complete exploration after the sestamibi scanning and anatomopathological confirmation of the removed glands. the pth values were obtained before surgery, by range of normality 15 and 65 pg/ml. results: the patients presented a mean average of pth 134 pg/ml. 1. pth/histology: pth/hyperplasia: n=16, mean=152, 4000, tip deviation=50, 10762, tip error=12, 52690 pth/adenoma: n=73, mean=132, 9775, tip deviation=52, 23478, tip error=6, 11362 2. pth/99mtc-sestamibi scintigraphy: pth/negative: n=81, mean=133, 8267, tip deviation=53, 56779, tip error=5, 95198 pth/positive: n=84, mean=135, 5757, tip deviation=53, 31358, tip error=5, 81699 3. pth means: n=83, minimum=50, 96, maximum=308, 00, mean=134, 7171, tip deviation=53, 28254 4. glandular weight means: n=102, minimum=100, maximum=7250, mean=1309, 92, tip deviation=1186, 400 conclusion: we didn't observe significant relation between the scintigraphy and the pth. there was obtained a statistically significant difference (p=0,038) between the averages of the weight of adenomas (1440, 28 mg) and hyperplasias (614, 5 mg). the comparison of the pth values of both groups hadn't got statistical significance. the results of the sestamibi scanning didn't show statistical relation with the pth values. aim: several authors have reported false positive i-131 accumulations due to various clinical conditions in the absence of residual thyroid tissue or metastasis of differentiated thyroid carcinoma (dtc). in this report, we present a case with dtc having false positive i-131 accumulation due to a large hydatid cyst in the liver is presented. case report: a 37 years old woman underwent bilateral near total thyroidectomy for 1.5 cm papillary thyroid carcinoma located right lobe. sonographic examination of the patient demonstrated an ovoid, complex cystic mass with dimensions of 15 x 10 cm in the right lobe of liver. the mass was well delineated, and contained septated cystic parts as well as solid appearing components. the appearance of the some solid parts was in favour of detached membranes. color doppler ultrasonographic evaluation yielded no vascular signal in the mass. these sonographic findings were found to be concordant with a type ce-3 hydatid cyst according to the world health organization classification. the immunoblot test was confirmed hydatid disease. surgical extirpation of the cyst suggested by interdisciplinary consultations was planned to be performed after the radioiodine therapy. two month later the thyroid surgery 100 mci (3700 mbq) radioiodine therapy was performed for ablation of the thyroid remnant. the post-ablative whole body i-131 scan displayed minor uptake in the thyroid bed concordant with residual thyroid tissue and a focal, intense and homogeneous uptake of radioiodine in right lobe of the liver which was reported to be a hydatid-cyst lesion by usg. conclusion: while some cystic lesions of kidney and liver have been previously reported as causes of false positive radioiodine accumulation, this is the first reported case of uptake i-131 by a hepatic hydatid-cyst up to our knowledge. we therefore suggest that hydatid cystic lesions should be considered as false positive i-131 accumulating pathologies while interpreting wholebody i-131 scans. a. mestre, m. negre, g. obiols, j. mesa, f. porta, j. castell-conesa; hospital universitari vall hebron, barcelona, spain. purpose: to assess the role of 123i scintigraphy in the initial staging of differentiated thyroid cancer in comparison with 131i post-treatment imaging. methods: this prospective study included 20 patients, 5 male and 15 female, age range 26-80 years. all of them were diagnosed of differentiated thyroid cancer (17 papillary, 3 follicular) and treated with total thyroidectomy. we compared 123i scans (10 of them with spet) with their corresponding post-treatment 131i whole-body images with a maximum interval of 2 months between them, evaluating the number of foci and localization in each exam. patients received a dose of 4 mci of 123i. images were obtained 12 to 24 hours after administration. therapeutic dose of 131i (100-150 mci) after was used as the gold standard diagnostic scanning. 19 patients were studied with rhtsh administration and one with thyroid hormone withdrawal. results: in 15 out of 20 patients 123i scan findings were completely concordant with those of corresponding post-treatment 131i images with a concordance rate of 75%. 17 patients showed the same number of foci in cervical region (concordance 85%) while three patient showed an increased number of lesions in 131i image. three patients showed more intense uptake in131i images than in the 123i ones. two out of 20 patients presented metastatic disease in 123i and 131i scans. nevertheless, at least two additional foci were observed on post-treatment 131i images. conclusion123i pretherapeutic scan is comparable to 131i post-therapeutic imaging in differentiated thyroid carcinoma patients with an acceptable concordance in cervical region and at distant site. although some lesions were missed on 123i images, no changes in therapeutic management of patients were observed. 131i versus 99mtc-sestamibi to detect thyroid cancer recurrence in cervical lymph nodes in cases with increased serum thyroglobulin s. gerali 1 , p. valsamaki 1 , j. koutsikos 1 , s. tsiouris 2 , e. pantazi 1 , e. karga 1 , s. luccetti 1 , c. zerva 1 ; 1 "alexandra" university hospital, athens, greece, 2 university general hospital of ioannina, ioannina, greece. aim: the detection of cervical node metastases from differentiated thyroid cancer (dtc), in the setting of increased serum thyroglobulin (tg), may be accomplished by the post-therapeutic 131i whole-body scan (131i-wbs). the method's effectiveness is directly dependent on the iodine-trapping ability of the cancer cells, under thyrotropin (tsh) stimulation (tsh>30 μiu/l). in this clinical setting, we used the non-specific tumor-seeking radiotracer 99mtc-sestamibi as an alternative diagnostic approach. scintigraphic findings were correlated with neck ultrasonography (us) and evaluated against the results of lymph node biopsy. materials & methods: we retrospectively studied 20 dtc patients [5 men, 15 women, aged 25-60 years (mean ± sd = 44.4 ± 13.3 years). the histologic types were: 12 papillary cell, 5 follicular cell, and 3 hürthle cell carcinomas. patients had undergone total thyroidectomy and 131i ablation therapy and eventually presented with elevated serum tg levels. we performed neck us and 99mtc-sestamibi wbs, 20 min after iv injection of 740 mbq tracer activity. repeat ablative dose of 131 (3700-5550 mbq) was then administered and posttherapeutic 131i-wbs was performed 3-7 days later. the findings of the three imaging diagnostic modalities were correlated and compared with the lymph node biopsy histology that provided the definite diagnosis. results: 99mtc-sestamibi identified 18/20 cases of cervical lymph node metastases (11 papillary, 4 follicular, and all 3 hürthle carcinomas). positive post-therapeutic 131 -wbs was observed in 5/20 cases. detection of dtc recurrence in cervical lymph nodes by 99mtc-sestamibi scintigraphy and post-therapeutic131i-wbs was accomplished with a sensitivity of 90% versus 25%, respectively. conclusion: the application of 99mtc-sestamibi in detecting dtc metastases in cervical lymph nodes seems rewarding, since it demonstrates higher sensitivity than 131i-wbs, probably due to additional recognition of dedifferentiated non-iodophilic lesions. also, no discontinuation of the thyroxine replacement / suppression therapy is required and the method offers high-quality imaging, with results available on the same day. we present our experience in the follow-up of these patients with serum calcitonin assays and dmsa (v) scans. a retrospective review of the hospital's medical records was performed. sixteen patients (11 males, 5 females, age; 32-60 yrs) with histologically proven medullary thyroid carcinoma, and who had basal serum calcitonin assays and dmsa (v) scans as part of their post-operative follow-up assessment, were included in the study. 56 dmsa (v) scans were performed on these between 1993-96. all patients had prior total thyroidectomy. two patients had synchronous papillary carcinoma of the contralateral thyroid lobe and 1 patient had men 2a syndrome. 7 patients had serum calcitonin assays performed pre-operatively or within 2 weeks of surgery. all 7 patients had calcitonin levels greater than 100pg/ml. the lowest level was 272 pg/ml. four out of 7 patients showed normalisation of the serum calcitonin levels within 6 months of surgery. of the 3 patients with elevated serum calcitonin levels, 2 patients showed an initial decline in calcitonin levels up to 12 months post-surgery (but still above 50 pg/ml) and a subsequent increase. both patients were found on subsequent dmsa (v) scans to have residual or recurrent foci of disease. the 3rd patient was lost to follow up. tc-99m dmsa (v) scans and serum calcitonin levels performed within a month apart were analysed. findings were concordant in 38 of 48 instances (79.2%) and discordant in 10 of 48 instances (20.8%). sensitivity of dmsa (v) scans for detecting recurrence was 71.4%, using calcitonin levels as the reference. there were no false positive scans. clinical follow-up periods ranged from 9-142 months. two patients had only one follow-up scan performed within 6 months of surgery and were considered lost to follow-up. at the end of their follow-up periods, 6 of 14 patients (42.8%) were disease -free, 3 patients (21.4%) had residual or recurrent disease; the other 6 patients' (42.8%) status had biochemical recurrence without detectable disease. in conclusion, calcitonin levels are a sensitive and specific indicator of disease recurrence in postoperative follow-up of patients with medullary thyroid carcinoma. calcitonin normalisation (<50 pg/ml) within 6 months of curative surgery may be a strong predictor of disease-free status whereas a less than complete normalisation of calcitonin may predict eventual disease recurrence. in cases of elevated calcitonin, tc-99m dmsa (v) is an affordable, readily available and sensitive imaging agent. objective: the objective of the study was to evaluate the usefulness and accuracy of intra-operative hand held gamma probes in minimally invasive radio-guided surgery (mirs) of parathyroid adenomas. material and methods: 8 patients who were suspected as having parathyroid adenoma by virtue of a high serum pth and were subsequently diagnosed as having a solitary parathyroid adenoma on the basis of localization study with tc-99m-sestamibi were included in the study. all these patients then further underwent minimally invasive parathyroid surgery by being injected with tc-99m-sestamibi 3 to 4 hours before their planned surgeries. a hand held gamma probe was used intra-operatively to precisely localize the adenoma followed by the surgery. results: tc-99m-sestamibi correctly identified and precisely localized the parathyroid adenoma in all 8 cases. intra-operative gamma probe also was able to localize the parathyroid adenoma and hence facilitated in the mirs. all patients have been disease and symptom free on a 6 month follow up. conclusion: gamma probe guided mirs is a very attractive surgical approach to treat patients with primary hyperparathyroidism due to a solitary parathyroid adenoma. the procedure is technically easy, safe, with a low morbidity rate and has better cosmetic results and lower overall costs than convention bilateral neck exploration. introduction: in primary hyperparathyroidism, the main diagnostic procedures for presurgical localization of parathyroid adenomas are ultrasound of the neck and radionuclide imaging. the sensitivity of the nuclear imaging has proven to be far superior to ultrasound as later is operator dependant. difficulties in radionuclide imaging arise when primary hyperparathyroidism presents with a multinodular goiter with an incidence ranging from 20% to 75% in endemic regions. case report: presented here is a case of a 42 year old female who presented with bony aches and pains. on examination she was found to have a mng. her labs showed the hormonal assays of the thyroid to be in normal range, however, she was found to have a high serum pth. she was advised a parathyroid scan for the localization of adenoma which showed an area of increased tracer uptake at the lower pole of the left lobe of the thyroid. this area however corresponded with a palpable left sided thyroid nodule on clinical examination. to remove any controversy as to the true origin of this nodule she was advised a tc-99m-pertechnetate scan. the pertechnetate scan showed an area of photon deficiency in the same area. the patient was then underwent an ultrasound which on doppler studied confirmed a parathyroid adenoma at the lower pole of the left lobe of the thyroid. the patient was then planned for a minimally invasive parathyroid surgery by injecting mibi 3 hrs before the planned surgery. a successful surgical outcome was reported and a parathyroid adenoma confirmed on histopatholgy. at 6 months follow up, her pth and calcium levels became normal and she had also shown remarkable recovery symptomatically. unusual metastatic localizations of differentiated thyroid carcinoma n. ben rais; ibn sina hospital, rabat, morocco. introduction: the majority of thyroid cancers have a slow evolution, a more often loco-regional extension, and a good forecast. remote metastases, when they exist, generally touch the osseous skeleton and/or pulmonary tissu. however, unusual metastatic localizations much more exceptional are possible. the authors report through this work two cases of atypical metastasis of differentiated thyroid carcinoma followed in nuclear medicine department of ibn sina hospital in rabat. material and methods: our two patients had initially underwent a total thyroidectomy for differentiated thyroid carcinoma histologically confirmed. they had profited 4 weeks after the surgical gesture from a reference isotopic exploration (131 iodine whole body scan and thyroglobulin dosage). the paraclinic assessment was supplemented by a computed tomography (ct). results: revealing symptomatology in the first 69 years old patient was dominated by a blindness associated with an elective up-take of radioactive 131-iodine on the level of hypophyseal gland extending to the sphenoid bone. the second 55 years old patient reported right basithoracic pains resisting to the usual antalgic treatment with a bulky mass driving back the kidney right to the bottom at ct with and important up-take 131-iodine at whole body scan; a surrenalectomy was thus carried out with conservation of the kidney. in the 2 cases the rate of thyroglobulin was considerably high. an activity of 3,7 gbq 131-iodine was managed with the 2 patients. the evolution was marked, in the short run, at the first patient by a recovery partial of the sight, the disappearance of pain in the second patient and a remarkable reduction of thyroglobulin rate at both. discussion: unusual metastasis of differentiated thyroid carcinoma constitute an exceptional entities in the evolution of the disease. their treatment and following up does not seem to be significantly different from that of the traditional metastatic forms, insofar as the 131-iodine therapy keeps all its value to improve or at least stabilize the evolution of this pathology. the diagnostic process and further therapeutic decisions in a case of the solitary pulmonary nodule (spn) pose a challenge in everyday medical practice. differentiation whether the spn is benign or malignant based on traditional methods, may be inconclusive and does not ensure prompt diagnosis and optimal medical management. in this context, evaluation of the usefulness of the receptor scintigraphy with somatostatin analogue 99mtc-depreotide in diagnosis of a spn seems to be essential and determines the aim of this study. material. examined group consisted of 35 patients with the spn diagnosed radigraphicaly. computed tomography (ct), somatostatin receptor scintigraphy (srs), and fine needle aspiration biopsy (fna) or surgery with histopathological verification were performed in all the patients. in each case the surgery type was selected based on pathological result: in some cases an operation was more radical with excision of the local lymph nodes. method. ap and pa projections of the planar images and spect examination were carried out between the 2nd and 4th h after iv injection of 99mtc-depreotide. radiopharmaceutical activity was 740 mbq. srs was performed using a dual-head gamma camera varicam (elscint, haifa, israel) equipped with high-resolution collimators. tomographic projections were acquired every 3° in 360° geometry, each of 25 s duration. a matrix of 128×128 pixels was applied (4.42 mm/pixel). reconstruction of the images was performed by means of the iterative method. semiquantitative analysis of 99mtc-depreotide uptake in the pulmonary nodules and lymph nodes was based on the calculation of the tumor/ background ratio (tumor activity/ activity in a region located in the contralateral lung). results. in 27 patients with radiotracer uptake visible in an area corresponding to the tumor location on ct, the diagnosis of pulmonary cancer was confirmed. false negative result was obtained in one case (no depreotide accumulation in a nodule which turned out to be a cancer). in 3 cases uptake of somatostatin receptor analogue was seen in the non-cancerous lesions (carcinoid in 2 patients and tuberculoma in 1 person). there was no tracer accumulation in 7 benign lesions. conclusion. obtained results suggest that srs performed with 99mtc-depreotide is clinically useful and may be recommended as a part of the diagnostic algorithm for the management of the spn. thallium-199-scintigraphy in differential diagnostics of inflammatory and neoplastic processes of lungs and mediastinum purpose: to estimate the efficiency of 199tl-scintigraphy in differentiating the inflammation and tumor of the lungs and mediastinum. materials and methods: the 199tl-scintigraphy has been applied in the investigation of 29 patients (13 male and 16 female of mean age of 42.0±26.0 years) with 30 affection localizations. the scintigraphy was carried out at early and at deferred phases (in 20 and 180 minutes after the intravenous introduction of 185mbq 199tl, respectively). the accumulation focus has been estimated visually, and the coefficients er, dr, and ri=dr/er have been evaluated. the 199tl-scintigraphy results have been compared with the data of clinical examinations and the results of treatment (n=29), radiography (n=29), and ct (n=22). the affection of the lungs and mediastinum have been confirmed in 23/30 cases (4/30 -inflammations, 19/30 -tumors), and rejected in 7/30 cases. results: the affections have been visualized in 18/23 (78.3%) cases (14/19 -tumors, 4/4inflammations). the absence of an 199tl-scintigraphy uptake has been found in 5/23 cases (5 false-negative results). the found absence can be referred to a tumor type and/or tumor smallness (d < 3 cm). the correlation between coefficients ri and er at inflammations (r=-0.95, p<0.05) and tumors (r=-0.37, p<0.05) is due to the delivery and removing 199tl from an accumulation focus by the blood-groove. we found that ri=-0,183 er+1.060 at inflammations, and ri=-0,180 er+1.335 at tumors. on this basis, we offer the formula ricrit.=-0.182er+1.197 to differentiate inflammations and tumors. thus, the quantitative criterium of an inflammation is ri<-0.182er+1.197, while at a tumor -ri>-0.047·er+0.979. conclusion: the differential diagnostics of inflammations and tumors in lungs and mediastinum has been found to be correct in 18/18 cases. the sensitivity, specificity, and accuracy of the tumor diagnostics by 199tl-scintigraphy have been estimated as 73.7%, 100% and 83.3%, respectively, and as 100% for all three parameters (estimated on a sample of small amount) of the inflammation diagnostics. s305 p25 -monday, oct. 15, 2007, 2:30 pm -4 :00 pm, poster area diagnostic oncology: planar scintigraphy and spect -breast cancer scintigraphy a. spanu 1 , f. chessa 1 , g. b. meloni 2 , d. sanna 1 , p. cottu 3 , a. manca 4 , s. nuvoli 1 , g. madeddu 1 ; 1 dept. of nuclear medicine university of sassari, sassari, italy, 2 dept. of radiology university of sassari, sassari, italy, 3 dept. of surgery university of sassari, sassari, italy, 4 dept. of pathology university of sassari, sassari, italy. aim: planar scintimammography (sm) acquired with a conventional gamma camera has proved a useful complementary tool to mammography (mx) in the diagnosis of bc, but with unsatisfactory sensitivity in small size carcinomas. in this study we assessed the role of planar sm with a high resolution dbc in the diagnosis of bc, comparing the results with those of mx. methods: a consecutive series of 129 patients scheduled for biopsy for suspect bc at conventional procedures (clinical examination, mx, us) was studied. 99mtc-tetrofosmin planar sm was acquired in all patients using a new developed small field of view high spatial resolution (1.6 mm) dbc (lumagem 3200s/12k) mounted on a modified mammography unit allowing the similar projections as mx as well as breast compression during acquisition. scintigraphic data were compared to mx findings and correlated to histological findings. results: 113 patients had bc (unifocal in 92 cases and multifocal in 21 cases) and 16 patients had benign disease; in total 132 carcinomas (40 10 mm and 92 > 10 mm) and 17 benign lesions were ascertained. dbc planar sm was true positive in 111/113 (98.2%) bc patients, detecting 129/132 carcinomas (overall sensitivity: 97.7%), and was true negative in 14/16 (87.5%) patients with benign disease, excluding malignancy in 15/17 lesions (overall specificity: 88.2%). sm sensitivity was 100% in carcinomas >10 mm and 92.5% in those 10 mm. globally, sm was more accurate than mx in 36/113 (31.8%) cases, detecting cancer in 8 patients with mx indeterminate for dense breast (7/8 tumors were <10 mm), assessing additional tumor foci (all <10 mm) in 5 pts with multifocal disease and correctly classifying 23 patients as affected by cancer (7 cases) or by benign disease (16 cases), all of these with inconclusive mammographic findings. however, mx was more sensitive than sm in 2 patients, in each of these detecting one bc < 10 mm, false negative at sm. conclusion: dbc planar sm appears a highly sensitive diagnostic tool in the detection of primary bc, also when small in size at a very early stage and in the assessment of multifocal disease. a wider employment of this procedure is thus suggested, especially in indeterminate or inconclusive mammographic findings to improve sensitivity and specificity of mx. aim: preliminary studies have demonstrated the usefulness of planar scintimammography (sm) with dedicated breast camera (dbc) in the detection of unifocal primary bcs. in this study we evaluated the usefulness of this radioisotopic procedure in the diagnosis of multifocal/multicentric bc, comparing the results with those of mammography (mx). methods: a series of 127 consecutive patients with suspected bc, imaged preoperatively from november 2005 to february 2007 with dbc planar sm in adjunct to standard procedures, including mx, was reviewed. following the i.v. injection of 99mtc-tetrofosmin, sm was acquired in all cases using a new developed small field of view high spatial resolution (1.6 mm) dbc (lumagem 3200s/12k) mounted on a modified mammographic unit allowing the similar projections as mx as well as breast compression during acquisition. scintigraphic data were related to final surgical histopathological findings and compared to those obtained with mx. results: at surgery, 20/127 (15.7%) patients had multifocal (12 cases)/multicentric (8 cases) bc, bilateral in one case, including 15 patients with palpable multiple ipsilateral invasive bc and 5 with non palpable multiple microscopic foci of carcinoma in situ. dbc planar sm was true positive for cancer in all cases, while mx was true positive in 19/20 cases and false negative in one who had 2 distinct foci (10 and 5 mm in size) of invasive carcinoma. sm assessed multifocal/multicentric condition in 14/15 patients with multiple invasive bc, showing additional tumor foci than mx in 4 cases, while in one patient missed a subcentimetric focus, also negative at mx. moreover, sm correctly defined tumor extension ascertained at surgery in all 5 patients with carcinomas in situ, including 4 with only microcalcifications without masses at mx. in no case mx was more accurate than sm. conclusion: high resolution dbc planar sm proved a very useful diagnostic tool in multifocal/multicentric bc detection correctly assessing local disease extension and demonstrating a better performance than conventional mx. a wider employment of this radiosotopic procedure is thus suggested as a complementary tool to conventional methods in planning the surgical treatment of multifocal/multicentric bc patients. correlation of mammographic density with the mode of scintimammographic 99mtc-(v)dmsa uptake in various breast pathologies v. papantoniou 1 , e. sotiropoulou 1 , s. tsiouris 2 , n. ptohis 1 , m. sotiropoulou 1 , a. tsigris 1 , a. stipsanelli 1 , k. sirgiannnis 1 , k. dimitrakakis 1 , p. valsamaki 1 , e. kounadi 1 , n. makris 1 , c. zerva 1 , a. antsaklis 1 ; 1 "alexandra" university hospital, athens, greece, 2 university general hospital of ioannina, ioannina, greece. aim: to investigate the mode of 99mmtc-(v)dmsa distribution in correlation with mammographic density, in women with dense breasts and various breast lesions. materials & methods: 55 women (aged 53.2±11.8 years) scheduled for breast surgery due to suspicious palpation and/or mammography, were submitted to doublephase (v)dmsa scintimammography (10 and 60 min after intravenous tracer administration), 2-7 days before surgery. dense breast (%) area on mammography ([dense breast area / whole breast area] × 100%) and tracer uptake (%) area on scintimammography ([tracer uptake area / whole breast area] × 100%) were calculated by computer-assisted means and were correlated with the histological findings. calculation of the lesion-to-background (l/b) ratios at 10 and 60 min was performed at the sites of maximal breast activity. retention ratio (rr = l/b60min minus l/b10min) and retention index (ri = [l/b60min minus l/b10min] / l/b10min] × 100%) were calculated and compared (mann-whitney u test) between the various breast pathologies. continuous data are expressed as mean ± sd; significance level was set at p<0.05. results: histology revealed 20 benign non-proliferating lesions (bnpl), 10 benign proliferating lesions (bpl), 17 carcinomas in situ (cis), and 14 infiltrating carcinomas (ic). bpl were associated with the highest breast density values, followed by cis. breast density was 31.48±14.68 in bnpl, 47.20±17.30 in bpl, 35.80±10.19 in cis, and 24.04±13.30 in ic. significant density differences were found between bnpl-bpl (p=0.031), bpl-ic (p=0.0039), and cis-ic (p=0.014). likewise, bpl were found to have significantly higher (%) tracer uptake compared to the other histologies. scintimammographic (%) uptake was 22.45±8.09 in bnpl, 31.79±9.25 in bpl, 26.39±8.73 in cis, and 15.3±9.2 in ic. (v)dmsa retention over time was profound in bpl and cis. rr was 0.32±0.35 for bnpl, 1.50±0.88 for bpl, 0.50±0.32 for cis, and 0.35±0.29 for ic, while the ri was 22.10±20.30, 49.80±25.80, 38.90±25.00, and 23.41±20.55, respectively. significant differences in (v)dmsa rr were found between bnpl-bpl (p=0.001), bnpl-cis (p=0.005), bpl-cis (p=0.048) and bpl-ic (p=0.02), whereas significant ri differences were found between bnpl-bpl (p=0.006), bnpl-cis (p=0.039), and bpl-ic (p=0.02). conclusion: (v)dmsa's kinetic behaviour is possibly related to the early onset of cell proliferation in the process of carcinogenesis, in women with dense breasts. furthermore, increased breast density is associated with benign proliferating lesions with potential of evolving into malignancy and also with cis. the combination of mammography and scintimammography may be helpful in selecting those women at risk, who could benefit from prophylactic treatment. a. spanu 1 , a. farris 2 , f. chessa 1 , d. sanna 1 , m. pittalis 2 , s. nuvoli 1 , g. madeddu 1 ; 1 dept. of nuclear medicine university of sassari, sassari, italy, 2 dept. of oncology university of sassari, sassari, italy. aim: conventional imaging procedures proved of limited value in assessing tumor response to neoadjuvant chemotherapy in patients with lapbc. in the present study we evaluated and compared the usefulness of 99mtc-tetrofosmin planar scintimammography (sm) and spect in monitoring the response to neoadjuvant hormone or chemotherapy in patients with lapbc. methods: 32 patients affected by lapbc were studied before and after completing hormone (10 cases) or chemo (22 cases) neoadjuvant therapy prior to surgery. in all cases, following 740 mbq 99mtctetrofosmin i.v. injection, both conventional planar sm and spect were acquired using a dual-head gamma camera equipped with hr parallel hole collimators. in 15 cases planar sm with a new developed small field of view high spatial resolution (1.6 mm) dbc (lumagem 3200s/12k) mounted on a modified mammography unit allowing similar projections of mammography and breast compression during acquisition was also acquired. planar and spect findings were evaluated visually, mutually compared and correlated with definitive histopathological findings in all cases. results: four patients had a complete pathologic positive response, while residual tumor was ascertained at histology in 28 patients. no uptake areas were detected at both conventional planar sm and spect, excluding residual tumor after therapy, in 4/4 (100%) cases, in accordance with histology. dbc planar sm was performed in 1 of these 4 cases resulting true negative. conventional planar sm detected residual tumor in 23/28 (82%) cases, resulting false negative in 3 patients with a pt1c tumor, including one mucinous bc, and in 2 patients with multiple and scattered subcentimetric tumor foci. spect was true positive in 25/28 (89.2%) cases, but missed the mucinous bc and the 2 subcentimetric tumors which were also false negative at conventional planar sm. however, these latter 2 carcinomas were identified only at dbc planar sm which was true positive also in the other 12 patients with macroscopic residual tumor in whom the procedure was performed. conclusion: both conventional planar sm and spect proved useful diagnostic tools in monitoring the response to neoadjuvant hormone or chemotherapy in lapbc. spect appears more sensitive than conventional planar sm in detecting residual tumor; however, our preliminary data seem to suggest that sensitivity can further increase by high resolution dbc planar sm, especially in subcentimetric tumor foci. these data need to be confirmed in larger series of patients. the role of 99mtc-mibi gated spect for assessment of anthracycline cardiac effects in breast cancer patients a. tzonevska, k. timcheva, m. dimitrova; national oncology hospital, sofia, bulgaria. aim: evaluation of adverse cardiac effects from anthracycline breast cancer therapy may enable identification of patients of risk for cardiotoxicity. the aim of the study is to assess the possibilities of 99mtc-mibi gated spect for early evaluation of patients of risk after anthracycline therapy. material and method: the study included s306 18 patients with breast cancer (mean age 53 years ) after anthracycline therapy ( total dose 600 mg farmarubicine ), 6-12 months after treatment. all of the patients had clinically normal cardiac status and performed echocardiography (echocg). gated spect myocardial scintigraphy was performed at rest after i.v. injection of 740 mbq of 99mtc-mibi. a spect gamma camera siemens diacam was used. data were acquired for 45 s for each projection using 64 x 64 matrix over 180°. images were gated at 8 frame per cardiac cycle with an r-wave trigger. myocardial perfusion in each segment was estimated and regional systolic wall thickening and ejection fraction (ef) were measured and compared to echocg. results: the results demonstrated normal myocardial perfusion, regional systolic wall thickening and ef in 11 patients. in 7 patients there was mean to moderate hypoperfusion affecting myocardial segments ( anterior segments in 4 patients, inferior segments in 3 patients ). among these patients, 2 patients established normal ef ( 70%-72%) and 5 patients had slightly reduced ef ( 48%-52%) and regional systolic wall thickening in the hypoprfused regions as these results matched the echocg findings. it is concluded that 99mtc-mibi can be of use for early detection of adverse effects of anthracycline cancer treatment, before positive echcg results. the role of 99mtc-mibi scintimammography in recurrent breast cancer z. rajkovaca 1 , j. mijatovic 1 , g. vuleta 1 , a. matavulj 2 , p. kovacevic 2 , n. ponorac 2 ; 1 clinical centre, banja luka, bosnia and herzegovina, 2 medical faculty, banja luka, bosnia and herzegovina. breast conservative surgery has now become commonplace as it is less mutilating than radical surgery. the probability of recurrent tumour in this form of surgery increases. post-surgery and radiotherapy changes as fibrosis, inflammation have reduced the accuracy of convectional method of breast imaging as x-ray mammography. the aim of this study is to asses the accuracy of 99mtc-mibi scintimammography in patients with suspected recurrent breast cancer in the breast or loco regional tissues. methods: nineteen (18) women (median age 46 years, range 23-64 years) with suspected recurrent breast cancer in the breast or loco regional tissues were investigated. after routine analyses (clinical examination, ultrasound, x-ray mammography and fine needle aspiration biopsy) they were examined by scintimammography (10 minutes after iv injection of 740 mbq of 99mtc-mibi). all patients with suspected recurrent cancer in the breast or loco regional tissues (12) undergone surgery and the final diagnosis was determined by histopathological examination. another 6 patients were followed 6-24 months. the scintigraphic studies were correlated with radiological findings and/or with histopathology. results: there were 11 patients with recurrent cancer (8 with loco-regional recurrent and 3 in another breast). x-ray mammography identified seven of these cancers. 99mtc-mibi scintimammography identified ten of eleven recurrent breast cancers. the one cancer not seen on scintimammography was positive on x-ray mammography. in the five out of seven patients without cancer, scintimammography were reported as having no changes consistent with cancer. x-ray mammography showed suspected cancer lesions in three out of seven patients without cancer. there were two false-positive scintimammograms and one false negative. axillary lymph node recurrence occurred in two patients. bought of them were positive on scintimammography. 99mtc-mibi showed higher sensitivity, specificity and accuracy per patient than did x-ray mammography (90.9% vs. 63.6%, 71.4% vs. 57.1% and 83.3% vs. 61.1%, respectively). conclusions: 99mtc-mibi scintimammography has high sensitivity, specificity and accuracy in patients with suspected recurrence of cancer in the breast or loco-regional tissues. to identifying recurrent breast cancer disease is better to use scintimammorapfy than x-ray mammografphy. aim: to evaluate breast scintigraphy in the diagnosis of breast cancer by quantitative analysis and image enhancement to emerge suspected lesions. breast scintigraphy demonstrates better specificity of mammography in cases where mammography is proven to be non-diagnostic (dense breast, scar tissue).. method: 12 patients with a suspicious breast lesion and an abnormal mammography completed a scintigraphic study of the breasts. 740-925mbq of tc99m-tetrofosmin is injected intravenously in the arm vein contralateral to the breast with the suspected abnormality. the patient was laid prone with a single breast dependent from the imaging table of a spect gcamera. the contra lateral breast was compressed against the table to prevent cross talk of activity. the images obtained, as an interfile , were transferred via procyon starlab program to a pc and processed by image pro plus, software for data analysis, visualization and application development that combines the tools necessary for interactive analysis and display. results: the visualization of the image improved significantly, by applying image-processing techniques. in the histograms of the image pixels, brightness/contrast deficiencies are illustrated. the image contrast is adjusted appropriately by applying spatial filters and gamma correction technique. highactivity chest and abdominal organs such as the myocardium and liver are masked out, in regions of interests rois, by count subtraction. a logarithmic scale is chosen so that low-count areas are enhanced. semi-quantitative parameters were determined to characterize and improve the sensitivity and specificity. the tumor to background ratio (t/b) was calculated by using regions of interest (roi) of standardized shape and size over the site of the greatest activity and the surrounding normal tissue and creating the corresponding profiles. focal, increased uptake relative to surrounding tissue is classified as a positive study through the profile index. in every case scintigraphic results are compared with histological findings. conclusion: breast scintigraphy seems to be a very promising alternative imaging technique, especially, where mammography proves to be non-diagnostic. image processing techniques improve both the specificity and the sensitivity of the technique. one of our near future goals is to classify the grade of malignancy through the technique of image processing in breast scintigraphy. tc99m-depreotide scintigraphy: priliminary study l. iordanidou, a. georgakopoulos, n. bolanos, e. trivizaki, s. saranti, k. rethimniotakis, n. stefanakos, p. koutsiouba; metaxa cancer hospital, piraeus, greece. aim:. accurate staging of disease recurrence is critical on treatment decisions. findings from conventional imaging can often be inconclusive, especially in areas previously treated with surgery or radiation. the aim of this study was to determine the potential role of 99m tc depreotide scintigraphy in the evaluation of breast cancer recurrence , particularly to intrathoracic tumor sites after primary treatment. patients and methods 99m tc depreotide scintigraphy (whole body and thoracic spect) was performed in 15 female patients (mean age 56, age range 23-79 years) who had previously treated for invasive breast cancer. the impact of 99m tc depreotide on defining the disease recurrence was determined by comparing tc99m depreotide results at the time of the examination with findings from conventional imaging (ci) performed before(mean time interval of 15 days, range, 0-40 days) the final diagnosis of recurrent or metastatic breast cancer was confirmed by histopathological findings or clinical and radiological follow up . results overall of the 15 patients under study, 13 patients had confirmed recurrent or metastatic breast cancer, and 2 were free of disease recurrence. eight of 15 female patients had equivocal findings on ci of the thorax, and 7 had findings indicative for metastatic disease. . 99m tc depreotide spect correctly identified the nature of equivocal findings as detected by ci imaging in 7 out of 8 patients: 6 patients were truth positive ( malignant) , 1 patient was truth negative ( benigh) and 1 patient false positive (infection). 99m tc depreotide scintigraphy detected in all 7 patients the metastatic lesions that had already been shown by ci imaging and in comparison with ci findings showed extent of disease increased in 5 (new metastatic lesions ) and no change in 2 patients. conclusions these preliminary results suggests that 99m tc depreotide scintigraphy is useful for detecting recurrent breast cancer and it seems to provide a better understanding of the extent of disease as compared with conventional imaging modalities. objectives: it is important for clinical physician to stage, to evaluate effectiveness, to diagnose recurrent and survived tumor in routine clinical practice. the purpose of this study was to validate the clinical application value of 18f-fluorodeoxyglucose (18f-fdg) using single photon emission computed tomography with coincidence detecting imaging in staging of lymphoma and evaluating the therapeutic effective. methods: eighteen patients with nhl were performed with 18f-fdg metabolic imaging preand post-therapy using a vertex plus epic mcd/ac from adac company. the imaging was performed 60 min postinjection of 18f-fdg 129.5-168.5 mbq using adac vertex plus mcd/ac (spect with coincidence detection). qualitative and semi-quantitative analyses were made during interpretation of 18f-fdg imaging. qualitative analysis is that malignant neoplastic lesions were identified if there were 18f-fdg concentrated area beyond normal tissues (brain, heart, gastricintestinal tract, kidney and bladder et al). semi-quantitative analysis, such as t/b (ratio of radioactive counts of tumor and normal tissue) was performed. when t/b > 2.0 the lesion are regarded as malignant lesions. 18f-fdg images were compared with synchronous routine images such as ultrasonography and ct. results: thirty studies were performed in 18 patients with nhl in this study. there were 21 true positives, 6 true negatives, 2 false positives and 1 false negative. the accuracy, sensitivity, specificity, positive predictive value(ppv) and negative predictive value(npv) were 90%, 95.4%, 75%, 91.3%, 85.7%, respectively. 18f-fdg imaging led to a change of 16.7% in the clinical staging, and 46.7% in the management. the ppv and npv of recurrence detected by 18f-fdg spect/pet were 100% and 80%, while ct's were 50% and 25% after therapy. four of five patients with negative entered clinical complete remission (cr), whereas all the 11 patients with abnormal 18f-fdg uptake relapsed or reprogressed. progression-free survival (pfs) with negative 18f-fdg was 16-47 months (median: 28.7 months) and pfs with positive was 3-46 months (median: 8.3 months). conclusion: 18f-fdg metabolic imaging using spect with coincidence detection plays an important role on clinical application of the diagnosis and management of patients with nhl. key words: 18f-fdg; spect; coincidence imaging; lymphoma rituximab and 0.5 ml of an medronate kit, reconstituted in 2 ml of 0.1m pb was irradiated for 20 min at 302 nm. irradiated solution was aliquoted into nitrogen-filled vials and stored at -80oc. each aliquot was labelled with 700 mbq of 99mtcpertechnetate. radiolabelled antibody was sterilised by filtration under aseptic conditions using a 0.2 um filter. the effectiveness of the labelling method was evaluated by determination of the number of free thiol groups per photoreduced antibody using 5-iodoacetamidofluorscein reaction method, radiochemical purity determination of 99mtc-rituximab by tlc and size-exclusion hplc and testing of in-vitro stability of the preparation. immunoreactivity of 99mtc labelled rituximab was further explored on ramos cells using a direct binding assay. until now six patients (age 42-70 y) with cd20+ lymphoblastic b-cell nhl and one with cd20-nhl as diagnosed by lymph node biopsy and planned for mabthera® or 90y-zevalin treatment, were injected with 500 mbq of 99mtc-rituximab. whole body and spect images were taken 1h, 3h, 6h and 24h post injection. scintigrafic results were compared with ct findings. results in all cases high radiochemical purity over 95% was observed with preserved affinity of 99mtc radiolabelled rituximab for cd20 antigen, irf being above 93%. on average 4.11 fee thiol groups per photoreduced rituximab were determined. in all patients expected activity was seen in the blood pool, liver, spleen and kidneys. accumulation of 99mtc-rituximab in involved sites was clearly seen on the whole body and spect images performed as early as 3 h p.i. in some patients and 6 and 24 h p.i images in all patients. pathological, moderately to markedly increased 99mtc-rituximab activity was seen in all ct confirmed nhl involved sites 6 h and 24 h p.i.. conclusion 99mtc-rituximab is a promising imaging agent suitable for assessing expression of cd20 in patients with nhl prior to (radio) immunotherapy. bone involvement in lymphoma:comparison of 99mtcmibi and 99mtcmdp scintigraphy d. vassileva 1 , a. tzonevska 2 , m. dimitrova 2 ; 1 national centre of haematology and transfusiology, sofia, bulgaria, 2 national centre of oncology, sofia, bulgaria. bone lymphoma is uncommon and presents diagnostic and therapeutic difficulties. aim:the purpose of the study was to compare 99mtcmibi and 99mtcmdp scintigraphy in bone lymphoma, with an attemt to define the relevance of each modality with respect to disease detection and possibly the interrelationships of scan pattens with disease activity. material and methods: 40 patients with malignant lymphoma (hodgkin's disease, non-hodgkin's lymphoma and myeloma) and suspected bone involvement were investigated. the bone scans were obtained at 2 hours after intravenous injection of 740 mbq 99mtc mdp and 30 min and 3 hours after i.v. injection of 740 mbq 99mtcmibi. the scintigraphic results were compared with the data of conventional imiging methods and hystological results. results: the results from the both scintigraphies were devided in 4 groups: i group-in 17 patients with osteolytic lesions both 99mtc mibi and 99mtc mdp scintigraphy were true positive for the presence of active disease. the mdp scans depend on the osteoblastic activities around the lesions. the scans detected 38 lesions, especially in the femur, humerus, ribs,sternum, thoracic and lumbar spine, pelvis. ii group-the 99m tc mibi scans were positive ( 7 lesions) and 99mtc mdp negative in 5 patients. 99mtcmibi accumulation attributed to bone marrow metastases may occur at an early stage, before the bone remodeling process can be detected on conventional bone scans. iii group-in 10 patients, positive 99m tc mdp scans and negative 99mtc mibi scintigraphy were found. pathological fractures and persistent reactive bone formation after therapy (17 lesions) were detected in patients by positive bone scintigraphy only. the 99m tc mibi image may become positive before the 99m tc mdp and may subsequently revert to normal in the presence of an abnormal 99mtc mdp scan. in one patient with positive 99mmdp scintigraphy demonstrated lesion in humerus, the bone biopsy showed osteomyelitis. iv group-no abnormal images on the both scintigraphy were found in 8 patients, defined as a desease remission. conclusion: 99mtc mibi scintigraphy is helpful in early diagnosis , in detecting the extraosseous lesions and in early remission after therapy in lymphoma. 99mtc mdp scintigraphy is of limited value for the initial diagnosis of sceletal involvement but is a sensitive method for the detection of pathological fractures and osteblastic activity after chemotherapy.the combination of 99mtcmibi and 99mtcmdp scintigraphy gives an accurate diagnosis and helps to asses the extent of the disease in lymphoma with bone involvement. the purpose of this ongoing clinical study is to optimize the follow up as well as the primary diagnosis of patients with neuroendocrine tumors. different methods, like f-dopa-pet/ct and in-111 octreotid spect/ct, conventional imaging modalities and biochemical markers are performed individually in a comprehensive concept. methods: up to now 42 patients with suspicion of recurrence of a neuroendocrine tumor or in a preoperative assessment have been examined in our department. in addition to conventional imaging studies (ct/mri or ultrasonography) f-dopa pet/ct, if demanded in 111-octreotid spect/ct, a complete patient history, physical examination and biochemical markers (including cga, a 24 h urine collection for determination of 5-hiaa and the predominant pancreatic peptide) were performed. results: 10 patients demonstrated pathological findings in the f-dopa pet/ct and/or in the in-111 octreotid spect/ct. the results from the two imaging modalities were helpful in deciding the primary treatment options, meaning adequate resection with curative or palliative intent for primary and regional lesions. the somatostatinreceptorscintigraphy allows additional information about the treatment option with somatostatin analoga. in one patient with recurrence of a carcinoid tumor (clinical symptoms, 5hies + cga elevated) f-dopa pet-ct demonstrated clearly the extent of the metastatic disease (multiple peritoneal and iliacal metastases). in-111 octreotid spect/ct, however, demonstrated only tracer uptake in the iliacal lymphnodes, the multiple peritoneal metastases showed no somatostatin receptor expression -showing the different tumor biology of the metastases in one single patient. conclusion: each of the performed modalities (mri,ct, ultrasonography, f-dopa pet/ct, in-111 octreotid spect/ct, patient history, physical examination and biochemical markers) are of great value and can contribute in the whole concept of treatment options, follow up and therapy monitoring in patients with neuroendocrine tumors. 111in-octreotide scintigraphy is a very important procedure for the staging and followup of somatostatine receptors expressing cancers. however, a major drawback of the technique is the lack of anatomical landmarks. the best solution to this problem is the fusion with radiological images obtained using spect/ct devices. since this kind of machines is not still widely available, we propose a simple way to improve the anatomic localisation of 111in-octreotide foci. patients and methods: 111inoctreotide images (after injection of 300 mbq activity) have been recorded at 4, 24 and, if necessary, 48 hours. according to the findings on the images acquired at 4 hours, planar and tomographic images at 24 hours have been obtained with a simultaneous double isotope acquisition, after administration of a bone tracer (99mtc-hmdp, 800 mbq) three different energetic windows have been centered respectively on the two 111in peaks (245 and 171 kev) and on the 99mtc peak (140 kev) we validated this technique in 10 consecutive patients. results: we show several images where the association between 111in-octreotide and bone scan provided useful information on the anatomical localization of the lesions visualized by the somatostaine scintigraphy. conclusion: double isotope tomography is a simple technique and it's easily feasible in every nuclear medicine department. this modality of image acquisition allows to improve the anatomical localization of 111in-octreotide scintigraphy. aim: pentetreotide is a dtpa conjugate of octreotide, a long-acting analog of the human hormone, somatostatin. 111in pentetreotide (octreoscan) binds to somatostatin receptors on cell surfaces, and can be used for scintigraphic localization of neuroendocrine tumors bearing corresponding receptors. the aim of the study is detection of primary and metastatic neuroendocrine tumors. patients and methods: the total of 20 patients (8 males and 12 females, age 53±7 years) patients were investigated. scintigraphy of the whole body, (and tomography 360o/6o if necessary) were performed 4h, 24h and 48 h after i.v. administration of 111mbq 111-in pentetreotide. if needed, the study was supplemented with liver/spleen radiocolloid and/or bone diphosphonate scintigraphy. the study was performed with orbiter gamma camera and microdelta computer, using medium energy collimator and two photopeak activities (171.3kev±20% and 245.4kev±20%). results: in the group with seven neuroendocrine carcinomas of unknown origin, there were six true positive (tp) findings (two with liver metastases, two with liver, lung, and bone metastases, one with liver and mediastinal lymph node metastases and one with liver and retroperitoneal lymph node metastases), while one was false negative (fn) (poorly differentiated carcinoma with retroperitoneal metastases). in four patients scintigraphy influenced further patient management. from the group of nine pancreatic neuroendocrine tumors, in five neuroendocrine pancreatic carcinomas there were three tp (two with liver metastases) and one fn (poorly differentiated). in two patients with pancreatic gastrinomas both findings were tp, while in one patient with insulinoma it was tp and in the other tn. in four patients scintigraphy influenced further patient management while in two contributed. from the group of four neuroendocrine lung tumors there were two tp (two patients with bronchial carcinoid, one with liver metastases and the other with liver, lung and bone metastases), in one patients with atypical lung carcinoid after surgery, finding was tn, while in one with neuroendocrine lung tumor (acth secreting) it was fn (small mediastinal tumor. in one patient scintigraphy influenced further patient management while in one contributed. because of the the high uptake of radiopharmaceutical, and widespread metastases, six patients were indicated for radionuclide therapy with 90y-dota tate, and three of them received it. conclusion: preliminary results show that scintigraphy of neuroendocrine tumors is a useful method in diagnosis, staging and follow up of the patients suspected to have neuroendocrine tumors in the lungs. it is also helpful in the appropriate choice of therapy, including the radionuclide one. centre, we noticed an increasing number of referrals for octreotide studies in patients with mild symptoms or signs suspicious for a net and raised gi peptides but no history of a net and no suggestion of a net on other imaging. therefore, an audit was undertaken to assess the use of octreotide studies in this patient group. method a retrospective review was performed of all octreotide studies performed in 2005 to firstly detect what percentage of referrals were performed for this group of patients. secondly, within this group, the number of normal and abnormal studies was examined. results 88 studies were performed in total in 2005 with 26 of these falling the category of interest. 23 of these were normal with the remaining 3 raising the possibility of an abnormality, but further imaging appeared normal. discussion & conclusions we concluded that octreotide studies did not appear to be useful in investigating this subgroup of patients. aim. the aim of this study based upon a large series of consecutive patients evaluated by spect 111in-pentetreotide for a neuroendocrine tumor, was to evaluate the variability of reconstructing parameters used during spect study, in relation to the patient body weight and body district, looking for the possibility to standardize such parameters. materials and methods. 124 patients underwent 111in-pentatreotide scintigraphy by 4-and 24-hr whole-body and planar scans, and 24-hr spect examination. all patients were injected with 140-150 mbq of 111in-pentetreotide at least 1 week after somatostatin analogs discontinuation. spect was sitematically acquired at the level of the head, chest, and abdomen. spect parameters were selected as follows: acquisition, gamma-camera dual-head, medium energy collimators, step and shoot method, no circular orbit, matrix 64x64, 30 sec. per view for a total of 64 views; reconstruction, two procedures were compared, iteractive method using 10 iterations vs. filtered back projection using butterworth filter with different cut-off and order values. results. the results we obtained are summarized on table (see below) , where reconstructing parameters of 111in-pentetreotide spect were correlated to patient's boby weight (b.w.) and body discrict. patients with b.w. patients with b.w. part lower than 70 kg greater than 70 kg head cut-off order 7-8 cut-off order 7-8 0,30-0,40 0,30-0,40 thorax cut-off order 7-9 cut-off order 7-9 0,35-0,50 0,35-0,40 order 7-9 abdomen cut-off order 7-9 0,55-0,80 order 7-10 0,50-0,70 order 7-9 0,55-0,80 order 7-10 conclusions. in our experience, the optimal spect images were obained by applying the butterworth filter. moreover, it was possible to standardize the reconstructing parameters for the body districts of the head and chest, while in the abdomen the choice of these parameters was more variable; this is probably due to the fact that 111in-pentatreotide is physiologically trapped in various abdominal areas, and in different manner as a function of time, especially the liver, the spleen, the bowel, and the urinary tract. aim: as spect/ct evolves, its applications, including ct parameters, need to be evaluated in order to improve diagnostic accuracy and to assure that radiation exposure is minimal. here, we evaluate the added value of an additional "diagnostic" ct-scan (centred on a solitary focus) in cancer patients referred for bone staging and, for whom, a conventional low-dose spect/ct acquisition was planned. material and methods: patients with a solitary focus observed on whole-body bone scintigraphy (wbs) and classified as indeterminate or suspicious, underwent a low dose spect/ct acquisition (120 kv, 30 mas, 5 mm slice thickness); the ct-scanning area being similar to that obtained during the spect acquisition. in addition, a "diagnostic" ct-scan (120 kv, 100 mas, 1.25 mm slice thickness) centred on the focus obtained from the ct-topogram, was performed. nuclear physicians considered prospectively wbs, low-dose spect/ct and finally the centred spect/ct. radiation dose exposure was evaluated by means of a computed tomography dose index (ctdi). results: thirty-one consecutive patients (mean age: 62 yrs +/-12) were included in the study. whole-body bone scintigraphy depicted solitary indeterminate or suspicious foci in 20 and 11 patients, respectively. after low-dose spect/ct, these foci turned out to be malignant, or benign, in 8 and 17 patients, respectively, and remained indeterminate in 6 patients. low-dose spect/ct altered the interpretation of the wbs results in 15 pts of the "indeterminate focus" group and 5 pts of the "suspicious focus" group. an additional diagnostic ct-scan was accurately centred in all but one patient and altered low-dose spect/ct results in only 1 patient, in whom a solitary indeterminate focus on wbs was classified as indeterminate on low-dose spect/ct and subsequently benign on diagnostic spect/ct. additional foci (not found by wbs) located outside the scanning area of the centred diagnostic ct-scan were found in 9 patients. ctdi measurements were 3.30 +/-1.44 mgy and 10.18 +/-2.97 mgy in low-dose and "diagnostic" ct, respectively. conclusion: these preliminary results show that, (1) a conventional low-dose spect/ct is adequate for patients presenting with a solitary focus on wbs, provides an acceptable radiation dose exposure and identifies 25/31 (80%) of foci; (2) a ct volume session should not be limited to the area of the solitary focus since additional foci overlooked by wbs and located outside the centred ct-scan occurred in 9 pts (29%) and thus required ct data acquired over the entire spect region of interest for thorough elucidation. 199tl-scintigraphy in differential diagnostics of inflammatory and malignant tumoral processes of the musculoskeletal system purpose: to estimate the efficiency of 199tl-scintigraphy in differentiating the inflammation and tumor. materials and methods: the 199tl-scintigraphy has been applied in investigation of 53 patients suffering the inflammatory and neoplastic diseases of the musculoskeletal system. the scintigraphy was carried out at early and at deferred phases (in 20 and 180 minutes after the intravenous introduction of 185mbq 199-thallium, respectively). the intensity and contour's sharpness of the radiotracer accumulation focus have been estimated visually, and the coefficients er, dr, and ri=dr/er have been evaluated. the thallium-199-scintigraphy results have been verified morphologically (n=46) and compared with the data of ultrasonic (n=18), 3-phase scintigraphy (n=11), mrt (n=7), wbc-scintigraphy (n=4), radiography, (n=56), ct (n=20), clinical examinations, and results of treatment (n=67). results: the affections have been visualized in 53/56 (94.6%) cases (33/36inflammations, 20/20 -tumors). the correlation between coefficients ri and er at inflammations (r=-0.74, p<0.05) and tumors (r=-0.35, p<0.05) is due to the delivery and removing 199-thallium from an accumulation focus because of blood-groove. we have found that ri=-0.050·er+0.892 at inflammations, and ri=-0.044·er+1.066 at tumors. on this basis, we offer the formula ricrit.=-0.047·er+0.979 to differentiate inflammations and tumors. thus, the quantitative and qualitative criteria of an inflammation are: (1) ri<-0.047·er+0.979; (2) at an early phase, the contour's sharpness of the radiotracer accumulation focus is better than at a deferred phase; (3) a homogeneous accumulation of radiotracer at a deferred phase. at a tumor they are: (1) ri>-0.047·er+0.979; 2) at an early phase, the contour's sharpness of the radiotracer accumulation focus is worse than at a deferred phase; 3) a heterogeneity accumulation of radiotracer at a deferred phase. conclusion: the use of the above formulated criteria results in 52/56 (92.9%) success in the differential diagnostics of inflammations and tumors. the sensitivity, specificity, and accuracy of the 199tlscintigraphy are estimated as 91.7 %, 90.3 % and 91.0 %, respectively in the diagnostics of inflammations, and as 95.0 %, 95.7 % and 95.5 % -in that of tumors. patients with lung cancer. furthermore,to quantify the octreotide uptake for the positive sr metastases in order to assess the potential benefit of somatostatin derivatives therapy. patients and methods: twelve patients (9 males and 3 females, aged from 33 to 77 years old) with histologically confirmed lung cancer were evaluated (8 with sclc and 4 with nsclc).final diagnosis of bone metastases was based on the combination of clinical findings, the results of imaging methods including x-ray, computed tomography(ct) and bone scintigraphy(bs).the octreotide scanning included anterior and posterior views at 4 and 24 hours tomographic images when it was necessary and quantification of sr regional uptake for detected bone metastases graded with score 0 to 3(0,no uptake; 1,low uptake; 2,moderate uptake; 3,intense uptake;).the images of each patient were evaluated independently by at least two nuclear medicine physicians. considering the small patient population no statistical analysis was performed. results: sr scintigraphy visualized the primary tumour in all cases. sr scintigraphy showed skeletal involvement in 7 patients (6 with sclc and 1 with nsclc). the detected bone lesions were fewer than in the bs (sensitivity on a lesion basis 72,2 %), although two patients demonstrated more widespread bone metastases than the bs . in the remaining 5 patients sr scintigraphy showed no skeletal involvement (sensitivity on a patient basis 58,3% ). in our series,10% of skeletal metastases showed strong uptake, 30% showed moderate uptake ,while low uptake was demonstrated in 30%.thirty percent of skeletal metastases showed no uptake. conclusion:111indium octreotide scintigraphy provides great potential for the visualization of receptor-positive metastases mainly in sclc patients. the patients with high sr uptake (grade 2 and 3) could benefit from the treatment with radiolabeled somatostatin analogues. aim: this study looked at the incidence of positive bone scans in patients with low prostate specific antigens levels and compared this with the published recommendations for bone scanning in prostate cancer. material & method: we looked at 100 bone scans in patients with known prostate cancer undertaken at our institution in 2006. these were all reported as clearly "negative" or "positive". scans which were in any way ambiguous were excluded from the study. we then looked at the prostate specific antigen (psa) levels in these patients and compared this to the published recommendations which state that bone scans can be confidently be excluded in cases where the psa< 5, should be omitted where psa<10 and can cautiously be omitted at psa<20. results: we had no positive bone scans at psa< 5 in agreement with the published data, however, there were 2 positive scans at psa <10; 3 positive scans at psa<15 and 5 positive scans at psa <20. this is an incidence of 5%, which is much higher than the published data would suggest. for those patients with high psa values >50, 18/30 (60%) patients had a positive scan in agreement with published data. conclusion: patients with prostate cancer and psa< 5 should not routinely have bone scan imaging but those with psa 5-20 have a 5% incidence of a positive scan and should be considered for bone scintigraphy. purpose: breast cancer is the most common form of malignant disease among women associated with metastases in bones. ca 15.3 and cea are two of the most widely used tests for monitoring breast cancer.99mtc mdp bone scintigraphy is the most widely using imaging test for early detection of bone metastases. carbon anhydrite antigen (ca) 15.3 is a high molecular weight glycoprotein defined by two monoclonal antibodies (df3 and 115d8), of clinical relevance in the monitoring of treatment and detection of recurrence in breast cancer. this is a prospective study evaluating the efficacy of ca 15.3 and cea in monitoring breast cancer and early detection of metastases in bones. methods: |sixty two females with high-risk breast cancer were included in the study. response evaluation was based upon clinical examination, -rays or histology and elaborated marker criteria. results : elevated ca 15.3 were found in 8 patients with breast cancer associated with bone metastases (19.04%) and 2 patients without bone metastases(10%). the sensitivity of ca 15.3 tests was 19%, whereas specificity was 90%. elevated cea levels were found only in 2 patients with breast cancer associated with bone metastases (4.87%). cea sensitivity was only 4.8% whereas specificity was 100%. the specificity of bone scintigraphy for early detection of bone metastases were 98% whereas specificity were 95%. the combination of cea and ca 15.3 increased the overall sensitivity by only 1.4%. ca 15.3 was a significantly more powerful marker than cea for early detection of bone metastases, but clearly less favorable than bone scintigraphy. conclusions: ca 15.3 monitoring should be considered an expensive and inefficient method for early detection of bone metastases from breast cancer, and it provides no additional value when used in combination with cea. bone scintigraphy still continuous to be most efficient test for early detection of bone metastases. (210) other malign disease (bladder ca, renal cell ca, colon ca, multiple myeloma, uterine ca, leukemia, lymphoma, malignant mesothelioma, thyroid ca, thymic ca, pancreatic ca, larynx ca, etc.). the most metastatic cancers for bone are prostate ca (43%), breast ca (24%), lung ca (17%), gastric ca (14%), respectively. for the other malignancy types, bone metastasis ratio is 27%. bone metastasis determined in 30% of the patients with malignancy. suspicious lesions were not evaluated as metastasis. we frequently find the metastatic locations at extremities, pelvic bones and vertebrates for prostate ca; vertebrates, ribs and pelvic bones for breast ca; ribs, vertebrates and pelvic bones for lung ca; vertebrates and pelvic bones for gastric ca; extremities and ribs for others. conclusion: visualisation of metastatic bony lesions in 1/3 of cancer patients indicated the importance of whole body bone scintigraphy for these patients. if we assume some of the suspicious lesions as metastasis, the ratio of metastasis is increase (40-65%). the excess amount of the bone metastasis and the frequency of the metastatic extremity lesions are unexpected. comparison of bone scintigraphy and x-ray imaging in the patients after revisal endoprotesis operation of hip joint. p. korol, a. kosiakov, n. shincarenko, d. levinskiy; clinical city hospital # 12 of kyiv, kyiv, ukraine. aim: the aim of the study to evaluate the level of disease after revisal endoprotesis operation of hip joint using of bone scintigraphy and x-ray imaging. material and method. 62 patients after revisal endoprotesis operation of hip joint were imaged by a standard method of whole body bone scan. intestinal uptake was observed visually 3 hours after the intravenous administration of 740 mbq 99m tc mdp. a whole body bone scan; anterior, posterior, oblique spot views of the hip joint region were obtained. the data of bone scan were compared with x-ray imaging. results. total number of 62 patients with bone scans and x-ray imaging was statistically evaluated. 38/62 pts (61%) with bone scans had in the field of hip joint inflammatory process that is indicative of instability of the hip joint endoprotesis. however, on x-ray imaging, inflammation in hip joint was identified in 6/62 pts (9 %) events only. in total there were 62 matching scans and statistical data showed overall good correlation r=0,58. within the group of different matching regions correlation varied: r=0,51 for head of hip; r=0,47 for broach of hip; r=0,56 for cervical of hip. conclusion. bone scintigraphy is more sensitive and specific method of the determination to stabilities of the hip joint than x-ray imaging in the patients after revisal endoprotesis operation of hip joint. complex regional pain syndrome i (crps) previously known as reflex sympathetic dystrophy (rsd) is a disabling condition with annual incidence estimated at 26.2/100,000 general population. symptoms include intense, prolonged pain and burning of the extremity, change in limb temperature, sweating and swelling. proposed mechanism is an abnormal response to noxious stimuli resulting in dysfunctional interaction between sensory, motor, immune and autonomic nervous systems. crps could be related to prior fracture or sprain, significant physical stress (surgery, myocardial infarction) or thought to be idiopathic in up to 40% of cases. important associations of crps with other clinical conditions include hepatitis c, cirrhosis, aids, pancoast and pancreatic tumors. crps is believed to represent a paraneoplastic syndrome in these conditions. our exhibit focuses on the radiographic/scintigraphic features of crps; reviews the current literature regarding association of crps with malignancy and presents an illustrative case of a patient who developed crps affecting the hand in association with metastatic bone lesion in proximal forearm. crps was the first presenting symptom of osseous metastasis in this patient. the main goal of this exhibit is to increase interpreters' awareness of crps, its potential association with malignancy, and the need for imaging investigations to establish the diagnosis and associated pathology. imaging features: plain radiography is normal in the early stages; patchy subchondral and peri-articular osteopenia can develop later, occasionally in combination with soft tissue swelling. three phase 99m-technetiumto evaluate the relapse frequency of malignant melanoma (mm) in patients (p) diagnosed of mm, who underwent surgery and sentinel lymph node detection and biopsy (slnb) materials and methods: 82 p (aged 20-90; mean 58,1) who underwent surgery and slnb during 1998-2002 were included. parameters studied were: absence/presence of disease, tumor relapse (local or spread to other organs) and number of deaths. these items were evaluated depending on: mm's localization ( head-neck -hn, chest -ch-, arms -a-or limbs -l-) and breslow index (bi). the survival was estimated by kaplan-meier method results: the slnb was positive in 68 p and negative in 14p. 94% of p studied with slnb negative were free of disease during our evaluation (4 years). depending on mm's localization: in 39p it was located in ch (48%). relapsed 7p of them (18%); (bi>4 mm in 5p and 0,75>bi4 mm 1p and 0,75>ib<4mm 1p). in 24p it was located in l (29%). relapsed 5p of them (21%; ib>4mm; slnb positive). local relapse in 4/5p and metastasis in 1/5p. none of the patients with mm located in a (11p; 13%) showed local relapse or metastasis. in the group of patient analysed the most frequent localization was ch, and the worst prognostic factors were: mm's localization (l and ch), ib>4mm and slnb positive. these results lean upon de value of slnb as a good method to foresay de long term tumor's relapse. aim multiple radioactive lymph nodes are often detected by lymphoscintigraphy to identify sentinel lymph node(s) (sln) in breast cancer patients. it is not clear whether these additional lymph nodes are "true" sentinel nodes, or second-echelon lymph nodes that have received radiocolloid particles passing through the sln. various criteria based on the degree of radioactivity regarding the "hottest" node have been proposed to define which radioactive lymph nodes should be removed in order to minimize the false negative rate of the procedure. aims of this study were: to determine the frequency with which the most radioactive node "fails" to be pn+ when the less radioactive lymph nodes contain metastatic disease; to establish which lymphoscintigraphic criteria best define the radioactive lymph nodes to be removed. a total of 576 patients referred to pisa university hospital with operable breast cancer underwent radiocolloid lymphatic mapping and radioguided sln biopsy. to determine how often a less radioactive sentinel node is positive for tumor when the most radioactive lymph node is not, we considered as slns both those with the highest counts and any additional radioactive lymph nodes counting 20% or more of the hottest node. we identified two groups of pn+ patients, the former in which the most radioactive node was positive for tumor and the latter in which the less radioactive lymph nodes contained metastatic disease when the "hottest" did not. results: a total of 113 out of 576 patients (19.6 %) were found to have sentinel node metastases detected by histology or immunohistochemistry. we identified 70 positive axillary nodal basins from 70 patients in whom at least one positive sentinel node was found and more than one sentinel node was harvested. in 16 out of these 70 nodal basins, a less radioactive lymph node was positive for tumor when the most radioactive sentinel node was negative. if only the most radioactive sentinel node in each basin had been removed, 23% of the nodal basins with positive sentinel nodes would have been missed. the "parallel" lymphoscintigraphic pattern (multiple lymphatic channels originating in the region of the primary tumor and running to different lymph nodes) was associated with increased likelihood of finding the "hottest" lymph node negative for tumor while another, less radioactive, sentinel node contained metastatic disease (11 of out 16 patients; 69%). conclusion: we suggest the intraoperative threshold of 20% for optimal detection of nodal metastases in breast cancer patients. aim: due to its ability to depict sentinel nodes (sn) in expected and unexpected sites of lymphatic drainage lymphoscintigraphy is an important part of the sentinel node procedure. however, in prostate cancer lymphoscintigraphy has limitations in indicating the anatomical localization of deep located sentinel nodes inside and outside the pelvis. for this purpose spect-ct was evaluated in addition to lymphoscintigraphy in patients scheduled for laparoscopic pelvic lymphadenectomy. methods: in 16 patients (mean age 64.1y, range 53-74y) with prostate cancer of the intermediate prognostic group (inclusion criteria: t3 or psa>10î¼g/l or gleason score >6) 99mtc-nanocolloid was injected peri/intratumorally in 2 depots of 0.1ml per lobe guided by transrectal ultrasound. images were performed at 15 min and 2-4h. delayed planar images were followed by spect-ct (spect: matrix 128x128, 60x25-sec frames, ct: 130 kv, 17 mas, b60s kernel) with 15-min acquisition using a hybrid camera. after correction for attenuation and scatter spect images were fused with ct and analysed using 2d orthogonal reslicing. sn were anatomically identified according to the lymph node groups inside/outside the pelvis and evaluated in relation to laparoscopic extended pelvic lymphadenectomy (epl) which was performed in all patients in combination with laparoscopic gamma probe guided sn dissection. results: mean injected dose was 232 mbq (range 203-275mbq). sn were visualized in 15 patients (94%). in all these patients drainage was bilateral. drainage to the lymphatic groups included in the epl area was seen in all patients and spect-ct enabled anatomical sn localization in all of them. in 6 patients (38%) additional sn, appearing in early images of lymhoscintigraphy, were visualized outside the area of epl (para-aortic, aortic-iliac junction, pre-vesical, inguinal). all sn outside the epl area were found at laparoscopy. sn metastases were found in 4 patients (25%). in two of these patients metastases were found in sn located outside the epl area. conclusion. in addition to the anatomical localization of pelvic sn in prostate cancer, spect-ct may lead to an accurate identification of sn outside the pelvis. the anatomical spect-ct information concerning the location of these sn may subsequently guide its resection using a laparoscopic gamma probe. aim: determine if the size of the metastases in the sentinel node (sn) of patients (p) affected of breast cancer smaller than 3 cm has any relationship with the finding of metastases in other axillary lymph nodes (am1 conclusion: the detection of the sentinel node with the combination of the gamma probe and the blue dye is also possible in t>3cm. in 50% of these patients axillary lymph node dissection can be avoided, and in 25% the sln is the only one affected. therefore we consider that these patients should be included as a general indication in breast cancer sentinel node detection. the usefulness of sentinel lymph node mapping in colon cancer staging: preliminary experience. aim the presence of regional nodal metastatic disease in colon cancer is an important prognostic factor. improving identification of lymph node disease would significantly better select patients who may benefit from adjuvant chemotherapy. our study aimed to determine the usefulness of sentinel lymph node (sln) mapping in detecting regional lymph node metastatic disease in patients with potentially curable colon cancer. materials and methods we prospectively studied 24 patients (18 men, mean age: 68 +/-7) with left colon cancer with no evidence of metastatic disease or lymphnode involvement at abdominal ct. patients underwent surgical resection with standard colectomy confined to the affected segment. 99mtc-nanocoll® (1mci/ml x 4) was injected submucosally at 4 sites around the tumour by colonoscopy 24 hours prior to surgery. lymphoscintigraphy was performed 3 hours after injection to verify radio colloid migration to the sln. slns were harvested ex-vivo from the mesentery of the resected specimen using a gamma probe. all nodes were examined by haematoxylin & eosin (he) staining. in addition sln were multisectioned and examined by immunohistochemical (ihc) staining with cytokeratin. results at least one sln was identified in 96% of patients (23/24), with a mean of 3 sln/patient (range=1-5). the mean number of lymph nodes from the standard lymphadenectomy was 21 (range=14-51). sln examination with he adequately predicted the regional nodal status in 13 of 23 (57%) cases (8 negative and 5 positive). in 6 patients (25% of all patients studied), ihc of sln was the only indicator of metastatic disease. sln failed to predict nodal metastatic disease in 4 patients (false-negative rate 26%). conclusions lymph node mapping using radio colloid is feasible in colon cancer, yielding a high rate of sln identification. although the false-negative rate is high (26%), sln technique improves staging in colon cancer patients, upstaging 25% of patients, who may benefit from adjuvant chemotherapy. follow-up in primary breast cancer after sentinel lymph node biopsy. during the follow-up (fu) period, we analysed the appearance of axillary and/or locoregional metastases in both groups by performing an echography of the axilla twice a year and annually a mammography. we also considered the presence of systemic metastases in both groups. results: in group a, 293 pts (81%) were followed-up for two to four years. one pt (0.3%) experienced axillary metastases after two years from surgery (pt1c, g3, idc with a single negative sln removed); four pts had locoregional recurrences; one pt developed bone metastases and four pts showed systemic involvement (total recurrences: 10 cases). in group b, 52 pts had only one positive sln (44%), two positive sln were found in 37 pts (32%), three positive sln were removed in 16 pts (14%) and more or equal to six sln were carried away in 12 cases (10%). among the 69 pts in this group who had a complete fu (19%), there were two cases of systemic metastases.conclusion: the accuracy of sln method was 100%. the risk of developing axillary metastases in pts with t1 breast cancer seems to be very low in our follow-up. objective: indication of sentinel node biopsy (snb) has not been fully established for patients with dcis. our aim was to relate the conversion rate to invasive carcinoma with sn positivity in high risk dcis, and also to refine the clinical presentation analysis in order to achieve a better patient selection for snb. relation between conversion rate and invasive carcinoma with sn positivity in high risk dcis did not reach statistical significance, thus a subset of selected high risk patients could not be redefined. however , the relevance of snb positivity cannot be overlooked in high risk dcis patients, and more studies are still needed to refine its final indication. radioisotopic identification of sentinel lymph node in early stages of cervical cancer with tc-99m nanocolloid (preliminary results) v. g. moschogiannis; "metaxa 's" cancer hospital, piraeus, greece. the aim of this study is to investigate the feasibility and the utility of the detection of sentinel lymph node in early stages of cervical cancer with radionuclide method. method: 11 women (median age 48,6 years) with cervical carcinoma, stage ia2 (no 1), stage ib1 (no 5), stage ib2 (no 5), underwent sln detection during primary operation. exclution criteria was stage iib or more advanced disease. one day before the surgery, patients were injected intracervical with a total dose of 74 mbq tc-99m nanocolloid, devided in four injections, and one hour after the injection a lymphoscintigraphy was performed. on the day of surgery, 2 ml of patent blue dye was injected in the cervix, at the same sites as the radioactive isotope injections. using a laparoscopic gamma probe and visual detection of blue nodes, the sln were identified and removed for pathological assesment. results: lymphoscintigraphy identified one or more sentinel nodes in 10 out of 11 patients (90,9 %), while blue dye identified sln in 7 pts (63,6 %). the combination of blue dye and radioactive tracer detected lymph nodes in 10 pts (90.9 %). in one woman, where the lymph nodes were not identified with tc-99m nanocolloid, the stage of the disease was ib2. in 4 pts, we had a bilateral visualisation of lymph nodes. the average number of sln per patient was 1,8. metastatic disease to the lymph nodes was found in 2 pts. in total, in 6 pts. the sentinel nodes were located in the distal parametrium, in 1 pt they were located paraaortic and in 3 pts, in the area of the external and internal iliac artery. conclusion: our findings confirm that sentinel lymph node detection with radiocolloid, in combination with blue dye, is feasible and improves detection rate in patients with cervical carcinoma and also allows the identification of lymph nodes in areas that are not frequently sampled. this technique must be evaluated in larger studies, that may lead to better treatment selection of patients with early cervical cancer. the sentinel lymph node (sln) is the first node in a nodal basin that receives the direct lymphatic flow from malignant melanoma (mm). however, in some patients, their lymphoscintigraphic study reveals the presence of lymphatic nodes in the area between the primary mm and the regional basin. these nodes are called "in transit nodes" or "aberrant nodes" and, by definition, they are also slns. aim: to determine the percentage and location of "in transit" slns in our group of mm patients and assess if it is really necessary to harvest them. method: in this study a total of 900 patients were included. the day before surgery a lymphoscintigraphy was performed by injecting 74-111 mbq of 99mtc-nanocolloid in four doses around the primary mm or the biopsy scar. blue dye was injected in the majority of patients a few minutes before surgical procedure. a hand-held gammaprobe was used to better localize the slns. results: lymphoscintigraphy showed "in transit" slns in 80/900 patients (8.8%). during surgical procedure 77 of them were harvested (96.5%). sln identification and excision proved most difficult to achieve in the popliteal and epithroclear regions. metastatic cells deposits were subsequently identified in 13 (16.8%) of these "in transit" slns. conclusions: lymphoscintigraphy has a pivotal role in the identification of "in transit" slns. the incidence of these nodes is relatively low in mm patients. however, these slns present metastatic deposits in a significant percentage of cases and it warrants a surgical search for them. role of spect-ct in sentinel node identification and intraoperative lymphatic mapping. first results of a pilot study in patients with breast cancer in thailand. c. chotipanich, y. kongdan, k. sumboonnanonda, r. suvikapakornkul, p. lertsithichai, k. cheuamsamakkee, s. promma, k. poonak, p. chouplywech, c. sritara; ramathibodi hospital,faculty of medicine, mahidol university, bangkok, thailand. purpose: to retrospectively evaluate the clinical usefulness of the role of spec-ct in sentinel lymph node identification in patients with breast cancer which has not yet been established in thailand. material and methods: a retrospective study of 20 women ranging from in the age of 29 to 80 years(median age 51 year) who underwent spect-ct lymphoscintigraphy from january 2006 to december 2006 was analyzed. all of the patients underwent lymphoscintigraphy with subareolar injection of tc-99m dextran with planar and spect-ct fusion imaging. planar and spect-ct fusion images were assessed separated by a nuclear medicine physician. sentinel lymph node biopsy guided by intraoperative injection of vital dye (blue patent) and hand held gamma probe was performed. results: the sentinel node was detected using two methods in all cases (100%) and positively metastatic in 93.75%. there were concordance between lymphoscintigraphy findings and blue dye in 95%. of the total 46 lymph nodes, planar imaging detected 31 nodes (67%), while spect-ct fusion detected 43 nodes (93%). spect-ct fusion detected 15 nodes, which were missed by planar imaging (7 were obscured by the scattered radiation from the injection site and 8 were misinterpreted as a single node on planar). one of the 20 patients (5%) had a non-nodal false positive on planar imaging, when further assessed in spect-ct data. in additional, spect-ct fusion imaging gave information on localization of sentinel lymph nodes (14 at level i, 1 at level ii, 2 at level iii, 3 more than one level), which could not be evaluated by planar imaging. conclusion: it can be concluded that spect-ct fusion is more feasible and useful for identification of sentinel lymph nodes in breast cancer and provides information on the anatomical localization. background: it is considered that previous excisional biopsy might affect the performance of the sentinel node localization in breast cancer, and it is the aim of this study to present our experience in the therapeutic approach of the sln biopsy in patients with previous excisional biopsy because of non-palpable breast cancer. methods: retrospective study of 482 cases of breast cancer in the period 2001-2006 divided in group a (110 patients) with prior diagnostic excisional biopsy and group b (373 patients) with non-previous surgery. lymphoscintigraphy was performed after peritumoral injection of 99mtc-colloidal rhenium sulphide (nanocis); the sentinel node was located with a gamma ray detection probe (europrobe) and periareolar isosulfan blue dye (lymphazurin). axillary lymph node dissection (lnd) was completed only when the sln was positive for metastasis or not located. results: table 1 . sentinel lymph node detection rates in previous excisional biopsy. number positive lympho-positive of patients scintigraphy gamma probe/blue dye a (previous 110 92 (84%) 105 (95%) excisional biopsy) in 5 cases the sln was not detected and axillary lymph node dissection was performed (2 positive and 3 negative for metastasis). because non-palpable lessions are smaller (most of them are microcalcifications) the rate of metastasis in the sln is clearly smaller than in the conventional group of palpable breast cancer. conclusion: lymphatic mapping and the combination of the gamma probe with the blue dye in the detection of the sentinel node is also feasible in patients with previous excisional biopsy. aim our work was aimed to a retrospective evaluation of our series of sentinel lymph node scintigraphy in order to evaluate the relationships between breast tumour dimensions and frequency of positive results. patients and methods in the last 7 years 310 patients, in tnm stage 1 or 2, all females, underwent sentinel lymph node scintigraphy for a breast cancer. the test was performed according to usual procedures (subcutaneous injection of 10 mbq of 99mtc-nanocolloid followed by repeated breast scans until the first lymph node was scintigraphically evident allowing the record of its position with a marker on the skin. at surgery, (a quadrantectomy was usually performed), the sentinel lymph node was histologically extemporaneously examined in order to detect the possible tumoral involvement. according to tnm system the patients were grouped as t1a (13 cases), t1b (64 cases), t1c (164 cases) and t2 (69) cases. due to the small number of subjects in class t1a in our study these patients were grouped together with t1b patients. statistical analysis of the differences of the positive case frequency between the groups was performed by chi square test. as expected, bigger tumour dimensions were associated with higher frequencies of positive cases. in fact, the frequency of positive extemporaneous studies resulted of 3 cases in the t1a-t1b group (3/77 = 0.039); of 29 cases in the t1c group (29/164 = 0.176) and of 17 cases in the t2 group (17/69 = 0.246). the frequency differences between group (t1a+t1b) and group t1c (p<0.006) and between group (t1a+ t1b) and group t2 (p<0.001) resulted highly statistically significant. the frequency difference between group t1c and t2 group did not reach statistical significance (p<0. 3, ns) . conclusions the relationships between breast cancer dimensions and lymph node metastatic involvement are well known, thus our data could not appear to offer a new and original contribution to address this issue. however, our study discloses some additional quantitative insights in order to evaluate the specific phenomenon of sentinel lymph node metastatic involvement and can, consequently, be of interest in breast cancer care. larger series of patents (the work is in progress) will allow us to study the frequency of positive sentinel lymph node scintigraphy according also with the different histotypes of breast cancer. sentinel lymph node scintigraphy (snc) in the preand perioperative diagnosis of breast cancer e. schmidt, z. szabo, g. szalai, e. kalman, g. tizedes, g. pavlovics, k. zambo; university of pecs, pecs, hungary. the importance of snc in the perioperative diagnosis of breast cancer is well-known. using the method with further completitions, results useful additional informations. the aim of our study was to establish, how these informations influence the treatment and management of the patients. patients and methodes: 100 women were observed whose breast cancer was proved by fine needle biopsy (fnb). snc was performed a day before the planned operation. the radiopharmaceutical (80 mbq 99mtc-senti-scint) was injected peritumoral, in 4-8 portions, using us guide. anterior and lateral planar scans were performed 1 and 3 hours after the injections from the chest and axilla. the projections of the sn were marked on the skin. with help of this markers us guided fnb and cytology of sn was performed in 71 cases. the operation was carried out the next day with removing of sn and low axillary blockdissection, or -in cases of metastatic laesions -total axillary blockdissection. in both group, dynamic lymphoscintigraphic images were recorded for 30 minutes immediately after the injection. then, static images were taken until the sln was visualised. two-four hours after the radiopharmaceutical injection, patients were taken to the operating room. before the incision, blue dye solution was injected peritumorally to all cases. aided by blue dye and gamma probe, sln detection was carried out during the operation. then, histopathological confirmation was performed. results: there was not a significant statistical differance between group i and group ii in terms of patients characteristics. in group i, identification rate of sln was 100% (17/17) in both lymphoscintigraphy and intraoperative gamma probe application. in 15/17 cases of this group, only one sln was observed in the axillary region; however, in 2/17 patients, slns were found in both axillary and internal mammary regions. there was a positive correlation among lymphoscintigraphy, intraoperative gamma probe application, blue dye and histopathological examination in 100% of this group. in group ii, detection rate of sln was 68.75% (11/16) in lymphoscintigraphy; however, this rate was 81.25% (13/16) in the intraoperative gamma probe application. all slns, which were detected with nuclear medicine techniques, were in the axillary region in this group. there was a positive correlation among lymphoscintigraphy, intraoperative gamma probe application, blue dye and histopathological assesment in 68.75% of group ii patients. however, this rate increased to 81.25% when the results of lymphoscintigraphy were excluded. conclusion: tc-99m hig, which appears to be more effective and successful than tc-99m nanocolloid, may be a preferable agent on sln identification in both lymphoscintigraphy and intraoperative gamma probe application in patients with early-stage breast cancer. usefulness of lymphoscintigraphic imaging prior to surgical detection of sln in breast cancer aim: the sentinel lymph node (sln) radioisotopic detection is a well established method in the surgical management of invasive breast cancer. however the interest of lymphoscintigraphy (ls) before surgery remains questionable. methods: in a prospective study including 51 patients with breast cancer, 74 mbq of radiocolloid (nanocoll* health amersham) were subcutaneously injected in the peri-areolar breast bearing a less than 2 cm tumor 1 day before surgery. all patients had a planar anterior ls with a large field of view camera (helix elscint general electric*) of the thorax, axillary and basicervical region. the body contour was imaged with a transmission view of a 57co planar source in the back of the patient. women were operated by 4 validated surgeons and divided into 2 groups: in group i (n=30) the more radioactive node was marked on the skin and the ls and report were known by the surgeon; in group ii (n=21), no marker was drawn and the surgeon does not know ls results. intraoperative identification of the sns was based both on blue dye mapping and probe detection (gammed iib eurorad system) scar length, surgical duration time and number of removed sln were compared within both groups using mann-whitney test. results: ls showed axillary sln in 90%, mammary internal sln in 9.8% and supra clavicular sln in 2%. the median scar length was not significantly different in both groups (p = 0.63): 37.5 mm [30] [31] [32] [33] [34] [35] [36] [37] [38] [39] [40] in group i and 37.5 mm [35] [36] [37] [38] [39] [40] in group ii. the median duration time for surgery was not significantly different (p = 0.15) in group i (15mn [11] [12] [13] [14] [15] [16] [17] [18] [19] [20] ) and in group ii (9 mn [8] [9] [10] [11] [12] [13] [14] [15] ). the number of removed sln was not significantly different (p = 0.22) in both groups (group i: 3 [1] [2] [3] , group ii: 2 [2] [3] objectives -to calculate the rate of detection of the sn in patients with bc subjected to n-c. -to establish the predictive value of the sn with respect to the axillary state. material and methods. we studied 43 patients with locally advanced bc subjected to n-c; age 27 -74 years (average 50 years). the initial size oscillated between 3 -9 cm (average 4' 9) , showing good answer 44' 1%, partial 41' 9% and bad 14%. they were administered between 37-111 mbq of 99mtc-nanocoloides in peritumoral intraparenchymatous location (18) or combined (intradermal and intraparenchymatous) (12). in nonpalpable cases the injection was guided by ultrasound or stereotaxy (13 cases). static images were taken between 30 minutes and 18 hours postinjection, being made external cutaneous mark of the sn. the sn was extirpated separately, being followed by a complete axillary ganglionary dissection. the histological study of the sn included staining with haematoxylin-eosin and inmunohistochemical in negative cases. results in the linfoscintigraphy at least one sn was visualized in 39 out of 43 patients (90' 7%), with drainage to internal mammary in 5 cases (11' 6%). the rate of intraoperating detection was 90'7% (39/43). two visible cases could not be localized in the operating room and 2 nonvisible cases could be extirpated. 3 out of 4 cases (75%) not located had axillary ganglionary affectation. the histological study of the sn with haematosylin-eosin was negative in 30 out of 39 cases (76' 9%) showing tumoral invasion of the rest of the chain in a single case (rate fn 2' 5%). 3 out of the 30 negative cases were positive with inmunohistochemical (10%), being in the three cases the only positive node. this was the only positive case in 7 (63' 6%), of the 11 cases with affectation of the gc. without axillary affectation a sensitivity for ganglionary affectation of 92' 3% with a npv of 96' 3% was obtained. conclusions. the technique of the sn is feasible in bc subjected to n-c with a rate of detection above 90%. the failure in the location of the sn seems to indicate bad prognosis due to the high incidence of ganglionary affectation. a negative gc or with micrometástasis can avoid the complete axillary node dissection due to the high npv for the rest of the chain. phytate lymphoscintigraphy (spect) and ct from december of 2006 to march of 2007. lymphoscintigraphy was performed 6 hours after subcutaneous injection under the nipple of tc-99m phytate using a gamma camera (symbia; siemens, forchheim, germany, and hoffman estates, ill.). contrast-enhanced ct was performed using acuillion 64 (toshiba medical systems, tokyo, japan). image fusion between spect data and ct volume data was performed using fusion soft (fused vision 3d) on siemens e.soft workstation. twenty-six patients were divided into 3 groups. the first group patients (8 patients) were examined without markers. the second group patients(14 patients) were examined by spect and ct with markers on the upper and lower ends of sternum ( 2 markers). the third group patients (4 patients) were examined with markers on the upper and lower ends of sternum and outside of the nipple of opposote side (3 markers) . a small vessel containing tc-99m was used as marker for spect and that containing beads of 2mm-diameter for ct. results: in the first group patients examined without markers, preparation of the fusion images of spect and 3d-ct were difficult. in the second group patients examined with 2 markers (the upper and lower ends of sternum), preparation of the fusion images were sometime difficult. in the third group patients examined with 3 markers (the upper and lower ends of sternum and outside the nipple of opposote side), the fusion images were easily prepared and the anatomical identification of sentinel lymph node of breast carcinoma could be easily performed. conclusion: the fusion images of spect and 3d-ct were easily prepared by placing markers at the upper lower ends of sternum and outside the nipple of opposote side. as a result, anatomical location of sentinel lymph nodes of breast carcinoma could be easily identified. resection of non-palpable breast lesions without needle-guide needs an intraoperative pathological examination to confirm lesion inclusion and healthy margins. in those hospitals without an intraoperative pathological resource, a second surgery may be needed. roll technique to guide surgeon is more extensive. the use of tracer inside the tumour allows the lesion resection with free margins and decreases the number of second procedures. moreover, an intraoperative image can be acquire intraoperatively with a portable gammacamera, which can predict if margins are involved. aim: to value the usefulness of an intraoperative gammacamera to assess non-palpable breast lesions resection. material and methods: patients: 42 women with non-palpable breast lesions were included, mean age 59 ± 7.8 years. injection: the day previous to surgery, an intratumoural injection of 99mtc-nanocolloid was performed guided by ultrasonography. lymphoscintigraphy: it was performed to know the lymphatic drainage and spread of radiotracer in the breast. surgery: the lesion was removed guided by a gamma-probe. an image of the surgical piece was acquired by the intraoperative gammacamera (sentinella s102, gem imaging, valencia, spain) and a second image was performed using a technetium pointer to draw the outline. an image over surgical bed was done to confirm the absence of activity after resection. ap: lesion inclusion and healthy margins were evaluated intraoperatively. results: all lesions were removed. centred lesion was found by portable gammacamera in 23/42, out of place in 15/42 and in contact in 4 cases. a pathological exam detected free margins in 15/23 with centred lesion (65%), affected margins in 10 of 19 with lesion not centred. that means a concordance of 60% (25/42). conclusion: bearing in mind these issues, the use of an intraoperative gammacamera can avoid an extra surgery in those centres without pathological exam during sugery, without delay in the surgical act. some aspects can raise the rate of concordance: to increase the number of projections or to improve the way of injection. objectives: the purpose of this study is to evaluate the efficacy of sln biopsy using imaging and gamma probe in oral cancers. material and methods: 26 patients (mean age = 54.5 yrs) with operable oral cancers with clinically negative lymph adenopathy were studied. standard neck dissection was performed in all. scintigraphy was performed a day before surgery by injecting tc-99m labeled nannocolloid submucosally in the peri-tumoral area. first lymph node to appear on the scan was labeled sentinel lymph node and marked on the skin. this hot node was explored intraoperatively using gamma probe followed by block neck dissection. results: the sentinel lymph node (sometimes associated with additional nodes) was identified in 23 patients (88.4% success rate). in 3 patient (11%) sln was not visualized on the scan (failed study). the gamma probe guided localization was successful in 17 while in 6 cases it failed. in 14 out of 17 (82%) cases sentinel lymph node stood in agreement with the result of histopathology of remaining lymph nodes (11 benign and 3 malignant). the remaining 3 lymph nodes, however, showed a discordance with the final histopathological result. sln was negative in all 3 cases with disease spread to other nodes (? skip lesion / varied drainage patterns). conclusions: early results of lymphoscintigraphy with gamma probe guided sln biopsy have been encouraging; however, a variable lymphatic drainage pattern may result in skip metastasis. therefore, we recommend that every hot lymph node should be biopsied to minimize the possibility of this discordance. further, studies should be undertaken to establish the operator learning curve in this technique. introduction: sentinel node biopsy quickly became standard of care in breast cancer, before consensus on the technique was reached and without randomised studies having shown a similar or decreased axillary recurrence rate. a review of twenty-six learningphase studies on sentinel node biopsy followed by routine axillary node dissection demonstrated a median false-negative rate of 7% (range of 0-40%), which is more than the 5% that is generally considered acceptable.1 axillary clearance is no longer done in patients with a tumour-free sentinel node. long-term follow-up results of such patients have now been published and these prompted this literature review to determine the axillary recurrence rate of the sentinel node procedure in breast cancer patients. methods: we searched the current literature for studies concerning patients with breast cancer, a clinically node-negative axilla, no subsequent axillary node dissection in case of a sentinel lymph node without disease, and a median follow up duration of at least three years. the axillary recurrence rate was calculated in the patients with a tumour-negative sentinel node biopsy. results: fourteen studies were published between 2004 and 2006 describing a total 3802 patients with a median follow-up time of 47 months. all papers describe the injection of a radiopharmaceutical and the use of lymphoscintigraphy. 99mtc-nanocolloid was the most common radiopharmaceutical, used in nine studies. ten investigators additionally injected blue dye intraoperatively and all surgeons used a gamma ray detection probe. twenty-four of the sentinel node-negative patients recurred in their axilla with a median time to recurrence of 19 months (range of 4-63 months). the median recurrence rate was 0.3% and calculated when corrected and weighed for the number of patients per study. conclusion. the sentinel node procedure was introduced to limit morbidity without exceeding the 1-2.3% axillary recurrence rate seen in the past after routine axillary clearance. it is gratifying that this review of studies with a long-term follow-up finds the recurrence rate in sentinel node-negative patients well within the desired range. (82%); mean age 53y (23-69y). lymphoscintigrapy was performed 2h post peritumoral radiocolloid injection. a subdermal reinjected dosis was performed in cases of no lymphoscintigraphy sentinel node detection post peritumoral injection. a handled gammaprobe was used to radioguide sentinel node surgery. axillary lymph node dissection (alnd) was performed on 186p (14%), (22p from group a and 164p from group b). the following parameters were analysed in both groups: sentinel node lymphoscintigraphy detection rate (snld) and the subdermal reinjection requierements (sr), sentinel node surgical detection rate (snsd), number of sentinel node metastases as well as the presence of metastases in other axillary lymph nodes. in the non sentinel node surgical detection group the rate of positive nodes was also analysed. results: data of pelvic sln scintigraphy helped to determine the direction of lymph outflow from tumor-affected testis or the stump of spermatic cord and prostate to sentinel lymph nodes by normal or changed lymph collectors. thus, sln scintigraphy led to exact determination of local lymph node dissection or delineation of fields' size and configuration for local radiation therapy. conclusions: finding of the lymph outflow routs with 99 mtc-colloid increases the validity of early lymphatic cancer spread detection, including or excluding cases of lymph nodes enlargement. determination of the lymph outflow routs gave an opportunity to configure the radiation fields within sites of 99 mtc-colloid accumulation. the aim of this study was preoperative scintigraphic imaging and subsequent intraoperative detection with small hand-held gamma probe and blue dye in some malignant tumours to identify the sentinel node (sln) of breast cancer group i and colorectal cancer group ii. method: group i -102 female with histologically proven breast cancer in early stage t1-t2 by palpable and non-palpable lesions. scans were performed in anterior, oblique and lateral view 2-3 hours after administration of 99mtc-colloid / 60 mbq in total volume 0.8 ml / peritumourally. by patients with non-palpable lesions (56 patients) injections were under sono-graphic guidance. the site of sentinel nodes was marked on the skin. the same method was used for 42 patients with colorectal cancer group ii, with more scans and without skin markers. results: group i -sentinel node was found in 91 /102 patients except nodes in the internal mammary chain and nodes located very close to tumour. the sensitivity in this group was 89%. all nodes were examined routinely and by immunohistochemical staining. histologically 25/91 sentinel nodes were positive (micrometastases in eleven). group ii involved 42 patients with colorectal cancer. lymph-nodes were found in 36 /42 cases. the sensitivity of the method in this group of patients was 86%. according to pathologist 14/36 had tumour positive lymph-node. the method of detection of the sentinel node in total mesorectal excision is not therapeutic but diagnostic method, and it has quite a high level of sensitivity. conclusion: this study has demonstrated feasibility of the proposed procedure. sentinel node biopsy requires a multidisciplinary approach (surgery, pathology and nuclear medicine) for reliable results. the association of blue dye (in breast cancer only) and intra-operative gamma probe has made the procedure more effective, less time-consuming and less invasive. lymphoscintigraphy and radioguided surgery can be very useful as a prognostic sign, whether it detects sentinel lymph-node (some with micrometastases that would otherwise be missed). this method is easy and safe. the histological examination of sln improves staging of the disease and can help in planning of the follow up treatment. initial experience of preoperative lymphocintigraphy and sentinel lymph node biopsy in thyroid cancer patient. c. chotipanich, y. kongdan, k. cheuamsamakee, s. amnuaywattakorn, c. sritara; ramathibodi hospital,faculty of medicine, mahidol university, bangkok, thailand. purpose: to evaluate the clinical usefulness of the lymphoscintigraphy and of hand held gamma probe procedure for slnb in well differentiated thyroid cancer which have not yet been established in thailand. material and methods: three female patients with thyroid nodule highly suspected for thyroid carcinoma by fine needle aspiration cytology ranges from the age of 23 to 41 years underwent preoperative lymphoscintigraphy. all of the patients underwent lymphoscintigraphy with intratumoral injection of tc-99m dextran 0.3 mci under ultrasonography guidance. sentinel lymph nodes were identified using gamma probe. results: three patients had papillary carcinoma.the sentinel lymph node was detected in all cases (100%). one patient showed a lymph node metastasis in the sentinel lymph node in the jugular compartment. there were no intra or operative complications. conclusion: this is the first report of slnd in thyroid carcinoma in thailand. our preliminary findings indicate that the identification of sentinel lymph nodes in thyroid cancer is a practical and safe method. in order to improve this technique as a standard procedure for staging of thyroid cancer further studies with a larger number of patients in thailand have to be done. key words: sentinel lymph node, thyroid cancer, lymphoscintigraphy radioisotopic identification of sentinel lymph node in early stages of cervical cancer with tc-99m nanocolloid (preliminary results) e. trivizaki 1 , v. moschogiannis 1 , s. saranti 1 , l. iordanidou 1 , p. zarganis 2 , k. rethimniotakis 1 , a. georgakopoulos 1 , p. koutsiouba 1 ; 1 department of nuclear medicine, "metaxa' s" cancer hospital, piraeus, greece, 2 department of gynecology, "metaxa' s" cancer hospital, piraeus, greece, piraeus, greece. the aim of this study is to investigate the feasibility and the utility of the detection of sentinel lymph node in early stages of cervical cancer with radionuclide method. method: 11 women (median age 48,6 years) with cervical carcinoma, stage ia2 (no 1), stage ib1 (no 5), stage ib2 (no 5), underwent sln detection during primary operation. exclution criteria was stage iib or more advanced disease. one day before the surgery, patients were injected intracervical with a total dose of 74 mbq tc-99m nanocolloid, devided in four injections, and one hour after the injection a lymphoscintigraphy was performed. on the day of surgery, 2 ml of patent blue dye was injected in the cervix, at the same sites as the radioactive isotope injections. using a laparoscopic gamma probe and visual detection of blue nodes, the sln were identified and removed for pathological assesment. results: lymphoscintigraphy identified one or more sentinel nodes in 10 out of 11 patients (90,9 %), while blue dye identified sln in 7 pts (63,6 %). the combination of blue dye and radioactive tracer detected lymph nodes in 10 pts (90.9 %). in one woman, where the lymph nodes were not identified with tc-99m nanocolloid, the stage of the disease was ib2. in 4 pts, we had a bilateral visualisation of lymph nodes. the average number of sln per patient was 1,8. metastatic disease to the lymph nodes was found in 2 pts. in total, in 6 pts. the sentinel nodes were located in the distal parametrium, in 1 pt they were located paraaortic and in 3 pts, in the area of the external and internal iliac artery. conclusion: our findings confirm that sentinel lymph node detection with radiocolloid, in combination with blue dye, is feasible and improves detection rate in patients with cervical carcinoma and also allows the identification of lymph nodes in areas that are not frequently sampled. this technique must be evaluated in larger studies, that may lead to better treatment selection of patients with early cervical cancer. radionuclide study of sentinal lymph nodes in breast cancer patients n. voit; institute of oncology of amsu, kyiv, ukraine. background. dissemination of breast cancer (bc) to lymph nodes plays is essential not only for survival but also for choice of tactic of the treatment. in accordance with a concept of sentinel lymph nodes (sln) a study of them is aimed to the identification of first draining nodes respectively to nodes of primary tumor. specific feature of sln is enlargement of first lymph node and visualization of afferent lymph vessel from tumor to it. aim was to study status of sentinel lymph nodes during their intraoperation detection using manual gamma europrobe. materials and methods. 20 bc patients were examined using lymphscintigraphy in combination with intraoperation detection of sln. a technique was performed using 99mtc-nanocole infused peritumoraly and intracutaneously (10 mbk/kg body weight) and 0.2-0.3 ml of water. next step of study was performed using ofect "e cam" (siemens). early (20 min) and late (2 h after administration of rpp) images were obtained. a day after intraoperation detection of sln was performed by manual gamma-probe. results. in accordance with the obtained data it was revealed that in 17 of 20 patients lymph nodes of axillar pool on side of the lesion were visualized. in 2 patients lymph nodes on contralateral side were detected. in 14 patients with visualized lymph nodes histological examination revealed sln. in 11 patients they appeared to be affected by metastases, in the remains -no malignancies. conclusion. examination of sln using manual gamma-probe can be used for estimation of pathways of metastatic spread and rate of malignant injury of lymph nodes in bc patients. using of lymphoscintigraphy in combination with gamma-detection and following biopsy of sln is a perspective direction in the development of organ-saving surgical interventions in breast cancer. aim of study: while investigating different kinds of tumours, the conception of sentinel node has been used in our hospital for many years. in our work we are trying to find out the usage of mapping of lymph node and its biopsy on those patients who suffer with carcinoma of colorectum. method: we examined a group of patients with carcinoma of colorectum. with the help of applied colloid 99mtc and patent blau we performed lymphatic mapping in a submucosly or subserosly circulatory way around tumor. the searched nodes were presrved and marked. marked nodes were later investigated in a histological and imunohistological way. conclusion: we are persuaded that in the foreseeable future with this method we will be able to specify staging and decide on an operation and actinotherapy extent, wich should be proved by an ongoing study with oncological and oncosurgical departments cooperation. in the future we can also see lymphatic mapping utilization on laparoscopic operationsin oncosurgery of colon and rectum. lymphatic mapping also brings a possibility to detect aberant lymph vessel and lymph nodes in tumour surroundings. aim: multi-drug resistance (mdr) is a major challenge in treatment of multiple myeloma (mm). 99mtc-mibi is washed out from malignant cells in the presence of p-glycoprotein (pgp) mdr1. this phenomenon results in non-visualization of the lesions and low sensitivity of whole body scan (wbs) in detection of active mm. the objective of the present study was to assess the value of sestamibi wbs in prediction of response to treatment and mdr. materials and methods: thirty four patients with mm (25 male, 9 female, 54.12±11.46 years) entered the study. thirteen patients had no previous history of treatment and 21 had history of previous chemoradiotherapy. the diagnosis and staging of the disease were based upon the standard criteria. for each patient routine laboratory tests, pgp measurement and wbs with 99mtc-mibi were performed in the beginning of the study and the response to treatment was assessed during one year follow up. the baseline wbs was considered positive for detection of active lesion when at least one area of non-physiologic increased activity was noted while the result of wbs was positive for mdr when the patient had active disease but no abnormal activity was seen. the value of the baseline pgp tests and wbs for prediction of patient's outcome and response to therapy were assessed. results: the sensitivity, specificity, positive predictive value, negative predictive value and accuracy of wbs for determining the active disease were 61.5%, 75%, 88.9%, 37.5% and 64.7%, respectively. in cases who were in active state, these values for diagnosis of mdr with wbs were 38.9%, 62.5%, 70%, 31.2% and 46.1%, respectively. also the above values for detection of mdr with pgp were 50%, 50%, 69.2%, 30.8% and 50%, respectively. the percentage of patients who were resistant to multiple course treatment during one-year follow up was 68.8% in cases with active disease and positive baseline wbs (11/16) and 70% in those with active disease and negative baseline wbs (7/10), with no statistical difference. conclusion: neither the baseline scan nor pgp findings are of great value in detection of mdr. furthermore, no difference was noted between the sensitivity of baseline wbs for detection of active lesion in the group of the patients who showed drug resistance later in the course of treatment and in the group with complete response to therapy. so, the low sensitivity of wbs for detection of active mm lesions is not definitely related to drug resistance. purpose: the aim of this study was to evaluate 99mtc-dtpa-deoxyglucose (99mtc-dtpa-dg) for the assessment of chemotherapy effect and biodistrbution in breastbearing nude mice. mehtods: each animal was xenografted subcutaneously in the right fore-leg with 1×107 cells per 0.2ml of the mcf-7 breast carcinoma cell line. on day 9 postinoculation, mammary tumor-bearing mice (18-23g, n=5 per each group) were administration a single i. v. injection of taxol (1.3mg/kg) and doxorubicin (0.6mg/kg) in group 1, taxol (2.6mg/kg) and doxorubicin (1.2mg/kg) in group 2 respectively. mammary tumor-bearing mice were treated with cisplatin (0.6mg/kg) in group 3 and cisplatin (1.2mg/kg) in group 4. 0.1ml of saline was injected intravenously in control group. on day 0, 3, 7, 14, 21, 28 post-therapy, tumor-bearing mice were imaged with 99mtc-dtpa-dg (0.1mci/mice, i.v. ) at 0.5-2 hours after administration. the radio of tumors to non-tumors (t/nt) was counted by roi technology. tumor volume and inhibition rate of each group were calculated. radioactivity in each sample tissue was calculated as the percentage of the injected dose per gram of tissue wet weight (%id/g). results: scintigraphy in tumor animal models demonstrated that tumor tissue could be clearly visualized with 99mtc-dtpa-dg. there was significance difference in the t/nt among group 1, group 2 and control group (f=10.18, p=0.001) on day 14 post-therapy. there was significance difference in tumor volume between group 4 and control group (p<0.01) on day 14, 21, 28 post-therapy. biodistrbution of 99mtc-dtpa-dg demonstrated tumor uptake was observed, at the same time less brain and heart uptake was observed. conclusions: 99mtc-dtpa-dg could assess the chemotherapeutic tumor response. the technique developed allows for mechanism-specific targeted assessment of cell nuclei activity using 99mtc-dtpa-dg. aim neuroendocrine gastroenteropancreatic tumors (negep) are relatively rare tumors arising from neuroendocrine cells. they are characterized by slow growth and by specific symptoms and syndromes. the location (foregut, midgut or hindgut) of the primary tumor affects the functionality, the clinical course, and the treatment of the disease. for inoperable, well-differentiated tumors, biotherapy with somatostain analogs (sa) or interferon alfa represents the treatment of choice with two purposes: to control symptoms and tumor proliferation. somatostatin receptor scintigraphy (octreoscan -o) has been proven to play an important role to plane the clinical management of patients (pts) with negep. aim of this work was to compare accuracy of o alone or in association with ct and chromogranin a (cga) serum level and to evaluate impact on quality of life of sa treatment. material and methods: we submitted 11 pts with primary negep tumors originated from foregut in 6/11 ( 36% stomach, 18% pancreas), from midgut in 4/11 ( 27% ileum, 9% coecum) and from hindgut in 1/11 ( 9% rectum) to o, ct and serum cga levels assessment. then, six of them received long acting sa treatment for a mean of 17 months and performance status was assessed by ecog criteria before and after therapy. 5/6 pts submitted to sa, followed by ct and serum cga, repeated o after at least 1 year. all pts were intravenously injected with 185 mbq of 111in-pentetreotide. 4, 24 and 48 hours whole body and abdomen o spect scan were obtained. results o diagnosed primary tumors or metastatic lesion in 7 and was truly negative in 3 pts. both the results were in agreement with ct and cga. o resulted false negative in 1 pts when compared with ct and cga serum levels. similarly ct and cga were, in two other pts, false positive and false negative, respectively. pts treated with sa, especially whose with no metastases, showed performance status improvement, except one, who suspended biotherapy after 1 month, because of side effects. its worth of note that in pts who after biotherapy had normal o and ct scan, also cga lowered within normal limits. conclusions in our limited series we showed a significant improvement of accuracy to detect negep by combining o, ct and serum cga and their association allows to select people to administrate somatostatin analogs, able to improve quality of life through a control of symptoms and tumor growth stabilization. aim: the aim of this study was to compare the efficacy of low dose tc-99m methoxyisobutylisonitrile (mibi) administration to high dose tc-99m mibi administration on intraoperative localization of parathyroid adenomas with gamma probe in patients with primary hyperparathyroidism (phpt). material and methods: twenty-seven patients with phpt were included in this study. these patients were divided into 2 groups. group i consisted of 13 cases ( 11 women, 2 men; mean age: 60.31 ± 16.17 years) to whom 37 mbq of tc-99m mibi was injected intravenously in the operating room 10 minutes before the start of the surgery. group ii was composed of 14 patients ( 9 women, 5 men; mean age: 58.79 ± 13.88 years) to whom 555 mbq of tc-99m mibi was administered 2 hours before the operation.the minimally invasive parathyroidectomy was performed in all cases. intraoperative localization of the pathological gland was carried out by the use of gamma probe in all subjects. surgical resection of the parathyroid adenomas was carried out. then, the excised tissues were evaluated histopathologically. parathyroid hormone (pth) level was registrated prior to and after the surgery in all cases. results: significant statistical difference was not found between group i and group ii in terms of patients characteristics. the parathyroid adenomas were identified (total 27 parathyroid adenomas) and excised in all group i (100%) and group ii (100%) patients. when the results of gamma probe application to the results of histopathological examination were compared, a positive correlation was found between them. in group i, the mean preoperative level of pth was 362 ± 74 pg/ml (reference range:12-72 pg/ml); however, the mean value of pth after the operation was 66 ± 35 pg/ml. in group ii, these values were 216 ± 26 pg/ml, 32 ± 9 pg/ml, respectively. the mean operation time was 71 ± 19 minutes in group i and 66 ± 18 minutes in group ii. there was not a statistical difference in the operation time between two groups. conclusion: low dose tc-99m mibi application may be prefered in the intraoperative identification of parathyroid adenomas with gamma probe in patients with phpt since this procedure appears to be as effective as high dose tc-99m mibi application. moreover, unlike high dose administration, low dose tc-99m mibi application does not require a long waiting period after the radiopharmaceutical injection and in this method the radiation exposure of the patient and operation team is much lower. aim: the aim of this study was to compare the effectiveness of low dose to high dose tc-99m methoxyisobutylisonitrile (mibi) applications on intraoperative identification of parathyroid glands in chronic renal failure patients with secondary hyperparathyroidism. material and methods: nineteen patients with secondary hyperparathyroidism were included in the study. patients were divided into two groups. group i included 9 patients ( 7men, 2 women; mean age: 25.11 ± 5.22 years) to whom 37 mbq of tc-99m mibi was injected intravenously in the operating room 10 minutes before the surgery. group ii consisted of 10 patients ( 6 men, 4 women; mean age: 37.44 ± 4.19 years) to whom 555 mbq of tc-99m mibi was administered intravenously 2 hours before the operation. aided by gamma probe, parathyroid gland localization was carried out during the operation in both group i and ii. all patients underwent surgical resection of the parathyroid glands which were then evaluated histopathologically. parathyroid hormone (pth) level was registrated prior to and after the parathyroidectomy in all subjects. results: regarding the patients characteristics, significant statistical difference was not observed between group i and group ii. the hyperplastic parathyroid glands were identified and excised (total 74 parathyroid glands) in all group i (100%) and group ii (100%) patients. when the results of gamma probe application to the results of histopathological examination were compared, it was observed that they were correlated. in group i, the mean preoperative level of pth was 629 ± 209 pg/ml (reference range:12-72 pg/ml); however, the mean value of pth after the operation was 32 ± 10 pg/ml. in group ii these values were 835 ± 359 pg/ml, 37 ± 14 pg/ml, respectively. the mean operation time was 166 ± 29 minutes in group i and 186 ± 57 minutes in group ii. a statistical difference was not found between two groups in the operation time. conclusion: the low dose tc-99m mibi application may be prefered in the intraoperative identification of parathyroid glands with gamma probe in patients with secondary hyperparathyroidism because it appears to be as effective as high dose tc-99m mibi application. additionally, in contrast to high dose, low dose tc-99m mibi application does not require a long waiting period after the radiopharmaceutical injection and with this method radiation exposure of the patient and operation team is much lower. radioguided sentinel node biopsy after breast surgery p. santoro 1 , c. mazzone 1 , g. d'eredità 2 , f. lauriero 1 , a. niccoli asabella 1 , g. rubini 1 ; 1 nuclear medicine, bari, italy, 2 general surgery, bari, italy. aim. previous breast surgery is often considered a controindication for subsequent lymphoscintigraphy and radioguided sentinel node biopsy (rsnb) because of surgery deep lymphatic drainage changes. this study wants to measure rsnb feasibility and accuracy after breast nodulectomy. patients and methods. between march 2005 and february 2007, 10 women, who were previously submitted to breast nodulectomy were enrolled. in all these women sentinel node wasn't dissected because of false negative extemporary histopathological examination on breast surgery piece. all women were submitted to lymphoscintigraphy on the day before surgery with subdermic tracer injection. nanocoll was injected in four points around scar in pts undergone higher-external quadrantectomy. in pts undergone a different quadrantectomy tracer was injected in 2 points around scar + in 2 points in higherexternal quadrant or in retroareolar site only. on the day after lymphoscintigraphy lymph node identified as sentinel lymph node (slns) was dissected during surgery. the radioactivity of lymph node was detected in vivo and ex vivo by intraoperative of gamma-probe (scintiprobe mr-100 pol. hi tech.). all lymph nodes were examined histopathologically with hematoxilin and eosin staining. lymph nodes metastasisnegative were immunostained with anticytokeratin antibodies. results. in 9 women, preoperative lymphoscintigraphy showed a sentinel lymph node; in one patient there wasn't tracer drainage (she was 73 years hold and with voluminous breast). preoperative identification rate: 90%. lymphatic metastases were detected only in 2 sentinel nodes of 2 women; these patients were submitted to total axillary dissection. both node metastases were located in sentinel nodes and axillary non sentinel nodes were all negative at histopathological and anticytokeratin antibodies stainings. at a median follow-up of 14 months, no axillary relapses were observed in patients who were not submitted to axillary lymphadenectomy (positive predictive value=100%). ct and pet/ ct, performed at our institution, were main imaging follow-up surveys. conclusions. rslnb after previous limited breast surgery appear feasible and reliable for its high positive predictive value. it is necessary to analize a larger number of women and to follow them for a longer period. aims: liver regeneration after loss of hepatic tissue is a fundamental parameter of liver response to injury. recognized as a phenomenon from mythological times, it is now defined as an orchestrated response induced by specific external stimuli and involving sequential changes in gene expression, growth factors production, and morphologic structure. much of the investigation on the mechanisms and kinetic of hepatic growth has been done only in partially hepatectomized animals and in hepatocytes primary cultures. the study of the hepatic extraction fraction (hef) by radioisotopic methods gives information about physiological mechanism of uptake, transport and allows also the excretion quantification of the hepatobiliary system by using 99mtc-ida derivates. this prospective study aimed to estimate the interest of hef in the evaluation of human liver regeneration / function of patients with hepatic tumoral disease underwent partial hepatectomy. methods: 22 patients with colorectal metastases (n=18), hepatocellular carcinoma (n=2) and others (n=2) were included. liver function was assessed after intravenous bolus injection of 99mtc-n-(3-bromo-2,4,6-trimethylphenylcarbamoilmethyl 1-iminodiacetic acid (mebrofenin) that was uptaked by the hepatocytes and eventually excreted via billiary pathway without any change to its chemical structure. the hef is calculated using deconvolution analysis of first pass curve coming from scintigraphic data. we evaluated the pre-operative hef and in the 5th day and one month after the hepatic resection. we considered the hef values of 98.8 ± 0.4% (med ± sd) as normal. for statistical analysis, t-student test was used. results: the pre-operative, 5th day or one month after the partial hepatectomy hef (med±sd) was 98.33±3.36%, 98.37±3.06% and 97.1±5.37%, respectively. there was not statistically difference between the three evaluations of hef (ns). conclusion: these results allow us to say that the human liver regeneration is early enough to normalize the hef at day 5 after partial hepatectomy, being this evaluation of undoubtedly interest to know the function kinetics and indirectly knowledge about human liver regeneration. additionally, this fast functional liver recovery has high clinical importance, once more aggressive adjuvant chemotherapy can start much early after surgical treatment. objectives: some studies have demonstrated that a newly developed body diffusionweighted (dw) mri is useful for differentiating benign or malignant lesions in patients with bone and soft tissue tumors. thallium-201 (tl) spect has been widely used for clinically same purpose. we compared dw-mri with tl-spect to clarify the characteristics of these two methods. methods: both mri and tl-spect were performed on 42 bone and soft tissue tumors (12 malignant lesions and 30 benign lesions), whose final diagnosis was based on histology. dw-mri was performed with an echo planar imaging sequence. the apparent diffusion coefficient (adc) value (×10<sup>-3</sup> mm<sup>2</sup>/sec) was calculated on the lesions. the early and delayed tl-spect were performed, and the uptake ratio of the lesion to the contralateral normal tissue was obtained on the early images (early ratio; er) as well as on the delayed images (delayed ratio; dr). the diagnostic accuracy of malignant lesions was evaluated by visual interpretation. the adc values as well as er and dr in the lesions were evaluated and compared for quantitative evaluation of dw imaging and tl-spect, respectively. results: high sensitivity was observed in both dw-mri and tl-spect in visual interpretation. low specificity was observed on dw-mri (44.4 %), suitable specificity was observed on tl-spect (80%). in quantitative assessment, the sensitivity, specificity were calculated when the cut-off value of adc was less than 1.7 on dw-mri, and the cut-off value of er was over 3.9 on tl-spect. specificity on adc was only 36.4%, although high sensitivity 100 % was observed. there were significant differences between the uptake ratio of the benign and that of the malignant lesions (er: 6.23 ± 2.13 vs 26.72 ± 8.91, p < 0.01; dr: 1.32 ± 0.42 vs 4.35 ± 1.45, p < 0.01). however, there was no significant difference between the adc values of the benign and that of the malignant lesions (4.29 ± 8.50 vs 1.76 ± 0.77), suggesting that the adc values might not be conclusive in distinguishing between the benign and malignant lesions. conclusions: the adc values of bone and soft tissue tumors overlapped and could not be used to differentiate between benign and malignant tumors. whereas the er values and delayed visual assessment of tl-spect has high diagnostic ability for bone and soft tissue tumors. therefore, tl-spect has a better diagnostic ability than dw-mri for evaluation of bone and soft tissue tumors. clinical usefulness of thallium-201 scintigraphy in diagnosis of desmoid-type fibromatoses: comparison of planar and spect images t. shinya 1 , s. akaki 2 , s. sato 2 , s. kanazawa 2 ; 1 okayama kyokuto hospital, okayama-city, japan, 2 okayama university medical school, okayama-city, japan. aim: it has been reported that delayed thallium-201 (tl-201) scintigraphy is useful for differentiating malignant soft-tissue tumor from benign lesions. physiological muscle accumulations increase on delayed images in most cases, which often make it difficult to evaluate tl-201 accumulation on planar images in patients with soft-tissue tumors. desmoid-type fibromatoses are relatively rare soft-tissue tumors of fibroblastic origin and are locally aggressive. they are classified within the intermediate spectrum of fibroblastic/myofibroblastic tumors in the who classification. there are several case reports that describe tl-201 accumulation in desmoid-type fibromatoses. currently, however, no detailed documentation exists which describes tl-201 accumulation in desmoid-type fibromatoses. the purpose of this study was to evaluate the usefulness of tl-201 accumulation on planar and spect images, and the pattern of change in patients with desmoid-type fibromatoses. material and methods: sixteen patients with desmoid-type fibromatoses underwent whole-body tl-201 scans preoperatively, and we studied 21 desmoid-type fibromatoses retrospectively (12 primary tumors, 9 recurrent tumors). in all 21 tumors, early and delayed images were acquired at 10-15 minutes and 2 hours after injection. tl-201 images were visually interpreted for degree of tl-201 accumulation and pattern of change. we employed a three-grade system to evaluate degree of tl-201 accumulation: 0 = no appreciable accumulation, 1= accumulation higher than that of normal muscle but lower than cardiac accumulation, 2 = accumulation higher than cardiac accumulation. we employed a three-pattern system in evaluating pattern of change on planar and spect images: pattern of decrease= more accumulation on early images, constant pattern= equal accumulation on both early and delayed images, pattern of increase= more accumulation on delayed images. surgical resection with histopathological analysis confirmed the diagnosis. purpose: cardiac sympathetic dennervation is a common event in synucleinopathies and the basis for to use scintigraphy imaging using iodine-labelled metaiodobenzylguanidine (123i-mibg) with diagnoses purposes in these diseases. our purpose is to explore diagnostic accuracy of this technique in order to differentiate patients with lewy bodies disease (lbd) from others with cognitive and movement disorders not associated to synucleinopathies. material and methods: series of cases constituted by 8 patients with lbd (mckeith revised criteria) and 9 control patients [essential temblor (5), parkinson's disease and dementia without sinucleinopaties (4)]. all the patients underwent scintigraphy imaging using 123i-mibg and early and late cordis/ mediastinum (c/m) rate was measured. c/m rates between groups were compared (mann-whitney u-test) and area under roc curve (aroc), sensitivity, specificity and proportion of correct classifications were calculated. results: there were not differences between groups in age and sex. early and late c/m rate were significant smaller in the group with synucleinopathies (u=15; p<0.05 in both cases). late c/m rate had a greater discriminatory ability (aroc=0.8) than early rate (aroc=0.77). for the late c/m rate, value 1.8 shows a sensitivity 0.88 and a specificity 0.82, with correct classification of 82% of the patients. conclusions: in this small series, scintigraphy imaging using 123i-mibg shows a good discriminatory ability to correct identification of lbd patients. we used the established criteria for the diagnosis of every disorder and the dsm-iv criteria for the diagnosis of dementia. the majority of the patients had an mri and the rest a brain ct scan. all the patients had a brain spet with 99m-tc hmpao (adult dose 740 mbq, single-headed camera, uhr parallel-hole collimator,30 sec/image, 128 images on a 128x128 matrix. we applied the neurogam software on the reconstracted data for the evaluation of rcbf alterations in specific brodmann(br) areas in the left(l) and right(r) brain hemispheres. results: from logistic regession analysis we found statistically sigificant correlation of a number of neuropsychiatric symptoms with alteration of rcbf in the following brodmann areas: 1) delusions related to hypoperfusion in 22l bra 2)agitation related to hypoperfusion in 46r bra 3)depression related to hypoperfusion in 7l and 45l bra 4)anxiety related to hyperperfusion in 5l bra 5)apathy related to hypoperfusion in 39l bra 6)irritability related to hypoperfusion in 5l bra 7)disinhibition is associated to dysfunction in several regions, related to hypoperfusion in 11r, 20l, 46r bra. conclusion: the data support the involvement of multiple cortical regions in both hemispheres in mediating social and emotional behaviour and the subsequent neuropsychiatric symptoms resulting from rcbf alterations in degenerative dementias. the contribution of dopamine transporter imaging to the distinction between dementia with lewy bodies and alzheimer's disease (besides tc-99m hmpao findings) x. geronikola-trapali 1 , i. armeniakos 1 , t. doskas 2 , g. stampoulis 2 , a. prentakis 1 , a. stefanoyannis 1 ; 1 university general hospital "attikon", nuclear medicine department, athens, greece, 2 university general hospital "attikon", neurological department, athens, greece. aim: distinguishing between dementia with lewy bodies (dlb) and alzheimer's disease (ad) is often very difficult because of the significant overlap between them. the pathological features of dlb include cerebral cortex loss, lewy body inclusions and loss of nigrostriatal dopaminergic neurons. on the other hand in ad there is no significant dopaminergic degeneration. the aim of this study was to evaluate the role of dopamine transporter imaging with i-123 ioflupane (datscan) in order to distinguish these two types of dementia in case of inconclusive tc-99m hmpao brain perfusion findings. materials & methods:22 patients over the age of 65 who fulfilled the dsm-iv criteria were studied. cognitive function was assessed using mmse, clock and verbal fluency test. neuroimaging data were obtained from mri scans and all diagnoses were made before and independent of the spect scans. applying these criteria 13 patients with ad (possible) and 9 patients dlb (possible) participated. ten controls, group matched for age and the same clinical assessments as dementia patients were recruited. our study included two different steps: 1st: we performed cerebral perfusion spect imaging 90 min after i.v. injection of 740 mbq tc-99m hmpao (ceretec -amersham). interpretation of the data followed. 2nd: one group of the above patients (i.e. without the predominant cbf pattern) were further evaluated with i-123 ioflupane (datscan). spect imaging was performed 3-4 hours after i.v. injection of 148 mbq i-123 ioflupane. results:the interpretation of tc-99m hmpao images revealed significant perfusion deficits in temporoparietal regions in the 6/13 ad patients. parietoocciptal deficits were identified in 5/9 dlb patients. we found evidence of datscan results: seven patients with neuropathology consistent with ad had a normal striatal uptake. three patients fulfilling the criteria of dlb showed a marked reduction of the tracer uptake in the putamen bilaterally. one patient with clinical diagnosis of dlb revealed a generalized bilateral decrease of uptake with preservation of the striatal shape. conclusion:i-123 ioflupane (datscan) improves significantly the distinction between dlb and ad patients (in life) and it could be a useful tool towards this direction. objectives: long-term chronic alcohol consumption is associated with regional structural brain damage and cognitive deficit including memory impairment. neuroimaging research has commonly linked chronic alcohol abuse with generalized frontal hypoperfusion. the aim of our study was to evaluate rcbf in alcohol induced cognitive decline and effect of memantine on rcbf. methods: twenty-eight patients (m:28, mean age: 59.0±7.1, age range: 39~67) who fulfilled dsm-iv criteria for alcoholic dementia were enrolled in the study. on resting state, we were studied with technetium-99m ethyl cysteinate dimer single-photon emission computed tomography (tc-99m ecd spect) before and after memantine treatment. these results were analyzed with spm2 (statistical parametric mapping version 2). results: brain areas with increased rcbf after memantine treatment in alcohol dementia; uncus (ba38) of both limbic lobes, parahippocampal gyrus (ba28) of left limbic lobe, both superior frontal gyrus (ba10), right inferior parietal lobule (ba40), cuneus of left occipital lobe (ba30), and left superior temporal gyrus. brain areas with decrease rcbf after memantin treatment in alcohol dementia; left medial frontal gyrus (ba6), cingulate gyrus (ba31) of left limbic lobe, left claustrum, right brainstem, left superior temporal gyrus (ba38), fusiform gyrus (ba20) of right temporal lobe, culmen of left cerebellum, and fusiform gyrus (ba37) of right occipital lobe. conclusion: we demonstrated increased rcbf of cognitive-related areas (ba10, ba28) of brain after memantine treatment in alchoholic dementia. in conclusion, we suggest that use of memantine will be a new possible treatment of alcohol induced cognitive decline. patients (4 initially mci and 4 normal at nt) clinical symptoms worsened; demtect became suggestive for d in the 4 mci cases and in 3/4 patients initially normal and for mci in the remaining negative patient. mmse became positive for d in the former 7 patients who were enrolled for therapy and persisted negative in the latter one, in all of whom spect worsened. the remaining 5/13 patients (4 initially mci and 1 demtect negative) did not show clinical/nt change, while spect further worsened in one mci patient persisting negative in depression case.conclusions: 99mtc hmpao spect may be a useful complementary tool to nt, in particular demtect, to identify and monitor mci and to early ascertain its progression to d. moreover, in our study, spect proved more sensitive than nt also preceding mci diagnosis in some cases. the purpose of the study is to demonstrate imaging features of pet brain in dementia and to determine whether the mri anatomic changes correlate with dementia. method: from january 2005 to december 2006, 15 patients with suspicion for dementia clinically performed fdg pet/ct (7 women, 8 men, age range from 45-80 y). pet/ct results were compared and correlated with most recent mri (1 day to 1 month). results: ten patients with alzheimer's disease diagnosed clinically were consistent with hypometabolism of the temporo-parietal cortices on pet-ct frequently in an asymmetric pattern, with increasing degrees of frontal cortex hypometabolism in relation to advanced disease. there was sparing of the occipital and cerebellar cortices and motor sensory strips. on pet-ct imaging, 2 cases showed temporo-parietal defects similar to alzheimer's disease, but there also was additional hypometabolism of the occipital cortices. these imaging findings were congruent with the clinical findings of visual hallucinations, leading to a diagnosis of diffuse lewy body disease. in this study, both alzheimer's disease and lewy body dementia correlated with age-appropriate global atrophy in 4 of total 12 dementia patients; 4 of 12 medial temporal lobe atrophy on mri. two patients presented clinically with alzheimer's type dementia. pet-ct with mr correlation showed vascular dementia in one patient, with wedge shaped hypometabolism in right fronto-temporal distribution and left cerebellar diaschisis. the other patient had bilateral mesial temporal hypermetabolism on pet-ct and increased signal intensity in the bilateral temporal lobes on t2wi of mri, representing limbic encephalitis. one patient had both normal pet/ct and mri. conclusion: pet is useful modality of illustrating metabolic distribution of dementia. medial temporal lobe atrophy and age-related brain atrophy are associated with dementia. mri can detect structural alteration and differentiate underlying non-dementia disease such as mesial temporal encephalitis. aim: dementia is the progressive decline in cognitive function due to damage or disease in the brain beyond what might be expected from normal ageing. particularly affected areas may be memory, attention, language, and problem solving. it`s a disease strongly associated with age; 1% of those aged 60-65, 6% of those aged 75-79, and 45% of those aged 95 or older suffer from the disease. the most common cause is alzheimer's disease. positron emission tomography (pet/ct 18f-fdg) is a valuable tool for understanding functional changes in brain's patients (pts) with several causes of dementia. as such, it can provide valuable physiological alterations for diagnosis, management and research of dementia disorders. pet helps to identify dementia causes and makes a differential diagnostic with other illnesses. the aim of the present study was to evaluate the value of the pet/ct 18f-fdg metabolic patterns for the differential diagnosis and the cause of dementias. material and methods: between january 2005 and march 2007, 26 pts (14 women, 12 men; age: 47-77 years; mean: 60.7 years), with isolated cognitive deficit or dementia (using standard clinical criteria) underwent pet/ct 18f-fdg brain studies, after a reversible illness had been excluded. pet/ct was performed in fasting pts 60 minutes after a 185 mbq 18f-fdg intravenous administration. some days before pet/ct, single photon emission computed tomography (spect/ct) was done in 10 of the 26 patients. fdg-pet brain scans results were evaluated and compared to spect/ct. results: 18f-fdg pet/ct scans confirmed the presence of a bilateral temporo-parietal hypometabolism pattern associated with alzheimer`s disease in 17/26 pts (65%); 9/17 presented a frontal involvement and 4/17 a occipital involvement. in 5 (19%) pts we can see fronto-temporal hypometabolism pattern suggesting a frontal lobe dementia and in 3 (12%) pts a bilateral temporal hypometabolism is present that could imply a premature stage alzheimer's disease. only 1 patient had a 18f-fdg-pet/ct pattern compatible with vascular dementia (4%). pet/ct and spect/ct are congruent positive results in all studies. conclusion: 18f-fdg pet/ct brain scan may provide clinician with additional information helpful to establish the cause of dementia after reversible illness has been ruled out. the purpose: is to demonstrate the imaging features of dementias on brain fdg pet and to determine whether visible anatomic changes on mri correlate with these findings. methods and material: fifteen patients (7 women and 8 men, age range 45-80 years) with clinically suspected dementia underwent fdg pet/ct from january 2005 to december 2006. the results of pet/ct were retrospectively correlated with the findings from the most recent available brain mri (1 to 30 days from the date of the pet/ct). results: ten patients with clinically diagnosed alzheimer's exhibited temporo-parietal cortical hypometabolism on pet, frequently in an asymmetric pattern, with increasing degrees of frontal cortical hypometabolism seen in relation to severity of disease. there was sparing of the occipital and cerebellar cortices and motor sensory strips. on pet imaging, 2 patients showed temporo-parietal defects similar to alzheimer's disease, but with additional occipital cortical hypometabolism. this additional abnormality was congruent with clinical findings of visual hallucinations, leading to a diagnosis of diffuse lewy body disease. of 12 patients with alzheimer's disease and lewy body dementia, 4 showed age-appropriate global atrophy, and 4 showed medial temporal lobe atrophy on mri. two other patients presented with alzheimer's type dementia, however pet-ct with mr correlation showed multi-infarct dementia in one, with wedge shaped hypometabolism in a right fronto-temporal distribution and left cerebellar diaschisis, while the other patient showed bilateral mesial temporal hypermetabolism on pet and increased signal intensity in the bilateral mesial temporal lobes on t2wi mri, consistent with limbic encephalitis. one patient had normal pet/ct and mri, despite clinical dementia. conclusions: pet is a useful modality for aiding in confirmation and differential diagnosis in dementias. medial temporal lobe atrophy and diffuse brain atrophy are seen with dementia but lack of specificity by mri. mri is a powerful tool for differentiating dementias from other underlying disease, such as mesial temporal encephalitis. cerebral spect with hypercapnia in the examination of cerebrovascular reserve capacity p. sirucek 1 , o. kraft 1 , t. hrbac 2 ; 1 clinic of nuclear medicine university hospital, ostrava-poruba, czech republic, 2 clinic of neurosurgery university hospital, ostrava-poruba, czech republic. aim aim of this diagnostic examination is choice of suitable patients with neurological deficit the most often after cerebrovascular accident with demonstrated carotid artery or intracranial artery occlusion. these patients would have benefit from bypass surgery (anastomosis between arteria cerebri media and arteria temporalis superficialis). methods from 2003 to 2005 we examined 37 patients (16 women, 21 men, average age 58.5 yrs. the oldest patient was 76 yrs old, the youngest 31 yrs old). scintigraphy was done by means of double-headed camera e.cam by siemens with convergent collimators fan beam (matrix size 128x128, zoom 1.23, degrees of rotation 180, number of views 64, time per view 20 sec.). processing was done by means of software e.soft. we have used filtered back projection reconstruction, filter butterworth (cutoff 0.5, order 5). in all patients we have done brain spect in native conditions and then after stress -by inhalation of air enriched by co2. after increase 2 kpa of partial pressure of co2 in expired air we injected i.v. 700 mbq radiopharmaceutical 99mtc bicisate (neurolite) and then we did brain spect. native (rest) and stress examinations were compared. visual evaluation divided findings in three-grade scale: cerebrovascular reserve capacity (cvrc) was normal in unchanged finding in stress and rest, cvrc was reduced or strongly lowered in worsening of finding in stress. results 15 pts had normal cvrc, 11 pts had cvrc decreased and 11 pts strongly reduced. 14 pts were operated: in 12 pts ec-ic anastomosis, endarterectomy in 2pts. in ec-ic anastomosis a blood flow was controlled by means of ultrasonography. in 10 pts anastomosis was functional and in 2 pts non-functional. 6 pts indicated improvement of neurological finding. 8 pts had unchanged finding, but from these 8 pts 5 patients had normal finding in time of surgery. 3 pts had pathological finding without change, but after surgery they were without another stroke. in these 3 patients we expect risk decrease of another cerebrovascular ischemic accident. conclusion examination of cvrc by means of brain spect and hypercapnia is an easy method which is able to help with choice of patients with cerebrovascular occlusion for bypass neurosurgery and to determine patients in whom surgery will improve neurological finding. introduction: interictal f-18 fdg pet is frequently used in the identification of epileptogenic foci in patients with intractable partial seizure. we have observed increased metabolic activity in the posterior ocular bulb (pob) in some patients with intractable partial seizure undergoing pet scanning in our facility. the purpose of the current study was to further investigate this observation by evaluating and comparing increased fdg uptake in (pob) in patients with seizure and in normal volunteers. methods: brain fdg pet/ct images for fifteen normal volunteers and 24 patients with intractable partial seizure referred for interictal cerebral were retrospectively evaluated. all studies were acquired on a dedicated pet/ct scanner (gemini, phillips) with low-dose, non-contrast ct. two nuclear medicine physicians, blinded to clinical data, indepedently analyzed the pob tracer activity. chi-square test and interrater reliability with kappa were used. brain mri was available in 23 of the 24 seizure patients. a radiologist reviewed brain mri studies for any possible pob pathology. results: of the 15 normal volunteers, 14 (93%) showed no significant fdg uptake in the pob. in the one volunteer with increased pob uptake, significant falx calcification of unknown significance was noted on the ct portion of the pet/ct exam. of the 24 seizure patients, 23 (96%) had increased fdg uptake in the pob: unilaterally in 3 and bilaterally in 21 cases. on a patient bases, statistical significance was present between the two studied groups (p = 0.000). on an individual eye basis (15 x 2 for normal volunteers + 24 x 2 for seizure patients =78 pob areas), a high interrater agreement (kappa 0.87) was present for most cases (73/78) demonstrating feasible delineation of normal from abnormal pob uptake. available brain mri of 23 patients showed no abnormalities at the pob or orbits. conclusion: when present, visually increased fdg uptake along the pob is abnormal and may be associated with seizure. however, further studies are needed to investigate underlying pathophysiologic mechanism(s) for this phenomenon. a prospective study including ophthalmological and neurological examination is pending in our institution. aim: there is a continuous scale of preoperative fdg-pet findings (from normal to abnormal) in temporal lobe epilepsy (tle) patients. the discrimination between normal variability and pathology seems to be a clinical challenge in some cases. the aim of this work was to define the cut-off point for different methods of fdg-pet evaluation and to define their accuracy. materials & methods: patients with refractory tle were indicated to preoperative fdg-pet from three departments. all 58 consecutive patients, in whom histopathology proved hippocampal sclerosis (hs), were included into this study. the control group consisted of 27 oncologic patients without any clinical signs of brain involvement. roc analysis was utilized for the assessment of accuracy of semi-quantitative parameters of manual evaluation by two operators as well as automated brain analysis using two software applications: scenium (siemens; alpha v.1.1) and brass (hermes medical solutions; v.3.4) . results: the areas under the roc curves were calculated for the extent of asymmetry in hippocampus 0,92 (brass), 0,91 (scenium); for side difference of z-value in mesial temporal lobe 0,93 (scenium); for manual assessment of asymmetry 0,95 (operator 1) and 0,91 (operator 2) and didn't differ significantly between respective methods. a similar analysis in all other regions of interest gave worse results. the correlation coefficient of subjective evaluation between both operators was r=0,971 (ci 95%: 0,956-0,981). the cut-off points for the best discrimination between hs and control groups were for asymmetry of hippocampus: 4,5% (brass) and 3,9% (scenium); for manual assessment of asymmetry: 6,9% (operator 1) and 6,7% (operator 2); for side difference of z-value in mesial temporal lobe: -1,2 (scenium). the extent of asymmetry assessed by all 3 methods was able to correctly predict the side of operation in 100% of patients with tle (ci 95%: 0,938-1,000). conclusion: fdg-pet is a reliable diagnostic tool for discrimination between patients with hs and control group. sensitivity and specificity is at the level of 90% approximately, regardless of the method of evaluation used. furthermore fdg-pet is capable to correctly predict the side of operation in 100% of patients with hs. completely automated analysis is less laborious and operator independent. it gives the same results as careful manual assessment. manual assessment requires meticulous compliance with standardized evaluation methods. objectives: to evaluate the diagnostic performance of our new 3d ordered subsets expectation maximization (osem) algorithm vs. conventional fbp (filtered back projection) reconstruction algorithm in the functional brain perfusion spect imaging with tc-99m hmpao and ecd in investigation of cerebrovascular decease, dementia, seizure disorders, tumors and arteriovenous malformation. methods: the tc-99m hmpao or ecd brain spect data for 55 patients (n=55) acquired for clinical purpose as a standard-of-care for the deceases listed above were retrospectively reconstructed. the subjects with independently confirmed (e.g. by mri studies) presence of perfusion abnormalities were selected for this study. the patients were administered 30 mci of tc-99m hmpao or ecd 60 minutes prior to imaging. prior to radiopharmaceutical administration, standard pre-injection protocol was applied including placing the patient in a dark, quiet room with minimal visual and auditory stimulation. the spect scans were acquired with a triple-head gamma camera (triad 88, trionix) equipped with low energy high-resolution fan-beam collimators (128x128, 360 degree, 3-degree stops for 25 s). the reconstructed images for the same patients were obtained using the standard-of-care clinical fbp algorithm with hanning filter (0.6 ny) and our new 3d osem algorithms. the same radiologists in blinded studies independently read them. our 3d osem algorithm is a fully 3d reconstruction method with fan-volume system model and with total variation optimization. the clinical findings from images reconstructed by the two algorithms were compared with ground truth information provided by corresponding complementary studies including ct, mri, pet, clinical examination and follow-up studies. results: we established an increase in the specificity and sensitivity in locating the site and spatial extent of brain perfusion abnormalities while using our 3d osem, as compared to fbp algorithm. conclusions: our new 3d osem algorithm applied to hmpao and ecd spect brain studies instead of conventional fbp algorithm resulted in improved diagnostic performance. to obtain a good quality ictal spect, the determining factor is the time delay from ictal eeg onset to tracer injection. aim: the aim was to study which phase of the eeg is the determining factor for reporting the lateralization of the ictal spect using siscom. the 3 key phases in eeg chosen for study are brain activity lateralization (bal) at the onset (bal_o), bal at the moment of tracer injection (bal_ti) and then again 20 seconds postinjection (bal_20) methods: the study consisted of 53 patients (27 males and 26 females) of an average age of 34 years, with drug resistant complex partial seizures. there were 23 temporal and 30 extratemporal seizures. the spects were ictal in 43 cases and postictal in the remaining 10, with an average tracer injection time of 47 seconds from seizure onset. brain spects were carried out after the injection oh hmpao-tc99m using an ecam gammacamera (siemens) and following siscom methodology for an accurate identification of the maximum brain activity during ictal spect. 2 analysis was used to establish which of these 3 eeg phases showed most agreement with the bal seen in the siscom. results: siscom identified bal on one side in 51/53 patients while eeg in 38. all 15 cases without bal using eeg, were lateralized using siscom. bal_o occurred in 35 patients, bal_ti in 31 and bal_20 in only 15. in the agreement study between bal_o and siscom, of the 33 cases with bal, 28 were lateralized on the same side and 5 in the contralateral side (p = 0.001). in the case of bal_ti, of the 29 patients that were lateralized, 28 of these patients were on the same side of the brain and only one in the contralateral side (p = 0.000). finally, in the case of bal_20, 15 patients were lateralized, 13 of these were on the same side and two on the contralateral brain hemisphere (p = 0.062). conclusions: the highest degree of agreement was between siscom and bal_ti. this suggests that the tracer injection time is the determinant in correct interpretation of ictal spect. purpose: i-123 iomazenil(imz) is a one of the benzodiazepine partial-inverse agonist and has been widely used to evaluate a distribution of central benzodiazepine receptors. some authors reported that 3d-ssp could be useful to detect subtle change of tracer distribution in brain. however, a result of 3d-ssp depends on the normal database. we hypothesized that a distribution of central benzodiazepine receptors may change with age. the purpose of this study was to evaluate an age-specific normal distribution of i-123 iomazenil(imz) spect imaging. method and materials: twenty-nine subjects who were hospitalized in our hospital were studied. imz brain spect and brain mri were performed within 2 weeks period. they were suspected of having epilepsy on the basis of clinical findings, but no significant abnormality was seen in their imz spect and no major abnormality in their mri. these findings visually interpreted by 2 radiologists. these subjects were classified into 4 groups by their age; 1-5 years (5 males, 3 females), 6-12 years (3 males, 4 females), 13-30 years (5 males, 3 females), and 31 years and older (2 males, 5 females). three hours after the intravenous injection of 167 mbq of imz, spect data acquisition was performed using a triple head digital gamma camera system. unpaired student t tests were performed to compare the imz accumulation in each group using 3d-ssp, and z score maps were obtained. two radiologists visually and independently evaluated these z score maps, and compared the imz accumulation between each group. results: the imz accumulation of the 1-5 years group in the cerebellar hemisphere was higher than the other 3 groups. it of the 1-5 and 6-12 years groups in the central sulcus were also higher than the other 2 groups. on the other hands, it of these younger 2 groups in the frontal lobe were lower than the other 2 groups. furthermore, it in the posterior cingulate gyrus and the occipitotemporal lobe increased with age. coclusions: according to our result, the distribution of imz could be change with age, and to assemble an age-specific normal database might be important. aim: to assess the role of brain perfusion spect in the management of patients with spontaneous intracerebral hemorrhage (sich). method: 19 sich pts were studied. all pts underwent same day ct and brain spect with 99mtchmpao, 24h-4d from onset of stroke. results: 14/19pts (73.68%) showed a larger perfusion defect than expected after ct. in 4 pts hematoma diameter was comparable on ct and spect; 1pt had quasinormal aspect of spect study. in pts with larger defects, spect revealed a large cold spot with similar size compared with ct, and a surrounding hypoperfused area. 6/19 pts revealed cortical hyperperfusion, adjacent to hypoperfused area and corresponding to a normal-appearing brain tissue on ct. in 3 pts we found crossed cerebellar diaskisis. in 2pts we found cortical hypoperfused area in the contralateral cortex, with normal appearing brain tissue on ct. discution: many mechanisms and scenarios were proposed in order to identify the pathologic factors involved in the pathology of sich: edema, ischemia, inflammation, microglial activation, hemotoxicity, apoptosis... all of these factors are affecting brain tissue surrounding hematoma and are responsible of the progressive neurological deterioration; most of these damages are not revealed by anatomical imaging techniques. despite the latest advances in medical treatment and neurocritical care, patients suffering sich still have a very poor prognosis, with a greater mortality and larger neurological deficits at the survivors than for ischemic stroke. in a significant number of our patients (73.68%!) brain perfusion spect revealed different types of perfusion changes in the brain tissue surrounding hematoma, corresponding to normal appearing brain tissue on the ct scans. further studies are definitely required to demonstrate prognostic significance of these changes, but we can assume that all these areas contain viable tissue that can be a target for neuroprotective strategies. conclusions: brain perfusion spect can play an important role in sich, by early demonstrating functional changes responsible of clinical deterioration, thus allowing prompt dedicated therapeutic intervention. aim: to evaluate influence of hypotensive treatment on cerebral perfusion and cognitive function in patients (pts) with arterial hypertension (ah). material and methods: the study involved 31 patients (19 males and 12 females, mean age 53±5) with moderate essential hypertension. perfusion brain spect with 99mtc-hmpao and comprehensive neuropsychological testing were performed before and after 3months of antaginist ca treatment. brain spect slices were divided into 14 symmetrical (right and left) regions of interest per patients: inferior and superior frontal lobes, temporal, anterior and posterior parietal, occipital lobes and cerebellar hemispheres. regional cerebral blood flow (rcbf)(ml/100g/min) in these regions was calculated. results: hypoperfused regions were revealed in 27 pts. all pts had no focal neurological symptoms. antihypertensive therapy within 3 month led to the brain perfusion improvement and positive effect on cognitive function in pts with ah. medical treatment followed by the increase in rcbf relative to baseline in right and left anterior parietal regions (47.6±0.7 vs 44.9±0.5, p=0.01; 47.3±0.6 vs 44.7±0.5, p=0.002, correspondingly), in left temporal cortex (50.8±0.8 vs 48.2±0.6, p=0.003), in left inferior frontal region (50.4±0.8 vs 47.1±0.5, p=0.003). also growth in cerebral perfusion in right and left superior frontal regions, in right inferior frontal cortex and right and left occipital regions was observed. measures of immediate verbal memory, delayed verbal memory and learning showed a significant increase theirs after treatment an average on 10% (p=0.0001), 15% (p=0.024) and 9% (p=0.004), correspondingly, as well as improvement in immediate and delayed visual memory, attention on 28% (p=0.00006), 26% (p=0.003), and 35,8% (p=0.01), correspondingly. relationship between the changes of cerebral perfusion and dynamics of cognitive status was found. improvement of immediate verbal memory correlated well with increase in rcbf in left temporal region (r2=0.339; p=0.018). betterment of delayed verbal memory related to growth in cerebral perfusion in left anterior parietal region (r2=0.26; p=0.042) and left inferior frontal region (r2=0.25; p=0.047). positive correlation was shown between dynamics of attention and changes rcbf in right and left anterior parietal regions (r2=0.55; p=0.001, r2=0.531; p=0.028, correspondingly). conclusion: our results suggest that brain spect is useful technique for evaluation of medical treatment dynamic and understanding of cognitive disorders mechanisms in patients with arterial hypertension. improvement of cognitive functions after treatment in patients with ah was connected with the increase in brain perfusion. efficacy assessment of encephalo-duro-arteriosynangiosis for childhood moyamoya disease using 3dimensional stereotactic roi template analysis of brain perfusion spect s. hyun, k. lee, s. lee, y. cho, e. lee, j. choi, y. choi, y. choe, b. kim; samsung medical center, seoul, republic of korea. objectives: we evaluated the efficacy of encephalo-duro-arterio-synangiosis (edas) for childhood moyamoya disease using 3-dimensional stereotactic roi template (3dsrt) analysis of brain perfusion spect. methods: eighteen patients (f: m = 14: 4, mean 7.9 ± 2.6 yr) with childhood moyamoya disease who underwent bilateral simple edas were included. resting and acetazolamide (acz) challenged cerebral perfusions were measured with 99mtc-ecd spect 8.9 ± 8.6 days before the one side operation and 15.8 ± 7.5 months after the other side operation. the spect images were anatomically standardized using spm99 followed by normalization of counts using proportional scaling with the mean value of cerebellum at 50. we calculated the cerebral vascular reserve index (cvri) image as follows: cvri (%) = [(acz image -resting image) / resting image] x 100. fully automated roi analysis with 3dsrt was performed on resting, acz, and cvri images. 3dsrt calculated the area-weighted mean value of 12 segments by quantification of 318 constant rois in each hemisphere. we compared the mean value of each segment between pre-and postoperative groups. wilcoxon matched-pairs signed-ranks test was used for statistical analysis. results: comparison between pre-and postoperative brain spect revealed no significant improvement in resting perfusion. after edas, there was significant acz challenged perfusion improvement in the central (pre 43.6 ± 7.3 vs. post 45.7 ± 4.8, p=0.003) and parietal region (pre 45.3 ± 9.4 vs. post 46.1 ± 8.1, p=0.008). cvri improved in the central region with a mean difference of 2.1 (pre -6.3 ± 7.0 vs. post -4.1 ± 4.7, p=0.016) and the parietal region with a mean difference of 2.0 (pre -7.0 ± 7.8 vs. post -4.9 ± 4.5, p=0.093). cvri in the lenticular nucleus region was significantly reduced (pre -0.6 ± 5.6 vs. post -3.9 ± 4.8, p=0.002). conclusions: pre-and postoperative cerebral perfusion and vascular reserve in childhood moyamoya disease can be effectively assessed by 3dsrt. our results provide objective evidence that simple edas improves cerebral perfusion in the middle cerebral artery territory without direct benefit in the anterior and posterior cerebral artery territories. 12 segments: callosomarginal, precentral, central, parietal, angular, temporal, posterior cerebral, pericallosal, lenticular nucleus, thalamus, hippocampus, and cerebellum aim of the study: to evaluate metabolic activity using 18f-fdg ct-pet in order to establish both carotid vulnerability to rupture and asymptomatic progression linked to plaque inflammatory cells. methods: 15 patients with symptomatic or asymptomatic unilateral carotid arteries were studied. all of them were scheduled for carotid endarterectomy (ce). 18f-fdg head and neck ct-pet was performed using a discovery st scanner (ge healthcare) prior to ce and 100 days following surgery. two speciality-trained persons blinded to the vascular examinations results reviewed and quantified the scans. two-centimeter circular regions of interest were drawn on ct images around the area including carotids in each slice, and then transferred onto the corresponding coregistered pet image to enable 18f-fdg uptake values based on maximum standardized uptake value. the analysis included vascular region 56 mm over and below the level of the carotid bifurcation, and slice-activity curves were calculated in order to visualize plaque and basal metabolism. results: carotid plaques with inflammatory infiltrates had a major 18f-fdg uptake (p<0.05). no significant correlation was found between degree of 18f-fdg uptake and time from symptoms to ct-pet imaging, symptomatic or asymptomatic patients, degree if carotid stenosis and vascular risk factors. we found significant correlation between the degree of 18f-fdg accumulation in carotids scheduled for ce and contralateral carotids (p<0.005). the 18f-fdg ratios in the contralateral arteries remained increased on the follow-up imaging at 100 days. statines treatment was correlated with more pronounced decreased in 18f-fdg-uptake at 100 days (p<0.05). conclusions: this is the first in vivo study using 18f-fdg ct-pet imaging demonstrating that carotid atherosclerosis is a bilateral disease. identification of inflammatory regions in the contralateral carotids has the potential to offer early aggressive pharmacotherapy in these patients. aim. we report our clinical experience with 99m tc-hmpao spect imaging in patients with giant intracranial aneurysm in order to identify patients without a sufficient collateral perfusion during internal carotid artery (ica) temporary occlusion test (tot). material and methods. 20 consecutive patients (1 man, 19 women; mean age 43 years; range 19-67 years) affected by a giant intracranial aneurysm, who could potentially benefit from permanent ica occlusion, underwent a tot to evaluate the efficiency of cerebral collateral perfusion. one patient with sudden onset of intese headache during tot (absolute contraindication for permanent ica occlusion) was excluded from this series whereas 19 patients were injected with twenty mci of 99m tc hmpao after a endovascular balloon had been blown up for ten minutes. images were obtained by a dual headed gamma camera using a circular orbit and a 3° step and shoot technique. data were processed after a backprojection and an attenuation correction, by using a low pass filter. both a qualitative and a semiquantitative analysis of images were performed. results. in 15 patients, no perfusion impairments were found and a permanent ica occlusion was made. the procedure resulted in aneurysm thrombosis and no signs of ischemic injures occurred in the follow-up period. four patients showed a reduced perfusion during tot. one of these patients underwent surgical revascularization by ec/ic bypass. a new tot, after surgical revascularization, revealed no perfusion alterations and the patient underwent permanent ica occlusion without any subsequent ischemic injury. conclusion. 99m tc hmpao is an effective tool in identifying patients who cannot undergo permanent ica occlusion. intracranial arteriovenous malformation (avm) is an abnormal collection of immature blood vessels within the brain. treatment of the brain avms includes three modalities: endovascular embolization, which reduces the size and vascularity of the lesion, standard microsurgery or radiosurgery. very little relevant literature concerning the role of spect in the evaluation of avm treatment through endovascular embolization encouraged us to study this problem. material. examined group included 13 patients ( 8 women and 5 men) at the age of 12-59 years. all the patients had been previously diagnosed with intracranial avm and subsequently qualified for the endovascular embolization procedure. the patients were in good clinical condition and had no symptoms of recent intracranial haemorrhage. methods. brain scintigraphy was performed on the same day, prior to embolization and 1-22 days after treatment. administrated activity of 99mtc-ecd (polatom, poland) was 491 to 925 mbq. spect examination was carried through 20 minutes after iv radiotracer injection with two-head gamma-camera varicam. acquisition was performed using high-resolution collimators, with one projection for each 3° in a 360° orbit. a matrix of 128×128 pixels was applied. filtered back projection with metz filter was used for reconstruction. regional cerebral blood flow (rcbf) was evaluated visually and semiquantitatively using voxel-based analysis with brain spect quantification software (compart, warsaw, poland). embolization procedure was performed under general anaesthesia. angiography was carried out using siemens equipment (multistar). partial or complete obliteration of avm was followed by postembolization angiography. results. no serious side effects were observed after embolization. in each patient, spect showed the nidus of avm as a region of decreased radiotracer accumulation. after embolization significant changes of perfusion (cut off cluster size-10,0 ml, cut-off percentage-10% in semiquantitative analysis) in an area adjacent to the avm nidus were found in 10 pts: deterioration of perfusion in 9 pts (10,8ml-68,7ml mean 35,4±23,9 ml, 14%-26% mean 17,7±2,9%) and improvement in 1 patient (13,7 ml, 16,5%). significant perfusion changes in the areas remote to the nidus were seen in 12 pts: 21 areas of perfusion deterioration and 14 regions of rcbf improvement after embolization. these areas were located in cerebral and cerebellar hemispheres both ipsilateral and contralateral to avm. conclusions. perfusion changes in patients with avm treated through endovascular embolization can be detected by means of 99m tc-ecd spect with voxel-based analysis. deterioration of perfusion after embolization seems to prevail over improvement. mean cerebral blood flow,response to paco 2 and rcbf distribution in the patients with diabetic mellitus a. komatani; yamagata univ., yamagata, japan. aim: the diabetes mellitus (dm) is widely known as a risk factor of many diseases e.g. retinopathy, nephropathy, neuropathy and angiopathy, etc. to confirm the possibility of dm as a risk factor for the cerebral infarction and/or vascular dementia, we inspected mean cerebral blood flow (cbf), its distribution, and flow reserve in patients with dm. materials: fifty-one males aged 62.1±11 and forty seven female aged 66.5±11 with dm. ten males aged 56.7±20 and twelve females aged 58.2±17.4 for healthy control. methods: mean cbf was measured using 133 xe-spect with kanno-lassen's method, and the flow reserve was estimated as a response to paco 2 by sodium bicarbonate (hco 3 -) injection. the distribution of regional cerebral blood flow (rcbf) was estimated using statistical parametric mapping (spm) with 99m tc-ecd. results: the mean cbf was 47.0±6.3 ml/100g/min in the group of dm patients, and 52.9±3.5 ml/100g/min in the group of healthy control. no significant difference was seen between the both groups (p=0.13). regional flow reduction in the white matter especially at the sub cortical region was observed in most of the dm patients. no significant difference in the mean cbf was seen between with and without complications of hypertension and/or hyperlipemia. the correlation between the mean cbf and the dilation of the disease tend to have negative correlation (p=0.025). the percent increase with the sodium bicarbonate injection was 19.1±8.4% in dm patients and 45.8±8.7% in healthy controls. the flow reserve in dm patients was significantly poor compared with control group (p<0.001). conclusion: the most obvious findings of dm patients were flow reserve reduction, and the reduced regional flow in the white matter especially at the sub cortical area. the reduction in mean cerebral blood flow was not so major characteristic of dm patients. dm should be a certain risk factor for the cerebral infarction and/or vascular dementia due to micro angiopathy with dm. brain metabolism in patients with unilateral carotid stenosis. regional changes evaluation after endarterectomy using ct-pet with 18f-fdg a. fernandez leon 1 , j. krupinsky 1 , m. font 1 , r. de juan 1 , p. pifarre 1 , a. carvajal 1 , f. rubio 1 , a. domenech 1 , c. gamez 1 , j. gispert 2 ; 1 idibell. hospital de bellvitge. unitat pet., barcelona, spain, 2 idibell. hospital de bellvitge, barcelona, sudan. aim of the work: atheroesclerosis is a chronic inflammatory disorder but it is still unclear whether patients with unilateral carotid disease are at higher risk of contralateral carotid artery progression. both carotid vulnerability to rupture and metabolic brain changes related to vascular disease may be linked to plaque inflammatory cells. imaging with 18f-fdg pet has been shown to be unique in detection of plaque inflammatory activity and secondary brain changes. methods: we studied 15 patients with symptomatic or asymptomatic unilateral carotid arteries. all of them were scheduled for carotid endarterectomy (ce). all patients received an integrated fdg-pet/ct using a discovery st scanner (general electric healthcare) prior to ce and 100 days following surgery. pet was performed with 3,71 mm slice thickness with no overlapping slices in 3d mode including brain and neck structures. a stiff cervical collar was worn to minimize patient movement. approximately 370 mbq of fdg was administered intravenously as a bolus and static emission images were obtained 30 min later. attenuation correction 4-slice ct helical scans (ctac) were obtained at 3,71 mm slice thickness, 120 kv tube voltage and 60 ma tube current. all images were pre-processed using the algorithms provided with the spm2 software package. images were normalized to the pet template and smoothed with a gaussian kernel of 8 mm fwhm. then, images were masked so that all remaining voxels had an activity higher than 80% of the brain global value in all cases. relative intra-subject changes in brain metabolism were determined in a voxel-by-voxel manner by subtracting the post and pre images and expressing this difference in percentage units relative to the first image [100x(post-pre/pre)]. finally, these images were thresholded and the number of voxels showing changes over/under 10% were recorded, as well as the average relative metabolic change in them. results: in 5/15 patients significant increased metabolism in unilateral or bilateral carotidean territories were observed after endarterectomy. in half cases there was concordance between brain changes and affected carotid. in 1/15 we observed decreased bilateral metabolism after ca. no changes were observed in 9/15 patients, all of them with left arterial disease. no significant correlation was found between brain changes and time from symptoms to pet imaging, symptomatic or asymptomatic patients, degree of carotid stenosis and vascular risk factors. conclusions: 18f-fdg ct-pet imaging can demonstrate bilateral changes in brain metabolism after endarterectomy, mainly in carotidean territories. objective to evaluate the efficacy and the diagnostic value of cerebral perfusion quantification in patients (p) with carotide artery stenosis (cas) who underwent surgical endarterectomy. materials and methods 11 p were studied. 5 showed right and 6 left carotide stenosis. most of them had bilateral cas and underwent surgery of the main affected artery. eco-doppler, basal and 3 months after endarterectomy 99mtc-spect with 25 mci of 99mtc-ecd scan (vg gems gamma camera, fan beam collimator) were performed in all p. the perfusion was analysed by spm2 comparing each patient's study (pre and post surgery) with a healthy control group. the changes in both the extension and intensity of the cerebral hypoperfusion before and after surgery were also evaluated. results a significant carotide artery flow improvement was found in all p by eco-doppler. in 3p the basal cerebral perfusion analysis by spm2 was normal. in 3 p an increase of the intensity (mean 42,6%) and extension (mean 272%) of the hypoperfused areas seen in the basal study was detected. in 5 p a decrease of the intensity (mean 42,6%) and extension (mean 62,8%) was seen. conclusion spm2 is a useful method to analyse the post surgery cerebral perfusion changes in p with carotide stenosis, detecting a significative hypoperfusion decrease (intensity and area) in 5 of 8 p. a post surgery worsening was found in 3p. these results are uncertain and further long term studies would be needed to clarify these findings. aim: study of brain perfusion in patients with arterial hypertension (ah) and type ii diabetes mellitus (dm). material and methods: fifty seven patients with moderate essential hypertension (mean age 51,6+5,7 years) were investigated by brain spect scanning with 99m tc-hexamethylpropylene amine oxime ( 99m tc-hmpao). thirty three patients were found to have ah without carbohydrate metabolism disturbance (gr.i) and 24 patients -ah with type ii dm (gr.ii) in stage of compensation and subcompensation. all patients had no focal neurological symptoms. spect was performed at baseline and during adenosine test. results: hypoperfused regions were revealed in all patients. the dercrease in radiopharmaceutical accumulation was found in 181 of 1188 brain regions in patients of gr.i. the most significant cerebral blood decrease was marked in parietal brain region (20%). hypoperfused regions were observed less frequently in temporal (16%), occipital (16%) and frontal (12%) brain lobes. cerebral perfusion disorders in patients with ah and dm were more pronounced in comparison with patients of gr.i (p=0,021). thus, 162 of 864 brain regions (19%) were hypoperfused in pts of gr.ii. microcirculation disorders of greater degree were found in occipital brain lobes, where hypoperfusion was revealed in 38 of 144 (26%) brain regions. the less pronounced decrease in accumulation of 99m tc-hmpao was observed in parietal (22%), temporal (18%) and frontal (14%) brain lobes. use of adenosine test in both patients groups did not affect cerebral perfusion in hemispheres (p=0,342 and p=0,768, respectively). however, in some cases brain perfusion decrease in individual regions was observed. at the same time in frontal lobe almost double increase in hypoperfused regions quantity as compared with baseline was found. this fact may testify to cerebrovascular reserve decrease in frontal region in these patients. conclusion: our results suggest that the signs of brain hypoperfusion and the decrease in cerebrovascular reserve take place in patients with essential hypertension and diabetes mellitus as well as in ah patients without it even if they have no focal neurological symptoms. the most pronounced cerebral perfusion disorders are revealed in patients with ah and diabetes mellitus in comparison with ah patients without carbohydrate metabolism disturbance. [123i]fp-cit is suitable for the quantification of dopamine (da) transporters localized on the membrane of presynaptic dopaminergic neurons. the practical use of [123i]fp-cit spect has become a routine diagnostic tool to investigate the integrity of the nigrostriatal pathway in vivo and also to directly assess the progression of parkinsonism. previous studies applying roi methods for data analysis have evaluated the effect of medications on the striatal da transporter imaging, that is however still debated. aim of the study was to evaluate the effect of treatment with dopamine agonist drugs on da transporters in patients with parkinson's disease (pd) by means of a voxel-based analysis of [123i]fp-cit spect data. spect [123i]fp-cit binding to the da transporters was evaluated in 21 patients both without any medication and during treatment with dopamine agonist drugs (ergot-derivatives and non-ergotderivatives) after reaching the maximal optimazed dose (mean 35 days). a 2-head gamma camera equipped with lehr collimators was used for data acquisition (128 x 128 matrix, pixel size 3 mm, 128 projections, 360° circular orbit) after the i.v. injection of 185 mbq of [123i]fp-cit. filtered back projection with a butterworth prefilter (0.4 cycles/cm, order 8) was used for reconstruction, applying uniform attenuation correction (0.12 cm-1). reconstructed data were realigned, spatially normalized to a [123i]fp-cit spect template and smoothed. individual voxels values were expressed as % of occipital mean counts. spm2 was then used for data analysis. both caudate and putamen [123i]fp-cit binding values were bilaterally not significantly different on baseline and during treatment (p<0.001). no statistically differences were also observed when comparing patients treated with ergot-derivatives versus non-ergot-derivatives. in conclusion, the results of the voxel-based analysis, a less operator-dependent approach than roi methods, confirm that dopamine agonist medications do not affect the spect imaging with [123i]fp-cit and support the needless of withdrawing both ergot-derivative and non-ergot-derivative drugs to measure da transporter levels. the absence of effect of this treatment on spect measurements is particularly important when the neuroprotective effect of dopamine agonist drugs is going to be assessed by [123i]fp-cit imaging. the diagnosis of alzheimer's disease (ad) versus lewy-body dementia (lbd) and parkinson's disease (pd) with dementia is often problematic, especially in patients with both dementia and parkinsonism. aim of the study was to assess the usefulness of spect with [123i]fp-cit, a dopaminergic presynaptic ligand evaluating integrity of nigrostriatal pathways, combined with rcbf spect for differentiating in-vivo lbd, pd with dementia and ad, by means of a voxel-based approach. most previous spect studies have applied roi methods for analysis, which are subjective and operator-dependent. fifteen patients with probable lbd, 15 with probable ad (nincds/adrda criteria) and 10 patients with dementing pd underwent rcbf spect with 99mtc-ecd and a brain spect with [123i]fp-cit. patients were matched for age, sex and severity of cognitive impairment (mmse). spect was performed with a dual-head gamma-camera 3-4 hr after the i.v. injection of [123i]fp-cit (185 mbq) and about 1 hr after 99mtc-ecd (900 mbq). comparison of the[123i]fp-cit striatal binding ratios and rcbf spect patterns among ad, lbd and pd was performed by means of the voxel-based spm analysis (spm2, unpaired ttest for statistical analysis). the spm analysis showed a significant (p<0.001) bilaterally reduced binding in caudate and putamen in lbd and pd patients compared to ad. striatal uptake was indistinguishable between patients with lbd and pd. ad patients had significantly (p<0.001) reduced rcbf in the temporo-parietal and frontal areas versus both the lbd and pd groups. lbd and pd patients showed significantly reduced (p<0.001) rcbf in the occipital regions versus the ad patients. whereas, no statistical differences in the rcbf patterns were found between lbd and pd patients. in conclusion, the spm voxel-based approach is a viable alternative to the method of roi analysis, and could be included in the routine clinical analysis. nigrostriatal impairment as evaluated by means of [123i]fp-cit spect allows to differentiate lbd or dementing pd from ad patients. the rcbf study adds further informations about the existence of a common or different neurobiological substrate underlying the clinical spectrum of parkinsonism-dementia. on the other hand, it appears that [123i]fp-cit and rcbf imaging cannot differentiate lbd from pd with dementia. background a differential diagnosis between idiopathic parkinson's disease (ipd) and multiple system atrophy (msa) is clinically difficult. we analyzed the difference in glucose metabolism between ipd and msa using spm (statistical parametric mapping). methods this study included 7 ipd patients (age range: 47-77 yr), 3 msa patients (age range: 57-65 yr) and 11 healthy controls (age range: 33-68 yr) who underwent f-18 fdg pet. using spm2 (statistical parametric mapping 2, wellcome department of cognitive neurology, london, uk) software, all the images were spatially normalized into the standard template, smoothed with 6 mm fwhm isotropic gaussian kernel. the count of each voxel was normalized versus the total count for the brain (proportional scaling in spm) to remove global cerebral blood flow differences between the individuals. images of ipd were compared with those of healthy controls and msa patients in a voxel wise manner using spm2 (uncorrected p < 0.01). the ipd patients were found to have a significant glucose hypermetabolism in comparison with the healthy controls in both basal ganglia, thalami, cerebellar areas and decreased metabolism in motor cortical areas. the msa patients demonstrated diffusely decreased cerebral glucose metabolism in both both cerebellar areas compared to the ipd patients. conclusion although the number of patients studied is small, spm analysis may be useful in differential diagnosis of patients with idiopathic parkinson's disease and multi-system atrophy. further studies including more patients may be warranted . normal or aspecific findings at ct/mr. brain spect was performed 3-4 hrs after 148 mbq 123i fp-cit (datscan, amersham health) i.v. injection by a dual head gamma camera with fan beam collimators. spect images were analyzed qualitatively and quantitatively calculating conventional putamen/occipital (p/o) and caudate/occipital (c/o) ratios normalized with phantom and compared to age matched normal controls (c) provided by the data processing software (normal values: p/o=8.25±3.79; c/o=7.76±3.54). when the two analysis data were controversial the binding potentials were determined by another software (neurotrans 3d, mirage) that corrects the partial volume effect applying the talairach atlas as anatomical 3d reference. results: 123i-fp-cit spect was normal at qualitative analysis in 56/134 (41.8%) patients without difference in both p/o and c/o ratio in respect of c, thus classifying these cases as affected by et. spect was pathological in 78/134 (58.2%) cases; in 48 of these, monolateral putamen uptake defects were ascertained in concordance with clinically evidenced site and p/o ratios (3.83±0.98) in all involved putamen were significantly lower than in controlateral ones (7.93±1.17; p<0.001) and c (p<0.00001). bilateral defects were detected in the remaining 38/78 pathological cases, clinically classified as monolateral; however, p/o ratio was bilaterally low only in 28/38 cases with mean values significantly lower (p<0.0001) than c in both putamen (left: 3.48±0.89; right: 3.84±1.07) while, it was low monolaterally in the remaining 10/38. however, in these latter, at 3d analysis, binding potentials were low bilaterally. all 78 patients classified as pd underwent l-dopa therapy. conclusions:123i-fp-cit brain spect may be useful in patients with clinically suspected resting tremor of recent appearance to clarify uncertain differential diagnosis between pd and et, thus permitting the most appropriate treatment. moreover, spect also gave more information on disease extension in respect of clinical data utilizing both qualitative and semiquantitative analyses, with 3d binding potentials evaluation obtaining higher performance in our cases. 2) the placement of rois in basal ganglia not uniquely defined. these issues are most prominent in patients with low tracer uptake in the basal ganglia (advanced pd, candidates for surgery etc.), but also of importance in longitudinal studies. we propose an automated method relying on histogram analysis that does not involve operator interaction. materials and methods the algorithm exploits the pharmacokinetic feature of high target-to-background ratios of the ligands. simple histogram analysis of the image slices containing the basal ganglia and occipital cortex can reveal estimates for specific and unspecific uptake. the histogram analysis consists of 3 parts: 1) thresholding for extraction of brain pixels, 2) calculation of the median pixel value in the brain as an estimate of unspecific uptake, 3) calculation of the median of the pixels with the highest tracer uptake corresponding to the size of the basal ganglia. the algorithm was tested on fp-cit images from 23 patients and compared to the manual "crescent roi" analysis. the parameter of interest was the ratio of uptake in the basal ganglia compared to the background. results in 15/22 datasets the agreement of the ratios was within 0.3, in 19/22 datasets within 0.5. datasets with "patchy" tracer uptake with areas of low uptake in the background region exhibited the largest differences. in one dataset, the algorithm failed to identify the slice with the basal ganglia. this dataset was excluded. conclusion despite its simplicity, the algorithm reproduces clinically reported results in most cases with good correspondence. deviations are prominent in cases with patchy unspecific uptake. in longitudinal studies the algorithm may provide valuable information as both inter-and intra-operator variance are removed. white matter normalization -a novel analysis method with improved sensitivity in pet perfusion studies of neurodegenerative diseases. p. borghammer 1 , k. y. jonsdottir 2 , a. gjedde 1 ; 1 pet center, aarhus university hospital, aarhus, denmark, 2 center for integrative functional neuroscience, aarhus university, aarhus, denmark. aim: in pet studies of cerebral blood flow (cbf) and glucose consumption, the data analysis is complicated by the very large inter-subject variability. to overcome this problem, data normalization is often carried out by dividing each voxel in a subject scan with the global mean (gm). it is an often overlooked fact, that even subtle differences in global mean between the groups introduce bias into the analysis. we suggest, that normalization to white matter mean (wm) might improve analysis sensitivity and diminish the risk of creating artifacts. materials & methods: 9 earlystage parkinson’s disease (pd) patients and 15 healthy age-matched controls underwent cbf pet scans while resting. we employed both region-of-interest (roi) and voxel-based statistics. the analysis was carried out on non-normalized data and after normalization to gm and wm mean, respectively. the findings of these three analyses were compared. results: roi: no significant differences were found in absolute values of cbf in whole brain or any of the 4 major lobes. after normalization to gm, pd patients had decreased cbf in parieto-occipital lobes, and in whole grey matter (all p<0.05). after wm normalization, we found significant differences in the same areas and additionally in the frontal lobe (all p<0.05). voxel-based: gm normalization yielded a single small voxel-cluster of significant decrease in the medial occipital lobe and a cluster of significant increase in left primary motor area (mostly white matter). wm normalized data disclosed 3 much larger significant clusters of decreases cbf in occipital lobe and lateral parietal lobe bilaterally (p<0.05 for all clusters), but no increases. conclusion: following wm normalization, significantly larger areas of cortical cbf decreases were detected than after gm normalization. conversely, only in gm normalized data, we detected increased cbf in pd. wm hyperactivity has been reported numerous times before in studies of pd patients. there is no basis or prior evidence for wm hyperactivity in animal models of pd. we propose, that the wm hyperactivity, reported in numerous pet studies of human pd, is an artifact created by wrongful normalization to gm, since gm is most likely decreased in pd, although this is rarely detected in the absolute data due to insufficient subject sample sizes. the wm normalization method seems to be more sensitive to detect expected (true) decreases and less prone to create artifacts such as wm hyperactivity. aim. 123 i-fp-cit is a neuroreceptor tracer successfully used in diagnosing dopaminergic deficit in parkinsons' disease (pd) at an early stage due to the loss of dopamine transporter (dat). this study evaluates the possibility of making a more extensive and larger early diagnosis of the dopaminergic damage using semiquantitative analysis of 123i-fp-cit spect in patients with suspected parkinson's disease compared to only qualitative tests. methods. the study was carried out on 154 patients with suspected pd. another 18 people were involved as a control group, they were similar age-wise to the pd group and at follow-up 24 months later essential tremor was evidenced and not pd. spect was carried out 4 hours after the dat tracer had been administered. both qualitative and semi-quantitative analyses were performed in the region of the striatum in the 154 patients studied. the semiquantitative analysis was made out and the patients with results superior to the 1 standard deviation of the established range were selected. result. in 134 patients out of 154 (87%) a reduction of dat activity in at least one region of striatum was evident. visual analysis of the images diagnosed dopaminergic damage to the putamen controlaterally to the side where the symptoms were present in 60.4%; to adjacent caudate nucleus in 31.3% and damage to the base nuclei isolaterally to the symptoms in 8.2%. while the semi-quantitative analysis gave the following results: 32.8%, 50.7% and 16.4% respectively.conclusions. the results indicate that 123 i-fp-cit spect allows a more accurate characterisation of the dopaminergic damage in patients with suspected parkinson's disease. g. p. sechi 1 , s. nuvoli 2 , v. agnetti 1 , k. paulus 1 , f. chessa 2 , g. cocco 1 , a. spanu 2 , g. madeddu 2 ; 1 neurology dpt, university of sassari, sassari, italy, 2 nuclear medicine dpt, university of sassari, sassari, italy. aim: in parkinson's disease (pd) patients we used 123 i-fp-cit spect to investigate whether the tripeptide gsh may have an effect on dat, gsh ability to cross the blood-brain barrier (bbb) being still debated. material and methods: twenty consecutive pd patients (h-y stage 1-35) were studied, 9 never been treated (group 1) and 11 on chronic carbidopa/levodopa and/or dopamine agonist therapy (group 2). in all pd patients and in 8 healthy subjects were performed: updrs motor battery and webster step-second test, and spect 3-4 hrs after 148 mbq 123 i-fp-cit (datscan, amersham ge) i.v. injection. spect images were evaluated both qualitatively and semiquantitatively calculating putamen/occipital (p/o) and caudate/occipital (c/o) ratios, normalized with phantom and compared to age matched normal controls (c) provided by processing software data. both group 1 and group 2 patients were treated for 6 weeks with i.m. gsh therapy, 600 μg twice daily, group 2 maintaining basal treatment. after gsh, pd patients repeated spect and neurological tests comparing data to basal values. results: at the first observation, in 15 involved putamen of group 1 patients and in 20 of group 2, p/o was low (<4.55), with mean values, in the 35 putamen, significantly (<0.0000001) lower (3.41±0.72) than the 5 not involved putamen (5.59±0.68), and those of healthy subjects (6.14±0.64) and c (8.25±3.70) ; no difference was ascertained between the latter 3 groups. in all cases c/o was normal. after gsh therapy, there was p/o increase in 25/35 involved putamen with an increment percentage >30 in 36% of cases, mean values (5.30±1.01) being significantly (p<0.004) higher than basal values (3.94±0.51); in 8/35 putamen p/o had no change and in the remaining 2/35 further decreased, but not significantly. in particular, an increment percentage >30% there was in 40% of group 1 putamen and in 15% of group 2. the 5 not involved putamen had no significant change. updrs slightly improved in 9 patients. conclusions: 123 i-fp-cit spect proved useful to evidence that gsh therapy may increase putamen dat binding, particularly in never treated pd patients in our series, thus indicating bbb penetration of this tripeptide. a potential therapeutic role of parenteral gsh might be suggested in pd patients. objectives: many studies show changes of serotonin transporter (sert) in various neuropsychiatric diseases. sert is also the primary target for selective serotonin reuptake inhibitors (ssris), widely prescribed for the treatment of major depressive disorder and other mood and anxiety disorders. so, in vivo measurement of sert function is useful tool for studying pathophysiology of neuropsychiatric diseases. recently, as most valuable candidate for measurement of sert function, 11 c-3amino-4-(2-dimethylaminomethylphenylsulfanyl)benzonitrile ( 11 c-dasb) was developed and showed its potential for evaluation of sert. use of 11 c-dasb thought to be able to investigate various neuropsychiatric diseases, but age-related change of sert density is reported in normal cases. in this study, we tried to measure the density of sert with 11 c-dasb in healthy volunteers, and evaluate the age-related change of sert density. methods: we studied sert activity in 10 male subjects (34-61 y old) using 11 c-dasb and pet brain imaging. pet examination was performed 90 min after intravenous injection of 11 c-dasb. regions of interest (rois) were drawn on mr images and pasted to corresponding pet slices. all subjects had also spect perfusion studies with 99m tc-ecd. three analytical methods without arterial blood sampling (the transient equilibrium, the linear graphical analysis, and the ratio of target to reference region) were used to estimate binding potentials (bps). cerebellum was used as the reference region in each method. results: bps obtained from each method had almost same values. test-retest reproducibility showed the verification of this study. a significant negative correlation was observed between 11 c-dasb sert binding and age (thalamus: r = -0.89; p = 0.001, striatum: r = -0.91; p = 0.001). decrease of 11 c-dasb binding was approximately 5% per decade in thalamus. conclusion: in this study, we showed the age-related decline of sert in thalamus and striatum with 11 c-dasb in normal subjects. these results indicate that 11 c-dasb can apply for clinical studies on treatment of neuropsychiatric diseases using age-matched controls. background: the prevalence of depression in parkinson's disease (pd) is about 40% and the rate of depression is twice that seen in other disabling diseases. however, the pathophysiology of depression in pd remains obscure. regional brain changes have been demonstrated in non-pd patients with depression with the core perfusion deficit in bilateral parietal regions. objective: to determine whether pd patients with major depression exhibit differential brain perfusion compared to non-depressed pd patients. methods: we studied 9 right-handed pd patients who fulfilled dsm-iv criteria for depression (dpd: 3 females, mean age 59±8 years, mean disease duration 11±2 years) and 15 right-handed non-depressed pd patients (ndpd: 2 females, mean age 59±8 years, mean disease duration 10±4 years). diagnosis of pd was made according to the uk parkinson's disease brain bank criteria. all dpd and ndpd patients were in hoehn and yahr stage 2 or 3 and matched for age, disease duration and severity (updrs-iii). we excluded patients with dementia, cognitive and/or executive function deficits assessed by the mini mental state examination, the frontal assessment battery and the wisconsin card sorting test. the beck depression inventory (bdi) was used to quantify the severity of depressive symptoms. all subjects underwent resting state 99m tc-ethylcysteine dimer brain perfusion spect. statistical parametric mapping (spm2) was used for data analysis (p<0.001 uncorrected). results: we observed hypoperfused regions in the left and right inferior frontal gyrus and in the left middle frontal gyrus; furthermore we found two areas of hyperfusion: the first one in the right thalamus and right hyppocampus and the other in the posterior cingulum, cerebellar tonsil and posterior lobe of left cerebellum. bdi mean score was 21±3 for dpd and 3±2 for ndpd (p<0.01, mann-whitney test); updrs-iii mean score did not differ between pd subgroups (dpd: 34±10, ndpd: 33±12). conclusion: our analysis outlined that major depression in pd is associated with hypoperfusion of inferior and middle frontal gyri. the findings suggest that loss of dopaminergic innervation in pd might cause impairment of fronto-striatal circuits and which plays a key role in the manifestation of depression in pd. introduction obsessive-compulsive disorder (ocd) has been suggested to be a neurobiological disorder arising from abnormalities in the serotonergic system. despite the therapeutic efficacy of serotonin uptake inhibitors, evidence from neurobiological studies does not provide consistent evidence for serotonergic abnormality. converging lines of evidence suggest a role for dopamine in ocd. objectives to investigate the binding potential change of [ 11 c]-sch23390 to dopamine d1 receptors in patients with ocd. methods seven patients fulfilling the dsmiv criteria for ocd and seven age and gender matched (39 +/-14 years) volunteers underwent a single 60 minute dynamic positron emission tomography (pet) scan with [ 11 c]sch23390 (630 +/-100 mbq) with a specific activity of 820 +/-400 ci/mm. pet scans were co-registered to individual mri and regions of interest compared. from the individuals mri, a cerebellar grey-tissue was defined as the reference region. logan graphical analyses was performed and distribution volume ratios (dvr's) defined for caudate, putamen, anterior cingulate, orbito-frontal-cortex and thalamus. results significant reductions (p = 0.026) in d1 binding potential were found in the caudate nuclei of patients in comparison to controls. conclusion this study is the first demonstration of a dopamine d1 abnormality in ocd. the findings implicate dopamine in the neurobiology of ocd and may help explain neuropsychological and neuroimaging findings associated with the disorder. background: cerebral activity patterns are distinctly modified by clozapine and typical neuroleptics. however, no study has directly compared to date the brain activity patterns while treatment with clozapine and other atypical antipsychotics. this comparison could contribute to a better comprehension of its respective mechanisms of action. the aims of this study were to compare the regional cerebral blood flow (rcbf) patterns of a group of schizophrenic patients who were switched from risperidone to clozapine due to lack of efficiency and to assess the corrrelation between the improvement in symptoms and the perfusion changes. material and methods: we have studied 9 patients (5 males; 7 paranoid and 2 undifferentiated patients, according to dsm-iv criteria) with 99m tc-hmpao-spect imaging at baseline (after a chronic treatment with risperidone) and after a month of treatment with clozapine. patients were performing a stroop test paradigm 10 minutes before and 10 minutes after a bolus intravenous inyection of 740 mbq of 99m tc-hmpao. spect images were analyzed with the spm99 (from the welcome dept. of cognitive neurology, london, uk) software package comparing baseline and after clozapine conditions. one-tailed significant threshold was set to p=0.001 with a minimum extent of 20 voxels. the correlation between the clinical improvement and the changes in rcbf was assessed with a spm general linear model using rank-transformed symptom scores and checking separately for direct and inverse associations. results: in comparison to the risperidone condition, brain perfusion with clozapina was significantly lower on the posterior orbital gyrus in the right side and on the ipsilateral parahippocampal gyrus. in addition, patients showed a higher perfusion as compared to risperidone on the inferior prefrontal cortex as well as on parieto-occipital region. positive symptom improved was directly correlated with the increase of activity in two frontal areas, left prefrontal and left premotor and the improvement in negative symptoms was directly related to the increase of perfusion on cerebellum and on visual association areas. however, no association was found between decreases in perfusion and clinical changes. conclusion: these data suggest that the effects of clozapine and risperidone on rcbf patterns during the perfomance of a cognitive test were quite distinct. the clinical changes correlated with the higher perfusion areas produced by clozapine. this may be consistent with the effectiveness of clozapine in patients that failed to respond to risperidone. hungary, 3 department of nuclear medicine university of szeged, szeged, hungary. several data suggest the role of the dopaminergic system in depression, but the results with functional imaging are contradictory. the selective serotonin reuptake inhibitor (ssri) antidepressants are believed to mainly act by selectively binding to the serotonin, but some of the ssris also exhibit other neuropharmacologic effects. the aim of this study was to evaluate the dat activity of untreated patients with unipolar depression and compared to healthy volunteers. we also studied the effect of sertraline on dopamin transporter activity in depression. materials and methods: we performed overall 30 123i-fp-beta-cit-spect examinations in 8 healthy controls (mini) and in 11 depressed patients (dsm-iv), the inclusion criteria was a score of at least 19 on the hamilton depression scale (ham-d, 21 items). in age-matched healthy subjects and in patients baseline 123i-fp-beta-cit-spect investigations were done, in the depressed patient group the dat spect was repeated after 3 weeks sertraline treatment. on the transversal reconstructed spect slices at the level of the basal ganglia, regions of interest were fixed by self-developed semiautomatic technique. the binding potential was estimated by the ratio of the specific to non-specific activity ({mean striatal activity-mean occipital activity}/mean occipital activity.) results: in the patients group, the median baseline binding potential was 3.16 (range: 2.67-3.6), in the control group, this value was 3.09 (range: 2.78-3.6). a mann-whitney u-test revealed that this difference was not statistically significant (z=-0.32, p=0.96). in the patient group, the median binding potential after sertraline administration was 2.79 (range: 2.64-3.33), which indicates a decrease of 9 % of fp-cit binding. ham-d scores showed 48% decrease after sertraline treatment. spearman's correlation indicated no significant relationship among binding potentials, ham-d scores, age, and education (p>0.5). conclusion: we didn't find any significant difference in the baseline values of dat activity between control and untreated depressed subjects. the ham-d score showed decrease after treatment, which prove effectiveness of therapy. sertraline treatment decreased the dat occupancy (9 %) but further investigations are needed to support this finding. aim: dopamine d2 receptor (d2r) availability appears to be important in addictive behavior. for example, low striatal d2r binding predicts high rates of intravenous cocaine self-administration in animals. the study of striatal d2r availability in mouse models of cocaine addiction may therefore be important to unravel the role of the d2r in addiction. additionally, endogenous dopamine release, induced by psychostimulants, may differ in drug-addiction. we recently developed a highresolution single-pinhole spect system to perform studies in small laboratory animals. in this study, we evaluated the feasibility to image d2r and to assess dopamine release in mice using the d2r antagonist [ 123 i]ibzm and our pinhole spect system. materials and methods: male c57bl/6j mice were scanned on our single-pinhole spect system [habraken et al. jnm 2001] . in this system, the mouse is tightly fitted in a cylinder which is positioned directly and horizontally above the pinhole aperture, and rotates during data acquisition. the pinhole collimator is connected to an adac arc3000 © scintillation camera. a 2-mm pinhole aperture was used. all experiments were acquired, step and shoot, with a 20% energy window around 159 kev in a 64 x 64 matrix, ror of 25 mm, field of view 28.8 mm. reconstruction was performed using the feldkamp algoritm. images were analyzed with fixed rois for the striatum and cerebellum. in a first study, mice were injected intravenously with 20 up to 70 mbq [ 123 i]ibzm and scanned continuously up to 2 h p.i. (10 frames of 12 min.) to study the pharmacokinetics of the radiotracer (7 studies in 4 mice). in a second experiment, the feasibility to assess dopamine release was evaluated. nine mice were injected 5 min. before ibzm injection (40 mbq) with saline i.p., and acquisition was started 90 min. (1 timeframe of 30 min.) after bolus injection of ibzm. approximately 1 week later, the same group of mice was rescanned, but now the mice received 2.5 mg per kg body weight amphetamine i.p. 5 min. prior to the injection of ibzm. results: injection of [ 123 i]ibzm resulted in clear specific binding in the striatum, with highest specific to non-specific binding ratios 90 min. after injection. in the second experiment, amphetamine induced a significant decrease in striatal ibzm binding ratios. conclusion: this study shows the unique possibility to image striatal d2r and to assess endogenous dopamine release in the mouse brain. aim: quantitative assessment of functional pet data is attractive since it can lower variability across institutions and may enhance the consistency of image interpretation independent of reader experience. various quantitative indices have been suggested for functional brain imaging of the dopaminergic system including advanced kinetic models and simplified semi-quantitative measures such as the specific binding index (sbi) computed as the ratio of uptake in a region with specific receptor binding to a reference region. a common problem with these indices is their dependence on the reference region of interest (roi) and the spatial resolution of the imaging system. therefore, partial volume effect results in underestimates of this index compared to the true value. materials and method: a new index named the specific uptake size index (susi), which considers total uptake in the object not just activity concentration, was recently proposed and claimed to be independent of roi size and system resolution. the validity of this index is assessed in this work using pet images acquired from an anthropomorphic striatal phantom study and 9 18 f-dopa studies of patients potentially suffering from parkinson's disease. for the latter, the external brain contour was drawn manually using the patient's coregistered mri to exclude the bony skull and cerebral border thus avoiding partial volume effect. the influence of roi size was assessed by drawing non-overlapping rois of different size around the striatum not necessarily covering the whole striatum. results: phantom studies showed that sbi measures based on maximum counts were 2.94 and 3.12 for right and left striatum, respectively, and proved to deviate considerably from the true value (8.0). the susi estimate is nearly constant in the striatum for rois greater than 57 cm 3 . below this volume, the susi estimates are not reliable. the clinical studies seem to report that the sbi derived from susi is always greater than the sbi derived from maximum counts in the rois. the sbi derived from susi that uses total uptake instead of maximum uptake is likely to be more accurate for small objects. conclusion: we have demonstrated using phantom and clinical data that the susi is approximately independent of the roi size allowing to guarantee good reproducibility of quantitative parameters estimates. significant increases and decreases of regional uptake were obtained using t-statistics at every voxel from patients and normal control groups. clusters consisting of a minimum of 50 contiguous voxels with an uncorrected p<0.01 were considered to be significantly different. results: the gmfcs scales of the spastic diplegia type cp patients were level 1 in 2 patients, level 2 in two and level 4 in one patient.the pyramidal tracts in the patients were grossly normal in terms of connectivity and white matter volume. [ 18 f]-ffmz binding was increased in the motor and premotor areas and bilateral visual cortices. conclusion; altered gaba a receptor binding in the motor cortices might play a important role in the pathogenesis of motor dysfunction in spastic type cp as the gabaergic signaling in the motor and visual cortices plays an important role in the development of peri-lesional or use-dependent plasticity after brain damage. msa is a neurodegenerative disease that manifests itself with clinical symptoms of parkinsonism combined with cerebellar ataxia, autonomic failure and pyramidal signs. the form with predominant parkinsonism (msa-p) accounts for 80% cases and its differentiation from parkinson's disease (pd) is often difficult. the aim was to examine potential role of scintigraphy in differerential diagnosis of msa-p and pd using binding potential of the striatum for 123i-fp-cit (datscan) and 123i-ibzm to reveal complex dysregulations in dopaminergic transporter/receptor system. methods: the study has been performed in patients suspected for diagnosis of msa-p based on clinical criteria including mri and poor response to dopaminergic therapy (n = 13), patients with verified pd (n = 25), and age-matched healthy controls in order to obtain normal values of diagnostic indices with fp-cit (n = 20) and ibzm (n = 9). inclusion of individuals and their informed consent has been approved by ethical committee of the hospital. in patients, both fp-cit and ibzm examinations have been performed with the same administered activity (185 mbq). control subjects underwent only one study, either fp-cit or ibzm. spect data have been recorded by triple-head gamma camera picker prism 3000 and dual-head gamma camera ge infinia-hawkeye. striatal binding capacity has been assessed visually and semiquantitatively as binding ratios striatal/occipital (sor) for fp-cit and striatal/frontal (sfr) for ibzm. results: in comparison with healthy controls, significantly reduced sor has been found in both msa-p and pd patients (p=0.01) in nucleus caudatus and in putamen. however, no difference has been found between the two groups of patients. in patients with msa-p, there was no difference in density of presynaptic dtransporters between nucleus caudatus and putamen. in contrast, sfr has been significantly reduced in nucleus caudatus and in putamen in patients with msa-p with respect to healthy controls (p=0.01) while no such difference was found in patients with pd. in 5 of 13 patients suspected for msa-p, diagnosis has been changed to pd due to normal density of d2 receptors in the striatum. in patients with msa-p, binding capacity for postsynaptic d2 receptors was reduced more in putamen than in nucleus caudatus (p=0.05). conclusion: assessment of dopaminergic transporter density in striatum using only fp-cit is not sufficient to differentiate msa-p from pd. instead, complex information is required on the dysfunction of dopaminergic transporter/receptor system in the striatum that can be obtained by comparison of fp-cit and ibzm scans. aim: to evaluate the usefulness of calculating an specific uptake index (sui) and the 123i-ioflupane spect (datsp) cut-off points as a supporting tool to diagnosis. material and methods: we included 327 patients (135 men and 192 women with an average age of 66) who had a diagnosis of suspected essential tremor (et) vs parkinsonian syndrome (ps). all patients received datsp four hours after a dose of 185 mbq loflupane -i123. using a visual appraisal method, we clasified the patients into normal (0), minor(1), moderate (2) and severe (3) . the quantification was made on two consecutive central transaxial views, drawing irregular and/or geometric regions of interest (rois) in striatum (str), caudate nuclei (c), anterior putamen (ap), posterior putamen (pp) and occipital. we calculated the sui using the following formula: counts in roi-counts in occipital/counts in occipital. we drew cor curves to determine discrimination cut-off points of pathological trouble. all data was captured and recorded in microsoft excel format, with analysis carried out using the statistical package, spss. results: the results from the visual appraisal method were 84 normal, 67 minor, 52 moderate and 124 severe patients. we calculated two discrimination cut-off points for the sui str of pathologic (1+2+3) and severe (3) with values < 5,5 (s 80%, e 60%) and <4,4 (s 80%, e 75%) respectively. we also calculated two discrimination cut-off points for the sui pp of moderatesevere (2+3) and severe (3) with values of <6 (s 80%, e 75%) and <6 (s 80%, e 75%) respectively. we related the sui in str, c, ap and pp and the differents pathological groups. we obtained statistically significant difference between the suiof the 3 group and the rest. conclusion: quantification of the sui is statistically significant to differenciate the severe group from the rest. the calculation of the sui pp is more useful given its highest sensitivity and especificity. regarding to gender and age , there were no significant statistical differences found. the visual appraisal method continues to be, in our case, the best tool for diagnosis to differenciate between these type of patients than obtaining quantitative values. aim it has been demonstrated that [ 123 i]fp-cit single photon emission computed tomography (spect) might be useful to characterize dopamine transporters (dat) loss in basal ganglia in parkinson's disease (pd), progressive sopranuclear palsy (psp) and lewy body disease (lbd) patients, but it is not capable to distinguish between these diseases. the aim of our study was to quantify serotonin transporters (sert) availability in the mesencephalic region of pd, psp and lbd patients by [ 123 i]fp-cit spect. materials and methods 60 patients (18 age-matched pd, 10 age-matched psp, 16 age-matched lbd and 16 age-matched healthy controls) were enrolled in this study. spect was performed in all cases after i.v. injection of 111 mbq of [ 123 i]fp-cit, using a double head gamma camera (infinia-ge). software coregistration of functional and morphological (mr) imaging data were then used to define regions of interest (roi) including mesencephal and the occipital lobe. the ratio of specific (mesencephal -occipital lobe) to non specific (occipital lobe) binding was calculated. results by semiquantitative analysis, the ratio of mesencephaloccipital lobe (specific) to occipital lobe (non specific) were different between pd (mean=0.78, range=0.4-0.9), psp (mean=0.14, range=0.10-0.22), lbd (mean=0.08, range=0.06-0.09). when compared to controls (mean=0.8, range 0.7-0.9), were not different for pd. as compared with control values, the psp and lbd patients had a significant reduction of specific [ 123 i]fp-cit binding in the mesencephalic region. conclusions our results suggest that sert in mesencephalic region can be used in diagnostic differentiation between pd, psp and lbd. our findings need to be confirmed in larger number of patients. objective: it is necessary to obtain an arterial blood sample to calibrate and individualize the standard arterial input function for regional cerebral blood flow mapping with iodine-123-imp (imp) autoradiographic (arg) method (j nucl med 1994; 35: 2019) . the objective of this study was to propose an alternative method without blood sampling to estimate individual calibration coefficients for arg method. methods: if the individual difference in the brain distribution volume (vd) of imp is small enough, the calibration coefficients for the standard input function (cf: (kbq/ml) / (cps/g blood)) can be estimated from a product of cf and vd that can be obtained by 2-compartment model analysis of brain time-activity data using the uncalibrated standard arterial input function. to validate this method, 109 consecutive patients with various cerebral diseases (67 ± 13 years old, m/f=60/49) were studied with imp dynamic spect. imp (167 mbq) was infused intravenously over 1min. immediately after starting the infusion, dynamic spect data acquisition (14 rotations/35 min) was performed. seven to ten minutes after starting the infusion, onepoint arterial blood sampling was performed to measure cf. by threshold percentages (5, 10, 20, 30%) to the maximum, the mean+2.5sd and the mean+2sd of voxel count in the brain, twelve whole brain time-activity curves (tacs) normalized by the volume of interest given in kbq/ml were generated. each tac was fitted to 2compartment model using the uncalibrated standard arterial input function to obtain a product of influx rate constant (k1: ml/min) and cf (cfk1), and efflux rate constant (k2: 1/min). dividing cfk1 by k2, the quotient (cfk1/k2) gave a product of cf and vd (cfvd). the correlation between estimated cfvd from 2-compartment model analysis and measured cf from arterial blood sampling was investigated in a set of brain tacs. results: measured cf ranged from 0.20 to 1.07 (0.49 ± 0.14). in every 2compartment model fitting, cfk1, k2, and cfvd could be determined with small error of estimate. among the eight conditions for determining the brain border, the best correlation between estimated cfvd and measured cf was noted in the set of tacs determined by the threshold of 10% to the mean+2.5sd of voxel count (cf=0.045 cfvd +0.216, r 2 =0.694, n=109, rmse=0.0776, p < 0.0001). conclusion: in arg method, the calibration coefficients for the standard arterial input function could be estimated without arterial blood sampling, using proposed linear regression equation. brain death is present when all functions of brain stem have irreversibly ceased. before discontinuation of artificial ventilation and organ harvesting the instrumental confirmation is necessary in addition to neurological findings. authors present own experiences with brain perfusion scintigraphy in the diagnosis of brain death. patients and method: 71 brain scintigraphies for confirmation of clinical diagnosis of brain death in 70 patients (45 male, 25 female, in age 18-78 years) were performed in the years [2003] [2004] [2005] [2006] . 63 patients were examined as potential donors of organs, seven from other reasons. about 700 mbq of 99mtc-hmpao was injected as bolus to central vein. dual-head spect gamma cameras with lehr collimators for acquisition of the date were used. flow images (2 s per frame) were acquired from the time of tracer injection to one minute. planar images in four projections or spect of the head were obtained subsequently. in brain death flow images show completely absent of the blood flow superior to the circle of willis circulation and planar images or spect demonstrate no radiopharmaceutical uptake in the whole brain. results: in 68 patients the brain death was unambiguously confirmed. in two patients (a female after cerebellar hemorrhage and a male after suicide of hanging with repeated scintigraphy after 24 h) had brain perfusion partly preserved and brain death was not confirmed. we did not find mismatch between dynamic and static images. no side effects were observed. conclusions: cerebral perfusion scintigraphy is simple, reliable, safe and cost-effectives method for confirmation of irreversibility of clinical signs of brain death. the great advantage against x-ray angiography is exactness of findings also in cases of head injury and after craniotomy. other advantage of perfusion scintigraphy is non-invasivity and there is no fear of damage of organs for transplantation due to injected x-ray contrast substances. aim: to determine whether age-matched normal database (ndb) is necessary for the detection of alzheimer's disease (ad) using brian fdg pet and automatic image analysis. material and methods: we generated 6 age-specific ndb sets ranging in age from 20 yr to 70 yr; each consisted of 10 males and 10 females. in order to assess the diagnostic performance using these ndbs to distinguish ad patients from normals, 34 patients (11 males, 23 females; mean age, 66.2 ± 8.2 yr) with probable ad and 20 normal subjects (10 males,10 females; mean age, 67.4 ± 8.0 yr) were recruited. the image analysis was performed using neurostat. the changes of relative fdg activity with age were measured for the posterior cingulate gyri and precunei (pcgp). a receiver-operating characteristic (roc) analysis was performed for comparison of the diagnostic accuracy using these ndbs. results: there was no significant difference in area under the roc curves (az) for the discrimination of ad patients from normals (table) . furthermore, there was no significant correlation between the relative fdg activity in pcgp and age. conclusions: our results indicate that age-specific normal database for fdg pet may not be necessary for the detection of ad. this could be explained by the lack of significant correlation between relative fdg activity in pcgp and age. aims: anatomical imaging methods, especially computerized tomography (ct) and magnetic resonance imaging (mri) are helpful in diagnosis of acute traumatic brain injuries (atbi) however, they are not as efficient as single photon emission computed tomography (spect) for the diagnosis of traumatic brain injury with chronic symptoms (tbics). our aim was to compare brain perfusion spect and ct or mri findings in patients with a history of thics being followed for more than one year. material and methods: ninety two patients fulfilled the criteria to enter our study. sixty-two of these patients had a history of a mild brain disease (group a) while the remaining 30 cases had a history of moderate to severe brain disease (group b) .the age of our patients ranged between 19-66 y, with mean age 40.55 ± 11.96 y. the mean post-traumatic period was 1.22 ± 0.43 y. these patients presented with various neurological signs and symptoms especially due to hypofrontality and hypotemporalism. brain perfusion spect with 99m tc-ecd and ct or mri were obtained in all patients with a maximum interval of one month between each procedure. in our study, the brain was divided into ten areas five regions in each hemisphere. the spect, ct and mri images were interpreted separately by two nuclear medicine physicians and two radiologists who were blinded to all study results. results: out of a total of 920 brain regions, brain perfusion spect revealed 460 lesions (50%) while, anatomic modalities ct or mri detected significantly less lesions (42.3%) (p<0.05). conclusion: brain perfusion spect may be more useful than anatomic imaging procedures in identifying tbics, especially in patients presenting with symptoms of hypofrontality or hypotemporalism. brain perfusion spect can be effectively used to identify the chronic complications of remote traumatic brain injuries. effect of aerobic training on tc99m-sestamibi uptake by rat brain: evidence for exercise augmentation of the blood-brain barrier (bbb) function ? introduction-aim: bbb effectively contributes to brain homeostasis maintenance. tc99m-sestamibi does not enter normal brain and its uptake is very low. cerebral capillary endothelium, a major bbb component, is characterized by a five-fold mitochondrial content compared to capillaries of systematic circulation. high mitochondrial density is potentially related to increased pumping energy demands of the bbb. mitochondria are also a known subcellular target of tc99m-sestamibi. moreover, p-glycoprotein, a membrane efflux pump, using tc99m-sestamibi as substrate is abundant on bbb. this study investigates the impact of the aerobic trainning on brain uptake of tc99m-sestamibi and a possible explanation is discussed animals and methods: twenty-four adult male wistar rats were allocated to a trained (n=13) and an untrained (n=11) group. endurance exercise on a motor-driven treadmill had the following characteristics: speed 25 m/min for 60 min, 5 days/wk for 14 weeks. on completion of the training program, tc99-sestamibi (5.6 mbq/kg body weight) was administered i.v. to all animals. two hours after injection, heart, brain, blood and various skeletal muscles of the hindlimbs were removed. tc99m-sestamibi uptake was calculated, after activity measurement in a well-type counter, as % of injected dose (id) per tissue gram. differences between trained and untrained rats were assessed for significance at p<0.05 level by the independent student's t test. results: tc99sestamibi uptake in both myocardium and skeletal muscles of trained animals was significantly higher than that of untrained, thus evidencing the effectiveness of the exercise scheme.tc99-sestamibi uptake was very low in brain, comparable to blood levels. however, uptake in trained rats was about double than in untrained: 0.0094 vs 0.0056 %id/g, p<0.001. conclusion: despite being low, tc99-sestamibi uptake in rat brain is increased after a period of aerobic training. both accelerated fuel transportation and increased prohibitive activity against various exercise-related metabolic products by the bbb during repeated exercise bursts, may induce mitochondriogenesis in bbb endothelium, thus explaining increased tc99-sestamibi uptake in trained animals. the purpose of this study was to investigate the neurological variables associated with chronic traumatic brain injury in amateur boxers. material and methods: cerebral perfusion changes were evaluated using technetium-99m hexamethylpropyleneaamineoxime single photon emission computed tomography (tc-99m hmpao spect). spect were performed in 14 boxers and 16 healthy volunteers. images were acquired using a dual-headed gamma camera equipped with high resolution parallel-hole collimators. quantitative analyses were done using brain spect assessment tool in general electric xeleris work station (neurogam). results: analysis of tc-99m hmpao spect images showed that the boxers had more cerebral perfusion changes than healthy volunteers. all cortical areas showed decreased blood flow especially in frontal and temporal areas in boxers. conclusion: in conclusion, the results showed that tc-99m hmpao spect could be helpful to investigate cerebral blood flow abnormalities in amateur boxers and differences from healthy volunteers. cerebral perfusion changes should be taken into consideration in evaluating boxers having any neurological symptoms. the difference of brain fdg uptake pattern between health adults and cancer patients m. si, j. liu, g. huang, x. sun; renji hospital, shanghai jiaotong university, shanghai, china. aim: to determine the difference of brain fdg uptake pattern between health adults and cancer patients. material and method: the brain fdg uptake patterns of 585 patients who performed pet/ct scan in our center from aug. 2004 to dec. 2005.were retrospectively studied. the inclusion criteria is: (1) absence of clear focal brain lesions (epilepsy, cerebrovascular diseases etc). (2) absence of metabolic diseases, such as hyperthyroidism, hypothyroidism and diabetes. (3) absence of psychiatric disorders and abuse of drugs and alcohol. (4)cancer patients were diagnosed definitely of variable cancers except brain cancer or brain metastasis. the normal group consists of 295 subjects for tumor screen and got negative results. the age is ranging from 21 to 88 yr. the cancer group consists of 290 various cancer patients. the age is ranging from 21 to 85 yr. both groups were sub grouped into six starting from 21 years old with the interval of 10 years old, and the gender, educational background and serum glucose were matched. all 12 subgroups were compared to the subgroup of normal 31-40 years old called control subgroup (84 subjects). the t-statistic analysis was applied to all brain images using the spm2 software. results: with the increasing of age, similar hypometabolic brain areas are detected in both normal group and cancer group ,they are mainly in the cortical structures such as bilateral prefrontal cortex, superior temporal gyrus(ba22),parietal cortex (inferior parietal lobule and precuneus(ba40),insula(ba13)),parahippocampal gyrus and amygdala(p<0.01)and are especially apparent in the prefrontal cortex(ba9)and sensory-motor cortex(ba5,7)(p<0.001). but characteristic hypometabolism in cingulate gyrus and bilateral cerebellum are only seen in cancer group.compared to the same age interval of normal subgroup, each cancer subgroup shows significant hypo-metabolism in cingulate gyrus (p<0.001),as well as bilateral cerebellum and basal ganglia(lentiform nucleus and thalamus)(p<0.01). conclusions: relative hypometabolism in limbic system such as cingulate gyrus and basal. fahr's disaese is a rare of unknown aetiology disorder characterised by massive symmetrical calcifications of the basal ganglia, dentate nuclei and subcortical white matter. although the clinical pattern of fahr's disease is variable; neurobehavioural, cognitive, extrapyramidal-cerebellar symptoms, dementia, seizures and speech disorders are most common clinical features. clinical and ct scan examination is enough for diagnosis. in the literature there is no study performed to evaluate the value of hmpao brain perfusion spect in fahr's disease to the best of our knowledge. the clinical, ct scan and hmpao brain spect findings of a 42 years-old woman with fahr's disease is reported. the patient presented to a neurologist with difficulty to use the upper limbs bilaterally (more prominent of the left side) and reduced movement ability six years ago. on neuropsychiatric examination; a mild deterioration of frontal functions was mentioned and computed tomography showed no abnormality. when symptoms progressed she was reevaluated and a non-enhanced ct scan revealed extensive, symmetrical intracranial calcifications involving the dentate nuclei and white matter of cerebellum, globus pallidus, putamen, caudate nucleus, internal capsule, thalami and centrum semiovale. serum levels of ionised calcium, phosphorus and parathyroid hormones were within normal range. she had no family history and was diagnosed as idiopathic sporadic fahr's diasease. spect images did not demonstrate perfusion abnormalities in all calcification foci visualised bilaterally on ct scan. hmpao brain perfusion spect images showed hypoperfusion in the left visual centre compared to that of right side and perfusion defect in the right basal ganglion. spect images did not demostrate perfusion abnormalities in all calcification foci visualised bilaterally on ct images. spect findings were not only congruent with the coresponding ct scan abnormalities but also correlated more specifically with the clinical findings. this case suggests that hmpao brain perfusion spect is useful in the clinical approach of fahr's disease providing more specific and clinically relevant information as compared to anatomical imaging. chronic fatigue syndrome (cfs) is an heterogeneous disease: disabling fatigue lasting at least 6 months and accompanied by numerous rheumatological, infectious and neuropsychiatric symptoms. nowadays there is not a test with enough sensitivity or specificity to constitute a reliable diagnostic tool. aim: to describe the usefulness of brain perfusion spect in the evaluation of patients with chronic fatigue syndrome (cfs), comparing the basal brain perfusion pattern with the cortical changes after physical exercise and a mental test. material and methods: thirty-five patients (29 female, mean age 46 years) with clinical criteria of cfs (holmes and fukuda) were included. all of them underwent a 99m tc-ecd brain perfusion spect (925 mbq, double-headed gammacamera) in basal condition and after a stress test. the study consisted in physical exercise in the morning and injecting the tracer at the middle of a neurocognitive test (wais modified) in the afternoon. all the brain spect were blindly evaluated by 2 experts, using a semiquantitative score: normal uptake (score 0), slight hypoperfusion (score 1), mild hypoperfusion (score 2) or severe hypoperfusion (score 3). cortical areas: frontal, temporal, parietal and occipital. results: 4 patients showed a normal brain spect in basal and stress condition and 5 patients (14.2%) showed decreased perfusion in both studies, without changes in the intensity and localization of perfusion deficits. in 26 patients (74.3%) changes in perfusion were appraised: eighteen (51.4%) showed decreased perfusion after psychological test with regard to basal condition (p= 0.0001). frontal and temporal lobes were predominantly involved. eight patients (22.8%) showed improvement in brain perfusion after the neurocognitive test (p= 0.001). conclusion: our results showed a high percentage of blood flow impairment in cfs patients, which worsened after a combination of physical and stress-mental test. brain perfusion spect might be a useful tool to improve diagnostic approach to an elusive illness such as cfs. the use of an objective neuroimaging method may help in the characterization and monitoring of brain perfusion abnormalities in cfs. the intoxication has adverse effects on health: digestive, endocrinologic and neurologic symptoms. these symptoms are unspecific (dizziness, asthenia, itchy sensation..) and often difficult to distinguish from a functional disorder. the aim of this work was to evaluate the brain perfusion changes in patients exposed to organophosphorate compounds. material and methods: nine patients (p) (9 women; aged 20-50 years; mean age: 42) with chronic exposure to organophosphorates were included. brain perfusion spect (25 mci 99m tc-ecd) was performed in all p using gems vg, hawkeye gamma camera and fan beam collimator. brain perfusion was analysed in all patients using spm2 program and comparing each patient with a healthy control group. in all cases neuropsychological test, electroencephalogram, ct scan were also obtained. results: in 2p the brain perfusion was normal. the 7 remaining showed hypoperfusion in different brain areas: 4p (parietal lobe -2 right; 2 left-); 1p (posterior frontal); 1p (right mesial temporal); 1p (posterior temporal, anterior and temporo-parietal). conclusions: in 7 of the 9 patients exposed to organophosphorates spm2 detected significant brain hypoperfusion. the cerebral lobe involved was variable. further studies are necessary to confirm these results. recently, the physikalisch-technische bundesanstalt (ptb) and the company aea technology (now: qsa global) organized a joint national comparison of 99m tc solutions in order to obtain information on the quality of routine activity measurements in nuclear medicine in germany. the participants were asked to measure the activity in p6-type glass ampoules and in syringes. the results and supplementary information on the instrument characteristics, uncertainties, radionuclidic impurities and steps for quality control had to be stated in a questionnaire prepared by the organizers. in this contribution, the 99m tc comparison results for two different geometries are presented and compared with results of previous comparisons. in particular the distribution of the deviations (a i -a i, ref )/a i, ref with the activity a i stated by the participants and the ptb reference activity a i, ref were analyzed. about 92% of the results fulfil the limitations prescribed by the european pharmacopoeia [1] , i.e. the deviation to the reference value is less than ±10%. the data clearly indicate a considerable reduction of the deviations compared to results obtained in previous comparisons [2, 3] . in spite of this improvement there is still a considerable number of results which do not comply with the ±10% criteria. these data were carefully analysed to detect potential causes for discrepancies and to find steps for further improvements of the quality in nuclear medicine. after a period in which the results of all participants were collected, all of them obtained a calibration certificate stating the reference activity value from the ptb. this document can be used as an important tool for quality control in the respective institute. [ (t) time from the elution to the labeling. test anova (p = 0.044 <0.05) indicates significant differences and test of bonferroni specifies that these occur between group 1 with respect to 2 and 3, and do not occur between groups 2 and 3. conclusions the increase of the rcp in groups 2 and 3 indicates that can be used eluents with a time over to 2 hours, unlike at the specified in the technical leaflet of the ceretec®. this radiochemical can be used in the leukocytes labeling without decrease in its efficiency. aim the development of 99m tc-labeled infection imaging agents will contribute in the differential diagnosis of infection versus aseptic inflammation. currently, there are several formulations for the labeling of fluoroquinolones with tc-99m that show contradictory data. our aim was the development of tc-99m analogs of fluoroquinolones (norfloxacin and ciprofloxacin) of well-defined structure as well as their biological evaluation in vitro and in vivo. materials and methods fluoroquinolones, fq (norfloxacin and ciprofloxacin) have been functionalized at the n atom of the piperazine ring, by conjugation on suitable bifuctional chelators, n, n-(2-picolyl)amino-diacetic acid (pada) and l-cysteine to form o-c 5 h 4 n-ch 2 n(ch 2 cooh)ch 2 co-fq (fq-pada) and hoocch(nh 2 )ch 2 sch 2 ch 2 ch 2 -fq (fq-cys) respectively. fq-pada and fq-cys reacted with [ 99m tc(co) 3 (h 2 o) 3 ] + (0.5 ml, 1-10 mci) and produced two types of neutral 99m tc complexes, fac-[ 99m tc(co) 3 (fq-pada)] and fac-[ 99m tc(co) 3 (fq-cys)]. in vitro studies were performed, by incubating these 99m tc complexes with 1x10 7 cfus of s. aureus and e. coli. in vivo studies were performed by injecting 10 μci of the 99m tc complexes via the tail vain in mice. results and conclusions the 99m tc complexes synthesized were analyzed by hplc and showed, in all cases, the formation of one radioactive species. in vitro studies of the 99m tc complexes resulted in 20-27% binding in s. aureus, while the binding to e. coli was found to be lower for all the compounds tested (10-15%). in vivo biodistribution studies in mice (5 and 120 min p.i.) showed that all the compounds present fast blood and soft tissue clearance. preliminary studies showed that only small percentage of activity accumulates in muscles with induced aseptic inflammation (turpentine oil, negative control) resulting in an inflammation to normal tissue ratio 1.5. further in vitro and in vivo evaluation is in progress, in order to prove the potential radiopharmaceutical use of these novel technetium-99m compounds as specific infection imaging agents. aim: the application of the heart-lung machine in human medicine implies the sideeffect of activated granulocytes which may cause inflammatory processes in the human organs. for this reason tc-99m hmpao labeled granulocytes were used to localize the inflammatory process in pigs. imaging was performed to determine the distribution of tc-99m hmpao labeled granulocytes in the organs and thereby the state of inflammation. material and methods: domestic pigs aged about 3 month weighing 34 -58 kg were examined. after gradient centrifugation of 80 ml venous blood from the animal to isolate the granulocytes for labelling with 93 -250 mbq tc-hmpao, the labeled granulocytes were then reinjected into the pig following thoracotomy. imaging was performed after at least 2 hours of incubation time with a dst-xli gamma camera (ge). in each case a whole body scan (ap; scan speed 6cm/min) was carried out and in some cases spect imaging (128 projections; acquisition time 30s/step). for quantification the geometric mean of the corresponding roi's over the liver, spleen, lung and brain of the anterior and posterior view of the whole body scan were obtained. the count rate was correlated to the administered activity and the weight of the animal. as reference organ the liver was selected. e.coli lps induced inflammations were generated as a positive control. results: the main part of the activity is located in the liver (30%). the activity in the spleen is decreased by a factor 1,8 and the activity in the brain is reduced by a factor 14 in comparison to the liver. partly found unexpected high count rates in the lung were related to pneumonia of the animals. artificially generated inflammations were well displayed. conclusion: this method is basically suitable for inflammatory process imaging in pigs. the presented model is herewith suitable to answer questions concerning inflammatory process imaging in human medicine. the animals should be pre-treated with antibiotics in individual cases to preclude unspecific activity enhancement if applicable. introduction: the recommended method (meth1) to determine the radiochemical purity (rcp) of tc-99m tetrofosmin (tfos) involves developing an itlc-sg strip in dichloromethane:acetone (65:35). in this system, colloids and hydrophilic impurities remain at near origin, free pertechnetate (tco 4 ) runs near the front, and tfos migrates with an rf of ~0.6. the disadvantages of this method include the need to prepare a fresh mixture of volatile solvents daily, sensitivity to spot size, and slight variations in the rf of tfos which result in falsely low rcp values using the cut and count technique. an alternative method (meth2) developed for rcp testing of tc-99m sestamibi (proulx et al, appl radiat isot 1989;40:95-7) has now been validated for tfos. methods: meth2 uses two strips of itlc-sg developed in 2-butanone and saline, respectively. in 2-butanone, insoluble impurities and tc-99m gluconate intermediate (gluc) remain at the origin while tfos and tco 4 migrate near the front, whereas in saline the impurities tco 4 and gluc migrate with the front and the remainder stays at the origin. rcp is calculated as 100% minus the two impurity measurements (note that gluc is double counted, however it is a very minor component). meth2 was compared with meth1 on samples of tfos and impure mixtures with free tco 4 , colloid, and/or gluc added. a preparation at high radioactivity concentration without oxygen venting was used to produce an additional impurity. results: with clinical preparations of tfos there was no significant difference in rcp measurements: meth1 96.9±0.7%, meth2 97.3±0.8% bound, n=12; paired t-test p=ns. with impure mixtures (0.1-97.7%) the regression line had the equation: rcp(meth2) = 0.944 rcp(meth1) + 3.9, n=14, r 2 =0.990. most importantly, in the critical region around the 90% cutoff, the meth2 produced results ~1% lower than meth1. in the period during which meth2 has been in routine use, it has detected one product failure and the result was confirmed by meth1. during this period the mean rcp was 96.8±1.5% (n=218). conclusions: this report presents validation of a new method for rcp testing of tfos which is rapid, uses standard solvents and media, does not require daily preparation of a mixture of volatile solvents, provides clear and reproducible separation between impurities, and can also be used with sestamibi. aim: quality controls on renal scintigraphic agent 99m tc-mag3 prepared following procedures recommended by manufacturer, in our experimental conditions, gave poorly reproducible radiochemical purity results and often below the minimum acceptable. for this reason we investigated if modification of physical and chemical variables involved in preparation and storage could enhance 99m tc-mag3 radiochemical purity. material and methods: parameters involved in this study were the following: time elapsed between elution and labelling, age of the technetium generator column, opposite sequence of dilution and heating steps, activity/volume ratio for labelling, duration of heating and storage temperature of labelled drug. moreover, we aimed to study 99m tc-mag3 stability beyond four hours from labelling. quality controls were performed immediately after labelling, at 30 minutes, at 1, 2, 3, 4, 6 hours and in some experiments till to 48 hours. as analytical technique a double paper chromatography (whatman n.1) was choosen, eluted with acetone to separate free pertechnetate and with acetonitrile: water (60:40) mixture to separate reduced hydrolyzed technetium. results: dilution after labelling is not recommended. storage at 4°c did not prolong stability, so it is also not recommended. the following parameters did not influence labelling yield and stability of 99m tc-mag3: time elapsed between elution and labelling, age of technetium generator column, prolonged heating. labelling with innovative activity/volume ratio (1.5 gbq in 2.5 ml) constantly gave higher radiochemical purity results compared to recommended ratio (11 gbq in 4 ml). beyond, it was demonstrated for both labelling procedures a prolonged stability of 99m tc-mag3 till to 8 hours after labelling. conclusion: 99m tc-mag3 chelation complex demonstrated an high physical chemical stability significatively influenced only by activity and volume used in labelling procedure. labelling with 1.5 gbq in 2.5 ml allows preparation of an higher number of doses from the same kit and the execution of diagnostic procedures requiring higher activities than conventional. finally, if evidences emerged from this study about 99m tc-mag3 prolonged stability will be confirmed by other experiments, it would be possible to administrate it till to 8 hours after labelling, a double time compared to 4 hours time interval recommended by manufacturer. aim: sodium iodide-123 is well known as a radioisotope that is used for studies of the thyroid and its metastases. 123 i labelled compounds are used for kidney, heart and brain studies.since demand for i-13 is increasing a serious effort for production of i-123 has performed. material and methods: for production of 123 i, a home made target was designed. the main part of the target contained; conical target vessel that was mounted in an aluminium cylinder of length 30 cm and diameter 8.5 cm for water cooling during bombardment. front and rear target windows made by titanium foil and cooling system. in addition, some other part such as a cold finger, decay vessel, vacuum pump and four fingers also designed and installed on the system. 123 i was produced from the reaction of 28 mev protons with 99.9 % enriched 124 xe with cyclon-30. bombarded xenon was transferred to the vessel and stored there up to about 6 hours to allow 123 cs decay to 123 i with the maximum efficiency. the remaining xenon gas was then transferred into the reservoir capsule using a cryogenic technique. the produced, 123 i which is deposited on the wall of the decay vessel, was rinsed out by dissolution in 0.05 μs water at 80ºc. nitrogen gas pressure was used for the transfer the 123 i solution to the chemical hot lab. the ph, and adjusted with sodium hydroxide. results and discussion: a sample of production was send to quality control. quality control results were in good accordance with the united states pharmacopoeia conclusion: using this system with the above specification, the production yield could be increased by increasing the current. the results shows no chmical or radionuclide impurity, and enable to produce i-123 withouht any more purification step. aims: in order to overcome the limitations of the reported methods, a short and simple method for the preparation of radioiodinated n-succinimidyl-4-iodobenzoate that is widely used for radioiodination of antibodies is described. material and methods: the method involves the reaction of in situe generated trimethylsilyl radioiodide from trimethylsilyl chloride with n-succinimidyl-4-[3,3(1,4-butanediyl)-triazene]benzoate available from the condensation of n-hydroxysuccinimide and 1-(4-carboxyphenyl)-3,3-(1,4-butanediyl)triazene in the presence of dicyclohehyl carbodiimide. the recent triazene was prepared by precipitating the diazonium ion of 4-aminobenzoic acid with pyrrolidine. a microwave-mediated rate acceleration was observed during the radioiodination step. results: activation of radioiodination reaction by exposure to microwave irradiation (in a domestic oven at 2450 mhz for 8 minutes) afforded the radioiodinated product in 81% radiochemical yield. conclusion: when compared with alternative methods, the present approach, which reduced the reaction sequence until 3 steps was faster and the method required less expensive reagents and purification was easier. aim: transarterial chemoembolisation (tace) is a promising approach in the therapy of malignant, hypervascularized liver tumors. developing and optimizing radioiodination reactions and adding the labelled product to an original drug-deliveryembolisation-system was the main goal of this present investigation. this may help to determine an individual, pharmakokinetical parameter and possibly will increase therapeutical effects in prospective animal and human studies. material and methods: in a first step iodogen ® as radioiodination agent was used for labelling anthracycline analogs (doxo-, epi-. dauno-, iododoxorubicin). the labelled products were characterized and separated by hplc (radio-and diodenarray-detektor) and tlc. in a next step another direct electrophilic radiolabelling [iodine monochloride (icl) methode] with c.a. i-123-nai and i-131-nai (20°, 30 min) has been performed. the subsequent hplc-isolating was changed by spe (sep-pak c18-cartrigde). after removing the solvent the product was solubilised in 0.9 % saline solution. results: the radiochemical yield (rcy) with iodogen-method was 9±3%. in comparison to that the iodine monochloride method achieved higher rcy's for doxo-(18±5%), epi-(12±8%), dauno-(20±7%) and iododoxorubicin (38±8%). in vitro stability of all products was controlled after 6h. specific activity lay around 100 mbq/μmol. conclusions: the direct iodination method with icl was proved to be a viable labelling possibility of anthracycline analogs. specific activities are very low, but these results are sufficiently working in case of use in combination with unlabelled therapeuticals in a chemoembolisation system. higher rcy's of iododoxorubicin can be explained by isotopic exchange. after validation of radiolabelling conditions and results the chemoemolisation system with radiolabelled anthracycline and the sterilisation of the used materials needs further investigation. this could lead to a proved method for nuclear medical imaging of a radio-chemoembolisat for locoregional application. the development of new pet radiopharmaceuticals demands strategies for the identification of dedicated targets. following the identification of a target, the "in silico" search for substrates is a promising approach to achieve specific drugs. methods: the search for targets for new radiopharmaceuticals demands the use of large scale gene expression data, usually obtained by gene array techniques. we used gene array data, obtained from 42 tissue specimen (25 human tumors, 17 reference tissue samples) to search for differencially enhanced genes, in order to identify possible targets for new radiopharmaceuticals. furthermore, ten samples from a human colorectal cell culture line were evaluated. gene expression data were obtained using the u133a and u133 plus 2.0 gene chip (affymetrix inc., santa clara, ca, usa). gene expression values were converted to relative expression values (rev): rev = 1000 * (gene expression value -minimum expression value) / (reference gene expression -minimum expression value). the genepet module of the pmod software (pmod technologies ltd., adliswil, switzerland) was used for data evaluation. the fast rigid exhaustive docking (fred) software (openeye scientific software, santa fe, nm, usa) was used to assess receptor/ligand properties. results: the gene expression data comprised 22283 (u133a) or 54675 (u133 plus 2.0) probe values for each tissue sample. following normalization, matrices were calculated for the ratios tumor/reference tissue as well as for the mann-whitney test variable of each gene. search strings were applied to select those genes related to receptors and cell membrane proteins. furthermore, discriminant analysis based on the support vector machines method (svm) was used to select those genes from the subgroup which provide the best discrimination between tumor and normal tissue. the final svm analysis provided 35 genes related to cell receptors, mainly belonging to the group of g protein-coupled receptors. following the identification of targets, the fred software was used to assess possible substrates for these receptors. conclusions: molecular biological data, obtained by gene array analysis, provide a promising approach for the development of new pet radiopharmaceuticals. the combination with computational drug software helps to select a subgroup of substrates for receptors and membrane structures, which are then further evaluated using conventional lab procedures. aim several radiolabelled amino acids have proven to be useful as a radiopharmaceutical substance for pet imaging of tumors. o-(2-[ 18 f]fluoroethyl)-ltyrosine (fet) seems to be one of these promising compounds. this 18 f-labelled amino acid can be synthesized with high radiochemical yield. large production and distribution is allowed by using 18 f. fet provides excellent quality for pet imaging of solid gliomas in brain. from these points of view fet is the right choice for our interest. the synthesis of fet is known, however, modification of the method for our facilities was necessary. the aim of this study was to adapt synthesis method in order to start production of fet as a commercial pet imaging tracer. materials and methods the synthesis was performed with tracerlab mx system (coincidence), which is originally designated for production of [ 18 f]fdg. therefore, some modifications in method had to be done. synthesis is based on phase transfer mediated nucleophilic 18 f-fluorination of o-(2-tosyloxyethyl)-n-trityl-l-tyrosine tert.butylester with subsequent hydrolysis by mixture trifluoroacetic acid / 1,2-dichloroethane. subsequently, purification of reaction mixture was completed by reversed phased hplc. quality control was done with hplc for radiochemical and enantiomeric purity. results because the production automat did not resist the mixture trifluoroacetic acid / 1,2-dichloroethane, we changed the deprotection step and applied 5m hcl. the fluorination yield ranged from 80 to 85% and overall yield was 40-45% (uncorrected for decay). radiochemical purity was over 95% and enantiomeric purity was 100%. conclusion we successfully developed and tested the synthesis of [ 18 f]fet in our production conditions. nowadays we are providing biodistribution and preclinical studies with animals. finally, we are intended to distribute fet to medical facilities. acknowledgement this work is supported by the project no aim: evaluation of a 68 ge/ 68 ga generator to produce carrier free 68 ga radionuclide and optimization of a synthesis method to obtain 68 ga-dotatoc for clinical purpose. materials and methods: imaging of sstr expressing tumours, such as neuroendocrine, lymphomas, meningiomas and breast cancers, has been greatly improved by utilization of 68 ga-dotatoc radiopharmaceutical and positron emission tomography. in this study 68 ga-dotatoc was synthesized from a 30 mci 68 ge/ 68 ga generator (cyclotronco., obninsk, russia) carrying out the following steps: i) 68 ga in cationic form 68 ga 3+ was eluted from the generator by a 0.1 m hcl solution and trapped in a cation exchange cartridge. ii) metallic and radionuclidic impurities, such as fe (iii) and zn (ii) were washed to waste by rinsing the cartridge with a 80% acetone / 0.15 m hcl solution. iii) 68 ga 3+ was eluted to the reactor with a 98% acetone / 0.05 m hcl solution and reacted with 14 nmol of dotatoc in a no buffered water solution. 68 ge (iv) breakthrough and ti (iv) impurities remained in the cartridge and were subsequently eluted to waste by 4 m hcl and water iv) after labelling, in order to eliminate not reacted 68 ga 3+ , the crude solution was passed in a apolar c18 cartridge where 68 ga-dotatoc was trapped. v) final product was eluted by ethanol and diluted with an appropriate amount of saline solution for the final formulation. during the validation of the method a complete set of quality controls including radiochemical purity by radio-tlc and radionuclidic purity by -spectrometry was performed; sterility of the preparations was also assessed. results: about 30 syntheses were carried out during six months of activity and an amount ranging between 555 to 296 mbq (depending on the 68 ge/ 68 ga generator life) of 68 ga-dotatoc was obtained. mean synthesis yield was computed to be 59±2 % (not corrected for decay) in a synthesis time of about 23 minutes. radiochemical purity was about 98 % and highest radiochemical impurity resulted in free 68 ga 3+ not reacted ( 68 ga-dotatoc: r f = 0.0 free 68 ga 3+ rf = 0.9). radionuclidic purity was observed to be greater than 99.9999 % and final solution resulted sterile. conclusion: after elution in cationic form and the purification steps described, 68 ge/ 68 ga generator can be considered a safe source of pure 68 ga for high yielding labelling of peptide or other molecules. 68 ga-dotatoc produced with this method can be efficiently utilized in nuclear medicine department for clinical evaluations. synthesis and biological evaluation of 11 c-labeled acyclic-and furo[2,3-d]pyrimidine derivative of bicyclic nucleoside analogs (bcnas) for structure-brain uptake relationship study of bcna tracers s. k. chitneni, j. balzarini, a. verbruggen, g. bormans; katholieke universiteit, leuven, belgium. we recently synthesized and evaluated several bcnas labeled with c-11, f-18 or i-123 as potential pet or spect tracers for non-invasive imaging of varicella-zoster virus thymidine kinase (vzv-tk) gene. these studies resulted in a new reporter gene/probe system but none of these tracers were taken up in the brain in biodistribution studies despite fulfilling the theoretical requirements for passive diffusion of such molecules through bbb. we have now synthesized and evaluated a 11 c-labeled bcna ([ 11 c]-(3)) with a hydroxyethoxymethyl side chain instead of a 2deoxy ribose sugar for bcnas, and a bcna without sugar moiety ([ 11 c]-(4)). methods: the precursor compounds (1) and (2) were synthesized by sonogashira coupling of 5-iodo-3-[(2-hydroxyethoxy)methyl]uracil and 5-iodouracil, respectively, with 3-hydroxyphenyl acetylene, followed by cyclization in situ. they were converted to non-radioactive (3) and (4) by methylation of the phenol for (3) and at the n-3 of the pyrimidine ring for (4) using ch 3 i in the presence of k 2 co 3 in dmf. the radiolabeling was achieved using [ 11 c]methyl triflate. the methylation products were purified using c-18 semi-prep hplc. the affinity (ic 50 ) of the non-radioactive compounds for vzv-tk was determined in vitro in competition with [[ 3 h]-ch 3 ]dthd. the logp of [ 11 c]-(3) and [ 11 c]-(4) was determined and their biodistribution was evaluated in normal mice at 2 and 60 min pi. results: synthesis yields were 25% for (1), 44% for (2), 56% for (3) and 32% for (4). the rcy for [ 11 c]-(3) and [ 11 c]-(4) was 28% and 50%, respectively, and the rcp was >99 % for both tracers. the identity of the tracers was confirmed by co-injection with the authentic (3) or (4). logp 7.4 value of both tracers was 1.2. ic 50 values of (1), (2), (3) and (4) for vzv-tk were 37, 64, 430 and 79 μm, respectively. similar to the previously synthesized bcna tracers, negligible brain uptake was seen at 2 min and 60 min pi for both [ 11 c]-(3) and [ 11 c]-(4), which were cleared mainly by the hepatobiliary system and to a lesser extent to the urine at 60 min pi. blood clearance was rapid for both tracers (<1.0% id in blood at 60 min pi). conclusions: lack of uptake in brain for [ 11 c]-(3) and [ 11 c]-(4) confirms that bcna tracers do not cross bbb despite their lipophilic character. in general, this observation can be extended to other uridine-or uracil-based nucleoside analogues also. this study was funded by the ecaim: fluoromisonidazole [ 18 f]fmiso, has been used with pet in humans for the identification of hypoxic tissue in stroke. however, [ 18 f]fmiso suffers from low cellular uptake into hypoxic tissue and slow clearance from normal cells, requiring long periods between iv-injection and imaging. in 2006 we have reported the radiolabelling of another class of compounds (sulfoxide containing nitrogen mustards) that have great affinity for hypoxic tissue. in this study, we have performed in vivo analysis to evaluate these compounds ([ 18 f]so101 and [ 18 f]so201) as potential imaging agents. method and materials: to determine the uptake of the tracers in the ischemic penumbra, mcao stroke-induced rats were injected with the desired tracer immediately after stroke. uptake times of 0.5, 1 and 2h post injection were assessed and autoradiography performed. a delayed injection study (injection 6 hrs post stroke, sacrificed 2 hrs post injection) was also performed to determine if the tracer is binding to the infarct tissue. autoradiography and histology was used to correlate infarct regions with uptake of the tracer. a pet/ct scan of so201 was also investigated. all data was compared to the current gold standard [ 18 f]fmiso. results: at 2h post injection, the density ratios and the hemispheric area of uptake of the three tracers ([ 18 (1, 2) carried out by distillation of the intermediate 18 f-fluorobromomethane (fbrme) and subsequent alkylation of dimethylaminoethanol (dmae) or by gas phase conversation of fbrme to 18 f-fluoromethyltriflate followed by dmae alkylation. the aim of this study was the investigation of a one pot synthesis without distillation on an automatic synthesis module for production of high radioactivity amounts of fmc. materials and methods: trapping the target water on an anion exchanger, elution with kryptofix® 2.2.2/potassium carbonate and azeotropic drying was performed according to a standard procedure. the nucleophilic substitution with dibromomethane as precursor was optimized with respect to time and temperature. the second reaction step was carried out by addition of dmae in acetone to the intermediate fbrme and also optimized with respect to time and temperature. subsequently the solvents were evaporated and a sodium hydroxide solution was added to the residue and heated for additional 10 min. by transferring the product solution over a cation exchange the fmc was trapped on the cartridge. after washing with ethanol and water, fmc was eluted with saline. the qc was performed by hplc and tlc. results: the strategy for the synthesis of fmc (according to (3) ) was transferred to an automatic, remote controlled synthesis unit. the optimization of the nucleophilic substitution results in a radiochemical yield of 50-60% in 10 min at 90°c. the alkylation reaction in the same reaction vessel proceeded with radiochemical yields of 70-80% in 12 min at 100°c. this result in an overall radiochemical yield of 35±5%, which only slightly differs from the non automatic synthesis (35-50% (3)). destroying the byproduct bromomethylcholine by basic hydrolysis was nearly quantitatively. total synthesis time was approximately 50 min. the radiochemical purity was >95%. conclusions: the two step one pot synthesis of fmc was successfully adapted to an automatic, remote controlled synthesis unit. this process allows the efficient and reliable production of fmc with high radioactivity amounts in less than one hour. references: (1) introduction: there is an increasing need for pet radiotracers to be produced at high specific radioactivity (sa) to delineate low population binding sites in man or for imaging studies on small animals. these studies often require radioligands with very high binding affinities, which also imposes the need for producing the radioligand at high sa. an example of these tracers is the high affinity dopamine d2/3 radioligand [ 18 f]fallypride which we are using for human and micropet studies. to perform these studies successfully and in particular to enable us to perform two pet studies consecutively from one radiochemical preparation we have investigated means to improve the sa of the final product. method and results: based on analysis of the various components of the radioligand synthesis, including the precursor's chemical purity, the key determinate of the sa of [ 18 f]fallypride was identified to be the cyclotron-generated [ 18 f]fluoride, prepared by the 18 o(p,n) 18 f method. using our standard [ 18 f]fluoride production protocol based on 45μa for 60min which produced 69-89 gbq, we obtained 7-14gbq of [ 18 f]fallypride at end-of-synthesis (eos). the sa was determined, using a calibrated radio-hplc-uv system, to average 170gbq/μmol (range 75-260 gbq/μmol, n=27). we then modified our [ 18 f]-fluoride production method to perform an irradiation consisting of 45μa for 5min in which the target product was then emptied unused. this was followed by a second [ 18 f]fluoride production (45μa for 60min) to be used for the radiosynthesis process. the amount of [ 18 f]fluoride (70-86 gbq) and the radiochemical product of [ 18 f]fallypride (7-21 gbq) did no change significantly. however the sa of [ 18 f]fallypride at eos was found to increase significantly to average 300 gbq/μmol (115-571 gbq/μmol, n = 19). with these sa we are able to perform two consecutive human studies within 4 hrs from eos while keeping to our imaging protocol criteria of 110 mbq dose and a maximum limit of 2 nmol of co-injected mass of fallypride. conclusion: using a two stage irradiation protocol we have been able to double the sa of our [ 18 f]fallypride product. as well as being at the required level for performing micropet studies these sa allows us to perform multiply pet studies from one preparation enabling more efficient use of our regular productions of this tracer. using this protocol has also enabled us to reduce the required activity of [ 18 f]fallypride to be produced while still obtaining the required sa's for our studies, therefore reducing radiation dose to the production staff. u. choudhry 1 , r. paul 2 , p. blower 2 , s. biagini 1 ; 1 university of kent, canterbury, united kingdom, 2 king's college london, london, united kingdom. background: current methods for 18 f labelling of peptides for pet imaging are timeconsuming and complex. more efficient (preferably single step) methods, analogous to 99m tc kits, are required because of the short half-life (110 min). we have previously shown that the reaction of fluoride with alkoxytrialkylsilanes is fast and that the product is stable to hydrolysis up to ph 7.5 when bulky alkyl groups are used. we therefore selected the tert-butyldiphenylalkoxysilane group for evaluation with nocarrier-added 18 f. aims: to demonstrate radiolabelling of a tertbutyldiphenylalkoxysilane with 18 f and establish appropriate conditions. material & methods: 18 f in k.2.2.2/ch 3 cn/k 2 co 3 was prepared by a conventional procedure: 2ml of aqueous f-18 (120 mbq) was passed through the qma cartridge (conditioned with 10 ml of 1m sodium bicarbonate and 20 ml water) and eluted in 2 ml k.2.2.2/ch 3 cn/k 2 co 3 solution. no azeotropic drying was performed. to this solution was added 0.5 ml tert-butyldiphenylmethoxysilane (1mg/ml in ch 3 cn) and 10μl trifluoroacetic acid (tfa). rp-hplc (water/acetonitrile/0.1% tfa) and tlc (silica/hexane) were performed after 5 min incubation at room temperature. results: both hplc and tlc showed the presence of a single radioactive, hydrophobic species corresponding to a bona fide cold sample of the tert-butyldiphenylfluorosilane (rt 11 min, rf 0.5) and no significant residual free 18 f (rf 0). conclusion: the alkoxytrialkylsilane prosthetic group reacts very efficiently at room temperature with 18 f in the presence of kryptofix without the need for drying by azeoptropic distillation, offering the basis of a very convenient route to radiolabelling biomolecules for 18 f pet. objectives: intra-arterial administration of particles containing beta-emitting radionuclides appears to be a useful alternative of liver tumour therapy. particles of a well-defined size are trapped in the vascular bed of the tumour and remain there while delivering a high dose of radiation in order to destroy both primary and metastatic liver tumours. methods: ho-pla-ms were prepared using the solvent evaporation technique. ho-acetylacetone complex and polylactic acid (pla) was dissolved in chloroform and consequently added to 2% polyvinyl alcohol. this mixture was stirred s332 for at least 12 hours until chloroform was evaporated. the precipitated microspheres were centrifuged, washed with distilled water and 0.1m hcl and finally collected on a cellulose nitrate filter. microspheres were placed in the screwed titanium ampoules and irradiated in the channel providing lower neutron flux in order to avoid radiation degradation of prepared microspheres. results: generally, 200mg of microspheres were irradiated at the neutron flux 10 12 cm -2 s -1 and the radioactivity reached after 30 minutes neutron irradiation ranged from 1100-1500mbq. the particle size distribution highly depended on the speed of the stirrer and on pla molecular weight. microspheres of the ideal size 20-50mm and the mean diameter of 27mm were obtained after stirring at 1200rpm and microsieving using 20mm and 50mm pore size sieves. holmium as a paramagnetic lanthanide was visualized using mri. study was performed using the polyacrilic glass phantom. non-radioactive microspheres containing holmium in 5% agar was used. the amount of microspheres used for visualisation ranged from 5 to 100 mg and and this amount corresponds with the amount intended for the future aplication. discussion: microspheres of the size of 20-50mm is considered to be an ideal size for immobilisation inside the tumour tissue. granulometric analysis proved minimally 86 % prepared particles conform to this dimension. mri study on holmium loaded microspheres provided image of sufficient signal strength within the all studied concentration range and seems to be promissing for possible imaging of microspheres after decreasing radioactivity owing to decay. . interest of ytracis ® radiochromatographic control prior to zevalin ® radiolabelling. aim: the zevalin ® (ibritumomab tiuxétan) radiolabelling with ytracis ® ( 90 yttrium) fails in about 2 per cent of cases despite following a rigorous and well tried procedure. the origin of the failures remains unclear in most cases. after experiencing a labelling failure in our department we performed a chromatic control of the ytracis ® marker solution. materials & methods: one patient who presented a recurrence from a refractory follicular lymphoma was referred to our department for a 90 y-zevalin therapy. the radiochromatographic purity (rcp) of the labelled zevalin ® was controlled by thin layer chromatography (tlc) using 3 strips of itlc-sg paper and 0.9% nacl solvent. in the present case the strip scanning performed with a radiochromatograph showed a rcp value of 77.5 ± 0.5% (m ± 1 sd) (normal > 95%), and an impurity peak with a migration front (rf) of 0.79 ± 0.02. for this reason, the treatment was cancelled. the analysis of the critical procedure steps (registration, storage, labelling, rcp control) and the manufacturer inquiry did not permit to identify the non conformity source. therefore the present ytracis ® lot has been controlled by tlc as well as 3 successfully used lots with the same procedure as performed for the zevalin ® rcp test. results: the tlc strip readings of the 3 control ytracis ® lots gave a single migration peak (rf: 0.67 ± 0.01). the tlc strip readings of the tested ytracis ® lot showed a first migration peak (rf: 0.67) corresponding to 64.6 ± 2.2% of the deposited activity. a second migration peak with a rf: 0.85 ± 0.04 not present on the control lots was detected corresponding to 33.3 ± 2.7% of the deposited activity. the impurity nature could not be identified due to the lack of product. conclusion: considering the possible failures of zevalin ® radiolabelling with ytracis ® we suggest to include a simplified and systematic rcp control of the ytracis ® solution during the source registration procedure. the rcp control is a main step before the zevalin ® labelling and the patient convocation. at present, no useful data is available concerning the efficiency and the safety of 153 sm-edtmp (quadramet®) therapy in patients with renal function impairment, especially in chronic renal failure treated with dialysis. we report the case of a 71years-old woman who suffered from painful bone metastases. her medical history consisted of untreated asthma, hypertension, left breast adenocarcinoma and chronic renal failure for which she benefited from haemodialysis 3 times a week. the patient was referred by the geriatric department to perform bone scintigraphy for the initial evaluation of skeletal metastases because of her hypercalcemia and bone symptoms. the bone scan revealed multiple secondary lesions. pain evaluation by visual analogic scale (vas) was expressed as 7 and the recorded motor score was 5/20. these findings were diagnosed as extensive metastases of her breast cancer. this patient was given the opportunity to benefit from internal radiotherapy with quadramet®. considering her renal failure and urinary excretion of 153 sm-edtmp after intravenous administration, nuclear physician decided that careful and cost-effective treatment could only be achieved by performing 80 % of the conventional activity, i.e. 29.6 mbq/kg (0.8 mci/kg) instead of 37 mbq/kg (1 mci/kg), 16 hours before haemodialysis. her haematological status recorded 48 hours before, made feasible the radionuclide therapy. the administration was performed in the nuclear medicine department without any problem. the clinical follow up included adequate monitoring of bone pain response, haematological status and supportive medication. treatment efficacy was assessed according to vas, motor score, analgesics consumption and performance status. painful osteoblastic lesions were significantly alleviated after internal irradiation (vas, 0 ; motor score, 19/20). onset of pain improvement took place 2 weeks after internal radiotherapy. there was an obvious decrease in opioid analgesics use in the active phase of the treatment.. no relevant haematological toxicity occurred. however, a temporally recoverable mild anaemia was observed. this finding was likely related to arterio-venous fistula inflammation. conclusion: in this case, management of painful bone metastases with sm-153 edtmp in a dialysis patient was successfully performed. our observation demonstrates that such therapy is feasible in patients under chronic haemodialysis. radionuclide production for biomedical applications has been studied in recent years at infn-lasa laboratory, in co-operation with the cyclotron laboratory of the joint research centre (jrc ispra, italy), taking advantage of extensive experience in the experimental nuclear physics and nuclear chemistry fields. several research aspects concerning radiation detection and the relevant instruments, the measurements of excitation functions of the involved nuclear reactions and the required radiochemistry methods have been investigated. the latest studies on high specific activity, accelerator-produced radionuclides in no-carrier-added (nca) form, for use in therapeutic applications and in related spet/pet diagnoses investigated, are: 1. nca 64 cu, produced by nat zn(d, xn), nat zn(d,2pxn) and 64 zn(d,2p) reactions for simultaneous + /metabolic radiotherapy, with intrinsic pet imaging, including the short-lived radionuclide 61 cu; 2. 186g re, produced by 186 w(p,n) and 186 w(d,2n) reactions, for bone metastases pain palliation by beta (1.1 mev) metabolic radiotherapy, including spect imaging; 3. nca 211 at/ 211g po, produced by the 209 bi( ,2n) reaction, with internal spike of the emitter 210 at from the 209 bi( ,3n) reaction (leading to very small amount of 210 po as radiotoxic long-lived impurity), for high-let metabolic radio-and immuno-radiotherapy; targets are irradiated at the scanditronix mc-40 cyclotron (k=40) of the jrc with proton or alpha beams up to 39 mev, 3 he 2+ particle beam up to 53 mev or deuteron beams up to 19.5 mev. activity measurements are performed either at jrc ispra or at lasa laboratory: , x spectra are measured with hpge detectors, spectra with pips detectors with a resolution of 17 kev (fwhm), and spectra with a conventional liquid scintillation counting lsc and spectrometry system with horrocks number capability for quenching correction, and a higher-resolution liquid scintillation portable spectrometer with / pulse shape analysis (psa) discriminator. in order to produce nca radionuclides suitable radiochemical separation processes for the radionuclides of interest, together with quality control checks must be developed. the radiochemical separations adopted are presented for each radionuclide produced. in order to evaluate production feasibility or to confirm the cross sections experimentally obtained, calculations for the involved nuclear reactions are carried out with the empire-ii code, taking into accounting the major nuclear reaction channels. objectives: due to the more favourable physical characteristics of 188 re, 188 re-lipiodol is an interesting alternative for 131 i-lipiodol in the treatment of hepatocellular carcinoma (hcc). a water-in-oil emulsion (w/o) was prepared as carrier system using lipiodol as oil phase, containing 99m tco 4 -/ 188 reo 4 in the inner aqueous phase. the aim of present study was to optimize the formulation of the w/o emulsion based on a plackett-burman 12-run statistical design. methods: 12 types of emulsions were prepared according to the orthogonal plackett-burman design. to optimize the formulation, the influence of causal factors such as rpm, rotation time, aqueous phase, oily phase, volume ratio, type and concentration of emulsifier was evaluated. for each run the cumulative percentage of administered activity released from each formulation (cpa), was calculated in vitro. the latter quantity will be an important indicator for the whole body irradiation of the patient. in vitro release rate characteristics were measured using a dialysis system. results: plackett-burman analysis showed a significant influence (p<0,05) on cpa for volume ratio (p = 0,0000), rotation time (p = 0,0000), emulsifier concentration (p = 0,0000) and oil phase (p = 0,000) with volume ratio as most important factor. no significant influence was found for the aqueous phase (p = 0,4241), type of emulsifier (p = 0,6817) and rotation rate(p = 0,8384). conclusion: stable lipiodolized w/o emulsions could be prepared according to the plackett-burman experimental design. based on our statistical screening design, volume ratio, rotation time, emulsifier concentration and oil phase could be identified as factors affecting the release characteristics of the formulation significantly (p<0,05). in further optimization steps, these factors should be taken into account. such conjugates were achieved when the ratios of rhil2:hynic reactions were set from 1:6 to 1:12 (ca. 50% efficiency of the substitution), and the purification step was performed on pd-10 column. the next most essential parameter of radiolabelling reaction was the ph of the reaction medium, which should be kept in the range of 6 -6.5. gf-hplc analysis indicated that two radioactive species of 99m tc-hynic-il2 (monomer and dimmer) are formed during radiolabelling, although dimmer could be selectively removed by purification on tc2 column. the optimized conditions of the wet-radiolabelling (30μg of rhil2:hynic, 1-30 mg of tricine, 15-25 μg of sncl 2 , ph 6-6.5, 60 min in rt) enabled to achieve 99m tc-hynic-il2 monomer (radiochemical purity >99%, specific activity ca. 9 mbq/μg il-2) with overall yield of ca. 60%. the two vial freeze-dried kit was prepared: first vial with 50 μg hynic-il2, second vial with 50 mg tricine and 40 μg sncl 2 . unfortunately, radiochemical purities of the 99m tc-hynic-il2 preparations obtained using the dry kit were unsatisfied and did not allow giving the purification step up. conclusions: our study showed that rhil-2 can be efficiently radiolabelled with tc-99m via bifunctional chelator -hynic, and tricine as coligand. however, investigation are still ongoing to receive one-step preparation of ready to use 99m tc-hynic-il2 radiopharmaceutical. aim: the purpose of this study was to compare biodistribution profiles and elimination pathways of dota-tyr(3)-octreotate (dota-tate) and dota-l-nal(3)-octreotide (dota-noc) labelled with in-111 in rats. whereas clinically used radiolabelled dota-tate shows high affinity to somatostatin receptor subtype sstr2 and low or absent affinity towards the other somatostatin receptor subtypes, dota-noc exhibits high affinity to somatostatin receptor subtypes sstr2, 3 and 5. materials and methods: for the cell experiments, rat pancreatic carcinoma ar42j cells expressing sstr2 receptors were employed. for biological experiments, male wistar rats (190-260 g) were used. the peptides were administered to rats intravenously in the dose of 0.2 μg per animal. the kinetics of the peptide uptake in the kidney was also studied on the proximal tubule-derived opossum kidney (ok) cell line. results: 111in-dota-tate and 111in-dota-noc showed high and comparable rates of internalization into ar42j rat pancreatic carcinoma cells in agreement with their similar affinity to somatostatin receptor subtype sstr2. both peptides under study exhibited similar distribution profiles in rats. radioactivity was rapidly eliminated from the blood and most organs and tissues. high radioactivity uptake in somatostatin receptor-rich organs and in the main elimination organ (the kidney) was determined. due to higher lipophilicity of 111in-dota-noc its plasma protein binding was higher, the blood radioactivity decrease was slightly slower and liver accumulation was significantly higher in comparison with 111in-dota-tate. the physiological internalization of radioactivity into somatostatin receptor-rich organs (the pancreas and adrenals) was for 111in-dota-noc about twice of that for 111in-dota-tate. no significant differences in the renal radioactivity uptake were found. these results were confirmed also in the study of the peptide uptake by the ok cells. elimination pathways were comparable for both peptides under study. conclusion: radiolabelled dota-noc represents promising somatostatin receptor-specific peptide for diagnosis and radiotherapy of some neuroendocrine tumours due to its very high uptake in tissues with high density of somatostatin receptors. the study was supported by the grant agency of the czech republic -grant no. 305/07/0535. whereas the peptides labelled with radiometals were eliminated into urine mostly in the parent form and only traces of metabolites were detected, a significant portion of metabolites of iodinated compounds (especially in the longer time intervals after dosing) in rat urine were found. in time intervals up to 1 hour after dosing, the distribution profiles of all peptides under study were similar. high radioactivity uptake in organs with high density of somatostatin receptors (the pancreas and adrenals) and also in the kidney was determined. whereas high radioactivity accumulation in the above-mentioned organs continued for a long time for the peptides labelled with radiometals, this uptake significantly decreased with time for iodinated derivatives. the physiological internalization of radioactivity in somatostatin receptor-rich organs is mediated by their somatostatin receptors. renal uptake and retention of the peptides involves glomerular filtration and subsequent partial reabsorption in the proximal tubular cells by endocytosis. the peptides could be consequently transferred to lysosomes and digested by proteolytic enzymes. resulting breakdown products remained in the lysosomes for a long post-injection period for the agents labelled with radiometals. on the other hand radioiodinated break-down products could cross biological membranes from the sites of metabolism to the central distribution compartment and finally be eliminated by urine. conclusion: the reason of different metabolites proportion of the peptides under study in rat urine was in different rates of externalization of brake-down products from the sites of biotransformation. k. durkan, f. yurt lambrecht, p. ünak; institute of nuclear science, izmir, turkey. aim: bombesin-like peptides are neurotransmitters and cancer growth factors. bombesin-like peptides express several human cancer, including small cell lung, prostate, breast, colon and pancreatic cancer receptors. litorin is a peptide derivative as amphibian bombesin. in this study, a new 99m tc labeled bn-like peptide (litorin) was prepared and biodistribution studies in normal rats were investigated. materials & methods: litorin was labeled with tc-99m by using 25 μg stannous chloride at ph 3.0. after the labeling procedure, the radiochemical analysis of radiolabeled peptide was determined by radio thin layer chromatography (rtlc) and radio high performance chromatography (rhplc). in vivo biodistribution studies were performed in normal male albino wistar rats with blocked and non-blocked receptors. the stability was investigated in human serum. results: labeling yield was 95.04±1.4%. serum stability results showed that in vitro stability of the radiolabeled peptide was quite high. the radiolabeling efficiency was 87.4±1.1 at 4h during incubation. significant uptake in bombesin/gastrin releasing peptide (bn/grp) receptor rich tissues such as the pancreas (23.56±0.01 %id/g, 30 min post injection) was observed. the uptake in the pancreas could be blocked by cold litorin (0.28±0.02 %id/g at 30 min). 99m tc-litorin exhibited very hydrophilic and eliminated via renal filtration and urinary excretion. conclusion: 99m tc-litorin showed high uptake in the gastrin-releasing peptide receptor-rich pancreas and might be useful radiopharmaceutical in the detection of bombesine receptor-expressing cancers in vivo. introduction: in the process of 153 sm production, the 154 eu (t 1/2 8,8 years, 123 kev, 569 kev, 247 kev) is generated like main radionucleidic impurity. however, the low proportion of this radionucleid in the final product, inferior to 0.0093%, assures its harmless. objective: to quantify the amount of 154 eu present in the waste generated by 153 sm-edtmp use and to evaluate its incidence in the waste management. material and methods: the remaining liquids of 10 quadramet ® vials of different lots and patients' urine collected during 6 h p.i were analysed. the emission espectrum's analysis of each sample and the estimation of the eu specific activity were performed with a nai(tl) detector. results: the average 154 eu ratio in vials versus the 153 sm nominal activity was 0.0032%, which agreed with manufacturer indication. the mean 154 eu ratio in vials and in urine were of 4·10 7 bq/l y 9·10 4 bq/l respectively. in both cases exceeded the valid limit for drinking water (833 bq/l). 154 eu / 153 sm-edtmp ratio in urine, was approximately of 0.3%. conclusions: the waste management program of 153 sm must consider current 154 eu ratio, establishing the suitable dilutions, in agreement with the characteristics of each center, as the final concentration must not exceed the valid limit for drinking water. biodistribution of the chemical species containing 154 eu and 153 sm seems to be differents. the potential of the 10-30 kda fraction of the water-soluble polymer polyethyleneimine, functionalised with methylene phosphonate groups (pei-mp) and labelled with 99mtc (6 hr half-life and 140 kev gamma), 117msn (13.6 d half-life, conversion electrons) and 186re (3.7 d half-life, 1.1mev beta-) has been described elsewhere. distinct differences in the biodistribution in animal models were found for the different radionuclides. 99mtc-pei-mp had high bladder and kidney uptake. 117msn-pei-mp had moderate reticuloendothelial uptake, reasonable bone-uptake and considerable uptake in the bladder wall. 186re-pei-mp showed rapid clearance of all organs as well as considerable and early excretion in the urine and little bone uptake. it is postulated that the size of the polymer complex changes with the different metal ions which is the reason for this difference in biodistribution. methods: nonradioactive sn(ii)-pei-mp and re-pei-mp were prepared according to the labelling procedures. parallel radiolabelled equivalents were used to prove the labelling was successful. as 99mtc is no-carrier-included, the mass of this metal ion is negligible and will not influence the result. therefore the kit formulation (a mixture of pei-mp, sn(ii), sn(iv) and buffer) was used to simulate 99mtc-pei-mp. all solutions were kept under ar and were analysed for size by conventional gpc using an agilent 1100 isocratic pump. results: the average gpc size results showed that the size of the polymer fraction is 25.4 kda, and 20.9 kda for the tc-99m kit formulation (99mtc-pei-mp), 27.3 kda for sn(ii)-pei-mp and 32.2 kda for re-pei-mp. conclusions: it seems that the polymer contracts upon complexation with sn(iv) due to ml2 complexes but expands with sn(ii) which prefers m2l complexes. as low specific activity re was used in earlier experiments, it was expected that the size of re-pei-mp would be considerably higher. 90 y is a widely used radionuclide in therapeutical nuclear medicine applications. to be safely administered to patients, 90 y solution must fulfill specific quality requirements; it must be at correct ph, endotoxin free, metal free, and it should have only minute amounts of long-lived parent nuclide 90 sr. the aim of this work is to develop a fast, efficient and reliable method to determine 90 sr content in 90 y solution. the separation of 90 y and 90 sr is performed by using highly selective extractive chromatographic sr resin. 90 y sample is loaded to the column in diluted nitric acid. yttrium under this condition does not retain on the column so it is first washed out and collected. yttrium fraction is measured with a dose calibrator. strontium is eluted from the column with water. the strontium fraction is evaporated to near dryness and dissolved in scintillation cocktail. finally the sample is measured with liquid scintillation counting (lsc). the problem in using lsc in 90 sr determination lies with the ingrowth of 90 y in the sample. high energetic 90 y spectrum (max. 2250 kev) overlaps 90 sr spectrum (max. 550 kev), hence obtaining a 'pure' 90 sr spectrum is impossible. an indirect mathematical model that utilizes counts of the beta spectra originating from each nuclide is a convenient method for subtracting 90 y from the 90 sr 90 y spectrum. a pure 90 y spectrum is measured and a window in the high energy area of the spectrum is selected. the window area is normalized with the yttrium-90 counts in the 90 sr 90 y spectrum. the two spectra are subtracted from each other resulting in a pure 90 sr spectrum. the developed method allows a rapid 90 sr content determination with 90 sr/ 90 y ratio as low as 10 -8 . the time needed for the entire quality control procedure is in the range of one hour. same mathematical method can be used to determine tungsten-188 content in rhenium-188 solution from 188 w/ 188 re -generator. (111). only the patients with normal globular volume (vg) and vp (vg exp<25% vg theoretical; vp exp<25% vp theoretical) have been studied. calculation formulas were: vg(hts/(1-hts)) for vp calc, 1,06 * age + 822 x body surface (bs) for female vg th, 1485 * bs -825 for male vg th, 1395 * bs for female vp th, 1578 * bs for male vp th. data were analyzed for means. a student test and regression analysis were performed using the excel program of microsoft, inc. results: the student test has shown that it existed a significant difference between vp exp and vp calc for males (p<0.05) and females (p<0.05). however, the regression analysis has shown a correlation of vp exp versus vp calc for males (r= 0.919 for 20 minutes blood sample) and females (r= 0.964 for 20 minutes blood sample). when the equations of correlation lines have been used to find vp exp from vp calc on a 2006 patient's sample, a significant difference was remained between the two vp. discussion and conclusion: according to these results, the use of 125 i-has seems to be indispensable to obtain a good estimation of vp. as it has been shown by morin, et al. in 1972 (ouest-médical, 25è année n°10, 10 mai 1972), the use of hts to calculate the vp calc. explains this result. hts is obtained from the formula: venous ht * x where x estimation is 0.91. in reality, x depends on the person. so to limit the viral risk linking to the use of 125 i-has, only red cell mass measurement by 51 cr will be done in research of myeloproliferative syndrome (vaquez disease, ) and 51 cr and 125 i-has will be used in other cases. to optimize the choice of the technique (single or double isotopes), we are developing a prescription medium in order to obtain all necessary informations to choose the best technique. aim activity measurement of 123 i radiopharmaceuticals, may be affected by several factors such as recipient shape and its nature (kind of glass, plastic, etc); as well as, the own attenuation produced by liquid volume in which radiopharmaceutical is dissolved. the aim of this study is the assessment of variation between measured activity and reference activity, using two different dose calibrators. as well as, the calculation of corresponding correction factors necessary to obtain the most exactly dose with each dose calibrator. material and methods we have used two dose calibrator for activity measurement: capintec crc ® -15r (dc1) and capintec crc ® -12 (dc2). activity measurement of 123 i was performed using the corresponding channel of each dose calibrator. 35 measurements of 123 i activity were performed to the radiopharmaceuticals into manufacturer vial, and others 35 after withdraw the whole radiopharmaceutical activity into a 5 ml syringe. those measurements were performed in both dose calibrators. the measured activity in each case was compared with reference activity. also, we have calculated the medium variation percentage (mvp) of measurements performed versus reference activity, as well as, the medium correction factor (mcf) for each measurement. results the mvp of measurements performed versus reference activity in case of dc1 was 12.63 ± 5.70 in syringe and in manufacturer vial -29.29 ± 1.82. in case of dc2 mvp in syringe was 29.67 ± 6.36 and in manufacturer vial -22.57 ± 0.08. mcf were calculated in each case. for dc1: syringe, 0.89 ± 0.05; manufacturer vial, 1.42 ± 0.04; and for dc2: syringe, 0.77 ± 0.04 and manufacturer vial, -22.57 ± 8.08. conclusions our results showed than measured activity for 123 i using manufacturer vial was significantly lower than reference activity, in both dose calibrators; while, on the contrary, when the radiopharmaceuticals was measured in syringe, the activity resulted higher than reference activity, and moreover, higher in case of dc2. in consequence, to get the most exact activity measurement of 123 i radiopharmaceuticals, it is necessary the calculation and use of the correction factor corresponding to the dose calibrate used to the measurement, both for manufacturer vial activity and syringe activity. introduction: dextrans are glucose polymers, whose versatility has led to their application in numerous fields. 99m tc-labelled dextrans have been proposed as possible substitutes for human albumin and labelled red blood cells in angiography and cardiac pool studies. objective: to assess the pharmacokinetics of a 99m tc-labelled dextran-70 preparation in rats. material and methods: eight wistar male rats with an average weight of 250g were administered with 18 mbq of 99m tc-dextran-70 in a volume of 300 μl via cannula in jugular vein. blood samples of 1 ml were taken at 10, 30, 60, 180, 360 and 480 min post-injection and kept in a flask with anti-coagulant; 0.5 ml of each sample was centrifuged to obtain plasma. aliquots of 0.2 ml of total blood and plasma were measured in a well counter for 5 minutes. the activity of each sample was determined as a function of time and the following pharmacokinetic parameters were determined: plasma concentration, apparent distribution volume and plasma clearance of the radiopharmaceutical. results: tc-labelled dextran-70 shows the characteristic kinetics of a vascular tracer. in every case le was tested: in vivo/in vitro method: 0.05-0.10ml 99m tc-rbc aliquots were added to 2ml of nacl 0.9% solution into sterile vacuum blood collection tubes. the tubes were centrifugated at 1300xg for 3 minutes and supernatant (cell-free plasma) was transferred into plastic test tubes. le was calculated by measurement, both cell-free plasma and rbcs packed, activities using a dose calibrator (capintec crc ® -15r). in vivo method: 4ml whole-blood was withdrawn from a peripheral vein using a 5 ml heparinnized syringe. it was centrifuged at 1300xg for 5 min and supernatant was transferred into plastic test tubes. le was calculated by measurement, both cell-free plasma and rbcs packed, activities using a well counter. le was expressed as percentage and the mean value and the standard deviation were calculated for each method. the gammacamera used was a double headed variable tangential philips axis. results average le of 39 99m tc-rcbs by in vivo/in vitro method was 98.45±2.19% (low le 91.57% and high le=100%), on the other hand, the 42 99m tc-rcbs by in vivo method yielded an average le of 93.26±2.24%, in a range of 89.36 to 99.38 percent. in each case, gammagraphics images were tested by two different independent testers, neither of them detected any undesirable uptake because of low quality of 99m tc-rcbs, or by any in vivo unlabelling. conclusions according to our results, the le using in vivo methods was slightly lower than le by in vivo/in vitro method. perhaps, both of them were into an acceptable range to be used for lvef studies. moreover, lvef studies performed have not shown any significant difference, so both methods are useful to get 99m tc-rbcs in fact, we think that the use of 99m tc-rbcs by in vivo method is preferable, because it is a simple system, easy to perform, safe and efficient to assess lvef getting good results and image quality. introduction: insulin-like growth factor 1 (igf-1) and its binding proteins, mainly igfbp3, have a very important role in the regulation of fetal growth. the synthesis of igf-1 and igfbp3 is regulated to diverse hormonal factors, such thyroid hormones. the purpose of this study is to determine the possible association between the hypothyroidism status of pregnant women and the levels of igf-1 and igfbp3 respectively. objective: assessment the relationship between thyroid hormone levels and igf-1 and igfbp3 serum levels in pregnant women. aim: the polyazaligands such as dtpa or dota are suitable for transitionmetal and lanthanide ions, and their complexes have found important use in the radioimmunotherapy and radioimmunodiagnosis. a key parameter for these applications is a fast and efficient complexation of a convenient radioisotope. acyclic dtpa forms complexes immediately; complexation with macrocyclic dota is much slower. however, the macrocycles are better from all other aspects (e.g. kinetic and thermodynamic stability). in general, the most suitable central ions for dota-like ligands are trivalent lanthanides and indium. the 111 in isotope was chosen for this study, because it has convenient radio-properties. we present here an investigation of two new bifunctional monophosphinic acid h 4 dota derivatives having distant paminobenzyl (do3a-p abn ) or carboxylic groups (h 5 do3ap pra ) suitable for a further conjugation. material and methods: do3a-p abn and h 5 do3ap pra were prepared according to the published procedures. 111 incl 3 was purchased from amersham plc.. the reactions were followed with radio-tlc on silikagel plates or rp-hplc on lichrocart c18 column (merck). biodistribution and elimination studies were carried out using male wistar rats. results: the studied ligands exhibit a fast complex formation at optimized conditions (ligand:metal ratio 2:1, ph 6.5, 40°c, 5 min). as expected, higher ph and temperature accelerate the complex formation reactions. however, ph where precipitation of colloid metal hydroxides can occur (>~7) is not suitable. biodistribution studies showed a rapid clearance from most organs including blood and muscle. the main elimination pathway was urine excretion mostly by the mechanism of glomerular filtration. conclusion: the resultes indicate that do3a-p abn and h 5 do3ap pra are promising for radiolabelling of target-specific biomolecules. initial the relationship between proinflammatory cytokines, il-6 and tnf-, and hyperthyroisdim is not well known. serum levels of cytokines may indicate activity levels of immune functions. on the other hand some hyperthyroisdim variant have a immune component. objective: to measure and compare serum concentrations of proinflammatory cytokines, interleukin-6 and tnf-, in patients with different hyperthyroid diseases. material and methods: analyses were conducted in sera samples drawn from 14 patients with graves-basedow disease, 22 patients with multinodular goitre, 13 patients with thyroiditis and 20 euthyroid controls. serum tsh, ft4, ft3, il-6 and tnf-concentrations were measured by irma or ria assays. statistical analysis: a one-factor anova and subsequent bonferroni test were performed. results: in-dota-tate in 100 μl is required. under these conditions the radiolabelled peptide is vulnerable to radiolysis and oxidation, which results in loss of biological activity. labelling conditions were investigated to obtain a chemically stable product with intact high and specific receptor-binding. moreover, high sa can only be achieved when the ingrowth of non-radioactive competing 111 cd is low. 111 cd is the decay product of 111 in. 111 incl 3 is produced and delivered every week, thus the radiolabelled peptide should preferably be stable for 1 week. 111 in-dota-tate was therefore tested chemically and biologically. materials and methods: labelling conditions like time of labelling, temperature during the labelling, specific activity and the addition of several quenchers (ethanol, ascorbic acid and gentisic acid) in different combinations and concentrations were tested. radiochemical purity (rcp) was determined by using a hplc c 18 column at t=0 up to 1 week after labelling biological stability of 111 in-dota-tate was tested (at 10 -10 m) by performing uptake and internalisation experiments using the somatostatin receptor expressing rat pancreatic cell line ca20948. parallel in vitro autoradiography was performed on rat brain sections, both with 5 *10 -10 m and 10 -10 m of 111 in-dota-tate. results: 200 mbq/nmol 111 in-dota-tate was prepared. use of quenchers was inevitable to maintain rcp and prevent loss of receptor affinity. conditions were optimal in the presence of ethanol, ascorbic acid and gentisic acid. at t=0 rcp was 97±0%, whereas after 1 week the rcp was 95±0%. uptake of 111 in-dota-tate (10 -10 m) to ca20948 cells was 40% [dose/mg protein] of which 90% was internalised. similar results were found in experiments throughout the week. receptor-binding of 111 in-dota-tate was confirmed on brain sections, and could be blocked in the presence of an excess (10 -6 m) of octreotide analogue. corrected for decay and exposure time the specific receptor-binding of 111 in-dota-tate to brain also remained constant. conclusion: optimised labelling conditions of 111 in-dota-tate and the presence of a combination of quenchers enables the production of this radiopharmaceutical with a high and intact rcp for a week. since the chemical status, and the intact high and specific receptor affinity are maintained, centralised production and shipment of "hot liquids" are now possible. aim in order to satisfy the good preparation norms in nuclear medicine all radiopharmaceuticals employed for diagnostic and therapy have to be tested by quality control (qc) by determining radiochemical purity (rp) the purpose of this study was to validate a simplified qc method for gamma and beta radiopharmaceuticals using storage phosphor screen technology and adapting the complexity of the optiquant software of cyclone perkin elmer to common usage. material and methods: gamma and beta radiopharmaceuticals habitually used in our laboratory (diluted 1:300 in normal saline) were tested by instant thin-layer chromatography (itlc). all the chromatographic strips were tested exposing phosphor screen (multi-sensitive medium ms) at progressively increasing times (from 10 to 100 seconds) to establish the better time of exposure (for the average of our strips: 20 seconds). then we have performed 10 itlc for each radiopharmaceutical to calculate the average of distribution areas of radiopharmaceutical and its impurities in order to find the background area. since cyclone can simultaneously measure different chromatographic strips, we have estimated a minimal distance (1.5 cm) between the various strips avoiding images superimpositions. we have compared 30 itlc results measured by cyclone and by gamma-counter and the agreement was excellent (correlation coefficient 0.99). then by the optiquant software we have saved in a scheme of lanes -templates-the exact dimensions of the chromatographic strips well as the distribution areas from the origin (o) to the solvent front line (f) and the background area of each radiopharmaceutical. results this simplified method is easy for user at all levels of computer expertise, moreover consent to scan a screen, display and analyze the image, report the data of various chromatographic strips at the same time with high sensibility and resolution, clearly visualizing the distribution of the radiopharmaceutical and its impurities. the scheme of lanes (templates) saved in the software optiquant allows a rapid, automatic and exact measure of rp (less than 2 minutes for 9 different strips at the same time) providing a profile for a graphical representation of data. conclusion this simplified method for the measurement of radiochemical purity is easy, rapid, optimized and standardized no matter who the users are. introduction: hidroxyethyl starch is the most used agent in the sedimentation of the erythrocytes during the radiolabelling procedure for leukocytes. colloid dextran-200, a plasma expander, have been proposed as possible alternative to hidroxyethyl starch in this process. objective: to assess the usefulness of the plasma volume expander colloid dextran-200 as an alternative to hydroxyethyl starch in the sedimentation of the erythrocytes in leukocytes radiolabelling by 99m tc-hmpao. material and methods: two identical samples of 44 ml of blood in 6 ml of acd were obtained from 27 patients referred to our department for labelled leukocytes scintigraphy. leukocyte concentrations were obtained by using a hes solution, following the established protocol. simultaneously, another leukocyte concentration was obtained using a 6% dextran-200 solution in saline solution of 0.9%. concentrations of leukocytes, platelets and red blood cells were determined in the plasma obtained. the efficiency of the labelling was estimated, the cell viability was calculated by means of the trypan blue method, and the in vitro leukocyte recovery and erythrocyte:leukocyte ratio in final suspension of labelled cells were determined. results are expressed as arithmetic means ± standard deviation. the student's t test for related samples was used to compare means, considering p < 0.05 as significant. results: aim: to assess the effect of scatter coincidences, partial volume, positron range and non-colinearity on the ratio of the specific striatal uptake to non specific uptake (sur) in fdopa pet studies. materials and methods: the simset monte carlo code was employed to simulate acquisitions of the pet/ct siemens biograph scanner. the study was performed by using a numerical model obtained from a ct-image of a striatal phantom. theoretical sur values of 0.5, 1, 1.5, 2, 2.5 and 3 were simulated. neither axial nor angular compression were considered. as a consequence, 1024 sinograms with 288 transaxial bins (bin size of 2.2 mm) and 288 angular positions were obtained. simulations were carried out with/without positron range and noncolinearity effects. true and scatter coincidences were stored separately so that an ideal scatter correction (isc) could be performed. a 3d iterative algorithm kept in the stir library (http://stir.sourceforge.net) was used to reconstruct the 3d pet data. the reconstruction parameters were: 32 iterations, 4 subsets and a reconstruction grid of 128x128x63 (x-y pixel size of 1.7 mm and z pixel size of 2.5 mm). different reconstruction strategies were employed in order to evaluate the effect of degradations: a) osem3d, reconstruction of the sinograms with total coincidences, b) osem3d+isc, reconstruction of the sinograms with only true coincidences, equivalent to an ideal scatter correction, c) osem3d+isc+pvc, reconstruction of the sinograms using the isc and including a partial volume effect correction and d) osem3d+isc+pvc+prc+ncc, reconstruction of the sinograms using isc, including a pvc and without positron range and non-collinearity effects. a linear regression analysis was carried out between calculated and theoretical surs. the slope of the linear fit was considered to be the recovered sur (rsur). in all cases, the correlation coefficients were also calculated. results: for all reconstruction strategies, the correlation coefficients were higher than 0.999. the slope of the linear fit was: a) osem3d: 0.551, b) osem3d+isc: 0.653, c) osem3d+isc+pvc: 1.012 and d aim recent developments in pet 3d scanners have enabled the spatial resolution to achieve 2-3 mm fwhm range. with such an optimization, even small patient movements during data acquisition can lead to severe image quality degradation. frequently, patients who undergo pet brain scans suffer from movement disorders. if a head cushion is used, the probability of involuntary movements is still high. monte carlo simulator codes may assume a relevant role in understanding the image implication of these occurrences. the aim of this work is to show the potentiality of the geant4 application for tomographic emission (gate) to simulate the results of head movements during a realistic static pet study in image quality. materials and methods we used gate platform to model the ecat exact hr+ scanner. an attractive feature of gate is its capacity to simulate the behaviour of the scanner's detectors and the signal processing chain. to achieve this, we have defined a resolution of 25% and energy blurring between 20%-30% at 511 kev, a global sensitivity for each crystal of 88%, and an energy window of 350-650 kev. we have applied a paralyzable dead-time model. a 2 coincidence time window and a delayed window were simulated. the hoffman brain phantom was used as an emission map to map 18f-fdg activity in ventricles, white and grey matter. a 150 mbq 18f-fdg administered activity 3d pet 15 minutes static hoffman simulation was performed. fiducial markers were simulated to allow the identification of movement occurrence directly in the brain sinograms. results we obtained 1024 2d sinograms with 288 radial bins and 288 azimuthal bins for 30 seconds time frames. a total of 1.03043e+10 18f decays were acquired for each static aquisition. a c language programme was conceived in order to obtain a sinogram representing the whole of simulated data. through an exploratory analysis we verify that a 1:706 relation between fiducial markers' activity and 18f-fdg brain activity allows clear visual identification of these markers on the sinogram containing the whole data. conclusions the preliminary results suggest that is possible to obtain realistic brain pet sinograms under realistic simulation conditions. we are currently simulating translation movements with different ranges of magnitude and to couple this information with marker activity v.s. marker dimension. rotation movements of different magnitudes will also be simulated. simulated sinograms will be used to develop a correction method suitable for correcting intra-frame movements. wall motion and thickening estimation in myocardial gated spect: a comparison between two commercially available programs l. s. maffioli, a. vignati, f. cammelli, c. songini; ospedale civile di legnano, legnano, italy. routinary interpretation of gated spect is based on a visual evaluation of the rest/stress perfusion images of the left ventricle, an analysis of global function expressed as ejection fraction (ef) and left ventricular volumes and an assessment of the regional wall motion and thickening in the gated spect images. in order to calculate left ventricular ejection fraction (lvef), end-diastolic volume (edv), wall motion (wm) and thickening (wt), various types of programs are commercially available. aim of the study: we evaluated the reproducibility of ef, edv, wm and wt results obtained from two commercially available software packages in a clinical model. methodology: fifty consecutive male patients with suspected or known cad were evaluated with rest myocardial gated-spect. each study was reconstructed using a standard filtered back-projection on the same processing workstation (odyssey philips). in order to avoid influences, pixel size and reconstruction parameters were maintained constant in all patients. two programs were compared to evaluate functional parameters: cedars-sinai quantitative gspect (qgs) and 4d-mspect (michigan university). so, on the same reconstructed slices, lvef, edv, wm (in mm) and wt (%) were computed in a 5 segment model (apex, anterior, septal, inferior and lateral wall), representing the whole left ventricle. statistical analysis was performed. results: a good correlation between the programs was found only for the estimation of lvef and edv (r 2 =0.74 and 0.96 respectively), while a poor correlation was found for wt and wm. the r 2 values for wt and wm are summarized in table 1 . qgs provided bad bull's eye images in 6 patients, and 4d-mspect, in 4 patients. conclusions: cedars-sinai quantitative gspect (qgs) and the 4d-mspect programs provide reproducible results for the estimation of lvef and edv. in spite of these favourable results, we noted that the estimation of wt and wm only moderately correlate between qgs and 4d-mspect. for these parameters, the poor correlation suggests caution for the clinical use of polar maps and values of wt and wm. aim various computer algorithms are available to segment the myocardium in gated myocardial perfusion scintigraphy, to calculate functional parameters such as left ventricular ejection fraction (lvef). the ability of these algorithms to reproducibly detect the myocardium will depend on how well defined the wall is in the images of the heart, and hence on the size of any myocardial defects and the count in the heart. this study was carried out to measure the inter-operator variability of lvef calculated with the cedars-sinai and stanford methods, and to determine how this varied with count and defect size. materials and methods 84 consecutive gated myocardial perfusion studies carried out at the bristol royal infirmary were included. a circular region of interest was drawn over the lao image of the heart and the count in the region was recorded; patients were grouped into upper quartile, lower quartile, and intermediate counts. the defect size was determined using the perfusion quantification package myoquant, and patients were grouped into no defect (40/84), defect size 1-4% (18/84) and defect size > 5% (26/84). data was processed to determine lvef using multidim (stanford) and qgs (cedars-sinai). results lvef was on average 3.7% (sd 5.6%) lower with multidim than qgs. inter-operator variability for lvef was 3.7% for multidim and 3.8% for qgs. lvef decreased with increasing defect size for both multidim and qgs. the difference in lvef between qgs and multidim decreased significantly, from 4.3% to 1.5%, as defect size increased from zero to > 5% of myocardium. inter-operator variability of lvef increased with perfusion defect size for multidim, but not for qgs. lvef, and the difference between qgs and multidim, did not change with count. the inter-operator variability was greater for lvef with lower count, for both multidim and qgs, but this was only significant for multidim. conclusion the inter-operator variability of lvef measurements in gated mps may be affected by algorithm, count and defect size. overall, qgs and multidim had very similar average inter-operator variability for lvef, but multidim was more affected by count -worse with low count -and defect size -worse with large defects -than was qgs. aim: imaging from the source that striking the whole crystal area with a uniform flux of photon, is the main method for calculation of non-uniformity in gamma camera systems. in such condition a perfect system produces images of uniform count density. however noise is a major problem in evaluation of non-uniformity in low count test images. noise causes random fluctuation in count density that is hard to distinguish from real non-uniformity in the image. in this study we used statistical methods in fourier domain for calculation of non-uniformity in simulation nuclear medicine images. methods and materials: using the monte carol method, uniform and nonuniform flood images of different matrix sizes and counts density were generated. the uniformity of the images was calculated using the conventional method (integral and differential uniformity) and proposed (fourier transformation) method. results: the value of integral and differential uniformity shows that these parameters are suitable for calculation non-uniformity only in small matrix size image (high count density). however fourier transformation could perfectly reflect the non-uniformity even at very low counts almost in all matrix size. discussion: in daily uniformity test (low count density image) it is not possible to quantify the non-uniformity of test image accurately. however if data is transformed into the frequency domain, non-uniformity may be better be distinguished from random noise in data. aim:simulation is the first step for improving the imaging tests and developing the imaging systems. simset is a routine powerful simulation software for simulating nuclear medicine systems specially pet and spect. it is necessary that the parameters of these simulation software be accuracy and according to standards in real systems. in this study we considered the simset software with intrinsic quality control tests.material and methods: we perform four routine intrinsic quality control tests(uniformity , spatial resolution , spatial linearity , energy resolution) in a virtual spect system that was simulated by simset. we also used the ncat softwares to produce the phantoms of quality control. these tests were performed according to the nema methods. the calculations were done in mathlab and for more accuracy all the procedures were repeated 5 times.result: we acquired integral and differential uniformity less than 1% for 1000 counts per pixel , spatial resolution less than 3 cm , spatial linearity less than 0.05% and energy resolution was exactly the same as the default value that be set. conclusion:all the parameters that we calculated were according nema standards. but the calculated values were ideally less than the parameters in real spect systems. it shows that it needs more study to extend the result of simulating to real condition. background: the discovery that the use of herceptin® (trastuzumab) in breast cancer may cause cardiotoxicity in some patients has led to calls for rigorous cardiac monitoring of patients, both to ensure that they are eligible for the drug and at regular intervals once therapy has begun. one of the techniques indicated for this cardiac monitoring is the gated blood pool study (muga scan). patients can only be accepted for therapy if their ejection fraction (ef) is within the normal range of the centre performing the study. it is therefore important that centres have a robust and reproducible method for measuring ef. the aim of this study was to assess the reliability of muga processing carried out at our centre. method: gated blood pool studies are performed following the administration of 800mbq tc99m in vivo labelled red blood cells. the studies were performed on a siemens ecam gamma camera with a high resolution collimator. the data was processed using nud hermes fuga software. we selected the 50 most recently reported muga studies which had been routinely processed by different operators. these 50 scans were retrospectively reprocessed by two experienced operators independently. the ef results initially reported were compared with those obtained by these investigators. results: for the 50 studies assessed, the mean (± sd) reported ef was 59.5 ± 7.9 %. the mean ef obtained by investigator 1 was 55.3 ± 8.9 % and the mean ef obtained by investigator 2 was 55.4 ± 9.9 %. using the paired t-test, there was found to be a significant difference between the reported efs and those obtained by both investigators (p<0.001). however, there was no significant difference found between the efs obtained by the two investigators (p>0.5). review of the original data processing, showed that the selection of the background region was not consistent, with regions of high activity (e.g. gut) included in a number cases. conclusion: in this preliminary review of our working practices, significant differences were found in the ef results reported when compared with subsequent re-processing by single operators carefully selecting the background region. further work is intended to ascertain other possible reasons for these differences and assess whether further training and regular review of practice is needed to ensure reliable results are reported. objectives: to enhance signal-to-noise ratio in a selected volume-of-interest (voi) centered on the heart and to improve diagnostic performance of nuclear spect studies. methods: the new method of simultaneous spect acquisition and reconstruction using a cone-beam and a parallel beam collimator has been introduced and evaluated. we simulated nuclear spect scans with tc-99m sestamibi using monte carlo method (simset). we also acquired spect data using physical phantoms on a two-head gamma camera (e.cam, siemens). the normal hearts, as well as hearts with various size defects were imaged. for tomographic reconstruction we used our new fully 3d ordered subsets expectation maximization (osem) algorithm with cone-volume system model combined with parallel-volume system model. total variation optimization regularization was also implemented in this approach. we evaluated signal-to-noise ratio improvement in the selected voi and accuracy of determination of the extent and location of the defects in the heart using our combined cone-beam/parallel-beam acquisition and reconstruction method, as compared to conventional parallel-beam only approach. results: we established an increase in the accuracy in locating the site and the spatial extent of heart abnormalities while using our combined cone-beam/parallel-beam acquisition and reconstruction method, as compared to parallel-beam only approach. conclusions: application of our new combined cone/parallel-beam method might results in improved accuracy in nuclear cardiology spect studies. i-123 mibg is a radiopharmaceutical used for evaluation of cardiac symphahetic function based on the heart to mediastinum count ratio (h/m ratio) in myocardial scintigraphy. images are acquired by detecting the photons within ±10 % energy window centered on the 159 kev photopeak. the radioactivity contains a considerable scatter fraction due to high energy gamma-rays with 529 kev (1.047 %) and others emitted from i-123. scattering and penetration of these high energy photons thrausk the lead the collimator are the prime cause of deteriorating image quality. the aim of this study is to evaluate validity of a monte carlo code for estimating the fraction of scattered photons for various types of collimators on i-123 mibg myocardial study. materials and methods: calculations were carried out using a monte carlo simulator which consists of the hexagon code modelled the collimator and the nai code modelled the nai detector system including the back-compartment. the code provides the energy spectrum for every pixel identifying the unscattered, the scattered and the penetrated photons. the simulated image was formed using these energy spectra. the phantom used in the measurement was made from the breast-shaped sheets of paper soaked with the i-123 solution. the organs such as chest wall, left-and right-lungs and heart, were simulated by the overlapped sheets having the different activity densities, respectively. the mix-dp plastic was used as the scattering medium. experimental data were acquired using the prism irix (philips) gamma-camera attached with various collimators such as the legap, the lehr and the megap. comparisons of the energy spectrum, the count profile and the planar image between the measurement and the simulation were made under the conditions with and without the scattering medium. results: the simulated count profiles along a line agreed well with the measurements. the simulated and the experimental planar images were compared with each other using the method of power spectrum analysis. the characteristics of the images obtained on the frequency domain and the subtracted images agreed between the simulation and the measurement. conclusion: monte carlo simulation of the scintillation camera system using i-123 enabled to reproduce the experimental images with a high accuracy. the present study is useful for the improvement of the quantitative evaluation on i-123 myocardial imaging. effect of administered dose level on image quality of brain perfusion imaging with 99m tc-hmpao: a quantitative analysis a. p. stefanoyiannis, x. geronikola-trapali, i. armeniakos, s. n. chatziioannou, a. prentakis, e. efstathopoulos, a. gouliamos; second department of radiology, nuclear medicine division, school of medicine, university of athens, athens, greece. aim: brain perfusion imaging by means of 99m tc-labeled hexamethyl propylene amine oxime (hmpao) is a well-established diagnostic procedure. the administered dose range recommended by the supplying company and reported in bibliography is rather wide (approximately 9.5-27 mci). in this study, a quantitative evaluation of the radiopharmaceutical performance for different values of administered dose (10, 15, 20 mci) was carried out, based on computer-generated indicators of image quality. subsequently, a generic image quality index was correlated with the administered dose, to produce an overall performance indicator. by means of this analysis, the necessity of higher dose administration was examined, taking into consideration patient absorbed dose. materials & methods: a sample of 78 patients (56 administered with 10 mci, 10 with 15 mci and 12 with 20 mci) was utilised. some patients were classified as normal, while others presented various forms of pathology. evaluation of image quality was based on contrast, noise and contrast-to-noise ratio indicators, denoted ci, ni and cnr respectively. calculation of all indicators was based on wavelet transform. an overall performance indicator (denoted pi), produced by the ratio of cnr by administered dose, was also calculated. results: the results of quantitative evaluation are presented in table 1, where the % differences of estimated indicators for 15 mci and 20 mci subsamples versus the control subsample of 10 mci are reported. calculation of skewness parameter revealed the normality of ci, ni and non-normality of cnr, pi populations. application of appropriate statistical tests (analysis of variance for normal and kruskal-wallis test for non-normal populations) showed that there is a statistically significant difference in ci (p<0.01), ni (p<0.001) and cnr (p<0.05), but not for pi (p>0.05) values. application of tukey test for normal populations ci, ni led to the conclusion that ci(10 mci) = ci(20 mci)<ci(15(mci) and ni(10 mci)>ni(20 mci), while ni(15 mci) can not be characterised. finally, application of non-parametric multiple comparisons showed that cnr(20 mci)>cnr(10 mci), while cnr(15 mci) can not be characterised. the discovery ste is a dedicated brain and whole body pet scanner, with design features that enable high image spatial resolution combined with high sensitivity. the scanner combines eight multislice helical ct scanner with a pet tomography which consists of 13440 bgo crystals arranged in 24 rings. the crystal sizes are 4.7×6.3×30 mm 3 in the axial, transaxial, and radial dimensions, respectively. the pet detector ring diameter is 88.6 cm with axial and transaxial fields of view (fovs) of 15.7 and 70 cm, respectively. the ct scanner is a 8-slice lightspeed. this study evaluated the nema2001 performance of the scanner. performance measurements of spatial resolution, sensitivity, image quality, scatter fraction and counting rate performance for 2d and 3d were made using the nema2001 procedures. the low energy thresholds of 2-dimensional and 3-dimensional are set to 375 and 425 kev, respectively, and the both high energy is 650 kev. the coincidence time window of 2d and 3d are set to 11.05 ns and 9.75 ns, respectively. in addition, images from the 3d hoffman brain phantom acquired in 3d modes is shown to demonstrate the image quality obtained from the scanner. the average transaxial (axial) fwhm resolution measured 4.9 (5.0) at r =1 cm and 5.6 (5.7) at r=10. the system sensitivity in the center for 2d and 3d was measured as 1.9 kcps/mbq and 9.9 kcps/mbq, respectively. the scatter fraction was 18.0% and 34.2% in 2d and 3d. the peak noise equivalent count rate (necr) was 92.97 kcps at 64 kbq/ml in 2d and 86.56 kcps at 18 kbq/ml in 3d for a noise-free estimation of randoms. the contrast of the 22, 17, 13 and 10 mm hot spheres in the image quality phantom in 2d (3d) were 62.2% (77.4%), 50.6%(64.8%), 39.4% (55.2%) and 18.2% (42.1%), respectively. the results show good system resolution and sensitivity in both 2d and 3d, making this scanner highly suitable for brain and whole body studies. the choice of two-dimensional (2d) compared with three-dimensional (3d) imaging and the effect of reducing the scan time duration in bgo based positron emission tomography computed tomography (pet ct) scanners remains a matter of discussion. in our study of 21 patients with known or suspected head and neck cancer (24 lesions total) we used a 2d and 3d acquisition protocol utilising 4min, 3min and 2min scan time durations on an axial single-field-of-view (sfov). the scan sequence was 2d 4min, 3d 4min, 3d 3min, 2d 3min, 2d 2min and 3d 2min to minimise redistribution and decay bias in results. semi-quantitative analysis was achieved by drawing regions-of-interest (roi) around each tumour maximum fdg uptake (suvmax) and associated uniform background mean uptake (b) in all scans to calculate suvmax, lesion signal / background ratio (i.e. suvmax/b) and image noise as the % coefficient of variation in the background (i.e. %cv in b). for suvmax in all paired scans 2d > 3d at 4min, 3min and 2min; differences were highly statistically significant (p<0.0001) with mean % differences of approximately 21, 23, and 23 respectively favouring 2d. lesion signal / background ratio differences between paired 2d and 3d scans were highly statistically significant at 4min, 3min and 2min (p<0.0001) with mean % differences of approximately 18, 19, and 16 respectively favouring 2d. noise differences between paired 2d and 3d scans were statistically significant at 4min, 3min and 2min (p<0.004; p<0.01, p<0.007 respectively) with mean % differences of approximately 18, 16 and 18 respectively favouring 3d. all lesions were seen irrespective of acquisition mode or scan time duration. we conclude that scan time durations of 3min may be implemented in 2d without significant loss of semi-quantitative information when applying our acquisition protocols and reconstruction algorithms in head and neck cancer patients on a bgo based pet ct scanner. aims: modern petct systems have detector configurations and reconstruction algorithms optimised for maximising patient throughput for whole-body fdg oncology studies. the aim of this observer study is to determine the optimum scanning time for such studies and to assess how bmi can affect this time. to understand more about perceived image quality, the relationship between image quality and image noise is also assessed. material and methods: twenty-five randomly selected patient studies were acquired in 2d mode on a ge dst petct scanner using list mode acquisitions, to allow the reframing of studies into imaging times of two, three, and four minutes per bed position. data was then randomised and presented to three observers in three sessions. in each session three datasets of variable quality were presented as a training set before the observer was asked to rate image quality of the 25 study patients using a five-point scale. image noise was also characterised at several locations throughout each dataset. results: reduced imaging time led to lower image quality scores, with paired comparisons showing the largest difference in scores (mean:0.64 95%ci:0.47 -0.81) between 3 and 2 minutes per bed position. using our imaging protocol, 4 minutes per bed position is necessary for an adequate (score > 3) scan in the majority of studies (18/25). the relationship between score and bmi for each scanning time is shown in table 1 . for bmi's less than 25, 3 minutes per bed position were adequate in (11/13) studies. for (4/5) studies with bmi > 30 a scan time greater than 4 minutes was required. image noise also decreased with imaging time in similar manner to image quality, and there was also a significant association between image noise and image quality (p < 0.05). however, no significant difference in noise was seen between adequate and inadequate scans, and no significant association was found between noise and bmi. conclusions: using our modern petct system and protocol, 4 minutes per bed position is adequate for most patients, although scanning time should be extended for obese patients, and could be reduced for those not overweight. furthermore our data shows a strong relationship between image quality and image noise. and 37 mm) and by a torso background (fillable compartments), whose volume is equal to 9700 ml, was used. the tank and the spheres were filled with a set of known 18 f-fdg concentrations in multiple experiments. in every setup, the six spheres were filled with equal concentrations of 18 f-fdg in a fixed standard background concentration of 0.138 μci/ml, simulating clinical situation. background activity concentration was calculated from the analysis of 100 fdg-pet studies. the experiments was repeated 15 times; in each measurement the contrast of the spheres was 20% inferior in comparison to the previous one; we obtained contrast value ranging from about 2000% to 40%. the emission scans were performed in 2d mode, acquiring a single bed centred upon the spheres. the transmission scans were performed in spiral mode, 120 kv, 80 ma, slice thickness 3.75 mm, pitch 1.5. a 2d iterative algorithm (osem, 30 subsets, 2 iterations) was used for image reconstructions. a ge xeleris workstation and an advantage windows workstation were employed for image analysis. for each measurement, contrast was estimated as a function of the diameter of the spheres. a contrast-detail curve was obtained, and contrast-detail threshold was estimated. to estimate volume of small lesions, we used a threshold at 40% of the maximum voxel intensity value of the lesion. results lesion nominal contrast is well correlated with lesion measured contrast (r 2 = 0.999). the tcdd (threshold contrast detail detectability) for the 10 mm diameter sphere is about 350%, for 13 mm diameter sphere is about 250%, for the 17 mm diameter sphere is about 100%, for the 22 mm diameter sphere is about 70%, for the 28 mm diameter sphere is about 40%. conclusionswe investigated the performances of our pet/ct scanner used in 2d modality for lesion detectability. next step will be the investigation of the effect of acquisition and reconstruction on lesion detectability. pet has a reputation in the quantification of brain perfusion and metabolism. recent advance of pet/ct brought a new era in oncology pet. most of newly shipped pet instruments are pet/ct scanners, all of which are designed to use mainly in 3d mode and ct based attenuation correction. although 3d acquisition and ct attenuation correction have many advantages, there are remaining problems in terms of quantitative accuracy. in this paper, we focus on the effect of direct photons from radioactivity outside the fov, and the accuracy of ct based attenuation correction. the lack of interplane septa of 3d scanner results in an increase of random events of direct photons from outside the fov. it may badly affect the accuracy of image. in particular, oxygen-15 gas inhalation study for brain, high radioactivity outside the fov exists throughout the scan. we performed an o-15 co2 gas inhalation pet scan in a healthy subject using 3d-lso pet/ct, under the steady state condition. thanks to the lso detector, better quality images were obtained than expected prior to the scan. however, random events were 50 % of true events. a high fraction of random must be derived from activity outside fov, especially from lung. in an experiment with external activities placing 15 cm apart from a phantom, image deterioration was observed with increase of the external radioactivity. to estimate the accuracy of ct based attenuation correction, we performed an experiment with high attenuation objects. a phantom with multiple rod inserts was used. six inserts were filled with same amount of radioactivity, and 5 of the 6 were also filled with contrast material of different density. with the increase of density, measured events tend to increase, even the same activities exists. it might affect the quantitative accuracy in the region with high attenuation. our goal is to establish a method to obtain highly quantitative brain pet images, using 3d pet/ct designed mainly for whole body scan. aim: contrast-to noise ratio (cnr), was studied as a function of emission scan duration (esd) and activity at the start of acquisition (a acq ) for different target sizes and target-to-background (t/b) ratios using a multivariate approach in a wide range of conditions approaching the ones that can be encountered in the clinical practice, using a 3d-lso based pet/ct scanner. material and methods: an annular ring of water bags of 3 cm thickness was fitted over an iec phantom in order to obtain counting rates similar to those found in average patients. a supplemental set of micro-hollow spheres was positioned inside the phantom. the phantom was filled with a solution of water and 18 f (12 kbq/ml) and the spheres with various t/b ratios of 22.5, 10.3 and 3.6. sequential imaging was performed to acquire pet images with varying background concentrations of about 12, 9, 6.4, 5.3 and 3.1 kbq/ml. the esd was set to 1, 2, 3, and 4 min/bed. lesion detectability was visually and quantitatively assessed. results: with t/b ratios of 3.6, 10.3 and 22.5 the 13.0, 8.1 and 6.5 mm spheres were detectable for the whole ranges of background activity concentration and esd, respectively. the regression equation that best summarizes the results obtained in a multiple regression model with cnr as predicted variable and t/b ratio, activity at the start of acquisition (a acq ), sphere area and esd as predictor variables may be written as: cnr=-20.1+ 17.5x(1-1/t/b)+0.25 x(aacq) 1/2 +0.0082 x sphere a +0.56 x (esd) 1/2 the multiple r 2 of model fitting equals 0.71. all of the variables were statistically significant predictors of cnr, whose variance can be accounted for, in order of increasing weight, by esd ( 4 = 0.60), t/b ratio ( 1 = 0.59), sphere a ( 3 = 0.37) and a acq ( 1 = 0.27). conclusion: cnr depends only slightly on a acq : the weight of a acq in explaining cnr is more than halved with respect to the contribution of esd. cnr values exhibited an essentially flat response for a acq in the wide range explored . (from 92.3 to 370.5 mbq). as cnr is closely related to lesion detection, this finding suggests that also lesion detectability might not strongly depend on the injected activity, in this range. if confirmed by further studies on lesion detectability on anthropomorphic phantoms, these findings would suggest using lower 18 fdg activities, which could be a gain both from a radiation protection and economical point of view. aim: the respiratory gating system varian rpm (real-time position management) was implemented on a ge discovery ste pet-ct scanner to reduce artifacts and drawbacks due to breathing. analyses of a moving phantom and patient acquisitions were performed to estimate the potential benefit of such a system in clinical practice. material and methods: a phantom containing 5 spheres of different size (volume ranging from 0.5 to 8 ml, filled with 18 f, lesion-to-background ratio of about 4:1) was acquired with a ge discovery ste pet-ct coupled to a varian rpm system. breathing motion was simulated with the standard imaging gating respiratory platform (period 4 s, amplitude 20 mm). two series of pet-ct acquisitions were performed: i) without taking into account the motion tracking (non-gated mode) ii) by dividing the breathing period in 6 bins and reconstructing pet-ct images for each bin (gated mode). then 6 patients showing uptaking lesions in lungs or liver were acquired. the maximum of the weight body standard uptake value (suv bw max ) was compared for gated and non-gated acquisitions for 13 lesions. the motion amplitude of each lesion was evaluated. results: in the phantom trial the images acquired in gated mode showed better recovery coefficients: for the 4 smallest spheres the enhancement ranges from 93% to 160%. for the largest one the relative increase is 37%. in patient acquistions in gated mode 6 lesions showed an increase less than 10% in suv bw max or a small decrease, 7 an increase from 11% to 99%. 6 lesions had motion amplitude less than 4 mm, showing an average enhancement of suv bw max in gated mode of 10%. 7 lesions with motion amplitude higher than 4 mm (up to 16 mm) showed an average increase in suv bw max of 27%. conclusions: when a periodic movement due to breathing is present in pet-ct exams, the varian rpm system provides a general improvement in the image quality, reduced motion artifacts in ct, higher suv in pet, more precise match of ct and pet, more accurate volume delineation for radiotherapeutic purposes. a high variability in the advantages of a gated acquisition was observed, depending on lesion features such as the motion amplitude. aim: f-18-dopa pet is a well-established method to image dopamine transporter system in human brain. in pet/ct scanners, ac is performed with a ct-based method (ct-ac) as compared to ge-68/ga-68 source transmission scan (s-ac) of pet only scanners. the influence of ct-ac on the determination of the influx constant (ki) to measure dopamine transporter expression is unknown. methods: ten volunteers and parkinson disease patients (55±15y) underwent a 38-frame 120-min or 25-frame 96-min acquisition after the injection of 120mbq of f-18-fdopa, performed after ac acquisitions (ct-ac: 140kev, 80ma; s-ac: 10-min transmission scan; discovery ls, ge). striatal and occipital rois were drawn and time-activity curves (tac) were generated summing the 5 central slices encompassing the striatum. ki was computed using the occipital cortex tac as input function. differences in striatal and occipital tac were characterized, and differences in ki derived using voxel-based kinetic analysis (pmod software). comparisons were performed with pearson's correlation and bland-altman plots. results: absolute differences in striatal and occipital tac between ct-ac and s-ac were <0.3kbq/ml (7%) in all studies (mean -0.01±0.16kbq/ml [-1±4%]). absolute difference in ki was <0.7e-3/min (7.7%) in any striatal voxel (mean -0.03e-3±0.3e-3/min [0.2±3.6%]). correlation of ki between both ac methods was excellent (y=0.9990 x+0.0, r=0.9947, p<0.0001) without systematic error (p>0.8). all measurement pairs were within bland-altman's reference range (-1e-3 to +1e-3/min). the largest variations were observed around the skull's outline and at the interface between air and bone, in relation to differences in ac maps resolution or minor patient motion (n=1). conclusion: ct-based ac introduces a difference <7% in tac and <8% in voxel-based striatal ki estimates as compared to source ac. average differences of 1±4%, an excellent correlation between ac methods and absence of systematic differences allows using both ac method or norms interchangeably when comparing patient groups. however, in follow-up studies aiming at assessing individual disease progression or response to treatment, the same ac method should be used to avoid introducing additional variability. v. schulz 1 , j. zeintl 1 , a. szikszai 1 , j. hornegger 2 , t. kuwert 1 ; 1 clinic of nuclear medicine, university of erlangen/nürnberg, erlangen, germany, 2 chair of pattern recognition, university of erlangen/nürnberg, erlangen, germany. aim: this study investigates the influence of ct-based attenuation correction on the quantification of uptake of i-131. methods: data sets acquired using a hybrid spect/ spiral-ct system (symbia t2, siemens, hoffman estates, il) in 48 patients with thyroid cancer were retrospectively analyzed. the whole group of patients was divided into a subgroup exhibiting i-131 uptake in the thyroid bed (n = 25; tg) and another one with foci located elsewhere (n = 23; ntg). using regions of interest (rois), ratios were determined between the counts in the focus and those determined in the whole transversal slice. roi measurements were performed in uncorrected tomograms (nac) as well as in images corrected for attenuation using the registered ct images (ac). the minimal distance of the focus to the surface of the body (dist) was correlated to the ratio between the values determined for ac and nac (ac/nac ratio). furthermore, the roi measurements were also performed in ac scans in which spect and ct images had been misaligned by 1 cm in one dimension beforehand (acx, acy, acz). results: the mean differences of i-131 uptake ratios between ac and nac were 9.04 % in tg and 21.43 % in ntg. both differences were, however, not significant due to their large standard deviations (p > 0.05). no significant correlation could be found between dist and the ac/nac ratio. ac using misaligned pairs of patient data sets led to a significant change of whole-slice uptake ratios for acx and acy in tg and for acz in ntg, the differences ranging between 2.90 to 21.39 % (p < 0.05). conclusions: ac did not affect i-131 uptake ratios significantly in our study, probably due to the fairly high energy of i-131 or also heterogeneities of the investigated group of patients with regard to the location of the foci of i-131 uptake. in i-131-spect scans, ct-based attenuation correction should be performed with particular attention to artefacts caused by misalignment between spect and ct. objective: in nuclear oncology, ga-67 spect studies can still play a useful clinical role. recently, hybrid spect/ct system provided nonuniform attenuation correction with the spatial distribution of attenuation coefficients using a ct data. the purpose of this study was to verify the effects of nonuniform attenuation correction on the hot spot lesion detectability in thoracic spect images with ga-67. methods: we evaluated 20 hot spot lesions from 14 patients with ga-67 thoracic spect. using our combined spect/ct system (millennium vg, ge), all patients underwent ga-67 spect and ct examinations. spect images were reconstructed with and without nonuniform attenuation correction. to assess the impact of attenuation correction, we compared the values of legion to normal tissue contrast. furthermore, we performed simulation study with numeric digital phantom consisted of lung and soft tissue attenuation coefficients. the phantom imitated a human thorax, in which several lung hot lesions were located in the lung field with homogeneous activity. after generating projection data from the phantom with taking attenuation into account, reconstruction was performed with and without attenuation correction. as with patients study, we compared the values of legion to normal tissue contrast. this simulation study was calculated using the software "prominence processor" developed by maeda. results: in the patients study, the average values of contrast increased from 3.41 to 6.43 with nonuniform attenuation correction. the contrast of hot spot lesions was also improved by nonuniform attenuation correction in the simulation study. on the other hand, without attenuation correction, legion to lung contrast was decreased significantly depending on the background activity in the lung. conclusion: nonuniform attenuation correction using spect/ct improves the lesion contrast in ga-67 thoracic spect imaging. (3), control study in men ii (1) and primary pheochromocytoma (16). the scintigraphic result was correlated with those obtained in morphologic imaging techniques and follow up during a mean time of 17 months. results: in 17 patients the scintigraphy was negative: in 9 of them the planar study was doubtful and spect-ct was negative and in 8 cases both of them were negative, showing the absence of uptake in the radiological lesions visualized in 6 of them (size of lesion < 20 mm). the scintigraphy was positive in 6 cases: 3 were positive in the planar imaging (in one of them, spect-ct localized higher number of metastases) and 3 were doubtful, contributing the spect-ct to the confirmation of pathological functionality and its location. the positivity of the 123i-mibg scintigraphy confirmed the clinical diagnosis of pheochromocytoma and the consequent indication of surgical treatment in all cases (6), except in one with diseminated disease. the diagnosis in the negative cases was essential hypertension or non-hipersecretory lesions. the performance of the spect-ct represented an increase of the specificity (100% vs 48% for planar imaging). conclusion: in 52 % (12/23) of cases the spect-ct helped to establish the final scintigraphic diagnosis contributing to a better diagnostic and therapeutic management accuracy. aim audit new low dose ct protocols used for localisation imaging on the philips precedence spect/ct system. method 3 low dose protocols for localisation ct (l-ct) have been created. all are helical with identical pitch and use the doseright-dom auto ma feature: • l-ct abdo: a body protocol for viewing conventional axial ct images (50mas, 120kv, collimation 16x1.5, slice width 3mm, rotation time 0.5s, ctdi v 3.5mgy). • l-ct abdo mpr: a modified version of l-ct abdo with thinner reconstructed slices (collimation 16x0.75, slice 1.5mm) making it more suitable for multi planar reconstruction (mpr). the mas was doubled (100mas, ctdi v 7.8mgy) to maintain the same noise level. • l-ct neck: a protocol for scanning the neck using the head filter (100mas, 120kv, collimation 16x0.75, slice width 2mm, rotation time 0.5s, ctdi v 15.2mgy). over 4 months, a range of spect/ct scans were performed of the body, neck or feet. an audit questionnaire was designed and completed by the reporting consultant radiologist to find out how l-cts were viewed, the amount of detail required in the image, an acceptable level of noise and if the overall image quality was acceptable. results 81 spect/ct scans were included in the audit, 4 using l-ct abdo (mean dlp 228mgy.cm), 72 using l-ct abdo mpr (mean dlp 227mgy.cm) and 5 using l-ct neck (mean dlp 508mgy.cm). 63 scans were viewed in mpr mode, including 2 of the l-ct abdo scans. image detail of <1mm, 1-2mm and 2-5mm were required in 1 (1%), 65 (80%) and 15 scans (19%) respectively. 11 (14%) l-cts were considered to have poor image quality, of which 6 were due to patient related artefacts. the other 5 unacceptable scans were of feet. 18 feet l-cts were audited, 13 were considered acceptable but comments were made on 4 of these indicating that a higher resolution ct would have been preferred. conclusion despite the subjective nature of these results, we now have an insight into some of the imaging requirements of l-ct. the majority of viewing and reporting was done in mpr mode requiring the thinner slices of the l-ct abdo mpr protocol. the low dose l-ct protocols are acceptable for most of our scans, except feet, where high resolution is critical (and more important than low noise). a new anthropomorphic phantom will be used to further develop these protocols and create new ones tailored to specific exam types. the audit will then be repeated. morphological image processing for automatic arm removal in spect-ct images. objectives: image fusion of longitudinal spect-ct and ct to ct studies is frequently required to detect significant changes with time. but accurate image registration is hampered by the presence of the patients arms in the field of view which may take radically different positions or even not be present in some imaging sessions. the objective of this study is to investigate the feasibility of automatic arm detection and removal even in the difficult case when the arms are touching the body. methods: the process of arm detection and removal consists of a: an automatic thresholding step is applied to each ct section to segment the data into foreground with value 1 representing the thorax , abdomen and arms if distinct from the body and background with value zero. b:holes frequently occur within the thorax and abdomen from air , gas etc, to remove these areas the morphological image operation of opening using structured elements is applied to smooth out the resulting sections. c:connected components are identified within each section and from the number and respective sizes of the detected regions the arms may be automatically detected and removed when distinct from the abdomen. d: should the number of regions detected not reflect the presence of the arms then the morphological operation of watershed segmentation is applied . this operation automatically separates or cuts apart objects that touch. it starts with our segmented binary image and calculates a distance map to find the fattest parts of the object, the peaks or local maxima of the distance map. purpose: the aim of this study was to control the inflammatory process and evaluate the volume of the inflamed synovium of the knee during the radiation synovectomy (rs) treatment of chronic synovitis. gadolinium-dtpa contrast-enhanced t 1weighted images are useful in identification of pannus tissue, which can be seen as areas of increased signal intensity adjacent to low signal intensity of joint fluid. the fusion of 166 ho-fhma (holmium ferric hydroxide macroaggregates) spet images and mri images is often inaccurate. to avoid this problem, we aimed this volume procedure to facilitate fusion of mri and spet images. methods and material: the patients with rheumatoid arthritis were treated with 166 ho-fhma. the spet images were taken after 24 hours of rs. the mri images were taken three times. the first mri imaged before rs and study was used as a reference to the later imaged mri studies. the second mri was taken after one week and third mri after three months after rs. all mri control images are taken in the same manner. the images are processed with region growing method to separate inflamed synovium of the knee. the region of interests (rois) masked in every slices of the study. all rois were checked by two independent radiologists. the volume calculation was confirmed by the 20 ml filled syringe in the same manner like patient studies. volume evaluation was possible and accurate with this procedure. result: this volume evaluation procedure shows clearly the effect of the therapy. comparing these volumes of the same patient we can see how inflamed synovium volume decreases. also the changes of the joint fluid volume can be evaluated. decreasing of the relative synovium volume after one week of rs and after three months of rs was average 24,6 % / 37,9%. conclusion: mri is an accurate procedure to estimate the volume of acute synovitis. the volume quantification of the inflamed pannus and synovial fluid was made possible by this procedure and the effect of the therapy is accurately determined. the volume evaluation of the treated knee with rois make possible to increase accuracy of spet and mri image fusion. objectives: reconstruction of pet images from projections is a problem which from a clinical perspective seems like a chapter completed in the mid eighties; in particularly replacing already established algorithms like fbp and osem are not easily accepted. this is well justified by lack of stability of the new algorithms, the often edgy looks of the resulting images, and in general by too complex ways of obtaining the results. methods: for obtaining quantitatively correct results for use in s342 multi-subject region-of-interest(roi) studies, it is also well known how crucial correct delineation of the roi's for the individual subjects are, making it possible to compare binding potentials for specific roi's between subjects. when delineating the roi's, it is essential not to include tissue outside the respective region while at the same time, it is beneficial to include as much tissue as possible to lower the noise in data. this leads to the well known trade-off between bias and variance, where the size of the region is the parameter that can be optimized. results: for a number of simulated tracer distributions, we demonstrate the effect that resizing the regions have on the mean activity within a region. segmented mr images are used for simulating the tracer a possible tracer distribution in the brain and the mean activity in the insula and putamen are set to known values. knowing the true mean activity, we visualize how a scaling of the regions minimizes the error on the mean activity. it is further shown how this scaling depends on the algorithm used for reconstruction and any filtering applied to the reconstructed images. among the reconstruction algorithms, we show how an edge-preserving algorithm allows us to defining larger regions in the sense that the size that minimizes bias+variance is closer to the size of the anatomical region. conclusion: for our simulations, we conclude that for obtaining quantitatively correct measures for the mean activities in the regions, we should define our regions smaller than the regions derived from the anatomical information and for a typical case, we can reduce our bias by half by choosing either penalized least squares or an edgepreserving algorithm instead of fbp. the pet-fdg dynamic acquisitions are usually used with compartmental methods which suppose a modeling stage. these techniques are not widely used in clinical routines because of their complexity. we propose a simple and direct non invasive approach without modeling stage. the aim of this work is the definition of the cerebral physiological kinetic curves activity of fdg since its injection. material and methods: 14 control subjects without cerebral diseases are evaluated for this study. all acquisitions are made on a biograph tm 6 pet/ct (siemens medical solutions) with 45 minutes total acquisition duration; an intravenous bolus of 18 f-fdg is done during acquisition. to determine the beginning of the volume reconstructions, the arrival time of the tracer in the brain is evaluated using list-mode files. the number and duration of the 34 reconstructed volumes (aw-osem) are respectively: 7x5 seconds; 7x10 seconds; 7x30 seconds; 7x60 seconds; 5x300 seconds; 1x465 seconds. in-house idl software (itt industries inc.) was developed to construct and analyze the fdg time activity curves of grey and white matter, arteries and veins. regions of interest (rois) for cerebral regions (8 rois for each matter and 6 rois for each vascular region) are drawn on the ct volume and then reported on pet volumes. normalization of the 4 curves of each subject is done either by using the accumulated true events during each interval of reconstruction or by using the accumulated activity of fdg in the venous region. the standard deviations (std) are calculated at each temporal sample of the "characteristic cerebral curves" (ccc) that we define as the mean subjects' curves. results: vascular fdg curves are constructed with good temporal sampling of the few seconds after the injection showing the fdg bolus arrival at early stage. the dispersion of the ccc is evaluated for normalized and unnormalized subjects' curves at late stage (between 105 seconds and 45 minutes). the maximum std to mean ratio of the grey matter is 0.39 for unnormalized curves, 0.22 for the true events based normalization and 0.17 for venous based normalization; for white matter the values are respectively 0.35, 0.23 and 0.22. conclusion: we have defined a direct approach describing the physiological normalized curves of fdg kinetics in the cerebral regions with good temporal sampling and low dispersion. this allows the definition of key parameters of the curves. the comparison of ccc with pathological cerebral curves could be done in diseases as alzheimer. the use of normal brain spect databases that are not age-matched to the subject(s) under investigation: a feasibility study l. barnden; the queen elizabeth hospital, adelaide, australia. voxel-based statistical analysis of brain spect with the spm package offers adjustment for nuisance effects that may produce false positive results or introduce regional nuisance variance that degrades the sensitivity for detecting effects of interest. for each voxel, the software essentially performs a linear regression of the nuisance parameter versus counts and removes (adjusts out) any effect before reporting results for the effect of interest. this 'analysis of covariance' can be used to adjust for age effects provided the ages of each subject are input to spm and, in principle, should permit use of non age-matched normal databases. this approach was assessed by dividing a 90 subject normal database into four age groups 18-29 (20 subjects), 30-44 (27) , 45-59 (28) and 60-81 (15) and running spm to detect significant regional differences between the 60-81 age group and each of the three other age groups with and without adjustment for age. without adjustment for age, significant regional differences were detected for all three age groups with spatial distributions that resembled the ageing effects for the whole database. after adjustment for age, there was no significant difference between the elderly and any of the other three subgroups except for one location for the 60-81 to 18-29 comparison. the coefficient of variation in gray matter suggested that using the youngest group of normals may confer a slight statistical advantage. this work demonstrates that, provided extreme age differences are avoided, it is acceptable to use a normal database that is not agematched to the patient(s) under investigation. introduction during the last years, siscom (substracted ictal spect coregistred to mri) analysis of multimodality images realised in the assessment of medically refractory partial epilepsy has been widely used. however, other methods can be explored like fractal analysis. indeed, this mathematical tool is known for its ability to characterize heterogeneities into a structure. the aim of this work was to present the preliminary results of an application based of this tool for the characterization of observable anomalies in ictal and inter ictal spect. methods we have developed an algorithm to evaluate the 3d fractal dimension (fd) of 3d images of spect. the fd is estimated by a differential box-counting approach which consists in iteratively subdividing the image on boxes with increasing size and to evaluate the df as the slope of the regression line binding sizes of the boxes and the mean of maximum deviations of gray levels in each box. as a first assessment of the algorithm, we used simulated data with a well defined fd. then we tested the algorithm on a database containing 21 patients with ictal and interictal exams and a control group of 60 volunteers distributed by age: 30 between 20 and 39 years, 17 between 40 to 59 and 13 more than 60. finally, as application we used the method on an imagebase of 10 patients with partial epilepsy. tc-99m hmpao brain perfusion ictal and interictal images were acquired on a brain dedidated system: the tomomatic 564 (medimatic). the procedure was to subdivide the images into subimages and to compare the fd of the paired subimages of ictal and interictal. results for the comparison of healthy groups and pathologic group, we found a significant difference (mann-whitney test, p<0.05) whereas no difference was observed between the different healthy groups. as for the final application, we found a significant difference between the subimage where hyper-fixation focus were detected. conclusion in consideration with these promising preliminary results, we are working on a method to perform a multidimensional fractal analysis (multifractal) of the images. this method will lead us to fine characterization of local heterogeneities and thus a better localisation of epileptic focus. nevertheless, routine application of ml techniques to large scale biomedical data set is still a relatively new occurrence. otherwise, complex configuration and datapreprocess is an obstacle for physicians. this study proposes an innovative and userfriendly machine learning software for large-scale molecular and clinical data. we choose the excel file with customized header as the data standard. we use support vector machine (svm) as our machine learning algorithm in the platform. svms are a set of related supervised learning methods used for classification and regression. for handling large-scaled molecular data, some feature selections methods like recursive feature elimination are introduced in the system. the platform is a module of the pmod software (pmod technologies ltd., adlisvil, switzerland). results: on the machine learning platform, we developed some applications and did some researches related to molecular and clinical data. some examples are illustrated as follows: (1) we developed a machine learning based tool for parameter imaging and kinetic modeling of dynamic pet study. we collected 227 studies of kinetic modeling as training samples and built different regression models for different pet parameters. using the models, we can predict the quantitative pet parameters of vois or pixels according to the tac. (2) classification study for gene expression data. the study addresses the problem to find a small subset of genes which provides the best discrimination for a specified classification, for instance to discriminate between normal and tumor tissues. this subset can then potentially be used for genetic diagnosis, or for drug discovery. (3) we did a prediction study of short-term survival in patients with advanced non-small cell lung cancer following chemotherapy based on fdg-pet. the study demonstrates that a full kinetic analysis of the 18f-fdg kinetics is helpful for the classification into short or long survival and may helpful to identify those patients who may benefit from this palliative chemotherapeutic protocol. conclusion: the new machine learning platform provided a very unique tool for the classification and regression analysis of molecular and clinical data. the studies on the platform show that it can be widely used in the medical and biological fields. coronary artery disease (cad) is one of the world's most premier causes of early mortality, so any improvement of diagnostic process is highly appreciated. in the clinical setting, cad diagnostic is performed in a sequential manner. the four diagnostic levels consist of evaluation of (1) signs and symptoms and ecg at rest, (2) ecg testing during the controlled exercise, (3) stress myocardial perfusion scintigraphy, and (4) coronary angiography, which is considered as the reference method. in our study we focus on improving diagnostic performance of stress myocardial perfusion scintigraphy. this method bases on series of medical images. in clinical practice, these images are manually described (parameterized) and subsequently evaluated by expert physicians. we present an innovative alternative to manual image evaluation -an automatic image parametrization of multiple resolutions, based on texture description with specialized association rules, and image evaluation with machine learning methods. our results show that multi-resolution image parameterizations equals the physicians in terms of quality of image parameters. however, by using both manual and automatic image description parameters at the same time, diagnostic performance can be significantly improved with respect to the results of clinical practice. our experiments with artex image parameterization algorithm in conjunction with bayesian machine learning (naive bayesian classifier) produced highly significant results, improving diagnostic accuracy, specificity and sensitvity by more 8.7-13.3%. while these values contribute to more accurate clinical diagnostics, the improvement of sepecificity by almost 9% also suggests that 9% of negative patients (no cad present) may be reliably diagnosed without resorting to coronary angiography. background: recently, it has been recommended that nhs clinical biochemistry laboratories routinely provide a measure of renal function, egfr (estimated glomerular filtration rate), based on the modification of diet in renal disease (mdrd) formula 1 which uses serum creatinine concentration, age, ethnic origin and gender. in our centre, a further modification is applied to the formula to account for the method of serum creatinine analysis. the aim of this study was to evaluate the accuracy of egfr in our centre by comparing with the "gold standard" 51 cr-edta gfr method. method: we measure 51 cr-edta gfr using a 2 sample technique following the recommendations in the british nuclear medicine society guidelines. 112 patients were included in this retrospective study of which 44 were male and 68 were female, with mean age 60 years (range 24-87 years). only patients who had 51 cr-edta gfr measurements within two weeks of a reported egfr were included. where egfr exceeds 90 ml/min/1.73m², it is reported as ">90" rather than an exact figure due to the decrease in accuracy with increasing gfr. results: for the 112 patients, mean (± sd) measured gfr was 67.5 ± 25.6 ml/min/1.73m² and mean egfr was 83.8 ± 32.2 ml/min/1.73m². the mean difference between measured gfr and egfr was found to be 16.3 ml/min/1.73m². the correlation coefficient was 0.74 and a paired t-test showed there was a significant difference between the two methods (p<0.001). limiting the analysis to patient's with egfr<90 ml/min/1.73m² led to a similar correlation (0.7) and again significant differences were found using the paired t-test (p<0.001). for these 61 patients, mean measured gfr was 51.2 ± 18.3 ml/min/1.73m² and mean egfr was 59.8 ± 18.7 ml/min/1.73m². the mean difference between measured gfr and egfr was found to be 8.6 ml/min/1.73m². conclusion: in this preliminary study, absolute values of gfr and egfr were found to be significantly different. in general, egfr was found to overestimate compared with measured gfr. our findings agree with previous work suggesting that egfr becomes less accurate as gfr increases. however, egfr may be a useful indicator of the intrapatient changes in gfr as qgs and ectb behave differently and produce variable results from one another, they should not be used interchangeably. introduction estimation of reliable cardiac ejection fraction for oncology patients is of great importance in the therapy follow-up procedure. aim the development of automatic processing algorithm for the determination of left ventricle and background regions. methods multiparametric method was applied for the lv roi determination in every sequential image of the representative cycle. from amplitude, phase and temporary dc images of fourier time analysis segmentation of both ventricle and atrium structures was performed in the phase histogram, the lv spatial structure was separated from the other heart components by the size condition and the local minimum counts in the dc component between lv and rv and la. backround region was computed from the definite number of pixels with minimum counts in the lv close vicinity. for quality control of segmentation the visual inspection during the analysis is provided for every frame and the manual lv delineation with manual or automatic background selection is used as an alternative method. results completely automatic computational algorithm is fast enough (less than 1 minute for 32 frames' study and 64x64 matrix) and gives highly comparable ejection fraction value to the standard 2 roi method (r > 0.98; n=30) for well separated lv from rv and lv from la studies. visual inspection of the computation procedure is provided for the lv edge delineation by the cine display mode and the time sequence of parametric images for ejection and filling rates. conclusions the new multiparametric pattern recognition method with the controlling visual tools was developed for the completely automatic processing of muga studies. for patient studies with careful positioning it can safely replaces the standard "manual" methods. aim: to investigate the effect of crystal thickness on the spatial resolution of pet detectors which use artificial neural network (ann) based positioning algorithms. finding this relationship is important in determining the best trade-off between spatial resolution and sensitivity for the optimal design of a pet detector. studies have been made to investigate this trade-off for the anger based positioning algorithms but not for the ann based algorithms. materials and methods: we took the approach of conducting monte carlo simulation studies due to the complex nature of this relationship. we chose parameter values for a continuous lso based positron emission mammography (pem) system. we used the builder, grit and detect2000 software programs for the simulations. the detector consisted of a continuous lso scintillation crystal with an area of 49x49 mm 2 and varying thickness levels of 3-30 mm. the hamamatsu h8500 multi-anode (8x8) flat-panel pspmt is assumed to be mounted on the crystal. monoenergetic 511 kev photons have been sent perpendicular to the crystal surface. training sets were constructed from simulated data on a 24x24 uniform grid with 1 mm for each interval with 100 photon incidences at each point for the first quadrant of the crystal. an energy threshold of 300 kev was set in order to reduce the influence of weak events, namely compton scatters. tests were performed on sets of simulated data on a 5x5 uniform grid with 6 mm for each interval taking 1000 photons at each point with the same energy discrimination. the inputs of the neural network, namely 64 pspmt-anode outputs were reduced to four as x+, x-, y+ and y-, one from each corner of the resistor network. results and discussion: initial results show that nonlinearity is considerably reduced and spatial resolution improved by the ann method at different thickness values, thus rising also the question of whether the more expensive and less light efficient but more sensitive lso should be prefered to nai. a look-upaim: the continuous crystal concept for pet offers a number of advantages such as low cost but suffers from edge effects, distortions and low spatial resolution when used with anger logic. in particular, resolution degrades rapidly with increasing crystal thickness. in this study, we aimed to develop and evaluate a new positioning and depth of interaction algorithm to be used with a continuous crystal small organ pet system in order to overcome these deficiencies. materials and methods: the algorithm we present uses a lookup table, which is constructed by using the pmt outputs of scintillation events, simulated at each sample point of a three dimensional grid covering the entire crystal volume using the detect2000 monte carlo simulation package. scintillation point estimation is done by matching the pmt outputs of an event with the data inside the lookup table. the nearest neighbor algorithm is used during matching. during the process, we apply a first threshold for each pmt output to eliminate low energy events and then a second threshold to the nn algorithm in order to remove probable compton scatterings inside the crystal which reduce resolution. the performance of anger logic and the new algorithms are compared over a limited region for a detector configuration consisting of 60x60x10 mm 3 continuous nai crystal coupled to 16 square pmts with dimensions 15x15 mm 2 each. the grid consists of 0.5 mm spaced points over the entire crystal volume. 511 kev rays are sent along a line perpendicular to the crystal face midway between the center and the edge of the crystal. results: the anger logic results in resolution loss due to uncertain depth of interaction along any line perpendicular to the crystal face. we obtained an average resolution of 2.4 mm with the new algorithm as opposed to nearly 3 mm with the anger logic. this reflects the reduction of the positional uncertainty caused by crystal thickness as well as the elimination of most compton scattered rays. furthermore, edge effects and nonlinearities are totally eliminated. simulation results show that the new algorithm implemented for a small organ pet can provide with acceptable performance in terms of resolution and distortion while offering a low cost alternative. this algorithm can also be used in the doi determination. availability of a shielding system for brain studies in 3d thorax scan aim to examine the potential availability of a shielding system for brain studies in 3d thorax scan using fdg. material and methods a pet scanner (ge advance nxi), a shielding system for brain studies (ipl neuroshield), a cylinder phantom ( 16cm × 15cm), iec body and nema scatter phantoms were used in this study. the cylinder phantom was filled with 111mbq of 18f to simulate the brain. the background region of the body phantom was filled with an activity of 5.3kbq/ml. the four hot spheres were filled with an activity concentration of 4 times that of the background. the largest two spheres were filled with water only. the lung insert filled with foam pellets and water was placed in the center of the phantom. the line source of the scatter phantom was filled with 116mbq. emission and transmission scans were performed in three conditions. in condition 1, the body and scatter phantoms were used according to the nema nu 2-2001 image quality measurement protocol. in condition 2, the cylinder phantom was used in addition to two phantoms used in condition 1 and placed on opposite side of the scatter phantom. in condition 3, the shielding system was used in addition to all phantoms and located between the cylinder and body phantoms. in every condition, emission data was acquired in 3d mode and for 20min, which was performed three times. transmission scan time was 20min. after compensated by randoms correction, model-based scatter correction and segmented attenuation correction, the acquired data were reconstructed using fore-2d iterative reconstruction with 1~10 iterations and 32 subsets. according to the nema protocol, the pixel values on each image were examined. results with the % contrast and the accuracy of attenuation and scatter correction, there was not much difference among the results in three conditions. however, the % background variability for 10, 13, 17, 22, 28 and 37mm spheres in condition 2 were about 1.19, 1.20, 1.21, 1.22, 1.22 and 1.23 times those of condition 1, respectively. those of condition 3 were about 0.96, 0.95, 0.93, 0.90, 0.88 and 0.87 times those of condition 2, respectively. these results show that the random events from the cylinder phantom were reduced by the shielding system. conclusion in 3d thorax study with fdg, our preliminary results show that the shielding system is potentially useful to reduce the random events from brain. aim. to describe and quantitatively assess the influence of a malfunctioning block detector on reconstructed pet images for a full ring block designed scanner. methods. by using raw data acquired with fully calibrated and perfectly functioning ecat hr+ pet scanner (cti-siemens) in 2d (span 15) and in 3d (span9) mode, one block detector with 100% loss of efficiency was simulated. the effect of defective block was studied with: -the 20 cm diameter 68 ge uniform phantom scanned at high counting statistics and reconstructed with fbp ramp filter and awosem 4i/16s (4 iterations, 16 subsets); -the anthropomorphic alderson phantom filled with 18 f and acquired at clinical counting statistics and reconstructed with awosem 2i/8s, as routinely used in wb-pet fdg studies, and 4i/16s. defective block was simulated also on 2d transmission and blank scan data to separately study the effect on μ-maps. taking as reference the original images, defective images were evaluated qualitatively and quantitatively by assessing % difference of suv ( suv % .). results. defective block severely affects measured μ-map: overestimated coefficients can be generated along the correspondent fan angle. a considerable reduction of such artefacts can be obtained by segmenting transmissive data. visually and quantitatively, defective block slightly influences reconstructed images of 2d or 3d emission data when segmented attenuation coefficients are used. as shown by reconstructed high counting statistics uniform images defective block generates different artefact shapes on 2d and 3d data: -in 2d mode with ramp fbp or 4i/16s awosem they appear as cold stripes along the fan angle covered by the defective detector; -in 3dmode a very slight distortion on the edge tangential to the fan is visible only with awosem. on the uniform and alderson phantom images, in regions where artefacts were visible suv% was less than 7%. conclusions.this study showed that for hr+ scanner, even a 100% loss of efficiency of a block, in spite of the evident defect on sinograms, does not substantially affect qualitatively and quantitatively 2d/3d mode reconstructed images ( suv% variations less than 7%) when segmented or non altered attenuation coefficients are used. simulations on patient studies are under evaluation to confirm results obtained with phantoms. it is worth noting that the clinical use of a scanner with a defective block is to help temporary patient management and not to change maintenance scheduler or lower the quality standards. contrast and sensitivity performances of elscint, general electric, siemens and smv multi-heads cameras. mbq tc-99m. a 20 cm-diameter cylindrical phantom with home made hot (4-20 mm) and cold (6-25 mm) rods inserts was filled with about 740 mbq tc-99m. a tomography of 120 or 128 steps over 360° was recorded in h-mode with a circular trajectory. using a 128*128 matrix and a hardware zoom, projection pixel size was adjusted to 3.7 mm for the vg, to 2.5 mm for the dst and to 2.7-2.9 mm for the other cameras. reconstructed slices were obtained by ramp filtered backprojection and chang attenuation correction using a ge vision 6.0 powerstation. hot and cold contrasts were determined using in-house developed software. from the known shape of the phantom and the pixel size, this software automatically proposed a template of regions of interest (roi) of predefined sizes. for each rod, two circular rois were used: one having the rod diameter and a smaller one. for each roi, the software computed the contrast using the roi mean pixel value and the roi minimum (cold) or maximum (hot) pixel value. the user was allowed to shift and rotate the template in order to coregister the rois with the rods and the background areas. results. the cold contrasts were very similar although the multispect-3, the dst and, to a lesser extend, the magicam delivered somewhat lower contrasts. the smv cameras, the multispect-3 and the magicam, but again to a lower extend, generated lower hot contrasts than the other cameras. among the cameras that presented the highest contrasts, the sensitivity of the e-cam was 10 to 30 % higher. conclusions. recent multi-heads cameras from ge and siemens perform equally well from the point of view of contrast in tomography but with differences in sensitivity amounting to 10-30 %. monte carlo simulation for in-111 imaging using a scintillation camera with a low-energy general purpose collimator indium-111 (in-111) emits gamma rays with two different energies, 171 kev (90%) and 245 kev (94%). for in-111 imaging, the use of a medium-energy (me) collimator is preferable to a low energy (le) collimator. the me collimator, however, has poorer spatial resolution than the le collimator. we reported the improvement in spatial resolution of in-111 imaging with the combination of the low-energy general purpose (legp) collimator and the collimator-penetration correction (cpc) by a blurring filter in eanm'06 athens. the aim of this study is to validate a monte carle simulator developed for investigating the cpc method on in-111 imaging using the legp collimator. material and methods: in order to simulate a commercially available scintillation camera, we modified the in-house monte carlo program (mcep code) that our coauthor has previously developed for the transport of photons and electrons in matter. in this modified mcep code, interactions of photons in the scattering medium, the camera collimator, the nai crystal, and the back-compartment (including the light guide, photomultipliers, and electronics located behind the nai crystal) were accounted for. furtermore, special attention was paid to collimator penetration. simulations were carried out for some in-111 sources in air and in water, and energy spectra in the energy range 50 -300 kev and images with two 20% energy windows set at the 171 kev and 245 kev photopeaks were calculated. images were separately obtained for unscattered, scattered and penetrated photons. in order to validate the modified mcep program, data acquisitions were performed using the gamma camera (gca7200a/di, toshiba, japan) equipped with the legp or megp collimators under the same condition as the calculations. results: the energy spectra calculated for both the legp and megp collimators were in good agreement with the measured ones. the simulated planar images for the in-111 source also agreed well with the experimental measurements in spatial resolution and the count profiles. the images simulated for the legp collimator's septal penetration of the 245 kev gamma rays were very similar to the acquired images. conclusion: the modified mcep program for the in-111 source was validated through comparison with experimental data measured on the real scintillation camera. since this program allows for an accurate septal penetration of the 245 kev gamma rays on the legp collimator, it is very useful for studying and optimizing the cpc method. as nuclear medicine imaging has been widely used in diagnostic and treatment, improving the image quality is so important which is not performed by conventional collimators. slit-slat collimator has been proposed for this purpose although the optimization of such collimators has not been performed yet. in order to compare the system with slit-slat and hexagonal collimator this work is performed, in which the gamma camera system with both slit-slat collimator and hexagonal collimator was simulated by monte carlo method. the simulation of hexagonal system was compared with practical results and a good correlation was found between them so in this way the validity of our simulation code was confirmed. the nai(tl) crystal thickness for simulated gamma camera systems with both slit slat and hexagonal collimator for detection of 140 kev photons was set to be 3/8 in .since in our case we compare slit slat and hexagonal system ,collimator parameters were chosen the same as legp collimator. the simulated ss collimators consisted of 50 lead plates and the imaging was performed by rotating the ss collimator from 0 to 180 in 73 steps of 2.5 each. spatial resolution, detection efficiency, geometric efficiency and modulation transfer function (mtf) of this system for both hexagonal and ss systems were evaluated and compared. moreover the mtf of ss system was confirmed by the fourier transform of point spread function. based on the mtf value, our result showed that the spatial resolution of mentioned systems are the same whereas the relative detection efficiency of the ss system was about 51.1 times more than efficiency of hexagonal system as well as the geometric efficiency of slit slat system, which is 1.34 times more than hexagonal. the results of this study show that the ss collimators have great advantages over than hexagonal collimators by providing much higher detection efficiency, besides higher geometric efficiency while maintaining a comparable spatial resolution. as a result using this collimator makes it possible to have a better image quality in nuclear medicine imaging systems. a. kamali asl 1 , s. sarkar 2 , s. star artifact is one of the conventional artifacts in nuclear medicine imaging which is produced by gamma penetration in collimator septa. this effect is more profound for high energy photons. thick collimator septa reduce septal penetration but lead to formation of hole pattern in detection area and consequently degrading the quality of images, (dark area under collimator surface). one of the most important issues in collimator design is to how to reduce contribution of photon penetration and hole pattern artifact in acquired images. a gamma camera system with both hexagonal parallel hole (hex) and slit-slat (ss) collimators was simulated by monte-carlo method. the validity of simulation was done with practical data for 140 kev photons and a good correlation was found between them. point spread function (psf), modulation transfer function (mtf), spatial resolution, efficiency, star artifact, hole pattern artifact and optimum geometry for ss collimator were evaluated for high energy photons ( up to 511 kev ) and were compared with those of a conventional hex collimator. the efficiency of the system with ss collimator after background subtraction was measured to be 30 times higher than hexagonal collimator and spatial resolution was 14.5mm and 15.8mm with 8% statistical error for ss and hex collimators respectively. based on our ss collimator optimum geometry, septal penetration was reduced while star artifact was remained unchanged.. by increasing the number of step rotation of ss collimator, a free star artifact imaging is achievable. the contribution of septal penetration of an optimum ss collimator was reduced more than 50% in comparison with hex collimator. consequently our simulation data showed that with ideal collimator material, contrast has been improved about 30-40% . our results showed that using ss collimator has a profound effect on increasing efficiency while the spatial resolution was comparable with the system using the conventional hex collimator. in addition to increasing efficiency, star artifact was removed and contrast was improved using high attenuation material such as depleted uranium or high density material. modelling of system response with depth-dependent resolution as part of iterative reconstruction has been proposed as a resolution recovery technique in spect. recently, such schemes have become commercially available by manufacturers within routine reconstruction software implemented at clinically practical processing times. as well as improving on reconstructed spatial resolution such schemes may offer improvements in terms of signal-to-noise by supporting a more accurate detection model. we have assessed the performance of one such scheme, the philips astonish, available as part of osem reconstruction for clinical spect data. on the basis of point spread function measurements in a thorax and neck phantom the algorithm demonstrated substantial improvements in fwhm and fwtm for the parameters tested both with 99m tc and 131 i spect data without affecting conservation of counts. an additional feature of precise modelling of the acquisition process appears to be an improvement in the statistical properties of the images with lower dependency on acquisition times. as convergence of statistical schemes is generally dependent on activity distribution the performance of the algorithm was assessed with more complex objects and with patient data. patient data were acquired with 'concurrent imaging' allowing multiples of 5 seconds i.e. 5, 10, 15 and 20 sec per projection recorded from the same scan in order to assess the effect of counting statistics. on the basis of test objects, depth-dependent resolution modelling shows encouraging results for recovering resolution in data acquired with wider collimation and higher sensitivity. preliminary results with 99m tc-mdp and post-therapy 131 i spect studies demonstrate improvements in signal-to-noise levels and reconstructed resolution. introduction: the cyclone storage phosphor imager is a digital film-less autoradiography system for qualitative and quantitative imaging of radioactivity. reusable storage phosphor screens capture and store the activity and are then scanned to create a high resolution digitized image. the phosphor-imager is a versatile tool in nuclear medicine for a broad range of applications. aim: to demonstrate the versatility of the phosphor-imager in common nuclear medicine techniques including in-vivo imaging, histology, quality control of protein radio-labeling and radionuclide uptake in cultured cells. methods: tissue from mice treated with 125i pr1a3 was exposed to storage phosphor screens. histological tissue sections of rat with 111in and 99tc labeled octreotide were exposed to storage phosphor screens. thin layer chromatography (tlc) plates spotted with 177lu octreotate and developed with solvent were exposed to storage phosphor screens. 111in cultured cells in multi-well plates and collimators were exposed to storage phosphor screens. conclusion: the storage phosphor-imager is a versatile tool in nuclear medicine. it offers high resolution and quantitative analyses with a linear dynamic range of 5 orders of magnitude. it detects activity with a better efficiency than film and can significantly reduce exposure times compared to film. the storage phosphor-imager is a useful and relatively inexpensive autoradiography device for gels, chromatograms, tissues and multi-well plates. determination of internal contamination is one of the important task in radiation accident management program. 137 cs is one of the important radioisotopes in radiological and nuclear accident. possibility for using routine gamma camera system for this situation could be of great value. an adult bottle mannequin absorption (bomab) phantom has been used for calculations. a gamma camera with low energy general purpose (legp) and high energy general purpose (hegp) collimators has been simulated with monte-carlo method and evaluated with practical data. the simulated bomab phantom has standard dimensions. minimum detectable activity (mda) and counting efficiencies for 137 cs and 131 i were simulated individually. also the members of bomab phantom with different contamination of 137 cs and 131 i have been studied. the result of benchmarking showed a good correlation between simulation results and practical data. for the first time our new data regarding mixed 137 cs-131 i source reveals strategies will exist for evaluation. the mda for 137 cs with gamma camera is several times higher than mda's whole body counter but availability and logistically using the gamma camera in large accidents will be appreciated for primary triage and response. in other way our results showed that using a thicker or higher density of crystal can to improve the quality of results. also background contribution has important rule in accuracy of mda. determination of the weights of downscatter windows in i-123 spect studies r. de nijs, c. svarer; copenhagen university hospital, copenhagen, denmark. aim iodine-123 emits photons of 159 kev which are detected in an imaging window. downscatter of high energy photons contributes significantly to this window, primarily by penetration of the collimator and backscattering into the crystal. for determining the weights in the triple energy window (tew) approach it is assumed that the count energy density varies linearly inside the imaging window. since the peak value of the backscattering is positioned at 172 kev close to the energy of the imaging photons this is not the case, and the correct weight might be significantly different. for low count (e.g. dynamic) studies broader energy windows are preferred and a method of determining the weights is needed, since the ratio of the downscattered photons in the imaging window and the downscatter correction window is not known. methods if it is assumed that there are no primary and scattered photons detected in the background of the projection data, the weight for a downscatter correction window can be determined by minimizing the background outside the object. as an illustration the dual energy window (dew) scatter correction was extended with a broad downscatter correction window d (184-216 kev). in the dew approach a scatter window s (98-143 kev) is subtracted from the imaging window i (143-175 kev). both the scatter and the imaging window were corrected for downscatter by subtracting the weighted downscatter window. final images were reconstructed from i-k1*d-k2*c=i-(k1-k2*k3)*d-k2*s, where c denotes compton scattering, k1 and k3 are downscatter weights for i and s, and the weight k2 is the empirical dew scatter multiplier which was assumed to be 0.5. measurements were performed on a 3-headed irix camera (philips medical) with legp collimators. reconstruction was performed with and without (down)scatter corrections in 128x128 matrices (2.33 mm pixel size) using fbp, a low pass 4th order butterworth filter at 0.3 nyquist and uniform attenuation correction. results human studies of both the serotonin (i-123-adam) and dopamine (pe2i-123) transport system were analyzed. the downscatter weights k1 and k3 were measured to be 1.10-1.16 and 1.30-1.38 for both studies. for a flat energy spectrum these values would be 1.00 (same window width) and 1.41 (=45/32), respectively. conclusions the weight of a downscatter window can be determined by minimizing the background in the projection data. this makes an extension of the dew approach with a broad downscatter window possible. objectives: we devised a new correction method that combined attenuation correction using a difference of intrinsic dual-energy between lower energy emissions (93kev) and higher energy emissions (185 or 300kev) without transmission scan and compton scatter correction using triple-energy window (tew) method for 93kev because of enhancing a difference of intrinsic dual-energy in 67 ga citrate ( 67 ga), and applied to jis phantom and tumor phantom spect studies. methods: attenuation coefficients ratio and counts ratio for 93kev/185kev or 93kev/300kev were calculated from spect data acquired by energy window of 71kev,185kev and 300kev, respectively. the jis phantom for concentration linearity and resolution measurements was used. in phantom study, size of tumor simulated 5 sphere types with 0.5, 1.0, 1.6, 2.0 and 3.0cm in diameter, and 3 tumor types were created with tumor to non-tumor (t/nt) activity ratios of 2.4:1, 4.4:1 and 6.6:1. the images reconstructed by non-attenuation-scatter (a(-)s(-)) as a conventional method, only scatter (a(-)s(+)) and attenuation-scatter (a(+)s(+)) correction were compared by visual and quantitative analysis, respectively. results: the adequate attenuation coefficients ratio and counts ratio for 93kev/185kev were 1.243 and 20, respectively. for jis phantom, concentration linearity was kept, and then fwhm was shown improvement. in the tumor phantom, the t/nt ratio was improved by attenuationscatter (a(+)s(+)) correction, and approached the real value. the quality of image for attenuation-scatter (a(+)s(+)) was higher than that for non-attenuation-scatter (a(-)s(-)). conclusions: it is suggested that a new correction method that combined attenuation correction using a difference of intrinsic dual-energy and compton scatter correction using triple-energy window (tew) method for 93kev is useful in 67 ga tumor spect studies. background and aim: in vivo neuroimaging techniques in correlation with mri imaging, offers a potential which can reliably assess early clinical and pre-clinical diagnosis in parkinson's disease. the aim of this study was to compare striatal's volume from mri volumetric measurements with the specific binding index (sbi) from regional datscans results method: in thirty five patients both dopaminergic imaging using i 123 -fp-cit spect and mri scanning were performed. specific binding index (sbi) has been calculated from regional datscan both for left and right striatum respectively, by applying the formulas: sbi left=( cv left/ cb-vv)/vs and sbi right=( cv right/ cb-vv)/vs where: cv left: total counts in left striatum roi, cv right: total counts in right striatum roi cb: total counts in background region divided by volume of the background region. vv: volume of roi, vs: volume of standard striatum (set to 11.2 ml) mri imaging has been evaluated by employing high spatial resolution t 2 -weighted sequence such as t 2 -weighted/ gradient-spinecho followed by a contiguous echo planar imaging sequence at the mid-brain striatal level in sagital projection. multi-planar reconstruction images have been analysed and volumetric measuerements created in order to compare volume in relation to the sbi results. statistical significance of these results was assessed using the mann-whitney test. results: the overall results show a significant relation between the two imaging modalities for discriminating normal, parkinsonian syndromes ( ps) and essential tremor (et) patients . aim: patients with carcinoma of the breast undergoing sentinel lymph node (sln) imaging in nuclear medicine may also undergo ultrasound guided wire localisation when the primary tumour is non-palpable. the wire localisation is performed by radiologists shortly after sentinel node imaging using 99m tc colloid. due to operational restrictions the wire localisations can only be undertaken after sentinel lymph node imaging. therefore, it was felt necessary to carry out a study to assess radiation dose to staff performing the wire localisation procedure. method: in our centre there are two regimes for patients undergoing sentinel lymph node localisation; patients injected with 20mbq of 99m tc colloid are sent for surgery on the same day whilst patients injected with 40mbq undergo surgery the following day. a number of dose measurements were performed including extremity, whole body and instantaneous dose rate readings during the procedures. chest and ring monitor badges were worn by the two radiologists whilst performing the wire localisations. in this study 10 patients were included of which 4 were injected with 20mbq and 6 injected with 40mbq. results: for the 10 patients the mean delay between injection and the wire localisation procedure was 1.25 hours (20mbq) and 2.75 hours (40mbq). the mean duration of all 10 procedures was 10 minutes.. all doses measured using the body and ring monitor badges were below the minimum detectable limits of 10μsv (whole body badge) and 300 μsv (ring). a mean instantaneous dose rate of 12 μsv hr -1 was measured at the minimum observed source-radiologist separation (20cm) for patients injected with 40mbq. based on this, body and finger dose estimates per procedure were calculated as 1.2μsv and 4.6μsv for the 20mbq patients and 1.9μsv and 7.7μsv for the 40mbq patients. conclusions: the measured dose estimates from our study show that doses received by radiologists performing ultrasound guided wire localisation procedures following patients injected with 99m tc colloid are insignificant. for comparison, in order to receive the annual public dose limit of 1msv any one radiologist would need to perform approximately 500 procedures per year. aim: radioguided surgery and sentinel lymph-node biopsy has become standard of care in patients with breast cancer. these procedures are usually done in operating room working in close proximity to an electrosurgical unit (esu) that is known to produce high levels of electromagnetic (em) fields. this study analyses the risks deriving from the interference of esu with the operation of a gamma-probe (gp) and suggests some practical recommendations intended to minimize them. methods: we investigated the function of 2 hand-held gps of different manufacturers (csi(tl) scintillator) evaluating their change in operations and malfunctions in the presence of strong em fields. while the tests were under way both esu and gamma probe have been set as for routine clinical use simulating a typical operating-room environment (esu's output power ranging from 80 to 250 w -full, ±50% and ±20% photopeak energy window). results: all devices tested were affected by electromagnetic interferences (emi) especially when the hand held gp was used in close proximity (<20cm) of the electrosurgical return-plate and the surgeon was coagulating tissues. the interferences recorded range from a simple buzzing noise to an erroneous data displayed. in the worst case the device emitted a continuous audio signal also there were no radioactive isotopes nearby. conclusions: our study demonstrates that gamma probes are particularly sensitive to electromagnetic disturbances that can be radiated during electrosurgery activities. based on the previous results the overall suggestions and recommendations intended to avoid these unwanted effects can be summarized as follows: • do not allow electrosurgery cables to lay over or contact the cables of gp; • do not place the esu's return-plate near the lymph-node excision region; • whenever possible, use the narrower energy windows setting for the intended purpose; • all sources of rf energy should be kept at a sufficient distance from gp. considering that electromagnetic radiation it's governed by the inverse square law we suggest to place the esu and all other accessories at least 0.5 meter away from gp. aim: we aimed to analyze the different steps involved in the maintenance procedures required to run a medical cyclotron. we are operating an iba cyclone 18/9, which is dedicated to clinical pet radionuclides production. cyclone 18/9 is a fixed energy cyclotron that accelerates hions until 18 mev and dions until 9 mev; our machine has eight exit ports equipped with five targets: one titanium liquid target "large volume" for 18 f production, one niobium liquid target "large volume" for 18 f production, one silver liquid target "small volume" for 18 f production, one aluminum gas target for 11 c production and one aluminum liquid target for 13 n production. materials and methods: eight scheduled maintenance interventions are required every year, 4 operated by iba field engineers and 4 by the hospital staff; the complexity of the maintenance interventions changes depending on which cyclotron part has to be checked. target maintenance: no need to open the cyclotron (no vacuum shut-down); targets must be disconnected from the cooling lines; mean execution time: 30 min/target source maintenance: cyclotron must be opened (vacuum shut-down); ion source must be disconnected from the cooling lines; mean execution time: 1 hour stripper-foils maintenance: cyclotron must be opened (vacuum shut-down); mean execution time: 10 min after every interventions a short beam is made on each target to verify the cyclotron yield. results: since the cyclotron started to produce radionuclides, in may 2003, we made twenty-eight maintenance interventions, operated in part by iba field engineers and in part by the hospital staff; intervention time varied from few hours to a maximum of two days. from the radiation protection point of view, the operator total body absorbed dose is mainly dependent on the time between the last radionuclide production and the intervention. for this reason maintenance intervention are scheduled on monday, after 2 days of cyclotron stop. up to now, from the collected data we measured a mean total body absorbed dose of 14 μsv (range 1-70 μsv) for hospital workers, with a mean time of stay inside the bunker of 34 min (range 5-85 min). conclusion: after three years of experience we can state maintenance interventions (i.e. routine target, ion source and stripper foils maintenance) can be performed by hospital staff without particular problems. on the other hand, for more technical demanding problems, field engineers has to be called on-site to perform the required procedures. background: phantoms using printed radioactive paper sheets from an ink-jet printer may be used to provide test objects with a close approximation to the 3d activity distribution in organs. however, these phantoms do not necessarily accurately represent the attenuation properties of soft tissue since they are made of a composite of paper and perspex. we propose that a stack phantom constructed of paper and sheets of spacing material can be produced with a close approximation to the attenuation properties of soft tissue, provided the correct ratio of paper to spacing material is used. aims: to measure the effective linear attenuation coefficient of paper, and to use this information to calculate the composition of a paper and spacing material stack phantom to have soft tissue (water) attenuation characteristics. the effective linear attenuation coefficients of paper and water were measured for 99m tc using a gamma camera (siemens e.cam) with an leap collimator in broad beam geometry. the paper was a standard office printer paper, 80 g/m 2 . the measured values were used to select a spacing material from published attenuation values. perspex was selected since it has a higher attenuation coefficient than water, to balance the lower attenuation coefficient of paper in the composite phantom, and because of its availability, low cost and ease of machining. the effective linear attenuation coefficient of perspex was measured, and the correct proportions of paper and perspex for use in the phantom were calculated. a stack phantom with these proportions was constructed and the linear attenuation coefficient of the paper-perspex composite was measured. results: the measured effective linear attenuation coefficients were 0.126 cm -1 for water, 0.094 cm -1 for paper and 0.144 cm -1 for perspex. this gives a required paper to perspex ratio of 0.554:1 for water equivalence. the linear attenuation coefficient of this composition was found to be 0.124 cm -1 (difference to water: 0.002 cm -1 ). in a 10cm thick phantom this difference in attenuation represents a small (1.8 %) increase in gamma ray penetration between soft tissue and the phantom. conclusions: paper-perspex composite stack phantoms can be constructed to have attenuation properties very similar to soft tissue, enabling pseudo-anatomical soft tissue equivalent phantoms to be produced. production of radioactive quality assurance phantoms using a standard inkjet printer. j. a. van staden, h. du raan, m. g. lötter, a. van aswegen, c. p. herbst; univ. of the free state, bloemfontein, south africa. aim: the use of a standard inkjet printer is proposed to produce radioactive phantoms that can be used for the routine quality control of gamma cameras. the purpose of this study was to evaluate the printed radioactive phantoms and demonstrate their use by the determination of the camera resolution. material and methods: the ink used to print the phantoms was obtained by adding a well mixed solution of black ink and 99m tc pertechnetate to the cartridge of a hewlett-packard inkjet printer. ms powerpoint software was used to create an image that is representative of the radioactive distribution required. the distribution was then printed on paper using the radioactive ink. imaging was performed with a ge 400at starcam camera fitted with a low energy all purpose collimator and alfanuclear acquisition software. the amount of activity to be deposited on paper per unit area was predicted and compared to the measured activity. the uniformity of the printouts was compared to the uniformity obtained with a standard 57 co flood source. joining two a4 size printed phantoms to create larger sources was evaluated. the spatial resolution obtained with printed sources was compared to that obtained using standard line source techniques. a resolution image was also obtained from a 99m tc printed bar quadrant phantom and compared to an image obtained with the lead bar pattern using a 57 co flood source. results: the results indicated that the uniformity of the printed phantoms compared well with those obtained with the 57 co flood source [integral uniformity 2.29% (printed source) and 2.10% ( 57 co flood source)], and the accuracy of the activity predicted to be deposited was better than 10%. there was no difference in the resolution measurements obtained with the printed sources and those obtained with the standard methods. conclusion: this study demonstrates that affordable phantoms can easily be created to evaluate system uniformity and resolution in any department where a standard pc and inkjet printer are available. aim: a lot of sophisticated models are available for the quantitative interpretation of dynamic pet data. parameters in these models are used to define quantities, such as metabolic rate, blood volume and flow, etc., characterizing the functional physiological and/or biochemical status of tissue in vivo. normally, these models are so sophisticated that the physicians cannot easily handle them without much experience. this study proposes an innovative machine learning method for parameter imaging and kinetic modeling of pet data, which can automatically predict the values of quantitative pet parameters using learned regression models from accumulated training studies of kinetic modeling. materials and methods: the support vector machine (svm) approach was used as machine learning algorithm in the tool. svms are a set of related supervised learning methods used for classification and regression. we used the cross-validation and grid-search for automatically choosing the kernels parameters. we choose the spreadsheet file with customized header as the data standard. based on the java implementation, the software is currently offered for different operating systems. by now, we collected 227 studies of quantitative pet parameters as training samples from 2-tissue compartments modeling. each training sample comprises the value of pet parameter as y value and input data as well as model data as x values. then different regression models are built for different pet parameters. using the models, we can predict the values of quantitative pet parameters of vois or pixels according to the tac of them. the tool is integrated to the pmod software (pmod technologies ltd., adlisvil, switzerland). results: squared correlation coefficient was calculated from cross-validation. the highest correlation coefficient was obtained for k1 for 0.859. two correlation coefficients were also very high: vb = 0.734, inf= 0.796. other three correlation coefficients were below 0.5: k2=0.338, k3=0.475, k4= 0.239. parametric images were also calculated for these parameters using the trained models. conclusion: the initial results show that machine learning based calculation of quantitative pet parameters is helpful for parameter imaging and kinetic modeling of pet data. it can be applied to any kinetic model based on the training studies of specific model from modeling expert. specially, the machine learning based method can be integrated with other kinetic models and be used as initialization technique for the models to decrease the number of iteration of the iterative-based kinetic methods. densitometry by dual-energy x-ray absorptiometry (dxa)is the gold standard for osteoporosis diagnosis and pharmacological treatment monitoring. the hologic qdr-discoverya densitometer offers a positioning scan mode and three different measurement scan modes: "fast-array", "array" and "high-definition", which differ in image definition, scan time and patient radiation dose. aim of this study was to assess a possible significant differences, between in-vivo bone mineral density (bmd) result measured by different scan mode and if this differences are clinically significant. patients enrolment started just after annually routine maintenance and calibration procedures by hologic inc. all acquisitions were performed by the same skilled operator. repeated acquisitions were performed for each skeletal site through the three different scan modes without repositioning of the patient between scans. analysis on whole patients and on a obese subgroup (body mass index > 30) was carry out. bmd was expressed as g/cm 2 and as t-score (sds from normal reference population database) for instrumental diagnosis (t-score > -1 sd for normal; t-score ranging between -1 and -2.5 sd for osteopenia and t-score < -2.5 sd for osteoporosis). 96 patients (12 man) for lumbar spine and 25 (2 men) for femoral neck were enrolled. we found a significant differences between bmd measurement in fast array/array mode and high definition mode (0,005 g/cm 2 p<0,001 anova, bonferroni's multiple comparison test). moreover, bmd differences were correlated with bone mineral content (bmc) values for fast array vs high definition (r=0,666; p<0,001) and for array vs high definition (r=0,485; p=0,014). the difference between different scan modes were statistically significant, but seem too small to be relevant in order to achieve a correct clinical diagnosis; 6.3% of lumbar spine instrumental diagnosis based on array mode measure was different from those calculated on high definition and 3.2% of total hip on fast array from high definition. our data suggest that for correct clinical diagnosis a physician evaluation of dxa results is needed. aim: renal volume measurement is an essential part of split renal function assessment in mr urography. the aim of this study was to assess the accuracy and repeatability of a three-dimensional segmentation algorithm based on the belief functions theory in calculating renal volumes from mr images. materials and methods: the true volume of 20 various sized animal kidneys was obtained by fluid displacement. each kidney was examined using two different mr units. 3d proton-density weightedacquisitions with incremental slice thickness were obtained. the mr volume was then measured with a segmentation algorithm based on the belief functions theory. two independent observers performed all segmentations twice. accuracy, intra-and interobserver variability were evaluated by the bland-altman method. the number and type of manual corrections were recorded, as well as the whole processing time. the mean renal volume estimated by fluid displacement was 114 ml (range, 38-224 ml). the maximal standard deviations of the difference were: 2.2 ml (accuracy), 1.2 ml and 1.8 ml (respectively intra-and inter-observer variability). segmentation of axial slices provided better accuracy and reproducibility as compared with coronal ones. overlapped coronal slices yielded poor results due to the partial volume effect. the mean processing time, including optional manual modifications, was shorter than 75 seconds. conclusion: the belief functions theory is an accurate and reproducible mathematic method to assess renal volume from mr adjacent images. in the 1980s the discovery of expression of somatostatin receptors on net cells made the use of somatostatin analogues in diagnosis and therapy possible. the aim of the study was to assess response of targeted radio-nuclide therapy with radio-labeled somatostatin analogue 90 y [dota 0 , d-phe 1 , tyr 3 ] octreotate (dotatate) and mixed 90 y/ 177 lu-dotatate in treatment of disseminated nets. materials and methods: 20 patients with diffuse nets were enrolled, divided into two randomization group by 10 pts. one group was treated by 90 y dotatate: 5men, 5 women, aged 56,7+/-11,2. second group was treated by 90 y/ 177 lu dotatate: 4 men, 6 women, aged 59,8+/-12,8. before therapy blood tests for hematology, kidney and liver function, cga were done. all patients underwent ct and scintigraphy with 99m tc-hynic-tate. treatments of 90 y -or mixed 90 y/ 177 dotatate were repeated 4-8 weeks apart up to total calculated doses -200 mci /m 2 ; per one course we usually used 100 mci. mixed amino acids infusion was used for kidney protection. results: 90 y dotatate: 1. regression of disease (pr -decrease of size and number of metastases, decrease of cga level, good clinical response) was observed in 5 pts 2. stable disease (sd-stable size and number of metastases, decrease of cga) was observed in 3 pts 3. 2 patients died no nephrotoxity was observed. wbc and plt levels were stable during therapy in 3 pts. in 6 pts leucopenia was observed (wbc level < 4 x10 3 / mm 3 ); serious neutropenia < 2 x 10 3 / mm 3 , was observed in 2 pts. plt level decreased in 5 pts, but thrombopenia was observed only in 1 patient . 90 y/ 177 lu dotatate 1. pr was observed in 4pts, 2. sd in 3pts. 3. 3 patients had progression of disease during the therapy, 1 of them died. in 2 pts increase of ceratinine level was observed (abnormal creatinine level from the beginning of therapy). liver tests were stable.wbc level was decreasing during therapy in all patients; we observed no serious neutropenia. plt decreased in 7/10 pts. conclusions: 1. it seems that 90 y dotatate or mixed 90 y/ 177 lu dotatate come to the same results in treatment of patients with diffuse neuroendocrine tumors in 6 month observation. 2. higher decrease of plt was observed in group treated by 90 y dotatate than 90 y/ 177 lu dotatate. 3. lower decrease of wbc was observed in group treated by 90 y dotatate than 90 y/ 177 lu dotatate, however in that group serious neutropenia < 2 x 10 3 / mm 3 was observed p425 results 90y-dota tate therapy in patients with neuroendocrine tumors -own experience of 2 years therapy j. kunikowska 1 , l. krolicki 1 , a. hubalewska-dydejczyk 2 , a. sowa-staszczak 2 , r. mikolajczak 3 , d. pawlak 3 , m. kobylecka 1 , j. maczewska 1 ; 1 med.univ. of warsaw, nm dept., warsaw, poland, 2 collegium medicum cracow, cracow, poland, 3 obri polatom, swierk, poland. the aim of the study was to assess response of targeted radio-nuclide therapy with radio-labelled somatostatin analogue 90 y-[dota 0 , d-phe 1 , tyr 3 ]-octreotate (dotatate) in the treatment of disseminated nets. material and methods: 12 patients (aged 56, 7+/-11,2): carcinoid-5pts, insulinoma-1pt, gastrinoma-2pts, pancreatic net-2pts, neuroendocrine cancer without primary tumor-1, stomach net-1pt were enrolled in the study. before the therapy, blood tests for hematology, kidney and liver function and cga were performed. all patients underwent ct scans and 99m tc-hynic/edda-octreotate srs. . scintigraphy examinations were made with two-head elscint gammacamera, using 99m tc labelled somatostatine analogueoctreotate, with 700-800 mbq activity; using planar and single photon emission computed tomography (spect) techniques. 4 and 24 hours after injection the data was acquired in 120x30s mode, matrix 128x128. ct scans were performed on ge light speed 16. images were acquired before iv injection of contrast media 5 mm slices thickness and in the arterial -1,25 mm, and portal venous phase-2 ,5mm.pmod software was used for fusion imaging. treatment with 90 y-dotatate was repeated every 4-6 weeks up to the total of 200mci/m 2 . mixed amino acids infusion was used for kidney protection. results: one year observation: regression of disease (prdecrease of size and number of metastases, decrease of cga level, good clinical response) was observed in 6pts, stable disease (sd-stable size and number of metastases, decrease of cga) in 3pts. 3 patients died. no nephrotoxicity was observed. wbc and plt levels were stable during therapy in 3pts (without chemotherapy). in 1 pt with previous chemotherapy (last course a month before radiotherapy), plt level decreased (220x10 3 /mm 3 to 47x10 3 /mm 3 after the first course); the patient died two months after the beginning of the therapy. in 8 pts leucopoenia was observed (< 4x10 3 /mm 3 ) but serious neutropenia (< 2x10 3 /mm 3 ) was found in 3 pts with previous chemotherapy. thrombocytopenia (plt < 100x10 3 /mm 3 ) was observed in 2 patients with previous chemotherapy. two years observation: prolonged pr -4pts; sd-3pts, progression of disease in 2pts: with gastrinoma and stomach net without hormonal activity (4 and 9 months after radiotherapy). blood tests stable. conclusion: pr and sd were observed in 9/12 patients with disseminated net. severe haematologic toxicity was mainly observed in patients after prior chemotherapy -the question of optimizing the time between chemotherapy and radiotherapy is still open. this study was supported in part by a research grant for scientific research (3666/p.05-6/05) from the ministry of health and ministry of education. o. solodyannikova, g. sukach, v. tratsevsky; institute of oncology of amsu, kyiv, ukraine. background. limitations of possibilities of radio-and chemotherapeutical methods for medullary thyroid cancer (mtc) resulted in use of radionuclide pharmaceuticals (rp) for its treatment. the most frequently used is 131 i-meta-iodinebenzilguanidin ( 131 i-mbg). problematic is monitoring of mtc patients and estimation of treatment efficacy. aim was the analysis of treatment results of mtc patients using 131 i-mbg and 99m tc-carbomec for the follow-up and estimation of the treatment effectiveness. materials and methods. 18 patients received intravenous 131 i-mbg (3700 mbk). there were no complications or side effects during 5 day stay at a clinic. three patients received repeated therapy with an interval of one year. the follow-up included scintigraphy (sg) of thyroid gland with 99m tc-carbomec, estimation of blood calcitonin level, ultrasonic examination and in some cases computed tomography. the repeatedly treated patients were under the follow-up during two years. during this period the whole-body scanning on residual dose of 131 i-mbg and three times with 99m tc-carbomec was performed. in seven patients, who received single 131 i-mbg treatment, diagnostic scanning was performed three times (follow-up -1.5 years). in eight patients, treated with 131 i-mgb, term of the follow-up -a year, diagnostic examinations with 131 i-mgb and 99m tc-carbomec were performed twice. in 25 patients diagnostic scanning with 99m tc-carbomec was performed after surgery, in 12 of them -once, in 13 -twice (follow-up -0.5-1.0 years). results. during observation various reactions for 131 i-mgb treatment have been detected. in 12 of 18 patients ultrasonography, sg and calcitonin level 6, 9, 12 months after the treatment didn't detect prolongation of the pathologic process. after first course of therapy in one patient increase of calcitonin level 6 months after resulted in appearance of hyperfixed lymph nodes on sg with 99m tc-carbomec. in one patient with metastatic foci in liver 131 i-mgb therapy and control with 99m tc-carbomec 6 months after didn't detect negative dynamics. in two patients with men syndrome and mtc sg with 131 i-mgb, performed on residual therapeutic dose, revealed rp decrease but sg with 99m tccarbomec performed 6 months after treatment and calcitonin level didn't reveal signs of disease progression. in 4 patients, who didn't receive 131 i-mgb, basing on diagnostic scanning with 99m tc-carbomec dissection of neck lymph nodes was carried out and sg with 99m tc-carbomec half a year after didn't detect prolongation of the process. conclusion. use of radionuclide therapy and diagnostics significantly increase outcomes of mtc patients' complex treatment and monitoring. p54 -monday, oct. 15, 2007, 2:30 pm -4 :00 pm, poster area radionuclide therapy/dosimetry -clinical thyroid, bone pain palliation and miscellaneous 1 a. k. sinha, male; national university hospital, singapore, singapore. paper describing therapeutic uses of radium was published; in 1936, {sup 24} na was administered as a therapy to a leukemia patient. three years later, uptake of {sup 89} sr was noted in bone metastases. during the 1940s, there was increasing use of iodine therapy for thyroid diseases, including thyroid cancer. radiolabeled antibodies targeting human tumors in animals were reported in 1973; antibody tumor imaging in humans was reported in 1978. since then development of new radioisotopes and new radiopharmaceuticals, coupled with improvements in technology, make therapeutic nuclear oncology an area of growth for nuclear medicine. our aim is to project the role of therapeutic nuclear medicine in different cancer and its related complication in poster presentation. these radionuclide therapy done at national university hospital, and singapore general hospital, singapore with i-131,receptor based antibodies, peptides and bone-seeking radionuclides. methods: it involved a retrospective review on the treatment of different type of the cancer and its related complications (thyroid cancer, non-hodgkin's b-cell lymphoma, neuroendocrine tumor, liver tumor and bone pain from metastatic disease) with radionuclides, performed at national university hospital and singapore general hospital, from 2003 to 2005 in the dept of nuclear medicine. results: results are encouraging and it will be presented in the poster. conclusions: globally increasing numbers of the cancer patients, including those with thyroid cancer, lymphoma, different form of neuroendocrine tumors, liver cancer, metastatic bone involvement with prostate and breast cancer, radionuclide therapy has already become an important component of modern medical practice. new drugs application (nda) is promising form of therapy on the new horizon in the field of targeted peptides and antibodies therapy. mapping of human genome is the greatest scientific achievement of this era. molecular methodologies that were developed during human genome project, led directly to the discovery of improved molecular targets for targeted therapy. the current era moving toward increasing sophistication of radiopharmaceutical formulation, including antibodies, peptides, nano particles, fusion proteins and small organic molecules which will lead to better agents and better patterns of practice for established practice. aim: the most widely accepted protocol for the treatment of painful bone metastases suggests to administer a weight-based activity of 153 sm-edtmp (sm) (37 mbq/kg). this procedure is obviously inadequate for over weighted patients, with the risk to deliver more than 2 gy to bone-marrow. in order to easily approach to a pre-therapy dosimetric evaluation, we tried to estimate the sm uptake by a dual mdp bone scan semiquantitative study. patients and methods: the bone uptake of 41 (15f/26m) pts with painful skeletal metastases was studied. the week before the treatment each pt underwent mdp bone scan with a double acquisition (10 min and 5-6 hrs p.i.) under the same conditions, in order to evaluate the skeletal uptake and personalize the radioactive amount of sm for the treatment. prior to inject mdp the patients were invited to void. 15 mins after i.v. injection the patients underwent total body scan (wb) with a double-head gamma camera, with particular attention to include the whole body in the field of view. a post-micturition acquisition was repeated 5-6 hrs later, under the same conditions. identical acquisitions were performed 5 mins and 24 hrs after sm injection. methods: rois were drawn in order to calculate the counts for each wb. the counts were decay corrected and the geometric means for opposite views were calculated. the uptake was estimated as: u=100xcnts(delayed)/cnts(early). statistical analysis was performed. results: mdp skeletal retention ranged from 26% to 89% (mean=64, sd=14). sm retention ranged from 38% and 93% (mean=66, sd=14). a good correlation was found between sm and mdp retention (linear regression coefficient r 2 = 0.84; y=0.95x+4.7). if two cases (who received zolendronate the day before the study) are excluded from the study (due to a markedly interference of bisphosphonate uptake), the correlation improves (linear regression coefficient r 2 = 0.89; y=0.99x+1.4). conclusions: the dual mdp bone scan methodology is useful to predict the retention of sm in patients with painful bone metastases. this approach can lead to a personalized dosimetry in planning radiometabolic treatment to administer the highest activity of sm, respecting the constraint of 2 gy to the bone marrow. recent zolendronate infusion could impair bisphosphonate uptake. aim: to investigate haematological safety after multiple doses of rhenium186-hedp, a betta-emmiting factor used in the palliative therapy of painful bone metastases. patients and methods: aiming to that, we evaluated 23 patients with painful osseous metastases (17 men with prostate cancer, 6 women with breast cancer), mean age=71.2+/-11 years, who received fixed doses (1300 mbq) of rhenium186-hedp, far off other therapeutic manipulations. of these, 13 patients (group a, mean age=70+/-13 years, 8 men) underwent multiple (2-6) radioanalgetic therapies (mean=3.3+/-1.0) and the rest 12 patients (group b, mean age=72.5+/-8.6 years, 11 men) underwent only one therapy. haematological status (hgb, wbc and plt count) and karnofsky pain scale (ks, estimated by an established numeric rating scale, values 0-100) of all patients were followed up every 15 days for 3 months after last therapy. results: respective pretherapeutic blood count absolute values (+/-sd) of groups a and b: hgb=12.9+/-1.5 and 11.7+/-1.3, wbc=7380+/-1870 and 7860+/-2480, plt=220+/-76 and 280+/-63 thousand. maximum percentile decrease of blood counts during the three month follow up period in groups a and b: hgb=6% and 7%, wbc=29% and 10%, plt=28% and 22.5%. paired t-test analysis did not show statistical difference in hgb values between pre-and post any radioisotopic therapy in both groups, while significant decrease in wbc count was seen only in group a (p=0.005). the plt count was clearly decreased after therapy in both groups (p=0.012 and 0.015 respectively), but significant myelosupression was evolved only in three patients of group a (one with grade 2 and two with grade 1 myelotoxicity). finally, patients with good pretherapeutic clinical status (ks>/=80, mean=87+/-5, n=10) had less decrease in plt count after therapy compared to those with ks<80 (mean=57+/-12, n=13) (respective decrease=14.9+/-15.9% versus 33.4+/-17.3%, p=0.015), irrespectively of patients' age, pre-therapeutic plt count or the number of radioisotopic therapies received. conclusion: rhenium186-hedp is safe enough to be readministered several times if an acceptable haematological baseline status exists, especially in those patients who present with a more favourable pretherapeutic karnofsky pain index. a. tsaroucha, g. meristoudis, t. liotsou, v. giannakopoulos, c. batsakis, a. balomenos, j. christacopoulou; dept of nuclear medicine,''sotiria'' hospital, athens, greece. introduction:the role of radionuclide bone palliation therapy in patients with prostate cancer as well as breast cancer is well established. aim: the aim of the study was to evaluate the efficacy and toxicity of radionuclide palliative treatment in patients with lung cancer. method: fourteen patients with lung cancer were included in this study. they were randomized in two groups. the first group a n =7 patients received 37mbq/kgr 153 sm-edtmp and the other group b n=7 received 1295mbq 186 re-hedp. all of them had a positive bone scan demonstrating a multifocal spread of osseous disease. blood cell counts and renal function tests were in all patients within safe limits. two of the patients were on non steroid anti-inflammatory drugs, two on weak opioids and ten on strong opioids analgesic therapy. pain was scored by an eight-point-rating-scale. pain response as well as possible myelotoxicity were checked 2,4,8 and 12 weeks after radionuclide administration. the treatment was deemed effective if the pain retreated by at least two points. results: four of the patients of group a and three of group b experienced obvious reduction of pain. however no patient demonstrated complete pain relief. the overall pain response was 50%. the onset of the palliative effect was between 2 to 4 weeks in both groups, and its duration ranged from 4 to 8 weeks. two of the responded patients reduced the strong opioids consumption and these two were retreated after 12 weeks . however retreatments were less effective than initial ones. flare phenomenon occurred in two patients, one of each group. one of them eventually responded to the therapy. mild transient myelotoxicity, concerning white blood cells and platelets, occurred in three patients, two of group a and one of group b. conclusions: patients with lung cancer and metastatic bone pain can benefit from radionuclide palliative therapy. although our sample was small, radionuclide analgesic therapy in patients with lung cancer seems to be less effective than in patients with prostate or breast cancer. the two radiopharmaceuticals did not show any difference in palliative efficacy or toxicity. radionuclide treatment for painful bone metastases in patients with hormone-refractory prostate cancer j. dolezal; teaching hospital, hradec kralové, czech republic. aim: to assess the efficacy of the 153 sm-edtmp treatment in patients with disseminated prostate cancer with bone metastases and pain. materials and methods: thirty-eight men (aged 50-83, mean 72 years) with bone disseminated hormonerefractory prostate cancer and bone pain received 153 samarium-edtmp. mean applied dosage was 40 mbq per kg of patient's body weight. karnofsky performance status, pain score (numerical rating scale), analgesic score (who) and blood count were evaluated before and 1 and 3 months after the treatment. results: significant pain relief was observed in 45% and 40% of patients, mild relief in 32% and 32% and no effect in 23% and 30% of patients one and three months after administration, respectively. the pain palliation was accompanied by an improvement in mobility and a decrease in necessary dosage of analgetics. mild and transient bone marrow suppression was observed as a side effect of 153 sm-edtmp treatment. none of the patients showed haematological toxicity grade 4, and only 3 patients showed grade 3 (nci ctc). the majority of patients had haematological toxicity grade 1 or 2. conclusion: after administration of 153 sm-edtmp bone pain palliation was observed in 70% of patients for three months. the haematological toxicity after 153 sm-edtmp treatment was mild and transient. values for group ii: 63+/-19, 67+/-27, 6.3+/-3.8% and 6.7+/-4.0%. with the exception of only one patient of group i who deteriorated scintigraphically, the ssi of the rest 22 patients was unchanged. paired t-test analysis did not show statistical difference in bsi pre-and post any radioisotopic therapy in both groups, while only in group i was seen a significant improvement in ks after the completion of therapies (p=0.036). furthermore, patients of group a (pretherapeutic bsi=3.4+/-2.2) had insignificant ks change (from 72+/-22 to 73+/-27), while those of group b, who set out with mean bsi=8+/-3, resulted in an interestingly better clinical outcome (ks from 68+/-13 to 84+/-13, p=0.012), although no difference in age, number of therapies or blood counts were observed. conclusion: in spite of a minimum scintigraphic deterioration in most patients throughout the follow up period, the post-therapeutical karnofsky scores might suggest an unexpectedly favourable clinical outcome, at least in a short-term follow up period, specifically in patients who present with a more adverse pretherapeutic bone scan and who would receive multiple rather single doses of rhenium186-hedp. introduction and aims: 153 samarium-edtmp has proved to be effective as palliative treatment in patients with difosfonate fixing bone metastases (as breast, lung, prostate cancer). its utility has also been demonstrated in patients with osteosarcoma bone metastases, when administered at high doses (from 1 to 30 mci/kg). prognosis of patients with osteosarcoma presenting bone metastases at diagnosis or with disease relapse or progression is generally very poor. aim of this study was to evaluate the feasibility of treatment with 153 samarium-edtmp at the doses of 10 mci/kg in 6 cases of osteosarcoma with multiple bone metastases, followed by re-infusion of peripheral blood progenitor cells (pbpg) gathered after administration of 2 cycles of ciclofosfamide and etoposide (ce). patients and methods: six patients with osteosarcoma were enrolled in the study: 4 were affected by osteoblastic forms and grading iv, 1 had condroblastic form -grade iii and 1 with a round cells form. two patients had metastases at onset (vertebral, pelvic, femoral and pulmonary) and went immediately treated with 153 samarium-edtmp, 3 patient was treated following the second disease recurrence (at femoral and pelvic levels), 1 patient underwent treatment after the the first recurrence (at femoral and pulmonary levels). 153 samarium-edtmp was administered via slow e.v. injection in a single dose of 10 mci/kg, followed 14 days later by re-infusion of pbpc (6.1x10 6 /kg cellule cd34+, range 5.8-7). all patients underwent pet-ct. results: treatment was well tolerated by all patients and no cases of severe extra-haematological toxicity occurred. white blood cell and platelet nadir took place respectively at days 12 (range 12-18) and 22 (18-25) from administration of 153 samarium-edtmp. thirty days after the administration of 153 samarium-edtmp one of the patients at second recurrence showed bone and pulmonary progression, the patient at first recurrence showed stable disease, on the other hand, the two patient treated at onset showed partial response (with meaningful improvement of pet scan and bone scintigraphy). approximately five months after the radiometabolic treatment three patients are died and one of patients affected by osteosarcoma with bone metastases at onset is well (partial response) conclusions: although results are still preliminary, high dose radio-metabolic treatment with 153 samarium-edtmp appears to be well tolerated and pbpc infusion allows to control haematological toxicity. aim: to assess the outcome results at 6 months follow up of patients with painful knee oa treated with single y-90 rs and factors that influence the results. methods: the rs treatment response was assessed retrospectively for 74 painful at exercise knees of 74 patients. the duration of oa symptoms was 24±9 months with 44/74 knee joints presented also pain during the night and 43/74 knees abnormal knee flexibility. knee joints were assigned according the steinbrocker radiological grading system (4 grade_0, 27 grade_i, 20 grade_ii, 21 grade_iii and 2 grade_iv). rs was performed with intra-articular knee injection of 185 mbq y-90 silicate according eanm guidelines. rs response was assessed at 6 months in terms of a 100-point visual-analog-scale (vas) pain improvement from baseline values, of the improvement of knee flexibility and pain remission during the night. rs success rate results were classified as poor (vas < 25), fair (vas >=25-50), good (vas >=50-75) and excellent (vas >75), with excellent and good results considered as success, while fair and poor results as failure. results: the percentage of vas knee joint pain improvement from baseline values was 66.0±24.8 %. there was a significant difference of the vas pain improvement in patients with the duration of disease symptoms less or more than 2 years (p=0.04), with the patient's age of less or more than 65 years (p=0.01) and with radiographic changes (p<0.001). with radiographic changes adjustment it was found that knees with no or mineral oa radiographic changes (steinbrocker-grade 0-i) respond better than those with more advanced changes (steinbrocker-grade iii-iv) in terms of vas improvement (77.9% versus 53.8%). the overall success rate for rs (vas 50), was 83.8%. failure response was 16.2%, with no response at all found on 4/74 knees. complete response as a complete remission and a 100% vas improvement was found on 7/74 knees. success rate was 100% for knees with no or mineral oa radiographic changes and 90% with steinbrocker-grade ii, while the success rate of knees with more advanced changes was 79.2%. after rs treatment, pain during the night was improved on 88.6% and knee flexibility was totally improved on 65.1%. these response values were significant different from the baseline values before rs treatment (p<0.001). conclusions: rs in patients with oa seems to be safe, without significant side effects and short time effective. our findings implicate rs might be more beneficial in the early stages of oa. study objectives: examination of anti-inflammatory effect of 166-holmium-phytate injection. methods: phases i-ii, randomized, simple-blind, placebo-controlled comparative study using increasing dosage. 31 patients suffering from chronic synovitis, rheumatoid arthritis and seronegative spondylarthritis were examined. the protocol commenced with screening. patients were randomly distributed into four treatment arms: group i. holmium phytate injectable suspension marked by 185 mbq 166ho + 40 mg of 1 ml triamcinolone acetonide/ta/ + 1 ml of 1% lidocaine injection./lid.inj./ group ii. 555 mbq 166ho. + 40 mg of 1 ml ta + 1 ml lid.inj. group iii. 925 mbq 166ho + 40 mg 1 ml ta + 1 ml of 1% lid.inj. group iv. solely 40 mg of 1 ml ta + 1 ml of 1% lid.inj. inflammatory activity of the affected knee-joint was tested prior to treatment, and the 14 th and 28 th days, and 3, 6, 9, 12, 24, 36, 48 and 60 months after treatment. testing was done based on the following parameters: measurement of swelling of knee-joint [cm]; flexion -heal buttocks distance [cm]; degree of knee-joint pain. visual analogue scale /vas-1-100/; patient's opinion on inflammation of knee-joint /vas-1-100/; doctor's opinion on given inflammation of knee-joint /vas-1-100/ results: even after 5 year period 88.2% of the findings were rated as excellent or good. 86.66% of the patients do not need another punction even after a 5 years period. we found no deviations in either haematological or chemical parameters during the study period. administration of holmium-166 phytate is a safe procedure. we did not detect symptoms of radiation sickness. during the study period, inflammation decreased in the group receiving 555 and 925 mbq. conclusion: ho-166 isotope is an effective radiopharmacy treating synovitis. due its adventageous features it produces less radioactive damage on the organism than the traditionally used isotopes (90-y, 169-er, 186-re). due to its physical parameters it is optimal to treat large joints, and medium size joints. 166-holmium-phytate has a: radiation type beta energy maximum: 1.84 mev; and radiation type gamma, energy maximum: 0.66 mev; soft tissue penetration: maximum 8.4 mm; /average: 3.3 mm /; half-life: 26.9 hours; particle size: 0.6-2 μm study objectives: measur the synovial thickness after 166-holmium radiosynoviorthesis by sonography. methods: phase i-iia, randomized, simple-blind, placebo-controlled comparative study using increasing dosage. 31 patients suffering from chronic synovitis, rheumatoid arthritis, or seronegative spondylarthritis were examined. patients: gender (male/female): 12-19; diagnosis (ra / snsa): 21 / 10; stage of knee joint x-ray (i / ii): 7/24; duration of synovitis (years): 7.9; duration of disease (years): 5.72; number of punctures before the ho-166 treatment: 18.76; number of steroid injections before the treatment: 18.85. the protocol commenced with screening. the patients were selected according to inclusion and exclusion criteria. patients were randomly distributed into four treatment arms: group i. 185 mbq 166holmium phytate /166-ho/ injectable suspension and 40 mg of 1 ml triamcinolone acetonide /ta/, and 1 ml of lidocaine injection 1 % group ii. 555 mbq 166ho injectable suspension, and 40 mg of 1 ml ta and 1 ml of lidocaine 1 % group iii. 925 mbq 166ho injectable suspension and 40 mg of 1 ml ta and 1 ml of lidocaine 1 %. group iv. solely 40 mg of 1 ml ta and 1 ml of lidocaine injection 1 %. there were 60 month follow-up period after the administration of the isotope. we measured the quantity of the synovial fluid and the thickness of the synovia before the treatment, and the 14 th , 28 th days and 3, 6, 9, 12, 24, 36, 48 and 60 months after the treatment. we measured the synovial thickness the following locations: in the midline, lateral and medial, by the condylus of femur medial and lateral. results: the thickness of the synovia decreased significantly in the group ii. (555 mbq) and iii. (925 mbq). after a transient improve (the steroid effect) the thickness of the synovia began to rise in the group i. (185 mbq) and in the control group. we find a significant correlation between the synovial thickness and the clinical improvenes. conclusions: the 166-holmium-phytate is an effective new radiopharmacon in the treatment of synovitis. we detect the clinical improvement by sonography. the effective dose is 555-925 mbq. ultrasound monitoring of the synovial thickness after 166-homium-phytate radiosynoviorthesis. two years results phase iii prospectiv study m. szentesi 1 , z. farbaky 2 , i. buday 2 ; 1 semmelweis univ., chair of introduction there is no consensus whether a fixed or a calculated activity of 131 i should be used for treatment of graves' hyperthyroidism. there is no evidence that precise dosimetry leads to an improved clinical outcome. a fixed activity designed to treat the majority of patients without attempting to ablate the thyroid gland, is a simple compromise strategy. aim the aim was to examine the quality of a method developed at our institution decades ago, based on estimating the 131 i activity one should use for treatment of graves´ disease. this method was compared with administation of a fixed activity of 400 mbq 131 i. material and methods our estimation method is based on the thyroid uptake of 99m tc-pertechnetate and the size of the thyroid gland, estimated by palpation. sixty consecutive patients with graves´ disease were randomised to receive either an individually estimated activity or a fixed activity of 400 mbq. in average, 308 mbq (range 260-380 mbq) was administered to 28 patients, and 29 patients received 400 mbq. three patients did not, after all, want radioiodine treatment. the patients were followed until they had started thyroxin substitution or, if still euthyroid, typically for one year. each time tsh, free t4 and free t3 were measured, and side effects were noted. results among the 28 patients who received an estimated activity, 8 (29%) were still hyperthyroid and needed further treatment. thyroxin substitution was started in 15 patients (54 %) after an average period of 3.0 months (range 1.4-8) . five patients were euthyroid after the treatment. of the 29 patients given a fixed activity of 400 mbq, 4 (14%) were still hyperthyroid. thyroxin substitution was started in 22 patients (76%) after an average of 2.8 months (range 0.5-9). one year after treatment 3 (10 %) patients were still euthyroid. in summarize, the success rate of the treatment was 71 % and 86 % in the estimated and 400 mbq group, respectively. this difference is not significant (p=0,17), but our findings are in accordance with other published studies. conclusion the study indicates that a fixed dose of 400 mbq as well as an estimated activity in the range of 260-380 mbq give a reasonable outcome and at the same time are in compliance with the alara principle. however, 29 % of the patients given an estimated activity needed more than one treatment of radioiodine compared to 14 % in the fixed activity group. this is a case of v.c., a 56 years old, female, from las pinas city, philippines, diagnosed as a case of graves' disease. during the course of therapy, the patient had allergy to antithyroid drugs (atds) and beta blocker (propanolol). she developed rashes all over the body sparing the face the day after taking her atds as well as propanolol, thus all medications were discontinued. other options, such as rai therapy and surgery, with their respective advantages and disadvantages were fully explained to the patient who then opted to undergo rai therapy. in our institution, we usually compute the dose based on the size of the gland and radioactive iodine-131 uptake measurements (raiu) rather than using fixed doses. thyroid scintigraphy and raiu were done which revealed poorly visualized thyroid gland and markedly diminished 24-hour uptake but normal 4-hour uptake [raiu -4 hour uptake: 26% (nv= 15-25%); 24 hour uptake: 6% (nv= 25-45%)]. * note: variations in normal uptake values compared to us are due to iodine deficiency still existing in some regions. because of the very low 24-hour uptake, we reviewed the probable causes, which can result in low uptake values. all causes were ruled out and the patient was advised to undergo two weeks of strict low-iodine diet prior to repeat thyroid scintigraphy and raiu. thereafter the result of repeat study showed diffuse thyromegaly with elevated uptake values indicating rapid trapping and organification processes [raiu -4 hour uptake: 82% (nv= 15-25%); 24 hour uptake: 68% (nv= 25-45%)]. the day after the study, the patient was given 10 mci i-131 based on the estimated weight of the gland, rapid thyroid iodine turnover ("small pool") and 24hour uptake. this was considered to be the highest allowable dose of rai to decrease the probability of relapse and the need for re-treatment. currently, approximately 4 weeks after the therapy, the patient is noted to have responded satisfactorily to therapy with resolution of symptoms. aim: the aim of the study was to analyze the outcome i-131 therapy for autonomous thyroid adenomas in 361 patients observed during 16 years. materials and method: we investigated 361 patients with plummer's disease (m/f ratio 1:6,1; mean age 49,8 ± 12,1 years). 84,2% of these patients had an unifocal nodule, while 15,8% had multifocal toxic autonomous nodules. the patients always stopped for weeks before administration of radioiodine therapy. we administered i-131 activity of 15 ± 4,5 mci. the mean duration of follow up was 4,36 years results: in 340 patients (94%) a single dose was administered and the other (21 patients -6%) needed 2-3 doses. after four years 90,3% of the patients who received a single dose were euthyroid with scenografic normalization. the percentage of euthyroidism was the same after ten years. the recurrent hyperthyroidism was 6,1% -12. in these patients the mean nodular weight was 49,15 gr, the mean administered dose per gram was 171,9±26,8 μci. the incidence of hypothyroidism was 2,6% within 0,5-7,1 years. in these patients the mean administered dose per gram nodular tissue was 177,1±37,4μci and the mean nodular weight was 34,7±12,6gr. the nodular weight was statisticaly higher in patients who had recurrent hyperthyroidism vs hypothyroidism (p=0,001) and vs euthyroidism (p=0,002). no differences were observed in the outcome between unifocal and multifocal nodules. conclusion: i-131 therapy is a simple, safe, effective and economical treatment of plummer's disease. euthyroidism can be achieved by determination of individual dose related to nodular weight and radioiodine uptake, also by preventing extranodular uptake and by evaluating more accurately the nodular weight the use of radioiodine for treatment of hyperthyroidism is based upon the radiationinduced cell changes resulting from the highly energetic beta-rays emitted by 131i. the magnitude of such effect appears directly proportional to the radiation dose. aim: monitoring the effect of radioiodine treatment in patients with nodular toxic goiter. material and methods: definitive radioiodine treatment is performed in 301 patients with nodular toxic goiter, 261 female, mean age 68,8 and 40 male mean age 68,6 .the disease duration is 48,19 months in female and 22,5 months in male. before treatment all of the patients passed sonography, if necessary fine needle biopsy, hormonal status, radioiodine uptake test and scintigrsphy. antithyroid drug treatment was withdrawn 7 days before radionuclide examinations. the radioiodine uptake is measured at 2, 4 and 24 hour, administered activity is 1,48 mbq. the scintigraphy was performed at 24 hour. the patients monitoring was performed at 3 rd month after treatment with clinical examination and hormonal measurements, at 6 th , 12 th and 24 th month with clinical examination, hormonal status, radioiodine uptake and scintigraphy. radioiodine treatment was performed with dose of 185-370 mbq. results: from 301 treated patients 261 are female with conservative treatment duration 48,19 months and this represents twice longer duration in comparison to the male.in definitively cured patients the radioiodine uptake decreased to values 34,5%, 6 months after treatment and the trend retained in the follow up controls and reaches to 72,01% compared to the initial values. in no effectively cured patients there is no significant variety in the test. the thyroid weight in the follow up period decreased with 32-48% in comparison to the initial values. definitive treatment is determined in 70,3% at 6 month, in 81,08% at 12 month and in 83,33% at 18 month after treatment and this trend is observed in follow up tests. all of the patients received antithyroid drug therapy for 1 to 3 months followed by hormonal control and clinical examination. conclusions:for the assessment of the treatment effectiveness and due establishment of disease relapse, the follow up period for 24 months after treatment is required.hypothyroid status after radioiodine treatment is an indicator for definitive treatment.the variety of the radioiodine uptake and the thyroid weigh are indicators for assessment of therapy effectiveness.the absorbed radioiodine dose in the thyroid gland is 55-220 gy . key words: hyperthyroidism, nodular toxic goiter, 131i diagnostics, 131i therapy, absorbed dose. the effect of radioiodine therapy on some parameters of oxidant/antioxidant balance in patients with subclinical hyperthyroidism s. s. abdelrazek, f. rogowski, a. zonenberg, m. szelachowska, a. niko ajuk, a. parfie czyk, p. szumowski, b. telejko, k. siewko; medical university of bialystok, bialystok, poland. oxidative stress plays an important role in hyperthyroidism-induced tissue damage. increased oxidative stress, with elevated levels of free radicals, together with diminished antioxidant have been described previously in patients with hyperthyroidism. aim: we aimed to determine whether patients with subclinical hyperthyroidism are subject to oxidative stress and whether radioiodine therapy has benefit effect on the oxidant and antioxidant status in subclinical hyperthyroidism. material and methods: we studied 30 patients with untreated subclinical hyperthyroidism, (25 female, 5 male), aged 23-78 years; 11 patients with multinodular goitre (mng), and 19 patients with solitary autonomous nodule (atn). 12 normal adult volunteers (age-and sex-matched) were studied as control group. qualification of these patients was based on clinical features and characteristic appearance on thyroid scintigraphy and ultrasongraphy. all the patients had normal levels of serum ft3 and ft4, serum tsh levels was less than 0.1 mu/l and effective half-life measured by the use of t24 and t48 was more than 3 days at the time of treatment. malignant changes were excluded in all nodules by fine needle aspiration biopsy. in the investigated groups, we evaluate malondialdehyde (mda) as a marker of oxidative stress, glutathione (gsh) and glutathione peroxidase (gpx) activity as a parameters of antioxidant system before and 6 months after treatment with radioiodine. the serum ft4 ft3 and tsh were evaluated before and monthly up to 12 months after rit, thyroid ultrasound, and thyroid scan were done again after12 months of 131 i therapy to assess the volume of thyroid gland and thyroid nodules. the activity dose was calculated by the use of marinelli's formula and ranged between 200 and 600 mbq. the absorbed dose ranged between 160-280 gy, and was proportional to thyroid volume. follow up control was done every 4 weeks. results: subclinical hyperthyroidism caused a significant increase in mda level (p < 0.05) as well as a significant decrease in gpx activities (p < 0.05) and gsh level (p < 0.05) compared to euthyroidism controls subject. achievement of euthyroidism after 6 months of radioiodine administration resulted in a significant decrease of mda level, significant increase of gsh level and non significant increase in gpx activities. thyroid volume reduced to about 47% (average), repeated rit given to one patient. conclusions: our results confirm the imbalance of the antioxidant/oxidant status in subclinical hyperthyroid patients. radioiodine therapy was more effective to improve these balances. aim: the aim of this study is to evaluate the effectiveness of the fixed dose (555 mbq) of radioiodine treatment on the function and the size of toxic adenoma (ta) and multinodular toxic goiter (mntg). patients' population: thirty patients (6 m, 24 f, age range 41-86, mean age 61.6) with ta and mntg were included in the study. twenty six patients had ta and 4 patients had mntg. fifteen patients had subclinical hyperthyroidism and 15 patients had overt hyperthyroidism. eight patients were previously treated with antithyroid drugs. method: thyroid scan were performed, volumes of nodules were measured sonographically, thyroid hormones, tsh level and 24 h iodine uptake were determined in all patients. all of them received fixed dose of radioiodine (555 mbq). every three months (min. 3 and max. 9 months) thyroid hormones, tsh and the volume of the nodules were measured. results: the initial mean volume of nodules was 8.12 ml (0.79-23.42ml). after 3 (n=37), 6 (n=24) and 9 (n=10) months the volume decreased to mean 5.32 ml (0.14-20.5ml) (p<0.01), mean 3.32 ml (0.23-19.6ml) (p<0.001) and 1.63ml (0.23-3.42ml) (p<0.01) respectively. subclinic hypothyroidism was developed in five patients during the follow-up period of nine months. only two patients were received the second dose of radioiodine after six months because of the persistent hyperthyroidism. overt hypothyroidism was not developed in any patient. the rest of the patients found to be euthyroid during the follow up after the initial treatment. conclusion: our data indicate that fixed dose (555 mbq) of radioiodine was effective in both functions and volumes of ta and mntg in a short time of period. aim: rai therapy has been used for over half-a-century for the treatment of hyperthyroidism. it is extremely effective option but there are no definite methods or tests to assess the final outcome of treatment as the response varies according to a number of factors. this study was carried out to assess pulse rate at six weeks post rai therapy as an initial clinical predictor of final outcome as documented at six months on follow up. materials & methods: fifty consecutive patients referred to the department of nuclear medicine, diagnosed as having hyperthyroidism from july 2004 to december 2005 were included in the study. 11(22%) males and 39(78%) females with an age range of 18-78 years (mean age 44.90) were given single dose ranging from 10mci(370mbq)-15mci(555mbq); mean dose 13.36mci(494.3mbq). the baseline pulse rate for every patient was recorded twice; taken by the staff nurse and nuclear medicine physician and average of the two documented. the patients were followed for at least six months post rai therapy on an out-patient basis and assessed both clinically and biochemically (t3, t4 and tsh). at six weeks the follow up pulse rate was again assessed and correlated with the tsh levels at six months. results: the baseline pulse rate per minute ranged from 80-130 with the mean pulse rate of 100.78 pre-therapy. the follow up pulse rate ranged from 68-116 per minute with the mean pulse rate 83.56 post rai therapy. it was observed that if the pulse rate was > 88 per minute at six months post therapy, this was related with an adverse outcome at six months post treatment. when correlated with the tsh levels this was statistically significant applying fisher exact test and chi-square test with p-value of 0.018 and 0.002 respectively. conclusion: assessment of pulse rate at six weeks post rai therapy can be used as an initial clinical predictor of final outcome at six months, however, more studies with a larger cohort of patients would help confirm this in due course. purpose: in view of the euratom 96/29 regulations, a study was performed in two greek centers, in order to evaluate radiation dose to family members of patients treated with radioiodine ( 131 i) for ablation (group i), follow-up treatment (group ii) and hyperthyroidism (group iii), provided that they followed hospital guidelines for 15 days. the annual dose limit for the public is 1msv/year. however, relatives helping in the support and comfort of patients are considered volunteers and dose constraints are established for them. this constraint for adult relatives (<60y) is 3msv during the patient's treatment. method: the radiation doses received by 30 adult family members (30 adults) of 20 patients treated with 131 i were measured using thermoluminescent dosimeters (tld) mounted on wrist bands, for 6 days. the administered activity was 3.7gbq (100mci), 7.4gbq (200mci) and 592-647.5mbq (16-17,5mci) for groups i, ii and iii respectively patient's exposure rates were also measured by a survey meter for distances 1, 2 and 3meters during the same period of 6 days. radiation safety instructions were the same for all groups. results: radiation doses to all family members were below the recommended dose constraints, for the measurement period of 6 days. the estimated doses to infinity were also calculated and found to be below the recommended dose constraints. the patient's exposure rates at 1m, at the time of their release from the hospital ranged between 15-48μsv/h, 4.3-155μsv/h and 7,48-34μsv/h for groups i, ii and iii respectively. conclusion: the radiation dose to family members of all groups is well below recommended dose constraints, provided that they comply with hospital guidelines. according to our results, 3 days of hospitalization is sufficient for groups i and ii. papillary carcinoma of the thyroid is usually an indolent tumor with a good survival prognosis especially when small and limited to the thyroid gland. the annual incidence of thyroid cancer per 1 million individuals in the czech republic is approximately 45-50 new cases, thyroid cancer is rare in children below 18 years of age -we have in our group 5% of children cancers and about 15% of microcarcinomas. thyroid cancer is five times more frequent in females than in males, the incidence increases with age. the median age at diagnosis is between 45 -50 years. the authors followed since 1959 to 2005 a cohort of 8300 the patients suffering from differentiated thyroid carcinoma and detect microcarciomas since 1959 to 2003 (n=7200 total patients). we studied this phenomenon and discovered that this change was limited to females and to the less advanced cancers t1. the number of papillary cancers in women with more advanced stages did not change as well as any differentiated cancers in men. this unexpected finding cannot be explained by differences in radioactive fallout, and other factors should be looked for, as age, better evaluation of thyroid morphology in women. the increase of t1 cancers is remarkable, as during the years 1976 to 1985 a total of 79 new t1 cancers were diagnosed in females compared to 359 new t1 cancers between 1991 and 2001, than more than six fold increase. in patients with a thyroid carcinoma of less than 1.0 cm in diameter, which represent 15% (n=1102) of all of our patients (n=7200) form 1959-2003, the prognosis is excellent and routine rj ablation is not indicated. however, we still prefer total thyroidectomy in these patients. recurrent disease was detected in 5% of these patients, usually in the form of lung metastases or recurrent disease, typically during the first five years at the diagnosis. we found lung metastases after 33 years after diagnosis in one patient! the fifths version of tnm classification classified tumours into the categories t1 (0-10 mm), t2 (10-40 mm). the new sixth version of tnm classification changes that clasiffication by shifting the categories into t1 (0-20 mm) and t2 (20-40 mm). this new version thus does not allow to distinguish the patients with significantly different probability of the metastasis occurrence in the 0-20 mm category. this research was supported by av cr 1et100750404 and by msmt cr 1m6798555601. v. voliotopoulos 1 , i. valais 1 , m. margaritaki 1 , v. gianakopoulos 2 ; 1 iatropolis magnitiki tomografia, athens, greece, 2 sotiria general hospital, athens, greece. the association between thyroid cancer and hypothyroidism is considered a rare event. in the international bibliography the incidence of coexistence of thyroid cancer and hyperthyroidism is between 0,3% and 16,6%. materials and methods: in our clinic since now, we treated 750 patients with thyroid cancer and 10 of them was operated at firs time for thyrotoxocosis and the malignancy was detected incidentally.70%of them were men and 30%women.among them 7 had moltinodular goiter and the rest 30% had graves'disease.the histological examination revealed 9 papillary, 1 follicular and 1 hurthle cells carcinoma. results: all patients received radioiodine therapy and in one patient because a high radioiodine uptake (11, 1%) and after 17 days of withdraw of t3 and a tsh level of 21, 2 ngr/ml we used the recombinant tsh (thyrogen).in the wbs 10 days after therapy in this patient the uptake was very intense in the thyroid bed. conclusion: the rate of incidence thyroid carcinoma in these subjects with thyrotoxocosis was similar to previous studies reported from other european countries. the ablation therapy 1 year after therapy was very successful and with no need for a new therapeutic session. despite many years of experience in thyroid cancer treatment the optimal dose of iodine-131 necessary for successful ablation is not established. the aim of the study was to compare the rate of ablation with different doses of radioiodine. the rate of ablation was compared in four groups of patients. statistical differences were evaluated with mann-whitney u-test, kruskal-wallis test or pearson's chi-square exact test and a p value less than 0.05 was considered to indicate statistical significance. 466 consecutive patients with papillary thyroid cancer (404 women, median age 47 years; range 14-79 years), who have undergone total thyroidectomy were retrospectively studied. ablative doses of i-131 were applied 4-6 weeks after the surgery. patients were hypothyroid, with tsh more than 30 miu/l. patients were randomized into four groups according to 131 i administered activity, starting at 24 mci (168 patients), then 40 mci (125 patients), 50 mci (65 patients), until 120 mci (108 patients). the outcome of thyroid ablation was assessed by conventional 5 mci whole body-scan, performed in hypothyroid state 6-9 months after ablation (first control study), and finally 12 months after (second control study). successful ablation has been defined as the absence of residual thyroid uptake in thyroid bed. the rate of successful ablation was similar in the group of patients received 24 and 40 mci (75% and 71.2% respectively). the higher rate of ablation (87.69% and 90.74%) was achieved in the groups treated with 50 and 120 mci of radioiodine. in conclusion, our study indicates that a 50 mci dose of radioiodine is a sufficient for a satisfactory thyroid ablation rate. use of low effectively 24 and 40 mci dose for initial ablation is justified by the convenience of administration, the lower expence and the lower whole-body radiation dose, and in our opinion this modality is convenient for group of patients with low risk of recurrent disease. introduction: although the differentiation thyroid cancer (dtc) has proven to be a good prognosis with significant decrease in mortality rates, many countries recently witnessed an increase incidence of this pathology. in this respect,this study aims at assessing 10 years of dtc management in national cancer centre, through a population survey. materials &methods: 750 patients were referred to the department of endocrinology and nuclear medicine, for dtc management between1996 and 2005.all patients have undergone a surgery with total thyroidectomy even for papillary microcarcinoma followed by an iodine 131ablation. results: this study confirms that the dtc incidence increased through the years essentially from 2001(between 2 to 3 times).the female sex is 6 times more frequent than in male (86%vs14%) with a median age at diagnosis stage between 30 to 49 years in 49% of patients. in 64 % of the cases (33% for solitary nodule), the multinodular goiter is the principal reason for the first consultation. even though the fine needle aspiration biopsy (fna) was performed only in 30% of patients, 70% were malignant. the papillary histology type is 5 times more frequent than follicular type (75% vs16%).86 % of patients have received an activity of 3.7gbq of i-131, while 9% have received 7.4gbq ,5% more than 7.4gbq as cumulative activity. after a minimum follow up of one year 78% of patients have had an undetectabletg. conclusion: although the increase incidence of dtc has been observed since 2001, the reasons according to our understanding are due to the early stage diagnosis using fna, the frequent availability of neck ultrasonography and the multidisciplinary approach, rather than the fallout atmosphere of radioactive iodine or the population's exposure to thyroid radiation. as for the rest of the results, it is noticed that a patient is generally a female sex in 80% of the cases, aged between 30 to 49 years in 49%.they present a multinodular goiter in 64% with papillary histology type in 75% aim: well differentiated thyroid carcinoma of the ectopic thyroid tissue is a very rare entity. our aim in this study is to determine the frequency of this clinical condition and to present the clinical experience obtained in the management of our patients with thyroid carcinoma of the ectopic thyroid tissue. material and method: the clinical records of 1800 well differentiated thyroid carcinoma patients treated and followed in our institution between the years 1990 and 2007 were retrospectively evaluated. the carcinoma focus was found in an ectopic thyroid tissue in 11 cases. the localization of the ectopic thyroid tissue was thyroglossal duct in 8 patients, parapharengeal region in one patient, submandibular region in one patient and submental region in one patient. results: mean age of the patients (8f; 3m) is 43,3 years. histopathological examination of ectopic tissue specimen revealed that 10 of the patients had papillary carcinoma and one of them had follicular carcinoma. near total thyroidectomy was performed in all of the patients. seven of 11 patients had a focus of well differentiated carcinoma in thyroid tissue also. the size of the thyroid tumor was between 13-35 mm in 3 cases and below 10 mm. (papillary microcarcinoma) in 4 cases, 3 of them being multifocal. two patients had regional lymph node metastasis; there was hyoid bone and regional muscle tissue invasion in another patient. only sub-total/near-total thyroidectomy was performed for two patients of the 4 patients whose thyroid gland was normal. for the other 2 patients with advanced disease and 7 patients who had carcinoma of the thyroid gland also; radioiodine ablation therapy was performed after thyroidectomy. two patients were lost to follow-up. mean remission time was 14.5 (6-42) months for the other 9 patients who are currently under follow-up (for 15-108 months) by sonographic examination and thyroglobulin level measurement at intervals. conclusion: the occurrence of ectopic thyroid tissue carcinoma is uncommon in regard to all thyroid carcinomas. the evaluation of thyroid gland for concomitant carcinoma in the thyroid tissue leads to the incidental detection of papillary microcarcinoma in majority of these patients. however, the clinical course of the disease is favorable with a management protocol similar to well differentiated thyroid carcinoma. if we hypothesize that stunning effect arose from either the ablative action of the diagnostic i-131 dose or the early effects of the therapeutic i-131 dose , this like stunning phenomenon should concern any thyroid remnants independently to the time interval between the above iodine doses. aim: the goal of this study was to investigate the presence of like stunning phenomenon in patients who received both diagnostic and ablative i-131 dose with a delayed time interval (>3 months) between them. material and methods: the study included 59 patients (5 men, 54 women, mean age 55 years) with a histology of differentiated thyroid carcinoma , disease limited into the thyroid bed and uptake 1.57±1.03. a therapeutic i-131 dose of 80-100 mci was given 4-12 months after the 5 mci i-131 diagnostic whole body scanning. all patients had a whole-body scan on the 8 th posttherapy day while 20 of them had it also on the 3 rd day. a quantitative estimation of the thyroid remnants was considered on the 3 rd day (dx) for the diagnostic wbs, on the 3 rd (rx 3 ) and 8 th (rx 8 ) day for the posttherapy wbs. the ratio therapeutic/diagnostic (rx 8 /dx) concentration of i-131 in residual thyroid remnants was calculated for all patients and stunning was considered when rx 8 /dx was lesser than 1. the ratio rx 3 /rx 8 and rx 3 /dx were also calculated for the 20/59 patients. results: of the 59 patients, 31(74%) exhibited rx 8 /dx <1 (likestunning effect). the like-stunning population included 12/16 (75%) patients with uptake > 2%, 13/23(56%) patients with uptake between 1% and 2% and 6/20 (30%) patients with uptake < 1%. among the 20 patients with posttherapy evaluation on the 3 rd and 8 th day, 14 patients had rx 3 /rx 8 >1 and rx 3 /dx>1, indicating a clear early curative action of the therapeutic i-131 dose and 3 patients had ratio rx 3 /dx<1 and rx 8 /dx<1 indicating a clear curative action of the diagnostic i-131 dose. conclusion: our results support the hypothesis that thyroid like-stunning phenomenon can be observed in patients with a diagnostic and a delayed consecutively therapeutic i-131 dose. this like-stunning effect could be the consequence of destructive effects from either the diagnostic or the therapeutic i-131 dose, mostly when the thyroid remnants are major. objective: studies have suggested that i-123 whole body scans (wbss) can underestimate the extent of well differentiated thyroid cancer. we wanted to find out if i-123 wbs images provide an accurate foundation for deciding the therapeutic dose of i-131. method: three hundred and thirty three i-123 wbss of 292 consecutive patients from january 2004 to march 2006 were retrospectively reviewed. all patients received total thyroidectomy for well differentiated thyroid cancer, and were on low iodine diet for at least 2 weeks, and reached tsh greater than 30 miu/l prior to the i-123 wbs. i-131 wbss were obtained after the patients were given high dose of i-131 (>100 mci) for remnant thyroid tissue, local recurrence, or metastasis. the i-123 wbs and post-therapeutic i-131 wbs were performed less than 2 weeks apart, the images were reviewed for abnormal radioiodine uptakes. results: in 298 cases, i-123 wbs and post-therapeutic i-131 wbs agreed on the extent of the thyroid cancer. however, in 35 cases, post-therapeutic i-131 wbss detected additional lesions such as further metastatic lymphadenopathy of the mediastinum or distant metastasis to the lungs. in 22 of these i-123 wbs and i-131 wbs discrepant cases, the therapeutic dose of i-131 may have been increased had the physician known about the presence of additional lesions. conclusion: i-123 wbs performed prior to high dose radioiodine therapy underestimated the extent of well differentiated thyroid cancer in 10.5% of the cases, and may have lead to suboptimal therapeutic dose in 6.6% of the cases. therefore, i-123 wbs images alone may not be accurate basis for determining the dose of radioiodine therapy. aim of the study: to determine the recurrences and disease related deaths in patients (pts) with differentiated thyroid carcinoma (dtc) treated by surgery and by radioactive iodine ( 131 i) as initial therapy. patients and methods: two hundred eighty dtc pts were operated and after that treated by 131 i once or several times. all pts received life-long hormonal therapy. duration of follow-up: mean 9.1 + 5.5 years, median 8.2 years, range 2 months-26.9 years. probabilities of the recurrences and disease related deaths were calculated by kaplan-meier's method and the significance of differences was determined by log-rank test. results: two hundred fifty eight pts were in the remission after initial therapy; the recurrences appeared in 46 (17.8%) of them during follow-up period. the probabilities of recurrences after 5, 10 and 20 years were 10%, 20% and 30%, respectively. the significant influence on the appearance of recurrences had: the absence of 131 i accumulation in tumor, incomplete remission, initial tnm stage iii and iv, pts' age >45 years and nodal metastases. the disease related deaths occurred in 27 pts (9.6% of all treated pts) during follow-up period; deaths occurred after recurrences in 13 pts (28.3% of pts with recurrences). the probabilities of disease related deaths after 5, 10 and 20 years were 6%, 9% and 17%, respectively. the significant influence on the deaths had: the initial tnm stage iii and iv, pts' age >45 years, distant metastases, absence of 131 i accumulation in tumor, masculine gender and nodal metastases. conclusion: all followed pts were initially treated surgically and by radioiodine. the appearance of recurrences progressively increased with years after initial therapy, so it is necessarily to follow-up pts till the end of their life. it is very important to treat pts until complete remission of disease is reached, to decrease the frequency of recurrences. disease related deaths occurred more frequently after onset of recurrences; it is indispensably to treat relapses to achieve the stable complete remission, if this is possible. the retrospective evaluation of metastatic bone disease in differentiated thyroid carcinoma ö. küçük, e. özkan, e. tokmak, p. tarı, g. aras; ankara university medical faculty, ankara, turkey. aim: bone metastases(bm) are seen clinically in 4%-13% of patients (pts) with differentiated thyroid carcinoma(dtc).due to difficult treatment, the prognosis is poor. we evaluated metastatic bone disease in our dtc group, retrospectively. material-method: bm were detected in 20 pts out of 596 with dtc who were treated and follow-up in our clinic between 1997-2006 (age range 26-72 years; 13f, 7m). papillary carcinoma was diagnosed in 9/20 pts and follicular carcinoma in 11/20. a total of 3.7-53.65 gbq (100-1450 mci) i-131 was given to each patient. the duration of follow-up ranged from 6 to 156 months. i-131 whole-body scan(wbs), tc-99m mdp whole-body bone scan, the determination of tg and antitg levels and/or a ct scan were carried out in the assessment of a diagnosis and follow-up of pts with bm. results: the frequency of bm were found 3.4% in our analysis. classification was performed according to detection time of bm. group1; 15 pts diagnosed with primary bm, group2; 2 pts with bm detected in post-ablative wbs, group3; bm diagnosed in the follow-up period in 3 pts. in group1, 8/15 pts had only bm, 1/15 pt had bone and brain metastases, 6/15 pts had lymph node and/or lung metastases also. in group2; 1 pt had only bm, 1 pt had bone and lung metastases. in group3; 2 pts had bone, lymph node and/or lung metastases, 1 pt had bone, lymph node, lung and brain metastases. in the follow-up period, 3 pts from group1 and 1 pt from group3 were died. the bm were seen in 9-72 months after the diagnosis for group3. bm were persistent after the therapy on the other hand, additional new lesions were observed. tg level was high in all pts remarkably except 2 pts (tg-max:158226 ng/ml). one of these 2 pts with normal tg level had high anti-tg level (150 iu/ml), the other one had normal anti-tg level (<20 iu/ml). 2 pts had anti-tg levels higher than tg levels. bm were persistent after the therapy on the other hand, additional new lesions were observed, especially in group1. discussion: the frequency of bm has been reported 4%-13%. this ratio were found 3.4% in our analysis. we observed higher ratio of diagnosed dtc with primary bm (75%) (grup1). its prognosis was worst than other groups. conclusion: tg is more important parameter than anti-tg and the prevalence of the other organ metastases is high in dtc pts with bm. aims: based on the icrp recommendations, the policy for releasing patients with differentiated thyroid carcinoma (dtc) who underwent thyroidectomy and received ablation doses of i-131, from the nuclear medicine departments should be based both on general national rules and specific regional conditions. the aim of this research was to study the kinetic, urinary excretion pattern and dosimetric characteristics i-131 to estimate the radiation doses to the public, and to check the policy for the release of these patients. materials and methods: twenty-nine patients with dtc who referred to our department were selected for this study. the mean radioactivity doses administrated was 4± 0.9 gbq (range 3.7-7.4). the instantaneous dose rates were measured immediately after the administration of therapeutic radioiodine with patients in the upright position at distance of 3 meters and just before they left the department at distances of 0.5, 1 and 3 meters using a survey meter. also, urine samples from each patient were collected every 2-4 hours for up to 3 days after radioiodine administration. results: the maximum dose received by the nursing staff was 1.6 msv/week, less than the dose recommended by the icrp. the dose rate and remaining activity values of 6 out of 29 patients were higher than those of the others and this contributed to a high standard deviation. only one of these six patients had metastases. it was noteworthy that other patients with metastases showed a moderate dose rate exposure or moderate remaining radioiodine activity in the body. on average sixty hours post administration of radioiodine, 70% of the administrated dose was excreted through the urine, 4% remained in the body and 26% decayed or excreted through other routes. conclusion: these results indicate that family members should take into consideration the duration and the distance of being in close contact with the above patients. the time-rate curve of urinary excretion of radioactivity in all patients showed multiple peaks due to the retention and redistribution of radioiodine within the body and the enterohepatic cycle of radioiodinated thyroid hormones. based on the study results, at least in countries as ours we strongly recommend changing the policy for release of all patients receiving radioiodine therapy except those who are capable to keep instructions properly. patients should be discharged when radioiodine body retention and instantaneous dose rate are less than 111 mbq and 20 msv/h at a distance of 1 m, respectively. aim: radioiodine therapy (rit) after a total thyroidectomy is the standard treatment of differentiated thyroid cancer (dtc). since more than 90% of the incorporated iodine in healthy patients is cleared by the kidneys, the rit of renal failure patients (rfp) affords high requirements concerning dosimetry. aim of this study was to determine the progression of activity in rfp and to compare the results to renal healthy patients with dtc (34 patients). material and methods: in the recent 10 years we treated 4 rfp with dtc. one of them was treated 3 times (2x rit + diagnostic scan (ds)), 2 twice and one patient once. consequently the activity progresses of collectively 8 rits were documented and assessed dosimetrically. applicated activities were between 865 and 1248 mbq (604 mbq for ds). the remaining activity was measured twice a day and immediately before respectively after the haemodialysis with an individual calibrated gamma probe. hence the mean halflife was determined with an exponential fit on the one hand, and the integrals between the single measured values on the other hand for calculating the mean whole body dose (wbd). haemodialysis was done on the first and third day after application. results: the calculated halflife averages 1.8 days (1.6 -2.1). the wbd per patient averages 129 mgy (40 -180) corresponding to a mean wbd of 0.128 mgy/mbq. in comparison, the effective halflife for non-rfp averages 0.6 days (0.3 -1.1) and the wbd averages 215 mgy (71 -442) corresponding to a mean wbd of 0.052 mgy/mbq. the mean elimination of radioiodine per haemodialysis averages 47% (+/-14%). conclusion: about 50% of the remaining activity is eliminated per haemodialysis. the effective halflife during the time interval between two haemodialysis in one patient varies depending on the grade of renal failure and should therefore be observed. the mean effective halflife for the total rit of rfp is increased 3 times compared to healthy patients. the dose per applicated mbq is enhanced correspondingly 2.5 times. therefore, we suggest to decrease the activity for rfp with dtc to an amount of 30% of the activity, administered in non-rfp. retrospective analysis of patients with differentiated thyroid carcinoma (dtc) e. urbanova, j. vizda; nuclear medicine university hospital, hradec kralove, czech republic. nuclear medicine has had a major impact on the management of dtc, especially in post-operative ablation, detection and therapy of recurrence or metastases. aim of this study was long term follow-up 25 patients ranged from 25 to 30 yrs after radioiodine therapy. method: during the period lasting from february 1973 till december 1977 radioiodine therapy was performed for 25 pts after thyroidectomy due to dtc. papillary carcinoma was diagnosed in 13/25 pts and follicular in 11/24 an in one pts histologically mixed type was found. thyroid hormones treatment was done to compensate the lack of endogenous hormones and to stop tsh secretion. follow up for all pts consisted from the wbs (whole body scintigraphy) performed after thyroid remnant ablation with 131 i. further clinical, plain x-ray of the chest, vocal cord and us (ultrasound) of thyroid gland and neck examination and periodic serum tg (thyreoglobulin) measurements and later wbs with 99m tc-mibi and rarely ct were performed. results: despite early detection and adequate initial treatment we observed after mean follow-up of ten yrs, three neck lymph-nodes recurrences and two pulmonary, one bone and one vocal manifestation of disease. so seven pts were retreat with radioiodine therapy. after 27 yrs seven pts showed recurrence due to pulmonary and bone metastases and five pts were follow-up for second carcinoma. two pts died due to cardiovascular disease and one after generalisation of the disease. completely free of disease after 30 years were 17 pts but lot of other complications were present (e.g. haematuria, hypertension, nephrolithiasis). two patients showed one side decrease in salivary function. maximum total administered activity of 131 i for one patient with repeated therapy for pulmonary, bone and brain metastatic process during 30 years was about 1200 mci. conclusion: the demonstration of distant metastases can be present after long period after beginning of the disease. for the evaluation of lung metastases in dtc, determination of tg levels and the 131 i wbs were the most important procedures. computed tomography is a useful addition, because 99m tc-mibi imaging alone may not be enough to detect lung metastases from dtc. short and long complications of 131 i treatment should be taken into the careful consideration with the benefit for the patient with long survival. our first experience with low dose radioiodine ablation therapy in low risk patients with differentiated thyroid carcinoma z. rajkovaca 1 , j. mijatovic 1 , m. skrobic 1 , g. mikac 1 , g. vuleta 1 , a. matavulj 2 , p. kovacevic 2 , n. ponorac 2 ; 1 clinical centre, banja luka, bosnia and herzegovina, 2 medical faculty, banja luka, bosnia and herzegovina. the optimal dose of iodine-131 for ablation of functioning residual thyroid tissue after (near)total thyreidectomy is controversial. the aim of this study is to present our experience with low (1.48 gbq) dose i-131 in ablation of differentiated thyroid cancer remnants in low risk patients. material and methods: a total of 58 patients (mean ages of 48.5 years, range 23 -72 years) with papillary and follicular carcinoma were treated first time in our department with i-131 for ablation of a postoperative thyroid remnant after (near)total thyreidectomy. patients with stage pt1 or pt2 n0m0 were including in the study. patients were divided into two groups according to size of postoperative residual thyroid tissue, level of thyroglobulin and age. group a, 40 patients received 1.48 gbq i-131, group b, 18 patients received 3.7 gbq i-131. six months after treatment, all patients were reassessed after withdrawing l-thyroxin for 4 to 6 weeks with i-131 whole body scan and serum thyreoglobulin measurement. a successful ablation was defined as the absence of thyroid bed activity in 185 mbq i-131 neck scan, the neck uptake of <0.3% of the administered activity and the thyroglobulin value of <5 ng/ml. results: in group a successful ablative therapy was seen in 35 (87.5%) of patients. of these 88.6% had papillary carcinoma on histopathology and 11.4% had follicular carcinoma. in group b successful ablative therapy was seen in 88.9% of patients. of these 11.1% had follicular carcinoma on histopathology and 88.9% had papillary carcinoma. there were no statistically significant differences between these two groups in relation to thyroid ablation. also, there were no statistically significant differences in thyroglobulin serum level 6 months after i-131 treatment. the remaining ones, 12.5% and 11.1% respectively, received the second course of i-131 for remnant ablation. 5/40 patients required therapy in group a and 2/18 in group b. response to low dose i-131 was same in patients with papillary and follicular type of carcinoma. conclusion: our evaluation of early efficacy of adjuvant radioiodine treatment in low risk patients with differentiated thyroid carcinoma shows no differences between two radioiodine activities -1.48 gbq and 3.7 gbq in relation to thyroid ablation. we recommend the activity of 1.48 gmbq in low risk patients. thyroid stunning phenomenon is the impairment of therapeutic 131 i uptake by normal or metastatic thyroid tissue, as a result of previous administration of a diagnostic activity of the same radionuclide. it has been demonstrated after the administration of diagnostic activities of 74-370 mbq (2-10 mci) of 131 i. we can avoid it using 123 i in the whole-body scintigraphy. however, even the ablative therapeutic activity itself may cause stunning, because of the high radiation dose absorbed by the thyroid remnant in the first hours of the iodine accumulation (self-stunning). aim to evaluate the occurrence of self-stunning in residual thyroid tissue after total thyroidectomy for differentiated thyroid cancer followed by 131 i therapeutic ablation. materials and methods a prospective study was conducted from 2005/08/09 to 2006/09/19 in 33 patients submitted to total thyroidectomy for differentiated thyroid carcinoma of follicular origin (26 female and 7 male, aged from 16 to 88, mean 48,91 ± 18,33 years). withdrawal of levothyroxine intake, low iodine diet throughout the foregoing week and analytical studies including iodinuria were required before undertaking both diagnostic and therapeutic procedures. cervical uptake was determinated 24 hours after oral administration of 11 mbq (300 μci) of 123 i. ablative therapeutic was performed 6 days later, with 131 i activities ranging from 925 to 6179 mbq (25 to 167 mci), mean 3367 mbq (91 mci). cervical uptake of the radionuclide was determined 24 hours later. we used a siemens e-cam dcr dual head gamma camera, equipped with medium and high-energy collimators for 123 i and 131 i respectively, to obtain segmentary images of the patient`s cervical anterior region, as well as the 123 i capsule to be administered and a known activity of 131 i, 30 cm from the detector. results in the diagnostic study, the cervical 123 i uptake varied between 1,1% and 29,8% (mean 6,8%). the post therapeutic uptake of 131 i oscillated between 0,42% and 17,82% (mean 4,2%). in all of the patients, a reduction in the cervical uptake of iodine ranging from -2,83% to -75% (mean -43,8%) was observed in the post therapeutic study, as compared with the diagnostic one. this reduction was found to be statistically significant (t = 5,822; p < 0,0001). conclusions we verified the occurrence of selfstunning in all of the 33 patients subjected to ablative therapeutic with 131 i. a. georgakopoulos, s. saranti, l. iordanidou, e. trivizaki, k. rethymniotakis, e. matselas, p. koutsiouba; metaxa's cancer hospital piraeus greece, piraeus, greece. if we accept the hypothesis that stunning phenomenon could be related to the curative radiation dose of iodine -131, either the diagnostic or the early therapeutic iodine-131 (i-131) action could contribute to a stunning effect production. aim: the aim of this study was to investigate whether the diagnostic or the early therapeutic i-131 radiation dose provoke a partial ablation, giving thus the stunned appearance of the thyroid remnants. material and methods: 48 patients with total/near total thyroidectomy (uptake 1.52±1.13) for differentiated thyroid carcinoma received the first ablative iodine dose (50-100 mci) within 3 months from the diagnostic 5 mci i-131 dose. the patients were evaluated with diagnostic wbs 72 hours after the administration of 5 mci i-131 and with posttherapy wbs 8 days after the ablative i-131 dose. furthermore 20 of the above patients were evaluated with onemore posttherapy wbs on the 3 rd day of the ablation. serum tsh, tg and anti-tg were considered in hypothyroid state. the patients were divided into 3 groups according to the uptake value. group a(uptake >2%) consisted of 16 patients, group b (uptake 1%-2%) of 7 and group c (uptake <1%) of 25 patients. a quantitative estimation of the thyroid bed activity was performed for the diagnostic, the 3 rd day posttherapy and the 8 th day posttherapy wbs. the ratio therapeutic/diagnostic (rx 8 /dx) concentration of i-131 in thyroid remnants was calculated and stunning was considered when the ratio rx 8 /dx<1. the ratios rx 3 /rx 8 and rx 3 /dx were calculated for the 20 patients with the additional 3 rd posttherapy day wbs. results: 25 of the 48 patients (52%) demonstrated stunning phenomenon (rx 8 /dx <1). between them 16/25(64%) had a 3 days interval between the diagnostic and the therapeutic dose, 6/25(24%) had a 4-10 days interval and the rest 3(12%) patients had a 31-90 days interval. the stunned population consisted of 11/16(69%) patients of group a, 3/7(43%) of group b and 11/25(44%) of group c. among the 20 patients with the 3 rd and 8 th day posttherapy wbs, 15 had rx 3 /rx 8 >1 and rx 3 /dx>1 indicating a clear early curative action of the therapeutic i-131 dose and other 3 patients had ratio rx 3 /dx<1 and rx 8 /dx<1 indicating a clear curative action of the diagnostic i-131 dose. conclusion: a partial ablation could be generated by either the diagnostic or the early curative therapeutical i-131. the density of this phenomenon seems to be directly proportional to the extent of the residual thyroid tissue. radioiodine treatment is contraindicated in pregnancy. still, inadvertent therapy does occur. radioiodine was given to two pregnant women with graves' disease and thyroid cancer respectively, both in their 20th gestational week. routine pregnancy tests based on urinary -hcg had failed to indicate pregnancy in both cases. methods: estimation of doses to the foetuses and foetal thyroids. scrutiny of pregnancy testing. results: doses to foetal thyroids were ablative (250-600 gy). total foetal dose in the graves' patient was 100 mgy and compatible with survival, whereas a foetal dose of approximately 700 mgy together with induced hypothyroidism was fatal for the foetus of the cancer patient. conclusions: routine pregnancy tests (urine -hcg) may not only fail early and but also later in pregnancy.the -hcg level can be low from mid term, especially in case of a male foetus. the possibility of pregnancy should be considered in all fertile women before therapy with radionuclides or cytostatic regimens, and a clinical investigation undertaken on wide indications with determination of serum -hcg, preferably together with an ultrasound examination. more than two decades ago, the radiation absorbed dose thresholds for successful radioiodine-131 (i-131) treatment of residual thyroid tissue and lymph node metastases (300 gy, n=30, p<0.05 and 80 gy, n=67, p<0.01, respectively) were established by maxon hr et al. n engl j med 1983. [1] . until today, these thresholds have been frequently cited in dosimetric context related to postsurgical thyroid cancer patients. the aim of this study was to review some quantitative dosimetric works published so far, in order to explore if the initially proposed thresholds [1] ). the data were adopted from available works exactly in the form in which they had been published or presented and were statistically analyzed using 2x2 tables. three-hundred gy has been not statistically proven absorbed dose threshold for successful ablation of remnant thyroid with i-131 [2, 3, 4, 5, 7] . suggested absorbed dose-rate threshold of 3 gy/h for successful thyroid remnant ablation [4] was not proven too. the lowest study-specific thresholds for successful thyroid remnant ablation were derived as follows: 40 gy (n=11, p<0.01) [5], 50 gy (n=39, p<0.01) [3] , 150 gy (n=37, p<0.01) [6], 1.6 gy/h .and. 100gy (n=40, p<0.05) [7] . further support of the latter values is the mean absorbed doses of therapeutic i-131 delivered for successful (147±128 gy) and unsuccessful (41±16 gy) thyroid remnant ablation (n=23, p<0.05), as presented in abstract by haq m et al. eur j nucl med mol imaging 2006. quantitative in-vivo data published to date does not support a widely-accepted dosimetric approach to thyroid remnant ablation based on the threshold absorbed dose of 300 gy. in contrast, intrathyroidal doses of i-131 in the range of 40-150 gy appear to be evidence based cut-off values required for significantly higher success-rate of thyroid remnant ablation in postsurgical thyroid cancer patients. aim: this study evaluates the incidence of radiation thyroiditis and its relationship with i-131 thyroid remnant uptake following i-131 adminstration for post surgical completion ablation therapy for thyroid cancer. methods: patients having an initial post surgical administration of either 1110 mbq or 3700 mbq i-131 between jan 1992 -dec 2006 were retrospectively reviewed. the activity of thyroid remnant i-131 on the 48 hour post administration scan was measured and correlated with neck symptoms experienced. following review of medical records, patients were classified as having insignificant, mild or severe thyroiditis based on no treatment, nsaids, or steroids respectively. statistical analysis was performed using ordinal and regular logistic regression for thyroiditis (yes/no). results: 183 patients were included (143f,40m;16-87 years). 68 patients received 1110 mbq and 115 patients received 3700mbq.the mean i-131 thyroid uptake was 70.3 mbq (range 0-481 mbq). 39/183 (21%) patients developed symptomatic radiation thyroiditis. incidence and severity of thyroiditis increased with increasing i-131 thyroid remnant activity (p=<0.0001). the risk of developing any degree of thyroiditis increased by 64% for every 37 mbq increase in activity (or= 1.73 (95% ci 1,36-1.99). severe thyroiditis was not seen with remnant uptake <74 mbq while 9/30 (30%) of patients with remnant uptake >111 mbq experienced severe thyroiditis. for patients treated with 1110 mbq and 3700 mbq, thyroid remnant ablation success rate was 75% and 82% (p=ns), incidence of any thyroiditis was 12% and 27% and incidence of severe thyroiditis was 1% and 8% (p=<0.05) respectively. conclusions: initial post surgical i-131 thyroid remnant uptake of >74 mbq often produces significant thyroiditis. lower initial administered i-131 activities may be desirable for low risk disease, particularly when a larger thyroid remnant is suspected. this lower initial administered dose does not appear to significantly compromise success rate of thyroid remnant ablation. 4) . after oral administration of 131-i the external whole-body dose rates were measured at a distance of 1 meter in each hospitalization day until the dose rates fall bellow the release dose rate level of 10μsv/hr. results: the dose rate decay was biexponential for all four groups. by considering the dose rate limit of 10 μsv/h at 1 m for releasing patients, %76.4 of patients satisfied this limit after 3 days , %88.7 after 4 days and %98.8 after 5 days. there was total of three cases with hospitalization times more than 6 days because of functional thyroid reminants and widespread metastasis. the cumulated dose received by the nursing staff was 54 μsv/week, less than the dose recommended by the international committee for radiation protection (icrp). discussion: our data clearly showed that suitable guidelines can be derived to limit the annual dose to less than 1 msv for children, members of the public and staff who may come into contact with cancer patient treated with radioiodine . aims: negative diagnostic 131 i whole body scan with elevated serum tg levels are found in 20% of patients with differentiated thyroid cancer (dtc). empirical radioiodine treatment has also been advocated by some researchers with controversial outcomes. we performed an anterospective study to aim the answer to abovementioned dilemma and also determine the capability of tl-201scintigraphy in these patients. materials and methods: we studied 21 patients with a mean age of 53 ± 14.17 years who had a history of follicular cell derived thyroid cancer (fcdtc) and elevated serum tg levels with a negative 131i diagnostic wbs and also were treated with radioiodine. in 15 patients also whole body scan with tl-201 was carried out. paired t test and correlation tests were carried out. a p-values of 0.05 or less were considered to be significant. results: the mean pretreatment and posttreatment tg were 227.23 ± 208.50 ng/ml and 163.43 ± 282.57 ng/ml respectively. there was statistically significant difference between pre and posttreatment tg (p value< 0.05). eleven cases showed at least 50 % decreased in tg value (remission group), 6 patients revealed less than 50 % decreased in tg value (stable group) while 4 subjects demonstrated tg increment in posttreatment tg relative to pretreatment tg value (progression group).there was no significant correlation between cumulative and also last i-131 doses in three groups (remission, stable and progression groups) [p value> 0.05]. in the posttreatment wbs, 10 patients showed abnormal findings in their images. in follow up scan with tl-201, 9 out of 15 cases had positive scan. in our study at least 50 % of subjects demonstrated the reduction or normalization of serum tg occurred in the first post-treatment follow up. thus, our study support benefits of empiric rai therapy of diagnostic rai scan-negative and tg-positive fcdtc patients .in addition, for the management of fcdtc patients who do not have rai accumulation and have elevated tg, other imaging modalities such as tl-201 scan are helpful. conclusion: we recommend rai therapy in dtc patients with elevated tg and negative wbs .in addition, at hospitals without access to pet, we can expect improvements in the detection of recurrence and metastasis to make a logical management after total thyroidectomy using i-131 and t1-201 as complements to each other. objectives: for radioimmunotherapy (rit) with y-90-labelled monoclonal antibodies, a surrogate nuclide for assessing biokinetics is necessary as y-90 is not appropriate for imaging. due to similar half-life, coordination chemistry and metabolic handling in-111 is used. however, differences in biodistribution of these 2 nuclides have been reported. here we present a method for an intraindividual comparison of blood biokinetics of in-111-and y-90-labelled anti-cd66 antibody for rit. methods: for five patients (1 male and 4 female, age: median 46 years, range 21-67 years) with aml or all blood serum activity data were collected during dosimetry (in-111) and therapy (y-90). the median and range of the applied activities for in-111 and y-90 were 134 mbq (78-146 mbq) and 3107 mbq (2172-4120 mbq), respectively. a set of 18 models (sums of 1 to 3 exponentials, with various combinations of shared or non-shared parameters) was chosen and fitted to the data of each patient. non-shared parameters means fitting the in-111 and y-90 data with extra parameters, while shared means using a common parameter for both nuclides. all parameters, which describe later parts of the serum time activity curve were fitted non-shared, as the treatment could affect serum time activity curve. the fit parameters were calculated using a minimum sum of squares algorithm. the model which supported the data best was selected using the corrected akaike information criterion. the models were ranked according to the akaike weights. results: the model when sharing the parameters of the first exponential between the in-111-and y-90-labelled time activity curves is ranked best in four out of five patients. one patient's data were best described sharing only the half-life, but not the prefactor of the exponential. all best models were substantially supported (wi = 0.70-0.96) by the data and r2 as a measure of goodness of fit was higher than 0.97. the areas under the curves from 0 to 4 h p.i. of the best fit model of in-111 and y-90 had a ratio of 1.02±0.03. conclusions: the introduced method is a powerful and straightforward approach for intraindividually quantifying similarities or equality of blood serum biokinetics. this is a pivotal step in the surrogate nuclide selection process, since equality or high similarity is a necessary, although not sufficient, condition for extrapolating from a pretherapeutical dosimetry on the therapeutic radiation absorbed dose. introduction a dosimetric study involves many different specialists and many different steps. it starts with the labelled of the radiopharmaceutical (in 111 cl 3 -dotatoc) and proceeds with the administration, the collection of biological samples, the scintigraphic exams and the physic and mathematical analysis of all data collected. aim we want to evaluate the contribution of different specialists involved in the collection data for dosimetric study before y 90 cl 3 -dotatoc therapy, the mantime and instrumentation-time for all steps. materials and methods the biologist of nuclear medicine department label the in 111 cl 3 -dotatoc with the help of a medical physicist for radioprotection. meanwhile a nurse make the infusion of the aminoacid to the patient. then a physician administer the radiopharmaceutical to the patient. immediately the collection of blood samples starts (nurse). the patient makes the complete urinary collection using dedicated containers that the biologist (who directs all steps) provides to change at established time intervals. the biologist divides all samples in test-tubes containing the same volume of liquid and then the physicist measures them by a spectrometric system. the tecnologist of nuclear medicine units performs five whole-body scans at the patient at difference times and days. the physicist performs the spect and ct applying appropriate reperies to the patients to carry out images fusion. using compartimental models and dosimetric software the physicist calculates residence-times and dosimetric data for critical organs and lesions. the result of all these work is delivered to the physicians who compiles therapeutic plane. results the patient is busy for four days. the biologist, as director of the entire procedure, is busy for all first day and for two hours in next days. the physicist is busy for four hours in first day, two hours in second day (for spect/ct) and for about three hours when all samples are collected for the data analyse. the nurse in busy in the first and second days (when he can work in routine too). the phisicians is busy for a few minutes the first day for administration and then for about two hours for the compiling of the therapeutic plane basing on the dosimetric data. conclusions all the procedure is time-expensive, but the dosimetric study is an important step of the therapy with y 90 cl 3 -dotatoc. to optimise the work is very important that all specialists involved are in harmony and organized. we already have performed 41 dosimetric study and we now have a consolidated organization. aim: peptide receptor radionuclide therapy (prrt) with lu-177 dota-tate is used for the treatment of patients with neuroendocrine tumors. the aim of our study was to determine the organ and tumor kinetics for dosimetric calculations. material and methods: 130 patients (aged 60+/-11 years; 57m, 73f) with metastasized neuroendocrine tumors (somatostatin expression verified before by ga-68 dota-noc pet/ct) were treated with activities of 2.5-7.4 gbq lu-177 dota-tate (1-5 cycles). on the basis of conjugated planar whole-body scintigraphies 0.5h, 3h, 24h, 48h and 72h p.i. the time-dependent whole-body, organ and tumor activities were determined and dosimetric calculations were performed according to the mird scheme using olinda software. blood samples were drawn from 23 patients to estimate the absorbed dose to the red marrow. to describe the kinetics we used the withdrawn s358 following parameters: mean half-life and uptake (fraction of injected activity/dose, id) which were calculated using the fit of the time-dependent activity curve to a mono-or bi-exponential function. results: the renal uptake decreased for the first 3-5 hours p.i. with a mean half-life of 1.0+/-0.5h, followed by a second phase with a longer half-life of 65+/-17h. the maximum kidney uptake was 4+/-1%. the uptake in the spleen was with 2+/-1.8% id stable until 24 hours p.i. and then showed a decline with a half-life of 72+/-19h. the tumor uptake showed an increase until 24h p.i. to a maximum of 0.1+/-0.1% id per unit mass and then slowly decreased with a half-life of 77+/-25h. liver metastases showed a higher maximal uptake (0.1+/-0.1%) as compared to lymph node metastases (0.08+/-0.07%). the blood kinetics were fitted to a tri-exponential function with large variation: half-life 1: 0.2+/-0.2h; half-life 2: 2+/-1.8h and half-life 3: 21+/-10h. the following organ absorbed doses were calculated: kidneys: 5+/-2 sv; spleen: 7+/-4 sv; metastases: 47+/-66 sv (44+/-38 sv for lymph node, and 60+/-86 sv for liver metastases). the resulting dose to the red marrow was 0.2+/-0.1sv. conclusions: the relatively low organ doses compared to y-90 labelled peptides for prrt correlate with the low clinical toxicity of the radiopharmaceutical. the effective treatment of patients with neuroendocrine tumors using lu-177 dota-tate is confirmed by the mean absorbed tumor doses. individual patient dosimetry should be performed due to the large interindividual variations concerning the organ and tumor doses. aim: an individualized quantitative method to calculate activity distribution and kinetics is needed for accurate, patient-specific dosimetry for optimized internal radiotherapy treatment. our objective is to design a clinically viable, simple procedure that will provide patient specific, quantitative and 4-dimensional (3d + time) estimate of the dose-rate absorbed from an internally delivered radiopharmaceutical. methods: the elements of the procedure are as follows: • quantitative reconstruction of spect data using patient-specific transmission or ct-based attenuation maps. our qspect method includes attenuation and scatter corrections, and accounts for system resolution, and cross-talk and septal penetration when needed. • quantitative data reconstructed from a spect scan are being combined with the information obtained from a series of 4-5 whole body scans (wb) in order to determine quantitative biokinetics of the tracer in tumours and critical organs. • estimation of dose delivered to organs of interest using three complementary elements: (a) voxelized 3d quantitative activity concentrations, (b) temporal information about biodistribution of this activity, and (c) analytical calculation of the delivered dose. this calculation will be based on the known physics of photon and particle interactions and will use our analytical photon distribution (apd) method. • for repeated radiotherapy treatments, 3d dose-rate maps may prove to be particularly useful, as the final goal of this project is the determination of the reliable dose-response relationship. materials: simulations and phantom experiments were performed in order to evaluate the accuracy of quantitation for different isotopes relevant for oncology and to design new acquisition protocols that would provide quantitative biodistribution information in clinical setting. investigated isotopes included tc-99m, in-111, i-123, and i-131. experiments used siemens e-cam + profile transmission system and ge infinia + hawkeye ct. activity in "tumour"-like containers placed in air and active background was measured using planar, wb, tomographic and a combination of two spect and five wb acquisitions. results: the results of our studies show that in planar and wb studies the quantitation errors vary from about 10-20% to 60-80% depending on the activity distribution and the method of data processing. our qspect technique results in activity estimation with errors in the order of 6-11%. similar accuracy levels were achieved in quantitatition of activity kinetics from a combination of spect+wb studies. conclusions: improved accuracy of biodistribution quantitation obtained from a combined protocol of spect+wb offers new promise for patient specific dosimetry. incorporated into our apd calculation these data will provide 4-d voxelized dose maps. dose assessment of salivary glands in radioiodine therapy d. shahbazi-gahrouei, z. shahi, k. ziaei; dept. of medical physics, isfahan uni. of medical sciences, isfahan, iran (islamic republic of). the use of radioactive iodine ( 131 i) has become an important adjunct to the treatment of thyroid cancer and hyperthyroidism. salivary gland has the ability to concentrate radioactive iodine under normal circumstances. salivary gland dysfunction and dry mouth are the common side effects of high-dose radioiodine therapy. the purpose of this study was to determine the absorbed dose of salivary glands. materials and methods: twenty patients who were divided into two groups of 10 were studied (a group without pilocarpine and the b group received pilocarpine during treatment). the absorbed dose of parotid glands and the submandibular glands of patients was measured using thermoluminescent dosimeter (tld) at three different times (24 hours, 8 days and 3 months after treatment). the attenuation coefficient of patients and the effects of pilocarpine were also determined. results: in group a total attenuation coefficient was 0.335, 0.323, and 0.357 for parotid glands and the right and left submandibular glands, respectively. in group b total attenuation coefficient was 0.462, 0.482, and 0.514 for parotid glands and the right and left submandibular glands, respectively. the results also showed the dose decreases to 1 cgy after 3 and 2 half life for a and b group, respectively. conclusions: the findings showed that the dose decreases to 1 cgy after 3 half life of iodine therapy. the exponential coefficient attenuation of salivary glands varied between 3% to 4%. pilocarpine should be effective to increase excretion of radioactive iodine and increases 1.5 to 2 times coefficient attenuation. aim: commercially available radiopharmaceuticals for radiosynovectomy (rso) are expensive and not always accessible for developing countries. cost effective and safe agents are therefore needed. herein we present the biokinetic data of rhenium-188-tin colloid (re-col) and phosphorus-32 colloid (p-col) in patients undergoing rso of the knee. methods: in 8 patients (pts) treated with 339±102mbq re-188 (1) in knee serial blood samples at 2, 4, 6, 12, 24, 36, 48, 60, 72 h and urine up to 72h were collected. additional, in 5 pts treated with 82±18mbq p-32 blood measurement at 1, 2, 3, 24h and urine sampling up to 24h were studied. median particle size range for re-col 5μm (range: 1-10) and for p-32 0.3μm (0.2-0.35), respectively. results: in rabbit animal model, retention of radioactivity in the synovium for re-col at 24 and 74h were 96.4±11.1% and 90.7±11.2% of id respectively. in patients undergoing rso of the knee with re-col, average %id in blood at 4, 12, 24 and 72h were 0.06±0.05%, 0.12±0.09%, 0.21±0.19% and 0.14±0.08% respectively. total excreted activity in urine at 72h was 1.65±3.00 %id (range: 0-8.987). for p-col %id in blood at 1, 2, 3 and 24h p.i. were 5.8±3. 1; 5.7±2.8, 4.4±3.3, 3. 8±3.4 respectively, and 3.7±2.0%id in 24h-collected urine. percent id in blood at 24h and the area under the curve up to 24hs were significantly lower for re-col compared to p-col, p<0.05 and p< 0.02 respectively. discussion and conclusion: p-col showed a longer retention in blood and a higher urine excretion than re-188 tin colloid indicating a lower in-vivo stability for p-col formulation. data suggest that blood radiation exposure is lower for re-col than for p-col. both radiopharmaceuticals are however, suitable for radiosynovectomy. as a generator product, re-188 provide excellent availability and can be cost effective which is however dependent on the frequency of use. p-32 as a cheep reactor product provide a good and cost effective alternative. reference: 1. jeong jm et al. appl radiat isot 2000,52:851-5 results of an iaea led crp e1.30.26 objectives : the objective of this work was to determine normal organ mean absorbed dose and effective dose equivalent and effective dose for 11 c-pib dosimetry in humans. methods : 3 patients (1 female, 2 male, mean age 60.3 y) were administered with a bolus infusion of 11 c-pib (dose range 300. 2 -377.7 mbq) and immediately scanned on a gemini pet/ct camera. sequential wholebody pet images, which extended from head to upper thigh, were acquired, representing 5 time points over a period of 60 minutes. resultant images were reconstructed using an iterative single scatter simulation algorithm. using in-house developed software, voi analysis for each time point was performed to obtain activity concentration in normal tissue. organs considered as source organs were brain, lung, liver, kidney, spleen, gallbladder contents and bladder contents. using reference man (icrp 23) values for organ volumes, the total activity was calculated per organ for each time point and the cumulated activity was determined from the area under curve of a bi-exponential fit to the resultant time activity curves. the cumulated activities were used as input to olinda. results : large accumulation of 11 c-pib was visualised in gallbladder, liver and urinary bladder. accordingly, the organs with the greatest mean absorbed dose (mean ± sd) were gallbladder wall (47.2 ± 14.5 μgy/mbq), urinary bladder wall (24.9 ± 11.3 μgy/mbq), liver (21.6 ± 4.6 μgy/mbq) and kidneys (12.5 ± 4.7 μgy/mbq). effective dose equivalent (ede) was 8.7 ± 1.7 μsv/mbq and effective dose (ed) was 5.0 ± 0.8 μsv/mbq. of note, due to its high absorbed dose, gallbladder wall has a large contribution towards ede, whilst not being considered in the calculation of ed. conclusions : organ dose estimates for 11 c-pib are comparable to other reported 11 c ligands. analyzed and used to determinate the red-marrow-dose. the residence-time in lesions, with s-factors (mird), are used to calculate lesions-dose. data are elaborated by compartimental-models to write the therapeutic plan. patients treated with y 90 cl 3dotatoc have been followed for appraising the course of disease. results we collected these average and range dose-data (mgy/mbq): red-marrow (0.07, 0.02 to 0.2); kidneys (2.34, 0.22 to 7.17); spleen (4.71, 0.03 to 28.0); liver (0.94, 0.05 to 6.47); urinary-bladder (1.47, 0.05 to 3.68); total-body (0.13, 0.05 to 0.30) . the dose to principal lesion has been calculated for 32 patients (average 23.45, 0.0005 to 238.2) . 22 patients had kidneys-dose less than lesion-dose and 29 patients had liver-dose less than lesion-dose. 20/32 patients had lesion-dose greater then red-marrow-dose, liverdose and kidney-dose. we followed 29 patients (3 patients not treated, 9 patients in progress of treatment). 23 patients had a positive results to the treatment (complete or partial result or disease stabilization) and 6 patients a negative one (progression of disease). among 23 patients with positive results, 12 had lesion-dose greater than critical organs-dose (reached 300 gy to lesion), for 6 patients the lesion-dose has not been calculated. only 1 patient who reached 300 gy in lesion had a negative responce. conclusions the variability of the dosimetric results shows the importance to perform a personalized dosimetric-study. follow-up showed that the patients treated till 300 gy to the lesion had a positive result to the therapy (only one exception). among the patients treated till the reaching of the dose-limit to the critical organs (lesion-dose less then 300 gy), 6 had a positive result. in conclusion, the therapeutic plan wrote on the base of dosimetric-study has a real utility. aim: the pharmacokinetics and dosimetric profile of 90 y-dotatoc is well known, being the kidney the critical organ. however, in end-stage renal failure, biodistribution could be altered and organs such as red marrow (rm) could be critical. the aim of this study was to evaluate the biodistribution and dosimetry of 90 y-dotatoc in a patient with end-stage renal failure undergoing dialysis. methods: a female patient affected by abdominal lymphnode metastases from endocrine carcinoma, asked to eradicate her disease with 90 y-dotatoc in order to be enclosed in the waiting list for renal transplant. the patient suffered from renal failure since the age of 18. at 56 years old she was operated for lymphnode metastases from gastrin secreting endocrine carcinoma of unknown origin. a subsequent octreoscan showed persistence of abdominal lymphnodes (35 mm). gastrin: 2490 pg/ml. 111 mbq 111 in-dotatoc were administered for dosimetry. blood samples and planar images were obtained up to 40h p.i. patient-specific dosimetry was evaluated by imaging analysis and actual organ masses (ct). the blood-derived method was used for rm dosimetry, considering the rm specific activity equal to that in blood. the number of disintegrations (nd) was obtained for all source organs; for rm, the rm specific activity equal to that in blood. the olinda/exm code was used to calculate absorbed doses. results: nds (h) in source organs were: 0.84 (rm); 7.52 (spleen); 9.46 (liver); 35.87 (remainder of body-rb). absorbed doses (gy/gbq) were significantly higher than published results (mean±sd): 22.4 (vs. 9.96±6.70), spleen; 2.52 (0.89±0.68), liver; 0.36 (vs. 0.07±0.03), rm, 0.47 (vs. 0.17±0.05), total body. this confirmed a redistribution of the activity usually eliminated through kidneys, with fast and higher uptake in liver and spleen. tumour dose was 14 gy/gbq. the treatment was considered feasible, with rm critical organ, liver second limiting organ, spleen irradiation of some concern. the patient conservatively received 1.11 gbq. therapy was well tolerated. only reversible grade 1 toxicity on wbc and plt, and grade 2 on hb, occurred. six months after octreoscan and mri showed disappearance of the lesions. gastrin: 268 pg/ml. conclusions: in patients undergoing dialysis, rm is the critical organ. these results showed the feasibility of 90 y-dotatoc therapy even in patients who would be logically excluded. in such cases, a deep analysis of the tumour dose and risk-benefit balance should guide, addressing 90 y-dotatoc to cases without other options. assessment of absorbed dose and therapeutic response of tumor in repeated high-dose i-131 anti-cd20 monoclonal antibody (rituximab) radioimmunotherapy for non-hodgkin's lymphoma nearby tumor. the shape of 2d-roi of tumor was determined from the mip pet image. the volume of tumor was measured from the ct image, the % change of tumor volume before and after rit was used to evaluate the therapeutic response. the value of ct-based tumor volume was compared with that measured by pet image at the cut-off suv of 1.5. in tumor dose estimation, the time-activity curve (tac) of tumor region was used, and the both absorbed fractions of beta-and gamma-ray were considered together. results: bi-exponential decrease was observed in fitting of tac of tumor. the values of ct-and pet-based tumor volume were 3.8 ± 1.1cc and 3.9 ± 2.1cc, respectively, and showed the linear relationship(r=0.9053). the values of absorbed dose for tumor and the %changes of tumor volume before and after rit were 131.6±89.5rad, were 45.4±19.3%, respectively, and did not show the linear relationship(r=-0.3312). the values of absorbed dose for tumor and the % changes of tumor volume did not show the linear relationship with the number of repeated administration(r=0.3307 and -0.1171, respectively). conclusion: aligning pet and planar images could estimate the quantitative values of absorbed dose to tumor. the data suggest that potentially equal absorbed dose and therapeutic response of tumor could be expected in repeated rit with i-131 rituximab for nhl. purpose: gastric cancer is one of the most common cancers, and is the second most common cause of cancer related mortality in the world. the a33 antigen is a glycoprotein which is homogenously expressed by more than 95% of colorectal cancers and 55% of gastric cancer and in the normal intestinal mucosa, but not in other epithelial tissues including gastric epithelium. in order to determine the in vivo characteristics of hua33, a cdr grafted humanized monoclonal antibody against the a33 antigen, a clinical trial was conducted in patients with gastric carcinoma. patients and methods: thirteen patients were entered into the study. they were assigned serially onto one of four dose levels (1.0, 2.0, 5.0, 10 .0 mg/m 2 ) of hua33. patients with early gastric carcinoma received a single infusion of 131 i-hua33 one week prior to surgery. biodistribution of 131 i-hua33 was evaluated by the imaging at least 3 occasions including on the day of administration and on upto 9 days. adverse events were assessed. ex vivo imaging and immunohistochemical analysis were performed on the samples of biopsy and surgical specimens. results: no dose-limiting toxicity was observed and the maximum tolerated dose was not reached. although cancer tissues with low expression of a33 by immunostaining in biopsied frozen sections did not show positive imaging with 131 i-hua33, cancers with high expression of a33 by frozen and paraffin sections in the biopsied specimen showed positive ex-vivo imaging and positive antigen expression in resected gastric cancer specimen, and the biodistribution analysis also showed tumor uptake of 131 i-hua33. conclusions: humanized monoclonal antibody hua33 demonstrated selective localization to gastric cancer that strongly expresses a33 antigen. these targeting characteristics of the hua33 indicate potential for the targeted therapy of advanced gastric cancer that is refractory to cytotoxic chemotherapy or recurrence after surgery, and could also be exploitable for the adjuvant therapy after curative resection of early gastric cancer. metabolic radiation therapy is mediated by emitter labelled radiopharmaceuticals allowing lethal target radiation. unfortunately, such medical practices using emitter radioisotopes is associated with an increase of medical staff radiation exposure in nuclear medicine department. this gives us reasons to quantify medical staff radiation in our department during 131-i lipiodol, 90-y-colloid and 153-sm edtm treatments of hepatocellular carcinoma, arthritis (radiosynovectomy) and bone metastases respectively. methods: 25 injections of 131 i-lipiodol, 11 90-y-colloid radiosynovectomy sessions and 5 153-sm-edtm treatments were studied. whole body doses (wbd) and right and left finger doses (rfd, lfd) for radiopharmacists (rp), nurses (n), radiologists (rd) and rheumatologists (rm) were evaluated by cylindric lif-thermoluminescent dosimeters (tld) placed on the waist or on the inward second finger. results: wbd for medical staff during 2.26±0.06 gbq 131-i lipiodol injections were 2.96±2.9, 5.6±5.1 and 14.7±13.3 μsv for respectively rp, n and rd. rfd and lfd were respectively 185.7±119 and 925.9±526 μsv for rp, 51.8±34.9 and 158.9±44.0 μsv for rd. the use of angioseal ® hemostatic puncture closure device deployed for haemostasis after 131-i lipiodol injections afforded a two fold decrease in rds' exposure compared to manual compression. during the 90-y colloid syringe filling sessions (mean activity per session: 30.3±10.1 mbq, n= 11), the wbd for rp was 10.3±15.9 μsv, rfd was 157.5±146 and lfd was 2488±3022 μsv. wbd for rm and n performing intra-articular infusions were respectively 1.05±1.71 and 4.29±3.9 μsv per 37mbq injected. fd, normalized to 37 mbq injected, were 104.0±118 μsv (rfd) and 289.2±673 μsv (lfd) for rm and 125.9±91.6 (rfd) and 146.0±85.7 μsv (lfd) for n. during 153-sm edtm syringe filling (2.40±0.2gbq) rp wbd was 0.96±2.1 μsv rfd was 55.9±20.3 and lfd was 157.9±162 μsv. n exposure during 153-sm-edtm administration was 28.6±25.8 (wbd) and 82.8±32.2 μsv (rfd) conclusion: fortunately, annual extrapolated wbd and fd doses remain under legal limits but observed values are not negligible and have to be added to those relative to 131-iodine treatment of thyroid disorders for example. such considerations may confirm the interest of protocol optimization, personal information and studies focusing on radioprotection. evaluation of factors affecting the accuracy and precision of a technique for quantification of volume and acticity with 111in spect. m. s. kotzassarlidou, c. tziaka, t. kalathas, a. raptou, n. salem, a. makridou; theagenion cancer hospital, thessaloniki, greece. aim: accurate in vivo volume and activity determination is essential in clinical research, especially for estimating organ absorbed dose during radionuclide therapy. in this study volume and activity concentration were estimated using single photon emission computed tomography (spect) for volume and activity concentrations of 111-in sources between 2.5-12.5 ml and 2-9 mbq/ml. all sources were of regular geometry. the influence of voxel size, source size and shape was studied. materials and methods: spect acquisitions have been carried out by sopha dst xli 2-head gamma camera over 360o, elliptical orbit and step and shoot mode, according to the following protocols: -64x64, 64 frames, 10sec/frame, -128x128, 128 frames, 5sec/frame. pixel size [cm] and system sensitivity, [cps/mbq] of both matrix sizes for 111-in spect have been determined in advance. processing was performed on vision workstation using a butterworth reconstruction filter (order 1, nyquist 0.25). attenuation correction was applied and transaxial images of one pixel thickness were obtained. the segmentation algorithm used for volume quantification was the autothresholding method. pixel value with the maximum counts in all slices was selected and percentage (60-90%) of it was determined. pixels of all slices with a value equal or greater than the predetermined value belonged to the source. volume estimation was obtained by summing the number of voxels within the source contour in each slice and multiplying their total by voxel volume. activity estimation was obtained by summing the counts of the above regions and dividing their total by acquisition time and the system sensitivity. results: the best correlation between nominal and measured volumes by 111-in spect images was obtained with threshold percentage of 80% and 65% for 64x64 and 128x128 matrix size respectively. error increases as nominal volume decreases (r=-0.718, p=0.001) for 64x64 whereas for 128x128 it increases proportionally to the threshold (r=0,883, p<0.0005). activity estimation was best obtained for threshold percentage of 70% for 128x128. conclusions: autothreshold technique is effective for in vivo volume and activity quantitation of lesions with volumes greater than the system spatial resolution (i.e. volmeas> 2.5ml). in case of smaller lesions ct is preferable for volume quantitation. where d k is the mean absorbed dose to region k (gy); a 0 is the administered activity (bq); s (r k r j ) is the mean absorbed dose in target region k irradiated by source region j; j is the residence time in source region j (s), which is j = t0 t a j (t)dt / a 0 = t0 t a j (t) / a 0 dt = t0 t %id dt. where a j is the activity of source region j at the time of t. we calculated the mean absorbed dose of critic organ by mirdose 3.0 software (internal dose information center at oak ridge institute for science and education, oak ridge, tn), using the dynamic bladder model (4h void) . we summed up the resident time of lungs and tumor as the "lungs" resident time. corrections were made for lungs masses. for the mass of tumor tissue ( m t ) we assumed unit density and employed the ct volume ( v t ) : m t =1× v t . tumor background subtraction was attempted using ct scans to estimate true background thickness. absorbed doses to tumor tissues (d t ) were estimated using the same approach taken for normal organs. s-factors for tumors were estimated by comparison with lungs. according to equation d t =m lungs ×(d " lungs" -d lungs )/ m t and d t =m lungs ×(d " lungs" -d lungs )/ m t , where d " lungs" , the mean absorbed dose of mixed lungs and tumor. by equation, we can easy to calculate the d t and d lungs . results: the absorbed dose of red marrow ranged from 0.44 to 0.73gy; thyroid, from 0.47 to 23.09gy; ovaries, from 0.50 to 0.77gy; testes, from 0.38 to 0.58gy; kidneys, from 1.71~4.55gy; liver, from 1.18 to 2.63gy; lungs, from 1.55 to 2.74gy; and effective dose equivalent from 0.48 to 0.80gy. the results shows tumors with highest uptake of (2.8±2.0)%id of 131 i-chtnt at 24h. the mean absorbed dose of tumors (within 50a) was [(8.28±2 .65), from 4.22 to 12.81]gy, 7d reached (65±4)%, 14d reached (89±2)%, and the tumor-to-nontumor ratio (t/nt) was 3.95±1.55 (from 1.63 to 6.29). conclusion: repeated intravenous 131 i-chtnt is needed because single intravenous dose of 131 i-chtnt could hardly depress the growth of tumor masses. objective: to study tgf-1 and bfgf expression in normal prostate and bph and inhibitory effects of specially designed sr 90 /y 90 applicator radiation on the expression in hyperplasic prostatic diseases. method: 50 bph patients were divided into two groups, the intracavitary exposure group and the hyperplasia group. all 35 patients in exposure group were treated with sr 90 /y 90 applicator. 12 patients were practiced operation 4 days after the exposure, another 12 patients were practiced operation 7 days after the exposure, and the rest 11 patients were practiced operation 15 days after the exposure. 15 patients in hyperplasia group were not treated with intracavitary exposure. expression of tgf-1 and bfgf were detected through immunohistochemical staining technique. results: tgf-1 positive expression rates of np and bph epithelial cells were higher than those in correspondent stromal cells (p<0.01). no statistically significant association was found between tgf-1 positive expression of epithelium and stroma in bph tissues and the correspondent expression in np (p>0.05). compared with the hyperplasia group, tgf-1 positive cell rates in bph epithelial and stromal cells were significantly increased 4, 7 and 15 days after sr 90 /y 90 applicator exposure (p<0.01). expression of bfgf existed not only in epithelial and stromal cells of bph, but also in normal prostatic tissues. the bfgf positive expression rates in bph epithelial and stromal cells were higher than those in np epithelial and stromal cells (p<0.01). bfgf positive expression rates in bph and np stromal cells were higher than those in corresponding bph and np epithelial cells (p<0.01). bfgf levels in bph epithelial and stromal cells descent sharply 4, 7 and 15 days after sr 90 /y 90 applicator exposure (p<0.01).conclusion: exposure of -rays from sr 90 /y 90 applicator had noticeable effects to enhance tgf-1 expression and inhibit bfgf expression in bph tissues. objective: to investigate expressions of bcl-2 and bax in benign prostatic hyperplasia (bph) tissues and influence of radiation from specially designed sr 90 /y 90 applicator on bcl-2 and bax expressions. method: 50 bph patients were divided into two groups, the intracavitary exposure group and the hyperplasia group. all 35 patients in exposure group were treated with sr 90 /y 90 applicator. 12 patients were practiced operation 4 days after the exposure, another 12 patients were practiced operation 7 days after the exposure, and the rest 11 patients were practiced operation 15 days after the exposure. 15 patients in hyperplasia group were not treated with intracavitary exposure. expression of bcl-2 and bax were detected through immunohistochemical staining technique. results: the bcl-2 positive expressions in both normal prostate(np) and bph epithelial cells were higher than those in corresponsive stromal cells(p<0.01),while the bcl-2 positive expressions in epithelial and stromal in bph tissues were higher than those in np(p<0.01).meanwhile, the bax expression in np epithelial cells was higher than that in bph(p<0.05),and the bcl-2 expressions of epithelia and stroma in bph were higher than the corresponsive bax expressions(p<0.01). no statistically significant association was found between the bcl-2 expressions of epithelia and stroma in np and the correspondent bax expressions(p>0.05).compared with the hyperplasia group, bcl-2 in bph epithelial and stromal cells reduced sharply, and bax positive cell rates increased distinctly 4, 7 or 15 days after the intracavitary exposure by sr 90 /y 90 applicator radiation(p<0.01). conclusion: bcl-2 and bax play an important role in regulation of prostatic apoptosis and the treatment of radiation with sr 90 /y 90 applicator before surgery can accelerate apoptosis in prostatic tissues. the purpose of this study was the quantitative analysis of the internal contamination with four uranium isotopes in the population living near the uranium conversion facility in port hope, ontario, canada; the oldest operating uranium processing plant in the world. the urine samples of symptomatic patients presenting with symptoms of musculo-skeletal, cns, immune system, and neoplastic disease were obtained from among a large population. control samples were also analyzed. the urine samples were analyzed in a specialized radiochemistry laboratory by mass spectrometry, including pre-concentration of urine by co-precipitation, oxidation of organic matter, uranium purification by ion-exchange chromatography, and icp-ms double-focusing thermo finnigan neptune multi-collector. natural uranium has a 238 u/ 235 u ratio of 137.88 and does not contain 236 u. background total uranium concentration in the urine of humans is 7 ng/l (usa nceh). our results show 4 of 9 samples containing uranium of non-natural origin. one sample was highly positive for depleted uranium (du) with a 238 u/ 235 u of 147.11 ± 1.42 and a relatively normal abundance of total uranium. this sample contained a concentration of 236 u with a 236 u/ 238 u ratio of 4.38 x 10 -6 ± 4.3 x 10 -7 indicating its reactor origin. three samples contained detectable amounts of 236 u, one being paradoxically high with a 236 u/ 238 u ratio of 5.53 x 10 -5 ± 3.9 x 10 -6 . one of these three samples contained a higher than normal concentration of total uranium (24.8 ng/l). the 236 u in these samples indicates its origin as contamination with non-natural uranium. the remaining five samples were negative for both depleted uranium and uranium-236. the history of uranium contamination of the vicinity of port hope has been verified in objective scientific literature 1 . our results suggest long-term contamination and possible adverse effects on the body burden of the current population of port hope. these preliminary results warrant additional multidisciplinary studies. aim: standard treatment of differentiated thyroid carcinoma (dtc) is total thyreoidectomy followed by radioiodine therapy (rit) and diagnostical i-131-whole body scan (d-wbs). radioiodine (ri) is eliminated via kidneys. in patients with dtc and end stage renal failure (esrf) doses between 760 and 1110 mbq were administered orally. the aim of this study was to evaluate the therapeutical effectiveness of rit using reduced amounts of ri. material and methods: during the last seven years 3 esrf patients suffering from dtc were treated with rit. one patient received four ri treatments . one patient got two rits and 1 d-wbs and one patient received two rits. the activity doses administered ranged between 752 and 1248 mbq for rit and between 385 and 604 mbq for d-wbs, respectively. hemodialysis was done on the 1 st and 3 rd day after ri administration. serum thyroglobulin (tg) was measured prior to and after ri applications using tg-sria( brahms, sensitivity 0,3 ng/ml) during tsh stimulation indium 111 oxinate is a radiopharmaceutical that decays by electron capture with a half life of 67 hours, emitting gamma radiation with energies of 172 kev and 246 kev as well as low energy auger electrons. indium 111 oxinate is used in nuclear medicine for the in-vitro labelling of separated blood cells, which are then administered to patients to investigate inflammation at the sites of infection and abscesses. because of the potential toxicity of its auger emissions indium 111 has also been evaluated recently as a potential tumour therapy, where indium 111 has been conjugated to somatostatin receptor analogues or to tumour-specific antibodies. aims: the aim of this investigation was to study the dna-damaging effects and cytotoxicity associated with cellular exposure to indium 111 and to evaluate the intracellular and intranuclear doses of indium 111 required to elicit cytotoxic effects. methods: we have investigated cellular toxicity of indium 111 oxinate in ht1080 fibrosarcoma cells and mcf-7 breast epithelial cells using the colorimetric mtt assay and the clonogenic survival assay. the results were compared with data obtained from similar experiments in which cells were treated with equimolar amounts of indium 111 oxinate that had been subjected to several weeks of decay, in order to determine the degree of cytotoxicity attributable to radioactive emissions. the single cell gel electrophoresis (comet) assay was also used to determine dna damage associated with exposure to indium 111 oxinate. cellular and nuclear uptake were measured using a phophorimager or a gamma counter. results: ht1080 cells that were subjected to 10 mbq/ml indium 111 oxinate exhibited 0.1 % cellular survival in the clonogenic survival assay compared to untreated control, while treatment with a molar equivalent of the decayed indium 111 oxinate exhibited 25 % survival compared with the same control. mcf-7 cells exhibited zero cellular survival when subjected to treatment with 5 mbq/ml compared to untreated control, while treatment with decayed indium 111 oxinate exhibited 38 % survival compared with the same control. the comet assay showed dna damage only at doses where cell toxicity was observed. cellular and nuclear uptake showed that 36% of indium 111 taken up by the cell was contained in the nucleus. the results demonstrate that radioactive emissions associated with 10 mbq/ml indium 111 oxinate elicit significant dna damage and cytotoxicity in ht1080 and mcf-7 cells. these data will allow correlation of intracellular dosage and nuclear proximity with cytotoxicity and dna damage. auger electrons and it effect on cell viability. in vitro preliminary results m. laranjo 1 , a. m. abrantes 1 , i. carreira 2 , m. f. botelho 1 ; 1 biophysics/biomathematics institute, ibili-faculty of medicine, coimbra, portugal, 2 biology institute, faculty of medicine, coimbra, portugal. aim: because auger electrons cause a high energy deposition limited to the area of the decay site the ensuing biological effects may represent an alternative in cancer radiation therapy. 99mtc is the most used radionuclide in nuclear medicine. besides its energetic gamma emission, its 6 hours half-life makes it the preferred radioisotope for patient administration. as 99mtc is also an auger emitter, the possibility to use it not only in diagnosis but also in treatment should be investigated. in order to examine the effects of 99mtc auger electrons in cancer cells, we investigated the survival and proliferation after exposure to 99mtc-pertechnetate. material and methods: adenocarcinoma colon cells (atcc -widr) developed in dulbelcco's medium with 10% of fetal bovine serum and incubated in 37ºc, 5% co2 atmosphere were used. 99mtc-perchnetate (85 mbq) was added to the medium during different exposure times (15, 30, 45 and 60 minutes) which resulted in absorbed doses of 0.75, 1.5, 2.2, 3 gy, respectively. after the incubations, 99mtc-perchnetate uptake was calculated. the cell viability and proliferation were evaluated 24, 48 and 120 hours after exposure. cell viability was evaluated by trypan blue exclusion test. this vital stain does not pass trough the membrane of living cells however, traverses the membrane at a death cell. with this method it is possible to estimate the ratio between living cells and death cells. to access cell proliferation we used mtt (3-[4,5-dimethylthiazol-2yl]-2,5-diphenyltetrazolium bromide), an yellow tetrazolium salt that is reduced in metabolically active cells to form insoluble purple formazan crystals. these are solubilized by the addiction of a detergent and then quantified by spectrophotometric means. results: regarding uptake of 99mtc-pertechnetate it increases proportionately to the incubation time (25% for 0.75gy; 20% for 1.5gy; 34% for 2.2 gy and 46% for 3gy). the viability indicates an increase of proliferation on the first 24 hours after irradiation, but after this time it decrease progressively with the time. 48h after treatment the proliferation values were 50% for 0.75gy; 61% for 1.5gy; 66% for 2.2gy and 37% for 3gy. 120h after treatment the proliferation values were 29% for 0.75gy; 32% for 1.5gy; 16% for 2.2gy and 15% for 3gy. conclusions: these preliminary results indicate that there are time dependent effects on proliferation and cell death. y. lin 1 , w. chang 1 , w. lin 2 ; 1 chunghsing university, taichung, taiwan, 2 taichung veteran general hospital, taichung, taiwan. the aim of this study was to investigate of various basic amino acid solutions and other compounds in order to assess their safety and their capacity to inhibit the renal uptake of in-111-dotatoc. materials and methods: male spraque-dawley rats (200-250 g) , in the presence of reuptake blocker, were injected with in-111-dotatoc. at 24 hours after injection, rats were sacrificed and organs were isolated and counted for radioactivity. results: lysine (400 mg/kg) were resulted in more than 40% inhibition of kidney uptake, but it may induce hyperkalacmia and metabolic changes. combination of arginine and histidine were also resulted more than 40% inhibition, nevertheless it have less side effect than lysine. maleate (400 mg/kg) were more effective to reduce renal uptake about over 50%. further, coinjection of colchicines (1 mg/kg), vincristine (0.1 mg/kg), noscapine (100 mg/kg), nocodazole (1 mg/kg) 5 hours before injection of in-111-dotatoc were significantly reduced kidney uptake (respective inhibitions of 31%, 26%, 41% and 46%). conclusions: administration of these compounds effectively reduce kidney radioactivity in order to allow the administration of higher doses of radiolabelled somatostatin analogues for scintigraphy and peptide receptor radionuclide therapy. introduction hyperthyroidism is a common disease in old cats and is preferably treated with radioactive iodine. treatment results are good, with 90-95% of the cats becoming euthyroid. concurrent subclinical kidney disease is not uncommon in this patient group and close monitoring of kidney function is mandatory. a recent research protocol at our institution necessitated the use of iohexol as a gfr marker to investigate kidney disease immediately prior to treatment with radioactive iodine. since it is generally known that iohexol reduces (radio)iodine uptake in the thyroid, this study was set up to evaluate its effect on absorbed dose in the thyroid and to investigate whether this procedure influenced long term outcome of treatment. materials and methods 43 hyperthyroid cats, presented for i 131 -treament, participated in this study. gfr measurement using iohexol was performed in 11 patients one day before injection of i 131 . 32 cats received only i 131 and functioned as control-group. the iohexol-group received an average activity of 109 mbq i 131 (sd ± 17 mbq); the control-group received on average 111 mbq i 131 (sd ±16 mbq). scintigraphic scans were performed 24, 48 and 120h post-therapy. a syringe with known reference activity was scanned using the same parameters. roi's were drawn over the thyroid region, background and reference activity for all time points. cumulative activity was calculated. a factor was obtained using mirdose3.1 software converting the cumulative activity into absorbed dose, taking into account the thyroid volume. results the mean estimated absorbed thyroid dose in the iohexol-group was 54 gy (sd ±9 gy), which was significantly different from the control group: 84 gy (sd = 12 gy) (p<0.01). of the cats that received iohexol, a higher percentage remained hyperthyroid (18%) 3 months after treatment compared to the control group (7%). these results however did not reach significance. (p>0. 1, 2 -test) . conclusion the administration of iohexol to evaluate kidney function reduces absorbed thyroid dose of 131 i in this small group of cats but does not seem to influence long-term outcome of feline hyperthyroidism. p60 -monday, oct. 15, 2007, 2:30 pm -4: tc-mibi were 11.2 μsv.h -1 ±2.3 and 43.1 μsv.h -1 ±11.9 respectively, at 5cm from the patients. for 201 tl, the average dose rates at the distances of 10, 50 and 100 cm from patients 3 hours after administration were 8.3, 2.4 and 1.2μsv.h -1 respectively. these values were in close agreement to the mean corresponding value of 9.2, 2.5 and 0.9μsv.h -1 obtained by munford et al 1989. the maximum departure dose rates at these distances were 0.14, 0.04 and 0.02μsv.h -1 .mbq -1 respectively. external doses rate of 201 tl fell gradually, until three days after administration. after injection of 99m tc-mibi a rising of the external dose within 1-3 hours was seen. the maximum departure rate per unit activity at the distances of 5,10, 50 and 100 cm were 0.12μsv -1 .mbq -1 , 0.09μsv -1 .mbq -1 ,0.03μsv -1 .mbq -1 and 0.01μsv -1 .mbq -1 respectively. significant exposure from patients after injection of 99m tc-mibi was limited on the few hours after administration. maximum and average absorbed dose of nuclear medicine staff from 201 tl were 4.6 and 2.7 μsv.h -1 , and for 99m tc-mibi were 18.1 and 9.8μsv.h -1 in each scan. conclusion: significant exposure from 99m tc-mibi for cardiac investigations has limited to a few hours after administration. in case of administration 201 tl the dose rates from the patients continues to decrease until three days after injection. these data could be considered as a base for calculative exposure dose in close contact during working hours of nuclear medicine staff. . one of the most effective treatments for thyroid carcinoma is the use of iodine-131. in recent months a number of patients with end stage renal failure have been referred to our hospital for thyroid ablation therapy. this has presented a number of challenges from a radiation protection perspective, for both the patient and the staff involved. in establishing this procedure we aim to provide an effective combination of treatments for these patients. in addition the radiation dose to all staff involved in this therapy must be considered. to date two patients in end stage renal failure, both requiring regular haemodialysis sessions, have been treated at our hospital. a multidisciplinary team was involved in establishing this procedure and helped to identify the risks involved. a dialysis facility was provided in one of our dedicated treatment rooms to enable the best possible arrangement for radiation protection purposes. all staff involved were given radiation safety training before the therapy was conducted. a member of the radiation safety team was also on hand for the duration of each dialysis session. each patient received 3000 mbq of i-131 in capsule form with dialysis sessions conducted immediately prior to the therapy and 48 and 96 hours after administration of the capsule. each patient was successfully dialysed on all three occasions, with no unexpected complications being noted. dose rate measurements were performed on a daily basis, which is a routine occurrence for all our patients. dose rates were also measured immediately prior to and after the completion of each dialysis session. all staff involved were provided with radiation monitoring in the form of whole body tld monitors, extremity monitors and electronic personal dose meters. our dose rate measurements show slower clearance rates, by approximately 30%, in these two patients when compared to 'standard' cases. however, this is to be expected as the main excretion route for i-131 is via the kidney. by implementing appropriate radiation safety training and methods staff doses were also able to be kept to a minimum. maintaining the regular dialysis schedule for both these patients also allowed us to deliver an effective therapy without compromising the patient's welfare. skin cancer is the most common cancer in humans. many different treatments are currently used in the management of this kind of tumours, and include surgical techniques, topical therapy and radiotherapy. the healing percentage usually range from 75 to 85% by using the best therapeutic treatments. in the present paper a new therapeutic option for the treatment of squamous cell carcinoma (scc) and of basal cell carcinoma (bcc) proposed. it consists in a superficial radiotherapy with beta emitters isotopes, characterized by the use of a synthetic resin incorporating radioactive 188 re, that is able to perform a selective irradiation treatment of the cancer lesion.53 patients with histologically confirmed diagnosis of bcc and of scc were enrolled for the treatment, by choosing the cases in which a relapse of the tumour was present, or in which a surgical operation would have been impossible or aesthetically unacceptable. all treatments were performed in the nuclear medicine dept. of s.eugenio hospital, rome. in all treated cases, an apparent clinical remission occurred in approximately 3 months; a complete healing was obtained in 100% of the treated cases, in 82 % of the cases after a single application. neither unaesthetic scars, nor side effects, were observed. after a follow up of 12-60 months, no signs of clinical relapses were present in any of the treated patients; when a histological examination was performed, a complete tumour regression was observed. treatment of verruca plantaris with microwave and 32 p application therapy y. ma, y. liu, p. lu, g. huang; renji hospital, shanghai jiaotong university, shanghai, china. aim: to study the clinical curative effect of verruca plantaris with microwave and 32 p application and its application value. material and methods: 161 patients with extremity verruca plantaris were chosen by random from outpatient, out of them, the 67 patients is male and 94 is female, their average age is 36.3±17.2s ( ±sd) years old, randomly divided them into two groups: (1) microwave treatment group have 65,the wart bodies were eliminated by microwave under local anaesthetize. (2) 96 individuals were treated with 32 p application therapy ,the liquid of radionuclide 32 p were dropped in gauze, drying them and then fixing them in corresponding focus surface for application therapy, randomly divided 96 patients into three groups with 8 hours,24 hours,48 hours application each time, a group has 32 patients average. about 5-6 times. and once a week until the lesion recovered. the clinical reaction and curative effect were observed. results: the clinical cure rate, recurrence rate, side effective occurrence rate and complication occurrence rate are 36.9%,53.8%,80.0% and 44.6% respectively in microwave treatment group and they are 96.9%,3.1%,37.5% and 15.6% respectively in the group of 32p application therapy. conclusions: the characteristics of treatment of verruca plantaris, with 32p application therapy are simple method , convenient, safety , little pain, notable curative effect, it is a kind of successful effective treatment method. using ligandtracer® to quantify protein-cell interactions in real-time l. vennstrom 1 , h. bjorke 2 , k. andersson 2 ; 1 ridgeview instruments ab, uppsala, sweden, 2 uppsala university, uppsala, sweden. aim: validate a novel biosensor (ligandtracer®) designed to detect how radiolabelled proteins bind to cell surface receptors in real-time and explore new possibilities with the biosensor. material and methods: different cell lines (e.g. a431 and skov-3) and radiolabelled proteins (e.g. egf and trastuzumab) known to bind to the receptors egfr or her2 were used in this study. cells and reagents were placed in ligandtracer grey and binding traces of the protein-cell interactions were recorded in real-time without user intervention. the results were compared to data obtained from classical protocols. results: the results obtained with ligandtracer grey agreed with classical protocols and was highly repeatable. the time resolution in ligandtracer data was superior to the classical protocols used. furthermore, the novel biosensor required less disposables and manual workload. conclusion: the automated, real-time binding traces obtained with ligandtracer relieve researchers from manual workload and provides data with higher time-resolution. apart from replacing manual protocols in protein-cell interaction measurements, this novel method opens up many new possibilities in the field of cell-based assays. p61 -monday, oct. 15, 2007, 2:30 pm -4 despite of progress in pediatric oncology, metastatic neuroblastoma in children over 1year of age still remains great challenge. nearly 90% of children in this group present bone marrow involevement. in staging of neuroblastoma , the assessment of tumoral infiltration of bone marrow is an important indicator of prognosis. for detection of bone marrow metastasis traditional staging includes bone marrow aspiration biopsy. another method, scintigraphy with radiolabeled metaiodobenzylguanidine (mibg), specifically taken up for cells of sympathetic origin, is now considered as the first line method for the staging and follow-up of neuroblastoma. the aim of this study was to assess the respective values of these two methods: mibg scintygraphy and bone marrow aspiration biopsy in determination of the extent of neuroblastoma. materials and methods: 131i-mibg scans and bone marrow aspiration biopsy were performed at a time of diagnosis and were repeated at interval of mean 6 months (from 3 months to 8 months) during at least two years. retrospectively there were evaluated 72 131i-mibg scans of 19 children ( 15 stage iv, 3 stage iii and 1 stage ii) and were compared with the results of bone marrow aspiration biopsy. mibg scan was divided into three groups:1-no tracer uptake in the skeleton, 2-diffuse uptake in the skeleton with or without focal lesion, 3 -focal lesion in one or more bones. results: there was no tracer uptake in 39 mibg scans, all of them had negative bone marrow aspiration biopsy. focally increased uptake was seen in 19 mibg scans but only in 5 of those 19 scans bone marrow biopsy was positive. diffuse uptake in the skeleton with or without focal lesion was detected in 14 mibg scans and bone marrow aspiration biopsy was positive in 10. conclusion: mibg scintigraphy has very high sensitivity and specificity for detection of bone marrow metastasis. to assess bone marrow involvement mibg scintigraphy is more sensitive than bone marrow aspiration biopsy. mibg scan seems to be very good method for staging of neuroblastoma even when bone marrow aspiration biopsy is negative. the study aimed to determine if the fetal anteroposterior renal pelvic diameter (rpd) is predictive of obstruction as determined by scintigraphy. methods: neonatal lasix augmented(f+20) mag 3 studies conducted over 21 months for the clinical indication of sonographically detected antenatal hydronephrosis (rpd> 4mm in mid trimester, mt, and > 7mm in the third trimester, tt) were retrospectively analysed. the sonographic mt, tt and postnatal (pn) rpd were noted. pnrpd> 5mm on the postnatal ultrasound was defined as postnatal hydronephrosis. this was based on scott and renwick's findings of 95% of the postnatal population falling in the 0-5mm range (br j urol 62:295-300). two blinded nuclear physicians classified the scintigraphic studies as 'obstruction' or 'no obstruction' based on the half time drainage (t1/2) and frusemide washout curves. results: a total of 40 patients (56 hydronephrotic kidneys) were identified with measurements at mt in n=31, at tt in n=50 and at pn in n=46. antenatal hydronephrosis detected in 3/50 tt kidneys had resolved on the postnatal ultrasound. a series of one-way anova's were performed separately for the right and left kidneys to compare the means of the trimester measurements for those that were obstructed on scintigraphy. though the probability of obstruction was greater at higher rpd, in all groups, there was no statistically significant difference for the mt and tt mean rpd measurements in the obstructed versus non-obstructed group (p>.05). the mean pnrpd was found the most reliable predictor of obstruction on scintigraphy (p=.020 rt and p=.007 lt). the ppv for prediction of obstruction with rpd>10mm is 54% and the npv for prediction of nonobstruction at rpd <10mm is 91%. the findings were also correlated with results of the micturarting cystourethrogram(mcu) when it was available. mcu was available in 27/40 patients and 40/56 kidneys. vesico-ureteric reflux(vur) was identified in 5/27 (18.5%) patients and 6/40(15%) kidneys. there was no statistically significant relationship between the rpd and presence of vur. conclusion: antenatal hydronephrosis is more prevalent in the male fetus. the pn-rpd has a higher predictive value for diagnosis of obstruction compared to the mt and tt measurements, with higher likelihood of obstruction at higher diameters. the negative predictive value is 91% to s364 exclude obstruction if pn-rpd<10mm.this group of patients can hence be observed with follow-up sonography rather than subjecting them to have renogram studies. objective: clinical presentation of myocarditis (myo) varies from asymptomatic cases to acute heart failure. endomyocardial biopsy (emb) is an invasive method, therefore another procedure would be advisable, especially in children. the aim of study was to investigate of the scintigraphy with 99m tc-anty-granulocyte antibody ( 99 m tcaga) usefulness in pediatric cases with suspected myo. methods: between 2005 between to 2006 aged 6,6 -17,6 yrs) with the symptoms of myo were evaluated at initial presentation and 6 month later. all pts underwent heart scintigraphy with 99m tcaga; 10-20mci the tracer activity was administered iv and acquisition in ap projection was performed 4 and 24 hours later. the estimation of 99 m tcaga uptake was evaluated by calculation of the heart-to-lung ratio (hlr), value of 1,50 or more was considered as a positive result. 99 m tcaga scintigraphy was performed in control group of 10 children with suspected enterocolitis (hlr 1, 50) . emb was performed with immunohistchemical method in 7 pts (no consent in one case). the results of heart scintigraphy were compared with emb. results: the mean time from onset of symptoms of myo which included fatigue, heart failure (n=4), ventricular arrhythmias (n=4), chest pain (n=3) to diagnosis of myo was 2,52 ± 3 mo. positive 99 m tcaga uptake was observed in 7 pts (mean hlr 2,04 ± 0,54), in 3 cases intense (hlr>2), in 4 moderate (hlr<2) and in 1 pt borderline (hlr 1, 50) . higher hlr (mean 2,12 ± 0,66) was found in the pts who presented within 2 mo of the onset of symptoms than in those who presented in later phase (mean hlr 1,74 ± 0,07). emb results showed evidence of myo in 6 pts, no evidence in one case. all 3 pts with hlr>2 showed evidence of active myocarditis in emb. follow up 99 m tcaga scintigraphy was performed in 6 pts (mean hrl 2,01 ± 0,53); follow up emb in 5 pts showed evidence of persistent inflammatory process in myocardium. conclusion: 1. 83,3% of the pts with positive heart scintigraphy showed evidence of myocarditis in emb. 2. intense myocardial uptake of antigranulocyte antibodies with hlr>2 strongly indicates active myocarditis. 3. although further studies are necessary to establish its sensitivity and specificity, scintigraphy with 99 m tcaga seems to be an advisable diagnostic method in pediatric cases with myocarditis. dynamic renal scintigraphy in patients with hydronephrosis e. urbanova 1 , i. novak 2 , j. vizda 1 ; 1 university hospital, nuclear medicine, hradec kralove, czech republic, 2 university hospital, pediatric urology, hradec kralove, czech republic. the aim of this study is to evaluate the kidney function before and after operation for hydronephrosis. stenosis of proximal ureter is the most common anomaly, causing dilatation of the renal pelvis and thus hydronephrosis. in all children in our study ureteropelvic obstruction was suspected and hydronephrosis with dilatation of renal pelvis was detected by ultrasound. for functional relevance of urinary tract obstruction dynamic renal scintigraphy (drs) was used. material and methods: during the past 35 months 36 children in age 1-10 years without clinical sign of infection were included in our study. preoperative data, early and late complications and outcome were recorded. imaging studies included urinary tract sonography and drs, which were compared pre and postoperatively. patients were hydrated before scintigraphy and were advised to empty urinary bladder before investigation. for drs as radiopharmaceutical technetium 99m labeled mag3 was used. frusemide was administered intravenously 15 minutes after the start of examination at dosage of 1.0 mg/kg body weight to achieve forced diuresis. scintigrams were recorded in posterior view. the zoom factor was chosen 1.5-2, matrix 128x128. total time of examination was 30 minutes. the definition of the region of interest (roi) for each kidney was either semiautomatic, using a roi drown around the kidney, or fully automated. it was routine to obtain post-void images for gravity-assisted drainage. quantitative functional parameters were interpreted in conjunction with image review and perfusion, parenchymal and excretory phases were described. an attempt was made to define the approximate limits of reversibility of stasis in affected kidney after operation, so drs was repeated in 24 children from our study 3-7 months after the operation. results: drs in comparison pre and post-operation in the 18 children showed marked improvement of washout (wo). in addition the six children with wo = about 15% also showed 7 months later small improvement at scintigraphy. conclusion: sonography is suited to documenting the anatomical situation and can be repeated without radiation burden, but drs can be used to assess the functional relevance of urinary tract obstruction before and after the operation. the careful attention to the technique of the examination is necessary, because there are still many controversies surrounding the physiology and interpretation of the renogram. early diagnosis and suitable therapy of functionally relevant urinary tract obstruction are very important to avoid chronic renal damage. aim: glomerular filtration rate (gfr) is generally considered the best functional measure among several important functions of kidney. cystatin c is a nonglycosylated basic protein produced at a constant rate by all nucleated cells and eliminated by glomerular filtration. serum cystatin c reflects renal function in children independent of age, gender, height, and body composition. recently, cystatin c has been studied as an alternative marker of gfr and more accuracy than serum creatinine.the aim of this study was to compare measured gfr by two-plasma sample method (tpsm) with serum cystatin c level in paediatric population. materials and methods: the study population comprised 34 consecutive patients (21 boys, 13 girls, mean age 8.2 ± 3.8), included thalassemia (n=18), acute lymphoblastic leukemia (all) (n=10) and fanconi anemia (n=6). blood samples were taken at 120 and 240 min post-injection of 37-74 mbq of tc-99m dtpa from the contralateral arm. slope-intercept method was used for tpsm gfr measurements. serum cystatin c level was also measured on all patients. results: tpsm gfr values varied between 35-150 ml/min/1.73m 2 (mean:91,9 ± 29 ml/min/1.73m 2 ). serum cystatin c levels ranged from 0.26 to 2.04 mg/l with a mean of 1,03 ± 0.40 mg/l. there were found statistically significant negative correlation between tpsm gfr and serum cystatin c level (r = -0.45, p<0.001) . regression analysis showed the curve equation formula as follow:gfr (ml/min/1.73m 2 ) = 129-(36 x serum cystatin c )ninetyfive % confidence interval is: 111.6-(20.2 x cystatin c) to 146.4-(51 x cystatin c); p< 0.001. conclusion: this study showed that there was statistically significant negative correlation between gfr value in tpsm and serum cystatin c level. cystatin c may reflect the quantitative renal function in the paediatric population. further studies are needed to validate this conclusion in paediatric population. there is increasing evidence that botulinum a toxin (boa) might have a powerful role in the management of children with functional voiding problems. the aim of this study was to analyze radionuclide uroflowmetry evidence of effectiveness of boa injection in treatment of dysfunctional voiding in children. patients and methods: study enrolled 9 female children, 5-11 year old, with dysfunctional voiding and recurrent urinary tract infection, in whom pharmacological and biofeedback treatment failed. a dose of 500 units of botulinum-a toxin (dysport) was injected intrasphincterically at 4 sites in all children. urodynamic and radionuclide uroflowmetry was performed in all children before, and 6 months after the treatment. radionuclide uroflowmetry was performed using 99mtc-dtpa or 99mtc-mag3 and the following parameters were analyzed: functional bladder capacity measured as voided volume plus residual urine volume, presented as a percent of predicted bladder capacity (fbc, %), residual urine volume presented as a percent of fbc (ru,%), voided time (vt,s), average flow rate expressed as voided volume divided by voiding time(afr, ml/s), peak flow rate expressed as afr multiplied by peak bladder emptying rate (pfr, ml/) and ejection fraction calculated as ratio of counts between peak bladder emptying rate minus minimal bladder emptying rate, and mean bladder emptying rate (ef,%). all children have been tested before and six month after the treatment using empirically designed international reflux study modified questionnaire, regarding daytime and nighttime symptoms, voiding and bowel habits and quality of life. results: the relative changes-each in comparison with the value before dysport injection therapy were as follows: fbc increased by 104% versus 101% (ns), ru decreased by 14% versus 28% (p<0.05), afr increased by 9ml/s versus 7ml/s (p<0.05), pfr increased by 18ml/s versus 14 ml/s (p<0.01), ef increased by 77% versus 67% (p<0.05) and vt decreased by 24s versus 32s (p<0.01). significant symptom score improvement was detected six months after the treatment, being decreased by 7 versus 20. no major side effects occurred. conclusions: although we surveyed only a few patients, the efficacy after boa injections in difficult-to-treat children with bladder dysfunction seems promising. only slight improvement of bladder function parameters detected by means of radionuclide uroflowmetry with the significant improvement of urinary tract symptoms six month after the treatment could be addressed to improvement in voiding dynamics and significant reduction of postvoid residual urine volume. these results raise hope of keeping high-risk children with bladder dysfunction under conservative control longer. before and after the furosemid provocation was 2,8/min and 4,2/min respectively. in 14 cases the number of waves actually increased, and there was no change in the remaining 4 cases. in 6 cases we compared the change in ureteral function before and after reconstructive surgery. the mean peristaltic wave number before the operation was 4,3/min, and decreased to 3,2/min afterwards. conclusion: according to previous studies, the ureter adapts to increased urine flow by increasing the transported bolus volume. in our study, megaureters adapted to the same challange by increasing the frequency, which is an indication of impaired renal drainage. the decrease in frequency following surgery may be the result of a succesful operation. b. ajdinovic 1 , l. jaukovic 1 , z. jankovic 1 , a. peco-antic 2 ; 1 military medical academy, belgrade, serbia, 2 university pediatric clinic, belgrade, serbia. objective: urinary tract infection (uti) is a common condition in children with vesicoureteral reflux (vur), and may lead to renal damage. the aim of this study was to determine the incidence and the pattern of abnormal dmsa findings in children with hystory of bacteriologically proven uti. materials and methods: standard 99m tc-dmsa renal scintigraphy was performed in 118 children (47 boys and 71 girls, aged from seven months to seven years ), six months after the initial infection. findings were classified according to the image appearance and relative kidney uptake (rku) and related to the grade of vur, sex and child's age. results: micturating cystourethrography (mcu) revealed vur (78 uni and 40 bilateral) of grades i, ii, iii, iv and v in 2, 47, 34, 19 and 16 patients respectively. dmsa images were normal with rku within normal limits in 48 patients and equivocal in 10 pts findings were interpreted as abnormal in 41 cases due to scarring, and in 19 pts with decreased rku. bilateral scarring was shown exclusively in children with bilateral vur. scarring rate was significantly associated with vur of higher degree (p<0.01) and male gender ( p<0.05). no significant difference was found between renal scarring and child's age in same gender group. poor kidney function (rku less than 10%) was shown in 7/118 patients. conclusion: renal damage on dmsa scintigraphy highly correlated with grade of vur. a strategy to perform mcu in only patients with abnormal dmsa finding is proposed. disordered gastric emptying is frequent and clinically important complication of diabetes mellitus (dm). the aim of this study was to determine gastric emptying rate(ger) in children and adolescents with type 1 dm, and to investigate relationship between ger and microalbuminuria in these patients. subjects and methods: ger with solid meals was assessed by a radionuclide method using solid meal in 33 diabetic children and adolescents and 25 age matched healthy controls. the patients were divided into two groups according to duration of diabetes as less than 5 years (group a) and longer than 5 years (group b). the patients ingested scrambled egg bound to 1 mci of tc-99m sulphur colloid bound to a scrambled egg. images were obtained from anterior and posterior projection in a 128x128 matrix with 1.0 zoom factor. the period of data collection began as soon as the subjects finished the meal. the data were acquired for 60 s per frame, for a total of 60 min. a region of interest corresponding to the stomach was outlined to the determine the gastric counts for each image. a power exponential fit was used to analyse the time-activity curve over the stomach and to calculate the half-time of gastric emptying. delay was recognized if ger was longer than 60 minutes. three consecutive timed overnight urine collections were used to calculate microalbuminuria. increased microalbuminuria was defined as a median value is greater than or equal to 7.5 μg/min. data were evaluated using mann whitney u analysis, kruskall wallis analysis and pearson's correlation tests. results: the mean values of ger were 151.72±154.46 minutes for diabetic patients and 115.42±133.85 minutes for control group; and the difference was not statistically significant (p=0.339). ger didn't differ significantly between group a and group b and control group (p>0.05). there was no significant difference of ger among in patients who have higher and lower microalbuminuria level (p>0.05). there was no correlation between ger and duration of diabetes and microalbuminuria (p>0.05). conclusion: we did not detect any significant changes of ger in children and adolescents with type 1 dm. no relationship could be found between microalbuminuria and ger. aim: scintigraphy with tc-99m dmsa is considered a reference method for assessment of renal parenchymal lesions and estimation of differential renal function (drf). however, comparisons with tc-99m mag3 indicated certain disadvantages of dmsa such as relatively higher radiation exposure to kidney and time consumption. tc-99m mag3 with high tubular secretion suggests that it may be useful in infants. the aim of this study was to evaluate the performance of tc-99m mag3 dynamic renal scintigraphy in the detection of renal parenchymal defects and in the estimation of drf comparing to tc-99m dmsa scintigraphy. materials & methods: a retrospective review of the records between april 2002 -january 2007 indicated that a total of 29 infants (20 boys and 9 girls) aged under 1 years, underwent both tc-99m dmsa and tc-99m mag3 scintigraphies within 3 weeks of each other. parenchymal phase of mag3 scintigraphy were compared to dmsa images for right and left kidneys, separately. the renal cortical analysis of mag3 scintigraphy was performed on the summed image obtained from dynamic images. and also, differential function was calculated in mag3 and dmsa studies and then compared. results: findings corresponded completely in 90% of patients. there was no statistically significant difference between calculated drf on dmsa and mag3 images. however, in the left kidney, mean mag3 value (52.21%) tend to be higher than that of dmsa (51.48%). there is a high correlation between the drf (r=0.91 and r=0.90; for the left and right kidney, respectively; p<0.01). accepting dmsa is a gold standard method to assess renal cortical lesions, the sensitivity and specificity of the mag3 cortical scintigraphy were calculated as 92% and 78%, respectively. compared with dmsa, mag3 was as sensitive as dmsa however lower specific than dmsa. the results showed that most of renal parenchymal lesions detected on dmsa scans can be identified on mag3 parenchymal scans. both studies can be equally used for the calculation of drf. tc-99m mag3 may be acquired for evaluating of renal parenchyma especially in infants because it is a feasible, useful, rapid (5 min) functional imaging method and lower radiation dose. because of low specificity of tc-99m mag3 cortical analysis, tc-99m dmsa scintigraphy have to be acquired in the definite diagnosis and management of renal cortical lesion therapy. aim: congenital diaphragmatic hernia (cdh) is often combined with primary hypoplasia of the pulmonary vascular bed, which is one of the most significant prognostic factors in patients with cdh. in this study, the values of lung perfusion and ventilation scintigraphies were investigated to assess the lung regarding pulmonary vascular hypoplasia in the pediatric patients with cdh. material and methods: 8 patients (3 boys, 5 girls) were included in the study. all patients had respiratory distress within the first 6 hours of life due to cdh. six patients had left-sided and 2 patients had right-sided cdh. all cases underwent a surgical repair of cdh in the newborn period (mean age: 3.88 days). the mean 113 ± 13 days after the operation, lung perfusion scintigraphy was carried out with 0.5 mbq/kg of tc-99m maa. the perfusion images were evaluated quantitatively. for quantitative analysis, the regional distribution of each lung was expressed in a percentage of total lung perfusion. next day, lung ventilation scintigraphy was performed with 0.4 mbq/kg of tc-99m dtpa by placing a see-through mask over the child's mouth and nose allowing them to be able to breathe as if via a nubulizer. ventilaton images were evaluated quantitatively in a similar manner as to the perfusion study. results: in one patient, the perfusion rate of the side of cdh was 31% and the ventilation rate of the same lung was 50%. because of the combination of the good ventilation and restricted perfusion, it was thought that primary pulmonary vascular hypoplasia might exist in this patient. in other 7/8 cases, the mean perfusion rate was 27.14 ± 5.53 % and the mean ventilation rate was 26.14± 4.81% in the side of the cdh. in these patients, a statistical difference was not observed between perfusion and ventilation results (p>0.05). having been considered that ventilation disorder with secondary perfusion disorder might develop, the pulmonary vascular hypoplasia could not be eliminated in these cases. conclusion: this study reveals that the combination of lung perfusion and ventilation scintigraphies, which are objective, quantitative, non-invasive, and easily performed methods, may helpful in determining the pulmonary vascular hypoplasia in pediatric patients with cdh. additionally, it can be suggested that these methods may be useful to evaluate the growth and development of lung affected by cdh especially during the first year of life when respratory function studies are difficult to obtain. using the same site for tracer injections and blood sampling makes edta clearances more acceptable to patients and ensures that blood samples will be successfully obtained. but there are predicted problems from tracer contaminating the samples or saline diluting the samples. in practical terms the two important questions are (a) whether same site sampling (sss) produces an increased rate of recognisable poor test results, and (b) whether it produces undetected bias or errors in the results. since february 2005 307 3-sample edta clearance studies have been performed, of which 14 had separate sites for injection and sampling, and the remainder used the same venous access for injection and blood sampling. in addition, 18 studies from another hospital (w) that used different sites were included. a review of the results produced the following:-recognised problems: were noted as follows:-venous access not obtained (5) ward lost samples (1) patient fainted (1) vein "blew" during tracer injection (1) tracer contamination of first sample (1) . unrecognised problems: were looked for by using the following quality assurance factors:-(1) the r 2 value of the log-plot fit to the data points. (2) the ratio v d / weight. (3) the first point position relative to a line drawn only through the second and third points. the different groups studied were group1 n=18 hospital w and group2 n=14 hospital a . both of these first two groups used separate sites for the tracer injection and sampling. groups 3 to 5 used the same site for injection and sampling, as follows:-group3 n=96 sss (antecubital fossa luer) group4 n=47 sss (pic line) group5 n=27 sss (luer in hand vein) group6 n= 13 any method but gfr<20ml/min. results: with one exception, none of the qa factors showed any difference between the groups studied. the exception was group 6 (low gfrs), and this group showed a lower r 2 value than the others. conclusion: the one case of sample contamination was detected by looking at the data and the routine qa values. assessment of the qa values in the remaining data did not suggest any undetected bias in the group results. objective: ureteropelvic junction stenosis and vesicoureteral reflux are the most frequent entities identified by antenatal hydronephrosis. aim: to determine the incidence and pattern of abnormal renal scintigraphy findings in postnatal investigation of children with antenatal hydronephrosis. patients and methods: twenty four infants (19 boys and five girls) who presented with antenatal hydronephrosis and mild to moderate hydronephrosis on ultrasound in newborn period were referred for renal scintigraphy. ten patients with vesicoureteral reflux documented on micturating cystoureterography received dmsa renal scintigraphy and 14 patients received dtpa scintigraphy. results: antero posterior pelvic diameter on ultrasound ranged from 11 to 24 mm. dmsa renal scans identified congenital scars in two boys with bilateral reflux of grade v and unilateral reflux of grade iii. global hypoplasia (relative kidney uptake (rku) less than 40%) was found in three, and poor kidney function (rku less than 10%) in two patients. significant obstruction was shown on dtpa diuretic renal scintigraphy in near the half of patients (6/14). some slowing in drainage (t1/2 greater than 10 minutes) with no reduction in differential renal function was identified in three patients. differential renal function less than 10% was obtained in one case. conclusion: high proportion of abnormal renal scintigraphy findings was obtained (70%). renal scintigraphy was useful in determination of underlying cause of antenatally detected hydronephrosis. pediatric urolithiasis is very important because of its effects on the growing kidney, the significant recurrence rate, the association with urinary tract infections (uti) and the long term outcome. in this study we aimed to determine the renal cortical state by dmsa in children with urolithiasis who had experienced uti during follow up. patients with urinary tract abnormalities were not included to the study. a series of 48 patients (30 boys, 18 girls) with a mean age of 82.2 ± 55.5 months and a mean follow up period of 26.6 ± 25.7 months were studied by dmsa. dmsa scar grading was performed for each subject according to imperiale et al. number of utis, the localization of the stones were noted. uti was treated with proper antimicrobial therapy. stone patients were treated medically according to their stone analysis or urinary metabolic analysis. 71 uti attacks were recognized during follow up. only 4 patients (8%) showed scars on dmsa. scar grading was 1 in two patients and 3 in two patients. of these four patients children with single uti showed score 1 on dmsa and children with 3 or more uti showed score 3 on dmsa. the localization and the side of the stones were the same in all subjects. we conclude that urolithiasis often coexists with uti and the risk of renal injury is not low . dmsa scan evaluation is important during the follow up of these patients. introduction -aim: gfr is the best measure of kidney function and is accurately measured by 51cr-edta, which follows bi-exponential kinetics. as the widely applied multiple sample technique assumes a monoexponential pattern of tracer elimination, gfr is overestimated and corrections for the missing, initial, fast component of tracer clearance have been incorporated in current european guidelines. these are the linear chantler's (ch) and the quadratic brochner-mortensen's (bm) corrections, diverging, however, at different gfr levels. the aim of the present study was to analyse the agreement between gfr measurements after applying the two correction methods at various gfr levels in a mixed adult population. patients and methods: four hundred ninety six pts (244 women), aged 52.4±15.4 yrs were enrolled in the study. pts were referred for gfr measurement for chronic kidney disease or as kidney donor candidates, renal transplant recipients and renal transplant donors. gfr was measured with the slope-intercept, two-sample technique after i.v. administration of 51cr-edta . values were normalized for body surface area calculated according to haycock's formula and were expressed as ml/min/1.73 m 2 . bland-altman analysis was applied for assessment of agreement. results: patients were allocated in low (<30, 139 pts), intermediate (30-90, 295 pts) and high (>90 ml/min/1.73 m 2 , 62 pts) uncorrected gfr groups. mean (sd) uncorrected gfr values were 18.8 (6.7), 56.9 (17.4) and 104.8 (13.3) ml/min/1.73 m 2 for the three groups, respectively. after ch / bm corrections, gfr values were 17.5 (6.2) / 17.8 (6.1), 52.9 (16.2) / 48.6 (12.8) and 97.5 (12.4) / 79.5 (6.7) ml/min/1.73 m 2 for the three groups, respectively. mean gfr differences (ch -bm) were -0.3 (0.2), 4.2 (3.5) and 18.0 (5.7) with 95% confidence limits -0.6 -0.0, -2.6 -11.0 and 6.8 -29.2 ml/min/1.73 m 2 for the three groups, respectively. -3) and gamma camera equipped with a low energy high resolution collimator interfaced with a computer. regions of interest (roi) were drawn over the whole kidneys. radioactivity-time curves were generated from the roi. time to peak activity (t max ), time from peak to 50% activity (t ½ ) and the uptake slope of each kidney were calculated from the renograms. the same protocol was repeated for the same animal 3 times at 3 days intervals at 2, 3 and 4°c higher temperature. blood pressure was measured using a catheter inserted into the femoral artery connected to a recorder and renal blood flow was also measured through renal artery using an electromagnetic blood flow sensor connected to a flowmeter. creatinine and urea in blood were measured in control and hyperthermic rabbits. results: during hyperthermia the experimental curves shifted to the right of the control curves indicating that there was a delayed renal uptake of 99mtc-mag-3 and clearance of radioactivity. this delay was proportional to body temperature. from body weight and height. linear regression analysis was applied to assess association between variables. results: all patients were overweight or obese, with bmi 29.7 ± 4.3 (range 25. 1 -44.6 ) kg/m 2 . gfr was 120.3 ± 20.2 ml/min. gfr was moderately correlated to bsa (0.66, p<0.0001), lbm (r=0.58, p<0.0001) and tbw (r=0.67, p<0.001) . prediction equations were: gfr = -28.2 + 76.3 x bsa, gfr = 60.2 + 1.04 x lbm and gfr = 35.0 + 1.00 x tbw. no statistically significant difference was detected between the slope coefficients (1.04 vs 1.00) conclusion: despite the common beliefe, tbw is equally good to bsa or lbm as a gfr predictor in overweight or obese patients with normal renal function, thus questioning the importance of bsa normalization. as we see at these results, no significant difference was found between group i and group ii, regarding the number of patients with skeletal metastases. conclusion: low levels (< 10 ng/ml) of serum prostaticspecific antigen can not eliminate the possibility of existance of skeletal metastases, as was expected. even more, as the difference of the pathological bone scans between group i and group ii was not significant, values of psa 4 ng/ml cannot be considered as a safe threshold for the exclusion of the indication of bone scan. background: the rutland-patlak plot is used in renography for determining relative kidney function and for separating blood background in the measured renogram. in the uptake phase the plot is a straight line, but the duration of this phase may differ from patient to patient. a good method for drawing the line in the patlak-rutland plot should be accurate and precise, while taking into account that data may show unusual behaviour or be noisy. aim: this work compares three methods for drawing the line with the aim of finding a method that gives reliable results on all groups of data. materials and methods: data were collected from 63 consecutive 99m tc-dtpa renographies routinely made in the department (126 kidneys). independent of this collection, 10 renographies were selected where at least one of the kidneys has a renogram with irregular behaviour early in the renogram, such as decrease in the renogram about 1 minute p.i., or unusually noisy data (16 kidneys with "problematic" renograms). from each renogram points for the rutland-patlak plot was calculated and three methods were used independently to draw the line: 1.) manual drawing on hardcopies by three independent observers. slope and intercept were determined afterwards. 2.) linear regression on the first 8 points measured after 1 minute p.i. (from 1 to about 2 minutes p.i.). 3.) points for linear regression were selected by an algorithm developed for the purpose, based on possible exclusion of early points and possible inclusion of points later than 2 minutes p.i., to reduce weighted residual variance. results: in the group of consecutive patients (126 kidneys) friedmann test showed significant differences among methods (p < 0.002). pairwise comparison showed no significant difference between method 1 and 3, whereas method 2 yielded slightly lower values of slope and slightly higher values of intercept than the other two methods. estimates on uncertainty gave similar results: no significant difference between method 1 and 3, significantly higher uncertainty estimates in method 2 than the other two methods. for the group of selected "problematic" renograms (16 kidneys) method 1 was used as reference method. method 2 failed in a number of cases compared to the reference method, whereas method 3 showed good results. see table. conclusion: method 3 gives results that are accurate and precise on normal and "problematic" renograms. the method is operator-independent. method 2 fails in a number of cases. results: among patients that underwent each of the three studies, no statistically differences were observed regarding age, sex, disease duration and type of lesion. 28/46 renograms (61%) were interpreted as abnormal (26 ou, 2 on). 12/21 dmsa renal scintigraphies (57%) were abnormal and 26/89 gfr measurements (29%) were also abnormal. conclusions: in patients with spinal cord lesion and neuropathic bladder, "functional" obstructions and parenchymal scars seem to be the most common nephrourological complications, while nephropathy detected by renogram and/or gfr measurement is found in a smaller number of patients. it is suggested that diuretic renogram and dmsa renal scintigraphy should be performed as part of the diagnostic and therapeutic management of all these patients. patients who were booked for dtpa renograms and edta clearances on the same day had those injections given at the same time, and the plasma samples were counted on a collimated gamma camera at the end of the day. an excel program was used to calculate the 99m tc-dtpa results (using times that had been recorded to correct for tc-decay during the day). after 48 hours to allow the technetium to decay, the 51 cr-edta was counted in a sample counter, and the results compared. it is sometimes difficult to differentiate peripelvical cysts / ppc / and hydronephrosis / hn /, based only on the symptoms of the patients / pts / and the data from the ultrasonography. the aim of the study was, using dynamic renal scintigraphy, to differentiate these two entities.we have investigated 35 pts, using 74-111 mbq 99mtc-ec. in all of them, the ultrasonographic data showed hypoechogenic area in the region of the kidneys' pelvis and it was difficult to differentiate ppc from hn. after performing renography, in 7 of the pts, there was an "accumulation" type of the curve, in 6-a "retention" type, in 14 -the curve was with a delayed excretion and in 8normal. in all of the pts with an "accumulation" or "retention" type of the curves, additionally a diuretic renography was performed / using 0.5mg/kg furosemid , injected on 20 min. p.i. of 99mtc-ec /, to differentiate obstructive from nonobstructive hydronephrosis. in the latter pts there was a quick outflow of the radioactivity from the pelvicaliceal system after the injection of the diuretic / t ½ 10 min./. using additional imaging methods and follow up of the pts, 22 of them with a normal or delayed excretion, finally were diagnosed as having only ppc, and from those with an "accumulation" or "retention' type -8 were with a non-obstructive hydronephrosis and 5-with an obstructive hydronephrosis, due to different reasons. only 1 patient with ppc had non-obstructive hydronephrosis. divided renal function of the kidneys with hn was lower -42.7% than that of the kidneys with ppc-50.1% / p<0.05 /. we consider, that using dynamic renal scintigraphy without or with diuretic, further elucidating of the diagnosis could be made and the appropriate therapy of the patient could be planed. conclusion: the renography is a reliable tool for differentiation of the ppc from hn. using additionally diuretic renography, not only differentiation of the obstructive and non-obstructive hydronephrosis could be made, but according to the obtained results, the following therapy could be chosen. excretory function. aim of the study was investigation whether clearance parametric images of kidneys widen the diagnostic capacity of traditional procedures. materials and methods: 70 individuals were studied in whom diabetes type i (insulin dependent) was diagnosed. a second group of 35 healthy volunteers served as controls. 210 individual kidneys were studied and their images and renoscintigraphic curves evaluated. in all individuals a dynamic kidney study was performed after administration of the 99m tc-ethylenodicysteine (ec) and erpf determined. after processing of aquired data conventional images were created by summation of scintigrams received in the phase of secretion of rf. from the same images the clearance images were created. both types of obtained images served for the evaluation of defects of kidney parenchyma. for both types of images a 3 level score scale was used to provide semiquantitative measure of observed pathology. renographic curves were evaluated by analyzing their shape, taking into account relative contribution of each kidney to total uptake (or erpf). elimination of urine from the pelvic and ureteral space was evaluated on basis of phase iii of the renogram. mean renal transit time (mtt) and mean parenchymal transit time (ptt) of the tracer were also calculated. results: analysis of clearance parametric images revealed that regional defects in function of renal parenchyma were more frequent in kidneys of patients with diabetes than in the controls (35,7% vs 8,6%). in conventional summation images there were no significant differences in defect frequency noted between the groups (2,9% vs.4,3%) . there were no differences between ptt and erpf between the groups (p=0,2 and 0,4 resp). relative uptake of ec in both groups did not differ and was within the normal range of values. there were a larger mean value of mtt and more frequent flattening of the curve in phase iii in patients with diabetes than in control group (p=0,02 and p=0,001, resp.) , what could be due to the functional uropathy, seen in diabetic patients. conclusions: 1. clearance parametric images reveal additional information on regional function of kidneys even if other values characterizing global function of kidneys are still within the normal range. 2. parametric clearance images should be included as a component of dynamic kidney studies. s. inanir, g. ege aktas, t. erdil, h. turoglu; marmara university, istanbul, turkey. aim: tc-99m dmsa renal cortical scan is a reference method in determining relative renal function (rrf). tc-99m mag-3 is also recommended for the estimation of rrf, particularly in young children. the aim of this study was to compare mag-3 and dmsa rrf estimations, and, to assess reproducibility of these estimations in children with unilateral hydronephrosis. methods: we reviewed mag-3 and dmsa scans in 19 children with unilateral hydronephrosis and a normal contralateral unit. all were imaged with 2 agents within 3 months. mag-3 rrf was calculated using 2 different time intervals (1-2 minutes and 2-3 minutes) and perirenal c-type region of background activity. no background correction method was used in the calculation of dmsa rrf. all data were processed twice by two independent operators. results: in the repeated estimates of mag-3 rrf, the maximum mean differences were 0.9% (sd:1.7%) within observer and 1.4% (sd:3.3%) between the observers. intra-method analysis showed statistically significant agreement between repeated measures of rrf for 2 agents as well as for 2 operators (intraclass correlation coefficients of early and later phase of mag-3 and dmsa rrf values were 0.979, 0.993, 0.996 for operator 1 and 0.986, 0973, 0.995 for operator 2, respectively, p<0.001). there were significant correlations between the mag-3 and dmsa rrf estimations (r=0.763/0.766 at 1-2 min, 0.835/0.825 at 2-3 min for the repeated measures of rrf for operator i, and 0.812/ 0.793, 0.83/0.88 for operator 2, respectively, p<0.01, pearson). when each scan was classified as normal or abnormal according to rrf values, inter-method analysis showed statistically significant agreement between mag-3 and dmsa rrf estimations (kappa statistic). however, a disagreement was revealed between the methods when borderline and supranormal estimates of rrf were taken into consideration. conclusion: in children with unilateral hydronephrosis, our results indicated a close correlation between dmsa and mag-3 rrf estimations with a good reproducibility. renal perfusion scintigraphy using technitium-99m is commonly performed after renal transplant to assess vascular flow to the transplanted kidney. this allows cases of vascular compromise to be detected early to minimize damage to the transplanted kidney. this retrospective study evaluates the outcomes of a series of renal perfusion scans performed in a tertiary care hospital in the post-operative management of renal transplantation. in addition, we define a renal transplant perfusion index (rtpi) as the ratio of the cumulative counts in the renal transplant to the cumulative counts in the aorta from start of the renal perfusion scan to time of peak aortic curve, and attempted to correlate the values in each patient with the eventual outcome. over a 6 month period, all recipients of a kidney transplant and who subsequently underwent renal perfusion scan within the same admission were recruited into the study. the medical notes were analyzed for scan results and patient outcome. a scan was deemed normal if no evidence of major vascular compromise was detected, abnormal if there is a perfusion defect seen and/or there is delay in perfusion to the transplanted kidney. a patient's outcome was deemed uneventful if there were no transplant-related complications prior to discharge (i.e. vascular compromise, biopsy-proven transplant rejection or acute tubular necrosis), and eventful if complications arose. a total of 43 patients were included. 30 scans were normal, of which 1 patient had an eventful outcome (transplant rejection). another 13 scans were abnormal, of which 9 patients had eventful outcomes (2 with vascular obstruction, 7 with transplant rejection or acute tubular necrosis). the sensitivity of this study in detecting a transplant-related complication was 90%, and the specificity was 90.6% (thus giving the likelihood ratio for a positive test as 9.6). the positive predictive value was 69.2% and the negative predictive value was 96.7%. the mean rtpi in patients with uneventful outcomes was 3.5 ± 1.56, compared to 8.91 ± 6.09 in patients with eventful outcomes. a tc-99m renal perfusion study has become a mainstay of management after renal transplant. this study quantifies its utility in predicting outcome after renal transplantation when done in the post-operative period. it also suggests that an elevated rtpi is associated with patients who develop acute post-transplant complications. the ectopic kidneys belong to the inherited abnormalities of the kidneys. the aim of the present study was to evaluate the function of the ectopic kidney with renal dynamic scintigraphy with 99mtc -dtpa. materials and methods: a retrospective study of the renal dynamic scintigraphies done between 2003 to 2006 year was done. out of 1864 renal scintigraphic examinations 15 patients with an ectopic kidney were found-8 men and 7 women with age from 15 to 70 years. in all of them diagnosis an ectopic kidney was put for the first time due to the scintigraphic examination. the scintigraphy was done on a gamma -camera siemens according to a predefined protocol with quantitative measurements in two phases: perfusion and secretionexcretion. 222 mbq/70kg /99mtc -dtpa was injected as bolus at the very beginning a quality assessment and quantitative determinations of t max, t ½, relative function of each kidney and glomerular filtration rate /gfr/ were done. results: in all 15 patients the ectopic kidney was found in the pelvis above the urinary bladder. in 3 patients the right kidney was ectopic and in the rest 12 the left one has an ectopic position. in 8 patients the ectopic kidney was hypoplastic. preserved kidney function with spastic drainage were found in 2 patients. reduced secretion, excretion and drainage were found in 10 patients. afunction of the ectopic kidney was seen in 3 patients. conclusion: we consider that renal dynamic scintigraphy with 99mtc -dtpa can be helpful either for diagnosis or for evaluation of the function of the ectopic kidneys aim: to evaluate if renal pelvic dilatation is associated with dysregulation of the rennin-angiotensin system (ras) in foetuses in the second trimester of pregnancy that could represent an early predictor of arterial hypertension development after birth. the study consisted of 26 non-diabetic heterozygousthalassemia pregnant women aged between 25 and 30 years, on their second trimester of pregnancy (21 st to 23 rd week of gestation). the foetuses had normal development and no obvious congenital abnormalities on ultrasound. maternal and foetal blood was collected and total rennin and active rennin were measured by an immuno-radiological (irma) method; inactive rennin (prorennin) concentration was calculated by subtraction of the active rennin from the total rennin concentration. foetal renal pelvis was evaluated by ultrasound. the mann-whitney u test was used to compare active rennin, prorennin, and the prorennin-to-active rennin ratio between maternal and foetal blood. the same comparison was performed between foetuses with and without pelvic dilatation, as well as between their mothers. continuous data are expressed as mean ± sd; significance was set at p<0.05. results: a significant difference as regards prorennin, active rennin, and their ratio was observed between pregnant women and their foetuses (p<0.01). furthermore, a significant difference was found in the prorennin-to-active rennin ratios between foetuses bearing renal pelvic dilatation and those without (p=0.004), while no significant ratio difference was found between their mothers (p=0.6). conclusion: dilatation of renal pelvis in the 2 nd trimester of pregnancy seems to upregulate the ras system, with all the possible consequences of renal dysfunction and arterial hypertension after delivery; thus ultrasonographic evaluation of the foetal renal pelvis and measurements of foetal rennin should be considered. foetuses prorennin (μu/ml) 571.7 ± 255.9 1620.9 ± 253.8 active renin (μu/ml) 64.9 ± 50.4 228. correlation with urodynamics and classification by american spinal injury association (asia) impairment scale refluxes (vur) and recurrent urinary tract infection. these situations can lead to scar formation in the renal parenchyma and renal failure that have serious impact on the quality of life and long term survival in this group of patients. the aim of this study was the detection by diuretic renogram of urological and/or nephrological complications in the special group of patients with spinal cord injury and neuropathic bladder. materials and methods: forty-six diuretic renograms were performed in patients with normal renal function (males/females= 34/12, mean age 36,7±12,6 years, mean disease duration 6,75±5,8 years) that were referred by the neuropathic bladder unit of the national rehabilitation center. all patients were classified according to asia impairment scale and underwent urodynamics. the different types of neuropathic bladder were defined according to international continence society (ics) terminology. one week after the urodynamics, the diuretic renogram was performed (i.v. injections of 120 mbq tc-99m mag-3 and 20 mgr furosemide at zero timeprotocol f0). our studies were classified as normal (n), ou and obstructive nephropathy (on). results: according to the asia impairment scale, patients were distributed as: a=30 patients, b=3 patients, c=4 patients, d=8 patients and e=1 patient and according to ics, detrusor and sphincteric mechanism overactivity was revealed in 40 patients, detrusor overactivity and sphincteric mechanism underactivity in 1 patient and detrusor and sphincteric mechanism underactivity in 5 patients. twenty-eight/46 renograms (61%) were interpreted as abnormal (26 ou, 2 on). on was detected in 2 males with disease duration of 31 and 17 years. no correlation was found between renogram results and asia impairment scale and type of neuropathic bladder dysfunction. conclusions: diuretic renogram revealed a great number of "functional" obstructions in patients with spinal cord injury and neuropathic bladder. the obstruction is independent of the type of neuropathic bladder. nephropathy is the future threat. the aim of this study was to established the alleles distributions of vdr fok i polymorphism and how one influence on intact parathyroid hormone /pth/ level and some biochemical markers of bone turnover -serum osteocalcin /oc/ and bone alkaline phosphatase /bap/ in predialysis patients with chronic renal failure /crf/. material and methods. forty patients -22 men and 18 women with crf were investigated. vdr polymorphism was detected about polymerase chain reaction. the serum oc was analyzed using an original kit elsa-osteo and an automatic minigamma counter /abbott, usa/. the bap was measured with special kit "alkphase-b" of metra biosystems. the level of pth was determined with an immunoenzymetric assay. the serum and urine creatinine, total calcium, phosphorus, total alkaline phosphatase were measured according to standard methods, recommended by ifcc. the results. the distribution of allelic variation of vdr fok i in predialysis patients were follow: 7/22.6%/ with "ff" alleles, 22/71.0%/ with "ff" and 2/6.4%/ with "ff" alleles. the level of creatinine clearance were similar in three groups. no significant difference in serum calcium, phosphorus, alkaline phosphatase existed among groups. the intact pth was highest in patients with "ff" alleles -204.71 ± 60.92 pg/ml versus 89.40 ± 19.57 pg/ml in patient with "ff" alleles and 105.10 ± 19.34 pg/ml in "ff" group /p < 0.05/. the bap in patients with "ff" alleles was higher then bap in patient with "ff" -36.38 ± 8.47 u/l versus 22.20 ± 1.71 u/l but the difference was not significantly. significantly higher serum oc levels were registered in predialysis patients compared to the healthy controls -120.48 ± 15.96 ng/ml versus 14.61 ± 1.02 ng/ml / p < 0.001/. the serum oc was highest in predialysis patients with "ff" alleles -145.72 ± 16.35 ng/ml but the difference was not significantly compare to patients with "ff' and "ff" alleles. conclusions: 1/ we detected the follow distribution of fok i allelic variation in our patients: 7/22.6%/ with "ff" alleles, 22/71.0%/ with "ff" and 2/6.4%/ with "ff". 2/ the intact pth was highest in patients with "ff" alleles and this is not due to difference of serum calcium and phosphorus. 3/ the serum oc and bap in patients with "ff" alleles were highest but compare to patients with "ff' and "ff" alleles the difference was not significantly continuous ambulatory peritoneal dialysis (capd) is an effective mode of management for end-stage renal disease. dialysate leakage represents a major noninfectious complication of this procedure. this technique may caused increased intraabdominal pressure resulting in hydrothorax and hernia with reported incidence of 2% to 6% and 9% to 24%, respectively. a 49-year-old male who was undergoing continuous ambulatory peritoneal dialysis (capd) for diabetes mellitus nephropathy had scrotal swelling on the first day of initiation of the procedure. peritoneoscrotal scintigraphy was requested in which tc-99m sulfur colloid (111 mbq; 3 mci) was mixed into a 2-liter dialysate bag under aseptic technique and instilled into the peritoneal cavity thru an indwelling catheter. sequential scintigraphy revealed gradual advancement of radiotracer via the right inguinal canal and reaching the right scrotum by 26 hour post-instillation. patient underwent right herniorapphy. one month postsurgery, peritoneal dialysis was resumed and scrotal swelling did not recur. p63 -monday, oct. 15, 2007, 2: introduction: dysphagia is a common and disabling symptom, often associated with tracheo-aspiration phenomenon, characterising different neurological and neuromuscular disorders. amyotrophic lateral sclerosis (als) is the most common degenerative motor neuron disease in adults and dysphagia is the most frequent symptom. aim: to evaluate the role of oro-pharyngo-oesophageal scintigraphy (opes) in the diagnostic approach to patients with als. materials and methods: 57 patients divided into two groups underwent opes: group a (control group) included 17 healthy volunteers (female/male 7/10; mean age 53±25 yrs); group b 40 patients (female/male 22/18; mean age 66±17 yrs) with als. opes is based on the rapid sequential acquisition of 480 images (8 frames/sec. for a total 60" examination); 10 ml of water containing 37 mbq of 99m tc-sulfur-colloid are administered by a straw to patients standing in an 80° right anterior oblique position in front of a gamma-camera with a large field-high-resolution-low energy collimator. the evaluation of sequential scintigraphic images and a/t curves allows a qualitative (bolus fragmentation with multiple swallowing, naso-pharyngeal or pharyngo-oral refluxes, premature ingestion of the bolus, laryngo-tracheal aspiration) and a quantitative analysis of swallowing disorders [oral, pharyngeal and oesophageal transit times (ott, ptt, ett) as well as retention indexes (ori, pri, eri), and tracheal aspiration percentage ( conclusions: opes appears to be a sensitive test in characterising different swallowing disorders that affect patients with als: propulsion defect (documented by increased oral and pharyngeal transit times, and retention indexes) and incoordinate swallowing (with tracheo-aspiration). opes is a simple, non-invasive and welltolerated test which can provide qualitative and quantitative information of the swallowing phases, useful for rehabilitative and therapeutic purposes. juice as sialogogue j. hsieh; chi mei medical center, yungkang city, taiwan. purpose: to assess the feasibility of using the locally popular and widely available dried sour plum as a substitute for the frequently used lemon juice in stimulated salivary gland scintigraphy (ssgs) and to evaluate the utility of parotid gland stimulated salivary excretion fraction (ssef) as a semi-quantitative functional parameter in pre-radiotherapy and post-radiotherapy head and neck cancer (hnc) patients. methods eighty patients with hnc underwent ssgs and ssef of parotid glands were determined. patients were classified into two groups: twenty in preradiotherapy group (pr) and 60 in post-radiotherapy group (po). each half of the group pr and group po were further subdivided into two groups using different gustatory stimulus: lemon group (l) and dried sour plum group (d). in group pr, those with subjective or objective xerostomia were excluded. in group po, patients underwent ssgs at least three months post-radiotherapy and includes only those who had completed the course of curative radiotherapy and had not received adjuvant or neo-adjuvant treatment. results the ssef of parotid glands greater than 50% was able to distinguish normal from abnormal salivary function in hnc patients. there is no difference between two different kinds of sialogogues l and d in both group pr and group po using 50% as a cut-off reference for a normal ssef. conclusions the use of dried sour plum as substitute for lemon juice is feasible in ssgs and the finding of using 50% as a cut-off reference for a normal ssef was able to distinguish normal from abnormal salivary function in hnc patients. the relationship between helicobacter pylori infection and obesity enteroclysis and xray angiography were negative too. results: twenty-three patients had positive scintigraphy with in vivo tagged rbcs and 12 patients had negative scintigraphy. gi bleeding stopped spontaneously in these 12 patients with negative scintigraphy and these patients did not undergo push-enteroscopy, intra-operative enteroscopy or surgery. final diagnosis of our 23 patients with positive scintigraphy was determined in 17 patients (push-enteroscopy -6 patients, intra-operative enteroscopy -7 patients or by surgery -4 patients). these 17 patients had following final diagnoses: bleeding small bowel arteriovenous malformation (6 patients), uraemic enteritis with bleeding erosions in ileum and jejunum (2 patients aim: the vanishing bile duct syndrome (vbds), is an acquired and pathologic process that occurs in the biliary tree and is recognizable as an absence of bile duct in an individual portal tract. the underlying processes responsible for bile duct loss include immunological, infectious, ischemic, metabolic, and toxic processes. the purpose of this study was to investigate the potential role of dynamic 99mtc-hida hepatobiliary scintigraphy (dhbs) in the evaluation of patients affected by chronic liver disease with histological liver involvement characterized by small bile duct injury. material and methods: the study comprised 10 consecutive patients (9 males, 1 female), aged between 38-57 years. at diagnosis, 9 showed chronic hepatitis c virus (hcv) infection, 1 wilson's disease. all patients underwent standard biochemical liver function tests including parameters of cholestasis gammagt (ggt) and alkaline phosphatase (af) and liver biopsy. dhbs was performed after i.v. injection of 110 mbq 99m tc-iminodiacetic acid. acquisition of images started at the moment of injection and time/frame acquisition was 20 sec for 60 min. time-activity curves were recorded from regions of interest placed over hepatic parenchyma and main intra-hepatic biliary ducts. quantitative analysis of the curves was performed using deconvolutional analysis and non-linear regression, measuring parenchimal and ductal time point at maximum peak counts (t max ) and t ½ of excretion. results: a liver biopsy revealed in all patients marked ductopenia consistent with vbds. laboratory parameters showed ggt elevation in 2 hcv patiens with concomitant increase of af in one of these. the analysis of quantitative data obtained by dhbs showed in all patients a slow blood clearance and excretion of hida documented by delayed time of parenchimal and biliary t max and abnormal parenchimal and ductal excretion t ½ . no correlation was found between hida t ½ ductal excretion and parameters of cholestasis. however, positive correlation between liver parenchimal/ductal t ½ and histologic scores was observed. conclusion: the dhbs is able to assess the different aspects of hepatic function in vbds. although the present study includes a small number of patients, we believe that this method may be of clinical value in revealing the real hepatic and biliary function showed by correlation with histologic data. its clinical use may be crucial in follow-up and in prognostic evaluation of vbds patients. aim meckel's diverticulum is the most frequent congenital anomaly of the gastrointestinal tract, with an incidence of about 2% of the population. it is a sacculation attached to the ileum due to the failure of the vitelline duct to disappear. the mucosal lining of meckel's diverticulum containes island of heterotopic mucosa, which may give cause to serious complications such as peptic ulcer, hemorrhage and perforation. the aim of our study was to compare scintigraphy with ultrasonography (us) in the detection of meckel's diverticulum. materials and methods we recruited 22 children, younger than 3 years of age, with painless rectal bleeding. all the patients underwent first scintigraphy and then ultrasound. for the scintigraphic evaluation 370 mbq (10 mci) of 99 mtc-pertechnetate (tco 4 -) were administered intravenously. the initial scan was made 30 min to 1 hr after the radiopharmaceutical administration. anterior abdominal images were obtained at a frame rate of one images every 30-60 sec over the course of 30 to 60 minutes. acquisition parameters were: single head gamma camera, parallel hr collimator, matrix 128x128, 120 frames. activity in the ectopic gastric mucosa should appear simultaneously than that of normal gastric mucosa. activity in the urinary tract, most often confused with for a meckel's diverticulum, usually first appears after activity is seen in the normal gastric mucosa. for the abdominal sonography a 5 mhz convex-array probe was used. sonographic demonstration of noncompressible, tubular, aperistaltic structure with a double-layered wall, located far from the cecum suggested for meckel's diverticulum. all us scans were reviewed by one of the authors blinded to the scintigraphic results. results 19 out of 22 patients showed abnormal scintigraphic findings with suggestive for meckel's diverticulum. ultrasound confirmed these results in 15 patients of the 19 seen by scintigraphy and was negative in 4 cases. conclusion ultrasound imaging is one of the most widely utilized medical imaging modality that will continue to improve the quality of healthcare in diagnostic application. however scintigraphy is easier to perform, is less operator dependent and has a better sensitivity compared to ultrasound. also scintigraphy is noninvasive, painless, relatively inexpensive. it can be concluded that scintigraphy is still of value in the diagnosis of patients affected by meckel's diverticulum. making of patient with hcv related hepatopathy. our results confirm that both, painless thyroiditis and graves disease, may occur during the treatment with ifn . in this connection, non immunogenic hyperthyroidism may be related to the acute release of hormones circulation (painless thyroiditis). a simple imaging method as pertechnetate thyroid scintigraphy allows to make a differential diagnosis between graves disease and painless thyroiditis and is essential to address the patients towards an appropriate treatment of hyperthyroidism. uptake (0.5-4%) ft4 (12-26 pmol/l) ft3 (3year old (mean 52.8±11.2) 29 (23 f, 6 m) multinodular goiter patients were included to the study. after taking blood and urine samples, tcpu tests and thyroid scintigraphies were done and the patients were evaluated with thyroid ultrasound. by performing i-131 uptake measurements 4. and 24. hour uptake levels were calculated. results: in this study, 21 of 29 patients (%72) had urinary iodine level above 100 μg/gr cre that indicates sufficient iodine intake. there was a significant negative correlation between tcpu levels and urine iodine levels as indicated in the literature. according to tsh levels, while 18 patients were euthyroid, 11 were hyperthyroid (6 subclinical, 5 overt clinic). tcpu levels were found to be higher in hyperthyroid patients than euthyroid ones, but this difference was not statistically significant. in 9 euthyroid patients there were hyperactive nodules. there was a significant positive correlation between patients' tcpu and i-131 4. and 24. hour uptake values. conclusion: in conclusion, our patients' median urinary iodine level was 130 μg/gr cre which was sufficient. after iodinisation, high percentage (%37) of patients were hyperthyroid. we found that half of euthyroid patients had hyperactive nodules which showed the importance of thyroid scintigraphy in the evaluation of multinodular goiter patients. correlation of tcpu and i-131 uptake levels suggest that tcpu can be used instead of i-131 uptake levels. our preliminary results suggest that it would be important to evaluate the relationship between urinary iodine and tcpu levels in larger series of mng patients after mandatory iodinization. abnormal thyroid function and/or with thyroid antibodies an important problem in nuclear endocrinology is the "blocking" of thyroid gland, which necessitates to postpone investigation, to experience adverse clinical effects of stopping medications and a delay of making diagnosis. the aim of the study was to introduce and to determine the clinical value of the scintigraphy with 99mtc-mibi in patients / pts / with a "blocked" thyroid. in 367 pts / aged 38-75 years /, indicated for a thyroid scintigraphy after proper preparation, an investigation was performed with 74 mbq 99mtc-pertechnetate, 20 min. p.i. in 15 of them (4.1%), the thyroid was "blocked" and additional scintigraphy was done with 370-555 mbq 99mtc-mibi, 15 and 120 min.p.i. it was estimated that in all pts there was a visualization of thyroid. in 1 of them, a large "hot" nodule was visualized in the early and late image. later on a differentiated thyroid carcinoma was proved histologically. in another 4 patients "cold" nodules on the early and late scans were detected and benign cysts were proved. therefore according to the type of the nodule, visualized with 99mtc-mibi and its kynetics, we could help in differentiation of the diseases, to chose the treatment option and to deretmine the prognosis of the patient. as a conclusion we consider, that a scintigraphy with 99mtc-mibi is a useful tool in pts with "blocked" thyroid. in addition -in patients with nodules, the investigation could help in their differentiation and therefore-a recommendation for therapy. purpose: the aim of this study was to determine an optimal radioiodine treatment by comparing the clinical and biochemical outcome of patients with graves disease treated with estimate doses of radioiodine to those treated with fixed doses. material and methods: a total of 116 consecutive patients of thyrotoxicosis treated with j-131 were divided into two groups according to the amount of j-131 administered:i group-67 patients who received estimated dose of 111-550 mbq(mean 230 mbq), ii group-49 patients who received fixed dose of 300 mbq.all patients were pretreated with antithyroid drugs and were stopped one week before using radioiodine therapy.in 41,4%(48/116) patients with recurrent disease were given an additional dose(total dose 710 mbq).the outcome were followed from 6 months to 18 years(median 11,3 years). results: at six months after single dose of radioiodine therapy, euthyroid state was achieved in 36% patients in the fixed dose group and 51% patients in estimated dose group. there was significant difference in the rate of development of euthyroid state in respect to the given dose of j-131 (p<0,05). 39% patients in the fixed dose group became hypothyroid,compared to 20% patients in estimated dose group.the median time to hypothyroidism was 26 weeks. 23% patients in fixed dose group remained hyperthyroidism six months after radioiodine therapy,compared with 29% patients in the estimated group.in that group significantly more patients who received low(150-220 mbq) doses remained hyperthyroid,compared to those who received high(<370 mbq) doses.the thyroid volume reduction was significantly (p <0,01) higher in successfully tred patients(58%) than in those that remained hyperthyroid(37%). conclusion: there was significant difference in outcome between the two treatment regimes.better control of thyroid states can be achieved by estimated j-131 dose,while fixed radioiodine offers an affective treatment option where is required rapid control of thyrotoxicosis and long term hypothyroidism is a recognized outcome. evaluated by visual examination (grading "high", "moderate" uptake and "no uptake") and by calculation of background radiouptake ratio (rur) was evaluated. results: 3 patients had a intense mibi retention and underwent surgery: (histology revealed papillary carcinoma and folliculary folliculary carcinoma in one pat. folliculary adenoma, 4 pts. had a moderate uptake and underwent surgery too-2 pat. have benign nodule in another two thyroiditis). using the 60/10-minute thyroid lesion to background radiouptake ratio (rur), malignant and benign thyroid nodules could be separated with a sensitivity, specificity, and negative predictive value of 84.4%, 82.45%, and 81.33%, respectively. the mean rur for malignant thyroid lesions was 1.67+/-0.18, whereas for benign lesions, the ratio was significantly lower, 0.32+/-0.20 (p=0.0005). conclusions: in patients, in whom a needle aspiration cytology is not possible (hampered by antigoagulation therapy), the tc-99m mibi scintigraphy appears to be a useful additional diagnostic tool in the preoperative assessment of suspected thyroid nodules differential diagnosis of the main types of hyperthyroidism is performed with the help of thyroid scan 99m tc-99m, which brings out the size, the shape, the nodularity and the functional state of the gland. a second scintigraphy, this one with 131 i, is necessary to estimate the therapeutic activity of 131 i in hyperthyroidic patients. both radionuclides are trapped by thyroid gland in a similar manner, however, 99m tc is not organified. hence, the results of both types of scans are not expected to be identical in all the circumstances. aim the aim of this study is to evaluate and compare the correlation between the uptake of 99m tc and 131 i in graves disease, toxic multinodular goiter and toxic autonomous nodule, in order to ponder, in these three situations, the performance of the 99m tc scan only, which exposes the patient to a lower radiation dose. materials and methods this is a retrospective study, based on a population of 100 patients, divided into 3 groups: a) 29 patients with graves disease; b) 30 with toxic multinodular goiter; c) and 41 with toxic autonomous nodule. all of them underwent a thyroid scintigraphy 24h after administration of 1,11mbq (30 μci ) of 131 i and a thyroid scan 15 minutes after the administration of 185 mbq (5 mci) of 99m tc pertechnetate. we used a siemens ecam dcr dual head gamma camera, with the same acquisition conditions (256 x 256 matrix), and the uptake of each radionuclide was calculated. the results in each of the 3 groups were correlationed and compared. results in plotting the 99m tc uptake against the uptake of 131 i, the best fit was a linear regression model for the three studied groups. the calculated coefficient of determination (r 2 ) was 0,1902 for patients with graves disease; 0,3777 for patients with toxic multinodular goiter; and 0,5427 for patients with toxic autonomous nodule. conclusions our results demonstrated a poor relationship between the uptake of 99m tc and 131 i in graves disease, toxic multinodular goiter and toxic autonomous nodule, especially in the former. thus, it will not be feasible to rely solely on the 99m tc thyroid scan and exclude the 131 i thyroid scintigraphy as part of the protocol in none of these situations. purpose: higher levels of urokinase-type plasminogen activator (upa) and its inhibitor (pai-1) are linked to the poor prognosis in a variety of malignances. upa and pai-1 were expressed in most thyroid carcinomas, as had been measured immunohistochemically. however, no relationship between their expression and clinicopathological parameters were described. aim of the present study was to investigate the expression and clinical relevance of upa and pai-1 in thyroid cancer. patients and methods: upa and pai-1 in paired cytosol samples of thyroid tumor and normal tissue were determined in 23 patients using enzyme-linked immunosorbent assay and correlated to the known prognostic features. results: both upa and pai-1 concentrations were significantly higher in malignant thyroid tumors (upa=1.342±2.944 and pai-1=17.615±31.933 ng/mg protein) than in normal tissue (upa=0.002±0.009, p=0,011 and pai-1=2.333±0.338 ng/mg protein, p=0,001) with positive correlation of the two proteins in the tumors. upa and pai-1 were significantly higher in anaplastic vs. well-differentiated cancers (upa p=0.014 and pai-1 p=0.026), if extrathyroidal invasion (upa p=0.019 and pai-1 p=0.009) or distant metastases (upa p=0.006 and pai-1 p=0.003) had been present, and in tumors whose size exceeded 1 cm in diameter (upa p=0.009 and pai-1 p=0.035). only pai-1, but not upa was significantly higher in multicentric vs. solitary tumors (p=0.012) and lymph node positive compared to lymph node negative patients (p=0.042). the differences of upa and pai-1 did not reach the significant level when patients with well-differentiated tumors below and above 40 years of age had been compared. survival analysis revealed the significant impact of both upa and pai-1 on the progression-free survival (pfs) (38.84 vs. 3.67 months for patients with low and high upa, respectively, p<0.001; 38.2 vs. 12 months for patients with low and high pai-1, respectively, p=0.016). conclusions: the correlation of high upa and pai-1 with the known prognostic factors of poorer outcome and with lower pfs rate in patients with thyroid cancers proved that these proteins could be an additional prognostic parameter. aim: to evaluate the changes of myocardial parameters in patients with confirmed primary hyperparathyroidism, asymptomatic for coronary artery disease (cad). a total of 16 patients (mean age 56.7 ± 6,2 years) with suspected primary hyperparathyroidism and no-cardiac related major symptoms (myocardial infarction, pectoris angina) were examined using cervical planar, spect and dynamic, and gated rest-cardiac spect acquisitions. we analyzed the myocardial-rest parameters including myocardial perfusion, left regional ventricular ejection fraction (lvef), regional motility and thickening. acquisition was performed by obtaining early dynamic study, planar cervical images at 15 min, 45 min and 2-3 h after iv administration of 740 mbq of 99m-tc-tetrofosmin (myoview); cardiac gated spect acquisition at 45 min post-injection. results: 13 patients (81,25%) were positive for parathyroid adenoma (99m-tc-tetrofosmin scintigraphy), and confirmed through ct/mri and surgical exeresis with histological exam. 5/13 patients (38,46%) had myocardial parameters changes including perfusion defects, decreased leftventricular regional ejection fraction, systolic thickening and motility disorders. 8 patients (61,54%) had normal myocardial perfusion scintigraphy result. 2 out of 3 patients with unconfirmed parathyroid adenoma had normal mps result. 1 patient have moderate perfusion defects. all the results were correlated with parathyroid hormone, calcium and phosphorus plasma and urinary levels. conclusion: among patients with primary hyperparathyroidism, a high percent was affected by important changes of myocardial perfusion and systolic function (38,46%). we have to underline that all these patients were asymptomatic for cad. we can therefore conclude that gated-spect is definitely a useful tool for management of patients with primary hyperparathyroidism. negative predictive value of undetectable tg level in tsh suppression during the early follow-up of low-risk differentiated thyroid carcinoma a. piccardo, s. morbelli, p. bianchi, f. barbera, g. villavecchia, m. cabria; ospedali galliera, genoa, italy. aim: is noted that tsh stimulated thyroglobulin(tsh-tg) alone is sufficient for early follow-up of low-risk differentiated thyroid cancer(dtc) patients with no clinical evidence of disease after thyroidectomy and thyroid 131i ablation. recent data indicate that serum thyroglobulin at the time of remnant ablation( ablation-tg) can be correlated with tsh-tg measured 12 months later and can predict persistent or recurrent disease in postoperative period. there is also consensus that, during long term follow-up, tg measurement during thyroid hormone suppression(thst-tg) are sufficiently sensitive to forgo further testing in a low-risk patient who is clinically free of disease and has had undetectable tg after recombinant human tsh(rhtsh) or thyroid hormone withdrawal(thw). however only a small fraction of relapsing dtc patients, at 12 month follow-up, show undetectable tg under t4 treatment(<0.1 ng/ml). the aim of this study is to evaluate, in low risk dtc patients early follow-up, the negative predictive value(npv) of undetectable thst-tg measurement and undetectable thst measurement + ablationtg compared with rhtsh-tg. materials and methods: we enrolled 113 patients with histologically proven dtc treated by total thyroidectomy and radioidine. in all patients we measured ablation-tg levels. inclusion criteria were: tumor grater than 1cm, smaller than 4 cm, limited to the thyroid, not of virulent subtype, which were completely resected with or without nodal metastases but without distant metastases, negative anti-tg antibodies. all patients present undetectable thst-tg at 12 month follow-up. at 1 year after radioiodine treatment, all patient underwent on rhtsh stimulated tg assay. results: based on rhtsh-tg assay(>2ng/ml), histology, clinical data and long term follow-up persistent/ relapsing disease was proven in 2 patients. tg positive(0.6-2.0 ng/ml) after rhtsh, with no evidence of disease was observed in 8 patients. 103 patients showed undetectable rhtsh-tg. the negative predictive value of undetectable thst-tg and rhtsh-tg were respectively 98.2% and 100%. the ablation-tg levels were < 5ng/ml in 81 patients. in this group the npv of undetectable thst-tg was 100%. conclusion: these data seem to indicate that undetectable thst-tg assay, evaluated by high sensitive methods combined with low ablation-tg levels may avoid a significant number of high cost rhtsh-tg. further confirmation on a larger group of patients are needed. the results sensitivity and specificity of 82% and 43% respectively, however with fna combination, the specificity of the combined procedure increased to 95%. serum tg measurement was detectable ( 2 ng/ml) in 31 tumor patients with a sensitivity of 80% but gave no localization information, which was important for surgical intervention. as a non-invasive imaging modality, fdg pet had a sensitivity, specificity, positive predictive value and accuracy of 63%, 75% and 88% and 65%. conclusion: ultrasonography of the neck is a practical modality that can be employed as first line investigation in papillary thyroid carcinoma patients with a clinical suspicion of loco-regional recurrent disease. it can be combined with radioiodine and pet findings and lead the patients to surgical intervention for a promising complete cure. retrobulbar 99mtc-diethylenetriamine-pentaacetic-acid uptake predicts the effectiveness of immunosuppressive therapy in graves' ophthalmopathy l. galuska 1 , b. újhelyi 1 , j. varga 1 , l. szabados 2 , a. erdei 1 , i. garai 2 , e. v. nagy 1 ; 1 university of debrecen, debrecen, hungary, 2 university of debrecen, pet-ct medical diagnostic ltd., debrecen, hungary. aim of study: in graves' ophthalmopathy, only patients with immunologically active disease respond to immunosuppressive therapy, while those in the fibrotic stage do not. in the present series we aimed to show if 99m tc-ethylenetriamine-pentaacetic-acid (dtpa) spet is able to predict the success of imunosuppressive treatment. patients and methods: 48 orbits of 24 patients with graves' ophthalmopathy (15 women and 9 men) were studied. patients with graves' disease and eye signs suggestive of activity of the orbital autoimmune process (cas 4) were entered in the study. all received corticosteroid treatment and 6 were additionally treated with orbital irradiation. dtpa spet was performed before, and 3 to 24 months after the initiation of immunosuppressive treatment. orbital dtpa uptakes were numerically quantified and compared before and after treatment. the calculations were performed for the entire orbit voi as well as the anterior and posterior segments separately. the control group consisted of 34 orbits of 17 patients who had no thyroid disease. results: in the control group, the dtpa uptake of the orbit as a whole, the anterior, and posterior segments were 7.9±2.6, 8.8±3.0 and 6.6±2.0 bq/cm 3 (mean±sd) respectively. the upper normal reference limit of posterior segment dtpa uptake was set to the 95% percentile of the control group, 10.07 bq/cm 3 . the mean dtpa uptake of the 48 orbits of go patients was higher before immunosuppressive treatment than after therapy (8.92±2.31 bq/cm 3 and 7.67±3.82 bq/cm 3 , respectively, p=0.0003). the anterior and posterior segment values correlated with those of the entire orbit. of the 35 orbits with an initial dtpa uptake 10.07 bq/cm 3 in the posterior segment, 11 % has improved, while of those 13 orbits with an initial dtpa uptake above 10.07 bq/cm 3 , 77% has improved. conclusions: for a favourable treatment outcome, the positive predictive value of an initial dtpa uptake >10.07 was 81.25 %, while a negative predictive value of a dtpa uptake 10.07 was 89.74 %. patients with dtpa uptake above 10.07 may be predicted as responders, while those with a dtpa uptake below this value have only low chance of benefit from immunosuppressive treatment. aim: marine-lenhart syndome (mls) was defined as graves`disease with autonomously functioning nodules. currently there exist no data about the actual incidence of this desease and the results of radioiodine therapy. methods: in a prospective trial 1110 patients with initial diagnosed hyperthyreoidism were evaluated. physical examination, interview, ultrasound, scintigraphy and determination of t3, t4, tsh and antibodies were carried out in all patients. all patients were followed up at least one year after radioiodine treatment. results: mls was diagnosed in 37 patients (incience 3.3%). following treatment with radioioidine 10 patients had normal serum tsh levels. hypothyreoidism was present in 14 patients and hyperthyreoidism persisted in 4 patients. a newly diagnosed orbitopathy was not observed after radioiodine treatment. conclusion: the actual incidence of mls was 3.3% in patients with newly diagnosed hyperthyreoidism. treatment with radioiodine offers the chance for euthyreodism but includes a significant probability for a second therapy. the optimal method to determine iodine-131 treatment doses is to obtain time-activity curves from serial measures, after administration of a trace dose. a simplified method is based on a 24-hours i-131 uptake. it's still unclear the potential usefulness of tc-99m scan (routinary performed during the diagnostic work-up) to estimate the iodine uptake. aim of the study. we evaluated the possibility to use the 20-minute tc uptake computed during standard tc scintigraphy to reliably estimate the maximum thyroid radioiodine uptake. methodology. we consecutively evaluated 104 patients: 52 with uni-or multinodular goiter (ng) and 52 with graves' disease (gd). each patient underwent both tc scintigraphy and i-131 uptake. tc scan was acquired with a gamma camera equipped with a lehr-p collimator, 20 ± 5 minutes after the i.v. injection of 111 mbq of the tracer. tc uptake was computed by measuring the syringe before and after injection under the same geometrical conditions. i-131 time/activity curve was obtained acquiring planar images with a gamma camera equipped with a hegp collimator at several times (6 hrs, 24 hrs, >95 hrs) after oral administration of 1.5 ± 0.5 mbq. thyroid uptake at any time was calculated according to standard methods. statistical analysis was performed. results. our data demonstrate different kinetics between ng and gd. mean iodine maximum uptake per mass of thyroid tissue (umax) resulted similar between groups: 2.8±1.8 (ng) and 2.6±1. 3 (gd) . mean time to reach max iodine uptake (tmax) resulted statistically different: 21.7±7.2 (ng) and 16.0±7.7 (gd) (p<0.0001). tc uptake mean values and standard deviation (s.d.) were 3.33 (1.73)% for ng and 8.03 (7.47)% for gd. the best fitting demonstrated a natural logarithmic correlation between tc uptake and umax for both ng and gd. a strong correlation was found between umax vs. the natural log of tc uptake. regression coefficients r 2 were: introduction: interferons (ifn) are a family of naturally occurring proteins with antiviral and immunomodulatory activities. there is a wide range of thyroid abnormalities related to ifn administration. thyroid autoimmunity has been widely reported as a side effect of ifn treatment as well as hypothyroidism and thyrotoxicosis. methods: a retrospective analysis of 6 radionuclide thyroid studies of patients who had thyroid scans and were on interferons was done. all patients had thyroid scans obtained after iv injection of 5 mci of tc99m pertechnetate as well as thyroid uptake after oral administration of 9 uci of i-131. results: there were six thyroid studies of five patients , four on alpha ifn for hepatitis c viremia and one patient on beta ifn for multiple sclerosis were identified. patients included 3 females and 2 males ranging in age from 45 to 50. patients had no history of thyroid disease prior to interferon therapy. scintigraphic diagnoses included one patient with simple goiter, one with subacute thyroiditis, one with diffuse toxic goiter and two with nodular toxic goiter. one patient developed first the nodularity then the hyperactivity in the intervening tissue later as seen on the follow up scan.conclusion: thyroid scintigraphy shows different interferon induced scintigraphic patterns and is valuable to differentiate hyperthyroidism due to graves' like pattern from ifn -induced thyroidits. adrenal or retroperitoneal masses preoperatively was beneficial. the number of positive cases continued to grow, indicating a more judicious referral in the recent years. conclusion: the experience of with in-house preparation of mibg was rewarding. the impact on clinical endocrine practice was so significant that mibg scintigraphy had become a routine investigation for all neuroendocrine tumours in our institution. the aim. data on the thyroid blood flow in healthy subjects without thyroid disease are scarce. the aim of our work was to evaluate the influence of thyrotropin (tsh) concentration on the peak systolic velocity (psv) in a group of healthy persons. patients and methods. we included 115 euthyroid subjects, 102 females, 13 males, aged 16 to 84 (mean, 37.8 ± 17.2 years). all subjects were negative for thyroid peroxidase antibodies (tpoab) and thyroglobulin antibodies (tgab). colour flow doppler sonography (cfds) was performed using a 7.5 mhz linear transducer. psv was measured at the level of intrathyroid arteries with a sampling volume of 2 mm. in each subject psv was expressed as a mean of five measurements. results. mean tsh concentration in all subjects was 2.048 ± 1.282 mu/l, (min. 0.426, max. 5.415 mu/l, reference value: 0.35 -5.5 mu/l). according to their tsh concentration, subjects were divided into 4 groups: first group with tsh between 0.426 and 1 mu/l (n = 25) had mean psv 8.5 ± 1.5 cm/s, second group with tsh between 1.001 and 1.5 mu/l (n = 26) had mean psv 9.2 ± 2.7 cm/s, third group with tsh between 1.501 and 2.5 mu/l (n = 31) had mean psv 9.1 ± 2.0 cm/s, and fourth group with tsh between 2.501 and 5.5 mu/l (n = 33) had mean psv 9.7 ± 2.1 cm/s. when compared with group one, psv was significantly higher in group four (p = 0.0167). additionally, in all subjects a significant correlation between tsh concentration and psv (r = 0.217, p = 0.021) was found. conclusion. we established a significant positive correlation between tsh concentration and psv in euthyroid subjects without autoimmune thyroid disease. the results are in accordance with the data on the stimulative influence of tsh on angiogenesis. radioiodine and 99m tc-peretechnetate uptakes are currently used for the assessment of thyroid function. 131 i has the disadvantages of high radiation dose due to itsemission, high energy rays and longer half life. 123 i is cyclotron produced agent and is costly. 99m tco 4 has the advantages of quick assessments, low radiation dose and better image quality. however, both studies need preparation of patient with low iodine diet and cessation of anti-thyroid /thyroid replacement therapy. 99m tc-sestamibi has been recently evaluated by various investigators for the assessment of thyroid function with an advantage that there is no need of such preparation. the current study was done to assess the 99m tc-sestamibi thyroid uptake and t max . for this purpose, nine euthyroid volunteers (group i), 11 patients with grave's disease (group ii), 12 patients with hypertrophic hashimoto's thyroiditis (group iii) and 12 patients with atrophic hashimoto's thyroiditis (group iv) underwent 99m tc-sestamibi thyroid scintigraphy. dynamic images of thyroid were acquired for 20 minutes along with static syringe images (pre & post injection) for two seconds. maximum uptake of 99m tc-sestamibi was seen at 5 minutes post injection in volunteers as well as in patients in various groups. images at 6, 10, 20, 60, 120 minutes revealed gradual tracer clearance from thyroid. in ev, 5 minutes 99m tc-sestamibi uptake was (mean±sd; 0.10± 0.05%). in gd and hht patients 5 minutes 99m tc-sestamibi uptake (mean ±sd; 0.72±0.54 % and 0.36±0.25% respectively) was greater than in ev (p<0.0001 and p=0.0005 respectively). aht patients revealed 5 minutes 99m tc-sestamibi uptake (mean±sd; 0.09±0.04 %) lower than in ev and hht (p=0.776 and p=0.0002 respectively). mean 5 minutes 99m tc-sestamibi uptake showed strong correlation with mean 20 minutes 99m tc-pertechnetate uptake in gd patients (r=0.89) and with tsh levels in hht patients (r=0.55). it is concluded that 5 minutes is optimal time interval between 99m tc-sestamibi injection and calculation of thyroid uptake. 5 minutes 99m tc-sestamibi uptake can differentiate euthyroid individuals from gd patients. no preparation with low iodine diet and cessation of anti-thyroid drugs before 99m tc-sestamibi uptake is a great advantages which possess its role as possible alternative radiopharmaceutical for thyroid uptake calculation. possible use of thyroid us and thyroid abexaminations in follow up in detecting high risk patients or early and subclinical hashimoto thyroiditis k. zaplatnikov 1 , w. wiedemann 1 , m. plotkin 2 , f. grünwald 3 ; 1 nuclear medicine clinic nürnberg, nürnberg, germany, 2 nuclear medicine department university hospital charite berlin, berlin, germany, 3 nuclear medicine department university, frankfurt, germany. aim patients with hashimoto thyroiditis (hit) show typically decreased echogenicity of the thyroid ultrasonography (us). in this study, we investigated the association between the us pattern, tsh values and level of thyroid antibodies (anti-tpo,tg-ab) in order to evaluate the usefulness of us for hit screening. method included were 150 consecutive pts with suspected hit (124 f, 26 m, mean age 47±27 yrs) and control group with 24 pts (16 f, 8 m, mean age 34±13 yrs). blood samples were analysed for thyroid-ab, tsh and periphere thyroid hormones. us or scintigraphy of the thyroid was performed in follow up (3 and 6 mo). results pat. with decreased echogenicity and high level of thyroid autoantibodes (n=90, gr.i) had a higher mean tsh (2.95 miu/l) compared with pts. with normal echogenicity and thyroid autoantibodes (n=31, gr. ii) (1.41 mu/l, p<0.0005). pts. with normal echogenicity had thyroid autoantibodies too (n=29, gr. iii) with mean tpo-ab (131±42 ng/ml) and tg-ab (82±35 ng/ml). pts. with decreased echogenicity (gr. i) had a higher level of thyroid autoantibodies (anti-tpo,tg-ab) than subjects from gr. iii (p<0.0001). conclusion we found a strong association between hypoechogenicity at thyroid us and higher levels of serum tsh/thyroid abs in pts suffering on hit. our results suggest that a decreased echogenicity represents a reliable sign of hit. however, a normal echo pattern cannot exclude a hit. this indicates a possible use of thyroid us and thyroid ab-examinations in follow up in detecting high risk pts or early and subclinical hit. application of somatostatin receptor scintigraphy in patients with thyroid associated ophthalmopathy j. deng; xijing hospital, fourth military med. univ., xi'an, china. the study aims at investigating the effectiveness of the orbital somatostatin receptor scintigraphy (srs) with 99m tc-oct in curing patients with active graves' ophthalmopathy disease and their response to the corticosteroid therapy. method: a somatostatin analog, oct, was labeled with 99m tc by a direct method. the compound's labeling efficiency was confirmed by paper chromatography. the subjects of the experiment were 15 patients with graves' ophthalmopathy (go) and four volunteers without eye disease or graves' disease (gd) as the control group (cg). during the study, single photon emission computed tomography (spect), computed tomography (ct) and the left and right lateral position planar imaging of the heads of the subjects were obtained four hours after the iv injection of 740mbq 99m tc-oct. corticosteroid therapy (methylprednisolone, 10mg po tid for 1 month) was then given to all patients in the next day and lasted for one month, after that the srs was repeated to all patients. radioligand uptake within each orbit (o) and occipital (oc) was measured using the region of interest (roi) method and the o-to-oc ratio was determined before and after corticosteroid treatment. clinical activity of graves' ophthalmopathy was evaluated before and after the treatment by calculating the ophthalmopathy index (oi). key results: comparing to the o/oc ratio of the control group at the scintigraphy (1.16±0.04, p<0.05), a significant change in the o/oc ratio was observed in 12 patients with active go between pretreatment and post-treatment (1.64±0.13 vs. 1.21±0.09, p<0.05). no significant change in the o/oc ratio was found between the cg and the 12 go patients after post-treatment (1.16±0.04 vs.1.21±0.09,p>0.05). there was no significant change in the o/oc ratio in 3 patients with inactive go (p>0.05) in both pre-treatment and post-treatment periods and in the cg (p>0.05). conclusions: in those patients with active graves' ophthalmopathy, somatostatin receptor scintigraphy showed markedly increased orbital uptake of 99m tc-oct. the study demonstrates that 99m tc-oct scitigraphy is a good indicator and able to predict the clinical response to the corticosteroid therapy in patients with go. this method should be considered as an objective and safe method to select proper treatment therapy. the use of real-time quantitative polymerase chain reaction (quantitative real time pcr) amplification of the human epidermal growth factor receptor (egfr) in 52 lung cancer patients and 8 cases of benign pulmonary disease and 10 healthy controls. results median concentration of free circulating dna in serum of lung cancer patients, benign pulmonary disease and healthy controls was 107.6ng/ml,76.86ng/ml and 18.8ng/ml, respectively. the diagnostic sensitivity, specificity and accuracy of free circulating dna for lung cancer was 71.2%, 50% and 68.3%, same as the diagnostic value of combinations for detecting lung cancer was 94.2%, 25% and 85%, respectively. conclusion the free circulating dna in the serum at diagnosis in lung cancer patients may be a new better tumor marker. sialoscintigraphy with 99m tc-pertechnetate in evaluation of salivary gland function in patients after radiotherapy with head and neck carcinoma j. niewiadomska, g. lapinska, d. kolataj, m. benke, i. kozlowicz-gudzinska, d. kiprian, a. sackiewicz; institute of oncology, warsaw, poland. radiotherapy in patients with head and neck carcinoma can result in temporary or permanent damage of the salivary glands. xerostomia can exert negative effects on the patients quality of life. aim: the aim of study was to evaluate salivary glands function in patients receiving radiotherapy due to head and neck cancer. materials and methods: 54 patients (47 men, 7 women, aged 35-78 years) with larynx and pharynx carcinoma were enrolled in this study and underwent scintigraphy prior to radiation therapy as well as in the 6th and in the 12th month of follow-up. the patients were divided in two groups. first group consisted of 37 patients with the area of parotid glands irradiated in 70%-100%. second group included 17 patients with the area of parotid glands irradiated in 20%-40%. in both groups 100% mass of submandibular glands was irradiated. each patient received total irradiation dose of 6600-7000 cgy. dynamic salivary scintigraphy was performed with single-head gamma camera spx4 after injection of 148 mbq tc99m-petrechnetate. gland function was stimulated with lemon juice at 20 min of the study. up (uptake ratio), t max (time at the max count), ms (maximum secretion) and ma (maximum accumulation) were calculated and analyzed. results: in both groups complete dysfunction of submandibular glands was observed in the majority of patients during 12 months after rt. in comparison with the first group, in the second the parotid glands damage was less and reversible. among patients with retained salivary glands function, higher values of ma, ms, up parameters were observed in cases with parotid glands irradiated in 20 -40%. conclusions: sialoscinigraphy is a valuable non-invasive method for assessing salivary glands function in total and for each gland separately. in patients with head and neck carcinoma, radiotherapy leads to salivary glands damage which may last up to 12 months after irradiation. degree of dysfunction is correlated with the area of irradiation. peritoneal dialysis and hydrothorax e. urbanova; nuclear medicine university hospital, hradec kralove, czech republic. continuous ambulatory chronic peritoneal dialysis (capd) is an affective renal replacement therapy for patients with end stage of renal disease. development of hydrothorax is serious but relatively less common complication. plain radiograph shows presence of hydrothorax but cannot establish its association with peritoneal dialysis and assessing the outcome of pleurodesis procedure. aim of this study was to show two patients (pts). with hydrothorax and capd. method both pts were undergoing caps for five monts. they were admitted to the hospital for breathlessness and right side chest pain. plain radiographs showed presence of hydrothorax. cytological examination of pleural fluid was negative for malignant cells. in view of transudative nature of pleural aspirate, a peritoneo-pleural communication was suspected. patients were subjected to peritoneal scintigraphy to establish the communication between peritoneal and pleural cavity. radiopharmaceutical 99m tc-colloid (administered activity 3mci) was injected into dialysate bag and infused through catheter into peritoneal cavity. to reach homogenous mixing of activity within peritoneal cavity the patient was asked to roll into bed. static scans incorporating thoraco-abdominal region were acquired at frequent time intervals with dual head gamma camera equipped with leap collimators. results by one hour some radioactivity was noted in right pleural space, but after two hours scintigrams were much better with ascent of activity up to apex of pleural space on the right side. hydrothorax was present in both pts on right side due to transit of dialysate fluid through peritoneo-pleural communication. conclusion peritoneal scintigraphy is simple, non invasive procedure with diagnostic value in evaluating connection between capd and hydrothorax. introduction. recently, a somatic point mutation of the b-raf gene (v600e) has been identified like the most common genetic event in papillary thyroid carcinoma (ptc), with a variable prevalence between the different series (23-62%). its detection can be made on thyroid biopsys as well as in cytological samples obtained by fine needle aspiration biopsy (fnab). for these reasons, it has proposed like a molecular marker in the early diagnosis of the ptc. objectives. to know the frequency of b-raft1799a in operated patients of thyroid cancer. to value the utility of the detection of this mutation in the ptc diagnosis. material and methods. the detection of mutation b-raft1799a was made in 77 patients with thyroid cancer diagnosis. for the test were used fixed paraffin-embedded thyroid tissue sections coming from the surgery. 25 patients had a thyroid fnab previous to the surgery in which also the presence of the mutation was analyzed. the techniques used for the detection of b-raft1799a were: dna extraction, pcr/rflp and mutation confirmation by sequentiation. results. of the 77 analyzed biopsies (63 ptc, 9 follicular carcinomas, 2 hurthle carcinomas, 2 anaplastic carcinomas and 1 high degree sarcoma), b-raft1799a mutation was positive in 40,3% of tumors (31/77). according to the histologycal type, the mutation was detected in 47,6% of ptcs (30/63): 52,6% of classic variant, 33,3% of micropapillaries (4/12), 41,7% of follicular or mixed variants (5/12) and 100% of the variant of high cells (1/1). the mutation was not detected in any of the histologycal types different from ptc. of the 25 patients who in the last had a previous paaf year, the mutation was positive in 32% of the patients (8/25) with a fnab previous to the surgery in the last year. conclusions. the presence of braft1799a mutation is specific of ptc and displays an elevated frequency in this group of patients. in 8 of the 25 patients with a previous fnab in last year, a precocious and definitive diagnosis of cpt could have been given by detecting braft1799a mutation in the cytology. waist circumference predicts silent myocardial ischemia in patients with diabetes mellitus: a myocardial perfusion study g. p. carboni, s. manfrini; università campus bio-medico, roma, italy. silent myocardial ischemia (smi) is a frequent condition in patients (pts) with diabetes mellitus but its mechanism and clinical relevance are still uncertain. aim:we screened for smi 34 consecutive such pts , mean age 57+-13 years , 74 % males , by rest/stress gated single photon emission computed tomography ( g-spect). methods: imaging was carried out on a dual-head gamma camera with thallium or sestamibi .extent of abnormal defects ads was considered significant when > than 10% of total lv pixels ( p ) and reversibility (myocardial ischemia) as a % of the ads p . visual images were analyzed with a score from 0 to 4. relationship between imaging results and clinical parameters such first-degree family history of diabetes (71% of pts) , waist circumference ( 97+-10 cm ) , mass body index ( 27+-3 ), duration of diabetes ( 10+-6 years ) , type of diabetes ( 82 % of pts with type 2 , 18% with type 1 ) ,total cholesterol (191+-4 mg/dl ) , ldl-cholesterol (114+-33 mg/dl) hdl-cholesterol ( 57+-37 mg/dl ) ,triglycerides ( 132+-75 mg/dl ) , hypertension ( 35 % of pts ) , glycosylated haemoglobin ( 7+-2% ) , c-reactive protein ( 1.6+-1.3 mg/l ) , current therapy ( insulin:in 41 % of pts ; ace-inhibitors: in 32 % of pts ; calciumantagonists: in 8% ; of pts ; statins: in 44% of pts ) were then analyzed for study . all pts were also followed-up for cardiac events ( ce ) for an average time of 6 +-3 months. results: overall pts , 20% (7/34) revealed clear-cut smi on g-spect but only 1 subject of these had a major ce after 1 month follow-up. on a logistic regression model ( chi-square = 50 , p < 0.0001 ) , smi was significantly associated only with waist circumference but not with the rest of clinical parameters. when data were adjusted for established risk factors and current therapy, results did not change ( p = ns for all). conclusions: this study suggest that pts with diabetes mellitus , abnormal waist circumference indicates predisposition to an accelerate development of smi . stress myocardial perfusion imaging may thus indicate early appropriate prevention and treatment. the aim of this study was to evaluate the possible application of bone mineral density measurement using dual energy x-ray absorbtometry (dexa) in the diagnosis of transient osteoporosis of the femur. methods: fourteen patients were included this study (9 males and 5 females), with age range 40-55 years. all patients presented with hip pain, diagnosed by bone isotope scan and confirmed by mri as transient osteoporosis of the proximal femur. all patients underwent dexa scan for bilateral proximal femurs. bone mineral density values and t-score values were recorded. bone density was considered normal if t-score >-1, consistent with osteopenia if tscore was (-1) -(-2.5) and consistent with osteoporosis if t-score was < -2.5. t test was used in statistical analysis and p<0.05 was considered significant. results: tscores in the affected femurs were ranging from (-0.7) and (-3.7) with a mean value of (-2.2). t-scores were consistent with osteoporosis in 5 patients, osteopenia in 8 and normal bone density in one. t-scores in the controlateral femurs were ranging between (0.2) and (-2.6) with a mean value of (-0.8), with significant difference compared to affected side (p<0.5). t-scores were consistent with normal bone density in 8, osteopenia in 4 and osteoporosis in 2 patients. t-score difference between the affected and the normal side was ranging between 0-1.4, and twelve patients (86%) had a tscore deficit in the affected side with more than 1 sd compared to the controlateral side. conclusion: dexa scan can detect significant drop in bone density in patients with transient osteoporosis of the femur. although most cases didn't show t-score values of osteoporosis, still using the t-score difference compared to the controlateral femur as cutoff value may have application in establishing the diagnosis. aim: spondylodiscitis still remains a diagnostical problem. the aim of the study was to assess the sensitivity and diagnostic value of bone scintigraphy and leukocyte scintigraphy in spondylodiscitis detection. material and methods: the documentation of 75 patients with clinically confirmed spondylodiscitis, who were treated at the department of infectious diseases between 2003 and 2006, was reviewed. according to algorithms valid in our hospital bone scintigraphy has to be done in patients with suspected spondylodiscitis if spine on plain x-ray is inconclusive. leukocyte scintigraphy is mainly used for detection of infective foci and in patients with fever of unknown origin. 99m tc dpd, activity 700 mbq, was used for bone scintigraphy. whole body scintigrams in ap and pa projections were done between two and four hours after radiopharmaceutical injection. if scintigrams were inconclusive, spect of suspected part of body was done. 99m tc hmpao labelled leukocytes, activity 450 to 500 mbq, were used for leukocyte scintigraphy. scintigrams of the whole body were performed 30 minutes and two hours after radiopharmaceutical injection. results: bone scintigraphy was done just before or during hospitalization in 40 (57%) patients. at the time of bone scintigraphy 24 patients had working diagnosis of spondylodiscitis or were suspected of having spondylodiscitis. 16 patients had different working diagnosis. radiopharmaceutical accumulation in the region with spondylodiscitis was: -increased in 38 (95%) out of 40 cases, -normal in 2 (5%) out of 40 cases. leukocyte scintigraphy was performed just before or during hospitalization in 21 (30%) patients. 9 of them had working diagnosis of spondylodiscitis or were suspected of having spondylodiscitis. radiopharmaceutical accumulation in the region with spondylodiscitis was:increased in 1 (5%) out of 21 cases, -normal in 12 (57%) out of 21 cases, -decreased in 6 (29%) out of 21 cases (absent activity in vertebral body), -irregular in 2 (9%) out of 21 cases (increased and decreased). the activity in the region with spondylodiscitis was normal in 4 out of 9 patients with working diagnosis of spondylodiscitis and decreased (absent) in 5 of them. conclusions: -bone scintigraphy is important investigation in diagnostic process in patients suffering for spondylodiscitis due to its very high sensitivity. -leukocyte scintigraphy is without diagnostic value in patients with spondylodiscitis. the spect technique was confirmed to be more sensitive than the conventional planar bone scanning for the detection of reactive bony lesions in patients with back pain (1) . the newly developed hybrid spect/ct device can provide enhanced anatomical localization of the lesions detected on spect. the aim of this study was to investigate the value of spect/ct bone scanning in the evaluation of patients with back pain, which has not been clearly examined yet. methods: we retrospectively evaluated bone scans of 75 patients with back pain (age 59 ± 23 years, 35 men) that had both planar and spect/ct images performed. planar, spect & spect/ct scans were separately reviewed by 2 observers for bony lesion presence, location, & specific diagnosis based on each scan. the confidence in each of these assessments was categorized as uncertain, probable or certain. the final diagnosis was confirmed by surgical/pathological, radiological correlation, or follow-up for up to 20 months. results: there were 143 lesions detected in 75 patients with final diagnosis of arthritis, degenerative disease, fracture, and normal scans. spect/ct findings were more accurate in predicting the final diagnosis (lambda value 0.96, uncertainty coefficient error reduction 92%) than spect alone (lambda value 0.85, uncertainty coefficient error reduction 75%). the localization certainty was significantly higher in spect/ct than spect alone (p < .05). as to lesion presence, spect significantly improved lesion certainty, without additional significant improvement by spect/ct. the diagnostic confidence in the determination of the underlying bony abnormality by spect/ct was significantly higher than spect alone (p < .05). conclusions: while the detection of bone scan lesion is significantly enhanced by spect, the hybrid spect/ct can additionally clarify the exact location of these lesions and visualize the associated ct changes. the improved certainty of these 2 factors is the likely reason behind the superior confidence in spect/ct specific diagnosis of the bone abnormality in patient with back pain. aim of the study: stress fractures (sf) have been considered a hazard of strenuous physical activities, such as the military training of army recruits. the aim of our study was to demonstrate the association between the findings of bone scanning and some clinical parameters of physical strain that result in bone injury in this specific group of young people. patients and methods: ninety four male recruits, 18-36 years old (mean=24±5 years), under a similar training program and with suspected sf of the lower extremities underwent three-phase bone scanning after injection of 550mbq 99mtc-mdp. they were divided into various groups according to: a) body mass index (bmi): (<25=normal, 25-29=overweight and >29=obese), b) duration of military service (0-2 months = recruits, and >2 months = post-trained soldiers), c) location of the primary symptoms (knees-tibiae, or feet), d) duration of pain symptoms (</=10 days or >10 days), e) pain intensity, in a 0-4 scale, where 0 = pain free and 4 = very intense pain, f) results of plain radiography (positive/negative) and g) results of bone scintigraphy (grade 0 = negative in all phases, grade 1 = positive only in the 3rd phase, and grade 2 = positive in all phases). paired chi-square statistical tests were applied for all parameters. results: seventy two patients (77% of the sum) had scintigraphically positive bone pathology (21 on the leg and 51 on the feet), while the rest 22/94 (23%) had negative bone scans. sf were found at 41 patients (57%), more commonly in the feet rather than the legs (x 2 =4.94, p=0.026) and in recruits rather than post-trained soldiers (x 2 =4.62, p=0.03). positive scintigraphic results also correlated to pain intensity (x 2 =5.29, p=0.02), although the former were not correlated to bmi, duration of pain, or the results of plain radiography. plain radiography had sensitivity=33%, specificity=76%, ppv=83%, npv=25% and accuracy=43% in the detection of sf, taken bone scintigraphy as "gold standard", with no correlation to any of the aforementioned clinical parameters of bone injury. conclusions: army recruits under the basic training program seem to suffer more severe bone lessions, located mainly in the feet, regardless of overweight or the duration of pain symptoms. regarding bone scanning as the "gold standard" diagnostic method, pain intensity is a strong predictor of an adverse clinical condition (bone fracture rather than a milder lession) bone scintigraphy and xray in detection of active osteoarthritis.their relation to type of knee pain. a roc analysis. aim: bone scintigraphy is a valuable method for detecting synovitis in knee joints with severe osteoarthritis. both clinical symptoms and proven hyperperfusion set the indication for radionuclide synovectomy (rs). the aim of our study was to evaluate the clinical usefulness of blood pool (bp) and static scan (ss) in respect with joint pain, clinical and x-ray findings. materials and methods: 412 knee joints of 206 patients (69±7.3years old) referred for setting indication for rs were clinically evaluated and classified by x-ray steinboecker system and type of pain (only under stress/ both under stress and rest). two-phase bone scintigraphy was performed according to the procedure guidelines of our department and intensity of tracer accumulation in joints was scored. to check scintigraphy or simple xrays' ability to evaluate dolorous active synovitis complete statistical receiver operating characteristic (roc) curves were analyzed. results: of all knee joints studied 85.9% were painful at exercise while 10% were continuously dolorous. in general bp was positive in 80.8% and ss in 72.3%. osteoarthritic joints were x-ray graded 8.5% as 0, 26.2% as i, 30.3% as ii, 27.2% as iii and 7.8% as grade iv. bp had a sensitivity of 0.91, specificity of 0.82, ppv of 0.96 and npv of 0.59 at exercise pain and 0.97, 0.28, 0.42 and 0.95 at continuous pain respectively. all values were critically better than these of ss and xray. area under roc curve for bp was larger than this for ss and for xray (the smallest) in painful joints (0.807, 0.752 and 0.61 respectively) with statistically significant differences. conclusion: bb scintigraphy is a useful technique for detecting active synovitis in knee joints with oa better than ss or simple xray. tracer accumulation is strongly related to the type of pain. introduction condylar hyperplasia is a common cause of crossbite malocclusion and facial asymmetry. treatment often includes surgery and it's necessary to know the growth activity of the hyperplastic condyles for treatment assessment. nuclear methods are beginning very useful in this pathology. objetives the aim of our study is evaluate the correlation between histopathologic findings and uptake intensity in spect in patients with condylar hyperplasia. patients and methods prospective study in 37 patients with clinical suspect of condylar hyperplasia and positive 99m tc mdp spect. the patients with increased uptake of 99m tc mdp in any tmj were considered positives and were classificated in three grades of uptake. all patients were referred to surgery (condylectomy or condylar shave). an hystologic study classified the samples in three activity grades. a stadystical analysis of spect and hystopatological finding was done. results condylar hyperplasia was confirmed by hystological findings in all cases. a strong correlationship was confirmed between the uptake intensity and anatomopatologycal findings. conclusions condilar spect with 99m tc mdp is an easy diagnostic method with high sensitivity for the diagnosis of condylar hyperplasia and is very useful to evaluate the grade of hyperplasia. progressive condition and early surgical intervention may prevent further deformity of the hip join. although the prognosis and treatment of these 2 conditions differ greatly, in the early stages the radiographic appearance of toh my be confused with avn. we will attempt to define radiologic characteristics that distinguish toh from avn. patients and method: in 2 years , 5 patients (2f, 3m) were referred with acute hip pain; 1 male with bilateral hip pain in the third trimester of pregnancy (6 hips). in all patients radiographs, bone scan and mri was performed. the diagnosis of toh was confirmed by complete clinical recovery and normal mri in the follow up with conservatively treatment.. results: no patients had radiographic changes. bone scanning showed uniformly increased uptake at the affected femoral head extending down into the femoral head in all patients. the changes on mri were a pattern of diffuse edema without focal defects, and intact articular surface, but 1 patient with focal defect which diagnosis was avn. conclusion: diffuse edema pattern on mri without focal defects and bone scanning with homogeneously increased uptake in the femoral head and neck is highly suggestive of toh. introduction: reflex sympathetic dystrophy (rsd) or complex regional pain syndrome is a condition of burning pain, stiffness, swelling and discoloration of the affected limb (commonly hands and feet). females are affected more commonly than male (3:1) . only one in five affected patients is able to return to a normal level of functioning. bone scan is highly sensitive (96%) and specific (98%). it is also a useful guide to prognosis. about 90% of patients with positive bone scan experienced a favorable response to steroid as oppose to 34% of those with negative scintigrams. case report: this is a 42 years old male presented with 6 weeks h/o severe burning sensation and pain in the left hand. he has had a laminectomy over c5-c7 about 10 weeks back. follow up mri revealed no nerve compression. x-rays of left hand was unremarkable. a three phase bone scan was performed with 720 mbq of tc-99m mdp. results: dynamic and blood pool images revealed abnormally increased blood flow over left forearm, wrist and hand. delayed images revealed diffusely increased tracer uptake over the left wrist, carpal, metacarpo-phalangeal and inter-phalangeal joints. a diagnosis of reflex sympathetic dystrophy was made. he was started on oral steroid therapy with analgesic for 3 months and responded well to the treatment. conclusion: it is concluded that three phase bone scan is a safe, non-invasive, cost effective, highly sensitive and specific modality for the diagnosis of reflex sympathetic dystrophy and also a good predictor of response to treatment. aim: fdg pet can assess the activity of several inflammatory diseases. idiopathic retroperitoneal fibrosis (irf) is a rare disease characterised by a fibro-inflammatory mass which surrounds the abdominal aorta and the iliac arteries and often causes obstructive uropathy. we explored the ability of fdg-pet to predict response to therapy and post-treatment relapse in irf patients (pts). methods: twenty-four consecutive irf pts (m/f:16/8; median age 58 yrs, range 9-82). the treatment was oral prednisone for 1 month and then prednisone+methotrexate or tamoxifen for 8 months. ct or mri were performed at diagnosis, after 4 months of treatment and at the end of treatment. pet was performed in all pts before treatment, and in 13/24 pts also after the end of therapy. the treatment-induced reduction in size of irf, as assessed by ct/mri, was defined as absent if <10%, mild if 10-50%, and marked if >50%. fdg uptake was graded from 0 to 3+. the pts were compared with 24 controls. results: at diagnosis, 22 (92%) pts showed a pathologic fgd uptake with 2 main patterns: diffuse (13/22 pts, 59%), and focal (9/22 pts, 41%). diffuse pattern: 10 had grade 3+, 2 had 2+ and 1 had 1+ uptake; the reduction in size of irf was marked in 9/10 (90%) pts with grade 3+ and 1 of 2 pts with grade 2+ and absent in 1 with 3+, 1 with 2+ and 1 with 1+. focal pattern: 3 had grade 3+, 4 had 2+ and 1 had 1+ uptake. a marked response was observed in only 1/3 pts with grade 3+; 2 mild responses in 2/4 pts with grade 2+; no response in 2/3 patients with grade 3+, 2/4 with grade 2+ and 2/2 with grade 1+. both pts without pathologic uptake showed no reduction. after the end of treatment, 6/13 pts had a residual pathological uptake whereas 7 had no uptake. posttreatment relapses were observed in 5/6 pts with a residual uptake, and in only 1/7 pts without. conclusions: the distribution and intensity of vascular fdg uptake may predict response to treatment in irf patients; a post-treatment residual uptake heralds disease relapse. spect/ct may provide an incremental value to routine indium-111 labeled wbc scintigraphy, as suggested by a recent report with a limited number of patients (1) . in this study, we verify this finding in a larger group of patients and also evaluate the different possible contributory factors to the diagnostic confidence of spect and spect/ct scans. methods: we retrospectively evaluated indium-111 wbc planar scans of 68 patients (age 55 ± 20 years, 39 men) with known or suspected infection that also had spect/ct performed. planar, spect and spect/ct scans were separately reviewed by 2 observers in respect to infection presence, location, and the specific diagnosis based on each scan. the confidence in each of these assessments was categorized as uncertain, probable and certain. the final diagnosis was confirmed by surgical/pathological correlation; follow up scan/radiological examination or up to 18 months clinical follow-up. results: in 10 planar images with uncertain infection location, spect improved 9 locations to probable sites that were further improved to 9 definite and 1 probable sites by spect/ct. correspondingly, in 38 probable location sites on planar images, spect improved 3 locations to definite sites compared with 37 definite sites improvement by spect/ct. conversely, spect significantly improved infection presence certainty in uncertain and probable planar subcategories, without significant additional improvement by spect/ct. in spect/ct, the specific diagnosis confidence was significantly higher when both infection presence and location site were certain, which was more frequently attained than with spect scans alone (45 vs 22, p < .001). final diagnosis was categorized as non-specific/abscess, specific soft tissue infection, osteomyelitis, combined osteomyelitis/soft tissue infection, and normal/physiological uptake. spect/ct findings were more accurate in predicting the final diagnosis (lambda value 0.91, uncertainty coefficient error reduction 87%) than spect alone (lambda value 0.69, uncertainty coefficient error reduction 60%). conclusions: in indium-111 wbc scintigraphy, the infection presence recognition is improved by both spect and spect/ct, while the use of spect/ct leads to considerable enhancement in infection localization as well. the significant improvement in both these factors is the likely reason for the high confidence in the spect/ct specific diagnosis of infection. 1. bar-shalom r, et al. j nucl med 2006; 47:587-594 objectives: in aortic aneurysm (an) tissues, chronic aortic wall inflammation is mediated by macrophage infiltration, which is playing important role for tissue degeneration. some studies have shown that weakening of the mechanical properties of the degenerated tissues may progress the expansion of the aneurysm. especially, saccular ans often expand rapidly and are suspicious for an infected aneurysm. in the present study, we hypothesized that fdg accumulated in saccular an walls because these lesions had strong inflammatory reaction with macrophage infiltration and investigated whether fdg accumulated in saccular ans. methods: a retrospective survey was conducted on 17 patients with an who underwent fdg-pet. after at least 5 h fasting, the study subjects received an intravenous administration of fdg. one hour after fdg injection, pet imaging was carried out. fdg images were visually evaluated for the presence of increased fdg uptake in the carotid arteries. we divided the 18 ans in 17 patients into two groups (saccular-type or fusiform-type) according to the morphologic characteristics. we assessed inflammatory marker (crp) and pathologic characteristics (atherosclerotic or inflamated) in two groups. results: 6 of 18 ans were divided into 6 saccular-type and 12 fusiform-type ans. 5 of 6 saccular-type ans were pet-positive, whereas only one of 12 fusiform-type ans was pet-positive. there was no significant difference in the values of crp and aneurysmal size in two groups. 10 ans proven pathologically were divided into 4 saccular-type (2 infected, 2 atherosclerotic ans) and 6 fusiform-type (all atherosclerotic ans). fdg accumulated in all of 4 saccular-type ans. conclusion: fdg frequently accumulated in saccular-type ans. ans in which fdg accumulates may have a high risk of rapid expansion and rapture because these lesions are suspected to have inflammatory reaction with macrophage infiltration. aim aim of this study was that of confirming additional clinical effectiveness using spect/ct with 99mtc hmpao-labelled leucocyte in infection and inflammation . materials and methods we studied ninety-seven patients (pts) (52 females and 45 males; mean age 58.75 ± 20.25 years); all patients underwent labelled leucocyte scintigraphy for known or suspected infectious or inflammation processes: 29 pts with orthopedic implants, 28 pts with suspected osteomyelitis ,8 pts with spondylodiscitis, 14 pts with fever of unknown origin (fuo), 12 pts with inflammatory bowel disease (ibd), 5 pts with suspected septic arthritis and 1 pt with suspected vascular graft. in addition with planar and whole body protocol images spect /ct was performed using dual head gamma camera equipped with a low-power x ray system (infinia hawkeye -g.e.healthcare ). after injection of 555 -740 mbq of 99mtc hmpao-labelled leucocyte spect/ct images of the interesting area were obtained in all cases at 2h or 4h according with the clinical query. final diagnosis of infection and inflammation was made on the base of bacteriologic, surgical data or clinical followup. results spect/ct results proved on the whole cases 43 true-negative and 50 true -positive, 2 false -negative and 2 false-positive results. in orthopedic implants and osteomyelitis cases spect /ct permitted to distinguish between soft -tissue infection and bone involvement and allowed to change clinical and surgical management in 64% cases; spect/ct detected precise localization in ileal and ileocolonic tract in positive ibd cases. additional value of spect/ct was in fuo cases since it permitted a diagnosis of renal abscess in 1 pt with polycystic kidney who previously underwent renal transplant, in another pt, abnormal focal uptake in catheter for haemodialysis and in 3 cases with liver , lung and sub-diaphragmatic abscess respectively. the overall sensitivity and specificity of spect/ct 99mtc-hmpao labelled-leucocyte was 96% and 95% respectively. conclusion spect/ct with 99mtc hmpao-labelled leucocyte is a useful tool for infection and inflammation detection that provides a precise anatomy localization, expansion and tissues differentiation mainly between soft tissue infections and osteomyelitis. furhermore, it underlines the role of 99mtc hmpao-labelled leucocyte in cases of suspected abdominal-pelvic or thoracic sites of infections increasing the diagnostic accuracy of positive findings. objective: hemodialysis (hd) activates neutrophils and causes increased lung retention. 99m tc fanolesomab is a monoclonal antibody that radiolabels white blood cells and myeloid precursors in vivo. it reacts with cd 15, expressed on the surface of polymorphonuclear neutrophils, eosinophils and monocytes. serious complications occurring < 30 min. after injection was reported in patients (pts) with compromised cardiopulmonary reserves. lung retention of this agent has not been addressed yet. we hypothesized that there might be an excess transient retention of these invivo labeled and probably activated wbcs in the lung capillaries post hd, which may contribute to pulmonary compromise. methods: we retrospectively and semi-quantitatively determined the degree of invivo labeled 99m tc wbc activity on anterior (a) and posterior (p) whole body images of the 23 consecutive pts. a and p rois were drawn in the upper (u), middle (m) and lower (l) lung zones and over the chest wall soft tissue background and used to calculate the geometric means of conjugate rois (lung uptake ratio). 6 pts without esrd and not on hd were used as controls. elapsed times from the last hd to imaging times were determined. result: mean± sd injection to imaging time: 178 ± 64 min (78-338). of the 17 pts with esrd on hd, 12 had hd < 24 hr before the imaging (group i), 5 pts had hd 24-48 before the imaging (group ii). geometric mean lung uptake ratios for right (r) u, rm, rl, left (l) u, lm, ll in group i were 2.28 ± 0.53, 2.75 ± 0.63, 3.07 ± 0.74, 2.36 ± 0.48, 2.95 ± 0.51 and 3.10 ± 0.75, respectively. those values for group ii were 1.80 ± 0.38, 2.17 ± 0.49, 2.46 ± 0.61, 1.62 ± 0.31, 2.02 ± 0.39 and 2.38 ± 0.48, respectively. control ratios were 1.93 ± 0.21, 2.12 ± 0.42, 2.58 ± 0.61, 1.79 ± 0.28, 2.12 ± 0.43 and 2.47 ± 0.51, respectively. a trend of subtle increase in lung uptake ratios was noted for group i, especially in left lung. however, differences weren't statistically significant. conclusion: a recent hd done < 24hrs might play a role in the activation of the invivo labeled 99m tcwbcs causing prolonged lung retention in esrd pts, which is not present > 24hrs. despite the strong trend, lack of statistical significance in group i pts might be due to relatively long (90-338 min) injection to imaging time and small pt population. purpose:in this study, we aimed to investigate the role of tc-99m hmpao white blood cell (tc-99m wbc) spect in the evaluation of bone infections in addition to tc-99m mdp 3-phase bone (tc-99m 3-p) scans and planar tc-99m wbc scans. materials and methods: the patients who had tc-99m 3-p and tc-99m wbc scans between january 2006 and march 2007 for the investigation of suspected bone infections were evaluated retrospectively. from these, 20 patients whose pathological, bacteriological, surgical data, and clinical onset showed infection were included to our study. for every patient, tc-99m 3-p, planar and spect tc-99m wbc scans were performed within one week. our patient group consisted 12(60%) males and 8(40%) females whose ages were 10-93 (mean age was 51.5) and who had bone infections in various localizations: 11 patients (55%) had infections of foot, 6 patients (30%) had infections of knee (3 of them had knee prosthesis), 2 patients (10%) had infections of hand, and 1 patient (5%) had infection of leg. results: the images of tc-99m 3-p and planar tc-99m wbc scans were evaluated together and tc-99m wbc spect images alone. the results were as followings: were enrolled the study. the patients were suspected of bacterial infection due to travmatic injury (18 pts), diabetic foot (13 pts) and prosthetic surgery (23 pts). whole-body images at 1, 4 and 24 hours after iv slow injection of 20 mci ciprofloxacin labelled with technetium-99m in-house were obtained. threephase bone scintigraphy was also performed in 42 patients in a period of 3 to 10 days. final diagnosis was obtained by microbiological and patological examinations and clinical follow-up for a period of 1 to 3 years. results there were 33 positive findings on tc-99m ciprofloxacin images and 31 of them were proved to be true-positive. staphilococci was the most common agent isolated by microbiological analysis. in one of the patients with false-positive finding, intensive bone repair was noted on bone scan images. ciprofloxacin imaging was true-negative in 14 patients and failed to show bacterial infection in 7 patients (chronic osteomyelitis in 2, hip and knee posthesis in 2 and diabetic foot in 3 patients). the overall sensitivity, spesificity, negative/ positive predictive value and accuracy of tc-99m ciprofloxacin imaging were 81% 88% 66%/93% and 83% respectively. conclusion tc-99m ciprofloxacin is a sensitive and practical procedure that can be used in detecting musculoskeletal infection. it also contrubutes to discriminate aseptic loosening and prosthetic infection and avoids unnecessary orthopaedic surgery. along with three-phase bone scanning false-positive results can be reduced where excessive new bone formation might be the potential cause of false-positive results. objectives: infection of hd vascular access site is a frequent cause of mortality morbidity in hd patients. the incidence is lowest in patients with avf. although the prosthetic hd access (avg and/or catheters) has been acceptable alternative to the native avf, the patients are often plagued by more complications (i.e., infection, thrombosis). aim of the study was to determine the accuracy of infection detection using invivo labeled tc-99m wbc imaging in patients with avf as hd access as compared to those with prosthetic hd vascular access (avg, catheter). methods: 24 consecutive patients with end stage renal disease being treated with hd and who had suspected infections were retrospectively analyzed. two nuclear medicine physicians evaluated the tc-99m wbc images in a blinded fashion. vascular access infection was diagnosed if radiotracer uptake at the site was focal fashion and more prominent than the surrounding blood vessels. the scan results were correlated with clinical/laboratory information, cultures and outcome. results: in 24 patients a total of 29 vascular access sites were evaluated. there were 13 avg, 5 avf, and 11 hd catheters. none of the avf was infected but 60% showed collateral formation. invivo labeled tc-99m wbc scan showed evidence of infection in 7/13 avg (%54) of the avgs, compare to 4/11 (36%) of the hd catheters (p: 0.09). when compared, avf versus prosthetic hd access (avg + catheters), the incidence of detected infection was 0% versus 46% (p: 0.07). the sensitivity, specificity, positive predictive value, negative predictive value and accuracy for the detection of infection with the tc-99m-wbc scan in avgs were: 100%, 67%, 78%, 100%, and 85%. the values for the hd catheter were 100%, 86%, 80%, 100% and, 91%, respectively. conclusions: a properly formed arteriovenous fistula is less likely than other types of vascular access to become infected. hemodialysis catheters and arterio venous grafts had similar rates of infection. the tc-99m wbc scan has an accuracy rate of 85-90% in detecting infection in arterio venous grafts and hemodialysis catheters i.e., prosthetic hemodialysis access. objectives: this was an intraindividual analysis of the utility of currently available radionuclide imaging techniques: 3 phase bone (3pbo), bone (bo), gallium (ga), bone/gallium (boga), labeled leukocyte (wbc), leukocyte/bone (wbc/bo), and leukocyte/marrow (wbc/ma), to determine the most accurate radionuclide technique for diagnosing the infected hip prosthesis. methods: 50 patients, 29 females, 21 males, 38-85 years old, with failed hip replacements, 43 total arthroplasty, 7 hemiarthroplasty, 4 weeks-20 years old, who completed all radionuclide imaging tests and who subsequently underwent surgery formed the basis of this retrospective study. one experienced nuclear physician reviewed all images. diagnostic criteria for infection were as follows: 3pbo= triad of periprosthetic hyperperfusion, hyperemia, & increased periprosthetic activity on delayed, bone, images; bo= increased activity around the shaft of the femoral component, ga= any increased periprosthetic activity except focal activity at the tip or trochanters, bo/ga= spatially incongruent distribution of activity or, if congruent, ga activity >bo activity, wbc= increased periprosthetic activity relative to contralateral limb or surrounding normal activity, wbc/bo= spatially incongruent distribution of activity or, if congruent, wbc activity >bo activity, wbc/ma= spatially incongruent distribution of activity. imaging results were compared with surgical, histopathological and microbiological results for all 50 prostheses. results: there were 25 infected prostheses. final diagnoses in the remaining cases include aseptic loosening (22), failed acetabular liner (2) , and component malposition (1) . imaging results are summarized in the for all prostheses the 3pbo scan demonstrated only moderate sensitivity and low specificity. for reasons that are as yet unknown, the test was not sensitive, but moderately specific, for diagnosing prosthetic hip infection, while in contrast, it was very sensitive, but not at all specific, for diagnosing prosthetic knee infection. conclusions: the 3 phase bone scan is of limited utility for diagnosing infection of lower extremity joint prostheses. the test is not sensitive for prosthetic hip infection and too nonspecific to serve as a screening test for knee prostheses. malignant otitis externa is a rare infectious disease of the external auditory canal commonly caused by pseudomonas aeruginosa. the disease may have a protracted course with extension to other bony and soft tissues structures of the skull base. evaluation of disease extent is crucial for initial management with further evaluation required to document resolution during treatment. ct will delineate bone and gross soft tissue involvement but may be normal in early disease. mri is useful to assess soft tissue extent of disease but assessment of resolution is difficult with both modalities. bone scintigraphy will detect early bone involvement but remains abnormal for some time therefore is unreliable for assessment of resolution or detecting early recurrence. gallium-67 citrate can be used to assess disease extent but like bone scintigraphy is non-specific and partly reflects bone activity. there is less published data on the use of in-111 white cell imaging which has been said to become negative before complete resolution. it is possible that this drawback relates to the imaging properties of in-111 and the difficulty of localising small low intensity foci of white cell accumulation on planar views. in three recent cases of suspected skull base osteomyelitis low intensity foci of white cell accumulation were identified on planar imaging with in-111 labelled white cells. use of spect combined with 'hawkeye' (low power ct: ge-millenium vg) allowed accurate localisation of these foci. dual isotope acquisition with combined in-111 and tc-99m mdp assisted in this process as the more intense and extensive uptake by the bone agent helps to identify the initial extent of disease and which transverse slices to examine in detail on the lower count data acquired with the in-111 spect. in each case imaging was repeated during the clinical course of the disease to document resolution with scintigraphic findings mirroring the clinical course. conclusion use of in-111 combined with tc-99m mdp spect and 'hawkeye' can be useful to assess extent of disease in suspected skull base osteomyelitis on initial presentation, to monitor response to treatment and to assist in determining when to discontinue antibiotics. it is possible that this may be more specific and may present a viable alternative to ga-67 citrate in such cases. careful attention to imaging parameters is required to avoid acquisition of meaningless data in view of the low counts obtained with in-111 spect particularly as disease resolution occurs. the utility of 99m; conclusion: many common diseases manifest themselves with no specific sign or symptoms, but with fuo associated to an increase of no specific marker of inflammation. our data show that, even if, most of patients with fuo had negative scintigraphy with leukoscan, it can help clinician to identify the cause of fuo and to decide the best therapeutic treatment. the main etiologies of fever of unknown origin (fuo) are infections, cancers, and noninfectious inflammatory preocesses. in this prospective study, we aimed to evaluate the diagnostic role of 18f-fluorodeoxyglucose (fdg)-pet in fuo, since this substance has an increased uptake by neoplastic and inflammatory cells. methods: the study included 23 patients (17 male, 6 female, mean age 51.3 ± 20.6 years, range 1-70 years) referred to our unit for fdg-pet study between march 2005 and december 2006. siemens lso hirez pet-ct camera was used for the record of the imaging. one hour after injecting 12-16 mci fdg, a whole body pet-ct from vertex to toe was obtained. results: among 23 patients studied by pet-ct, 14 (60.1%) had foci with increased fdg uptake. the remaining had normal findings. among those patients with increased fdg; malignant neoplastic process, inflammatory process, and infection were diagnosed in 7, 6, and 1 patients respectively. modern combination chemo-and radiotherapy have raised long-term survival of hodgkin lymphoma (hl) to more than 80%. however, the longer follow-up has shown serious long-term adverse effects related to the treatment, including heart and lung diseases, and secondary malignancies. in order to reduce these long-term side effects, alternative therapeuties are becoming more tailored to the individual patient's prognosis. in this regard, an important predictor of outcome is the early establishment of treatment response. conventional methods as ct scan have proven to be poorly accurate to this purpose. recently, early interim fdg pet/ct has been reported as a strong and independent predictor of progression-free survival in hl. in particular, a positive early interim fdg pet/ct is highly predictive of progression in patients with advanced stage or extranodal disease. in the present prospective study, we collected 13 consecutive patients with newly diagnosed hl since 2004. all patients underwent initial staging with fdg pet/ct (it was positive in all patients) along with standard staging procedures, including ct. fdg pet/ct was repeated after 2 (fdg pet 2) and 4 cycles of chemotherapy, and after completion of chemotherapy (abvd schedule). evaluation of this last fdg pet/ct was discriminant to decide for radiotherapy in bulky disease. the follow-up range was of 4-28 months. all the fdg pet2 negative patients are in complete disease remission, except for one case (patient 2/see table) who experienced early relapse, resistant to autologous bone marrow transplantation. she is now in disease progression and a shift in lymphocyte depletion histo-type has been documented. results are shown in the subtotal splenectomy is effective in decreasing both the hematologic complications of hs and infectious complications of total splenectomy. the objective of this retrospective study on 61 patients was to identify clinical and/or biological factors which could predict the rate of regrowth of the splenic remnant and influence the beneficial effect of subtotal splenectomy on red cell life span. material and methods : sixty one patients (m=34 ; f=27) with hs who underwent subtotal splenectomy between february 1985 and march 2005 were included in this analysis. for each patient, preoperative and postoperative clinical and biological data were collected: date of first symptoms, the clinical and biological indications for subtotal splenectomy (propensity for fatigue , number of transfusions, associated cholelithiasis, mean values of haemoglobin and reticulocyte counts), patient's age at the date of surgery. postoperative growth and functional value of the splenic remnant were assessed by abdominal single photon emission computed tomography (spect). acquisitions were performed after injection of autologous heat damaged red blood cells labelled with technetium 99m. splenic volume was calculated on reconstructed axial slices by means of a threshold algorithm previously validated on a phantom study. results & conclusion: statistical analysis was done with r software. mean values of haemoglobin, reticulocyte counts and clinical scores were compared between preoperative and postoperative follow-up periods. median delay between subtotal splenectomy and splenic scintigraphy was 538 days (range 167-6503). three patients developed splenic necrosis postoperatively and were dropped from the statistical analysis of predictive factors. the mean splenic volume measured by spect was 205 ml (range 34 ml -601 ml ; median= 166 ml). the mean haemoglobin values increased from 9.1 g/dl before surgery to 12.2 g/dl after surgery. univariate and multivariate analyses were performed to identify the predictive variables of splenic regrowth. we describe a case of hairy cell leukemia (hcl) coexistent with non-hodgkin's lymphoma (nhd). this combination is reported to be extremely rare with no clear demonstration of the clonal relationship between the two condition. after a previous failure of purine analogs therapy, our patient was successfully treated with rituximab resulting in normalisation of blood cell count cessation of blood transfusion and negative iliac crest biopsy. unfortunately, the patient developed intense and persistent bone pain during the 1 st line treatment for hcl. skeletal x-rays, whole-body ct scan and bone mri were unremarkable and bone scintigraphy showed non-specific changes. laboratory examinations were normal. to better evaluate these non-specific findings, a fdg-pet/ct was performed, followed by a guided bone marrow biopsy of the left femoral diaphysis. this demonstrated an aggressive high grade lymphoma, characterized by immunoblasts and polymorphous centroblasts in a diffuse pattern, expressing cd20, cd79a, cd10, ig k for a 30 %, nuclear and cytoplasmic bcl-6 antigen, a high proliferative index (mib-1 >90%), and alk negative. these parameters, along with the absence of a low-grade component, were consistent with the diagnosis of primary bone marrow diffuse large b-cell lymphoma (lbcl). shortly afterwards, ldh rapidly increased to 3780 u/l and hb levels decreased to 9 g/dl; esr was 120 mm, ferritin was 2857 ng/ml, fibrinogen 1000 mg/dl, 2 -m 6 mg/l. an attempt was made to assess and compare b cell clonality of both disorders using a seminested pcr approach, as previously described (1); unfortunately no major ig h gene rearrangements could be detected in both disorders with the primer pairs used for the assay. in may 2004 the patient was started on weekly chemotherapy scheme (vacop-b). diffuse bone pain rapidly resolved and hb concentration, esr, 2 -m and ldh normalized. unfortunately in july, six weeks after chemotherapy, she became sleepy and developed loss of memory, and central nervous system involvement with lbcl was confirmed with csf cytology and immunophenotyping. brain mri showed diffuse subependimal disease. therefore, the patient was given both intrathecal and systemic 3 rd line chemotherapy with progressive neurological improvement. however, her clinical condition showed rapid deterioration culmibnating in cessation of chemotherapy. the patient eventually died of progression of her disease in august 2004. it can be recommended the early performance of fdg-pet/ct in poorly understood bone pain to identify bone and bone marrow localization of nhd. objective: the aim of our retrospective study is to compare the recurrence (local, regional node or distant metastasis) after sentinel lymph node biopsy (slnb) with and without axillary lymph node dissection (alnd) in patients with breast cancer. patients and methods : between may 1998 and september 2002, 277 patients with early-stage invasive breast cancer (<ct2, cn0, cm0), underwent slnb in our institution. 167 patients were treated with alnd after slnb and 110 patients without. all patients were classified pn+ or pn0 based upon presence or absence of metastatic lymph node by pathologic analysis. a total of 69 patients (24.9%) were pn+. the median follow-up period is 72 months (range 16-104). the site of first recurrence was classified as local, regional node or distant metastasis. results : recurrence occurred in 21/277 patients (7.6%). the median interval to recurrence was 38 months. local, regional node and distant metastasis recurrence occurred respectively in 1.9%, 0% and 2.9% of pn0 patients treated with slnb alone (n=103), and in 1.9%, 0.9% and 2.9% of pn0 patients treated by slnb with alnd (n=105). in patients with positive nodes (n=69), regional node recurrence and distant metastasis are sensibly more frequent (respectively 1.6% and 12.9%), while local recurrence is comparable (1.6%). conclusions : as reported by several others teams, our study demonstrates that local, regional node and distant recurrence rate in patients treated by slnb without alnd, providing sln is negative, is not greater than after alnd. this remains true after a long time follow-up (over 5 years). our results support that slnb alone in sln-negative patients is a safe method to assess axillary lymph node status in early-stage breast cancer. (100) 105 (100) 0 (0) 0 (0) 1-3 0 (0) 0 (0) 7 (100) 55 (88.7) 4-9 0 (0) 0 (0) 0 (0) 5 (8.1) >10 0 (0) 0 (0) 0 (0) 2 (3.2) median follow-up 66 months 77 months 56 months 74 months median interval to 35 months 50 months 33 months recurrence recurrence 5 (4.9) 6 (5.7) 0 (0) 10 (16.1) local 2 (1.9) 2 (1.9) 0 (0) 1 (1.6) regional node 0 (0) 1 (0.9) 0 (0) 1 (1.6) distant metastasis 3 (2.9) 3 (2.9) 0 (0) 8 (12.9) alnd, axillary lymph node dissection; sln, sentinel lymph node; aln, axillary lymph node aim: although it is well documented that previous excisional biopsy is not a contraindication in sentinel lymph node biopsy (slnb), there are studies reporting problems caused by previous surgical applications. in this study we aimed to review retrospectively if there is a relation between problems encountered and presence of previous excisional biopsy during snlb. material and method: a total of 167 female patients were included in the study. seventy two of them were patients having previous excisional biopsies. 1 mci of tin colloid was injected at 4 quadrant around areola intra/subdermally 18 hr before surgery. patients were imaged at anterior and lateral projections and during operation slns were excised with the guidance of gamma probe. results: application difficulties were analysed in 3 main topics and were seen in 9 patients. dilated lymphatic channels showing activity stasis caused problem in 3 patients. leakage of the activity in a localization other than injection site was the case in 3 patients (into the biopsy cavity in 1 and in an intradermal pouche in 2 patients). non-vizualization of sln at first injection was the problem in 3 patients. when occurence of this problems and presence and localization of previous biopsies were compared no correlation was detected between dilated lymphatics and biopsies. presence of dilated lymphatic channels were more often in non-biopsied patients (5/95) than biopsied patients (3/72) . although dilated lymphatics increased operation time did not prevent detection of slns. all patients showing activity leakage have had biopsies within 3 weeks with periareolar insicions. leakages formed focal activity accumulation areas mimicking sln appearences. the real sln could not be visualized in patient having leakage into the biopsy cavity. in other 2 patients having leakage into dermal pouch slns are succesfully identified. all patients with nonvisualized slns at first injection were patients having previous biopsies. in 2 of them with a second intraparenchimal injection done just before the operation slns could be detected. in the 3rd patient who had additionally morbid obesity sln could not be identified. conclusion: although previous excisional biopsies do not compromise the effectiveness of the technique, especially when done with periareolar insicions it may cause problems in periareolar injection technique. detection of sentinel lymph nodes in breast cancer: every day practice and pitfalls g. moulin-romsee 1 , e. d'hondt 1 , f. persyn 1 , b. van calster 1 , s. ceyssens 2 , p. neven 1 , s. stroobants 1 ; 1 ku leuven, leuven, belgium, 2 uza, antwerp, belgium. the sln technique has radically changed the management of breast cancer by reducing the need for axillary lymph node dissection. controversy and variety in every day practice however exists. we investigated the effect of different methodologies as part of an internal iso audit. methods: initially, 40 mbq tc-nannocolloid was injected peritumoral and images were acquired after 30-45 min and 2 hours (group i, april-september 2005). because a decreased visualisation on scintigraphy was noted (group ii, january-april 2006), the procedure was adapted (group iii, may-september 2006). the tracer was injected subdermal and for the 2-day protocol, the dose was increased to 80 mbq. if lymphoscintigraphy was negative after 2 hours another 40 mbq was injected periareolar. differences in patients characteristics, visualisation and identification rate between the 3 patients groups were statistically analysed. results: scintigraphic visualisation and surgical identification rate was 79% and 91% for group i, 71% and 90% for group ii and 87% and 97% for group iii. except for age, patients' characteristics were similar (bmi, hooked wire). the odds of finding a preoperative sln is significantly higher in group iii compared to both other groups (or=2.84) which is explained by the higher count rate of the resected sln (p=0.0008). other factors that are associated with a decreased detection rate are hooked wire (or=0.416), bmi (or=0.87) and age (or=0.94) discussion: we advocate the use of a single subdermal deposit since it drains more rapidly and is easier to perform. failure to detect a sln is more frequently in association with hooked wire, higher age and patient overweight. when a 2-day protocol is used, sufficient dosage should be used to ensure strong signal perioperatively. aim axillary treatment for breast cancer can increase resistance to lymph outflow from the arm. lymphatic collector vessels may have to pump against a chronically raised afterload, leading to lymphatic collector pump (lcp) failure and breast cancerrelated lymphoedema (bcrl). a new lymphoscintigraphic technique was used to measure lcp function in normal and bcrl arms. materials and methods in an ethics committee approved study we first measured hand to axillary lymph node transit time (t transit ) using intradermal injection of 99m tc-human igg ( 99m tc-hig, 10mbq) using -camera imaging. lcp force was assessed by placing a sphygmomanometer cuff at 60mmhg around the upper arm before injection and retention of 99m tc-hig distal to the cuff and absence of axillary counts at >t transit indicated inhibition of lcp function. after t transit max cuff pressure was lowered by 10mmhg steps until 99m tc-hig passed under the cuff and reached the axilla, indicating the pressure (p pump ) lymphatics could overcome. results t transit was 10±7[sd]min (21 min for t transit max) in 7 healthy subjects (52±10years). lcp force (p pump ) was assessed in 16 healthy controls (54±6years) and 16 women with bcrl (60±8years, 12-56% forearm swelling). p pump was 39±14mmhg in controls, and lower at 24±19mmhg, in bcrl subjects with swollen forearms (p=0.014, unpaired t-test). background and aim based on our previous experience with radioguided occult lesion localisation (roll) in the breast, we have recently introduced similar roll method for the detection of clinically non-palpable lesions in the neck with 99mtclabelled macroagregates (99mtc-maa). patients and methods radioguided biopsy was performed in 9 patients (3 males and 6 females, age 27 -79 years) who had ultrasonographically proven non-palpable lesions in the neck. in 4 these were clinically suspected to be lymphoma, in 2/3 patients with papillary thyroid carcinoma (ptc) who already had total thyroidectomy and radioiodine ablation or therapy these were suspected to be ptc lymph node metastases and in 1/3 a relaps in the thyroid bed. in 1 patient repeated supraclavicular lymph-node biopsies were inconclusive, in another a primary ptc was cytologically suspected to be located in a thyroglossal duct cyst. the radiotracer (99mtc-maa 3.7 mbq in 0.1 ml volume) was injected intratumorally under the us guidance. all the patients underwent planar scintigraphy of the neck imediately after radiotracer application -1-2 hours before surgery. the location of the injected radiopharmaceutical in the neck was marked on the patient's skin with a point 57-co source and indellible ink. injected activity, taken up by the neck lesions, was intraoperativelly detected and located with a gamma probe. in all patients scintigraphy revealed intense focal uptake in the neck. all the marked lesions were intraoperativelly easily detected with gamma probe. histopathological findings confirmed lymphoma in 4 (follicular b-cell in 2, anaplastic large cell in 1 and hodgkin's lymphoma in 1 patient) and ptc metastases in 2 patients. in a patient with thyroglossal cyst histopathology excluded any neoplastic infiltration. in a patient in whom repeated supraclavicular lymph node biopsies were inconclusive, a radioguided biopsy revealed a metastasis of a poorly-differentiated pancreatic adenocarcinoma. in one patient with ptc and elevated tg levels after total thyroidectomy and repeated radioiodine therapies, suspected to have a relaps in the thyroid bed, histology of a scintigraphically and intraoperativelly »hot« paratracheal lesion was negative, probably due to the fibrosis as a consequence of surgical and radioiodine therapy. conclusion our work suggests that intraoperative radioguided detection of nonpalpable lesions in the neck after 99mtc-maa under the us guidance is simple and accurate method. the aim of the study was to determine the reliability of the diagnostic procedure of radioguided occult lesion localization (roll) and to detect sentinel lymph nodes in occult lesion localization (snoll) using two kinds of radiopharmaceuticals. a total of 67 female patients (mean age 56), in whom mammography, breast ultrasound, and fine needle aspiration cytology detected high risk occult lesions, were enrolled in the study. material and methods: the day before surgery (18hrs) under ultrasound guidance 74 mbq 99mtc-maa (from 55.5 mbq to 92.5 mbq) in a volume of 0.2 ml was injected into the center of the lesion. usually about ten minutes after radiotracer was injected, anterior and oblique scintigrafic images were acquired. the breast contour was outlined with flexible marker 57 co and the nipples marked with point source ( 241 am). on the day of surgery 15 mbq of 99m tc-nanocolloid in a volume of 0.2 ml was subdermally injected above the marked localized breast lesion. images made twenty minutes later in anterior and anterior-oblique projection revealed a sentinel lymph node. results: in all patients scintigraphy uncovered activity in the lesions and sentinel lymph nodes. the average lesion size of 6.2 mm was detected mammographically, and of 5.7 mm with ultrasound. cytological findings confirmed invasive ductal malignant tumors in 38 (56.7%) and suspect in 7 (10.5%) patients. puncture of the suspect lesion was not performed in 21 (31.3%) patients and only one patient (1.5%) had normal findings. tumerectomy was performed in all patients. patohistological findings confirmed malignant breast cancer in 57 (85.1%) patients, of which metastases in sln were detected in five (8.8%). conclusion: the obtained results show that a method of choice for a safe and quick localization of the occult breast lesion and sln is the combination of simultaneous detection of the occult localized breast lesion with 99m tc-maa under ultrasound guidance and the detection of sln with a lymphoscintigraphic subdermal injection of 99mtc-nanocolloid. introduction: chyluria may present as chylous clot, chylous clot retention, hematuria, flank pain, dysuria, weakness, fever and weight loss. it is a late manifestation of filariasis, a parasitic infestation endemic in south east asia. other associated conditions include repeated retroperitoneal infection, especially tuberculosis, trauma, genitourinary or gastrointestinal tumors, malignancy of the thoracic duct and thyroid, ureteric stone, hydrocele, inguinal hernia and pregnancy. lymphangiography has been the main imaging modality in investigating chyluria, chyloperitoneum and chylothorax. however, it requires tedious cannulation of lymphatics, is invasive and is not readily reproducible. lymphoscintigraphy using 99m tc labeled colloid delineates the pattern of lymphatic drainage, is fast, non-traumatic and has no known side effects. we are reporting a case of chyluria developed after a spinal surgery in which lymhoscintigraphy was used to localize the lymphorenal fistula. case history: 67 years old male who had a history of laminectomy over l3-l4 level and after 7 months he presented with complaint of chyluria and repeated urinary retention. on examination his vitals were normal and his cbc, lfts and serum creatinine were within normal limits. his urine reported milky in color with enormous fat and cellular component. his ultrasound abdomen revealed right renal cyst and mild prostatic enlargement. lymphoscintigram was performed with 37 mbq (0.5 cc volume) of 99m tc labeled nannocolloid injected subcutaneously as 0.25 cc aliquot in 2 nd and 3 rd interdigital spaces of both feet. 3 hr delayed whole body images revealed reduced traveling and relatively less outlined left inguinal lymph nodes, a normal flow and well outlined inguinal lymph nodes were seen in the right lower limb. there was evidence of visualization of tracer in the left kidney with appearance of para-aortic lymph nodes consistent with left sided lymphorenal fistula. a follow up cystography confirmed the appearance of chylous urine from the left ureter. patient refused surgery. discussion: chyluria is a relatively common condition is south east asia. lymphangiography has been the main imaging modality but it is invasive and requires expertise for canulation and significant radiation exposure. lymphoscintigraphy using tc-99m labeled colloid is safe, non-invasive and reproducible technique and gives less radiation exposure. it is invaluable in detection of site of lymphorenal fistula and cystoscopy during active chyluria helps to determine relative severity of the involved site of urinary tract. thus these two investigations together help determine the site of operation. granulocyte-colony stimulating factor (g-csf), a hematopoietic growth factor, is widely used to accelerate recovery from neutropenia after severe chemotherapy, both decreasing the risk of infection and mobilizing peripheral blood stem cells. g-csf is commonly administrated to healthy donors to mobilize peripheral blood stem cells for allogeneic hematopoietic stem cell transplantation. adverse events from g-csf use in healthy donors been described in approximately 30% of cases, and are comprised predominantly of bone pain, headache, and general fatigue. pulmonary complications caused by g-csf include cough, dyspnea, and interstitial or alveolar pulmonary edema with mild-to-severe deterioration of blood oxygen level. few cases of acute respiratory distress syndrome (ards) following g-csf administration have been reported. the present study was designed to determine the pulmonary clearance rate of tc-99m diethylenetriaminepentaacetic acid (tc-99m dtpa) in healthy donors for allogeneic hematopoietic stem cell transplantation and the role of tc-99m dtpa aerosol scintigraphy in the early detection of lung involvement. material and methods: five healthy donors (2 female, 3 male; aged 25 ± 9 years) were studied. tc-99m dtpa aerosol inhalation scintigraphy and pulmonary function tests (pft) were performed before and after 4 days g-csf administrations. on the basis of the scintigrams the percentage decline in activity per minute (kep) was evaluated, which represented an accurate parameter of lung membrane permeability. results: increased lung epithelial permeability was observed in all of the donors after 4 days g-csf administrations. there was statistically significant difference between two studies (1.17 ± 0.43 and 1.74 ± 0.72 for left lung; 1.24 ± 0.44 and 1.61 ± 0.62 for right lung, p<0.05, paired t test). but no significant change was observed in pft (p>0.05). conclusion: our preliminary results show that subclinical alveolitis may be present in healthy donors after g-csf administrations since it is known that an increase in the epithelial permeability of the lung is an early manifestation of interstitial disease. assessment of mean transit time in the engrafted lung with xe-133 lung ventilation scintigraphy improves diagnosis of bronchiolitis obliterans syndrome in living-donor lobar lung transplant recipients t. shinya 1 , s. sato 2 , k. kato 2 , s. akaki 2 , h. date 2 , s. kanazawa 2 ; 1 okayama kyokuto hospital, okayama-city, japan, 2 okayama university medical school, okayama-city, japan. aim: staging of bronchiolitis obliterans syndrome (bos) after lung transplantation is based on declines in forced expiratory volume in 1s (fev 1 ). use of computed tomography (ct) has been described for early detection of bos. the aim of this study was to evaluate the usefulness of 133 xe ventilation scintigraphy in early detection of bos after living-donor lobar lung transplantation (ldllt) and to compare 133 xe wahout imaging with ct finging for early detection of bos after ldllt. material and methods: subjects comprised 30 double-lung recipients and 1 single-lung recipient, who had undergone ldllt at our institution and survived >1 year. clinically diagnosed bos developed in 6 recipients. declines in graft function were evaluated using a combination of 3 methods: dynamic spirometry; computed tomography; and 133 xe ventilation scintigraphy. findings for all transplanted lungs were compared between ct and 133 xe washout imaging. assessment of 133 xe washout was assessed using mean transit time (mtt) of bi-and unilateral lungs. correlations between mtt of bilateral lungs and fev 1 % were evaluated. differences between mtt of bos and non-bos lungs and between mtt of non-bos and donor lungs were also evaluated on bi-and unilateral lungs, respectively. an appropriate cut-off value for mtt of bi-and unilateral lungs was set for the diagnosis of bos. results: in all 6 bos cases, prolonged-washout images of engrafted lungs revealed early-phase bos with declines from baseline fev 1 , while only 1 bos case could be detected using ct. a significant correlation was identified between mtt and fev 1 % (r=-0.346, p<0.0001). mtt of bi-and unilateral lungs was significantly longer in bos lungs than in non-bos lungs (p<0.0001). the cut-off mtt for bi-and unilateral lungs for diagnosis of bos were set at 62.19 s and 64.77s.conclusion: our data show that 133 xe washout imaging offers excellent potential for early detection of bos compared to early ct findings. using 133 xe washout imaging and mtt with radioactive tracer offers a non-invasive indication of selective ventilatory function in grafted lungs after ldllt. mtt appears useful for identifying bos after ldllt and allows evaluation of graft function in bi-and unilateral lungs. pet and ct evaluate of pulmonary nodules in an integrated pet/ct system w. s. huang 1 , c. y. cheng 1 , c. y. chang 1 , c. s. liu 2 , c. h. ku 3 , j. k. lee 4 ; 1 department of nuclear medicine, tri-service general hospital, taipei, taiwan;, taipei, taiwan, 2 department of radiology, tri-service general hospital, taipei, taiwan;, taipei, taiwan, 3 school of public health, national defense medical center, taipei, taiwan., taipei, taiwan, 4 dept. of nm, chung shan med. univ. hosp., taichung, taiwan., taichung, taiwan. aim: the fdg pet and ct have proved useful in evaluating pulmonary lesions. this study was performed to compare the respectively diagnostic power of pet and ct in the evaluation of single pulmonary nodules (spn). material and methods: a total of 117 patients with spn and without previous history of malignancy were analyzed. of them, 66 with known spn, the other 51 were accidentally found from a physical check-up. both pet and ct images were independently interpreted and were graded by the 5-point scales as described (radiology 1996; 200:135) . equivocal pet and ct image (grade 2) were dealt with 3 conditions: 1) dropped, 2) regrouped in to positive results or 3) regrouped into negative results. malignant diagnosis was based on histological findings or a clinical/ radiological follow-up at least 12 m. four comparisons were applied to assess the performance including 1) ct; 2) pet; 3) test in parallel (ct or pet positive); and 4) test in series (ct and pet positive). we used student's t test for univariate continuous variables and the 2 test for categorical variables and fisher's exact test whenever the expected 2 value for at least one cell was <5 (sas version 9.13, cary, nc). receiver operating characteristic curves were applied to calculate the areas under the curves of interest and for comparisons (medcalc version 8, mariakerke, belgium). results: pet yields 8 equivocal results, 4 of them had negative ct that turned out to be benign lesions. the other 4 patients had both equivocal pet and ct and two of them proved to be malignant. ct revealed 17 equivocal results, 7 were confirmed by pet as malignancy, the other 5 were benign. 10 out of the 17 ct equivocal lesions turned out to be malignant. conclusion: pet and ct play synergic role in the combined pet/ct scanner. fdg pet produced less equivocal lesions. combining interpretation of both pet and ct information helps resolve more than half of equivocal lesions. key words: 18 f-fdg; pet/ct; single pulmonary nodules running title: pet/ct in pulmonary nodules aim: to evaluate the situation of the work-up of patients with suspected pulmonary embolism at the national level especially in relation to the use of new diagnostic methods. method: we used a questionnaire send to all nuclear medicine departments in the czech republic. questions were selected to evaluate the methodology of the lung scintigraphy from the aspect of performance, results description, use of criteria and several time and quantitative parameters. we also asked about some concomitant and concurrent examinations. results: 36/46 (78%) departments filled in and returned the questionnaire. as to methodology, the planar images (4 or 6 to 8 views) are mostly used; only 2 departments perform only spect. lung perfusion scintigraphy is available only during working hours on working days; only in 1 department also on weekends. ventilation scintigraphy is performed only selectively. in the assessment of images, mostly standardized criteria in combination with any own are used (predominantly modified pioped). radionuclide venography is performed on all but 4 departments, thrombi imaging is not available at all. the number of perfusion scans declined yearly about 2%, ventilation scans increased about 10% and venography declined about 20% between years 2003 and 2005. ct scanners with less than 4 slices are mostly available for ct angiography. conclusion: the main drawback of lung scintigraphy is its time unavailability and predominance of planar imaging. the increase of ventilation scintigraphy could be done by the effort to increase specificity. the decline of perfusion scans is not significant, although it could be done by the low quality of ct scanners. long lasting exposure to toluene that is commonly used in automobile and spray paints, may cause in occupational asthma. in this study, we aimed to investigate the effect of toluene on tc-99m clearance rate of alveolar epithelium and on spirometric lung function tests in auto painters who exposed to toluene at least for ten years. twenty-eight autopainters with a mean age of 36.4±7.2 years and a healthy group with a mean age 33.7±8.7 were included in the study. tc-99m dtpa aerosol inhalation scintigraphy, and spirometric lung function test was administered to all subjects. clearance half time (t½) and penetration index (pi) on the first minute image after tc-99m dtpa scintigraphy were calculated. t½ and pi values were (48.91±19.96 and 0.36±0.04) for painters, and (35.73±6.91 and 0.34±0.034) for healthy group, respectively (p=0.034, p=0.032). there was a negative correlation between mean t½ and %fvc, %fev1 values (p=0.043, p=0.029, respectively). whereas, a positive correlation was observed between mean pi and fev1/fvc, %fef25-75 (p=0.037, p=0.045). comparison of pef values between painters (416.51±146.52) and healthy subjects (507.64±119.51) yielded significantly different results (p=0.038). however, t1/2 and pi did not correlate with pef. in painters group, t½ and pi significantly differed when painters with obstruction (49.50±8.06, 0.31± 0.04; respectively) compared with painters who did not have obstruction (43.91±9.08, and 0.36±0.03; respectively) (p=0.011, p=0.011, respectively). toluene exposure duration did not show a relationship with t½, pi and sft. our results indicate that toluene exposure affects bronco alveolar permeability and may cause obstructive changes that might be demonstrated by sft. however, we could not detect any relationship of toluene exposure duration with any parameter. to show if toluene exposure duration has any affect on occupational asthma development further studies are needed. technetium labeled human polyclonal immunoglobulin g (99mtc-hig) scintigraphy in the early detection of pulmonary involvement in connective tissue diseases (ctd) considering analgesics as the first option. if these fail, other therapeutic options can be considered, including metabolic radiotherapy with 153 sm as the greatest exponent. aim: evaluate 153 sm treatment response in patients with painful bone metastases. material and methods: we studied 35 patients (26 men; 9 women) with ages between 10 and 86 years old (with a mean age of 60.4 years) with painful bone metastases resistant to analgesic therapy. 37 mbq/kg of 153 sm were administrated intravenously. each patient remained hospitalized for 6 hours in our nuclear medicine unit in a room, conditioned for metabolic radiotherapy treatments. pain was evaluated following a visual scale before and after treatment (considering: total response: improvement > 4 points; partial response: improvement 2 -4 points; no response: improvement 2 points). results: in 27 out of 35 patients (77%) an effective therapeutical response was observed. 11 of these 27 effective responses (41%) showed a total pain disappearance, while in the remaining 16 (59%) the pain was partially soothed. the therapy was repeated in 2 patients, obtaining an efficient response, similar to the previous one. treatment was effective for 8 to 16 weeks (average: 13.6 weeks). no response was observed in 8 out of 35 patients (23%), including 3 patients who suffered sudden-deaths in where the response could not be evaluated. conclusions: treatment using 153 sm may result effective in painful bone metastases resistant to analgesic therapy. if the symptoms reappear, a new dose would achieve equally satisfying results. accurate interpretation of fdg-pet images requires optimal knowledge of the normal distribution of the tracer in various anatomical structures. this distribution may change due to age, gender, and physiologic conditions. our aim was to assess cervical spinal cord fdg-pet uptake as a function of age and gender. methods: head and neck fdg-pet images of 65 subjects were retrospectively assessed (21 male, 44 female; age: 21-74 years). the subjects had undergone head and neck fdg-pet imaging for a variety of reasons. the subjects did not have any evidence of fdg uptake which could interfere with measurement of spinal cord uptake. the subjects had no previous history of chemotherapy and radiation therapy. fdg uptake in the cervical spinal cord was visually evaluated. mean and maximum standardized uptake values (suvs) of cervical spinal cord were calculated for all subjects with visible spinal cord uptake. subjects were separated into three age groups, each consisting of two decades, and into two groups based on gender. one way anova and t tests were used for statistical analysis to calculate the differences of mean and maximum values for age groups and for gender. results: amongst 65 subjects, 62 had visible cervical spinal cord fdg uptake. three did not have visible cervical spinal cord uptake. the mean suv ranged from 1.3-2.7, the maximum suv ranged from 1.4 -2.9. averages and standard deviations (sd) of the mean and maximum suvs for age groups from the youngest to the oldest were 1.71 ± 0.33, 1.79 ± 0.41, 1.89 ± 0.29, and 1.98 ± 0.40, 1.95 ± 0.45, and 2.02 ± 0.26, respectively . averages and sd of the mean and maximum suvs for men were 1.86 ± 0.27 and 2.00 ± 0.24, respectively, and 1.75 ± 0.37 and 1.96 ± 0.43, respectively, for women. there were no statistically significant differences between the mean and maximum suvs amongst age groups or between genders. conclusion: these preliminary data show that fdg uptake within the normal cervical spinal cord is not affected due to aging or gender. further studies are required to confirm our results and to determine the significance of this observation in normal and pathological states. fusion of near-isotropic spiral ct to 2d nuclear medicine data to improve the accuracy of roi delineation in hepatobiliary and renal imaging b. corcoran, m. carroll, m. buxton-thomas; king's college hospital, london, united kingdom. objective in dynamic planar hepatobiliary imaging of auxiliary liver transplants and both dynamic and static renal imaging, regions of interest (roi) are used to generate time activity curves (tac) and to calculate the relative function of two organs. on the hepatobiliary image it is often difficult to differentiate the native and transplant livers. in both static and dynamic renal imaging, the edges of poorly functioning kidneys are often difficult to identify. the advent of high resolution spiral ct, available through pacs connectivity, now allows near-isotropic quality orthogonal images to be reconstructed. we use the coronal anatomical data to improve the delineation of the organs. fusing the coronal data to nuclear medicine imaging allows the more accurate rois to be applied in generating the tac and the calculation of physiological divided function. method for calculation of divided function from the dynamic data a composite image of the uptake phase is created. on a hermes workstation, orthogonal coronal sections are generated from high resolution spiral ct (transverse slice width = 0.74 mm, slice separation = 1.48 mm). a coronal section through the liver is chosen which clearly shows the division between the native and transplant. the summed ct image is fused, using mutual information rigid transformations, to the composite nm image. accurate rois drawn on the ct image are then applied to the nm image and divided function is calculated from the relative regional counts. result the method was applied to several patients undergoing sequential post-transplant hepatobiliary imaging (99mtc-ida) where spiral ct of the liver was available. the ct data provided greater confidence in differentiating the two functional regions of native and transplant liver. the method has also been applied to the deconvolution analysis of renograms (99mtc-mag3) and static renal scans (99mtc-dmsa). conclusion in hepatobiliary investigations for monitoring liver transplants, coronal images generated from spiral ct can be used to improve roi delineation in the calculation of relative function between native and auxiliary liver regions. the method has also been shown to have a useful application in the renal imaging of poorly functioning kidneys. with promising results from ongoing clinical trials, alpharadin™ (ra-223) looks destined to become commonplace in nuclear medicine. this paper aims to introduce the radiation protection requirements with ra-223 to those less familiar in working with short-lived alpha emitters and dispel some common misconceptions. traditional teaching of radiation protection has focussed on beta-and gamma-emitting radiation due to their more common application, ease of detection and less stringent regulations for handling open radioactive sources in the laboratory. as such, alpha-emitting radionuclides have traditionally been confined to research or use in sealed sources. in some countries, alpha emitters have developed an unwarranted reputation as a dangerous form of radiation. it is important to emphasise that alpha radiation only poses a radiation risk when long-lived alpha-emitting radionuclides become incorporated into the body and irradiate a small area of tissue for a long period. outside of the body, there is a much lower risk when working with alpha radiation compared to beta radiation and working procedures are often simpler. alpharadin™ is an alpha-emitting radiopharmaceutical in clinical development for tumour therapy and pain palliation in patients with skeletal bone metastasis. the alpha emitter ra-223 does not have inherent properties that make it a dangerous radionuclide. on the contrary, radiation protection parameters for alpharadin™ offer some significant advantages when compared to traditional beta emitters (table1). comparison of radiation protection parameters for ra-223, sm-153 and sr-89 aim the purpose of this study was to analyse the radiation emergency triage, treatment and hospital protection procedures in london after the contamination of alexander v. litvinenko with the polonium 210 in london 2006. identifying strengths and weaknesses allowed us to draw conclusions for improved future radiation emergency management (rem) strategies particularily for hospitals. materials we researched numerous public documents and conducted interviews with medical professionals at various hospitals involved in the case. methods we reconstructed the sequence of emergency management procedures such as triage and the treatment of the patient as well as radiation protection measurements taken. we then identified key characteristics and compared them with typical hospital rem procedures for radiation victims. furthermore, we then analysed the results in the light of radiation mass casualties to detect the weaknesses of current disaster management concepts. results the medical effects of internal contamination with the radioactive isotope polonium 210 was not immediately diagnosed. a treatment plan was applied rather late. the single case allowed an intensive care with technical resources and a number of medical professionals to diagnose the patient which would have been impossible if the number of casualties was higher. the psychological effects of the radiological contamination remained rather unclear. the patient died a few weeks later. the received dose and exact cause of his death (radiation vs. toxicity in particular) are still disputed. conclusion our research shows that the contamination with radioactive isotopes in general still remains a very unusual challenge for medical professionals. even specialist hospitals confronted with cases of radiation poisoning are quickly taken to the limits of their diagnostic and treatment capacity. only the concentration of medical specialists and the intense usage of resources could eventually help to diagnose the illness. we can conclude that other non-specialist hospitals would perform rather inadequately if confronted with the same case and much worse if there were more casualties of that kind. future improved emergency management strategies will strongly rely on adequate, continuous and specialised training of hospital staff, appropriate equipment as well as communication and triage among hospitals. aim: the aim of this study is to evaluate the efficiency of the radiation protection program of a department of nuclear medicine equipped with a pet and therapy units. material and method: the department has a workplace monitoring system. we calculate the mean dose of the radiation exposure levels that the workers were submitted in each part of the department and compare with the whole body dosimetry, during one year. the workplace monitoring system is a tam radiation meter system from tema sinergy, italy and consists on eight geiger-muller detectors with a dose rate range between 0,1 μsv/h and 0,02 sv/h and an energy sensitivity from 50 kev to 1 mev. the whole-body dosimeters are tld. the eight detectors are installed in: radiopharmacy, waiting room for accompanying persons, waiting room for injected patients (at two points), room for injected patients, pet radiopharmacy, pet command room, and waiting room for pts injected with 18f-fdg. the monitoring data of each main area is compiled in a 24 hour database. results: the monitoring results, in each area per year were: conclusions: when compared with each other, we conclude that the results match: the mean dose in the main areas where the workers usually are and the whole body values. the mean dose for the area monitoring system was 4,36 msv/year and the mean dose for the whole body dosimetry was 2,16 msv/year. these results are in the scope of the national legislation and the european regulation of radiation protection and are demonstrative that we are working in good conditions of radiation protection. since several years, our department of nuclear medicine works with the department of haematology in the field of radioimmunotherapy of non hodgkin lymphomas using antibodies (anti cd 20 zevalin® schering-bayer, anti cd 22 immunomedics) labelled with high activities of yttrium 90 (y 90) (cis bio international and nordion). the manipulation of such activities of a ß-emitter can induce a great exposure of the hands of the personnel when appropriate radioprotection procedures are not applied. at the beginning, we used the radioprotection material present in our laboratory, but with increasing experience we added some improvements in our practice: -use of a shielded suit -use of an electric infusion pump for zevalin® administration -use of radiation attenuating gloves for ß-emitters -use of a radioprotection kit in polymethyl-methacrylate (pmma) supplying by schering-bayer -local production of a pmma protection box for the perfusion of the anti cd 22. material and methods: *in 2005, an electronic dosimeter was placed under the gloves at the palm of one hand of the radiopharmacist during these steps. *in 2006, more precise studies were made with tld chips placed at the palm and at the extremities of the thumb and the index. day, and is a minimally necessary criterion of agencies that accredit nuclear medicine laboratories. tracking trends in daily qc on a monthly basis is helpful in detecting developing camera problems, which if addressed in a timely manner, will avoid unnecessary unscheduled camera downtime and maintain image quality. increasingly, the environment in which hospitals and clinics operate is through consortiums, which, by virtue of their design, necessitate the development of standardized, uniform means of detecting and documenting problems and methods of solving these problems. we have implemented algorithms written in a version of visual basic on commercial nuclear medicine computers to analyze intrinsic and extrinsic flood uniformity values for a wide range of gamma camera models from various manufacturers. these algorithms use data transmitted via ethernet among 3 sites using the dicom standard. computed parameters include integral and differential uniformity values for full field of view and central field of view regions of interest, which are generated automatically and are tailored to each detector type. output values are stored automatically in ascii files, which are updated each time the analysis programs are run. the display format of flood fields is adjusted automatically for as few as 1 up to as many as 8 simultaneously displayed individually normalized flood fields for flexibility of recording floods on film. algorithms written in mathcad (mathsoft, inc.) further analyze the resultant ascii files, segregating uniformity values for each detector of each camera in groups of monthly values, deleting duplicate records, plotting uniformity versus date curves, identifying values that exceed predetermined action levels and tabulating the number of times a detector does not meet standard criteria, prompting required attention for uniformity problems. a microsoft word file is generated automatically as a permanent record. these sets of algorithms have been instrumental in providing an ongoing method of guaranteeing standardized high quality imaging at different sites and facilitating certification by accreditation organizations. aim: to fully implement alternative services that internet offers to the easy transfer of complete patients' examinations. prosperity of easy interchange in every day practice of nuclear medicine found its application through the internet media. we use a simple and safe way to interchange images and diagnostic information between the scintigraphic acquisition and processing location and the clinical department in order to improve patient's health care and young doctors' education. we present our experience in transferring patient data, spect slices, 3d spect images in video (movies) form and animation display to medical specialists. materials and method: images and patient reports are transferred and saved through dedicated software to a workstation that transform gamma-camera scintigraphic images in a pc readable format. the data are transferred to the local server pc via a local area network -in which the medical system computer is also included-and are modified by procyon starlab ge software to bmp type image files. spect slices and/or 3d processed spect images as well as dynamic or gated studies can be send to the connected pc. medical record data are combined with the images and movies in a hypertext file that can be sent as an attachment via an e-mailer functioning under windows environment. the receiver side should be equipped with a similar e-mailer and can view or print patient's set of images and data through a suitable browser. the mailed series of images are characterised by diagnostic quality analogous to that of the original sets that someone can see as simple series or in a cine form of tomographic slices, dynamic studies and 3d images in a gamma camera. results:transfer via e-mail has been used in our center for the exchange of complete studies including data, images and movies to and from our colleagues when particular patients are concerned. furthermore, both patients' files and educational files can be downloaded, from our department ftp location, by a unique password. conclusion: a full patient template transfer enables the archiving of particular files from the authors' institute database ensuring the security desired and it has been proven to be a quick and safe mean of exchange of dynamic set of nuclear medicine information between physicians and scientific centers. usual www connection gives the possibility of patients' data transfer as well as interchange of relative comments towards both directions. cost effective solution has been achieved using standard hard-and software. picture archiving and communications system: a convenient connecting point between nuclear medicine and radiology for higher specifity k. f. wurm, m. zobel, b. clewing; department of radiology and nuclear medicine, göppingen, germany. aim: picture archiving and communication system (pacs) has become an important component of many radiological departments. the major benefit of pacs based on its ability to communicate images and reports to different physicians in a short and common modality. the aim of our study was to create the benefit for nuclear medicine results using pacs as the connecting point to additional radiological images. material and methods: in a period of 6 months we investigated 100 patients with different bone lesions, metastases and inflammatory deseases. all patients underwent bone scintigraphy with 99mtc-hdp. all images were evaluated and adjudged. in a second view the additional informations of radiological issues using pacs were documented. results: 76/100 patients presented an area with increased focal activity in bone scintigraphy. using the early pictures after 10 min. additional pathological results could be detected. in correlation with radiological images using pacs 14 cases are documented as an unambiguous benign lesion, previously adjudged as a suspected area. 12/76 cases were adjudged as a benign lesion, however using pacs pathological lesion were documented. conclusion: the progressive spread of picture archiving and communication system (pacs) in medical imaging constitutes some of the most common changes in the radiological and hospital activities during the last decade. using pacs as the connection point between radiological and nuclear medicine images both department have a benefit and the numbers of false positive/false negative results are reduced. pacs creates a synergy that will be otherwise only realized using spect/spiral-ct hyprid imaging. uptake of technetium-99mdimercaptosuccinic acid in cats e. vandermeulen 1 , a. dobbeleir 1 , h. ham 2 , a. piepsz 3 , t. waelbers 4 , s. vermeire 1 , k. peremans 1 ; 1 department of medical imaging of domestic animals, faculty of veterinary medicine, ghent university, ghent, belgium, 2 department of nuclear medicine, university hospital, ghent, belgium, 3 saint-pierre hospital, brussels, belgium, 4 department of medicine and clinical biology of small animals, faculty of veterinary medicine, ghent university, ghent, belgium. aim: the purpose of this study was to calculate the fractional uptake (fu) of technetium-99m dimercaptosuccinic acid (tc 99m -dmsa) in cats at 2, 4 and 24 hours and to test the influence of prone compared to supine positioning on the fu due to flexible kidney position in cats. material and methods: a total of 20 cats were injected with a mean dose of 146,5 mbq tc99m-dmsa. the cats were anesthetized (induction with propofol, maintenance with isoflurane on oxygen) and anterior and posterior images were acquired in prone position at 2, 4 and 24 hours after injection. rois were placed over the kidneys and the geometric mean kidney activities calculated. additionally, a second anterior and posterior view was acquired with a calibrated source positioned between the kidneys. the calibrated source activity was obtained by substraction of the activities in a large roi on both anterior views. this was repeated for the posterior views, and the geometric mean of the calibrated source was calculated. from the posterior and geometric mean activity, the attenuation correction value can be calculated. the kidney uptake was calculated from the geometric mean of kidney counts and the attenuation value. after decay correction the uptake was expressed as a fraction of the injected dose (fu). in 10 cats these tests were repeated in the supine position. results: the mean values of fu in cats scanned in prone position were 0.164 ± 0.071 for the left kidney and 0.151 ± 0.079 for the right kidney at 2 hours. fu values at 4 and 24 hours were respectively 0.175 ±0.076, 0.195 ± 0.074 for the left kidney, 0.162 ± 0.090 and 0.175 ± 0.080 for the right. in supine compared to prone position, a small but systematic lower fu was observed: the difference being 0.016 at 2 hours, 0.010 at 4 hours and 0.006 at 24 hours. conclusion: fractional uptake of 99mtc-dmsa can be calculated up to 24 hours. a small uptake increase is observed over time. using the method of geometric mean minor differences were obtained in prone and supine position. this difference decreases at 24 h, which might indicate a higher background contribution in prone position. organotypic slice cultures (osc) of human brain specimens represent an intriguing experi-mental model for translational studies addressing, e.g., stem cell transplantation in neurodegenerative diseases or targeting invasion by malignant glioma ex vivo. however, long-term viability and phenomena of structural reorganization of human osc remain to be further characterized. here, we report the use of the positron emission tomographic radiopharmaceutical f-18-deoxyglucose (fdg) for evaluating the viability of brain slice preparations obtained either from postnatal rats or human hippocampal specimens. anatomically well preserved human hippocampi obtained from epilepsy surgery (n = 3) and rat hippocampus slice cultures obtained from six day old wistar rats (n = 6) were dissected into 350 μm horizontal slices using a vibratome. all slices where placed onto interphase nylon culture plate inserts, subsequently transferred into six-well culture dishes containing 1.2 ml of culture medium and kept in a humidified atmosphere at 37°c and 5% co2 for at least 3 days. the slices were incubated with 1 -10 mbq fdg in phosphate buffered saline up to 1 h, either with or without supplementation of glucose at a concentration of 2.5 mg/ml. radioactivity within the medium or slice cultures was measured using a gamma-counter. in addition, distribution of radioactivity was autoradiographically visualized and quantified as counts per mm2 tissue per mbq fdg (cd) for the whole slice. all experiments were carried out at least in triplicate. in rat hip-pocampal slices, fdg accumulated over 60 minutes with a doubling time of approximately 30 minutes and reached 1,300,000 ± 68,000 counts/mm2, whereas the incorporation of the radioactive label in human slices was in the order of 1,500,000 ± 370,000 counts/ mm2. the elevation of glucose concentration within the medium led to a significant three-fold decrease of fdg accumulation in rat slices and to a 2.4-fold decrease in human specimens. in conclusion, fdg specifically accumulated in organotypic brain cultures of human or rodent origin. fdg is thus suited to investigate the viability of osc. furthermore, these preparations open new avenues to study the factors governing cerebral fdg uptake in normal and diseased brain tissue ex vivo. changes in metabolism and gene expression in hepatomas expressing antiangiogenic genes u. haberkorn 1 , j. hoffend 1 , a. altmann 1 , k. schmidt 1 , a. dimitrakopoulou-strauss 2 , l. strauss 2 , m. eisenhut 2 , r. kinscherf 1 ; purpose: human troponin i (trop), the soluble receptor for vascular endothelial growth factor (sflt) and angiostatin (astat) are potent inhibitors of endothelial cell proliferation, angiogenesis and tumor growth in vivo. transfer of these genes into tumors may induce changes not only in perfusion, but also more general ones such as changes in metabolism. experimental design: after generation of morris hepatoma (mh3924a) cell lines expressing trop, sflt or astat we quantified 18 ffluorodeoxyglucose ( 18 fdg) uptake by dynamic positron emission tomography (pet) after tumor inoculation in aci rats. furthermore, expression of glucose transporter-1 and 3 (glut-1; glut-3) as well as hexokinase-1 and -2 were investigated by rt-pcr and immunohistomorphometry. in addition, changes in gene expression were measured using gene arrays. results: fdg uptake, vascular fraction and distribution volume were significantly higher in all genetically modified tumors. immunohistomorphometry showed an increased percentage of hexokinase-1 and -2 as well as glut-1 and -3 immunoreactive (ir) cells. using gene arrays and comparing all three groups of genetically modified tumors, we found changes in expression of 36 genes related to apoptosis, signal transduction, stress or metabolism. conclusions: trop, sflt or astat expressing mh3924a tumors show enhanced influx of 18 fdg, which is caused to several factors: enhanced exchange of nutrients between blood and tumor, increased amounts of glucose transporters and hexokinases and increased expression of genes related to apoptosis, matrix and stress which induce an increased demand for glucose. a. altmann 1 , k. schmidt 1 , j. hoffend 1 , a. dimitrakopoulou-strauss 2 , l. strauss 2 , m. eisenhut 2 , r. kinscherf 1 , u. haberkorn 1 ; 1 university hospital, heidelberg, germany, 2 dkfz, heidelberg, germany. purpose: growth of malignant tumors is dependent on sufficient blood supply. thus, inhibition of tumor angiogenesis is emerging as promising target in treatment of malignancies. human calreticulin (hcret) is a potent inhibitor of basic fibroblast growth factor (bfgf)-induced endothelial cell proliferation in vitro and bfgf-induced angiogenesis and tumor growth in vivo. experimental design: to obtain more information about functional changes in the angiogenic process we established morris hepatoma (mh3924a) cell lines expressing hcret (hcret-mh3924a). the effects of hcret expression on proliferation and apoptosis of human umbilical vein endothelial cells (huvecs) were measured in co-culture experiments in vitro. to evaluate changes in tumor perfusion h 2 15 o was used for positron emission tomography studies in vivo. additionally, immunohistological quantification of vascularization, apoptosis and proliferation as well as gene array analyses were performed. results: the in vitro experiments demonstrate reduced proliferation and increased apoptosis in huvecs when being co-cultured with mhhcret cells. in support, tumor growth of mhhcret is diminished in vivo together with a reduction in pcna staining and an increase in apoptosis as determined by immunohistology. however, tumor perfusion and blood volume are increased in hcret-mh3924a corresponding to an increased microvessel density. furthermore, hcret-transfected tumors show changes in expression of genes related to angiogenesis, apoptosis, stress, signal-transduction and metabolism. conclusions: hcret expression leads to inhibition of tumor growth, increased apoptosis and changes in the expression of multiple genes involved in angiogenesis, stress reactions, signal transduction and apoptosis which indicates a multifactorial reaction of tumors. an enhanced microvessel density is seen as part of these reactions and is associated with increased perfusion as measured by pet. aims progressive improvement in the noninvasive imaging of different tumor associated antigens has lead to study a series of pancarcinoma radioligands. among them, monoclonal (radio) antibodies for cell adhesion molecule integrin v 3 occurring on both the tumor and endothelial cells that line tumor infiltrating blood vessels has recently gained widespread support from preclinical trials in our laboratories. in this study, this effort continues by applying iodine 131 ( 131 i)-labeled monoclonal antibody to visualize and quantify the subunit 3 of integrin v 3 in three histologically different types of murine tumors. material and methods monoclonal antibody anti-cd 61 (2c9.g2) against the subunit 3 of the integrin v 3 was directly labeled with 131 i using a standard iodogen method. the radiochemical purity of the resulting mab-131 i of 99% was achieved in a reaction time just after the iodination, and 95.6 and 93.7 %, respectively after 2 and 24 hr post-labeling. the diagnostic value of the mab-131 i radiotracer was elucidated by planar scintigraphic imaging followed by quantification of the tumor integrin subunit 3 level in male c57bl/6, c3h and balb/c mice 3 wk after s.c. inoculation of the syngeneic lewis lung (llc), breast or sarcoma (l1) murine cancers, respectively. the imaging and biodistribution studies of the mab-131 i radiotracer were done 24 hr after a single intravenous injection of 4 to 50 μg mab-131 i in tumor-bearing mice. results the transplanted tumors expressing the subunit 3 of the integrin v 3 were visualized on the scintigraphic images of all the examined murine tumor experimental models. on the images the liver and kidneys and the bladder were also the organs with the highest activity levels, illuminating the renal excretion pattern of the radiolabeled tracer. muscle, brain and skin tissues had relatively low activity uptake. biodistribution analysis, studied 24 hr after 10 μg mab-131 i injection, revealed a quite similar profile of the tumor-to-muscle count ratio (t/m) of 9.73; 9.56 and 9.45 for llc, breast and l1 tumors, respectively. the tumor-to-non tumor ratio (t/nt) for selected organs was increased with increasing the radiotracer dose up to 20 μg. the binding potential extrapolated from the graphical analysis of scintigraphic data correlated well with the biodistribution studies. conclusion the present study showed that the radiolabeled monoclonal antibody, mab-131 i that binds to the 3 subunit of the v 3 integrin, is able to target and image murine tumor tissues independently of their histological origin. phage display for the identification of a hepatoma binding peptide t. prenzel 1 , a. altmann 1 , w. mier 1 , s. krämer 1 , m. eisenhut 2 , u. haberkorn 1 ; 1 university hospital, heidelberg, germany, 2 dkfz, heidelberg, germany. hepatocellular carcinoma (hcc) is usually diagnosed at a late stage and has a high recurrence rate after resection. increasing the concentration of chemotherapeutics in a carcinoma and thus lowering the side effects for the organism is a problem in the diagnosis and therapy of hcc. a prerequisite for a specific accumulation in the tumour are molecules with a high binding affinity for tumour cells. due to their small size peptides are very useful tracers showing easy penetration into tumor tissues. the aim of this work was the identification of peptides with high affinity for hepatoma cells using different selection conditions. methods: we used a 12 amino acid phage display library to identify hepatoma specific peptides. this libraray was exposed to hepg2 cells. six peptides with the selected amino acid sequences were synthesized by solid phase peptide synthesis and radiolabelled with radioactive iodine. the properties of these peptides were evaluated by in vitro binding experiments. furthermore, a biodistribution study was performed in tumor bearing mice. results: five of the six peptides showed low binding to hcc cells. the linear peptide e7 with positive binding was investigated by further studies. in in vitro binding experiments these cells showed the highest peptide binding rate after ten minutes with no evidence of internalization. competition experiments demonstrated that binding of i-125-e7 was reduced by the addition of unlabeled peptide. e7 binds weakly to huh7 cells and primary human hepatocytes. the half life determined in human serum was more than one hour. peptide degradation products were isolated and characterized by mass spectrometry. we assume a a rapid deiodation and breakage of ammonium early after incubation start. biodistribution studies of e7 in balb/c nu/nu mice carrying hepg2 tumours revealed a two-fold higher e7 accumulation in the tumour as compared to the liver. conclusions: the peptide e7 showed some properties that make it a possible carrier for liver cancer imaging or the delivery of isotopes or drugs to hepatocellular carcinomas. further investigations will be necessary in order to characterise the value of e7 and its derivatives. purpose: histone deacetylase (hdac) inhibitors trigger differentiation, decrease cell proliferation and induce apoptosis in tumor cells. furthermore, they seem to act selectively to alter transcription of fewer than 2% of expressed genes. suberoylanilide hydroxamic acid (saha) is a new hdac inhibitor used in phase i/ii clinical trials. in order to determine whether there is preferential tumor accumulation of saha we studied the uptake of the drug in 3 sensitive tumor cell lines. experimental design: after labelling of saha with iodide a mtt assay was done to assess the effects of iodination on therapeutic efficacy in different tumor cell lines (thyroid carcinoma, hepatoma, colon carcinoma). therefafter, uptake, competition and efflux studies were done using i-125 labeled saha. finally, a biodistribution study was performed in tumor bearing mice. results: iodinated saha analogs showed equal toxicity as compared to unmodified saha. the uptake of i-125-saha was time dependent with a plateau at 1 h and was inhibited by the presence of unlabeled saha with ic50 values around 800 nm. furthermore, a rapid efflux was observed with a 60% decrease of intracellular activity after 10 minutes. the biodistribution study showed high accumulation in liver and kidney and a moderate accumulation in the tumor. also a rapid washout was seen with 2.9%id/g and 0.13%id/g in the tumor at 1 h and 4h after tracer administration, respectively. the tumor to organ ratios were highest for brain 3 and for for 1 h and 4 h) and muscle (1.6 and 2.3 for 1 h and 4 h). conclusions: iodinated saha showed rapid efflux and no preferential tumor accumulation. for therapeutic activity tumor selective uptake may be not a necessary condition. rather low amounts of the drug seem to be sufficient to change the balance between acetylated and non-acetylated histones in a manner that leads to differentiation, inhibition of proliferation and apoptosis. radiolabeling and biodistribution of pkf115-584, an inhibitor of the wnt signalling pathway u. haberkorn 1 , w. mier 1 , m. eisenhut 2 , b. beijer 1 , a. altmann 1 ; 1 univ.hosp., heidelberg, germany, 2 dkfz, heidelberg, germany. the wnt signalling pathway plays key roles in cell fate specification, cns patterning and control of asymmetric cell division. constitutive wnt signalling is observed in many tumors including colorectal carcinoma where >90% have an activating mutation of the wnt canonical pathway leading to an accumulation of beta-catenin. the binding of beta-catenin to tcf4 represents a promising target for therapy and could be used for imaging of the wnt signalling pathway. methods: after labeling of pkf115-584, a small molecule interfering with the beta-catenin/tcf4 interaction, with i-125 we performed uptake studies in vitro using two human anaplastic thyroid carcinoma (c643 and sw1736) and two human colon carcinoma (hct116 and caco2) cell lines. efflux experiments were done with sw1736 and hct116 cells. finally a biodistribution study with i-131-pkf115-584 was performed in tumor bearing mice. results: we observed a time dependent uptake with a plateau after 1 h incubation with a higher uptake in the thyroid carcinoma cell lines as compared to the colorectal carcinoma cells. no significant efflux was seen during the first 30 minutes after incubation of the tumor cells. the biodistribution study revealed different values with 5%id/g for sw1736 tumors and 4.1%id/g for hct116 tumors at 1 h after tracer administration. this uptake was followed by a decrease in activity with 3%id/g and 1.8%id/g at 2 h and 4h for sw1736 and 2.9%id/g and 0.9%id/g at 2h and 4h for hct116. tumor-to blood ratios at 1h were 19 for brain, 4.5 for muscle and 1.6 for liver at 1h for sw1736 tumors. these remained stable until 4 h. similar data were obtained for hct116 tumors. conclusions: iodinated pkf115-584 may be used as a tracer for the visualization of wnt signalling. however, at present its exact binding site -beta-catenin, tcf4 or the complex of both -remains to be elucidated. preparation and in vitro evaluation of 99mtc-hyniclactadherin as a potential radioligand for apoptosis detection studied. they were divided into three groups randomly: ason, son and asonblocked group. pcna ason and son were both radiolabeled with 99m tc after being coupled with hynic and were injected to the former groups respectively, and the latter were given unlabeled ason before the injection of 99m tc -hynic-pcna ason as control. then scintigraphy experiments were performed on all the objects. after the last imaging session, the animals in the first group were sacrificed and their aortic arteries were removed for ex-vivo scan. moreover, the arteries were dissected into segments for well counting, pathological examinations and pcna staining. results: abdominal aortas of all the rabbits could be seen soon after the injection. however, accumulated radioactivity was observed only in the rabbits in the first group 2 hours later, and the count ratios of the lesion to the background of the abdomen were 2.75 ± 1.03 while 1.31± 0.08 for vessels of the son group (p < 0.01) and 1.27 ± 0.03 for the blocked group (p < 0.01). the ex-vivo scan of the arteries revealed good correlation of tracer accumulation. the atherosclerotic lesions were predominantly of american heart association class ii. the percentages of injected dose for the plaque and non-plaque vessels were 0.042±0.10 and 0.022±0.07, respectively (p < 0.001). the pcna index was (72.25 ± 8.02) % and (3.39 ±9.28) %, respectively (p < 0.001). there is a significant correlation between these two sets of data by regression analysis(r=0.66, p< 0.05). conclusion: 99m tc-pcna ason scintigraphy can reveal the abnormally increased radioactivity of the lesions of the atherosclerotic arteries in rabbit model and it has potential to be used to diagnose the atherosclerosis noninvasively. objective: the aim of the study was to determine the location and range of fdg uptake in knee joint and to detect the influence of aging on fdg uptake. methods: thirty seven patients (age range 23-82 years, 21 m and 16f) who had fdg pet which included lower extremities and who had no known disease of the knee joints were included. maximum standardized uptake value (suv max) was measured by placing regions of interest (roi) around the medial, lateral synovia, joint space, entire knee and patello-femoral joint in all the subjects. several roi's were placed on adjacent axial slices in the above mentioned regions of interest and average suvmax for each region of interest for both knees was calculated for all subjects. analysis of suvmax was carried out for the effects of age. the correlation of knee fdg uptake with aging was also determined. results: there is positive correlation between suvmax measurements in all knee compartments and age where the r (pearson correlation) measured 0.4 for all regions of the knee (p<0.05). the most affected part of the knee by age was the medial synovium where the p value was less than 0.01. the average suvmax ± standard deviation (sd) for medial, lateral synovia, joint space, entire knee and patello-femoral joint was 0.75±0.2, 0.76±0.2, 0.69±0.2, 0.85±0.2 and 0.5±0.2 respectively. conclusion: there is significant correlation between age and metabolic activity in different regions in the knee and effects of aging was noted most in the medial synovium. the increased fdg uptake in the knees with aging may be secondary to cumulative effect of weight bearing on knee joints with increasing age. the increased metabolic activity can also be secondary to inflammation associated with degenerative joint disease, the incidence of which also increases with normal aging. further studies to investigate the role of fdg-pet in aging and related disorders such as degenerative joint disease would be of further value in clarifying the nature of our finding. to increased metabolic activity. brown fat occurs often in the supra-clavicular region and the increased fdg uptake can complicate the interpretation of the pet-studies. materials and methods: a thin, 13-year-old girl with the diagnosis of malignant melanoma was pet/ct scanned with 272 mbq 18f-fdg (intravenous injection while supine). after injection, she continued resting supine for 30 min and was scanned 60 min post injection. the scan showed an extremely high uptake in the brown fat. the scan was performed during the winter months where the patient was exposed to cold temperatures and a new scan was requested. three months later, a new scan was performed where a more envolved pre-scan preparation was prescribed for the day of the examination. the patient was instructed to keep warm from the time she woke up and during transportation to our pet centre. after arrival, she was kept warm, 1 mg oral diazepam was given, and she rested supine 30 min prior to injection of 293 mbq 18f-fdg and 30 min after. the last 30 min she was allowed to sit, but still kept warm and the scan was performed 60 min post injection. results: the first pet scan demonstrated a very high uptake of fdg in brown fat in the chest and neck area and the scanning could not be optimally reported. the second scan was without brown fat uptake and was clinically relevant in following the patient's illness. conclusion: planning and simple preparatory procedures like keeping warm prior and throughout the whole injection/uptake process and a comfortable room temperature are important to avoid increased fdg uptake in the brown fat. muscle relaxing medication like diazepam can be useful if the patient is nervous or agitated. fused pet/ct images aids in image interpretation and it is often possible on axial slices to differentiate between brown fat, muscle and lymph nodes. however, it is important to prevent uptake in brown fat as much as possible to avoid confusion between pathologic and physiologic activity. the 131-iodine whole body scintigraphy has high sensitivity for the detention of bone, lymph nodes, and pulmonary metastasis of differentiated thyroid carcinoma, in particular when acquired after the administration of therapeutical activities. but if this scintigraphic images supplies functional information, sensible and precocious, possesses, on the other hand, slight anatomic detail, not allowing to locate the source of the pathological alteration. to get an anatomic reliable reference of areas of hyperfixation of 131i detected in the whole body scintigraphy after therapy, it might be an advantage to have a simultaneous acquisition of bone scan with 99mtc-mdp and 131i. aim we intend to describe the technical procedure and to present some images resultant from the application of this protocol to 6 patients with thyroidectomy, for differentiated thyroid carcinoma, for localization of focal hyperfixations detected in the 131i whole body scintigraphy after ablation therapy. materials and methods in the whole body scintigraphys acquired 7days after the administration of the therapeutical activities of 131i, were detected focal hyperfixations of 131i in the thorax that, for its localizations, could involve pulmonary or bone structures. after 2hours of the administration of 99mtc-mdp, were acquired, simultaneously in the peak of energy of the two radioisotopes, whole body scan, segmentary images of the thorax and, in some cases, thorax spect. it was used a gamma camera siemens e-cam dcr dual-head, equipped with high energy collimators. before the reconstruction of the tomographic studies, we added the corresponding plans of each isotopes. the visual analysis of the segmentary images was facilitated by the use of a software that allows to overlap the images of the two isotopes and to individually vary the brightness and contrast scales of each one of them. results the analysis of the acquired images allowed to verify that the 131i focal hyperfixations found in the 6 studied patients were secondary lesions in the bone. conclusion the simultaneous acquisition of bone scintigraphy with 99mtc-mdp and 131i whole body scintigraphy, in double window of energy, with the help of a processing commercial software, allowed the anatomic localization of areas of focal hyperfixation of 131i, contributing for the orientation of the patients later imagiologic studies. in-111 labelled octreotride and spect/ct image fusion from two seoarated equipments -clinical case i. paula, t. coutinho, a. fonseca, l. pereira, l. bastos; instituto portugues oncologia, porto, portugal. aim: in-111 labelled octreotride (octeroscan tm ) is used for imaging somatostatin receptor expression in tumours and their metastases. precise location of the lesions is quite difficult and the spect/ct image fusion can improve accuracy and provide additional information on the anatomic location of increased uptake of octeroscan tm . this clinical case illustrates that the registration and fusion of images from independent acquisitions by spect and ct can be useful in the location of increased uptake of octeroscan tm , and shows the benefit of the resultant images when compared with the conventional whole-body spect. material and methods: we show the case of a 68 years old female patient with suspected neuroendocrine tumour. a whole-body scan with mibg i-123 plus a whole body spect octeroscan tm scan (e-cam siemens) and ct images (biograph 6 pet/ct by siemens) were acquired. the spect and ct scan were performed sequentially with 3 perforated pmma markers with approximately 30 mm 3 with 2 to 3 mbq of tc-99m, which can be seen both in transmission and emission tomographic images, attached to the skin over the bilateral iliac crests and the sternal furcula. the reconstruction of the spect and ct raw data as well as the manual registration and fusion of both sets of images was made with the syngo siemens software based in invariability of the position of the tc99m markers relative to the patient body. results: whole-body scans with mibg i-123 were negative. first octeroscan tm whole-body scan showed only two small lesions in the upper abdomen and in the bowel. the second octeroscan tm whole-body scan and spect images showed abnormal uptake sites but only spect/ct fusion images showed the exact location of the metastases in the upper abdomen, bowel, liver, upper mediastine and a small lesion on the right breast (suspicious of breast cancer). conclusion: this case illustrates the benefit of spect/ct octeroscan tm and the usefulness of combining spect and ct images from two separated devices without a dedicated spect/ct device. we show that spect/ct fusion images has a clear advantage over conventional whole-body scan and can lead to a more precise lesion location in the case of octeroscan tm somatostatin receptor expression. the effect of activity outside the field of view in estimation of human neuroreceptor binding with pet. t. shiraishi, m. shidahara, k. tanimoto, a. ando, t. miyamoto, r. koganezawa, h. fukuda, k. watanabe; national institute of radiological sciences, chiba, japan. objectives: to estimate the binding of radioligands for neuroreceptors, quantitative analysis using dynamic pet scan data of target regions with a reference region in the brain is the traditional strategy to estimate the binding of radio-ligands for neuroreceptors. in the study estimating the binding potential (bp) of dopamine d2 receptor, high activities were sometimes observed in lung, liver, gallbladder, intestine and urinary bladder, as well as in the brain. those activities accumulated in the tissues outside of field of view (fov) have effect on quantification of pet scanner as noise, especially on the reference region owing to non-existence of dopamine d2 receptor. in this study, we analyze the effect of the activities outside of fov on bp value using 2d and 3d acquisitions. methods: pet scanning was carried out using cti-simens ecat exact hr+. we prepared the high activity (12kbq/ml) phantom used as the activity of target region and the low activity (3kbq/ml) phantom used as the activity of reference region. both of them were filled with 68 ge-68 ga source, and another phantom filled with 18 f solution (220mbq) was fixed outside of fov as the noise. after 10min pre-injection transmission scan, pet scans were performed with 2d and 3d modes under decaying the radio-activity outside of fov. the pet scan at decaying radio-activity outside of fov to a background was used as ideal scan. rois were placed on target and reference region, bp values were calculated with the roi values. results: the radio-activity of reference region was +1.5% higher compared to that of ideal scan in 3d mode. in 2d mode, by the contrast, the increase of radioactivity of reference region were +0.5%. as for the bp value, the decrease of bp value compared to that of ideal scan was -2.9% in 3d mode, while that of 2d was -0.7%. the coefficient of variation (cv) of bp values in 3d mode was obviously higher than that of 2d due to the radio-activity outside of fov. conclusion: based on our analysis, it is clear that the bp values were underestimated due to increase of the radio-activity outside of fov, especially in 3d mode. furthermore, because of radioactivity outside of fov, the bp values of 3d mode were varied widely, while bp value of 2d was stable. these results indicate that human neuroreceptor pet studies estimating bp values should use 2d acquisition mode to suppress the effect of radioactivity outside of fov. abstract datscan is a diagnostic tool used routinely to differentiate patients with parkinson's disease from those with essential tremor. by using 123 iodine labelled dopamine active transporter proteins to image the pre-synaptic striatal uptake in the basal ganglia region of the brain. data suggests datscan has 97.5% sensitivity in differentiating between parkinson's disease and essential tremor aim to investigate whether the clinical diagnosis of patients whom present with parkinson's syndromes would be affected depending on if the images were analysed using a qualitative or quantitative method. to assess the difference in the image interpretation of 3 separate health care professionals. methods a blinded anonymous retrospective analysis of 50 patient studies was interpreted by; 1. consultant radiologist 2. experienced clinical technologist 3. trainee clinical technologist the results were compared with the original clinical report by a different radiologist. each study was interpreted twice at different times, using; a) qualitative analyses of image b) quantitative analyses using proprietary software. results table 1 n/a software references to a normal range so there is no equivocal range. a mismatch was when operators report disagreed with the original report. the qualitative data shows that 2 of the 3 operators are fairly comparable with the original clinical report. the radiologist had mismatched the report with original report in 2 (4%), technologist 8 (16%) and trainee 5 (10%). the quantitative and qualitative results for the technologist show a large difference and are possibly due to the operators rois. the radiologist and trainee appear to have good agreement between qualitative and quantitative results. further analysis comparing the studies original report with an abnormal quantification result hence mismatch with the original report indicated radiologist 10 (20%), technologist 20 (40%) and trainee 21 (41%). conclusion qualitative assessment results indicate less variability between each grade of operator and the current gold standard original report. there is a wide variability in quantification between operators and original report that is likely to represent the difference in patient roi's. this may be due to the complexity of the software but could be improved by further training. the clinical data, we studied the current situation on the exposure to fingers and efficacious measures to decrease and monitor the exposure. methods: with ned (nuclear educated dosimeter: unfors, sweden) as a semiconductor dosimeter, first, we measured energy response and direction response as sensor characteristics and then the each medical staff in the five different clinical workplaces put the dosimeter on the index finger of their dominant hands to measure the dose. the staff's details are as follows: physician who injects ri drugs into the patients, radiological technologists who extract technetium from the mo-tc generator and handle ri drugs, physician who injects 18 f-fdg-pet drugs, pharmacists who test the fdg and radiological technologist who position the patients. results: as the energy becomes higher, the response tends to be lower. it is because the energy response is a semiconductor element. based on the result, we set a calibration constant. the direction response ended in good result except sensor-cable junction part. the finger dose of the physician who injected ri drugs was 22.36 μsv, radiological technologists handling 99m tc 29.60 μsv per day (consultation period 20 days), physician who injected 18 f-fdg-pet drugs 51.29 μsv (80 cases, right finger 53.85μsv, left finger 47.27 μsv), pharmacists who tested the fdg 31.48μsv, and radiological technologist who positioned the patients 1.94μsv. this dosimeter can measure a real-time finger dose easily and its high sensitivity helped us to know the exposure situation effectively. (table 1 and 2). conclusion: this dosimeter provides a simple and effective solution to radiation protection procedures and follow-up. we measured the finger doses of nuclear medicine staff in our institute this time and found that the value ended in less than the annual limit (500 msv per year). but, workers who use 18 f-fdg pet showed high exposure compared with no-pet case, and it should be considerd reduction of radiation exposure methods. introduction: the dynamic renal scintigraphy used dtpa-tc99m and captopril test constitutes a process of noninvasive functional exploration for the diagnosis of rénovascular hypertension. it permits to distinguish the hypertension induced by renal arterial stenosis from the stenosis of meeting associated with a primitive arterial hypertension. case report: a 14 years old girl, without notable pathological antecedent, developed two months before the first consultation, a severe arterial hypertension with cephalgias and buzzing in the ears. the clinical examination objectified a breath in the left lumbar pit to the auscultation. the renal angiography objectified a stenosis of infrarenal aorta due to circumferential parietal thickening associated to renal arteries stenosis more marked in the left side. the dynamic renal scintigraphy after administration of captopril highlighted a marked collapse of the rate of tracer collecting exceeding 40% on the left side with an increase in the time of collecting on the right side testifying to a frankly positive test prevailing on the left. a transluminal angioplasty of the left renal artery and a revascularisation surgery on the right side were carried out. the evolution was marked by an improvement of blood pressure figures, which contributed to a considerable reduction of posology of the antihypertensive treatments. discussion: the dynamic renal scintigraphy using dtpa-tc 99m with captopril test constitutes a noninvasive process, little irradiant for patients. its principal goal is to affirm the incrimination of the renovascular stenosis in the arterial hypertension genesis and to determine which hypertensive patients, with a renal arterial stenosis, could be treated successfully by the surgical or endoscopic revascularisation of the kidney. usefulness of oro-pharyngo-esophageal scintigraphy in the evaluation of inhalation into the tracheobronchial branch: a case report acquired image by count setting(100 kcnt), that scan time of 4mm pin hole collimator was longer than 6mm pin hole collimator about 2.04 times(mean time-4mm:286.73 sec, 6mm:140.27 sec). thyroid images by the 4mm pin hole collimator was acquired within about 5 minute except in the case of low level thyroid uptake like hypothyroidsm. we confirmed that the region of nodule was discriminated by 4mm hole better than 6mm hole through image of patient who has nodule. even if detected count value in the 4mm pin hole collimator was 60% of 6mm pin hole collimator in the image of patient who has nodule, nodule portion of thyroid was certainly discriminated in the 4mm pin hole collimator's image. we confirmed that scan time of each diseases were needed better in 4mm hole.(hyperthyroidism -1.94 times, hypothyroidism -2.1times, goiter -1.8 times, thyroidal nodule -2.18 times) 4. conclusion although scan time is longer by using 4mm pin hole collimator if we adjust time and count, 4mm pin hole collimator image is more useful than 6mm pin hole collimator image. especially, it provide useful diagnostic information in pantient who has nodule. racial variations in bone scintigraphy: an original investigation r. allie, q. siraj; royal hospital haslar, portsmouth nhs trust, gosport, united kingdom. by merit of its high sensitivity for early detection of bone pathology, bone scintigraphy remains the modality of choice for investigating sports injuries. this department regularly performs bone scans on military patients referred for musculoskeletal problems for the early detection of stress fractures and other musculoskeletal pathologies. for some time we have noticed that there appears to be a difference in the bone-to-soft-tissue uptake between caucasians (whites) to afro-caribbeans (blacks). bone scans of 54 military recruits (41 males, 43% blacks and 13 females, 38% blacks) were analysed. all subjects were injected and imaged according to departmental protocol using the same gamma camera. regions of interest were plotted over the bone and soft tissue to obtain bone-to-soft-tissue ratios. these were compared for each ethnic group. the results showed a significant statistical difference (p = 0.005) between the two groups. these findings were independent of gender, dose and waiting times. there was also a significant difference in respect to acquisition times (p = 0.004) for 500k counts. though many options were explored, no obvious cause could be determined for this phenomenon. more research is required to shed further light on the matter; however, the various plausible hypotheses will be discussed. aim: to learn about acute osteomyelitis as a complication in varicella and about imaging findings at different points in the course of the disease. background: acute osteomyelitis is a rare complication in varicella. to our knowledge only 40 cases have been reported in the litterature. materials and methods: the clinical symptoms, findings and course of the disease are illustrated by 2 patients, a boy (18 months) and a girl (6 years) admitted to our hospital. bone scintigraphy ( 99m tcmethylenediphosphonate) and radiography were performed on the first or second day after admission in both patients. mr imaging was performed in the girl the 3. day. radiograms and scintigrams were performed later in both patients. results: the first scintigrams showed increased activity in the distal part and slightly reduced activity in the proximal part of the right humerus in the boy, and increased activity in the left tibia metaphysis in the girl. scintigrams after 6 days in the boy showed further increased activity in the right humerus, now affecting the whole diaphysis.scintigrams after 3 weeks were normal in the girl. the first radiograms were negative in both patients. radiograms after 10 days showed irregular osteolytic lesions and periostal reactions in the proximal humerus diaphysis in the boy. later radiograms showed slowly normalizing conditions. radiograms in the girl after 1 month were normal. the mr images in the girl showed bone marrow edema in the left lateral tibia metaphysis and medial femur condyle. both patients recovered completely after adequate treatment with antibiotics. discussion: the scintigraphic findings in the boy could represent reactive hyperemia in the distal part of the humerus diaphysis and a transient reduced perfusion, before activity accumulation in the proximal diaphysis, where the infection was localized. bone scintigraphy, preferably a multiphase study, is positive in osteomyelitis within 24-48 hours after onset of symptoms, with 90-95% sensitivity. radiographs do not show significant changes the first days, even weeks, but are necessary in the follow-up. . mr imaging allows early detection of osteomyelitis, bone marrow edema appears during the first days of infection. the sensitivity is ~100%. conclusion: acute osteomyelitis is a serious complication in varicella and should be considered in any child with pain in a limb or joint after an episode of varicella. successful treatment depends on early detection. bone scintigraphy and mr imaging are sensitive methods showing pathological changes within the first days of osteomyelitis. background/aims. circulatory and pulmonary complications are common in patients with cirrhosis and portal hypertension and some patients have gas exchange abnormalities that may progress to the hepatopulmonary syndrome (hps). the prevalence of hps is, however, variably reported from 8 to 20%, but its precise relation to the liver function is poorly understood. the aims of the present study were by means of lung perfusion scintigraphy (lps) to assess the prevalence of hps in consecutive portal hypertensive cirrhotic patients in relation to patient characteristics and during a 100% oxygen test. methods.forty-one patients (56.9±8.8 yrs,15 women and 26 men) with alcoholic cirrhosis (child class a/b/c: 14/18/9) entered the study. all underwent a haemodynamic investigation with the determination of splanchnic and systemic haemodynamics. all had a contrast-enhanced echocardiography (cee) and a lps performed to diagnose extrapulmonary shunt fraction (epsf) and hps. in addition, measurement of pa,o 2 , alveolar-arterial oxygen gradient (pa-a,o 2 ), lung diffusing capacity (dl,co) and a 100% oxygen test were performed. results. all patients had portal hypertension (hvpg: 15.5 ±6.7 mmhg). five patients had a positive cee and epsf above 6%. three of these patients had a pa,o 2 below 10.7 kpa giving a frequency of hps of 7%. the dl,co was reduced in 81% of the patients and correlated significantly with metabolic liver function (gec: r=0.39, p=0.01), splanchnic haemodynamics (post-sinusoidal resistance: r=-0.47,p=0.004; hepatic blood flow: r=0.42,p=0.012), and systemic haemodynamics (central blood volume: 0.42,p=0.006; plasma volume: 0.37,p=0.016; blood volume: r=0.42,p=0.006). pa,o 2 was reduced below 9.7 kpa in 15% and pa-a,o 2 was above 2.7 kpa in 58% patients. pa-a,o 2 was significantly higher in patients with positive cee, 15.5±2.2 vs 9.6±3.2 kpa than in those with a negative cee (p<0.001). the change in pa-a,o 2 after 100% oxygen inhalation was significantly reduced in child class c patients,-17.8±10.3 kpa, compared with child class a and b patients( p<0.05). moreover, the change in paa,o 2 correlated with the epsf fraction in the total patient population (r=-0.32, p<0.05). conclusions. whereas pulmonary dysfunction in cirrhosis is frequent and relates complexly to metabolic, splanchnic and central systemic haemodynamic complications, the prevalence of patients fulfilling the criteria of hps is below 10% even in patients with advanced disease. lps is considered a useful contribution in the evaluation of pulmonary dysfunction in cirrhosis. aim: emboli cause ventilation/perfusion (v/p) mismatches, usually with typical triangular character. however, in the area of middle lobe and lingula they might differ in form on sagittal tomographic images. mismatches are sometimes observed only in these areas and they may cause dilemma in interpretation. we wanted to validate if these type of changes are caused by emboli or movement of lung position during first 20 minutes, known otherwise in cardiology as "upward creep" of the heart. materials and method: before perfusion spect, 25 consecutive patient performed two ventilation (v) spect. first and second ventilation studies were then compared with each other and v1/v2 quotient was calculated in order to estimate changes in lung position during the first 20 minutes. images were validated visually and quantitatively. change index was expressed as the fraction of the lung volume that had a quotient (v1/v2) below 0.9 or above 1.1. results: visual and quantitative analysis did not show significant changes in lung position due to "upward creep" that can influence false interpretation of mismatches caused by pulmonary embolism. conclusion: v/p mismatches identified in middle lobe and lingula by spect are reliable for interpretation for pulmonary embolism. correlation between ctpa and v/q scintigraphy in the diagnosis of pulmonary embolism s. rep, j. fettich; nuk.med.department, ljubljana, slovenia. introduction: a pulmonary embolism (pe) is a blockage of a pulmonary artery caused usually by an embolus. this can be diagnosed using v/q scintigraphy showing absent perfusion and normal ventilation of the affected lung segment or using ct pulmonary angiography (ctpa). in this case iodinated contrast medium is injected i.v. and pe is shown as filling defect of the affected pulmonary artery. aim: the goal of our study was to detect relationship between absent perfusion showing with v/q scintigraphy and defect of the affected pulmonary artery showing with ctpa. patients and methods: our study includes 20 patients with ctpa positive results for pe. ctpa and v/q planar scintigraphy was performed within 48 hours all patients. for v/q scintigraphy we used 133xe (140 mbq) for ventilation and 99mtc-maa (160 mbq) for perfusion in four projections. lungs were divided into anatomical lobes (upper lobes, lower lobes, middle lobe and intermediate lobe). each lobe was evaluated as having normal perfusion, ventilation/perfusion defect mismatch or match on v/q scan, and partial or total occlusion of a segmental pulmonary artery on ctpa. the results of v/q planar scintigraphy and of ctpa were compared. results: analysis of ctpa perfusion showed normal perfusion in 37.5% lobes, partial occlusion in 41.6% lobes and total occlusion of pulmonary artery in 20.9% of lobes. ventilation was not successfully performed in 1 patient (5%). in 45% of segments ventilation was affected. perfusion results showed absent perfusion in 20%, decreased perfusion in 49.2% and in 30.8% of lung segments the perfusion was normal. results of both methods corresponded in 72% and did not in 28%. conclusion: according to our results abnormalities corresponded in the 72% of segments with both methods. in 11% of segments disparity of the results was due to the fact that pe can be caused not only by complete but also by partial occlusion of the pulmonary artery. in 12 % of segments the results were false positive on v/q mainly due to ventilatory changes (indeterminate v/q results). in 5% of segments v/q results were false negative most probably due to better resolution of ctpa as compared with scintigraphy. asynchronous appearance of double parathyroid adenomas in a patient with primary hyperparathyroidism t. athanasoulis, a. fothiadaki, t. karianos, a. tsakmakli, v. makripoulias, f. athanasouli, c. zerva; "alexandra" university hospital athens, greece, athens, greece. during work up of a male patient 61 years old with a discovered raised calcium level who demonstrated primary hyperparathyroidism (pth=1300 pg/ml and serum calcium ca=13 mg/dl), a double phase parathyroid scintigraphy with mibi was performed. a large area of hyperactive parathyroid gland localized at the lower left lobe of the thyroid gland. the patient was operated and a giant parathyroid adenoma was removed at the indicated location of the study which was confirmed histologically. the patient was followed up for the following two years during which his calcium and parathyroid hormone levels were normal. during a normal check up seven years later an elevated serum calcium level was found (ca= 10, 9 mg/dl). at that time a cervical ultrasound was performed and pth was measured. the value of pth was 138 pg/ml confirming a mild hyperparathyroidism. a double phase sestamibi technique followed by a pertechnetate scan was used for further evaluation. an enlarged area of hyperactive parathyroid gland localized below and directly opposite of the lower right thyroid lobe extending to the upper mediastinum was discovered. an mri was performed which confirmed the appearance of a mass (5, 5 cm x 3 cm x 2, 4 in dimensions) localized in the upper mediastinal area at the tracheo-esophageal groove with its lower border in contact with the aortic arch. a surgical removal was performed and the histological study confirmed that the removed mass was a huge parathyroid adenoma. this case report indicates that despite the fact that a parathyroid adenoma is discovered and removed, this does not exclude the possibility of asynchronous appearance of a second adenoma. bonescintigraphy -adjustment of administrated activity a. eriksson, centralhospital, karlstad, sweden background: diagnostic reference levels (drl) for nuclear medicine is established in sweden by the swedish radiation protection authority, ssi. drl is the given level of specific activity that shall not be exceeded. currently all patients that undergoe a bonescintigraphy in karlstad receive the same activity irrespective of weight and age. question: is it possible to individually adjust administrated activity by combination of age and bodyweight without loss of quality? method and material: adjustment of activity is done by creating an index of age divided by bodyweight. relation of activity to index is given by a prestudy of 57 patients injected with 400 mbq or 600 mbq hdp-tc. results: 19 patients received standard activity 600 mbq and 23 patients got individually adjusted activity. mean counts per image was 1,70 mcts respective 1,64 mcts. the decrease in administrated activity was 9,8% for the adjusted group. variance of counts per image decreased from 0,14 to 0,05. conclusion: individually adjusted activity by this model yields same quality in the image as a standard activity. the decrease in administered activity is positive both for the staff and the patient. radiation protection during two decades in a nuclear medicine department s. kristiansen, a. nielsen; department of nuclear medicine, aalborg hospital, aalborg, denmark. aim: the aim of this study was to follow the yearly radiation doses during two decades to staff working in department of nuclear medicine, aalborg hospital. we focused on the development in procedures, the number of examinations, and the physical working environment. this includes radiation protection in general nuclear medicine and pet/ct. materials and methods: data has been taken from list of examinations sent to the ministry of health since 2000 and measuring results of personal dosimetry from the same ministry since 1990. until 1997 the department had very old and narrow quarters. when moving to new facilities in 1997 and when establishing pet procedures in december 2005, our primary goal was to increase distance between the radiation source (the patient) and the technologists in order to reduce occupational exposure. the following was taken into consideration: •large, simple but functional rooms. •a new laboratory section with a direct hatch to the injection room. •a special waiting area for patients confined to bed. •improved shielding in preparation settings. •electronic personal dosimeters. •introduction program for new staff where the main topics are: radiation protection, personal dosimeter, receiving and registration of radioactive sources and pharmaceuticals, circumstances for pregnant and breastfeeding staff and handling of radioactive waste. •radiation protection is taken into consideration whenever changes are made or new procedures are implemented. •dosimeter measuring results are discussed at staff meeting. results: among the examinations giving the highest radiation dose to the staff are bone scintigraphy, myocardial scintigraphy and pet scannings. the number of bone scintigraphies has been almost stable since 2000. the number of myocardial scans has increased from 124 scans in 2000 to 595 scans in 2006. the department started pet/ct scans in 2006 and made 416 scannings the first year. evaluating technologists working since 1990 in nuclear medicine the average occupational radiation dose has not increased. conclusion: we found that it is very important to develop the physical working environment currently while having focus on its functionality. furthermore the electronic personal dosimeter, updated guidelines for procedures and introduction of new staff is significance to keep radiation dose low. this has been introduced in our department, and despite an increase in the number of scannings, the radiation dose to the staff has not increased. cyclotrons are commonly used for production of radioactive isotopes for nuclear medicine purposes. as part of the site safety system, the nuclear process requires installation of a stack radiation monitoring system (srms) to determine the released activity during routine operation. this srms requires determination of a conversion factor for converting the radiation detector readings into concentration unit. defining the conversion factor is done mainly by calibration process of releasing a known amount of activity. it is important to have a precise estimation of the converting factor in order to enable the design of an optimal duct that shall provide maximum detection sensitivity. a computer program was developed for determining the stack conversion factor based on simulating the positron emitter isotopes free mean pass in the duct and the motion direction of the 511kev energy photons created by positron annihilation. the obtained conversion factor (by the software) is based on the radiation detector sensitivity for 511kev energy photons, the user definitions for the stack dimensions and the cross section of the duct. this algorithm is acceptable since all pet isotopes produce 511kev photons. a local calibration factor is designated to adjust the software conversion factor to the self-characteristics of the specified detector. adjustment is done by locating a calibrated radiation source in a pre-determined location and comparing between the expected reading calculated by software and the detector actual reading. the detector readings, converted into activity concentration along with the air flow data, are used to accumulate the total activity release through the duct. the software simulation has been performed on few square and round ducts of different dimensions and the results were compared to the actual calibration releases. results show a very high correlation between the software simulation and the actual releases. the conversion factors found to be in the range of 1cps per 60nci/m 3 for duct with cross section of 700cm 2 . due to the high correlation between the simulation and the calibration releases, the simulation may now be used to estimate the design ventilation system sensitivity in order to improve the minimum detectable activity and to be compatible with the restrict regulation of detecting concentration level as low as 3nci/m 3 . this high correlation can reduce the amount of activity releases that are accumulated during the calibration process as part of the annual release activity under the site license and reduce the allowed released activity derived from the site routine operation. introduction: the nuclear medicine technologist(nmt) is the healthcare professional who is able to cover the whole range of nm procedures in the clinical routine. the period of education is a fundamental part of the educational process and for this purpose considerable resources investment is dedicated to it. the possibility of knowing how to confront the most varied situations in italy(i), in 27 european(eu) and mediterranean nations, determines a professional growth in the sector. aim: the nmt is an important part of a team of healthcare specialists; the aim of this work is to identify nmt formative processes, working situations and economical capacities. in i, education and training is quite similar than in eu: during the initial months of the university course(average 3 years), nmts acquire the basic theoretical elements, follow the courses which help to develop didactic, then anatomy, pathology, equipment in the radiology area(60%); at the end, nmt deals with other fields of application of the ionizing radiations. the range of tasks permitted of nmt varies from country to country, and there is considerable overlap with other professional groups. results: according to several published reports, there are approximately 90000radiological+nm technologist in the world; 60000 of them in europe (25%men+75%women). there are 1500 nmts operating throughout italian nm-pet departments. in addition to historical/cultural traditions, differences in teaching and the characteristics of university course programming create different technical procedures in nmt routine (diagnostic imaging, radiation protection, etc.); legislation is relative flexible in all countries, with 24-40 working hours per week with additional extramural nmt activity; the duties of chief-nmt are always dedicated to management of logistic problems(80%) and financial resources(20%). credit points must be collected by the exam for ce sessions in every countries. italian nmt salary is 1.5 times lower than 80% of eu. professional benefits (extra days off or special bonus) are taken into account only in the mediterranean area or intercontinental countries. conclusions: the training and the professional qualification of nmt represents a first step towards a governance of healthcare working activities; it's important to underline main nmt goal: one high standard of work for nmt in countries. fundamental for the changeover of nmts is the ability to acquire/process spet&pet-ct images, in addition to performing quality control of nm technologies. it's in the interest of healthcare quality that nmts take responsibility for providing of high quality service and performance in clinical routine, with professional competence and global competition. introduction: assuming that the modern concept of a nuclear medicine department should ideally include a positron emitting tracers (pet) production facility, there is a need to optimize the design of an integrated facility (here considered as the opportunity to build from the beginning) in order to allow the distinct patterns of functioning and circulation (patients, public, professionals, products, ) to occur in an harmonious and most efficient way. the purpose of this study is to integrate the ultimate concepts concerning aspects so crucial as radiation protection, ergonomics and the practicability and efficiency of the unit, considered as a whole. material and methods: starting with a bibliographic review, done according to the most recent developments on regulations and legislation, essentially at international level but also regarding eventual national particularities and following with practical knowledge, obtained from recent (real) implementation of similar units -and information shared by the responsible entities -we aim to build a complete and structured project, with an objective planning (blueprints), able to serve as basis for real implementation of an unit with an updated and optimized integrated vision of the current production and diagnostic processes. results and conclusions: the final blueprints of the unit are based on studies concerning not only the previous research on current legislation, but also the current assumption of best practices and fundamental principles related to radioprotection (as the alara principle), production (as the cgmp rules) and diagnosis (international guidelines). these blueprints demonstrated the practical result of that research and consist, briefly, on the obtained optimal structuring of the diagnostic side of the unit (as well as the production side) combined together in order to facilitate the necessary interaction, even if maintaining its respective independence and individual protection (compulsory condition to assure best practices) even in case of simultaneous operation. results: in the first patient tg level decreased from 8.3 ng/ml to 3.0, 1.1 and 0.09 ng/ml after 1 st and 2 nd and 3 rd ri application, respectively conclusion: there is a significant reduction of tg levels in esrf patients with dtc during the course of therapies using reduced activity doses. tg levels in all patients were lower then 1 ng/ml after the 2 nd therapy same-patient perfusion spect data were acquired by alternating between nr and bh every 15 seconds. the ct protocol was standard breath hold. these data were transferred to the lungguide (nihon advanced biologic, japan) workstation via dicom where non-rigid spect/ct image co-registration and fusion were performed using lg-ifm. due to the small difference in displacements, bh-spect/bh-ct registration was taken to be the "gold standard" to which nr-spect/bh-ct registration was compared. the differences in the position of the the diaphragm and the bottom of the lungs and in bh ct and nr spect, respectively, were measured. after lg-ifm registration with, we evaluated the difference of bh-spect/bh-ct and nr-spect/bh-ct fusion images in the lung lower field. results: lg-ifm mis-registration was observed in 5 of 40 cases (0.13 ± 0.05%) in nr spect/bh ct fusion images czech republic -the result of the questionnaire 3 rd medical faculty rehling 1 ; 1 clinical physiology and nuclear medicine positive cd10/weak glut-1 (13.9±4.6, n=3), negative cd10/strong glut-1 (11.0±0.9, n=8) were significantly higher than those of negative cd10/negativeglut-1 (4.3±0.9, n=3) using kruskal wallis test (p=0.035), suggesting that fdg uptake variation is related not only glut-1 but also cd10 (thus muc2) we present synthesis, radiochemical synthesis, and preclinical data on a series of novel radiofluorinated alkyne agents as potential pet agents for the detection of amyloid plaques. one such pet agent, av-144 binds avidly to abeta (a ) with a ki = 4.5 ± 0.9 nm (vs. 125i-impy) and localizes specifically to a in ad brain tissue máthé 1 , i. foldes 2 ; 1 nat is it possible, from stress images only, to decide if a myocardial perfusion rest study is needed? present our experience about the unwished effects that appear during the administration of 123 i-ioflupano/fp-cit in patient with movement disorder. material and methods. a total of 113 consecutives patients (49% male; mean age 65.3y) were men are studied between xii/'05 to i/'07. the patients were grouped according to the clinical prescription in 8/106 (7.55%) patients were reported pain during the injection, red flush and irritation in the zone of puncture in spite of its reinjection in another vein assuring a correct canalization. in 1/106 (0,94%) was observed slight headache with slight reddening face. three of these patients were referred for reevaluation in a follow-up protocol (3/9; 33,3%) presenting similar reactions to the first time when the exploration was repeated. comments. the administration of 123 i-ioflupano/fp-cit is a procedure of limited adverse reactions and if appear, are of slight intensity spect are inaccurate for both algoritims, and that 180 degree spet recontructed with osem can offer an acceptable alternative. however, 180 degree spect recontructed with fbp is superior for this purpose parisella 1 , a. lenza 1 , f. scopinaro 3 ; 1 ospedale sant'andrea the main component of paint thinner used in industry is toluene. toluene can diffuse into many body fluids and tissues; and causes formation of reactive oxygen species (ros) which are the main agents responsible for cellular damage. antioxidant enzymes such as sod, gsh-px and cat are part of the natural cell defense system against ros mediated injuries. matrix metalloproteinases (mmps) play an important role in physiologic and pathologic processes, including extracellular matrix turnover, tissue degradation and repair, cell migration and inflammation. an imbalance between the expression of mmps and tissue inhibitor of metalloproteinases (timps) is believed to cause some pulmonary inflammatory diseases. especially, the imbalance between mmp-9 and timp-1 expression may play an important role in airway inflammation. we aimed to investigate the alveolar clearance by tc-99m dtpa radioaerosol inhalation scintigraphy in auto painters, to assess effects of exposure to toluene on clearance rate of alveolar epithelium and to determine the correlation between tc-99m dtpa radioaerosol lung scintigraphy findings and mda, antioxidant enzymes, mmp-2, mmp-9, timp-1 levels. twenty eight auto painters, and control group were included in the study. tc-99m dtpa radioaerosol inhalation scintigraphy was performed in all subjects. clearance half time (t½) and penetration index (pi) on the first minute image were calculated. the mean t½ values and pi of toluene exposed workers were significantly higher than those of control group (p=0.034, p=0.032 respectively). the sod and gsh-px levels of auto painters were significantly higher than those of the control group (p=0.016, p=0.003, respectively). conversely, cat and mda levels was not significantly different between groups (p>0.05). we observed a statistically significant increase (p=0.042) in mmp-9 levels of toluene exposed workers compared with the control group, whereas the mmp-2 and timp-1 levels of painters were less than those of control group that not reached to statistical significance (p>0.05). a positive correlation was observed between pi and gsh-px levels (p<0.05) in the painters. there were no correlation between scintigraphic findings and other parameters in any subjects. our findings indicate that occupational exposure to toluene in auto painters has effect on bronco alveolar epithelial permeability, which is supported by prolonged tc-99m clearance half time and increased penetration index. we also found increase in antioxidant enzymes and mmp-9 levels. in the light of these findings, it might be concluded that long lasting toluene exposure may lead into occupational lung diseases. study objectives: measur the synovial thickness after 166-holmium radiosynoviorthesis by sonography. methods: phases iii, prospectiv study. 30 patients suffering from chronic synovitis, rheumatoid arthritis were examined. the protocol commenced with screening. the patients were selected according to inclusion and exclusion criteria. holmium phytate injectable suspension marked by 600 mbq 166holmium phytate injectable suspension, and 40 mg of 1 ml triamcinolone acetonide and 1 ml of lidocaine 1%. there were 24 month follow-up period after the administration of the isotope. inflammatory activity of the affected knee-joint was tested prior to treatment, and the 3 th and 3, 6, 12, 24 and 36 months after treatment. we measured the synovial thickness the following locations: in the midline, lateral and medial, by the condylus of femur medial and lateral. results: during the study period, inflammation decreased. in the first two years excellent and good results were recorded in 93.3%. two years after radiosynoviorthesis 93.3% of patients did not need another punction. the thickness of the synovia decreased significantly. we find a significant correlation between the synovial thickness and the clinical improvenes. conclusion: the 166-holmium-phytate is an effective new radiopharmacon in the treatment of synovitis. we detect the clinical improvement by sonography. the effective dose is 555-925 mbq. references: margit szentesi: radiosynoviorthesis with ho-166 phytate. first clinical results eanm post-congress scintific meeting. radionuclide therapy in theory and practice. györ, hungary. 5. szept. 2002 . szentesi m., 1 környei j., 2 antalffy m., 2 törkö j. 2 tóth gy., 2 jánoki gy., 3 balogh l., 3 : study of intraarticular application of 166-holmium ihpp in rabbits. world journal of nucl. med. 1. suppl. 2. s243. sept. 2002 . szentesi m., 1 takács s., 1 farbaki zs., 1 nagy e., 1 környei j., 2 antalffy m., 2 törkö j., 2 tóth gy., 2 jánoki gy., 3 balogh l. 3 géher p., 1 comparitive study of applying increasing doses of 166 ho-phytate injectable suspension in chronic synovitis. (comparative, randomized, single-blind, placebocontrolled study with increasing dosage). eur. j. nucl. med. suppl. 2. 498. 2003 . szentesi m., 1 takács s., 1 farbaky zs., 1 nagy e., 1 környei j., 2 antalffy m., 2 törkö j. 2 tóth gy., 2 jánoki gy., 3 the first article on radiosynoviorthesis was published in 1952 by fellinger. the traditional isotopes cause whole body radiation of 10 rad. isotope specialists have aspired to produce an isotope incurring lower radiation loads. (pirick, russel, sledge, junsing song) 166-holmium-phytate produced by us: radiation type beta energy maximum: 1,84 mev; radiation type gamma energy maximum: 0,66 mev; soft tissue penetration: maximum 8,4 mm; average: 3,3 mm; half-life: 26,9 hours; particle size: 0,6-2 μm study objectives: examination of anti-inflammatory effect of 166-holmium-phytate injection. methods: phases iii, prospectiv study. 30 patients suffering from chronic synovitis, rheumatoid arthritis were examined. the protocol commenced with screening. the patients were selected according to inclusion and exclusion criteria. holmium phytate injectable suspension marked by 600 mbq 166holmium phytate injectable suspension, and 40 mg of 1 ml triamcinolone acetonide and 1 ml of lidocaine 1 %. there were 36 month follow-up period after the administration of the isotope. inflammatory activity of the affected knee-joint was tested prior to treatment, and the 3 th and 3, 6, 9, 12, 24 and 36 months after treatment. evaulation was based on the criteria as described by müller, rau and scütte the score system was developed by the authors. results: during the study period, inflammation decreased. in the first three years excellent and good results were recorded in 93.3%. three years after radiosynoviorthesis 93.3% of patients did not need another punction. administration of holmium-166 phytate is a safe procedure. we did not detect any symptoms of radiation sickness. we found no deviations in either haematological or chemical parameters during the study period. conclusion: holmium-166 phytate isotope is an effective radiopharmacy treating synovitis. due its adventageous features it produces less radioactive damage on the organism than the traditionally used isotopes . due to its physical parameters it is optimal to treat large joints (knee) and medium size joints (hips, shoulder, elbow, wrist, ankle) . effective dosage is 555-925 mbq. references: margit szentesi: radiosynoviorthesis with ho-166 phytate. first clinical results. eanm post-congress scintific meeting. radionuclide therapy in theory and practice. györ, hungary. 5. szept. 2002 . szentesi m., 1 takács s., 1 farbaki zs., 1 nagy e., 1 környei j., 2 antalffy m., 2 törkö j. 2 tóth gy., 2 jánoki gy., 3 background: early and continuous prophylaxis in haemophilia is of paramount importance due to the susceptibility of the young and immature skeleton to repeated joint bleedings. in developing countries, financial aspects of clotting factor a or b replacement play a major role in patients' management. radiosynovectomy (rso) offers an alternative treatment option to surgical or chemical synovectomy and may reduce the need for clotting factor substitution. a.1.1. methods: in a multicenter effort 96 patients from 4 centers underwent rso of the knee following repeated bleeding episodes. rso was performed applying three radiocolloid formulations (y-90-silicate, re-188 tin and p-32 chromic phosphate). average age was 12.2 (range 4-18 years). standard injected activities were 185 mbq for y-90, 450mbq for re-188 and 60mbq for p32. the injected activity was tailored to patients' age; 2-6 one third, 7-10 one half and 11-16 years three quarters of adult dose. patients were referred by the haematological outpatient clinic. the frequency of bleeding episodes was documented. prior to the rso the frequency of knee joint bleeding was reported from patients' records. results: with exception of one case with circumscribed and reversible skin necrosis along the injection tract or reversible swelling of the knee joint, there were no other serious side effects. within the one month period prior to rso, all patients had at least 3 bleeding episodes per month. following the rso, number of bleeding episodes dropped significantly (a total of 391 bleeding episodes during the one month prior to rso dropping to 53 at one month, 50 at 3 months and 32 at 6 months following the rso, x 2 < 0.001 ). during a 6 months follow-up period, 48% of the patients had no bleeding episodes (100% reduction), 38% had an 80% reduction and 14% had a 50% reduction. based on the feedback by the children and their guardians, there was a significant improvement of the life quality attributed to improved mobility and lesser drop-out days from school. conclusions: our results indicate that rso is effective in preventing joint bleeding in the paediatric population. in addition there is a significant cost benefit attributed to reducing the need for clotting factor substitution (medication cost to treat one bleeding episode 2000-4000us$ vs. 70-100usd for rso using p-32 or re-188). following an initial period of scepticism, the acceptance of the procedure improved significantly. results of an iaea led crp: e1.30.26 radiation synovectomy may be indicated for the treatment of chronic synovitis. a number of factors may affect its current use, including availability, limited evidense for its efficacy compared to intra-glucocorticoid, and concerns regarding the potential long term effects of radiation exposure, particularly in younger patients. specific chromosome-type abnormalities in peripherial lymphocytes can be useful indicators of whole-body radiation exposure. the frequency of these aberrations has been shown to increase in patients who have had radiation synovectomy using yttrium-90 /y-90/ by up to five times compared to baseline levers.166-holmium-phytate /166-ho/ is a new radiopharmaceutical currently on trial which appears to have less extra-articular leakage than y-90 compounds. the aim of this study was to indentify any increase in specific chromosome-type abnormalities, using published criteria, in patients following 166-ho synovectomy of the knee. 18 patients / 7 men, 10 women/ in whom the analyses were performed had a mean age 45yr range /24-72 yr./ results: there was no increase in scored chromosome-type abnormalities after 166-ho synovectomy. conclusion: this study further supporth the relative safety of 166-ho compared to oder radiopharmaceuticals. p55 -monday, oct. 15, 2007, 2: aim: use of rhtsh aided rai therapy for differentiated thyroid cancers has increased over past few years. this study has been done to assess the clinical usefulness of rhtsh aided rai therapy for patients of differentiated thyroid cancers administered rai for either residual remnant ablation (rra) or irresectable and metastatic disease. materials and methods: 12 patients (9 females; 3 males) 14-68 years (mean age 33.75); of differentiated carcinoma of thyroid given rhtsh aided rai therapy for either rra or irresectable and metastatic disease from october 2003 to february 2007 were included in the study. 10 patients had papillary carcinoma while 2 had follicular carcinoma. 7 patients had stage i, 2 stage ii, 1 stage iii while 2 had stage iv disease. 7 patients were given rhtsh aided rai therapy for rra while 5 had either irresectable or metastatic disease. 11 patient's tsh did not rise adequately after surgery or due to functioning metastatic disease while 1 opted for rhtsh aided therapy because of the problems associated with thyroxine withdrawal. rai given ranged from 100mci(3700mbq)-170mci(6290mbq); mean dose 140.42mci(5195.54mbq). all the patient's baseline tsh, thyroglobulin (tg) and anti-thyroglobulin (anti-tg) levels were recorded. 0.9mg i/m injections of rhtsh were given at day 1 & 2 and tsh levels recorded 24 hours post injection. rai therapy was given if tsh level was >30μiu/ml. all patients underwent whole body scan prior to discharge. patients were followed at 3 months interval on outpatient basis. the mean follow up was 23.5 months. if the valid tg levels came down to negligible levels at 3 months complete response (cr) was documented; if tg levels reduced significantly but not negligible, was termed as partial response (pr), if no significant difference noted; stable disease (sd) and if increased progressive disease (pd). results: 10 patients had valid tg levels. the baseline tg levels ranged from 0.5->30000ng/ml. the baseline tsh levels ranged from 0.718-10.8μiu/ml. after the rhtsh injection the tsh levels rose to (34.8-96.9 ) after first injection and (33.1->75) after the second injection. all patients are alive; 5 patients had cr, 4 had pr while 1 had sd. 2 patients were too soon to assess at the time of review. the overall response rate was 90%. conclusion: rhtsh aided rai therapy yields good results with an appreciable response rate, therefore it can be used for effective therapeutic administration of rai for both rra and in cases of irresectable or metastatic disease. detection of ectopic gastric mucosa in meckel´s diverticulum by 99m tc-pertechnetate disodium scintigraphy in patients with the lower gastrointestinal bleeding, retrospective study j. dolezal; teaching hospital, hradec kralové, czech republic.aim and background: to present our twelve-years experience with the perfusion 99m tc-pertechnetate disodium scintigraphy of meckel's diverticulum in patients with lower gastrointestinal bleeding. gastric mucosa may be presented in meckel´s diverticulum and associated with the peptic ulcer disease and the lower gastrointestinal (gi) bleeding and the 99m tc-pertechnetate scintigraphy can help to make diagnosis of ectopic gastric mucosa. material and method: one hundred patients -22 adults (14 males, 8 females, aged 18 -78, mean 26 years) and 78 children (39 boys, 39 girls, aged 1 -17, mean 8 years) underwent 99m tc-pertechnetate scintigraphy. all patients had melaena or hematochezia with anaemia. the morphology imaging and the endoscopy were negative in all patients. the dynamic scintigraphy of the abdomen was started immediately after i.v. administration of 99mtc-pertechnetate. the static image of the abdomen was done after it. as necessary the spect was added to improve sensitivity, specificity and better spatial specification. results: four patients (two boys -two-and ten-years-old, one girl -four-years-old and 24-years-old male) had positive scintigraphy. all patients underwent surgery and meckel diverticulum with ectopic gastric mucosa (by histology) was detected. gi bleeding stopped spontaneously in patients with negative scintigraphy. these patients did not undergo intra-operative enteroscopy or surgery. conclusion: 99m tc-pertechnetate scintigraphy can help to detect ectopic gastric mucosa in the abdomen and improve a management of patients with lower gastrointestinal bleeding. aim: rapid detection and localization of the bleeding sites are important factors for the clinical management of patients with active hemorrhage. the aim of this study was to assess the accuracy of technetium-99m (tc-99m) labeled red blood cell (rbc) scintigraphy in patients with suspected gastrointestinal bleeding. material and methods: between december 1997 and august 2002, we selected 95 patients (53 women and 42 men, age range 18-87 years) with clinical suspect of gastrointestinal bleeding consecutively referred for tc-99m rbc scintigraphy. the results of tc-99m rbc scintigraphy were compared with those of oesophagus gastro duodenoscopy and angiography. results: tc-99m rbc scintigraphy was positive for active gastrointestinal bleeding in 39 (41%) patients and negative in 56 (59%) patients. gastrointestinal bleeding was confirmed by other procedures in 31 of the 39 patients (79% true positive rate) with positive rbc scintigraphy (by oesophagus gastro duodenoscopy in 26 patients and by angiography in 5 patients). in 23 (74%) of the 31 true positive patients, rbc scintigraphy demonstrated active bleeding already in the early (within 30 min) phase of the study. in the remaining 8 patients (26%), rbc scintigraphy resulted positive only after delayed (between 3-15 hours) acquisition. therefore, the acquisition of delayed images increased the sensitivity of the method. in 8 of 39 patients with positive rbc scintigraphy, gastrointestinal bleeding was not confirmed by other procedures (20% false positive rate). among the 56 patients with negative rbc scintigraphy, the lack of gastrointestinal bleeding was confirmed by oesophagus gastro duodenoscopy and/or angiography in 39 patients (70% true negative rate). among the remaining 17 patients with negative rbc scintigraphy, 14 patients had gastrointestinal bleeding by oesophagus gastro duodenoscopy and 3 by angiography. rbc scintigraphy had a sensitivity of 64 %, specificity of 83%, positive and negative predictive values of 80% and 69%, respectively. conclusion: tc-99m rbc scintigraphy is a useful and safe non-invasive test for the diagnosis and the management of patients with suspected gastrointestinal bleeding. in particular, the possibility to re-image patients over an extended period is helpful in identifying intermittent bleeding sites. radionuclide assessment of gastric emptying in relapsing-remitting multiple sclerosis b. g. chaushev, a. klisarova, p. bochev, n. deleva, b. ivanov; mbal st.marina -varna,bulgaria, varna, bulgaria. aim assessment of gastric motility disorderders in relapsing-remitting multiple sclerosis (ms) using dynamic scintigraphy of gastric emptying by 99mtc. material and method evolution of gastric emptying was performed in 15 patients with ms (8 males and 7 females), aged 30,6± 6,33 years, with 6,5± 3,7 years of disease duration. the diagnosis ms was defined according to mcdonald's criteria. the clinical impairment was rated according to the expanded disability rating scale (edss). none of the patients have subjective complaints, suggestive of gastroparesis. at the time of the study all patients were in remission and free of corticosteroid treatment. dynamic gastroscintigraphy was carried out in the morning after evening fast, with 8-12 hours abstention of tobacco, drinks and medication influencing gastric motility function. the patients was took breakfast consisting of semi-solid food, labeled with 1 mci / 37 mbq / tc-99m sc. parameters of the protocol included 5 frames. the first image was achieved at 0 minute and the next ones were achieved after 30 minutes interval during two hours or until stomach evacuation goes above 50%. the time needed for semi-emptying of stomach was determined from all received images. we were drawing region of interest, which includes the whole stomach from all projections. time-activity curve that represents the movement of radioactivity in region of interest was generated and half emptying time was calculated (with up to 60 minute's normal range). results our results demonstrate delayed gastric emptying in more than half of the patients (53%) with values ranging from 37,7% to 49,2%. we found gastric motility disorders in patients with more pronounced functional deficit, as assessed by edss. sex, age and disease duration have not a significant impact on gastric emptying. conclusion autonomic dysfunction is an integral part of the pathological process in ms with involvement of almost all somatic systems. dynamic scintigraphy of the gastric emptying in ms provides possibilities to evaluate the gastric motility. the evacuatory disturbances are an essential factor, impacting on the health status and on the quality of life. they appear even in patients without subjective complaints and with relatively mild neurological deficit. key words: multiple sclerosis, gastric emptying, dynamic scintigraphy introduction: tc-99m mibi which is widely used in nuclear cardiology, is excreted via the hepatobiliary system thus enabling to make comments concerning this system of elimination. the nonalcoholic fatty liver disease (nafld) which is associated with mitochondrial dysfunction and has the potential to progress to cirrhosis has recently been drawing attention with its increased incidence due to predisposing factors such as obesity and diabetes (dm) . aim: in this retrospective study, mibi findings in normal and obese patients (pts) groups and the influence of accompanying risk factors on these findings were investigated using the rest images of myocardial perfusion scintigraphy (mps). method: regions of interest (rois) of the liver (l) and right lung (rl) were drawn in the anterior projection using the rest mps images of the pts referred to our department for coronary artery disease (cad) work up. the liver index (l/rl) was calculated using the ratios of average counts obtained from the related rois. the body mass index (bmi) was calculated with the help of the medical records at the time of the mps. the presence of dm and hyperlipidemia (hl) was investigated from the pts' medical records and history. the pts who had a known liver and/or lung disease, those who smoked or drank alcohol, with a low lvef or perfusion defects on rest mps images were excluded from the study. finding: the data of a total 249 pts (159 females, 90 males, average age: 60,49±11 years, height: 1.63±0.1 m, weight: 77,22±15 kg) were analysed. no significant change was observed in the l index with respect to an increase in bmi in the overall assessment of the study group (r:0.008, p:0.9). the cases with bmi>30 and dm (n:38, l index 2.5±0.77) showed a significant degree of decrease in their l index (p:0.029); while in the cases with bmi>30 and had only hl (n:29, l index: 2.88±1.12) a significant change was not detected (p:0.57). conclusion: in the study group the liver uptake ratio of mibi was significantly decreased in the presence of both obesity and dm as compared to normal individuals. however, similar findings were not observed in the presence of only obesity or obesity and hl. although histopathological verification is a must, these findings suggest hepatocyte dysfunction in pts with nafld who has similar pts characteristics. the present findings need to be confirmed in prospective studies that enable kinetic analysis of hepatic function with simultaneous histopathologic analysis. p64 -monday, oct. 15, 2007, 2:30 pm -4 the aim of this work has been to evaluate the results obtained by radioguided parathyroid surgery in patients diagnosed of primary hyperparathyroidism due to parathyroid adenoma (pa). methods. inclusion criteria: patients diagnosed of primary hyperparathyroidism, a previous positive 99mtc-mibi scan (including spect or spect/ct), pathological diagnosis and clinical/biochemical follow-up > 9 months.according with these criteria we have included in our study 49 patients. radioguided parathyroidectomy was performed between february 2004 and july 2006. the day of surgery, a low dose (136-222 mbq) of 99mtc-mibi was injected and a planar scan was performed in order to draw a cutaneous mark in the localization of the pa. the interval between tracer injection and surgery was determined on the basis of the previous scan, ranged between 20 m. and 2 h. on surgical theatre an intraoperative hand-held gamma probe was used. in all cases we determined intraoperatively pth levels and performed a pathological diagnosis. a radioguided removal of the pa, reduction of intraoperative pth levels > 60% and a pathological diagnosis of pa were used as criterions for successful excision of the abnormal gland. results. in 48 patients (98%) radioguided removal of the pa was achieved. in 37 patients the pa was eutopic (1 double adenoma) and in 11 ectopic. scintigraphic localization of the pa was concordant with surgical localization in 46 patients, in two was nonconcordant (2 eutopic adenoma), and in 1 the pa was non detected on surgery. radioguided surgical technique was minimally invasive in 38 patients, unilateral or bilateral cervicotomy in 10 (5 previous cervical surgery, 2 nodular goiter, 1 double adenoma, 1 four glands revision and 1 non surgical detection) and sternotomy in 1 (ectopic mediastinal adenoma). biochemical follow-up revealed normocalcemia in 47 patients and persistent hyperparathyroidism in 1 (2%). conclusions. radioguided parathyroid surgery is a safe and effective method in the surgical treatment of primary hyperparathyroidism due to pa. we achieved a 98% of surgical detection with a 2% rate of hyperparathyroidism persistence/recurrence. aim: although total thyroidectomy is accepted to be the main component of the therapy in differentiated thyroid carcinoma (dtc), completion thyroidectomy (ct) is a controversial issue due to its morbidity potential. the aim of this study is to evaluate the efficacy of ct with the aid of gamma probe, using i-131. materials and methods: 152 patients (109 female, 43 male; mean age: 42, range: 17-75) who had undergone ct, between april 2003 -january 2007, with the help of gamma probe, after labelling with i-131 were enrolled in this study. the patients have undergone the primary operation with the diagnosis of either benign multinodular or solitary nodular goitre, and dtc was diagnosed in the operation specimen. the patients, while not under thyroid hormone replacement therapy in the 6 th week or later after the operation and with tsh<30 mu/l, remnant thyroid tissue 2 grams and/or suspicious malignant findings in the remnant tissue due to ultrasonographic examination, were evaluated by the council of thyroideal diseases of our hospital, and ct was decided. 0.1-0.2 mci. i-131 was given orally to the patients 48-72 hours prior to surgery, and thyroid scintigraphy were obtained on the operation day. ct were performed with the guidence of gamma probe. 127 patients underwent bilateral, and 25 unilateral remnant thyroid tissue resection. results: preoperative mean remnant thyroid tissue mass was measured ultrasonographically to be 7,8±1,6 grams. intraoperative mean ratio of thyroid activity to background activity(t/bg) was detected to be 13,1±3,3 and the mean ratio of thyroid bed activity to background activity after the excision (tb/bg), 1,5±0,2. (p<0.001). mean operative time was 72±8 minutes. tsh levels were > 30 mu/l in all patients after the 6 th week and no remnant thyroid tissue was detected in 143 patients either by ultrasonography or scintigraphy. while the mean tsh level of the patients was 8,4±3,4 mu/l preoperatively, it was 61,9±20,7 mu/l postoperatively (p<0.001). malignancy in the remnant tissue was detected in 38 (25,3 %) patients. 5 (3,2%) patients had transient hypoparathyroidism and 2 (1,3%) had transient recurrent laryngeal nerve palsy postoperatively. none of the patients had persistent hypoparathyroidism and recurrent laryngeal nerve palsy.conclusion: in patients with dtc who had undergone subtotal thyroidectomy or lobectomy in the primary operation, ct with the guidence of gamma probe after labelling with i-131, is a safe procedure with minimal complications. i-123 adam spet in athyreotic patients with and without suppressive thyroxine therapy. aim: to evaluate the added diagnostic value of spect imaging over planar imaging of parathyroid scintigraphy performed in primary and secondary hyperparathyroid (hpt) patients. materials and methods: 136 patients with primary hpt (no. 94) or secondary hpt (no. 42) underwent pararathyroid localising imaging in our centre, and then were operated on by the same surgical equipe. parathyroid scintigraphy consistsed of a double-tracer 99m tc-pertecnetate (150 mbq)/ 99m tc-sestamibi (550 mbq) subtraction scintigraphy plus perchlorate per os (400 mg) accordingly to rubello's protocol (ejnmmi, 2003; 30(2) :189-2); spect imaging was obtained immediately after planar imaging using the following parameters: acquisistion, elliptical orbit, 60 x 2 steps, 30 sec./step, 128 x 128 matrix, processing, filtered back projection and butterworth filter using different cut-off levels and order calues depending on the location, depth and uptake of the parathyroid enlargement. high resolution -10 mhz -ultrasonography (us) was also routinely associated. results: sensitivity in localising parathyroid enlargements using double-tracer subtraction scintigraphy, spect alone, and us were: 90%, 84%, and 62% in primary hpt, and 56%, 68%, and 75% in secondary hpt. interestingly, combining double-tracer scintigraphy and spect information sensitivity rose up to 94% in primary hpt (instead, in this series, us did not improve sensitivity, even if allowed a better location of the parathyroid enlargement in some cases). on the other hand, us allowed a mild increase of sensitivity in patients with secondary hpt. this was related to the fac that us was able to detect some very small parathyroid enlargements which were not seen at scintigraphy. however, it has to be underlined that us gave 14% false positive results in comparison to 2% of scintigraphy, especially in secondary hpt patients. conclusions: on the basis of our data, it seems reasonable to argue that the combination of planar double-tracer subtraction scintigraphy and spect is an optimal pre-operative localising procedure in primary hpt patients. conversely, in secondary hpt patients, neither scintigraphy nor us showed a very high accuracy: a combination of all these methods in secondary hpt could be recommended. tc-99m radio-guided completion thyroidectomy in patients with differentiated thyroid carcinoma aim: completion thyroidectomy (ct) is crucial in patients with differentiated thyroid carcinoma (dtc) who had either subtotal thyroidectomy or lobectomy as the initial operation. whether ct is associated with an increased complication risk is controversial. the aim of this study is to evaluate the efficacy of tc-99m radio-guided surgery with gamma probe in performing ct. materials-methods: 27 patients with the histopathological diagnosis of dtc after the initial operation, with the tumor diameter 1 cm, tsh < 30 mu/l, remnant tissue > 2 g. in ultrasonographic examination and/or suspicious malignant foci in the remnant thyroid tissue, and undergone ct with the aid of gamma probe using tc-99m were enrolled in this study retrospectively. on the operation day, 3-5 mci, 0.5 ml tc-99m pertecnetate was injected through the forearm 10 minutes prior to the incision, and bilateral remnant tissue resection was performed with the guidence of gamma probe. results: intraoperative mean ratio of thyroid activity to background activity(t/bg) was detected to be 9.3 ± 2.3 and the mean ratio of thyroid bed activity to background activity after the excision (tb/bg), 1.3 ± 0.3. (p<0.001). mean operation time was 74 ± 9 minutes. tsh levels of all patients one month after the surgery were >30 mu/l and no remnant thyroid tissue was detected either by ultrasonography or thyroid scintigraphy, except in two patients. preoperative mean tsh level of the patients was 7.3 ± 3.1 mu/l, while it was 61 ± 16.4 mu/l postoperatively, (p<0.001). malignancy in the remnant tissue was detected in 5 (18.5 %) of the patients. transient hypoparathyroidism occured in 1 ( 3.9%) patient postoperatively. persistent hypoparathyroidism or recurrent laryngeal nerve damage occured in none of the patients. conclusion: in patients with dtc who had undergone subtotal thyroidectomy or lobectomy in the primary operation,tc-99m radio-guided ct is a safe procedure with minimal complications. the diagnostic value of tc-99m mibi gated myocard perfusion spect in detection of silent myocardial ischemia in asymptomatic patients with type ii diabetes mellitus aim: in this study, we aimed to evaluate the diagnostic value of tc-99m mibi gated myocard perfusion spect (mps) in the detection of coronary artery disease (cad) and silent myocardial ischemia (smi) in the patients with asymptomatic type-2 diabetes mellitus (dm). material and methods: for this purpose, 35 patients with type-2 dm and 15 volunteers without any cardiac symptom as a control group were included in this study. exercise tolerance test (ett), echocardiography and tc-99m mibi gated mps were performed to the patients and volunteers. computed tomography coronary angiography (ctca) was performed in the patients with coronary ischemia or infarct detected in tc-99m mibi gated mps. biochemical analyses lipid profile of the patients and the volunteers were evaluated for the risk of cad. the results were analyzed and compared visually and statistically. results: the data of the present study revealed that silent myocardial ischemia was found at a high rate (25.71%, n=9) in 35 patients with type-2 dm. severe cad in ctca was detected in four of nine patients with ischemia or infarct in tc-99m mibi gated mps (44.4%). left ventricular diastolic dysfunction in echocardiography, ischemic pattern in ett and high risk of cad according to biochemical analysis were detected in the same four patients. at the end of statistical evaluation, we found that tc-99m mibi gated mps showed significant correlations with ctca, echocardiography, ett, hba1c, risk of cad and diabetic age in diabetic patients with cad. conclusion: in conclusion, we propose that tc-99m mibi gated mps is a reliable and non-invasive method, which can be used to detect silent myocardial ischemia and cad in the patients with type-2 dm. were subjected to 22 pet studies. all patients were treated previously with total thyroidectomy and 131 i treatment. the routine protocol during the follow-up included 131 i whole-body scan (wbs). thyroxin treatment was withdrawn (four weeks) and patients were on an iodine-free diet before wbs. tg, anti-tg antibodies, ft 3 , ft 4 and tsh were determined. patients with negative wbs and elevated tg or with suspicion of recurrence were subjected one week later to a pet study. pet findings were verified by pathology report or other imaging techniques (ct, mri, ultrasound) . results: at the time of the pet study, mean thyroglobulin values were 106 ng/ml (5-400 ng/ml). in three cases, the value was <1ng/ml but there was suspicion of recurrence based on clinical examination. tsh values were always >50 μui/ml and antithyroglobulin antibodies were negative. pet detected disease in 17/22 studies (77%), localized as follows: 12 cervical lymph nodes, 7 mediastinal lymph nodes, one lung metastasis and one bone metastasis. pet findings were verified by ct scan in 11 cases and by ultrasound and mri in 6 cases. in all cases, presence of disease was confirmed by postoperative pathology report. pet was negative in 5 studies; four patients remained disease-free in the follow-up, and lymphatic metastasis was confirmed intra-operatively in one patient. conclusion fdg-pet localized the metastasis in 17/22 (77%) of the studies performed in patients of dtc variants with poor prognosis (tall cell or hürthle cell carcinoma), modifying the subsequent therapeutic approach to these patients. the role of 99mtc-pertechnetate thyroid scintigraphy in hyperthyroid hcv positive patients treated with interferon (ifn ) background: the occurrence of thyrotoxycosis in the course of therapy with ifn for hcv related chronic hepatitis is well known. however, a differential diagnosis between painless thyroiditis and graves disease is needed to provide a proper clinical management of patients with thyroid disfunction and liver disease. aim: to determine the value of pertechnetate uptake in the thyroid gland of patients with low tsh serum levels found in the course of treatment with ifn or within one months from drug withdrawal. patients and methods: thyroid scintigraphies of 21 patients (17 f; mean age 44 yrs) treated with ifn and with low tsh values (mean tsh serum value: 0.07±0.13 mu/l; normal range: 0.26-5.0 mu/l) were retrospectively evaluated. thyroid images were obtained at 20 minutes after intravenous injection of 111 mbq of 99m tc-pertechnetate and the tracer uptake value was calculated as percentage of injected activity (normal range: 0.5-4%). results: pertechnetate uptake values were out of normal range in 16/21 patients; 13 of them had a low uptake value (a) and 2 had an uptake over the normal upper limit (b). a normal uptake value was seen in the remaining 6 patients (c) whose circulating hormone levels were into a normal range (see table) . discussion and conclusion: although hypothyroidism is considered the most frequent thyroid disease in the course of ifn therapy, the differential diagnosis of different forms of thyrotoxicosis has an important role in the clinical decision the aim of this study was to compare the effectiveness of fixed and calculated dose i-131 treatment efficiency in patients with graves disease. materials and methods: we retrospectively analysed 139 patients with graves disease who treated with radioiodine in a manner of calculated or fixed dose approach between the years of 2000-2006. study group consisted of 31 male and 108 female patients (range: 19-78, mean age: 44±14,46 years old). mean follow-up interval was 15±15 months. twenty four patients excluded from the study due to failure in follow-up. one hundred and fifteen patients received single dose i-131. sixteen of these 115 patients received i-131 via calculated dose and 99 fixed dose approach. mean doses for both groups were as follows: 9±4.4 mci for calculated dose group (range 3-17 mci); 9±2.6 mci for fixed dose group (range 3-20 mci). the criteria for successful therapy was defined as euthyroidism or hypothyroidism after radioiodine therapy and, the existence of hyperthyroidism six months after therapy was considered as unsuccessful therapy. results: for 16 patients who recieved calculated doses success ratio was %44 [hipothyroid (%31), euthyroid (%13)] after treatment. success ratio was %65 [hipothyroid (%57), euthyroid (%8)] for 99 patients who recieved fixed doses. hipothyroidism occured 1-27 months (mean: 6±5,6) after treatment. 16 patients recieved second doses and success ratio in this group was %80 [(hipothyroid (%53), euthyroid (%27)]. one patient whose thyroid volume was 127 g, recieved third dose and after total 60 mci rai-131 finally patient was euthyroid. although the difference in success ratios and frequency of hipothyroidism weren't statistically significant, success rates and frequency of hypothyroidism was higer in fixed dose group. this statistical problem may be related to small number of patients in calculated dose group. low success ratio in the calculated group can be a consequence of low dose/gr factor (100 mikrocurie per gram). conclusion: our results were in agreement with literature with respect to success rate and frequency of hipothyroidism in graves' disease with fixed dose of radioiodine. success rates can be improven by using higher dose/gr factors in calculated group. aim: 131i-mibg scintigraphy is shown to be useful in imaging of neuroendocrine tumours. a technique of in-house iodination of mibg, developed in our department in 1993 was found to be very cost-effective. our experience in 131i-mibg scintigraphy with the tracer prepared in-house was analyzed. materials and methods: records of 131i-mibg scintigraphy, carried out in our department between 1994 and 2006 were reviewed. results: a total of 714 studies were performed during this period. there was a significant increase in the number of scintigraphy studies in the latter half of this period -265 during 1994 to 2001, and 439 during 2001 to 2006 . the clinical indications were pheochromocytoma and paragangliomas (261 cases), carcinoid tumours (47), neuroblastoma (88), medullary thyroid carcinoma (56) and others (262), with more of neuroendocrine tumours in the latter half of study period. evaluation of aim: hiv patients receiving haart may develop body fat changes and low mineral density (bd), but whether these conditions are related is unclear. we further investigated whether a relationship exists between osteopenia/osteoporosis and lipodystrophy (ld)/lipoatrophy (la) in hiv patients on haart. methods: sixtyfive male patients, aged 31 to 53 yrs, with hiv infection haart (treatment duration: 39.8±12.3 mths) were consecutively studied; all cases had normal bmi (range: 18 to 25); 21 patients had ld, 14 la while 30 had no fat changes (nfc). there was no percentage difference between the 3 groups in hiv infection and haart duration and in cdc stage, while the percentage of ld which included protease inhibitors (pi) in their haart regimen was significantly higher than both la and nfc patients. in all cases we measured by dexa (hologic qdr -4500 a) bd (g/cm 2 ) in lumbar spine, with t-score calculation according who criteria, and fat mass (fm; g) both in trunk (t) and appendicular (a) regions with t/a ratio calculation. results: globally, 44/65 (67.7%) patients had low bd values, with osteoporosis in 14 (21.5%) cases and osteopenia in 30 (46.1%); the frequency of osteoporosis was higher in ld patients (38%), than in la (14%) and nfc (13.3%), but with significant (p<0.05) difference only between ld and nfc. bd was lower in ld than in la and nfc, but not significantly. t-fm was significantly (p<0.01) higher in ld than in la and nfc, and a-fm was significantly lower in la than in ld (p<0.05) and nfc (p<0.01) with no difference between the latter two. t/a was significantly higher in ld (1.86±0.48) than in la (1.4±0.3) and nfc (1.14±0.38) as well as it was in la than in nfc. t-fm correlated negatively with bd and t/a positively with pi therapy duration. conclusion: bone mass loss, even osteoporosis, may occur in hiv patients on haart with significantly higher frequency in pi treated patients who had lipodystrophy with t fat accumulation, in our cases. an inverse correlation seems to exist between t-fm and bd in haart patients, but it is unclear whether the pathogenetic mechanism leading to t fat accumulation and bone mass loss is common. aim: body fat changes are common in hiv infected patients receiving haart, mainly if protease inhibitors (pi) are present in their regimen, but the pathogenetic mechanism is still unclear. we evaluated quantitatively body fat composition in hiv patients treated with haart to ascertain both fat loss and fat distribution changes in order to identify possible therapeutic and host related associated risk factors. methods: we enrolled 136 hiv patients receiving haart, 87 m and 49 f; according cdc stage, 54 patients were stage a, 44 stage b and 36 stage c. at clinical examination, fat changes were present in 76/136 patients (fc) and absent in the remaining 60/136 cases (nfc). in all patients we measured by dexa (hologic qdr -4500 a) fat mass (fm; g) in whole body (w), trunk (t), peripheral regions (p), arms (a), legs (l) and calculated t/p ratio and total weight (tw). we also measured bmi, cd4 counts and hiv rna and determined cd4 count nadir and rise from nadir and haart duration, including pi, nrti and nnrti. results: we found significantly lower values of wfm (p<0.01), pfm and lfm (p<0.00001) in fc than in nfc; afm was also lower in fc, but not significantly. moreover, tfm and t/p were higher in fc than in nfc, but significantly (p<0.00001) only for t/p. no significant difference was ascertained in tw, bmi and in cdc stage between the 2 groups of patients. fc patients had significantly (p<0.00006) longer haart duration in respect of nfc (42.6±8.9 vs 33.8±5.4 mths), in particular pi and nrti duration; significantly higher current cd4 count (p<0.02) and cd4 rise from nadir (p<0.006) were also ascertained in fc than in fnc, while nadir showed no difference. wfm, pfm and lfm negatively and t/p positively correlated to pi and nrti therapy duration. conclusion: in hiv patients on haart fat loss with distribution changes, mainly involving peripheral regions, may occur, significantly higher in fc and in nfc. the pi and nrti longer exposure and the better immune recovery, both conditions affecting adipocite metabolism, could represent probable risk factors for fat loss in our fc cases, to be considered in haart patient follow up. aim the glomerular filtration rate (gfr) is measured frequently in cancer patient receiving cytostatics, because some of the pharmaceuticals are excreted by filtration in the kidney and some may also be nephrotoxic. the treatment dose of a few specific drugs is adjusted and calculated in relation to gfr and may be discontinued if gfr decreases severely. in denmark, gfr is assessed by plasma clearance of 51 cr-edta ( 51 cr-labelled ethylenediaminetetra-acetic acid), which is a highly reliable method, but indeed also time consuming. due to the frequent need of gfr-estimation it appears relevant to look for a more simple method for estimating gfr. in this study we therefore explored the possibility of replacing 51 cr-edta (gfr) by an estimate (egfr) from plasma creatinine, sex and age of the patients according to . material and methods cancer patients having a least four 51 cr-edta measurements performed in 2005 were included in the study. information concerning gender, age, weight, diagnosis, chemotherapy, plasma creatinine and gfr were obtained from the files and egfr was calculated using the cockroft-gault formula. results in 2005, 48 patients (13 women and 35 men) were subjects to at least four gfr measurements. mean age was 47 years (range 21-77 years) and the diagnostic profiles included: sarcoma (36%), cancer of the bladder (27%), germ cell tumors (13%), cervical cancer (8%), lung cancer (4%), unknown primary (4%) and various (8%). all patients were treated with nephrotoxic chemotherapy such as cisplatin, carboplatin and ifosfamide. on average, gfr decreased continuously from the first to the last measurement: 97, 90, 84 and 81 ml/min (16%). egfr, however, first increased and then decreased with no difference between the first and last values: 101, 104, 108 and 104 ml/min. as a consequence, the ratio gfr/egfr decreased significantly from 0.99 to 0.82. conclusion: in patients receiving nephrotoxic cytostatics gfr and egfr agreeded at the first examination but a 16% fall in gfr was not detected by the egfr. consequently, plasma clearance of 51cr-edta can not be replaced by egfr from plasma creatinine and the cockroft-gault formula in these patients if the aim is to calculate the specific dose as accurate as possible in order to monitor the toxicity of the various treatment strategies and to ensure the highest efficacy. [1] the variation in age, body habitus, glycemia level, duration of uptake period and partial volume effects are important factors that influence the suv level. the purpose of this study was to quantitavely assess the differences of suvbw (suv measurement based on body weight) in normal tissues (blood, hepatic parenchyma, spleen, kidney, bone marrow, muscle, stomach, brain) and to evaluated the degree of correlation with body weight and age. materials and methods 35 consecutive patients having 18 fdg-pet/ct studies were evaluated retrospectively (19 m and 16 f mean: 61 ± 12.57 y.o. and body weights ranged from 48 to 120 mean: 75 ± 16). approximately 1 h after injection of 5 mbq/kg of 18f-fdg, whole-body ct images were acquired without contrast media. a whole-body emission pet scan was performed with 3 min acquisition per each bed position (pet/ct: discovery ste, ge). roi were placed at the same level with no know abnormality. mean suvbw were compared, and the correlation between fdg uptake and body weight, patient age was assessed by using the pearson correlation coefficient test. results the mean suvbw values for cerebellum, kidney, stomach, liver, bone marrow, spleen, blood and muscle were 7.21 ± 2.21, 2.46 ± 0.86, 2.24 ± 0.73, 2.03 ± 0.41, 1.92 ± 0.56, 1.79 ± 0.43, 1.52 ± 0.32 and 0.73 ± 0.21. body weight correlated well with mean suvbw (blood r = 0.49, p < 0.01; kidney r = 0.46, p<0.01; spleen r = 0.37, p = 0.03; stomach r = 0.36, p = 0.03; bone marrow r = 0.33, p = 0.05; liver r = 0.32, p = 0.06; muscle r = 0.3, p = 0.08; cerebellum r = 0.21, p = 0.24) the suvbw showed no significant and very weak correlation with age ranged from r = -0.25, p = 0.15 (kidney) to r = 0.14, p = 0.44 (spleen). discussion although there was a wide variance in the suvbw, it showed a strong significant positive correlation with body weight in blood, kidney, spleen, stomach and bone marrow. the best correlation between glucose consumption and body weight was observed when the suvbw was > 1.52 ( blood) with exception of cerebellum. the suv bw showed no significant correlation with age. conclusion suvbw are weight-dependent indice for fdg uptake in tissues. there are however some notable differences between the r correlation coefficient with regard to the selection of normal tissues. aim: to investigate the diagnostic potential of a new semiquantitative sacroiliac index in bone scintigraphy, as a method to distinguish chronic, non-infectious, inflammatory sacroiliac disease (cilbp) from low back pain of mechanical/non-inflammatory origin (mlbp) in young males. patients and methods: we studied a relative homogenous population sample of 133 young males, aged 18-36 years, including the age when many sacroiliac diseases emerge. of these people, 32 (group a) had cilbp, verified by clinicolaboratory and other imaging procedures, 29 (group b) had mlbp similarly verified, and the rest 72 (group c) had been scintiscanned for reasons irrelevant to sacrospinal disease. all of them were also subgrouped by age criteria. after planar static bone scanning, two rectangular and symmetrical regions of interest (rois) were drawn onto the bottom third of the sacroiliacs, as well as a third one which encompassed the whole l4 vertebra. finally a non-dimensional numerical value called "r" was created for all patients, by the equation r = total counts/total pixels of the "hottest" of the two sacroiliac rois divided by the counts/pixels corresponding to the l4 values (r = si/l4). results: the statistical analysis showed negative correlation of r with age in all three groups (p=0.04 for group , 0.012 for group and 0.05 for group c). regardless of age, the mean value of r of group's b patients (1.53 +/-0.12) appeared significantly lower (p=0.002) than group's a (1.66 +/-0.17) and unsignificantly higher (p=0.12) than group's c (1.49 +/-0.14), while group's a mean value of r also appeared significantly higher than group's c (p<0.0005). conclusions: the si/l4 ratio seems to decrease with ageing -at least in the young ages-, irrespectively of the presence of cilbp, and its clinical potential seems to be helpful in the distinction of patients with cilbp from both the normal people and from patients with mlbp. to our knowledge, there is no other study of this semiquantitative index in young male adults with cilbp using the above methodology, but a larger population sample would still be necessary so to accurately standardize the normal value range of si/l4 ratio. f. marafi, a. syed, a. esmail, a. elgazzar; mubarak al-kabeer hospital, jabriyah, kuwait.aim: post-polio syndrome causes new weakening in muscles previously affected by the polio infection and in muscles that seemingly were unaffected. patients present with musculoskeletal pain, weakness, and fatigue that probably result from overuse and misuse of muscles and joints. the objective of this study is to review patterns of poliomyelitis on bone scintigraphy. material and methods: bone scans of 6 adult patients, five females and one male, aged 35 to 51 years, known to have paralytic poliomyelitis were studied. five patients had unilateral while one has bilateral disease. patients' complains included knee, shoulder, neck and/or back pain. all the patients underwent three-phase bone scan acquired 5 minutes (blood pool) and 3 hours (delayed) post-intravenous injection of 25 mci of tc99m mdp. studies were reviewed by two nuclear medicine specialists and findings were recorded. results:the following patterns were recognized: (1) markedly decreased blood pool activity in all affected limbs particularly distal to the knee (both limbs in the patient with bilateral disease), (2) deformed ipsilateral hemipelvis with relatively reduced radiotracer uptake in all patients with unilateral disease with minor degree of asymmetry in the patient with bilateral disease, (3) stress changes in the contralateral lower extremity illustrated by relatively increased radiotracer uptake diffusely in the bones of the lower extremity and (4) degenerative changes of multiple joints (shoulders, knees, ankle and spine). significant scoliosis was only noted in the patient with bilateral disease. conclusion: bone scintigraphy shows several poliomyelitis related findings predominantly due to skeletal asymmetry with unilateral disease. awareness of the characteristic scintigraphic findings is important to avoid misdiagnosis on bone scan which can help also in the follow up of post poliomyelitis changes. purpose: to examine the observer variation for bone scintigraphy in the detection of occult scaphoid fractures in daily practice, using only the early bone scanning images. methods: one hundred subsequent bone scans of patients with a suspected scaphoid fracture but negative initial radiographs were prospectively included to calculate the inter-and intra-observer variation. three nuclear medicine physicians independently evaluated all bone scans at two different points in time with a three months interval. the observers filled out a blinded scoring sheet for each patient. they scored if a scaphoid fracture was present or not. in addition they scored the presence or absence of another fracture. the inter-and intra-observer variation was analysed using the kappa statistic. results: the inter-observer variation showed substantial agreement for a scaphoid fracture and almost perfect agreement for another fracture. the intraobserver variation showed almost perfect agreement for both a scaphoid fracture and another fracture. conclusions: in the present study early static images of bone scintigraphy for suspected scaphoid fractures showed very little inter-and intraobserver variation. in addition, expertise does not seem to have a negative influence on the results. this enhances the possibility of using bone scintigraphy in daily practice. aim: to determine normal limits for quantitative 99m tc-hdp three phase bone scintigraphy regarding flow distribution at ankle and mid foot level. materials and methods: 62 consecutive patients referred to bone scintigraphy and without known pathology in the legs or hips were included. 51 patients were eligible, 29 females and 22 males. the population was divided into three groups according to age; less than 50 years (n=17), between 50 and 69 years (n=20) and older than 70 years (n=14). quantitative three-phase bone scintigraphy was performed in all patients. first phase consisted of a dynamic planar uptake in anterior projection immediately after a bolus injection of 700 mbq 99m tc-hdp with a matrix size of 128 by 128 pixels with a legp collimator, dorsal view, and recording of 120 frames at two frames per second. a processing protocol with standardised size rois was used to quantify flow distribution at ankle level and in the mid foot using the area under the curve for each roi during the first ten seconds of initial bolus passage. results: blood flow distribution at ankle and mid foot level for the three age groups is presented in table 1. conclusion: we suggest the normal range for distribution of blood flow at ankle level determined by quantitative three phase bone scintigraphy to be 36/64 (i.e. mean + 2sd). since variation in blood flow at ankle and mid foot level increases with age most probably because of uneven development of arteriosclerosis and various joint diseases, normal ranges for blood flow distribution at ankle level is wider among people older than 70 years. at mid foot level the normal range for blood flow is as wide as 20/80. the reference levels presented have been produced with the intention to quantify blood flow distribution at ankle and mid foot level among patients with various pathological conditions in particular charcot foot. aim: the aim of this study was to determine whether there is a difference between the left and the right proximal femur bone mineral densities (bmds) and, therefore, whether it is necessary to measure bmd of the femur bilaterally in determining bone loss. material and methods: this study was performed on 399 subjects (353 women, mean age 55 ± 11 years; and 46 men, mean age 54.9 ± 15 years). bmds of both hips (femoral neck, trochanter, intertrochanter and ward's area) were measured using dual energy x-ray absorptiometry (dexa) (qdr_4500-hologic densitometer). the statistical software spss version 10 for windows (spss, inc, chicago, il) was used for statistical analysis. a paired t-test was used to assess the right versus left (r-l) differences in bmds of the said regions. the results of bmd measurements were expressed in units of grams per square centimeter (g/cm²) as means (m) and standard deviations (sd). the 2-tailed pearson correlation was used for correlation analyses between r-l bmds. results: the mean femoral neck and trochanter bmds in total subjects were higher in the right leg than the left (0.787 ± 0.130 vs. 0,768 ± 0.129, p< 0.001; and 0.637 ± 0.117 vs. 0.629 ± 0.115, p< 0.005, respectively). similar results were also obtained in females (0.784 ± 0.129 vs. 0,767 ± 0.126, p< 0.001; and 0.633 ± 0.115 vs. 0.624 ± 0.113, p< 0.005, respectively). in males, a significant right versus left bmd difference was found only in femoral neck (0.810 ± 0.136 vs. 0,779 ± 0.146, p< 0.005). there were significant correlations of bmd between all the right and the left femoral regions (p< 0.001). conclusion: although bmds of the right and the left femoral regions were strongly correlated, there were significant r-l differences of bmd in femoral neck (in males and females) and trochanter (in females). therefore, bilateral femur bmd should be taken into consideration in evaluating a possible bone loss.aim: the purpose of this series of cases was to describe clinical findings and patterns of the triple phase bone scans in young patients with clinical examination suggesting medial tibia stress syndrome (mtss) or "shin splint", term frequently used synonymously with this disorder. material and methods: this study included seven patients (11 limbs) selected retrospectively with clinical examination suggesting mtss that underwent plain radiographs and triple phase bone scintigraphy (tpbs) with technetium-99methylene diphosphonate dimmer (mdp) during the period from june/2006 to february/2007. patients generally reported diffuse tenderness along the posteromedial edge of the tibia and complained of exercise-induced pain after starting physical activity. results: five patients had bilateral symptoms and two had unilateral pain. mean duration of symptoms was about 6.1 weeks. there were 6 male and 1 female. age ranged from 19 to 35 years old (mean value=24.71). patients included 4 runners (2 military recruits and 2 recreational runners), 1 professional basketball player, 1 recreational soccer player and 1 recreational gymnast. all the patients related exercise-induced pain in the beginning of activity. one recreational runner related an unbearably pain when he continued the activity. radiographs were normal in all patients. perfusion and blood pool images of isotope bone scans were normal in all cases. delayed bone scintigraphy showed characteristic longitudinal linear uptake in 4 limbs (2 patients) and focal uptake (longitudinally spindle-shaped uptake) in 7 limbs (5 patients). conclusion: in this study, all patients with clinical examination suggesting mtss had scintigraphic abnormalities. most of them had focal uptake (longitudinally spindle-shaped uptake) in the bone scan. it was an unexpected finding once mtss pattern most usually found in other studies is longitudinal diffuse uptake (double stripe sign, tubular pattern or longitudinal linear uptake), more related to bone remodeling. in the current study, most patients were recreational athletes. this fact suggests that many of these problems result from poor or misguided training regimens. bone scintigraphy was an important tool to confirm the clinical diagnosis of mtss and exclude other causes of lower leg pain such as stress fracture, nerve compression syndrome and extertional compartment syndrome. accurate diagnosis is essential in early phase after the onset of pain to establish specific treatment and ensure return to sports activity. transiet osteoporosis of the hip (toh) is an uncommon condition. it presents with progressively worsening hip pain gradually increasing without history of trauma. there is a characteristic discrepancy between substantial clinical disability and minimal physical findings. this condition is characterized by a predictable bening course, with complete clinical recovery. unlike toh, avascular necrosis (avn) is a introduction-aim: early diagnosis of osteomyelitis (om) in the diabetic foot reduces the need for amputation, but detection is difficult. coexisting disorders such as soft tissue infection and charcot arthropathy (ca) may obscure the clinical and radiological manifestations of om and bone biopsy is not routinely performed. the aim of this prospective study was to evaluate the efficacy of tc99m-hmpao-labelled leucocyte scan (hmpao-ls) for the diagnosis of om in the complicated diabetic foot, in comparison with other commonly used diagnostic modalities. patients and methods: forty five diabetic patients with clinical suspicion of om in 54 pedal sites were enrolled in the study. all patients had pre-existing pedal abnormalities including pedal ulcers (n=36), ca (n=27), and toe or foot amputation (n=21). c-reactive protein levels (crp), esr and white blood cell count (wbc) were measured at inclusion. all patients underwent plain radiography, three-phase tc99m-mdp-bone scan (mdp) and hmpao-ls. tc-99m-sulfur colloid bone marrow scan (bms) was additionally performed in 6 patients to interpret abnormal leucocyte uptake in ca. spatially congruent bone/leucocyte findings were interpreted as positive for om. incongruent hmpao-ls /bms indicated om superimposed on ca. diagnosis was confirmed by long-term clinical and radiological follow-up or bone biopsy. results: among the 54 pedal sites investigated, 26 foci of om, 6 cases with acute charcot arthropathy (aca) and 22 sites with simple soft tissue infection (sti) were diagnosed. patients with om had higher crp compared with those with aca or sti (24.6 vs 10.3 and 7.5 mg/l , p<0,05). wbc and esr were not significantly different among the three groups of patients. plain radiography was insensitive (34.6%), but very specific (96.4%) while three-phase bone scan was extremely sensitive (100%), but not specific (10.7%) for the diagnosis of diabetic foot om. the sensitivity, specificity and accuracy of hmpao-ls were 95%, 88% and 91.1%, improved to 95%, 100% and 97.8% respectively with the addition of bms. conclusion:among laboratory tests, elevated crp is better marker of om in the diabetic foot compared with leucocytocis or elevated esr. plain radiography is the least sensitive imaging method for early diagnosis of om and bone scan is the least specific method for detecting om in patients with pre-existing pedal abnormalities. tc99m-hmpao-labelled leucocyte scan is the most accurate radionuclide method for the diagnosis of om in the diabetic foot. the addition of bone marrow scan improves the specificity of leucocyte scan for diagnosing om superimposed on ca. aim: in the large-vessel vasculitis, in particular takayasu arteritis (ta), clinical signs and laboratory tests are not good markers for evaluating the vascular disease activity. aim of this study is to evaluate if fdg-pet can have a role in assessing the inflammatory activity and the extent of the disease in patients (pts) with ta by a correlation between 18f-fdg uptake, acute-phase reactants and the clinical outcome. material and methods: we studied 28 consecutive pts with large-vessel vasculitis in steroid treatment (m/f 5/23; age 52±15yrs; 23 ta and 5 giant cell arteritis). a total number of 37 pet studies was acquired. fdg uptake was evaluated using a visual score (0-1-2-3), in 7 different vascular areas and a total vascular score was calculated.pet was performed at the same time of the evaluation of acute-phase reactants [erythrocyte sedimentation rate (esr), c-reactive protein (crp) and interleukin-6 (il-6)] and assessment of disease activity according to the kerr criteria. results: the frequency of elevated esr was higher (p 0.049) in presence of vascular fdg uptake (50%) than in absence of uptake (16%). esr was higher (p 0.026) in pts with vascular fdg uptake (33±22) than in pts with no uptake (20±13). the pet score was significantly (p 0.019) higher in pts with high esr (5.7±4.2) than in pts with normal hsr (2.7±2.9). the correlation of pet score was significant with ers (r=+0.41 p 0.013) and il-6 (r=+0.48 p 0.037) and not with crp (r=+0.20 ns). the pet score was significantly higher (p 0.011) in pts with active disease (6.6 ±4.6) than in pts with inactive disease ( , colon carcinoma=3, kaposi sarcoma=2, lung tumors=2, anal carcinoma=2, myeloma=2, cervical carcinoma=1, hcc=1, brain tumor=1) underwent fdg pet/ct studies to identify areas of hiv replication and/or tumor increase. all 123 hiv-positive patients had a combined pet and ct body scan (discovery ls pet ct, ge healthcare, milwaukee, wi, usa) from the base of the skull to the pelvis with [18f]fluorodeoxyglucose (fdg) and 5 patients also had brain studies with fdg. fdg accumulations (visual and quantitative) were rated, on a per patient basis, as true positive(tp) or true negative(tn), and false positive(fp) or false negative(fn), based on final clinical data. results: 44/123(36%) hiv-positive patients had proven malignancies (nhl=32, hl=8, lung cancer=1, anal cancer=1, brain tumor=1, hcc=1) in cytology/histology and conventional diagnostic imaging procedures (ct, mri, abdominal us, thorax x-ray). in this context, overall sensitivity (tp/tp+fn), specificity (tn/tn+fp) and accuracy (tp+tn/tp+tn+fp+fn) of pet/ct scanning with fdg was: 84%, 58%, 69% respectively for diagnosis of nhl diseases; 100%, 69%, 81% respectively for diagnosis of hl and 80%, 44% and 64% respectively for diagnosis of other neoplastic diseases. moreover, nodal fdg uptake showing active hiv replication areas was well identified in 18/123 hiv-positive subjects, and lung infections were correctly diagnosed in six more hiv-positive cases. the standardized uptake values (suvmax) over nodal lesions from lymphoma (nhl plus hl) were in the range of 3.4-21 and in active hiv replication were in the range of 1.5-2.5. conclusion: in our patient series, fdg pet/ct scan misjudged in the separation of malignancy from infection in some cases. however, pet/ct provided accurate localization of malignant and infective disease allowing biopsy of specific sites. even if abnormal fdg uptake occurs in subjects' nodes with detectable viral load, evaluating active lymphoid tissues during hiv infection from malignant lymphomas was possible. the effect of recent hemodialysis on invivo labeled 99m tc wbc lung retention in patients with end stage renal disease (esrd)aim: several clinical studies are evaluating the therapeutic potential of delivery of various progenitor cells (pcs) for treatment of injured hearts. the only noninvasive in vivo imaging method for evaluation of homing of transplanted haematopoietic pcs (hpcs) used so far was labelling the cells with 111in-oxine. the aim of our study was to evaluate radiolabelling of cd34+ haematopoietic pcs with 99mtc-exametazime and to examine use of radiolabelled cells to monitor myocardial homing. materials and methods: human hpcs were mobilized with granulocyte-colony stimulating factor and collected by aphaeresis. cd34+ cells were enriched with an immunomagnetic separation device (isolex 300i). amount of collected cd34+ cells per patient varied between 78 to 497 million. a fraction of of the cells (20-27%) was radiolabelled with 600mbq of 99mtc-exsametazime and incubated for 20 min at room temperature. to remove unbound radioactivity, the cells were washed with cell free media. cell viability was assessed by trypan blue exclusion assay before radiolabelling and 5 and 150 min after labelling. labelling stability of hpcs was assessed 150 min after cell labelling. 87-205 mbq of radiolabelled cells was injected into open coronary vessel through a micro catheter. spect images were obtained 2 and 16 hours after hpc injection. results: labelling efficiency of hpcs was up to 40.2% depending on the amount of cells available for radiolabelling. according to trypan-blue staining, viability of radiolabelled hpcs before and immediately after the labelling was 82.9% and 83.2% respectively, whereas viability 150 min after labelling was 61%. labelling stability of hpcs 150 min after cell labelling was 60.8%. spect images obtained 2 and 16 hours after hpcs injection enabled us to evaluate the arrangement and percentage of transplanted hpcs accumulated in the heart muscle. additionally it was possible to evaluate their migration and accumulation in the reticuloendothelial system of the liver, spleen and bone marrow. conclusion: we can conclude that 99mtcexametazime labelling of hpcs is feasible, and in vivo imaging with spect provides a non-invasive method for sequentially monitoring cell trafficking with good spatial resolution. red cell mass, plasma volume, blood volume and their deviations from expected normal values in patients with end stage chronic renal disease. results: pvk was correlated (r 2 :0.7 p<0.001) with pcv and bmi in all patients especially in men (r 2 :0.92). rcvk in all patients was also strongly correlated (r 2 :0.77 p<0.001) with pcv and bmi. rcvk in men is affected only by bmi (r 2 :0.74 p<0.01), while in females both pcv and bmi's influence reach statistical significance. in general, drcv and dpv are strongly related to bmi and pcv (r 2 : 0.78 and 0.6 respectively). in men pcv and w predict drcv and dpv (r 2 :0.8 and 0.9 respectively) whereas in female subjects only drcv is strongly correlated (r 2 :0.9 p<0.01) with pcv and w. serum fe seems to have a predictive role in drcv and dpv estimation. no other significant correlation among biochemical parameters (urea, creatinine, pth), total duration of dialysis and blood volumes was found. conclusion: not only radionuclide measurement of blood volumes but their promt estimation as well from the above equations has an important role in decision making in patients at esrd providing a applicable estimation of their anaemia. aim: to assess the contribution of an integrated spect-ct (infinia-hawekeye 4, ge healthcare) in patients undergoing 99m tc-radiolabelled blood cell imaging. material and methods: 39 consecutive patients underwent 99m tc-radiolabelled blood cells imaging. among them, 11 patients had 99m tc-red blood cell imaging (rbc) for suspicion of liver or spleen hemangiomas (n=9), and for suspicion of splenosis (n=2); additionally, 28 patients had 99m tc-hmpao-white blood cell imaging (wbc) for detection of active crohn's disease (n=15), and for suspicion of infection (n=13). following the routine protocol, a low-dose unenhanced spect-ct study (2.5ma, 140kv, eff.d 2msv) was performed. spect-ct findings were compared to planar and spect results. final reports were correlated to morphological imaging, clinical and surgical reports. results: in the rbc group, 7/11 patients had a positive study suggestive of liver or spleen hemangiomas (n=5) and splenosis (n=2). spect-ct was particularly useful for appropriate differentiation between physiological uptakes and pathological uptakes (vessel hot spots vs. liver lesions), as well as for precise anatomic localization of functional splenic remnants. all liver lesions >1.5cm were assessable on the low-grade ct, but liver or spleen lesions <1cm were not always distinctly detected. in some patients, respiratory motion artifacts also impaired the ct quality. in the wbc group, 10 patients had a positive study suggestive of infection on planar imaging. spect-ct was particularly helpful for a more accurate diagnosis of osteomyelitis vs. soft tissue infection (n=9), or for confidently ruling out a liver abscess (n=1). in 12 patients with crohn's disease (cd), spect-ct allowed better anatomic localization of disease extent, and exclusion of intra-luminal bowel activities. in 1 patient, spect-ct helped identify an entero-cutaneous fistula from ileostomy; in 6 patients with active cd, the low-dose ct showed a colon wall thickening with a lumen narrowing matching a hot spot on the spect part. conclusion: in 99m tc-radiolabelled blood cell imaging, a low-dose multi-slice spect-ct, the infinia-hawkeye -4, was found useful for improving the interpretation confidence, and thus, the diagnostic accuracy. aim: behcet's disease (bd) is a multisystem disorder characterized by vasculitis, and consists of a triad of recurrent ulcers of the oral and genital mucosa with relapsing uveitis. the prevalance of pulmonary involvement varies in the range of %1-10 in various studies and its complications are severe and life threatening. we aimed in this study to investigate the changes of pulmonary epithelial permeability of patients with bd using 99m tc-dtpa aerosol scintigraphy. material and methods: twenty-one non-smoking patients with bd (8 females, 13 males; mean age: 38.67±8.86 years) and 15 healthy voluntary non-smoking controls (8 females, 7 males; mean age: 50.87±12.45 years) underwent 99m tc-dtpa aerosol inhalation scintigraphy and pulmonary function tests. subjects inhaled 1480mbq of 99m tc-dtpa for 4 minutes in supine position. scintigraphic data were recorded dynamically (1frame/min) in posterior projection on a 64x64 matrix for a 30 min period using with a double headed gamma camera (infinia, ge, tirat hacermel, israel) equipped with a low-energy all purpose parallel hole colimator. half time of 99m tc-dtpa clearance (t 1/2 ) were calculated by placing a mono-exponential fit on the curves. penetration index (pi) was also calculated by dividing the peripheral total counts by the sum of the peripheral and central total counts on the first minute image, in order to quantify the distribution of the inhaled aerosol. results: the clearance half time of 99m tc-dtpa radioaerosols in bd's patients (24.81±6.2 min) were faster than in normal control group (46.47±22.33min) (p=0.002). there was also a significant difference between pi of patients with bd (14.66±3.01) and that of controls (20.56±6.10) (p=0.0005). no correlation was found between the mean t 1/2 values of 99m tc-dtpa clearance and the spirometric measurements except fev 1 in bd patients (r=0.48; p=0.03). pi were correlated with fev 1 in bd patients (r=-0.44; p=0.048). conclusion: lung epithelial permeability of the patients with bd was found significantly lower than that of normal subjects. the result of this study demonstrated that the assessment of lung epithelial permeability using 99m tc-dtpa aerosol scintigraphy could predict the presence of lung involvement in patients with bd. . detect of pulmonary emobolism in patients with deep venous thrombosis using 99m tc -technegas/ 99m tc-maa lung scan s. l. chen, b. l. li, w. liu, y. gu; institution of nuclear medicine,zhongshan hospital,fudan university, shanghai, china. the existence and severity of pulmonary thromboembolism(pte) was still one of the major clinical concerns. the aim of this study was to assess the use of lung ventilation/perfusion (v/q ) scan in the investigation of pte, and compared the results of lung ventilation/perfusion (v/q ) scan with ct angiography (cta) or mr angiography (mra). methods: a total of 85 patients with deep venous thrombosis (dvt) underwent v/q planar scan and chest x-ray , cta or mra were performed also. the modified prospective investigation of pulmonary embolism diagnosis(pioped) diagnostic criterion was used for interpretation of lung scintigraphy. according to the data of perfusion-ventilation scintigraphy, the patients was consider with a high pretest probability of pulmonary embolism, intermediate probability of pulmonary embolism, low probability of pulmonary embolism, lower clinical probability of pulmonary embolism or normal. the patients with a high pretest probability, intermediate probability and low probability were positive, lower probability and normal patients were negative. results: among the 85 patients, 29 patients with a high clinical probability of pulmonary embolism (34.1%) by 99mtc -technegas/ 99mtc-maa lung scan, 7 patients with a intermediate clinical probability of pulmonary embolism (8.2%), 6 patients with a low clinical probability of pulmonary embolism(7.1%), 1 patients with a lower clinical probability of pulmonary embolism (1.2%), another 42 patients were normal(49.4%). pulmonary embolism was detected in 42 of the 85 patients (49.4 percent). compared with the data of lung v/q scan detect and cta or mra examination in the patients with clinical probability of pulmonary embolism, 76% patients showed different blood vessel abnormality findings between lung v/q scan defect and cta or mra. we found that in patients with partly pulmonary embolism, the blood flood could pass away the stricture artery. so the perfusion scan of the patients maybe was normal, the perfusionventilation scintigraphy couldn't found pathological vascular disease. moreover, when the small pulmonary embolism was in the laterale or outboard segment of the lung, cta or mra maybe mistake diagnosis and the perfusion-ventilation scintigraphy could found pathological vascular disease. conclusions: lung v/q scan was a considerably effective technique to detect pte. the combination of v/q scan and cta (or mra) could provide more comprehensive and accurate diagnosis information. and a larger outcome study is needed. comparison of ventilation-perfusion scintigraphy and contrast enhanced computed tomography in patients with pulmonary embolism k. f. wurm, t. zelesny, u. wacker, a. hentz, f. dammann; department of radiology and nuc. med., göppingen, germany.aim: ventilation-perfusion scintigraphy has been the main imaging modality used in the evaluation of patients with suspected acute pulmonary embolism. since the introduction of multi-slice devices computed tomography has been used as an equivalent imaging method. the aim of our study was to correlate the results of ventilation-perfusion scintigraphy with spiral ct pulmonary angiography. material and methods: we evaluated 40 patients (23 women, 17 men, mean age 62 years) with suspected acute pulmonary embolism (symptomatic patients and increased d-dimer blood test). all patients underwent computed tomography and ventilation-perfusion scan. scintigraphic examinations were obtained with two head gamma camera, using tc-99m labelled human albumin microspheres. spiral ct scans were performed with the use of radiological contrast and multi-slice device. we compared the results of these three investigations. the sensitivity and specificity were evaluated. results: the ventilation-perfusion scintigraphy presented matching results in 21 of 40 cases. 16 of them presented an identical issue in computed tomography. in 19 of 40 cases we found a mismatch of ventilation-perfusion study. in 15 cases computed tomography could confirm a positive acute lung embolism. the sensitivity and specificity of lung perfusion scan in detecting lung embolism was 89% and 82%. computed tomography revealed a sensitivity and specificity of 92 and 95 %. conclusion: the results of ventilation-perfusion scintigraphy confirm a high sensitivity for diagnosis of lung embolism. in correlation computed tomography presented a similar sensitivity with additional specific informations. both modalities shall be accepted further on as an important diagnostic tool for patients with suspected lung embolism. pfeifer, n. millman, j.mortensen; rigshospital, universityhospital of copenhagen, københavn ø, denmark.a 49-year old woman, suffering from stridor and dyspnoe was diagnosed with tracheobronchial amyloidosis of transthyretin type (attr). pulmonary involvement in attr is uncommon. according to the patient's symptoms and for prognostic reasons it was important to rule out cardiac amyloidosis as frequently seen in attr. the usefulness of 99m tc -aprotinine scintigraphy in detecting extra abdominal lesions of amyloidosis and especially early cardiac involvement has previous been shown (1) . thus, the patient was evaluated with 99m tc -aprotinine whole body scintigraphy supplemented with single photon emission tomography (spect) and computer tomography of the chest using the vg hawkeye ge hybrid system. there was a close correlation between a) the scintigraphic findings of amyloid deposits in the central airways and b) the wall changes of the right upper bronchus as seen on the low quality ct (hawkeye) and c) the right upper lobe atelectasis shown on chest x-ray. no extra pulmonary amyloid deposits were found. conclusion: 99m tc -aprotinine scintigraphy with spect/ct detected amyloidosis in the central airways that correlated closely to the clinical and histological findings. reference: (1) objectives: the purpose of this study was to evaluate the usefulness of tl-201 chloride/tc-99m mibi, for the investigation of lung lesions, after comparison with ct and histological findings. methods: scintigraphy with tl-201 chloride and tc-99m-mibi was performed in 24 patients [19 men, aged 48-80 years and 5 women aged 66-78 years] with radiographic findings lung nodules, suspicious for malignancy. factors of the early and delayed static scans (hot, warm or cold uptake), the early and delayed retention indexes, the blood flow and the tumour retention index were obtained from tl-201/tc-99m-mibi scintigraphy. tumour retention indexes were classified into three grades; slightly (>0.9), moderately (0.9-0.8) and severely (<0.8) decreased. grade of tissue differentiation of tumour (well, moderately or poorly differentiated) and tumour size (t1 t4) were examined. scintigraphic indexes and tumour characteristics were compared. results: the early static scan and tumour size showed a correlation with the blood flow index. however, the delayed static scan did not show any relationship with blood flow index and tumour size. the tumour retention index with tc-99m-mibi had a tendency to decrease in malignant tumours, and showed a significant correlation with the grade of tissue differentiation of the tumour. regarding tl-201 chloride we obtained a 88.8% sensitivity, 80% specificity, 87% accuracy, a 94.1% positive prognostic value and a 66.6% negative prognostic value. conclusions: the tendency of the tumour retention index to decrease in tc-99m-mibi scintigraphy might imply the malignancy of the nodule investigated and would be an additional useful parameter for the accuracy of the diagnosis. introduction: in patients with ctd, the early detection of the pulmonary involvement is mandatory. pulmonary function tests (pfts) are considered to be valuable noninvasive diagnostic modalities. among them, carbon monoxide lung diffusion (dlco) reduction that is consistent with pulmonary fibrosis and microvascular damage is widely considered as the earliest and most sensitive index for the evaluation of pulmonary involvement. in previous studies we proposed the usefulness of hig scintigraphy in the evaluation of lung involvement in ctd. the aim of our study was the evaluation of hig lung scintigraphy, in the early detection of the pulmonary involvement in ctd patients. methods: fifty-two non-smoking patients suffering from scleroderma, rheumatoid arthritis or systemic lupus erythematosus (males/females 8/44, mean age 54.8 years, mean duration of disease 8.4 years) and referred to our institution for detection of possible pulmonary involvement were included in this study. patients were submitted to pfts (dlco, forced vital capacity [fvc] and total lung capacity [tlc]) and hig scintigraphy within a week. for semiquantitative interpretation of hig scintigraphy, a region of interest (roi) analysis was performed on the posterior view (sum of the mean activity for each lung divided by mean left ventricular activity / 2 = average score). the average score was correlated with pfts. pearson's correlation coefficient r was calculated. a probability p<0.05 (two-tailed) was considered to indicate statistical significance. results: pfts abnormalities were detected in 40 patients (dlco reduction in 39, fvc reduction in 13 and tlc reduction in 19 patients). a statistically significant negative correlation was detected between hig scores and each one of the pfts [dlco (r=-0.46, p<0.001), fvc (r=-0.42, p=0.002) and tlc (r=-0.43, p=0.002)]. in 14 patients isolated dlco reduction (normal fvc and tlc) was detected. hig scores were greater in these patients comparing to them with dlco within normal range (0.58 vs. 0.51, p<0.01). discussion and conclusion: dlco reduction was the commonest pulmonary function abnormality in our patients. the isolated dlco reduction might be attributed to pulmonary microvascular damage and increased membrane permeability, which constitutes one of the possible 99mtc-hig uptake mechanisms. by this pathway, hig lung scintigraphy seems to be useful in the early detection of the pulmonary involvement in ctd patients. aim: the aim of the study is to documentate intraoperative gamma probe applications in neck surgery in our hospital. material and method: between january 2006-march 2007 with the guidance of intraoperative gamma probe 17 patients underwent parathyroidectomy, 9 well differentiated thyroid cancer patients; complementary thyroidectomy, 2 medullary thyroid carcinoma patients; recurrent tumor exicion and 1 carcinoid patient; tumor excision. before parathyroidectomy 20 mci of tc99m-mibi was injected and during 2 hours static images were obtained every 10 minute in order to detect maximum parathyroid/thyroid uptake. at the operation day according to this optimal timing 1 mci tc99m-mibi was injected. for complementary thyroidectomy 500 μci i -131was given per orally 24 hours before the surgery and patients were imaged at 4-8th hour following i-131 injestion. in medullary thyroid carcinoma patients 1 mci of tc99-dmsa(v) and in carcinoid patients 1 mci tc99m-mibi was injected 10 minutes before the operation. results: in parathyroidectomy patients during operation except 1, ideal timing for peak parathyroid/thyroid uptake ratio was reached. obtained parathyroid/thyroid ratios were quite variable and changed between; 1.5-37. in complementary thyroidectomies thyroid/background ratios were between; 10-90. tumor/background ratio was 3-6.5 in medullary carcinoma and 5.8 in carcinoid. conclusion: optimization of injection time before surgery is very important in radioguided parathyroidectomy. this can be reached with the cooperation of departments of surgery and nuclear medicine. in parathyroidectomies, complementary thyroidectomies and in various tumor excisions beside a guidance potential, gamma probe help surgeons to instantly verify accurate removal of the targeted tissues. graft-versus-host disease (gvhd) is common compication of allogeneic bone marrow transplantation (bmt) in which functional immune cells in the transplanted marrow recognize the recipient as "foreign" and mount an immunologic attack. the chronic form of graft-versus-host disease (cgvhd) is defined as that which occurs after 100 days. chronic gvhd demages liver, skin and mucosa, and the gastrointestinal tract like in acute gvhd (agvhd), but also causes changes to the connective tissue of the skin and exocrine glands. function of salivary glands, as exocrine glands, is very often observed in patients suffering from cgvhd. aim:the aim of this study was to evaluate the function of major salivary glands with dynamic salivary gland scintigraphy (dsgs) in hematologic patients suffering of cgvhd after allogenic bmt. methods: dsgs was performed after iv. injection of 370 mbq tc99mpertechnetate, with gamma cammera above parotid (pg), submandibular salivary glands (sg) and oral cavity (oc). dsgs lasted 60 minutes (one frame-one minute), with per os stimulation in 40. minute with ascorbic acid tablete. time-activity curves (tac) were generated over pg, sg and oc as regions of interest. activity in oc was estimated on static scintigram 90. minutes after iv. injection.using tac and scintigrams, dsgs findings were graded from 1 to 4 according to shall at all. ( sct grade 1-normal finding, sct grade 2-moderate function damage, sct grade 3serious function damage, sct grade 4-very serious function damage). dsgs was performed in five patients, seven to ten months after allogenic bmt. two pts. were male and three female, aged from ninetheen to thirty nine years. three patients suffered from acute leucaemia and two from mielodisplastic syndrome. results: three pts. suffered from agvhd and all pts. were diagnosed as having cgvhd in skin, mucosa and liver. four pts. had feeling of dry mouth (xerostomia). all pts. with xerostomia had patological scintigraphic finding: two pts. had sct grade 2 and the other two sct grade 3. in pts. without xerostomia scintigraphic finding was negative. conclusion: this preliminary results sugests that dsgs, as objective test, can detect disfunction of salivary glands in patients suspected of chronic graft-versus-host disease, improving diagnosis and forehand therapy of cgvhd. bone metastases are a frequent complication in oncological patients, and can deteriorate their quality of life by the appearance of bone pain, and, to a less degree, fractures or medular compression. bone pain treatment is multidisciplinary, aim: objective of this study is the evaluation of the staff radiation extremity exposure from preparation and application of 90 y-zevalin (activity/patient<1.184mbq) in our hospital. material and methods: data from the first 9 therapeutic administrations were considered. the chemists performed the radiolabelling at a high protection standard in a dedicated hot cell, using shieldings in plexiglas for vials and syringes, tele-tongs and an automatic dispensing system. technicians were involved in activity dose preparation only before buying the current dispensing system. physicians administered the radiopharmaceutical through slow activity infusion (duration nearly 15 min). all operators wore both latex and anti-x gloves. thin-layer tlds (lif:mg,cu,p) were fixed to the fingertips to measure the local skin dose, hp(0.07), at the position with the highest risk of exposure to adequately protect the hands. 10 tlds were given to the chemist and the technician, while 4 to the physician. results: as for the chemist fingertips, the 75 th percentile of the dose distribution (hp(0.07)) is 0.583 msv/gbq, while the 95 th is 2.657 msv/gbq. for each radiolabelling the sum of all fingertips adsorbed doses was performed. the mean of these values is 6.82+/-1.23 msv/gbq. the medians of the radiolabelling fingertips doses range from 0.08 to 0.63 msv/gbq, while the means range from 0.18 to 2.05 msv/gbq. the ratio between the highest and the lowest absorbed dose to the fingertips is extremely variable per radiolabelling, observing values from 11.2 to 247.3. technician doses are lower than the chemist ones, ranging from 2.5% to 77.8% compared to the latter. as for the physician the medians of the fingertips doses range from 0.22 to 1.87msv/gbq/administration, while the means range from 0.19 to 1.90msv/gbq/administration. conclusion: when working at low radioprotection level, the exposure of the staff might exceed the annual skin dose limit of 500msv. it is due to carry out an extremity monitoring with fingertips dosimeters suitable to betaradiation, stated the high risk of the method. aim: radionuclides have been used worldwide for diagnosis and treatment. their use in brasil have started in 1955 and have been increasing progressively, benefiting thousands. scintigraphic methods have significant role in brazilian physicians practice. despite its great importance, nuclear medicine's image was tarnished by nuclear disasters as chernobil (1986) and goiania (1987-brazilian disaster linked to radiotherapy). those events boosted fear in public opinion concerning the use of radiation in medical procedures, even those that utilize small amounts of it like nuclear medicine. this work aims to evaluate how widely spread is knowledge about nuclear medicine among its patients, to find out their personal view and fears about procedures and specially if fear of radiation is usual. materials & methods: after reading and accepting informed consent, adult patients underwent a multiple choice questionnaire. research took place in a private service of nm in teresina, brazil during january-march 2007. results: 525 patients were interviewed, 268 women and 257 men, ages ranging from 18 to 94 years old. most patients (77.1%) have never undergone a nuclear medicine procedure before; 316 (60.2%) had never even heard about this medical field. from the 209 (39.8%) that already knew something about nuclear medicine, 92 (44%) received information from relatives or friends. patients under 18 years old were not asked to answer the questionnaire. a great majority (80.8%) believe that the exam will be useful in solving their health problem. besides, 27% think it is a very advanced procedure and 14.9% declared insecure due to their lack of information. only 149 (28.4%) patients reported to have some kind of fear; 66 (44.3%) from them said to be afraid of bad result; 38(25.5%) feared it could be painful and only 18(12.1%) were afraid of exam's radiation. others kinds of fears, as allergic reactions, injection, suffocation, distressed 83(55.7%) of the patients. conclusion: although many had already heard about this kind of procedure, lack of information is still usual among them. therefore, greater efforts for public diffusion of social benefits of nuclear medicine are needed. fear of bad result is the most frequently mentioned, probably because it may represent life-threatening situations as bone metastasis and coronary insufficiency. twenty years after brazilian main nuclear accident (goiania), fears of radiation seem not to be very important among patients. m. gerhardt, t. pulawska, s. b. søndergaard, b. zerahn; herlev hospital, copenhagen county, herlev, denmark. to evaluate the effect of music composed with the purpose of being calming, on heart rate and motion artefacts during image acquisition in rest and stress myocardial perfusion scintigraphy. material and methods: 124 patients referred for myocardial perfusion imaging on the suspicion of ischemic heart disease were included in a randomised cross over study. only studies with successful gating during both rest and stress image acquisition were included. 50 patients listened to music during acquisition of rest images and not during stress image acquisition and 51 patients did vice versa. the study comprised 50 women and 51 men. the music played is named musicure and composed with the purpose of creating a relaxed atmosphere. the music is non vocal, slow in tempo and performed with acoustic and electric instruments and nature sounds. heart rate was registered before and after each image acquisition. motion artefacts were evaluated by two independent specialists in nuclear medicine using a semiquantitative four point scoring system. after each image acquisition the patients filled in a questionnaire with their evaluation of the calming effect of music/no music, whether they liked the music played or if they would prefer to select the style of music played, and if they would prefer to listen to music during the acquisition or not. results: during stress image acquisition there was a significant decline in heart rate of -3.2 (±5.3) bpm, (p=0.008) among patients who did not listen to music. this decline in heart rate was significant for women alone; -4.2 (±5.9) bpm, (p=0.01) but not for men; -2.4 (±4.7) bpm, (p=0.3). regardless of music being played or not there was no significant effect on heart rate during rest acquisition and there was no difference in the frequency or severity of motion artefacts. 92% of the patients preferred to listen to music during image acquisition, and 51% would prefer to select music of their own choice. 79% of the patients declared that the music had a calming effect, 17% no effect, and 4% found it to be distressing. conclusion: listening to music during acquisition for myocardial perfusion imaging after stress prevents a decline in heart rate in particular among women and has not any adverse effects on the frequency and severity of motion artefacts. a vast majority of patients preferred to listen to music during image acquisition, although half of the patients preferred to select the music style themselves. flood field uniformity quality control (qc) is an essential function that must be performed daily before a gamma camera can be placed into clinical service for that purpose. clinical audit (ec directive97/43/euratom): systematic examination or review of medical radiological procedures which seeks to improve the quality and the outcome of patient care through structured review whereby radiological practices, procedures and results are examined against agreed standards for good medical radiological procedures, with modification of practices where indicatedand the application of new standards if necessary. implementation of med directive. clinical audit shall be arranged to supplement the self-evaluation of practices. objective must be that clinical audit be carried out every 5 years to cover all essential radiological practices in health care. ten points of interest to be covered by clinical audits are defined in the degree. introduction in any medical investigation the result standards in terms of sensitivity, specificity and accuracy are expressed. for stress myocardial perfusion scintigraphy (smps) in ideal non-selected population these values are all around 90. according to the references they can be much lower in compromised group of patients. to assure appropriate work quality every diagnostic laboratory should periodically perform the quality control of the whole laboratory as well as of every individual results interpreter . aim aim of the study was to control the quality of smps results reading in our nuclear medicine laboratory in a compromised group of patients. the whole laboratory as well as every individual interpreter was controlled. patients retrospectively the smps readings of 351 pts, 270 (77%) men, 81 (23%) women, mean age of 59±10 y (31-84), were compared to the results of coronary angiography. 144 (41%) pts suffered recent mi, in 37 (11%) pts cabg and in 104 (30%) ptca was performed. methods the smps results, denoted as positive or negative, were compared to the results of coronary angiography. by their comparing, sensitivity, specificity and accuracy of smps were expressed for the whole group as well as for the individual readers of scintigrams. results conclusion: the great difference in diagnostic accuracy among the readers of scintigrams was found. these results were a good reminder of the whole group and especially of certain individuals for approving the quality of their work. advantages and problems of digital documentation and reporting in nuclear medicine o. nickel, a. helisch, m. schreckenberger; klinikum der j. gutenberg-universitaet, mainz, germany.aim: archiving and online reporting with digital documentation (without hardcopy) requires certain technical prerequisites and an adapted workflow. as well the image display on the workstations used for reporting as the image archive are to be optimised for easy and fast access, a good report quality and a safe long-term availability of the archived data. material and methods: all the image data from our modalities (5 gamma cameras, 1 pet scanner, 1 ultrasound) are sent by dicom transfer immediately after acquisition to the department pacs system "tomomagine"(bs industrieelektronik, germany). the reporting physicians use windows workstations with two monitors for text and images. quality control of the image monitors is done by test images (e.g. smpte). all images can be displayed with the tomomagine viewer, which was developed especially for nuclear medicine: spect and pet slice data can be viewed interactively with 3d navigation in 3 planes and mip projections; overlays of pet/ct or spect/ct can be displayed as well. all image data of a patient can be loaded online in a short time by using the archive database. 24 hours after acquisition the images are sent automatically to the central pacs system of the hospital; this system distributes the patient studies to the department servers of the referring physicians. results: the image management of a digital archive has some problems compared to a conventional archive with film or paper hardcopies: the monitor and graphics mode for image display must be able to display all relevant levels of grey. some lcd monitors that we tested were bad or even useless in this respect. a document on paper or film can be easily removed, an electronic document, which has been sent to a ris/pacs, may have already been copied to several places; therefore its elimination can take very much effort. by the temporary storage of images in a local image archive and delayed transfer to a central pacs this problem can be minimized. the use of a local image archive improves the speed of access to the image data compared with a central pacs, the redundant archiving (local and central) increases the long term data security. conclusion: the use of a local image archive in nuclear medicine, together with a centralized pacs can improve the workflow during reporting and image archiving.aim: lactadherin binds with high affinity to phosphatidylserine exposed on the surface of apoptotic cells. it is the aim of this project to synthesize 99mtc-hyniclactadherin and to measure its ability to bind to apoptotic hl60 leukemia cells. materials and methods: bovine lactadherin was isolated from milk, conjugated with hynic and labelled with 99mtc using tricine as the coligand. the conjugate was separated on a biosep-sec-s 3000 hplc column and stability studies with and without bsa carrier was carried out by tlc. hl60 cells (human leukaemia cell line) were made apoptotic using etoposide. multiple cell aliquots were added different amounts of 99mtc-hynic-lactadherin. the procedure was repeated with untreated hl60 cells to evaluate 99mtc-hynic-lactadherin binding to non-apoptotic cells.results: the amount of conjugated hynic per protein molecule was determined spectrophotometrically to be 4. the relatively low yield of the hplc purification (19 ± 2 %, n=3) relates to the fact that lactadherin most likely adhered to the column. the stability tests showed that in the presence of bsa the rcp only decreased from 94 % to 92 % during a five hours period. the non-stabilized solution plunges from 90 % to 35 % rcp during the same period. a significant difference in binding activity between apoptotic and control cells (136 ± 6.6 %) was achieved with a 99mtc-hyniclactadherin concentration as low as 11.6 nm. furthermore, the difference in binding to apoptotic and normal hl60 cells reached a plateau at 30.9 nm label resulting in an 320 ± 16.9 % increase. when native lactadherin was added in excess the radioactivity in the pelleted apoptotic cells dropped to 2 ± 0.14 %. this strongly suggests that the binding of 99mtc-hynic-lactadherin to apoptotic cells is mediated by the same mechanisms as for unlabeled lactadherin. conclusion: 99mtc-hynic-lactadherin has been synthesized, tested for stability and in vitro biological binding activity. the data clearly show that the compound is a potential imaging agent for apoptosis recognition. aim: annexin v is known to bind to phosphatidylserine which is exposed on the outer surface of the cell membrane of cells undergoing apoptosis. it has been shown that bovine lactadherin a milk fat protein isolated from milk has affinity to phosphatidylserine and apoptotic cells as well. in vitro binding studies of 99mtc-hynic-lactadherin indicate that it binds to apoptotic cells. we want to present the results of the biodistribution studies in mice and tracer kinetic studies in pigs of 99mtc-hynic-lactadherin and 99mtc-hynic-annexin v. materials and methods: normal mice were injected with approximately 1 mbq in 100 ul of 99mtc-hyniclactadherin or 99mtc-hynic-annexin v and sacrificed after 10 min, 1 h or 3 h. the animals were dissected and major organs were collected in counting tubes and the distribution of radioactivity was measured. tracer kinetic studies in pigs were done by a combination of non-invasive scintigraphy and katheterisation. results: the biodistribution studies in mice showed a relatively fast blood clearance. the relative uptake of 99mtc-hynic-lactadherin (n = 3)/99mtc-hynic-annexin v (n = 3) 1 h post injection was 5.1±0.3/6.1±0.3 in blood, 84.0±0.4/18.3±2.4 in the liver, 4.6±0.5/2.4±0.4 in the spleen and 6.3±0.8/73.2±3.0 in the kidneys. accordingly, scintigraphy in pigs showed high liver uptake of 99mtc-hynic-lactadherin (n = 3) and high uptake of 99mtc-hynic-annexin v (n = 3) in the kidneys. renal extraction of 99mtc-hynic-lactadherin was about 3% whereas the extraction of 99mtc-hynic-annexin v fell from 17-1% 2-120 min p.i. conclusion: these tracer kinetic studies in mice and pigs showed that 99mtc-hynic-lactadherin is mainly taken up by the liver in contrast to 99mtc-hynic-annexin v which is mainly taken up by the kidneys. these results combined to the apoptosis recognition ability of 99mtc-hynic-lactadherin makes this radiotracer a potential new imaging agent for apoptosis in different organs with an advantage to 99mtc-hynic-annexin v for imaging apoptosis in the kidneys. transport and phosphorylation of f-18-deoxyglucose (fdg) in the tumor cells determine the kinetics of the tracer and the accumulation. however, experimental data gave evidence that other processes like angiogenesis may have an impact on the tracer kinetics. this study is focussed on the combined evaluation of pet and angiogenesis related gene expression. methods: dynamic pet fdg studies were performed in 25 patients with colorectal tumors within two days prior to surgery. volumes-of-interest (voi) were used to obtain time-dependent tracer concentrations from the tumor region and a reference area. vois over the descending aorta were used to retrieve fdg total blood concentration data. a two-tissue-compartment model was fitted to the data and the transport constants k1-k4 as well as the fracional blood volume (vessel density, vb) were calculated using the evaluation software pmod (pmod technologies ltd., adliswil, switzerland). tumor specimen as well as specimen from a reference area(normal colon) were obtained by surgery and quantitative gene expression data were obtained by gene array analysis using the u133a gene chip (affymetrix inc., santa clara,ca,usa). pet and gene array data were evaluated with the genepet module of pmod. results: a quantiative data evaluation was performed in 25 patients, comprising 32 specimen of tumors and normal colon tissue. suvs were highly variable between 0.9 and 19.4 suv for this collective. angiogenesis related genes were enhanced by a factor of 2.9, when tumors and normal colon were compared. classification analysis demonstrated that 5 angiogenesis related genes provided the best discrimination between malignancies and reference tissue. the correlation/regression analysis demonstrated significant correlations (p<5 %) for the suv, fractal dimension (heterogenity of the tracer), k1, k3, and the fdg influx. summary: angiogenesis has a significant impact primarily on the kinetic data (k1, k3), but also on the global fdg uptake. a detailed analysis of the fdg kinetics can help to classify the grade of angiogensis in primary colorectal tumors. fifteen patients between ages 37 and 70 years of age (mean 54 yrs), with stage iia-iii recurrent cervical carcinoma treated with radiation therapy or chemotherapy and radiation therapy were enrolled. mr was performed on a 1.5 tesla scanner (ge scanner), the ct and pet was performed in a pet/ct scanner, (ge discovery st). mr scans were performed for radiation planning tumor delineation and pet ct's were performed for ruling out nodular metastasis. mr and pet/ct scans were done with a time interval less than 60 days. pet and ct were coregistered during acquisition in the pet/ct scanner. mr volumes were co-registered with the ct part of the pet/ct using 5-6 internal anatomical fix points. the gtv were retrospectively delineated on transverse sections of ct (center 0 hu; width, 300 hu and tumor consistent criteria like contrast enhancement) and mr (t2 weighted) scans independently by two physicians with training in radiology and nuclear medicine, working in a blind fashion. gtv's were evaluated with different modalities on a single integrated eclipse planning system (varian medical systems). gtv was autosegmented on pet scans using a lower activity level defined as 50% of maximum activity corrected for regional background results: the preliminary results demonstrated that on average gtv defined in pet smaller than in both ct and mr.the final result will be demonstrated at the meeting. conclusion: the combined pet/ct scan demonstrates an easy and observer independent definition of gtv for radiotherapy. the size of gtv was found smaller compared to determination by mr and ct. aim: cd10/neutral endopeptidase (cd10) and intestinal-type mucin (muc2) are known to associate with colorectal carcinogenesis and local invasion. the purpose of this study is to investigate the relationship between clinicopathological factors and fdg uptake in pet-ct in colon cancer, focusing on the expression of cd10 and muc2. methods: in this study, 25 patients (61.9±13.6 year old 10 women, 60.7±13.6 year old 15 men) with colon cancer were contiguously selected from april to september 2006. preoperative pet-ct was performed in all of them. to determine the relationship between clinicopathological factors and standardized uptake values (suvs) in colon cancer, we analyzed the tumor differentiation, tumor size, lymph node metastasis, vascular invasion, lymphatic invasion, and the expression of muc2 and cd10, in paraffinated tissue using immunohistochemial stain. in addition, the expression of hexokinase (hk-ii) and glucose transport (glut-1), and cell proliferating activity using ki-67 were evaluated. results: all of the 28 cases studied were positive for glut-1, specifically 6 of glut-1 weak positive and 19 of glut-1 strong positive. there were 14 cases of cd10 positive, 17 cases of muc2 positive. cd10 showed negative correlation with muc2 (rho=-0.65, p<0.001). muc2 expression exhibited the positive correlation with ki-67 (rho=0.37, p=0.067). there was no statistical significance among suvs and various clinicopathological factors such as tumor differentiation, size, lymphatic or vessel invasion, lymph node metastasis, ki-67, and hk-ii. furthermore, no clear correlation was found between a very simple animal model of liver infection consists of the intraperitoneal injection of clamidia pneumoniae, which results in an activation of hepatic kupffer cells in 30% of the animals. this kupffer cells dis-regulation can be associated to primary biliary cirrhosis. aim of this study was to assess the predictivity of fdg small animal pet for the early identification of reactive animals, possibly identifying not only the peritoneal inflammation caused by the injection but also the liver kupffer cells activation and behaviour (are they originated from the peritoneum or from the liver itself?). we used 7 adults balb/c mice (10-11 weeks) which were intraperitoneally injected with purified c. pneumoniae elementary body suspension (the inoculum preparation contained 2.0x10^7 inclusion forming units). 2,7,10 and 20 days after, the animals underwent a fdg small animal pet (ge, explore vista). we administrated 20 mbq of fdg via the tail vein. uptake time was 60 min, acquisition time 20 min. images were reconstructed with osem 2d iterative reconstruction. animals were considered positive if a visual abnormal fdg uptake was present in the abdomen and/or in the liver. we found that 3/7 animals had a positive pet scan 2 days after inoculum within the peritoneum. 7 days after inoculum all these animals presented an increased peritoneal fdg uptake, which disappeared 10 an 20 days after inoculum. the other 4 animals had negative scans 2,7,10 and 20 days after inoculum. no hepatic signs of inflammation were detected in any of the animals. these results reflect the biological behaviour of this animal model previously reported in literature (world j gastroenterol, 2006 oct 28; 12(40) ) which shows an inflammatory response in about 30% of the subjects. this inflammation, probably connected with the liver reaction, could be very early detected by fdg pet (those that were positive intraperitoneally). however, this imaging method was never able to identify the liver kupffer cells activation. these preliminary data indicates that, although predictive for reactive animals, fdg small animal pet is not the most appropriate technique to in vivo evaluate kupffer cells movements and behaviour. a reporter gene-reporter probe method or a in vitro cell labelling tracking method may be more accurate to fully in vivo understand the kupffer cells behaviour.aim: differentiation between cancerous growth and inflammatory reaction may be sometimes difficult. the glucose analogue, 2-18 f-fluoro-2-deoxy-d-glucose ( 18 f-fdg) accumulates in the areas of high glucose metabolism, such as rapidly growing tumours or active inflammatory foci. however, 18 f-fdg is specific neither for cancerous growth nor inflammation, thus causing false-positive findings. vascular adhesion protein 1 (vap-1) is a human endothelial protein whose cell surface expression is induced under inflammatory conditions, thus making it a highly promising target molecule for studying inflammatory processes in vivo. we hypothesized that positron emission tomography (pet) with gallium-68-labeled 1,4,7,10-tetraazacyclododecane-n',n'',n''',n''''-tetraacetic acid conjugated synthetic peptide targeted to vap-1 ( 68 ga-dotavap-p1) could be feasible for differentiating tumours and inflammatory foci. we compared the biodistribution of 68 ga-dotavap-p1, 18 f-fdg, 11 c-choline and 68 ga using experimental rat model. 11 c-choline is a marker for cellular proliferation and it has been extensively used for pet imaging of prostate cancer. free 68 ga also accumulates in both the tumours and inflammatory foci. to establish an in vivo model, athymic rats were s.c. implanted with human bxpc-3 pancreatic adenocarcinoma cells and sterile skin/muscle inflammation was caused by turpentine oil. dynamic 2h pet imaging and ex vivo organ distribution measures were performed 24h after induction of inflammation. results: our results revealed that the 68 ga-dotavap-p1 was able to visualize inflammation better than tumour and it was more inflammation-selective than other tested tracers. the difference between 68 ga-dotavap-p1 vs. 68 ga and vs. 11 c-choline was statistically significant (p<0.001). the most tumour-selective tracer was 11 c-choline. the difference between 11 c-choline vs. 68 ga and vs. 68 ga-dotavap-p1 was statistically significant (p<0.001). however, 18 f-fdg showed the highest target-to-background ratios (table) . conclusion: our results indicate that 68 ga-dotavap-p1 targeting vap-1 was capable of differentiating tumour from inflammatory foci in our animal model and it was almost as sensitive as 18 f-fdg for inflammation imaging. a minority of tracers developed for scintigraphic detection of infection and inflammation could theroretically discriminate bacterial infection from sterile inflammation. however, for some of these tracers these claims could not be confirmed. recently, the radiolabeled thymidine kinase (tk) substrate 1-(2'-deoxy-2'fluoro-beta-d-arabinofuranosyl)-5-iodouracil (fiau) has been proposed as an agent to image bacterial infections, based on presence of endogenous tk in bacteria. in the present study, we investigated [i-125]fiau targeting in rats with bacterial and sterile inflammation. to prove that fiau uptake was tk-mediated, e. coli tk-negative bacteria were generated and inoculated intramuscularly (im) in rats and fiau uptake was studied. methods. fiau was labeled with i-125 using the trimethyl tin precursor. aim: angiogenesis is a prominent feature of rheumatoid synovitis. v 3 integrin is expressed at high levels on the synovial formation of new blood vessels in rheumatoid arthritis. synovitis in rabbits could be suppressed by blocking this integrin with cyclic rgd peptide based v 3 antagonists injected directly into the joint. the multi-pinhole (mph) single-photon emission computed tomography (spect) technique and in-111 labelled cyclic rgd peptide (111in-dota-e-[c(rgdfk)]2) allows to detect vascular joint alterations in arthritis-mouse-models. methods: mph-spect-measurements were performed under short general anaesthesia in collagen-induced-arthritis (cia) mice, which had arthritis of front and back paws. all mice were independently scored macroscopically before starting the studies. control mice were compared with the mph-analysis of arthritis-mouse-models. spect data was acquired with a conventional gamma camera (prism 2000 s, philips) which was outfitted with a new constructed mph-collimator (12 pinholes with a diameter of 1.5mm). after the injection of 35.6±14.2 mbq (mean±sd) in-111 labelled rgd peptide, a dynamic measurement between 0 and 60 minutes p.i. was performed. results: the high sensitivity of the mph-technique allowed the dynamic visualisation in the uptake of rgd peptide in the ankles and other organs of the mice. mph-spect allows to detect all arthritic lesions (n=7) and a quantitative analysis. the regional evaluation showed that after 6 minutes, the percentual accumulation 1 h p.i. in the inflamed paws was 0.34%±0.27% while in healthy control mice (n=5) a significant lower uptake of 0.09%±0.03% was measured (p(1)=0.0047, mann-whitney). no significant difference was observable in the knee joints between healthy and arthritic mice. conclusion: the results of our studies suggest a correlation between arthritic inflammation and accumulation of cyclic rgd peptides in cia animals in vivo. the mph-spect technique in combination with a cyclic rgd peptide can be used as a diagnostic instrument for imaging joint pathologies and for an accurate and quantitatively precise monitoring of therapy studies. aim: image quality using the specific serotonin 2a-receptor radioligand 123 i-r-91150 is variable in dogs. since the p-glycoprotein is expressed in the blood-brain barrier, amongst many other organs, we wanted to evaluate the effect of ketoconazole, a pglycoprotein modulator, on the brain uptake of this radioligand in dogs. materials & methods: three 7-year-old healthy female beagle dogs were included. two spect scans were performed; one baseline scan and one scan after administration of ketoconazole. ketoconazole was administered orally during 3 successive days; two days before scanning at a dose of 100mg/kg, one day before scanning and the day of scanning at a dose of 50mg/kg. the radioligand 123 i-5-i-r91150 was injected (mean 166 mbq) intravenously 90 minutes prior to acquisition. acquisitions were performed under general anaesthesia (premedication with medetomidine, induction with propofol and maintenance with isoflurane in oxygen). acquisitions were performed with a triple head gamma camera (triad, trionix), equipped with lehr hole collimators. images were reconstructed with hosem iterative reconstruction and application of a butterworth-postfilter (cut-off, 1,2 cycles/cm, order 8). roi's were drawn over eight cortical regions (left and right fronto-, temporo-, parieto-, and occipito-cortical area) and one global subcortical region. the uptake in the cerebellum (area void of serotonin 2a-receptors) was used as a reference for non-specific binding in addition to free ligand. radioactivity measured in the cortical areas was assumed to represent the total activity. the binding index was operationally estimated as (mean counts/pixel in regional cortex)/ (mean counts/pixel in cerebellum). results: on visual inspection a clear improvement was noted after administration of ketoconazole. the mean counts/pixel in the total brain was 85,3 ± 40,6. after administration of ketoconazole the mean counts/pixel in the total brain was 96,4 ± 43,1. the mean serotonin-2a binding index of the baseline scan in the frontal cortex was 1,47 ±0,01. after administration of ketoconazole, the mean serotonin-2a binding index increased to 1,93 ± 0,16. this is a mean increase of 31,7%. conclusion: the results of this study demonstrate a trend towards an increased brain uptake of serotonin 2a-receptor radioligand 123 i-r-91150 after use of ketoconazole. despite clear improvement of image quality, no statistic conclusions can be taken due to a low number included subjects. further investigations are necessary to confirm these preliminary findings. aim. to determine possibilities of quantitative imaging of the mouse thyroids using the nanospect/ct small animal imaging system. materials and methods. phantom and in vivo measurements were made with the nanospect/ct device. phantoms of two point sources distributed in homogenous flood source of cylindrical for were created. 99mtc and 131i isotopes were used to fill in radioactivity. 99mtc activities ranged from 2 mbq in points to 40 mbq, 131i activities ranged from 0.3mbq to 3 mbq. flood activities were between 10-40 mbq. in vivo imaging of 3-3 mice with the respective isotope was performed using activities of 99mtc of 10-40 mbq injected iv. or 3-5 mbq of 131i.imaging was done 30-60 minutes post inj. thyroids were then removed from mice and measured in a welltype counter and compared to standard activities to determine real activity. results. roi-quantified voxel activities were the same in the measured phantoms and the calculations of two digits post zero. in vivo results were the same with an error of 6% with 99mtc, with 131i the error depended on the signal intesity and count-noise ratio. conclusions. nanospect/ct allows the correct absolute quantification of activity located in voxels both in vitro and in vivo if a good signal-noise ratio can be obtained. objective: poor in vitro and in vivo delivery is limiting the use of oligomers for imaging and therapy. streptavidin (sa) may be used as a convenient link between biotinylated antisense radiolabeled oligomers and transmembrane carriers added to improve delivery provided that antisense and carrier function is not compromised thereby. methods: nanoparticles with 20 mer uniform phosphodiester (po) or phosphorothioate (ps) dnas against the mdr1 mrna or a 25 mer phosphorodiamidate morpholino (morf) against the survivin mrna were linked to sa along with cholesterol, a 10 mer tat or 10 mer polyarginine carrier. the 99m tc radiolabel was always on the oligomer. results: as evidence of unimpeded carrier function, the morf/sa/tat and morf/sa/polyarginine nanoparticles accumulated 10 fold more than the morf/sa and the naked morf controls after 12 h in survivin+ mcf7 cells while all po nanoparticles showed increased accumulations at all times with compared to without carriers in three mdr1+ cells but not so the ps dna nanoparticles because of its high protein affinity. evidence of antisense targeting were the statistically higher cellular accumulations of the antisense morf nanoparticle than the sense morf nanoparticle control and statistically higher accumulations of the po dna nanoparticle in the three cell types in order of their mdr1 expression levels. in xenografted mice, the ps dna/sa/tat and ps dna/sa/cholesterol nanoparticles were accumulated in all tissues including tumor much higher than the po nanoparticles. these results show that the high protein binding affinity of the ps dna was expressed despite the presence of the sa. conclusions: the preparation of oligomer carrier constructs was greatly simplified over covalent conjugations by using sa as a linker. the sa linker had no apparent detrimental influence on the function of the carriers or antisense oligomers. these observations suggest that sa provides a convenient means of linking oligomers, carriers and, eventually, antitumor antibodies without compromising properties. the aim of this study was to investigate the effect of food and time on intestinal activity in technetium 99m tetrofosmin stress myocardial perfusion scintigraphy. based on a pre-study sample size calculation, we estimate the study population to comprise a total of 150 patients. patients were recruited at a single center and underwent a two day exercise-rest tc-99m tetrofosmin single photon emission computed tomography (spect) imaging. patients were randomized to food or no food (450 ml of water and two slices of white bread with butter versus no drink or food) versus early or late spect (within 15 min from injection of tracer versus 30-60 min after injection of tracer) in a 2 x 2 factorial design. patients with abnormalities on their stress test also had a rest spect. the food/time allocation used for the stress test was used for the rest as well. rest data will be reported separately. patients were randomized in blocks of four. most patients received adenosine pharmacological testing with moderate (25w) bicycle exercise. frequency of intestinal activity was assessed visually on spect images on 3 different planar projections. inferior myocardial wall and abdominal activity adjacent to the myocardium was evaluated visually on a 5-point semi-quantitative scale, ranging from no to severe intestinal overlay and a final accept/repeat spect decision. evaluation was performed by a trained observer blinded to the pre-spect details. the primary endpoint is the percentage of accepted first time spect in each cohort in the intention to treat population. secondary endpoints include proportion of approved first time scans in each cohort as per actual time and food (per protocol analysis), intestinal activity according to method of exercise testing, and time from injection to final acceptance of the scan (including repeat scans). an interim analysis has been planned at 75 patients (estimated to be late april, 2007). the final results will be presented at the meeting. the aim of study was to explore the possibilities of the use of dicom standard (digital imaging and communications in medicine) in our department. we used it in comparison of new commercial software package (4dm spect) with the existing (qgs) for the quantification of left ventricular ejection fraction (lvef). lvef values obtained with 4dm spect, 8 and 16 frames/cycle were also compared. material and methods: twenty patients (9 male, 11 female, mean age 57 ys) referred to stress and/or rest gspect study with 99mtc mibi, were enrolled. studies were performed with two detector camera system (ecam), first with 16 frames/cycle, and immediately after that with 8 frames/cycle for each patient, according to the recently published eanm/esc procedural guidelines for myocardial perfusion imaging (gspect, high count study), with total duration of 26 minutes (13 minutes for each study). after the reconstruction, the 16 and 8 frames/cycle data were processed with 4dm spect program. original 8 frames studies were also copied from esoft to icon working station, using the dicom key, where reconstruction and qgs processing was performed. mean lvef values were compared, and statistical significances were checked with paired t test. results: 4 dm spect-8 fr 4 dm spect-16 fr qgs -8 fr mean lvef % (range%) 68 % (57-76%) * ** 71 % (62-82%) 63 % (54-73%) * p<0.01 between 8 and 16 fr 4dm spect **p<0.01 between 8 fr 4dm spect and qgs mean lvef values obtained with 8 frames 4dm spect were 5% higher than with 8 frames qgs program. difference between 8 and 16 frame mean lvef values in 4dm spect was smaller, but both results turned to be statistically significant (p<0.01). conclusions: dicom transfer from one to another working station was successful in all cases. significant differences between 16 and 8 frame 4 dm spect study were found, and between 8 frames studies obtained with two software programs. since more prominent differences were found with different programs, it can be concluded that lvef values should always be processed with the same software package, especially when follow up of patient is needed. the dicom successfully enabled the comparison of the two software packages. aim: both stress and rest examinations are usually performed to diagnose ischemia or infarction in the left ventricle. if the stress study is performed first and the images show normal findings, it might be unnecessary to perform the rest study. the aim of this study was to evaluate if it is possible to avoid rest studies in some patients without making false negative interpretations. material and method: the gated-spect studies performed using a two-day nongated stress/gated rest 99m tc-sestamibi protocol from 532 consecutive patients were investigated. the patients had a mean age of 62±11 years, and 49% were men. myocardial perfusion scan was performed for the diagnosis of cad in 421 patients and for management of known cad in 107 patients, previous myocardial infarction in 79 patients and previous revascularisation in 98. visual interpretation by one experienced physician at the time of clinical reporting was used as the gold standard for the scintigraphic presence of myocardial infarction or ischaemia. rest, stress and gated images as well as clinical information were available for this interpretation. only the stress images (slice images and polar plots) were examined independently by 2 physicians and 3 technologists regarding the question if a rest study was needed or not. results: the clinical evaluation of the rest and stress images by the experienced physician showed normal findings, i.e. no signs of infarction and ischaemia, in 360 cases. the five observers decided that rest was unnecessary in 70, 135, 87, 94 and 43 of these studies respectively. a false negative classification, i.e. rest study not necessary in a case were the gold standard interpretation was infarct or ischaemia, was found in 1, 3, 0, 2 and 0 cases respectively. conclusion: the results show that it is possible to avoid rest studies in a significant number of patients with no or only few false negative interpretations.technologists and physicians did not differ substantially in the interpretations. h. lehtinen, a. sonkki; university hospital of turku, pet centre, turku, finland.the aim of this poster is our practical experiences of cardiac cta and perfusion studies performed at turku pet centre, finland. coronary cta combined with the cardiac perfusion study is one of the best and most reliable non-invasic tests in diagnosis of cad. the study provides seamless team work with many occupational groups like medical laboratory technologists, physicians and the physicists. the radiographer's role is to prepare patients, inform them of the study and do the scan. materials and methods. at first we prepare the patient for the cardiac study. the patient fills an interview form where we will see his current medications, possible former reactions to contrast agents, allergies, diabetes and kidney diseases. while the patient lies down we observe heart rate, check blood pressure and set an intravenous cannula. optimal heart rate is stable and under 60 bpm. if it's above 60 bpm the physician gives beta-blockers intravenously. oral nitrate spray is given to each patient before the scan. cta demands breath holds so it's good to exercise this with the patient before the study. the scanner used is ge vct 64-slice pet-ct scanner. cardiac cta consists of a calcium score scan and a coronary scan with contrast media. we use an automatic dual head injector system for injecting contrast media and nacl bolus chaser. the cta scan is then followed by the perfusion studies with 15 olabelled radio water, first basal perfusion and then adenosine stress perfusion. during the perfusion studies we monitor ecg and the blood pressure according to our protocol. after the study we observe the patient for awhile and advise him to drink a lot because of the possibility a nephrotoxic reaction due to iodine-containing contrast. conclusion. cardiac cta combined with pet perfusion is an excellent example of a multimodalitystudy, as the anatomic information of ct images is combined with the functional information of pet. it has been very challenging, exciting and rewarding to do these studies. standard indicator of sestamibi regional washout in the myocardium purpose: in recent years, it has been shown that washout of mibi is observed in myocardial ischemia lesions, and a method for its evaluation is discussed. we obtained the standard indicator for regional washout from early and delayed mibi images and evaluated its usefulness. method: in 14 healthy volunteers without abnormalities, such as cardiac diseases, hypertension or electrocardiographic abnormalities, spect images were acquired one hour after intravenous administration of 740 mbq of mibi of (early image), and subsequently, three times, up to five hours (delayed image 1, delayed image 2 and delayed image 3). to draw a polar map from each sequential spect image, the regional washout rate obtained from the mean count in three areas of the myocardium was plotted, and the gradient was calculated with the approximate equation. results: comparison of gradients in the linear approximation and exponential approximation from the early image to delayed image 3 in each area showed no significant differences ( and rca=-4.549±0.621, showed significant difference (p< 0.05) for the lad and lcx, but not for the other vessels (p=ns). the respective r 2 were 0.9303, 0.9295 and 0.9145, with no significant differences among the three (p=ns). as for correlation between the linear approximation and exponential approximation, the linear approximation approached 1 more closely than the curve approximation, however, no significant difference was observed. conclusion:it was suggested that the regional washout of mibi in healthy myocardium would decrease with a gradient of linear or curve approximation. since there was no significant difference between the approximated line and curve, evaluation of the gradient with the linear approximate expression may provide a constant gradient, and therefore, it can be used as an indicator of the washout rate. t. iimori, t. fujibuchi, h. sato, k. sawada, y. uchida, t. kawata, m. fujita, s. shindo, y. kuwabara; chiba university hospital, chiba, japan.background and purpose: by 99m tc -mibi scintigraphy, a myocardial morphologic assessment (hypertrophy or enlargement) and functional assessment are also enabled as well as myocardial perfusion evaluation, and they contribute to the assessment of myocardial viability. recently, there are some reports that accumulation and clearance of mibi are related to severity of heart failure. therefore, we evaluated the utility of scatter correction for precise energy count in calculating h/m (heart/mediastinum) value of mibi in the planar image. method: 1) phantom simulation study: in the phantom, myocardial region was filled by 0.123mbq/ml with mibi, liver region was filled with 0.025mbq/ml of mibi, and mediastinum was filled by water. we imaged the phantom with static collection (preset time; 200,000 counts, matrix; 512*512), and repeated with the different main window widths and sub window widths in order to determine the appropriate window width for scatter correction by tew. we used nmse (normalized mean square error) for their evaluation. 2) clinical evaluation: with the appropriate windows determined by the phantom, we measured h/m value of mibi in 54 patients with heart failure (43 male, 11 femail, mean age 54.8±15.5 years), and compared with raw data for the relation with the clinical data such as ejection fraction (ef). since 123 i-mibg imaging is well-established as a gauge of chf, effect of scatter correction by tew in mibi was also evaluated for the correlation with 123 i-mibg. result: main window width with 140kev±10% and sub window width with 122kev±2.5% were appropriate in scatter correction by tew by the phantom study, respectively. 2)correlation coefficient between h/m value and ef in patients with chf was r=0.12 without scatter correction, and it improved to r=0.25 with scatter correction. correlation coefficient with h/m value and 123 i-mibg h/m value were r=0.62 without scatter correction, however, it increased to r=0.90 with scatter correction. conclusion: we proposed appropriate windows for the scatter correction in cardiac imaging by 99m tc-mibi by phantom study, and proved its utility by applying to the clinical cases. background: stem cells represent one of the new therapeutic possibilities for severe co ronarydisease, the effect being tested in many trials. most centers use intracoronary injections, but some recommend intramyocardial injection, to obtain maximal homing and retention of the cells in the ischaemic myocardium. details about differences between these administration techniques are completely unknown. the purpose of the present study was to examine the retention of in-111 labelled human stem cells injected into porcine, left ventricular (lv) myocardium. methods: in-labelling was performed as previously described by our group (ejnm 2006 (ejnm , 33:1171 (ejnm -1177 . the labelled cells (2) (3) (4) were injected into the pigs (35-40 kg) via a cardiac catheter into the lv walls in 10 small depots (total volume injected = 2 cc). subsequent static gamma camera images were obtained (170 and 245 kev dual window, megp collimator) over the next 6 days to monitor the clearance of the labelled cells from the myocardium. on the second day 100 mbq sestamibi was given iv. after the planar image and cardiac spect performed 30 min later. the energy windows for spect were 25% around 155 and 245 kev. results: it was easy to localize, in the homogenous sestamibi visualization of the lv myocardium, the remainder of 2-4 mbq in-111, distributed in 2-5 hot spots, in the apex, posterior wall, septum etc. by the daily planar "pure" in-111 images the retention of the indium could easily be calculated after correction for physical decay: (day 2, 3, 4, 6). discussion and conclusion: this technique with a lower energy window centered around 155 kev during spect, permitting only part of the general myocardial activity uptake to be visualized as a background. it nicely demonstrated the myocardial localization of <1 mbq in-111 activity accumulations from labelled stem cells injected into the heart of 35-40 kg pigs. introduction lvef, edv and esv are good clinical indicators of left ventricular function and volumes, routinely measured by echocardiography (echoc). in former decade the emory cardiac tool box (ectb) was developed, a toll for assessing left ventricular function and volumes from gated spect myocardial perfusion scintigraphy (gspect). gspect myocardial function assessment provides an important incremental information. aim of the study the aim of the present study was to validate the accuracy of the ectb in assessing lvef, edv and esv from gspect using echoc as a reference values. patients and methods 44 consecutive patients, 29 males and 15 females; mean age 63+/-12 y, range 39 -87 y, with suspected or known coronary artery disease were examined using 99mtc-mibi gspect (8 gates/cardiac cycle) 60 min after tracer injection at stress. the gspet data were reconstructed using an automatic algorithm employing filtered back projection (fbp) and further analyzed by emory cardiac (ec) toolbox. all patients underwent two-dimensional (2d) m-mode echoc in the same diagnostic evaluation. optimization of myocardial fdg-uptake in f18-fdg pet-ct by a standardised hyperinsulinemiceuglycemic clamp protocol and acipimox k. krommes, g. pleschberger, v. meyer, h. kässmann, c. pirich; salzburger landeskliniken, nuklearmedizin, salzburg, austria. the assessment of myocardial viability by f-18 fdg pet has become a standard procedure in nuclear cardiology. metabolic imaging of the heart requires designated protocols that reflect alterations in substrate metabolism under ischemic conditions. it was the aim of the study to analyse the efficacy and practicability of a standardised hyperinsulinemic-euglycemic clamp protocol in clinical routine. method: cardiac f-18 fdg imaging was studied in 68 patients from 2005 till february 2007. 52 patients were non-diabetic (76 %) and 16 patients were diabetic (insulin and non-insulin dependent; 24 %). every patient was given a dosage of 250 mg acipimox on the study day. the hyperinsulinemic-euglycemic clamp protocol differentiates between non-diabetic, diabetic non-insulin-dependent and diabetic insulin-dependent patients. for each patient group, there is a predefined pattern for application of oral glucose or/and insulin (maximum single insulin dose 8 iu) according to the blood glucose level. results: according to our protocol the following procedure was necessary in our patients: • no insulin / no glucose: 1 patient • no insulin / glucose: 28 patients • insulin / glucose: 30 patients • insulin / no glucose: 9 patients 58 patients needed glucose, of whom 54 patients (93 %) got 75 g glucose and 4 patients (7 %) got 37,5 g glucose. after glucose application, 28 patients (48 %) required no insulin, and 30 patients (52 %) needed insulin to lower the blood glucose level. 39 of 68 patients were given insulin, 30 of them after glucose application and 9 patients without glucose. in detail, 29, 6 and 3 patients received respective dosages of 4, 6 and 8 i.u. insulin. one patient was given 26 i.u. insulin. diagnostically adequate imaging quality was achieved in 64 cases (94 %) and even in 14 of 16 diabetics (88 %). cardiac fdg-pet imaging of 2 patients was not successful due to vomiting of the oral glucose drink. conclusion: for metabolic imaging of cardiac glucose consumption by means of f18-fdg pet-ct a strategy combining the use of acipimox and the hyperinsulinemic-euglycemic clamp protocol is feasible and results in adequate imaging quality in the vast majority of patients. the protocol is even successful in a diabetic population. aim: in our department, myocardial perfusion scintigraphy (mps) is usually performed using a 2-day rest-stress 99m-tc-sestemibi protocol. with more referrals and wishes of additional procedures for routine and research purposes there is a growing pressure on the staff and a waiting list seems inevitable. we examined if resource utilization could be improved by applying the lean concept originally introduced by toyota for optimizing automobile production. material and methods: implementations of lean has as its core five concepts: 1. specify value in the eyes of the customer; 2. identify the value stream and eliminate waste; 3. make value flow at the pull of the customer; 4. involve and empower employees; 5. continuously improve in the pursuit of perfection. in terms of mps, concepts 2-4 were applied. first, we established an "as-is" flow diagram, which required a) an interview guide, b) interviews of secretaries, booking, laboratory technicians, and physicians, c) sketching of a so-called swimming lane diagram, and d) the "as-is" flow diagram. from the "as-is" diagram it was easily seen which activities could be combined, reduced, or eliminated. based on these observations a "to-be" diagram eliminating all "waste" could be established in a process involving and empowering all relevant employees. results: the "as-is" diagram identified the following pre-scan steps as candidates for a change: i) non-appearance of patients, ii) measurement of body weight and height, calculation of body mass index and sestamibi dose, iii) preparations and check of patient dose, iv) positioning of intravenous cannula and dose injection, v) check of medication and withdrawal of relevant drugs before stress acquisition, and vi) entering of informations into a working sheet and the patient protocol. similarly, the following post-scan steps were candidates for a change: vii) information to the patient of preparations for the succeeding stress examination, viii) precautions on day-2 in case these instructions had not been followed. conclusion: these and other simple changes, which could eliminate or streamline the many extra procedures, lightened the pressure on the personnel, made the working rhythm more fluent and stable, and yielded extra time for patient care as well as the conductance, processessing, and finalizing of each single mps study. in this way, the "low hanging fruits" were collected. in addition, a further gain could be obtained in at least ¼ of the patients by converting the sequence rest-stress to stress-rest and leaving the rest study undone in case the stress study was normal. aim: gated myocardial spect provides an estimate of left ventricular ejection fraction (lvef). most commonly gating is performed with 8 frames per cardiac cycle although 16 frames per cycle may provide more accurate estimates of left ventricular function. the aim of this study was to compare same day repeatability of left ventricular ejection fraction using 8-frame or 16-frame gated spect. method and materials: in patients referred for routine myocardial spect a 16-frame gated spect study (study a) was performed 1 hour after injection of 600 mbq 99mtc -mibi. a second 16-frame gated spect study (study b) was performed immediately after without the patient leaving the gamma camera. 8 frame studies were constructed from 16 frame studies. gated studies were processed with qgs software. repeatability is reported as the mean difference (study a -study b) ± 1.96 sd. results: 15 repeated studies (7 stress and 8 rest studies) were performed in 11 patients. in study a, 16frame studies produced significantly higher lvef than 8-frame studies (mean lvef 66.5%, vs 61.9%, p < 0.0001). repeatability of lvef in 8-frame and 16-frame studies were 1.7 ± 9.9% and 2.6 ± 10.8% respectively. the difference in lvef was not statistically significant in neither 8-frame nor 16-frame studies. in stress studies lvef was significantly lower in study b than in study a (repeatability 3.4 ± 7.0% [p = 0.02] in 8-frame studies and 4.4 ± 9.8% [p=0.03] in 16-frame studies). in rest studies no change in lvef was observed (repeatability 0.1 ± 11.5% in 8-frame studies and 1.0 ± 11.2% in 16-frame studies). no correlation between difference of lvef and change of heart rate, perfusion defect size, edv or esv was observed conclusion: there is significant variability of same day left ventricular ejection fraction measured with gated spect. repeatability seems not to be affected by frame rate, but appears to be poorer in stress studies than in rest studies. these observations should be taken into account in serial evaluation of left ventricular function with gated spect studies. . recently there has been an increase in the number of acute chest pain and pre-surgical patients (pts) with cardiac risk factors treated at community hospitals in the u.s. many of these pts require immediate cardiac care which has significantly added to hospital stays and health care costs. yet both federal and state reimbursements for institutions seeing these patients have decreased. aim: to develop a patient care pathway and pacs ( picture archiving and communication system ) to maximize immediate care for cardiac and pre-surgical patients while reducing the patient's hospital stay when possible. length of hospital stay was recorded for all uncomplicated cases. method: this project was a cooperative effort among the cardiology department, hospital administration, stress laboratory, cardiac care floor and nuclear medicine. a tc-99m gated myocardial perfusion imaging (mpi) was performed on all low and intermediate risk chest pain and pre-surgical patients within 24 hours of admission and preliminary results were provided to the attending physician within 2 hours of completion of the test. 450 patients (261 females, 189 males) with an age range of 18 to 95 years (mean = 64) underwent a one day rest and stress (exercise or pharmacologic stress with adenosine or dobutamine) gated spect mpi. a rest/stress dose of 370mbq/1.11gbq (10/30 mci) of tc -99m tetrafosmine was used. a siemens e-cam gamma camera with 4d ms spect software was used to reconstruct orthogonal views. results: 373 pts (83%) had negative mpi findings and were discharged with 24 hours of the exam. 31 pts (7%) had positive mpi findings and were immediately sent to coronary angiography and discharged within 2 to 3 days post mpi. 37 pre-surgical pts (8%) with negative mpi findings went to surgery within 24 hours. 9 pts (2%) with positive mpi results went on to have cabg. conclusions: all low and intermediate risk chest pain pts were discharged within 24 hours of mpi which represents an improvement over past hospital stays for these pts. pre-surgical pts with negative mpi results were immediately sent to surgery. these data suggest a significant reduction in hospital costs and stays. introduction: even if filtered backprojection (fbp) methodology still has a very well established role in routine image processing in nuclear cardiology, actually, with the general improvement of computational power available, an increasing number of nuclear medicine departments worldwide tend/is interested on the use of iterative methods (im). with this paper, it is intended to expose some main considerations, always with clear practical purposes, sharing our own studies and experiences. material and methods: the first part of the study consisted on the analysis of the different possibilities available within the current software options brought widely available by the furnishers of equipment. once concluded, sessions of practical tests started: the main goal was to establish the relative practicability of the options predefined on the first part of the study. hence, we used one group of 10 different myocardium perfusion scintigraphic studies, which had been processed with the distinct methodologies previously defined. we have compare data related with the processing operation itself for each case, with main focus on parameters as the time spent (from the operators as well as the system's immobilization, for instance) and complexity (here considered as essentially related with the degree of operator's intervention). in order to establish the clinical value of each methodological option, the resultant images were evaluated by 5 independent physicians, according to different criteria, always based on its clinical value. conclusions: it had been clarified and justified what seems to be the best option for the use im in routine image processing, in the specific case of mpi. introduction: it is worldwide very common that patients who will undergo a myocardium perfusion scintigraphy are requested to be in fasting condition. even if this idea is generally accepted, the scientific evidence underlying this requirement seems to be far from objective and/or consensual. the main goal of this work is to contribute for the study of in vivo biodistribution and pharmacokinetics of 99mtcsestamibi with and without fasting. material and methods: the same normal volunteer was imaged twice under different physiological conditions: the first study was done without fasting and the second one in fasting condition. anterior projections of thoracic and abdominal regions were acquired during 120 minutes, starting immediately after intravenous injection of the tracer. regions of interest in myocardium, liver, gallbladder and proximal intestine were drawn and a related timeactivity curve was then obtained. data was compared and correlated with the normal gastrointestinal tract physiology. results and conclusions: biodistribution and pharmacokinetics of 99mtc-sestamibi under those distinct physiological conditions had appeared slightly different, particularly in the case of organs such as the liver and the gallbladder. based on the obtained results, the authors assume first, the need to study further this subject and, secondly, maybe there is a need to review patient preparation procedures in the specific context of myocardium perfusion imaging. objectives: fdg-pet has suboptimal sensitivity in the diagnosis of brain metastases (bm). the presence of such metastases may result in cerebellar asymmetry (ca) of fdg uptake or crossed cerebellar diaschisis (ccd). previously, ccd has been studied qualitatively to describe the neuronal dysfunction of the cortico-pontocerebellar-system caused by supratentorial bm. we aimed to evaluate the potential added value of semiquantitative analysis of ca in the diagnosis of bm by comparing cerebellar uptake in patients (pts) with and without bm as well as in normal volunteers (nv) methods: a total of 73 subjects studied: 18 nv and 55 cancer pts including 30 without bm (g1) by mri and 25 with bm (g2) as confirmed by mri, pet or histopathology. pet/ct scans of all subjects were retrospectively reviewed and one symmetric roi in bilateral cerebellar (cbl) cortex was drawn. differential values were calculated as 100 -(suv1/suv2), whereby suv1/suv2 corresponds to the cerebllar hemisphere with the lower/higher suvmean, respectively. differential values of groups nv and g1 were used to determine the cut-off for ca determined as mean -2x standard deviation. mann-whitney and t-tests were used for statistical analysis. results : differential values of nv and g1 showed no significant difference (mean 3.1 +/-2.4 vs. 2.6 +/-1.7, p = 0.474) with values ranging from 0-7.9%. cut-off for ca was determined as differential values 6.7%. 10/25 pts (40%) in g2 were found to have ca suggesting affection due to bm. 3/13 pts (23%) with unilateral supratentorial (st) metastasis showed contralateral ca consistent with ccd (frontal, parietal, occipital) which is compatible with published data. three pts demonstrated ca ipsilaterally to st foci (frontal, temporal/parietal occipital). despite bilateral st foci, 2/3 pts developed ca. 2/4 patients with cbl metastasis revealed ca caused by ipsilateral foci whereas 2 pts with bilateral cbl foci showed no ca. bm could be identified by pet/ct in 21/25 pts (84%) as increased or decreased fdg-avidity. pet/ct failed to identify bm in 4/25 patients (16%) which however could have be decreased to 3 (12%) if evaluation of ca was used. conclusions: detection of ca in fdg pet may indicate the presence of bm, and thus may have an added value in the diagnosis of bm, particularly if semiqunatitative measurement is used instead of subjective visual assessment. prospective validation of our findings is needed. measurement of suv as a means to evaluate glucose metabolism in solid tumours may aid in defining response to treatment. aim: we have evaluated fdg-suv changes during neoadjuvant chemo-radiotherapy in larc patients, in comparison with pathological response determined at surgery performed at the end of treatment. methods: thirty-three patients undergoing a novel treatment regimen have been evaluated with fdg pet during treatment. baseline pet studies were obtained from neck to pelvis for staging purposes. scans obtained after 12 days of treatment and presurgically were carried out only on the pelvis. suv corrected for body weight was obtained for each study. maximum suv values and average suv values were obtained by drawing an irregular three-dimensional region of interest which semiautomatically defined the tumor area based on preset threshold values. values were recorded for the three studies and changes compared to treatment outcome which was defined on pathologic evaluation of surgical specimens at the end of treatment and scored on a five level tumor regression grade scale (trg). results: in 55% of tumours a complete or near-complete regression was observed at the end of treatment. in the remaining patients considered non-responders only partial or no regression was observed. baseline suv showed no correlation with the overall outcome. conversely, a strong correlation was observed between suv values measured 12 days after the start of treatment and the pathological response (trg). the most important factor in predicting tumor response was found to be the early suv change (variation between the baseline and the 12 day scan). the suv values measured on the pre-surgery scan were not as predictive of the overall outcome. we could define a cutoff value of the early average suv change that predicted treatment response in 100% of patients, whereas for early maximum suv change this was correct only in 31/33 patients. conclusions: fdg-pet is an effiecient and powerful tool for monitoring changes of tumour activity during the course of treatment. in particular, the early changes occurring shortly after beginning of treatment allow a very efficient evaluation of response which is more accurate for average suv compared to maximum suv. evaluation of dispersion of suv obtained by different pet system; preliminary cylinder phantom study h. otake 1 , y. takahashi purpose: suv (standardized uptake value) is a useful tool for the evaluation of the uptake of fdg in tumor lesion, however, reliability of its accuracy in different condition such as different camera or institution has not been evaluated enough. in our study, suvs obtained by five pet systems with different acquisition condition and reconstruction method were compared by phantom study. materials and methods: five cameras, set-2400(shimadzu), acquiduo(toshiba), biograph lso(siemens), discovery (ge) and gemni (philips) were used. the same amount of radioactivity of f-18 was filled in a cylinder phantom with the size of 200 mm tall and 200 mm in diameter (type-3, anzai-sogyo, tokyo, japan ). in phantom filled with same concentration of f-18, different sized round spots (8, 12, 14, 18, 22, 27mm) filled with f-18 solution containing activity corresponding to suv 2.5 were placed in equal interval. suv of different spots were measured and compared with background. suv were calculated using formula by kubota et al. max suv obtained by roi methods was used as a representative value. 3d acquisition method and image reconstruction by fore-osem method was applied. results: minimum detectable size were different in each pet system. suvs by ct attenuation correction pet system were higher than those by external radiation source. in routine condition, maximum difference of suv was 45.7%, whereas, 22.6% in condition under image reconstruction. conclusion: for the early detection or follow up of cancer patients, contribution of fdg-pet is recently recognized and the number of study are increasing rapidly. however, we should pay attention about the follow up pet study by different pet camera, which may show different suv value. as shown in our study, maximum difference of suvs by different camera was 45.7%, therefore, precise information of each pet study such as name of pet camera, acquisition condition and reconstruction method is recommended to be added to each results. aim: it is now a well know fact that the interpretation of abdomino-pelvic images in pet/ct can be altered by normal tracer fixation or accumulation in different organs and anatomic structures, such as the bowel, the ureters or the bladder. the purpose of this presentation is to show the advantages of the administration of furosemide and laxatives to the patient, as part of the preparation for a late second image acquisition when in presence of equivocal findings in first acquisition. methods: we present six examples of pet/ct (siemens biograph 6 hirez) whole-body image acquisitions performed 60 minutes after the i.v. administration of approximately 370 mbq of 18 f-fdg, adjusted according to the patient body weight. images were visually analysed after iterative reconstruction using the common parameters for these patients. when equivocal 18 f-fdg foci were found along the course of urinary or intestinal tract, a second late abdomino-pelvic image acquisition (approximately 3h later) was performed after administration of furosemide (20-40 mg) and/or laxatives (sodium citrate and sodium laurilsulfoacetate). the second late images were then compared visually with the correspondent first acquisition ones. results: we show a comparative study of the images acquired before and after administration of furosemide and laxatives to remove equivocal 18 f-fdg activity. as can be seen, the late images acquired post-furosemide and post-laxative administration, show enhanced information when compared with the first abdomino-pelvic pet/ct evaluation. this clearly allowed a more accurate distinction between physiologic and pathological 18 f-fdg uptake, improving the diagnostic accuracy.conclusions: the administration of furosemide and laxatives and late image acquisition in pet/ct, after equivocal first diagnosis, due to retention of 18 f-fdg along the intestinal and urinary tracts, proved to be of great utility in the above mentioned examples. in conclusion, this presentation shows the usefulness of this simple, non-invasive interventional procedures in ruling out suspected tracer fixation that is otherwise difficult to evaluate. objectives: to assess the value of a image fusion and change protocol for early detection of disease progression or recurrence. each patient underwent pre-surgery imaging with in-111 octreotide , i123 mibg and spiral ct and post surgery imaging with in-111 octreotide , i123 mibg and spiral ct at approximately 6 monthly intervals post surgery. spect and whole body imaging (wbi) with in-111 octreotide is carried out at 24 and 48 hours pi . i123 mibg spect and wbi is performed at 4 hrs and further wbi at 24 hours pi. methods: a composite data set comprising the 24hr, 48 hr octreotide, 4hr mibg and ct transaxial images is created by mutual information based image fusion for each patient's follow up imaging sessions. change detection is carried out between the octreotide spect 24hr and 48hr image sets to detect and eliminate significant changes corresponding to normal physiological excretion e.g. in the gut. remaining areas of stable, significant uptake are reviewed in the context of the co-registered 4hr mibg spect and ct data. pre -surgery and any previous post-surgery composite data sets are fused and compared to the current data to detect areas of significant change and potential areas of tumour recurrence or progression. results: of the 12 patients included to date, 6 exhibited stable disease, 4 demonstrated disease progression and 2 disease recurrence . conclusion: the advent of accurate image fusion software and ready availability of ct through pacs has enabled the development of comprehensive image protocols for follow up imaging in patients with neuroendocrine tumours. this image fusion and change detection protocol is also directly applicable to patient data acquired with new hybrid spect-ct systems. with the improvement of gamma cameras systems and software, spect has become a usual practice in most nuclear medicine departments. however, the development of other techniques in nuclear medicine conditioned the impact of new advances in spect methodology. spect provides significant technical challenges for the nuclear medicine technologist, concerning to data acquisition and image processing and reconstruction. many new advances in spect methodology are becoming available, such as whole body spect acquisition and iterative 3d reconstruction (3d osem). whole body spect acquisition is a new technique of image acquisition, allowing the 3d visualization of whole body. the application of this method is especially important in bone studies, excluding additional planar views, and improving the recognition and identification of lesions. the aims of this study are to describe the benefits of spect imaging based on whole body acquisition in bone studies and iterative 3d reconstruction (in relation to backprojection and the most widely used iterative reconstruction method, 2d osem) and analyse the impact, advantages and limitations of this methodologies, essentials to produce highest quality scans and reduce some image artefacts. material and methods: the acquisition of whole body spect was performed on a dual-head camera (siemens e.cam signature), using low-energy and high resolution collimators. a 20% energy window centered on 140kev was used for data acquisition. imaging was performed with the patient in supine position. images were acquired as 128×128 matrices with use of a 360º arc. for each of the 5 positions considered, 32 projections were acquired, each 15 seconds in duration with a non-circular orbit, step and shoot mode. tomographic images were lately submitted to different reconstruction methodologies. results and conclusions: the whole body spect acquisition applied to bone studies is an effective, relatively cheap and easy to apply technique, that consume a short period of time (40 minutes), allowing the 3d visualization of whole body, advantages that guarantees its superiority by themselves in relation to conventional whole body bone scan. in concern to reconstruction of the data, iterative 3d reconstruction algorithm provides significant improvements in image quality due to higher spatial resolution, lower noise, reduction of distortions and artefacts, improved image contrast and more accurate and easier to interpret images compared to backprojection and conventional iterative 2d reconstruction method. aim: oblique projections have been suggested to enhance sentinel node (sn) detection in breast cancer by supplementing anterior projection (ap) and lateral projection (lp). sn close to tracer depots can be especially difficult to detect. this may be remedied by moving the breast before acquiring ap or lp to increase distance between injection site and axilla. however, in some patients movement of the breast may be inadvisable, e.g. to avoid hook-wire displacement in patients with nonpalpable tumours. we wanted to compare a 45° anterior oblique projection (ao-45) with ap and lp to investigate if this improved scintigraphic detection of sn in patients, where the breast could not be moved due to a hook-wire. furthermore, we wished to test the influence on observer confidence. material and methods: all women with non-palpable breast cancer scheduled for sn procedure and hook-wire implantation in 2006 were eligible (n=75). fifteen were excluded: reinjection of tracer s402 (n=6), contamination artefacts (n=2), bilateral tumours (n=1), non-available images (n=3), non-available surgery results (n=2) and multiple wire-implantations (n=1). 99mtc-nanocoll (2 x 10 mbq) was administered using both a peritumoral and a periareolar injection. scintigraphic images were obtained using a single-headed gamma camera (mediso, hungary) equipped with a low energy high resolution collimator. dynamic images in ao-45 were obtained for 20 minutes after injection and a summed image from 15-20 minutes comprised the early ao-45. following dynamic acquisi-tion, successive 5-minutes planar images were acquired in ap and lp. late images in ao-45 and ap were obtained successively starting 85 minutes after injection. for each patient, the five images were reviewed randomly and independently without knowledge of other projections or the number reported and confirmed by surgery. results: in all 60 patients, one or more sn were identified, in 11 patients (18%), one or more were positive for metastases. in 47 patients (78%), ap was sufficient. we found additional sn in ao-45 alone in 3 of 60 patients (5%); one was positive for metastasis. in another 10 patients (17%), ao-45 also showed additional sn, but these were also visualized in lp. in the former 47 patients, ao-45 improved observer confidence in 14 (23%) and in the latter 10, observer confidence was improved with ao-45 in 6 (10%). conclusion: adding oblique projections to standard ap and lp for sn detection in non-palpable breast cancer demonstrated a few more detected sn, and improved observer confidence in one third of the patients. to ascertain whether imaging patients at 6 hours post injection will demonstrate sln(s) if the initial 3 hour image is negative. method: sentinel lymph node (sln) images are usually acquired the day before surgery. four injections of 10 mbq 99m tc nano-colloid in 0.5 ml are injected peri-areolar. the nipple area is then massaged for 5 minutes. 3 hours post injection anterior, lateral and oblique images are acquired on 256 matrix with lehr collimator. a cobalt flood source is used to outline the patient. if no nodes are seen on the 3 hour image a further 10 minute oblique image is acquired at 6 hours, again on 256 matrix with lehr collimator. at surgery, 2 ml of blue dye is also injected peri-areolar. results: 10 out of 302 patients (<4%) demonstrated no nodes at three hours. 2 patients went to surgery before delayed images could be acquired. of the remaining 8, 4 (50%) images indicated nodes at 6 hours. of the 4 patients, with negative images at 6 hours, 3 had low activity nodes found at surgery using a gamma probe and in 1 patient the nodes were detected with blue dye only. conclusion: imaging at 6 hours post injection can improve the sln localisation if the 3 hour image is negative. interdisciplinary databases for evaluation of nuclear medicine procedures m. móldrup 1 , w. vach 2 , p. hóilund-carlsen 1 ; 1 odense universitetshospital, odense c, denmark, 2 university of southern denmark, odense c, denmark. we have established interdisciplinary databases the stem of which are nuclear medicine procedures in heart disease and cancer. using our database for breast cancer as an example we present its important characteristics and our experiences with it. material and methods: the database includes prospective and chronological data from mammography, nuclear medicine, surgery, pathology, oncology, and clinical genetics. its purpose is to ensure that all patients are included, check the quality of the sentinel lymph node (sln) procedure, evaluate its usefulness in terms of a constantly high identification rate, reliable detection, and treatment of extra-axillary slns, and long term follow-up with regard to axillary and distant recurrences. all parties agreed upon purpose, rules, and which data should be recorded for each patient. we created the questionnaire sheets with a common lay-out suited for typing of data, e.g., yes or no. all questions must be clear and unequivocal allowing simple answers only. each panel must have blanks for crosses or numbers, not text. spaces for "unknown" or "not done" are mandatory to ensure all questions are considered. in each department a contact person collects and controls data before submission to us, where they are checked once again by a controller before typing. in collaboration with the statistical research unit we have established an organization ensuring creation of proper webbased databases, relevant questionnaires, control of submitted data sheets, typing (twice) of data, error correction, etc. patient id is converted to a serial number to ensure anonymity. a set of basic data are available to all parties at all times. all can have their own data within a fortnight. interdisciplinary data are provided after application. an updated set of all data is available twice a year. results: the database has created a positive and unique collaboration between departments. all parties can check the entire patient course, including waiting and procedure times. it has become clear what is good and less good, if there are patterns of non-visibility of slns, reoperation, rates and appearance times of lymphedema, effects of treatment, new procedures, etc. conclusion: interdisciplinary databases yield closer collaboration and better understanding between parties. the fact that each department has its own questions means that data are much more comprehensive, detailed, correct, and up-todate than in nationwide cancer databases. datasheets and controllers are still necessary to ensure data reliability. nucl. med. 27, 235-238 (1986) ]. we use 3 computer-controlled modules in connection with an automatic dose dispenser. the modules are installed in pharmaceutical class b cells surrounded by a class c laboratory. materials & methods: all the 900 batches were analyzed according to the european pharmacopoeia (ep) to verify: •radiochemical purity (hplc, tlc); •ph (ph indicator strips); •sterility (all the batches has been sent to an external gmp compliance laboratory); •bacterial endotoxins (turbidimetric method); •chemical purity (hplc); •radionuclide purity (nai detector); •half-life (measuring the activity at different times in a dose calibrator); •residual solvents (gc-based method for measurement of residual methanol, acetone, ethanol and acetonitrile. detections limit was 25 μg/ml for all 4 solvents); • kryptofix 2.2.2 (method developed by mock et al [nucl. med. biol. 24; 2:193-195, (1997) ]; •bubble point of sterilization filters. depending on the requested amount of activity for in-house scheduled scans and of external costumers requests, we usually bombarded 1.6 ml of [ 18 o] h 2 o for 50 to 100 minutes at 30-35 μa beam current with a pettrace cyclotron and using alternatively two targets. [ 18 f] fobtained by (p,n) reaction is transferred to the automated synthesis modules, which synthesise [ 18 f] fdg within 25 minutes. furthermore 3 minutes are required to empty the target and additional 20 minutes are necessary for the automatic dispensing unit to dispense activity in vials for qc, back-up and sterility in addition to vials for a variable number of costumers. all the samples are filtered (at 0.22 μm) into sterile evacuated collecting vials in pharmaceutical class a environment. results:the number of rejected batches over 900 was 33 and was due either to mechanical problems as leakage of fittings, tubes and valves or to solvent-/radiochemical impurities exceeding the ep limits. none of the batches was positive to sterility or pyrogenicity tests or presented problems due to the radiochemical purity or half life. conclusion: based on our experience we conclude that solvents impurities represent a crucial point in fdg production and great attention must be focused on an accurate method for residual solvents detection. background: immunoscintigraphy is an attractive tool for tumor and other imaging purposes, with iodine ( 123 i / 131 i) and 111 indium(in) as popular isotopes for radiolabelling. i-labelling may be obtained by the iodogen and other methods, in needs some chelator, e.g. dtpa. the aim of this study was to produce and evaluate, in an experimental mouse model, a good labelling technique for in vivo use of a specific monoclonal antibodies (moab) against a human breast cancer (bc) antigen, muc-1. materials and method: 131 i and 123 i labelled anti-muc-1 (muc) moab were synthesized by the iodogen method. after one sephadex purification step free 131 i or 123 i were <5%. the i-muc was then injected into bc xenograft tumors in 5 mice. as control a nonsense i-labelled moab, anti-tnp, was injected into other mice with the same bc tumors. by gamma camera monitoring and well counting of the tumors the retention of the moab were compared. 111 in labelling of polyclonal igg ab modified with dtpa-anhydride were done 11 times, before labelling muc. dtpa-anhydride was suspended in dichloro-methane (dcm) to avoid hydrolysis. just before adding the igg solution, dcm was evaporated with nitrogen. igg-dtpa was then separated from dtpa-anhydride by gel chromatography before adding 111 in-citrate. results: iodine-: in the first series of bc xenografts 131 i labelled muc was retained longer than anti-tnp (p<0.05), both according to imaging and well counting. however, in the following 2 identical mouse tumor series, radio-iodine was rapidly removed from muc anti-tnp in the xenografts, and high iodine uptake was noted in the thyroid gland. indium: labelling efficiency of igg-dtpa varied from 40 to 90% (mean 70). generally, but not always, purification with one sephadex column increased purity to >90%. the in-muc has not yet been tested in an in vivo mouse model. conclusion: in vitro labelling with iodine is generally simple, but in vivo stability of i-labelled antibody must be carefully evaluated since de-iodination in vivo often occurs. inlabelled antibodies are, according to literature, usually stable in vivo, but chelatorbased in-labelling procedures may be a greater challenge for a reproducible production of a highly purified, radiolabelled antibody. aim: a radiation detection system for target monitoring was designed, developed and optimized for its use as a diagnostic tool for cyclotron startup, maintenance and operational needs. the system was installed for monitoring the radiation levels next to the cyclotron target during and after bombardment. the system permits a rapid assessment of the quality of any particular run in which isotopes are produced as radionuclides for pharmaceutical labeling. cyclotrons are produce short-lived positron-emitting isotopes that are used as research tools in identifying physiological mechanisms and in diagnostic procedures for numerous medical problems with the positron emission tomography (pet) instrument. the short half-lives characterizing the positron-emitting isotopes necessitate that they be produced at the desired activity, as rapidly as possible, so that they will be available for the scheduled procedure. this raises a need for automated control sensors that can monitor the production process. method: a computerized radiation detection system was developed for monitoring the radiation levels next to the cyclotron target, during and after the isotope bombardment in an attempt to show that a particular cyclotron run might be faulty. the system utilized a bgo scintillation detector focusing on measuring the photons at the energy window of 511 kev; and a geiger muller detectors design for measuring the gross gamma radiation. the system monitored the radiation levels throughout the production run as well as the activity before and after the transfer procedure, when the measurement of isotope activity takes place. the installed system input on-line the results into computerized software, and used as part of an overall diagnostic and control tool of the bombardment run. results: the target radiation detectors provided an early warning of a malfunction or an irregular run. this information could lead to operational decisions in order to prevent delay in the production and availability of the isotope. the system predicted and quantified accurately the actual amount of radioactivity being produced, thus it assured quality control during isotope production. the system also helped in troubleshooting target problems immediately after their occurrence and identified the stage at which the malfunctioning took place. conclusion: the results obtained from the developed system indicated that such a measurement tool can serve as a powerful instrument for sensing various target conditions. this can be translated to an awareness of problems in the early stage during isotope production, and provide early notification to the cyclotron operator that a particular run is malfunctioning. aim at present, most nuclear medical departments have instrumentation that allows them to perform tommographic studies in a continuous circular method. with the present work, we aimed to compare quality of images obtained by simple photon emission tomography with two approaches, continuous circular and step-and-shoot circular acquisitions. material and methods for both methods, continuous circular acquisition and step-and-shoot circular acquisition, we tried to establish associations between acquisition parameters (independent variables) -number of projections for each detector, time for each projection; and measurements of image quality (dependent variables) -noise, contrast, resolution and sensitivity. the experimental series was defined using a non probabilistic method by convenience, with sixteen studies of a jaszczak fantom, model ecat/dlx/p, in which eight studies were acquired in a continuous circular mode and the other eight in circular step-and-shoot mode. the statistical analysis was performed with package spss version 14. results the percentage of noise was inferior in studies in continuous circular mode, the contrast measured with the 4 spheres gave identical results in the two acquisition methods, the resolution was higher in step-and-shoot mode and the detection sensitivity was higher in continuous circular mode. conclusion we conclude that the tommographic acquisition in continuous circular mode presents identical image quality to the one in step-and-shoot circular mode. the quantification of low activity in plasma of a positron emission tomography tracer is performed in pet research to derive a kinetic model for a particular biochemical process. to define the kinetic model, the concentration of radioactivity in the parent compound present in the plasma must be measured at several time points. a radio-hplc is used to measure low levels of radioactivity in a compound throughout rapid sequential experiments with the nearby presence of another compound causing a high background level. both the measured compound and the background level are caused by compounds labeled by a positron emitter isotope. the time separation between the parent compound and the metabolite one is limited, therefore optimization of the measured volume and its geometrical configuration can improve the minimum detectable activity. improving of the mda is important for achieving a better reliability and validity in measuring biochemical processes with pet. the research was based on an analytical study, followed by software simulation and feasibility experiments for increasing the measuring sensitivity of an hplc metabolite radiation detector. as a first analytical step a mathematical model for the coincidence measurement probability from a pet tracer radioactive compound was developed. by using this model, an estimation of the number of coincidence counts was made, and its influence on detection sensitivity from the system configuration parameters was assessed. results of the mathematical model were compared to those obtained by software simulation.. finally an experiment was performed under similar conditions those in the mathematical modeling and software simulation. a high correlation between the mathematical modeling and the software simulation was found. the results indicated that an optimum for the measured volume and its geometrical configuration can be found. a curve representing the measured coincidence counts as a function of volume was obtained from the experimental results. the experiment validated the analytical study, showing that optimization can be achieved for each case based on the time separation between the parent compound and the metabolite one. a new method for improving the mda for the data acquisition during kinetic modeling, based on optimizing the measured volume seen by coincidence detection configuration is suggested. the mda is defined by both the signal and the background levels. the s404 reduction in the sensitivity for the signal measurement is negligible compared to the reduction in the background level, and is achieved by increasing the distance between the measured parent compound and the metabolite one. we have developed a simple image registration method for 99m tc-mdp planar bone scintigraphy and x-ray images in patients with suspected scaphoid fracture. this method is based on immobilisation of the wrist in a vacuum pillow equipped with three multi-modality fiducial markers ( 57 co-source collimated by a punched coin, 2.5 cm) during image acquisition followed by computer assisted semi automatic image registration (casair). the aims of this study were to investigate the feasibility of the vacuum pillow to immobilize the wrist and to evaluate the accuracy of casair. materials & methods: wrist movement between two examinations was assessed in five healthy individuals. a small metal disk ( 1.3 cm) was taped radially to the volar side of the carpus. two x-ray images were acquired with the wrist immobilized in a vacuum pillow equipped with three fiducial markers. between the two acquisitions the subject walked around for about 5 minutes. the two images were registered with casair and the distance between the centres of the metal disc on the carpus in the two images picture was measured. accuracy of multi-modality image registration with casair was estimated from 19 clinical fusion images. the distance between the centres of each fiducial marker on the x-ray image and scintigraphic image was measured. results: mean wrist movement as evaluated by consecutive xrays was 0.8 mm (range 0 mm to 1.4 mm ). accuracy of casair was 0.4 mm (range 0.2 to 0.7 mm). conclusion: the vacuum pillow provides a feasible and accurate method of immobilisation of the wrist and image registration with casair provides very accurate image registration of nuclear medicine and x-ray images. in consideration of the size of the scaphoid bone the magnitude of misregistration with the proposed method has no clinical impact. introduction:in routine practice of spect acqusition,the image acquisition time per projection is a cause of concern eventually leading to increased overall acquisition time of a clical study.the present study was therefore undertaken to optimize the overall aquisition time irespective of whether fbp or osem reconstruction technique is used.the objective of the study also included comparative evaluation of the images obtained by either reconstruction techniques. materials and methods:the raw image data were retreived from dst-xl sopha gamma camera work station and were then subjected reconstruction using both fbp and osem technique on xeleries work station.the aquisition time was also manipulated to 15 seconds per view from 30 seconds per view/projection.the reconstructed images were obtaine for reduced acquisition time keeping all other parameters identical nad by using both reconstruction techniques.the reconstructed images were blinded for independent evaluation by two nuclear medicine physicians in the nuclear medicine department of the institute. results and conclusions:the overall image information and quality remained unchanged even after reducing the acquisition time from 30 seconds to 15 seconds per projection irrespective of whether fbp or osem reconstruction method was used for skeletal images.in addition the intercomparison of fbp and osem reconstructed images revealed that the image information was better delineated in osem reconstructed images as compared to fbp reconstructed images. the image optimization in terms of reduction in acquisition time without any loss of image information would help reducing overall study time in spect aquisition.in addition use of osem reconstruction technique appears to be the order of the day in image processing and would provide improved image information delineation. the generally used filtered back projection(fbp)method is likely to be influenced by high accumulation, especially in the liver and biliary system, and it is often difficult to reduce the waiting time for imaging with a tc preparation. in this study, reduction of artifacts using the projection mask method was studied. method: a model was prepared to generate artifacts from the liver using a cardiohepatic phantom. mask processing of 100 counts was applied to spect images acquired over 360 degrees at intervals of 6 degrees and the obtained projection data of 60 slices other than the myocardium. a similar mask processing was also applied to clinical cases after ami and compared. for analysis, decreases and variations of the counts were measured with a polar map and a circumferential profile curve (cpr) on a short axial image. results: in the phantom, a significant difference in the count was observed (p< 0.001) between normal processing and mask processing, that is, the average count was 47.49 for normal processing and 41.93 for mask processing. variances in the area with visually observed artifacts with the cpr were 5.08 for normal processing and 4.02 for mask processing, indicating smaller variations with the mask processing. the counts and variances in an area with visually observed artifacts in clinical cases were 8.68 and 27.14 respectively, which were significantly reduced to 7.85 and 18.72 by mask processing (p< 0.001). conclusion: the projection mask processing method is an effective means for removing artifacts from the liver and the gallbladder, and imaging may be available from the early period after myocardial injection of the 99mtc tracer. aim: in pet study, the coincidence count rate (cr) in the imaging of standard image quality phantom (iq phantom) is different from that of the actual clinical data. therefore, clinically optimal injection dose cannot be estimated using the data of iq phantom. in this study, we made an anthropomorphic pelvis phantom (pelvis phantom) which can provide the cr equivalent to clinical data and investigated whether the optimal injection dose could be estimated using this pelvic phantom. materials and methods: the pelvic phantom was made by putting high radioactivity area imitating the urinary bladder in the iq phantom and by using bone-equivalent material for pelvic bone model. at first, the images of the pelvic phantom were acquired changing its radioactivity using both 2d and 3d acquisition modes. obtained crs were compared to those of pelvic images of actual patients. then, single photon ratio (spr) indicating the maximal necr was determined in the pelvic phantom imaging. using this spr, the spr obtained from patients' data was normalized. the optimal injection dose of fdg per kg of body weight was calculated according to the relationship between spr and the injected dose. results: the good correspondence was shown between cr of pelvic phantom data and that of clinical data when sprs were 2.6 to 3.9mcps for 2d imaging, and 6.0 to 10.7mcps for 3d imaging. the spr at the maximal necr in the pelvic phantom imaging was 12.4mcps in 3d acquisition whereas no peak was found in 2d mode. the optimal injection doses calculated using spr in 3d imaging were 282mbq and 400mbq for the body weight of 40 kg and 80kg, respectively. these results were empirically acceptable. conclusion: the imaging of pelvic phantom showed the cr similar to human bodies, indicating that the statistical quality of the obtained data in human studies can be estimated by this phantom. and, using spr of this phantom, the optimal injection dose per body weight could be simulated in 3d imaging. introduction: phantoms for the determination of the size of pixels should be big, rectangular, homogeneous and easily available. however, they must not "jut out". the nema homogeneity phantom can meet these requirements if its position is adjusted to whole body scanning. material and methods: the nema phantom was filled with 1 gbq of 99m-tco4 and placed on the examination table with its long edges parallel to the examination table. a square tile of 31.5 cm was put on top of the phantom and was aligned to one of the short edges of the nema phantom to facilitate a comparison of the resulting defect with that of a static image. pixel numbers were determined by applying rectangular roi to the edges of the phantom and of the tile. by this, the numbers of pixels of the x-and y-axis could be determined and compared with the length and width of the phantoms. we compared the data of a prism 2000 camera with those of an lfov camera that had not been approved yet by our hospital at the time when we did the exams. we did a static scan and two whole body scans (180 and 100 cm) with both cameras. results tile 315 the accuracy of osem and fbp reconstruction algorithm for the determination of the thyroid volume: a fantom study a. ergulen, g. durmus-altun, f. ustun, s. erol, s. cıldavil, s. berkarda; trakya university, edirne, turkey.background_individualised dosage models are frequently applied for radioiodine therapy in patients with graves' hyperthyroidism. in these dosage schemes the thyroid volume (tv) is an important parameter. iterative reconstruction algorithms produce accurate images without streak artifacts as in filtered backprojection. they allow improved incorporation of important corrections for image degrading effects, such as attenuation, scatter and depth-dependent resolution. the aim of this study was to compare the accuracy of osem and fbp reconstruction algorithm for the determination of the tv in fantom study, and to comparing estimted tv 360 and anterior 180 degree spect acquisition methods and results_the osem (it:2, sbs:4) and fbp (bw cut-off:0.5, order 6) algorithm was employed in reconstruction. at quantitative analysis 360 and anterior 180 degree 131-i thyroid spect , the volume of thyroid were calculated for 20%-30%-40% uptake levels of wather-filled thyroid fantom. for estimation of tv, linear regresion analysis was eployed and final regresion equations were generated for each acqusitions and filters. the thyroid images were filtered, and after applying a threshold method an automatic segmentation algorithm was used for the volume determinations. the best estimation of tv was observed on 180 degree spect acquisition and fbp algoritims. estimated tv(ml)=56+(0.002 * calculated tv)-(0.23 * average count of thyroid); r:0.99, r 2 :0.98, p:0.01, se of estimation: 0.158). th predicted tv was 49.8+/-0.83 ml (min:48.97, max: 50.93) and see of ptv was 0.118+/-0.038 ml. conclusions_the comparisons with osem and fbp indicate that thyroid volume estimations with 360 aim high resolution scintigraphy ( hrs) can be useful in radio-guided surgery (rgs) and small animal imaging. devices are generally based on arrays of sensible elements: room temperature semiconductor arrays or scintillating crystals arrays that can be coupled with position sensitive photomultipliers (pspmt). here we describe a small field of view (fov) portable cameras based on 1 and 4 inches 2 pspmt. materials & methods these cameras show a peculiar crystal-collimator-pspmt matching that allows the exact positioning of all the scintillating elements inserted in the square holes of a parallel tungsten collimator. this arrangement ensures no crosstalk of rays or light among crystals. the scintillation light emerging from each crystal is revealed by a pspmt (h8500 or r8520-00-c12). the anodes allow event positioning through the reconstruction of the maximum of the multiplied charge distribution by the centroid algorithm. data are then selected with an appropriate energy window and transferred to a workstation. we studied the spatial resolution and the homogeneity of two cameras both equipped with 2.4x2.4x5 mm 3 csi (tl) crystals and a 25 mm long collimator. a thin plexiglas container filled with 99m tc was used to check homogeneity and pixel identification. a derenzo phantoms with the diameter of the holes ranging from 2 to 4 mm was positioned at contact, at 1, 2, 3 cm distance from the collimator and filled with 99m tc to assess the camera spatial resolution. results the energy resolution was 19.1 % fwhm of the 99m tc peak over the whole fov area. both cameras showed homogeneity within ± 5% between max and min pixel counts. pixel identification showed average peak to valley ratio of 20:1. spatial resolution was 3.3 mm at 1 cm, 4.9 mm at 3 cm, 6.0 mm at 5 cm and 10.9 mm at 10 cm distance. conclusion measurement of resolution were performed to foresee the working conditions of hr cameras. actually when nuclear physicians show to surgeons sentinel nodes or parathyroid glands, they are on contact with the source or at few cm distance. both detectors were used for rgs and showed hot nodes less than 2 mm large and distant 2.5 mm each other. in several instances a spot detected as single node by anger camera showed the presence of two near nodes. aim the aim of our study is to evaluate the correlation between the bone density measured with quantitative us technique (qus) and with dual x-ray absorbiometry (dxa). material and methods we studied 12 patients (47-57 years; mean: 52). bone status was assessed by quantitative ultrasound, using dbm sonic 1200 (igea, italy), which measures amplitude-dependent speed of sound (ad-sos [m/s]) and bone densitometry by the use of unigamma plus/compact (l'acn, italy), which measures bone mineral density. we correlated the t-score parameters obtained in qus e in dxa scan. "t-score" compares the patient's bmd with the young-normal mean bmd and expresses the difference as a standard deviation (sd) score. the qus was performed in menopausal ambulatory in gynaecology department, measuring the bone tissue at the metaphysic of the proximal phalanges of the last four fingers of the non-dominant hand. after the ultrasound bone densitometry, the women underwent the dxa scan of lumbar spine (l2-l4). the bmd is calculated in g/cm 2 . we had exposed t-score as diagnosis of normality, osteopenia and osteoporosis according to world healt organization normal range. results according the who definitions, osteopenia was found in 7 patients and normal bone density in 5 patients with quantitative us technique . with dxa method, osteopenia was found in 7 patients, normal in 4 patients and osteoporosis in 1 patient . conclusions concordance was found between the bone density measured with qus and with dxa in 8 patients, while 4 patients results were discordant. some studies in literature showed an agreement of 0.2-0.8 between qus methods and dxa in our study the agreement between the diagnosis in qus and in dxa is 0.47. it agree the literature data. our intention is to continue this study, extending the case study. aim: neuroendocrine tumors may be treated by peptide receptor radionuclide therapy. in order to target somatostatin expressing tumors dotatoc was coupled to a ßemitter yttrium-90 (y-90) or lutetium-177 (lu-177) which results in a high radiation dose in the tumor tissue. the elimination of the peptide occurs via the kidneys. y-90-dotatoc shows tubular reabsorbtion and accumulates in the kidneys. therefore, a major complication of y-90-dotatoc-therapy is the radiation-induced nephrotoxicity. in this study we determined the effects of y-90-dotatoc-therapy on renal function with tc-99m-mag-3 scintigraphy. methods: 29 patients (19 m; 10 f) between 28 and 78 years (average: 57,5 years; median: 62 years) have been examined. all patients received a minimum of three dotatoc-therapies in combination with a nephro-protective amino acid infusion according to the heidelberger standard protocoll. the dynamic scintigraphy was carried out from dorsal position (multispect 2, fa. siemens) with a weight dependent application of tc-99m-mag3. between the 21st. and 50th. minute p.i. a blood sample was taken at the opposite arm. the blood was centrifuged and 1 ml serum was measured in a gammacounter using repeat determination. the evaluation of the tubular excretion rate (ter) was done on a xeleris workstation. the ter of any examination was normalized using a specific patient standard. the average after the second, third and forth therapy was verified with the t-test procedure and deviations from average were analysed. results: after the second and third therapy there was no significant change in renal function with a probability of p=0,19 (n=29) after the second therapy and p=0,25 (n=20) after the third therapy. a significant aggravation of the renal function was shown in 11 patients p=0,001 (n=11) after the fourth therapy. in 3 of 11 patients the ter was pathological. conclusions: three cycles of y-90-dotatoc therapy are well tolerated by the kidneys, and a significant reduction of renal functions were not observed. however a significant reduction of the ter was found after the 4th cycle in some patients. however, the renal function dropped into the pathological range in 27.2% of these patients. we conclude that the risk of a nephro-toxicity by a y-90-dotatoc-therapy is negligible during the first 3 cycles. after the 4th cycle of y-90-dotatoc therapy, a reduction of renal function may occur, but the clinical relevance is low. this presentation will outline some of the additional duties that may be encountered by a nuclear medicine technologist (nmt) working in the field of rit research. radioimmunotherapy is being increasingly used, particularly in the treatment of haematological malignancies. a stem cell transplant with prior rit involves input from a range of specialities such as oncology, haematology, nursing, radiopharmacy, physics, imaging, and laboratory services. it is vital that the multidisciplinary team works in harmony to deliver this service. the large number of staff members involved adds complication to making patient appointments and has led to some overlapping of roles in order to offer a continuous service. rit is a complex and evolving technique and many procedures will be new to a nuclear medicine technologist entering the field. the additional duties performed by a nmt at southampton include coordination of patient appointments for rit clinical trials, performance of elisa assays, quality control of radio labeled antibodies by hplc and itlc, administration of dosimetric and therapeutic infusions, assistance with dosimetry calculations and bremstrahlung imaging. these duties will be illustrated with reference to a clinical rit trial currently being undertaken at this institution. aim the aim of this study was to determine the radiation dosimetry of no-carrieradded (nca) 123 i-metaiodobenzylguanidine (mibg) compared to carrier-added (ca) 123 i mibg, in the same subjects. materials and methods nine healthy subjects were injected with 185 mbq nca 123 i mibg and on a separate occasion with ca 123 i mibg. anterior and posterior whole body (wb) scans were made with a dual-head camera at 30 min, 1.5, 2.5, 4.5, 6, 24 and 48 h post injection to obtain organ timeactivity data. blood samples were collected at the same time points in order to determine activity in the total blood volume. urine was collected in five portions up to 48 h in order to monitor the excretion. one set of regions of interest (rois) was drawn for ten source organs and different background regions on the wb scans, and then applied to each wb scan. the counts in the rois were corrected for background. the geometric mean net counts were calculated, and corrected for attenuation, efficiency, decay, and expressed as a percentage of injected activity. curve fitting was applied to the time-activity data to obtain the total number of disintegrations in each source organ, from which the absorbed doses to all organs was calculated (olinda/exm software). the effective dose (msv/mbq) and effective dose equivalent (msv/mbq) were then determined. results the effective dose of nca 123 i mibg was equal to ca 123 i mibg (0.029±0.002 msv/mbq vs. 0.029±0.002 msv/mbq, respectively; p=0.181). the effective dose equivalent of nca 123 i mibg corresponded with that of ca 123 i mibg (0.025±0.002 msv/mbq vs. 0.026±0.002 msv/mbq, respectively; p=0.055). the myocardial wall showed 25% more uptake for nca 123 i mibg compared to ca 123 i mibg. the radiation dose to the myocardium was thus higher for nca 123 i mibg compared to ca 123 i mibg (0.035±0.006 msv/mbq vs. 0.029±0.004 msv/mbq, respectively). conclusion no essential differences were found in absorbed dose between nca and ca. the higher myocardial uptake of nca favours the use of nca over ca for the assessment of myocardial imaging. characteristic evaluation of a real-time semiconductor dosimeter and measuring finger dose in nuclear medicine departments t. fujibuchi 1 , t. isobe 2 , t. iimori 1 , y. uchida 1 ; 1 chiba university hospital, chiba-shi, japan, 2 kitasato university, sagamihara-shi, japan.background and purpose: workers who use radiation sources in the nuclear medicine field have the highest risk of exposures to their fingers. until now, tlds have been the only reliable dosimeter to measure finger doses. however, the usage of tlds is complicated, its procedure is time-consuming and it is used in other fields as well. in this study, we measured finger doses by using a semiconductor dosimeter for the nuclear medicine examination and evaluated its sensor characteristic. after having aim: the tracheo-bronchial inhalation is the most invalidating symptom shown by patients with neurological disease and it is the most frequent cause of death. oro-pharyngo-esophageal scintigraphy (ofes) allows both functional and semiquantitative study of the various stages of swallowing. material and methods: we studied with ofes a woman who underwent to high dosage radiotherapy treatment for rhinopharyngeal carcinoma. the patient developed progressive and ingravescent dysphagia, with ipomobility of the right arm. the patient, placed in a 80° right anterior oblique upright position, in front of a large-field-of view gamma-camera, was given a single 5 cc bolus o water labelled with 37 mbq of 99m tc-nanocolloid. eight images/sec are acquired (0.125 sec/frame) for one minute, with dynamic acquisitions using a 64x64 matrix and zoom 1 of the visual field from oral cavity down to epigastric area. two second after the beginning the patient is invited to swallow the liquid in a single time and a static image lasting 60 seconds is then acquired at the end of examination, to evaluate the presence of tracheo-bronchial aspirate. for the presence of massive inhalation the study was completed with a spet-tc. the parameters analysed were: oral, pharyngeal and esophageal transit time, oro-pharyngeal and esophageal retention index, percentage of tracheo-bronchial aspirate. the study was performed at the time of diagnosis, after the treatment by positioning the low pressure cuffied tracheostomy tube and finally after functional laryngectomy. results: ofes shows a massive tracheo-bronchial inhalation at first study with ritention of bolus in the both lungs and a lengthier oral and pharyngeal transit times and an increase in the oro-pharyngeal retention index. a spet-tc confirms the pulmonary aspiration and shows a sovra-elevation of the right lung as consequence of inhalation. the ofes performed after positioning of the cuffied tracheostomy tube shows absence of inhalation in tracheo-bronchial tract after oropharyngo-esophageal transit of liquid bolus with a presence of small aspiration in the right lung in tardive acquisition. the cuffied tracheostomy tube was changed with a standard tracheostomy tube and the ofes shows again massive tracheo-bronchial inhalation. then the patient was submitted to functional laryngectomy. a scintigraphic study performed subsequentely shows absence of tracheo-bronchial inhalation. conclusion: ofes in neurological patient is a simple, inexpensive, non invasive and reliable technique that shows the presence of bolus inhaled and quantifies tracheobronchial aspirate. ofes is a useful and accurate tool to monitoring the response to medical and/or surgery therapy. ger on children with recidive bronchitis(rb) m. hudournik; general hospital celje, celje, slovenia.aim: in this examination we are finding how frequent ger as a cause for rb. materials and methods: in this examination have been included 80 children (53 men, 27 women) in an age from 2 mounts to 14 years. doctor's notes for these children have: rb (35 children), vomiting (23), cough (14) and allergy (8). the images of these children has been taken in lying position after a normal meal. radiofarmac was tc-99m-lyomaa (dose upon 7,4 mbq -37 mbq), which has been to apply through the nasogastric tube or to drink up. gamma camera was set up behind the patient. the field of view includes the mouth, sternum and abdomen. images are generated every 30 s for 1 h on 64x64 matrix. after 2-3 hours we have taken delay images of lungs to find out the aspiration tc-99m-lyomma in to the lungs. results: from all (80) in this examination included children has had 22 (27,5%) ger and from this 22 has ha dan aspiration in the lungs. in examination has confirmed with diagnosis, rb 37%, vomiting 26%, allergy 12% and cough 14% ger. children average age with rb diagnosis has been 2,9 years . most children (18) with rb has been 1-2 years old, 39% of them has had a ger. conclusion: frequency of ger on children with rb is 37%, especially with children at approximate age 2 (39%). introduction: the collaboration problems that arise from the observation and care of patients could be codified to nursing interventions classification (nic), to obtain finally results codified agreed to nursing outcomes classification (noc). these collaboration problems, interventions (nic) and results (noc) applied to patients referred for treatment of hipertiroidism could identify and develop interventions to optimize ant obtain the wished results so the patient feels more comfortable in the visit to our service. methodology: since 2004 the nursing in our service are explore these aspects in the daily care of patients (approximately 8 patients weekly), and have been identified the collaboration problems that usually presents this type of patients. the most frequent were: administration of radionuclides, informed consent, radioprotection advices, nursing registry, discard pregnancy in women in fertile age. once identified these collaborations problems an interventions, codified according the nic criteria are applied: administration of oral medication (2304), agreement with the patient (4420), support in making decisions (5250), identification of risks (6610), documentation (7920), advise before conception (5247). all patients fulfilled a report (survey form) about the satisfaction for the care received in the service. this form was complimented at 90% of patients. all patients facilitated a satisfaction survey when they left our service, which was answered for the 90% of them. results: after application the interventions we had a satisfactory results in 85% of patients. these results codified agreed the noc were: behaviour of fulfillment (1601), well-being (2002) , knowledge: prescribed activity (1811), knowledge: preconception (1822). conclusions: the use of the methodology according nanda criteria could diminish the collaboration problems in patients referred to treatment with i-131. we acquired image that used orbiter gamma camera with pin hole collimator. also we acquired the thyroid phantom and the 4-q bar phantom image to compare resolution. the patient image aquired by 300 sec or 100 kcnts. and phantom image acquired by 500 kcnts. we calculated thyroid/bkg ratio from the image that is setted with 300sec. and then compared scan time from the image that is setted with 100 kcnts. additionally, we investigated that the time required of each diseases(hyperthyroidism, hypothyroidism, goiter, nodule). when we acquired image by time setting(300sec), using 4mm pin hole collimator and 6mm pin hole collimator, that result of thyroid/bkg ratio was as low as 1.89 times in 4mm pin hole collimator(ratio -4mm:21.64, 6mm:40.89). and we the relative high number of persons who daily attend to nuclear medicine departments is an important factor regarding disease transmission. although the permanence of these people in the facilities is usually quite short in time, there is always the possibility to transmit or receive infectious agents (both through organic material or airborne transmission). the goal of this work is, firstly, to "make the diagnosis" of the present situation, identifying what kind of infectious agents are present at nuclear medicine departments (and if different nm departments present different profiles, according to their characteristic turnover of patients), and, secondly, to suggest appropriated technical solutions for their control/elimination, when possible (otherwise, at least, to obtain their minimization). this abstract relates with the first part of the work (as it is still on progress). material and methods: as a first step, it was performed the characterization of the present situation, via an adequate analysis/detection of the main pathological agents (focusing only on bacteria and fungi) present in the diagnostic equipment, as well as in other important "hot spots" in a nuclear medicine department, where the spreading of these agents was believed to be more prone to happen (such as keyboards). it had been collected and microbiologically analysed bacteriological samples from those pre-established spots in several distinct nuclear medicine departments. the information collected is actually being related to the different kind of scintigraphic studies that are performed in those departments (and/or the different "specific profiles" of the departments itselves). the cleaning methodology (agents used and respective frequency) used in these departments is being taken into account and related with the results obtained. results and conclusions: according to the results obtained, it had been possible to identify the main infectious agents and to make the "point of the situation" in distinct profiles of nm departments, being believed that this should be the starting point to further studies, now aiming to identify methodologies able to control the incidence of nosocomial infections related with nm departments. 3 ben-gurion university of the negev, beer-sheva, israel. the 18 o oxygen isotope is widely used in cyclotron targets for the production of the 18 f positron emitting isotope. the latter's rapidly increasing use in medical imaging generated a need to improve the diagnostic tools for controlling the cyclotron production of 18 f and 18 o during the enrichment process. a highly reliable measurement of 18 o concentration is important for the 18 o manufacturer to validate its purity, and for the 18 f producer, to assure that that it is produced with the required activity and quantity at the end of the cyclotron run. this work describes a process that can validate the concentration of these isotopes and that should prove useful to both parties. the manufacturing of 18 o water involves several stages to obtain the final required concentration of 18 o (98.5%). by carrying out isotopic analysis repeatedly throughout these stages, the concentration of each isotope can be validated. a radiation detector was used to measure the gamma field for different levels of 18 o enrichment during the production of 18 f. the gamma radiation dose rate and the accumulated dose were measured for a target loaded with recycled water, or 98% enriched 18 o water, or 16 o water. the detector readings from the nuclear interaction in the cyclotron target were compared to the measured beam current, the existing indicator for the bombardment. the variations in the radiation level were calculated and compared to the different levels of 18 o activity in the water, obtained repeatedly throughout the enrichment process, to establish a relationship. the isotope analysis test during enrichment enabled the manufacturer to maintain the 18 o enriched water concentration level in the short run, and the 18 o production quantity rate in the long run. the water enrichment was not reflected by the accumulated beam current when measuring cyclotron protons; however the calculated ratio between the radiation level and the accumulated beam current gave a factor of up to 2.4 during the target water bombardment at the various stages. this study presents a comprehensive solution for monitoring and validating 18 o enrichment during the manufacturing stage, as well as the production of 18 f. the isotopic analytical test enabled malfunction identification at the early stages of the 18 o manufacturing process which assured quality and quantity. during the bombardment, the beam current did not indicate any difference in the level of enrichment. however, the radiation monitoring system provided a useful tool for distinguishing between different enrichment levels during the production runs. calibration of i-131 in dose calibrators routinely used in nuclear medicine departments s. tastan 1 , n. kucuk 1 , e. ibis 1 , e. turkoglu 1 , k. kir 1 , a. soylu 2 ; 1 ankara university, ankara, turkey, 2 monrol a.s, ankara, turkey.introduction: a dose calibrator is one of the most important instruments in a nuclear medicine center since it is crucial to give the right amount of activity to the patient. the calibrator is a well-type ionisation chamber, which has long term stability and can measure activity to the desired level of accuracy. however, it is sensitive to even small changes in geometry, container type, density and volume of samples. material & method: in this study ,which is part of a project supported by the iaea as a crp,performance tests of biodex atomlab-100 dose calibrator were performed according to " iaea technical report series no: 454" . the calibration was done by using an i-131 standard solution provided by the iaea to all participants of the project in various countries. the solution was 178 mbq/ 5 ml in a 10r schott vial with teflon-coated stoper and aluminium uncrimped seal,uncertainity (3 %, k=2) . correction factors were calculated for the 10r vial, 5 ml syringe and the vial which is routinely used in our laboratory . during the transfer to syringe/vial, necessary amount of carrier solution was added to bring final solution to original mass. results: calibration factors were 1.027, 0.982, 1.029 respectively 10r vial, 5 ml syringe and routine vial. gum ( iso guide to the expression of uncertainty in measurement) were used to analyse all uncertainty components. the table demonstrates correction factors with the calculated uncertainities. conclusion: this study demonstrated that dose calibrator measurements are sensitive to small changes in container type and geometry altough total mass is the same. in many countries don't have national measurement laboratories. therefore, it is important that performance tests, calibrations and audits of radioactivity measurements in radiopharmacies and clinic so that measurement errors can be avoided.correction factor with uncertainities 10 r vial 1.027 x activity ± 0,0187 k=1 routine vial 1,029 x activity ± 0,0583 k=1 5 ml syringe 0,982 x activity ± 0,0583 k=1 introduction. usually the patients coming for the first time to our diagnosis unit for a pet study show a high degree of unknown about details of that. this fact induces a high degree of anxiety that could be assessed in nursing diagnosis according nanda classification. on basis this diagnosis could be planned nursing interventions (nic). objective: to evaluate nursing diagnosis of anxiety and the effectiveness of the application of interventions (nic) according to noc criteria in patients who are going to perform a pet study. material and methods: from i/'05 to vi/'05 110 patients have been studied for first time using pet, under suspicion of malignant disease. for this purpose, patients with alteration of conscience level are excluded. the degree of anxiety is evaluated by means a numerical scale likert type, before and after the application of the plan of care. results: after the application of the nursing care plan a 10% of patients reduce in 3 points the anxiety level, in 65% this reduction is of 2 points and in a 5% in 1 point according likert scale. conclusions: the application of the nursing plan of care in patients, who first perform a study pet, diminished the level of anxiety in a significant proportion. high performance liquid chromatography evaluated the stability of levofloxacin and stannous chloride for injection x. q. zhou, g. x. cao, r. j. zhang, x. f. qin; jiangsu institute of nuclear medicine, wuxi, jiangsu province, china.aim: levofloxacin is a sort of broadspectrum antibiotic which is often used to treat infectious diseases at present. the method about determination content of levofloxacin tablet using spectrophotography was reported. 99m tc-levofloxacin is a new specific infect imaging. we prepared levofloxacin and stannous chloride for injection by freeze-dry. it is most important for radiopharmaceutical. we determined the concentration and evaluated the stability of levofloxacin in levofloxacin and stannous chloride for injection for the first time. methods:the concentration of levofloxacin and the concerned substance in levofloxacin and stannous chloride for injection were determined by reverse high performance liquid chromatography (hplc). the stability of levofloxacin and stannous chloride for injection and the radiochemical purity were examined under the different conditions of light, temperature, humidity. we used citric acid and acetonitrile (79:21) as mobile phase, adjusted ph to 4.0 using triethylamine. the mobile phase was pumped at 1 ml/min through the lichrospher c18 (4.6×250mm,5μm) at room temperature. the detective wavelength was 293nm and the sensitivity was 0.01aufs .the number of theoretical plates was exceed 2500 using the model 600 high performance liquid chromatograph and 2487 uv detection (waters aim: to guarantee presentation of all studies from pacs to a particular examination on a given imaging modality (in our case pet) after a query from his. material: pet ecat accel (siemens, erlangen, germany), dicom modality tool kit (the offis computer science institute, oldenburg, germany). method: his is interconnected with pacs via unique identifier (on pacs side with the seek key "accession number") for selecting all image data for particular examination on given imaging modality. the imaging modalities without the possibility to write down this unique identifier to a corresponding data item (most often if native image format is used -e.g. ecat7 for pet ecat accel) can usually use the data item only for a unique "study id". now there arises a problem if it was necessary to make additional studies for a particular examination, as the previous image study would be unwantedly overwritten. the only possible solution is simulated modification of "study id" for additional studies. for the purposes of proper archiving and selecting all the studies appertaining to a given examination on pacs it is necessary, after the conversion of the native image format to dicom, to write down backwards in the blank data item "accession number" the original unmodified value. on the basis of the above mentioned was for simulated "study id" generation modified before now designed dicom modality worklist in the form of an intranet application. after the conversion of the native image format ecat7 to dicom on the evaluating workstation esoft siemens are the image data going to pacs received by a temporally pacs running on hospital intranet server. here is reconstructed backwards the original value of the "accession number" from data item with simulated "study id" and is at once written into the corresponding blank data item in the format dicom. the data repaired in this way are resent to target pacs and after their successful archiving deleted from temporally pacs. results: such solution allows medical staff to make very simply additional studies on scheduled imaging modality for a given examination such that all of them could always be presented after a query from his. conclusion: the methods with the usage of free software tools may not always be easy to perform but sometimes are the only possible. moreover, they are in some cases the cheapest option. aim: vaccination using dendritic cells is a new therapeutic approach for patients with disseminated malignant melanoma. this phase i-study examines safety and migration of alpha-type i dendritic cells versus pge2 dendritic cells in patients with malignant melanoma. methods: the treatment consist of vaccination with the patients own dendritic cells, which are injected intradermally or directly into the lymph nodes. at the onset of treatment we are looking for the migration comportment of radiolabeled dendritic cells generated by 2 differently preparation processes. at present six patients with malignant melanoma in stages iii and iv (ajcc,1) were included. alpha-type i dendritic cells and pge2 dendritic cells were radiolabeled with approximately 1.4 mbq 111 in-oxin. thereafter, a minimum of 1 x 10 6 alpha-type i dendritic cells were injected intradermally of the right upper leg, and the same amount of pge2 dendritic cells into the left upper leg. migration was investigated by dynamic examination during 30 min. furthermore, static scans were performed inguinal for another 10 min. with and without shielding of the injection area. additionally, whole body scan, including 4 radioactive standards (activities 0.04 mbq -0.4 mbq) were performed with a scan speed of 10 cm/min. late scans were acquired 24 hours and 48 hours after injection. results: scintigraphically, lymph nodes were visualized at 24 and 48 hours after injection. positive lesions were semi-quantitatively analysed by drawing regions of interest (roi) above the injection area, inguinal lymph nodes and radioactive standards. after correction for half-life, 79 (± 4)% after 24h and 55 (±7)% after 48h of the initial activity was found in the injection area of both cell types. mean of ratios (counts in lymph nodes/ counts in injection area) of alpha-type i dendritic cells were 0.72 after 24 hours and 2.11 after 48 hours. for peg2 dendritic cells, the ratios were 1.35 after 24 hours and 3.75 after 48 hours. in all 6 patients, differences in migration of both cell types were not significant (p=0.27). conclusion: alpha-type i dc have a lower tendency to migrate than pge2-dc in vivo, but the differences observed are not significant. our data do not provide information about the stimulating behaviour of dendritic cells for an antitumor tumor reaction. up to now, the optimal type of dendritic cells is not synthesized. however, the cells used in this study show potential for further clinical studies.